The Project Gutenberg EBook of A Text-book of Diseases of Women, by Charles Bingham Penrose This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you'll have to check the laws of the country where you are located before using this ebook. Title: A Text-book of Diseases of Women Author: Charles Bingham Penrose Release Date: June 26, 2017 [EBook #54982] Language: English Character set encoding: UTF-8 *** START OF THIS PROJECT GUTENBERG EBOOK A TEXT-BOOK OF DISEASES OF WOMEN *** Produced by deaurider, Wayne Hammond and the Online Distributed Proofreading Team at http://www.pgdp.net (This file was produced from images generously made available by The Internet Archive) Cover was created by the transcriber and was placed in the public domain. 123 A TEXT-BOOK OF DISEASES OF WOMEN BY CHARLES B. PENROSE, M.D., Ph.D. Formerly Professor of Gynecology in the University of Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia With 225 Illustrations SIXTH EDITION, REVISED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1908 Set up, electrotyped, printed, and copyrighted July, 1897. Revised, reprinted, and recopyrighted May, 1898. Reprinted December, 1899. Revised, reprinted, and recopyrighted December, 1900. Revised, reprinted, and recopyrighted July, 1901. Reprinted January, 1902. Revised, reprinted, and recopyrighted, June, 1904. Reprinted August, 1905. Revised, reprinted, and recopyrighted March, 1908. Copyright, 1908, by W. B. Saunders Company. PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA 4 5 PREFACE TO THE SIXTH EDITION. I have carefully revised this book for the sixth edition, and have made those changes and additions that have been rendered necessary by the increase of our knowledge of gynecology. CHARLES B. PENROSE. 1720 Spruce Street, Philadelphia. March, 1908. 67 PREFACE. I have written this book for the medical student. I have attempted to present the best teaching of modern gynecology, untrammelled by antiquated theories or methods of treatment. I have, in most instances, recommended but one plan of treatment for each disease, hoping in this way to avoid confusing the student or the physician who consults the book for practical guidance. I have, as a rule, omitted all facts of anatomy, physiology, and pathology which may be found in the general text-books upon these subjects. Such facts have been mentioned in detail only when it seemed important for the elucidation of the subject, or when there were certain points in the pathology that were peculiar to the diseases under consideration. I am indebted to Dr. H. D. Beyea for several pathological drawings, and to Dr. Wm. R. Nicholson for the preparation of the Index. CHAS. B. PENROSE. 89 CONTENTS. CHAPTER I. PAGE The General Causes of Diseases of Women 15 CHAPTER II. Methods of Examination 19 Examination of the Abdomen, 19.—Examination of the External Genitals and Pelvic Structures, 22. —Vaginal and Bimanual Examination, 23.—Examination of the Rectum, 33.—Examination of the Bladder, 34.—Antisepsis, 35. CHAPTER III. Diseases of the External Genitals 36 Vulvitis, 36.—Inflammation of the Vulvo-vaginal Glands, 38.—Suppuration of the Vulvo-vaginal Gland, 39.—Cysts of the Vulvo-vaginal Glands, 40.—Pruritus Vulvæ, 42.—Kraurosis Vulvæ, 44.—Varicose Tumors of the Vulva, 46.—Hematoma of the Vulva, 46.—Papilloma, 46.—Elephantiasis, 47. —Adhesions of the Clitoris, 48. CHAPTER IV. Diseases of the Vagina 49 Inflammation of the Vagina, 49.—Tumors of the Vagina, 51.—Atresia of the Vagina, 52.—Vaginismus, 53.—Coccygodynia, 54. CHAPTER V. Anatomy and Mechanism of the Perineum 56 CHAPTER V1. Injuries to the Perineum 62 Slight Median Laceration of the Perineum, 67.—Median Tear involving the Sphincter Ani, 68. —Laceration through the Sphincter Ani, involving the Recto-vaginal Septum, 73.—Laceration in One or Both Vaginal Sulci, 75.—Subcutaneous Laceration of the Muscles and Fascia, 85. CHAPTER VII. Results of Laceration of the Perineum 87 Rectocele, 87.—Cystocele, 88.—Enterocele, 91.—Subinvolution of the Vagina, 92. CHAPTER VIII. The Position of the Uterus and the Mechanism of its Support 94 CHAPTER IX. Prolapse of the Uterus 101 CHAPTER X. Anteflexion of the Uterus 119 CHAPTER XI. Retroflexion and Retroversion of the Uterus 127 CHAPTER XII. Laceration of the Cervix Uteri 148 CHAPTER XIII. Inflammation of the Cervical Mucous Membrane (Cervical Catarrh) 166 CHAPTER XIV. Congenital Erosion and Split of the Cervix 174 CHAPTER XV. Cervical Polypi; Hypertrophic Elongation of the Cervix; Chancre of the Cervix; Tuberculosis of the Cervix 178 Cervical Polypi, 178.