A text-book of diseases of women

Preface

This book on the diseases of women has been prepared as a companion volume to the author's "Text-book of Obstetrics," the two volumes covering the whole subject of gynecology. It is based on an experience of twenty years.

The illustrations are mainly original, for the most part from the author's service in the Howard Hospital, of Philadelphia. The others are properly credited. The micro-photographs were prepared by Drs. J. C. Hirst and McConnell. The section on anesthetics is written by Dr. B. F. Roller, the author's anesthetizer.

A special effort has been made to describe the palliative treatment of diseases of women and such curative treatment as can be carried out by the general physician. A separate section has been devoted to the detailed description of modern operative technic.

The anatomical, rather than the pathological, classification of diseases of women has been adopted, as in the author's judgment the most logical and convenient.

The aim of the work is to present a concise description of all the diseases peculiar to women, with especial attention to diagnosis and treatment, adapted to the needs of the medical student, the general physician, and the specialist.

1S21 Spruce Street, L^ September i , igo^.

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Part Ii.— Anomalies Of Development In The Gen- Ital Tract Page 17

Ovaries, 54 — Fallopian Tubes, 54 — Uterus, 55 — Absence or Rudimentary Development of Uterus, 56 — Uterus Unicornis, 57 — Uterus Didelphys, 59 — Uterus Bicornis Duplex, 61 — Uterus Bicornis Unicollis, 61 — Uterus Cordiformis, 61 — Uterus Incudiformis, 62 — Uterus Septus, Subseptus, Partitus, Semi-part-tus, 62 — Anomalies of Development in Cervix, 63 — Atresia of Cervix, 63 — Arrested Development of the Cervix, 64 — Hypertrophy of the Cervix, 64 — Absence of Vagina, 65 — Stenosis of the Vagina, 70 — Vulva, 71 — Atresia of Vulva, 71 — Arrested Development of Urogenital Sinus, 71 — Hyperplasia and Hypertrophy of Vulvi, 72 — 111 Development of Vulva, 72 — Hypertrophy of Chtoris, 72 — Anomalies of Hymen, 73 — Retention of Mucus and Blood within the Genital Tract, 74 — The Treatment of Retention within the Genital Canal of Menstrual Blood and Mucous Discharge, 78 — Hermaphroditism, 79 — Pseudohermaphroditism, 81.

Part Iii.— Diseases And Injuries Of The Vulva

\^ulvitis, 92 — Gangrene, 99 — Pruritus Vulvae, 100 — Kraurosis Vulvae, 103 — Cysts and Benign Tumors of the Labia, Vestibule, and Groins, 105 — Elephantiasis, no — Varicocele, no — Urethral Caruncle, III — Hydrocele of Round Ligament, 114 — Rodent Ulcer, 114 — Tuberculosis, 115 — Carcinoma, 116 — Sarcoma, 119 — Syphilis, 121 — Pudendal Hernia, 122 — Diseases of the Clitoris, 122 — Injuries of the Vulva, 123 — Coccygodynia, 125.

Part Iv.— Diseases And Injuries Of The Vagina . . 131

Vaginitis, 137 — Tuberculosis, 141 — Acquired Stenosis and Atresia, 141 — Injuries of the Vagina and Pelvic Floor, 145 — Treatment of a Cystocele, 163 — Treatment of Lacerations of Perineum and Pelvic Floor, 169 — Secondary Perineorrhaphy, 169 — Secondary Operation for a Median Perineal Tear, 170 — Secondary Perineorrhaphy for Complete Tear of Perineum, 170 — Secondary Perineorrhaphy for Injury to the Levator Ani Muscle, Rectocele, Overstretching and

II 12 Contt^nts

PAGE

Subinvolution of \'agina, 176 — New-growths of \'agina, 185 — Cysts. 1S5 — Fibromata, 1S7— Sarcoma, 188 — Carcinoma, 189 — Pointed Condylomata, 190 — Foreign Bodies in \'agina, u)2 — Fecal Fistula in \'agina, 192 — \'aginismus, 194.

PART v.— INJURIES AND DISEASES OF THE CERVIX . 198 The Treatment of a Lacerated Cervix, 206 — Cervicitis, 214 — Erosion, 214 — Endocervicitis, 216 — Ulceration, 218 — Tuberculosis, 218 — Acquired Atresia, 220 — New-growths, 221 — Myomata, 221 — Carcinoma, 225 — The Roentgen and Finsen Rays for Inoperable and Recurrent Cancers of Cervix, 261 — Hydatidiform Sarcoma of Cervical Endometrium, 261.

