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LAURENCE WELii 

THE 

PRACTITIONER'S GUIDE 

TO THE 

DIAGNOSIS AND TREATMENT 

OF 

DISEASES OF WOMEN 



BY 



' DR. GUSTAVUS M. BLECH 

k 

PROFESSOR OF OPERATIVE SURGERY, JENNER MEDICAL COLLEGE, 

SURGEON-IN-CHIEF AND ATTENDING GYNECIST MAIMONIDES 

POLYCLINIC, MEMBER AMERICAN MEDICAL ASSOCL\TION, 

MISSISSIPPI VALLEY MEDICAL ASSOCIATION, FOUNDER 

AND EX-SECRETARY WEST CHICAGO 

MEDICAL SOCIETY, ETC. 



^ 



M. ROBERTSON & CO. 

CHICAGO 
1903 



The Clinio Puiiltriiino C(». 
Chicago. 






TO 

PINCKNEY FRENCH, M. D. 

PROFESSOR OF SURGERY IN BARNES MEDICAL COLLEGE 

AND TO 

ROLLIN C BLACKMER, C M.M. D. 

PROFESSOR OF OBSTETRICS IN BARNES MEDICAL COLLEGE 

THIS BOOK IS DEDICATED 
AS A TOKEN OF ESTEEM AND RESPECT 

BY THE AUTHOR. 



PREFACE. 

It was with great reluctance that I accepted the invitation on the part 
of the publishers to write a small, concise work on so important a branch of 
surgery as is gynecology. 

I realize that the market is already overfilled with excellent treatises and 
text-books, atlases, student's manuals and quiz-compends. 

Why, I asked myself, add one more? 

Nevertheless, I have reason to believe that this little book will be wel- 
comed by not a few, for all theoretical discussions have been sacrificed in 
order to serve the every day needs of the general practitioner. 

During my career, short as it is, I have met many older practitioners 
who were satisfied to prescribe a douche or to paint the pubic region with 
iodine for pain located in the pelvis. Some have diagnosed retroflexion when 
there was decided anteflexion and introduced a bad fitting pessary, which 
aggravated the symptoms. I know of at least one case of carcinoma of the 
cervix which was treated by a family physician for six long months as an 
"ulceration of the womb." 

I could cite examples like the above ad nauseam. In conversation these 
practitioners admitted their inability to follow the larger works, for lack 
of either preparatory training or time. 

The book, therefore, has been written, for general practitioners who have 
had no clinical advantages as students. . . 

If it serves as a stimulus for further study, if it will prove helpful to the 
reader to make correct diagnoses, to institute more effective treatment and 
to recognize when to refer certain patients to surgeons of established reputa- 
tion, the midnight oil burnt while writing the book, though weary from the 
day's hard toil, was well spent. 

In conclusion I wish to ask for the indulgence of the readers for many 
shortcomings, this being my first larger literary attempt. 

Suggestions and corrections will be thankfully received. 

Dr. Gustavus M. Blech. 

Chicago, February, 1903. 



CONTENTS 



p&re 

Preface 5 

Chapter I. The Office and Equipment of the Gynecist. 9 

Chapter II. Antisepsis and Asepsis 11 

Chapter III. Examination of Patients 17 

Chapter IV. Microscopic Examination 29 

Chapter V. Disorders of Menstruation 35 

(Amenorrhea. Dysmenorrhea, Menorrhagia and Metrorrhag'ia.) 

Chapter VI. Leucorrhea 42 

Chapter VII. Sterility 45 

Chapter VIII. Diseases of the Vulva 49 

1. Adhesions of the Labia 4f 

2. Hyperplasia of the Vulva 49 

3. Inflammation of the Vulva. . : SO 

4. Gangrene of the Vulva 52 

5. Vulvar Abscess .^ 52 

6. Syphilis of the Vulva 53 

7. Pruritus Vulvae ■ 53 

8. Tuberculosis of the Vulva 54 

f . Tumors of the Vulva 55 



Chapter IX. Diseases of the Vagina 58 

Introductory 58 

1. Imperforate Hymen and Hematocolpos 59 

2. Abnormalities of the Vagina 60 

3. Atresia Vaginae 60 

4. Vaginismus , 61 

5. Colpitis , 62 

6. Tumors of the Vagina 64 

Chapter X. Diseases of the Uterus 66 

1. Malformation 66 

2. Atresia Uteri and Hematometra 66 

3. Stenosis of the Uterus 67 

4. Metritis 68 

5. Malposition of the Uterus 72 

6. Tumors of the Uterus 79 

Chapter XI. Diseases of the Tubes and Ovaries 83 

Chapter XII. Electrotherapy in Gynecology 85 

Chapter XIII. Curettage 100 

Chapter XIV. Massgige in Gynecology 105 

Appendix 108 

Bibliographical List Ill 



CHAPTER I. 

THE OFFICE AND EQUIPMENT OF THE GYNECIST. 

The physicis^n who desires to diagnose and treat diseases of women must 
equip his office for that purpose, according to certain scientific principles. 

The time when a physician's "consultation room," differed from that of 
the lawyers only in the library, has passed. The practitioner of to-day is 
expected to be a scientific craftsman ; he needs in addition to his **study" 
and reception room a workshop, or, if you please, a laboratory. 

The golden (?) era when the Doctor Medicinae, sat in his comfortable 
arm-chair, dressed in a neat Prince Albert suit, listening to the complaints 
of his clients and handing out prescriptions, has vanished, to return no more. 

To-day, the doctor must work — and seriously at that, with bared arms 
and surgically cleansed hands, with delicate, sterilized instruments. He 
must furthermore make chemical and microscopic examinations of the se- 
and excretions of the various organs, of the blood, etc. ; he cannot expect to 
cure his cases with the fountain-pen and prescription blank exclusively, but 
he will have to use his fingers and hands, electric apparatus, mechanical ap- 
pliances, etc., leaving but the smallest portion of labor to be done by the 
pharmacist. 

No fixed rules can be laid down how an office should be arranged for 
gynecic work. 

The physician who is ready to treat women, no doubt, will also do nose' 
and throat, rectal, genital (male) and general minor surgical work, and the 
arrangement will have to be madie to suit these needs, the details of which 
will greatly depend on the means and taste of the individual physician. 

The following practical suggestions will prove of some value : 

1. Decorate your waiting room and study, in any way you like, but 
have your room for all examinations and treatments of women as simple as 
possible. 

2. Allow no carpets or draperies in this room. They are "dust catch- 
ers" and an abomination before the god of asepsis. 

3. When purchasing office furniture, buy none of those expensive, fancy, 
upholstered examining chairs and tables so widely advertised, but use such 
as will retain no filth and dust, but which can be easily cleansed, and if 
necessary, sterilized. 



10 DISEASES OF WOMEN. 

4. Purchase a cheap sterilizer (a fish-kettle or a flat agateware pan 
will do) if you must be economical. 

5. Keep your instruments in a case which can be easily kept clean. 

6. A small table for the various chemicals and instruments, as may be 
necessary for each examination or treatment, a few wash basins, a slop jar, 
a stand for g^auzes, towels, cotton, etc., is all that is needed for ordiinary 
work. 

7. No office is properly equipped without a gfood farado-galvanic bat- 
tery. A good static machine is desirable but not essential. 

The accompanying cut shows the authors workroom in which many 
plastic and minor gynecic operations have been performed without a single 
case of infection. (See Fig. i.) 

All work of a character apt to cause filth is done by me in a separate 
room, which for reasons of economy must serve also as a study. 

In this study X-ray examinations are made, static treatments adminis- 
tered, cases of fracture dressed in plaster of Paris, stomach lavage per- 
formed, etc. 

In one comer a table and necessary utensils are set apart for the treat- 
ment of acut€ gonorrhea in the male, in another corner, near a window, a 
large table serves as a "laboratory" for chemic and microscopic examina- 
tions. (See Fig. 2.) 

In country towns where rent is cheap and "flats" unknown, the physician 
could no doubt afford to use four rooms and have a separate room for each 
class of work, which, of course, is very desirable. 

But no matter what arrangement is decided upon, the room in which 
the women are to be treated, should be so arranged as to permit of its being 
kept in the cleanest possible condition. The more the physician will copy 
the smaller operating rooms of modern hospitals, the nearer he will have his 
examining and operating room to the ideal. 



CHAPTER II. 

ANTISEPSIS AND ASEPSIS. 

