Gynecological diagnosis

Front matter

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Preface

Some years ago a prominent surgeon who had been attending one of my clinics, remarked when the clinic was over: "I think I understand the treatment and I know how to do most of the gynecological operations, but where I find great difficulty is in the diagnosis."

At the present time the medical profession is devoting an ever-increasing amount of attention to diagnosis, and it seems fitting to describe at length this somewhat blind subject, gynecology, for the benefit of those who have not had an opportunity to study it in the special hospitals and clinics.

A practical text-book, embodying simplicity of technique and concise statement of essentials, has been the aim. The methods of procedure of the pathological and bacteriological laboratories have been omitted because of the assumption that the physician in making a diagnosis has always at his command the services of a trained pathologist and bacteriologist, or can consult text-books devoted exclusively to these subjects. The attempt has been made to keep in the background the rare diseases which are of so much interest to the specialist and to give prominence to the common affections usually met by the general practitioner. While the book is written entirely from the clinical point of view, the salient points of the anatomy and the latest views of the pathology have been summarized at the beginning of each chapter, and the literature has been scanned for new ideas of value to the practitioner.

The differential diagnosis is entered into extensively and is summarized in many places in the form of tables of parallel columns.

Particular attention has been paid to the diagnosis of the diseases of the bladder and of the rectum because of my belief that these organs are too often neglected. A chapter on diseases of the breast has been included because the breast is a part of the reproductive system in women and has intimate relationship with the uterine organs. The importance of the recognition of uterine disease in early life, which, when undiscovered, frequently causes disastrous results later, has led to the writing of the chapter on the gynecological affections of infancy and childhood. In the preparation of this chapter I have been fortunate in having the assistance of my friend, Dr.

viii PREFACE

John Lovett Morse, who kindly revised the manuscript. The chapter on the menopause is an attempt to shed light on this important but little understood period of woman's life.

An original feature of the book is an alphabetical index of illustrations — of which there are two hundred and fifteen — in the front. Thus the reader can find any desired figure without laboriously going through the entire list. The attempt has been made to place each figure next to the text it illustrates and all references to figures, as well as to subjects cited in other parts of the book, are accompanied by page numbers. Every chapter is headed by a resume of its contents with page references, and all the illustrations, as well as the titles of the subject-matter, are also included in a very full index at the end.

The views here expressed and the methods described are those that have found favor in my practice, and they are put forward not with the feeling that they are new, original, or all-inclusive, but that having proved useful to me they may help others also to unravel the knotty problems of gynecology.

My thanks are due to Dr. Howard A. Kelly, Dr. E. C. Dudley, and the other authors who have kindly loaned illustrations from their works; to Dr. Henry T. Hutchins for revising the chapter on malignant diseases of the uterus and the section on the collection of the discharges and tissues for microscopic examination; to Dr. Howard W. Beal for assistance with the section on indirect cystoscopy; to Miss Florence L. Spaulding and Miss Ruth O. Huestis for original drawings; and especially to Messrs. D. Appleton and Company, who have shown never-failing courtesy and who have assisted in every possible way in the making of the book.

Walter L. Burrage.

Boston

Part II Special Diagnosis

PAGE

The Diagnosis of Endometritis, Including Gonorrhea and Erosions of the Cervix Uteri . . . 16.3

The Diagnosis of Pelvic Inflammation (Pelvic

Peritonitis and Pelvic Cellulitis) . . . 187

The Diagnosis of Congenital Anomalies of the Uterus, Laceration of the Cervix Uteri, and