Part Vi.— Displacements And, Diseases Of The Uterus 264

Mobility and Position of the Uterus, 269 — Displacements, 270 — Retroflexion and Retroversion, 270 — .\nteposition, Anteversion, and .Anteflexion, 291 — Prolapse, 294 — Inversion, 306 — Metritis, 310 — Acute Metritis, 310 — Chronic Metritis, 311 — Subinvolution, 312 — Superinvolution and .\trophy, 313 — Injuries of the Uterus, 314 — Foreign Bodies, 315 — Hysteralgia, 315 — Neoplasms of Uterus, 316 — Fibromyoma, 316 — Treatment of Fibromyomata, 338 — Radical Treatment of Fibromyomata, 342 — Sarcoma, 353.

PART VIL— DISEASES OF THE ENDOMETRIUM; DISOR- DERS OF MENSTRUATION; STERILITY .... 355 Endometritis, 355 — Neoplasms, 364 — Adenocarcinoma, 364 — Sarcoma, 370 — Endothelioma, 372 — My.xomatous Polyps, 373 — Menstruation, 373 — Menstrual Molimina, 376 — Connection between Ovulation and Menstruation, 379 — Amenorrhea, 381 — Vicarious Menstruation, 384 — Menorrhagia, 384 — Dysmenorrhea, 385 — Membranous Dysmenorrhea, 388 — Sterility, 389.

Part Viii.— The Fallopian Tubes; Extra-uterine Pregnancy 392

The Fallopian Tubes, 392— Diseases of the Tubes, 394— Congestion, 394 — Displacements, 395— Inflammations, 395— Hydrosalpin.x, 406 — Hematosalpinx, 409 — Tuberculosis, 409— Neoplasms, 412 — Symptoms of Tubal Disease, 413— Treatment of Tubal Inflammation, 415— Extra-uterine Pregnancy, 426— Clinical History, 427— Changes in Uterus and Vagina, 427— Clinical History and Pathology of Tuljal Pregnancy, 429— Clinical History of Interstitial Pregnancy, 432— Clinical History of Tubo-ovarian Pregnancy, 432— Clinical History of Ovarian Pregnancy, 432 — Clinical History of .\lxlominal Pregnancy, 433 — Clinical History and Pathology of Utero-abdominal Pregnancy, 433 — Terminations of Extra-uterine Pregnancy, 433 — Symptoms of Extra-uterine Pregnancy, 437— Symptoms of Interstitial Pregnancy, 439 — Symptoms of Abdominal Pregnancy, 439— Diagnosis

Contents 13

PAGE of Extra-Uterine Pregnancy, 439 — Prognosis of Extra -uterine Pregnanc)', 440 — Treatment of Extra-uterine Pregnancy, 440 — Pregnancy in One Horn of a Uterus Bicornis or Unicornis, 444.

Part Ix.— Diseases Of The Ovaries 445

• Displacements, 448 — Prolapse, 449 — Ovarian Hernia or Ovariocele, 451 — Ovarian Congestion, 453 — Ovarian Hemorrhage, 456 — Atrophy, 458 — Inflammations, 459 — Tuberculosis, 460 — Actinomycosis, 461 — Chronic Oophoritis, 461 — Neoplasms, 463 — Simple Serous Cysts, 464 — Pseudomucin Cystadenomata, 465 — Serous Cystadenomata, 471 — ■ Papillomatous Growths in Ovarian Cysts, 472 — Ovulogenous Ovarian Tumors, Dermoids and Teratomata, 474 — Teratoma, 479 — Carcinoma, 479 — Stromatogenous Neoplasms, 481 — Fibromata, 481 — Sarcomata and Endotheliomata, 482 — Parovarian Cysts, 484 — Clinical History of Ovarian Tumors, 486 — Twisted Pedicle, 487 — Rupture, 488 — Inflammation and Suppuration, 489 — Symptoms and Diagnosis of Ovarian Tumors, 490 — Treatment of Ovarian Tumors, 495 — Foreign Bodies, 504 — Echinococcus Cysts, 504 — Implantation and Transplantation, 504.

