T

HERE are certain gynecologi

are of

cal affections that special interest to the internist, and I shall utilize the time available to touch briefly on three of them.

First, in regard to focal infections, that is, inflammatory foci that may be the cause of distant joint trouble. In connection with focal inflammations we hear a great deal about the tonsils, with their deep crypts which may harbor infection indefinitely, and about the nasal accessory sinuses which frequently become occluded with resulting pus retention. Now, in the female genital tract there are two sites in which these same conditions are frequently found. One is the cervix. The glands of the cervix. uteri are long and many-branched and have a comparatively small opening which is quickly occluded by inflammation. The bacteria penetrate into the long glands, the outlet ducts become occluded and deep foci of inflammation remain. These foci are so deeply placed that they are out of reach of applications. That is why cervicitis persists in spite of strong bactericidal applications within the cervical canal. The antiseptic never reaches the inflammatory foci, which

'Read before the Eighth Annual Clinical Session of The American Congress on Internal Medicine, St. Louis, Mo., February 18 to 23, 1924.

are not near the surface but deep in the cervical wall. There the process may keep on indefinitely, unless over come by the resisting agencies of the patient's tissues or by effective treatment.

Now this portion of the uterus is rather insensitive. Cervical inflammation as a rule causes little or no pain, and though there is some discharge the patient attaches little importance to that. Consequently, deep-seated cervicitis may be present without the patient complaining of pelvic symptoms, and even without her suspecting the presence of an inflammatory focus in that locality. So in your search for inflammatory foci in a troublesome case of arthritis do not forget the cervix uteri.

Another favorite site for the localization and persistence of pyogenic bacteria is the Fallopian tube of either side. The frequency and persistency of inflammatory foci in the Fallopian tubes, are explained by the anatomical relations and structure of the tubes. The uterine portion of the tube, through which infection enters from the uterus, has a very small canal which is quickly closed by inflammation. In the outer wider portion of the tube, the mucosa is disposed in complex longitudinal folds. These projecting folds are very numerous and extensive, practically filling the

lumen of the tube with their delicate prolongations. In this mass of delicate folds, inflammation soon plays havoc. The folds become agglutinated, forming closed pockets in which pus collections form. In a short time both ends of the tube are sealed and the tubal interior is disorganized. The infected tube becomes a series of pus pockets surrounded by a wall in which the lymph and blood vessels are well organized to act as highways for bacteria seeking distant parts.

In the early stage of tubal inflammation there is usually considerable peritoneal irritation, with resulting pelvic pain and soreness, and also some tendency to increased menstrual flow. These symptoms of course vary with the severity and extent of the inflammation. In many cases there are troublesome symptoms calling attention to the pelvic focus. In other cases, however, the acute disturbance subsides in a few days and after that the patient has only occasional pelvic symptoms, sometimes only at menstruation, and not of sufficient severity to cause her to think there is any serious pelvic trouble. An inflammatory focus in the tube may persist thus in a chronic state over a long period-so long that the slight disturbance of the acute stage is forgotten, and careful questioning may be required to recall

it.

In any case of persistent trouble, probably of focal origin but for which no focus can be found elsewhere, these two sites in the pelvis the cervix and the Fallopian tubes should be investigated.

Next comes the cancer problem. I do not intend to inflict upon you a dissertation on the frequency of cancer

of the uterus nor on the results of failing to recognize it. That story has been told often and well by many, particularly through the splendid work of the American Society for the Control of Cancer. Just a word as to the insidiousness of uterine cancerhow it grows silently and unsuspected. At first it is only a small hardened area on the vaginal portion of the cervix, or, it may be up in the cervical canal or in the endometrium. There is no pain and no marked disturbance of any kind. After a time there may be some discharge or perhaps a little bleeding, but this is so slight that the patient gives it no attention. In many cases the process runs along without any definite local symptom, until far advanced. Then something causes bleeding, the individual goes for examination and an advanced cancer is found-too late for curative treatment.

In this connection I wish to make just two points one concerns myself and the other concerns you. Long ago I became so impressed with the insidiousness of pelvic carcinoma, seeing so many advanced cases with symptoms of only a few weeks duration, that I vowed to miss no opportunity to call attention to the subject. All that any of us can do in this direction is so little compared with what needs to be done, that every one should give serious thought as to how he individually may do his best to bring to light these unsuspected cases of malignant disease. This brings up the question as to whether we ought to advise every woman approaching forty to have a pelvic examination to determine if there is any evidence of beginning cancer. Considered simply from

one standpoint it is easy to answer, yes. But the problem is not so simple as that. There are many factors that militate against telling every woman aged forty who may consult us that she should have a pelvic examination. In the first place, there is the natural disinclination of the patient to have a pelvic examination at all, and of course this disinclination is much increased when there are no symptoms making the need of the examination apparent. Again, the suggestion of the possibility of cancer disturbs some patients unduly. To some individuals who never had a worry nor a thought in that direction, the suggestion of the possibility of cancer brings a haunting fear, that even several examinations may not eradicate. Again, the physician naturally feels a delicacy in advising something for which the patient may see no very good reason except the pecuniary benefit to the physican. And this pecuniary benefit lessens to some extent the force and effectiveness of his advice. In connection with pelvic carcinoma this applies especially of course to gynecologists not so much to you as internists. For that reason I feel that you are in a peculiarly favorable position to secure acquiescence and action on any advice you may give in this respect.

