CHAPTER III THE INTERPRETATION OF THE CLINICAL HISTORY (Part 2)

the appearance of the flow, shown by increase of muscular strength, tendon reflexes, lung capacity, and heat production. The least activity is during the flow, the lowest point being reached on the fourth day. There is a slight reaction in the week following the cessation of the flow, an intermenstrual equilibrium of two or three days, to be followed by a gradual rise to a maximum two days be- fore the next flow, and so on from month to month. The Menopause. — The climacteric or cessation of the flow usually occurs from the forty-fifth to the fiftieth year, the discharge at this time becoming less and less in amount and of irregular occur- rence, gradually stopping altogether in from six months to two years. Menstruation may stop short without any period of irregu- larity and there may be no disturbance of the nervous system, although the latter is more common. If a woman begins to menstruate early the menopause is apt to be late, and vice versa. It is a family characteristic sometimes to have the menopause early or late. In case of fibroid tumors of the uterus the menopause is commonly delayed until the fiftieth year or later, and in subinvolution and chronic metritis the menopause comes late. Vasomotor disturbances are to be looked for during the meno- MENSTRUATION 17 pause. The monthly rhythm which has existed since the fourteenth year is to be done away with, the sexual organs are to atrophy and become functionless. If the woman is in perfect health we shall expect nature to accomplish the change gradually as it was estab- lished, and without an upsetting of the general health. Too often, for one reason or another, the health is not rugged, then ensue hot flashes, sweating, palpitation, headaches, nervous irritability, and derangements of function in many organs, more especially those most closely controlled by the sympathetic nervous system. It is a mistake to consider uterine hemorrhage as a part of the normal menopause. It seldom occurs unless there is a definite local cause in the shape of a fibroid tumor, a cancer, chronic subinvolu- tion with hyperplastic endometritis, misplacement of the uterus, or other lesion. These uterine diseases may have caused no symp- toms, though existent for many years. Search should always be made for them. The Atrophic Changes in the Genital Organs and the Body Altera- tions of the Menopause. — The changes in the genital organs and in the body consist of (a) shrinking of the uterus in size. The mus- cular tissue becomes less thick and gradually the uterine cavity is shortened or even obliterated, the mucosa becoming thinned and the glands reduced in number. The epithelial cells grow smaller and lose their cilia. The vaginal portion of the cervix shrinks and does not project into the vagina, (b) The vagina is shortened and narrowed and its walls lose their elasticity and the mucous mem- brane its rugae, (c) The ovaries shrink to small knobs of fibrous tissue, the Graafian follicles disappear, and the Fallopian tubes become mere cords, (d) The fat disappears from the vulva, the labia majora become flabby, and the mons veneris loses its prom- inence, (e) The pubic hair turns gray after the hair of the head has lost its color. (/) The breasts also atrophy and become flabby, and (g) the body weight is increased. The menstrual flow may cease prematurely at an early age, even as early as the twenty-fourth year, the causes being general or local. As to the general causes not much is known beyond that they have to do with the nutritive and vascular systems. The local causes arc diseases which destroy the ovaries, as chronic infective inflammation, and removal of the ovaries by operation. It is worthy of remark that when functionating ovaries have been 2 18 INTERPRETATION OF THE CLINICAL HISTORY removed the distressing nervous symptoms of the climacteric are much more severe than when the menopause occurs with the ovaries in place. (The menopause is discussed fully in Chapter XXIX.) Vaginal Discharge. — Any discharge from the vulva is popularly referred to as leucorrhea or whites. A certain amount of moisture is normal and is made up of the secretions of the sebaceous and sweat glands of the vulva, the lubricating mucus secreted by the glands of Bartholin lying in the posterior portion of the labia majora, — most active during times of sexual excitement, — and by the secretions of the uterus. The vagina has no secretion proper and no glands, the vaginal secretion, so-called, being that poured out of the uterus together with epithelium and bacteria made acid by a bacterium which flourishes in the vagina under normal conditions. The fluid is milky and small in amount. The secretion from the cervix is tenacious, transparent, and thick ; that from the endometrium of the uterine cavity is clear, transparent, and thin. Both have an alkaline reaction. Skene's glands at the orifice of the urethra also secrete a mucus, which is thought to protect the meatus urinarius during coitus. Under normal conditions the combined discharge should not soil the clothing except just before and just after the menstrual periods, when all the