HEALTH SCIENCES STANDARD HX00038636 M^IOI Columbia (Bnttierstttp COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY MEDICAL GYNECOLOGY MEDICAL GYNECOLOGY BY HOWARD A KELLY, A.B., M.D., LLD., F.R.C.S. (Hon. Edinb.) PROFESSOR OP GYNECOLOGICAL SURGERY IN THE JOHNS HOPKINS UNIVERSITY, AND GYNECOLOGIST TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE ; FELLOW OF THE AMERICAN GYNECOLOGICAL SOCIETY ," HONORARY FELLOW OP THE EDINBURGH OBSTETRICAL SOCIETY ; HONORARY FELLOW ROYAL ACADEMY OP MEDICINE IN IRELAND ; FELLOW BRITISH GYNECOLOGICAL SOCIETY ; HONORARY FELLOW GLASGOW OBSTETRICAL AND GYNECO- LOGICAL SOCIETY ; HONORARY MEMBER OF THE ROYAL MEDICAL SOCIETY OF EDINBURGH ; CORRE- SPONDIRENDBS LND EHRENMITGLIED DER GESELLSCHAFT fOr GEBURTSHULFE ZU LEIPZIG ; EHRENMITGLIED DER GESELLSCHAFT FOR GEBURTSHCLFE U. GYN. ZU BERLIN ; CORRESPON- DIRENDES MITGLIED DER K. K. GESELLSCHAFT DER AERZTE IN WIEN ; MEMBRE ASSOCIE ETRANGER, SOCIETfi D'OBSTETRIQUE, DE GYNficOLOGIE ET DE PKDIATRIE DE PARIS ; MEMBRE CORRESPONDANT fiTRANGER DE LA SOClfiTE DE CHIRURGIE DE PARIS ; MEMBRE DE L'ASSOCIATION PRAN9AISE D'UROLOGIE, PARTS ; MEM. HON. SOCIETI ITALIANA DI OSTETRICIA E GINECOLOGIA, ROME, ETC., ETC. WITH ONE HUNDRED AND SIXTY-FIVE ILLUSTRATIONS FOR THE MOST PART BY MAX BROEDEL AND A. HORN SECOND EDITION NEW YORK AND LONDON D. APPLETON AND COMPANY 1912 CoPYKiGHT, 1908, 1909, 1912, by D. APPLETOX AND COMPANY PRINTED AT THE APPLETOX PEESS NEW YORK, V. S. A. H/2. TO THE IDEAL GENERAL PRACTITIONER, A MAN OP WIDE CULTURE IN HIS PROFESSION, IN CLOSE TOUCH WITH ALL THE SPECIAL- TIBS, THE BELOVED FRIEND OF HIS PATIENTS, AND ABOVE ALL, IN EVERY RELATION OF LIFE A SINCERE AND A DEVOUT CHRISTIAN : TO Dr. BRICE W. GOLDSBOROUGH this book is affectionately dedicated Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/medicalgynecologOOkell PEEFACE TO SECOND EDITION I AM glad that a second edition of Medical Gynecology has been called for and I trust that it will be as kindly received as the first. In order to make the book more useful to the general practitioner I have added a chapter on Diseases of Advanced Age, and I have extended the brief account of the Menopause considerably. Dr. Curtis F. Burnam has written the paragraphs on Salvarsan, as well as those on Radiotherapy and Radiography ; in the use of radium his experience has been unusually large. Several new illustrations have been added and the whole of the volume has been carefully re-edited by those who helped me prepare the first edition. My great desire throughout has been to do some- thing to serve the general practitioners of the country, among whom I have so many very close friends. Howard A. Kelly. PREFACE. What a transformation two generations have witnessed in the field of gynecology ! From modest beginnings, as a sort of a minor specialty coupled with diseases of children and often professed by general practitioners with no special training, it has grow^n to the dignity of a major surgical specialty, so extensive that many gynecologists of to-day claim the entire field of abdom- inal surgery as their proper domain by right of discovery and conquest. This period of surgical evolution is now at last clearly at an end and I deem it a fitting time to review once more, from our new and advanced standpoint, the relationship of our specialty to the field of general practice. To my mind the evolution of scientific medicine must ever run this course : The general practitioner yields up to a little group of investigators that por- tion of his territory which is most obscure and difficult, in which he has made the least progress; the field is diligently cultivated and a specialty is formed. Then in time the specialist so simplifies the etiology, the diagnosis, and the treatment, that he is able to hand back a part at least to the general practi- tioner, with whom he continues in relations of harmony and sympathy, so that both work conjointly to a common end, namely, the extinction of disease and the amelioration of its ravages. It will be my effort in the following pages to review my special field, in an endeavor to return to the general practitioner that portion of it which he ought to recover by right of his prior lien. Two subjects stand out preeminently as the field of the practitioner of medicine, namely, hygiene and prophylaxis. He also sees and is often per- plexed by the sequelae of the various gynecological operations. A variety of minor operations he must often be prepared to do, notably, suture of the recently torn perineum, dilatation and curettage of the uterus, etc. Largely in his hands also lies the fate of the great army of cancer patients, wdio to-day apply to the specialist, as a rule, too late for relief. I have often heard the cry ne sutor ultra crepidam, during the twenty- five years I have been practising medicine, but it has not seemed to me to be trespassing too far on other fields to take up such every-day topics as hysteria and its allies, headache, backache, and constipation. I am indebted to the kind cooperation of my friend and colleague Dr. Lewellys E. Barker for the chapter on neurasthenia, hysteria, and psychas- X PKEFACE. tlienia. Tliis chapter offers tlie first explicit and detailed statement which Professor Barker has as yet made touching his methods of dealing with this class of cases. It constitutes a most difficult branch of therapeutics with which his name is associated as a pioneer, and I am thankful to have this definite expression of ideas from such an authority upon a suljject in regard to which the gynecologist so often stands in need of the advice of an expert neurol- ogist. Dr. Lilian Welsh, Professor of Physiology in the Woman's College of Baltimore, and Dr. Mary Sherwood, Director of the Gymnasium at the Brvn Mawr School, have written the chapter on the hygiene of the growing girl, dealing with the most fundamental question of our work. My old friend Dr. Walter L. Burrage has written the chapter on gonorrhea as well as that on fibroid tumors of the uterus. Dr. Prince A. Morrow, our great American authority on venereal disease, has supplied that on syphilis ; and abortion comes from the pen of Dr. Edward J. 111. The section on movable kidney is by Dr. P. "VT. Griffith; enteroptosis is by Dr. Thomas P. Brown and mastur- bation by Dr. P. L. Dickinson. The book has been fostered from its incipiency by my friend and co-laborer, Dr. Caroline Latimer, without whose aid it could not have been written. She has nursed it throughout with unwonted solicitude and after revision and cor- rection sent it forth into the world to battle for a living. I am indebted for help and suggestion to Dr. W. L. Burrage and Dr. C. P. Burnani through a large part of the book ; to Dr. T. R. Brown in the chapter on constipation, headache, insomnia, and obesity; to Dr. G. W. Dobbin, Dr. Pichard Xorris, and Dr. J. M. Slemmons in the chapter on injuries and ail- ments after labor. Dr. TT. S. Baer has given me valuable advice concerning the treatment of backache, in which chapter I draw special attention to sacro- iliac disease, and Dr. G. L. Hunner has assisted me in revising the chapter on cancer. The illustrations, one hundred and sixty-three in number, have almost all been made by Messrs. M. Brodel and A. Horn, my longtime faithful coad- jutors. In many of them we have worked on comparatively new lines, securing a more realistic and greater artistic effect in certain cases where it was formerly necessary to rely solely upon diagrammatic representation. Such illustrations are line drawings of examinations, postures, methods of treatment, and others which will be readily recognized from their generic resemblance. HowAED A. Kelly. CONTENTS CHAPTER PAGE I. Consulting Room and Appointments. Gynecological Examination . . 1 II. Hygiene of Infancy and Girlhood 40 III. Normal Menstruation. Menopause 78 IV. Dysmenorrhea. Dilatation. Membranous Dysmenorrhea .... 105 V. Intermenstrual Pain 132 VI. Amenorrhea. Vicarious Menstruation 140 VII. Menorrhagia and Metrorrhagia. Extra-uterine Pregnancy . . .163 VIII. Constipation. Headache. Insomnia. Obesity 207 IX. Backache. Coccygodynia 250 X. Acute Infectious Diseases as a Cause of Pelvic Disease .... 265 XI. Vaginitis. Vulvitis. Cervicitis. Endometritis 275 XII. Pruritus. Vaginismus. Masturbation . . . . . . . . 295 XIII. Displacements of the Uterus 317 XIV. Pelvic Inflammatory Disease 335 XV. Sterility 346 XVI. Gonorrheal Infection 375 XVII. Syphilis 392 XVIII. Abortion 452 XIX. Injuries and Ailments following Labor 477 XX. Fibroid Tumors 488 XXI. Carcinoma. Diagnosis and Palliative Treatment 513 XXII. Cystitis 543 XXIII. Functional Nervous Diseases Met with by the Gynecologist . . . 565 XXIV. Appendicitis in Association with Pelvic Disease 586 XXV. Splanchnoptosis. Movable Kidney 597 XXVI. Post-Operative Conditions 622 XXVII. Diseases of Advanced Age 635 xi ' LIST OF ILLUSTRATIONS. FIG. PAGE 1. A simple form of consulting and reception room 2 2. Arrangement with examining room separated from consulting room .... 2 3. The gynecological examining table 7 4. Piezometer used to register the depth and amount of abdominal pressure made . 8 5. Deviation of the sigmoid flexure 9 6. Bimanual examination by vagina and abdomen 10 7. Bimanual examination of the uterus 11 8. Bimanual examination of pelvic organs by rectum and abdomen 12 9. Trimanual examination . 13 10. Bimanual examination showing the method of palpating a fibroid tumor ... 14 11. Bimanual examination showing the method of detecting an ovarian tumor . . 14 12. Outlining the enlarged uterus or other pelvic tumor 15 13. Palpating an ovarian cyst seen in sagittal section . .16 14. Registering markings on transparent material 17 15. Permanent record of an ovarian cyst 18 16. Photographic copy of a gauze tracing 19 17. Exposing the cervix uteri and the vault of the vagina through a Nelson speculum . 20 18. The knee-breast posture 21 19. Method of lifting up gluteals in knee-breast posture 22 20. Examination of the vagina, vaginal vault, and cervix in the knee-breast posture . 22 21. Examining the rectum in the left lateral (Sims') posture 23 22. Introducing a cylindrical metal speculum in Sims' posture 24 23. Patient in Sims' posture exaggerated 24 24. The examination of a child about six years old 25 25. Case of tubercular peritonitis in colored child 26 26. Organs on right side whose affections are liable to be confused 28 27. Examining a ureteral catheter with wax tip 29 28. Examining the cervix and vault of vagina with Kelly's cylindrical speculum . . 32 29. Rectal instruments .35 30. Method of introducing long rectal speculum 36 31. Inspection of bowel with simple head mirror using electric light 37 32. AUigator forceps used to touch upper bowel .39 33. The home of a family of ten persons .' 46 34. A court in a crowded city district 47 35. Toilet accommodations for twenty-two families 48 36. Open-air gymnasium, girls' day. Patterson Park, Baltimore 49 37. Model gymnasium suit . 59 38. Adjustable desk with narrow box 60 39. Desk similar to that shown in Fig. 38 but not adjustable ...... 61 40. Swimming pool. PubHc bath system. Patterson Park, Baltimore .... 62 41. Faulty carriage in young girl 63 42. Effect of physical training upon faulty carriage 63 43. Case of slight lateral curvature of spinein school girl 64 xiii XIV LIST OF ILLUSTEATIOXS. FIG. PAGE 44. Same case, after one month's systematic exercise 64 45. Case of severe lateral curvature of spine in schoolgirl 64 46. Same case, after, three months' daily exercise - . . .64 47. Interior of cadaver showing constriction and displacement due to corsets . . 70 48. Shoemaker's walking shoe for girls 71 49. Impression of foot of school-girl with outline of shoe worn 71 50. Soles for normal feet — Shoemaker's soles 71 51. Normal endometrium: endometrimu near menstruation; endometrium after meno- pause 81 51A. Disc pessary for relieving incontinence of urine 103 52. Instruments used in dilation and curettage of the uterus 123 53. Cervix caught and exposed by retracting the posterior vaginal wall .... 124 54. Dilation of the cervix with Goodell-Ellenger dilator 125 55. A case of atresia of the vagina 142 56. The same ease of atresia showing lengthening of A'agina from pressure . . . 143 57. A conglutination of the labia minora 144 58. An elongate infantile ovary 150 59. An early pregnancy, showing globular enlargement of uterine body .... 152 60. A placental polyi^ 166 61. A cervical polyp 167 62. A large submucous myoma 168 63. Subinvolution of the uterus 172 64. Polypoid endometritis 175 65. Various sites of implantation of ovum in extra-uterine pregnancy .... 195 66. Pi'egnancy in the ampulla 196 67. Pregnancy in a rudimentary left uterine horn 197 68. Right uterine tube the seat of an extra-uterine pregnancy 198 69. Extra-uterine pregnancy; tubal abortion 198 70. Case shown in Fig. 69 with coagulum turned out 199 70A. A myomatous uterus resembling a fetus in its contour 205 71. Posture in defecation, showing the efficient use of abdominal pressure . . . 210 72. The ordinary sitting posture in defecation . 211 73. An adaptation of the modern sanitary closet to utilize the crouching posture . . 212 74. Method of applying the tliermo-light for backache 258 75. Abscess of left Bartholin's gland 277 76. Treatment of vaginitis in knee-breast posture 283 76A. Cylindrical speculum and alligator-forceps applicator, used in treating vaginitis 284 76B. Cylindrical speculum for vaginal treatment . . 284 76C. Instrument and materials for treating vaginitis 285 76D. Appliance for distending vagina with water or air 286 77. Craig's sharp curette for use in endocervicitis 289 78. Polypoid endometritis, natural size 292 79. A polypoid endometritis, showing a section of the endometrium .... 293 80. A urethral caruncle resembling a small dark hematoma 305 81. Different degrees of uterine displacement 319 82. A retroflexion which is natural and cannot be corrected 320 83. A case of complete prolapse of the uterus 321 84. Showing manner of applying a gauze pack in vagina 323 85. The five most useful kinds of hard-rubber pessaries 325 86. Method of bimanual reposition of a retroflexed uterus 326 87. An exaggeration of the normal anteflexion of the uterus 327 88. Showing manner of introducing a ring pessary 328 89. Showing manner of introducing a Smith pessary 328 90. Showing manner of carrying a Smith pessary into place 329 91. Showing a ring pessary in place 330 LIST OF ILLUSTRATIONS. XV FIG. PAGE 92. A form of pessary (Menge) useful in some cases of prolapse of the uterus . .331 93. Different steps in an operation for prolapse of the uterus 332 94. An operation for the cure of prolapse . . . . 333 95. Treatment of pelvic abscess by incision 342 96. Some of the causes of sterility brought together in one diagram 357 97. Cyst of the left Bartholin's gland 358 98. Acute anteflexion of the uterus 362 99. Acute retroflexion of the uterus causing sterility 363 100. A monocystic tumor causing sterility 366 101. The various sites in which the gonorrheal organism is apt to become implanted . 377 102. The gonorrheal organism, the gonococcus of Neisser 378 103. The gonorrheal organism, the gonococcus of Neisser 378 104. A case of gonorrheal vaginitis in a child eleven years old 382 105. Chart showing ages at which gonorrhea is most frequently found in little girls . 383 106. Bent hairpins used as a speculum 388 107. The examination of a little child for gonorrheal infection 390 108. Method of treating gonorrhea in the child in knee-breast posture .... 390 109. Specula of various sizes adapted to one handle used in abortion 466 110. Method of irrigating the infected uterine cavity 472 111. A cervico-vaginal fistula following labor 478 112. A complete perineal tear showing a characteristically pentagonal form . . . 479 113. A typically relaxed vaginal outlet 480 114. A vaginal outlet calibrator 481 115. A partial tear of the perineum 485 116. The sutures tied and the torn surfaces united 485 117. A complete tear of the perineum involving the sphincter muscle .... 485 118. A deeper tear of the perineum extending up the left sulcus 485 119. The physician dressed in a sterile gown 486 120. Showing a fibroid tumor beginning interstitially and growing in diff'erent directions 489 121. Showing the manner of growth of a subserous fibroid 490 122. An interstitial myoma distorting the cervical canal 491 123. Showing the manner of growth of a submucous myoma 492 124. A submucous polyp growing in a myomatous uterus 492 125. A myoma growing in the anterior wall of the uterus 493 126. A myoma growing in the posterior wall of the uterus 493 127. A myoma simulating pregnancy 501 128. Fibroid tumor beginning to undergo degeneration 502 129. Myoma growing in such a direction as to cause pressure upon bladder . . . 503 130. First stage in operation for removal of a fibroid tumor 511 131. Second stage in operation for removal of a fibroid tumor 511 132. Squamous-cell carcinoma of the cervix with extension to bladder and rectum . . 514 133. Squamous-cell carcinoma of the cervix with cauliflower mass springing from anterior lip 521 134. Adeno-carcinoma of the body of the uterus 521 135. Three principal foci from which cancer may originate 522 136. Early stage of squamous-celled cancer with disease confined to posterior lip . 522 137. Extension of disease seen in Fig. 136 522 138. Disease still confined to posterior lip, formation of craterous cavity beginning . 523 139. Progress of cancer seen in Fig. 138 523 140. Early stage of columnar-celled cervical cancer with areas of disease in both lips . 523 141. Progress of disease seen in Fig. 140 523 142. Diagram showing advanced stage of cancer 524 143. Serrated irrigating curette 526 144. Microscopical appearance of normal endometrium 528 145. Microscopical appearance of cancerous endometrium 529 XVI LIST OF ILLUSTEATIOXS. FIG. PAGE 146. Advanced stage of cervical carcinoma witli formation of pyometra .... 534 147. Cervical carcinoma with cervix exposed for curettage 534 148. Spoon-handled scoop curette •. . . 535 149. Loop curette for use in cancer 535 150. Open-air cystoscope 550 151. Manner of introducing open-air cystoscope 551 152. Cystoscope in place 551 153. Manner of inspecting interior of bladder through head-mirror 552 154. Suction apparatus for treatment of cystitis 553 155. Dickinson's two-way catheter 559 156. Metliod of irrigation of bladder 560 157. Metliod of continuous irrigation of bladder 563 158. Diagrammatic representation of the displacement of abdominal organs in splanch- noptosis 598 159. Gauze record of marked displacement of stomach 601 160. Showing throe degrees of displacement of kidney 607 161. Gauze record of displacement of right kidney . . 617 162. Diagram showing nodule of ovarian tissue remaining after removal of ovary and causing menstruation 628 163. Diagram showing results of condition seen in Fig. 162 629 164. Pyokolpos and pyometra due to complete stricture of the vagina .... 639 165. Hegar dilators . 640 MEDICAL GYNECOLOGY. CHAPTER I. CONSULTING ROOM AND GYNECOLOGICAL EXAMINATION. (1) Consulting room: Reception room, p. 1. Office arrangements, p. 2. History taking, p. 3. (2) Gynecological examination: Instruments, p. 5. Preparation of patient, p. 6. Examining table, p. 6. Abdominal examination, p. 6. Examination of stomach, p. 9. Vaginal examination, p. 10. Bimanual examination, p. IL Gauze records of abdominal tumors and displaced viscera, p. 17. Inspection, p. 19. Leucorrhea, p. 20. Examination in knee-breast position, p. 23. Sims position, p. 23. Examination in children, p. 25. Examination standing, p. 26. Examination under anesthesia, p. 26. Examination of virgins, p. 27. Pain as a symptom in examination, p. 27. Notes of examination, p. 29. (3) General principles of treatment: Outlining course of treatment, p. 30. Hygienic rules, p. 30. Palliative treatment, p. 31. (4) Examination by rectum, p. 33. THE CONSULTING ROOM. The general practitioner who intends to practise gynecology ought to devote the best space on the first floor of his house to the reception of his patients. Whenever it is possible he should arrange for three rooms : a reception room; a consulting room, where he meets his patients and takes their histories; and an examining room with its paraphernalia, where the patient can prepare for the examination and dress in comfort afterwards. The reception or waiting room ought to be cheerful, sunny, and clean; simply and attractively furnished, and well supplied with current light lit- erature to beguile the period of waiting. Time is well spent in exercising ingenuity and taste to secure articles of furniture and wall decorations which show marked individuality. Unfortunately, not everyone realizes how impor- tant it is that the first impression made upon the patient should be a pleasant one, tending to inspire confidence in the physician to whom the patient is about to confide the most important interest in life, her health. A cheery kindly wife, a pleasant secretary, and even a bright-faced maid are all assets of much value in helping to hold a nervous impatient patient. It is a serious mistake to put an office in a basement in order to get it out of the way or to avoid sacrificing the family parlor ; on the other hand, nothing is more dreary than the use of the family sitting room for such a purpose. Moreover, patients are never favorably impressed by an introduction to family portraits in crayon, nor by the cheap, gaudy pictures and startling plush furniture which are so common everywhere. Everything about the reception room should express 2 1 COXSULTIXCt room AXD gynecological EXAMIXATION. seriousness of purpose, taste, and dignity. In other words, the physician should consider what object lesson his office shall teach to his Avaiting patients. It is also a mistake, I feel sure, whenever it can be avoided, to force patients to go to a large office building, use a common elevator, and wait in groups on benches, among the patients of other doctors. Such herding of the suffer- ing and the sorrowful robs life of its refinement. Again no one material quality in these days teaches such important spir- itual lessons and appeals to patients' higher instincts more than scrupulous cleanliness in their surroundings. A bright clean reception room and a spot- less examining room are instantly accepted as guarantee that the physician himself is a votary of the modern doc- trine of antisepsis and carries it out in all his practice. O O, Con s Lilting Room nece ption O Fig. 1. — A Simple Form of CoxsTn^TiXG .\2st> Re- CEPTiox Room. The examining table in the consulting room is placed conveniently to the light which falls on the back of the operator as he sits at the foot of the table; this corner of the room is screened off. Fig. 2. — Aeraxgemext -stith Examixixg Room Separated from the Coxsitltixg Room. The patient arranges her clothing behind the curtain indicated bv the waw lines. A simple office arrangement is shown in Fig-ure 1 in which, when space is limited, a portion of the consulting room is utilized as an examining room. A somewhat more elaborate arrangement is shown in Figure 2, including a reception room, a consulting room, and a separate examining room. The toilet arrangements in the examining room are placed at one end and behind curtains. When more elaborate arrangements still are necessary, I recom- mend the scheme in use in my own suite of apartments. There is first a large reception room, while adjoining that is the room where the secretary and typewriter have their desks; the consulting room is next to this, and behind HISTORY TAKING. 3 there are three examining rooms. Washing and toilet facilities are provided in a sejDarate apartment. Such an arrangement facilitates thorough work for the specialist whose time is precious and provides for the occasional patient who has to rest before leaving the house. A nurse should always be on hand, if possible, to receive the patient and prepare her for examination, as well as to render any assistance required after- wards. She should be dressed in a regular nursing costume, with a scrupu- lously clean cap and apron, and she ought to be a woman of digTiified appear- ance, preferably not too young. ISTothing so serves to tone the patient up for the ordeal of an examination as a nurse of the right kind ; indeed, she will in many instances be able to hold on to a patient who thinks of leaving the physician for another. If she has training and ability, she will often learn in time to give material assistance in investigating a case by emphasiz- ing to the doctor the matters of complaint and directing his attention to those issues which seem paramount to the patient. The j)hysician should ever meet his patient with courtesy and a warm personal interest ; showing by his manner that he esteems it a high compliment that she has been willing to entrust him with the care of her health. History Taking. — There are three ways of taking a history: (1) to fill in an outline, such as that given in the text, and then to add the special mat- ters complained of; (2) to let the patient ease her mind by first telling all her troubles, after which the outline is filled in ; or ( 3 ) a combination of these two methods, by listening and asking occasional questions. ISTo one way suits all cases. If a patient is nervous and distressed, a few routine questions directed in a kindly reassuring manner, will serve to give her time to collect herself and set her at ease. If she has her ailments much on her mind, and is impatient to pour them out, it will be best to let her talk freely at first, and then to fill in the outline afterwards. In each instance a general outline should be filled in and the history should be written down. After the name follows the residence, age, social state (married or not), and if married, how many children, miscarriages and labors, as well as the character of the men- strual period, as to regularity of intervals, duration, amount of flow, and pain. The occurrence of leucorrhea should then be noted. I think it is best, as a rule, at about this juncture to let the patient tell her own story briefly in her own words, interrupting occasionally if she becomes prolix or wanders off to unimportant details. While the patient is talking, the physician jots down his notes, taking up the line of her suggestions from time to time and asking more particularly and specifically regarding the nature of certain com- plaints. Having in this way secured a complete history, the outline is further filled in by suitable questions relating to all the other important organs in the body, including headaches, backache, digestion, regularity of the bowels, urination, etc. I find it an excellent course, while taking the history, to under- line important facts ; for instance, if the patient has it very much on her mind that she has no children, I write the word sterility and underscore it. 4 COISrSULTING BOOM AND GYNECOLOGICAL EXAMINATION. Date Diagnosis Name Occupation Par Instr. deliv. Menstr. Hist. S TV M age Resides Mis Le Complains now of the following symptoms Hist, of development of present condition Patient of Dr fever Gen. previous hist. rheum. fevers., ere. Family Hist: Husband. Physical Exam, of Pelvis and Abdomen. Vag. Outlet Vagina Cervix Uterus Uterine tubes and ovaries Gen. appearance JVeight Headaches Pack ache Sleep Appetite Digestion Powels Urination Urinay-y Anal. Pladder Rectum Kidneys Sketch Outline of Treatment to be followed INSTRUMENTS FOR GYNECOLOGICAL EXAMINATION. 5 If she has severe headaches, I underscore that word, and so on. If she has been told elsewhere that she has a tumor, I underscore the word. By thus underlining several catch words, the physician is not liable in the subsequent examination to overlook any ailment which the patient has much on her mind. I sometimes find it helpful, as I take a history or make an examination, to note down in a short column, one below another, the special complaints as well as any suggestions that occur to me as to lines of treatment to be carried out. It is a good plan to fill out some such outline as shown on the opposite page in each case. THE GYNECOLOGICAL EXAMINATION. After taking the history, the next step is the physical examination. It is always important to bear in mind the purpose of such an examination, and to remember that especial care must be taken to discover the cause of the patient's discomfort or suffering. In making a gynecological examination it is necessary to bear in luind that the investigation of the pelvic organs is always a trial and source of distress to the patient who is not an habituee of the office. For his own sake as well as for the patient's, and as a mark of the respect which he owes to all womankind, the physician will always carefully protect the patient and avoid all undue exposure. The methods of examina- tion in this country and in Great Britain have thus far ever been charac- terized by a modesty and a consideration for the feelings of the patient which do honor to our profession. When that sense of modesty becomes blunted, our specialty will have taken a lamentable and a distinctly retrograde step. Great care should also be taken not to expose a patient even when she is under anesthesia and unconscious, during preparation for an operation. The first examination should include a consideration of every important organ of the body. The physician must never forget that a large percentage of his patients have other ailments than those which are covered by gyne- cology. The condition of the chest must be looked into, and inquiry made into a history of tuberculosis, pleurisy, or any form of heart disease. After a survey of the other organs, the physician concentrates his attention upon the abdomen, which must be studied from thorax to pelvic diaphragm with extreme care. Instruments, — The few instruments necessary to the gynecological arma- mentarium in the examining room are: Sims' speculum, ITelson trivalve specula, 2 sizes, large and small, Kelly cylindrical speculum, with long handle, for use in the knee-breast position. Dressing forceps. Tenaculum. Uterine sound. 6 constjltijstg eoom and gynecological examination. Traction or bullet forceps. Packer. Applicators. Scarifier. Cotton and wool i^ledgets, of various sizes. I^itrate of silver solutions of varying strengtlis, from 5 to 40 per cent, in 2 oz. bottles of amber glass. Borogiycerid, 6 oz. Metal instruments are best sterilized in a fisb-kettle by boiling in a 1 per cent solution of sodium carbonate for five minutes. After every use tbe instru- ments should be washed with soap and hot water and re-sterilized. There is great risk of spreading gonorrhea and even syphilis by the use of contaminated instruments. An ordinary washing or rinsing in hot water does not serve to render an instrument sufiiciently clean for use. After sterilization all the instruments should be placed in an orderly manner on a clean towel, laid on a white porcelain ware tray, and covered with another towel so as not to offend the eye of the patient. The physician ought to wash his hands briefly witH soap and water and a scrubbing brush before each examination, and thoroughly immediately after it is over. A sample of urine should, as a rule, be secured as part of the examination. The most satisfactory specimen is that which is taken by a nurse, after cleansing the orifice of the urethra, with a sterile glass catheter, having a piece of rubber tubing six inches long on the outer end, which serves to convey the urine into a sterile test-tube. Preparation of the Patient. — The patient should be prepared for the exam- ination by removing all clothes, baring the abdomen from thorax to symphysis. She ought always to remove her corsets. The physician ought not to consent to attempt an examination hampered, for example, by a union suit of under- wear or by corsets. If the patient deems her condition serious enough to compel her to apply to a physician for examination, it is at least worth her while to offer him the best possible opportunity to make his examination with thoroughness. The best examining table is a simple rectangailar structure, like a big box with drawers or like a kitchen table, upholstered with leather or covered with a folded blanket and clean sheets (see Fig. 3) ; two supports, projecting about eight inches from the foot of the table, support a crossbar which may be notched so as to catch the heels. The under part of the table may be con- veniently supplied with drawers and utilized for holding linen, supplies, etc. The measurements of the examining table that I use are: Leng-th forty-five inches, breadth twenty-four inches, height thirty inches. I prefer a table of this kind to the various examining chairs advertised, although I began my work with a chair. Abdominal Examination. — The examination is first made with the patient lying on her back. If the examiner's hands are cold, they should be immersed ABDOMINAL EXAMINATION. / in warm water, after which the abdomen is palpated. It is my custom, and I think it is the best plan, first to feel the upper abdomen, running the hand across it and making pressure at several points, to make sure there are no undue prominences, or areas of tenderness, resistance, or fluctuation. I then examine the right hypochondrium, and if no resistance is felt, use both hands, pressing deeply into the right flank and feeling for the kidney. If this is not discovered at once, I tell the patient to breathe deeply, and this may bring it down between the fingers. Sometimes with the 1 Fig. 3. — ^The Gynecological Examining Table. The top is covered with leather, well padded, on this is placed a blanket covered with a linen sheet. A drainage cushion is serviceable in protecting the table from contamination from discharges. In my office I sometimes use a much smaller cushion than that shown in the figure. The drawers serve for the storage of clean linen, towels, dressings, pessaries, etc. fingers pressing in deeply from behind and from the front simultaneously, a wedge within is felt, as the patient takes a deep breath, descending from under the ribs, entering the angle and pressing the fingers gently apart; with the act of expiration, the wedge retires back under the ribs again. In this way, the lower pole of the kidney can often be felt. With a deep inspiration it descends until it is felt as far as the renal notch, the second degree of displacement; or again, it slips down entirely below the fingers, which now lie above the upper pole, when the descent is one of the third degree. If the kidney cannot be felt in this way, it can sometimes be found by raising the head and shoulders and letting the patient lie on the left side, when the intestines drop away from the side under examination. On sitting up and leaning forward, or on standing up and leaning forward, a loose kid- 8 COXSULTIXG KOOil AXD GYISrECOLOGICAL EXAMII^-ATION. ney can often be felt to best advantage; sometimes a markedly displaced kidney becomes evident only after the patient has been walking about a great deal just before the examination. The edge of the liver at times feels sur- prisingly like a kidney, but, as a rule, the sharpness of the edge serves to Fig. 4. — Piezometer Used to Register the Depth and Amount op Pressure Made. It is also A Paix Index. distinguish the liver. In thin patients, a distended gall bladder can often be felt, hanging pendulous into the abdomen from beneath the margin of the ribs. It is best to complete the examination of all the other abdominal organs before examining the stomach. ABDOMINAL EXAMINATION. 9 The way to outline the stomach is to give a teaspoonful of the bicar- bonate of soda dissolved in a small glassful of water, following this at once with a teaspoonful of tartaric acid in a like amount of water. The patient must drink lying down, and she must resist the impulse to belch up the gases which at once begin to distend the stomach visibly under the abdominal wall. This examination is best put last. The colon and the vermiform appen- dix are next palpated. If the patient complains of any tenderness or there is any reason to suspect ajDpendicitis, a good way to compare the relative tender- ness on the right and on the left sides is to use a piezometer (see Fig. 4), it' ^'t "\ Fig 5 Deviation of the Sigmoid Flexure. The bowel crosses the promontory of the sacrum on the right side, then returns to the left pelvic brim, and drops into the pelvis just behind the uterus. which is designed to register accurately the amount of pressure necessary to produce pain, as well as to record the resistance, by means of the depression made in the abdominal wall. The piezometer consists of a spiral spring in a hollow cylinder within which travels a piston ending in a button. If the button is pressed into the abdominal wall, the amount of pressure made is measured on an index, while the depth to which the button depresses the wall is measured by a wheel which slips freely up and down the shaft of the piston. The sigmoid flexure is palpated to discover any accumulations of fecal matter (see Fig. 5). The pelvis is palpated above the symphysis, by mak- 10 CONSULTING EOOM AND GYNECOLOGICAL EXAMINATION. ing pressure inwards towards the pelvic floor and noting any areas of resistance or any tender spots. Vaginal Examination.^ — The pelvic organs are next examined by the vagina, (a) by touch and (b) by insi^ection. In making such an examina- tion, the points to be noted by inspection are : (1) Changes in position (displacements). (2) Peculiarities of form, size, or consistency, such as are produced by inflammations or tumors. (3) Alterations in sensibility. By touch the finger may recognize a lax, everted condition of the vaginal orifice, often found after multiple childbirth. The vaginal walls are next examined and may be found rugose and in their normal condition, or often, as in women who have borne many children, flaccid, smooth, and pouting. We thus note at once by touch whether or not the vaginal orifice is tightly Fig. 6. — Bimanual, Examination by Vagina and Abdomen. The index finger of the right hand and the index, middle, and third fingers of the left hand are easily brought close together and used to question the structures lying between them. closed, and whether the vagina occupies its normal relations to the pelvic floor, as it stretches back over the floor of the pelvis to the cervix which lies in the sacral hollow, or whether, on the other hand, the orifice is broken down and VAGINAL AND BIMANUAL EXAMINATION. 11 the tissues are pouting, forming what has been appropriately called a sacro- pubic hernia (Berry Hart). The examining finger also notes carefully a cervix in descensus, that is to say, lying low down in the vagina, perhaps just behind the symphysis pubis, and the cervix in its normal position well back in line with the ischial spines. The form and size of the cervix are noted. The conical cervix, with a rounded hard surface, is readily distinguished from the fissured, infiltrated cervix, or a friable cervix converted into a cauli- flower mass by malignant disease. If there is much vaginal discharge, it is well to wear ^ thin glove in order to protect the hand during such examina- tions, and avoid even the slightest risk of carrying over an infection to the next patient, perhaps a woman in labor. Fig. 7. — Bimanual, Examination of the Uterus. The upper hand indents the walls of the abdomen and rests upon the fundus while two fingers of the lower hand, introduced into the vagina, rest upon the cervix. Palpation in this way reveals the size and form of the uterus. Bimanual Examination. — The examiner next investigates the condition and positions of the deeper pelvic organs by using his free hand through the abdominal wall to press down through the superior strait and act conjointly with the vaginal hand (see Figs. 6 and 7). A bimanual examination reveals the exact position of the uterine body, whether inclined for- ward in normal anteposition, or backward in retroversion or retroflexion. Then, displacing the uterus to the riglit or to the left, the condition of the uterine tubes and of the ovaries is investigated. If there is a simple enlarge- 12 CO:^rSULTI]^G EOOM and gynecological EXAMINxiTION. ment, it is easily detected as shoAvn in the figure; an enlargement associated with adhesions is recognized as a more or less immovable mass to one side or other of the. body of the uterus. During the bimanual examination, the mobility of the organs is tested. The question must be asked and answered whether the uterus has its normal play, and whether or not the ovaries are free. This question of mobility of the uterus becomes a matter of the utmost importance in dealing with cancer. When a cancer is found in the cervix, the first important query is this: Has the disease extended beyond the uterus into the broad ligaments in the direction of the pelvic wall? The answer to this inquiry is found by attempting to throw the uterus up and down in the pelvis thus performing a sort of ballottement with it; if it feels fixed or hinged on one side, this, as a rule, constitutes a contra-indication to a radical operation. It must never be forgotten, however, in seeking to give the patient the benefit of every reasonable doubt, that the fixation may be Fig. 8. — BmANUAL Examination by Rectum and Abdomen. It is easily seen from this figure to what depth the index finger of the left hand can be carried into the rectum, in this way reaching the posterior surface of the uterus and both tubes and ovaries. effected by inflammatory and not by cancerous infiltration, and that it may also be due to an inflamed, adherent tubo-ovarian mass in one or both sides. The clearest approach to the pelvic organs above the vaginal vault is by the combined rectal and abdominal examination (see Fig. 8). The uterus, tubes, and ovaries are felt in this wav with the utmost distinctness. BIMANUAL EXAMINATION. 13 Before -witlKlrawiug the finger from tlie vagina, tlie bladder is palpated through the anterior vaginal wall, and the little delicate ureteral cords are felt, stretching from the position of the internal ureteral orifice around the pelvic wall to the side of the cervix in the lateral fornix above ; the normal ureters are always quite small, freely movable cords. Any enlargement, or thicken- FiG. 9. — Trimanual Examination Showing the Index Finger in the Rectum Palpating the Posterior Surface of the Uterus while the Thumb of Same Hand Locates the Position OF and Fixes the Cervix. ing, or irregularity indicates disease of the ureter and of the kidney on the same side. By thus discovering a thickened ureter in a case of pyuria, a diagnosis of tuberculosis of the kidney can often be made within a few seconds. Such a diagnosis must, of course, be confirmed by further topical examination and by urinary analysis. If the uterus is inclined to slip from under the examining finger in the ordinary recto-abdominal examination, it is sometimes a good expedient to fix the lower pole of the uterus with the index and middle fingers in the rectum, at the same time carrying the thumb into the vagina (see Fig. 9), and so locating and fixing the cervix; making a sort of tri- manual examination, in which the uterus sits poised, as it M^ere, on the 14 cojstsulting room and gynecological examination. fingers and thumb of the hand operating throngh the inferior strait, while the upper hand, palpating through the abdominal wall, examines the body Fig. 10. — Beviantjal Examixatiox Showij^g the Method of Palpating and Distingthshtng a Fibroid Tumor on the Posterior Sl'Rface of the Uterus. of the uterus on all sides. (The method of examining the bladder is given in Chap. XXII.) "When any enlargement of the intrapelvic structures is felt during a bimanual examination, the fundamental question to be answered is whether the growth is uterine or ovarian? A uterine tumor (see Fig. 10) can be best outlined in a combined rectal and abdominal examination, as shown in the figure. The uterine growth Fig. 11. — Bimanual Examination Showing the Method of Detecting an Ovarian Tutmor Lying Back of the Uterus and Displacing it Forward. BiMANtfAL EXAMINATION. 15 is in this way felt to be continuous with the uterine wall, from the cervix up on to the growth and from the fundus down over its convexity. In moving the uterus the enlargement at once moves with it, and there is, as a rule, no appreciable interval between the two. The tumor is then uterine. In such a case as that shown in the figure, the next question is whether the uterus is in anteflexion with a tumor imbedded in its posterior wall or whether it is in retroflexion with the tumor growing from its anterior wall. This question is usually easy to answer, as a uterine tumor, which is practically always a fibroid, is denser than the nor- mal uterus, has a more rotund form, and is often nodular; furthermore, a Fig. 12. — The Examiner is Engaged in Outlining the Enlarged Uterus or Other Pelvic Tumor. The outer limits of the tumor are marked out in a series of dots with the aniline pencil as seen in the figure. minute handling of the mass frequently shows just a little play of motion between the uterine body and the tumor. The relation of the normal ovaries to the uterus also serves to mark out the uterine body. The uterine sound carried up on to the uterus gives the direction of the cavity at once, and shows whether it is in front of or behind the uterus. An ovarian tumor (see Fig. 11) usually lies more or less lateral to the uterus, and is distinctly fluctuating, while there is also a well defined interval between the tumor and the womb. Palpation of the smaller struc- tures about the tumor with careful attention sometimes reveals its connection with the uterus by the ovarian ligament. If the uterus is then caught with a GAUZE KECOEDS OF ABDOMINAL TUMOKS AND DISPLACED VISCERA. 17 tenaculum forceps and pulled down towards the vaginal outlet, there is at first an indistinct movement on the part of the uterus, followed by a more tardy communicated movement on the part of the tumor. If the tumor is pushed upward in the direction of the umbilicus, the uterus, as a rule, does not follow it at once. An additional point in favor of an ovarian tumor is the discovery of a normal ovary on one side, while on the opposite side the ovary cannot be felt, its place being taken by a cystic tumor. Gauze Records of Abdominal Tumors and Displaced Viscera.- — I have found the method about to be described of the utmost value in making permanent records of my cases of abdom- inal tumors and misplaced organs, such as stomach and kidneys; and it is one I would earnestly recommend to ^practitioners at large, who can easily, with a little prac- tice, acquire the slight degree of skill necessary to make the tracings. There are several reasons wdiy this method of studying cases is important. In the first place, it is con- ducive to a more careful ex- amination and palpation of the tumor. It requires more time than an ordinary inves- tigation and therefore is of advantage to both operator and patient. Again, the de- liberation necessary is justly calculated to impress the pa- tient with the fact that the ex- amination is being made with that extreme care and pains- taking attention to the more minute as well as the large features of the case which a grave situation demands. The first step is to make an outline of the tumor by means of a series of dots on the surface of the skin with an aniline pencil, while the bimanual examination is being made (see Fig. 12). If the marks are not easily made on the skin, it will be sufiicient to wet the surface with a little alcohol. By giving the fingers a little vibra- tory movement, as shown on the left hand in Figure 13a, the outlines of the cyst or tumor are more delicately appreciated, since each slightest thrill is com- municated to the vaginal fingers resting on the lower pole of the growth. After ->%- .. i J Fig. 14. — After the Examiner has Outlined the Tumor ON THE Skin in Aniline and has Marked Out such Landmarks as the Anterior Sxtperior Spine, the Symphysis and the Margin of the Ribs, He then Lays a Glass Plate on the Abdomen, Covered with THE Transparent Material on which He Registers the Markings on the Skin, easily seen through the Glass. A crayon or carbon pencil is better for this purpose than an aniline pencil. 18 CONSULTING ROOM AND GYNECOLOGICAL EXAMINATION. the tinnor lias been dotted out in outline and the dots have been connected by a continuous line, the landmarks of the abdomen, as the symphysis, the anterior superior spine, and the margins of the ribs are outlined with aniline (see Fig. 136). The next step is to make a transfer of the record on the abdomen Fig. 15. — Shows a Permanent Record of an Ovarian Cyst and the Outlines of the Abdomen. The little figure in the lower right-hand corner shows the relation of the uterus to the tumor, the symphysis lies below. to a piece of stiffened gauze material ( Suisse, nainsook, or organdie) laid over the abdomen upon a glass plate as shown in Figure l-i. The skin markings are all visible through the glass, and it is an easy matter to reproduce them INSPECTION. 19 with a crayon pencil as tliey are projected npon tlie gauze, which is carefnlly held immovable while the transfer is made. The appearance of such a gauze record is shown in Figure 15. The record is then filed away to serve as a literal transcript of the case in lieu of an ordinary diagrammatic sketch, or for future comparison, in case the patient returns at a subse- quent time and it is im- portant to know whether the tumor has grown or not. In using the record to test the growth or change in position of the tumor, an entirely fresh record should be made at the sec- ond visit, independently of the first one. Then the two gauzes should be laid one on the other, when any difi^erence in size is easily appreciated. For the sake of dem- onstration I give a photo- graphic copy of the gauze record of a fibroid tumor (see Fig. 16). I have a large number of these rec- ords which not only serve the purposes indicated, but are most valuable in teaching as well. Inspection. — The examiner next proceeds to inspect the vulva, the vagina, and the cervix. A broken down or gaping vulvar orifice is often a most conspicuous object. The vulvovaginal glands (Bartholin's glands) should be' examined, as they are sometimes the seat of chronic gonorrheal infec- tion. By squeezing the external urethral orifice, a lingering infection at that point is brought to light in the form of a little drop of pus exuding onto the surface. A cystocele and a rectocele are formed by the walls of an everting vagina, associated with a descent of the uterus. The upper vagina and the cervix can sometimes be seen in these cases by simply pulling back the peri- neum with two fingers. For making a specular examination of the vagina, I like best on the wdiole a trivalve speculum (JSTelson's). This is easily intro- duced by drawing back the posterior wall of the vagina with one or two fingers, at the same time slipping the well-oiled blade into the vagina, pressing a little backward so as not to impinge upon the urethra or strike the pubic arch. The position of the cervix having been located by the finger, the end of the speculum is directed downward and backward, so that when it is opened, the Fig. 16. — A Photographic Copy of a Gauze Tracing made in THE Case of a Large Fibroid Tumor of the Uterus. The name and clinical data attached to the corner are omitted. 20 CONSULTING EOOM AND GYNECOLOGICAI, EXAMINATION. cervix lies plainly in view between the three blades (see Fig. 17). The color of the vagina is noted, and any discharges found are spread out on a slide for microscojjic examination. When there is much leucorrhea, a large infil- FiG. 17. — Exposing the Cervix Uteri and the Vatti^t of the Vagina through the Nelson SPEcuLmi. trated cervix is often found pouring out a tenacious, mueo-purulent material (endocervicitis). This is the common sign of a chronic gonorrheal infection, or of a simple chronic cervical infection following childbirth. The condition is not a sign of endometritis farther up. Leucorrhea. — ^\Vhen a patient complains of leucorrhea, it is always im- portant to determine the source of the discharge. As a rule, it is either vaginal or cervical. Cervical discharges may come from the mucous lining of the cervical canal from the external up to the internal os. A dis- charge from the uterine cavity (endometritis) is rare; I declare this in direct opposition to the commonly received opinion. The vaginal is readily distinguished from the cervical discharge by its more milky, thin, and uniform consistency; in pregnancy it may be of a curdy character. The cer- vical discharges, on the other hand, are always stringy, mucoid, or muco-puru- lent. In a doubtful case it is sometimes a good plan, after cleaning out the vagina, to prove the source of the vaginal discharge by placing a tampon in LEUCOKKIIEA. 21 the vagina, adjusting it carefully to the cervix and vaginal vault. The patient should then keep quiet for a few hours, when the tampon is carefully removed and inspected. If the discharge is vaginal, the whole tampon is wet; if it is cervical, the accumulation is more in a little pool in the depression made by the cervix (Schultze's method). I hear a great deal in correspondence with physicians in different parts of the country and from patients who come for treatment, of " ulcerations " and " erosions of the womb." To most women, " ulceration " is a grave, well nigh incurable malady, accountable for all sorts of lower abdominal aches and pains and general ill health. It is important to call the attention of the pro- fession to the fact that ulceration of the neck of the womb is an extremely rare ailment, which not one physician in five hundred has ever seen. The condition called ulceration is, as a rule, an ectropion of the cervix, commonly 1 S. TlIK KXKK-T|-RF,AST PoSTTTI?K. CTVTKG A PERFECT ExPOSTTRE IN EXAMINING ANY OF TITF IToLI.OW Pelvic Viscera, the Rectum, the Vagina, or the Bladder. Note the approximation of the chest to the table, the spreading out of the elbows, and the direction of the face to one side, as well as the slight incurvation of the back. The patient should be at rest and feel well supported in this posture. Most cases do well with the thighs at an angle of about 65 degrees to the body as shown here in the figure. In other cases a better exposure is secured when the thighs are vertical and the angle is about 50 degrees, while in a few others still the relaxation is best when the thighs are drawn up a little under the abdomen and the angle is about 40 degrees. associated with laceration. It does not demand treatment, unless there is at the same time an infection of the glands causing the discharge of a muco- purulent secretion. Anything causing congestion of the cervix, or a swelling up of its mucosa, will cause the cervical mucosa to roll out into the vaginal Fig. 19 — ExjoniN-ATTOX zn" Kxee-breast Posttee shotvixg ^Iethod of Lifttxg up Glttteai-s axd Posterior Vagixai, Wall thts Lettln'g Air rxro the Vagin^a foe the Lsteoductiox of the Speculttm or the Examixatiox of the Bladder. Fig. 20. — ExA^r^^■ATIo^" of the Vagina, "S'agixal Vatt-t, axd CER^•IX ix the Kxee-breast Posture A^^TH the Kelly Ctlixdrical !Metal Speculum haatxg a Stout Haxdle. 22 EXAMINATION IN" KNEE-BEEAST POSITION. 23 surface, where it appears as a dark red spot surrounding the os; but this is not a laceration or an erosion. Treatment of this condition, as a rule, is misapplied. Examination in the Knee-breast Position. — An examination in the knee- breast position (see Fig. 18) is often of the utmost service in exposing every part of the vagina, with the cervix, to view. This posture is of the greatest utility in applying treatments to the inflamed vaginal walls, as the rugse are Fig. 21. — Examining the Vagina in the Left Lateral Position. The upper buttock is raised and the speculum slipped into the vagina. The posterior wall is then retracted so as to expose the interior. thus all smoothed out and the vagina appears as a broad, smooth surface. A good way to let air into the vagina before introducing the speculum is shown in Figure 19. The examination is then best made by means of the writer's cylindrical metal speculum, with a large handle, as shown in Figure 20, which exposes every part and protects the vulvar orifice when treatments are given. The Sims' position (see Figs. 21 and 22) is one in which the patient lies semi-prone, with the right leg drawn a little above the left, and with the left arm behind the back or hanging over the edge of tlie table. The posture assumed is one in which, if the abdomen were opened, the pelvic viscera would be poured out onto the table. The pelvis must be so disposed at the edges of Fig. 22. — Inteodxjcing a Cylindrical Metal Speculum with a Stout Handle for Examination AND Treatments in the Sims' Posture. Fig. 23. — Patient in Sims' Posture Exaggerated by Decided Elevation or the Foot of the Table. The figure also shows the method of pulling apart the buttocks and letting air into the vagina to facilitate the introduction of the Sims' speculum. 24 EXAMINATION IN CHILDKEN. 25 the table as to afford a convenient view of the parts when the speculum is inserted, with the perineum retracted and the vagina ballooned out with air. If the table is elevated as shown in Figure 23, the distention of the vagina is greater and a better view is often afforded. Examination in Children. — The examination of a child suffering from a vaginitis is always easiest to make in the knee-breast position, as it causes no pain, and affords a perfect exposure of the entire vagina and the cervix, impossible by any other method (see Fig. 18). To make the examination entirely painless, the nurse should slip a little pledget of cotton attached to a thread saturated with a ten per cent solution of cocain just inside the Fig. 24. — The Examination of a Child about Six Years Old, sho"wing the Facility with which THE Entire Pelvis can be Palpated by a Bimanual Rectal and Abdominal Examination, Owing to the Relatively Large Size op the Examining Hand. hymen. Then after five to ten minutes the little patient is put in the knee- breast posture and the cotton removed, when the vesical speculum Ko. 10 is introduced and the vagina at once balloons out and can be seen in all its parts by a reflected light. It is usually easy, without the knowledge of the child, to apply a thorough treatment, say a five to ten per cent solution of nitrate of silver, to all parts of its walls, or to insert a small medi- cated tampon, saturated with, say, thirty per cent to fifty per cent solution of argyrol, attached to a fine thread, by which it can be withdrawn in six to twelve hours. 26 CONSULTI^^G KOOM iVNB GYNECOLOGICAL EXAMINATION, When it is necessary to make a careful examination of the pelvic organs in a child, it is always best to do so at one sitting and to make the examination thorough by giving an anesthetic. A few drops of chloroform is all that may be necessary to relax the little patient completely. The examination should be made as shown in Figure 24, through the rectum and lower abdomen, and never through the vagina. The ex- treme simplicity as well as the facility of such a bimanual recto-abdominal examina- tion is readily appreciated upon noting that the hands of an adult are relatively much larger in proportion to the pelvis of a child than to that of an adult. For this reason the pelvic organs in a child are all easily within reach of the bi- manual touch. When an ovarian tumor is found in a child, it is usually sarcomatous and de- mands careful handling on account of its friability, as well as ]3rompt removal on account of its liability to become dissem- inated. A large ascitic accumulation in a child (see Fig. 25), in the absence of any other evidence of grave disease, is apt to be tubercular, especially in the col- ored race. A large tumor springing from one side and more or less filling the pelvic abdomen, is soft and fluctuating, but not within the peritoneal cavity, is generally a sarcoma of the kidney. Such tumors have been observed in children of very tender years. Examination Standing. — It is important, where the patient has a descensus, or other displacement of the pelvic organs, to examine her in the erect posture, as she stands before the examiner with one foot on a low stool. In this way marked differences between the organs in the dorsal and in the vertical position are often found. Examination under Anesthesia. — It often happens that the ordinary digital and bimanual examination leaves a doubt as to the condition of the deeper pelvic organs, the position and condition of the body of the womb, the uterine tubes, and of the ovaries. Under these circumstances it is always best to request a more complete and a deeper examination, with the patient completely relaxed by an anesthetic. By this means entire relaxation is secured, and the resistance which tlie patient often cannot control on account of pain, is done away with ; while at the same time, the uterus itself can, under anes- FiG. 25. — A Case of Tubercular Peri- tonitis IX A Colored Child abou't NixE Years of Age. Note the rotund, ovoid, distended abdomen manifestly due to an accumulation of fluid in a child not too ill to be about. EXAMINATION OF VIRGINS. 27 tliesia, be drawn well down to the vulva and so made much more accessible to touch. Before making an examination under anesthesia, the bowels should be well opened, and the stomach empty. It is a good rule to have the patient rest a day or two afterwards. The best anesthetic for such a pur- pose is nitrous oxide gas. The gas can be given and the examina- tion made within three to five minutes; consciousness follows at once, and there is no distressing nausea or depression afterwards. Sometimes after starting the gas, the patient is stertorous and does not relax; a few whiffs of ether combined with the gas then serve to produce entire relaxation, after which the gas alone is continued. It is possible, if it is necessary, for a patient to get up within a few minutes after such an examination and go home. Examination of Virgins. — Young unmarried women ought, for decency's sake, always to be examined for the first time under an anesthetic; in this way their feelings are spared the shock and the distressing ordeal, and the examination made is complete and satisfactory, an exception under such cir- cumstances without an anesthetic. It is always well to secure permission at the same time, if only a slight operation is required, such as a dilatation for dysmenorrhea, to proceed with it at once, to avoid giving an anesthetic again. The empty rectum is the one important avenue of approach in making a deep investigation under an anesthetic. The finger should be carried well above the cervix uteri, through the valves, until the posterior surface of the uterus and of the left broad ligament are plainly felt. Too much force must not be used in palpating; I have known several instances in which the rectal wall has been perforated by an examining finger, compelling the examiner to suddenly and unwillingly turn surgeon, open the abdomen, and sew up the rent. Pain. — When a patient comes with a complaint of a definitely located pain it is most important for the physician, in the course of his examination, to discover which organ is causing the suffering and then, by gentle pressure or manipulations, to try to reproduce the pain so that the patient may feel con- vinced that the source of her discomfort has been located, for if she can declare with conviction that the pain aroused is exactly the same pain, felt in the same spot, he will secure her hearty cooperation in following any rational plan for her relief. Patients sometimes complain of pain in the pelvis, when a careful examination shows that no abnormality can be detected in any organ. Here, as a rule, the pain is complained of whenever any part of the pelvic peritoneum or any pelvic organ is squeezed slightly betwe'en the fingers of the two hands. If this fact is carefully noted and remembered, many unneces- sary, often mutilating operations will be avoided. When intermittent attacks of pain arc complained of, unless the examiner can dis- tinctly reproduce tlie pain or touch the very spot, the patient ought to be kept under observation until a typical attack comes 28 CONSULTING ROOM AND GYNECOLOGICAL EXiVMINATION. on. The physician should be called, by day or night, to make a careful investigation as to the exact character of the attack and the site of the sensi- tiveness. If he has had much experience, he will very often be able to say at once " the attack is one of renal colic," or " it is undoubtedly due to gall stones," etc. The right side of the abdomen is peculiar in that we find there a chain of at least five organs, beginning at the margin of the ribs and extending down to the pelvic floor, and some of the morbid conditions affecting these organs are liable to be mistaken one for another. These organs are: the gall bladder, the right kidney, the cecum, the vermiform appendix, and the right uterine tube and ovary (see Fig. 26). It might at first sight seem impossible that anyone familiar with abdominal diseases could mistake a disease in such an organ as the gall bladder, for instance, at the upper end of the chain for a disease of the tube and the ovary at its lower end. Such mistakes have occurred, however, and that in the hands of some of our best diagnosticians. The physician who would avoid errors of this kind must not only familiarize himself vnth the signs belonging to the diseases characteristic of each of these organs, he must also, in every case where anyone of them ap- pears to be affected, exam- ine the other organs as well. The cases which most fre- quently give rise to mistakes are those of more or less vague, but persistent pain in the right part of the ab- domen, whether in the loin, or anteriorly, or extending down in the direction of the pelvis, or in the back below the crest of the ilium. These sufferers may go the rounds for many years with no more definite complaint than a vague but very real unrest, which the patient attributes without doubt to " something wrong in her right side," until some one is found with sufiieient skill to determine which link in the chain is at fault. My own experience has sho^vn me that over Fig. 26. — Shows the Organs on the Right Side whose Affections are Liable to be Confused One with An- other. Bj^ careful reetal palpation the ovary and uterine tubes are felt; by careful palpation in the right iliac fossa a diseased appendix can be reached ; and the right kidney can be examined with unerring certainty by injecting its pelvis through the ureter. PAIN AS A SYMPTOM IN" EXAMINATIOlSr. 29 sixty per cent of these cases of ill defined right-sided pain are due to some trouble in the kidney, usually a displacement, with a kinking of the ureter, and retention of urine in the renal pelvis. It is an easy matter for anyone experienced in catheterizing the ureters to pass a renal catheter up into the right kidney, inject fluid into the pelvis, and thus bring on a mild attack of renal colic. The patient, as a rule, will at once identify the pain thus induced, with the pain from which she has been suffering, both as to situation and char- acter. The catheter which is passed up the ureter for the purpose of injecting the kid- ney, if tipped with wax, may show scratch marks when ex- amined under a lens of low magTiifying power, revealing the presence of a stone in either the pelvis of the kidney or the ureter (see Fig. 27). Backache . — -The most se- rious mistakes and the gravest disappointments often result from operative procedures cor- recting retro-displacements of the uterus, done in the hope of relieving a backache. As a matter of fact, the backache so common in women is rarely due to a displacement; it is either an affection per se and purely local, or it is dependent upon an anemia and a general condition of ill health (neurasthenia). From backache to uterus in women, and backache to kidneys in men, is a fallacious mode of reasoning. When the pain is situated very low down in the back, the coccyx should be examined carefully bimanually, with one finger in the rectum. Occasionally, a well localized, severe pain in the coccyx is relieved by the extirpation of the structure, but, as a rule, coccygeal operations are failures and are greatly over- done, to the discredit of surgery (see Chap. IX)'. Notes of Examination. — The notes of the examination' should always be care- fully compared with the complaints of the patient, which ought, as a rule, to be written down in her own characteristic words ; if the anatomical findings do not tally with the statements made by the sufferer, or afford a reasonable Fig. 27. — Examining a Ureteral Catheter that has BEEN Wax-tipped and Passed through the Bladder UP into the Pelvis of the Kidney and Carefully Withdrawn. The examiner is using a lens and holding the catheter so that the light strikes the uppermost glis- tening surface as he turns the catheter between thumb and forefinger, while looking for the gouges or scratch marks indicative of the presence of a stone in the upper urinary tract. 30 CONSULTING ROOM AND GYNECOLOGICAL EXAMINATION. exj)lanatioii of tlio complaints, llie examiner should not rest satisfied imtil lie lias made a further and more searching investigation and perhaps dis- covered the cause for the discrepancy between the subjective sensation and the objective findings. When the patient comes complaining of pain, and the examiner finds a displacement of some sort, he should be very cautious about promising that the correction of the displacement will serve to relieve the pain. It will be safer to promise nothing more than a good mechan- ical result from the operation, while expressing the reasonable hope that the discomfort will be relieved. GENERAL PRINCIPLES OF TREATMENT. Outlining a Course of Treatment. — With the statements of the patient clearly borne in mind, and with the patient before him and fresh from the examina- tion, the gynecologist should be prepared at once to outline a course of treat- ment. Whenever there is a lingering uncertainty as to the condition, a ten- tative course may be tried with a view of proceeding, if necessary, at a later date, to more radical procedures. It is my custom in puzzling cases to note all the facts ascertained and then to add a list of the doubtful matters still to be determined. In general, the lines of treatment are: (1) General, hygienic. (2) Palliative. (3) Radical, by operation. When in doubt it is best to proceed from the simpler to the more serious modes of treatment. Having outlined a scheme, the physician should stick to it until it is fairly tried, when he may be justified in assuming a more aggressive course. If no local condition is discovered to account for the discomfort complained of, a general hygienic course may be adopted, extending over a period of some weeks or months. Hygienic treatment involves these various factors : Rest. — Early hours in retiring; breakfast in bed; rest an hour before and an hour after each meal, or lying down six half -hours in each day. A splendid rest may be obtained by regularly putting on a night-gown and going to bed for an hour to an hour and a half in the afternoon. Food. — Simple, nourishing food, avoiding pastry, pickles, condiments, and fried articles. Some easily digested food betweeh meals and before going to bed, such as a cup of milk, malted milk, gruel, or broth. Exercise. — Some exercise must be taken every morning and afternoon, whether in walking, driving, working in a garden, or playing golf. Medicine. — A bitter tonic such as Calisaya bark, or a pill of caluniba and gentian, one grain each. Opium must never be given in any form to induce sleep. If it is necessary to give some sedative for a few nights in HYGIENIC MEASURES OF TREATMENT. 31 order to break tlie habit of sleeplessness, one of the milder hypnotics must be used (see Chap. VIII). Massage. Cold morning sponge. Regular evacuations of the bowels. Sunlight baths. Often the mere assurance that there is nothing serious the matter will send the patient rejoicing on her way, ready to take plenty of exercise, to live in the open air, to take her food with relish, and to enter once more into natural home relationships. Such is the discipline of the mind over the feel- ings. I have many times seen a patient walk into my office the picture of woe, with all her functions disordered, because she has been told she had an incurable disease which rendered it necessary to remove her uterus, uterine tubes, and ovaries. Upon my assuring her that there was nothing whatever the matter with these organs, she has left my office radiant, a woman in per- fect health. Palliative treatments may be followed out while keeping a patient under observation. Palliative treatments are applied by the vagina in the form of: (1) Painting of the cervix and vagina. (2) Applications of caustics to the cervix and the uterine cavity. (3) Packs in the vagina. (4) Douches in the vagina. (5) Pessaries. For painting the cervix and the vault of the vagina, a strong tincture of iodine (Churchill's) was largely in vogue a couple of decades ago. The nitrate of silver in strong solution, ten to forty j^er cent, may be used on the diseased cervical mucosa. In using any powerful solutions for treating the cervix or the glands within the cervical canal I commonly employ a cylindrical metal speculum with a stout handle like that shown in Figure 28. This serves to isolate the cervix and to protect the sur- rounding parts from the cauterizing effects of any of the drugs used. It is doubtful if uterine treatments for " endometritis " are not far more danger- ous than useful. Many cases of salpingitis have been set up in this way. Packs support the uterus and provoke a watery discharge when glycerin is used. They do not do much to cure any disease. Douches as hot as can be borne often give much relief; just how far they are curative is doubt- ful. Pessaries are being more and more rarely used. They have a use- ful, but limited field. The question of their use is discussed in detail in Chapter XIII. While undergoing a course of palliative treatment, vaginal packs con- sisting of cotton and wool tampons carrying boroglycerid, may be applied to the vagina and the cervix; hot water douches, as hot as can be borne comfortably, say 105°— 115° F., continued for ten or fifteen minutes once or 32 COInTSTJLTIIS^Ct EOOM and GYNECOLOGICAI. EXAMINATIOlSr. twice a clay, are serviceable after removing the pack. The bowels should be kept unloaded bv giving a flaxseed enema, made by boiling four table- spoonsful of the whole seeds in a quart of water for ten minutes, then strain- ing and injecting the soothing mucilaginous fluid warm. Massage may be Fig. 28. — ExA^^xrN■G tete CER^^x and Vattlt of tfte Vagixa with Kellt's O-ltxdrical Metal SpecultjM with Stout H.andle. This instninient is most convenient for exposing the cervix and protecting the rest of the vagina wliile treating the cer"\dx with canterj-, etc. given to quicken the circulation and process of nutrition, cold or hot packs at night to induce rest, and a cold spinal douche in the morning. In deciding to do an operation, it is always most important to be sure that the operation will relieve the complaint. If a minor operation is suggested, such as the repair of a lacerated cervix, the physician should take gTeat pains to determine that there is no other serious affection which he is likely to leave unrelieved. In my personal experience, the operation for laceration of the cervix is generally a most useless gynecological procedure, often unnecessarily performed. It is often recommended when the patient is in reality suffering from a uterine displacement associated with a broken down vaginal outlet, EXAMINATION OF RECTUM. 33 and sometimes even in the jDresence of a grave iniiammatory trouble involving tlie uterine tubes, EXAMINATION OF RECTUM. The rectum, owing to its proximity to the other pelvic organs, and its frequent association with many of their diseases, is as much a part of the field of the gynecologist as are the organs lying in front of the vagina and uterus, namely the urethra and the bladder. The specialist or the general practitioner, who fails in his gynecological examinations to take the rectum constantly into account, will often in this way lose important opportunities to make a correct diagnosis. It is only necessary to recall the close anatomical connection of the rectum with the perineum, with the vagina, and with the cervix, as well as its constant contact with the body of the uterus and the left uterine tube and ovary, to realize that these claims are not exaggerated. The wonder is not that the rectum is so often involved, but that lying as it does, it does not more frequently enter, as an important complication, into a great variety of gynecological ailments. The rectum is of interest to the gynecol- ogist in the following ways: (1) It may itself be the cause of diseases of the pelvic structures, as when a carcinoma of the rectum extends to the vagina, or the uterus, or the pel- vic peritoneum. The constant overloading of the rectum often causes stasis of the pelvic vessels, and either through this means or through the attendant toxemia, is a common cause of dysmenorrhea. In children, a form of pruritus is occasioned by the escape of thread worms from the rectum out onto the vulva. (2) The rectum is liable to be affected in its turn by diseases of the pelvic organs; for example, it may be choked by a large uterine fibroid, if it is one large enough to choke the pelvis which has been caught under the promon- tory of the sacrum; or again it may be pressed upon by ovarian tumors; or its lumen may be invaded by pelvic abscesses. Almost all cases of extensive pelvic, that is to say uterine tubal inflammatory disease, involve the rectum as well as the adjacent struc- tures; extensive disease in the pelvic cellular tissue may choke the lumen of the bowel at the pelvic floor down to the size of the little finger. A vicious retroflexion may cause obstinate constipation, as in the earliest and now classical case observed by Koberle. Large pouting hemor- rhoids may be only a sign of a blockade in the pelvic circulation, induced by inflammatory masses at mid. pelvis. Further, we have but to recall the cases of complete septal tear, extending from the vagina into the bowel and ruptur- ing one or both sphincters. (3) Diseases of the rectum are sometimes mistaken for uterine or ovarian diseases. This error is a grave one, inasmuch as mutilating operations may be and have been performed on the innocent genital organs, when the disease actually lay within the rectum. Hemorrhoids produce a bearing down sensation, easily mistaken for the bearing down caused by a 34 consultinct room aistd gynecological examination. displacement of the uterus; a cancer of the rectum, high up, has been repeatedly mistaken for a pelvic tumor of some other kind ; and most im])ortant of all, a proctitis, with its j^elvic distress and vague pains is commonly overlooked or mistaken for chronic disease of the ovaries and tubes. I recall also in this conection the cases so much talked about a generation ago, where a fissure of the rectum, causing pains reflected to other parts of the pelvis, was often mistaken for uterine or ovarian disease. It is manifestly important for all these reasons that the gynecologist should include the rectum and its diseases within the scope of his inquiry in almost every case, and further that he should, if necessary, be ready to apply the appropriate treatment. I would lay great stress then upon the rou- tine examination of the rectum. I have no doubt at all that in every hundred cases examined in this way by one who has newly taken up the sub- ject, a number of surprising discoveries will be made. The reason for the neglect of this field in the past has lain in the difficult and unsatisfactory character of the examinations, which elicited no positive information. Even recently, the method in vogue has been to investigate the diseases of the rectum situated above the anal margin with the index finger, which at best cannot do more than reveal a few of the gross changes. A dis- tinguished proctologist and author of a large work on rectal diseases once declared at a large society meeting at St. Louis, that he had no interest in diseases of the rectum that did not manifest themselves to his educated touch ! Concurrently with the finger examinations, various thin-bladed bivalve and trivalve specula were used, in the vain hope of seeing as well as feeling some- thing; but these little instruments were in reality almost wholly useless, for they did little more than expose the sphincter area, and as much of the bowel above as might prolapse between the narrow blades of the speculum. It was with rectar diseases as with eye diseases a few decades ago, when the patient had either amblyopia or amaurosis ; in amblyopia the patient saw nothing, but the physician saw something, while in amaurosis neither patient nor physician saw anything. Several men, such as Sims and J. G. Carpenter, had looked into the rectum, using a Sims' speculum in a Sims' or an elevated posture, but the action was incidental, and they never appreciated the value of the method enough to advertise it or insist upon its universal acceptance as the one method of the highest importance, and so fundamental and absolutely necessary in all satisfactory examinations and treatments of the rectum above the sphincters. ISTo other person took particular note of their use of the Sims' speculum in this way and nothing was accomplished. One insuperable added difficulty was the want of a proper instrument to make a thorough investiga- tion of the bowel, for the Sims' speculum is but a make-shift. I took up this subject in the eighties, while yet in Philadelphia, and in April, 1895, I pub- lished an article in the Annals of Surgery (vol. 21, p. 468), in which I insisted upon the importance as well as the entire feasibility of always exam- ining the rectum in an elevated posture under air distention, using a long METHOD OF RECTAL EXAMINATION. 35 eylindrical speculum with a large handle, which I devised especially for this purpose. Method of Examination (see i'ig. 29). — A good single speculum for gen- eral use for this purpose is one fourteen centimetres long and twenty -two millimetres in diameter (5^ X f in.). A serviceable long proctoscope is Fig. 29. — Rectal Instruments. Four specula of different sizes, a conical dilator for dilating the sphincter, and long alligator forceps for conveying cotton or gauze high up into the rectum. twenty centimetres long, and a sigmoidoscope may be used which is thirty centimetres in length or even more. The handle, from ten to thirteen centi- metres in length, affords a strong grasp for the fist. The obturator of the speculum must not be pointed, nor yet too blunt. Aside from the speculum, the following instruments are needed: A head mirror to reflect an electric light, gaslight, lamplight, or daylight ; a long pair of alligator forceps used in swab- bing out the bowel. The bowel ought to be empty when the patient assumes the knee-breast posture, having laid aside all constricting articles of dress, espe- 36 CONSTJLTIiN^G ROOM AiS^D GYISrECOLOGICAL EXAMIXATIOTs^. cially corsets and articles likely to Lind the cliest aiKl limit tlie tendency of the viscera to gravitate towards the diaphragm. The end of the speculum is now well oiled and introduced by thrusting it in a direction slightly down- wards and into the pelvis through the anal orifice (see Fig. 30). A good way to effect its introduction is to push it a little way into the anus, and then quickly withdraw it, when the anal orifice at first contracts vigorously and then relaxes ; now in the act of relaxation, the bowel is caught by surprise, as it were, and the speculum thrust quickly in before another contraction can take place. As soon as the speculum enters about two inches, its deeper intro- duction into the bowel beyond should be conducted under the guidance of the eye, looking down its liunen into the bowel (see Fig. 31). Only those who have a large experience in carrying the specuhun into the upper bowel ought ever to make the attempt to push it on up the bowel without removing the obturator and watching each step in the advance. With the removal of the Fig. 30. — Shows the Method of Ixtroditcixg the Loxg Rectal SPEcrxmi for the Purpose EXAMIXING the ExTIRE LeX-GTH OF THE Lo'U'ER BoWEL. obturator, the air rushes in with a distinct suction sound and distends the rectal canal : at times it does so suddenly, at other times slowly step by step, until the air expansion reaches up to the hollow of the sacrum, to the promontory of the sacrum, and even beyond it into the sigmoid. I thought in my first efforts that I could look well up into the descending colon, where METHOD OF KECTAL EXAMINATION. 37 I could feel the end of the speculum through the abdominal wall, apparently not far from the ribs. In this, however, I was misled, and I have not yet been able to use a colonoscope. As the light reflected by the head mirror is directed into the bowel, the ampulla is first seen and the sharp-edged over- lapping valves which limit it just above on the right and the left. With the Fig. 31. — Shows the Inspection of the Bowel with a Simple Head Mirror Using a Reflected Electric Light. illumination properly directed, the examiner will easily keep the instrument well within the lumen of the bowel so as not to cut .the mucosa, as he carries it successively higher and higher until the uppermost limit of expansion is reached. Oftentimes this upper limit is marked by a little puckered depres- sion in the midst of a series of concentric folds. It is important not to mis- take this normally contracted empty bowel for a stricture of the rectum or of the sigmoid. The soft margins of the normal lumen at this point can readily be examined Math a metal instrument, a searcher, or a scoop, or by pushing up a large soft catheter. It is well, in the course of the examination, to notice and to touch the promontory and the hollow of the sacrum against which the distended bowel closely applies itself. As the instrument is gradually withdrawn, the character of the mucosa on all sides is noted, its natural red- ness, the vessels which course like streams and subdivide into lesser and lesser 38 CONSULTING ROOM AND GYNECOLOGICAL EXAMINATION. tributaries, sometimes tiny little points, the openings of glands are visible, the valves are each noted with particular care, they may be extensively over- lapping, making the bowel tortiions, or have thickened, inflamed margins or be almost obliterated. The signs of rectal inflammation are evident in a diffuse haziness or velvety appearance of the mucosa, associated with the disappear- ance of the normal vascularization, and often, although the tissues bleed easily, no vessels at all can be seen; old inflammatory trouble often leaves behind patches of brownish discoloration seen mottling the mucosa everywhere ; ulcers are always plainly visible ; polyps are readily seen pendant in the lumen, and occasionally the ragged, bleeding, granulating surface of a carcinoma fills the lumen and forbids the further introduction of the speculum. When the bowel is strictured by syphilis, by tuberculosis, or by early cancer, one can often use a smaller speculum with advantage, one about twelve or fifteen millimetres in diameter. It is important in such cases, when it can be done without risk, to carry the speculum above the diseased area to discover the healthy bowel above, and so to determine the extent of the disease. For the examination of the hemorrhoidal region, a shorter speculum, four centimetres long, which I call a sphincteroscope, is of value. The mucosa of the bowel prolapses into this on withdrawing the obturator, and the hemorrhoids swell up. It is of an occasional advantage to have a sphincteroscope made with a fenestra on one side about two-fifths of an inch in diameter, cut through the entire length of the tube. This allows any diseased tissues within the sphincter area to drop into the lumen for examination and treatment. With the sphincteroscope one also sees fistules and fissures to better advantage. Methods of Treatment of Rectal Diseases. — It does not lie within the scope of my undertaking to do more than to touch upon this important special branch, so closely allied to the gynecological field. The following are some of the general guiding principles; the bowel, which has been thoroughly evacuated beforehand, can be well cleansed with pledgets of cotton dipped in warm boric acid solution and introduced by means of the long alligator forceps (see Fig. 32). An application is in like manner readily made to ulcers by means of cotton pledgets, saturated with a two or a five per cent silver solution; this can be done with as much accuracy as in the treatment of a sore throat. Inflamed areas in the upper bowel can be treated by packing with gauze carry- ing a ten per cent ichthyol solution in water and glycerin. A cotton bolus makes a good pack too. These packs thus applied to the upper bowel, or to the whole bowel from the sigmoid down, can be left in place until they are passed in the course of nature by the patient. When maligTiant disease is discovered, it is easy with a pair of cutting sharp-edged forceps, with short jaws working like alligator forceps, to remove a piece of the tissue for microscopic examination. In the treatment of fissure, it is sufficient to give the patient enough gas to make her unconscious, and to use the conical dilator (see Fig. 29, p. 35), so as to thoroughly overstretch the sphincter area until the tips of five fingers METHOD OF TREATMENT BY RECTUM. 39 can be introduced. This can also be done with two Sims' specula, one a little narrower than the other, introduced together and then separated widely, also Fig. 32. — Using the Alligator Forceps holding Pledget op Cotton to Touch or Cleanse a Por- tion OF the Upper Bowel. effecting a thorough dilatation. In some cases it is well to make light longi- tudinal cuts with a scalpel through the base of a fissure, so as to divide the superficial sphincter fibres. CHAPTER II. HYGIENE OF INFANCY .\ND GIRLHOOD. (1) Hygiene of infancy and childhood: General considerations, p. 40. Causes of infant mortality and ill-health among children, p. '41. Remedial measures — Education of mother, p. 41; public hygiene, p. 44; water supply and disposal of sewerage, p. 44; clean air, p. 44; public control of milk supply, p. 44; improvement of housing conditions, p. 45; pub- lic parks, etc., p. 49; protection against infectious diseases, p. 50. Summary-, p. 51. (2) Hygiene of the school girl: School-going age, p. 51. Hygienic habits, p. 52. Physical con- dition, p. 54. Condition of eyes, p. 56. Condition of ears, nose, and throat, p. 57. School-building and appliances, p. 58. Physical training and medical gj-mnastics, p. 59. School Hfe in relation to puberty, p. 65. Summar\', p. 67. (3) Hygiene of puberty and of occupation: Hygiene of puberty — Nutrition, p. 67; exercise, p. 68; rest and sleep, p. 68; emplo\TQent. p. 69; bathing, p. 69; clothing, p. 70; instruction in physiology' of reproduction, p. 72; hygiene of menstruation, p. 72. Hygiene of oc- cupation — Industrial life, p. 74; social life, p. 76; college hfe, p. 76. HYGIENE OF INFANCY AND CHILDHOOD. G-eneral Considerations. — The most important factor in the development of a healthy girl baby into a healthy yonng woman is an intelligent mother, and no more nrgent problem calls for solution to-day than that of securing adequate training for the duties of maternity. Maternal instinct and maternal love plus family traditions are not sufficient equipment for rearing a healthy family. They must be guided by maternal intelligence, vhile maternal intelligence, in its turn, must be aided and supplemented by a broad and enlightened public health policy. The care of the health of the groving girl begins vith the education of her mother. It is not necessary at present to multiply text books for teaching medical students and practitioners elementary facts concerning the hygiene of infancy and childhood. Medical literature is rich in material easily available for instruction. On the scientific side there is pretty general agTcement as to the hygienic measures vhich ^vhen applied in the family and in the community "will preserve and promote the health of infants and children. The medical profession has the knowledge necessary to decrease enormously the death rate of infants and children, and at the same time to increase proportionally the average of health. What it lacks is the power to apply this knowledge, because it has not control of the necessary agencies. The remedial measures in ques- tion are entirely those of preventive medicine, and they require the cooperation of educational and social forces, the formation of public opinion, legislative enactment, and administrative control. 40 CATJSES OF INFANT MORTALITY AND ILL-HEALTH AMONG CHILDKEN. 41 Causes of Infant Mortality and of Ill-health among Children. — It is estimated that of all children born into the world eightj-five to ninety per cent are healthy at birth, and excluding mortality in infants resulting from immaturity, mal- formations, and injuries of parturition, the high death rate among infants, as well as much of the physical deterioration of the growing child, is directly traceable to external and, therefore, controllable causes. In his testimony before the English Interdepartmental Committee on Physical Deterioration, Dr. Eicholz, H. M. Inspector of Schools, says, " Other than the well-known specifically hereditary diseases which affect poor and well-to-do alike, there appears to be very little real evidence on the pre-natal side to account for the widespread physical degeneracy among the poorer population. There is accord- ingly every reason to anticipate rapid amelioration of physique so soon as improvement occurs in external conditions, particularly as regards food, cloth- ing, overcrowding, cleanliness, drunkenness, and the spread of common prac- tical knowledge of home management. In fact, all evidence points to active rapid improvement, bodily and mental, in the worst districts, as soon as they are exposed to better circumstances, even the weaker children recovering at a later age from the evil effects of infant life." So long as a community can rest content in the belief that a large infant mortality is the natural method of ridding the race of the unfit, the doctrine of laissez-faire can be accepted with tolerance. If, however, it seems probable that the influence of environment must be reckoned as a greater cause of infant mortality and of physical unfitness than the influence of heredity, it may be wiser for society, as it certainly will be easier, to preserve the lives and health of the children born than to stimulate an increase in a birth rate now diminishing. As it is an open question whether the race, as a whole, suffers mental or physical deterioration from a diminished rate of production among the superior stocks, it is unquestionably a matter of public policy as well as of common humanity that conditions of living in communities should be made favorable to the preservation of the life and health of all infants and children. Remedial Measures Demand Activities of Public Hygiene and of Personal Hygiene.- — Malnutrition, due to insufficient or improper food, and infec- tions are the greatest causes of infant mortality and of physical deterioration in the growing child. These causes have their origin in poverty, igno- rance, neglect, lack of cleanliness, lack of protection from sources of infection, and lack of proper education of the child. Each one of these sources of evil has a public as well as a private aspect, and thus their removal involves activities of the State as well as of the individual. The great function of the physician in hygiene is to instruct and to guide his individual patients, and to direct and lead all those movements for social reform that aim to improve conditions of hygienic living. In modern preventive medicine the family physician assumes renewed importance and dignity. Education of Mother Essential. — It is interesting to note in cur- rent medical literature the practical unanimity with which podiatrists are 42 HYGIENE OF IXFANCT AST) GIRT.IIOOD. demanding that women mnst be educated for maternity, and this whether the podiatrist works mainly with the poor and ignorant, or with the ignorant and Avell-to-do. Dr. Hollopeter, in his presidential address before the annual meet- ing of the American Society of Podiatrists (1905), says, " A troublesome obstacle that the pediatrist encounters to-day is the general ignorance and helplessness of the young mother. . . . Instruction in the details of the baby's care, and proper guidance in the study of home modification of milk is often the main function of the medical attendant, and a maternal mind previously prepared in hygienic instruction is a great help." Of interest, too, is the insistence with which thoughtful women are demanding that the education of girls shall include some efiicient training for the duties of family life. The numerous papers of Mrs. Ellen H. Richards, Mrs. Mary Hinman Abel, and others, with the discussions found in the proceedings of the Home Economic Conferences at Lake Placid, represent the trend of educated opinion and effort iij this direction. There seems to be general agreement among physicians and social reformers as to the necessity of giying all women some systematic training for home- making; there is a fair ag-reement as to the essentials of such training; but the methods by which all actual and potential mothers may receiye instruc- tion adapted to their particular needs have not yet been deyised. In recent years courses in the household arts, cooking, sewing, etc., haye been introduced into many schools in this country ; school physiology, too, has been widely included in public school curricula, as a result of temperance agitation, but it cannot be said that the teaching has been adequate or effectual. The value of any such courses for yoimg children is extremely doubtful. Experience has shown that if the teaching of these subjects is to be of real value, it must be brought very near to the period when the knowledge and skill acquired are to be practically applied by the individual in her o^vn household. The English Interdepartmental Commission on Physical Deterioration recommends, in addition to courses in higher schools, the establishment of con- tinuation classes for instruction in domestic science, at which the attendance of working girls and others who have left school at an early age should be made obligatory twice a week during certain months of the year. " The course of instruction at such classes should cover every branch of domestic hygiene, including the preparation of food, the practice of household clean- liness, the tendance and feeding of young children, the proper requirements of a family as to clothing, everything in short that would equip a young girl for the duties of a housewife." Training of the kind here suggested, gi^-cn at a proper age and in an efficient way by teachers specially prepared for the work, will doubtless even- tually be made part of the compulsory education of girls in our public schools. This will come when the puldic mind fully grasps the idea that a nation's welfare depends as much upon the physical efficiency of its citizens as upon their general intelligence. EDUCATIOlSr OF MOTHER. 43 Whatever scheme is finally adopted for the universal education of mothers, it is clear that instruction must be given to some classes of women in their own homes under medical and sanitary supervision. There is at present in this particular field of preventive medicine great opportunity for private initia- tive through philanthropic effort. The work of the various Instructive Visit- ing ]^urses' Associations and similar organizations in our large cities has already demonstrated how quickly health conditions in the homes of the poor can be imjDroved as a result of sympathetic instruction. What it is now pos- sible to give in cities to* the very poor should be available everywhere for women of the better classes. There is need for a new class of health officials — women trained especially in dietetics and the general care of children whom physicians could send to their private patients to instruct them and help them in keeping children well, as they now use trained nurses in the care of the sick. In this connection a study of the foundation and results of Dr. Pierre- Budin's " Consultations for ISTurslings " should be familiar to all physicians having the care of women and children. " Every medical man," Prof. Budin says in his lectures, " ought to regulate the feeding of all infants born under his charge. The lying-in period being accomplished, he considers his respon- sibilities at an end and leaves the poor woman to her own devices in rearing her child. She is expected to have an intuitive knowledge of infant feeding. She might as well be expected to conduct her own confinement. With proper direction the safety of almost every infant can be ensured, and diarrhea, marasmus, rickets, and other dietetic diseases ban- ished from the community." Prof. Budin's "Consultations" are held for both free patients and for those who can pay. They are really classes for the instruction of pregnant women and mothers of young infants. Among other results he has been able to show that the function of lactation is not disappearing among women, but, on the contrary, the great majority of women, by proper food and hygienic care during pregnancy, are able subsequently to nurse their children. It can easily be imagined that a rapid hygienic trans- formation, public and private, could be made in any given locality if every physician who delivered a woman should be held responsible for the infant's life and health during its early years. Practitioners themselves would quickly acquire a better knowledge of dietetics and the relation of food to health and growth. They would promptly devise some method of effectively educating mothers and nurses to whom the care of young children is directly committed. When medical inspection of public school children becomes an accepted policy for all public scliools of all gTades, it will be easy to foresee the possi- bility' of an extension of the system to include an inspection of children before the school-going age. Mrs. Parsons in " The Family " already suggests, in addition to the training of girls of all economic classes in the care of young children, a system of State supervision of the home education of actual and potential public school children, by an extension of the functions of the medical inspectors of schools and school nurses. The school nurse who follows 44 HYGIENE OF INFANCY AND GIRLHOOD. school children to their homes has already demonstrated that improved hygienic conditions for the younger children may be expected when mothers are given sanitary instruction in their homes. Public Hygiene. — Ability to obtain food, and "intelligent mothering" are primary essentials in maintaining the life and preserving the health of infants and children, but they are not sufficient. Only by the aid of the community or of the State can the home secure a pure and suf- ficient water supply ; efficient removal of sewage and garbage ; pure and clean food, including pure clean^ milk, and clean air; proper housing conditions ; and protection from infectious diseases. The last fifteen years have witnessed a great awakening in our country to the dependence of the individual health upon public sanitary measures. Object lessons there are in plenty demonstrating the ability of preventive medicine to diminish mortality and morbidity, if trained health officials are vested with necessary power. It is only necessary to mention Havana and Panama. In ISTew York City, infant mortality has been decreased fifty per cent in twelve years by an improvement in public hygienic con- ditions. Water Supply and Disposal of Sewage. — Education regarding the relation of the public health to a pure water supply and efficient disposal of sewage has gradually secured for urban communities in this country satisfac- tory efforts towards proper conditions, but much remains to be done before this can be said of small communities. The demonstration of the relation of flies and other insects to infectious diseases gives increased imjDortance to the necessity for proper disposal of human excreta. Better protection of water supply or efficient purification, with sanitary disposal of sewage, are reforms widely needed in suburban places. Clean Air. — The pollution of the air with smoke and dust, and the methods of street cleaning, or the lack of it, have a very direct effect upon the health of children. The dangers from dust are greater for them than for the adult, both because they have less power of resistance to many infectious diseases, and because their habits of play and their low stature bring the entrance to the respiratory apparatus nearer the floor and the street. Public Control of Milk Supply. — Efforts to secure pure and clean milk have not kept pace with medical knowledge of its relation to the health of infants and children. In the last few years, mainly through the efforts of the medical j^rofession, it has become possible for the well-to-do in most large cities of the United States to obtain pure, clean milk, usually an impossibility in country districts. Philanthropy has made this possible, also, for the poor of many cities, who can now obtain at a nominal price, at various distributing stations, clean fresh milk or sterilized milk for children. The results in ISTew York from the stations established by Mr. ISTathan Strauss are well known. It is difficult to understand the conditions of milk production that are still PUBLIC CONTROL OF MILK SUPPLY. 45 tolerated in rich farming communities, in towns, and in villages, since experi- ence has taught how quickly a good quality of milk can be secured by intelli- gent effort. In every locality where physicians have combined to secure a clean pure milk they have succeeded promptly. Eochester, l^ew York, furnishes an example of what may be accomplished by a capable health official, and the results obtained by the various milk commissions organized in recent years show how promptly practical results follow the concerted action of physicians. The Milk Commission organized by the Philadelphia Pediatric Society and that by the 'New York County Medical Society are notable examples. Statis- tical information is already forthcoming showing an astonishing decrease in the mortality of infants directly traceable to an improvement in the milk supply. What has been accomplished in larger and smaller cities of the country in the production of certified milk by milk commissions ought to be matters of common knowledge to physicians and stimulate them to similar activities. The first Walker-Gordon milk was supplied from an ordinary farm, with ordinary cows, by the work of one farmer's family. Some encouraging results in Elmira, InT. Y., have recently been reported, wdiich afford a good illustra- tion of what may be done in smaller places. A w^oman was found with some general knowledge of the benefit of clean milk, who was willino- to take up the work. She built a new barn, and had her herd tested for tuber- culosis. A standard of 10,000 bacterial count was established and the other usual conditions imposed. The milk was cooled, bottled within a few min- utes after it was drawn and then put into a crate, the top of which was filled with crushed ice. The night and morning milk was delivered to the consumer not more than ten hours from the time the oldest of it was drawn the night before. This was accomplished simply by using the means at hand, and what has been done in Elmira could be done in a score of other cities of the sam.e size. Continued public agitation, aided by the work of the agricul- tural experiment stations, should make the work of milk production a trained industry under constant public supervision. Improvement of Housing Conditions. — The movement for im- proved housing conditions of the poor in cities is of great hygienic sig-nificance. Overcrowding, with its attendant evils of bad air, uncleanliness, lack of sunlight, and bad sanitation is, after improper and insuf- ficient food, the greatest cause of death and sickness among children. There is at hand, easy of access, an ample bibliography demonstrating the wretched conditions existing in many of our cities. Booth in his " Life and Labor in London " says, " Crowding is the main cause of drink and vice." As " drink and vice " are the greatest causes of hereditary degenerations, over- crowding, both by its direct and indirect influence upon the health of children, must be reckoned as a principal source of physical deterioration among them. Figure 33 shows a room in which ten persons lived, ate, drank, and slept, and 46 HYGIENE OF INFANCY AND GIELHOOD. wliicJi was tlie only place in which one of them, a boy of five or six, could recover from a broken leg. As a result of the activity of social workers and philanthrojjists it has been demonstrated: (1) That improvement in health promptly follows better housing conditions, and (2) that model tenements are a paying investment. A great sanitary reform, therefore, need not be impeded Fig. 33. — The Home of a Family of Ten Persons in Baltimore. (Taken by Mr. Scott of Hughes & Co., Photographers, Baltimore.) by economic reasons. Stringent tenement house laws with rigid enforcement must be considered a vital hygienic necessity for the health of a large number of children. A study of the housing conditions in Baltimore, made by Miss Janet Kemp under the direction of the Association for the Improvement of the Condition of the Poor and the Charity Organization Society, furnishes a recent contribu- tion to this subject (1907). This admirable study illustrates well the necessity for watchfulness of conditions even in a city where no tenements are supposed to exist, and shows how rapidly the growth of tenements may proceed within the four walls of dwellings intended for single families. With our present hygienic knowledge, the sanitary conditions under which the poor live in over- crowded houses and tenements should not be tolerated in decent communities (see rig. 34). The hygienic results in tenement house reform aimed at by IMPEOVEMENT OF HOUSING CONDITIONS. 47 such movements as this appeal to the most selfish interests, as well as to the most altruistic. The children of Dives in his palace arc menaced by the con- FiG. 34. — A Court in a Crowded City District. (From "Housing Conditions in Baltimore.") ditions surrounding Lazarus in the slums. Twenty-two families living in forty-four rooms facing each other across a small court with no other outlook, 48 HYGIElSrE OF IXFAWCT AND GIRLHOOD. sharing among them two privies with three compartments, and one hydrant, the court owned privately and, therefore, independent of the Street Cleaning- Department, in a city with no contagions disease hospital, present a difficult problem to preventive medicine (see Fig. 35). Fig. 35. — Toilet Accommodations for Twenty-two Families. (From "Housing Conditions in Baltimore.") An interesting question might be raised here as to the effect on the health of the gTowing child of life in the apartment houses for the well-to-do, which have multiplied with such rapidity in recent years in all large centres of population. PTTBLIC PAEKS, PUBLIC PLAYGROUNDS, PUBLIC BATHS. 49 Public Parks, Public Playgrounds, Public Baths. — The exten- sion of city park systems, especially the establishment of small parks, the use of school yards and city lots for public playgrounds, out-door gymnasiums and swimming pools are all powerful influences in promoting the health of the growing girl. Towns as well as cities have much to gain by encouraging out-door life among children. Especial emphasis must be placed on the necessity of making adequate provisions for girls in all arrangements for sports and games in the open air Fig. 36. — Open Air Gymnasium, Girls' Day. Patterson Park, Baltimore. which are under public control. Out-door swimming baths and gymnasiums for boys should be duplicated for girls, or reserved for them at specified times (see Fig. 36). Traditions as to what is proper for girls are difficult to over- come, but mothers must learn to keep their little daughters in the open air as much as possible, and to encourage those plays and sports which take them put of doors. The public playgrounds where girls may spend hours in the open air under watchful control are a great educational force in both the physical and moral development of the child. They should not be for the poor only, but also for those who can afford to pay for the care given. They ought to be in all towns and villages, where it should be possible at all seasons 50 hygiejste of infancy and girlhood. of the year for joimg children to play in the open air under proper guidance. It would be difficult to estimate the beneficial effect of such out-door life luider efficient direction upon the health of girls. Public aids to personal cleanliness by the establishment of public baths and laundries in congested districts of large cities are legitimate charges upon the public purse. They are material aids to encouraging cleanliness of children among those classes who need it most. Protection against Infectious Diseases. — Infectious diseases with their sequelae are, after malnutrition, the greatest source of illness, acute and chronic, among children, while the chronic ill health of adults is often trace- able to imperfect recovery from some of the ordinary infectious diseases of childhood. The prevention of infectious disease is, therefore, of the gTcatest imjDortance to the good health of the growing girl. Moreover, there is every reason to believe that not a few of the gynecological affections from which so many women suffer have their starting point in the infectious dis- eases most common in childhood (see Chap. X). The knowledge now in possession of scientific medicine as to the etiology and prophylaxis of many infectious diseases is ample to enormously diminish their incidence in child life and their effects upon the health of the adult. It is well known to physicians that the prevention of infectious diseases among children involves: (1) Knowledge of the exciting cause, or of some effective method of preventive inoculation; (2) power to control those external con- ditions by which sjDCcific infective agents are multiplied and propagated; (3) power to control those external and internal factors by which resistance to infection is increased. They know, too, that the ability of the individual phvsician in private practice to limit the spread of infectious diseases is confined: (1) To preventive inoculations; (2) to trying to secure isolation; (3) to instructing parents in matters of personal and public hygiene; (4) to calling to his assistance such administrative control as is operative in his par- ticular community for the enforcement of public health measures for the com- mon good. Sanitary reforms of public health administration are as necessary for the physician in his practice as for the general public. Among the measures which may be expected to materially diminish infec- tious diseases in the future are: (1) Multiplication of laboratories for research into causes of infectious diseases and the measures for their prevention; (2) thorough reorganization of public health departments with a great extension of their powers; (3) employment of such health officers only as have had special training for their work or have shown a special fitness for it; (4) medical inspection of all school children; (5) establishment of health laboratories, at such convenient centres in small communities that all physi- cians may have the skilled assistance in bacteriological and clinical diagnosis which the best municipal laboratories now give to city physicians; (6) estab- lishment of isolation hospitals for infectious diseases, or isolation wards in all hospitals receiving state aid; (7) the practice of better personal hygiene. HYGIENE OF THE SCIIOOE GIEI.. 51 Tlie adoj)tion of effective measures of public hygiene can be secured only by a vigorous campaign of education in the principles and practice of pre- ventive medicine. The thinking public must be convinced that health is secured best by preventing disease, not by curing it. That it is easier to obtain from the public means to cure than to prevent is illustrated by what has been accom- plished in the campaigTi against tuberculosis. State aid for incipient curable cases is -accepted generally as good public policy, w^hile the necessity of pro- vision for the isolation of advanced cases, which are the greatest menace to public health, esj)ecially to that of children, has received as yet little public recognition. Summary. — 111 health among children is largely the result of post-natal influences. To maintain their life and promote their health requires suffi- cient and proper food, fresh air, cleanliness, sleep, rest, exer- cise, the formation of hygienic habits by education, and protection from the harmful influences of environment. Physicians are in- formed or should be informed about these matters, but their knowledge is of little value unless they can secure its practical and intelligent application in the household through mothers and caretakers ; and in public through public opinion, legislative enactment, and administrative control. The duty of the profession, so far as hygiene is concerned, is to inaugurate some systematic plan for instruction of mothers of all classes on subjects of personal hygiene ; and of the general j)"i^blic in matters of public hygiene. HYGIENE OF THE SCHOOL GIRL. School-going" Age. — Most girls spend a part of the period from six or eight to seventeen or eighteen at school. Many States determine this fact by the enactment of compulsory education laws. In every intelligent community the schools are tacitly considered to offer the best means for the development of the mind of the child ; they should aid and supplement the home in the develop- ment of the body. lio fixed rule can be given as to the age at which the small girl should be placed in school ; the decision in each case must be based upon a comparative study of both the home and the school and the physical and mental status of the individual child. For the weak and anemic girl with poor physical inheritance and with home possibilities of good nourishment and out-door life — six to eight years is too early; the same girl from a dirty insanitary home is certainly better off in school. At whatever age the girl enters school, her education has already been begun and carried far at home ; habits have been formed, principles instilled, and tendencies developed and trained. The best school available for the con- tinuation of this education should be chosen, co-educational or otherwise. In early school life at least, sex difference should not be emphasized in the selec- tion of the school nor in courses of training. There is no essential differ- ence in the physical needs of growing children. All animal necessities are the 52 HYGIENE OF INFANCY AND GIEXHOOD. same, the same food is eaten, cell processes arc similar, tlie same exercises are enjoyed. Boys and girls like equally well to ride, to swim, to climb trees, to play basket-ball. Exercises for children should not be restricted, or adapted, or classified on a sex basis as boyish and girlish. Playfair says, " Up to the time of puberty there is comparatively little difference between the sexes in health, in disease, or in any other condition. Conventionally, they are separated and different modes of education and training wall soon make such difference as there is more marked, but boys and girls play together, w^ork together, and are generally on a footing of perfect equality, there being little essential which distinguishes one sex- from the other." As education progresses the boy is trained to courage, endurance, and manliness, is taught to protect the weak, to be depended upon, to provide for himself and others, and, in short, is educated with the idea that he is to be the head of a family, to bear civic responsibility, to assist in guiding national affairs, to be economically independent. The girl is trained to directly opposite notions; she is expected to be helpless and dependent, and this undoubtedly is a distinct hygienic disadvantage. In recent years there has been a recoil from older ideas and the trained intelligence of educated women has been successfully applied to many of the problems of the child's education. As the education of mothers progresses and becomes more specific, still better results in the education of girls will be attained. ISTo degree of native intelligence, no advantage of modern educa- tional method is too great for the woman who is to be a mother, no knowledge, but may be put to use in the care of a home or training of a child. There is no possibility of over development of the powers of either father or mother when we consider that, biologically speaking, the production and education of children is the greatest human achievement. It is the duty of parents to bear children with good physical and mental capacities and to train their natural endowments to their most perfect develop- ment. Each successive generation should be superior to the preceding by at least some small increment of physical strength and mental or moral vigor. Oppenheim says, " The spirit of the hour calls for a strenuous effort, a desire to improve upon the past, a noble dissatisfaction that can be quieted only by an active exhibition of individual endeavor." The nearest duty to the indi- vidual is but the greater duty to the race, and a parent's apparently egoistic effort for the welfare of his own offspring is, in a larger sense, a contribution to race' development. Hygienic Habits of the School Girl. — A girl at the school age is the product of her home environment and brings to the new conditions of her life a phys- ical preparation which is the direct result of her inheritance and home care. Her general condition and power of resistance should be at the maximum. She should have certain fixed hygienic habits. Her food, her clothing, her hours of rest and of sleep should be regulated by the solicitous care of intelli- gent parents. The breakfast, the bath, the care of the nails and teeth, attention to the evacuation of the bowels should be matters of daily routine. These early HYGIENE OF THE SCHOOL GIKL. 53 lessons in physical education are an important part of the parents' responsi- bility to the child. A surprising number of school children habitually eat no breakfast. In- ability to take breakfast is always sufficient reason for keeping a child from school. Two reasons for this are obvious : the work of the morning will make far greater demand upon the child's vitality, if energy furnished by break- fast is lacking ; and, in the interest of the school, the fact should be determined whether the child is suffering the initial symptoms of contagious disease, in which case she should not be permitted to mingle with other children. A daily bath may be considered a hygienic necessity. It is a matter of common observation that mothers who are careful to bathe a baby daily throughout infancy consider a weekly bath adequate for the same child as it grows older. This is true, not in the homes of the poor alone, but often in those where complete bathing facilities exist and the physical work of keeping clean is reduced to a minimum. Under the conditions existing at present in many homes the schools must furnish instruction in personal hygiene, and it would be an advantage if they were equipped with shower baths in order to carry out such teaching practically. In some continental cities the shower bath is part of the daily school routine. Teachers should encourage children from homes lacking bathing facilities to make use of the public baths in those cities where such systems exist. The child should have learned, too, that clean clothing is as necessary to personal cleanliness as a clean skin and that the underclothing should be frequently changed. Many children from the better classes are not carefully trained in this particular. The care of the teeth in young children is of great importance. Too much stress can hardly be laid upon the necessity of early training in habits of mouth cleanliness, not only because of the importance of preserving the teeth, but also because of the relation of the bacterial flora of the mouth to many infectious processes. The habit of daily evacuation of the bowels is largely a matter of early training. 'No more important habit can be cultivated in infancy and childhood. Most cases of persistent constipation in adult life are attributable to a failure to establish this early habit, to dietetic errors, or to neglect of a tendency towards constipation (see Chap. VIII). Haste and disorder in the early morning hours are very unfavorable to the establishment of regular habits of going to stool. The hour of rising should be regulated to allow time sufficient for the bath, the toilet, the breakfast, and the evacuation of the bowels. Breakfast should be ready promptly at the hour ; many cases of ill health in growing children can be traced to a habit of going to school without breakfast, or of swallowing their food hastily without mastication, or to a failure to observe the regular time of going to stool. The Dress of Young Girls. — The method of dressing little girls according to present standards is almost ideal. Simplicity of style, lack of constriction and pressure, lightness combined with warmth, support by shoul- 54 HYGIENE OF INFANCY AND GIRLHOOD. ders and thorax, materials well chosen, and shoes of good shape combine to make the well dressed yonng girl a strong contrast to her older sisters. Physical Condition of the School Girl. — It is very desirable that the physical condition of every girl abont to enter school be determined by medical exami- nation. Unless a child is in good physical condition, she may not only be unable to profit by the advantages offered, but even be harmed by attendance at school. It is futile to attempt to educate children Avho are not in physical or mental condition to be educated ; moreover, the school-going age is the most favorable period for attention to many defects or tendencies which have been overlooked during infancy and early childhood. Corrective and preventive work may be carried far during these plastic years, and much may be accom- plished toward right development which, later in life, would be found to be impossible. It is equally important that the child entering school should not be a source of danger to other children, as she will be if she is suffering from any form of . communicable disease. Unless both the physical and mental status of each child is intelligently determined, she cannot be properly classified. Underfed children, those who have errors of vision, adenoids, or scoliosis are frequently considered to be mentally retarded, whereas experience has shown that many such cases may be returned to the normal classes, if their physical condition receives the necessary attention. Of a large number of Boston school children classed as truant or backward ninety-five per cent were found to be physically defective. Under the conditions of the present day a system of medical inspection of schools furnishes the most efficient method for obtaining the facts which will enable any community to render the schools the best means for the development of the child and for its preparation to receive the greatest benefit from education. It is astonishing that the public has been so slow to recog- nize the value of what seems such a self evident proposition. Many European countries have had a system of partial inspection for some years. Japan introduced medical inspection in 1893 and in 1906 had eight thousand four hundred and twenty-four inspectors, while the whole United States had but six hundred. Although medical inspection in the United States has been slow of adoption and is limited in application, ISTew York has the most compre- hensive and highly developed system of medical inspection of schools in the world. It was established in 1896, one hundred and fifty inspectors were appointed, and during the first year six thousand eight hundred and twenty- nine pupils were excluded on account of various diseases. In 1902 six oculists were added to the staff. Subsequently a corps of trained nurses made the work more effective by securing immediate attention to minor ailments and to skin and parasitic troubles. A short statement of results during the year between March 27, 1905, and March 31, 1906, is instructive. .-'' PHYSICAL CONDITION OF THE SCHOOL GIKL. 55 Number of Examinations made, 79,065. Poor nntritioii 4,537 Enlarged ant. cervical glands , 22,493 Enlarged post, cervical glands 4,989 Chorea 1,184 Cardiac disease 1,332 Pulmonary disease 885 Skin disease 1,574 Deformity of spine 674 Deformity of chest 500 Deformity of extremities 663 Defective vision 24,534 Defective hearing 1,633 Defective nasal breathing 8,974 Defective teeth 29,386 Defective palate 936 Hypertrophied tonsils 13,411 Post-nasal growths 7,375 Defective mentality 1,477 l^umber v^here treatment was necessary 50,913 That sixty-three per cent of all children who enter the schools of 'New York need medical treatment is a tremendous indictment against the efficiency of the home, and demonstrates also the inability of the medical profession to prevent disease when its relation to the family is entirely dependent upon the volition of parents. There are no available published statistics for comparison from private schools which draw their pupils exclusively from the well-to-do classes, but even here, wherever careful medical examinations and re-examina- tions have been made, a surprisingly large percentage of girls have been found suffering from remediable physical defects, the most common of which are poor nutrition, defects in vision, defective hearing, enlarged tonsils and post-nasal growths, and chronic skin affections. To these various causes of ill health a careful analysis may trace most of the disturbances of function of the reproductive organs in girls and young women which do not result from congenital malformations, the effects of trauma, or infections. The educational processes of the schools are not entirely blame- less, but they are not responsible for the large percentage of acquired ill health in women so often charged against them. Faulty nutrition is the source of more ill health among school girls than all other causes combined. Measurements of large numbers of school children have shown clearly the direct relation existing between nutrition and growth. Chlorosis, many skin troubles, low power of resistance to some acute and chronic infections, slow recovery after acute 56 HYGIENE OF INFANCY AND GIELHOOD. infections diseases, and a low average of general health are all directly traceable to malnutrition. A relatively small number of under- fed children reach a reasonable proficiency in their school work. Good nutrition, therefore, is essential to good education. This ques- tion of nutrition is one for the family, but its recog-nized importance has found expression in some localities in Continental Europe in the provision of breakfasts and luncheons for the poor, with the result of astonishing better- ment in both physical and mental condition of the children. But evidences of malnutrition are common, also, among girls of the better classes, who often fail to eat enough plain, nourishing food, or suffer from loss of appetite con- sequent upon an indulgence in unsuitable food at the family table, or upon sweets obtained between meals from candy and cake shops and soda-water fountains in the vicinity of school houses. A warm, nourishing, mid- day luncheon is essential for a girl's good health. School sessions must be arranged with this in view, and where the distance makes it impos- sible for the girl to go home to obtain it, the school should see that suitable provision is made in or near the school building. In this latter case the food furnished should be supervised by the school principal, and an effort be made, at least, to guide the choice of the individual girl as to the kind and quantity of food eaten, Thomas Madden Moore says : " If the State, for reasons of public policy, determines that all children shall be compulsorily educated from their earliest years, it should certainly afford the means by which this may be least injuriously and most effectively carried out, by providing sufficient food as well as education for every pauper child compelled to attend school." Condition of Eyes of School Girls. — The result of the examination of the eyes of school children in those schools where medical inspection has been introduced are sufficiently significant to warrant the statement that no child should be permitted to enter school without having had the eyes examined by an ophthalmologist. The ophthalmic inspectors of I^ew York City found thirty-three and one-third per cent of children in the schools with defects of vision of sufficient importance to interfere with the proper pursuit of their studies. The effect of eye-strain on the general health of the child, the possi- bility of some interdependence between eye-strain and certain disorders of menstruation, insomnia, and nervousness, the presence of eye-strain as a causative factor in the production of scoliosis are all subjects which are being earnestly discussed, and the conclusions of those who can speak with authority show that no defects of vision can be regarded as trivial. Many parents are extremely averse to sending their children, especially girls, to an ophthalmol- ogist, permitting the child to suffer the consequences of a physical defect with no more reasonable excuse than the dislike of the esthetic effects of glasses. Attention to the eyes of children on entering school would protect them against the increasing percentage of defects of vision in the higher schools. Dr. Kerr, from his observations in London, found that ninety-five per cent of children between six and six and one-half years of age have normal visual acuity, A PHYSICAL CONDITIO]Sr OF THE SCHOOL GIEL. 57 steady increase in myopia is noted in the ascending grades. Dr. Hermann Colin, after testing ten thousand pupils, found twenty-two per cent with myopia in the youngest classes and fifty-eight per cent in the higher. School construction and school appliances should recognize the needs of the eyesight of the school child in the lighting and color of rooms, size, form and type of hooks, work from black-boards, school seating, methods of teaching writing, substitution of paper for slates. Kindergartens require too much close work from children. Condition of Ears, Nose, and Throat. — Many girls in both public and private schools are found to have defective hearing in one or both ears. Since ninety per cent of such cases are probably curable, if discovered early and properly treated, it becomes a matter of great importance that the cases which have escaped detection until the school-going age should receive suitable care before a condition of permanent deafness is established. Many cases of defective physical development and impaired health are directly due to the limitation of breathing capacity resulting from hypertrophied tonsils and post-nasal growths. Inasmuch as the tonsils and the peri-tonsillar mucous membrane of the j)harynx are often* the portals of infection for acute rheumatism, endo- carditis, and otitis media with mastoiditis, abnormal conditions of the tonsils and naso-pharynx, both acute and chronic, must receive careful and prompt attention. Acute tonsillitis in children can never be looked upon as an unim- portant disease, and following such attacks children should be kept from school until their health is fully restored. Kisch holds that there is some interde- pendence, either nervous or circulatory, between hypertrophy of the tonsils and disorders of menstruation, and cites instances of retardation of the appear- ance of menstruation and lack of development at puberty which were quickly corrected after the removal of hypertrophied tonsils. This observation receives some confirmation in the fact that a large proportion of the cases of either slight or severe dysmenorrhea among one hundred school girls between the ag-es of thirteen and eighteen, under careful medical supervision, had enlarged tonsils, or had had them removed. The rapid development, both mental and physical, frequently observed in the individual girl after surgical attention to these conditions is most striking, l^o less marked is the improvement after operation in minor conditions, as the adenoid expression, mouth breathing, defective nasal development, and the hoarse or nasal voice frequently accom- panying enlarged faucial and pharyngeal tonsils. Without doubt future inves- tigation will show causative relations between adenoids and serious diseases not at present referred to them, but we have even now sufficient knowledge to insist that the development of the growing girl shall not be threatened by the lack of their removal. The importance of determining the exact physical status of each girl upon entering school has been emphasized. It is equally essential that the results of such examination be followed by skilled attention to the defects discovered. It is of small avail to the welfare of the individual girl that the fact has been 58 HYGIENE OF INFANCY AND GIRLHOOD. revealed that the eyes are myopic, that scoliosis is present, or that adenoids obstruct the nasal passages, if means are not taken to remove such handicaps. Unfortunately, parents, and even family physicians, frequently oppose any active measures for removing such defects, as in a case of advanced scoliosis, recognized by the school physician in its incipiency, which failed to have any effective treatment because of the attitude of the family physician. School Buildings and Appliances and the Health of the School G-irl. — If the girl presents herself at the school clean and well, she should find the environ- ment of the school favorable to the preservation of her health and furnishing protection against infectious diseases. It may be truthfully said that most American schools do not, at present, afford such environment. Ideal condi- tions can be secured only by efficient sanitary oversight of school construction, school furnishings, and school administration. When one considers that the schools are often centres of infections, possibly the most common source for young people, it is evident that all communities should establish medical inspec- tion and sanitary supervision as a measure of public hygiene. Indeed it is questionable whether compulsory school attendance is warrantable without the protection afforded by such compulsory supervision. School architecture has made great strides in recent years, and many modern school buildings in both city and country districts are admirably adapted to their purpose; but even in these, the hygienic demands of the school have not always received the attention demanded by their importance, while many old school buildings are entirely unsuitable for use, on account of their location, construction, lack of suitable heating and ventilation, and of proper lighting. In all school build- ings, even the best, school management is responsible for important hygienic necessities that often receive scant attention ; over-crowding and improper seat- ing are common, out-houses and toilet rooms are insufficient, unsuitable, or uncared for; methods of school cleaning are inefficient and even dangerous; drinking cups are used in common; school books, pencils, and other appliances used in common are not cleaned nor disinfected ; children habitually dirty are not separated from the clean, nor is there provision anywhere for school baths. A more widespread knowledge of existing conditions in schools, as well as a better general knowledge of sanitation, will be necessary before better sanitary conditions will be common in all schools. The number of cases of communicable parasitic and skin diseases discov- ered among school children by medical examiners suggests the desirability of separating the habitually dirty children from the clean. The services of the school nurse in following up cases of this nature have been productive of very marked improvement in the condition of personal cleanliness of individual children. Health talks to mothers under the joint supervision of educational and health authorities Avould be far-reaching in hygienic results. The dangers of dust as a carrier of disease germs make a reform in methods of cleaning school-rooms necessary. Janitors and care-takers must be supervised and trained in the best methods of moist cleaning and dusting. PHYSICAL, TRAINING OF THE SCHOOL GIKL AND MEDICAL GYMNASTICS. 59 Boston is said recently to have spent one thousand dollars in one year for feather-dusters ! Out-houses and toilet-rooms must receive more enlightened attention. Dirty, unsanitary, and unsuitable closets are common, and usually there is no supervision except that given by the care-taker. The conditions of these closets is in many ways a menace to health as well as to morals. Moreover many cases of constipation in adult life may be traced back to school condi- tions where the closets provided were so disgusting as to inhibit in a sensitive child the desire to go to stool, or to evacuate the bladder. All teachers of the young should be instructed in the elements of personal and of school hygiene. Their intelligent initiative and cooperation is neces- sary in all measures for rendering school attendance a healthful experience. The teacher's ideas of ventilation, for instance, are what eventually determine the condition of the air of the school-room ; her example in matters of per- sonal cleanliness, neatness, and clothing may influence markedly the habits of the girls under her care. ISTo system of medical super- vision can be adequate or effective without the cordial cooperation of teachers who have an intelligent knowledge of the objects to be gained. Physical Training and Medical Gymnastics. — Carefully supervised physical training is one of the most important and rational fac- tors in the life of the school girl. J. Madison Taylor says : " Children cannot be expected to grow up properly unless directed." This fact is easily demonstrated by a comparative study of girls who have had every favorable oppor- tunity for spontaneous growth and those who have had the advantages of systematic train- ing in a modern gymnasium. Indeed the physical differences between girls of sixteen or seventeen who have had well-directed gym- nasium work and those who have not had it are so marked that an experienced examiner has little difficulty in separating the one class from the other by simple inspection. ]^o one with medical training who has had the oppor- tunity of examining large ninubers of healthy girls in preparatory schools and observing the effects of good gymnasium work upon them, can fail to become an enthusiastic advocate of systematic educational gym- nastics as a necessary part of a girl's education. Fig. 37. Moujiij Gymnasium Suit, USED IN Madame Osteeberg's Physical Training College, England. 60 HYGIENE OF INFANCY AND GIRLHOOD. Various systems of gymnastic training are used in this country and each system has certain advantages, but whatever the system, the work, to be use- ful, must be regular, systematic, and adapted to the needs of the average healthy girl. It should he given by a special teacher trained for the work, should require a special dress for the girls (see Fig. 37), and should have a room built and equipped for the purpose. It needs always careful and con- tinued medical supervision. It must seek to gain two results: (1) The gen- eral systemic effects of exercise, such as improvement in respiration, circula- tion, digestion, etc., including the acquisition of increased nervous control over bodily movements; (2) the correction of physical defects, such as faults of posture, carriage, etc., which are not the result of pathological changes in tis- sues, but are largely due to the environment of school life. All the systemic effects of exercise gained in the gymnasium could doubt- less be obtained from out-door athletics with the additional advantages of the open air, were it possible to make girls take this in definite amounts systematically and regularly under guidance, but this is not possible. The corrective work distinguishes the re- sults gained in the gym- nasium. The necessity for such work is shown by the fact that eighty per cent of girls who enter college with- out previous good gymna- sium training show defects of posture and carriage which are almost entirely lacking in those who have had systematic gymnastic work. In this connection reference should be made to the subject of proper school seating, as this is one im- portant factor in causing defects that need remedy. Although the principles of correct school seating are Fig. 38. — Adjustable Desk with Narrow Box; Both Seat ^ray,^ aiiTi-nla -fpTo- cplinol^ AND Desk are Adjusted to the Pupil when Seated. very Simple, lew scuuoib have proper seats and desks. Many are non-adjustable, and many of the so-called adjustable seats and desks cannot be properly fitted to the individual pupil. The rules to be followed are : (1) The height of the seat should equal the distance from the floor to the under part of the knee; (2) the height of the desk should equal the distance ■■ V ^Hp ^^ '^^I^^^I^IB ■ ^^^^^^^^f ^ .-.r. M Ks P m ■^■p ^fk '----r-^ ^ m w M ■ r^- ^^3 ^ PHYSICAL TEAINIISTG OF THE SCHOOL GIKL AND MEDICAL GYMNASTICS. 61 from floor to elbow plus tliree-quarters of an inch ; ( 3 ) there should be a minus distance of at least half an inch between front edges of desk and seat ; (4) the box of the desk should be sufficiently narrow at its front edge to permit above adjustment without pressure upon knees. Measurements should be taken and the desk and seat of each girl prop- erly adjusted at the begin- ning of each school year. The growth of the girl should be watched during the year and readjustment made whenever necessary. The accompanying illustra- tions show an ideal adjust- able desk (Fig. 38) prop- erly fitted, also a so-called adjustable desk incapable of adjustment on account of the depth of the box at the front edge (Fig. 39). In every scheme of phys- ical training out-door ath- letics should supplement the work in the gymnasium. The habit of out-door exer- cise should be established in the early years of life and the growing girl taught to regard it as one of the essentials of healthful living. Several hours each day should be spent in the open air by every girl attending school. It would be well if the school could make compulsory a definite amount of out-door exercise under guidance. Nearly all the sports and games boys are taught in the open air can be used equally well for girls, when guarded by medical inspection. Playf air says : " One chief reason for the more frequent break-down of girls than boys at school is probably that the male's work is safeguarded by an amount of physical exertion in the way of sports which tends to keep him in health, and that this is usually compulsory in boys' schools, and optional in girls'." School grounds should be ample. Athletic fields for girls are as necessary as for boys. Playgrounds in parks should be set aside for girls. They should receive instruction in swimming. School swimming pools and public swimming baths (see Fig. 40) afford facili- ties for such instruction, which are easily popularized. The habit of taking exercise in the open air, firmly fixed on the girl, makes it a necessity for her when her formal education is completed, and this is of inestimable valiie in maintaining and promoting her health in after life. 1m. -Desk "with Irons Similar to that Sitoavn in Fig. This is sold as an adjustable desk, but the box is six inches in width at the front and cannot be adjusted to the majority of pupils without pressure upon the knees. 38 62 HYGIENE OF IlSTFAlSrCT AND GIET.HOOD, The medical pxaminer must carefully differentiate in school girls those cases of slight myopathic asymmetry; faults of carriage, as protruding head and abdomen; and careless postnre, from those more serious cases in which a slight lateral deviation of the spine has been neglected nntil it has become l^athologic, involving the bony structures and requiring special corrective work, Fig. 40. — Swimming Pool Belonging to Public Bath System. Patterson Park, Baltimore, Girls' day. or medical gymnastics. The prevention of scoliosis, and its early cure, is of especial importance for girls, because of the changes which may result in the bony pelvis and their effects upon the mechanics of parturition. The early recognition of this defect in girls is imperative. Most cases are unfortunately not subjected to physical examination until well established. Every general practitioner should know the diagnosis and the probable etiology of scoliosis, but the treatment should not be undertaken by the school gymnasium. Schul- thess thinks that, although schools and attitudes in study may be a detrimental factor in lateral curvature, they do not furnish the chief etiological influence. J. M. Taylor holds that many faults of attitude are due to original errors of construction, some hereditary. One of the latest theories of the etiology of scoliosis assumes the faulty construction of the bodies of the vertebrae as the predisposing factor. This theory receives some confirmation in the fact PHYSICAL TRAlNllSfG OF THE SCHOOL GIKL AND MEDICAL GYMNASTICS. 63 demonstrated by tlie medical examination of many school cliildren from six to eight years of age that very few are absolutely symmetrical even at this early age. All sucli children need careful watching throughout the whole period of school life, in order to determine whether they improve constantly under general care, careful attention to nutrition, and simple bi-lateral work in the gjmmasium, or whether there is increasing asymmetry and a necessity for corrective work. Tlie treatment of scoliosis is not a legitimate part of school work, and should not be undertaken by the school gymnasium. It needs medically supervised special individual work, given by women specially trained in the apjDlication of gymnastics and massage to orthopedic cases, as well as sufficiently intelligent and sympathetic to encourage the child and inspire her to put forth her best exertion in the persistent and long-continued effort needed for the improvement of her deformity. The child should not be taken from school unless it is clearly shown that the school, even when the amount of work it demands is modified, is undoubtedly affecting her general health. Much harm often comes to the girl by separating her from her class, interfering with her education, and concentrating her attention upon her physical condition, thus sowing the seeds of physical introspection and invalidism. Fig. 41.- -Faulty Carriage in Young Girl WITHOUT Actual Defect. Fig. 42. — Effect of Physical Training upon Faulty Carriage Shown in Fig. 41. 64 nYGIEXE OF IXFAIv'CY AXD GIEEITOOD. Eeference to the illustrations (see Figs, -il aud 4il ) Avill show the possi- bility of improTcmcnt iu carriage under supervised exercise. The results of Fig. 43. — A Case of Slight Lateral Cueva- Fig. 44. — Same Case as that Shotvx in Fig. TURE OF SpIXE IX A ScHOOL GlEL DETECTED 43 AFTER OXE MoXTH'S SYSTEMATIC EXER- BY School Physical Ex.^iixatiox. cise. treatment in a case of slight lateral curvature in a school girl Tvhose defect was discovered by medical examination in school and given special treatment Fig. 45. — A Case of Se-st:re Lateral Cuhva- Fig. 46. — S.^me Case as that Showx ix Fig 45 TUKE OF the SpLVE IX A SCHOOL GlEL. AFTER ThREE MoXTHS' D.A.ILY EXERCISE. SCirOOL LIFE IN" ITS RELATION TO PUBERTY, 65 of the kind suggested, is shown in Figures 43 and 44. Similar improvement in a severe case is shown in Figures 45 and 46. School Life in Its Relation to Puberty. — It is useless to concentrate atten- tion u]30u one period of a girl's life and to attempt by over solicitude at this time to remedy the effects of early mistakes in hygienic living and hered- itary tendencies. It is unreasonable to anticipate normal puberty in the weak, poorly nourished, and imperfectly developed girl who has been permitted to violate the laws of health throughout childhood. The advantage of a good physical start in life is most apparent at the age of sexual development. The physiologic demands upon the growing girl are greatest at this time. That the period from twelve and a half to fourteen and a half years in girls is that of gTeatest increase in height and weight is indicated by the following tables : TABLE SHOWING RATE OF INCREASE IN WEIGHT OF GIRLS FROM AGE OF 62 to 151 years. Frederic Burk, Am. Jour. Psych., April, 1898 Several Thousand Observations. Age. Average for each age. Absolute annual increase. Annual increase. In pounds. In pounds. Per cent. 6i 43.4 n 47.4 4.3 9.9 8i 52.5 4.8 10.0 9i 57.4 4.9 9.3 m 62.9 5.5 9.6 m 69.5 6.6 10.5 m 78.7 9.2 13.3 m 88.7 10.0 12.7 14i 98.3 9.6 11.9 15| 106.7 8.4 8.5 TABLE SHOWING RATE OF GROWTH IN HEIGHT OF GIRLS FROM 6i to 15i years. Rep. U. S. Com. of Ed., 1896-97. Franz Boas. Number op Observations 4,000. Age. Average height for Absolute annual Percentage annual each year. increase. increase. 6i Inches. 43.3 Inches. 7i 45.7 2.4 5.5 8i 47.7 2.0 4.4 9* 49.7 2.0 4.2 lOi 51.7 2.0 4.0 m 53.8 2.1 4.1 m 56.1 2.3 4.3 m 58.5 2.4 4.3 144 60.4 1.9 3.2 15i 61.6 1.2 2.0 66 HYGIElSrE OF INFANCY AND GIRLHOOD. That strength docs not keep pace with muscle growth is shown by the falling off in strength tests, and is plainly indicated by the careless carriage and awkwardness of many girls at this age. Inability to give fixed attention to work and listlessness, demonstrate accompanying mental inertia. The school curricnlnm should take cognizance of the physiological and psychical changes going on in the pubescent girl. Under twelve years the pressure and stimu- lation of the school are of little consequence to the normal girl. She is not likely to respond mentally in a way harmful to her health, but in tlie follow- ing years the demands of the present school Mall contain factors unfavorable to her best development. Henderson in his " Education and the Larger Life " has expressed the conditions well when he says : " The lower schools would be good if the high schools would let them, and the high schools would be good if the colleges would let them, and the colleges would teach the knowledge of most worth, if the community would let them. Apparently, it is a superior madness which drives us." Whatever harm educational methods of this high pressure system inflict upon a girl's health, close observation of girls in college and in preparatory schools certainly places the responsibility upon the pre- paratory schools. School work must be adapted to the capacity of the average girl, not to the ability of the exceptionally gifted. The school, however, is frequently held responsible for the ill health of individual girls, when it has really furnished the only favorable environmental conditions under which they have lived, B. Sachs finds the chief causes of break-down in school life are the tendencies of parents to force a child to keep up with other children who are mentally or physically stronger and in the conditions of life in homes and in society. " Mental fatigue," he says, '' is no more a morbid symptom than physical fatigue, provided it be tran- sitory and be recovered from promptly after a short period of relaxation. It is the school alone which in our American life exerts the slight restraining influence which our children need above all else." To what extent the injurious consequences which may reasonably be ascribed to school conditions manifest themselves by disturbances • of menstrua- tion is a difficult question to answer. Certainly the amount of menstrual dis- turbance occurring among school girls has been much over-estimated. Engel- mann has tabulated five thousand cases of beginning menstruation and finds about sixty per cent with more or less menstrual pain. Chapman thinks that fully seventy-five per cent of girls Avould give a history of painful menstrua- tion. Clark says, " The menstrual function should, of course, occur painlessly and with perfect periodicity, but it is quite rare to find this function unat- tended with some discomfort and very frequently there is the most intense cramplike pain, which totally incapacitates the patient for one or more days before the onset of the fiow and for one or two days after it is established." These figures are not corroborated by a study of the menstrual history of a group of school girls under medical supervision for several years preceding and following puberty. Such a study shows that in about seventy-five per cent HYGIENE OP PUBERTY. 67 of school girls normal menstruation occurs. In a representative group from a private school only twenty-five per cent reported habitual discomfort. Fifty- six per cent of these, or fourteen per cent of the whole, remained away from school regularly one or two days ; thirty -six per cent of these, or nine per cent of the whole, had sufficient pain to go to bed for one or two days. Statistics of girls of the same grade in public schools, the girls being less likely to report slight discomfort, show still smaller percentages. Summary.- — The best physical development of the growing girl demands : (1) More rational home care and training throughout childhood and youth ; (2) school conditions which furnish every facility for healthful life and growth, best secured by a wide extension of an effective system of medical inspection and sanitary supervision; (3) com- pulsory physical training in the schools ; (4) revision of the curriculum of preparatory schools to relieve the pressure of school work. HYGIENE OF PUBERTY AND HYGIENE OF OCCUPATION. Hygiene of Puberty.- — Reference has already been made to the necessity of recognizing the years marking the advent of puberty in school curricula. It is convenient to take up here more directly a consideration of the personal hygiene of this period. A rational hygiene of puberty must be based upon an understanding of the physiological and psychical changes which the girl is undergoing. It is a period for wise direction and sympathetic guidance. All the resources of physical and moral education must be brought into play to establish right habits of living, for the future woman is moulded at this time. The physiology of fatigue is too obscure at present to determine with scien- tific exactness the amount of work, mental or physical, which may be taken as a safe standard for the normal girl with average mental capacity, but it is certain that from her twelfth to her fifteenth year she should have the benefit of any doubt, and the school and home should require too little rather than too much. Strain and stress of emotional life, in especial, must be avoided. Much of the re-education needed as a therapeutic measure in the treatment of the psychasthenia of adult women will become unnecessary when the girl is properly educated at this age in the home and in the school. ITutrition. — This is a point which requires close attention. Diseases of malnutrition common at this period depend as often upon improper food as upon insufficient food. Rich and poor may suffer equally; the one from overfeeding and improper feeding, the other from lack of food. A plain, mixed diet taken at regular intervals must be insisted upon. Patience and perseverance on the part of mothers, with cordial cooperation between mothers and teachers, will be required in this matter of diet. Girls frequently suffer from the dietetic errors, dietetic fads, and dietetic neglect of the family table. It is as easy to teach them to eat good plain food at regular intervals 68 - HYGIENE OP INFANCY AND GIRLHOOD. as it is to teach them to read good books. The school hours of the child and the business hours of the father may conflict, but the home must meet the difficulties. The importance of a knowledge of dietetics in relation to health and gTowth cannot be urged too strongly upon the general practitioner. Mothers and young girls need very definite instructions as to the kind of food to be taken and its quantity. It must not be forgotten that the processes of nutrition involve the excretion of waste as well as the in-take of new material. The care of the health of the growing girl involves the prevention and often the cure of constipation as well as attention to the demands for evacuation of the bladder. Exercise. — Exercise in the open air, after ' nutrition, is the greatest hygienic need of puberty. The necessity and use of systematic gymnastic work under medical supervision as an essential part of the school education has already been insisted upon, but this work in the gymnasium cannot take the place of exercise in the open air. The school and the home should pro- vide for out-door sj)orts and games. Tennis, golf, hockey, basket-ball, rowing, swimming and skating are all particiilarly useful for the developing girl. All sports into which the spirit of competition enters should be carefully guarded. The value of inter-school and inter-collegiate athletics for girls is extremely doubtful, as excessive physical and mental strain cannot be avoided. The athletic ideal is not to be aimed at; what is required is to cultivate a desire for the pleasurable satisfaction that comes with healthy fatigue of the muscles by work in the open air. Among all exercises great stress should be laid upon walking; girls should acquire a love for brisk cross-country walking. Care in advising exercise and athletics must be observed ; neurotic girls, girls with heart lesions, anemia and other physical disabilities must be kept off basket- ball teams, tennis tournaments, and other games where excitement runs high. Physical trainers cannot be trusted to judge of medical conditions, and family physicians are frequently at fault. This matter of exercise in the open air should receive careful attention from the family physician; offhand advice to refrain from some particular exercise, or advice to strenuous exercise not adapted to the individual girl often work irreparable harm. The general practitioner should be familiar with the physiology of exercise, with the methods of physical training used in the schools, with the nature of the vari- ous athletic games and their adaptation to the needs of the individual girl. He should be able to give definite directions as to the kind of exercise to be taken and its amount. It is his duty before prescribing exercise for any par- ticular girl to make a thorough physical examination, and before advising against exercise to examine most carefully into the life and habits of the girl for causes for her complaints rather than to ascribe them to systematic exercise. Rest and Sleep. — Eight or nine hours should be the minimum require- ment for sleep, and this should be taken in a w^ell ventilated, clean room. HYGIENE OF PUBERTY. 69 Alcoves, recesses, dark rooms, corners, are unsuitable places for beds. Girls quickly acquire the habit of sleeping with all the outside air they can get, irrespective of its temperature, and the windows of the bed-room should be freely opened at all seasons of the year. The bed clothing must be sufficient for warmth, but light in weight. Single beds should be provided. Simplicity in the furnishings of the bed-room and scrupulous cleanliness are to be aimed at. Bare floors with rugs easily cleaned, washable curtains and hangings, and walls easily renovated are desirable. With a better understanding of the rela- tion of dust to disease we may look for great modifications in the popular standard for the furnishing of bed-rooms, in which approximately one-third of life is spent. Employment at Home. — The time available for exercise in the open air is interfered with by many unnecessary exactions upon the girl in the household. What these are would involve a discussion of the whole question of the organization of the household and the teaching of domestic science which has no place here. Household work should form an essential part of the education of every girl ; but the unnecessary and thoughtless demands made upon the growing girl in poorly organized households are part of a bad moral and physical training. Long hours of practice on the piano must be avoided. The posture, if long-continued is bad, the confinement is bad, and the attempt at prolonged attention is bad. If skill in the use of musical instruments can be acquired only by long consecutive sittings, then, for the average girl, a choice must be deliberately made between music lessons and good health. A reform in the method of teaching music, especially the piano, is much needed. Sewing on the machine for long consecutive periods is objec- tionable for precisely the same reasons. Long-continued stand- ing for any purpose is also harmful. Frequent changes of posture give most favorable conditions for a normal pelvic circulation. Bathing. — The bathing habit, if not already established, must receive attention. The bath for cleanliness and the bath for stimulation should be enforced. Most girls must be taught that the minimum of cleanliness requires a full bath at least twice a week with soap and warm water, and at the least, daily attention to the exposed parts of the body, to the axillae, the external genitalia, and to the feet. It is curious to note hov/ averse mothers are to the use of soap in care of the face of the girl for fear of its effects upon the skin, when they cheerfully acquiesce in its necessity for the delicate skin of the baby. It is difficult even in acne to enforce proper cleanliness of the skin of the face. Most girls, too, must be taught the value of a cold bath as a part of the morning toilet, in the form of a plunge, a sponge, or a shower, with brisk friction subsequently. Such a bath should follow any form of active exercise. Baths other than these referred to belong to the resources of hydrotherapy and ought to be taken under medical supervision. 70 HTGIENE OF INFANCY AND GIELHOOD. Clothing. — At the establishment of puberty with the develoj)ment of the physical characteristics of the woman, the child's clothes are replaced by those of the adult. A woman's clothes are the despair of the hygienist. The dic- tates of fashion pay slight attention to the physiological demands of clotliing. Tight collars, tight corsets, heavy skirts supported by the hips and waist, shoes too small and badly shaped, and a total disregard of the use of clothing in the maintenance of body temperature characterize the dress of the so-called " well-dressed " woman. With such standards before her, with the awakened desire of making herself attractive forcing itself upon her consciousness, the difficulties of adajDting the dress of the pubescent girl to her hygienic needs are well-nigh insurmountable. Rebellion at first against the corset is strong, but she accepts it, adapts her feelings to it, and finally defends it. In a thousand measurements of women and girls, showing a constriction of the waist varying from one to five inches Fig. 47. — Interior Applarance of a Cadaver Showixg Constriction and Displacement Due to Corsets. (From forth-coming "Sm-gery of the Kidnej'," by H. A. Kelly.) and more, one single woman in the series could be brought to acknowledge that her corset felt too tight. While opinions as to the causal relation between the corset and pelvic congestions, movable kidney and enteroptosis in women differ, there is no doubt, as Glenard has shown, that the corset produces arti- ficially, while it is worn, the dislocations of the organs brought about by other causes. This is well illustrated by reference to the diagrams (see Fig. 47). As an article of dress for the girl the corset must be looked upon as distinctly prejudicial to healtli, and as entirely unnecessary. Other more hygienic gar- ments may be made to give whatever support the bust needs. HYGIENE OF PUBEKTY. 