—Hypertrophic Elongation of the Vaginal Cervix, 178.—Chancre of the Cervix, 180.—Tuberculosis of the Cervix, 180. CHAPTER XVI. Cancer of the Cervix Uteri 181 10 CHAPTER XVII. Diseases of the Body of the Uterus 199 Acute Corporeal Endometritis, 199.—Chronic Corporeal Endometritis, 201.—Exfoliative Endometritis, or Membranous Dysmenorrhea, 212.—Senile Endometritis, 213. CHAPTER XVIII. Subinvolution of the Uterus; Superinvolution of the Uterus 215 CHAPTER XIX. Cancer and Sarcoma of the Uterus 218 Cancer of the Body of the Uterus, 218.—Malignant Adenoma, 221.—Sarcoma of the Uterus, 225. —Diffuse Sarcoma of the Mucous Membrane, 225.—Sarcoma of the Uterine Parenchyma, 227. —Chorio-epithelioma or Syncytioma Malignum, 228. CHAPTER XX. Fibroid Tumors of the Uterus 230 Adenomyoma of Uterus, 257. CHAPTER XXI. Hematometra; Hydrometra; Pyometra 259 CHAPTER XXII. Tuberculosis of the Uterus 261 CHAPTER XXIII. Inversion of the Uterus 264 CHAPTER XXIV. Diseases of the Fallopian Tubes 272 Inflammation of the Fallopian Tubes, or Salpingitis, 276.—Acute Salpingitis, 277.—Chronic Salpingitis, 279.—Suppuration of the Pelvic Cellular Tissue, 303. CHAPTER XXV. Diseases of the Fallopian Tubes (Continued) 306 Tuberculosis, 306.—Adenoma, Myoma, Cancer, Sarcoma, Actinomycosis, and Syphilitic Gummata of the Fallopian Tubes, 313. CHAPTER XXVI. Tubal Pregnancy 314 Ovarian Pregnancy, 329. CHAPTER XXVII. Diseases of the Ovaries 330 CHAPTER XXVIII. Diseases of the Ovaries (Continued) 334 Hernia of the Ovary, 334.—Prolapse of the Ovary, 335.—Inflammation of the Ovary, Oöphoritis, or Ovaritis, 339.—Acute Oöphoritis, 339.—Chronic Oöphoritis, 341.—Apoplexy of the Ovary, 346. —Ovarian Hydrocele, 346. CHAPTER XXIX. Cystic Tumors of the Ovary 349 Oöphoritic Cysts, 350.—Follicular Cysts, 350.—Glandular Cysts, 354.—Dermoid Cysts, 359. —Teratoma, 361.—Paroöphoritic Cysts, or Papillomatous Ovarian Cysts, 362. CHAPTER XXX. Cysts of the Parovarium 368 Comparison of Oöphoritic, Paroöphoritic, and Parovarian Cysts, 372.—Glandular Oöphoritic Cyst, 372. —Paroöphoritic Cyst, 373.—Cysts of the Parovarium, 373. CHAPTER XXXI. Natural History and Treatment of Ovarian Cysts 374 11 12 Secondary Changes or Accidents of Ovarian Cysts, 374.—Inflammation and Suppuration, 374. —Torsion of the Pedicle, or Axial Rotation, 375.—Rupture of Ovarian Cysts, 377.—The Clinical History of Ovarian Cysts, 378.—Examination, 383.—Treatment of Ovarian Cysts, 387. CHAPTER XXXII. Solid Tumors of the Ovary 390 Fibromata, 390.—Myomata, 390.—Sarcomata, 391.—Carcinomata, 392.—Ovarian Papillomata, 393. —Tuberculosis of the Ovary, 393.—Tumors of the Ovarian Ligament, 394. CHAPTER XXXIII. Malformations of the Genital Organs 395 Uterus Unicornis, 396.—Uterus Didelphys, 396.—Uterus Bicornis Duplex, 396.—Uterus Bicornis Unicollis, 397.—Uterus Cordiformis, 397.—Uterus Septus, 397.—Malformation of the Vagina, 397. —Hermaphroditism, 399. CHAPTER XXXIV. Disorders of Menstruation 402 Amenorrhea, 405.—Acute Suppression of Menstruation, 407.—Scanty Menstruation, 407.—Vicarious Menstruation, 408. CHAPTER XXXV. The Menopause 409 CHAPTER XXXVI. Genital Fistulæ 412 Vesico-vaginal Fistula, 412.—Urethro-vaginal Fistula, 420.—Vesico-uterine Fistula, 420.—Uretero- vaginal Fistula, 421.—Recto-vaginal Fistula, 421. CHAPTER XXXVII. Diseases of the Urethra and Bladder 423 Diseases of the Urethra, 426.—Urethritis, 427.—Stricture of the Urethra, 430.—Prolapse of the Mucous Membrane of the Urethra, 431.—Vesico-urethral Fissure, 431.—Dilatation of Urethra, 433. —Urethrocele, 434.—Urethral Neoplasms, 434.—Urethral Caruncle, 434.—Urethral Cysts, 435. —Polypus, 435.—Sarcoma and Cancer of the Urethra, 436.—Diseases of the Bladder, 436.—Cystitis, 437.—Vesical Calculus, 447. CHAPTER XXXVIII. Gonorrhea in Women 448 CHAPTER XXXIX. The Technique of Gynecological Operations 457 Operating-room, 461.—Apparatus, 462.—Operator, Assistants, Nurses, 463.—Sterilization of Dressings, Towels, etc., 466.—Sterilization of Instruments, 466.—The Water, 467.—Sponges, 468. —Discipline of the Operating-room, 469.—Anesthesia, 470.—Preparation of the Patient, 471. —Instruments, 475.—The Dressing, 479. CHAPTER XL. The Technique of Gynecological Operations (Continued) 480 Abdominal Drainage, 480.—Gauze-drainage, 482.—Indications for Drainage, 484.—Vaginal Drainage, 487.—The Incision of the Abdominal Wall, 487.—Exploration of the Abdomen, 489.—Protection of the Intestines and Omentum, 489.—Toilet of the Peritoneum, 490.