Columbia Wini\itxsiitp y^\^-\^ College of ^fjp^iciansi anb burgeons ^tltvtntt Hihvavp DISEASES OF WOMEN Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofwomenOOcros Fig. 1. Antero-posterioi" Section of Pelvis (semi-diagrammatic). In order to show the structures and relations exactly as they are in what may be considered a typical woman in the erect posture, a detailed study was made of many drawings from frozen sections for the internal relations, and of several well-formed women in the normal standing posture for the contour and external relations. This gave a result differing considerably from the usual representation of a patient standing, made by taking a drawing of a section of a flattened cadaver and turning it upright, The lumbar curve is more marked, the lower abdominal wall and the buttocks are more prominent and there is a change of the relations of the internal organs to the external landmarks. For the internal relations the admirable frozen sections of Sellheim were principally followed, and the exactness with which the pelvis and contents of the actual sections fitted into the contours of the living models was most pleasing and instructive. (Redrawn and colored from original drawing by Dr. R. Waiter Mills.) DISEASES OF WOMEN T BY HARRY STURGEON CROSSEN, M.D., F.A.C.S. ASSOCIATE IN GYNECOLOGY, WASHINGTON UNIVERSITY MEDICAL SCHOOL, AND ASSOCIATE GYNE COLOGIST TO THE BARNES HOSPITAL; GYNECOLOGIST TO ST. LUKE'S HOSPITAL, MISSOURI BAPTIST SANITARIUM AND ST. LOUIS MULLANPHY HOSPITAL; FELLOW OF THE AMERICAN GYNECOLOGICAL SOCIETY AND OF THE AMERICAN ASSOCIA- TION OF OBSTETRICIANS AND GYNECOLOGISTS. FOURTH EDITION, REVISED AND ENLARGED WITH EIGHT HUNDRED ENGRAVINGS ST. LOUIS C. Y. MOSBY COMPANY 1917 Copyright, 1907, 1910, 1913, 1917, By C. V. Mosby Company Press of C. V. Mosby Company St. Louis TO THE MEMORY OF DR. HENRY HODGEN MUDD THIS WORK IS RESPECTFULLY DEDICATED AS A SLIGHT TOKEN OF APPRECIATION OF HIS SPLENDID PROFESSIONAL ATTAINMENTS, HIS UNSELFISH DEVOTION TO THE CAUSE OF MEDICAL EDUCATION AND HIS INSPIRING PERSONAL FRIENDSHIP PREFACE TO FOURTH EDITION The two principal additions in this revision are, first, numerous draw- ings and photomicrographs illustrating gynecologic pathology; and, second, a chapter on the ductless glands in their relation to gynecology. The draw- ings and photomicrographs were made from material in the Gynecologic Laboratory of the Washington University Medical School, and in their prep- aration invaluable assistance was rendered by Dr. Otto Schwarz, in charge of the Laboratory. The helpful chapter on the ductless gland system w^as written at my request by Dr. Hugo Ehrenfest, to whom I am indebted also for his great kindness in seeing the book through the press, my doing so being prevented by an early call to war duty. The drawings are by Mr. Ivan F. Summers and present his usual satisfying excellence. H. S. Crossen. PREFACE TO THIRD EDITION The scope of this work is fully set forth in the previous editions. The method of presentation has proved so satisfactory that no change is indicated. Serologic diagnosis and treatment, as applicable in gynecologic work, has received consideration. The treatment of inoperable cases of severe uterine prolapse and eystocele, has been given special attention and a number of new drawings have been made to elucidate the action of the most effective pes- saries for this condition. New facts have been added under a number of other topics. The new illustrations are by Mr. Ivan F. Summers, whose patience and skill I much appreciate. H. S. Crossen. PREFACE TO SECOND EDITION The character of this work is indicated in the extract from the preface to the first edition. My endeavor has been to present clearly and in detail the foundation facts and principles of Gynecology — the anatomic, pathologic, diagnostic and therapeutic information underlying successful gynecologic work. Two hundred pages of text and fifty original illustrations have been added. The index, upon which the practical usefulness of a medical book so largely depends, has been greatly amplified, so as to include references and cross- references to every diagnostic and therapeutic item. In the new text special attention has been given to the presentation of pelvic inflammation and of tubal pregnancy — two live and important subjects, upon each of which an enormous and chaotic mass of information has accumulated. To properly emphasize the established landmarks and point out important features of advance work — such was the task. Disturbances of function merit, and have received, careful and detailed consideration, both from the diagnostic and therapeutic standpoint. Medico-legal complications are claiming more and more attention each year, and those connected with gynecology are considered in a detailed and practical way. My thanks are due to Mr. Thos. Jones, the artist, for the careful Avork shown in the new drawings. I would appear remiss in gratitude did I not express my. appreciation of the gratifying reception accorded the first edition by teachers and prac- titioners. H. S. Crossen. EXTRACT FROM PREFACE TO FIRST EDITION This work is devoted exclusively to the diagnosis and treatment of Dis- eases of Women as those diseases are met with in the office and at the bed- side by the general practitioner. No space is given to other considerations, except as necessary to bring the work to its highest usefulness as a prac- tical guide in the lines indicated. While no space is taken up with detailed technical descriptions of major operations, much care is taken to set forth clearly the differential diagnosis of the various conditions requiring such operative treatment, the kind of operation called for by the particular con- ditions present, what the operation is intended to accomplish, the prepara- tion of the patient for operation and the after-care necessary to complete the restoration to health. In my experience as a consultant and as a teacher I find that the two principal stumbling-blocks encountered in the way of accurate gynecologic work are, first, the difficulty of determining exactly the conditions present in the pelvis, and, second, the lack of a clear understanding of the indications governing the selection of the particular treatment best adapted to each of the various classes of cases under each disease. Special consideration is given to these important phases of the subject. My endeavor throughout has been to present the important points CLEARLY and SYSTEMATICALLY — SO clcarly and so systematically that they will be readily understood and well retained in mind for use at the bedside. To this end much thought has been given to the arrangement of the text, so as to shoAv not only the facts of a subject, but also the mutual relation of the facts and their bearing and relative importance in the diagnosis and treat- ment. The necessary facts are presented clearly and fully, and unincum- bered by the vast and confusing mass of gynecological knowledge with which the specialist must deal. To this end, likewise, the illustrations have been most carefully selected, with the one idea of making clear the points under consideration. From the extensive field of gynecological literature I have endeavored to bring the BEST illustration available . to elucidate each point. Those from reference works necessarily cover a wide range, and I wish here to express my hearty thanks to the authors and publishers of the works so used. I have added over two hundred and twenty illustrations of my own. In these I have endeavored particularly to show the actual care and handling of the patients, thus bringing to those who have not had the opportunity of gynecologic hospital training many facts which can be satisfactorily pre- 9 10 . PREFACE seiitecl in no other M'ay. For tliis purpose I have had taken over five hun- dred photographs. Only a part of them, however, could be used in this work on account of limited space. ]Most of these photographs were taken by my clinical assistant, Dr. E. E. AVobus, to whose skill and patience I bear appre- ciative tribute. My thanks are due to my colleague, Dr. Henry Schwarz, Professor of Obstetrics in AVashington University, for helpful suggestions. I wish to thank Dr. F. J. Taussig and Dr. H. A. Hanser, my Senior Clin- ical Assistants, for valuable help in various ways. To Dr. R. AY. Mills, the artist, I wish to express my appreciation. His painstaking care and fidelity in representation are apparent in all the draw- ings made by him. For engravings of instruments I am indebted to Mr. C. AA\ Alban, instru- ment dealer, of this city. The publishers have aided me throughout by their courtesy and cordial cooperation, for which I wish to express my sincere thanks. H. S. Crossen. PUBLISHER'S NOTE Having barely started on a thorough revision of this volume for its fourth edition, Dr. Harry Sturgeon Crossen Avas called to active war duty as a member of the Medical Officers Eeserve Corps. Many new illustrations, most carefully selected and prepared by him in the course of the last few years, and notes in regard to the many changes contemplated were turned over to Dr. Hugo Ehrenfest, Professor of Obstetrics and Gynecology, St. Louis University, who willingly had accepted Dr. Crossen 's request to finish the preparation of the manuscript for the new edition. We gratefully acknowledge Dr. Ehrenfest 's valuable and, indeed, en- thusiastic aid in accomplishing this difficult task within a very limited time. A comparison with the last edition will readily show the extent and thoroughness of his work. The latest advances in the science and iDractice of gynecology find their proper consideration in every part of this new vol- ume. In a special chapter the important and interesting problem of the rela- tion of the endocrin gland system to gynecology is discussed by him, more comprehensively and systematically than ever before attempted in any text- book of gynecology. If the very carefid reader here and there should dis- cover minor incongruities of thought or advice, we trust he will excuse them by remembering the difficulties under which this thorough revision actually has been accomplished. CONTENTS CHAPTER I Gynecologic Examination Methods History, 33 ; Physical Examination, 44 ; Abdominal Examination, 46 ; Examination of External Genitals and Adjacent Structures, 62; Vaginal Examination (Digital), 69; Vagino- abdominal Examination (Bimanual), 83; Recto-abdominal Palpation, 107; Bimanual Examina- tion of a Virgin, 108; Recto-vagino-abdominal Palpation, 109; Palpation of Coccj'x, 110; Instrumental Examination, 111; Pelvic Examination Under Anesthesia, 127; Preparations for Gynecologic Examination, 138; Non-Gynecologic Examination Methods, 152. CHAPTER II Gynecologic diagnosis Prominence of the Abdomen, 164; Movement of Abdominal Wall, 181; Discoloration of Abdominal Surface, 181; Tension of Abdomen, 182; Tenderness in Abdomen, 183; Mass Felt on Abdominal Palpation, 191; Area of Dullness in Abdomen, 195; Points in the Examination of External Genitals, 209; Points in the Vaginal Examination, 261; Points in the Vagino- abdominal Examination, 275 ; Mass or Induration, 291 ; Points in the Differential Diagnosis of Various Masses in the Pelvis, 327 ; Points in the Speculum Examination, 329 ; Pain in Pelvis or Lower Abdomen, 337; Backache, 343; Reflected Pains, 343; Disturbances of Function, 344, CHAPTER III Gynecologic Treatment Rest, 347 ; Applications to the Lower Abdomen and Exterior of Pelvis, 348 ; Applications to External Genitals, Vagina, and Cervix, 353 ; Intrauterine Treatment, 391 ; Applications within Rectum, 404 ; Applications to the Lower Abdomen and Interior of Pelvis, 405 ; Appli- cations to Body Generally, 412; Postural Methods and Exercise, 414; Internal Treatment, 417; Operations, 420. CHAPTER IV Diseases op the External Genitals and Vagina Points in Anatomy, 421 ; Classification of Diseases, 431 ; Gonorrhea, 431 ; Simple Vulvitis, 451; Follicular Vulvitis, 454; Erysipelas of Vulva, 455; Phlegmonous Vulvitis, 456; Gan- grenous Vulvitis, 457; Diphtheritic Vulvitis, 457; Eczema of Vulva, 457; Intertrigo, 459; Herpes of Vulva, 461; Prurigo of Vulva, 461; Parasitic Diseases of Vulva, 462; Simple Vaginitis, 463; Parasitic Vaginitis, 466; Diphtheritic Vaginitis, 467; Emphysematous Vag- initis, 467; Adhesive Vaginitis, 468; Simple Ulcers, 470; Chancroid, 472; Syphilis, 479; Tuberculosis of Vulva, 484; Tuberculosis of Vagina, 486; Malignant Disease of the Vulva, 487; Malignant Disease of the Vagina, 488; Ulcus Rodens Vulvae, 490; Urethritis, 492; Peri- urethral Abscess, 492; Prolapse of Urethral Mucosa, 494; Urethral Caruncle, 494; Inflamma- 13 14 CONTENTS tion of the Vulvo-vaginal Gland, 496 ; Abscess of Vulvo-vaginal Gland, 496 ; Sinus of Vulvo- vaginal Gland, 497; Cyst of Vulvo-vaginal Gland, 498; Condylomata of Vulva, 499; Cysts of Vulva, 503; Cysts of Vagina, 503; Non-malignant Tumors of Vulva, 505; Non-malignant Tumor of Vagina, 505; Stasis Hypertrophy of Vulva, 505; Pudendal Hernia, 509; Pudendal Hydrocele, 511; Hematoma of Vulva, 512; Varicose Veins of Vulva, 514; Injuries of External Genitals, 515; Kraurosis Vulvae, 516; Pruritus Vulvae, 518; Hyperesthesia of the Vaginal Entrance, 523 ; Adhesions of Prepuce, 525 ; Adhesions of Labia, 525. CHAPTER V Relaxation axd Fistulae Points in Anatomy, 527; Relaxation of the Pelvic Floor, 533; Colpocele, Rectocele, Cystocele, 558; Recto-Vaginal Fistula, 561; Vesico-Vaginal Fistula, 566. CHAPTER VI Diseases of the Uterus Points in Anatomy, 577; Pathologic Changes, 595; Classification of Diseases, 596; Localization of Diseases, 597; Erosion of Cervix, 598; Ulcer of Cervix, 601; Acute Endo- cervicitis, 603; Chronic Endocervicitis, 606; Laceration of Cervix Uteri, 608; Idiopathic Hypertrophy of Cervix, 624; Cervical Polypi, 625; Hyperplasia of Endometrium, 628; Acute Infected Endometritis, 633 ; Acute Simple Endometritis, 637 ; Chronic Endometritis, 638 ; Subinvolution of Uterus, 657 ; Hyperinvolution of Uterus, 659 ; Sclerosis of the Uterus, 660 ; Tuberculosis of the Uterus, 664; Syphilis of the Uterus, 666; Echinococcus Disease .of Uterus, 666. CHAPTER VII Displacement of the Uterus Points in Anatomy, 669; Backward Displacement of the Uterus, 671; Prolapse of the Uterus, 696; Other Displacements of Uterus, 704. CHAPTER VIII Non-Malignant Tumors of Uterus Fibromyoma of the Uterus, 704; Symptoms and Signs, 723; Pregnancy and Fibroid, 750; Lipoma of the Uterus, 754. CHAPTER IX Malignant Disease of the Uterus Carcinoma of the Cervix Uteri, 755; Carcinoma of the Corpus Uteri, 789; Sarcoma of the Uterus, 794. CHAPTER X Pelvic Inflammation Points -in Anatomy, 799; Fallopian Tubes, 799; Pelvic Peritoneum, 804; Pelvic Connec- tive Tissue, 805; Acute Pelvic Inflammation, 807; Chronic Pelvic Inflammation, 833; Differen- tial Diagnosis of Chronic Pelvic Inflammation, 848. . CONTENTS 15 CHAPTEE XI Other Affections Pelvic Tuberculosis, 868; Extrauterine Pregnancy, 873; Other Pelvic Disorders, 904; Hemorrhage, 904; Fulminating Pelvic Edema, 905; Tumors of Fallopian Tubes, 907; Varicose Veins of Broad Ligament, 908; Eehinocoecus Disease of Pelvis, 909; Pseudotuberculosis of Peritoneum, 909. CHAPTER XII Tumors of the Ovary and Parovarium Points in Anatomy and Physiology, 910; The Ovary, 910; The Parovarium, 922; Classifi- cation, 922; Cystic Tumors of the Ovary, 923; Solid Tumors of the Ovary, 953; Tumors of the Parovarium, 955. CHAPTEE. XIII Malformations Points in Development, 960 ; Anomalies of Development, 964 ; Imperforate Hymen, 966 ; Atresia of Vagina, 966; Double Vagina, 967; Malformations of the Uterus, 968; Pseudo- hermaphroditism, 969. CHAPTEE XIV Disturbances of Function Points in Physiology (Normal Menstruation), 972; Absence of Menstruation (Amenor- rhea), 976; Scanty Menstruation, 988; Excessive Menstruation (Menorrhagia), 988; Painful Menstruation (Dysmenorrhea), 993; Intermenstrual Pain, 1015; Irregular Menstruation, 1016; Precocious Menstruation, 1016; Vicarious Menstruation, 1016; Dyspareunia, 1017; Sexual Impotence, 1019; Sterility, 1020; Leucorrhea, 1025; Bloody Discharge, 1030. CHAPTEE XV The Internal Secretory Glands in Eelation to Gynecology Historical Facts, 1035; Definition of Internal Secretion, 1036; Chemical Nature of Internal Secretions, 1037; Intergiandular Eelation, 1038; Influence of Individual Endocrin Organs on the Genital Apparatus, 1040; Gynecologic Anomalies Due to Disturbed Endocrin Gland Function, 1050; Therapy, 1057. CHAPTEE XVI Invasion of the Peritoneal Cavity Abdominal Section, 1065 ; Indications, 1066 ; Contraindications, 1066 ; Dangers, 1067 ; Preparations, 1067; Eegular Steps, 1073; Special Points, 1076; Vaginal Section, 1082; Advantages, 1082; Disadvantages, 1083; Selection of Cases, 1084; Preparations, 1084; Steps, 1085; Conservative Surgery, 1085. CHAPTEE XVII After-Treatment in Operath'e Cases After-treatment in Abdominal Section, 1089 ; After-treatment in Vaginal Operations, 1103. CHAPTEE XVIII Medico-Legal Points in Gynecology Eape, 1108; Foreign Bodies Left in Abdomen, 1118; Other Conditions, 1124. ILLUSTRATIONS Relations of the Pelvic Organs FIG. PAGE 1. Antero-posterior section of pelvis (Color Plate) Frontispiece 2. Contour and measurements of two models 34 3. Antero-posterior section, with intestines out 35 4. Posterior view of pelvic organs 36 5. Anterior view of pelvic organs 36 6. Relation of pelvic organs to external surface 37 Gynecologic Examination Methods The History 7. Indicating general pelvic distress •. . 38 8. Backache from pelvic disease 39 9. Sacral pain from pelvic xlisease 39 10. Pain in right tubo-ovarian region 39 11. Pain in appendix region 39 12. Pain in right kidney region, laterally 40 13. Pain in right kidney region, posteriorly 40 14. Gynecologic history card, face 43 15. Gynecologic history card, reverse 43 Abdominal Examination . 16. Patient arranged for abdominal examination 45 17. Profile of normal abdomen 45 18. Abdominal surface with landmarks 47 19. Abdominal surface with landmarks 48 20. Palpation of the abdomen, first step 49 21. Palpation of the abdomen, second step 49 22. Palpation with both hands 49 23. Deep palpation with both hands 49 24. Piezometer 50 25. Abdominal surface divided into quadrants 50 26. Usual anatomic division of abdominal surface 51 27. Division of abdominal surface with circle 52 28. Regions, by division with circle 53 29. Various areas of significant point-tenderness 54 30. Point for kidney tenderness, laterally 55 31. Point for kidney tenderness, posteriorly 55 32. Relation of kidney to last rib 55 33. Trying for a fluid wave across abdomen 55 18 ILLUSTRATl JNS FIG. ^^GE 34. Differentiating a fat wave from a fluid wave 57 35. Attempting to displace a mass upward 58 36. Ordinary percussion of abdomen 60 37. Deep percussion of abdomen i .... 60 38. Lines for mensuration of abdomen 61 Examination of External Genitals 39. Patient arranged for examination of external genitals and adjacent structures ... 63 40. Normal external genitals 64 41. Normal external genitals, multipara 64 42. Pressing pus from urethra 67 43. Appearance of pus about urethral opening 67 44. Drop of pus pressed from Skene's gland 67 45. Vulvo-vaginal gland ' .... 67 46. Appearance of pus about vulvo-vaginal gland 68 47. Palpating vulvo-vaginal gland 68 Vaginal Examination (Digital Examination) 48. Position of fingers for vaginal examination 70 49. Hand gloved, ready for examination 70 50. Position of thumb and outside fingers 71 51. Bony arch above vaginal opening 74 52. Testing the pelvic floor with one finger 76 53. Testing the pelvic floor with two fingers 77 54. Showing separation of examining fingers 77 55. Another method of testing pelvic floor 78 56. Palpating rectum through vaginal wall 79 57. Method of everting anal tissues ' 79 58. Showing possible eversion in some cases 80 V a gino- Abdominal Examination {Bimannal Examination) 59. Bimanual examination, outside Angers folded in palm 84 60. Bimanual examination, outside fingers extended in gluteal crease 84 61. Palpating body of uterus 85 62. Depressing abdominal wall too close to pubes, sectional view 85 63. Depressing wall too close to pubes, outside view 86 64. Depressing wall at right height 86 65. Bimanual examination, body of uterus not found in front . 87 66. Retroverted uterus found behind 87 67. Retroflexed uterus found behind 87 68. Palpating sides of uterus with one finger 89 69. Palpating sides of uterus with two fingers 89 70. Drawing uterus down, to aid in examinatioii 90 71. Invagination of perineum, elbow on knee 92 72. Same as Fig. 75 in bimanual examination 93 73. Invagination of perineum, ell)ow against iliac crest 94 74. Palpation of lateral regions, first step 94 75. Palpation of lateral regions, second step 94 76. Showing marked depression of abdom= -' ' in pelvic palpation 95 ILLUSTRATIONS 19 FIG. PAGE 77. Palpating the tubo-ovarian region 96 7&. Palpating the left tubo-ovai :du region . 97 79. Palpating the right tubo-ovarian region 98 80. Determining attachment of mass to uterus 99 81. Determining attachment to posterior part of uterus 100 82. Palpating region of i-ight ureter 101 83. Location of pelvic nerve roots 102 84. Palpating pelvic nerve roots 102 85. Method of palpating coccyx . 109 Instrumental Examination 86. Instruments for regular speculum examination 112 87. Bivalve speculum in place 113 88. Gaylor 's scissors 114 89. Introducing the bivalve speculum, first step 115 90. Speculum carried half way in 115 91. Speculum turned and carried all the way in 115 92. A, Schultze tampon; B, ordinary tampon 117 93. Suction bulb 117 94. Types of Sims' speculum; Graves' speculum changed to Sims' type 117 95. Patient in Sims' posture 120 96. View from above, showing Sims' posture 120 97. Method of introducing Sims' speculum 121 98. Method of holding Sims' speculum 121 99. Cervix uteri brought into view 122 100. Instruments for exploration of interior of uterus 126 101. Eecto-abdominal palpation 130 102. Method of palpating the pedicle of a tumor 131 103. Eecto-vagino-abdominal palpation 132 104. Glandular hyperplasia of endometrium 133 105. Same, sectioned transversely 133 106. Interstitial hyperplasia of endometrium 133 107. Same, high power 133 108. Adenocarcinoma of endometrium 135 109. Same, high power 135 110. Curettings, incomplete abortion 135 111. Same, high power 135 112. Exploration of interior of uterus with finger 137 113. Kitchen table arranged for gynecologic examination 139 114. Simple instrument boiler 142 115. Small instrument and dressing sterilizer 142 116. Articles needed for preparing for gynecologic examination 143 117. Use of gloves and drop-bottle for liquid soap 143 118. Wall fixture for liquid soap 144 119. Patient arranged in bed for abdominal examination 145 120. Patient arranged in bed for vaginal examination 146 121. Patient arranged in bed for bimanual examination 147 122. Showing position of arms for accurate deep pelvic palpation 148 123. Eegular cross-bed position 149 124. Partial cross-bed position 150 20 ILLUSTRATIONS Gynecologic Diagnosis Fronninence of Abdomen FIG. PAGE 125. Obesity^ patient lying on back 165 126. Testing thickness of abdominal wall, first step 165 127. Testing thickness of abdominal wall, second step 165 128. Obesity, patient standing 166 129. Obesity mistaken for ovarian tumor 166 130. Obesity mistaken for pregnancy 166 131. Tumor of abdominal wall 167 132. Small umbilical hernia 168 133. Large umbilical hernia 168 134. Contour of relaxed abdominal wall, patient recumbent . 169 135. Same as Fig. 134, patient standing 169 136. Space between separated recti muscles 170 137. Projection of abdominal contents between separated recti muscles 170 138. Depression of wall between separated recti muscles 171 139. Tympanites mistaken for pregnancy 171 140. Moderate ascites in relaxed abdomen 172 141. Marked ascites, showing contour 173 142. Extreme ascites, showing contour 173 143. Extreme ascites, with pyramidal contour 174 144. Extreme ascites, with different contour 174 145. Extreme ascites, view from in front 175 146. Contour of abdomen in pregnancy 176 147. Contour of abdomen in case of distended bladder 176 148. Case of ruptured bladder, section 176 149. Contour of abdomen in case of large pelvic cyst 177 150. Contour of abdomen in case of large solid tumor 177 151. Case of large cystic tumor 178 152. Case of extrophy of bladder 178 153. Contour of abdomen in case of retroperitoneal tumor 179 Tenderness or Mass m Aidomen 154. Eight lower abdomen, important areas indicated 183 155. Point to seek for right tubo-ovarian tenderness 184 156. Point to seek for appendix tenderness 184 157. Palpating for the appendix 184 158. Another method of palpating for the appendix 184 159. Point to seek for tenderness of right ureter 185 160. Left lower abdomen, important areas indicated 186 161. Eegion for right kidney tenderness laterally 187 162. Eegion for right kidney tenderness posteriorly 187 163. Eight upper abdomen, important organs indicated 188 164. Site for gall-bladder tenderness or mass 189 165. Showing the direction of growth of various pelvic and abdominal tumors .... 192 Area of Dullness in Abdomen 166. Indicating area of dullness from distended bladder 193 167. Indicating area of dullness from enlarged iiterus 193 ILLUSTRATIONS 21 FIG. . P^GE 168. Indicating area of dullness from very large central pelvic mass . 194 169. Indicating dullness from enlarged liver 195 170. Indicating dullness from enlarged spleen 195 171. Area of dullness in moderate ascites, patient on back 196 172. Eelation of fluid to intestines in ascites 196 173. Eelation of mass to intestines in tumor 196 174. Showing gravitation of ascitic fluid to lower side 196 175. Indicating dullness in moderate ascites, patient on side 197 176. Indicating dullness in moderate ascites, patient standing 198 177. Area of resonance in case of extreme ascites, patient on back 199 178. Same as Fig. 177, patient standing 200 179. Same as Fig. 177, the two resonant areas contrasted 201 180. Dullness in case of ascites and tumor, patient on back 202 181. Same as Fig. 180, patient standing 203 182. Same as Fig. 180, two areas of dullness contrasted 204 183. Indicating dullness in large tubo-ovarian mass 204 184. Indicating dullness in largQ appendiceal mass 204 185. Indicating irregularity of dullness from uterine flbromyoma ' . 205 186. Indicating regularity of dullness from large ovarian cyst 205 187. Area of dullness in case of retroperitoneal growth r • • 206 188. Indicating dullness in kidney tumor, without inflation of colon 207 189. Same as Fig, 188, with inflation of colon 207 190. Kidney tumor removed in case of Fig. 188 208 Changes About External Genitals 191. External genitals of virgin 209 192. External genitals diagrammatic 209 193. Various forms of hymen 210 194. Various forms of hymen 210 195. Various forms of hymen 210 19'6. External genitals of married women 210 197. External genitals, parts prepared for operation 211 198. External genitals with some perineal laceration 212 199. Follicular vulvitis 217 200. Kraurosis vulvae 218 201. Chancroidal ulcers of vulva 219 202. Tubercular ulcer of vulva 220 203. Epithelioma of right labium 221 204. Beginning epithelioma of labium 221 205. Epithelioma of clitoris 221 206. Case of adherent prepuce 223 207. Same as Fig. 206, after treatment 223 208. Adherent labia minora 22o 209. Imperforate hymen 223 210. Hematocolpos 224 211. Distention of uterus and tubes from imperforate hymen 224 212. External genitals in case of absence of vagina 224 213. Double vagina 225 214. Same as Fig 213, each vagina spread open 225 215. Complete laceration of perineum 225 22 ILLUSTRATIONS FIG. P^GE 216. Complete laceration of perineum 226 217. Separation of sphincter ends in old complete laceration 226 218. Central perforation of perineum by child's head 227 219. Laceration of hymen from rape 227 220. Complete laceration of perineum from rape 227 221. Laceration of perineum, with resulting fistula, from violent coitus ..'.... 228 222. Old laceration of pelvic floor from labor 229 223. Moderate cystocele and rectocele 230 224. Same as Fig. 223, showing section 230 225. Large cystocele 231 226. Testing for cystocele with sound in bladder 232 227. Small rectocele 232 228. Large rectocele 233 229. 230. Differentiating between rectocele . and colpocele . 233 231. Hematoma of vulva 234 232. Stasis-hypertrophy of labia minora 234 233. 234. Stasis-hypertrophy of vulva " 235 235. Stasis-hypertrophy and edema 236 236. Marked stasis-hypertrophy 236 237. Stasis-hypertrophy with causative ulceration 236 238. Elephantiasis of vulva 236 239. Varicose veins of vulva 237 240. Small masses of condylomata 237 241. Vulva covered with massed condylomata . . 237 242. Syphilitic condylomata about vulva 238 243. Syphilitic condylomata, flat variety 238 244. Syphilitic condylomata, pointed vai'iety 239 245. Abscess of vulvo-vaginal gland 240 246. Abscess of vulvo-vaginal gland 241 247. Cyst of vulvo-vaginal gland 241 248. Hypertrophy of labia minora 242 249. Enormous hypertrophy of labia minora (Hottentot apron) 242 250. Hypertrophy of clitoris 243 251. Carcinoma of labium, beginning . 243 252. Carcinoma of labium, later stage 244 253. Carcinoma of labium, still later stage 244 254. Carcinoma of vulvo-vaginal gland 245 255. Sarcoma of labium , 246 256. Small fibroma of labium 246 257. Large fibroma of labium 246 258. Small cysts of labium ■ 247 259. Large cyst of labium 247 260. Large cyst of labium 248 261. Cyst of clitoris 248 262. Inguinal hernia, becoming pudendal 249 263. Vaginal hernia, becoming pudendal 249 264. Prolapse of urethral mucosa 250 265. Urethral caruncle 250 266. Suburethral abscess 251 267. Exploring suburethral abscess-sinus 252 268. Prolapse of uterus, showing various stages 252 ILLUSTRATIONS 23 FIG. PAGE 269. Prolapse of uterus, cervix at vestibule 252 270. Prolapse of uterus, uterus half out 253 271. Complete prolapse of uterus '. 254 272. Prolapse of uterus, bladder not prolapsed 254 273. Prolapse of uterus and bladder 255 274. Testing for prolapse of bladder with sound 255 275. Prolapse of uterus in nullipara 256 276. Prolapse of uterus in virgin 256 277. Bimanual examination in prolapsus uteri 257 278. Three portions of the cervix uteri 257 279. Hypertrophy of infravaginal portion of cervix, diagrammatic 257 280. Case of hypertrophy of infravaginal portion of cervix 258 281. Hypertrophy of supravaginal portion of cervix 258 282. Hypertrophy of intermediate portion of cervix 25S 283. Peculiar hypertrophy of cervix 258 284. Pedieulated fibroid tumor of uterus 259 285. Complete inversion of uterus, with placenta attached 260 286. Small cyst of vaginal wall 260 287. Medium-sized cyst of vaginal wall 261 Changes Found hy Vaginal Examination 288. Small uterine fibroid projecting into vagina 263 289. Large uterine fibroid projecting into vagina 263 290. Differentiating a pedieulated fibroid with sound 263 291. Sarcoma of uterus projecting into vagina 264 292. Grape-like sarcoma of cervix, forming mass in vagina 264 293. Inverted uterus, forming mass in vagina 265 294-302. Differentiating inversion from fibroid 267 303, 304. Diagnosis of inversion of uterus 267 305. Sounding uterus in diagnosis of inversion 268 306. Partial inversion caused by fibroid 268 307. Small cysts of vaginal wall 268 308. Anterior vaginal hernia 268 309. 310. Relation of cervix uteri to examining finger 270 311. Anteflexion of cervix uteri 271 312. Eversion of cervical mucosa from inflammation , 272 313-318. Lacerations of cervix uteri 273 319. Softening of cervix in early pregnancy 273 320. Section of cervix in late pregnancy, showing cervix still of full length 273 321. Carcinomatous nodule in cervix 274 322. Nodule due to cyst of cervix 274 Changes in Corpus Uteri 323. Retrodisplacement of uterus, showing first, second, and third degrees 276 324. Uterus displaced by full bladder ■ 276 325. Uterus displaced by inflammatory mass 276 326. Uterus displaced by tumor . ■ 277 327. Uterus displaced by adhesions 277 328. Uterus enlarged from early pregnancy 278 329. Early pregnancy with slight retrodisplacement 279 24 ILLUSTRATIONS FIG. PAGE 330. Early pregnancy with marked retrodisplacement 279 331. Pregnant uterus sectioned, showing cause of Hegar's sign 280 332. Explaining Hegar 's sign 281 333. Palpating for Hegar's sign, uterus in front " . 281 334. Palpating for Hegar's sign, uterus behind 281 335. Small fibroid nodules in uterus 282 336. Larger fibroid nodules in uterus ' . . . . 282 337. Fibroid nodules in uterus . 282 338. Single fibroid causing slight enlargement of corpus uteri 283 339. Enlargement of corpus uteri from pregnancy, about four months 283 340. Enlargement of corpus uteri from pregnancy, about four months , . 284 341. Pregnancy of about five months 284 342. Pregnancy at full term 284 343. Height of fundus uteri at different weeks of pregnancy 285 344-346. Irregular shapes that pregnant uteri may present . 285 347. Interstitial pregnancy 286 348. Pregnancy in right half of septate uterus 286 349. Uterus enlarged by large single soft fibroid 287 350. Uterus symmetrically enlarged by fibroids 288 351. Subperitoneal fibroids 288 352. Single large fibroid choking pelvis 289 353. Large fibroids filling pelvis and lower abdomen 289 354. Uterus enlarged from carcinoma 289 355. Large fibroid and early pregnancy 289 356. Small fibroid and late pregnancy 290 357. Uterus distended with menstrual blood 290 358. Uterus enlarged by collection of pus and gas 290 Mass in Pelvis or Lower Ahdovien 359. Three areas in the pelvis 291 360. Parametrial inflammation contrasted with ischiorectal inflammation 291 361. Mass in right ureter 292 362. Abscess in broad ligament 293 363. Hematoma in broad ligament 293 364. Cyst in broad ligament 294 365. Ovarian cyst beside uterus 295 366. Hematometra in rudimentary horn of uterus 296 367. Thickened tube and ovary prolapsed into cul-de-sac 297 368. Fibroid back of cervix uteri 298 369. Fibroid above retrodisplaced uterus 298 370. Abscess behind uterus 299 371. Blood-mass behind uterus 299 372. Ovarian cyst behind uterus 300 373. Testing mobility of mass behind uterus 301 374. Fibroid in front of uterus 303 375. Bladder tumor in front of uterus 304 376. Tuberculosis of bladder, forming mass in front of uterus . 304 377. Inflammatory exudate filling pelvis 305 378. Inflammatory roof above vagina 305 379. Pelvis filled with bony tumor 306 ILLUSTRATIONS 25 FIG. I'AGE 380. Pelvis filled with ovarian cyst 306 381. Salpingitis nodosa 308 382. Thrombosis of veins of broad ligament ; . . 308 383. Tubal pregnancy in right side ^ 309 384. Pregnancy in rudimentary horn of uterus 310 385. Pregnancy in rudimentary horn of uterus 311 386. Various locations of appendix 312 387. Various locations of cecum 313 388. Displaced right kidney 314 389. Palpation of movable kidney, first step 315 390. Palpation of movable kidney, second step 315 391. Double pyosalpinx with adhesions 316 392. Double pyosalpinx without adhesions 316 393. Pyosalpinx with extensive adhesions 317 394. Right hydrosalpinx . . . • 318 395. Small ovarian cyst of right side ...■.., 318 396. Graafian follicle cysts which have become intraligamentary 319 397. Large pelvic mass formed by uterine fibroids and carcinoma ■ 321 398. Extrauterine pregnancy, advanced 322 399. Extrauterine pregnancy with lithopedion 322 400. Lithopedion removed 322 401. Left kidney displaced into pelvis 323 402. Large cystic fibroid 323 403. Ovarian cyst with long pedicle • ' ' ^^^ 404. Large dermoid cyst 325 405. Ascites and uterine fibroid 326 Changes Seen Through Speculum 406. Primary cancer of vaginal wall 329 407. Secondary cancer of vaginal wall 330 408-410. Varieties of normal cervix •. . 331 411. Senile cervix 331 412. Discharge from cervix 331 413. Laceration and erosion of cervix 331 414. Erosion and cysts of cervix 331 415. Lacerations and erosions of cervix 33L 416. Lacerations and erosions of cervix 333 417. 418. Testing for laceration of cervix 334 419. Beginning epithelioma of .cervix 334 420. Beginning carcinoma of cervix . ■ "^34 421. Epithelioma, cervix destroyed 335 422. Epithelioma, cervix destroyed and surface infolded 336 423. Epithelioma of cervix, appearing as a papillary growth 337 424. Showing usual origin of reflex pains in the various regions 343 Gynecologic Treatment 425. Patient arranged for long, hot vaginal douche 360 426. Preparation of vaginal tampons ^"^ 427. Tampon-capsules ^'" 26 ILLUSTRATIONS FIG. PAGE 428. Hodge pessary and modifications 372 429. Pessary in place . 373 430. 431. Introducing pessary 378 432, 433. Introducing pessary ... 379 434. Introducing pessary 380 435. Introducing pessary 381 436. Flexible ring pessary, inflated ring pessary, and disk pessary 384 437. Menge pessary 385 438. Gehrung pessary , 386 439. Introducing Gehrung pessary 386 440. Introducing Gehrung pessary 388 441. introducing Gehrung pessary 388 442. Hewitt pessary 389 443. Applicators for intrauterine treatment 395 444. Knee-chest posture 414 445. Knee-chest posture with pelvic organs outlined . 415 446. Knee-chest posture with patient draped for treatment . 415 Additional Illustrations for Various Diseases 447. 448. Anatomy of Skene's glands 424 449, 450. Anatomy of Skene's glands 425 451. Veins of external genitals 426 452. Arteries and nerves of external genitals 426 453. Cross section of vagina 428 454. Gonococci stained in pus 437 455. Gonococci much enlarged to show form . . .' 437 456. Pediculus pubis 462 457. Thrush fungus 466 458. Adhesive vaginitis . 469 459. Sarcoma of vagina in child ■ 489 460. Same, high power • 489 461. Scattered condylomata of vulva 500 462. Large masses of condylomata 500 463. Pointed condyloma, cross section 501 464. Fibroma of vagina 501 465. Excision of external genitals . ' 507 466. Excision of varicose veins of vulva 514 467. Sectional view of pelvic floor, diagrammatic 528 468. Superficial structures of pelvic floor 529 469. Levator ani muscles • 530 470. Eecto-vesical fascia 530 471-473. Pelvic sling ' ... 531 474. Pelvic floor from above 532 475. Deep lateral laceration of pelvic sling on each side 536 476. Median laceration into rectum, but not into sling 536 477. Instruments for repair of pelvic floor 543 478. Eecent lacerations from labor 544 479. 480. Regular repair of pelvic floor ' 547 481, 482. Eegular repair of pelvic floor 548 483, 484. Regular repair of pelvic floor 549 ILLUSTRATIONS 27 FIG. PAGE 485, 486. Regular i-epair of pelvic floor 550 487. Old laceration of pelvic floor 551 488. Emmet's operation — lines of tension 552 489. Emmet 's operation — denuding 552 490. Emmet's operation — general scheme of suturing 553 491. 492. Repair of complete tear of j)erineum r • • 554 493, 494. Repair of complete tear of perineum 555 495, 496. Repair of cystocele 559 497, 498. Repair of cystocele 561 499. Fistulae of genital tract 562 500. Regular operation for vesico-vaginal fistula 571 501. 502. Flap operation for vesico-vaginal fistula 572 503. Anterior view of uterus 577 504. Anterior-posterior section of uterus 577 505. Uterus, Fallopian tube, and ovary 578 506. Reconstruction of uterus, showing shape of cavity 579 507. Uterus and appendages of young child 579 508. Uterus, tube, and ovary of fourteen-year-old girl 579 509. Uterus, tube, and ovary of twenty-year-old multipara 579 510. Pelvic contents of large fetus ' 580 511. Comparisons of nulliparous uterus with niultiparous uterus . . . ". 580 512. Relation of uterus to vagina and bladder 581 513. Endometrium of infant 581 514. Uterine wall of child 583 515. Same, high power 583 516. Normal endometrium 584 517. Gland and stroma of endometrium 585 518. Menstruating endometrium, early stage 586 519. Same, later stage 586 520. Senile endometrium 587 521. Cervical gland 588 5iii!. Cervical gland, cross section 588 523. Blood supply of uterus 589 524. Blood supply of uterus 590 525. Lymphatics of uterus 591 526. Distribution of uterine lymphatics to various groups of glands 592 527. Ligaments of uterus 594 528. Section through an erosion of cervix 599 529. Cervical erosion 600 530. Cervical ulcer 602 531. Same, high power 602 532. Lacerated cervix with erosion 610 533. Instruments for repair of cervix 615 534. Areas for denudation for repair of cervix 616 535. Areas of denudation 616 536. Incision through scar-tissue at the angles 616 537. Denudation completed and sutures passed in right side 618 538. Sutures tied 619 539. Section through cystic cervix 621 540. Cystic cervix 621 541. Area for amputation in cystic cervix 622 28 ILLUSTRATIONS PIG. PAGE 542. Line of excision and method of suturing in partial amputation of cervix .... 622 543. Partial amputation of cervix 623 544. Partial amputation completed 624 545-547. Regular amputation of cervix . 626 548. Regular amputation of cervix 627 549. Polypi of cervix 627 550. Fibrous cervical polypi, cross section 628 551. Normal uterus and endometrium 639 552. 553. Polypoid endometritis 641 554. Glandular hyperplasia of endometrium . 642 555. Same, high power 642 556. Polypoid formation in hyperlastie endometrium 643 557. Instruments for curettage 644 558. Kitchen table arranged for curettage 645 559. Patient in position at end of operating table 646 560. 561. Cleansing vagina after patient is anesthetized 647 562. Self -retaining speculum introduced 648 563. Sterile sheet in place 648 564. Introducing large dilator 649 565. Large dilator in place 649 566. Introducing curet 650 567. Method of holding curet 651 568. Returning uterus to its normal position after curettage 651 569. Putting in vaginal packing 652 570-573. Dressing after curettage 653 574. T-bandage 654 575. Section of endometrium thirteen days after curettage . 655 576. Section of endometrium thirty-one days after curettage 655 577. Section of endometrium three months after curettage 656 578. Section of endometrium fifty-three days after application of caustic 656 579. Fibrosis of uterus 662 580. Normal uterine wall 662 581. Tuberculous endometrium 663 582. Section of pelvis showing normal position of uterus 669 583. View from above, showing position of uterus 670 584. Bimanual replacement of uterus 676 585. 586. Bimanual replacement of uterus 677 587. Bimanual replacement of uterus 678 588. Bimanual replacement of uterus 679 589. Bimanual replacement of uterus 680 590. Puncturing tenaculum forceps 692 591. Transplantation of round ligaments 693 592. Transplantation of round ligaments 694 593. Transplantation of round ligaments 695 594. Uterine fibromyoma 698 595. Adenomyoma • 698 596. Interstitial fibroid 705 597. Fibrous capsule of myoma 705 598. Same, high power 705 599. Same, higher power 705 600. 601. Multiple fibromyomata 706 ILLUSTRATIONS 29 FIG. PAGE 602. Multiple fibromjomata 707 603. Multiple fibromyomata 708 604. Encapsulated myoma, low power 708 605. Submucous fibroid 709 606. Photomicrograph — ^uterine wall fibroid pressing against endometrium 710 607. Polypoid type of submucous fibroid 711 608. Diffuse adenomyoma of uterus 712 609. Hyaline degeneration of fibroma 712 610. Same, high power 712 611. Cystic cavity in uterine fibromyoma 713 612. Large cystic fibromyoma 714 613. Large subserous fibroid 715 614. Necrosis of part of intraligamentary fibromyoma 716 615. Suppurating fibromyoma 716 616. Necrosis of whole fibromyoma 717 617. Perforation of uterus by necrotic fibromyoma 718 618. Section through uterine sarcoma 719 619. Photomicrograph of sarcoma of uterus ' 720 620. Sarcoma developed in cervical stump after supravaginal hysterectomy for fibromyoma 721 621. Section of original fibromyoma, showing sarcomatous areas 722 622. Displacement of bladder by large fibromyoma 723 623. Lipoma of uterine wall 753 624. Early cervical carcinoma 756 625. Microscopic picture of squamous-cell carcinoma of cervix 756 626. Same, higher power 756 627. Carcinomatous plug in cervical gland 757 628. Adenocarcinoma of cervix 757 629. Same, high power 757 630. Advanced cervical carcinoma 758 631. Cervical carcinoma, papillary growth 759 632. Epithelioma of cervix, more advanced 760 633. Advanced adenocarcinoma of cervix 761 634. Epithelioma of cervix, in late stage 762 635. Epithelioma of cervix associated with fibromyoma of corpus uteri 763 636. Same as Fig. 635, section of uterus and fibroid . 764 637. Damage to ureters and kidneys by advanced cancer of cervix 765 638. Necessary line of excision in radical operation for cancer of cervix uteri .... 777 639. Cancerous uterus removed by Wertheim's radical operation 782 640. Beginning carcinoma of corpus uteri 790 641. Corpus carcinoma, early stage 790 642. Corpus carcinoma, advanced stage 790 643. Adenocarcinoma of corpus uteri, microscopic section, low power 791 644. Same, high power 791 645. Same, high power 791 646. Carcinoma of corpus uteri in advanced stage 792 647. Chorioepithelioma of uterus '^^3 648. Chorioepithelioma of uterus "^"^ 649. Same, microscopic section '•^"^ 650. Same, higher power '"'^ 651. Beginning sarcoma of corpus uteri • 79o 652. Slight enlargement of corpus uteri from sarcoma 796 30 ILLUSTRATIONS FIG. PAGE 653. Advanced sarcoma of corpus uteri 796 654. Sarcoma of endometrium 797 655. Sarcoma of endometrium, microscopic section 797 656. Same, high power 797 657. Sarcoma of endometrium, entire uterus 798 658. Section of genital tract, showing continuous opening into peritoneal cavity . . . 800 659-661. Cross sections through normal Fallopian tube 801 662. Cross section through normal Fallopian tube 802 663. Cross section through normal Fallopian tube 803 664. Connective tissue of pelvis 806 665. Thrombo-phlebitis .809 666. Instruments for opening pelvic abscess 814 667. Opening pelvic abscess — incision of vaginal wall 815 668. Opening pelvic abscess — blunt dissection through connective tissue 815 669. Opening pelvic abscess — puncturing abscess wall 816 670. Opening pelvic abscess — drainage tube in place 816 671. Drainage tube with cross-piece 818 672. Drainage tube with cross-piece, another method 819 673. Vaginal section for acute pelvic inflammation — sectional view 822 674. Vaginal section for acute pelvic inflammation — view from above 828 675. 676. Proctoclysis apparatus 829 677. Chronic salpingitis, mild 835 678. Salpingitis, with exudate 836 679. Chronic salpingitis, cross section 837 680. Normal tube, cross section 837 681. Chronic salpingitis, low power 837 682. Same, higher power 837 683. Pyosalpinx, wdth and without surrounding exudate 838 684. Section through large pyosalpinx 839 685. Specimen. Large pyosalpinx 839 686. Diffuse pelvic suppuration 840 687. Ovarian abscess and tubo-ovarian abscess 841 688. Hydrosalpinx . 842 689. Hydrosalpinx. Microscopic section 843 690. Same, higher power 843 691. Nodular salpingitis 844 692. Pelvic adhesions 845 693. Pelvic cellulitis (parametritis) 845 694. Various situations in which a parametritic mass may be found 846 695. Cystic ovary 847 696. Direction of extension of gonococcal infection 857 697. Direction of extension of streptococcal infection 861 698. Pelvic tuberculosis, peritoneal form 869 699. Pelvic tuberculosis, tubal form 870 700. Giant cells in tubal tuberculosis 871 701. Same, higher power 871 702. Situation of ovum in various forms of tubal pregnancy 875 703. Pelvic hematocele • • 876 704. Blood mass from repeated small hemorrhages 877 705. Free intraperitoneal rupture of tube 878 706. Free intraperitoneal hemorrhage 878 ILLUSTRATIONS 31 FIG. PAGE 707. Tubal abortion — tube distended . . 879 708. Tubal abortion — extruded clots and embryo , 879 709. Early tubal pregnancy " . . 879 710. Advanced tubal pregnancy 880 711. Same, microscopic section 881 712. Pelvic hematoma 881 713. Mother and child in case of extrauterine pregnancy carried to near term .... 882 714; Sarcoma of Fallopian tube, low power 907 715. Same, high power 907 716. Treatment for varicose veins of broad ligament 908 717. Showing attacliment of ovary to broad ligament 910 718. Section of ovary, showing hilum and medullary portion and cortical portion . . 910 719. Graafian follicle 911 720. Graafian follicle and ovarian stroma 912 721. Development of the ovary 913 722. Ovarian stroma with immature follicles 913 723. Corpus luteum 914 724. Corpus luteum, very large 914 725. Corpus luteum, showing interior arrangement 914 726. Ovai'ian stroma, corpus luteum 915 727. Lutein cells 915 728. Corpus luteurii, high power 915 729. Corpus albicans 915 730. Corpus albicans ... - 916 731. Scars in ovary 917 732. Parovarium and paroo^jhoron, embryonic 917 733. Parovarium, with surrounding structures 921 734. Follicular cysts of the ovary 924 735. Follicular cyst in ovary 924 736. Corpus luteum cysts 925 737. Lutein cells, the distinguishing feature in the wall of corpus luteum cysts . . , 926 738. Cyst involving part of ovary 927 739. Cyst involving entire ovary 927 740. Tubo-ovarian cyst . 928 741. Patient with large ovarian cyst 928 742. Pseudomucinous cyst, with jelly-like contents 929 743. Pseudomucinous cyst, sliowing secondary growths 930 744. Lining of pseudomucinous cyst 931 745. Same, high power 931 746. Lining cells of pseudomucinous cyst and of serous cyst contrasted 932 747. Small serous cyst, showing internal papillary projections 932 748. Larger serous cyst 933 749. Serous cyst, with secondary growths projecting through wall 933 750. Bilateral papillary ovarian cystoma 935 751. Dermoid cyst of ovary 936 752. Dermoid cyst of ovary 937 753. Hair switch from ovarian dermoid 937 754. Balls of sebaceous material from dermoid cyst 937 755. Ovarian dermoid • 938 756. Same, microscopic section 940 757. Ovarian cyst, with torsion of pedicle 946 32 ILLUSTRATIONS FIG. PAGE 758. Ovarian fibroma ' 947 759. Same, microscopic section 948 760. Same, higher power 948 761. Ovarian carcinoma, low power 948 762. Same, high power 948 763. Solid, medullary ovarian carcinoma 949 764. Same, cross section 950 765. Same, microscopic section 950 766. Primary solid ovarian carcinoma, low power 951 767. Same, high power 951 768. Krukenberg tumor of ovary ' . ■ 952 769. Same specimen on cross section 952 770. Same, microscopic section 953 771. Distribution of metastases in the case of Krukenberg tumor 953 772. Metastatic ovarian sarcoma, microscopic section 954 773. Same, higher power 954 774. Small parovarian cyst 956 775. Parovarian cyst 956 776. Wall of parovarian cyst, microscopic section , 957 777. Large parovarian cyst ,i 958 778. Development of pelvic organs, indifferent stage 961 779. Development of pelvic organs, female 961 780. Development of pelvic organs, male 962 781. Development and malformations 963 782. Development of external genitals 964 783. Pseudohermaphrodite, external view 970 784. Pseudohermaphrodite, explanatory section 970 785. Stem pessaries • ^^^^ 786. Dudley operation 1010 787. Dudley operation • . . . . 1011 788. Dudley operation ■ lOH 789. Suturing in front of cervix • • 1013 790. Dressing abdominal incision 1074 791. Conservative surgery of ovary and tube 1087 792. Strapping abdomen after removal of sutures 1092 793. Cutting adhesive straps for inspection of healed incision 1093 794. Scar exposed 1094: 795. Tray of articles for care of drainage tube 1096 796. Syringe and catheter for rapid removal of large quantity of fluid from tube . . 1097 797. After-treatment in vaginal operations — pitcher douche 1104 798. After-treatment in vaginal operations— vulvar dressing 1105 799. Catheterization— keeping the labia apart 1106 800. Catheterization — grasping the catheter some distance from the point 1100 DISEASES OF WOMEN CHAPTER I GYNECOLOGIC EXAMINATION METHODS The physician Avho wishes to do accurate work in diagnosis must be in pos- session of certain facts, as follows: Knowledge of the anatomy and physiology of the organs involved. Reliable history and examination of the patient. Knowledge of the diseases to which the parts are liable. The essential organs in the group of structures involved in gynecologic* diseases are shown in Figs. 1, 3, 4, 5 and 6. They are as follows: 1. The ovaries, in which the ova are formed. 2. The Fallopian tubes, which conduct the ova from the ovaries to the uterus. 3. The uterus, which receives and nourishes the fertilized ovum and expels the fetus at term. 4. The vagina, which is the connecting link between the uterus and the outside world. There are also several accessory structures — namelj^, the external gen- itals, the perineum, the pelvic floor, the pelvic peritoneum and the pelvic comiective tissue. The gross anatomy of these organs and the prominent facts in their physiology are sufficiently known to you, from general anatomic and physi- ologic study, to permit immediate consideration of the methods of obtain- ing the facts on which the diagnosis may be based. HISTORY When called tt) see a patient with pelvic disease, the first thing to do is to obtain what information the patient can give concerning her trouble. This information, obtained from the patient or her friends, is designated the *As to the pronunciation of "gynecology," the weight of authority is decidedly in favor of soft g, short y and the accent on the third syllable — jin e kol' o je (Webster's Unabridged Dictionary, Century Dictionary, Standard Dictionary, Gould's Medical Dictionary, Keating's Medical Dictionary). A few authorities differ, some favoring soft g and long y, and others favoring hard g and long y. 33 r ) / \ / / A N — / 1 ( ^ \ / 1 \ / V / \ / \ \ w / \ \\ y ( \ w \ \ \ \ \ \ \ \. / \ A \\ W \ ^ W / \ \ .'- \ \ \ y \ .V ^ \ \ \ \ \ \ V ^1 \\ H \\ I ;:::^ 1 ] \ \ \ \ ^. -\ j^l ( ^ -^ \ \ -"\ ^\ \1 Las t lur b^sf. ne.- f L ^l ^/ 7 i ^ t •— ^ r \ \ ^ h a -^ 1 / ^\ (/. > ^ '^v r / / La t u- rb s 11 ne- \i^ ^// ^ V f / I. f/ f) ^ — ~ \ /^ // /■''y L- ^c n/ f j u ^^ "~^ ; / /~ V, €5 ^ r^^ > Jy / ■■■ f ^fi n— \.: \^ ,^ ^ T >— , V. -^ > U/y W /, // \ ^ NT 1 \ . ( ( ^ ) V^ U V^ ^ — - ~) / /, \ \ K.V ^ J^' ^ ^ ^ i-''/y .% ,>= >-= / / ^' \ 'T^^ ig-- ^k "Jm /^ / (?' \ \ ■+.S- ^^ :=^ \ ^ i c \ > V- \ \^ I; \ Q^ ^ V-lt . \ t "-^ r Y \ \ r \ 1^, / \ s 1 / / \ iikoA / FniCc ^ ^ / / \ / ^caU ^'tol- / / / Tf 1 1 1 / ; / / Fig. 2. A. Exact Contour and Measurements of the woman selected for Fig. 1. B. Exact Con- tour and Measurements of another model, presenting a more pronounced lumbar and abdominal curve. The small squares represent one-inch squares at life size. (R. Walter Mills.) (A) Artist's model, aged 28, mother of two children (6 and 8 years old respectively), has worn corset practically none, is in good health and fairly muscular. Height 5 ft. 7 in., weight 140 lb., bust measure 36 in., waist 27 in. (2 in. above umbilicus), circumference at umbilicus 30 in., hips 39 in., thigh 22^ in. (2 in. below gluteal crease), antero-posterior diameter of body at waist 6J4 in., antero- posterior diameter of thigh (2 in. below gluteal crease) 6^ in. The other data are given on the out- line. To conform to the so-called "perfect form" the hips should be a trifle larger and the weight some- what more. (B) Young woman, aged 27, never pregnant, has worn corset very little, is in good health and muscular. Height 5 ft. 4 in., weight 114 lb., bust measure 32 in., waist 24 in. (2 in. above umbilicus), hips 38 m., thigh 22 in. (2 in. below gluteal crease), anlero-rosterior diameter of body at waist dV^ in., antero-posterior°diameter of thigh (2 inches below gluteal crease) (>Vt in. The other data are given on the outline. The lumbar and abdominal curves are more pronounced than in A. The numerous exact measurements given in Fig. 2 constitute valuable data to guide in medical drawings of this character. TAKING THE HISTORY 35 history, and should include facts covering all the important points. The following outline indicates the information to be obtained, and also pre- sents a convenient order in which to question the patient and record the systematic history: Preliminary Questioning — To ascertain the principal complaint (character, location, duration, etc.) and put the patient at ease. Fig. 3. Antero-posterior Section of Pelvis. Showing left half of body, with intestines removed. (Kelly — Operative Gynecology.) History Record Social Items — Xame, address, age, married, occupation. Previous Health — General health, abdominal inflammation, nervous disturbances, operations, etc. Pregnancies — ConJinements, miscarriages, sterility. Menstrual History — Beginning, regularity, duration, amount, pain, last two menstrua- tions. 36 GYNECOLOGIC EXAMINATION METHODS Beginning of Present TrouWe — When, how, cause. Principal Symptoms — Character, time of onset, duration of each. Disability — Confinement to bed, interference with work, etc. Complications — Character, onset, duration. ramily History — In special cases, nervous disturbance, tuberculosis, etc. Previous Treatment — Different kinds, results. Summary of chief symptoms demanding relief. Fig. 4. View of Pelvic Organs from Behind. (Tlickinson— American Textbook of Obstetrics.) Fig. 3. Pelvic Organs from in Front. (Dickinson— ^mericaw Textbook of Obstetrics.) Preliminary Questioning-. Of what symptoms does the patient complain? A question directed to bring out this information will at once enlist the TAKING THE HISTORY 37 patient's interest and relieve any temporary embarrassment she may feel. The prominent symptoms are soon given, and serve to indicate lines of special inquiry when taking the systematic history of the case. The system- atic inquiry is begun at some convenient point in the patient's narrative. - Social Items. It is well to put down at this time the facts not strictly medical, for if postponed some of them are liable to be overlooked alto- gether. Record accurately the patient's name, address, age, whether married or single; and if single, the occupation; if married, how long. If she has been married more than once, or if a widow or if living apart from her hus- band, she will probably mention the fact and also any correlated facts bear- Fig. 6. Relation of the Pelvic Organs to the External Surface of the body. American Textbook of Obstetrics.) (Dickinson- ing on the present disturbance. In some cases it may be advisable, for busi- ness reasons, to note other items of information — for example, the husband's occupation and business address. Previous Health. Ascertain whether or not the patient Avas Avell and strong before the beginning of the present trouble. Any serious illness, whether connected with the pelvic organs or not, should be inquired into. It may be an important factor in the origin of the present disturbance or it may point to some complication which must be taken into consideration in the treatment. Of particular importance are serious nervous disturbances, attacks of abdominal inflammation, and operations. 3g GYNECOLOGIC EXAMINATION METHODS Pregnancies. Labors. Has the patient had children? If so, how many and when? Was there serious trouble during any labor, or during any preg- nancy, or afterward? Make particular inquiry as to whether the labor was so severe that instruments had to be used, or whether the labor was followed by indications of sepsis or of laceration of the pelvic floor or cervix uteri. If after any labor the patient was sick in bed for two or three weeks, with pain in the lower abdomen and fever, she probably had sepsis in some form, the usual form being septic endometritis. Another very common history of mild sepsis is that the patient gets up as usual, but does not feel strong and after a few days takes a ''backset" and returns to bed or drags about the house with soreness in the lower abdomen, some fever, and marked weakness. Of course, delays in convalescence after labor may be caused by complications outside the genital tract, but generally they are due to some trouble in the genital Fig. 7. Indicating General Pelvic Distress. This distress may be due to bladder or uterine or tubal or ovarian disease on one or both sides. tract, such as infection of the uterus or subinvolution of the uterus or lacera- tion of the pelvic floor. Miscarriages. Have there been any miscarriages? If so, how many and when and at what stage of pregnancy did each occur? What was the cause of each miscarriage ? Did it follow some accident, or was it due to some acute disease such as typhoid fever or pneumonia? If there have been repeated miscarriages, inquire carefully and circumspectly as to evidences of syphilis. Have the miscarriages been brought about intentionally (criminal abortion)— if so, in what way? AVas each miscarriage complete and no trouble follow- ing? When incomplete, part of the fetal membranes are retained in the uterus and cause a persistent bloody discharge. Sepsis also may occur. Sterility. When the patient has been married a long time and there has TAKING THE HISTORY 39 been no pregnancy, it is Avell to inquire as to why there has been no pregnancy, and if treatment has been undertaken for the sterility. Menstrual History. How old was the patient when she began to men- Fig. 8. Backache from pelvic disease. Indicating Fig. 9. Backache from pelvic disease. Indicating pain in the central lumbar region. pain extending down over the sacrum. Fig. 10. Indicating pain in right tubo-ovarian Fig. 11. Indicating pain in the appendiceal region. region. struate? Has the menstruation been regular and of proper duration and amount, and free from severe pain? If there has been menstrual disturbance — for example, absence of menses, or excessive menstruation or irregular men- struation or intermenstrual bleeding- — ascertain the duration and severity of 40 GYNECOLOGIC EXAMINATION METHODS each. Invariably ascertain the date and duration of the last two menstrua- tions that pregnancy may be excluded. Beginning' of Present Trouble. How long has the patient been sick? Ascertain accurately when the present trouble began. If it has been of long duration, pass back of the several exacerbations and get the approximate date of the first acute attack or first appearance of decided symptoms. What were these first symptoms? How severe were they? "What was done for them? What caused the trouble at that time? Had there been a severe sick spell or an injury of any kind? Had there been a labor or miscarriage or menstrual disturbance or recent marriage or extra work or anything that might have acted as a cause ? Character and Duration of Principal Symptoms. Get an account of the present trouble from the day it began down through the important changes Fig. 12. Indicating pain in the region of the right kidney. Fig. 13. Another common way of indicating the dragging pain that accompanies disease and displace- ment of the kidney. to the date of consultation. This does not mean to waste time with a mass of unnecessary detail but to ascertain, by well directed inquiries, the order of development and duration of the principal symptoms, such as pain, fever, swelling, discharge, etc. Locate definitely the site of the pain or tenderness or other distress com- plained of. Is it in the tubal region or appendix region or over the uterus or about the ureter or kidney ? Have the patient point out the exact location of the pain. Figs. 7 to 13 indicate the location of the pain in various affections. This definite localization helps to clarify the situation and makes the patient more careful and reliable in her statements. Of course, no diagnosis should be attempted from such necessarily uncertain localization by the patient. This TAKING THE HISTORY 41 simply indicates what group of organs are probably affected and enables the physician to question the patient more definitely and accurately before begin- ning the physical examination. Ascertain the frequency and duration of the exacerbations of the disease. Has the trouble been getting worse gradually and continuously, or have there been exacerbations followed by remissions, with partial or complete disappear- ance of the symptoms'? Disability. How much of the time has the patient been confined to bed? If able to be up and about part of the time or all the time, how much work or walking or shopping has she been able to do? Is the patient engaged in any work aside from her household duties ? If so, what is it and has it any bearing on the origin or continuation of the present trouble ? Does she do any of her own housework? If so, how much? Is it executed with facility, as when she was well, or is there pain and disability ? Ascertain carefully the character of the distress associated with the work. What time of day does it come on, where is it located, is it a sharp pain or a dull aching or a dragging-weight and pressure? What posture aggravates or relieves it, does it necessitate lying down, does it recur soon after rising, is it present every day, does it vary from week to week or month to month? Ascertain also the effect on the general health and nutrition. How much has the patient lost in weight or has she gained ? Complications. Inquire concerning complications or associated diseases. Frequently there are complicating bladder or rectal or other local disturb- ances, and the extent of these should be determined. Inquiry should be made, also, for symptoms of diseases of remote organs, either complications of the pelvic trouble or intercurrent diseases. All the vital organs of the patient must be considered in estimating the influence of the pelvic disease and in forming the plan of treatment for it. Many serious mistakes in diag- nosis and in treatment have occurred because the physician permitted some marked local lesion to obscure his vision of the whole patient. In addition to the heart, lungs, kidneys, and digestive tract, the condition of the patient's blood, as indicated by her color, and the condition of the nervous system, as indicated by her appearance and actions, should be con- sidered; and if there is evidence of disease in any direction, further investiga- tion should be carried out. Family History. In some cases certain items of the family history are important, particularly nervous disturbances, tuberculosis and cancer — though the influence of family tendency to cancer has been much exaggerated. Other family items of importance in gynecologic cases are hemophilia and men- strual peculiarities, especially very late or very early menopause. Previous Treatment. Question the patient as to the character and dura- tion of the previous treatment and its apparent effect. Was it internal treat- ment or local treatment at home (douches, vaginal suppositories, or tablets 42 - GYXECOLOGIC EXAMINATION METHODS or tampon-capsules; or local treatment at office (vaginal applications, tam- pons, intrauterine treatment) or operation (curetting, repair of pelvic floor or cervix, vaginal section or abdominal section). Summary. After completing the history and before beginning the exam- ination, fix in mind the chief symptoms for which the patient seeks relief. Keep these in mind while making the examination and endeavor to find the lesion or condition that causes each of them. These symptoms serve to indi- cate the directions for special investigation. The diagnosis should be made, to a considerable extent, as the examination progresses. Before finishing the examination, you should have formed an opinion as to whether or not you have found the cause or causes of the symptoms which brought the patient to you. Keep a Record A short record, giving in a systematic way the principal facts of a case, may be made quickly and more than repays for the time consumed. And the principal advantage is not the permanent record it gives for reference after some years, though that is important, especially to the teacher, but the fact that it systematizes and steadies and improves the physician's work day by day. Such an account of the case in black and white, referred to frequently as the patient returns for treatment, is a constant stimulus to accurate diag- nosis and a constant help in the treatment, particularly if the case is a long continued one. Again, in court a physician is supposed to have some record of his work. You may at any time be called upon to testify as to the exact findings in the case of some patient whom you saw one or two or three years before. The record should embody the important facts in the history, in the ex- amination findings, in the treatment given, and in the subseciuent progress of the case. The great drawback to records is the time required to make them. In order to make them at all, the physician must have some arrangement by which the record may be made in a very few minutes. This is where printed forms are advantageous. On a printed form the physician may, in a few minutes, put down the notes necessary to make an accurate account of the case. Record cards, printed as desired, and ai-ranged as a card index, constitute a very convenient record system for the busy practitioner, and at a moderate cost. The author uses -l:x6 cards, printed on one side for the prmcipal record (Fig. 14), the back of the card (Fig. 15) being used for extra notes. When more space is required blank cards are attached as needed. When it is desired to have a sketch of the condition, a small outline of the pelvis or abdomen is stamped at some clear space on the card (with the required rubber stamp, of which any desired kind may be obtained at small expense) and the tumor or inflammatory mass or displaced organ is then draAvn in. The author uses TAKING THE HISTORY 43 two kinds of form cards — identical in size but differing in color. For the regular gynecologic history and examination, a white card is used. If the patient is subjected to operation, a buff ''operation card" is added. If one DATE NAME ADDRESS oe. PREVIOUS H. CONFIN. MUC OEG. o > P4IN WITH ILL. REO. PlIM LAST MENSTR. PRESENT ILLNESS EXAM. INO DIAG. Fig. 14. Gynecologic History Card. The original card is 6 in. wide and 4 in. high. OUTLINE OF TR. Fig. IS. Reverse side of History Card. 44 GYNECOLOGIC EXAMINATION METHODS does not wish to invest in specially prepared cards and holders, a start may be made with some blank cards of the desired size, arranged upright in the ordinary desk drawer. Is a Pelvic Examination Required? After obtaining all the information the patient can give concerning her illness, the next step is to make the physical examination, provided there are symptoms making such an examination necessary. In the case of a virgin, pelvic examination is rarely indicated until after general therapeutic measures have been tried and have failed to give relief. Occasionally a young woman or a girl will present such serious symptoms that an examination is indicated at the first visit, but such cases are extremely rare. On the other hand, in the case of a majrried woman, if decided pelvic symptoms are present, an examination should, as a rule, be made at once, particularly if there has been previous treatment without satisfactory result. If the patient is menstruating, the examination is of course postponed, unless the symptoms are serious and urgent. A non-menstrual bloody discharge is not a contraindication to examination, but rather an additional indication for it. If the patient is extremely anxious to avoid the examination, treatment without it may be tried for a while in a suitable case, even though immediate examination seems decidedly preferable. When a girl is examined, her mother or some other relative should be present. PHYSICAL EXAMINATION The order of examination which the author finds most convenient, when the patient can be placed on the table, is as follows: Abdominal Examination. Inspection of External Genitals, Meatus, Perineum, etc. Vaginal Examination (Digital). Vagino-abdominal Examination (Bimanual). Instrumental Examination. Exceptionally Examination of Eectum. Pelvic Examination under Anesthesia. Examination of Bladder. When the patient is seen at home, the order of examination is more fre- quently abdominal, vaginal, vagino-abdominal and, when indicated, a digital examination per rectum. Inspection of the external genitals and the specu- lum examination are usually not required in such a case. PHYSICAL EXAMINATION 45 HoAvever, if there are symptoms pointing to disease of the external gen- itals, the parts should of course be inspected. Also, in any case, if it is thought that information of value may be obtained by the speculum examination, that procedure should be carried out. Fig. 16. Patient on table and arranged for abdominal examination. Fig. 17. Profile of Normal Abdomen. Patient arranged for abdominal examination. 46 GYNECOLOGIC EXAMINATION METHODS ABDOMINAL EXAMINATION Have the patient lie near tlie edge of the bed or table, in a comfortable position, with the head slightly raised on a pillow and the knees drawn np sufficiently to relax the abdominal muscles (Figs. 16, 17, 119). The abdomen is subject to: Inspection — Contour, Color, Eruption, Striae, Scars. Palpation — Tension, Tenderness, Mass, Fluctuation, Fluid Wave. Fat Wave, Fetal Movement, Uterine Contraction, Friction Rub. Percussion — Area of Dullness. Auscultation — Fetal Heart Sounds, Vascular Murmur. Menstruation — For accurate comparison. INSPECTION OF ABDOMEN Contour, Movement, Color, Eruption, Striae, Scars The principal thing to determine by inspection is contour. Determine also the other items mentioned — movement of wall, color, eruption, striae, scars — but usually they are of secondary importance. As to contour, there may exist, one of several conditions, as follows: The smooth, moderately full contour of the normal abdomen (Figs. 17, 18, 19). The flat, sunken abdomen of wasting disease, with empty intestines. A swollen, prominent abdomen (Figs. 139 to 151). The significance of prominence of the abdomen is taken up in detail in the chapter on Diagnosis (Chapter ii). PALPATION OF ABDOMEN Tension, Tenderness, Mass, Fluctuation, Fluid Wave, Fat Wave, Fetal Move- ment, Uterine Contraction, Friction Rub. Tension and Tenderness As to tension, we determine whether the wall is soft and easily depressed, or is firm and resisting from muscular tension. The latter condition may be due to nervousness or fright, the patient fearing that the examination will cause pain, or it may be due to genuine tenderness from inflammation or irri- tation beneath the wall, as in peritonitis or intraperitoneal hemorrhage. The best way to begin palpation is to place the palmar surface of the whole hand flat on the abdominal wall (Fig. 20). Hold it there perfectly quiet for a moment, that the patient may see that you are not going to cause pain. Then, as the muscular tension relaxes, depress the wall carefully with the fingers (Fig. 21) in various directions and situations as the hand is moved PHYSICAL EXAMINATION 47 about over the surface. Begin the movement of the hand gradually, almost imperceptibly at first, perhaps at the same time directing the patient's atten- tion away by a question or two. When the patient's attention is fixed on the palpating hands, there is likely to be troublesome tension of the wall. As the examination proceeds, deep palpation is made in various parts of the abdo- men in order to exclude disease in the various regions. Palpation with both S < ,^/ I Fig. 18. The abdominal surface with the rib margins and the iliac crests outlined. hands (Fig. 22) assists much in determining the character and consistency of the tissues between them and under them, particularly when the abdomen is rather full. If a resisting area is found, work the fingers around it, de- pressing the wall and examining all portions of it (Fig. 23). The palpation should always be made gently, for, if the manipulations cause pain or frighten the patient, the wall is immediately made tense and then no satisfactory ex- amination is possible. 