secretions are increased in amount and may necessitate wearing a napkin. Abnormal constituents of the vaginal discharge, such as pus or blood, should be noted, also a bad odor or irritating qualities. (This subject is discussed at greater length in Chapter X., page 143.) Pain. — Pain in gynecological affections is generally situated in the inguinal and lumbro-sacral regions. Backache. — Backache is not characteristic of any special uterine disease and it may have no relation at all to the pelvic contents. All we can say is that it is very often present in women suffering with gynecological diseases. Backache is very common in women between the ages of thirty and fifty who are in a nervously run- down condition. One sort of backache due to sacro-iliac sub- luxation as described by Joel E. Goldthwait (Boston Med. and Surg. Journal, 1905, Vol. 152, 593) must be differentiated from rheumatism of the muscles in the lumbo-sacral regions. The sacro- PAIN 19 iliac articulations are true joints and there is increased mobility in them as well as in the symphysis pubis in women during preg- nancy and during menstruation. In certain women, especially those having spinal curvature who are the victims of subluxation, only one sacro-iliac joint is tender to pressure, and the displace- ment is the cause of backache as well as referred pains in the hip, leg, and ankle on the same side as the loose joint, caused by pressure on the sciatic nerve. These symptoms are not limited to the time of pregnancy and labor, though exaggerated then. The symphysis pubis is generally a loose joint also in these cases and may be painful to the touch, especially during menstruation. The mobility and tenderness of all three joints should be tested in any case of backache. Muscular rheumatism is detected by tenderness on pressure of the following muscles: — the erector spina?, — the longissimus, — the sacro-lumbalis, or the quadratus, — and by pain caused by the use of any of these' muscles. When a patient with lumbo-sacral rheumatism starts to straighten up, there is great pain, which abates after a few minutes' use. A patient with this affection sits or lies preferably with the body bent forward. Coccygodynia is a painful affection of the coccyx and is charac- terized by pain between the folds of the buttocks and by tenderness on pressure applied to the tip of the coccyx. (See page 159.) Pain in the groins is common in uterine diseases. In acute pelvic inflammation it is generally pronounced, especially when the peritoneum is involved. In chronic uterine disease it may, or it may not, be present. If existent it is generally a dull, continuous pain. If on the right side it is to be differentiated from the sharp intermittent pain of appendicitis, and the pain and tenderness on deep pressure in this situation, in cases of uterine disease, are, as a rule, lower down than in appendicitis. A hearing-down feeling, or a sense of weight in the pelvis, is a very frequent complaint. If, in answer to your question, the patient states that she has pain, ascertain where it is situated; the point of greatest intensity; whether it is constant or intermittent, fixed or radiating; what sort of a pain, dull, sharp, or stabbing. Describe it in the patient's own words as far as possible. The relation be- tween the pain and menstruation, if any, should be inquired into; also the effect of exercise. The situation of the pain often shows 20 INTERPRETATION OF THE CLINICAL HISTORY the nature of the lesion. Thus, pain in the sacral region may mean rectal disease, and pain above the pubes, disease of the bladder. This is not always the case, as is shown by the fact that disease of one ovary is often referred to the opposite side of the abdomen, therefore we must be on the lookout for referred pain. Abdominal swelling, indicating a tumor of any sort, is to be asked for. If present, when was it first noticed, — what is its exact situa- tion,— has it increased in size since it was first detected, and if so how much and how fast, — whether or no there has been pain in the swelling or tenderness on pressure. In the case of a suspected ovarian tumor, ask whether there has been a loss of flesh about the chest and shoulders coincident with the increase in the size of the abdomen. The occurrence of jaundice in connection with a tumor in the upper abdomen, as indicating disease of the liver or gall-bladder, is to be noted, also the relation between a tumor in the flank and impaired function of the kidneys, pointing toward tumor of the kidney. A swelling of the abdomen in a woman of child-bearing age may mean pregnancy, however improbable such a diagnosis may seem, — therefore ask always the date of the last menstruation. Bear pregnancy in mind even if the probable diagnosis is fibroid, ovarian cyst, or other tumor; pregnancy, intra- or extrauterine, may coexist as a complicating condition. It has happened several times in the author's experience that a surgeon of high reputation has discovered pregnancy in the course of an abdom- inal operation, undertaken for " abdominal tumor" without a more exact diagnosis. Bladder Symptoms. — The fact should be borne in mind that women, as a