Every intelligent physician and surgeon is supposed to be familiar with 
the rudimentary principles of antisepsis. It is sad indeed to see many 
younger practitioners violate the cardinal rules of surgical cleanliness in 
their daily work. 

Carl Beck, the famous New York surgeon, in his book on surgical 
asepsis, relates how an old prominent physician pushed aside a nail-brush, 
offered him by an assistant, and holding up his fingers exclaimed, "My 
fingers are clean, what's that for?" 

The same author tells of a practitioner about to introduce an old, dirty 
catheter, who replied to an expressed doubt about the cleanliness of the 
instrument, "Sure, look! lean blow through it, there are no incrustations.'' 
These are examples of instances occurring daily. 

While it is true that some surgeons never become aseptic operators 
simply because surgical cleanliness is not born within them, yet, if certain 
rules would be strictly followed, a great deal of the mischief so frequently 
produced would be prevented. 

There still reigns confusion in the minds of most practitioners in regard 
to the exact meaning of the terms : antisepsis and asepsis, nor is the same 
definition given in all standard works on surgical subjects. 

Etymologically the following definitions are undoubtedly the correct 
ones : 

Asepsis means an ideal condition, free from pathogenic germs. 

Antisepsis is the application of any efficient means to get rid of the 
germs. 

The agents used for the removal and destruction of germs are : 

1. Mechanical: Scrubbing, washing with soap and water, etc. 

2. Chemical: Carbolic acid, bichloride of mercury, lysol, formalin, 
peroxide of hydrogen, etc. 

3. Thermic : Boiling water, condensed steam, dry heat, etc. 

In former years surgeons depended greatly on carbolic acid and similar 
chemicals, which as is well known, are very toxic agents, and have done 
much damage by irritjating wound surfaces and by poisoning the patients* ; 
It is but natural that scientific surgeons should have strived to'dSscQVf 



12 



DISEASES OF WOMEN. 



ways and means to destroy the ^enns without destroying animal cells or 

harming the patient at the same time, with the result that the use of toxic 
chemical?^ (antiseptics) was reduced to a minimum and less harmful agents 
substituted, which change some surgeons baptized: aseptic surgery vs, 
antiseptic surgery. 

Thus, in many works, when the authors speak of "aseptic precautions*' 
they really mean non-toxic antiseptic precautions. 

The above explanation is essential to prevent confusion and to render 
the terms u.sed in this book intelligible. 

Limited space forbids the author from describing in full the modem 
technique of antisepsis. It will be time usefully spent to study special mono- 
graphs on the subject* (See bibliographic list,) 

The following suggestions, condensed as they are, must necessarily be 
incomplete. They will answer the purpose, however, if the reader will 
rigidly follow them in his practice. 



liiMi.iii iih<rtiifcli;limi»iiirji|k|^ 



Fig. 3. — "Fish kettle'* boiler- sterilizer. 



I. Sierilisation of Instruments. All instruments such as specula, re- 
tractors, catheters, knives, tenacula, dressing forceps, applicators, dilators, 
sounds, etc., should be constructed of metal only. Wooden handles are to 
be condemned. (Glass catheters are cheap and can be employed but are apt 
to break.) 

The simplest way of sterilizing metal and glass instruments is by boiling 
them for fifteen minutes in a i per cent solution of carbonate of soda. The 
soda prevents rusting. It matters very little in what container the instru- 
ments are boiled, ^\ny metal or tin-pan, kettle, boiler, even those usually 
found in the household, will do. 

The container should first be thoroughly scrubbed with Sapolio and 
rinsed out with water. 



AMTISEPSIS AND ASEPSIS. 



13 



All sorts of "trays'* and "tish-kettles*^ are sold in the instrument shops 
for that purpose. 

'* Baking" the instruments in a dry-heat sterilizer has been recommended 
by European surgeons. This method has never become popular in this 
country. 

Sterilization by steam is quite a favorite in this country. Steam and 
boihng have only one drawback, they dull the edges of knives. 

This objection is overcome by a method of sterilization with formalde- 
hyde gas. 



Fig. ^--Schermg^s formalin steriHster, 

Fig. 4 illustrates the simplest and yet most efficient formaldehyde 
rilizen It is sold in this country by Schering & Glatz, of New York, who 
"also furnish the formaldehyde pastils necessary for the generation of the 
gas. 

The best fuel for the lamp is wood-alcohol, which is not only cheaper 
than pure alcohol, but gives a more intense flame. 

The instruments are placed on the perforated shelves in the sterilizer, the 
lamp lit, two or three pastils put in the metal dish over the lamp and the door 
closed. After ten minutes everything in the sterihzer is aseptic. The fumes 
of formaldehyde are irritating to the conjunctiva and mucous membrane of 
the nose, but do no harm. 

The moment an instrument comes in contact with anything that cannot 
be considered aseptic after it has been sterilized it is unfit for use and must 
be sterilized anew. 



DISEASES OF WOMEN. 



2. Sterilhation of Gauges and Cotton. These materials can, of course, 
be sterilized the same way as instruments. For obvious reasons, however, 
sterilisation of gauze and cotton by boiling is impracticable. They can be 
sterilized in a steam sterilizer preferably in one, which enables their sub- 
jection to dry hot air after their saturation with steam. They also can con- 
veniently be sterilized in Schenng's formaldehyde sterilizer. 

The average surgeon will hardly care to spend time and labor on the 
sterilization of dressings, unless he uses large quantities. Gauzes marketed 
in hermetically sealed glass jars or cartons are reliable, provided they come 
from firms of repute. In this the physician should be particularly carefuL 
Of late many small dealers have sprung up who manufacture medicated and 
plain gauzes. 1 have seen one wash out the container with hydrant water, 
dry it in the air and pack the gauze In it with hands which have not been 
washed, though he had just finished his lunch. 

It is self evident that when the physician wishes to keep in stock gauzes 
and cotton in an aseptic condition it is essential that they be preserved in 
hermetically sealed glass containers which, too, must first be sterilized. 

4. SieriHzatio7i of the Hands. The surgeon, his assistants and nurses 
must take special pains in the preparation of their hands, even when the most 
trivial operation is to be performed. Although the same nde should hold 
good with reference to examinations, in practice this cannot be carried out. 

Many authors claim that the human hand can never be rendered ab- 
solutely sterile, no matter what method be adopted, although this hypothesis 
has been disputed. • 

The chief difficulty in the cleansing of the hands lies in the finger nails. 

The following is an excellent description of how to cleanse the hands 
and forearms, given by Dn Carl Beck, in his work entitled ""A Manual of the 
Modern Theory and Technique of Surgical Asepsis," as follows: ''The 
hands and forearms of the surgeon are best cleansed according to Furbring- 
er's and Kummers methods, which depend more upon mechanical thorough- 
ness than upon the choice of any special antiseptic. The skin must be 
f brushed energetically with very warm water and green soap for three to 
five minutes, and then be dried with a sterilized toweh Scrupulous cleans- 
ing of the finger nails with a small metal nail-cleaner is of the greatest im- 
portance. Not less tlian one minute, preferably longer, should be devoted 
to the nails. The surgeon should have his nails cut short and rounded. Nail- 
files must be avoided, as they form irregular surfaces from which the mic- 
robes cannot so easily be removed as from a sharp cut done with a scissors. 
The wearing of rings during an operation shows a misconception of th 
principles of asepsis. Even if the rings be exceptionally clean, the littl 



4 

4 



ANTISEPSIS AND ASEPSIS. 15 

folds of the skin beneath them can shelter micro-organisms. After cleaning 
the finger nails the skin must be rubbed for about one minute with a sterilized 
gauze tampon dipped in pure alcohol (80, per cent). 

"This procedure is followed by washing and rubbing with a bichloride 
solution (i-iooo) for another minute. If contamination with especially in- 
fectious material shortly before the operation was inevitable, the whole pro- 
cedure recited above must be repeated. The entire process of disinfection 
should consume from five to ten minutes." 

Instead of green soap, the author would recommend the use of synol 
soap which has decided antiseptic properties and does not injure the skin. 

For ordinary examinations it will suffice if the hands are thoroughly 
cleansed with synol soap and water by means of a brush (which should al- 




FiG. 5. — Surgeon's rubber glove. 

ways be kept in an antiseptic solution), followed by an ablution with alcohol 
or by dipping the hands in a bowl containing an antiseptic solution. Freshly 
laundered towels can be looked upon as aseptic for purposes of drying the 
hands when an examination only is to be made. 