Part X.— Diseases Of The Pelvic Connective Tis- Sue And Of The Peritoneum 506

Inflammation, 508 — Injuries, 511 — Neoplasms, 514 — Fibromyomata, 514 — Echinococcus Cysts, 516 — Actinomycosis, 517 — Varices or Varicocele of Broad Ligament, 517 — Phleboliths, 518 — Pelvic Peritonitis, 519 — Pelvic Hematocele, 520.

PART XL— DISEASES OF THE URINARY TRACT 522

Examination of the Female Urinary Tract, 527 — Cystoscopy, 527 — Congenital Malformations of the Bladder, 535 — Displacements of the Bladder, 535 — Diseases of the Bladder, 535 — Cystitis, 535 — Contraction of the Bladder, 539 — Neoplasms of the Bladder, 540 — Vesical Calculus, 541 — Urinary Fistula, 541 — The Treatment of Ureteral Fistula and of Surgical Injuries of the Ureters, 551 — Malformations and Diseases of the Urethra, 556 — Total Defect of the Urethra, 556 — Partial Defect of the Urethra, 556 — Atresia Urethrae, 5.56 — Urethralgia, 557 — Urethritis, 557 — Granular Erosion of Urethra, 558 — Stricture, 558 — Vesico-urethral Fissure, 559 — Neoplasms of Urethra, 559 — Dilatation or Dilatability of the Urethra, 560 — Displacements of Urethra, 562 — Prolapse of Urethral Mucous Membrane, 563 — Foreign Bodies in Urethra, 565 — Urethral Fistula, 565 — Tuberculosis of Urethra, 565 — Floating Kidney, 566.

Part Xii.— The Detailed Technic Of Gynecic Sur- Gery 577

The Operating. Room, 577 — Operating Table, 585 — Instruments and their Preparation, 586 — Special Instruments, 589 — Dressings and the Packing of the Autoclaves, 591 — Sutures and Ligatures,

14 Contents

r.M.K 5^)3 — The Preliminary Treatment and K.xamination of the Patient, 596 — Hand and Skin Cleansing, 508— Preparation of Patient for an Abdominal Section, 600 — Preparation of Patient for a Plastic Operation, 602 — Preparation of Surgeon; Clothes, Gowns, and Gloves, 602 — Anesthesia and Anesthetics, 603— The Technic of an Abdominal Section, 611 — The Technic of a Vaginal Section, 640 — The Technic of a Plastic Operation, 642— Technic of Dilatation of the Cer\ix and Curettage of the Uterine Cavity, 645— The After-treatment of an Abdominal Section, 646 — The Treatment of Shock during and after an Abdominal Section, 654 — Sef|uels of Abdominal Surgery, 655 — The After-treatment of a Plastic ()])eration, 660.

INDEX 665

A TEXT-BOOK

OF

DISEASES OF WOMEN

HIRST

Part I. The Gynecological Examination; Local Treatment

In eliciting the symptoms of a disease peculiar to women, the subjective and the objective s}'mptoms should be investigated. The former are experienced by the woman and must be communicated by her; the latter are determined by the senses of the examining physician, usually by inspection and palpation.

The subjective symptoms are obtained by questioning the patient. Obviously, too much importance must not be attached to them. The woman ma}- not have accurately observed her condition ; she may misinterpret what she feels ; she may be neurasthenic or hysterical, and therefore may exaggerate or simulate symptoms. 1 She may purposely give a false history, or she may be incapable of making a statement if she is drunk, delirious, unconscious, or insane. The subjective symptoms, however, possess a certain value, and should always be ascertained if possible. Time is saved and errors of omission are avoided by a routine series of questions in regular order. Thus, the patient's age and social state; any important diseases or accidents in her past life; a hereditary tendency to cancer or tuberculosis ; the number of children or miscarriages, if any ; difficulty in the labors or afterward.

Menstruation. — The age at which it first appeared ; the intervals between the periods; the duration of the flow; its character and quantity. Are clots passed? Has the discharge a foul odor? Is there intermenstrual bleeding? Has the menopause occurred ? If so, when ; and has there been any bloody discharge since ?

Leukorrhea. — If there is a mucopurulent discharge, what are its exact character and quantity? Is it constant? Has it a foul odor ? Does it appear midway between the periods ?

Pain is next inquired for ; its situation and character ; whether it is influenced by menstruation; if it is worse before, during.