48 GYNECOLOGIC EXAMINATION METHODS In a case of suspected appendicitis or one sided inflammation, the difference in tension of the abdominal wall on the two sides is of diagnostic importance. Ordinarily the difference of tension may be determined with sufficient accuracy by palpation. If desired, the piezometer (Fig. 24) devised by Kelly (Johns Hopkins Hospital Bulletin, Sept., 1904) may be used. Fig. 19. Another abdominal surface, with the ribs and crests outlined. This patient is rather stout. Notice how much the landmarks differ from those in Fig. 18. Having determined the general tension and tenderness, search is made for local tenderness. The exact location of the tenderness should be carefully determined, and also whether it is circumscribed to that area or extends to other areas. When the area of tenderness has been accurately located, we PHYSICAL EXAMINATION 49 knoAv what organs are likely to be affected, and the further differentiation between affections of those organs may be proceeded with. Regions of the Abdomen. For convenience in designating the location of Fig. 20. Palpation of the abdomen. First step. Fig. 21. Palpation. Depressing the wall with the Hand flat on abdominal surface. fingers of one hand, in various situations. Fig. 22. Palpation with both hands. Fig. 23. Deep Palpation with both hands. 50 GYNECOLOGIC EXAMINATION METHODS tenderness or of a mass, the abdomen is divided into regions. There are many methods of division. A simple and useful one is the division of the surface into quadrants by an imaginary horizontal line passing through the umbili- cus and a vertical line through the same point (Fig. 25). Fig. 24. Piezometer, for measuring the tenderness to pressure and the muscular resistance. Fig. 25. The abdominal surface divided into Quadrants. This is very convenient for designating in a general Avay the location of large masses, but it is not sufficiently definite for the accurate localization of small masses or points of tenderness. PHYSICAL EXAMINATION 51 For the more definite localization, the time honored division into squares, by tAvo vertical and two horizontal lines (Fig. 26), is the one generally fol- lowed in anatomic and diagnostic works. However, as a practical working division for diagnostic and teaching purposes, this has been found decidedly inconvenient and unsatisfactory, as is attested by the many attempts of clinicians to devise a simple method of dividing the surface and of designating the various regions. Fig. 26. The usual anatomic division of the abdomen into nine regions by two transver'=e lines and two vertical lines. The upper transverse line is at the level of the cartilages of the ninth ribs, and the lower with the highest points of the iliac crests. The two parallel vertical lines pass through the cartilages of the eighth ribs and the middle of Poupart's ligaments. Failing to find a method of division that was satisfactory to the author, he devised that shown in Fig. 27, which, so far as he knows, is original. The only lines not marked by natural landmarks are a circle with a two-inch radius about the umbilicus and a short straight line extending horizontally for two inches from each side of the circle. The regions are designated as right lower, left lower, central lower, right upper, left upper, central upper, umbilical, and right and left lumbar (Fig. 28). This method of division is simple, and the names are easily remembered 52 GYNECOLOGIC EXAMIXATIOX METHODS and are self-explanatory. In fact, these designations are the ones commonly used in conversation among physicians in describing the location of a mass or area of tenderness. For example, we speak of tenderness in the right lower region of the abdomen, or, more briefly, in the "right lower abdomen," or in the "left lower abdomen," or in the "right upper abdomen," etc. Within each of these principal regions there are one or more points which are of special interest. The special interest attaches to each one of these points because well-defined tenderness limited to such point usually means Fig. 27. Division of the abdomen into regions by means of a circle with a two-inch radius and two-inch horizontal lines. an affection of a particular organ. It must be kept in mind, however, that in some cases such point-tenderness is due to an affection of some adjacent organ (as when inflammation within the cecum causes tenderness in the appendix region), or cA-en of some distant organ which has become displaced (as Avhen the right kidney has become displaced into the appendix region). Again, in some cases tenderness is due to an organic or functional dis- turbance of the nerves of the alxlominal wall or to reflected pain, due to a PHYSICAL, EXAMIXATIOX 53 lesion in some otlier part of the abcloniinal cavity or to some organic or functional lesion in a distant part of the body. But even in these exceptional conditions the tenderness is usually not genuine "point-tenderness," but is more extensive and can be traced in some direction sufficiently far to in- dicate its probable origin. Fig. 28. Another abdomen divided with the circle and short horizontal lines, and showing the names on the primary regions. The area within the circle carries the usual designation, "umbilical region." 54 GYNECOLOGIC EXAMINATION METHODS With the exceptions above mentioned kept in mind, the special areas of ''point-tenderness" are of great help in the differential diagnosis of ab- dominal lesions. K. t St 'hO. Tr-O^ Fig. 29. Various areas of significant Point-tenderness. These are the areas to be investigated during the course of an abdominal examination. PHYSICAL EXAMINATION 55 The author does not approve of the method of naming the principal, or primary, regions of the abdomen from the significant point-tenderness situated therein. For example, to designate the right lower abdomen as the "appen- diceal region, " as is done by some authorities, leads only to confusion. It is no more the appendiceal region than it is the cecal region, or the tubo-ovarian Fig. 30. Point for Kidney Tenderness laterally. Fig. 31. Points for Kidney Tenderness in the back. Fig. 32. Relation of the Kidney to the lower margin of the last rib. (Butler — Diagnostics of Internal Medicine.) Fig. 3Z. Trying for a Fluid Wave across the abdomen. region, or the ureteral region. The term ''appendiceal region" should be reserved for the very circumscribed area immediately over the appendix, the same as the terms "tubo-ovarian region" and "ureteral region" should 56 GYNECOLOGIC EXAMINATION METHODS be limited to the areas containing those structures. Then, when we speak of tenderness in the appendiceal region, there is no question as to the exact location of the tenderness. The principal areas of significant point-tenderness are shown in Fig. 29. There are, of course, also many areas of secondary importance — of secondary importance because tenderness or a mass therein is not of such definite significance. After locating accurately the point of greatest tenderness, try to trace the tenderness in various directions. This is especially useful in cases which are doubtful, because the tenderness is not typically situated or is not well limited. For example, take a case in which the most marked point-tenderness is situated about midway between the right tube, the appendix and the ureter. It may be due, among other things, to disease of the tube or ovary, or of the ureter or cecum, or of the appendix or small intestine, or of the peritoneum. Determine if well-marked tenderness can be traced down toward Poupart's ligament and the tube. If the tenderness does not extend in that direction, it is probably not due to trouble about the tube or ovary. Then try to trace it to the ureter and along the ureter downward toward the bladder and upward toward the kidney. Determine also if it spreads over the cecum and extends up along the ascending colon, as it is likely to do Avhen caused by inflammation of the large bowel. Determine if it extends through the abdo- men generally, including the umbilical region and beyond. If it does not extend in any one of the directions mentioned, but is strictly limited to the point designated, it is probably due to appendix trouble, which probable diagnosis must be strengthened or weakened, as the case may be, by other signs present and by the history of the trouble. In those cases in which there is a question as to whether or not the tender- ness is due to trouble in the ureter, particularly where the tenderness extends over the whole right lower or left lower abdomen, or is so acute as to prevent the deep palpation necessary to accurate localization, palpation of the lumbar region laterally and posteriorly is of much assistance in the differential diag- nosis. Well marked ureteritis is usually accompanied by pyelitis and kidney tenderness. In such a case there is distinct tenderness over the kidney later- ally (Fig. 30) and also posteriorly (Figs. 31, 32). Mass in the Abdomen When a mass is discovered, determine as far as possible its position, size, shape, consistency, tenderness, mobility and attachments. The position of a mass indicates in a general way the organ or group of organs from which it arises. Keep in mind, hoAvever, that it may be due to some adjacent organ, or even some distant organ displaced into that region. The size and shape of a mass is determined by ascertaining its length, breadth, thickness, and general contour. The length or height of a tumor pro- PHYSICAL EXAMINATION 57 jecting up from the pelvis is usually designated as so many inches or centi- meters above the pubic symphysis, or beloAV the umbilicus or above the umbilicus. The breadth may be given approximately in inches or centimeters, stating at the same time Avhether or not the mass is situated sj-mmetrieally on either side of the median line, or the mass may be referred to as filling the pelvis from side to side or as filling the abdomen. It is sometimes difficult to convey a satisfactory idea of the general contour of a mass by a detailed description, when it may be very quickly conveyed by referring to some well- kno"\^Ti object, e. g., an egg, a lemon, a kidney, or an hour-glass. Another method of recording the size and shape of a mass is to draw it i \ Fig. 34. — Differentiating a Fat Wave from a Fluid \\'ave. The Fat Wave is stopped by the pressure in the median line. within a stamped outline of the pelvis and abdomen. Still another expedient, devised by H. A. Kelly (Medical Gynecology, Chapter i), is to outline the mass and the landmarks in the individual patient on a large piece of gauze or muslin applied over the abdomen, the same being preserved as part of the case record. The consistency of a mass should be carefully determined. Is it uniformly solid or does it present hard nodules, or does it contain fluid? If the mass con- tains a collection of fluid of sufficient size, there may be elicited that peculiar sensation known as fluctuation, the recognition of which is one of the first 58 GYNECOLOGIC EXAMINATION METHODS lessons in surgical work. If there is a large collection of fluid, as in a case of marked ascites, a fluid wave, started by tapping on one side of the abdomen, may be felt by the other hand applied to the other side (Fig. 33). A somewhat similar wave may be caused, also, by a thick layer of subcutaneous fat (fat wave) . In such a case, however, if an assistant press lightly in the median line with the ulnar edge of the hand, the fat wave will stop at the line of pressure (Fig. 34). A distinct fluid wave maj^ be obtained in any large collection of fluid Avith a comparatively thin wall. It is present in well marked ascites, in unilocular cysts and in multilocular cysts with one or more large cavities. Occasionally the fact that there are different large cavities in the cyst may be surmised by a distinct difference in the fluid wave as obtained through different parts of the cyst. In a cyst .with small cavities no fluid wave is obtained, as there is Fig. 35. Attempting to Displace a mass upward in order to determine if it has a pelvic attachment. not a large enough single cavity, although fluctuation may be as clear as in a single large cyst. Also, in a cyst with thick gelatinous contents a fluid Avave may not be obtained. The tenderness of a mass as determined by palpation is of much importance in differential diagnosis. In acute inflammation (as in acute salpingitis or peritonitis), or in acute irritation (as in hemorrhage from tubal pregnancy), the tenderness is very marked. On the other hand, in uncomplicated ovarian or uterine tumors, tenderness is slight. The mobility and attachments of a mass are determined by attempting to move the mass in different directions. The fingers are worked in deeply about the mass at various points, and it is determined just what part may be easily displaced and what part is fixed (Fig. 35). The fixed point of a mass usually indicates its jDoint of origin — i. e., the organ involved. The presence or absence PHYSICAL EXAMINATION 59 of mobility helps to determine whether or not the mass is bound down by inflammatory exudate or is retroperitoneal, or is in the abdominal wall. Occasionally a mass is not mobile because it is so large that it fills the ab- dominal cavity. Some retroperitoneal masses (particularly kidney tumors) present marked mobility in certain directions. Fetal Movement, Uterine Contraction, Friction Rub In late pregnancy, fetal movement, caused by the fetus changing position or kicking, may not infrequently be felt. Dipping the hands in cold water and then laying them flat over the uterus may cause, the fetus to move. The absence of fetal movements is of no diagnostic signiflcance, but the presence of them is of course certain evidence of existing iDregnancy and con- sequently well worth trying for in a doubtful case. The same may be said of the intermittent contraction and relaxation of the pregnant uterus. In some cases alternate hardening and softening of the uterus may be very distinct, and is positive evidence of the character of the mass under the hands. A friction rub may sometimes be felt in a case of active peritonitis, particu- larly in the local plastic or irritative peritonitis that not infrequently takes place when a tumor lies against the abdominal wall. The hand is pressed over the mass during forced respiration. Occasionally the friction rub may be obtained over the liver or spleen when there is a local peritonitis there. PERCUSSION OF ABDOMEN Areas of Dullness Percussion over the abdomen serves to conflrm the information obtained by palpation, and also brings out some new facts — for example, by outlining accurately the area of dullness it shows at what portion of the abdominal wall the tumor or fluid lies against the wall, and at what portion there is interven- ing intestine. It shows also whether the mass or fluid changes relations when the patient changes position. In a ventral hernia (intestinal) it shows that the large mass, which might be taken for a tumor or inflammatory mass, is resonant — i. e., it contains air, and, therefore, must, under ordinary circum- stances, contain intestine. The use of superficial and deep percussion in succession may give valuable information in some cases. Ordinary percussion (Fig. 36) is moderately light and superficial, and gives resonance over all the normal abdomen, except where the liver lies against the wall. In marked obesity, however, superficial percussion is likely to give only dullness over all the abdomen, while deep per- cussion (a hard percussion stroke against the finger pressed in deeply — Fig. 37) gives resonance. 60 GYNECOLOGIC EXAMINATION Ml.THODS A tumor of the wall or of the omentum ordinarily gives dullness in light percussion and resonance in deep percussion. Fig. 36. Ordinary Percussion, which is usually rather superficial. Fig. 37. Deep Percussion. Notice how the left index finger is pressed into the abdomen, so as to thin out the wall and get closer to deep structures. Endeavor to get definitely in mind exactly the reason for the dullness or resonance found in a particular case, and then its diagnostic significance will be clear. AUSCULTATION Fetal Heart Sounds, Vascular Murmur Auscultation, either by the ear direct (a sheet intervening) or by the stethoscope, should always be employed when there could be any confusion with advanced pregnancy, as in a ease of large ovarian tumor or large fibroid. The fetal heart sounds are the only sounds pathognomonic of pregnancy. The placental murmur may be simulated by the large vessels of a tumor. The ab- sence of fetal heart sounds does not exclude pregnancy, for even in cases of normal pregnancy they cannot always be heard. Auscultation should be em- ployed also in obscure cases of pain in the abdomen, particularly if accom- panied by pulsation. The pain may be due to an aneurism of the abdominal aorta, which occasionally runs its course unrecognized until rupture and sud- den death. In auscultation for aneurismal murmur with a stethoscope, be careful that the abdominal wall is not pressed firmly against the aorta with the stethoscope, for such pressure will cause a murmur in a normal vessel. Excessive gurg-ling" in the intestines may be heard in most intestinal diseases i ^"HYSICAL EXAMINATION 61 accompanied with tympanites. It is heard particularly in the region of the ileocecal valve or about a partial obstruction or over a loop of bowel in peri- staltic movement. Gurgling over a large mass indicates that one or more intes- tinal coils are between it and the abdominal wall. This intestine may be in front because the mass is retroperitoneal or because an intestinal coil is adherent over the mass, or because the mass is made up partly or wholly of adherent intestinal coils. 11^ Fig. 38. Showing the lines for Mensuration. A friction sound may occasionally be heard in local peritonitis, particularly over the areas of fresh plastic peritonitis or over a tumor. MENSURATION OF ABDOMEN Measure the abdomen when it is very large or when there is a growing tumor, or when for other reason it may be desirable to know exactly any differ- ence in size some weeks or months hence, or when it is desired to speak with accuracy concerning the size of the abdomen in the case of a large growth. The measurements are made with the ordinary tape-line. AVhen measuring 62 GYNECOLOGIC EXAMINATION METHODS a patient, take enough measurements to make an accurate record. Measure- ments along the lines shown in Fig. 38 will show variations with a large growth in any part of the peritoneal cavity. They are as follows: 1. From umbilicus to sternal notch. 2. From umbilicus to pubes. 3. From umbilicus to right anterior superior iliac spine. 4. From umbilicus to left anterior superior iliac spine. 5. Circumference of body at level of umbilicus. 6. Circumference of body 3 inches above umbilicus. 7. Circumference of body 3 inches below umbilicus. EXAMINATION OF EXTERNAL GENITALS AND ADJACENT STRUCTURES If the patient complains of irritation about the external genitals, or of itch- ing or burning, or of frequent or painful urination, or of sores or swelling, or discharge, the parts should be inspected in a good light. For this examination, as the patient is lying on the table, the lower extremities are covered with a sheet, the skirts are pushed above the knees and out of the way, and the hips are brought to the end of the table, as shown in Fig. 39. A general inspection is then given the parts, to ascertain if they are prac- tically normal (Figs. 40, 41) or if there is marked abnormality. The labia are then separated, to expose the vestibule and urethral and vaginal openings, and also the openings of the ducts of- the vulvo-vaginal glands. By examination determine if any of the following conditions are present: Discharge — Muco-epithelial, Muco-purulent, Purulent, Bloody, Watery. Inflammation — Gonorrheal or otherwise. Ulcer— Simple, Chancroidal, Syphilitic, Tubercular, Malignant. SweUing- — Inflammatory, Stasis Infiltration, Edema, Hematoma, Hernia, Cyst. New Growth — Condyloma, Urethral Caruncle, Lipoma, Fibroma, Ma- lignant Growth. Malformation — Adhesions of Labia, Pseudohermaphroditism. Determine also the Condition of Hymen — Intact, Lacerated, Destroyed. Condition of Perineum — Normal, Lacerated (wide opening, vaginal walls visible, shallow perineum, scar tissue, fistula). DISCHARGE ABOUT EXTERNAL GENITALS Muco-epithelial, Muco-purulent, Purulent, Bloody, Watery Muco-epithelial Discharge (normal). The normal mucus secretion from the cervix moistens and macerates the vaginal epithelium. The mixture of this cervical mucus and vaginal epithelium appears at the external genitals as a EXAMINATION OF EXTERNAL GENITALS 63 white, crumbly discharge. Usually it is hardly noticeable, only just enough to keep the parts normally moist. At the menstrual periods, and under other conditions favoring pelvic congestion, it may increase so as to be somewhat annoying to the patient, though hardly of pathologic importance. Muco-purulent Discharg-e. When there is inflammation or persistent con- gestion in the uterus, the mucus secretion is much increased, and there are Fig. 39. Patient in position for Examination of External Genitals and adjacent structures. thrown out, at the same time and for the same cause, many leukocytes, Avhich mix with the mucus, giving it somewhat of a purulent character, the promi- nence of the purulent feature depending on the amount of this admixture of dead leukocytes. If it contains enough mucus to be noticeable, the discharge is sticky and stringy, and may be drawn out into long threads. Purulent discharge presents the appearance of pus, as from an abscess or inflamed surface, either thin pus or thick yellow pus. Determine just where 64 GYXECOLOGIC EXAMIXATIOX :METH0DS Fig. 40. External Genitals, i. Mons veneris. 3. Left Labium Majus, drawn aside. 3. Clitoris. 4. Left Labium Minus, slightly larger than the average. 5. Vestibule. 6. Urethra. 7. Duct of Vulvo- vaginal Gland. 8. Vaginal Entrance. 9. Remains of Hymen. 10. Fourchette. //. Anus. (Byford — Manual of Gynecology.) Fig. 41. Practically Xormal External Genitals — multipara, labia together, labia minora can hardly be called abnormal. The corrugations of the EXAMINATION OF EXTERNAL GENITALS 65 this comes from — i. c, whethev i'l'oiu the uvethi-a or vulvo-vagiiial gland, or inflamed surfaces on the external genitals or from the vagina. Dip the tip of a cotton-wrapped applicator in this pnrnleiit discharge and spread some on a microscopic slide. If possible, secure some discharge from the urethra or vulvo-vaginal gland, for the pus from these situations is much more satisfactory for microscopic examination than the mixed vulvar or vaginal discharge. To secure urethral pus, separate the labia, cleanse the meatus, and compress the internal end of the urethra by pressure against the anterior vaginal wall with the tip of the index finger. Then, still maintaining the pressure, draw the tip of the finger along the urethra toward the meatus (Fig. 42). This brings the urethral pus to the meatus (Fig. 43). Chronic inflammation in the urethra is likely to be situated in Skene's glands, and in such a case some pus may be pressed from these small glands by compressing the urethra (by pressure through anterior vaginal Avail) just back of the meatus. In some cases, particularly in a multipara, the urethral mucosa pouts out, so that by careful examination the orifice of one or both of Skene's glands may be seen. Fig. 44 shows such a gland-opening (left side) and also a drop of pus which has been pressed from the gland on the right side. The vulvo-vaginal glands (Bartholin's glands) are situated symmetrically on either side of the vaginal opening, as shoAvn in Fig. 45. The opening of the duct of the gland of each side is situated laterally, just in front of the remnants of the hymen and a little beloAV the middle of the lateral margin of the vaginal opening. Draw aside the labia in this situation and look for the opening of the gland, and determine Avhether or not the opening is reddened and if there is any discharge from it (Fig. 46). To examine either vulvo-vaginal gland, to determine if there is anj^ thick- ening or tenderness from infl.ammation, or if pus can be squeezed from it, grasp the region of the gland between the index finger in the vagina and the thumb outside, as shown in Fig. 47. When securing secretion for microscopic examination, it is well to take discharge from different localities, making the spread Avith the applicator-tip in the form of different letters for different regions — for example, U (urethra), V (vagina), C (cervix). If the specimens are to be sent to a laboratory, stick a small label to each slide, and Avrite on it the date, the patient's initials, and the exact locality from Avhich it Avas taken. In a doubtful case of urethritis, in Avhich no secretion can be secured at the first examination, direct the patient to pass no urine for tAvo or three hours before the next examination. Detailed directions for staining the gonoeoecus Avill be found under Gonorrhea in Chap- ter IV. Bloody Discharg-e. The discharge is red or brown, the intensity of the color depending, of course, upon the amount of blood. It varies all the Avay 66 GYNECOLOGIC EXAMINATION METHODS from a slight reddish or broAvnish tinge, hardly noticeable, to practically pure blood or clots. The blood may be mixed with any of the other pathologic discharges— muco-puruleut, purulent or watery. The causes of blood in the vaginal discharge are enumerated in Chapter ii. Watery Discharge. A portion of the discharge appears like Avater. This may be associated with the normal muco-epithelial discharge or with a muco- purulent or purulent discharge. The most common cause of a watery dis- charge is the decomposition of a malignant tumor-mass in the vagina or uterus, giving the characteristic watery, foul-smelling discharge of advanced cancer or sloughing fibroid. INFLAMMATION ABOUT EXTERNAL GENITALS Gonorrheal or Otherwise Inflammation is indicated by redness and tenderness, either diffused or in spots. It is usually accompanied by smarting or burning on urination. The smarting on urination and the increased frequency of urination are most marked Avhen the urethra is involved. ULCER ABOUT EXTERNAL GENITALS Simple, Chancroidal, Syphilitic, Tubercular, Malignant If an ulcer is found, determine its position, size, shape, consistency (edge and underlying tissues), tenderness and mobility (Avhether fixed to under- lying deep structures or freely movable). Determine also the character of the discharge from it, and whether it bleeds readily on touching. Notice whether the base is made of regular granulation tissue or has yellow dots scattered in it, or is filled with a slough. Examine also the edges — do they slope from within outward, as in an ordinary ulcer when healing, or are they sharp-cul and perpendicular, or undermined as in a rapidly spreading chancroid? Is there a red acute-inflammatory zone about the ulcer or is there a wide area of chronic infiltration (chronic inflammation, malignant) ? Is there only a single sore or are there several? Are the inguinal glands affected? If so, in what way? Is there any other condition indicating the cause and character of the ulcer ? For the differential diagnosis of the various kinds of ulcer see the consideration of ulcers in Chapters ii and Iv. SWELLING ABOUT EXTERNAL GENITALS Inflammation, Stasis Infiltration, Edema, Hematoma, Hernia, Cyst Swelling may l)e inflammatory (as in acute edema or abscess), or ob- structive (as in edema from ol)structi()ii l)y heart or liver disease or from tumoi' in abdomen oi- pelvis). Thei'e may be obsti'uctive edema and infiltra- EXAMINATION OP EXTERNAL GENITALS 67 Fig. 42. Method of pressing pus from the depth Fig. 43. of the urethra to the meatus. Aiiijearaiice of pus at the urethral opening. Fig. 44. Slight eversion of urethral mucosa, so that openings of Skene's glands come into view. Tin left side the gland opening is seen. On right side a drop of pus has been squeezed from the gland and partially obscures the field. (Kelly — Operative Gynecology.') Fig. 45. \'ulvo-vaginal gland (D) and duct (O of right side. ( Dyford, after Muguier — Manual of Gynecology.) 68 GYNECOLOGIC EXAMIXATIOX METHODS tioii from scar-tissue about tlie pubic arch (stasis hypertrophy J, or edema and infiltration from obstruction of vessels by til aria (elephantiasis). The swelling may be a pudendal hernia, which originates either as an inguinal or a vaginal hernia. The swelling may be a retention cyst, the most common of which is cyst of the vulvo-vaginal gland. For complete enumeration and differential diag'- nosis of vulvar swellings see Chapter ii and Chapter iv. Fig. 46. Appearance of pus about the opening of Fig- ■+/. Palpating the left vulvo-vaginal gland, the left vulvo-vaginal gland. to determine if there is thickening or tenderness, or if pus can be pressed from it. NEW GROWTHS ABOUT EXTERNAL GfENITALS Condyloma, Urethral Caruncle, Lipoma, Fibroma, Malignant Growths Condylomata are small papillomata, from pin-head to hazel-nut size, that appear about the labia and meatus as the result of chronic irritation. They are seen most frequently in gonorrhea and secondary syphilis. Occasionally condylomatous growths unite to form a large mass, as shown in Chapter ii. Caruncle is a papilloma occurring about the meatus. Usually it is ex- tremely tender. DIGITAL VAGINAL EXAMINATION 69 Fibroma, lipoma and other non-nialignant tumors are rare, although they do occur occasionally, fibroma being the most frequent. Malig-nant growths in this situation very rapidly reach the stage at which complete extirpation is impossible, hence the importance of recognizing the condition very early. CONDITION OF HYMEN Intact, Lacerated, Destroyed Does the hymen present the virginal appearance, or is it lax and the open- ing large, as from sexual intercourse, or is it destroyed from labor, being represented by only a few remnants (carunculae myrtiformes) ? CONDITION OF PERINEUM Wide Opening, Vaginal Walls Visible, Shallow Perineum, Scar-tissue, Fistula For the detailed diagnosis of lacerations see Chapter ii. VAGINAL EXAMINATION (DIGITAL) In the vaginal examination, or digital examination, as it is frequently designated, one or two fingers are introduced into the vagina and the struc- tures within reach are palpated. In this way valuable information may be obtained in certain cases. It is also a preliminary step to the important vagino-abdominal or bimanual examination, to be taken up later. Method of Examination Use two fingers for the vaginal palpation where the size of the vaginal opening will permit. A much deeper and more accurate examination can be made with both the index and middle finger, than Avith the index finger alone. Ordinarily in the examination of a married woman, even one Avho has had no children, two fingers may be introduced Avithout difficulty, provided the fingers are Avell lubricated and care is taken to cause no pain. It is important also to separate the labia Avith the fingers of the other hand Avhile the examining fingers are being introduced, for, if the hair and labia are alloAved to roll in Avith the examining fingers, much pain is caused the patient and the opening is considerably narroAved. It is achasable to use rubber gloves in practically all cases. When intact, they give complete protection against syphilis or other infection Avhich might come through an unnoticed abrasion about the fingers. Another advantage is that less scrubbing of the hands is needed after the examination. Frequent severe scrubbing of the hands and the use of strong antiseptic solutions keep the skin in an irritated, unhealthy condition, particularly in cokl Aveather. 70 GYNECOLOGIC EXAMINATION METHODS Fig. 48. Position of the fingers for the vaginal and vagino-abdominal examinations. Fig. 49. Same hand, gloved and ready for the examination. DIGITAL VAGINAL EXAMINATION 71 When rubber gloves are used, all the infectious material is removed with the gloves, Avhich are washed and boiled and are then ready for the next exam- ination. Fig. 48 shows the position of the fingers ordinaril.v preferable in the vaginal and bimanual examination. Fig. 49 shows the hand gloved and ready for the vaginal examination. Fig. 50 shoAvs the disposition of the outside fingers and the thumb as the examination is. being made. The third and fourth fingers are folded into the palm ,of the hand as far as possible, and care is taken to maintain extension of the thumb, so that it does not infringe upon the genitals in the region of tho clitoris. For the same reason, in the deep Kig. SO. The gloved hand making the vaginal examination. The thumb is held awaj' from the genitals, and the third and fourth fingers are folded into the palm. internal palpation the wrist should be dropped low and the examining fingers directed upward, so as to throw the thumb away from the genitals. In the yery deep palpation in the sides of the pelvis, when the thumb is necessarily in the way, it should be turned far to one side or the other, and thus kept from contact with the sensitive areas (Fig. 76). In regard to the disposition of the third and fourth fingers, it is advantageous in some cases, particularly in very stout patients, to extend these fingers along in the internatal fold, as shown in Fig. 60. In these exceptional cases this permits deeper penetra- tion of the examining fingers. In beginning the examination, as the examining fingers are being intro- 72 GYNECOLOGIC EXAMINATION METHODS duced, there is frequently a tendency on the part of the patient, who is nervous for fear of pain or uncertain as to whether there will be pain, to contract the muscles of the pelvic floor and thus interfere with the vaginal examination. In such a case, if one finger be introduced a short distance and steady pressure backward be made against the muscle (Fig. 89), it slowly relaxes and the second finger may be introduced beside the first. Remember, that to obtain more space at the vaginal orifice, either in digital examination or in introducing a speculum, always press downward against the pelvic sling. Above and to the sides of the opening is the bony arch (Fig. 51),. and if an attempt is made to overcome the resistance by direct forward pressure, without depressing the perineum, the soft tissues above are pinched between the finger or instrument and the bony arch, causing the patient pain and in- creasing the muscular resistance. In a woman Avho has borne children the opening usually admits the U\o fingers somewhat easier, and the temporary muscular resistance above men- tioned is seldom encountered. What Structures to Palpate With one or tAvo fingers, well lubricated and introduced into the vagina,- palpate the following structures: Vaginal Walls — Roughness, Tenderness, Discharge, Induration, Swell- ing, Stricture. Base of Bladder — Tenderness, Induration. Urethra — Tenderness, Induration, Discharge. Vulvo-vaginal Glands — Tenderness, Induration, Discharge, Red Spot. Size of opening. Resistance to backward pressure, Pelvic Floor \ Protrusion of vaginal walls, Scars and distortions. Thickness of perineum. Rectum — Tenderness, Induration, Hemorrhoids, Fistula, Fissure. Position, Size and shape. Consistency, Tenderness, Mobility, Direction of canal. Laceration and eversion of lips. Size and shape of external os. Pericervical Tissues— Tenderness, Induration. Cervix Uteri DIGITAL VAGINAL EXAMINATION • 73 VAGINAL WALLS Roughness, Tenderness, Induration, Swelling, Stricture 111 acute vaginitis and in some cases of chronic vaginitis the surfaces Avithin the vagina have a rough, granular feel and are tender on pressure. An astringent douche — for example, a bichloride douche, or one containing zinc sulphate or tannic acid or alum — will cause a similar roughness. But if the vagina is both rough and tender, it is almost certainly inflamed, providing the tenderness is not due to some perivaginal trouble. Of course, the diag- nosis of vaginitis does not depend on this alone, but is aided by facts deter- mined in the speculum examination, and also by the history of the case. "When discharge is felt in the vagina, the assumption is that it comes from the uterus unless there are indications of inflammation in the vagina. If the vagina is roughened and tender, the discharge probably originates there. Whether or not it really does originate there, is determined in the speculum examination. Induration, or a hard place felt at some part of the vaginal wall, may b? due to infiltration of the wall itself (inflammation, scar-tissue, small cyst, ma- lignant disease) or to some trouble back of the wall. A swelling or mass in the vaginal wall or bulging into the vagina frciii any direction may be due to any one of a number of conditions which are men- tioned in detail in Chapter ii. A stricture (narrowing) or atresia (occlusion) of the vaginal canal may be a congenital malformation or may be an acquired condition resulting from injuries, in labor or othei'Avise, or from severe or protracted inflammation, as in the adhesive or obliterative vaginitis seen frequently in aged patients. The narrowing of the canal may be due also to pressure of a tumor or an in- flammatory mass around the vagina. BASE OF BLADDER Tenderness, Induration The base of the bladder lies directly beneath the central part of the an- terior vaginal wall and is readily palpated. In cystitis or other painful affec- tion involving the base of the bladder, tenderness is found. When induration or abnormal hardening or thickening is found, ascertain whether it is a dis- tinct mass Avith definite outlines (foreign body or tumor of the bladder), or a diffuse infiltration (infiammatory, tubercular, malignant) of the bladder Avail or of the vesico-A^aginal septum. 74 GYNECOLOGIC EXAMINATION METHODS URETHRA Tenderness, Induration, Discharge The urethra, as it extends from the bladder forward under the pubic arch, is easily palpated through the anterior vaginal wall, immediately beneath which it lies. In inflammation of the urethra there is usually considerable tenderness, and, in many cases, decided induration or thickening. A thicken- ing due to a new growth may be easily outlined in this way. Palpate the --r i- ■ .'-"'' » . '. ■^•-^ ^ ~---.^„,^- \ ■ ^'■- * i ' : \ r - #** ^'^ y ^ \ / s / \ ^•. > / \ / \ / \^ / * / « / » / \ \ V ^ \ * . Fig. 51. The bony ai'ch, which bounds the vaginal oiiening aliove. uretJira from within out-ward — i. e., from the bladder toward the meatus. The palpation is more accurately and conveniently accomplished in that way. and at the same time any discharge in the urethra is carried to the meatus, where it is seen and a specimen secured for microscopic examination. Remember that inflammation may persist indefinitely in Skene's glands, just within the meatus. To secure secretion from the glands for examination DIGITAL VAGINAL EXAMINATION 75 ill such eases, introduce the index-finger within the vagina and compress the urethra just back of the meatus, and then move the finger forward. In parous women the opening of each gland may often be found by rolling out the urethral mucosa slightly and examining closely for the opening (Fig. 44). VULYO-VAGIXAL GLAND Tenderness, Induration, Discharge, Eed Spot The vulvo-vaginal gland (gland of Bartholin) of each side lies just lateral to the remnants of the hymen, and opens by a short duct in front of and a little beloAv the middle of the lateral margin of the hymenal attachment. A convenient way to palpate the glands is to catch the tissues lateral to the gland opening (the opening may be easily seen in the situation just described) between a finger in the vagina and the thumb outside (Fig. 47). When normal the gland is scarcely noticeable by ordinary palpation. When inflamed, however, there is thickening, and the gland is felt as a small firm nodule. There is tenderness also, and, if the gland is pressed upon, some discharge (pus) may appear from duct. ]\Iake a smear preparation of this for staining for gonococci. In a case of al^scess or cyst the nodule will be much larger. A well- marked red spot or small red area involving the opening of the gland duct indicates previous inflammation of the duct, and is presumptive evidence of a previous gonorrhoeal infection (as other forms of inflammation seldom involve the gland or duct), and should always lead to further investigation, to estab- lish the presence or absence of this disease. PELVIC FLOOR Size of Vaginal Opening, Resistance to Backward Pressure on Pelvic Floor, Protrusion of Vaginal V/alls, Scars or Distortions, Thickness of Perineal Body- Is there loss of support at the pelvic outlet! Is there so much relaxation, due to imperfect healing of an open tear or of a subcutaneous tear, or due to subinvolution of the pelvic sling, that the pelvic organs are not satisfactorily supported? To determine this, investigate the following points: Size of Vaginal Opening. In the adult virgin the opening in the hymen will usually admit the little finger without much stretching. In a married woman two fingers can usually be introduced for examination without caus- ing pain, provided the care previously mentioned is exercised. If the vaginal opening will readily admit three fingers, it is decidedly en- larged and there is considerable interference with the integrity of the perineal body. The perineal body is not, however, an important factor in the real 76 GYNECOLOGIC EXAMIXATIOX METHODS supporting power of the pelvic floor ; hence a relaxed vaginal opening does not necessarily mean a relaxed pelvic sling, though it usually accompanies the same. Resistance to Downward and Backward Pressure on the Pelvic Floor. Usually in the woman who has borne children there is not the firm support back of the posterior vaginal wall, and extending well up toward the cervix, that is found in nullipara. There is not, however, the marked difference one "svould naturally expect from the enormous stretching that necessarily takes place in childbirth. The provisions of Nature for the restoration of the parts to near their Fig. Testing the left sulcus. former condition ai-e wonderfully effective when not interfered with by tears or over-stretching or su])iin'olution. The resistance in each sulcus may be tested Avith one finger, as shown in Fig. 52, to determine if there has been a tear in the levator ani in that region, with consequent relaxation. A much more satisfactory method of testing the integrity of the pelvic floor is to introduce the two examining fingers and turn tliem so that their palmar surfaces are directed backward. Then press backAvard and dowmvard on the pelvic floor, at the same time separating Hie fingers as widely as pos- sible (Fig. 53). DIGITAL VAGIXAL EXA^nXATIOX 77 The fingei-s in tlie ^'agilla are separated as sh()\\ii in Fio-. 54. This iiia- iieuver AviU give a very good idea of the amount of support furnished ])y the pelvic sling and of the downward displacement of the pelvic organs that is per- mitted when the patient is standing. Another useful method is to introduce the two index fingers, side hy side, into the vagina and then separate them ^videly in a direction dowuAvard and outward (Fig. 55 j. If the fingers can he carried to the bony sides of the arch with but little muscular resistance, the front part of the levator ani muscle and accompanying fascia has been torn, and thei'e is decided loss of support in the pelvic floor. If now the patient be directed to bear down, the loss of support becomes still more evident. Occasionally, even in case of marked injury to the pelvic sling, the support Avill seem yevy good during the fii-st part of the examination because of the muscular tension. Fig. 33. Testing the pelvic floor. The vaginal fingers are separated widely, as explained in Fig. 54, and pressed downward. Fig. 54. Showing the relative position of the fingers when in the vagina, while testing the pelvic floor. The strong fascial layer of the pelvic sling probably constitutes the prin- cipal factor in continuous support, for the muscles cannot contract continuously. Now, the fascia may be so torn and. stretched that it furnishes little or no continuous support, and yet, as long as the muscles stay contracted, there seems to be a fairly good pelvic floor. Any error in this respect may be avoided by watching for it, and securing entire relaxation before the exami- nation is finished. Protrusion of Anterior or Posterior Wall. To further test the loss of sup- port, separate the labia and insti-uct the patient to bear doAvn. The resulting 78 GYNECOLOGIC EXAMINATION :mETHODS bulging of the structures gives some idea of liow poorly the pelvic floor sup- ports the organs, provided the patient really bears, down when she thinks she does. The downward displacement of the vaginal walls and pelvic diaphragm may be still further shown by introducing the two examining fingers and pressing backward and downward, at the same time separating the fingers widely, as mentioned in testing the strength of the pelvic floor. When the patient is in the upright posture, this downward displacement of the vaginal wall is of course more marked, particularly in cases of pro- lapse of uterus and vaginal walls. But it is rarely necessary to examine a patient in the standing posture, for the diagnosis as to the character and extent of her trouble may usually be made without it. I''ig. 55. Testing the pelvic floor by the two index fingers, introduced together and then separated. Scars or Distortions of Vaginal Wall or Perineum. Sometimes there are deep scars running up the vaginal wall at the site of tear, indicating a sevei-e injury of the pelvic sling. These scars may extend out onto the perineum and be seen in the inspection already mentioned. Thickness of Perineal Body. The thickness of the perineum remaining may readily be determined by catching the perineal tissue between the finger in the rectum and thumb in the vagina. A membranous perineum (torn in- ternally, but not much on the skin surface) may be demonstrated by examin- ing Avith a finger in the vagina and the thumb outside over the perineum. DIGITAL VAGINAL EXAMINATION" 79 RECTOI Tenderness, Induration, Hemorrhoids, Fistula, Fissure Above the perineum the anterior rectal wall is closely applied to the pos- terior vaginal Avail. Turn the examining fingers so that the palmar surfaces are directed backvard, and palpate the rectum (Fig. 56 j. If there is any pain- ful affection in that portion of the rectum, there will l)e decided tenderness. If an induration is felt, determine whether it is a distinct mass Avith definite outlines (foreign body, fecal material, tumor in rectum), or a diffuse infiltra- tion (inflammatory, syphilitic, tubercular, malignant). Very frequently firm fecal masses will be felt through the posterior vaginal wall. Sometimes these Fig. 56. Palpation of rectum through posterior vagina] wall. (Ashton — Practice of Gynecology.) Fis Method of everting the anal tissues for inspection. are large enough to cause a l^ulging of a part of the wall, while in exceptional cases they are so large as to interfere decidedly with bimanual examination. In the loAver part of the i-ectum these masses cause no trouble in diagnosis, for in that situation their character is easily recognized. In the upper part of the rectum, however, and in the sigmoid region such a mass may cause con- fusion in diagnosis, for it may reseml^le a prolapsed ovary or an inflammatory mass in the cul-de-sac or about the tube. The distinguishing characteristics of a fecal mass are three: (a) it is not particularly tender, (b) it has usually a putty-like consistency and may be dented, the dent remaining, and (c) it may sometimes be pushed along to a different position in the boAvel. In a doubtful ease the bowels should be 80 GYNECOI.OGIC EXAMINATION METHODS moved thovouohly by a purgative and the rectum cleared with an enema, and the patient again examined. In a patient Avith a lax pelvic floor the anal tissues may be everted by pres- sure from within the vagina by one or two fingers, as indicated in Fig. 57. When the tissues are very lax, the anus may be opened widely and the rectal Fig. 58. Indicating the amount of possible eversion of anal tissues v/hen the pelvic floor is las. (Dudley — Practice of Gynecology.) mucosa exposed (Fig. 58). This turning out and examination of the anal tis- sues is advisable whenever there is pain on defecation, or bleeding or other evi- dence of trouble in this region. In this wa}^ the presence or absence of hemorrhoids or fistula or fissure may be determined. CERVIX UTERI Position, Size, Shape, Consistency, Tenderness, Mobility, Attachments, Direc- tion in Which it Points, Laceration with Eversion of Lips, Size and Shape of External Os The cervix uteri is felt at the upper end of the vagina as a firm, conical body, projecting through the upper portion of the anterior Avail (Figs. 1 and 3). It is distinguished from the surrounding vaginal Avail by its greater hardness. DIGITAL VAGINAL EXA:^riNATION 81 Position of Cervix. The iioi-inal position of the cervix is from three to three and one-half inches from the vaginal orifice. The fingers are carried toward the top of the vagina until the tip of the finger touches the cervix. If the vaginal orifice comes well up to the upper end of the third joint of the finger, the cervix is in normal position (the author assumes a hand of average size, with index finger about three and three-fourths inches long). If the cervix is encountered by the finger before it is introduced that far, the cervix is too low. If not encountered at that point, it is too high. Another method of determining the position of the cervix is to ascertain if it is above or beloAv the level of the ischial spines, for normally the lower margin of the cervix lies about at the interspinal line. The diagnostic significance of abnormal position of the cervix is given in Chapter ii. In cases where, after examination in the dorsal posture, it is still uncertain as to whether or not there is serious descent of the uterus, the patient may be examined in the standing posture. The patient stands, with one foot slightly elevated on the round of a chair or on a small stool, while the examiner, sit- ting on a chair in front of her, makes the vaginal examination. In this pos- ture a decided descent of the uterus, which might disappear Avhen the patient lies down, is at once appreciable. Examination in this position is employed also to detect the ballottement of early pregnancy in doubtful cases. Exami- nation in this posture, however, is rarely required, for in almost all cases the information necessary to a diagnosis may be obtained by the more common methods of gynecologic investigation. Size and Shape. The size and shape of the cervix varies much in dif- ferent individuals, and in the same individual at diiferent periods of life. In Avomen who have never been pregnant the normal cervix has the shape of a rounded cone about one inch wide, and projects into the vagina from one-half to three-quarters of an inch. The external os is small and round, and is at the flattened apex of the cone. In certain abnormal cases the cervix is very long (an inch to an inch and a half) and pointed. This condition is known as conical cervix. It is fre- quently accompanied by a very small external os ("pinhole os"), and is one cause of sterility. In women who have borne children the cervix is larger and broader, and comparatively shorter. The os is a transverse slit and is irregular in shape, and may be large enough to admit the finger-tip. There are usually small scars and irregular depressions from lacerations in labor. When the cervix has been severely lacerated, there may be two or three distinct lips. Again, it may, on account of chronic inflammation, become enlarged to two or three times its normal size and may be felt as an irregular ball at the top of the vagina. Consistency. The normal cervix is like hard connective tissue, almo.st as hard as tendon. Its consistency is closely approached by that of the end of 82 GYNECOLOGIC EXAMINATION METHODS the nose when firmly pressed upon. Durmg pregnancy the cervix softens, the softening beginning at the lower end and gradually involving more and more as pregnancy advances. The softening is so marked that the softened portion is sometimes missed entirely, the cervix being apparently simply shortened. This is what gave rise to the former idea that the cervix became gradually shortened as pregnancy advanced. The softened portion feels like thick velvet or a fold of vaginal wall as it slips back and forth beneath the examining finger. It is hard to describe satisfactorily, but when once felt is easily recognized afterward. A partial idea of it may be secured by the fol- lowing experiment. Cover a finger with a piece of heavy velvet with a very thick nap, the nap side out. Then shut the eyes and Avith the other hand, with the fingers usually used in vaginal examination, endeavor to make out exactly the thickness of the nap by passing the fingers over it with varying pressure and in different directions. First make firm pressure so as to appreciate the fingers beneath, then make light pressure so as to estimate the thickness of the nap. These same maneuvers are carried out in appreciating the presence and extent of marked softening of the cervix. This softened velvety condition of the cervix is very characteristic and should ahvays arouse suspicion of pregnancy. Some softening of the cervix is found in certain cases of inflammation of the cervix, and also in cases where its circulation is interfered with, as when the pelvis is filled with a tumor or with a mass of inflammatory exudate, or where there is marked dis- placement of the uterus. Abnormal hardening of a portion of the cervix may be due to scar-tissue, to cystic disease, to a fibroid nodule or to malignant infiltration. Tenderness of Cervix. The cervix is much less sensitive than the vaginal wall, and rarely becomes very sensitive even when diseased. The pain com- plained of when the cervix is pressed upon is usually due to the pulling upon inflamed periuterine structures, by the resulting movement of the uterus. Mobility of Cervix. Normally the cervix is freely and painlessly movable for a short distance in all directions. Its range of mobility may be dimin- ished by scar-tissue or by malignant infiltration in the upper part of the vagina, or by an inflammatory exudate in the pelvis, or by a uterine tumor or by any pelvic tumor that fixes the uterus. Its range of mobility may be increased by laceration or overstretching of the supports, posteriorly or an- teriorly or laterally, a frequent accompaniment of pelvic floor injuries. Attachment of Cervix. Is the cervix attached or fixed to the pelvic wall at some point ? If so, where and by what 1 Direction of Cervix. Does the cervical canal — i. e., the axis of the cer- vix — point across the vagina, about toward the coccyx, as it should (Figs. 1 and 3) ? "When you find the cervix pointing along the vagina toward you, do not jump at the conclusion that there must be a backward displacement of BIMANUAL EXAMINATION" 83 the uterus. It may he tliat otlier rather common condition — anteflexion of the cervix. Laceration of Cervix, Eversion of Lips. The presence or absence of this condition is determined when ascertaining the size and shape of the cervix. For the various conditions thus produced see Chapter ii. Size and Shape of External Os. These items are determined by palpa- tion of the OS when ascertaining the general size and shape of the cervix. The various conditions of the external os are shown in Chapters ii and vi. PERICERVICAL TISSUES Tenderness, Induration The tissues about the cervix, immediately beneath the vaginal Avail, may be palpated, and tenderness or induration noted. If induration is present, note whether it is a distinct well-defined mass or diffuse infiltration and thicken- ing of the tissues. VAGINO-ABDOMINAL EXAMINATION (BIMANUAL) The vagino-abdominal examination is, as its name implies, an examination from the vagina and the abdomen at the same time. The pelvic structures are caught between the fingers in the vagina and the fingers over the abdomen, and carefully examined by indirect touch (Figs. 59, 60). By it the body of the uterus is located and outlined. The region to each side of the uterus is palpated and also the space back of the uterus. It is determined if there is any abnormal mass in the pelvis or if there is any area of marked tenderness. To the beginner in gynecologic work this important bimanual examina- tion is often unsatisfactory. He has heard a great deal about tubal and ovarian disease, and he expects to feel the tube and ovary at once. He exam- ines a patient, or several patients, and can feel neither tube nor ovary if they are normal. Then he is discouraged, and thinks that he has learned nothing from the examination. And probably he has not learned much, for the simple reason that he was feeling for something that he could not feel, and did not know the significance of what he did feel. Close attention to the details of the examination will prevent this unprofitable experience. The information concerning the Bimanual Examination may be divided as folloAvs: Palpation of Uterus — Position, Size, Shape, Consistency, Tenderness, ^Mobility, Attachments. Palpation of Tubo-ovarian Region — Tenderness, Mass or Induration. Palpation of other Regions — Tenderness, Mass or Induration. 84 GYNECOT.OGIC EXAMINATION METHODS General Observations — Impoi'tance of the Educated Touch, Tram One Hand, Use Two Fmgers, Examme Deeply in Pelvis, May Draw Down Uterus, Preferable Position for Examiner, Condi- tions in Different Patients, Get Intestines out of the Way, Dimin- ish Tenderness. PALPATION OF BODY OF UTERUS Position, Size, Shape, Consistency, Tenderness, Mobility, Attachments Locating the Corpus Uteri Steps. The locating of the corpus uteri will be much facilitated by pro- ceeding as follows: Fig. 59. liimanual Examination, showing also the disposition of outside fingers and left thumb. (Kelly — Ofcratk'c Gynecology.) Fig. 60. Showing the other disposition of third and fourth fingers along the gluteal crease. This allows deeper penetration of the examining fingers in certain exceptional cases, particularly in very stout patients. (Kelly — Operative Gynecology.) 1. With two fingers in the vagina, locate the cervix and then push the cervix backward and upA^'ard. 2. Then, with the fingers of the abdominal hand depressing the abdominal wall into the depth of the pelvis back of the uterus, bring the fundus uteri well forward. 3. Then, with the pressure still maintained in the direction indicated, slip the vaginal fingers in front of the cervix (Fig. 61). The body oljhe uterus is thus caught firmly between the fingers below and aliove, and may be clearly felt and outlined. BIMANUAL EXAMINATION 85 Two Common Errors. The following errors are made so often b}' students and i^raetitioners that the author thinks it advisable to call particular atten- tion to them. Error 1. Depression of the Abdominal Wall too Close to the Pubes. If the uterus happens to be far forAvard, this causes no trouble, but if the uterus is very high, as it frequently is from a fcAV hours' urine in the bladder or other normal or abnormal cause, the depression of the wall close to the pubes tends to push the uterus backward (Figs. 62, 63). Consequently it is not felt between the examining fingers, though there is no real displacement, or was none before this examination was begun. To avoid this error, depress the abdominal wall near the promontory of the sacrum, about midway between the pubes and the umbilicus (Fig. 64). In rig. 61. Showing the third step in the palpation of the uterus. (Montgomery — Practical Gynecology.) Fig. 52. Depression of the abdominal wall too close to pubes. Sectional view. (Ashton — Practice of Gynecology.) particularly difficult cases it is Avell to start very high and bring the fingers down upon the sacral promontory, and then allow them to slip over the prom- ontory into the posterior part of the pelvis. They are then brought forward until the body of the uterus is felt or until the vaginal and abdominal fingers are so closely approximated that the absence of the uterus from that part of the pelvis is demonstrated. Error 2. Prequent Shifting of the Position of the Abdominal Fingers. Some students gouge about in the loAver abdomen in various directions in an effort to feel the fundus uteri with the abdominal fingers. This is likely to 86 GYNECOLOGIC EXAMINATION METHODS make the examination a failure in a normal case and it is almost certain to do so in a difficult ease. Remember that tension of the abdominal wall interferes with the examination and may defeat it entirely. Remember also that the ten- sion is increased by frequent movements of the abdominal fingers, such as placing them in one position after another in rapid succession, and particu- larly by endeavoring to gouge in rapidly and forcibly in various parts of the pelvis in an endeavor to overcome the resistance of the wall. Keep in mind that most of the effective palpation is done with the vaginal fingers, the principal function of the abdominal fingers being to bring the body of the uterus within reach of the vaginal fingers and then hold it there while palpa- > Fig. 63. Depression of abdominal wall too close to the pubes. Outside view. Fig. 64. Depression of abdominal wall at the proper height. tion is being carried out. Get clearly in mind. just exactly Avhat movements are necessary to best palpate the uterus. In order to avoid this error just mentioned, place the abdominal fingers so that the depression of the wall will be into the back part of the pelvis, and then carry the fingers by steady and continuous pressure toward the desired region. When you have advanced the fingers as far as possible, hold them there steadily and direct the patient to take a deep breath and then to let the breath all out. As expiration takes place, the fingers may be carried deeper into the pelvis — not by any sudden forcing movement, but by strong steady BIMANUAL EXAMINATION 87 pressure that does not excite muscular contraction' and resistance. If still the fingers are not deep enough in the pelvis, the same movements may be re- peated several times. Because the uterus is not felt at once, do not cease the pressure there and begin to depress the wall at some other place. Start the Fig. 65. Explaining one condition in which the Fig. 66. Search is then made in the posterior uterus is not found in the front part of the pelvis. part of the pelvis, and the uterus is found in retro- (Ashton — Practice of Gynecology.) version. (Ashton — Practice of Gynecology.) Fig. 67. Indicating the examination findings when the uterus is in retroflexion. Notice the marked angle which is palpable posteriorly at the junction of the cervix and corpus uteri. (Ashton — Practice of Gynecology.) 88 GYXECOLOGIC EXA^IIXATIOX ^lETHODS fingers in the right direction at first and then l^eep them going in that direc- tion steadily, firmly, persistently, Avithout relaxing the pressure, until the depth of the pelvis is reached and the uterus felt. In the subsequent steps of the palpation of the uterus the slight move- ment of the abdominal fingers that is necessary to bring them in position for good counter-pressure at the various parts of the uterus may usually be made without relaxing the pressure, as the skin is loose enough to be slipped about over the underlying structures. If the body of the uterus is not found in front of the cervix (Fig. 65 ), then search behind the cervix (Figs. 66, 67) and then to each side of it. If the patient has no mass obstructing the pelvis and no extreme tension of the abdominal vail, the body of the uterus should be distinctly made out. Facts to Determine AYhen the body of the uterus has been located, then fix in mind the follow- ing facts concerning it: 1. Position of the Corpus Uteri. Is it in anterior position, as it should be, or is it displaced backward or down to one side ? 2. Size of Corpus Uteri. Is it apparently normal in size (about three inches long) or is it as large as the fist, or as large as a child's head? Figs. 68 and 69 indicate the method of palpating the margin of the uterus and also the method of determining its A\-idth by separation of the vaginal fingers. 3. Shape of the Corpus Uteri. Is it approximately pear-shaped and of regular contour, or is it distorted by fibroids or other tumors? 4. Consistency of Corpus Uteri. Is it apparently a firm, solid body or does it contain fluid, or are there hard nodules in it, or is there marked softening ? 5. Tenderness of Corpus Uteri. Does pressure on the uterus cause pain or does the attempt to move it cause pain? 6. Mobility of Corpus Uteri. Can the uterus be moved freely up and down, to right and left, forward and backward, or is it fixed more or less firmly by an inflammatory exudate or by a tumor ? 7. Attachment of Corpus Uteri. Does the uterus seem to be attached or fixed to the pelvic wall at some point ? If so, where and by what ? In determining the various facts about the uterus, material assistance is given in some cases by separating the fingers laterally, as indicated in Fig. 69, or by separating them antero-posteriorly, placing one finger behind and the other in front of the cervix. AYhen it is impossible to reacli the various parts of the uterus sufficiently to obtain the necessary information, the cervix may l)e caught Avith a tenacu- lum forceps and the uterus pulled somewhat downward (Fig. 70). Care should be taken, however, not to pull the uterus down vei-y far, because of the danger of overstretching the utcro-sacral ligaiuents. BIMANUAL EXAMINATION 89 PALPATION OF LATP:RAL EEGIOXS OF PELVIS Tubes and Ovaries, Mass, Induration, Tenderness In this region, on each side, lies the lai-ge area of connective tissue, beside the cervix and lower part of the corpus uteri. Here induration from inflam- mation or other cause is felt at once, Ioav about the cervix, just under the vaginal wall. Higher, beside the uterus, lie the Fallopian tube and the ovary. They are near the upper part of the broad ligament and so close together that ordinarily it is impossible to say, simply from the position of a mass there, Avhether it springs from the tube or from the ovary. Hence the region is spoken of as the "tubo-ovarian" i-egion, as both organs lie there. The tubo- ovarian region lies high, and to palpate it satisfactorily requires special care. Steps in Palpation of the Lateral Regions In palpating the tubo-ovarian region of the left side, proceed as folloAvs: 1. Place the tips of the vaginal fingers to the left side of the cervix, and then push them backwai-d and outAvard and upward as far as possible. Fig. 68. Palpating the margin of the uterus, to rleterniine enlargement or irregularity. (Edgar — Practice of Obstetrics.) Fig. 69. Estimating the width of the uterus by separating the vaginal fingers so that one goes to each side of the uterus. (Edgar — Practice of Obstetrics.) In order to carry the finger-tips sufficiently far into the posterior lateral area of the pelvis, it is necessary to push the perineum for some distance into the pelvis. This is best accomplished usually by utilizing the force of the body muscles, transmitted to the elboAV either through the knee (Figs. 71, 72), with the foot on a small stool, or through the iliac crest (Fig. 73). This 90 GYNECOLOGIC EXAMINATION METHODS leaves the arm muscles free for the deep delicate manipulation necessary to accurate palpation of the pelvic contents. 2. With the abdominal fingers locate the anterior superior spine of the ilium on the left side and then bring the fingers directly inward (not down- ward toward the pubes, but directly inward or slightly upward) toward the median line for about two inches (Fig. 74) , 3. Then, at that point, depress the abdominal wall into the posterior part of the side of the pelvis (Figs. 75, 76) until the tips of the abdominal fingers come close to the tips of the vaginal fingers. This brings the fingers near to each other back of, or at least in the region of, the tube and ovary (Fig. 77). 4. If the adnexa are not felt in the back part of the pelvis, then bring Fig. 70. Drawing the uterus down with a tenaculum forceps to brihg it within reach of the examining fingers. (Dudley — Practice of Gynecology.) the fingers of the two hands, held in the same relation to each other, slowly downward toward the pubes (Fig. 78). In this Avay the tube and the ovary are made to pass between the examining finger-tips and may be felt if de- cidedly enlarged. The fingers are then carried on downward and tOAvard the median line in order to palpate the front part of the pelvis. By proceeding gently, so as not to excite contraction of the abdominal muscles, and at the same time steadily pressing the two sets of fingers toward each other, a little with each expiration, the finger-tips may be brought almost together in the various parts of the pelvis. In these manipulations the palpation proper is made principally with BIMANUAL EXAMINATION 91 the vaginal fingers, the abdominal fingers serving simpl}- to push the struc- tures down within reach of the fingers below. A common error is to bring the tips of the examining fingers together too close to the pubes ; hence the palpation is of the tissue in front of the tube and ovary, even if they are in normal position. It must be kept in mind also that the tube and ovary are likely to be displaced, especially if diseased, and the displacement is nearly always backward; hence the importance of getting far back in the side of the pelvis when endeavoring to accurately palpate these structures. In order to avoid this error, be certain that the point of depression of the abdominal wall is Avell above the tubo-ovarian region, so that when depressed into the pelvis it will lie back of the tube and ovary. In palpating the right side of the pelvis follow the same directions, sub- stituting ''right" for ''left" (Fig. 79). Facts to Determine In the exploration in the tubo-ovarian region take particular care to search for: Tube and Ovary — Usually not felt if normal ; Abnormal Mass — Enlarged Tube or Ovary, Exudate, Tumor; Induration — Inflammatory Infiltration or Exudate, Adhesions, Scar- tissue : Tender Area — Normal Sensitiveness of Ovaries, Inflammation, Hyper- esthesia, Tenderness from other cause. Tube and Ovary. In many cases the normal tube and ovary can not be dis- tinctly felt, even by the experienced examiner, and the inexperienced Avill find it difficult even in comparatively easy cases. When the tube or ovary is de- cidedly enlarged, it can be felt to slip between the examining fingers as a distinct thickening or as a small rounded mass. After locating the adnexa, as above described, it is sometimes advantageous to try to trace the tube out from the uterus. The fundus uteri is located, the examining fingers (vaginal and abdominal making united counter-pressure) pass to the upper outer angle, and then feel for the tube as it leaves the uterus and runs along the top of the broad ligament. The best place to locate it usually, when not abnormally indurated, is just beyond the angle of the uterus. It is a much firmer cord here than farther out, where the cavity be comes large and the tube soft. The normal Fallopian tube may be felt in a suitable case (thin patient with relaxed abdominal Avail and relaxed pelvic floor), in the position indicated, as a small soft cord about the size of a slate pencil. It presents very much the consistency of a piece of rubber tubing. It may, in a suitable ease, be traced outward and is then lost in a region of the ampulla, where the tube becomes very soft and the ovary comes into prominence as a soft rounded movable 92 GYNECOLOGIC EXAMINATION METHODS body, a trifle larger than the end of the thnnib and sensitive to pressure. When the tube is inflamed it becomes harder and larger, and is more easily felt. It then feels very much like a rather firm piece of rubber tubing of about the size of a lead-pencil or larger, extending outward from the angle of the uterus, Avith irregular curves and bendings and enlargements. From this size it may enlarge to a mass that fills all that side of the pelvis. Usually, however, when the inflammation is at all severe, adhesions or plastic exudate surround the tube and ovary, binding them and the surrounding structures together in one mass and making their separate differentiation impossible. Fig. 71. Invagination of the perineum and pelvic floor, the force being transmitted through the knee. If on examination the pelvic tissues are all soft and yielding, and no par- ticular pain is caused by the palpation, you may be certain that the tubes and ovaries are not seriously diseased, though you may not have felt them. Mass in Lateral Part of Pelvis. The ])elvie tissues, with the exception of the uterus, are soft and yielding, and any fii-m body may be felt through them, either a tumor or an inflammatory exudate or a firm blood-clot. Fluid blood or serous exudate can not be felt unless it is incapsulated. If a mass is found to either side of the uterus, determine concerning this mass the same facts that you did concerning the uterus — namely, its position, size, shape, BIiMANlTATi EXAMINATION 93 consistency, tenderness, in()l)ility and attachments. Detei-iiiiiie particularly Avhether or not it is attached to the utei'us, and, if so, whether by a bi'oad attachment or by a narrow one. Induration in the Lateral Part of Pelvis, In some cases Avhere there is no distinct mass felt, there is a very definite hardening of tissues at some point. Instead of the tissues being soft and pliable, and easily pushed before the ex- amining finger, as they are normally, there is a stillness and fixation and resistance, as though there were infiltration and thickening, and the struc- Fig. 72. Use of this maneuver for invaginating the pelvic floor in the deep bimanual palpation. tures beyond can not be satisfactorily palpated. This resistance and fixation of tissue without a well-defined mass is designated b}- the term "induration." It may be due to infiltration (inflammatory, tubercular, malignant) of the tissues, to inflammatory exudate or surfaces, to adhesions, to scar-tissue or to a tumor not yet developed far enough to form a distinct mass. Tender Area in Lateral Part of Pelvis. The ovaries are usually rather sensitive on bimanual palpation, and allowance must be made for this normal sensitiveness when estimating the diagnostic significance of tenderness in this region. 