#. M "^^ 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 I I ■& i^o '-••■ 1 1 ' CIHM/ICMH Microfiche Series. CIHM/ICIVIH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de niicroreproductions historiques ii Technical and Bibliographic Notes/Notes techniques et bibliographiques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be tibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming, are checked below. Coloured covers/ Couverture de coulaur I I Covers damaged/ D D D n D D D Couverture endommagie Covers restored and/or laminated/ Couverture restaurde et/ou pelliculde r~n Cover title missing/ D Le titre de couverture manque Coloured maps/ Cartes g^ographiques en couleur Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Relii avec d'autres documents Tight binding may cause shadows or distortion along interior margin/ La re liure serrie peut causer de I'ombre ou de la distorsion le long de la marge intdrieure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajouties lors d'une restauration apparaissent dans le texte. mai9, lorsque cela itait possible, ces pages n'ont pas 6x6 filmies. Additional somments:/ Commentaires suppldmentaires: L'Institut a microfilm^ le meilleur exemplaire qu'il lui a dt6 porsible de se procurer. Les details de cet exemplaire qui sont peut-dtre uniques du point de vue bibliographique, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la mithode normale de filmage sont indiqu6s ci-dessous. I I Coloured pages/ D Pages de couleur Pages damaged/ Pages endommagies Pages restored and/oi Pages restauries et/ou peiliculdes Pages discoloured, stained or foxe< Pages dicolories, tachetdes ou piqu6es Pages detached/ Pages ddtachies Showthrough/ Transparence Quality of prir Qualiti indgale de I'impression Includes supplementary materit Comprend du materiel suppldmentaire Only edition available/ Seule Edition disponible |~~1 Pages damaged/ r~n Pages restored and/or laminated/ r7| Pages discoloured, stained or foxed/ I I Pages detached/ r~~| Showthrough/ I I Quality of print varies/ I I Includes supplementary material/ I I Only edition available/ Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image/ Les pages totalement ou partiellement obscurcies par un feuillet d'errata, une pelure, etc., ont it6 filmdes d nouweau de facon d obtenir la meilleure image possible. This item is filmed at the reduction ratio checked below/ Ce document est film^ au taux de reduction indiqu6 ci-dessous. 10X 14X 18X 22X 26X 30X J 12X 16X 20X 24X 28X 32X T7- The copy filmed here has been reproduced thanks to the generosity of: IVIedical Library IVIcGill University (Montreal The images ^^poearlng here are the best quality porsible considering the condition and legibility of the original copy and in keeping with the filming contract specifications. Original copies in printed paper covers are filmed beginning with the front cover and ending on the last page with a printed or illustrated impres- sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page with a printed or illustrated impres- sion, and ending on the last page with a printed or illustrated impression. The last recorded frame on each microfiche shall contain the symbol ~»> (meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. ly/laps, plates, charts, etc., may be filmei at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: L'exemplaire filmA fut reproduit grice h la g^n^rositi de: IVIedical Library McGill University Montreal Les imiiges suivantes ont 4tA reproduites avec le plus grand soin. compte tenu de ia condition et de la nettet« de Taxemplaire f iimi. et en conformity avec les conditions du contrat de filmage. Les exemplaires originaux dont ia couverture en papier est imprimte sont fiimte en commenpant par ie premier plat et en terminant soit par ia dernidre page qui comporte une empreinte d'impression ou d'illustration. soit par ie second plat, selon le cas. Tous les autres exemplaires originaux sont filmte en commenpant par la premldre page qui comporte une empreinte d'impression ou d'illustration et en terminant par la derniAre page qui comporte une telle empreinte. Un des symboies suivants apparaftra sur la dernlAre image de cha^ue microfiche, selon ie cas: le symbols -^> Sijnifle "A SUIVRE", ie symbols V signifie "FIN". Les cartes, planches, tableaux, etc., peuvent Atre filmte A des taux de reduction diffirents. Lorsque le document est trop grand pour fttre reproduit en un seul clichA, il est film« d partir de i'angle sup^rieur gauche, de gauche d droite. et de haut en bas. en prenant ie nombre d'images n^cessaire. Les diagrammes suivants illustrent ia mithode. 