71 The weight of clothing and its support should be regulated. The weight of skirts should he kept at a minimum. It is a rule to which few exceptions are found that the entire weight of women's skirts is supported from the waist — and yet the reasons for supporting a woman's clothes hj the thorax are greater than those demanding such support for the little girl. The clothing sold in the shops represents the habits of the community, and the impossibility of buying suitable garments for girls of sixteen shows how early the women's clothes with their dis- advantages are forced upon the girl. A properly fitting shoe is necessary for the sup- port of the body, for correct carriage, and for the maintenance of the integrity of the arch of the foot. The shoe of the average young woman is too small, while its shape is grotesque and absurd (see Fig. 48). Its size, its shape and its heel interfere to such an extent with the mechanics of support and with the circulation Fig. 48. — Shoemaker's Walk- ing Shoe for Girls. Fig. 49. — Impression of Foot OF School Girl with Out- line OF Shoe Worn. Fig. 50. — (a) Proper Soles for Normal Feet. (6) Shoemaker's Soles (Whitman). (From W. L. Pyle, "Personal Hygiene.") as to make it both a direct and indirect cause of local injury and of remote disturbances of the general health. ISTo reform in woman's dress is more 72 HTGIEXE OF IIS'FAiSrCT AXD GIRLHOOD. urgently needed than an adaptation of the shoe to the function of the foot. Figure 49 shows the relation between a foot of normal shape and the shoe into which it is commonly forced. Figure 50 shows shoes adapted to the shape of the foot and the proper fulfilment of its function as a means .of support to the body. Instruction of Growing Girl in the Physiology of Reproduc- tion. — All women who have the care of growing girls in the school or in the home should have an iutelligent knowledge of the physiological changes going on in the developing girl. They should have the ability to teach girls in some proper way before the first menstrual period a few simple facts about repro- duction, and the very little that is known about the significance of the men- strual flow. Such instruction will be of benefit to girls morally as well as physically. There is little doubt that the ignorance which envelops this whole subject for the average mother and teacher, and the secrecy maintained about it, result in great harm to the mind and body of the developing girl. Sexual information girls get in plenty, but the sources from which it is obtained are too often ignorant and vicious servants and companions, obscene literature, and bad advertisements. There is no real difiiculty in giving the necessary instruc- tion in a helpful way, provided it is given with knowledge and sympathy by a woman who has the affection and confidence of the girl. This is a part of the education of the girl that preeminently belongs to the mother, but, unfor- tunately, for the present at least, this teaching must be relegated in most cases to the schools, and therefore teachers should be properly instructed. The general introduction of the study of biology into high school courses and into those of teachers' training schools is making women teachers familiar with the great facts of organic reproduction, and th'e difficulties of giving them ade- quate instruction in the physiology and hygiene of the reproductive system have practically disappeared. The nature study now common in most schools will make the task of instructing girls of thirteen comparatively easy, provided the teacher has tact and knowledge. Great care must be taken not to direct the attention of the girl to her sexual organs, nor to sexual things. It is for this reason that an active life out of doors with many varied interests outside of herself should be encour- aged. Her reading must be carefully guided. Introspective habits should be discouraged, and an objective life cultivated. Hygiene of Menstruation. — The periods of the menstrual flow in the healthy girl require no marked deviation from her normal hygienic habits. Great cleanliness of person and of clothing must be enjoined, in opposition to the prevalent idea that bathing and changing underclothing must be avoided. The daily bath must not be intermitted ; a cold sponge bath may be substituted for a cold plunge, but there is no necessity for changing the habit of daily bathing, while the underclothing requires more frequent changing than at other times. Girls should not be taught to use a vaginal douche after each menstrual period. HYGIENE OF PUBERTY. 73 The diet should be plain and unstinmlating, in other words a diet suitable for a girl at any time may be taken during the menstrual period. There are many fanciful ideas about the effect of various articles of food upon the men- strual flow, but there is no evidence that, in the normal girl, the function is affected by using any particular article of diet. Excessive exercise should be avoided. Many women take habitually the same amount of exercise, and teachers of physical training, who do not suffer from dysmenorrhea, make no difference with their systematic exercise, appar- ently with no ill effects. Some healthy girls habitually rest a day or two at the menstrual period because they have been taught to do so, but unless there is marked dysmenorrhea, this is not necessary — on this question of rest during the menstrual period nothing has been added to our knowledge to vitiate the conclusion drawn by Dr. Mary Putnam Jacobi in 1875 (" The Question of Rest for Women during Menstruation " ) . She says, " There is .nothing in the nature of menstruation to imply the necessity or even the desirability of rest for women whose nutrition is really normal. The habit of periodical rest in them might easily become injurious. Many cases of pelvic congestion developed in healthy, but indolent and luxurious, women are often due to no other cause." The treatment of the disturbances of the menstrual function will be dis- cussed in future chapters, but it may be permitted here, in discussing the hygiene of the growing girl, to emphasize the necessity of extreme care to avoid the suggestion of pelvic disease to the young woman or to the growing girl. Un- fortunately, the possibility of giving or withholding the suggestion is not often in the power of the physician. The teaching of gynecology twenty-five years ago, with the constant pelvic examinations, local treatment with douches, tam- pons, etc., dilatations and curettage for " the moral effect " has fixed pretty firmly in the minds of women the idea that the most frequent source of ill health of girls is to be found in the pelvis. A prominent gynecologist of a gen- eration ago told his patients that if a woman knew the danger she was in from her pelvic organs she would not step from her carriage to the pavement; the effect of such teaching upon practitioners and patients has been harmful in the extreme. It has been hardly possible in the present generation for a neurotic or hysterical girl, or one suffering from malnutrition, to reach the age of seventeen without having passed through some more or less prolonged gynecological treat- ment by the general practitioner, or, if she has avoided the physician, without having used largely the various nostrums or local applications of the patent medicine venders. It is difficult even for a healthy girl to rid her mind of constant impending evil from the uterus and ovaries, so prevalent is the idea that woman's ills are mainly " reflexes " from the pelvic organs. If symp- toms are suggestive of pelvic disturbance a young woman should be examined under an anaesthetic. Local treatment should be avoided unless absolutely necessar3^ On the other hand, pelvic examination when symptoms point to its necessity, must not be postponed by considerations of false delicacy. Here 74 HYGIENE OF INFANCY AND GIRLHOOD. again women suffer from the secrecy wliicb^ for them, has surrounded all the phenomena of reproduction. Hygiene of Occupation. — The relation of the school to the health of the girl during the school-going period (eight to seventeen) has been fully considered, hut as there is an increasing tendency to prolong the education of girls beyond the high school, and since many girls leave school before the age of seventeen, a discussion of the hygiene of the growing girl would be incomplete without a reference to the conditions favorable or unfavorable to her health in the envi- ronment in which she finds herself subsequent to her withdrawal from the sec- ondary school. This involves a discussion of the relation to the health of girls and young women, (1) of industrial life, (2) of the social life of the leisure classes, (3) of college life. This part of the subject may be conveniently re- ferred to as the hygiene of occupation, using the phrase with another than its usual hygienic significance. Occupation both mental and physical is a physiological necessity for girls and women ; some regular and systematic work, whether in the household or outside of it, contributes to their health, while the lack of it is one of the most frequent sources of ill health among unmarried women. It must be remem- bered that occupation should be interesting and should not require excessive physical or mental strain. More women probably suffer in health from lack of work than from its effects. Occupation is harmful to health, if the external conditions under which work is done are unhygienic, or if by its nature it requires too great an expenditure of energy or too prolonged attention. Women too often hold occupation responsible for bad effects upon the health w^hich are really due to the faulty personal hygiene of the worker. Influence of Industrial Life upon the Health of Women. — The agitation of the question of child labor in the last few years has revealed con- ditions for young girls some of which are inhuman and intolerable — they are so bad as to be absolutely defenceless from social and economic reasons irre- spective of health, and reform will come, though perhaps slowly, that will make it impossible to exploit the work of a girl who has not reached the age of puberty. The special dangers to health of various individual occupations can- not be taken up here. Considerable experience with working girls demon- strates that the ill effects upon health due to external conditions are: (1) Long confinement in-doors in superheated, badly ventilated, dirty rooms ; ( 2 ) work permitting little change of posture and enforcing either long-continued sitting or standing; (3) contact with unhealthy work companions suffering from tuberculosis or other infectious diseases. These conditions are common to the poorly paid unskilled laborer and to the skilled. Clerks in offices and teachers in schools are often under worse conditions for their health than factory girls. The remedy for these conditions will never be effective until all places of employment for women are under rigid inspection of a competent health depart- ment with power to enforce sanitary conditions. This inspection should eventu- ally include employment at home and conditions under which domestic servants HYGIEIVTE OP OCCUPATIO]Sr. 75 live. Among the various results that have grown out of the campaign against tuberculosis has been the institution by great employers of labor here and there throughout the country of the physical examination of employees in industrial establishments. There is every reason to look for a gradual extension of medi- cal inspection to all those who work in close contact with each other, with the resulting improvement in personal and general hygiene which always follows systematic medical inspection of special classes. The health of the working girl suffers too often from faults of personal hygiene. Malnutrition due to insufficient and improper food is among the most frequent causes of ill health. Either no breakfast, or a hasty breakfast of bread with coffee or tea, no luncheon or an insufficient one^ with fatigue often so gTeat that no supper is eaten, is a frequent history of these cases, if the physician persists in getting at the personal habits. Coffee and tea may be the chief dietary. Tonics prescribed for the working girl who needs food, and recreation out-of-doors give little result. Many working girls spend money for drugs, jDrescribed by physicians, pharmacists, and friends that ought to be used for buying food. The education of the working girl, too, as to the relation of food to energy, and of the kind and quantity of food she needs is important, but the kind of food she needs must be easy to get, or she goes without it. Constipation, too few hours of sleep, and these spent in rooms occupied by several others, with no ventilation, are, with faulty diet, and unhygienic clothing, the principal causes of bad health among working girls 'which they can, in a measure, control. In so far as her occupation increases these faulty habits common to rich and poor alike, so far her occupation is responsible for her ill health, in addition to the bad environment of shop and factory. Shorter hours, with encouragement in simple out-door recreations, and more ample pro- vision for these would bring about great improvement in the average health of the working girl. Influence of Social Life upon the Health of Women. — The life of the young woman of the leisure classes whose school education is com- pleted at sixteen or seventeen is too often distinctly unfavorable to her health. It is tacitly understood, though not always consciously expressed, that for four or five years her main function is to make herself attractive and to enjoy life, acquiring irregularly and incidentally some knowledge of the management of a household. Her standards of attractiveness, and her standards of pleasure usually have no hygienic basis. The exactions of an active social career under the most favorable conditions are unquestionably a source of excessive physical and emotional fatigue. Indolence alternates with over-stimulation, intellec- tual activity is in abeyance, the desire for entertainment and excitement is insatiable, physical exercise is irregular, lacking, or excessive, and clothes are used for ornament according to the dictates of fashion without considering the needs of the body. The necessity for rest and for sleep is disregarded. The poor try to keep pace with the rich. It is in this exclusively social life that the 76 HYGIENE OF INFANCY AND GIRLHOOD. foundation is often laid for the ill health of adult women which is frequently and carelessly attributed to '* over-education." Influence of College Life ui)on the Health of Women. — The effect of college education upon the health of women has been the subject of much discussion in medical and in general literature. These discussions have been obscured usually by the loose way in which the phrase "'higher educa- tion " has been used to desig-nate any kind of school education from the high school to the university. It seems now generally conceded that as much edu- cation as a girl may get in the schools before her seventeenth year is not only not harmful, but if given under proper conditions, is distinctly favorable to her health. An examination of the arguments upon which injury to health of women is predicated as a result of education beyond the high school finds them based upon the hypotheses: (1) That mental activity is in itself harmful to the health of women (this in recent years is not often suggested) ; (2) that emotional stress and strain represented by worry and anxiety necessarily accom- pany the conditions of college life, and bring about such interference with gen- eral nutrition as to produce permanent injury, showing itself principally in some failure of the reproductive organs manifested by menstrual disturbances, or, after marriage, by sterility, or failure in the function of lactation. Statis- tics have been collected designed to show that college life has serious effects upon the menstrual function, upon rate of marriage, and upon the production of children. The fallacy of the statistical method and the method of the questionnaire as bearing upon the subject involved is easy of demonstration, but cannot be discussed here. That a childless marriage, however, or a small family always indicates either sterility on the part of a woman, or lack of desire to bear chil- dren is an untenable proposition, though one that too often passes without chal- lenge in current literature. Any physician who has had wide and intimate acquaintance with college women knows that they do not evade, on the con- trary, they welcome the duties and responsibilities of married life, and bring to their performance mental and physical attributes from which society and the race may profit. Obviously, the effect of college life upon the health of the individual girl can be determined only by a knowledge of her physical condition at entrance, her- personal and family history, her hygienic habits, the exactions of college life, as well as by continued medical observation during her course, together with a medical knowledge of her subsequent history. If one college com- munity, drawing its students from all parts of the country, may be taken as fairly representative, it may be confidently stated that conditions of college life are distinctly favorable to the health of young women. In a long series of observations in one such community not a single instance of nervous break- down or chronic ill health has been observed in which the legitimate de- mands of college life could be considered an essential etiological factor. This point may be illustrated by reference to the frequently quoted statistics of HYGIENE OF OCCUPATIOlSr. 77 G. W. Engelmann, apparently showing that college life brings about menstrual disturbances. In the first place, an analysis of more than one thousand his- tories does not corroborate his figures. Sixty-five to seventy per cent of college women never suifer with dysmenorrhea. Taking two classes giving relatively high percentages for dysmenorrhea of two hundred and thirty-two, sixty-five, or twenty-eight and two-hundredths per cent, had some menstrual disturbance when they entered college ; of these, only thirty-two, or thirteen and seventy- three hundredths per cent, had sufficient dysmenorrhea to require a day's rest at each period. JSTine of these were otherwise healthy girls that no stretch of imagination could have regarded as injuring themselves by mental and physical over-exertion. Among these nine was the only girl in whom dysmenorrhea increased during her college course, and in no single case was it necessary to consider that college work had any causative relation to the dysmenorrhea. For the girl with fair health who can enter college " without conditions " there is nothing to fear and much to be gained by prolonging education through a four years' course. Why should it be unhealthful? The girls have regular, systematic employment. They have the mental satisfaction which comes from accomplishing definite, progressive work. The wide elective system makes their intellectual effort pleasurable, since they may choose what interests them and satisfies their desires. Mental work alternates with physical exercise. Their food is well chosen. Their hours of rest and of sleep are usually regu- lated with intelligence. They have congenial companionship, and they are, for the most part, contented and happy. General Summary. — The great function of woman is to bear and to rear children. The primary requisite for this is a healthy body. To rear children women need intelligence. Good health and intelligence are not incompatible. Whatever in a final analysis may be shown to interfere with a woman's physical capacity to bear children, or her ability to rear them is, for her, unhygienic. The health of the growing girl is a result of her heredity and her environ- ment. Her heredity will be more favorable when- public opinion makes good health in men and women a primary element of attractiveness, and hence 'an important factor in sexual selection. Her environment, represented by the family, the school, and the community, will be more favorable when the family secures and applies a better knowledge of personal hygiene, especially of food and its relation to health, growth, and energy ; when the school possesses and applies a better knowledge of the physiology of fatigue, physical and mental; when the community acquires and applies a better knowledge of infectious diseases and the means for their prevention. CHAPTER III. NORMAL MENSTRUATION AND THE MENOPAUSE. (1) Normal menstruation: Theories, p. 78. Mechanism, p. 80. Age of first menstruation, p. 82. Duration of menstruation, p. 83. Amount, p. 85. Interval between periods, p. 85. (2) Menopause: Age, p. 87. SjTiiptoms, p. 88. Local changes in genital organs, p. 88. Hemor- rhage, p. 88. Vaginal discharges, p. 89. Care of general health, p. 89. NORMAL MENSTRUATION. Theories. — Menstruation is a term used to characterize a discharge of bloody fluid which takes place from the uterus at stated periods throughout the time of sexual activity in the life of women. This definition makes no attempt to deal with the etiology of menstruation, because, though this has been the subject of speculation for many years, our knowledge in regard to it is still quite incomplete. An understanding of the true nature of menstruation presents certain pecul- iar difficulties, arising from the fact that menstruation is confined to human beings and some of the higher apes, so that the method of investigation usual in physiological research, animal experimentation, is not easily available. It would not be profitable to enter here upon any detailed discussion of all the differing theories of menstruation; I shall, therefore, content myself with a brief account of three, which seem to me especially worthy of attention. Two opposing hypotheses have coexisted for a number of years. One of these, of which the chief exponents are Pfliiger and Bischoff, holds that men- struation is dependent upon ovulation and coincident with it. According to this view, the Graafian follicle, by its swelling during its development, excites nerve impulses, which, being reflected upon the vaso-motor system, give rise to local congestion. The congestion involves both the uterine and ovarian circulations and in the end produces a hemorrhage from the uterine mucous membrane as an accompaniment to the liberation of the ovum from its follicle. This theory has been modified by Reichert and others, who hold that the hem- orrhage which constitutes menstruation takes place because the ovum discharged prior to its occurrence is not impregnated, and, in the absence of any stimula- tion to further gTowth towards the formation of the decidua of pregnancy, a retrograde metamorphosis takes place in the uterine mucous membrane, accom- panied by a discharge of blood. This theory seems in opposition to the fact, observed in my clinic, that with the discharge of blood the mucosa reaches its fullest development. 78 THEORIES OF MENSTBUATIOK. 79 The opposite view, of which Kiegel is the chief exponeiat, maintains that ovulation and menstruation are tv/o entirely independent functions ; that the discharge of the ovum may take place at any time and without any reference to the act of menstruation. In support of this theory it is urged that men- struation sometimes continues after the removal of both ovaries; and further, that conception has been known to take place in women who have never men- struated, or have done so only a few times, at periods remote from conception. Moreover, as I have seen in many instances, women sometimes pass from one pregnancy to another without menstruation. Some of these objections the supporters of the opposite view answer by calling attention to the fact that menstruation after the removal of the ovaries, persists, in almost every instance, for but a few months, and can then be explained by long-established habit. In the cases where it has continued permanently, there is good reason to believe that some ovarian tissue has been left behind ; it is never due to a mythical third ovary. An argument of much greater significance is the occasional occur- rence of conception at dates known to be independent of menstruation. It is possible, however, to reconcile the two conflicting views by the supposition that although menstruation is not dependent upon ovulation, some relation exists between them by which they are, as a rule, coincident; conception, therefore, takes place in the majority of cases, near the time of menstruation, but if the relation between the two is disturbed, it may occur at some date entirely unas- sociated with menstruation. This represents the point of view held by some persons at the present time. In addition to these theories as to the relation of ovulation and menstrua- tion, a new view was promulgated about four years ago by L. Frankel, who claims that the act of menstruation is governed by the corpus luteum. Frankel, in his account of his theory, ascribes the idea to Gustav Born, who reckoned the corpus luteum among the secreting glands and attributed to it the func- tion of stimulating the uterine mucous membrane to receive the ovum and foster its further development. Frankel, in considering this view, reached the conclusion that if it were true, the influence of the corpus luteum over the implantation of the ovum (nidification) is only one part of a much more extended function, and he instituted investigations along this line. He first proved by experiments on rabbits that if the corpus luteum was destroyed by means of the galvano-cautery shortly after the ovum was fertilized, the ovum failed to enter the uterus, or, if the destruction was delayed until the ovum had had time to enter the uterus, it failed to develop. A further set of experiments showed that destruction of the corpus luteum was accompanied by atrophy of the uterus, one process being in direct proportion to the other. If, as these experiments seem to demonstrate, the corpus luteum is responsible for the nutrition of the uterus, and, incidentally, for the attachment and develop- ment of the ovum, the next question in logical sequence is : What is the relation of the corpus luteum to menstruation? If destruction of the corpus luteum occasions atrophy of the uterus, it ought to cause suppression of menstruation. 80 XOEMAL :MEXSTErATIOX AXD THE MEXOPAUSE. In order to elucidate this point, Frankel made nse of certain celiotomies, performed for such purposes as ventro-fixation when the pelvic organs were healthy. In nine such cases he destroyed the corpns Inteum and waited to observe the effect npon the next menstruation. In five ont of the nine, men- struation was completely suppressed for a period varying from three to eight weeks after the time at which it was expected. In three of the remaining four cases, there was a slight bloody discharge from the genitalia a few days after the operation, which the patients themselves interpreted as menstruation; Frankel, however, thought it more probable that it was nothing more than the bloody discharge accompanied bj pelvic pain which is often observed after abdominal operations of any kind, especially as in each instance the regular menstrual period did not appear at the expected time, being delayed until eight weeks after the operation. In only one case, therefore, out of the nine, was menstruation unaffected, and a single negative instance out of so large a number can probably be explained by some special circumstance. Frankel, indeed, suggests several reasons for the exception; for instance, the corpus luteum may not have been entirely destroyed ; or there may have been a double ovulation ; or the secretory activity of the corpus luteum had already proceeded so far that the necessary stimulus to menstruation had been given. In conclusion, Frankel oifers the following suggestions as to the working of his theory : The uterus, like every other organ in the body, has its own blood vessels, both afferent and efferent. These are not dependent upon the corpus luteum for nutrition, but without it they cannot impart the life energy neces- sary to induce the hyi^eremia which, if the ovum is fertilized, leads to the fur- ther phases of its development, or, if it remain unfertilized, results in men- struation. Frankel has published several communications upon the subject. His principal paper (" Die Function des Corpus luteum," Arch. f. Gyn., 1903, vol. 68, p. -i38) is a long and interesting one. It gives his experiments in detail and contains some thoughtful speculations on the relation between pathologic conditions of the corpus luteum and certain morbid conditions of the uterus and its appendages, such as extra-uterine pregnancy, ovarian tumors, and some inexplicable cases of sterility. This interesting theory, so attractive at first sight, is being widely tested, but is as yet far from being substantiated. Mechanism. — The mechanism of menstruation, as Hirst says, is better understood than the causation. The process of menstruation consists mainly of a diapedesis of blood through delicate capillaries, newly formed in a thick- ened and congested endometrium, the provision for carrying blood to the mem- brane being better than that for carrying it away. Some of the newly-formed and delicate capillaries rupture and a discharge takes place. Leopold has given the following description of the condition of the uterine mucous mem- brane during menstruation: " The mucous membrane is 8 mm. (0.315 in.) thick, swollen, dark MECHANISM OF MENSTRUATION. 81 brownish-red, soft almost to liquefaction, but perfectly intact, and sepa- rated by a sharply defined boundary line from the paler muscular tissue of the uterus. The uterine glands, which are 0.5 to 0.75 mm. (0.0197 to 0.0296 in.) wide, are considerably lengthened and can be seen by the naked eye. In the superficial portion of the mucous membrane, which is well preserved and only in certain spots lacks its epithelium and adjacent cells, may be ^ S^ Ho ( In " s^en an immense and enormously hypertrophied )A^ 7) o y li I a capillary net-work, the vessels of which have irregular outlines and lie in the uppermost layer of the mucous membrane." (Quoted by Hirst, " Diseases of Women," second edition, 1905.) Figure 51 shows the changes taking place in the endometrium near menstruation (1) as com- pared with its normal condition (2). o r^^r^ ^ V- ^^i4^ v| i e ^ i 1 3 Fig. 51. — (1) Normal, Endometrium of a Patient Twenty-six Years Old, near Menstruation, Magnified Twenty-five Diameters. (2) Normal Endometrium of a Patient Forty-one Years Old, Magnified Twenty-five Times. (3) Endometrium after Menopause, Magni- fied Fifty Times. T. S. Cullen, "Cancer of the Uterus." Veit, as a result of a study of the uterus during menstruation, divides the changes taking place into three periods: ( 1 ) Premenstrual congestion, in which the capillaries are distended ; there is a transudation or exudation of blood into the intercellular tissues, the meshes of which are widened, and an accumulation of blood under the sub-epithelium, which is raised into little hillocks by the sub-epithelial hematomata. (2) Escape of the accumulated blood through the interstices between the epithelial cells, which are pushed apart; some of them may be carried away 7 . . - 82 NORMAL MEXSTEUATIOX AND THE MENOPAUSE. by the blood as it forces its way out. There is also some desquamation of the glandular epithelium. (3) Post menstrual involution, in which the mucosa shrinks and the extravasated blood remaining in the intercellular tissue is absorbed. The sur- face epithelium, lifted awaj from its subjacent tissue sinks again to its normal level ("Handbuch der Gynakologie," Bd. III). The gross changes taking place in the genital organs are those belonging to congestive conditions elsewhere in the body. The uterus, ovaries, tubes, and vagina are swollen and darkened in color. The uterus, in particular, is en- larged in size, the mucous membrane is thro^^^l into folds, and the cervix is softened. At the beginning of menstruation, the flow is composed of mucus streaked with blood, but when menstruation becomes established, the discharge consists of pure blood mixed with a little mucus and epithelial cells from the nterine cavity and the vagina. As the flow subsides it returns again to its mucous character. Menstrual blood is dark in color, alkaline in reaction, and, owing to the presence of mucus, it does not coagulate unless it is excessive in amount. Age of First Menstruation. — The age at which menstruation first takes place is given by difi^erent authorities at from twelve to fifteen. The following averages are taken from different text-books on gjTiecology: Ashton, twelve to fourteen; Garrigues, thirteen to fourteen; Hart and Barbour, thirteen to fifteen; Hirst, fourteen; Emmet, fourteen; Montgomery, twelve to fourteen; Penrose, thirteen; Gilliam, thirteen. Cases, however, are sometimes met with in which it occurs below or above the extremes of these averages, with- out being in the slightest degree remarkable. Anything below ten or above twenty, however, must be considered abnormal. Cases of precocious men- struation are nevertheless constantly being reported, and Strassmann has col- lected fifteen instances where it appeared during the first year of life. It must always be borne in mind that precocious menstruation is frequently the manifestation of some morbid condition of the uterus or its appendages, such as ovarian tumors, myomata, and affections of the endometrium. Kiedl has recently reported a case in which menstruation began at two years old and con- tinued regularly up to six years, when the child came under observation. Ex- amination of the external genitalia showed the mons veneris to be covered with hair, as well as the labia, which were well developed. The vaginal outlet admitted the index finger. On opening the abdomen a round-celled sarcoma of the left ovary which weighed two and a half kilogrammes (about five and a haK pounds) was found and removed. The right ovary was small in size and contained a few cysts. The uterus was as large as that of a girl of seventeen. Early menstruation, unaccounted for by local lesions, is usually the indication of vigorous sexual activity, which will probably extend over a prolonged period, so that in cases where menstruation is established under the average age, its cessation will, in all probability, be correspondingly late. AGE OF FIRST MENSTRUATION. 83 The most complete treatment of the subject is by the late George J. Engel- mann (" Age of First Menstruation on the !North American Continent," Trans. Amer. Gyn. Soc, 1901, vol. 26, p. 77). The conclusions reached are based on 12,402 observations of his own, made upon women of American birth, although in many instances of foreign parentage, covering the territory from Canada to all but the most extreme of the Southern States. To these are added 5,955 observations upon white women and negresses, made by others; to which he adds certain data touching the semi-civilized races on this continent (In- dians and Esquimaux), making a total of 19,405 observations upon American- born women. The 12,402 observations made by Engelmann himself represent all phases of temperature and climate from the subarctic conditions of north- ern Canada to the almost tropical environment of jSTew Orleans, and from the Atlantic coast to the Mississippi valley. In parentage they cover a number of nationalities, including English, Irish, German, and Erench, only those most commonly met with being given. The conclusions drawn as regards Amer- ican-born women are, briefly, as follows : The age of first menstruation in the American-born woman on this conti- nent is 14.3 for the laboring classes, such as are seen in free dispensaries; and 14.2 for the educated classes, seen in private practice. The writer con- cludes by saying, " Climate has practically no influence ; race very little ; mentality, surroundings, education, and nerve stimula- tion stand out prominently in this country as the factors which deter- mine precocity." There seems to be little, if any difference, between girls of foreign parentage and those who have had American progenitors. It is well known, of course, however, that there exists a wide difference between countries as to the age of first menstruation. Eor example, it occurs at the age of eighteen in the girls of Lapland and at eight to ten in the aborigines of Australia and in the natives of Southern Prussia, Egypt, Servia, and Sierra Leone. It has always been customary to ascribe this difference between nationalities entirely to the cli- matic effect of heat in hastening puberty, and of cold in retarding it. Cer- tainly the evidence in the main supports this idea. That there is something to be said, however, in favor of the view that race as well as climate may be concerned, may be deduced from the fact that the Esquimaux of Alaska, where certainly climatic conditions are of a nature to retard rather than to accelerate development, menstruate at the age of thirteen. xis regards our own countrywomen, Engelmann's statistics indicate four- teen years as the average age for the appearance of menstruation. An impor- tant predisposing factor in fixing the age in any given case, however, is the customary time for the family. It is always well, therefore, to inquire at what age the mother began to menstruate. Duration. — The length of the menstrual period varies considerably in dif- ferent persons. When once the individual standard is established, however, it should remain fixed, and any marked or prolonged variation from it 84 NORMAL MEXSTRUATION AXD THE MENOPAUSE. is generally associated Avitli a failure of general health, although it does uot necessarily imply the presence of a local lesion. Authorities differ as regards the limits of the menstrual period, and I quote the opinions expressed in sev- eral well-kno^^-n text-books : Ashton, three to six days ; Garrigues, four days ; Hart and Barbour, two to eight days ; Hirst, three to seven days ; Mont- gomery, two to eight days ; Penrose, two to seven days ; Gilliam, four to five days. In all these cases the statement is made didactically and no statistics are given, nor have I found any figures npon the subject except in the case of Emmet, who goes into the subject in great detail and gives four to five days as the general average. I have collected and tabulated one thousand cases from my private case-books, taking, of course, only the history of men- struation under its normal conditions, before it had been affected by the abnor- mal conditions for which I was consulted. I eive these results in tabular form. TABLE SHOWING DURATION OF MENSTRUATION IN 1,000 CASES. 1 day. 1-3 days 2 2-4 3 3-5 4 15 15 36 59 105 85 115 Total. 112 136 83 68 37 122 12 1,000 It will be seen that the limits in this table are twenty-four hours and seven to eight days. All authorities I have consulted make the shortest duration two days, but the number of my cases which lasted only one day seemed to me quite large enough to warrant taking this as my lowest limit. Again, some gynecologists make the upper limit eight days ; my experience, how- ever, leads me to agree with those who consider anything over a week as abnormal. It is so common, however, to find menstruation prolonged a trifle beyond its last complete day that I have included cases lasting into the eighth day. While collecting these cases, my attention was attracted by the fact that in many of those in which menstruation lasted over six days, it was noted that the flow was more or less in excess of the normal. I made a second analysis, therefore, of 200 cases in which the duration of the flow was over six days, and I found that in 52 of them it was noted as free, while in 68 it was excessive; the whole number in which it was in excess of normal being 120, or six-tenths of the whole. This appears to me strongly suggestive of the fact that a duration of more than six days is so frequently pathologic that it should never be regarded as normal, unless it is clear from other data that the patient's health is fully up to par. If she is anemic, or shows evidence of malnutrition by failure INTERVAL BETWEEN MENSTRUAL PERIODS. 85 of appetite, or of strength, or of weight, menstruation is probably in excess of normal, even though it has not occurred to her or her relatives that there is anything amiss. This is the class of cases in which such marked improvement follows a simple curettage, for the performance of which there has seemed but little local indication. Exclusive of cases such as these, where an excessive flow has become estab- lished so insidiously or so early as to be accepted as normal, the duration of the menstrual period which is habitual may be regarded as the proper standard for the individual woman, and if her health does not deteriorate, it usually remains unchanged through life. Amount. — The amount of blood lost at each menstrual period is extremely difficult to estimate, and cannot, indeed, ever be determined with real accuracy. Different authorities give it as varying from two to eight ounces (60 to 240 c.c). The usual rough way of estimating it by the number of protectives needed is too unreliable to be any guide as to the actual amount lost, although it is a fairly good way of determining an increase or diminution in any indi- vidual case. Most of the blood is lost during the first two days of menstrua- tion, whatever may be the length of the period. For the first few menstrual periods, before the function is well established, the amount often varies con- siderably, being excessive at one period and scanty at another, but in the course of a few months, as a rule, a standard will become fixed, and this should remain undisturbed during the remainder of menstrual activity. The sigTiificance of variations from the established standard in the direction of either excess or decrease will be considered in Chapters VI and VII. I will only say here that any deviation from the normal which lasts more than a short time should be brought to the attention of a physician, who is the only person qualified to judge of its real importance. Variations from the normal in amount or dura- tion are of much more conseqlience than those which take place in the inter- vals between the menstrual periods. Interval Between Periods. — In normal menstruation there is far less indi- vidual variation in the intervals between the periods than in either their dura- tion or amount. From time immemorial twenty-eight days has been accepted as the standard fixed by nature, for which reason, no doubt, it has always been believed among uncivilized people that the periodicity of menstruation depends upon the phases of the moon. In this instance statistics agree with common belief more closely than is often the case, and they show beyond any question that the large majority of women menstruate at intervals of four weeks; there is, however, an appreciable number who do so at longer or shorter intervals. I have investigated the subject by collecting and analyzing one thousand cases from my own case-books, with the following results, which I give in tabular form: 86 NOEMAL MEXSTEUATIOX AXD THE ME:S'0PAUSE. TABLE SHOWING INTERVAL BETWEEN MENSTRUAL PERIODS IN 1,000 CASES. 21 davs 22 23 23-25 24 24-25 25 TotaL 22 1 6 1 6 2 9 26 days 27 28 29 30 31 35 5 1 942 1 2 1 1 1,000 Various Avriters whom I have consulted give twenty-eight days as the inter- val for the large majority of cases, but they do not, with one or two exceptions, enter into statistics. The exceptions are : Krieger ("Die Menstruation," I. D. Berlin, 1869) 28 davs 70 % 30 " 13.7% 27 " 1.4% Hart and Barbour (" Manual of Gynecology," 1904). 28 days 71 % 30 '■ 14 % 21 " 2 % 27 " 1 + % Webster ("Text-book of Diseases of Women," 1907). 28 days 71% 30 " 14% The preponderance of the twenty-eight-day type is the same in all, hut it will l)e seen that in my list the next highest proportion belongs to the twenty- one-day t^'pe, which in Hart and Barbour's list is the third, and is not men- tioned at all by the others. Where the proportion is so excessive in favor of any one type it would require statistics covering a good many thousands to establish results as concerns the lower percentages; the main point, however, remains the same in all, namely, that twenty-eight days is the custom for so large a proportion of women that it may be considered as the established rule, although there are constant exceptions to it within the limits of health. The interval between the periods is sometimes irregiilar for a little while after menstruation is first established ; indeed, there is a general impression, not only among the laity, but among medical men that it is usually the case. Emmet found, however, that out of 2,447 women, 72.33 per cent were reg-ular from the first; 18.92 per cent after a certain period; while 8.74 per cent were never regular ("Principles and Practice of Gynecology," 3d edition, 1884, p. 147). Strict adherence to individual habit, as I have said, is not so closely asso- ciated with health as it is to the duration of the flow or to its amount, and even after regularity is established, variations of a day or two in anticipation or delay are very frequent and need excite no apprehension. MENOPAUSE. 87 MENOPAUSE. Introductory. — Menarche and menopause are technical terms used to desig- nate respectively the beginning and cessation of the menstrual life in women, the beginning and the end of a period of reproductive activity. In English the terms " puberty " and " change of life " are more commonly used and well un- derstood by the laity. With the menopause the woman steps out of those cyclical changes which for thirty years have represented the sigTi manual of her femininity, nature's signs of the successive maturation and periodical casting off of the ova, and a constant call to the fulfilment of her law in the exercise of the reproductive function. It is by pregnancy and lactation alone that the monthly cycle of changes is normally interrupted at irregular intervals for periods approximating two years — as a rule, well within the outer confines of this thirty-year period and avoiding the two termini, the beginning and the end. The menopause marks the passing of the reproductive function, and with its cessation the entrance of the woman upon a new and final stage of her exist- ence, two-thirds already past, a final third remains to be accomplished under new conditions. The " change of life," as it is fitly called, is indeed the major crisis in the life of an adult woman. A man is apt, after a life of hard work (and this applies especially to our business men), to pass through a sort of grand cli- materic in his early sixties, after which he realizes that his forces are abated, and it is well to walk quietly in shady paths as the sun visibly nears its horizon. Tor a woman the change is of another kind and at an earlier period. She meets her major crisis some time in the forties or early fifties, when, with the cessation of the monthly function, she realizes that the fires of youth are flickering, that there will be no more babies to be nursed, and her life is freed henceforth from those periodical, oftentimes burdensome fluctuations in health. The clock which was wound up at fifteen has run for thirty years, sounding its four-weekly cycles and regulating the affairs of her domestic and social life. With the change she becomes matronly, and with her increased avoirdupois and years of experience behind her, assumes a greater dignity and a tone of authority in those affairs of life which have come within the range of her activities. It is at this period, when freed from the many trammels of younger womanhood, that she often enters into a new and calm enjoyment of intellectual occupations, enters more into society and finds more time for hus- band and the children rapidly growing up about her, and becomes, if she has used her opportunities well, a more important factor in society. Woe, then, to the woman whose life has been spent in mere pleasure seek- ing, who has neglected the cultivation of mind and heart, and who knows noth- ing of the peace and poise found in the comforting assurance of a Christian faith. How wearisome the life of such a one becomes, when, possessed only of overripe personal charms, she no longer attracts as a belle, is unable to acquire 88 NOKMAL me:xstkuation and the menopause. new interests, and, casting about for a new anchorage and finding none, simply drifts on into an unhappy, retrospective old age. With too many of our poorer class the change of life after years of hard labor is but the narrow antechamber leading into decrepit age. How often is the physician, who is himself hale and hearty in the forties or early fifties, startled when he discovers some such broken-down old woman to be several years his junior. This is the fault of our present world spirit, which holds nothing so cheap and negligible as human health and human lives. According as the menopause is well and safely passed will tlie woman be a^Dt to enjoy good or ill health throughout this remaining period of her life; a period of life, therefore, rightly called '' critical." The term " menopause," strictly speaking, applies to the complete cessation of and the last menstrual periods ; but, as commonly and conveniently used, it covers a longer period, including the first irregularities of menstruation which mark the beginning of the end, as well as all the subsequent periods up to the last one, together with the subsequent settling-down period, reestablishing the health on a new basis. The period of irregular menstruation is often desig- nated by women as " the dodging time." The menopause thus constitutes one of the most striking differences between the sexes. Puberty is common to both, but in man the procreative power then received is carried forward into old age and then declines by imperceptible de- grees, while in woman it ceases in middle age. For every woman there looms upon her mental horizon as she approaches the forties this pending crisis through which she must pass, associated by tradition in the minds of many with a fear that when the change supervenes the bloom of life will be worn off and the burdens of age assumed. Such a prevalent yet utterly false view was voiced by the French lady who sadly referred to her more youthful attractions in the w^ords, " When I was a woman." This is true, if a woman reaches maturity impressed with the notion that her horizon in life is limited by her reciprocal relations to the opposite sex and by her reproductive activity, that after the cessation of this function there will remain but little of interest for her during the remaining twenty or twenty-five years (over thirty -three per cent of her mundane existence) other than to train her daughters to occupy a similar field of procreative activity. This is the view of life taken by two hundred millions of the Mohammedan world. (See John Foster Fraser's " The Land of Veiled Women.") There is, however, a larger and truer view, which it is our special duty as physicians to inculcate as we superintend the physical and mental cul- ture of our wards, and that is the conviction that life is but a school in the vestibule of eternity leading to larger spheres of activity, responsibility, and enjoyment, and that each age is equally important, and each brings with it its own peculiar opportunities for spiritual development and achievement. Child- hood is the age of acquisitiveness and sharp discipline, with untainted joys shared at no later period. Early maturity opens up vistas of duties and new and happy relationships, almost a miraculous revelation of the possibilities of MENOPAUSE. 89 happy fellowship and service. Later, maturity merging insensibly, as it ought, into old age and then into the more abundant, untrammeled life beyond, places the crown of experience and authority upon a worthy head. It can truly be said to-day that many of our noblest citizens, most devoted to the common welfare, are women at this time of life. Woe to the nation that misses from its midst little groups of devoted, unselfish women such as we know to-day in all our larger cities. W. L. Burrage speaks of the change wrought by the menopause as " a period of rejuvenescence," and quotes the ancients, who de- clared that " the gauge of age is not years, but vital force." THE NORMAL MENOPAUSE. The normal menopause, the final stoppage of menstruation, is contempo- raneous with the cessation of ovulation, and takes place in an average of 1,082 cases at, forty-five years and nine months (Tilt). Schaeffer, of Berlin (see table following from Veit's Handhuch), found in a series of 903 cases that the average age was 47.26 years. Satisfactory statistics for women in hot coun- tries are wanting. THE MENOPAUSE CAME AT THE AGE OF 28 years in 1 30-34 ' " 4 35 " 2 36 " 3 37 " 2 38 u 7 39 " 14 40 " 24 41 " 15 42 " 52 43 '' 46 44 " 48 45 " 87 46 " 58 47 " 78 48 " 90 49 " 86 50 " 100 51 " 54 52 " 58 53 " 42 54 u yj 55 " 9 56 " 3 57 Total o CO CO case cases 'Before 40 years in 33 cases, or 3.65%^ -Of 40-44% years in 185 cases, or 20.50% 'Of 45-49 M years in 399 cases, or 44.19% >0f 50-54% years in 271 cases, or 30.01% 'Of 55-57% years in 15 cases, or 1.64% 99.99% Average age of menopause in 903 cases = 47.26 years. Schiilein, of Berlin, had a case (quoted by Schaeffer) which continued to menstruate regularly until she was sixty-two years old. This woman's men- 90 NORMAL MENSTKUATION AND THE MENOPAUSE. striial life extended over a period of forty-seven years (Veit, Hand. d. Gyn., 1908, p. 77). The fact that a woman has borne a number of children does nut bring on the menopause at an earlier date. The general average duration of menstruation is 30.52 years. It is always important in estimating the probable age of cessation to inquire as to family history, the daughter in this often following the type of the mother. Burrage (" Gynecological Diagnosis," p. 597) gives the following table of ages at which the menopause occurred in 1,291 cases taken from the older writers, who de- voted a closer attention to this subject : Between the Years No. of cases. Percentage of all cases. 36-40 .* 272 595 940 334 150 11.87 41-45 25.97 46-50 41.03 51-55 14.58 Before 35 and after 55 6.54 I myself think that the nearly twelve per cent between thirty-six and forty would to-day bear closer inspection and criticism, as the occurrence of a physio- logical menopause before forty is rare. I know personally of one case in which the change of life occurred in a married multiparous woman with all the customary associated symptoms at twenty-six years of age. She is now over forty-five and has been in perfect health in the intervening years. The cessation of menstruation took place suddenly in 137 out of 500 cases, Avhile the .average duration of the diminishing flow in 265 cases was 2.2 years (Tilt, " The Change of Life," p. 18). Symptoms and Diagnosis. — The only w-ell-defined anatomical changes which take place at the menopause are found in the ovaries, which are smaller and harder and contain no ripening follicles. The uterus becomes somewhat smaller and firmer and the Eallopian tubes gTadually atrophy, but these changes are only initial at the menopause and aje completed and most marked in old age. Outside of the ovaries, the next important change is in the increase of adipose tissue in the body, especially in and about the abdomen; gradually, also, in some women there are found coarse, scattered hairs about the body, especially on the face. It is probably owing to this fact that most women have the impression that with the menopause there is a loss of femininity. The normal menopause gives rise to but slight disturbances and calls for no active treatment. The physician may recommend to those in position to act upon his advice more rest and greater freedom from household cares and re- sponsibilities, with regular hours of rest and careful regulation of the bowels. The menopause is not a state of disease or unstable health, but is, like puberty, simply a critical period — a time of instability in which the woman passes out of one type and regimen of life into another. So far is the meno- pause per se from being a malady that it may, and often does, liberate the MENOPAUSE. 91 patient from the sufferings and discomforts of many years, wiping out, as with a sponge, the pains, the hemorrhages, and the nervousness of three decades' duration. To such a one the change is a manifest blessing, and she first begins to live after the menstruations have ceased. The physician must be loath to make a diagnosis of menopause in a woman under forty, although patients will often consult him under the impression that they are changing. By consulting Schaeffer's table it will be seen that only 3.65 per cent change before forty years of age. Such a diagnosis must never be made merely because menstruation has be- come irregular and scanty for a few periods. When, however, such irregularity persists for many months, and there are concomitant flushes and nervousness, associated with diminution or cessation, the presumptive diagnosis, in the absence of any discoverable local lesion, is change of life. Pregnancy must always be borne in mind and excluded. It must always be distinguished from simple amenorrhea in a woman who has been exposed to cold and whose menstrua- tion is checked for several periods. In such cases there is generally marked malaise and periodic headaches with other symptoms of a menstrual nisus. Again, women in the late twenties or early thirties will sometimes take on an excessive amount of fat and cease menstruating. A pathological menopause may be suddenly brought on by the superinvolution of the uterus following a difficult labor with severe infection. In such cases the examination shows that the uterus is small and atrophic and destined henceforth to remain inactive. The menopause may also be brought on prematurely by a too radical curettage with a sharp instrument, removing all or nearly all the uterine mucosa. This unfortunate accident has happened with a number of good gynecolpgists. A shock or great grief may bring on the menopause in the late thirties or early forties suddenly and completely. Occasionally one notices a periodical hemorrhage from the hemorrhoidal vessels, which acts as a safety valve in place of the menstrual discharge. Pregnancy During the Menopause. — Pregnancy may occur at any period of life in which a woman menstruates regularly. It may also occur rarely during the irregular menstruations of the change, and even after the change has taken place ! Several authors have investigated the question of the possibility of pregnancy in the late forties, the fifties, and even at sixty years of age and over. An investigation by English authors was stimulated by the interest felt in the celebrated case of Joanna Southcote, who at the age of sixty-four was pro- nounced pregnant by a committee of medical men ! The diagnosis was made without a digital examination, and the event proved that the gentlemen were mistaken. Our own Fordyce Barker, after an investigation of all the extraordi- nary published cases, came to the conclusion that but few of the recorded late preg-nancies were well established, and only found one he considered perfectly trustworthy, she was fifty-five years old. Tilt says that he knows of three instances in which conception occurred dur- ing the change of life. One of them was single and forty-seven years of age ; 92 NORMAL MENSTKUATlOiSr AND THE MENOrAUSE. lie quotes another of a Avoman of forty-seven who was delivered of her tenth child eighteen months after the cessation of the menstrual flow. A lady who was married at the age of eighteen bore her first child at forty-eight; another, quoted by the same author, married at nineteen and bore her first child at fifty. These cases, of course, have a medico-legal value when the distribution of prop- erty depends upon the possible birth of an heir. He only found one case where a woman who had reached fifty-five had given birth. Pie gives the following data from the British Birth Register: Ages of mothers when their children were born Under 20 8,301 20-25 70,924 25-30 121,781 30-35 126,808 35-40 98,950 40-45 49,660 45-50 7,022 Above 50 167 Total Children born from 1831 to 1835 483,613 The question whether or not a woman up in the forties is pregnant is always an important one. It often happens that if she has been married a long time without children, or if late married and has strong maternal instincts, she anx- iously watches for the cessation of menstruation as the sure sign of a pregnancy. Again, on the other hand, a society woman may dread a pregnancy in the forties, when she has had no children for sixteen or eighteen years, through a false sense of shame. She may also base her conviction not only on the skipping of several periods, but upon the fact that the abdomen is increasing in size, and it may be she has felt some motions within and has perhaps had some unusual sensations in the breasts. These " fetal movements " may be so clearly defined as to mislead even those who have passed through several pregiiancies. One of my patients, a worthy widow, knowing that pregnancy was impossible, took upwards of sixty dollars' worth of worm medicine, so convinced was she that she harbored a living tenant. The physician will suspect that the case is not one of pregnancy when he discovers fiushings with perspirations following and in- creased nervousness, with a slight menstruation, which the patient is inclined to dismiss as " insignificant " ; he will become more skeptical when he finds that these symptoms have persisted for some months and that the enlargement of the abdomen does not correspond to the calculated time of the pregnancy. A fat omentum and increased fat under the skin of the abdominal walls may interfere with percussion and make an external examination by palpation difficult and puzzling. All doubt will be set at rest when he makes a combined vaginal and abdominal examination and finds the vagina unchanged and the cervix hard and the uterus small and empty. In a puzzling, doubtful case, especially in a fat woman, there should be no hesitation in urging a careful examination under complete anesthesia, then surely all doubts will be set at rest. If the question- able pregTianey is reckoned to be within the first or the second month and there is a reasonable doubt, he can well afford to wait and watch a couple of months to see whether the corresponding enlargement of the womb takes place. One of the most important and distressing reasons for investigating these self-supposed pregnant women with extreme care is that in many instances they are suffering MENOPAUSE. 93 from an actual abdominal enlargement due to a fibroid or to an ovarian tumor, and not to a growing fetus. It has happened to every active surgeon to meet one or more of these women about the change of life who have even gone so far as to make all the baby clothes and engage the nurse for the expected confinement : here joy and eager expectation are converted into the tragedy of an operation. In one sad case a middle-aged woman came to me with a complete infant's ward- robe, and I found only carcinoma and ascites. A little different from these are the cases of pseudocyesis or an illusory abdominal enlargement due to fat or a gaseous distention, or both. A curious case in the hands of Dr. C. F. Bumam is the following: A widow, about forty- five years old, of clear mind, with good antecedents, suddenly conceives the notion that she is pregnant; menstruation stopped for four months when she had a scanty flow. She was so insistent that she suffered great lower abdominal pain that the abdomen was opened and the uterus suspended. In spite of all assurances she still believed herself pregnant and milk came into her breasts. This is manifestly a case for an expert psychiatrist in conjunction with the physician. Menopause following Lactation. — Sir James Y. Simpson and Chiari have pointed out the fact that atrophy of the uterus and complete cessation of men- struation sometimes occur after a normal puerperium, due to the exhaustion of a prolonged, excessive lactation. R. Frommel, in investigating 3,000 cases, dis- covered lactation atrophy of the uterus in twenty-eight — mostly young women who were poorly nourished. The uterus in some was found contracted and small, its cavity measuring from 5 to 5^ cm. These were cases of concentric atrophy. In others the cavity was not shortened, but its walls were thin and relaxed — eccentric atrophy. The cervix sometimes atrophied, at other times remained normal, while the adnexa were always small and atrophic. He found this group practically hopeless from a therapeutic standpoint. Thorn, follow- ing up these observations, demonstrated the astonishing fact that every nursing woman who did not menstruate exhibited a hyperinvolution in some degree, and that up to a certain point it is physiological. Upon the cessation of lactation and the resumption of regular menstruation the uterus resumed its natural size. Fraenkel found in 10,088 patients 95 cases of lactation atrophy of the uterus. Their average age was twenty-nine years, the average number of preceding births 3-4. The most marked diminution in size was noticed in the third month, while from the fifth month on the size of the uterus increased. (See Doderlein in Veit's Handbuch.) Minor Ailments in the Normal Menopause. — Biliousness is often noticed among the minor ailments, characterized by a disgust for food, headache, lassitude, and constipation. Such cases are helped by a course of blue mass with com- pound colocynth pills, two grains of each every night for a week, associated with the free drinking of saline waters, keeping the emunctories active. For colic and flatulence with sluggish bowels Tilt recommends one grain of the extract of opium with two of the extract of colocynth in a pill, two to be 94 NORMAL MENSTEUATION AND THE MENOPAUSE. taken the first iiigiit and one after, followed by siilpliur as a laxative in the morning. Exaggerated nervousness is best treated by free use of bromides for a couple of weeks. Tilt recommends three drams of the bromide of soda with the same amount of the tincture of orange peel in a simple elixir sufficient to make six ounces, giving a tablespoonful of this in a little water at four o'clock in the after- noon and two tablespoonfuls at night. Such a plan of treatment is continued daily for two weeks, and then alternate days for two or three weeks more. If sleep is difficult, ten grains of chloral may be added to the dose at night. He also strongly recommends six to twelve grains of extract of henbane taken in two-grain pills in the course of a day. In the analysis of 500 cases he found headache in over 208, or over forty- one per cent, and generally either frontal or occipital. I have rarely noted the sincipital headaches mentioned as characteristic by the earlier writers. When the headache is severe and throbbing, tincture of aconite may be given in con- siderable doses, beginning with five drops four times a day and increasing to twenty. The patient experiences some relief if the head is bathed with Easpail's sedative lotion, compounded as follows : ^ Liq. ammon oij Sod, chloridi 5ij Sp. vin. camph oiij Aquse q. s. ad o^xxij M. S. Apply — and also from rubbing the scalp with cold cream made up with one dram of camphor to the ounce, or by bathing in Cologne water containing as much cam- phor as it will dissolve. When the patient is plethoric, with a full pulse, flushed face, and but a scanty flow, relief is often found when menstruation comes on freely. Here the old-fashioned treatment of bleeding and taking from six to twelve ounces from the forearm is undoubtedly of benefit. This treatment may be associated with a brisk purge and cream of tartar lemonade and hot foot baths, at the same time limiting the diet, giving light breakfast and no meat. In this, as in all other cases, the urine should be carefully examined. For a debilitated and anemic patient the contrary plan of treatment must be followed. Let there be rest, good feeding, red meats, and tonics. A good tonic is the citrate of quinine and iron in syrup, about three to five grains in the elixir of calisaya (a teaspoonful) three times a day. !For patients greatly troubled by perspirations saturating their undergarments Tilt has suggested the wearing of a long, thin flannel dress over the nightgown to prevent the too sudden chilling off. In excessive nervous manifestations it is well to inquire carefully into the previous history of the patient, whether she had any unusual nervous attacks at the time of puberty or later, and also concerning the family history and its MENOPAUSE. 95 tendencies. When there is a marked history of insanity in the family, the physician will watch the patient with unnsual care, not hesitating to use seda- tives freely and seeing that she lives a quiet, well-regulated life until the periods are well over and the danger past. ABNORMAL MENOPAUSE. The menopause becomes abnormal when any of its customary symptoms are greatly exaggerated, or when certain abnormal and pathological conditions arise. Any unusual symptoms demand the closest attention and a prompt and thorough investigation. It is at this time of life that certain serious pel- vic diseases are of tenest found, and for this reason the most care- ful attention should be given to each case presenting any ab- normal symptoms. While, on the one hand, women at large are apt to exaggerate for the benefit of the expectant younger women the minor discom- forts which they advertise must of necessity mark this period ; the same public with a strange fatuity borne of the neglect of ages of experience, greatly under- estimates the real major dangers, dismissing such sym.ptoms as pain and serious floodings with the assurance " that is what you must expect — it is only the change of life." Many a precious life has been sacrificed and many a loved mother has been called to leave the family circle in the bloom of womanhood, because of an inoperable cancer, because she has been thus encouraged by fool- ish friends to delay reporting the first abnormal symptoms to a physician, until, when finally forced to seek advice, she finds it is too late. It would be better for womankind if every married woman in the land were subjected to a com- petent physical examination soon after passing forty years of age, whether she had unusual symptoms or whether she had none. Women are sometimes so harassed with the sudden fiushes that they almost lose control of themselves and feel obliged to open a window or to rush out of doors to get fresh air and cool off. In occasional instances the sweats are so distressing as to saturate the clothing. I give lutein tablets made of the dried corpus luteum taken from the ovary of the pig three times a day to relieve these conditions. For bad sweats also give aromatic sulphuric acid in doses of 15 drops three times a day, or atropia in -^jj^-gT. tablets. I prescribe the following pills : I^ Atrop. sulph gr. -g-^-g- Zinci. oxid gr. j Ex. gentian gr. j M. ft. pil. 1. Make 50. Take 1 after each meal. The fiushings of a normal menopause rarely ever approach in severity, fre- quency, or the duration of time over which they extend, those distressing, burn- ing-up, overpowering rushes of heat often experienced at an artificial meno- pause induced by the removal of the ovaries. Headaches may be severe, and nervousness is observed in all grades, from a mild emotionalism up to complete irresponsibility and even insanity. 96 K^oi^:\rAL :\rEXSTErATTox axd the :MEX0PArsE. In cases of milder disorders and somewhat exaggerated nervous symptoms, giddiness and flushes, if the patient's circumstances will permit, a trip abroad to a foreign watering place may be of great value, entailing, as it does, the bene- fits of a change of society, the constant stimulus of expectation amid novel sur- roundings, coupled with freedom from responsibilities, with regular prescribed exercises and diet. DISEASES AT THE MENOPAUSE. Burrage (id. sitp.) gives an instructive table of 115 of his patients, with their leading symptoms and his diagnosis in each case. My own experience has also shown me that the following conditions are not infrequently observed, and are, therefore, important at this period: (1) Cancer of the body or cervix of the uterus. (2) Endometritis. (3) Polyps. (4) Fibroid tumors. (5) Ovarian tumors, multilocular, dermoid, and malignant tumors. (6) Leucorrhea, vaginal and cervical. (7) Pruritus. (8) Bearing down, relaxed vaginal outlet. (9) Uterine displacement. (10) Incontinence of urine. (11) Tumors of the breast. (1) Cancer. — In the entire list of diseases which are liable to affect a woman at the menopause, cancer of the body and of the neck of the womb holds by far the most important place. All of the other affections combined, while individ- ually important, are of trifling gravity as compared to this great scourge of our race, most commonly observed at this period. Cancer of the cervix is oftenest seen between the ages of forty-five and fifty, and cancer of the body is manifest a decade later. (See T. S. Cullen, " Cancer of the Uterus.") Wertheim's list of 500 cases of cancer of the cervix (" Die Erweiterte Ab- dominale Operation," 1911) shows that in 352 cases, or approximately seventy per cent, the women were of forty years and above, and 198, or 39.6, were between forty and fifty. There is no other disease so dreaded and none so widespread. It invades all families, and it strikes terror to every heart when any of the symptoms appear in a loved relative or friend. There is no other disease, not even excepting tuberculosis, against which the entire medical profession should wage such unremitting warfare until it is rooted out. But, as yet, we do not even know its cause, and for this reason we are unable to anticipate and to prevent its occurrence by any care or foresight. For this reason we are limited to surgery as our sole resource, but even this too often fails because the patient applies to the physician when the growth has reached a stage when it has passed the MENOPAUSE. 97 liiiiif-s wlieu a successful radical operation is practicable. Never can the sur- geon say " I am sure this disease will never come back." As a rule, the chances are against the patient, and too often the operation is merely palliative. The whole question of the treatment of cancer, therefore, at the present day hinges upon the early recognition of the disease, upon finding out at the earliest possi- ble moment that the patient has it, and this responsibility rests not with the surgeon and not with the specialist, but with the general practitioner. I have dwelt at length upon this subject in the chapter on Cancer of the Uterus under the heading " Prophylaxis." I do not hesitate here to give added emphasis to so vital a matter by a brief summarized repetition. In order to get our cases in the operable stage, and as early as possible, there are only two plans feasible : (a) To discover the disease before it has caused any symptoms at all. To this end I have for many years recommended a systematic examination of all women after childbirth, and as soon as the childbearing period is over. (&) The other is to instruct the public and the general practitioner so care- fully that every woman who complains of the slightest abnormality about the pelvis — above all, if it is of the nature of a discharge — should at once be sub- jected to a searching examination. Then, if cancer is found, or if it is sus- pected, she should reach the hands of a surgeon within a week from the day the lesion is found. That this ideal is attainable, the work done in Germany, already cited, has clearly shown. If the patient has an excessive flow, or a watery or foul discharge, or any pelvic pain, she must at once seek her physi- cian, and her physician must at once make a careful digital and visual vaginal examination, and not rest satisfied until he has determined the source of the trouble, fearful lest he should overlook an early case of cancer. If the physician has not enough gynecological experience to give him confidence in his own judg- ment, he must then suspect every case of reddened, thickened, nodular cervix with bleeding. Far better suspect fifty cases where there is no cancer than miss one case. He may feel certain that the cervix which bleeds readily on scraping it with the finger nail, or with an instrument, or one which has an irregular, ragged appearance, with some evidences of superficial sloughing, is cancerous. If there is no obvious cause for hemorrhage such as I have just described, then the parts should be carefully cleansed and a small curette introduced into the cervical canal and up into the uterine body and gently moved about, to see whether or not it provokes a free flow, or brings away little pieces of fleshy tissue. All such cases must be put promptly into the hands of a specialist; the physician must never temporize by giving douches or making topical appli- cations " to avoid frightening the patient " until at last he is driven to consult a specialist, and learns that while he has played with the case, squandering his opportunity, the disease has been advancing. AVhen the physician is justified in feeling greater confidence in his own opinion by a familiarity with gynecolog- ical cases, and is uncertain in his diagnosis, he may give an anesthetic or use cocaine injected locally into the cervix, and, excising a piece of cervical tissue. 98 xoR:\rAT. mexstruatiox axd the mexopause. put it at once into a five-per-cent solution of formalin, and send it to a competent pathologist for microscopic examination. If the patient has a somewhat pro- longed history of hemorrhages, and the vagina and the cervix appear perfectly normal, while the body of the uterus feels enlarged, then it is best to put the patient under an anesthetic and curette thoroughly, and remove as much as possible of the uterine mucosa, and send it to a microscopist to detennine whether it is cancer of the body of the uterus. (2) Metritis. — Metritis, or inflammation of the body of the womb, was, curiously enough, one of the keystones of the uterine pathology of our prede- cessors, taking the place of the endometritis of fifteen years ago. These conditions are no longer accepted as the causes of hemorrhage at the menopause, and I pass them by. Endometrial Hypertrophy. — Occasionally profuse flow at the meno- pause is caused by a polypoid overgrowth of the endometrium. All cases bleeding excessively in this way should be placed under anesthesia and sub- jected to a thorough curettage, which will remove the cause and, as a rule, cure the hemorrhage. This hypertrophy is not merely an endometritis, and I do not know of any form of endometritis which is in any sense peculiar to this period of life. Sclerosis of the Uterine Vessels with Hemorrhages. — One of the fairly common causes of excessive, protracted, blanching uterine hemor- rhages is hypertrophy of the body of the uterus (subinvolution), associated with sclerosis of the uterine vessels. A bimanual examination shows that the uterus is considerabh' symmetrically enlarged. Such uteri have frequently been removed on a clinical symptomatic diagnosis of cancer of the body of the womb. On cutting through the thick wall of the uterus, the vessels stand out from the musculature like so many little white worms. This is a condition to which attention has been drawn especially by Pichevin, Petit, Bland Sutton, and A. H. P. Barbour. The diagnosis of arterio-sclerotic disease may be made when the clinical sigTis cited are present in a patient at or near the menopause who has a large uterus and suffers from excessive or protracted hemorrhages, without pain, where further dilatation and curettage has sho^^^Ti that there is no malignant disease of the endometrium. The proper treatment for this condition is a complete hysterectomy in a woman well over forty. In younger women a subtotal operation perpetuates the menstrual function and spares her the sequelae of the sudden complete change. (3) Polyps. — Oftentimes when a patient has been bleeding excessively, a vaginal inspection will reveal the presence of a cervical or a uterine polyp. Such a discovery is one of the most satisfactory in gynecology, as the hemor- rhages are often severe and protracted, even threatening life, while the means of treatment are so satisfactory and so certain in cure. Such a polyp may hang down into the vagina, a soft, red, fleshy, bleeding mass the size of a pigeon's egg, attached inside the cervix by a long slender pedicle. Pibroid polyps, or MENOPAUSE. 99 fibroid tumors, extruded from the body of the uterus, are apt to be large, shaped like an orange, with a broader pedicle. Their delivery from the uterus is often associated with expulsive pains. Such tumors, I thinly, are best removed by — after placing the patient under an anesthetic and duly cleansing the parts — catching the tumor on the right and on the left sides and splitting down through the fibroid nodule until it is divided into halves ; then each half is enucleated sejjarately, leaving the capsule, particularly at its base, intact. It is dangerous to cut directly through the pedicle, as there may be a partial inversion of the uterus at this point. A group of small, raspberry-red, mucous polyps is sometimes seen within the cervical canal. These can be caught with the forceps and clipped off or thoroughly burned out with a Paquelin cautery. (4) Fibroid Tumors. — In a critical analysis of 1,674 cases examined by Thomas S. Cullen and myself (see Kelly-CuUen, " Myomata of the 'Uterus "), it was noted that, when the myomata do not impinge on the uterine mucosa, the menopause will usually occur at the normal time ; but if at a later date the myomata become submucous, bleeding is likely to take place. These tumors, growing like minute seeds in the uterus and reaching an appreciable size in from three to five or ten years, often first come into prominence toward the end of the child-bearing period, at about the time of the menopause. Fibroid tumors at this period are the cause of hemorrhages, of abdominal enlargements, and a sense of pressure in the lower abdomen, as well as vesical disturbances. Tor this reason every patient at the menopause who complains of any of these symptoms must be examined carefully bimanually, if necessary, under an anesthetic; and the examiner must bear in mind the likelihood of finding a fibroid tumor. He must further be aware that fibroid tumors thus found are apt to defer the menopause until the patient is fifty years or older. A patient, therefore, of forty-two to forty-five years of age, who is menstruating excessively and in whom a fibroid tumor is found, has not the hope of relief from her periodical losses by the speedy onset of the menopause. This fact determines our course of action in these cases, which must be aggressive; namely, hysterectomy when the tumors are provocative of symptoms, (5) Ovarian Tumors — Multilocular Cysts, Dermoids, and Malignant Tumors. — Among the major affections liable to spring into prominence at the menopause are the various kinds of large ovarian tumors. Although these tumors com- monly begin to grow in the late thirties or early forties, they often do noli attract the attention of the patient and induce her to seek the advice of a physi- cian until about the time of the menopause. Spencer Wells (" Ovarian and Uterine Tumors," 1882) gives a list of 1,000 ovariotomies in which 227 cases were between forty and fifty and 235 over fifty years of age. The discovery of an ovarian tumor is usually purely accidental ; either the patient in dressing notices an unusual hardness in the lower abdomen which alarms her ; or, having suffered from peculiar irregular menstrual discharges, protracted and intermittent, with or without a sense of pressure or bearing 100 NORMAL MENSTRUATION AND THE MENOPAUSE. clown in the pelvis, she goes to the physician, who, on examination, finds the litems more or less fixed and a resistant mass in one or both sides of the pelvis. The classical multilocular ovarian cyst is recognized, as a rule, by its con- tours, being made up of one or two large cysts together with a number of smaller ones with slight depressions between them. The large cysts are more or less elastic and fluctuating. A dermoid cyst may float up in front of the intestines if it is free, and is apt to be symmetrical and spherical in form ; many dermoids, however, begin at once to form adhesions with the pelvic viscera and are bound down and re- sistant and hidden under a mass of pelvic inflammatory disease. There is a peculiar kind of multilocular cyst which is found at this time, malignant in character, against which the examiner must be especially on his guard. In cases of this sort the disease is usually bilateral, fills out both poste- rior quadrants of the pelvis, and is attached to the broad ligaments, the pelvic floor and walls of the uterus, and the intestines above. The uterus is fixed anc^ difiicult to outline. The cyst contents are thick, more or less gelatinous, and the tumor is filled, especially at its base, with sprouting papillary masses. Even when the operation is promptly done, as it must be done, the patient is fortu- nate indeed if the disease has not already spread beyond the limits of the ovary and out into the broad ligament and the tissues of the pelvic wall. The opera- tion in such cases must be extremely radical. (6) Leucorrhea, Vaginal and Cervical. — A leucorrhea, vaginal and cervical, is commonly noted in the various text-books as one of the distressing conditions of the menopause. In my own practice I have not been particularly struck wdth a leucorrhea associated with the menopause wdiich is not simply an in- heritance from the woman's previous menstrual history. Tilt says that out of 260 women in whom the menstrual function had ceased, 143 had never been subject to leucorrhea; of the remaining 117: The vaginal secretion was increased at cessation in 77 cases. It was diminished in ; : .... 24 " It remained stationary in 16 " Many women only note the leucorrhea after the cessation of menstruation. In a number it is of trifling importance, and needs no treatment unless the patient asks for it for the sake of cleanliness. In such simple cases all that is necessary is to prescribe a menthol douche. I commonly have this prescription put up in the form of tablets as follows, patient dissolving two of the tablets in a pint of hot water and using it when tepid : ^ Menthol gT. 1 Sodium bicarbonate gr. 12 Sodium biborate gr. 12 Powdered alum gr. 6 If the leucorrhea is troublesome, it is important to make a careful exami- nation and determine whether it comes from the cervical canal or from the MENOPAUSE. 101 vaginal wall. The cervical leucorrhea is usually seen oozing out of the cervix, a tenacious, mucopurulent discharge. A vaginal leucorrhea is not thick and tenacious, but thin, yellowish or white. When the leucorrhea comes from the vagina, the latter is usually reddened, showing signs of patchy inflammation. For the treatment of these conditions I would refer to the chapter on Leucor- rhea. A marked vaginitis with shrinking of the vagina belongs rather to the diseases of old age, q. v., although sometimes found at this period and some- times even earlier. A good douche is a teaspoonful of sulphocarbolate of zinc to a pint of water, (7) Pruritus. — Itching occasionally troubles patients at this period, but I refer to this in another part of the book, associating it more with the diseases of old age. The first two steps to take in investigating a case of pruritus at middle age is to discover whether or not the patient has diabetes, and then to find out whether or not the itching is caused by any irritating cervical or vaginal discharge. In the latter case great relief is often experienced by the application of a strong solution (ten to twenty per cent) of nitrate of silver, followed by a boro-glyceride pack and later by borax douches, a teaspoonful to a pint of warm water. A distressing pruritus ani may be kept up by a slight thin vaginal discharge. When the pruritus is not dependent upon these causes, much relief is obtained by warm hip baths. A good lotion is made by adding two drams of powdered acetate of lead to four ounces of milk, applying this several times a day, allowing it to dry on the surface. When the lotion gets watery it should be thrown away. Tilt further lauds the use of a solution of nitrate of silver, about eight per cent or weaker, well rubbed into all the recesses of the membrane, (8) Bearing Down and Relaxed Vaginal Outlet. — I have associated these two conditions here under one caption because they may be either closely related or one exist entirely independent of the other. It is not uncommon at this period for patients to comjilain of a more or less distressing bearing down, which keeps them conscious of their pelvic organs. Often the feeling itself is not so troublesome, but the patient fears lest it means a displacement of the organs and an operation. In such cases a careful examination should be made, not only with the patient lying on her back when the examiner seeks to recognize a broken-down, relaxed vaginal outlet, but with the patient standing to see whether or not there is a tendency of the uterus to fall decidedly toward the vaginal orifice on straining a little. A relaxed condition of the vaginal orifice is common at the change of life for many reasons: the patient may have had it for a number of years, but failed to take any active steps for its relief so long as she was liable to bear children; again, for this or other reasons, she postpones an operation until past the child-bearing period. In all these cases where there is a pouting, relaxed, broken-down condition of the vaginal outlet with uterine displacement, the wiser plan is to operate and bring tlie levator jnuscles together, restoring the outlet to its original integrity. 102 NORMAL MEK"STErATION AKD THE 3MEXOPAUSE. (9) Uterine Displacement. — Closely connected with the condition just de- scribed is retroflexion and downward displacement of the uterus. When the uterus is large and bearing down on the pelvic floor, whether in retroflexion or descensus or both, it is a wise plan to suture it in a good ante position by one or other suitable operation ; when, however, the uterus is not abnormal in size and the history shows that the retrodisplacement has persisted all through the menstrual life, and especially if she is unmarried or nulliparous, she is not likely to derive any benefit from the operation of putting the uterus into posi- tion, no matter how tempting to the surgeon. The plausil)le argument is unfortunately fallacious : the patient has for a long time suffered from bearing- down symptoms, the body of the uterus is found tipped back or retroflexed; what more natural than the conclusion that the correction of the trouble will relieve the discomforts. A careful study of the history of many of these cases will show that, aside from the displacement and the pelvic complaints there is a long nervous history with complaints of other kinds, and that the pelvic trouble is but part and parcel of a constitutional condition which cannot be relieved by surgery. If the displacement is not associated with a broken-down outlet, the sequel of labor, and if it is not associated with a decided enlargement of the uterus, then let the operator be careful to avoid promising relief by the mere surgical correction of the malposition. (10) Incontinence of Urine. — From the time of the menopause on, inconti- nence of the urine is noticed with increasing frequency. The patient first notices a little dribble, the escape of a few drops on to her person upon cough- ing, laughing, or sneezing, or upon stepping down or on any sudden exertion. This may increase until she notices that she is wet pretty much all the time. At the same time the occasional dribblings are not sufiicient to empty the blad- der, so the toilet is used about as often as heretofore. Sometimes in these cases there is a histoy of a severe confinement and some similar disturbances dating from that event. A careful examination shows no urinary affection and no evidence of cystitis. At the most there is some gaping of the vaginal orifice and dropping of the anterior wall of the vagina, with a downward dis- placement of the urethra and the neck and base of the bladder. A systematic examination shows nothing special unless it be in some cases a lazy closure of the sphincter at the neck of the bladder. The surgeon is strongly tempted to recommend an operation at once, lifting up the floor of the vagina " to support the floor of the bladder." This proves a failure. He then suggests resecting the anterior vaginal wall to support it and " to prevent the bladder from coming down," doing a cystocele operation and carrying the denudation out beyond the neck of the bladder. This, too, fails, and he is then at his wits' end. I find the cure for these cases, both in the class of patients we are describing and in those who are older (for it is largely a disease of old age, as the trouble gTows worse as the patient begins to lose the padding of intra-j^elvic fat) is the following: If the patient is so old that slie seriously objects to an operation, if the vaginal outlet is fairly well MENOPAUSE. 103 Fig. 51 A. — Disc Pessary, which is Often Suitable in Relieving lis continence OF Urine. lifted up and will support a pessary, a good, snug-fitting disk pessary, which stifi^ens out the vagina and makes just a little pressure at the neck of the blad- der, such pressure as the finger might make while gently pushing the neck of the bladder against the symphysis, will give considerable and, occasionally, entire re- lief. It is worth while to try several pes- saries, each varying a little in size, to see which one does its work best. (See Fig. 51^.) In the case of a younger woman, or of an older woman who is not relieved by a pessary and wants a radical cure, I believe the best treatment is to make an oval vagi- nal incision under the neck of the bladder, extending down to but not through the ure- thral mucosa, then carefidly dissecting out on either side so as to undermine the neck of the bladder. The sphincter mus- cles are found and sutured snugly together with several buried silk sutures. The vagina is then closed over this and the operation completed. Such cases are relieved with practically uniform success. (11) Tumors of the Breast. — According to Williams, in 1903, 10,000 women were suffering from carcinoma of the breast in England and Wales. In an analysis of 13,824 primary neoplasms collected from London hospitals, covering a period of twenty-one years, 2,422, or seventeen per cent, were tumors of the breast, and all but 25 of these, or 2,397, were of the female breast. Velpeau ("Diseases of the Breast," Syd. Soc, 1856), classifying 273 cases of scirrhous and encephaloid tumors of the breast, says there were 95 between forty and fifty, and 123 over fifty years of age, and remarks: " So that it is between forty and fifty, and then between fifty and sixty, that the female breast is incontestably more exposed to cancer, whether in the form of scir- rhus, or with the characteristics of encephaloid." He united in the following table 281 cases of hypertrophy, cysts, small interlobular fibroids, and ade- noid tumors of the breast, and found they were said to have originated at the following ages : Up to 30 76 30 to 40 64 40 to 50 80 50 to 60 ; 19 ' 60 to 80 31 Age not noted '. 11 281 V. Angerer, of Miinich, has had 306 women with cancer of the breast^ of whom 116 were between forty and fifty years of age. 104 NORMAL, MENSTRUATION AND THE MENOPAUSE. The average age of the beginning of a carcinoma in women has been com- puted by Horner as 51.45, and by Winniwarter as 45.3; by Gebele as 50.8. About forty to forty-six per cent occur in the period following the meno- pause. S. W. Gross gives the average age for the appearance of carcinoma of the breast as between forty and fifty. r. Martin quotes Gross as declaring that a discharge from the breast in any woman over forty years of age is pathogiiomonic of cancer. Retraction of the skin over a lump is always a serious sign. A w^ell-defined tumor of the breast at the time of the menopause should always be held as malignant until an operation proves the contrary. The safe plan is to assume that every cystic or non-malignant tumor is likely to become maligTiant later on. Occasionally, judging from my own experience, errors in diagnosis are not infrequently made by the most expert. I have noted re- garding cancer of the womb. The same urgency and immediate operation per- tains also to tumors of the breast. CHAPTER IV. DYSMENORRHEA. (1) Dysmenorrhea: Definition, p. 105. Menstrual molimena, p. 105. Classification, p. 106. Causes of dysmenorrhea when no pathological lesions can be found, p. 107. Causes of dysmenorrhea associated with gross pelvic lesions, p. 110. Remedies for temporary relief, p. 113. Remedies for permanent rehef, p. 117. Dilatation, p. 121. (2) Membranous dysmenorrhea, p. 128. Definition. — The name " dysmenorrhea " signifies simply painful menstrua- tion, and is applied without discrimination to all varieties of suffering asso- ciated with the performance of the menstrual function. The fact that we are still in the dark as to the etiology of menstruation is a serious obstacle to a better understanding of the true nature of dysmenorrhea. As things stand at present the theories advanced to explain it and the practices employed to relieve it are purely empirical. Menstrual Molimena. — In any consideration of dysmenorrhea we find our- selves in a difiiculty at the outset, from the fact that it is impossible to say exactly what constitutes normal menstruation. Theoretically, a woman in per- fect health ought to know no difference between the menstrual and intermen- strual periods, but this state of things exists only among uncivilized people. The effect of civilization, and more especially of the complex conditions of our modern life, has been to intensify nervous excitability to such an extent that, the woman who menstruates to-day without pain or reflex disturbances of some kind is altogether exceptional. Entire absence of suffering is indeed so unusual that text-books of gynecology all devote some space to what is called " menstrual molimena," that is to say, those local and general disturbances which it is assumed must habitually attend menstruation. These disturbances consist of a certain amount of pain, situated in the pelvis and extending through the back and thighs; and of nervous excita- bility, manifesting itself most commonly in headache, depression, and disin- clination to exertion. The symptoms frequently precede menstruation by a period varying from a few hours to a few days ; in some cases they are relieved by the establishment of the flow, while in others the suffering is increased by its appearance. The nervous symptoms, such as headache, and reflex disturbances of various kinds, are sometimes more marked than the local suffering. The condition described may be considered as constituting normal menstruation; any marked increase upon the symptoms being patho- logical and coming under the head of dysmenorrhea. 105 106 DYSMENORRHEA. The constancy with which menstrual molimena occur has been investigated by Marie Tobler (Monatsschr. f. Gel. u. Gyn., 1905, vol. 22, p. 1), who interrogated one thousand and twenty women with this point in view. She found that twenty-six per cent had local pain and both physical and mental disturbance, the term physical disturbance being used to indicate such consti- tutional phenomena as a sense of general discomfort, of malaise, or of weak- ness. Four and four-tenths per cent had only local suffering. Fourteen per cent had local and physical, but no mental disturbance; eleven per cent had physical and mental, but no local disturbance ; six and nine-tenths had physical, but no local or mental disturbance. Seven and eight-tenths had mental dis- turbance only; five and six-tenths had mental and local, but no physical dis- turbance ; while sixteen per cent were free from disturbance of any kind. In three and three-tenths per cent the patients felt better than at any other time ; while in three and six-tenths per cent they felt better during the period, but were more or less disturbed just before or after it. The reflex symptoms accompanying menstruation are extremely varied. In addition to headache, which is so common as to call for no comment, pains in the joints are often present, even in cases where no rheumatic or gouty tendency exists. Eye strain is quite common, with marked contraction of the field of vision in some cases, especially when there is a tendency to exophthalmic goitre. Skin eruptions, such as eczema and acne, make their appearance or are increased in virulence. Suffering of any kind to which the patient is subject, either temporaril}^ or permanently, is apt to recur or to be exacerbated with the occurrence of menstruation; for instance, neuralgia in any part of the body is more likely to attack its victim at that time, and even so common a malady as toothache is influenced by it. Classification. — From the standpoint of the subjective symptoms, dysmenor- rhea may be divided into two classes, one, in which the character of the men- strual discomfort is identical with that which we have just defined as normal, but is much more severe; another in Avhich the suffering is not only more severe, but of a different character from that just described. In the class characterized by increase of the usual suffering, the pelvic pain begins from one to two days to a week before the appear- ance of the flow. It is of a dull, dragging character, extending all through the back and down the thighs, and is often accompanied by severe headache, occasionally associated with nausea, extreme lassitude, and nervous excitability. In some cases the symptoms are greatly relieved by the establishment of men- struation ; in others they continue throughout its duration. In the second class of cases, the pain begins just before, or exactly with the appearance of menstruation. It is sharp, well-defined, and cramp-like in character, coming on in paroxysms whicli last a minute or two and recur at short intervals. This form of dysmenorrhea is less often accom- panied by reflex disturbances than the other. There is still another variety of dysmenorrhea in which both types of CAUSES OF DYSMENOKEHEA. 107 pain are present, the spasmodic form being superadded to the dull per- sistent pain and the two being present in varying proportion. I shall refer again to these two types of dysmenorrhea in the discussion of its treatment; at present I will proceed at once to consider the various theories as to its causation. CAUSES OF DYSMENORRHEA WHERE NO PATHOLOGICAL LESIONS CAN BE FOUND. It has long been recognized that dysmenorrhea is not necessarily associated with a demonstrable abnormal condition of the reproductive organs. On the contrary, dysmenorrhea of the most severe and obstinate character may exist in the absence of any discoverable local disease what- ever, while some cases of advanced disease in the uterus and appendages are entirely free from pain in menstruation. Vari- ous theories have been developed to explain the existence of dysmenorrhea in the absence of uterine or ovarian disease, the most widely recognized of which are the following: Mechanical Dysmenorrhea. — This theory presupposes a constriction of the uterine canal, by means of which the escape of the menstrual fluid is impeded. It was first advanced by Sir James Mackintosh of Edinburgh and was further developed by Marion Sims and Sir James Y. Simpson. In detail it is based on the assumption that an obstacle is present in the uterine canal, and that in order to force the blood past this obstacle the uterus con- tracts forcibly, the contraction being realized subjectively in the form of uterine colic and constituting the pain known as dysmenorrhea. The obstacle in question, according to the advocates of the theory, may be : ( 1 ) A kink in the cervical canal, due to an anteflexion, or, more rarely, a retroflexion; (2) a stenosis of the internal os, which may be congenital, or the result of spasmodic contraction of the circular muscle fibres at the internal os, or of premenstrual swelling of the mucosa ; ( 3 ) a congenital stenosis of the external os or of the entire cervical canal; (4) intra-uterine polypi acting as ball valves; (5) clots of blood, or (in membranous dysmenorrhea) a membrane forced into the internal os. This theory affords a most plausible explanation of the clinical features of many cases of the spasmodic variety of dysmenorrhea, where the pain is sharp and colicky, comes on shortly before the flow, and is associated with scanty menstruation, becoming more free as the pain subsides. It received substantial support from the fact that dilatation of the cervix, which was sup- posed to remove the obstruction and should, therefore, theoretically, relieve the 23ain, was, clinically, a perfect success in many cases. These facts caused it to receive a ready Avelcome, but further experience and a closer oxamination of the results liave to a large extent destroyed confidence in it. Vedeler {Arcli. f. Gyn., 1883, vol. 21, p. 211) has shown that out of a large number of women with 108 DTSMENOEKHEA. anteflexed uteri, the percentage of those free from dysmenorrhea is as great as of those who suffer from it. Duncan has pointed out that observation of the section of a uterus in extreme anteflexion shows that the flow of blood along the flexed canal would be obstructed only in a degree which could not practically be of the slightest importance. Moreover, the uterine sound has been passed repeatedly through the internal os during menstruation, showing that at this time the stenosis does not exist. Again, it is estimated that the amount of menstrual blood lost is one drop in three minutes, and it has been demonstrated that menstrual blood flows easily at this rate through a tube much smaller than any possible stenosis of the os, or of the canal. It has also been shown that during the acme of the pain, and just before the' flow is established, there is no blood in the uterus at all. In support of the theory it has been urged that when a uterine sound is passed into the nulliparous uterus, resistance is often encountered, but this does not necessarily imj^ly the presence of a pathological stenosis, and careful examination usually shows that the difficulty arises from the tip of the sound being caught in the folds of the mucosa, or from its encountering a flexion. Dysmenorrhea Associated with Maldevelopment of the Reproductive Organs. — Insufficient development of the reproductive organs is often associated with painful menstruation, but the relation between the two is not yet determined. Some authorities claim that this form of dysmenorrhea is a neurosis ; others, that it arises from a deficiency in the calibre of the blood vessels, which are too small to receive the increased amount of blood necessary to establish the menstrual hyperemia ; others, again, consider it due to the fact that the uterine cavity is too small to accommodate the swollen endometrium ; and still another view claims that anteflexion is present in all such cases, on account of the maldevelopment of the anterior surface of the uterus, and that while the increased blood pressure tends to straighten the flexed organ, the resistance rendered by the lack of distensibility of the uterine parenchyma occasions the pain. ISTone of these explanations can be accepted as satisfactory, and although there is no doubt that maldevelopment of the pelvic organs is an important causal factor in many cases of dysmenorrhea, we are at present unable to say more than that the incompletely developed organ is not capable of prompt, efficient response to a normal impulse, and therefore does not carry out its function with ease, hence the pelvis is not relieved of its increased blood pressure and there is a tendency to stasis. A poor physical development is often associated with a similar condition of the pelvic organs, but mal- development of the uterus and adnexa is not necessarily associated with gen- eral defective development. Women in robust health, whose only ailment is dysmenorrhea, sometimes present imperfectly formed uteri and ovaries of the puerile type. Neurotic Dysmenorrhea. — In some instances, dysmenorrhea is undoubtedly a pure neurosis, explicable as a hyperesthesia of the endometrium; in other words, it is an abnormal perception of the uterine contractions physio- CAUSES OF DYSMENOEEHEA. 109 logically present at every menstrual period, but not usually appreciable, it being supposed that uterine colic is analogous to intestinal colic and due to a tetanic spasm of the circular fibres at the internal os. The pain may be due also to a physiological difficulty occasioned by the breaking down of the mucous membrane of the capillaries which induces a sort of pelvic headache. In dysmenorrhea of this type the patients are not anemic, their functions are well performed, and examination shows their reproductive organs normally devel- oped, so that the dysmenorrhea must be considered as a pure neurosis whose exact nature cannot be clearly defined. It frequently happens that dysmenor- rhea will make its appearance during neurasthenia in women who have never suffered from it before. In such cases it is often a nice question how much the dysmenorrhea is the result of the neurasthenia and how much it is occa- sioned by local disturbance of the organs. Nasal Dysmenorrhea. — In 1897 Tleiss advanced a theory of dysmenorrhea based on the fact that certain cases could be relieved by the application of a twenty per cent solution of cocain to the so-called " sexual spots " in the nasal mucous membrane, urging in support of his theory that at the time of men- struation these spots increase in size and consistency, become cyanotic, and bleed easily. The theory found some supporters, amongst them J. Mackenzie, but it has never met with general acceptance. A most sensible paper on the subject by G. Kolischer (Amer. Jour. Obst., 1904, vol. 49, p. 804), ascribes the good results observed in certain hysterical patients to the effects of sugges- tion, and points out that cocainization of other mucous surfaces produces the same effect. For instance, in two cases where relief was promptly experienced after the application of cocain to the " sexual spots," the same benefit was obtained at the next menstrual period from the application of cocain else- where, in one case to an erosion of the cervix, and in the other to a previously cleansed rectum. Dysmenorrhea from General 111 Health. — There is still another variety of dysmenorrhea, common in young girls in whom the menstrual habit is becom- ing established, and usually associated with a variety of dyscrasias, the most prominent of which are anemia and chlorosis. This form does not usually persist beyond the twentieth year, although it is occasionally met with in young married women. Many of these patients live among poor hygienic surroundings which keep their physical vigor below par ; others, on the con- trary, are found among the higher classes who live amidst luxurious condi- tions, but are victims to the overstrain caused by the perpetual rush and excitement of constant social engagements, or the present efforts towards the higher education of women. These are the principal theories concerning the etiology of dysmenorrhea not associated with gross pathological lesions of the reproductive organs. Other explanations less well recognized are to be noted also. Chronic endo- metritis, causing pain in menstruation through hyperesthesia of the endo- metrium is sometimes spoken of, and also chronic ovaritis; but neither 110 BYSMENORIIHEA. of these causes has jet been demonstrated. In sixty-four cases of dysmenor- rhea without abnormalities of the pelvic organs, which were treated in my clinic by dilatation and curettage, chronic endometritis Avas found on micro- scopical examination in only four cases, and in no one of the four was it well marked. A form of painful menstruation, known as ovarian dysmenor- rhea, is sometimes spoken of, in which there is extreme tenderness of the ovary during the period, demonstrated by pressure upon it, and explained by thickening of the ovarian capsule preventing the expansion of the ovary during the period of congestion; it has never come under' my observation. Perimetritis and salpingitis are sometimes the cause of pain in men- struation on account of the peritoneal pain occasioned by contractions of the tubes and uterus. Some writers recognize another form of dysmenorrhea known as "neuralgic " which is classed with the pure neuroses as analogous to intercostal or facial neuralgia. Dysmenorrhea is sometimes met with in women of a gouty or rheumatic constitution as a manifestation of the diathesis; its association with the dyscrasia being demonstrated by the entire relief afforded from remedies appropriate to its alleviation. In dysmenorrhea, not otherwise explicable, occurring in women with a rheumatic or gouty his- tory, it should always be borne in mind as a possible cause, even if there are no other manifestations of the diathesis. CAUSES OF DYSMENORRHEA ASSOCIATED WITH GROSS PATHOLOGICAL LESIONS. While there are many cases in which a most severe dysmenorrhea is present without the slightest local lesion or displacement, there are also a considerable number where it exists in the presence of some pathological condition, of greater or less significance, by which, there can be no doubt, it is sometimes induced. In order to investigate this matter, I inquired into the histories of one thousand patients admitted consecutively into the Johns Hopkins Hos- pital, and found that two hundred and twenty-nine of them suffered from dysmenorrhea which was apparently the result of a definite pelvic lesion. The abnormal conditions which may occasion dysmenorrhea are many and various, but the three most frequently met with are: (1) backward displacement of the uterus ; (2) pelvic inflammatory disease ; (3) myoma. Of the cases spoken of, forty-one per cent were associated with retrodisplace- ments of the uterus ; thirty-seven per cent with pelvic inflammatory disease ; and eleven per cent with myomata. The remaining eleven per cent were dis- tributed among various minor conditions. Retroposition of the Uterus. — Dysmenorrhea is more commonly associated with retroposition of the uterus than with any other abnormal condition of the pelvic organs. An analysis of a number of cases of backward displace- ments, treated at the Johns Hopkins Hospital, made by my former associate. Dr. G. R. Holden, showed that out of one hundred and twenty nulliparae, one CAUSES OP DYSMENOERHEA. Ill hundred and nine, or ninety per cent, suffered from dysmenorrhea before operation. In multipara?, backward displacements are not so frequently asso- ciated with dysmenorrhea, there being one hundred and thirteen cases of it in two hundred and two cases of retroposition, or fifty-six per cent. Dys- menorrhea is occasionally the only symptom caused by the displacement, but more often it is only one of a series of manifestations, although, perhaps, the most severe. There is no constant type of dysmenorrhea associated with retro- position ; it is more apt to continue throughout the entire period than the dys- menorrhea of nulliparae without lesion. Gastric symptoms, headache, and other neurotic manifestations are often marked features, owing to the neuras- thenia which almost invariably accompanies such cases. Pelvic Inflammatory Disease. — About one-third of all the inflammatory con- ditions of the uterus, tubes, or ovaries, acute or chronic, are accompanied by dysmenorrhea. The proportion of cases with menstrual pain is about the same in acute and chronic affections, and the intensity of the suffering bears no relation to the extent of the pathological process. Cases in which the entire pelvic organs are the seat of inflammatory disease may have no pain in menstruation whatever, while a few adhesions binding down lightly one tube or ovary, or both, may give rise to severe suffering. Here also there is no constant type of pain. The suffering usually comes on a few days before the flow and lasts through the entire period. It is commonly dull in character, and is often referred to a wide area over the abdomen, back, and thighs. There may be no symptom of the condition except dysmenorrhea. Myomata. — During the year 190 Y the histories of two hundred cases of myoma in women under forty-five were examined at the Johns Hopkins Hos- pital to ascertain what percentage of their number suffered from dysmenorrhea. Ninety-four of the cases were white and one hundred and six black. Only those cases were considered positive which " showed the onset of dysmenorrhea with the present illness." Of these two hundred cases of uncomplicated myoma (adeno-myoma not included), twenty-five per cent showed that painful men- struation had made its appearance since the onset of the trouble for which the patient sought advice. This estimate of the proportion of dysmenorrheas asso- ciated with myoma may seem low, but another set of investigations carried on at the Johns Hopkins a little earlier gave a percentage of twenty per cent, which is even lower. Dysmenorrhea is most frequently seen with submucous and inter- stitial myomata and is rare in the subperitoneal form. Here, again, there is no distinctive form of suffering. Severe dysmenorrhea is most often observed in the case of small tumors, and I pause here to call attention to the fact that a number of apparently inexplicable dysmenorrheas are due to the presence of extremely small myomata. In a case which passed through my hands not long since, the patient had been suffering for some years with extreme dysmenorrhea and more or less constant pain, so that her general health was quite broken down. When the uterus was 112 DTSMENOEEHEA. opened a very small submucous myoma was found and removed, with complete relief of the suffering. TREATMENT OF DYSMENORRHEA. An important question which at once arises in almost every case of dys- menorrhea is the propriety of making a local examination. There should, of course, be no hesitation in the case of married women, or in cases of inflam- matory disease. But there are many instances of young women who suffer from dysmenorrhea pure and simple, when the question of examination must receive careful consideration. It is always best to exhaust all general thera- peutic measures before making it; and, in a large number of cases, if these are carried out conscientiously over a long period of time, the suffering will be relieved. If, however, the case is an aggravated one when first seen; if it persists in defiance of all therapeutic measures; if it cannot remain under observation ; or, if the circumstances are such as to prevent the general meas- ures being consistently carried out, an examination should be made under an anesthetic. With this precaution, an examination can be made without injury to the hymen, while, should any simple operation such as dilatation and curettage be indicated, it can be performed at the same time. Such a course enables the physician to dispense with the endless local treatments which are so objection- able in young women. The. various remedial measures which experience shows to be beneficial are as follows: GENERAL REMEDIAL MEASURES. Attention to General Health. — In all cases of dysmenorrhea the closest attention to general health is indicated. In a large proportion of cases the patient will show more or less evidence of malnutrition of some kind or other, and this should be the object of persistent attention. A proper quantity of nutritious food is essential, and if, as often happens, the appetite is so impaired as to make it impossible to consmne this at ordinary meals, the deficiency should be made up by feeding the patient in small amounts at frequent inter- vals. A glass of milk, a cup of beef tea, a sandwich, some malted milk, or any light nutritious food taken between meals and just before going to bed will generally be sufficient, and as the general condition improves, the appetite will increase. Sleep. — A case of the kind under consideration should always have fully eight hours' sleep and more, if possible. In young girls who have not attained maturity, or in cases where the patient is markedly anemic, there must always be more, either at night or in the day time. An excellent plan is a sleep of one or two hours in the early afternoon. All late hours and excitement should be avoided with young girls at school, and the greatest care should be exercised to prevent over-exertion. The requirements of our large TREATMENT OF DYSMENOKRHEA, 113 schools are such as to tax the caiDacities of a growing girl to the utmost, and if she is to keep up to them she must have every external aid in the healthy- regulations of her life out of school hours. A young girl suffering from dys- menorrhea should never be sent to school during the menstrual period ; and in a good many cases she should be taken away altogether for some months, or a year, if necessary. Fresh Air and Exercise. — A considerable amount of time spent in the open air is of vital importance. The conditions of a woman's life in this respect are greatly improved upon what they were a generation ago, and a variety of outdoor amusements are now open to her. Walking, riding, driving, bicycling, or some form of active game, such as tennis, golf, or basket ball, are very desirable ; and some hours spent out of doors, in all but the most inclement weather, should form part of the routine of each day. Rest. — More benefit is derived from rest in the treatment of dysmenorrhea than from any one other remedy. Absolute rest in bed during the periods is essential. Every patient suffering from established dys- menorrhea should remain in bed for two to three days at each menstruation, and whenever it is possible, the rest should begin before the appearance of the flow. Careful observance of this rule in conjunction with other remedies will, in many cases, completely relieve the dysmenorrhea, and the patient will be able after some months to resume ordinary habits during menstruation. In other cases it will be necessary to continue the practice of rest in bed for at least the first twenty-four hours each time, if the relief from suffering is to be permanent. Regulation of the Bowels. — Dysmenorrhea is frequently associated with constipation, so frequently, indeed, that keeping the bowels open, and even a little relaxed at the time of the menstrual period, is often most effectual in giving relief. I have known one case in which perfect relief for several periods was obtained by taking a heaping teaspoonful of Husband's magnesia every morning for three or four days before menstruation. In young girls who suffer from dysmenorrhea, it will often be discovered on close questioning that there is no regular evacuation of the bowels, and that the patient is quite unaware of the importance of the habit to either her general health or her menstruation. In such cases it is well to focus attention upon this point until the constipation is overcome, and this will often result in entire relief of the menstrual suffering. REMEDIES FOR RELIEF OF PAIN DURING MENSTRUATION. Opium should rarely be given for the relief of dysmenorrhea, any more than for any other form of protracted suffering characterized by paroxysms, that does not tend to a fatal issue. The various forms of alco- holic stimulants so much in vogue are also contraindicated. There is a strong tendency among the poorer classes to seek relief in either 9 114 DYSMEXOREHEA. gin or wliiskev, and this point should be especially borne in mind among dis- pensary i)atients. The various patent medicines taken for the relief of pain all contain a large percentage of alcohol and their use should be systematically discouraged. The percentage of alcohol by volume in some of these com- ]")0unds, as given by the Massachusets State Board Analyst, is as folloTvs : Lydia Pinkham's Vegetable Compound 20.6 Peruna 28.5 Paine's Celery Compound 21.0 Jackson's Golden Seal Tonic 19.6 Schenk's " Sea-weed Tonic," " entirely harmless " ! 19.5 Ayer's Sarsaparilla 26.2 Hood's Sarsaparilla 18.8 It is necessary, however, or at any rate desirable, to combine a stimulant with the coal-tar preparations which are so much used for the relief of dys- menorrhea, in order to counteract the depressing effect upon the heart exercised by that class of remedies. Five grains of phenacetin with two teaspoonfuls of whiskey are sometimes given for the relief of menstrual pain, but it should always be given by the physician in the form of a prescription, and never put into the patient's hands as a remedy for general use, which she is at liberty to renew at her discretion. The evils of alcoholic stimulation are so great, however, that I prefer to give twenty to thirty drops of the aromatic spirits of ammonia in a little water. The following formulae for the relief of menstrual pain I have found use- ful in my practice : ^ Pheuac. 1 __ ' > aa „ . ffr. n Salol i ^ •' M. Pt. charta. ]\Iitte tales no. vi. S. One powder every four hours. 3^ Potass, bromid 3ij Elixir guaran. and celer foij ]M. S. One dessertspoonful every four hours in hot water. I^ Acetanil. (Phenac.) gr. v Codein gT. ss M. Pt. charta. Mitte tales no. iv. S. One powder and repeat in an hour. 19 Apiol gr. 1 Pt. caps. no. xii. S. One capsule each night and morning for two or three days before menstruation. TREATMENT OF DYSMENORRHEA. 115 I>! Hydrastis canacl f§ij S. Twenty-five drops in a wineglassfnl of water twice a day, beginning a week before menstruation and continuing through the flow. Dr. Walter L. Burrage recommends the various Ilelonias compounds, which he has found useful. The best of them, in his opinion, are " Mistura Helonin Compound " and the fluid extract of " ITelonias Compound." These preparations are safest, as they do not contain an opiate, and the quantity of alcohol per dose is infinitesimal. The compound mixture of helonin, known as " Green Mixture," because of its brilliant color, may be given in doses of a teaspoonful in half a teacupful of hot water every fifteen minutes during a paroxysm of pain, or three times a day during the intermenstrual period, or for a week before the flow is expected. The two following prescriptions given by B. C. Hirst (" Diseases of Women," 2d edition, p. 421) seem likely to be valuable: I^ Acetanil gr. ij Ammonite carb gr. iij Heroin gr. ^t M. Ft. pil. Mitte tales no. vi. S. One pill every hour for three hours. ^ Tinct. opii camph f.oj Tinct. zingerb f§j Spts. chlorof 3ij Syrup, acac f^ss Aq. menth. pip., q. s. ad f.oiv M. S. ~ One tablespoonful when required for cramp. In cases where the flow is scanty and the pain begins before its appear- ance, to be relieved by its establishment, I have found great benefit from the use of a rectal injection containing a heavy dose of sodium bromide in hot saline solution; it acts as a local sedative and also stimulates the flow by dilating the blood vessels. The formula for it is as follows: 3^ Sodii bromid gr. xl Hot saline sol., yo^ of one per cent Oj M. S. Inject into rectum and retain. Another rectal injection from which benefit is obtained is : T^ Antipyrini gr. xv Sod. chlor gr. xxx M o fSviij M. S. Inject into rectum and retain. 116 DYSMENOEEHEA. The apiilication of heat externally often gives much relief. Hot water bags are excellent^ or hot sand bags. A hot mustard foot bath is sometimes of service. Tor the latter purpose I use two teaspoonfuls of mustard in a foot-tub full of water, as hot as can be borne. In cases where the pain is of tlie congestive character, T. A. Emmet recommends a plan of treatment directed to the relief of venous engorgement ("Principles and Practice of Gynecology," 3d edition, 1884, p. 177). A foot bath as hot as can be borne should be given, followed by some kind of hot drink. A hot mustard plaster is then applied along the spine. This should be about three inches in width and reach from the cervical region of the spine to the sacrum. As a rapid action is desired, the unadulterated mustard must be rubbed up into a thick paste with warm water and then reduced to the proper consistency by adding an ounce or two of syrup or molasses, which will at once develop the volatile oil. A piece of unstarched muslin, sufficiently long and some nine inches in width, is laid out at full length and the mustard is spread down the middle for one-third of the width, so that when the strip is folded over, the mustard will be covered on one side by two thicknesses of the cloth. The surface which is covered by the single thickness of cloth must be warmed and kept folded together until applied. The skin will become reddened in from ten to twenty minutes and the plaster must not be allowed to remain longer, even though the patient should not complain of pain occa- sioned by it. When the flow is delayed, dry cups, in Emmet's opinion, are more efficacious than the mustard plaster in bringing it on. These must be put on each side of the spinous processes and only in the immediate neigh- borhood of any point which may be found tender on pressure. The relief is more prompt when four to six large tumblers are used than it is with the ordinary sized cupping glasses. Unless the tumblers are unusually thick and heavy, there is no difficulty in making them hold on, after properly exhausting the air, by igniting a little alcohol which has been poured directly into the glass or upon some cotton on a piece of paper stuck to the bottom. The damp cotton must be firmly pressed against the bottom of the glass before dropping on the alcohol, and any excess of alcohol which may have run down to the edge of the glass carefully wiped up in order to avoid burning the patient. Eifteen to twenty minutes is long enough for the cups to remain in one place, after which they may be shifted to another. It may be necessary to repeat this treatment month after month until the local disease underlying the dys- menorrhea has yielded to treatment. During the interval between the men- strual periods, the general health must be carefully watched according to the rules laid down. A Turkish bath is often beneficial when taken within a week before the expected period. When the pain is intense and all other remedies have failed, morphin may be given hypodermically as a last resort. As a rule, a single dose of one- eighth or one-fourth of a grain will be sufficient. It should always be controlled by the physician, and if a marked neurotic element is pres- TKEATMENT OF DYSMENOEKIIEA. 117 ent he must exercise extreme caution, especially if the dose is repeated several times. The patient must be in ignorance of what she is taking. REMEDIES FOR PERMANENT RELIEF OF DYSMENORRHEA. Pessaries. — Dysmenorrhea associated with retrodisplacements of the uterus is sometimes relieved by a pessary. In one case I found entire relief afforded by one of the Smith-Hodge variety. As to the selection of a suitable pessary and its application, see Chapter XIII. Thyroid Extract and Calcium Lactate. — Dr. J. E. B. Branch, of Macon, Ga., has communicated some interesting results obtained with thyroid extract and also with calcium lactate. In one young woman of twenty-seven, who had suf- fered for twelve years with severe pains in the lower abdomen, backache and headache, nausea and scant flow, there was complete relief obtained by giving thyroid extract 5 gT. t.i.d. In several cases this treatment failed, and in some even made conditions worse. In two, splendid results were obtained by giving 10 gr. of calcium lactate t.i.d., beginning a week before the expected onset of period, continuing till its end. Electricity. — The treatment of dysmenorrhea by electricity was of interest fifteen years ago, and promised excellent results. The method has failed be- cause of a failure of interest in the question of the use of electricity in gyne- cology. It seems a matter for regret that the electrical treatment of various gynecological affections should not receive more attention, and I quote from some of the early papers in hopes that the methods described may be of use to-day. W. B. Sprague (Ann. Gyn. and Fed., 1891, vol. 4, p. 402) says: " I have learned to take my battery with me whenever called to relieve a woman suffer- ing at the menstrual period. I generally use a Kidder five-post battery, and use the current from the extreme posts (the A-E current) with the shell of the magnet well drawn out. I secure a current of great tension, which is the best for relief of pain. Placing the positive electrode, covered with some absorbent material well moistened, in the lumbo-sacral region, I use a small electrode over the hypogastrium with a kneading, rotary, and vibratory motion. This not only relieves the pain greatly, but increases the flow, so the only contra-indication is a tendency to menorrhagia. I also use the static and galvanic currents to pal- liate the pain, with less benefit — the former under similar conditions to those in which the faradic current is indicated, the latter in menorrhagia. . . . Only a moderate current is required in most cases — from five to twenty-five milliam- peres— but in cases of severe hemorrhage it is necessary to use from fifty to sixty milliamperes. Strong currents, while necessary to check hemorrhage, generally increase the pain at first, but cessation usually follows, if it be gradually re- duced and followed by the sacro-pubic administration for a few minutes fol- lowing the removal of the internal electrode." A. Lapthorn Smith (Amer. Jour. Ohst., 1891, vol. 26, p. 161) states that he has found the most important agent in the treatment of dysmenorrhea of uterine origin to be the apj^lication of the mild galvanic current to the 118 DYSMENOEEHEA. inside of the uterus by means of the ordinary uterine sound, insulated to within two and a half inches of its end, to the handle of which was attached the negative pole of the battery. The treatment is nsnally less painful than the passage of the sound, as will appear from the following brief description of the method : " After a careful bimanual examination for the purpose of excluding pregnancy and ascertaining the position and condition of the pelvic organs, the vagina is disinfected by a douche, if this has not already been done, at the patient's home. An ordinary Simpson's uterine sound of large size is then bent to the ascertained curve of the uterine canal, passed through the flame of the spirit lamp, cooled, and insulated with a clean piece of rubber tubing to within two and a half inches of its extremity, or less, if we have reason to think that the uterus is undeveloped. In the handle of the sound a hole has been bored, just large enough to hold the tip of the conducting cord from the negative pole or last zinc of the battery. The sound is then guided into the os uteri on the tip of the finger until it meets with some obstruction, when a current strength of ten milliamperes is turned on. In a minute or two the obstruction will seem to melt away and the sound will glide into the cavity of the uterus. The current is now gradually raised until the patient says she can feel it in the uterus, generally between twenty and fifty milliam- peres. being at once lowered on the slightest complaint of pain. At the end of five minutes the current is gradually turned off again, when the sound will be found to drop out almost of its own accord, and very much more easily than it entered. This may complete the seance, or, as an adjuvant and safe- guard a boroglycerid tampon may be inserted. The patient may return home on foot and resume her duties forthwith, as such mild applications do not require any precautions in the way of resting, etc. The positive pole of the battery is attached to the ordinary clay abdominal electrode." The following case is cited by Dr. Smith as an instance of the success of the above mode of treatment : " ]\Iiss W. was sent to me on the third of Jime, 1888, by Dr. Eeddy with a uterine fibroid and an enormous hypertrophy of the cervix. Her sufferings every month were imendiiraljle. She had been employed as cook in a private family, but had to give up her situation, as during menstruation she was totally incapacitated. She described the pain as agonizing, her screams being heard all over the house. I gave her two applications a week from then till July 28th of the same year, less than two months, when she reported that she had had a period absolutely free from pain, I continued to treat her for another month, but she has never had a painful period since, and was still menstruating regiilarly up to a few months ago when I saw her last, in perfect health, and doing all the catering and cooking for a large boarding house." A more recent paper than these is one by A. H. Goelet {Internal. Jour. Surg., March, 1900). In this he speaks most highly of electricity in the treat- ment of dysmenorrhea associated with stenosis, obstruction, or flexion. In cases of flexion it may be necessary to use tampons in conjunction, to support TEEATMENT OF DYSMENOKEHEA. 119 the uterus at a higher place in the pelvis until its weight is diminished and it is no longer dragged down. For the purpose of overcoming obstruction in the canal, whether associated with flexions or not, moderate electrolysis is employed. This produces distinct widening of the canal which promotes drainage of increased secretion, pent up in the cavity as the result of obstruction. The strength of the current (galvanic) employed for the purpose should not exceed ten milliamperes, and the duration of the application should be three or four minutes. Thus cauter- ization is avoided as obviously objectionable, since it would eventually lead to permanent stenosis from cicatricial contractions. The frequency of the appli- cations may be every second day for the first week or two, according to the condition ; twice a week during the third ; and cessation during the menstrual period. If complete relief is obtained at this stage, one application may be made two or three days immediately preceding the next two succeeding periods. The electrode is inserted with a speculum in the vagina or along the index finger as a guide. Strict antisepsis must be preserved throughout. The instru- ments and hands must be clean and the vulva and vagina thoroughly irrigated with an antiseptic solution immediately before treatment. Following each application the pelvis is submitted to faradization with the current from the long fine wire coil by means of the bipolar electrode in the vagina for the purpose of overcoming the pelvic hyperemia which constantly accompanies this form of dysmenorrhea. These applications should be continued for ten to fifteen minutes. Goelet considers that dysmenorrhea due to ovaritis and salpingitis, without suppuration, is amenable to this mode of treatment, if the details are carried out with care. In these cases, particularly where there is much sensitiveness to digital pressure in the vagina, the treatment should begin with faradization (bipolar) through the vagina with the most sedative current obtainable, and these applications, which are repeated every twenty-four hours, should be continued each day for fifteen minutes, maintaining the current constantly throughout the application at a point where it is barely appreciable to the patient. The strength of stimulation of the current should be increased only with the decrease of sensitiveness. When this has been accomplished, negative electrolysis of the canal is employed, when necessary, to promote drainage from the uterine cavity and tubes. In the beginning it is best to start with an application of only five milliamperes and continue it only two minutes. The application is repeated in two or three days, if no reaction follows to show that it is contra-indicated. The applications to the canal should be discontinued as soon as the necessity for drainage is no longer indi- cated, but the faradic applications are to be continued every second or third day until the cure is complete. Dysmenorrhea due to anemia and impaired nutrition will yield to vigorous applications of static electricity, consisting of sparks over the spine and especially over the sacrum; sparks to the hypogastric region, repeated 120 DYSMENOEEHEA. daily, or every second day; and the application of a stimulating static breeze applied generally. The applications are discontinued during menstruation. From two to three months are usually required to effect a cure. Dysmenorrhea due to imperfect development of the uterus and ovaries can only be benefited by electricity, if treatment is instituted before the patient has attained maturity. The applications must be made directly to the uterus with the object of stimulating this organ, and through it, the ovaries. An electrode with two and a quarter inches of exposed surface is inserted into the uterus and connected with the negative pole of the faradic apparatus. The other pole terminating in a felt electrode the size of the hand, is placed over the lumbar region and the current is employed as strong as it can comfortably be borne. It should be maintained for five or ten minutes and its strength constantly increased throughout the application, so as to maintain a stimula- tion throughout, the object being to excite an increased blood flow to the uterus. The applications should be repeated every second day at first, and later every third day. Applications of static electricity at the same time will aid mate- rially by stimulating an increased general nutrition. The method which is particularly effective is the static breeze: sparks to the spine, over the sacrum, and to the hypogastrium, with the breeze to the head for five to ten minutes after the other application. The static spark exercises a decided revulsive effect which relieves internal congestion, stimulates the general circulation, and, together wdth the breeze, promotes nutrition. The breeze to the head quiets nervous irritation and induces natural sleep. It will be seen that the various advocates for the use of electricity in gyne- cology differ in regard to the details of its use, and no doubt every practitioner who makes use of it will find it expedient to develop his own method. It is to be hoped that gynecologists, and general practitioners who practice more or less gynecology, will give the use of electricity in the treatment of dysmenor- rhea a thorough trial during the next few years, for it would seem to offer a fair prospect of relief in certain intractable cases, although it is still upon probation. Operative Treatment. — Permanent relief from dysmenorrhea, if other reme- dial measures fail, must be obtained from operative treatment. In cases where the suffering is caused by lesions of the pelvic organs, the cure of these lesions will generally be followed by the disappearance of menstrual pain, but the treatment of such cases belongs to the specialist. Tor the relief of dys- menorrhea not associated with organic lesions, however, there is one form of operative treatment so simple as to be within the scope of the general practi- tioner, and therefore within the limits of this work, namely, dilatation of the cervix uteri, followed, when it is indicated, by curettage of the endometrium. In cases where the organs are apparently normal this mode of treatment has yielded the following percentage of good results in my clinic. Out of ninety-five cases, eighteen were entirely relieved with no subsequent return of the pain, and fourteen were greatly benefited, the pain never return- DILATATION. 121 ing to its former severity. The periods of observation in these cases extended over from one to twelve years. Of the remaining cases, seven were re- lieved completely or in great part for periods of from one to twelve years, after which the dysmenorrhea returned. In thirty-nine instances, therefore, out of ninety-five, the results might be considered satisfactory. In twenty-one cases there was no relief at all, while the remaining thirty-five cases experienced more or less relief for a few months, but within a year the pain returned in the same severity as before. When the dysmenorrhea returns after a few years or months of comfort we are justified in recommending a second operation. There is no symptom complex by which the cases where dilatation may be expected to do good can be differentiated with certainty from those in which it will not. In general, however, we may anticipate relief in cases where the pain begins a few hours before the flow, is sharp in character, and lasts but a short time. A marked neurasthenia does not necessarily forbid a good result, but if permanency of relief is to be secured, the neurasthenia must also be cured. An excellent plan in such cases is to institute a thor- ough rest cure by an ether examination and a dilatation, with curettage, if necessary. DILATATION. This operation does not yet stand upon a scientific basis, for its mode of action is not clear and its results are far from uniform. It must always be borne in mind that not every case of dysmenorrhea is suitable for dilatation. The general practitioner, and even many a specialist, often make the mistake of beginning the treatment of every case of dysmenorrhea by dilatation, without a proper preliminary search for the cause of pain, for- getting that in certain cases the pain is due to the presence of definite lesions, such as ovarian disease, pelvic peritonitis, or small interstitial fibroids, which are not of a nature to be relieved by such treatment. In order to make clear the relation of dysmenorrhea to a variety of pelvic affec- tions which are apt to escape detection upon a superficial examination, I analyzed two hundred and fifty-five cases, taken consecutively, of pelvic perito- nitis with adherent tubes and ovaries, tubercular peritonitis, hydrosalpinx, and catarrhal salpingitis, and found that out of the two hundred and fifty-five cases, one hundred and eighty suffered from dysmenorrhea, while it was absent in only seventy-five cases. If the physician has determined by a careful examination that no lesions of the kind described are present, and if the various remedial meas^ures have been tried without success, dilatation should always be performed, and fol- lowed by curettage, if the latter seems advisable. Choice of Method. — Slow dilatation by means of laminaria or tupelo tents, much used in Germany, has been generally abandoned in this country, for fear of septic infection. The class of uteri which need dilatation 122 DYSMENOKKHEA. and curettage are often already infected, and the introduction of a hard for- eign body in the form of a tent, which bruises and lacerates the tissues while it is being introduced and keeps up a constantly increasing pressure, affords just the condition most favorable to the entrance of pathologic organisms into the system. In many instances the patient recovers from the operation with a chronic pelvic inflammation, and not a few deaths have been due to sepsis originating in this manner. A fatal case of infection following slow dilata- tion has been reported by Dr. T. S. Cullen (Johns Hopkins Hosp. Rep., 1897, vol. 6, p. 109). The patient was a young woman whose physician had thought it necessary to induce an abortion in the fourth month of pregnancy, and therefore he inserted a slippery elm tent into the uterine cavity. A few hours afterwards the patient suddenly became deathly pale and fainted away. On recovering she complained of great pain in the abdomen and had a slight uterine hemorrhage. Four days later she had a profuse hemorrhage, but it was not possible to ascertain whether the fetus had been expelled. On the fifth day she had a severe chill, followed by high temperature, marked abdominal distention, and extreme tenderness over the abdomen. The chills continued at irregular intervals until the sixteenth day, when symptoms of peritonitis appeared and death took place at the end of twelve hours. At the autopsy the peritoneum was found to contain several quarts of purulent fluid and the uterus was enlarged and softened. It was removed, and when the alcoholic specimen was examined it proved to measure 13 X 9 X 6 cm., while its cavity was 9 cm. in length. The latter contained six pieces of wood (the component parts of the elm tent), Avhich, when united, formed a perfect cone with a hole perforating its base. The uterine walls were extensively necrotic and cocci were found everywhere in the uterine blood vessels, as well as in the thin sheet of fibrin which covered the uterus itself. This case is an excellent illustration of the fact that the tent ought only to be used in clean cases, that is to say, where there is no suspicion of any cervical or intra-uterine infection. I would not use it in a septic abortion or a sloughing fibroid. Gradual dilatation by means of Hegar's graduated dilators has been successful in some cases. According to this method dilatation should be begun by dilators, measuring 3 to 5 mm. in diameter, the size being increased day by day during the interval between menstrual periods until 8 to 10 mm. is reached. Rapid dilatation is, however, the method now most generally employed and it is certainly the safest. Preliminaries to Operation. — The bowels must be carefully emptied by means of either a teaspoonful of liquorice powder the night before the opera- tion, or an equal amount of miagnesium sulphate on the morning of it. If it seems necessary, this may be followed by an enema of warm soap and water. The operating table is covered by a sterilized sheet and a rubber pad is laid over one end of it. The patient, after being anesthetized, is placed upon this in the lithotomy position. The vagina is now cleansed with soap and water DILATATION. 123 on pledgets of cotton introduced by means of a long forceps. After this, it is irrigated with a solution of bichloride of mercury, 1 : 1,000. The best anesthetic is nitrous oxide gas, and if this does not give sufficient relaxation, a few whiffs of ether may be administered and the gas resumed. The whole operation should not take over five minutes. A careful bimanual examination Fig. 52. — Instruments used in Dilatation and Curettage of the Uterus. These instruments are in order from left to right, Sims' speculxim; two traction forceps; dressing forceps; tliree iiterine dilators; two serrated curettes; one gauze packer; one uterine sound; bottle of formalin solution for specimen secured. of the pelvic organs should always be made while the patient is under the anesthetic. ISTot only does it afford valuable information as to her condition, but if the direction of the uterine canal is known, it greatly aids the intro- duction of the dilators. The instruments used are shown in Figure 52. Operation of Rapid Dilatation. — In the virgin the well-anointed index finger must be introduced into the vagina slowly and gently,' to avoid injuring the hymen. When the finger touches the cervix, a pair of tenaculum forceps is introduced and the cervix firmly grasped by its anterior lip. The finger is then withdrawn, and traction made with the forceps until the os uteri is seen at the vaginal outlet (see Fig. 53). When the orifice is small, or the examining finger large, the position of the cervix must be determined without vaginal examination by a careful rectal palpation, in order to avoid injuring the hymen, after which the tenaculum forceps are introduced into the vagina, and under the guidance of the rectal finger the anterior lip of the cervix is cau- 124 DYSMENOEKHEA. tiouslj drawn down to the outlet. In married women, and in those who have borne children, the posterior vaginal wall may be readily retracted by a Sims' or a Simon speculum or even with two fingers, so as to expose the cervix, which is then grasped by the tenaculum forceps and drawn down. Fig. 53. — ^The Cervix Caught and Exposed by Retracting the Posterior Vaginal Wall with a Speculum, Grasping the Anterior Lip with a Bullet Forceps, and Drawing it Down to the Vaginal Outlet. Dilators of the Goodell-Ellinger pattern of three sizes are needed (see Fig. 52). The smallest of these, which has smooth blades, is 4 mm. in diameter, while the two larger, which are 5 and 6 mm. in diameter, respectively, are both corrugated, as recommended by the late Dr. William Goodell. My own dilators have a spring between the handles, but are not provided with either ratchet or screw. The handles are bent at an angle and are made large enough to be grasped in the full hand; the dilating end is blunt and slightly curved. Light instruments with a strong curve and a tapering point are dan- gerous and must not be used. The smallest dilator is now taken up, poised delicately between the fingers like a pen, and gently introduced within the external os, after which it is DILATATIOlSr. 125 pushed np the canal to the internal os (see Fig. 54). The dilator must never be grasped with the handles braced against the palm of the hand and forced through obstructions. When resistance is encountered, as it commonly is, in passing from the internal os into the uterine cavity, the dilator must be with- drawn a little until by repeated efforts and without force, it finally passes the obstruction and slips in. The danger of forcing a sharp dilator into the uterine canal without due precaution is considerable. I have seen a death resulting from neglect of the precaution (Amer. Jour. Ohst., 1891, vol. 24, p. 42). The surgeon pierced the posterior wall of an ante- flexed uterus at its cervical junction and bored a hole into the peritoneum. He then inserted a coarse sponge tent into the cervix, which projected partly within the peritoneal cavity. The patient died in a few days of peritonitis, in spite of an effort which I made to save her by opening and draining the Fig. 54. — Dilatation of the Cervix with the Goodell-Ellenger Dilator. abdomen. The risk of perforating an anteflexed uterus is so manifest that I cannot avoid the conviction that such an accident has happened more fre- quently than is generally known. The blades of the dilator being well introduced, the canal is first dilated in one direction ; the pressure is then relaxed and, when the blades have closed, the dilator is rotated a little, so as to dilate another portion of the canal, this 126 DTSMENOEKHEA. process being continiied all around the circle back to the first point. The cervix yields to these repeated gentle impacts from within on all sides and is gradually and equably dilated to the necessary extent without laceration. In this way the canal is opened up within a minute or two, sufficiently to admit a large corrugated dilator with which the dilatation is continued in like manner from side to side, antero-posteriorly and at all points between. This extent of dilatation, which is large enough to admit the introduction of a bougie 1 cm. in diameter, is usually sufficient for the relief of dysmenor- rhea ; a somewhat greater dilatation may be obtained by using the largest size dilator, but not without risk of great injury to the cervix. It is never justi- fiable to attempt the dilatation of the cervical canal sufficiently to permit the introduction of the index finger into the uterine cavity, for it can be accom- plished only by extensive rupture of the cervix. The method just described, in which the cervical canal is dilated through successive impacts on it from all directions, is far better than the common method of opening a dilator controlled by a ratchet or screw and expending all the force in one direction until the fibres split and a tear is produced. The damage done the cervix, the gTcater danger of septic infection, and the possi- bility of cancer developing in the scar which remains after the rent heals, are great objections to forcible dilatation in one direction. In many cases it is advisable to follow up the dilatation by curettage, and the method for doing this will be found in Chapter VII. After dilatation the patient should be kept in bed for from one to fourteen days, according to conditions. If her general health is good and her nervous system undisturbed, twenty-four hours will be sufficient ; but if she is anemic and reduced by continued suffering, advantage should be taken of the oppor- tunity afforded by the operation to give her as long a rest as possible, with the advantage of care, attention to diet, and other essentials to complete recovery. A neurasthenic patient should always be kept in bed after the operation for ten days to a fortnight. Dilatation, as I said, is the only form of operative treatment for dys- menorrhea which comes within the scope of this work. Removal of the ovaries in intractable cases, however, sometimes comes before the general prac- titioner, because his advice is sought as to its advisability by the patient or her relatives. I cannot leave the subject without speaking emphatically against such a practice. The removal of diseased ovaries is an entirely different mat- ter; the removal of healthy ovaries for the relief of dysmenor- rhea is almost never justifiable. The only occasions in which it can ever be so, are the rare instances in which long continuance of pelvic pain is wrecking the patient's health and disabling her to such an extent that she is incapacitated for self support or for the performance of imperative household duties. In an extensive gynecological practice I do not think I average one case a year of this kind. The patient's word or that of her relatives must never be taken as a gauge of the amount of suffering experienced, for, with EEASONS AGAINST REMOVING OVARIES TO RELIEVE DYSMENORRHEA. 127 every intention to be honest and avoid exaggeration, it is almost impossible for them to be accurate. If such a measure is in contemplation, the physician must convince himself of the intensity of the pain by his own observation of the patient through several periods. The effect upon her general health is also a reliable test. So long as the suffering is confined to the men- strual periods, and the interval is free from pain, the patient's health rarely suffers to any great degree; if, however, as sometimes happens, she is never wholly exempt from pain, some degree of neurasthenia is almost certain to ensue, with loss of appetite, sleep, and general impairment of physical con- dition. Under such circumstances as these the patient loses v/eight and strength, her face acquires a haggard, anxious expression, and there is every indication to the practiced eye that her general health is much impaired. Another point upon which I should like to lay stress in this connection is that the fact of ovaries being cystic is no reason, per se, for their removal. It is not definitely decided whether any clinical symptoms arise from the cystic follicles from the size of a pea to that of a cherry, which are often observed. One thing is quite certain, however, namely, that small cystic follicles never of themselves justify the removal of an ovary, or a piece of an ovary. The removal of one ovary is sometimes suggested for the reason that it is " down," but this expression is just about as scientific as saying that the palate is " down and needs cutting." How great may be the influence for good of the conscientious general prac- titioner in cases of this kind is shown by the following case which recently passed through my hands : A young woman of two or three and twenty was brought to me with the following history : About two years before she had begun to suffer from dys- menorrhea after a fall from her horse. She lived in the country, on a farm, where no medical attendance was within reach except that of the general prac- titioner in the neighborhood. He attended her for some time without success, and then, finding that she was, if anything, worse and that her limited means prevented her coming to the city to consult a gynecologist, he suggested asking the advice of a well-known general surgeon who passed his summer holidays in the neighborhood. The surgeon made a pelvic examination and advised the removal of one ovary, on the ground that it was cystic. This he did and for a short time the patient improved, but within six months she was suffering as much as ever. The same surgeon was again consulted and insisted that the only possible remedy was the removal of the other ovary. The patient and her family consented, with reluctance, but fortunately for the issue, the country physician, who still had the case in charge, set before them earnestly that the removal of both ovaries in a girl not much over twenty, who was, moreover, engaged to be married, w^as too serious a step to contemplate without the opinion of a competent gynecologist as to its necessity, and that it was their duty to make an effort to obtain this, no matter what exertion or sacri- fice it involved. Accordingly, the patient was brought to me, and I made an 128 DYSMENOEKHEA. examination under ether, at which I found nothing whatever the matter. I dilated and curetted, however, thinking the case one where it was likely to be beneficial, and the patient has ever since (nearly five years) been free from anything more than a trifling amount of pain. Yet her whole future would have been sacrificed had it not been for the influence of her physician. MEMBRANOUS DYSMENORRHEA.* There is one kind of painful menstruation so peculiar as to demand special consideration. This is the form known as " membranous dysmenorrhea," char- acterized by severe cramp-like pains, resembling those of labor, followed by the expulsion of the lining membrane of the uterus, either whole or in part. The cases vary in severity from the typical form in which a complete cast of the uterine cavity is discharged at each period with great suffering, to a mild type where only small fragments of the endometrium are discharged at intervals of several months, with a trivial amount of pain. When the membrane is passed entire, which, however, rarely happens, its nature can be readily recog- nized by floating it in water ; a shaggy outer coat can then be distinguished, of narrow triangiilar form, with little openings at the base corresponding to the tubal orifices and a larger opening corresponding to the internal os. The affection is not a disease sui generis, but a condition which develops under varying conditions, complicates different pathological processes, and presents a variety of microscopic appearances. Some writers have, therefore, suggested that the term " membranous dysmenorrhea " should be abandoned in favor of "exfoliative endometritis" (Wyder, Arch. f. Gyn., 1878, voL 13, p. 39) or *' exfoliation of the menstrual mucosa " (Lohlein, Zeitschr. f. Geh. u. Gyn., 1886, vol 12, p. 465). History. — The condition was first recognized by MorgagTii (" De Sedibus et Causis Morborum," 1779, Bk. Ill, Letter 48), who reported a case and gave an excellent description of its clinical course. The first microscopic study of the membrane was made by Ernst Heinrich Weber, and the term " mem- branous dysmenorrhea " was given in 1846 by Oldham (London Med. Gaz., 1846) and Simpson (Edin. Med. Jour., 1877). The resemblance to decidual tissue excited a prolonged discussion in Germany as to whether all cases of membranous dysmenorrhea were not really early abortions, and it is only within the last thirty years that the two conditions have been clearly differ- entiated. The first adequate histological study in modern literature is that by Wyder (loc. cit.). Von Franque, in 1893, made an elaborate study of the pathological anatomy (Zeitschr. f. Geh. u. Gyn., 1893, vol. 27, p. 1), and since then numerous isolated cases have been reported, but little new infor- mation has been added to the subject. *A paper by Dr. Elizabeth Morse {Johns Hopkins Hospital Bulletin, 1907, vol. 18, p. 40), which is based upon an investigation of four cases of membranous dysmenorrhea in my clinic, is the foimdation of this section. MEMBRANOUS DYSMENORKHEA. 129 Etiology.. — The etiology and pathogenesis of the condition are obscure, partly, no doubt, because the affection is really rare and specimens for study are not often available. The most important etiological factor is a preceding endometritis, arising after childbirth, abortion, or a gonorrheal infection. In some cases there is a retroflexion of the uterus or some abnor- mality of the appendages. A considerable number of cases, however, occur in young unmarried women, where there is no history of infection and the pelvic organs on examination are apparently normal. In these cases there is, of course, the possibility of an overlooked vaginitis in childhood or an endometritis accompanying one of the exanthemata. Clinical History. — In the first class of cases, where there is a history of infection, menstruation is usually regular and normal until a labor or an abortion takes place, followed by fever ; or, it may be, there is an attack of gonorrheal endometritis. After the occurrence of some such cause, dysmen- orrhea appears and is accompanied, in the course of a few months, by extrusion of the menstrual membrane. In the second class of cases, where the pelvic organs are normal, the menstrual history shows no irregularities and the dys- menorrhea, followed by the expulsion of the membrane, appears without any perceptible exciting cause whatever. In both classes the pain is intermittent and -cramp-like in character, closely resembling labor pains, and the membrane is usually passed on the second or third day of menstruation. After the mem- brane is discharged, the pains cease and there is often a copious flow. Macroscopic Appearance. — The menstrual membrane, when it is discharged, forms a triangular sac, having the shape of the uterine cavity ; sometimes it has rounded holes at the sides of the tubal openings. The "outer surface is ragged ; the inner smooth. The thickness of the membrane varies from that of tissue paper to two or three millimetres. A membrane of greater thickness suggests decidua. Complete casts of the uterine cavity are more rarely found in membranous dysmenorrhea than in pregnancy. In the majority of cases the membrane is passed in fragments. Microscopic Appearance. — From a microscopic point of view, the membranes discharged from the uterus may be divided into two classes, namely, exfoli- ated mucosa and fibrinous easts. In the first class of cases, exfoliated mucosa, there are two different types. One of these is that of interstitial endometritis, in which the stroma cells are of normal size and appearance and there is an infiltration of leucocytes. Hemorrhage, exudate, and fibrin are usually present in addition. In the other type the stroma cells bear a strong resemblance to decidua. They are enlarged, oval or polygonal in form, and have large vascular nuclei with abundant protoplasm ; all grada- tions may be traced between them and the normal stroma. In some cases the entire membrane is composed of these altered cells, while in others, glands exist; occasionally two layers, one compact and one spongy, can be distin- guished. It often happens that the two types are found in the same membrane. The large stroma cells are usually supposed to be the result of hyperemia and 10 130 DYSMENORKHEA. irritation. Tliej are not peculiar to this condition, but are found also in glandular lijpertropliy and edema of tlie endometrium, where they are ac- counted for by circulatory changes. In the second class of cases, the fibrinous casts are composed of a network of fibrin, containing in its meshes red corpuscles, leucocytes, and remnants of the cells of the mucosa. There is some difference of opinion as to whether this second group of cases should be considered as true cases of membranous dysmenorrhea. They develop, however, in connection with endometric processes and are passed with the same symptoms as organized membranes ; in fact, cases have been rej3orted where a patient passed a fibrinous cast at one time and a membrane of altered mucosa at another. Moreover, it is impossible to separate the two varieties anatomically, on account of the many transitional forms between the simple fibrinous casts and the well pre- served endometrium. Mechanism of Separation. — The mechanism of separation of the membrane is obscure. The theory most generally accepted is that the hyperj)lasia of the stroma cells causes an obstruction to the escape of blood into the superficial layers, and therefore it spreads out into the deeper portions of the uterus, which yields at the weakest point on account of the friability due to chronic hyperemia and the youth of the connective tissue cells. The membrane is, so to speak, dissected free by hemorrhage. The free bleeding which so fre- quently follows the expulsion of the cast is in favor of this view; while, on the other hand, the fact that blood is often found distributed through all parts of the membrane is supposed to be against it. The degenerative changes which are taking place in the membrane must also be an important factor in causing separation. Diagnosis. — The clinical history of membranous dysmenorrhea is, of course, extremely suggestive of the diagnosis, nevertheless, it can never be positively made without a microscopic examination, for there are two other kinds of casts discharged from the vagina which may simulate the menstrual mem- brane to the naked eye. These are vaginal casts and decidual casts. Vaginal casts are thrown off, either as the result of an exfoliative vaginitis or of treatment of the vagina with strong chemicals, such as silver nitrate. In the case of exfoliative vaginitis the tissue may be passed during men- struation or independently of it, but if the discharge occurs with menstrua- tion and is accompanied by suffering of a cramp-like character, the case may readily be mistaken for one of membranous dysmenorrhea. How easily a mistake may be made in the absence of a microscopic examination is shown by the fact that out of eleven specimens sent to my laboratory at the Johns Hopkins Hospital with the diagnosis of " membranous dysmenorrhea," only four proved to be genuine. The others showed decidua in three instances and vaginal epithelium in two; while of the remaining two specimens, one was uterine polyp and the other blood clot. It must always be remembered that an exfoliative vaginitis may accompany membranous dysmenorrhea, and Leo- MEMBEANOUS DYSMEKOKEHEA. 