94 GYNECOLOGIC EXAMINATION METHODS Fig. IZ. Transmitting the force to the elbow through the iliac crest in deep bimanual palpation. Fig. 74. Palpation of the left lateral region. Fig. 75. Palpation of the left lateral region. Placing the fingers of the abdominal hand. They Depressing the abdominal wall deeply into the should be on a level with, or a little above, the pelvis, anterior superior spine (indicated by the cross). BIMANUAL EXAMINATION 95 Tenderness on palpation may accompany almost any pathologic condi- tion in the pelvis, but it is especially marked in inflammatory trouble, in peritoneal irritation from blood in the peritoneal cavity and in neuralgic af- fections of the pelvis. Fig. 1(>. A view from another direction, showing the marked depression of the abdominal wall in deep pelvic palpation. PALPATION OF OTHER REGIONS In the same way, as already described, careful exploration is made of: Posterior Part of Pelvic Cavity — Tenderness, Induration, Mass; Anterior Part of Pelvic Cavity — Tenderness, Induration, Mass; Ureteral Regions — Tenderness, Induration, Mass; Pelvic Nerve Trunks — Tenderness ; Lower Abdomen — Tenderness, Tension, Induration, Mass. If a mass is found, determine as accurately as possible its position, size, shape, consistency, tenderness, mobility and attachments. The method of determining whether a mass is attached to the uterus, and. if so, how intimately, is shown in Figs. 80 and 81, Avhere the sulcus between the uterus and the mass is being palpated to determine its depth. In the case of a tumor with a long pedicle it is well to have an assistant hold the tumor up in the abdomen out of the way, while the examiner, by bimanual palpation. 96 GYNECOT.OGIC EXA^riNATION ^[ETHODS feels Avhether or ]iot there is any comieetion Avith the uterus or appendages. Also, the uterus may be caught Avith a tenaculum forceps and pulled down- ward (Fig. 102), assisting still further in palpation. Another point is that in the case of a broad attachment to the uterus the mass and uterus move as one body, whereas with a long attachment the two may be moved separately. In palpating the interior part of the pelvis, if the body of the uterus is not felt in front and still the vaginal and abdominal fingers can not be brought Avell together, have the patient pass the urine, and then examine again. If the patient can not urinate, or does not seem to empty the blad- der well, she may be catheterized. A spontaneous urination in the upright posture empties the bladder better, and is safer than catheterization, which may be folloAved by cystitis. A partly filled bladder is not felt as a distinct Fig. n. The ovary caught between the examining fingers. (Ashton — Practice of Gynecology.) mass, and yet there may be half a pint or more of urine — enough to make the palpation very unsatisfactory. The peculiar thing about this condition is that there is nothing to indicate it, except the difficulty in locating the body of the uterus in deep palpation. No mass is felt and the tissues are all soft and yielding and there is no particular pain. The fingers seem to sink into the pelvic tissues well, but for some unaccountable reason the uterus is dif- ficult to feel. It seems too far back in the pelvis and yet Avhen you try to bring the fingers together in front of it, they do not come together aa'cU. When such a condition is encountered in an apparently normal abdomen (no marked obesity or musculai' tension) it is probably due to a collection of urine in the bladder or to intestinal coils in the pelvis. If it does not disappear after the bimanuaIj examination 97 bladder is evacuated, then elevate the patient's hips, to get the tympanitic intestinal coils out of the pelvis. The bladder and other tissues in front of the uterus should be palpated (Fig. 62) to determine if there is any mass or any marked tenderness. The region of the ureter on either side is an interesting area which is usually overlooked in pelvic palpation. The ureter extends on each side from the base of the bladder backward, outward and upward, about half an inch from the cervix uteri. Ordinarily it is not felt. In a suitable case, however, it may be felt as a rather indefinite cord or line of tension, extending from Fig. 78. The abdominal fingers moving downward. the base of the bladder in the direction indicated. Fig. 82 indicates the method of palpating this region. If inflamed, the ureter is tender on pressure. If infiltrated and thickened, it is easily felt. If a stone is lodged in the lower poi'tion of the ureter, it may be felt. In this Avay the author Avas able to de- termine definitely that a stone Avas lodged in the left ureter, a short distance from the bladder, in the case of a pregnant A\oman Avith such sudden severe pain and threatening symptoms that it Avas at first feared that the trouble Avas rupture of an extrauterine pregnancy. The patient eventually recovered and carried the child to term. If much inflammation has taken place about a stone or an infected por- tion'' of the ureter, there may be considerable periui-eteral infiltration that in 98 GYXECOLOGIC EXAMIXATIOX METHODS a measure obscures the ureter, and gives the signs simply of a cellulitis at that side of the uterus and extending toward the bladder. A cellulitis associated with persistent bladder symptoms should be carefully investigated, with the idea that it may come from the ureter. Determine if the induration runs into the region of the ureter and if there is tenderness farther up along the ureter or in the kidney, or if the urine gives evidence of disease in the urinary tract. In a considerable proportion of the cases presenting persistent bladder irri- tability and classed as chronic cystitis, the trouble is really located in the ureter. Inflammation or tuberculosis of the lower part of the ureter gives symptoms very closely resembling chronic cystitis. Fk 79. Palpating right tubo-ovarian region. In cases where pelvic neuralgia or neuritis is suspected, palpate the pelvic nerve trunks (Figs. 83 and 84). Sometimes the pelvic tenderness, Avhich at first seems widespread, may l)e localized in its greatest intensity along the nerve trunks of one or both sides. These may be reached by deep palpation per vaginam or per rectum. • GENERAL OBSERVATIONS ON BIMANUAL EXAMINATION It may seem hardly worth Avhile to take the trouble to make out all these little points in regard to the uterus or a mass beside the uterus, but it is worth while, and the farther one advances in diagnosis the more he appreciates this BIMANUAL EXAMINATION 99 fact. The ability to make a correct diagnosis in deep seated pelvic disease depends largely on the ability to answer the above questions correctly, and until one can determine facts as above indicated, in regard to the uterus or other pelvic mass, one's diagnosis is simply a guess and not a diagnosis at all. Importance of the Educated Touch The author desires to emphasize the importance of training the hands — of acquiring the "tactus eruditus." The following quotation from an article by the author on the subject brings out this point: ''The multiplication of in- struments for diagnostic purposes has, to some extent, obscured the importance of the educated touch. The beginner in gynecologic work is bewildered by Fig. 80. Method of determining how intimately a mass is attached to the uterus, sulcus between the two. (Kelly — Operative Gynecology.) Palpating the the great variety of specula, tenacula and other instruments for diagnosis, and he is accordingi}^ impressed with the idea that the principal thing is to learn how to use instruments, and then to use them on every occasion. One of the first duties of a teacher in gynecology is to displace this erroneous idea by showing the importance of the use of the hands. Most of the serious dis- eases of women affect structures that lie beyond the reach of sight. To the teacher falls the duty of directing the student's efforts in such a way that he will acquire the ability to distinguish these intrapelvic conditions in the only way that such conditions can be distinguished, namely, by touch. After the student has, by lectures, supplemented by charts and demonstrations, been 100 GYNECOLOGIC EXAMINATION METHODS helped to form a mental picture of tlie normal organs — their position, size, shape, structure and relations — then comes the task of helping him to recog- nize such conditions by the sense of touch. This is not a matter of a few days. It takes Aveeks and months of patient work and many careful examinations, to be able to recognize normal conditions. The abdominal wall and the vaginal Avail intervene between the examining fingers and the important organs. These intervening structures vary so much in thickness, in consistency, in tension and in sensitiveness, that there is infinite A-ariety in the facility Avith Avhich the organs may be outlined. Again, the organs themseh-es vary much Avithin nor- mal limits, in different individuals and in the same indiAndual at different times. "The beginner must learn to read the conditions first by learning the Fig. 81. Determining what attaclinient there is between the uterus and a cyst back of it. The uterus is caught between the hands and brought forward and the examining fingers are crowded in between the uterus and the mass. (Ashton — Practice of Gynecology.) separate letters, so to speak, and then learning Avhat certain groupings of let- ters mean. The separate items that must be recognized in this examination are the position, size, shape, consistency, tenderness, mobility and attachments of the organs. This takes much time and patience and Avell directed efforts through many examinations. It can not be learned from lectures. It can not be learned by seeing someone make examinations and applications. It can be learned only through repeated bimanual examinations by the student him- self, under competent instruction. Hence the importance of the clinical por- tion of a gynecologic course. "Though it takes considerable time to learn to recognize normal condi- tions, the time is Avell spent, for no real progress is possible Avithout this BIMANUAL EXAMINATION 101 knowledge. The normal must be known before the abnonnal can be appre- ciated. This is self-evident and yet how many students at graduation, and physicians long after graduation, find it difficult to feel more than the vaginal walls and cervix. ''In the recognition of pathologic conditions, the same points must be considered (position, size, shape, consistency, tenderness, mobility and attach- ments), and this information, supplemented by the history, determines the diagnosis. This determination of the particular pathologic conditions pres- ent is accomplished almost altogether by the hands, either in the ordinary bimanual examination oi- in the examination under anesthesia. Fig. 82. Palpating the region of the right ureter. (Ashton — Practice of Gynecology.) *'I do not wish to minimize the value of diagnostic instruments (specula, sounds, curets, etc). They are often helpful and in some cases indispensable to a positive diagnosis, and their use should not be neglected. But I want to emphasize the fact that in gynecologic examinations generally, instruments are of secondary importance and only supplemental to the trained hand." Take every opportunity to educate the fingers to appreciate as accurately as possible the various conditions found in the pelvis. When examining a suitable case, outline the uterus and all the pelvic structures as clearly as you can, even if not necessary to the diagnosis in that particular case. Each care- ful examination made serves to educate the fingers, or rather serves to educate the mind to appreciate what is between the fingers, and prepares you to make out the exact conditions in difficult cases. 102 GYNECOLOGIC EXAMINATION METHODS Train One Hand In the bimanual examination, it is well to train one hand for the vaginal manipulations. For this purpose, either the right or the left hand may be selected, as the examiner finds more convenient. The author uses the left, Deep epigastric . ' ' femoral riiiK Obtur art ' Obtur foramen art- art. .orrh. arteries tirethr Fig. S3. Showing the exact situation of the large nerve roots in the pelvis. In the illustra- tion the large nerve roots appear a shade darker in color than the other structures. (Kelly — Operative Gynecology.) Fig. 84. Palpating the pelvic nerve trunks per rectum. (Dudley — Practice of Gynecology.) BIMANUAL EXAMINATION 103 leaving the right free for the abdominal palpation and for the handling of instrnments. The advantage of nsing the same hand in vaginal manipnlations in practically all cases, is that the power of discrimination by the fingers of that hand increases as more and more examinations are made. At the same time, the abdominal hand becomes accustomed to the abdominal manipulations and as the examining hands are in practically the same relation in every case, deviations from the normal are more readily recognized and more accurately defined than if the two hands were used indiscriminately and hence in different i-elations. This is especially true when the examiner has the advantage of only a limited number of examinations. In exceptional cases, it is an advantage to use first one hand and then the other for vaginal palpation. In some cases, the right side of the pelvis can be explored better with the fingers of the right hand and the left side with the fingers of the left hand. / ; , . / Use Two Fingers / j^X<^^ ^^^^<^^r Use two fingers in the vagina when the vaginal opening is large enough to permit their use without pain. A deeper and more accurate examination can be made with two fingers (index and middle finger) than with the index finger alone. The upper part of the vagina is capacious. The only difficulty is at the vaginal entrance. By lubricating the fingers well, and depressing the peri- neum and working carefully, the two fingers may be used without discomfort in practically all parous women, and in most non-parous women who have been married. Examine Deeply in Pelvis In many cases, in order to palpate the posterior part of the pelvis and par- ticularly to satisfactorily palpate the tubo-ovarian regions, the vaginal fingers must reach farther than their length will permit. The extra reach is secured by carrying- the perineum into the pelvis (invagination of the pelvic floor) by strong steady pressure inward. The soft structures closing the pelvic outlet can be carried for a considerable distance inward without particular discom- fort to the patient, provided all the muscles are relaxed. In parous women, from one to two inches may usually be thus added to the effective length of the examining fingers. The force required, while not great, is likely, if exerted by the arm muscles alone, to interfere Avith delicate palpation by the examining fingers. It adds much to the effectiveness of the examination to exert this pressure by the body muscles, leaving the arm muscles free for the internal palpation movements. This may be accomplished either by placing the left foot (when examining with the left hand) on a stool or chair-round and resting the elboAV on the knee (Figs. 71, 72), or by letting the elbow rest against the hip (Fig. 73). 104 GYNECOLOGIC EXAMINATION METHODS May Draw the Uterus Down It is advantageous in the bimanual examination in some cases, to cateli the cervix Avith the tenaculum forceps and draAv the uterus down-ward, so that the examining fingers may reach higher on its posterior surface (Fig. 70). This is useful in those cases where the uterus lies so far back in the pel- vis that it is difficult to reach. After making the vagino-abdominal exam- ination in the usual way, the tenaculum may then be introduced by touch and the cervix caught and brought down. Only light traction should be made — not enough to unduly stretch the sacro-uterine ligaments, which might lead to subsequent trouble. The au- thor desires to protest against the statement made by some authorities to the effect that the normal uterus may with impunity be pulled down until the cervix appears at the vaginal opening, or may without harm be turned into extreme retroversion, for the purpose of palpating the posterior surface or even hooking a finger in the rectum over the fundus and palpating the an- terior surface. The uterus is usually movable in all directions, but the movements here mentioned are far beyond the normal range and can be ac- complished only by undue stretching of the structures intended to prevent such displacements. Of course, when the pelvic structures are already over-stretched and lax, as in cases of laceration of the pelvic floor with descent of the uterus or in cases of movable retrodisplacement, these extreme maneuvers may be carried out without further damage, and, in doubtful cases, Avith great advantage in regard to accuracy of diagnosis. In a patient with practically normal uterine supports, however, the pulling down of the uterus or the backAvard displace- ment of the uterus for diagnostic purposes or for therapeutic purposes (as in curetment or repair of cervix), should be of very limited extent. It is easy to over-stretch the uterine supports but it is not so easy to restore tone to these structures so that they will again hold the uterus in just the right way. This is particularly important in regard to the postcervical supports (sacro-uterine ligaments and adjacent tissues) which are stretched every time the cervix is pulled doAvmvard. When these are once over-stretched and rendered lax, it is practically impossible to keep the uterus permanently in proper position except by operation. Preferable Position for Examiner For the vaginal and bimanual examinations, it is decidedly advantageous for the examiner to stand directly in front of the vagi]ial opening, as shoAvn in Fig. 71. This is especially important when very deep pelvic palpation is necessary. This is the usual position Avhen the patient is examined on the table with footrests so that the lii])s may be brought entirely to tlie end of the taljle. BIMANUAL EXAMINATION 105 When a patient is examined in bed, hoAvever, the usual directions are to pass the examining arm under one thigh. This puts the examining arm and liand at a decided disadvantage. The examiner should sit so that the ex- amining arm passes between the thig'hs as shown in Fig. 121. This puts the arm directly in front of the genitals, the same as in the examination on the tal)le. This brings the arm and hand in the most advantageous position for accurate palpation deep in the pelvis, as the reader can easily demonstrate to his own satisfaction by giving a trial to each method in some difficult case requiring deep palpation. Conditions in Different Patients The facility Avith Avhich the bimanual examination can be made varies much in different patients. In some, the fingers on entering the vagina are checked by the strong contraction of the muscles of the pelvic floor. . When such is the ease, turn the palmar surface of the examining fingers backward and make steady pressui'c against the posterior vaginal wall and the contract- ing muscles. This gives you an idea of the strength of the muscles of the pelvic floor and soon, under the pressure, the muscles relax. Another trouble- some obstacle to deep bimanual examination is tension of the abdominal wall. The methods of overcoming this have already been explained. In a thin patient, with a large vagina and a relaxed abdominal wall, the uterus can be outlined and the appendages felt, and any abnormal mass, even a small one, can be satisfactorily palpated. In a stout patient, Avith a thick layer of fat over the abdomen, the ordi- nary bimanual examination is often unsatisfactory, particularly if there is inflammatory trouble Avith tension of the abdominal Avail. In such a case, a mass of considerable size, if situated high in the pelvis, may be missed entirely. The only Avay to determine exactly the pehdc contents in such a case is to make an examination under anesthesia. Such an examination should be made in those cases where the symptoms are urgent enough to make an innnediate accurate diagnosis necessary. Get Intestines Out of the Way In some cases, particularly when there is considerable tympanites, dis- tended coils of intestine interfere with the bimanual palpation of the pelvic structures. To overcome this difficulty, elevate the patient's hips into the Trendelen- burg posture. Then Avork the intestines out of the pelvis and hold them out as the hips are sloAAly loAvered into a more comfortable position. Leave the hips rather high, as high. as the patient Avill stand without discomfort, and direct her to keep all the nuiscles loose and breathe quietly, so as not to force the intestinal coils back into the pelvis. The regular bimanual palpation may then be carried out, undisturbed by the troublesome intestinal coils. 106 GYNECOLOGIC EXAillNATION METHODS This is a very convenient maneuver also for getting a pedicnlated tumor out of the pelvis, that its pedicle and point of origin may be accurately de- termined by bimanual palpation. In case the table is not arranged for the convenient elevation of the hips, the hips may be elevated by means of pillows or the patient may be placed in the knee-chest posture for a few moments. With the clothing well loosened and the correct knee-chest posture assumed, the distended intestinal coils fall out of the pelvis better than in the Trendelenburg posture, but in the exertion of assuming the dorsal posture again they are likel}^ to be partiallj- forced back. Avoid this as much as possible by directing the patient to keep the upper part of the body on the table (not to raise it, as in partly sitting up) and to keep the abdominal muscles loose. Also place a thick pillow under the hips, as the dorsal posture is assumed. An additional expedient is to put a speculum in the vagina and in the rectum while the patient is in the knee- chest posture. The vagina and rectum then balloon with air, forcing the intestinal coils out of the pelvis. The specula are then removed and the openings close, retaining the air which helps to keep the intestinal coils out of the pelvis in the subsequent movements. Diminish Tenderness In many patients satisfactory pelvic exploration is prevented by tender- ness, particularly in that large class of cases in which pelvic inflammation is a primary or complicating lesion. In some of these cases the sjanptoms are so urgent that an examination under anesthesia at once is advisable. In most of the cases, however, the symptoms are not so threatening as to necessitate immediate examination under anesthesia. The patient has come for a diag- nosis but an accurate diagnosis can not be made because of the tenderness which prevents deep palpation. What shall the examiner do under these cir- cumstances? There are two measures which are useful in diminishing the tenderness and abdominal tension. 1. Administration of a sedative. The patient may be given 14 gr. of codeine phosphate hypodermatically, or % gr. or 14 gr. of morphia, and ex- amined again after half an hour. If thought preferable, an appointment may be made for the next day and an order given for the sedative to be taken by mouth one hour before your visit. In the meantime the patient is kept quiet in bed and the bowels well opened. It is well to have an enema given half an hour before ex- amination. 2. Treatment for the inflammation. The patient is kept in bed, the bowels Avell opened, hot vaginal douches given and the regular treatment for acute or subacute pelvic inflammation carried out. This treatment con- tinued for a few days or a Aveek will do much toward diminishing the ten- derness, so that a thorough pelvic examination may lie made. RECTO-ABDOMINAL PALPATION 107 RECTO-ABDOMINAL PALPATION 111 many cases it is of decided advantage to follow the vagino-abdominal examination by a recto-abdominal examination. In this form of bimanual examination, the index-finger, gloved and lubricated, is introduced into the rectum and passed upward between the sacro-uterine ligaments as far as possible up the posterior surface of the uterus. With the fingers of the other hand pressing down the organs from above, all the structures within reach are palpated with the palmar surface of the rectal finger (Fig. 101). Disadvantages Ordinarily, palpation of the pelvic structures may be carried out much more thoroughly by vagino-abdominal examination than by recto-abdominal examination. Without anesthesia but one finger can be used in the rectum and this finger lies at a considerable distance from the uterus and adnexa, unless carried very high. It can not usually be carried very high on ac- count of the encircling sphincter and pelvic floor, except by the use of such force as to cause pain and resistance. In some cases where the pelvic floor is lax, the examining hand may easily carry the perianal structures some distance into the pelvis, thus allowing the examining finger to pass high up back of the uterus and permitting accurate bimanual palpation of the ad- nexa. The facility with which the organs may be felt is increased by catch- ing the cervix with a tenaculum forceps and bringing the uterus somewhat lower. In all but exceptional eases, however, accurate examination of the pelvic contents by recto-abdominal palpation is practicable only under anes- thesia. However, such palpation as can be carried out without anesthesia gives information of value in some cases, as indicated in the following paragraphs. When Useful It is well to employ digital examination per rectum, or conjoined (bi- manual) recto-abdominal palpation, in the following cases: Mass in Cul-de-sac. Rectal palpation is useful when there is a mass of inflammatory exudate or a tumor Ioav in the peritoneal cul-de-sac back of the uterus. In the case of an inflammatory mass in that situation, fluctuation may be in some cases detected while it is not yet appreciable by vaginal examination. Malignant Infiltration. In malignant disease of the cervix extending out into the parametrium, rectal palpation Avill in some cases give additional information as to the extent of the infiltration and the mobility or fixation of the uterus. Rectal Disease. When a patient gives symptoms pointing to rectal dis- ease, the rectum should of course be examined by palpation and also by in- 108 GYNECOLOGIC EXAMINATION METHODS sijeetion through i-ectal speeuluni if necessary to determine the exact condition. Obscure Cases. In eases where the other methods do not sliow lesions sufficient to account fov the symptoms, a rectal examination should be made to determine if there is any rectal or perirectal disease that might account for the pelvic pain and distress. Occasionally in a Virgin. The information concerning- the uterus and adnexa thus obtained is usually very indefinite, as explained below. In such examination the landmark is the cervix uteri, which may be easily felt through the rectal wall. Notice if there is a distinct mass back of the cervix (inflammatory mass, tumor, fundus uteri in retrodisplacement) or a point of special tenderness anywhere in the lower part of the pelvis. BIMANUAL EXAMINATION OF A VIRGIN As previously explained, local examination in the case of a virgin is to ))e avoided if possible. When it is necessary to make an intrapelvic exam- ination, what method should be used? The direction has been given, in A^arious works, to examine virgins by the rectum when it is necessary to determine the condition of the uterus or ad- nexa, in order to avoid stretching the hymen. In a virgin those conditions which militate against a satisfactory palpation of the uterus and adnexa by recto-abdominal examination, are at their height. Usually after such an ex- amination without anesthesia the examiner knows but little more concerning the uterus and adnexa than he did before the examination. Of course if there is a good sized mass low in the pelvis or a particularly tender area, its pres- ence is determined. But the information is usually too indefinite for an exact diagnosis. Such an examination does very well however, to ''break the ice" so to speak, and it may be explained then that the conditions are such that a vaginal examination is advisable. In some cases the recto-abdominal ex- amination is very satisfactory, the required information being obtained with fair accuracy. Ill the rectal palpation, the cervix uteri can be felt through the i-ectal Avall. If there is no mass back of the cervix (inflammatory mass or tumor or fundus uteri deep in cul-de-sac) and no area of particular tenderness in the pelvis, it may be advisable to postpone further local examination and try general therapeutic measures for several weeks or months. Usually, however, when the symptoms are severe enough to Avarrant any local examination, they are severe enough to Avarrant a recto-abdominal ex- amination under anesthesia, or a stretching of the hymen sufficiently to admit one finger, so that the regular A'aginal and vaginal-abdominal examina- tion may be m^de. The condition of the uterus and the adnexa may be much more definitely determined in this Avay than by rectal i^alpation. In a large proportion of virgins, even the regular vagino-abdominal pal- RECT0-VAG1N0-A15D0MINAL I'ALI'ATION 109 patioii does not permit aeeurate outlining of the uterus or of adnexal masses. Consequently, in the case of a virgin Avhere there is serious pelvic trouble necessitating an accurate palpation of the pelvic contents, an examination under anesthesia is usually required. In cases where the necessity of a thorough pelvic examination is apparent from the first, it is prefei-able, in a girl or a young unmarried Moman, to at once examine the patient under an anesthetic. This eliminates the mental shock of the procedure and at the same time permits a thorough exploration. It is well to employ recto-ab- dominal palpation first and then, if necessary, vagino-abdominal palpation. In addition, any operative measure required for diagnostic or therapeutic purposes may be carried out, for example, dilatation and cui-etment of uterus or removal of hemorrhoids. RECTO-VAGINO-ABDOMINAL PALPATION In exceptional cases Avhen making the recto-abdominal examination, it is advantageous to introduce the thumb into the vagina in order to grasp the Fig. 85. Method of palpating tlie coccyx. The hand shonld be gloved. (Hirst — Diseases of IVometi.) lower part of a mass between the finger in the rectum and the thumb in the upper part of the vaginal canal, the structure being pushed down within reach by the abdominal hand (recto-vagino-abdominal palpation). Where a mass is low enough to be grasped in this Avay, its outline and consistency can be very accurately determined. It is only in the cases of large vaginal open- ing and relaxed floor that this method is applicable, and to be of mucli service anesthesia is usually required. Occasionally, however, it is useful in the ordinary examination. 110 GYNECOLOGIC EXAMINATION METHODS The author recalls in particular one puzzling case, that was referred to him for differential diagnosis, in which this maneuver was of much assist- ance. The patient presented a mass of moderate size, pretty well filling the pelvis. The mass contained fluid, the cervix was somewhat softened and the uterine body could not be definitely located. The differentiation was be- tween an enlarged uterus containing fluid (normal or abnormal pregnancy) and some other fluid mass (cystic fibroid, extrauterine pregnancy, hydrosal- pinx, ovarian or parovarian cyst). The history was uncertain and the find- ings in the ordinary examination were not positive. The crucial point was to identify the body of the uterus. Was this large mass the body of the uterus enlarged (pregnancy) or was the body of the uterus of practically normal size and located somewhere in the mass? Sounding of the uterine canal was not permissible until pregnancy could be excluded. The lower posterior part of the large mass presented a small firm portion, Avhich might be the normal-sized body of the uterus displaced or simply a firm portion of an enlarged uterus. The firm area was so covered over and surrounded by the mass that the author could not make satisfactory bimanual palpation of it, neither could he definitely outline it through a suffi- cient extent by either vaginal or rectal palpation. Finally he tried to grasp this firm portion of the mass between the finger in the rectum and the thumb in the vagina. As the vaginal opening and pelvic floor were lax, he could carry the thumb to the top of the vagina without much discomfort to the patient, and by crowding the mass down with the abdominal hand, was able to grasp the firm portion between the finger and the thumb of the left hand and separate it from the fluid mass sufficiently to trace its outline and get the consistency throughout. It was of about the size, shape and consistency of tlie normal uterus, and by working the finger and thumb toward each other above this firm part, he could demonstrate that the fluid portion of the, mass had a separate wall. He now felt safe in introducing the sound, Avhich confirmed the palpation findings. This firm area was the displaced body of the uterus, otherwise practically normal, and the surrounding fiuid mass Avas a separate affair, an ovarian or parovarian cyst. A modification of this method is to introduce the middle finger into the rectum and the index finger into the vagina and palpate the structures be- tween the fingers, as the uterus is pushed down from above. This particular method of recto-vagino-abdominal palpation has been found useful in deter- mining the extent of involvement of the parametrium in cases of carcinoma of the cervix uteri. PALPATION OF COCCYX In cases of persistent pelvic pain where no sufficient cause is found about the uterus or adnexa, the coccyx should be palpated. This small bone at the tip of the sacrum is not infrequently the site of neuralgia or rheumatism (af- fecting the joints or adjacent muscles) or a chronic inflammation resulting INSTRUMENTAL EXAMINATION 111 from an injury sustained months or years before. These injuries usually can he traced to childbirth tliough occasionally such a condition will result from a fall or bloAv. In rare cases, neuralgia or rheumatism or inflammation may become manifest here without previous injury. Tenderness of the Coccyx or a mass about any portion of it or a deformity, may be easily determined by an examination with the index finger (gloved) in the rectum and the thumb over the coccyx (Fig. 85). The examination is most conveniently made Avith the patient lying on her side. In this Avay the coccyx may be accurately outlined and any deviation from the normal determined. In some cases the coccyx appears to be normal until an attempt is made to move it, when there is severe pain, indicating trouble in the joint or about the fasciae or muscles. INSTRUMENTAL EXAMINATION This term includes those manipulations in which it is necessary to use instruments. Coming under this classification are the following: Inspection of Vagina and Cervix through the Speculum (Speculum Examination) . Excision of Tissue from Cervix for JMicroscopic Examination. Exploration of Interior of Uterus Avith the Sound. Exploration of Interior of Uterus Avith the Curet. SPECULUM EXAMINATION By means of certain instruments the A^aginal Avails may be spread apart so that those Avails and the cerAdx uteri may be seen. Information of much value in some cases may be obtained in this Avay. Instruments for Regular Speculum Examination The instruments needed for this examination are shoAvn in Fig. 86. They are as foUoAvs: A Speculum for separating the A'aginal Avails; A long Dressing Forceps for sponging out the vagina, usually called "Uterine Dressing Forceps;" A Tenaculum Forceps, or "Volsellum," for catching the cervix and bringing it better into a'Icav. A Specimen Scissors. Vaginal Speculum. The bivalve speculum (Fig. 86, a) is the kind most frequently used in ordinary office Avork. It consists of Iavo blades, Avhich are introduced closed and then opened by a mechanism at the handle. The vaginal Avails are thus held apart (Fig. 87) and a very good aqcav of the Avails and cer- vix may be obtained. The bivalve speculum is convenient and gives good ex- posure of the cervix in most cases. There are many different modifications of the blades and also of the 112 GYXECOLOGIC KXAMIXATJOX .METHODS mechanism for separating the bhides. The most satisfactory form that the author has found is shown in the illustration. It is called the Graves specu- lum and has the advantage that it can he easily and quickly transformed into a fairly satisfactory Sims' speculum, -which is a decided convenience in office work. Three sizes are useful — small (virgin), medium and large. The cervix is easier exposed in most cases if the anterior blade of the speculum is some- what shorter than the posterior. Some specula are made A\'ith three blades, instead of two, constituting a ti'ivah'e speculum. They are made on the same general principles as the Fig. 86. Instruments for the regular speculum exsmination. a. Bivalve Speculum, of which it is well to have three sizes — large, medium, and small. b. Dressing Forceps for swabbing out vagina. c. Tenaculum forceps for catching cervix to bring it well into view. d. Specimen Scissors, a small strong hawk-bill scissors for clipping small specimens from the cervix in suspicious cases. bivalve but the mechanism is more complicated and. usually, Avithout corre- sponding benefit. The bivalve speculum is used A\-ith the patient in the dorsal posture (Fig. 39). For sterilization of specula and other instruments, see Preparations for Examination, at the end of this chapter. The Uterine Dressing' Forceps (Fig. '^'o. l)i is a long strong forceps for sponging out the vagina and for making vaginal applications. It may be straight or curved as preferred. The author finds the forceps \\\t\\ a straight shank and a slight curA-e near the end more convenient than the much curved instrument. A vaginal depressor for pushing the A'agiual \\-a\\ out of the way IXSTRU MENTAL KXAMIXATIOX 113 is usually mentioned in an examining set. but it is generally not necessary, as the vaginal wall may be pushed aside sufficiently \vith the dressing forceps. The Uterine Tenaculum Forceps is needed for catching the cervix and liringing all parts of it into view. It should be light but strong, especially about the lock, where it is likely to work loose (Fig. 86, cj. •"♦Jf^S*-^***^ Fig. 87. Bivalve Speculum in place. Sectional view, showing relations of speculum and exposure of the cervix and vaginal vault by opening the blades. The Specimen Scissors are for clipping out a small piece of tissue from the cervix, in cases presenting an appearance suspicious of malignant disease. The one shown in Fig. 86, d, the author has found very convenient and satis- factory. It presents at the end a small sharp "hawk-bill" which cuts through the firmest tissue, clipping out a small piece with but little pain or bleeding. 114 GYNECOLOGIC EXAMIXATIOX ^[ETHODS The aiitlior apprupriated it t'roiii the tliroat specialist's ariiiaiueiitariiim, where it is catalogued as the ]\Iiles tonsil iDitnch. Another convenient instrument for this purpose is the Gaylor specimen scissors shown in Fig. 88. Steps in the Regular Speculum Examination Introducing- the Speculum. The blades of the speculum are closed and the outer surfaces lubricated and the speculum held iu the right hand, while with the other hand the labia are separated and the perineum depressed some- what with one finger (Fig. 89). The speculum is then introduced and carried all the Avav to the upper end of the vagina without being opened. In most cases the speculum passes the vaginal entrance most easily when held with its width almost vertical, the edge being held just far enough to one side to miss the urethra iFig. 90). AVhen well within the vagina, it is ttirned trans- verseh' and carried in as far as it will go iFis". 91). ,-i>' Fig. 88. Gaylor's Scissors for the removal of pieces of cervical tissue for microscopic examination. Care is necessary that painful pressure ])e not made on the urethra oi' other structures beneath the pubic arch. Eemember that when more room is required, the pressure must always be directed against the perineum, Avhich will gradually yield. Atiother common mistake with the inexperienced is to open the blades too soon, before the speculum has been introduced all the way. The blades are not in far enough to satisfactorily expose the cervix and in closing them again for further introduction, pain is likely to be produced by pinching the vaginal wall. Exposing the Cervix. After the blades have been introduced well up to the top of the A'agina, they are opened and the cervix and vaginal walls exposed fFig. 87). By turning the speculum in various directions, all parts of the cer- vix and upper end of the A'agina may be seen. If the cervix does not come Avell INSTRUMENTAL EXAMINATION 115 into view it may be caught with a tenaculum forceps and brought downward somewhat and turned from side to side, exposing all portioiis of it and of the vaginal vault. Fig. 89. Introducing the bivalve speculum. First step — depressing the perineum to give room for the speculum to be introduced. Fig. 90. Introducing speculum. It has been Fig. 91. The speculum carried all the way in and carried part way in. Notice the oblique position, turned into position for opening, which prevents painful pressure on the urethra. 116 GYNECOLOGIC EXAMINATION METHODS Cleansing" the Vagina. If there is secretion obseiiring any part of the vag- inal wall or cervix, wipe it away with cotton held in the dressing forceps and dipped in an antiseptic solution. Exposing Lower Portion of Vaginal Walls. To inspect the middle and lower portions of the vaginal Avails, turn the speculum so as to bring the va- rious portions of the walls opposite the opening between the blades. Another way is to inspect the various portions of the Avails just beyond the end of the speculum, as it is AvithdraAvn. Specula Avith skeleton blades are made, but they are not necessary and ordinarily they are likely to prove unsatisfactory in a good many cases because of the prolapsing of the redundant vaginal Avails through the large openings. Information Obtained in the Speculum Examination The information sought in the speculum examination is obtained by in- spection of the folloAving structures: Vaginal Walls — Color, Discharge, Redundancy; Cervix Uteri — Position, Color, Size and Shape, Lacerations, Deviation of Axis, Eversion, Erosion, Hypertrophy, Cystic Change, Ulcer; External Os — Size and Shape, Color of Edges, Discharge, Polypi. Vaginal Walls. Are the Avails of normal color or is there congestion? If congestion, is it active or passive? If the Avails are bright red, that means actiA^e or arterial congestion and is due to inflammation or irritation. If the Avails haA^e a bluish tinge, that means passiA^e or A^enous congestion and indi- cates either pregnancy or some interference Avith the circulation, as by a pel- A^c tumor or exudate or by failure in compensation in heart disease. If there is discharge, determine Avhether it originates in the A^agina or in the uterus. If the vaginal Avails are lax and redundant, they tend to collapse about the speculum. Cervix Uteri. Is the cervix in Ioav position, so that it iis easily exposed Avhen the speculum is in but a short distance, or is it higher than normal, so that it can not be well exposed with the speculum of ordinary length ? Is the color normal or is there congestion, either active or passiA^e? Here, as in the vaginal Avail, active congestion means inflammation or irritation and passive congestion indicates either pregnancy or obstruction of the circulation. A bright red area extending a considerable distance out from the os, is usually due to the peculiar condition called "erosion." In regard to the size and shape, inspection may shoAv the cerA^ix to be: Normal. Long Conical. Lacerated, but largely united again. Lacerated and not united, but Avithout complications. Lacerated and everted, eroded, hypertrophied, or Avith cystic change or Avith a genuine ulcer. INSTRUMENTAI. EXAMINATION 117 Fig. 92. A, Schultze Tampon; B, Ordinary Tampon. Fig. 93. Suction Bulli and Tube for the aspiration of Cervical Secretion. Fig. 94. A. Sims' Speculum, two blades of different sizes attached to one handle; B. Flange attached to one blade to hold back buttocks; C. Graves' IJivalve Speculum changed to the Sims type. 118 GYNECOLOGIC EXAMINATION METHODS Is the axis of the cervix directed across the vagina, as it should be nor- mally, or ALONG the vagina, as in retrodisplacement of uterus or anteflexion of cervix ? External Os. The size and shape show whether or not, there has been laceration and consequently are of considerable medico-legal importance in certain cases, because furnishing strong evidence for or against a previous childbirth. The color of the edges show whether they are normal or the seat of inflammation or erosion. The discharge may be of any of the varieties previously described. There is normally a clear sticky tenacious mucus in the cervix and about the external OS. The first effect of inflammation and irritation is to make this more abundant and later it becomes mixed with pus. As long as the cervical inflam- mation is a prominent part of the process, the tenacious, stringy quality will be a prominent feature of the discharge. If there is the least suspicion of gonorrhea, make a spread of the discharge for microscopic examination. In exceptional cases it may be advisable to use a tampon to determine the amount of discharge and whether it comes from the uterus or vaginal Avail. A Schultze tampon (Fig. 92, a) or an ordinary tampon (Fig. 92, b) is intro- duced. The patient is directed to report at the office after a specified number of hours, Avhen the- tampon is carefully remoA^ed and examined as to the amount and location of discharge upon it. With the suction bulb and tube (Fig. 93) discharge lying in the uterine canal may be AvithdraAvn for diagnostic or thera- peutic purpose. Occasionally a small polypus Avill be seen presenting at the external os or hanging by a pedicle. Difficulties in the Speculum Examination Poor Lig'ht. If the light is so poor that the cervix and upper portion of the vagina can not be seen, the ordinary head mirror, used in throat work, is of much assistance. At night, in emergency examinations and treatment, the light from a lamp may, Avith the head mirror, be throAvn into the vagina and the landmarks easily seen. Painful Abrasions. If there are painful abrasions or fissures about the vaginal orifice Avhich interfere Avith the examination, the sensitiveness may be diminished by the application of a small piece of absorbent cotton soaked in a 10% cocaine solution. Leave this in place for three to five minutes, then re- move it and proceed Avith the examination. Redundant Vaginal Walls. When the vaginal Avails are very lax and redundant, as sometimes occurs because of subinvolution f olloAving lab&r, they collapse about the speculum in such a Avay as to hide the cervix. This diffi- culty may in some cases be overcome by using a longer speculum. When this does not expose the cervix satisfactorily, put the patient in Sims' posture and use the Sims speculum. INSTRUMENTAL EXAMINATION 119 Examination with Cylindrical Speculum The cylindrical speculum consists simply of a tube with the outer end flaring and the inner end cut obliquely. It may be made of metal or hard rubber or glass. The cylindrical speculum is useful in certain forms of treat- ment, particularly when it is desired to apply to the cervix medicines from which the vaginal walls should be protected, but it is not much used in ex- amination work. When in the examination of a girl it is necessary to inspect the cervix, this may be accomplished without disturbing the hymen by placing the patient in the knee-chest posture and using one of Kelly's cystoscopic tubes. This is simply a small cylindrical speculum and, with the patient in the knee-chest posture, when the tube is introduced the vagina balloons out to some extent with air. Then by means of a light reflected from a head mirror, the cervix and vaginal walls may be inspected and if necessary treated. Such an ex- amination, however, is seldom required, In the virgin, a local examination should not be made except for urgent symptoms, and in cases with urgent symptoms the requirement is usually for a thorough bimanual examination under anesthesia, rather than for a speculum examination. Examination with the Sims Speculum . The Sims speculum is a perineal retractor and for use requires the patient to be put in the Sims posture. Like any other retractor, it must be held in place either by an assistant or by a mechanism (speculum holder), of which there are several varieties. The Sims speculum consists of a blade, somcAvhat resembling a duck's bill, and a handle. As usually made two blades are placed on one handle, a large blade at one end and a small blade at the other. (Fig. 94, a). A further improvement is a flange near the larger blade (Fig. 94, b). This flange holds the fleshy part of the right buttock up out of the way. The Graves bivalve specu- lum, mentioned above, is easily and quickly changed into a satisfactory Sims speculum (Fig. 94, c), so it is not usually necessary to get a special Sims speculum. The Sims Posture. The principal points about the Sims posture, called also "left lateral posture" and the "semiprone posture," are as follows: 1. All constriction must be removed from around the waist. 2. The patient lies on her left side, with left arm and hand behind her and the front of the chest turned toward the table as far as possible Avithout discomfort. When in proper position, the upper part of the body rests on the left breast. 3. The hips rest near the loAver left corner of the table and the body extends diagonally across the table toAvard the right side. 4. The left thigh is draAAii up so that it forms an acute angle Avith the 120 GYNECOLOGIC EXAMINATION METHODS body, and the right thigh is draAvn up still more, and alloAved to drop over the lower one. This puts the patient in the position shoAvn in Figs. 95 and 96. It permits the abdominal wall and the intestines and uterus to fall forward. Use of Sims' Speculum. To introduce the speculum, the right labia are raised thus exposing the vaginal opening and then the speculum point, Avell lubricated, is carefully worked into the opening. At the same time, the Fig. 95. Patient in Sims' posture. Notice how the uiiper knee drops over the under one. perineum is pulled somewhat backward with the speculum i^oint, in order to give more room for the point to slip in (Fig. 97). The blade is then car- ried all the way in. The speculum is then grasped firmly and pulled backward, thus retracting the perineum and exposing the interior of the vagina (Fig. 98). As the speculum is introduced the vagina be- comes distended with air, and when the perineum Fig. 96. View from above, show- ing the arm behind the patient. (Dickinson — American Textbook of Obstetrics.) INSTRUMENTAL EXA>J INATION 121 is retracted the cervix and anterior vaginal wall may be seen. To bring the cervix into still better view, catch it with the tenaculimi forceps and bring it slightly toward the opening (Fig. 99). When Indicated. The Sims speculum Avith the Sims posture is of decided advantage in the following conditions: 1. When the bivalve speculum fails to satisfactorily expose the cervix. This may be due to the vaginal walls being so lax that they fall about the blades and obscui-e the cervix or it may be due to the vaginal opening being so small that tlie l^lades can not be sufficiently separated. Again, in some cases of Fig. 97. Introducing the Sims speculum. Fig. 98. Speculum in place, and showing also tlic method of holding the same and of keeping the upper buttock out of the way. inflammation of the uterus or about the uterus, the bivalve speculum can not be opened sufficiently because the anterior blade causes pain by pressure on the inflamed structures. 2. "When it is desired to expose a lacerated cervix without spreading the lips apart. The bivalve speculum, as it is opened, separates the lips of the lacerated cervix, causing considerable distortion and making it rather hard to judge of the amount of eversion ordinarily present. Again, the weight of the uterus pushes the cervix into the vagina, in some cases making the cervix ap- 122 GYNECOLOGIC EXAMINATION METHODS pear longer than it really is. In this way the bivalve speculum may lead to an erroneous diagnosis of elongation of the cervix. 3. When it is desired to expose the cervix with the least possible stretching of the vaginal opening. The vaginal opening may be so tender that the bivalve speculum can not be satisfactorily opened. Again, in removing cer- vical sutures after simultaneous repair of both cervix and perineum, it is im- portant to avoid stretching the newly healed perineum. In these cases, a nar- Fig. 99. Cervix caught with tenaculum forceps and brought into view. row Sims speculum introduced in the Sims posture, causes the vagina to bal- loon and exposes the cervix and vaginal vault with much less stretching of the vaginal orifice than would be necessary with the bivalve speculum. 4. When it is desired to sound the uterus or to dilate the cervical canal or to make an intrauterine application. 5. When the vagina is to be packed, either for holding the uterus forward or for hemorrhage. 6. In clearing out the uterus with the curet for incomplete miscarriage. INSTEUMENTAL EXAMINATION 123 111 many such cases where the miscarriage has just taken place, if the patient be placed in the Sims posture and all the manipulations made carefully, the uterus may be thoroughly cleared out with but little pain and hence without an anesthetic. 7. When treating a sinus or abscess opening in the posterior vaginal fornix. When making the incision back of the cervix for pelvic abscess, the dorsal posture is the better one, as the cervix may be held out of the way by strong traction, but in the after-care of the case, the Sims posture is usually preferable. It causes the patient less pain and gives much better exposure of the opening back of the cervix. EXCISION OF TISSUE FROM CER\^X FOR MICROSCOPIC EXAMINATION In many cases the naked-eye examination of the cervix is not sufficient to make a positive diagnosis between malignant disease and certain other affections of the cervix. In a suspicious case, particularly one that resists treatment, a small piece of the affected area should be excised for microscopic examination. A very convenient instrument for this purpose is the specimen scissors shown in Fig. 86. With this a small piece of the suspicious tissue may be clipped out of the cervix. If there is much bleeding, a suture may be placed under the bleeding surface and tied. Usually, however, a styptic application, with a firm vaginal packing, Avill stop the bleeding. The specimen excised from the cervix and also all curettings should at once be placed in a small bottle of alcohol (95%) or formol (10%) and forwarded to the pathologist. EXPLORATION OF UTERUS WITH SOUND Through the speculum the interior of the uterus may be explored with the uterine sound. The uterine sound (Fig. 100, a) is pliable so that it may be bent to accommodate it to the uterine canal in different cases. It is graduated so that the exact depth of the canal may be told. It has a bulbous end so that there will be less danger of its puncturing the uterine wall. Introduction of Uterine Sound The sound should not be introduced by touch, as was formerly the custom and as is shown even in some recent textbooks, for when used in that way it is very liable to carry infection into the uterus. Before sounding, the speculum should be introduced, the cervix exposed and caught with a tenaculum forceps and the cervix and vicinity cleansed with a reliable antiseptic solution. Then the sterile sound is introduced into the uterus without touching the vaginal wall. Before introducing the sound, the approximate location of the fundus uteri should be determined by bimanual examination and the sound should be 124 GYNECOLOGIC EXAMINATION METHODS shaped and guided accordingly. The sound can usually be most conveniently introduced with the patient in the Sims posture and the cervix exposed with the Sims speculum. After the sound is sterilized do not touch the intrauterine portion with the fingers. If the end requires bending, dip a piece of absorbent cotton in a reliable antiseptic solution and grasp the uterine portion of the sound Avith this for bending. No force should be used in the introduction of the sound, other than is necessary to overcome a very slight stenosis. If the sound does not pass easily in the supposed direction of the canal, withdraw it slightly and try in other directions. If it does not then pass easily or if it causes much pain it should not be used further. Information Obtained by Uterine Sounding- As mentioned later, the introduction of the uterine sound is dangerous and rarely necessary. When it is necessary to use it, the information obtained should cover the folloAving points: Size and Shape of Cervical Canal. Is there stenosis! If so, is it located at the external os or the internal os or between the two! Is there antefiexion of cervix? This is indicated by a sharp bend forward of the canal at the internal os. In such a case, even Avhen there is no o])struction, the sound often stops at this i)oint because it impinges on the posterior wall of the canal, and if force were used the Avail AA'ould be injured. Curve the sound sharply so as to throAv the point forAvai'd in a direction to pass the bend. Position of Body of Uterus. Does the point of the sound pass in the direction normally occupied by the uterine canal or is the canal, and conse- quently the body of the uterus, displaced? If so, is the displacement back- AAard or forAA^ard or lateral! The direction of the canal helps also in deter- mining AA-hich of tAA'o masses in the pehds is the uterus, in cases in Avhich this can not be otherwise determined. Length of Uterine Cavity. Is there enlargement of the uterus? If so, to Avhat extent? In chronic intlannnation and in subinvolution there is slight enlargement. In tumors, particularly in large intramural fibroids, there may be great elongation and distortion of the uterine cavity. Pain. There is usually some pain as the sound passes the internal os. In certain cases of inflammation and of neuralgic trouble, the pain is much increased and the excessive tenderness may extend to the entire endometrium. Bleeding. A drop or tAvo of blood may folloAv sounding AA^hen the uterus is normal, but many drops or a slight stream folloAA-ing careful sounding, indi- cates a pathologic condition of the endometrium. Contraindications to Uterine Sound There is considerable danger in the use of the sound, even Avhen handled Avith care. It may carry infection into the uterus or it may, by the irritation, stir to activity a chronic inflammation or it may injure the Avail of the canal INSTRUMENTAL EXAMINATION 125 or it may perforate the iitei-iis and enter the peritoneal cavity. The danger of perforation is especially marked in a iiterns recently pregnant or the seat of malignant disease. When proficiency in the l)imannal examination is acquired, the introduction of the uterine sound will seldom be necessary. Eemember the folloAving rules as to sounding the uterus: Do not sound unless there is some special reason for it. Do not sound when there is active inflammation in the vagina or cervix with the body of the uterus free or when there is an acute or subacute salpingitis. Do not sound when there is a suspicion of pregnancy. If not exti-emely careful, you are liable in some doubtful case to inad- vertently sound a pregnant uterus and cause serious trouble for the patient and for yourself. To avoid this, it is a good plan always, just before introduc- ing the sound, to ask the patient, "When did you menstruate last!" and to ask yourself, "Is there any suspicion of pregnancy in this case!" If there is suspicion of pregnancy, put the patient on some treatment that can not inter- fere with pregnancy and watch the case until the next menstrual period. If you doubt the patient's statement that she is menstruating regularly, tell her that you must see her when menstruating the next time, that you may deter- mine the nature of the flow. In that way you can determine Avhether or not she really menstruates. EXPLORATION OF UTERUS" WITH CURET The exploration of the interior of the uterus with the curet, Avithout anesthesia, is for the purpose of removing pieces of tissue for microscopic ex- amination. Usually curetment under anesthesia is preferable. In some cases, however, there are contraindications to anesthesia or for some other reason it is thought best to try to secure some tissue for microscopic examination so that a diagnosis may, if possible, be made before giving an anesthetic. The curet used for such exploration should be small and should have a sharp cutting edge (Fig. 100, d). Method of Procedure The preparations are the same as for sounding the uterus — in fact, ex- ploration with the sound should immediately precede exploration with the curet. The slight dilatation required and the subsequent exploration with the curet, are usually best carried out with the patient in Sims' posture. In some eases the cervix will readily admit this small curet without dilata- tion. Usually, however, some dilatation is necessary and this is most easily effected with the graduated dilators (Fig. 100, b) of metal or hard rubber. Be- ginning M'ith the small size, the dilators are introduced one after another until 126 GYNECOLOGIC EXAMINATION METHODS the required dilatation is secured. The cervix is caught and steadied with a tenaculum forceps, while dilatation is being made. As a substitute for uterine dilators, the ordinary steel bougies for the male urethra do very Avell in most cases. If preferred, the dilatation may be effected with a small bladed dilator (Fig. 100, c) or a curved uterine dressing forceps. The bladed instrument is introduced closed and then gradually opened sufficiently to give the required dilatation. This is more painful usually and less convenient than the gradu- ated dilators. All the manipulations should be made gently, and nothing more Fig. 100. Instruments for exploring the interior of the uterus. a. Uterine sound. b. Three graduated metal dilators for enlarging the cervical canal. c. Small branched dilator. d. Small ex- ploring curet. e. Intrauterine applicator. than slight dilatation should be attempted, as it would cause too much pain. This dilatation without anesthesia is not practicable in the virgin, ordinarily, though in some cases it can be carried out very well. A method of securing a wider opening by slow dilatation is by packmg the cervical canal with antiseptic gauze. If carried out carefully this is safe, and is sometimes effective. Under the same antiseptic preparation as for the . other methods of dilatation, a thin strip of gauze is introduced into the uterus. PELVIC EXA^IINATION UNDER ANESTHESIA . 127 past the internal os if possible, and the cervical canal is packed firmly Avith it, the end ])eino' left ont of the cervix. This is held in place hy a vaginal packing of the same material. The patient should go to hed as soon as she reaches lioine and remain there until the time for the next treatment. In t^venty-four hours the packing is removed and the cervical canal is found considera])ly softened and dilated. Formerly tents were much used for dilating the cervix. Such a tent was simply a dry cone of some substance Avhich, when moist, gradually expanded with sufficient force to dilate the cervix. The dilatation required several hours and sometimes several days, the patient in the meantime being given morphine on account of the pain. The substances used Avere sponge, laminaria and tupelo. Many deaths Avere caused by infection resulting from the use of tents, and even in skilled hands and Avith all the modern antiseptic precautions, tents still cause serious trouble at times. Consec|uently their use has been al- most abandoned. If used at all, the tent should be covered with a- sterilized rubber tent cover. After the required dilatation has been secured, the curet is introduced and portions of the diseased endometrium removed for microscopic examination. If there is persistent bleeding after the use of the curet, an intrauterine appli- cation of a 10 per cent copper sulphate solution may be used. If the bleeding still persists, a small piece of antiseptic gauze should be packed firmly into the uterine cavity and the vagina also packed Avith gauze. The gauze may be remoA^ed in tAvo days and an antiseptic A^aginal douche giA^en once o'r twice daily for a fcAv days. Contraindications. The use of the curet for diagnosis is contraindicated by the same conditions that contraindicate the sound. The use of the curet Avithout anesthesia, as just described, is not nearly as satisfactoi'y as the regu- lar curetment under anesthesia. PELVIC EXAMINATION UNDER ANESTHESIA The advantage of anesthesia is that it eliminates pain and muscular ten- sion, the tAvo factors that make the ordinary pelvic examination incomplete and unsatisfactory in certain cases. Preparations In preparation for this examination the patient's boAvels should be moved Avith a purgative on the prcAdous day and the rectum should be cleared out Avith an enema an hour or tAA'o before the examination. The same preparatory exami- nation of the heart, lungs and urine should be made as though the anesthesia were for an operation. Have ready a light strong tenaculum forceps, so that the cervix may be caught and the uterus pulled doAvii as desired. If the in- 128 GYNECOLOGIC EXAMINATION METHODS . terior of the uterus is to he explored, the autiseptic preparation for curetment must he carried out. Examination Methods The various manipulations employed in examination under anesthesia are as follows: Vagino-ahdominal palpation, Eeeto-ahdominal palpation, Recto-vagino-ahdominal palpation, Recto-vesieal palpation, Curetment, Exploration of interior of uterus with finger, Excision of piece of cervix for examination. VAGINO-ABDOMINAL PALPATION In vagino-abdominal palpation under anesthesia, the same manipulations are employed and the same facts concerning normal and abnormal pelvic structures are sought, as in the ordinary vagino-abdominal (bimanual) exam- ination. Under anesthesia, however, the examination is much more thorough. Deep palpation may be made in all portions of the pelvis, and the uterus, tubes, ovaries and abnormal masses may be clearly outlined in nearly every case. The position, size, shape, consistency, mobility and attachments of a pelvic mass may be determined with far more accuracy than without anesthesia. In all doubtful eases, this method of examination should l)e employed be- fore subjecting the patient to abdominal section. In the examination under anesthesia, the manipulations must always be made carefully and gently, otherwise a collection of pus may be broken open internally, causing peritonitis, or the sac of a tubal pregnancy may be rup- tured, causing fatal hemorrhage. EECTO-ABDOMINAL PALPATION The recto-abdominal palpation under anesthesia is made for the same pur- pose as the vagino-abdominal palpation and in the same way except that two fingers of the gloved hand are introduced into the rectum instead of into the vagina. Much additional information may in this way be obtained in some cases because, under anesthesia, the fingers can pass further up the posterior surface of the uterus. By catching the cervix with a tenaculum forceps and pulling the uterus downward, the posterior surface of the uterus and the ovaries and the broad ligaments may be palpated with but little intervening tissue. To get the full benefit from this method, particular attention must be paid PELVIC EXAMINATION irNTDER ANESTHESIA 129 to details. After tlie patient is Avell under the anestlietic and as much infor- mation as possible has been secured by vagino-abdominal palpation, then make the reeto-abdominal examination as follows: 1. Cleanse the rubber glove from all vaginal secretion or put on a fresh one (that no infection be carried into the rectum), and lubricate the glove with a drop or tAvo of liquid soap. If the bare fingers have been used for vaginal examination, cleanse them and put on a rubber glove. If no rubber glove is at hand, fill the space under the nails of the examining fingers by scraping across a bar of, soap and then lubricate the fingers with a drop or two of liquid soap or with an abundance of vaseline or other bland ointment. If no rubber glove is worn, the examining fingers should, immediately after the examina- tion, be dipped at once (before putting them in soap and Avater) into a strong antiseptic solution (e. g., bichloride 1-1000) and scrubbed in that Avith a piece of cotton. After that they are put through the regular scrubbing Avith soap and Avater and a brush. This immediate cleansing in a strong antiseptic solu- tion before the regular scrubbing Avith soap and AA'ater, aids in removing the odor. 2. Introduce tAvo fingers into the rectum. Under the anesthetic, the sphincter ani is readily dilated to admit the tAvo fingers as they are carefully Arorked in. A much more thorough recto-abdominal palpation of the pelvic interior may be made Avith tAvo fingers in the rectum than Avith only one. The fingers are Avorkecl past the rectal folds, up betAveen the sacro-uterine ligaments, Avhich serA^e as landmarks, and then as far up beyond as possible. The anus and pelvic fioor are pushed into the pelvis as far as they Avill go, by firm pressure against the elboAv of the examining arm, the elbow resting on the knee or against the hip, as in deep A^agino-abdominal palpation. In this Avay the tips of the examining fingers may be carried far up into the posterior part of the pelvis. There may be some difficulty in finding the rectal canal in the region of the sacro-uterine ligaments. Sometimes the interior of the rectum feels like a large pouch Avithout any opening extending higher. If you are satisfied to make the pehdc palpation by attempting to carry up the Avail of this pouch, you will be much hampered. By locating the cervix uteri and then the two sacro- uterine ligaments and Avorking round to get past the rectal A^ah^es and folds, a small opening Avill be felt extending upAvard betAveen the sacro-uterine liga- ments. FoUoAv this up (it dilates easily) and you Avill find further progress unobstructed. The fingers are carried as high as they Avill go and then the ab- dominal Avail is depressed from aboA'-e b}^ the other hand (Fig. 101). 3. The various structures in the i)Osterior and central parts of the pehns are then caught betAveen the hands and outlined and otherAvise examined by palpation, one at a time. The palpation proper is made principally AAdth the rectal fingers, the abdominal fingers serving simply to push doAvn the struc- tures to Avithin reach of the fingers beloAV. In this ])al])ation, the guide is the 130 ' GYNECOLOGIC EXAMliSTATlON METHODS bod}^ of the uterus. The fingers pass up the posterior surface of the uterus to the fundus and then out to the lateral region of each side, palpating the tube and ovary and any abdominal mass. In a patient with only a moderately thick abdominal wall, the ovaries and tubes may be distinctly outlined, unless they are obscured by adhesions or by an inflammatory mass or by a tumor. 