A Text-Book of Diseases of Women

CHAPTER I.. The General Causes of Diseases of Women.

THE GENERAL CAUSES OF DISEASES OF WOMEN.

Gynecology is the study of diseases peculiar to women. As woman possesses organs which man has not, and as the parts--physiological and social--that she plays in life differ from those played by man, we should expect to find her afflicted with a certain number of diseases, peculiar to her, which are dependent upon her anatomy, physiology, and mode of life. Such diseases occur in barbarous as well as in civilized women; and similar diseases, peculiar to the female, occur in the lower animals. Thus, in the cow and the mare we find tumors of the vagina, prolapse of the vagina and uterus, fibroid tumors, sarcoma and cancer of the uterus, and some forms of ovarian cysts. Cysts of the tubes and the ovaries are exceedingly common in old mares; cats and goats are similarly affected.

From a pathological point of view, however, the civilized woman unfortunately differs from her barbarous sister, and from the female of the lower animals, in many important particulars. She is more liable to the pathological conditions which, more or less, all females have in common. These conditions appear in a more severe form, and are followed by more disastrous results, in the civilized than in the barbarous state.

The female among the lower animals and among savages seems to be about equal in proportionate strength and physical endurance to the male, though in size and in gross muscular strength she may be his inferior. Her subordinate position is often due not so much to any difference in strength as to the fact that the male possesses weapons--as the horns of the deer--with which nature has not endowed the female; and though she is liable to more diseases than the male, yet her relative position does not seem to be materially altered by this fact. The bitch is as enduring as the dog. The female grizzly is as ferocious and as dangerous as the male. The mare is as fast as the horse. The squaw among the American Indians can lift and carry burdens which the lazy buck would not attempt.

How different it is with the civilized woman, as we know her in this country! The average healthy woman in this country is very much inferior in physical strength and endurance to the average man, and this inferiority is tremendously increased when she becomes sick from any of the diseases to which her sex is liable.

The increased liability of the civilized woman to disease is in a large measure due to her poor physique. But this is not all.

The causes of many of the diseases with which the gynecologist has to deal cannot be traced so easily.

Fibroid tumors of the uterus, which are so common among the colored women of this country, are said by Tait to be unknown among their African cousins, who are removed by but a few generations.

The most common causes of diseases of women are injuries received during parturition; sepsis; venereal diseases; errors of development; improper mode of life and clothing during the period of development; neglect during menstruation; and celibacy.

The results of the injuries received during parturition are most numerous. They may appear immediately, a short time after labor, or at some remote period. The disabilities attending laceration through the sphincter ani or a recto-vaginal or vesico-vaginal fistula appear before the mother leaves her bed. The suffering from a laceration of the cervix, a subinvolution of the uterus, or a retrodisplacement may not be felt for some weeks or months after labor; while the still more remote result, the development of cancer, may not appear for many years, though it can be positively traced to the lesion in the cervix as the primary cause.

Septic infection of the genital tract kills or makes invalids of many women. The infection occurs at the time of a miscarriage or of a normal labor, or it may be acquired from the dirty instruments or the dirty hands of a physician. It is not a cause of disease among civilized women alone, but occurs among barbarous and semi-barbarous races.

Venereal disease, especially gonorrhea, has been said to be the most common cause of disease among women. The disease extends from the external genitals through the uterus and Fallopian tubes, causing sterility, chronic invalidism, and death from peritonitis.

Errors of development are frequent causes of disease and suffering among women. Atresia of the vagina or of the cervix uteri, by causing retention of the uterine discharges, produces most serious pathological conditions. Arrested development of the whole or of part of the uterus is a common cause of disease.

Improper clothing and an improper mode of life during the period of development are most fertile sources of diseases of women. Clothing which contracts the waist, as well as clothing which, though not unduly tight in the inactive state, yet interferes with abdominal respiration during activity, is most injurious. Such clothing diminishes the capacity of inspiration by restricting abdominal expansion, and thus crowds down the pelvic organs toward the pelvic floor; and the continuous support to the abdominal walls diminishes their natural muscular strength and places the woman in a condition predisposing to the various displacements of the uterus.

An improper mode of life, irregular hours for sleeping and eating, insufficient exercise, and lack of fresh air and sun, resulting in poor muscular development, seem to predispose the woman, as the man, to a variety of pathological conditions; but as the reproductive apparatus in woman is more delicately organized, and as, during the period of active life, this is really her chief part, it more especially suffers as a result of any general systemic derangement.

Neglect during menstruation, especially in the young girl, is a frequent cause of subsequent suffering. The effect of menstruation upon the whole system is remarkable. The nervous, vascular, and digestive systems all share in the menstrual function. The usual work of the girl at school or other employment should be altered to suit the altered conditions of her body at the menstrual period. Long school hours and close mental application or active exercise are too often continued at this time.

Celibacy is an unnatural state and a common cause of disease. Certain forms of fibroid tumors of the uterus are more common in single than in married women, and more common in sterile than in childbearing women. And the painful cirrhotic ovaries of the old maid are the result of the unceasing menstrual congestions never relieved by pregnancy and lactation.

CHAPTER II.. Methods of Examination.

METHODS OF EXAMINATION.

In order to make a complete gynecological examination, we must examine the abdomen, the external organs of generation, and the pelvic structures.

=Examination of the Abdomen.=--In order to make a perfectly satisfactory examination of the abdomen, the woman should be in bed, with all clothing removed except the undershirt and the night-dress, which should be drawn well up above the costal margin. Examination made with any constricting clothing about the waist or about the lower thorax is most unsatisfactory.

The abdomen is examined by inspection, palpation, percussion, and auscultation.

The woman should lie flat upon her back, and the abdomen should be thoroughly exposed. We can then determine by inspection the presence of dilated veins or of lineæ albicantes, the general size and form of the abdomen, the occurrence of any abdominal movement, and the presence of any asymmetry in the abdominal contour, such as would be made by the bulge of a tumor or the displacement of an abdominal organ. The shape of the abdomen, even though symmetrical, is often diagnostic of certain intra-abdominal conditions. Thus, an abdominal enlargement that is due merely to fat presents a different contour from the enlargement caused by tympanitic distention of the intestine. The enlargement due to ascites, or free fluid in the peritoneum, differs in contour from that caused by an encysted collection of fluid.

It should be remembered that lineæ albicantes are not always the result of pregnancy, but that they may have been caused by distention of the abdomen from some other cause.

Palpation.--We can determine most by palpation of the abdomen. The examiner should always remember that it is most important to secure the patient’s confidence, and to proceed so gently, slowly, and gradually in performing palpation that no voluntary or reflex contraction of the abdominal muscles may impede his manipulations.

In cases in which there is a sore or tender spot within the abdomen the contraction of the recti muscles may be altogether involuntary, persisting even when the patient is anesthetized. We see this in the rigid right rectus muscle of appendicitis. The hands should be warmed, and palpation should be performed with both hands. A certain amount of gentle stroking or massage of the abdomen will secure the patient’s confidence by making her feel that she will not be hurt by any sudden violent pressure, and will also prevent reflex contraction of the muscles. By proceeding in this way, slowly, the examiner can palpate the whole of the abdominal surface, exploring first the structures lying most anterior, and then, pressing the fingers more deeply, he can examine the more posterior structures.

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