It should always be remembered that after a thorough mechanical cleans- 
ing of the hands, they can be at once rendered thoroughly aseptic by slipping 
a pair of sterile rubber-gloves over them. The gloves should always be used 
when the physician has recently handled infectious cases or septic material. 

Many surgeons operate without exception with gloves, while others use 
them only in septic cases. 

For digital examination of the rectum and vagina, finger cots made of 
fine rubber are very useful. 

The tactile sense is interfered with but very little by the use of rubber 
gloves or cots, provided the rubber is of the finest possible make. 

Fig. 5 represents a glove made by the Miller Rubber Mfg. Co. 

5. Disinfection of Stittirin^ Material. Four forms of suturing ma- 
terial are employed in gynccic operations; silk, silkwormgut, catgut, and 
silver wire. 



16 DISEASES OF WOMEN. 

Silk is not only the cheapest but also the most reliable suturing^ material 
although the number of surgeons giving silkwormgut the preference is very 
large. 

Both can be sterilized by boiling or steam. Whichever method is chosen 
the material can be cut in suitable lengths, woimd around a spool or a piece 
of narrow glass tubing or twisted in skeins, placed in a stout test tube, which 
should be loosely stoppered with a piece of cotton and then either thrown in 
the boiling water or placed in the steam sterilizer for fifteen minutes. When 
through, the cotton is pressed very tight into the tube with either a sterilized 
pair of forceps or with the thoroughly disinfected hand, when the tube can be 
placed aside until needed. 

Catgut is very valuable in abdominal operations, but can be spared in 
plastic operations or in minor gynecic surgery. It is rather a difficult thing 
to properly sterilize this suturing agent and the usual methods will not suf- 
fice. Prolonged and complicated procedures must be instituted which space 
prevents from reciting. Those who are interested are referred to larger 
works on surgery. The best advice that can be given the general practitioner 
is not to prepare catgut himself but secure ready made and prepared catgut 
from sources which are known to be trustworthy. 

Silver wire is but rarely used at present in gynecic operations. It is best 
sterilized the same way as the other metallic instruments, just before each 
operation. 



CHAPTER III. 

EXAMINATION OF PATIENTS. 

No intelligent and rational treatment can be suggested and carried out 
in any case, in which no diagnosis has been made. A diagnosis in gynecic 
practice Can only be made after a thorough and systematic examination. 

The physician should insist on a thorough examination in each case, and 
where objections are offered, after an explanation, pointing to the necessity 
of an examination, has been presented, it will undoubtedly be better for the 
physician to altogether decline to treat the case. 

Each case should be recorded in a special book or the ''card system" can 
be employed, whichever the physician prefers. 

The examination is oral and physical. The latter can be divided into 
physical proper and chemical, histo-pathologic and bacteriologic. 

(a) oral examination. 

It is advisable to permit the patient to narrate the story of her affliction in 
her own way. Many irrelevant things will be told, to be sure, but the 
physician will gain an idea in regard to the nature of the ailment and know 
in what direction to look for further details. 

The following questions should be asked and recorded in each case. 
(Variations to suit each individual case can of course be introduced at the 
option of the examiner.) 

(a) Name? 

(b) Address? 

(c) A^e? 

The exact age of the woman is not essential. All the physician cares to 
know is whether the patient has reached puberty or whether she has reached 
the end of her sexual career. 

The doctrine that certain diseases attack people only when "old" or 
"young'' is erroneous, cancer, for instance, having been observed in young 
unmarried girls, and women over fifty have given birth to children. 

(d) Occupation. The influence of certain occupations on the genital 
system is too well known to need any discussion here. Women who make a 
living by sewing are apt to suffer from congestion of the pelvic orgaifis. 
Again the constitution is frequentlv undermined in the various sweat-shops 
and in factories where dust or unhealthv vapors have to be inhaled. 

17 



.:^^^> 



18 DISEASES OF WOMEN, 

(e) Social Condition, (Single, married, divorce or widow?) A reply 
to this question should be taken by the physician cum grano salts. Not every 
single woman is necessarily a virgin, while a married woman may have to 
be classified among the "single" women. A knowledge of the sexual history 
of the patient, will enable the physician to form his own conclusion under 
what category to place the patient. 

(f) Questions Concerning Menstruation, A complete history of men- 
struation should be obtained by the physician. The following questions sug- 
gest themselves as essential to obtain satisfactory information : 

"Have you been menstruating at all?" 

"Do you menstruate regularly?" 

"How long does each period last ?" 

"What is the character and quantity of the discharge?" 

"Is there any pain preceding or accompanying the flow?" 

"Of what character are these pains?" 

(g) The physician should next ascertain the number of childbirths and 
miscarriages. He should inquire whether the labors have been normal or in- 
strumental, when each took place, and whether the miscarriages, if any, were 
spontaneous or induced. Although no positive conclusions can be drawn 
from answers to these questions the physician will often be able to trace to 
these events, the origin of many afl^ections. 

(h) Discharge. In former years the physician was satisfied to make a 
diagnosis of "whites" or Icucorrhea, to prescribe a wash, and then he con- 
sidered his duty well done. To-day we know that any kind of a discharge, 
cither from the vagina or uterus, is an indication only, a symptom of an 
existing disease. 

A full description of the importance of this symptom will be found in 
a subsequent chapter. It will not suffice for the physician to interrogate his 
patient in regard to the nature of any discharge she might have, but he will 
have to form his own opinion by personal inspection, and if necessary, by a 
microscopic examination. 

(i) Special Questions. Before closing the verbal examination, the ex- 
aminer should note the character and locality of any pains, he should also- 
inquire about the condition of the bowels and bladder, in fact, of all im- 
portant organs, such as the nervous, circulatory, respiratory and digestive 
apparatus. 

If the above be carried out systematically, valuable data can be secured 
which may prove of great service to the physician at any future time as 
means of comparison and observation. 



EXAMINATION OF PATIENTS. 

A diagnosis should never be made from an oral examination alone, and 
[the physician shoitid in every case proceed to the 

(b) physical examination. 

The order of a physical examination should invariably be as follows : 

1, Inspection of the external genitalia. 

2. Examination of the vagina and cervix with one or two fingers. 

3. Bimanual examination of the uterus and adnexa, 

4, Examination of the abdomen. 

5. Examination of the uterus and cervix with speculum and instru- 
cts. 

6, Microscopic examinations* 

POSITION OF PATIENT IN PHYSICAL EXAMlNATIONa 

When a physician is called to a patient's house, a gynecic examination 
of the patient can be made while the patient is in bed or on a couch, in a 
way to be described later on. Whenever possible, it is more convenient to 



Fig. 6.— Two kinds of legholdcrs. 



^^■"the surg^eon to place her on a kitchen table. In order to hold the legs in a 
proper position any kind of a leg-bolder manufactured for that purpose or 
a long- towel will do. (See Fig. 6.) 

In his office the g^'necist should have an operating or examining table, 
especially constructed for such purposes. There are many kinds advertised, 
ranging in price from about twenty to one hundred dollars or more. If tliey 
are made of wood and upholstered, ihey should not be used, for the simple 
reason that fluids and blood are retained by these tables, so that they can- 
not be kept clean. 

In the writer's opinion an ideal table should be made of material which 
can be easily cleansed and sterilized (glass or iron). It should permit the 



20 



DISEASES OP WOMEN. 



physician to plate his patient in any position he may see fit ; it should be 

built substantially so as not to roll away at the least jarring and, last, but not 
least, it should not be expensive. 

The author uses in his office a 'Ter^son Table/' which is constructed 
entirely of metal and answers all practical purposes. It can be washed with 
antiseptic solutions without detriment, (Figf. 7.) 

The "positions'* usually adopted by the physician are three: The dorsal, 
Sims* and the genu-pectoral. 



^{^^ 



Fto, y. — Ferguson's ascpticable chair-table. 



In order to get the full benefit nf the dorsal position the patient's perinenm 
should be an inch over the front of the table, antl the heels placed in the 
5t!rrups and brought as close to the buttocks as is fconsistent with the patient's 
comfort : the knees must be kept wide apart. (Figs. S and 9O 

Every woman will greatly appreciate if a clean sheet be thrown over her 
extremities and abdomen. A slit in the sheet will enable the examiner to 
reach the g^enital apparatus without subjecting the patient to useless cx-» 
posure. 



tX AM IN ATI ON OF PATIENTS. 

