A text-book of diseases of women

Front matter

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Book_

I /-I

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.

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.

Chapter I. Page

The; General Causes of Diseases of Women 15

CHAPTER H.

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 HI.

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 Vulvae, 42. — Kraurosis Vulvae, 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 VI.

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.

io CONTENTS.

CHAPTER VII.

PAGE

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.

IvACERATlON OF THE CERVIX UTERI 1 48

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

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.

CONTENTS. 1 1

CHAPTER XVIII.

PAGE

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 130

12 CONTENTS.

CHAPTER XXVIII.

PAGE

Diseases of the Ovaries (Continued) 334

Hernia of the Ovary, 334. — Prolapse of the Ovary, 335. — Inflammation of the Ovary, Oophoritis, or Ovaritis, 339. — Acute OSphoritis, 339. — Chronic Oophoritis, 341. — Apoplexy of the Ovary, 346. — Ovarian Hydrocele, 346.

CHAPTER XXIX.

Cystic Tumors of the Ovary 349

Oophoritic Cysts, 350. — Follicular Cysts, 350. — Glandular Cysts, 354. — Dermoid Cysts, 359. — Teratoma, 361. — Paroophoritic Cysts, or Papillomatous Ovarian Cysts, 362.

CHAPTER XXX.

Cysts of the Parovarium 368

Comparison of Oophoritic, Paroophoritic, and Pai'ovarian Cysts, 372. — Glandular Oophoritic Cyst, 372. — Paroophoritic Cyst, 373. — Cysts of the Parovarium, 373.

CHAPTER XXXI.

Naturae History and Treatment of Ovarian Cysts . 374

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.

Soeid 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 Genitae 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.

CONTENTS. . 13

CHAPTER XXXV.

PAGE

The Menopause 409

CHAPTER XXXVI.

Genital Fistula 412

Vesico-vaginal Fistula, 412. — Urethro- vaginal Fistula, 420. — Vesico-uterine Fistula, 420. — Uretero-vaginal Fistula, 421. — Recto- vaginal Fistula, 421.

CHAPTER XXXVII.

Diseases op 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 {Co?itinued) 4S0

Abdominal Drainage, 480. — Gauze-drainage, 4S2. — 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 XU.

Treatment after Celiotomy 404

1 4 CONTENTS.

CHAPTER XLH.

The Special Technique of Operations upon the Uterus and the Uterine Appendages 502

Removal of the Uterine Appendages (Salpingo-oophorectomy), 504. — Removal of an Ovarian Cyst, 512. — Operation for the Removal of Intraligamentous Cysts, 5 1 4. — 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.

The Effect of the Removal of the Uterine Appendages 535

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 afnicted 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

GENERAL CAUSES OF DISEASES OF WOMEN. 77

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 oi the uterus. 2

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. I^ong 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.

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 linese albican tes, 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 bv -tvmpanitic 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 linese albicantes arc 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 senerally 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 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. i). 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

METHODS OF EXAMINA TION.

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 nymphse, the fourchette, the orifices of the ducts of the vulvovaginal 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.

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. 1. — Woman in the dorsal position with feet supported in Edebohls' stirrups.

(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,

Fig. 2. — Bimanual examination.

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.

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

METHODS OF EXAM IN A TION.

should be palpated methodically in order. The vaginal ringer 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,

Fig. 3. — Bimanual examination ; median sagittal section of the pelvis.

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.

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, i : 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

ME THODS OF EXAM IN A TION. 2 J

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.

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),

Fig. 4. — Double tenaculum.

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

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

FlG. 5. — Bimanual examination with one linger in the rectum, drawn down with the double tenaculum.

The uterus is may be that in these cases a rectal examination will be sufficient for diagnosis.