CHAPTER III THE INTERPRETATION OF THE CLINICAL HISTORY (Part 1)

CHAPTER III THE INTERPRETATION OF THE CLINICAL HISTORY The address, nationality, and occupation, p. 9. Age, p. 9. Social condition, p. 10. Dypareunia, p. 11. Children, 11. Family history, p. 12. Previous history p. 12. Constitutional diseases, p. 12. Chief complaint and present illness, p. 13. Menstruation, p. 13: Puberty, p. 14; The menopause, p. 16; The atrophic changes in the genital organs and the body alterations of the menopause, p. 17. Vaginal discharge, p. 18. Pain, p. 18: Backache, p. 18; Muscular rheumatism, p. 19; Coccygodynia, p. 19; Pains in the groins, p. 19. Abdominal swelling, p. 20. Bladder symptoms, p. 20. The bowels, p. 21. Present illness, p. 22. This is a chapter of probabilities ; not instructions how to make an offhand diagnosis, but a sifting of the evidence as it is presented, the diagnosis being held in reserve until after the physical examina- tion, and until after any supplementary evidence has been elicited in the way of answers to questions which may be suggested by the examination. A knowledge of the normal conditions is essential, if the value of the abnormal symptoms is to be estimated correctly. The Address. — This is important not only as a matter of business but ae showing the possible effect on the patient's health of a healthy or an unhealthy locality. Nationality. — The colored race is especially prone to fibroids. Cancer is seldom found in a negress. Occupation. — Confinement in poorly lighted and ventilated work- shops, long working hours, heavy lifting, insufficient food and pro- longed standing on the feet aggravate, if they do not cause, pelvic disorders. On the other hand, a sedentary life with no real exercise may act as a contributory cause of pelvic disease. Age. — The age of the patient suggests the special disturbances found in the various epochs of life. In infancy malformations and inflammations of the lower genital tract are to be expected. At this time the infections are generally limited to the vulva and vagina, and tumors, displacements, and traumatisms seldom exist. Vulvo-vaginitis is not uncommon in little girls. 9 10 INTERPRETATION OF THE CLINICAL HISTORY Failure of the menses to appear previous to the sixteenth year should excite no apprehension ; after that it is apt to indicate under- development of the uterine organs. During the period of sexual maturity nearly all of the lesions of the genital organs may be found. The effects of gonorrhea are seen most often between the ages of twenty and thirty. Tumors of the breast are most frequently malignant between the ages of forty and sixty. Under the age of thirty-five a large abdominal tumor is more likely to be ovarian ; after that age it is more apt to be a uterine fibroid. A patient suffering from uterine hemorrhage more probably has endometritis or a polypus if under twenty; a polypus or some condition resulting from gestation, from twenty to thirty; fungous endometritis, polypus, or fibroids from thirty to forty; fibroids and malignant disease from forty to fifty. After fifty, malignant disease is the probability. Social Condition. — Congenital malformations may be brought to the patient's attention for the first time after marriage. Certain inferences may be drawn from the single or the married state of a patient as regards the cause of menorrhagia or metrorrhagia, as shown by the tables on pages 137 and 139, Chapter X., also as regards leucorrhea, as found on pages 144-146. Pregnancy is always to be considered if the patient is not a virgin. An early question as to the patient's social state, whether single, married, or a widow, may obviate embarrassing queries as to sexual re- lations and may throw light on the possible causes of her com- plaints. For instance, a recently married woman, always a sufferer with dysmenorrhea, finds the symptom aggravated and unbearable since her marriage. A periodic pelvic congestion, due to mal- position or malformation of the uterus, has been accentuated by the congestion which attends sexual relations. A recently married woman complains for the first time of smarting on urination, and leucorrhea. Suspicion of infection with the gonococcus at once arises in the physician's mind. The possibility of pregnancy or venereal infection should never be lost sight of, notwithstanding the patient's statement that she is single or a widow, great caution and tact being exercised, however, in making inquiries. The final question as to the truth or falsity of the suspicion should be left until after the physical examination in any event, and in many CHILDREN 11 cases can not be made at all without causing serious and unjustifi- able trouble in the family of the patient. Dyspareunia. — Dyspareunia dating from the time of marriage indicates smallness of the introitus vaginae or urethral caruncle, if the pain is at the beginning of coitus. If the pain is experienced after the penis has been introduced into the vagina the cause is apt to be pelvic inflammation or a tender cervix or ovary. Children. — Sterility. — The absence of children may be important, for if a patient has been married many years and has not been pregnant, the inference is that the cause of the sterility rests with her and not with her husband, the latter being in good health, and we may expect to find some underdevelopment or malformation of the sexual organs. If there is any doubt as to the husband's virility a specimen of his semen should be examined for sperma- tozoa before subjecting the wife to gynecological treatment. (See Chapter X., page 147.) Carcinoma of the cervix, common in parous women, is rare in nulliparae, whereas cancer of the body of the uterus is more apt to occur in women who have not borne children. Complete or rela- tive sterility is often found in women suffering with fibroids. Number of Children. — The number of children a woman has had is important because child-bearing without a