bladder and so placed that, seen from the front, it occupies one lateral half of the urethra and bladder beyond. When in this position the speculum divides the bladder into two compartments; for example, supposing the speculum occupies the right lateral half of the urethra and bladder, then the orifice of the left ureter is in view." With the orifice in view the introduction of the catheter can be accomplished by sight.

4. The simplest of all methods, however, is to find the interuretric ligament or else the junction of the ureter and the trigone by vaginal indagation, according to the methods explained in Chapter II. (Palpation of the Ureters). The point of the catheter is then introduced into the bladder and turned down upon the trigone where it can be felt by the vaginal finger. With the end of the catheter on the vesical surface of the vesico-vaginal septum, and the finger on the vaginal, we should have but little trouble in getting the inter-uretric ligament between them, and tracing it to the uretral orifices, which are about an inch apart. The direction of the ureter having been determined by vaginal palpation, the catheter is given a corresponding direction, and guided as far as possible up the ureter by the vaginal finger.

In attempting this manoeuvre for the first time an anesthetic should be given, and great care be taken to keep the end of the slightly curved catheter upon the base of the bladder, and to avoid using force or poking about too freely. As the bladder walls yield to pressure there is some danger of thinking that the catheter or probe is a couple of inches up the ureter when it is only in the bladder, and of poking it into or through the walls or against inflamed pelvic tissues. It should be felt by the vaginal finger to pass under the broad ligament. Moderate dilatation of the urethra including the neck of the bladder renders the introduction easier. If folds of the bladder interfere, a few ounces of water may be injected into it. The end of the catheter, being on the finger, can be guided with great delicacy, and there is not so much danger of doing harm as in Pawlick's method, which requires either sufficient pressure upon the base of the bladder for the end of the instrument to produce a projection on the septum, or else a nice judgment in determining when the instrument arrives at the point in the bladder opposite that marked by the eye upon the vaginal wall; nor as in Simon's and Lewer's methods, which require considerable rough handling of the urethral walls.

As it is hardly possible to catheterize or probe the ureter in every instance, it is better to desist after a few unsuccessful attempts, and wait for another opportunity.

General Manner of Conducting an Examination in Making a Diagnosis. Having, from the history of the case, located the disease in some portion of the pelvis, and having determined that an examination

must be made, we first resort to a digital exploration. If the rectum seems to be the seat of the trouble, we should put the patient on her side with the knees drawn up, and explore the rectum and if necessary the pelvic interior as much as possible through the anus. When the patient is a young virgin such an exploration may be made to indicate where the disease resides, and sometimes may do away with the necessity of a vaginal examination. If, however, she have had previous vaginal examinations, or have borne children, and have symptoms that leave no doubt as to the existence of pelvic disease outside of the rectum, she should be put, preferably, in the dorsal position and examined per vaginam. In the unmarried the finger will, in passing, recognize the condition of the hymen and amount of contraction of the orifices. In the childbearing woman it is sufficient at first to pass the finger slowly so as to be able to recognize the amount of relaxation or contraction of the orifices, sensitiveness or flabbiness of the mucous membrane and lower portions of the urethra and rectum. If extensive alteration be found the parts may be immediately inspected; if not, the manipulations about the vulva are better left until the close of the examination, that irritation or contraction of the sensitive parts, as well as disagreeable impressions upon the patient, may not be produced at the outset. My practice is to note the general condition of the vulvo-vaginal entrance as I introduce the finger, and to press the finger end into the tissues as I withdraw it after the palpation of the deeper structures, but to leave the inspection, vaginal eversion and grasping of the perineum between the fingers in the rectum and the others over the skin and vulvo-vaginal surface, until after the speculum is withdrawn.

If a digital exploration through the rectum be desirable, it may be made as soon after the vaginal examination as the hands can be cleansed or after the speculum has been used. Examinations of the urethra should usually be delayed until toward the end, as they are apt to cause irritation and unnerve the patient.

As the instrumental examination gives us but a small part of our information, it is well, before using it, to determine as nearly as possible the position and condition of each pelvic organ by the various forms of intra-pelvic and bimanual palpation. The probe or sound can seldom give us any accurate information as to the position of the organ unless the cervix is turned forward, or unless the uterus is fixed by adhesions; hence in ordinary cases I wait until I have exposed the os by the speculum before using it. The speculum usually turns the axis of the uterus so that the sound or probe may, unless contra-indications exist, be introduced with safety until it meets with resistance.

The experienced gynecologist can usually determine by the digital exploration the appearance to be presented through the speculum, and

needs the instrument chiefly for treatment. The general practitioner will require it, however, to diagnose the amount and character of uterine ulceration and congestion and the discharge. The character of ulceration, whether simple erosion, granulating or dissecting; the color, whether normal, pale, dark red or dark blue; the shape of the os and labia, and position of deposits or enlargements, etc., should be accurately noticed.