131 pokl, who rejDorts a case of this kind (Arch. f. Gyn., 1876, voL 10, p. 293), considers the cause of the two processes the same, namely, a superficial hem- orrhage arising from extreme hyperemia and extending through the cervix into tne vagina. Hoggan (Arch. f. Gyn., 1876, vol. 10, p. 301) describes a case in which the upper part of the membrane was composed of uterine mucosa and the lower of vaginal epithelium. As a rule, vaginal casts and pieces of vaginal tissue are thinner, rougher, and more like parchment than membranes from the uterus, and no glandular openings are seen upon the surface. In differ- entiating from decidual casts the history must first be considered, since this form of cast is larger and more vascular than those of the dysmenorrheic mem- brane, and if chorion-like villi be found on microscopic examination, the diag- nosis of extra-uterine pregTiancy is, of course, clear. If decidua alone are pres- ent, it is a case of normal pregnancy. In an interesting case of my own the patient brought me two casts, one of which had been passed with menstrua- tion, while the other, which appeared after the interval of a month, w^as an extra-uterine pregnancy. The greatest difficulty arises in cases where it is necessary to make a differential diagnosis between an early abortion and a men- strual membrane containing the decidua-like cells. This question occurs usu- ally in cases of early abortion, before the decidua has reached its full develop- ment and typical form. The diagnosis must rest upon the fact that the cells in the menstrual membrane do not show the enlarged epithelioid appearance so often found in the mature decidual cell, and also that they have a more abundant protoplasm with more sharply defined outlines. Moreover, the pro- toplasm of the decidual cell loses its fibrillated appearance and takes a deeper eosin stain. The diagnosis can usually be made upon the microscopic evidence alone, but cases sometimes occur in which the final decision must include the clinical history. Treatment. — The treatment in membranous dysmenorrhea is discouraging, and the prognosis as to recovery, either with or withoiTt it, is not good. When the underlying condition is obscure, the treatment most often adopted is curettage a few days before menstruation, followed by the classical appli- cation of iodine or carbolic acid and glycerin to the uterine cavity. This procedure may give temporary relief, but the patient generally relapses within a few months. Any associated lesions or abnormalities of the uterus or appendages should, of course, receive appropriate treatment. Sterility is the rule in membranous dysmenorrhea, although a few patients recover and become pregnant. CHAPTEE V. INTERMENSTRUAL PAIN. Definition, p. 132. History, p. 132. Age, p. 133. Relation to sterility, p. 133. Relation to child-bearing, p. 133. Date of pain, p. 134. Character of pain, p. 135. Dui-ation cf pain, p. 135. Period of time dui'ing which pain lasts, p. 136. Pressure and nature of discharge, p. 135. Relation to menstruation, p. 135. Location of pain, p. 135. Relation to lesions found on examination, p. 135. Methods of treatment and their results, p. 136. niustrative cases, p. 137. Conclusions, p. 138. Definition. — Intermenstrual pain is the name given to a form of suffering characterized by pelvic pain occurring on a fixed date between two menstrual periods, in some cases midwav between, and in others on a definite date after the preceding period or before the following one. The Germans give the name " Mittelschmerz " to this affection, but this does not seem an accu- rate designation, since the pain does not always occur in the middle of the intermenstrual periods. iSTor does the term "intermediate dysmenor- rhea" appear more appropriate, for the special characteristic of the pain is that it occurs in the interval between the menstrual periods and is, therefore, distinct from dysmenorrhea. The term used by the French, " douleurs intermenstruelles," or its English equivalent, "intermenstrual pain," seems the most exact, as well as the most descriptive name for this affection. History. — The disorder was first described, so far as I know, by Sir William Priestley in 1872. He then reported four cases, selected, he says, from a number of others {Brit. Med. Jour., 1872, vol. 2, p. 131). Priestley says frankly that, at the time at which he WTote, any opinion as to the nature and causation of the affection was purely conjectural, and the years that have elapsed have contributed little to our knowledge on the subject. Priestley's theory regarding it is based on the fact that shortly before menstruation one or both ovaries become turgescent, an event known to take place, and this tur- gescence lasts through the menstrual period, continues for a few days after its cessation, and then gradually subsides. In Priestley's opinion it is not unrea- sonable to suppose that the preparation for an approaching period should take place as much as ten to fourteen days before its OQCurrence. Under normal conditions this preparation is not accompanied by any appreciable signs ; but the presence of abnormal conditions in the ovary, or even of undue excitability where no structural change is apparent, may cause the preparatory stage to be as difficult and painful as the later stages, which are accompanied, in many cases, by painful menstruation. 132 KELATIONS OF INTEEMENSTEUAL PAIN". 133 Since the appearance of Priestley's article cases of intermenstrual pain have been reported from time to time, sometimes accompanied with suggestions as to its etiology. In looking over the literature of the subject I have been surprised to find that although the total number of cases definitely reported is small, most of the formal reports are followed by the mention of other cases occurring in the practice of those present; so that it would seem the affec- tion is by no means so uncommon as it is usually believed to be, and it is possible that if all the cases coming under observation were carefully recorded, some definite conclusions might be reached as to its nature and etiology. I have collected all the cases which I could find in the literature, and after add- ing fourteen from my own case-books, I have made a careful analysis of the whole number, sixty-four. Space does not permit me to give any detailed account of so large a number here ; I must confine myself to a brief statement of the main points brought out by the analysis, adding a few illustrative cases from my own records. Age. — The age at which intermenstrual pain began was noted in forty-one out of the sixty-four cases. In only three did it begin with first menstrua- tion; in all the others menstruation had been established for some years before it appeared. In ten cases (including the three beginning with first menstrua- tion) the patient was under twenty when the pain began ; twenty-nine of the remaining cases were between twenty and thirty-five ; while two were over thirty-five. It seems reasonable, therefore, to conclude that intermenstrual pain is an affection belonging to the period of full sexual activ- ity. Besides these forty-one cases, there were twenty-three in which the age of the patient when intermenstrual pain began was not stated, and could not be calculated from the other data. In seven out of the twenty-three, however, the age of the patient when she came under observation was given, six of them being between twenty and thirty-five, while one was forty-eight. Sterility. — Out of the sixty-four cases, thirty-two had never had children or miscarriages (eleven of them being married and twenty-one single). Thir- teen had had neither children nor miscarriages for as much as five years, and in most cases much longer. Fourteen had had children, or miscarriages, or both, within five years ; and the condition of five as regards child-bearing was not stated. Or, to put the matter in another form, thirty-two cases were sterile ; thirteen relatively sterile; fourteen fertile; and five unknown. These results seem to support the statement made by some persons that intermenstrual pain is associated, in the majority of cases, with sterility. Relation between Intermenstrual Pain and Child-bearing. — Of the fourteen cases in which the patient had had either children or miscarriages, there were five in which the pain began after the birth of the last child, and three in which it began after a miscarriage. In six cases it was not stated whether the pain began before or after preg-nancy. It would seem, therefore, that it is at any rate possible that child-bearing is, in some cases, an exciting cause. In three cases of intermenstrual pain, where pregnancy occurred, the suf- 134 INTERMElSrSTETTAL PAIN. fering ceased entirely during the pregnancy and during lacta- tion, returning on the reestablishment of menstruation. Bate of Pain. — The data on this point are not so full as could be wished; in some cases the statement is made that the intermenstrual pain occurred a certain number of days after menstruation, leaving it uncertain whether this means after the beginning or the end. In other instances, where the date is defi- nitely stated to be after the end, the lenglh of the period is not mentioned, and therefore the cases cannot be compared with others where the date is definitely stated from the beginning. The value of the cases reported by Storer (Boston Med, and Surg. Jour., 1900, vol. 142, p. 397), which are by far the largest number given in any one instance, is somewhat depreciated for this reason. There appears to be no doubt, however, that intermenstrual pain occurs always about the middle of the intermenstrual period, and ex- tends into the second half of it. In nine cases the date of the pain was given as " midway " and in two of these, which were in my own practice, the pain was so exactly between the periods that the date of the approach- ing one could be foretold from the day upon which the intermenstrual pain appeared ; that is to say, if the intermenstrual attack occurred on the twelfth day after the beginning of menstruation, the next period would be upon the twenty-fourth day. The following record taken from one of these cases illus- trates this point: Menstruation December 1 Intermenstrual pain , . " 10 Interval 9 days Menstruation " 19 " 9 " Intermenstrual pain " 30 " 11 " Menstruation January 10 " 11 " Intermenstrual pain " 21 " 11 " Menstruation February 1 " 11 " Intermenstrual pain " 17 " 16 " Menstruation March 5 " 16 " In another case, reported by Sorel (Arch, de toe. et de gynee., 1873, vol. 14, p. 269), a record of this kind was kept, extending over one hundred and forty-seven periods, and although the intermenstrual pain did not occur with the absolute exactness shown in the two cases just mentioned, it varied dis- tinctly according to the date of the menstrual jDcriod which was to follow. Out of seventeen cases in Avhich the intermenstrual pain was dated from the beginning of the preceding menstruation there were only four in which it was stated whether menstruation occurred regidarly every twenty-eight days, and in the absence of this information it is impossible to estimate the relation of the pain to the approaching period. Further information as to the date of intermenstrual pain in relation to the following menstrual period is much needed, if definite conclusions on this point are to be drawn. All that can be said at present is that there seems good reason to think that the date of intermenstrual pain is associated with the menstrual period fol- lowing the pain rather than that preceding it. RELATIONS OF INTEEMENSTETJAL PAIN". 135 Character of Pain. — 'No special form of pain is present. In some cases it is noted as dull and in about an equal number as sharp; in only a few cases was it ]Daroxysmal. Duration of Pain. — This varies from a few days up to the whole time be- tween the occurrence of the pain and the appearance of the next menstrual period. In the majority of cases it lasts three to four days. Period of Time which the Condition May Last. — This also varies. In one case it had existed only a few months when the patient came under observation, while in another it had lasted twenty-two years. There was one case (Sorel, loc. cit.) where it began with the first menstruation and ceased only with the menopause. In no case was it self-limited. Presence and Nature of Discharge. — In thirty-nine cases out of sixty-four a discharge was present. Its character varied greatly, being sometimes a simple leucorrhea, sometimes clear and watery, and sometimes yellowish and irritat- ing. In a few cases it was bloody or blood-stained. Attempts have been made to establish a relation between the intermenstrual pain and an accompanying discharge, but there seems nothing to support . such an idea. The fact that in three out of six cases in which the discharge was bloody or blood-stained there was an endometritis, a polyp, or a submucous fibroid, suggests strongly that in cases where a discharge exists it is connected with associated lesions, and not directly associated with the intermenstrual pain. Menstruation. — Intermenstrual pain does not seem to be in any way asso- ciated with dysmenorrhea. In twenty-seven cases menstruation was noted as painful, while in twenty-three it was painless. In the remaining cases this point was not recorded. It was regular in a good many more cases than it was irregular, and such irregularity as occurred was in the line of anticipation. In only one ease was it noted as delayed. There was a tendency to excess in fifteen cases, in contrast to four where the flow was scanty. On the whole, however, menstrual variation is a point upon which information is lacking, and special attention to it in future reports is desirable. Location of Pain. — In a large proportion of cases the intermenstrual pain was situated, roughly speaking, in one or the other ovarian region; in two it was in both ovarian regions at the same time ; while in five it was in the right and left regions alternately. Relation between Pain and Lesions Found on Examination. — The lesions observed in cases of intermenstrual pain are somewhat indefinite in character. In a good many cases nothing which could be considered a lesion was present. In those where lesions or abnormalities existed there was sometimes a relation between its nature and the location of the pain, and sometimes none whatever. Eor instance, out of twenty-four cases where the pain was situated in the region of the ovary, there were eight in which there was tenderness and thickening of the ovary ; one of hematoma of the ovary ; one of hydrosalpinx ; and one of salpingitis. There were also five cases in which there was tenderness, witli or without swelling, in the broad ligament on the side corresponding to the 136 INTEEMENSTKUAL PAIIS". pain. Of the remaining eight cases in which the pain was situated in the ovarian region, no deviation from normal could he detected on examination. Of eight cases where the pain was situated in the hypogastrium, one was a double salpingitis and another a double salpingo-ovaritis. Of the remaining six cases of hypogastric pain, one was recorded as normal, four were displacements of the uterus, and the remaining case was a large fibroid. Of six cases where the pain was stated to be " in the lower abdomen," there were five displace- ments, and of the sixth there is no record. In all the remaining cases (thirty- four) the records are too indefinite to be available for use as statistics. So far as they go, then, these results would seem to indicate that intermenstrual pain is not necessarily related to any one location, but rather that the location is determined by the coexisting abnormal conditions. Treatment and its Results. — The results of treatment in intermenstrual pain, so far, are discouraging. In no case in my collection has it shown itself self- limited, while in one case (Sorel, loc. cit.) it lasted throughout the whole men- strual life. Of the various modes of treatment adopted, the results are as fol- lows: Dilatation and curettage was tried in eleven cases, entirely with- out benefit, except in one instance where the uterus was steamed out after it, and in this case the intermenstrual pain had lasted but a few months. Ova- rian, parotid, and thyroid extracts were given in one case without relief, but in another the thyroid alone was followed by complete recovery. Elec- tricity over the ovarian region was tried in four cases, two of which were somewhat improved, while the other two derived no benefit whatever. Removal of one ovary and tube was tried in four cases where the localization of pain in the ovarian region seemed to indicate it. In one instance the pain was relieved for a period of eight years, and in another it has now been absent for six; the other two cases were entirely unbenefited. The appendages were removed on both sides in five cases, two of which were among the cases mentioned where one ovary was first removed without benefit. The results in one instance are not definitely stated, although, judging from the context, they were good ; of the other four cases, three were entirely relieved and the other not at all. In the latter instance, however, menstruation continued after the operation and it is to be supposed that some ovarian tissue remained behind. Suspension of the uterus was tried in three cases of retro-displacement, with complete relief in one case, partial relief in another, and none at all in the third. Partial relief was also obtained in three cases from a course of baths or medicinal waters ; in one case frora absolute rest in bed during the attacks of pain, with straightening of the uterus, which was in extreme ante- flexion; and in one case from the use of a Hodge pessary for extreme anteflexion, together with the relief of a coexisting endometritis. Complete relief resulted in one case from the use of an intra-uterine pessary for marked anteflexion; in two cases from six months' treat- ment for endometritis, nature not stated; in one case from the cure of TREATMENT AND ITS RESULTS. 137 an eroded cervix; and in one from rest in bed during the attacks, with support of the uterus by tampons. All that can be determined from these records is that the treatment of coexisting local conditions will sometimes relieve intermenstrual pain. It should always be tried, together with attention to general health and absolute rest in bed during the attacks of pain. In regard to the effect of the removal of one ovary and tube, the results are too scanty to warrant an opinion. Re- moval of both appendages can probably be depended upon to give relief as a last resort, provided the pelvis is not so matted with adhesions as to make com- plete removal impossible. It would be interesting to know the effect of induc- ing the cessation of menstruation by removing the uterus without disturbing the ovaries. I give here three illustrative cases from my own records : Case L — Mrs. J., age thirty, November 13, 1894, Case-book V, E"o. 113. This patient had had three children, the youngest of whom was six years old at the time she consulted me. At the birth of her second child, eight years before, the perineum was badly torn, and it was repaired some little time later. The second menstrual period after the operation was followed by the intermen- strual pain, which had occurred regularly since then. It appeared exactly between each two menstrual periods, so much so that if it occurred on the thirteenth day from the beginning of menstruation, the following menstrual period was on the twenty-sixth. The pain was situated in the lower abdomen and lasted from six to twelve hours. Menstruation was regular, painless, and somewhat free. Just before the intermenstrual pain began, there was a yel- lowish discharge from the vagina, which lasted until the pain v/as over. On examination of the pelvic organs the uterus was found anteflexed and the outlet torn through the sphincter. The ovaries and tubes were free from dis- ease. The outlet was repaired at the Johns Hopkins Hospital, and in April, 1907, when the patient was last heard from, she w^as still suffering from the attacks of intermenstrual pain, although for the last three or four years they have been much less severe than formerly. Her general health is much improved. Case II.— Miss W., age thirty-nine, October, 1897, San. 'No. 512. This patient began to have intermenstrual pain when she was eighteen years old, four years after menstruation began. The pain occurred on the fourteenth day after the beginning of menstruation. It was situated in the right ovarian region and was dull in character, with a sense of weight. Menstruation was comparatively painless, a little frequent, but not excessive. There was a con- stant leucorrhea, which was increased with the intermenstrual attacks. On examination the uterus was found sharply retroflexed. Suspension of this was followed by rapid recovery with entire relief of intermenstrual pain and great improvement of general condition. The patient is now (1907) in excellent health. Case III. — Miss L., age thirty-nine, February, 1900, San. ISTos. 929 and 138 INTEKMENSTEUAL PAIN. 1,226. Intermenstrual pain began a year before she consulted me. The first attack was accompanied by a rise of temperature to 102° E. After the second attack the pain in the pelvis became habitual, with exacerbations at the inter- menstrual periods. The pain was situated on the right side of the pelvis with a focus of gTcatest intensity over the region of the right ovary. There were occasional paroxysms of extreme pain in the rectum, extending up through the right side of the pelvis. Each intermenstrual attack was accompanied by head- ache, nausea, and nervous exhaustion, and also by a yellowish irritating dis- charge from the vagina, which was sometimes blood-stained. Menstruation was painful, and after the habitual pain set in became profuse and frequent. Examination showed a small fibroid uterus and considerable tenderness over the base of the right broad ligament, exactly corresponding to the focus of the pain. Dilatation and curettage relieved the menorrhagia, but not the inter- menstrual pain. The various gland extracts were tried without benefit; nor was there any relief from electricity or vesication over the right ovarian region. The patient's health became much affected from the incessant pain; she lost nearly thirty pounds and had a haggard appearance. About eighteen months after she was first seen the right ovary and tube were removed. JSTothing abnormal was found on opening the abdomen, and the appendages, except that they were swollen and congested, presented nothing abnormal. Relief from pain was immediate and the patient's general health was completely reestab- lished. In concluding the consideration of this subject I may say that a study of these cases leads me to form an opinion substantially in agreement with that of Priestley, namely, that intermenstrual pain is definitely associated with the physiological changes in the ovary which result and end in ovulation. This view, of course, makes intermenstrual pain depend upon the menstrual period which follows, rather than upon that which precedes it, although it is usually associated with the latter in recorded cases. But the fact that the cases in regard to which I have fullest data all show a definite connection with the succeeding menstruation is one reason for my opinion. Moreover, the other opinions expressed as to the cause of intermenstrual pain do not seem to be tenable. Eor instance, it has been claimed that it is purely a nervous manifestation ; but if this w^ere the case, the removal of both appendages would in all probability be followed by nervous manifestations in some other region of the body, in other words, by a change of neurosis, whereas it gives complete relief. Eurthermore, the fact that the absence of ovulation during pregnancy and lactation is accompanied by a cessation of inter- menstrual pain supports the view that the ovaries are directly concerned in it. It has been suggested that intermenstrual pain is associated with fibroid tumors, and one observer claims that he has observed a swelling of fibroids during an attack of pain; but out of the sixty-four cases just considered there were only six of fibroid tumors. Croom (Edin. Med. Jour., 1896, vol. 1, p. 703) agrees with Priestley in associating intermenstrual pain with ovulation. CON"CLUSIONS. 139 but "whereas Priestley connects it with the process of preparation for approach- ing ovulation accompanied by menstruation, Croom believes that ovulation takes place at the time of intermenstrual pain, independent of menstruation. It is difficult to see, in this case, why the date of intermenstrual pain should vary in accordance with the menstrual period following it ; moreover, it is hardly possible that ovulation would take place regularly between two menstrual periods for a number of years, and even through the whole of sexual activity. Everything, in fact, which is known in regard to intermenstrual pain, thus far, seems to support the theory which associates it with approaching ovulation, taking place under difficulties which are, as yet, imperfectly understood. Should Frankel's theory as to the relation between the corpus luteum and menstruation prove correct, some light may be incidentally thrown upon the etiology of intermenstrual suffering. Further knowledge of the subject must depend upon information furnished by a large number of records, and it is greatly to be wished that all cases of intermenstrual pain should be carefully observed and duly reported. I am convinced that such cases are much more numerous than they are supposed to be. The points which should be noted are: (1) Age of patient; (2) married or single; (3) children or miscarriages; (4) date at which intermenstrual pain occurs, with special reference to following menstrual period; (5) length of time pain has lasted; (6) location of pain; (7) duration of pain; (8) character of pain; (9) age at which pain began; (10) condition of menstruation as regards pain, regularity, and amount; (11) presence and nature of vaginal discharge; (12) results of pelvic examination or of abdominal section; (13) treatment and its effect. CHAPTEE VI. AMENORRHEA. (1) Definition, p. 140. (2) Causes of primary amenorrhea: Maldevelopment, p. 140; atresia, p. 142. (3) Causes of secondary amenorrhea: Physiological, p. 145; mechanical, p. 145; constitutional, p. 146; functional, p. 149. (4) Symptoms and diagnosis, p. 150. (5) Treatment: Operation for imperforate hymen, p. 154; galvanic stem pessaries, p. 155; elec- tricity, p. 155; general treatment, p. 155; treatment for chlorosis, p. 155; treatment for functional amenorrhea, p. 159; pituitary amenorrhea, p. 159; emmenagogues, p. 160. (6) Vicarious amenorrhea, p. 160. Definition. — Amenorrliea, or absence of the menstrual flow, is a symp- tomatic condition accompanying a variety of affections. It may be broadly divided into two classes : one in which menstruation fails to appear at the usual age, and one in which it ceases after it has been established. The first of these is known as primary amenorrhea, or emansio mensium, and the second as secondary amenorrhea, or suppressio mensium. CAUSES OF PRIMARY AMENORRHEA. The non-appearance of the menstrual flow at the customary age is always a matter for serious consideration. There are two different conditions from which it may arise : (1) failure of development (aplasia or hypoplasia) on the part of the reproductive organs; (2) atresia, causing obstruction of the genital tract of some sort. The second class is not, strictly speaking, an amen- orrhea at all, but a retention of the menstrual fluid; it is convenient, how- ever, for practical purposes, to consider such cases under this head. Maldevelopment. — Amenorrhea due to failure of development is really a rare condition, although its existence is often assumed. It is to be suspected in the case of a young girl in her teens, who has never menstruated, and is easily demonstrated by a local examination, when the uterus will be found to have a characteristic shape, the cervix being large and disproportionately long, while the fundus is small and infantile in type. The following case is of this kind: Miss McC, age nineteen (San. 'No. 2396), March, 1907. The patient had had complete amenorrhea for three years ; before this date menstruation had been regular and painless, but alwaj^s scanty, lasting only one day. The abdomen was opened for the purpose of removing the appendix ; the right kidney was also suspended. On examination the external genitalia, vagina, 140 OATTSES OF PEIMAEY AMENORRHEA. 141 and cervix uteri were found normal, wliile tlie uterus, ovaries, and tubes were infantile in type. Tlie ovaries were elongate, white, smooth, and sclerotic. The right ovary measured 4 X 1|^ X 1^ cm. No corpus luteum was present. In cases where there is aplasia of both uterus and ovaries there will be no attempt at ovulation, and therefore no symptoms of menstruation. If, on the other hand, there is aplasia of the uterus while the ovaries are healthy and functionally active, ovulation will take place as usual and will be accompanied by the customary menstrual molimena, .namely, pelvic pain, headache, and nerv- ous manifestations of different kinds, recurring at intervals of about four weeks. As the uterus is incapable of responding, no relief is afforded by the customary discharge, and the patient's sufferings often increase until her general health is impaired. Cases in which amenorrhea is associated with the absence of one or more of the organs of generation must be included in this class, as well as those in which diseased conditions have caused sufficient degeneration of the ovaries to destroy their function before puberty. A case of this kind, in which, as sometimes happens, the patient was to all appearance perfectly developed physically, is given by W. B. Chase (Amer. Jour. Ohst., 1898, vol. 38, p. 512). The patient was a married woman, twenty-four years old, of fine physical development, and apparently in good health, although she had never men- struated. She had been married about two years and had had no prospect of children. When she was about eighteen she began to have attacks of pelvic pain, accompanied by headache and nervous excitability, which recurred regu- larly every four weeks. These attacks gradually increased in severity until her sufferings, especially from headaches, became so severe that she and her family' feared insanity. During the preceding year she had perceived an abdominal enlargement and could clearly define a tumor. On examination the growth was easily perceptible, though the abdominal walls were fat; it was as large as a five months' pregnancy. All the rational indications pointed to a uterus distended with menstrual fluid from atresia of the cervix, but the uterus, which was pushed up under the pubes, admitted the sound to the usual depth. As the patient was anxious for any operation which offered a prospect of relief from her sufferings, the abdomen was opened, when the pelvic contents were found to be almost completely M^alled off by peritoneal adhesions, although the patient was never conscious of having had peritonitis. Two tumors were found, one a multilocular ovarian cystoma attached to a smaller growth containing a shrunken ovary the size of a large lima bean, within which was a corpus luteum. The other tumor was a dermoid cyst, containing hair and sebaceous material, which had entirely usurped the place of the right ovary. ISTeither of the uterine tubes could be found. It was plain that the futile attempts at ovulation with its attendant suffering, as well as the womanly development, had been occa- sioned by the presence of the small amount of ovarian tissue left in the cystoma. 142 AMEXOEEHEA. Atresia. — In primary amenorrhea arising from atresia of the genital tract, the ohstruction may exist at any point, that is to say, there may be an imper- forate hymen, an atresia of the vagina, or (rarely) an atresia of the cervix. In such cases ovulation, when it begins, is accompanied by menstruation, and as it is impossible for the menstrual flow to escape, it collects behind the point of atresia, causing distention first of the vagina, then of the uterus, and finally of the uterine tubes. The customary menstrual molimena are present and are sometimes accompanied or followed by bleeding from the nose, or some other mucous membrane. At first the suifering is slight, but with each recur- FiG. 55. — A Case of Atresia of the Vagixa. The tip of the index finger rests at the vault of the vagina showing great shortening. ring period it increases until the patient's general health is, in some cases, considerably impaired. A congenital atresia, with absence of the vagina above the point at which the- tip of the finger rests, is shown in Figiire 55. Figure 56 shows the depth to which a shallow vaginal pocket can be thrust into the pelvis by blunt pressure from without. This patient was married and came to me to consult me for sterility. Atresias of the genital tract resulting in primary amenor- rheas were not long ago considered to be always congenital, except in the rarest instances; within the past twenty-five years, however, it has been shown that most of them are really the result of infectious inflammatory processes, origi- nating for the most part in the acute infectious diseases, especially typhoid and scarlet fevers. This subject is more fully discussed in Chapter X ; I cite here, CAUSES OF PEIMAET AMEISTOKEHEA. 143 however, one illustrative case related by L. Pincus {Monatsschr. f. Geh. u. Gyn., 1903, vol. 17, p. 751). A young girl, seventeen years of age, who had never menstruated, had been ill for some weeks with a mild attack of typhoid fever, when she suddenly Fig. 56. — The Same Case of Atresia. The examiner is pushing in the index finger and showing the potential lengthening of the vagina under strong blunt pressure from without. complained of severe pain over the symphysis. An area of resistance about the size of a fist had already been discovered in that locality. The pain now complained of was at first ascribed to an effort at menstruation, and this idea was confirmed by the patient's having a discharge of thick, brownish blood from the genitalia a few hours later. Shortly after this occurred she became worse, and within twelve hours she died, with every indication of peritonitis due to per- foration. ISTo autopsy was permitted, but an examination of the external geni- talia, made shortly before death, showed a slight tear in an otherwise closed hymen. The patient's mother said that her daughter had been in the habit of having attacks of abdominal pain resembling colic for the past few years ; she also stated that about four and a half years before her daughter had had an attack of scarlet fever, and, for some time after her illness, there was a discharge from the vagina. It was clear that the scarlet fever had set up an inflammatory process in the vagina inducing an atresia retrohymenalis, 144 AMENOKEHEA. with imperforate hymen, and this resulted by degrees in hematocolpos, hematometra, and probably hematosalpinx. The typhoid fever induced a menstrual flow, or an atypical metrorrhagia, and resulted in a rupture of the tubes and of the closed hymen. The atresias of childhood are, for the most part, of a harmless character, consisting of a conglutination of the labia in their inner surface. This cohesion is continued up to and above the level of the urethra, where there is an open- ing, through which the urine escaj)es freely and by which the menstrual dis- FiG. 57. — ^A Conglutination of the Labia Minora Just Below the Clitoris and Above the Level OF THE Urethra. This is quite certainly the remains of an extensive adhesion in childhood, of which the lower part has been ruptured, wliile the tell-tale bridge, in a protected situation above, lingers to tell the story of the original condition. charge may escape, later on, without difficulty. I take it that the origin of the adhesion of the nymphse in the case of a woman who had borne children (see rig. 57) is susceptible of no other explanation. Here the marital rela- tion and labor have destroyed all the lower part of the cohesion, leaving only this tell-tale bridge behind. J. C. ISTott in 1843 called attention to a form of atresia of the vagina aris- ing in young infants without any demonstrable cause {Ame7\ Jour. Med. Sci., 1843, vol. 5, p. 246). He cites two cases of infants, perfectly normal at birth and healthy in every respect, who were found several months later to have CATTSES OF SECONDARY AMENORRHEA. 145 a closure of tlie vagina. In neither case was there any history of inflam- mation; and in both the vagina opened spontaneously in the course of a few months. In addition to these two distinct classes of primary amenorrhea, every physician is familiar with cases where absence of menstruation at the usual age is occasioned by general backwardness of development, arising from constitutional weakness or else following an acute disturbance of some kind. These cases are usually recognizable from the history, as well as from the general appearance of the patient. In considering this group it must always be borne in mind that in some families puberty is unusually late, with- out any definable reason for the delay. CAUSES OF SECONDARY AMENORRHEA. Secondary or acquired arnenorrhea may arise from a variety of causes, which can be classified as physiological, mechanical, constitutional, and, what may be called for want of a more definite name, functional. Physiological Amenorrhea. — The great physiological cause of amenorrhea is pregnancy, a fact which should always be borne in mind; for, unless it is kept first on the list of possible causes, disastrous mistakes will be made, espe- cially by those who undertake a course of active local treatment. Amenorrhea is usual, though not invariable, during lactation, and it should cease with its conclusion. Prolonged lactation, however, as Vineberg points out, sometimes results in atrophy and consequent amenorrhea which persists after lactation is over. The other physiological causes of amenorrhea are child- hood and the menopause. During childhood the whole organism is under- going those changes which eventually express themselves in ovulation; while the menopause represents the physiological relief from the cyclic changes which follow the exhaustion of the rej>roductive system. Mechanical Amenorrhea. — This form includes cases of character similar to those just described under the primary amenorrhea due to atresia. Obstruc- tion of the genital canal may occur after the establishment of menstruation as well as before its appearance, resulting in like manner in the suppression of the flow. Imperforate hymen is the only atresia of the genital tract belonging exclusively to the class of primary amenorrheas. Obstruction at points above the hymen may result from an infection, although the fact that infectious diseases are so much more frequent in childhood makes this factor less frequent than it is in primary amenorrhea. There are other causes, how- ever, which can arise only after sexual maturity, or even in some instances, after parturition. ISTot a few cases of atresia of the vagina or cervix are due to necrosis following difficult labor, while the prolonged or inju- dicious use of pessaries is another cause. Jacobson (8t. Louis Courier of Med., 1906, vol. 34, p. 58) has seen several cases of atresia from this cause. Under the head of mechanical amenorrhea we must also include those cases 11 146 AMEN-OREHEA. in M-liicli there is a failure in devclopmeut uf tlic genital organs sufficient to render menstruation iiifre(|Tieiit and scanty, apjiearing in sonie instances only a few times during the whole period of reproductive activity, although it is not enough to suppress the function altogether. It may also he caused hy hums, scalds, or by the application of too strong caustics to the vagina or the cervix. Sir J. Y. Simpson has reported a case in which atresia of the cervix was occasioned by the application of the actual cautery to the edges of a vesico-vaginal fistula, caused by extensive slough- ing of the upper part of the vagina after childbirth (" Diseases of Women," 1872) ; and Yeit mentions a case in which cicatrization took place in a short time from the application to the vagina of a tampon soaked in a fifty per cent solution of chloride of zinc. Constitutional Amenorrhea. — This form is found in almost all diseased con- ditions, acute or chronic, which make heavy demands upon the vital forces. Such a repression has always been regarded as a conservative effort on the part of nature to preserve the patient's strength ; in a few instances, however, it has been shown that the morbid condition is associated with an atrophy of the genital organs. Thorn (ZeitscJir. f. Geh. u. Gyn., 1889, vol. 16, p. 57) con- siders that in all exhausting diseases there is a temporary atrophy of the uterus and ovaries which is the immediate cause of the amenorrhea, and he cites a number of cases to establish his point. Chlorosis. — The commonest constitutional cause of amenorrhea is chlo- rosis. W. Stephenson in 1889 (Trans. Obst. Soc, London, 1889, voL 31, p. 101:) called attention to the fact that this disease was too much neglected by gynecologists and the same accusation might be made to-day. As a constitu- tional disorder, chlorosis falls under the domain of general medicine, but, owing to the disturbances of menstruation, whether amenorrhea or menorrhagia, which are among its distinguishing features, it has certainly a claim upon the atten- tion of the gvnecologist. Chlorosis, as defined by Stengel {Tweni. Cent. Med., vol. 7, p. 326), is " primarily a blood disease dependent upon disturbances of the hematopoetic system " ; " not a disease resulting from blood destruction, but rather from imperfect hematogenesis." The ultimate causes of the imperfect blood devel- opment are obscure. The disease is characterized clinically by a deficiency in the hemaglobin of the red blood corpuscles gTeatly in excess of the diminution in their number: a peculiarity first pointed out by Duncan in 1S67. In the early stage of chlorosis the number of red corpuscles may be hardly below nor- mal, even though the hemoglobin is extremely reduced, but, as the disease progresses, the number of the corpuscles diminishes, while the striking dispro- portion between them and the percentage of hemaglobin persists. The reduc- tion in the hemoglobin, as Stengel says, is primary, the reduction in the cor- puscles secondary. The shape of the red corpuscles is often changed, and the specific gTavity of the blood is usually reduced in proportion to the diminution of the hemaoiobin. The total amount of blood is not diminished and some CAUSES OF SECONDARY AMEWOREHEA. 147 observers claim that it is increased. No special changes are observed in the white corpuscles and they are not increased as in other forms of anemia. The cansal relation between chlorosis and disturbances of menstruation is not yet understood. Virchow in 1872 showed that it was associated with an imperfect development of the heart and large arteries and also, in many cases, with imperfect development of the sexual organs. He considered, that the defective development of the circulatory system was primary, while that of the sexual organs was secondary. Rokitansky, on the other hand, believed that chlorosis was necessarily associated with imperfections in the development of the sexual organs. Trankel (Aixh. f. Gyn., 1875, vol. 7, p. 465) showed that in certain cases of chlorosis there was an imperfect development of the genital organs while the heart and other organs were normal. Stephenson (loc. cit.) insisted that the imperfections in the evolution of menstruation observed in chlorosis constitute as constant a feature in the disease as imperfections in the evolution of the red blood corpuscles. He also agreed with Virchow in believing that a special diathesis or peculiarity of constitution predisposing to the development of the disease was present in most cases. The general trend of opinion in the present day is to the effect that the amenorrhea almost always present in chlorosis is the result of the impoverish- ment of the system, as in simple anemia. It is difficult, however, to reconcile this view with the intimate relation between chlorosis and the sexual system. The fact that the disease is hardly ever met with in childhood or after the menopause and that it makes its appearance at periods corresponding to epochs of special significance in the sexual life of women, speak strongly in favor of a direct relation between it and the reproductive organs, of which the men- strual disturbance is but the outward expression. The majority of cases of chlorosis occur between the ages of fourteen and twenty-one, which is the time when the sexual function is established ; while there is a small nundier of cases in which it occurs (or recurs) between the ages of twenty-four and thirty- five, the period of full sexual maturity and greatest reproductive activity. Complete amenorrhea is not common in chlorosis. In most cases the flow appears at long and irregular intervals and is extremely scanty. In sixty- five cases examined by Hayem, menstruation was diminished in thirty-six, and completely suppressed in twenty-four, while in four it was normal or a little increased. In a few rare cases chlorosis is accompanied by profuse men- struation, and both Virchow and Frankel have pointed out that in such cases the ovaries are hypertrophic instead of being of the usual infantile type (see Chap. VII). Contrary to expectation, the establishment of menstruation is early rather than late in chlorotic patients. Constipation is so often a marked feature in chlorosis that Sir Andrew Clark believed the disease was really due to a copremia from absorption of ptomaines and leucomaines from the lower intestine. Emotional and nervous disturbances are sometimes well marked and some writers have held the disease was a neurosis. Disturbances of the heart and cir- 248 AMENORRTTEA. c Illation leading to syncope, breathlessness, and, possibly, cyanosis, are present. Tuberculosis. — A frequent cause of constitutional auK'norrbea is tuber- culosis. The disturbance of the function dates from the earliest stages of the disease, and the patient and her relatives not infrequently regard the amen- orrhea as the cause instead of the result of the tulDerculosis. Acute diseases of all kinds, infectious or otherwise, are frequently accompanied by amenorrhea, which usually lasts through convalescence until health is re-established. Anemia, both primary and secondary, is usually attended by suppression of menstruation, more or less complete, and it also occurs after loss of blood from any cause, especially after post-partum hemorrhage, when the patient may not menstruate for months after she has resumed her normal habits of life. Malaria is an occasional cause of amenorrhea and should always he suspected in districts where it prevails. Syphilis, chronic nephritis, and diabetes mellitus and in- sipidus are all occasionally accompanied by amenorrhea. Chronic digestive disturbances which impair nutrition may be associated with cessation of menstruation, especially gastric ulcer. In the various maladies now held to be caused by disease of the glands concerned in the internal secretions, amenorrhea is often a symptom, but whether in these cases it is simply a conservative effect or whether there is some direct connection between these disorders and the sexual organs is not yet known. Atrophy of the uterus is often noted in acromegaly according to Yeit. Kleinwachter has shown that in Basedow's disease there is a general atrophy of the genitalia both external and internal (Zeitschr. f. Geh. u. Gyn., 1889, vol. 16, p. 14-4), and his observations have been con- firmed by Theilhaber (Arch. f. Gyn., 1895, voL 49, p. 57). Obesity is an occasional cause of amenorrhea. In a case reported by Lomer (Centrhl. f. Gyn., 1893, vol. IT, p. 641) the patient gained fifty pounds in six months and became so corpulent that she could hardly move. She complained of dizziness, flushes of heat, and bleeding at the nose. Scari- fication and blood-letting at the external os uteri relieved the symptoms. Whenever a young woman who complains of amenorrhea is much above the average weight for her age and height, esj^ecially if the increase coincides with the cessation of menstruation, the physician will do wisely to turn his atten- tion to the vices of nutrition which are responsible for the obesity. The in- crease of weight is considered to be akin to that often seen at the menopause, both being associated with a repression in the activity of the uterus and ovaries. H. C. Coe (Med. Rev. of Revs., 1906, voL 12, p. 506) suggests that an amenorrhea associated with obesity may be nothing but an early symptom of the obscure disorders arising from disturbances of internal secretions, and that the recognition of this fact may be of service in making an early diagnosis. He cites an illustrative ease in which amenorrhea, accompanied by a marked CAUSES OF SECONDARY AMENOEKHEA. 149 increase in weight, preceded acromegaly, and further the case of another patient, under treatment for Hodgkin's disease, where irregular and scanty menstrua- tion ending in complete amenorrhea lasting for some time preceded the glandu- lar enlargement. There was a little anemia present in the last case, but not enough to account for suppression of menstruation. Chronic poisonings, particularly of lead, occasion amenorrhea. The habitual use of opium or morphin induces in time a more or less com- plete cessation of menstruation. The use of alcohol at first increases the men- strual flow, but eventually it may check it, in consequence of degenerative changes in the tissues. Attention has been called by W. H. Baldy to the possibility of amenorrhea arising from the uric acid diathesis {Phil. Med. Summ., 1903-4, vol. 25, p. 239) which it is well known may occasion dysmenorrhea. Functional Amenorrhea. — The term functional is used to define that form of amenorrhea in which a patient with normal generative organs and in average health, ceases to menstruate without any apparent objective cause, local or constitutionaL Excitement, shock, or sudden fright will act to cause menstruation to be delayed or missed altogether. I have known a case where a period was missed from no other apparent cause than the loss of sev- eral nights' sleep just at the time its appearance was expected. The mere expectation of pregnancy sometimes acts to prevent the flow in the case of unmarried women who have exposed themselves to the risks of it. It often happens in such cases that the next succeeding period appears normally. Again, an intense desire for children may focus the attention upon menstruation and so control the function as to suppress it entirely, leading to the confident hope that pregnancy has taken place. Haultain (Edin. Med. Jour., 1900, vol. 2, p. 339) advances the idea that amenorrhea of the kind known as functional is the effect of an impairment of controlling nerve centres. Another form of amenorrhea is that due to changes of climate. It is a matter of common observation that differences of climate or altitude occa- sion disturbances of menstruation, a change to the seashore being generally accompanied by an increase in menstrual flow, while that to a higher altitude may be attended by the reverse. Tilt says that he was once consulted by a lady, who had shortly before established a large boarding school for girls near London, because so many of her scholars who came from a distance suffered from amenorrhea that she feared there was something unhealthy in the location. This class of cases, as well as those arising from shock, fright, or excitement, are explicable on Haultain's theory. Over-study and exhaustion of the nervous system are also frequent causes of functional amenorrhea. Ex- posure to cold during a menstrual period with a consequent sudden stop- page of the flow, which may or may not return next time, is usually classed as a functional amenorrhea. Besides the causes of amenorrhea cited, there are certain cases in which menstruation occurs at irregular intervals for which no definite reason can be 150 AMENOEKHEA. assigned Could we follow the evolution of the corpus luteum in these cases we should probably be able to understand better the causal nexus ; the first step is to determine whether Frankel's theory as to the relation between men- struation and the corpus luteum can be established. SYMPTOMS AND DIAGNOSIS. Amenorrhea in itself is only a symptom common to a variety of conditions, and in many cases where it is the sole clue the physician must follow the vari- ous possible causes until he discovers the particular condition which is effective in the case under observation. In a case of primary amenorrhea the first question to be considered is whether there is maldevelopment of the pelvic organs, or an obstruction at some point in the genital tract, or whether it is merely an expression of gen- eral backwardness of development. The doubt can be set at rest at once by a local examination, but the conscientious physician will hesitate to take this step in the young and unmarried until he is sure it is indispensable. The crucial point is the presence or absence of menstrual molimena. If no such symptoms have appeared the case is either one of backwardness of development or of maldevelopment (aplasia of the reproductive organs). Under these cir- cumstances the physician is justified, if the girl is not more than sixteen or seventeen, in waiting, in the hope that nature and a little attention to general hygiene will remove the difficulty. If menstruation does not appear within a reasonable time a bimanual rectal and abdominal examination may always be made under anesthesia, when, if Fig. 58. — An Elongate Infantile Ovary with Puerile Ttpe of Uterine Body Associated WITH AN Amenorrhea. the case is one of faulty development, the uterus will be found to be of an infantile type with a small undeveloped fundus and a disproportionately large cervix, while the ovaries are elongate, smooth, and smaller than at puberty (see Fig. 58). SYMPTOMS AND DIAGNOSIS. 151 If, on the contrary, the patient gives a history of recurrent attacks of pel- vic pain, headache, dizziness, and nervons excitability, accompanied, it may he, by bleeding from the nose or some other mucous surface, the case is either one of maldevelopment with ovaries functionally active, or of an atresia in the genital tract. Here an examination must be made at once to obviate seri- ous consequences, namely the formation of hematocolpos, hematometra, and hematosalpinx, with rupture and consequent peritonitis. What harm may arise in such cases from neglect is shown by a case of Gebhard's (Veit's " Handbuch der Gynakologie," 1898, vol. 3, second half, p. 60). A girl of seventeen with a primary amenorrhea consulted a physician on account of a severe colicky pain in the abdomen. The physician made no inquiry into the menstrual function nor did he suggest any local examination. Inspection of the abdomen showed a painful diffuse tumor above the symphysis extending towards the right, which he took for a perityphilitic exudate ; for the relief of this he made an incision in the ileocecal region " to evacuate the pus." Instead of an abscess he found a large circumscribed dark red swell- ing, looking like an ovarian tumor, which he did not attempt to remove. The patient then entered the clinic where the diagnosis was apparent on the first inspection of the genitals and the tumor was seen to be a large hematocolpos due to an atresia of the hymen. It was relieved by an incision. Imperforate hymen is at once .recognized by the marked bulging tumor of a livid or dark brown color, which fluctuates distinctly upon palpation, pro- truding between the labia; posteriorly it is limited by the perineum, laterally by the inner surface of the labia, and anteriorly it reaches to the posterior margin of the urethra. If the growth is sufficiently large to fill the lower abdomen, rising as high as the umbilicus, the wave of fluctuation is readily transmitted from above downward to the tumor at the vulva. A rectal examination reveals an elongate sac filled with fluid, occupying the position of the uterus and vagina and conforming in its general direction to the axis of the pelvis. Great care must be taken in the examination not to rupture the thin tubal sacs lest a fatal hemorrhage or an attack of peritonitis should be induced. Pregnancy must be considered in every case of amenorrhea, coming on in women who have menstruated regularly up to the time of the sudden onset of the suppression, if the patient is still within the child-bearing period. It must also be considered in atypical cases where the menstruation has been irregular. The examiner does not insult his presumably chaste patient by bearing this condition in mind and proceeding at the first step he takes in his diagnosis to exclude it from the category of possibilities in any given case. Pregnancy is diagnosed by recognizing the rotund enlargement of the uterus, sometimes soft and boggy, sometimes firm, but almost always more or less globular. In some cases, it feels as if jointed onto the cervix which may be mistaken for the uterus itself, while the body above, containing the fetus^ appears to be a tumor attached to it by a pedicle (see Fig. 59). Ilegar has 152 AMENOKEHEA. shown that softening of the uterus caused bj pregnancy is not symmetrical; the neck retains a certain resistance, when the body has already become soft, and the upper part, which contains the o\Tim, is tenser than the lower empty part which may be pressed together between the fingers like a soft membrane. This sign is of great importance in the early diagnosis of pregnancy. Anyone Fig. 59. — An Early Peegxanct SHO"«axG the Globitlar Enlargement of the Uterine Bodt. The cervix is often flexible at the point under palpation and may feel like an organ detached from the semi-fluctuant mass above. acquainted with the extraordinary relaxation of the lower segTuent in the sec- ond or third months will avoid the not uncommon mistake of taking the cervix to be the whole uterus and the pregnant body for a loosely attached tumor, a pregnant tube, cyst of the ovary, etc. In amenorrhea of women over forty, there is always a possibility of the menopause. Women are prone to assume that "the change of life is work- ing " as early as thirty-five or even earlier, but a cessation of menstruation before forty-one or two is rare and the physician should accept it as a diag- nosis only after he has failed to find any other cause and after the lapse of some months. The physiological amenorrheas of childhood and lactation require no comment. Secondary amenorrheas of the mechanical variety are easily recognized by the existence of menstrual molimena without a regular occurrence of the habitual discharge, and examination shows the nature and seat of the obstruc- tion. There are certain cases of secondary amenorrhea, caused by faulty devel- opment, when the defects are not sufficient to cause primary amenorrhea, but menstruation is so far affected that it takes place at infrequent intervals, it may be only a few times in the whole course of the sexual life. The history of such cases is very suggestive and examination makes the diagnosis clear. In patients of this class the physical development as well as the general health is sometimes SYMPTOMS AND DIAGNOSIS. 153 excellent; on the other hand, the patient may be poorly developed and of a manifestly feeble constitution. In constitutional amenorrhea the history will generally supply the clue to diagnosis. Chlorosis is the commonest cause and here the appear- ance is so characteristic as to suggest it at once. The complexion has a peculiar, transparent, waxy, greenish hue, from which the disease derives its name, unlike that of other forms of anemia. The conjunctivae are unnaturally white and clear and there is usually a disturbed heart's action, manifested in short- ness of breath, palpitation, and great fatigue on exertion. When the disturb- ance of the circulation is marked, there is apt to be more or less congestion of the terminal blood vessels so that the skin has a muddy cyanotic look, which to some extent masks the typical greenish hue. Menstruation is disturbed by a more or less complete amenorrhea; the flow is of a peculiar, characteristic,, pinkish color. The age of the patient is a point which must be considered, since the majority of cases occur between fourteen and twenty-one, with a smaller proportion between twenty-five and thirty. An examination of the blood is always necessary to complete the diagnosis ; its appearance as it flows from the body is characteristically thin, pale, and watery. The hemaglobinometer shows that the percentage of hemaglobin is re- duced, while the hemacytometer demonstrates that the number of red corpuscles is not diminished proportionately. In a series of ninety-four cases investigated by Dr. C. E. Simon, the average hemoglobin value was forty-two and a half per cent, while the lowest in the series was seventeen and a half per cent. There are certain rare cases of great reduction in the number of red corpuscles. One is mentioned by Hay em, where only 937,360 were counted, and three by V, Limbeck in which the red corpuscles were 1,750,000, 1,850,000, and 1,930,000 respectively. In the amenorrhea of tuberculosis, patients usually complain of phthis- ical symptoms, although among the ignorant classes the cough, loss of weight, and other early symptoms of phthisis may escape the recognition of the patient and her family and she may complain of the amenorrhea and nothing more. The suppression of menstruation following acute diseases offers no diffi- culty in diagnosis. In some chronic conditions the whole body must be carefully examined, as well as the lungs, the sputum, and the blood. Obesity associated with amenorrhea suggests some vice of nutrition which must be carefully investigated, and the suggestion made by Coe as to disease of the glands employed in internal secretion deserves to be borne in mind. TREATMENT. Primary amenorrhea, due to atresia with accumulated menstrual secretions above, is the only form in which there is any necessity for inmie- diate action, and this form of amenorrhea is not really a true amenorrhea at all, although it is conveniently considered under this head. If the general 154 AMENOEKHEA. practitioner has convinced himself that an atresia of the genital tract exists he should send the patient without loss of time to a gynecologist. A form of obstruction which may claim the attention of the general practitioner is an imperforate hymen. It is better to refer this class of cases as well as those in wliich the atresia is situated higher up to a specialist, but as circum- stances may arise in which the general practitioner is obliged to deal with this condition himself and as the operation itself is a simple one if performed with extreme antiseptic precautions, I give the details of its execution. Operation for Imperforate Hymen. — Once more I earnestly insist upon the most rigid asepsis at every step. Lives have been repeatedly lost from sepsis coming on rapidly after opening such accumulations, especially where the tubes have been dilated. The blood adhering to the sac and the thin walls, together with the sudden change in the pressure in the blood vessels, affords material for sepsis, as well as a ready avenue for the invasion of the neighboring peritoneal cavity through necrosis of the thin tubal walls. This danger can be avoided, however, by a thorough cleansing of the field, by care against infecting the tract while operating, and by a thorough packing with iodo- form gauze so as to protect the field for some days after the operation. After the external genitals are cleansed and the operator has put on sterile rubber gloves, the bulging membrane is opened by a crucial incision, dividing it into four triangular flaps at its base. The thick tarry fluid is allowed to escape slowly and on no accoim.t must it be hastened by pressure from above, for fear of rupture. The canal is then washed out for from five to ten minutes with a warm saturated boric acid solution introduced under low pressure through a long, curved, glass douche nozzle. Pains must be taken to empty the vaginal and uterine cavities of all the accumulated blood. An abundance of iodoform and boric acid powder (1:T) is dusted into the vagina and iodoform gauze loosely laid is packed into the uterus and the vagina down to the vaginal outlet. The urine is drawn, the powder sprinkled on the outside, and a pad of sterilized cotton is laid on and held in place by a sterilized T-bandage. The internal dressings may be left in place for from four to five days or even longer, pro- vided everything is going on well and they do not become saturated sooner. Whenever they are wet and secretions are found to be escaping at the vulva they must be changed by bringing the patient to the edge of the table or bed under a good light, withdrawing the pack with forceps and reinserting it by means of a packer, thus using every precaution to avoid infection by keeping the gauze from all contact with the fingers, the buttocks, etc. By this method sepsis is avoided and the one great danger eliminated. The patient should be kept in bed for from one to two weeks. Cases where there is maldevelopment of the reproductive organs should also be referred to a gynecologist, although there is not the same need for immediate action as in the case of an obstruction of the genital tract. When the ovaries are able to perform their function while the uterus is too imper- fectly developed to respond, there is usually no relief from the constantly TREATMENT. 155 recurring suffering except in the removal of the ovaries, but this should only be done in imperative cases, where the suffering is extreme. Galvanic stem pessaries laid within the uterus have been recommended for puerile organs as well as for those cases where menstruation occurs at infrequent, long, or irregu- lar intervals, but without, in mj opinion, any reasonable claim. Moreover, as Herman has shown {Med. Press and Circ, London, 1893, vol. 55, p. 269), they often irritate the endometrium, as shown by resulting hemorrhage and leucorrhea, and set up an infection which may spread along the uterine tubes to the peritoneum, setting up a fatal peritonitis. The value of the galvanic current in this form of amenorrhea has been much praised by some writers, the negative pole being applied inside the uterus (Apostoli). I am not pre- pared to utter a sweeping denial of these claims and I am willing to concede that it is perhaps worth trying for a few months. The cathode shaped like a sound is introduced into the uterus, while the positive pole, a long dispersing electrode, is placed on the abdomen. Treatments of ten minutes' duration are given three times a week ; the strength of the current should be twenty to thirty milliamperes. In the amenorrhea of young girls, whether primary or secondary, the treat- ment should first of all be directed to diverting the patient's attention from the pelvic organs by assuring her and her relatives that a little time and patience will regulate the function. Anemia, often present, must receive consideration. Iron is beneficial in most cases, but there are a certain number in which cod liver oil appears to do more good. E^ourishing food and plenty of fresh air and exercise are essential elements in the treatment. In schoolgirls the question of over-study should receive earnest attention. No night study whatever should be allowed, and the amount of work done in school hours reduced to a minimum. In any case where the amenorrhea is obstinate or of long standing and the patient's health is manifestly below normal, it is the wisest plan to take her out of school altogether for some months or a year. The worst that can result from such a course is the delay of a year in graduation, and the disappointment attendant on this is a trivial matter compared to her physical welfare. Great attention must be paid to keeping the bowels open, as constipation is closely asso»ciated with amenorrhea. The prescription for constipation given in chlorosis is of use in all forms of amenorrhea (see p. 143). Secondary amenorrhea due to constitutional causes must be treated by attention to the particular cause in each individual case, when the relief of the underlying condition will almost certainly be followed by the re-establish- ment of the menstrual function. In chlorosis the great indications for treatment, as Herman has said (loc. cit.), are fresh air, light, food, iron, and laxatives, to which might be added another item of great importance — intervals of rest. It is a matter of common observation that chlorosis is most prevalent in unhealthy surround- ings; indeed, there seems much to favor the theory of Virchow and Stephen- J 56 AMENORKHEA. son that the disease depends upon a constitutional predisposition, engendered by damp, darkness, unhealthy food, and general want of hygiene. Sunlight and fresh air form an essential part of the treatment. The character of the food must be nutritious, and as Stanley has pointed out {Birmingliam Med. Rev., 1906, vol. 59, n. s., p. 102) the diet should contain a large pro- portion of such foods and vegetables as yield a considerable amount of min- erals, especially iron. As Stanley remarks, the diet of working girls, among Avhom chlorosis is most prevalent, sometimes consists largely of meat and is always particularly deficient in the class of foods just mentioned. Milk, eggs, and any nutritious easily digested foods are suitable, and it must be remem- bered that when the appetite is poor and capricious, as it is in all forms of anemia, especially chlorosis, any article of food not absolutely injurious will be of service, if the patient has a fancy for it. Of all remedies employed in the treatment of chlorosis, iron has always held the first place, although exactly how it works is not known. Carbonate of iron in the shape of Blaud's pills, is the preparation considered most efiicacious by authorities in general. The formula is : I> Ferri sulph., . , aa gr- ij Potassi carb., ; MuciL trag., q. s. M. et ft. pil. j. Mitte tales 100. It is best to begin with one pill three times daily, after each meal, and increase the dose gradually up to three. Hay em recommends the oxylate of iron, as less irritating to the stomach than the carbonate, in pill form, in doses of one to five grains. The tincture of the chloride of iron also gives excellent results, in doses of two to thirty drops, well diluted with water; an old well-seasoned preparation should be used. Reduced iron is another useful preparation, in pill form, the dose varying from one to five grains after each meal. Herman {loc. cit.) recommends the ammonio- citrate of iron combined with an alkali carbonate and made up with spirits of chloroform to make it palatable. The following formula is effective : 3^ Ferri et ammon. cit 3j Potassi carb gr. xxiv Spts. chlorof foj Aq. dest., q. s. ad fovj M. S. One dessert-spoonful after each meal. When the stomach is too irritable, as it sometimes is, to allow of iron being given by the mouth, it must be administered hypodermically. Dori, cited by Pratt (N. Y. Med. Times, 1905, vol. 33, p. Y7), considers the ammonio-citrate of iron best for hypodermic use. He finds that jDatients are able to tolerate large doses of iron given in this way when the adminis- tration by mouth is out of tlie question. The daily dose is three centigrams TEEATMEFT. 157 (about one-lialf of a grain) dissolved in a gramme of water (about half a teaspoonful) injected into the interscapular region. ISFext to iron, arsenic gives the best results in the treatment of chlorosis. It may be given as Fowler's solution (liquor potassi arsenitis), dose two to five drops three times a day; or as a pill in the form of arsenious acid, dose one-thirtieth to one-fiftieth of a grain. In some cases it is best to give arsenic hypodermically, and for that purpose I have found a French prepara- tion, the cacodylate de sonde, give excellent results. Manganese, so highly recommended in the treatment of all forms of amenorrhea, is considered by Stengel to be useless in chlorosis. If it is tried it should be in the form of the dioxide, dose two to five grains in pill three times a day. A good prescription in which arsenic and manganese are combined with iron is the following: ^ Ferri sulph gr. ij Acidi arsen gr. ^V Mangani diox gr. iij Mucil. trag., q. s. M. et ft. pil. j. Mitte tales 100. S. One pill three times a day. A course of chalybeate or arseniate waters is sometimes useful. Forchheimer finds the best results in the treatment of chlorosis by combining an intestinal antiseptic with a blood preparation. He gives five grains of hydronaphtol and salol before each meal and five grains of hemo- gallol after it. If the latter preparation cannot be obtained, large quan- tities of beef juice may be substituted, or any preparation which con- tains blood, care being taken to make sure that it really measures up to its claims. It is certain, according to Pratt (loc. cit.) that in some cases of chlorosis antiseptics succeed where iron fails. The success of this plan of treat- ment seems to agree with Clark's theory that chlorosis is caused by the absorp- tion of poisonous products, ptomaines, etc., from the large intestine. The constipation, which almost always accompanies chlorosis, requires constant attention. Salines are the best form of laxative, and if anything stronger is required to start the bowels, calomel may be administered in broken doses of one-eighth to one-sixth of a grain, at intervals of half an hour, until one grain has been taken. The following prescription recommended by Hart and Barbour is excellent even if somewhat bitter: ^ Magnesii sdlph 5j Quin. sulph gr. xxiv Acidi sulph. dil f 3ii j Aq. ■ dest, q. s. ad f ."^vj M. S. One tablespoonful three times daily. The bitter is really a valuable adjuvant to the purge. 158 AMENORRHHA. Gastric symptoms must be met according to tlie indications. When there is an excess of hydrochloric acid, hirge quantities of an alkali may be given before meals. In some cases, where the glands of the stomach are atrojDhied, Pratt (loc. cit.) recommends stimulating the small intestine by the administration of the ferment of the pancreas or by papain. The dose of pancreatin is five to fifteen grains in powders, while that of papain is two to five grains in the same form. Vomiting, according to Stengel (loc. cit.) is best treated by minute doses of calomel combined with a local sedative, such as cocain, one-fortieth to one-twentieth of a grain; dilute hydrocyanic acid, one to two drops; creosote, one-quarter to one-half drop; or carbolic acid, one grain. An excellent prescription for this purpose is the following: ^ Hydrarg. chlor. mit gr. j Acidi carbol gr. vj Bismuthi sub-nit., q. s. M. et ft. pil. no. viii. S. One pill every hour until relieved. JSTervous symptoms, when they are present, must be treated accord- ing to the indications. In cases combined with chorea, which are not infre- quent, arsenic is the best remedy. For the severe headache which sometimes accompanies chlorosis, the various coal-tar preparations may be tried, or the bromides. Finally, one most important remedy in chlorosis is rest. Hayem insists strongly upon this point, as well as Taylor, cited by Pratt (loc. cit.), who says that the classical treatment of chlorosis with iron and purgatives is not assisted, but rather counteracted by the accompanying prescription of exer- cise. " Against fresh air," he says, " I have nothing to say, as long as it does not involve exercise either by walking or riding. It is, of course, partly a question of proportion; the worse the case, the more absolute should be the rest. In a slighter degree of anemia, or in one already recovering, carriage exercise may be allowed, while in the severer forms the patient may with advantage be kept in bed entirely, the most certain means of keeping her abso- lutely at rest. An intermediate prescription is that the patient shall only get up for three or four hours in the afternoon." Edgecombe has sho^^Ti that under normal conditions there is a fall in the percentage of hemaglobin during the day with a rise at night. Moreover, the daily diminution is increased by exercise. His observations were made upon healthy persons, but they are significant of what rest may do in building up hemaglobin, Hayem has shown that when chlorotic patients are allowed to walk about, the blood pigment present in the urine is greatly increased over the amount present during rest. It is safe to say that the routine prescription of fresh air and exercise in chlorosis is one which should be modified. Fresh air is important, but active exercise should be proscribed. In well-marked TEEATMENT. 159 cases absolute rest in bed should be prescribed until there is a decided increase in the percentage of heiiiogl<»l)in. After this point is reached, the patient should have passive exercise in the open air, with massage. In milder cases it is enough to insist upon rest in the recumbent position for several hours every day, and the absence of active exercise. In the treatment of chlorosis it must always be remembered that relapses are frequent, and therefore the treatment should always be kept up for some time after the patient is apparently restored to health. In amenorrhea occurring during the course of tuberculosis, attention should be directed to the tubercular affection. Should the primary condition be arrested and the general health restored, menstruation will return, while if the disease progresses, the absence of the menstrual flow should be regarded as a benefit. The amenorrhea which accompanies or follows severe illnesses should also be looked upon as a blessing, since the absence of the menstrual flow is nature's effort to conserve strength. 'No treatment is necessary beyond atten- tion to the general health, and the patient and her relatives can be assured that with the return of health the function will almost certainly be re-estab- lished. A functional amenorrhea, as a rule, requires no treatment. In cases where it arises from shock, alarm, or nervous disturbance, the physician can only counsel patience until the nervous system has had sufficient time to recover. In cases where there is a sudden stoppage of menstruation from exposure to cold, the treatment should be calculated to restore the circulation to its normal rhythm, for the causes at work probably act mainly through the vaso-motor system. The patient should have a hot tub or hip bath and be put to bed, warmly covered up, with hot-water bottles, and a hot poultice over the hypogastrium. I have myself cured one case of over a year's standing by feeding large amounts of the fresh corpus luteum. The patient sometimes suffers from attacks of headache, dizziness, and flushes, recurring at intervals corresponding generallj^ to the expected menstrual periods. In such cases as these the discomfort can often be relieved by scarifying the cervix until a few ounces of blood have been removed. W. L. Burrage has successfully treated cases of this kind by the application of leeches to the cervix. Pituitary Amenorrhea. — It seems more than likely, in view of accu- mulating clinical facts, that amenorrhea, dysmenorrhea, and menorrhagia are frequently due to disturbances in the function of the internal secretory organs, notably the pituitary body, the thyroid gland, and the suprarenal capsules. The normal pituitary gland may exercise an important control over and stimulate the ovarian function. If this conjecture is correct, then a lowered activity, as found in pituitary tumors and cyst cases, would explain the pro- duction of a peculiar class of cases of amenorrhea which present the following well-defined symptom complex: A comparatively young woman begins to have scanty menstruation, and in a few months' time the flow ceases altogether, 160 AMENOEEHEA. while during the same period she takes on flesh to a remarkable degree. There is complete loss of sexual desire, she has a polyuria and headaches. In such a case give pituitary extract grs. 1^, three times a day. If there is lowered blood pressure combine it with suprarenal extract. Emmenagogues. — I do not myself recommend the class of medicines knoA^TQ. as emmenagogues. Their action is extremely uncertain, and should menstruation appear while one of them . is in course of administration, its ai^pearance is probably due to causes apart from the drug. In amenorrhea due to unsuspected pregnancy, the use of emmenagogues has been followed by most disastrous consequences. The principal remedies falling under this head are : Manganese. — This is best given in the form of dioxide, two to five grains three times daily in the form of a pill. The permanganate of potash may be substituted, dose one-half to one grain three times a day, also in pill. Apiol (Garden parsley). — The dose of this remedy is three to six minims, administered in capsules, after each meal. The administration should, be begun several days before the flow is expected. Aloes. — This should also be begun several days before menstruation is due, in the form of purified aloes, dose one gTain; or aloin, one-half of a gTain, both in pill form three times daily. There is one other variety of amenorrhea which cannot be included under any of the classes just discussed, and that is the amenorrhea due to the super- involution following severe labor. It is fortunately rare, but it must always be borne in mind whenever a persistent amenorrhea is noted after labor. Nothing can be done to relieve it. VICARIOUS MENSTRUATION. Vicarious menstruation is a term used to describe a condition in which in the absence of the regular menstrual flow a substitutive hemorrhage occurs from some other part of the body. There is some disagreement among the members of our profession as to whether a vicarious menstruation really exists, some persons contending that the cases reported will not bear analysis (Wilks, Brit. Gyn. Jour., 1886-7, vol. 2, p. 177) ; others maintaining that there is a sufficient number of authentic cases to establish the reality of its existence (R. Barnes, ibid., p. 151). As Withrow has pointed out (Amer. Jour. Ohst., 1892, vol. 25, p. 164), this disagreement arises partly from a lack of exactness as to definition. Menstruation has been usually defined as a periodical discharge of blood and endometrial debris from the uterus, and if the presence of endometrial debris is considered essential to the definition, a discharge from any other organ than the uterus cannot constitute menstruation, therefore under such a definition vicarious menstruation does not exist. It has been suggested as more appro- VICARIOUS MENSTRUATION. 161 priate that the term vicarious hemorrhage should be substituted for vicarious menstruation. The term, as used here, is intended to signify a discharge of blood taking place from an organ other than the uterus, at intervals corresponding in a general way to those existing between the menstrual periods, menstruation being at the same time wholly or partially suppressed. Under this definition, vicarious menstruation is of two different kinds : one in which the regular menstrual flow takes place as usual and is accompanied by hemorrhage from some other organ (supple- mental) ; another in which the menstrual flow is absent and its place is taken by hemorrhage elsewhere (substitutional). The nose is the most frequent situation for vicarious hemorrhage, but there is hardly a mucous surface in the body from which it has not been observed to take place: the stomach, the intestinal tract, the lungs, the bladder, the vagina, the eye, the ear, the tonsils, and the gums have each in turn been reported as the seat of the flow, as well as the nipples and the umbilicus. It has also been observed to take place from the sur- face of old cicatrices, and, in a few rare instances, from the skin, representing, it may be, the " bloody sweat " long classified among medical curiosities. One special form of vicarious hemorrhage is the discharge of blood from the bowel which sometimes takes place at long intervals after operations for the removal of the sexual organs, and represents the absent menstrual periods. A discharge of this kind rarely continues after a few months. The efficient underlying cause of vicarious menstruation is not yet understood. It is manifestly a part of the ovarian function, probably of the corpus luteum in process of formation, to stimulate a vaso- motor congestion, which in some cases is general, as shown by the throbbing full feeling in the head accompanied by pain before the appearance of the menstrual flow; and when the blood is once discharged the tension elsewhere is reduced. We do not know, however, by what cause this local congestion followed by discharge of blood from the uterus is determined. If the possi- bility of relief through the natural channels is taken away, the efferent impulse is diverted and concentrates itself upon the spot in the body at which the vessels can be most readily dilated and ruptured. The impulse instead of being reflected from the ovaries back to the uterus is reflected to whatever vascular area responds most readily to it. The reasons for this selective action in a given case, however, are obscure. Withrow (loc. cit.) mentions an interesting instance of heredity in connection with vicarious hemorrhage, in which there were two sisters, neither of whom had ever menstruated, although their genital organs were normal. One of them never showed any signs of menstruation, but the other had attacks of epistaxis occurring at intervals which corresponded in a general way to what should have been menstrual periods. The attacks began at puberty and 12 162 AMENOREHEA. continued np to the age of fortv-oiie. A niece of these women, tlie danghter of au older sister, resembled them in never menstruating, her pelvic organs, like theirs, being normal. She also had attacks of epistaxis at intervals of about four weeks for a number of years, the bleeding taking place always at night. All of the women were married and all remained sterile. The treatment of vicarious menstruation must depend upon the nature of the case. The causes of the accompanying amenorrhea must first be ascertained and, if possible, removed, for when menstruation is re-established, the vicarious hemorrhage will, in all probability, cease. Seeliginan (Centrbl. f. Gyn., 1893, vol. 17, p. G42) advises the use of a hot douche during the time supposed to correspond to the intermenstrual periods, for the purpose of induc- ing the menstrual flow. In cases where liormal menstruation cannot occur, the vicarious hemorrhage is often a safety-valve which it is not well to shut down. If the relief from the vicarious hemorrhage is not sufficient to relieve the head- ache, flushing, and dizziness it is sometimes a good plan to scarify and deplete the cervix. In rare cases the vicarious liemorrhage is so profuse as to require measures for its control. Under these circumstances the usual remedies for checking hemorrhage should be tried, adapting them to the situation from which the liemorrhage proceeds. The application of ice is of service, and where the hemorrhage is from the stomach Kiistner recommends gastric lavage with iced water. In exceptional instances radical measures are indicated. Webster (" Text- book of Diseases of Women," 1907, p. Ill) mentions two cases of vicarious hemorrhage under his care in which he was obliged to remove the ovaries (in both instances diseased) because life was endangered by the repeated hemor- rhages. He does not state the situation of the vicarious hemorrhage. Fischel (Prag. med. Wochenschr., 1894, 'No. 12) has been obliged to resort to the same radical measure in a case of rudimentary uterus accompanied by vicarious men- struation in the form of hematemesis. CHAPTEE VII. MENORRHAGIA AND METRORRHAGIA. EXTRA-UTERINE PREGNANCY. (1) Definition, p. 163. (2) Classification of forms of uterine hemorrhage, p. 164. (3) Symptoms and Diagnosis, (a) Local causes — Abortion, p. 165; polypi, p. 166; submu- cous myomata, p. 168; carcinoma of the cervix, p. 169; carcinoma of the fundus, p. 170; sarcoma, p. 172; chorio-epithelioma, p. 171; retrodisplacements, p. 172; subinvo- lution of uterus, p. 172; inversion of uterus, p. 173; acute endometritis, p. 174; chronic endometritis, p. 174; hypertrophy of the endometrium, p. 175; polypoid endometritis, p. 175; tuberculosis of the endometrium, p. 176; cystic ovaries, p. 176; pelvic hemato- cele, p. 177; corpus luteum cysts, p. 177; inflammation of the tubes and ovaries, p. 177; extra-uterine pregnancy, p. 177; sclerosis of uterine blood vessels, p. 177; calci- fication of uterine blood vessels, p. 178; (6) Constitutional and vascular causes, p. 179. (4) Diagnosis of uterine hemorrhage in general, p. 180. (5) Treatment. General considerations, p. 183. Medicinal measures, p. 184. Mechanical meas- ures, p. 186. Surgical measures, p. 188. Constitutional measures, p. 193. (6) Extra-uterine pregnancy. History, p. 194. Etiology, p. 195. Diagnosis, p. 199. Preg- nancy mistaken for extra-uterine pregnancy, p. 201. Fibroid tumors mistaken for preg- nancy, p. 204. Treatment, p. 206. Definition. — Uterine hemorrhage is of two kinds: one, which is periodical, that is to say, associated with the normal menstrual flow, is for this reason called monorrhagia (monthly bleeding) ; the other, occurring at irregular intervals and standing in no manifest relation to menstruation, is known as metrorrhagia (simply uterine bleeding). In some cases it is easy to use these two terms with discrimination, while in others it is impossible, because the conditions co-exist. Precisely the same causes often give rise to monor- rhagia and to metrorrhagia, as, for example, incomplete abortion, cancer of the cervix or of the body of the uterus, fibroid tumors, and extra-uterine pregnancy. It is plain, therefore, that it is not always possible to be minutely particular in the classification of any particular case under one or the other category, and that the terms are simply used as a matter of general convenience. There is no difficulty in recognizing a case of uncomplicated metror- rhagia, for any uterine hemorrhage occurring at times other than the regu- lar menstrual periods comes under this head. The recognition of a monor- rhagia is more difficult, for the question whether the menstrual flow is, or is not excessive must be, within certain limits, a personal one. The normal habitual discharge of a plethoric woman would be a serious loss to another of slight build, with but little blood to spare. Each woman soon learns her individual norm which she can comfortably bear, and realizes that if it is greatly exceeded for several periods her general health begins to sufl^er. The common method of estimating the amount of blood lost by the number of 163 164 MENOKKHAGTA AXD :\rETT;OPvT;nArrIA. extPvA-t:tert:n'e TEEGNAITCT. pieces of i^iroteetive gauze or '' na})l-:ins '■ used is a fairly j-clialile ^vay of e-auo-ins: an increase, but it is not a reliable ffuide as to tlie absolute amount. In general terms, it may be said that menorrhagia exists "wben two to three times the usual amount of blood is lost, coming away in spurts or gushes of bright red color or accumulating in clots in the vagina, to be discharged at intervals. The amount of Wood lost may be so great as to exhaust the patient greatly and even endanger life and it is always an important point in the physician's duty to decide whether the loss is sufficient to impair the health. A notable characteristic of menorrhagia is the fact that the flow is greater when the patient is on her feet and moving actively about. Typical menorrhagia, then, is characterized by an excessive flow at the menstrual period. There are two different types of the condition which may exist separately or conjointly: a flow which is excessive throughout the period, and one which is unduly prolonged beyond its normal limits. A persistent menorrhagia of either t\'pe reacts upon the patient's health, inducing anemia, shortness of breath, and general debility. FORMS AND CAUSES OF MENORRHAGIA AND METRORRHAGIA. The causes of uterine hemorrhage belong im.der three classes : Local, con- stitutional, and vascular. Local causes, due to conditions present within the pelvis, are the following: Abortion, Polypi, Submucous myomata, Carcinoma of the cervix. Carcinoma of the fundus, Sarcoma, Chorio-epithelioma, Ketrodisplacements of the uterus. Subinvolution of the uterus, Inversion of the uterus, Acute endometritis. Chronic endometritis. Hypertrophy of the endometrium, Polypoid endometritis, Tuberculosis of the endometrium, Cystic ovaries. Pelvic hematocele. Corpus luteum cysts. Inflammation of the tubes and ovaries, Extra-uterine pregTiancy, Sclerosis or atheroma of the uterine blood vessels, Calcification of the uterine blood vessels. LOCAL CAUSES OF UTEIUNE JlEMOlJiillAGE. 165 Constitutional Causes: Anemia, especially pernicious anemia, Rheumatic diathesis. Scurvy, Phthisis, Infectious diseases. Vascular Causes : The causes lying in the vascular system are notably : Cardiac disease with a vascular stasis, especially mitral regurgitation. Hepatic disease with a portal stasis, as in cirrhosis. SYMPTOMS AND DIAGNOSIS. LOCAL CAUSES. Abortion. — In married women threatened or incomplete abortion must al- ways be suspected as the cause of a menorrhagia until its existence is disproved ; only in this way will mortifying mistakes be avoided. Threatened Abortion. — The symptoms indicating a threatened abor- tion are, pains due to uterine contraction and loss of blood. Loss of blood, no matter how slight, in the early months of pregnancy should always be regarded with anxiety, for if it does not proceed from an impend- ing miscarriage, it must be due either to an endometritis or, in the later months, to an abnormal placental implantation. When due to threatened abortion the discharge is not usually profuse at first; it may be of a dirty brown or a brownish red color, or it may consist of fresh red blood and coagula. This premonitory bleeding may hang on for weeks, or it may be shortly followed by the complete expulsion of the ovum, when it ceases. The diagnosis of threatened abortion must be made from the history of a missed period and the presence of some uterine enlargement, on account of which the patient herself thinks she is pregnant. In many cases an abortion has occurred before in a similar manner. Incomplete Abortion. — The symptoms of incomplete abortion are a complex of pain, hemorrhage, and, it may be, the expulsion of membranes. One characteristic of the hemorrhage often present, is that it comes in spurts or gushes and keeps up with slight intermissions until the miscarriage is complete. It sometimes happens, however, that the abortion has occurred so early that no suspicion of pregnancy has arisen, and a curet- tage undertaken for the relief of the hemorrhage reveals its true cause. In a recent case of this kind in my own practice the patient complained of irregu- lar menstruation, sometimes profuse and sometimes scanty. For about three months before I saw her the flow had been excessive and had lasted from six to seven days. Her family physician ascribed it to a polyp, seen hanging to the uterus. On curetting I removed a large amount of endometrial debris 166 MENOEKHAGIA AND METROKKHAGIA. EXTKA-UTEKINE PEEGNANCY. which macroscopicallj resembled carcinoma; microscopical examination, how- ever, showed syncytium and villi, the remains of an incomplete abortion. Yet there had been no suspicion of pregnancy. In doubtful cases the diagnosis of incomplete abortion must always rest upon the microscopical examination of curettings from the endo- metrium. The most characteristic appearance in the often abundant tissue removed is little villous threads and dark coagula interspersed through the fleshy masses. Histologically, a glandular hypertrophy may predominate, in which the glands are dilated and convoluted, with little tit-like processes springing from their lumina; the epithelium is somewhat flattened and the stroma of the mucosa shows marked swelling of the cells, which persists for several Aveeks after the abortion. AVhile these appearances are suggestive of pregnancy, a positive diagnosis must rest upon the discovery of villi. In the early months these will be found to show two layers of epi- thelial covering, the interior of which is made up of cuboidal cells, while the outer, syncytial layer, appears as a ribbon of protoplasm with nuclei distributed through it; this outer layer sends out protoplasmic buds which u L ^1 f^ form new villi and in the cen- Hemorrh- placenta tre of these buds are five to forty nuclei forming the pla- cental giant cell. The interior of a villus is composed of mucoid tissue rich in blood vessels. A Placental Polyp. — A pla- cental polyp (see Fig. 60) is one in which, after the expul- sion of the fetus, the long retained fetal elements and blood become welded together and moulded into conformity with the uterine cavity. The placenta, still preserving its attachment to the uterine wall, becomes coated with layers of old coagula until it hangs down into and out of the cer- vix, a rounded, pedunculate, polypoid mass. Mucous Polyp. — A mucous polyp is a soft growth, produced by a localized hyjjertropliy of the uterine mucosa, which becomes pedunculate. It is fre- quently associated with endometritis and with fibroid tumors. Its size varies fvoni that of a pea to a walnut and occasionally it is larger. Cervical polypi (see Fig. 61) are most frequently pedunculate and protrude from Ext. OS 'yf^ pro^ ^' Fig. 60. — A Placental Polyp, the Prodxtct op an In- complete Abortion, formed by the Contractions of the Uterus acting on Hemorrhage taking place Slowly at the Placental Site. (After Bumm.) LOCAL CAUSES OF UTEKINE HEMOREIIAGE. 167 the external os, while those within the uterine cavity are often found near the tubal ostia. The one prominent symptom in uterine polypi is hemorrhage, which is sometimes severe. The diagnosis is easily made when the polyp can be seen hanging into the vagina or just within the os uteri, Fig. 61. — A Cervicai. Polyp, Appearing as a Dark Red Mulberry Mass Just Within the Cervix, AND Causing Hemorrhage. where it looks like a smooth, round, fleshy ball. Sometimes a number of little red polypi depend from the cervix. A microscopical examination shows mucous membrane with uterine glands ; the glands are mostly normal, but when they are dilated and form small cysts, the epithelium becomes cuboidal and the cavities contain desquamative epithelial cells. The stroma, especially near the tip of the polyp, often shows hemorrhage and edema. When no polyp can be seen, the diagnosis may be extremely difficult and sometimes can be made only by exclusion ; that is to say, no other probable cause being found for a protracted hemorrhage at every period, persisting for months, and asso- ciated with the fact that the uterus is not markedly enlarged, warrants the assmnption that the trouble is due either to a polyp or a small submucous fibroid tumor. Occasionally, a polyp can be removed with the curette, but, as a rule, an incision into the uterus is necessary to discover and remove it. Small sessile fibroid OTowths should be treated in the same manner. 168 2*rE:S^OKKIIAGIA AIS^D METRORRHAGIA. EXTKA-UTERINE PREGNANCY. Fig. 62. — ^A Large SuBMucotrs Myoma (&), Solitahy and Filling the Uterine Cavity. The uterus has been spht from the cervix (a) up to the fundus and out into each ■ cornu. Submucous Myomata. — ]\Iost mjomata are interstitial in the beginning, but it often happens tliat a tumor, beginning in this manner, is carried down in the course of its development into the uterine cavity where it is attached either by a broad base or a pedicle of varying length (see Fig. 62). The two characteristic symptoms of submucous myomata are hemorrhage and pain. The hemorrhage is often ex- cessive and reduces the pa- tient's strength to the last degree. The pain arises from the expulsive efforts of the uterus to push the foreigii body without the cervix, and is severe, intermittent, and expulsive in character like that of labor. Cases some- times occur in which the pain is slight and the chief symp- tom is hemorrhage. It also happens occasionally that a thin serous oozing from the tmnor is a marked symptom. Direct examination shows a rounded tumor in the vagina or just inside the cervix. By passing a finger around it on all sides the tumor will be found to be smooth and to have a pedicle within the uterus. If the growth is still retained inside the uterus, the pedicle may be demonstrated by passing a sound around it on all sides. A myoma within the uterus has the characteristic feel of a ball in a cup and it may sometimes be rotated so as to show that it has a narrow pedicle above. A myoma sessile within the uterus may sometimes be diagnosed without difficulty by introduc- ing the index finger through the cervix, the other hand being used to make counter pressure through the abdominal wall. "Wlien the canal is too small to admit the finger, a sound may be employed instead. By noting the increased depth of the uterine cavity and tracing its irregularities by the sound moving within it and by palpation per rectum and per abdomen at the same time, an accurate idea may be obtained of the size and location of thp tumor. Such a fibroid tumor is always larger than a mucous polyp. To differentiate between a myoma and a uterus which is inverted, either wholly or in part, the peritoneal surface of the uterus must be palpated by the rectum when, if there is any inversion, the corresponding depression on the peritoneal surface will be felt. Furthermore, in inversion the neck of the tumor stops short inside the cervix on all sides. A submucous myoma is sometimes mistaken for cancer of the cervix, which is not surprising, because when the patient suffers for a long time from profuse hemorrhage she acquires a cachectic look resembling that of cancer, and, moreover, when there is a sloughing myoma it gives rise to LOCAL CAUSES OF UTEKINE HEMOKRHAGE. 169 frequent fetid discharges. The distinction must be made by observing the loca- tion of the tumor and its density as contrasted with the friability of cancer. The smaller myomata are quite smooth on the surface while the larger are nodulated. The myoma presents a distinct, well-rounded tumor, contracted above a pedicle which enters a canal; the cancer, on the other hand, is a tumor with a broad attachment to the cervix, not within the uterus, and often only to one point. The diagnosis between a small submucous myoma within the body of the uterus, which cannot be felt, and a cancer of the fundus may be difficult, but if the endometrium is curetted and the curettings examined micro- scopically, the characteristic changes will always be found, if the growth is cancerous (see Chap. XXI, p. 503). As a rule, these submucous and peduncu- late myomata are not single, but form part of a group of tumors occupying the body of the uterus. This greatly simplifies the diagnosis, as the enlarged multinodular uterus is early recognized as myomatous, the presumptive infer- ence being that the particular growth which is giving rise to the hemorrhage is of the same nature. Carcinoma of the Cervix. — From the age of thirty, cancer of the cervix must always be considered in the diagnosis of uterine hemorrhage. The fre- quency with which the disease occurs and the rapidity of its advance make it important to recognize it at the earliest possible moment, as every week of delay in radical treatment (extirpation) of a uterine cancer is precious time lost. It is in this class of cases that the policy of delay can too often be justly laid at the door of the general practitioner by his fellow specialist as a fault which makes him responsible year by year for the loss of many lives. It is of vital importance that the general practitioner should recognize the fact that anemia and cachexia are only present in the last stages of the disease and that pain does not usually appear until it has progressed beyond the cervix. An operation, to be successful, must be performed before the appearance of these signs, and, as a rule, it is the general practitioner who sees the case while there is still time to save life. Cancer of the cervix is extremely rare in women who have not borne children. Menstruation is usually regular up to the time the cancer begins and may or may not be affected by it. The symptoms of carcinoma, whether of the body or of the cervix, are hemorrhage, watery, foul dis- charges, pain, emaciation, and cachexia. Watery discharges and hemorrhage are the earliest and most marked symptoms, although the latter may be absent altogether. The hemorrhages occur at other times than the regular periods and vary in frequency, occurring at intervals of a few weeks to several months. A watery discharge is often an earlier symptom than the hemorrhage ; it may irritate the external genitalia and, as the disease advances, it becomes purulent and malodorous. Pain is not, as a rule, present until the disease has advanced beyond the cervix ; some patients, however, complain of cramp-like pain of the uterus or of frequent backache 170 MEXOEKIIAGIA AND METKOKEHAGIA, EXTKA-UTEKIXE PKEGNAKCY. in the early stages. As the disease progTesses, the gTOwth presses upon the nerve trunks, and the pain is no longer limited to the pelvis, but extends to the thighs, knees, and doT\Ti the legs. In the early stages and often np to a late period, the patient looks well, keeps her usual weight, and is not at all anemic; in all but a few eases, however, the later stages are accompanied by great emaciation, anemia, and that peculiar unhealthy pallor of the skin characteristic of malignant disease. A vaginal examination in the early stages of cervical carcinoma shows the cervix to be slightly enlarged, firm, and glazed in appearance, while a few fine finger-like processes may project from the surface. The examining finger is often covered with blood when withdrawn. In more advanced cases the upjDcr part of the vagina is filled with a friable cauliflower -like growth, which breaks down on touch. On tracing this upward it will be found to spring, as a rule, from one of the cervical lips. It is at this stage of the disease, while it is still limited to the cervix, that the diagnosis is a matter of such vital importance, for the results of operation performed during this period, reported during the last few years, are most encouraging, and seem to indicate plainly that ultimate recovery may be looked for in a good many cases, if operative interference is not delayed. As cervical cancer progTesses, the gTOwth breaks down; the cervical lips are enlarged and present a ragged uneven surface extending over a more or less extensive area at the vaginal vault. The floor of the eaten-out area is very hard, but small pieces break off under a little pressure made by the finger. In later stages all traces of the cervix disappear and the vaginal vault is occupied by a small, puckered, ulcerated, hard, nodular area covered by a necrotic brown or greenish slough. Carcinoma of the Fundus. — Cancer of the body of the uterus is a disease of women over forty and usually over forty-five., The uterus is commonly enlarged, although not always, and the cervix is hardly ever involved. The hemorrhage is here painless and persistent, lasting ten days or longer, and the discharge is apt to be dark and often watery as well. It is odorous only in the later stages. An atypical fiow, coming on in a woman who has passed the menopause and whose uterus is not markedly enlarged or nodular, as in a fibroid uterus, ought always to arouse more than a suspicion of cancer of the body. The early diagnosis of cancer of the fundus must depend entirely upon the microscopical examination of the scrapings from the endometrium. Whenever there is the slightest reason to suspect the existence of the disease, the uterus must be curetted without loss of time and the curettings carefully examined (see Chap. XXI, p. 503). I would repeat that in the early stages of either form of uterine carcinoma., a positive diagnosis can be made only froui a uiicroscopical examination of the curettings from the uterine lining. Sarcoma. — Sarcoma of the uterus, like carcinoma, may occur at either the cervix or the fundus. The symptoms are much the same as those observed LOCAL CAUSES OF UTEKIJSTE HEMOEBHAGE, ^71 in carcinoma; namely, hemorrhage, watery, foul discharges, and pain, together with more or less cachexia in appearance. Examina- tion of the scrapings from the endometrium will show the characteristic appear- ance of sarcoma if it is present. There is a peculiar form of cervical sarcoma known as botryoidal, or grape-like, in which the vagina is filled with masses of vesicular bodies, made up of rapidly growing nodules, each with its own little vesicular pedicle. Only a few cases of this disease have been reported; I have myself seen but one, many years ago, in which, not recognizing the condition, I amputated the mass at the cervix. The operation was followed by a rapid recurrence and the invasion of all the surrounding tissues. Another form of sarcoma appears as deep-red or bluish masses involving the vagina as well as the cervix, which once seen can never be forgotten. Chorio-epithelioma. — Chorio-epithelioma or deciduoma malignum, is a new growth developing after a normal pregnancy, an abortion, or the expulsion of a hydatidiform mole. It has sometimes been known to occur before the mole was expelled. Whenever a patient gives a history of monorrhagia following recovery from a labor, a miscarriage, or especially the expulsion of a mole, and examination shows that the uterus is enlarged, the presence of chorio-epithelioma must be suspected. The diagnosis can be made with certainty only by examination of the curettings from the endometrium, and it must be remembered that in curettage for chorio- epithelioma it is easy to get a piece of the uterine wall which will suggest a fibroid tumor. Histologically, the tumor is composed of blood spaces surrounded by the elements of the growth, derived from both layers of the fetal ectoderm and presenting in an exaggerated manner the peculiar charac- teristics of these cell elements. The syncytial masses present are multinuclear, with dark staining nuclei and numerous vacuoles. The elements from the Langerhans' layer are large cells with clear protoplasm and vesical nuclei in which karyokinetic figures are frequently visible. These are especially percep- tible about the margins of the growth and invade the surrounding muscular tissue. The first evidence of growth may be found in metastases into the vaginal walls or into other organs, and in some instances the entire growth disappears. It is not always easy, however, to distinguish chorio-epithelioma from a benign hydatidiform mole by means of the curettings, and all the clinical facts must be weighed, together with the histological findings, in order to differentiate between the two conditions. Profuse uterine hemorrhage beginning a few weeks (six on an average) after the termination of pregnancy and leading to profound anemia is strongly suggestive of deciduoma. In some instances the interval of development has been as much as a year after the previous pregnancy; where a still longer time has elapsed, the question must be considered whether a pregnancy has not occurred of which the patient was Ignorant. A fetid, watery discharge is sometimes present; pain has been noted in some cases, but is not a prominent symptom. In many instances marked irregular fever has been observed, which, in a case under my 172 MENORRHAGIA AND METRORRHAGIA. EXTRA-UTERINE PREGNANCY. notice, was unassociated with leucocytosis. The uterus is usually enlarged to the size of about a three months' pregnancy. Retro-displacements. — Backward displacements of the uterus are frequently accompanied by menorrhagia. The symptoms, in addition to the hemor- rhao-e, are, pain in the back, aggravated by exertion and standing; a feeling of weight and bearing down in the pelvis; and leucor- rhea. Examination will at once reveal the presence of the displacement, its nature, and its degree. Fig. 63. — Subinvolution of the Uterus, which is 13 cm. Long and Enlarged in the Proportion SHOWN BY Comparison with the Normal Uterus Superimposed Above. This patient had for a long time suffered with profuse hemorrhages at the time of the menopaxise. There was no tumor or malignant disease. Subinvolution of the Uterus. — This condition arises from the arrest of invo- lution in the uterus whicli has exj^elled the products of conception. It may occur after either a miscarriage or a labor at term. After the increase in size of the uterus during the development of the ovum, the organ normally LOCAL CAUSES OF tlTEKlNE liEMORRIlAGE. 173 undergoes retrogressive changes by which it is restored to nearly the size which it was before impregnation. But if these retrogressive changes fail to take jDlace, the uterus remains large and boggy, while the endometrium becomes thick and succulent (see Fig. 63). The symptoms of this condition are pain and feeling of w^ eight in the pelvis, with a sense of bearing down. Menorrhagia is always present and frequently leucorrhea. Examina- tion shows the uterus to be enlarged, boggy, and frequently displaced, and these facts, together with the history, which shows that the patient dates her condition from a confinement or a miscarriage, establish the diagnosis. Inversion of the Uterus. — Inversion of the uterus can occur under two dif- ferent conditions: (1) Immediately after labor, as the result of it ; (2) gradually, in a non-puerperal uterus along with the expulsion of a tumor attached to the uterine wall. The amount of inversion varies from a simple depression at the fundus (inversio incom- yleta) to a complete turning inside out of the organ (inversio completa). Any condition which favors relaxation of the musculature of the uterus and a patu- lous cervix, predisposes to inversion. The exciting cause is usually some direct mechanical pressure exerted from above. There seems good reason for believ- ing that many cases of post-partum inversion are due to violence exercised during labor. In the non-puerperal, or pathological variety, the most common cause is a submucous fibroid attached to the fundus ; the uterine cavity below the tumor is relaxed and the expulsive efTorts, like those of labor, which accom- pany fibromata, force the tumor downward, until finally, in extreme cases, it passes through the cervix into the vagina, dragging with it the portion of the uterine wall attached to it. If the tumor is submucous and becomes pedunculate, the peritoneal surface of the uterine wall may undergo no dis- placement, in which case there will be no inversion. If, on the other hand, the tumor remains sessile, the whole thickness of the uterine walls and peri- toneum may follow as it descends, creating an indentation on the peritoneal surface which is at first slight, but gradually becomes more deeply depressed until, with the escape of the uterus into the vagina and out at the vulva, com- plete inversion is brought about. The tumor causing the inversion need not arise from the fundus ; it may be attached to a lateral wall. The acute form of inversion, which immediately follows labor, does not come within the scope of this work. In the chronic variety the com- monest symptom is menorrhagia, or metrorrhagia, or both, since hemorrhage occurs with great ease from the exposed mucosa. If the inversion is the result of labor, the patient will give a history of hemorrhage dating from it and sometimes state that it was particularly severe just after delivery. In the non-puerperal variety there is no such clue, and the inversion may not suggest itself to the physician as the cause of the hemorrhage for which he is consulted, until he makes a bimanual examination. In extreme cases a red, bleeding, pyriform tumor, about three centimetres in diameter 174 MENORRHAGIA AND METRORRHAGIA. EXTRA-UTERINE PREGNANCY. below and contracted above, will be found filling the vagina. Bimanual pal- pation shows a depression entering the tumor on its peritoneal surface, while the fundus is absent from its normal position. When the inversion is com- plete, the cervix cannot be distinguished at the vaginal vault, which seems continuous with the tumor. If the inversion is incomplete, the cervix remains as an enlarged ring, into which the sound may be pushed for a short distance. The presence of the orifices of the uterine tubes at the lower end of the tumor is also a diagnostic point of considerable importance. The differential diagnosis between inversion and myoma has been given above (see p. 154:). Acute Endometritis. — This is a rare condition, although often mentioned. There are no special symptoms connected with it, and the diagnosis can be made only from examination of the curettings. Histologic- ally, tlie surface epithelial cells are often swollen to two or three times their natural size, Avhile the adjacent cells may be compressed. There is a tendency to cell proliferation and between the epithelial cells are many polymorpho- nuclear leucocytes and small round cells. The glands in the superficial por- tions show swollen epithelium, with a tendency towards proliferation, together with a small round-celled and polymorpho-nuclear-celled infiltration. Some of the gland lumina are partially filled with leucocytes. The deeper portions of the glands are often normal. The stroma shows much infiltration super- ficially, with polymorpho-nuclear leucocytes and small round cells, the infil- tration diminishing towards the muscle. The muscle tissue underneath is rarely much altered. Chronic Endometritis. — This condition is also rare. The prevailing habit of describing all uterine scrapings as examples of endometritis is greatly to be deplored, since it interferes with our getting a satisfactory knowledge as to the real frequency of the affection and tends to encourage unnecessary operating. The so-called fungoid endometritis is not really a pathological entity at all and the name ought to be avoided. Chronic endometritis is oftenest associated with old cases of pyosalpinx and is rarely found in ordi- nary scrapings. The slight liability of the uterine mucosa to this affection is due to two factors: First, the tendency of pus-containing tubes to close completely at the uterine end, by which one avenue of infection is shut off; second, the form and position of the uterine canal, which are such as to afford good drainage. Chronic endometritis, when present, is characterized by the unevenness of the mucosa, in which the epithelium is stunted, low, cylin- drical, or cuboidal. The glands, in some places, are diminished in number and vary in size ; some of them being narrow above and distended below. The epithelium of the dilated glands is somewhat flattened. The stroma is denser than it is normally, especially in the superficial portions, the nuclei tend to become spindle-shaped, and there is much round-celled infiltration. There are practically no poljonorpho-nuclear leucocytes. The deeper portions of the stroma are often normal and there are no changes in the muscles. LOCAL CAUSES OF UTERINE ItEMORTlXIAGE. 175 Hypertrophy of the Endometrium. — Hypertrophy of the endometrium, some- times called chronic hyperplastic endometritis, is generally the result of an over-supply of blood to the uterus. Any condition, therefore, which induces pelvic congestion is likely to be accompanied by an increased growth of the endometrium. The symptoms are, profuse and prolonged men- stru,ation with a shortening of the intermenstrual period. Some- times there is metrorrhagia, and cases occasionally occur in which there is a continual hemorrhage, the menstrual periods being distinguished by an increase of the flow. Leu cor r he a is almost always present, occasionally tinged with blood. Examination shows a uterus increased in size and weight, fre- quently softer than normal in the early stages of the affection and hard in the later. There are two different forms of hypertrophy of the endometrium: glandular and interstitial, both of which may exist at the same time. In the glandular form the glands, which are increased in number, are spiral, and the gland spaces are dilated, with an excess of epithelium in their lumena. The surface epithelium of the endometrium is also proliferated, but the single epithelial layer in the glands or on the surface is never duplicated, except in the senile form of the affection. In interstitial hypertrophy there is at first a round-celled infiltration of the inter-glandular connective tissue. The glands themselves are widely separated and compressed. The surface epithelium is sometimes exfoliated and when the condition has become chronic the round cells become spindle-shaped. If the glands are much compressed they may atrophy and disappear. The uterine mucosa becomes a single layer of epithelial cells on the surface of the uterine cavity. Polypoid Endometritis. — In this form of endometritis, the uterine cavity is choked by a mass of growths resembling multiple polypi, in which the glands Fig. 64. — Polypoid Endometritis, showing an Extensive Papillary Overgrowth of the Uterine Mucosa. (From T. S. Cullen.) are dilated and the blood vessels increased in size and number (see Fig. 64). It is usually seen in quite young women, and is characterized by profuse men- strual hemorrhage, sometimes of the most severe description. The only condi- tion for which it is likely to be mistaken is malignant disease, and the di- 176 :MEXORRriAGiA and METRORKHAGIA. EXTRA-rTERIXE PREOXAXCT. agnosis is easily made from the uterine scrapings, ^vhicli must always be carefully examined under the microscope (see Chap. XXI, p. 527). Tuberculosis of the Endometrium. — ^lenorrhagia is occasionally caused by tuberculosis of the endometrium, which is nearly always secondary to tuberculosis of the tubes. It luay be miliary, a part of a general tubercular process, or of the chronic diffuse form. The chronic diffuse form is that with which we usually have to do. It begins, as a rule, at the fundus, being sec- ondary to a tubercular tube. The first visible alterations are little yellowish- white nodules under the surface one to two millimeters in diameter, which may increase in size and numbers and then coalesce and break down, forming an ulcer with an undermined edge. The disease extends from the endometrium into the uterine muscle. Histological examination in the early stages shows the epithelium of the surface intact and the glands normal, while the tubercles are found scat- tered throughout the superficial portions of the uterus ; these consist of agg-rega- tions of epithelial cells, later they are surrounded by small round cells, and at a still later stage, the giant cells are found in the centre. The surface epithelium over the superficial nodule is frequently flattened and plain. In a marked case the glands are encroached upon and it is at times impossible to distin- guish some of the epithelial cells from the gland epithelium ; in other cases tubercles are seen partly projecting into and obliterating the gland cavity; and again, the gland may be filled with caseous material. In the most ad- vanced cases the cavity is lined by caseous material devoid of nuclei, below which lies a zone of typical tubercular tissue consisting of epithelioid cells and tubercles ; in the deeper portions a stray gland may survive where the process has gone deep enough to involve the muscle. The glands are often entirely absent. Bacilli are found with varying frequency, sometimes sparse sometimes abundant, and most numerous in the advanced cases with marked caseation. In my experience, they are much more readily found than in tuberculosis of the tubes. In the early stages of the disease the tubercular process may be entirely unsuspected and the curettings may look like the nor- mal uterine mucosa: but where the disease is advanced, the presence of soft cheesy masses will at once arouse suspicion. Xecrotic carcinomatous tissue may present a somewhat similar appearance, but the characteristic branching found in cancer does not occur in tuberculosis. In advanced cases the diag- nosis may be reached from the examination of the uterine discharge, which contains tubercle bacilli. It has happened several times in my experience that tuberculosis has been found in a purely accidental way while submitting the uterine scrapings to the routine examination. On other occasions I have found a tubercular endometrium on curetting the uterus immediately after removing the tubercular tubes. Enlarged Cystic Ovaries. — Menorrhagia arising from enlarged cystic ovaries occurs in youth, or at any rate in women under thirty-five. There may be no symptom but hemorrhage. LOCAL CAUSES OF UTERINE HEMOEEHAGE. 177 Pelvic Hematocele. — Menorrhagia from this cause is usually associated with pelvic inflammatory disease. The symptoms are more or less con- stant pelvic pain, dysmenorrhea, and hemorrhage. Examination shows the uterus to be full of old viscid blood ; it is more or less immobile and may be tender on firm pressure. Irregular lateral masses will be found fill- ing out the pelvis behind the broad ligaments. Corpus Luteum Cysts.- — Menorrhagia is the only symptom arising from this form of cyst. It is impossible to distinguish it from monorrhagia arising from follicular cysts. , Inflammation of the Tubes and Ovaries. — Menorrhagia is a common accom- paniment of tubal inflammation. The period is lengthened, the interval short- ened, and the quantity of blood lost unnaturally great. In rare instances the monorrhagia becomes a metrorrhagia so profuse and long continued as to cause profound anemia and actually threaten life. In exceptional cases menstrua- tion is scanty or there may be amenorrhea, by reason of atrophic changes in the uterus and appendages. There is usually a history of neurasthenia and diges- tive disturbances with loss of weight and failing strength. Often there is the history of infection. Examination shows lateral inflammatory masses or else the uterine tubes are large, hard, and distended to a sausage shape. Extra-uterine Pregnancy. — Menorrhagia is one of the striking symptoms of an extra-uterine pregnancy; but usually something in the history suggests the cause of the hemorrhage. In many cases there will have been the usual symptoms which accompany the early stages of normal pregnancy, namely, cessation of menstruation, morning sickness, fullness of the breasts. The diagnosis of this condition is of such importance that it is con- sidered in a separate section (see p. 194). Sclerosis or Atheroma of the Uterine Blood Vessels. — The physician some- times encounters cases in which monorrhagia, or metrorrhagia, or both occur in women nearing middle life, for which none of the causes just discussed can be assigned. Even if the hemorrhage is so severe as to necessitate removal of the uterus to save life, nothing will be found, except that it is somewhat enlarged and from a macroscopic point of view simply superinvoluted. Exami- nation with the microscope, however, shows sclerotic changes in the uterine blood vessels. The smaller vessels in the mucosa are increased in number and their walls, instead of consisting of practically nothing but a layer of endo- thelium, are thickened by a deposit, around which is a layer of concentric lamellffi of fibrous tissue with well-stained nucleii. This condition is a local affection which does not involve the uterine artery and is not associated with a sclerosis of the other vessels of the body. The diagnosis of it can be made only by exclusion. It was first noted, according to Barbour, by Pichevin and Petit in 1895 {Gaz. med. de Paris, ISTov., 1895) and has since been discussed by Barbour himself (Jour. Ohst. and Gyn. of Brit. Emp., 1905, vol. 7, p. 387) and by E. L. Dickinson [BrooMyn Med. Jour., 1906, vol. 20, p. 45). Let me utter a word of caution here, however, against considering every woman who 13 178 INIElSrORRHAGIA AND METROEETTAGIA. EXTEA-UTEEINE PEEGNANCT. suffers from liemorrhage at the meuopause, aud has been shown free from cancer, to be a case of capillary sclerosis. There are many cases of " symp- tomatic hemorrhage " at the time of the climacteric which recover with rest, packing-, and the exercise of a little patience. Calcification of the Uterine Blood Vessels. — Henri Arnal, in a thesis on the senile nterns (Abst. by P. Petit, La sem. gyn., 190G, vol. 11, p. 33) has pointed ont that calcification of the nterine blood vessels is by no means infre- quent, being- present in fifty per cent of the uteri observed by him. The degen- eration begins in the middle fibrous coat of the artery and extends towards the periphery or the inner coat, sometimes invading and breaking down the latter. The degree of calcification is not in proportion to the age of the patient ; for example, there were no more calcified vessels in a woman of eighty-seven than in another woman of sixty. Tt seems probable, therefore, that other fac- tors than mere age enter into the degenerative process, possibly the same which are observed in angio-sclerosis of the uterus before the menopause, or in neuro-arthritis. These vascular lesions are liable, of course, to cause the formation of intraparietal hematometra, accompanied by more or less hemorrhage, and this form of metrorrhagia, which has been little noted, is important, because any hemorrhage from the uterus after the meno- pause is liable to be taken as evidence of cancer. In any suspicious case the uterus should be curetted and the scrapings carefully examined. This condi- tion is frequently associated with grave vascular lesions in other parts of the body; one patient of Petit's died from the effects of a pulmonary embolism and another from a thrombus in the left cerebral hemisphere. I have investigated the frequency with which the different local causes just discussed are found in menorrhagia, with the following results : Out of three thousand nine hundred and fifty-four gynecological cases treated in the Johns Hopkins Hospital between June 11, 1894, and March 25, 1899, there, were six hundred and seven in which hemorrhage from the uterus occurred. The local causes associated with them are these : Carcinoma uteri, one hundred and sixty cases, or tv:enty-six and three- tenths per cent. Myomata (simple and uncomplicated), one hundred and twenty -nine cases, or twenty-one and three-tenths per cent. Myomata (complicated with pelvic inflammatory disease), twenty-two cases, or three and six-tenths per cent. Pelvic infiammatory disease (alone), eighty-three cases, or thirteen and seven-tenths per cent. Abortion and sequelae, forty cases, or six and five-tenths per cent. " Endometritis," thirty-two cases, or five and three-tenths per cent. Petroflexion of the uterus, twenty-nine cases, or four and eight-tenths per cent. Relaxed vaginal outlet, twenty-three cases, or three and a half per cent. Polypi of uterus, twenty cases, or three and two-tenths per cent. CONSTITUTIOlSrAL AND VASCULAR CAUSES OF UTERINE HEMORRHAGE. 179 Extra-uterine pregnancy, seventeen cases, or two and eight-tenths per cent. Cystoma of the ovaries, twelve cases, or one and nine-tenths per cent. Other causes were : Anteflexion of the uterus ; sarcoma of the uterus ; each three cases. Stenosis of the cervix uteri; sarcoma of the ovary; pregiiancy; each two cases. Pyometra; hematometra; corpus luteum cyst; retroposition ; hemophilia ; cyst of Gartner's duct ; fibroma of the ovary (malignant) ; dilated glands ; subinvolution ; gland hypertrophy ; " menorrhagia and metrorrhagia ; " each one case. Of the six hundred and seven cases, eighty-seven showed menstruation to be prolonged or profuse, or both ; and of these eighty-seven, fifty-seven, or sixty-five per cent, were cases of myoma of the uterus, including myomata complicated with pelvic disease. CONSTITUTIONAL AND VASCULAR CAUSES. The diagnosis of uterine hemorrhage arising from constitutional or vascular causes must rest upon the history of the case and the exclusion of any local cause. In young girls the establishment of the menstrual function is often attended with irregularities which may manifest themselves in excess as well as in deficiency. The following case is an illustration of how much may be done in such menorrhagias by patience and the employment of palliative measures. Miss G-., age sixteen, J. H. H., 'No. 11750, Dec, 1904. The patient was always in good health until she was fourteen, when she began to menstruate. Menstruation was too frequent and too profuse from the onset, the periods recurring every two weeks. At first the flow lasted only two days, but by the end of two years, at which time she entered the hospital, the hemorrhage had become almost continuous. Her hemoglobin count was then only forty-eight per cent. She had been curetted three times and the last time a surgeon of high standing had said that the hemorrhage was caused by cancer and that a hysterectomy was the only means of saving her life. I curetted her as soon as she came under my care, and removed an excessive amount of pale, flabby, endometrium, in long projecting tufts. She was discharged at the end of three weeks, but the hemorrhage shortly returned and she was re-admitted about four months later. Her hemoglobin count was then only forty per cent. I curetted the uterus again and cauterized it, with relief from hemorrhage for nearly a year, when the flow again became excessive. I then curetted a third time, making in all six curettings in three years. This last curettage was in May, 1906, and in June, 1907, a little over a year, she was free from more than a slight excess in menstruatir*n. There is a rare form of chlorosis in which the uterus and ovaries, instead of being small or even infantile, as is usually the case in this affection, are markedly increased in size, while menstruation, instead of being deficient in amount, is excessive. An occasional constitutional cause of menorrhagia, not often recognized^ is 180 MENOERHAGIA AND METROERHAGIA. EXTRA-UTERINE PREGNANCY. syphilis. B. MacMonagle; of San Francisco, lias had a case of persistent menorrhagia which nothing relieved until a complaint made b}' the patient of dizziness and a tendency to fall clown, suggested specific disease and led Dr. MacMonagle to prescribe iodide of potash; this relieved the head symptoms, and immediately afterward the menorrhagia disappeared. In making a diagnosis as to the cause of any case of menorrhagia, the physician will do well to bear in mind the age and condition of the patient. If she is a yoimg girl, malignant disease of any kind may generally be ex- cluded, and in all probability several other local causes. In the case of yoimg girls the irregularity is most apt to be caused by the slow and imperfect development of the uterine vessels, in the last stage of her corporeal evolution. Chlorosis is sometimes associated with this state of things. Young girls are also apt to suffer from an excessive flow following influenza, pneumonia, scarlet fever, or small-pox. A persistent hemorrhage in their case is sometimes associated with a glandular polyp, or, more rarely, with a polypoid endometritis. Family tendencies must also be borne in mind. In umnarried women between thirty and forty years of age, excess of menstruation is most likely caused by a slight displacement (retroflexion as a rule), in eases where the increase begins suddenly. "When the onset is gradual, it is probably caused by a polyp, or else by a fibroid tumor, or, quite frequently, by tuberculosis of the uterine tubes. In married women, a threatened or an incomplete abortion must always be assumed as the efficient cause until its existence is disproved. Fibroid tumors also frequently come into play with this class of cases. Alm ost every woman who presents herself in the late thirties with large fibroids and a history of menorrhagia will also give a history of an excessive fiow for some years previous, the cause of which had not been recognized. After the age of thirty-five, cancer comes into play as an active cause of hemorrhage. The frequency with which this disease exists makes it impera- tive to be always on the watch for it, in order that it may be recognized at the earliest possible moment. Every week of delay in active treatment (extirpa- tion) of cancer is precious time lost. If a woman over forty is troubled with an increasing instead of a diminishing menstrual flow, sometimes marked in its earliest stages by a watery discharge, and if, on examina- tion, the uterus is found somewhat enlarged, cancer of the uterine body is to be suspected The investigation of any case of uterine hemorrhage should be carried on as follows: First, a careful history must be taken in which the patient's age and condition are noted, together with her family history and its tendencies. Second, a careful physical examination of the chest and abdomen must be made, when, if anything amiss is discovered, as for example,, a bad heart lesion, the diagnosis may be cleared up at once. I have seen a case in which the patient came into the dispensary complaining of menorrhagia and with a his- tory which suggested no local cause except, possibly, incomplete abortion. It GENBKAL DIRECTIONS FOK DIAGNOSIS OF UTERINE HEMORRHAGE. 181 was observed, however, that she was extremely short of breath, and examina- tion of her heart showed that it was enormously dilated. Examination of the pelvic organs showed no local trouble of any kind. Systematic treatment for the heart lesion improved her general condition greatly and with this improvement the monorrhagia was also much relieved. Let me here utter a word of protest against the too hasty local examination of young unmarried women made by many practition- ers and pseudo-specialists. In almost all such cases it is best to assume that the simpler condition (e.g., constitutional disturbances) accounts for the trouble, and to use appropriate remedial measures for general treatment, endeavoring above all to gain the kindly aid of time in setting things right. If, however, an excessive flow persists in spite of all measures for its relief, an examination should be made under an anesthetic, when appropriate measures for relief can be taken at the same time. In a married woman, or in an unmarried one with a long history of ex- cessive menstruation, there should be no delay in making an examination. A simple inspection of the introitus, revealing the deep bluish color of pregnancy, may clear up the diagnosis at once. The finger introduced may at once touch a polyp lying in the vagina or feel its smooth surface just within the cervix. A softened cervix is a sign of pregnancy, while a nodulated enlarged cervix, due to endocervicitis, or a friable cancerous cervix speaks for itself at once. A bimanual examination is next in order to detect any enlargement of the uterine body, should it exist, and if it does, to determine whether it is uniform and more or less globular, in which case it is due to pregnancy, to a subinvoluted uterus, a cancerous uterus, or a polyp within the uterine body. Fibroid tumors are usually asymmetrical and multiple. Diseased conditions lateral to the uterus, such as the unilateral tumor of extra-uterine pregnancy, a malig- nant ovarian tumor of greater or less size, or the hardness and tender- ness induced by an inflammatory condition of the ovaries, if -they are marked, may all be at once detected. If the diagTLOsis is not clear, it is best for diagnostic purposes to make a more thorough examination of the uterus and the lateral structures by putting the patient completely under the control of the examiner through the use of an anesthetic. Whenever an anesthetic is used for diagnostic purposes, it is well to obtain the patient's consent beforehand to the performance of any sim- ple operation which may be required, such, for example, as a curettage. Let me note here that the cases which most often escape diagnosis are those in which there is a small polyp or fibroid tumor, perhaps not over half an inch in diameter, in the uterine cavity. In several such cases occur- ring in women under forty, where I have excluded every other local cause, I have opened the body of the uterus through the vagina by detaching it from the bladder and splitting it up the anterior wall ; or else, through the abdo- men, making an incision in an antero-posterior direction through the fundus 182 MENORKHAGIA AND METEOKEHAGIA. EXTEA-rTEEINE PEEGNANCT. into tlie cavity, as though I were about to cleave the organ into two parts. A little tumor inaccessible by the ordinary means of exploration has thus been dis- covered and removed with entire relief of the hemorrhage. A case of this kind is the following: The patient complained of excessive flow; and on examination the uterus felt enlarged and thick, but nothing else could be observed. The cervix was therefore pulled down to the outlet, dissected away from the vaginal vault, and freed nearly up to the os internum. It w^as then split up into the uterine cavity and the finger introduced. A mucous polyp as large as the end of a thmnb was at once felt on the posterior wall towards the left. This was curetted off Avith a large scoop curette. The cervix was then closed with buried catgut sutures and the vagina tmited, with a narrow iodoform gauze drain in the centre. Several times, on opening the uterus in this way, I have found nothing but a peculiar feathery condition of the endometrium, particu- larly marked in the cornua of the uterus, and after this had been thoroughly removed by the curette the hemorrhage ceased. In the midst of all these possible causes, the diagnosis of the cause of uterine hemorrhage may, to a comparatively inexperienced practitioner, appear a matter of the utmost difficulty. This is not the case, however, for, as a rule, it is quite easy to say that the hemorrhage springs from a certain source within a few minutes after seeing the patient. As soon as the causes just discussed receive a little clear analysis they will be found to fall into groups, and there- fore it is not necessary to go over every possibility with painstaking care in order to reach a diagnosis by exclusion. For example, if a patient comes into the physician's ofiice out of breath and cyanosed, and the fingers touching the pulse detect an irregularity, there is at least a suggestion that the cause of the uterine hemorrhage which she complains of lies in a valvular heart lesion. Again, a patient with extreme anemia comes in, and in answer to the question whether the anemia began first and was followed by the hemorrhage, or vice versa, she asserts that the hemorrhage came first. This makes it clear that the hemorrhage is probably due to a local lesion, and if the hand placed upon the abdomen recognizes an enlarged nodular uterus, the cause is appar- ent — the hemorrhage comes from uterine fibroids. Or, it may be, that the patient volunteers the information that she was pregnant one or two months when the hemorrhage began, when examination will likely reveal a threatened or an incomplete abortion. When there is no obvious cause the question must be approached somewhat after this manner: There is no manifest systematic disease and judging by the fact that the trouble began recently, the cause is probably a local one. This being the case, a pelvic examination must be made, when it may be that the vagina will be found normal and that there will be no evidence of lateral dis- ease in the tubes and ovaries, but as soon as the cervix is seen the matter will be settled hj the evidences of carcinoma. From this time on then, the whole GEISTEEAL TREATMENT OF UTERINE HEMORRHAGE. 183 attention can be concentrated upon the uterus as the organ from which the hemorrhage proceeds and as that in which the cause of it is to be found. If, however, the cervix proves normal, the next question will be: is the uterus enlarged ? If it is, the enlargement, if nodular, may be due to a myoma or a sarcoma ; or if it is uniform, to a pregnancy or a carcinoma of the fundus. It must always be borne in mind, however, that small nodules may be found in carcinoma. If all these manifest signs fail, the patient must be more minutely exam- ined under anesthesia and, if necessary, the uterus must be dilated and curetted, in order that the scrapings of the mucosa may be examined under the micro- scope, for such an examination may reveal an incipient carcinoma, an endo- metritis, or the remains of an abortion. TREATMENT. The treatment of uterine hemorrhage in order to be efficient must reach the cause; it is plain, therefore, that a correct diagnosis is- essential to a cure. Sometimes it happens that the diagnosis and the treatment proceed pari passu, as, for example, in curettage of the endometrium, when a diagnosis is made and a cure effected at the same time. The hemorrhage arising from irregularity in the establishment of men- struation in young girls is best treated as a physiological affection of the young tissues which are taking on a new function. Rest is the prime factor in such cases, that is to say, rest in bed for two to three days in each menstrual period, beginning, if possible, before the flow appears. Dr. Ethel Vaughan finds that, many young girls are entirely relieved by abstinence from active exercise, such as long walks, the use of the bicycle, or playing tennis just before menstruation. If due precautions of this kind are observed for from six months to a year, a proper norm will probably be established. It is most important to keep the bowels well regulated, and a course of tonic treatment is an excellent adjuvant. I should, for example, give arsenic and quinine in some such formula as this : ^ Acidi arsenios gi"- sV Quin. sulph gr. ^ Extr. calumb gr. j M. et ft. pil. j. Mitte tales 1. S. One pill three times daily. Iron is best avoided in this class of cases and ergot is of no value. Strych- nin, however, is often useful. A good way to equalize the circulation is to draw blood from the pelvic organs by giving the patient a hot bath and putting her to bed. If, in spite of all precautions and general remedial measures, the flow continues excessive, an examination must be made, and if the case seems suitable for curettage it may be performed at the same time. In treating 18-1 MEXOEEHAGIA AXD METROEEIIAGIA. EXTEA-UTEEIXE PEEGXAXCT. yoimg girls or yoimg unmarried women, no benefit arises from persistent local treatment in the form of donches and applications ; sncli measures as these should in every case be assiduously avoided. Attention of this kind is well described as " gynecological tinkering." In cases of severe hemorrhage it becomes necessary to treat the hemorrhage independently of the local ' cause, which must be dealt with later on. The measures likely to be useful in immediate treatment are as follows: Rest in bed in the reciunbent position with the foot of the bed elevated about ten inches. Absolute quiet must be enforced in the patient's room, no visitors should be admitted, and all occasion for excitement or worry excluded. The bowels must be carefully regulated, preferably with salines. Some of the medicinal remedies discussed below should be given, and, if the flow still persists, the vagina must be tamponed according to the directions given. In extreme cases it may be necessary to give an injection of normal saline solution. The best method of doing this is to infuse the solution into the cellular tissue under the breasts, as follows : two bottles are prepared, each con- taining a litre fthirty-four fluid ounces) of a sixth-tenths per cent salt solu- tion, at a temperature of 100° Y. This can be prepared by adding a small teaspoonful of common salt to a pint of water. A rubber tube, six feet long, is placed in each bottle, attached to which is a long, slender, sharp aspirating needle. Instead of two bottles and tubes, one bottle can be used with a T attachment. The solution must be free from all organic particles, such as bits of cotton from the plug in the bottle in which it has been sterilized. The skin of the breast is carefully disinfected, after which the breast is grasped and lifted up from the chest, while the needle, with the salt solution flowing into it, is thrust into the cellular tissue, well under the glandular substance. The bottle is elevated above the patient about six feet, in order to give a sufiicient hydrostatic pressure to force the fluid into the tissues. As a rule, it requires about twenty minutes to infuse from seven hundred to a thousand cubic centimetres of the solution under both breasts, taking one after the other. If the svmptoms are urgent, both breasts may be infused at the same time. As the infusion proceeds the gland becomes greatly distended, and not infre- quently the salt solution spurts out of the nipple in a fine jet. At the com- pletion of the operation, a piece of adhesive plaster must be placed over the point of puncture, to prevent a reflux of some of the injected fluid. In none of the cases in which I have employed this form of repletion of the circulation has there been the slightest ill effect in the way of local inflammation about the breasts. The various measures for the relief of uterine hemorrhage may be divided into four classes ; namely, medicinal, mechanical, surgical, and con- stitutional. Medicinal Measures. — There are various drugs which have considerable in- fluence in controlling uterine hemorrhage, though there are none which can be depended upon to effect a permanent cure. MEDICIKAL TREATMENT OF UTEKINE HEMOKKHAGE. 185 Ergot. — Ergot is a remedy much in use formerly, but largely abandoned now. It is given in the form of the fluid extract, dose fifteen drops in water, or as ergotin, dose one-tenth to three-fourths of a grain in pills. Hydrastis canadensis. — This drug, commonly known as Golden Seal, has a direct action on the vaso-motor nerves and is therefore useful in cases of sub-involution, interstitial fibroids, and all forms of uterine con- gestion. The dose of the fluid extract is fifteen to thirty drops in water, three or four times a day ; or it may be given in the form of hydrastin, dose one-eighth to one-fourtli of a gTain in pills. It is best to give it during the intermenstrual jjeriod or else to begin the administration a week before the flow is expected. Viburnum prunifolium. — This is a remedy highly recommended for use in the monorrhagia associated with constitutional conditions, or in that which accompanies the establishment or cessation of men- struation. The fluid extract is the best form for its use, dose thirty drops to two teaspoonfuls. Apiol. — Apiol (garden parsley) has recently been much spoken of in the treatment of monorrhagia. I have seen a case in which it gave great relief. It should be given between the menstrual periods in the form of capsules, dose three to six minims, several times a day, or else it should be begun just before the period and continued through the first day or two. Styptic in. — This is a drug which has found favor in the treatment of uterine hemorrhage Avithin the last few years. Abegg (Centrhl. f. Gyn., 1899, vol. 23, p. 1333) has written of it in the most favorable terms. Unlike ergot it does not cause uterine contractions, its hemostatic action being central. The blood pressure is lowered and it has a certain sedative action which relieves the pain associated with menorrhagia. According to Gottschalk, it is useful in the following conditions: (1) Climacteric hemorrhage; (2) subinvolution which does not depend on placental or membranous retention; (3) fiemorrhage of reflex order, caused by disease of the appendages or of the parametrium, when the uterus itself is healthy; (4) congestive hemorrhage in young girls; (5) hemorrhage due to fibroids (but not to submucous polyp). In Gottschalk's opinion the action of the drug is more certain if it is injected into the gluteus muscle. For hypodermic use a ten per cent aqueous solution is best, the dose being one to two minims. Styptol is recommended by K. Witthauer {Centrhl. f. Gyn., 1904, vol. 28, p. 997) as being cheaper and more efficacious than stypticin. The dose is one grain, three times daily, until the fiow begins, when one and a half grains are given every three hours through the period. Adrenalin. — The extract of the adrenal glands has been given for the relief of menorrhagia with some success. The dose is fifteen drops of a 1 : 1000 solution, three times a day. Calcium. Chloride. — This is occasionally of service, in doses of five grains after each meal during the intermenstrual period, the frequency being increased to intervals of two hours during menstruation. 186 MENORRHAGIA AND METRORRHAGIA. EXTRA-UTEEINE PREGNANCY. Gallic Acid. — This is a remedy higbly recommended by T. A. Eimnet and, more recently, by W. L. Tajdor. Both Emmet and Taylor advise com- bining the acid with cinnamon, which has also, in their opinion, a bene- ficial effect in controlling hemorrhage. It may be done after the following formula : ^ Acidi gallici oij Tinct. cinnam fovj Aq. dest., q. s. ad fovj M. S. One tablespoonful every three or four hours. In cases where there is marked congestion of the uterus or ovaries, Taylor finds great benefit from combining one of the bromides with cinnamon and ergot in the following formula : J^ Ferri exsiccat gr. viij Potass, bromid Sjss. Ext. ergot, fl f3ij Tinct. cinnam f5vj M. S. One to two teaspoonfuls three times daily. Mechanical Measures. — The mechanical measures used for the relief of uter- ine hemorrhage are: Hot douches; tampons (packs); cold applica- tions ; electricity ; intra-uterine applications. Hot Douches. — This mode of treatment is highly recommended by many authorities. The mode of administration is as follows : The patient should lie in the dorsal position with the hips on a bedpan, so that the vaginal vault is below the orifice of the vagina and the water will be in direct contact with the pelvic organs while it is in circulation. The temperature should be between 110° and 120° F. A lower temperature than this is not only ineffectual, but injurious, because, instead of stimulating the blood vessels to contract, it re- laxes them. Each douche should last from fifteen to twenty minutes, and one to two gallons of water is usually sufficient. Tmce a day, morning and night, is generally often enough to use a douche, but there are some cases in which it may be necessary to give it three times a day. As a rule, the injections are used between the menstrual periods and discontinued when menstruation ap- pears, but if the flow is greatly in excess, there is no objection to using them throughout the period. Vaginal Tampons (packs). — The vaginal tampon is a most efficient means of controlling uterine hemorrhage. In cases where the amount of blood is greatly in excess from the beginning of the flow, the tampons should be introduced soon after menstruation begins, but if the loss of blood is due to prolongation of the menstrual period, it is better to wait for several days after menstruation has been established before inserting the pack. Tampons are made of non-absorbent cotton, of wool, of lamb's wool in bulk, or, sometimes, MECIIxVNICAL TEEATMENT OF UTERINE HEMORRHAGE. 187 of strips of gauze. To insert the tampons a trivalve speculum is necessary, if the patient is in the dorsal position ; a Sims' speculum, if the Sims' position is used; or, better still, a Kelly's cylindrical metal speculum, with the patient in the knee-breast position, when the vagina balloons out and is easily distended with a firm pack to its utmost capacity. A tampon should remain in place from eighteen to twenty-four hours. When it is removed the parts should be carefully cleansed by a douche and another pack inserted. Uterine Tampons. — Intra-uterine tampons of sterilized gauze may be used, packed very tight and left in position for forty-eight hours. These cannot be introduced, however, without extensive dilatation of the cervix, and they are not generally of much service, except in abortions. Bouriaut of Geneva has suggested that intra-uterine injections of a two per cent solution of glycerin should be used instead of tampons. Ten to fifteen cubic centimetres (about half an ounce) of the solution are injected and the injection is repeated two to four times, if necessary. The method is highly recommended in hemor- rhage from uterine atony, and that due to fibroma (cited from Monod, Montreal Med. Jour., 1905, vol. 34, p. 22). Cold Applications. — In cases where excessive hemorrhage must be stopped at once, the application of cold may be tried by placing an ice-bag over the lower abdomen and another over the lumbo-sacral region. This is not, however, a mode of treatment which is often advisable, as patients suffer- ing from loss of blood usually require the stimulating effect of heat. Electricity. — The treatment of uterine hemorrhage by electricity, much advocated some years ago, has now fallen somewhat into disuse. The results from it, however, were often favorable, and there seems no doubt that it is of service in a good many cases and may obviate the necessity for a radical operation. The application is made by means of a platinum electrode, with a movable insulating sheath. The electrode is j)assed up to the fundus of the uterus, while the insulating sheath is adjusted so as to reach just beyond the internal OS. As the bleeding comes from the body of the uterus, it is absolutely neces- sary to see that the current affects the body of the uterus and not the cervix. Moreover, strong currents cause stenosis of the cervical canal. A large clay pad is placed on the wall of the abdomen, just above the pubes, and connected to the negative pole, while the intra-uterine electrode is connected to the positive pole. At the first application, only a mild current should be used, not more than twenty milliamperes ; subsequently, it can be slowly raised until the gal- vanometer indicates thirty-five to fifty milliamperes. This is kept up for from ten to fifteen minutes. The patient need not stay in bed during the progress of the treatment, and, except in extreme cases, she can come to the physician's office to receive it. The applications are made twice a week. An antiseptic vaginal douche should be used every morning and evening. The electrode must, of course, be absolutely clean and should be placed in an antiseptic solution like any other 188 MENOKRIIAGIA AND METKOKEHAGIA. EXTRA-UTEEINE PKEGNANCY. instrument before being used. The number of applications will vary according to the severity of the case. Half the number required to reduce the amount of blood lost to normal proportions must be given to produce permanent relief. The treatment is suspended for a week during menstruation, but if the flow has not ceased at the end of that time, it is resumed. In some cases, where there is an incessant flow, there may be some difficulty in knowing exactly what is the proper date for menstruation, but by closely questioning the patient it will generally be found that in one week out of every four the loss is greater than at any other time, and this may be taken as the normal time for menstruation. As a rule, no improvement begins until several applications have been made, and then the flow diminishes rapidly. With a current of twenty milliamperes, properly applied and slowly raised, the patient feela little, if any pain. The sensitiveness of the uterus, which is present at first, usually goes off after the first two or three applications (J. E. Parsons, Lancet, 1901, vol. 1, p. 547). Intra-uterine Applications. — -The application of caustics to the interior of the uterus during the intermenstrual periods is often of great service in controlling uterine hemorrhage, and of these caustics nitric acid is the best. Before using it the vagina must be carefully protected with gauze packed around the cervix. It is best to use a cylindrical speculum, which fits snugly around the cervix, and pass up the fuming nitric acid on a pledget of cotton by means of an applicator to the fundus. Great care must be taken to avoid any excess of the acid, and the applicator must be immediately withdrawn. Surgical Measures. — Operative procedures are far more often indicated in the treatment of menorrhagia and metrorrhagia than in dysmenorrhea or amen- orrhea,, for many cases of uterine hemorrhage are due to grave organic disease which requires surgical measures for its relief ; moreover, the effects of frequent or prolonged loss of blood upon the general health is serious enough in itself to call for operative interference in some cases. The only operation for the relief of uterine hemorrhage which comes within the scope of this work is curettage of the endometrium. This is a simple measure, easily per- formed, and giving excellent results in a large number of cases, provided care is exercised in the selection of suitable cases and in the performance of the operation. It frequently happens that the general practitioner is called upon to perform it for the relief of uterine hemorrhage, and also for the purpose of ascertaining the nature of the disease present from an examination of the scrapings. Whenever the general practitioner discovers, or has reason to sus- j)ect that his patient is suffering from malignant disease of any kind, it is his duty to refer her at once to a specialist, no matter what may be the inconvenience or discomfort to her or her relatives, nor how plausible the rea- sons for delay. Fibroid tumors, also, in some cases, demand radical meas- ures for their relief, but there are many cases of uterine hemorrhage associated with abnormal conditions of the endometrium, such as retained products of conception, endometrial hypertrophy, endometritis, submu- SURGICAL TREATMENT OF UTERINE HEMORRHAGE. 189 cons fibroids, or polypi, in \v]ii(']i curettage is beneficial, and often effects an entire cure, if not at once, within a few months, and possibly after one or two repetitions. The operation is one of such simplicity that its performance is quite within the province of the general practitioner, under due precautions, and therefore I give a description of it in detail. Method of Curettage. — The patient is prepared and cleansed, and the uterus dilated according to the directions given for dilatation in Chapter IV (see p. 122). The serrated, sharp, perforated spoon curette (see Fig. 52, p. 123), poised between the thumb and the first and second fingers, is then easily introduced into the dilated canal. The whole inner surface of the uterine cavity from the fundus to the cervix is next carefully scraped, the superficial portion of its lining membrane being removed in strips and short pieces. The healthy basis is recognized by the greater resistance and by a slight grating sensation communicated to the fingers. The separated lining membrane is expelled through the cervix by means of a series of intermittent contractions and the discharge may also be assisted by using the curette to scrape it out. The hemorrhage from this operation is never sufficiently severe to call for meas- ures to control it. Some persons are in the habit of introducing gauze into the uterine cavity, but it has never been my custom. The patient should be kept in bed for from three days to a week. Before I leave the subject I should like to say a word of caution in regard to the danger which accompanies curettage, if it is not attended by the same care and vigilance practiced in every surgical procedure, and especially those requiring an anesthetic. If the uterus is soft or the condition of the body wall pulpy and like wet blotting paper (a condition not to be recognized by any digital examination) then the curette or the sound may pass directly through the uterine wall into the abdominal cavity, and, in a septic case, set up a virulent peritonitis. In order to avoid this contingency, the operator must guard against using much force, the curette must be handled with the greatest gentleness and should never be pushed against the uterine wall. If the instrument should perforate the wall, it must not be reintroduced ; a drain should be inserted, and the patient put to bed and watched. If the case is known to be septic, and the curette passes through the uterus, the abdomen should be immediately opened, the area excised, and the opening closed with catgut. W. Hessert (Amer. Jour. Ohst., 1905, vol. 51, p. 26) has collected from the literature a number of cases in which the uterus has been perforated during curettage and gives the following general principles which should be observed in order to avoid such an accident: (1) Make an accurate pelvic diagnosis, as to size, position, mobility, and consistency of the organ. Determine the presence or absence of tumors upon or within the organ. Observe, if possible, its contractility. Determine the condition of the adnexa and the possi- 190 MENORRHAGIA AND METRORRHAGIA. EXTRA-tTTERlNE PREGNANCY. bility of pus tubes, ovarian tumors, pelvic abscesses, and the like. In other words, get as clear a picture as possible of the pelvic organs. (2) In curetting post-partum, bear in mind the possible extreme fria- bility of the uterus. The cervix should be amply dilated -to admit the finger. The direction of the cervical canal and the uterine cavity should be accurately determined l)y means of a graduated sound. The question of angu- lation backwards or forwards should be known before introducing dilators^ especially Goodell's. Disregard of this precaution has been the cause of most perforations made with Goodell's dilators. Avoid the ratchet and screw, but use the hands in dilating carefully. Dilate slowly, so as not to split the cervix, meanwhile turning the instrument around to all points of the circle. (3) A sharp curette is best for the purpose. Be careful in the use of the placental forceps in pulling down anything which may be felt in the uterine cavity, as it may be omentum or gut. ISTever use a volsella forceps for this purpose. (4) Except in the presence of septic endometritis the use of the irrigator is generally superfluous. If it is used, a non-toxic solution, such as boric acid, should be employed. Avoid strong solutions, such as sublimate. If there is the least suspicion of perforation, omit all irrigation. The injection of caustics, such as liquor ferri chloridi, tincture of iodine, chloride of zinc, etc, is not without danger, and should be employed only where there are special indications. Any condition causing atrophy of the uterus is one which, by ren- dering the uterus unduly friable, is likely to result in perforation. The local conditions associated with uterine atrophy are: carcinoma, myoma, pel- vic tuberculosis, pelvic abscess, recent abortion, and others. The general or constitutional conditions accompanied by atrophy are leukemia, diabetes, nephritis, Addison's disease, tuberculosis, pernicious anemia, and the acute infectious diseases. Curettage for Remnants of Abortion. — Curettage for the removal of a dead ovum or the remains of an incomplete abortion requires a few words of special direction, because of the danger arising from the readi- ness with which sepsis may invade the upper genital tract in the presence of either of these conditions. In cases which are already septic, the avoidance of a general infection and the safety of the patient depend upon the complete removal of the ovum and the establishment of artificial drainage through the dilated cervix. There is no way by which a septic uterus can be thoroughly disinfected. Cases which are not septic will not become so, if the operation is aseptically performed and the aseptic conditions maintained afterwards. In curettage shortly after an abortion has taken place, the anterior cervical lip is caught with a tenaculum forceps, a blunt spoon curette is introduced, and used with gentle force over the whole surface of the uterus, loosening and bringing down the membranes, which begin to pour out of the os. Undue force must not be used, lest the curette perforate the softened uterine wall and pass into the abdominal cavity, exposing the j)atient to the imminent risk of a septic CURETTAGE FOR REMNANTS OF ABORTION. 191 peritonitis. I have known a case in which curettage was performed two and a half months after an early abortion (three weeks) in which several blocks of firm whitish material were removed from one side of the uterus, when, without the use of any force whatever, the curette suddenly perforated the fundus. After loosening the membranes with the curette a pair of fenestrated placental forcej)S is inserted, which brings away the placenta, the decidua, and the fetus, if it has not been previously expelled, whole or in pieces. When the canal is large enough, as is usually the case in a miscarriage after the third month of pregnancy, the index finger, well sterilized, should be inserted and the whole interior of the womb palpated. Unsuspected pieces of tissue may be found clinging to it, especially in the placental area. These can be freed by the palmar surface of the finger, assisted by the external hand acting through the abdominal walls and affording a point of resistance. The uterine wall, thus bared in places, feels almost as thin as paper and must be gently handled. When curettage is difficult and uncertain, the entire separation of the remains of the ovum may be effected by the finger alone, assisted by the hand making counter-pressure through the abdominal walls. The finger-nails must never be used to scrape off tissue from the uterine walls, as such a practice would often introduce sepsis, and if the case is already septic, the operator would be sure to carry infection away with him to inoculate other patients. Irrigation of the uterus after curettage for abortion is not necessary, unless the contents are septic, when the cavity must be repeatedly washed out with a warm boric- acid solution, introduced by means of a curved glass douche nozzle, the blunt end of the nozzle being used to aid in detaching clots and small particles of debris. The uterus may be drained for forty-eight hours by packing its cavity loosely with gauze, the ends of which are allowed to hang out of the cervix into the vagina ; my own practice, however, is simply to place a loose pack in the vagina, which is renewed every twenty-four hours. Patients should be kept in bed for two weeks or longer after curettage for abortion, in order to allow involution of the uterus to take place. Care of the patient is just as important at this time as in the puerperium after a normal labor. Examination of Scrapings Removed by Curettage. — The scrapings from the endometrium should always be examined, for they afford reliable evidence as to the nature of the condition underlying the hemorrhage. The following conditions should always be looked for : ISTormal uterine mucosa. Acute endometritis. Chronic endometritis. Decidual endometritis. Mucous polypi. Remnants of abortion. Tuberculosis of the tubes and ovaries. Carcinoma of the uterus, body and cervix. Sarcoma of the uterus, body and cervix. 192 MENOERTtAGiA AND METROHEHAGIA. EXTEA-UTEEINE PEEGNANCT. The fovinaliu method of preparation, fire^l introduced by Dr. T. S. CuUen {Johns Uopl'ins IIosp. Bull., April, 1895), and later by Pick, is the best, as it obviates the tedious delay incident to the older methods of preparation and permits a diagnosis to be made, in case of necessity, with a competent pathol- ogist at hand, within tifteen minntes. The procedure is as follows: (a) Place frozen sections of the fresh tissue in a five per cent aqueous solu- tion of formalin for from three to five minutes. (b) Immerse in fifty per cent alcohol for three minutes. (c) Place in absolute alcohol one minute. (d) Wash in water. (e) Stain in hematoxylin for two minutes. (f) Decolorize in acid alcohol. (g) Rinse in water, to which has been added two or three drops of am- monia, which rapidly brings back the characteristic hematoxylin color. (h) Stain with eosin. (i) Transfer to ninety-five per cent alcohol. (j) Pass through absolute alcohol, creosote, or oil of olives, and mount in Canada balsam. When it is not of the first importance to save time, finer sections may be obtained by CuUen's second method, in which the tissues are first hardened in formalin, as follows: The sections are placed immediately in a ten per cent solution of formalin, kept in small bottles always at hand. Within three or four hours they are sufficiently hardened to cut readily, when frozen sections are made and left in a fifty per cent solution of alcohol for three minutes, after which the succeeding steps are taken as before described. Curetted specimens must always be placed in a bottle by themselves and labelled at once with the patient's name and the date. When the sections are cut, no similar open dishes containing other specimens should be lying about, nor should sections under consideration be passed through the fluids together with other sections, in order to avoid the terrible mistake of confusing the two cases and so leading to erroneous conclusions. Serious mistakes have followed the mixing of specimens, jSTormal Uterine Mucosa. — The standard for comparison from all curetted specimens is the normal uterine mucosa ; this presents, microscopically, an even surface covered by a single layer of cylindrical ciliated epithelium. The glands are round or oval-shaped on cross section, and in a few places they may be seen to open on the surface. They are usually equidistant and are lined with one layer of cylindrical ciliated epithelium. An occasional bifurcation is seen in the deeper layers of the gland. Lying between the glands is found the stroma of the mucosa or so-called lymphoid tissue. . The cells, however, are much larger, and on close examination bear no resemblance to lymphoid tissue ; the nuclei of the stroma cells are oval, vesicular, and appear to best advantage in specimens hardened in Miiller's fluid. The arteries of the stroma are usually CONSTITUTIONAL TREATMENT OF UTERINE IIEMOKEHAGE. 