sufficient interval of recuperation between the labors frequently results in some sort of pelvic ailment. Therefore, note the ages of the children. The history of each confinement is of the greatest service in determin- ing the origin of a pelvic inflammation, a misplacement of the uterus, or lacerations. A difficult forceps delivery followed by fever and a tedious convalescence may mean all three, though not necessarily. Miscarriages and Abortions. — A history of each miscarriage or abortion should be secured with reference to the birth of children ; if before, the interruption of labor can not be due to injuries re- ceived at labor; if subsequent to a difficult and complicated con- finement, an abortion may wTell be caused by the labor. The probable cause of an abortion in the patient's estimation, whether attended by hemorrhage or fever and how long the patient was confined to her bed, are points to be ascertained. These facts often reveal the starting point of an attack of pelvic inflammation, or anemia and subsequent debility due to loss of blood. If repeated 12 INTERPRETATION OF THE CLINICAL HISTORY abortions have occurred they may indicate syphilis, tuberculosis, or a deeply lacerated cervix. Family History. — How much of a role heredity plays in the etiology of pelvic disease is not determined. Cancer and tuber- culosis are found occasionally in members of the same family. It sometimes happens that several sisters will all have a similar lesion of uterine underdevelopment. I have seen three sisters, each suffering from marked pathological anteflexion. A premature or delayed occurrence of the menopause is frequently a family charac- teristic. So is the symptom of dysmenorrhea. Family history, as a rule, does not have an important influence on diagnosis. Previous History, on the other hand, is of great importance. We have noted how an abortion may be the starting point of an attack of pelvic inflammation to be followed, perhaps years later, by serious lesions of the pelvic organs. So a history of " inflammation of the bowels," without assignable cause, may mean pelvic inflammation, the nature of the treatment employed at the time of the attack throwing some light on the probable diagnosis. An attack of soreness of the vulva associated with a purulent discharge, with or without smarting on urination, may well mean gonorrhea. Adhesions of the labia minora, and of the prepuce to the clitoris, and even imperforate hymen, may be caused by inflammation of the vulva in childhood due to diphtheria, scarlet fever, measles, or gonococcus infection. Nocturnal enuresis is caused, sometimes, by adhesions of this sort. Therefore, when possible, the mother of the patient should be questioned whether her daughter had vulval soreness and discharge when a child. A lack of control over the bowels when loose, during the months following a labor, leads us to expect to find injury of the sphincter ani, also inability to control the urine when standing, or on laugh- ing and coughing, make us look for injury of the vaginal wall and perineum and dislocation downward of the urethra. Injury of the pelvic floor is present if the patient complains of the noisy escape of air from the vagina when she suddenly changes the position of her body, or strains. Constitutional Diseases. — All general constitutional diseases have a bearing both as causative agents and aggravating influences on pelvic disorders; therefore they should be inquired into in getting MENSTRUATION 13 the history. It so often happens that a woman in her usual good health is not seriously incommoded by a pelvic lesion and when pulled down by a long illness is overwhelmed by uterine symptoms. The physician should move slowly in drawing conclusions as to cause and effect, and also in judging of the weight to be attached to the uterine disease. It should never be forgotten that the whole is greater than any one part and that general constitutional diseases take precedence over gynecological affections. It is the sick woman we are to treat. Chief Complaint and Present Illness. — It is very easy for the en- thusiastic specialist to bend his energies to the making of a new ostium to a diseased Fallopian tube, or to the resection of a diseased ovary, quite forgetting for what the patient consulted him; that because he has found an abnormality of the pelvic organs, this must of necessity be the cause of the symptoms. He loses sight of the symptoms and doesn't always make a proper effort to relieve them, being led away on a futile hunt for anatomical perfection. Note, then, your patient's chief complaint, and when you have finished with the case, turn to your notes, refresh your memory, and see whether this complaint has been relieved. The duration and character of the present symptoms should be noted, such as pain, leucorrhea, abdominal swelling, and symptoms relating to the bowels or bladder, and do not slight the indications of the state of the general health as shown by the amount and character of the sleep, the state of the digestion, and the strength to accomplish customary daily tasks. Menstruation. — Menstruation may be defined as a discharge of bloody fluid which takes place from the uterus at stated periods throughout the time of sexual activity in the life of women. The causation of the discharge is still in doubt. Frankel ("Die Function des Corpus luteum," Archiv fur Gyn., LXVIIL, 1903, 438) considers that the corpus luteum in the ovary has a determining influence on menstruation. It is plain that the ovaries have something to do with this function because, when they are removed, menstruation ceases. As menstruation occurs only in human beings and some of the higher apes, it is difficult to settle the relation of menstruation to ovulation and to the normal or abnormal corpus luteum by animal experimentation. The mechanism of menstruation consists of a diapedesis of 14 INTERPRETATION OF THE CLINICAL HISTORY blood through delicate