—Closing the Abdominal Incision, 491. CHAPTER XLI. Treatment after Celiotomy 404 CHAPTER XLII. The Special Technique of Operations upon the Uterus and the Uterine Appendages 502 Removal of the Uterine Appendages (Salpingo-oöphorectomy), 504.—Removal of an Ovarian Cyst, 512.—Operation for the Removal of Intra-ligamentous Cysts, 514.—Marsupialization of the Cyst, 516. —Operation for Removal of the Uterus, 517.—Supra-vaginal Amputation of the Uterus, 518. —Preservation of the Ovaries in Hysterectomy, 523.—Complete Abdominal Hysterectomy, 523. —Vaginal Hysterectomy, 527.—Combined Vaginal and Abdominal Hysterectomy, 531.—Abdominal Myomectomy, 533. CHAPTER XLIII. 13 14 The Effect of the Removal of the Uterine Appendages 535 Index 537 15 A TEXT-BOOK OF DISEASES OF WOMEN. CHAPTER I. THE GENERAL CAUSES OF DISEASES OF WOMEN. Gynecology is the study of diseases peculiar to women. As woman possesses organs which man has not, and as the parts—physiological and social—that she plays in life differ from those played by man, we should expect to find her afflicted with a certain number of diseases, peculiar to her, which are dependent upon her anatomy, physiology, and mode of life. Such diseases occur in barbarous as well as in civilized women; and similar diseases, peculiar to the female, occur in the lower animals. Thus, in the cow and the mare we find tumors of the vagina, prolapse of the vagina and uterus, fibroid tumors, sarcoma and cancer of the uterus, and some forms of ovarian cysts. Cysts of the tubes and the ovaries are exceedingly common in old mares; cats and goats are similarly affected. From a pathological point of view, however, the civilized woman unfortunately differs from her barbarous sister, and from the female of the lower animals, in many important particulars. She is more liable to the pathological conditions which, more or less, all females have in common. These conditions appear in a more severe form, and are followed by more disastrous results, in the civilized than in the barbarous state. The female among the lower animals and among savages seems to be about equal in proportionate strength and physical endurance to the male, though in size and in gross muscular strength she may be his inferior. Her subordinate position is often due not so much to any difference in strength as to the fact that the male possesses weapons—as the horns of the deer—with which nature has not endowed the female; and though she is liable to more diseases than the male, yet her relative position does not seem to be materially altered by this fact. The bitch is as enduring as the dog. The female grizzly is as ferocious and as dangerous as the male. The mare is as fast as the horse. The squaw among the American Indians can lift and carry burdens which the lazy buck would not attempt. How different it is with the civilized woman, as we know her in this country! The average healthy woman in this country is very much inferior in physical strength and endurance to the average man, and this inferiority is tremendously increased when she becomes sick from any of the diseases to which her sex is liable. The increased liability of the civilized woman to disease is in a large measure due to her poor physique. But this is not all. The causes of many of the diseases with which the gynecologist has to deal cannot be traced so easily. Fibroid tumors of the uterus, which are so common among the colored women of this country, are said by Tait to be unknown among their African cousins, who are removed by but a few generations. The most common causes of diseases of women are injuries received during parturition; sepsis; venereal diseases; errors of development; improper mode of life and clothing during the period of development; neglect during menstruation; and celibacy. The results of the injuries received during parturition are most numerous. They may appear immediately, a short time after labor, or at some remote period. The disabilities attending laceration through the sphincter ani or a recto-vaginal or vesico-vaginal fistula appear before the mother leaves her bed. The suffering from a laceration of the cervix, a subinvolution of the uterus, or a retrodisplacement may not be felt for some weeks or months after labor; while the still more remote result, the development of cancer, may not appear for many years, though it can be positively traced to the lesion in the cervix as the primary cause. Septic infection of the genital tract kills or makes