193 found in small bunches ; the veins are large, single, and thin-walled. The blood in the veins is separated from the stroma cells by one layer of endothelium. The line of demarcation between the mucosa and the muscle is usually well-defined ; occasionally, however, a gland penetrates the muscle for some depth, when it is invariably accompanied by a considerable amount of stroma. This dipping of a gland in the muscularis must not be mistaken for a pathological condition. The appearance suggestive of malignant disease, whether carcinoma or sarcoma, will he found described in Chapter XXI (see p. 527). The other conditions in regard to which conclusions can he drawn from the exam- ination of curettings will be found under their separate headings in the diag- nosis of monorrhagia. Constitutional Measures. — Under this head come those measures which may be employed to remove the constitutional causes underlying certain cases of uterine hemorrhage. Cardiac and hepatic disease are both sometimes associated with monorrhagia, or metrorrhagia, or both, and when this is the case the relief of the underlying cause will relieve the local hemorrhage. In cases of cardiac derangement, digitalis in tonic doses, ten to fifteen drops, three times daily, is frequently of great benefit. After the heart's action has been improved, strychnin and arsenic are of value. A marked rheumatic diathesis must receive appropriate treatment as well as anemia or scurvy. Tor hepatic derangements, calomel is usually indicated, with attention to diet, exercise, and general hygienic measures of every kind. General Suggestions. — In conclusion, the following suggestions may be made as to the treatment of uterine hemorrhage in general: If the hemorrhage is due to the retained products of conception, to hypertrophy of the endometrium, endometrial polypi, endo- metritis (acute or chronic), submucous myomata, or decidual en- dometritis, curettage is certainly indicated, and will afford relief in a large proportion of cases. It is better to resort to this measure as soon as the diag- nosis is clear than to wait to try a long course of topical treatments which rarely, if ever, do any good. It must always be remembered that it may be necessary to repeat the curettage several times. Should curettage of the endo- metrium reveal the presence of can'cer, sarcoma, chorio-epithelioma or extra-uterine pregnancy, the patient must be at once referred to a specialist, no matter what difficulties, real or imaginary, are put in the way of such a course. Cases of subinvolution or inversion of the uterus, interstitial or sub-peritoneal myomata, sclerosis of the uterine vessels, or corpus luteum cysts, should also be sent to a specialist, although there is not the same pressing need for haste as in the cases mentioned above. Fibroid tumors giving rise to uterine hemorrhage must be differ- ently 'treated according to the indications in each individual case; these are discussed at length in Chapter XX. Uterine hemorrhage due to constitu- tional or vascularcauses is distinctly the work of the general practi- tioner and must receive his most careful attention. The indications for treat- 14 194 MENORRHAGIA AND METRORRHAGIA. EXTRA-UTERINE PREGNANCY, ment in such cases belong to the works on general medicine in whicli the conditions underlying the uterine hemorrhage are discussed. It is greatly to be desired that physicians in general should make this class of patients the object of their careful study, for they are more likely to be benefited by the attention of the general practitioner than that of the specialist. EXTRA-UTERINE PREGNANCY. History. — Few subjects in the whole range of his ^^ractice excite so lively an interest in the general practitioner as extra-uterine pregnancy. Of all the mysterious processes of life, the most mysterious is that an ovum can become fertilized and gTow on ground foreign to its normal development. Xatural interest in this extraordinary phenomenon is great and it is enhanced by the fateful possibilities of the situation as well as the tragic outcome which may, at any moment, determine a doubtful diagnosis and rob the poor victim of life. For these reasons, and because such cases fall, in the first stage, into the hands of the family physician in the majority of cases, it is important that he should know something in detail of the course of such pregnancies not interrupted by the surgeon ; of the methods of their diagnosis ; and of the j)i'oper means for their relief. Extra-uterine pregnancy was once thought to be extremely rare, but it is now known to be comparatively common. There are few jDhysicians who have been ten years in practice without seeing at least several instances, sometimes in a single year. Veit has shown that many of those cases of irregular menstruation associated with colic, which pass off without special treatment, or with a little watchful attention on the part of the physician, are, in reality, a relatively mild ending to an extra-uterine pregnancy. For this reason, as we can readily see, all deviations from the norm during pregnancy ouglit to excite the liveliest attention on the part of the responsible medical attendant. It may be said then that extra-uterine pregnancy in its early stages belongs to the general practitioner ; as soon as the diagnosis is made, however, the case should at once, as a matter of propriety, be transferred to the domain of the surgeon. If it were possible, it would be best for the patients if all cases could be classified as surgical from the outset. As to the promptitude with which this transfer is effected from the purely medical to the purely surgical domain, it is interesting to note that the experience of one case is sufficient to quicken the diagnostic powers to such a degTee that subsequent cases are detected much earlier, and in consequence subjected to a relatively earlier appropriate radical treatment, which is always operative and extirpative. In order to grasp his subject properly, the general practitioner must be familiar with the causes of extra-uterine pregnancy, with its course if left alone, and with the various diagnostic signs, which we will now take up. An extra-uterine ovum may lodge in any one of the six places indicated in ETIOLOGY OF EXTEA-TJTEEINE PREGNANCY. 195 Fig. 65. — Various Sites of Implantation of THE Ovum in Extra-uterine Pregnanct. 1, ovarian pregnancy; 2, implantation upon the tubo-ovarian fimbriae; 3, implantation within the fimbriated extremity of the uter- ine tube ; 4, attachment of the ovum in the ampulla; 5, isthmial attachment; 6, inter- stitial implantation. Kgnre 65, proceeding from within outwards: (1) in tlie ovary; (2) in the tubo-ovarian iinihria; (3) just within the grasp of the tubal fimbria; (4) in the ampulla; (5) in the isthmial or narrow part of the tube; (6) or, finally, in the interstitial portion of the tube, where it traverses the uterine wall. The commonest of these sites is the ampulla implan- tation and the next com- monest the isthmial. The interstitial form is rare and of the ovarian only a few examples have ever been seen. Etiology. — There is no one cause which can be said to be commonly operative in extra-uter- ine pregnancy, and this is only what we might reasonably expect from our knowledge of pregnancy in its early stages. The spermatozoa meet and fructify the ovum at or near the ovary, and it is the function of the uter- ine tubes, which have afforded the spermatozoa an avenue of access from the uterus to the ovum, to transmit the ovum in turn to its proper resting place in the uterus. The small spermatozoa travel up the uterus and down the tube by their own active propulsive movements, while the larger ovum must be swept towards the uterus, through the ampulla of the tube, p-ast all the tubal folds, into the narrow isthmus, and so through the interstitial portion of the tube into the uterus, where it commonly lodges near one cornn. An extra-uterine pregnancy is brought about by any cause whatever which tends to hold the ovum back until it is too large to travel further down the constantly narrowing tube. Let us note categorically, and with but brief dis- cussion, what these efficient causes may be: 1. Adhesions may bind the tube down, or bands may cut across it, so as to produce an ileus, as it were, preventing the propulsion of the ovum, while not necessarily hindering the spontaneous movements of the spermatozoa. This is the oldest view and undoubtedly the obstruction operates in many cases, though it must be borne in mind that many of the adhesions and inflammatory changes seen at an operation have occurred after the pregnancy and not before it; therefore they cannot be reckoned among the causes in a particular case. 2. Tumors of the tubal mucosa have been noted as plugging the lumen of the tube, accounting for the obstruction in a few rare in- stances. Fibroid tumors at the uterine cornu, distorting and block- ing the isthmial portion of the tube, have been found occasionally. 196 MENOKRHAGIA AND METROKRHAGIA. EXTEA-UTEEINE PREGNANCY. Fig. 66. — H., Church Home, January 23, 1903. Pregnancy in the ampulla in which a striking feature is the presence of the cyst lying under the tubo-ovarian fimbriEe. Hemorrhage to the amount of about 1^ liters into the peritoneal cavity. Operation. Recovery. Nine-tenths natural size. (Case of T. S. Cullen.) 6, A long, narrow, winding tube of tlie 3. A tubo-ovarian cyst, by distorting the tube, may sometimes act as a cause. (See Fig. 66.) 4. Inflammation of the tubal mucosa by which its cilia are destroyed, has been noted also, though, as Bumm remarks, this view pre- supposes the presence of enough cilia to carry the ovum to its lodging place. 5. Diverticula in the tube sometimes serve to catch and lodge the ovum, wrap- ping it around as it were. These diverticula, however, are so commonly found in normal tubes, that it is evident some other cause must first act to retard the progress of the ovum before it slips into the diverticulum, fetal type is undoubt- edly the cause in some cases. 7. The migration of the ovum into an atretic tube. The sper- matozoa enter by a patulous tube and fertilize the ovum, Avhich then passes over into the opposite atretic tube. (See Fig. 67.) 8. Many extra-uterine ova contain monstrous fetuses ; in such cases the size of the ovum must act to hinder its advancement and so cause a tubal implantation. It will be seen from these facts that not one, but many causes are continu- ally acting to make extra-uterine pregnancy a common ailment in every com- munity. The determination of the cause in any given case can only be made, if at all, at the operating table, or rather after the operation in the pathological laboratory. Even then, with every possible advantage afforded by clinical his- tory, a careful operation, and the benefit of numerous microscopic sections, it is often impossible to say why the extra-uterine pregnancy occurred. The only aid the practising physician can derive from the operation is the knowledge derived from statistics that there is a peculiar liability on the part of those women who have had one extra-uterine pregnancy to have another. All of our extra-uterine pregnancy cases ought therefore to be watched with a peculiar solicitude lest they become pregnant again, and if they do become pregnant, lest it turn out to be an ectopic growth. The accidents which may happen to the ovum in an extra-uterine pregnancy are many. It practically always ends its existence by a violent death, caused by S' 4) +-■■ O I- 52 ^ ^^ g^-^- S -rt "~ aJ ai "^ C " r^ fl— ' jqq' O o -p -H (U !2 >-. !- MpS TS O 3 g+^_g 2^ S 5 g PT3-S M3 > O 3 aj hS a o 03 V- <- O J)- tH C Q< 5 2 "3 _2 .s -^ C T.i^ "^ *^ *^ "a S ^ (D C P^ C-^ „ aoj 03-" 3 ■Jf aj ce g S'fl " C o => S.2 E^ oj 03 rt g £ S a) Cl fc a; 3 t, Q .2 ^, O § 2 rt Y y 01 G aj ,^3 KPryjajOgJjCltD CL iS"'-^ "oj aj i- ^ ^ :; ' -S 2 ^ C "S - T^ "^ K L- d 198 MENOEEHAGIA AISTD METEOEEHAGIA. EXTEA-UTEEIXE PEEGNANCY. the rupture of its containing sac (see Fig. 68), or bj a tubal abortion, by which it slips out of the sac into the peritoneal cavity. (See Figs. 69 and 70.) Sometimes the ovum, encapsulated in a surrounding hemorrhage, deprived of its nutrition, dies, and shrinks into an innocuous hard nodule in the tube; this termination is unusual. Only in the rarest instances, once out of thousands of cases it may be, does the extra-uterine fetus go on developing to term. Then false labor pains come on, and if the condi- tion is not recogTiized and the babe removed by an ab- dominal section, it dies and becomes mummified in the midst of the intestines, to undergo changes resembling Fig. 68.— R. W. U., Aror.ST 17, 1903. Gi-x. No. 10672. The iliGHT Uterixe Tube is seen to be the Seat of ax Ex- TRA-UTERIX-E PrEGXAXCY, -milCH HAS RuPTURED, DlS- CHARGix'G Blood ixto the Peritoxeal Cavitt. The Seat of Rupture is Plugged by Clots axd Villi. adipocere later on; or, in- cased and infiltrated with lime salts, to form a lithopedion or stone child. Although the fetus is apparently thus satisfactorily disposed of, it is not and never can become a safe giiest, as long as it is harbored in the body. It is likely Fig. 69. — Extra-uterix'e Pregx'axcy; Tubal Abortiox. The bleeding is checked by a large coagu- lum distending and thinning out the tube; the fimbriated opening is greatly distended, but the greater diameter of the clot in the ampulla prevents its escape. Wall of tube averages 1 mm. in thickness. Operation. Recover^-. Jtily 7, 1896. Natural size. at any time to cause an intestinal obstruction through adhesions, or to set up an inflammation which only ends when it has been discharged bone by bone from the rectum, the bladder, the vagina, or through the abdominal wall, it may be years afterwards. DIAGNOSIS OF EXTRA-UTEKINE PBEGNANCT. 199 Diagnosis. — The diagnosis of an extra-uterine pregnancy in the early months is almost always made after the rupture of the sac; it is not difficult to make, if the striking set of signs which I will enumerate categorically, with brief annotations, are borne in mind. 1. There has been a cessation of menstruation, perhaps one or two periods, or the patient may have gone but a few days or a week over the time. 2. Nausea and other changes which the patient is accustomed to as- sociate with an early pregnancy are noted as the weeks pass by. Fig. 70. — CVjaglum Iik-Nld ()i i — Showing a cast of the tube extending up into the isthmus. On its surface lies the fetus. Natural size. 3. The patient thinks she is pregnant, but is inclined to believe there is something wrong or unusual with this particular pregnancy. 4. Recurring pains in one side are often noted. 5. A sudden attack of agonizing pain sometimes constitutes the first symptom. This may come on in sleep, but it is apt to appear during exertion, as while sitting in the closet, or at work reaching or lifting. 6. With the pain comes collapse and the sudden develop- ment of extreme and increasing anemia. 7. Sighing, gasping, respiration which is rapid and small mark the worst cases. 8. If the patient survives her first attack, she suffers at 200 MENOEEHAGIA AND METKOEEHAGIA. EXTEA-UTEEINE PEEGXAISTCT. intervals from repeated similar ones, with irregular uterine discharges. Objectively, the physician sometimes (but not always) notes: 1. The blue or cyanotic vagina, so indicative of pregnancy. 2. An enlarged uterus, as big as a two months' pregnancy, rarely larger. 3. A tumor, at the side of or behind the uterus but always more or less one-sided, which is peculiarly sensitive to touch. ■i. If the sac has ruptured, the blood poured out causes the tumor to grow rapidly, increasing with each successive severe pain and coincident hemorrhage. Sometimes the lower abdominal wall shows a boss as big as a fist. To the vaginal touch the tumor feels peculiarly boggy and lacks the well-defined outline of other tumors, or the hardness of in- flammatory affections. If there is no rupture, nor escape of the ovum or blood through the fim- briae of the tube, then the fetus dies and the sac shrinks, while under an ob- servation extending over two or three weeks. This is a rare finding and ought never to be waited for. The breasts show milk as the pregnancy goes on developing. The patient often declares that she has passed a shaggy skin-like structure (decidua), or, more fortimately, keeps it to show to the physician and ask his opinion as to its nature. The decidua may come away in shreds, or it may be found only on curetting the uterus ; this should always be done in a case of uncertainty. The finding of decidua, or the passing of a decidual cast in the presence of a uterine tumor, practically settles the diagnosis. The anemia is often so profound that the patient is almost undistinguish- able from her own bed sheets. The pulse is tiny and thready, or may even have vanished at the wrist. There is little or no fever until the clots become infected. Xot all of these signs must be expected in any one case ; indeed, the picture is rarely a complete one. A few are sufiicient for practical purposes, of which the most important are : Presumptive evidence of pregnancy. A sensitive tumor at the side of the uterus. The fact that the uterus contains no ovum. Attacks of severe abdominal pain. Four conditions are liable to be confused with extra-uterine pregnancy, namely : [N^ormal pregnancy. An ordinary uterine abortion. Salpingitis and pelvic inflammatory disease. Appendicitis. EXTEA-UTEKINE PEEGNAISTCY ANB NORMAL PKEGWAlSrCY. 201 EXTRA-UTERINE PREGNANCY AND NORMAL PREGNANCY. It is sometimes difficult to distinguish between an extra-uterine and a nor- mal pregnancy, and in some cases it may not be possible to make a correct diag- nosis at once. It is not, of course, in those cases of extra-uterine pregiiancy which run a thundering course, where the patient is seized with an agonizing pain, falls in collapse and rapidly becomes anemic while engaged in common domestic duties ; it is not, I say, in these cases, but in the more quiescent ones, that a mistaken diagnosis may occur. If the symptoms are of only moderate intensity, the physician may be lulled into thinking that per- haps after all he is dealing with nothing more than a regular pregnancy with some slight deviations from the normal. In every case where there is serious doubt, it is best to keep the patient under close observation, to keep her quiet and to examine more than once, then, if the doubt is not cleared up, her bowels should be well emptied and a thorough examination made under complete anesthesia. We have in both conditions a like cessation of menstruation, with nausea, and a presumption on the part of the patient that she is pregnant. A local exam- ination, too, reveals some enlargement of the uterus, and in the early months it may often be difficult to say whether the womb is just large enough for the period of pregnancy or not. When there are no further signs than these, we cannot even suspect an extra-uterine pregnancy. In order to arouse suspicion there must enter into the clinical history certain added elements: (1) severe pain in the lower abdomen, (2) a repetition of such attacks of pain, (3) the strong suspicion on the part of the patient that all is not right, (4) marked tenderness, (5) a uterus which is not duly developed if the pregnancy has gone beyond the third month, (6) a lateral tender mass. Often the free, repeated vaginal, bloody discharges leave the practitioner in no doubt, but that if the case is one of a uterine pregnancy, it must inevitably terminate in abortion. He will then feel free to act promptly by anesthetizing, curetting the uterus and making a careful bimanual examination through the rectum, in this w^ay clearing up the diagnosis. The task of deciding between the two conditions, extra-uterine and intra- uterine, differs materially according as the pregnancy is early or advanced. In an early pregnancy we look for evidences of a mass at the side of the uterus with hemorrhage, and more or less profound systemic disturbances in« the extra-uterine condition, as contrasted with the absence of any mass or clots accumulated in the pelvis, with a uterus lying within the pelvis which is more or less softened and enlarged to correspond to the month in a normal preg- nancy, while in an advanced normal pregnancy with a living child, the evi- dence for an extra-uterine condition lies almost always in the distinctness with which the parts of the child can be felt through the abdominal walls. Pregnancy Mistaken for Extra-uterine Pregnancy. — I have seen a great many cases of this sort. I had one myself about twenty-five years ago, the woman 202 MElSrORKHAGIA AND METKOKKHAGIA, EXTEA-UTEKIXE PKEGISTANCY. who had had several children became pregnant, and experiencing some sharp pains on the left side came to me for examination. I found a uterus which seemed to me to be not much above the normal size, and a well-defined tnmor to the left. At the operation, the tumor was discovered to be a large cystic ovary, while the uterus was duly enlarged to correspond to the third month of preg- nancy. The cyst was removed and she recovered and had a child in due time per vias naturales. A more attentive examination under anesthesia would have saved the error. These cysts are so characteristically globular and thin walled and can, as a rule, be felt so readily connected with the ovary, that they ought not to be confused with any other condition. Again a mistake of this kind must be guarded against. In the early months of pregnancy the cervix maintains its integrity, while the uterine body often becomes remarkably softened and it may be flaccid so that it seems at the first touch to be entirely independent of the cervix, and rather like some boggy tumor lying near by. In such a case the examiner catches the cervix and draws it down until he feels its upper end, which, if it is a long cervix, he may readily mistake for the fundus of a small uterus, the natural inference then is that the ill-defined mass beyond is an extra-uterine pregnancy. Such a mistake will not occur if the examination is made under an anesthetic and the direct organic connection between the cervix and the mass above more carefully studied. Again a pregnancy may be mistaken for an extra-uterine pregnancy when the ovum lodges in one uterine cornu, and this softens remarkably as the preg- nancy advances, while the opposed half of the uterine body remains hard. I have seen this condition repeatedly during the past twenty-five years and watched it gradually disappear as the pregnancy advanced into the fourth or fifth months. Dr. R. L. Dickinson has called particular attention to it in a paper published. The condition is a most puzzling one when seen for the first time, resembling either an extra-uterine pregnancy pure and simple or an interstitial ovum developing in that portion of the uterine tube which traverses the uterine cornu, or again, a j^i'egnancy in one horn of a bicornuate uterus. An examination per rectum may only serve to confirm the suspicion that the pregnancy is ectopic. Added to the surprising anatomical facts is the additional one that the condi- tion is often associated with much pain in the sac. If, however, the examiner is well on his guard, he will recognize by a rectal examination under anesthesia that the softish mass occupies exactly the position of one whole side or of the right or left upjDcr corner of the uterus, and at the same time he will notice the extraordinarily broad connection with the remaining portion of the uterus and will correct the erroneous notion formed at a previous examination, that the mass is in any sense really distinct from the uterus. I must confess I don't know just how to distinguish this condition from an interstitial pregnancy, except that interstitial cases seem to be so rare, and on the other hand these cornual cases seem to shade off into those in which EXTRA-TJTEKINE PKEGNANCY AND NORMAL PREGNANCY. 203 the whole of one side is softened. It is yet possible that many of this group are in reality interstitial and subsequently become intra-uterine, in accord with a number of clinical observations made about two decades ago. One of my patients some years ago had so much pain with her condition that although I was tolerably sure of my diagnosis, I opened the abdomen to verify it, when I found a bluish thin-walled cystic mass about 6 cm, in diameter at the right uterine cornu sessile on the firm uterine body. The fetus after- wards escaped per vaginam. Cases of advanced pregnancy mistaken for extra-uterine pregnancy are almost always those with phenomenally thin abdominal walls. The sharply defined limbs of the fetus seem to lie in direct contact with the wall without any intervening tissue. A case of this kind occurred in the wife of a physician from Iowa, unusual in that the one-sided hardening and want of development of the uterus per- sisted well into the fifth month. I examined most carefully and counseled delay, my visitor waited for some time not without trepidation, then he took his wife home and later wrote me of her timely and natural delivery. The general practitioner often finds it hard not to jump at once to the conclusion that he is dealing with a mature extra-uterine ovum. The specialist to whom he brings the case at once makes a careful vaginal or rectal examina- tion, under anesthesia if needs be, in order to answer the deciding question, " Where is the uterine body ? " If the fetus is extra-uterine, it will be a simple task to find and outline a normal uterine body and so confirm the diagnosis. With rare, very rare exceptions the pregnancy is normal and goes on to term and a normal delivery. In several instances patients have come to me because the consultants at home had urged an operation then and there to save the mother's life from imminent peril. I incurred, I fear, the lasting displeasure of two physicians in the Southwest who were more than usually positive and insistent, by venturing to say the child was in the uterus and the pregnancy might proceed unmolested. The event verified the prediction, though it took place in rival hands. There was a case of advanced pregnancy in the practice of the late A. K. Minich, of Philadelphia, which he took for extra-uterine from a vaginal exami- nation, for while he felt the cervix high up and the large fetal head could be distinguished with the utmost plainness in the cul-de-sac low down, a most careful examination showed that this was one of those rare cases of retroflexion of the pregnant uterus persisting almost to the end of pregnancy, that is to say, while the uterine body developed above, a diverticulum remained below in which the head was lodged. At the end of the pregnancy this disappeared entirely, and I attended her later in a normal labor. I saw a case but recently with one of my colleagues. A woman who had never been pregnant ceased menstruating early in July. On September 30th, while sitting in a chair, she was suddenly taken with severe pain in the lower abdomen. Since that time she had been obliged for some ten days to stay 204 ME^^OEKHAGIA A^^I> :\IETEOBKHAGIA. EXTKA-UTEEIK^E PEEGNAI^'CT. I^rettT constantly in bed^ \vitli severe pains. There was extreme tenderness over the abdomen, some pallor associated with localized congestions, tympany, and slight fever, varying from 99° to 100.8° F. The bowels were constipated and there was bearing down. When I examined her I found a more or less diffuse distention of the lower abdomen, and felt the coils of intestine, appar- ently adherent, running over the mass. Vaginal examination showed extreme tenderness and the uterus appeared lost in the mass. There was no vaginal flow. The vagina was discolored- dark. The uterus could not be felt biman- ually on account of the general tenderness, but there was a fulness and resilience at the vaginal vault on all sides. The extra-uterine pregnancy seemed so clear that I sent her to the hospital. On returning I made an incision without further examination, and the pregnancy proved to be intra-uterine and normal, while the pains were undoubtedly caused by strong omental adhesions to the abdom- inal wall. The adhesion was severed and the patient has since done well. The error in the diagnosis would not have occurred if I had examined the patient under anesthesia just before the operation, and this ought always to be done. The error of considering an extra-uterine pregnancy as a normal pregnancy in utero is a far commoner one than the opposite mistake upon which I have just dwelt. Almost all extra-uterine pregnancies are so mistaken in the early months, and this is the cause of many of the tragedies which occur with such a dramatic ending. A patient who becomes pregnant whether intra-uterine or extra-uterine ceases to menstruate, and step by step acquires certain of the signs of pregnancy, such as nausea, fulness of the breasts, discolorization of the vagina, some en- largement of the uterus, the formation of a tumor which can be felt above the symphysis. Until there is some unusual sensation or discomfort or accident, such as pain and hemorrhage, the patient has no reason to think that there is anything wrong with her. When, however, things begin to go wrong and the termination of the pregnancy seems threatened or she falls over in a faint, a doctor is called for and the local examination reveals a uterus which is empty, and a mass situated at one side of the uterus. Associating this with the dis- charge and the history of pain, the physician promptly makes a diagnosis of extra-uterine pregnancy and operates. All these familiar signs are so well known to the average practitioners of to-day, that they only have to be repeated to the successive generations of graduating students to perpetuate the clear teachings of our immediate predecessors who cleared up this difficult field. One sometimes, however, meets with cases which have been strangely neglected in spite of the plainest evidences of an extra-uterine pregnancy. It is important for this reason, in order to rescue more lives from such a sudden and dreadful death, to iterate and reiterate the important signs by which extra-uterine preg- nancy is to be distinguished from normal. Fibroid Tumors Mistaken for Pregnancy. — Fibroid tumors are perhaps the commonest of all major g^mecological ailments, and it is not surprising that occasionally a group of tumors may be found which closely resemble the form of the fetus. At least two such cases have come under my notice, and another EXTEA-UTERINE PREGNANCY AND NORMAL PREGNANCY. 205 lias occurred in the practice of Dr. E. E. Montgomery. Tlie figure in tlie text shows the characteristic appearance and the ease with which the tumors might readily be mistaken for the prominent parts of the child. Again, given an abdomen moderately distended with ascites, such as is occasionally seen in con- FiG. 70A. — A Myomatous Uterus Resembling a Fetus in Its Contour. The enlarged uterus measured II X 13 X 21 cm. The nodule just behind the left ovary might readily have been mis- taken for the head on palpation, and the large one behind the right ovary for the buttocks. The appendages were normal. The right tube apparently emerges from a small myoma. nection with fibroids, and in this a pedunculate fibroid tumor, one may easily recognize the sign of ballottement pushing the tumor back in the fluid, when its pedunculate or hinged attachment causes it to return against the examining finger. In this way one of the most characteristic signs of pregnancy is mim- icked. In both these classes of cases other signs of pregnancy are absent, and an attentive examination will show that there is no real ground for supposing its presence, though in one case a patient had gone so far as to make a wardrobe for the expected infant. The diagnosis may be made between extra-uterine pregnancy and abortion, by noting the passage of an ovum in the latter, and the absence of the lateral tumor, as well as the less intense, agonizing character of the pains. If there still remains a doubt, it is best to examine under anesthesia and to curette the uterus. The danger is far greater of mistaking an extra-uterine pregnancy for an abortion, than of mistaking an abortion for an extra-uterine pregnancy. When the patient is stout and the tumor is a small one, situated in the isthmus ; or when there is a flaccid ovum in the ampulla and the fluid blood is distributed through the in- testines, the greatest expert may not be able to decide immediately just what the trouble is. In cases of serious continued doubt, it is best to make a vaginal or abdominal incision and set the uncertainty at rest. A salpingitis may be accompanied by marked fever and is often bilateral. But even here a pyosalpinx may upset the diagnosis of the most expert practitioner. The symptom commonly lacking is the uterine hemorrhage ; if there is time to wait and curette, there is of course no decidua. A Graafian follicle cyst or a small ovarian tumor may also be the source of an error. 206 MENORRHAGIA AISTE METRORRHAGIA. EXTRA-IJTERIN"E PREGNAKCT. In appendicitis, we have the pain, and the muss extending np into the right iliac fossa ; also the fever and the increased lencocyte conut; but with these signs there is the absence of anything pointing towards pregnancy nor is there a tnmor to the side of the womb. It is an old diag-nostic measure, and one of value, to use a small aspirating needle to puncture the vaginal vault and withdraw some of the dark fluid blood. He who has done this in the presence of a tumor and the pains in a case of presumptive pregnancy can afford to be very wise and very positive as to his diagnosis ! ISTeed I caution the physician to treat the little expedient with the same care as to asepsis as he would a major operation ? Treatment. — If the patient has been suddenly smitten down with severe ab- dominal pain and hemorrhage, if there is evidently some kind of a mass in the pelvis while she is markedly anemic, it is best to consider the diagnosis while getting the instruments out of the kit to open the abdomen and stop the hemor- rhage. There should be no academic discussions under such circumstances, for such cases brook no delay, and he who acts or secures action most quickly will save the most lives. It is self-evident that in the pres- ence of bleeding which will eventually destroy life, every minute is precious. While summoning surgical aid in cases of hemorrhage, the physician should enjoin absolute rest, flat on the bed, with the legs and arms evenly bandaged from the toes and fingers up to the trunk to keep the blood in the body. The foot of the bed should be elevated from ten to eighteen inches, to keep the blood more in the heart and head. It is best not to give cardiac stimulants; dig- italis especially ought never to be used. Most important of all remedies, as a rule, is the infusion under the breasts, of one thousand cubic centimetres of a normal saline solution six-tenths per cent; that is to say one made up with a small teaspoonful of table salt to the pint of warm water passed slowly in by gravity through a large cannulated needle from a fountain syringe. It is well to consume about half an hour in this operation (see p. 184). To the saline solution may be added twenty to thirty minims of a solution of adrenalin (1:1000). While waiting for surgical aid, much may be done to save time by getting the room ready, and by preparing plenty of hot water, towels, and clean vessels. It is often best to give the preliminary cleansing of the abdomen in bed before administering the anesthetic. The physician must see to it that the patient remains as short a time as possible under the anesthesia, and the surgeon must be ready to begin the operation as she is lifted onto the table. CHAPTER VIII. CONSTIPATION. HEADACHE. INSOMNIA. OBESITY. (1) Constipation: Definition, p. 207. Effects, p. 207. Act of defecation, p. 208. Etiology, p. 212. Frequency, p. 213. Diagnosis, p. 214. Treatment, p. 216. (2) Headache: Frequency, p. 224. Etiology, p. 224. Diagnosis, p. 229. Treatment, p. 229. (3) Insomnia: Frequency, p. 238. Etiology, p. 238. Treatment, p. 239. (4) Obesity: Definition, p. 244. Etiology, p. 244. Treatment, p. 245. Adiposis dolorosa, p. 248. CONSTIPATION. Definition. — Constipation is the infrequent action of the bowels, in conse- quence of which the waste products of the intestinal tract are retained for periods of one or more days beyond the normal. Habitual constipation may also be defined as a sluggish habit of the body, in which the bowels fail to respond to the presence of the fecal matter, which should excite a desire for evacuation as it is propelled into the rectum. It is one of the commonest ab- normal conditions with which the physician has to deal, and is the cause of much ill-health and discomfort in women. Effects. — In constipation, nutrition and metabolism are interfered with and serious circulatory disturbances arise from the choking of the in- testinal tract; from the copremia (constipation anemia) caused by absorp- tion of the poisonous retained products; and from the local stasis in the hemorrhoidal vessels, which may be continued up into the portal system and into the liver. Patients habitually constipated are apt to show it in their faces: a muddy complexion in young girls, often associated with facial acne, is characteristic of constipation. Constipation is also apt to be manifested in the temper, which is melancholic, and also in the listlessness, which takes the place of energy. The mechanical circulatory disturbances and the poisonous products reab- sorbed from the lower intestinal tract have often a pronounced effect upon the digestion, inducing, apparently, a sluggishness in the upper intestinal tract, with gas, belching, and loss of appetite. In a word, so long as a pronounced constipation is the habit of the body, all the organs are bathed daily in blood rendered impure by the absorption of fecal products, and the consequences are usually those which might be legiti- mately expected. It would be interesting and important to determine how far a habit of constipation may be responsible for the slow evolution of far graver diseases of the organs of the body cavity and of the brain. 207 208 COIirSTIPATION. HEADACHE. INSOMNIA. OBESITY. The local expression of constipation in women is often pronounced. In the first place • the retention of feces in the rectum, especially in that part which, lies back of the uterus, above " the third sphincter," frequently gives rise to colicky pains in the pelvis which are easily mistaken, as are the tender masses themselves when felt through the vagina, for diseased ovaries. I once opened an abdomen thinking I had an acute recrudescence of a pelvic peri- tonitis, to find nothing but a mass of unchewed, undigested beans in the rectum in this situation. The pelvic stasis produced by the constipation is not only the cause of the hemorrhoids readily seen at the anal orifice, but of a similar dilata- tion of the venous channels in direct communication with them above. This pelvic congestion makes itself felt in a sense of weight and bearing dovni, referred to the pelvis at large, and it may also be responsible for the large varices seen in the broad ligaments on opening the abdomen. To this local stasis some authors of repute refer certain cases of endometritis. A marked and a misleading sensitiveness is apt to characterize the organs involved in it. Backache of the sacral form is a common feature. ]^ot a few cases of dysmenorrhea in young girls are due to habitual constipation and are relieved when a daily action of the bowels is established. Constipation is commonly associated with many pelvic ailments, and is often a source of trouble after abdominal operations. To realize the whole bearing of constipation upon the health of the indi- vidual, it is necessary to have some definite knowledge of nature's scheme for the evacuation of the bowels as the completion of the whole process of digestion. The process of digestion attains completion in the large intestine, and by the time the food reaches the rectum all the nutritious material which can be assimilated has been absorbed, almost all the liquids have been taken back into the system, and nothing remains but an indigestible residuum, connnonly known as feces. When the normal quantity of food taken into the body cavity daily is estimated, it is evident that the residue remaining after digestion and ab- sorption of the three meals should also be daily removed, if the digestive tract is to be kept open and its functions properly maintained. In a normal condi- tion, the rectum ought to be evacuated once in twenty-four hours, and the whole structure of the intestinal tract is arranged to further this end. The peristaltic action of the muscular coats of the large and small intestines is constantly at work to drive the food onward, while the valves occurring at frequent intervals throughout the intestines are so arranged as to facilitate its downward move- ment. The propulsion of the column of ingestion from the last meal also serves as a powerful stimulus to the intestinal tract beyond to empty itself into the next succeeding portion until the end of the tract is reached, where it should normally produce a desire for an evacuation. Defecation. — Expulsion of the residual mass, which is known as the act of defecation, is accomplished through the relaxation of the sphincter ani mus- cles, aided by the peristaltic action of the intestinal tract above, associated with ACT OF DEFECATION. 209 the voluntary action of the abdominal muscles. We are accustomed to think of such an action as voluntary, because the part taken in it by the abdominal muscles is impressed upon the consciousness, but it really originates in and arises fundamentally from the peristaltic action of the muscular coat of the intestines, which is independent of volition, as shown by defecation taking place under certain conditions without the knowledge of the individual ; for example, it constantly occurs in this manner after the section of the spinal cord. The anatomical arrangements are such that the act of defecation, as planned by nature, should progress as a steady, gentle evacuation of the lower intestinal contents, without any risk of eversion or prolapse of the mucosa. The regular evacuation of the bowels is largely influenced by the character and amount of the food taken into the body. If little food is eaten, there will, of course, be little residue, and if the food is too readily assimilated, it will almost all be absorbed, and there will be little or nothing to pass down into the rectum. It follows, therefore, that a mixed diet, composed of a variety of easily assimilated foods, as well as other kinds which contain sufficient fibrous, inert, and indigestible matters to form a residue, is that best adapted to the regulation of the bowels, as well as to the other needs of the body. People who change their diet materially, or take, for a time, less amounts than they are accustomed to, as in travelling, visiting, or taking a sea voyage, are apt to sufi^er from irregular action of the bowels, until they have adjusted themselves to the new conditions. In normal defecation four factors are present, namely: (1) The lower bowel and the rectum must have something to handle ; that is to say, a mass of excrementitious matter extending like a broken or faceted column upward towards the pelvic brim. (2) The material present must excite an impulse to evacuation, that is to say, the physiological sensibility of the rectum must be normal. (3) The mechanism of the muscular apparatus of the lower bowel, and the voluntary muscles of the abdominal walls must be such that they shall be duly able to expel the accumulated ex- crement. (4) While the lower part of the column of excrement is in the act of passing the sphincter area the upper part of the rectum must in turn send down its contents to be expelled in due order. All these conditions are fulfilled in every normal act of defecation, which, if examined attentively, will be seen to resemble a miniature act of parturi- tion. In the first place, there are slight premonitory feelings of uneasiness, becoming more and more decided and insistent, and finally ending in a well- defined " bearing-down pain." At the suitable moment the levator ani relaxes and lets down the pelvic floor, upon which the fecal mass enters the internal sphincter area, which in its turn also relaxes. Then, with the contraction of the abdominal muscles and the forward inclination and approximation of the thighs to the abdomen, the external sphincter area yields, the bolus passes 15 210 COiXSTIPATIOX. HEADACHE. II^SOMK^IA. OBESITY. tliroiigli and escapes, and the miniature delivery is accomplished, formally defecation should represent parturition without pain. It is interesting to note that the internal sphincter muscle is in some measure under the control of the will; the act of bearing down relaxes it, while a voluntary act of drawing up, that is to say of lifting the levator and tightening the external sphincter, tightens the internal sphincter simultaneously. The best and most efficient method of defecation and that which best econo- mizes expenditure of force, when, as is often the case, there is a difficulty in expulsion, is found in attendance upon nature's call after the manner of all primitive people in a squatting posture in the bushes sub Jove (see Fig. 71). In this natural and instinctive habit lies perhaps the strongest link in the chain which binds us to-day to our ancestral life. Everywhere, the yokel who retires behind the barn, and the schoolboy who insists upon climbing up onto the seat, seek to perpetuate it, not to mention the number of highly civilized society men who day by day leave their traces behind them, as they wear off the varnish Fig. 71. — Postttre ix Defecatiox, sho-wixg the Efficiext Use of Abdoaiixal Pressure tx the Croitchixg Positiox, the Axterior Abdomixal "Wall beixg Supported by the Close Applica- Tiox of Thighs to the Abdomex. from the modern inconvenient seats with the soles of their shoes, a mute but eloquent testimony to their necessity. Naturam ex-pelles furcd iamen usque recurret. The disadvantage of the high water-closet seats found everywhere lies in the fact that in the act of expulsion there is no support to the anterior abdominal ACT OF DEFECATIOIN'. 211 wall and force is lost there (see Fig. 72), as anyone can feel by placing the fingers in the inguinal rings and straining. It lies also in the fact that the direction of the strain is faulty. One of two things should he done to remedy Fig. 72. — Posture in Defecation. The ordinary sitting posture with body slightly inclined, showing the loss of force, indicated by the arrows pointing toward the lower anterior abdominal wall. this evil : either the closet seats ought to he set low in the floor, or a little bench ought to be provided which will bring the feet up to a point about eight and a half inches from the level of the seat (see Fig. 73). Either of these measures will necessitate widening the opening in the seat for about two inches at a point two-thirds of the way back, on account of the change in the form of the but- tocks and the greater prominence of the ischial tuberosities. The rectum does not normally harbor feces. As soon as the fecal mass descends from the sigmoid and is felt in the lower rectum it should be expelled. If the impulse is resisted, it either returns to the upper bowel by a reverse peristalsis, or, if this is prevented by the accumulation above, it re- 212 CONSTIPATION. HEADACHE. INSOMNIA. OBESITY. mains in the rectum and blunts the normal sensibility, constipation being the outcome. Etiology. — ^Retention of feces, constipation, or obstipation may arise from a variety of causes, which are : 1. Lack of a right habit in attending to the function of the bowel. 2. Lack of exercise. 3. Lack of proper food. 4. Injury to the mechanism at the end of the bowel, due to parturition. 5. Redundant sigmoid with a long meso-sigmoid. 6. Diseases of the intestinal tract, or of the pelvic organs. It will be seen that these causes must operate more frequentlj- in women than in men. Perhaps the most important is habit, or rather the failure on the part of the individual to establish, or to maintain a regu- lar habit of body. Many women pay no attention whatever to the regular action of the bowels, except when forced to do so by their excessive and increas- ing discomfort. The reason for this among the poor may well lie in the atrocious ar- rangements for the care of the bodily functions afforded by our civic authorities, whereby, for instance, one closet is made to serve for several families. In a tenement in Baltimore, two closets do service for twenty-two families (see Fig. 35, p. 48). Associated with the use of such " conveniences " is often an advertising of the necessity which borders close on indecent exposure. Better for the poor girl to restrain her natural desires and force the function into an intermittency of expression, which is marked by intervals of days. We will do well to seek here for one of the po- tent causes of the immorality which is everywhere on the increase. With the better-to-do wom- an, a false modesty often restrains her from attending to this function; she is afraid of meeting some one on the way. Again it is frequently put off as a mere matter of in- convenience until nature's calls are so often stifled that at last the sense gTows blunt and the constipation habit is established. Too numerous also are the cases in which a grown man or woman, whose training has been neglected in this respect in childhood, continues to suffer at maturity : the responsibility for constipation of this sort must rest on parental shoulders — a word to the wise is sufficient. Fig. 73. — ^An Adaptation of the Modern Sanitary Closet TO Utilize the Crouching Posture by Raising the Feet tvithin Eight and a Half Inches of the Level OF THE Seat by Means of a Stool. ETIOLOGY OF CONSTIPATION. 213 Lack of proper exercise and sedentary occupation often result in constipation. Persons whose occupations afford them little or no opportunity for active exercise are peculiarly liable to it. Weakness of the abdom- inal muscles interfering with the passage of the food downward is often associated with a lack of physical exertion. A feeble or capricious ap- petite, which interferes with the consumption of a sufficient quantity of food, is another result of insufficient exercise. Parturition often seriously interferes with the mechanism of the lower bowel by causing a rupture of the levator ani fibres, especially those interlock- ing with the internal sphincter, so that the bowel is no longer lifted up, but drops forward in the direction of the ruptured perineal muscles. In such a case as this the efforts at expulsion tend to produce eversion of the vaginal outlet so that the expulsive power is lessened or rendered nugatory. In addition to the causes enumerated, any of which may exist while the patient is in perfect health (except for the presence and the effects of the con- stipation itself), there are sundry diseased conditions in which retention of feces occurs. The passage of feces may be mechanically interfered with by the pressure of morbid growths, either benign or malignant, situated in different parts of the abdomen or pelvis, as well as by stricture arising from any cause whatever. Chronic disease of the intestinal mucosa may result in atony of the whole intestine, indeed Osier reckons that the most frequent local cause of constipation is atony of the colon, particularly of the muscles of the sigmoid flexure by which the feces are propelled into the rectum. ("Practice of Medicine," 1892, p. 421.) A redundant sigmoid with its long meso-sigmoid affords a convenient place for the lodgment of fecal masses ; the profession is, indeed, just beginning to attribute importance to this congenital anatomical condition as a cause of an obstinate form of constipation. ITotable work on these lines has been done by Clark and Pancoast in their X-ray studies in Philadelphia. In some cases Clark has operated wath conspicuous success. Some proctologists attribute importance to a thickened inflamed con- dition of the rectal valves, associated with a marked overlapping of their margins, rendering the channel more tortuous. One of the most serious hindrances to the normal activity of the bowel is a tight corset. Frequency. — In order to ascertain something as to the frequency and the extent of constipation in my daily consultation practice, I have analysed five hundred cases from my gynecological case-books, taking them in order. The age of the youngest patient was twelve and a half and that of the oldest sixty- nine. The total number of cases of constipation, either habitual or occasional, was one hundred and sixty-four out of five hundred, or about thirty-three per cent. Of these, sixteen are noted as occasionally constipated, while seventeen suffered to an extreme degree. Only fifty-seven of the hundred and sixty-four were 214 COIS^STIPATION". HEADACHE. INSOMNIA. OBESITY. accustomed to use any means to overcome the difficulty, forty-four of this num- ber taking medicines of various kinds, and thirteen using an enema. Another noticeable fact is that in almost all of the cases in which there was no record of any means employed for relief, the constipation is noted as excessive or as having existed for a number of years. The number of these cases suffering from headache may be taken as a rough indication of the extent to which the body in general was affected by the loaded condition of the bowels. Of the hundred and sixty-four, eighty com- plained of headache in varying degrees of severity, while five suffered from dizziness without actual pain, making, in all, rather more than half of the entire number. In some of the cases in which the constipation is noted as most marked there was no headache at all, while others, where it was mild or occa- sional, suffered intensely with it. In some cases of habitual constipation at- tacks of sick headache with nausea and vomiting were noted as ac- companying the menstrual periods. The number of cases in which there was any indication of irritation of the intestinal mucosa was small, as there were only five cases where there was mucus in the stools, and but two where there was blood. Diagnosis. — In making a diagnosis of constipation as the cause of symptoms complained of, the first point to be established is that it exists, and this is a matter of less simplicity than it seems. So many women, as I have said above, pay little or no attention to the condition of the bowels that the physician is constantly liable to be assured that they act with perfect regu- larity, when they are really emptied only every three or four days. It is neces- sary that he should be explicit in his inquiries and that he should make sure the patient understands that nothing but a daily motion is considered normal. When it is established that a constipation is present, we must next consider its form and its causes, ascertaining the following facts : 1. What is the state of the general health ? 2. What amount of exercise is taken ? 3. Is sufficient food ingested to form a fecal mass demanding expulsion? 4. Where does this mass lodge ? Is it in the sigmoid flexure and descend- ing colon ? 5. Is there an accumulation in the caput coli ? 6. Is there an accumulation in the rectum ? It is sometimes convenient to classify the constipation according to the dif- ferent parts of the large intestine in which the fecal matter tends primarily to lodge: as rectal, and, if rectal whether ampullar or upper rectal, that is, above the utero-sacral ligaments; or sigmoid ; or colic. Obstruct- ive forms of constipation, when the obstruction is low down, say in a concentric narrowing of the rectum due to cancer, often develop slowly and . insidiously. In order to ascertain to wliich of the above classes the constipation belongs the patient must go without a purgative for two, three, or more days; during DIAGlSrOSIS OF CONSTIPATION. 215 "which time careful daily examinations must be made in order to determine where the feces lodge. In a woman, palpation will reveal the presence of any considerable accumulation in the region of the cecum, which when clogged has a doughy pasty feel, is movable and often sensitive. Only in extreme cases can masses be felt above the cecal region in the transverse and the descend- ing colon, j^ot infrequently, however, they can be perceived in the sigmoid flexure, which is perceptible to the touch in the iliac fossa, or behind the symphysis, or near the promontory. A rectal and vaginal examination will reveal the presence of feces in the lowest portion of the bowels. In these cases I constantly use the protoscope, introducing it as far as the sacral promontory. The patient is put in the knee-breast position and by using a long speculum, eighteen centimetres long and twenty to twenty-two millimetres in diameter, I can examine the whole lower bowel. In young women it will often prove that the lower bowel is empty and that the difficulty lies in the fact that the fecal mass does not descend into the rectum. Such an investigation is invaluable in suggesting approximate methods of treatment, of which I shall speak later. Another form of constipation, which can be detected by this method of examination, is that in which the overloaded bowel is only relieved of a portion of its contents at each act of defecation. It is often a good plan to examine women who are much troubled with constipation within an hour or two after what they consider to be a satisfactory evacuation. In women who have borne children, the vaginal outlet should always be examined in order to ascertain whether there is a rupture of the muscular fibres and a consequent tendency to eversion. This eversion can be produced arti- ficially by inserting one or two fingers into the rectum and pushing the mucosa forward in the direction of the vaginal outlet until a marked pouch is formed by the protruding vaginal mucosa. It must next be ascertained how long the constipation has existed and, if possible, what occasioned it. If it is habitual and has lasted a number of years without any known definite starting point, it is probably the result of careless habit ; but if it has developed recently, after years of regularity, the possibility of some local cause must be considered, such as pressure from a pelvic tumor, a malignant growth in the intestine itself, or a stricture. The diagTLOsis of these affections belongs to the surgeon, but the general prac- titioner should be able to decide upon their probable existence. To review then, in any given case it must be determined: that constipa- tion exists ; that it is of mild or severe type ; that it is associated with such and such local or general disturbances ; that the pa- tient is or is not free from organic disease. A careful palpa- tion of the abdomen must be made to detect the lodgment of fecal matter at the head of the colon or in the transverse and descending colon, especially at the flexure; an endeavor must be made to map out the sigmoid flexure ; and lastly, a local pelvic examination must be made to determine 216 COITSTIPATION. HEADACHE. INSOMNIA. OBESITY. whether there is or is not an obstruction which may account for the con- stipation on purely mechanical grounds. It is a good plan to fill out some such scheme as this in the case-book: Constipation note : JSTanie. Age. Weight. 1. How long has constipation persisted ? 2. Did it follow any acute disease or change in habits? 3. Does it date from a confinement? 4. What are the longest intervals between evacuations ? 5. What remedies has the patient been accustomed to use ? Treatment. — The treatment of constipation is three-fold: (1) preventive; (2) to relieve the present condition by unloading the bowel; (3) to regulate the function so that it will act automatically and without artificial aids. (1) Prevention.^ — The first point in the treatment of habitual constipa- tion is the establishment of a regular daily habit. This applies especially in the training of young girls, with all of whom a daily effort at a fixed time is sufficient to create a habit which becomes at last a second nature. The morning call, to one thus trained, becomes an imperative demand which is never neglected. In those who have not too long neglected this salutary habit, the mere attitude of expectation, created by a persistent morning visit to the closet, is enough after a while to regulate the function. A case in point which shows the influence of the mind over the body, is one where the patient suffered extremely from constipation until she became a " Christian scientist," after which she made an effort to empty the bowels every day, sitting with Mrs. Eddy's manual of Christian Science in her hand, with perfect success ! The treatment of constipation by mental influences is strongly advocated by Paul Dubois (" The Psychic Treatment of ISTervous Disorders ") as follows: " I would dare to say that the cure of constipation is certain if one uses these means, but if this treatment is to be efficacious it must be prescribed with entire conviction. This I insist upon, and to those who want to make the attempt I will give the following advice: (1) Draw the patient's attention to the inconvenience of laxatives and enemas ; prohibit them altogether ; burn your bridges without fear. (2) State that one always succeeds by this intelligent treatment. If you have already had some success along such lines in your practice, describe them with convincing eloquence. (3) Ask your patient when he gets up and takes his breakfast. Ton can, to a certain degree, take his habits into account. If he gets up at half-past seven, for example, give him the following prescription in writing: (a) 7.30 a.m. — Rise. (&) 7.45 a.m. — Drink a glass of cold water. For those who have a superstitious reverence for medication give an infusion of quassia prepared the evening before, (c) S a.-m. — Hearty breakfast with milk, coffee or tea, according to choice, and even chocolate for those who are not constipated by this food. Use bread (Graham, TREATMENT OF CONSTIPATIOlSr. . 217 if possible) and butter, with honey or preserves, (d) 9 a.m. — Try to go to the toilet at a fixed hour. ' Do not go at any other time and refuse to do so, saying to your intestine : ' You would not move at nine o'clock ; now you can wait until to-morrow ! ' (e) Use a copious diet, giving the preference to vege- table foods. " But do not be content with enumerating these measures and putting them on paper ; explain them, comment upon them, and enumerate the ' invita- tions ' which the prescriptions contain. The patient will reply to you : ' But I have already tried to go at a fixed hour. I have already taken a glass of cold water.' " You can reply to him : ' My dear sir, six cannons can make a breach where one or two are not enough. Go on bravely and you will succeed ! ' " And last of all, do not suppress the suggestive effect which you have just produced. An excellent confrere, who for long years practised this treatment, told me- that he was well satisfied with it, but that he had, nevertheless, had some failures. Astonished at this, I made him go over the prescriptions which he had given. They were as complete as though I had dictated them myself. I tried to find the cause of the failure, when my confrere added : ' However, I have never discouraged the patient and I have told him if this does not work there are still other means ! ' This counter-suggestion was sufficient to explain his failures. When, one wishes to convince one of anything it does not do to suggest the idea of possible failure." Those who would prevent constipation must also see to it that their patient's diet is of a proper sort, not too highly seasoned, nor of concentrated fancy foods, and not too much meats, but sensible amounts of simple, bulky, nutritious arti- cles, such as are constantly found on the table of the farmer. A diet largely vegetarian, starchy foods, legumes, coarse bread, fruits, fresh and stewed, all conspire to regulate the function and to make it easy of performance. Let me enumerate a list for selection : Oatmeal and various breakfast cereals with cream. Graham bread, rye bread, corn bread, bran bread, Boston brown bread, dry Swedish bread, German Schwarzbrod, which can now be bought in most of our large cities. Plenty of fresh butter on the bread, for fats generally help to relieve constipation. Honey or molasses at breakfast. Soft boiled eggs, cabbage, sauerkraut, cauliflower, lettuce and salads of all kinds, sj)inach, peas, Lima beans, string beans, lentils, carrots. Fruits, especially stewed prunes, figs, and plums ; in the berry season all berries with seeds are valuable aids. The best beverages are plain water and buttermilk. I would suggest some such simple regimen as this to start with : A glass of cold water on rising. Breakfast : Oatmeal, cream of wheat, etc., with cream. Bread with plenty of but- ter; corn bread, or corn cakes, or Johnny cake, with honey or mo- lasses ; soft boiled eggs, fish. Weak coffee, buttermilk, malted milk. 218 CO>;STIPATIOX. HEADACHE. INSOMNIA. OBESITY. Lunch : A little cold meat, rice, caviar, sardines, anchovies. Potato, string beans, asparagus. Salad. A simple jmdding; cheese and crackers; baked apples. Dinner : A thick soup, bread or cheese straws. Shell fish. Celery, olives, rad- ishes. White or sweet potatoes and vegetables of all kinds ad libi- tum. Salad. Xuts ad libitum. Fruits. Grape juice. I have made no allowance here for a fashionable dinner in many courses. Some people find that an apple eaten every day in the evening or in the morning regulates the function. Again so simple a device as a glass of cool water in the morning on rising is all that is needed. It may be that hot water is more agi-eeable as well as more acceptable to the stomach. A glass of cool water containing a little lime or lemon juice is often more effective. Sometimes patients do not drink enough water, and for such persons a glass of water every two hours between meals should be prescribed. An invaluable simple medicament acting like the natural mineral waters is the phosphate of soda taken every day, a tea- spoonful in a glass of water early in the morning. Daily exercise is a prime requisite. Let no one, adult or maiden, think that this important function will regulate itself if they simply eat, and sit, and talk, and dawdle about. Active stimulating exercise is imperative ; a good long walk in good company, golf, horseback, swimming, rowing, or at a pinch, 'pour pis aller, home gymnastics in the fresh air of a well ventilated room with the windows wide open. Equally important with general muscular exercise is the care of the skin by a daily cold bath followed by rubbing with a coarse towel, and deep breathing exercises associated with the regular muscular exercise. When the abdominal muscles are lax, especially after confinement, they can be strengthened by lying flat on the back and rising to a sitting posture by the abdominal muscles alone without any aid from the hands or arms. C v. Wild even recommends these gymnastics several times a day for the puerperal patient from the tenth to the twelfth days onwards. If a young woman will discard the rigid tight-fitting corset when she beg'ins to take exercise adapted to making her breathe deeper and strengthen her loins, she will have taken one most important step towards regulating this function. (2) Galvano-f aradism. — This form of treatment is recommended by Erb (" Handbuch der Elektrotherapie "). The galvano-f aradic current has proven of great use in stimulating the atonic bowel into normal activity and in overcoming chronic constipation. Brose, who writes after considerable experi- ence, found that out of twenty-nine cases of chronic constipation treated by this means alone, twenty-eight were relieved, the remaining patient giving up the TREATMENT OF CONSTIPATION. 219 treatment because there were no perceptible results after five sittings (" Die Behandlung d. chron. Obstipation mittels d. Galvano-farad. Stromes," Fest- schrift zu Prof. Dr. Meyer ^ Gottingen). Brose used a strong galvanic current of from fifty to seventy-five milliam- peres and a faradic current as strong as tbe patient could bear. He made use of large electrodes eight by eight inches in size, placing the positive pole on the sacral region and the negative on the abdomen. The sittings averaged from four to six for milder degrees of the condition, to thirty or forty in more severe varieties. C. V. Wild uses the same remedy somewhat differently. The patient lies upon her back with her head raised a little and with knees drawn up. She rests upon one pole, a plate nine by twelve centimetres (about three and a half by five inches) while a round electrode is used on the anterior abdominal wall. The anode is used behind, the kathode in front. The current employed is of a strength of five to ten milliamperes and is given by pressing the electrode deep into the walls. Decided contractions of the muscles in the abdominal wall can be avoided, if necessary, by weakening the faradic current. That current is best which is felt to excite definite peristaltic contractions, easily recognized through thin walls. The sitting lasts about five minutes. The result of such a treatment is often prompt, but subsequent treatments are needed to increase and render permanent the effect. Out of twenty-six cases treated in this way, twenty-four are noted as cured, while two gave up the effort. The number of treatments varied from fifteen to one. With increasing experience the worst cases were relieved in six sittings. If the patient will not regulate her diet and exercise, nor make a faith- ful attempt to evacuate the bowels at a certain hour, adapting her diet and beverages to encourage this regularity of habit, then nothing remains but to resort from time to time to some of the numerous devices all of which are for a time more or less efficient. The worst thing that can be done is to treat a case of constipation by simply prescribing as the ultimate goal one of the well known and often much advertised popular remedies, famil- iarly known as " little black pills," French grains, or by their initials as A. S. & B. pills. Sanger, in a most earnest appeal (Centrhl. f. Gyn., 1890, vol. 14, p. 349) insists on giving up all these common medicaments, which as he declares, never cure, but only serve to fix and perpetuate a constipation, forging the chains of habit upon one who has sought the physician to find deliverance. At the utmost these vaunted constipation remedies should be used but for a short time for temporary effect and merely as expedients on the way to better things, namely, the cure of the evil. In the old or infirm, wliere hygienic measures cannot be carried out, their use is not so objectionable. For such a purpose cascara sagrada in one or other of its two forms, namely, the solid or the fluid extract, is the simplest and best remedy. 220 CONSTIPATION. HEADACHE. INSOMNIA. OBESITY. 1^ Ext. cascarae sagradae gr. ij M. Ft. pil. 1. S. Take at bedtime. Or ^ n. ext. cascarse sagradae (aromat.) S. Thirty to sixty drops at bedtime. Little pills of aloin are valuable in some cases. 1^ Aloin gr. -|- Strych. sulph gr. To" Ext. bellad gr. To" M. et ft. pil. 1. S. Take at bedtime. A small dose of podophyllin, half a grain or less, may be added to the last prescription, if desired. For patients wbo insist upon regulating themselves with drugs, the whole gamut of the pharmacopeia may be rim, for no one remedy or prescription does service week after week. For such I mention the following : Rhubarb, in the form of the following prescription: I^ Pulv. rhei gr. 1^ Sod. bicarb gr. 1^ Oil peppermint gr- to" M. et ft. pil. 1. S. Take at bedtime. Aloes soc, one-half of a grain, and the extract of nux vomica, one- sixth of a grain, may be added. Podophyllin resin in pills containing one-twentieth of a grain, and compound liquorice powder, in doses of from one to three teaspoonfuls or in the form of compressed tablets, are good remedies. Calomel is the best remedy for an occasional unloading, say once in ten days. A single dose of three to five grains may be given at night followed by a saline (Rochelle salts, two drachms) in the morning. Asafoetida with capsicum is said by Anders to be of benefit in senile atrophy with flatulence. A skilful old practitioner whom I knew when I was a boy prided himself on a mixture of this kind: ^ Magnes. sulph 3j Magnes. carb 3ss. Inf. gent, comp 3ss. Aq. menth. pip Sjss. M. S. Shake well and take at bedtime. The advantage of this prescription is that there is no danger of the patient becoming the devotee of n drug. TREATMENT OF CONSTIPATION, 221 A good laxative for children is the following formula: ^ Pulv. rhei gr. y o" Sulphur gr. ^ Sod. phos. exsic gr. 1 01. menth. pip TTt -^ M. et ft. pil. 1. S. Take at bedtime. Senna leaves cooked with prunes or figs and made into a paste is readily taken by children and is effective. Massage of the abdominal muscles is one of the best means at our disposal, especially in cases where outdoor exercise is deficient. A metal ball covered with leather, and weighing four to six pounds, may be rolled over the abdomen every morning for five to ten minutes to stimulate peristalsis. The simplest of all adjuvants are the natural mineral waters: Friedrichs- hall, Apenta, Hunyadi, Carlsbad salts, a teaspoonful in a glass of water every, morning. If the constipation is of long standing, it is well to give a laxative, fol- lowed in six or eight hours by an enema, and then to repeat the laxative on one or two successive days in order to insure a complete evacuation of the lower intestinal tract. In this manner the sluggish bowel is often compelled to yield up the accumulation of weeks, to the utter astonishment of the patient and often of the physician as well. Such a course is imperative in preparing for any gynecological operation. If it is neglected, the surgeon may have occasion for anxiety for several days after the operation, until the bowels begin to move, and then there is often a regular debacle, with reports of one or two bedpans filled with the malodorous materials, when the depression vanishes, the temperature and pulse drop, and the facies change from a sallow pinched expression to a natural one. In the preparation for operations upon complete laceration of the perineum and sphincter ani, it is my custom to give compound liquorice powder in doses of three to six teaspoonfuls. Enemata. — These are perhaps the simplest and safest means of unload- ing the bowel and avoiding drugs. In cases where the extreme lower bowel is habitually loaded and there seems to be a lack of expulsive power, I find it efficacious to inject from two to six ounces of. warm sweet oil, passed slowly in with a soft catheter at a slight elevation at bedtime. It ought to act naturally the next morning. A glycerin suppository is sometimes efficacious in the same way. Large enemata of warm sweet oil from a half to one pint, introduced slowly and gently, have been used in Germany with success. The action here is upon the upper colon as well as the lower bowel. Sweet oil taken freely by the mouth at meals with food, or taken deliberately as a laxative (tablespoonful) at meal times has corrected the habit -in some instances. 222 CONSTIPATIOX. HEADACHE. INSOMNIA. OBESITY. Of the watery euemata tlie flaxseed enema is tlie best. I make it by taking two tablespoonfnls of flaxseed to a pint of cold water, boiling it for ten minutes, and then straining out the seeds. The whole shonld be injected while still warm (not hot!), and should be of a mucilaginous consistency. A simple emulsion is made of cotton-seed oil, with enough soap and warm water to make up a pint. A satisfactory purgative enema is com- posed of sulphate of magnesia (Epsom salts) four ounces, glycerin two ounces, turpentine two drachms, and warm water four ounces. This enema is always effectual, but it may be exhausting to a weak patient. I often use it without the turpentine. Caution : A too frequent use of large enemata may distend the lower bowel, cause loss of tone, and so increase the difficulty it is attempting to overcome. When the constipation is associated with torpidity of the liver, small doses of calomel must be given from time to time, followed by a saline. A broken dose of calomel, consisting of one-eighth of a grain given every half hour for eight doses, is the best way to administer it, with a glass of Apenta water next morning. In all obstinate constipation coming on in middle life, bear in mind the possibility of malignant disease of the intestine, or the pressure from pelvic tumors, or a stricture ; these can be detected by a local exam- ination either with the finger or with one of Kelly's proctoscopes. In a woman who has borne children and in whom the vaginal outlet is lax and gaping, a pouting and eversion of the vaginal walls, especially the pos- terior wall (rectocele), is often seen, if the patient is told to press down. In these cases a suitable operation repairing the outlet often does much to relieve the difficulty of evacuation by restoring the muscular and tendinous structures, so that the pressure in the act of defecation is no longer lost in the vagina, but acts instead on the rectal sphincter. The care of the bowels immediately after abdominal opera- tions is a matter for much care and decision, and as it sometimes happens that this duty is left to the lot of the physician in charge of the case by the operator, I give some general directions in regard to it. If the bowels are thoroughly moved, as they should be, before the operation is performed, they need not act again until the second, or even the third day. This first action is best accomplished by means of the flaxseed enema described above, and when the bowels have been once opened, there should then be an action every twenty-four hours. A special enema, which I have found useful in some cases, is composed of cotton-seed oil, four ounces, glycerin, two ounces, turpentine, two drachms, and enough soap and water to make up a pint. For distention with constipation following operations I have found milk of asafoetida, four to eight ounces, used warm, very effectual. As no exer- cise can be taken, some form of assistance may be necessary to keep the bowels open eacb day. Cascara is the best drug for this purpose, but it may be made a general rule that lar2:e doses of a laxative medicine should never be TEEATMENT OF CONSTIPATION. 223 given to a patient lying on her back and obliged to evacuate the bowels in that position. Unless a mild dose of eascara (forty to sixty drops of the aroma- tized fluid extract) is sufficient, it is best to continue the flaxseed enemata as long as the patient remains in bed. Sanger, v^ho has been largely followed in his own country, lays great stress on some such plan of procedure as the following: In the first place, the work- ing principle is to wean the patient as soon as possible from all drugs. To do this it is necessary to win her confidence completely, both as to the importance of the undertaking and the ability of the physician to effect a cure. At first a few drugs are used to tide over the difficult period of breaking off, but later even these are given up absolutely, until finally nothing but a little bella- donna is used, and that only occasionally. Cascara, Sanger considers no better than any other purgative. After giving up laxatives in this way a period of persistent constipation follows, which may last for eight days or longer. This should be explained to the patient beforehand, and she should be assured that nature will, in time, take care of the difficulty. Sanger uses no special diet, declaring that " no diet is the best diet." It is, however, important to see that several glasses of water are taken daily, or else whey, buttermilk, or sour milk. Fresh and cooked fruits are used as well as coarse bread. In addition to this an attempt at regularity of habit is enforced. Most important is some daily active exercise, especially in the gymnasium. Injections are used to as limited an extent as possible; and purgative mineral waters are rejected (ich halte dieselben (Brunnencuren) geradezu filr werthlos). Most important of all methods in the treatment is the massage of the abdomen associated with the use of electricity, especially in lax abdomens. This plan has proved successful in the hands of one of the most eminent gynecologists Germany has yet produced. I give it again here in outline: 1. 'No medicines except a little belladonna occasionally. 2. Let the patient remain constipated, if necessary, for over a week. 3. In the meantime use ordinary diet with the addition of fruits. 4. See that she takes plenty of water between meals. 5. See to it that some active exercise is taken. 6. Use abdominal massage. Y. Use abdominal electricity. 8. Encourage in the meantime a regular habit by waiting upon nature at a fixed time. By these simple means an obstinate constipation habit may be overcome. 224 CONSTIPATION. HEADACHE. INSOMNIA. OBESITY. HEADACHE. Headache is perhaps the commonest of all the ills that flesh is heir to. It is, indeed, an ailment so frequent that, as a rule, it arouses no attention nor does it excite any solicitude as to the welfare of the patient. jSTeverthe- Jess, headaches, to those who suffer from them, are an aggravating and dis- tressing disorder, often robbing life of its zest and sweetness and liable at any time to interfere with plans of enjo^Tiient or occupation. Repeatedly recurring headaches are peculiarly hard to bear, and, if not relieved, may render life a burden. A headache is nothing more or less than a symptom, which often leads up through a tangled skein to some remote and unexpected disorder. Persistent headaches, however, are often most difficult to relieve, so that the sufferer goes from one physician to another, tries all manner of patent medicines, and, as a rule, sooner or later consults a variety of specialists to see if some master in his own department cannot detect an abnormality which is the cause of the continued pain. After the general practitioner, the stomach specialist may be consulted, and he, finding a trifling subacidity, prescribes hydrochloric acid; this fails to bring relief, and as the patient hears of some brilliant cures wrought by the oculists, she goes to the nearest one of repute, who finds a mild astigmatism and prescribes glasses, which also fail to relieve. She then consults a gynecologist, feeling sure that the secret of the recurring suffering must lie concealed in those mysterious pelvic organs which control the cycles of her life from childhood to old age. The gynecologist, in turn, finds a slight uterine deviation from the normal, and puts in a pessary, after which she is either resigTied to her fate, or becomes addicted to morphin, or some of the many dangerous patent medicines, advertised ^rith superb impudence not to kill but to relieve suffering. It is because so many of these patients with headaches apply sooner or later to the gynecologist, that I have felt it important to say a few words upon the subject. Frequency. — I have investigated the frequency with which headaches occur in connection with pelvic and abdominal disorders, by going over five hundred entries in my case-books, and I find that one hundred and seven of the five hundred suffered from headache of one kind or another, in different degTees of severity ; in thirty-two cases, the headaches were associated with the men- strual period. Etiology. — He who would treat headaches successfully, must in every case look deej^er than the throbbing, aching head, and search for the underlying cause or causes. Indeed, it is chiefly in this way that the intelligent and trained practitioner differs from the quacks who advertise their nostrums in the daily papers. While the practitioner investigates and removes causes and so often cures the ailment, the parasite upon the profession treats all cases ETIOLOGY OF HEADACHE. 225 alike, considers headaclie a disease per se, and for the sake of his ten or twenty cents' gain supplies a remedy which he swears will cure the malady, in reality giving temporary relief only by benumbing the brain. This he does even at the risk of life itself, without any conscience at all, trusting to the lax admin- istration of our criminal laws, if he should be arraigned for murder. The nostrum vender is thus on a par with those brutal savages who waylay and slay their hapless victim for the purpose of stealing so trifling an article as his penknife or a few pennies in his pocket. In undertaking to treat rationally and successfully the cases of headache which come to me as a gynecologist, I must keep in mind all the various com- moner causes of the ailment, lest I make the mistake so often attributed to a specialist, namely, that of seeing only my own little territory, and considering that all humanity's ailments in one way or another must flow from the pelvis. In treating headaches in women, I note in the first place, that men are relatively free from this affection to a remarkable degree, and that when men do suffer from headaches, they are apt to arise from overindulgence at the table ; in such a case the ache of the next day is clearly gastric in its origin. Furthermore, the severe and lasting headaches of men about middle life are sometimes the premonitors of grave organic disorders, as, for example, Bright's disease. I discern from these facts that two forms of toxemia, a tran- sient and a permanent form, are at work, and that it must be the toxic by- products in the blood which produce the symptom, headache. I note, too, that a whole group of headaches, often seen in women, the nervous head- aches, are conspicuously infrequent in men. A little further thought sug- gests, what is quite certainly true, that the reason for this difference lies in the less active physical and intellectual life of the woman, and at once fur- nishes valuable ideas as to treatment. If this is true there ought to be less headache among our college women than among those who go out at once into society life. I think we shall not go far wrong if we classify most of our cases of head- aches under one or other of the following headings : Toxic, those due to ptomaine, or leucomaine poisonings (uric acid, etc.), to fevers, to Bright's disease, constipation, and various intestinal disorders, etc. ISTeurasthenic, those associated with the nerve exhaustions, so common in our women to-day. Vaso- motor, congestive and unilateral headaches, often associated with neurasthenia, but frequently noted, too, in women in robust health. Anemic, a cry of the brain for food, like the pain in over-tired muscles. The headaches of children at school, while often ocular, are sometimes but the cry of a tired, over-worked, often underfed organ, which ought to lie fallow while the rest of the body is undergoing its evolution towards adult life. Reflex, from the eye, nose, or frontal sinus. Hereditary, in cases where often no other cause can be assigned. In migraine it is frequently the only explanation which can be offered. 16 226 coisrsTiPATioN. headache, insomnia, obesity. Brain disease, as in syphilis and meningitis, traumata and brain tumors. In the investigation of a particuhir case, the j)hysician must try to trace it up to one of these groups, and then to analyze the particular causes there operative. The first step is to inquire as to the frequency of the headache, its intensity, its duration, and its relation to the menstrual period. Menstrual headaches are vaso-motor in origin (I do not believe they are toxic) ; as a rule, the premenstrual form is relieved when the flow appears and the menstrual form when a sufficient flow is established. I have not found any particular association between pelvic affections and the especial variety of headache which occurs on the top of the head ; in my expe- rience the sincipital headache is rare. Patients with nerve exhaustion are apt to suffer from a dull j)ain or pressure in the back of the head and the upper part of the spine. Intense and persistent headache is one of the commonest symptoms among neurasthenics. Headache due to eyestrain is apt to be frontal in character. Where any symptoms, such, for example, as eye-tire, point to the eye, and where other avenues of inquiry have been exhausted, it is always Avell to call upon a com- petent ophthalmologist for his opinion. !N^asal polyps may give the first evidence of their presence in the severe headaches they provoke. A little difficuity in breathing, especially if it is marked at the time of the headache, should call for an examination of the upper respiratory passages. Frontal sinus disease may in like maimer occasion intense pain in the head with local and supra-orbital tenderness. It must never be forgotten that headache is sometimes a marked symptom of malaria, or of typhoid fever in its incipiency ; such cases are occasionally seen in the wards of a large hospital. A routine examination of the blood is of great service in such instances. Anemia is sometimes the self-evident cause of headache, particularly in women who have lost much blood by uterine hemorrhages. Many grades of anemia can only be recognized by the hemaglobinometer, an instrument so simple that it ought to be in the hands of every practitioner advanced enough to consider it important to use a thermometer in his daily practice. In severe nocturnal headaches, syphilis must always be looked for. In the headache of Bright's disease the increase of arterial tension is often evident in the hard bounding pulse; the tension is easily measured with one of the simple mercury pressure instruments connected with a constricting band on the arm (the Riva-Bocci, or one of its derivatives). Some patients date their severe headaches from an over-exposure to the heat of the sun (insolation), producing a profound vaso-motor disturbance, after which the least exposure or fatigue serves to bring on a violent attack. In reviewing the history in a puzzling case, heredity must receive close ETIOLOGY OF HEADACHE. 227 attention, as it may be the only assignable cause. Dr. Ira J. Prouty, of Keene, ]Sr. H., tells me the case of a professor in a college, who graduated in medicine and then had to give np the idea of practising, because he suffered, as did his father before him, from severe headaches every two weeks. I find it always well, too, to inquire as to any severe trauma to the head, received perhaps in childhood, and in case there is such a history, to ask the opinion of a good nerve specialist. Habits of food and habits of drinking must be looked into, espe- cially the latter in these days. Many headaches are alcoholic and grow worse as the patient continues to imbibe the poison. With men, tobacco is a potent cause and in certain ranks of society to-day, this factor needs con- sideration in treating women. After reviewing in this manner the various possible causes of headaches, and excluding any possible unusual cause, the physician can settle down to a minute and careful investigation of those causes which are most commonly operative in women, one or more of which is usually at work in any given case. Auto-intoxication from the gastro-intestinal tract due to fer- mentation of food must always be thought of and eliminated by questioning, or, if there is any doubt, it must be settled by washing out the stomach and analyzing its contents. The question of fermentation in the tract lower down must always be considered. This is most apt to be noticed after opera- tions, when it often simulates an incipient peritonitis. Constipation is perhaps the most fruitful of all causes of headache, and it is all the more insidious because women become so habituated to the condition of sluggish bowels, that they fail to realize the importance of its bearing upon their general health. A vaginal examination often reveals a fulness of the bowel, surprising to the patient who " has just had an action." The finger feels a bolus through the posterior vaginal wall, and often there are a number of tender masses (scybalse) above the vault w^hich may mislead a neophyte into proposing an abdominal operation. Potent among the causes of headache in women is domestic infelicity. An unfaithful or an unkind husband works like a carking care on the nervous system, robbing life of all its spontaneity and joy. The poor victim gives up her friends, she soon ceases to take any active exercise, and mopes about the house ; feeble appetite, indigestion, and anemia follow, and the foundation is Avell laid for regularly recurring severe headaches. The late Prances Power Cobbe has given an able description of this form of headache in an article entitled " The Little Health of Ladies " (LittelVs Living Age, Peb. 2, 1878). "It is many years," she says, "since, in my early youth, I was struck by a singular coincidence. Several of my married acquaintances were liable to a peculiar sort of headache. They were obliged, owing to these distressing attacks, to remain very frequently in bed at break- fast time and later in the day to lie on the sofa with darkened blinds and a considerable exhibition of eau-de-cologne. A singular immunity from the 228 CONSTIPATIOX. HEADACHE. IXSOMI^IA. OBESITY. seizures seemed to be enjoyed Avlieu any pleasant society was expected or tlieir husbands happened to be in a different part of the country. By degrees, put- ting my little observations together, I came in my own mind to call these the ' bad husband headaches,' and I have since seen no reason to alter my diag- nosis. On the contrary, I am of opinion that an incalculable amount of female invalidism arises from nothing but the depressing influence of an unhappy home. Sometimes, of course, it is positive unkindness and cruelty that the poor creatures endure. Much more often it is the mere lack of affection and care and tenderness for which they pine as sickly plants for sunshine. Some- times it is the oppression of an iron will over them which bruises their pleasant fancies, and lops off their innocent whims till there is no sap left in them to bud or blossom any more. I^ot seldom the misery comes from frequent storms in the household atmosphere — for which the woman is probably as often to blame as her companion, but from which she suffers doubly, since, when they have passed, he goes out to his field or his merchandise, with what spirits he can muster, poor fellow, while she sits wherever the blighting words fell on her to feel all their bitterness. ... To those who can get up and walk away the importance which she attaches to them seems inexplicable." In some cases, however, the fault lies in a self-centered or evil disposition with outbreaks of bad temper and tantrums, or long periods of sullen brood- ing over fancied wrongs. One of the most distressing forms of headache is that induced by constant weeping. The wise physician who is the friend of the patient, as well as her medical adviser, will always in puzzling cases squint with one eye in this direction, and will, where his advice is called for, treat the moral as well as the physical ailments of the family. Is the patient a neurasthenic ? If she is, the physician must expect head- ache as one of the expressions of the deficient nerve capital. In addition to the headaches just enumerated we have the simple nervous headache and the sick headache, or migraine. Various explanations have been given of the latter, but none are satisfactory. Edward Liveing, who has written exhaustively on the subject, considered the attacks to be nerve storms nearly related to epilepsy, that is to say, a form of periodic discharge from certain sensory centres : a picturesque way of summarizing the phenom- enon, if not an adequate explanation. Observations made by Mangelsdorf of Kissingen show that in every case of migraine there occurs a well-marked acute dilatation of the stomach, and that a frequent repetition of these dila- tations leads to a permanent gastric atony. Mangelsdorf claims to find these same dilatations in epileptics during the attacks, which would be another point in evidence of close resemblance between epilepsy and migraine. Other authors regard sick headaches as a va so-motor neurosis and support this view by the fact that during the attacks the temporal artery on the affected side sometimes becomes hard and firm, as in arteriosclerosis. There can be no doubt that sick headaches frequently depend upon gastro- DIAGNOSIS OF HEADACHE. 229 intestinal disturbance. W. P. Millspaugh {South. Calif. Practitioner, 1907, vol. 22, p. 513) points out that migraine must be distinguished from another class of cases in which headache is frequently occasioned by disturbance of the gastric secretion, whereas in migraine the headache and the gastric dis- turbance are in all probability due to a common cause, which, according to some persons, is uric acid or one of its near relatives among the incompletely oxidized end-products of nitrogen metabolism. In the former class of cases there is hypersecretion of gastric juices, while in migraine the secretion is diminished. In ordinary hyperchlorhydria the correction of the hyperacidity will often, according to Millspaugh, relieve the headache, and he suggests that such headaches may be reflex from the irritation of the stomach induced by the excess of hydrochloric acid. In some of the cases of the kind coming under his own observation, however, he was inclined to suspect that the alkalis used to correct the acidity were effective by checking a gouty poison which might have been the real cause of the whole trouble. Diagnosis. — In undertaking a patient complaining of headache I would, in the first place, distinguish whether the headaches were those incidental to some other well-defined trouble and not, as a rule, intense. If, for example, the patient is anemic from the loss of blood from the uterus, I would expect the symptom, headache, to disappear with the correction of the local disorder. I would place in a different category those intense headaches where the distress in the head overshadows whatever other ailments there may be, and, if I have determined that the case under treatment is one of that kind, devote myself at once to the minute examination of every function of the body to discover the cause. It would be well to fill in some such outline as the one given on page 230, as a good starting point to clear the way for further investigation. Usually the diagnosis of a case of headache involves the discovery of a variety of causes, all of which conspire to reduce the health below the average norm, when the headache becomes the natural cry of the brain for more and better nutrition. Tor example, a nervous, tired, anemic woman enters my office with a dysmenorrhea, or with a descensus and dragging of the pelvic organs, associated with poor appetite, lack of exercise, and sleepless nights ; in such a case I expect, as a matter of course, to hear that the patient also has headaches, and in undertaking to treat the general condition and the local pelvic ailment, I expect the headaches to disappear as the health improves. Treatment. — The treatment of headache is twofold : that designed to give immediate relief; and that looking towards the removal of the cause and the prevention of the recurrence of the pain. It will be well to glance briefly at the kinds of treatment we have at our disposal before taking up the use of the particular remedy in any special case. 1. In the first place there are those remedies which promptly and efficiently remove the temporarily acting cause, as in a toxic headache from gastro-intestinal fermentation. Such a remedy is calomel, 230 CONSTIPATION, HEADACHE. INSOMNIA. OBESITY. Name Age Married Children Miscarriages Menstrual function : regularity duration pain relation to headaches ? Headache age first noted? growing worse ? location of pain ? character of pain ? average duration ? what remedies used to relieve ? amount Associated pheno?nena ? eyes flushing of face or pallor nausea and associated stomach symptoms character of food taken digestion sleep anemia urine other ailments ? amount of exercise? habit as to bath character of home life^ cheerful? any evidences of yieurasthenia ? any illness font ivhich headaches date ? TREATMENT OF HEADACHE. 231 given in three to eight grain doses, followed by a saline purge, in the form of Rochelle salts, the citrate of magnesia, or Carlsbad salts, some six or eight hours later; the good old blue mass pill, given in doses of six to ten grains, is too much out of vogue. Sometimes, where the table is at fault, emesis and lavage are the best immediate means of giving relief . In milder cases, powders of calomel and soda may be given. I^ Hyd. chl. mit gr. ^ M. et ft. ch. 1. Mitte tales no. viii. Sig. Take one powder every half hour until bowels move and head is relieved. Some persons get better results from a single dose of calomel, two to three or five grains. 2. Then there are the remedies which act by relieving conges- tion. Such are blood letting, drawing six to eight ounces from the median vein of the forearm; the use of hot baths, hot water being added after the patient gets in, until it is as hot as she can bear; hot mustard hip baths, and hot mustard foot baths, putting about a tablespoonful of Coleman's ground mustard to the gallon of water. The amount of mustard must depend a little on the sensitiveness of the patient's skin. Counter-irritation over the upper part of the spine is some- times a great relief. A mustard plaster may be tried, or chloroform liniment laid on flannel and held close over the upper cervical vertebrse as long as it can be borne. I have known a case in which great relief was experi- enced from painting the upper part of the spine with the tincture of iodine. In some forms of nervous headache, when the face is flushed and the temples throbbing, an ice-bag over the occiput or the frontal region is more beneficial, or cold compresses, made by holding wet towels on ice and laving' them around the head from time to time. 3. Remedies which act by toning up the nervous system. Here first and foremost come hygienic measures, such as the morning cold plunge, with lively friction to the skin; massage; electricity, either applied generally, or to the scalp during a headache. Gentle frictions to the scalp of ten. exercise a sedative influence, lessening or dissipating the pain. A high-frequency current in the form of a brush discharge, and the wave current of static electricity are much used as a general nerve tonic in the intervals. 4. Hygienic Means. — Regular exercise in the fresh air, par- ticularly breathing exercises, expanding the chest and quickening the circula- tion. If the patient is not Aveak, it is well to exercise to the sweating point, then to take a cold sponge, and rest for half an hour to an hour. It is impor- tant for patients needing hygienic treatment to sleep in a room with open 232 CONSTIPATIOK". HEADACHE. INSOMNIA. OBESITY. windows, or, if possible, in the outside air on a verandah, both winter and summer. Room exercises, if no other are available, are invaluable, especially those which strengthen the abdominal muscles, and thus aid both by giving support to the abdominal viscera and by relieving venous stasis in the abdomen. For example, on awaking in the morning, while -lying flat on the bed, raising the body slowly to a perpendicular attitude about twenty times a minute with- out any aid from the arms; or raising both legs to a perpendicular position, while the body remains horizontal. Kaising one leg at a time only exercises the psoas and iliacus muscles, but raising both feet brings the abdominal mus- cles into play. Again, standing erect and bending forward with stiff legs, until both hands, arms extended, are brought as near the floor as possible, and then rising slowly again, strengthens the back muscles, completing the circle of the body cavity. The physician must exercise discretion, however, in ordering systematic exercises, and in using such remedies as tend to stimulate the processes of health by shocking the surface, as the cold bath ; he must not prescribe a nerve- exhausting routine of this sort for a jaded woman with no latent powers of response. To do this is as wise as it is to whip a fagged-out horse. A regular system of hydrotherapy, such as can be found on the Continent of Europe, and in some of our more advanced institutions, is often of the utmost value. Associated with this hygienic regimen, it is well to use bitter tonics. One of the best of these is nux vomica in increasing doses, beginning with ten drops in water three times a day, and increasing the amount by one drop at each dose until the patient is taking twenty to twenty-five drops three times daily. If there is any twitching of the muscles or stiffness of the jaws, the remedy must be discontinued, and when resumed, the dose must be fixed below the amount which was given before. Strychnin often works admirably and better than nux, given in pilules, containing each one-thirtieth of a grain, increasing the dose rapidly until one-tenth of a grain is being taken three times a day. For a patient who has headaches often and is below par. Dr. I. J. Prouty often gives : ^ Ammon. bromid gr. v Tr. nux vomica TTL x Elix. simpl oj M. S. Take in water after meals ; the nux should be increased from time to time until t^-enty to twenty-five drops are taken each time. 5. Prevention should be written in large letters and hung on the walls of every consulting room, and prevention and hygienic measures walk well hand in hand. By prevention I mean such a careful inquiry into the gen- TREATMENT OP HEADACHE. 233 eral condition and the habits of the patient, both as to exercise, hours of sleep, character of amusements, reading, and, above all, diet, as shall elucidate the probable causes at work in causing the headaches. It may be, especially in thoughtless young persons, that late hours, and unhealthy, exciting reading are at fault ; it may be that the day is all spent indoors, ending up with the theatre or a hot ballroom. Most frequently, however, the fault is dietary ; sometimes the capricious appetite craves only highly seasoned food and pastry, with strong black coffee or tea several times a day. In all these things to know is to act, and to effect a cure, a word to the wise is ever sufficient. Where the suffering arises from anemia of the brain, it is sufficient to check the flow of blood which is causing it, or to restore the normal corpuscular balance of the blood to cure the headache. Iron is indicated in most cases of headache accompanied by anemia and may be given in any of the various preparations already discussed (see Chap. VI, p. 156). In some instances, however, the pain is increased by iron, and it is best to substitute arsenic (see Chap. YI, p. 157) or cod-liver oil. I have found that the use of a large electric light (thirty-two candle power), "thermal electric light," in a parabolic reflector, applied to the side of the head and the back of the neck is of value, but possibly suggestion plays a more or less important role here. 6. Remedies which act upon arterial tension. — In all cases with high blood pressure, as evidenced by the full bounding pulse, the bromides of soda, of potash, andof magnesia, given in doses of ten grains or more, in one to two teaspoonfuls of simple elixir every hour until the pain is relieved, are of the utmost service. ISTitroglycerin in doses of one-hundredth of a grain every few hours, as occasion arises, is of inestimable value, especially in the old, whose arteries are in bad condition. But the best of all remedies in such cases is the nitrite of soda in half -grain doses, three times a day, con- tinued as long as the tension remains high; it is particularly valuable where there is a sort of status of headache. Marked disturbances of the circulation are sometimes seen after serious operations, with high pressure and headache. The sodium nitrite is invaluable here. On the other hand, in cases of headache where the arterial tension is low, ergotin in doses of one- fourth of a grain, increased up to one grain if necessary, three times a day, is of great value. In the headaches of pregnancy, the bromides are most useful, associated with diuretics and mild purgatives. Y. Remedies which remove the cause, when that is intra- cranial or circulatory.— The iodide of potash in syphilitic headache is the great specific remedy of this class. ISTo social status lies beyond the pale of this disease, and the drug is always worth trying in intense persisting headache with visual symptoms, when other remedies fail. The tol- erance of the drug may prove to be the only diagnostic factor discoverable. Quinine in malarial headache is similarly valuable. If the case is a frank one, the remedy may be tried in doses of five to ten grains, three times 234 cojSTSTipatiox, headache, insomnia, obesity. a day, watching its effect and stopping it, if there is any buzzing or roaring in the ears. Quinine is sometimes of value in headache where no malarial ele- ment exists ; in such cases it is supposed to act by raising blood pressure. In rheumatic headache, the uric acid diathesis which underlies it demands a course of ajDpropriate treatment, for which I must refer to the text-books on general medicine. Lauder Brunton recommends : 3> Pot. bromidi gr. xv Sod. salicylat gr. v M. et ft. charta. Instead of the salicylate, aspirin may be used in doses of six to seven grains, repeated every two to three hours, during an attack. Trepanation, excision of a scar, of an area of fracture, or of a spiculated bone pressing on the brain is a brilliant remedy, but one which is successful in too small a percentage of cases, even where the indica- tions for it seem to exist, to justify its being advised with assurance ; a well- defined hope is all that can be held out. The same thing may be said in regard to the removal of the ganglion of the fifth nerve for intense one-sided headache. In cases of this kind only a competent neurologist can decide as to the probability of relief by this means. Remedies which act through a mild sedative effect or by inducing sleep are invaluable when the pain is unbearable, but, unfortu- nately, though brilliantly successful in affording relief, they do nothing to effect a cure. First among these is the sulphate of morphin, given hypoder- mically, in doses of a quarter, of a grain, or, in extreme cases, a half. The extract of cannabis indica, one-half to three-quarters of a grain, in pill form, is often of great value. It is not easy, however, to obtain a reliable 23reparation of this drug; if a good article is foimd, it is best, as H. C. Wood long since advised, to secure all of it and use that alone. It must always be borne in mind in giving cannabis indica that some individuals have a marked susceptibility to it. The bromides and chloral belong in this class of remedies, but the latter is a dangerous drug for the patient to take into her ovti hands. A good prescription for the bromides is: 19 Ammon. brom ^J Elix. simpl fojss. M. S. Take a tablespoonful and repeat every hour until relieved. In more severe cases a substantial dose of the bromide must be given and chloral added, according to the following, or some similar prescription: ^ Sod. brom 3ij Chloral hydrat ^j Elix. simpl f3jss- M. S. Take a tablespoonful and repeat in one to two hours if necessary. TREATMENT OF HEADACHE. 235 Hoffman's anodyne (compound spirits of ether) is a remedy whicli has often rendered good service in the past, but has been largely abandoned, owing to the difficulty of getting a really good preparation containing the heavy oil of wine. It should be taken in teaspoonful doses in a wineglassful of water. Last in this group of remedies I mention the coal-tar preparations, valuable when used judiciously, but dangerous in careless hands, that is, in the hands of the patient herself or of the quack advertiser. The cases now and then coming to light before coroners' juries are but a small index of the numerous deaths from this cause to be laid at the door of the quacks. In some cases an idiosyncrasy exists which makes an ordinary dose of any coal-tar preparation dangerous ; the heart's action becomes unduly depressed, a fact shown by blue- ness of the lips and nails, or even of the whole circulation ; the cyanosis may be perceptible to others, when the patient herself is unaware of it. There is drowsiness, amounting in severe cases to coma, and if the drug is continued for some time, it induces a nephritis. As I write, I hear of the death of an ac- quaintance who had taken his mistress to an abortionist in ISTew York City. He had a weak heart and was suffering from a severe headache. The abortion monger gave him a coal-tar ready relief remedy, and in one hour he was dead. This is but one among hundreds of similar cases. Caution spelled in large letters is the warning to place on every coal-tar prescription. A good prescription is : 1^ Phenacetin or acetanilid gr. iij— v CafFein gr. j Sod. bicarb gr. iij M. et ft. ch. 1. S. Take as directed. The caffein serves to balance the depressing effect of the acetanilid. Some physicians prescribe a dose of whiskey with each dose of acetanilid, but the evils of alcohol are so great that I prefer using aromatic spirits of ammonia in twenty to thirty drop doses in a little water. The aromatic spirits alone in water is an excellent remedy where the stomach is somewhat disturbed. In using coal-tar preparations there always lurks the danger of forming a habit which in the end endangers life by its effects upon the heart. Migraine or Sick Headache. — I will now devote a little time to the considera- tion of sick headache and its management. In sick headache, prodromic symptoms are often present; of which the most constant is the sensation of a blinding light. Some patients display marked psychical disturbances, either of excitement or of depression. Dizziness and giddiness are not uncommon precursors; and in the gouty or rheumatic form, the head- ache is often preceded by stiffness or shooting pains in the joints. The headache at first is often situated on one side of the head ; in some cases it always starts on the same side, Avhile in others it alternates. It generally 236 CONSTIPATION. HEADACHE, INSOMNIA. OBESITY. begins in one spot near the temple, and extends downwards along the affected side, sometimes following, roughly speaking, the course of the fifth nerve and extending to the shoulder and arm. Shortly after the onset of the headache, one of the chief symptoms, nausea, appears, and, as a rule, increases until it ends in violent vomiting and retching, when at first the contents of the stomach are ejected and later bile. In severe attacks, when the retching con- tinues long after the stomach is emptied, it greatly exhausts the patient. Vaso- motor disturbances are also a marked feature of sick headache, the face being at times deadly pale, and at other times a burning red. When the pain is confined to one side, the vaso-motor disturbance is similarly restricted. One peculiar feature attending some sick headaches is an overpowering sense of drowsiness, sometimes so irresistible as to overcome even the severity of the pain and induce heavy sleep in the intervals of vomiting. Sick headaches in women have a marked tendency to appear at the menstrual periods, either before, during, or after menstruation. The duration of the sick head- ache is usually from twelve to twenty-four hours ; they generally leave the patient utterly exhausted. Young women, with strong recuperative powers, recover quickly, but older persons are often incapacitated for several days. As life advances, however, the headaches usually show a tendency to decrease in violence, although there is likely to be a period of great severity about the time of the menopause. After menstruation has ceased, they occur, as a rule, much more rarely. Treatment. — In sick headache it is useless to give remedies by the mouth during the violence of the attack, for the stomach will not retain them. A hypodermic of morphin is practically the only drug which can give any relief, but it is only in cases of extreme suffering or occasions of special urgency that the physician is justified in resorting to this measure. Under no circum- stances must he allow the patient to use the hypodermic syringe herself, for the recurrent nature of the disorder peculiarly favors the formation of a drug habit. Occasionally, a strong mustard plaster over the upper cervical region gives some relief, but, as a rule, when a headache of this kind has once begun, the only thing to be done for the patient is to keep her absolutely quiet in a darkened room, until the violence of the attack has subsided. A great deal can be done for the relief of such headaches, however, by prophylaxis. Persons subject to them are well aware that the attacks are most frequent if their general health is depreciated, or if they are exposed to unusual excitement or fatigue. TVhen it can be established that they are asso- ciated with a gouty or rheumatic constitution, the underlying condi- tion should be treated. Constipation should be especially guarded against, for in many cases the permanent relief of a constipated habit has been followed by permanent relief of the headaches. Xot infrequently a torpid liver exists in such cases, and the administration of a small dose of calomel at inter- vals of al)nnt ten days for a period of several months Avill do nuich towards relief. A lu'okcn dose of one-half to one grain in powders, or tablets of one- TREATMENT OF MIGRAINE. 237 eigl;ith of a grain, at intervals of half an hour, followed next morning by a saline pnrge, is the best form of administration. A wholesome varied diet, plenty of fresh air and exercise, attention to the bowels, and avoidance of over-fatigue and excitement will do a great deal towards reducing the frequency of these headaches. The physician must always bear in mind the fact that headaches of this description are sometimes due to uremic poisoning, and he should never be satisfied to treat a case without assuring himself positively as to the presence or absence of nephritis. 238 CONSTIPATION. HEADACHE. INSOMNIA. OBESITY. INSOMNU. I do not know whether an nnusiially large percentage of patients with in- somnia calls for relief at the consulting rooms of the gynecologist, or whether the world at large is becoming more and more afflicted with this disorder, but of one thing I am sure, that sleeplessness is a distressingly common ailment. With the exception of the neurologist, it probably falls to the lot of the gyn- ecologist to see more insomnia than any other specialist. It behooves him, therefore, not only to pay close attention to those cases which fall peculiarly under his sphere, but, in order that he may intelligeutly select his cases, to have some clear knowledge of the causes and treatment of insomnia in general. For this reason I give here the conclusions drawn from my personal experi- ences in this common and most trying malady. Etiology. — The causes of insomnia are not, as a rule, recondite ; they lie in the mode of life, in upbringing, in occupation, in domestic arrangements. Let us review a few of them. In the first place, sleeplessness is peculiarly common among neurasthenics, and whatever produces neurasthenia, con- spires to produce insomnia. Some neurasthenics, especially women, are such because of a fundamental defect in the nervous system ; others again are acquired neurasthenics through over-exertion. The recognition of these two classes has an important bearing on the prognosis in insomnia. Constant over-taxation in attending to life's duties without relaxation produces first, a sense of weariness which, as a rule, is neglected; the next symptom is apt to be an insomnia which cannot be so easily overlooked, as it soon begins to interfere seriously with the daily activities of life. Con- stant, fixed, strained attention to any pursuit produces a fulness in the head which leads to sleeplessness. Continued excitement, vexation, or a great sorrow brings about the same result. It must also be remembered that a persistent insomnia is sometimes the prodrome of grave nervous disorders. In children, excessive study produces insomnia. Some patients date their insomnia from habits be- gotten in childhood, practices due to a lack of proper parental control, relative to proper hours of going to bed. It is always important to inquire as to heredity, as sleeplessness, in a large percentage of cases, is inherited from a maternal or paternal ancestor. These and kindred causes seem to show that insomnia is kept up by a loss of vaso-motor control, or a vaso-motor exhaustion, resulting in dilatation of the capillaries. The habit of turning night into day, or as one of my associates puts it, " the habit of pottering around at night," begetting later and later hours, tends to produce a wakefulness which is hard to overcome. One of my friends who acquired an insomnia in this way, found that a small dose of TREATMENT OF INSOMNIA. 239 whiskey would give the much needed rest ; but the drug soon overmastered the patient, who died a confirmed drunlvard. Coffee and tea arc responsible for the wakefulness of some patients. There are diflferent forms of insomnia, namely, the early night, the early morning, and the all night forms. In other, distressing cases, there is fitful sleep or half sleep, when it seems to the patient that she has really been awake all night. Some people think they do not sleep, when in reality they get a number of hours of good rest. A night nurse slipping into the room at intervals through the night will often correct a false impression of this kind ; but it is not always well to tell the patient that she has had a good night's rest, as she may resent it. Treatment. — For practical purposes cases of insomnia may be grouped, I think, under three heads, namely : 1. Cases complicated with some other ailment, in which there is a reasonable hope that upon removal of the complication, the insomnia will disappear. 2. Cases in which the insomnia is associated with symptoms of a pronounced nervous disorder, and is of a more extreme form. 3. Simple, mild insomnia, which may be looked upon as a transient disorder, perhaps associated with some minor ailments in the genital tract, or in the nervous system. Cases of the first and last groups come continually, and come appropriately to the gynecologist for relief. The distinction between either of these and cases of the second group, however, is sometimes difficult to make, as no hard and fast line can be drawn between cases which are closely linked to the mild neurasthenics on the one hand, or are inseparably connected with a mild pelvic disorder on the other. Sometimes the test of two or three weeks' observation alone will tell. In all doubtful cases, a neurologist ought to be called in to assist in the decision. Bad, inveterate, and malignant neurasthenics do not belong by rights in the gynecologist's hands at all. The remedies I have found useful and applicable in the milder and inter- current cases, dissociated from any profound affection of the nervous system, may be grouped as follows : 1. Removal of the cause. 2. Hygienic remedies. 3. Drugs. 1. First and foremost it is necessary to remove any evident cause for the insomnia. A direct cause, as, perhaps, some gross lesion in the pelvis, or, it may be, some hidden cause, acting alone or with some minor pelvic lesion, will conspire to upset the nerve balance and bring .about persistent sleeplessness. A local affection, such as a relaxed vaginal outlet, letting the uterus down and permitting the pelvic structures to drag on their attach- ments, will produce nervous exhaustion, as well as a nagging displaced 240 CONSTIPATION. HEADACHE. INSOMNIA. OBESITY. kidne}'. I would then proceed at once to correct these troubles, and would expect the general care, the feeding, the massage, the fresh air, and the sunshine baths, that ought to follow an operation, to relieve the insomnia too. Do not let the patient be impatient about it, however, for the relief may be more positive after she is up on her feet again and able to walk out naturally, taking health- ful exercise without the previous drag. She wall then grow normally tired and sleep normally afterward. The first thing then is to operate soon, if the patient needs it, and to work on the insomnia while the other reparative processes are going on, so as to cure the sleeplessness, if possible, pari passu with the healing of the wound. 2. Hygienic Means of Relieving Insomnia. — These are by far the most important, indeed they are the sheet anchor of all successful treatment. Hygiene is the purpose of all forms of treatment, whatever they may be. However they may begin, in hygiene they must end, in order to be successful and self-perpetuating. The patient who is better while in the hospital after an operation must be committed with sedulous care to mother Hygeia on leav- ing. It is not enough for the physician to be able to claim that the wound healed well and the patient slept while she was under his care. The hygienic means at our disposal are these : A good bed. A cool room. A proper hour for going to bed. RegTilation of the diet. Cold and hot baths. Spinal douches. Cold packs. Massage. Electricity. Empty bowels. It is not my proper role to go minutely into these measures which are more fully described in works on hygiene and general treatment. Some patients sleep much better on a particular kind of a bed, one on a hard bed, another on a soft cushiony one; and when this is the case, the bed should be provided without thought of economy. A cool room, temperature sixty degTees Fahrenheit or lower, is conducive to rest; and when it can be arranged, it is a good plan to have the bed, duly sheltered, out of doors. It is a mistake, however, to get into a cold bed and to be kept awake by cold feet. The bed ought to be well warmed in winter, and if the patient cannot sleep well between linen or cotton sheets, soft blankets may be tried. Before going to bed, a hot bath (110° E.) may serve to draw the blood to the skin away from the head and so give an impetus to sleep at the outset. Whenever anything is done to promote sleep TREATMENT OE INSOMNIA. 241 before retiring, it is important to see that nothing stimulates thought or turns the attention actively in another direction, after the preventive measure is taken. I shall not say more about the diet than to indicate that a simple nu- tritious food is best. Late suppers and such nerve excitants as alcoholic beverages, tea, or coffee should be avoided. It is often of benefit, however, to give the patient a cup of gruel or hot malted milk on retiring, say about two hours, after a moderate supper. The fermentation in the stomach imposed by a heavy dinner keeps many persons restless and awake; this must always be looked into. Whatever mav be the difficulty in sleeping, the patient must go to bed at a reasonable hour, say ten o'clock or earlier, and not later than eleven. Patients who wake up in the night are often helped by taking some food ; a glass of milk is the simplest, for it can stand close to the bedside ready for use. When the patient takes a holiday cure, there is nothing like the activities of a simple camp life and a good rubber air bed in the woods to promote sound refreshing sleep. The bowels must be kept emptied regularly, as a copremia is often the cause of wakefulness. Massage is a gTeat help for a time, but it is only a temporary expedient, for the most part for the bedridden, as the patient must soon be thrown on her own resources to find natural healthful exercise day by day. General electricity works in a manner analogous to massage and is a good alternant with it. Sometimes an early night wakefulness is relieved by the application of electricity and a gentle massaging of the scalp. Of all the remedies for sleeplessness at our command the cold pack is, perhaps, the most generally useful. It is given in this way: The patient is placed upon a rubber sheet with a woolen blanket on top of it. Her nightdress is then taken off while she is kept well covered with a blanket, and she is then turned upon her side. A sheet is wrung out of water at the temperature or- dered, which may be anywhere from 100° F. to the temperature at which it runs from the spigot. The sheet must be so folded that the thin edge will be at the outside of the bed. The patient is then rolled in the sheet so that she is entirely enveloped in it, after which the edges of the blanket are brought be- neath her, each layer tucked in carefully, and the rubber blanket finally brought over the whole so that her entire body is covered by it. A hot-water bag must be placed at the patient's feet. If she does not warm up promptly, additional blankets may be used. She should remain in the pack for from five to twenty minutes, and when taken out, she must be carefully rolled in a dry blanket and briskly rubbed with a Turkish towel, after which her nightdress is replaced and she is put between sheets again. Our best neurologists to-day are making large use of hypnotism and suggestion in inducing sleep. To effect anything by this means, the physi- cian must know his patient well enough to inspire confidence and must engage 17 242 COXSTIPATIOX. HEADACHE. IXSOIMXIA. OBESITY. lier aid iu a coiiiiuun cau^e, operating' against a cuumjuu enemy, insomnia. The attitude of expectation thus created must be enhanced by the external conditions of the moment, such as retiring at a fixed hour, quieting the mind, and com- posedly awaiting the advent of the expected guest, sleep. The worst cases of insomnia must be treated, like bad neurasthenics, by absolute isolation and rest in bed for several weeks or longer, under the charge of one nurse, the patient not even being allowed to hear from a relative or read a letter, much less receive visitors. What shall I say about the treatment of that most distressing of all forms of wakefulness which springs from a mental distress, when the poor victim, un- able, as in the daytime, to escape from her anxiety in many hourly distractions, lies, and thinks, and tosses, and readjusts her circumstances, dwelling, perhaps, on some critical event, in which, if she had acted differently, her distress would have been spared. The true physician will not play the coward here, but will esteem it his highest privilege, according as he has grace given him to inter- vene, to heal the moral or the family ill, as well as the physical, and so to put the wearied mind at rest. This is the truly difficult side of our labors, far more difficult than any mere laboratory analysis, and for this reason many men, even among those who are accounted great, run away from it incontinently. Drugs. — I now come to the drug treatment of insomnia, much decried, but everywhere used, and in most cases necessary for a limited time. The drug is a crutch for the cripple on the road to the house of Hygeia, and sometimes the cripple cannot get there without it ; or she gets there much faster for the temporary, judicious, carefully supervised aid of the crutch. My list of drugs is but a short one: Trional, aspirin, veronal, codein, sulphonal, bromide of potash, chloral. The ideal hypnotic has not, and it is safe to say, never will be. found ; in fact it would be a mis- fortune if one were ever discovered, as it would then be used universally and persistently, to the exclusion of the return to natural sleep by the gateway of hygienic methods. It will be seen upon examining the different drugs on the list that there is not one which can be kept up indefinitely. " For temporary use " ought to be written on the label of the vial containing any one of them. Prescriptions for them ought not to be re-filled except by order of the physician, because of the extreme danger of forming the drug habit, as well as that arising from the pathological effects they may have upon the kidneys or the circulatory system. Aspirin, in five to ten grain doses, is of use where the insomnia is asso- ciated with headache. For wakefulness which occurs as soon as the patient goes to bed, trional, in doses of five to ten gTains, is one of the best remedies we have; for wakefulness in the latter part of the night, sulphonal in doses of ten grains is better. I have known the combination of the two to work beautifully. TEEATMENT OF INSOMNIA. 243 ^ Trional gi\ v Siilphonal gr. vii M. et ft. charta. S. Take at bedtime. It must always be remembered that siilphonal is occasionally extremely in- jurious to the kidneys, especially if given for a long time. There is a certain class of patients who go to sleep easily, but cannot stay asleep. With them it is a good plan to give ten grains of siilphonal about four o'clock in the afternoon and ten grains of trional at bedtime. Trional, in some cases, is more effective if given in a suppository containing fifteen grains. Another excellent remedy is veronal. Five to ten grains is the usual dose, though as much as fifteen grains may be given. Veronal must be watched and stopped if it produces any unpleasant symptoms. The bromideof sodium or of potassium in combination with veronal gives excellent results. I^ Potass, bromid oiij Veronal gr. xlviii Elix. simpl foiij M. S. Tablespoonful at bedtime. This combination will give a nervous, overAvroiight, excited patient a good night's rest when everything else fails. It must always be given in solution, never in powder form, as it has a tendency to irritate the stomach. In a bad case of insomnia, a combination of bromide and chloral may be used for one or two nights. I^ Potass, bromid gr. xl Chloral hydrat gr. xx Elix. simpl f §ss. M. S. Take at bedtime. Hyoscin hydrobromate, given hypodermically in a dose of one-hun- dredth to one-sixtieth of a grain, is of value in extremely nervous cases bor- dering on insanity. 244 CONSTIPATION. HEADACHE. INSOMNIA. OBESITY. OBESITY. It is not niY intention to do more here than refer to obesity in general and to give briefly in ontline such simple facts as ought to be in the possession of the practitioner who undertakes to treat any form of it. Obesity, corpulence, or an excessive deposit of adipose tis- sue in the body is a common affection among women, sometimes in association with disorders of the pelvic organs, and so characteristic of married women advancing beyond middle life that it almost constitutes the typical character- istic of the sex at this period. The fat, as a rule, is uniformly deposited in all situations where it is normally present, namely, about the face, the shoulders and arms, the chest, the abdominal walls, within the abdomen, and over the thighs and legs. When the superincumbent fat finds no support below, it falls downwards in transverse folds, creating a double chin, wattles on the back, or great folds across the lower abdomen, hanging over the symphysis. In such patients the specific gTavity of the blood is usually increased and, as a rule, the percentage of hemoglobin, creating a plethora. The most serious complication, however, is extensive dej)osits of fat about the heart and in the intermuscular interstices, by which the organ itself is literally smothered ; even the coats of the arteries are sometimes affected. Etiology. — Heredity is a strong predisposing cause in obesity and is some- times the only one which can be assigTied. Anders (" Practice of Medicine," 1900, p. 1226) noted that out of two hundred and two cases of obesity in his practice heredity was distinctly traceable in sixty per cent ; in fourteen cases out of the number it had existed from childhood. Gout and rheumatism are factors in a good many cases. Fibroid tumors are often accompanied by an increase in weight, while ovarian troubles are associated with a tendency to emaciation. In some cases of anemia or chlorosis the patient gains flesh from the non-oxidation of food. Amenorrhea is often accompanied by obesity and under these circum- stances the gain in flesh is often extremely rapid, it may be as much as fifty or sixty pounds in the course of a few months (see Chap. VI). The estab- lishment of the menopause, as is well known, is accompanied, in the majority of cases, by an increase in weight, and the same thing is observed to follow the removal of the ovaries before their functional activity is com- plete. Exactly what governs the increase of adipose tissue in the three latter classes of cases is not known; the most we can say is that with the disappear- ance of the ovarian function and the glandular corpora lutea the tendency to take on flesh, which has up to that time been held in abeyance, gains the upper hand; this is especially apparent in the Jewish race. Symptoms. — The symptoms of excessive adipose tissue (polysarcia) are: in- disposition to engage in active pursuits, or even to walk or take the TREATMENT OF OBESITY. 245 most moderate exertion; breathlessness on moderate exertion; plethora, as shown by the frequent flushing of the face, increased by exertion and often ending in dizziness. In young women, the rapid taking on of fat is marked, as a rule, by the lessening of the menstrual flow, which may even cease altogether for months or years — this form of amenorrhea is com- monly associated with sterility. Treatment. — The first stej) to be taken in the treatment of obesity is to ascer- tain the cause and, if possible, remove it. If the patient gives a history of gout she must be put upon a proper regimen for it. In anemia and chlorosis the administration of iron, arsenic, and cod-liver oil is often accompanied by a decrease in weight instead of a gain, as in other affec- tions, for example, tuberculosis. The obesity associated with amenorrhea is dependent upon the underlying condition which occasions the suppression of menstruation, and, as a rule, can only be successfully dealt with through it. In such cases I always try lutein tablets, five grains each, made from the dried corpora lutea of swine, given three times a day. In some cases they are followed by excellent results. In the obesity of women approaching or past the menopause the following lines of treatment are of value: When the patient is a large eater the amount of food must be cut down ; and with the lessened ingestion of food the patient will do well to spend more time in the thorough mastication or " insalivation " of what she takes. Most women over forty take more food habitually than is at all necessary at a period of life when the activities of growth and of child-bearing are at an end. Unfortunately, those women who consult the gynecologist on account of excessive fat are generally troubled with the affection in its less distressing forms, and they are, as a rule, unwilling to take any trouble or practice any self-denial to lessen their weight, least of all to modify their habits of life. If, however, the patient is disposed to take her condition seriously and to regulate her life each day so as to reduce her weight, a regular course of treatment should be prescribed, during which she must be under medical supervision both as to the effect as tested by the scales and as regards her general health. Before prescribing such a course of treatment the physician should make out an outline of the patient's history and of the line of treatment proposed. I give the following outline as a suggestion: ISTame. Age. ^N^umber of children, if married. Menstruation, as regards regularity and amount. Menopause. Present weight. Increase in weight over usual amount. Rapidity of increase. Symptoms associated with increase in weight. 2-16 CONSTIPATION. HEADACHE. IXSOMXIA. OBESITY. Food, amount, character, regularity of meals, amount eaten between regular meals. Write out a description of average meals, break- fast, dinner, supper or lunch. Water, amount taken. Alcoholic beverages. ^Vniount of exercise taken and nature. Any mental peculiarities, especially sluggishness suggesting myxe- dema. With these data before him as a working basis, the physician should under- line the prominent factors in the case, such as menopause ; amenorrhea; increase in weight within three years; much fat and starch in ordinary diet: excessive amount of water taken; exercise only about the house. The physician must then proceed to treat each case according to ideas sug- gested by prominent facts brought out in this investigation. The following general principles are always to be borne in mind : It is necessary to promote the oxidation of fat in the system and prevent the ingestion of new supplies ; in order to accomplish this the amount of fat-forming foods must be limited, while the amount of exercise and other factors increasing fat destruction must be increased. In the first place it is well to diminish the total quantity of food. The average diet for an adult is one hundred and twenty-five grammes of albumen, eighty of fat, and three hundred and fifty of starch. In attempting the reduction of obesity the albuminoids must be diminished least and the fats and starches to a much greater degree. Most cases of obesity would improve on one hundred and twenty-five gTammes, or more, of albumen, forty of fat, and one hundred and fifty, or even less, of starch. It is wisest, however, to reach this amomit of reduction by degrees. In the later stages of the treatment, when considerable amoimts of tissue have been lost, the non-nitrogenous foods should be increased, so that the albuminous tissues of the body do not become wasted. The treat- ment must be kept up for weeks or months as the case requires, and the cure must not be considered complete until the weight is brought down to what is normal for age, size, and sex. A rapid loss of weight at the beginning of the treatment is not desirable ; two to three pounds a week is much better for the patient than a larger amount. If any benefit is to be derived from the treatment, the physician must insist upon its being conscientiously carried out and the patient must be willing to comply Avith the directions. Where compliance with directions is difficult or impossible at home, it is an excellent plan to send her to some Spa, such as Carlsbad, Marienbad. or in this country, to the Hot Springs of Virginia. The following diet list for olesity is taken from Friedenwald and Rurah (" Diet in Health and Disease," 1905) : TREATMENT OF OBESITY. 247. GENERAL RULES FOR OBESITY. " Guard against sugars, starches, and excess of fat-forming foods. A cer- tain amount of fat with the food is essentiaL Let beginning impairment of the patient's streng-th be the sign to give more liberal diet. Diminish fluids, especially at meals, when not more than five ounces should be given. May substitute saccharin for sugar. May take: Soups (very little, if any). — Chicken broth, oyster soup, clam broth, thin beef-tea. Fish. — All kinds except salt varieties, salmon, or bluefish. Meats. — Once a day only; lean beef, mutton, chicken, game, veal. Eggs. — Boiled and poached. Farinaceous. — A limited amount of dry toast, aerated bread, shredded wheat biscuit, gluten biscuits, beaten biscuits, zwieback, Vienna rolls, soup-sticks, crusts, Graham gems, hoe-cakes. Vegetables (fresh). — Asparagus, celery, cresses, cauliflower, greens, spinach, lettuce, white cabbage, tomatoes, string-beans, stuffed pep- pers, radishes, very little if any potatoes. Dessert. — Cheese, grapes, oranges, cherries, lemons, currants, apples, peaches, berries, acid fruits, roasted fruits (little sugar). Beverages. — Limited quantity of water, buttermilk, tea, coffee (no sugar or milk), light wine diluted with Vichy. Mineral waters. — Avon Springs, Eichfield Springs, Crab Orchard, Londonderry Lithia, Hunyadi, Carlsbad, Friedrichshall, Eubinat, Puellna, Villacabras. Continue for several weeks drinking one glass of Kissingen water thirty minutes after each meal one day, and one glass of Vichy water similarly the next. May use artificial compounds. Must avoid : Fats in excess, beverages in excess, thick soups, salmon, bluefish, eels, herrings, and all salt fish, pork, sausages, spices, hominy, oatmeal, macaroni, potatoes, parsnips, turnips, carrots, beet-root, rice, water- melons, muskmelons, puddings, pies, cakes, sweets, milk, sugar, malt and spirituous liquors. I also give another dietary taken from Anders (loc. cit.), which illustrates what may be ordered in individual cases : Morning Meal. — Fine wheat bread, 1^ ounces ; a soft-boiled egg ; milk, 1 ounce ; sugar, 77 grains ; coffee, 4^ ounces. ]!^oon Meal. — Soup, 3 ounces ; fish, 3 ounces ; roast or boiled beef, veal, game, or poultry, 6 to 8 ounces ; green vegetables, 1^ ounces ; bread, 1 ounce; fruit, 3 or 4 ounces; no liquid (or only 4 or 5 ounces — 120.0- 148.0 c.c. of very light wine). 248 CONSTIPATIOlSr. nEADACHE. INSOMNIA, OBESITY, Afternoon Meal. — Sugar, Y7 grains; coffee, 4 ounces; milk, 1 ounce; occasionally bread, 1 ounce. Evening Meal. — Caviar, ^ ounce; one or two soft-boiled eggs; beefsteak, fowl, or game, 5 ounces ; salad, 1 ounce ; cheese, 1 drachm ; bread, rye or bran, -J ounce ; fruit or water, 4 to 5 ounces. Should there be a history of gout or of rheumatism, a course of diet spe- cially applicable must be made out. A good deal can be done in the way of prophylaxis during childhood in cases where the family history shows that obesity is likely to occur at maturity. In such cases careful attention must be paid to appropriate exer- cise, systematic daily cold baths, fresh air, and the reduction of fats and fari- naceous food. There has been much talk of late years of the extract of the thyroid gland in the reduction of obesity. In cases of myxedema it is known to be of great value and there are certain doubtful cases, where no symptom of myxedema exists excej^t mental sluggishness, in which small doses of the thyroid, say two grains three times a day, have a remarkable effect. It is always allowable to try the gland in such cases, keeping the patient under careful observation, but should there be any indications of injurious effects, manifested by tachycardia, or irregular heart action, suffusion of the face, syncope, vertigo, or marked headache, it must be stopped at once. The indis- criminate use of the thyroid in any and every case of obesity is extremely dangerous and ought not to be encouraged, as it acts as a depressant and also causes gastro-intestinal disturbance. In conclusion mention may be made of the four principal methods of reduction of obesity, namely, those of Banting, Von ISToorden, Oertel, and Ebstein. The distinguishing characteristics of these are: Banting reduces the amount of farinaceous food, depending almost entirely upon j)i"oteids. Von ISToorden reduces the amount of food as a whole, giving a large proportion of meat and restricting the amount of sugar and starches; the amount of liquids is also reduced. Oertel's treatment is based largely upon the reduction of liquids to as small amount as can be borne ; the diet allows rather more carbohydrate and fatty food than that of Banting and rather less than that of Ebstein. Oertel carefully includes the use of graduated exercises in his course of treatment. Ebstein gives less proteids than Banting, but more fat and carbohydrates, in fact, he allows a greater proportion of fat than is found in any other dietary. ADIPOSIS DOLOROSA. This affection, otherwise known as Dercum's disease, is characterized by the deposit of fat in masses situated in different parts of the body, pre- ceded and attended by pain. It is an affection peculiar to women and appears during the middle period of life. jSTeuralgic pains associated with the fatty ADIPOSIS DOLOROSA. 249 masses occur in different parts of the body. Sometimes the fatty deposits become so large that they form huge pendulous masses ; these never appear on the hands or feet. This affection differs from other varieties of obesity by the pain associated with it and by the irregular distribution of the fat. In some cases of the affection the thyroid gland has shown a marked tendency to atrophy. Dercum states that he has seen great improvement from the use of the thyroid extract in the treatment of the disease. CHAPTEE IX. BACKACHE. COCCYGODYNIA. (1) Backache: Frequency, p. 250. Etiology, p. 250. Treatment, p. 256. (2) Coccygodynia: Definition, p. 260. Early cases, p. 260. Etiology, p. 261. Symptoms, p. 262. Diagnosis, p. 263. Treatment, p. 263. BACKACHE. Frequency. — Backache is one of the commonest disorders to which women are heirs. Pain in the back is not often felt by either the yoimg or the old; it seems rather to belong to middle life, that is to say, to the period between the thirties and the fifties. The pain varies in intensity from a mild intermittent ache, coming on when the patient is tired, perhaps in association with a head- ache to a suffering of such intensity that she feels as though her back were breaking in two, and is unable to rise from a couch or chair without suffering, often expressed in loud groanings. Etiology. — It is not my purpose to make more than passing mention of those acute lumbagos which come on after exposure, or after sweating and allowing the wet clothes to dry on the back. The pain in such cases often begins without any warning, striking the patient utterly unexpectedly, like a bullet traversing the lumbar muscles (German, Hexenschuss). From that time imtil the attack is over, all muscular exertion causes pain, often extreme, and even agonizing. The best treatment in such a case is rest in bed, a hot relaxing bath, or ironing the lumbar muscles with a hot iron as hot as can be borne through flannel, for ten or fifteen minutes. It can also be cured by thorough deep Swedish massage, the treatments being given twice a day and continued for from twenty-five to thirty minutes. The best drug is aspirin in ten grain doses, followed by four or five doses of five grains each, at intervals of an hour. It is a good plan, in some cases, to inaugurate the treatment with ten grains of Dover's powder, to produce a free sweat. Sufferers from acute lumbago often find that they can ward off a fresh attack by wearing a flannel bandage, or by using a Jaeger wool bandage, made for this purpose. A plan of treatment diametrically the opposite to this is absolute fixation of the affected parts by strapping. Backaches must be distinguished according to their location as lumbar, lumbo-thoracic, sacral, or coccygeal (to be considered under the cap- tion coccygodynia, page 260). The common areas of location of aches in the posterior part of the lower trunk are: The coccygeal region, somewhat 250 ETIOLOGY OF BACKACHE. 251 hidden in the cleft of the buttocks; above this the sacral or the sacro-iliac region; above this again the lumbar region; and lastly an area above the lumbar in the lower thoracic region. These regions must always be considered as representing the structures below the skin, for example: 1. The coccyx, whether dislocated forwards or fractured, as well as the ligaments attached to it laterally. 2. The fascia overlying the sacrum with the erector spina? muscles and the sacro-iliac joints. 3. The lumbar fascia, the erector spinae, the quadratus, and the psoas muscles. 4. The serratus posticus inferior muscle. They are further distinguished according as the pain is fixed in one spot or radiates. The direction of radiation is almost always downwards. In some cases the pain is central, in others more lateral, to right or left, or on both sides. Patients, as a rule, consider that backache is due to kidney disease, if they are men; or to uterine disease, if women. It is true that pain in the back is sometimes associated with these conditions, and care should always be taken to ascertain how far they are accountable in any given case ; but the idea, so firmly fixed in the lay mind, that backache is always attribu- table to one or the other cause is erroneous. My own experience teaches me that a backache is not often directly dependent upon any pelvic disease, though it is a common con- comitant. I would attribute most lumbar aches rather to the neurasthenic or run-down condition of the patient, inviting a local disorder in a weak spot. This is often proven by the fact that the mere correction of a minor pelvic ailment, apart from the care of the general condition, does not do away with the backache ; whereas patients with aggravated pelvic ailments, where we would most expect backache, often do not complain of it to any great extent. It is common to find backache associated with pelvic tumors or inflammatory masses pressing on the sacral nerves as well as with retrodisplacements of the uterus and chronic constipation, but, as I have said, I attribute the backache rather to the general run-down condition of the patient than to the local intra- pelvic disorder. Backache is always a common symptom in nerve exhaus- tion arising from whatever cause. A common cause of the severe post- operative backache is the straight-out dorsal posture in which the patient lies during a long operation. The pain from the wrenching of the lumbar sinews is often far more intense than that directly associated with a major surgical operation. It becomes a matter of the first moment to distinguish, wherever we can, between the muscular rheumatisms of the sacral region and the lower back, and the sacro-iliac joint affections which cause similar pains in these regions. 252 BACKACHE. COCCYGODYJSTIA. In the first place, tlie rheumatic trouble may have come on as a sequel to an acute attack. Again, pain in the muscles may be aroused by pressure on the muscles themselves, either upon the erector spinae, or into the substance of the erector, the longissimus, the sacro-lumbalis, or the quadratus. The pain is provoked by such attitudes as serve to put these muscles on the stretch ; and, what is most important, the pain in the muscles tends to get better with a little exercise. The patient who starts out with groanings and with great difficulty, taking a halting gait, soon steps along as though per- fectly well. Schreiber (" Die mechanische Behandlung der Lumbago," Wiener Klin., 1887, p. T7) says that an intense dull pain widely extended from the sacrum to the third dorsal vertebra, not accompanied by much limitation in the move- ments of the vertebral column, indicates rather an involvement of the fascia lumbo-dorsalis than an affection of the muscles. When bending is possible, but straightening the spinal column is difficult and painful, the erectors are affected. Such patients preferably sit, or lie with the body inclined forward. On the other hand, difficult painful bending forward indicates an affection of the flexor muscles, the quadratus and the psoas. The psoas affection is evident in the distress occasioned by bringing into play its function of rolling the thigh outward. "When the pain is higher, in the region of the fourth to seventh ribs, not influenced by bending the spine, but excited by breathing, the serratus posticus is the affected muscle. The affections of the sacro-iliac joint are often quite different. The importance of this class of cases was first fully appreciated by Goldthwait {Bost. Med. and Surg. Jour., 1905, vol. 152, pp. 593, 634), who attributes many backaches in women to a sacro-iliac luxation. The condition still awaits recognition at the hands of the profession at large. Goldthwait says that the sacro-iliac articulations are true joints, and are by no means as stable as has been supposed, so that under normal conditions, some definite motion exists. There is always a physiological increase in this motion during pregnancy, and " possibly always, certainly occasionally, dur- ing menstruation. Injury, disease, a general lack of muscular and ligamen- tous tone, all are factors which cause an excess of the normal amount of motion. ... As the female pelvis is less firmly constructed the mobility is more easily obtained." I continue to quote as far as possible from Dr. Gold- thwait's monograph : " As the cases are studied, they at once divide themselves into groups : the first including those in which there is definite relaxation associated with pregnancy, representing an exaggeration of a normal physio- logical condition; the second, those cases in which the relaxation is associated with menstruation, apparently representing also a physiological condition, apart from any pathological change with which we are at present familiar ; and the third, the cases in which the lesion is due to trauma, general weakness, or some definitely known pathological process. In general, the relaxation asso- ciated with pregnancy is more marked, as it is also more rapid in its develop- AFFECTIONS OF THE SACRO-lLlAC JOINT. 253 ment, but it is also more certainly and quickly rectified by treatment when the cause is removed. With the non-pregnant eases the relaxation is not as marked; there is no sudden onset with severe symptoms, but it is more insid- ious and also more troublesome in treatment, as the apparent cause is repeated at the return of each menstruation. . . . " The cases which properly belong to the third group are not only more numerous, but many of the characteristics are different from those in the other groups. Only one joint may be affected instead of all three, as is common in the others, and the referred pains in leg and hip are much more common in this group than in those previously considered. The lateral deformities or deviation of the body to one side, due to the partial displacement of the bones on one side and not on the other, are common. The onset may be sudden. The so-called ' stitch ' in the back following strain or overwork is in most instances due to the slipping of these bones, and in these cases the lesion rep- resents a definite sprain, the severity of the symptoms depending upon the severity of the injury, as with sprains of other joints. The onset at other times may be more insidious, and may be part of a definite joint disease, the symptoms being due to weakness resulting from the disease, or from the pres- ence of accompanying bone and joint structure thickening, the hypertrophic arthritis (osteo-arthritis) being the most common of these affections. " In the general relaxation which follows prolonged recumbency upon the back, the lumbar spine straightens, and the back becomes flat. With this, the upper portion of the sacrum, being a part of the antero-posterior curve of the lumbar spine, is drawn backward. This is undoubtedly the explana- tion of the frequency of backache and leg pain developing at night after sleep, and also explains the more common backache after operations in which the profound relaxation produced by the anesthetic, together with the straight hard table, make the joint strain inevitable. The common way of relieving the night pain by stretching upon first waking, which draws the lumbar spine forward, is also understood with this knowledge of the anatomy. ... " At times the lesion apparently represents simply an excess of a normal physiological process. At other times trauma is a definite factor, ' sitting down hard,' or the ' giving way ' under severe strains, such as lifting, being the two most common forms of injury. Attitudes or postures are also of im- portance in causing a predisposition to joint weakness or displacement. . . . " In stout persons, either men or women, the drag of the large abdomen causes lordosis with resulting pelvic-joint strain, and explains the frequency of the sacro-iliac weakness in this type of individual. In this connection, imdoubtedly, the present so-called straight-front corset, if tightly worn, must be harmful by causing an unnatural amount of lordosis and by producing too great pressure upon the anterior portion of the iliac crests. . . . " Any motion in which the trunk or thigh muscles are used, whatever the position of the body, necessarily causes the bones to slip about or the joint to be strained. In the severest cases standing or walking is impossible, the 254 BACKACHE. COCCYCtODYNIA. patients describing the sensation as ' breaking apart in the middle/ or as the body ' settling down into the thighs.' With some the npright position and even walking is possible only for a few minutes, the bones apparently being held by strong muscular effort, but as soon as this relaxes, either from fatigue or in unexpected motion, the helplessness at once returns. In the mildest cases the symptoms have been so vague that the exact nature of the difficulty has been appreciated only by- a most careful process of elimination. " Of the symptoms which have been associated with this condition there is apparently quite a wide range. In the most extreme degree of relaxation or disease the helplessness is profound, nothing but recumbency being possible, while the slightest motion, such as raising the knee or moving the foot, is associated with definite movement of the pelvic joints and consequent pain and discomfort. A^Hien perfectly quiet there is little pain other than back- ache, and this is worse after sleep, during wdiich the spinal muscles become relaxed and the joint strain is increased. All three of the pelvic articulations may be tender to pressure, and the abnormal mobility may be easily demon- strable. In some of the cases sitting is impossible unless the weight of the body is supported, usually by placing the elbows on the knees or by holding the seat of the chair with the hands. On walking, the movement of the but- tocks up and down may be quite evident. " In the cases in which the relaxation or disease is less marked the symp- toms vary more, both as to the nature of the special symptoms, and as to their constancy. At times, only at the menstrual period is there any trouble or are the symptoms severe enough to cause much inconvenience. " Probably the most common complaint is of backache, referred at times definitely to the sacro-iliac articulations, but often simply to the sacral region. This is usually worse on lying upon the back or with any back-straining exer- cise or occupation carried to the point of fatigue. When lying upon the back, the flattening of the lumbar spine necessarily strains the sacro-iliac ligaments and is evidently the cause of the backache. As this takes place only when the muscles are relaxed, it explains the pain developing during sleep, the patient often being wakened with the severe suffering. This is usually relieved by stretching or by some other change of position in which the lumbar spine and the sacrum are drawn up. The backache which develops when the patient is up and about may be brought on by any posture which causes strain on the sacral ligaments, such as lounging, sitting with the lumbar spine thrown back, or prolonged standing and walking. At times the backache is produced by a jar or by some sudden, misstep in which the muscles are taken off their guard. At such times there is, as a rule, a distinct sensation of slipping or giving out, and the leg may actually ' give way,' just as the knee joint locks or ' gives w^ay ' if caught with a loose cartilage. The pain or backache may be referred to one synchondrosis or both, and with this there may be discom- fort referred to the symphysis. In the cases in which the pain has been referred at first to one synchondrosis there has nearly always developed, AFE'ECTIONS OF THE SACEO-ILIAC JOiNT. 255 sooner or later, a similar condition upon the other side, although frequently of less severity. " Referred pains are quite common, and are probably due to the pressure or pull upon the nerves in the sacral region. The lumbo-sacral cord passes directly over the upper part of the sacro-iliac articulation, and it is easy to see that a slight displacement or the thickening or nodes resulting from dis- ease might cause pressure upon this nerve trunk. Undoubtedly the pressure or irritation of the nerve received in this way causes many of the pains referred to the leg. They may be referred to any part below the seat of the trouble, to the thigh, the hip, the calf, or down the back of the leg following the sciatic distribution. These pains are practically always more upon one side than the other, but usually both sides are somewhat affected, and this, together with the fluctuation in the character of the pain, suddenly coining on or passing off, is of importance in differentiating between this condition and other conditions in which leg pains occur. That the nerves are pressed upon or irritated is not to. be wondered at when the anatomy is considered. In fact, in any displacement which may occur, or in the hypertrophic arthritic thick- ening^ the edge of the bone is so exposed that pressure or irritation of the nerve is almost to be expected. The severity of the pain is at times very great. In two of the patients it was so intense that lying down was impossible and the nights were spent pillowed up in chairs, " Objective Symptoms : The objective symptoms are such as would be expected from our knowledge of the condition. The motions which would bring strain ,upon the weak part are guarded, in the severe cases this reflex guarding leading to great disability. It may be impossible without assistance to get up or to lie down. Stooping is always made guardedly and in the severe cases this may be impossible unless the knees are flexed and the spasm of the hamstring muscles released. On standing, if the sacrum is at all displaced, the lumbar curve of the spine may be obliterated or even reversed ; the whole attitude being suggestively peculiar. If one side is more involved than the other, a marked lateral deviation of the body may be present, this always being away from the affected joint. A slight degree of this lateral deviation is very common. " Forward bending, if attempted when standing with the knees straight, is limited, but is always more free if the knees are flexed, as when sitting. In the first position the hamstring muscles which are attached at the tuberosity of the ischium are made tense, and by causing strain upon the sacro-iliac articulations develop the muscular spasm. . . . The character of the disease will be determined by the general appearance of the patient and the appear- ance locally; that is, the presence or absence of an abscess, the presence or absence of a tumor suggesting a new growth, and the presence or absence of the same disease in other joints. In the hypertrophic arthritic process, which is by far the most common form of disease seen in the sacro-iliac articula- tions, there almost always is at the same time disease of the spine with the 256 BACKACHE. COCCYGODYXIA. limitation of motion and other symptoms characteristic of the disease in that region." ]\Iore recently Goldthwait (Bost. Med. and Surg. Jour., 1911, March 16) has shown how weakness or partial displacement of the lumbosacral ar- ticnlation, with resulting pressure on the cauda equina or nerve roots, is respon- sible for many cases of " lumbago," "' sciatica " and " paraplegia." Other causes of backache must also be borne in mind. For example, acute infectious processes, such as typhoid fever and a gonorrheal arthritis. An agonizing backache is one of the most characteristic symptoms of the onset of small-pox. Congenital deformities and osteo-arthritis due to spondylolisthesis also give rise to distressing and persistent pain in the back. Treatment.- — I shall speak first of the sacro-lumbar rheumatic affec- tion, in which it is important, first and foremost, not to promise that a speedy cure will follow the relief of any co-existing minor ailment, such as an anteflexion, a laceration of the cervix, or a retroflexed uterus. It may he necessary to correct these errors (except the anteflexion), but the patient must be forewarned that the backache will take longer to relieve. Whatever local measures are employed, general tonic hygienic means must also be used to build up the health and to rest and feed the tired nerves. For this purpose give nux vomica, beginning with a few drops (five) three times a day in water and increasing daily by three drops until twenty or twenty-five are reached. I find useful a pill made after this prescription : ^ Ex. calumbse aa gT. J Ex. gentian ) M. ft. pil. 1. S. Take one pill after each meal. Dr. C. G. Hollister {Med. and Surg. Reporter, 1888, vol. 58, p. 201) found marvelous relief in a series of cases treated with this prescription: ^ Pot. iodidi 8ss. Pot. bromidi Sss. Tr. colchici sem fojss. Syr, aurantii cort foij Aquae q. s. ad f ovj M. Sig. One teaspoonful three or four times a day, or oftener, until the bowels are slightly acted upon. Massage is one of the best methods of treating backache, but it must not be given in the form of mere superficial skin frictions; the trained fingers and thumbs must first seek out the painful spots and then skilfully and thor- oughly rub them, so as to increase the local circulation and thereby dissipate the morbid products in muscle and nerve sheaths. In order to give the massage effectively, the patient lies flat on the abdomen on a hard mattress laid on the floor, or on a low bed. It cannot be properly given on a soft yielding bed, which lacks sufficient resistance, and dissipates TREATMENT OF BACKACHE. 