^ One of my patients put the fur of a cat in her urine; another wrapped tresses of her own hair around the fecal masses she defecated, suggesting the communication of a dermoid cyst with the bladder and bowel.

2 17 or after the flow. Is it affected by a sudden jolt or jar, or by coitus? Does it occur midway between the periods (" Mittelschmerz ") ?

Backache should be asked about separately: Is it worse on exertion or on first arising in the morning? Is it affected by mental effort ? Is its situation the small of the back or the veryend of the spine ?

When the patient stands erect, is there a sense of prolapse, or lack of support? Is there an actual protrusion from the vagina?

Is there any peculiarity of defecation or urination?

Fig. I. — Characteristic gesture of tubo-ovarian pain.

Finally, the general health should be investigated : loss of weight, pallor, feeble circulation, headache, localized pains remote from the sexual organs; sleeplessness and nervousness must be asked about. The answers to all these questions may suggest further inquiries. It is often advisable to inquire into the sexual relations of married women, more particularly as to the means which may be taken to prevent conception.

Conclusions of a certain value may be drawn from the answers to these questions. If a woman has pain above Poupart's ligaments, worse before or after men.struation, and somewhat relieved during the flow, she probably has a tubo-

Objective Symptoms 19

ovarian inflammation, which is usually more acutely felt on the left side, even though both sides are equally affected. If there is inflammatory disease of the uterine appendages, there is usually an acute pain in consequence of a jolt or jar, as in a sneeze, and in coitus. In describing the situation of this pain the patient usually makes a characteristic gesture.

If there is backache, worse in the morning and not aggravated by exertion, there is probably a strong neurasthenic element in the case, or there may be rheumatism of the lumbar muscles. Backache only appearing on or much aggravated by exertion in the erect posture suggests retroversion of the uterus or injury of the pelvic floor. Pain in the end of the spine should arouse a suspicion of neurasthenia or hysteria, for this is a favorite seat of imaginary pain ; but it may indicate coccygodynia in consequence of an injury to the bone or its joints.

It is unwise, however, to form too strong a preconceived opinion from the subjective symptoms alone. Even an experienced specialist, on making a physical examination, may occasionally imagine he finds the signs of a condition which really does not exist, if his mind has been too firmly preoccupied by the thought of some disease suggested by the patient's statements.

Objective Symptoms. — While the patient is entering the office, giving her history, and replying to the physician's questions, information of some value is obtained by an observation of her appearance and behavior. A slow, cautious gait, with the body bent forward, the hand perhaps resting on the abdomen, an evident care to avoid a jolt or jar, and an apprehensive expression on the face are indicative of pelvic peritonitis or peritoneal irritation. The cachexia of cancer, the intense pallor of anemia from metrorrhagia, the greenish-yellow skin of chlorosis, the sallow complexion of sepsis, the evidence of malnutrition in the fades ovaviana, the shifty glance and twitching eyelids of hysteria are all suggestive and should be noted. There are lines of care upon the face and a prematurely aged look in many a case of uterine displacement. The cosmetic effect of a uterine suspension, for example, is often very striking. The most valuable objective symptoms, however, are appreciable by the sense of touch.

Palpation of the pelvic organs in women is most often practised by a digital examination of the vagina, assisted by counterpressure upon the lower abdomen {combined vaginal and abdondnal examination ; bimanual exannnatioii). The patient is usually placed upon her back, preferably on a specially constructed table, with the buttocks projecting slightly beyond its edge, the trunk flexed just above the sacrum, the pelvis slightly elevated, the thighs well flexed upon the abdomen, the legs upon the thighs, the knees widely separated, and the feet supported upon stirrups not too far apart. This posture relaxes the abdominal muscles and removes the intestines from the pelvic cav-

Fig. 2. — Examining table for office practice.

ity. The lower bowel and the bladder should be empty. Corsets should be removed and the clothing loosened around the waist. A sheet is so arranged about the patient that her limbs and body are covered and her underclothing is concealed from view, but ready access to the genitalia by touch and sight is permitted.

Fig. 3. — Office sterilizer for instruments. The water is kept boiling during the

office hour.

If a suitable table is not at hand, the patient may be arranged across a bed with the feet supported on chairs.