The dorsal position will be found the most useful for tlie practitioner, 
for he can get along without assistants, which is not the case with Sims* 
position, which requires the presence of some person to hold a Sims' speculum 



;.:r^ 



''/i7> 



Fig. 8. — Dorsal position for examination. 

or retractor. The author can see no advantage to be had from Sims' posi- 
tion which is becoming obsolete. 

The genu-pecloral or knee-chest position, is to be employed when it is 
desired to change the position of the uterus from backward to forward (see 
chapter on Retroflexion and Retroversion) and in cystoscopy (Fig. lo). 



^.-t^ 



Fig. 9, — -Dorsal position for operation. 

The reader can gain a far better idea of the various positions by observ- 
ing the photographs, which have been taken by the author for this book, 
than from lengthy descriptions, hence, tfie above remarks will have to suf- 
fice. 



22 



DISEASES OF WOMEN. 



1. INSPECTION OF THE EXTERNAL GENITALS, 

The exammer sits on a low stool or chair between the feet of the patient 
and through the sHt in the sheet, thrown over the patient, who is in the 
dorsal position, exposes the external genitals and anus to full view. In day 
time the light should come from a window l>ehind the examiner so that the 
rays fall obliquely over his shoulders. In night time any good light (prefer- 



thinuuuitbuni'.' <i mm 



Fig. io. — Knee-chest position. 

ably a white Welsbach light) should be reflected by means of ati ordinary 
head mirror. 

The examiner, remembermg the nonnal anatomy of the genitals, will at 
a glance note the condition of the clitoris, urethral orifice, labia majora. 
labia minora, hymen, perineum and anus. He will detect the presence of 
discharges from the urethra and vagina, chancres, fissures, tumors, abscesses 
and other congenital or acquired abnormalities. 



2. DIGITAL EXAMINATION OF THE VAGINA AND CERVIX, 

The next step in a systematic examination is the exploration or palpation 
of the vagina and vaginal cervix by means of the index finger, or, as may 
sometimes prove necessary^ by the index and middle fingers combined. 

T!^ physician should early accustom himself to employ either hand, for 
frequently the position of the patient while in bed» or an injury to the right 
hand may necessitate the use of the other. It goes almost without saying 
that in no instance should an examination be made unless the hands have 
been rendered surgically clean. 



EXAMINATION OF PATIENTS. 23 

As the examiner is apt to infect his hand when there is the slightest 
abrasion of the epidermis, sterilized rubber gloves or cots should be slipped 
over the hands or fingers. 

The exploring finger should be oiled with some sterilized lubricant 
(glycerine, oil, vaseline, etc.) and introduced into the vagina by a slight 
boring and pressing motion. Unless there be a condition described as 
"vaginism" or severe inflammation, the exploration of the vagina should 
be painless. If the examination elicit pain a maximum of gentleness is 
necessary. Sometimes in severe cases no satisfactory examination can be 
made and general anesthesia has to be resorted to. 

Not infrequently the examination of the vagina awakens sexual desire 
in sensual women. The examiner is cautioned to be as stern as possible with 
such -patients. 




Fig. II. — Author's way of arranging hand for vaginal examination and massage. 

In virgins, care should be taken not to tear the hymen and a rectal ex- 
amination may have to suffice, unless there be imperative indications to the 
contrary. In such cases the physician had best first secure the permission of 
the patient and her relatives. 

The position of the fingers is of some consequence for a successful ex- 
amination. Fig. II shows the correct way to arrange the hand. 

What can the examining fingei; detect ? The condition of the anterior and 
posterior walls of the vagina, the vaginal cervix and frequently many ab- 
normalities in Douglas' space. 

Sweeping the finger alongside the walls, any tenderness, tumor or ulcera- 
tion present will be detected. The cervix can be palpated for its shape, posi- 
tion, size and consistency, the os will show whether the woman is a nullipara 
or otherwise; if pregnancy be present a peculiar soft, doughy, velvety feel 
is experienced by the finger when touching the lips of the cervix. 

Tears of the cervix are more readily recognized by the examining finger 
than by direct inspection through a speculum. Fistulae will be suspected 



24 



DISE.iSES Of WOMEN. 



when an uncvenness^ feeling like an indentation is detected in the vaginal 
walL 

Extra-uterine prcg-nancy, exudates and abscesses in the parametrium 
can frequently be recognized by the examining finger while pressing against 
the fornix* 

3. BIMANUAL EXAMINATION. 

The author must express his astonishment at the attempt of some other- 
wise brilliant surgeons and writers on gynccic practice, to discourage the 
routine bimanual examination, It is true that many of them have made cor- 
rect diagnoses by a simple digital examination, but what does this prove? 
Nothing, it is feared. 

The author knows of many medical celebrities and of many obscure prac- 
titioners who have the ability to make diagnoses of pulmonary tuberculosis^ 
typhoid fever or pneumonia on entering the sick room even before feeling 
the pulse of the patient. 

Certainly there is something in the facial expression wliich tells the tale. 
But is this scientific and absolutely reliable? The majority of physicians 
who have had" even a limited experience will answer in the negative. With- 
out examination of heart, lungs, spleen, liver and intestines, — no diagnosis. 
This is, and should be a law, not to be transgressed. 

The same holds good with reference to bimanual examination of the 
uterus and its adnexa, which should be practiced in every first examination 
in order to either positively exclude or detect certain pathologic changes. 
The unaided exploring finger in the vagina cannot always recognize tumors 
or inflammation of the tubes, ovaries and of the supra-vaginal part of the 
uterus. 

The other, free hand has to be placed over the pubic (hypogastric) region 
and its four fingers gently, but firmly pressed into the abdominal wall in 
order to meet the finger in the vagina, thus pressing down the uterus and 
adnexa, the location and condition of which organs can frequently be recog- 
nized almost as clearly as if the abdominal wall had been opened, particularly 
so in lean women. 

It is true that this is not always the case, in fact, in very painful affections 
the abdominal muscles are contracted to a stage of rigidity not easily over- 
cotne by pressure, but a great deal can be accomplished in the majority of 
cases by patience and perseverance. In all cases when a bimanual examina- 
tion meets with difficulties the physician should instruct the patient to breathe 
deeply or engage her in a conversation, in order to cause a relaxation of the 
abdominal muscles. 



EXAMINATION OF PATIENTS. 25 

It is self evident that in excessively obese women a bimanual examination 
can never be altogether satisfactory, but even in such women, fibroid tumors 
of medium size have been diagnosed without much difficulty by beginners in 
the author's class. 

By means of the bimanual examination, the position of the entire uterus 
can be easily made out, the finger in the cervix pressing against the external 
OS, while the fingers of the hand on the abdomen try to find and grasp the 
fundus. By pressing alongside the uterus this organ can be mapped out in 
its entirety and the ovaries and tubes pushed down to be easily palpated by 
the finger in the vagina, which naturally must change its position depending 
which side is to be palpated. 

(4) EXAMINATION OF THE ABDOMEN. 

The abdomen should be subjected to special examination, when the 
presence of a tumor in the pelvis has been ascertained and in all cases of sus- 
pected pregnancy. -The examination consists of inspection, palpation, per- 
cussion, auscultation and mensuration. 




Fig. 12. — Miller's bivalve speculum. 

Inspection, The abdomen should be well exposed, and all tight garments 
loosened and pushed out of the way. The trained eye, will, at a glance de- 
tect any abnormal enlargement, irregularity in the contour of the abdomen, 
changes in the pigmentation (the so-called strice albicantes) and any ab- 
normality of the navel. The diagnosis of abdominal dropsy can, as a rule, 
be made by inspection alone. 

We next proceed to palpate the abdominal walls. By lifting up the ab- 
domen we can judge of its thickness and mobility. Pressing in deeply with 
the tips of all fingers we gain valuable information in regard to the form, 
size and consistency of the tumor or tumors in the pelvis. 

Percussion is of great help to the examiner. Solid and liquid masses arc 
characterized by .a dull, flat sound, whereas the intestines give a tympanitic 
sound. 



% 



DISEASES OF WOMEN, 



AuscuUation aids in the eslablishmefit of tbe diagnoses of pre^ancy and 
aneiiri&m. In the former we may hear die fatal heart sounds^ and a blowing 
sound in the larg^e vessels aJongstde the titertis, in the latter a peoiUar noise, 
which of course is not conclusive evidence of the presence of aneurism and 
must be supported by other clinical evidence. 