The Diagnosis of Malpositions of the Uterus . 215

The Diagnosis of Fibroid Tumors of the Uterus 244

The Diagnosis of Malignant Diseases of the

The Diagnosis of Diseases of the Ovaries . . 284

The Diagnosis of Diseases of the Fallopian Tubes 324

The Diagnosis of Extra-Uterine Pregnancy . . 340

The Diagnosis of Diseases of the Vagina . . . 354

The Diagnosis of Diseases of the Vulva . . . 388

The Diagnosis of Uterine Pregnancy, Abortion,

and Hydatidiform Mole 417

The Diagnosis of Diseases of the Urethra . . 444

The Diagnosis of Diseases of the Bladder . . 457

The Diagnosis of Diseases of the Ureters . . 486

The Diagnosis of Diseases of the Rectum . . 494

The Diagnosis of Diseases of the Breast . . 531

The Diagnosis of the Gynecological Affections

of Infancy and Childhood 555

INDEX . 627

LIST OF ILLUSTRATIONS

Abdomen, cavity of, shape of 86 221

division of, into quadrants and indication of bony landmarks . 18 65

organs of, origin of tumors in . . 129 304

Anal canal 191 495

cast of 192 496

Anal region, diagram of 195 515

Applicator, uterine 37 93

Ascites, abdomen of, seen in profile 131 307

cross section of , dorsal position . 132 310

lateral position 133 311

Bartholin's gland, cyst of left 174 409

Bartholin's glands, abscess of 176 411

abscess of ducts of 175 410

Bladder, ballooned by air, patient in knee-chest position 54 112

base of, showing diverticula 185 458

normal, laid open from in front 51 106

overdistended 84a 217

papilloma of 190 482

stone in 186 463

tuberculosis of ureteral orifice in 187 469

varix of 188 474

Bladder phantom, for practising cystoscopy 58 118

Blood vessels, uterine and ovarian 8 47

Body, vertical median section of 6 44

of childbearing woman 84 216

Breast, diffuse bilateral hypertrophy of 201 541

dissection of lower half of, showing milk ducts 198 534

division of, into quadrants 200 538

lymphatics of 199 535

right, vertical section of 197 533

scirrhous cancer of 202 547

Calibrator, meatus, Kelly 44 101

Carunculse myrtiformes 165 397

Catheter, bladder, long silver 43 101

ureteral, Kelly 48 103

Cervix, adeno-carcinoma of canal of, early stage Ill 268

cancer of, early stage 110 267

erosion of, with lacerations 69 185

fibroid of 108 254

hypertrophic elongation of 88a 225

xi xii LIST OF ILLUSTRATIONS

Cervix, laceration of, bilateral, with erosions 79 205

crescentic 81 207

stellate 80 206

unilateral (diagram) 83 209

with eversion of lips (diagram) 82 209

prolapse of 88 224

squamous-celled cancer of, early stage 110 267

supravaginal, elongation of 88 224

Controller, current, for use with electric cystoscope 57 117

Curette, uterine 31 90

Cylinder, vertical, filled with fluid, representing abdominal cavity . 7 45

Cystocele 148 367

diagram of 148a 368

Cystoscope, bladder, Kelly 49 104

ureter, Nitze 56 116

Cystoscopy, modified knee-chest position used in 53 111

removing urine from bladder in, by suction apparatus 55 113

Decidua, uterine, in extra-uterine pregnancy 143 345

Depressor, vaginal, Hunter 29 89

Dilator, urethral, double-ended, Kelly 45 102

uterine, Wathen 34 92

uterine, Hanks 33 91

Endometrium, normal 65 167

Enteroptosis, body pose in 19 67

Evacuator, bladder, Kelly 46 102

wash-bottle, Kelly 55 113

Extra-uterine pregnancy, ampullar, early 140 341

mole and fetus removed 141 342

ampullar, late 145 350

isthmial, section of uterus of 146 352

Fallopian tubes, development of, in fetus 71 198

Fissure in ano 194 504

Fistula in ano, blind internal 196a 517

complete 196 517

Fistulse, genital, scheme of, after Dudley 189 476

after Gilliam 155 385

Forceps, bladder, alligator 50 105

curette, Emmet 30 89

rectal, alligator 62 125

uterine dressing, Bozeman 23 83

vulsellum 25 84

Gauze records of abdominal tumors 20 75

Genital organs, development of, five diagrams illustrating . . 158-162 395