The physician cleanses his left hand and anoints the first two fingers with an unguent. The best for the purpose is composed

Palpation

Fig. 4. — Instruments laid out for routine office work: A Sims', skeleton, Goodell, and Collin's speculum ; a repositor, uterine sound, Emmet's curetment forceps, Thomas' applicator, and two dressing forceps of different lengths. The instruments have been boiled, are laid on a clean towel upon a glass-top table and covered with another towel so that they shall not alarm the patient. If the temperature of the examining room is over 70°, as it should be, the instruments need not be warmed before introduction into the vagina. If the room is cold, they should be momentarily dipped in the water boiling in the sterilizer. Immediately after use they are washed, boiled again, dried, and laid out as before.

Fi£

5. — Patient in the dorsal gynecological position, with sheet draped to protect the underclothing, but exposing the genitalia.

The Gynecoloi^ical Examination of glycerin and Iceland nio.ss, scented with oil of roses. ^ If there is leukorrhea, a foul discharge, a suspicion of gonorrhea or syphilis, a short rubber glove without a gauntlet should be worn. The forefinger approaches the vulvar orifice in such a manner that it first comes in contact with the posterior commissure, which is pushed backward toward the sacrum as the finger enters the vagina. Unless care is exercised about this point, the vestibule and the region around the clitoris, the most sensitive portions of the external genitalia, may be fir.st touched before the vaginal orifice is found, causing the patient unnecessary pain. In

inserting the finger into the vagina it should be remembered that the canal runs backward toward the sacrum, and not upward in the axis of the trunk. As soon as the cervix is located, pressure is made upon the lower abdomen with the fingers of the free hand to locate the fundus uteri and to press it downward toward the finger in the vagina, until the corpus uteri is caught between the fingers of the hand above and the finger in the vagina, which has been shifted from the cervi.x, against which its palmar surface first rested, to the anterior vaginal \ault. In this way the position, size, shape, consistency, and mobility of the uterus are determined. To palpate the appendages on the left side, the middle finger of the left hand is inserted alongside the forefinger, because thus a half inch in length is gained, the third and little fingers are flexed in the palm of the hand, the thumb is extended, and the hand is scmi-supinated. The extended fingers of the right hand are placed with their tips in a line above Poupart's ligament, and perpendicular to it, well outuard toward the anterior spine of the ilium, with the palmar surfaces of the fingers directed downward and inward. This hand is semi-pronated. Pressure is exerted

' A glycerin jelly, a jeliy of cucumbers and liydrastis, a thick mucilage of quince seeds, or plain glycerin are all preferable to ])i.-trolatum, which stains linen and clothing.

Fig. 6. — Short rubber glove fi gynecological examinations.

Fig. 7. — Introduction of the forefinger in a vaginal examination, by retracting the

perineum

Fig. S. — Bimanual examination of the uterus. Introduction of the fingers of the left

hand, which is then supinated.

The Gynecolosfical Examination by the external hand downward and inward, until the ovary is caught between the external and internal fingers, and the tube can be rolled between them. To examine the appendages on the right side, the first two fingers of the right hand must be inserted in the vagina and the fingers of the left hand are used externally. It is sometimes useful to pull the uterus down by a single or double tenaculum in order to palpate it and its appendages, but in the vast majority of cases more can be accomplished by pressure from above than by traction from below, and every one

Fig. 9. — Bimanual examination of the left tube and ovary.

should aim to dispense with the tenaculum in a combined examination, for it causes unnecessary traumatism and may be responsible for infection.

As the woman lies upon her back it is usually advisable to follow the vaginal by a rectal examination. Tlic forefinger, protected by a thin rubber finger-cot, is well anointed and is passed into the rectum its full length. Pressure is made above the pubis by the free hand, as in a combined vaginal and abdominal examination. To palpate the uterine appendages, the left forefinger is

Examination in the Erect Posture 25

used for the left side of the pelvis, the right forefinger for the right side, counterpressure being made in the iliac regions, as already described. Very rarely it may be desirable to make a combined rectal, vaginal, and abdominal examination, which is accomplished by inserting the forefinger of the left hand in the rectum, the thumb in the vagina, and by making pressure with the free hand on the lower abdomen. The cervix and lower uterine segment can then be grasped between the thumb and the forefinger.