Mensuration is accomplished -with an ordinary tape measure placed 
around the most prominent part of the tumor. The distance between the 
navel and symphysis pubis or ensiform cartilage, also the girth at the level 
of the navel, etc., are ways of estimating the extent of the abdominal en- 
largement. Such measurements have no particular diagnostic value, but are 
useful when we wish to watch whether a swelling increases or decrease^ in 
time. 



4 



Fig, 13.— Cavana*s short speculum. 

(5) EXAMINATION BY MEANS OF INSTRUMENTS. 

In order to see the entire vagina, cervix and the uterine canal, special 
instruments must be employed to make these parts accessible. The number 
of so*called specula invented, is legion. Many a would-be gynecist seems to 
consider it the acme of fame to invent or rather modify a speculum, even 
though this invention or modification consists only in the addition of a screw 
or mechanism, complicating the little instrument and making it less useful. 
One need only glance at the illustrated catalogues of the various instru- 
ment houses to be convinced of this truth. 

For purposes of examination, application and even operation the so-called 
bivalve speculum is the best because it is the simplest and allows not only an j 
inspection of the cervix, but of the fornix as well 



EXAMINATION OF PATIENTS. 



27 



Figs. 12, 13, 14, illustrate three bivalve specula whicli in the author's 
"opinion are the best. Either of them can be introdiiced into the vaf^ina and 
opened by pressure on the handles to full capacity, thus allowing the surgeon 
perfect control. 

The so-called tubular and tri- valve instruments^ in fact^ all other specula 
are either useless of difficult of handling. These instrunienls are to be used 



Fig. 14.— Gravels speculum. 

in dorsal petition. When the examiner sees fit to employ Sims' nosition, 
either Sims' speculum or any appliance constructed like ordinary retractors 
will do. The bivalve specula should be introduced while closed, with the 
blades in a horizontal position, the labia major| and minora are held apart 
with the thumb and middle finger of the other hand and the blades pushed 



Fig. 15, — Uterine endoscope, 

in, directing the speculum towards the os, the position of which has been as- 
certained by the preliminary digital examination. 

When the blades are all in they are opened to any desired degree and held 
fast in this condition by whatever contrivance the speculum possesseSi 



28 DISEASES OF WOMEN. 

Should the cervix not appear in the speculum, the latter should be pressed 
up or down until the os occupies a space between the two blades. 

It is then we can observe the condition of the vagina and vaginal cervix. 
If we wish to go a step farther and directly inspect the uterine cavity, this 
can be accomplished by a special uterine endoscope depicted in Fig. 15. Of 
course, when the external os and uterine canal are very narrow this cannot 




Fig. 16. — Kelly's cystoscope. 

be easily done, if at all, and the cervix will have to be dilated first. (Sec 
the chapter on Curettage for the technique of dilatation.) 

The bivalve specula are now manufactured in several sizes, the smallest 
of which can be used for virgins. 

Kelly's cystocope (Fig. 16) is also an excellent instrument for the in- 
spection of the vagina and cervix in virgins. 



CHAPTER IV. 

MICROSCOPIC EXAMINATION. 

No gfeneral practitioner can afford to be without a good microscope. 
How ii he going to demonstrate without one the presence of casts in the urine 
or tubercle bacilli in the sputum? No blood examination, furthermore, is 
complete without a microscopic examination. 

Although good diagnoses in gynecic practice can be made by the various 
methods of examination as described in the preceding chapter, the micro- 
scope is, nevertheless, of great value, particularly when' malignant disease 
is suspected, or infection to be demonstrated. When the clinical evid'ence 
leaves us in doubt, it is the microscope which settles all disputes and acts 
as a reliable adviser in regard to the steps to be taken. 

The reader is warned, however, not to depend in all cases on the micro- 
scope exclusively as it is only in conjunction with all other methods of ex- 
amination that it is of great value and help. 

Those who have used the microscope before will find very little trouble in 
acquiring such technique as is required in gynecic practice. Those who have 
never handled the microscope before but who mean to do scientific work 
in gynecic practice and want to equip themselves accordingly, will find this 
chapter of great value inasmuch as the same materials can be employed fqr 
the examination of bacilli and abnormal growths found in other portions of 
the human anatomy. 

This chapter is primarily intended for such practitioners who have not 
had the opportunity of a training in microscopy. It is self evident that our 
remarks must therefore be limited to the examination for bacilli and cocci. 
The examination of tissues requires skill and experience and cannot very 
well be acquired by reading. 

I would advise every one not familiar with histo-pathology to transmit 
specimens to pathologists of recognized ability. Every large city has several 
special laboratories for just such work. In Chicago excellent and strictly 
scientific work is done in the laboratories of Profs. A. W. Evans, Maximilian 
Herzog or Carl Theodor Gramm, either of whom supplies directions for the 
collection, preservation and transmission of specimens. 

We will now briefly consider the instruments necessary and some methods 
now in vogue. 

2d 



30 



DISEASES OP WOMEN. 



The microscape ttsed by the author is mapiifactxired by Beck of London 
(sold l>y Frank S, Betz & Co,, Chicaj^o, at S69), and is satisfactory in every 
respect. More expensive ones are not esserttial, 1 

If has 2 eye pieces, 3 lenses (one 1-3 inch, one 1-7 inch and one i-t_2 inch 
"oil immersiofi'*), coarse and fine adjustment, an Abbe condenser with iris 
diaphragm, and a double reflector. It can be reclined in any angle desired. ' 

TIjc various stains (formulae for which will be found later on) are best 
preserved in ordinary glass-stoppered bottles. Some prefer such that are_ 
stoppered with a rubber cork into which is fitted a pipette. 



/' 



nl'^ 



Fig. 17. — Beck microscope. 



Tt would refjuire too much space to describe in detail every bit of glass- 
ware and metal apparatus needed for microscopic work. 

The reader will gain a better idea as to what he needs for his laboratory | 
table, for at least one class of work by carefully reading the following de- 
SCrijylion bow to examine a drop of pus or sputum for tubercle bacilli, 

A drop of the sample is taken up with a tmre-ioop (made of platinum and i 
attached to a i^lass* nul). wbicb must first be heated to a red heat in the 
flajne of cither an alcohoi lamp or a Bunsen ^as burner, in order to be ret 
dered absolutely sterile. 



/ MICROSCOPIC EXAMINATION, 31 

The bit of pus or discharge caught orr the loop is deposited on an ab- 
sohttely clean cover ^lass (a round or a square thin piece of glass). This 
glass should be dipped in alcohol and ether and is best cleansed with a piece 
of clean silk or Japan paper. Cloth should not be used, as particles of the 
texture are apt to stick to the glass and confuse the microscopist when he 
views his object through the microscope. 

The drop as placed on the cover glass is usually too thick for a micro- 
scopic examination. Another cover glass, which, naturally, should be as 
clean as the first one, is placed on top and then gently slid apart. In this way 
the original drop is spread as thinly as possible and divided over the entire 
areas of both cover glasses. Both cover glasses with the specimen on top 
are placed on any clean object (preferably white filter paper) and left for a 
few minutes to dry. They should be protected from contamination with 
bacilli found in the air by a watch glass placed over them. Each cover glass 
is then grasped near its margin with a pair of delicate forceps (preferably 
with Stewart's cover glass automatic forceps; costs about 15 cents), speci- 
men on top and is slowly passed through the flame of an alcohol lamp three 
times. 

The specimens are now ready to be "stained." By "staining" is meant 
nothing else but coloring or dyeing of the specimen and the germs it con- 
tains, to enable us to easily recognize them under the microscopic lenses. 

In order to examine the pus or any other liquid for tubercle bacilli we 
need two stains and a decolorizing agent. (See formulary below.) 

The staining process is called Ziehls' method or carbol — fuchsin stain. 
From this solution a few drops are taken up with an ordinary medicine drop- 
per, and dropped over the object on the cover glass, covering it completely 
with the stain. The cover glass is held for 3 to 5 minutes, about four inches 
over the flame, which causes the superfluous staining fluid to evaporate, the 
object itself becoming thoroughly stained. Care should be taken not to per- 
mit the staining fluid to "boil" in which case the cover glass must be re- 
moved for a few seconds to cool. The staining fluid should not be allowed 
to evaporate too rapidly as otherwise the bacilli will not become thoroughly 
dyed. To prevent this, more staining fluid should be added from time to 
time, sufficient to keep the cover glass fully covered, during the maneuvre. 