rule, urinate at less frequent intervals than men. In obtaining a history it is important to inquire as to the patient's habit as regards micturition, before drawing conclusions as to the abnormality of the symptoms. The occurrence of bladder affec- tions is rarer in women than in men. Frequency of urination on standing or exertion, with inability to hold the urine, may mean a stone in the bladder, whereas constant desire to urinate may be due to cystitis or urethritis; therefore it is necessary to inquire whether the frequency is by day or by night. Smarting on urination indicates some irritation of the" vulva or urethra. Inability to control the urine at all shows a fistula from THE BOWELS 21 the bladder into the vagina, either directly, or by way of the uterus; lack of power over the bladder on laughing, sneezing, and coughing means lack of support to bladder or urethra from injury to the pelvic floor or to the anterior vaginal wall. These are samples of the class of facts which should be learned. (The subject is con- sidered at length in Chapter X., page 151.) Ask: — How often the patient urinates? How frequently at night? How much pain in the act? When the pain is most intense? How long the pain lasts? Is it possible to control the urine when the desire to urinate occurs? Is the trouble getting better or worse? Is it affected by menstruation? Is it better or worse when the bowels are free? When did the difficulty begin? What is the supposable cause? Is the trouble the same now as at the beginning? What treatment, if any, has been used? The Bowels. — Constipation is the rule in a large proportion of women suffering with gynecological affections. At least a third of all such patients are so affected, according to reliable statistics. The statement, however, that a woman is constipated does not describe the condition with sufficient minuteness. Many women pay little attention to their bowels, considering defecation as a troublesome function to be disregarded as long as possible. Therefore, it is necessary to make careful inquiries to determine that constipation really exists. The amount of fecal matter passed depends, of course, on the amount and character of food ingested. People of irregular habits as regards their food should be expected to pass a variable amount of fecal matter; four to eight ounces is said to be the normal amount passed in twenty-four hours if the patient is living on a mixed diet. The amount is more if the diet is vegetable rather than if animal. Habits of a lifetime have a controlling influence on defecation, and a person may evacuate the bowels regularly every other day or twice a day and yet be within the limits of the normal. We must inquire whether the bowels move regularly, i.e., without medicine, enema, or artificial aid of any kind, at stated periods of time, and what those times are; whether the action is full, or scanty, and the stools solid, semisolid, or liquid; whether there is pain on defecation at the time (hemorrhoids) or lasting after the movement (fissure of the anus); whether the stools are ribbon- like (stricture of the rectum) ; whether offensive (decomposition) ; containing blood, mucus, or pus (hemorrhoids or fistula in ano); 22 INTERPRETATION OF THE CLINICAL HISTORY whether there is escape of gas involuntarily (some injury of the sphincter, or fistula in ano). In some cases of injury of the pelvic floor the patient finds that the only way she can evacuate the rectum is by making digital pressure in the vagina. Prolapse of the rectum on straining at stool is to be borne in mind in getting the history. Inquiry should be made as to the length of time constipation has existed, whether it is habitual or intermittent, and whether, in the patient's mind, there is any assignable cause. The physician should consider a pelvic tumor, rupture of the pelvic floor, a stricture, or malignant disease of the intestine as possible causes of constipation. (See Chapter X., page 156.) Present Illness. — Under this heading we group together the symptoms which go to make up the complaint for which the patient consults the physician. They consist of the data as to the functions of the different organs. Appetite, digestion, and sleep receive con- sideration in the detail justified by their importance in any given case, also any symptoms indicating derangement of the heart, lungs, kidneys, or other organs. Variations in the body weight are important as showing changes in the nutrition. Other things being equal, a greater weight shows increased vigor and strength; such a statement .being susceptible of modification in the case of very fat people. In this portion of the history the physician has an opportunity to show his ability as an internist and by his knowledge of the science and art of medicine to keep his patient, if possible, on the main line of practice instead of shunting her on to the sidetrack of specialism. It is always wise to note the exact date of the last menstruation before finishing the history. A habit of doing this will go a long way toward preventing awkward mistakes. Finally, as a matter of record, make a memorandum of the patient's peculiarities of form and figure.