Chapter XV., page 244. It is enough here to counsel a thorough (Part 2)

in Chapter XI., p. 183. Cancer originates in the senile uterus, — more frequently cancer of the body, and less frequently cancer of the cervix, — the latter being a disease rather of the menopause. Any bloody vaginal discharge or a watery leucorrhea in an old woman should arouse the suspicion of cancer in the mind of the practitioner, and should lead to a thorough local examination. The Vagina. — The vagina, as was pointed out in the section of this chapter on the menopause, undergoes certain changes at the menopause which persist in old age, becoming more marked after the latter period of life is well advanced. The vagina is shortened, cone-shaped because of excessive atrophy in its upper portion, its walls are thinned and non-elastic. Later in life the diminution in caliber may be so great as to make coitus impossible. The atrophied, thinned mucosa may be the seat of inflammation. Senile vaginitis, which is described in Chapter XX., p. 365, is a very common affection and often results in adhesions. The symptoms consisting of a burning sensation in the vagina, dyspareunia, a feeling of weight in the pelvis accompanying a thin irritating leu- corrhea, are not characteristic. The diagnosis is made by a local examination. The Vulva. — The vulva shows signs of marked atrophy in old age. The hair of the mons veneris and labia majora becomes gray and scanty. The fat under the mons and in the labia dis- appears gradually after the post-climacteric period of hypernu- trition has been passed, and the labia become flabby and wrinkled so that they no longer come? together firmly in the median line. Therefore the vulva gapes in varying degree's in different indi- viduals, and the openings of the vagina and urethra are not so well protected from infection as in the younger woman. The mucous membrane of the vestibule is glassy, thin and smooth, and may show areas of ecchymosis. Pruritus vulva? (see Chapter X., p. 160) is a common affection, so are various dermatoses of which eczema is the most common. Kraurosis vulvae may occur in the aged, and primary cancer has been found very rarely in the vulva at this time of life. [i] 40 INDEX Abdomen, auscultation of, 72 cavity of, shape of, Fig. 86, 221 division of, into quadrants and in- dication of bony landmarks, Fig. 18, 65 gauze records of, 74, Fig. 20, 75 in late pregnancy, appearance of, 427 inspection of, 64 mensuration of, 74 in case of ovarian tumors, 304 organs of, origin of tumors in, Fig. 129, 304 palpation of, 68 percussion of, 71 skin of, appearances of, 66 swelling of, in case records, 8 in clinical history, 20 walls of, fat in, differentiated from ovarian tumor, 310 fibromyoma of rectus muscle in, 310 movements of, 66 with ascites, cross-section of, dorsal position, Fig. 132, 310 lateral position, Fig. 133, 311 Abortion, diagnosis of, 436 etiology and frequency of, 437 inevitable, diagnosis of, 439 oxytoxic drugs a cause of, 437 partially or wholly completed, diag- nosis of, 440 symptoms of, 438 syphilis, a cause of, 437 threatened, diagnosis of, 439 varieties of, definitions of, 436 Abscess, anal, 514 submucous, 515 appendiceal, differentiated from pel- vic cellutitis, 196 ischio- rectal, 515 mammary, 542 pelvic, 193 mapped out by bimanual touch, 42 Abscesss, pelvi-rectal, 515 psoas, differentiated from pelvic cellulitis, 196 sub-mammary, 542 sub-urethral, differentiated from cys- tocele, 368 from dislocation of urethra, 447 Absence of any organ (see organ speci- fied) Acetonemia, odor of breath in, 61 Acetonuria, in extra-uterine preg- nancy, 353 Acromegaly, attended by amenorrhea, 419 Actinomyces. See Salpingitis, acti- nomycotic Acute diseases, a cause of sterility, 151 Address, in clinical history, 9 Adhesions, a