12 3 1 2 • 3 4 5 6 i^dd Q^ CR/>/VUaJa/ . V^J • ^ ] '9'Oi^ THE ADDRESS IN GYNJlCOLOGY. ST WILLIAM GAEDNER, M.D., ' "^ U Professor of Gynaecology in McGill University, and Gynaecologist to the Royal Victoria Hospital, Montreal. Reprinted from the Montreal Medical Journal, S'ptembcr, 1900. WILLIAI^ GAHDNKR, 1866, THE ADDRESS IN GYNAECOLOGY. nv William Gardner, M.D., Professor of Gynujcology in McGill University and Gynaicologist to the Royal Victoria Hospital, Montreal. Delivered before the Canadian Medical Association, Ottaiva Meeting, ICOO. MISTAKES IN DIAGNOSIS AND TREATMENT. From the si^andpoint of a consultant of over twenty years standing, I ■Imvo learned something of the mistakes in diagnosis and treatment made by myself and others^. I have conceived the idea that some con- sideration of this subject might not be unprofitable before a meeting mainly of general practitioners. It is a trite saying, that we learn more from our failures tlian our suc- cesses. It is, perhaps, equally tr.!' thtot we leairn more fro.n our mis- taken than correct diagnosis. The lessons we thu^s learn are often pain- ful and the experience bitter, but they are not likely to be forgotten. Accuracy in the diagnosis of pelvic conditions depends mainly on education of the sense of touch. This can only be obtained by long and patient practice and much opportunity for making examinations. All teachers of practical gynajcology will bear me out when I speak of the difficulty in giving to the medical student more than a few oppor- tunities on the patient. It is far other with the teacher of clinical medicine, who can in most cases allow an unlimited number of students to examine a Ohest or lung case. Nevertheless, many fewer mistakes would be made if attention were given to a few simple details. In this, as in everything else in medicine, the grand i^afeguards against mistakes are system and method in case- taking and examination. As a rule r woman's pelvic organs cannot be sa:tisfactorily examined if she lie on a bed or couch. The many advan- tages of a table, a firm surface, for the physician's comfort, have only to be experienced to be realized. I am well awaire of the difficulty in get- ting many Avomen to consent to this, especially if the practitioner be young. Suitable personality and tactful manners will, in most cases, lead to success. The condition of the adjacent viscera, the bladder and rectum, is all important. The rectum must have been emptied before the patient comes to the examining table. With reference to the bladder, ;my own practice, learnt by personal experience, is to empty the bladder by 2 catiheter after the patient is in position on the table. The advantages are tliat : (1) We may note the presence or absence of discliargos, siich aa that of gonorrhcea, about tlie genitals, and their character, a very important kind of evidence which we should lose if we allowed the patient to j)iass water naturally. (3) There are many women who when asked to pass water immedi- ately before a pelvic examination are unable from nervousness to do so. (3) We get an uncontamin'ated specimen of iirine for examimition. When from a suitable position of the patient, whereby the abdomiiml muscles are thoroughly relaxed, we may still have to contend with rigidity from nervousness or ticklisliness on the part of the jmtient, this may be overcome by la mana'uvre which I frequently jwactico with suc- cess. It consists in making a series of circular, frictional movements over the lower abdomen. These should flrsit be in a circle of relatively wide diameter, the whole abdomen, but gradually narrowed to one much smaller. What do we g^ain by this m.anceuvre ? If gently executed we overcome rigidity of the abdominal muscles and we displace gradually the intestines. These movonionts are tlie first tihinig done in the practice of the Thiire-Brandt nietiiod of pelvic massage. Metlical students and doctors of little experience hkve often com- plained to me of being unable to roach the 'structures at the upper and back part of the pelvis because their fingers were too short. The re- latively 'long, posterioi' vaginal wall can be, in a sense, shortened by steady, gentle, continuous i>ressure on the perineum, whereby it is par- tially turned into 'the vagina. In physical ex!amination for pelvic diagnosis I would strongly urge caution in the use of the sound. Apart from the danger of inducing abortion in unsuspected pregnancy, unless strict asepsis be practised, the sound is a dangei'ous instrument. Many a woman has died of the uterine sound. In the grdat majority of cases it cannot be used without abrasion of some part of the uterine canal. Unless instrument, hands, and field of operation be sterile, there is great danger of infection, and this has often been the consequence, setting up more or less serious and sometimes fatial pelvic inflammation. With all due respect to the great Sir James Simpson and others whose names are so intira!ately connected with the use of the sound, I am con- vinced that it is a much overrated instrument. In hands skilled in bimanual palpation it is rarely necessary, while in hands unskilled, it will hardly 'ever add to useful, prlactical understanding of the case. As a consultant I have learnt that the sound is a great deal too much used by the general practitioner. Mistakes in the diagnosis of retroversion of the uterus, either way, thttt id to say, miataking retrovoreion for other conditions or mistaking other conditions for retroversion, are certainly amongst the commonest. But, indeed, accurate diagnosis in complicatetl conditions, (and compli- cated conditions are common and ithe most important) is often most difficult. A common mistake is overestimating the importance of re- troversion, of the displacement per se, in a comiplicated case, as of pelvic inflammation directly inducing the displacement. Such an imperfect or mistaken diagnopis may lead to an attempt to rophujo the uterus by sound or repositor, and to its mechanical