The specimen is now washed off with sterile water and decolorized ■ 
follows: 

The decolorization is accomplished with a 15 to 25 percent 
sulphuric acid, either by dropping a few drops on the spedifl 
mersing the latter in a small dish containing the decoloriziii 



32 



DISEASES OF WO MEM, 



decolonzer h allowed to act on the specimen for about thirty seconds, 
ratht^r until the red color is just extinguished. 

By this process the red color is removed from the cells and debris bu 
not from the bacilli, which retain the red dye. 

The specimen must next be washed off with sterile water. A special 
**waier-holiIc'* is very usefid for that purpose as a small stream of water can 
be turned on the subject by blowing into the air-tube. 

Tlic decolorizing agent thus having been removed, the specimen is best 
stained ag^ain (counterstained) with a strong^ watery solution of methylene 
bine. This is done by simply covering the specimen with the stain for thirty 
seccnds, and then washing^ with sterile water tmtil a very faint blue remains. 
When die specimen is dry it is ready to be examinetl under the microscope 

A drop of Canada Baham is placed on a clean slide, tl\e cover glasi 
(specimen, or, as it is frequently called, film-side down) placed on the drop 
which spreads and holds the cover eflass li^ht to the slide (miscroscnpists 
call this mounting in Canada Balsam), The specimen can now be examined 
with cither the 1-7 inch or the oil immersion {!-t2 inch) lens. Owing to 
the two stains ihe field will appear bhic, the tubercle bacilli, red. 



* 

M 



GABBET's MOntFICATlON- 



Gabbet modified the above procedures by decolorizing and counters tain- 
iug" at the same time. The solution he uses is g;^iven in the ''Formulary" ' 
below. He first stains the specimen with carbnl-fuchsin. washes whh distilled 
water and then treats the specimen with his solution for thirty seconds,] 
washes until a faint bhie color remains, dries and mounts in the way as] 
described above. 

The above descriptions are so detailed that even a beginner in microscopy! 
by followino^ closely the directions filven could not fail to examine sputum, 
pus or any liquid for tubercle bacilli. Tn addition to this he has become ac- 
quainted with the paraphernalia necessary for the work, which are simplel 
and inexpensive. 

The most important of all ^crms in fi^ynecic practice is the gonococcusJ 

The microscopic examination of pus or dischargees for gonococc! h\ 
simpler yet The method to be pursued consists in the staining of the speci- 
men with methylcne-blue solution only. The superfluous stain is washed oflF 
with sterile water. If gonococci are present they can be seen as a rule in the 
puS'Cells and appear like small ortyanisms in pairs, resembling the head of a 
screw, or like a large period cut in two, Germans see in the organisms a 
resemblance to their popular biscuit called a "semmel/' 



MICROSCOPIC EXAMINATION. 33 

In very doubtful cases special stains should be employed but their de- 
scription cannot come within the scope of this book. 

A word in regard to histo-pathologic examination. As already men- 
tioned such work cannot be successfully done by physicians who lack labora- 
tory training and even if the structures be very plain, they will hardly be 
able to properly interpret them, unless they resort to such methods as : "hard- 
ening" "block-mounting," "cutting" and "staining" of the parts. 

Nevertheless the beginner should lose no opportunity of examining the 
scrapings from the uterus, etc., in the following way, which is the simplest 
and most practical known — the "teasing" method : 

Select the thinnest films (they must be fresh) and put them in any so- 
called "isolating' or "maceration" fluid (I use Ranvier's, see Formulary) for 
from 12 to 24 hours, after which, by shaking, it is easy to separate the cells ; 
or the tissues can be "teased" to minute particles by two needles, inserted 
in needle holders, all of which should be done on a clean glass slide. . 

The specimen is now stained for from i to 3 minutes with hematoxylin, 
a drop of Canada Balsam placed on top and over it a clean cover glass. The 
preparation is now ready to be examined. Begin all histo-pathologlc ex- 
aminations with the lowest power (1-3 inch) lens and use the higher power 
glasses to study details of structure. 

FORMULARY. 

I. CARBOL-FUCHSIN «TAIN. 

Fuchsin (15 grains) i gram 

5 per cent aqueous sol. carbolic acid (20 drachms) ... 80 c. c. 

95 per cent alcohol (5 drachms) 20 c. c. 

Or: 

Fuchsin T part 

5 per cent aqueous sol. carbolic acid 100 parts 

Alcohol 10 parts 

2. METHYLENE-Bt-UE STAIN. 

Methylene blue ( 10 grains) 0.6 grams 

Distilled water (i ounce) 30. grams 

Or: 

Methylene blue 2 parts 

Alcohol 15 parts 

Distilled water 85 parts 



""^ '«» ia^'.'T'i V,'',' 3 ', " i3!= --'LTy A3n rcccciiczsL 

If .^i^.TVsat 'X-!it 

'•"d^jrrriK ii'-i-f ^ pars 

I^fri:>rf irir.*r 75 ports 

A-WatsV: aS-xrx? 2S vois, 

'.K-^'CAit »^>tr r» rob, 

7''/ ;vy c, r, o: a \^::z^i:r, v>!rt5cr; of anrrrior.ia a!irr-. a stiniitioa of one 
YVAZiiTt^. 'A rJSu^TTAt/yzv'fr- 'ffrVrlv^c ri 5:x c. c. of abs^Itnc alcohol, is added. 
Av/f^ lyv 'froj/, 7fc^ Vy>-::ori fr -!:xpo«ed to tr=e a:r and light, in an unstop- 
y^'-A V/iV:, fr/r thr^ or fo^ir cay- : :: -5 then n!tered. and twcnty-^vc c c 
//f 0yc^TfT)^ and t'A'entv-fiv<t c. c, of n:ethy!:c alcoho! are added. The mix- 
fur^ \\ aXfrfB'tA Uf htnti'i unt!: :zs crAor becomes dark, and is again filtered 
and j/rewTvH 5n a Ix^ttle with a closely fitting stopper. It keeps well, but 
%t$^/isM wA \tt uv^d for two m^^/nths after it has been prepared. 



CHAPTER V. 

DISORDERS OF MENSTRUATION— INCLUDING HEMORRHAGE 
• FROM THE UTERUS. 

Woman's life, sexually, can be divided into three stages : 

First, from birth "^ to puberty. 

Second, from puberty to menopause. 

Third, from menopause to death. 

The period from puberty to menopause, which is designated as the period 
of sexual life, characterizes itself by a periodic function, consisting ...in a 
bloody discharge from the ovaries and uterus, lasting on the average three 
days, and occurring about every twenty-eight days : Menstruation, periods, 
catamenia, monthlies, etc. 

Constitutional or local derangements may cause anomalies of this func- 
tion. While such an anomaly could not be considered a disease per se, any 
menstrual disorder must be treated as such, the treatment, of course, being 
principally directed against the disturbing cause whenever this is possible 
or practicable. We have three anomalies of menstruation: amenorrhea, 
dysmenorrhea and menorrhagia. We will consider each of them separately. 

(a), amenorrhea. 

Definition, Lack of the menstrual flow (or a very scanty one) in the 
mature woman. 

It is physiological in pregnancy and during lactation, in all other cases 
pathological. 

Causes, They are either local or constitutional. Defective development 
of the ovaries or uterus make this function impossible and in such cases we 
speak of primary amenorrhea, primary meaning that menstruation never oc- 
curred before. As a rule amenorrhea due to defects of the genital organs 
is also permanent. 

We cannot call amenorrhea a condition where menstruation is delayed 
on account of retarded puberty. The beginning of menstruation at an ad- 
vanced age cannot be regarded as amenorrhea proper, as this is found to be 
characteristic and hereditary in some families and even nations. The time 
when menstruation is first to appear depends upon habits, disposition, climate 
and surroundings, as does also the cessation of this function, 

96 



DISEASES OF WOMEN. 



Secondary or transUetry amenorrhea is the term applied to cessation 
the mentrual flow after it has occiirred once or several times. It is som 
times called "suppression of the menses" b«t we would rather see this term 
applied to a real suppression, i, e. when a woman is menstruating, the flow 
ceastn^ at an usually early time, perhaps abruptly as frequently happe: 
with patients who expose their feet to wet cold during their periods. 