4. Then catch the cervix with a tenaculum forceps and draw it down gently, and have someone hold the forceps to keep the uterus in the downward position. This drawing downward and forward of the cervix, throws the fun- dus backward so that it is caught between the rectal fingers and the abdom- inal fingers, and its size, shape, consistency, mobility and attachments may all be accurately made out. The fingers then pass to the adnexa, determining the same points con- cerning them. If there is a movable mass of doubtful origin, have some one catch it from the abdominal surface and pull it up towards the abdominal cavity so that the Fig. 101. Recto-abdominal palpation. The hand should be gloved. (Montgomery — Practical Gynecology.) examining fingers (rectal and abdominal) may meet between the mass and the pelvic structures. In this way, the pedicle of the mass (if it arises from the pelvis) ma}^ be felt and traced to its origin, and also its length and thickness determined (Fig. 102). This is sometimes referred to as Hegar's method of examining the pedicle of a tumor. 5. Cautions. Particular care must be exercised that the structures be not injuriously pressed or pulled upon, for as the patient is anesthetized the usual warning complaint of pain is absent. There are three points that it may be well to mention particularly: (a) Do not use much force in palpation. A pus sac may be broken, causing peritonitis, or a tubal pregnancy may be disturbed sufficiently to cause a fatal hemorrhage. In fact, a patient with suspected tubal pregnancy should not be examined under anesthesia until she is got to the hospital or PELVIC EXAMINATION UNDER ANESTHESIA 131 until things are ready in the home, so abdominal section could be carried out immediately should threatening symptoms arise during the examination. Again, if much force is used the examining fingers may be pushed through the rectal Avail into the peritoneal cavity. Kelly mentions cases in "which this accident occurred and in which immediate abdominal section, or vaginal sec- tion, was carried out to repair the rent in the bowel wall and prevent fatal peritonitis. (b) Do not draw down the uterus very far nor very forcibly, for reasons already given. It is a good rule to bring the uterus down no further than is absolutely necessary to satisfactorily palpate it. In most of these cases all that is necessary is a slight downward displacement, that permits the fundus to go somewhat backward so that it can be grasped well between the rectal fingers behind and the abdominal fingers in front. The extreme downward displace- ment of the cervix, to the vaginal entrance or even outside, is not necessary nor advisable, except in cases where there is already prolapse of the uterus. The Fig; 102. Palpating the pedicle of a tumor, with the tumor pushed up into the abdominal cavity and the uterus caught with a tenaculum forceps and pulled downward. (Montgomery — Practical Gynecology.) occasion for it does arise if the fingers are carried up the rectum by invagina- tion of the pelvic floor, as above described. (c) The suggestion to use the whole hand in the rectum for exploration in difficult cases, was long ago made and carried out with disastrous results. This method should not be used. It has led to rupture of the rectum, with fatal peritonitis. Furthermore, no need for it is experienced if the palpation with two fingers is carried out with close attention to the details above given. RECTO-VAGINO-ABDOMINAL PALPATION In some cases, additional information may be obtained by this method. AVith the two fingers in the rectum, the thumb of the same hand is passed into the vagina and the lower part of the pelvic mass or of the uterus is grasped be- 132 GYNECOLOGIC EXAMINATION jVIETHODS tween the fingers and the tluinih, the strnctures being pressed down withm reach by the abdominal hand (Fig. 103). In some cases, this is of decided assistance in outlining a small mass low in the pelvis and in determining the exact consistency of different parts of it. In certain cases, where there is a wide vaginal opening and relaxed pelvic floor, the examiner may palpate the nterns or other mass Ioav in the pelvis, Avith almost as much accuracy as though it were removed and lying free in the hand. A modification of this method is to introduce the middle finger into the rectum and the index finger into the vagina and palpate the structures between Fig. 103. Recto-vagino-abdominal palpation. One or two fingers of the gloved hand are intro- duced into the rectum and the thumb into the vagina, and the uterus, or other mass low in the pelvis, is grasped between them, as it is pushed down by the abdominal hand. (Montgomery — Practical Gynecology.) the fingers as the uterus is pushed down from above. This method of recto- vagino-abdominal palpation has been found useful in determining the extent of involvement of the parametrium in cases of carcinoma of the cervix uteri. RECTO-VESICAL PALPATION In the tecto-vesical palpation under anesthesia, a medium sized urethral bougie (about 21 F) is introduced into the bladder, and one or tAVo fingers into the rectum. The tissues betAA'een the rectum and the end of the bougie are carefully palpated by the i-ectal fingers. This method is used in only tAA'o conditions — (a) in determining the presence or absence of the uterus in cases of atresia of vagina and (b) in distinguishing betAA^een inversion of the uterus and a large pedunculated fibroid hanging from the cervix. In a very stout patient, this method may be the only means of making a positive diagnosis in PELVIC EXAMINATION UNDER ANESTHESIA 133 the classes of eases mentioned. If the bladder is not irritable, this method may be employed gently Avithout anesthesia, but the examination under anes- thesia is far more satisfactory. Fig. 104. Curetting. Glandular Hyperplasia of the Endometrium. The glands are sectioned longi- tudinally, showing the cork-screw shape. C^ Fig. 105. Same curettings of a Glandular Hyper- plasia of Endometrium, sectioned transversely. Glands lumina lying close to each other. ^ % '.y ;••- •» ■'. ■ ■ x" i ' V ^■■'r -■">. r^- .. -^--J' ■ ■. ^- , ' ' ' ' * "^» • • ■ 'V "* ♦ • '♦ <■ -'.-vlfi^i.^.' Fig. 106. Curetting. Interstitial Hyperplasia of the Endometrium. Low power. Fig. 107. Curetting. Interstitial Hyperplasia of the Ivndomctrium. High power. 134 GYNECOLOGIC EXAMINATION INIETHODS Caution. Palpation with the finger introduced through the dilated ure- thra, the author mentions only to condemn. It is dangerous in that it is liable to cause permanent incontinence of urine, a condition which resulted in several reported cases. GUEETMENT UNDER ANESTHESIA Curetment for diagnostic purposes is carried out the same as regular curetment for therapeutic purposes. By it tissue is obtained from all por- tions of the endometrium for microscopic examination. As previously stated, this is much more satisfactory than the partial curetment without anesthesia, for by the curetment under anesthesia, tissue is removed from j)ractically all parts of the cavity. Consequently, if in the subsequent microscopic examina- tion no malignant tissue is found, we may be fairly certain that there is no malignant disease. Furthermore, regular curetment under anesthesia com- bines with its diagnostic value a decided therapeutic effect, for it removes the diseased endometrium and diminishes bleeding and discharge. As will appear later, curetment is often indicated in a particular ease by both therapeutic and diagnostic considerations. For example, when a patient has uterine bleeding or discharge that resists ordinary treatment, curetment is indicated to- stop the bleeding or discharge and also to furnish tissue for microscopic examination. Of the various conditions that give rise to persistent bleeding and dis- charge the following produce characteristic changes in the endometrium: Chronic endometritis. Hyperplasia (Figs. 104, 105, 106, 107), Malignant disease (Figs. 108, 109), Tuberculosis of the endometrium. Recent abortion (Figs. 110, 111). There are other conditions, for example, extrauterine pregnancy, in which the microscopic appearance of the curettings is not pathognomonic but in which the information obtained in this way, added to the symptoms, may make the diagnosis positive in an otherwise doubtful case. Collecting' Curettings In a diagnostic curetment, observe the following points: 1. Remove the endometrium from all parts of the uterine cavity. 2. Put all the curettings directly into a small vessel and shake with water to remove blood-clots. If the water is so bloody that it is desired to change it for further washmg, it is poured through gauze. The gauze catches the curettings, which are then emptied into fresh water. The water into which curettings are placed should be clear and clean. Normal saline solution is PELVIC EXAMINATION UNDER ANESTHESIA 135 ^P .M^'-' Fig. 108. Curetting. Adenocarcinoma of the Endometrium. L,ow power. Fig. 109. Curetting. Adenocarcinoma of the Endometrium. High power. Fig. 110. Curretting. Incomplete Abortion. Chorionic tissue and blood, Fig. 111. Curetting. Incomplete Abortion. An- other case. Typical chorionic villi and a few decidual cells, left upper corner. 136 GYNECOLOGIC EXAMINATION METHODS preferable to i3lain water as it causes less swelling of the cells, hence it should be used for the washing when the curettings are to be subjected to any par- ticular or special examination. 3. Then transfer all the tissue fragments, without compression, to a small bottle containing 95% alcohol or 10% formol solution and send to the laboratory. 4. If the pathologist is in a distant city, the little bottle should be corked securely and put in a mailing tube or wrapped with cotton and otherwise packed securely for safe transmission. 5. With the specimen, send a note stating the nature of the specimen (curettings from within uterus), when obtained, name and age of patient and some of the important facts in the history of the case. EXPLORATION OF UTERINE CAVITY M^ITH FINGER Exploration of the interior of the uterus with the finger may be employed when satisfactory information can not be obtained otherwise. The cervix may he dilated in the same manner as for curetment, i. e., with a strong bladed dilator, but the dilatation must be carried much further, as it takes a larger opening to admit the finger than to admit the curet. The dilatation required for satisfactory exploration with the finger must be so wide that it is only in exceptional cases that it can be secured in the non-puerperal uterus with the ordinary dilator. To secure satisfactory dilatation, Schatz's metranoikter may be used. This consists of two blades separated by a strong spring. They are intro- duced into the cervix closed. The removal of the introducing handle releases the spring which gradually effects wide dilatation of the cervix, within twelve to tAventy-four hours. The pain is controlled by morphine. This instrument causes Avide dilatation and may be used in preparation for examination under anesthesia where for some particular reason it is desired to palpate the interior of the uterus. It may be used also to dilate the cervix for curetment without anesthesia or even for exploration of uterus with the finger without anesthesia. Hirst has modified the Schatz metranoikter, making it with four blades instead of two. A more certain' and satisfactory method, when the patient is given an anesthetic, is to dilate the cervical canal to the usual extent with the regular l)laded dilator and then divide the Avail of the cervix with a knife or scissors, in the median line anteriorly up to or above the internal os. The bladder must of course first be separated from the cervix and pushed up out of the Avay. This alloAvs a thorough exploration of the interior of the uterus AA-ith the finger. It is a rather formidable procedure for exploration alone and usually is employed only after preparations have been made to do a hysterectomy or other operation immediately after the exploration, if such is found necessary. After sufficient dilatation lias been obtained by one of the methods men- PELVIC EXAMINATION UNDER ANESTHESIA 137 tiuiied, the finger is iiitroduced into the uterine cavity and the vails palpated, the uterus at the same time being pushed downAvard and steadied by the other hand the same as in bimanual examination. Some additional information may be obtained by this method, for example, we may determine the presence of irregularities of the uterine wall, of projecting growths, of softened or broken down places or of areas of induration. Exploration of the uterine cavity with the finger is seldom necessary in the non-puerperal uterus. In all but exceptional cases, the diagnosis may be made without it. In the puerperal uterus, it is exceedingly useful for deter- Fig. 112. Exploration of the interior of the uterus with the finger. This represents a puerperal uterus with retained placental remnants. (Edgar — Practice of Obstetrics.) mining the presence of placental remnants (Fig. 112) and for safely clearing out the same. In the recently pregnant uterus no special dilatation measures are necessary because the cervix is so soft that abundant dilatation is secured with the ordinary bladed dilator or in some cases even with the finger alone. INSPECTION OF THE UTERINE INTERIOR The metroscope is an electrically lighted endoscopic tube adapted in length and caliber to viewing the interior of the uterus. Its use may be advis- able in rare conditions, but the fact must be recognized that the additional information it gives is very slight and is more than over-balanced by the danger that will result from its general use. RADIOGRAPHY The Rontgen-ray examination has proved invaluable in the differential diagnosis of pelvic conditions, especially in the differentiation of ureteral, bladder and intestinal lesions. It is of help also in advanced cases of extra- uterine pregnancy, in dermoid cysts with teeth, and in suspected foreign bodies (instrument left at operation). In certain exceptional cases valuable help in diagnosis may be obtained by introducing a sound or bai'iuni mixtui-e into the 138 GYNECOLOGIC exa:mixation isiethods corpus uteri, and then identifying it by fluoroscope and plates. The suggestion also has been made to answer the question of the permeability of the Fallopian tubes in eases of sterility, by intrauterine and intratubal injection of barium mixture folloAved by X-ray examination. Such investigations should be car- ried out only under very strict precautions and by experienced gynecologists. The danger from such injections is very decided, the benefits so far reported have been practicalh^ nil. Peterkin (Urologic and Cutaneous Review, Vol. XVIII, 1914) devised a method of determining the relation of the uterus to the bladder and ureters and pelvic walls (e. g., in prolapse) by inserting a special metal plug in the cervix uteri and then employing radiography. EXCISIOX OF TISSUE FROM CERVIX Excision of a piece of tissue from the cervix for microscopic examination may be quickly carried out following curetment or other exploratory exam- ination, when thought advisable. In this Avay a positive diagnosis of malig- nant disease of the cervix may be made in the early stage. This aid to diag- nosis should be carried out during the examination under anesthesia whenever a suspicious ulcer or induration is present. A small wedge-shaped portion of the suspicious area, including some healthy tissue, is excised and the wound thus made is closed by one or two sutures. The sutures should be left in place about ten days, the patient in the meantime receiving one or two antiseptic douches daily. She need not remain in bed. PREPARATIONS FOR GYNECOLOGIC EXAMINATION The various points considered under this head may be grouped as folloAvs: Office Arrangements. Directions to Patient. Antiseptic Preparations. Soap, Brushes, Lubricant. Use of Rubljer CtIovbs. Avoid Unnecessary Exposure. Preservation of Specimens. Examination on Bed. OFFICE ARRANGEMENTS There are three things of particular importance in the handling of gyne- cologic iDatients: 1. Screened Area in the Consulting Room. The portion of the room that is used for the examination should be suitably screened from the other part, so that the patient may remove the corset and make such other arrangement of the clothing as she wishes, in privacy. It is very convenient to have a separate PREPARATIONS FOR EXAMINATION 139 room for the examiniiig-room, with an attached toilet-room. Where no sepa- rate room is available, a neat substantial screen, affording the patient privacy for the required preparation, does very well and is inexpensive. 2. Table. A satisfactory table for gynecologic examinations is the reg- ular surgical chair with footrests. The advantage of the footrests is that the patient's hips may be brought to the end of the table without her feet being forced so near the buttocks as to be uncomfortable. Fig. 113. Kitchen table, with portable foot-rests attached ready for a gynecologic examination. In the absence of the surgical chair, portable footrests may be attached to a plain kitchen table (Fig. 113). With these portable footrests are fur- nished also tall uprights for use as legholders, by which the feet and legs may be held out of the way during examination under anesthesia or during an operation. They are convenient for use during minor operations at the pa- tient's home. 3. Nurse. When a physician is doing much gynecologic work it will be found a wise investment to have a nurse, to prepare the patients for ex- 140 GYXECOLOGIC EXAMIXATIOX METHODS amiiiatioii and to prepare the necessary articles needed in office examination and treatment. Aside from the great convenience to the pliysician, it malves the patients more at ease and in addition tends to protect the physician from blackmail by designing persons. AVhere a nnrse is not required for other Avork, she may be hired just for the office hours and thus the expense reduced. DIRECTIONS TO PATIENT Direct the patient to remove the corset and loosen all bands about the Avaist, so that the clothing may be pushed up and down sufficiently to bare the abdomen. This is necessary at first, for the first examination should be thorough, including examination of the entire al)domen as well as the pelvic exploration. Examination of the breasts may be necessary in cases of sus- pected pregnancy. If there are indications of disease of the heart or lungs, those organs also should be examined, and the same is true of the nervous system. In the subsequent visits, it may not be necessary to remove the corset or loosen the clothing, depending of course on what treatment or further exam- ination is recjuired. It is not necessary in ordinary cervical or vaginal treat- ments. Any treatment however necessitating deep bimanual palpation, such for example as replacement of a retrodisplaced uterus, requires the removal of the corset and loosening of bands. After completing the al)dominal examination, direct that the hips be brought to the foot of the table. The patient is covered with a clean sheet and under the sheet the skirts are pushed up above the knees and out of the way. The sheet is then parted so as to expose the genitals only, being draped so as to cover other parts. It is well, as a rule, to inspect the genitals, for often information of value is obtained in cases where the history gives no intimation of disturbance externally. If it is thought unnecessary to inspect the genitals, the hand is carried under the sheet for making the vaginal and vagino- abdominal examination. ANTISEPTIC PREPARATIONS If you Avish to protect your patient and likcAvise your hands from the danger of infection, certain antiseptic precautions must be taken. The neces- sary measures are simple and easily carried out, and if employed regularly become more or less of a hal)it. The needed disinfection wi]] ])c indicated hy iiamiiig the dangers to bs avoided, Avhich are as folloAvs: 1. Infection of the ])atient from your liands. If your hands are A\'ell cleansed before each exainination, there can be no infection from them. 2. Infection of youi- liands from the patient. If there is a scratch or aln-asioii aiiywliere aliout the fingei-s, the hand shonhl l)e (M)\-cred Avith a rul')l)er PREPARATIONS FOR EXA^flNATION 141 glove (Fig. 49). If no rul)])er glove is at hand, a riil)l)ei' lingei'-eot slionld 1)e slipped over the al)raded tingei- oi- the abrasion covered with collodion spread over a few fi1)ers of cotton. If the collodion rubs off during the examination of a patient with syphilis or chancroid or other infectious disease, the abra- sion must be immediately touched with pure carbolic acid or nitric acid and again covered with collodion. We hear a great deal about the danger of the patient becoming infected, but very little about the danger to the physician; and yet there are few physicians of experience who do not number among their professional friends, one or more who have become infected with syphilis through abrasions of the hands. Dudley states that he is acquainted M'ith not less than twenty physicians who have been infected with syphilis through abrasions of the fingers in digital examinations. Each physician must look out for himself and his family. Eemember that "prevention is better than cure," and, it ma}^ be added, a great deal easier. 3. Infection of the patient from instruments. If the insti'uments are sterilized each time before use, there can be no danger, from them. 4. Infection of the patient from the table. To prevent this, place under the patient's hips a rubber pad or piece of rubber cloth and over that a clean folded towel, or a sheet of white paper, which is changed with each jDatient. Precautions. The precautions to be taken in order to avoid infection may be summed up in three rules, as follows : 1. Disinfect and Protect the Hands. Trim the finger-nails short and clean under them. Cleanse the hands well with soap and water and dry them with a clean towel. Protect any abrasion on the hand with a clean rubber glove. If there is any break in the protecting epithelial layer of the vulva or vagina or cervix, or if the interior of the uterus is to be explored, the hands should be further cleansed in 1-2000 bichloride or other reliable antiseptic solu- tion (i. e., they should be put through the regular process of surgical disin- fection) or boiled rubber gloves may be slipped on. 2. Sterilize the Instruments. This may be accomplished by soaking them in pure carbolic acid (95%) for ten minutes or in a 10% carbolic solution for thirty minutes. A safer plan is to boil them for five or ten minutes. For boiling the instruments, a 1% solution of sodium carbonate (washing soda) is preferable to plain water. It dissolves the resisting capsule of bac- teria and destroys them more quickly (in five minutes boiling) and also tends to diminish rusting of instruments. Any kind of a pan, set on a stove or over an alcohol lamp or gas flame, will do for an instrument boiler. The ordinary fish-boiler of granite-iron makes a very good instrument sterilizer. A satis- factory simple boiler for instruments is shown in Fig. 114. Nicer and more convenient instrument boilers may be purchased as desired. There are a number of satisfactory patterns. The one shoAvn in Fig. 115 has the advantage that the dressings for a small operation may be sterilized at the same time with the instruments. 142 GYNECOLOGIC EXAMINATION METHODS 111 office or clinic Avork when tlirongii examining a patient, wash the instruments and drop them into the boiler and in a few minutes they are sterilized, ready to use for another patient- or to be put away. Edged instru- ments, such as knives and scissors are more or less dulled by the boiling. Con- sequently when there is plenty of time, it is better to sterilize them by soaking them in carbolic acid or other suitable antiseptic. When a knife is put in with other instruments for sterilization the cutting portion should be wrapped with cotton. The instrument tray also must of course be sterile. It is contaminated every time a soiled instrument is laid back in it and unless disinfected may carry disease from one patient to another. To obviate this, each instrument after use may be laid on a clean towel (if it is to be used again during that examination) or dropped in a basin for later cleansing. Again, a light shal- low pan may be used as an instrument boiler and instrument tray combined, Fig. 114. A simple instrument boiler. Fig. lis. A small instrument and dressing ster- ilizer. The dressings for a small operation may- be sterilized in the trays above the boiling instru- ments. the instruments being boiled in it each time before use. This gives, in a few minutes, sterile instruments in a sterile container. 3. Do not Touch the Intrauterine Part of any Instrument. This rule should be very carefully observed, for in it lies one of the secrets of avoiding infec- tion of the uterine cavity in office examination and treatment. The hands may have been well disinfected or they may have been covered with boiled rubber gloves, giving a perfectly sterile covering, but in office work the field of examination has not been disinfected. The hands necessarily touch undisinfected surfaces and hence do not remain sterile. Consequently, when handling an instrument for intrauterine work, it is important, even when wearing rubber gloves, to observe the rule not to touch that part of the in- strument that is to enter the cervical canal. When bending the end of the uterine sound, dip a large piece of absorbent cotton in a reliable antiseptic solu- tion and grasp the part to be moulded with that. If the uterine canal is to be cleansed with a cotton-wrapped applicator, use one of those previously pre- fUEPAltATIONS FOR EXAMINATION 143 Fig. 116. The articles needed for preparing for the gynecologic examination, arranged con veniently on a stand, a. Finger-nail instruments, b. Rubber gloves, c. Powder for dusting in rub ber gloves, to make them slip on easily. d. Liquid soap- in a drop-bottle. e. Hand brushes. / Bichloride solution. fir. Cotton balls. h. Lubricant in compressible tube. Fig. 117. Method of using the drop-bottle containing liquid soap. 144 GYNECOLOGIC EXAMINATION METHODS pared, as described under intrauterine treatment in Chapter iii. If one must be prepared for immediate use, be sure to cleanse carefully the fingers that touch the cotton and also, before introducing the cotton, dip it in an antiseptic solution. The other antiseptic precautions necessary in intrauterine exploration and treatment have already been given. SOAP, BRUSHES, LUBRICANT Soap. Use some liquid preparation of green soap. The free use of such a soap is the most important step in hand disinfection. A number of excellent and convenient preparations of liquid soap have been put on the market by various firms, in drop bottles (Fig. 116, d) from which the soap may be dropped as needed without waste. Such a bottle may be filled with ordinary tincture of green soap (tincture sapo viridis) or any other required prepara- tion, i3urehased in quantity or made up as desired. Fig. 117 shows the use of Fig. 118. A convenient wall-fixture for liquid soap. Slight upward pressure on the metal stem at the bottom causes the soap to flow into the open hand. the drop bottle. A still more convenient arrangement is the stationary holder- for liquid soap, fastened just above the. washstand. Fig. 118 shows a good pattern. Slight upward pressure against the projecting stem at the bottom causes the liquid soap to flow into the hand. Some liquid preparation should be used entirely for soap. The ordinary cake soap is not effective for surgical cleansing. Brushes. For cleansing the irregularities about the fingers, a brush is necessary. The ordinary small hand-brush of vegetable fiber with a plain back (Fig. 116, e), does very well. Such brushes are cheap and will stand boiling and are effective as long as the fiber portion is uniformly stiff. When a brush becomes too soft from repeated l)oiring, it should be thrown aAvay or PREPARATIONS FOR EXAMINATION 145 laid aside to be used on surfaces where a softer brush is required, such as the abdominal surface or genitals of patient being prepared for operation. A brush used in scrubl)ing the hands after examining an infected or doubt- ful case, must be boiled before being used again. It is convenient to have several brushes boiled and kept in a jar ready for use. They may be kept dry or in an antiseptic solution. Lubricant. A drop or two of liquid soap on the wet fingers or glove makes a most satisfactory lubricant. The smallest ciuantity lubricates thor- oughly and is in a measure antiseptic and is easily removed. The author does not find glycerine satisfactory. Unless used in such large quantity as to be inconvenient, it does not lubricate Avell. In the absence of liquid soap, any clean unirritating ointment will do. When an ointment is used, it is well to have it put up in a compressible tube (Fig 116, h), for then the unused part is kept sterile. Fig. 119. Patient arranged for abdominal examination in bed. USE OF RUBBER GLOVES The author wishes to call attention to the routine use of rubber gloves in examination and office treatment, particularly in cases where any infection is present or suspected. For ordinary office Avork, it is convenient to put them on dry. When a small amount of boric acid powder or talcum powder is dusted into each glove, it slips on easily. The glove-covered hands are then put through the regular 146 GYNECOLOGIC EXAMINATION METHODS washing with liquid soap and water. After the examination, the gloves are slipped off and thrown into a basin for subsequent boiling. Thus the infective material is kept away from the washstand as well as from the hands. After the office work is finished, water is poured into the basin of soiled gloves and they are boiled for ten minutes. It is well to have a towel in the basin to pro- tect the gloves from injury by direct contact with the hot metal bottom and Fig. 120. Patient arranged for vaginal examination in bed. In this and the two succeeding photographs, the sheet has been pushed aside to show the necessary relations. As a rule the ex- amination can be conducted under the sheet without any exposure of the genitals. sides. After the sterilization, the gloves are taken out, cleansed in water to remove all foreign particles adhering to them, dried on a clean towel (being turned inside out often enough to secure good drying) , dusted inside and out with a drying powder, wrapped in a clean towel, and laid away for subsequent use. When there is an examination or treatment requiring sterile hands, a PEEPARATIONS FOR EXAMINATION 147 pair of the rubber gloves is wrapped in a small towel and dropped into the water on top of the instruments, to be boiled with them. Two or three pairs of rubber gloves, kept ready for use, constitute one of the best investments the practitioner can make, for the following reasons: 1. They protect the hands from syphilitic or other infection through some unnoticed crack or abrasion, 2. They prevent disagreeable odors clinging to the hands, as otherwise happens in vaginal examination in cases of advanced uterine cancer and in all rectal examinations. 3. Tliey do away with the severe scrubbing of the fingers and hands, which is otherwise necessary after each examination of treatment of a patient with any form of infection. This frequent severe scrubbing keeps the skin rough and in bad condition. ••-ir. : J^-atti ammmm illiriliilfllilS ^M i n ' Fig. 121. Deep bimanual examination with the patient in bed. Showing the relations of the examining, hand and arm. The examiner sits on the side of the bed and the arm lies between the widely-separated thighs, so that the examination is made from directly in front of the pelvis. 4. Boiling the gloves after use eliminates all danger of carrying contami- nation from one patient to another and keeps the infective material away from the washstand and other office fixtures. 5. When an absolutely sterile covering for the hands is desired, it is easily secured by boiling the gloves immediately before use. 148 GYNECOLOGIC EXA^^IIXATIOX :\IETHODS AVOID rXXECESSARY EXPOSURE In all the steps of the examination and in all examinations and treat- ments, avoid exposing the patient any more than is necessary. Do not let your study of the clinical and scientific features of the case so preoccupy your mind that you neglect this. The carelessness manifested in this respect by some physicians is ex- tremely reprehensible. This careless disregard of the natural modesty of the patient is seen both in private Avork and in clinic work but especially in the Fig. 122. Deep bimanual palpation with the patient in bed. showing the abdominal arm between the thighs. The other arm is partially hidden by the sheet. latter, where it is just as reprehensible as in the former. To the physician studying the difficult features of a case in an endeavor to save the patient's life or restore her to health, this may seem a small matter — but nevertheless it is an important one and should be thought of. Furthermore, the poor patient, who in the clinic puts herself under the care of the teacher and his assistants, is just as much entitled to thoughtful consideration in this matter as the M-oman in better financial circumstances who comes as a private patient. PREPARATIONS FOR EXAiSIINATIOX 149 PEESERYATION OF SPECIMENS The preservation of specimens for microscopic examination is a very sim- ple procedure and yet in many doubtful cases, curettings or cervical polypi removed or pieces of tissue passed spontaneously, are thrown away or kept iii such a manner that they are not fit for microscopic examination. Thus is lost a valuable aid to early diagnosis, in conditions where early diagnosis is im- portant. Fig. 123. Regular "cross-bed" position. The patient is turned directly across the bed, with the hips resting on the edge of the bed and each foot on a chair. A good all-around preservative for these specimens is alcohol (95%). It is nearly always at hand and it preserves the specimen indefinitely in good condition for microscopic examination. As soon as possible after removal and without unnecessary handling, the specimen is dropped into a small bottle con- taining the preservative and then forwarded to the pathologist. A 10% solution of formol is another good preservative. Formol, which is a 40% solution of formaldehyde gas, is knoAvn also as formalin and as formal- dehyde solution. For particular points in the saving and transmission of curettings for diagnostic purposes, see previous pa^es (Curetment under Anesthesia). 150 GYNECOLOGIC EXAMINATION METHODS EXAMINATION ON BED When a patient is seen at her home, sick in bed, the methods of explora- tion employed are usually abdominal, vaginal, vagino-abdominal and, in some cases, recto-abdominal. A patient who is too sick to come to the office for a pelvic examination, is usually suffering, not with a superficial disturbance that can be seen by inspection of the external genitals or through a speculum, but with some deep-seated trouble, the nature of which can be determined only by deep internal palpation. In such a case, the inspection of the genitals and Fig. 124. Another method of arranging a bed-patient for examination of external genitals. This is useful when the patient is very sick or when movement is painful. The hips are simply slipped to the edge of the bed and one foot placed on a chair. the speculum examination add nothing of importance to the information other- wise obtained, and as they are particularly disagreeable to the patient they may be dispensed with. In such a case, the abdominal examination is first made. The patient is directed to move to the edge of the bed and the clothing is loosened and pushed up and down, to expose the abdomen, and the knees are drawn up to relax the abdominal muscles (Fig. 119). The abdomen is then examined by the various methods previously explained. PREPARATIONS FOR EXAMINATION 151 The vaginal and vagino-abdoniinal examinations, Avith deep bimanual palpation, may be conveniently and satisfactorily conducted with but little disturbance to the patient by observing the following directions, some of which were partially carried out in arranging for the abdominal examination : 1. Direct the patient to move close to the left edge of the bed. There is but little disturbance — she lies just as she is in the bed, except nearer the left edge (or the right edge, if the examiner uses the right hand for the internal palpation). A patient seriously sick, even with j)eritonitis, may usuallj^ be moved over sufficiently without much pain. 2. Remove the heavy bed-clothing, all except the sheet with perhaps a light blanket, and have the patient draw up both knees so that the feet are near the buttocks (Fig. 120). 3. Sit on the bed, or on a chair placed at the side of the bed, against the patient's left foot and direct the patient to separate the knees widely. The sheet is then raised sufficiently to permit the examining hand (with the index and middle fingers well lubricated) to be passed between the patient's thighs (Fig. 121) — not under one thigh, as ordinarily directed. The hand is carried to the perineum and the examining fingers are introduced deeply into the vagina, taking care to depress the perineum sufficiently to allow their intro- duction without pain. 4. After the simple vaginal examination is completed, then the right hand, passed under the sheet, is made to depress the abdominal wall into the pelvis as in the regular bimanual examination (Fig. 122). In Figs. 120 and 121 and 122, the sheet has been pushed aside in order to show the necessary relations. Ordinarily the entire examination may be conducted under the sheet and without exposing the patient in the least. The author calls special attention to the details given above because he finds that their accurate carrying out aids materially in securing needed in- formation in deep-seated pelvic troubles. By following the directions closely, the examining hands and. arms are made to occupy practically the same ad- vantageous relation to the pelvis as in the regular office examination with the patient at the end of the table — that is, the examination is made from directly in front of the pelvis. The usual procedure of sitting on a chair besides the bed, with the examining arm passed under the thigh (instead of between the thighs) is much less effective when deep pelvic palpation is required. While the examination steps above mentioned are generally the only ones required when the patient is sick in bed, there are some cases in which further examination is advisable. Whenever the patient complains of sores about the genitals or of itching or burning or profuse discharge, the genitals should be inspected in a good light. Ijikewise in any case in which it is thought that additional information of value may be obtained by the speculum examina- tion, that procedure should be carried out. For the inspection of the external genitals and for the speculum examina- 152 GYNECOLOGIC EXAMINATION :METH0DS tion, the patient may be turned across the bed with the hips near the edge and each foot resting on a chair (Fig. 123). This is often referred to as the '^ cross-bed" position. If movement of the patient to this extent is likely- to cause pain, she may be simply turned slightly and one foot placed on a chair while the other foot rests on the bed, as shown in Fig. 124. NON-GYNECOLOGIC EXAMINATION METHODS IN GYNECOLOGIC CASES The physician must consider the whole patient. His work is to ascer- tain AA'hat is troubling the patient — in whatever part of the body the disease may be located or Avhatever organ or organs may be affected. Tt is not enough to find one well-marked disease. All the important troubles present, both organic and functional, should be found, for then only is the physician in a position to .judge accurately as to how far each disease is responsible for the patient's disability and what the line of treatment should include and what the result will probably be. To do this the physician must employ, in gynecologic cases, various methods of examination which belong to other departments of medicine, and the detailed consideration of which would be out of place here. The author will simply call attention here to the classes of patients with pelvic symptoms in which such extragynecologic examinations are especially required in the course of diagnosis or treatment. The examination methods to which the author wishes to call attention are, aside from the usual physical examination of the chest, as follows : Examination of Urine. Blood Examination. Sputum Examination. Examination of .the Xervous .System. EXAMINATION OF URINE IN GYNECOLOGIC CASES The examination of the urine gives important information as to the metab- olism of the body and as to the condition of the most important excretory organs. In the following cases it is especially important that the urine be examined. 1. When the patient is seriously sick from any cause. In such a patient it is important to know the state of the body metabolism and excretion. 2. AVhen there are bladder or kidney or ureteral symptoms. Do not treat the patient for weeks or months for frequent painful urination or pains in the kidney region, without examining the urine to see whether or not there is a local lesion. And when there is trouble in the urinary tract, make frequent examinations that you may keep posted as to the improvement. BLOOD EXAMINATION 153 3. When the patient is to undergo anesthesia, either for operation or exam- ination. The discovery of diabetes niellitns or chronic interstitial nephritis is made with much more satisfaction to yourself and much better prognosis to the patient before anesthesia than afterward, when the patient may be in diabetic coma or uremic convulsions. Again, in the milder cases, it is not pleasant to be obliged to date the patient's persistent nephritis from your operation or anesthesia, when in all probability it was there before, but you have no proof of it. Again, a knowledge of the patient's kidney function may cause you to postpone the operation or anesthesia for a time, until the tem- porary disability is overcome. 4. In doubtful cases — cases in ^hich the cause of the patient's local symp- toms or general debility is not clear. You wonder why the patient does not pick up and improve more rapidly under your excellent treatment. You are annoyed by the patient's reiterated complaint of the bladder irritability or the loin-pain or the headaches that come without reason or the digestive dis- turbances that persist without good and sufficient cause. There is a hidden cause. It may be in the urinary tract. It may, on the other hand, be in the digestive tract or in the blood or in the nervous system or in the lungs. Find it. BLOOD EXAMINATION IX GYXEC0L0C4IC CASES The points in blood examination which are helpful in certain patients with gynecologic symptoms are the hemoglobin jDercentage, the red-cell count, leucocytosis, poikilocytosis and certain special conditions (Widal, Abderhaldeu, and Wassermann reaction, malaria Plasmodium, iDj^ogenic bacteria or other bac- teria in the blood). The classes of cases or conditions in which definite infoi-mation on one or more of these points may be of material assistance are as follows: Marked Anemia. Acute Conditions of Doubtful Character. Inflammation of Uncertain Progress. Inflammation with Uncertain Resistance. Blood Examination in Marked Anemia In gynecologic patients with marked anemia, there are three conditions in which a blood examination is especially useful : 1. When the Cause of the Anemia Is Not Clear. You may be mistaken in your idea that the persistent anemia and increasing weakness is due to the chronic pelvic disease. Possibly the patient has one of the various forms of pernicious anemia. An examination of a stained specimen of the blood will tell at once. The author remembers a patient whose anemia was supposed to be due 154 GYNECOLOGIC EXAMINATION METHODS to an associated chronic malaria and she was treated for that many months, until her condition became desperate. "When the author saw her, there Avere some pelvic symptoms but not sufficient to account for the deterioration of general health. Being at a loss to account for the anemia and weakness, and finding nothing of special importance in the urine, he took specimens of the blood. Examination of these made the case clear at once. There was an advanced leukemia, of which the patient died within a few months.. The pelvic disturbance had nothing to do with the serious symptoms. In a doubtful case, if not prepared to make the blood examinations your- self, make some cover-glass spread preparations of the blood, pack them securely in a pill-box or other suitable container and mail them to a pathologist with a brief statement of the history of the case. 2. When Anesthesia or an Operation Is Required. In a patient markedly auemic, anesthesia is a serious matter even though it is only for a small opera- tion or simply for examination. All the organs are below par and some condition that would be a trivial matter at other times might lead to a fatal termination. A red-cell count or a hemoglobin estimate will give definite information as to the oxygen carrying power of the blood. If the hemoglobin is below 30%, the operation or anes- thesia should be postponed if possible until the patient has been put in a bet- ter condition, by the administration of iron and such other tonics as are indicated. 3. When Trying to Overcome Serious Anemia. In such a case a hemoglobin estimate or blood count at regular intervals will show definitely the effect of the treatment. Blood Examination in Acute Conditions of Doubtful Character There are several conditions arising in patients with pelvic symptoms in which the ascertaining of one or another fact concerning the blood is a decided help in determining the cause of the patient's serious illness. 1. Fever. The patient has persistent fever and pelvic disturbance, but the cause is not altogether clear. Is the fever due to uterine or pelvic inflamma- tion from puerperal or non-puerperal infection, or is it due to typhoid fever or malaria? Malaria may usually be easily excluded by the administration of quinine, but not always. Examination of the blood, taken at the proper time, will show almost certainly whether the trouble is typhoid fever (AVidal reaction, no leucocytosis) or malaria (plasmodium, no leucocytosis) or something else. The author recalls two cases in particular in which he felt that decided help was given by the blood examination. He was called to see a patient who had had a miscarriage several days before and during the past two days there had been considerable fever. The temperature (forenoon) was 101°. Pelvic examination showed no decided pathologic condition. The local conditions BLOOD EXAMINATION 155 seemed about as thej^ should be at that time after a miscarriage. When the author saw her that night, the temperature had gone to lOS'^, but Avas sub- siding. There was evidently serious trouble and arrangements Avere made to clear out the uterus the next morning. That night when thinking over the case, for he was somewhat puzzled by it, it occurred to him that it might be typhoid fever, though no particular evidence of this had been noticed in the examination, except a persistent headache out of proportion to the fever. The next morning the temperature v/as again lower and he felt safe in waiting for the report of the blood examination before disturbing the uterus. A positive Widal reaction was found and the subsequent course of the disease showed it to be typhoid fever, from which the patient recovered ^vithout any uterine disturbance. Particular inquiry revealed tile fact that the patient had been feeling "under the weather" for some days before the miscarriage. Possibly the miscarriage was due to the beginning typhoid fever, though of that the author is not certain. In the other case referred to, the author was called in consultation to see a young woman who for tAvo or three days had had fever, running up to 103° and 101° in the afternoon but loAver in the morning. The patient had had a miscarriage a ^Yeek before and examination showed a subacute gonorrhea. There was considerable discharge and gonococci in abundance but no decided evidence of a septic metritis or of a periuterine inflammatory focus. Because of the regularity of the fever and the absence of the evidences of a local lesion sufficient to account for it, the author suspected typhoid fever. Blood examination shoAved no Widal reaction, neither Avas there a marked leucocy- tosis. A second blood examination gave the same result except that there Avas more leucocytosis. Typhoid fcA^er Avas thus excluded. The author then sent the patient to the hospital on account of the pelvic trouble and in a short time there dcA^eloped unmistakable signs of a focus of pelvic suppuration, AA'hich Avas drained per A'aginam Avith satisfactory result. The pus from the abscess shoAA'ed a mixed infection, but principally gonococci. 2. Pain. There is severe persistent pain in the pelvis and marked tender- ness, without much fever. Is the pain due to severe pelvic neuralgia, or other functional nervous disturbance, or to bleeding from tubal pregnancy? Ordi- narily the differential diagnosis is easily made by the symptoms and physical signs. But AAdien the blood in the peritoneal cavity is fluid (no induration) and not of sufficient quantity to seriously affect the pulse, the pain and tender- ness (preA'enting satisfactory pelvic examination) are about the only signs present. If decided hemorrhage is present, a leucocytosis may be found. AVhen the pain is associated with fever, a marked leucocytosis (principally polynuclear) points to some acute inflammatory trouble, such as salpingitis or appendicitis. In uncomplicated pelvic tuberculosis or tubercular peritonitis there is no leucocytosis. In Certain Post-operative Conditions leucocytosis may be of assistance in 156 GYNECOLOGIC EXAMINATION METHODS connection with the other symptoms. The patient has abdominal pains and there is marked distention of the abdomen and vomiting and persistent failure to secure a bowel movement. Is it gaseous distention of a sluggish bowel or intestinal obstruction? It is said that the latter condition nearly always gives a leucocytosis of 20,000 Avithin the first 24 hours, while in simple distention the leukocyte count is but little above normal. If this observation proves gen- erally true, it will be a most valuable help in the early differential diagnosis in these Yei'y trying cases. Blood Examination in Inflammation to Determine if it is Spreading Here the point is to determine the presence or absence of marked patho- logic leucocytosis, and the important thing is not so much the absolute in- crease of leukocytes as the relative increase of polynuclear leukocytes. In physiologic leucocytosis, which takes place under many ordinary normal conditions (after a meal, after a cold bath, after exercise, during pregnancy, in the puerperium, during menstruation), the relative proportion of 60% to 75% polynuclears is preserved. In the ordinary pathologic leucocytosis the proportion of polynuclear leukocytes runs higher, particularly in the presence of pus. As a general proposition it may be said that polynuclear leucocytosis is present wherever there is acute resistance to the spread of intiammation or irritation. It is present then in practically all ordinary inflammatory lesions, except when the acute symptoms have subsided and the absorption has ceased (focus is well walled off) or where the inflammation is so very virulent that the body resistance is overwhelmed and there is little reaction. It is absent in uncomplicated typhoid fever, malaria, tuberculosis, influenza and measles. In the following cases the blood examination may help some in determin- ing Avhether the inflammation is seriously spreading. 1. Acute Salpingitis (Non-puerperal). The patient is in the midst of a primary attack of salpingitis with accompanying pelvic peritonitis, or there is an acute exacerbation of an old salpingitis. The fever is running moderately high and there is much pain. Is it safe to wait for the interval operation to remove the diseased structure or should the operation be carried out now in the presence of this fresh virulent infection? If the inflammation is sub- siding, the former plan is the better. If the inflammation is spreading and threatening a general peritonitis, the latter plan is the better. In all but exceptional cases, the ordinary symptoms and examination find- ings, if carefully worked out and considered, will place the patient decidedly in one class or the other and with far more certainty than will a blood test. In some doubtful cases, however, repeated examination of the blood at short intervals, to determine whether the leucocytosis is rising or falling, will aid materially in deciding the question. 2. Puerperal Sepsis. Here also the ordinary examination methods furnish SPUTUM EXAMINATION 157 the most reliable information concerning the local and general condition, and they must not be neglected or slighted in the false hope that laboratory tests will supply the desired knowledge. But in eases that are still doubtful, in spite of careful analysis of the symptoms and examination findings, considerable help may in some instances be obtained by repeated examinations of the blood at short intervals to determine w^hether the leucocytosis is rising or falling, and to determine also the number and character of the bacteria in the blood at different times. The exact determination of these two facts may give substantial aid, in excep- tional cases, in directing treatment and in prognosis. Blood Examination in Inflammation to Determine the Vital Resistance Pathologic leucocytosis means resistance. A slight inflammation aw^akens a slight resistance (slight leucocytosis). A severe inflammation awakens a strong resistance (marked leucocytosis), if the patient has the required vital force. There are exceptional cases in which the infection is so very virulent that the vital forces are overw^helmed and offer but little resistance, but these cases are comparatively infrequent. In ordinary acute inflammation of severe grade, a good leucocytosis means good body resistance and reserve force, and a poor leucocytosis means poor body resistance. This is the case particularly ^rith inflammation of the serous membranes, including the peritoneum. This fact may be turned to account in cases of advanced general perito- nitis that are not seen until late and where it is a question whether an opera- tion could possibly do any good. A marked leucocytosis means that there is still decided vital resistance and there is a chance of recovery if nature is judiciously aided in the fight. The absence of w^ell-marked leucocytosis, in the presence of this severe and active inflammation, means that the patient's reserve force is exhausted, and operation would probably have no effect except to hasten death. In at- taching importance to leucocytosis in a patient in this desperate condition, be careful that you be not misled by the leucocytosis that comes ''in articulo mortis." ' SPUTUM EXAMINATION IN GYNECOLOGIC CASES The two points of importance are the presence or absence of tubercle bacilli and the presence. of elastic fibers, indicating destruction of lung tissue. The gynecologic cases in which sputum examination is required are those presenting the following conditions : 1. Suspected Pelvic Tuberculosis. Pelvic tuberculosis is nearly always secondary to a tubercular focus elsewhere in the body, and the most frequent sites of the primary focus are the lungs and the intestinal tract. The patient may not acknowledge that she has a cough, it is so slight. But the direction to save, in the bottle that is given her, all the mucus that can be got up in 158 GYNECOLOGIC EXAMINATION METHODS the morning, will usually bring sufficient for examination, if there is any trouble there. 2. Unwarranted Emaciation and Debility. The patient has some pelvic disturbance but not enough to cause the poor general health. "What does cause it? Possibly it is from beginning -pulmonary tuberculosis. Determine whether or not such is the case. EXAMINATION OF THE NERVOUS SYSTEM IN GYNECOLOGIC CASES That portion of the nervous system distributed to the pelvis furnishes its quota of local painful disturbances (neuralgia, neuritis, transferred pains) and local paralyses, which must be taken into consideration in the diagnosis and treatment of pelvic diseases. There are, in addition, certain general diseases of the nervous system which cause complaint of pelvic symptoms and occasion much confusion in diagnosis. They are principally four, as follows : Hysteria, . Neurasthenia, Hypochondria, Melancholia. The recognition of these diseases depends of course on a knowledge of the clinical manifestations of each disease and a careful consideration of the symptoms presented by the patient. This differential diagnosis can not be taken up here. It will suffice to call attention to certain classes of patients with pelvic symptoms in which this special investigation of the nervous system should be carried out. They are as follows: 1. Very Nervous Patients. The author uses the term ''nervous" in the ordinary commonly-accepted meaning of the word. The patient is perturbed more than one would expect under the circumstances. She may be simply frightened or embarrassed or, on the other hand, she may have some decided organic disease of the brain or nervous system, or some functional nervous disturbance. The patient may have a well-marked pelvic lesion, but that does not cause the evidences of an imstable nervous system. What does? This particular ■ consideration of the nervous system need not necessarily be made at the first visit. The patient may be observed for a time, and possibly it will be seen that the nervous manifestations largely disappear as acquaintance is established. As long as the nervous symptoms persist, how- ever, they constitute an undetermined factor in the case, with a possible bear- ing on the patient's loss of health. 2. Pelvic Distress Without Corresponding Lesion. The complaint of a gynecologic affection for which no evidence can be found, not even tender- ness, may be due to pronounced hypochondria. MISCELLANEOUS EXAMINATION METHODS 159 The i^ersistent manifestation by the patient of a fixed idea tliat slie has some pelvic disease, which in fact is not present, may be due to beginning melancholia. On the other hand such complaints may be due to a deliberate attempt on the part of the patient to deceive the physician — ^hoping thereby to secure an opinion that would be useful in a suit for damages or for divorce, or hoping that the physician may use some examination method or treatment that would lead to an abortion. EXAMINATION FOE DISTURBANCE OF THE ENDOCRITIC GLAND SYSTELI The system of ductless glands bears a very intimate relation to the develop- ment and functioning of the reproductive organs. It is this glandular system that is principally at fault in a considerable proportion of cases of amenor- rhea, menorrhagia, dysmenorrhea and other derangements of function. This subject is such an important one that a special chapter is given to it, and there (Chapter xv) the diagnostic points are given along with the physiologic and therapeutic data. MISCELLANEOUS EXAMINATION METHODS There are a number of other examination methods which are occasionally useful in gynecologic cases, particularly the four below mentioned. Serum Test for Pregnancy. The serum test is useful in those cases in which the ordinary examina- tion signs are not conclusive for or against pregnancy. Also, in unmarried women where pregnancy is suspected and yet it is thought inadvisable to sug- gest a local examination. An examination of the blood, ostensibly on account of the poor health, may give positive evidence of pregnancy. This test, brought out by Abderhalden in 1912, is based upon the fact that during pregnancy the blood contains a proteolytic ferment which causes cleavage of placental albumen. The test is complicated and requires labora- tory apparatus and trained supervision. It is not necessary to describe here the various steps in the test. Any one interested in the complicated details may find an interesting description of them, and a review of the literature, in an article by Schwarz (Interstate Med. Jour., Vol. XX, No. 3, 1913). When carried out under proper supervision and checks, the blood test shows certainly the presence or absence of the placental ferment. The reac- tion is present from the seventh week of pregnancy, continues during preg- nancy, and disappears about two weeks after the termination of pregnancy, regardless of the time (period) of termination. A positive reaction means 160 GYNECOLOGIC EXAMINATION METHODS that the patient has placental tissue in the body or lias had within two weeks past. The placental tissue may be in the uterus or it may be in the tube or in some other extrauterine situation. The fetus may be living or dead. On the other hand, there may be no fetus, only placental tissue. The reaction is given by hydatidiform mole, by chorioepithelioma without recent preg- nancy, and by any condition giving placental tissue with its resulting ferment. If the above facts and limitations be kept in mind, the test may be used to advantage in a number of classes of cases. Serum Test for Gonorrhea The complement-fixation test is useful in identifying those gonorrheal cases in which the gonococcus can not be demonstrated. This serum reaction begins about three weeks after infection and persists as long as there is an active focus of gonococci in the body. It becomes helpful, therefore, in that large class of subacute and chronic cases in Avhich the gonococci have disap- peared from the discharge. In these cases the diagnosis, heretofore, has had to rest on the history and certain incidental examination findings. In a consider- able proportion of these cases the history and examination signs are uncertain and a positive diagnosis of the character of the inflammation therefore impos- sible. These include cases of deep-seated pelvic inflammation and also of dis- tant foci, such, for example, as inflammation of joints or of serous membranes (endocardium, pleura), in all of which a positive diagnosis is required as a guide to most effective treatment. The diagnosis in these doubtful cases may be cleared up with fair certainty by the complement-fixation test — provided the work is carried out by one well trained and Avith proper laboratory facil- ities and one familiar with the various pitfalls to be avoided in reaching con- clusions. The gonococci in different cases are not identical organisms, but may be- long to different ' ' strains ' ' that react differently. Hence the antigen for the test must be prepared from many strains, and even then may possibly miss the strain present in the particular case to be tested. Again, the results are not dependable if the individual has had meningitis or has been vaccinated against meningitis. There are a number of other tests such as the skin reaction, the injec- tion of gonococcus vaccine, and the ophthalmic reaction, which may prove of value, but they are still experimental and uncertain. In the last few years much work has been done towards developing these serum tests for gonor- rhea. An excellent resume of the work to date, with its bearing on diagnosis and treatment, is given in a recent contribution by Abraham Sophian (Port- ner-Lewis: Genito-Urinary Diagnosis and Therapy). MISCELLANEOUS EXAMINATION METHODS 161 Tuberculin Test 111 cases of suspected pelvic tuberculosis, the tuberculin test may give material aid in reaching a jjositive decision. There are several methods of making the test. The tuberculin may be injected under the skin, constituting the subcutaneous tuberculin test of Koch. It may be worked into an abrasion of the skin, as in the cutaneous tuberculin test of Von Pirquet. It may be combined with an ointment and rubbed into the unbroken skin, as in the per- cutaneous tuberculin test of Moro. Also, any of the mucus surfaces may be used for the percutaneous reaction. A solution of tuberculin may be dropped into the eye, constituting the conjunctival test of Wolff-Eisner and Calmette. The subcutaneous test and the cutaneous test are the tAvo most used. The percutaneous test is too uncertain and the conjunctival reaction is too dan- gerous to the eye. Significance of the Reaction. When the test is carried out under proper precautions the reaction is specific — it is produced by tuberculosis antibodies only. It is essentially a test for the antibodies rather than for the tubercu- losis itself. To be antibodies there must, of course, be a tuberculous focus, which produces the toxin that stimulates the cells to the production of anti- bodies. On the other hand, there may exceptionally be a tuberculous focus without the production of antibodies, or at least without the production of antibodies in sufficient quantity to give a characteristic reaction. This ab- sence of antibodies may depend on the condition of the lesion itself (quiescent, thoroughly walled off) or upon some general condition of the patient which prohibits the usual antibody formation from the toxin irritation. In patients markedly cachetic, from advanced tuberculosis or other disease, the vital reaction is often so sIoav that antibody formation is interfered with. The same result has been noted in many acute infectious diseases, including scarlet fever and measles. In a patient in fair physical condition and with no other acute disease, a negative reaction shows certainly the absence of tuberculosis (except a com- pletely quiescent focus), while a positive reaction shows certainly the pres- ence of tuberculosis. It must be kept in mind, however, that the test does not show the location of the tuberculous lesion. Simply because a patient with a suspicious lesion in the pelvis gives a good tuberculin reaction, it does not necessarily follow that the pelvic lesion is tuberculous. The tuberculous lesion may be in a lung or a kidney or in the intestinal tract or it may be a bone lesion, etc. Whether or not the focus giving the tuberculin reaction is in the suspicious pelvic lesion, must be determined by other evidence. Some very serious mistakes have been caused by overlooking this fact. Subcutaneous Tuberculin Test (Koch). One to ten milligrams of tuber- culin is injected subcutaneously, in one dose or in several doses at intervals of two or three days. In a healthy individual this produces no reaction. In an 162 GYNECOLOGIC EXAMINATION METHODS individual liarboriiig tuberculosis antibodies, it x>roduces a decided reaction. The reaction is general, local and focal. The general reaction is the one taken as characteristic of the subcutaneous test, and the most important feature of this is the rise in temperature, which appears in twelve to thirty-six hours and disappears in one to three days. The maximum temperature varies in different cases from 100 to 103, and is accom- panied by corresponding subjective symptoms — aching, nervousness and gen- eral discomfort. The local reaction consists of swelling and redness at the site of the in- jection — more than would be caused by ordinary bacterial contamination. The focal reaction consists of increased congestion about the tubercular focus. The disturbances from the focal congestion may be sufficient to aid some in identifying the location of the tubercular lesion. Cutaneous Tuberculin Test (Von Pirquet). Tuberculin, diluted or undi- luted as preferred, is worked into the superficial lymph spaces of a small area by a specially devised scarifier, which is furnished ^vith the materials for the test. A control lesion is made Avith the same scarifier, thoroughly freed from tuberculin. Alcohol precipitates the tuberculin on the scarifier and hence should not be used — the thorough cleansing of the scarifier being made with water. The reaction reaches its height usually in 21 hours, and if positive, indi- cates tuberculosis antibodies in the individual. Cachectic conditions and acute diseases interfere with this test the same as with the subcutaneous test. In suitable subjects, the cutaneous test has proven very reliable, and on account of the convenience and slight disturbance, it has largely displaced the injec- tion test. All instructive work on the diagnostic and therapeutic use of tuber- culin, is the recent volume by Pottenger (Tuberculin in Diagnosis and Treat- ment). Wassermann Reaction • This blood test for syphilis has proved exceedingly helpful in many doubt- ful cases, and has s„erved to clear up the diagnosis in many cases presenting an obscure and bafiflmg symptom-complex. However, there has been a tendency in some quarters to place too much reliance upon the AYassermann reaction and its modifications. The diagnosis should not be based upon this test alone without other evidence, as there are other conditions that may give rise to this reaction. CHAPTER II GYNECOLOGIC DIAGNOSIS The diagnosis in any case is based upon the symptoms given by the patient and the signs fonnd on examination. It should, as far as possil^le, be both an anatomic and a pathologic diagnosis — that is, it should state the location of the lesion and the character of the pathologic process. Method of Diagnosis Accurate diagnosis is much facilitated by a grouping of diseases under certain prominent symptoms. This is the natural method, the one that is fol- lowed unconsciously. The prominent sign or symptom in the case brings to mind a group of diseases, and then by the consideration of other ascertained facts, the diagnosis is narrowed down to one or two diseases. This differentia- tion should be made as one proceeds with the examination. For example, suppose, during an examination, a sore (ulcer) is found on the external genitals. Immediately arises the question, "Is this a chancroidal ulcer or a syphilitic ulcer or a tubercular ulcer or a malignant ulcer or a simple ulcer f" Endeavor to settle the question then and there. Recall the facts in the history bearing on the differential diagnosis. Notice the character- istics of the lesion. Are there, hi other parts of the body, evidences of syphilis or tuberculosis or malignant disease! Is there an irritating discharge, that could cause a simple ulcer? Each important sign must be thus critically considered, and the habit of doing so should be assiduously cultivated. In a few cases the diagnosis is ap- parent from a few prominent facts, but in most cases, particularly in deep- seated and serious diseases, the diagnosis must be established by a critical analysis of the mass of information obtained in the history and examination. It is this critical analysis, this testing and elimination of diseases that do not stand the test, that makes the difference between the careful diagnosis and the snap diagnosis, between a real diagnosis and a guess, between a reliable diagnostician and an unreliable one. This effective application of the signs to the diagnosis should, as far as practicable, be made promptly and rapidly as they are encountered in the ex- amination. Though in a systematic history and examination, all the important facts are supposed to be obtained, yet if the application of the symptoms to the diagnosis is made as one proceeds, certain points of particular importance in the diagnosis in that case will be given the special attention Avhich they re- 163 164 GYNECOLOGIC DIAGNOSIS quire. Hence the importance of having mentally stored, and ready for immediate use, the diagnostic significance of the various facts brought out in the history and in the examination. The following resume of the diagnostic significance of certain signs and symptoms is given, not as a complete collection of the diagnostic points in the various diseases, but simply as a working plan for the rapid differentiation of the more common gynecologic affections and other conditions likely to be confounded with them. The rarer diseases and the less common diagnostic points and the conditions present in anomalous cases, may be found in the appropriate chapters. POINTS IN THE ABDOMINAL EXAMINATION In this examination the abdomen is, as already explained, subjected to inspection, palpation, percussion, and, in exceptional cases, to auscultation and mensuration. The principal points of diagnostic importance in connection with the abdominal examination are, in the order in which they are encountered in the examination, as follows : Prominence of Abdomen, Movement of Abdominal Wall, Discoloration of Abdomen, Tension of Abdomen, ~ Tenderness of Abdomen, Mass in Abdomen, Area of Dullness in Abdomen. PROMINENCE OF THE ABDOMEN Decided prominence of the abdomen is due to many different affections, which may be conveniently arranged in five groups, as follows : A. Some Affection of Abdominal "Wall ; B. Something in Intestines; 0. Something in Peritoneal Cavity; D. Some Enlarged Organ; E. Tumor from Pelvis or Abdomen. A. Abdominal Prominence From Some Affection of Wall Obesity (Fig. 125). There is evidence of fat deposit in other parts of the body. The abdominal wall may be picked up as a thick roll, and the fingers made to almost meet beneath (Figs 126, 127), showing that most of the prom- inence is due to the thickness of the wall. There is no distinct localized mass, like a tumor in the wall. PROMINENCE OF ABDOMEN 165 Percu-ssion gives resonance all over the abdomen. Sometimes a distinct "fat vrsLve" may be obtained, but it may be distinguished from a "flnid wave" by the expedient shown in Fig. 34, and also by percnssion. In some Fig. 125. Obesity. The most prominent feature in this case is the marked Obesity — see Fig. 128 There is also a fibroid tumor of the uterus and a small amount of ascitic fluid. Fig. 126. Testing the thickness of the Abdominal Fig. 127. Testing the thickness of the Abdominal Wall. First step. Wall. Second step. The fingers carried beneath the wall. 166 GYNECOIiOGIC DIAGNOSIS Fig. 129. Obesity, mistaken for ovarian tumor. This patient vva.', sent to a hospital for operation for a supposed ovarian cyst. (Hirst — Diseases of Women.) Pig. 128. Obesity. Patient standing. Same patient as shown in Fig. 125. Notice t'.ie thick roll of subcutaneous fat that drops down below the general contour of the abdomen. Fig. 130. Obesity, mistaken for pregnancy by patient. (Williams — Obstetrics.) PROMINENCE OF ABDOMEN 167 cases, when the patient stands, a distinct roll of fat drops below the general abdominal contour, as shown in Fig. 128. Fig. 129 shows a case of obesity mistaken for ovarian tumor and sent to a hospital for operation. Fig. 130 shows a case of obesity which was mistaken for pregnancy. Tumor of Wall. There is a distinct mass, which is superficial and moves with the Avail and is apparently inseparably connected with it. The mass may be picked up and the fingers approximated beneath it. There is no apparent Fig. 131. A Tumor of the Abdominal Wall. (Montgomery — Practical Gynecology.) connection with any intraabdominal organ. There is dullness on light per- cussion, but resonance on deep percussion. Fig. 131 shows a tumor of the abdominal wall. Inflammatory Mass in Wall. Same as tumor with evidences of inflamma- tion added — pain, tenderness, fever and, in some cases, redness and fluctua- tion. Some years ago the author witnessed, as a visitor, an operation upon a supposed strangulated ventral hernia. The patient gave a history of a long- standing swelling some distance to the left of the umbilicus. This suddenly 168 GYNECOLOGIC DIAGNOSIS enlarged and became painful, the enlargement being accompanied by abdom- inal pain, vomiting, constipation and evidences of inflammation in the mass. The patient was brought before a medical class for operation. As the hernial site was evidently infected, it was decided to open the abdomen elsewhere and deal with the intestine through the clean opening. Accordingly the peri- Fig. 132. A small Umbilical Hernia, with a relaxed abdominal wall. (Hirst — Diseases of Women.) Fig. 133. A large Ventral Hernia at the site of an operation scar. (Hirst — Diseases of Women.) toneal cavity was opened by a median incision. Exploration showed that the peritoneal surface of the abdominal wall on the affected side was perfectly normal. There was no hernia. The trouble was an abscess of the abdominal wall, probably resulting from the suppuration of a tumor. A large operative PROMINENCE OF ABDOMEN 169 opening into tlie peritoneal cavity in such close proximity to an abscess, made a very uncomfortable state of aifairs for the surgeon, particularly as the abscess was so large and so near the surface that it was thought necessary to open it at once. It was opened as far as possible from the median incision. The patient recovered. Ventral Hernia. There is a distinct localized protrusion, which is most pronounced when standing or sitting, and diminishes when the patient lies down. Coughing makes the mass prominent and gives a distinct impulse to it. The mass is resonant on percussion, when containing intestine, and is partially Fig. 134. The Contour of a Relaxed Abdominal Wall, with the patient Recumbent. Fig. 135. Same patient (Fig. 134), Standing. Notice the marked Projection of the Relaxed Ab- dominal Wall. or wholly reducible. AYhen the mass is reduced, the margin of the opening may be felt. Fig. 132 shows an umbilical hernia. Fig. 133 shows a ventral hernia in an operative scar. When strangulated and so inilamed as to pre- vent satisfactory palpation, a ventral hernia may give much trouble in diag- nosis, particularly if it contains only omentum. Relaxation of Wall. There is general protrusion of wall when sitting or standing, which largely disappears when patient lies down, unless tympanites 170 GYNECOLOGIC DIAGNOSIS Fig. 136. Median grooving of the abdominal wall where there is Separation of the Recti Muscles. The woman is represented as lying on her back. (Webster — Diseases of Women.) Fig. 137. Patient with marked Separation of the Recti Muscles. The illustration shows the marked bulging between the separated recti as the head and chest are raised from the table, the abdominal muscles being thus made to contract. (Webster — Diseases of Women.) PROMINENCE OF ABDOMEN 171 is pronounced (Figs. 134, 135). On palpation the walls are lax and no abnor nial mass is felt. The abdomen is everywhere resonant on percussion. Fig. 138. Patient with marked Separation of the Recti. The photograph from which this illustration was made, was taken as the upper part of the body was being raised from the table. The physician's fist is buried in the gap between the muscles, which are contracting. In this case there was pronounced pendulous abdomen. As the patient lay relaxed on her back, the distance between the muscles at the level of the umbilicus measured five and one-half inches. (Webster — Diseases of Wo me 71.) Fig. 139. Tympanites, mistaken for pregnancy by the patient. The small figure in the upper corner shows the internal condition as determined by the bimanual examination, the uterus being of normal size. (IJdgar — Practice of Obstetrics.) 