257 the force applied to the muscles of the back. It is not necessary to remove all the clothes ; the best material between the hand of the masseur and the patient being sheep's wool. Kneeling close by the patient on the floor or standing at the side of the couch, the masseur kneads the painful structures overlying the sacrum, or in the lumbar regions, taking care to avoid making any marked pressure directly on the bone itself. In the beginning only mod- erate strength should be used, but the pressure must gradually be increased to a maximum, at first with the tips of the fingers, then the knuckles, and finally the whole fist. The kneading movements are followed by hacking mo- tions, in which the muscles are struck with the side of the open hand, the force being increased from piano, through forte, to fortissimo. In giving the knead- ing movements, the masseur works most comfortably on the same side as the structure under treatment, while in giving the hacking movements, he operates best across the patient. It is most important, says Schreiber, whose description I am following as closely as possible, to persist in giving the active local treat- ment in those very places where, according to the statement of the patient, the pain is most sharply felt. When the deepest muscles are involved, such, for instance, as the multifidi spinse, as evidenced by the great difficulty or impossibility of rotating the spinal column, pressure movements must be used which demand all the strength of the operator, using not only his hand, but the entire weight of his body. The hacking movements are not made from the shoulder joints but from the elbow. The amount of force used will depend upon the grade of the trouble, and upon the character of the muscular struc- tures under treatment, as well as upon the amount of subcutaneous fat, and the experience of the physician. Any little periods of rest in the treatment may be employed to test the progress made ; if the patient feels pain, the treat- ment must be begun again and directed to the painful spot. The following movements are to be recommended: Sitting and rising from a chair, a divan, a stool, without the assistance of the arm. Bending over. Lifting up objects, without bending the knees. Sitting and putting on the shoes. Standing and putting on drawers. Climbing up onto a stool. Climbing up onto a chair. Jumping down from the stool. Jumping down from the chair. Bending pelvis forwards, backwards, sideways. Making circular movements with pelvis. Climbing over a staff. Schreiber recommends that these movements should be repeated ten times. While at first they cause lively pain, this disappears in about half an hour, and they can be done without any suffering at all. 18 258 BACKACHE. COCCYGODYNIA. Those who are inclined to feel despondent over the treatment of an invet- erate lumbago, would do well to recall the emphatic statement of Schreiber, namely, that his collective experiences justify him in the assertion that every muscular rheumatism, whether acute or chronic, wherever it is located, can be healed by mechano-therapy. Even cases of twenty years' standing are susceptible of the relief of the 25ain and the com- plete restoration of function within a relatively short time. A good liniment for the patient's use is chloroform and aconite liniment. Some patients are benefited by a coarse salt rub, night and morning. Great relief is experienced for a time by the application of the familiar hot- water bag, though it is not curative. I used to relieve my patients for a long period, and in many cases effect a cure, by brushing the affected area lightly six to eight times with the Paquelin cautery heated to a cherry-red heat. If passed quickly over the surface the cautery never blisters, but leaves behind a slightly red streak. Some patients dread the notion more than the thing itself. This treatment may be used every five to seven days. Static electricity has been used with beneficial results in many cases. Where all other means have failed, the disease has been treated by the injec- tion of five milligrams of cocain in solution under the arachnoid of the spinal column, with instant relief. Fig. 74. — Shows Method of Applying the Thermo-light for Backache. Note the convenient Sims' lateral posture of the patient and the distance of the light from the back. A method which relieves perfectly and permanently a large percentage of cases, is to use heat and light rays by means of a thirty-two candle TREATMENT OF SACEO-ILIAC AFFECTIOlSrS. 259 power electric light in a large parabolic reflector (sec Fig. 74:). This may be applied for about ten minutes every day, shifting the light over the surface when it grows too hot in one place. If the skin is covered with a wet towel the treatment is more easily borne ; the moisture shuts off some of the heat rays, but does not interfere with the chemical rays. Patients invari- ably express themselves as greatly relieved at once and usually go on improving day by day. In many of the cases much relief has been obtained by using woven elastic trunks, fitted about each thigh, and then about the buttocks. These are laced or buckled, so that the pressure may be controlled, and represent one of the most reliable of the various supports. Another support and one which has probably been more satisfactory than any other, except perhaps the elastic trunks, has been devised by R. B. Osgood. It consists of a sacral pad to which a spring steel crib is attached. The ends of the crib curve backward, and to these wide webbing belts are attached, which, when fastened in front, crowd the sacral pad firmly against the upper half of the sacrum because of the curve in the crib part of the brace. The brace is kept in place by attaching it to the corsets by means of steels, and these not only hold the brace down, but, by steadying the lumbar spine, at the same time lessen the tendency to strain the sacro-iliac joints. In order to keep the brace in' place when sitting, a narrow strap is attached at the base of the crib, which is tightened when the thighs are flexed and prevents the brace from springing away from the body. This brace, in connection with the elastic trunk, has given relief in the severe cases when either alone was not satisfactory. Sacro-iliac Disease. — In sacro-iliac disease, proper support must be given to the pelvis. Goldthwait's treatment for the sacro-iliac cases varies according to the extent and the pathology of the lesion. The malposition, as he has dis- covered, is a backward subluxation of the upper part of the sacrum, either unilateral or bilateral, the correction of which may be brought about in sev- eral ways. Sometimes the patient is greatly relieved by lying at night on a firm bed with a firm hair pillow under the hollow of the back. In the more severe cases Goldthwait has succeeded in correcting the luxation by extending the spine, the legs resting on one table, and the head and shoulders on another, with the face down- wards and the body hanging unsupported between. The sacrum is thus replaced and a plaster jacket is applied. In cases of recent injury, rest may be enjoined and later a removable jacket applied, to be worn for several months. In the joint strains or the relaxations without displacements of the bones, which represent the greatest number of cases, some sort of firm support to the pelvic bones is all that is necessary, and there need be little interruption to the activities of daily life. Goldthwait employs a spring steel brace, extending up the spine and so adjusted as to make firm pressure over the sacrum. In other cases in women, a wide webbing belt attached 260 BACKA.CHE. COCCYGODTNIA. to the base of the corsets and kept up by the insertion of light steels gives enough pelvic support to ntford relief. 8nch belts are made more efficacious by attaching a lirm pad in the back so as to make pressure over the upper part of the sacrum. I have cited Goldthwait in detail in order to aid in placing this important matter before the profession at large and to stimulate investigation into a class of ailments Tvhich, although common, has not hitherto been recognized. The practitioner may not feel inclined himself to undertake treatments so decidedly orthopedic in their nature, but it is at least important that he should discern these affections as a cause of backache, and be able intelligently to secure the cooperation of a specialist in bringing relief to a patient "who must otherwise continue to suffer indefinitely. The distressing post-operative backaches can be avoided by keeping the limbs and the body slightly flexed during an opera- tion, by using pads and cushions under shoulders and knees, and, above all, under the small of the back. Anyone who will try lying on a hard flat surface without an anesthetic will find that it is a severe, almost unbearable strain to remain in the position for half an hour or more. COCCYGODYNIA. Definition. — Coccygodynia is a term coined by Sir James Y. Simpson, to designate several affections whose most marked characteristic is pain in and about the coccyx. The absence of any knowledge as to pathological conditions associated with the affection permits the grouping under one head of several troubles whose chief feature is pain in a common situation. As a clinical complaint, coccygodynia presents definite and clear-cut char- acteristics. Early Cases. — The condition was first recognized by Dr. J. C. Xott of Mobile, whose original publication on the subject appeared in the New Orleans Medical Journal for May, 1844, under the title " Extirpation of the os coc- cygis for neuralgia." Xott's description of the clinical symptoms is lively and the theories he advances to explain the pain are ingenious. The patient was twenty-five years old, unmarried, and what we should, to-day, call a neuras- thenic. Xott says " her condition was a truly pitiable one. Her general health was completely shattered and her strength exhausted with dyspepsia, constant nervous headaches, menstruation regular but difficult, excruciating pain at the jDoint of the coccyx, pains in the uterus, vagina, neck of the bladder, and back. The most prominent symptom was the exquisite pain at the point of the coccyx, which became intolerable when she sat up, walked, or went to stool, or, in short, when motion or pressure were communicated to it in any way." This condition had followed a blow on the coccyx four years pre- viously from which the patient recovered after several weeks' suffering, the pain not returning until about ten months before she was seen by Dr. ]^ott. ETIOLOGY OF COCCYGODYNIA. 261 As medicines had already been faithfully tried, E'ott at once proposed extir- pation of the bone as the only chance of relief. The operation was performed, of course without an anesthetic, through a vertical incision about two inches long. The bone was disarticulated at the second joint for about two inches, separated from its muscular and ligamentous attachments, and so dissected out and removed. 'Nott observes that the nerves were exquisitely sensitive and the operation, though short, was, he says, " one of the most painful I ever performed." The last bone of the coccyx was carious and hollowed out to a mere shell, l^ott further remarks, " this case is novel and instructive — I know of no one like it on record. E^o doubt many similar cases have occurred and their true nature been overlooked. I have another at this moment." The result of ISTott's treatment was an entire recovery. I have thus particularly described this early case, both because I wish to do credit to an able surgeon, one of the most original of our American pioneers, and because, aside from the antiseptic precautions which would now be present, the operation, as done to-day, does not differ in any important particular from its prototype in Nott's hands sixty-four years ago. Sir James Y. Simpson first disseminated a knowledge of coccygodynia and he also operated for its relief by cutting the ligaments of the sides of the coccyx. His earliest publication on the subject was in the Medical Press and Circular for July, 1859 ; a full account is also given in his " Clinical Lectures on Diseases of Women," published in 1863. Simpson's publications were fol- lowed at this time by others on the same subject, but of late the affection has fallen into undeserved neglect, little attention being paid to it except in quack advertisements, as can be seen by looking through the Index Medicus for the last five years. Etiology. — Coccygodynia is peculiarly a disease of women; I do not know of any disease, affecting an organ common to both sexes, which is so exclusively feminine. Beigel, as long ago as 18Y5, noted that it occurred in children. Many cases begin with a fall upon the coccyx or a blow in which it is struck; in most of my cases such a history was given, though no fracture, dislocation, or necrosis of the bone was found at operation. A common source of injury to which patients frequently attribute the trouble, is horseback riding ; one of Simpson's cases suffered intensely for years after a fall from a horse. Pregnancy and labor are important factors, though not so influential as Scanzoni believed, for he states with emphasis that thirty-four cases observed by him had all borne children. But in seven successive cases which I operated upon at the Johns Hopkins Hospital, three were unmarried, one had never had a child, and in not one of the other three was there a his- tory of an instrumental or even of a severe labor. The close analogy of coccygodynia with rheumatic pain in the fascia and muscles above, must be borne in mind, for it is within the range of pos- sibility that the affection may prove to be one, not of the bone, but of the tendinous structures. Rheumatism has been assigned as the cause in many 262 BACKACHE. COCCYGODYKIA. instances, and in one of Simpson's cases the pain began from sitting upon the damp gTOund. Coccygodynia is often associated with uterine and other pelvic ail- ments, although I do not believe there is any direct causal relationship, what connection exists being j)robably an indirect one through the general impres- sion made upon the health and the consequent neurasthenia. Proctitis and various rectal complaints occasionally cause disturbances similarly referred. 'Noit called the affection " a neuralgia of the coccyx " and M. Graefe comes back to the same interpretation, declaring after a careful study of his cases, all of whom had borne children, that he does not believe it is due merely to the trauma of labor, but that consecutive changes in the coccygeal plexus are to blame which are analogous to intercostal neuralgia, but as little capable of macro- or microscopical demonstration. SeeligTuiiller, in Eulenburg's Eeal Encyclopedie, under the caption " Coccygodynia," follows Graefe's idea and gives the affection an equivalent name, " l^euralgie des Plexus Coccygeal." I have cited these different opinions as to etiology, because here as else- where, the rational treatment must go hand in hand with our convictions as to the cause. In a general way it may be said that nervous people are most subject to the complaint, but it not infrequently appears in those who show no other sign of a neurosis. Symptoms. — The essential symptom of coccygodynia is pain in and around the coccyx. Its intensity varies all the way from a mere suggestion or a dull aching, to excruciating suffering, requiring morphin for its relief. The pain may be intermittent, but it is usually continuous, with an intensity which varies greatly from day to day. The onset is usually gradual, but not by any means always. The act of sitting down or rising always exaggerates the pain, and in some cases sitting becomes unbearable; so that it has been called " the sitting pain." In one of my patients this annoyance was met by having a hole cut in the chair upon which she was accustomed to sit. But it is not always possible to provide such a convenience, and the sufferer may be driven to sit uneasily, first on one hip and then on the other. Occasionally in walking each step brings on a twinge of pain and the patient is grad- ually reduced to a sedentary existence. The act of defecation is almost always associated with increased dis- comfort. Most patients with coccygodynia find the trouble worse in preg- nancy. In one of my cases it was severe at such times, but almost absent in the intervals. The causes at work in a given case of coccygodynia cannot, as a rule, be ascertained. It is certain that the majority of cases are not dependent upon abnormal length or mobility of the coccyx, nor upon- fractures, dislocations, or anchylosis or necrosis of the bone. Anchylosis is too common a condition, for Hvrtl, in a collection of one liuudro(l and eighty coccyges, found there were thirtv-two in which a luxation and a consecutive ancliylosis was present. DIAGNOSIS AND TREATMENT OF COCCYGODYNIA. 263 !Kott, the pioneer in this field, was inclined to lay great stress upon mechanical conditions. Diagnosis. — Coccygodynia, in its milder grades, is quite common, but the severe cases are rare. Although little attention is paid to it by the profession, it is astonishing how well known it is to the laity. There is scarcely a com- munity without its well-known sufferer from " elongated spinal column," " fractured or dislocated coccyx," or some similarly named malady ; this is probably due largely to the dissemination of quack literature. The condition is readily discovered on examination, in which the patient should lie in the dorsal or the left lateral posture; the index finger is then introduced into the rectum, and the coccyx grasped between the thumb and finger. Movement of the coccyx often reproduces the pain exactly. A further thorough examina- tion must be made of the pelvic organs in order to exclude disease there. Treatment. — The treatment of a coccygodynia will depend upon the severity of the case. In the lighter forms much can be accomplished by mild meas- ures, such as proper hygienic and medical remedies, while the severer cases, as a rule, yield readily to surgical treatment. In addition to these measures, faradization may be used. By this means, Graefe (Zeitschr. f. Geh. u. Gyn., 1888, vol. 15, p. 344) cured all his cases, five of them in from five to eight, and the sixth after twelve sittings. One pole is applied to the sacrum and one to the coccyx and the surrounding tis- sues. Seeligman put one pole in the vagina, and so cured a violent case of twelve years' standing with a single treatment. Bearing in mind the close analogy of this disease to the lumbago group of affections described in the preceding section, a thorough-going massage treatment ought to be faith- fully tried before resorting to surgery. If these gentler means fail to persuade the pain to let go its hold, then surgery comes in as a boon, as the operation of removing the coccyx is neither difficult nor dangerous. Simpson's operation of election consisted simply in freeing the coccyx from all its muscular and fascial attachments ; by this means he cured a number of cases, but it is technically as difficult as and less certain than the removal of the coccyx. In bad cases of coccygodynia, the removal of the coccyx is almost always curative. I relate the following illustrative case: Miss M., age twenty-six, Johns Hopkins Hospital, June, 1899. The patient complained of dysmenorrhea and a severe pain in the coccyx. She came of a healthy, in no way neurotic family, and had always been well up to the time her present trouble began. The dysmenorrhea had been present four years and the pain in the coccyx about one year. Formerly, menstrua- tion had been entirely painless ; it was always regular. The pain in the coccyx was associated with a sense of fulness and swelling; since its onset it had grown steadily worse, until it was impossible for her to sit do\ATi directly on the bone, and movement of the bowels was extremely painful. The great discomfort constantly endured was gradually producing nervous exhaustion. 264 BACKACHE. COCCYGODYNIA. Physical examination showed a well nourished and fully developed woman, with a retroflexed uterus, movable, and normal in size, normal tubes and ovaries. The coccyx was of normal size and position and not very movable; it was, however, exquisitely sensitive to pressure or the least movement. In view of these findings, the cervix was dilated and the uterus suspended, hoping that the relief of the intra-pelvic condition would also relieve the coccygodynia. In this I was disappointed, as she was in no way improved; so I operated again and removed the coccyx. The wound healed j)romptly, and the opera- tion gave complete relief. The patient married later, has had several children, and remains in perfect health. Sedatives and analgesics, such as morphin and cocain, ought always to be employed with the greatest care, as they only afford temporary relief and are liable to induce a pernicious habit worse than the disease itself. CHAPTER X. ACUTE INFECTIOUS DISEASES AS A CAUSE OF PELVIC DISEASE. (1) Atresia of the vulva and vagina, p. 265. (2) Inflamniation of the ovaries and uterus, p. 268. (3) Malaria and disease of the pelvic organs, p. 271. (4) Metastases to the sexual organs during parotitis, p. 272. ATRESIA OF THE VULVA AND VAGINA. It is now a well-recognized fact that atresias of the genital tract, hitherto supposed to be congenital in all but the rarest instances, are sometimes acquired in the course of the acute infectious diseases, and that, in all probability, much may be done towards their prevention by a recognition of this fact. Atresia of the vulva or the vagina may arise from infectious dis- ease at any period of life, but it is far more frequent in childhood. A seemingly trifling infection of the genitals accompanied by insignificant symptoms may lead to a complete closure of the vagina or the hymen which will remain unob- served until suspicion is excited by the absence of menstruation at puberty. Atresias are then a class of affections which is of the utmost importance for several reasons. In the first place they have hitherto been comparatively neg- lected by the gynecologist, and in the second, it lies entirely within the province of the general practitioner to recognize them at their outset, which, as yet, has hardly ever been done, and to prevent their extension by the application of suitable remedies. One of the first suggestions as to a causal relation between closure of the genital tract and infectious disease was made by Mossmann in 1881 (Amer. Jour. Ohst., 1881, vol. 14, p. 564). Fifteen years later ISTagel (Zeitschr. f. Geh. u. Gyn., 1896, vol. 34, p. 381) pointed out that it is rare to find a true congenital atresia of the vagina without some arrest of development in the uterus and adnexa, and stated that, in his opinion, most cases of so-called con- genital atresias of the vagina or hymen, where the uterus and adnexa are nor- mal, are acquired. He further held that the majority of such cases are the result of inflammation of the vulva or vagina arising during the course of the acute infectious diseases in childhood. Pincus, writing of primary amenor- rhea in 1903 (Monatsschr. f. Geh. u. Gyn., 1903, vol. 17, p. Y51) laid stress upon the fact that many cases of retarded menstruation, accepted without ques- tion as due to congenital obstruction, are really caused by atresia occa- sioned by infectious disease. In confirmation of this opinion he points out that in four hundred and thirty-nine cases of atresia of the genital tract collected by 265 266 ACUTE INTECTIOTTS DISEASES AS A CAUSE OF PELVIC DISEASE. Xeuo-ebauer (I. D., Berlin, 1895) the proportion of acquired to congenital was two to one (exclusive of cases arising after parturition). The following in- structive case is cited by P incus : A girl of fifteen had a severe attack of scarlatina, during which she menstruated for the first time. Before and after this menstruation she had a vao'inal discharge lasting three weeks, which at times was stained with blood. She became thin and pale, complaining of irritability of the bladder and a feel- ing of uneasiness in the rectum, with headache and occasional fever. Menstrua- tion did not return, and at the end of two months she applied at the clinic for relief, when examination showed that the entrance to the vagina was closed by a superficial membrane of a dark red color, traversed by blood vessels and some- what excoriated. On rectal examination the pelvic organs were found normal, but a mass was felt in the lower part of the vagina. The superficial membrane was then incised and about two teaspoonfuls of a thick, purulent fluid evacu- ated ; six days later a vaginal examination showed that the hymen itself was not closed, but completely covered by the membrane just described, which was easily stripped off. The atresia was in all probability the effect of an inflam- matory process set up by the scarlatina, but had the disease occurred a few years earlier, the condition of the genital organs by the time puberty was reached might have been such as to suggest that it was congenital. The following cases of atresia of the genital tract, reported as the effect of infectious disease of various kinds, have been collected from literature, prin- cipally from ISTeugebauer {loc. cit.) : Typhoid fever. — According to Pincus, typhoid fever is the most fre- quent cause of atresia, although the fact, he thinks, is little known. The lit- erature of the subject bears out his opinion, and I have collected nine cases, the largest number associated with any one disease : Boehm (Busfs Mag., 1856, vol. 46, Hft. 1). L. Mayer (Monatsschr. f. Geh. u. Frauenk., 1865, vol. 26, p. 20). Skene \'' Diseases of Women," 1889, p. 102). Lwoff {Wratscli, 1893, ^o. 28). Eberlin (Zeitschr. f. Geh. u. Gyn., 1893, vol. 25, p. 93). Steidele (" SammL von Beobacht.," vol. 2, p. 24). Zweifel (Centralh. f. Gyn., 1888, vol 12, p. 474). Small-pox. — The next largest number of cases reported is from small-pox: Scanzoni (" Traite des maladies des organes sexuels des femmes," 1858, p. 416). Alberts {Schmidt's Jalirh., 1878, vol. 178, p. 45). Johannovsky (Arch. f. Geh. u. Gyn., 1877, vol. 11, p. 371). Barthelemy (Ann. de gyn., 1881, vol. 2, p. 23). Richter ("Comment. Goettingae," vol. 2, Part II). Dysentery : Arnold (cited by Puech, Gaz. des hop., 1861, p. 277). Przewoski (cited by iSTeugebauer, loc. cit.). ATRESIA OF THE VULVA AND VAGINA. 267 Pneumonia : Scliultze (I. D., Jena, 1882). Brose {These de Paris, 1896). Erysipelas : Bourgeois (Meissner's " Forscliung.," vol. 5, p. 149). Cholera : Ebell (Beiirdg. f. Geh. u. Gyn., 1872, vol. 1, p. 51). Scarlatina : Pincus (Monatsschr. f. Geh. u. Gyn., 1903, vol. 17, p. 751) (two cases). Diphtheria. — It Avould seem that diphtheria, with its known tendency to invade mucous membranes in other localities than the throat, would be respon- sible for inflammation of the genital tract as often as or oftener than other infectious diseases, but this does not seem to be the case. T have found but one case in which atresia of the vagina was reported as arising from it, and that was reported by Orth and cited by ISTeugebauer (loc. cit.). Measles. — Pincus states that, to the best of his belief, no case of atresia of the vagina arising from measles has been published. Two cases of imper- forate hymen, however, have been reported by Wuth (I. D. Jena, 1893) which possibly arose from this cause. In both instances the patients, who were suffering from primary amenorrhea, had had measles in childhood, but no other infectious disease; in one case a distinct scar could be traced along the closed hymen. The whole number of cases cited is not so large as might be expected, but it must be remembered that it is only within recent years that attention has been called to the subject, and these cases have been collected from papers written to develop points quite distinct from the question under discussion. I have met with fifteen cases of atresia where no mention is made of causation; in a few instances the context implies that it was considered congenital, but in not one of these cases is there any mention of the previous history of the patient as regards infectious diseases. The ease with which acquired atresia may be overlooked is shown in the case of Pincus just cited, and another case reported by him shows the importance of minute inquiry into the presence of infectious diseases in childhood. A girl of fifteen, who had never menstruated, died in the third week of typhoid fever from peritonitis induced by rupture of a uterine tube. Exam- ination of the external genitalia, made shortly before death, showed a fresh tear in an otherwise imperforate hymen, which had doubtless occasioned re- tention of the menstrual fluid with resulting hematosalpinx and rupture of the tube. The patient's mother stated that her daughter had an attack of scarlet fever about four years before, after which she had a vaginal discharge con- taining " little fragments " (probably shreds from coagulation or necrosis). This information was obtained only by persistent inquiry, and in its absence the case might easily have been set down as congenital. 268 ACUTE INFECTIOUS DISEASES AS A CAUSE OF PEI.VIC DISEASE. INFLAMMATION OF THE UTERUS AND OVARIES. In most of the text-books on gynecology, I find the " eruptive fevers/' the " acute exanthemata," or the " acute infectious diseases " mentioned in the list of specified causes of ovaritis and endometritis, hut in none which I have seen is there any more particular mention of the subject, with one exception, namely, " A Text-hook on Diseases of AVomen," by C. B. Penrose, 1001, pp. 197, 330. Periodical literature is little more satisfactory, for of the papers scattered here and there at wdde intervals, only two are important. Ovaries. — Lawson Tait (''Diseases of the Ovaries," 1883, p. 100) called attention in 1874 to the occurrence of pelvic peritonitis after attacks of scarla- tina or small-pox, stating that he had observed a number of cases of the kind in question during an outbreak of small-pox at Birmingham. Tait was of opinion that there was a special variety of inflammation of the ovaries associated with certain of the exanthemata which might or might not be followed by general atrophy of the organs, and some years later he pub- lished a case of superinvolution of the uterus which he believed to be of this kind. After the publication of Tait's opinion the possibility of a special form of inflammation of the genital organs associated with infectious diseases was occa- sionally discussed, but only two of the contributions to the subject are based upon scientific evidence. The first of these papers, by Lebedinsky (Abst. in Centrhl. f. Gyn., 1877,. vol. 1, p. 110) treats of the changes observed in the ovaries after death from scarlatina. The macroscopical appearances were found to be unaltered, but microscopical examination showed that the Graafian follicles were in a state of parenchymatous inflammation, varying in degree from a slight cloudy swelling to complete destruction of the epithelium. The younger the follicle the more severe the changes. The stroma of the ovary was not affected except from hyperemia of some of the solitary follicles in the connective tissue. The great- est changes were found in the ovaries of a child eight years old, who had measles three weeks after recovery from scarlet fever, and died after an illness of eight days. Here the greater part of the follicles was filled with a finely granular structureless mass, and the greater part of the cortical layer of the follicles had altogether disappeared. Scar tissue was present at all stages of the inflammatory process. Lebedinsky considered that the changes in the ovary were similar to those taking place in other parenchyma- tous organs during scarlatina, and believed that the degeneration of such a number of follicles results in more or less impair- ment of the function, sufficient in some cases to affect the reproductive capacity. The second article is by Skrobansky (Jour, d'ohst. et de gyn., Oct., 1901) and contains the results of investigations into the condition of twenty-seven ovaries belonging to women and cliildren dying of scarlatina, diphtheria. INFLAMMATION OF THE UTERUS AND OVARIES. 269 typlioid fever, and miliary tuberculosis. In all cases the ovaries had undergone more or less degeneration, but its character was the same, no matter what was the form of infection. Furthermore, neither the intensity nor the duration of the disease made any difference in the extent of the affection. In some instances where the disease was most virulent, the changes in the ovaries were of the slightest, while in others, where the disease was much lighter in intensity, the ovaries were considerably affected. From these facts Skrobansky and Lebedinsky draw the same conclusions, namely, that the changes caused by infectious diseases upon the ovaries are exactly the same as those produced by them upon other parenchymatous organs. Since the appearance of the second of these papers, a case of abscess of the ovary during typhoid fever has been reported by B. C. Plirst (/ow?\ Amer. Med. Assoc, Feb. 11, 1905), and another in which the uterine ap- pendages were inflamed during the same disease by E. Dirmoser (Centrhl. f. Gyn., 1904, voL 28, p. 117Y).' Uterus. — The changes wrought by infectious diseases upon the uterus were investigated by Massin {Arch. f. Oeh. u. Gyn., 1891, vol. 40, p. 146), and I believe his conclusions have not been contradicted. He gives a brief review of the literature and shows that up to the time he wrote, opinions upon the subject were so contradictory that it might be considered an open question. He examined the changes in the uterus, both gross and microscopical, in eighteen cases, two of which had died of croupous pneumonia, three of typhoid, one of dysentery, and twelve of ''relapsing fever." In all of them he found definite inflammatory changes in the endometrium, accompanied, in many instances, by hemorrhage leading to a typical hemorrhagic condition. The inflammatory changes were the same as those observed under ordinary circumstances, but they varied in in- tensity with the disease, as in all cases where the temperature was persistently high there was hemorrhage, while it was present in only half the number of the milder cases. The substance of the uterus was little, if at all affected, although in a few cases the changes appeared to extend out from the endometrium. Massin concluded, therefore, that the acute infectious diseases must be regarded as one of the causes of uterine disease in women, and especially, he says, in those cases where the disease occurs before puberty. The question whether the endometrium is liable to be affected during gonor- rheal vaginitis in little girls has been recently investigated by Jung (Centrhl. f. Gyn., 1904, vol. 28, p. 991). He examined nine children between the ages of two and nine, in whom the gonococcus was known to be present in either the vagina or the urethra when the child entered the hospital. The examina- tions were repeated every eight days in order to ascertain whether the gonococ- cus was still present in the cervical secretion, and were kept up for three or four months. Jung came to the conclusion that infection of the cervical 270 ACUTE IXFECTIOIJS DISEASES AS A CArSE OF PEEVIC DISEASE. secretion Ity the aouococcns, altliougli it iiii women, whose sole symptom and complaint is "^ ^ <»* ' • , excessive hemorrhage at the menstrual period ; or extension of the flow beyond its normal dura- tion. These patients in aggravated cases are waxy, almost hydremic, short of breath and in- ^ 'J capable of any. other than a most sedentary exist- >, -v ence. The hemorrhage, at first bright, becomes ^ X ^ -.) watery as it is prolonged. It is not too much *> . " \ ■ to say that the bleeding is sometimes fright- ^^^ \ ' . ^, ful. The anatomical basis of this hemorrhage ~ , ^ "1 Fig. 79. — A Polypoid Endometritis, showing a Section of THE Endometrium with some of the Underlying Mus- ^ CULARIS taken FROM A PoiNT NEAR THE MiDDLE OP THE . Uterine Cavity. The redundant polypoid condition of .._^-^- •-- .--■ - ^^^^^^^^^^r^^ the mucosa hanging downward toward the cervix is evident. The surface of the polypi is covered with a single layer of epithelium continuous with that of the tm- derlying glands, while the stroma is abundant and dense, owing to a marked small round-celled inl.l- tra,tion. The uterine glands are diminished in number. Froni T. S. Cullen, ' ' Cancer of the Uterus." :^-v 294 -^TTLYITIS. TAGIXITIS. CEEVICITIS. EXDOMETEITIS. resembles a condition of multiple polypi choking the nterine cavity (see Fiff. 78). The elands are ereatlv dilated and the blood vessels increased in number and size, but there is no evidence of invasion of the muscle, as is the case in adeno-carcinoma. A microscopic examination of the curettings should be made in all cases, in order not to mistake a cancer or a sarcoma for the disease in question (see Tig. 79). The methods of treatment are by chemical cautery or by the use of nitric acid or nitrate of silver to the interior of the uterus. The risk of setting up an inflammation in the uterine tubes by the use of these drugs is so gTcat that they ought to be gen- erally abandoned. The actual cautery has been used in the form of air (zestokausis), and steam (atmokausis). It is difficult to regulate these agents and prevent them from burning too deeply into the "svalls of the uterus, thus producing sloughs ; for this reason I do not recommend their use. The third method of treatment, curettage, is the safest of all. This should be preceded by a dilatation of the cervix, and followed by a thorough, gentle use of a sharp curette by the method described in detail in Chapters IV and YII, pp. 123 and 189. SENILE ENDOMETRITIS. A senile endometritis differs markedly in some of its clinical aspects from the ordinary forms foimd earlier in life. A careful description of this affec- tion has been given by H. L. Dunning (Jour. Amer. Med. Assoc, 1904, vol. 43, p. 767). The "vvomb is small and shovs no marked changes in the body. The diseased endometrium pours out a milky purulent discharge. This is often associated ^vith erosion of the cervix and erosion, adhesions, and con- tractions at the vaginal vault. The vagina itself, bathed in the irritating secretions, is smooth, reddened, and often covered with reddish patches. The discharge accumulating in it is often offensive. A vulvitis of the shrivelled external genitals may be present and marked by intense itching. The puru- lent or bloody purulent discharges from the uterus are often mistaken for signs of carcinoma. It is in these cases that the cervix, having lost its epithelium, sometimes becomes agglutinated, converting the uterus into a closed cavity which becomes distended with the accumulation of discharges and converted into a pyometra, or if gas also forms, into a pyo-physometra. The patient, is apt to suffer from distress and burning in the lower abdomen and this is gTeatly aggTavated if the cervix becomes closed. Owing to absorption of the poisonous products there may be anemia and cachexia. The ordinary senile endometritis is not associated with fever. The inflammatory changes are found in the thin senile endometrium in which the glands, after dipping for a short distance below the surface, turn to extend parallel to the myometrium. The treatment is by dilatation for drainage and the application of weak solutions of nitrate of silver (five to ten per cent). CHAPTER XII. PRURITUS. VAGINISMUS. MASTURBATION. (1) Pruritus: Definition, p. 295. Etiology, p. 295. Symptoms and diagnosis, p. 297. Treat- ment, p. 297. (2) Vaginismus: Definition, p. 304. Etiology, p. 304. Prognosis, p. 306. Treatment, p. 306. (3) Masturbation: General considerations, p. 309. Etiology, general and local, p. 310. Preva- lence, p. 310. Methods, p. 311. Clinical findings, p. 312. Effects, p. 314. Diagnosis, p. 314. Preventive treatment, p. 314. Curative treatment, p. 315. PRURITUS. Definition. — Pruritus is a general term wliicli signifies neither more nor less than an itching. Hebra defines pruritus as a chronic disease of the skin, which though lasting for months and years may be characterized by no other symptom than itching. The skin may show no alteration at all, or else only such as arises from the constant scratching of the parts excited by the intense irritation. The term pruritus is used here to designate simply an itching of the vulva. Etiology. — The changes in the skin, so often observed in pruritus, are sec- ondary to the disease, and arise from the itching and consequent scratching or else from the presence of irritating discharges. These secondary changes do not constitute the affection, though they undoubtedly aggravate it, and for this reason the physician must always look behind the superficial affection for some one of the variety of causes in which it may have originated and by which it is, as a rule, maintained. In many cases the profound skin changes, when once induced, are sufficient in themselves to keep up the pruritus even after the original cause is removed ; in fact, these cases move in a truly vicious circle : the itching provokes scratching, and the scratching, in its turn, causes changes in the skin which excite more itching, and this again provokes the desire for relief by renewed scratching, and so the disease grows constantly worse, feed- ing itself upon the very means which the victim instinctively seeks for relief. In general two sets of causes are recognized as inducing pruritus, and perhaps a third. These are : (1) Irritating secretions, acting upon the parts and often associated with a local infection. (2) Neuroses. (3) Blood alterations. Diabetes may be cited as an example of the third class. Sanger con- sidered that the pruritus observed in diabetes was hematogenous and analogous to the pruritus seen in jaundice. Many authorities believe, however, that the local action of the urine is sufficient in itself to explain the presence of irri- 295 296 PETJEITUS. VAGINISMUS. MASTTJKBATION. tation in this locality. Yeit points out that men with diabetes suffer from pruritus of the scrotum and believes that the irritation is due to some other constituent in the urine than grape sugar, as he tried putting gTape sugar compresses on the vulva of some patients without provoking itching. It is an interesting question how far pruritus is associated with constitutional gout. As to the neurotic form of pruritus, the term is used in a general sense, as it is in nervous dyspepsia, being often employed to cover an igno- rance of the true local cause. It should be recognized that the term is one of convenience only, such as we are still often obliged to use, so long as we are unable to discover locally acting causes. The most satisfactory group of cases is that constantly enlarging one in which the disease can be attributed to some irritating or infectious secretion, continually discharged over the parts, and thus keeping up a constant irritation. It is possible that eventually some hitherto unrecogTiized organism, peculiarly adapted to gTOwing in the moisture and secretions of the parts, will be found at the bottom of almost all cases, and we shall be able to refer a large number of them to a uniform cause. "Webster considers that pruritus consists essentially in a slowly progres- sive fibrosis of the parts (subacute inflammation of the papillary bodies), especially of the labia minora and the clitoris, by which the nerves and their endings are chiefly involved. Leopold holds that pruritus is almost always due to an old chronic endometritis. The following causes of pruritus must be kept before the physician when he investigates any particular case : (1) Pediculus pubis. (2) Ascarides, (3) Thrush. (4) Diabetes. (5) j^ephritis. (6) Menstrual discharge. C^) Gonorrhea. (8) Vaginitis. (9) Pessaries. (10) Pregnancy. (11) Cervicitis. (12) Carcinoma. (13) Endometritis. (14) Tuberculosis. (15) Masturbation. (16) Menopause. (IT) Varices. (18) ISTeuroses. (19) Gouty diathesis. (20) Eczema. SYMPTOMS AND DIAGNOSIS OF PKURITtTS. 297 Symptoms and Diagnosis. — From whatever cause the pruritus arises, it varies in intensity from a slight or an occasional irritation, mani- festing itself in sensations of an itching, pricking, or creeping char- acter, all the way to an irritation so severe as to be a continual torment, making the day miserable and turning the night, designed by nature for rest and refreshment, into a curse. In such cases the sufferer becomes haggard and worn with sleepless nights, made hideous by the con- stant impulse to relieve the horrible itching by tearing at her person, while she longs for morning to bring the activities of another day to afford a little distraction from the Promethean vulture. So intense is the suffering in these cases that the patient sometimes loses all self control and leads an isolated life, in order that she may attend uninterruptedly to the imperative demands of the disease, which excite an uncontrollable desire to rub the affected parts. Cases have even been known when, after years of suffering, the patient has committed suicide as the only means of relief from torture. Those who are blessed with immunity from this dreadful disease may be thankful that they know nothing of the suffering which it entails. The local changes in the parts are characterized in the beginning by a reddening of the surface and then by the appearance of small flat papules, the skin over which is speedily scratched off. As the disease progresses, the skin becomes thickened and white, while long scratch marks are often perceptible. The vulvar hairs to a large extent disappear, and such as remain are broken off short; the parts are often moist with secretions. Later on, the white area increases in extent, and as the skin thickens, the nor- mal anatomical outlines of the parts disappear. The clitoris is marked by a slight eminence or else disappears under a sort of thick white blanket, while the labia assume an almost pachydermatous appearance. When the disease is thus far advanced, the patient, as a rule, is almost beside herself with the continuous desire to tear at the parts. The changes in the affected parts are best described in the words of the dermatologist as inflammatory para- keratosis (Veit). There is an enormous thickening of the horny layer of the epidermis with an extensive small-celled infiltration just below. A pus- tular folliculitis is sometimes associated with the original pruritus, arising from infection of the parts irritated. Treatment. — In almost every case of pruritus the suffering is so intense as to call for immediate relief of the local condition, but the permanent cure can only be effected by the removal of the underlying disease. One of the first steps in the treatment is a careful analysis of the urine, in order to discover a possible nephritis or diabetes. It sometimes happens that itching of the external genitalia is the first symptom of sugar in the urine. If the presence of sugar is determined, the treatment must, of course, be directed to the fundamental disease ; nevertheless, it is most important to keep the parts clean and free from contamination by sponging them with a rectangular pad of gauze wet with a saturated solution of boric acid in water. Pediculi 298 PEUKITUS. VAGINISMUS. MASTTTKBATIOW. or tlieir uits can always be found by carefully examining the vulvar liair>5. They are readily destroyed by washing thoroughly with green soap and warm water and then with a decoction of fish berries. This pro- cedure should be repeated at intervals of a few days. Shaving the parts is another good method of destroying them, as well as the application of a mixture of sweet oil and carbolic acid (ten per cent). In the case of little girls who complain of itching at the vulva, two things should always be borne in mind, namely, ascarides and uncleanliness. Ascarides are likely to be associated with anal pruritus, and when this is the case, an examination of the stools serves to clear up the diagnosis by revealing the presence of the worms. The ova are easily found in the feces, if the worms are at all abundant. Cleanliness should be enforced by insisting upon the gentle and careful, but thorough use of warm water and pure castile soap every few days. It is a pernicious training which teaches children that the genitalia should never be touched, for the natural secretions are thus allowed to accumulate, causing irritation and congestion. Thrush, growing in whitish patches on the parts, should be removed by a thorough cleansing with warm water and castile soap, followed by dusting with dry powder, made according to the following formula: ^ Ac. salic gr. ij Pulv. camph gr. jv Ac. borac. 3vj Pulv. amyl 3ij j\I. Ft. charta. S. Dust on with a little pledget of cotton twice daily, after careful cleansing. A saturated solution of chlorate of potash in water used as a wash is also a good way of curing thrush. Sometimes pruritus is excited and kept up by a vaginal discharge of a gonorrheal character. The peculiarity of a gonorrheal discharge, aside from the fact that its seat of predilection is the vulva, is a tendency to invade the cervical glands and provoke a ropy, mucoid, purulent discharge, the gonor- rheal nature of which can only be determined with certainty by microscopical examination. In some cases of pruritus, however, associated with a tough muco-purulent discharge from the vagina, an examination with the microscope reveals the presence of the yeast fungus and some of these cases are associated with gonorrhea; in such cases the use of permanganate of potash is beneficial. The application of brewer's yeast has also relieved the difficulty. In questioning or examining a patient with pruritus accompanied by a vaginal discharge, the physician must remember that the itching is more often provoked by a slight discharge of a thin quality than by a profuse leucorrheal TREATMENT OF PRURITUS. 299 one. A good method of testing the relation of the discharge to the pruritus is to insert a tampon in the vagina and leave it there for twenty-four hours. The patient will often declare that she has had no itching at all, while the tampon was in place, which affords a valuable hint as to the treatment. Dilatation and curettage of the uterus (see Chaps. IV and VII), cauterization of the cervix, or the relief of a vaginitis (see Chap. XI) may in such cases be followed by immediate relief. The physician must not be too sanguine, however, as to an immediate and permanent cure. All cases of pruritus should be kept under observation and examined at intervals of every few weeks for a period of several months. Pruritus limited to the post-menstrual period does not, as a rule, call for treatment. If it is severe enough to cause decided distress, however, the physician need not hesitate to order hot vaginal douches of a saturated solution of boric acid or bichloride of mercury (1:5000). If a pessary is worn too long, it sometimes provokes a vaginal discharge resulting in pruritus; in such a case tolle causam. et tollitur effectus. When the cause is removed and a few saline douches taken, the disease disappears. Common table salt in the proportion of two teaspoonfuls to the pint of hot water makes a good douche. We now come to an interesting group of cases, unfortunately still a large one, in spite of the most careful efforts to make a causal classification of them. I refer, on the one hand, to wdiat is known as the neurosis group of cases, and on the other, to those advanced cases with extensive tissue changes in which the original cause, whatever it may have been, has long since disappeared. The question of treatment in these difficult cases, which more than all others demand our sympathy and aid, is one of peculiar importance. In the first place, let me insist that whatever local treatment is adopted, we must never omit those powerful aids, good health, hygiene, a well- regulated diet, daily baths, and tonics. The patient must take suf- ficient exercise and a sufficient amount of suitable, non-stimu- lating food, A cold bath in the morning and a warm one at night with a careful cleansing of the parts will aid greatly in the recovery. There is no danger of contagion to other persons through using the common bath-tub, nevertheless, a due regard to the feelings of othprs will suggest the propriety of using a separate sitz bath for cleansing the genitals. While the patient is under observation an occasional mild hypnotic should be given to secure a good night's rest (see Chap. VIII). A prescription for this purpose should, however, never be put into the patient's hands, or she will almost surely abuse it. About once in five days a dose of chloral, ten to twenty grains, and sodium bromide, grains forty to sixty in six to eight ounces of warm water may be thrown into the rectum at bedtime. Of the various tonics and alteratives, arsenic is the best. It may be combined with a simple bitter in pill form as follows; 300 PEITEITUS. TAGIXISMUS. MASTUEBATIOX. 1^ Ac. arseuios gi'- iro Ext. calumb. ) __ ^ ,- aa 2.T. 1 Ext. gent. ) ^ -• M. Et. piMa i. Mitte tales Xo. 100. S. Take one pill after each meal. In the advanced forms of the disease, where there are marked local changes, relief is sometimes afforded by painting the parts with pure ichthyol. After the ichthyol is applied, the patient must wear a vulvar pad to protect the clothing. Much benefit is sometimes secured by a careful application to all the diseased parts of a ten per cent solution of nitrate of silver, repeated once in every ten days or longer (Olshausen). The abnormal insensi- bilitv of the parts is such that the usual sensations of pain and even of touch are largely in abeyance, and this is so marked that a three to eight per cent solution of carbolic acid in water with a little glycerin and alcohol can be borne without discomfort and much subsequent relief. This mixture may be left in the patient's hands to apply as she feels the need of it. A five per cent carbolic acid ointment made up with lanolin, according to the following formula, may be used: ^ Pulv. camph gr. jv Menthol gT. x Ac. carbolic. ..... = .... = = ..... gT. xxv Lanolin = ,..,..... oj M. S. Ajiply externally. A small well-defined area of beginning pruritus has been cured by treating it with pure carbolic acid, the application being lim- ited to the spot. Cocain ointment sometimes affords relief. I> Cocain hydrochl gr. vj Lanolin Bj M. S. Apply externally. Coating the parts with cod-liver oil gives temporary relief. Xaph- thalin and anesthesin in a ten per cent solution, made up with lanolin, thoroughly applied to the parts has been found useful. A method of treatment in vogue at a time when men paid more careful attention to the compounding of prescriptions than they do now, was to put the patient to bed and bathe the parts with a continuous application of a zinc oxide lotion, made according to the following formiTla : ^ Zinc, oxidi '^ij Mist, acacia^ .5] Aq. rosne 5v M. Et. lotio. S. Tse externally. TREATMENT OF PRURITUS. 301 This must be washed off thoroughly with a thin starch solution and the parts covered with benzoated ointment (West). Scanzoni recommends the use of a solution of caustic potash in water, about seven per cent, lightly applied with a brush, copious ablutions of cold water being used as the disease improves. A hip bath of water as hot as can be borne, containing as much sea salt as will make it about as strong as sea water, is often of value. C. Ruge (Centrhl. f. Gyn., 1896, vol. 20, p. 480) takes the positive posi- tion that pruritus is almost always of local origin, being due to some chronic or bacterial source of irritation, and that, therefore, it can almost without exception be cured, even in the worst cases, by a thorough cleansing of the parts. The best way to carry out Ruge's suggestions is to put the patient under an anesthetic, and after shaving the parts, to remove all the epidermis which will come off without exciting hemorrhage, by means of a scrubbing brush and soap. T'laischler, following the same idea, recommends applying a twenty per cent solution of nitrate of silver. In one case he gave complete relief by using a fifty per cent solution. A ten per cent thymol salve (Gottschalk) is a valuable remedy for the relief of the itching. R Thymol 10 parts Ung. petrolat 100 " M. S. Apply externally. Soaking the parts in a one per cent solution of nitrate of silver for hours at a time is sometimes of great assistance in producing a permanent alteration for good in the condition of the parts. C. D. Meigs described a case which he considered was due to a trichiasis of the vulva. He found that the hairs springing from the margin of the mucous membrane were pouting inwards, so as to irritate the membrane and occasion the most distressing itching. When these were removed the pruritus disappeared. I have found much relief attended the use of a lotion of lead water and laudanum made up with lime water instead of plain water. ^ Liq. plumb, subacet f3ij Tine, opii f 3ij Liq. calcis fovj M. S. Apply externally. Another remedy which often gives relief is a two per cent carbolic acid poultice. I have used cherry laurel water with great satisfaction (Aq. lauro. cerasi), when the genuine article can be secured. The following pre- scriptions for topical applications are given by Goodell: 302 PEUEITTJS. VAGINISMUS. MASTUKBATIOIT. ^ Cbloralis „ , I aa oiv Campnorse ; Rub into oil and add : Ung. simplicis 5] Pulv. ac. borac Sjv M. S. Apply externally. ^ Ac. acetici 5] Glycerina? oii] M. S. Apply externally. ^ Sod. borat 5ij Morpb. mnriat gT. xx Ac. bydrocyan. dil f3j Glycerine f oj Aq. rosse ad fovii] M. S. Apply externally T^'itb a pledget of cotton. For pruritus of diabetic origin, Goodell speaks most bigbly in favor of tbe following formula, used by Dr. James Simpson of Pbiladelpbia, namely, fifteen grains of tbe salicylate of soda, in glycerin, given by tbe moutb every four bours. Scbleicb's solution (see p. 277) injected into tbe mons veneris bas been found beneficial in some cases. I sbould be inclined to extend tbe use of tbis injection to tbe ilio-inguinal and genito-crural nerves above and tbe perineal nerves below. Tbe use of tbe galvanic current bas been followed by brilliant results in some cases in tbe bands of several autborities. Cbolmogoroff {Cenirhl. f, Gyn., 1891, vol. 15, p. 612) cites an instance wbere be cured a severe case of two vears' standing in six applications. Tbe metbod of application is as follows : Tbe positive pole (anode) is introduced into tbe vulva at tbe vaginal ori- fice, wbile tbe negative pole (katbode) is carried by means of cotton wet witb salt solution all over tbe affected parts. Tbe sitting sbould last from ten to fifteen minutes. Tbe patient sbould take tbe current as strong as sbe can comfortably bear. H. von Campe also cured a bad case of five years' standing by tbis metbod {CentrU. f. Gyn., 1887, voL.ll, p. 521). Tbe X-ray may be tried in tbe treatment of pruritus, but its value bas not yet received clinical confirmation. If cleansings (Euge), batbs, topical applications, • and galvan- ism, employed wbile tbe cause of the affection is being sougbt for, do not succeed in relieving a distressing case of pruritus witb extensive cbanges, it is best to resort to surgery and excise all tbe diseased tissues, cutting away tbe clitoris, tbe nympbse, and tbe adjacent parts of tbe labia TREATMENT OF PRURITUS IK PREGNANCY. 303 majora in the form of an inverted A, drawing the remaining tissues inward, and attaching them to the mucosa at the vaginal orifice. Hirst (Amer. Med., May, 1903, p. Y85) cured a case by excising the nerves going to the parts, after exposing them by making four incisions, two in the groins and two in the buttocks. It is not within the scope of my present purpose, however, to do more than indicate the value of surgery as a last, but most helpful resource. Pruritus in Pregnancy. — There is one special form of pruritus which occurs in pregnancy and is peculiarly distressing. It usually appears in the later months and the patient complains of the most distressing sensations of heat, swelling, and itching of the parts. An examination shows the external genitals red and swollen and often excoriated by scratch-marks. The vagina also is swollen, and covered with a curdy white discharge. It is the association with a vaginal aifection which distinguishes this form of pruritus from other varie- ties. The condition comes to an end with the termination of pregnancy, but it is often difficult to cure before its natural terminus is reached. The patient should be kept quiet and use a hot permanganate douche (one to three per cent) two or three times a day. Bathing with equal parts of alcohol and water is of service, to which may be added sufficient coca in to make a one to two per cent solution. If the itching persists in spite of mild local treatments, the patient may be put into the knee-breast posture and, after the vagina is exposed through a large cylindrical speculum, it is everywhere swabbed out with a five per cent solution of nitrate of silver. This treatment will bring away a superficial cast of the vagina in the course of a few days. After three days the douche treatment may be resumed, until the vagina appears normal. Ashwell recommends the following prescription of Meigs, using the language of the latter in doing so, " having been a great many times consulted for the relief of pruritus vulvae and most frequently by pregnant women, I have rarely had occasion to order anything more than the following formula, namely: ^ Sod. biborat §ss. Morph. sulph gr. vj Aq. rosse dest Sviij M. S. Apply three times a day to the affected parts with a piece of lint, after washing with tepid water and soap and carefully drying the parts. In the worst forms of the affection it has been found necessary to termi- nate pregnancy. 304 PEUKITUS. VAGINISMUS. MASTURBATION. VAGINISMUS. Definition. — Vaginismus is an affection first named and fully described hj Marion Sims. It is cliaracterized by violent reflex spasmodic con- tractions of tlie muscles around the entrance of the vagina, namely, the sphincter vaginae, the levator ani, the transverse perinei, and the adductors of the thighs. This condition of muscle spasm is called forth either by an attempt at coitus or the effort to make an examination of the vagina. It is a disease of married life and for the most part of young women, per- sisting sometimes for many years. Sims, whose descriptions of it are unsur- passed in clearness, says : " By the term vaginismus I mean an excessive hyper- esthesia of the hymen and vulvar outlet, associated with such involuntary spasmodic contractions of the sphincter vaginse as to prevent coition. This irritable spasmodic action is produced by the gentlest touch ; often the touch of a camel's hair brush will produce such agony as to cause the patient to shriek, complaining at the same time that the pain is that of thrusting a knife into the sensitive part. In a very large majority of cases the pain and spasm conjoined are so gTeat as to preclude the possibility of sexual intercourse. In some in- stances it will be borne occasionally, notwithstanding the intolerable suffering, while in others it is wholly abandoned, even after the act has been repeatedly, as it were, perfectly performed." The spasm of the muscles about the vaginal orifice varies with different patients, all the way from a distress which, though severe, can be endured and with great difiiculty overcome, by a woman who is determined to submit to her wifely obligations, to the most uncontrollable apprehension and agonizing pain. The area of sensitiveness in vaginismus is situated about the urethra, the hymen, and especially the posterior commissure, from which it extends over the entire vulva. In some cases there are manifest changes at the orifice in the form of exquisitely tender deep red spots ; fissures may also be found in the vulva, resembling painful fissures of the anus. A picture of vaginismus is sometimes seen in the examining room, when the physician, perhaps with large fingers and clumsy efforts, attempts to force the digit through the vulva and hymen in his efforts to penetrate the vagina. The mucosa at the vaginal orifice is naturally delicate and sensitive, and it is capable of acquiring an extraordinary degTee of sensibility through the attitude of ex- pectancy, whether of pleasure or of pain. This shrinking and supersensitiveness constitute one of the safeguards of young womanhood before the maturation of the sexual function. Etiology. — As a rule, the vaginismus is present from the first attempt at coitus and acts as an insuperable barrier, so that when the parts are examined by a physician, the hymen is found intact. In some cases, however, intromis- sion is occasionally successful and the vaginal orifice, when examined under an ETIOLOGY OF VAGINISMUS. 305 anesthetic, presents no abnormality. It is noteworthy that vaginismus is rarely present among the poor, while it is often seen in the hypersensitive women of the leisure classes with neuropathic constitutions. Masturbation has been assigned as a cause in some cases. Vaginismus may be the consequence of a gonorrheal infection. It is sometimes due also to some degree of male impotence, whereby the rela- tionship is not fully consummated at first. The element of anxiety and uncer- tainty associated with ill-directed efforts on the part of the husband is not without its effect upon his co-respondent wife. The lihedo sexualis, which nor- mally obtunds and renders transitory the natural pain of the first cohabitation, disappears, and an attitude of anxious expectancy takes its place, which, in time, is converted into apprehension and abhorrence, so that instead of grati- fication, the wife feels disgust, and instead of pleasure, pain. Fig. 80. — A Urethkal Gakunclk Rkskmbling a Small Dakk Hematoma Springing from the Right, Posterior Margin of the Urethra. On closer examination it is seen to be an intensely injected tumor springing from the mucosa. It is usually sessile and often extends upward into the urethra. 21 306 PKTJKITUS, VAGINISMUS, MASTUEBATIOlSr. There is a urethral form of the disease which I would associate with a gonorrheal infection, in which the meatus urinarius is swollen, red, everted, and exquisitely tender. The pain on contact is fully equal to that induced by a urethral caruncle. Here the vaginal orifice and all the surround- ing parts can be freely touched, provided only the urethra is let alone; while any contact with or attrition of the urethra provokes a violent and utterly un- bearable pain. Sometimes when the parts at the vaginal orifice are exquisitely sensitive and the patient shrinks from the slightest and gentlest contact, shrieking when the finger im]3inges upon the j)arts, the whole trouble will prove to arise from a cause of no greater significance than a urethral caruncle (see Fig. 80). The true caruncle is a deep-red, well-defined, vascular tumor projecting from one side of the urethra and often flattened like a cockscomb or, when sessile, a mulberry mass. A little minute observation will distinguish this well-defined tumor from the general reddening and swelling of the meatus just described. Occasionally, vaginismus is seen in a physically ill-matched pair, that is to say a little woman, childlike in both person and temperament, wedded to a man of large frame with insistent sexual desires. Here, where the manifest dispro- portion of body is carried into a like absence of correlation in the sexual organs, great distress may be occasioned by the marital approach, ending in a condition of general hysteria with a well-marked vaginismus. This explanation of vaginismus, as being due to disproportion between the intromittent organ and the receptive channel, is one which appeals to the lay imagination as the great common factor in producing the disease. It is, however, extremely rare. Another cause of vaginismus, more frequently noted, is the displacement of the fourchette and the orifice upwards and forwards, making the channel difii- cult of access, and rendering the urethra and clitoris liable to injury from too frequent forcible impacts. Prognosis. — The prognosis as to recovery in vaginismus when left alone is bad. Pregnancy is rare under the circumstances; nevertheless, it may take place, and when this is the case the vaginismus is usually relieved, though not necessarily so. Sims cites a remarkable instance in which the family physician anesthetized the wife for the first coitus, which then offered no difficulty; he continued to do this at bi-weekly intervals for a year, when she became preg- nant and bore a child at term. The old pain returned, however, and it became necessary to resume the " ethereal relations." Sometimes the distressed and suffering wife secures an immunity from any approach and lives from year to year as in her maidenhood, a virgo intacta. Treatment. — Every case of vaginismus must be taken seriously and faith- fully treated until a permanent recovery is assured. The first step is to secure for the wife rest and freedom from importunity. If she is subjected to con- tinual approaches and submits to frequent ineffectual attempts to overcome the difficulty by the natural method, the nervous system often breaks down and she becomes a physical and mental wreck. In order to secure the quiet which TREATMENT OF VAGINISMUS. . 307 she needs, she must sleep alone ; some sedative should be given for a few days at the beginning of the treatment to secure a habit of sleep. It is most important to keep up a hygienic regimen by using daily cold baths or spongings, as well as early rest and exercise each day, according to the needs of the individual case. The active treatment of a vaginismus begins with the effort to discover some well-defined local cause which can be removed. As a rule, it is impossible to make a thorough examination in the usual manner on the office table. The patient, with the best will in the world, involuntarily draws her thighs to- gether, and even if the examiner by dint of persuasion and great difficulty suc- ceeds in introducing a well-oiled finger he has accomplished nothing. It is best then to insist upon a complete examination under anesthesia at the outset, secur- ing permission to remove any minor cause of the trouble which may be found at the same time. Careful inquiry must be made beforehand as to the potency of the husband and as to any history of gonorrhea. Nitrous oxide gas wdll not suffice to induce the necessary relaxation ; ether or chloroform must be used. The vulva is examined for signs of inflammation, fissures, or red spots. The condition of the urethra is noted as to whether it is swol- len, red, or everted. A urethral caruncle, if present, must be treated according to the following method: (1) it must be thoroughly removed down to and beyond its base; (2) this may be done under cocain anesthesia (ten per cent), by laying a pledget of cotton saturated with the drug on the growth for ten minutes; (3) when the growth is pedunculate, it may then be grasped, drawn forward, transfixed, tied both ways, and then cut off well beyond the ligature. The removal of a sessile growth is a delicate piece of plastic work, and the physician would do wisely in such a case to consult a specialist. Any fissures or little superficial ulcerations surrounded by an intensely red area near the hymen are noted. The hymen itself is observed, to ascertain whether it is intact, and whether inflamed or not. The vagina and the cervix uteri are examined for evidences of gonorrhea. It is a good plan to dilate the cervix in order to facilitate pregnancy. If gonorrhea is found, an effort may be made to wipe it out at once by using a strong (thirty per cent) solution of nitrate of silver, carefully applied to all the affected parts. A gonorrheal urethritis is also well treated by repeated applications of a two to three per cent solution of silver. If the case is not extreme, two remedies may be tried : first, putting a pledget of cotton saturated with a ten per cent solution of cocain at the vaginal orifice for ten minutes and removing it just before coitus; secondly, the immediate application, upon removing the cocain, of a quantity of vaselin to the parts. If this plan works well, it can be repeated. In simple cases, that is to say cases w^here there is no inflammatory basis and no inflammation has been superadded, the use of the galvanic current has succeeded in several instances in effecting a complete cure. Lomer (Centrhl. f. Gyn., 1889, vol. 13, p. 8Y0) cites a case lasting five years and associated with frequent involuntary perineal contractions, in which he used a weak, barely 308 PETJEITUS. VAGIIiriSMUS. MASTTTKBATION. perceptible galvanic current every two or three days for four or five min- utes at a time. In six weeks the patient was completely cured and had had no return of the trouble at the end of six months. Another similar case was cured by him in like manner. In both cases there was dysmenorrhea, which was also relieved to some extent by the treatment. If inflammatory areas or fissures are found in the neighborhood of the vaginal outlet they should be dissected out in a linear manner and the mucosa carefully brought together with a fine catgnit suture. When no evident cause is found, or when the hymen is intact or deeply red- dened, no plan which has yet been devised is equal to that of Marion Sims, namely, removal of the hymen, the incision of the vaginal ori- fice, and the subsequent dilatation of the orifice. The patient is pro- foundly anesthetized and the parts cleansed, after which the hymen is seized on one side anteriorly by a pair of rat-toothed forceps and pulled out, being excised at the same time well down to its base in one continuous piece on the right and left sides posteriorly. "When this has been done it was Sims' custom to pass two fingers into the vagina to stretch the outlet and then to make a deep cut in each sulcus about two inches long, united at the raphe, and prolonged in the form of a Y quite down to the perineal integument. Each cut was about half an inch or more above the sphincter vaginae, half an inch over its fibres, and an inch from its lower edge to the perineal raphe. These operations were then followed by the insertion of a bougie or a dilator three inches long and an inch and a half in diameter in order to stretch the opening. This was worn for two hours in the morning and t^vo or three in the afternoon for a period of two or three weeks. The bougie is of conical form and open at its outer end, with a depression for the urethra. The plan of having the patient repair to the physician's ofiice regTilarly for the purpose of having him stretch the outlet by the insertion of specula of successively larger sizes does not seem to be worth trying, from the experience of many persons, though it suggests itself as useful. Veit, who has made a most careful study of the treatment of vaginismus, has given up the excision of the hymen to a large extent in favor of two radi- ating incisions, cutting through, not only the hymen but the sphincter vaginae as well. Then, to check the hemorrhage, the wound is closed with superficial and deep sutures of the vulva, passed in the same direc- tion, and attaching the vagina to the vulvar mucosa. Veit uses interrupted silk sutures and removes them in ten days, after applying cocain. The effect of such an operation is to convert the nulliparous outlet into the shape of a parous one. After recovery from this operation, the outlet is habituated to the passage of tubular specula, increasing in size, imder cocain anesthesia. Finally, when the patient can stand the introduction of a speculum, three centimetres in diameter, without cocain and without the use of any lubricant, she is discharged as cured. Veit insists that the important point in this treatment lies in the after manage- ment of the case. GBNEBAL COJNTSIDEKATIONS ON MASTUKBATION. 309 MASTURBATION IN WOMEN. General Considerations.' — A strong instinct of repugnance impels us to gloss over this section of preventive gynecology, and to revolt when sacrilegious hands are laid on our ideal of purity. But the family practitioner is under obligation to see that the mother warns and watches her growing girl; he may no longer ignore the prevalence of the danger ; he must recognize the marks of the yield- ing to this temptation in time to help ; and he cannot avoid some study of auto- erotism in women if he would give effective counsel at critical periods. In a restricted space conclusions only can be given. Reversing the usual order, how- ever, the common degrees of the habit among ordinary individuals will receive attention rather than the rarer excesses of the unbalanced. Yet these lesser troubles are the more difficult, since there is no recess in the world so truly impenetrable as that chamber of the adolescent's mind where she hides her questioning concerning the vague stirrings of love and sex-consciousness. If we start with the proposition that some curiosity about the awakening genital sensations of puberty is normal, and some pressures and frictions instinctive, then we may fairly consider restriction of such experimentation a stage of ad- vance, and entire freedom from contacts a high degree of self-control. Animals in youth and in the periods of sexual excitement exercise such practice ; in some tribes low in the scale it is universal among the women; in the Orient and in ancient times there has been the uttermost openness of excess. Such primitive instincts, often reinforced by neurotic heredity and a will little trained in self- control, leads the child directly toward trial of these excitements. Boys teach each other this vice more often than girls do. The muscular activities of the young male, and the traditions of the hurtfulness of excess, make for moderation, whereas the secretiveness of the girl lessens the chances of detection or confession of a solitary indulgence that is self-taught. Among the crowded poor and the ignorant foreign population evil communications are facile. But in any individual, in adolescence, the soil is fertile, with its emo- tional and affectional fervors and introspective intensities. " These years are sensitive to all matters pertaining to sex, even very remotely, to a degree about which the ordinary parent is densely ignorant and optimistic." It should not surprise us then, if, in the common absence of all instruction, and in the pres- ence, let us say, of some pelvic disturbance, the habit were often started. Add to the monthly rush of blood to the genitals, the friction of the napkin, the suggestiveness of the hot-water bag, the lying awake in day dreams in bed the iirst day of the period, and we may well fear such arousing at some time during the seventy periodical opportunities between puberty and nubility. The danger zones are these : Infancy ; puberty and the years immediately following ; school and factory life ; engagement ; marital maladjustment ; widow- hood; the pre-climacteric sexual activity; and any long period of nervous in- 310 PEUEITUS. VAGI^'ISMUS. ilASTUEBATIO]!?'. tensity or breakdown. Hare before puberty, the usual time of beginning is just afterward, and the average time of excess is within the next four years. General Causes. — Parents who are intemperate, whether through weakness of will or excess of passion, transmit such tendencies. Among neurasthenics more than half hare been masturbators at some time, and the most pronounced cases are very generally found among them. The two great main causes, however, are: defective education, and its result, defective seK-control. Ignorance of the simplest sex knowledge, infirmity of body, absence of absorbing and healthful occupation, insufficient out-door exercise, lack of a constant stream of elevating influences and stimuli — all these favor the habit, particularly where, as in cer- tain natures, there is capacity for an overplus of sexual passion. Among the most potent factors are undoubtedly these three : Emotional excesses, when feel- ing fails to be translated into action, whether it be roused to frequent intensity by novel, or theatre, or sermon; self-indulgences, such as late rising, and all idleness, sulky reticence, and hysterical outbreaks ; and intimacies of the person, whether the liberties be with other girls, or with boys and men. Local Causes. — Irritation frcmi lack of cleanliness is found not alone among the tubless. The fastidious not infrequently fail to clean the space beneath the prepuce and the interlabial grooves. Vulvitis, eczema, parasites, leucorrheal discharges, and highly acid, concentrated, or diabetic urine bring about irri- tations and scratching. Ill-fitting clothing may also do so. Rectal worms, anal fissure, and chronic constipation are some of the causes of congestion and itch- ing. All pelvic disorders whatever, and particularly ovarian irritations, draw the attention to these sensations, and such inflammations and displacements con- stitute the most important of the local causes. Prevalence. — We have no means of estimating the frequency either of minor degrees of self-abuse or its occurrence among healthy individuals. Among boys " whenever careful researches have been undertaken, the results are appalling as to prevalence." For women of loose life and certain peasants there are fig- ures showing a very frequent occurrence. Among women of a good class there are some indications that it is by no means uncommon, as for instance, where one thousand consecutive gynecological cases showed well-marked vulvar hyper- trophies in over one-third. By one-third of this third, full admission was made, so that it is fair to attribute the findings in the remainder to the same cause, especially as categorical denial was forthcoming in only one in fifty. The above figures bear only, however, on women with pelvic disorders, in whom more or less chronic attention to the sex organs has been necessarily present. On all sides of such questions one must beware of exaggeration. " The difference," says the astute Dooley, "between Christyan Scientists an' doctors is that Christy an Scientists think they'se no such thing as disease, an' doctors think there ain't annythin' else." It cannot be too strongly stated that in a very large proportion of instances of masturbation in women the matter is a physical rather than a sexual one. It might be said to be sexless. By this is meant that sensual images and desires METHODS OF MASTUKBATIOK. 311 are infinitely less often consciously associated with the practice in women than in men. The distinction applies particularly to the intelligent classes. Among refined and delicate women, the pent-np sex hunger may take this outlet without recognition of the real meaning of the impulse, and nothing is more astounding on the part of clear minds, than the failure to make the connection between their knowledge of physiology and social practices and their genital sensations. Aversion to men is not uncommon in association with it. Methods. — In infants the means, in nearly all instances, is thigh compres- sion, the child being seated, and swaying its body until flushing and excitement and staring end in the deep breathing of the climax. In the worst cases the thigh rubbing is almost incessant during the waking hours. At this age the practice is far more commonly seen in girls than in boys. In girls of four or five manual friction of the prepuce is the method. Tell-tale hypertrophy of longitudinal folds and the frequent pigmentation often render the habit easy to recognize in an early stage. After puberty the habit may be mental, vulvar^ vaginal, urethral, mam- mary, or any combination of these. The fifth is presumably rare, but the occasional hypertrophies and pigmentations about the nipple point to breast congestion as a feature of some cases. The psychic form of solitary sexual indulgence is most difiicult of all to study or describe, its shadings are so various, its ignorances of actuality so colossal. Vaginal masturbation is rare because of the fear of harming the hymen and thus destroying virginity. The usual vulvar method is digital pressure, applied to the labia minora, or to the prepuce. To and frO sliding of these parts, hard pressed against the symphysis and descending rami of the pubes, or forward and backward over the edge of the subpubic arch, produces nerve excitation and alternate filling and emptying of the cavernous structures of the bulbs of vestibule, clitoris and labia. That the labia minora, which in their structure can be truly called erectile, are the most common point of attack, is shown by their being the most frequent seat of hypertrophy, while enlargement of the clitoris is distinctly unusual — perhaps because its make-up does not admit of the same acute edemas. Pressure with the thighs seems as effective in producing enlargement as manualization. While sitting with crossed thighs, a slight bending forward of the trunk brings the vulva against the seat of the chair, and rhythmic adductor action produces the orgasm. In highly sensitive states the adductor rhythm alone is sufficient, and this, at times, without motion evident to any onlooker. Indeed, the extent of the need of watchfulness can never be grasped unless it is known that when self-abuse has reached its keenest pitch in certain individuals the effective pressures or frictions are so simple that a girl can reach the climax in bed with her mother without suspicion. A roll of bedclothes or nightdress held between the upper thighs, or, prone, beneath the vulva ; the heel, brought up against the pudenda ; vulvar contacts with the corner of a piece of furniture or the key in a drawer — any one of these may constitute an individual process. The vaginal douche tube and hot water excite very few women, and the bicycle 312 PEUKITUS. VAGINISMUS. MASTURBATION. saddle is to be exonerated ; the sewing machine in large shops has, however, been accused of fostering the habit. Time. — The nsual time of indulgence is at the end of menstruation. The day or two immediately preceding the flow is the period next most fertile in temiDtation. Springtime brings attacks especially strong. When a pelvic dis- order, such as a cervical erosion, occurs or gTows Avorse, the torment is prone to light up again. An ordinary frequency is two or three times in the immediate neighborhood of the period, and once or twice (if at all) between. This may continue for years, while, at times, months of freedom elapse. Contrary to the usual belief, the day is as much to be feared as the night. Where a statement is made concerning twelve or fifteen conclusions in twenty-four hours, it is impossible not to believe that in most instances the climax is feeble or brief, but it must never be forgotten that women bear sexual excesses better than men — better, that is to say, physically ; worse, morally. With some the solitary orgasm is said to be no more fatiguing than the. normal relation, with others it is infinitely more so. Clinical Findings. — There are certain stages and degrees recognizable in the development, and various locations, of the hypertrophies about the vulva. Stages : Increase ; full development ; atrophy. Degrees : Moderate ; average ; very great. Location : Labia minora ; prepuce ; fourchette and perineum ; accessory nympha? ; clitoris ; meatus ; pelvic floor and levator ; vagina — eight in all, any combination being possible. To these may be added varicosities of the broad ligament and bladder base, and the mammary hypertrophies. A typical case presents the following changes : After pubertj^ the prepuce is a tiny tent over a small clitoris. The lesser labia are smooth and of an inverted V shape in transverse section, forming small, pink ridges closed in between the rounded cushions of the outer lips. After some months of active traction, the nymphffi are larger, thicker, darker along the outer edges, and, together with the prepuce, exhibit the simpler foldings, as well as beginning protrusions. Perhaps some area demonstrates the pathology by characteristic acute edema, showing recent trauma. Thereafter, within two or three years, the fullest development may be looked for in aggravated cases, though the maximum findings here described as belonging to the vulvar habit are very rarely grouped in a single individual. This virgin of eighteen, a well-developed brunette of excellent antecedents and personal history, refined, reticent, and studious, is suffering from mental and physical depression, headache, dys- menorrhea, leucorrhea, bladder irritation and menorrhagia. The breasts are large, the nipples prominent, the primary areola distinctly pigmented, elevated, and bearing follicles, with the secondary areola plainly visible. A strong growth of pubic hair covers rotund, coarse-skinned labia majora. Between these outer labia protrudes, in all postures, a corrugated roll of brown- black skin. Thickened, elongated, curled on themselves, thrown into tiny, close-set, irregular folds that cross at all angles as in a cockscomb, each lesser eLINICAL FINDINGS IN MASTURBATION. 313 labium hangs in a double fold, its anterior projection partly concealing the rear portion. Unrolled, this little elephant ear, elastic and insensitive, reaches one inch, or even two, beyond the major a, and then drops back, wrinkling into deep furrows. The enlarged and prominent whitish sebaceous glands feel to the touch like a multitude of embedded sand grains. (The pigment deposit is present or absent according to the general coloring.) The prepuce, thickened and lying in rounded folds or wrinkling plaits, is continuous with these lesser labia. They unite in a sweep behind the vulva so that the fourchette and the perineal raphe are as dark and corrugated as they. Laterally, from them, two bridges of the same fine-laid furrowed folds run across the shallow sulcus that lies between inner and outer labium onto the labia majora, like an accessory or intermediate pair of smaller labia ; and this duplicature hangs up or puckers the centre of each labium minus. The prepuce is partly adherent, and under- neath it smegma lies hidden. The fully developed clitoris rounds its back and projects its tip under this thick cover nearly an inch in advance of the face of the symphysis. On each side a couple of prominent veins twist along the inner aspect of the labia majora. The wide meatus presents two curious ear-like flaps or tabs when drawn open. Into these ridges the forward edges of the hymen run. The openings of the vulvo-vaginal and urethral glands are red- dened and gaping. The hymen is too small to admit the finger-tip. The deeply pigmented anus with its powerful sphincter is surrounded with small piles, and finally, the pelvic floor muscles are increased in vigor and thickness and in susceptibility to spasm. Vaginismus is not uncommon. The last stage is shrinkage, with or without spotty pigment. The habit ceases. The vulva ages. Its muscles relax, and the surfaces of the lesser labia become smoother as the muscular and elastic fibers in them atrophy, but the curtain-like lips still show abnormal and characteristic increase in area, if not in thickness, and still hang in delicate folds that cross no longer. Shrivelling is never sufficient to bring them back to the former narrow ridge of projecting skin, and although the cockscomb may smooth out its surface, some of the hall marks of the aggravated habit persist for life. Traction or friction applied to the meatus or urethra result in hypertrophies. Tiny ear-like tabs or projections of the lateral edges of the meatus — on the sum- mit of which elongated urethral glands open — have been called urethral labia, but they are an enlarged anterior section of the hymen (urethral hymen). Dilatability or gaping of the lower third of the canal is sometimes sufficient to admit the finger-tip. A varied assortment of articles, such as hairpins, passed into the urethra to excite sensation, have slipped into the bladder, and called for surgical interference. The vaginal habit may or may not be a later stage of vulvar excitation in any given instance. The very gradual dilatation of the hymen, extending over a long period, explains the remarkable freedom from injury and the astonishing elasticity and insensitiveness belonging to the aggravated cases of years of pelvic floor massage. Dr. R. L. Dickinson has seen at least fifteen non-parous women 314 PEUEITUS. VAGINISMUS. MASTUKBATION. in whom the hymen readily yielded to a circle of six to nine inches, admitting the hand. Yet some of these hymens spring hack to a closed puckered curtain which the eye cannot distinguish from the virgin maidenliead. In a later stage of the same habit, relaxation has taken place and the vulva sags open, though the woman may have had no children at term. The full-term head cannot tear these elastic pelvic floors unless its exit is precipitate. The large variety of foreigTi bodies which have been used to supplement the digits, or have been found in the vagina, need not be enumerated. Effects. — The physical results of self-abuse, in all but the extreme cases, seem to be surprisingly small. Endometritis, vaginal catarrh, and trigonitis result from long indulgence. jSTeurasthenia is probably coincidence rather than consequence. Protracted masturbation, not associated with sexual images, tends to apathy or aversion toward the sex-act, but the contrary is true where there is longing for normal gratification. In the excessive forms of the vice, as with relaxed pelvic floors, the capacity for pleasure in coitus is lost. If the physical evils are not many, the moral penalties, on the contrary, are disproportionately great. The undermining of self-respect, the tortures and the shame react on the general health surely and frequently and deeply. But there is no diag- nostic behavior or appearance. Diagnosis.- — This presents no difficulty in advanced typical cases of the vulvar habit, as described above, and in general it can, in my view, be safely said that no well-marked area of corrugation about the female genitals is pro- duced in any way but by pressures. The minor and the mental manifestations offer troublesome problems, for which space is lacking here. After some measure of the patient's good-will and confidence has been secured, and the physician is reasonably certain of his premises, the matter may be broached if he fears there is a persisting habit. There is nothing in practice more diffi- cult than the approach to the subject — except perhaps the retirement from it. Good women, particularly, possess no lang-uage and no terminology, either for their feelings or their anatomy. Their words, meaning much or little, are liable to any kind of misconception. The sphinx is not more silent. Secretiveness and skill of fence are developed to the highest degTce. Denial springs in- stinctively to their lips, or professions of ignorance of what can be meant. Therefore, it is best to put through a set speech steadily. In carefully chosen words the growth of the habit in an average case is outlined, and the successful points lead the patient to think all her trouble is known. The first alarm has time to subside in assurance that this is not denunciation, but help. Admission is rarelv to be asked for in adults. The warning suffices. In voung girls the threat of telling the mother in case the habit is continued forms a powerful deterrent. Preventive Treatment. — It rests with her training, not whether a girl shall" be tempted, but whether she shall be enslaved by the habit. Self-control is everything, with the help of good muscle and ample nutrition, outdoor tire and cold-water sprays, elevating environment and cleanness of comrades, judicious TREATMENT OF MASTURBATION, 315 work, and wholesome hardship. Her ideals cannot be too high, nor her con- science too alert, but the stimuli can readily be too intense. Well-timed and reiterated impact of good influences, as in church service and social service, is vital, but prolonged religious emotionalism has no stone wall dividing it from sexual agitation. Fervid preoccupation with art, music, or the literature of feeling presents dangers less gross, but not less real than contacts with loose thinking. From every excess of intensities and unsanities we shall do well to guard. " Whatever else we may deem wise or unwise as to the instruction of the young girl in the details of sexual gratification, there can be no doubt about their teachers." The physician is the m^oral sanitarium directly responsible. It is for him to urge on the reserved woman what she will call the most difiicult task of her life. Her telling is to be matter of fact, yet reverent ; neither vague and sublimated, nor specific and suggestive ; not too casual, yet not so freighted with import and interest as to arouse curiosity and invite experiment, and with just two purposes : namely, to so dispose the mind of the child that thereafter she shall bring to the mother her questionings, and to anticipate communications from the girl's companions in a matter wherein the right point of view is every- thing. Thus by successive stages, as the questions arise, and by illustrations drawn from plants and animals, the mother shows how the holy mysteries of sex were instituted and ordained. In the absence of researches amons: ffirls the proper age for each stage cannot yet be defined. The Y. M. C. A. camps have shown us that at from eight to ten in the tenements and from twelve to fourteen in the better houses, the boy has found out from his comrades about many sex matters. Young girls in school are sometimes surprisingly informed, and parents astoundingly ignorant of this fact. At any rate, the reckless and forward, the hysterical and passionate, the brooding and introspective should be studied and cautioned.* Curative Treatment. — Confession, however fragmentary, is a long first step toward recovery. " Remorse for sexual sin is still the religious teacher's great opportunity." The doctor may " show great things and difficult," urge the immediate action that will break loose from the particular vicious association, start work to uplift others, and secure a promise to report. These, with strong mental suggestion of control, will go far. The issues must be clear. The lure of temptation lies largely in its intellectual vagueness. To think out the real implications is largely to loosen the habit's hold. Whereto is all this leading? The life is readjusted. House habits and work habits are studied, and nerve- wrecking tensions let go. Our motto should be, " To replace is to conquer." The taking up of an outdoor hobby, like a nature study, can bring about that muscular fatigue which is found to be the best single remedy for the male. Swimming, hydrotherapy, gymnastic games, skating, tennis, golf, wheeling *The Wood- Allen Publishing Co.'s books (Ann Arbor, Michigan) are not condensed enough, but furnish an excellent guide for mothers. Stanley Hall's "Adolescence" (Appleton) is the best scientific presentation in English. 316 PRUKITUS. VAGINISMUS. MASTURBATION. and horseback — all are good, but bard to get in cities. Forced nutrition is usually needed, and a general upbuilding. Tea, coffee, and alcohol are cut off, A hard bed with minimum covering in a cool room ; immediate evacuation of the bladder when first conscious, and prompt rising, followed by the cold spray or cold spinal douche, are desirable. Bromides help over crises, whatever the period of the month or the day temptation comes, and valerianates spread this quiescence further, where bromides would disturb. Actual pelvic disorder calls for cure, by the briefest means available, in order to remove the local irritant. This is right in all but the neurasthenic class. Here anatomic cure does not mean symptomatic cure, except with tumors and gross prolapses. Care is exercised to associate fear of pain with examina- tion. Operation is preferred to office treatment or home treatment on the part of the patient. Stripping the prepuce is desirable whenever adhesions are com- plete or retained accumulation considerable. Circumcision is useless^ except where adhesions with accumulation persistently recur. In conclusion it may be said that whatever the divergence of opinion con- cerning danger or diagnosis, prevalence or effects, we can agree that there is on us the troublous duty of moral prophylaxis, the need of sane instruc- tion of the teachers of children, formulation and comprehension of what the danger signals are, and the mastery of means that will strengthen the body and energize the will. Inasmuch as we do it not — CHAPTEE XIII. DISPLACEMENTS _0F THE UTERUS AND THEIR TREATMENT BY PACKS AND PESSARIES. Normal position of the uterus, p. 317. Abnormal positions of the uterus, p. 318. Diagnosis and symptoms of retro-displacements, p. 322. Treatment of retro-displacements, p. 323; packs, p. 323; pessaries, p. 325; operative treatment, p. 332. Treatment of prolapsus, p. 333. Before considering the question of displacements of the uterus it is important to define briefly its normal position, because it is the only proper standard by which to measure a displacement. If my views as to the normal position of the uterus are incorrect, then I must, of necessity, estimate as mis- placements a great many cases which are perfectly normal. The older writers had the idea that the uterus must lie in one particular position in the pelvis, gently inclined forwards or slightly anteflexed, and to this norm they endeavored to accommodate all their patients. As a consequence of this false conception, great numbers of women were put upon treatment for this condition who needed none at all, and the variety of pessaries devised, particularly for anterior displacements of the uterus, .was without end. With a correct notion of the posture or postures of the uterus, the vast field of anterior displacement therapy disappeared into the gynecological waste-basket, and with it the host of pessaries over which our immediate predecessors spent so much thought and wasted so much ingenuity. NORMAL POSITION OF UTERUS. The uterus normally lies in a state of mobile equilibrium, that is to say, it is poised or swung between its broad ligaments, ready to respond to any force however gentle exerted upon its anterior or posterior sur- faces. It lies generally with fundus inclined forward, and cervix turned back- wards towards the lower part of the sacral hollow. As the bladder is emptied, the fundus drops still further forward, and the uterus comes to lie in a more decided anteposition, while if the bladder becomes distended, the situation is reversed, and the body is lifted on the distended bladder ; in cases of extreme distention is even thrown over into retroposition. The general position of the normal uterus is fundus anterior, cervix posterior, and as it swings in this position, the least increase of intra-abdominal pressure above forces the viscera down upon the posterior surface of the uterus and so increases the ante-displace- 317 318 displaceme:xts of the utekits. ment. Xo anterior position of the uterus is abnormal, except that of an ex- treme flexion of the bodv on the cervix. This is a congenital condition associated with imperfect development of the uterus and is not to he remedied by palliative treatments through the vagina, or by the use of any kind of a pessary. It is in cases of this kind that a dilatation of the cervical canal is often done, associated with a deep incision of the posterior wall of the cervix at the angle of flexure, so as to open the cervical canal and secure free exit for the menstrual discharge. Plausible as such an operation appears in the description, it unfortunately does not often relieve the dysmenorrhea which torments these patients, and although successfully done to overcome sterility, a simple dilatation of the cervix is, as a rule, equally efiicient. ABNORMAL POSITIONS OF UTERUS. Categorically stated, the abnormal positions of the uterus are these: Anteflexion (acute). Eetroversion. Eetroflexion. Eight lateroflexion. Left lateroflexion. Ascensus. Descensus. Prolapsus. Torsions. jSTumerous combinations of these malpositions. Although this list of malpositions seems a formidable one, there are prac- tically only two or three of them which are of clinical sigTiificance. These are : retroversion and retroflexion, best considered together; descensus; and prolapsus. Anteflexion, as I have said, is a congenital condition, causing in itself no symptoms and requiring no treatment. The other mal- positions are either pathological varieties or dependent upon some disease of the pelvic organs. Ascensus, or the pulling of the uterus up into the abdominal cavity, is due to an association of the body of the uterus with a tumor, such as a fibroid or an adherent ovarian tumor, gTowing in the direction of the abdominal cavity; or to a slinging of the uterus to the abdominal wall by a suspension operation. The displacement itself demands no particular attention. The latero-displacements also are produced by the push or pull of a tumor ; or by that of a pelvic inflammatorv mass ; or by the contraction of scar tis- sue in old inflanmiatory cases, which drags the cervix in the direction of the focus of inflammation. These conditions demand notice only as clinical feat- ures of value in making a diagnosis in connection with pelvic inflammatory trouble. ABNORMAL POSITIONS OF THE UTEEUS. 319 Torsions. — A slight degree of rotation low down on the right side exists commonly and may almost be considered normal. Any inflammatory disease causing an unsymmetrical drag or pull may exaggerate this. Large myomatous tumors and tumors of the ovary may cause such twisting as to completely shut off the circulation and cause gangrene. Such conditions are usually considered under tumors of the uterus or ovaries. Retropositions are by far the most important. It is in retroversion and retroflexion, especially when associated with descensus, that the patient's general health is liable to suffer, and she experiences local discomforts ; it is in these cases, therefore, that an appropriate therapy is always likely to afford entire relief. Between anteflexion and retroflexion with descensus, the uterus occupies a number of positions, as shown in Figure 81. If a case is watched from the Fig. 81. — Different Degrees of Uterine Displacement, from a Normal Slight Anteflexion to A Decided Retroflexion with Descensus. first, these steps on the backward and downward progress may be recognized, even to its final appearance at the outlet and its escape as a complete prolapsus. Frequency of Retroflexions. — The relative frequency of retroflexion, as contrasted with other gynecological ailments, is found in the following state- ment taken from my records at the Johns Hopkins Hospital : Out of the thirteen thousand and six hundred gynecological cases, there were eleven hundred and 320 DISPLACEMENTS OF THE UTEETTS. eightv-six of retroflexion, and of this number four hundred and fifteen were uncomplicated retroflexions, three hundred and sixteen being associated with pelvic adhesions, a broken-down vaginal outlet (commonlv called laceration of the perineum), appendicitis, etc.. Out of one thousand operations of all kinds, extending from August 27, 1904, to iSTovember 9, 1905, there were ninety-five cases of retroflexion; of this number sixty-nine were married women and twenty-six were single. In ten per cent of the ninety-five cases an operation was done upon the vaginal outlet. Varieties of Retroflexion and Retroversion of the Uterus. — These forms of displacements differ according to whether they are found in nulliparc'e or in parous women. In the nuUiparous woman and in the virgin, a tilting back of the uterus is not infrequently found, in which the uterus lies, as it were, reclining in the sacral hollow, as one rests at ease in a rocking chair. If there are no symptoms of pelvic pain, irregular catamenia, and dysmenorrhea, such dis- placements do no harm what- ever, and ought not to be treated. Where the vagina is preternaturally short a Fig. 82. — A Retroflexion which is NATniAL axd caxxot retroflexion mUSt be COnsicl- BE COHEECTED OX AcCOTTXT OF THE AbXORMALLY ShORT -, ■, -, Yagixa. The anterior fornix, although it can be pushed erecl aS tilC UOrUiai pOSltlOn of^SUTe?^'"''"'^'''''"*'^''"^^'''^^^*^^'''^^^''*^"'''* foi' ^^le Uterus (see Fig. 82). There is no doubt at all that thousands of young women are under treatment for retrodisplacements, impressed by their physicians that it is a serious malady, who would be far better off if they were let entirely alone, or if the time and money expended were directed to the simple endeavor to build up their health. At the same time there are occasional cases in young women, in which there is a marked downward displacement, with the fundus of the uterus tilted backward, and often associated with a misplaced ovary, where there is a distinct dragging pain and a marked dysmenorrhea. In such cases where the symptoms are distinctly local and clearly referable to displacement, gTeat relief generally follows replacement of the uterus. It is the cases of neurasthenia, with more or less general aches and pains, and suffering which seems more particu- larly ovarian in character, that are rarely relieved by mechanical methods. Retroflexion in a woman who has borne one or more chil- dren is associated with a relaxation of the broad ligaments, and with a rupture PKOLAPSUS OF THE UTEEUS, 321 at the vaginal outlet, involving the levator ani fibres, and leaving the outlet gaping, with more or less eversion of the anterior and posterior vaginal walls. The cervix in such cases is at a much lower point in the vagina than is normal, in fact that conditions seem almost reversed. The cervix lies forward, one or two finger breadths from the symphysis, while the fundus lies backward, low down in the sacral hollow, where the cervix formerly lay. The examination in such a case is not completed until the patient is examined while standing, with one of her feet resting on a low stool. While in this position, on making the least strain, the vaginal Avails are felt to roll out, and the cervix is found to descend lower in the vagina. Prolapsus of the uterus is simply an advanced stage of this retrodisplace- ment just described, associated with descensus, which is the first step towards the formation of a complete prolapse. A complete prolapse, or escape of the entire uterus from the pelvic cavity, is rarely brought about within a short period of time; as a rule, the descensus increases week by week until the cervix appears at the vaginal outlet, and next escapes from the outlet, until finally the entire uterus, or, it may be, a long drawn out supra- FiG. 83. — A Case of Complete Prolapse of the Uterus with both Vaginal Walls. with the cervix, hangs hke a bag between the thighs. The vagina, vaginal cervix, like a stem of -macaroni, communicating with the body above, hangs between the thighs (see Fig. 83), at the apex or on the anterior surface of a sac made up of vaginal walls, containing a diverticulum from the bladder in front, and it may be some projection of the rectum or the small intestines behind. The pain present in these cases is most aggravated when the prolapsus is in the process of formation, while the dragging is still going on, and the tis- 33 322 DISPLACEMENTS OF THE UTERUS. sues are yielding. When the prolapse is completed, altliougli the patient may be greatly incommoded by the mass, the sacropnbic hernia, which hangs between her thighs, the suffering is not so great, as there is no longer any stretching going on. Prolapsus is usually found in women well over forty, no longer in the child-bearing period, so that for this as well as for mechanical reasons, preg- nancy is extremely rare. The chief dangers in this condition are associated with the difficulty in emptying the bladder. Cystitis may occur, stones may be formed in the sacculus lying in the hernia, and an ascending infection may cause death. As a rule, however, there is but little danger to life. Symptoms and Diagnosis of Retrodisplacements. — A retroflexion is objec- tionable because of the disabilities it induces. The patient who was once active and energetic now feels more or less tired all the time, has a dragging sensation generally referred to the brim of the pelvis posteriorly, is apt to suffer from constipation and prolonged menstruation, and is often seriously incommoded by frequent urination. If pregnancy occurs, an abortion is apt to take place; although in favorable cases, the uterus rights itself, and after the third or fourth month there is no further difficulty, but rather a relief. If the retroflexed pregnant uterus becomes incarcerated and unable to escape from the promontory up into the abdomen, as a rule, an abortion takes place. This is the simplest and safest solution. Sometimes the pressure is so great as to occlude the urethra and cause an exfoliation of the vesical mucosa. A simple manual replacement, with the patient in the knee-breast position under anesthesia, in which the cervix is pulled doT\Ti towards the outlet, while the fundus is pushed up with two fingers introduced into the emptied rectum, will at once relieve all discomforts and place the uterus in a position to carry its burden to term. The diagnosis of retrodisplacement is made by feeling the cervix lower dovTi in the vagina than its normal position, instead of lying well up at the vault, while the rounded fundus is easily felt through the posterior vaginal vault (see Fig. 81, p. 319). The rounded mass at the posterior vaginal vault must be distinguished from an ovarian tumor or a fibroid tumor of the pos- terior surface of the uterus. This is done in the first place by grasping the cervix with the tenaculum forceps and drawing it down, while the finger dis- tinctly recognizes the continuity between the cervix and the fundus in the angle posteriorly. Then upon making a bimanual examination, with one hand pal- pating through the abdominal walls, the absence of any fundus anterior to the cervix is noted, while at the same time the fundus felt below can be pushed up so as to come within the reach of the abdominal fingers. If there is any doubt about the condition, a little anesthesia will enable the operator to make a still more searching examination bimanually through the rectum and the abdominal wall, bringing the finger into the closest contact with the posterior surface of the uterus, and enabling him to outline the ovaries at either side. In examining a young woman with an intact hymen, it is always best to TREATMENT OF EETRODISPEACEMENTS. 323 spare her feelings and suggest an anesthetic at once, to clear up the situation. I find as a rule that nitrous oxide gas is sufficient for this purpose; if it does not produce enough relaxation, a little ether may be given. Where an anesthetic is objectionable, a ten per cent solution of coca in may be inserted by the nurse, upon a pledget of cotton attached to a thread placed just behind the hymen; this measure obliterates the sensitiveness, after which the exam- ination can be made with far less distress and resistance on the part of the patient. The examiner ought always to avoid any injury to the hymen. This can be done by conducting the entire examination through the rectum. It is my rule in such cases to suggest to the patient, if she has been complaining of dysmenorrhea, that any simple operation, such as a thorough dilatation, should be done at once, so as not to subject her to the discomfort of two acts of anesthesia. Treatment of Retrodisplacements. — The treatment of a retrodisplacement may be either palliative or radical. Among the palliative treatments Fig. 84. — Showing Manner of Applying a Gauze Pack to the Vault of the Vagina by Means of A Packer, for the Purpose of Holding the Uterus up and in Place. must be reckoned the application of packs to the vagina, with a view of hold- ing up the uterus, and the use of pessaries for the same purpose. Radical treatments are operative in character. A vaginal pack, or tampon, is made of large pledgets of absorbent cotton or wool, or of a long strip of gauze (see Fig. 84) saturated with some drug, and introduced into the vagina, .where it forms 324 DISPLACEMEXTS OF THE UTERUS. a supporting column, holding nj) the nterns. The medicament most commonly used is a solution of boric acid in glycerin, called boroglycerid. A teaspoonful C)f this is laid in a piece of absorbent cotton, shaped like a little saucer, attached to a thread. This is then placed at the vaginal vault under the cervix with a thread hanging outside. One or perhaps two or more pledgets of cotton are similarly introduced, using an instrument called a packer, to carry the cotton up into place. Underneath the pledgets of cotton it is well to place a tampon of wool, which does not collapse like the cotton, and gives an elastic support to the whole. Such a tampon should be left in place from twelve to twenty-four hours, after which the patient removes it and takes a douche, using permanganate of potash, two to three per cent, in warm water for the jDurpose; or a teaspoonful of Labarraque's solution, the formula for which is as follows: ^ Liq. soda; chlorinatse oj Aqu£e Oj ■ M. S. Use as a vaginal douche. Such packs may be renewed from week to week, the douching being con- tinued in the intervals. A pack is not to be left in for several days, as it is liable to become sour and to set up irritation. A good plan of putting in a pack is to place the patient in the knee-breast position and lift up the perineum, when the whole vagina balloons out, and it is much easier to place a suppository or a supporting pack in position. The cervix should be drawn down with a tenaculum, so as to dislodge a non-adherent fundus or to gain as much room as possible, should it be adherent. The action of the pack is for the boro- glycerid to provoke a free watery discharge and thereby deplete the sur- rounding tissues, while the cotton and wool form an elastic supporting colimin within the vagina on which the uterus rests, preventing displacement down- wards when the patient is on her feet and propping the distended walls of the pelvic blood vessels, thus giving the patient a sense of relief. I sometimes see patients who have become accustomed to the use of packs where no displace- ment or anatomical abnormality of any kind whatever can be detected. Such patients, who have worn packs a long time, experience a sense of discomfort without them, and unless a strong effort is made to wean them from the prac- tice, they are likely to remain tied to the doctor's office from year to year. Cases of this sort, where there is really no trouble demanding the pack, are a disgTace to the gynecological profession. Pessaries in Retrodisplacement and Descensus. — Pessaries are valuable instruments in giving relief in cases of ret rodispla cement, or descensus, or both. As a rule, their use is only temporary, for a few weeks or months, when an appropriate 0]>eration should be done so as to free the patient from the necessity of local treatment. Sometimes, however, as in pro- lapsus in an older woman who has a serious organic disease, such as a heart lesion, and an operation is contra-indicated, a pessary is used permanently to KULES FOE THE USE OF PESSAKIES. 325 keep up the uterus and vaginal walls. The various forms of pessary are shown in Figure 85. Pessaries ought always to he made of hard ruhher. Soft rubher should he discarded, as it becomes foul and provokes vaginitis. The hard-rub- FiG. 85. — The Five Most Useful Kinds of Hard-rubber Pessaries. Their Size is Slightly Re- duced AS SHOWN BT THE CENTIMETRE MEASURE Below. (1) Smith pessary with strong Upper curve of the posterior bar and pointed nose. (2) Hodge pessary with broad anterior bar; the curved form of the pessary, seen from the side, is shown on the right. (.3) Comn:ion hard-rubber ring pessarjr, the most generally useful of all. (4) Gehrung pessary, the most valuable form in cases of cystocele, and in prolapse where the vaginal outlet is still good ; the outline of this pessary is shown on the right. (5) Reinforced Munde-Thomas-Smith pessary. Thomas added the thickening of the posterior bar to the Smith pessary (1) ; while Munde changed the pointed nose of the anterior bar into a broader one, more like the Hodge form. All these pessaries are made in several sizes. ber pessaries may be left in place for periods varying for from several months to a year. The operator should be sure when the pessary is introduced that it is perfectly clean. A pessary should never be taken from one patient and, after simple washing, introduced into another. The ring pessary alone of all the different kinds can be disinfected by boiling in water. Other pessaries, which are liable to lose their form by boiling, should be washed with soap and hot water and then immersed in a solution of bichloride of mercury for several days. The use of the pessary is simply to spread out the vaginal walls. When the uterus is freely movable, it may be put in a normal position before 326 DISPLACEMENTS OF THE UTERUS. a pessary is placed. A measurement should be made of the length of the vagina, by means of the finger or a sound, from the upper limit of the posterior cul- de-sac down to the posterior surface of the symphysis at a point corresponding to the junc- tion of the lower and middle thirds of the urethra, in order to determine the length of the pessary to be used. Fig. 86. — Showing Method of Bimantjal Reposition of a Reteoflexed Uterus. Note index finger of left hand pushing the cervix forward, while the right hand presses upon the posterior surface of the fundus uteri. Manual Reduction. — Let me say here that manual reduction of the uterus, while it seems an ideal procedure as it appears on a diagram, lacks two important elements of the ideal in actual practice. In the first place it is not always easy to accomplish and may hurt the patient a good deal ; in the second place, a uterus so replaced, as a rule, refuses to stay where it has been put. For this reason, I do not pause to lay great stress on this phase of the treatment of retrodisplacements. The replacement is effected by getting hold of the back of the fundus with the hand on the abdomen (see Fig. 86), at the same time pushing the cervix back with the finger of the other hand, in this way assist- ing the organ to reach its normal fundus-ante position. After replacement it is well to exaggerate the anterior position decidedly before putting in the tampon (see Fig. 87). It sometimes happens that the simple introduction of a pessary sets a retro' position of the uterus into anteposition. Before introducing the pessary the vagina should be clean and the bowel free of fecal matter. The well-lubricated pessary is then placed inside of the vagina, encircling the cervix as if it is a ring, and this may be done without attempting to raise the fundus ; the pessary itself will often serve to correct the retroposition of tlie uterus, if its presence is sufficient to maintain the uterus in a correct position. The essential con- RULES FOR THE "USE OF PESSARIES. 327 ditions for the use of a pessary are the absence of a lateral inflammatory disease, which would be aggravated by the hard sides of the pessary, and a vaginal outlet sufficiently closed or snug enough to keep the pessary within the vagina. If the vaginal out- let is much broken down, any pessary, however well placed, will roll out as soon as the patient is on her feet, or with the first act of straining. There is one pessary, the Gehrung, which will correct an eversion of the anterior vaginal w^all, called a cystocele. The pessary is held in the fingers, as shown in the diagram (see Fig. 85, 'No. 4), and inserted by hooking it down over the perineum, and then rotating it gently till the entire pessary is brought within the vagina. It is then turned with the index finger, pressing on one or the other of its bars until the cervix comes to lie in the position shown in the diagram. Other pessaries commonly used are the simple ring (Fig. 85, ISTo. 3) in sizes from four to ten centimetres in diameter; and the rubber ring, which should be about ten millimetres in thickness ; it is a serious mistake to use rings made of narrow rubber less than six millimetres in thickness, as these Fig. 87. — Shows an Exaggeration of the Normal, Anteflexion of the Uterus, Produced by Bimanual Manipulation. are more liable to cut through the vaginal walls. Whenever there is some tendency to prolapsus, it is better to use rings with thicker margins, and in prolapsus, a disc of rubber is often valuable, with simply a little hole (one to two centimetres in diameter) in the middle. In such cases a shell pessary is often useful. I believe, as a rule, hard-rubber rings will serve all the purpose Fig. 88. — Showing Manner of Introdttcing a Ring Pessary, by Drawing Back the Posterior Vaginal, Wall, and Pressing Back^svard with the Pessary as it is Introduced in a Slightly Oblique Direction. It is important to avoid pressing upon the pubic bone or the more sensitive structures near the symphysis. Fig. 89. — Showing Manner of Introducing a Smith Pessary. The index finger of the left hand pulls back the vaginal waU, while the right hand introduces the pessary without bruising the structures lying anteriorly. 328 INTRODUCTION OF PESSARIES. 329 and fulfil nearly all indications better than the so-called lever pessaries, known as the Hodge, Albert Smith, Smith-Thomas, Smith-Thomas-Mnnde (Fig. 85, !Ro. 5). When a lever pessary is used in retroflexion, the broad posterior bar of the Thomas pessary is more satisfactory than the old-fashioned Smith, while the same pessary with a square nose in front is more satisfactory than the pointed nose of the Albert Smith pessary. The pessary ought never to stretch the walls of the vagina so as to produce an ischemia. It is a temptation, it appears, to many physicians to insert a large pessary, of the style which I have long called a Horse Pessary; this stretches the vaginal walls out tremendously in every direction, producing a result which would be very satisfactory if the instrument did not lie in contact with living tissues liable to ulcerate. A pessary should fit snugly, but rather loosely, although not so loosely as to be unable to keep its position. There should be room on all sides to insert easily between the pessary If it is uncer- tain what kind of a pessary to use, it is best to start out by trying a ring. Then if this does not do well, to try, say the Smith-Thomas-Munde. The ring pessary is inserted in the man- ner shown in Figure 88, pushing pos- a finger and the vaginal wall. teriorly against the perineum. and avoiding any violent impact on the urethra or the anterior vulvar tissues. The Smith or Munde pessaries are held and inserted in the manner shown in the diagram (see Fig. 89). After thus slipping the pessary into the vagina, it is put in position by the index finger pressing the posterior bar back behind the cervix (see Fig. 90). Fig. 90. — Showing Manner of Carrying Smith Pessary into Place. The pessary, having been introduced into the vagina, is caught by the in- dex finger, which rests upon its posterior bar, and carried well behind the cervix, when the pessary is in position. The whole pessary should then lie well within the vagina and behind the symphysis, and no part should be visible at the vaginal outlet. Figure 91 shows ring pessary in position. The thick ring pessaries, the disc pessaries, the shell pes- saries, and the bayonet handle pessaries (Menge) should be reserved for prolapsus cases. In these cases, the pessary must be larger, as a rule, than for retroflexion, so as to take up more space in the overstretched vagina, and at the same time too large to escape through the vaginal outlet when once intro- duced. The simpler the form of pessary which does the work, the better for the patient. Sometiuies a pessary seems to fulfil the indication in an ideal man- ner, so long as the patient is on her back, but as soon as she gets on her feet, 330 DISPLACEMENTS OP THE UTEEUS. the part lying behind the symphysis slips down, appears at the vulva, and so escapes. The physician here realizes that, if in some way he could prevent the pessary falling forward in this manner, he would be able to keep it inside, and so give entire relief. This indication was met by our predecessors by the Fig. 91. — Sho'wixg a Rdjc Pessary en^ Place, axd its Relatioxs to the Cervix an"d the Vault of THE Vagena. Zwank pessary, an instrument which could be introduced closed and then opened out by means of a screw arrangement in the handle. These pessaries, however, did incalculable harm in cutting through into the tissues, and have, for this reason, fallen into a well-deserved disrepute. This indication is well met by the Menge pessary, with a rounded stem, which is inserted into the pessary and fixed with a bayonet lock after the pessary has been introduced (sec Fig, 92). Pessaries cause abrasion or ulceration of the vagina because they are too large and exert undue pressure in one place, or because the polished surface of the hard rubber becomes incrusted with lime salts and thus roughened. To gaiard against this roughening and to make sure that the pessary fits well, it should be removed and inspected after each menstrual period for several months, and thereafter at intervals of two or three months during the time it is worn. IWTRODTJCTIOiq" OF PESSAKIES. 331 In fitting a pessary it is often necessary to bend it. To do this without destroying the polish it must be thoroughly greased and held just above the flame of an alcohol lamp, taking care not to let the grease catch fire, for if it does the rubber will burn, leaving a rough spot. Patients who wear pessaries find it necessary, as a rule, to use douches; a good douche is made of sodium bicarbonate and borax, a teaspoonful of each to the pint of warm water, which can be taken once a day injected with a Davidson's syringe, using the long hard-rubber nozzle introduced to its fullest extent into the vagina. If a drop of menthol is added to this Fig. 92. — ^A Form of Pessary (Menge) Useful in Some Cases of Prolapse of the Uterus. The stem prevents the pessary from rotating and thus from presenting at the vaginal outlet and escaping. and thoroughly mixed with the powder before dissolving, the douche is more refreshing. '^ Menthol gtt. j Sod. bi-carb 3j Sod. bi-borat 3j S. Dissolve in a pint of hot water and use as a douche. 332 DISPLACEMETiTTS OF THE UTERTTS. Vaginal suppositories of borogljcerid and gelatin plain or combined with Hydrastis, ichthjol, tannin, or alnm, are often useful in place of the douche. Operative Treatment. — The radical or operative treatment for retro- displacements consists in the use of natural or artificial supports to hold the uterus in an anteposition and keep the fundus forward in advance of the cervix. The simplest form of operation is that used in nulliparous women where one of several supra-pubic operations may be employed. The Alexander operation acting on the round ligaments by shortening them in the inguinal canal has long been in vogue, but it is at present being generally abandoned. Fig. 93. — Shows the Different Steps in an Operation for Prolapse of the Uterus. (1) Rep- resents the amputation of the cer^dx by removal of the area indicated by shading. (2) Represents the resection of the anterior vaginal wall for correction of the cystocele. (3) Shows the operation for building up the vaginal outlet and thus narrowing the opening. (4) Is the suspensorj.- ligament attaching the fundus to the abdominal wall. (5) Represents the alternate operation to this, namely, the shortening of the round ligament by Gilliam's operation. The advisability of such an operation belongs to a specialist, but the general practitioner must judge what cases it is desirable to send him for advice. For the information of the physician, I have indicated two of the forms of operation used for the correction of an extreme prolapse. In one, the simpler, TEEATMEISTT OF PROLAPSUS. 333 the cervix, wliicli, as a rule, is elongate, is amputated (see Fig. 93, 1) then the anterior vaginal wall is resected (Fig. 93, 2) ; and, finally, the vaginal outlet is built up so as to give a strong support to the outlet (Fig. 93, 3). An abdominal operation may be added to hold the vagina forward, either by direct action of the fundus, or by drawing the round ligaments through the Fig. 94. — An Operation for the Cure of Prolapsus in Women Who have Passed the Child-bear- ing Period and tvhere there is a Marked Cystocele. The uterus is intereallated, or fixed between the bladder and the anterior vaginal wall. The shaded area in the perineum represents the customary closure of the relaxed opening. abdominal wall (Gilliam's operation). In the other forms of operation, which effectively holds the uterus in place in even the most difficult cases, the body of the uterus is brought out between the bladder and the vagina as shown in Figure 94. After this the vaginal outlet is built up as in the operation shown in the previous figure. Treatment of Prolapsus. — While retroflexion and simple relaxation of the vaginal outlet are easy, prolapsus is often exceedingly difii- cult to cure. The flaccid vaginal walls, with a loose uterus above, are apt to roll out of the best-formed vaginal opening, as a wet glove is turned inside out. In almost all cases of prolapsus, a series of operations is necessary to effect a cure. I have already spoken of the three forms of pessaries in use 334 DISPLACEMENTS OF THE UTERUS. in this condition, and when they do afford relief in women of advanced years, especially in those who are very stont, it is far better to use them than to resort to any more or less aggressive treatment. A pessary cannot be used successfully, however, unless there is a more or less well-formed outlet to hold it in. If there is a fairly good outlet, then it is worth while to spend some little time in persevering effort to find a suitable pessary. Whenever there are ulcerations on the everted vaginal mucosa, the uterus and vagina ought to be pushed back into the pelvic cavity and the ulcerated surfaces treated by inserting glycerin tampons, and keeping the patient in bed until they are healed (see Fig. S-4, p. 323). Each time the tam- pon is removed a prolonged hot douche is given, six quarts of water as hot as can be borne at a temperature of 110° to 116° F., given by means of a foun- tain syringe, after which another pack is inserted. If the bladder is affected with cystitis, as sometimes happens, it should be treated by daily irrigations with a boric acid solution of half saturated strength, as hot as can be borne. A good wav to do this is to attach a funnel with a long rubber tubing to the end of the catheter and after filling the funnel with the solution, raise it two to three feet above the level of the patient as she reclines on her back. Let the fluid run into the bladder until the patient complains of gTcat discomfort, then pinch the tube, and disconnect it from the catheter. Care should be taken not to let any air go into the bladder, as it is apt to produce distress. If the progTCSs towards recovery is not rapid enough, the boric acid solu- tion may be alternated with one of hot nitrate of silver, 1 : 1000 in strength. Should these means fail to give relief the patient must be referred to a spe- cialist with a view to operative treatment. CHAPTEE XIV. PELVIC INFLAMMATORY DISEASE. Definition, p. 335. Etiology, p. 336. Varieties, p. 336. Diagnosis, p. 337. Treatment, p. 341. DEFINITION. The term "pelvic inflammatory disease" is applied to an ex- tensive group of affections of an inflammatory nature, involving the pelvic viscera. The result of such an inflammation is the agglutination of the con- tiguous viscera, often associated with the formation of localized swellings, consisting of abscesses or accumulations of serum, which are walled off from the rest of the abdominal cavity above. These affections are so exceedingly common that they are seen by every general practitioner, and their treatment forms a large part of the surgical work which the gynecologist is called upon to do. The group of pelvic inflammatory diseases is subdivided into a number of specific affections, each one of which tends to differ from the others in its mode of onset, in its course, and in its termination; the group as a whole, however diverse its causes, is united by one peculiarity, namely, that of inflammatory reaction, which results in the formation of adhe- sions between the inflamed structures and the circumjacent peritoneum. • In the first broad analysis of the subject inflammatory affections may be divided into two sorts: one which is infectious, resulting from the invasion of pathogenic organisms ; the other which is non-infectious and results from the irritative action of some chemical product, either of the uterine tubes or of the ovaries, upon the peritoneum, provoking an inflam- matory reaction without the formation of pus. The non-infective cases of pelvic peritonitis, as a rule, arise from the ovaries (excepting in the case of a tubal hematocele) ; the most con- spicuous cases of this class are the extensive hematomata arising from diseased corpora lutea. The blood poured out under these circumstances provokes violent adhesive inflammation in the surrounding peritoneum, in which both ovaries are usually involved, being walled in by the dense attach- ments of the uterus, tubes, and bowels to one another. The infectious cases, in most instances in which the avenue of inva- sion can be detected, are traceable from the uterus upwards, through the uterine tubes, and so onto the peritoneal surfaces. They differ from the non- 335 336 PELVIC INFLAMMATORY DISEASE. infective, above cited, in that their chief seat is in the uterine tubes^ which may show extraordinary changes, becoming converted into serous or pus sacs (sacto-salpins), sometimes of great size. ETIOLOGY. The inflammation, whatever its cause, is usually traceable to a definite focus where it resides at first, and from which it extends intermittently to the surrounding structures. The focus is generally manifest in the greater in- tensity of inflammation, and the greater density of the adhesions at this point. It is important to note the fact that while the organ which forms the focus of the disease is often injured beyond the possibility of restoration, the adjacent organs are frequently only incidentally affected, being involved in the adhesions resulting from the pelvic peritonitis, and although affected, often not seriously injured structurally. The chronic forms of pelvic inflammation, which are seen for the most part by the gynecological specialist, have, as a rule, been progTessing for months, and frequently for many years ; they are often ambulatory, visiting one oflice after another, and clinic after clinic, seeking relief. The acute florid forms, on the other hand, are oftener seen by the general practitioner, who is called in where there is a fresh gonorrhea, and in the first attack of pelvic peritonitis ; or again, he sees his patient through her confinement, and then watches the development of a phlegmon on the pelvic floor, or a peritonitis in the puerperal period, VARIETIES. The following forms of pelvic inflammatory disease are those com- monly seen: Gonorrheal infection. Puerperal infection. ; Tubercular infection. Corpus luteum cysts. Ectopic pregnancy. Abscess of the vermiform appendix. Infected dermoid and ovarian tumors. This is purely a clinical classification ; a more scientific division based bac- teriologically on the infecting organism, is the following: (1) The gonococcus, producing gonorrheal abscesses in the tubes or ovaries, with pelvic adhesions. (2) The streptococcus, seen oftenest in puerperal infections and com- monly invading the cellular tissues with the production of a brawny phlegmon. (3) The staphylococcus and the colon bacillus, producing ab- SYMPTOMS AND DIAGNOSIS. 337 scesses in tlio puerperal period, or by a secondary invasion in gonorrhea and tuberculosis ; as well as from an infected vermiform appendix. (4) Tlie tubercle bacillus, causing cheesy and nodular tubes, with more or less extensive dissemination into the pelvic peritoneum. (5) The group of non-infectious inflammations, already referred to. SYMPTOMS AND DIAGNOSIS. It is a matter of the utmost importance that the general practitioner, who handles the gross materials of all the specialties in his daily practice and sep- arates such as need further elaboration to send to the specialist, should recognize clearly all his cases of pelvic inflammatory disease. As a rule, I am sorry to say, this group of affections is not promptly recognized to-day, and in many instances a diagnosis is forced upon the reluctant practitioner simply by the lapse of time, and by the fact that the patient continues to suffer and is failing in health, in spite of a course of polypharmacy. In this way a sort of diagnosis is made perforce, which is not creditable to the medical man, and on account of the serious loss of time, is often injurious to the patient. It is in order to bring the practitioner into closer touch with these cases, and to lay before him simple and satisfactory methods of making a diagnosis, without entering into unnecessary refinements, that these lines are written. Looking at the pelvic inflammatory cases symptomatically, there are, in general, two groups, the non-sensitive and the sensitive. One of these, the non-sensitive, is an extraordinary class, in which there may be even widespread adhesions, more or less involving all the jDclvic organs, but the patient may liave no particular discomforts of any kind, and may not have complained of any pelvic disease at all, until some irregularity of function, such as excessive monthly periods, or a growing mass at length forces her to seek advice. At present, we are not in a position to explain the lack of pain in these instances. The diagnosis cannot be made by symptoms, for there are few or none, but only by a bimanual examination in the course of a routine investigation, when the adherent masses in the pelvis will be dis- coverable. The sensitive group are those suffering from pain, which in prac- tically all cases is present at the menstrual periods and which in the more pronounced cases becomes continuous and almost unbearable. Tlie pain may be intermittent or continuous ; at times it is excessive, at others but slight, or altogether absent. Practically, all acute cases are very, painful from the start, and the suffering continues until the disease either disappears or subsides into a chronic state. The pain is usually localized in the pelvis, and, as a rule, the painful area can be covered by the palm of the hand laid upon the lower abdomen over the right or left ovarian re- gions. On the right side the pain is sometimes located near enough to the brim of the pelvis posteriorly to cause considerable doubt as to whether or not 23 338 PELVIC IXFLAMMATOET DISEASE. the vermiform ajDpendix may be at the root of the trouble. When the pain becomes intense, it is apt to extend over the whole lower abdomen, into the iliac fossa, and down one of the legs, following the anterior crural and sciatic nerves, or into the lumbar region of the side af- fected, in other words, the lower abdomen and legs are involved. The pain due to a bona fide pelvic disease differs from the more or less ill- defined pains of a hysterical or a neurasthenic patient, in that the inflammatory pain has a definite habitat. The pain of inflammation is a fixed pain; it is never in one place to-day and then at some remote part of the body to-morrow, one day perhaps in the shoulder, and the next in the foot or the calf of the opposite leg, etc. It is a safe working hypothesis to conclude that a patient who complains of a definite pain, and who from day to day and week to week is definite in her complaint as to the character and site of the pain, has some gross trouble. This, I say, is a safe working hypothesis. It is not, however, safe to operate upon a patient upon such an indication; but, given such a definite complaint, I would give the patient an anesthetic, carefully examine the pelvic organs, and clear up the diagnosis in that way. As a rule, the pelvic inflammatory pain is gradually increased at the menstrual periods, becoming sharper with the congestion of the organs; in some cases it becomes intolerable at this time, but it is possible that the pain is not felt at all at the periods. In many instances, the pain is continuous, dull, aching, grinding, tearing in character, with exacerbations brought about by exercise, fatigue, etc. A sense of burning in the abdomen, often noted on the left side, over the pelvis or above it, is commonly associated with a neurosis without objective changes. Fever is a variable factor; when there is no pus, there is, as a rule, no fever, or at most but slight elevations of temperature. When there is an acute infection or an exacerbation of an old infection associated with fever, there is an increase in the number of white blood cells in the blood (leucocytosis), from the normal seven to nine thousand wp to fifteen to thirty or more thousand. This leucocytosis is gTeater in the puerperal than in the gonorrheal infections, and runs a course fairly pa.ralleling the febrile curve. The absence of leuco- cytosis does not show the absence of an abscess in the pelvis. When pus is present, and the process is not acute, there may also be no fever at all, or an elevation of only one half or one degTee. With the extension of an infection from a focus of su]3puration, however, the patient may run an acute febrile course for some days or weeks. Fever is found in all acute cases, varying in intensity with the character of the infection, and being most intense in the streptococcus puerperal patients. In making a diagnosis of a pelvic inflammatory disease, close attention must be paid to the history, and often from this alone such strong presumptive evidence may be gathered, that a fairly accurate conjecture can be made. In an acute case the cause, as a rule, is all too obvious; a young women SYMPTOMS AND DIAGNOSIS. 339 comes to her plivsician with a free purulent vaginal discharge, the external parts may be more or less inflamed, and the cervix pouring out some secretions. After suffering from such symptoms for a few days or longer, she is seized with severe cramplike abdominal pains, with fever and great tenderness over the lower abdomen, so that she is obliged to go to bed. Or it may be that a young married woman comes with the same history ; the doctor discreetly takes the husband aside and asks him if he had any gonorrheal disease at marriage, and he acknowledges an infection a few months back, but says his doctor dis- charged him cured, after a brief treatment. Again, the same history repeats itself after a menstrual period, when the portals for infection are thrown open through the increased congestion and succulence of the mucous membranes. The same sort of an infection is also prone to occur in the puerperal period. The examination in acute cases reveals great tenderness at the vault of the vagina and the most delicate manipulation shows that this extends out laterally over the pelvic floor. In one and all of these cases there is an acute gonorrheal process at work. The history points to the diagnosis, and the microscopical examination of the secretions, showing intracellular diplococci in the pus cells, proves it beyond question. A gonorrheal infection may be inferred in cases of women of loose life, who are continually exposed to infection ; or it may be suggested in married women by circumstances relative to the condition and habits of the husband, known only to the physician. In the unmarried, pelvic inflammatory disease is very apt to be due either to gonorrhea or tuberculosis. If the moral character is above suspicion, tuberculosis or corpus luteum cysts must be seriously considered. A gonorrheal infection may, as a rule, be proven from the character of the cervical dis- charge, and sometimes from the enlargement of the vulvo-vaginal glands ; or from a lingering infection in the urethral glands, in which pus is easily squeezed out by a little pressure under the pubic arch ; or it may be shown by the vaginal secretions, or from recrudescences of vaginitis, in which the gono- cocci become evident. Whenever it is possible, a little of the cervical secre- tion should be thinly smeared on a glass slide and examined under the micro- scope. If the general practitioner is not prepared to do this he can send the slide by mail to some one who is competent (see p. 276). Puerperal cases often date from a bad labor with protracted use of forceps, followed by fever, and a slow getting up. These also are often gonor- rheal in nature. If the examination of the discharge shows the absence of such a specific organism as the gonococcus, one of the staphylococci is prob- ably at fault. The patient often comes with the definite statement that she has not been well since her last labor, or since a miscarriage. Tuberculosis may often be suspected from the body habit, from the ex- istence of tuberculosis elsewhere, from the family tendency; it may be associ- ated with the uterine discharge and proven by curettage, and the finding of tuberculosis of an endometrium. Tuberculosis is apt to affect women in the first half of life who have not borne children. 340 PELVIC I]SrFLA:MMATOEY DISEASE. When curettage is performed in pelvic inflammatory disease, the operator must be careful not to rupture any adhesions or to open an abscess by tractions on the uterus. If there are any lateral masses the uterus ought never to be pulled upon. If it is curetted, this should be done with the organ remaining in situ and with as little disturbance as possible. Corpus luteum cysts have a tendency to rupture and pour blood into the cul-de-sac of Douglas, thus exciting an inflammatory reaction and leading to the formation of large adherent masses. An exactly similar process follows the rupture of extra-uterine pregnancy leading to the formation of the once much discussed hematocele. Disease of the Vermiform Appendix. — The physician must always bear in mind that pelvic inflammatory disease is associated in not a few cases with disease of the appendix. This point is an important one, as the expectant plan of treatment is not suitable in cases where the appendix is concerned. This subject is more fully discussed in Chapter XXIV. A further group of inflammatory affections, often bilateral, are associated with the small dermoid cysts, which may provoke a most vio- lent inflammatory reaction. Dermoid cysts at every period of their growth are peculiarly liable to provoke a non-infectious irritative peritonitis with dense adhesions to the contiguous structures. These cases offer, perhaps, as good an example as could be found of a well-defined peritonitis in the absence of any micro-organisms. The invasion of the cyst by organisms is associated with febrile disturbances, increased pain, and the formation of pus. Papillary cysts also form a peculiar group, almost always bilateral, in which the ovaries grow as large as the fist, and are filled with a mucilaginous material and papillary outgrowths which soon perforate the thin sac walls and spread on to the surrounding peritoneum. These cysts almost invariably pro- voke a violent inflammatory adhesive reaction. After taking a careful history and trying to get presumptive evidence of some one of these causes, the bi- manual examination is made. While a history of a fixed pain with exposure to infection, associated with or without vaginal discharge, may lead to a diagnosis of pelvic inflammatory disease, such a diagnosis can never be made with certainty until the disease is directly recognized by the examining finger. Upon introducing one or two fingers, the cervix may at once be noted to be immovable or rel- atively immovable. Carrying the finger a little farther up, a distinct swelling at the vaginal vault, posterior and lateral to the cervix, may make the diagnosis positive within a few seconds, even without any further investigation. Any swelling which is felt in this way by the vagina can also be more distinctly felt through the empty rectum as the finger enters the narrowed channel, back of the swelling, and is carried on above over its rounded, posterior eminences, which separate the finger from the uterus. If these distinct signs of inflam- matory trouble are not readily found, it is well to suggest an examination under anesthesia. For the purpose of making a most complete anesthetic examina- SYMPTOMS AND DIAGNOSIS. 341 tion, it is often sufficient to give the patient nitrous oxide gas, but the addition of a little ether may be necessary in many instances to secure a complete relaxa- tion. When the patient is under gas with the bowels well emptied, the cervix is caught by the tenaculum forceps and drawn carefully down, pulling the body of the uterus with it, while the finger is introduced into the rectum, and by invagination of the perineum, carried as higli up in the pelvis as possible, to some point not far below the promontory of the sacrum. With the vaginal finger or fingers thus hooked around the uterus, tubes, and ovaries, and used as a sensitive, posterior plane ready to recognize any transmitted motion and any varying degrees of hardness in structure, the upper or abdominal hand is used to make pressure upon the various pelvic structures and bring them within the reach and touch of the fingers in the rectum. In this way, the uterine body is outlined, the posterior surfaces of the broad ligaments are palpated, the ovaries are clearly felt, and the examiner has the assurance that if there were any enlargement of the uterine tubes, they would be felt also. Where an abscess is suspected he must be careful not to drag the uterus far down, and not to use force in touching the lateral structure, for fear of rupturing it. The simplest form of pelvic infiammatory disease which can be found is an adherent ovary. To find this the physician must so far have mastered the technic of the bimanual examination that he is able to recogTiize and handle a normal ovary per rectum. The posterior surface of the uterus and the fundus being large objects are easily found with a little practice ; then, feeling gently out to the right or left of the cornu uteri just under the angle, the utero-ovarian ligament is first felt, and then, following this outwards, the ovary itself. It is hard, slightly irregular, or a little nodular, perhaps^ contains a large follicle, from two to three centimetres in diameter and always movable. If the ovary is adherent, it cannot be lifted from its bed, or else the little string-like adhesions are felt to snap as it is freed. Uterine tubes only lightly adherent, and not otherwise altered, cannot be felt. It is most important to distinguish these pelvic inflammatory cases from cases of a sensitive pelvic peritoneum. It is not uncommon to see women who complain of extreme pain when any portion of the pelvic peritoneum is touched. For example, when a perfectly normal uterus is being palpated bimanually, they cry out with severe pain. This fact, namely, that the pain is complained of when normal structures are under touch, ought to put the examiner on his guard, so that he will attribute a like importance to the same complaints uttered when the structures lateral to the uterus, which cannot be so clearly outlined, are under examination. It will be seen from this that it is never safe to make a diagnosis from pain alone. TREATMENT. Prophylaxis. — There is but little use in uttering any warnings regarding the gonorrheal affections, as they are introduced under circumstances over which the temperate advice of the physician has practically no control. 342 PELVIC IXFLAMilATORY DISEASE. This aspect of the question rests largely in the hands of those parents and educators who look at the formation of character and a chivalrous respect for woman as the chief factors in an education. Puerperal infection will be avoided by aseptic conduct of labor and the puerperium, as described in Chap- ter XIX. Over the tubercular affections, the corpus luteum cysts, and the neoplasms of the ovary, we can also exercise no control. Forms of Treatment. — Treatment may be expectant, or palliative, or radical. In the acute forms there is rarely any call for active radical interference in the earliest stages. ^Tiere the highest skill is available, how- ever, it is sometimes possible to cut short an acute attack, where, for example, there is a gonorrheal infection of the tubes, by opening the posterior cul-de-sac, and draining the peritoneum freely. This plan of treatment has been devised and successfully carried on by that able gynecologist, the late Dr. F. Henrotin of Chicago (Trans. Amer. Gyn. Soc, 1895, vol. 20, p. 232). In the more acute conditions, and where there is no fever at all, rest is the sheet anchor in the treatment. The patient ought to be flat on her back in bed, and the bowels ought to be kept emptied. Prolonged hot saline douches may be given, making the temperature of the douche as near 120° P. as the patient can comfortably bear it. A tablespoonful of salt may be added to the quart of water, and the douche continued for from ten to twenty minutes. Patients who are suffer- ing severely sometimes derive great relief from poultices on the abdomen. Where there is a painful swelling on the lower ab- domen, an ice-bag over it with a towel intervening serves to restrain the inflammatory process and gives much comfort. In a more acute case, where there is manifest fluctuation, the vaginal vault should be opened. This is best done by bringing the patient to the edge of the bed or side of the table, with legs flexed on the abdomen ; the cervix is then exposed by retracting the posterior vaginal wall, grasped, and held forwards, while the vault of the vagina, just behind the cervix, is opened with a pair of scissors from side to side. The peritoneum is soon visible just above the incised vagina (Fig. 95), and this is also carefully opened, at once effecting an entrance into the abscess, or else exposing its wall which is laid widely open. After all the pus is evacuated, the cavity may be thoroughly wiped out with a pledget of gauze, grasped in a pair of long forceps, after Avliieh it is loosely packed with an iodoform gauze drain. The opening into the vaginal vault tends to close rapidly. It may have to be enlarged once or twice in the course of the convalescence, however, before the abscess cavity has completely collapsed. Fig. 95. — The Vaginax, Vault is Exposed and THE Cervix Caught by A Stout Forceps and Held a Little For- ward WHILE ax Ellipti- cal Ixcisiox is Made Posterior to the Cer- vix. Through this incis- ion the peritoneum is opened and the abscess evacuated. (From Kelly- Noble " Gynecology and Abdominal Surgerv," 1907, Vol. I.) FOEMS OF TREATMENT. 343 In a case which is clearly and beyond peradventure improving, the physician is warranted in waiting from week to week, keeping the patient under close observation. In a case which does not improve, or which grows worse, he should, after making a careful diagnosis, seek the advice of a specialist in ab- dominal surgery, either a gynecologist or a general surgeon, and consider the question of a more radical oiDcration, either by the vagina or by the abdo- men. It is not our province here to enter upon the technic of these radical operations. The treatment in a chronic case is either operative or non- operative. All those cases should be operated upon in which there is a demon- strable abscess, or any large mass or masses, within the pelvis. It is important to do this, and to do it without delay, as the inflammatory cases with masses or tumors to the right and to the left in the pelvis are liable to exacerbations with rupture in the direction of the peritoneum, or into the bowel, or the blad- der. Every case in which any lumpy or resistant areas are felt to the one side or the other should be looked upon as probably operative and referred to a specialist for an opinion. The utmost that can be done for the non-operative cases is to wait awhile to see if ISTature cannot relieve all the symptoms and cure the disease her- self. ISTature's great coadjutor in bringing this result about is Time. While waiting for the beneficial effects which are to accrue from time, the physician must exercise an intelligent supervision, watching the subsidence of the trouble from week to week, with gentle examinations from time to time, meanwhile prescribing such a regimen as will promote the end in view, while, at the same time, he restrains the patient from doing those things which will be likely to prove harmful. To these ends he enjoins much rest, late rising, and early bedtime, and rest for an hour after meals, forbidding active exercise and late hours. He must also see that the lower bowel never becomes clogged. Hot vaginal douches of plain hot water with table salt (two teaspoonfuls to a pint), once a day for say ten to fifteen minutes at a time, are often both re- freshing and helpful. Some patients are helped by painting the vaginal vault with a strong tincture of iodine (Churchill's) about once a week, follow- ing this with a boroglycerid pack. This is done by nesting a teaspoonful of boroglycerid in a pledget of absorbent cotton, the size of the palm of the hand, tied with a string, folding this together, and placing it against the vaginal vault. The pack is removed in twelve hours by pulling on the string which hangs outside. I would repeat these packs about every third day. A douche must not be given while the pack is in the vagina. Massage should not be given to the lower abdomen, although general massage is useful. Electricity, I believe, is of no service. When a case does not promptly improve, a specialist must be asked to see it ; by neglecting to do this a malignant tumor may be encouraged to groAv, or a case of pelvic inflammatory disease arising from the vermiform appendix may be overlooked and allowed to grow worse, 344 PELVIC ijstflammatory disease. ManN' of the cases of pelvic inflammatory disease are due to tuberculosis which cannot get better until the disease is removed by surgery. I ^vish especially to call the attention of the practitioner to the pro- priety of conservatism in many of these cases which come to operation. It is always comparatively easy to do a radical operation, that is to say, to take out both tubes and ovaries; but a more restricted removal of the diseased organs only, will conserve, at least, the function of ovulation and internal secretion, and it may be that of conception too, thus saving the patient much distress of mind and avoiding tlie disagreeable sequelae of the extirpative treatment. It sometimes happens that the physician, though he may not know as much as the specialist, is yet better able to safeguard the best interests of the patient, even on the operating table. This he can do in two ways, in the group of affections under consideration. In large abscesses he may cast his vote in the consultation in favor of pelvic drainage by the vaginal route. Paradoxical as it may seem, the worst cases sometimes get well in this way, with a good drain in the vault of the vagina, quicker than some of the apparently simpler cases which cannot be drained. At any rate, a patient with a big abscess can often be drained with perfect safety, when it would be most hazardous to attempt a complete extirpation. Later, if she needs it, the extirpation can be done with safety in the absence of pus. Again, the attending physician may be called upon to decide for or against conservatism. To make an intelligent decision he must bear in mind the fact that in all cases of pelvic inflammatory diseases the ovaries are involved in adhesions simply because of the accident of their location close to the fimbriated extremities of the tubes, out of which the infectious materials are poured into the peritoneum. When the disease is of long standing, and the ovaries are withered through compression from the inflammatory exudate in which they lie embedded, it is of no use trying to save them. When the adhesions are not so bad, and the ovary, freed from its bed, appears comparatively healthy, it may be saved with the assurance that it will continue to carry on its functions per- fectly, even though the tube has to be removed. Conservatism of the tubes in pelvic inflammatory disease is, as a rule, misdirected energy, but ovarian con- servatism is well worth while. If the patient is excessively anxious for offspring, the uterine tube may be amputated and its end left patulous. If then the ovary is not removed, at least a hope of conception is preserved, and this serves to ward off the distress of mind which would otherwise darken the life. If the whole ovary cannot be kept, a piece may be retained. If a good ovary is kept on one side and a good tube in the other, there is a fair hope of conception taking place. When an ovary is the seat of a hematoma, and buried in a mass of adhesions, being itself converted into a mere shell, the uterine tube belonging to it, and the uterus when liberated from the adhesions, may prove entirely normal or else capable of perfect regeneration and restoration to normal fuuetiraial activity. CONSERVATISM IN TREATMENT. 345 When both ovaries form adherent hematomata, conservatism, as a rule, is not worth while. In considering conservatism these facts must be borne in mind : (1) It is useless to run risks of a continuance of the troubles from which the patient is suffering, for the sake of preserving the menstrual function, if she is forty years old or more. (2) If the patient is single and middle-aged, without any expectation of marriage, the exercise of conservatism is less important. (3) If the patient has to labor for her own living, it is best not to take too many chances of the return of the disease by leaving any crippled structures. (4) It is dangerous to save tubes containing purulent or milky fluid. An old and apparently harmless salpingitis has been opened up, and the tube cleansed and dropped back into the pelvis, and this has resulted in the death of the patient. (5) If the patient wants above all things to be well, then the physician will be less inclined to take chances with conservatism. (6) As a rule, the results of conservatism are disappointing, and the patient ought always to be forewarned that it may be necessary to repeat the operation, and to make it more radical, if the first conservative effort proves a failure. When and what to conserve in recent cases, and when and what not to con- serve is a matter of fallible judgment; hence the common failures, even in the most experienced hands. CHAPTEE XV. STERILITY. Definition, p. 346. National importance, p. 347. Development of knowledge on the subject, p. 350. Etiologj' in themale, p. 351. Etiology in the female, p. 357. Diagnosis and treat- ment, p. 369. DEFINITION. Steeiltty is a disease of married life aifecting the generative and procre- ative pcAvers of the contracting parties, so that the marriage remains fruitless. If either husband or wife is incapable of procreation, the effect is the same as though both were affected. Sterility is absolute when an individual has utter incapability, and relative when the difficulty is removable and there is a possibility of off- spring, if only the partner is sound. Some women are sterile because their part- ners are incapable of procreation. Sterility is relative or facultative when brought abotit by voluntary sexual abstinence or by practices which pre- vent conception. That wedlock also is jDractically sterile in which, though con- ception frequently occurs, the product is cast off in an unnatural state by abortion or miscarriage. It is of the utmost importance to distinguish between male and female sterility, and the most notable advance in our knowledge of the subject within the past generation has been due to a careful discrimination in this respect. For example, when a wife appeals to a physician for relief of sterility, he does not now commit the blunder of focussing his attention upon her alone, but insists upon a careful investigation of the procreative powers of the husband as well. One-Child Sterility. — There is one special and important form of sterility, known as '" one-child sterility," in which a woman conceives promptly after marriage, and then never does so again. Sometimes the reason is not discover- al)lc. V)Ut the majority of such cases arise from puerperal infection; or a latent gonorrhea, recrudescent in tlie puer]Teral state; or a fresh gonorrhea acquired from the incontinent husband. Again, a fibroid tumor starts to grow and in- terferes with future conceptions. In rare cases there is an atrophy of the uterus with more or less amenorrhea. The causes, as a rule, are not difficult to eluci- 346 NATIONAL IMPORTANCE. 