The condition of the vaginal mucous membrane should also be noted. In pregnancy and in some cases of pelvic disease it is altered in color to correspond with the cervix. In cases of uterine disease it is altered in color either independent of the cervix, or is not altered as much as the cervix, if at all.

An examination of the interior of the bladder, or a dilatation of the uterine cavity, or in fact any long-continued manipulation, should be avoided if possible at a first examination, or at the office. Our endeavor must be to benefit the patient, and to do that we should study to avoid doing any harm. For particulars as to examinations see Chapters II, and III.

CHAPTER V.

DISEASES AND ACCIDENTS OF THE LABIA AND PERINEUM.

ADHESION of the labia, and consequent occlusion of the vagina, sometimes occurs in infancy, or early childhood, as well as in adult life. The adhesions of infancy are so feeble and easily broken up, that they may be considered a trifling affair. Upon examining the parts, it will be found that there is no development of adhesive tissue, but the mucous membrane of the two sides is merely glued together by the mucus accumulating and drying between the parts, when in close contact, from want of cleanliness. The vaginal orifice is closed up to the urethra above, and down to the fourchette below. The treatment consists in separating the labia, by forcibly pressing each in opposite directions, until the adhesion gives way, and washing and oiling them once a day afterwards to keep them from adhering again. Should we not be able to separate them in this way, the point of a silver catheter may be passed down so as to effect it. There will be no need of any other instruments in the case.

On one or two occasions I have seen firm tissual cohesions of the labia in childhood as the effect of ulcerative vulvar inflammation. This form of adhesions may be so firm as to require the use of the knife. They are, however, always superficial, and we may generally introduce a bent probe or director behind the adhesions from above. When this is the case, it is, I believe, the best plan to separate them, by drawing the bent director through the adherent part. The same care as in the infant will prevent them from adhering again.

The most grave labial adhesions we meet are in the adult, as the effect of neglected inflammation of the vulva after childbirth. They may entirely close the vaginal orifice by the coaptation of the entire inner surfaces of the labia. I have met with more than one instance in which the hairy margins of the labia were so nicely adjusted to each other, that it was difficult to distinguish the point of original separation, from the posterior commissure to the urethral orifice, and the finest probe would not reach the vagina anywhere. The depth of the adhesion may be very great, involving much of the vaginal cavity.

These cases are very embarrassing, and are seldom perfectly remedied. It is decidedly the best plan not to interfere with them until the menstrual accumulation fills up all the vaginal cavity remaining inadherent, and then our object should be to reach the accumulation with a small trocar as near the middle of the adherent parts as possible. Placing our patient in the lithotomy position, the catheter

should be introduced into the urethra, the urine all drawn off, and the urethra held as near the symphysis pubis, or as far from the middle line of the vagina, as practicable. The catheter should be thus held by an assistant, while the forefinger of the left hand should be placed in the rectum. With this preparation we may safely introduce the trocar into the collection of fluid as felt by the finger. The fluid being drawn off, the outer extremity of the perforation may be increased by laceration as far as may be desired, and as deeply as the surgeon may consider it safe. The whole cavity should be thoroughly cleansed by a syringe with soap and water and the opening may be maintained by a glass plug. If the opening is superficial, the treatment will not be protracted; but if it is deep, it will be tedious. It should be continued until all danger of closure is past, and it will be best to keep the patient under our supervision for some time after this appears to be the case.

Wounds.

The labia are sometimes wounded by external violence and sometimes torn during labor. When the wound is deep enough to reach the bulb of the clitoris, alarming and sometimes fatal hemorrhage is the result. Professor Meigs gives an instance of great hemorrhage from these parts in a woman who had fallen upon a chair so as to cut through one of the labia. A case of fatal hemorrhage was caused in this city about four years since, in the following manner, as well as it could be learned from a legal investigation: A drunken husband returned home late at night, and, as was his wont under such circumstances, beat and kicked his wife, who was probably also inebriated. He kicked her with great violence in the genitals, and the square-toed heavy boot, in penetrating the pelvis, had cut off one labium and deeply wounded the other. In six or eight hours after the occurrence the woman was found dead, with such copious effusion of blood from the wounds as, in the opinion of the examining jury, to account for the fatal result. I saw a case many years ago, where the patient was wounded by a knife in one labium so as to cause very profuse hemiorrhage.

As hemorrhage is the important effect of these wounds, our efforts should be directed to its suppression. The bleeding part should be pressed by the hand firmly against the pubic ramus of the side upon which it is situated until temporarily arrested, when an elastic air-bag or plug of oiled cotton or lint may be introduced to fill up the vagina, and a hard compress placed and held firmly by bandages, so as to press the wounded part between the two. When wounds of the labia are large and gaping, the hair should be removed, and the wound treated according to ordinary rules for external wounds. The rents occurring in labor do not, in the great majority of cases, require any special treatment, cleanliness and quiet being all that is required.