external, at beginning of third month 157 392

Gland, Bartholin's, cyst of left 174 409

LIST OF ILLUSTRATIONS xiii

Glands, Bartholin's, abscess of 176 411

abscess of ducts of 175 410

Hand, examining, showing protective sleeve 2 31

Hegar's method of palpating pedicle of ovarian tumor 126 301

sign, bimanual palpation for 179 425

Hematocele, pelvic 142 343

Hematocolpos, diagram of 171 398

Hematometra, diagram of 172 398

Hematosalpinx 139 335

diagram of 173 399

Hemorrhoids, types of 193 499

Hydatidiform mole 182 442

Hydrosalpinx 138 334

Hymen, different forms of 163-170 397

Interstitial pregnancy 144 346

Irrigator, uterine, Bozeman-Fritsch 35 92

Isthmial tubal pregnancy, section of uterus of 146 352

Ligaments, utero-sacral, course of, in intraligamentous tumor . . 135 317

in retroperitoneal tumor 134 316

Maturity, precocious, case of 207 565

Os, external, parous „ . 66a 169

virginal . 66 168

Ovaries, infantile 117 286

Ovary, cyst and tumor regions of 120 290

cyst of, adherent, arrangement of peritoneum in 124 292

intraligamentous, arrangement of peritoneum in 123 292

pedicle, arrangement of peritoneum in 122 292

very large, showing emaciation and "facies ovarina " .... 125 294

normal, pedicle, arrangement of peritoneum in 121 292

of mature woman 118 287

senile 119 289

tumor of, cross section of body of 127 302

tumors of, Hegar's method of determining relation of, to uterus . 126 301

pedicle, formation of (4 diagrams) 121-124 292

Ovary and tube seen from behind 116 285

Parovarium, large cyst of, seen in profile 128 303

Pelvimeter , .... 42 98

Pelvis, contents of, from above 9 48

female, normal 9a 50

showing accessibility of contents to palpation 10 52

with hand in position as for vaginal examination 4 37

floor of, diagram showing structures of . 150 373

of new-born child, longitudinal median section of 204 558 xiv LIST OF ILLUSTRATIONS

Perineum, laceration of, complete median 151 374

partial lateral 152 375

Peritoneum, reflections of folds of, in pelvis 70 189

Position, dorsal 3 32

knee-chest 13 56

bladder, vagina, and rectum ballooned by air in 54 112

modified for cystoscopy 53 111

side-view, showing vertical thighs 14 57

lithotomy 15 58

raised pelvis 16 59

Sims 11 53

diagram of 12 54

standing 17 60

Precocious maturity, case of 207 565

Pregnancy, extra-uterine. See Extra-uterine pregnancy

interstitial , . 144 346

tubal, early ampullar, abortion in 140 341

mole and fetus removed from tube 141 342

isthmial, uterus of 146 352

late ampullar, four months' 145 350

section of uterus, showing decidual modification in 146 352

Probe, uterine 22 82

Procidentia 87 223

Proctoscope, long 61 124

short 60 123

Pyosalpinx 137 333

Rbctocele . 149 369

diagram of 149a 370

Rectum, ballooned by air, patient in knee-chest position . .'. . . 54 112

lower part of, diagram of 195 515

Salpingitis, tuberculous 136 331

Searcher, ureteral, Kelly 47 102

Sound, uterine 21 78

Separator, urine, Luys 59 119

Speculum, bivalve. See Speculum, vaginal, Brewer and Graves

rectal, Sims 63 126

uterine, Burrage 36 93

vaginal, Brewer 26 87

Edebohls 32 91

Graves 27 87

Sims 28 88

Table, examining 1 27

Tenaculum, uterine 24 83

Touch, bimanual, diagrammatic drawing 5 38

Tubercles of bladder wall 187 469

LIST OF ILLUSTRATIONS xv

Ureter, orifice of, jet of urine spurting from 52 107

Urethra, caruncle of ' 184 454

mucous membrane of, prolapse of 183 449

Uterine organs of an infant at birth seen from above 205 562

Uterus, anteflexion of, in the little girl 90 230

pathological 91 231

bicornis 74 199

bicornute, one external os, two uterine cavities 78 201

bipartitus 72 199

body of, adeno-carcinoma of, early stage 112 269

horizontal section of upper part of .....' 67 171 cavity of, Kelly's methods of exploration of, exploring with finger 41 97