347 date after a careful history has been taken and a pelvic examination has been made. Sterility is an affection which may be congenital or acquired, as, for example, in the male a congenital sterility may be associated with cryptorch- ism or epispadias, while an acquired sterility may be due to gonorrhea. In the wife the congenital form may be due to imperfect development of the internal genital organs, the acquired to pelvic inflammation. A woman is presumptively sterile who has not become pregnant within the first three years of married life. NATIONAL IMPORTANCE. The question of sterility is a problem of the highest national importance, for upon the fertility of the dual units (husband and wife) which go to make up the body politic depends the healthy national life. All wealth, all that is best in art and science, all precious stores of tradition may become worse than useless, a mere mockery of what might have been, if accompanied by a progressive sterility. Dr. Hunsberger has shown in an article on " Race Suicide " {Jour. Amer. Med. Assoc, Aug. 10, 1907) that among families which can properly have children the population will not materially increase if there are fewer than four children to each pair. The intention of the Creator ex- pressed to the first pair in the primal command coupled with the first bless- ing (Gen. i:28) is rendered nugatory by sterility. Fertility is the natural outcome of right, clean living. Such a condition as a congenital, unavoidable sterility in either sex is rare ; a vast amount of that decadence which con- stitutes a national problem is of the avoidable kind, and such sterility is almost Avithout exception volitional ; that is to say dependent upon illicit sexual relations. In tliis way the percentage of sterility is an index to the morals of a na- tion. If the birth rate sinks below the death rate of a community, immoral- ity and vice of all sorts prevail, and, looked at from this standpoint, it will at once be seen that the treatment of sterility, when the disease is marked enough to affect national statistics, is a deep and a difficult, if not a hopeless problem. Drs. Newsholme and Stevenson {Jour, of the Roy. Statistical Soc, Mar., 1906) have an interesting paper on this subject in which they point out as a source of declination, not increased poverty but the propagation of " the gospel of comfort," which is becoming the ethical standard for all civilized nations. Also the increasing practice of artificial prevention must mean a lower moral standard, because the increasing fertility in such poor countries as Ireland and ISTorway hardly accords with the attempt to explain sterility on economic grounds. ISTor, they further remark, is the decline due to physical degenera- tion affecting the generative powers a cause of decrease in fecundity. The presumption is that the fall is due to conditions within the control of the peo- ple — a social form of felo-de-se. The following table, prepared by Dr. Jacques 348 STERILITY. Bertillon, is quoted as to tlie annual births per 1,000 women, aged fifteen to fifty, in four cities Classification. Paris. Berlin. Vienna. London. Very poor quarters Poor quarters Comfortable quarters Very comfortable quarters Rich quarters Very ricli quarters Average 104 95 72 65 53 34 157 129 114 96 63 47 200 164 155 153 107 71 197 140 107 107 87 63 80 102 153 109 The general conclnsion arrived at is that as the decline seemed almost uni- versal and " people did not change their morality in a large number of different countries at a given time without some extremely definite cause," a strong economic factor, that is, " the gospel of comfort," was in reality the deter- mining one. Among the most valuable works dealing with this question from a broad standpoint is one by Matthews Duncan (" Sterility in Women." J. A. Churchill, London, 1884). Duncan found that even among the better class sterility was increasing. Five hundred and forty absolutely sterile women con- sulted him within five years. These had been married between the ages of fifteen and forty-two, and three hundred and thirty-seven had been wives over three years. He has considerable confidence in stating one in ten as very nearly the true amount of sterility of marriages in Great Britain ; for women delaying the commencement of fertility beyond sixteen months already exhibit a degTce of relative sterility. The annual summary of births, deaths, and causes of death in England and Wales, and in London and other large towns, for the year 1906 shows that the marriages in England and Wales during the year 1906 numbered 269,734, corresponding to a rate of 15.6 persons married per 1,000 of the population at all ages. This rate was 0.3 per 1,000 above the corresponding rate in 1905, but was 0.2 per 1,000 below the average rate in the ten years between 1896- 1905. The births registered in 1906 numbered 934,391, and were in propor- tion of 27.0 per 1,000 of the population at all ages; this rate was 0.2 per 1,000 below the rate in 1905, and lower than the rate in any other year in record ; compared with the average in the ten years 1896—1905 the birth rate in 1906 showed a decrease of 1.7 per 1,000. The deaths registered in 1906 numbered 530,715, and were in the proportion of 15.4 per 1,000 of the population; this rate was 0,2 per 1,000 above the rate in 1905. Compared with the average in the ten years 1896—1905 the death rate in 1906 showed a decrease of 1.4 per 1,000. (London Times ^ June, 1907.) The table below shows the calculated amounts of sterility at different periods of married life in women married at different ages, the table being calculated for twentv months. NATIONAL IMPORTANCE. 349 Showing the Relative Sterility of a Mass of Wives Married at Different Ages at Suc- ceeding Epochs in Married Life. Age of Mother at Marriage. Proportion sterile about the 5th year of married life is about 1 in Or a percentage of Proportion sterile about the 10th year of married life is about 1 in Or a percentage of Proportion sterile about the 15th year of married life is about 1 in Or a percentage of Proportion sterile about the 20th year of married life is about 1 in Or a percentage of Proportion sterile about the 25th year of married life is about 1 in. Or a percentage of 15-19. 20-24. 25-29. 30-34. 35-39. 2.78 35.9 2.61 38.3 1.68 59.4 1.51 66.0 1.19 84.1 2.09 47.9 1.71 58.3 1.39 71.8 1.24 80.8 1.57 63.8 1.32 75.5 1.10 90.9 1.05 95.5 1.24 80.4 1.02 97.6 1.13 88.6 1.00 99.65 1.01 98.7 Total. 2.09 47.9 1.61 62.1 1.26 79.2 1.11 89.8 1.01 99.03 Showing the Variations of Sterility According to the Ages of the Wives. Ages op Wives at Marriage. 15-19. 20-24. 25-29. 30-34. 35-39. 40-44. 45-49. 50, etc. Total. Number of wives. . . 700 1,835 1,120 402 205 110 46 29 4,447 First children 649 1,905 809 251 96 10 2 3,722 Sterile wives 51 311 151 109 100 44 29 725 Percentage sterile. . 7.3 27.7 37.5 53.2 90.9 95.6 100 16.3 Proportion sterile, 1 m 13.72 3.60 2.66 1.88 1.10 1.05 100 6.13 The main element, says Duncan, in expectation of sterility is the age at marriage, but statistics suggest other laws, namely, that the question of a woman's being probably sterile is decided in three years of married life, only seven per cent bearing after this period. Another law is that when the expectation of fertility is greatest the question of probable sterility is soonest decided and vice versa, for it has been noted that of wives married from twenty to twenty-four who are all fertile, only six and two-tenths per cent began to bear after three years of marriage. Also, in writing of age, he says that " although it seems absurd to rank marriage among the causes' of sterility, yet the conclusion that it is so, at least in the very young, appears to be inevitable." Showing the Initial Fecundity of Women under Twenty Years op Age Within the First Two Years of Marriage. Ages op Wives Newly Married. 16. 17. 18. 19." Number of wives newly married 43 4 10.7 7.7 12.90 108 27 4.0 3.3 30.00 225 98 2.3 2.1 46.44 314 Number of wives mothers within two years of marriage Proportion of latter to former is 1 in 177 1.8 Proportion after correction for immaturity is 1 in ... . Or percentage 1.7 57.84 350 STERILITY. So that the Legislature, by raising or depressing tlie majority age, might exercise control over the population. In England about nine thousand young persons of the age of twenty and under twenty-one marry annually, and one hundred and thirty-nine thousand at twenty-one to twenty-five. Another test of sterility given by this author is: How^ soon after marriage does a woman bear her first child ? Some statisticians give eleven and a half months, but Ansell, quoted by Duncan as the most accurate authority, gives data of six thousand and thirty-five cases, showing a mean interval of sixteen months. Showing the Intekval, Between Marriage and the Birth op First Children. Year AFTEH MaKRIAGE. Number of First Children. Year after Marriage. Number of First Children. 1 2 3 3,159 2,163 421 8 9 10 11 7 7 4 137 11 o 5 69 12 4 6 26 13 3 7 21 14 2 Total. 6,035 And the annexed table also shows there is no good presumption of sterility till the fourth vear of married life is entered on. DEVELOPMENT OF KNOWLEDGE. The history of the recognition and treatment of sterilitj^ is fraught with interest no whit behind that of many other branches of medicine and surgery wdiich have undergone such remarkable evolution within the past two or three decades. Until recently the conception which prevailed was that there was but one form — ^that w^hich was evidently commonest in Biblical days, when w^e read in the inspired record of the sterile women that '' The Lord had closed up all wombs" (Gen. xx. 18), and of the relief of such condition, "■ God opened her womb" (Gen. xxx. 22). With the increasing '^ civilization " of the world a number of new causes have become operative which were overlooked until recent times. Even so short a time ago as the days of Marion Sims, closure of the womb w^as practically the only condition recognized and all cases were sub- jected to the same treatment — dilatation. At this period — the sixties and seven- ties of the last century — the w^ife was always treated, the treatment being always one and the same thing. I^oeggerath ("Die latente Gonorrhoea im weiblichen Geschlecht." Bonn, 1872), neglected and ridiculed like most pioneers who essay to overthrow settled convictions, was the apostle of the new doctrine which rightly threw the re- sponsibility for the common sterility upon the uncured and often incurable gonorrheas transferred from the courtesan to the wife, from the bawdy house ETIOLOGY OF STEKILITY IN THE MALE. 351 to the marriage bed. Slowly, very slowly, aided by the powerful pen of Max Sanger of Germany (Verhand. d. Deutsch Gesell. f. Gyn. u. Geh. Miinchen, 18S6) did the views of JSToeggerath become the conviction of the medical pro- fession at large. Following the discovery, of this writer, wrought out of his remarkable in- sight and analysis of his chemical findings, the extraordinary discovery of the gonococcus by N^eisser placed the question of the diagnosis of catarrhal and gleety discharges in both sexes beyond a peradventure and hastened the recep- tion of ISTeisser's discovery by putting incontestable evidence into the hands of the profession. Had it not been for the work of ISTeisser, Bumm, Wertheim, and others, I suppose this important question would still be under discussion and the wife still receiving, as she readily accepts, all the blame for the often distressing situation. We note in the history of this interesting subject the following illuminating facts : (1) The age-long recognition of the fact that sterility may be due to closure of the neck of the womb. (2) The discovery of the importance of gonorrhea, especially in its latent forms, and particularly in the male. (3) The discovery of the gonococcus giving scientific precision and cer- tainty to the views of ISToeggerath. (4) Greater skill in examining the internal genitalia in woman revealing tubal, ovarian, and pelvic inflammatory diseases often responsible for sterility and hitherto unsuspected. It would be gratifying to add that pari passu with the discovery of these new causes have gone the therapeutics of the condition. Unfortunately, as is too often the case, therapy lingers with laggard feet outside the doors of etiology. Although it is here my professed aim to deal with medical gynecology alone, I cannot discuss this important subject without giving at least brifef con- sideration to the question of male sterility. It is crudely supposed and is everywhere accepted by the laity that ability to complete the sexual act is of itself siifficient proof that the husband is capable of begetting offspring and the responsibility for sterility does not rest on his shoulders, that is to say in more delicate and technical terms that potentia coeundi is equivalent to potentia generandil ETIOLOGY IN THE MALE. There are two kinds of incapacity for ]3rocreation on the part of the male which entail sterility in the wife. (a) Inability to enter upon or complete the sexual relation. (6) Where the relation is apparently in every respect normal, the seminal fluid is partly or wholly devitalized, containing few or no living well-developed spermatozoa. 352 STEKILITT. Sterility of the first kind in the male may arise from marked congenital deformities such as epispadias and hypospadias, exstrophy and cryptorchism. It may also be due to extreme self-abuse in youth and the exhaustion of the sexual ]30wers by early excessive venery. I have seen one instance of a man postponing marriage until the sixties and then selecting a beautiful young wife rather that she might preside over his house than for love he bore her: he had no sex desire and, held in check by his indifferent wife, was unable to consum- mate the marriage relation. All the conditions of male sterility belonging to this category are at once manifest, being allied to an impotence which is almost invariably a source of acute distress and shame to the victim, who for this reason rarely ventures to enter on the married state. Such conditions are not affected by treatment, least of all by any of the wretched quack devices by which the victims are deluded from year to year to the depletion of their purses, but without quenching the spark of hope which renders them susceptible to the next lying advertisement of the lowest parasites prostituting the name of doctor. I would single out particularly the disgusting exhaustion ajDparatus employed to delude the poor victim by inducing a transient semblance of vitality. Under such circumstances the thoughts of the patient are best diverted into happier channels, and if unmarried, let the assurance be given that life holds within its compass a promise of nobler things than that of permitting the brain to revolve around the genital organs as the centre of interest. The second group comprises males affected with gonorrhea, the de- structive effects of which are seen in the epididymis, the vas deferens, the seminal vesicles, and the prostate gland. If through this cause both testicles are rendered functionless, or both vasa deferentia closed by an epididymitis or a deferinitis the result will be an azoospermia or a fluid in which there will be no living spermatozoa. A chronic vesiculitis or a chronic prostatitis will develop an oligospermia in which the living elements are few and far between or in which they are altogether absent, though dead ones or only those with feeble motile powers may be found — ^necrospermia. These affections render the male incapable of generating offspring (im- potentia generandi), though capable of an apparently normal sexual relation (potentia coeundi). A vesiculitis can be discovered by a rectal examination which reveals tenderness and fibrous thickening about the seminal vesicles. Pressure on these organs — " milking " them — will often induce a discharge into the urethra which can be examined at once. In the same way the prostatic secretion can be secured and examined. Casper (Monatsh. f. Urolog., 1900, vol. 5, p. 385) found prostatitis in eighty-five per cent of cases of chronic urethritis; that is, in a gTOup in which the disease had persisted over two months. Out of two hundred and fortv-two cases of double epididymitis col- ETIOLOGY IN THE MALE. 353 lected by Finger, this eminent authority found two hundred and seven cases of azoospermia, while Kehrer (" Beitrage zur klinischen und experimen- tellen Geburtskunde und Gynakologie," 1892, p. 76) found an azoospermia in tliirty and twenty-one hundredths per cent of ninety-six sterile marriages. Sanger, in analyzing 110 such marriages, found: in 53.6 p. c. normal sperm, " 11.8 " oligospermia, " 33.6 " azoospermia. These data are sufficient to show the extreme importance of investigating the male in every case of sterility, and the determination of male sterility is easy if the microscope is used. It should be borne in mind that it is not enough to rely upon the general assurance of the man, and least of all upon that of the wife, that he " is all right." The sperm is best secured for examination after a coitus condomatus, or by the act of withdrawal and the discharge of some of the semen into a small bottle which is corked and at once dropped into a bottle of warm water jacketed with flannel, which should be kept warm, not hot, until examined microscop- ically. In view of such examinations the husband should remain continent for four or five days, and will do best to break his abstinence in the early morning. The physician must never forget that even though repeated examinations show azoospermia, at a later date a few living cells may be found and conception be possible. Such are some of the cases in which pregnancy occurs after years of sterile married life. When, as the result of his analysis of the two factors involved in every case of sterility, the physician finds that the trouble lies at the husband's door it is his duty either to say nothing or to lay the blame where it belongs. But in no instance should the wife be allowed to suffer continual mental disquietude or be subjected to unnecessary treatments for an ailment which is not primarily hers. The fellow feeling which sometimes induces the physician to gloss over the husband's defect and lay an unmerited burden of worry and sorrow on the shoulders of the innocent wife is not creditable to our profession. The hope of procreation is apparently forbidden by the conditions of azoo- spermia, but the cautious physician will always carefully avoid, for two reasons, giving a hopeless prognosis. First, the event may disappoint his expectations by the temporary nature of the condition in some cases. Every man with a large experience can recall cases where conception has occurred after ten, twelve, or even more years of sterility. Second, the effect on the man thus condemned may make him morbid or melancholic. In regard to the proportion of cases in which the husband is responsible for the sterility, I give some statistics taken from the excellent work of F. Schenk (" Die Pathologic und Therapie der Unfruchtbarkeit des Weibes," p. 90 et seq.). 24 354 STEEILITT. '• Lier and Aselicr, who examined the s-tatistics of primary sterility, that is to say of women who had never conceived, found in 227 cases in Prochownik's clinic, that 76 sought advice on account of sterility, 151 on account of various gynecological affections. The husbands of these women were examined in 132 cases, and it was found that 42, or 31.8 per cent, had no living sperm cell (azoospermia), while 11, or 8.3 per cent, were impotent; 41 of the men had infected their wives with gonorrhea, and only 38, 28.8 per cent, were healthy. According to these figures the fault lay on the side of the man in 71.2 per cent of the eases. In 39 cases where the husband was examined, or 29.5 per cent, there was a definite obstacle to conception on the part of the woman. There were 50 men who refused examination, and 27 of these had infected their wives with gonorrhea; 45 men could not be examined, for various reasons, and in this gToup 13 wives were found to have gonorrhea. ... ^^ In 197 cases of acquired sterility examined by Lier and Ascher, the causes of it were found to be distributed as follows : Coitus reservatus 48 cases Azoospermia 2 " Gonorrheal infection 35 " Puerperal infection 27 " Various genital affections 85 " " In this group, leaving out of consideration cases of facultative (volun- tary) sterility, the fault lay with the man in 18.8 per cent of the whole. . . . " Sanger investigated material covering the period between 1891 and 1899, and found 397 cases of primary sterility and 21 cases of secpndary sterility. "• I. Of these 397 sterile marriages both man and wife were examined in 110 cases. The examination of tlie semen showed normal sperm cells in 59 cases. In 13 cases there was deficiency of semen (oligospermia), in 37 there was azoospermia, and in 1 case impotentia coeiindi. Taking these statistics just as they stand we find a percentage of 46.4 in which the sterility was on the male side. Of the 59 men with normal sperm cells, there were 28 who had certainly had gonorrhea, and of this number the wives were infected in 14 cases, making the total proportion of male sterility in these 110 cases 65, or 59.1 per cent. Only 45 marriages could be found in which no blame could be attached to the husband. . . . " If these 110 cases are analyzed and the proportion of causes of sterility stated in percentages, the results are as follows: " (a) Direct sterility due to the man by reason of impotence, azoospermia, or oligospermia, 51 cases 46.4 per cent Indirect sterility due to the man through the transmission of gonorrhea to his wife, 14 cases 12.7 " Total of male sterility 59.1 per cent ETIOLOGY IN THE MALE. 355 " (6) Sterility in the woman caused by Endometritis fimgosa 6 cases Parametritis post, atr 5 Stenosis of cervical canal and ext. os 16 " — 14.5 Anomalies of development 3 Stenosis with endometritis 7 Retroversion and retroflexion 4 Ovarian cyst 1 case Loss of semen 1 JSTo pathological finding 2 cases Total of 45 cases . . .' 40.9 per cent " These statistics approach closely to those of Lier and Ascher, which made the percentage of cases, in which both parties were examined and the fault lay with the husband, 71.2 per cent. Lier and Ascher found direct sterility caused by azoospermia and impotence in 40.1, and indirect sterility, through transmission of gonorrheal infection, in 31.1 per cent of their cases. " II. In 287 cases of primary sterility the woman only was examined, with the following results : " (a) Gonorrheal infection was found in 107 cases, or 34.8 per cent. In 28 of these cases, or 9.7 per cent, fresh gonorrheal infection was present, in the form of urethritis. Bartholinitis, endometritis, etc. In 79 women, or 27.5 per cent, there were inflamm.atory changes of the adnexa such as pyosalpinx, salpingo-oophoritis, and chronic peri-salpingo-oophoritis. "(h) Besides these 107 cases in which the woman had gonorrhea with resulting sterility for which the husband was responsible, there were 33 men with gonorrhea whose wives showed no evidence of it. Of this number 16 had gonorrhea without involvement of the testicle; 11 had single epididymitis with the gonorrhea ; and in 6 there was a double epididymitis. As the semen of these men Avas not examined, it cannot be said with certainty whether the sterility was due to gonorrhea in them or to non-gonorrheal disease in the wife. The various affections found to exist in these 33 women were as follows : " Infantile uterus 2 cases Stenosis (uterus parvus) 6 " Escape of semen 2 " Eungous endometritis 8 " Simple endometritis (with stenosis) 5 " Retroposition of uterus (with stenosis) 4 " Chronic atrophic parametritis 2 Myomata of uterus • 1 case Adipositas 1 Anemia 1 356 STERILITY. " (c) Of the remaining 147 eases in wliicli the woman only was examined no gonorrheal infection was found, while there was no record of gonorrhea in the man, either through examination of the semen or admission on his own part. In the absence of any examination of the semen, it is not justifiable to charge the sterility to the wife, even though she is found to have a definite gyn- ecological afi^ection. The genital affections in these cases are as follows: " Inflammations of non-gonorrheal origin. Tuberculosis of the adnexa 1 case Fungous endometritis 13 cases Parametritis, atroph. post 4 " cc T^- 1 , 18 cases JJisplacements. Retroflexion and retroversion of uterus 6 cases " " " " " with metritis 1 case " " " " " " stenosis of external os. . . 9 cases " Anomalies of development. Complete stenosis of the cervical canal and of the external orifice of the uterus, due to anteflexion of a small uterus 28 cases Anteflexion uteri parvi (without stenosis) 4 " Stenosis with fungous portio 1 case Atresia and stenosis of the hymen 4 cases Fetal uterus 1 case Infantile uterus 7 cases Hypoplasia of the uterus 1 case Atrophy of uterus (climax precox) 1 " In addition to these : Stenosis of cervix and of external os with endometritis ■ 26 cases " " " " " " " parametritis 3 " u i\.r 1 29 cases J\ eoptasms. Polyp of cervix 1 case Carcinoma of cervix 2 cases Ovarian cystoma 4 " Myomata of uterus 9 " 16 cases " Constitutional causes. Anemia (chlorosis) 6 cases Adipositas 6 " Tuberculosis of lung 2 " 14 cases ETIOLOGY IN THE FEMALE. 357 " In the remaining cases where the pelvic organs were normal there was vaginismus in 2 cases; intact hymen in 1 case; loss of semen in 1 case; while in three cases which sought advice on account of sterility no hindrance to conception whatever could be found, " III. In the investigation of secondary sterility there were 21 cases in which the woman only was examined, and in these the causes of sterility were as follows : Gonorrhea with disease of adnexa. 6 cases " without disease of adnexa (endometritis) ... 3 " // Tr-> 11* y C8-SGS ruerperal diseases. Pelvic peritonitis 1 case Fungous endometritis with parametritis 2 cases Parametritis with disease of the adnexa 1 case " (uncomplicated) 1 " 5 cases " The percentage of puerperal diseases in the causation of secondary sterility is 24 per cent, while that of gonorrhea is 43 per cent." ETIOLOGY IN THE FEMALE. Anatomical and Physiological Causes. — Bearing in mind that certain devia- tions from the normal sometimes cause sterility, it becomes important to con- sider first the anatomy and physiology of the female genital organs. Stenosis Infected Barth gl. Atresia of vag. "Fig. 96. — -Some of the Causes of Sterility Brought Together in One Diagram. These are: An infection of Skene's or of Bartholin's gland significant of gonorrhea; atresia of the vagina; stenosis of the cervix; a polyp hanging into the uterine cavity; fibroid tumors; a fibroid at the attachment of the uterine tube ; a parovarian cyst splinting the tube and separating it from the ovary ; a nodular salpingitis due to gonorrheal or tubercular inflammation; an atresia of the tube, of inflammatory origin; ovarian and tubal adhesions. 358 STERILITY. The various conditions likely to be found associated with sterility, when any demonstrable lesion exists, are shown for the sake of clearness and appeal to the eye in Figure 96, These may be traced categorically, step by step, from the vaginal orifice upwards : A gonorrheal infection of Skene's glands. An infection of Bartholin's (vulvo-vaginal) gland. A stricture of the vagina. A narrow cervix. A uterine polyp. A uterine fibroid tumor, either in the wall or blocking a tube. A parovarian cyst. A nodular salpingitis, from gonorrhea or tuberculosis. An atresia of the uterine tube from inflammation. Ovarian adhesions. The vulva is significant only in so far as a small mons with small labia and a slight capillary development such as one sees in children approaching their teens, should at once put the physician on his guard, as this condition may indicate a similar want of development of internal organs. Fig. 97. — Cyst of the Left Bartholin's Gland, often an Indication of a Gonorrheal Infection AND THE Cause of Sterility. ETIOLOGY IN THE FEMALE. 359 Three things must be carefully noted in examination of the vulva in its deej)er portion where the vulvo-vaginal (Bartholin's) glands lie buried close to the entrance into the vagina and posteriorly. Each of these notable marks suggests the existence of a chronic gonorrheal affection. ( 1 ) The gland itself may feel like a little dense sclerotic mass the size of a small bean (see Fig. 97), the residuum of an old gonorrheal affection called by Sanger adenitis glandulce Bartholince scleroticans. (2) The duct of the gland may feel like a little dense cord. (3) The outlet of the gland where it discharges above at the vulvo-vaginal orifice near the hymen may appear intensely red ; it is often likened to a flea- bite, and has been called the macula gonorrhceica. Caution, however, must be used in drawing an inference from the macula alone. It is, in my experience, not a safe guide. If the gland or its duct is diseased, careful squeezing may cause a little pus to exude which should be transferred to a cover slip and exam- ined microscopically. The Hymen. — A rigid or unruptured hymen shows that coitus has never been completed, if attempted. The signs of a defloration, whether accomplished digitally, instrumentally, or sexually, are always evident in the hymen. The most important sign is to be noted in its elasticity, which easily admits one or two fingers into the vagina without distress. If the well-oiled finger can be readily introduced into the vagina without eliciting a cry, a con- clusion may be drawn that some penetrating body has entered the same channel. A single digital examination is thus sufficient to destroy the signs of virginity. Too often the occasion for such unnecessary rupture lies in the examination of a young girl who simply begins to complain of a dysmenorrhea. Repeated unskilled examinations and treatments of young persons effect nothing ' for their cure and constitute a crime closely allied to rape. More than two cen- turies ago Severinus Pinseus uttered the sound dictum, " Magnum est crimen perrumpere virginis hymen." Let it be inscribed over the door of every con- sulting room. On or about the hymen one often finds tender red spots, carefully described by Sanger ; these are frequently the outcome of a chronic gonorrhea. The Urethra. — The urethra may appear swollen and red, bleeding to the touch and constituting a source of much distress, causing the patient to shrink from examination. This, too, is often due to gonorrhea. Skene's Glands. — Often the seat of a chronic gonorrheal infection is found in Skene's glands (glandulse paraurethrales) manifested by a puffi- ness and eversion of the lips of the urethra, exposing one or both of the glandular orifices which normally lie concealed just within the external meatus. On squeezing the glands by pressing up under the urethra and milk- ing them outwards with the finger tip a drop of pus may be forced out of one or both sides. If Skene's glands are empty, then it is well to dry the urethral orifice and to stroke the entire urethra dovmwards from the neck of the blad- der to the meatus externus, taking up any discharge thus brought to light 3Q0 STERILITY. for furtlier examination. A gonorrheal infection tlnis discovered ^vill be evi- dence of a chronic urethritis. It should be borne in mind that a careful distinction must be made between a milky discharge often seen and due to an accumulation of epithelial debris within the glands and a purulent discharge. The microscope only is competent to decide. In its chronic form a urethritis occasionally (in women rarely) results in a stricture of the urethra. This is readily found by attempting _ to pass an ordinary urethral catheter. A large experience justifies the state- ment that I have hardly seen more than six cases of strictural urethra in women. The Y a gin a. — Two deformities in the vagina call for notice: fi.rst a double or septate vagina in which the canal is divided up to the cervix which presents two openings (or a), one in each half. This is a condition of arrested development in Avhicli the uterus may also be septate or two-horned, or in which while one-half of the uterus is developed the opposite half may remain rudimentary. Startling as this condition appears at first sight it does not cause infertility ; the real danger lies in the possibility of a conception tahine; place in the rudimentary side followed by early rupture, or in late rupture of the more developed side. Second, there may be stricture of the vagina, either congenital or acquired. In both cases the vagina ends in a cul-de-sac, but in the congenital form the uterus above is undeveloped; in the acquired the uterus is not affected. It must be borne in mind that many of the cases formerly labelled congenital atresia were in reality atresias due to sloughing of the vagina occur- ring in the course of a scarlatina, a severe typhoid fever, or some other infec- tious disease in childhood. An atresia may follow the sloughing incident to a difficult lal)(»r inducing a one-child sterility. An atresia well within the introitus may not be dis- covered until the medical examination is made, as the shortened vagina may lengthen from intercourse. A reddened, inflamed, patchy, or granular vagina, with a milky secretion (colpitis maculosa or granulosa), is often evidence of an old gonor- rhea. The excessive acidity of the vaginal secretion, which frequently exco- riates the vulva and the adjacent skin, may also serve to destroy the sperma- tozoa. The reaction of the vaginal secretion must always be tested with blue litmus paper. Another cause of sterility is shortness of the vagina, or, in the acquired form, a broken-down vaginal outlet which refuses to retain the spermatozoa. Patients often complain of the latter condition, namely, the escape of the seminal fluid, which is, to them, a seemingly self-evident cause of their condition, but it is doubtful how far it is really instrumental in it. I am not, myself, disposed to assign any great importance to it in the causation of sterility. ETIOLOGY IN THE FEMALE. 361 Affections of the ISTeck of tlie Uterus. — Between the vagina and the cervix there is a great change in anatomical conditions. The vault or laquear vagina?, where an abundance of semen is deposited, is exchanged for a narrow cervical canal, entered by a constricted orifice and leading up into a flat channel, also rigid, out through the uterine tubes and through the star- shaped channel of the isthmial portion of the tubes into the labyrinth of folds in the tubal ampullae where the spermatozoa normally meet the ovum. Con- sidering the complexity of the arrangement, the wonder is that the conjunction between the sj)erm cell and the ovum is ever effected. The progress of the spermatozoa may be hindered by various abnormal conditions, which are here considered in order. Elongation of the Cervix (col tapiroides). — An elongate cervix lying in the axis of the vagina and projecting down toward the outlet may present an obstacle to the passage of the semen. This condition is, as a rule, associated with a sharp anteflexion of the uterine body, and its importance lies, not so much, perhaps, in the length of the cervix or in the flexion, as in the maldevelopment to which both conditions are due. Smallness of the Cervical Orifice. — A diminutive opening of the cervix into the vagina is the only cause of sterility commonly recognized by the laity as well as by the general practitioner. When the orifice is minute (pin- hole size) and no other probable cause can be found on careful examination, the condition is worth consideration as likely to be an efficient barrier to the entrance of the spermatozoa. Diseases of the Uterus.- — Erosion of the cervix is characterized by an enlarged and puffy condition of the os, which lies in the centre of a reddened area presenting a granulated appearance. Such a condition may be due to hyperemia and swelling of the mucosa of the cervix, which having no other situation in which it can expand, rolls out at the cervical os and so becomes apparent at the vagina. In other cases the erosion is clearly a physiological extension of the cervical mucosa into the vaginal portion of the cervix. This is the innocent affection so often and so persistently treated under the name of " ulcers of the womb," a condition which, in reality, almost never exists. Infections of the Cervix, Gonorrheal and Otherwise, Includ- ing Endocervicitis and Cervicitis. — A simple erosion of the cervix must not be mistaken for a gonorrheal infection of the cervical glands, which in some respects it resembles. A gonorrheal cervicitis or endocervicitis is char- acterized in the first place by a tenacious mucoid or muco-purulent discharge. This ropy discharge, so often seen in women, comes invariably from one source, and that is the glands opening onto the cervical canal. There is often a marked congestion and puffiness of the cervix, which bleeds easily on touch, and is inclined to bleed copiously when caught with tenaculum forceps. Sometimes there is a marked eversion of the cervical mucosa which allows the secretion to be seen issuing from the glandular orifice. This form of infection is deep- seated and obstinate in character, persisting for years, and sometimes until 362 STERILITY. the natural atrophy of the parts brings relief. The cervical glands are par excellence the seat of a chronic gonorrhea. Laceration of the Cervix. — Cervical laceration is sometimes a cause of one-child sterility; but a word of caution is necessary here against over- estimating the importance of the condition from this point of view. Laceration of the cervix has been the bug-bear of the medical profession for about a gen- eration, and it is now time it was laid in its grave. A simple laceration, by which the cervical os is converted into a slit, or else the cervix forms two distinct lips, more or less deeply notched on either side, must be regarded as physiological, and calls for no surgical interference whatever. How many women in whom this condition existed have been the victims of the meddle- some surgery of the past ! Even a deep laceration, converting the cervix into two well-defined flaps, has no bad effect upon the general health, though I am not prepared to deny that it may not act as a factor in the production of sterility. The serious cervical lacerations are those in Avhich there is an infec- tion of the cervical glands with hyperemia, infiltration, and eversion, super- added to the laceration. Such cases of infected cervices undoubtedly operate to maintain sterility, both by the infiltration which they induce and by the tough secretion arising from them which plugs the cervical canal. Cancer of the Cervix. — Cervical carcinoma is a disease usually asso-. ciated with an acquired sterility. The patient who has a cancer of the cervix has usually borne children, but ceases to conceive when the cancer appears. The affection has no practical bearing on the subject in hand further than exists in the fact that the sterile woman is compar- atively immune from this dreadful malady. Cervical Polyp. — A polyp of the cervix also may prevent conception. These little, soft, mucoid tumors are usually rose-colored or dark red and hang pendent in the cervical canal, ap- pearing like a plug in the external os. Endometritis. — A gon- orrheal endometritis, except in the acute form or during the puerperal period, is ex- tremely rare. All conditions associated with menorrhagia Fig. 98. — Acute Anteflexion of the Uterus with Ooni- t m i i i i i CAL Cervix tending to become Tapiroid. A sign of and collated Under the head abnormal development. Pregnancy is not apt to occur in . /• , these cases. 01 endometritis are factors m ETIOLOGY IN THE FEMALE. 363 the causation of sterility. I believe, however, that more cases of sterility are caused by intra-uterine medicative treatments than are cured by them. Displacements of the Uterus. — Extreme anteflexion (see Fig. 98) can hardly be regarded as a cause of sterility, which lies rather in the unde- veloped state of the uterus from which the anteflexion itself arises than in the po- sition of the organ. The strong forward flexure of the uterus must not be confused with the moderate forward inclination present in every sound woman. Retroflexion of the uterus (see Fig. 99) may prevent- conception, but it does so most frequently in the case of women who, hav- ing borne one child, acquire a marked retroflexion with a descensus. In the case of a nullipara it is wise to be ex- tremely guarded as to the prognosis of cure of a Steril- Fig. 99. — Acute Retroflexion of the Uterus which is • ,,■11 1 ,1 Sometimes the Cause of Sterility, but more often Oc- lly tnrOUgn measures aaapxea casions Abortion in the Early Months. to relieve the retroflexion. Infantile or Puerile Uterus. — Women with scanty or irregular menstruation due to a small uterus, of infantile or puerile form, rarely con- ceive at all. Such a uterus, however, must not be confused with one which is merely slightly smaller than the average. In the infantile type the body of the womb is tiny, the cervix disproportionately large, and the ovaries also infantile (see Fig. 58, p. 150). Myomatous Tumors of the Uterus. — Sterility is so often asso- ciated with myomata that there can be no doubt of a causal relationship between the two. Many women in whom myomata develop at an early age never con- ceive at all ; others conceive and abort ; and others, again, who apply to the physician for relief from large myomata when they are in the late thirties or early forties, give a history of having borne one or two children. When we consider the disturbances of menstruation which exist in such cases, the watery discharges from the mucosa, and the changes in the size and form of the uterus, together with the frequent displacements of the tubal orifices, the compression and distortion of the lumen of the tubes and the frequently associated disease of the adnexa, we wonder that such women should conceive at all. Olshausen, who has written more than any living authority on myomata, collected 1,731 cases from various sources, and found on analyzing them that 30 per cent 364 STEKILITY. were sterile. These figures, however, are probably not absolute. Scborler, fol- lowing, as I have done in portions of this chapter, the excellent work of F. Schenk (loc. cit.), found in a statistical examination of 253 cases that sterility prevailed in 9 per cent of the polypoid myomata; in 18.70 per cent of the cervical: iu 24.7 per cent of the interstitial; in 38.8 per cent of the submucous; and in 47.8 per cent of the subserous. Yon Winckel found that of 108 cases examined bv him, 41.6 per cent had had only one child. These figures, how- ever, are not in accordance with the general vital statistics of Saxony, which showed only 22.7 per cent of oue-child marriages in general. After this apparently unanimous agreement touching the causal relation- ship of myomata to fertility, Hofmeier investigated 327 myoma cases and reached utterly different conclusions. He found, for example, that while 20.5 per cent of this group was sterile, 15.2 per cent of all his gynecological cases was sterile also. Thinking it hardly permissible to draw the conclusion that nivomata stood in direct causal relationship to the sterility, he pointed out that the average age of the women in it was forty-two years and that the sterile marriages had lasted, on an average, sixteen years. He considered it improbable that the fibroid could have begun to cause the sterility as early as the twenty-sixth year in the absence of any symptoms ; and therefore he was of opinion that as the sterility almost invariably dated from a time of life wlieu it was highly improbable that myomata existed they could not be sup- posed to exercise any influence upon its causation. For instance, out of 326 women with myomata, 202 had had children, an average of 3.2 to each woman. Xow the average of all the married women in Bavaria, Saxony, and Prussia, is 4.5 per cent, so that the difl^erence is not great. Here, also, Hofmeier con- siders that the sterility tegins too far back to have been influenced by the myoma appearing so many years afterward. Hofmeier follows another line of argument when he notes that out of 503 cases of primary and secondary sterility, where there were no children, or only a sin2:le birth occurred within the first five years of married life, there were onlv 7 cases with fibroids, and of these 7, the sterility in 4 was explicable on other grounds. On the other hand, Hofmeier claims that the presence of mvomata in women of more advanced age actually favors conception, as he found that in a series of 23 pregnancies complicated with myomata, only one was under thirty, while 13 were lietween forty and fortv-seven years of age. He claims that this group of cases is evidence that myomata are the cause of an increased activity of the whole sexual apparatus, not of the ovaries alone, and that this is the reason the sexual organs preserve their function so much longer than is usual in cases of fibroids. This question is still the subject of discussion, but in my opinion, the following facts may be considered as established in regard to it: (1) That the presence of fibroid tumors acts as a hindrance to conception and this hindrance becomes greater as the tumors increase in numbers and in size. ETIOLOGY IN THE FEMALE. 365 (2) That the influence of fibroid tumors is felt long before they are recog- nized clinically, and that they may prevent conception while still of small size, that is to say, twelve or fifteen years before they are perceptible. (3) That they tend to induce abortion. (4) That while fibroid tumors, as a rule, are an obstacle to pregnancy, it may occur in spite of them, even in advanced cases. Such cases always come before the attention of the gynecologist. (5) That one common cause of the large amount of sterility in women with fibroids is the tubal and ovarian disease so often associated with them. One important point which must be borne in mind in this connection is that a ease of sterility, otherwise inexplicable, may be due to small myomata which are discovered only upon a most searching examination. Furthermore, in cases of sterility where the husband is sound and no apparent cause for the condition can be found in the wife, a fibroid tumor should be suspected if the uterus is clearly larger than normal and somewhat irregular in form. Diseases of the Adnexa. — This is an interesting group of cases belonging to a class which are peculiarly difficult to investigate on account of the inac- cessibility of the organs, namely, those cases in which the sterility is due to disease of the uterine tubes or the ovaries. It is because it is difficult to get at these organs and therefore to obtain an accurate knowledge of their condi- tion that they are frequently forgotten in the clinical examination. Maldevelopment of the uterine tubes is sometimes the cause of sterility. Such tubes are unusually long, often tortuous, and with little or no distinction between isthmus and ampulla, a condition which has also been reckoned among the causes of extra-uterine pregnancy. Again, the lumen of the tubes may be compressed by a fibroid tumor and they are liable to be dis- torted and impeded in their movements by common peritoneal adhesions as well as bound down and flexed by them. A mild attack of gonorrhea, which passes out into the pelvic peritoneum through the tubes, is sure to be followed by more or less extensive adhesions involving these delicate structures and inter- fering with their function. In the case of hydrosalpinx the lumen of the tube is completely occluded, so that no ova can be transmitted to the uterus and sterility is the inevitable result. Again, a suppurative infection of the uterine tubes (pyosalpinx) is often an efficient cause of sterility, and when it occurs in a woman who has never borne children, it is usually the result of a gonorrheal infection. I have just examined a woman, married eight years, without children and exceedingly anxious to have them, who is suffering from a large abscess of the right tube bulging forward into the abdominal cavity under the abdominal wall as well as a smaller one of the left tube. Diseases of the ovary are not often a cause of sterility. The ovary is peculiarly persistent in the performance of its function from puberty to the menopause. When the other structures in the sexual apparatus are mal- developed, the ovaries may be elongate and smooth, with no follicles of an 366 STERILITY. infantile type (see Tig. 58, i\ 150). Large Graafian cysts, two inches or more in diameter, may be associated with sterility, but liow far they act in the prevention of conception is not yet determined. Blood cysts of the ovary are more serious hindrances, on account of the associated pelvic peri- tonitis imbedding both ovaries and tubes. Ovarian tumors, both cystic and dermoid, are an obstacle to conception, though they do not form an actual barrier to it. The most common cause interfering with the function of the ovary and preventing the extrusion of the ovum or its reception and trans- mission by the tube, is a pelvic peritonitis, due to an infection travel- ling through the uterus, out through the tubes, and onward to the pelvic peri- toneum. The ovary, under these conditions, becomes completely embedded in a mass of adhesions, which may so far interfere with its circulation as to cause atrophj". Cases of ovarian abscess are rare and do not call for consideration in connection with sterility. A parovarian cyst, such as is often found be- tween the outer extremity of the uterine tube and the ovary, serves to fix, splint, and flatten the fimbriated extremity and to push it away from the ovary (see Fig. 100). This condition would seem almost of neces- sity to prevent the ovum from reaching the tube and the uterus, for which reason I present the figure. Positive evidence that it does so, however, is not as yet forthcoming. General Diseases as a Cause of Sterility. — Many systemic affections are so constantly found associated with sterility as to demonstrate conclusively the existence of a causal relationship. The etiologic connection, in some cases, is quite clear, as when some general disease causes an atrophy of the uterus, that is to say, a withering in size of an organ which was previously of normal dimensions. A very severe labor may also cause uterine atrophy and thus occasion a one-child sterility. Other causes are tuberculosis and nephritis, as well as such acute infectious diseases as mumps, scarlatina, and acute rheumatism. The acute infectious diseases may also bring about a premature atrophy of the ovaries (see Chap. X). Conspicu- FiG. 100. — One of the Possible Causes of Steeility. A monocystic tumor, with clear watery contents, splinting the tube and separating it widely from the ovary. ETIOLOGY IN THE FEMALE. 367 ous among the affections which may canse atropliy of the pelvic organs and consequent sterility are the chronic poisonings, alcoholism and morphin- ism. In both these conditions it is not uncommon to find a disappearance of the menstrual function for months at a time. Patients with aggravated heart disease also do not often become pregnant. Excessive fat seri- ously interferes with the function of the sexual organs ; for example, out of two hundred and fifteen such cases Kisch found twenty-one per cent sterile. Gebhard associates the changes in the ovaries under these circumstances with those in the thyroid gland and suprarenal bodies. An enormous accumulation of fat may sometimes interfere with conception through the mechanical hin- drance which it presents. The relation of obesity to changes in the sexual organs is discussed in Chapter VIII. Violent psychical disturbance may be the cause of the disappear- ance of menstruation for a long period of time ; such a case, for instance, is cited by Kisch, in which a woman went ten years without menstruating or conception, after seeing a child run over. The association of chlorosis with the disturbances of menstruation is interesting. According to Virchow there are tv/o varieties of this condition, one in which the sexual organs are imper- fectly developed and another in which there appears to be an excess of devel- opment ; in the former group there is a complete amenorrhea and in the latter a monorrhagia (see Chap. VI). Dyspareunia. — It is a moot question how far the absence of sexual desire (anaphrodisia) is responsible for sterility. If a sterile woman has no desire for the relationship and no satisfaction in its completion, she is sure to regard the fact as the cause of her disappointment and to give it a promi- nent place in her complaint. Kisch considers that the sexual feeling is a matter of importance, as he found twenty-six cases in which it was absent out of sixty-nine sterile women. Hegar, on the other hand, considers that the sexual inclination of women in general is, on the average, but slight and that it plays but little part in the question of conception. This group of cases may be divided, according to Strassmann, into three classes, namely : (1) Those in which the sexual feeling is simply absent. (2) Those in which there is a feeling of repulsion. (3) Those in which the relation is actually painful. I am myself inclined to believe that the simple absence of sexual desire, when the organs of generation are normal, has little or nothing to do with sterility. Sanger, quoted by Schenk, does not mention it once in a series of four hundred and eighteen cases. Repulsion, on the other hand, may cause sterility, as in a case under my own care, where I discovered a rigid double liymen in a woman who had been married for a number of years. She told me that she had a strong repulsion toward the sexual act and that her husband had agreed not to touch 36g STEKILITT. lier. In auotlier iiistancp, a beantifnl voimg girl refused throughout some fifteen years of married life to allow her aged husband to touch her, on account of his awkward manner of approach. Pain is operative as a cause of sterility when, owing to some local affec- tion at the vaginal orifice or above the vault, the distress excited by the marital approach is so marked that the husband either occupies a separate bed or at least approaches his wife only at long intervals. I have also seen cases in which a decided pain was complained of, particularly on the left side above the vaginal canal, where nothing abnormal whatever could be discovered, although sometimes the suffering could be reproduced by digital pressure. Such cases belong to the neuroses and are met with in the class of women who complain excessively of pain in the course of examination of the pelvic organs, although no disease can be found. The occurrence of a localized pain, situ- ated deep within the pelvis and most frequently felt toward the end of the sexual act, should always excite suspicion of a pelvic inflammatory affection and lead to a searching examination. Vaginismus, a term proposed by Marion Sims, was used by him to designate a condition found in a certain class of women, who shrink from, or absolutely avoid coitus on account of a hyperesthesia of the vulva in the neigh- borhood of the hymen which induces strong muscular contractions. Sometimes the nervous apprehension is so great that the adductor muscles are thrown into a spasmodic condition, preventing the separation of the thighs ; at others a lively nervous hysterical condition is excited, associated with a complete con- traction of the sphincter vaginae and levator ani which hinders any approach (see Chap. XII). This group of cases must not be confounded, however, with those in which the patient is simply hysterical and seeks to avoid the sexual act from lack of desire, nor with those other cases where the hjoneneal vault is rendered exquisitely tender by little superficial ulcerative areas, a well- defined pathological condition of a gross character. Yeit considers that in some cases, where the vaginismus is due to a neurosis pure and simple, the condition is often attributable to masturbation inducing an excessive local irritability. I have not, myself, seen any instances which I could attribute to this cause. The marriage of cousins according to Mantegazza and G. Darwin, cited by Schenk, does not seem to occasion sterility. Goehlert, however, quoted by the same vrriter, concludes from a study of the royal families of Europe that blood relationship in marriage, repeated for generations, is a serious ele- ment in its causation, showing that of one hundred and eighteen marriages related by blood in the dynasty of the Capetinger forty-one were sterile ; in the house of Wettin seven out of twenty-eight ; in "Wittelsbach nine out of twenty- nine ; in that of Hapsburg-Lothringen eight out of twenty-five ; that is to say, out of two hundred marriages between blood relations, sixty-five or thirty-two and five-tenths per cent were sterile. TREATMENT. 369 TREATMENT. The first step in the treatment of sterility is to investigate the canse, and the first thing to be done in such an investigation is to inquire into the con- dition of the would-be mother, remembering that only grave and for the most part self-evident diseases, whether local or constitutional (except diabetes and nephritis), are likely to hinder conception. The next point to be considered before planning a course of treatment, is whether one or both would-be parents are affected, and to this end the condition of the husband should always be investigated. As a rule, the husband should not be questioned in the presence of the wife, for every man who exacts purity in his wife in her antecedent relations will naturally profess before her to have lived up to no lower stand- ard himself. When the husband is questioned alone, it is worth while, in America at all events, to inquire whether his life before marriage was one of purity and continence. If he admits illicit relations, then it is well to ask whether he has had syphilis or gonorrhea, and, if he has had gonorrhea, whether one or both testicles were affected ; also whether he had a protracted gleety discharge with the gonorrhea, and whether such a discharge was present at the time of his marriage. The questioner must remember that many men, who have stimu- lated an old and latent gonorrhea into fresh activity in the first months of married life, are inclined to consider the resulting discharge as nothing more than the natural results of excess. In examining both the man and his wife it is well to follow some scheme, like that adopted by F. Kehrer (loc. cit., p. 78), or like a somewhat fuller outline such as that which I present on pages 370 and 371. A series of records kept on a scheme of this kind would be of great statistical value in this country. ISTo matter what the find in either case both husband and wife should always be examined. If the husband is found to be at fault, the gynecologist would do well to refer him to a competent andrologist (Sanger) commonly known to-day as a " g.-u. specialist." Pinard says that the husband should never be told that the case is hopeless, as he has known two or three to take their own lives under such circumstances. The physician may almost alwaj's assure the husband with azoo-, oligo- or necrospermia that there is a hope of his recovery, for numerous cases can be recalled, in the hands of different specialists, in which after repeated examinations a few living sperm cells have been found and where, though long delayed, conception has taken place. In making a diagnosis of the cause of sterility in the woman preparatory to treatment, the examiner must bear in mind three things : (1) Can any obstruction be discovered which is likely to interfere with the progress of the ovum to the uterus ? (2) Is there any mechanical hindrance which prevents the progress of the spermatozoa upward into the cervix, through the uterus, and out into the uterine tubes, where conception normally takes place ? 25 370 Name. Age. STERILITY. Outline for Examination of Husband^ Year of marriage. Sexual history before marriage. General appearance and present state of healths Condition of testes and epididymis. " vasa deferentia. *' " vesicult^ seminales. " prostate gland. Coitus nortnal ? Average frequency of coitus. Condition of semen., examined after days' interval since last coitus. Manner in which semen was obtained. Semen examined nuinher of hours after coitus. Manner in which semen is preserved. Microscopical examination — Normal. Nccrospermia, Oligospermia. Azoospermia Prostatic cells. Pus. Gonococci. Chobstearine balls. Corpora amylacea. treatment. 371 Outline for Examination of Wife. Name. Age. Year of marriage. Pregnancies^ miscarriages. General appearance and present state of health. Previous diseases^ especially of an infectious character. Menstrual history^ as to regularity^ duration^ amount^ and presence of pain. Leucorrhea^ especially any discharge first noted after 7narriage. Suspected abortions. Infections following abortions. Previous gynecological affections and treatments directed to the relief of sterility or uterine disease. Any abnormality about the vulva^ vagina., cervix., uterus., uterine tubes., ovaries., sexual feeling. Diagnosis of cause., or probable cause of the sterility. 372 STERILITY. (3) Is tliere any endometrial condition (polyp, myoma, endometritis) which is likely to prevent the attachment of the fertilized ovnm ? He mnst then look for any gross disease of the vnlva, vagina, or cervix. 'Next he mnst examine the nterns in order to ascertain the presence of tumors or displacements ; and, finally, he must investigate the condition of the ovaries to determine whether there is any disease, characterized by enlargement, already evident on bimanual examination. If he finds no cause for the sterility in any of these localities, he reviews the case for a gonorrheal infection, tak- ing specimens of urethral, vaginal, or cervical secretions for microscopical examination. The following conditions associated with a sterility are susceptible of relief : (1) Imperforate hymen. (2) Vaginismus. (3) Eetroflexion. (4) Anteflexion. (5) Endometritis. (6) Stenosis of the cervix. (7) Uterine polyp. (8) Fibroid tumor. (9) Parovarian cyst. (10) Ovarian and dermoid cysts, when unilateral. (11) Gonorrheal infections of the genital tract below the uterine tubes or above the uterus, if one-sided. (12) Various other infections, which it is not necessary to differentiate. The conditions which are not susceptible of relief are these: (1) Absence of the vagina and of the uterus. (2) Infantile uterus and ovaries. (3) Extensive fibroid tumors of the uterus. (4) Extensive inflammatory changes. If nothing can be found on making the usual careful bimanual examina- tion, the patient should be anesthetized and the pelvis explored. If no fault is then found, a thorough dilatation of the cervix should be done and, if called for, a curettage (see Chaps. IV and VII). An imperforate hymen is best treated by complete excision (see Chap. VI). If there is any vaginismus it must be treated as laid down in Chapter XII. In sterility of long standing, a retroflexion ought to be corrected. First a pessary may be tried, and then, if that does not relieve the situation, an operation, drawing the uterus forward by its round ligaments. Ante- flexion of an extreme character is rather a sig-n of maldevelopment than a mere postural disorder. Here the cervix may be dilated and then divided back to the vault in the median line. A plug of gauze left in for a few days will serve to keep the wound open. Endometrial conditions are best treated by curettage. Cicatricial TREATMENT. 373 stenosis is still the commonest discoverable canse of sterility, and when no other condition can be found to account for it, it is safe to consider this the probable hindrance. The dilatation for its relief should be done thoroughly, at one sitting, using a small, a medium, and a large dilator in such a manner as to open the cervix widely, without tearing it. The details of the operation are described in Chapter IV, but I add a word of emphasis here in regard to one or two important points. The best dilators for the purpose are the parallel dilators of the Goodell-Ellinger type. The cervix should be equally dilated in all directions, up to and including the internal os, until it is sufficiently stretched to admit a bougie eight to ten millimetres in diameter. I do not think it advisable to dilate the cervix every month. It is wiser to correct the trouble, and then let nature have a chance to regulate her functions. N^either do I place any great confidence in the vari- ous cutting operations practised on the cervix and still less on those more dan- gerous operations involving the cervical canal (discission). I have already spoken of two precautions which should attend every dilating operation, which, in my opinion, should never be called " a little operation " or " no operation at all " ; but it may be well to repeat my caution here. (1) The physician must be sure that there is no intrapelvic inflammation, which would be liable to be lighted up by this manipulation. I have seen some distressing cases, in which the patient was said to have been " perfectly well until the doctor dilated the womb," after which a latent infection flared up, until the pelvis filled with pus, all in consequence of neglect of this precaution. (2) The same care as to cleanliness of the vulva, the vagina, and the instruments must be employed as in a major operation. Carelessness in this particular also may light fires which can only be extinguished by the sacrifice of all the structures concerned. In most cases where dilatation of the cervical canal is necessary, the patient suffers more or less from dysmenorrhea, and curettage is called for as well. It is well, however, to warn the patient that she must not expect conception to take place at the very next period, but be content to wait patiently for at least a year. A uterine polyp may be suspected as the cause of the sterility when the menstrual flow tends to be hemorrhagic, or when the uterus is enlarged, or when the polyp can be seen or felt at the external os. It should be removed by surgical means. Fibroid tumors may be removed by enucleation rather than by ampu- tation of the uterus, with the hope of subsequent pregnancy in younger women. Out of ninety-four abdominal myomectomies, performed in my clinic, where pregnancy was hoped for, it occurred in thirteen. Of this number twelve went to term, and one miscarried. Out of thirteen vaginal myomectomies where pregnancy might be looked for, it took place in tM^o. Parovarian cysts, unless very large, can be removed readily, sparing the uterine tube and the ovarv. 374 STEKILITT. When no gross lesion exists, gonorrhea must be sought for. To this end a cover slip ought to be taken in every case, without exception, and exam- ined for intracellular diplo cocci (gonococci). The discovery of gonor- rheal infection gives the treatment a definite object, namely, that of removing the infection from its various resting places. If the disease has progTessed as far as the peritoneum, involving the ovaries in adhesions and converting the tubes into sacs (hydro- or pyosalpinx) the case is not a hopeful one, as far as the cure of the sterility is concerned. If there is pus in the tubes, the best plan is to refer the patient to a gynecologist who may open them freely, and make a wide drainage opening below into the vagina; even under such conditions, conception may occur after the parts have recovered from the operation. Delicate restorative ojDorations done on closed tubes are but rarely successful in bringing about conception. When the gonor- rhea affects the cervix, which is its seat of predilection, and where next to the tubes it does most harm, the best plan is to burn it out with a Paquelin cautery or scrape it out with a Craig's curette, as described in Chapter XL In one of my patients, thirty-two years of age, who had an acquired sterility of twelve years' standing, I found a large everted cervix pouring out a muco- purulent secretion. Three cauterizations with a Paquelin cautery, after Hun- ner's method, cured the discharge and fifteen months later she bore a healthy child (Mrs. S., Case-book XYI, Xo. 84, Jan., 1906). The vagina should be treated as described in Chapter XI, or as recommended by Sanger, with a fifty per cent solution of chloride of zinc, applied thoroughly with a large cotton applicator, care being taken not to burn the external genitals. Follow- ing this application a loose pack of gauze, coated with zinc oxide salve, may be inserted and left in situ for twelve to eighteen hours. Any gonorrheal affection of the external glands should be relieved, and an infected vaginal gland should be incised. Skene's glands (para-urethral) should be probed and cut down into through the vagina, so that they are opened and drained to the very bottom. This little operation may be done under a two per cent solution of cocain injected into the adjacent tissues. CHAPTEK XVI. GONOCOCCUS INFECTION (GONORRHEA). History and general considerations, p. 375. Prevalence, p. 376. Organs usually affected, p. 376. A. constitutional as well as a local disease, p. 377. Description of the gonococcus, p. 377. Different tissues in which the gonococcus is found, p. 378. Gonotoxine, p. 379. Curability of gonococcus infection, p. 380. Clinical course and symptoms, p. 380. Acute gonococcus infection; sub-acute and chronic gonococcus infection, p. 380. Vulvo- vaginitis in little girls, p. 381. Latent gonorrhea, p. 384. Gonorrhea and marriage, p. 384. Diagnosis, p. 384. Treatment, p. 386. GoN-ococcus infection is a Letter name than gonorrhea, time- honored though the latter is, because it does not carry with it necessarily the stigma of a venereal disease. This consideration is especially important in vulvo-vaginitis in children where there is often no suspicion of a direct venereal origin of the infection. History. — The disease is of great antiquity; it was common among the Greeks and Komans, and even before that time there are references to it in literature. In the fifteenth chapter of Leviticus careful instructions are given to the Israelites as to the measures to be adopted to avoid contagion from a running from the urethra. It is not probable that the nature of the disease was fully appreciated until recent times, the term gonorrhea signifying a flow of semen (y6vooop Curette, which is Convenient in Some Cases. 536 CANCEK. OF THE UTERUS. Cauterization. — TTlien tlie bleeding following curettage is very profuse, it is sometimes necessary to cauterize in order to control it ; and there are many cases in which cauterization is desirable for its ovna. sake, either with or with- out curettage, W. B. Chase has given a good description of the method of using the actual cautery, which I quote (Amer. Jour. Obst., 1904:, vol. 49, p. 83 : " Where large areas of ulceration are attacked and the tissues are friable, the curette may be first used to advantage. This is likely to result in pretty active hemorrhage. The hemorrhage may be controlled by the application of pledgets of cotton applied with pressure, first dipped in dilute acetic acid, usually of half strength, or by the use of the adrenalin chloride. After this the cautery knife is apj)lied at a dull red heat imtil the surfaces are thoroughly charred. The after dressing consists of five per cent iodoform gauze, reapplied daily after the parts have been cleaned with peroxide of hydrogen. In all manipulations of the cervix the gTeatest gentleness should be used. The use of bivalve specula should be avoided, as they are likely to impinge upon the cervix and occasion hemorrhage. Dressing is best done with the patient in the Sims' position, and the parts exposed by means of a Sims' speculum. The only exception is when the posterior vaginal wall is involved. The slough separates usually in from one to two weeks. Daily dressing must be faithfully applied every day until healing follows, or, if it should not ensue, the dress- ings must be continued in order to keep the parts as aseptic as possible." When healing is imperfect and unhealthy granulations reappear, they may be touched with carbolic acid or nitrate of silver, pure or diluted as the case may indicate. After the first day or two the parts should be douched, when the gauze is removed by a solution of lysol (one drachm to a quart of normal salt solution), or the same amount of a fifteen-volume formalin, one drachm to a quart, or a weak solution of tincture of iodine. A certain skill is required in the use of the thermo-cautery. The cautery knife must be of just the right temperature ; that is to say, hot enough to burn the structures and not hot enough to disintegTate them too rapidly, which causes trouble and hemorrhage. Great care must be taken to avoid going beyond the area involved and injuring the bladder, the ureters, the rectum, or the intestine. jSTo pain is experienced, as a rule, from the use of the actual cautery, provided the cutaneous surfaces are untouched; on the contrary, nothing so effectually relieves the pain caused by the disease as the actual cautery. The vaginal surfaces may be protected from injurious heat by using strips of asbestos paper of proper size and shape. The choice between a portable galvano and a Paquelin cautery is largely a matter of circumstances and convenience. The liability of most galvano- cautery batteries to get out of order is an objection, and it is never safe to begin a thermo-cautery operation without a second apparatus, either galvanic or Paquelin, in reserve. In some cases the cauterization may have to be repeated at intervals of two, three, or six months. PALLIATIVE TREATMENT. 537 X-Ray. — H. K. Pancoast, official skiagrapher of tlie University of Pennsyl- vania Hospital, expresses the following opinion as to the results of X-ray treatment of uterine cancer (Kelly-Noble, " Gynecological and Abdominal Surgery," 1907, vol. 1, p. 321) : " The X-ray may prolong the life of the patient. This is a fact worthy of recognition in many instances. The relief of pain has been observed by reliable authorities, and so frequently, too, that it must be recognized as a commendable result due directly to the treatment, and not to psychic effect. Pain is relieved in a large percentage of cases. This prob- ably results largely from the direct anodyne effects of the rays. When the pain is due to presence of a mass upon the large nerve trunks, little relief can be ex- pected. A lessening of the discharge and a decrease or a cessation of hemorrhage are frequently among the favorable results, and are often brought about early." It seems, therefore, that when it is possible to bring the patient under the care of a reliable radiograjDher and the expense of the treatment is within her means, it is worth while to test its efficacy in any given case. Unless a really reliable X-ray operator is at hand, however, it had better not be attempted, as the care- less or unskilful use of the method has produced the most disastrous results. Radium. — The salts of radium used in pencils containing not less than 15 and preferably from 30-50 milligrams, are valuable adjuncts in treating some cases of malignant diseases of the pelvic organs. First of all, let it be noted that radium is not a substitute for surgery, its use here is supplementary to the surgical operation. But it does do what surgery cannot possibly accomplish. Its field of greatest usefulness in cancer of the cervix is after extirpation. Here we have to note two classes of cases : First those in which it is manifestly impossible to extirpate the disease, and here the radium is used to effect those more distant operations inaccessible to the knife. I have, for example, opened the abdomen and literally carved a large cancerous uterus out of its widely impeded bed and then given several weeks of all night treatments with an average dose of 32 milligrams. The effect of this was to cause a remarkable shrinkage in the hardened diseased tissues and a manifest improvement in the patient's condition; relief of pain and cessation of hemorrhage and for a time apparently complete cure. But I have not yet seen an advanced case of this kind which did not later recur. Wickham, however, has reported two such cases. Secondly, radium is of the utmost value in treating recurrences at the vaginal vault. I had a case which recurred in the right vault about a year after operation, the disease extended like a finger back to the posterior pelvis. I thrust the radium pencil into it for twenty-four hours on three occasions and she recovered perfectly with no recurrence in two years. Another use for radium is in cancer and other tumors of the bladder. I have at present under my care a woman sent to me by Dr. Guy L. Hunner, with an inoperable bladder, carcinoma projecting far out into the organ, fixed and occu- pying the whole left wall, edematous and looking like a cockscomb. This has disappeared under treatments, until in place of the redundant fungating masses 538 CANCER OF THE TJTEETJS. we have an ulcerated surface with remarkable general improvement and sup- pression of the immense hemorrhages filling the bladder with clots and causing previously uncontrollable agonizing pain. This whole subject is still new, but we are undoubtedly on solid ground and each year will add to our acquisitions. Methylene Blue. — The treatment of cancer by methylene blue was first intro- duced in 1891 by Professor Mosetig-Moorhof, who read a paper before the Vienna Society of Physicians ; and almost at the same time one appeared by two Italians, Cucca and Ungaro (Rassegna d'ost, e gin, 1891, vol, 26, p. 598). The first person to advocate the use of the method in this country was Willy Meyer {N. Y. Med. Jour., April 11, 1891), and its application to uterine cancer, either of the body or the cervix, has been especially investigated by H. J. Boldt {Merck's Bull., Jan., 1893). The cancerous tissue is first thoroughly curetted with the sharp curette and the bleeding surface tamponed with dry iodoform gauze. Twenty-four to forty- eight hours later the gauze is removed, and after proper disinfection of the field of operation the methylene blue is injected. The patient is placed in the Sims' position and the surface exposed to view by means of a Sims' speculum and a Hunter's depressor. The parts are thoroughly dried with aseptic ab- sorbent cotton and the needle is introduced to the fundus uteri, the syringe having been filled with an aqueous solution of blue (pyoktanin), 1 : 100. The needle is inserted any distance from half a centimetre (one-fifth of an inch) up to its full leng-th, according to circumstances. The depth to which it is introduced is governed by the thickness of the part where the injection is made. While pushing the needle still deeper, the fluid is gradually pressed out by the piston so that the deeper tissues are infiltrated by fresh staining fluid. One syringeful will answer for two or three punctures. The fluid is next injected into the parametria on both sides, then into the posterior vaginal wall, and lasth- into the anterior infiltrated vaginal wall, sometimes mak- ing as many as fifteen " punctures at one treatment. It is best to begin with the most distant point, because on withdrawal of the needle some of the fluid returns through the needle puncture and discolors the tissues adjoining, a thing which would interfere with the requisite amount of precision for succeeding injections did it occur more proximally. A large cotton tampon is introduced into the vagina in front of the cervix and some protection must be worn, for even with the greatest care the clothing is apt to become stained. On the second day after the injection, the patient removes the tampon by means of the string attached to it, and uses a douche of warm water, after which she returns to the doctor's office for another treatment. The injections are repeated every second day for some little time. Methylene blue has been given by the mouth in cases where the emplo^mient of injections was difficult or impossible, and has been strongly recommended by Dr. Abraham Jacobi {Jour. Amer. Med. Assoc., 1906, vol. 47, p. 1515). Dr. Jacobi claims that this method of administration is prefer- PAI.LIATIVE TREATMENT 539 able to local injections, because the latter are very painful and patients are unwilling to submit to them for any length of time. He has used the internal method of administration for fourteen or fifteen years and obtained the best results from it. The drug is given in pill form in doses of two grains a day, increasing slowly up to three, four, or six grains. Larger doses have been given, but in Dr. Jacobi's opinion, they are not required. It is a good plan to have each pill made up with the extract of belladonna, to as much as three-fourths of a grain in twenty-four hours ; but if the dose of methylene blue is increased, the belladonna must not exceed the original amount. Arsenious acid, one- fortieth to one-twentieth of a grain; strychnin, one-sixtieth to one-fortieth of a grain; or nux vomica, one-half to two grains, may also be combined with the methylene blue. Patients should be warned at the beginning of the treatment that the urine will be stained blue from the drug, and that a stain on the linen cannot be removed. It is sometimes stated that methylene blue internally will cause dysuria, but in Dr. Jacobi's experience this does not often happen. He believes the use of the belladonna prevents this effect. In many of the cases reported, the methylene-blue treatment has been effectual in relieving pain, in improving the functions of the affected part, and improvement of the general condition. Moreover, it is claimed that with the steady use of it, it is possible to avoid the use of morphin up to the last stages of the disease. Locally, there is a more healthy appearance of ulcerating sur- faces with cicatrization towards the edges ; the discharges become scanty and less offensive, and shrinkage occurs in the growth itself. It occasionally happens that the administration of the drug, whether by injection or by the mouth, is followed by disagreeable symptoms. There is nausea, vomiting, a weak slow pulse, headache, and general malaise, which appear, as a rule, on the day of injection or the day following. Now and then there is a slight rise of temperature. Locally, there is sometimes edema around an injected area, accompanied by slight redness and pain on pressure, but these disturbances disappear quickly. The only really serious result which has been known to follow the use of the remedy is the formation of sinuses which give exit to a dark blue fluid. Sometimes a few of these softened foci join and form a swelling containing pus. When this happens, the abscess must be opened, not by the customary long slit, but by a small puncture just sufficient to let out the fluid. This accident, however, does not occur often and seems to be associated with the use of strong solutions. The injection of methylene blue into the uterus requires not only the most rigid antisepsis, but considerable knowledge of surgery, and unless the physi- cian has had a good deal of surgical experience, it is best for him to administer the drug by the mouth. Whichever method he employs let him make sure that the preparation of the drug is perfectly pure and unadulterated. Thyroid Extract. — The treatment of inoperable cases of cancer by means of thyroid extract has of late been the subject of discussion. The extract may 540 CAKCEE OF THE UTEEUS. be given in subst-ance in capsules, or the fluid extract may be used. The dose varies from four to six gTains a day according to the individual susceptibility. In primary carcinoma it is best to begin with large doses, but in the recurrent form small ones answer better. Some physicians are of opinion that the remedy is more successful in secondary carcinoma than in the primary form. Trypsin. — The use of trypsin in the treatment of carcinoma was suggested by Beard of Edinburgh, whose experiments on mice afforded the hope that it might be of gTeat service. Opinion seems still to be divided, however, on the question of the beneficial results derived from it, and some persons have re- ported considerable harm arising from it, e. g., "W. A. Pusey {^Jour. Am. Med. Assoc, 1906, vol. 16, p. 1763). Acetone. — The treatment of inoperable carcinoma by means of acetone is strongly advocated by George Gellhorn {Jour. Amer. 2Ied. Assoc, 1907, voL 48, p. 1100), and should the future fulfil the present promise, there is no doubt that it will be a valuable palliative form of treatment. Dr. Gellhorn experi- mented for eighteen months with different chemicals which he thought might offer some improvement in the existing conditions for treatment of inoperable cancer, and finally found that he obtained unexpectedly good results with acetone, in regard to which he says : " In the limited number of cases in which it has been employed it seems to have successfully met the chief requirements in the treatment of inoperable cancer of the uterus." Acetone is present in all normal urine and is familiar to the clinician from its occurrence in the urine in diabetes mellitus, in certain forms of digest- ive disturbance, and in some cases of carcinoma. It is a transparent, colorless, mobile, and volatile liquid with a characteristic pungent sweetish taste and odor. If applied to the skin, it causes a sensation of cold. Tissues j)laced in it shrink and harden rapid;ly owing to its intense hygTOscopic qualities, and if left in the fluid more than haK an hour they are, as a rule, too hard for the microtome knife. It was Dr. Gellhorn's idea to utilize these hardening powers for practical purposes. If the ulcerating surface of the cancer could be hardened, in vivo, the discharge could be checked and the escharotic portion would be cast off. The resulting free surface could then be hardened, and it would, perhaps, be j^ossible to harden deeper portions, or even the entire tumor, thus rendering the malignant growth temporarily harmless. The treatment must, if possible, be preceded by a thorough curetting of the ulcerating area. The curetted cavity is then carefully dried with cotton sponges, and from one-half to one ounce of acetone is poured into it through a Ferguson or some other tubular speculum. The narcosis may then be inter- rupted and the patient left in the same position from fifteen to thirty minutes. The acetone is then allowed to run out through the speculum by lowering the pelvis, and the cavity is packed with a narrow gauze strip soaked in acetone. The healthy mucosa of the vagina and the vulva ai'e cleansed with sterile water and dried. After the preliminary curetting and cauterization the regular treat- PALLIATIVE TREATMENT. 541 ment is administered two or three times a week, beginning on the fourth or fifth day after the operation. For the preliminary treatment the patient must, of conrse, be in a hospital or in her own house, but the further treatment may be administered in the physician's consulting room. It is done without an anesthetic and may be given with the patient on the ordinary examining table or chair. The pelvis of the patient is raised and the tubular sj)eculum inserted into the cancerous cavity; it is then filled with acetone, and may be held in place by the patient's hand for half an hour, after which it is emptied in the manner above described. Care must be taken to prevent the acetone from running over the vulva and the perineum. As the cancerous area diminishes, smaller and smaller specula can be employed. The immediate effect of the treatment is to check any slight oozing almost immediately. The surface of the crater is covered with a thin, whitish film, which becomes light brown wherever there is an extravasation of blood. The normal vagina is not appreciably irritated. On the vulvar mucosa and the outer skin an excess of acetone produces a faint whitish discoloration, which soon disappears. Tliere is no pain from the cauterization, although a slight stinging sensation may be experienced if the acetone has touched the skin. This passes away rapidly, however, if the affected part is washed with cool water. Anodynes are not needed after the treatment, except in special cases. One of the most distinct beneficial effects is a marked reduction of the intense odor. The discharge becomes watery, then gradually subsides, and with it dis- appears the intense and disagreeable odor attending it. The hemorrhages also cease to recur, and after two or three weeks of treatment a considerable diminution in the size of the cavity may be noticed. Its walls become smooth and firm, there are no more polypoid excrescences, nor can the finger remove any friable tissue. The absence of hemorrhages and weakening discharges causes a great im- provement in the general condition of the patient ; on the other hand, sensations of pain caused by the extension of the cancer to adjoining organs or nerve trunks beyond the reach of the acetone are not relieved and require the use of an anodyne as before. In Gellhorn's experiments frequent examinations of the urine were made, in order to ascertain if there was any absorption of acetone into the organism, but they were all negative. The number of cases upon which the acetone treatment has been tried is, so far, too small to form positive conclusions; the results, so far as they go, are, nevertheless, so good that it seems reasonable to hope that a valuable palliative measure for inoperable cases has been found. Even though the pain is not affected by it, the relief from hemorrhage and from the characteristic odor, which is one of the most distressing features of the disease, recommends the treatment most highly to our notice. The ease with which it can be con- ducted by the general practitioner, and the absence of ill effects, add greatly to its value. 542 CANCER OF THE UTEEITS. General Eemedial Measures. — In all cases of inoperaLle cancer, every care must be taken to keep the patient's general condition as good as possible. Her digestion and appetite ninst be kept np by appropriate measures, and she must have as much fresh air as possible. In the use of remedies for the relief of pain the greatest caution must be exercised. It is sometimes said that there cannot be any objection to the unrestricted use of opium v^hen there is no possibility of recovery, but it must be remembered that, unless the resources of opium are carefully husbanded, they will fail be- fore the close of life, and the patient will be left with no protection against suffering at the time when it is most intense. Even the largest doses will at last prove ineffectual. It is best, therefore, to avoid the use of opium as long as possible, and when this can no longer be done, it must be given carefully by the physician or the nurse, and the amount modified according to necessity. In the beginning of the disease, before the pain has become intensely severe, relief may be obtained from the coal-tar preparations such as phenacetin, anti- pyrin, and others. Aspirin, the acetic ether of salicylic acid, has been highly spoken of in this connection, especially by Ludwig Goth (Med. Bldtt., Feb. 11, 1904). It is said to relieve pain very quickly and without disagreeable after- effects. The dose is one gTamme (fifteen gTains) daily. If this dose does not give relief it is of no use to continue it. Vaginal injections of chloral hydrate in strength of 10:1000 have been recommended for relief of pain and for disinfection of the vagina. Opium is best administered at first in the form of codein, one-fourth of a grain, increased as occasion requires. When this fails it will be necessary to have recourse to opium itself, which generally does better than morphin. It is well to administer it at first disguised in some stimulant, such as wine of coca. The patient, ignorant of the drug, will not learn to depend on it. Hemorrhages, when they occur, are best controlled by douching with hot water and packing with gauze. Vinegar and ice-water have been recom- mended as excellent styptics. Adrenalin has been used very successfully in the hemorrhages of carcinoma. Peters (Zeitschr. f. Gyn., 1904, ISTo. 27) recommends it in normal salt solution of 1 : 2000 or 1 : 3000. This is applied for two minutes to the cavity of the uterus. Throughout the illness the vagina should be frequently washed out with Labarraque's solution (see Chap. XIII, p. 324) as a disinfectant and deodorant. Creolin, 1: 500, is also useful for this purpose. It is of great importance to keep the surroundings of the patient cheerful. But if she supposes that a knowledge of her real condition is being with- held from her, uncertainty and suspicion may react most unfavorably on her. If she asks direct questions they should be truthfully answered, and if she seems to be fretting in silence it is best to draw out exactly what are the ex- tent of her suspicions and deal with them as fully as seems necessary to ensure her peace of mind. Her family, or at any rate some responsible member of it, should be fully informed of the nature of the disease and its progTess. CHAPTER XXII. CYSTITIS. Definition, p. 543. Classification, p. 543. Etiology, p. 544. Symptoms, p. 547. Diagnosis, p. 548. Treatment, p. 544. DEFINITION. Cystitis is an inflammation of the bladder, caused by micro- organisms; it is associated with the discharge of pus and sometimes of blood in the act of urination, which, as a rule, is increased in frequency and painful. Cystitis is, therefore, an inflammatory affection and must be distinguished from simple hyperemias, such as are often found in the trigonum of the bladder and present many appearances of inflammation, but without any evidences of infection and without pus in the urine. Cystitis is also readily distinguished from the frequent urination (pollakiuria) often noted in nervous patients, or in those whose urine contains some irritating substance. CLASSIFICATION. There are different kinds of cystitis, and it may be classified in a variety of ways. First, according to the intensity of the disease. In some cases it is so mild as to escape the attention of the patient ; in others, so intense as to make life itself a- burden. Second, into acute and chronic forms, a most important classifica- tion. The acute are marked by suddenness of onset and intensity of symptoms, but they are of short duration, passing soon into the chronic stage. Most cases develop slowly and are chronic from the first. Third, according to location. The patch of cystitis may be seated in the vault of the bladder, in the posterior wall, or at the base. The disease may be limited to one of these foci, or it may spread out from one or from sev- eral of them until the entire bladder wall has an angry, beefy-red appearance. Tourth, according to the character of the infecting organism. By this classification we have: Tubercular cystitis. Gonorrheal cystitis. Colon bacillus cystitis. Proteus cystitis. Streptococcus cystitis. Staphylococcus cystitis. 543 544 CYSTITIS. Several rarer forms of more interest to the bacteriologist than to the prac- titioner. Fifth, according to the portal of infection. When the bladder is infected by organisms carried directly to it by the blood, the infection is primary ; and when the organisms proceed from a focus of infection in some other organ, as the kidney or one of the uterine tubes, it is secondary. Sixth, according to the direction in which it progresses. Cystitis is ascending when the infection is introduced from below, and ascends from the urethra upwards; descending when it is introduced above, and proceeds •from the kidney downwards. A latent cystitis is not infrequently seen in surgical patients, examined as a matter of routine for urinary infections before operation, whether they complain of any bladder symptoms or not. This group of cases is an important one, as the recognition of the disease before operation in any given case relieves the surgeon of responsibility, and refutes any imputation of having caused the trouble by neglect, in the event of an exacerbation during convalescence. ETIOLOGY. The commonest source of cystitis in these days is the urinary catheter, especially when emploj^ed during the puerperal period or after surgical opera- tions. Put a catheter in unskilled hands, and cystitis is pretty sure to follow its use. The blame for lack of skill may fall upon the shoulders of the doctor, as well as of the nurse, the latter of whom is too often made a scapegoat. I know of an instance of an old practitioner who catheterized a patient in hard labor, introducing the catheter several times. The baby was born dead and a number of curious little holes were found punched into its brains. These were produced by the catheter, which had been forced through the urethra and then through the baby's skull. An unclean catheter will cause cystitis in the vast majority of cases, but with proper attention to cleanliness no trouble will ordi- narily arise from its use. The reason cystitis so often dates from confinement, and especially from repeated catheterization in the puerperal period, lies in the fact that in diffi- cult labor the bladder is always more or less injured, the resisting powers of the patient are lowered, and the lochia bathing the external genitals and the urethra are a constant source of infection. Added to this is the awkward posi- tion of the patient as she lies in bed and the swollen condition of the vulva. A catheter introduced under such circumstances, even if considerable care is taken, is pretty sure to convey some infection. The cystitis which arises after an operation is also occasionally unavoidable, even with the best skill and technic. This is undoubtedly due to the reduced condition of the patient, who has passed through the shock of an operation and whose reparative processes are consequently much below par. Under these cir- cumstances she is unable to resist an infection which would be easily thrown ETIOLOGY. 545 off under normal conditions. The attending circumstances of pelvic operations are frequently so damaging to the bladder that the wonder is, not that we have cystitis, but that it does not develop oftener. Take, for example, a hystero- myomectomy or an abdominal hysterectomy for carcinoma, and we have to do with patients under conditions most favorable for the development of cystitis, as follows : (1) A depressed state of health before operation. (2) Often a condition of severe mental depression. (3) A severe mutilating operation. (4) Severe trauma exercised upon the bladder itself. (5) In some cases, protraction of the operation which taxes the vital forces to their utmost. (6) Considerable, sometimes excessive loss of blood. (7) In the case of carcinoma, injury of the bladder at the point of detach- ment from the uterus and the vagina, an injury which must heal by suppura- tion during convalescence. (8) Constraint of posture after operation, when the patient lies on her back and is unable to empty her bladder properly on account of the unusual position, so that there is either an overdistention or a residuum of urine after voiding. (9) Complications during convalescence causing elevation of temperature, which further lowers resistance. With all these favoring conditions it is not remarkable, as I have said be- fore, that cystitis is a common complication of the convalescence in pelvic surgical cases. The reason for the frequency of cystitis in those cases which have to be catheterized repeatedly, is found in the fact that the external urethra and the parts of the urinary canal adjacent to the external orifice are normally the habitat of a profuse bacterial flora, especially the colon bacillus. The history of a patient suffering from cystitis often throws great light upon the case. In young women and unmarried women, where the disease is seen in an aggravated form and there is a history of suffering of years' stand- ing, where the urine is cloudy, and there is a continual desire for urination night and day, the disease is apt to be tubercular, and to arise from a tuber- cular infection of one or, it may be, both kidneys. Often there is no complaint whatever of any discomfort in the loin, even with an aggravated disease in the kidney. These cases are frequently mistaken for primary vesical tuberculosis, whereas a primary tuberculosis of the bladder is one of the rarest of urinary affections. In women, a vesical tuberculosis is almost always descending from the kidney; while in men, it may be ascending from the genital organs or descending through the ureters. Again, a patient, a married woman, may state that she dates all her vesical difficulties from a confinement, when it was necessary to catheterize her fre- quently. Cases of this kind are, as a rule, colon bacillus infections. Some- times the patient blames a physician or a nurse unjustly, in response to the 36 546 CYSTITIS. desire natural to human nature to find fault with some other person when anything goes wrong. In taking a history, the actual present condition should first be inquired into as follows : How often the patient urinates ? How frequently at night ? How much j)ain in the act ? When the pain is most intense ? How long the pain lasts ? Is it possible to control the bladder when the desire for urination occurs ? Is the trouble tending to get better or worse? Is it affected by menstruation ? Is it worse when the bowels move ? When these points are settled it is best to go back in the history and ask : How and when did the urinary difficulty begin ? When was the patient last perfectly well ? Does the trouble date from any particular event, such as a confinement or an operation ? Is it attributable to catching cold? Did it begin in a severe form, or with a slight distress, increasing fre- quency of urination, and pain? Did it, perhaps, begin with frequency of urination without any pain at all ? What treatment, if any, has been tried up to the time of inquiry? I give here two typical histories, one in which the pain began sharply and the cystitis is referred to a particular event; another where the cystitis came on gTadually, from no known cause. Case L— Mrs. A. L. M., age forty, April, 1907 (San. Xo. 2421). This patient complained of a bloody discharge, which proved to be due to cancer of the cervix uteri. Her family history was negative, she had always had good health, and was the mother of four children. Up to the time of her admission to my private hospital she had never had any bladder or kidney trouble, and the urinary examination showed clear urine, a specific gTavity of 1.018, acid reaction, no sugar, no albumen, and no abnormal microscopical elements. The cervical cancer was favorable for operation, as it was still limited to the uterus. An abdominal pan-hysterectomy, after the method of Wertheim, was performed. Subsesquent to operation the patient had to be catheterized, and three days later she began to have intense burning pain in the bladder with a great desire to void urine. The pain was excruciating. Examination of the urine showed abundant pus, some red blood cells, considerable bladder epi- thelium, and a pure culture of the colon bacillus. The patient was at once put on urotropin, fifteen grains three times daily, and was given all the water she could drink. In addition to these remedies, the bladder was irrigated daily with a solution of boracic acid. After the first few days the pain and SYMPTOMS. 547 discomfort ceased, but for a month there continued to he some pus cells present in the urine and some bacteria, and it was not until nearly six weeks after the operation that the urine was perfectly normal. The patient was discharged a few days later, and went home cured of her cancer and relieved of her cystitis. Case II. — Miss E. E., age twenty-seven, May, 1907 (San. :^o. 2443). This patient complained of pain and frequency of urination. Her family his- tory was entirely negative as to bladder disease or nervous ailments. Her health had never been strong, though appetite and digestion were always good. Menstruation had been always regular, painless, and in every way normal. The bladder trouble had begun insidiously three years before. At first there was nothing more than a slight increase in the frequency of urination, but this increased gradually and became associated with pain. The condition continued to develop in spite of local treatment carried out by her physician, until the patient had lost much flesh and was in a great deal of pain. The urine, exam- ined on the day of her admission to my private hospital, was of normal acidity, with a specific gravity of 1.030 ; it contained no pus, no blood, no casts, and no bacteria. Examination of the bladder showed it to be of normal size with about four hundred cubic centimetres' capacity. Its appearance was normal everywhere except for an area of reddening and ulceration in the vertex, lying in a transverse direction. This was about four centimetres long by one wide. The ureteral orifices were perfectly normal and secreting actively. An attempt was made to treat this patient by local applications and by irrigations, but the treatment caused such intense pain that it had to be abandoned. I then made a suprapubic opening into the bladder and excised the ulcer as well as another small piece of the bladder, which was reddened. The wounds in the bladder were sewed up with catgut and the suprapubic opening closed with it. The healing was prompt and the relief almost immediate.. The second exam- ination of the urine in this case disclosed a colon bacillus infection Avith some pus, and this persisted until after the operation. When the patient finally left the hospital there was no infection and no pus in the urine. A case of this kind, in a young unmarried woman, coming on insidiously, and with an almost clear urine, is highly suggestive of tuberculosis ; in this case it was only after the administration of tuberculin and the repeated inocu- lation of guinea-pigs with negative results that it was excluded. SYMPTOMS. Local Symptoms. — Frequency of micturition is one of the cardinal symptoms of cystitis, and there is no true cystitis without it, yet on the other hand there may be urgent desire and great frequency without any cystitis at all. This is the rock on which the general practitioner is often wrecked, when he hazards making a diagnosis of cystitis from frequency of urination alone. The frequency varies from an evacuation every hour or half hour to one every ten or fifteen minutes day and night, or to a constant tenesmus and strangury. 548 CYSTITIS. The desire to void oftener than usual is, as a rule, the first symptom noted bj the patient and the last to subside, often persisting even after the entire disappearance of pus and bacteria from the urine. Frequent urination, there- fore, and pain, are the chief symptoms by -^hicli the patient judges as to her OA^TL improvement. Pain is a symptom not always felt at first; it usually follows frequency of urination. "When felt it is localized in the bladder and does not radiate ; it is of a burning, cutting, bearing-down character, and varies from a simple annoy- ance at the time of urination or before it to an aggravated continual suffering, from which there is no relief, day or night. The pain of a cystitis is easily provoked by the introduction of a soim-d into the bladder, a proceeding which is often followed by bleeding. In all cases of cystitis, the pelvis ought to be examined as a matter of routine, to see if there is any tumor pressing on the bladder or any inflam- matory disease about the uterus. The presence of pus in the urine may simply be due to a lingering gonorrheal urethritis, which is usually manifested by a reddened sensitive ex- ternal urethral orifice. A pyelitis is distinguished by the presence of pus in tlie urine, without the presence of the other sigTis of a cystitis, and also by the amount of albumen found in the urine, which is larger than can be accounted for by the amount of pus found. A urologist, by catheterizing the ureter, will be able to trace the pus to its source above. As I have said elsewhere, an acid pyuria, without organisms easily found and growing on the common culture media such as agar or gelatin, is due, as a rule, to a tubercular kidney. General Symptoms. — Fever, headache, loss of appetite, constipa- tion, and emaciation, are noted only in the most aggTavated cases of cystitis. By the time the patient is so far reduced, she keeps her bed, as a rule, all the time. In the presence of such general symptoms, especially if they persist, the practitioner should quickly make up his mind that he is dealing with some severer ti'ouble of which the cystitis is only a part. In the vast majority of such cases the trouble is a kidney infection. DIAGNOSIS. There can be little doubt that a cystitis exists when the patient is troubled with frequent urination and passes milky or turbid urine with pain. It is important to examine the urine immediately when passed, so as not to mistake urine rendered cloudy by chilling and deposition of phosphates for infected urine carrying pus. Only the more marked cases of cystitis can be diagTiosed in this rough manner. The better plan is to cleanse the orifice of the urethra thoroughly, take a catheterized specimen, and either examine it microscop- ically, or send it to a pathologist for examination and report. Five grains of chloral or ten drops of chloroform to the ounce will keep the urine from undergoing decomposition on the way. DIAGNOSIS. 549 I might lay down the general rule that whenever a patient com- plains of frequency of urination and the trouble is persistent, the physician should make a microscopic examination of the urine. If the urine has been voided, two serious sources of contamination must always be allowed for: first, a little admixture of leucorrheal dis- charge furnishes pus, and in the second place smegma bacilli often give rise to a faulty diagnosis of tuberculosis. It is necessary, therefore, in case pus or suspected tubercle bacilli are found, to secure a catheterized specimen for the next examination. This will often relieve a seemingly serious situation. The practitioner, if inclined to do a little experimental work with a guinea- pig, can easily clear up the diagnosis of a tubercular cystitis by collecting a little of the sediment of the urine in a hypodermic syringe and injecting it under the skin of the groin of a guinea-pig, after carefully washing and shav- ing the area to be punctured. If tubercle bacilli are present, distinct nodules can be felt two or three weeks afterward in the enlarging inguinal glands, and if the animal is killed a little later, the tubercular glands are easily recognized. A small dose of tuberculin, say one to three miligrams, given under the skin, will also provoke a decided fever when the disease is tubercu- lar, the temperature rising to 103°, 104°, 105° F., with marked local reaction at the site of the disease. The local reaction manifests itself in pain and also by the excretion of bacteria and pus in the urine. If pus is found in the voided urine, it must be remembered that it may come from the kidney, even when the patient has definite vesical symptoms. The general rule may be laid down that in every case of cystitis, the kidneys must be borne in mind by the investigator from the very begin- ning of his treatment to the end, unless he is able himself, or has called in a friend skilled in urology, to catheterize the ureters, and to prove that while, urine containing pus comes from the bladder, that wdiich comes from the kidneys is free from it. Whenever there is any fever associated with a cystitis, for which there is no other obvious cause, and such conditions as malaria are excluded by blood examinations, the. examiner must always suspect a latent pyelitis as the primary source of the cystitis or of the cystic symptoms. A pyelitis of this kind often gives rise to no symptoms whatever tending to draw attention to its existence. A valuable fact to bear in mind here, is that in pyelitis the percentage proportion of albumen is generally markedly greater than that found in a cystitis containing a like amount of pus. Moreover, the cystitis albumen ring is thin and faint, while pyelitis in the greater number of cases yields a well- defined ring. When there is a proteus infection and in consequence an. alkaline urine, the pus cells become converted into a mucoid substance, the urine is slimy and stringy, and contains no well-defined pus cells which can be seen 550 CYSTITIS. under tlie microscope. This form of cystitis may be paradoxically called a pyuria without pus. As already said, a patient who has a ^jersistent acid pyuria, lasting for months and years and slowly getting worse, has, as a rule, a tubercular kidney. The great majority of tubercular kidneys give such a history as this and they generally suffer for years before the disease is recognized. When a patient has a pyuria with some symptoms of cystitis and no bacteria are found in the urine, after making the usual examination, it must always be remembered that the later histories of similar cases have often proved them to be tubercular. The colon bacillus is the commonest infecting organism, and it may fol- low the introduction of an unclean catheter, or even repeated catheterizations carefully performed, in the puerperal period or after gynecological operations when resistance is lowered. An intense distressing cystitis, with pus and blood in an alkaline urine, due to a p rote us infection, is often encountered. The physician ought not to continue to treat a case indefinitely, unless he notes marked improvement as the result of his efforts ; if he does not, it is imperative to directly in- spect the bladder through an open- air cystoscope (see Fig. 150). There are urologists in every large city who are familiar with these instru- ments and capable of using them skilfully. Many general practition- ers, especially those accustomed to use throat instruments, find them- selves perfectly competent to employ these little instruments, to examine the bladder, to make a diagnosis, and to apply treatments. It is true that the cystoscope has thus far rested for the most part in the hands of specialists, but that is simply because it is comparatively new and its field is a new one; moreover, the technic of the treat- ment of these disorders has been in the process of evolution. Xow that all difficulties and obstacles are overcome, there is no reason why the general practitioner should not take over as much of this work as he has incli- nation and skill to assume. The examination is made with the following instruments and acces- sories : Fig. 150. — Shotvs Ma^-xer of Holding Cysto- scope, Preparatory to its Introductiox into THE Bladder. The thumb presses upon the handle of the obturator. Fig. 151. — Shows Patient in the Knee-breast Posture. The left hand of the examiner separates the labia and exposes the urethra, while the right hand begins the introduction of the cystoscope. Note the upward direction which the cystoscope first takes. H^-C^^'^^ ^^^^^^ Fig. 152.--Shows Cystoscope in Place. Note the change in direction which has taken place in the axis of the cystoscope, which is now pointed to the posterior wall of the symphysis pubis. 551 552 CYSTITIS. A little pledget of cotton tied to a thread to convey cocain into the urethra. A calibrator or dilator to dilate the external urethral orifice. A speculum with which to look into the bladder. A head mirror to reflect an electric light or daylight into the bladder. A simple suction apparatus to empty the bladder of any remain- ing urine. An applicator for treatments. An examination of this kind can be made, as a rule, under local anesthesia by inserting a pledget, saturated with a ten per cent solution of cocain, just inside the urethral orifice. In ten minutes the mucosa will be so benumbed that the little conical dilator can be inserted, and, with a rapid movement, the urethra can be stretched wide enough to admit a 'No. 10 speculum (ten milli- metres in diameter). The speculum is then introduced, as shown in the fig- ures (see Figs. 151 and 152), the patient being in the knee-breast posture. It must be remembered that the urethra describes an arc around the symphysis, Fig. 153. — Shows OsTtrRATOR Remo\'ed ant> the Method of Usixg Light and Head Mieror in the Inspection of the Interior of the Bladder. and in introducing the speculum, it must be made to follow a similar arc. The light is then reflected into the bladder from the head mirror, and the entire inner surface can be easily inspected (see Eig. 153). If there is an accumu- lation of urine in the vertex, it can be removed with the suction apparatus DIAGNOSIS. 553 (see Fig. 154). If this apparatus is sterile, uncontaminated urine can thus be secured and examined bacteriologically as well as chemically. If the blad- der is in a very bad condition, it is preferable to make the first examination under complete anesthesia, so as to avoid suffering and any straining efforts. In looking into a normal bladder, the walls appear dull and whitish, and are traversed by vessels like the background of the eye, which divide up like the little branches of a stream, leaving between them the whitish non-vascular areas. When there is any inflammation, the white areas be- come flushed, pale red, or rose red, or even intensely Fig. 154. — Ili^ustrates the Use of Suction Apparatus for Removing Urine which Accumulates IN the Bladder during Examination. beefy red. The mucosa swells and becomes hazy, and the vessels disappear, until, in the most severe "cases, no vessels at all are visible. In milder cases of inflammation, the cystitis is seen to be localized about the trigonum, or upon the posterior wall, or at the vertex. There is often an intense area of inflam- mation, which gradually shades off into neighboring sound tissues. Our present conception of cystitis influenced as it has been by these local examinations is very different from that entertained two decades ago. The idea of cystitis then was that the whole inner surface of the bladder was inflamed. ^N'ow it is known that the patchy cystitis, with areas of normal bladder mucosa between the inflamed foci, is much the commonest form. I cannot lay too great emphasis upon the importance of not making a diagnosis of cystitis from the symptoms of frequent 554 CYSTITIS. and painful micturition alone. These two symptoms may be found Avith stone in the kidney, stone or foreign body in tlie bladder, or the irrita- tion produced by a neighboring gynecological inflammation. To make a probable diagnosis of cystitis there must be the added element of pus in the urine; though even here the disease may not reside in the bladder but in the renal pelvis above, in some exceptional cases. The crucial sign of cystitis is the inflamed bladder as seen through the cystoscope. Tubercular forms of cystitis are apt to show areas of ulceration, and if, as is usually the case, the disease is a descending one, the most marked ulceration is around the ureteral orifice of the affected side. Distinct tubercles are not often seen. In proteus cystitis, the bladder shows patches of intense, almost glistening white concretions, seated on a base of intense inflam- mation. The value of such a local examination is evidently very great. ISTot only is it a source of encouragement to see that the disease is often more localized than had been suspected, but it is valuable for the sake of comparison from week to week in determining whether or not the patient is improving, or whether there is some rebellious area which refuses to advance further on the road toward healing. Differential Diagnosis. — Cystitis may be confused with simple frequent urination (pollakiuria). Trigonal hyperemia. Pelvic tumors and inflammatory conditions. Urethritis. Ureteritis. Pyelitis of various kinds. Tuberculosis of the kidney. Stone in the bladder and kidney. If pus and bacteria are absent the disease cannot be a cystitis, even though the patient urinates frequently. Frequent urination of this kind is foimd in diabetes, as well as in hyperemia of the trigonum of the bladder in nervous patients, where the urine is excessively acid. TREATMENT. Preventive Treatment. — Here as elsewhere in medicine, it is far more important to prevent the disease and all its attendant suffering, than to cure it when already arisen; for it is always easier to prevent a disease than to cure it. Many cases of cystitis could, undoubtedly, be avoided by careful prophylaxis. These are, especially, those which follow confinements and sur- gical operations, when it is very important to watch the bladder and to make sure that it does not become overdistended, atonic, and liable to accumulate large amounts of residual urine which is prone, in the weakened condition of the patient, to become foul. PEEVENTIVE TREATMENT. 555 following confinements it is important to steer between difficult extremes : on one hand catheterizing too often, and on the other hand, not often enough when there is a tendency to overdistention of the bladder. It is a good plan in a first confinement to teach the patient before delivery how to use a bed- pan in emptying the bladder as she lies on her back in bed. If the bladder can be felt after confinement distended above the symphysis, it ought to be emptied. One important way of avoiding overdistention of the bladder is always to use the catheter to empty it before applying the obstetric forceps. The discharges are kept sweeter and cleaner, if every time the patient is changed or catheterized, a powder (one part iodoform and seven parts boric acid) is sprinkled within the outlet. ISTot uncommonly, a patient who is voiding very frequently is really suf- fering from overdistention of her bladder. If there is much lower abdominal pain, and a careful palpation of the lower abdomen or vaginal examination justifies the suspicion that the bladder is overdistended, the question is quickly set at rest by catheterization. On the other hand, it is necessary to be careful not to interfere too early or too often. There is, on the part of some surgeons, a tendency to meddle too much with the bladder and to catheterize with too great a regularity. There should be no prescribed rule establishing the use of the catheter in all cases at certain intervals of time. Many patients, if they are allowed to suffer a little inconvenience from the distending bladder, will, from this very fact, urinate spontaneously after waiting a while, and will then be able to take care of the vesical function themselves. Moreover, if the catheter is resorted to early, the patient becomes dependent upon it, and its use may have to be con- tinued for several weeks. With the protracted use of the catheter, the risk of infecting the bladder is enormously enhanced, and, like the pitcher which goes often to the well, the break in the technic with resulting infection occurs at last, and cystitis is established. As regards the avoidance of post-operative cystitis, too much im- portance cannot be laid upon not using the catheter at all. A patient, even after a severe operation, had better be propped up in bed supported by her nurse than undergo a catheterization. It is also advantageous to teach the patient to void urine when lying down before the operation. In the last two thousand cases in my service at the Johns Hopkins Hospital the patients were not catheterized and there were only twenty-four cases of marked cystitis after operation. This is in decided contrast to our old records, where every patient was catheterized as a matter of routine for a number of days. Twenty-two of these twenty-four cases followed abdominal operations ; but in all of them cystitis developed afterwards, in spite of the fact that there was no catheteriza- tion. The average case of post-operative cystitis, due to catheterization of the urethra when there has been no serious disturbance of the bladder by opera- tion, is a mild affair and yields readily to treatment. On the other hand, in the extensive operations necessitated by cancer of the cervix, there is such 556 CYSTITIS. destruction, of both the vascularization and the innervation of the bladder, that a cystitis may develop which is extremely obstinate and in some cases incurable. In using the catheter all necessary precautions should be taken in every instance. In the first place, the nurse or the doctor who handles infected cases ought to wash the hands thoroughly, scrubbing them with soap and hot water after every treatment, as well as before each new treatment. The patient to be catheterized is then: (1) Exposed as she lies upon her back, with knees drawn up and separated. The vulva is held widely open with thumb and forefinger of the left hand, so as to give a perfect exposure of the urethral orifice. (2) It is a good plan to draw a little rubber finger cot on thumb and fore- finger of right hand. (3) A sterile dish containing a warm boric acid solution and some pledgets of cotton about three centimetres in diameter, should be placed on the bed not far away from the genitalia. (4) A gauze or cotton pad is placed under the patient, or perhaps a curved basin. (5) The nurse then takes up the cotton in the boric acid solution with a pair of sterile forceps. (6) She cleanses thoroughly the urethral orifice and the adjacent portions of the vestibule, using several pledgets of cotton one after the other, and apply- ing the solution efi^ectively, but taking care not to rub hard, and not to hurt the patient or abrade the delicate tissues. Having thus cleansed the field she then takes a sterile glass catheter from a receptacle. The catheter with a piece of rubber tubing on the end, three or four inches long, is held delicately poised between thumb and index finger. (Y) The end of the catheter is dipped in sterile sweet oil, introduced into the urethral orifice, and with a slightly curved motion, following the curve of the under surface of the symphysis by dropping the outer end as it is carried upwards and inwards, it is introduced into the bladder. The catheter must never be grasped firmly with the fist, as though the nurse were determined to overcome any obstacles encountered by a main force ; neither must it be pushed straight in, as though the urethra were a straight tube. (8) The urine running out of the rubber tube is collected for examina- tion, if desired, in a suitable vessel. Uncontaminated urine is easily secured for bacteriological examination by drawing the rubber tube off from the end of the catheter while the urine is still running, and letting a few drops or a few cubic centimetres run into a sterile agar tube. Unless the nurse is skilled in catheterizing she would do better, I think, to use a soft-rubber catheter, which finds its own way up the urethra. The two objects in catheterization are, first, to introduce the cath- eter without carrying in any infectious material, which is effected by exposure and cleanliness; and, second, to avoid any trauma or MEDICINAL TREATMENT. 557 laceration of the urethral mucosa. If the second rule is observed the catheterization is done without hurting the patient at all. I am aware that the above method of catheterization sounds very much like a small surgical operation, but unless all these precautions are taken, it is impossible to avoid causing a certain number of distressing cases of cystitis, and it is a matter of primary importance that our nurses, as well as our prac- titioners, should be taught to consider this little procedure as parallel in dignity to a minor surgical procedure. It is the constant necessity of exercising such care as this in every relationship between themselves and the patient which raises the calling of physician and nurse to the dignity of a skilled profession, and makes the difference between a true practitioner and a quack. When the physician finds that it is going to be necessary to catheterize his patient more or less frequently during a convalescence, as after a severe confinement, one of the best prophylactic agencies is the use of uro tropin, say ten gTains three times a day until the danger of infection is over. Urotropin finds its best field as a preventive in such cases, and as an indispensable adjuvant in treating fresh infections ; it is less effective in old, well-established cases of cystitis. It seems to have more effect upon the colon bacillus than upon any other organism; it is useless in cases of tuberculosis, and is probably most effective in cases of cystitis and pyelitis following typhoid fever. In surgical cases, prophylaxis can do a great deal to prevent cystitis following and complicating the convales- cence. With this in view, the surgeon should handle the bladder as little as possible and avoid all bruising of its tissues, especially any violence in rubbing down or detaching the bladder from the cervix uteri. If the bladder is widely detached from the uterus, as in hysterectomy, the vaginal and peritoneal surfaces should be brought together so as to cover over the wounded sur- faces and limit the area of suppuration, protecting the bladder. In our hysterectomies for cancer of the cervix, my former resident, Dr. John A. Sampson, found that a drainage of the bladder by artificial vesico-vaginal fistula prevented the occurrence of cystitis, which was exceedingly common without it. Treatment of an Existing Cystitis. — In treating a cystitis which has already become established, we must at once separate those cases which come on in the young gradually and without apparent cause, or with such an alleged cause as catching cold, as well as cases of long standing, from those which have begun within a period of, say, a few weeks, from some easily assignable cause, such as a trauma from operation or a confinement. Cystitis in the young is very apt to be due to a tubercular infection, and this fact must always be borne in mind until the nature of the infecting organism is definitely and positively known. All persistent acid pyurias in young people are presumptively tubercular until the contrary is proved. If tubercle bacilli are found in the urine, the case is not one which is amen- able to medical treatment. When tubercle bacilli are found, the case is almost certainly one of tuberculosis of the kidney, with sec- 558 CYSTITIS. ondary involvement of the bladder. It is often hard to convince a general practitioner of this fact, because these patients not only frequently eonijilain first of the bladder, but ofttimes the entire complaint throughout the whole illness is vesical, so that great astonishment is expressed when the con- jecture is hazarded by the specialist that the kidney is the real seat of the disease. A gonorrheal cystitis usually dates from a florid attack of gonor- rhea, affecting the genitalia as well as the urinary organs, and beginning with- an acute urethritis and cystitis. It is important to remember that an infection, primarily tubercu- lar, is often followed by the invasion of other pus-producing organisms, which cause more or less extensive suppuration and a marked febrile reaction. Albarran, of Paris, has dra^vn particular attention to this class of cases. A cystitis beginning to run an acute course, with frequent urination and the passage of pus, mucus, and blood, ought not to be subjected to any active local treatments. Catheterizations and irrigations, and local medications of all sorts, as a rule, only serve to aggTavate the disease, which often tends to heal spontaneously without meddlesome interferences. The best treatment for an acute cystitis is absolute rest in bed, a nutritious soft or liquid diet, and abundant diluents by the mouth, say a tumbler of water containing twenty grains of citrate of potash every two hours. If the pain is severe, a bella- donna and opium suppository is the best sedative we can use. 19 Extract of opium gr. i Extract of belladonna gr. i 01. theobromse q. s. M. et ft. suppository 1. Mitte tales vj. S. One suppository every 6 to 8 hours if pain is severe. A good suppository is: ^ Trional gr- Codeige • g^- M. et ft. suppository 1. I would, as a rule, confine the patient to a milk diet or its equivalent, and allow fruits, but cut off all red meats and condiments. A prolonged hot vaginal douche (110° E.) g-iven for ten to fifteen minutes twice a day may alleviate the inflammation. Hot applications, poultices, or fomentations of flannel wrung out of hot water over the lower abdomen are valuable adjuvants. Urotropin should be given, five grains every three or four hours for some days at the beginning. If this makes the urine more irritating, the dose should be lessened or suspended. LOCAL TREATMENT. 559 A good mixture in the acid cases is: I^ Pot. citrat. 3j v Tr. hyoscyanii fSvj Elix. simpl q. s. ad. f 5vj S. Tablespoonful every 2-3 hours in water. I find the following drugs of occasional assistance: Fluid extract of triticum rejens, fluid extract of zea mais, oil of sandal wood, copaiba, methylene blue, sweet spirits of nitre. I do not know anything as to the real value of the old remedies once held in such repute, namely, uva ursi, buchu, pareira brava, pipsissewa. The methylene blue in doses of three grains three times a day, in capsules, sometimes quiets pain, but does not control the disease. Triticum and zea mais serve to make the urine bland, given in doses of half a teaspoonful, well diluted, every three or four hours. Oil of san- dal wood and copaiba are given in five to ten minim capsules after food. They sometimes do good, but oftener they upset the stomach. Sweet spirits of nitre in doses of one teaspoonful every two or three hours, well diluted, also relieves pain and is valuable in mild cases. Tincture of hyoscyamus in thirty drop doses may be given every two or three hours by mouth. It is well to dilute freely all medi- cines taken by mouth. If instead of subsiding, the case continues to run a peracute course, as in diphtheritic cystitis or in the sloughing form follow- ing a severe labor, but one plan of treatment is left, and that is J^ /f to open and drain the bladder through the vagina. These drain- age cases are very much helped by placing the patient in a hot water bath for several hours every day (Hunner). Local Therapy. -In. cystitis ''^'^^IS.^S'^T^.T'SLrj^l which is not running an acute mtrodxiced and the clamp re- " moved from the tubing, allow- COUrse, local therapy can do ing the urine to escape. The - _ - , , . clamp is then re-applied, after a great deal. I would advise which the contents of the bulb .1 I, -n . ^ /^^^^1 is emptied into the bladder. the lollowmg plan: (1) Ine symptoms should be carefully and minutely written out: frequency of urination, etc., amount and character of pain, the appearance of the urine, and the amount of sediment of pus after standing for a definite length of time. (2) A short course of treatment, lasting a few weeks, should then be insti- 560 CYSTITIS. tilted. The jJaii iiiu>t lir definite, and the physician slioiild make up his mind not to contiune it indefinitely, but to abandon it for a more aggressive course in case there is no marked improvement in a reasonable period of time. A mild course of treatment consists in rest, keeping the patient at the same time as much in the fresh air as possible, and in the winter out in the sunshine, the due regTilation of the bowels, and daily or every other day treatments of the bladder. The simplest plan of treatment is the following: A Dickinson two-way glass catheter (see Fig. 155) is used, with a bulb holding about an ounce of a 1:1500 nitrate of silver solution on the upper catheter. The catheter is introduced with extreme gentleness, and the urine in the blad Fig. 156. — iShotvixg Jlovi- a Dickixsox or axt Ttvo-wat Catheter Cax be Used ix^ Irrigatiox of THE Bladder. der allowed to run out. Then after stopping up the lower end of the catheter, the bulb is slowly squeezed until the silver solution is forced into the bladder. The patient retains this fifteen or twenty minutes, if possible, before voiding again. If the 1 : 1500 solution gives no discomfort, the sti'ength should gTad- ually be increased until 1 : 1000, 1 : 500, or even 1 : 100 is used. LOCAL TREATMENT. 56J Formula for solution of nitrate of silver 1 : 1500 : ^ Arg. nitrat gr. ^ Acidi borac gr. vj Aq. destil fgj M. S. Inject warm into bladder. A strong stock solution of boric acid may be made up and diluted as used. If these instillations do not give prompt relief, or for any reason are not well borne, irrigations may be used, the bladder being washed out with a half saturated warm solution of borax, or with a boracic acid solu- tion as hot as can be borne, following this by an injectioii, through the irrigating funnel (see Fig. 156), of a nitrate of silver solution 1:1000 or stronger as the patient is able to bear it. In some cases the irrigations and instillations may be alternated with advantage. After a certain line of treatment has been carried out for two or three weeks, there is often a distinct gain in changing to another line of treatment for a time. It seems as though we catch the bladder by surprise, and are able to get a hold on the disease, which has become used to the first method of treatment. (3) If a short course of treatment, such as that prescribed above, does not promptly relieve the cystitis, a specimen of urine should be taken by catheterization, five grains of chloral added to the ounce, and sent to the near- est laboratory for examination and report. I suggest this here for the con- venience of practitioners who are at a reasonable distance from laboratory convenience but have not been accustomed to using them. It is really advis- able, as a rule, to take this step at the outset, as it will save the occasional mistakes in treating tubercular cases which demand surgical treatment from the first, and are never much benefited by mild local measures. If, with rest, and drugs, and diet, and instillations, and irrigations, the cystitis holds on, showing no signs of marked improvement, the next step is (4) Topical Treatments. — It is one of the healthy signs of the day that many general practitioners are closely enough in touch with the various specialties to perform certain minor surgical operations, to operate for an urgent appendicitis, and to apply treatments to the throat and nose, as well as to undertake a variety of lesser gynecological procedures. Such men, if familiar with the use of the head mirror, could also with a little pains ^dis- tinguish inflammatory patches in the bladder through my open air cystoscope and apply topical treatments when the areas involved are not too large. To do this it is necessary to put the patient in the knee-breast position and to look into the bladder in the manner described in the section on examination of the bladder (p. 552). The bladder, expanded with air by posture, is emptied by suction, when the inflammatory areas are seen through a specu- lum two-fifths of an inch in diameter. It is equally easy to use an applicator and to touch the affected spots with a two to five per cent solution of silver nitrate. Such treatments may be applied every three to five days, irriga- 37 562 CYSTITIS. tions and mild instillatious being used in tlie meantime. Any case wliicli fails to improve rapidly ongiit not to be held onto indefinitely, bnt should be sent to a trustworthy urological specialist. (5) Opsonic Treatment. — The profession looks with eager interest to-day towards the opsonins for relief from chronic infections. I do not know that this plan has as yet had any satisfactory trial in bladder disease. The proper course for opsonic treatment would be to make a culture from the patient's urine and to inoculate the organism causing the cystitis; then from this to make a vaccine of the dead organisms, which is injected as a toxine to inhibit the activity of the living germs in the vesical tissues by stimulating the production of antitoxines in the patient's body. These toxines for the vari- ous organisms can be secured to-day from several enterprising firms who can keep them in stock. (6) Drainage of the Bladder by the Yagina. — This method of treatment belongs to the realm of the surgeon, and it is not my purpose to dwell upon the operation here, further than to indicate that the drainage may be quickly and efliciently made by putting the patient in the knee-breast posture and then opening the air-distended bladder through the vagina by pushing a knife through the septum in the middle line between the internal urethral orifice and the neck of the uterus. Such a drain should be kept open by sew- ing the vesical to the vaginal mucosa ; unless this is done, the wound closes too rapidly to be of much service. When the simple drainage does not suffice, irrigations entering through the urethra and running out by the drainage open- ing may be kept up for from two to four hours each day (see Fig. 157) ; or the patient with the drain may be put into the tub for several hours each day. Under such treatment marked improvement usually takes place in the course of a few months. If after several months the bladder is cleared up to one or two red and bleeding areas the surgeon should then be sought to excise these by a suprapubic operation. By one or another of these methods practically all cases of cystitis, except tubercular cystitis in the last stages, are amenable to treatment. I know of no disease, however, which requires more constant exercise of good judgment in devising plans of treatment and in persisting in spite of many discouragements for sometimes as much as several years. Some of the best results I have ever seen have been gained by treatments extending over three or four years. In the end, however, the disease was cured, health restored, and the patient delivered from a distressing malady. The result in such a case makes all the labors trifling in comparison however onerous they may have seemed at the time. The following case illustrates how much may be accomplished by sustained effort in these cases. Mrs. E. K. B., age thirty-nine, April, 1907 (San. 'No. 2440). The patient's family history was good and menstruation had always been regular and painless. She had been married fifteen years, but had never had a child; she dated her trouble from marriage. About fourteen years before coming to me, she began to have a severe leucorrhea, and her physician, in LOCAL TEEATMENT. 563 order to cure this, put a stick of silver nitrate into the urethra, which caused sloughing of the entire mucous membrane. This caused her intense suffering for weeks and left her with a permanent incontinence. She was then exam- ined by a distinguished Chicago surgeon, who told her that the sphincter had been entirely destroyed. She had had, in all, about eighteen ojDerations to cure the incontinence, and finally had a spout-shaped urethra made for her. By putting a pledget of cotton underneath this, she obtained fair control over the bladder, nevertheless there was a considerable irritation in it as well as pain. The urine contained the colon bacillus and a few red blood Fig. 157. -Method of Continttous Ibrigations of the Bladder with the Patient in Bed on a Bedpak. cells. An examination of the bladder by the cystoscope showed a normally shaped bladder of normal capacity. The mucosa looked fairly normal, except for an ulcerated area on the posterior wall. This ulcerated area had been treated for months by one of my associates with local applications without relief. I opened the bladder suprapubically, examined its interior, and found that there was only one place of disease, namely, an ulcer on the posterior wall, which was three centimetres long and two wide, I excised this ulcer. 564 CYSTITIS. sewed up the bladder wall with fine catgut, and also closed the suprapubic opening. To help the incontinence I used a paraffin injection under the urethra. The patient was discharged a month later feeling well, with perfect continence, and a normal looking bladder. This was one of those resistant cases which yield to nothing but a surgical operation. A simple but valuable form of drainage which sometimes works admirably is effected by the insertion of a self-retaining catheter through the urethra. Some urethrse will tolerate this instrument quite well and for a long period of time. The catheter serves to keep the bladder emptied and at rest, while at the same time it affords a way of irrigating the bladder as often as may be necessary without the distress occasioned by catheterizing the patient every time. One of my cases did well in this way under a constant irrigation with a weak boric acid solution. This was affected by fastening two small rubber catheters together with rubber cement and introducing them into the bladder ; they were held in place by a perineal pad fastened with a tape around the waist. The fluid ran in slowly through one catheter, circulated in the bladder, and escaped by the other. This avoided the making of a vesico- vaginal fistula. CHAPTER XXIII. FUNCTIONAL NERVOUS DISORDERS MET WITH BY THE GYNECOLOGIST. Introduction, p. 565. Varieties of functional neuroses: Hysteria, p. 566. Neurasthenia, p. 567. Hypochondria, p. 568. Psychasthenia, p. 569. Diagnosis of functional neuroses, p. 572. Prognosis, p. 576. Treatment, p. 576. INTRODUCTION. Many patients who complain of symptoms referable to the genito- urinary organs, the lower abdomen, or the back, and who appeal to the gynecologist for aid, are, in reality, suffering from nervous disorders and require treatment directed toward the nervous system rather than local therapy. Unless the gynecologist is familiar with the general characteristics of the functional neuroses, he will often be led astray in diagnosis, and will be induced to institute local measures of treatment, which, by focussing the atten- tion of the patient upon her symptoms, will lead to their perpetuation rather than to their amelioration. If, on the other hand, he has learned how to un- mask the functional neurosis, and, having attained this point, to direct his treatment toward the general condition of the patient, he will often score suc- cesses quite impossible otherwise, he will enhance his own reputation, and in- crease greatly the value of his service in the community. In the functional neuroses, the symptoms presented by the patient may resemble very closely those of organic disease. Frequent and painful micturition may excite suspicion of the existence of a urethritis or a cystitis. Pain in the back or in the legs may suggest some uterine displacement. Hyperesthesia in the ovarian region may make the gynecologist think of a serious ovarian disease ; difficulty in walking may suggest disease in the sacro-iliac joints, or a sciatica; nervous disturbances of intestinal origin may cause fear of the ex- istence of organic lesions in the large bowel or its neighborhood. Dysmenorrhea and headaches in the neurotic are often considered indi- cations for dilatation and curettage. Such examples might be multiplied almost indefinitely, and every working gynecologist, who has had his eyes opened to the functional disturbances of the nervous system, is familiar with the mani- fold ways in which the symptoms may ape those presented in organic disease. It seems worth while, therefore, in a work on medical gynecology, to direct attention to some of the general characteristics of the functional 565 566 FUNCTIONAL NEEVOUS DISOKDEES MET WITH BY THE GYXECOLOGIST. neuroses; to discuss the diagnosis of these disorders at least briefly, paying special attention to the means of differentiating them from certain organic affec- tions with ^vhich they may be confounded; and, also, finally to outline the modern mode of treatment directed toward the nervous system in general, rather than toward the local manifestations. VARIETIES OF FUNCTIONAL NEUROSES. There is still much discussion even among internists as to the proper classification of the abnormal neural and mental phenomena which we are con- sidering, Xo two neurologists, perhaps, will agTee entirely as to classification and terminology. The various functional neuroses seem to go over into each other, without very sharjD limitation, and some writers suggest that we do away with the special terms, and group all these deviations from the normal under the general title of the psyc hone u roses. Those who have had much experience, however, in the study of these disorders are able to recognize certain toleral;)ly definite types, Avhieh recur over and over again, and for convenience of description and record it is desirable that to these types special names should be given. At least five such types are worthy of general recogTiition, namely, hysteria, neurasthenia, traumatic neurosis, hypochondria, and psychasthenia. For a full description of the phenomena in these various types, the special text-books of jSTeurology and Internal Medicine must be con- sulted. For the purpose of this volume, however, a few brief sentences of definition will suffice. Hysteria, contrary to a widely prevailing opinion, is a relatively rare disease. Xeurologists now understand by it a very definite type of nervous disorder, and eliminate from it many of the bizarre nervous symptoms which, to the uninitiated, imply manifestations of hysteria. The most striking feature of hysteria is the extraordinary susceptibility of the patient to sug- gestion. The disease is in reality a mental disease, and should be so regarded, especially in treatment. The symptoms which the patients present are both bodily and mental, but the mental symptoms predominate, and are by far the most important to understand. It is common to divide the symptoms of hysteria into two great groups, the so-called stigmata, and the so-called accidents of hysteria. By the stigmata of hysteria are meant the phenomena of the disease which tend to be permanent. These include the hysterical anesthesias, the hysterical amnesias, the hysterical aboulias, and the hysterical alterations of character. By the accidents of hysteria are meant the more transitory and episodal phenomena of the disorder. Under this heading of accidents are in- cluded the convulsive crises, the paralyses, the contractures, the somnambulisms, and the deliria which may occur. These various disturbances of function met with in hysteria appear to be NEURASTHENIA. 567 due to abnormal ideas in the minds of the patients. It is not to be understood, however, that the symptoms are not real ; nothing can possibly be more real to a patient than the symptoms of hysteria. The remarkable fact about the symp- toms is that they can be produced by suggestion, and that they are curable by persuasion (pithiatic phenomena in the sense of Babinski). Neurasthenia is a much more common affection than hysteria, and a large number of patients who suffer from true organic disease become neurasthenic later on as a result of the strain upon the nervous system, due to the organic affection. Still many of the cases develop in the absence of a demonstrable organic disease, owing to an improper mode of life or to mental or physical over- exertion ; they may also arise from faulty nutrition, or from the effects of some nervous shock, or prolonged nervous strain. In this disease, often designated as " irritable weakness," the patients are frequently more excitable than normal, but are incapable of enduring activity, owing to the tire which results from the exercise of almost any function. The symptoms in neurasthenia are both psychic and somatic. They vary greatly, but certain of theni recur so fre- quently that they deserve special mention. Perhaps the most constant symp- tomatic feature in neurasthenia is fatigability. The patients complain that they can do nothing without an excessive feeling of fatigue ; if they walk, if they read, if they try to follow their ordinary occupation, they are soon forced to desist by an overwhelming feeling of exhaustion. Associated with these symptoms of fatigue, headache or a sense of pressure in the head, pains in the back, and sleeplessness are frequently complained of. It is not surprising that patients with these symptoms should become mentally depressed, and the mental state is often clearly recognizable in the facial expression. JSTeurasthenic patients very frequently complain of disturbances of the di- gestive apparatus, circulatory apparatus, and the genito-urinary apparatus. The symptoms may be referred to one of these systems alone, or to two or more of them simultaneously. Among the disturbances of the digestive apparatus most frequently complained of are the various forms of indigestion; the neurasthenic finds that she is upset by certain kinds of food ; she may complain of a heavy feeling, of soreness in the region of the stomach; she suffers from gaseous eructations, and from distention of the abdomen with gas ; sometimes she is nauseated, and occasionally asserts that the eating of certain articles of food is invariably fol- lowed by vomiting or regurgitation; she is sure that she has an idiosyncrasy for milk, or for vegetables, or for some one of the varieties of food which enter into the daily diet of the normal individual. Constipation is very frequent, and many of these patients resort constantly to laxatives, purgatives, or enemata for relief. More rarely a troublesome diarrhea is complained of. Among the circulatory symptoms presented by neurotic patients may be mentioned the subjective palpitation, pain or anxiety in the pre- cordial region, with throbbing of the abdominal aorta, and of the 568 ruNCTioisrAL jSTekvous disoedees met with by the gyistecologist. peripheral arteries. Beating in the head is a symptom which is often very troublesome. Of the genito-urinary disturbances met with among neurasthenics, frequent or painful micturition, imperative micturition, and nocturnal micturition, flattering feelings in the region of the bladder, anomalies of the menstrual flow (quantity, quality, pain), disturbances of sexual desire and sense, and the like, are not un- usual. In searching for the etiology in these neurasthenic cases, the physician who knows how to ferret it out will be surprised to find how often the cause lies in some ethical or social relation which has been responsible for a great nervous shock or strain. This fact cannot be too carefully borne in mind, inasmuch as treatment will often prove unavailing while the cause is permitted to persist. Another fact which the medical practitioner should never forget in connection with neurotic patients is, that a neurasthenia producing symptoms referable to the genito-urinary, the circulatory, or the di- gestive apparatus maybe due to the existence of some obscure organic disease in some other part of the body, far removed perhaps from those parts to which the symptoms most complained of are referred. A beginning apical tuberculosis, a slowly developing brain tumor, an uncorrected anomaly of* refraction, a persisting sinusitis, an over-function of the thyroid gland, a hypertrophic osteo-arthritis of the spine, or a flat-foot may be the organic basis of nervous symptoms which give no clue as to their origin. In no part of medicine, therefore, is it more necessary to make a thorough systematic routine examination of the whole body than in patients coming to us with neurasthenic symptoms. The condition known as traumatic neurosis is perhaps not so often confused with gynecological diseases as some of the other fimictional neuroses. After railroad accidents or other traumatisms, however, patients may develop symptoms, the result ' of the nervous shock, which so closely resemble disor- ders belonging to g^mecology that they appeal to that quarter for aid. When a thorough gynecological examination reveals the absence of local disease, sufii- cient to account for the symptoms complained of, the gynecologist will do well to seek for psychic or physical trauma which might give rise to a so-called traumatic neurosis. Hypochondria is much more commonly met with in men than in women, but it does occur in the latter, and the g;>mecologist should be familiar with the symptoms which hypochondriacal patients complain of. In this disorder it is the nosophobia or fear of disease which is especially characteristic. Our bodily organs are supplied with sensory nerve fibres along which impulses are carried centripetally to the brain. In normal life these impulses, though of the gTcatest importance for the coordination of the activities of the body and for tlie maintenance of normal conditions in the vegetative and psychic life of the individual, go on below the threshold of consciousness ; we are totally un- PSYCIIASTHENIA. 569 aware of them. In hypocliondriacal conditions these centripetal impulses no longer remain subconscious; the patient begins to feel abnormal sensations in various parts of her body and attempts to interpret them. Her general sense of life and her general bodily consciousness are different from what they were before. She complains of feeling badly and describes vague distressing sensa- tions which keep her in a constant state of discomfort ; her mood alters and she may become very much depressed, fearing the existence of serious disease in some one of her organs. It is often very difficult to convince the hypochon- driacal patient of the non-existence of demonstrable organic disease. The ab- normal sensations and the continual discomfort are such real things in the psychic life of the patient that any amount of argumentation on the part of the physician frequently fails to allay the patient's fears. Psychasthenia. — A mental disorder which is extremely common, but which has only of late been adequately recognized, is the condition which is now designated as psychasthenia. In some one of its manifestations it is per- haps the commonest functional nervous disorder which the gynecologist will meet with. Any physician who sees a large number of patients each day is sure to have among them several who present psychasthenic phenomena. The psychasthenic state was formerly confused with hysteria on the one hand, and with neurasthenia on the other, but since the very careful in- vestigations of Pierre Janet, of Paris, medical men have been taught how to differentiate this state from the others to which it is more or less closely allied. The severer forms of the affection have been well described by C. L. Dana, of J^ew York, under the term phrenasthenia, and English writers, notably Hack Tuke and Mickle, have written of several varieties of the disease under the captions of " imperative ideas " and " mental besetments." In this coun- try a large number of psychasthenic states have been included in descriptions of neurasthenia; thus, for example, the various phobias described by Beard are now separated from neurasthenia proper, and classified under the heading of psychasthenia. Too much stress, however, must not be laid upon classifica- tion. It is perhaps impossible to draw a distinct line between psychasthenia in its milder forms, and some of the neurasthenic states, and even hypo- chondria is regarded by some as a mental state which may occur either in neurasthenia or psychasthenia, or in the early stages of the more out- spoken psychoses. A careful study of Janet's book, entitled " Les Obsessions et la Psy- chasthenic," Paris, 1903, can be heartily recommended to any one who desires to familiarize himself with the main features of this remarkable disorder. Psychasthenic patients suffer almost constantly with the sense of incom- pleteness or of insufficiency, from disturbances of the feelings of reality, and from other symptoms referable to the lowering of the so-called psychological tension. It is probably owing to these funda- mental disturbances that the other phenomena, which are clinically, perhaps, more characteristic of the malady, develop, namely, the obsessions, the 570 FUXCTIO:srAL jSTEKYOUS DISOEDEES met "WITH BY THE GYNECOLOGIST. pseudo-liallucinatioiis, the impulses, the mental manias, the tics, the forced agitations, the fears, the anxiety conditions, the sense of strangeness and unrealitv, the phenomena of deper- sonalization, and the like. The imperative ideas or obsessions presented by psychasthenic pa- tients differ much in content ; the idea has a permanence, entirely out of accord Tvith its importance and its practical utility ; it comes up into the head of the patient over and over again in spite of herself, and do what she vill, she cannot rid herself of it. Sometimes it is an idea of sacrilege, sometimes an idea of crime, sometimes an idea of shame regarding herself or her body, or, perhaps, an idea of incurable disease. Every gynecologist is familiar with the patient who, in spite of repeated assurances to the contrary, is convinced that she has some serious disorder of her ovary, of her uterus, of her bladder, or of her kidney; the whole intellectual interest of the patient centres in her health, or in the disorder of that health which she assumes does exist. Very frequently some painful thought is associated with some normal process in the body ; indescribable anxiety is associated with the function of micturition, or of defecation, for example. Other patients have a sense of shame connected with their bodily appearance; they are too fat, or they are imperfectly developed in some part, or they complain of some peculiar movement of the body, or of abnormal blushing, or of persistent pimples, or of abdominal distention. The most bizarre idea may become focal in consciousness, and despite the greatest effort to become marginal, remain focal. It is curious that most of these fixed ideas are associated in a certain degree with self-accusation. Indeed it is the scrupulosity of the psychasthenic patient which often characterizes her especially. When the patients complain of abnormal impulses, the impulses are nearly always directed to the performance of some evil deed, and the acts which they think themselves forced to perform are extreme in nature; the patients describe them as most sacrilegious, most criminal, most dangerous, or most odious. As a matter of fact they rarely yield to the impulses which they say dominate them. These imperative ideas and impulses are present in the most outspoken cases of psych asthenia. It is the less outspoken cases, with milder symptoms, which are more likely to be met with by the gynecologist, and which, at first, may puzzle him. The feelings of insufficiency and incompleteness characteristic of the milder psychasthenic states are those most important to recognize; too little attention is paid to them, because they are feelings to which even the normal mind is occasionally subject. The incompleteness described by the pa- tient may refer to her actions, to her intellectual processes, to her emotions, or to her personality. A woman presenting gynecological symptoms may in paren- thesis tell us that she has noted an increasing difficulty in action, or that she feels that all effort is useless, or that she is no longer a capable woman, that PSYCHASTHENIA. 571 she is troubled about making up her mind about things, that she is doubtful or hesitates before doing things, that she is discontented with life, that she suffers from being over-humble, or that she is in a state of revolt or resentment regarding conditions in which she finds herself placed. Other women complain that they have noticed a growing indifference to things in which they were for- merly interested, and in which they know they should still have a lively interest. A persistent sense of boredom is not an infrequent complaint in the gynecological consultation room. Other patients suffer from an indefinable anxiety or dis- quiet ; women frequently say that, in order to relieve their minds of their local troubles, they are compelled to resort to various diversions or exciting occu- pations. Besides these subjective complaints which the women themselves report, their husbands or friends may also describe to the physician observations which they have made, and which are quite in accord with the subjective complaints of these patients. The daily observation of the husband, if he have his eyes open to these modifications of psychic function, may have put in evidence cer- tain disturbances of the will, of the intellect, or the emotions of his wife ; he may have noticed a growing indolence, an increasing lack of resolution, a cor- responding feebleness of effort, the quick development of fatigue on exertion, a dislike for new surroundings or occupation, a preternatural social timidity, an abnormal inertia, or even outspoken crises of exhaustion; or he may have noticed that his wife has gradually become more forgetful, or that the memory is slower than it formerly was, or that she pays less attention to what is said to her, often appearing distrait and wrapped in revery. On the emotional side, he may have observed a real indifference which is unnatural, an increasing de- pression of spirits sometimes reaching actual melancholy, an exaggerated emo- tional reaction to the ordinary occurrences of life, a desire of being controlled, or an abnormal desire to control others ; an inordinate craving for affection, or for the expression of her own affection. One of the most characteristic disturbances to which these psychasthenic women are subject concerns the so-called sense of reality. In the first clinical conversation with such a patient she may volunteer the statement that things seem unnatural to her, that everything looks hazy, or as though a veil were drawn between her and the external objects. In other patients, while things outside themselves appear natural to them, a feeling of some change in their own bodies is complained of; they realize that they are different from what they formerly were ; they state that they are only half alive, or that they feel as though they were dead or dying, or as though the mind were separate from the body. Examples such as these will enable the physician to recog-nize other similar complaints which belong in the same category. A word as to some of the forms of mental manias presented by the more severe types of psychasthenic patients may here be in place. Some of these patients are tormented by an eternal questioning concerning the nature of things, or concerning anything which they happen to think about; or they 572 FUNCTIONAL NEKVOUS DISORDERS MET WITH BY THE GYNECOLOGIST. have manias of liesitation or deliberation ; in others the need of precision is overwhelming; if any little thing is out of place in their houses, they suffer intensely, and make others suffer for it. Others have troubles in the use of certain numbers, especially the number seven or the number thirteen; still others cannot pass certain objects without touching them ; some are compelled always to pay attention to a whole series of precautions before undertaking anything, and some state that they are continually besieged with premonitions of im- pending occurrences. Among the emotional agitations presented by the psychasthenic pa- tients, various sorts are common: fear of disease, fear of going insane, fear of places, fear of animals, fear of people, fear of anything. It is to be remembered, in psychasthenia especially, that the symptoms tend to be periodic in course. A psychasthenic woman has, in the majority of in- stances, inherited a pathological nervous system, so that anything which lowers the general vitality will tend to give rise to a psychasthenic state, and this state will persist until the general health is again improved enough to raise the level of j)sychasthenic tension sufficiently high to overcome the symptoms. It is not at all uncommon in such patients to find that they have suffered similarly for shorter or longer periods several times before, at intervals of months or years. Some see in this the possible relation of psychasthenic states to the more severe psychoses of well-known circular type. However this may be, the periodicity of psychasthenic manifestations is a fact which should always be kept in mind in connection with diagnosis and prognosis. In addition to the various types of functional disorder which are more or less characteristic, and which have been briefly described above, the gynecologist will often meet with slight nervous manifestations which he may find difficult to classify. Some of his patients, for instance, may complain of a tendency to hurry, to worry, or to be abnormally irritable ; others will ask for relief from a morbid self-consciousness, or an abnormal personal sensitiveness, or an indefinable state of apprehension; the husband, in turn, may confiden- tially appeal to the physician to notice a habit of contradiction in his wife, or a resentful disposition. In such cases, the physician will do well to be on his guard, and seek for other less manifest abnormal neural symptoms ; here a thorough psychic inquiry is important, and the more the gynecologist trains himself in the technic of psychic methods of inquiry, the greater will be his success in the management of such cases. DIAGNOSIS OF THE FUNCTIONAL NEUROSES. Mistakes are perhaps more frequently made in connection with the diag- nosis of the functional neuroses than in any other part of medicine. In thou- sands of women the diagnosis is undoubtedly entirely overlooked, and these patients are transferred from specialist to specialist, who treat their reflexes DIAGNOSIS. ' 573 and sometimes do more liarm than good by concentrating tlie attention of tlie patient npon lier symptoms by making local applications. On the other hand, those who are impressed with the importance of the psychic and nervous symp- toms, unless they are very careful in the exclusion of organic disease, may, through their efforts to treat the general condition, overlook an important local cause which has been responsible for the origin of the nervous symptoms, and which will cause them to persist until it is removed. It is, therefore, desirable that the gynecologist, the general internist, and the neurologist should cooperate in the study of cases which present a combination of gyn- ecological complaints with general nervous manifestations. If, on the one hand, the internist would consult the gynecologist more frequently, in order that he may be sure of the presence or absence of a gynecological lesion; and if, on the other hand, the gynecologist would refer more of his patients to the neurologist and the general internist for a thorough systematic study and report, fewer mistakes would be made. The great difficulty of the internist is to find a gynecologist to whom he can refer patients for ex- amination, who v/ill not be too much impressed with slight local gynecological lesions, and who will be broad-minded enough to understand that not every gynecological disturbance in a patient presenting general nervous symptoms deserves radical local treatment; and the difficulty of the gynecologist, in his turn, is to find a neurologist or an internist whom he can trust to pass judgment upon the relative importance of the general manifestations pre- sented by patients who have applied to the gynecologist for aid. ISTevertheless, it is only through the hearty cooperation of the internist and the various special- ists that the highest success can be obtained in the treatment of patients, and every physician who, by his broadness and soundness of judgment, contributes to the growth of mutual confidence among medical practitioners in this respect will be of great service in the community in which he lives. It will be obvious from what has been said above in regard to the symp- tomatology, that it is the consideration of the woman as a whole which is all important in these cases. A narrow specialization is disastrous, and yet the general examination must avail itself of the most modern refinements of diag- nosis in all the special branches. Every practitioner then should arrange some cooperative organization by means of which he will be able to provide himself with all the data necessary for the exclusion of organic disease, and the deter- mination of the exact degree and significance of existing organic disease in all parts of the body. A careful consideration of the individual symptoms presented, and the grouping of these symptoms, will permit a decision as to the particular form of nervous or mental malady with which one is dealing. The most important clues to the three main types of functional disorder are as follows: For hysteria, the suggestibility; for neurasthenia, the fatigability; and for psychasthenia, the sense of incompleteness and insufficiency, the indecision, the interrogations, the doubts, and the fears. 