invalids of many women. The infection occurs at the time of a miscarriage or of a normal labor, or it may be acquired from the dirty instruments or the dirty hands of a physician. It is not a cause of disease among civilized women alone, but occurs among barbarous and semi-barbarous races. Venereal disease, especially gonorrhea, has been said to be the most common cause of disease among women. The disease extends from the external genitals through the uterus and Fallopian tubes, causing sterility, chronic invalidism, and death from peritonitis. Errors of development are frequent causes of disease and suffering among women. Atresia of the vagina or of the cervix uteri, by causing retention of the uterine discharges, produces most serious pathological conditions. Arrested development of the whole or of part of the uterus is a common cause of disease. Improper clothing and an improper mode of life during the period of development are most fertile sources of diseases of women. Clothing which contracts the waist, as well as clothing which, though not unduly tight in the inactive state, yet interferes with abdominal respiration during activity, is most injurious. Such clothing diminishes the capacity of inspiration by restricting abdominal expansion, and thus crowds down the pelvic organs toward the pelvic floor; and the continuous support to the abdominal walls diminishes their natural muscular strength and places the woman in a condition predisposing to the various displacements of the uterus. 16 17 18 An improper mode of life, irregular hours for sleeping and eating, insufficient exercise, and lack of fresh air and sun, resulting in poor muscular development, seem to predispose the woman, as the man, to a variety of pathological conditions; but as the reproductive apparatus in woman is more delicately organized, and as, during the period of active life, this is really her chief part, it more especially suffers as a result of any general systemic derangement. Neglect during menstruation, especially in the young girl, is a frequent cause of subsequent suffering. The effect of menstruation upon the whole system is remarkable. The nervous, vascular, and digestive systems all share in the menstrual function. The usual work of the girl at school or other employment should be altered to suit the altered conditions of her body at the menstrual period. Long school hours and close mental application or active exercise are too often continued at this time. Celibacy is an unnatural state and a common cause of disease. Certain forms of fibroid tumors of the uterus are more common in single than in married women, and more common in sterile than in childbearing women. And the painful cirrhotic ovaries of the old maid are the result of the unceasing menstrual congestions never relieved by pregnancy and lactation. 19 CHAPTER II. METHODS OF EXAMINATION. In order to make a complete gynecological examination, we must examine the abdomen, the external organs of generation, and the pelvic structures. Examination of the Abdomen.—In order to make a perfectly satisfactory examination of the abdomen, the woman should be in bed, with all clothing removed except the undershirt and the night-dress, which should be drawn well up above the costal margin. Examination made with any constricting clothing about the waist or about the lower thorax is most unsatisfactory. The abdomen is examined by inspection, palpation, percussion, and auscultation. The woman should lie flat upon her back, and the abdomen should be thoroughly exposed. We can then determine by inspection the presence of dilated veins or of lineæ albicantes, the general size and form of the abdomen, the occurrence of any abdominal movement, and the presence of any asymmetry in the abdominal contour, such as would be made by the bulge of a tumor or the displacement of an abdominal organ. The shape of the abdomen, even though symmetrical, is often diagnostic of certain intra-abdominal conditions. Thus, an abdominal enlargement that is due merely to fat presents a different contour from the enlargement caused by tympanitic distention of the intestine. The enlargement due to ascites, or free fluid in the peritoneum, differs in contour from that caused by an encysted collection of fluid. It should be remembered that lineæ albicantes are not always the result of pregnancy, but that they may have been caused by distention of the abdomen from some other cause. Palpation.