capillaries, newly formed in a thickened and congested endometrium, the vessels for the arterial supply being more capacious than those for the venous return. Some of the capillaries rupture and the blood flows out. The flow at first is mucus streaked with blood, during the height of menstruation it is blood mixed with a little mucus, and toward the end it becomes more mucous in character. Menstrual blood is dark in color, alkaline in reaction, and, because of the mucus it contains, does not clot unless the mucus happens to be deficient. The mucus renders it more watery than ordinary blood. It has a peculiar odor given to it by the sebaceous glands of the vulva which are especially active during menstruation. Puberty. — The average age at which menstruation is established, in temperate climates, is fourteen years. Variations of a year or two from this type occur within normal limits. It occurs earlier in the city girl who is subjected, perhaps, to intimate association with the other sex and to sexual temptations, than it does in the country girl, or in a girl carefully brought up in comparative seclu- sion. This rule applies to the lower animals. If a bull is placed in the pasture with a herd of heifers, heat appears earlier in the heifers than it does when they are segregated. In women of strong sexual passion the function of menstruation is established earlier and lasts longer than common. The discharge of ova from the Graafian follicles of the ovary has been known to take place before menstruation is established, and it may continue after the menopause. The functions of menstruation and ovulation are not directly dependent one on the other, but both appear to be governed by the same portion t of the sympathetic nervous system. Cases of precocious menstrua- tion are occasionally reported, and it has been known to occur as early as a few days after birth. There are many cases on record of menstruation at a few weeks or months of age. Development of the external genital organs and the breasts, increase in body size, and often the growth of hair on the pubes goes with precocious menstruation. The diagnosis is not established unless the loss of blood recurs at monthly intervals and a physical examination of the child shows evidences of premature development. It is unusual for menstruation to be established before the twelfth year. On the other hand its appearance is seldom delayed beyond MENSTRUATION 15 the eighteenth year. A case is on record, however, where a woman married at thirty-four, menstruated for the first time at forty-five, and bore a child at forty-six. According to the investigation of Rossi-Doria, an Italian physician, who recorded the data in over thirty thousand women, delayed menstruation goes hand in hand with pelvic disease. He found 39.21 per cent of pelvic malforma- tions in women who had not menstruated until twenty years or over. The normal rhythm of menstruation is a lunar month of twenty- eight days. A woman may enjoy perfect health in every respect and yet vary many days from the normal rhythm. Many women menstruate every three weeks, others every five weeks, with perfect regularity. In getting a history of the menstrual function it is necessary to specify the rhythm of the flow as well as the regularity. It is well to remember also that some women are regular at times and irregular at other times. The duration of the flow is from four to seven days. Here also a variation within normal limits of two days either way is to be noted. The greatest amount of blood is lost in the first two days. A discharge of mucus before and after the flow is common. The average amount of blood lost at a single menstruation is from four to six ounces. It is impracticable to measure this exactly and we are forced to resort to the inexact method of counting the number of napkins used. As the napkins vary in size, are used to the point of saturation by some women and barely stained by others, no definite information can be obtained. Inquiry on these points, however, will give the physician an approximate estimate which should be recorded in detail in his notes. About two well-saturated napkins a day may be considered as being normal. Whether menstruation is excessive in any given case depends in a certain measure on the physique of the patient; a full-blooded, plethoric woman may menstruate eight or nine days, using three or more well- saturated, large napkins a day; while an anemic, thin woman may be depressed by the amount of blood lost in a period of four days, using two napkins a day. The character of the flow is of importance. Note clotting, an acid reaction, a bright arterial color, and any change in odor. Attendant disturbances of other functions, before, during, and after menstruation, such as nausea, headache, depression of spirits, 16 INTERPRETATION OF THE CLINICAL HISTORY variations in the action of the bowels or bladder, are very commonly observed, and should be chronicled. Menstruation is generally attended with a greater or less degree of a sense of fulness and weight in the region of the pelvis; often- times a certain amount of pain is to be considered as not abnormal. The menstrual period is a time of instability of the circulation and of the nervous system. The body temperature is slightly elevated, the thyroid gland is enlarged, and the tonsils and vocal cords may be swollen so as slightly to impair the singing voice; so also, in some cases, there are salivation and swelling of the mucous membrane of the turbinate bones at this time. There is increased vascular tension and increased secretion of the sweat glands and of the sebaceous glands, especially those of the external genitals. Some women are affected by skin diseases at their catamenia, notably herpes, or small macular ecchymoses about the flexures of the elbows or knees. A rhythmical wave of all the physiological processes has been demonstrated by Von Ott. The greatest activity is manifest just before