574 FUNCTIONAL NERVOUS DISOEDEES MET WITH BY THE GYNECOLOGIST. There are certain forms of organic disease that present symptoms which practitioners too often regard as entirely functional in origin. It will be desirable to refer to some of these in detail, bearing in mind, of course, the special needs of the gynecological practitioner. A beginning tabes, though less common in women than in men, may give rise to local symptoms whose significance the physician may underesti- mate. A difficulty in passing urine, a complaint of rectal, vaginal, or vesical pain, especially if it occur in the form of paroxysmal attacks or crises, a marked change in the sexual desire or sense, should make one suspicious of the existence of degeneration of the posterior funiculi of the spinal cord, and should lead one to make at least an examination of the state of the general bodily sensation and the reflexes, especially the pupillary and patellar reac- tions. Should any anomaly be found, the patient should be subjected to a thorough routine neurological study, to determine the presence or absence of a latent locomotor ataxia. More rarely, lesions of the cauda equina or conus medullaris may give rise to genito-urinary or rectal symptoms with which the gynecol- ogist must be familiar. An incontinence of urine or feces, or an anesthesia in the region of the vulva or mons veneris, should put the jDhysician on his guard and make him test the Achilles reflex as well as search for other evi- dences of organic change in the lower part of the spinal cord or spinal canal. An osteo-arthritis of the lower portion of the vertebral col- Timn, or the sacrum, or of the sacro-iliac joints may give rise to symptoms which lead the patient to the gynecologist. Pain in the small of the back, or in the sacrum, or sacro-iliac organs, or down the backs of the thighs and legs may be associated with disturbances of locomotion and with anomalies of position of the spine or pelvis. Here a careful physical exam- ination, associated with an X-ray iphotogTaph of the lower vertebral column and of the sacro-iliac joints should clear up the diagnosis. Another disorder to which attention has recently been drawn, especially by the orthopedic surgeon, Goldthwait, of Boston, is the relaxation of the sacro-iliac joints which so frequently occurs in women, especially at middle life, and in those who are overnourished, or who, for one reason or another, have been compelled to remain in bed for a considerable period of time (repeated pregnancies, gynecological operations, rest cures, etc.). By means of the so-called sacro-iliac test, the attitude assumed, the history of the case, and the exclusion of other diseases, the g-j^Tiecologist should learn to recog- nize these cases and refer them to the orthopedist for mechanical treatment (see Chap. IX). Mucous colitis is a manifestation too often maltreated by the gyne- cologist and by the gastro-enterological practitioner. Sometimes a mucous colitis is undoubtedly due to irritation from a misplaced uterus, or perhaps to reflex irritation, but in the majority of cases it should be looked upon as a nervous disease and treated by measures directed toward the improvement of DiAGisrosis. 575 the general health rather than by local applications. It is not uncommon to see cases treated for months and years by intestinal lavage, oil enemata, astrin- gents, or other local measures with progressive deterioration of the patient. In most of these cases the complete cessation of local treatment is advisable, and the patient, if put to bed, isolated from her friends, overfed, and suitably encouraged, will get well. A word should perhaps be said with regard to the danger of confusing the symptoms of an early multiple sclerosis with hysteria or with other functional neurological manifestations. This is a mistake which the best neu- rologists dread, and where there is the least doubt, a complete routine neuro- logical investigation should be resorted to before drawing the final inferences regarding the diagnosis. Of course, in the outspoken cases with scanning speech, nystagmus, intention tremor, and pallor of the optic papillae, there can be no doubt, but in cases in which the classical symptoms are not in evi- dence, there is great danger of overlooking this serious condition. Hyperthyroidism is a condition often associated with nervous dis- turbances ; it is far more common than is realized by the average family prac- titioner. ISTot infrequently it accompanies diseases of the genito-urinary organs, and when it does so, it may in reality be responsible for the symptoms which the patient presents, rather than the local gynecological lesion which has been recognized, and for the treatment of which the patient has come to the physi- cian. Periuterine inflammation has long been kno^^^l to be frequently asso- ciated with symptoms of hyperthyroidism, and Freund's report on the subject is an admirable statement of the facts. As Albert Kocher has pointed out, too, a diminution of the menstrual flow is very common in patients suffering even from the milder forms of Graves' disease. In a patient presenting obscure nervous symptoms, especially one complaining of apprehension and indefinable anxiety without apparent cause, the physician should make the tests necessary to determine whether or not a hyperthyreosis exists ; if a tachy- cardia (or better pycnocardia) exist continually; if there be a struma, espe- cially if it be vascular in nature, pulsating visibly, and giving a thrill to the palpating finger, and especially if bruits are audible over the point of entrance of the thyroid arteries into the thyroid gland, the diagnosis may be regarded as certain, and the patient should be referred to a surgeon skilled in the tech- nic of partial thyroid extirpation and arterial ligature. Rapid tremor of the fingers in this disease is exceedingly characteristic, and is a test which can be applied in a moment, often pointing the way to the diagnosis. A familiarity with some of the eye-signs in patients with hyperthyroidism is also a great help, and often keeps the physician from overlooking the affection. By ask- ing the patient to follow the finger as it is gradually moved downward, it is possible to make out whether or not the eyeball runs ahead of the eyelid, so that the white sclera shows between the cornea and the upper lid (von Graefe's sign). Or, if the patient is asked to look at the ceiling, and then at the end of her nose, he can determine whether or not there is tendency to inability to 576 I"UNCTION"AL NERVOUS DISORDERS MET WITH BY THE GYNECOLOGIST. iiiaintain the condition of convergence (Mobins's sign). Or, be may notice whether or not the visnal aperture is much widened, and if involuntary wink- ing be lessened or incomplete (von Stcllwag'g sigTi). Of course, when there is exophthalmos it is the most striking and characteristic sign and recognizable even by the laity, but it should not be forgotten that marked protrusion of the. eyeballs is absent in perhaps two-thirds of the cases of hyperthyroidism. PROGNOSIS. The jDatients and the patients' friends are always anxious to know whether or not the condition they come to be treated for is curable, and here long experience in dealing with the functional neuroses is necessary before that matured power of judgment can be gained which will permit the physician to speak to the patient with anything like accuracy as to the outcome which may Le expected. With the modern studies of the psychoneuroses, new hope can be held out to these patients. Many women who formerly would have been doomed to a lifetime of incapacity and non-productiveness can now be restored to very good health and be made useful members of the community. In the treatment of the milder forms of hysteria and psychasthenia, and especially in the treatment of neurasthenia, in all forms except those in which there is a pronounced hereditary taint, the results are very gTatifying. In the gTaver forms of hysteria, in the severer forms of psychasthenia, and in outspoken cases of hypochondriasis, we have to deal with mental disorders which often tax all the resources of the physician, and which sometimes the best-directed efforts known to modern neurology and psychiatry fail to cure. In nearly all cases, however, even the most severe, it is possible to get great relief, provided the psychic factor is clearly recognized, and the proper methods of treatment, especially the resources of psychotherapy, are applied. TREATMENT. For a full discussion of the treatment of these disorders works upon ISTeu- rology. Psychiatry, and Internal ]\Iedicine must be consulted, but the general principles will be briefly referred to here. In the first place it cannot be too strongly emphasized that any routine treatment of these cases is likely to be harmful. In no part of medicine is a definite individualization of the therapy more necessary. Great harm is done in the routine application of the so-called " rest cure," and rather than recommending a systematic routine it would be nearer the truth to state that no two nervous patients need the same treatment. Preceding all treatment there should be established, as has already been said, a very exact anatomical, functional, and etiological diagnosis, and the diagnostic study should have been extended to all parts of the body of the patient. Only by strict adherence to this rule can serious REST CURE. 577 mistakes be avoided, and medicine kept from the pitfalls which beset the work of quacks and irregular healers. Having formed a judgment as to the actual condition which exists, the patient should be frankly told the results of the study and the opinions of the physician as to the nature of her disease, and the rationale of the treatment to be followed. If a cause of the disorder has been made out and found to be still persist- ing, the first indication in treatment is, of course, its removal, and the physi- cian who bears this fact in mind will be very much surprised to find how often by a change of environment, or by intervention in some social relation, the whole clinical picture can be speedily altered. Again, if some organic disease be found to exist, and the physician conscientiously feels convinced that it is responsible for the nervous symptoms, treatment should be directed toward this, either at once or after such preliminary preparation as seems necessary. An incipient tuberculosis, an osteo-arthritis, an eye- muscle anomaly, a displaced uterus, bleeding hemorrhoids, or a gonococcal trigonitis will receive its appropriate attention, and after its indications have been met, the health of the patient can be built up by gen- eral reconstructive measures, and then the nervous symptoms may be expected to disappear. In cases in which the condition is predominantly a psych oneurosis, the gynecologist may undertake the treatment himself if he is interested in this work and has the facilities for caring for psychoneurotic patients; or he may refer the patient to an internist or neurologist who devotes his attention especially to such treatment. The best means of combating the psychone ureses known to medical men at present, consist in rest, isolation, the improvement of nutri- tion, and psychotherapy. In addition to these main therapeutic instru- ments, certain adjuvant measures are more or less helpful, such as the use of electricity, drugs, etc., especially in combating some of the symptoms. Rest may be prescribed in various ways, though usually physicians apply .the well-known " rest cure " of Weir Mitchell. When this treatment is adopted, it is common to keep the patient on her back in bed completely at rest, phys- ically and mentally, for a period of from four to six weeks, after which she is gradually permitted to return to various physical and mental activities. A prolonged rest of this sort is especially helpful in cases of neurasthenia and in psychasthenic states, associated with emaciation. The most bril- liant results are obtained in the patients who have suffered from nervous dis- turbances of digestion and who have reduced their diet gradually until they have gotten into a state in which they are eating far less than is required to nourish them. Many of these patients have had the erroneous idea that they should exercise more as their emaciation progressed; some one has told them to keep up strenuous physical exercise, and not a few of them who apply for treatment will be found to be following daily some rigidly prescribed system 38 578 FUXCTIOXAL IVEEVOUS DISOEDEES MET WITH BY THE GYNECOLOGIST. of gymnastics, despite the miserable state of their nutrition. It is very impor- tant to remember, however, that not every nervous patient needs rest in bed. Some patients do badly in bed, and mnch experience and medical tact is neces- sary to decide when this treatment should be tried and when it should be avoided. Some of the severer jjsychasthenic cases especially do badly in bed, and though in the treatment of the obese nervous patient a short stay in bed may be desirable at the beginning of the treatment, any prolonged sojourn in the recumbent position is harmful for her. In all the severer forms of the psychonenroses (but of course not in the milder forms of the disease) isolation of the patient is abso- lutely necessary if the best results are to be obtained. This is one of the most important features of the cure as it was carried out by Weir ]\Iitchell, and it is a feature which unfortunately has been honored more in the breach than in the observance by those who have attempted to imitate Mitchell in his management of nervous patients. It is not always easy to get the consent of patients to submit themselves to complete isolation from family and friends. Even when the patient and her friends consent to isolation, too frequently the physician and the nurse do not maintain her in the necessary degree of separation. For instance, many medical men have made the error of attempting to isolate neiwous women in bedrooms in their own houses. This is almost invariably unsuccessful, and it is, as a rule, better not to make any pretence of isolation at all, than to try to carry it out in this ineffectual way. The patient and her friends mean to observe isolation when they promise to do so in the patient's own house, but they almost always find it impossible to adhere to the rules. It is, therefore, very desirable when isolation is prac- tised, to remove the patient to an institution (sanitarium, hospital, or private house specially arranged for the purpose) in which she will see no one except her j)hysician and nurses, and in which she will not come in contact even with servants who have attended to her before. ' In arranging for the isolation it is necessary to tell the patient that during her stay she will not be permitted to have any communication whatever, either verbal or written, with her family or friends, except by special permission. It should be said to her, however, that in case anything happens at home which she really should know about, she will be told ; hearing nothing is to mean to her that everything is going well, and that there is no reason for her to worry about home conditions. When the importance of isolation is fully recognized by the physician and all these details are explained and impressed upon the patient, she and her friends will usually consent to it, and a g-reat step forward has been taken toward getting the patient well. Here again individualization is necessary, and the physician will after a while acquire the experience which will permit him to decide which patient ought to be isolated and which should not be. During the period of complete rest and isolation, it is important, in order, in the first place, that a strict regime may be closely followed, and in the second place that the patient may not be too lonesome, that she shall have DIET. 579 the care of a special nnrsc who devotes herself entirely to her. The expense of this is, of course, prohibitive in many cases, and then one has to make compromises corresponding to the particular conditions. Many cases do very well with the ordinary ward nurses in hospitals and sanitaria. The diet of the patient should be, of course, carefully looked after; a very large proportion of nervous people complain of disturbances of digestion, and a great many prejudices have to be overcome at the begin- ning of the treatment. In the majority of instances this is best accomplished by taking a firm stand with regard to the administration of milk in small quantities every two hours during the first few days of the treatment. Many patients will assert that it is absolutely impossible for them to take milk, and the physician in these cases usually does well to make a firm statement to the patient that in the early stage of the treatment she will receive nothing but milk. She should be assured at the same time that given in the way in which it will be ordered for her, she will suffer little or no inconvenience from it and be able to digest it satisfactorily. It is well to tell her that in case she seems to suffer from the first feeding or two, she is to pay no attention to the symptoms, but to take the ration of milk when it comes with the same conscientiousness as she would a dose of medicine. Even when the patient vomits the first feeding or so, I have always found that in functional cases, by persisting with a small quantity every two hours, all difficulty is soon over- come. As to the exact times of giving the milk, I have found the routine administration recommended by Dubois in his book entitled " The Psychical Treatment of ISTervous Disorders," to yield very satisfactory results. In the wards of the Johns Hopkins Hospital the food-administration at the begin- ning of treatment is as follows : First day. . Second day Third day . Fourth day Fifth day . . Sixth day. . Hours of Day. 7 a.m. 9 a.m. 11a.m. 1p.m. 3 p.m. 5 p.m. 7 p.m. 9 p.m 3 ^ 6 9 12 12 3 ^ 6 6 6 6 3 ^ 6 9 3 6^ 3 ^ 6 9 9 9 3 6 6 6 6 In twenty-four Hours. '24 ounces. 36 ounces. 48 ounces. 57 ounces. 60 ounces. 60 ounces. On the sixth day add bread, butter, sweets or honey at the first meal, with the twelve ounces of milk. On the seventh day the regimen changes abruptly, and without tran- sition the patient will take: Breakfast. — Twelve ounces of milk, bread, butter, honey, or preserves. At ten o'clock in the morning, eight ounces of milk. Lunch (or dinner). — A full meal without permitting any choice. This should be varied and copious, but without wine. 580 FUXCTIOXAL XEKVOUS DTSOEDEES MET WITH BY THE GTIS'ECOLOGIST. At four o'clock take eight ounces of milk. Dinner (or supper). — Should be equally copious. At nine o'clock eight ounces of milk should be taken. As soon as solid food is given the patient is advised to masticate thoroughly, adopting this feature of the so-called Fletcher system : " When eating chew very thoroughly everything that is taken into the mouth (except water, which has no taste) until it is not only liquefied and made neutral or alkaline by saliva, but until the reduced substance all settles back in the folds at the back of the mouth and excites the swallowing impulse into a strong inclination to swallow ; then swallow what has collected and has excited the impulse, and continue to chew at the remainder, liquid though it be, until the last morsel disappears in response to the swallowing impulse, l^ever forcibly swallow anything that the instincts connected with the mouth show any disposition to reject. It is safer to get rid of it beforehand than to risk putting it into the stomach." j!*^o one measure has been more successful in my hands than the adoption of this dietetic regime, and nurses and house ofiicers who have followed the cases in the medical wards are one and all enthusiastic about it. While one need not fear the administration of large quantities of protein to patients who are nervously below par, it is perhaps well to give this protein largely in the form of milk and eggs, rather than in the form of meat ; some meat should be given, but certainly not more than one or two portions per day. Whether or not it is the proteins of the meat themselves or the extractives as- sociated with the proteins which are harmful to some people, we do not yet know. Most nervous patients appear to do better when the meat is not pushed too much. Where constipation exists, the diet should contain liberal quantities of stewed fruits and vegetables (especially carrots and spinach), and the patient should be advised to eat half a pound of Graham bread per day. This dietary, together with a teaspoonful of lime juice in a glass of Avater at 6.30 a.m., will often overcome the difficulty of constipation. Whether she has the inclination thereto or not, each patient should try to have a movement exactly one hour after the beginning of her breakfast each morning; a regailar habit is in this way soon formed. Until the habit is established, the patient is permitted an enema each third day, in case no natural movement occurs. In a few instances one is obliged to give cascara or some other mild laxative for a time, but the physician who is conscientious in the treatment of constipation without drugs will succeed more often than he who resorts to drugs in every case. When the patient is resting in bed, it is well to keep her flat on her back with only one pillow, for several weeks. It is customary to give a cold sponge at 55° to 60° r., followed by an alcohol rub each morning; some hydrothera- peutic measure in the evening is often of advantage. Where there is insomnia especially, the cold pack will frequently give the patient a good night's rest. It is rarely necessary to use hypnotics, and I am convinced that one of the CONVALESCENCE. 581 commonest mistakes made in the treatment of nervous patients is the too fre- quent resort to trional, sulphonal, veronal, and other sleep-inducing drugs ; a single dose or two at the beginning of the treatment may perhaps be permitted, but it is interesting to find how often insomnia can be gotten rid of without the use of any drug whatever. In my experience, the majority of cases of insomnia yield without any use of pharmacotherapy. A cold pack at night, while useful in many cases of insomnia and especially in phlegmatic or apathetic patients, may be actually harmful in a very irritable or hyperesthetic woman. In its place a warm pack or a prolonged warm bath may yield better results. During the period of complete rest, the patient does not sit up at all except on going to stool, or when propped up in bed with pillows, for her meals. Where it is possible to run the patient's bed out-of-doors in the daytime, it is very desirable to do so; even in the coldest winter weather these nervous patients do well out-of-doors. They must, of course, be kept warm ; if necessary with the use of Jaeger underwear, blankets underneath as well as above the patient, hot-water bottles, and a woolen cap for the head. Patients may sleep out-of-doors at night, or if they sleep in bedrooms, they should have all the windows of their room widely open. At the end of the period of rest, usually at the end of about five weeks, the patient begins to sit up ; during the first day she is given a back rest for one hour, and this is increased to tw^o hours on the next day. On the third and fourth day she is permitted to sit in a wheel-chair for an hour, and the time is gradually increased during the next few days. On the eighth day a walk of ten minutes is allowed, and if all goes well, the walk is increased until at the end of a fortnight, or even less, the patient may walk five miles a day with- out special fatigue. If much weight has been put on, care must be taken that the arches of the feet do not yield to strain at this time, and if pain is com- plained of on walking, suitable orthopedic shoes, or even temporary supporting plates for the feet, may be required. When the patient begins to be up and about she is allowed a quick morning plunge in water at the tap temperature, and this replaces the cold sponge of the resting period. Setting-up exercises and calisthenics are often advantageous during the after-cure, and mild forms of occupation, sewing, knitting, crochet work, and the like, are helpful. Early in the cure, even when the patient is at complete physical rest, the nurse is instructed to read aloud for periods of increasing length during the day, and later on, the patient may be permitted to read herself under super- vision as to time and subject, being thus gradually led back to normal life and intercourse. Special dietetic measures are necessary where there is a tendency to obesity, to diabetes, or to gout, the details of which cannot be consid- ered here. In patients suffering from hyperthyroidism, the protein portion of the diet should consist almost wholly of milk, inasmuch as meat seems to stimu- late the activity of the thyroid gland. Massage is an important aid in the administration of the rest cure, espe- 582 FUNCTIONAL NERVOTJS DISOKDEES MET WITH BY THE GYNECOLOGIST. ciallj in that it makes tlie patient more comfortable in bed. There is a mistaken idea abroad that it takes the place of exercise by influencing metabolism in a similar way. Careful metabolic studies prove that there is no metabolic effect from massage comparable with that which is exerted by physical exercise. It seems probable, therefore, that massage in nervous patients exerts its good effect through stimulation of the sensory nerves of the skin and muscles, through facilitation of the lymph flow, and, in part at least, through its psychic effect. More important, however, than the rest, the diet, and the massage in the treatment of the psychoneuroses is the use of the patient's mind in bringing about the cure. Psychotherapy and re-education are the sheet anchors of the therapeutist in the functional neuroses. The exact mode of application of the psychic measures in the treatment of nervous disease will vary with each practitioner, and everyone does best to develop the methods most suitable to his own personality and his own needs. Certain general directions, however, may be helpful, and certainly during the last fifty years great progress has been made in the application of psychic methods in re-educating nervous patients back to health. At the outset of the treatment a full explanation of the condition of the patient to herself is a great help. It is unwise to deceive her. If an organic lesion exists, it should not be denied, although it may be necessary to refrain from laying emphasis upon it. Any direct question that the patient may ask should be frankly an- swered, and she should be told, as far as the physician is able to tell her, the meaning of any lesion which exists and the relation of the symptoms to it. If no organic lesion can be found on the application of careful tests, it is a great comfort to the patient to be told unhesitatingly by the physician the negative results of the study. Her mind is relieved, and when she is assured by the doctor that the sj-mptoms are in his opinion " nervous " in origin, and curable, her hope is excited and she makes a start toward getting well. Much encouragement is necessary to the depressed patient, especially where a fear of insanity or of incurable disease exists, and the physician who under- takes properly to care for these patients must be willing to spend a good deal of time with them. A visit of half a minute or a minute is totally insufiicient ; they often require a long explanation and a full statement, especially at the outset. Too much time, however, should not be spent with the patient, for then the physician's assurances will lose in force. Brief, clear, and emphatic pronouncements are most helpful; argumentation with a nervous patient should never be indulged in, for, in my experience, it only does harm to argue with irritable nerves. The method of avowal, that is the open declaration by the patient to the physician of any painful or secret experience which she may believe to be as- sociated with the origin of her symptoms, should be encouraged. The delicacy of such conversations should, however, always be borne in mind, and the physi- cian must win the confidence of liis patient before lie can expect full frankness i-tegarding these experiences. Any unnecessary inquisitiveness into the patient's PSYCHOTHERAPY. 583 past experiences should always be avoided, and when an avowal is necessary and important, the physician should see to it that it is made without injury to the self-respect of the patient. The physician should not shrink from the trouble of listening to the unburdening of soul; a knowledge of the mental content of the patient will often give him clues for the exertion of salutary psychic influences, and the " confession " is nearly always followed by relief to the patient. In this connection the so-called " psycho-analysis," described by Freud, of Vienna, is very interesting. By this method, an attempt is made to discover by particular association tests the existence of complexes of ideas to which strong feelings are attached. Jung, of Zurich, has of late been working out a method which he asserts is practical for clinical analysis, and Jung's method, it is said, yields results much more quickly than the slower process used by Freud. By the use of suitable stimulus-words and watching the reactions, it seems possible to tell when a definite, painful, psychic complex, unbearable in the patient's consciousness and accordingly suppressed, has been touched. By laying this complex bare and disintegrating it, it is said to be possible to help severe forms of psychoneuroscs which have been entirely irresponsive to other therapeutic means ; especially in the severer forms of hysteria, successes, it is said, have been scored by this method. The two most important measures in psychotherapy are, however, those known as persuasion and suggestion. In the use of persuasion the physician makes an appeal to the higher psychic functions; the mind is won over by the presentation of suitable reasons, and not by the exertion of authority, force, or fear. In suggestion, on the contrary, an idea is introduced into the brain of the individual without his control ; the higher functions are not utilized, or if affected, they are inhibited ; the influ- ence is exerted through the subconscious mind. Even when an effort is made to restrict psychotherapeutic efforts to persua- sion, just now the measure more popular among medical men, it is difficult to say how much of the effect is really due to persuasion, and how much of it to suggestion; at any rate, the physician usually feels more comfortable himself if he endeavors to produce his psychotherapeutic effects through the use of the patient's reason, than by resorting to the more occult influence through the subrational. The establishment of medical obedience from the very be- ginning of the treatment is essential. The cooperation of the patient must be gained, and she must give an imequivocal consent to do exactly what she is told to do, at least during the first period when she is under the physi- cian's care. She sliould be told that she will not be asked to do anything un- reasonable, or to follow any instructions prejudicial to her welfare, but that slie must obey, even wlien the reason of some of the orders may not be clear to her, or seem to her trivial and arbitrary. It is wise to leave nothing to the decision of the patient at first, and it is especially important that neither the 584 FUNCTIONAL NERVOUS DISORDERS MET WITH BY THE GYNECOLOGIST. doctor nor the nurse yield to whimsical requests, or alter a routine inaugurated, because the patient offers objection to it. Exhortation and all forms of moral treatment are better avoided at the beginning, especially in the severer cases. Later on the patient will, in all probability, wake up to an understanding of her condition herself, or she may be gradually instructed regarding it. After the physical side of the treatment has been fully cared for, it will become neces- sary by steady training to improve the attention of the patient, and to educate her emotions and her will. Gradually, as a result of this training, she may learn completely to control herself, and the medical absolutism may be replaced by self-direction. As Dubois points out, it is well to hold before her the ideal of " mistress of herself," as something at which she must constantly aim. The physician should not underestimate the importance of a proper kind of nurse to aid him in the treatment of his nervous patients. ISTot every woman graduated from a training school is suited to this kind of work. It is necessary that the special nurse have a strong character, and good control of her own emotions ; moreover, it is desirable that she have an education equal to or better than that of the patient whom she cares for. If she also possess the social qualities which will endear her to her patient, it is a distinct advantage. Above all she must know how to make herself respected and esteemed, and she should be given adequate authority, in order that her directions shall be fol- lowed, although it is an essential that in all her relations to the patient she must be good-natured and kind. The physician, on his visits to the patient, must show by his behavior to the nurse that he regards her as his representative in his absence, that he has confidence in her, and that he expects the patient to consent to everything that is done for her without objection. It is just as well, however, for the nurse to let the patient feel that everything that is done for her is the result of specific instructions given by the physician, for patients will resent discipline which they have reason to believe has originated in the nurse's rather than in the doctor's mind. During convalescence the physician must avail himself of various methods of psychic stimulation and re- education, and here his knovdedge of the world and of the men and women in it, their hopes, their desires, and their failings, will be most helpful to him. He must consider how to keep the attention of his patient focussed upon her cure, and how to prevent her from giving herself unhealthy suggestions. In other words he must teach her so to train her attention that the action of the mind becomes healthy, and that it cease to dwell upon the abnormal. He must excite in his patient the desire to get well, and must convince her as the treat- ment progTesses that she is in reality getting well. He must teach her the importance of overcoming little difiiculties, assuring her that as she does one thing after another to which she may be disinclined, she will acquire an ever- increasing power of self-control, and that sooner or later her self-mastery will be regained. On the emotional side, a prolonged training is often necessary in order to get rid of abnormal fears, anxiety, and apprehension. The patient should PSYCHOTHEEAPT. 585 be taught to cultivate the useful and invigorating emotions; she should be taught the dangers of excessive emotion of any kind, and the great harm of indulging in such passions as anger, hate, and fear. The positive rather than the negative side should be followed. Faith, hope, and love should be encouraged, and then worry, fear, and despair will disappear of themselves. Finally, work, physical and mental, must be undertaken, for in a projDerly directed occupation-therapy lies the greatest hope for mak- ing the cure permanent. These nervous women have to be educated gradually how to take up their work, and the physician's ingenuity will be greatly taxed in order to decide as to the particular physical and mental occupations suited to the individual cases coming under his care ; one patient will be benefited by gardening, another by some active mental pursuit. In all cases the program of the day should be carefully arranged, and the patient should be encouraged to follow it closely. The work should be chosen in accordance with the ability and previous training and occupation of the patient. It should be interesting to her and should be such as to be capable of giving expression to her better self. This is scarcely the place to deal with the use of suggestion, and es- pecially of hypnotic suggestion. That this method of therapy is ad- vantageous in some cases there can be no doubt, but experience has taught that the application of hypnotism is much more limited than those who hailed it so enthusiastically at first were inclined to believe. It is possible, however, that fear of the appearance of quackery and charlatanism has prevented physicians from making use of this measure even to the extent to which it may very properly be applied. CHAPTEE XXIV. APPENDICITIS AND DISEASES OF THE PELVIC ORGANS. Conditions under which appendicitis is associated with disease of the pelvic organs, p. 586. Ap- pendicitis and coexisting pelvic disease: Inflammatory disease, p. 587; tuberculosis, p. 588 tumors, p. 588. Independent affections of the appendix and the pelvic organs, p. 589 Differential diagnosis between appendicitis and pelvic disease: Inflammatory disease, p. 589 ovarian cyst, p. 590; ruptured tubal pregnancy, p. 591. Appendicitis and dysmenorrhea, p. 592. Appendicitis in the child, p. 595. CONDITIONS OF ASSOCIATION BETWEEN APPENDICITIS AND PELVIC DISEASES. The earliest allusion to a relation between inflammation of the appendix and diseases of the reproductive organs was made, I believe, by H. C. Coe (Neio York Polyclinic, 1894, vol. 4, p. 73), and almost simultaneously by J. T. Binkley (Amer. Jour. Obst, 1894, vol. 29, p. 474). Both of these ob- servers call attention to the fact that appendicitis may be associated with disease of the uterine adnexa, and that the primary infection may be seated either in the appendix or in the tubes and ovaries. Contributions to the subject have appeared repeatedly since then, and it is now a well-recognized fact that disease of the pelvic organs in women may be associated with disease of the appendix in any one of the three following ways : First, the disease of the appendix is primary and that of the pelvic organs secondary. Second, the disease of the pelvic or- gans is primary and that of the appendix secondary. Third, the disease of the pelvic organs and the disease of the appendix coexist, independently of each other. In my clinic at the Johns Hopkins Hospital I had occasion, during the ten years immediately preceding the year 1904, to remove the appendix in two hundred and forty cases, the majority of which were combined gynecological and appendical affections. Of these two hundred and forty cases, there were ninety of acute appendicitis uncomplicated with any gynecological affection ; in sixteen others the appendix was removed purely as a prophylactic measure ; while in the remaining one hundred and thirty -four cases a gynecological affection of some kind was associated with disease of the appendix. These statistics agree very fairly with those of Hermes {DeuUcli. Zeitsclir. f. CJiir., 1903, vol. 68, p. 191) and of Peterson (Trans. Amsr. Gyn. Soc, 1904, vol. 29, p. 350). Hermes performed seventy-fivo la]3arotomies for the relief of pelvic disease and found that in forty cases, or a little over fifty-three per cent, the 586 APPENDICITIS AND ASSOCIATED PELVIC DISEASE. 587 appendix was affected; while Peterson, in two hundred operations of the same kind, found that the appendix was diseased in nearly fifty per cent. APPENDICITIS AND ASSOCIATED PELVIC DISEASE. In some cases where it is definitely known that a gynecological affection exists, it is a matter of importance to decide whether or not there is a com- plicating appendicitis. The fact that the appendix is frequently involved in pelvic affections is now too well known for such accidents to occur as that re- ported some years ago by Tait and Wiggin, in which, during the course of an operation upon the pelvic organs, the appendix (being involved in dense ad- hesions) was removed without the knowledge of the operator, and the fact dis- covered only on the autopsy table. It must always be remembered that when independent affections, either acute or chronic, coexist, one may be masked by the predominating symptoms of the other. This fact is of special importance in the case of an acute pelvic inflammation. Appendicitis should be suspected when there is extreme severity of both abdominal and constitutional symptoms, with paroxysmal pain localized at or near McBurney's point. Pelvic Inflammatory Disease. — Pelvic inflammation is by far the most frequent disease of the pelvic organs complicating appendicitis. Out of the hundred and thirty-four cases in my clinic in which appendicitis was found to be associated with pelvic disease of one kind or another, there were sixty-four in which the pelvic affection was inflammatory. In the majority of cases in which inflammation of the pelvic organs and disease of the appendix are associated, the primary infection is in the pelvis. The associated diseased conditions are not always on the right side, for in the case of an unusually long appendix and an abnormally movable cecum, it is quite possible for the appendix to become attached to the left tube or ovary. In forty-four cases, cited by Peterson, the disease was confined to the right adnexa in eight instances, to the left adnexa in six, while in thirty cases both sides were affected. Even when the appendix does not occupy the pelvic position it is possible for it to become infected under certain conditions, as in puerperal infec- tions or in gonorrheal salpingitis, if the enlarged tube happens to be situated a little higher up than usual. Generally the appendix is attached to the tubo-ovarian mass by more or less firm adhesions, the appendix itself show- ing practically no gross changes ; but careful examination of such appendices reveals that comparatively few are perfectly healthy, a mild catarrhal inflam- mation being the affection most often found. More severe lesions are not un- common, an unsuspected diffuse inflammation being found in certain cases at operation; moreover, there may be various residual conditions, namely, strictures, obliteration, or cystic distention. The causal relation of the pelvic disease to the inflammation of the appendix may be direct or indirect. In the first case, the 5gg APPEXDICITIS AXD DISEASES OF THE PELVIC OEGAXS. appendix is involved in the pelvic exudate from the beginning; the adhesions thus formed become organized, and blood and lymph vessels are established between the appendix and the tube, through which the infection is readily- transmitted. It seems probable, however, that the pelvic disease usually limits the movements of the appendix by fixing it in adhesions, and by producing stasis, acts as a predisposing factor in the development of appendicitis. The history of the onset and progress of the illness is the most important point in determining its original focus. It is frequently possible to obtain a clear his- tory of puerperal or gonorrheal infection; but in these cases, clinical evidence of the appendical complications, as a rule, is conspicuously absent. Tuberculosis of the Pelvic Organs. — This condition not infrequently involves the appendix in the peritoneal adhesions which usually accompany it, and in a numlier of cases the walls of the appendix are invaded by the tul^ercular process, even where there is no evidence of other extension of the disease. Out of seven cases which I examined, where the appendix was adherent to the tubercular tulje. it was slightly infiltrated with tubercles in four. Tumors of the Tterus and Ovaries.- — Adhesions between the appendix and cysts of the right ovary are frequently observed, and occasionally the appendix is attached to a left ovarian cyst. Out of about three hundred operations for cystoma in the Jolms Hopkins Hospital, the appendix was found adherent to tumors of the right side in sixteen cases, and to those of the left in three. In some instances the appendix is merely secondarily involved in the general adhesions which so frequently surround pelvic tumors, and are the residue of an old widespread peritoneal reaction. Dermoids and cysts with torsion of the pedicle are particularly apt to give rise to general adhesions, and it is in such cases that the appendix is most often involved. In our series of cases, the cyst had become twisted upon its pedicle in one-fourth, and in these the appendical adhesions were unusually dense and extensive. In some in- stances the appendix is adherent to the otherwise smooth surface of the cyst, or to the broad ligament. In some cases the tip only is adherent ; in others the entire appendix, including its mesentery, is plastered to the surface of the tumor. The organ itself may be practically normal, but in the majority of instances its walls are thickened and rigid, while kinks, strictures, and other results of an inflammatory process are commonly present. Parovarian cysts also are frequently complicated by appendical ad- hesions or by acute or chronic appendicitis. In malignant ovarian growths the appendix may become invaded secondarily by the new growth. Uterine myomata are less frequently complicated by disease of the appendix than ovarian cysts, and as in ovarian tumors the appendix usually presents evidence of chronic inflammatory changes. Extra-uterine pregnancy is complicated with a]ipendicitis in a considerable number of instances. Person- ally, I recall seven cases, forming al)Out ten per cent of the cases of extra-uterine pregnancy in my clinic, in which the appendix was adlierent to the sac, or was acutelv inflamed. APPENDICITIS AND COEXISTING PELVIC DISEASE. 589 INDEPENDENT AFFECTIONS OF THE APPENDIX AND THE PELVIC ORGANS. The possibility of the coexistence of pelvic and appendical disease must always be borne in mind, especially in cases which are being treated for pelvic disease. Quite often, after removal of ovarian or uterine tumors not compli- cated by adhesions, investigation of the cecal region will reveal the presence of independent appendical disease. Thus, in a case of myoma under my own care, the appendix was found completely filled and distended by two large con- cretions; in another case of myoma, the appendix was obliterated and en- veloped in adhesions. In cases of extra-uterine pregnancy the existence of an independent appendicitis has been frequently observed. T. II. Chase {Halm. Month., 1903, vol. 38, p. 520) cites an interesting case of a young woman who was brought into the hospital with a history of trauma over the right lower quadrant of the abdomen, produced by falling face downwards in the street upon a pile of cobble-stones. On her entrance, three bruises were visible over the right iliac fossa. After keeping her under observation for a few days the abdomen was opened, and a chronic salpingitis was found on the right side, with an acutely inflamed appendix, but no sigTis of communication between the two. The treatment of appendicitis and coexisting pelvic disease, whether in- dependent of, or related to each other, belongs in almost all cases to the surgeon, and such cases should be referred to him as soon as they are recognized. DIFFERENTIAL DIAGNOSIS BETWEEN APPENDICITIS AND PELVIC DISEASE. The differential diagnosis between appendicitis and disease of the pelvic organs is of much more importance to the general practitioner than the diag- nosis of coexisting disease, whether independent or not, because in the early stages of certain affections, early salpingitis for example, palliative treatment may be all that is needed; whereas, in acute appendicitis, immediate operation is imperative. Inflammatory Disease of the ITterine Adnexa. — The affection most often con- founded with appendicitis in women is inflammation of the ovaries and tubes. Each condition presents characteristic differences, however, and careful attention to these and to the history of the case in its early stages ought to prevent mistakes. Abdominal pain, associated with nausea and vomit- ing, may appear as suddenly in one affection as in the other, and there may be pain on local pressure over the right lower abdomen in both, but in pelvic disease the local pain and tenderness are usually situated more deeply in the pelvis and the right inguinal region, intense suffering being elicited on deep pal- pation over Poupart's ligament. Vaginal examination may show ten- derness in both cases, but if it is on both sides, or is confined to the left 590 APPENDICITIS AND DISEASES OF THE PELVIC ORGANS. side, the trouble is probably perimetritis and not appendicitis. There are, how- ever, cases in which confusion may arise because the appendix occupies the pelvic position, and therefore the pain and tenderness are situated deep down in the pelvis ; moreover, if the organ is of unusual length, it may extend to the left even as far as the ojDposite side. In such cases reliance must be placed on the earlier symptoms as described in the history. In the onset of appendicitis the pain is apt to be paroxysmal in character, while in pelvic inflammation it is more steady and less intense. Pelvic inflammation is usuall}' accompanied in the early stages by a vaginal discharge, sometimes of a yellowish character, and often associated with burning on urination ; these symptoms may exist several days before the abdominal pain appears. With appendicitis there is often a history of previous attacks of pain or digestive disturbance. It is not usual to find a tumor in the early stages of either affection, but later on a more or less well-defined resistance, situated posterior or lateral to the uterus, is generally present in both, and it may signify either pelvic inflammation or pelvic ap- pendicitis. In appendicitis, however, the resistance is usually situated higher up and extends from the posterior border of the right broad ligament to the iliac fossa; whereas in pelvic inflammatory disease the tumor is deep down in the pelvis, and it is often possible to determine the enlarged tube by bi- manual, vaginal, and rectal palpation. R. T. Morris considers that abdom- inal rigidity is the principal diagTiostic sign between acute appendicitis and salpingitis. If it is absent, appendicitis may be excluded with tolerable cer- tainty. When an acute pelvic inflammation is accompanied by a spreading or general peritonitis it cannot be distinguished from appendicitis, unless there is an unusually clear and reliable history. The development of a pelvic infection in a young girl, or an unmarried woman of good character, should always excite a suspicion of primary appendi- citis, even when bimanual examination shows definite disease of the adnexa on both sides, as in many cases it will be found on operation that the tubo-ovarian disease is due to a secondary infection of the tube. As MacLaren observes, " a young woman's reputation may be smirched by the discovery of pus tubes, where operation demonstrates that the tubal suppuration was due entirely to inflammation of the appendix." Ovarian Cyst. — Confusion in the diagnosis between appendicitis and ovarian cyst with torsion of the pedicle is very common. N^iot (These de Paris, 1901) cites eleven instances of dermoid cysts with twisted pedicle, mistaken for appendicitis ; and in two out of five cases of torsion observed by Fowler, the patient had been sent to the hospital with a diagnosis of appendicitis. Acute torsion is most apt to occur in cysts of medium size, which have not previously produced any swelling, the subjective symptoms being absent or very insig- nificant, and this makes the diagnosis difficult. The sudden onset of severe pain, often accompanied by nausea and vomiting, may closely simulate acute appendicitis. In the early stages the character of the pain is diffuse and con- tinuous, while in acute appendicitis, before localization in the right iliac fossa, DIFFERENTIAL DIAGNOSIS BETWEEN APPENDICITIS AND PELVIC DISEASE. 591 it is colicky; at a later stage, after peritonitis lias supervened, the pain is very iiiucli the same in both conditions. Sometimes it is possible to distinguish at the outset a well-rounded, elastic ovarian tumor, while in appendicitis a tumor is rarely observed in the early stages, and, if it is, it has not the sharp outline of the cyst. Fluctuation is sometimes suggested as a guide in the diagnosis of some kinds of dermoids and multilocular cysts, but it is an indefi- nite sign, and not to be depended upon. Palpation, which may be serviceable in outlining the tumor, is unsatisfactory in many cases on account of the rigidity of the abdominal walls. In the case of a cyst, the tumor is sometimes readily palpable after the early acute reaction subsides; whereas, in appendicitis not complicated with diffuse peritonitis, the abdomen, with the exception of the region of the appendix, becomes soft and natural. When peritonitis complicates the situation, a differential diagnosis is impossible, but in general it may be noted that the peritonitis accompanying ovarian cysts is of a milder type, and is not associated with the severe constitutional symptoms observed in peritonitis originating from appendicitis ; moreover, the abdominal tenderness is usually pronounced. Examination by the vagina and the rectum may afford valuable information regarding the nature of the trouble, and it may be possible in this way not only to outline the cyst, but also to recognize the twisted pedicle, which is felt extending from the side of the uterus up to the abdominal mass. Several instances have been reported of a mistake in diagnosis be- tween appendicitis and ovarian disease in the child. In one of these, reported by Porter (1892), the little girl, who was eleven years old, had shown no signs of approaching puberty. She had had four attacks of pain in the right iliac fossa, one of which disappeared suddenly under the influence of a warm rectal enema, and the others spontaneously. When she came under observation during the fourth attack, there was a slight elevation of tempera- ture with pain and exquisite tenderness in the right iliac fossa, and a sensitive tumor just above Poupart's ligament. The tenderness and the tumor both seemed to be rather too far down for the appendix, and a diagnosis of appendi- citis was made with som.e hesitation, disease of the uterine adnexa having been considered and rejected. Operation showed a right ovarian cyst the size of a small egg, its pedicle twisted by three complete turns and showing signs of beginning gangrene. Ruptured Tubal Pregnancy. — A diagnosis between appendicitis and ruptured tubal pregnancy is seldom difficult, if an accurate history of the events leading to the attack can be obtained, as well as a clear description of its onset. The history of irregular menstruation, especially the statement that a period has been delayed for a week or more with a subsequent slight irregular flow, is strongly suggestive of a tubal pregnancy. The onset of an attack with sudden agonizing pain followed almost immediately by fainting and marked pallor, is pathognomonic. Chills, vomiting, and involuntary evacuation of the bowels may occur at the outset of either a ruptured tubal pregnancy or an acute per- forative appendicitis. Tenderness and muscle spasm over the right iliac fossa 592 APPENDICITIS AND DISEASES OF THE PELVIC OEGANS. ma J be observed in a right tubal preguancy ; usually, liowever, the local signs are situated deeper in the pelvis; in bimanual examination the enlarged tube can generally be palpated. Finally, it may be said that the most important point in arriving at a correct diagnosis is the recognition of the fact that con- fusion may arise. APPENDICITIS AND DYSMENORRHEA. It is now generally acknowledged that chronic inflammation of the appendix is often associated with painful menstruation. Ochsner, writing on appendicitis as a cause of inflammatory disease of the uterine adnexa {Jour. Amer. Med. Assoc, 1899, vol 33, p. 192), makes a passing allusion to dysmenorrheas arising from the association of appendicitis with disease of the ovaries or tubes on the right side, and remarks that whenever the pain in dysmenorrhea is entirely on the right side, especially if it is situated high up, it is well to suspect that the disturbance of the appendix is complicated with disturbance of the ovaries. In the next year A. MacLaren published an interesting paper on the rela- tionship between dysmenorrhea and chronic appendicitis, in which he emphasizes the fact that in chronic appendicitis, menstruation is often pain- ful without any disease of the uterus or adnexa (Amer. Gyn. and Obst. Jour., 1900, vol. 17, p. 14). He calls attention, most appropriately, to a class of cases familiar to every physician of experience, in which a young girl, who has men- struated for several years without any disturbance or suffering whatever, sud- denly takes cold or has some slight inflammatory symptoms, after which she begins to suffer with the menstrual period, the pain increasing each time until her nervous system is more or less shattered. These cases are usually consid- ered to be neurasthenic, and there is no doubt that many of them, possibly the majority of them, are so ; but, in MacLaren's opinion, there is a certain proportion in which the menstrual pain is really due to a chronic inflanunation of the appendix, which undergoes a slight exacerbation at each jDeriod, on ac- count of the congestion normally accompanying every menstruation. In some cases the chronic appendicitis exists before menstruation begins, and then dysmenorrhea is present all through menstrual life, until the appendicitis is discovered and relieved. Other contributions to this subject have been made from time to time, but the total amount of information concerning it is small. There is an excellent discussion of the subject, however, by Soupault and Jouaust in a paper called " Appendicite larvee et des troubles menstruels " (Bull, et mem. de la Soc. med. des hop. de Paris, 1903, vol. 20, p. 1307). The writers begin by commenting on the fact that although medical literature is richly supplied on other points connected with the appendix, it contains scarcely anything on its relation to dysmenorrhea. Soupault had himself observed a number of cases of menstrual pain associated with appendicitis, and believed that they presented certain char- acteristics which should aid in the diagnosis. APPENDICITIS AND DTSMENOERHEA. 593 In dysmenorrhea associated with appendicitis, according to him, the suffer- ing begins several days before the flow is due and reaches its maximum just as it begins. Sometimes the pain disappears suddenly, as if by magic, as soon as the flow is established ; in other cases it lasts through menstruation, diminishing gradually. It is exceptional for the attacks of pain to occur at each menstrual period; they usually accompany menstruation at more or less distant intervals, without any definite explanation of their appearance on any particular occa- sion. The intensity of the suffering varies in different attacks in the same person, being sometimes so slight as to be barely perceptible, while at other times it is so severe as to be unmistakable. Occasionally, though rarely, there are symptoms of appendicitis during the intermenstrual periods, and when this is the case the diagnosis is greatly facilitated. Gastro-intestinal symptoms, especially entero-colitis, are often present as well and contribute greatly to an understanding of the case. Certain other signs and symptoms observable during the attack are, in Soupault's opinion, strongly suggestive, if not absolutely diagnostic. The most constant of these is spontaneous pain situated low down in the right iliac fossa and limited strictly to the right side. It is rarely lancinating in character, but resembles colic, and is accompanied by a sensation of discomfort and of pressure in that locality. The pain is generally intermittent and transient; it yields readily to mild therapeutic measures and usually disappears on the ap- pearance of menstruation. There is tenderness on pressure over the right iliac region, but not by any means always over McBurney's point; it is often near the umbilicus or it may be in the groin, in which case it is liable to be attributed to the right ovary. It is noticeable that the tenderness disappears as soon as the attack is over, and the right iliac fossa becomes soft and painless during the intermenstrual period. The abdominal pain is almost always accompanied by some digestive disturbance which lasts only a short time. There may be nausea and vomiting, at first of food, and afterwards of bile. The presence of diarrhea and vomiting, either separately or together, is of great diagnostic im- portance. The constitutional symptoms are not well marked. There may be a little headache, pain in the limbs, and shivering, but these all disappear spon- taneously. The point of great importance in these cases is the temperature. When taken in the axilla it is often quite normal, when, if taken in the rectum at the same time, there will be some elevation, 37.5° to 39° 0. (99.5° to 102° F.). The pulse shows a corresponding acceleration, being usually about 100. These modifications of pulse and tempera- ture are constant, and it is upon them that the diagnosis chiefly rests. According to Soupault the association between menstrual pain and appendi- citis may be explained, in some cases, by the fact that there are adhesions be- tween the appendix and the adnexa on the right side, in which blood vessels and lymphatics develop, and these become easily congested under the influence 39 594 APPENDICITIS XND DISEASES OF THE PELVIC OEGAXS. of menstruation. In other cases, where no adhesions arc present and the ap- pendix lies free in the abdominal cavity, it is easy, he thinks, to explain the congestion by means of vaso-motor disturbances affecting an organ in a state of lowered resistance. Soupanlt cites seven cases of dysmenorrhea associated with appendicitis out of the number observed by him, and I give one of them which affords a good illustration of the chief diagnostic points. Case VII. — Miss E., nineteen years old, seamstress, of a robust appearance. She had always had good health and had menstruated regularly and without suffering until a year before, when she had an attack of abdominal pain limited to the right side and accompanied by vomiting of a greenish character. The attack occurred two days before menstruation and lasted forty -eight hours, sub- siding as soon as the menstrual flow appeared. She remained in bed during the menstrual period, and then got up, feeling perfectly well. During the ensuing year she had three siiuilar attacks and was also troubled with a certain amount of entero-colitis, with mucous stools. At the end of nearly a year she had a fourth attack, when she was seen by Soupault. Her temperature was then 39° C. (102° F.) ; there were nausea, bilious vomiting, diarrhea, and pain on pressure in a circumscribed location in the abdomen, low down and near the groin. These symptoms had been present for two days when she was seen. As soon as menstruation appeared, they all began to subside and disappeared grad- ually as menstruation proceeded. A diagnosis of chronic appendicitis was made and laparotomy performed two weeks later, when the appendix was found to be much enlarged and surrounded by adhesions. At its lower end there was a cavity containing a suiall quantity of malodorous pus. The patient had no further trouble with menstruation and the entero-colitis also disappeared. In many cases of dysmenorrhea, where the pain is entirely on the right side, it is well to suspect appendicitis, especially if the patient has teen free from pain in the early years of menstrual life. If, on careful observation of the attacks, the diagTiostic points given by Soupault can be established, namely, the disappearance of pain on the establishment of menstruation, or at any rate at its close, the presence of diarrhea and other di- gestive symptoms, and, especially, the elevation of temperature when taken in the rectum, it is tolerably safe to conclude that the case is one of chronic appendicitis in which the dysmenorrhea is merely a mani- festation. Tlje only class of cases in which the diagnostic peculiarities do not hold good, in Soupault's oj^inion, is that in which it is necessary to differentiate be- tween an inflamed appendix and a lesion of the right tube and ovary giving rise to pain in menstruation. The symptoms just discussed may be foimd in such cases as well as in those where the appendix alone is at fault, and the physician must depend upon the history of the individual case for his differential diagTiosis, making special inquiry as to the possible infection of the genitalia, the presence of menstrual irregularities, and APPENDICITIS IN THE .CHILD. 595 of muoo-purulent vaginal discliarges. One point of importance is the fact that a lesion of the uterine adnexa rarely remains quiescent between the menstrual periods, while in the class of cases under discussion it is unusual to find any expression of the trouble except at menstruation. In either instance such cases belong to the surgeon. Finally, I would call attention to the fact that dysmenorrhea is some- times the direct result of acute appendicitis. An inflammation of the appendix, which subsides without operation, will occasionally be followed by dysmenorrhea, when the patient has previously been free from menstrual suffering altogether; and whenever this is the case, the presence of a chronic appendicitis should be suspected. The treatment of dysmenorrhea associated with appendicitis does not differ from that of dysmenorrhea from other causes. The prominence of the digestive symptoms will probably call for remedial measures. For the vomiting I know nothing better than the prescriptions given already for use in chlorosis (see p. 158) ; while for the diarrhea the best remedy is the com- bination of bismuth and paregoric. ^ Bismuth, subnit 3ij Tine. opii. camph fojss. Aq. dest . q. s. ad. f ovj M. S. Shake well and take one tablespoonful every four hours, until pain subsides. The question of operative treatment belongs, of course, to the surgeon, to whom the case should be referred without loss of time. It would seem that this is a class of cases which, as Soupault suggests, is peculiarly suited to inter- val operation (operation a froid) during the intermenstrual periods. APPENDICITIS IN THE CHILD. It may not be out of place here to say a few words in regard to certain peculiarities of appendicitis in the child. There is an undoubted etiologic relation between intestinal worms and certain forms of appendicitis in children. Ascaris is the variety most fre- quently found, trichocephalus next, and then oxyuris. The frequency with which trauma figures in the causation of appendicitis is now an ac- cepted fact, and it is plain, of course, that with children, whose activity exposes them especially to its influence, trauma must especially be often a causal factor. The diagnosis of appendicitis in children is frequently obscure. There is sometimes a prodromic stage, in which there is more or less of gastro- intestinal disorder without any signs distinctly suggestive of appendicitis. In children there are apt also to be misleading symptoms associated with the thoracic viscera, and often the first indication of appendicitis in a child is a pneumonia, a pleurisy, or even a bronchitis. The examina- 596 APPEIiTDICITIS ANT) piSEASES OF THE PELVIC OEGAlSrS. tion of a cliilcl for appendicitis should never be considered complete without an examination of the chest. Another notevorthv point in the early diagnosis of appendicitis in children is that the earlv stage of it is apt to be associated in them with disturbances of motion. A few cases have been reported in which the first symptom ob- served was a difficulty in walking. Dr. R. D. Freeman, of South Orange, IST. J., reported to me a case in which he was calling upon another member of the family, when he happened to notice a little girl, eleven years old, who was limping as she played tennis in the yard close by and standing in a position suggestive of hip disease. On inquiry it was found that she had complained for a few days of indefinite pain in the lower abdomen, and on calling her into the house and making an examination a tender fluctuating mass was found in the right iliac fossa. The right leg was flexed and abducted, there were muscu- lar rigidity over the lower abdomen and considerable pain on pressure over and around the mass. The rectal temperature was 103° F., and the pulse 90. She had had no considerable pain at any time and no chill. At the operation, per- formed at midnight of the same day, a large abscess surrounding the appendix was evacuated and the remains of a sloughing appendix removed. V. P. Gibney (Amer. Jour. Med. Sci., 1881, vol. 81, p. 119) has reported cases of appendicitis mistaken for hip disease, and several striking cases of this kind have come under the observation of Drs. W. S. Baer and J. M. T. Finney of Baltimore. An examination by the rectum should never be neglected in ap- pendicitis in the child, since the index finger reaches higher in the infantile pelvis than in that of the adult, and thus the suspected area is more easily touched. It has been shown that in almost every case where the disease has extended beyond the appendix the extension has taken place along the right pelvic wall, where the inflammatory mass can readily be felt. In making his abdominal examination, the surgeon should always bear in mind that the ad- hesions in a child are extremely delicate, and more than ordinary care must be exercised in order to avoid rupturing them. A case has been known in which the adhesions around a localized abscess were ruptured during sleep, and another in which rupture took place during an effort at stool. Whenever an attack of appendicitis in the child is suspected, the patient should be kept in bed and an ice-bag placed over the abdomen. The diet should be liquid, and sufficient opium prescribed to keep the bowels at rest. It is of the utmost importance in these early stages to avoid active treatment, such as purgatives and enemata, which are calculated to do much harm. A specialist should always be called, if possible, as soon as any suspicion of appendicitis is entertained. Should an operation be performed, the child is often very restless after its performance, and to keep it quiet becomes a difficult matter. Under these circumstances a Bradford frame affords an excellent means of assuring relative immobility for the first few days, while the infected area is being walled off from the general cavity of the peritoneum. CHAPTER XXy, (1) SPLANCHNOPTOSIS— ENTEROPTOSIS—GLENARD'S DISEASE. (2) MOVABLE KIDNEY. (1) Splanchnoptosis — Enteroptosis — Glenard's disease, p. 597. (2) Movable kidney: Anatomy, p. 605. Amount of normal and abnormal mobility, p. 606. iStiology, p. 606. Frequency, p. 608. Palpation of kidney, p. 609. Symptoms, p. 610. Differential diagnosis, p. 613. Treatment, p. 617. SPLANCHNOPTOSIS— ENTEROPTOSIS— GLENARD'S DISEASE. SpLAJsrcHJsroPTOSis, from the Greek words signifying descent of the viscera, has been much studied during the past few years. The original term enteroptosis should be used according to its etymology to signify descent of the intestines, although it is used by most people as a synonym for splanchnoptosis, that is, to mean descent of all the abdominal viscera. In designating the special form of descensus we use special terms, thus: gas- troptosis, of the stomach ; hepatoptosis, of the liver ; neph- roptosis, of the kidneys ; splenoptosis, of the spleen, and colop- tosis, of the colon. In Figure 158 I have given an illustration of the various visceral ptoses based in part on a series of splendid studies made by Clark and Pancoast of Philadelphia. To the anatomists and pathologists we owe the first recognition of the dis- ease, Morgagiii being the first to describe the condition anatomically, while Virchow, in 1853, called attention to displacement of the intestines, ascribing the condition to partial peritonitis, and regarding its mechanical effects as the starting point of a number of cases of dyspepsia and indigestion. Among the older clinicians, Aberle, Payer, Rollet, and Oppolzer referred to the rela- tion between hysteria and floating kidney, and Kussmaul called attention to the symptoms due to change in form and position of the stomach. It was Glenard, however, the distinguished physician of Lyons, whose work at the adjacent health resort of Vichy brought him in contact with many cases of digestive disturbance, who first aroused general interest in this condi- tion. The disease is therefore often spoken of as Glenard's disease. Glenard believed that in enteroptosis he had found the anatomic basis for one type of, so-called, nervous dyspepsia. Anatomy. — To go into the anatomy of the abdominal viscera is not within the scope of the present work. Suffice it to say that they are held in posi- tion by a number of different forces: by the negative pressure of the thoracic cavity acting through the diaphragm; by vascular, peritoneal 597 598 SPLANCHNOPTOSIS ENTEKOPTOSIS GLENAKD S DISEASE. and ligamentous attachments; by the pressure of the different organs upon each other; and by the supporting power of the abdominal muscles. Fig. 158. — Composite PicxrRE from over 100 Skiagraphs in Possession of Dr. H. K. Paxcoast, OF Philadelphia, showing Displacement Doavnward of all the Abdominal Organs as the Result of Constriction of the Lower Thorax. The liver shows Riedel's lobe ; the stomach has descended into the pelvis, carrj^ing the transverse colon with it. Note the hour-glass contraction of the fundus of the stomach. The right kidney has descended moderately. (From forthcoming " Surgery of the Kidney," by H. A. Kelly.) Xormally, however, no organ is absolutely fixed, each being capable of slight movements due to various physical factors, such ns the position of the patient, the amount of food ingested, the passage of urine and feces, and the respiratory and circulatory movements. ETIOLOGY AND SYMPTOMS. 599 In advanced cases of splanchnoptosis the position of the viscera very closely resembles that seen in embryonic life, and this is regarded by some per- sons as an argument in favor of the congenital origin of the condition. Etiology. — As regards the pathogenesis of splanchnoptosis very divergent views are held, some authorities maintaining that the condition is congenital, others that it is acquired, while others again hold a middle ground. Glenard believes that the first step in the condition is a falling of the right colic flexure, due to a weakening of thethepato-colic ligament; it may follow preg- nancies, strains, injuries, abdominal operations, wasting dis- eases, appendicitis, etc., but it is primarily due to a constitutional defect affecting the strength and supporting powers of the mesenteric tissues. Stiller believes that there is a characteristic sign of the condition in the floating tenth rib, while Mathes states well the congenital theory, when he says " splanch- noptosis is a constitutional hereditary anomaly of the entire organism, a lack of vital energy in all the vital tissues." Many persons believe that the condition is acquired, not based on a con- genital defect, and as special causes of the condition they mention the wearing of tight belts and corsets, pregnancy and parturition, wasting diseases, the removal of abdominal tumors or of ascitic fluid — in fact, any condition which tends to increase the pressure above the abdominal organs, decrease the pressure below them, or diminish the size or the expansile power of the lower thoracic zone. According to Keith, who has done much work on this subject, splanchnoptosis is the result of a vitiated method of respiration, and should be assigned to a place among the respiratory diseases ; he believes that the contraction of the diaphragm, especially the crura, is the most important agent in producing the displacement, although before this descensus takes place, either the thoracic supports of the diaphragm must have yielded, or the antagonistic abdominal muscles been hampered or weakened, as, for example, by tight corsets. A study of a large number of cases has convinced me that, although the condition may be acquired in a number of cases, in the majority, the underlying cause is a definite con- genital defect, and that this latent predisposition is fanned into the actual disease by some malady of an exhausting nature, such as conditions associated with loss of weight, especially if rapid ; conditions which produce sudden changes in the intra-abdominal pressure ; lack of proper nourish- ment; and increased pressure in the lower thoracic zone, as by tight lacing. Symptoms. — The symptoms of splanchnoptosis are extremely varied. On the one hand, there may be no symptoms whatsoever, while on the other, the symptom-complex may be more protean and complex than in almost any other condition. Certain symptoms are especially referable to the ptosis of the special viscera, while other symptoms are dependent upon the degree of involvement of the nervous system. As to the relation between neurasthenia and splanchnoptosis there is a wide divergence of opinion, some holding that the neurasthenia is essential, the splanchnoptosis 600 SPLA^^CHNOPTOSIS EKTEEOPTOSIS GLENAED S DISEASE. incidental, others the reverse view, while still a third group believes, and I think rightly, that in most cases each condition represents a congenital fragility of tissue, independent, primarily, of the other, hut reacting very deleteri- ously upon it, moreover the two are frequently associated. The picture usu- ally presented is that of a thin, pale, young man or woman with a deficient amount of fat, a nervous and worried expression, a long thorax constricted in its lower half, and thin, soft abdominal walls, who complains of many dyspeptic and nervous symptoms and sometimes of pain in various portions of the abdomen as well. The patient often complains of a feeling of lack of abdominal support, and sometimes of a loose body in the abdominal cavity. Glenard himself divides the symptoms into three special groups — lack of tone of the abdominal walls, descent of the various abdominal vis- cera, and a stenotic condition of the large intestines. Others have paid especial attention to the respiratory and circulatory symptoms, dyspnoea, asthmatic attacks, etc. As to symptoms referable to a special organ it must be remembered that in many cases they are due to the displacement of several viscera, not of one, but the author sometimes loses sight of other ptoses, and ascribes all the symp- toms to the descensus of the organ he is especially studying. This is peculiarly the case in displaced kidney, for many of the symptoms ascribed to this con- dition are in reality due to descensus of the stomach or of the intestines ; while our gynecological brethren should remember that, in many cases, retroflexion or retroversion of the uterus is but a part of a general splanchnoptosis, the vast majority of the symptoms ascribed to the displaced uterus being in reality due to the displacement of other organs. Under these conditions, the expectation of relief from all symptoms by suspending the kidney or the uterus is abso- lutely without foundation, and is based on a complete misconception of the facts. Symptoms especially associated with the stomach are the splashing sound, which is often heard, and others referable either to the associated atony of the stomach wall, or to the dilatation, which so frequently accom- panies gastroptosis, and the associated anomalies of gastric secre- tion. In cases of displacement of the stomach, especially of the vertical and subvertical type, gastrectasy is very likely to occur with its char- acteristic symptom-complex, particularly if the patient indulges in frequent indiscretions of diet, while in gastroptosis subacidity is the rule, the degi-ee of diminution of the free hydrochloric acid depending upon the extent of the associated dilatation. Of symptoms especially referable to movable kidney alone may be men- tioned Dietl's crises, intermittent hydronephrosis, hepatic colic, due to pressure on the duct, pain either dull and constant, or intermit- tent, and the feeling of a floating body in the abdomen, due prob- ably to congestion of the kidney, while recently many persons have called attention to the frequent association which seems to exist between right floating kidney and chronic appendicitis. DIAGNOSIS. 601 As regards the liver, hepatalgia, hepatic colic, gall-stone at- tacks, asthma, and the sensation of a floating body have been ascribed to this organ's displacement. A movable spleen often gives rise to sensations of dragging and pain and the patient is almost always conscious that a body of some kind is moving about in the abdominal cavity. The symptoms, in fact, are exactly similar to those of a displaced kidney. In my own cases this movability of the spleen has not been associated with a general splanchnoptosis. Symptoms definitely referable to displacement of the intestines are in- testinal fermentation, intestinal pain, mucous colitis, and con- stipation. Diagnosis. — The diagnosis of the condition is easily made ; the characteristic expression and body form, the long flat chest, the weakened abdominal muscles, and the protean symptom-com- plex should at once attract our I attention. In diagnosing gas- r\ troptosis the best methods are ' \ 1 percussion, combined as a rule I I \ with inflation of the organ \ / \ by means of carbon dioxide gas | / "^"^-^-^ or through a stomach tube (see I ^^ , i Fig. 159), or, more accurately / t X ) ^.--— •"""^'"^ still, by the use of the X-rays / vll^" 'W after making the patient swallow I I <* a bismuth emulsion. In case of ^ ^ | '^ • nephroptosis we use palpa- , . / ;-x i f tion, examining the patient in -• V | j'j both the prone and the upright '^x. • \,, "^--X^-^Jt..---^ . position, and I have shown \^ ^ — ;— -^ / ^-AjJ ' j (Amer. Jour. Obst., 1899, voL I v ^ i 40, p. 328) that a characteristic ^— - -' Dietl's crisis may be produced ^ig. 159.-Gauze Record ^ofJWarked Displacement by injecting fluid into the renal pelvis through a urethral catheter; in the case of the liver we make use of palpation, percussion and inspection, always being careful to do so with the patient in both the prone and the upright positions, also deter- mining, as in the case of the kidney, whether the organ can be replaced in its normal position by manipulation; in the case of the spleen we palpate with the patient standing and the patient lying down, while in the case of the intestines inspection of the peristaltic movements, palpa- tion of the stenosed portions of the intestine, inflation through a rectal tube, or X-ray photography after the injection of bismuth emulsion gives us the diagnosis. Most of these patients give the so-called belt test of Glenard; that is. 602 SPLANCHNOPTOSIS ENTEK.OPTOSIS GLENARD's DISEASE. the sjmjDtoms are much relieved if the physician stands behind the patient and lifts up the loAver abdomen with his hands, while in most cases the symptoms are markedly ameliorated by the assumption of the prone position. The char- acteristic body form has been studied mathematically by Harris and others, who have given a formula expressed in terms of various body diameters, which will tell whether splanchnoptosis is likely to be met with. Frequency. — The condition is extremely common, as shown by the fact that Glenard finds it in one out of every five women who come to Vichy, and in one out of every forty men, while Einhorn finds the condition in six per cent of males, and thirty-five per cent of females ; of course, it must be remembered that most of the patients who consult these physicians are suffering with digest- ive disorders, and the percentage is consequently considerably higher than that which would be obtained in a general clinic, although Thorndike has recently found the condition a hundred and twelve times in two hundred and seventy- two general patients in Boston. As regards pregnancy a series of several hundred cases shows that about fifty per cent had borne children, about fifty per cent had not ; as regards involvement of the two kidneys, of seven hundred and twenty-seven cases of renal displacement, the right alone was involved five hundred and fifty-three times, the left alone eighty-one times, and both ninety- three times. Treatment. — The most practical and the most important division of the sub- ject is that devoted to the prevention and treatment of the condition. In discussing the prophylaxis of splanchnoptosis we should keep in mind that the majority of such patients have a congenital tendency, which brings about marked displacement of the various viscera, however, only after they have been exposed to various secondary influences. For this reason it is extremely important that persons with the characteristic body form, especially children, should be guarded with great care ; they should be made to rest at certain times, especially after meals ; everything should be done to increase their bod}^ weight ; carefully selected exercises should be employed to strengthen their abdominal muscles, and massage should be given. They should be taught breathing and standing exercises so that their lower thoracic zone may be strengthened as regards its muscles, and increased as regards its volume. Careful attention should be paid to everyone during and after acute and chronic diseases, espe- cially if associated with much loss of weight, after the removal of abdominal tumors or ascitic fluid; and after childbirth. In these last three conditions it is absolutely essential that an abdominal bandage be worn until normal intra-abdominal pressure relations obtain again. We should especially insist upon the danger from wearing tight belts and tight corsets, especially those where the pressure is applied in the hypochondriac and upper abdominal regions. As to the treatment proper of splanchnoptosis it may be divided into three groups: (1) Treatment by medicine, diet, and general hy- gienic measures, including rest, exercise and massage ; (2) treat- TREATMENT. 603 ment by bandages, pads, plasters, belts and supports of various kinds; (3) operative treatment. In regard to treatment it seems to me that splanchnoptosis in the majority of cases should be treated by medi- cal, hygienic and mechanical means, while operative treatment should only be used where the symptoms are definitely referable to the dis- placement of an especial organ, or where, although the symptoms cannot be definitely referred to any special organ, all other means of treatment have proven failures. Treatment by medicine, diet and general hygienic measures is of extreme importance in splanchnoptosis. As to the diet this depends largely upon the condition of the stomach, and whether or not atony and dilatation are present. Usually a simple mixed dietary is advisable, with rather small meals and often extra food in the shape of raw eggs and milk between meals ; fluids had best be taken in very small amounts while eating ; in some cases a dry-meat and stale-bread diet is advisable, while in a number of instances where the nervous symptoms were well-marked, I have obtained excellent results by treating the patient as in neurasthenia with systematic over-feeding begun by rest and an absolute milk diet. As regards medicines these are but little indicated; iron and arsenic for the anemia, strychnin as a general nerve tonic, alkalies to lessen the gastro-intestinal fermentation, hydrochloric acid if the stomach shows de- ficiency in this, are indicated in this condition ; while for the constipation aloes, cascara or the salines may be' used, if successful results are not obtained by the use of enemata, especially those of oil, or by massage, electricity, hydrotherapy, and exercise. Lavage is indicated in case of gastrectasy. Rest is extremely important, especially in those eases deficient in weight; this is peculiarly advisable after meals. In some cases a systematic rest cure has produced wonderful results in my experience. Massage both general and abdominal, systematic exercises, especially those designed to de- velop the abdominal and thoracic muscles, hydrotherapy and electricity, are all of value. Treatment by bandages, pads, plasters, belts and supports of various kinds should always be tried in splanchnoptosis; the object of these is, of course, twofold: to increase the intra-abdominal pressure, and to decrease the size of the lower half of the abdominal cavity. They should always be ap- plied with the j)atient on the back with the hips elevated, so that the organs will have fallen back into approximately their normal positions, and the direction of the pressure should always be from below upwards and backwards. Among various abdominal bandages may be mentioned the elastic bandage of Glenard, Longstreth's belt, Gallant's special corset, and Rose's method of bandaging with adhesive plaster. Some authors advise the use of pads, especially for support- ing the liver, the kidney, and the stomach, but in my experience these have not proven satisfactory. 604 SPLANCHNOPTOSIS ENTEROPTOSIS GLENAED S DISEASE. Operative treatment, as we have said before, sliould only be used in those cases where the symptoms are definitely referable to the displacement of an especial organ, as, for example, Dietl's crises in nephroptosis, or in those cases where medical, hygienic and mechanical means have been tried without success. As to the objects of the operation, they are in the main to fix the organ in approximately the normal position, and at the same time to allow a slight degree of mobility. In the case of the kidney the old forms of nephropexy have been aban- doned, such as suture through the perirenal fat, through fat and capsule, through a capsule which has been previously split and partially dissected, through the kidney substance, and packing the kidney so that strong adhesions may form. I call attention especially to the value of the Brodel stitch in nephropexy, as its holding power is from two and a half to three times that of the ordinary stitch. In the case of the stomach various operations have been devised, such as fixation of the stomach to the anterior abdominal wall, fixation to the dia- phragm, lifting the colon by fixing both its flexures to the abdominal wall, various procedures to shorten the stomach ligaments, and Coffey's operation of slinging the stomach in a hammock made of omentum; of these Beyea's gas- tropexy has probably given the best results. In the case of the liver stitching the organ to the thoracic or abdominal wall and the formation of adhesions by irritating the surface of the liver have been advised. In the case of the spleen operation is rarely necessary, but if torsion with pain, swelling, and possible gangTene occurs, splenectomy should be done. In the case of the intestines numerous operations have been done re- cently : sigmoidopexy or even resection of the sigmoid ; in some cases resection and anastomosis of the colon, and in some cases resection of the abdominal wall where there is a marked diastasis of the recti muscles. ANATOMY OF TIIE KIDNEYS. gQS MOVABLE KIDNEY. Anatomy. — It will probably be wisest at the very outset to recall briefly those anatomical conditions abont the kidney which are indispensable to a thorongh understanding of the anatomy and the anatomical relations of the kidney in nephroptosis or movable kidney. The kidneys are bean-shaped organs weighing about four ounces in the fe- male and a little more in the male, and placed retroperitoneally in the loin on each side of the spinal column. Each kidney, measured roughly, is four inches long, two and a half inches broad, and one and a quarter inches thick, and pos- sesses an anterior and a posterior surface, an outer and an inner border, and an upper and a lower convex extremity. The direction of the kidneys is not exactly vertical, but rather down- ward and slightly outward, with their anterior surfaces looking forward and outward, while their posterior surfaces look backward and inward. The outer border is convex, while the inner border is concave and forms the hilum where the vessels and ureter join the kidney. The upper end of each kidney lies in the hypochondriac and epigastric regions, and the lower pole projects into the adjacent portions of the umbilical and lumbar regions. They extend from about the level of the eleventh dorsal to the second or third lumbar vertebra, and are thus within about two inches of the iliac crest. The right kidney is placed a little lower than the left, possibly on account of the position of the liver. The kidney possesses several coverings or capsules of different struc- ture and consistency, all of which probably play an important part in maintain- ing the organ in its proper position. Snugly encasing the kidney parenchyma is its own true capsule, a thin, smooth membrane composed mostly of fibrous and elastic tissue. ^Normally this capsule is not firmly united to the kidney proper, and unless there has been previous inflammation, it can be easily stripped ofl^. The kidney with its fibrous capsule is next surrounded by a layer of fat, the fatty capsule or "tunica adiposa." This fatty capsule is permeated by fine elastic fibres and cellular tissues, which unite it to the adja- cent inner and outer coverings. The union between the fibrous and the fatty capsules is, however, very delicate and they can be easily separated unless there has been some previous pathological change. The amount of fat varies in different locations, being more abundant posteriorly upon the convex border, at the hilum, and just below the lower pole, while anteriorly there is comparatively little. The perinephritic adipose layer is not marked before the tenth or twelfth year of life. The tunica adiposa has a peculiar " canary-yellow " color, which is easily distinguished from contiguous sub- peritoneal fat and acts as a valuable landmark in renal surgery. We have described from within outward the kidney proper, the fibrous 606 MOVABLE KIDNEY. capsule, tlic tunica adiposa, and we now come to the last structure, which is of especial interest in its relation to movable kidney; that is, the perinephritic fascia, sometimes called Gerota's capsule. This is a firm, fibrous covering, composed of an anterior and a posterior layer, which meet above and to the outer side of the perirenal fat, but do not fuse below or anteriorly. Thus in a kidney of abnormal mobility the path of least resistance is downward and inward. As mentioned above, the kidneys are placed retroperitoneally, only portions of their anterior surface coming in contact with the peritoneum. Amount of Normal and Abnormal Mobility. — Some writers attempt to classify movable kidney according as it has or has not a mesentery, but any classi- fication I make here will be based entirely upon clinical and not upon anatomical findings. Each kidney moves to some extent with respira- tion, descending during inspiration and ascending during expiration. This movement usually occurs within the fatty capsule, though in some cases the fatty capsule itself moves to a slight extent within the perinephritic fascia, or movement may occur in both at the same time. What, then, should we consider a normal and what an abnormal mobility? Upon this point there is a wide variance of opinion among writers, but all agree that any kidney whose range of mobility is less than one and a half inches should not be con- sidered abnormally movable. It is also generally held, and probably correctly so, that the normal movement is slightly more in women than in men. An explanation for this is given in the different shapes of the renal fossae in the two sexes. The terms used to designate the degrees of abnormal mobility are various and often confusing. I prefer to stick to the three simple terms, palpable, movable, and floating (see Fig. 160). By palpable we mean those cases where less than half of the kidney can be felt on deep inspira- tion. Movable includes those eases where half, two-thirds, or even all of the kidney can be felt, but where it cannot be displaced to any other portion of the abdomen. Floating includes those cases in which the kidney can be grasped and brought up to the abdominal wall or carried to some other portion of the abdomen. Although this classification is entirely clinical, it furnishes a good working basis. For instance, if a patient comes with abdominal symptoms resembling those which we should naturally expect to find with a freely movable kid- ney, and upon examination the kidney is found to be simply palpable, the chances are that it is not the cause of the symptoms. Whereas, if the kidney is found movable or floating, the physician must seek diligently to find some connection between the abnormal renal mobility and the symptoms of which the patient complains. Etiology. — Upon no other phase of movable kidney is there so much differ- ence of opinion or lack of any absolute proof as upon its etiology. If half a dozen prominent physicians were asked to-day what they considered to be the ETIOLOGY. 607 one most important factor in the causation of movable kidney, they would probably all give different answers. Glenard maintained that movable kidney was not a clinical entity at all, but simply part of the general condition of enteroptosis, and he is credited with the statement that " enteroptosis can be present without nephroptosis, but Fig. 160. — Showing Three Degrees of Displacement of the Kidney. In the first degree (palpable) the lower pole is only just perceptible to the touch. In the second degree (movable) the upper pole just emerges from under the costal margin. In the third degree (floating) the entire kidney can be palpated. never nephroptosis without enteroptosis," a statement which clinical observa- tions do not confirm, for unquestionably there are cases of movable or even floating kidney in which no displacement of other organs can be discovered. Becker and Lennhoff were the first to definitely emphasize the great impor- tance of body-shape as an etiological factor in nephroptosis. These writers maintained that the vast majority of persons having a movable kidney had also a peculiar form of chest and abdomen which was somewhat cone- shaped in appearance, with the apex pointing downward; while those cases in which there was no nephroptosis presented rather a cylindrical appearance. To be more accurate, they measured the distance from the suprasternal notch 608 MOVABLE KIDNEY. to the tojD of the sjTnphysis pubis with the patient flat on her back, and divided this distance by the smallest circumference of the abdomen, and to avoid frac- tions, multiplied the result by one hundred. The index thus obtained usually varied betveen sixty-five and ninety-five, and in practically every case in which there was marked nephroptosis, the index was high, that is, above seventy-five. Becker and Lennhoff also examined many South Sea Islanders, with whom the customs of civilization, as clothing, tight lacing, etc., could be eliminated, and found that movable kidney was just about as frequent as in civilized races. Deletzine and Volkoff ascribe the more frequent occurrence of movable kid- ney in women than in men to the difference in the renal fossae of the two sexes. They showed that in men the fossee in which the kidneys lie are fairly deep and wider above than below, that is, funnel-shaped ; while in women they are more cylindrical and wider below, especially on the right side. Pregnancy has been given the most conspicuous place as an etiological factor by some persons, and its advocates maintain that it acts by the contrac- tion of the diaphragm during labor; the lessening of the intra-abdominal pres- sure after the expulsion of the uterine contents ; and finally, the loss of tone of the abdominal muscles with a resultant flaccid and pendulous condition which also tends to lessen the intra-abdominal pressure and thus favor a prolapse of the kidney. Gynecological conditions, such as malpositions of the uterus and pel- vic timiors, may possibly by their traction upon the ureters have a slight tend- ency to displace the kidneys. Trauma, either single or repeated; certain occupations requiring heavy lifting; and also prolonged constipa- tion necessitating severe straining, may in some instances assist in displacing the kidneys. Harris {Jour. Amer. Med. Assoc, June 1, 1901) probably came nearer the truth than any other writer when he said : " The fallacy of supposing that preg- nancy, lacerations of the perineum, displacements of the uterus, etc., are in- strumental in causing movable kidneys, is unanswerably shown by the fact that over forty per cent of the cases of movable kidneys were found in unmarried women, in women who have thus never been pregnant, who have intact perineal floors, and whose uteri are in normal position. That these factors may, and perhaps at times do, aggTavate the condition caused by other influences is ad- mitted." We may conclude by saying that it is becoming more and more probable that there is no single cause of movable kidney, but rather a combination of influences working together. Frequency. — It is a well known fact that movable kidney is much more frequent in women than in men. Statistics vary gi-eatly as to the relative frequency in the two sexes, but it is probably ten times more common in women. The disposition of the pelvic organs in women, together with the effects of labor, are probably of some etiological importance, but it will most likely be METHOD OF PALPATION. 609 proven that the differences in the body shape in the two sexes is also of great consequence. Observers vary greatly in their opinions as to the relative frequency of mov- able kidney in women, due in part to the fact that each has a separate standard by which he decides whether a kidney is abnormally movable. From statistics taken upon white women in the Gynecological Dispensary of the Johns Hopkins Hospital, I feel safe in saying that at least twenty per cent have a movable kidney. In most of the cases it is the right kidney which is in descensus, while in a small per cent the nephroptosis is bilateral, and in a still smaller per cent the left kidney alone is movable. JSTephroptosis may occur in children, indeed there are many cases on record, but it is rare compared to its frequency in adults. Palpation of Kidney. — There are numerous methods and positions for palpating a movable kidney, each of which has its advantages and disad- vantages, but the necessary prerequisite for a thorough palpation of any kidney is a complete relaxation of the abdominal muscles. Some surgeons in palpating prefer to use only one hand ; for example, in examining the right kidney they use the left hand, placing the fingers in the loin below the twelfth rib and external to the erector spinse muscles, with the thumb on the abdomen, and attempting to palpate the kidney by bringing fingers and thumb together. I prefer the bimanual palpation, however, which is per- formed as follows: In palpating for the right kidney the left hand is placed in the loin below the twelfth rib and just outside the erector spinse muscles, and the right hand is placed over the abdomen just below the costal margin external to the rectus muscle. The patient is then instructed to take a fairly deep breath, and during expiration the hands are brought together. As mentioned above, the whole secret lies in securing a thorough relaxation of the abdominal mus- cles, and to obtain this the position of the patient is most important. She may be on her back in a reclining position, about midway between the sitting posture and complete dorsal decubitus, and with the thighs slightly flexed. This usually gives a good relaxation, there is some tendency for the kidneys to descend by gravity, and either side may be examined without changing the position of the patient. Another excellent position is to have the patient stand, and in order to examine, for instance, the right kidney, have her lean forward and a little to the right, with the right foot placed on some object about six inches high. This will secure good relaxation and give gravity full play. Another method is to place the patient in the left lateral or Sims' position to examine the right kidney, and in the right lateral position to examine the left kidney. It sometimes happens that a movable kidney can be distinctly felt at one examination, but cannot be made out subsequently, owing to the fact that it has slipped up under the ribs and is temporarily held in that position. Fre- quently, however, if the patient will walk briskly about or make some exer- tion, the kidney will fall down into its abnormal position and be easily felt. 40 610 MOVABLE KIDNEY. In some cases it is helpful to try the bimanual vibratory palpation as de- scribed in the Journal of the American Medical Association, June 1, 1907. ■This method is performed as follows : With one hand placed below the lower pole of the kidney, or tumor, as the case may be, the other hand makes light taps over the mass at the rate of about three to five a second, and with an ampli- tude not exceeding one centimetre. As long as the palpation is made over the mass the vibratory waves are transmitted to the under hand, but just as soon as the outer limits are passed, these impulses can no longer be felt, and thus any object can be more accurately outlined than by the ordinary methods of palpation. Symptoms. — Probably no other pathological condition in the abdomen pre- sents such varied and often vague symptoms as movable kidney. The symptoms in a great many cases are so far distinct from, and have apparently so little connection with the kidney, that they are frequently attributed to some other organ. A large proportion of the movable and also of the floating kid- neys do not cause symptoms, l^early every practitioner of much experi- ence can recall cases in which the kidney had " run wild " and could be dis- placed to the iliac fossa or even to the opposite side of the abdomen, but which had caused absolutely no discomfort. While on the other hand, a comparatively slight abnormal mobility has caused violent manifestations of pain, nausea, vomiting, etc., which have been completely relieved by proper treatment of the kidney. Whenever, therefore, in the routine examination of our patient we accidentally discover a prolapsed kidney of which the patient is ignorant, and which has given her no trouble, it is best to let well enough alone and avoid interference; it is of great importance that the patient should be kept in blissful ignorance of her condition, for it frequently hap- pens that the very knowledge of the fact that the kidney is out of place will induce a long train of the mental and nervous disorders known as neurasthenia. Pain. — The cardinal symptom of movable kidney is pain, which, how- ever, varies greatly both in character and intensity in different cases, and even in the same person at different times. The pain commonly associated with movable kidney, however, is a dragging or aching sensation, which may be so mild that the patient is barely conscious of its existence, or, in many cases, is so severe that she cannot keep about at all, and is only partially relieved by lying down. The attacks of intense pain, called " Dietl's crises," are present only in exceptional cases. Dietl (Wien. med. Wochensch., 1864) considered these "crises" to be the result of a temporary kink or twist of the renal vessels and a consequent strangulation; comparable in character to the strangulation of a hernia. The explanation now generally accepted and advocated especially by Osier is that the paroxysms are due to a kink in the upper part of the ureter, causing a damming back of urine into the pelvis and calicos, and thus a transient hydronephrosis. The artificial reproduction of the exact symptoms of a SYMPTOMS. 611 Dietl's crisis by the distention of the kidney with sterile water, which will be described later, certainly seems to substantiate this view. An attack of sharp pain may excite the first suspicion, either to patient or physician, of an abnormally movable kidney, for although there may have been previously slight aches and pains, they are usually ascribed, without an exam- ination, to a " touch of indigestion," lumbago, or neuralgia, until acute sjnnp- toms necessitating a thorough investigation clear up the diagnosis. These paroxysms usually come on rather suddenly, often following severe exercise, jolting, or even an indiscretion in diet. The patient is seized with a sharp agonizing pain in the region of one of the kidneys, accompanied by a feeling of nausea and faintness. The pain is most frequently confined to the region of the kidney, but it sometimes radiates downward along the course of the ureter, or across to the other side of the abdomen, or upward even to the shoulder-blade. If seen within the first hour or so after the onset, a correct diagnosis can usually be made, for on examination the physician discovers slight enlargement of the kidney, which upon palpation causes an accentua- tion of the symptoms of nausea, faintness, or even partial collapse, from which the patient is already suffering. In the most severe cases, after several hours there may be marked abdominal distention and tenderness, and the patient becomes bathed in a cold sweat, so that the condition could be easily mistaken for one of intestinal perforation or even of peritonitis. Sometimes the symp- toms continue severe for several days, but, as a rule, within twenty-four hours the pain and tenderness subside and the patient makes a rapid recovery. There may be a noticeable decrease in the amount of urine, with albumen, casts, or even blood voided during an acute attack, followed by a compensatory increase of pale urine with low specific gravity during the subsidence of the symptoms. A marked temporary hydronephrosis, occuring in a Dietl's crisis, affords a typical example of the so-called " phantom-tumor," for on examination a large mass can be outlined in the flank, which a day or so later has completely disappeared. Between the Dietl's crises the health of the patient is most commonly excellent, except for occasional slight dragging pains and some discomfort, but she is kept in a constant state of anxiety, knowing that the slightest error in exercise or diet may precipitate another attack. The great danger to be feared in these cases of temporary or intermittent hydronephrosis is that they will become changed into a permanent hydronephrosis or even pyonephrosis. Gastro-intestinal. — Although gastric symptoms are not common mani- festations of movable kidney, yet symptoms referable to the stomach, in- testine, appendix, or gall bladder are occasionally seen. As a rule, the symptoms are mild in character and amount only to slight flatulence, dyspepsia, or constipation, but they may be so severe as to simulate acute gastritis, gastric ulcer, appendicitis, or gall 612 . MOVABLE KIDNEY. stones. Moullin (Lancet, Decemlier 10, 190-i) rcijorted an interesting ease in which the symptoms resembled those of gastric ulcer: '' The patient was a married woman, forty-four years of age, who had had nine children, six of whom were living. For the last twenty years she had suffered from pain in the epigastrium, shooting around to the back and shoulders. The pain invari- ably came on from a quarter to half an hour after meals. Solid food made it worse, vomiting was frequent, and was rather encouraged as it relieved the pain. Scarcely a day passed without at least one attack, and for the past nine months there had been no respite. Twenty-one months ago there had been three attacks of hematemesis, the amount said to have been as much as three quarts, and there was melena at the same time. The abdomen was large and flabby. Ac- cording to the patient's account she had been getting thinner. The stomach was not dilated nor displaced, the lower border being situated about two inches above the umbilicus. There was a little tenderness on deep pressure to the right of the epigastrium, but no tumor could be felt. Both kidneys were mov- able, the right one in particular descending so far when the patient strained or coughed that it came quite below the thorax and the hands could be made to meet above it. While in the ward lying in bed waiting for operation, the vomiting, which had been more and more troublesome and which was the im- mediate cause of her seeking admission, ceased entirely, and the pain after food diminished so materially that it scarcely interfered with her comfort. This led to the conclusion that the mobility of the right kidney was the chief, if not the sole, cause of her symptoms, whether it acted mechanically by dragging upon the duodenum and pylorus, or whether it irritated the splanchnics in some way, leading to persistent congestion of the mucous membrane of the stomach with its attendant consequences, chronic gastritis and hematemesis." In this case the kidney was suspended with complete relief of the severe pain and vomiting. The ease with which nephroptosis may simulate appendicitis is well shown by a case which was operated upon at the Johns Hopkins Hospital about four years ago (Gyn. 'No. 1097Y). The patient, a colored. woman, age twenty-four, had had neither children nor miscarriages. She had always suffered from dysmenorrhea and irregular menstruation. Until December 18, 1903 (about three weeks before her operation), she had not menstruated for six months, but she had suffered practically no pain. On the above date the menstrual flow began and lasted two to three days, accompanied by pain in the right side of abdomen, which persisted off and on, growing more and more severe and cramp- like in character. The attacks of pain were accompanied by nausea, vomiting, and obstinate constipation, and the patient was confined to bed for two to three days during each attack. She said that during the acute symptoms she had no desire to urinate, and frequently did not void her urine for two or three days, and when she did there would be only a small amount which caused some smart- ing and burning. Owing to the rigid condition of the abdomen, the physical examination was very unsatisfactory, and although the right kidney was found movable, it was not suspected as the seat of the trouble. A diagnosis of ap- DIFFERENTIAL DIAGNOSIS. gl3 pendicitis having been made, a laparotomy was done and a normal appendix removed. As the symptoms continued and the operation did not reveal any cause, the kidney was suspected. Sterile water colored with methylene blue was injected into the right kidney, which reproduced the exact symptoms of which the patient complained, proving conclusively the renal origin. Biliary. — Attacks of colic in the right side accompanied by nau- sea and vomiting as well as intense jaundice seem characteristic of gall-stones, but all of these symptoms may be caused by a movable kidney. I recently had such a case in which I made a diagnosis of gall-stones and then did an exploratory laparotomy which disclosed a normal gall-bladder and gall-ducts, but showed the right kidney pressed against the common bile- duct. I closed the abdominal incision, put the patient upon a kidney-bag, and suspended the kidney. She recovered promptly from the operation and has now been perfectly well for about two years. ISTervous. — Although the nervous manifestations of a movable kid- ney are vague and indefinite, they are none the less real. Headaches and vertigo are common. A bright and cheerful person may become fretful and irritable, and in extreme cases even approach hypochondriasis. Circulatory. — Venous congestion and edema of the leg have been reported as occurring in association with movable kidney, but it must have been an exceptional case. 1 have never seen one of the kind myself. It is worth noting, however, that Rayer attributed a swelling of the leg which he found at an autopsy to a movable kidney present upon the same side. Urinary. — Except for the changes in the amount of urine occur- ring in a Dietl's crisis, the urinary manifestations are not very charac- teristic. There might be a little albumen or a few casts, but these occur in so many conditions that it is difficult to say whether it is the result of or merely coincident with the nephroptosis. Occasionally, a little blood is seen in the urine by the aid of the microscope, an4 a few years ago Cabot, of Boston, reported a case of severe hematuria with anemia and weakness, resulting from a movable kidney, all of which were relieved by nephropexy. The occurrence of hematuria, however, would indicate that some other change in the kidney was associated with the movability, and we know that bleeding kidneys which are not movable have been cured by nephropexy. Differential Diagnosis. — The great majority of the cases of movable kidney with or without symptoms can and should be correctly diagnosed by any prac- ticing physician; but on the other hand, there are a certain number of cases which puzzle even the best of clinicians. As I have said before, we should always hesitate a long time before ascribing any symptoms to a movable kid- ney unless the kidney can be felt, and even then we should try to eliminate pathological conditions of any other abdominal organ. After a positive diag- nosis has been made, the physician will be perplexed over and over again to know just how much of the symptoms of which the patient complains should 614 MOVABLE KIDNEY. be attributed to the faulty position of the kidney and just how much to a neurotic element. I will mention briefly some of the conditions with which movable kidney is most likely to be confused, and give a few points of differential diagnosis. Distended Gall Bladder. — A very movable right kidney may descend to the left so far as to protrude as a rounded organ beneath the margin of the liver and be confused with the gall bladder. By manipulating the kidney or by turning the patient on her right side, it may be forced back into its normal position. In these cases there is usually a sufficient absence of previous history to suggest involvement of the gall ducts, and the jaundice which may occur is. said to be not so intense as that caused by a tumor of the gall bladder. Although both the kidney and gall bladder move with respiration, the for- mer can be grasped and held down during expiration, while the latter cannot. The gall bladder can be moved to the right or to the left but not downward, while a freely movable or floating kidney can be displaced in almost any direc- tion. Also the edge of the liver can usually be felt separate and distinct from the movable kidney, whereas, between the gall bladder and liver there is no sharp and definite demarcation. The position of the colon, especially when dis- tended, may in some cases be helpful in differentiating the two conditions. A movable kidney when displaced has a tendency to slip back into its position in the loin, whereas a gall bladder, although it may be pushed back into the loin, will tend to spring forward to the anterior portion of the abdomen. It must be borne in mind that a movable kidney and a distended gall bladder frequently occur in the same person, and each may cause symptoms. Tumors Arising from the Pelvis. — That a floating kidney may be confused with timiors arising from the pelvis is well shown by a case operated upon at the Johns Hopkins Hospital. A white woman, age forty-six (Gyn. Xo. 10286), mother of six children, entered the hospital in February, 1903, with the following history: In September, 1901, she noticed considerable sore- ness in both groins, and while palpating her abdomen observed a lump in her right side which she could move about almost anywhere in the abdomen. In February, 1902, she consulted a physician, who examined her and told her she had an ovarian tumor. Since then she had had considerable discomfort on the right side, mostly a dull, throbbing, aching pain, which was usually confined in the right groin, but which at times ran upward under the " small ribs." The pain was worse at night and patient rested best on her left side. She had had backache ever since she had borne children. Her appetite was good, her bowels regTilar, and micturition normal. After a thorough examination, including a distention of the kidney with sterile water and reproduction of the exact pain, a diagnosis of movable kidney was made, and nephrorrhaphy done, with a complete relief of symptoms. Before venturing a diagnosis in doubtful cases between movable kidney and a tumor of pelvic origin, a vaginal or rectal examination should DIFFEKENTIAL DIAGNOSIS. 615 always be made, for in many cases a distinct pedicle can be felt connecting the tumor with the pelvis, which instantly clinches the diagnosis. The order of frequency of the various tumors arising from the pelvis which are confused with the kidney is, probably, ovarian cysts (usually dermoid) ; pedunculate, subserous, uterine myomata ; and occasionally paro- varian cysts. ISTaturally, these tumors would have to be fairly small and with a long pedicle. The points to be emphasized in differentiating these tumors from movable kidney are: (1) A careful history of the onset and duration. (2) Impossibility of displacement upward behind the ribs into the loin. (3) Possibility of feeling tumor on vaginal or rectal examination. (4) Possibility of distinguishing a pedicle, on vaginal or rectal examina- tion, felt to connect the tumor with the pelvis. (5) Movement in the arc of a circle, whose centre is in the pelvis. (6) A gradual increase in size demonstrated by careful observation. Tumors of the Pylorus. — A case reported by Osier ("Lectures on the Diagnosis of Abdominal Tumors "), in which he mistook a tumor of the pylorus for a floating kidney, illustrates the similarity which may occur between the two conditions. His case was a colored woman, aged fifty-six years, who entered the hos- pital complaining of pain in the abdomen and vomiting. She had been married twelve years and had had six children and four miscarriages. She was always healthy until the onset of her present symptoms, which were entirely of a gastro-intestinal nature, about four months before her admission. The physical examination was as follows : " The walls are very loose, flabby, and thrown into many folds. In the right hypochondriac and right epigastric regions there is a marked rounded prominence, which extends below to within two centimetres of navel and reaches nearly to middle line. It descends slightly with inspiration. On palpation this proves to be a solid mass, which can be grasped and is freely movable. It is irregular, rounded, not reniform, but is smooth at its upper and right borders, more irregular below and to the left, but a definite hilum is not to be felt. To the touch there is conveyed a sense of firm yet elastic resistance, such as is given by a solid organ. On prolonged palpation no gas is felt passing through it. It is extraordinarily mobile and can be pushed into the epigastric region far over into the right hypochondriac region, and below into the right lumbar and iliac regions to a level with the line of the anterior superior spines. On firm pressure the liver margin can even be forced into the iliac region. It can also be pushed into the right hypochondriac region, so as to be covered almost completely by the ribs, and in subsequent examinations this was not infrequently the situation in which it was found, and from which it could be dislocated only by the deepest inspiration or by deep pressure in the renal region. The mass is not tender even on firm pressure. There is dulness over it, but not complete flatness. The patient notices that 616 MOVABLE KIDNEY. the mass changes in position as she moves about, and when she sits up it moves far down into the abdomen, while when on her back it is frequently beneath ihe right ribs. When this mass is out from beneath the right costal margin the right kidney cannot be felt, nor on the left side on the deepest inspiration, could the kidney be palpated. Beyond these are depressions in the renal regions. The edge of the liver cannot be felt; the area of splenic dulness is not in- creased ; the edge cannot be reached even on deep inspiration." In discussing the case, Dr. Osier mentioned the possibility of a pyloric tumor, but concluded by saying: " Here the mass is of unusual mobility and can be passed into the renal region on the right side. It has not a reniform shape, but it has the consistence and resistance of the kidney. A point very much in favor of its renal character is the mobility dovTiward, and a tumor of this sort, which can be pushed up beneath the ribs and also far down to the iliac regions, is certainly highly suggestive of floating kidney. Another impor- tant fact is that, in a woman with such a lax abdominal wall, no right kidney can be felt. The gastric disturbance and dilatation of the stomach present are both explicable on the view that this tumor mass has compressed the duodenum and caused a secondary dilatation. Xor is this, considering the history of so many cases, inconsistent with the view that the tumor mass may be really a kidney. On the other hand, the tumor has not the shape of a kidney and a distinct hilum cannot be felt. Xo left kidney can be palpated, and it may be that this is an instance of conglomerate kidney, such as was found in Polk's celebrated case." An exploratory laparotomy showed the tumor to be a solid growth of the anterior wall and lesser curvature of the stomach in the pelvic region. It is very rare that a case as confusing as this one is encountered, for if a careful history is taken-with especial reference to the duration of symptoms and loss of weight and strength, and a thorough j^hysical examination is made, com- bined with a microscopical and chemical examination of the gastric contents, a diagnosis is usually not difficult. Nephrolithiasis. — Stone in the kidney or nephrolithiasis may give symptoms which closely resemble those occurring with a movable kidney, and vice versa. For a differentiation, a careful microscopical examination- of the urine, together with its reaction, is important, and it is especially helpful to contrast the urines obtained by catheterization of each ureter. The urine obtained from catheterization of the ureter on the suspected side should be examined for small fragments of calculus which may be brought do^vn. The X-ray is naturally a valuable aid in differential diagnosis, but it cannot always be relied upon, for the stone may be so soft or else so located that it is not shown on the radiograph. A more valuable means of diagnosis is the wax-tip catheter, which is made by immersing the end of an ordinary ureteral catheter in a mixture of dentist's wax and olive oil. This is then passed up into the kidney, withdrawn, and DIFFERENTIAL DIAGNOSIS. 617 examined with a hand-lens, when, if a stone is present, little gouges or excava- tions can be seen in the wax, whereas a normal pelvis or ureter will leave the tip unaltered (see Fig. 27, p. 29). Eecal Accumulations. — The beginner, in palpating for a movable kid- ney, may sometimes be confused by the accumulations in the colon, but after a little practice the soft boggy feel of the feces becomes almost pathognomonic. Probably the best single means at our disposal of differentiating pathological conditions of the kidney, especially movable kidney, from affections not of renal origin is the artificial reproduction of renal colic. For those who may be interested, this method is published by Kelly (loc. cit.) and H. T. Hutchins (Amer. Jour. Ohst., 1906, vol. 54, p. 331), and will be described here only briefly. After a thorough history relative to any previous kidney or bladder trouble is obtained, the patient is told that the bladder will be examined, and nothing is said of the kidney. With the patient in the knee-breast position, a catheter just large enough to fill the ureter is passed up into the renal pelvis ; the patient is then allowed to lie on her side, and the rate of flow of urine from that kidney is carefully noted. A syringe filled with sterile water colored with methylene blue is now attached to the catheter and the fluid is slowly forced into the kid- ney, the exact amount being measured, provision having been previously made to collect reflux, should any occur. As soon as the pelvis is moderately dis- tended, there will naturally be some pain, and almost invariably the patient will, without any questioning, volunteer the information as to the character of the pain, whether it is the same pain of which she has previously suffered or not. If her former pains are not re- produced, the chances are that the kidney is not at fault; if they are reproduced, there is very little doubt as to the renal origin. It is a good plan in studying a movable kidney to make an aniline outline according to the method described in Chapter I, p. 17, and then to transcribe this to a gauze record as shown in Figure 161. Treatment. — As in other pathological conditions, so in movable kidney, there are numerous treatments which, although harmless per se, are yet dangerous in that they give false hope and consume the time which should be given to more effective measures. I refer to such as electricity, massage, and cold Fig. 161. — Gauze Record of Displacement of the Right Kidney. 618 MOVABLE KIDNEY. showers, which theoretically tone up the weak and flaccid abdominal wall, increase the intra-abdominal pressure, and give a better support to the viscera, but which practically are of very little value. Palliative.-^ Among the palliative, or to speak more correctly, non- operative forms of treatment for displaced kidney the bandage is, perhaps, the most important. In many cases a properly fitting bandage, combined with the use of suitable gymnastic exercises, not only affords temporary relief, but effects a permanent cure. The cases suited for treatment by means of a band- age are numerous; indeed, the only class in which it is contra-indicated are those in which hydronephrosis has begun, and these can be readily excluded by catheterization and injection of the kidney. A properly fitting bandage should give relief as soon as it is put on. There is no fixed period of time during which it should be worn. It is of great importance that gymnastic exercises should be employed in connection with the bandage, in order to streng-then the abdominal muscles.* These can be taken in the morning before the bandage is put on or in the evening after it is removed. They consist of some form of bending movements which bring the abdominal muscles into action, and the physician should prescribe those which he thinks most likely to be beneficial in each case. Many patients with a displaced kidney are much emaciated, and in such cases everything should be done to increase the body weight. Specific directions must be given for diet and the kinds of food carefully selected. The methods of eating also must be regiilated, and the directions on this point given for the treatment of neurasthenia will be found valuable in the class of patients now under discussion (see Chap. XXIII). With improvement in nutrition and an increase in the strength of the abdom- inal muscles a displaced kidney may become &s.ed in its normal position, and even when there is no fixation, anatomically speaking, all the symptoms may be relieved and the relief persist even after the bandage is disused. It must always be remembered, however, that there are some cases in which it is impossible to give relief by means of a bandage, and this may be due to some anatomical peculiarity in the individual. The bandage itseK should be snugly fitting and made of an elastic mate- rial. Its upper border ought to be just below the margin of the ribs and its lower at the iliac crest. The entire lower part of the abdomen should be covered. Such a bandage should always have some kind of attachment by which it is pulled down. Any intelligent instrument maker can make such a bandage, but in no case should the physician allow his patient to definitely adopt it until he has assured himself that it fits. I have found it of service in cases where the bandage is made from measurements to send a pattern, cut from the patient. The principle of the bandage is to afford support to the lower abdomen ; very occasionally additional benefit may be secured by placing an extra pad inside of it so that pressure is applied just where the kidney would descend. The bandage should always be applied while the patient is lying down. It may seem superfluous to say that before applying it the kid- TREATMENT. 619 ney should be replaced in its proper position in the loin, but, as a matter of fact, patients will often complain that they have not been relieved by a band- age or have even been made worse by it, and upon examination it will be found that the kidney is in the iliac fossa or in the opposite side of the abdomen with the tight bandage above it ! In no case should a bandage be applied with- out first excluding all kidney disease other than the movable kidney. In case tlie symptoms are not relieved and the physician has assured him- self that there is no fault in its mode of application, he should begin to think of some other renal condition as the cause of the trouble and consult a spe- cialist. It must always be remembered that certain patients are so much annoyed by a bandage that they do not improve as they should. During an attack of renal colic the patient should be put to bed and kept flat on her back until all acute symptoms have subsided. Some sedative, as trional, codein, or even morphin, is indicated, and hot fomentations to the ab- domen prove both soothing and helpful. If the gastro-intestinal symptoms are prominent, a limited diet, preferably liquid, is advisable for a few days after the attack. Radical. — (1) ISTephrorrhaphy. — ''Stitching up" the kidney gives the best results of any method of treating nephroptosis of which we are acquainted. It is difficult to lay down any general rule to determine which cases are and which are not suitable for nephrorrhaphy, for each case must be decided to a great extent upon its own merits. We may, however, divide all cases of nephroptosis into three great groups with reference to nephrorrhaphy. (a) Those cases in which nephrorrhaphy is contra-indicated. — Under this heading we include all cases which have given no symptoms, and especially those cases of which the patient herself is ignorant; also those cases of unilateral or bilateral nephroptosis associated with marked general viscerop- tosis, and in which the symptoms are relieved by a suitable binder. Even if the bandage does not give relief, nephropexy is still contra-indicated unless the symptoms are very severe and can be shown to be caused by the kidney and not by the descensus of the other viscera. (6) Those in which nephrorrhaphy may or may not be done, according to influencing factors. — This group comprises the largest number of cases of nephroptosis with symptoms. What would in some cases be ample indication for an operation would not in other cases be sufficient to justify it. Naturally, we would not hastily advise an operation in a woman of the better class who leads a life of ease and who, with the aid of a binder, gets along fairly comfortably ; whereas, the same pathological conditions found in a washerwoman who is upon her feet all day at hard work and to whom health is absolutely essential, would be sufficient indication for radical treat- ment. We must also be duly influenced by the mental and nervous condition of the patient, for naturally we can hope for and expect better results in per- sons who are intelligent and frank about their symptoms, than in those who are neurotic and prone to emphasize every little ailment. Probably the one 620 MOVABLE KIDNEY. most important symptom which should guide us in our course of treatment is pain, and we should hesitate a long time before advising operation solely for nervous or gastro-intestinal disorders; for these latter symptoms are so fre- quently associated with a neurotic temperament that unless we are extremely careful we are apt to bring a valuable ojDeration into disrepute b}^ applying it to unsuitable cases. (c) Cases in which nephrorrhaphy is absolutely indicated. — When in spite of a quiet life, rest in the recumbent posture, and a carefully applied binder, the pain, faintness, and other acute symptoms continue, more radical treatment is absolutely indi- cated, both for the relief of symptoms and the prevention of compli- cations. A few statistics gathered from the gynecological records of the Johns Ho]3- kins Hospital will convey an idea of the frequency of nephrorrhaphy at this institution. In the first thirteen thousand three hundred and thirty-eight gynecological patients admitted, the right kidney was suspended one hundred and twenty- seven times. It was suspended alone in seventy-two cases, with the left kidney in ten cases, and with other operations in forty-five cases. The left kidney was suspended thirty-eight times, in twenty-eight of which there was no other operation, while in the other ten cases the right kidney was also suspended. In all these cases only one was in the colored race and one hundred and fifty-five in the whites. There were no deaths. Of the thirteen thousand three hundred and thirty-eight cases admitted, approximately eight thousand were white patients, showing that of all white cases admitted to the gynecological service, less than two per cent were operated upon for movable kidney. As mentioned previously, statistics carefully taken in reference to movable kidney among gynecological patients, indicate that it occurs in twenty per cent or more of all cases. Thus we see that less than ten per cent of all cases of movable kidney in white women are operated upon, showing how foolish it would be to advise radical treatment, simply because the kidney was in an abnormal position. The result of nephropexy, when done in suitable cases, is excellent, being successful in nearly one hundred per cent of cases. The failures which occur can usually be attributed either to too hasty operation in cases which have not been properly differentiated, or to the fact that there is some other pathological condition in the kidney which has been overlooked and to which appropriate treatment should also have been given. Sometimes after nephror- rhaphy there is a slight dragging pain which was not present before operation, but which is so trifiing compared with the symptoms relieved by operation, that the patient considers herself cured. The mortality of nephrorrhaphy in the hands of the best surgeons TREATMENT. 621 is jDractieally nil, while the mortality by all operators, both good and bad taken together, would probably be less than three per cent. The advantages of nephropexy over nephrectomy are numerous and self- evident. It would be poor judgment, to say the least, to remove an organ when a conservative operation will give the same or even better results, with a far smaller mortality. (2) JN^ephrectomy. — As m.entioned above, nephrectomy should never be done in a simple uncomplicated movable kidney. There are, however, times when nephrectomy is necessary and the operation of choice, but then the indi- cation is not the mobility of the kidney but some other pathological condition which is coincident with or resultant from it, such as tuberculosis, stone, or a high grade of hydronephrosis. Also it is sometimes justifiable in cases of floating kidney which have become more or less fixed in some other portion of the abdomen and cannot be replaced in the loin. Before removing a kidney it is necessary to be sure that the other kidney is normal and capable of doing compensatory work. CHAPTEE XXVI. POST-OPERATIVE CONDITIONS. General health, p. 622. Constipation, p. 625. Food, p. 625. Exercise, p. 625. Local pain, p. 626. Headache, p. 627. Menstruation, p. 627. Artificial menopause, p. 628. Suppuration of abdominal wound, p. 631. Enlargement of scar, p. 632. Tenderness of scar, p. 632. Alteration in position of intestines, p. 632. Hernia, p. 633. Ileus, p. 633. Fever, p. 634. The constantly increasing nnmber of gynecological operations during the last twenty years has taught the medical profession many things in connection with them which were not at first understood. One of these facts is that an uninterrupted immediate convalescence, after a major, or even a minor opera- tion, does not necessarily imply the immediate and complete recovery of perfect health on the part of the patient. A period of months, and in many cases of a year or more, must often elapse before the woman who has been relieved of a serious pelvic affection really reaches normal health once more. This retardation of complete recovery arises partly from the shock of the operation, but it is far more frequently the result of a general depreciation of health wrought by years of suffering, of disturbed sleep, of impaired digestion, of deprivation of fresh air and exercise, and, in many cases, of constant anxiety as to the outcome of the ailment. To rejuvenate vital forces which have, for a long time, been more or less profoundly exhausted, is a task which often re- quires much constant care and attention in the fateful post-operative period, but it is one well worth the pains, for upon the management or the mismanagement of the case at this time the patient's future well-being, in a large measure, depends. It is, as a rule, upon the broad shoulders of the general practitioner that this burden falls, and happy is he who, in these days of multi-surgery, carries this burden well. Only a small proportion of our patients are able to continue to command the services of the specialist who has done the operation for any considerable period afterwards ; indeed, many of those who come from a distance are in the utmost haste to return to their homes as soon as their immediate recovery is assured and the healing of the wound will permit. These patients must, of necessity, depend entirely upon their family physician for attention during the (often prolonged) surgical convalescences of which I speak. Let me, as far as I have light upon this important subject, dwell upon some of the important features of a home convalescence. General Rules. — First and foremost, the golden rule for physician and surgeon alike is this : ISTever tell a patient that if she consents to any surgical 622 GENEBAL HYGIENIC MEASUKES. 623 operation, however necessary it may be, she may expect at once to be a well woman when she rises from the bed. On the contrary, inform her explicitly that she may be obliged to travel the road towards health for weeks, or months, or sometimes even longer. The operation must never be recommended as a piece of legerdemain, or in any sense a sort of a miracle, but simply as an absolutely necessary first step on the road towards health. Until this first step is taken, none of the other steps towards the goal can follow. Too often a feeling of magic associated with the operation is impressed by innuendo, or perhaps by the eager attitude of the doctor, anxious to persuade his patient to take a necessary step and to see her started on the way. Greater care in stating the case correctly, giving the operation its true share and no more, will cause fewer heartburns and reproaches, as the weary patient travels the tiresome road towards complete convalescence. The daily life of the patient should be carefully regulated for at least a year after an operation done to remove a cause of protracted ill health. This necessity for subsequent care depends not so much upon the extent of the operation, or the size of a tumor removed, as upon the length of previous suffering, and the wearisome vigils, with consequent depreciation of the strength. A patient of this kind ought for several months to take her breakfast in bed, and then not to dress for from half an hour to an hour later. She will also do well to rest for half an hour before and after each meal, and, if possible, lie down for an hour every afternoon. In order to get the benefit of her afternoon rest, she should take off all heavy clothing, corsets, and shoes, put on a loose wrapper, and lie flat on the bed or on a com- fortable lounge. Most restful of all is it to doff the day clothes down to the skin and to put on a nightgown. It is not advisable to read anything in these brief rest periods, for if she can sleep, so much the better. She ought to go early to bed, not later than ten o'clock, and this rule should be inflexible. Rest then is the sheet anchor of a convalescence. Many persons sleep better if they take some light refreshment just before retiring, a glass of milk, a raw egg, a cup of hot malted milk, a sandwich, or some crackers ; occasionally, on the other hand, food taken just before sleep disturbs the rest. Bad sleepers and over- nervous women sometimes wake up in the wee hours and keep lonely vigils until they are utterly exhausted; for such cases some light nourishment taken when they wake is often enough to induce sleep again. The periods of rest by day, as well as that by night, should be taken in a well-ventilated, cool room. If there is a porch available, there is no tonic half so good as the bracing fresh air, both by day and by night, with the body well covered in a cozy bed. I believe that in the near future we are destined to hear much more about the out-of-door, open-air treatment of our surgical cases, both immediately after the operation and in the later convalescence. The appetite and the digestion call for careful attention and super- vision, and, as a rule, it is a good plan to prescribe some form of bitter tonic. The following I have often found useful : 624 POST-OPERATIVE CONDITIONS ^ Extr. gentian, _, ~ , ■ ?■ aa cr -i Extr. calumb., ) ' & • j M. Et. pil. i. Mitte tales 100. . S. One pill three times daily. If there is much anemia, and iron is needed, I know nothing better than our old stand-by, Blaud's pill, given in gradually increasing doses (see Chap. VI, p. 156). Iron may also be given effectively in combination with quinine and strychnin. 3^ Eerri sulph. exsic gr. j Quin. sulph gr. ij Strych. sulph gr. -jV M. Et. pil. i. Mitte tales 100. S. One after each meal. In cases where nervous exhaustion is well marked, nux vomica in increasing doses, as recommended by Osier, is often beneficial. Begin with ten drops in water, three times a day, and increase the amount by one drop with each dose, until the patient takes twenty or even as much as twenty-five drops, three times a day. If there is any twitching, or stiffness of the jaws, the remedy must be discontinued for a time and resumed later, in a smaller dose. It may be objected that such a careful course of living reduces the patient to a condition of semi-invalidism, and that, hampered by such restrictions, she has but little larger opportunity to enjoy life than before the operation, which was accepted as an open sesame to health. The wise physician will make answer that the operation was only done because it was necessary to health, and that if health can be secured, the purchase price of a longer or a shorter convalescence is not a matter of such great moment, provided the wage question does not have to enter into the calculation. The wise patient will learn that rest and quietude have their lessons to teach, and that time thus employed may be even more profitably spent than days of bustling activity. It often happens that she who thus rests much alone, for the first time faces the real issues of life, and is for the first time startled to hear the still small voice of the long-stifled inward monitor, more potent in the formation of character than all the obtrusive noisy activities of the world of society. He, too, is a wise physician who seeks to inculcate this lesson. The plan I have thus briefly outlined will be modified and adapted to meet the necessities of individual cases. Write over the door of every convales- cent woman festiyia lente, and let it be the parting greeting after each visit. The physician Avill do well to have such an understanding, not only with the patient, but with her relatives as well, in order that, realizing the benefits to accrue, they may lend their hearty cooperation and refrain from vain imagin- ings that because the patient is not immediately restored, the operation has not CONSTIPATION. FOOD. EXERCISE. 625 been a success. There is no greater charity for a poor, self-supporting woman •than to ^ive her a good long holiday, in the country if possible. Some short- sighted philanthropic souls unfortunately take it for granted that into the hos- pital and out again is all that the occasion calls for, and that anything short of immediate recovery is a species of ingTatitude on the patient's part. Constipation. — For some time after most abdominal operations the patient is apt to be troubled with a constipation, which may be obdurate ; the physician must see to it that the bowels are kept regular. The means of doing this are discussed at length in Chapter VIII, and I Avill not repeat them here further than to remark that I have found cascara sagrada the best drug, both in the period of immediate recovery as well as in the more remote. The dose of the fluid extract is ten to thirty drops, and of the tincture half a teaspoonful to two dessertspoonfuls. It not infrequently happens that cases where a large dose is needed in the beginning are able to decrease it after a little while, and by continuing to diminish it by degrees, a normal condition of the bowels is at last established, which requires no interference. I would repeat Sanger's urgent injunction — away with drugs, use general massage, give electricity over the ab- domen, and insist on a natural evacuation, even if it takes days to get nature to do it unaided. This course takes courage, but it has the backing of our best men. If it is tried, it must be with conviction. If the physician is willing to fight the battle without drugs, but finds that the general tonic remedy has not been sufficient to regulate the habit, I find the simplest and best of all means of aiding the patient is the use from time to time of a flaxseed enema. This is made in the following manner: Two tablespoonfuls of the whole seeds are put in a pint of cold water, brought to the boiling point, and boiled for ten minutes. The mucilaginous solution thus made is strained through a fine sieve and allowed to stand until tepid, when it is injected slowly into the bowel. The best time to do this is about half an hour after breakfast. An enema of this kind, being similar in consistency with the bowel movement, is calculated to have a soothing effect upon the mucosa of the bowel. Food is an important factor in the treatment, and daily evacuations must not be expected where only small amounts are taken. The diet ought to be looked after, up to complete recovery ; it should be simple and nutritious, and not too concentrated. A little food between meals serves to prevent exhaustion ; it acts also as a mild diversion, helping to divide up the day pleasantly, and to relieve the tedium of waiting for the health which sometimes seems to come on leaden wings. Exercise. — The question of exercise during a protracted convalescence is im- portant. At first, a little at home, then out onto the porch, and then perhaps a drive, or a walk for a short distance. When the means are limited, the trolley cars often offer diversion and variety with plenty of fresh air. With the grow- ing improvement, regular out-door exercise or employment of a character suited to strength and taste should be encouraged. It is a mistake, however, to 41 626 POST-OPEKATIVE CONDITIOlSrS. advise anytliing strongly against natural inclinations and tastes. Light gar- dening, when available, is a most beneficial occupation. Tennis is too strenuous an exercise, but croquet and golf are excellent. When the patient is free to do as she pleases, it is often a wise plan to send her for a few months to some mountain or sea-side resort, v\'here she can have plenty of op- portunity for exercise in the fresh air, coupled with pleasant companionship. Lifting and straining must be forbidden for about a year after a laparotomy, in order not to strain an abdominal scar. Alternate rest and exercise, duly proportioned and supplementing one another, are by far the most valuable means we possess of restoring com- plete health. And although these simple natural processes are by no means so dramatic and so impressive as some of the other resources of our medical arma- mentarium, they are, nevertheless, by far the most valuable; and, albeit they seem so simple, by far the most difficult to use correctly and successfully. Local Pain. — Of all the distressing sequelae, pain is the most likely to plunge the patient who has been through an operation into despondency, and to delay the convalescence. It is a fact that an habitual pain does not by any means always disappear immediately after the operation, even when the cause has been removed. As a rule, it is relieved at once, but where it has existed for years, and especially where much morphin has been given, the " pain-habit " may be established, and it takes time and close attention to break it off. The experienced physician will always assure his patient in advance that the con- tinuance of a certain amount of suffering is not inconsistent with its complete disappearance in the near future. He must exercise extreme caution in using remedies for pain at this time, as the risk of a drug habit is as great as before the operation. A patient of some moral fibre will often bear the pain cheerfully when assured that it will soon go. If she is hypersensitive, nervous, and lacking in force of character, it may be necessary to give some relief, but it must not be any form of opium, and it ought not to be a drug; it should come from the moral force of the physician himself, as he upholds and carries the weakling along, day by day, until she can at last stand alone. If any drug is given, it ought to be in the physician's hands and not in the patient's, who is always safer if she does not know what she is taking. The worst sufferers and the most difiicult to control for some time after an operation are those women who have been in the habit of taking morphin to relieve their pain. I have cured a great many morphin maniacs by doing an operation and then, after the patient is confined to her bed and I have entire control of her, I do not allow any sedative whatever to be given. There may be a great deal of suffering for a few days or a week, but she comes out of her trial impressed by the fact that she is able, after all, to bear some real severe pain without the drug. In this way a certain amount of moral force is de- veloped in a character which seemed before to be lacking. In other cases the habit is best broken off gradually. The patient may be too weak and prostrated by her disease to stand the immediate withdrawal of a drug which, in some HEADACHE. MENSTRUATION. 627 cases, she has been taking in large amounts, as much as fifty grains per day. In such cases the large part of the battle consists in the personal interest shown by the physician, and in the moral support he gives the patient in keeping up her courage as she joins with him in the fight for emancipation from the en- slaving habit. The battle with the drug can always be won if the physician adopts the right attitude, and secures first the confidence of the patient and then her cooperation. It is most important during the stress of the battle to keep careful watch upon any visiting relatives, friends, or old nurses, who may undo all the good that has been accomplished by bringing in the drug in an underhand way. There are a certain class of hysterical patients who are inclined to exag- gerate suffering and who refuse to acknowledge the relief they have received ; these call for extreme patience and a calm judicial treatment of their com- plaints, coupled with persistence in a right course when it is once carefully mapped out. Headache. — Besides the pelvic suffering associated with the particular lesion from which the patient has suffered, there is sometimes a tendency to head- ache, which only time can overcome. These headaches, as a rule, are the ex- pression of an exhausted nervous system, whose capacity for resistance has been sapped by long-continued ill health; they disappear as vigor comes back and the nervous system regains its tone. In some cases, nux vomica in substan- tial doses (twenty to twenty-five drops) Avill do much to give relief, but the best dependence is time, with fresh air, and the slower process of building up the general health. Local pains and headaches are often good gauges of the pa- tient's staying powers. If the pain comes on after walking, driving, or any other exertion, it may, as a rule, be taken as an indication that the patient has rather exceeded the wise limit of her strength ; and if, in time, the headaches show no tendency to decrease in severity or frequency, it is evident that the nervous system is still over-taxed and the cause must be sought out. If there is no steady improvement in the patient's general or local condition from month to month, it is always best to communicate with the specialist who had her under his care ; but if the improvement is steady, however slow it may be, there is no reason for anxiety. Menstruation. — Most of the affections in women for which pelvic operations are performed are accompanied by disturbances of menstruation, and it may be some time before the function is again normal in its performance, even though the abnormal conditions which led to its disturbance are removed. All such patients must be extremely careful during menstrua- tion for a considerable time. It is, as a rule, best at first to remain in bed as long as the flow lasts, and the ordinary habits of life at that time must be resumed with caution. For some patients it is sufii- cient to spend the first twenty-four hours of the period in bed. Curettage of the uterus is almost always followed by some disturbance of menstrua- tion, especially as regards amount, which is often excessive for one or two 628 POST-OPERATIVE CONDITION'S. periods, althougli sometimes the flow is temporarily absent or scanty. When the curetting has been done for the relief of menorrhagia, it often happens that the first menstrual period, and it may be the second and the third, will be as jDrofnse as before the oi^eration, or even more so, a fact which is apt to excite apprehension in the patient's mind, lest the operation has been a fail- ure. It is important, therefore, for the physician to assure her that the diffi- culty is one of common occurrence and will subside spontaneously in the course of a few months. It is best for the physician to tell the patient before any pelvic operation that she must not expect her menstrual period to be normal immediately afterwards. In this way he will relieve a gTeat deal of appre- hension when the period is delayed, or when it is excessive. Artificial Menopause. — When an artificial menopause has been in- duced, the patient will experience more or less of the discomforts incidental to the normal change of life. The severity is in proportion to the age of the. patient; that is to say, the nearer she is to the normal menopause the less will be the discomfort, but if the artificial cessation of menstruation occurs early in life, the disturbances accompanying it are most distressing. They are generally first experienced about the time when the next period after the operation should appear, and they usually continue for eighteen months to two years. In excep- tional cases, they last for as much as five years. Waves of heat and flushes passing over the body at intervals like a draught of hot air are the commonest of these manifestations; sometimes the face is reddened and there may be a feeling of giddiness. Some patients complain of a sen- sation of a gulf suddenly yawning before them, accompanied by a dread of falling into it. These sensations last for a few seconds to several minutes, and after they subside, there is a feeling of great ex- haustion, while the skin is covered with perspiration. Some per- sons suffer from great depression, almost amounting to melancholia, while others are troubled with constantly recurring headaches. Sometimes the symptoms recur at regular intervals corresponding to the menstrual periods; in other cases there is no definite pe- riodicity. Obscure rheu- matic pains in different parts of the body are a frequent symptom, and lo- FiG. 162. — Diagram showixg XoDrxE of Ovahiax Tissue 1 " 1 1 -P f 1 .\djacext to the Right Uterixe Cohxu axd Causixg caiizeci C Clem a 01 tUC Mexstrtjatiox. In this case a double oophorectomv had lionrlc o-nrl -Poof moTT l^o r,h presumably been done. ^ naUClb anQ.ieei may DC OD- served. I liave re]ieatedly had patients come to me, more frequently ten or fifteen years ago than of late, who liad been operated upon for some pelvic disease, ARTIFICIAL MENOPAUSE. 629 Fig. 163. — Diagram showing the Results of Hematoma For- mation AND Infection Arising from a Nodule such as SHOWN IN Fig. 162. whicli in the judgment of the surgeon had necessitated the removal of both ovaries, who yet continued to menstruate regularly. After some experience with this class of cases, 1 was able to aver that on opening the abdomen I would find traces of ovarian tissue and corpora lutea at one or ^au^^^z^^^i other cornu uteri (see Fig. 1G2), in the form of a few little nodules cut off close to the ligature. Sometimes this little bit of ovarian tissue does a great deal of mischief by forming a hematoma or a cyst (see Fig. 163), and contracting adhesions to the neighboring loops of intes- tines. In cases of this kind there has often been a local- ized infection. Schmalfuss (" Zur Castration bei l^eurosen," Arcli. f. Gyn., 1885, vol. 26, p. 1) divides the neuroses occurring under these circumstances into the follow- ing classes: (1) Symptoms referred to the lumbar section of the spinal cord, such as throbbing and pain in the back, pain in the iliac region, pain extending from the back to the abdomen and radiating down the thighs, pressure in the pelvis, downward tugging, anesthesia or hyperesthesia of the vagina and vulva, and pain on urination and defecation. (2) Neurotic symptoms localized in different parts of the body, such as cardialgia, pressure in the epigastrium, sensation of fulness, belching, vomiting, and globus hystericus. (3) A distinct neuropathic condition, with general pain, vaso- motor disturbance, vicarious menstruation, respiratory, gastric, and intestinal attacks of various sorts, cramps, and epileptiform convulsions. Of all the sequelEe following. the production of an artificial menopause, in- sanity is the most important. It may, however, occur after any pelvic opera- tion, and even after one done for some condition belonging to general surgery. The class of women most apt to become insane under such conditions are those who have well-marked neurotic temperaments, and in women of this kind, especiallv if there is any family history of mental disease, the induction of an artificial menopause for any reason less important than the preservation of life would seem to be contraindicated. The treatment of the symjDtoms accompanying the artificial meno- pause does not differ in any way from that of the same conditions occurring with a normal change of life, and will be found described in Chapter III (see p. 90). 630 POST-OPERATIVE CONDITIONS. I have been able to give a great deal of relief in these cases by the adminis- tration of lutein in twenty grain doses, three times a day; in some cases given continuously, in others given periodically when the discomforts are greatest, and continued for about ten days at a time. The lutein is made by squeezing out the corjDora lutea from the ovaries of the pig obtained at the slaughter- house. The corpora are then rapidly dried, powdered, and compressed into tablets. In many instances I have obtained remarkable results from the use of this remedy. I have not found the ordinary ovarian extract made from the dried tissues of the ovary itself of any particular value. There is one prescription, which I give here, that I have found to be most beneficial in the class of women now under discussion: 1 30 1 300 ^ Strych. sulpli gr Atrop. sulph gr Extr. calumb gT. j M. Ft. pil. i. Mitte tales 30. S. One pill three times daily. Phlebitis. — Phlebitis is an inflammatory affection of the veins, resulting in the formation of a thrombus, by which the lumen of the vein becomes occluded. In the milder forms of phlebitis the occlusion is only temporary, lasting little over a couple of weeks, but in the severer gTades the venous lumen is permanently occluded, and the return blood is compelled to find new channels. There are two forms of phlebitis, the septic and the non-septic. Sep- tic phlebitis is especially noted in puerperal cases and after septic opera- tions, and is, therefore, but rarely encountered as a sequel to gynecological procedures. I speak here only of those forms of phlebitis which are seen in the lower abdomen and the legs, more particularly in the femoral veins. Phlebitis may begin in the deep veins of the pelvis, as evidenced by the fever and location of the pain before the onset of the femoral phlebitis. The commonest site of the pain and tenderness at first, however, is over the femoral vein right under Poupart's ligament, from which point they extend in a char- acteristic line down the thigh, follow^ing the great vessels. Kronig believes that the phlebitis usually begins in the femoral vessels and that it is mechanical in its genesis. The usual time of onset is about two weeks after the operation of which it is the sequel. The cardinal and distressing signs of phlebitis are: (1) 'Pain in the pelvis and the thigh affected. (2) Edema of the leg. (3) Embolism, formed by the thrombus breaking loose and migrating to the lungs. Fever, usually of a low grade and short duration, is observed preceding and accompanying the attack. PHLEBITIS. SUPPUKATION OF THE WOUND. Q3J The danger of embolism is over before the patient leaves the hospital, and therefore does not concern the general practitioner in his management of the case after she has returned to her home. I have observed phlebitis after the following operations : Hystero-myomectomy • 24 times Removal of the vermiform appendix 2 " Removal of ovarian cysts. 8 " Exploratory laparotomy 3 " Salpingo-oophorectomy 6 " Hysterectomy for cancer 4 " Suspension of the uterus 7 " Suspension of the kidney 3 " Repair of the relaxed vaginal outlet 10 " Opening and draining of a pelvic abscess 1 time The treatment of phlebitis is never one of active local therapy. A patient suffering from it must not be hurried home from the hospital, but should stay at least five weeks in bed on her back after the onset of this trouble- some complication. When the patient reaches home she is liable to suffer from pain and from the swelling. The course of treatment should then be, first of all, expectant. She must understand that no great improvement is observable, as a rule, in a period of time less than eight to twelve months. Patience must therefore be inculcated from the first. An elastic bandage applied each day before rising gives much relief by supporting the limb and preventing edema. The patient should spend much of her time in rest, and keep the limb elevated. Massage is helpful in restoring the circulation. If there is much swelling of the superficial veins during convalescence it should not be interfered with. I know of a case in which the enterprising doctors dissected out the swollen veins of the thigh and abdomen which formed the relief circulation; the result was a gangrene of the thigh calling for a hip- joint amputation. I do not recall any case of phlebitis which has not recovered, though the improvement in some cases has been not less than two years in coming. Suppuration of the Wound. — A suppuration developing in the wound some time after the operation is always a sign of a lingering infection which, as a rule, has developed in the post-operative period. This suppuration may occur in the abdominal wall covering the wound, or arise from the deeper parts. The superficial suppurations, as a rule, arise from the use of non-absorbable suture material, chromicized catgut, silk, silver wire, or silkworm-gut. In the days Avhen it was customary to tie off the pedicles with silk (especially braided silk), it was common to note the fistula? discharging pus, due to infection of the deep ligatures. Every case of suppuration should be treated seriously. In the acute stage, poultices should be applied, and as soon as the wound is sufficiently opened, it should be carefully examined with a crochet hook to see if there is 532 POST-OPEEATIVE CONDITIONS. a ligature within, wbicli can be eauglit and ^yitlldra^vn. It is always best for the general practitioner to be present at operations upon bis patient, and to be fully informed at tbe time, both as to the exact operation done and the charac- ter of the sutures and ligatures used. In this way he will be able to form a better idea as to the cause of the suppuration should it occur. Some of the late suppurations arise from the slow healing of a drainage tract, in cases in which it has been necessary to drain the pelvis, because of an extensive infec- tion. If the suppuration is more than a slight abscess, it would be best to give the patient an anesthetic, to open the wound freely, determine its cause and remove it, and then to let the wound close up with free drainage. Small areas may be cleaned out and douched with carbolic acid, in the hope of a rapid recovery. Enlargement of the Scar. — It frequently happens that a patient who has been very thin, even emaciated, for a long time before a radical operation, in conse- quence of continued ill health, begins to gain flesh as soon as her ailments are relieved. If she gains in weight rapidly, the scar will yield from side to side, as the girth of the abdomen increases, until it becomes as much as two centi- metres (three-fourths of an inch) or more in width; moreover, it often becomes pitted, pigmented, and unsightly. I know of nothing to improve this condition, and I do not believe that any kind of bandage does any good. There is a tendency, especially among negTesses, to the formation of keloids in the scar tissue. Tenderness of the Scar. — "While the wound is young and pink, it is somewhat common for the patient to complain of soreness, itching, or shooting pains in the scar. In nervous women this tenderness may persist for years. Eelief is best obtained by gentle massage and by arranging the clothing so as to avoid direct pressure on the sensitive area. Alteration in the Position of the Intestines. — One of the sequela? brought about shortly after the operation is alteration in the position of the intestines, and it may continue to give trouble for a considerable time. Additional loops of intestine drop down into the pelvis in order to fill the vacated space, and adhesions of the omentum and intestine over the inner surface of the peri- toneum are apt to be formed. These adhesions do not, as a rule, give rise to serious trouble, though in a certain number of cases they occasion pain in the lower abdomen, with tormina, nausea, and vomiting from constant dragging upon the transverse colon and pulling the stomach downward. In some cases they occasion obstinate constipation. As a rule, disturbances of this kind do not require any interference and pass away of themselves before long, but they are occasionally so severe as to make it best to send the patient back to the surgeon who operated, in order that he may decide whether it is necessary to re- open the abdomen for relief. The release of the adhesions with an aseptic closing of the abdomen has been followed by immediate disappearance of all bad symptoms in those cases where they have been severe enough to require operative procedures. HERNIA. ILEUS. 