—We can determine most by palpation of the abdomen. The examiner should always remember that it is most important to secure the patient’s confidence, and to proceed so gently, slowly, and gradually in performing palpation that no voluntary or reflex contraction of the abdominal muscles may impede his manipulations. In cases in which there is a sore or tender spot within the abdomen the contraction of the recti muscles may be altogether involuntary, persisting even when the patient is anesthetized. We see this in the rigid right rectus muscle of appendicitis. The hands should be warmed, and palpation should be performed with both hands. A certain amount of gentle stroking or massage of the abdomen will secure the patient’s confidence by making her feel that she will not be hurt by any sudden violent pressure, and will also prevent reflex contraction of the muscles. By proceeding in this way, slowly, the examiner can palpate the whole of the abdominal surface, exploring first the structures lying most anterior, and then, pressing the fingers more deeply, he can examine the more posterior structures. Fluctuation in an encysted fluid accumulation is generally readily determined. While one hand is placed against one side of the fluid mass and the opposite side is percussed by the fingers of the other hand, the wave of fluctuation is easily felt. Sometimes a thrill or a false wave of fluctuation is observed in the subcutaneous fat of obese women. This disturbing element may, however, be eliminated by an assistant pressing the ulnar edge of his hand in the median line upon the abdominal surface, thus stopping the fat wave of fluctuation. Special organs in the abdomen sometimes require special methods of examination. It is very often necessary for the gynecologist to examine the kidneys, because many women have movable or floating kidneys, and the nervous, gastric, and abdominal symptoms may be due to this condition. The presence of a floating kidney may often be determined by inspection; the presence of a movable kidney, however, must be determined by palpation. This should be performed with the woman in the sitting, or standing, erect posture; or sitting upon the edge of a chair, with the body inclined somewhat forward and the hands upon the knees; or lying upon a bed, on the side opposite the kidney that is being examined. One hand should be placed over the lumbar muscles; the other hand should be placed upon the anterior abdominal wall immediately below the costal margin, and should be pressed backward. If the kidney lies below its normal position, it may in this way be brought between the two hands, and can be felt to glide upward as the hands are pressed together. In case a movable kidney cannot readily be found, because it may have returned to its normal position, it may often be brought down again if the woman is made to cough. In a thin woman the vermiform appendix may sometimes be felt through the abdominal wall; and in cases of pain and inflammation in the right iliac region it is sometimes important to determine whether or not the trouble has started in the vermiform appendix or in the Fallopian tube. In order to palpate the vermiform appendix the examiner should stand upon the right side of the woman, who is lying upon her back, and should place the tips of the fingers of the right hand at about the junction of the upper and middle thirds of a line drawn from the middle of Poupart’s ligament to the umbilicus. By pressing backward firmly and gently, pulsations of the right common iliac artery may be felt; and then by drawing the hand directly outward it will pass over the different structures in this region lying between the palpating hand and the posterior abdominal wall. The appendix may often be felt, especially if it is indurated by inflammation. Percussion of the abdomen should be performed with the woman in the dorsal position; though, if the examiner 20 21 22 suspects the presence of free fluid in the peritoneum, or ascites, much may be learned by percussing in different positions and noting the accompanying changes in the percussion-note. Percussion should then be performed with the woman upon her back, upon the right side, upon the left side, sitting up, and upon the hands and knees. An encysted fluid accumulation will give practically the same result in percussion in all positions, while free fluid will gravitate to the most dependent portion. Auscultation of the abdomen is best performed with the stethoscope. By it we may hear fetal heart-sounds, uterine souffle, placental bruit, peritoneal friction sounds, and the peristaltic sounds of the intestinal tract. All of these sounds are of importance, and the presence or absence of any of them may have an important bearing upon the diagnosis of the case. Examination of External Genitals and Pelvic Structures.