It is sometimes necessary to examine a patient in the erect

Fig. 10. — Examination in the erect posture.

posture — for example, to determine the degree of prolapsus uteri. For this purpose the woman's skirts are raised above her waist and are pinned behind or are removed. A sheet is pinned around her waist, draped so that it falls to the ground, and the two edges overlap in front six to twelve inches. The patient stands with her legs apart. The examiner kneels on his right knee, facing the patient; the left hand is inserted under the sheet, through the opening in the front, and the forefinger is passed into the vagina, the physician's elbow being supported by his knee.

Palpation of the abdomen should constitute a part of every routine examination. Tumors or other abnormalities may thus be detected which might not be appreciable in a vaginal or a combined examination. Abnormal mobilitx' of the kidneys is overlooked in a considerable proportion of women if abdominal palpation is omitted.

The patient is prepared for abdominal palpation by removing the corsets, loosening the skirts and the underclothing about the waist, and exposing the skin from the sternum to the pubis. The woman lies flat upon her back, with the knees slightly elevated and the feet supported. The examiner stands beside her and

Fig. II. — Abdominal palpation.

with outstretched hands makes pressure at first lightly, then more deeply from the flanks toward the median line, and from top to bottom of the abdomen. Deep pressure with the finger-tips may be needed in certain areas. The contour of an abdominal tumor may be determined by grasping it as one grasps the fundus uteri in Crede's method of expressing the placenta. By approximating the finger-tips from without inward and at the same time making deep pressure the abdominal walls are lifted away from the abdominal contents. In this way mere obesity is differentiated from an intra-abdominal tumor.

To palpate the kidneys the patient should be made to sit bolt upright, upon the examining table, with the abdomen freely ex-

Palpation of the Abdomen posed, the back and head supported, the arms hanging loosely by her side, and all the muscles as relaxed as possible. The examiner, standing beside her, places one hand on the lumbar region and slips the fingers of the other under the floating ribs in front. In this manner the kidney is caught between the two hands and its mobilit\' can easily be tested. Another posture frequently used for palpation of the kidneys is assumed by the patient, seated, leaning forward, with the upper portion of her trunk supported by a nurse. The examination of the kidney in the erect posture with flexed trunk, in the knee-elbow and in the Sims' position is described under the head of Floating Kidney.

Fig. 12. — Testing the thickness of the abdominal walls.

A satisfactory pelvic and abdominal palpation ma}- be impossible without anesthesia. In an unmarried woman anesthetization should always be insisted upon unless she has been examined and perhaps treated before. If the patient is a young girl, it is better to keep her in ignorance of what is to be done, and, if possible, the vaginal should be replaced by a rectal examination. If there is uncontrollable rigidity of the abdominal and pelvic muscles, hypersensitiveness of the genital region, or if for any cause the examination is difficult and the result is not perfectly clear, a physician should refuse to give his opinion of the case until an examination under anesthesia is permitted. The best anesthetic for the purpose is chloroform. It secures perfect relaxation quickly, and does not, as a rule, nauseate the patient, used in the small quantities and for the short time required. Ether is too slow in its action and causes too much nausea. Nitrous oxid gRv, does not relax tlie muscles enough. Ethylbromid and chlorid are too dancrerous.

Pig. 1^. — Palpation of the left kidney, as the patient, sitting erect, leans forward

against the nurse.

Inspection of the Pelvic Organs and of the Abdomen. — As the

patient is arranged for a digital examination of the vagina, her vulva is e.xpo.scd to view and should be inspected before the physician in.serts his finger. The entrance of the vagina and the vestibule are exposed by separating the labia majora with the thumbs or forefingers. The vagina itself, its vault, and the cervix uteri are exposed by the use of a bivalve or a duck-bill (Sims') speculum. The former is the more useful instrument of the two. The Collin's, Goodell's, and the skeleton are the most convenient

Introduction of Bivalve Speculum models. Two sizes must be provided, for muciparous and nuUiparous women.