172 GYNECOLOGIC DIAGNOSIS Separation of Recti Muscles. The recti muscles are ordinarily held firmly together by the junction of the sheath of one side with that of the other side, forming a strong fibrous sejDtum in the median line. In some cases of abdom- inal distention from pregnancy or a tumor, the tissue between the recti muscles is greatly stretched laterally and remains so. This gives a wide Aveak place between the recti muscles, in which the tissues are lax and thin (Fig. 136). When the patient raises her head and shoulders from the pillow, or otherwise makes strong intraabdominal pressure, there is bulging of this weak portion of the wall between the recti (Fig. 137). In such a case, the hand may be sunk deeply into the abdomen between the separated recti muscles (Fig. 138). B. Abdominal Prominence From Something in Intestines Gas (tympanites). This may cause marked prominence when associated with relaxation of abdominal wall. There is no distinct mass felt on palpa- Fig. 140. Ascites. A moderate amount of fluid in a relaxed abdomen. Notice how the abdomen spreads out at the sides. (Kelly — Operative Gynecology.) tion. Percussion shows hyperresonance over all the abdomen. There are usually symptoms indicating gastric or intestinal indigestion. Tympanites is frequently associated with enteroptosis. Fig. 139 shows tympanites Avhich the patient mistook for pregnancy. Fecal Impaction. Fecal impaction may cause localized prominence in any part of the abdomen but it is usually situated along the course of the colon. The diagnosis depends largely on the exclusion of other causes of enlargement, the history of constipation and the effect of treatment directed toward clearing out the intestinal tract. Have the patient take a purgative PROMINENCE OF ABDOMEN 173 Fig 141 Marked Ascites. Notice the gentle slope at the lower and upper portions of the abdomen. In the' case of a tumor the rise is usually much more abrupt. (KeUy — Operative Gynecology.) Fig 142. Extreme Ascites. In the patient from which this photograph was taken, the abdomen was so distended with fluid that the wall was raised higher than the mesentery would permit the in- testine to float, giving dullness about the umbilicus as well as elsewhere (see Figs. 177, 17S . ine rise of the wall from below is rather abrupt. There is also edema of the wall, as shown by the per- sisting groove where the skirts were tied about the waist. 174 GYNECOLOGIC DIAGNOSIS until free bowel movements are secured, then a large enema and then retui- for another examination. Fig. 143. Another case of extreme Ascites, giving dullness about tlie umbilicus as well as in the flanks. Notice the markedly pyramidal form of this abdomen. (Hirst — Diseases of Women.) Fig. 144. Another case of extreme Ascites, giving dullness about the umbilicus and showing a very abrupt rise of abdominal wall below. (Hirst — Diseases of Women.) C. Abdominal Prominence From Something- in the Peritoneal Cavity General Ascites. This may be slight (Fig. 140) or marked (Figs. 141, 142, 143, 144). In ascites, i.e., free fluid in the peritoneal cavity, the abdomen is inclined to spread out at the sides and flatten at the top. There is usually a distinct fluid wave, obtained as previously explained (Fig. 33), which may be distinguished from a fat wave as shoA\m in Fig. 34. When the patient is turned on the side or when she sits or stands, the area of dullness changes, PROMINENCE OF ABDOMEN 175 because the Huid seeks the lowest part of the peritoneal cavity. Figs. 171, 175, 176). Another diagnostic point is that in some cases where there is free fluid in the peritoneal cavity, when the patient stands there is decided protrusion of the umbilicus (Fig. 145), which protrusion disappears when the patient is in the recumbent posture. Encysted Fluid (pus or serum or blood). A distinctly limited collection Fiar- 145. Extreme Ascites. Patient standing. Notice the protrusion of the umbilicus, which is pushed out by the fluid behind it as the patient stands. This is the same patient shown in Fig. 142. of fluid, w^alled off or encysted, may be present in peritoneal tuberculosis and also in abscess from salpingitis or appendicitis. There may be considerable solid exudate associated with the sAvelling, and also other evidences of inflammation, either septic or tubercular. The diagnosis between the two forms of inflammation may usually be readily made from the history and the accompanying symptoms. Extrauterine pregnancy, like the inflammatory 176 GYNECOLOGIC DIAGNOSIS Fig. 146. Contour of the abdomen in Pregnancy, with patient recumbent. (Edgar — Practice of Obstetrics.) ^< /(/// y/ 'inp}nj Fig. 147. Contour of the abdomen in a case of Distended Bladder. The patient is in labor. Notice how well the bladder prominence stands out from the general abdominal prominence due to the pregnant uterus. (Norris — American Textbook of Obstetrics.} Fig. 148. Frozen section of the body of a woman who died from Rupture of a Distended Bladder. The cause of the retention of urine was a retro- verted uterus four months pregnant. (Norris — American Textbook of Obstetrics, from Arch, of Gyn.) PROMINENCE OF ABDOMEN 177 processes just mentioned, may present the evidences of encysted fluid. For the points in differential diagnosis, between extrauterine pregnancy and ordi- nary pelvic inflammation, see Chapter xi. Pseudocyst of the Lesser Omentum. Following injuries of the pancreas Fig. 149. Contour of the abdomen in a case of large Cystic Tumor (parovarian). Notice the abrupt rise of the abdominal wall at both the lower and upper portions. (Kelly — Operative Gynecology.) Fig. ISO. Contour of the abdomen in a case of large Solid Tumor (uterine fibroid). The irregularity, so common in solid tumors, is well marked. (Kelly — Operative Gynecology.) or disease of the same, there may be a collection of fluid in the lesser peritoneal cavity, causing prominence of the abdomen and evidence of encysted fluid. The diagnosis is usually made during the progress of the operation. In all 178 GYNECOLOGIC DIAGNOSIS these cases of encysted fluid or solid exudate, there is dullness over that joortion of the mass lying against the abdominal wall and resonance elsewhere. D. Abdominal Prominence From Some Enlarged Organ Uterus Pregnant (Fig. 146). There is dullness over the mass and reso- nance at the sides (Fig. 167). There is no change of outline of dullness on Fig. ISl. Another case of large Cystic Tumor. Here the tumor (an ovarian cyst) is extremely large and the rise of the abdominal wall at both lower and upper portions is very abrupt. (Bovee — Practice of Gynecology.) Fig. 152. Appearance of the abdomen in a case of Extrophy of the Bladder. A carcinoma has developed in the deformed and turned-out bladder. (Kelly — Oj'eratk'e Gynecology.) PROMINENCE OF ABDOMEN 179 change of position of patient. There are also the varions signs of pregnancy, inclnding the fetal heart sounds if the pregnancy is far enough advanced. Bladder Distended with Urine. The retention of urine to such an extent that the distended bladder produces a distinct prominence of the abdomen, happens occasionally in pregnancy with retrodisplacement of uterus (Fig. 148), in labor (Fig. 147), in pelvic tumors compressing the urethra and in certain nervous affections. There is dullness over the mass and resonance at the sides. There is usually a frequent desire to urinate, with the passage of onlv a small amount of urine. But there may be a constant dribbling of Fig. 153. Contour of the abdomen in a case of Retroperitoneal Tumor (sarcoma). The project- ing mass in the region of the umbilicus is well shown. The outline of the palpable mass and also the area of dullness are shown in Fig. 187. (Patient of Dr. Flsworth Smith, Jr., to whose kindness the author is indebted for this photograph.) urine due to overdistention. If the bladder be emptied with a catheter the diagnosis becomes clear. Use a long soft-rubber catheter, as the ordinary female catheter may be too short to reach the entrance of the bladder, and if the catheter be not flexible it can not follow the devious course of the distorted urethra. Patients have died from rupture of the bladder due to unrecognized overdistention (Fig. 148). Spleen Enlarged from chronic malaria, leukemia or other cause. 180 GYNECOLOGIC DIAGNOSIS Liver Enlarged from malignant disease, hypertrophic cirrhosis or other cause. Gall-bladder Enlarged on account of occlusion of duct and distention with mucous secretion and inflammatory exudate. It sometimes becomes so much distended as to form a large cystic mass in the right side of the abdomen. E. Abdominal Prominence From a Tumor A Tumor Projecting up from the Pelvis (Fig. 149). Such a tumor has its point of attachment in the pelvis, the free margin of the growth extending upward into the abdominal cavity. The growth may be either cystic or solid. There is dullness over the mass and resonance at the sides (Fig. 168). There is no decided change of outline of dullness with change of position of patient, except where there is complicating ascites. There are found also the usual symjDtoms caused by the particular variety of pelvic tumor present. The ordinary new growths that project up from the pelvis are : Fibroid tumor of uterus (Fig. 150). Malignant tumor of uterus (carcinoma, sarcoma). Cystic tumor of ovary (ovarian cyst, Fig. 151). Cystic tumor of broad ligament (parovarian cyst). Solid tumor of ovary (fibroma, carcinoma, sarcoma, papilloma). Solid tumor of bladder (Fig. 152). Solid tumor of rectum. A Tumor Connected with some Abdominal Structure (Fig. 153). Such a tumor has its point of attachment in the abdomen with the free margin of the growth extending toward, and sometimes into, the pelvic cavity. There is dullness over that portion of the mass lying against the abdominal wall and resonance elsewhere, unless there be associated ascites. There are symptoms also pointing to the organ affected and the nature of the growth. The principal tumors that originate in the abdomen are : Solid Tumors of the Cecum, Sigmoid, or other parts of the Intestinal tract (usually malignant). Solid Tumor of the Stomach (usually malignant). Solid Tumor of the Liver (usually malignant). Solid Tumor of the Spleen. Solid Tumor of Kidney. Solid Tumor of Pancreas. Solid Tumor of Eetroperitoneal Structures (Fig. 153). Cystic Tumor of Kidney. Cystic Tumor of Pancreas. Cystic Tumor of Omentum. Cyst of ^Mesentery. Pseudocyst of lesser Omental cavity. DISCOLORATION OF ABDOMINAL SURFACE 181 MOVEMENT OF ABDOMINAL WALL In certain cases some information may be obtained by watching the move- ments of the abdominal wall. In painful affections within the abdomen, such as peritonitis or intraperi- toneal hemorrhage or intestinal obstruction, the wall is held rigid to a con- siderable extent and the respiratory movements of the wall are very slight. In the case of a tumor splinting the wall, the portion of the wall raised by the tumor remains stationary, while the remainder shows the respiratory movements. It is important to know whether or not a tumor moves with respiration. As a rule a tumor of an abdominal organ moves up and down with the dia- phragm in respiration, and this up and down movement may often be dis- tinctly seen and felt through the wall at the lower margin of the growth or at the prominent part of the mass. If the tumor is firmly adherent to the wall, this movement under the wall can not then take place. In some cases this fact may be turned to account in determining the presence or absence of adhesions. A growth from the pelvis does not move with respiration. Movement of the child may sometimes be plainly indicated in late preg- nancy by a prominence moving beneath the wall, due to an extremity moving from one part of the uterus to another and pushing out the wall as it moves. Occasionally the intermittent contraction of a pregnant uterus may be noticed by its raising the wall as it becomes firmer and more prominent. Pulsation of the abdominal wall may be due to an aneurysm. Not infre- quently, especially in thin patients, the pulsations of the normal aorta are transmitted to the overlying wall, either directly or through an intervening tumor. In some eases of intestinal obstruction or marked tympanites, a distinct peristaltic wave may occasionally be seen to pass across the abdomen in the course of the distended bowel. It is usually accompanied by a cramp-like pain. DISCOLORATION OF ABDOMINAL SURFACE Occasionally there is a well-marked central line of pigmentation, extend- ing from the pubes to the umbilicus (Fig. 18). This is usually the result of a previous pregnancy. Dilated Veins at the lower part of the abdominal surface, as a rule, mean that there is some mass compressing the intrapelvic veins. Edema of the wall may be due to inflammation in the wall, or to heart or liver or kidney disease. Striae (Fig. 16) from a former stretching of the wall, usually mean a former pregnancy continuing to near term, but they may come from any large tumor or from a former obesity of the abdominal wall. Such striae are occa- sionally seen on the thighs of patients who have been stout. 182 GYNECOLOGIC DIAGNOSIS When tlie wall is relaxed, i.e., has been overstretched and has not regained its tone, it is very uneven and the skin appears wrinkled and corrugated. This folded redundant condition is nearly always present in decided enteroptosis. The eruption of secondary syphilis (syphilitic roseola) is occasionally of decided help in determining the character of an atypical vulvar lesion. An eczema or other eruption near the site of a proposed operative incision, may necessitate postponement of the operation until the eruption is cured. A scar indicates that there was at one time a burn or a blister or an area of ulceration of the wall or an injury of the wall or an operative incision. TENSION OF ABDOMEN Tension of the abdominal wall interferes very much Avith a thorough pel- vic examination. It is due to one of the following conditions : Fear or Timidity or Embarrassment, causing the muscular wall to be held tense. This tension usually disappears as the examination progresses and the patient sees that you are not going to cause pain. Even in very troublesome cases, relaxation of the wall may usually be secured by directing the patient to take a full breath and then let the breath all out. During expiration, when not forced, the wall relaxes and deep palpation may be made. In sinking the fingers into a region or about a mass for palpation, proceed gently and firmly and steadily toward the desired point, going a little deeper with each expira- tion. Do not gouge or jab or endeavor to reach the depths of a region by sudden forced movements. These all invite failure by causing reflex contrac- tion of the abdominal muscles. Inflammation, Local or General, beneath the wall causes tension of the overlying muscles. This tension is usually both voluntary and involuntary. The patient can relax the wall to some extent but not entirely, providing the inflammation is acute and severe. There is also marked tenderness over the aifected area and other evidences of an inflammatory affection. Mass, Solid or Containing Fluid. If lying immediately beneath the wall this gives a sensation of tension or resistance to the palpating fingers. In excep- tional cases, as in an extra large tumor or very marked ascites, the abdomen may be so filled that the outer abdominal wall is stretched and tense. Hysteric Contraction of the muscular wall is sometimes seen. When taking place in an irregular Avay (part contracted and part relaxed) and asso- ciated with tympanitic distention and with marked hyperesthesia, it may cause the condition known as ''phantom tumor," which has led to so many serious mistakes in abdominal diagnosis. The administration of a purgative to clear out the intestines and diminish the tympanites and of some nerve sedative to diminish the hyperesthesia and nerve irritability, may remove the tension sufficiently to admit of a satisfactory examination. If not, the patient should be examined under anesthesia, provided the symptoms are serious enough to TENDERNESS IN ABDOMEN 183 make a positive diagnosis necessaiy at once. Under anesthesia the tension of the abdominal wall disappears, and deep palpation may be made in the affected region and the presence or absence of an abnormal mass determined. TENDERNESS IN ABDOMEN For the purpose of studying the significance of tenderness in the abdo- men, it is convenient to divide the cavity as previously explained, into nine Fig. 154. The Right Lower Abdomen. The organs commonly affected and the areas accordingly of particular interest, are indicated by the stippling. regions: the right, left, and central portions of the lower abdomen; the right, left and central portions of the upper abdomen; the central portion of the abdomen (umbilical region); and the right and left lumbar regions (Fig. 28). In any of these, a local tenderness takes on particular significance. Again, there are certain diseases that cause a diffuse tenderness, extending throughout the whole abdomen. 184 GTKECOLOGIC DIAGNOSIS Fig. 155. Indicating the point to seek for Ten- Fig. 156. Indicating the point to seek for Appendix derness due to Tubal or Ovarian disease of the right Tenderness, side. Fig. 157. Palpating for the Appendix itself, to determine whether or not there is any appreciable infiltration and thickening of it. When thickened, the appendix is felt as a small tender roll, deeply- placed. Fig. 158. Another method of palpating the Ap- pendix. Beginning near the umbilicus, the fingers are carried in deeply and then brought slowly out- ward toward the anterior superior iliac spine. As the appendix passes under the examining fingers, it is felt as a small roll between the fingers and the posterior abdominal wall. TENDERNESS IN ABDOMEN 185 Tenderness in Right Lower Abdomen (Fig-. 154) Tubal or Ovarian or Broad Ligament Disease (inflammation, tumor, ex- trauterine pregnancy). The tenderness is most marked low in the side near Poupart's ligament (tubo-ovarian region, Fig. 155). It does not ordinarily extend to the appendix region though it may, in exceptional cases, involve both regions. A mass may be felt on vagino-abdominal palpation between the uterus and the pelvic wall. There is a history of uterine and pelvic inflamma- tion or other pelvic disturbance. Fig. 159. Indicating the site to search for Tenderness of the Right Ureter. This- may be found any- where from the point indicated to some distance inside the circle, towards the umbilicus. Appendicitis. Tenderness is most marked at about the middle of a line draAvn from the right iliac spine to the umbilicus (McBurney's point, Fig. 156). By sinking the fingers deeply into the abdomen near the umbilicus and then carrying them outward toward the iliac spine, the appendix may often be felt to roll under the fingers as a tender cord (Figs. 157, 158). There is usually a history of stomach or bowel disturbance and of attacks of pain radiating about the umbilicus and finally settling do%vn in the appendix region. 186 GYNECOLOGIC DIAGNOSIS Some Disease of the Cecum or Ascending Colon. Inflammation, tumor and intussusception are the more common affections of the cecum. They present much the same local signs as mild appendicitis. The tenderness and the mass are not localized to the appendix region, however, but extend up along the ascending colon. Ureteritis. There is a painful point over the ureter (Fig. 159) and tender- ness extending up and down the course of the same (Fig. 154). There is Fig. 160. The Left Lower Abdomen. The organs commonly affected and the areas accordingly of particular interest, are indicated by the stippling. usually pain extending from the kidney along the ureter, to the bladder. There is nearly always decided tenderness over the kidney (Figs. 161, 162). Movable Kidney. A rounded mass is felt on deep palpation in or near the appendix region. It is somewhat tender. It is movable and may be dis- placed upward into the kidney region. Special methods for palpating same are shown later (Figs. 389, 390). There is a history of irritable bladder. TENDERNESS IN ABDOMEN 187 particularly when standing or walking. There may be pain radiating from the kidney region along the ureter to the bladder. The urinary findings will indicate whether or not there is inflammation or irritation along the urinary tract. Kidney Disease, for example, a tumor or tuberculosis or inflammation, may cause tenderness extending from the kidney down into the right lower abdomen. Kidney disease is indicated by tenderness and enlargement found in palpation, and by the urinary findings. Intestinal Disease. Painful diseases of the small intestine, either acute or chronic, may give rise to tenderness in the right lower abdomen. Tubercular Peritonitis and other forms of peritoneal disease occasion ten- derness here, when extending to this region. Fig. 161. The point for Kidney Tenderness Laterally. Fig. 162. The point for Kidney Tenderness Posteriorly. Nervous Affection. Various organic and functional nervous diseases cause marked hypersensitiveness of the abdominal surface and of the intraabdominal structures. The pain complained is out of proportion to any obvious sign of disease. By palpating over the abdomen it is found that there is tenderness everywhere, even up on the chest walls. Pinching up the skin may cause almost as much pain as the pressure on deeper structures. General observa- tion of the patient will show that she is nervous. Special examination will show evidence of neurasthenia, hysteria or other disease of the nervous system. 188 GYNECOLOGIC DIAGNOSIS Tenderness in Left Lower Abdomen (Fig. 160) The affections that cause tenderness in the left lower abdomen are the same as those just given for the right lower abdomen, substituting the sigmoid flexure and the descending colon for the appendix, cecum and ascending colon. Fig. 157 shows palpation for left tubo-ovarian tenderness and Fig. 158 indicates the point for left ureteral tenderness. ■i / ;l Fig. 163. The Right Upper Abdomen. The site of the gall-bladder, the area of particular interest in this region, is indicated by the letters, G. B. Tenderness in Central Lower Abdomen Intestinal Disease. There are many affections of the intestines that give pain on pressure in the central lower abdomen, for example, ordinary enteritis, mucous enteritis, tubercular enteritis and typhoid fever. The tenderness is widespread, usually extending into the upper part of the abdomen. There are TENDERNESS IN ABDOMEN 189 also the gastro-intestiiial symptoms that accompany these diseases and, in ad- dition, the symptoms and signs peculiar to each disease. Inflammation of Uterus. The tenderness is confined to the central part of the lower abdomen and is elicited usually only by deep pressure. There are also the various special evidences of uterine inflammation. Pelvic Inflammation. Pelvic inflammation in any form is likely to give rise to tenderness extending throughout the lower abdomen. Even if the in- flammation is confined strictly to the tube on one side, there is usually some tenderness on pressure in the median line. There is a history of pelvic inflam- mation, with characteristic tenderness of the affected adnexa in the bimanual examination, and perhaps also a distinct mass. Fig. 164. Indicating the site for Tenderness or a Mass due to disease of the Gall-bladder. It may- be found anywhere from the point indicated downward and outward to the margin of the ribs on the right side. Bladder Disease. The tenderness is very low, just above the pubes. There is a history of frequent, painful urination. Pressure on the affected region may cause a desire to urinate. Examination of the urine will show evidences of bladder or kidney disease. Tubercular Peritonitis. This tenderness is widespread over the abdomen. There is encysted fluid or a mass of exudate or general ascites. The trouble is usually chronic. There may be evidence of tuberculosis elsewhere (lungs, intestines). There is no apparent focus of ordinary infection, such as salpin- gitis or appendicitis. 190 GYNECOLOGIC DIAGNOSIS Tenderness in Right or Left Lumbar Region Renal and Suprarenal affections are the pathologic conditions peculiar to the lumbar regions, and the usual causes of tenderness there. Fig. 161 indi- cates the point in the lateral lumbar region to make pressure for kidney tender- ness, and Fig. 162 shows the point posteriorly. In palpating for a mass in the same region, one hand may be placed behind and the other in front so as to catch the structure betAveen the palpating fingers. Tenderness in Right Upper Abdomen (Fig. 163) Diseases of the Gall-bladder or of the Liver are the common causes of tenderness in the right upper abdomen, the usual condition being cholelithiasis or hepatitis or tumor of the liver. Fig. 164 indicates the point to seek for gall-bladder tenderness. It may be found anywhere from the point indicated by the finger outward to the costal margin. Occasionally an affection of the pyloric end of the stomach or of the duodenum or of the hepatic flexure of the colon or of the right kidney, causes tenderness extending well into the right upper abdomen. But in practically all these conditions the tenderness may be traced out of this region and for a considerable distance along the organ affected. Tenderness in Left Upper Abdomen Diseases of the spleen or of the splenic flexure of the colon or of the cardiac end of the stomach or of the left kidney or suprarenal capsule, ai^e the usual causes of tenderness in the left upper abdomen. The left hypo- chondriac region is the area for splenic tenderness. The dragging pain from an enlarged spleen is usually referred by the patient to this area. Tenderness in Central Upper Abdomen Tenderness in this region is usually due to an aft'eetion of the stomach, or of the liver. In doubtful cases, when there is so much widespread tenderness that there is uncertainty as to whether it is from the stomach or the liver, remember that stomach disease is often accompanied by attacks of pain under the left shoulder-blade while liver disease is frequently accompanied by pain under the right shoulder-blade. Less frequently, tenderness in the region is due to disease of the pancreas or to some affection of the peritoneum. Tenderness in Umbilical Region Diseases of the small intestine and diseases of the peritoneum and omentum, are the usual causes of tenderness localized in this region. In the lower outer portions of the region the ureters encroach, and may cause point tenderness on one or both sides (Fig. 159). MASS FELT ON ABDOMINAL PALPATION 191 Diffuse Tenderness Throughout Abdomen The usual causes of this are general peritonitis, tubercular peritonitis, gastro-enteritis, neurasthenia and hysteria. Appendicitis, gastritis and many other conditions give rise to tenderness or j^ain which is diffuse at first, but it soon becomes distinctly localized. MASS FELT ON ABDOMINAL PALPATION The masses of particular interest in gynecologic diagnosis are those situ- ated in the lower abdomen. For exact differential diagnosis these are pref- erably taken up later. Consequently here the author will simply indicate by name the various masses found. It must be kept in mind, however, that in addi- tion to the various masses that may originate in any region, masses from elsewhere may be found in that region, because of growth or displacement or both. In Fig. 165, the arrows indicate the usual direction of growth, or displacement, of a tumor of the various organs outlined. Mass Felt in Right Lower Abdomen (Fig-. 154) Tubal Inflammation (salpingitis, pyosalpinx, hydrosalpinx). Tubal Pregnancy. Tubal Tumor (fibroma). Ovarian Inflammation (oophoritis, ovarian abscess, cystic ovary). Ovarian Tumor (cystic, solid). Parovarian Tumor (cystic). Fibromyoma of Uterus. Appendiceal Inflammation or Tumor. Tumor of Cecum. Movable Kidney or Tumor of Kidney. Mass Felt in Left Lower Abdomen (Fig. 160) Here are found the same conditions as described for the right side, sub- stituting sigmoid flexure for cecum and appendix. Mass Felt in Central Lower Abdomen Pregnant Uterus. Fibromyoma of Uterus. Malignant Tumor of Uterus. Distended Bladder or Tumor of Bladder. Pelvic Inflammation with Exudate. Pelvic Tuberculosis. Tubal Pregnancy. Ovarian or Broad Ligament Tumoi-, groAving in from the side. 192 GYNECOLOGIC DIAGNOSIS Appendiceal, Cecal, Sigmoid or Kidney Mass, extending in from the side. Occasionally, Spleen, Liver, Gail-Bladder, Stomaeh, Pancreas or Peritoneal Masses, extend into this region. Mass Felt in Right Upper Abdomen (Fig-. 163) Enlarged Liver. Enlarged Gall-bladder. Tumor of Liver. ^^• Fig. 165. Showing the Direction of Growth of Tumors of various Abdominal and Pelvic organs. In practically all cases, the direction of enlargement is toward the umbilical region. (Kelly — Operative Gynecology.) Abscess of Liver. Tumor of Pyloric End of Stomach. Tumor of Duodenum. Tumor of Hepatic Flexure of Colon. Tumor of Kidney. Abscess of Kidney. Tuberculosis of Kidney. MASS FELT ON ABDOMINAL PALPATION 193 Fig. 166. Indicating the Area of Dullness due to moderate Distention of the Bladder. Fig. 167. Indicating the Area of Dullness from a large Mass of regular outline springing from the Center of the Pelvis, for example the pregnant uterus. The dotted line shows the upper limit of the mass as determined by palpation. 194 GYNECOLOOIC DIAGNOSIS Mass Felt in Left Upper Abdomen Enlarged Spleen. Tumor of Spleen. Abscess of Spleen. Tunior of Cardiac End of Stomach. Tumor of Splenic Flexure of Colon. Tumor of Kidney. Abscess of Kidney. Tuberculosis of Kidney. Fig. 168. Indicating the Area of Dullness from a Central Pelvic Mass which has enlarged to such an extent that it nearly fills the abdomen. Notice that the corona of resonance, surmounting the area of dullness, is symmetrical on the two sides. If the mass were lateral, for example, an ovarian or parovarian tumor, the area of resonance would be decidedly less on the side of the tumor than on the opposite side. Mass Felt in Central Upper Abdomen Tumor of Stomach. Tumor of Left Lobe of Liver. Fecal Impaction in Transverse Colon. Tumor of Transverse Colon. Tumor of Duodenum, Tumor of Pancreas. AEEA OF DULLNESS IN ABDOMEN 195 AREA OF DULLNESS IN ABDOMEN An area of dullness in the abdomen indicates that something' solid or fluid is lying against the abdominal wall, pushing the intestines away or flatten- ing out the intestine between the mass and the wall. When an area of dull- ness is found in percussing over the abdomen, the first thing to do is to ascertain its exact outline. The getting of the shape of the area clearly in mind is much facilitated by outlining it, wholly or partially, with a lead pencil or other marker. This outlining of the area shows what region or regions it is situated in, and also shows whether or not it is of such position and size and shape as would be likely to be caused by the enlargement of any adjacent organ. In some cases the employment of both superficial and deep percussion may aid some in differential diagnosis. -7 Fig. 169. Indicating the region for Dullness from Enlarged Liver. Fig. 170. Indicating the region for Dullness from Enlarged Spleen. Then determine if the area of dullness can be shifted by pressure — by attempting to push about any mass that may be in the abdomen. Then determine if the outline of the dullness changes with the position of the patient. For example, mark out the area with the patient lying on the back, then have her turn on one side and mark it in that position. Then have the patient stand, if she is able, and mark the outline of the dullness in that position. This is of much importance in the diagnosis of free fluid in the peritoneal cavity. An area of dullness Avhere there should be resonance may be due to any of the following conditions : — An enlarged organ — for example, the bladder distended with urine (Fig. 196 GYNECOLOGIC DIAGNOSIS 166), a pregnant uterus or other median mass (Figs. 167, 168), the liver en- larged from various causes (Fig. 169) or the spleen enlarged' from various causes (Fig. 170). The dullness extends to the region normally occupied by Fig. 171. Showing tlie Area of Dullness in moder- ate Ascites, with the patient b'ing on her back. Fig. 172. Showing the reason for the disposi- tion of the Dull and Resonant Areas in a case of moderate Ascites. (Butler — Diagnostics of In- ternal Medicine.) Fig. 173. Indicating the relation of the Dull and Resonant Areas in the case of a Tumor occupy- ing the central lower abdomen. (Butler — Diag- nostics of Internal Medicine.) Fig. 174. Ascites. Representing the patient turned on one side. The fluid gravitates to the under side, leaving the upper fiank resonant. (Butler — • Diagnostics of Internal Medicine.) the organ. It has about the shape to be expected in symmetrical or asym- metrical enlargement of the organ in question. There are other evidences of disease of that organ. There is nothing else found to account for the dullness. AREA OF DULLNESS IN ABD0:MEN 197 Each of these points should be considered, when endeavoring to ascertain wliether or not a mass is due to enlargement of some particular organ. Free Fluid in Peritoneal Cavity (Ascites). In this condition the fluid of course seeks the lowest part of the peritoneal cavity, being drawn there by gravity, and the upper margin of the fluid, represented by the upper margin of the area of dullness, is approximately horizontal. As the patient changes position, the fluid changes its relative position, to conform to the law just given — hence the change in the outline of the area of dullness, which is so characteristic in these cases. To illustrate the application of this law, take a case of moderate ascites. With the patient on her back the dullness would be as represented by the dark area in Fig. 171, with a corona of resonance Fig. 175. Indicating the Area of Dullness in a case of moderate Ascites, with the patient turned on the left side. about the umbilicus, which is the highest point. Fig. 172, which represents a cross section of the body in such a case, explains the cause of the dull and re- sonant areas. Fig. 173 shows the contrasting condition produced by a tumor, and the area of surface dullness produced by the same is indicated in Fig. 167. When the patient with ascites turns on her side, the fluid shifts as indicated in Fig. 174 and the area of dullness changes as shown in Fig. 175, the upper flank becoming resonant. When the patient stands, the fluid again shifts, seeking the lowest part, and the outline of dullness changes to that shown in Fig. 176. Notice that in alb positions of the patient, the fluid occupies the loAvest part of the peritoneal cavity, and the upper margin of the fluid 198 GYNECOLOGIC DIAGNOSIS is approximately horizontal. Of course the height of the area of dullness varies in different cases depending on the amount of fluid in the cavity. The illustrations already referred to indicate the dullness in the cases of ascites of moderate severity. If there is only a small amount of fluid in the cavity, there may be only a small area of dullness appreciable in each flank, as the patient is lying on her back, "When the patient turns on the side, the area of dullness increases appreciably in the lower side and disappears entirely in the upper flank. When the patient stands, there may be a small area of dullness in lower abdomen just above the pubes, or there may be no dullness appreciable anywhere in the abdomen, because the amount of fluid is so small that it is all concealed in the depth of the pelvic portion of the peritoneal cavity. On the other hand, in exceptional cases the amount of fluid is so Fig. 176. Indicating the Area of Dullness in moderate Ascites, with the patient standing. great that it fills the peritoneal cavity and raises the abdominal wall above the intestines (higher than the mesentery will permit the intestines to float), giving dullness about the umbilicus as well as elsewhere. This does away with the corona of resonance about the umbilicus, which is so characteristic a feature of ordinary ascites. Fig, 142 shows a patient sent to the author with a supposed ovarian cyst. The general appearance was very much like that t)f a cyst distending the abdo- men. The area about the umbilicus was dull, excluding ordinary ascites. In percussing carefully over the whole abdomen, however, the author found an area of resonance in the left upper abdomen. Fig. 177 shows the outline of AREA OF DULLNESS IN ABDOMEN 199 this area when the patient was lying on her back. Fig. 178 shows the outline of the area of resonance when the patient was standing. A comparison of these two areas (Fig. 179) showed that there was decided variation in the area of dullness with the change of position, without any important change in the general shape of the abdomen, a condition that could be caused only by free fluid in the peritoneal cavity. As the patient stood, there was distinct bulging of the umbilicus (Fig. 145) and distinct fluctuation through the thin umbilicus. There was present also edema of the abdominal wall. On vaginal examination, no tumor was felt in the pelvis. These signs were considered Fig. 177. A case of Extreme Ascites. Same patient as shown in Fig. 142. Showing the Area of Dullness when the patient is on her Back. The light area is all that is resonant. sufficient to exclude ovarian cyst, and the author sent the patient back to her physician with a diagnosis of ascites. As there was no decided kidney disease or heart lesion, the marked ascites was supposed to be of hepatic origin, which diagnosis was confirmed by the woman's death from sudden gastric hemor- rhage and by the partial postmortem examination, the details of which were kindly given the author by her physician. Figs. 143 and 144 show other cases in which the amount of ascitic fluid was so great that the abdominal wall was raised above the intestines, and the corona of resonance about the umbilicus was consequently absent, 200 GYNECOLOGIC DIAGNOSIS Again, ascites may be associated with an abdominal tumor, either as a complication or from some intercurrent disease. In either case, the association of the two is indicated by the outline of the area of dullness with the patient in ditferent positions. Fig. 125 shows a patient presenting obesity and a fibroid tumor and moderate ascites. The obesity was very apparent on inspection. On palpating, to determine if there were any further causes for the prominent abdomen, the author found that there was a distinct mass extending upward from the pelvis into the central abdomen. Xothing more was found on palpation, except considerable tenderness over the tumor. Pass- Fig. 178. Extreme Ascites. Area of Dullness with patient Standing. Same patient as shown in Fig. 177. Notice the marked change in the resonant area. The upper limit of the dullness is now almost hori- zontal. The former marks have not been completely removed. ing to percussion of the abdomen, with the patient lying on her back there was dullness over the mass extending, in the median line, to a short distance above the umbilicus and extending symmetrically to each side. In trying to determine accurately the area of dullness in the left side, the author found that it extended horizontally along the flank as shown in Fig. 180. Percus- sion in the right flank showed a])out the same area of dullness there. The patient was then directed to stand and percussion was again employed. When AREA OF DULLNESS IX ABDOMEN 201 standing, the area of dullness was as shown in Fig. 181. A comparison of these two outlines (Fig. 182) makes it plain that there was an unchanging area of dullness (due to the tumor) and a changing area of dullness, due to free fluid in the peritoneal cayity (ascites). Encysted Fluid. This may l^e serum or ordinary pus or tubercular pus. Fig. 179. Extreme Ascites. Same patient as shown in Fig. 177. The Two Resonant Areas contrasted. The area enclosed by the solid line is resonant when the patient is on her back, while all elsewhere is dull on percussion. The area enclosed by the dotted line is resonant when the patient stands, while all elsewhere is dull. The change of outline of the dullness on change of posture is clearly marked. * There is dullness over the mass and resonance elsewhere (Figs. 183, 184). There is no change in the outline of the dullness on change of position of the patient, such as occurs with free fluid. A rather rare condition of special interest coming under this category is the pseudocyst of the lesser omental cavity. An encysted collection of fluid occupying the cavity occasionally appears several weeks or months following 202 GTXECOLOGIC DIAGNOSIS ail abdominal injury. Injuries so resulting are supposed to have involved the pancreas, it being held that the collection of fluid in the lesser omental cavity is due to the irritation from pancreatic fluid, ^vhich found its way from the damaged pancreas into the cavity mentioned. The small opening that leads from this lesser peritoneal cavity into the greater peritoneal cavity (foramen of AYinslow'), becomes closed in the beginning of the trouble and the fluid is confined within the lesser cavity. As this cavity lies back of the intestines, the mass of encysted fluid is partially covered by intestinal reso- nance, presenting the characteristic percussion signs of a retrointestinal mass. Tumor from the Pelvic Organs. The tumor may be solid or cystic. It may be situated in the center or laterally or may fill the whole abdomen. There is dullness over that portion of the mass lying against the abdominal Fig. 180. A case of Ascites and Tumor. Same patient as shown in Fig. 125. Showing the Area of Dullness with patient on her Back. The central dullness is caused by the tumor and the lateral dullness by ascitic fluid. The dullness is practically the same on the two sides. wall and resonance elsewhere, unless there is associated ascites. There is no decided change of outline of the dullness with change of position of the patient. The growth may spring from the uterus (Fig. 185) or from the ovary or broad ligament. The latter growths are usually situated well to one side at first but later may fill the whole lower abdomen. Vsually in such a growth there is still a corona of resonance surrounding the upper part of the growth and extending well into each flank. In other cases the tumor grows into the flank and crowds the intestines upward and into the opposite flank. In such a case there is dullness over all the front of the abdomen and also in one flank, there being resonance in the opposite flank only (Fig. 186). There is no change of the outline of resonance with change of position of the AREA OF DULLNESS IN ABDOMEN 203 patient, the distinct resonance in the opposite flank remaining even when the patient is turned well over on that side, provided there is no complicating ascites. Tumor from Some Abdominal Organ. There is dullness over that portion of the mass lying against the wall and resonance elsewhere, unless there is associated ascites. Such a tumor may spring from the liver or from the spleen or from some part of the gastro-intestinal track. The usual sites for Fig. 181. Ascites and Tumor. Area of Dullness with patient Standing. Same patient as shown m Fig. 180. Notice the marked change in the upper limit of the dullness. It is now almost horizontal. The former marks have not been completely removed. tumors in the digestive track are the pyloric end of the stomach, the cecum and the sigmoid flexure of the colon. Tumor of Some Retrointestinal Structure. The characteristic feature of retroperitoneal masses (either inflammatory masses or new growths) is that there is intestinal resonance in front of them. When the groAvth reaches a large size the intestines are usually pushed aside over a considerable area, so that a part of the palpable tumor mass shows dullness and a part shows intestinal resonance. Fig. 187 shows such an abdominal groAvth. The size of the palpable tumor is indicated by the dotted outline and the area of dullness 204 GTXECOLOGIC DIAGNOSIS Fig. 182. Ascites and Tumor. Same patient as shown in Fig. 180. The Two Areas Contrasted. The solid line shows the border of the dull area when the patient is on her back and the dotted line when she is standing. The change of outline of the dullness on change of posture is very evident, making it beyond doubt that, whatever other abnormal condition tiere may be in the a])domen, there is certainly free fluid. iN'otice also that as the patient stands, the upper margin of the dull area (dotted line) is approximately horizontal. Fig. 183. Indicating the situation of the Area of Dullness due to a large Inflammatory ^lass or a small Tumor arising from the right Tubo-ovarian region. Fig. 184. Indicating the situation of the Area of Dullness due to an Inflammatory Mass arising from the Appendix or Cecum. AREA OF DULLNESS IN ABDOMEN 20J I'ig. H Indicating the Irregularity and grotesqueness of form often presented by the Dull Area in Uterine Fibromyoinata. Fig. 186. Indicating the outline of the Area of Dullness in a case of large Ovarian Cyst from the right side, the tumor having become so large that it has crowded the intestines out of the right flank, and its dull area joins with that of the liver. The left flank is resonant and remains so in all i^ostures. 206 GYNECOLOGIC DIAGNOSIS is surrounded by the solid line. Inflation of the stomach in this case caused the area of dullness to disappear almost entirely, showing that the growth sprung from some structure back of the stomach cavity. A retrointestinal tumor may spring from the pancreas or from the mesenteric glands or from the retroperitoneal glands or adjacent structures or from the kidneys or suprarenal glands. A kidney tumor not infrequently forms a large mass ex- tending from the lumbar region towards the pelvis and the median line. The characteristic percussion sign of a kidney growth, or other retroperitoneal growth in that region, is that the colon resonance can be made out in front of it. "When the growth is large, the colon may be flattened out by compression between the tumor and the abdominal wall, and in that case no colon resonance Fig. 187. The Area of Dullness in a Retroperitoneal Growth. Same patient as shown in Fig. 153 (Dr. Flsworth Smith's patient). The area enclosed by the solid line is dull on percussion. The dotted line shows the outline of the growth as determined by palpation. would be obtained in the ordinary examination. But the colon resonance can be easily brought out by inflation of the colon with air, introduced through a rectal tube by means of the ordinary double bulb or an atomizer bulb. This point is well illustrated by the following ease. Mrs. M. was sent to the author for operation for a fibroid tumor of the uterus. There was a large mass lying in the left lower abdomen, easily palpable and extending to the uterus. Super- ficially it prevented the appearance of a pediculated subperitoneal fibroid. On deep palpation, however, this prominent mass was found to be connected with a deeper mass which extended up into the lumbar region. By manipula- AREA OP DULLNESS IN ABDOMEN 207 tion the whole mass could be displaced upward somewhat, sufficiently to show that its point of origin was probably in the left lumbar region and not in the pelvis. "When the tumor was displaced upward, the vaginal and abdominal fingers, in the vagino-abdominal examination, could be made to meet between the mass and the uterus, and no pedicle connecting the two could be felt. The diagnosis then lay between a kidney tumor and an enlarged spleen. The palpable portion of the mass did not have the characteristic shape of either the kidney or the spleen, but it approached nearer the shape of the spleen. There were no kidney symptoms. Percussion showed dullness all over the mass (Fig. 188) — there was no colon resonance. But the mass was more deeply placed than an enlarged spleen usually is, and the upper end seemed Fig. 188. Indicating the Area of Dullness in the case of Kidney Tumor, before inflation of the colon. Fig. 189. Indicating the Area of Dullness in the case of Kidney Tumor, after inflation of the colon. to extend directly into the kidney region. The colon was inflated in the office examination, and the colon resonance at once stood out well on percus- sion (Fig. 189), demonstrating that the mass was back of the colon and there- fore probably a kidney growth. The correctness of the diagnosis was proved at the operation. Fig. 190 shows the mass, which was a cystic tumor of the kidney. The growth was so large that it was necessary to remove it by trans- peritoneal nephrectomy. The entire absence of kidney or bladder symptoms was due to the fact that the left kidney was totally destroyed and had not been secreting, all the kidney work being done by the right kidney. 208 GTXECOI.OGIC DIAGNOSIS A rare and interesting form of retroperitoneal growth is the retroperi- toneal lipoma, ^vhich nsually has its origin in the perirenal fat. It may grow extensively in A^arions directions and in some eases become so large that it fills the abdomen, pushing the intestines aside or flattening Fig. 190. The Kidney Tumor itself after removal, in the case presenting the signs shown in Figs. 188 and 189. them out on its surface. Keynolds reported a very extensive tumor of this kind. He was able to collect forty-nine cases from literature. Tumor or Inflammatory Mass in Abdominal Wall. This may give rise to dullness on superficial percussion or even on moderately deep percussion. But very deep percussion will show some resonance all over, except in cases Avhere EXAMINATION OF EXTERNAL GENITALS 209 the mass is so extremely large that the diagnosis is plain from other signs. Fig. 131 shoAvs a growth situated in the abdominal wall. POINTS IN THE EXAMINATION OF EXTERNAL GENITALS The appearance of the external genitals in the virgin is shown in Fig. 191. The same structures are shown diagrammatically and with names on the parts in Fig. 192. The appearance of the hymen differs much in different cases, as indicated in Figs. 193, 194, 195. In the married woman the vaginal ^IROIN 'C'Urcl\€tt€ Fig. 191. External Genitals of a Virgin. Photo- graph from a cadaver. (Dickinson — American Text- book of Obstetrics.) Fig. 192. Diagrammatic representation of the External Genitals of a X'irgin. (Dickinson — Ameri- can Textbook of Obstetrics.) opening is larger and dilatable and the labia minora are better marked, being much larger and considerably corrugated (Fig. 196). "When the patient has had children, the hymen is ordinarily destroyed and the vaginal opening is still larger. In some eases when the labia are spread apart for the examina- tion, the hymen may be traced out in its entirety, with breaks here and there from the tears in labor. In other cases, the torn portions have been largely destroyed by pi-essure during the labor and there remains only an occasional 210 GYNECOLOGIC DIAGNOSIS m m M Mt. Fig. 193, 194, 195. Showing the various forms of Hymen. (Dickinson — American Textbook of Obstetrics.) Fig. 196. External Genitals of a Married Woman. (Dickinson — American Textbook of Obstetrics.) exa:\iinatiox of external genitals 211 Fig. 197. This photograph was taken -with the camera very close to the patient and with the operating speculum in place. The Relations of the Urinary Meatus and the Labia Minora and the Vaginal Opening are well shown. 212 GYNECOLOGIC DIAGNOSIS tag of tissue along the vulvo-vaginal junction. These irregular tags of tis- sue constitute the "carunculae myrtif ormes. " The corrugated condition of the labia minora is shown in Fig. 197, in which the genitals have been shaved as for operation. The relations of the urethral opening to the margin of the vaginal opening and to the labia are exceptionally well shoAvn in Fig. 197, in which the operating speculum is in place. Fig. 198 gives a clear idea of the appearance when there is moderate laceration of the perineum. V-\\ •Tr Fig. 198. External Genitals of a Multipara, with some Perineal Laceration. (Dickinson — American Text- book of Obstetrics.) DISCHARGE ABOUT EXTERNAL GENITALS As explained in Chapter i, there is normally a slight discharge about the external genitals, sufficient to keep the parts moist. Abnormal discharge may be only an increase in the normal muco-epithelial discharge or it may be muco-purulent or purulent or watery or bloody. The various kinds of discharge are conveniently considered under the two terms, leucorrhoea and bloody discharge. EXAMINATION OF EXTERNAL GENITALS 213 Leucorrhea Under this term the author includes all varieties of pathologic discharge from the genitals, except discharge containing blood. Regarding leucorrhea due to extragenital disturbances only, that is hardly probable, as the leucorrhoea in itself is evidence of local disturbance. There are, however, certain cases in which the functional disturbance, evi- denced by the leucorrhea, is dependent largely on malnutrition or on pelvic congestion from extragenital causes. The mild leucorrhea found in the anemic or cachectic, may disappear when the patient is put in good general health. Again, in pelvic congestion from heart disease or from some general cause, there may be present a mild leucorrhea which disappears when the functional pelvic congestion is corrected. In this sense, leucorrhea may be said, in some cases, to be due to extragenital causes and its relief to depend on treatment of the same. In all but exceptional cases, however, leucorrhea is due to one or more of the following local conditions : Inflammation or Ulcer of Vulva. There is a history of discharge from the vulva, of burning or itching and of frequent urination with perhaps some pain. Examination of the external genitals shows redness, either general or localized to certain areas. There is tenderness and discharge and also evi- dence of the cause. If the trouble is an ulcer, it may be simple, chancroidal, syphilitic, tubercular or malignant. Further examination shows no discharge from the vagina and no evidence of trouble there. Acute Vaginitis. There is a history of a free yellow discharge of short duration, irritation of vulva and frequent urination with some burning. Ex- amination shows a yellow discharge and redness of vulva. If gonorrheal, there is usually involvment of vulvo-vaginal glands, also the discharge shows gonococci. The vaginal walls are rough and hot and tender — too tender to admit of satisfactory bimanual examination. When exposed with the specu- lum, the vaginal walls are reddened, and there is not enough discharge from the cervix to account for the leucorrhea. Chronic Vaginitis. This occurs principally in children. There has been a yellow discharge for several weeks or months, with irritation of the vulva and some bladder irritability. Examination shows a yellow discharge and some redness of the vulva, with more or less tenderness. The discharge should be examined for gonococci. If the patient is a child, no vaginal exam- ination is made. If an adult, examination shows tenderness and chronic thickening and roughening of vaginal walls, usually most marked in the posterior fornix. Speculum examination shows redness of the vaginal walls, either generally or in patches, and there is not enough discharge from the cervix to account for the leucorrhea. Adhesive Vaginitis. This occurs principally near or after the menopause. There is a history of chronic discharge, with irritation of the vulva and some- times bladder irritability. On examination it is found in most cases that the 214 GYNECOLOGIC DIAGNOSIS discharge is slight and is sticky or "gluey" in character, though in excep- tional eases it is free and purulent. In some cases there are scratch marks, resulting from the. patient's attempts to overcome the pruritus. On vaginal examination, the vaginal walls are found adherent in spots, especially at the upper part of the vagina. If the adhesions are recent, they separate easily with some bleeding. If the adhesions are old, they are firm and in some cases the vagina is almost obliterated by the process. When the walls are separated with the speculum, in the less advanced cases, irregular spots which are raw and bleed slightly may be seen. Ulcer of Vagina. This may be simple, chancroidal, syphilitic, tubercular or malignant. There is a history of an acute or chronic discharge, and prob- ably also of other evidences of the disease causing the ulceration. Examina- tion shows a discharge about the vulva and more or less irritation of the surfaces. When making the vaginal examination, the indurated edges or base of the ulcer may be felt. The speculum exposes the ulcer to view, and further investigation shoAvs it to be the sufficient cause of the discharge. Acute Endocervicitis. There is a history of a tenacious, stringy discharge, of recent origin. There may or may not be irritation of the external genitals. Vaginal and bimanual examination show nothing special. Speculum examina- tion shows a stringy tenacious discharge coming from the external os. There is also congestion of the cervix and usually erosion about the external os. Chronic Endocervicitis. There has been a discharge for a long time. Vaginal and bimanual examination shoAv no evidence of involvement of the corpus uteri or the adnexa. Speculum examination shows a very tenacious, stringy mucopurulent discharge from the external os, with more or less surrounding erosion. In many cases there has been also severe laceration of the cervix, the evidences of which may be felt and seen. Laceration of Cervix. In these cases, the discharge is due not so much to the tear itself as to the subsequent eversion and irritation and chronic in- flammation. The various appearances presented by the lacerated cervix are shown later in this chapter, under "Points in the Speculum Examination." Ulcer of Cervix. Such an ulcer may be simple, chancroidal, syphilitic, tubercular or malignant. There is a history of leucorrhea. In the vaginal examination the ulcer of the cervix may or may not be felt, depending on whether or not there is any induration in the edges or base. When the cervix is exposed with- the speculum, the ulcer is seen, presenting a distinctly-marked margin, and a base of granulation tissue (epithelial covering entirely lost). Malignant Disease of Cervix. This may appear in the form of an ulcer, with indurated margins and base, or as a papillary growth from some spot on the cervix or within the cervix. For the various appearances of beginning malignant disease of the cervix, see under "Points in the Speculum Examina- tion" in the latter part of this chapter and see also Chapter ix. Polypi of Cervix. Polypi of the cervix, of various kinds, may give rise EXAMINATION OF EXTERNAL GENITALS 215 to consideralDle leucorrhea, though usualh' a bloody discharge is the prom- inent feature in these cases. Acute Endometritis, whether gonorrheal or due to other infections follow- ing labor or miscarriage, gives rise to free discharge. There is a history of recent labor or miscarriage or instrumentation or gonorrhea, or a history of chronic endometritis due to one of these causes. Examination shows a free discharge, the character of which points to the cause of the trouble, as ex- plained ill Chapter vi. Vaginal and bimanual examination show tenderness of the body of the uterus, but no tenderness around the uterus, unless there is complicating trouble. Speculum examination shows a free purulent or sanguino-purulent discharge coming from the uterus. Chronic Endometritis. Hyperplasia of Endometrium. There is a history of chronic leucorrhea. Examination shows nothing in the vagina or cervix to account for the discharge. The body of the uterus may be somewhat enlarged or tender, though not necessarily so. Through the speculum, it is seen that the discharge comes from the uterus and not from inflammation of the vaginal walls.. The character of the discharge indicates that it conies largely from the endometrium and not from the cervical glands. Retrodisplacement of Uterus causes leucorrhea by causing persistent congestion of the endometrium. Fibroid of Uterus causes leucorrhea by causing chronic irritation of the endometrium, both by direct pressure and by interference with its blood supply. Cancer of Corpus Uteri causes leucorrhea by the breaking-down of the cancerous area, and also by the chronic irritation of the adjacent endometrium. Periuterine Disease causes leucorrhea by causing chronic congestion of the endometrium. Functional Cong'estion of the uterus or pelvis, possibly due to ovarian hyperactivity, causes leucorrhea by causing nutritive changes in the endome- trium and cervical mucosa. Bloody Discharge From Genitals Bleeding, not connected with menstruation, may vary from a streak of blood, or a slight coloring of a muco-purulent discharge, to a free flow of blood. Occasionally there is a hemorrhage sufficiently free to threaten the patient's life. In most cases, however, the bloody discharge is slight and irregular, and is of serious import only because it may have a serious condi- tion for its cause. Any of the following diseases may cause a bloody discharge from the genital tract, the character of the discharge varying from a muco-purulent discharge only slightly streaked with blood, to a profuse flow of blood and clots. All the conditions mentioned in the first part of the list give rise also to 216 GYXECOLOGIC DIAGNOSIS leucorrhea and are mentioned under it. Tlie other conditions occur with pregnancy and must be thouglit of whenever a bloody discharge is present. Inflammation or Ulcer of Vulva, - particularly malignant ulcer. Acute Vaginitis. Chronic Vaginitis. Adhesive Vaginitis. Ulcer of Vagina. Acute Endocervicitis. Chronic Endocer^dcitis. Laceration of Cervix. Ulcer of Cervix. Cancer of Cervix. Polypi of Cer^dx. Acute Endometritis. Chronic Endometritis. Eetrodisplacement of Uterus. Fibroid of Uterus.^ ' Cancer of Corpus Uteri. Periuterine Disease. Functional Congestion. -^ Threatened Miscarriage. The patient may have missed the menses only a few days or she may be several months pregnant. Threatened miscarriage is usually accompanied by considerable pelvic pain. In exceptional cases there may be bloody discharge for several hours or a day or two, before pains begin. In some cases by questioning the patient, it will be found that, failing to come unwell at the proper time, she has been taking medicine to ''bring on the flow" (produce an abortion). Miscarriage. Here there are sharp cramp-like pains, with the expulsion of blood clots and pieces of membrane or a formed fetus, depending on the period of pregnancy at which the accident happens. Then the pain sub- sides and after a few days the bloody discharge ceases. Incomplete Miscarriage. The uterus is not entirely emptied and the re- tained remnants cause a persistent bloody discharge for one or two weeks after it should have stopped, and there is also resulting subinvolution of the uterus. The blood may pass as a muco-sanguinous discharge or in clots. It may disappear when the patient stays in bed, to reappear when she gets up. This is probably the most frequent cause of persistent bleeding in women of the child-bearing age. There is usually little pain after the miscarriage has taken place. The principal symptom is the bleeding, with the resulting anemia and weakness. If infection takes place, the symptoms of sepsis are added. Placenta Previa. Bleeding from this cause does not usually take place ^ INFLAMMATION OP EXTERNAL GENITALS 217 until the pregnancy has advanced so far that the diagnosis is perfectly clear. Laceration of Cervix with Pregnancy. The cervix is lacerated and everted and eroded, and there is added the softening and congestion from pregnancy. There are no pains such as accompany miscarriage. There may be some slight pain or uneasiness in pelvis, which is relieved by lying down. The bloody discharge persists, off and on, without apparent evidence of threatened miscarriage or other intrauterine disturbance. Tubal Pregnancy. The rupture of a tulial pregnancy, or a tubal abortion, is nearly always followed in a few days by an irregular bloody discharge, which may persist for several days or several weeks. In some cases, pieces of decidua are expelled with the bloody discharge. There are also the other evidences of tubal pregnancy (see Chapter xi). Fig. 199. Follicular Vulvitis. (A. Martin, after Huguier— ^ S ^^^|&|K£V7 jf&^S^^ ( I 1 ^y / jA \^ ^ rb, ■1 1 1 i i i 1 Fig. 212. The appearance of the external gen- itals in a case of Absence of the Vagina. (Kelly — Operative Gynecology.) LACERATIONS ABOUT VULVA AND PERINEUM 225 Fig. 213. The appearance of the external gen- itals in a case of Double Vagina. (Kelly — Operative Gynecology.) Fig. 214. Same case as Fig. 213, with Speculum Introduced, exposing the two vaginal canals and the half cervix at the top of each. (Kelly — Operative Gynecology.) Fig. 215. Complete Laceration of the Perineum. The sphincter ani muscle has been torn and the ends are separated. The small dark area is an exposed portion of the red mucosa of the rectum. (Hirst — Diseases of Women.) 226 GYNECOLOGIC DIAGNOSIS Fig. 21C. Another case of Laceration through the Perineum into the Rectum. Notice the separation of the sphincter ends and also the patch of rectal mucosa. (Hirst — Diseases of Women.) Fig. 217. Representation of the conditions present in an old L^aceration through the Sphincter Ani. Notice the wide separation of the sphincter ends and also the exposed rectal mucosa. Each end of the torn sphincter ani muscle is indicated by a slight dimple in the skin. (Kelly — Operative Gynecology.) LACERATIONS ABOUT VULVA AND PERINEUM 227 Fig. 218. The scar and opening resulting from a "Central Tear" of the perineum. This is a very rare condition. The child passed out through the lac- eration-opening, situated between the posterior com- missure and the rectum, instead of through the vag- inal opening proper. (Hart and Barbour — Manual of Gynecology.) Fig. 219. Laceration of the Hy- men from Rape, in a girl aged twelve. The child died in ten days of peritonitis. (Edgar — Practice of Obstetrics.) Fig. 220. Complete Laceration of the Pelvic Floor in an infant of eight months, from Rape. (Edgar — Practice of Obstetrics.) integrity of the pelvic floor are shown in Chapter i. Fig. 222 shows a severe tear of the pelvic floor, with resulting relaxation and loss of support. Figs. 215 and 216 show complete tears of the perineum into the rectum. The red mucosa from within the rectum shows at the site of the rectal tear. The torn ends of the sphincter ani produce a slight dimple in the surface covering them (Fig. 217). Fig. 218 show-s a central tear of the perineum, a very unusual form to result from childbirth. 228 GYNECOLOGIC DIAGNOSIS Lacerations from Other Causes. Fig. 236 shows a laceration of tlie hymen from forcible coitus (rape) in a girl aged twelve. There were also deeper injuries, causing peritonitis, from which she died in ten days. Fig. 220 shows a tear from the same cause involving the perineum in an infant. Fig. 221 shows a deep tear of the perineum, causing a recto-perineal fistula, from violent coitus. Fig. 221. Laceration of i'erineum with resulting Fistula, from \iolent Coitus. (Hirst — Diseases of Women.) ^SWELLIXCI ABOUT EXTERNAL GENITALS Colpocele, Cystocele, Rectocele. These swellings appear as the result of lacerations. Fig. 222 shows a severe second degree tear, involving practically all the perineum down to the sphincter ani muscle, and also a posterior colpocele. Figs. 223 and 224 show such a laceration with the anterior and posterior vaginal walls beginning to protrude, and there is also protrusion of the bladder and rectum (cystocele and rectocele). In such a condition, if the patient be directed to bear down, the protrusion will become still more marked. Fig. 225 shows marked protrusion of the anterior vaginal wall ac- companied by the base of the bladder (cystocele). The fact that the bladder wall is prolapsed along with the vaginal wall, is indicated by the fact that the patient has more or less difficulty in urinat- ing, and in some cases she must push back the mass before she can urinate satisfactorily. When there is doubt as to wliether the bladder wall comes SWELLING ABOUT EXTERNAL GENITALS 229 do'^ra, the lowest part of the bladder cavity may be located with a steel bougie (Fig. 226). Fig. 227 sho-vvs slight rectocele (protrusion of the posterior vaginal Avail accompanied by the anterior rectal wall). Fig. 228 shows a large rectocele. The point as to whether or not the rectal wall really follows the prolapsed vaginal wall, may be settled in such a case by rectal examination (Figs. 229, 230). Inflammation of Vulva (erysipelas, cellulitis). There are the usual signs and symptoms of acute inflammation. Owing to the large amount of loose cellular tissue, the inflammatory infiltration may cause very marked swelling. W ^C^v^ .