—To examine the external organs of generation and the pelvic viscera the woman should be placed upon a table. In some cases the physician may be obliged, for want of proper facilities or on account of the physical condition of the patient, to make his examination upon a bed. Such an examination, however, is never so satisfactory or so thorough as the examination made with the woman upon the examining-table. A great number of gynecological tables have been introduced. The one which seems to the writer the best, on account of its simplicity and the perfect relaxation of the abdominal muscles furnished by it, is shown in the accompanying illustration (Fig. 1). It is a plain wooden table, at the foot of which are attached the upright supports for holding the stirrups for the feet, such as have been devised by Dr. Edebohls. By this arrangement the feet and legs are supported without any effort on the part of the woman; when the buttocks are drawn well down to the foot of the table there is a certain amount of flexion of the pelvis upon the trunk, and the most complete attainable relaxation of the abdominal muscles is secured. When the woman has been placed in this position the examiner should investigate thoroughly, and in order, the following structures: The anus, the perineum, the labia majora, the nymphæ, the fourchette, the orifices of the ducts of the vulvo-vaginal glands, the hymen or its remains, the vestibule and the small glands of the vestibule, the external urinary meatus, and the clitoris. To determine any pathological condition of these structures it is necessary that the physician should be familiar with the appearance in the normal woman, and to gain such essential knowledge we should avail ourselves of every opportunity offered to make a critical examination of the external genitals of women, going over all the different structures in order. Fig. 1.—Woman in the dorsal position with feet supported in Edebohls’ stirrups. Vaginal and Bimanual Examination.—Having examined and noted the condition of the external genitals, the physician should next proceed to examine the vagina. The index finger of the right or the left hand should be gently introduced into the vagina. The condition of the vaginal walls, and the direction, consistency, form, etc. of the vaginal cervix, may be determined. The shape and size of the os uteri should be noted. The ulnar edge and the tips of the fingers of the other hand should then be placed upon the abdomen, immediately above the symphysis pubis, and gently pressed backward and downward toward the vaginal finger (Fig. 2). In this way the various pelvic organs, the uterus, Fallopian tubes, ovaries, and ureters, may be palpated between the two hands, and their position, size, shape, and consistency may be determined. Such an examination is, of course, made much more easily in a thin woman than in a fat one. A thin woman a few weeks after labor may be examined most easily, on account of the relaxation of the abdominal and vaginal walls. Fig. 2.—Bimanual examination. This is called the bimanual method of examination, and the student will find that as he acquires practice in this method he will gradually depend less upon examination by the uterine sound and the speculum, and will rely altogether upon his sense of touch, his ability to palpate. It matters not which hand be used in making the vaginal examination. It will, however, be found that the hand that is used the more frequently will become the more proficient. In making the bimanual examination the structures should be palpated methodically in order. The vaginal finger notes the condition of the cervix uteri. If the fundus be in the normal position, the uterus can then be taken between the abdominal hand (upon the fundus) and the vaginal finger (upon the cervix) (Fig. 3). The shape, size, mobility, and consistency are noted. The vaginal finger is then passed anteriorly and laterally toward either uterine cornu, while the abdominal fingers pass over to the posterior aspect of the same cornu. The ovarian ligament and the proximal end of the Fallopian tube may thus be felt. Passing farther outward, the whole of the tube and the ovary may be examined. The same procedure is then applied to the opposite side. 23 24 25 Fig. 3.