To introduce a bivalve speculum, the instrument is grasped in the fingers of the right hand, near the junction of the blades, which are held close together. The tips of the blades are dipped in a jar of unguent. The forefinger of the left hand is inserted in the vagina to locate the cervix and to indicate the direction of the vaginal canal. As the finger is withdrawn the

Fig. 14. — Exposure of the clitoris, vestibule, vaginal introitus, and fossa navicularis.

right labium majus is pushed to one side and the vaginal entrance is thus made to gape. The speculum is now inserted with the long axis of the blades corresponding with the direction of the vagina — namely, backward toward the sacrum, rather than upward in the line of the trunk; the tips are turned so that their long axis corresponds with the long axis of the vulvar orifice, and the screw is directed downward. As the instrument is passed into the vagina it is turned on its long axis so that the blades rest against the anterior and posterior vaginal walls, and the screw so The Gynecolog-Ical Examination

which separates them is on tlie left-hand side of the woman's pelvis, where the examiner's right hand may easily manipulate it. If the proper direction of the speculum is maintained while it is being inserted, the cervix is exposed as the blades are separated ;

Fig. 15.- — Collin's speculum.

Fig. 16. — GoodeU's speculum.

Skeleton bivalve speculum.

but the mistake is commonly made of not pointing the instrument far enough backward, so that wiien it is opened the anterior vaginal vault is exposed and the cervix is hidden beneath the po.stcrior blade. Shoukl this be the case, the blades.

The Sims' Speculum are allowed to collapse, the instrument is withdrawn a little and then pushed far backward toward the sacrum until the cervix comes into view as the blades are separated. If the vagina is long and its walls are relaxed, a single tenaculum may be required to catch the cervix, by passing it into the external os with the hook directed upward and catching hold of the anterior lip. A bivalve speculum properly introduced and widely enough opened is usually self-retaining, leaving the operator's hands free for whatever manipulations may be required.

If a Sims' speculum is used in the dorsal position, the ante-

^"1 -4

IHfcipr i

Fig. 18. — Introduction of the bivalve speculum.

rior vaginal wall pi"olapses into the vulvar orifice and obscures the view of the deeper portion of the canal, so that a retractor is required to push it upward out of the way. Special instruments are devised for the purpose, but the ring handle of one blade of a two-bladed instrument, such as a Pean's forceps, answers the purpose perfectly. Edebohls has devised a self-retaining duck-bill speculum with an attachment to catch discharges and irrigating fluids, which is often very useful in the dorsal decubitus.

The best results with the Sims' speculum are obtained, however, in the Sims' or semi-prone lateral position and in the knee-chest posture. In the Sims' position the patient is placed upon her side, usually the left, with the under arm behind her back, the trunk in a semi-prone position, the thighs well flexed upon

Fig. 19. — Sims' specula. Detachable blades of varying sizes and liandle.

Fig. 20. — Sims' speculum. Blades of two sizes in one instrument.

Fig. 21. — Nott's vaginal depressor.

the abdomen, and the legs upon the thighs, the upper leg and thigh being soniewiiat more strongly flexed than the lower. The advantages of the Sims' position are increased if the table on which the woman lies is tilted .so that the abdomen is made still more dependent. The knce-che.st postin-e is assumed by resting

The Knee-chest Posture upon the knees and chest, the face turned aside so that one cheek rests upon a flat pillow and the arms so disposed that the patient can not yield to her instinctive impulse to rest upon the elbows.

Fig. 22. — Sims' position.

Fig. 23. — Sims' position. Patient draped with sheet, arranged so as not to interfere with the examination or manipulations.

The thighs should be perpendicular to the surface of the table, and the back should present a straight line or a somewhat concave curve at an angle of 90 degrees. 3

Fig. 24. — Knee-chest posture. Thighs perpendicular to the table ; back at an angle

of 90 degrees.

M^

^H

^^1

F'g- 25. — Knee-chest posture. Sheet draped around patient. Posture faulty. Thighs not perpendicular.

Introduction of the Sims' Speculum

Fig. 26. — Introduction of a Sims' speculum.

Fig. 27. — Sims' speculum, introduced and held by a nurse.

To introduce the Sims' speculum in the Sims' position, the convex surface of the blade is well anointed, the handle is grasped in the full hand, the vaginal orifice at its posterior commissure is opened by raising the upper buttock, and the blade of the instrument is inserted with the long axis of its tip in coincidence with the long axis of the vulv^ar orifice. As it is inserted the blade is turned until the handle points directly backward toward the sacrum. The handle must also be inclined somewhat away from the perineum, else the blade will slip out. An assistant holds the handle firmly in the full hand and makes considerable traction backward and outward. A retractor may be needed for the anterior wall, and a tenaculum may be required to bring the cervix into view, although usually the vagina is well distended with air and every part of the canal is plainly displayed, except