treatment by poss'ary, with, most probably, disastrous results. This lefids me to speak of mistakes in overestimating the importance of deviations of the uterine axis from the normal. No more fierce wordy wars h!ave ever been fought than by gynaBcologists over the relative im- portance and order of oocuiTcnce of dis.place(ments, and those changes in the circulation and nutrition of the uteriis to which we apply the term cihronic metritis. The transactions of the Obstetrical Society of Lon- don of about thirty years ago teem with the discussions. While most of us cl'aim to have obtained a ^wsition nearer the truth, the consultant still finds in the body of the profession imperfect views, and inadequate conceptions of the subject. It seems often to be forgotten that the uterus in health is essentially a very movable organ. It is pushed back- wards by a distended bladder, forward and upwards by a distended rec- tum, and by every act of respiration, especially by forced respiration as in coughing, vomiting, or violent effort, it is deviated from what may be considered the norm, and liUl suah displacements, temporary it is true, are attended with relatively little in the way of symptoms attribut- able to the uterus. I am next led to speak of another mistake which we have made in the past, but wbicli we are, some of us ^at least, now rectifying, and 'lat is in failing to recognize that in many women a displaced uterus is only one element, though certainly a very important one in a case of more or less general descent or sagging of abdominal viscera, the condition of enteroptosis. For many years I have in every case I examine made a point of examining for the position of the kidneys as well as other vis- cera of the abdomen. Displacements of these organs in gynaecological cases are of extreme frequency. It is true that descent of the kidney does not always cause symptoms. In other oases the symptoms are grievous. In the parous woman they are especially so. The commonest and perh'aps the most important mistake here is iu,overestimating the importance of the pelvic condition and neglecting to take inti account the rest. The repair of a lacerated perineum, the necessary colpor- rapihies, and the performance of a selection from the various forms of g in their fixation of tlic uterufi, may for these reasons he disappuintin results. In the managtnient of dis|'lacenionta by many practitioners mistakoe are often made in ovorostimatmg the usefulne.>'s uf pessaries, in the selection of ctuses suitable for their employment, in tlie siilection of a pes- sary for a particular case, and in the neglect of the very fretpienlly necessary preliminary treutment of the patient and the parts against which the pessaa-y will lie. Oft times too, there is lucking an adotpiate conception of the necessary care of a patient wlio is wearing siu-'h an a})- pliance. The oon«equence is that appliances, which in suitable selocled oases are undoubtedly most useful, suifer undue tad unmerited discredit. The sensations of the patient which suggest to her mind displacement of the uterus and which are apt to be aocoplcil by tlie iuexperienccH.1 physician, are often due solely to vaginitis. This condition, when of the fundus of the canal where it is often mainly or exclusively present, c*an only with ease or certainty he diagnoscMl and treated by the Sim's method of examimvtion. This method of examination, it "would api)ear, is huirnt by only a small proportion of those who practice gyntecology. It requires the patient to lie on a table in the neeess*iry position, to have her clothing loose, Uml to breathe quietly and naturally. All these conditioiLS being fulfilled, the use of the Sim's speculum is merely an accessory, for the bent handle of a pewter spoon or even the finger will bometimes suflice to retract the perineum and posterior vaginal wall and expose the now distended vagina, the result of atmospheric jwessure act- ing under lalterod relations of abdominal and pelvic organs. A carefid oxamination by this methoaa-ed to bear me out. Failure in the recognition of existing pregnancy is rarely pardoned by a woman. Failure to discover that she is performing the supreme function of her sex, and to give her credit for it, is to her a grievous fault. Apart from this there is the obvious imiportance of early knowledge of the fact in order that plans may l)e made and necessary arrangements put in tiiain. The cases are few in which a diagnosis cannot be made by a careful investigation of histoiy, symptoms and physical signs, negative and positive. I must, however, not forget to admit th!at we are not always freely admitted to possession of each of tliuso souroos ol' evididiue. Many wamon axo proverbially inacourato aa to dates and in the doseriptiou of .symptoms, and wo mtwt oyer be on our giiiu'd against the designing woman, legitimiitely or illegitimately pregnant, who wiHliuts to rid herself of tlie concoptioii, and who hoj)e8 that by the use of thi' sound or oilier instrument iiicautioufily used by the practitioner, her purpose may be eU'eeted. While history, symptcmis, and the condition of tl e breasts nre all important, the supreme value in tlie eetiniation of the various sources of evidence is to be placed on the biniimunl palpation of the uterus. I am in the habit. of impressing