result of pelvic peritonitis, 192 and incarceration of ovarian tu- mors, 315 Age, in clinical history, 9 Alcoholism a cause of sterility, 151 Alligator bladder forceps, Fig. 50, 105 rectal forceps, Fig. 62, 125 Amenorrhea, 139 as a symptom of pregnancy, 419 primary, 139 secondary, 141 Ammonia coefficient in vomiting of pregnancy, 435 Ampulla of Fallopian tube, Fig. 116, 285 Anal canal, anatomy of, 122 region, diagram of, Fig. 195, 515 Anatomy of organ. See organ speci- fied Anemia, a cause of sterility, 151 in fibroid tumors, 258, 261 Anomalies. See organ affected Anteflexion. See Uterus, anteflexion of Anuria, 156 627 628 INDEX Anus, abnormally small, 498 abscess in, 514 at third month of fetal life, Fig. 157, 392 canal of, Fig. 150, 373, Fig. 191, 495 cast of, Fig. 192, 496 cancer of, 526 chancre of, 511, 512 chancroids of, 511, 512 condylomata lata of, 512 development of, Figs. 158-162, 395 eversion of, for inspection of hem- orrhoids, 502 fissure of, 503 gumma of, 512 imperforate, 497, 561 inspection of, 121 lipoma of, 523 mucous patches of, 511 papilloma of, 522 protrusion from, as a symptom, 158 soft fibroma of, 523 syphilis of, 510 syphilitic ulcerations of, 512 tuberculosis of, 513 vaginalis, 393 Anxiety, polyuria in, 485 Appendicitis differentiated from sal- pingitis, 336 Applicator, uterine, Fig. 37, 93 Apprehension, a cause of polyuria, 485 Arbor vitse of cervical canal, 204, 209 Areola, anatomy of, 421, 532 primary, 421, 532 secondary, 426, 535 Arnal, views of, on diminution in size of uterus in old age, 624 Arterial tension, high, in menopause, 613 Arteriosclerosis, nienorrhagia in, 136 Ascites, abdomen of, seen in profile, Fig. 131, 307 differentiation of, from fibroid, 263 from ovarian cyst, 308 encysted, 308 Auscultation of abdomen, 72 Backache, 18 Bacteriuria in children, 579 Ball, Sir Charles, case .of absence of rectum, 496 Ballantyne and Thompson, cases of prolapse of uterus in infants, 562 Ballottement, external, 429 internal, 427 Barker, Fordyce, cases of late child- bearing, 602 Bartholinitis, 409 Bartholin's glands, abscess of, 409, Fig. 176, 411 abscess of ducts of, Fig. 175, 410 anatomy of, 391 cancer of, 414 collection of discharges from, 61 cyst and abscess of, differential diagnosis of, 412 cyst of, differentiated from entero- cele, 371 differentiated from hernia, 413 cyst of left, Fig. 174, 409 cysts of, 408 lurking places in, for infection, 180 Baudelocque. See Pelvis, conjugate diameter of cases of regular menstruation dur- ing pregnancy, 469 Baumgarten and Poffer on acetonuria in extra-uterine pregnancy, 353 Bearing-down feeling, 19 Bender, X., and Lardennois, G., ob- servations that fibroids may be in- vaded by cancer metastases, 255 Berger, H., cases of melancholia at menopause, 615 Bichat, observations on old age, 622 Bimanual touch. See Touch, bi- manual; also Palpation, bimanual Bladder, absence of, 457 adenoma of, 483 anatomy of, 101 anomalies of, 457 base of, showing diverticula, Fig. 185, 458 calculus of, 462 in children, 582 cancer of, 483 capacity of, measurement of, 109 catheterization of, 108 clonic spasm of, 109 INDEX 629 Bladder, contracted, a cause of fre- quency of micturition, 154 contraction of, 461 development of, Fig. 71, 198, Figs. 158-162, 395 diseases of, 457 in children, 578 displacement of, downward, 461 lateral, 462 upward, 461 distended, 459. See also Bladder, overdistended differentiated from large ovarian tumor, 314 differentiated from small ovarian tumor, 300 diverticulum from, 458 double, 458 eversion of, through urethra, 462 exstrophy of, 459 fibroma of, 483 fistulse of, 474. See also Fistula foreign bodies in, 463 functional disturbances of, 151, 484 hernia of, 462 hypertrophy of wall of, differen- tiated from cystocele, 368 inflammation of, 465 irritability of, 485 landmarks