incising anterior wall 39 95

transverse incision anterior to cervix 38 94

laid open 40 96

chorioepithelioma of posterior wall of 114 281

development of, in fetus 71 198

didelphys 73 199

double, with double vagina 147 358

fibroids of, interstitial and submucous 104 248

intraligamentous . 105 249

large tumor filling pelvis and simulating pregnancy .... 109 256

multiple 102 246

polyp in vagina, large 107 252

submucous, large, showing distortion of uterine cavity .... 106 250

simulating inversion 101 245

pedunculated, simulating inversion 99 241

simulating partial inversion 95 241

subserous, side view of abdomen containing large tumor . . . 103 247

tumor of cervix 108 254

fundus of, height at various weeks of pregnancy 130 306

inversion of acute puerperal 93 239

complete 98 241

with pedunculated subserous fibroid of abdominal evolution . 100 241

partial 97 241

caused by submucous fibroid 296 241

of left horn 94 241

normal, position of 6 44

pregnant, enlargement of, in late pregnancy 181 428

pregnant at sixth week, diagrammatic side view, during contraction 178 423

during relaxation 177 422

section of 178 424

prolapse of 87 223

partial 89 227

reconstruction of, showing shape of uterine cavity and cervical

canal 64 166

retroposition with anteflexion 91 231

retroversion of 92 235

caused by overdistended bladder 84a 217 xvi LIST OF ILLUSTRATIONS

Uterus, sarcoma of 113 279

section of, in isthmial tubal pregnancy 146 352

transverse longitudinal 68 172

septus 75 199

unicornis 76 199

with accessory corau 77 199

Vagina, ballooned by air, patient in knee-chest position 54 112

chorioepithelioma of, metastatic 115 282

cyst of anterior wall of 154 381

cyst of posterior wall of 153 380

development of, in the fetus 71 198

double, with double uterus 147 358

infantile, examination of, with cystoscope 205 559

longitudinal section of, showing S-shaped curve 85 219

prolapse of 88 224

Vulva, at beginning of third month of fetal life 157 392

diagram of 156 389

infantile 203 556

PART I GENERAL CONSIDERATIONS

Chapter I Introduction

Diagnosis, the foundation of gynecology, is elusive. The consultant frequently hears it said by the attending physician, " Doctor, I know how to do this operation, but what puzzles me is to know when it is indicated."

The educated touch is the keystone of the diagnostic arch; symptomatology, sight, instrumentation, microscopic findings, are but accessories. To train the touch requires time and application. As in learning any handicraft, the beginning is of great importance. Those who neglect to perfect themselves in the proper technique at the start, who never acquire "good form" as they say in athletics, never progress beyond a moderate degree of excellence. The practitioner who persists in making the bimanual examination with thejpatient in bed or on a yielding surface, or neglects to incommode her to the extent of causing to be loosened all clothing about the waist, never becomes, a good diagnostician. The reasons for this will appear later.

There is no department of medicine in which the patient is less able to judge from her own observation of the correctness of the diagnosis than in gynecology. Unlike the dermatologist, for example, the gynecologist does not have trained upon his work the critical eye of his patient.

She is unable, also, to judge of the nature of the treatment employed. It is especially easy for a physician who has made an error in diagnosis to persist in a chosen line of treatment without discovering his mistake, for the relations between cause and effect are often most shadowy; also, consultations are relatively infrequent in this department of medicine. Because of the delicate nature of the confidences called for, and the sensitive portion of the anatomy involved, the patient shrinks from subjecting herself to repeated examinations at the hands of different physicians.

