The obtu

first two inches with the obturator in place. rator should then be withdrawn and the speculum pushed farther in, the operator watching and guiding its course around the rectal valves or folds of mucous membrane,

OLENTZO

so as to prevent injury to the walls of the rectum. Anesthesia is not necessary for this procedure.

Examination of the Bladder.-It will readily be understood that all the hollow viscera are much more easily examined when their walls are separated by distention with air than when the walls are collapsed. The bladder is most readily examined in this way. The woman should be placed in the knee-chest position, or in the dorsal position with the hips elevated above the abdomen. In either position the intestines fall from the pelvis, and when the urethra is opened air enters and distends the bladder. This distention is most certainly accomplished in the knee-chest position. In women who are not very fat, however, the extreme dorso-sacral position is equally good. The details of this method of examination. are described on a later page.

The uterine sound is an instrument by which the length of the uterine cavity may be determined (Fig. 15). The sound, which is a large surgical probe, somewhat curved to adapt itself to the normal shape of the uterine axis, is made of pliable metal, so that the curvature may be changed readily to suit any case. The sound is graduated, and at a position of 21⁄2 inches from the tip is a small elevation marking the length of the normal uterine cavity.

FIG. 15.-Ute

rine sound.

The uterine sound was at one time used a great deal to determine the length and direction of the uterus, and

perhaps to assist in determining the character of the uterine contents or of the endometrium. With our present methods of examination, however, the sound is of but little if any use. The size and direction of the uterus can in nearly all cases be determined by bimanual examination. The use of the uterine sound is by no means free from danger. Many cases of septic endometritis and salpingitis have been caused by it, and the physician has often unintentionally committed an abortion by passing the sound in a pregnant woman. uterine sound should never be used in a routine way. It should never be used unless one expects to determine with it something that cannot be determined by simpler methods of examination.

The

The most thorough aseptic precautions should be observed when the sound is introduced. The vulva, vagina, and cervix should be cleaned and the sound should be sterilized. The sound should never be introduced if there is any suspicion of pregnancy.

CHAPTER III.

DISEASES OF THE EXTERNAL GENITALS.

.

Vulvitis.-Vulvitis, or inflammation of the vulva, is not a common disease. The vulva is composed of several parts which are anatomically distinct, and, though all these parts are usually involved in an acute attack of inflammation of the vulva, yet the symptoms of the disease and the pathological appearance depend to a great extent upon the structures which are principally affected. The labia majora, the nymphæ, the vestibule with its mucous crypts or glands, the clitoris, the external urinary meatus, and the ducts of Bartholin's glands may all be involved in the inflammation. The sebaceous glands. of the labia may be especially involved, producing a form of sebaceous acne which has been called follicular vulvitis. Inguinal adenitis may accompany vulvitis.

The appearance of the parts is that characteristic of inflammation of the skin and mucous membrane in any other part of the body. The mucous membrane becomes red and swollen; the labia may become edematous; an abundant purulent discharge covers the parts, and unless cleanliness is practised the irritation from the discharge spreads to the inner aspects of the thighs, the perineum, and the anal region.

The patient suffers with local pain, which is increased by walking and by the passage or contact of urine.

The usual cause of vulvitis is gonorrhea. The condition is sometimes secondary to other diseases. It may be caused by the irritation from the discharges of a vesico-vaginal or recto-vaginal fistula, from a cancer of the cervix or in some forms of endometritis. Girls and

women who are unclean may be attacked by vulvitis as a result of irritation from decomposed smegma, sweat, urine, etc. The oxyuris, or thread-worm, may enter the vulva from the rectum and cause, in unclean children, sufficient irritation to produce inflammation. Vulvitis from uncleanliness is most likely to occur in hot weather after prolonged exercise. It not infrequently attacks children, especially those of a strumous diathesis, whose hygienic surroundings are poor. In such cases the suspicions of the parents may demand a medico-legal examination; and it is of importance to remember that vulvitis of this kind is not rare, and is not due to violation or contagion. Vulvitis in little girls may be also due to gonorrhea, independently of violation. This is the cause of epidemics of vulvitis and vaginitis in girls crowded in houses, hospitals, or asylums. The disease is spread by contamination from towels or bed-clothing.

The essential points of treatment to observe in the acute stage of vulvitis are rest in the recumbent posture and perfect cleanliness. The labia should be separated and the parts frequently bathed and cleaned with warm water. Various local washes or applications are of use. A warm solution of boracic acid (3j to a pint of water), the dilute solution of the subacetate of lead, or a solution of bichloride of mercury (1: 5000) may be used.

If the disease is of gonorrheal origin, the parts should be painted once or twice a day with a 2 per cent. solution of nitrate of silver, applied after the discharges have been gently washed away.

As the disease subsides the inflammation may be found to persist in the crypts of the vestibule, the urinary meatus, and the ducts of Bartholin's glands. It is very important that all remains of the inflammation, especially if it be of septic or gonorrheal origin, should be eradicated before the woman is discharged from treatment. The presence of any focus of inflammation, even though latent, is a constant source of danger to the woman; for septic organisms or material may be carried from the external

genitals to the higher parts of the genital tract, as the uterus and Fallopian tubes, with the most disastrous results.

Sometimes a small drop of pus will be observed escaping from one of the small glands or crypts of the vestibule, about the urinary meatus, after the inflammation has disappeared in other parts of the vulva. In this case the gland should be punctured with a fine cautery-point or a fine wooden probe or point saturated with pure carbolic acid or other caustic.

If the disease persists in the external meatus or urethra, it must be treated by the local applications appropriate for urethritis.

Inflammation of the Vulvo-vaginal Glands.-The vulvo-vaginal glands are two in number. They are

FIG. 16.-Appearance of the external genitals in a woman with gonorrhea: G. m., gonorrheal macula situated at the base of a vaginal caruncle.

about the size of a bean, and are situated deeply on the inner aspect of the labia majora, where they may be felt in thin women. The duct of the gland is about one