in, 103 loculate, 458 myoma of, 483 new growths of, 480 normal, laid open from the front, Fig. 51,106 overdistended, incontinence in, 154 shape of, Fig. 84a, 217 papilloma of, 482, Fig. 190, 482 primary tumor of, in children, 582 removing urine from, by suction apparatus, Fig. 55, 113 rupture of, 460 in retroflexion and incarceration of pregnant uterus, 432 sarcoma of, 484 stammering of, 109, 465 stone in, 462, Fig. 186, 463 in children, 582 tuberculosis of ureteral orifice in, Fig. 187, 469 Bladder, vagina and rectum ballooned by air, in examination of, Fig. 54, 112 varicose veins of, 474 varix of, 474, Fig. 188, 474 wall of, drumming of, 465 hypertrophy of, differentiated from cystocele, 368 thickening of, a cause of stricture of ureter, 489 Bladder phantom, Fig. 58, 118 Bladder symptoms, 151, 484 in case records, 7 in clinical history, 20 Bland-Sutton, case of frequent hot flashes in menopause, 613 case of multiple seedling fibroids, 244, 251 on hydatid fremitus, 299 on myomatous affection of Fallopian tubes, 338 on ovariotomy performed on children, 576 Blood pressure in menopause, 613 vessels, uterine and ovarian, Fig. 8, 47 Bloodgood, J. C, classification of diseases of the breast, 536 on sarcoma of the breast, 549, 551 Blum, case of three mammae, 538 Boils of vulva, 407 Bokai, case of ligation of clitoris, 575 statistics of rectal prolapse in chil- dren, 584 Boldt, H. J., views on severe grades of exfoliative cystitis, 468 Bondi, J., on varieties of cysts of the labia minora, 413 Bonney, C. W., cases of rupture of pyosalpinx, 333 Borner, case of premature menopause, 600 case of unexplained flowing at meno- pause, 619 case of prolapse in virgin at meno- pause, 620 is ovulation abolished with cessation of menstruation? 599 Bowels, in case records, 8 in clinical history, 21 630 INDEX Bozeman dressing forceps, 83 Bozeman-Fritsch uterine irrigator, Fig. 35,92 Brain, disease of, cause of incontinence of urine, 155 Breast, absence of, 538 adenocarcinoma of, 546 with papilloma in the cysts, 546 age changes of, 534 anatomy of, 533 areola of, anatomy of, 421, 532 primary, in early pregnancy, 421 secondary, 426, 535 cancer of, 545 cancer cysts of, 548 differentiated from galactocele, 548 colloid adenocarcinoma of, 546 colostrum in, 427 comedo-adenocarcinoma of, 546 cyst of, simple, 540 differentiated from cancer cyst, 541 cystic adenocarcinoma of, 546 development of, incomplete, 538 diseases of, 531 classification of, 536 dissection of lower half of, showing milk ducts, Fig. 198, 534 division of, into quadrants, Fig. 200, 538 enlarged glands in axilla, a sign of tumor or inflammation of, 553 enlarged supraclavicular glands in late cancer of, 554 fullness of, a symptom of pregnancy, 420 galactocele of, 539 hypertrophy of, diffuse bilateral, 540, Fig. 201,541 in puberty, 535 infantile, 539 lactation, 535 senile parenchymatous, 540 in early pregnancy, 421 in late pregnancy, 426 infantile, 534 inflammations of, 542 lactation hypertrophy of, 535 late cancer of, cachexia in, 554 Breast, late cancer of, discharge from nipple in, 553 enlarged supraclavicular glands in, 554 metastases to other organs in, 553 signs of, 553 skin metastases in, 553 ulceration of skin in, 553 lymphatic glands of axilla, enlarged in inflammation of, 553 lymphatics of, Fig. 199, 535 medullary carcinoma of, 546 milk ducts of, 532 neuralgia of, 539, 553 nipple of, anatomy of, 532 discharge from, in late cancer, 553 discharge of blood from, 545, 546 Paget 's disease of, 548 retraction of, 553 of puberty, 535 pain in, 553 phantom tumor of, 539 rheumatism of pectoral muscle in, 553 right, vertical section of, Fig. 197, 533 sarcoma of, 549 scirrhous cancer of, Fig. 202, 547 scirrhous carcinoma of, 548 senile, 536 supernumerary mammae of, 538 symptomatic lesions of, 539 syphilis