-s Fig. 222. An old Laceration from Labor. Most of the perineum has been torn and there is protrusion of the posterior vaginal wall (posterior colpocele). (Baldy — American Textbook of Gynecology.) Hematoma of Vulva. There is rapid swelling following a puncture with a hypodermic needle or a fall or other injury. There is marked enlarge- ment, painful on pressure and presenting in a short time discoloration from l)lood pigment. ^ There is no fever nor erysipelatous redness nor other evi- dence of acute inflammation. Fig. 231 shows a hematoma of the vulva. Edema of Vulva (from heart or liver disease or from pressure by a pelvic tumor). This produces a boggy, painless swelling Avhich pits on pressure. There is no evidence of acute inflammation or of hematoma. There may be accompanying edema of the abdominal Avail and loAver extremities. There is found some internal trouble to account for the edema (heart disease Avith 230 GYNECOLOGIC DIAGNOSIS failing circulation, tumor or inflammatory mass obstructing the pelvic circu- lation) . Stasis Hypertrophy of Vulva. There is a gradual development of tis- sue hypertrophy, Avith more or less inflammatory infiltration. The swelling is not particularly painful and there is no decided pitting on pressure. It is accompanied by scar-tissue, resulting from chronic ulceration, of such extent and so situated at the vaginal entrance as to obstruct the lymph and blood circulation (Figs. 232, 233, 234, 235, 236). Fig. 237 shows the scar-tissue about the bony arch, distorting the tis- sues and interfering with the return flow of blood and lymph. Fig. 223. Cystocele and Rectocele of moderate extent. (Thomas and Munde — Diseases of Women.) Fig. 224. Cystocele and Rectocele of moderate extent. Sectional view. (Thomas and Munde — Diseases of Women.) Another cause of stasis hypertrophy, is the infiltration and hypertrophy due to the lymph vessels being choked with a parasite, the filaria sanguinis hominis. This is seen almost exclusively in tropical countries. Elephantiasis of Vulva. The term "elephantiasis" is very appropriately applied to the cases of enormous labial hypertrophy, such as shoAvn in Fig. 238. The stasis hypertrophy previously described is often spoken of as "elephantiasis," but it does not seem advisable to use the term so loosely (see Chapter iv). Varicose Veins of Vulva. These not infrequently cause marked swelling, SWELLING ABOUT EXTERNAL GENITALS 231 as shown in Fig. 239. Serious enlargement of the veins is found most fre- quently in pregnancy or in the case of some pelvic tumor or inflammatory mass obstructing the pelvic circulation. Alarming hemorrhage has followed the rupture of an enlarged vein in such cases. Condylomata of Vulva. From Chronic Irritation. As a result of per- sistent irritation and discharge al)out the vulva, small papillary masses grow Fig. 225. Large Cystocele. (Montgomery — Practical Gynecology.) from the skin at various points (Fig. 240). They may come from any per- sistent irritation, though chronic gonorrhea is the most frequent cause. Sometimes they appear in great profusion and occasionally they coalesce and form large papillary masses (Fig. 241). These papillary growths are called pointed condylomata, in contradistinction to the flat condylomata which are usually due to syphilis. From Syphilis. In secondary syphilis, white areas with infiltration suf- 232 GYNECOLOGIC DIAGNOSIS >«^ Fig. 226. Testing for Cystocele with Sound introduced into bladder. (Ashton — Practice of Gynecology.) Fig. 227. Small Rectocele. (Hirst — Diseases of Women.) SWELLING ABOL'T EXTERNAL GENITALS 233 ficient, to raise them above the surface, often appear about the external geni- tals. Ther may be few or many (Figs. 242, 243), and they may be raised much or little. They are usually flat condylomata, only rarely being pointed or papillary (Fig. 244). Vulvo-vaginal Gland Cyst or Abscess. The swelling has much the same appearance whether it be a cyst or an abscess. Figs. 245 and 246 show abscesses of the glands. Fig. 247 shows a cvst of the gland. Fig. 228. Large Rectoccle. (Hirst — Diseases of IVoiiicn.) Figs. 229 and 230. Method of Differentiating between Rectocele and Posterior Colpocele. The index finger in the rectum determines whether or not the rectal wall follows the prolapsing vaginal wall. The hand should be gloved. Fig. 229, Rectocele. Fig. 230, No Rectocele. (Ashton — Practice of Gynecology.) 234 GYNECOLOGIC DIAGNOSIS Fig. 231. Hematoma of the Vulva. (Hirst — Diseases of Women.) Fig. 232. Stasis Hypertrophy of the Labia Minora. {Uirst^Diseases of Women.) SWELLING ABOUT EXTERNAL GENITALS 235 Hypertrophy of Labia. The hypertrophies affect principally the labia ininora, either the free portion on one or both sides (Fig. 248) or that portion extending up over the clitoris as the prepuce. The hypertrophied portions contain mnch redundant tissue and are corrugated and usually somewhat Fig. 233. Stasis Hypertrophy of the Vulva. (Hirst — Diseases of Women.) Fig. 234. Stasis Hypertrophy of the Vulva. (Hhst— Diseases of Women.) 236 GYNECOLOGIC DIAGNOSIS Fig. 23S. Stasis Hypertrophy about external genitals and edema from pregnancy. (Dickinson — American Textbook of Obstetrics.) Fig. 236. So-called Elephantiasis — probably stasis hypertrophy. (Byford, after Winkel — Manual of Gynecology.) Fig. 237. Stasis Hypertrophy of Vulva, with enlarged parts raised so as to show the ulceration and scar-tissue about the pubic arch. (Kiliani — Surgical Diagnosis.) Fig. 238. Elephantiasis of the Labia. (Baldy- American Textbook of Gynecology.) SWELLING ABOUT EXTERNAL GENITALS 237 Fig. 239. Varicose Veins of the Vulva. (Hirst — Diseases of Women.) Fig. 240. Small Masses of Condylomata. Practical Gynecology.) (Gilliam- Fig. 241. The whole vulvar re- gion occupied by Massed Condylo- mata. (Kuestner — Kurxes Lchrbuch der Gynaekologie.) 238 GYNECOLOGIC DIAGNOSIS Fig. 242. Syphilitic Infiltration and Condylomata about the vulva. (Hirst — Diseases of Women.) Fig. 243. Syphilitic Condylomata. Flat variety. (Bovee — Practice of Gynecology.) SWELLING ABOUT EXTERNAL GENITALS 239 pigmented. In some cases the hypertrophy becomes very marked, as in the Hottentot apron, shown in Fig. 249. Hypertrophy of Clitoris. This is much rarer than hypertrophy of labia. Occasionally the clitoris is considerably enlarged. Fig. 250 shows such a case. Malignant Disease of Labia or Clitoris. Malignant disease (carcinoma or sarcoma) appears upon the labia as a small reddened nodule, which later ulcerates. Fig. 204 shows a beginning carcinoma of left labium majus. Fig. Fig. 244. Syphilitic Condylomata. Pointed variety. (lihst^Diseascs of Women.) 251 shows a small carcinoma of labium minus. Figs. 252 and 253 show car- cinoma of the labium at a later stage. Fig. 254 shows an advanced carcinoma of the vulvo-vaginal gland. Fig. 255 shows a sarcoma of the labium. Fig. 205 shows a carcinoma of clitoris. Non-malignant Tumor of Labia or Clitoris. Fibromata and lipomata and cysts occur here, though not very frequently. Fig. 256 shows a small fibroma of the left labium majus. Fig. 257 shows a larger solid tumor of the labium. Fig. 258 shows a number of small cysts on the labium. Figs. 259 and 260 show large labial cysts. Fig. 261 shows a cyst of the clitoris. Pudendal Hernia. A hernia of intestine or omentum or other intraperi- 240 GYNECOLOGIC DIAGNOSIS toneal structure, may take place througli the inguinal canal and appear in the labium majus of that side (Fig. 262). Another form of pudendal hernia is that which comes by way of the vagina (Fig. 263), the protrusion taking place in front of the uterus in some cases (Fig. 308) and behind the uterus in others. Pudendal Hydrocele. A collection of fluid occasionally occurs in the canal of Xuck, forming a hydrocele, which corresponds to hydrocele of the cord in the male. ■-^r«- Fig. 245. Abscess of \'ulvo-vaginal Gland, left side. (Kelly — Operative Gynecology.) Tumor of Round Ligament. Fibromyoma of the round ligament is a rare condition and one that causes much distortion of the structures about the inguinal canal, consequently it is likely to lead to an erroneous diagnosis. It should be considered whenever there is a peculiar swelling in the neighbor- hood of the inguinal canal. Prolapse of the Urethral Mucosa (Fig. 264). This occurs to a slight ex- tent in many women who have borne children or have had inflammation of the urethra. Not infrecpiently the protrusion is marked and no doubt leads in SWELLING ABOUT EXTERNAL GENITALS 241 Fig. 246. Another case of Abscess of ^'ulvo-v:lL;l;..^l Gland, right side. (Hirst — Diseases of Women.) Fig. 247. Cyst of the Vulvo-vaginal Gland. (Montgomery — Practical Gynecology.) 242 GYNECOLOGIC DIAGNOSIS many cases to an erroneous diagnosis of caruncle. The prolapsed mucosa en- circles a considerable part of the circumference of the meatus, and a close inspection will show that the small mass presents the smooth, though irregu- lar, surface of hypertroj)hied mucosa, instead of the papillary projections usually present in urethral caruncle. Again, the meatus is much widened Fig. 248. Hypertrophy of the Labia Minora. (Hir.st — Diseases of Women.) Fig. 249. Enormous Hypertrophy of the Labia Minora — the so-called "Hottentot Apron." The first cut shows the patient standing, with the hypertrophied labia hanging between the thighs. The second cut shows the patient on her back, with the labia separated. (Garrigues, after Zweifel — Diseases of Women.) SWELLING ABOUT EXTERNAL GENITALS 243 from the previous injuiy or inflammation, and the prolapsing of the mucosa may bring into view the orifice of the duct, or Skene's gland, on one or both sides (Fig. 44). Urethral Caruncle (Fig. 265). This is a distinct new growth, usually papillary in form, springing from the region of the meatus. It may have a Fig. 250. Hypertrophy uf the Llituns. illirbt — Diseases of U'odicii.) Fig. 251. Carcinoma of Labium Minus, beginning. (Hirst — Diseases of Women.) 244 GYNP^COLOGIC DIAGNOSIS Fig. 252. Carcinoma of- Labium at a later stage. (Hirst — Diseases of Women.) Fig. 253. Carcinoma of I,abium in a still later stage. (Hirst — Diseases of Women.) SWELLING ABOUT EXTERNAL GENITALS 245 narrow pedicle or a broad attachment, but does not tend to encircle the meatus as does prolapsed mucosa. Malignant Disease of Urethra. This starts usually in some small spot of irritation about the meatus, and in the early stage presents a small ulcer or induration. Later the infiltration involves the vestibule, urethra and adjacent tissues. Suburethral Abscess. This consists of a pouch formed by a diverticulum «<«**^'^ Fig. 254. A large Carcinoma of the left Vulvo-vaginal Gland. (Kelly — Operative Gynecology.) from the urethra, usually from the inferior wall. Inflammation and suppura- tion take place in this pouch, which may or may not drain irregularly into the urethra. When distended, it may project at the vaginal orifice (Fig. 266) like a small cyst of the anterior vaginal wall. Fig. 267 gives a clear idea of the condition. Prolapse of Uterus (Fig. 268). When the uterus prolapses sufficiently, 246 GYNECOLOGIC DIAGNOSIS Fig. 255. Sarcoma of Labium. (Hirst — Diseases of Women.) Fig. 256. A small Fibroma of left Labium Majus. (Baldy — American Textbook of Gynecology.) Fig. 257. A large Fibroma of the Labium. (Montgomery- — Practical Gynecology.) SWELLING ABOUT EXTERNAL GENITALS 247 Fig. 258. Small Cysts of the Left Labium Minus. (KeUy— Operative Gynecology.) i Fig. 259. A large Labial Cyst, {mrst— Diseases of Women.) 248 GYNECOLOGIC DIAGNOSIS Fig. 260. Another large Labial Cyst. (Hirst — Diseases of Women.) Fig. 261. A Cyst of the Clitoris. (Kellj- — Operative Gynecology.) SWELLING ABOUT EXTERNAL GENITALS 249 Fig. 262. An Inguinal Hernia becoming Pudendal. (Dudley — Practice of Gynecology.) Fig. 263. A Pudendal Hernia which came by way of the Vagina. (H. Macnaughton-Jones, after Winckel— Diseases of Women.') 250 GYNECOLOGIC DIAGNOSIS the firm cervix, with the external os near the center, appears at the vestibule (Fig. 269), or it may come farther out as shown in Fig. 270, or it may come still farther, so that the entire uterus is outside the body (Fig. 271). The bladder may or may not prolapse along with the uterus. Fig. 272 represents a case in which the bladder does not prolapse. Fig. 273 represents a case in which the bladder does come down Avith the displaced uterus. The method of locating the bladder by the introduction of a sound, is shown . XFirT" Fig. 264. Prolapse of the Urethral Mucosa, gomery — Practical Gynecology.) (Mont- Fig. 265. Urethral Caruncle. (Montgomery- Practical Gynecology.') in Fig. 274. Ulcers of various sizes and shapes, may appear on the exposed irritated surfaces. Such ulceration is shown in Fig. 271. Prolapse may occur in a woman who has never had a child (Fig. 275) or even in the virgin (Fig. 276). The position of the fundus is made out by recto-abdominal palpation, as indicated in Fig. 277. Elongation of the Cervix produces a condition which is not infrequently mistaken for prolapse. If the hypertrophy atfects only the infravaginal por- tion of the cervix (Fig. 278, a) the vaginal walls are not carried down but SWELLING ABOUT EXTERNAL GENITALS 251 Fig. 266. Suburethral Abscess. View from in front. (Kelly — Operative Gynecology.') 252 GYNECOLOGIC DIAGNOSIS Fig. 267. Testing for Suburethral Abscess. (Ashton Fig. 268. Prolapse of the Uterus, showing the — Practice of Gynecology.) various steps in the process. (Kelly — Operative Gynecology.) Fig. 269. A case of Prolapse of the Uterus. The cervix is at the vestibule. (.U'lrst— Diseases of Women.) PROLAPSE OF UTERUS 253 remain in normal position, producing the condition shown in Figs. 279 and 280. When the elongation affects the supravaginal portion (Fig. 278, c), both vaginal walls are carried down with the protruding cervix, producing a condi- tion (Fig. 281) very likely to be mistaken for uterine prolapse, unless the depth of the uterine cavity be measured or the body of the uterus be carefully outlined by bimanual palpation. In these cases the dragging of the relaxed and redundant vaginal walls, seems to be an important factor in producing Fig. 270. Another case of Prolapse of the Uterus. The uterus comes still farther out. 254 GYNECOLOGIC DIAGNOSIS Fig. 271. Another case of Prolapse of the Uterus. The uterus and vagina lie outside the body. The ulceration, so frequent in these cases, is very evident. (Hirst — Diseases of Women.) Fig. 272. Prolapse of the Uterus. Sectional view. The bladder remains in place. (Kelly — Operative Gynecology.) DIAGNOSIS OF PROLAPSE 255 Fig. 2'/ 5. Prolapse of the Utcrvis and Bladder. (Doederleiu and Krcenig — ()perati:-e Gynackologie.) Fig. 274. Testing for Prolapse of the Bladder with the uterus, by means of a sound in the bladder. (Ashton — Practice of Gynecology.') 256 GYNECOLOGIC DIAGNOSIS Fig. 275. Prolapse of the Uterus in- a Nullipara. (Hirst — Diseases of Women.) Fig. 276. Prolapse of the Uterus in a Virgin. (Kuestner — Kiir::es Lehrbudi der Gynaekologic.\ DIAGNOSIS OF PROLAPSE 257 the elong-ation of the cervix. When the hypertrophy or stretching, as the ease may be, affects the intermediate portion of the cervix (Figs. 278, b), the anterior vaginal wall is usually carried do^m while the posterior wall remains in place (Fig. 282). The time-honored division of the cervix into three por- tions, as indicated in Fig. 278, is convenient for fixing in mind the conditions ordinarily present in these cases, but it must be remembered that in manv Fig. 277. Locating the body of the L'terus by recto-abdominal palpation in a case of suspected Prolapse. (Ashton — Practice of Gynecology.) Fig. 278. The Three Divisions of the CervLx: Fig. 279. Hypertrophy of the Infravaginal Por- (a) Infravaginal Portion, (b) Intermediate Portion, tion ot the Cervix. (B/ford — Manual of Gynecol- (c) Supravaginal Portion. (Byford — Manual of ogy.) Gynecology.) OYiSTECOLOGIC DIAGNOSIS Fig. 280. Hypertrophy of the Infravaginal Portion of the Cervix. (Kelly — -Operative Gynecology.) Fig. 281. Hypertrophy of the Supra- vaginal Portion of the Cervix, carry- ing down the vagina and cervix to the vulva. The uterine cavity in this case measures five and a half inches. An area of erosion is present on the posterior lip of the cervix. (Gil- liam — Practical Gynecology.) Fig. 282. Hypertrophy of the Intermediate Por- tion of the Cervix, carrying down the anterior vag- inal wall and bladder but not the posterior vaginal wall. (r>yford — Manual of Gynecology.) Fig. 283. A specimen presenting a peculiar Hypertrophy of the Cervix. The posterior vaginal wall is carried down but not the anterior. (Herman — Diseases of Women.) TUMOR OF UTERUS 259 cases the vaginal wall does not run very much further up on the posterior part of the cervix than it does on the anterior and, consequently, elongation of the middle or intermediate portion of the cervix does not always carry down the anterior vaginal wall and leave the posterior in place — in fact, in the case shown in Fig. 283, it has carried down the posterior wall and left the anterior. The differentiation from prolapse of the uterus is made by locating the fundus uteri at about the normal position in the pelvis, by vagino-abdominal or recto-abdominal palpation, and, if necessary, by sounding the uterus to determine the length of the uterine cavity. In elongation, the cavity is in- Fig. 284. Pediculated Fibroid Tumor of the Uterus, protruding at the vulva. (Kelly — Operative Gynecology.) creased in length sufficiently to account for the appearance of the cervix at the vulva. In prolapse of the uterus, there is usually some elongation of the supravaginal portion of the cervix by the dragging of the prolapsing vaginal walls, but it is of secondary importance. In the cases in which the elongation of the cervix is the principal lesion, there is usually some prolapse of the uterus, due to the dragging of the heavy cervix. Tumor of Uterus. A mass appearing at the vulva, may be a pediculated fibroid (Fig. 284) or a malignant tumor from the uterus. 260 GYNECOLOGIC DIAGNOSIS Fig. 285. Complete Inversion of the Uterus, forming a large mass at the vulva. This is a post- partum inversion and the placenta is still attached to the turned-out fundus uteri. (Williams — Obstetrics.) Fig. 286. A small Cyst of the Vaginal Wall. (Hirst — Diseases of Women.) VAGINAL EXAMINATION 261 Inversion of Uterus (Fig. 285). This rare condition may produce an ap- pearance very closely resembling a necrotic, bleeding tumor protruding from the vulva. The internal conditions are shown in Fig. 293. Vaginal Cyst. This may be confounded with cystocele or vaginal hernia or suburethral abscess. The differential diagnostic points are the absence of inflammation, the distinct fluctuation, the tenseness of the sac containing the fluid and its attachment to some part of the vagina. Figs. 286 and 287 shoAv such A^aginal cj^sts. Fig. 287. A medium-sized Vaginal Cyst, caught with a forceps and brought into view. (Hirst — Diseases of Women.) POINTS IN THE VAGINAL EXAMINATION ROUGHENING OF VAGINAL WALLS Astringent Douche. Any astringent douche, for example, one containing alum or bichlorid, will cause temporary roughening of the vaginal Avail. But there is no particular tenderness. ^ Inflammation. It is found in acute vaginitis, simple or gonorrheal, and 262 GYNECOLOGIC DIAGNOSIS in some cases of chronic vaginitis. In addition to the rough granular feel, there is tenderness of the wall, and the speculum examination shows red- dening. TENDERNESS ON VAGINAL PALPATION Inflammation of Vaginal Entrance. The tenderness is noticed as soon as the examining finger begins to enter the vagina. There may be diffuse red- ness of the surface around the vaginal orifice or there may be simply reddened areas that are tender on pressure or there may be abrasions or slight fis- sures or there may be one or more distinct ulcers. Inflammation of Vulvo-vaginal Gland or Duct. There is swelling and tenderness at the site of the gland and redness about the duct, and in some cases pus may be squeezed from the duct. Hyperesthesia of Vaginal Entrance. There is great exaggeration of the reflex sensibility of the tissues immediately about the vaginal orifice, and yet no evidence of inflammation or flssure or ulcer or other adequate cause for pain. In some cases the reflex excitability is so great that contact causes spasm of the levator ani and associated muscles to such an extent as to pre- vent the examination. This uncontrollable spasmodic closure of the vaginal orifice is known as '' vaginismus." Inflammation of Vagina. There is purulent discharge and the vaginal walls are rough and hot. Speculum examination shows marked reddening of the walls (arterial congestion) and also discharge upon them. Inflammation of Urethra. The tenderness is along the lower part of the anterior vaginal wall and is complained of when pressure is made along the course of the urethra. There may be distinct thickening about the urethra, which may be felt as a firm cord beneath the pubic arch. In most cases there is redness about the meatus, and some discharge may be pressed out by com- pressing the urethra from above downward (Figs. 42, 43). Inflammation or Other Painful Aff'ection of the Bladder. Pain is caused by pressure upAvard along the middle of the anterior vaginal wall, which lies against the base of the bladder. There are also the symptoms of bladder ir- ritation (frequent urination, painful urination), and also the findings on uri- nary analysis. Inflammation or Other Painful Affection of the Rectum. Pain is caused by pressure backward along the posterior vaginal wall (Fig. 60). There is also evidence of rectal irritability (pain on defecation, rectal tenesmus), and possibly the passage of blood or mucus. Inflammation Around Uterus (cellulitis, salpingitis, pelvic peritonitis). Pain is caused by pressure on the vaginal wall around the uterus, either in front of the cervix or behind it or at one side. Pain is caused also by any at- tempt to move the uterus, as by pushing on the cervix. VAGINAL EXAMINATION 263 MASS FELT IN VAGINAL PALPATION Prolapsed Vaginal Wall (colpocele). The vaginal wall is more redundant than it ought to be and part of it descends toward the opening. It may be the anterior vaginal wall (anterior colpocele) or the posterior vaginal wall Fig. 288. A small Pediculated Fibroid of Uterus, projecting into the vagina. Gynecology.) (Montgomery — Practical Fig. 289. A large Pediculated Uterine Fibroid Fig. 290. A Pediculated Fibroid, with the sound lying in the vagina. (Thomas and Munde — Diseases in place to differentiate it from inversion of the 9/ Women.) uterus. (Dudley — Practice of Gynecology.) 264 CtYxecologic diagnosis big. 291. A Sarcoma of the Uterus projecting into the vagina and causing partial inversion of the uterus (Kelly — Ope ratk-e Gyii ecology. ) X Fig. 292. Grape-like Sarcoma springing from the Cervix uteri and forming a mass in the vagina. (Kuestner — Kurzes Lehrbuch der Gynaekologie.) MASS FELT IN VAGINAL PALPATION 265 (posterior colpocele) (Fig. 222) or both. Tlie mass presents the character- istics of relaxed vaginal wall. There is no distinct firm body in it. Prolapse of Bladder (cystocele). In some cases of prolapse of the anterior vaginal wall, the bladder follows the vaginal Avail (Fig. 224). This is known as cystocele, as previously explained. The bladder wall is soft and, therefore, can not be felt distinctly in the mass, as the uterus can. It is noticed, however, that there is much moie soft tissue in the mass than would be Fig. 293. Inversion of the Uterus, forming a mass in the vagina. (Kelly — Operative Gynecology.) furnished by the prolapsed vaginal wall and, as the bladder lies next to the vagina, it is to be assumed that this extra tissue is bladder wall. ►Sometimes there is enough urine in the prolapsed pouch of bladder to give fluctuation. Usually there is some bladder irritability (frequent, painful urination), and in some cases the patient has found that she must push back the mass each time before she can urinate satisfactorily. If there is still doubt as to Avhether or not the bladder descends with the vaginal wall, and it is important to know 266 GYXECOLOGIC DIAGNOSIS Fig. 294. Beginning Inver- sion of the Uterus. Fig. 295. Submucous Fi- broid with short pedicle. Fig. 296. Submucous Fi- broid and beginning Inver- sion. Fig. 297. Partial Inversion of Uterus. Fig. 29S. Submucous Fi- broid witb long pedicle. Fig. 299. Pediculated Fi- broid and partial Inversion. Fig. 300. Complete Inver- sion of Uterus. Fig. 301. Pediculated Fi- broid filling upper part of vagina. Fig. 302. Complete In- version of Uterus, with a pediculated subperitoneal Fibroid occupying the nor- mal site of the uterus. Figs. 294 to 302. Inversion of the Uterus and Conditions that Simulate it. (Dudley — Practice of Gynecology.) J MASS FELT IN VAGINAL PALPATION 267 certainly, introduce a steel urethral bougie (about No. 20F) and see if the tip passes easily into the mass (Fig. 226). Prolapse of Anterior Wall of Rectum (rectocele). The anterior wall of the rectum may follow the posterior vaginal Avail in its descent' through the vaginal orifice (Figs. 227, 228). A digital examination per rectum will quickly show whether or not the cavity of the rectum extends into the mass (Figs. 229, 230). Prolapse of Uterus (Fig. 268). The cervix is felt much loAver (closer to the vaginal entrance) than normal, or it may present at the vaginal orifice or even project far outside (Fig. 270). Bimanual examination shoAvs that the body of the uterus also is lower than usual (Fig. 296), and consequently that the condition is prolapse of the uterus and not simply elongation of the cervix. Fig. 303. Diagnosis of Inversion of the Uterus. Fig. 304. Fig. 303 shows the method of determining the absence of the body of the uterus from the pelvic cavity. Fig. 304 shovi's the determination of the presence of a cup-shaped depression above the cervix. (Ashton — Practice of Gynecology.) Elongation of Cervix. The cervix is felt much loAver than it ought to be. Bimanual examination shoAvs that the body of the uterus is in normal position. If the bimanual examination does not make plain the length and position of the body of the uterus, the uterus may be sounded. This Avill shoAv that the length of the uterus is sufficient to account for the Ioav position of the cervix. In some cases the tAvo conditions, prolapse of the uterus and elongation of the cervix, are both present. Tumor of Uterus. There is a solid or semisolid mass lying in the vagina (Figs. 228, 229, 290, 291, 292). The finger may be passed all around. betAveen 268 GYNECOLOGIC DIAGNOSIS the mass and the vaginal wall. When the finger is passed around the mass, its connection with the cervix is felt. It may spring from a portion of the cervix within reach, or it may be connected with a pedicle extending up into the canal. Inversion of Uterus (Fig. 293). There is a mass the size of the uterus Fig. 305. Differential Diagnosis of Inversion by means of the sound. On all sides the sound is stopped a short distance within the cervix. (Ashton — Practice of Gynecology.) Fig. 307. A group of small Cysts of the Vaginal Wall. (Montgomery — Practical Gynecology.) Fig. 306. A Pediculated Fibroid Causing In- version of the Uterus. This shows also a danger to be avoided in treatment. Amputation of the fibroid by cutting across the pedicle at the level of the line A, B, would open the peritoneal cavity. (Thomas and Munde — Diseases of Women.) Fig. 308. Anterior Vaginal Hernia. Practice of Gynecology.) (Ashton — MASS FELT IN VAGINAL PALPATION 269 lying" in the vagina, having a raw looking mucous surface exposed. Palpation of the upper part of the mass shows that it is connected with the cervix by a broad pedicle, and the dilated cervical ring may be felt around it. Figs. 294 to 302 give a clear idea of inversion and conditions that may be confounded with it. Bimanual examination (under anesthesia, if necessary) shows the body of the uterus absent from where it should be (Fig. 303), and instead there is a cup like depression above the cervical ring (Fig. 304). Also, a sound will not pass up into the uterine cavity but is stopped on all sides a short distance within the cervical opening (Fig. 305). There may be inversion associated with a tumor (Fig. 306). Tumor of Vaginal Wall. This is usually a cyst. A rounded mass contain- ing fluid is felt and, tracing it up, it is found to be attached to the vaginal wall (Fig. 307). It can not be reduced into the peritoneal cavity like a hernia, neither is there any evidence of any obstructive bowel disturbance. Solid tumors of the vaginal wall sometimes occur. Vaginal Hernia (Fig. 308). This is felt as a soft elastic mass, causing projection of the vaginal wall. It can be reduced into the peritoneal cavity but returns when the patient coughs or bears down. It disappears when the patient is in the knee-chest posture, unless strangulated or incarcerated. There may or may not be symptoms of intestinal obstruction, partial or complete. Absicess Pushing Vaginal Wall Inward. Such an abscess may arise in the connective tissue beside the cervix or in the posterior cul-de-sac or in front of the cervix or as an ischio-rectal abscess. It may arise also in the recto- vaginal septum. Rectum Distended With Fecal Masses. If the fecal masses are in the lower part of the rectum their character is apparent, but if in the upper part of the rectum, back of the uterus, they may be confused with other masses. The characteristics of such a fecal mass are that it is situated in the course of the rectum, that it is not particularly tender, that it has a putty-like con- sistency and may be indented by the examining finger and the dent remains, that it may be moved along to a different part of the rectum and that an enema removes it. Tumor of Rectum. There is a mass felt through the posterior vaginal wall. There are the evidences of rectal irritation and also the facts that may be made out on rectal examination. Tumor of Bladder. A mass is felt through the anterior vaginal Avail. There are the evidences of bladder irritation (frequent, painful urination) and also the urinary findings. Mass in Cul-de-Sac of Douglas. This is felt back of the cervix and may be a retroflexed uterus (Fig. 369), a tumor (Fig. 368), a prolapsed ovary or tube (Fig. 367), an inflammatory exudate (Fig. 377), an abscess or a hema- tocele. 270 GYNECOLOGIC DIAGNOSIS CHANGES IN CERVIX UTERI FELT ON VAGINAL EXAMINATION Displacement of Cervix. Forward Displacement (pointing forward) may be due to backward displacement of the nterus (Figs. 309, 310), to anteflexion of the cervix (Fig. 311) or to an inflammatory mass or a tumor back of the cervix pushing it forward. Backward Displacement may be due to a distended bladder (Fig. 324), or a tumor of the bladder, to an inflammatory mass or a tumor in the front part of the cervix pushing it backward or to old adhesions back of the cervix pulling it backward. Lateral Displacement of the cervix may be due to an inflammatory mass, a blood mass or a tumor at the side of the cervix pushing it toward the opposite side, or to old adhesions or to scar tissue in the vaginal wall on one side pulling the cervix to the same side. Enlargement and Distortion of the Cervix may be caused by inflamma- tion with eversion of mucosa (Fig. 312), or by laceration with eversion of Fig. 309. Fig. 310. The Relation of the Cervix to the Examining Finger. Fig. 309. Retroversion of the Uterus, showing the Relation of the Cervix to the examining finger. Compare this with Fig. 310, which shows the relation of the cervix to the examining finger when the uterus is in normal position. (Keating and Coe — Clinical Gynecology.) mucosa (Figs. 313 and 314), or by chronic inflammatory infiltration and ob- struction of gland ducts from scar-tissue, causing cystic degeneration (Fig. 318), or by a fibroid tumor of the cervix or by a malignant tumor of the cervix. Idiopathic elongation of the cervix, also, may cause it, but that is a very rare condition. Softening" of the Cervix may be due to normal pregnancy or to extra- uterine ]3regnancy or to a recent pregnancy (terminated by labor or miscar- riage). In Fig. 319, the softened portion is represented by the dotted area. This feels soft, like the vaginal wall or like velvet, as explained in Chapter I. It has been aptly said that "the cervix normallj^ has about the consistencj^ of the tip of the nose. When it is soft as the lip, look out for pregnancy." CHANGES IN CERVIX UTERI 271 Tliis softening begins at the lower part of the cervix in the first few weeks of pregnancy and graclually progresses upward nntil, in the last month, the whole cervix is so softened that it is sometimes hardly felt in the examina- tion. That this is a softening, and not a shortening as was formerly sup- posed, is shown in Fig. 320, where it is seen that the cervix at term is still of normal length. Occasionally marked chronic congestion, from the presence of a tumor or inflammatory mass, will he accompanied by some softening of the cervix. Fig. 311. Anteflexion of the Cervix Uteri. In this condition the axis of the cervix points toward the examiner, as in retroversion, though the corpus uteri is well forward. Hard Nodule in the Cervix may be due to scar-tissue from laceration, to a fibroma, to beginning malignant disease (Fig. 321) or to a glandular cyst (Fig. 322). In scar-tissue, the induration corresponds Avith the scar and fol- lows the course of the scar, and it does not increase in size under observation. In cystic disease (Chapter vi) if the nodule be punctured and pressed upon, the characteristic clear glairy substance will be extruded and the induration will largely disappear. In fibromyoma fibroids elsewhere in the uterus may be found, making it probable that the cervical nodule is similar in nature. A nodule in the cervix that does not correspond with any of the conditions just 272 GYXECOLOGIC DIAGNOSIS nientioned, may be begimiiiig malignant disease. A j^iece of it should be excised and submitted to microscopic examination, to establish certainly the diagnosis at a time when a diagnosis %vill do some good. Tenderness of the Cervix usually means inflammation around the uterus. The tissue of the cervix is ordinarily not painful to pressure even when dis- eased. The tenderness so often complained of when pressure is made on the cervix, is usually due to a slight involvement around the uterus and consequent pulling on inflamed periuterine tissues due to the moving of the uterus. Fig. 312. Eversion of the Cervical Mucosa due to inflammation within the cervix. (Cullen — Caticer of the Uterus.) There has been no laceration of the cervix in this case, the patient being a Nullipara. This eversion of the cervical mucosa by inflammation only, without previous laceration, is a rare condition. It is likely to lead to a mistaken diagnosis of laceration of the cervix. It is also of medico-legal importance, as the appearance of laceration ma}- lead to the erroneous conclusion that the patient has at sometime given birth to a child. Fixation of the Cervix may he due to inflammatory exudate, to a tumor about the uterus or to sear-tissue in the upper part of the A'agina. Abnormal Mobility of the Cervix is due to stretching of the supporting tissues around it and of the pelvic floor below it. CHAXGES IX CERVIX UTERI 273 Fig. 313. Fig. 314. Figs. 313 and 314. Side and Front Views o£ a Simple Bilateral Laceration, requiring no treatment. Fig. 313. F'ront view of a Unilateral Laceration requiring no treatment. Fig. 316. Side View of a L'nilateral Lacera- tion. Such a laceration may cause abortion in the early months of pregnancy. Fig. 317. Side View of a Bilateral Laceration, Fig. 318. Front View of a Bilateral Laceration, requiring treatment. The lips are everted, and the showing eroded area and Xabothian follicles. Xabothian follicles stand out as small hard lumps. Figs. 313 to 318. Lacerations of the Cervix Uteri. (Tialdy-^Ainencan Textbook of Gynecology.) Fig. 319. Palpating the Cervix to Determine Soft- ening. The light stippled area represents the softened portion. The uterus is represented as enlarged from early pregnancy. Fig. 320. Section of the Cervix, in preg- nancy at term, showing that the cervix is still of Full Length. The sensation of shortening imparted to the examining finger is due to the softening, causing the lower part to be not easily appreciated by the finger. (Dickinson, after \\'aldeycr — American Textbook of Ob- stetrics.) 274 GYNECOLOGIC DIAGNOSIS Fig. 321. Beginning Carcinoma within the Cervix, causing a Hard Nodule which can be felt on digital examination. (Kelly — Operative Gyneeology.) f Fig. 322. Cysts of the Cervix. These fetl like Hard Nodules and hence may lead to a mistaken diagnosis of malignant disease in the cervix, as happened in the case from which this specimen was taken. At operation the carcinoma (which was diagnosed from curettings) was found to be confined to the corpus uteri, as shown in the specimen, instead of extending to the cervix as was previously supposed. (Kelly — Operative Gynecology.') VAGINO-ABDOMINAL EXAMINATION 275 MASS FELT IN CERVICAL CANAL On palpating the cei'vix some one of the following small masses may in some cases be felt just within the external os or projecting slightly from it. Blood Clot. This is soft and easily broken, if it projects far enough to permit of its being caught between the fingers. When it is up in the canal so that only the lower edg€ or end can be felt, it may feel very much like a piece of tissue. Introduce the uterine dressing forceps beside the finger and catch the small mass and bring it outside for inspection. Placental Remnants. In incomplete miscarriage a small piece of tissue may often be felt in the cervical canal, showing that there are retained rem- nants that must be removed. It is in this same class of cases that a firm blood clot in the cervix may lead to an erroneous diagnosis, hence the importance of removing the small mass Avith a forceps so that it may be examined to de- termine certainly whether it is a piece of tissue or only a blood clot. To de- termine if it has the bushy projections of placental tissue, spread it out in water. If it is of doubtful character, submit it to miscroscopic examination. It may be a broken off papillary mass from a malignant growth in the uterus. Mucous Polypus. Mucous polypi are frequently found projecting from the cervix or up in the canal (Chapter vi.) They may be so soft as to be hardly noticed in the digital examination but, when projecting from the canal, are very apparent in the speculum examination. Fibrinous Polypus. This is a polypus which has gradually enlarged from accretions of fibrin about a placental . remnant or other small mass in the uterine cavity. Its character is determined by microscopic examination. Fibroid Polypus (Fig. 288). This is a small pediculated submucous fibroid, the pedicle of which has become stretched sufficiently to permit the mass to appear at the external os or to project from the same. It may be attached in the body of the uterus or in the cervix, usually the former. Malignant Polypus. A malignant growth in the cervix or in the body of the uterus may send out a papillary projection that appears at the external OS as a polypus. Again malignant change may be present in, or may develop in, apparently simple polypi. For this reason all polypi of whatever kind removed from the cervix should be preserved that their exact character may be determined by microscopic examination. POINTS IN THE VAGINO-ABDOMINAL EXAMINATION CHANGES IN CORPUS UTERI Backward Displacement of the Uterus (Fig. 323). The body of the uterus is not made out in front (Fig. 65). In the back part of the pelvis there is felt a body, apparently continuous with the cervix, and of the size, shape and consistency of the corpus uteri (Figs. 66, 67). It may be movable or fixed, 276 GYNECOLOGIC DIAGNOSIS tender or not tender. No other mass is felt in the pelvis. Siicli a mass is in all probability the body of the uterus in backward displacement. If some of Ihe necessary points can not be made out distinctly and there are circum- stances which make it important to know at once the exact location of the corpus uteri, this may l)e determined certainly by introducing the sound into the uterus. But do not use the sound except when there is some special Fig. 323. Retrodisplacement of the Uterus, showing the first, second and third Degrees. (Skene — Diseases of Women.) VAGINA RECTUM Fig. 324. Uterus displaced backward by a Full Fig. 325. Uterus displaced laterally by an Inflam- Bladder. (Montgomery — Practical Gynecology.) matory Mass. (Edgar — Practice of Obstetrics.) CHANGES IN" CORPUS UTERI 277 reason for doing so, and remember the contraindications to sonnding given in Chapter i. This retrodisplacement of the body of the uterus may be due to a full bladder (Fig. 324) or to an inflammatory mass in the front part of the pelvis or to a tumor. On the other hand, the displacement itself, with or Avithout an accompanying inflammatoiy trouble, may be the principal lesion. Fig. 326. Uterus puslied to the left side by a Tumor or Inflammatory Mass in the opposite side. (Findley- Diagnosis of Diseases of Wonen.) I'ig. Z17. Uterus Drawn to the left side by Adhesions or Infiltration in the same side. (Findley — Diaynosis of Diseases of Women.) Forward Displacement of the Uterus. ForAvard displacement of the body of the uterus may be due to the body of the uterus being heavy and softened, as in early pregnancy (Fig. 328) and also in certain inflammatory conditions, or to an inflammatory mass or a tumor pushing the fundus forward and down- ward. 278 GYNECOLOGIC DIAGNOSIS Placenta Orif. int. uteri Orif. ext. uteri Excav. lesicouter. Pa)'ies recti Vesica urin. V. dorsalis clitor. " Clitorin Fornix vagin. post. M. sphincter ani ext. funica muscul. recti M. sphincter ani ext. Urethra Tunica muscul. urethr. Vagina Fig 328. Frozen Section of a body showing the Uterus Enlarged from early Pregnancy. Notice the sharp anteflexion of the softened uterus. (Waldeyer— Das Becken.) CHANGES IN CORPUS UTERI 279 fig. 329. Early Pregnancy with Retrodisplacement of uterus. (Edgar — Practice of Obstetrics.) Fig. 330. Early Pregnancy with a more marked Rttrodisijlacement of the uterus. (Edgar — Practice of Obstetrics.) 280 GYNECOLOGIC DIAGNOSIS Lateral Displacement of the Uterus may be caused by an inflammatory mass (Fig. 325) or by a blood mass (Fig. 363) or by a tumor (Fig. 326), push- ing the uterus toward the opposite side. It may be due also to old adhesions drawing the uterus to the side (Fig. 327), or it may be due simply to a heavy uterus leaning to the side. Slight Enlargement of the Uterus may be caused by early pregnancy. There is usually decided anteflexion of the softened uterus in this early stage (Fig. 348). Occasionally there is backw^ard displacement of the pregnant uterus (Figs. 329, 330). From about the sixth to the twelfth week there is a peculiar softening and compressibility of the lower portion of the body of the uterus which contrasts markedly with the less compressible portion above. This is known as Hegar's sign, and when well marked is a strong •"-v-^ Fig. 331. A Sectioned Uterus in early Pregnancy, showing the two halves and the interior arrangement which gives Hegar's Sign. (Edgar, after Pinard — Practice of Obstetrics.) indication of early pregnancy. Fig. 331 sIioavs the section of a uterus in early pregnancy. Fig. 332 explains the sensation imparted to the examining flnger. The examination may be made in the usual Avay, with the abdominal fingers back of the uterus (Fig. 333), or the abdominal fingers may be pressed in front of the fundus uteri, which is displaced somewhat backward, while the vaginal fingers are placed behind the uterus (Fig. 334). Slight enlargement of the uterus may be due also to tubal pregnancy or to chronic inflammation or to one or more fibroid tumors (Figs. 335, 336, 337, 338) or to carcinoma of the corpus uteri (Fig. 339) or to sarcoma or to lipoma or to pyometra (Fig. 358) or to tuberculosis of the uterus (Chapter vi). CHANGES IN CORPUS UTERI 281 Marked Enlargement of the Uterus may be due to normal pregnancy (Flg-s. 340, 341, 342). Fig. 343 shows the height of the fundus at the various weeks of a normal pregnancy. Bear in mind that the pregnant uterus is not always regular in shape, but is occasionally quite irregular (Figs. 344, 345, 346). Enlargement may be due also to a pregnancy somewhat abnormal, for example, presenting backward displacement or hydramnios or hydatidiform mole or hematom-mole. Again, marked enlargement of the uterus may be ssT^^e. Fig. 332. Showing the Sensations imparted to the examining fingers by different portions of the uterus in Early Pregnancy, particularly the marked Compressibility of the portion just above the internal os (Hegar's Sign). (Dickinson — - American Textbook of Obstetrics.) Fig. 333. Palpating for Hegar's Sign, with the uterus forward in the usual position. (Edgar — Practice of Obstetrics.) Fig. 334. Palpating for Hegar's Sign, with the fundus uteri pushed backward, the abdominal fingers being in front and the vaginal fingers back of the cer- vix. (Williams — Obstetrics.) caused by interstitial pregnancy (Fig. 347) or by pregnancy in a septate uterus (Fig. 348). Aside from pregnancy, the usual causes of marked enlargement of the corpus uteri are fibromyomata (Figs. 349, 350, 351, 352, 353) and malignant disease (Fig. 354). In some cases there is an association of fibroid and pregnancy (Figs. 355, 356) or of malignant disease and pregnancy. 282 GYNECOLOGIC DIAGNOSIS In rare instances the uterus has become enlarged from menstrual blood retained because of atresia of the cervix (hematometra, Fig. 357) or from a collection of pus (pyometra) or of pus and gas (pyophysometra, Fig. 358). Softening' of the Corpus Uteri is caused by the various forms of intra- uterine pregnancy. In most cases of early pregnancy the characteristic com- pressibility of a portion of the uterus (Hegar's sign) may be made out, and =^ i ^ = --t' : 1 ' , 4 ^\\ / f V ■" " / \ I ^-"^ Fig. 335. Hard Nodiiles in the Corpus Uteri, due to small Fibromyomata. (Montgomery — Prac- tical Gynecology.) .Fig. 336. Larger Fibromyomata, in various sit- uations in the uterine wall. (Schaeffer — Hand-Atlas of Gynecology.) Fig. 337. Other varieties of Fibromyomata, giving rise to a diffuse and more uniform enlargement of the uterus. (Montgomery — Practical Gynecology.) CHANGES IN CORPUS UTERI 283 Fig. 338. A Single Fibroid in the posterior wall of the uterus. (Byford — Manual of Gynecology.) v'irC' Fig. 339. Slight Enlargement of the Corpus Uteri caused by Carcinoma. (Cullen — Cancer of the Uterus.) 284 GYNECOLOGIC DIAGNOSIS Fig. 340. Pregnancy, about four months. (Edgar — Practice of Obstetrics.) t .'V Fig. 341. Pregnancy, about five months. (Edgar — Fig. 342. Pregnancy at Full Term. (Edgar- Practice of Obstetrics.) Practice of Obstetrics.) CHANGES IN CORPUS UTERI 285 when well mai'ked is of much assistance in differential diagnosis. Softening of the corpus uteri may be caused also by extrauterine pregnancy and like- wise by a recent pregnancy (i.e., for a few weeks following labor or miscav- I'iage). It is caused also by edema of the uterine wall, from adjacent inflam- mation or from a tumor interfering with the circulation or from marked dis- placement. Fig. 343. The Height of the Fundus Uteri at various weeks of Pregnancy. (Williams — Obstetrics.) Figs. Fig. 344. 344, 345, and 346. Fig. 345. Fig. 346. Irregular Shapes that Pregnant Uteri may present, and which may lead takes in diagnosis. (Edgar — Practice of Obstetrics.) 286 GYXECOLOGIC DIAGNOSIS yratir-- Amruon Uterine cavily C ervi>; . - Partially separate; placenta. Fig. 347. Interstitial Pregnancy. (Williams, after Bumm — Obstetrics.) Fig. 348. Pregnancy in the Right Half of a Septate Uterus. (KeWy— Operative Gynecology.) CHANGES IN CORPUS UTERI 287 Fig. 349. Uterus Enlarged by a large soft single Fibroid. (Bishop — Uterine Pibromyomata.) 288 GYNECOLOGIC DIAGNOSIS Hard Nodules Felt in the Corpus Uteri may be due to parts of the child ill pregnancy or to fibromyomata or to a malignant tumor. In rare cases an atheromatous or sclerotic process may cause hardening of areas appreciable to the finger. Also, a mass of exudate or some adherent structure may cause Fig. 350. Uterus Symmetrically Enlarged from Fibroids. This might be mistaken for a pregnant tlterus, on account of the close resemblance in shape. (Kelly — Operative Gynecology.) Fig. 351. Subperitoneal Fibroids, showing the irregularity and distortion often present. (Kelly — Operative Gynecology.) a hard mass that appears, on bimanual examination, to be a part of the uterus. Marked Tenderness of the Uterus may be caused by inflammation of the uterus, by inflammation around the uterus, by hemorrhage around the uterus, by pelvic neuralgia or by functional hyperesthesia (hysteria, neurasthenia). CHANGES IN CORPUS UTERI 289 Fig. 352. Single Large Fibroid in anterior uter- Fig. 353. Large Fibroids, filling the pelvis and ine wall, choking the pelvis. (Kelly — Operative lower abdomen. (A. Martin — Atlas of Gynecology.) Gynecology.) Fig. 354. Uterus Enlarged from Carcinoma. The Fig. 355. Fibroid Tumor and Pregnancy, the interior of the uterus is occupied by the growth and tumor forming the most of the mass. (Dudley — it has extended through, forming some nodules on Practice of Gynecology.) the outer surface. (Kelly — Operative Gynecology.) 290 GYNECOLOGIC DIAGNOSIS Fixation of the Uterus may be due to an inflammatory mass, to a hemoi-- rhagic mass, to old adhesions, to a new growth or to scar-tissue from vaginal laceration. Abnormal Mobility of the Uterus is due to overstretching of the supports around it and of the pelvic floor below it. Fig. 356. Fibroid Tumor and Pregnancy, the Fig. 357. Uterus distended with Menstrual Blood- pregnancy forming the larger part of the mass. (Hematoraetra), due to atresia of the cervix. (Mont- (Norris, after Simpson — American Textbook of gomery — Practical Gynecology.) Obstetrics.) Fig. 358. Uterus, enlarged by a collection of Pus and Gas (Pyophysometra) above an occluded cancerous cervix. {Kelly—Operative Gynecology.) MASS OR INDURATION IN PELVIS 291 MASS OR INDURATION In Pelvis or Lower Abdomen, Felt on Bimanual Examination MASS LOW IN PELVIS, AND TO RIGHT OF CERVIX A. Mass or Induration Firm (No Fluid Felt) 1. Body of the Uterus Displaced to the Right. The mass is directly con- tinuous with the cervix and is about tlie size and shape of the body of the uterus. The uterus can not be felt elsewhere. If not adherent or very tender, it may be pushed back to the normal position of the corpus uteri. The uterus may lie somewhat to one side, though freely movable, or it may be drawn to one side by adhesions, or it may be pushed over by a tumor or an inflammatory mass or a blood mass. The displaced uterus may be of a normal size or it may be enlarged. If enlarged, it may be of regular shape or distorted. It may be of normal Fig. 359. The Three Spaces or Areas in the Pelvis. A. Peritoneal Cavity. B. Subperitoneal connective tissue area or Parametrial Space. C. Ischio-rectal Space. The white line betvi^een B and C represents the levator ani muscle. (Dudley — Practice of Gynecology.) Fig. 360. On the right is a large inflamma- tory mass in the Parametrial Space. This is what is meant ordinarily by the term Pelvic Cellulitis. On the left is a small inflammatory mass in the Ischio-rectal Space. From inflammatory trouble in this region comes the well known Ischio-rectal Ab- scess. (Dudley — Practice of Gynecology.) consistency or softened or presenting hard nodules. If there is inflammation in the uterus or around it, it may present decided tenderness. Whether it is movable or fixed depends on the cause of the displacement. If there is attach- ment by adhesions to the pelvic wall or to an inflammatory mass or to a tumor, determine whether it is at the lower or upper part of the uterus. 2. Salpingitis Vidth Exudate, extending to the side of the cul-de-sac. The inflamed tube itself is situated higher, but some fibrinous peritoneal exudate has extended down so that it is felt to the right side of the cervix posteriorly. 3. Salpingitis with Prolapse of Thickened Tube. The enlarged and in- durated tube may be movable, or it may be bound in its abnormal situation by adhesions. 292 GYNECOLOGIC DIAGNOSIS 4. Salpingitis with Secondary Infiltration of the connective tissue about the cervix. This presents practically the same signs low in the pelvis as a primary cellulitis, but in addition there is felt higher, the mass formed by thickened tube and peritoneal exudate. 5. Oophoritis with Prolapse of Ovary. The ovary is usually enlarged and cystic, but none of the cysts are yet large enough to give distinct fluctuation. Ordinarily, the ovary feels much softer on palpation than either an infiltrated tube or a mass of exudate. This softness may be so marked as to lead to the erroneous idea that fluctuation (a well marked cyst) is present, while in fact the ovarian tissue may be practically normal. The chronically inflamed ovary is occasionally as firm as other tissue which is the seat of inflammatory infiltra- Fig. 361. Mass in Right Ureter. It is a Calculus of enormous size, situated in the ureter and extending into the bladder wall; a, calculus; h, upper part of right ureter (thickened); c, left ureter; d, sigmoid; e, left Fallopian tube; /, bladder pushed to one side. (Bovee — Practice of Gynecology.) tion. This is the case particularly in the cirrhotic ovary, which is also usually smaller than the normal ovary. The fact that the mass, felt to the right of the cervix posteriorly, is the ovary, is determined by noticing its position, size, shape, consistency, tender- ness, mobility and point of attachment. The ovary is usually decidedly tender, even when normal, and pressure upon it produces a peculiar sickening pain. One of the characteristics of the prolapsed ovary, when not adherent, is that it is freely movable. It slips away from the examining finger and may MASS OR INDURATION IN PELVIS 293 1)6 pushed up out of the lower part of the pelvis. Following the mass up and making deep bimanual palpation, its point of attachment is found to be in the tubo-ovarian region. If there has been any peritoneal exudate, the ovary is likely to be fixed in its abnormal position by adhesions. 6. Small Abscess from any of the above conditions, near the posterior lateral part of the cervix and with such a thickened wall that no fluctuation Fig. 362. Mass beside Uterus, formed by Abscess in broad ligament. (Montgomery — Practical Gynecology.) is obtained. There is a point of marked tenderness, with fixation of the tis- sues in the vicinity. If of recent origin there will be some fever, but in an old abscess the temperature may be practically normal. The history of the trouble and the findings elsewhere in the pelvis will indicate the character of the primary lesion. Fig. 363. Hematoma of Right Broad Ligament. (Montgomery — Practical Gynecology.) 7. Adhesions at the side of the cervix from any of the above affections. In the absence of pus or active infiammation, there is usually not much tenderness. The principal signs are induration, without a definitely-outlined mass, and fixation. 294 GYNECOLOGIC DIAGNOSIS 8. Cellulitis. This may be acute or subacute. The induration is situated very low and blends with the cervix. It may be a small mass or may fill all that side of the pelvis, extending out to the pelvic wall. As a rule its shape corresponds approximately with the connective areas (Fig. 359). If the in- flammation is in the parametrium (above the levator ani), it is immediately about the cervix (Fig. 360). If it is below the levator ani, in the ischio-rectal space, the induration will be lower, along the vaginal wall and rectum, and there will be induration near the anus. In jDelvic cellulitis, except in the acute cases, the induration feels exceptionally hard, possibly because there is but little intervening soft tissue between the examining finger and the infiltra- tion. The hardness is so marked in some cases as to give the impression of a cartilaginous growth from the pelvic wall. The uterine attachment of the mass is low, principally about the cervix. The outer extremity extends to the pelvic wall, where it is intimately attached over a broad surface (Fig. 360). Fig. 364. A Parovarian Cyst, forming a large Mass and displacing the uterus. Pi-actice of Gynecology.) (Ashton- 9. Small Abscess from Cellulitis, with wall so thick that no fluctuation is obtained. There is a point of marked tenderness, with some fever, and u mass of induration presenting the characteristics of cellulitis. 10. Scar-Tissue from Former Cellulitis. As explained elsewhere, uncom- plicated cellulitis, like other forms of lymphangitis, runs its course and ends in resolution or abscess formation with discharge of the pus. In either case the accompanying inflammatory infiltration eventuates in the formation of new connective tissue which contracts like other scar-tissue, causing persist- ent induration and fixation of tissues in the affected area. There is not much tenderness from the scar-tissue itself, but the resulting compression or con- striction of nerves and interference with the circulation liy distortion, may exceptionally cause persistent tenderness and pain. 11. Scar-Tissue from Laceration in Labor. Not infrequently tears of the MASS OR INDURATION IN PELVIS 295 cervix are so extensive that they involve the vaginal wall and the parametrium, giving scars that may be felt beside the cervix. The induration may bo linear or vs^idespread. The fixation of the cervix may be slight or marked, depending on the amount and situation of the scar-tissue. Usually there is not much tenderness. 12. Malignant Infiltration of the parametrium, extending from the cervix uteri or the bladder or the rectum. The induration is firm and is situated im- mediately beneath the vaginal wall and usually follows approximately the outline of the connective area. Ordinarily there is not much tenderness, un- less there is complicating inflammation. The amount of fixation of the cervix depends on the extent of the infiltration. 13. Fibroid of Uterus, growing into right broad ligament. The mass pro- jects out from the side of the uterus, has a rounded well-defined outer border and is firm and not tender. The mass is fixed by a broad attachment to the side of the uterus but the uterus and mass together are movable in the pelvis, Fig. 365. An Ovarian Cyst growing in beside the uterus. (Montgomery — Practical Gynecology.) unless the mass is so large that it extends to the pelvic wall or there is com- plicating infiammatory fixation. 14. Affection of Right Ureter. A mass about the ureter may be caused by inflammation in and around the ureter. The inflammation may be due to a stone lodged in the ureter or to tubercular ureteritis or to an ascending pus infection. The mass is situated in the course of the ureter, is small at first and may give the impression of a small nodule like an enlarged gland in the tis- sues. It is firm, very tender, fixed, but not intimately attached to any of the adjacent organs until extensive infiltration has formed. Fig. 361 shows a mass from the right ureter. A mass from the ureter is accompanied by blad- der irritability and urinary abnormalities. 15. Solid Tumor of Ovary or Tube, bound down by adhesions and forced to grow towards the cervix. The mass would necessarily become of consider- able size before reaching that region. It is approximately spherical, though of somewhat irregular outline. It is firm and usually somewhat tender be- 296 GTXECOLOGIC DIAGNOSIS cause of the aecompanving inflammation, but not as tender as an inflamma- tory mass of the same size would be. It is fixed in the pelvis and attached to all surrounding structures. The uterus is usually pushed far to the op- posite side, but the history does not show the severe disturbance that would necessarily accompany a purely inflanmiatory mass of like size. B. Mass Contains Fluid (Fluctuation May be Obtamed) 1. Pelvic Abscess (Fig. 362) from salpingitis, with secondary involvement of connective tissue; or from primary cellulitis; or from suppuration in a fibroid tumor, in a cyst or in a hematoma in this situation. The mass usually fills in all the lower part of that side of the pelvis, and is surrounded VULI/A. Fig. 366. Hematometra in a Rudimentary Horn of the Uterus. (Montgomer}- — Practical Gynecology.) by infiltration which shades off gradually into the surrounding tissues. The area of fluctuation is surrounded by induration. There is marked tenderness at the point of fluctuation, which diminishes usually as the periphery of the mass is reached. There is fixation of all the involved tissues and of the adja- cent organs, including the uterus. The history and the findings elsewhere in the pelvis, indicate the seat of the primary inflammation. 2. Pelvic Hematoma (Fig. 363). This usually comes from a tubal preg- nancy, which has ruptured between the layers of the broad ligament. The induration runs down close around the cervix, and may be small or may fill all that side of the pelvis extending up to the ti)p of the broad ligament. It has a general rounded outline, much more so generally than an inflam- MASS OR INDURATION IN PELVIS 297 matory infiltration in the connective tissue, tliougli it is limited anteriorly and posteriorly by the separated peritoneal layers of the broad ligament. It is largely fluid and there is distinct fluctuation over a considerable area, as in a cyst. Also, there is not so much surrounding induration as in an abscess, though usually considerably more than in a cyst. The tenderness is not nearly so marked as in a collection of blood in the peritoneal cavity. Of course the tenderness varies somewhat, being more marked when the hemor- rhage is recent and extensive, in which case it may be very marked. Ordi- narily the tenderness from a hematoma is not nearly so marked as tender- ness from an abscess. There is fixation of the mass in the situation in which it is found, and, if extensive, it fixes the uterus to the pelvic w^all. The history and the findings elsewhere will show the cause of the trouble. 3. Hydrosalpinx coming low in the pelvis. The cystic mass runs up into Fig. 367. Thickened Tube and Ovary prolapsed into the cul-de-sac behind the uterus. (Montgomery — Practical Gynecology.) the tubal region. It is somewhat elongated and sausage-shaped and extends from the upper angle of the uterus to the pelvic wall. It fluctuates freely and gives the impression of a thin-walled cyst. Frequently some induration from exudate or adhesions, may be felt. It is not tender ordinarily. It is somewhat movable, though not as much so as a small pediculated ovarian tumor. It is attached to the uterus and to the pelvic wall and along the upper part of the broad ligament. 4. Parovarian Cyst (Fig. 364). It is situated near the center of the broad ligament and, if as large as an orange, it begins to come down about the cervix just beneath the vaginal wall. It is approximately spherical, though somcAvhat irregular in shape. It fluctuates freely throughout and the fluid seems very close to the examining flngers. There is no tenderness, unless complicated by inflammation or neuritis or other painful aifection. It is flxed, as a rule, but not firmly. The peritoneal layers of the broad 298 GYNECOLOGIC DIAGNOSIS ligament stretch sufficiently to permit considerable movement in some cases, especially later, when the cyst has become so large that it rises out of the pelvis. The uterus is displaced to the opposite side, and the cyst is attached to it and to the pelvic wall, but not intimately as a rule. If inflammation takes place about the cyst then there is marked fixation and attachment to all adja- cent organs, and the cyst as it grows may elongate the body of the uterus. 5. Ovarian Cyst growing toward the cervix (Fig. 365). An ovarian cyst which has been fixed in the pelvis by inflammation may grow in this direction. It presents the same characteristics as a parovarian cyst compli- cated by inflammation, except that fluctuation is not so uniform throughout the mass. There may be firm portions representing thick septa or small areolar cysts. 6. Cystic Fibroid. This presents the ordinary characteristics of a fibroid, except that there is a point of fluctuation and there may be some tenderness. Kig. 36S. A Fibroid Tumor, forming a Mass behind the uterus. (Montgomery — Practical Gyne- cology.) Fig. 369. A Retroflexed Uterus and a Fibroid, forming a Mass behind the cervix. (Montgomery — Practical Gynecology.) 7. Uterus Containing' Fluid and displaced to one side. This fluid in the uterus may be due to pregnancy, normal or abnormal, or to a cystic fibroid or to pus in the uterus or to blood in the uterus. 8. Rudimentary Horn of Uterus, containing blood (Fig. 366) or other fluid. There may be pregnancy in such a horn (Fig. 385). 9. Vaginal Cyst. Vaginal cysts may come from remnants of the Wolffian duct or from aberrant gland structures ' in the vaginal wall. They protrude into the vagina more or less, are small and rounded, have fluctuation through- out with a thin wall and are not tender unless complicated. They are fixed in the lower part of the pelvis and lie just beneath the vaginal wall, to which they are' closely attached. 10. Ureter Greatly Dilated. The fluid in the dilated ureter may be urine (hydro-ureter) or pus (pyo-ureter). The upper part of the ureter and the kidney is usually dilated also (hydronephrosis, pyonephrosis). A fluctuating MASS LOW AND BEHIND CERVIX 299 swelling is found in the region of the ureter, accompanied by symptoms of bladder irritation and urinary evidences of disease. The retained urine may be discharged at times through the bladder. The swelling then largely disap- pears, to reappear when the obstruction again occurs and the sac refills. A careful investigation as to the amount and character of the urine discharged with the variation in the size of the mass, is an important step in the diag- nosis of such a mass. MASS LOW IN PELVIS, AND TO LEFT OF CERVIX A. Mass or Induration Firm (No fluid felt). Same as on right side. B. Mass contains Fluid (Fluctuation obtained). Same as on right side. MASS LOW AND BEHIND CERVIX A. Mass or Induration Firm 1. Body of Uterus Displaced backward to the 3rd degree (Fig. 67). Any of the various solid conditions of the uterus previously mentioned may be present. 2. Salpingitis with Exudate extending into the cul-de-sac. Fig. 370. An Abscess behind the uterus, gomery — Practical Gynecology.) (Mont- Fig. 371. A Blood Mass filling the pelvis and running down behind the uterus. (Montgomery — • Practical' Gynecology.) 3. Salpingitis with Prolapse of the thickened tube into the cul-de-sac (Fig. 367). The prolapsed tube may be movable or adherent. 4. Salpingitis with Secondary Infiltration of the connective tissue back of the uterus. 5. Oophoritis with Prolapse of the ovary. The prolapsed ovary may be 300 GYNECOLOGIC DIAGNOSIS movable or adherent. Tlie characteristic palpation signs of a prolapsed ovary have already been given. 6. Small Abscess behind the cervix, from any of the above conditions and with such a thick wall that no fluctuation is obtained. 7. Adhesions behind the cervix, from any of the above affections. 8. Cellulitis. For the characteristic palpation signs of cellulitis, see under Mass to Eight of Cervix. 9. Small Abscess from Cellulitis, with wall so thick that no fluctuation is obtained. 10. Scar-Tissue from Former Cellulitis. This is not nearly so frequent in th's region as peritoneal adhesions. 11. Scar-Tissue from Laceration in Labor. This is found occasionally, though it is rare in this situation. ]\tost of the deep lacerations extend laterally. Fig. 372. An Ovarian Cyst lying back of the uterus. (Ashton— Practice of Gynecology.) 12. Malignant Infiltration from cancer of cervix uteri or from cancer of the rectum or from cancer of the bladder. 13. Fibroid of the Uterus growing posteriorly from the cervix or lower part of the corpus uteri (Figs. 368, 369). 14. Affection of Ureter with exudate extending back of the uterus. The differential diagnostic points of a ureteral mass have already been given. 15. Solid Tumor of Ovary or Tube, forced to grow into the cul-de-sac. 16. Fecal Mass in Rectum. Along the lower part of the posterior vaginal wall such masses cause no trouble in diagnosis, but in the region of the cul- de-sac they may lead to a mistake. The characteristics of such a fecal mass are that it is situated in the course of the rectum, that it is not particularly tender, that it is of putty-like consistency and may be indented (the dent re- maining) and that it may be moved along to another position in the canal. MASS LOW AND BEHIND CERVIX 301 If there is still doubt, direct the patient to take a purgative to give a good boAvel movement and the next day an enema to clear out the large bowel, and then return for another examination. 17. Tumor of Rectum. The mass is in the wall of the rectum and there are usually symptoms of rectal irritation, ^\dth the passage of blood and mucus. 18. An Abdominal Organ Prolapsed into the cul-de-sac. A wandering kidney or spleen may be found in this situation. It may be movable or fixed. It presents somewhat the characteristics of the organ involved, i.e., it has about the size, shape, consistency and tenderness. If movable, it may be pushed back into the normal situation of the organ. An examination in the Trendelenburg posture may aid very materially in this. The knee-chest pos- Fig. 373. Showing the Method of Testing the Mobility of such a Mass. (Ashton — Practice of Gynecology.} ture, taken for a few seconds, may cause the organs to return to the abdominal cavity. Careful examination may show the organ absent from its normal position. If it is the kidney, there may or may not be bladder symptoms or urinary abnormalities. B. Mass, Behind Cervix, Contains Fluid 1. Pelvic Abscess (Fig. 370) from salpingitis, from oophoritis, from cel- lulitis, from hematocele or hematoma, from a suppurating solid tumor or from a suppurating cyst. 2. Intraperitoneal Hemorrhage (Fig. 371). This usually comes from lubal pregnancy, with rupture of the wall of the tube or abortion from the end 302 GYNECOLOGIC DIAGNOSIS of the tube into the peritoneal cavity. Blood in the peritoneal cavity presents one of three conditions, as f oUoavs : a. The blood may be free in the cavity. This, like ascites, does not give rise to any distinct mass or induration, hence does not require consideration here. The characteristics of this condition are given in Chapter xi. b. Clots and fibrinous exudate forming a mass about the affected tube and extending from the tube into the cul-de-sac. This forms a mass. If there is a large amount of plastic exudate, the mass is rather firm and with definite outlines. If the mass is made up principally of recent blood clots, it is soft and the outlines indistinct. This condition is found in those cases where there are repeated slight hemorrhages. This is a dangerous state of affairs for, though the bleeding has stopped temporarily, any exertion, or a disturbance of the clots by an examination, may start a severe hemorrhage. c. Some blood has run into the cul-de-sac and a firm roof of fibrinous exudate has formed above it, shutting it off completely from the general peritoneal cavity. This condition is called pelvic ''hematocele," and repre- sents the least dangerous condition of intraperitoneal hemorrhage. The physical signs of intraperitoneal clotted blood and exudate are practi- cally the same as those of inflammatory exudate, with the exception of the temperature. There is usually but little fever after the first forty-eight hours, and in many cases not much at any time. Of course, if suppuration comes on later in the blood mass, then the ordinary signs of suppuration appear, includ- ing fever. The diagnosis of a blood mass, rather than an inflammatory mass, must rest largely upon the absence of decided fever in the presence of acute symptoms and upon certain points in the history and progress, indicating a tubal pregnancy. These points are given under tubal pregnancy in Chapter xi. 3. Hydrosalpinx low in the cul-de-sac. The prolapsed and distended tube may be movable or adherent. 4. Parovarian Cyst pushing back behind cervix and filling the posterior part of the pelvis. 5. Ovarian Cyst in cul-de-sac (Figs. 372, 373). A small ovarian cyst may easily drop into the cul-de-sac. If it becomes adherent it will remain there, choking the pelvis as it enlarges. 6. Cystic Fibroid. This presents the characteristics of a fibroid, with fluctuation and some tenderness added. 7. Uterus Containing Fluid and displaced backward. The fluid in the uterus may be due to pregnancy or to a cystic fibroid in the wall or to pus or to blood. 8. Small Cyst of Some Abdominal Structure lying in cul-de-sac. Such a cyst may come from the omentum, from the mesentery or from a prolapsed kidney or spleen. 9. Ureter Greatly Dilated (hydro-ureter or pyo-ureter) and filling in back of the uterus. MASS LOW AND IX FRONT OP CERnX MASS LOW AND IN FRONT OF CERVIX 303 A. Mass or Induration Firm 1. Uterus Displaced Forward. There may be any of the solid conditions of the uterus already mentioned. 2. Fibroid Tumor of Uterus (Fig. 374). 3. Malignant Disease of cervix extending forward or of the urethra ex- tending backward or of the vagina, may give induration in front of the cervix. 4. Cellulitis, between uterus and bladder. The characteristics of an in- duration from cellulitis have alreadv been a-iven. Fig. 374. A Fibroid forming a Mass in front of the uterus. (Thomas and Munde — Diseases of IVotnen.) 