No doubt some of you feel, as I for a long time felt, namely, that it was carrying the matter too far to advise every woman approaching the menopause to have a pelvic examination to eliminate cancer. But the facts of long experience including the harrowing episodes of finding advanced cancer with only short duration of symptoms in the case of personal friends and in the wives of professional colleagues-these sad experiences have changed my views. The hard logic of time and events has convinced me of the advisability of this examination in all women approaching forty years of age. In the early stage uterine carcinoma and ovarian carcinoma often practically symptomless. This fact is well known, but it appeals to us usually only in a general and impersonal way. The seriousness of the situation is brought home, however, when we visualize the possibilities in the case of each woman who comes to us, confidently trusting her future health to our keeping. Considered in this individual and personal way I am sure you will reach the conclusion I have, namely that it is our duty to advise pelvic examination, to detect or eliminate early cancer, in every woman approaching forty who asks us to assume responsibility concerning her health.

O

PHTHALMOLOGY, like any other branch of medicine, will prosper generation after generation only to the degree in which it properly relates itself to its environment. This, of course, means constant adjustment and readjustment to changing conditions. Sometimes the change in environment is only to be noted after decades and adaptation is slow; at other times it is sudden and compels an abrupt right about face.

Environment for a branch of medicine is immediate and mediate. The immediate is its relation to the other branches of medicine, to medical education, medical research and medical practice, private and institutional. Its less immediate environment is its relation to the individual, to groups and organizations such as schools, corporations, to the city, district, state or nation.

Just how does ophthalmology stand thus, socially? Is it in a healthy state, what is going on about it, what is it doing? Is it properly related to its environment and what changes should be made?

First in its relation to medical education it is accused of trying to make eye specialists out of undergraduate

students.

1 Read before the American Congress on Internal Medicine, St. Louis, Mo., February 20, 1924.

So great has become the criticism of specialization that in 1922 a group of the most eminent medical educators in the country including one of your own branch, Dr. Wilbur of Leland Stanford, meeting here as the Committee on Medical Education and Hospitals of the American Medical Association, presented a report to the House of Delegates advocating the abolition of all teaching of undergraduates by specialists and advocating that all special teaching be done by the departments of medicine, surgery and obstetrics. I will read just one paragraph. Such a reading often does any given report a grave injustice but in this case it does not do any injustice:

If these subjects are adequately taught there will be no need to include the specialties except in an elementary way. The professors of medicine and surgery can readily bring the essential to every specialty into their routine teaching.

The specialties, taught as they are at present, belong outside the undergraduate medical curriculum. They can be included in the medical curriculum when they are taught by men who can range over the body instead of having their vision limited largely to body orifices.2

Teachers of ophthalmology the country over have been quick to deny

Report of the Council on Medical Education and Hospitals of the American Medical Association to the House of Delegates, May 22, 1922, pp. 14-16.

the imputation that they are making specialists out of undergraduates and contend that they are trying to give the student less theory, no unnecessary physics, no refraction, less of operations, as few didactic hours as possible and a maximum of pathological and clinical ophthalmology. We admit that, as in other departments, and certainly not excluding internal medicine, there are too many classroom exercises, too little dispensary work, too few beds, too few laboratories, and too few instructors.

The neglect of the dispensary in ophthalmology is, however, particularly to be regretted because here the major part of the departmental activity should be carried on just as I believe it should be from the college standpoint, in otolaryngology, children's diseases, neurology, dermatology and genito-urinary diseases. The neglect of the eye dispensary is clearly evident in a committee report submitted to the American Ophthalmological Society last year in which it is shown that aside from three schools the average of new cases per day in the eye dispensaries of Class "A" colleges is only 4 cases. Ten cases would be a minimum, for eye material is more than half refraction and operative leaving very little of external and fundus disease which the student really should have in abundance. Good teaching is seldom to be done on so limited a material. What is the trouble? One shortcoming which again is by no means peculiar to ophthalmology is that the head of the department does not give enough time to the work. He usually spends two half days a week on it whereas five

half days is, in my opinion, an irreducible minimum. Furthermore, in contrast perhaps with some other lines of work it is easily possible to give this much time as head of an eye department and still make a good living in the other half of the day, so there is no excuse for it on this score. There is another defect common to many communities and to a number of departments, namely, the lack of integration between the best dispensary and charity hospital material in the district with that of the medical college. I refer to the separate isolated charity hospital for eye diseases, for children's diseases, for obstetrics, for ear, nose and throat, for orthopedics, for mental diseases, etc.

Patients have been well cared for in many of these institutions and there has been good teaching done in them but the best care of patients and the best teaching cannot be done in them now or ever again in the future. Eye work suffers because these institutions still attract such a large proportion of the charity material of so many large cities including Boston, New York, Philadelphia, Baltimore, New Orleans, Chicago and San Francisco.

What may be expected of ophthalmology in these respects in the future? Undoubtedly our teaching will be freed of the criticism of trying to make specialists out of undergraduates, and heads of departments will soon be willing to give ample time to the work. As to the prospect of bringing any considerable part of the material of the eye infirmaries of the country under the control of the medical schools it can only be said that it is so logical that it is bound to come, that