633 Hernia. — The most serious of all post-operative local conditions is, of course, a ventral hernia in the abdominal scar. The number of such hernias becomes less every year, with the progressive improvement of surgical technic and the careful training of operators ; nevertheless, they do occasionally occur, especially when the patient has overexerted herself before recovery was complete, and when increase in weight has been unusually rapid. There is only one form of treatment which can be relied upon for permanent relief, namely, radical operation, and such cases should be placed in a surgeon's hands as soon as possible. Palliative treatment by means of supports gives temporary re- lief, but as the tendency of all such hernias is to grow larger, it can be of no permanent benefit. Ileus. — Among the more serious late sequelae is an ileus, or a post-operative obstruction of the bowels. This untoward sequel may develop from little begin- nings, such as a rumbling and twisting with pain, which grows gradually worse from week to week ; or it may come on as an acute obstruction. Hand in hand with the difficulty in moving the bowels go the pains or tormina. The pain is developed by the contractions in the bowel, proximal to the obstruction ; in thin patients the pattern of the contracting loops can be traced on the surface of the abdomen. With the contraction, more or less gurgling is heard. Such a difficulty arises, as a rule, from the post-operative adhesions, either to the abdominal wall about the incision, or to the seat of the operation, as an ovarian or a uterine stump. Sometimes it is due to a broad film of adhesions (forming immediately after the operation) which by the movements of the bowel has been rolled together to form a powerful lymph as strong as a rope. As a rule, such difficulties show themselves while the patient is still in the hands of the surgeon, who must continue to supervise his patient until he is sure no late accident is liable to arise. If mild remedies do not succeed in keeping the patient's bowels open, and if the tendency toward ileus is clearly progressive for a few days, the practi- tioner ought not to wait long, but should put his patient again in the care of the surgeon, in order that he may carefully consider the question whether or not the abdomen ought to be opened to liberate all adhesions. It is better to err on the side of early action in these cases, than to wait until long and ex- hausting efforts have robbed the patient of much of her strength before making the incision and undertaking what may prove to be a long and difficult operation. The cancer cases which are sent back by the surgeon to die in the hands of the general practitioner must not be neglected by him. They ought, on account of their condition, to receive even more constant tender care than the more promising, hopeful cases. I have already dwelt on these cases in the chapter on inoperable cancer of the womb (see Chap. XXI). In all of these cancer cases, it is important to keep the parts clean with repeated douches and applications where the disease can be reached, to keep the bowels open, to keep up nutrition, and as long as the patient is able to bear it, to keep her in the fresh air. Mild sedatives may be used to relieve the pains at first, and later 634 POST-OPEEATIVE CO^'DITIO>"S. morpliin will have to be used, but it is be~t tri priitp'one tlii? period as long as possible, in order to husband ciur resijurce- in 'it-Lding v.-ith the pains during the last few months. The morphin should \>e used at first as sparingly as pos- sible, in doses of an eighth of a grain, gradually increased according" to neces- sity, in Tvhatever lLj-c- niay }>e required to relieve the suffering. Fever is a late sequel -which the general ^jractitioner riught not to see. Any fever observed at a late date can l)e but the contintiance of some post-operative infection. Tvhich must have manifested itself vrhile the patient was still in bed. l^o siu'geon ever discharges a febrile patient. If fever arises after a normal convalescence, the physician must look fca- n.alaria. and carefully consider typhoid, or some other new affection. One 'of ri;v i ;,Tif>nts v.-h'j had a suspension of the uterus, as she was getting well deveLj]--; n. liiysterious fever which I cotild ncit explain in any way. She left my care and carne back six months later with a tertiary syphilis I In numerous cases I have seen malaria break otit. and typhoid fever, too, in the course of the convalescence, ptizzling f'jr a time all who were caring for the invalid. Latent tul:>erculosis mav also manifest itself in this wav. CHAPTER XXVII. DISEASES OF ADVANCED AGE. Marriage, p. 636. Pruritus, p. 636. Cancer of the clitoris and vulva, p. 636. Tumor of the urethra, p. 636. Hypersensitive vaginal orifice and atrophy of the vagina, p. 637. Vaginitis of atrophic character, p. 637. Cancer of the womb, p. 638. Pyokolpos, pyometra and physometra, p. 639. Fibroid tumors, p. 640. Ovarian tumors, p. 640. It is universally and naturally conceded that an advanced age ought at least to afford immunity from all those diseases which affect the sexual organs, which have done their work and passed into a condition of presumably innocuous desuetude. For this reason, any signs of activity in the pelvic organs of the old or any apparent " rejuvenescence " in the form of a bloody discharge is naturally viewed with suspicion and alarm. There is reason, therefore, whether on the ground of timely warning or of reassurance, for a brief consideration of the affections of age, even though we define this period somewhat loosely and with apologies for the lower limit assumed, as one beginning some years after the menopause, say in the fifties, and extending to the close of life. Age, as we shall see, gives no complete immunity from gynecological dis- eases, even though the special functions of the organs have been long in abey- ance. I shall consider the question of the relation of age to these special diseases from a double point of view : First, to what diseases are the old liable ? Sec- ondly, when surgical procedures are called for, do the old bear them as well or worse than younger women; in other words, is age any contraindication to an operation ? The changes occurring in age are characteristic. They begin imperceptibly with the menopause, but do not become strikingly evident for many years, so slowly do they advance. The chief characteristic is an atrophy or a hypoplastic condition of the organs and tissues. The uterus becomes as small as that of a girl before puberty, the ovaries are sclerotic and contracted, linear or beanlike fibrous structures containing no maturating follicles, the uterine tubes are also greatly lessened in size and no longer trumpet-shaped. The external genitals present a withered appearance, the hair becomes gray, the labia withered and flaccid, and the vaginal outlet is smooth and inelastic, while the vagina also has lost its rugse and is converted into a smooth inelastic tube. 635 636 DISEASES OF ADVANCED AGE. The following conditions call for consideration in advanced age: ( 1 ) Marriage. (2) Pruritus. (3) Cancer of the clitoris and vulva. (4) Vascular tumors of the urethra. (5) Sensitive vaginal orifice, and atrophy of the vagina. (6) Vaginitis with or without occlusion of the vagina. (7) Cancer of neck or of the body of womb. (8) Pyokolpos, pyometra and physometra. (9) Fibroid uterine tumors. (10) Ovarian tumors. (1) Marriage. — A first marriage in a woman who is well beyond the meno- pause is usually a serious mistake if her husband is physically vigorous. Only a complacent, convenient marriage of two old people for companionship may entail no hardship upon the wife, who is unfitted at this time of life to begin her sexual activities. Let the woman of advanced age remain single if she will not suffer pain and humiliation. (2) Pruritus in the old differs in no way from that in younger women, ex- cept that it is oftener seen in an aggTavated form, having begun at an earlier period and existed longer. These cases usually call for surgery to extirpate the disease, sometimes completely removing both labia and the clitoris. Such operations are safe and well borne, the age of the patient does not in any de- gree increase the risk. (3) Cancer of the clitoris and vulva are sometimes found in the old, and de- mand a most radical operation, including the extirpation of inguinal glands of the affected side. Here, too, age is no contraindication to the most exten- sive eradication of the disease. (4) Tumor of the Urethra. — Vascular tumors are occasionally found at the external urethral orifice in women past the menopause. These are of three kinds : (a) More or less from infiltrated rapidly growing ulcerated excrescence, a cancerous growth, sometimes associated with cancer in the adjacent tissues. (&) A pedunculated deep-red sensitive caruncle which has no particular relation to this time of life. (c) A thickening and eversion of the lips of the urethra, appearing when closely examined like a prolajose of the urethral mucosa. I think that in the case of any marked eversion of the lips of the urethra causing discomfort and bleeding readily, the physician would do well to con- sult a specialist before treating the cases to make sure they are not malignant. In the moderate eversions presenting red pouting lips, the best treatment is a two- per-cent solution of silver nitrate, applied every other day on a cotton pledget pressed against the parts and held there for t^\'enty to thirty seconds. Occa- sionally a patient can be taught to treat herself, and this is better, as the treat- VAGINITIS OF AN ATROPHIC CHARACTER. 637 ment may have to be kept up for some weeks and again resmned on the slight- est evidence of a return of the difBculty. (5) Hypersensitive Vaginal Orifice and Atrophy of the Vagina. — With the ex- treme involution of the vagina it becomes narrov^er and shorter and its walls lose all traces of the folds and corrugations found at an earlier period. The mucosa becomes pale with spots here and there, and the outlet has the same smooth appearance with perhaps a remnant of two or a caruncle. A smooth outlet with spots like ecchymosis is often sensitive, and a source of much dis- comfort in the marital relation. I know of no other way of treating these cases than the application of that sovereign remedy for inflamed mucous membrane, silver nitrate in a three- to five-per-cent solution on alternate days, coupled, with the advice to make free use of a lubricant to lessen the friction in the sexual approach. (6) Vaginitis, or more correctly kolpitis, of an atrophic character is, perhaps, the commonest and the most characteristic of the genital diseases of the aged. It is rarely met with before the menopause, but becomes frequent from about the age of fifty upwards. The patient has sensations of burning, weight and bearing down, a fullness in the pelvis, which is soon associated with a slight purulent discharge, some- times tinged with blood. The blood in the discharge lends great importance to this distressing, but not dangerous malady, as it is for this reason apt to be mistaken for a cancer by the general practitioner. Let me here earnestly remark that it is far better to err in this safe direction than to commit the opposite error ; it is better to think that every suspicious case is cancer until the contrary is clearly proved. Do not wait until the diagnosis is made certain by the supervention of other symptoms. The diagnosis of vaginitis senilis is probable when a patient who has had a slight leucorrheal discharge notes a slight bloody stain also on her napkin. Examination shows the usual senile changes in the vagina, while the vaginal vault is the seat of the most marked alterations. The vault is narrower, and often ends in a. little pocket not much larger than the end of the finger or thumb. In this pocket the diminutive cervix may be felt with difficulty. Again, a striking characteristic of a case may be one or two sharp-edged falciform folds at the vaginal vault, shutting off a pocket above. The best way to examine these cases is in the knee^breast position, when the vagina distends and all parts can be well seen through a small tubular speculum with a stout handle. The sharp folds stand out with pockets above them, and the little reddened cervix is easily distinguished. The etiology of the condition appears to be this : the parts having lost their vitality and resisting powers are easily invaded by the common pyogenic organ- isms, an inflammation is set up with ulceration, and destruction of the super- ficial epithelium, then, either healing takes place with the formation of scar tissue, which on shortening forms the falciform bands felt, or agglutination of 638 DISEASES OF ADVANCED AGE. opposed inflamed surfaces occurs with a corresjjondiug narrowing of the vagi- nal vault This process is then but a simple senile vaginitis carried some steps farther. In almost every instance the marked anatomical changes take place at the vaginal vault, where the secretions natui'ally stagnate. Treatment. — Douches serve well to keep the parts clean, but have no per- manent curative value. A warm boric-acid (5j to a pint) douche may be given twice a day to remove the secretions. The curative treatment must be applied in the doctor's ofiice. It is sometimes a strong temptation to break up all septa and separate adher- ent surfaces under anestheti-c, hoping by subsequent packings to keep up the parts separated until they have healed again in their normal relationships. I cannot commend this plan for two reasons — first of all, the trouble in- variably gravitates back to its old status, and in the second place, the patient is really not suffering from these completed changes, but from the underlying inflammatory process which has produced them. The treatment must then be directed to the disease — ^to destroying, or so far inhibiting the activities of the pus-producing organisms that the inflam- mation disappears. This is done by putting the patient in the knee-breast posture and introduc- ing a cylindrical speculum as large as she can comfortably bear. (See Figs. Y6A and B.) With a head mirror the whole vagina is inspected and all secretions removed with pledgets of cotton; then take a cotton applicator and saturate it with a five-per-cent solution of silver nitrate, and swab the whole vagina thor- oughly with this, reaching the bottom of every crevice and every pit, and seeing that the application reaches all parts, as the speculum is withdrawn, all the way down to and including the external oriflce. There may be some disa- greeable aching after this, so it is well to keep her abed for a few hours or a day. Xo douches are to be taken for three or four days. As soon as the sil- ver-cauterized surface epithelium begins to come off, which it may do in one piece, douches are used twice a day until another application is to be made in from ten days to two weeks. From one to three such treatments may suf- fice to cure the disease, or at least check it so decidedly that it is no longer annoying. (7) Cancer of the Womb. — Cancer of the womb occurs frequently in women of advanced age. In Wertheim's list of 500 cases of cancer of the cervix (" Die Erweiterte Abdominale Operation bei Carcinoma Colli Uteri," 1911) there were 154 over fifty = 30.8 jDcr cent, showing the frequency and importance of considering both the liability and the dangers of an operation at this period. It is not my purpose to dwell upon this subject further than to point out that the disease occurs with this relative frequency, and to note as well that age constitutes no obstacle whatever to a radical operation for its relief. In- deed the disease often advances more slowly and is less malignant in the aged than in the young. PYOKOLPOS, PYOMETEA AND PIIYSOMETRA. 639 (8) Pyokolpos, Pyometra and Physometra. — These conditions are marked bj an accumulation of pus in the vagina, and in the uterus, or by air in the uterus. They are closely allied conditions due to an occlusion in the genital tract with an accumulation of secretions above it. Pyokolpos is rare, I have seen but one case, that figured in the text. The patient, fifty-seven years old, had had some operation for atresia about puberty. She then menstruated normally all her life, remained unmarried, and passed through a natural menopause at forty-five. Twelve years later she came to me complain- ing intensely of her bladder. I found an atresia of the vagina (see Fig. 164) about an inch inside, and above this a large fluctuating tumor, on top of which the body of the uterus sat like a cap, well below the umbilicus. Some hard nodules felt by rectum justified the di- agnosis of atresia of the vagina, with a large pyokolpos due to cancer of the womb and vagina. I opened the narrow bridge of the atresia by a careful dissection between rec- tum and vagina, and let out about 500 c.c. of pus from the vagina, and then by pres- sure emptied about 50 c.c. from the uterus itself; the cervix and vagina were found to be the seat of an extensive cancerous growth. Pyometra is a commoner affection and is one of the truly characteristic diseases of the old (the other being occlusive vaginitis). It arises from an occlusion of the cervix, due to a disease associated with a discharge of an infectious nature; that is to say, either an endocervicitis or a cancer of the cervix. Let me speak first of the latter. Oftentimes a patient, especially an elderly woman, has a slow growing cancer which chokes the cervix and dams up any uterine secretions, and these of the tumor above until the uterus becomes a thinned-out distended sac full of pus, or, if gases, too, are formed, of pu.s and air (pyo-physometra). These patients suffer from much lower abdominal tenderness, which the physician is too apt to attribute to the obvious cancer, they are relieved as soon as the cancer is scraped away, affording a free exit to the pus pent up in the womb. It behooves the doctor, therefore, always to be alert in his cancer cases, looking for such accumulations in cancer patients who complain of much pain. Again, when a simple endocervicitis occludes the neck the result is the same; in time a painful, purulent accumulation forms, and this, unless he is Fig. 164. — Pyokolpos and Pyometra DUE TO Complete Stricture of the Vagina. 640 DISEASES OF ^IDTAXCED AGE, miicli on liis guard, the attending physician will mistake for a simple cervi- citis and vaginitis. He mnst look with more than suspicion on every elderlv woman who Tias a fetid leucon*hea, w^hich varies considerably in amount and is associated with tormenting pains at intervals. The first step is to dilate the cervical canal and to make sure by curettage that there is no cancer developing inside the cervical canal or in the uterine body. After this evacuation a free exit must be maintained by using cervical dilators, and there are none better than Hegar's graduated series. It is not nec- essary to expand the canal more than 10-12 mm. in diameter, and this is better done with these instruments than with the usual branched dilators, which are more liable to rupture the friable tissues. After dilating the cervix: and emptying the uterine sac, then apply thoroughly on a pledget of cotton, or on a strip of gauze, with a string attached, a solution of formalin, 1 : 2,000, to be left in situ for half an hour. This should be done every three or four days until the infection clears up and the secretion from the uterus looks like simple mucus. (9) Fibroid Tumors. — Two things should be known about fibroid tumors, rirst, that they do occur with considerable frequency in the old. Out of 1,307 cases reported upon by T. S. Cullen and myself, there were 196 between forty-six and fifty years of age :^ to fifteen per cent ; there were 101 cases between fifty-one and sixty years = 7.7 per cent, and there were 13 over sixty-one years. The second fact of importance is to be able to assure any patient in advanced years, approaching such an operation, that age alone has no appreciable effect upon the outcome of an operation. Fibroid tumors do not call for operation unless they are doing some harm. A tumor choking the pelvis or a larger tumor making serious or distressing pressure on the abdominal viscera, or a tumor complicated by lateral inflammatory disease calls for operation. (10) Ovarian Tumors. — The ovaries begin to atrophy with the menopause, and so confer a relative immunity to tumors of these organs. Still, ovarian tumors have been observed, and the dread in an elderly woman of such an operation is apt to be so great that it becomes a matter of importance to in- FiG. 165. — Hegar Dilators. Very valuable in slow dila- tions of the cer\'ix uteri for dysmenorrhea, also in dilat- ing the urethra. OVAEIAKT TUMORS. 641 quire how frequently these cases are seen, and what are the statistics of oper- ations for their relief. Bland-Sutton (" Surgical Diseases of the Ovaries and Fallopian Tubes ") inquired into this subject in the late eighties, and in the early nineties I investigated it with Dr. Mary Sherwood, collecting in all " 100 cases of ovariotomy performed in women over seventy years of age." We found that although a number of the cases dated back to the early ovariotomy days, and many operators w^ere concerned, yet the surprisingly low mortality of twelve per cent prevailed. Thirty of the cases were over seventy-four years, and only two of these died. There were only two dermoid cysts. About 40 cases in this creditable list are to be set to the account of our countrymen. For the encouragement of any thus afflicted I append a list of all the cases of eighty years and over I have been able to find. (See " Surgical Dis- eases of the Ovaries," 1896. Bland-Sutton.) Schroeder Pippingskold . . . Owens Richardson .... Heywood Smith . Homans Spencer Edis. Bush Remfrey Kraft Owens * Thornton Cartledge 80 R. 80 R. 80 R. 80 R. 81 R. 82 R. 82 R. 81 R. 84 R. 83 R. 84 R. 87 R. 94 R. 803^ R. " Krankheiten d. Weibl. Geschl." "Finska Laken Handlingen," Helsingfors, 1884. J. Brit. Gyn. Soc, iv., p. 88. Brit. M. J., 1891, i., p. 523. Lancet, 1894, i., p. 1618. Bost. M. and S. J., 1888, p. 454. Brit. M. J., 1893, ii., p. 1271. Brit. M. J., 1892, i., p. 860. Brit. M. J., 1894, ii., p. 67. Tr. Obstet. Soc. London, xxxvii, p. 152. Hospitalstidende, Copenhagen. Lancet, 1895, i., p. 542. Tr. Obstet. Soc. London, xxxvii., p. 158. South. Sur. and Gyn. Trans., 1896, p. 153. * A second operation on third patient on this list. The first two cases are added from a nearly similar list given by Leonard Eemfrey in the Trans, of the Obstet. Soc. of London, 1895, p. 158. The last one was operated upon by Morgan Cartledge and is recorded in the South. Sur. and Gyn. Trans., 1896, p. 153. Spencer Wells (" Ovarian and Uterine Tumors," 1882, p. 256) remarks: " Dr. Ogle writes to me that in deaths due to ovarian dropsy or ovariotomy during the past ten years, seven were of women over eighty-five years of age." This is evidently from the public health records of Great Britain. Leon Peaudeleau {Marseilles medical, 1903, p. 756) records a case of an ovarian cyst found post mortem in a woman of eighty-two. 42 INDEX Abdomen, chain of organs on right side of, 28. examination of, 6. Abdominal operation. See operation. Abel, Mrs. Mary Hinman, on training young girls for home life, 42. Aberle, on hysteria and floating kidney, 597. Abortion, 452. artificial, 303, 473. complications of, 460. criminal, 473. definition of, 452. etiology of, 454. frequency of, 452, history of, 452. incomplete, 165. mechanism of, 457. " missed," 454. prognosis of, 460. septic, 470. symptoms and diagnosis of, 458. threatened, 165. treatment of, 460. Acetanilid, use of, in treatment of head- ache, 235. Acetone in treatment of inoperable can- cer, 539. Acne, facial, associated with constipation, 207. Acromegaly, association of, with amenor- rhea, 148. Addison's disease, diagnosis between, and pigmentary syphilide, 413. Adenitis, gonorrheal, 385. Adenoids in school-girls, 57. Adenoma, diagnosis of, 501. Adenomyomata, 489. Adnexa, uterine, disease of, and appendi- citis, 586, 587, 589. associated with infected fibroids, 497. Adnexa, uterine, disease of, cause of abor- tion, 456. cause of sterility, 365. removal of, for dysmenorrhea unjus- tifiable, 126. for intermenstrual pain, 137. Adrenalin in uterine hemorrhage, 185, 206, 542. Air, pure, essential to public health, 44. Albarran, on tubercular infection of blad- der, followed by other infections, 558. Alberts, case of smallpox followed by atre- sia of genital tract, 266. Albumen, presence of, in cystitis, 549. in Dietl's crisis, 589, 611, 613. in pyelitis, 548, 549. in syphilis, 426. Albuminoids, reduction of, in treatment of obesity, 246. Alcohol, effects of, on headache, 227. on menstrual flow, 149. on syphilis, 396, 441. percen+age of, in patent medicines, 114. Alcoholism a cause of abortion, 454, 456. of amenorrhea, 149. of sterility, 367. Alimentary system, syphilis of, 421. Aloes, as an emmenagogue, 160. in constipation, 220, 603. Aloin, 220. Alopecia, 420. Alum in vaginal douche, 248. Amann, on isolation of gonococcus in blood current, 378. on production of gonorrhea, 379. Amenorrhea, 140. blood in, 163. constitutional, 145, definition of, 140. from imperforate hymen, 151, 643 644 IK"DEX. Amenorrliea, from maldevelopment. 140, 177. fuuctional, 149, 159, 367. in acute diseases, 148. in atresia of genital tract, 142, 151, 153. in clilorosis, 146, 155. in chronic diseases, 148, 159. in obesity, 148, 245. in super-involution of uterus, 160. in tuberculosis, 148. mecbanical, 145. physiological, 145. priraary, 140. secondary, 140, 145. symptoms and diagnosis of, 150. treatment of, 153. Ammonia, aromatic spirits of, with coal- tars, 114, 235. chloride of, in treatment of infantile syphilis, 443. output of, in relation to total nitrogen excretion, 474. Amnion, imperfect vascularization of, a cause of abortion, 454. Amyloid degeneration of fibroid polyp, 496. Anaphrodisia a cause of sterility, 367. Anatomical causes of sterility in female, 357. Anchylosis, relation between, and coccy- godynia, 262. Anders, on diet in obesity, 247. on heredity as cause of obesity, 208. Anemia associated with amenorrhea, 148. with dysmenorrhea, 109. with fibroid tumor, 498, 504. with headache, 225, 233. with obesity, 244. Anesthesia, chloroform, in examination of fjelvic organs in child, 26. in protection of perineum, 484. general, in examination of bladder, 563. in examination of pelvic organs, 26. in mechanical evacuation of the ute- rus, 468. in pruritus, 301. in vaginismus, 307, 308. local, in excision of piece of cervix, 526. in incision of abscess of Bartholin's gland, 278. Anesthesia, local, in removal of urethral caruncle, 307. nitrous oxide gas, in diagnosis of retro- displacements, 323. in dilatation of cervix, 123. in fissure of rectmn, 38. in gynecological examination, 27. Anesthesin in treatment of pruritus, 300. Angina pectoris due to syphilis, 425. An sell, on interval between marriage and birth of first child, 350. Anteflexion of uterus. See Uterus. Antisepsis, intestinal, in treatment of chlorosis, 157. Antitoxin in diphtheritic vaginitis, 281. Anton, on statistics of hereditary syphilis, 432. Anus, fissures of, a cause of masturbation, 310. Apartment houses, effect of, on health of child, 48. Apenta water in constipation, 221. Aphthae, diagnosis between, and syphilis of oro-pharyngeal cavity, 421. Apiol, as an emmenagogue, 160. in menorrhagia, 185. Aplasia of reproductive organs a cause of amenorrhea, 140, 150. Apostoli, on galvanic current in treatment of amenorrhea, 155, 507. Appendicitis, association of, with pelvic disease, 587. cause of abortion, 455. diagnosis between, and pelvic disease, 589. dysmenorrhea associated with, 592. in child, 595. independent coexistent pelvic disease and, 589. relation between, and extra-uterine pregnancy, 589. and movable kidney, 552. simulation of, by movable kidney, 611, 612. Appendix vermif ormis, examination of, 9. Aristol in treatment of nasal syphilis, 442. Arnal, on uterine hemorrhage fromi calci- fication of uterine' blood-vessels, 178. INDEX. 645 Arnold, case of atresia of genital tract following dysentery, 266. Arseniate waters in treatment of chloro- sis, 157. Arsenic, hypodermic administration of, 157. in chlorosis, 157. in chorea, 158. in headache, 233. in obesity, 245. in pelvic disease associated with mala- ria, 272. in pruritus, 299. in splanchnoptosis, 603. manganese and, 157. Arsenious acid in cancer of uterus, 538. in chorea, 157. in pelvic disease associated with mala- ria, 272. Arterial tension, increase of, a cause of headache, 226, 233. Arterio-sclerosis in syphilis, 397. Arteritis in syphilis, 425. Arthritis, gonorrheal, 377, 381, 385. syphilitic, 428. Asafcetida, in treatment of threatened abortion, 462. in treatment of constipation, 222. milk of, as enema, 222. Ascarides, a cause of appendicitis in chil- dren, 595. a cause of pruritus, 296, 298. Ascites, complicating fibroid tumors, 500. relief of, followed by splanchnoptosis, 599. Asepsis, in dilatation of cervix, 122, 373. in gynecological examination, 6. in mechanical evacuation of uterus, 467, 469. in operation for imperforate hymen, 154. in treatment of chancre, 404. in use of intra-uterine tampons, 466, 509. in use of obstetrical forceps, 482. Ashton, on age of first menstruation, 82. on duration of menstrual period, 84. Ashwell, on treatment of pruritus in preg- nancy, 303. Aspirin in cancer, 541. in insomnia, 242. in lumbago, 250. in rheumatic headache, 234. Asymmetry in young girls, 63. Athletic fields for girls, 61. Athletics, interschool and intercollegiate, 68. outdoor, for school girl, 61. Atresia of cervix, 145, 146. of genital tract, a cause of primary amenorrhea, 140. due to infectious diseases, 142, 265. to cholera, 267. to diphtheria, 267. to dysentery, 266. to erysipelas, 267. to measles, 267. to pneumonia, 267. to scarlatina, 143, 266, 267. to smallpox, 266. to typhoid fever, 143, 266. in infants, 144. necessity for operation in, 153. Atresia of uterine tubes causing sterility, 358, 365. Atresia of vagina, congenital, 142. due to difficult labor, 145. to infectious diseases, 142, 265, 479. to pessaries, 145. to trauma, 146. Atrophy of uterus, cause of sterility, 366. in acromegaly, 148. Australia, age of first menstruation in, 83. Auto-intoxication, cause of headache, 227. Ayer's Sarsaparilla, percentage of alcohol in, 114. Azoosperraia, causes of, 352. prognosis of, 353, 369. Backache, 250. character of, 251. etiology of, 251. formulae for relief of, 256. frequency of, 250. from constipation, 208. from sacro-iliae affections. See Sacro- iliac joints, locations of, 250. 646 INDEX. Backache, massage for, 256. post-operative, 251, 260. prophylaxis of, 250. treatment of, 256. Bainbridge, on etiology of cancer, 514. Balano-preputial furrow, chancre on, 400. Baldy, W. H., on amenorrhea caused by uric acid diathesis, 149. Ball, metal, in treatment of constipation, 221. Bandage, abdominal, in acute lumbago, 250. in movable kidney, 618. in splanchnoptosis, 603. necessity for, after abdominal opera- tions, 602. Glenard's elastic, 603. Bandaging, in anemia, 206. in phlebitis, 631. Rose's method of, in splanchnoptosis, 603. Banting's method of reducing obesity, 248. Bar, on abortion, 454. Barbour, on hemorrhage from sclerosis of uterine blood-vessels, 177. Barnes, K., on vicarious menstruation, 160. Barthelemy on case of smallpox followed by atresia of genital tract, 266. Bartholinitis, 276. Bartholin's glands, abscess of, 276, 278. cyst of, 276, 277. examination of, 19. excision of, 277. infection of, after labor, 480. cause of sterility, 358, 359. in gonorrhea, 380. in vulvitis, 276, 277. susceptibility of, to gonorrheal infec- tion, 380. Basedow's disease, amenorrhea in, 148. Bashford, on malignant tumors, 516. Baths, cold, in menstruation, 72. in treatment of headache, 231. in treatment of pri;ritus, 263. hot, in amenorrhea, 160. in dysmenorrhea, 116. in headache, 231. in insomnia, 240, Baths, hot, in inenstruation, 72. in pruritus, 263, 301. mustard, 116, 231. Beard, on "phobias," 569. on trypsin in cancer, 539. Beigel, on coccygodynia in child, 261. Belt-test, 601. Bernutz and Goupil, on gonorrhea in cau- sation of. pelvic peritonitis, 375. Bertillon, table by, on annual birth rate, 348. Bichloride of mercury. See Mercury. Binkley, on appendicitis and pelvic dis- ease, 586. Bismuth subnitrate, emulsion of, for X- ray examination of stomach, 601. powder for gonorrheal infection in child, 391. Black wash, in treatment of chancre, 404. Bladder, examination of. See Cystitis, gonorrheal infection of, 376, 378, 386. inflammation of. See Cystitis, palpation of, by vagina, 13. syphilis of, 426. Blaud's pills, formula for, 156. Blood, alterations in, a cause of pruritus, 295. in chlorosis, 146, 153. in pelvic disease associated with ma- laria, 272. in syphilis, 394, 395, 398. changes in specific gravity of, in chlo- rosis, 146. in obesity, 244. Blood-letting, general, in headache, 231. local, 161. Blood-vessels, changes in, during syphilis, 397, 425. Boaz, on increase of height in young girls, 65. Boehm, on case of atresia of genital tract following typhoid fever, 266. Boldt, H. J., on cervical cancer in nulli- parae, 517. on fibroid tumors and heart disease, 505. on methylene blue in treatment of in- operable cancer, 537. on stypticin in treatment of uterine hemorrhage, 508. INDEX. 647 Bone, excision of spicule of, for relief of headache, 234. Bones, syphilis of, 427. Boroglycerid, action of, 324. packs in vaginitis, 285. suppositories in gonorrhea, 389. Bougies in treatment of vaginismus, 308. of iodoform, in chancre of meatus uri- narius, 404. Bourgeois, on case of erysipelas followed by atresia of genital tract, 267. Bowels, care of, after abdominal opera- tions, 222. before abdominal operations, 221. during prolonged convalescence, 628. evacuation of, hindered by tight corset, 213. importance of daily habit in, 31, 53, 212. influence of diet on, 209. proper posture in, 210. Brace, steel spring, in treatment of sacro- iliac joint relaxation, 259. Bradford frame in appendicitis in child, 596. Brain, disease of, cause of headache, 226. indication for abortion, 474. in syphilis, 428, 430, 431. Brandes, on abortive treatment of chan- cre, 404. Bright's disease, arterial tension in- creased in, 226. artificial abortion in, 474. headache in, 225, 226. migraine in, 237. syphilis a factor in, 426. Bromide of potash. See Potassium. Bromide of sodiiin:i. See Sodium. Bromides in gonorrhea, 386. in headache, 158, 233, 234. in insomnia, 243. Bronchi, syphilis of, 423. Brose, case of atresia of genital tract fol- lowing pneumonia, 267. on galvano-faradism in treatment of constipation, 218. Brown atrophy of heart, 504. Brunton, Lauder, formula of, for relief of rheumatic headache, 234. Bubo, 345, 402. Bumm, E., description of gonococcus by, 377. on the causes of sterility, 351. on the gonococcus in squamous epithe- lium, 378. Burnam, C. F., on cervical cancer in a nullipara, 517. Burrage, W. L., on anatomy of meatus urinarius, 380. on electricity in treatment of fibroids, 459. on heart disease and fibroids, 504. on helonias compounds, 115. on leeches applied to cervix for amenor- rhea, 145. Bursae, syphilis of, 427. Cabot, on hematuria associated with mov- able kidney, 613. Cachexia, cancerous, 518. Caffein in treatment of headache, 235. Calcification of fibroid tumor, 495. of uterine blood-vessels, a cause of hem- orrhage, 178. Calcium chloride in treatment of uterine hemorrhage, 185. Calcium lactate in treatment of dysmen- orrhea, 117. Calibration of vaginal outlet, 479. Calmann, on necessity for cultures of gonococcus, 385. Calomel, hypodermic injection of, 439. in chancre, 404. in constipation, 157, 220, 222. in gonorrhea and syphilis in child, 391. in headache, 229. in infantile syphilis, 443. in migraine, 200. in syphilis, 439, 442. in torpidity of liver, 222. in vomiting, 158. von Campe, H., on galvanic current in pruritus, 302. Camphor in treatment of vaginitis, 285. Camp-life in treatment of insomnia, 241. Cancer of cervix, age when most frequent, 169, 517. curability of, 520. diagnosis of, 520. exertion cause of hemorrhage in, 518. 648 INDEX. Cancer of cervix, local signs of, 170, 520. microscopical signs of, 170, 527. progress of, 520. relative proportion of, to cancer of fun- dus, 517. trauma in causation of, 516. Cancer of fundus, curability of, 520. curettage for purposes of diagnosis in, 170, 526. . local signs of, 170, 525. microscopical signs of, 527. Cancer of intestines, removal of piece of, for examination, 38. Cancer of pelvis complicating fibroid tu- mors, 500. Cancer of rectum, diagnosis between, and pelvic tumor, 3-1. Cancer of uterus, 513. acetone in treatment of, 539. age at whicli most frequent, 170, 517. association of, with fibroid tumors, 496. cachexia in, 169, 518. cauterization in, 536. clinical history of, 517. congenital transmission of, 517. contagion of, 514. curability of, 520, 531, 532. diagnosis of, 517. disinfection in, 516, 542, 633. duty of physician in, 516, 520, 530, 533, 542. education of public in regard to, 519, 530. emaciation in, 169, 519. endometrium in, changes of, 527, 528. etiology of, 513. examination of pelvic organs in, 520. extension of, to other organs, 508, 534. hemorrhage in, 169, 518, 519, 542. heredity in causation of, 515, 516. hygienic measures in, 541. importance of early diagnosis in, 169, 519, 530, 533. in old age, 638. infection in, 515. local signs of, 520. menstruation in, 169, 517. methylene blue in treatment of, 537. microscopic sigTis of, 525. operation for, 532, 533. Cancer of uterus, opium in treatment of, 538, 541, 634. pain in, 169, 170, 518, 519. palliative treatment of, 533. progress of, 170, 522. prophylaxis of, 630. pruritus caused by, 396. pyometra in, 533, 534. radium in treatment of, 537. trypsin in treatment of, 539. thyroid extract in treatment of, 539. vaginal discharge in, 169, 170, 518, 519. varieties of, 520. X-ray in treatment of, 537. Cannabis indica, in treatment of head- ache, 234. in treatment of imminent abortion, 462. Capillary dilatation a cause of insomnia, 238. Capsicum in constipation, 220. Carbolic acid douche in infectious disease, 271. Carbolic acid internally for vomiting, 158. Carbolic acid locally in abscess of Bar- tholin's gland, 278. in cancer of cervix, 536. in membranous dysmenorrhea, to uter- ine cavity, 131 . Carbolic acid lotion in treatment of pru- ritus, 298, 300. Carbolic acid poultice in pruritus, 301. Carbonic acid gas, inflation of stomach by, 601. treatment of gonorrhea by, in nascent state, 388. Carcinoma. See Cancer. Carlsbad, treatment of obesity at, 246. Carlsbad salts, 221, 231, 462. Carpenter, J. G., on examination of rec- tum, 34. Carriage, faulty, in young girls, 63. Caruncle, urethral, associated with vagi- nismus, 306, 307. Cascara in chronic constipation, 219. in post-operative convalescence, 222, 625. in rest cure, 580. in splanchnoptosis, 555. INDEX. 649 Casper, on prostatitis in connection with urethritis, 362. Catheter, Dickinson's two-way, 560. indications for use of, in labor, 486. injury from, 386, 544, 555. method of using, 556. self-retaining, 564. wax-tipped, in diagnosis of renal cal- culus, 29, 616. Cautery, actual, in carcinoma of uterus, 536. in cervicitis, 288. in endometritis, 294. in fibroid tumors, 509. Celsus, on abortion, 452. Cervicitis. See Endocervicitis. Cervix uteri, atresia of. See Atresia. cancer of. See Cancer. chancre of, 400. elongation of, a cause of sterility, 361. erosion of, associated with intermen- strual pain, 136, 137. cause of sterility, 361. mistaken for cancer, 525. real nature of, 21. excision of a piece of, 525. expulsion of ovum into, 457. fistula of, 478. gonorrheal infection of, the cause of sterility, 287, 361, 374. gradual dilatation of, dangers of, 122. in artificial abortion, 469, 475. in labor, 482. incision of anterior wall of, 501. infection of, after labor, 480, 486. signs of, 20. injury to, a cause of abortion, 456. inspection of, 20. laceration of, after labor, 478. associated with abortion, 461. cause of backache, 256. cause of sterility, 362. operation for repair of, 32, 486. leucorrhea from, 20, 287. plaque-like areas of, mistaken for can- cer, 525. position of, in vaginal examination, 11. rapid dilatation of, 123. after-treatment of, 126. cases suited to, 121. Cervix uteri, rapid dilatation of, dangers of, 125, 353. for dysmenorrhea, 121. for intermenstrual pain, 136. for pruritus, 299. for sterility, 371. for vaginismus, 307. in abortion, 469. in labor, 482. instruments for, 123. method of, 123. preliminaries to, 122. repair of, following laceration in labor, 486. scarification of, for suppressed menstru- ation, 159, 162. stenosis of, a cause of sterility, 358, 361, 373. associated with dysmenorrhea, 107. susceptibility of, to infection, 380, 517. ulceration of, mistaken for cancer, 518. " weeping," 287. Chancre, 399. abortive treatment of, 404, 437. diagnosis of, 402. differential diagnosis between, and chancroid, 403. digital, 401, 404. extra-genital, 401, 403. ex-ulcerative, 400. herpetiform, 400, 403. Hunterian, 400. in female, 400. incubation period of, 399. induration of, 399. labial, 401. mixed, 400. multiple, 400. nasal, 401. of eyelid, 401. of face, 401. of nipple, 401. of tongue, 401, 403. of tonsil, 401. relapsing, 401. source of infection, 449. time of appearance of, 393, 399. treatment of, 404. ulceration of, 399. varieties of, 400. 650 II^DEX. Chancroid, 403. Chantemesse and Podvryssotsky, on hered- ity in neoplasms. 515. Chapman, on frequency of dysmenorrhea, 66. Charpentier, on measles as a cause of abortion, 455. Chart showing age at which gonorrheal infection is most frequent in children, 383. Chasan, S., case of smallpox in fetus with healthy mother, 454. Chase, T. H., on appendicitis and chronic salpingitis existing independ- ently, 589. Chase, W. B., case of primary amenor- rhea. 141. on method of cauterizing uterus in can- cer, 536. Cherry laurel water in pruritus, 301. Child, appendicitis in, 595. coccygodynia in, 261. examination of pelvic organs in, 25. gonorrheal vaginitis in, 381, 389. Childbirth. See Labor. Childhood, infectious diseases in, a cause of pelvic disease, 265. Children, gonorrheal peritonitis in, 280. causes of ill-health among, 41. movable kidney in, 609. remedies for constipation in, 221. splanchnoptosis in, 602. Chloasma, uterine, diagnosis between, and pigmentary syphilide, 413. Chloral hydrate, as vaginal douche in in- operable cancer, 541. in insomnia, 242. in pruritus, 299. Chloroform liniment in backache, 258. in headache, 231. Chlorosis, ages at which most frequent, 147, 153. blood in, 146, 153. blood pigment in urine during, 158. constipation in, 119, 157. definition of, 146. dysmenorrhea in, 109. emotional disturbances in, 147. gastric symptoms in. 158. heart and arteries in, 119. Chlorosis, importance of, to gynecologist, 120. in school-girls, 119. intestinal antisepsis in treatment of, 157. menstrual disturbances in, 146, 147, 153, 179, 180, 367. nervous symptoms in, 147, 158. obesity associated with, 244, 245. pubert;s- early in, 147. relapses in, 147. rest in treatment of, 158. sexual organs in, 147. special diathesis in, 147. sterilit;^' and, 367. treatment of, 155. Cholera, atresia of genital tract following, 267. Chorio-epithelioma cause of uterine hem- orrhage, 171. de Christmas, on toxic product of the gonococcus, 379. Ciniselli, on electricity in treatment of fibroid tumors, 507. Circulation, disturbances of, abortion from, 455. constipation from, 207, 208. in movable kidney. 613. in neurasthenia, 567. uterine hemorrhage from, 180. Circulatory system, syijhilis of, 424. Claisse, A., on etiology of fibroid tumors, 494. Clark, Sir A., on copremia as a cause of chlorosis, 143, 147, 161. Clark, J. G., on radical operation for can- cer, 530. Clark and Pancoast, on redundant sig- moid in causation of constipa- tion, 213. on splanchnoptosis, 597. Climate, influence of, on first menstrua- tion, 83. on suppression of menstrual flow. 149. Clothing, unsuitability of, in women, 70. Coal-tar preparations, dangers of, 235. in dysmenorrhea, 114. in headache, 158, 235. in inoperable cancer. 541. necessity of stimulants with, 114, 235. INDEX. 651 Cobbe, Y. P., on domestic infelicity as a cause of headache in women, 227. Cocain, in nasal dysmenorrhea, 109. in pruritus, 300. in coccygodynia, 264. in vaginismus, 271. in vomiting, 158. injection of, under spinal cord, 258. Cocain anesthesia. See Anesthesia. Cocain ointment. See Ointment. Coccygodynia, 260. diagnosis of, 263. etiology of, 261. examination in, 263. faradization in, 263. first operation for, 261. frequency of, 263. massage in, 263. neuralgia and, 262. pain in, character of, 262. pelvic disease and, 262. pregnancy and, 261, 262. relation of, to rheumatism, 261. treatment of, 263. Coccyx, bimanual examination of, 29. Coe, H. C, on appendicitis and disease of uterine adnexa, 587. on malaria and ovarian pain, 272. on relation between internal secretion and amenorrhea with obesity, 148. Coifee, cause of insomnia, 239, 241. Coffey's operation for displacement of stomach, 604. Cohn, H., on myopia in school children, 57. Cohnheim's theory of neoplasms, 494, 515. Cold, exposure to, a cause of functional amenorrhea, 149, 159. College life, influence of, on health of young women, 76. College women, dysmenorrhea in, 77. Colitis, mucous, 574, 601. Colles' law, 448. Colon, atony of, a cause of constipation, 213. examination of, 36. Colon bacillus infection, effect of urotro- pin on, 557. in cystitis, 550. Colonoscope, 37. Col taperoides, 361. Complexion, effects of constipation upon, 207. Compress, cold, in headache, 231. Condylomata, diagnosis between, and non- syphilitic vegetations, 416. formation of, 400. in infantile syphilis, 443. in moist papular syphilide, 415, 416. treatment of, 442. Conglutination of labia, a cause of pri- mary amenorrhea, 144. Conjunctiva, gonorrheal infection of, 378. Conservatism in treatment of pelvic in- flammation, 344. Constipation, 207. backache from, 208, 251. classification of, 214. defective toilet accommodations a cause of, 212. definition of, 207. diagnosis of, 214. diet for, 217. during rest cure, 580. dysmenorrhea associated with, 113, 208. effects of, 207. enemata for, 221. etiology of, 212. exercise in prevention of, 213, 218. frequency of, 213. galvano-faradism for, 218. headache caused by, 214, 227. in amenorrhea, 155. in chlorosis, 147, 157. in enteroptosis, 601. in growing girl, 53, 68. in neurasthenia, 567. insomnia caused by, 241. masturbation caused by, 310. mental influence in treatment of, 216. migraine caused by, 236. morbid growths a cause of, 213, 215, 222. movable kidney caused by, 608. post-operative, 625. prophylaxis of, 216. retroflexion of uterus a cause of, 33. torpidity of liver in, 222. treatment of, 157, 216. 652 IKDEX. Constitutional diseases, cause of abortion, 455. cause of amenorrhea, l-iS. cause of uterine hemorrhage, 179. danger of curettage in, 190. indication for artificial abortion, 171. Consulting room, 1. Contagion, danger of, in pruritus, 299. question of, in cancer, 515. Copaiba, in treatment of cystitis. 559. rash from, mistaken for syphilitic erup- tion, 112. Copremia, 117, 157, 207, 241. Cornea, syphilis of, 428. " Corona veneris," 414. Corpus luteum, administration of, in amenorrhea, 159, 245. association of, with obesity, 244. disease of, a cause of hematoma, 335, 340. influence of, upon menstruation, 80, 139. upon ovum, 79. relief of symptoms at menopause, ad- ministration of, for, 95, 630. Corset, tight, hindrance of, to action of bowels, 213. to breathing, 218. injury done by, to growing girl, 70. splanchnoptosis caused by, 599. Coryza, syphilitic, 434. Cotton-root, abortion caused by, 456. Cousins, marriage of, in relation to steril- ity, 368. Craig, D. H., on early symptoms of can- cer, 519. method of curetting cervix, 289. Craig's curette, 289, 374. Cucca and Ungaro, on methylene blue in treatment of uterine cancer, 537. Cullen, T. S., on danger of tents in dila- tation of cervix, 122. on fibroid tumors, 99, 492. on formalin method of preparing micro- scopical specimens, 193. Cupping glass, Thomas', 461. Cups, dry, in treatment of dysmenorrhea. 116. Curettage of cervix. See Endocervicitis. Curettage of endometrium, before \ise of acetone, 540. Curettage of endometriiun, for endome- tritis, 294. for fibroid tumors, 188, 510. for inoperable cancer, 534. in abortion, 190, 469, 470. in diagnosis of cancer, 170, 526. in sterility, 373. instruments for, 123. method of, 189. risks in, 189, 373, 468. rules for, 189. Curette, Craig's, 290, 374. irrigating, 526. loop, 535. sharp, 189, 190, 469. spoon, 189, 535. Cushion, obstetrical, 486. Cystitis, 543. albumen in, 549. ascending, 544. catheterization a cause of, 386, 544. constitutional symptoms of, 548. cystoscopic examination of bladder in, 387, 550. definition of, 543. descending, 544. diagnosis of, 548. differential diagnosis of, 554. drugs in treatment of, 559. etiology of, 544. gonorrheal, 386, 558. infections causing, 386, 543, 549, 550, 558. instillations in treatment of, 560. irrigation in, 561. continuous, 564. labor, followed by, 480, 486, 555. latent, 544. method of taking history in, 546. opsonic treatment of, 562. post-operative, 544, 555. preventive treatment of, 488, 554. situations of, 543, 553. symptoms of. 547. topical treatment of, 561. tubercular, 554, 557. iirinary symptoms of, 547. vaginal drainage in, 562. varieties of. 543. Cystoeele, Gehruug pessary for, 327. in gynecological examination, 19. INDEX. 653 Cystoscope, Kelly open-air, 550, 552, 561. Cysts, blood, 366. Graafian, 366. of Bartholin's glands, 276. of corpus luteum, 177, 340. ovarian, 340, 366, 588, 590. papillary, 340. parovarian, 366, 373. Dactylitis, syphilitic, 428. Dana, C. L., on phrenasthenia, 569. Daniel, C, on disease of adnexa associated with fibroid tumor, 497. Darwin, G., on marriage of cousins, in re- lation to sterility, 368. Davidson syringe, 331. Decidua, dangers of retention of, after abortion, 457. gonoccoecus affecting, 378. inflammation of, 456. Deciduoma malignum. See Chorio-epithe- lioma. Defecation, act of, 208. factors in, 209. involuntary, 209. pain during, in coccygodynia, 262. proper posture in, 210, 211. Deferinitis, cause of male sterility, 352. Defloration, signs of, 359. Deletzine and Volkoff, on movable kidney in the two sexes, 608. Dercum's disease, 248. Dermo-pulmonary fumigation method of treating syphilis, 439. Descensus of uterus. See Uterus. Desk, school, 60. Diabetes, amenorrhea caused by, 148. pruritus caused by, 295, 297, 302. syphilis in etiology of, 397. Diarrhea in neurasthenia, 567. Dickinson, R. L., on elasticity of hymen, 313. on uterine hemorrhage from sclerosis of blood-vessels, 177. Dickinson's two-way catheter, 559, 560. Diet, in chlorosis, 156. in constipation, 217. in hemorrhage from uterus, 509. in movable kidney, 615. in obesity, 245, 247. Diet, in post-operative convalescence, 625. in pruritus, 299. in rest cure, 580, 581, 582. in septic abortion, 470. in splanchnoptosis, 603. regular, during menstruation, 73. in prevention of headache, 233. in prevention of insomnia, 241. in prevention of migraine, 237. Diet lists for constipation, 217. for obesity, 247. Dietetics, knowledge of, 68. Dietl, on attacks of pain in movable kid- ney, 610. Dietl's crises, 600, 601, 609, 613. artificial production of, 29, 610, 613. Digestion, disturbances of, cause of amenorrhea, 148. in neurasthenia, 567. effects of constipation on, 207. process of, 208. Dilatation of cervix. See Cervix. of sphincter for fissure of rectum, 38. of vaginal orifice, 308. Dilator, conical, for sphincter, 35. Dilators, Goodell-Ellinger, 124, 190, 373, 469, 501. Hanks', 387. Hegar's, 122, 482. Diphtheria, atresia of genital tract from, 267. Diphtheritic vaginitis, 281. Dirmoser, E., case of inflammation of ute- rine appendages during typhoid fever, 269. Diseases, acute, followed by amenorrhea, 148, 153, 159. chronic, accompanied by amenorrhea, 148, 153. exhausting, followed by splanchnopto- sis, 599, 602. Displacements of uterus. See Utertis. Diuretics in treatment of headache during pregnancy, 233. Dobell's solution in treatment of syphilis, 442. Dohm, on presence of gonococcus in mu- cous membrane, 378. Doleris, on colloid degeneration of fibroid tumors, 496. 654 INDEX. Domestic science, compulsory instruction in, at school, 42. Domestic unhappiness a cause of head- ; ache, 227. Dori, on hypodermic administration of iron in chlorosis, 156. Douches, vaginal. See Vaginal douches. Douleurs interrtienstruelles, 132. Dover's powder in treatment of acute lum- bago, 250. Drappier, on alcoholic poisoning as cause of abortion, 456. Dress of school-girl, 53. Drugs, abortion induced by, 456. Dubois, Paul, on psychotherapy, in treat- ment of constipation, 216. in treatment of neurasthenia, 584. on milk in treatment of nervous disor- ders, 579. Ducrey's bacillus, 400. Dudley, E. C, on packing uterus for hem- orrhage from fibroid tumors, 509. Dmnitriu, on use of curette for incom- plete abortion, 468. Duncan, J., on chlorosis, 146. Duncan, M., on increase of sterility, 348. on spasmodic dysmenorrhea, 108. Dunning, H. L., on senile endometritis, 294. Dupuytren, on frequency of fibroids in married women, 494. Dupuytren's pills in treatment of syphilis, 438. Dust, dangers of, in schools, 58. Dysentery, atresia of genital tract caused by, 266. inflammation of uterus in, 269. Dysmenorrhea, 105. associated with acute appendicitis, 595. with chronic appendicitis, 592. with fibroid tumors. 111, 498. with general ill-health, 109. with gout, 110. with maldevelopment of reproductive organs, 108. with neurasthenia, 109, 565, 592. with pelvic inflammation. 111, 337, 338. with rheumatism, 96, 110. with sterility, 373. Dysmenorrhea, calcium lactate in, 117. causes of, in absence of gross lesions, 107. in presence of gross lesions, 110. dilatation of cervix for, 107, 121, 373. electricity for, 117. examination of pelvic organs in, 112. formulae for relief of, 114, 115. from constipation, 113, 208. from overloaded rectum, 33. general remedial measures for, 112. in college women, 77. in displacements of uterus, 110, 318, 320. in school-girls, 66. mechanical, 107. nasal, 109. neuralgic, 110. neurotic, 108. operative treatment for, 120, 126. ovarian, 110. pessaries for, 117. reflex symptoms in, 106. remedies for immediate relief of, 113. for permanent relief of, 117. thyroid extract in, 117. varieties of, 106. Dysmenorrhea, membranous, 128. associated with sterility, 131. character of pain in, 129. clinical history of, 129. definition of, 128. diagnosis of, 130. etiology of, 129. history of, 128. macfoscopical appearances in, 129. mechanism of separation of mem- brane in, 130. microscopical appearances in, 129. treatment of, 131. Dyspareunia, 367. Ear, gonorrhea of mucous membrane in, 378. syphilis of, 429. Ears, condition of, in school-girls, 57. Ebell, case of atresia of genital tract caused by cholera, 267. Eberlin, case of atresia of genital tract caused by typhoid fever, 266. INDEX. 655 Ebstein, on treatment of obesity, 248. Eclampsia, indication for artificial abor- tion, 474. Ecthyma vulgaris, diagnosis between, and ecthyma form of syphilide, 418. Eczema, impetiginous, diagnosis between, and impetiginous form of syphil- ide, 417. Eczema of palms, diagnosis between, and syphilis, 415. Eczema of vulva, cause of masturbation, 310. cause of pruritus,' 296. diagnosis between, and vulvitis, 276. Edema, localized, during artificial meno- pause, 628. Edematous degeneration of fibroid tumor, 496. Edgar, J. C, method of dilating cervix in labor, 482, 483. Edgecombe, on fall in percentage of hemo- globin during day, 158. Education of mothers, 40, 41, 52. Education of public, prophylaxis of can- cer by, 520, 530. of infectious diseases, 50. of syphilis, 449. Egypt, age of first menstruation in, 83. Eieholz, on physical deterioration, 41. Einhorn, on frequency of splanchnoptosis, 602. Electricity in treatment of amenorrhea, 155. of coecygodynia, 260. of constipation, 218, 223. of dysmenorrhea, 117. of fibroid tumors, 507. of functional neuroses, 577. of headache, 531. of insomnia, 241. of intermenstrual pain, 136. of pruritus, 502. of sacro-iliac rheumatism, 258. of splanchnoptosis, 603. of uterine hemorrhage, 187. of vaginismus, 307. Embolism, in anemia from fibroid tumors, 504. post-operative, 630, 631. Emmenagogues, 160. Emmet, T. A., on age of first menstrua- tion, 82. on cervical cancer in nullipara?, 517. on congestive dysmenorrhea, 116. on injury to cervix a cause of abortion, 456. on irregularity of menstruation at pu- berty, 86. on length of menstrual period, 84. Emphysematous vaginitis, 281. Emplastrum de Vigo, 442. Endocarditis, association of, with fibroid tumor, 505. gonorrheal, 377, 378. syphilitic, 425. Endocervicitis, 287. cause of sterility, 361. symptoms of, 287. treatment of, 287. Endometritis, abortion caused by, 456. acute, 174, 291. chronic, 174, 291. caused by constipation, 208. danger of uterine treatment in, 31. definition of, 291. discharge in, 20. dysmenorrhea caused by, 110. following labor, 480. glandular, 175, 292. gonorrheal, 291. intermenstrual pain caused by, 136. malarial influences in, 271. membranous dysmenorrhea from, 129. polypoid, 175, 180, 292. precocious menstruation from, 82. pruritus from, 296. rarity of, 175, 291, 292. sterility caused by, 362. tubercular, 176, 291. varieties of, 293. uterine hemorrhage from, 174, 293. Endometrium, changes in, at menstrua- tion, 80, 81. from cancer, 527, 529. curettage of. See Curettage. examination of scrapings from, 191, 527. gonorrheal infection of, in children, 269. hypertrophy of, a cause of hemorrhage, 175. irritation of, by stem pessary, 155. 656 INDEX. Endometrium, normal, 80, 193, 528. rarity of inflammatory changes in, 291. tuberculosis of, 176, 291. Endoscope, Kelly, in treatment of gonor- rhea, 387. Engelmann, G., on age of first menstrua- tion in America, 83. on frequency of menstrual pain, 66. on menstruation in college women, 77. Enemata, rectal, arsenic administered by, 272. caution in use of, 222. cotton-seed oil, 222. flaxseed, 32, 222, 625. formulae for, 222. in constipation, 221. in post-operative convalescence, 222. in rest cure, 580. in splanchnoptosis, 603. purgative, 222. sedative, 115, 299. Enteritis, ulcerative, associated with syph- ilis, 423. Enteroptosis. See Splanchnoptosis. Epididymis, syphilis of, 425. Epididymitis, cause of male sterility, 352. Epilepsy, due to syphilo-toxines, 397. relation of, to migraine, 228. Epithelioma, diagnosis between, and syph- ilis of oro-pharyngeal cavity, 423. Epithelium, columnar, gonococcus infec- tion of, 378. squamous, gonococcus infection of, 378. Epispadias, cause of male sterility, 347, 352. Epsom salts. See Magnesium sulphate. Erb, on galvano-faradism in treatment of constipation, 218. Ergot in expectant treatment of abortion, 463. in hemorrhage after abortion, 469. in uterine hemorrhage, 185, 508. Ergotin in headache with low arterial ten- sion, 233. in uterine hemorrhage, 185. Erosions of cervix. See Cervix. Eruption, syphilitic, 394, 411. Eruptive fevers. See Exanthemata. Erysipelas, abortion caused by, 455. atresia of genital tract caused by, 267. Erythema multiforme, diagnosis between, and a syi^hilitic eruption, 412. Erythema of mouth and throat, syphilitic, 421. Esophagus, syiDhilis of, 423. Esquimaux, age of first menstruation among, 83. Ethyl, chloride of, local anesthesia from, 277. Examination, gynecological, 5. abdominal, 6. anesthesia in, 26. bimanual, 11. by inspection, 19. by palpation, 10. by rectum, 33. gauze records in, 17. in child, 25. in knee-breast posture, 23. in Sims' posture, 23. in virgins, 27. notes of, 29. of colon, 9. of gaU-bladder, 8. of hemorrhoidal region, 38. of kidney, 7. of liver, 8. of sigmoid flexure, 9. of stomach, 9. of vermiform appendix, 9. of vulva, 19. pain in, 27. standing, 26. trimanual, 13. vaginal, 10. Examining room, 1. Examining table, 6. Exanthemata, endometritis due to, 270. membranous dysmenorrhea from, 129. ovaries affected in, 268, 270. Excitement, amenorrhea due to, 149. insomnia due to, 238. migraine due to, 237. Exercise, outdoor, during menstruation, 73. effect of, on hemoglobin, 158. for school-girl, 61. importance of, at puberty, 68. in amenorrhea, 155. in constipation, 218. INDEX. 657 Exercise, outdoor, in dysmenorrhea, 113. in headache, 231. in pelvic diseases, 30. in prophylaxis of migraine, 237. in pruritus, 299. lack of, a cause of constipation, 199. Exercises, breathing, in constipation, 218. gymnastic, for school-girl, 59. in constipation, 218, 223, in headache, 232. in movable kidney, 618. in splanchnoptosis, 603. Exfoliative vaginitis, 281. Exophthalmos, 576. Exstrophy a cause of male sterility, 352. Extension in treatment of sacro-iliac joint relaxation, 259. Extra-uterine pregnancy. See Pregnancy. Eye, syphilis of, 428. Eyelid, chancre of, 401. Eyes, examination of, in school-girls, 56. Eyestrain, at menstrual periods, 106. headache caused by, 226. in school-girls, 56. Faradic current. See Electricity. Fatigability, characteristic of neurasthe- nia, 567, 573. Fatigue, avoidance of, in prophylaxis of migraine, 237. Fatty degeneration of heart associated with fibroid tumors, 504. Fatty infiltration of heart associated with fibroid tumors, 504. Fenwick, on association between fibroid tumor and heart disease, 505. Fermentation in lower intestine a cause of headache, 227. Fetus, adhesions between, and membranes, 454. death of, from infection, 454. deformities of, from hemorrhage into chorion, 454. unusual size of, a cause of extra-uterine pregnancy, 195. Fever, during post-operative convales- cence, 634. headache due to, 226. syphilitic, 394. Fibro-cystic degeneration of fibroid tu- mors, 496. Fibroid tumors, abortion due to, 499, 504. age at which most frequent, 493. anemia from, 498, 504. ascites mistaken for, 500. cancer of pelvis mistaken for, 500. classification of, 489. complications of, 496. constipation from, 503. danger to life from, 505. definition of, 488. degeneration of, 495. delivery obstructed by, 480, 503, 504. diagnosis of, 498. direction of grovTth of, 490. dysmenorrhea from. 111, 498. effect of, on distant organs, 504. on neighboring organs, 503. etiology of, 494. in families, 494. frequency of, 493. gauze record of, 19. gelatin in treatment of, 508, 509. heart disease associated with, 504. hemorrhage from, 168, 180, 497, 506. heredity in causation of, 494. infection in causation of, 494. infection of, 496. in negro race, 493. in old age, 640. interstitial, diagnosis of, 500. distortion of uterine cavity by, 490. locations of, 490. intra-uterine treatment of, 509. latent, 495. leucorrhea in, 498. life history in, 494. origin of, 489. packing in treatment of, 509. pain in, 498. pedunculate, 168, 169, 499, 501, 510. pelvic inflammation complicating, 500. pregnancy with, 499, 512. radical operation for, 512. rectum choked by, 33. rest in treatment of, 506. sexual irritation a cause of, 494. situations of, 493. sterility from, 363, 364, 373, 499, 504. 658 INDEX. Fibroid tumors, structure of, 488. submucous, 168, .500. diagnosis of, 501. distortion of uterine cavity by, 491. dysmenorrhea from, 111. expulsion of, from cervix, 491. manner of growth of, 491. method of removal of, 510. non-operative treatment of, 506. surgical treatment of, 509. subperitoneal, diagnosis of, 499. dysmenorrhea from, 111. manner of growth of, 490. non-operative treatment of, 506. stypticin in treatment of, 508. symptoms of, 497. thyroid extract in treatment of, 508. treatment of, 505. ureters compressed by, 503. vaginal douches in treatment of, 508. varieties of, 489. Fibromyoma. See Fibroid tumor. Fibrosis of external genitalia a cause of pruritus, 296. Finger, on azoospermia, 296. on inoculation of monkeys with syphi- litic serum, 398. Fischel, on vicarious menstruation, 162. Fish-berries, decoction of, in treatment of pruritus, 298. Fistula, cervico-vaginal, 478. repair of, 486. Fissures in ano, cause of masturbation, 310. treatment of, in j)rophylaxis of abortion, 461. Fissures of rectum mistaken for disease of uterus and ovaries, 34. Flaischler, on treatment of pruritus, 301. Flat-foot, neurasthenia from, 568. Flaxseed enemata. See Enemata. Fleck, on relation between fibroid tumors and heart disease, 505. Fleiss, on nasal dysmenorrhea, 109. Fletcher system of mastication, 580. Forceps, alligator, 35, 38. axis traction, 482, 483. rules for use of obstetric, 482. Forchheimer, on treatment of chlorosis, 157 Formalin in preservation of specimens, 193. in treatment of cervical cancer, 536. in treatment of gonorrhea, 388. Formulae for use in abortion, 461, 472. in amenorrhea, 156, 157, 158. in backache, 256. in constipation, 220. in a child, 221. in cystitis, 558, 559, 561. in disinfection, 324, 331. in dysmenorrhea, 114, 115. in gonorrhea, 386.. in headache, 231, 232, 234, 235. in insomnia, 243. in post-operative convalescence, 624. in pruritus, 298, 300, 301, 302, 303. in vaginitis, 284. in vulvitis, 277. Fournier, on chronic intermittent method of treating syphilis, 441. on conditions necessary for curing syph- ilis, 441. on digital chancre among physicians, 402. on late syphilitic lesions, 445. on mercury in treatment of syphilis, 437. on mildness of secondary symptoms, 395, 396. on smoking as a cause of cancer in syph- ilitic subjects, 441. on statistics of hereditary syi^hilis, 432. on transmission of syphilis to third gen- eration, 436. Fowler, on mistaken diagnosis between appendicitis and dermoid cyst with torsion of pedicle, 590. Friinkel, L., on chlorosis, 147. on corpus luteum and menstruation, 79, 139, 150. von Franque on membranous dysmenor- rhea. 128. Freeman, R. D., on appendicitis in child, simulating hip disease, 596. Freud, on psycho-analysis, 583. Freund, on fatty degeneration of fibroid tumor, 496. on hyperthyroidism, 575. INDEX. 659 Friedenwald and Eulirah, on diet in obes- ity, 246. Friedrichshall water, use of, in constipa- tion, 221. Fright, a cause of amenorrhea, 149. Fritsch, on gonorrheal infection of rectal mucous membrane, 378. on necessity for cultures in gonorrhea, 385. Frontal sinus, headache from disease of, 226. Functional amenorrhea, 149. Furuncle, diagnosis between, and chancre, 403. Gallant's corset for splanchnoptosis, 603. Gall-bladder, examination of, 8. distention of, mistaken for movable kid- ney, 614. Gall-stones, simulation of, by movable kid- ney, 613. Galvanic current. See Electricity. Ganglion of fifth nerve, removal of, for headache, 234. Gangrene in fibroid tumors, 494. Garbage, adequate removal of, a hygienic necessity, 44. Gastrectasy, 600. Genital tract, atresia of, primary amenor- rhea from, 142. infectious diseases a cause of, 266. Garrigues, on age of first menstruation, 82. on duration of menstrual period, 84. Gastric symptoms in chlorosis, 158. in dysmenorrhea associated with retro- flexion, 111. in migraine, 229. in movable kidney, 611. in neurasthenia, 567. in splanchnoptosis, 600. Gastritis, acute, simulation of, by movable kidney, 611. Gastro-intestinal tract, auto-infection from, 227. syphilis of, 421. Gastropexy, Beyea's method of, 604. Gastroptosis, 597. Gauze, bichloride, preparation of, 466, Gauze records, 17. Gebhard, case of primary amenorrhea due to atresia of hymen, 151. on changes in glands associated with obesity, 367. on etiology of fibroid tumors, 494. Gellhorn, G., on acetone in treatment of inoperable cancer, 539. on exfoliative vaginitis, 581. Genitalia, external, changes in, from mas- turbation, 312. changes in, from pruritus, 297. Genital organs, female, aplasia of, a cause of amenorrhea, 140, 146, 150. atrophy of, in Basedow's disease, 148. local changes in, at menopause, 90. syphilis of, 426. Genito-urinary system, disturbances of, in neurasthenia, 567. syphilis of, 425. Gerota's capsule, 606. Gibney, V. P., on appendicitis in child simulating hip disease, 596. Giemsa's method of staining the spiro- cheta pallida, 392. Gilles, on syphilis of spinal cord, 431. Gilliam, on age of first menstruation, 82. on duration of menstrual period, 84. Gin in treatment of dysmenorrhea, 114. Glans penis, chancre of, 401. Glenard, on enteroptosis, 597, 599, 600, 602. on movable kidney, 607. Glenard's belt test, 601. disease, 597. elastic bandage, 603. Glossitis, diagnosis between, and syphilis of oro-pharyngeal cavity, 622. Gloves, rubber, necessity for, in vaginal examinations in general, 11. in gonorrheal vaginitis, 282. in labor, 486. Glycosuria in pruritus, 296, 297. Goehlert, on sterility in royal families, 368. Goelet, on electricity in treatment of dys- menorrhea, 118. Goldthwait, on relaxation of sacro-iliac joints, 252, 259, 260, 574. 660 rNDEX. Gonococcus, bacterial nature of, 377. colorization of, 378, 385. cultivation of, 379. description of, 377. detection of, 385. isolation of, 378. scarcity of, 376. tissues most favorable to, 378. Gonococcus infection, antigonococeus se- rum for, 379. clinical course of, 380. cocain anesthesia in treatment of, 387, 388. constitutional treatment of, 386, 391. curability of, 380. danger of spreading, during treatment, 6, 282, 286. definition of, 375. diagnosis of, 384. discharge in, 298, 380, 381. douches for. 389. dry treatment in, 389. effect of, on distant organs, 377. endometritis caused by, 291. examination in, 385. history of, 375. immunity in, 379, 380. in little girls, 381, 389. in pelvic inflammation, 339. intentional transference of, 383. latent, 375, 384. localities especially subject to, 275, 276, 287, 357, 376. local treatment in, 386. male organs affected by, 352. marriage and, 384. organs most frequently affected by, 376. prevalence of, 376. pruritus caused by, 296, 298. re-infection, 384. sequelae of, 384. smears from secretion of, 385. sterility from, in female, 358, 365, 384. in male, 354, 369, 384. tissues affected by preference by, 378. treatment of, 386, 389. uterine tubes affected by, 365, 381, 383. vaginismus associated with, 306, 307. vaginitis caused by, 280. vulvitis caused by, 275, 276. Gonococcus infection, vidvo-vaginitis caused by, in little girls, 381, 389. Gonorrhea. See Gonococcus infection. Gonotoxine, 376, 379. Goodell, W., on treatment of pruritus, 301, 302. " Gospel of Comfort," 347. Gossypiimi, in hemorrhage after abortion, 469. in threatened abortion, 463. Goth, L., on aspirin in inoperable cancer, 541. Gottschalk, on etiology of fibroid tumors, 494. on treatment of pruritus, 301. on treatment of uterine hemorrhage, 185. Gout, constitutional, headache due to, 225. migraine due to, 218, 229, 235, 236. obesity due to, 244. 245, 248. pruritus due to, 296. Gown, obstetric, 486. Graefe, ^il., on relation between coecy- godynia and neuralgia, 262. on treatment of coccygodynia, 263. von Graefe's sign, 575. Graves' disease, amenorrhea associated with, 575. Gray oil, 439. " Green mixture," 115. Green soap in pruritus due to pediculi, 298. Gummata of bones, 427, 428. of brain, 431. of esophagus, 423. of iris, 429. of joints, 428. of kidney, 426. of liver, 424. of 'lungs, 424. of mammary gland, 427. of muscle, 427. of periosteum, 427. of peritoneum, 427. of rectum, 423. of testicles, 426. of tongue, 422. of trachea, 424. of urethra, 425. INDEX. 661 Gummata of uterine tubes, 427. of uterus, 427. of vertebras, 428. production of, 398. treatment of, 437. Gummatous hepatitis, 423. Gusserow, on age when fibroid tumors are most frequent, 493. on fatty degeneration of fibroids, 496. Gymnastic exercises. See Exercises. Gymnasium suit, 59, 60. Gynecological examination. See Exami- nation. Gynecological history-taking, methods of, 3. scheme for, 4. Gynecological operations. See Operation and Operative treatment. Hair, syphilis of, 420. Hands, sterilization of, 6. vaginitis due to, 282. Harkin, A., case of enlargement of paro- tid gland during successive preg- nancies, 273. Harris, on characteristic body form in splanchnoptosis, 602. on etiology of movable kidney, 608. Harris, P. A., on method of dilating cer- vix during labor, 482, 483. Hart, B., on sacro-pubic hernia, 11. Hart and Barbour, on age of first men- struation, 82. on age when fibroid tumors are most frequent, 493. on interval between menstrual periods, 86. on length of menstrual periods, 84. prescription by, for constipation, 157. Haultain, on functional amenorrhea, 149. Hayem, on blood pigment in urine during chlorosis, 158. on disturbances of menstruation in chlorosis, 147. on number of red blood corpuscles in chlorosis, 153. on oxylate of iron in treatment of chlorosis, 156. on rest in treatment of chlorosis, 158. Headache, 224. classification of, 225. constipation the cause of, 214, 227. diagnosis of, 229. etiology of, 224. formula} for relief of, 231, 232, 234, 235. frequency of, 224. hydrotherapy for, 232. in brain disease, 226. in chlorosis, 128. in men, 225. in neurasthenia, 225, 226, 228, 565. in pregnancy, 233. in syphilis, 226, 394, 440. investigation into cause of, 226. menstrual, 105, 106, 226. nervous, 225. nocturnal, 226. outline for cases of, 230. prophylaxis of, 232. reflex, 225, 226. remedies for immediate relief of, 229. rheumatic, 225, 234. sedative remedies for, 234. sick. See Migraine. treatment of, 229. varieties of, 225. with movable kidney, 613. Health, amenorrhea from disturbance of, 155. dysmenorrhea from disturbance of, 109, 112. general care of, at menopause, 93. at menstrual periods, 72. influences injuring, 75. injurious influence of malnutrition upon, 45. Health of community, dependence of, upon public sanitation, 44. Heart, changes in, associated with fibroid tumors, 504. associated with obesity, 224. Heart disease, in chlorosis, 147. indication for artificial abortion, 474. sterility caused by, 367. uterine hemorrhage caused by, 192. Heart, syphilis of, 424. Hebra, on pruritus, 295. Hegar, on disease of fetal membranes, 454. 662 INDEX. Hegar, on relation between absence of sexual feeling and sterility, 367. on trauma in causation of abortion, 455. Hegar's graduated dilators, 122, 482. sign in diagnosis of early pregnancy, 151, 500. Hellender, on septic infection in abortion, 463. Helonias compounds, in treatment of dys- menorrhea, 115. Hematocele, pelvic, a cause of uterine hemorrhage, 177. Hemogallol, in treatment of chlorosis, 157. Hemoglobin, increase of, in obesity, 244. percentage of, an indication for radical operations, 504, 511. reduction of, from exercise, 158. in chlorosis, 146, 153. reduction of, in anemia from fibroid tu- mors, 504. variations in percentage of, by day and by night, 158. Hemorrhage, uterine, after curettage, 628. anemia from, 182, 200, 498, 504. at menopause, 88. constitutional causes of, 179, 192. constitutional measures of relief for, 192. curettage for, 189, 510. danger to life from, 505. definition of, 163. diagnosis of, 180. during infectious diseases, 271. examination of pelvic organs in, 181. examination of uterine scrapings in, 191. family tendency to, 180. from abortion, 165, 460, 464. from calcification of uterine blood- vessels, 178. from corpus luteum cysts, 177. from endometritis, acute, 174. chronic, 174, 393. polyiioid, 175. tubercular, 176. from enlarged cystic ovaries, 176. Hemorrhage, uterine, from extra-uterine pregnancy, 175, 200. from fibroid tumors, 168, 180, 497. from hypertrophy of endometrium, 175, 293. from imperfect development of ute- rine blood-vessels, 180. from inflammation of uterine ad- nexa, 177, 337. from inversion of uterus, 173. from mucous polyp, 166. from placental polyp, 166. from retrodisplacements, 172, 322. general means of relief in, 192. in cancer, 169, 170, 518, 519, 542. in chlorosis, 147, 180, 367. in chorio-epithelioma, 171. in young girls, 179. indication for artificial abortion, 464. indication for radical operation in fibroid tumor, 504, 510. investigation into causes of, 180. local causes of, 165. mechanical means of relief of, 186, 508, 509. medicinal means of relief of, 184. proportion of different local causes in, 178. rest in treatment of, 183, 184, 506. saline infusion in treatment of, 184, 206. vascular causes of, 179. vicarious, 160. Henderson, on conditions of work in schools and colleges, 66. Henrotin, F., on drainage in pelvic ab- scess, 342. Hepatic disease, uterine hemorrhage from, 192. Hepatoptosis, 597. Heredity, influence of, upon age of pu- berty, 83, 145. Heredity in causation of cancer, 515, 516. of fibroid tumors, 494. of headache, 225, 226. of insomnia, 238. of obesity, 244. of psyehasthenia, 572. of vicarious menstruation, 160. INDEX. 663 Heredity in prognosis of functional neu- roses, 576. Herman, on treatment of chlorosis, 155, 156. on galvano-stem pessary in treatment of amenorrhea, 155. Hermes, on number of gynecological op- erations in which the appendix is affected, 586. Hernia, sacro-pubic, 11, 322. ventral, after abdominal operations, 633. Herpes, buccal, diagnosis between, and syphilis of the oro-pharyngeal cavity, 422. Herpes progenitalis, diagnosis between, and chancre, 402. Hessert, W., on danger of perforation in curettage, 189. Hildebrandt, on ergot in treatment of fibroid tumors, 509. Hippocrates, on abortion, 452. Hirst, B. C, on age of first menstruation, 82. on duration of menstrual period, 84. on mechanism of menstruation, ■ 80, 81. on method of excising nerves in pruri- tus, 303. on ovarian abscess in typhoid fever, 269. Hochsinger, statistics by, of hereditary syphilis, 432. Hodgkin's disease, amenorrhea preceding and accompanying, 149. Hoffman's anodyne for relief of headache, 235. Hofmeier, on etiology of fibroid tumors, 494. on relation between fibroid tumors and heart disease, 505. on relation between fibroids and steril- ity, 364, 504. Hoggan, on membranous dysmenorrhea, 131. Hollister, C. G., formula by, for relief of backache, 256. Hollopeter, on education of young moth- ers, 42. Holt, L. E., on vulvo-vaginitis in chil- dren, 381. Home Economic Conference, discussion in, upon education of girls, 42. Home, employment at, for girls, 69. Home-making, importance of training for, 42. Hood's Sarsaparilla, percentage of alcohol in, 114. Horseback, riding on, a cause of coccygo- dynia, 261. Housing conditions, necessity for im- provement in, 45. Huber, on frequency of gonorrhea among prostitutes, 376. on frequency of rectal gonorrhea, 386. Huggins, R., on susceptibility of cervix to cancerous changes at time of menopause, 517. Hunner, G. L., case of glass catheter ex- tracted from the bladder, 435. method of cauterizing cervix, 288, 289, 374. on hot bath in drainage of bladder in cystitis, 559. Hunsberger, on race suicide, 347. Hunter, William, removal of largest fibroid tumor on record, 488. Hunyadi water in constipation, 221. Hurdon, E., on decidual inflammation as cause of abortion, 456. Hutchins, on artificial production of re- nal colic, 617. Hutchinson, Jonathan, on syphilis and marriage, 445. on " syphilitic imitation," 417. Hyaline degeneration of fibroid tumor, 495. Hydrargyri, emplastrum, 442. Hydrargyrum cum . creta, in primary syphilis, 438. in treatment of infantile syphilis, 443. Hydrastis canadensis in treatment of ute- rine hemorrhage, 185, 508. Hydrocyanic acid for relief of vomiting, 158. Hydronaphthol in treatment of chlorosis, 157. Hydrosalpinx, sterility due to, 365, 374. Hydrotherapy in treatment of headache, 232. of splanchnoptosis, 603. 664 INDEX. Hygiene, defects of, in schools, 58. function of physician in, 41. of infancy and childhood, 40. of menstruation, 72. of occupation, 74. of puberty, 67. of school-girl, 51. public, 44. remedial measures in public, 41. Hygienic measures in amenorrhea, 155. in backache, 256. in cancer, 541. in constipation, 217. in dysmenorrhea, 112. in gynecological affections in general, 30. in headache, 231. in insomnia, 240. in neuroses, 575. in post-operative convalescence, 622. in prophylaxis of abortion, 461. of masturbation, 314. of migraine, 236. in pruritus, 299. in splanchnoptosis, 603. in syphilis, 441. in vaginismus, 306. Hymen, caution against injury to, 112, 322, 359. dilatability of, 314. excision of, 363. imperforate, method of operation for, 154. primary amenorrhea due to, 145, 151. sterility due to, 357, 359, 372. intact, in vaginismus, 304. removal of, 308. Hyperthyroidism, 568, 575, 576. Hypnotics, care in use of, 242. danger in repeating prescription for, 242, 299. Hypnotism in treatment of functional neuroses, 585. in treatment of insomnia, 241. Hypochondria, 568. Hypochondrium, examination of right, 7. Hyi^oplasia of genital organs. See Geni- tal organs, Aplasia of. Hypospadias a cause of male sterility, 352. Hyrtl, on relation between coccygodynia and anchylosis, 264. Hysterectomy, drainage of bladder after, vphen done for cancer, 557. followed by cystitis, 545. indications for, in fibroid tumor, 511. Hysteria, " accidents " in, 566. characteristics of, 566, 573. definition of, 566. frequency of, 566. reality of, 567. "stigmata" in, 566. syphilo-toxines a cause of, 397. Ichthyol in disease of upper bowel, 38. in gonorrhea, 389. in pruritus, 300. Heus, post-operative, 633. Ill, E. J., on abortion in myomatous ute- rus, 456. on frequency of abortion at menstrual periods, 453. on injury to cervix a cause of abortion, 456. on intra-uterine injection of alcohol in septic abortion, 471. on number of abortions, 453. on operation during pregnancy causing abortion, 457. on syphilis in causation of abortion, 455. on urethral dilators in mechanical dila- tation of cervix, 469. Imperforate hymen. See Hymen. Impetigo vulgaris, diagnosis between, and impetigo form of syphilide, 417. Impetigo-form syphilide, 417. Impulses, abnormal, 570. Induration, syphilitic, treatment of, 404. Industrial life, influence of, on health of women, 74. Infancy, hygiene of, 40. Infant, syphilis in, 434, 435, 443. Infant mortality, 41, 44. " Infantilism " in hereditary syphilis, 435. Infection, cancer from, 515. conjugal, in syphilis, 448, 449. conveyed by instruments, 6, 282. death of fetus from, 454, 455. INDEX. 665 Infection, fibroid tumors caused by, 494. gonorrheal, of genital tract, ; situations most often affected, 275, 358, 376. of urethral glands. See Skene's glands, of vulvo-vaginal glands. See Bar- tholin's glands, infant mortality from, 41. of bladder, after labor, 480, 555. after operation, 544, 555. cause of backache, 256. precautions against, in catheterization, 486, 556. schools a centre of, 58. syphilitic. See Syphilis. Infectious diseases, cause of mortality, 50. cause of pelvic disease, 50, 265. protection of children from, 50. uterine hemorrhage during, 271. Inflammation of pelvic organs. See Pel- vic inflammation. Ingestion of mercury, 438. in infants, 443. Injections, rectal. See Enemata. Insalivation of food, 245, 580. Insolation a cause of headache, 226. Insomnia, 238. classification of, 239. cold packs for, 241, 580. drugs for relief of, 242. during rest cure, 580. duty of physician in, 242. etiology of, 238. formulae for, 243. frequency of, 238. hygienic measures for relief of, 240. importance of, to gynecologist, 238. treatment of, 239. Instillations of bladder, 560. Instructive Visiting Nurses' Association, 43. Instruments, infection conveyed by, 6, 282. method of sterilizing, 6. Instruments required, for cystoscopic ex- amination of bladder, 552. for dilatation and curettage, 123. for gynecological examination, 5. Instruments required, for mechanical evacuation of uterus, 469. Intermenstrual pain, 132. absence of, during pregnancy and lacta- tion, 133, 138. age of appearance of, 133. character of, 135. date of occurrence of, 134, 139. definition of, 132. discharge with, 135. duration of attack of, 135. history of, 132. length of time attacks of, are repeated, 135. lesions associated with, 135. literature of, 133. locations of, 135. relation of, to menstruation, 135. relation of, to sterility, 133. ' synonyms for, 132. theories as to causation of, 132, 138. treatment of, and its results, 136. value of further reported cases of, 139. Internal secretion, glands concerned in, disturbances of, associated with amenorrhea and obesity, 148, 153. Interstitial hepatitis, syphilitic, 423. Intestine, inspection of, through head- mirror, 36. malignant disease of, a cause of consti- pation, 215, 222. treatment of inflamed area in, 38. Intestines, alterations in position of, after operations, 632. displacement of. See Splanchnoptosis, irritation of mucosa of, a cause of con- stipation, 213, 214. syphilis of, 423. Intramuscular injections of mercury, 439. Intra-uterine injections of alcohol in sep- tic abortion, 471, 472. of iodoform and glycerin, 471. of glycerin, 187, 509. Intravenous injections of mercury, 440. Inunction, mercury by means of, in in- fantile syphilis, 443. in syphilis, 438. Inversion of uterus. See TJtertxs. Iodide of potash. See Potassium. 666 INDEX. Iodine, tincture of, iu cancer of cervix, 536. in gonorrheal infection, 388. in membranous dysmenorrhea, 131. in syphilis of bones, 442. Iodoform and gelatin injection in septic abortion, 471. Iodoform bovigies in treatment of chan- cre, 404. Iodoform gauze in tampons, 464, 465, 466, 469, 476. Iodoform powder, after artificial abortion, 476. after catheterization in the puerpe- rium, 555. in the dry treatment in gonorrheia, 389. Ireland, increasing fertility in, 347. Iritis, syphilitic, 429. Iron, hypodermic administration of, 156. tincture of chloride of, locally, in diph- theritic vaginitis, 281. Irrigation of bladder, 597. continuous, 564. Irritants, external, effects of, on local se- verity of syphilis, 396. Isolation in treatment of functional neu- roses, 577, 578. in treatment of insomnia, 242. Itching in pruritus, 295, 297. Jackson's " Golden Seal Tonic," percent- age of alcohol in, 114. Jacobi, A., on the administration of meth- ylene blue by mouth in treat- ment of uterine cancer, 538. Jacobi, Mary Putnam, on question of rest during menstruation, 73. Jacobson, on atresia of genital tract from use of pessaries, 145. Janet, on psychasthenia, 669. Janitors in schools, necessity for training, 58. Jaundice, pruritus associated v?ith, 295. Jequirity, exfoliative vaginitis from use of, 281. Jewish race, tendency to obesity in, after middle life, 224. Johannovsky, case of smallpox followed by atresia of genital tract, 266. Joints, gonococcus in pus of inflamed, 378. pains in, associated with menstruation, 106. associated with migraine, 235. syphilis of, 428, 442. Joseph, M., on etiology of syphilis, 392. Jullien, on curability of gonorrheal in- fection, 380. on etiology of syphilis, 392. Jung, on gonorrheal inflammation of en- dometrium in little girls, 269. on treatment of functional neuroses, 583. Kassowitz, on statistics of hereditary syphilis, 432. Kehrer, on azoospermia, 353. on examination of patient for sterility, 369. Keith, on electricity in treatment of fibroid tumors, 507. on faulty respiration as a cause of splanchnoptosis, 599. Kelly, H. A., on examination of rectum under air distention, 34. on production of artificial renal colic, 29, 601, 617. Kelly's cylindrical metal speculum. See Speculum. Keloids, formation of, in scar after lapa- rotomy, 632. Kemp, Janet, on housing conditions in Baltimore, 46. Keratitis, syphilitic, 428. Kerr, on normal visual aCuity in young children, 56. Kidney, anatomy of, 605. backache in diseases of, 251. capsules of, 605. normal mobility of, 606. normal position of, 605. palpation of, 7, 609. sarcoma of, 26. secondary infection of, by gonococcus, 376. syphilis of, 426. tuberculosis of, 548, 550, 557. Kidney, movable, and appendicitis, 600, 612. INDEX. 667 Kidney, movable, artificial renal colic in diagnosis of, 29, 617. bandage for, 618. biliary symptoms in, 613. circulatory disturbances in, 613. degrees of mobility of, 606. diet in treatment of, 618. Dietl's crises in, 610. differential diagnosis of, 613. etiology of, 606. fecal accumulation mistaken for, 617. frequency of, 608. gall-bladder, distention of, mistaken for, 614. gastro-intestinal symptoms of, 611. gymnastics in treatment of, 618. hematuria in, 613. hysteria associated with, 597. in child, 609. indications for radical treatment of, 619. insomnia accompanying, 239. nervous symptoms of, 613. operations for, 604, 619. pain in, 610. palliative treatment of, 618. palpation of, 609. pelvic tumor mistaken for, 614. pyloric tumor mistaken for, 615. renal calculus mistaken for, 616. shape of body associated with, 607. suspension of, 619. symptoms of, 609. urinary symptoms of, 613. vibratory bimanual palpation of, 610. Kidney colic. See Renal colic. Kisch, on absence of sexual feeling and sterility, 367. on hypertrophy of tonsils and disorders of menstruation, 57. on obesity and sterility, 367. Klebs, on etiology of fibroid tumor, 494. on etiology of syphilis, 392. Klein, on necessity for making cultures of gonococcus, 385. Kleinwachter, on abortion due to changes in uterine ligaments, 456. on atrophy of genitalia in Basedow's disease, 148. on etiology of fibroid tumors, 494. Klemperer, on cachexia in malignant dis- ease, 518. Knee-breast posture. See Posture. Kneise, on curette in incomplete abortion, 468. Knox, J. H. M., on compression of ureters in fibroid tumors, 503. Koberle, case of retroflexion caused by constipation, 33. Kocher, on Graves' disease as a cause of amenorrhea, 575. Kolischer, on nasal dysmenorrhea, 109. Kraus, on gonococcus infection of uter- ine tubes, 378. Krieger, on length of intervals between the menstrual periods, 86. Kronig, on tissues affected by the gono- coccus, 378. Kubinyi, on danger of intra-uterine treat- ment for hemorrhage from fibroid tumors, 509. Kussmaul, on displacement of stomach, 697. Kiistner, on gastric lavage in treatment of vicarious menstruation, 162. Labarraque's solution, formula for, 324. in condylomata, 442. in displacements of uterus, 323. in inoperable cancer, 542. in vaginitis, 285. Labia, chancre of, 400. conglutination of, 144. swelling of, during parotitis, 273. Labor, axis-traction forceps in difficult, 482, 483. catheterization after, 486, 555. cause of coccygodynia, 261. choice of nurse for, 487. cystitis following, 544, 555. danger of undilated cervix in, 482. forceps in, 482. gynecological affections following, 478. infection following, 478, 479. injury to cervix in, followed by cancer, 517. malarial influence upon, 271. mechanical injiiries from, 478. methods of dilating cervix in, 482. nervous exhaustion after, 478, 480. 668 IKDEX. Labor, pathological sequelte of, 478. pelvimetry essential in difficult, 482. pliysiological sequelas of, 477. precautious agaiust cystitis in, 486, 555, against infection in, 482, 488. protection of perineum in, 483. repair of lacerated cervix after, 486. of perineum after, 484. sterilized suit for physician in, 486. Laceration of cervix, 21, 32, 478, cause of one-child sterility, 362, repair of, after labor, 486. Laceration of perineiun, immediate re- pair of, 484. Lactation, absence of intermenstrual pain during, 133, 138. prolonged, cause of atrophy of genital organs, 145. Lactic acid bacterium, 379. Laeto-peptin in treatment of tertiary syphilis, 440. Laminaria tents. See Tents. Landau, introduction of yeast treatment in vaginitis by, 286. Lanolin, in pruritus, 300, Lapland, age of first menstruation in, 83, Latero-displacements of uterus. See Uterus. La Torre, on electricity in treatment of fibroid tumors, 507. Laudanum and lead-water in treatment of pruritus, 301. in treatment of vulvitis, 276. Laundries, public, 50. Lavage, gastric, for relief of headache, 231. in gastrectasy, 603, in vicarious menstruation from stom- ach. 161, Lead poisoning, abortion from, 456, amenorrhea from, 149. Lebendinsky, on changes in ovaries dur- ing scarlet fever, 268, 269, 270. Leeches, application of, to cervix, 159. Lefour, on iibroid tumors in causation of abortion, 504. Lehmann, on fibroid tumors associated vrith heart disease, 505. Lemanski, on malaria and pelvic affec- tions, 271, 272. Lenharz, on the gonococcus in ulcerative endocarditis, 378. Leopold, on changes in endometrium dur- ing menstruation, SO. on chronic endometritis as a cause of pruritus, 296. on merabranous dysmenorrhea, 124. Leprosy, diagnosis between, and tubercu- lar syphilide, 420. Leucoderma syphiliticum. See Syphilide, pigmentary. Leucomaine poisoning, headache caused by, 225. Leucoplasia of tongTie, 422, 442. Leucorrhea. See Vaginal discharge. Levaditti, on method of staining spiro- cheta pallida, 393, on spirocheta pallida in renal epithe- lium, 398. von Leyden, on isolation of gonococcus in blood, 378. on presence of gonococcus in mucous membrane, 378, Lichen planus, diagnosis between, and miliary papular syphilide, 414. Lier and Ascher, on statistics of male sterility, 354. Ligaments, broad, induration of base of, a cause of abortion, 456. induration of base of, in prognosis of cervical cancer, 533, tenderness of, associated with inter- menstrual pain, 135. Light and heat rays in treatment of back- ache, 258. iu treatment of headache, 233. von Limbeck, on number of red blood cor- puscles in chlorosis, 153. Lip, chancre of, 401. Lipomyoma, 496, Liquor sodse chlorinatse. See Labar- raque's solution. Liquorice powder for constipation, 220, 221, Lithopedion, 198, Liveiug, E., on causation of migraine, 228, Liver, displacement of, 601, 604. INDEX. 669 Liver, examination of, 8. syphilis of, 423. torpidity of, a cause of constipation, 222. a cause of migraine, 236. Lobenstein and Harrar, on birth-rate of babies with gonorrheal mothers, 378. Lochia, gonococcus infection in, 378. Loeffler's bacillus in diphtheritic vagi- nitis, 281. Lohlein, on membranous dysmenorrhea, 128. Lomer, on galvanic current in vaginis- mus, 307. on iodide of potash, in habitual abor- tion, 462. on obesity as cause of amenorrhea, 148. Longstreth's belt for splanchnoptosis, 603. Lumbago, acute, 250. Lungs, syphilis of, 424. Lupus vulgaris, diagnosis between, and tubercular syphilide, 419. Lustgarten, on etiology of syphilis, 392. Lutein for functional amenorrhea, 159. for obesity accompanied by amenorrhea, 245. for symptoms associated with an artifi- cial menopause, 630. with the abnormal menopause, 95. Lwoff, on atresia of genital tract due to typhoid fever, 266. Lymph glands, induration of, in syphilis, 358. infection of, in gonorrhea, 381. Lymphangitis, accompanying septic abor- tion, 471. in syphilis, 402. Lysol in treatment of inoperable cancer, 536. Mackenzie, J., on nasal dysmenorrhea, 109. Mackintosh, Sir J., on mechanical dys- menorrhea, 107. Maclaren, A., on appendicitis and dys- menorrhea, 592. on appendicitis and salpingitis, 590. MacMonagle, B., on syphilis as a cause of uterine hemorrhage, 180. " Macula) gonorrhoicse," 359, 385. Madlener and Menge, on the gonococciis in uterine muscle, 378. Magnesium sulphate. See Saline laxa- tives. Malaria, influence of, in causation of amenorrhea, 148. in causation of headache, 226, 233. in convalescence from gynecological operations, 634. on labor, 271. on menstruation, 271. on ovarian neuralgia, 272. on pelvic disease in general, 271. on pregnancy, 271. on puerperium, 271. Maldevelopment of genital organs, cause of amenorrhea, 140, 147, 150, 154. cause of dysmenorrhea, 108, 120. cause of sterility, 256, 360, 363, 365. Malformations in infantile syphilis, 436. Malignant disease of intestine, a cause of constipation, 215, 222. examination for, 38. Malnutrition, causes of, 41. infant mortality from, 41. Mammary gland, swelling of, during parotitis, 273. syphilis of, 427. Mandl, on the gonococcus in submucous tissues, 378. Manganese, as an emmenagogue, 160. in chlorosis, 157. Mangelsdorf, on migraine associated with dilatation of stomach, 228. Manias, mental, in psychasthenia, 571. Mantegazza, on marriage of cousins and sterility, 368. Manual reduction of uterus, in preg- nancy, 322, 462. method of, 326. Marienbad, treatment of obesity at, 246. Marriage between relatives a cause of sterility, 368. gonorrhea and, 384. interval between, and birth of first child, 350. period after, at which sterility presum- ably begins, 349. 670 INDEX. Marriage, relative sterility of wives at different epochs in, 341). syphilis and, 443. Martin, on fatty degeneration of fibroid tumors, 496. Maslovski, on experiments on gonotoxine, 379. on gonococcus in placenta and decidua, 378. Massage in backache, 256. in coccygodynia, 263. in constipation, 221, 223. in insomnia, 241. in movable kidney, 617. in palliative treatment of gynecological affections, 31, 32. in pelvic inflammation, 343. in post-operative phlebitis, 631. in rest cure, 581. in splanchnoptosis, 603. of uterus in incomplete abortion, 467. Massin, on inflammation of uterus due to infectious disease, 269, 270. Mastication, importance of, 580. in treatment of obesity, 245. Masturbation, 309. a cause of fibroid tumors, 494. a cause of pruritus, 296. a cause of vaginismus, 296. clinical findings in, 312. constitutional causes of, 310. curative treatment of, 315. diagnosis of, 314. effects of, 314. general considerations affecting, 309. in animals, 309. local causes of, 310. methods of, 311. periods of life when most frequent, 309. prevalence of, 310. prophylaxis of, 314. time of, 312. Maternity, education of women for, 40, 41. Mathes, on etiology of splanchnoptosis, 599. Mayer, L., case of typhoid fever followed by atresia of genital tract, 266. McNaughton, case of ovarian metastasis during parotitis, 272, 273. case of swelling of mammary gland during parotitis, 273. Measles, abortion caused by, 455. atresia of genital tract caused by, 267. Meatus urinarius, character of chancre upon, 400. protection of, by the labia urethrse, 380. Mechanical amenorrhea, 145, 152. treatment of, 153. Mechano-therapy in treatment of sacro- lumbar rheumatism, 258. Medical inspection of schools, 54. Medicine in general treatment of gyne- cological affections, 30. Meigs, on pruritus due to trichiasis, 301. on pruritus during pregnancy, 303. Melancholia at an artificial menopause, 628. Melchior, on the gonococcus in the urine of cystitis, 378. Membranous dysmenorrhea. See Dys- menorrhea. Meningitis, headache caused by, 226. Menopause, 87, 244, 245. age of, 89. abnormal, 95. artificial, menstruation after, 79, 629. production of, for dysmenorrhea, ob- jections to, 126. symptoms of, 628. treatment of, 630. carcinoma of uterus at, 96, 517. hemorrhage from uterus at, 98, 520. local changes in genitalia at, 90. obesity at, 244, 245. pregnancy in, 91. premature, 80. pruritus at, 296. symptoms of, 90. vaginal discharge at, 520. Menorrhagia. See Hemorrhage from uterus. Menstrual molimina, accompanying amenorrhea, 150, 151, 159. constancy of, 106. definition of, 105. nature of, 105. INDEX. 671 Menstrual molimina, relief of, in sup- pressed menstruation, 159. Menstrual periods, abortion most fre- quent at dates corresponding to, 453, 462. amount of ilow during, 85, 163. bath during, 72. character of flow during, 82. duration of flow during, 83, 85. excess of flow during, associated with excess of duration, 84. excessive. See Hemorrhage from Uterus. exercise during, 73. gonorrheal infection most frequent at, 384. interval between, 85. local symptoms at, 105. migraine at, 236. pain during. See Dysmenorrhea. pruritus after, 296, 299. reflex symptoms at, 106. rest during, 73. in post-operative convalescence, 627. sacro-iliac joints relaxed at, 252. variations of, at puberty, 86. Menstruation, age of first, 82, 83, 147. among aboriginal people, 105. cancer of uterus in relation to, 517. cessation of. See Menopause. changes in genitalia during, 80. college life in relation to, 77. conception in absence of, 79. continuance of, after removal of ova- ries, 79, 629. corpus luteum in relation to, 80, 139. definition of, 78. hereditary influence in determining first appearance of, 83, 145. hygiene of, 72. intermenstrual pain in relation to, 135. mechanism of, 80. neurasthenia in disturbances of, 568. ovulation in relation to, 78. painful. See Dysmenorrhea. precocious, 82. profuse. See Hemorrhage from uterus. proportion of woman's life covered by, 87. school-life in relation to, 66. Menstruation, suppression of. See Amen- orrhea, theories of, 78. vicarious, 160. definition of, 160. etiology of, 161. heredity in, 161. situations of, 160. treatment of, 161. varieties of, 160. Mental development influenced by heredi- tary syphilis, 435. Menthol douche, 384, 331. powder, 284. Mercurial stomatitis, 422. Mercuric baths, in treatment of infantile syphilis, 443. Mercury, bichloride of, in chancre, 404. in diphtheritic vaginitis, 281. in disinfection of pessaries, 325. in preparation of sterile gauze, 466. in preparation of sterile towels, 465. in prevention of abortion, 461. in treatment of infantile syphilis, 443. methods of administering, in syphilis, dermic, 442. dermo-pulmonary, 439. hypodermic, 439. intramuscular, 439. intravenous, 440. ingestion, 438. inunction, 438. for infantile, 439. principal preparations of, employed in treatment of syphilis, acid ni- trate, 442. ammoniate of, ointment, 442. benzoate of, 439. bichloride. See Mercury, bichlo- ride of. blue ointment, 442, 443. cacodylate, 439. calomel, 439, 442, 443. Dupuytren's pills, 439. gray oil, 439. hydrargyrum cum creta, 438. oleate, 443. oleate ointment, 442. protoiodide pills, 438. salicylate, 438, 439. 672 INDEX. Mercury, principal preparations of, em- ployed in treatment of syphilis, salicylo-arsenate, 439. tannate, 438. white precipitate, 442. principles of administration of, in syphilis, 437. Metastases to genital organs in parotitis, 272. Methylene blue in treatment of cystitis, 559. of gonorrhea, 388. of iiterine cancer, locally, 537. by mouth, 538. Metrorrhagia. See Hemorrhage from uterus. Mewes, on statistics of hereditary syph- ilis, 432. Meyer, W., on methylene blue in the treat- ment of inoperable cancer, 537. Michaelis, on isolation of gonococcus in blood, 378. Mickle, on psychasthenia, 569. Microscopic examination, in cancer, 525. in cystitis, 548, 549. in gonorrheal infection, 385. in pelvic inflammation, 339. in vaginitis, 280. in vulvitis, 276. method of preparing slides for, 276. method of preparing urine for, 548. Micturition. See Urination. Midwives, duty of, in prophylaxis of can- cer, 531. harm done by careless, 487. Migraine, acute dilatation of stomach in, 228. at menstrual periods, 236. clinical history of, 235. dizziness in, 235. duration of an attack of, 236. etiology of, 228. gastric disturbance associated with, 236. giddiness in 237. heredity in causation of, 225. prodromic symptoms of, 235. . prophylaxis of, 236. psychic disturbances in, 235. relation of, to epilepsy, 228. Migraine, situation of pain in, 235. treatment of, 236. uremic poisoning in causation of, 237. vaso-motor disturbances in, 228, 236. Milk, in rest cure, 579. Walker-Gordon, 45. Milk Commissions, 45. Milk supply, public control of, essential to health of community, 44. Millspaugh, W. P., on association between migraine and disturbance of gas- tric secretion, 229. Mind, distress of, a cause of headache, 227. a cause of insomnia, 242. power of, over body in gynecological af- fections, 31. use of, in treatment of functional neuroses, 582. Mirror, head, in examination of bladder, 552. of rectum, 35. Mitchell, Weir, on rest cure, 577, 578. Mittelsclimerz, 132. Mixed chancre, 400. Mixed infection in gonorrhea, 379. Mobius' sign, 576. Montgomery, on age of first menstrua- tion, 82. on age of menopause, 87. on duration of menstrual period, 84. Moore, T. M., on duty of the state to pro- vide sufficient food for school child, 56. Morgagni, on displacement of abdominal viscera, 597. on membranous dysmenorrhea, 128. Morphin, habitual use of, a cause of amenorrhea, 149. in coceygodynia, 264. in dysmenorrhea, 116. in migraine, 236. in inoperable cancer, 542. in renal colic, 619. in vulvitis, 277. Morphin habit. See Opium. Morris, R. T., on importance of abdomi- nal rigidity in diagnosis between acute appendicitis and salpingi- tis, 590. INDEX. 673 Morrow, P. A., on professional secrecy with syphilitic patients, 447. Morse, Elizabeth, on membranous dys- menorrhea, 128, foot-note. Mortality, from infectious diseases, 50. from nephrorrhaphy in movable kidney, 620. from radical operation for fibroids, 512. in children from external conditions, 41. in fibroid tumors, 505. infant, causes of, 41. decrease of, in New York from im- provement in public hygiene, 44. Mosetig-Moorhof, on methylene blue in treatment of uterine cancer, 537. Mossmann, on atresia of genital tract from infectious disease, 265. Mother, abortion due to causes in, 455. education of, 40, 41. relation of, to child in syphilis, 433. specific treatment of, in hereditary syphilis, 443. Motion, disturbances of, in appendicitis in child, 596. in treatment of sacro-lumbar rheu- matism, 257. Motor system, syphilis of, 427. Moullin, on movable kidney simulating gastric ulcer, 612. Mouth, hygiene of, in syphilis, 441, 442. • syphilis of, 421. Movable kidney. See Kidney. Mucous patches, 421, 449. treatment of, 442. Multiparas, frequency of abortion in, 453. Mumps. See Parotitis. Muscles, abdominal, exercises for strengthening, 218, 232. massage of, 221, 223. weakness of, a cause of constipation, 213. lumbar, ironing of, in treatment of lumbago, 250. rheumatism of, 251, 256. syphilis of, 427. Mustard baths in dysmenorrhea, 116. Mustard plasters on back of neck, for re- lief of headache, 127. for relief of migraine, 132. U Mustard plasters on spine for dysmenor- rhea, 116. Myocarditis due to syphilis, 425. Myomata. See Fibroid tumors. Myomectomy, reasons for choice of, in fibroid tumors, 511. Myopia in school children, 57. Myxedema, obesity associated with, 248. Myxomatous degeneration of fibroid tu- mors, 496. Nabothian follicles, 287, 525. Nagel, on atresia of vagina caused by in- fectious disease, 265. Nails, syphilis of, 420. Naphthalin, in treatment of pruritus, 300. Napoleon, family history of cancer, 515. Nasal dysmenorrhea, 109. Naso-pharynx, syphilis of, 424. Nauss, on fibroid tumors a cause of abor- tion, 505. Necrosis of fibroid tumors, 496, 502. Necrospermia a cause of male sterility, 352, 369. Negroes, frequency of fibroid tumors in, 493. Neisser, discovery of gonococcus by, 351, 375. on abortive treatment of chancre, 404. on inoculation of monkeys with syph- ilis, 432, 436. Nephrectomy for movable kidney, 621. Nephritis, chronic, amenorrhea in, 148. chronic syphilitic, 426. contraindication to operations for fibroids, 511. headache from, 225, 226. migraine from, 237. pruritus from, 396. sterility associated with, 360. Nephropexy for movable kidney, 620, 621. Nephrorraphy for movable kidney, 619, 620. Nerve centres, lesions of, due to syphilis, 446. Nerves to the eye, syphilis of, 428, 429. Nervine, anti-, treatment for" syphilis in neurasthenic patients, 441. 674 INDEX. Nervous exhaustion after labor, 478, 480. headache from, 226. Nervous headache, 225, 228. Nervous system, exhaustion of. See Neu- rasthenia, syphilis of, 430. Neugebauer, on atresia of genital tract caused by infectious diseases, 266. Neuralgia, associated v^ith coccygodynia, 262. of ovary, influenced by malaria, 272. Neurasthenia, backache in, 241, characteristic of, 567, 573. circulatory symptoms of, 567. digestive symptoms of, 567. dysmenorrhea in, 109, 365, 567, 592. etiology of, 568. fatigability in, 567, 573. frequency of, 567. genito-urinary symptoms of, 568, 569. headache in, 225, 226, 228, 567. insomnia in, 238, 239, 567, 581. retrodisplacement of uterus a cause of, 320. spinal pain in, 226. splanchnoptosis associated with, 599. syphilo-toxines a cause of, 397. Neurologist, reasons for cooperation of, with gynecologist, 573. Neuropathic constitution influenced by syphilis, 441, 446. Neuropathic patients, treatment of syph- ilis in, 441. Neuroses, associated with syphilis, 396, 397, 430, 441, 446. cause of pruritus, 295, 296, 299. functional, abnormal impulses of, 570. after oophorectomy, 629. diagnosis of, 572. diet in treatment of, 579. emotional training in, 584. etiology of, 568. hyperthyroidism in, 581. hypnotic suggestion in treatment of, 585. hypochondria, 568. hysteria, 566. isolation in treatment of, 578. massage in treatment of, 581. Neuroses, functional, medical obedience in treatment of, 583. neurasthenia, 567. nurse in, 584. obsessions in, 570. persuasion in treatment of, 583. prognosis of, 576. psychasthenia, 569. psycho-therapy in treatment of, 582. re-education in treatment of, 582. suggestion in treatment of, 583. traumatic, 568. treatment of, 576. types of, 566. varieties of, 566. Neurotic dysmenorrhea, 108. Newsholme and Stevenson, on reasons for decline in population, 347. van Niessen, on etiology of syphilis, 392. Night, habit of working in, a cause of in- somnia, 238. Niot, on dermoid cyst with twisted pedi- cle mistaken for appendicitis, 590. Nitre, sweet spirits of, in cystitis, 559. Nitroglycerin, for headache with high ar- terial tension, 233. Noble, on degeneration of fibroid tumors, 473, 495, 496, 497. on disease of uterine appendages associ- ated with fibroid tumors, 497. on fibroid tumors and heart disease, 505. on mortality in myomectomy, 512. Nocturnal headache due to syphilis, 226, 430. Noeggerath, on the gonococcus as a cause of sterility, 250, 375. von Noorden's system of treatment for obesity, 248. Norway, increased fertility in, 347. Nose, condition of, in school-girls, 57. mucous membrane of, gonococcixs in, 360. syphilis of, 424, 442. Nosophobia, 568. Nott, J. C, on atresia of vagina in in- fants, 144. on coccygodynia, 261, 262, 263. INDEX. 675 Nulliparae, rarity of cervical cancer in, 169, 362, 517. Nurse, choice of, in labor, 487. in inoperable cancer, 542. in rest cure, 579. in treatment of functional neuroses, 584. office, 3. school, 58. wet, specific treatment of, in hereditary syphilis, 443. syphilitic infection conveyed to, or received from, nursling by, 399. Nutrition, at puberty, 67. defective, a cause of ill-health in school-girls, 55. impairment of, by constipation, 207. importance of, to education of children, 56. Nux vomica, for backache, 256. for constipation, 220. for headache, 232. in inoperable cancer, 538. in post-operative convalescence,. 624, 627. Obedience, importance of, in treatment of neuroses, 583. Obesity, amenorrhea associated vpith, 148, 208, 245. blood, changes in, accompanying, 244. definition of, 244. diet in, 246. diet lists for, 246, 247. disturbance of internal secretions asso- ciated vpith, 148. etiology of, 224. heart, changes in, caused by, 224. heredity in causation of, 224. prophylaxis of, 248. Spa treatment of, 246. sterility associated vs^ith, 245, 331. symptoms of, 244. synonyms for, 244. systems of treatment of, 248. thyroid gland in treatment of, 248. treatment of, 245. Obsessions, 570. Obstetric forceps, rules for use of, 582. gown, 487. Obstetrician, duty of, 482, 486. Occupation, hygiene of, 74. sedentary, a cause of constipation, 213. Occupation therapy in post-operative con- valescence, 625. in treatment of functional neuroses, 585. Ochsner, on dysmenorrhea and chronic appendicitis, 592. Oertel's system for treatment of obesity, 248. Office, arrangements of, 2. nurse in, 3. Oil, cod-liver, 155, 233, 245. locally, 300. cotton-seed, 222. of pennyroyal, 456. sweet, 221, 298. Ointment, belladonna, 404. blue, 442, 443. benzoated, 301. carbolic acid, 300. cocain, 300. thymol, 301. Ointments, mercurial, 304, 442, 443. Old age, cancer of clitoris and vulva in, 636. of uterus in, 638. pruritus in, 636. pyokolpos, pyometra and physometra in, 639. tumor in, fibroid, 640. of urethra, 636. ovarian, 640. vagina in, atrophy of, 637. hypersensitive orifice of, 637. vaginitis in, 637. Oligospermia, male sterility from, 352, 353, 372. Oliver, on atrophy of chorionic villi, 455. Olshausen, on fibroid tumors and steril- ity, 363, 505. on injury to cervix a cause of abortion, 456. on nitrate of silver in treatment of pru- ritus, 302. on septic abortion due to criminal in- terference, 460, 470. One-child sterility, definition of, 347. due to atresia following labor, 260. 676 I]S"DEX. Oue-cliild sterility, due to atrophy of uterus after laboi% 366. due to gonoeoccus infection, 384. due to retroiiexion after labor, 363. Onychia, syphilitic, 421. Oophorectomy. See Ovaries, removal of. Operation, Alexander, 332. backache after, 251, 260. convalescence from. See Post-operative convalescence, cystitis following, 544. during pregnancy, a cause of abortion, 487. for dilatation and curettage, 123, 189. for imperforate hymen, 154. for lacerated cervix, 32, 486. for redundant sigmoid in cure of con- stipation, 213. for retrodisplacement of uterus, 332, 333. radical, for cancer, contraindications to, 633. importance of early, 169, 520, 530, 532. indications for, 532. for fibroid tumor, choice of, 511. contraindications to, 511. indications for, 506, 510. mortality from, 512. time for, 512. Operations, abdominal, alterations in po- sition of intestines after, 632. care of bowels after, 222. constipation after, 208, 625. enlargement of scar after, 632. fermentation in lower intestines after, 227. hernia after, 633. ileus after, 633. suppuration of wound after, 631. tenderness of scar after, 632. Operative treatment in amenorrhea, 154. in cervicitis, 288. in coccygodynia, 263. in dysmenorrhea, 120. in endometritis, 294. in extra-uterine pregnancy, 206. in movable kidney, 619. in pelvic inflammation, 344. in pruritus, 302. Operative treatment in splanchnoptosis, 604. in sterility, 372. in uterine hemorrhage, 188. in vaginismus, 308. in vulvitis, 277. Ophthalmia, gonorrheal, prevention of, 386. Opium habit, cause of amenorrhea, 152. cause of sterility, 367. cure of, during post-operative convales- cence, 626. risk of, in coccygodynia, 264. in dysmenorrhea, 177. in insomnia, 242. Opium in dysmenorrhea, 117. in gonorrhea, 386. in imminent abortion, 462. in inoperable cancer, 541, 542. in renal colic, 619. Oppenheim, on individual endeavor, 52. Oppolzer, on hysteria and floating kidney, 597. Opsonic treatment in cystitis, 562. Optic nerve, syphilis of, 429. Oral cavity, gonoeoccus in mucous mem- brane of, 378. Orchitis, syphilitic, 425. treatment of, 443. Oro-pharyngeal cavity, syphilis of, 421. Orth, case of atresia of genital tract fol- lowing diphtheria, 267. Osier, on atony of colon, causing consti- pation, 213. on explanation of Dietl's crises, 610. on nux vomica in increasing doses, 624. on tumor of pylorus simulating mova-- ble kidney, 615. Osteo-arthritis, cause of backache, 256. of vertebrae, misleading symptoms asso- ciated with, 574. Osteomyelitis, syphilitic, 428. Osteoscopic pains in syphilis, 394. treatment of, 442. Ovarian adhesions, association of, with sterility, 358, 366. formation of, in pelvic inflammation, 341. Ovarian dysmenorrhea, 110. Ovarian extract, at menopause, 95. for intermenstrual pain, 136. INDEX. 677 Ovaries, amenorrhea from aplasia of, 141, 147, 150. atropliy of, in exhausting diseases, 268. bimanual examination of, 11. cystic enlargement of, a cause of ute- rine hemorrhage, 176. hyperesthesia of, in functional neuro- ses, 565. hypertrophy of, in chlorosis, 147. infantile, 141, 147, 150. inflammation of, in infectious diseases, 268. irritation of, a cause of masturbation, 310. mobility of, 12. metastases to, in parotitis, 272. normal, removal of, for amenorrhea with menstrual molimina, 155. for dysmenorrhea, 126. for vicarious menstruation, 162. menstruation after, 79, 629. obesity following, 244. symptoms associated with, 629. vaginitis following, 282. pain in, associated with malaria, 272. physiological changes in, possibly asso- ciated with intermenstrual pain, 132, 138. sterility associated with maldevelop- ment of, 365, 372. syphilis of, 427. Ovaritis, chronic, and dysmenorrhea, 109. Ovary, abscess of, associated with septic abortion, 471. cause of sterility, 366. in typhoid fever, 269. cyst of, diagnosis between, and pedun- culate cystic myoma, 499. disease of, mistaken for disease of rec- tum, 33. gonococciTS infection in substance of, 378. prolapse of, associated with retrodis- placement of uterus, 320. tumor of, and appendicitis, 588. bimanual examination of, 15. diagnosis between, and retrodisplace- ment of uterus, 322. in child, 26. permanent record of, on gauze, 18. Ovary, tumor of, precocious menstrua- tion associated with, 82. rectum choked by, 33. sterility caused by, 366. Ovary and tube, removal of, on one side for relief of intermenstrual pain, 136, 137. Overcrowding a cause of mortality in children, 45. Ovulation, relation of, to menstruation, 78. Ovum, attachment of, in extra-uterine pregnancy, 194. causes of abortion due to, 454. influence of corpus luteum upon, 79. Ozena syphilitica, 424. Packs, cold, for relief of insomnia, 32, 241, 580, 581. hot, for relief of insomnia, 32, 581. vaginal. See Tampons. Pad in sacro-iliac rheumatism, 259. in splanchnoptosis, 603. Pain, habit of, 626. post-operative, 626. production of renal, for purposes of diagnosis, 29, 617. significance of, in gynecological exami- nation, 27, 29. symptom of cancer, 169, 518, 519, 531. of cystitis, 548. of movable kidney, 610. of pelvic inflammation, 337. Paine's Celery Compound, percentage of alcohol in, 114. Palmar and plantar syphilides, 415. Palpation, abdominal method of, in gyne- cological examination, 7. in movable kidney, 609, 610. Pancoast, H. K., on splanchnoptosis, 597, 598. on X-ray in treatment of uterine can- cer, 537. Pancreas, syphilis of, 424. Papulitis, syphilitic, 429. Paraffin, injection of, in chronic cystitis, 564. Paralysis, general, syphilitic, 397, 430, 437. 678 INDEX. Paralysis of nerves to eye, from syphilis, 428, 429. Parasitic diseases, prevalence of, among school-children, 58. Parasyphilis, 396. Parks, public, beneficial effect of, 49. Parotid gland, enlargement of, during pregnancy, 273. for intermenstrual pain, 136. Parotitis, metastases during, to sexual or- gans, 272. Paronychia, syphilitic, 421. Parsons, Mrs., on state supervision of home education, 43. Parsons, J. E., on electricity in treatment of uterine hemorrhage, 188. Parturition. See Labor. Patent medicines, percentage of alcohol in, 114. Pediculus pubis, pruritus due to, 296, 298. Pellanda, C, on fibroid tumors, 505. Pelvic abscess, incision of, through vagi- nal vault, 342. rectum choked by, 33. Pelvic circulation, disturbances of, caus- ing hemorrhoids, 33. stasis of, inducing constipation, 208. Pelvic disease, acute infectious diseases the cause of, 50, 265. appendicitis associated vpith, 586. coccygodynia associated with, 262. influence of malaria upon, 271. masturbation caused by, 310. Pelvic inflammation, appendicitis with, 587, 589. conservatism in treatment of, 344. definition of, 335. . diagnosis between, and appendicitis, 340, 589. diagnosis of, 337. dysmenorrhea with. 111, 337, 338. etiology of, 336. examination in, 339. exppctant treatment of, 342. fever in, 338. fibroid tumors complicating, 497, 505. gonocoecus infection in, 341. infective, 335. local signs of, 339. Pelvic inflammation, menstruation af- fected by, 177, 337. non-infective, 335. non-sensitive, 337. opening abscess in, 342. palliative treatment of, 343. puerperal infection in, 339. radical treatment of, 344. sensitive, 337. sterility caused by, 365. symptoms of, 367. tubercular, 369. varieties of, 366. Pelvic tumor, cancer of rectum mistaken for, 34. constipation caused by, 222. diagnosis between, and movable kidney, 614. Pelvimetry, 482. Pelvis, syphilis of, 427. Pemphigus, presence of, at birth a sign of hereditary syphilis, 434. Penrose, C. B., on acute infectious dis- eases in the causation of pelvic disease, 268, 270. on age of first menstruation, 82. on duration of menstrual period, 84. Pericarditis due to syphilis, 383. Perineum, abscess of, 276. complete tear of, 33, 479. method of immediate repair of, 484, 485. protection of, in labor, 483. Periosteum, syphilis of, 427, 442. Periostitis, syphilitic, 427, 428. Peritoneum, gonocoecus in, 378. syphilis of, 427. Peritonitis, gonorrheal, in child, 280. Peritonitis, pelvic, after scarlatina, 268. after smallpox, 268. cause of sterility, 366. Periuterine inflammation, abortion • caused by, 473. dysmenorrhea with, 110. hyperthyroidism with, 575. Persuasion in treatment of functional neuroses, 583. Pessaries, atresia of genital tract caused by, 145. choice of, 329. INDEX. 679 Pessaries, cleanliness essential in use of, 282, 325. douches with, 331. essentials for use of, 326. in dysmenorrhea, 117. in palliative gynecology, 31. in prolapse of uterus, 333. indications for use of, 324. infection conveyed by, 282. measurement for, 326. method of introduction of, 328, 329. pruritus caused by, 296, 299. use of, in fibroid tumors, 506. in retrodisplacements, 324, 326. vaginitis caused by, 282. varieties of, 325. galvanic-stem, 155. Gehrung, 325, 327. Hodge, 325, 329. lever, 329. Menge, 329, 330. ring, 325, 327, 329. in position, 330. Smith, 325, 329. Smith-Thomas-Munde, 325, 329. Zwank, 330. Peters, on adrenalin in treatment of in- operable cancer, 542. Peterson, E., on fatty degeneration of heart in fibroid tumors, 496. on relation of appendicitis to pelvic af- fections, 586, 587. Pfliiger's theory of menstruation, 78. Phalanges, syphilis of, 428. Pharynx, chancre of, 403. Phlebitis, danger of, in anemia from fibroid tumors, 504. in septic abortion, 471. post-operative, 630. Phosphorus poisoning, abortion from, 450. Phrenasthenia, 569. Physical development retarded by heredi- tary syphilis, 435. Physical training in education of girls, 59. Physician, duty of, in extra-uterine preg- nancy, 203. in finictional neuroses, 582. in inoperable cancer, 533, 542, 633. in mental distress, 242, 582. Physician, duty of, in post-operative con- valescence, 622, 624, 628. in prophylaxis of cancer, 109, 520, 530. in sterility due to husband, 353, 369. to syphilitic patient after marriage, 448. to syphilitic patient before marriage, 444. liability of, to digital chancre, 402. relations of, to professional nurse, in nervous cases, 584. responsibility of, as to conservatism in radical operation for pelvic in- flammation, 344. as to infection of the pelvic organs during an acute infectious dis- ease, 265, 270. Physiognomy in hereditary syphilis, 435. Physiological amenorrhea, 145, 151. Piano, excessive practice upon, injurious to school-girl, 69. Pierre-Budin, on infants' food, 43. on instruction of mothers, 43. Piezometer, 9. Pinard, on male sterility, 372. Pincus, on atresia of genital tract due to infectious disease, 143, 265, 266, 267. on dangers of steaming the interior of the uterus, 509. Piorkowski, on etiology of syphilis, 392. Pithiatic phenomena, 567. Pityriasis, rosea, diagnosis between, and syphilitic eruption, 412. syphilitic, 414. versicolor, diagnosis between, and syph- ilitic eruption, 412. Placenta, gonococcus infection of, 378. method of removing, 483. Plaster, diachylon, for syphilitic psoria- sis, 442. mercuric, in treatment of syphilis of bones, 442. Playfair, on benefits of physical exercises to study, 61. on sex in education, 52. Playgrounds, public, beneficial effects of, on health of growing girl, 49. Plethora a symptom of obesity, 244, 245. 680 INDEX. Pneumonia, abortion during, 455. atresia of genital tract due to, 267. inflammation of uterus due to, 269. Pollack, Flora, on statistics of venereal disease in little girls, 383. PoUakiuria, 543, 554. Polyi3, fibroid, 492. mucous, 166, 492. nasal, headache caused by, 226. placental, 166. uterine, cause of sterility, 358, 362, 372, 373. cause of uterine hemorrhage, 166. diagnosis between, and threatened abortion, 458. Polypoid endometritis, 175, 292, 294. Pomeroy and Voorhees, rubber dilator bags of, 482. Population, reasons for present general decline in, 347. right proportion of increase in, 347. Porter, on torsion of ovarian cyst in child mistaken for acute appen- dicitis, 591. Post-nasal growths a cause of defective physical development, 57. Post-operative convalescence, daily life in, 623. diet in, 625. exercise in, 625. fever in, 634. headache in, 627. local pain in, 626. menstrual irregularities in, 627. phlebitis in, 630. tonics in, 624. Posture, dorsal, in cervicitis, 288. in examination of movable kidney, 609. in gynecological examination, 6. in introduction of uterine tampons in abortion, 465. in treatment of gonorrhea, 387. of vaginitis, 284. knee-breast, in gynecological examina- tion, 23. in gynecological examination in child, 25. in introduction of pack, 324, 509. in rectal examination, 35. Posture, knee-breast, in treatment of gon- orrhea in child, 389. in treatment of pruritus, 303. in treatment of vaginitis, 282, 284. in vaginal drainage of bladder, 538, 562. lateral. See Sims', lithotomy, in dilatation and curettage, 122. Sims', in gynecological examination, 23. in introduction of pack, 323, 509. in treatment of vaginitis, 285. Sims' exaggerated, in gynecological ex- amination, 25. standing, in gynecological examination, 26. in movable kidney, 609. in prolapse of uterus, 321. Potassium bromide, in headache with high arterial tension, 233, 234. in insomnia, 243. prevention of abortion, 462. Potassium chlorate in treatment of pruri- tus, 298. Potassium iodide in habitual abortion, 461, 462. in infantile syphilis, 443. in syphilic headache, 323. in tertiary syphilis, 437, 440. Potassium permanganate, in chancre, 404. in gonorrhea, 388, 389. in pruritus, 298. in pruritis of pregnancy, 303. in vaginitis, 285. Poverty, cause of malnutrition and of in- fection, 41. Pott's disease simulated by gummata of the vertebrae, 425. Poultice, carbolic acid, in treatment of pruritus, 301. Pratt, on chlorosis, atrophy of gastric glands in, 158. hypodermic use of iron in, 156. intestinal antisepsis in, 157. rest in, 158. Precocious menstruation, 82. Pregnancy, avoidance of, in syphilis, 448. coccygodynia associated with, 261, 262. diagnosis in early stages of, 151, 458. INDEX. 681 Pregnancy, extra-uterine, accidents liable to occur in, 196. anemia in, 200. attachment of ovum to different lo- calities in, 194. diagnosis of, 199. diagnosis between, and appendicitis, 206, 588,-591. etiology of, 195. false labor pains in, 198. hemorrhage in, 206. history of, 194. menstrual irregularities in, 177, 199. normal pregnancy and, 201. signs of, 199. treatment of, 206. extra-uterine pregnancy mistaken for, 201. fibroid tumor, associated with, 499, 512. mistaken for, 204. obstacle to, 363, 504. Hegar's sign in, 151, 500. intermenstrual pain absent during, 133, 138. malarial influence in, 271. manual reduction of uterus in, 322, 462. "molar," 454. movable kidney caused by, 608. parotid gland enlarged during, 273. prolapse of uterus an interference with, 322. pruritus caused by, 296, 303. ruptured tubal, diagnosis between, and appendicitis, 206, 543. sacro-iliac joints relaxed during, 252. splanchnoptosis caused by, 599. vaginismus a bar to, 306. vaginitis in, 281. Preparation of patient for gynecological examination, 6. Preventive medicine, education of public in principles of, 50. importance of protection from syphil- itic infection as branch of, 444. Priestley, Sir W., on intermenstrual pain, 132, 138. Primiparse, frequency of abortion in, 453. Proctitis, coccygodynia associated with, 262. Proctitis, diagnosis between, and chronic disease of uterine adnexa, 34. gonorrheal, 386. Proctoscopef 35, 215, 222. Prostate gland, syphilis of, 426. Prostitutes, acute gonorrhea in, 380, 381. frequency of gonorrhea in, 376. rectal gonorrhea in, 386. sterility of, 384. Protargol in treatment of gonorrhea, 388, 389. Protoiodide pills in syphilis, 438. Prouty, I. J., on heredity as a cause of headache, 227. Prowe, on frequency of gonorrhea in pros- titutes, 376. Pruritus, 259. anal, 33, 262. association of, with jaundice, 295. definition of, 295. diabetes the cause of, 295, 297. diagnosis of, 297. etiology of, 295. electricity for, 302. formulae for, 298, 300, 301, 302, 303. gonorrheal, 298. in child, 298. in men, 296. in old age, 636. in pregnancy, 303. itching in, 295, 297. pessaries a cause of, 299. post-menstrual, 299. skin changes in, 295, 297. surgery in, 302. symptoms of, 297. thrush with, 298. treatment of, 297. vaginal discharge with, 298. Prussia, Southern, age of first menstrua- tion in, 83. Psychasthenia, 569. characteristics of, 569, 573. definition of, 569. differentiation of, from other neuroses, 569. feeling of incompleteness in, 569, 570, 573. frequency of, 569. mental manias in, 570, 571. 682 IXDES. Psychasthenia, objective symj)toms of, 571. obsessions in, 570. prognosis of, 576. subjective syirptoms of, 569. treatment of, 577. Psychic disturbances, cause of abortion, 455. cause of sterility, 367. Psycho-analysis, 583. Psycho-therapy, 242, 582. Psoriasis, diagnosis between, and miliary- papular syphilide, 414. diagTiosis between, and papulo-squani- ous syphilide. 414. of palms, diagTiosis between, and palmar and plantar syphilide, 415. syphilitic, of tongue. See Leucoplasia. Ptomaine poisoning, headache due to, 225. Puberty, clothing at, TO. early, in chlorosis, 147. employment at, 69. exercise at, 68. heredity in determining age of, 83, 145. hygiene of, 67. menstruation irregular at, 86. physiology of reproduction, instruction in, at, 72. sleep at, importance of, 68. school-life in relation to, 65. Puech, on atresia of genital tract caused by infectious diseases, 266. Puerperal infection, appendicitis, and, 587. pelvic inflammation from, 339. sterility from, 357. Puerperium, malarial influence upon, 271. Purgative enemata, 222. Piisey, W. A., on injurious effects of tryp- sin in inoperable cancer, 539. Pyelitis, albmninuria in, 548, 549. artificial abortion indicated in, 474. diagTiosis between, and cystitis, 549. pyuria in, 548. Pylorus, tumor of, mistaken for movable kidney, 615. Pyopietra in cervical cancer, 533, 534. in old age, 639. in senile endometritis, 294. Pyo-physometra in senile endometritis, 294. Pyosalpinx, labor followed by, 479. sterility associated with, 365, 374. Pyuria, acid, association of, with tuber- culosis, 550, 557. in cystitis, 548, 549. in pyelitis, 548. thickening of ureter associated with, in tubercular kidney, 13. Quack literature on coccygodynia, 263. Quacks, coal-tar preparations misused by, 235. treatment of fibroid tumors by, 505. treatment of headache by, 224. treatment of male sterility by, 352. Quinine, contractions of uterus induced by, 469. Radium iu treatment of uterine cancer, 537. Payer, on relation of hysteria to floating kidney. 597. on swelling of leg associated with mov- able kidney, 613. Reception room, physician's, 1. Rectal enemata. See Enemata. Rectal valves, thickening of, a cause of constipation, 213. Recto-abdominal examination, 12, 13. in child, 26. in virgins, 27. Rectocele, 19, 479. Rectum, cancer of, a cause of constipa- tion, 215. mistaken for a pelvic tumor, 34. dysmenorrhea due to overloading of, 33. examination by, in appendicitis in child, 596. in constipation, 215. in gynecological practice, 33. in imperforate hymen, 151. instruments required for, 35. method of conducting. 35. of pelvic organs, in child, 26. in virgins, 27. extension of cancer of cervix to, 513, 524. INDEX. 683 Rectum, fibroid tumor pressing upon, 33, 498, 503. fissure of, 34, 38. gonococcus infection of, 3Y6, 378, 386. inflammation of. See Proctitis, inspection of, through head-mirror, 36. pelvic disease extending to, 33. separation of, from attachments of le- vator ani muscles after labor, 479. stasis of pelvic blood-vessels from over- loading of, 33. stricture of, 38. syphilis of, 423. temperature in, in appendicitis, associ- ated with dysmenorrhea, 593, 594. treatment of disease in, 38. Re-education, in treatment of functional neuroses, 584. Reichert's theory of menstruation, 78. Relapsing fever, inflammation of uterus from, 269. Relatives, marriage between, a cause of sterility, 368. Renal colic, artificial production of, 29, 617. in movable kidney, 610. treatment of an attack of, 619. Reproduction, instruction of young girl in physiology of, 72. Repulsion a cause of sterility, 367. Respiratory system, syphilis of, 424. Rest, therapeutic uses of, during men- strual period, 73, 627. during post-operative convalescence, 623. in chancre, 404. in chlorosis, 158. in dysmenorrhea, 113. in functional neuroses, 576, 577. in gynecological affections in general, 30. in hemorrhage from uterus, 183, 184, 506, 509. in imminent abortion, 462, 463. in insomnia, 242. in intermenstrual pain, 137. in splanchnoptosis, 603. Rest cure, 576, 577. Retina, syphilis of, 429. Rheumatic diathesis, in amenorrhea, 149. in dysmenorrhea, 96. in headache, 225, 234. in migraine, 235, 236. in obesity, 244, 248. Rheumatism, acute, a cause of ovarian in- flammation, 270. a cause of sterility, 366. muscular, relation between, and coccy- godynia, 261. sacro-lumbar, diagnosis between and sacro-iliac joint affections, 251. treatment of, 256. Rhubarb in constipation, 220. Richards, Mrs. Ellen H., on training young girls for the duties of home, 42. Richter, case of atresia of genital tract due to smallpox, 266. Ricord, on chancre as source of infection in syphilis, 449. Riedl, case of precocious menstruation, 82. Riegel's theory of menstruation, 79. Riis, method of radical operation in can- cer, 530. Rilli and Vockenrodt, on attachment of the spirocheta pallida to the red blood corpuscles, 432. Riva-Rocci instrument for measuring ar- terial tension, 226. Rokitansky, on attachment of ovum to cervical mucous membrane, 458. on chlorosis, 147. Rollet, on hysteria and movable kidney, 597. Rose's method of bandaging in splanch- noptosis, 555. Roseola, syphilitic, 412. Rosinski, on presence of gonoccocus in mucous membranes, 378. Rubber bags, dilatation of cervix in labor with, 482. Ruge, C, on formation of papillae in vagi- nitis, 280. on treatment of pruritus, 301. Rupia, 418. Sacro-iliac joints, relaxation of, backache in, 252. 6Si IISDEX. Sacro-iliac joints, relaxation of, charac- teristics of, 252. etiology of, 252. objective symptoms of, 255. referred pains in, 255. subjective symptoms, 254:. treatment of, 259. Salicylate of soda in diabetic pruritus, 302. Salicylic acid, in treatment of condylo- mata, 442. Saline infusion, in bemorrbage from ex- tra-uterine pregnancy, 206. . in menorrbagia, 184. preparation of, 184. Saline laxatives, in cblorosis, 157. in constipation, . 221. in beadacbe, 231. Salivation in mercurial treatment of syphilis. 43S. Salol iu treatment of chlorosis. 157. Salpingitis, association of, \rith dysmen- orrhea, 110, 111. with sterility, 358. diagnosis between, and appendicitis, 587, 588, 590. diagnosis between, and extra-uterine pregnancy, 173. 591. syphilitic. 427. Salvarsan in syphilis. 408. Sampson, J. A., on drainage of bladder after hysterectomy for cancer, 577. on method of radical operation for cancer, 530. Sanger, on infection of Bartholin's glands, 359. on gonococcus as cause of sterility, 351. on male sterility, 353, 354. on pruritus in diabetes, 295. on relation between female sterility and absence of sexual feeling. 267. on treatment of constipation without drugs. 219. 223. 625. on treatment of infections of the vag- ina with chloride of zinc in solu- tion, 374. Sanger and Schwartz on the percentage of gonorrhea among all patients, 376. Sanger's "maculae gonorrhoicae," 359, 385. Sanitary inspection of schools, 58. Sanitation, public, influence of, on indi- vidual health, 44. Sarcoma of kidney in child, 26. of uterus, a cause of hemorrhage, 170. Sarcomatous degeneration of fibroid tu- mors, 496. Scanzoni, case of atresia of genital tract due to smallpox, 266. on caustic potash for pruritus, 301. on fibroid ttunors in causation of ster- ility, 504. on pregnancy and labor as the cause of coccygodyuia, 261. Scar, abdominal, enlargement of, 632. tenderness in, 632. Scarification of cervix uteri in amenor- rhea accompanied by menstrual molimina, 159. Scarlatina, abortion in, 455. atresia of genital tract from, 267. atresia of vagina from, 143, 266. inflammation of ovaries in, 268. pelvic peritonitis after, 268. Scarlet-fever. See Scarlatina. Schaudinn and Hoffmann, discovery of spirocheta pallida, 392. Scheuk, F.. on statistics of male sterility, 353. Schenk's Sea-weed Tonic, percentage of alcohol in, 114. Schiller, H., on yeast treatment of vagini- tis, 286. Schleich's solution of cocain and mor- phin, formula for. 277. in abscess of Bartholin's gland, 277. in treatment of pruritus, 302. Sclerosis, early multiple, diagnosis be- tween, and functional neuroses, 579. Schmalfuss, on reflex symptoms accom- panying an artificial menopause, 629. School buildings, necessity for medical inspection of, 58. School-girl, age of. on entrance, 51. amenorrhea in. from overstudy. 155. assymmetrv in, 63. INDEX. 685 Scliool-girl, athletics for, 61. bowels, care of, in, 53. breakfast a necessity to, 53. desk, proper height of, for, 60. dress of, 53. dysmenorrhea in, 66, 109, 113. gymnastics for, 59. hygienic habits in, 52. importance of attention to physical de- fects in, 57. medical inspection of, 43, 50, 54, 62. at intervals, 63. menstrual function in, 72. out-door exercise for, 61. physical training of, 59. spinal curvature in, 62.- teeth, care of, in, 53. School-teachers, necessity for instruction of, in hygiene, 59. School for girls, architecture of, 58. beneficial effects of, 66. centres of infection, 58. defective hygiene in, 58. gymnastics in, 60. medical inspection in, 43, 50, 54. playgrounds attached to, 61. provision of lunch in, 56. seating in, 60. toilet accommodations in, 59. Schreiber, on method of massage for sacro-lumbar rheumatism, 257. on motion in treatment of sacro-lumbar rheumatism, 257, 258. on muscular rheumatism of sacral re- gion, 252. Scoliosis, prevention of, by corrective gymnastics, 62. theory of association of, with faulty construction of the bodies of the vertebrae, 62. treatment of, 63. Scriptures, verses from, on sterility, 347, 350. on gonococcus infection, 375. Schroder, on fibroid tumors in causation of sterility, 504. Schulthess, on relation of schools to lat- eral spinal curvature, 62. Sciatica mistaken for a neurosis, 565. Seborrhea of scalp in syphilis, 420. Seborrhea of scalp in syphilis, diagnosis between, the circinate papular syphilide, 415. Secretions, from cervical glands, 275, 287. gonorrheal, 298, 385, 389. in cervicitis, 287. in endometritis, senile, 294. in pelvic inflammation, 339. in pruritus, 299. in syphilis, all contagious, 398. in vaginitis, 280, 282, 283. in vulvitis, 276. in young children, 381. irritating, a cause of pruritus, 295, 296. method of collection of, for microscopi- cal examination, 276. normal vaginal, fatal to gonococcus, 379. Sedative enemata in treatment of dys- menorrhea, 115. in treatment of pruritus, 299. Sedatives in cystitis, 558. in dysmenorrhea, 114. in headache, 234. in inoperable cancer, 541. in insomnia, 242. in masturbation, 316. in threatened abortion, 462. in vaginismus, 307. in vomiting of chlorosis, local, 158. Seeligman, on treatment of vicarious menstruation, 162. Seeligmuller, on relation between coccy- godynia and neuralgia, 262. on treatment of coccygodynia, 263. Seitz, L., on hydramnion in early preg- nancy, 454. on syphilis in causation of abortion, 455. Sellheim, H., on incomplete abortion, 458. Semen, method of collecting, for exami- nation, 353. Semola, on syphilitic influence in angina pectoris, 425. Sepsis, dangers of, from remnants of abortion, 190. in catheterization, 556, 557. in curettage, 189, 373. in expectant treatment of threatened abortion, 463. in intra-uterine treatments, 509. 686 INDEX. Sepsis, dangers of, in mechanical evacu- ation of uterus, 467. in operation for imperforate hymen, 154. in tents for dilatation of cervix uteri, 122. in uterine tampons, 465, precautions against, by obstetrician, 482, 486. Serum, antigonococcus, 379. Serum-therapy in syphilis, 440. Severinus Pinseus, on rupture of hymen, 359. Sewage, necessity for adequate removal of, 44. Sewing-machines, excessive use of, at pu- berty injurious, 69. Sexual activity associated with precocious menstruation, 82. Sexual emotions, disturbances of, associ- ated with sterility, 367. in neurasthenia, 568. Sexual intercourse, excessive, a cause of abortion, 455. prohibition of, in threatened abortion, 462. in treatment of vaginismus, 306. " Sexual spots," 109. Shape of body associated with movable kidney, 607, 609. with splanchnoptosis, 600, 601, 602. Shock, in the etiology of amenorrhea, 149, 367. of functional neuroses, 568. Shoemaker, G. E., on hemorrhage in early diagnosis of uterine can- cer, 520. Shoes for young girl, 71. Sick headache. See Migraine. Sierra Leone, age of first menstruation in, 83. Sigmoid flexure, condition of, in constipa- tion, 215. palpation of, 9. redundancy of, a cause of constipation, 213. operation for relief of, 213. Sigmoidoscope, 35. Silver, nitrate of, formula for solution of, 561. Silver, nitrate of, in causation of ex- foliative vaginitis, 281. in treatment of cervical cancer, 536. of chancre, 404. of cystitis, 334, 560. of endocervicitis, 288. of gonococcus infections, 307, 387, 388, 389, 391. of mucous patches, 442. of pruritus, 300, 301. of pruritus in pregnancy, 303. of rectal disease, 38. of senile endometritis, 294. of vaginitis, 284. Simon, C. E., on reduction of hemoglobin in chlorosis, 153. Simpson, J., on pruritus of diabetic ori- gin (formula), 302. Simpson, J. Y., on atresia of cervix caused by application of the ac- tual cautery, 145. on coccygodynia, 260, 261, 262, 263. on membranous dysmenorrhea, 128. on the mechanical theory of dysmenor- rhea, 107. Sims, J. Marion, on examination of rec- tum, 34. on mechanical theory of dysmenorrhea, 107. on surgical treatment of vaginismus, 308. on vaginismus, 304, 306, 368. Sims' posture. See Posture. Sims' speculum. See Speculum. Skene, on age of first menstruation, 87. on local changes in genitalia accom- panying the menopause, 88. on typhoid fever followed by atresia of the genital tract, 266. Skene's glands, infection of, in gonor- rhea, 380, 381, 385. in vulvitis, 276. method of exposing, 388. sterility due to gonorrheal infection of, 358, 359, 374. treatment of gonorrheal inflammation of, 388. treatment of inflammation of, 278. Skin, affections of, in young girls, owing to malnutrition, 55, 58. INDEX. 687 Skin, changes of, in pruritus, 295, 297. eruptions of, associated with menstrua- tion, 106. hereditary syphilis of, 435. syphilis of appendages of, 420. Skrobansky, on inflammation of the ova- ries in acute infectious diseases, 268, 269, 270. Smallpox, atresia of genital tract follow- ing, 266. in fetus, 454. pelvic peritonitis after, 268. Smegma bacillus, mistaken for pus in urine, 549. Smith, A. L., on electrical treatment of dysmenorrhea, 117. Smoke, dangers of, to public health, 44. Smoking. See Tobacco. Social life, influence of, on health of women, 75. Sodium bicarbonate in disinfecting douche, 331. Sodium, bromide in treatment of dysmen- orrhea (rectal enema), 115. of headache with high arterial ten- sion, 233, 234. of insomnia, 243. of pruritus (rectal enema), 299. Sodium nitrite in headache with high ar- terial tension, 233. Sodium phosphate in treatment of consti- pation, 218. Sodium salicylate in rheumatic headache, 234. Soupault and Jouaust, on dysmenorrhea caused by appendicitis, 592. Spa treatment of obesity, 246. Specula, rectal, 35, 36, 38. tubular, in vaginismus, 308. Speculum, Burrage's uterine, 509. Kelly's cylindrical metal, for examin- ing pelvic organs in knee-breast posture, 23. for examining the pelvic organs in the Sims' postvire, 24. for insertion of vaginal tampon, 187. for painting the cervix, 31. for treating gonorrhea in a child, 389. Nelson's. See Trivalve. Sims', in dilatation of the sphincter, 39. Speculum, Sims', in examination of pel- vic organs in Sims' posture, 23. in examination of rectum, 34. in insertion of intra-uterine tampons, 465. in introduction of vaginal tampons, 187. in treatment of gonorrhea, 387. trivalve, in insertion of vaginal tam- pons, 187. in inspection of vagina, 19. tubular, in acetone treatment of cancer, 540. in treatment of vaginismus, 308. vesical, in examination of bladder, 532. in examination of vagina in child, 25. Sphincter area, dilatation of, 38. Sphincter vaginae, division of, in vaginis- mus, 308. Sphincteroscope, fenestrated, 38. Spina ventosa, 428. Spinal-cord, syphilis of, 431. Spine, lateral curvature of, in school- girls, 62. improvement of, under systematic gym- nastic exercises, 64. Spirocheta pallida, demonstration of, in lesions and in fetus, 392, 393. disappearance of, on administration of mercury, 393. discovery of, 392. in blood-vessels, 397. in chancre, 402. in heredo-syphilitic lesions, 434. in mixed chancre, 400. in renal epithelium, 398. in syphilitic lesions in apes, 393. value of, in diagnosis of syphilis, 402, 445. Splanchnoptosis, anatomical basis of, 597. characteristic body shape of, 600, 601, 602. definition of, 597. diagnosis of, 601. etiology of, 599. frequency of, 602. hygienic measures of treatment of, 603. medical treatment of, 603. operative treatment of, 604. relation of, to neurasthenia, 599. 688 IISTDEX. Splanchnoptosis, symptoms of, 599. treatment of, by bandaging, 603. Spleen, displacement of, 601. syiJhilis of, 424. Spondylitis, syphilitic, 428. Sponge tents. See Tents. Sprague, W. B., on electricity in treat- ment of dysmenorrhea, with de- scription of method, 117. Standing posture, examination in. See Posture. Stanley, on chlorosis, 156. Starch, reduction of, in food, in treatment of obesity, 246. Steam, cauterization of uterine cavity by, 136, 509. Stengel, on chlorosis, 146, 157, 158. Stephenson, W., on chlorosis, 146, 155. Sterdele, case of atresia of genital tract caused by typhoid fever, 266. Sterility, 346. absolute, 346. acquired, 347. congenital, 347. definition of, 346. development of knowledge concerning, 351. duty of physician in, 353, 369. etiology of, in female. See below. in males. See below, intermenstrual pain associated with, 133. laws governing, 348, 349, 350. morality of, 347. national importance of, 347. one-child, 346, 362, 366, 384. period after marriage when it begins, 349. prevalence of, 347. progressive, 347. relative, 346. relative at different epochs in marriage, 349. schemes for examination for, in, 370, 371. treatment of. See below. Sterility in female, caused by anaphrodi- sia, 367. by anatomical and physiological pe- culiarities, 357. Sterility in female, caused by affections of neck of uterus, 361. by atresia of vagina, 142, 360. by cervical affections, 361, 362. by constitutional conditions, 366. by displacements of uterus, 363. by dyspareunia, 367. by endometrial affections, 362. by fibroid tumors, 363, 393, 504. by gonococcus infection, 358, 361, 365, 384. by imperforate hymen, 359. by infantile uterus, 363. by infection of Bartholin's glands, 359. by infection of Skene's glands, 359, 374. by ovarian affections, 365. by relaxation of vaginal outlet, 360. by repulsion, 367. by stenosis of cervix, 361. by tubal affections, 365. by vaginismus, 306, 368. treatment of, 369. by cauterization of cervix, 374. by cauterization of vagina, 374. by correction of displacements, 372. by curettage, 373. by dilatation of cervix, 372. by enucleation of fibroids, 373. by excision of hymen, 372. by incision of Bartholin's and Skene's glands, 374. by opening and draining uterine tubes, 374. by removal of parovarian cysts, 373. by removal of uterine polyps, 373. by treatment for gonorrhea, 374. Sterility in male, forms of, 351. frequency of, 353. history of knowledge in, 350. method of examining for, 353. prognosis in, 353, 369. statistics as to frequency of, 354, 355, 356. Sterilization of instruments, 6. of towels, 465. Stern and Jacquet, on the gonococcus in the pus of inflamed joints, 378. von Stellwag's sign, 576. INDEX. 689 Stiller, on etiology of splanchnoptosis, 599. Stimulants, alcoholic avoidance of, in in- somnia, 241. in combination with coal-tars, 114, 235. in treatment of dysmenorrhea, 113. Stomach, displacement of, 597. diagnosis of, 601. operative treatment of, 604. symptoms of, 600. dilatation of, and migraine, 228. fermentation of, a cause of insomnia, 241. palpation of, 8. syphilis of, 423. Stomatitis, mercurial, diagnosis between, and syphilis of the oro-pharyn- geal cavity, 422. Storer, M., on intermenstrual pain, 134. Strain, nervous, in causation of neuras- thenia, 568. Strassmann, cases of precocious menstru- ation, 82. on fibroid tumors and heart disease, 505. on relation of sterility to absence of sexual feeling, 367. Stratz, on amylaceous degeneration of fibroid tumors, 496. Strauss, Nathan, interest of, in free milk stations, 44. Stricture of intestine, cause of constipa- tion, 213, 222. of rectum, examination of, 38. of urethra, in women, 360. Stumpif, on statistics of abortion, 453. Sturgis, r. E,., on parallel between consti- tutional effects in syphilis and gonococcus infection, 377. Stypticin in treatment of uterine hemor- rhage, 185, 508. Styptol in treatment of uterine hemor- rhage, 185. Suburethral abscess, 278. Suction apparatus for removal of urine from bladder, 552. Suggestion, susceptibility to, in hysteria, 566. in treatment of functional neuroses, 583. 45 Suggestion, susceptibility to, in treatment of insomnia, 541. Sulphonal in treatment of functional neu- roses, 581. in treatment of insomnia, 242, 243. Suppositories, rectal, belladonna and opium in cystitis, 558. glycerin, in constipation, 221. patent medicines in, 281. trional and codein in cystitis, 558. vaginal, in displacements of uterus, 332. in gonococcus infection, 389. Suprarenal gland, changes in, associated with sterility and obesity, 367. extract of. See Adrenalin. Suppuration of abdominal wound in post- operative convalescence, 631. Sutton, Bland, on number of fibroid tu- mors, 488. on seedling fibroids, 495. van Swieten, liquor of, in treatment of syphilis, 438. Swimming pools for girls, 61. Syphilides, acne form of pustular, 416. circinate papular, 415. confluent impetiginous, 417. diagnosis of, 412. ecthyma form of pustular, 417. erythematous, 411. gummatous, 418. impetigo form of pustular, 417. lenticular, 413. lichenoid, 414. macular, 412. maculo-papular, 412. miliary papular, 414. moist papular, 415. nummular, 413. palmar, 415. papular, 413. papulo-squamous, 414. pigmentary, 412. plantar, 415. pustular, 416. serpiginous, 419. tubercular, 418. variola form of pustular, 416. vegetating, 419. vesicular, 416. 690 INDEX. Syphilis, abortion from, 445. accidental causes influencing, 396. benign rapid, 396. causal agent in, 392. conceptional, 433. congenital, 432. definition of, 392. eruption of, 394. evolutionary modes of, 393. fever in, 394. headache in, 226, 233, 394. ignorance a cause of transmission of, in marriage, 449. infantile, 434, 443. infiltration in, 395. initial lesion of, 393, 399. inoculation of, 398. instruments a cause of infection in, 6. intermediate period of, 394. iodide of potash in treatment of, 437, 440. irregular, 396. marriage and, 443. mercury in treatment of. See Mercury, morbid anatomy of, 397. mouth, hygiene of, in treatment of, 441. mucous patches the chief source of in- fection in, 449. parasyphilis, 396. post-conceptional, 434. precocious malignant, 396. primary incubation of, 393, 399. primary stage of, 393. prodromal symptoms of, 394. prophylaxis of, by education, 449. reinfection in, 397. secondary incubation of, 394. secondary stage of, 394. sources of, 398. stages of, 393. toxines in, 396. transmission of, to third generation, 436. treatment of, 437. antinervine in, 441. dermo-pulmonary, method of, 439. duration of, 440. hygienic measures of, 441. hypodermic method of, 489. Syphilis, treatment of, in late manifesta- tions, 446. ingestion method of, 438. intermittent method of, 438. inunction method of, 438, 443. iodide of potash in, 437, 440. mixed, 440. object of, 437. salvarsan in, 408. time for beginning, 437. Wassermann reaction in, 405. variations of type of, 395. Syphilis, hereditary, 432. conceptional, 433. manifestations of, 434. maternal transmission of, 433. mixed transmissions of, 433. modifications of, 433. paternal transmissions of, 432. post-conceptional, 434. teeth in, 435. treatment of, 443. Syphilis, primary, abortive treatment of, 404. bubo, 402. chancre, 399. diagnosis of, 402. incubation period of, 399. initial lesion of, 399. prognosis of, 403. situation of lesions of, 400, 402. treatment of, 404. Syphilis, secondary, characteristics of, 411. diagnosis of, 412. syphilides in, 411. treatment of, 442. varieties of, 411. Syphilis, tertiary, diagnosis of, 419. of alimentary system, 419. of appendages to skin, 420. of circulatory system, 424. of eye and ear, 428. of female reproductive organs, 426. of genito-urinary system, 425. of motor system, 427. of nervous system, 430. of oro-pharyngeal cavity, 421. sjTDhilides of, 418. treatment of, 440. INDEX. 691 Syphilis and marriage, 443. duty of physician after, 448. duty of physician before, 446. safety in, 443. secrecy in, 447. social effects of, 444. sources of infection in, 449. statistics of, 449. Syphilo-toxines, 396. Syrup of Gibert, 438. Tabes, association of, with syphilis, 431, 446. diagnosis between, and functional neu- roses, 5Y4. prevention of, by mercuric treatment, 437. Tables on annual birth-rate, 348. on duration of menstrual period, 84. on examination of physical condition of school-children, 55, 65. on initial fecundity of women under twenty, 349. on intermenstrual pain, 134. on interval between marriage and birth of first child, 350. on interval between menstrual periods, 86. on menopause, 89. on relative sterility at different ages, 349. Tait, Lawson, on pelvic peritonitis asso- ciated with acute infectious dis- ease, 268. Tait and Wiggin, case of removal of ap- pendix, 587. Tampons, uterine, asepsis in use of, 465, 466. in abortion, 465. in uterine hemorrhage, 187. method of introduction of, 187, 465. vaginal, boroglycerid in, 285, 324. function of, 31. in abortion, 461, 464. in displacements of uterus, 353. in fibroid tumors, 509. in gonorrhea, 389. injudicious use of, 324. in menorrhagia, 186. in prolapse of uterus, 334. Tampons, vaginal, in pruritus, 299. in retrodisplacement, 323. • in uterine hemorrhage, 186, 464, 509, 642. in vaginitis, 285. method of introducing, 323. Tarnowsky, on influence of syphilis in so- ciety, 437. Taylor, J. M., on physical training of children, 59, 62. Taylor, K. W., on gonorrheal origin of uterine disease, 376. Tea and cofl^ee, avoidance of, in insomnia, 239, 241. Teeth, care of, in school-girls, 53. syphilitic, 435. Temper, effect of constipation upon, 207. headache caused by, 228. Tendon sheaths, gonococcus in pus of in- . flamed, 378. Tendons, syphilis of, 427. Tenement houses, defects of, injurious to public health, 45. Tents, in treatment of chancre, 404. sponge, in artificial abortion, 475. in mechanical evacuation of uterus, 469. risks of, in dilatation of cervix for dysmenorrhea, 122. Testicles, diagnosis between cancer of, and syphilis of, 426. syphilis of, 425. Theilhaber, on atrophy of genital organs in Basedow's disease, 148. Thermal-electric light in treatment of backache, 258. in treatment of headache, 233. Thomas, T. G., on frequency of fibroids in negro race, 493. Thomson, A., on adhesions between fetus and membranes, 454. Thorn, on atrophy of uterus and ovaries after all exhausting diseases, 146. Thorndyke, on frequency of splanchnop- tosis, 602. Thrombosis, danger of, in anemia from fibroid tumors, 504. '. Thrush, a cause of pruritus, 296, 298. 692 IISTDES. Thyroid gland, changes in, associated with functional neuroses, 568, 575. with obesity and sterility, 367. extract of, in treatment of adiposis do- lorosis, 249. of dysmenorrhea, 117. of fibroid tumor, 508. of inoperable cancer, 539. of intermenstrual pain, 136. of obesity, 248. of symptoms at menopause, 89. Tilt, on functional amenorrhea, 149. on the menopause, 89, 90, 91. Tobacco, excessive use of, headache caused by, 227. injurious in syphilis, 422, 441. Tobler, Marie, on constancy of menstrual molimina, 106. Toilet accommodations, defective, associ- ciated with constipation, 59, 212. with immorality, 212. Tongue, epithelioma of, associated with excessive use of tobacco, 422, 441. diagnosis between syphilis of, and epithelioma, 422. Tonsils, chancre of, 401, 404. hypertrophy of, associated with, defec- tive physical development, 57. associated with disturbances of men- struation, 57. Toothache, association of, with menstrua- tion, 106. Torrey, J. C, on antigonococcus serum, 379. Torsions of uterus. See Uterus. Teuton, on gonococcus in squamous epithelium, 378. Toxemia, headache from, 226. Trachea, syphilis of, 424. Trauma, effects of, on severity of syph- ilis, 396. in causation of abortion, 455. of appendicitis in child, 595. of cervical cancer, 516. of coccygodynia, 261. of functional neuroses, 568. of movable kidney, 608. Treponema pallidum. See Spiroclieta pallida. Trichiasis of vulva a cause of pruritus, 301. Trigonum, hyperemia of, distinction be- tween, and cystitis, 543. Trimanual examination, 13. Trional for relief of insomnia, 242, 243, 581. of renal colic, 619. Trivalve speculum. See Speculmn. Troitski, on metastases to ovaries during parotitis, 272. Trypsin in treatment of inoperable can- cer, 539. Tuberculosis, abortion in, 455. amenorrhea in, 148, 153, 159. beginning apical, a cause of neuras- thenia, 568. effect of, on severity of syphilis, 396. latent, developing during post-operative convalescence, 634. of bladder, 545. of kidney, 545, 548, 549, 554, 557, 558. pruritus from, 260. sterility from, 366. syphilis in etiology of, 397. Tuberculosis of endometrium a cause of uterine hemorrhage, 176. Tuke,'H., on psychasthenia, 569. Tumors, abdominal, constipation caused by, 213. gauze records of, 17. splanchnoptosis caused by removal of, 599, 602. brain, headache caused by, 226. neurasthenia caused by, 568. fibroid. See Fibroid, ovarian, appendicitis associated with, 588, 590. bimanual examination of, 15. gauze record of, 18. in child, 26. rectum choked by, 33. pelvic, cancer of rectum mistaken for, 34. constipation from, 213, 222. backache caused by, 251. Turkish bath in treatment of dysmenor- rhea, 116. Turpentine enemata, 222. INDEX. 693 Typhoid fever, abortion in, 455. abscess of ovary in, 269. atresia of genital tract following, 266. backache caused by, 256. headache caused by, 226. inflammation of ovaries in, 269. of uterine appendages in, 269. of uterus in, 269. Ulcer, epitheliomatous, of face, 419. gastric, simulation of, by movable kid- ney, 611, 612. varicose, mistaken for ulcerative gum- mata, 420. Ulcerations, tubercular, mistaken for syphilis of oro-pharyngeal cav- ity, 422. of uterus (so-called), 21. of vagina, 334. Ulcerations of cervix. See Cervix. Unger, on isolation of gonococcus in the blood current, 378. United States, age of first menstruation in, 82. Uremic poisoning. See Nephritis. Ureters, catheterization of, for purposes of diagnosis, 29, 548, 617. compression of, by fibroid tumors, 503, 505. palpation of, by vagina, 13. secondary infection of, by gonococcus, 376. thickening of, in tuberculosis of kidney, 13. Urethra, caruncle of, 306. chancre of, 400. gonococcus infection of, 306, 359, 376. stricture of, 360. syphilis of, 425. treatment of gonococcus infection of, 387. Urethral dilators in mechanical evacua- tion of uterus, 469. Urethral glands. See Skene's glands. Urethritis, gonorrheal, 260, 387. Urination, frequency of, in cystitis, 547, 549, 553. in functional neuroses, 565, 668. Urination, frequency of, retrodisplace- ments of uterus, 322. frequent and painful, in gonorrheal in- fection of genitalia, 385. increase in amount of, during Dietl's crises, 411, 413. Urine, albumen in, in cystitis, 549. in pyelitis, 548, 549. blood in, during a Dietl's crisis, 611, 613: blood pigment in, during chlorosis, 158. preservation of, for examination, 548, 561. pus in, during cystitis, 548, 549, 554. removal of, from bladder with suction apparatus, 553. routine examination of, by gynecolo- gist, 6. sugar in, a cause of pruritus, 296, 297. Urotropin in prevention of cystitis, 557, 558. Uterine' tubes, abscess of, accompanying septic abortion, 471. chronic disease of, mistaken for proc- titis, 34. closure of, from infection, 275, 335, 365, 376. gonococcus infection of, 376, 378, 381. inflammatory disease of, involving the rectum, 33. maldevelopment and disease of, a cause of sterility, 365, 374. syphilis of, 427. " Uterine stones," 495. Utero-sacral ligaments, shortening of, a cause of abortion, 456. Uterus, abnormal positions of, 318. affections of neck of, cause of sterility, 361. anteflexion of, cause of sterility, 363. congenital nature of, 318. risks of dilatation in, 125. ascensus of, 318. atrophy of, after exhausting diseases, 148, 190, 366. backache in disease of, 251. bimanual examination of, 11. carcinoma of. See Cancer, changes in, after the menopause, 90. during menstruation, 81. 694 INDEX. Uterus, danger of applications to interior of, 294, 509. curettage of, for diagnosis of cancer,- 170, 525, 527. for hemorrhage, 189, 510. for inoperable cancer, 534. for remnants of abortion, 190, 467. for sterility, 373. method of, 189. disease of, mistaken for disease of the rectum, 33. displacements of, 317. gonococcus in muscular coat of, 378. infantile, cause of amenorrhea, 150. cause of sterility, 363. inflammation of, due to infectious dis- ease, 269. inversion of, a cause of menorrhagia, 173. mistaken for submucous fibroid, 502. involution of, imperfect after abortion,, 470. manual reposition of, 326, 462. massage of, in incomplete abortion, 467. mechanical evacuation of contents of, in abortion, indications for, 464. instruments needed for, 469. method of procedure in, 467. mobility of, an indication for operation in cancer, 532. mobility of, on bimanual examination, 12. normal position of, 11, 317, 320. packing with gauze for displacement of, 323. packing with gauze for hemorrhage of, 187, 469. prolapse of, abortion due to, 456. age when most frequent, 322. cystitis associated with, 322, 334. etiology of, 321. treatment of, 333. retrodisplacements of, 353. backache due to, 251, 256. congenital, 320. constipation due to, 33, 322. diagnosis of, 322. dysm.enorrhea associated with, 110, 320. importance of, 319. Uterus, retrodisplacements of, indications for treatment of, 320. manual reduction of, 326. membranous dysmenorrhea associated with, 129. neurasthenia from, 320. operative treatment for, 332. pessaries in reduction of, 324. relaxed vaginal outlet associated with, 320. short vagina a cause of, 320. splanchnoptosis a cause of, 600. statistics of frequency of, 319. sterility caused by, 363, 372. symptoms of, 322. varieties of, 320. rupture of, in fibroid tumors, 505. subinvolution of, a cause of hemor- rhage, 172. superinvolution of, a cause of amenor- rhea, 160. suspension of, for retrodisplacements, 332. syphilis of, 427. torsion of, 319. " ulcerations of," 21. vaginitis following removal of, 282. Vagina, absence of, a cause of sterility, 372. atresia of, congenital, 142, 267. difficult labor a cause of, 145, 260. in infants, 144. infectious diseases a cause of, 142, 145, 265, 360. pessaries a cause of, 145. sterility resulting from, 360. trauma a cause of, 146. chancre on walls of, 400. deformities of, a cause of sterility, 360. drainage by, in cystitis, 562. examination by, in constipation, 215. gonococcus infection of, 376. gonorrheal inflammation of, a cause of sterility, 376. inspection of, 19. measiirement of, to fit a pessary, 326. painting vault of, 31. palpation by, 10. INDEX. 695 Vagina, septate, dangers of conception with, 360. shortness of, a cause of retrodisplace- ment of uterus, 320. a cause of sterility, 360. stricture of, a cause of sterility, 360. Vaginal discharge, acidity of, fatal to gonococcus, 379, 384. at menopause, 100. difference between, and cervical, 20. early syraptom of cancer, 169, 518, 519, 520. first symptom of gonococcus infection, 385. in gynecological examination, 20. in vaginitis. See Vaginitis, masturbation due to, 310. peculiarities of, in gonorrhea, 380. pruritus due to, 296, 298, 303. with fibroid tumor, 498. Vaginal douches, disinfecting, in diph- theritic vaginitis, 281. in inoperable cancer, 542. in vaginitis, 284. in vulvitis, 276. with pessaries, 331. hot, in cystitis, 510. in hemorrhage from uterus, 186, 608. in pelvic affections in general, 31. in pelvic inflammation, 342. in pruritus, 299. in vaginitis, 283. sedative, in cancer, 541. Vaginal examination, of pelvic organs, 10. restriction of, in threatened abortion, 463. Vaginal outlet, relaxation of, constipation associated with, 215. contraindication to use of pessary, 327. defecation interfered with by, 222. insomnia caused by, 239. recognition of, on examination, 10. retroflexion associated with, 320. sterility associated with, 360. Vaginismus, definition of, 304. etiology of, 304. galvanic current in treatment of, 307. gonococcus infection a cause of, 305. prognosis of, 306. Vaginismus, rest in the treatment of, 306. sterility from, 306, 357, 368, 372. suffering from, 304. surgical treatment of, 308. urethral form of, 306. Vaginitis, 280. age when most frequent, 280. applications for relief of, 284. diphtheritic, 281. douches for, 283. emphysematous, 281. etiology of, 282. exfoliative, 281. gonorrheal, 280. membranous dysmenorrhea caused by, 129. office treatment of, 284. of pregnancy, 281. packs for relief of, 285. post-operative, 282. pruritus caused by, 393. pufi-box treatment of, 285. senile, 282. treatment of, in general, 282. varieties of, 280. yeast treatment of, 285. Valerian in treatment of masturbation, 316. in treatment of threatened abortion, 458. Varicella, diagnosis between, and variola form of pustular syphilide, 417. Variola, diagnosis between, and variola form of pustular syphilide, 417. Vaso-motor disturbances, headache due to, 225. Vaso-motor exhaustion a cause of insom- nia, 238. Vaso-motor neurosis, explanation of mi- graine as, 228. Vaughan, Ethel, on rest in treatment of excessive menstruation, 183. Vedeler, on dysmenorrhea associated with an anteflexed uterus, 107. Veit, description of gonococcus by, 377. on atresia of vagina from application of chloride of zinc, 146. on atrophy of uterus in acromegaly, 148. 696 INDEX. Veit, ou diabetes in the causation of pru- ritus, 296. on local changes in pruritus, 297. on masturbation as a cause of vaginis- mus, 368. on sexual irritation as a cause of fibroid tumors, 494. on surgical treatment of vaginismus, 308. on uterine changes during menstrua- tion, 81. Veronal in treatment of functional neu- roses, 581. in treatment of insomnia, 243. Vesical tuberculosis, 545. Vesiculitis, chronic, a cause of male ster- ility, 352. Viburnum prunifolium,' in treatment of uterine hemorrhage, 185, 462. Vicarious menstruation. See Menstrua- tion. Vineberg, on amenorrhea associated with prolonged lactation, 145. Virchow, on chlorosis, 147, 155. on displacement of the intestines, 597. Virginia, Hot Springs of, treatment of obesity at, 246. Viscera, abdominal, displacement of. See Splanchnoptosis. Virgins, examination of pelvic organs in, duty of physician as to, 112, 150, 181, 323. method of, 27, 383. Vomiting, pernicious, a reason for artifi- cial abortion, 474. treatment of, in chlorosis, 158. Vulva, atresia of, caused by infectious disease, 146, 265. gonococcus infection of, 376. infantile character of, associated with maldevelopment of genital tract, 358. inspection of, in gynecological examina- tion, 19. syphilis of, 426. trichiasis of, a cause of pruritus, 301. Vulvitis, age when most frequent, 275. gonococcus, infection in, 276. in child, 276. [ Vulvitis, localization of, 276. masturbation associated with, 310. nature of, 275. rarity of, 275. symptoms of, 276. treatment of, 276. vaginitis associated with, 280. Vulvo-vaginal glands. See Bartholin's glands. Vulvo-vaginitis in little girls, ages when it is seen most frequently, 383. complications of, 391. importance of, 381. methods of contracting, 382. sequelae of, 384. symptoms of, 381. treatment of, 389. Waiting room, 1. Walker- Gordon milk, 45. Walther, on quinine as a contractor of the uterine fibres, 469. Wassermann, production of gonococcus by, 379. Water, drinking, abundance of, in consti- pation, 218, 223. necessity for purity in public supply of, 44. reduction of, in treatment of obesity, 247. Water-closet, suitable height of seat in, 210. Weber, on membranous dysmenorrhea, 128. Webster, on case of vicarious menstrua- tion requiring radical treatment, 162. on fibrosis of external genitals as the cause of pruritus, 296. on interval between the menstrual pe- riods, 86. Weeping, continual, a cause of constant headache, 228. Weight, at birth, affected by gonococcus infection in mother, 378. excessive. See Obesity, increase of, in girls, 65. Weir, W. H., on cervical cancer in nulli- parae, 517. INDEX. 697 Welt-Kakels, Sara, on gonorrheal vulvo- vaginitis in little girls, 363, 381, 382, 383. Wertheim, on cancer, 96, 530. on gonocoecus in blood-vessels and se- rosa of peritoneum, 378. on gonocoecus in substance of ovary, 378. on gonorrheal infection a cause of sterility, 351. on re-infection in gonorrhea, 380. West, on proportional frequency of fibroid tumors in married women, 494. on zinc ointment in the treatment of pruritus, 301. Whey, in treatment of constipation, 223. Whiskey, danger of, in dysmenorrhea, 114. in insomnia, 239. von Wild, on galvano-faradism in the treatment of constipation, 219. on gymnastics in the treatment of con- stipation, 218. Wilks, on vicarious menstruation, 160. Williams, J, W., on fibroids in the negro race, 493. on use of the obstetric forceps, 483. Williams, R., on heredity in causation of cancer, 515. von Winckel, on emphysematous vagini- tis, 281. on myomata and sterility, 364. Winter, G., on association betv^een fibroid tumors and heart disease, 505. on prophylaxis of cancer through edu- cation of the public, 530. on sarcomatous degeneration of fibroid tumors, 496. Withrow, on vicarious menstruation, 160, 161. Witthauer, on styptol in treatment of ute- rine hemorrhage, 185. Wood, H. C, on impurity of the prepa- rations of cannabis indica, 234. Worms, intestinal, and appendicitis in child, 595. rectal, a cause of masturbation, 310. a cause of pruritus, 33, 298. Wuth, case of imperforate hymen prob- ably caused by measles, 258. Wyder, on membranous dysmenorrhea, 128. X-ray in diagnosis betvpeen renal calculus and movable kidney, 616. in diagnosis of enteroptosis, 601. of gastroptosis, 601. of osteo-arthritis, 574. of redundant sigmoid, 213. in treatment of pruritus, 302. of uterine cancer, 537. Xeroform in treatment of chancre, 404. Yeast, brewer's, in treatment of gono- coecus infection, 388. in treatment of pruritus, 298. in treatment of vaginitis, 286. Yeast, fungus, in pruritus, 298. Zinc, chloride of, atresia of vagina follow- ing the therapeutic use of, 146. in cauterization of vagina for gonor- rheal infection, 374. in treatment of chancre, 404. oxide of, as lotion in treatment of pru- ritus, 300. as ointment in treatment of gonor- rheal infection in a child, 391. as powder, in treatment of chancre, 404. in syphilitic lesions, 442. in syphilitic lesions in child, 443. valerianate of, in prophylaxis of abor- tion, 462. Zweifel, on case of atresia of genital tract following typhoid fever, 472. on frequency of gonorrheal infection, 376. (6) THE END. J COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE BORROWED JUL 2 9 94S ^wsi'M9ei CZ8I1 140)M 100 RGlOl Kelly K292 1912