Professor of Gynecology at Ohio Medical University; Gynecologist to the Protestant Hospital.

In presenting this subject, "Diagnosis of Pelvic Diseases," I am reminded of the fact that many doubtful conditions exist even after the most careful study and dextrous examination. Indeed if this were not true, I would be obliged to offer an apology for the subject of this paper, as it would certainly seem superfluous to discuss a matter which is positive and as well understood by one as by another.

To the subject of this paper could have been added-and doubtful points in the diagnosis of pelvic diseases as well. It is unfortunate for us that the causative factors in the production of diseases, pelvic or non-pelvic, behave differently in different individuals. It is equally unfortunate that the administration of medicines have dissimilarity of action with different persons.

At the present time we understand something about the things that produce most diseases. When this has passed from one person to another we can expect certain phenomena, but we are not prepared to state beforehand what will necessarily follow. There may be a duplicate of the first, there may be a modification, there may be the first condition with a complication or the co-existence of other pathologies.

These departures and varieties make our studies hard, make our diagnosis difficult and our prognosis often uncertain. Then, again, if we knew the within and the without conditions or influences which cause these changes from the original, we could do much more towards correct diagnosis than we are able to do at present. I am taking this standpoint, that diagnosis of pelvic

*Read before the Columbus Academy of Medicine, December 3, 1900.

diseases, while it has much improved from what it was a few years ago and is still advancing, there remains yet uncertainty and doubt as to many troubles.

If we knew all the causes and the effects of these, our work would be easier and our results would be better.

Much and decided progress has been made in determining the etiology of disease, but we are obliged to acknowledge that much investigation, together with patient experiment, must follow, before we can reach that period of exactness that will allow us to point with scientific pride to our diseased patient and say that this is positively a certain disease and is confined only to certain anatomical structures.

The gynecologist at the present time has little to do with pelvic conditions before the period of womanhood; in fact this subject is generally understood to pertain to diseases of women and not to ages less than puberty. Qualifying this statement, we certainly do not go earlier into the case than approaching womanhood.

This is due, perhaps, to natural causes, viz., the greater frequency of diseases during puberty, genital life and menapause, and those diseases peculiar to advanced age. We, perhaps, also have a tendency to restrict ourselves in this matter and are apt to forget that conditions, which are not actually present during childhood and up to puberty, are even during these years provided for by habits, social surroundings and certain idiosyncrasies.

We should ever be mindful that heredity plays its favorable or unfavorable part according to the previous methods of parents or antecedents.

Other illustrations could be cited, but from these I desire to indicate that many forms of inflammation must be dealt with as though treating a single disease.

So closely associated are the anatomical structures found in the female pelvis, and possessed with such delicate functions, that when a diseased condition develops in one organ or in some part of an organ, we may reasonably presume that near by, if not more remote structures, will participate in this trouble, or at least will be subjected to some jolt or jar as a result of the primary trouble.

For example, I may say that a pyosalpinx rarely ever exists (if at all) without giving rise to pelvic peritonitis, and also to a pelvic cellulitis. The cellulitis and peritonitis arising from the same causes as the salpingitis and not being separate lesions.

Pelvic abscesses in general are only the outcome of the afore named conditions, and do not, in my opinion, exist as independent factors. It is not difficult in many instances to trace the infection from its inception to its finish, noting the lesions occasioned thereby, with a great degree of certainty.

Undoubtedly most of you have noticed a specific vulvitis traverse all the structures from the vulva to and including the peritoneum. You have stood by the bedside of patients dying of puerperal peritonitis, and asked yourself who or what is responsible for this; knowing that you and your attendants had exercised good judgment in the management of the case. The answer comes, continuity of membrane has permitted the carrying of infection from some point below the peritoneum, or there has been direct involvent through the uterine structures.

The matter of routine examinations on the part of physicians and gynecologists is not, in my judgment, a proper procedure. Women do not, as a rule, favor this course, and allow it in many instances under protest. Consent under these circumstances means embarrassment and humility to the patient, and the result is frequently unsuccessful, owing to this fact.

The inquiry then suggests itself as to when a vaginal examination should be made? This is a matter that the physician must largely decide, but I would indicate that it should not be done until a thorough history of the case, past and present, has been. obtained, summarized and the deductions assure us that sufficient trouble exists to warrant a physical examination. Getting a thorough history of the case is helpful if the examination follows, is more satisfactory to the patient, and as a matter of record is of incalculable value.