—Bimanual examination; median sagittal section of the pelvis. The condition of the ureters may be determined by placing the vaginal finger in either lateral vaginal fornix and drawing it outward and forward, when these structures will pass over the end of the finger. When the ureters are indurated by inflammation they can be plainly felt. By the method of examination here advised the physician will always make a visual examination before making a digital one. There are several advantages derived from this procedure. In the first place, no examination of a woman is thorough unless a careful visual examination of the external genitals has been made. The discovery of discharges and of lesions of the external genitals may throw much light upon the condition found higher up in the pelvis. Again, the examiner protects himself. A great many unfortunate cases of syphilis have been acquired by physicians from a primary sore upon the examining finger. A preliminary visual examination enables one to guard against this danger. The primary sore occurs upon the end of the examining finger or upon the web between the index and middle fingers—the part of the hand that is pressed against the fourchette. The hands of the physician should, of course, be surgically clean before making an examination, and the grease or oil which is used as a lubricant should be clean. The hands should always be washed, after separating the parts to make the visual examination, before the finger is thrust into the vessel containing the lubricant. It is best to place a small portion of the lubricant on a plate or a saucer for each individual patient, and thus avoid the danger of contaminating the rest. Carbolized oil, borated vaseline or cosmoline, and a thick sterile solution of soap are good lubricants. Neutral green soap diluted with boiled water to the consistency of thin jelly is a very agreeable lubricant which may easily be washed from the hands and the vagina. If practicable, the woman should receive a vaginal douche of bichloride-of-mercury solution, 1:4000, and the vulva should be washed, before making a bimanual examination. The examiner should always clean the external genitals of all discharges before introducing the vaginal finger. In this way we avoid the danger of carrying septic material from the external genitals to the upper portion of the genital tract. This preliminary cleansing is not desirable before the external genitals have been examined; for much may be learned from observation of the discharges which bathe or escape from the various structures. If practicable, a cleansing vaginal douche of bichloride-of-mercury solution should be administered after the bimanual examination. Fig. 4.—Double tenaculum. The examination of the uterus and other pelvic structures is often facilitated by dragging the uterus downward with a tenaculum while the vaginal or the bimanual examination is being made. Sensation in the cervix is so slight that little or no pain is experienced in this procedure. The anterior or posterior lip of the cervix is caught with the single or the double tenaculum (Fig. 4), guided along the vaginal finger or introduced through the speculum, and the uterus is drawn down by an assistant in case the bimanual examination is being made, or by the external hand of the examiner in case a simple vaginal examination is made. When this is done the utero-sacral ligaments are made tense, and can be felt like two cords extending from the sides of the cervix outward and backward to the pelvic wall. The posterior surface of the uterus can be palpated often as high up as the fundus. The method is especially useful when the examination is made by the rectum, and in this way the whole posterior surface and the fundus of the uterus may be palpated (Fig. 5). The contraindications to a vaginal examination are virginity, the presence of a hymen, and any acute inflammatory or painful condition of the vulva or vagina. None of these conditions, however, forbid an examination if an exact diagnosis is essential to the proper treatment of the case, and can be made only in this way. It may be that in these cases a rectal examination will be sufficient for diagnosis. Fig. 5.—Bimanual examination with one finger in the rectum. The uterus is drawn down with the double tenaculum. Rectal examination of the pelvic structures is made in a way similar to that already described for the vaginal examination. Bimanual examination may be made by palpating the various organs between the rectal finger and the abdominal hand. The Vaginal Speculum.