So-called tncarious menstruation, which means periodical hemorrha^ 
from other organs than the uterus, as the nose, ear, rectum, lun^^, stonnai 
or even open sores in association with anenorrhea and re^rded as a su 
stitute for menstruation, is not believed to exist by many eminent authoritie 
At any rate it is exceedingly rare, and then other diseases must be borne i 
mind (haemophilia). 

If the absence of the flow is due to mechanical occlusion of the uteru: 
vaifina or vulva so that the menstrual blood cannot flow out, such retenti' 
cannot be regarded as amenorrhea proper. 

Two of the principal diseases causing amenorrhea (and delayin 
puberty) are anemia and chlorosis. But a great many other grave con- 
stitutional diseases may produce amenorrhea— tuberculosis, typhoid fever, 
etc. 

Certain affections of the ovaries or uterus causing atrophy or partial de^^ 
St met ion of these organs^ are responsible for the cessation, of the menstrual 
flow. In fact all diseases causing general malnutrition are apt to suppress 
diminish the monthly flow. Nervous disturbances, excessive mental strai 
fright, grief and similar conditions are frequently to be held responsible 

The diagnosis is comparatively easy. The patient calling our attention to 
the total absence of the flow, or its scantiness, we will have to discover the 
causing factor. Pregnancy and lactation must first be excluded. Certain 
unfortunate and even married women complain of amenorrhea, well know 
ing that they are pregnant in order to mislead the surgeon, and to cause 
him to produce abortion by an instrumental intra-uteriiie examination. We 
always have to be on our guard in this direction. 

A careful history of the case must be taken, lungs, tirine, etc., examine' 
anemia sought for and if no constitutional disease be found, a careful ex- 
amination of the entire genital apparatus, will reveal the cause at last 

The Prognosis depends entirely on the cause. If this can be removed o^ 
remedied the prognosis is good. 

The treatment consists in the therapeusis of the causing disease. One o! 
the general rules is to restore nutrition by tonics, food, moderate exercise, 
rest, massage, electricity, etc. In anemia and chlorosis iron in easy digestible 
form should be prescribed. 






uAI , 

lin^l 



DISORDERS OF MENSTRUATION. 



When due to atrophy of the ovaries and uterus, tonics and sensible local 
(treat rnents (see respective chapters) are indicated. 

Suppression of the menstrual flow due to exposure to cold we£, uuist be 
treated with hot baths or dry heat applied to the lower extremities and 
diaphoretics internally. If amenorrhea be due to defective development of 
the ovaries or uterus, very little, if anything can be €lone. The so-called 
emeJiagfogues^ — drugs which are supposed to produce the menstrua! fiow 
(savine oil, erj^ot, permanganate of potassium, quinine) arc rarely used, at 
this time, as there is hardly any indication for them. They are dangerous 
drufj^s and frequently taken with the intention of producing' abortion. 



(b). dysmenorrhea* 



t Definition. Physiologically the function of menstruation is associated 
nth some pain. When the pain becomes excessive or when other disagree- 
blc reflex symptoms (nausea, vomiting, headache, etc.) occur, we have 
abnormal menstruation and term it dysmenorrhea. The pain sometimes pre- 
cedes or follows the flow only or both takes place. 

Causes, Similar to amenorrhea this affection can be caused by local dis- 
orders of the sexual apparatus and by general constitutional diseases. 
^^ Certain affections like congenital stenoses of the internal or external os 
rof the cervix or of the entire uterine canal, or acquired narrowing of their 
caliber due to versions and flexions of the uterus or tumors, prevent the flow. 
Stronger contractions, and therefore painful ones are necessary to expel 
the menstrual blood. In such cases we deal with so-called mechamcal 
dysmenorrhea, 
^fc Inflammatory diseases of the uterus and its neighboring tissues (metritis, 
^endometritis, perimetritis, parametritis) and ovaries (chronic ovaritis and 
perioophoritis) are apt to cause dysnienorrhea. The periodical congestion 
in menstruation causes hut little pain and inconvenience in otherwise healthy 
ovaries or in the uterus but increases in inflammatory diseases of these organs 
tfie already existing abnormal amount of congestion, thus causing also ex- 
cessive pain — ovarian and canj;(esiive dysmenorrhea. 

Dysmenorrhea is sometimes met with in neurotic and liysteric women, or 
in young anaemic virgins, in whom no pathological change can be detected 
in either the uterus or ovaries. In such cases we have to consider the de- 
ficient nutrition of the whole body and the deranged function of the nervous 
system as the immediate cause of the menstrual abnormality — neural j^ic 
dysmenorrhea. 

In addition to these four varieties we have another that characterizes itself 
by tM shedding away of a membrane from the uterus, which is the decidua 



38 



DISEASES OF WOMEN. 



xnensirnMs^fttembranous dysmenorrhea. The causes of this form of ab- 
normal menstruation are not established beyond doubt as yet. 

Inflammatory conditions of the uterus seem to be one of the princip; 
causes. 

Diagnosis. The dia|?nosis of dysmenorrhea, as such, is easy enough, but 
we do not ^ain much by it for intelligent treatment. It is essential that the 
variety be recognized and the causes, if possible, discovered. A careful ex- 
amination of the vagina, uterus and ovaries will demonstrate the presence 
or absence of any local affection liable to cause dysmenorrhea. If the lat 
ter be the case, it is neuralgic dysmenorrhea due to either general malntitri 
tion or a deranged nervous system. 

The diagnosis of membranous dysmenorrhea offers no difficulties. The 
finding of the expelled membrane is sufficient to recognize it as decidua 
menstruahs. 

The treatment is cither palliative or curative. The physician is often 
consulted to reljeve pain or to arrest reflex symptoms during an attack. Of 
course, the rational way is to make a correct and full diagnosis and to 
remedy the cause, but in case of emergency we are often compelled to resort^ 
to palliative treatment. The physician who promptly relieves the poor suf- 
ferer has a fair chance to be entrusted with the treatment of the case in order 
to prevent another attack. 

The hypodermic injection of morphine and atropine in suitable doses is 
very popular and effective. It is too popular almost to be administered by 
a physician. The administration per os is to be preferred. Haydn *s 
Viburnum comp., a teaspoonful in yi glass of hot water ever>^ hour, has 
proven satisfactory in our hands. It is to be preferred to opium, which 
stupefies the patient. Patients should not know when they get an opiate for 
they might resort to it frequently and that deplorable condition known as 
''morphinism" would result. Rest in the horizontal posture is to be recom- 
mended, a hot sitz bath should be taken, the bowels kept regular by some 
saline cathartic or cascara sagrada in palatable form. Vomiting requires 
pepsin, menthol, small pieces of ice and as a last resort cocain. 

The curative or rational treatment of dysmenorrhea is, the treatment of 
the cause. In mechanical dysmenorrhea the cervical canal should be dilated 
frequently with steel sounds or with special uterine dilators as described in 
Chapter XI 11. Flexions and versions of the uterus must be corrected. Intra- 
or extra-uterine tumors should be extirpated, in short, all should be done to 
bring the uterine cavity and the cervical canal in shape and caliber, so as to 
admit free passage of the flow. 






DISORDERS OF MENSTRUATION. 39 

The congestive variety requires antiphlogistic, diuretic and diaphoretic 
internal therapeusis. Locally we will scarify the cervix, administer pro- 
longed hot douches, or treat the inflamed uterus itself after a manner to be 
described later. The ovarian form, is the one that gives the least satisfactory 
results. Constitutional, combined with local antiphlogistic treatment, counter- 
irritation, applied to the ovarian region, rest and sedatives are about ^11 the 
therapeutic means at the physician's disposal. In severe cases oophorectomy 
may be considered. 

The neuralgic variety requires much judgment on the part of the physi- 
cian. The general malnutrition must be remedied, any existing organic or 
functional derangement treated according to the principles of general med- 
icine and such remedies prescribed that have a beneficial influence on the 
nervous system. In membranous dysmenorrhea any existing inflammation 
of the uterus must be treated. A method that promises the most satisfactory 
results is curettage of the uterus to be followed by frequent intra-uterine ap- 
plications of full strength hydrozone, tincture of iodine, or a mixture of 
iodine and carbolic acid. In our experience zinc and other escharotics have 
not proved satisfactory. 

(c). MENORRHAGIA. 

Definition. Menorrhagia is the term applied to excessive menstrual flow. 
Hemorrhages from the uterus, non-menstrual in character, are termed 
metrorrhagia. Both are not diseases per se^ but symptoms of either a gen-, 
eral or local affection. 