By this procedure many cases will not be examined that otherwise would, while another class will receive attention that otherwise might be neglected.

Determining then that an examination should be made, which method should be first used? There is considerable argument in favor of the digital examination at the outset, but I am favorable to the ocular examination first, because with this

method anomalies and diseased conditions can be accurately decided, which might not be discovered by digital examination, and if so would in most cases require inspection to make the examination complete. In addition, it is a protective measure to the physician. By inspection I have promptly decided in numerous instances against inserting my fingers into the vagina.

A few days ago I examined a patient by sight and found a chancre upon the cervix, which I would have failed to find, besides incurring a risk slight though it might have been. Having very briefly referred to methods of examination, I desire to speak first of inflammation of the cervix and body of the uterus. The existence of inflammation of the endometrium as a chronic affection is disbelieved by many.

The chronic condition being called catarrh and congestion. From a diagnostic standpoint, considering physical appearances, uterine catarrh is not an inapplicable term; notwithtsanding this, we must be mindful of the fact that the irritation present and the discharge manifest are the results of inflammation, further back than this, the microscope often determines the character of the inflammation, and I trust I may receive your pardon for suggesting that all discharges from the genital tract should be examined in this way, when there is doubt or suspicion as to its

nature.

Time will not allow classifying the various forms of cervical inflammation, and I do not believe the classifications as generally given are of any special importance from a curative standpoint. I believe it would be a safe presumption to presume that these inflammations are caused by micro-organisms. I do not believe this to be so in all cases, but when doubt exists, this is not a bad choice. In this connection then, I will only speak of endocervicitis, or as it is generally understood, cervical catarrh.

In summarizing a history of this disease, I would expect it to read nearly as follows: Leucorrhea, irregular menstruation, sterility, backache caused by standing or walking. Each symptom, of course, is variable, such as slight or severe leucorrhea, severe or mild backache. Menstruation though irregular may not be markedly so, or it may amount to a metorrhagia. Sterility may be relative or absolute. The most prominent symptom, however, is leucorrhea. The normal discharge is not in health sufficient to attract attention, unless it is due to a slight natural

increase just before or after menstruation. The leucorrhea varies in color; white when mixed with mucus corpuscles, yellow when pus corpuscles are present, brown when mixed with blood. Color has little to do with the sticky character of leucorrhea, which is always present. Much importance attaches, however, to a discharge which stiffens the patient's linen and leaves a greenish yellow tinge. I believe this symptomatic of gonorrhea. I only incidentally refer to this as it does not especially belong to cervical catarrh. By ocular examination a cervical catarrh can easily be differentiated from an inflammation of the vagina. In the former case, the os will be found filled with mucus, which hangs out over the posterior lip and into the vagina. Upon attempting to remove this it will be found difficult to do, and may have to be scraped off with an instrument.

Relative to physical appearance of the cervix, and especially in the multiparous woman, laceration is present, margins eroded generally hard, and covered with granular nodules. In other cases the os stands widely open and the lips, one or both, pout ; when only one it is oftenest the anterior. In the multipara the os is surrounded by a patch of excoriated tissue in which the outer epithelial layers have been scaled off. Absolute distinctions between endocervicitis and endometritis are not always possible.

When the cervix is enlarged, lips thickened, lacerated, pouting and eroded, presenting granulations or excoriations with a viscid discharge, it is evident that we have a cervical catarrh. Remembering the history of a cervical catarrh, you will be able to note the difference in this as compared with an endometritis. This disease usually follows abortion, labor or gonorrhea, and occurs most frequently in multipara. In this we have leucorrhea and menorrhagia, the menstrual discharge sometimes amounting to great quantities, the patient becoming anemic as a result. Occasionally dysmenorrhea is present, but not generally. Retention of mebranes and pieces of placenta, cervical lacerations, conditions which interfere with the circulation, thereby favoring congestion; cellulitis and peritonitis being examples. Tumors, misplacements, the use of pessories and especially the intrauterine stem pessary; these symptoms, to which enlargement of the uterus may be added, are usually confirmative of catarrh of