VOL. 48, No. 4 July, 1956 247

LeucorrheaJULIAN 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 com-plaints which bring the woman to the physi-

cian, 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 whohave not at sometime experienced some degree ofleucorrhea; but leucorrhea in the great majorityof women is neither troublesome, bothersome norrequiring of protection.

Moreover, because of the rapid eradication ofearly cervicitis incidental to acute gonorrhea, andthe expanding practice of effective postpartumtreatment of the traumatic cervix resulting fromlabor or abortion, indicative of good obstetrics, asignificantly decreasing number of women, duringthe past 10 or 15 years, are presenting themselveswith chronic infective endocervicitis (intractableleucorrhea).

Leucorrhea (literally white discharge) is not adisease, but an objective expression of a multiplic-ity of organic process-physiologic, pathologic(local and constitutional), and endocrinopathic;under which headings leucorrhea will be hereindiscussed.

Its color depends on its composition: the bluishwhite from desquamated epithelium and mucus,yellow or greenish yellow from pus and bacteria,chocolate color from old blood or blood-coloredfrom fresh blood; it may be watery from serum,mucilaginous from mucin or creamy from pus; itmay be odorless or there may be a very offensiveand sometimes putrid odor. The mucous secretionfrom the cervix normally is alkaline 9.2, is clearand glistening in appearance; while that from thenormal vagina is acid 3.8 to 4.5.

ETIOLOGY

Physiological leucorrhea is encountered pre- orpostmenstrually, sometimes at ovulation and sexualexcitement; during early pregnancy before coale-scence of the decidua capsularis with the decidua

lateralis obliterating the uterine cavity; it may bea hydrorrhea gravidarum; or it may be replacementleucorrhea, which is periodic with or without moli-mena, requires protection and is of the approxi-mate amount and duration as normal menstruation.It occurs in some young women before the onsetof menarche and in some women following thephysiologic menopause. These require no specialtreatment; reassuring the patient of the innocenceof such leucorrheas is all that is necessary.The pathologic local: Here one has to consider

vulvovaginitis-bacterial, trichomonal, monilial,tuberculous; foreign bodies (sponges, tampons, pes-saries) in the vagina; irritating douches, infectionsin Skene's and Bartholin's glands, endocervicitisfollowing the trauma of labor or abortion; some-times uterine fibroids by irritation; endometritis,pyo-salpingitis profluens or hydrops tubae pro-fluens, and the last but by all counts the most im-portant, especially in women definitely past themenapause, is the appearance, de novo, of leucor-rhea (serous) or of altered leucorrhea.

This latter should be invariably investigated forpossible early carcinoma of the endometrium orthe endosalpinx or, rarely, of the cervix; thoughcarcinoma of the cervix is usually encounteredmuch earlier.The constitutional causes include such condi-

tions as anemia, pulmonary tuberculosis, chronicnephritis, diabetes mellitus and other diseases asso-ciated with debility as well as those of the circula-tory system that produce congestion of the pelvicorgans such as chronic passive congestion of heartdisease and cirrhosis of the liver.

Examples of the endocrinopathic leucorrhea areseen in endometrial hyperplasia or polyps, senilevaginitis and the hyperplastic cervix.

Treatment of leucorrhea due to these conditionsis indicated; for example, thyroid extract, uterinecurettage, estrogen, et cetera.

DIAGNOSIS

The diagnosis of leucorrhea, it is obvious,

243 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION JULY, 1956

resolves itself into the detection of the underlyngcausative condition. This indudes a thorough his-tory as respects the color, whether or not theleucorrhea is periodic, associated or not with anyparticular event or if protection is required.Any leucorrhea, occurring for the first time, or

is increased, which cannot be readily accounted foror is questionable, should be smeared and/or cul-tured; and if still questionable, uterine curettage orbiopsy should be done, constitutional causes havingbeen ruled out by a thorough general and pelvicexamination including indicated laboratory pro-cedures. And if the underlying cause is found, cor-rect treatment is indicated.Of the many and varied conditions responsible

for leucorrhea, chronic infective endocervicitis hasgiven the physician greatest concern. The diagnosisis easily and readily made from history (intractableleucorrhea), and by use of the vaginal speculumto visualize the source (cervix) of the discharge,cervical erosion, Nabothian cysts and, sometimes,an enlarged cervix.

It is in the consideration of treatment, particu-larly during the reproductive period, where theresources of the physician are constantly challengedfor satisfactory results.

Hence, we shall discuss, in more detail, thetreatment of chronic cervicitis, since the greatmajority (at least 60 per cent) of leucorrhea ispostpartum and post-abortal.

If the cervicitis is mild (six weeks to ten weekspostpartum) with little or no cervical erosion,Nabothian cysts or enlarged cervix, we have foundthat ionization with 2 per cent copper sulfate orzinc sulfate solution is uniformly effective, mostsatisfactory and without resultant scar-tissue steno-sis. The copper or zinc is aoplied, for six to tenminutes, to the endocervix by positive galvanismthrough a cervical electrode. This procedure isrepeated 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, Nabothiancysts and/or enlarged cervix, the use of chromicacid as described', has proved the most efficient,inexpensive and satisfactory method that it hasbeen 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 thecervix are better reserved until after menopause,because of the resulting scar tissue dysmenorrheaand possible dystocia. Electrocoagulation throughits anaerobic action and healing, though a littleexpensive and technical, could be used cffectivelyand satisfactorily, during the nubile period, andwithout such undesirable results. Cervical biopsyof any suspicious areas to rule out possible co-exist-ing carcinoma is imperative, before treatment isundertaken.

Furthermore, the elimination of the irritation,by eradication of mild postpartum endocervicitis,reverses, at the same time, the pH. of an unhealthyneutral or alkaline vaginal secretion to the normalacid 3.8 to 4.5.The result of this procedure is restoration of a

state of normalcy, in the tissues, unfavoreMe tothe development of cervical carcinoma, a diseaseessentially of the parous woman, predominantlyduring the childbearing period.

Finally, in my opinion, if every postpartum orpost-abortal cervix (infected) were treated thusly,and the scar tissue removed (trachaelorrhaphy)following childbearing, a long step will have beentaken in the direction of prophylaxis of cervicalcarcinoma.

LITERATURE CITED

1. Ross, J. W. Chromic Acid for the Treatment ofChronic Infective Endocervicitis, Am. J. Obst. andGynec., Vol. 33, No. 2, 1937.

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