5. Bladder Disease. This may be a tumor (Fig. 375) or tuberculosis (Fig. 376) or chronic inflammation. B. Mass, in Front of Cervix, Contains Fluid 1. Bladder Distended with Urine (Fig. 324). "Whenever, in making a bimanual examination, a cystic mass is felt in front of the uterus, catheterize the patient if necessary to eliminate a full bladder. 2. Uterus Containing- Fluid. This is usually due to pregnancy, though it may rarely be due to pyometra or hematometra. 3. Pelvic Abscess. A pelvic abscess in this situation is usually due to a cellulitis. 4. Pelvic Hematoma. Occasionally a hematoma from tubal pregnancy will dissect in between the uterus and bladder and give a fluctuating mass in this region, but this is very rare. 5. Vaginal Cyst. This projects into the vagina, and the fluid appears to 304 GYNECOLOGIC DIAGNOSIS Fig. 375. A Tumor of the Bladder. (Ashton — Practice of Gynecology.) Fig. 376. Tuberculosis of the Bladder, forming a Mass in front of the uterus. (Dudley — Practice of Gynecology.) MASS LOW AND FILLING PELVIS 305 be just beneath the vaginal walh Its point of attachment is very low, ap- parently in the vesico-vaginal septum. 6. Parovarian Cyst. Such a cyst may grow in between the uterus and the bladder. 7. Cystic Fibroid. A fibroid groAving from the anterior part of the cervix may displace the l)ladder upward and give a mass just in front of the cervix. Fig. 377. Inflammatory Exudate filling the pelvis and forming a firm roof above the examining fingers The resisting "roof" usually follows about the line indicated in Fig. 378. Fig. 378. Indicating the general direction of the lower surface of the "roof of exudate" in most cases. (Thomas and Munde — Diseases of Women.) MASS LOW AND FILLING PELVIS A. Mass or Induration Firm 1. Extensive Inflammatory Exudate or infiltration, from salpingitis, oophoritis, peritonitis or cellulitis (Fig. 377). This extensive inflammatory exudate fixes all the organs, as though plaster of Paris had been run in around them and had hardened there. On making the vaginal examination 306 GYNECOLOGIC DIAGNOSIS Fig. 379. Pelvis filled with a Bony Tumor from the pelvic wall. (A. Martin — Atlas of Gynecology.) Fig. 380. Pelvis and Lower Abdomen filled with a Mass composed of a Pregnant Uterus and an Ovarian Cyst. (Williams, after Bumm — Obstetrics.) MASS HIGH IN RIGHT SIDE 307 tliere is found a firm roof above the examiiiiiig fingers, on approximately the plane indicated in Fig. 378. 2. Extensive Bleeding in the pelvis, in the form of hematoma or hema- tocele or blood clots without limiting roof of exudate. 3. Large Fibroid in lower part of uterus. This may be any one of the various forms of fibromyoma. 4. Malignajit Disease of cervix or corpus uteri or of bladder or of rectum. There may be malignant disease and fibroid. 5. Tumor from Pelvic Wall (Fig. 379). B. Mass, Low and Filling Pelvis, Contains Fluid 1. Uterus Pregnant. The enlarged and fluctuating uterus may be in normal position or in displacement (Fig. 330). It may be regular in shape or very irregular (Figs 344, 345, 346). 2. Parovarian Cyst. This may grow low in the pelvis and fill it, displac- ing the organs in various directions. 3. Ovarian Cyst. An ovarian cyst bound down by adhesions, may fill the pelvis and extend to the lower part of it. There may be some complicating condition, for example, an ovarian cyst and pregnancy (Fig. 380). 4. Pelvic Abscess with extensive exudate or infiltration may fill the pelvis. The point of fiuctuation is usually behind the cervix. Most of the mass is firm, and there is the firm inflammatory roof previously mentioned. 5. Collection of Blood in pelvis. This may be present in the form of hema- toma or hematocele. In addition to an area of fluctuation, there is usually the firm roof due to accompanying infiltration and exudate. MASS HIGH, IN PELVIS OR LOWER ABDOMEN, RIGHT SIDE A. Mass or Induration Firm 1. Uterus Displaced. Any one of the various solid conditions of the uterus previously mentioned may form a mass in the center of the pelvis or to one side. 2. Salpingitis. There may be simply a thickened tube (Fig. 381) or a large mass of exudate. 3. Pyosalpuix, with small amount of pus and such a thick wall that no fluctuation is obtained. There may be very little peritubal exudate or a great deal. 4. Oophoritis, without any cyst large enough to give fluctuation. There may be little or no exudate or there may be a large amount of exudate. 5. Adhesions, from any of the above conditions. The adhesions may be slight or extensive. 6. Cellulitis, in upper part of broad ligament, or resulting scar-tissue from same. 308 GYNECOLOGIC DIAGNOSIS 7. Thrombosis of Veins of Broad Ligament (Fig. 382), This condition, though rar©, probably occurs more frequently than is generally supposed. 8. Solid Tumor of Ovary or Tube. This may be small or large, movable or adherent. 9. Extrauterine PregTiancy. This may be tubal pregnancy (Fig. 383) or pregnancy in a rudimentary horn of the uterus (Figs. 384, 385). For the special evidences of extrauterine pregnancy see Chapter xi. Tubal pregnancy, Fig. 381. Salpingitis Nodosa. (Thomas and Munde — Diseases of Women.) with its resulting hemorrhage and plastic exudate and adhesions binding to- gether the various structures and giving a tender mass in the tubo-ovarian region, is most frequently mistaken for an ordinary inflammatory m.ass. 10. Pelvic Tuberclosis. The mass presents the characteristics of a chronic inflammatory mass, which in fact it is. The fact that the inflammation is tu- Fig. 382. Thrombosis of Veins of the broad ligament. (Schaeffer — Hand-Atlas of Gynecology.) bercular must be determined by other features of the case than the pelvic palpation. For these other diagnostic points, see pelvic tuberculosis in Chap- ter XI. 11. Fibroid Tumor of Uterus. This is subperitoneal and may be pedicu- lated (Fig. 351) or sessile (Fig. 352). 12. Appendicitis with Exudate. The mass is situated about the appendix and the history points to bowel trouble, rather than to tubal trouble. In some cases the appendix extends into the tubal region, causing more or less MASS HIGH IN RIGHT SIDE 309 confusion in diagnosis. The various situations which the appendix has been found to occupy in different cases, without change of the position of the ce- cum, are shown in Fig. 387. In cases where the cecum varies from the usual position, the appendix may be still farther from its normal position, as indi- cated in Fig. 386. In a case of appendicitis there may be a point of pain and tenderness elsewhere in the abdomen, in addition to that in the appendix region. Then immediately arises the question, ''Do any of these additional areas of tenderness represent an additional lesion or is the pain and tender- ness simply reflex from the inflamed appendix?" The author's friend, Dr. Leon- idas Kirby, of Harrison, Arkansas, recently called his attention to the following method of identifying the reflex areas of tenderness. With the patient's knees drawn up to relax the abdominal muscles as in regular abdominal pal- pation, note the areas of tenderness. Then make steady pressure exactly over the appendix sufficient to cause decided pain and, while maintaining this Fig. 383. Tubal Pregnancy in the Right side. (Dickinson — American Textbook of Obstetrics.) pressure over the appendix, palpate with the other hand the areas which are tender. When the tenderness in the other areas is reflex, it disappears as long as the pressure over the appendix is maintained, to reappear as soon as the pressure over the appendix ceases. Dr. Kirby has found this simple expedient very helpful in a considerable number of doubtful cases. 13. Fecal Mass, in cecum and extending along the ascending colon. 14. Tumor of Cecum. This is usually malignant. It presents chronic irritation in the cecal region, generally leading to a diagnosis of chronic ap- pendicitis. There are exacerbations of trouble at times, due apparently to irrita- tion in the cecum from retained fecal material. In some cases there is a swelling in this region, that comes and goes. It is most marked usually during the days of pain and disappears largely Avhen the bowels are well opened. Later a permanent mass appears, though it may vary considerably 310 GYNECOLOGIC DIAGNOSIS in size at different times, due to the varying amount of fecal material in the cecum. This same history may be present at times in chronic cecitis without a tumor, but in such a case of course there is no permanent tumor, unless there is some complicating inflammatory trouble around the cecum. . 15. Intussusception. The mass extends along the cecum and ascending colon. There is the history of intestinal obstruction, the passage of bloody mucus from the bowel and the rectal tenesmus. It is most frequent in children. 16. Displaced Kidney (Fig. 388). The mass has approximately the size and shape of the kidney and is tender when pressed upon. Pressure usually causes a desire to urinate, and it may cause pain running along the ureter to the bladder. The prolapsed kidney is usually somewhat enlarged. Unless adherent in its malposition, it may be returned to its bed in the loin. This facility with which the kidney slips up into its bed when the patient is lying on her back, sometimes interferes with the diagnosis, for palpation then would show no displacement of the kidney. In order to prevent a prolapsed kidney Fig. 384. Pregnancy in the Rudimentary Horn of a malformed uterus. Sanndcr's Year Book, 1904.) (Jay's Case — from being pushed into place unawares, during palpation in the vicinity, it is well to grasp the lumbar region firmly, as shown in Fig. 389. This fixes the kidney in its abnormal position, where it can be palpated by the fingers of the other hand, as shown in Fig. 390. Another way to examine a movable kidney in its lowest position, is to palpate the loiii while the patient is standing. The patient must lean forward on some support in such a way as to relax the ab- dominal muscles. 17. Tumor of Kidney. Such a mass may be traced up into the kidney region. If the tumor and kidney are prolapsed, they may be returned to the loin, if not adherent. There are usually dragging pains in the loin, and blad- der symptoms. Urinary examination may give decisive information. A very satisfactory method of palpating the kidney region for a mass, or for deep tenderness, is to use both hands, one behind and the other in front, the lum- bar structures being caught between them. 18. Perinephritic Abscess, Avithout distinct fluctuation. This may dissect MASS HIGH IN EIGHT SIDE 311 down into the lower abdomen, and even into the pelvis, and still be so deeply situated as not to give definite fluctuation, except under anesthesia. The mass may be traced uj3 into the kidney region. There is colon resonance over it. There is marked tenderness in the lumbar region, and usually decided swelling there. There is the history and the ordinary signs of kidney dis- turbance, associated with the general and local evidences of suppuration. 19. Psoas Abscess, without distinct fluctuation. This causes a deep seated mass in the lower abdomen, which may give no fluctuation until it approaches the surface in the neighborhood of Poupart's ligament. As it is usually tuber- cular, the marked local tenderness and the high fever and chills of ordinary deep suppuration are generally absent. A careful examination, however, will Fig. 385. Pregnancy in a Rudimentary Horn of the Uterus. As there is no communicating cavity between the uterine cavity and site of the pregnancy in the rudimentary horn, the spermatozoa evidently came by way of the opposite tube, as indicated by the small arrows. (Kelly — Operative Gynecology.) show more or less fixation of the thigh. When an attempt is made to move the thigh in any direction that pulls the psoas muscle, the movement is re- sisted. There are also other evidences of caries of the lumbar vertebrae. 20. Enlarged Liver or Solid Tumor of Liver. The liver occasionally be- comes so enlarged from disease or abscess formation that its lower border is pushed into the right lower abdomen. The direct connection of the mass with the usual liver dullness may be demonstrated, and the lower border and left border of the mass has the shape of the liver and there is a history indi- cating liver disease. A tumor from the liver usually lies in front of the in- testines and its connection with the liver may be directly sho^^nii by palpation and percussion. Also, there is a history of liver disturbance. 312 GYNECOLOGIC DIAGNOSIS 21. Movable Liver. Exceptionally the liver may be so movable, that it sinks into the lower abdomen. The mass lies in front of the intestines, has the shape of the liver and may be returned into the liver region unless ad- herent. 22. Tumor of Abdominal Wall (Fig. 131). This is a rare condition, and for that reason it is likely to be forgotten, resulting in a mistaken diagnosis. The distinguishing signs of a tumor of the abdominal wall are given in the first part of this chapter. hind cecum. mesial fo cecum over ueurrL. II n .1 under » behind tUo-cecdt^ Junctioa in iliac fossa along iliac vessels Fig. 386. Diagram showing various positions in which the Appendix vermiformis may lie, with the cecum in the usual place. (Kelly — Diseases of the Appendix.) 23. Inflammatory Mass in Abdominal Wall. This presents about the same signs as a tumor of the wall, with evidences of inflammation added. 24. Tumor of Round Ligament. It arises somewhere in the course of the round ligament, either in the pelvic cavity or in the inguinal canal. If large, it necessarily produces great distortion of the parts. It may cause much confusion in diagnosis if the fact be not remembered that a tumor occasionally arises from this ligament. 25. Some Central Abdominal Mass. One of the firm masses mentioned as MASS HIGH IN EIGHT SIDE 313 usually appearing in the central abdomen, may be displaced to one side or may become so large that it extends far over to both sides. 26. Mass from Opposite Side. Occasionally an enlarged organ or a tumor from one side, will become so much displaced as to appear to belong to the other side. B. Mass, High in Right Side, Contains Fluid 1. Uterus Displaced. The fluctuation may be due to pregnancy or, very rarely, to pyometra or to hematometra. Fig. 387. Diagram showing various positions which the Cecum and Appendix may occupy, in cases where the cecum is displaced. Kelly — Diseases of the Appendix.) 2. Pyosalpinx (Figs. 391, 392, 393). There is a tender mass in the tubo- ovarian region, with slight or well-marked fluctuation. The mass is fixed and the uterus also is fixed. There may be a large amount of firm exudate or very little. There is usually a clear history of infection followed by the usual evi- dences of pelvic inflammation, including persistent endometritis with dis- charge. If the trouble is gonorrheal, the symptoms may be mild, and if of long standing the pus-tube may not be very tender. But there is more tender- ness and more thickening and fixation than occurs with hydrosalpinx or ovarian cyst or parovarian cyst. 3. Ovarian Abscess. This presents practically the same history and the same signs as a tubal abscess. In fact, it is sometimes impossible to say with absolute certainty whether the pus is in an enlarged tube or an en- larged ovary. As the former is the usual condition, we assume in a given case, that the pus is in the tube, unless there is something special pointing 514 GYNECOLOGIC DIAGNOSIS otherwise. Occasionally in an abscess in this region, the form can be made out as distinctly round (probably ovary) or distinctly long and sausage-shaped (tubal). 4. Tubal Pregnancy. This presents the history and examination signs of an inflammatory mass, with the history and progress of tubal pregnancy. There is, in the class of cases now under consideration, sufficient fluid blood encapsulated somewhere to give fluctuation, either about the tube or in the posterior cul-de-sac. Fig. 388. Movable Kidney, showing the outline of the displaced kidney as determined by palpa- tion. Notice that the kidney comes well below a line drawn from the umbilicus to the right anterior superior iliac spine (marked by a cross). 5. Pelvic Tuberculosis. There are the signs of a chronic inflammatory mass, with a collection of fluid (tubercular pus), and the history and progress of the case present the characteristics of local tuberculosis, as explained in Chapter xi. 6. Hydrosalpinx (Fig. 394). About the same as ovarian cyst except that it is oblong and extends from the uterus to the pelvic wall and is attached along the border of the broad ligament. The signs are much like those due to parovarian cyst, except that the hydrosalpinx is situated high while still small. There may or may not be a history of pelvic inflammation at any MASS HIGH IN RIGHT SIDE 315 time. Its intimate attachment to the uterine horn is an important diagnostic point. 7. Ovarian or Parovarian Cyst (Figs. 395, 396). A fluctuating mass, somewhat moval)le, of sIoav growth, with no acute symptoms if not compli- Fig. 389. Palpation of a Movable Kidney, with a patient on her back. First Step. The loin is grasped as here shown, to prevent the displaced kidney . from slipping unnoticed back into its place at the beginning of palpation. Fig. 390. Palpation of a Movable Kidney, with patient on her back. Second Step. Palpating the kidney with the right hand, while it is held in displacement with the left hand. 316 GYNECOLOGIC DIAGNOSIS cated, unless caught in the pelvis, and there is considerable abdominal en- largement before very troublesome symptoms appear. The mass is attached in the pelvis and, by further examination, its attachment may be traced to the tubo-ovarian region. Fig. 391. Double Pyosalpinx with adhesions. (Montgomery — Practical Gynecology.) Fig. 392. Pyosalpinx with no adhesions. (Kelly — Operative Gynecology.) 8. Cystic Fibroid. The greater portion of the mass is usually solid and presents the characteristics of a uterine fibroid. 9. Large Perityphlitic Abscess. Presents the history of appendicitis with persistent septic symptoms, and the evidences of a pus collection in the vicinity of the cecum. MASS HIGH IN RIGHT SIDE 317 10. Cystic Tumor of Kidney. The tumor may be traced up toward the loin. It is freely movable usually, unless there has been inflammation about it. Good fluctuation is not obtained through a moderately thick abdominal ■wall, unless there is some large cavity or a number of small ones with very thin walls-. The tumor may be made up of innumerable small cysts and yet, in the ordinary examination, appear as a solid tumor. Under anesthesia the fluctuation may usually be distinctly made out. Tenderness is slight unless there is complicating inflammation. The enlarged kidney is usually displaced doAvnward considerably, so that there is room in the loin up into which it may be pushed. The colon lies over the mass, between it and the abdominal wall. This may not be apparent at first, the colon being flattened out against the wall and causing no resonance on percussion. The fact that the colon Fig. 393. Pyosalpinx with very extensive adhesions. (Kelly — Operative Gynecology.') is over the mass is easily demonstrated by inflating the rectum and colon with air. This was necessary in the case of the tumor shown in Fig. 190 (see also Figs. 188 and 189). 11. Hydronephrosis and Hydro-ureter. Occasionally the kidney and ureter on one side Avill become very much dilated, forming a sac filled with fluid (urine). There is usually a history of kidney pains and bladder disturb- ance extending over a long period and varying much at different times. The characteristic feature is that the sac fills at times, producing a sw^elling with more or less tension and pain, and then after a variable time there is a dis- charge of a very large quantity of urine with disappearance of the swelling and relief of the symptoms. After a time the sac fills again and discharges. A crucial point in the diagnosis of such a condition is the coincidence of the disappearance of the swelling and the discharge of an extraordinarily large 318 GYNECOLOGIC DIAGNOSIS quantity of urine. Too mucli dependence should not be placed on the his- tory, as it is more or less uncertain and may lead to an erroneous conclusion. Before the patient is subjected to operation, in cases where the symptoms are not urgent, she should be required to make daily measurements of the amount of the urine passed during one of the periods of appearance and disappear- ance of the swelling, in order that any marked increase in the amount of urine, as the swelling disappears or diminishes, may be known positively. R.T. R.L. R.O. L.O. R.L. Fig. 394. Right Hydrosalpinx. U, Uterus split open. R.T. Right Tube, distended with fluid (hydro- salpinx). R.L. Round ligaments. R.O. Right ovary. (Keating and Coe — Clinical Gynecology.) Fig 395. Ovarian Cyst of Right side, displacing uterus to the left. Practical Gynecology.) (Montgomery- 12. Pyonephrosis. When the dilated kidney or ureter becomes filled with pus, there is marked disturbance, with fever, chills, pains extending from kidney to bladder, usually marked bladder disturbance and definite urinary findings. Palpation of the kidney and along the course of the ureter gives MASS HIGH IN RIGHT SIDE 319 marked tenderness. An important feature in tliese eases of painful kidney trouble is the point-tenderness on deep pressure in the lumbar just over the kidney. (Fig. 162). This helps to differentiate kidney-tenderness from tender- ness due to appendiceal or other intraperitoneal inflammation, which differ- entiation may in some cases be practically impossible by palpation in front. Usually, however, careful palpation in front will show clearly that the tender- ness is in the kidney and along the course of the ureter. 13. Perinephritic Abscess, large enough to give fluctuation. This may burrow into the pelvis or towards Poupart's ligament. It gives deep fluctua- tion and presents the symptoms and signs of deep suppuration in the kidney region. 14. Psoas Abscess, large enough to give fluctuation. This may burrow into the pelvis, or beneath Poupart's ligament to the femoral opening. It Fig. 396. Graafian-Follicle Cysts of the ovaries, which have become intraligamentary. Operative Gynecology.) (Kelly- presents fluctuation, both superficial and deep, and gives the symptoms and signs of tuberculosis of the lumbar vertebrae with involvement of the psoas muscle. 15. Dilated Gall-bladder. Occasionally the gall-bladder becomes so greatly enlarged and displaced, that it extends into the lower abdomen. The con- nection of the fluctuating mass with the liver may be traced, and there is a history of gall-stone disease or other liver disturbance. 16. Central Abdominal Affection. One of the cystic masses mentioned as usually appearing principally in the median line, may be displaced to one side or may become so large that it extends far over to both sides. 320 GYNECOLOGIC DIAGNOSIS 17. Mass from Opposite Side. Occasionally a cystic mass from one side will become so much displaced that it appears to belong to the opposite side. In a ease operated recently, there was an ovarian cyst extending to the um- bilicus. The history indicated that it had been unusually movable, occupying various positions, in the lower abdomen. When seen, the patient had been sick in bed several days with abdominal pains and evidences of a mild peritonitis. The large fluctuating mass occupied the left and central portions of the lower abdomen and pelvis. The small uterus was crowded into the posterior part of the pelvis behind the cyst. The cystic mass was not very tender, but it was fixed immovably by adhesions. From its location there seemed no room for doubt that it arose from the left side. On opening the abdomen, however, it was found that it was a right ovarian cyst which had fallen over to the left side in front of the uterus. The pedicle had become twisted, with resulting hemorrhage into the cyst and fibrinous peritonitis about it. To the torsion of the pedicle, with the resulting hemorrhage and peritonitis, Avere due the acute symptoms and the recent fixation of the cyst. MASS HIGH, IN PELVIS OR LOWER ABDOMEN, LEFT SIDE A. Mass or Induration Firm Same as on right side, substituting Sigmoid flexure for Cecum, and Spleen for Liver, and leaving out Appendicitis. B. Mass Contains Fluid Same as on right side, substituting Cyst of Spleen for dilated Gail-Blad- der, and leaving out Perityphlitic Abscess. MASS HIGH AND IN MEDIAN LINE In Pelvis or Lower Abdomen or Central Abdomen A. Mass or Induration Firm Any of the solid masses mentioned as occurring in the Right or Left side, may extend to the Median line or across it. There are, however, certain flrm masses that arise in or near the median line and, consequently, may be classed as belonging to this median region. 1. Solid Tumor of Uterus. Fibroid tumors are the most frequent cause of firm enlargement of the uterus, though occasionally a malignant tumor of the corpus uteri will cause marked enlargement. The characteristics of these have already been given. There may exceptionally be both carcinoma and fibroid (Fig. 397). MASS HIGH AND IN MEDIAN LINE 321 2. Abdominal Pregnancy and Lithopedion (Figs. 398, 399, 400). 3. Solid Tumors of Omentum, Small Intestine or Mesentery. These usu- ally appear near the median line, and the signs vary with the location. The Fis 397. Large Mass in Pelvis formed by Uterine Fibroids and Carcinoma. (Cullen- Cancer of the Uterus.) diagnosis rests upon the presence of a mass presenting the symptoms and signs to be expected in a tumor from one of these structures, and for which no more common disease would account. Such tumors usually are accompanied by gastro-intestinal symptoms. 4. Tumor of Pancreas. A deep-seated mass in the median line, accom- panied by decided evidences of pancreatic disturbance, and presenting syiiap- toms and signs for which nothing else w^ill account. * 322 GYNECOLOGIC DIAGNOSIS Fig. 400. Showing the Lithopedion re- moved, and also the site of the Tubal pregnancy. (Kelly — Operative Gynecol- ogy.) Fig. 399. Extrauterine Pregnancy with I,ithopedion. Showing the Lithopedion in situ. (Kelly — Operative Gynecology.') MASS HIGH AND IN MEDIAN LINE 323 5. Retroperitoneal Tumor (Fig. 187). It lies back of the intestines, is rather movable, more so than would be expected from a pancreatic tumor, and is without evidences of disturbance of any particular organ, 6. Enlarg-ed Lymphatic Glands. This condition presents the evidences Fig. 401. The Kidney Displaced into the Pelvis. (Dudley — Practice of Gynecology.) Fig. 402. A Earge Cystic Fibroid. (Montgomery — Practical Gynecology.) 324 GYNECOLOGIC DIAGNOSIS of a retroperitoneal or mesenteric mass, accompanied with a disease causing glandular enlargement, such as Hodgkin's disease, or with recent ulceration in the intestine (tubercular or typhoid). 7. Tubercular Peritonitis, Avithout enough fluid to give fluctuation. Tuber- cular inflammation, with the exudate and resulting mass, may occur at any part of the peritoneal cavity, but is likely to extend into the median line, if not there primarily. The patient presents the evidences of a chronic or Fig. 403. Ovarian Cyst with a long slender pedicle. (Montgomery — Practical Gynecology.) subacute peritonitis with nothing else to account for it, and the presence of tuberculosis in the intestines or in the lungs. 8. Displaced Abdominal Organ. Several cases are recorded in which a displaced organ, such as the kidney (Fig. 401) or the spleen, has led to an er- roneous diagnosis and an erroneous operation. MASS HIGH AND IN MEDIAN LINE 325 B. Mass, High and in Center, Contains Fluid Any of the fluid masses mentioned as occurring in the Right or Left side, may extend to the median line or beyond it. There are, however, certain fluctuating masses that arise in the median line and hence may be said to belong to this region. 1. Pregnant Uterus. This may be any size, may be normal or abnormal, and the shape of the uterus may be regular or irregular. 2. Cystic Fibroid (Fig. 402.) It presents the evidences of a fibroid along with fluctuation in a part of it. Where such a condition is found, be careful to exclude pregnancy complicating the fibroid. Fig. 404. Dermoid Cyst filling front of pelvis and displacing the uterus backward. (Montgomery — Practical Gynecology.) 3. Distended Bladder (Fig. 147). This may cause much confusion in examination and diagnosis. The diagnostic points have already been given. It has happened that the unrecognized distended bladder ruptured with fatal results (Fig. 148). 4. Ovarian or Parovarian Cyst (Figs. 403, 404). The diagnostic points have been given briefly in this chapter, and are given in detail in Chapter xii. 5. Ascites. For the differential diagnosis of ascites, see text and illus- trations under Percussion in this chapter. 6. Ascites and Tumor (Fig. 405). The important percussion signs of ascites and tumor have already been mentioned and illustrated in this chapter (see Figs. 180, 181, 182). 7. A Cystic Tumor of Omentum, Intestine or Mesentery. A considerable 326 GYNECOLOGIC DIAGNOSIS number of cystic tumors of the omentum and mesentery have been reported. Such tumors may cause much confusion in diagnosis, unless it be kept in mind that they may be encountered. The symptoms and signs they present depend on the situation, and may be worked out for the different situations by a consideration of the surrounding structures and the signs that would likely result. The diagnosis depends largely on the exclusion of the more common conditions. Fig. 405. Ascites and Fibroid. Tiie combination closely simulated pregnancy. The abdomen was distended with a Fluid Mass having a Solid Mass inside, and the peculiarly shaped fibroid gave ballotte- ment. (Montgomery — Practical Gynecology.) 8. Pseudocyst of the Lesser Omental Cavity. This is usually preceded some months by an al)dominal injury involving the pancreas. It is likely to be of rather slow growth, and the injury may be overlooked unless the his- tory is carefully inquired into. In all cystic masses of doubtful character near the center of the abdomen, this should be thought of. 9. Cyst of Pancreas. A true cyst of the pancreas may present much the DIFFERENTIAL DIAGNOSIS OF VARIOUS MASSES 327 same symptoms and signs as the pseudocyst of the lesser omental cavity re- sulting from an injury of the pancreas. Space can not be taken to give in detail the differential diagnosis of these various upper abdominal conditions. The author wishes simply to call attention to the conditions that may be encountered, and the presence or absence of which must be determined by the examiner through further study. 10. Cyst of Urachus. This and other rare abnormalities are occasionally met with. A cyst of the urachus is found in or near the median line, and be- tween the peritoneum and the anterior abdominal wall. It may communicate with the umbilicus, causing an intermittent discharge there, or with the blad- der or with neither. POINTS IN DIFFERENTIAL DIAGNOSIS OF VARIOUS MASSES IN THE PELVIS OR LOWER ABDOMEN The majority of mistakes in diagnosis are due not so much to want of knowledge as to lack of application of the knowledge possessed. A diag- nosis in a difficult case implies (first) a careful examination, by which are ob- tained the essential facts of the case, and (second) correct reasoning and a logical conclusion, based on those facts. A mistake in diagnosis may be due to failure to get all the essential facts — some important points being over- looked. In order to prevent this in the class of cases under consideration (presenting a mass in the pelvis or lower abdomen), the author gives the following table of points to be considered. In a difficult case, consult this table and notice whether or not you have obtained the information avail- able on the various points mentioned. Examination Findings 1. Position of mass. 2. Size. 3. Shape. 4. Consistency. 5. Tenderness. 6. Mobility. 7. Attachments. 8. Apparent point of origin. 9. Relation to uterus. 10. Position of uterus. 11. Size of uterus. 12. Shape of uterus. 13. Consistency of uterus. 14. Tenderness of uterus. 15. Mobility of uterus. 16. Discharge from uterus. 17. Discoloration of cervix or vagina. 18. Eelation of mass to tube and ovary. Relation of mass to pelvic wall. Relation of mass to vaginal wall. Bladder (full, distended, urinary incontinence, induration in bladder, pain on pressure). Rectum (containing fecal masses, or indurated or painful on pres- sure). 19 20 21 22 528 GYNECOLOGIC DIAGNOSIS 23. Mass elsewhere (arising from uterus or about tube or along colon). 24. Colon or small intestine between mass and abdomen wall. 25. Outline of dullness. 26. Shifting of outline of dullness. 27. Hard masses within a cystic mass. 28. Pulsation of mass, felt on exam- ination. 29. Fetal movements, felt on exam- ination. 80. Vascular murmur heard. 31. Fetal heart sounds heard. 32. Fever present. 33. Emaciation, or fat deposition. 34. Breast disturbance (tenderness, enlargement, enlarged veins with milk formation). 35. Evidence of disease of heart, lungs, liver, kidneys, gastro-in- testinal tract, spleen, pancreas, nervous system. History and Subjective Symptoms 36. Manner of onset, prominent symp- toms and apparent cause. 37. General course since. 38. Menstrual disturbance. 39. Intermenstrual bloody discharge. 40. Leucorrhea. 41. Pain in lower abdomen or pelvis (pressure, aching, sharp pain) or about external genitals, or backache (sacral, lumbar, loin) or thigh pains. 42. Fever. 43. Disability. 44. Variation in weight. 45. Abdominal enlargement. 46. Morning sickness, or persistent nausea or vomiting at other times. 47. Breast disturbance — pains, ten- derness, enlargement, pigmen- tation, enlarged veins, milk formation. 48. Bladder or rectal disturbance, pre- ceding or accompanying the trouble. 49. Evidence of disease of the heart, lungs, liver, kidneys, gastro- intestinal tract, spleen, pan- creas, nervous system. Progress Under Observation 50. Steady increase or decrease, or exacerbations, etc. If Examination Under Anesthesia Notice : 51. Exact position of mass. 52. Exact size and shape. 53. Consistency throughout. 54. Exact mobility. 55. All the attachments. 56. Point of origin. 57. Exact relation to adjacent organs, to uterus, to Fallopian tubes, to ovaries, to rectum, to colon. 58. Uterus — exact position, size, shape, consistency, (tenderness not ap- preciable) , mobility, attach- ments. 59. It may be advantageous to make recto-abdominal examination also. 60. If cervix is suspicious of malig- nant disease, excise a piece for microscopic examination. POINTS IN SPECULUM EXAMINATION 329 If Necessary for Diagnosis, and Per- missible Under the Conditions Present, Explore the Uterine Cavity : 61. With sound, to determine depth and direction. 62. With curet, to secure tissue for microscopic examination. 63. With finger, to determine consist- ency of uterine wall (softened area, hard nodule) and pres- ence of retained placental rem- nants or projecting polypoid growths. POINTS IN THE SPECULUM EXAMINATION In the speculum examination, direct inspection is made of the vaginal wall and the cervix. Fig. 406. Primary Malignant Ulceration of the Vagina. (Montgomery — Practical Gynecology.) Conditions of Vaginal Wall The vaginal wall may present arterial congestion, venous congestion, bleeding areas or distinct ulceration. Arterial Congestion of the Vaginal Wall indicates inflammation, usually 330 GYXECOLOGIC DIAGNOSIS acute, or active irritation, as by an irritating discharge or pessary or other foreign body. The differential diagnosis of the various forms of vaginal in- flammation has already been given in this chapter, when considering leucor- rhea. Occasionally there are cases of chronic vaginitis in which there is arterial congestion in spots. In such chronic cases there is likely to be infil- tration and hypertrophy of the congested areas, giving rise to the condition known as granular vaginitis. Venous Congestion of the Vaginal Wall should always arouse a suspicion of pregnancy, for that is the most common cause. It may be caused, also, by Fig. 407. Secondary Malignant Ulceration of the \'agina. In this case there was a carcinoma of the endometrium, and the discharge caused an implantation carcinoma where the cervix came in constant contact with the posterior vaginal wall. (Kelly — Operative Gynecology.) a tumor or other pelvic mass that interferes with the vaginal circulation, or by extrapelvic conditions that cause venous stasis in the pelvis, such as heart disease with failing compensation. Bleeding Areas on Vaginal Wall, without a distinct ulcer, are found principally in senile or adhesive vaginitis, which is described in Chapter iv. A Distinct Ulcer on the Vaginal Wall may be simple, chancroidal, syph- ilitic, tubercular or malignant. In the case of a_ malignant ulcer, it may be primary on the vaginal wall (Fig. 406) or it may be secondary (Fig. 407), the POINTS IN SPECULUM EXAIMINATION 331 Fig. 408. Fig. 409. Fig. 410. Figs. 408 and 409. Varieties of Normal Cervix in the Virgin. Fig. 410. Cervix of Multipara. (Norris, after Heitzmann — American Textbook of Obstetrics.) Fig. 411. A Senile Cervix, with upper part of vagina. (Edgar — Practice of Obstetrics.) Fig. 412. Discharge from the Cervix- Uteri, as seen through the speculum. (Massey — Conservative Gynecology.) Fig. 413. Discharge, with Laceration and Erosion of the Cervix. (Massey — Conservative Gynecology.) Fig. 414. Erosion of the Cervix, with a few scattered cysts. (H. MacNaughton- Jones — Diseases of Women.) 332 GTXECOLOGIC DIAGNOSIS {iicVTiul rji- er'osioii oi'cf^rxnx. Der-ij sif'ilato Incorali with erosion of one lip. u) to irnior os . Fig. 415. Lacerations and Erosions of the Cervix. (Mann — American System of Gynecology.) POINTS IN SPECULUM EXAMINATION 333 ruihil.-ial laci-i-L-lioi; ho\'0!'.(! vn':;;itai instM-h'iii l)oul)l(> i.)iii-a!i.jn Doul.l. bt>VOTlf! \ ( nilii ijU' I Fig. 415. Lacerations and Erosions of the Cervix. (Mann — American System of Gynecology.) SM GYNECOLOGIC DIAGNOSIS most common source of secondary malignant ulceration of the vaginal wall being carcinoma of the cervix uteri. Conditions of Cervix Uteri The appearance of the normal virgin cervix is shown in Figs. 408 and 409. The appearance of the approximately normal cervix in the parous woman is shown in Fig. 410, and a cervix that has undergone the senile atrophy is shown Fig. 417. 418. Figs. 417 and 418. Testing for the extent of the tear, in cases where the cervix has the appear- ance of a ball. The center of the anterior lip (A. Fig. 417), and of the posterior lip (B) are each caught with a tenaculum and brought together, as indicated in Fig. 418. (Baldy- — American Textbook of Gynecology.) Fig. 419. Beginning Epithelioma of the Cervix. (Sampson — Johns Hopkins Hospital Bulletin.) Fig. 420. Beginning Carcinoma of the Interior of the Cervix. (Sampson — Johns Hopkins Hospital Bulletin.) in Fig. 411. Fig. 412 shows discharge from an unlacerated cervix, while Fig. 413 shows discharge and laceration. Erosion of the cervix is a very common condition, being present to a greater or less extent in most cases where there is an irritating discharge. Fig. 414 shows erosion of the cervix, the shaded area extending out from the external os representing the red angry-looking erosion. A few small glandular cysts are also visible. Various appearances of lacerated cervix, as seen through the speculum, are shown in Figs. 415, POINTS m SPECULUM EXAMINATION 335 •'ig. 421. Kpithelioma of the Cervix. The cervix has been destroyed, leaving only an area of cancerous ulceration at the top of the vagina. (Kelly — Operative Gynecology.) m GYNECOLOGIC DIAGNOSIS 416. Ill a considerable proportion of cases, distinct lips are not at first appar- ent, the lacerated cervix having the appearance of a ball (Fig. 417). In such a case, if the anterior and posterior portions of the cervix be caught with a forceps or tenaculum and brought together, as indicated in Fig. 418, the ex- tent of the laceration becomes apparent. Fig. 422. Epithelioma of the Cervix. The cervix has been destroyed and the affected area has been drawn in, by the gradual contraction of the infiltrated tissues, until no cancerous tissue can be seen. Palpation, however, shows that there is infiltration of the area enclosed within the dotted line. (Kelly — Operative Gynecology.) Malignant disease of the cervix causes many thousands of deaths annually and yet in the beginning it is entirely local and, when recognized early, can be completely removed. The diagnosis is considered in detail in Chapter ix. Here the author wishes simply to call attention to the fact that beginning malignant disease may make very little change in the general appearance of the cervix. PAIN IN PELVIS OR LOWER ABDOMEN 337 Any suspicious area should be carefully investigated and, if necessary to a posi- tive diagnosis, a small piece should be excised for microscopic examination. Beginning malignant disease of the cervix is shown in Figs. 419, 420, 421. Fig. 422 shows the cervix destroyed and drawn in by contracting tissue, so that Fig. 423. Epithelioma of the Cervix, appearing as a Papillary Growth. {KeWy —Operative Gynecology.) no ulceration is visible through the speculum. But in the vaginal palpation in this case distinct induration was felt in the area bounded by the dotted line. Fig. 423 shows a case where the carcinoma has appeared in the form of a papil- lary growth. PAIN IN PELVIS OR LOWER ABDOMEN Pain in the pelvis or loAver abdomen may be due to: 1. Salpingitis, Acute or Chronic. Pain referred to tubo-ovarian region (Fig. 155). History of preceding uterine inflammation, with cause for same. If chronic, history of preceding exacerbations. On abdominal palpation, ten- derness in tubo-ovarian region. On vaginal and bimanual examination, there is found vaginal discharge (evidence of preceding uterine inflammation) and marked tenderness in tubal region. Mass is indurated, extending up to uterine horn and out to pelvic wall. Fixation of upper part of uterus and pain on movement of uterus. Absence of special signs of tubal pregnancy or of 338 GYNECOLOGIC DIAGNOSIS chronic oophoritis. Mass may be solid (consisting only of exudate or infiltra- tion) or may give more or less fluctuation, due to serous fluid (hydrosalpinx) or to pus (pyosalpinx). AH these conditions are included under the term salpingitis. 2. Oophoritis, Acute or Chronic. Acute or subacute inflammation of the ovary ordinarily j)resents practically the same diagnostic points as salpingitis, is usually associated with, and overshadowed by, the salpingitis and is in- cluded under the general term "pelvic inflammation." There is, however, one rather common form of oophoritis not associated with salpingitis, namely, the cystic or cirrhotic form. When not associated with salpingitis or peri- toneal exudate, there is felt on bimanual examination, a tender mass in the tubo-ovarian region — rounded, about the size of the ovary or larger, softened, with occasionally a fluctuating area, movable, often lying lower than the ovary usually does (prolapse of ovary behind uterus) and when pressed upon pro- duces a peculiar sickening pain. There is absence of peritoneal exudate and there is no fi^xation. 3. Pelvic Cellulitis. Signs same as in salpingitis except induration very hard (unless collection of pus) and occupying connective tissue areas, situ- ated lower at side of uterus and intimately connected with uterus or pelvic wall. 4. Endometritis, Acute or Chronic. Pelvic pain slight, sense of weight and pressure in the pelvis. Uterine discharge, excessive menstruation, tenderness of uterus, no induration or marked tenderness outside uterus. 5. Backward Displacement of Uterus. If uncomplicated, the pelvic pain is slight but there is a sense of pressure and weight. Body of uterus absent in front of cervix. Back of cervix can be felt a mass which, on further investi- gation, proves to be the body of the uterus. 6. Fibroid Tumor of Uterus. Unless tumor is very large and chokes pelvis, pelvic pain is slight but there is a sense of weight and pressure. Frequently uterine discharge and excessive menstruation. No history of uterine infec- tion or attacks of pelvic inflammation. Firm mass firmly attached to uterus, not tender, not movable separately from uterus, but uterus and mass mov- able together in pelvis (i.e., no fixation of uterus and mass to pelvic wall) ex- cept when tumor is so large as to fill pelvis. In deep seated fibroids, mass may appear as an enlarged uterus. 7. Cancer of Uterus. Leucorrhea, with occasionally a streak of blood. No pain at first but later, when uterus is much enlarged (cancer of corpus) or infiltration involves parametrium (cancer of cervix), pain appears. If in the cervix, there is indurated area or an ulcer that resists treatment, and a piece should be excised for microscopic examination. If from the body of uterus, there is a leucorrheal discharge or a blood-streaked discharge that resists treatment, the interior of the uterus should be curetted and the scrapings examined microscopically. In the later stages there is a bleeding mass, with PAIN IN PELVIS OR LOWER ABDOMEN 339 indurated margins, at site of cervix, or a bloody, watery fonl-sraelling dis- charge from the interior of the uterus. A bloody foul-smelling watery discharge does not necessarily mean cancer. It may be due to a fibroid, the dif- ferential diagnosis being made by microscopic examination of clippings or curettings, when necessary. 8. Painful Menstruation (Dysmenorrhea). Pain due to menstruation alone, occurs only at the menstrual periods, though pain from most any pelvic disease may be much increased at the menstrual period, on account of the menstrual congestion and increased nerve sensitiveness. The various causes of dysmenorrhea and the differential diagnosis, are given in Chapter xiv. 9. Pregnancy, with Threatened Miscarriage. Pains are usually some- what paroxysmal, missed menses, morning sickness, pains in breasts, begin- ning softening of cervix, uterine body enlarged and softened, elasticity of middle segment (Hegar's sign), bluish coloration of vaginal walls and cervix. 10. Incomplete Miscarriage. History of early pregnancy, pain and pass- ing of blood clots or "pieces of flesh," foUoAved by a bloody discharge ana occasional pains. The pains are usually slight (unless infection has taken place), the principal symptom being the persistent bloody discharge. Cervix and body of uterus softened. Cervix open, and sometimes pieces of membrane and of blood clot may be felt projecting out of it. 11. Tubal Pregnancy. Missed menses, morning sickness, uterus slightly enlarged and softened, tender mass in tubal region. Diagnosis on these signs not justifiable, unless previous examination of pelvis has shown it free from tubal or ovarian inflammatory trouble. If rupture takes place, pain and ten- derness are so marked and so severe at first as to preclude satisfactory palpa- tion of tubo-ovarian regions. If hemorrhage is severe, pulse is affected. If slight, pain disappears and mass can be made out beside uterus or behind it. The signs at this stage (slight peritoneal hemorrhages and resulting peritoneal irritation and exudate) are the same as for acute salpingitis with exudate, with the following special features : a. Bloody vaginal discharge, beginning within a few days after onset of pain and continuing in an irregular way from one to several weeks. b. Only slight fever or none. With enough acute inflammation to cause such severe symptoms, there should be considerable and persistent fever. c. Evidence of internal hemorrhage, to a greater or less extent. d. Exacerbations of pain without apparent cause and without decided elevation of temperature. e. Absence of recent intrauterine pregnancy (miscarriage and infection are very common causes of ordinary salpingitis). 12. Pelvic Tuberculosis. Evidences of pelvic inflammation (tenderness, induration or mass beside or behind the uterus or filling pelvis, fixation of 340 GYNECOLOGIC DIAGNOSIS Uterus, fever and exacerbations), with the special features given for pelvic tu- berculosis in Chapter xi. 13. Tumor of Ovary, Broad Ligament or Fallopian Tube. A mass (usually soft, fluctuating) in tubo-ovarian region, not tender, usually freely movable. Not intimately attached to uterus, no fixation of uterus unless mass is large enough to displace uterus to side of pelvis. Ovarian growths are usually freely movable and tend to rise out of the pelvis, while broad ligament growths are held firmly within the broad ligament and cause pain and uterine dis- placement while still small. 14. Laceration of the Pelvic Floor. Loss of support in pelvic floor causes more or less dragging and pressure in pelvis (though rarely severe pain), pres- ent principally when patient is on her feet, much relieved when she lies down. Feeling of weakness at pelvic outlet, and may be protrusion of parts (colpo- cele, cystocele, rectocele, prolapse of uterus). Examination shows marked loss of support in pelvic floor. 15. Acute Vaginitis. Pelvic pain slight and very low (more of pressure and weight and burning), free discharge, vulvar and urethral irritation. Ex- amination shoAvs purulent discharge and evidences of acute inflammation of vagina. There are a number of extragenital diseases that may cause pain in the pelvis and lower abdomen and that may be confounded with gynecologic af- fections, and that consequently must be taken into consideration in differential diagnosis. Among them may be mentioned the following : 16. Appendicitis. Pain more diffused through abdomen and about um- bilicus at beginning of attack. Tenderness at McBurney's point, and no particular tenderness over tube. Mass in appendix region, and not in tubo- ovarian region. Attacks associated with gastro-intestinal symptoms rather than with uterine symptoms, though pain may be worse at menstrual periods on account of menstrual congestion. Mass may involve both regions — if in virgin probably appendicitis, if in married woman probably salpingitis. 17. Mucous Colitis. Causes severe attacks of pain in lower abdomen and pelvis, and has frequently been mistaken for uterine or tubal or ovarian dis- ease. Patients have been given pelvic treatment for months and years and have even had the ovaries removed when the trouble Avas none other than this peculiar affection of the colon. The affection is known by various names, such as membranous enteritis, tubular diarrhea and mucous colic. Osier states: "It is a remarkable disease, to which attention has been paid for several centuries. It is an affection of the large bowel characterized by the production of a very tenacious, adherent mucous, which may be passed in long strings or as a continuous tubular membrane. I have twice had op- portunity of seeing the membrane in situ, closely adherent to the mucosa of the colon, but capable of separation without any lesion of the surface. Ac- cording to AV. A. Edwards, 80 per cent of the recorded adult cases have been N IN PELVIS OR LOWER ABDOMEN 341 ill Avomeii. The cases are almost invariably seen in nervous or hysterical women or in men with neurasthenia. All grades of the affection occur, from the passage of a slimy mucous like frog-spawn to large tubular casts a foot or more in length. Microscopically the casts are, as shown by Sir Andrew Clark, not fibrinous but mucoid and even the firmest consist of dense, opaque, transformed mucous. It is due to a derangement of the mucous glands of the colon, the nature of which is quite unknown. The disease persists for years, varying extremely from time to time, and is characterized by paroxysms of pain in the abdomen, tenderness, occasionally tenesmus, and the passage of flakes or long strings of mucous, sometimes of definite casts of the boAvel. The attacks last for a day or in some cases for ten days or two weeks. Mental emotions or worry of any sort seem particularly apt to bring on an attack. Occasionally errors in diet or dyspepsia precedes an outbreak. Membrane is not passed Avitli every paroxysm, even when pains and cramps are" severe. There are instances in which the morphia habit has been contracted on ac- count of the pain. There may be marked nervous symptoms, and authors men- tion hysterical outbreaks, hypochondriasis and melancholia. The diagnosis is rarely doubtful (when this affection is in mind) but it is important not to mistake other substances for membranes, thus the external cuticle of asparagus and undigested portions of meat and sausage skins, sometimes assume forms not unlike mucous casts, but microscopic examination will quickly differ- entiate them." This affection may prove confusing when associated with endometritis or other pelvic lesion. The points in the differentiation of mucous colitis from a serious painful pelvic disease, are the character of the pain (resembling in- testinal cramps and extending throughout the lower abdomen), the passage of characteristic masses of mucous in some of the attacks and the absence of any palpable pelvic lesion to account for the symptoms. 18. Other Intestinal Affections — digestive disturbance, enteritis, colitis, dysentery, typhoid fever, chronic constipation (with distention and toxemia), intestinal tuberculosis. Each of these may cause pain in the lower abdomen and, if there happens to be accompanying uterine symptoms, may lead to a mistaken diagnosis. Pain is more widespread and variable. Tenderness on palpation is more general and ill-defined, all the lower abdomen being more or less tender and the tenderness may extend above the umbilicus and into the flanks. Uterine and tubo-ovarian region not especially tender. No palpable lesion in pelvis to account for symptoms. Special gastro-intestinal symptoms elicited on questioning. 19. Peritoneal Tuberculosis. This very closely resembles ordinary chronic pelvic inflammation in its symptoms and course. The differential diagnostic points are given in Chapter xi. 20. Kidney or Ureteral Affections — movable kidney, nephrolithiasis, pyone- phrosis, ureteritis, and tuberculosis of kidney or ureter. Each of these affec- 342 GYNECOLOGIC DIAGNOSIS tions causes attacks of pain, involving the lower abdomen and pelvis. Pain begins in kidney region and extends downward along ureter to bladder. There may or may not be accompanying bladder disturbances (frequent or pain- ful urination, vesical tenesmus). On examination, tenderness in kidney region is elicited by accurate palpation of kidney and along ureter, and there may be displacement or enlargement of kidney. On bimanual examination, there is tenderness in bladder or along ureter and no palpable lesion of genital or- gans sufficient to account for symptoms. There are pathologic findings in the urine. 21. Bladder or Urethral Inflammation or Tumor. History of bladder symptoms (frequent or painful urination, vesical tenesmus, urinary changes). On examination, tenderness is confined to urethra, bladder or ureters, there are pathologic findings in urine and no palpable lesion of genital organs sufficient to account for the symptoms. If the case is still doubtful, instru- mental examination of urethra, bladder or ureters may give decisive informa- tion. 22. Rectal and Anal Diseases — proctitis, hemorrhoids, fissure, new growths. History of rectal symptoms (pain on defecation, discharge of mucus and per- haps blood at times, protrusion of hemorrhoidal mass). On examination, ten- derness and other abnormalities are found about anus and extending up along course of rectum. No palpable lesion in genital organs to account for symp- toms. 23. Nervous Diseases — transverse myelitis, neurasthenia, hysteria, pelvic neuralgia. The history indicates disturbance of the nervous system, there are the special features of one of these nervous affections and there is no palpable lesion of genital organs sufficient to account for the symptoms. Pelvic tender- ness is confined to the pelvic nerve strands or to the otherwise apparently nor- mal ovaries. For thorough pelvic examination it may be necessary, in order to overcome muscular tension, to examine under anesthesia. 24. Coccygodynia (painful coccyx). The painful affections of this bone, either following injury or of spontaneous origin, are often mistaken for some genital or rectal affection. The pain is described by the patient as at the very end of the spine, and may radiate from there into the pelvis or down the thigh. It is noticed especially in positions that occasion movement of the bone (the act of sitting or rising, or straining at stool, or walking up or down stairs) or that cause pressure on the bone (resting on hard surface, riding on rough road). On examination with the finger in the rectum and the thumb outside on the bone (Fig. 85), there is marked tenderness on palpation of the bone and pain on movement of same. There may be deformity, indicating previous injury or inflammation. The marked tenderness is limited to the region of the coccyx. There is no palpable lesion of the genital organs to account for the symptoms. REFLECTED PAINS 343 BACKACHE Backache, either in the limibar region or extending down over the sacrum, may be caused by most any of the conditions mentioned under ''pain in the pelvis and loAver abdomen." It is not necessary to repeat them here. In addition, backache may be caused by affections of the muscles, nerves, ligaments or joints of this region, or by affections of the bones or spinal cord. Xntffriia. Enclnnirtritls Bladder > Di^phrapaa Ovary Fig. 424. Showing the usual cause of Reflex Pains in the various regions. (Dana — Textbook of Nervous Diseases.) REFLECTED PAINS Reflected pains do not occupy as large a place in gynecologic symptoma- tology as formerly. We have come to look upon these distant pains in gyneco- logic cases usually as an indication of some intercurrent or complicating trouble at the site of the pain or of an abnormal condition of the nervous sys- 344 GYNECOLOGIC DIAGNOSIS tern, rather than as a direct reflex from the pelvic trouble. Careful investiga- tion will show this to be the case in the great majority of instances of so-called reflex pains. In rare cases, hoAvever, the connection between the distant pain and the pelvic lesion seems very close, as where, for example, a pain in the head or other situation is made to disappear by correction of a retrodisplacement of the uterus, only to reappear as soon as the uterus returns to its malposition. When reflected pains do occur they are likely to be found as indicated in Fig. 424. DISTURBANCES OF FUNCTION The various disturbances of function (amenorrhea, menorrhagia, irregu- lar menstruation, dysmenorrhea, dyspareunia, sterility) constitute important symptoms of disease in certain cases. They are considered in detail in Chap- ters XIV, and xv, where the various causes, and consequently the diagnostic sig- nificance, of each are given. Those disturbances of function due to derange- ments of the ductless glands are considered in Chapter xv. CHAPTER III GYNECOLOGIC TREATMENT In gynecologic treatment the folloAving therapeutic measures are em- ployed : Rest. Complete Rest, in bed. Partial Rest, from work. Sexual Rest. Applications to Lower Abdomen and Exterior of Pelvis. Moist Heat. Hot- Stupes. Hot Pastes. Hot Poultices. Hot Sitz-baths. Hot Moist Pelvic Pack. Dry Heat, Hot Water Bag. Japanese Stove. Hot Water Coil. Electrotherm. Hot Air Chamber. Hot Dry Pack. Cold Applications. Ice Bag. I Cold Coil. Cold Sitz-bath. COUNTERIRRITANT APPLICATIONS. Mustard (poultice, plaster). Cantharides (plaster, collodion). Tinct. Iodine. Applications to External Genitals, Vagina and Cervix. Douches. Concentrated Solutions. 345 346 GYNECOLOGIC TREATMENT Powders. Tablets. ' Vaginal Suppositories. Tampons. Tampon-capsules. Pessaries. Submucous Injection of Substances. Local Blood-letting. Curet. Cautery. Electricity. X-Ray. Finsen Light. Radium. Intrauterine Treatment. Medicated Applications within uterus. Hot Water L^rigation. Curetment. Cauterization. Electricity. Cervical Dilatation. Vacuum Treatment. Applications Within Rectum. Enemata, Low and High. Hot Water Irrigation. Applications to Lower Abdomen and Interior of Pelvis. Pelvic Massage. Pressure Treatment. Electricity. Applications to Body Generally. Bathing. Friction Rubbing (with alcohol, salt, brush, etc. General Massage. Dress Corrections. Postural Methods and Exercise. Knee-Chest Posture. Trendelenburg Posture. REST 347 General Exercise. Special Exercise. Internal Treatment. Medicines. Diet. Psycho-therapy. Operations. REST Complete Rest in bed is necessary Avhen acute inflammation is present and in acute exacerbations of chronic inflammation. In an acute attack of vaginitis, endometritis, salpingitis or acute pelvic peritonitis, the patient should be put to bed and kept there until the pain and fever subside. When the inflammation is severe and accompanied by much pain, the patient should use the bed-pan and should not be permitted to get up to a vessel beside the bed. Also, rest in bed for a few days will temporarily diminish the pain of chronic inflammation and the backache and distress that accompany loss of support in the pelvic floor. It is a rule, with but few exceptions, that in pelvic disease strict rest in bed, combined with laxatives and hot vaginal douches and hot applications to lower abdomen, will in twenty-four to forty-eight hours relieve the pain to such an extent that the patient is comfortable. The exceptions to this rule are : Active spreading inflammation of the peritoneum. A collection of pus with tension. Recurrent hemorrhage, as in tubal pregnancy. Threatened abortion. A tumor compressing pelvic nerves. Neuritis and neuralgia. In these conditions the pain may be. persistent and severe in spite of absolute rest. By keeping these things in mind, the effect of rest becomes a help in differential diagnosis in certain cases. Partial Rest is advisable in many cases that do not require complete rest in bed. The work of some patients, requiring as it does much Avalking or long standing or constant running of the serving machine or lifting of chil- dren, tends to aggravate and prolong certain pelvic affections and for that reason it may be necessary to have the patient stop work for a while, even though she can ill afford financially to do so. Again, it may be advisable to direct a vacation to some distant point for the patient who is dragged down by household duties or the care of children or office work or the exactions of 348 GYNECOLOGIC TREATMENT society. The rest from care, the change of environment, the direction of the thoughts and activities into new channels, will in some eases do more than anything else toAvard restoring the patient to health. Directions should of course be given for whatever additional therapeutic measures are neces- sary during the visit. Sexual Rest is necessary in many cases, particularly in inflammatory troubles. In some cases coitus must be absolutely forbidden and in other cases restricted, as the marked congestion accompanying it is likely to ag- gravate the trouble. In acute inflammation it is rarely necessary to say anything on this point, as the painfulness of coitus itself prevents it. In subacute inflammations however and in chronic conditions aggravated by pelvic congestion, when the trouble resists treatment and it seems probable that coitus is interfering with the cure, it is advisable to stop sexual intercourse or restrict it. This may be accomplished by one of three ways, as follows: a. Instructing the patient or her husband regarding it. This is some- what embarrassing and not very effective, though it is sometimes the best plan. b. Use of vaginal tampons, the tampons to be worn continuously and changed only in the office. In this way the beneficial effect of tampons is secured and at the same time coitus is restricted. The tampon-capsules when indicated for other purposes, may be used so as to accomplish this object also — the patient being directed, on removing each tampon, to take a douche and immediately introduce the next one. c. Sending patient on a trip away from home. Here also the sexual rest is only incidental, though quite important in conditions aggravated by pelvic congestion. APPLICATIONS TO THE LOWER ABDOMEN AND EXTERIOR OF PELVIS These applications are used to relieve pain and limit inflammation. MOIST HEAT Hot stupes are made by folding a piece of flannel several times, making a pad large enough to cover the lower abdomen. This pad is wrung out of very hot water and quickly applied to the abdomen and covered with a piece of thin oilcloth or a heavy towel. The thin oilcloth is preferable, as it keeps in the heat and moisture better and is not so heavy. As soon as the pad begins to cool, another one is wrung from the hot water and slipped in place as the first is removed. If the stupes are changed frequently and thus kept hot, they are very effective in relieving pelvic pain. They have some effect in all painful conditions, but the most marked ef- HOT APPLICATIONS 349 feet is seen in the pain of inflammation. The elficiency of tlie hot stupes may be increased by adding one or two tablespoonfuls of turpentine to the hot water in the basin. To some patients, however, the odor of turpentine is disagreeable and disturbs the stomach and with such it should not be used. The disadvantages of hot stupes are that they have to be changed very frequently and that they soon get the bedclothing damp. Hot Pastes. There is a material for external use, consisting of an earthy silicate for a base and having incorporated glycerine and mild antiseptics with a pleasant odor. This is very convenient for application to the lower abdomen for it holds the heat and moisture well. This material, with slight variations, is put up by a number of firms and given ditferent names (gly- kaolin, antiphlogistin, etc). Under one of the trade names, it may be pur- chased at any drug store in one or two pound cans. The method of its ap- plication is as follows : Take off the lid and set the can in a pan of hot water on the stove until the paste is thoroughly heated. It is then thin enough to spread easily with a spatula or knife or spoon handle. It is spread directly on the skin in a thick layer (about one-half inch thick). The whole lower abdomen is covered with a thick layer of the hot paste, which is cov- ered with a piece of flannel and outside of this is placed the hot-water bag or Japanese stove to keep it warm. The paste sticks tight to the skin at first, but after twenty-four hours usually there has been sufficient perspiration beneath it to, loosen it and cause it to come off easily. It is then removed and a fresh layer applied immediately. A fresh application is made every twenty- four hours, as long as hot applications are desired. Flaxseed Poultice retains the heat well and is much used as a home remedy when hot applications are desired. It is not nearly as convenient nor cleanly as the hot pastes but is about as efficient if changed often and kept up for several days, and is often at hand when the other things are not available. The flaxseed poultice is made as follows: Take two parts of ground flaxseed (flaxseed meal) and five parts of boiling water and mix with constant stirring. AVhen mixed, spread thick (one-half inch) on a piece of thin muslin or cheese-cloth. Have the cloth large enough so that you can leave a margin on each side to fold over. The poultice should cover one-half the cloth and the other half can then be laid over after the margins are turned in. If a hot-water bag or Japanese stove is at hand put that over the poultice to keep it hot. Hot Sitz-bath. The patient sits in a small tub, preferably of special de- sign, containing water enough to cover the hips, genitals and lower abdomen. The water should be as hot as the patient can stand without discomfort (105^ to 115°). She should remain in the sitz-bath from twenty to thirty minutes and then be dried and put in bed. It may be repeated daily or several times daily, as found most beneficial. The hot sitz-bath is sedative in effect and relieves very much the pain of pelvic inflammation. In inflammation it should be used onlv in those cases where the patient may make the necessary 350 GYNECOLOGIC TREATMENT movements without detriment. It is useful also in helping the onset of the menses in amenorrhea or suppressed menses. Hot Moist Pelvic Pack. Instead of making the hot applications to the lower abdomen only, they may be extended all around the pelvis. The whole pelvis is encased in the hot stupe or compress, and over all a large piece of thin rubber cloth or table oilcloth is placed. A woolen blanket also is wrapped around the patient to keep in the heat and moisture. This may give much relief from the suffering in acute suppression of menses, in acute pelvic inflammation and in severe pelvic neuralgia. DRY HEAT Hot-Water Bag. The hot-water bag produces almost the same effect as the hot stupes, and keeps hot a longer time without change and is much more convenient to manij)ulate. If the effect of moist heat is desired, a hot stupe may be applied and a hot-water bag placed over it to keep it warm. If no hot- water bag is at hand, a large flat bottle filled with hot water may be used. This should be securely corked and wrapped in a thick flannel cloth. If no suitable bottle is available, a plate, heated and wrapped in a flannel cloth, may be used, or a stove-lid or other article that will retain the heat. Japanese Stove. This consists of a small flat metal container, about the size of the hand, in which is burned a compressed powder resembling char- coal. This little container may be purchased at the drug store for a feAv cents and is very convenient for applying dry heat or for keeping a moist application warm. If it is wished very hot, two or three sticks, instead of one, of the powder may be lighted and dropped in. If one stove is not large enough, two or three may be used. Hot-Water Coil. This consists of a coil of rubber tubing and a boiler, the former being attached to the latter by tubing in such a way as to cause a constant circulation of hot water through the coil. It is very nice but rather expensive. Electrotherm. This electric heating pad is heated by a current through a cord, which is to be attached in the ordinary electric light socket. This, like the other dry heat appliances, may be used alone for dry heat or over a moist application for moist heat. Hot-Air Chamber. The apparatus is the same as that for applying hot dry heat to the joints or other parts of the body, the chamber for gynecologic cases being made to fit about the pelvis and lower abdomen. The tempera- ture that will be borne varies with individuals and also with the length of time employed. At first a temperature of 120° for twenty minutes will suf- fice. After a week or so the patient may bear a temperature of 135° to 150° for 45 minutes. The temperature should not be high enough to cause discomfort above a slight tingling of the skin. The air chamber may be heated with COLD APPLICATIONS 351 electric lights, instead of in the ordinary way. This is a convenient way and one in which the heat is easily regulated. The effect of the hot air chamber is to cause marked redness of the skin, free perspiration and a hastening of the absorj)tion of chronic pelvic exu- dates. Cases of chronic pelvic inflammation are the ones suitable for treat- ment. In several cases, exudates were absorbed in 14 to 20 sittings. No bad after effects w^ere noted. Cooling is allowed to take place gradually and the patient is then dried and lies in bed for an hour. It takes consider- able time, about an hour to each patient, but after the apparatus is once started it may be left in the care of an experienced nurse. Without any special treatment about 90 per cent or more of pelvic ex- udates tend to become absorbed, if the patient is kept quiet. This natural process is hastened by laxatives, hot douches and heat to the abdomen. This particular method of applying heat over a long period is very convenient in hospitals where the apparatus is kept on hand or in homes where electricity is available. In cases of persistent exudate without evidence of a remaining focus of infection, it is well to give this method a trial. Hot Dry Pack. Dry heat may be applied all around the pelvis by packing around it hot water bags or hot bottles or other containers for maintaining the heat, the skin being well protected by layers of flannel. COLD APPLICATIONS In some cases cold gives more relief than heat, though the cases in which it will do so can not be certainly determined without trial. It has been stated that cold gives more relief when the pain is due to active inflam- mation and the hot applications in other cases. In the author's experience, that rule does not hold good. On the other hand, in the majority of cases, pelvic pain, inflammatory or otherwise, is relieved more by hot applications than by cold. Consequently, the author's rule is to use hot applications flrst and, if they fail to give relief, then the cold. There are several ways of applying cold. To get the best sedative effects it must, like the heat, be maintained continuously, or almost continuously, for several days. Ice Bag. The ordinary ice bag is a convenient and satisfactory method of applying cold. If no regular ice bag can be secured, the ice may be put in a hot-water bag. The ordinary hot-water bag fllled with ice does fairly well as a substitute for an ice bag but it is not as convenient, for the ice has to be broken into very small pieces. If no rubber bag of any kind is at hand, the broken ice may be wrapped in a towel and placed in a piece of table oilcloth, the edges and corners being pinned up so that no Avater can leak out. Cold- Water Coil. One end of the coil is attached to a vessel of ice water so that the water runs through it slowly and keeps it cold. The other end 352 GYISTECOLOGIC TREAT.MEXT conducts the water from the coil to a waste bucket beside the bed. If the hydrant water is cold enough; the tube leading to the coil may be attached to the hydrant. Cool Sitz-bath. This is used, not as a sedative Ijut as an active stimu- lant to the pelvic organs. It is taken the same as the hot sitz-baths except that the temperature of the water is 70' to 50^, and the patient does not stay in so long — only five to twenty minutes. It may be given gradually, i.e., the water is tepid at first and gradually cooled to 60' or 50'. In some .cases of amenorrhea the cool sitz-baths may prove more beneficial than the hot. They should, however, be given cautiously and in. strong individuals only and should not be continued unless good reaction comes on. As in a cool general bath, the reaction should be encouraged and increased by prompt drjdng and brisk rubbing. COrXTEEIRRITAXT APPLICATIONS Mustard Plaster. A mustard plaster or mustard poultice is applied over the lower abdomen just long enough to produce marked redness of the skin. It should not be left on long enough to blister. This gives a quick and wide- spread counterirritation of the skin and assists materially in relieving acute deep-seated pain. The effect is transitory, however, and needs to be con- tinued by the ordinary hot applications. If there is smarting of the skin after removal of the mustard, apply a layer of vaseline and a thin cloth under the hot applications. The addition of turpentine to plain hot stupes is a form a counterirritation, and in some cases assist A'ery much in relieving pain. Of course, this should not be applied to the abdomen in a case where an abdom- inal operation may be necessary soon. Cantharides Plaster. Small fly blisters over areas of persistent pain often do much good in cases of chronic pelvic inflammation without marked lesion and in cases of pelvic neuralgia. The blister should be small, from the size of a quarter to that of a dollar, and should be carefully protected from infection until healed. Cantharides Collodion is very convenient for making the small fly blis- ters. Paint it over the area which it is desired to blister and repeat after twenty-four hours if no blister has appeared. Tincture of Iodine. This is painted over the ovarian region of the af- fected side once or twice daily until the skin becomes tender. Then it is stopped for a few days until the tenderness subsides somewhat, when it is renewed. By varying the application as indicated In- its effect on the skin, a constant mild counterirritation may he kept for weeks, often with decided diminution of pain. VAGINAL DOUCHES 353 APPLICATIONS TO EXTERNAL GENITALS, VAGINA AND CERVIX VAGINAL DOUCHES The vaginal douche is used for four purposes — for simple cleansing, for astringent effect, for antiseptic effect and for the specific effect of hot water. Cleansing' Douche. The simple cleansing douche is used when there is a troublesome increase in the normal muco-epithelial discharge or when there is a muco-purulent discharge without pain or evidence of inflammation or marked relaxation of the tissues. Plain boiled water comfortably warm (100° to 105°) may be used, but if there is much discharge it is well to put a teaspoonful of ordinary salt or a teaspoonful of sodium bicarbonate to each pint of water, or the carbolic douche may be prescribed. The simple cleansing douche may be taken with the fountain syringe or with the bulb (Davidson) syringe. It may be taken with the patient lying in bed or in a sitting posture over a vessel. In all vag- inal douches the point of the syringe nozzle should be so large that it can not enter the cervical canal. Serious disturbance and even death has followed the accidental injection of the douche solution into the uterus. The point of the nozzle should be three-fourths inch in diameter, with the end closed and the openings at the sides. When it is necessary to use a slender nozzle (as in giving a douche to a virgin) it should be very short. Vaginal douches should be used only when there is some definite indica- tions for them. In healthy women the constant use of douches or the routine use of them for indefinite periods, is not advisable. They are not required for mere cleanliness, in fact, they interfere in a measure with the normal germicidal vaginal contents, which nature has provided to keep the vagina in a healthy condition and to protect the structures above. Astringent Douche. The astringent douche is used when the vaginal walls are lax and atonic or in the various erosions and other chronic inflammatory lesions of the cervix and in cases where there is soft, bleeding tissue about the cervix or vagina. As a mild astringent and sedative douche with some antiseptic effect, a solution of aluminum acetate is exceptionally efficient. Dissolve the powder in boiling water, and then allow it to cool sufficiently for the douche. It is rather difficult to dissolve, that from some manufacturers more so than from others. The aluminum acetate is excellent to use in connection with the hot douche, the last two quarts of the hot irrigating douche being saturated with it. When a stronger astringent effect is desired, the zinc sulphate and alum douche or the tannic acid douche may be used. These strong astringent douches are used principally in cases of soft, bleeding tissue in the vagina or in cancer of cervix or vaginal wall. They may be used also with benefit in relaxation of vaginal tissues and in erosions and other chronic inflammatory lesions of the cervix, in cases where it is impracticable to use the hot douche. 