4 INTRODUCTION

We have to do in this book with the question of diagnosis alone and it will be my endeavor to point out how best to make it. More stress will be laid on the interpretation of symptoms and signs in the light of experience than is usual in text-books on gynecology because it is thought thereby to help the practitioner.

That pathological conditions may exist without any symptoms at all should never be forgotten. For instance, a woman may have a double uterus, detected for the first time at the gynecological examination which follows labor, or a patient may have a small dermoid tumor of the ovary, discovered only when she comes to the physician to learn why she has never had children.

A judicious combination of the deductive and inductive methods seems to be the most practical way of presenting the subject; a result accomplished by describing the steps of the examination and the processes followed in arriving at a diagnosis, as nearly as may be, as they occur in actual practice.

Particular attention is paid to the minutiae of the history-taking, the management of the patient, and the smallest details of the examination, because of my belief that matters which seem trivial to many are in reality the solid groundwork of a correct diagnosis.

Mistakes in diagnosis are unavoidable even in the experience of the most expert. To make a mistake because an inadequate examination was made or no examination at all is an unpardonable sin. Experience teaches that finality in diagnosis is not always a possibility in gynecology, and even after the most painstaking history, analysis of the symptoms, and physical examination, we may fail to distinguish between two or three possible conditions. Our object is to reduce the uncertain cases to a minimum.

Chapter II The Clinical History

Method of getting the history, p. 5. Case-record systems, p. 6. Form for case records, p. 6.

METHOD OF GETTING THE HISTORY

Many busy practitioners slight the clinical history, the taking of which should precede every physical examination. This is a mistake which carries its own retribution in the form of a slipshod diagnosis. A clear and exhaustive history not only serves as a guide in making the physical examination, but also develops symptoms which otherwise may be overlooked. There are few cases which are not better diagnosed by a careful preliminary questioning of the patient. The physician gains his patient's confidence, so necessary for a successful physical examination. If she becomes prolix or strays from the important point, a question will often bring her back. It is well to note especially, perhaps b}^ underlining, the symptoms that seem most important to her, so that in subsequent interviews these may be under special observation. It is generally better to talk with the patient alone when getting the history, as there are important facts which will be suppressed if a third person, whether a nurse or a relative, be present. Sometimes it happens, however, that important facts are to be obtained from the husband, and, in the case of a young girl, from the mother. A desirable practice is to review the history after the physical examination in the light of the facts brought out by the examination and to cross-question the patient as to the truth. Avoid, as far as possible, asking leading questions and assenting too readily to the answers. Be sure that the answers represent the truth.

THE CLINICAL HISTORY

CASE-RECORD SYSTEMS

A good method for case records is the envelope, card-catalogue system. A filing cabinet with several drawers is obtained. Large, ungummed envelopes, and also a set of cards just fitting into the envelopes and the drawers as well, are procured. For use at the bedside it has been my custom to carry in a leather pocket-case a block of prescription blanks, six by four inches, which fit the envelopes of my filing cabinet. At the office I use cards of the same size. Every card and envelope is marked on the left-hand top corner with the patient's name and filed alphabetically in the cabinet. One advantage of the envelope system is that additional memoranda, such as notes on treatment and other data, may be filed in the same envelope, and it is not necessary to copy the notes taken at the bedside before filing them.

Many gynecologists have printed case sheets, either in a book or as loose pages or cards. It is well to have some schedule to follow so that the same order may be observed in all cases and important facts may not be omitted. To the beginner a printed form is invaluable, but to the physician of experience it is hardly worth while to take up desirable room on the cards with printing which may be of no use in many of the cases. The object is to get a schedule in mind, rather than to have it printed before you.

FORM FOR CASE RECORDS

Date :

Name in full :

(In the case of a married woman both own first name and husband's first name for purposes of future identification.) Address : Nationality :

Occupation : Age :

Social Condition : Single. Married, (how many years)

Widow : (how many years) Children : (how many and ages)

Miscarriages or abortions : (number, and at what weeks or months of pregnancy.)