this on my students. If, with empty bladder 'and roctuni, and everything else favourable in tJie position of the patient, you cannot easily de^ne the uterine body, so distinctly iirm in the nulliparous condition, then suspect pregnancy. It is thus soft in the condition of pregnancy, and comes neiiirly to the feel of the roof of the vagina and other structures in the pelvis. If the uterus can be defined, the value of the so-called IJeg^ar's sign, — the sudden increase of size above the junction of the body find the cervix — is very great. It is in early pregnancy that mis- takes in diagnosis are most frequently made, but I have known not a few in the more advanced stages. Oases are not unknown of all the ar- rangements having been made for operation for ovariotomy, and the patient mean^\■'hile being delivered of a full term child. This has oc- curred to men of world-wide reputation, the (authors of books and numerous papers on obstetrical and gynfecologieal subjeotfl. In one in- stance which ocoiirred to mo. ovarian cyst had been diagnosed, and the woman being in great distress from the enormou.s distension, .she had been twice tapped. She travelled over five hundred miles to re«ich me for operation, all the preliminaries having been arranged. I found her resting on her hands and knees in my v;-aiting room and in that position .she had remained during the night in the sleeeir process of growth so closely do they lie to the uterus, tbit by jjositioii and consistence they now and tlieii closely simu- late the common, solid tumour of the uterus. The diagnosis of uterine fibromyoma from intrapelvic cancor, usually ovarian, in its early sLiges is by no means always easy. One mistake of tliis kind occurring a good many years ago mortified me very much. The ]>hysical signs were such that my diagnosis was multiple fibroids. In a few weeks, failure of flesh and strength tod the appearance of peritoneal fluid aroused sus- picions of malignant disease, which were confirmed by exploratory operation. All ovarioton.'sts and abdominal .surgeons of much experience have been disappointed an ^ saddened by the appd-arance of intrapelvic and abdominal cancer v'thin a year or two after a smooth recovery from the operation for renujv if an ovarian tumour, apparently quite innocent in its -haractei-s. Lawson Tait used to remark something to the effect that eve^-y ovarian tunumr had in it the elements of malignancy. His remurk was doubtless the outcome of the experience I have alluded to. It would be more correct to say that if the whole of every ovarian tumour were submitted to careful microscopic examination by a com- petent pathologist, many which appear benign would show malignant cihara0t.ers. This hci is a strong argument, if any were needed at the present day, for the prompt removal of every ovarian tumour -as soon as possible after its discovery. In malignant tumour of no other organ is radical cure by operation so hopeful. i^othing in the experience of the gynaecologist is so saddening 'as that of cancer of the uterus. In tlie vast majority of the cases when first seen the only verdict to be rendered to the anxious patient is "too late" to do anytiiing but make the last months of life as little miserable as possible. In by far the larger numiber the woman does not seek advice 8 from her ardinaxy medical attendant, until hor case is hopeless for ladi- oal core. In rare instances even when opportunity for examinatiun has been given, the true nature of the case is not suspected. In my ex- perience the worst cftse of this kind was that of a woman who was sent to me by her medical attendant in the hope that I might be abi ^o cure a vesico-vaginal hstulu, tlie result of cancer of the cervix that nad extended to and perforated the vesico-vfiginal septum. This neglect of uterine cancer is due more than anything else to the delusions so imi- versal in the popidar mind concerning .so-c*alIed change of life, delusions whix^h I regret to say are shared by a small though I am pleased to say diminishing section of the general pi'ofession. Such are the prevalent ideas, that lat the age of from forty to fifty women are subject to pro- fuse and irregular discharges of blood, and that tlie essential symptoms of cancer are pelvic pain and foetid leucorrhoea. The expericncef] gynaecologist knows that, save in a few exceptions, menopause is not attended with menorrhagia or metrorrhagia, except wlicn some form of organic disease exists, and that such symptoms demand prompt pelvic examination. If this be true of women who have not yet attained menoj>ause it is viistly more true of those who have ceased to have dis- charges of any kind for montlis or yaars, and yet I have known a num- ber of instances of women of fifty land over, one of sixty-fiv?, in wliich the appearance of a bloody discharge was welcomed, and announced with pride to hew friends by the woman as a return of the distinctive characteristic of womanhood, — ias a renewal of youtli. One woman said to her friends, " I am getting young again." In my experience the a]i- pearance of bloody discharge in a woman wlio ha*; ceased to menstruate metens malignant disease and nothing else in ninety-five per cent, of tlie cases. In the other five per cent, the source of the blood is that inter- esting form of vaginitis