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VOL. 48, No.

July, 1956

247

Leucorrhea
JULIAN WALDO Ross, M.D. Professor and Head, Department of Obstetrics and Gynecology, Howard University and Freedmen's Hospital

LEUCORRHEA is one of the three chief complaints which bring the woman to the physician, the other two being pain and hemorrhage. This triad has been aptly designated the P.H.D.pain, hemorrhage and discharge of gynecology. There are a few, if any, normal women who have not at sometime experienced some degree of leucorrhea; but leucorrhea in the great majority of women is neither troublesome, bothersome nor requiring of protection. Moreover, because of the rapid eradication of early cervicitis incidental to acute gonorrhea, and the expanding practice of effective postpartum treatment of the traumatic cervix resulting from labor or abortion, indicative of good obstetrics, a significantly decreasing number of women, during the past 10 or 15 years, are presenting themselves with chronic infective endocervicitis (intractable leucorrhea). Leucorrhea (literally white discharge) is not a disease, but an objective expression of a multiplicity of organic process-physiologic, pathologic (local and constitutional), and endocrinopathic; under which headings leucorrhea will be herein discussed. Its color depends on its composition: the bluish white from desquamated epithelium and mucus, yellow or greenish yellow from pus and bacteria, chocolate color from old blood or blood-colored from fresh blood; it may be watery from serum, mucilaginous from mucin or creamy from pus; it may be odorless or there may be a very offensive and sometimes putrid odor. The mucous secretion from the cervix normally is alkaline 9.2, is clear and glistening in appearance; while that from the normal vagina is acid 3.8 to 4.5.
ETIOLOGY

Physiological leucorrhea is encountered pre- or postmenstrually, sometimes at ovulation and sexual excitement; during early pregnancy before coalescence of the decidua capsularis with the decidua

lateralis obliterating the uterine cavity; it may be a hydrorrhea gravidarum; or it may be replacement leucorrhea, which is periodic with or without molimena, requires protection and is of the approximate amount and duration as normal menstruation. It occurs in some young women before the onset of menarche and in some women following the physiologic menopause. These require no special treatment; reassuring the patient of the innocence of such leucorrheas is all that is necessary. The pathologic local: Here one has to consider vulvovaginitis-bacterial, trichomonal, monilial, tuberculous; foreign bodies (sponges, tampons, pessaries) in the vagina; irritating douches, infections in Skene's and Bartholin's glands, endocervicitis following the trauma of labor or abortion; sometimes uterine fibroids by irritation; endometritis, pyo-salpingitis profluens or hydrops tubae profluens, and the last but by all counts the most important, especially in women definitely past the menapause, is the appearance, de novo, of leucorrhea (serous) or of altered leucorrhea. This latter should be invariably investigated for possible early carcinoma of the endometrium or the endosalpinx or, rarely, of the cervix; though carcinoma of the cervix is usually encountered much earlier. The constitutional causes include such conditions as anemia, pulmonary tuberculosis, chronic nephritis, diabetes mellitus and other diseases associated with debility as well as those of the circulatory system that produce congestion of the pelvic organs such as chronic passive congestion of heart disease and cirrhosis of the liver. Examples of the endocrinopathic leucorrhea are seen in endometrial hyperplasia or polyps, senile vaginitis and the hyperplastic cervix. Treatment of leucorrhea due to these conditions is indicated; for example, thyroid extract, uterine curettage, estrogen, et cetera.
DIAGNOSIS

The diagnosis of leucorrhea, it is obvious,

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

JULY, 1956

resolves itself into the detection of the underlyng causative condition. This indudes a thorough history as respects the color, whether or not the leucorrhea is periodic, associated or not with any particular event or if protection is required. Any leucorrhea, occurring for the first time, or is increased, which cannot be readily accounted for or is questionable, should be smeared and/or cultured; and if still questionable, uterine curettage or biopsy should be done, constitutional causes having been ruled out by a thorough general and pelvic examination including indicated laboratory procedures. And if the underlying cause is found, correct treatment is indicated. Of the many and varied conditions responsible for leucorrhea, chronic infective endocervicitis has given the physician greatest concern. The diagnosis is easily and readily made from history (intractable leucorrhea), and by use of the vaginal speculum to visualize the source (cervix) of the discharge, cervical erosion, Nabothian cysts and, sometimes, an enlarged cervix. It is in the consideration of treatment, particularly during the reproductive period, where the resources of the physician are constantly challenged for satisfactory results. Hence, we shall discuss, in more detail, the treatment of chronic cervicitis, since the great majority (at least 60 per cent) of leucorrhea is postpartum and post-abortal. If the cervicitis is mild (six weeks to ten weeks postpartum) with little or no cervical erosion, Nabothian cysts or enlarged cervix, we have found that ionization with 2 per cent copper sulfate or zinc sulfate solution is uniformly effective, most satisfactory and without resultant scar-tissue stenosis. The copper or zinc is aoplied, for six to ten minutes, to the endocervix by positive galvanism through a cervical electrode. This procedure is repeated at five-day intervals for three or four

applications. If the cervicitis is moderate to severe (10 to 12 weeks or longer) with cervical erosion, Nabothian cysts and/or enlarged cervix, the use of chromic acid as described', has proved the most efficient, inexpensive and satisfactory method that it has been our privilege to employ for the past 25 years. Moreover, in our observation and experience, such treatment methods as the Sturmdorf operation, electrocauterization and electroconization of the cervix are better reserved until after menopause, because of the resulting scar tissue dysmenorrhea and possible dystocia. Electrocoagulation through its anaerobic action and healing, though a little expensive and technical, could be used cffectively and satisfactorily, during the nubile period, and without such undesirable results. Cervical biopsy of any suspicious areas to rule out possible co-existing carcinoma is imperative, before treatment is undertaken. Furthermore, the elimination of the irritation, by eradication of mild postpartum endocervicitis, reverses, at the same time, the pH. of an unhealthy neutral or alkaline vaginal secretion to the normal acid 3.8 to 4.5. The result of this procedure is restoration of a state of normalcy, in the tissues, unfavoreMe to the development of cervical carcinoma, a disease essentially of the parous woman, predominantly during the childbearing period. Finally, in my opinion, if every postpartum or post-abortal cervix (infected) were treated thusly, and the scar tissue removed (trachaelorrhaphy) following childbearing, a long step will have been taken in the direction of prophylaxis of cervical carcinoma.
LITERATURE CITED

1. Ross, J. W. Chromic Acid for the Treatment of Chronic Infective Endocervicitis, Am. J. Obst. and Gynec., Vol. 33, No. 2, 1937.

A slender and restricted diet is always dangerous in chronic diseases, and also in acute diseases, where it is not requisite. And again, a diet brought to the extreme point of attenuation is dangerous; and repletion, when in the extreme, is also dangerous.-Hippocrates

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