of, 544 tumors of, age as affecting, 550 diagnosis in general of, 549 duration of, 551 early diagnosis in, 549 history as affecting diagnosis of, 550 mobility of, 552 rare forms of, 537 situation of, 551 varieties of: adenoma, cystic, 545 adenofibroma, 544 cancer, 545 average duration of life in, 545 fibro-epithelial, 544 myxoma, intracanalicular, 544 papilloma, intracystic, 545 veins of, enlarged in early pregnancy, 421 INDEX 631 Brewer bivalve speculum, Fig. 26, 87 Broad ligaments. See Ligaments, broad Burrage uterine speculum, Fig. 36, 93 used in packing uterus, 96 Cabot, A. T., case of horny-celled cys- titis, 470 Calibrator, meatus, Kelly, Fig. 44, 101 Campbell, R. P., on the diagnostic significance of spirochseta pallida, 407 Canal, anal, Fig. 191,495 Canavan, M. M., case of ulcerative vaginitis in bacillary dysentery, 364 Cancer. See Organ affected Cancer and fibroids, to be excluded from statistics on the menopause, 590 Cantharides, a cause of cystitis, 467 Capacity of bladder, 109 of pelvic cavity, 98 Carcinoma. See Cancer and organ affected Caruncle. See Urethra Carunculae myrtiformes, Fig. 165, 397 Case-record system, 6 Case-records, form for, 6 Casper, on appearances of bladder by indirect cystoscopy, 117 Catheter, bladder, long, Fig. 43, 101 ureteral, Kelly, Fig. 48, 103 Catheterization in children, 578 of bladder, 108 of ureters, 115 caution against, 479 Cauliflower growth. See Cervix, can- cer of Causation of disease in any organ. See organ affected Cellular tissue, pelvic, anatomy of, 192 Cellulitis, pelvic, 192 diagnosis of, 194 differential diagnosis of, 195 differentiated from appendiceal abscess, 196 from pelvic hematocele, 196 from pelvic peritonitis, 195 from psoas abscess, 196 from pyosalpinx, 196 from subserous myoma, 196 Cellulitis, etiology and pathology of, 192 symptoms of, 193 Cervicitis. See Endocervicitis Cervix, adenocarcinoma of, diagnosis of, 275 differential diagnosis of, 276 adenocarcinoma of canal of, 268 early stage of, Fig. Ill, 268 anatomy of, 204 appearance of, in early pregnancy, 422 atrophy of, at menopause, 594 canal of, collection of discharges from, 62 cancer of, a cause of stricture of ureter, 489 cauliflower growth, 271 diagnosis of, 271 differential diagnosis of, 272 differentiated from erosion, 186 from fibroid, 265 early stage of, Fig. 110, 267 infiltrating, 272 squamous-celled, 267 early stage of, Fig. 110, 267 ulcerating, 272 chancre of, differentiated from erosion, 186 chancroids of, differentiated from cancer, 275 from erosion, 186 condylomata of, differentiated from cancer, 273 elongation of, hypertrophic, Fig. 88a, 225 case of Huguier, 225 differentiated from prolapse, 229 false, 209 erosions of, 184 cause of sterility, 150 differentiated from cancer, 274 from cancerous ulceration, 186 from chancre, 186 from chancroid, 186 from tuberculous ulcer, 186 from ulceration, 186 follicular, 185 in children, 563 papillary, 185 G32 INDEX Cervix, erosions of, purple m color in early pregnancy, 422 simple, 184 with lacerations, Fig. 69, 185 fibroids of, 247 follicles of, hypertrophied, differen- tiated from cancer, 273 gumma of, differentiated from cancer, 275 hypertrophic elongation of, true, 225, 229 inflammatory thickening of, differen- tiated from cancer, 273 lacerated, a cause of hemorrhage at menopause, 618 lacerations of, 204 a cause of sterility, 150, 151 bilateral, Fig. 79, 205 with eversion of lips, Fig. 82, 208 crescentic, Fig. 81, 207 differential diagnosis of, 210 etiology of, 204 mechanism of production of, 205 old, 209 recent, 208 results of, 206 stellate, Fig. 80, 206 unilateral, Fig. 83, 209 mucous polypi of, differentiated from cancer, 273 myoma of, differentiated from can- cer, 273 of purplish color in early pregnancy, 422 papillary tuberculosis of, differen- tiated from