354 GYNECOLOGIC TREATMENT Care must be taken that the solution does not irritate the vaginal wall. It is well to begin with a weak solution and advance to the stronger as toleration is established. Astringent douches should be taken with the patient in the horizontal posture, preferably with the hips elevated on the bed-pan, as described in the technic of the long hot douche (Fig. 425). Antiseptic Douche. The antiseptic douche is used in those cases of puru- lent discharge or muco-purulent discharge in which the admixture of pus is so prominent that an active germicidal effect is important. One of the best of the germicides for making a strongly antiseptic douche is the only standby, hydrarg. bichloride, used in the strength of about 1-5000 or, where a weak anti- septic is desired, 1-10,000. Some state that it is dangerous to use such a strong antiseptic as a vaginal douche on account of the danger of poisoning. This is hardly probable, however, with the strength mentioned and under pre- cautions. The author has prescribed it freely for a number of years and he noticed no untoward results. The author is careful not to use it when there is a large raw surface in the vagina or when there is an opening communicat- ing with a large pelvic abscess cavity or when the cervical canal stands open so that the solution might easily pass into the uterus. Absorption from the intact vagina is not probable. In prescribing, it is well to have the con- centrated solution colored so no mistakes will arise, for it is a violent poison. Another efficient and very satisfactory douche is formol, 1-5000 to 1-3000. Formol, as purchased in the drug stores, is a 40 per cent solution of formalde- hyde gas. Formol is a very strong antiseptic and must be used in weak solu- tion or it will cause irritation. Five to ten drops to two quarts of warm water is usually sufficient, though for special conditions the strength may be increased with some patients. Hot Vaginal Douche. The hot vaginal douche is cleansing and may be made antiseptic or astringent, but its special and distinct effects are the relief of pain, the limitation of inflammation, the hastening of absorption of exudates and the toning up of relaxed tissues. These effects are brought about by the prolonged application of hot water to the vaginal walls and cervix. To get the best effect, it is essential that particular attention be given to certain details of its administration. These details are usually carried out in an incomplete way, for the importance of their full employment is not at all appreciated by the patient and as a rule only partially by the physician. Hence, ordinarily, the hot douche amounts to little more than a cleansing douche, the specific effect of the heat being almost wholly missed. This is an important subject for, given properly, the hot douche is one of the most effective non-operative measures used in the treatment of gyneco- logic diseases. Furthermore, it is an inexpensive and simple measure, the necessary articles costing but little, and the douche may be given to the pa- tient by any woman of ordinary intelligence, if definitely instructed. It has also the least possibilities of harm of the various methods of local treat- VAGINAL DOUCHES 355 meiit and is the least disturbing to the anatomy and physiology of the parts. The specific effect of the hot douche was recognized more than forty years ago by that prince of clinical" investigators, T. A. Emmet, and clearly set forth in his splendid work published in 1879, from which the following quotation is taken: "It has been stated that the sympathetic system of nerves presides over nutrition and the organs of generation and that every blood vessel, to the minutest capillary, is covered by a network of nerve filaments communicating (lirictly with the different ganglia. "When nutrition is impaired, there is naturally a want of tone in the blood vessels. It is only by exciting reflex action through these nerves that the necessary tonicity will be restored. "We have three agents for exciting this reflex action, viz., electricity, cold and heat. "Electricity exerts a decided effect during the time of the passage of the current, but the impression is too transitory and the agent is only to be relied upon as a valuable adjuvant. "Cold is a prompt excitor of reflex action, by which the vessels con- tract, but on reaction taking place the parts will become more congested than before, with both the arteries and veins distended. "Heat, unless at a temperature that would destroy the p.arts, does not act as promptly in causing this contraction as either electricity or cold. In fact, its immediate effect is to cause relaxation and to increase the congestion of the parts, but if its application be prolonged, reaction ensues and contraction takes place. In other words the reaction from heat is contraction. The capil- laries are excited to increased action and as they contract from the stimulus of these nerves, the tonic effect extends to the coats of the larger vessels, their caliber in turn becomes lessened and with this approach to healthy action the congestion is diminished. The popular belief is that heat relaxes and in- creases the congestion of the parts, and such indeed is the case at first. But a hot poultice is never applied with the object of increasing the congestion, but, as any 'old wife' would express it, to draw the 'fire' or inflammation out — in other words it lessens the congestion by stimulating the blood vessels to contract. That such is the effect, from the continued use of a poultice, is fa- miliar to everyone and is shoT\ai by the blanched and shriveled appearance of the tissues after its removal. The hands and arms of a washer-woman be- come swollen at first, from the increased flow of blood when in hot water, but the fact is quite as familiar that they afterwards become markedly shrivelled. "To place the hands in cold water will at once cause the skin to shrivel, as the vessels are stimulated to contract, but we are all familiar with the fact that reaction promptly comes on, and a larger quantity of blood returns to the parts than was driven out. The immediate effect of cold, therefore, is contraction, and with reaction comes dilatation; but the reverse is true of heat, which causes at first dilatation followed, however, by contraction. "AVith these practical points before us, we resort t« the prolonged use 356 GYNECOLOGIC TREATMENT of hot water, by vaginal injections, to gradually bring about the required contraction and tone in the pelvic vessels. Whenever inflammation exists we have congestion of the arterial capillaries. . . . The congestion may be either venous or arterial. This remedy is not to be considered a ' cure all, ' but one of the most valuable adjuvants, under all circumstances, to other means. ''If a vaginal injection has been properly administered, the mucous membrane will be found blanched in appearance, and the usual size of the canal lessened in calibre, as after the use of a strong astringent injection. As the patient lies on the back with her hips elevated, the action of gravity will be brought into play, by which the veins will be rapidly emptied sufficiently to relieve the over-distention. When in this position also, the vagina will become fully distended by the weight of water and kept so, since only the surplus amount can run off into the bed-pan beneath. The hot water will then be in contact with every portion of the mucous membrane under which the capillaries lies. The vessels going to and from the cervix and body of the uterus pass along the sulcus on each side of the vagina, and their branches enclose the vagina in a complete network. ... If then we are able to cause the vessels of the vagina to contract, through the stimulus of the hot water, we can directly or indirectly influence a large part of the pelvic circulation. It is most important to appreciate the necessity for elevating the hips, by which plan so large a portion of the venous blood becomes drawn off by gravitation. If the stimulus of the hot water is then applied, so as to cause the vessels to contract still more, we will, for a time at least, have the pelvic circulation reduced almost to a natural condition. In order to allow the condition of con- traction to be as prolonged as possible, I generally direct the injection to be given at night, in bed, just as the patient is ready to retire. Thus, by con- stantly causing these vessels to contract, and by resorting to every other means of lessening the supply of blood in the pelvis, we will succeed eventu- ally in securing a proper vascular tone. "No plan of treatment could be more rational or appeal more forcibly to the good judgment of everyone. But, unfortunately, from a neglect of de- tails, it is rare that the slightest beneflt is derived from these injections, al- though so many years have elapsed since the profession has been fully instructed as to their mode of action. For fifteen years at least, I have been experimenting by different methods in the use of hot water, and have had during that time as large a number of cases as would be likely to be at the service of anyone, and I have arrived at the conclusion that it is an im- possibility for a patient to give these injections to herself so as to derive their full benefit. Not the slightest advantage is received from them when admin- istered with the patient in the upright position, or, as is the usual method, while seated over a bidet, for, given thus, the water does not dilate the pas- sage but returns along the nozzle of the syringe. I have found that the best method of all is to have the injections given while the patient is placed on her knees and elbows or chest. In this position we have the assistance both VAGINAL DOUCHES 357 of gravity and the pressure of the atmosphere to empty the pelvic veins, while the water is able to act on a much larger surface of the vagina than it is when the patient is in any other position. But this position is a difficult one to assume, since those who are in the greatest need of hot water have not the strength to remain in it long enough to accomplish the purpose, and consider- able difficulty is also experienced in keeping the patient dry. This latter difficulty, however, can in a measure be overcome by using a funnel-shaped receptacle, with an India rubber tube attached to the smaller end, the two sides being indented sufficiently to enable the patient to keep it in place by keeping the thighs together. But for the larger number of cases, the position on the back, with a bed-pan to elevate the hips, will be found the most con- venient. Few women are so situated as to be unable to get someone to ad- minister the injection properly, and the inconvenience of soliciting aid is a trifling one considering the benefit to be derived from it, since experience has shown that, unless the details can be carried out fully, the process only in- volves a waste of time and a tax on the strength of the patient. ''The temperature and quantity of water are to be varied according to cir- cumstances. When treating the early stages of inflammation, it is necessary that the temperature should be elevated rapidly from that of blood heat to 110°, or to as high a degree as can be borne by the patient, and that the injection should be often repeated. For ordinary use, a gallon of water at two or ^ree deg re e s abov e blood heat is generally sufficient, but the temperature ^^fcJ[^P!^nnmined at the highest point by the addition of hot water from j^^^to time. The hour of bedtime is usually the best in which to seek for the beneficial effects of hot water on the reflex system in allaying the local irritation, for prolonged vaginal injection at a high temperature will often, when given by an experienced hand, act with more promptness than an ano- dyne in allaying the nervousness and sleeplessness of a hysterical woman. I have frequently known a patient, after being well rubbed and having received an injection, to fall asleep before the nurse had completed the process and to be so overcome with drowsiness as to be but little disturbed on removing the bed-pan. ''In rare instances and from a condition I am unable to explain, cases are met with where a sensation of weight and an uncomfortable feeling are experienced after an injection of water at the usual temperature. In some instances so much disturbance resulted that occasionally I was obliged to abandon its use. But I have long since ascertained that the injection is well borne at a lower temperature, generally about 95°, and that after a week or two the temperature can be gradually increased. "This 'cooking process,' as it has been facetiously termed, is rendered easier by the use of ivory or some other nonconducting material, for the nozzle of the syringe, since the patient suffers more discomfort from the heated metal surface of the ordinary nozzle coming in contact with the out- 358 GYNECOLOGIC TREATMENT let of the vagina than from any degree of heat in the water which it is ad- visable to employ. "To the injection (generally to the last pint) may be added glycerine, chlorate of potash, chloride of sodium, carbonate of soda, borax, castile soap, sulphate of copper, muriate of ammonia, brewer's yeast, permanganate of potassa, carbolic acid or any other remedy which may seem to be indicated. *'As the patient improves in health, the quantity of water for the injec- tion may be lessened and the temperature gradually lowered and then dis- continued. But for some months it would be prudent, for a few days after each period, to resume the injections at a degree or two above blood heat, and to have recourse to them whenever their use should seem indicated to counteract the effect of some imprudence. "I do not claim to be the first person under whose direction a vagina was ever washed out with warm water, but I do claim to be the first to use the agent in a systematic manner, for the treatment of the diseases of women, and to have done so with a definite purpose."* Directions for the Hot Vaginal Douche In prescribing the hot douche, take pains to give explicit directions on the following points : 1. Articles Required. Direct the patient to buy a yard of thin oilcloth, a douche pan, a fountain syringe, a bath thermometer and a four-ounce bottle of lysol. The patient wishes the most effective treatment, not half-Avay measures. These articles cost but little and are necessary to the proper care of the case. The piece of oilcloth is to be placed under the douche pan to thoroughly protect the bed. It does very well. A piece of white rubber cloth is nicer but a little more expensive. A very convenient form of douche pan is that shown in Fig. 425. It should have an opening for attachment of rubber tubing to conduct the water to a vessel beside the bed, so that when desired, several gallons of water may be used without emptying the douche pan. This pan holds a large quantity of water and is easily cleansed, and by closing the outlet with the screw cap it may be used as an ordinary bed-pan. A douche pan of this or some similar style can be purchased for a small amount and is just as much a necessity in the proper treatment of the case as medicines that cost more. The fountain syringe should be of good size (3 or 4 qts.), the syringe- nozzle having an end three-fourths inch in diameter and with the openings at the sides (Fig. 449). The nozzle is kept in 2 per cent lysol solution (two teaspoonfuls to a pint of boiled water) when not in use. Immediately after ^Principles and Practice of Gynecology, by Thomas Addis Emmet, M.D. VAGINAL DOUCHES 359 US© each time, it is washed out with a stream of water and then dropped into the antiseptic solution. The bath thermometer should register as high as 120° F. It is kept wrapped in a clean towel. Each time before use it is cleansed in the lysol solution. After use it is again cleansed in the lysol solution, dried and wrapped in towel. The antiseptic is used for cleansing the douche nozzle and the thermom- eter, and for mixing with the last two quarts of the douche water when it is desirable to do so. Any antiseptic desired may be used. Lysol is easily ob- tained, may be mixed in approximately the required proportions very easily, does not corrode when mixed in a metal vessel, is of such color and odor that it is not likely to be mistaken for something else and does about as well as anything so far as antiseptic effect is concerned. For a douche use one-half per cent (one teaspoonful to the quart). If an astringent effect is desired, use; alum (two teaspoonfuls to the last two quarts) or aluminum acetate (one' teaspoonful to the last two quarts), instead of the lysol. If a still stronger astringent effect is desired, the zinc sulphate douche or the tannic acid douche may be used. 2. Have some one give the douche as follows: — Scald out the douche bag and tubing with boiling water and hang it about the feet above the level of the bed. Get a tea-kettle of boiling water and a large pitcher of warm water, as warm as the douche may be comfortably begun with (about 105° by the bath thermometer). Put the piece of thin oilcloth on the bed, and on this an ironing board. Put the douche pan on the lower part of the board and a quilt on the upper part, to make it comfortable for the patient, and a pilloAv for her head. If the upper edge of the douche pan is uncom- fortable, cover it with a folded towel. The tube of the douche pan leads into a bucket beside the bed. When the patient is arranged, the hips should be considerably higher than the rest of the body (Fig. 425). Take the douche nozzle out of the lysol solu- tion, rinse off the lysol in the pitcher of douche water, attach the nozzle to the douche tubing and introduce it into the vagina. Pour some of the warm water from the pitcher into the douche bag and allow it to run. If some air runs from the douche tube into the vagina, that is beneficial for it helps to. separate the walls. As the patient can take the water warmer and warmer increase the temperature, ])ringing it up to 115° if not too uncom- fortable. Keep up the hot irrigation, ordinarily, for thirty minutes or more, using as much water as necessary to maintain the irrigation for that length of time. The water runs slowly (only tAvo or three feet elevation) and three or four gallons is usually enough. 3. If it is desired to make the latter part of the douche especially astrin- gent, as when the parts are relaxed and atonic, a suitable chemical is added. 360 GYNECOLOGIC TREATMENT The aluminum acetate is excellent for this purpose, a teaspoonful of the powder beiiii^ dissolved in the last two quarts of the irrigating fluid. If a strong antiseptic effect is needed, as in a case of purulent discharge, the required antiseptic is added to the last two quarts of the hot water. In inflammation (subacute or chronic) considerable additional benefit is secured by introducing to the top of the vagina, immediately after the Fig. 425. Patient arranged for the Long Hot \'aginal Douche. Notice that the patient's hips are elevated and that the douche pan has an outlet tube leading into a bucket beside the bed. The douche nozzle has a thick end and the openings are at the side, so that there is no possibility of the water being forced into the uterine cavity. The douche bag may be hung at any height required to give the desired rate of flow. douche, a vaginal capsule containing a tampon with the upper end saturated with some glycerine preparation (ichthyol-giycerine or boro-glycerine). This tampon is left in place from twelve to tM^enty-four hours, when it is removed and the douche repeated. This is an excellent method of treating subacute or chronic pelvic inflammation and also acute exacerbations of the same. LOCAL TREATMENT 361 4. After the Douche, the patient slides over to another part of the bed while the douche pan, etc., is being removed, and should remain quiet for at least an hour. 5. The Frequency with which the douche should be repeated varies with the case. In chronic inflammation, when the patient is up and at work and suffering but little, once a day may be sufficient. In such a case the prefer- able time is in the evening, as the patient is then in bed for several hours afterwards. In cases of more severity or where the one douche does not produce satisfactory results, a douche in the forenoon may be added — the patient re- maining in bed at least one hour afterward. In the cases where the patient is confined to bed, the douche is given, ordinarily twice daily. In severe cases of acute pelvic inflammation, after it is seen that the uterus is clean and draining and any other focus of infection opened, it may be beneficial to give the hot douche every six hours and in some exceptional cases, it is advisable to keep up an almost constant irriga- tion of the parts for some days. 6. This hot vaginal douche, with its specific effect, is beneficial in prac- tically all inflammatory conditions of the pelvis, in relaxation and want of tone in the pelvic tissues, in pelvic congestion and in pelvic neuralgia. In these conditions it must not be depended on to the exclusion of other neces- sary measures, operative and non-operative, but it is to be used in conjunction with these, as indicated by the requirements of the particular case. Where many gynecologic cases are treated, it is well to have a printed slip to give each patient who is to take the douche, setting forth definitely, in a few plain words, the necessary directions. By having this to refer to, the person who gives the douche will give it much more nearly as it should be given and therefore much more effectively. LOCAL TREATMENT Before taking up the details of the office treatment of gynecologic dis- eases, it would be Avell to get a clear idea of what good can be done and what harm can be done by such treatment. The importance of ordinary office treatment is, on the Avhole, still rated much above its actual value. This statement applies especially to the appli- cation of medicines to the vaginal walls, to the cervix and to the interior of the uterus. In some affections for which this method of treatment is generally and persistently employed, it does no good and much harm. There is, however, no warrant for those wholesale condemnatory state- ments made from time to time which, reduced to their essence, mean that when any pelvic disturbance is severe enough to require treatment, it re- quires operation. Such teaching is very far from the truth and is almost, if not fully, as erroneous in theory and deplorable in results as the former teach- 362 GTXECOLOGIC TREAT^IEXT ing that "local treatment" Avas the most important measure in the handling of patients Avith pelvic disease. Happily the treatment of gynecologic dis- eases is no longer based upon obscure theories and opinions empirically ex- pressed, but upon the rational application of kno^vn remedies to demonstrated pathologic conditions. Though there is still much to be learned and much that is obscure, as there always ^vill be about a subject so intimately con- nected with the mysterious processes of life, the essential features of most of the diseases and the main effects of the principal methods of treatment are open to the understanding of all who will give the necessary time and study to the subject. Critically reviewing the demonstrated pathologic changes present in the various gynecologic affections, it is evident that in a considerable pro- portion of the serious diseases, effective treatment is necessarily operative, for the al3normal changes are of sucli nature that they can be iirfiueuced only by direct handliug and treatment of the affected organs. On the other hand, there are many conditions that may be much influenced by non-operative measures carried out at home, such as attention to general health, internal medicine, special exercises, posture, hot or cold external applications, hot vaginal douches, etc. Much eff'ect is exercised also over certain condi- tions, by local treatment in the office — pessaries, tampons, packings, pressure ti-eatment. massage, dilatation and A'arious medicinal applications to the vagina or cervix or within the uterus. Xo one of these methods should be used until sufficient knowledge has been obtained to shoAv what the principal effects of that method are and in what conditions we in&y reasonably expect decided benefit from such effects. The method just now under consideration is the application of concen- trated solutions to the cervix uteri, the vaginal wall or the external genitals. What good can such applications do? 1. They may exercise an antiseptic or an astringent or an anesthetic or an irritating effect, limited to the surface on which they are applied. 2. They may destroy tissue (cautery). 3. They may draw off fluid from tissues adjacent to the vaginal vault (hygroscopic effect), as in the use of glycerine in various combinations. This may diminish the pain (interstitial pressure) of an inflammatory or edematous infiltration and possibly assist nature in limiting the inflammation and hasten- ing absorption. This effect is very desirable, but in acute and subacute cases its beneficial effect is more than overbalanced hy the trips to the office. In such cases the effect may l^e more advantageously secured by having the tampon-capsules used at home, immediately after the douche. Occasionally, in the case of a chronic exudate, when the patient can get about without disturliance. it may be used with decided effect in office work. ■4. They may possibly influence deep pains by counterirritation at the vaginal vault. This is applicable only in eases of chronic exudate or pelvic neuralgia, and even in these it is of dnulitful utility. AVhere the decidec] LOCAL TREATMENT 363 relief of pain that sometimes follows counterirritation at the vaginal vault is due to the mechanical drawing of the blood from the adjacent tissues to the dilated vessels of the vaginal surface, or to a reflex deep anemia from the irri- tation of surface nerve-filaments, or to a purely sensory effect on the deeper nerves by irritation of the corresponding superficial nerves, the author is not prepared to say. Possibly it is not due to any of these but to some other factor in the treatment (pressure, cleansing, posture). Formerly much importance Avas attached to counterirritation at the vaginal vault, and a woman with pelvic inflammation could hardly be consid- ered initiated into treatment until the vaginal vault and cervix had been painted with Churchill's tincture of iodine. It is not so often used now, for we have more effective measures. What harm can such applications do? 1. May cause the patient to come to the office Avhen the dressing and coming do more harm than the application does good. This is true of all acute inflammations (even vaginal and vulvar) and of practically all sub- acute inflammations of the uterus and deep pelvic structures. 2. May cause postponement of effective treatment, by holding out false hope, until the disease is much more difficult of cure or is past cure. This applies to chronic inflammations of the .corpus uteri and peritoneal struc- tures, to deep-seated inflammatory troubles of the cervix uteri and to begin- ning cancer of the uterus. 3. May convert a neurasthenic or hysteric into a confirmed invalid by fixing attention upon, and exaggerating the importance of, some trivial local disturbance. In such patients the frequent calling of the attention to some minor disturbance in any part of the body is deleterious and particularly so if the disturbance is in the genital tract, for the importance of minor disturb- ances there is greatly overrated in the minds of people generally. For this reason, in patients with neurasthenic or hysteric tendency, it is advisable to avoid repeated local treatments, even in some conditions where otherwise one would feel that they might be beneficial. Occasionally local treatment of an un- important lesion two or three times, principally for psychic effect and to gain the patient's confidence by letting her see that you appreciate all that is there, is beneficial. Usually, however, the same effect is better accomplished by a thorough examination and then an unequivocal dismissal of those organs from the list of damaged structures. The concentrated solutions used for application to the vaginal walls or cervix, are applied through a speculum by means of a pledget of cotton held with a uterine dressing forceps, or by means of a cotton-wrapped applicator. These solutions may be divided into several groups, according to effects. The author does not give all the solutions under each group but only some well known examples. 364 GYNECOLOGIC treat:ment Solutions Used 1. Antiseptic and Astringent Solutions. Protargol Sol. 2% to 10%. Argyrol Sol. 20% to 40 %o. Silver Nitrate Sol. 2% to 10%. Bichloride Sol. 1 to 500. Tinct. Iodine. Copper Sulphate Sol. 10%. Adrenalin Chloride Sol. 1-1000. Liq. Ferri Subsnlphatis. Silver Nitrate solution is the one formerly most commonly used as an antiseptic application to the genital tract. It is still used largely and with excellent effect, though there are some other preparations with the same effect and without the pain on application and the discoloration of the cloth- ing incident to the use of silver nitrate. Silver nitrate is the pioneer of the silver preparations. It is used in the treatment of vulvitis, vaginitis, erosion and ulcer about cervix, endocervicitis and endometritis. The strength used, for vulva and vagina is usually 2 per cent to 4 per cent, the weaker being used at first when the parts are particularly sensitive and the stronger later as the sensitiveness becomes less. A sensitive inflamed surface or an abrasion or ulcer is usually much diminished in sensitiveness after one or two applica- tion, and the application seems also to stimulate repair. For application to an eroded area or an ulcer on the cervix, 4 per cent to 10 per cent is used to stimulate repair. During the last few years a number of silver preparations have been put forward as superior to silver nitrate for local application. Protargol and argyrol are two that have stood the test of extensive use. They have about the same or perhaps a better effect than silver nitrate, do not irritate so much and do not form permanent stains on the clothing and skin. The protargol is used in the same strength as silver nitrate. The argyrol must be used much stronger, 20 per cent to 40 per cent. It is the least irritating of the silver preparations. The bichloride solution is strongly antiseptic and mildly astringent. Tincture of iodine (either the ordinary tincture or Churchill's tincture) is a useful antiseptic and stimulant to chronically inflamed areas or to ero- sions or ulcers. It was formerly much used as a counterirritant application to the vaginal vault in chronic pelvic inflammation, but more effective measures for the treatment of this disease are now available. The copper sulphate solution is used to check bleeding and to stimulate healthy cell action in eroded and ulcerated areas. It has a tendency to check bleeding from all ulcers except those due to beginning malignant disease. LOCAL TREATMENT 365 Consequently it is helpful in the differential diagnosis of a malignant ulcer, as explained in Chapter ix. Liq. Ferri Subsulphatis may be used when a strong hemostatic applica- tion is needed for a bleeding area. Adrenalin affects different parts of the mucosa of the genital tract in a different manner. It seems, in some cases at least, to have no effect on the mucosa of the vagina, but a pronounced effect on that of the uterus. 2. Cauterizing- Solutions. Carbolic Acid 95%. Iodized Phenol. Nitric Acid— C. P. Carbolic acid is employed as a cauterant application to unhealthy ulcers on the cervix or vaginal wall, particularly chancroidal ulcers. Iodized phenol is a milder cauterant, more superficial and less irritating than carbolic acid and also less effective. Nitric acid is a very deep and pain- ful cauterant. It is now seldom used, as carbolic acid is effective and is easier handled and causes less subsequent disturbance. 3. Hygroscopic Solutions. Glycerine. Boro-giycerine (Boric acid 50%). Carbol-giycerine (Carbolic acid 2%). Ichthyol-glycerine (Ichthyol 10%) Protargol-glycerine (Protargol 10%). Tannic-acid-giycerine (Tannic acid 10%). The glycerine preparations are used for the hygroscopic (water-extract- ing) effect of the glycerine and also for the special effect of the particular drug incorporated with the glycerine. The application is made by soaking one end of a tampon in the desired glycerine preparation and then introduc- ing it through the speculum into the upper part of the vagina, the medicated end being placed against the cervix. These glycerine tampons are used particularly in acute and chronic inflammatory conditions in the pelvis. They seem to assist materially in diminishing the pain and soreness and they cer- tainly exercise a decided effect on the adjacent tissue fluids, for the patients often remark on the large amount of water which comes from the vagina when using these glycerine tampons. 4. Anesthetic Solutions. Cocaine Sol. 10%. Cocaine Sol. ^% (for hypodermic injection). Eucaine Sol. Chloretone Sol. The 10 per cent cocaine solution is used for local application to painful 366 GYNECOLOGIC TREATMENT sores or abrasions, to dimmish pain during examination or for cauterization. The Yi per cent cocaine solution is used as a subcutaneous or submucous injection, for removing small growths or pieces of tissue for microscopic examination. POWDERS Powders may be applied by means of the powder blower or they may be placed on a cotton or gauze tampon, which is then placed in the upper part of the vagina. Powders innumerable have been used for this purpose, and as a rule any powder that is a good antiseptic application for wounds is good also as a vaginal application. Powders are used principally for the antiseptic and drying effect or for an anesthetic effect. 1. Antiseptic and Drying. Pulv. Boric Acid. Xeroform and Boric Acid (1 to 4). Bismuth Subnitrate. Bolus Alba. Aristol. Pulverized boric acid is used as a mild antiseptic and drying powder. It is bland and can hardly cause irritation even with children. Xeroform and boric acid (1 to 4) is preferable when a stronger antiseptic powder is desired, in fact, it is the powder the author ordinarily uses, except when some special astringent or anesthetic effect is desired. Xeroform has proved a very satis- factory substitute for iodoform. Its action in stimulating healthy granula- tion, is very much like iodoform and it has practically no odor. It is about as effective as the other iodoform substitutes and less expensive. Bolus Alba, mixed with dried yeast, has been highly recommended as a vaginal application in cases of leucorrhea, with the idea that the yeast fungi inhibit the growth of other bacteria. Gonorrheal infections are probably favorably influenced by this powder. 2. Anesthetic powders. Orthoform, Xeroform and Boric Acid (1-1-4). Chloretone, Xeroform and Boric Acid (1-1-4). Orthoform is a powder that is decidedly anesthetic and for that reason is advantageously combined with powders used in the treatment of pain- ful affections of external genitals, vagina and cervix. The anesthetic effect is, of course, most marked when the poAvder is used pure, but, like cocaine, it has a devitalizing effect on poorly nourished tissues and may cause super- ficial sloughing if used too strong. The author has had such an experience with it in treating superficial abrasions due to senile pruritus vulvae — the orthoform, when dusted on pure, causing the abrasions to become very exten- TABLETS AND SUPPOSITORIES 867 sive instead of smaller. A similar experience, in a patient past the menopause, was related to him by one of his colleag'ues. Chloretone can be used to advantage whenever there is pruritus or a sense of soreness in the vagina or about the external genitals. It is very satisfactory as a dusting powder to painful ulcers, chancroidal and other- wise. As a dusting powder, it is diluted Avith a bland poAvder and combined Avith an antiseptic poAA^der as above indicated. TABLETS Compressed tablets containing antiseptic or astringent or anesthetic drugs, are put up for vaginal use. They may be introduced to the upper part of the vagina by the patient, either folloAving a douche or without a douche, once or twice daily or more often as directed by the physician. Tablets of various formulae for vaginal use may be obtained. They are very convenient in cases Avhere it is desirable to have the patient use some drug betAveen the office treatments or where the patient can not come to the physician or be seen by him often enough for regular treatment. Thdy are not as effective, however, as powder applications made with speculum ex- posure of the affected area and held in place by a tampon, as in office treat- ment. In prescribing tablets use only those put up by a reliable house, so that you can depend on the stated formula and knoAv just Avhat you are using. The effect of these tablets, dissolved in the vagina, as of other vaginal medication, is of course only local (limited to superficial effect on the vagina and cervix) and has practically no influence on deep-seated or serious vaginal or uterine or periuterine lesions. Tablets of various shapes and alleged formulae and called by fancy names, are put up for vaginal use by patent medicine venders and peddled from house to house by women agents. They are put forth as wonderful discoveries that will cure all "female diseases," and like other alleged 'Svonderful discoA^eries" they deceive many a poor Avoman with unfounded hopes, the falseness of Avhich in serious diseases she often discovers only AAdien the disease is past cure. It is another case of "blind leading the blind" or, Avorse still, of avarice leading the blind. VAGINAL SUPPOSITORIES AND CONES Vaginal suppositories furnish another method of applying medicine to the vaginal wall and cervix. In vaginal suppositories, the active ingredient is incorporated Avith cocoa butter or other suitable material Avhich melts in the vagina. Vaginal sup- positories are used principally in the treatment of chronic vaginitis in chil- dren, in cases in Avhich it is difficult or impracticable to employ the ordinary and more effective methods of vaginal treatment. GYNECOLOGIC TREATMENT TAMPONS A vaginal tampon is simply a piece of absorbent cotton or common cot- ton or wool or gauze, of the desired size and shape, with a short string at- tached, so that the tampon may be removed from the vagina by the patient after a specified time. One way to make a cotton tampon is to take a rather thick piece of cot- ton (common cotton or absorbent cotton) of the required length and width and thickness and tie one end of a strong string firmly about the middle. Fold the cotton at the place where the string is tied. This brings the free ends together. If it is desired to use a solution, the free ends are dipped in it. If it is desired to use powder, the free ends are spread out so as to make a depression in which the powder is placed. This end of the tampon is then caught with the long uterine dressing forceps and carried up to the cervix. Leave the string long enough so that the end will project from the vagina, that the patient may easily catch it and remove the tampon at the end of twelve to twenty-four hours as directed. It is well to make the string into a loop as indicated in Fig. 426. Tampons made of surgical wool are prefer- able when the principal effect desired is support, as they are much more elastic than the cotton and retain their elasticity longer. In some cases the wool proves to be irritating to the vaginal walls. To prevent this and yet secure the springiness imparted by the wool, the wool tampon may be cov- ered with a thin layer of common cotton. It is a good plan to keep prepared, ready for use, a number of tampons of different sizes. They may be prepared during leisure and they are then ready when needed, and thus is saved considerable time and inconvenience. When the vagina is tamponed with a strip of gauze or with cotton balls without strings, it is referred to as a vaginal tamponade. The author has included all these packings under the general term "tampons." Tampons of cotton or wool or gauze or vaginal packings of the same, are used for the following purposes: 1. To secure the effect of drugs incorporated in the gauze or cotton or held in place by them. 2. To occlude the vagina after operations in its upper part. 3. To stop hemorrhage. 4. To keep inflamed surfaces separated. 5. To support the pelvic organs. 6. To prevent coitus. Tampons are much used for holding medicine against the cervix and vaginal vault. If the medicine is in solution, for example, one of the glycerine preparations, the end of the tampon is dipped into the solution and then ap- plied to the vaginal vault and left there, to be removed by the patient after twelve to twenty-four hours. If the medicine is a powder, it is dusted freely USE OF TAMPONS 369 about the cervix and some of it is placed on the end of the tampon, which is introduced as before. When used to occlude the vagina after an operation, the gauze or cot- ton is simply a surgical dressing, the same as when applied to an external Fig. 426. Preparation of Tampons, a. A piece of cotton of the required size with a strong string tied about the middle and also a loop tied. b. The same, with the ends folded up preparatory to re- ceiving powder in the hollow formed there or to being dipped into an application-solution. _ c Another satisfactory way of making a tampon. The piece of cotton is folded and the ends are tied together and the string looped, d. A small bowl containing tampons ready for use. 370 GYNECOLOGIC TREATMENT wound. The gauze or cotton may be simply sterile or it may be impregnated with some antiseptic, as in bichloride gauze, iodoform gauze, etc. When gauze or cotton is used to check hemorrhage it should first be wet in some antiseptic solution and then squeezed as dry as possible before being packed into the vagina. Used in this way it makes a much more effec- tive hemostatic than when used perfectly dry. For keeping intlamed surfaces separated, tampons of cotton or gauze- strips are used in the various forms of vaginitis. To support the uterus or hold it in position, dry gauze or cotton or wool Fig-. 427. Tampon-Capsules. a. Large size. b. Small size. c. The cap removed, showing the tampon, d. A tampon-capsule prepared, ready for introduction. The cap was removed and the medicine poured into the cap, which was then replaced, parent cap. The dark ichthyol mixture shows through the trans- is used. Wool has more "spring" in it than cotton or gauze, consequently a wool tampon is the best in eases where only support is required. Sometimes the wool tampon irritates the vagina, in which case it may be covered with a thin layer of cotton as before mentioned. When cotton is used for sup- porting tampons, ordinary cotton is better than absorbent cotton, as the latter absorbs fluids rapidly and soon loses its elasticity. A tampon or tam- ponade for support should be put in with the patient in the Sims posture or in the knee-chest posture. USE OF PESSARIES 871 TAMPON-CAPSULES Ordinarily, all tampons are introduced by the physician. "When, how- ever, it is advisable that tampons be applied at home by the patient, be- tween the office visits or in conditions in which the patient can not well come to the office, the tampon-capsule may be used. The tampon-capsule is a large capsule of special design containing a plain wool tampon with a string attached. There are two sizes (Fig. 427). They come in boxes of a dozen and may be purchased from the druggist or wholesale drug-houses. They are convenient for use immediately after the hot douche, to secure hygro- scopic effect. Just before use, the patient removes the cap from the capsule, pours in about a half a teaspoonful of any desired medicine (usually boro-gly- cerine or ichthyol-glycerine), replaces the cap and introduces the capsule, medicated end first, up to the vaginal vault. Here the capsule soon melts, liberating the medicine and tampon, and the latter holds the former in place. PESSARIES Pessaries are appliances introduced into the vagina for the pur- pose of holding the uterus or vaginal wall in proper position. They are made of hard rubber or soft rubber, usually the former. Those made of soft rubber are generally hollow and contain air or flexible wire. Occasionally a pessary is made of glass or block-tin or some other material. Pessaries are used principally for the following affections : For Backward Displacement of the Uterus. For Prolapse of the Uterus. For Prolapse of the Anterior or Posterior Vaginal Wall. For Backward Displacement of Uterus In retrodisplacement of the uterus the pessary is used after replace- ment, to hold the uterus in proper position. Occasionally a pessary is used to support the uterus somewhat when complete replacement is not practicable. Varieties Used Innumerable forms have been recommended, and to attempt to men- tion all of them would be a waste of time. The following four varieties are the principal ones used at present in the treatment of retrodisplacement, and they are sufficient in practically all cases in which a pessary is the prefer- able method of treatment. 1. Hodge Pessary (Fig. 428, A). This pessary, devised by Hugh L. Hodge, Professor Diseases of Women in the University of Pennsylvania from 1835 to 1863, may be taken as the type of the hard rubber ring pessaries. It is the original model from which nearly all other pessaries of that character 872 GYNECOLOGIC TREATMENT descended. It is still much used and, as explained later, is the most suitable one for certain conditions. 2. Albert Smith Pessary (Fig. 428, B). Albert H. Smith modified the Hodge Pessary in two important particulars. He narrowed the anterior end so that it fits well up into the narrow portion of the pubic arch, the point projecting slightly into the arch. This tends to keep the pessary from turning or slipping about in the vagina and at the same time causes the anterior part of the pessary to lie higher— so that it is out of the way and does not inter- fere with coitus or with the introduction of a douche nozzle. . His other modification was a lengthening of the posterior arm of the pessary. This pushes the posterior vaginal fornix further upward and backward, thus in- creasing the ability of the pessary to hold the cervix uteri well back in the pelvis. 3. Thomas Pessary (Fig. 428, C), sometimes called the Smith-Thomas pessary. T. Gaillard Thomas modified the Smith pessary (which was itself A B C Fig. 428. A. The Hodge Pessary. B. The Albert Smith Pessary. C. The Thomas Pessary. a modification of the Hodge pessary) by thickening the posterior end into a bulbous enlargement. This distributes the pressure over a larger surface of the posterior fornix, and in that way tends to prevent pressure injury of the vaginal vault at that point. 4. Inflated Ring- Pessary, to be described later. Action of the Pessary The action of the Hodge pessary and its modifications, as ordinarily used in a case of retrodisplacement, is to hold the cervix back in the hollow of the sacrum. As long as the cervix is held well back in the pelvis, the fundus uteri will stay forward where it belongs. The pessary holds the cervix uteri back in place by holding back the posterior vaginal vault (to which the cervix is closely attached) and also by pushing upward and back- ward on the sacro-uterine ligaments, thus putting them on the stretch. To USE OF PESSARIES 373 accomplish this, the anterior portion of the pessary must have a rather firm support, which it gets from the pubic arch (with intervening soft tissues) and the pelvic floor. The action of the pessary, with its many curves, seems to be a veritable puzzle to many students and to not a few practitioners, yeMit is clear enough when properly approached and studied. In order to maKe the matter clear to the author's classes in a short explanation, he is accustomed to approach the subject synthetically so to speak, i.e., to gradually build up in mind such a pessary. We know that after a movable retrodisplaced uterus has been replaced, if we keep the cervix well back in the pelvic cavity, that is, a cer- tain, distance from the vaginal outlet, the fundus will stay forward (Fig. 429). Suppose then that we introduce a straight stick that reaches from the pubic Fig. 429. The Pessary in Place. The action of the pessary is to hold the posterior vaginal fornix, and with it the attached cervix, well backward and upward in the pelvis. (Skene — Diseases of Women.) arch to the posterior vaginal vault. Now as long as the anterior end of the stick is supported by the pubic arch, neither the posterior vaginal fornix nor the cervix, which is closely attached to it, can approach the vaginal outlet. The cervix can move up and down through a small arc, but it cannot come any nearer the vaginal outlet and consequently as the cervix is held Avell back in the pelvis the fundus uteri stays forward. This is practically the action of the pessary. It takes its fixed point of support from the pubic arch (the soft tissues intervening), being held up against the narrow part of the arch by the pelvic floor. As long as the an- terior end of the pessary is properly supported (held stationary) the posterior end holds the posterior vaginal vault and the attached cervix well back in 374 GYNECOLOGIC TREATMENT the pelvis. The ring shape of the pessary and the various curves are simply to adjust it comfortably to the adjacent structures. The open ring permits the pessary to lie up well out of the way in the lateral angles of the vaginal canal and also permits the cervix to project through the pessary and the uterine secretions to flow outward without hindrance. The marked upward bend of the posterior portion of the pessary increases its ability to push the posterior vaginal fornix upward and backward and put the sacro-uterine ligaments on the stretch. The long upward curve of the front part of the pessary with the narrow anterior end permits the anterior end to lie up out of the way in the narrow part of the arch, and also furnishes a slope against which the perineum and front part of the pelvic floor acts advantage- ously, helping to support the pessary in both an upward and backward direc- tion and thus taking some of the pressure off the extreme anterior end. If all the pressure on the pessary were transmitted to the very end, it would cause pain by pinching the soft tissues between the pessary and the bony arch. With the long steep upward curA^e, however, a large part of the down- ward and forward pressure is borne by the pelvic floor. The little trans- verse notch or downward, dip at the anterior end of the pessary is to prevent pressure on the urethra as the pessary lies well up in the angle of the pubic arch. The two principal factors in the support of such a pessary are the pubic arch and the pelvic floor. As to just which furnishes the most support, it is hard to say — probably there is much variation in different cases, depending on the conformation of the parts and the shape of the pessary. AVhen the pelvic floor is severely torn it permits the pessary to sink lower in the pelvis. The anterior narrow end lies at a wide part of the arch, a part too Avide to furnish support for it and it slips outside a short distance. This permits the cer^dx to come forAvard and then the fundus goes backAvard. NoAV in such a case, if Ave use a pessary AAdth a Avider anterior end (e.g., the regular Hodge pessary) it, being AAader, impinges on the sides of the arch and holds the cervix back AA^here it belongs. In very severe laceration, the marked relaxation of the pehdc floor alloAvs the pessary to come so Ioaa^ — to such a very Avide part of the arch — that not even the Hodge pessary Avill stay in. In such a case some temporary relief may be given by other styles of pes- sary to be mentioned later. Selection of Pessary The selection of the pessary best adapted to a particular case concerns the style, size and special modiflcations. As to style or form, in retrodisplacement the author prefers the Thomas pessary in all but exceptional cases. The adA'antages of this form are : a. XarroAv anterior end that lies Avell up out of the Avay. There is little or no interference Avith coitus or Avith the introduction of the douche nozzle. USE OF PESSARIES 375 b. Long steep anterior slope on Avhich the pelvic floor can act to advan- tage in assisting in the support of the pessary. c. Long posterior arm, which tends to keep the posterior vaginal fornix ■well up. d. Thick posterior end, Vvdiich distributes the pressure over a wide sur- face of the posterior vaginal fornix and thus prevents injurious pressure or ulceration at any point. The exceptional cases in which the Thomas pessary is not satisfactory, are as follows : 1. AVhere there is a severe laceration of the iDelvic floor. Li these cases a pessary with a wider anterior end is reciuired, as previously explained. Here the regular Hodge pessary is usually the preferable one. In lacerations of extreme severity, where the parts are so relaxed that neither the Hodge nor Smith nor Thomas pessary will stay in, the inflated ring pessary or one of the other forms mentioned under prolapse may give some temporary relief. For permanent relief in such a case operative measures are required. 2. AVhere the posterior vaginal fornix is too small or shallow to accom- modate the large bulbous end. In such a ease the Smith or the Hodge pes- sary may be used. In each of these the posterior bar is of small diameter and will fit into a small posterior fornix. If the pelvic floor is not too badly torn the Smith pessary is the preferable one of the two, as it has the narrow anterior end and the long posterior arm. 3. AVhen there are painful inflammatory lesions about the uterus or a prolapsed and tender ovary. In some of these cases the pessary may be worn without discomfort after the parts have been held in place by tampons for a few days. In others, the tenderness persists and any form of pessary which pushes well up behind the cervix causes pain and hence can not be worn. In such cases the inflated ring pessary sometimes gives considerable relief 1)y diminishing the dragging of the heavy uterus on the inflamed adnexa and broad ligaments. As a rule, however, in such cases time spent with pes- saries is time wasted, as far as any permanent relief is concerned. As to the size of pessary to be selected, the approximate length may be determined by measuring with the examining fingers the distance from the posterior vaginal vault (pushed well up) to the pubic arch. The length of the pessary should be a trifle less than this. The width of pessary which the vagina will accommodate may be determined approximately by the ap- parent roominess of the vagina as felt on vaginal palpation. A special maneu- ver for this purpose is to introduce the two examining fingers to the upper part of the vagina, separate them laterally as far as the vaginal walls will permit and then withdraw them in the antero-posterior diameter (the largest diameter of the vaginal outlet), retaining them as nearly as possible in the original position. However, the size of pessary that will keep the uterus in position with the least discomfort can be determined certainly only by trial, and several 376 GYNECOLOGIC TREATMENT pessaries may have to be worn for a short time before the most satisfac- tory one for that particular case is settled upon. A pessary that is too small fails to hold the uterus in position and tends to slip out. A pessary that is too large causes pain. It is better to give too small than too large a pes- sary, as the latter may cause severe pain after it has been in place a day or two, and if the patient is a long way from the physician and can not suc- ceed in removing the pessary herself, she may experience much suffering. The special modifications refer to slight changes in shape from the regu- lar form, occasionally required to make the pessary more comfortable or more satisfactory in retaining the uterus in position. 1, General narrowing of the pessary. The pessaries as purchased main- tain a ratio between the width and the length (the longer the pessary the wider it is). As a rule this is desirable. In some cases, however, the vaginal opening is too small to admit a pessary of sufficient length. To overcome this difficulty drop the pessary in hot water for a moment, until it becomes slightly pliable, then remove it with a forceps, grasp it with a towel and squeeze it so as to narrow it laterally to the required extent, and hold it thus until it cools. The cooling may be hastened by holding it in cold water. Do not keep it very long in the hot water or it will become so pliable that it flattens into a simple ring, and all the characteristic curves are lost. 2. Local Bending. Occasionally it is desired to bend a hard rubber pes- sary at some particular point, so as to change an ordinary curve to an unusual one or to change one form of pessary to resemble another form, which is needed but is not on hand. To make these local bendings, coat that part of the pessary to be bent liberally with vaseline or other ointment and hold it high above the flame of an alcohol lamp or Bunsen burner. Hold it close enough to the flame to heat the pessary well at the exact area it is desired to bend but not close enough to burn off the ointment. In a few moments the pessary is softened sufficiently to permit bending. If the pessary is brought too close to the flame, it is burned and the smooth surface roughened. In 1859, J. Marion Sims introduced the block-tin modification of the Hodge pessary, the advantage of this material being that it is sufficiently pliable to be moulded to any shape and yet firm enough to hold the shape given it. The block-tin pessary was the favorite with T. A. Emmet and was highly recommended by him, but it is not so frequently used at the present time. Ordinarily the hard rubber pessary is preferable. Pessary Used Only After Replacement The pessary is ordinarily not used until the uterus has been brought forward. The pessary is not, as many suppose, used to push the fundus uteri forward, neither is it used to prop the fundus forward. The pessary has nothing to do directly with this part of the uterus. All the pessary does is USE OF PESSARIES 381 When the pessary is found satisfactory at the second and third visits, it is to be assumed that it will prove satisfactory right along, and as long as the patient feels well she need not return, except every month or six weeks as above indicated. This return at regular intervals of a few weeks is im- portant in every case (though, exceptionally, the intervals may be longer) for three reasons — (a) because the pessary is liable to accumulate concretions that may prove irritating, (b) because long-continued pressure may produce ulceration at some point in the posterior vaginal fornix and (e) because it is ' ""^3c%^:^ Fig. 435. Introducing the Pessary. The posterior end depressed and being pushed past the cervix. The pessary is shown in place in Fig. 429. important to know whether the pessary is doing the work it is used for, and if everything is going as it should. Injurious pressure on the Avail is indi- cated by a distinct groove or ridge with infiltration in the affected area. When such is present, the pessary should be left out for a few weeks or a dif- ferent form used. If necessary to leave the pessary out for a time and trouble is experienced from the uterus returning to its malposition, packing in the knee-chest posture or in the Sims posture may be employed during 382 GTXECOLOGIC TREATMENT this interval. In many eases, however, a resort to the knee-chest posture night and morning is all that is necessary. Douches. The patient wearing a pessary should take a vaginal douche every day or every few days. If the discharge is very free it may be advis- able to take two or three douches daily. If there is practically no discharge two douches weekly may be sufficient. Ordinarily the patient is directed to take a douche once daily or every other day. The kind of douche to be taken varies with the conditions present — a large hot douche or an astringent douche when the indications previously given for them are present. AYhen there are no special indications, prescribe the bichloride douche or the alumi- num acetate douche. Knee-chest Posture. The knee-chest posture (Fig. 445) taken by the patient night and morning, is very useful in those cases in which the uterus tends to return to its old position or in which the patient complains of down- ward pressure in the pelvis. It causes the patient some inconvenience and is not necessary when the pessary holds the uterus well up and entirely relieves the symptoms. But in many cases of damaged pelvic floor, its use along with the pessary is very advantageous. The activity of the patient need not be curtailed on account of the pes- sary. The pessary is meant to hold the uterus in proper position and restore the patient to comparative health, so that she can pursue her usual activities without disturbance. If the patient can not pursue her usual activities, after the pessary has been worn a month or two, the pessary has failed of its pur- pose, and some more effective method of treatment is indicated. As to coitus, the fact that a pessary is being worn is no bar to sexual inter- course. With the Thomas pessary and the Smith pessary, the anterior end lies so high in that it interferes but little, if at all. Even with the Hodge pessary, coitus may, in some cases, be accomplished with but little inconveni- ence. Coitus, however, causes marked pelvic congestion and this increases the liability of discomfort resulting from the pressure of the pessary. Conse- quently for the first few weeks, while the pessary is on trial so to speak, coitus had best be discontinued. Later, after the uterus has been sometime in its proper position and the pelvic structures are adjusted to the pessary, no re- striction in this direction is necessary ordinarily. In some cases, the replacement of the uterus and wearing of the pessary is carried out principally to increase the chance of pregnancy, and in such cases coitus is permissible from the first. It is well to mention this fact to the patient or her husband, as otherwise it may be thought that coitus is not pos- sible while the pessary is in place. If pregnancy should develop, the pessary should be worn just the same until the uterus has become large enough to prevent its sinking back into the pelvis. The douche should then be taken only warm — not hot, for a hot douche mav excite uterine contractions and lead to miscarriage. Usually along in the USE OF PESSARIES 383 third or fourth month the pessary is taken out, as it is of no further use and if left in longer it might cause irritation and disturbance. Occasionally a pessary excites pain shortly after pregnancy takes place. If so, it should be removed, the patient being directed to take the knee-chest posture two or three times daily, to keep the fundus uteri forward. Tampons or tamponade of the vagina to keep the uterus forward is not advisable in these cases, as it might lead to miscarriage. When to Discard the Pessary The time at which the pessary may be discarded varies much in differ- ent cases, and in each case is more or less a matter of trial. A very good rule is to leave out the pessary after the uterus has remained in position continu- ously for three or four months. Direct the patient to return in two or three days. If the uterus has returned to its old backward position, replace it and use the pessary again for several months. If the uterus maintains its forward position Avith the pessary out, direct the patient to return again in two wrecks. If then the uterus is in proper posi- tion and the patient feeling well she may be discharged, being directed to re- turn if symptoms should at any time reappear. In some cases the pessary may be permanently discontinued in three or four months, but in more cases it must be worn for six months or a year, while in certain cases, it must be worn a still longer time or even indefinitely. If after the pessary is removed, the uterus shows a tendency to go back- ward, it is well to have the patient take the knee-chest posture occasionally for some months. The Inflated Ring Pessary The action of the inflated ring pessary (Fig. 436, B) is principally to raise the uterus and adjacent tissues somewhat and to support them. It has no particular action in holding the cervix well back in the pelvis nor in main- taining the uterus in a proper forward position. Consequently the field of usefulness of this particular form of pessary is in those cases in which the uterus can not be got into the forward position or can not be maintained there. The simple supporting of the uterus, thus overcoming the slight prolapse which is present in most cases of retrodisplacement, often gives the patient much relief, though the retrodisplacement has not been corrected. On the other hand, such a pessary is sometimes used by the physician or by the patient on her own responsibility (this form of pessary being frequently advertised to the laity), in cases where complete replacement could be easily accomplished. In such a case, complete replacement with the subsequent use of the Thomas or Hodge pessary would tend to effect a cure, while the effect of the inflated ring pessary is imperfect and only temporary. In the cases in which the inflated ring pessary is useful, some radical 384 GYNECOLOGIC TREATMENT measures are usually preferable and the pessary is simply a temporary expedi- ent to make the patient more comfortable while she is getting ready for opera- tion. Some patients, however, prefer to wear the pessary indefinitely, even though it affords only partial relief, rather than submit to any operative measure. This pessary requires a douche every day and should be removed and cleansed at least every Aveek. It requires more care to prevent incrustation and irritation. The patient can usually remove and reintroduce the pessary satisfactorily herself after a little practice. Just before introducing it, the patient should take the knee-chest posture for a few minutes. Then lying on her back or side she introduces the pessary, which has been previously cleansed and lubricated. When coitus is desired, the pessary may be taken out in the evening and left out until morning. If desired a loop of strong string may be attached to the pessary to facilitate its removal. If the pessary becomes deflated, it may be reinflated with a hypodermic syringe, the needle being introduced through the thick spot designed for that purpose. A B c Fig. 436. A. Flexible Ring Pessary. B. Inflated Ring Pessary. C. Hard Rubber Disk Pessary. A pessary of about this form is made of hard rubber (Fig. 436, C) and is used in the same way. It does not become deflated and is less likely to ac- cumulate incrustation and irritate the vaginal wall. It is unyielding, however, and for that reason is more likely to produce painful pressure at some point. Also a smaller size must be used, for this pessary can not be compressed, as the inflated rubber pessary can, to pass the vaginal oriflce. 5. Flexible Ring Pessary. The flexible-rubber ring (Fig. 436, A) is some- times preferable to the inflated ring, particularly in cases where there is very free discharge. The opening being larger, the free discharge escapes easier and consequently there is less retention and irritation. Pessaries for Prolapse of Uterus The treatment for prolapse is to raise the uterus and maintain the fundus in a forward position. The pessary that accomplishes this in a case of retro- displacement is likewise beneficial in a case in which the prolapse is the prin- cipal feature. Consequently, in the milder grades of prolapse, a Thomas or USE OF PESSARIES 385 Smith or Hodge pessary may be all that is necessary to maintain the uterus in its proper position. In many cases of prolapse, however, more so than in retroclisplacement, the pelvic floor has been torn so much that this form of pessary will not stay, in satisfactorily. In such a case, a large inflated rubber ring pessary may be introduced and then turned so it will not slip out. This does not hold the cervix back in the pelvis and the fundus forward, but it does plug the vaginal Fig. 437. The Menge Pessary. A. The i.