which the late Professor Hildebrandt of Konigsberg proposed to call "vaginitis adhesiva idcerosa." As regards the significance of pain and foetid discharge, I wish to say with all the authority I may command as a consultant, that while invariably present in the advanced stages, they are almost as invariably absent in the ojrly and manageable stages, and yet it has many times been replied to me when I had announced my diagnosis, "why the woman has had no p'fl.in or ill-smelling discharge." If there is one early symptom of cancer more suggestive, even signifi- oant I ought to say, of the early stage of cancer of the uterus, cervix or body, it is the appearance of a thin, serous, slightly turbid, sometimes pinkish at first, and for many weeks iLsually inodorous, discharge. Thi? so-called 'meat-water* discharge at any age ought at once to arouse suspicion in the mind of the practitioner consulted and lead him to in- t 9 sist on an exaiiiiuatiou with all the authority he can command. The reasons should be given if necessary, and if he is refused he should wash his hands promptly of all responsibility in the case. Malignant disease of tlio body of tlie uterus is undoubtedly very rare as coni^mrod with similar disease of the cervix, but I have found that its frequency and the possibility of it are much underestimated by many pi-actitioncrs. The symptoms in a given case have led to the suspicion uf m'alignant disease, the patient has been examined, the cervix has been found smootii and healtliy, and tlie uterine body normal in size and symmetrical. Then, too often, has it been concluded that there is no cause for alarm, and the fatal mahidy, which could only have been re- vealed by the dilator and curette, is allowed for a time to go on with its stealthy jmce till other more prominent symptoms arise. And now 1 come to 'another class of mistakes, very common, much less serious in their results it may be, but certainly of great importance from the point of view of their eifects on tlie patient's prospects and the practitionei''s reputation. I allude to an underestimate on the one hand and overestimate, more freciuent perhaps, on the other htod of the in- fluence of disease and dc aigement of woman's sexual system on her symptoms and health generally. While it is true that there is scarcely an organ or function of tlie body which m'ay not be disturbed reflexly or sympathetically by diseases or disturbances of function, and in many instances even by the physiological perfonnance of function of woman's sexual system, yet it is most necessary that in every individu'al case the symptoms should be studied in the light of heredity, early training, and any other influences which may have determined the type of nervous system. And for the rest, in studying a gynfficological case the same methods should l)e i)ursued 'as those by wliioli every ease of disease is or should be studied, every organ and function carefully interrogated. In this way only may be avoided such grievous mistakes as removing healthy ovaries for painful menstruiation, when that disorder is merely a local expression of a morbidly sensitive nervous sj'stem, inherited, or, as it may be, in many cases, acquired. I feel that I must not conclude my discussion of this subject without an allusion to a class of mistakes wliicli concern and influence the sexual liygiene of woman. Such are the mistakes of omission of the family doctor who fails to urge the mothers or guardians of young girls to in- form those under tlieir charge of the important matters pertaining to sexu'al hygiene. No girl can know by intuition the significance and im- portance to her health of a normal performance of the function of men- struation. How many instances have we not known of fright from the appearance of the discharge, of the use of cold water to remove it as an unclean thing, of its disregaird or of its deliberate arrest so that the pur- suit of pleasure might not be interfered with. Such is undoubtedly often the result of ignorance, though many times also from wilful dis- regtod of wai'nings of the coMequences. In my experience there are few mothers or guardians of young girls who instruct in the necessary, way those under their charge in this most important matter. This often appears to be a mere question of neglect but I am certain it is also very often from a shame-Daced aversion on the part of mothers to dis- cuss such matters with their daughters, and so a most important source of influence and a bond of confidence between mother and daughter are never acquired. If the young girl has to learn of this miatter from friends and companions of her own age, or from mature women other than her mother, she -may also learn from them other things she had better not have known. There would doubtless have been little difficulty in further pursuing this line of thought. Suffice it to say th"at I have indicated mistakes the most oommon in my experience, and the most serious in their re- sults, and if it be thought by some who have heard me that something is due in self defense for the selection of suoh a subject as that I have chosen for this address, let it only be that it is in some measure a con- fession. I have included in the list mistiakos of my own, humiliating enough they have been, as well as those of otliers.