—The speculum is an instrument through which a visual examination is made of the vagina, the external os uteri, and the vaginal cervix. A great number of specula have been invented. At the present day the best two instruments of this class are the bivalve speculum, such as Goodell’s (Fig. 6), and the duck-bill speculum (Fig. 7), or perineal retractor, invented by Sims. 26 27 28 29 Fig. 6.—Goodell’s speculum. Fig. 7.—Sims’ speculum. Fig. 8.—Sims’ depressor for the anterior vaginal wall. The bivalve speculum is introduced with the woman upon her back, in the dorso-sacral position already described. The vulva and the vagina should be cleaned. The speculum should be warmed by placing it in hot water, and should then be lubricated with the soap solution or with vaseline. It should be introduced with the blades closed and the plane of the blades lying not exactly in the median sagittal plane of the body, but inclined at a small acute angle to this plane, one edge of the speculum being directed toward either vaginal sulcus. The instrument is passed into the vagina toward the position in which, by a previous digital examination, the vaginal cervix had been found to lie. The instrument is then turned with the handles toward either thigh, so that the blades become parallel to the anterior and posterior vaginal walls, in order that, when separated, they will open the vaginal slit. The handles are brought together and the blades opened. When the vaginal cervix comes well into view the blades are fixed in place by the screws (Fig. 9). Fig. 9.—Goodell’s speculum in position. In some cases, where the cervix points well forward or well backward, it may be readily brought into view through the speculum by catching it with a tenaculum. By means of the bivalve speculum we are able to make a partial inspection of the vaginal walls, an imperfect inspection of the vaginal vault, and a good inspection of the vaginal cervix and the external os. Applications can be made to the cervix, but none of the minor operations of gynecology can be performed through this speculum. The Sims speculum enables us to make the most thorough inspection of the vagina, the vaginal vault, and the vaginal cervix. The Sims speculum is merely a hook or retractor for the perineum, and may be introduced with the woman in the dorsal position, the Sims position, or the genu-pectoral position. If the Sims speculum is introduced in the dorso- sacral position, it is necessary to hold forward the anterior vaginal wall in order to obtain a view of the cervix. Fig. 10.—The Sims position. The Sims position, which is also called the latero-abdominal position, is shown in Fig. 10. The woman is placed on the bed or table upon her left side. The side of the face is upon the pillow; the left arm is behind the back, so that the left breast rests upon the table. The thighs are flexed upon the abdomen at an angle of about 90° to the trunk. The right thigh is more flexed than the left, so that the right knee may touch the table above the left knee. The legs are flexed on the thighs. In this position there is a tendency for the intestines, following the force of gravity, to fall from the pelvis, and for the uterus and other pelvic viscera to be drawn up. When the perineum is retracted with the blade of the Sims speculum, air will enter the vagina and the vaginal slit will become distended (Fig. 11). To facilitate inspection of the cervix it is usually necessary also to push forward the anterior abdominal wall by some kind of depressor, such as the one shown in Fig. 8. Fig. 11.—The cervix uteri exposed with the Sims speculum. Fig. 12.—The knee-chest position. The genu-pectoral position or the knee-chest position is shown in Fig. 12. The side of the face is upon the pillow; the breast is upon the table; the thighs are vertical. In this position the intestines fall from the pelvis, and the other pelvic viscera are drawn upward by the force of gravity. If the anus is opened, air rushes in and distends the rectum. If the perineum is retracted, air enters and distends the vagina. If the urethra is opened, the bladder is likewise distended. The position is the most useful one for inspection of the rectum, vagina and vaginal cervix, and the bladder. The Sims speculum, with the woman in the dorsal, the Sims, or the knee-chest position, is the most useful instrument 30 31 32 33