FORM FOR CASE RECORDS 7

Family History. — General predisposition to cancer, lung trouble, heart disease, kidney disease, or rheumatism. If the parents are dead, what were the causes of death. Early or late occurrence of the first menstruation and of the menopause, or the occurrence of dysmenorrhea or uterine disease in sisters or female relatives.

Previous History. — Special reference to gynecological affections; as attacks of vulvar inflammation, or smarting with micturition, as indicating gonorrhea; "inflammation of the bowels," as indicating pelvic inflammation; lack of control over the bowels or bladder, showing injury of the sphincter ani or of the pelvic floor; the account of any operation which may have been performed on the genital organs. The infectious diseases may point to inflammatory affections of the vulva and vagina in childhood.

Menstruation. — Age at which first menstruation occurred ; whether normally established, the subsequent rhythm, duration, quantity, and quality of the flow; whether accompanied by pelvic pain, if so, the situation, character, and duration of the pain, also whether before, during, or after the flow; whether disturbances of other functions at the time of menstruation, as nausea, headache, depression of spirits; any recent irregularities in the rhythm, quantity, or character of the flow; intermenstrual pain, if so, exact dates of beginning and end of pain. Is menstruation accompanied by leucorrhea, or not.

Vaginal Discharge. — Character, amount, when most in quantity, duration.

Pain. — Other than menstrual, situation, duration, character.

Confinements, Miscarriages, and Abortions. — Labors normal, rapid, tedious, or instrumental; whether injuries received or symptoms suffered; convalescence normal or not; stitches taken, fever following. Miscarriages or abortions, dates of occurrence and at what weeks of pregnancy; supposed cause or causes; attended by much flowing or fever; convalescence, good or bad.

Bladder Symptoms. — Frequency of micturition by day and by night; smarting on urination; control of urine on laughing and coughing and on standing and walking; pain in region of bladder on micturition ; color and quantity of urine passed.

Present Illness. — Duration; particulars as to present symptoms such as pain, situation, character; leucorrhea, when first noticed,

8 THE CLINICAL HISTORY

character, as thin, glairy, thick, purulent, bloody, or offensive; whether constant, or before and after menstruation.

Date of the Beginning of the Last Menstruation.

Abdominal Swelling. — When first noticed, progressive increase in size, stationary or smaller, painful or not.

Bowels. — Regular movement every day or constipated; full action or scanty; liquid, semi-solid, or solid stools; offensive odor; gas in bowels; blood, mucus, or pus with the stools; painful defecation.

General Health. — Appetite, digestion, sleep; whether an increase or decrease in body weight ; headache ; backache.

The General Appearance of the patient should be noted as regards height, approximate weight, complexion, color of lips, peculiarities of form, if any.

Analysis of Urine.

Treatment Advised.

Chapter III The Interpretation Of The Clinical History

The address, nationality, and occupation, p. 9. Age, p. 9. Social condition, p. 10. Dypareunia, p. 11. Children, 11. Family history, p. 12. Previous history p. 12. Constitutional diseases, p. 12. Chief complaint and present illness, p. 13. Menstruation, p. 13: Puberty, p. 14; The menopause, p. 16; The atrophic changes in the genital organs and the body alterations of the menopause, p. 17. Vaginal discharge, p. 18. Pain, p. 18: Backache, p. 18; Muscular rheumatism, p. 19; Coccygodynia, p. 19; Pains in the groins, p. 19. Abdominal swelling, p. 20. Bladder symptoms, p. 20. The bowels, p. 21. Present illness, p. 22.

This is a chapter of probabilities ; not instructions how to make an offhand diagnosis, but a sifting of the evidence as it is presented, the diagnosis being held in reserve until after the physical examination, and until after any supplementary evidence has been elicited in the way of answers to questions which may be suggested by the examination.

A knowledge of the normal conditions is essential, if the value of the abnormal symptoms is to be estimated correctly.

The Address. — This is important not only as a matter of business but ae showing the possible effect on the patient's health of a healthy or an unhealthy locality.