cancer, 273 removal of tissue from, for examina- tion, 62 sarcoma of, 280 syphilis of, differentiated from can- cer, 275 tuberculosis of, differentiated from cancer, 273 ulcer of, from papule, differentiated from cancer, 275 simple, differentiated from cancer, 274 from erosion, 186 tuberculous, differentiated from cancer, 274 Cervix, tuberculous, differentiated from erosion, 186 Chancre. See Vulva, Vagina, Cervix, Anus, and Urethra, chancre of Chancroids. See Vulva, Vagina, Cer- vix, and Anus, chancroids of Change of life. See Menopause Chiene, ovariotomy on three-months- old child, 293 Child, new-born, longitudinal median section of, Fig. 204, 558 Childbearing, in case records, 7 late, 601 Childhood, gynecological affections of, 555 Children, examination of, 556 number of, in clinical history, 11 Chlorosis, amenorrhea a symptom of, 419 Cholemia, menorrhagia in, 135 Chorioepithelioma. See Uterus, Vagi- na, and Tube, Fallopian Chromocystoscopy, 119 Chute, A. L., case of infected diverticu- lum of bladder, 458 Claisse, A., theory as to etiology of fibroids, 250 Cleanliness in vaginal examinations, 28 Climacteric. See Menopause Clitoris, Fig. 156, 389 anatomy of, 390 at third month of fetal life, Fig. 157, 392 malformations of, 393 prepuce of, adherent, 557 Cloaca, Fig. 159, 395 Clothing, loosening of, as preparation for examination, 24 Clover crutch leg-holders, 57 Coccygodynia, 159 in clinical history, 19 Coccyx, pain in, 159 Coitus, barred by vaginismus, 379 excessive, a cause of abortion, 437 of cystitis, 467 of sterility, 151 injuries of hymen due to, 401 of vagina due to, 376 painful, 146 through dilated urethra, 444 INDEX 633 Coitus, unnatural, a cause of gonor- rheal proctitis, 510 Collection of tissues and discharges, 61 Colostrum. See Breast Colpitis, 361 Combined vagino-abdominal touch, 38 Comby, J., on vulvar hemorrhages in little girls, 572 Complaint, chief, in clinical history, 7, 12 Conception, factors essential for, 149 late in life, 601 without sexual feeling, 149 Condylomata, acuminata and lata. See Vulva and Anus Congenital anomalies and malforma- tions. See organ affected, anom- alies and malformations of Congestion, pelvic, a cause of leucor- rhea, 145 of menorrhagia, 135 of sterility, 151 Conjugate diameter of pelvis, 96 Constipation, a cause of fissure in ano, 503 of hemorrhoids, 500 of retroversion, 236 in clinical history, 21 Controller, current, Fig. 57, 117 Cord, spinal, diseases of, retention and incontinence of urine in, 485 Corpus luteum. See Ovary Craig, M., views on mental disease at menopause, 615 Cryptomenorrhea, 139, 140 Cullen, T. S., on adenomyoma of uterus, 245 Cullingworth on hemorrhage in the new-born, 572 Cultures, method of taking, 62 Current controller, Fig. 57, 117 Curette, uterine, Fig. 31, 90 forceps, Emmet, Fig. 30, 89 Curetting, dangers of, 93 technique of, 90 Currier, A., on the menopause among American Indians, 588, 598 Cylinder, vertical, likened to cavity of abdomen, Fig. 7, 45 Cyst. See Ovary, Vagina, and Paro- varium, cyst of tubo-ovarian, 334 Cystitis, 465 a cause of dysuria, 153 catarrhal, 467 chronic, hypertrophy of bladder wall in, differentiated from cystocele, 368 classification of, 466 cystoscopy in, 473 diagnosis of, 471 etiology and pathology of, 466 examination of urine in, 471 exfoliative, 468 in children, 581 palpation of bladder in, 472 symptoms of, 471 tuberculous, 468 ulcerative, 468 vesicular, 470 with cornified patches, 470 with yellowish plaques, 471 Cystocele, Fig. 148, 366, 367 at menopause, 621 diagram of, Fig. 148a, 368 differential diagnosis of, 367 Cystoscope, bladder, Kelly, Fig. 49, 104 ureter, Nitze, Fig. 56, 116 Cystoscopy, direct, 110 electric, 117 indirect, 117 instruments used in, 99 removing urine from bladder by suction in, Fig. 55, 113 D alton, J. C, case of