Nationality. — The colored race is especially prone to fibroids. Cancer is seldom found in a negress.

Occupation. — Confinement in poorly lighted and ventilated workshops, long working hours, heavy lifting, insufficient food and prolonged standing on the feet aggravate, if they do not cause, pelvic disorders. On the other hand, a sedentary life with no real exercise may act as a contributory cause of pelvic disease.

Age. — The age of the patient suggests the special disturbances found in the various epochs of life. In infancy malformations and inflammations of the lower genital tract are to be expected. At this time the infections are generally limited to the vulva and vagina, and tumors, displacements, and traumatisms seldom exist. Vulvo-vaginitis is not uncommon in little girls.

Failure of the menses to appear previous to the sixteenth year should excite no apprehension ; after that it is apt to indicate underdevelopment of the uterine organs.

During the period of sexual maturity nearly all of the lesions of the genital organs may be found. The effects of gonorrhea are seen most often between the ages of twenty and thirty. Tumors of the breast are most frequently malignant between the ages of forty and sixty. Under the age of thirty-five a large abdominal tumor is more likely to be ovarian ; after that age it is more apt to be a uterine fibroid.

A patient suffering from uterine hemorrhage more probably has endometritis or a polypus if under twenty; a polypus or some condition resulting from gestation, from twenty to thirty; fungous endometritis, polypus, or fibroids from thirty to forty; fibroids and malignant disease from forty to fifty. After fifty, malignant disease is the probability.

Social Condition. — Congenital malformations may be brought to the patient's attention for the first time after marriage. Certain inferences may be drawn from the single or the married state of a patient as regards the cause of menorrhagia or metrorrhagia, as shown by the tables on pages 137 and 139, Chapter X., also as regards leucorrhea, as found on pages 144-146. Pregnancy is always to be considered if the patient is not a virgin. An early question as to the patient's social state, whether single, married, or a widow, may obviate embarrassing queries as to sexual relations and may throw light on the possible causes of her complaints. For instance, a recently married woman, always a sufferer with dysmenorrhea, finds the symptom aggravated and unbearable since her marriage. A periodic pelvic congestion, due to malposition or malformation of the uterus, has been accentuated by the congestion which attends sexual relations. A recently married woman complains for the first time of smarting on urination, and leucorrhea. Suspicion of infection with the gonococcus at once arises in the physician's mind. The possibility of pregnancy or venereal infection should never be lost sight of, notwithstanding the patient's statement that she is single or a widow, great caution and tact being exercised, however, in making inquiries. The final question as to the truth or falsity of the suspicion should be left until after the physical examination in any event, and in many

CHILDREN 11

cases can not be made at all without causing serious and unjustifiable trouble in the family of the patient.

Dyspareunia. — Dyspareunia dating from the time of marriage indicates smallness of the introitus vaginae or urethral caruncle, if the pain is at the beginning of coitus. If the pain is experienced after the penis has been introduced into the vagina the cause is apt to be pelvic inflammation or a tender cervix or ovary.

Children. — Sterility. — The absence of children may be important, for if a patient has been married many years and has not been pregnant, the inference is that the cause of the sterility rests with her and not with her husband, the latter being in good health, and we may expect to find some underdevelopment or malformation of the sexual organs. If there is any doubt as to the husband's virility a specimen of his semen should be examined for spermatozoa before subjecting the wife to gynecological treatment. (See Chapter X., page 147.)

Carcinoma of the cervix, common in parous women, is rare in nulliparae, whereas cancer of the body of the uterus is more apt to occur in women who have not borne children. Complete or relative sterility is often found in women suffering with fibroids.

Number of Children. — The number of children a woman has had is important because child-bearing without a sufficient interval of recuperation between the labors frequently results in some sort of pelvic ailment. Therefore, note the ages of the children. The history of each confinement is of the greatest service in determining the origin of a pelvic inflammation, a misplacement of the uterus, or lacerations. A difficult forceps delivery followed by fever and a tedious convalescence may mean all three, though not necessarily.