Causes, Gisneral. The number of constitutional diseases apt to pro- 
duce either menorrhagia or metrorrhagia is large. We will name the most 
important ones, abstaining from further detailed description (see resp. text- 
books) : Bright's disease, obesity, phosphorus poisoning, malaria, cardiac 
disease, tuberculosis, icterus, plumbism, purpura, etc. Menorrhagia from 
the uterus may also accompany acute fevers. Local : Almost all pelvic af- 
fections can produce menorrhagia and metrorrhagia — ^principally all in- 
flammatory diseases of the uterus or its appendages, tumors, flexions and 
versions of the uterus and others too numerous to mention. Retained 
placenta pieces and adherent secundines after abortion almost always pro- 
duce uterine hemorrhages. 

Metrorrhagia is also often observed in pregnant women, who shed w«*wi 
in the earlier part of pregnancy, without miscarriage. A 
diagnosis, we would first of all, call attention to the £ 
hemori^iage from the female generative passages r 
uterus. 



40 



DfSEASES OF WOMEN. 



A hemorrhage can also come from the urethra, vulva or vagina. 

Another question to be answered is: Is the flow (we refer to the men- 
struaU of course) really excessive? As no standard amount can be fixed, 
only one rule can be suf^^gested; that the first few periods are to be con- 
sidered as the normal i^auge for each particular individual, for what would 
be a normal Bow in one woman may be a menorrha^ia in another. These 
two questions being answered, pregnancy must be excluded and last but 
not least, the local or constitutional cause discovered. We admit that this 
IB sometimes very difficult. 

Prognosis depends entirely on the cause and constitution of the patient. 

Treatment. Removal of the cause is the first law in rational therapy. 
However, in all kinds of hemorrhages, the first law is : stop the hemorrhage, 
and next remove the cause. A consumptive who is attacked with a pul- 
monary hemorrhage would hardly have reason enough to be thankful to his 
*'cause-hmiting" medical attendants, who will prescribe creosote and cod* 
liver oil, without first attempting to arrest the hemorrhage. Let modem 
scientists call it palliative treatment only, it is, nevertheless, to be considered 
first. 

The first thing to be ordered is perfect rest in the horizontal position. It 
is advisable to have the hips and lower extremities elevated. Towels, wrung 
out in cold water should be applied to the abdomen and lumbar and sacral 
regions* Internally the fluid extract of. ergot (25 drops every hour, to be 
diminished gradually) should be given. Among other remedies, for internal 
use, which are very beneficial m milder cases are the following: Oil of cin- 
namon, oil of erigeron, diluted sulphuric acid. Care must be taken not to use 
any of those remedies during pregnancy, as they are apt to produce abortion. 
In such cases besides rest and cold externally, opiates can be administered. 

In metrorrhagia, sometimes, though rarely, the bleeding may be so pro- 
fuse that life might be destroyed in an hour s time. In such cases mechanical 
means must be resorted to. Vaginal injections with exceedingly hot water^ 
practiced for ten minutes continuously, sometimes control the hemorrhage. 
If this prove a failure the uterine canal must be tamponed with iodoform 
gauze. These tampons should be removed after 24 hours. Meanwhile in- 
ternal remedies, as described above, should be given. Tonics and stimulants 
are indicated in almost all cases of menorrhagia and metrorrhagia. The 
arrest of the bleeding, however, must not satisfy us. We must next make 
a careful diagnosis and treat any existing general disease, as outlined inj 
standard works on the principles and practice of medicine. Local diseases! 




DISORDERS OF MENSTRUATION. 41 

must be treated, in a manner to be described in the following pages. Re- 
tained secundines must be removed by curettage. As a rule profuse or re- 
peated hemorrhages depress the vitality of the patient and undermine her 
constitution. Such patients should be put on maltine, iron, quinine, strych- 
nine, hypophosphites and light but nutritious food. 



CHAPTER VI. 



LEUCORRHEA. 

The older physicians understood under the term leucorrhea a white dis- 
charge coming from the vagina. It was conceived by them as an independent 
disease, to be treated by astringent washes. Since pathology has become 
a more exact science and the microscope a valuable aid in gynecic diagnosis 
that idea had to be abandoned for a more rational one. 

We know now that the very word is a misnomer, as are also its synonyms 
"fluor albus" and the lay expression '*whites." Perhaps such simple words 
as vulvar, vaginal or uterine discharge would be best, but an old term can- 
not be easily eradicated, hence we must stick to "leucorrhea." 

Any discharge found in the vagina is abnormal, for while it is true that 
the vaginal tract is moist and slippery when in a normal condition, not even 
a drop of discharge can be detected with the naked eye. 

When we study the various discharges as they appear to the naked eye, 
we observe that they are either thin (serous) or thick (purulent) and in 
color either white, yellow, brown or red, depending on the pressence of pus, 
blood, epithelial cells, etc. The discharge may come from the vulva, vagina 
or uterus. 

Authors vary in the classification of leucorrhea. For practical purposes 
it is perhaps best to divide it in specific and non-specific forms. In the light 
of modern pathology it is utterly impossible to look upon leucorrhea as an 
independent disease. It is a symptom accompanying either a local or con- 
stitutional disease. True, frequently, leucorrhea is the only symptom present 
and in spite of a careful (?) local and general examination, no cause can be 
discovered. The fault in such cases lies with the examiner, not with science. 

As a rule the clinical picture, supported by the history of the case will 
suffice to enable the examiner to make a correct diagnosis. 

In such cases the examination of a drop of discharge by means of power- 
ful lenses will throw much light on the nature of the case (see Microscopic 
Examination). 

Leucorrhea is a symptom accompanying constitutional as well as genital 
diseases. Among the former those are prominent which liavc a tendency 
to weaken the constitution, thus, not only such grave affections as tuber- 

42 



LEUCORRHEA. 43 

culosis and chlorosis will be found to cause leucorrhea, but also nervous af- 
fections and even the so-called psychoses. 

Worry, excitement and fatigue due to overwork are all factors to be con- 
sidered. It is the poor, hard-working shop-girl who suffers from leucor- 
rhea, though no organic disease can be demonstrated. 

Among the local affections producing leucorrhea, all inflammatory af- 
fections of the vagina and uterus are apt to produce a white discharge'which 
may vary in regard to its consistency and virulency, depending upon the 
exact nature of the infection. 

In the man acute forms of inflammation of the genital tract we frequently 
see the discharge tinged with blood, while in the woman, in certain infec- 
tions, the discharge will assume a darker hue, which is undoubtedly due to 
the admixture of decomposed blood and broken down organic material. 

Under the specific forms of leucorrhea the discharge due to gonorrhea 
are the only ones to be considered. As regards the treatment of leucorrliea 
common sense dictates that a washing out of the discharges from the vagina 
will do but little good as long as the cause is permitted to remain undis- 
turbed. 

Thus frequently the physician must feel that his services could be spared 
were some rich philanthropist to provide hard working girls who toil until 
exhausted without sufficient recompense to feed the body properly. 

Here the physician can do but little good and but resort to such measures 
as are known to build up the constitution. Iron, strychnine, manganese, are 
to be prescribed. The physician who is expected to be enlightened on all 
topics pertaining to the welfare of mankind should earnestly endeavor to 
familiarize himself with the nutritious value of foods so as to be able to 
properly advise such of his clients with whom economy is of paramount issue. 
Recommend rest and fresh air. The physician should teach the patients to 
make every effort to inhale fresh air day and night, and finally should rec- 
ommend cold ablutions to the back to be followed by friction with a course 
towel, which procedure can be practiced every morning and evening. 

It has been the author's lot to see many young shop-girls, mostly 
orphans, thrown on the resources limited to the starvation wages, paid by 
the millionaire owners of department stores, in whom a regimjen as de- 
scribed, carried out systematically from five to eight weeks, result in a 
gradual disappearence of the leucorrhea while at the same time their vitality 
improved correspondingly. 

When it is noticed that there is a disposition to pulmonary tuberculosis, 
the leucorrhea will not disappear permanently unless the condition of the 
lungs and the entire system can be improved. 



44 DISEASES OF WOMEN. 

It is just the f^ynecist who can do a great deal towards preserving life 
by searching and finding evidence of incipient consumption when called upon 
to treat the "whites," by extinguishing the flame before it has taken firm root 
and consumed too much of lung tissue. 

Guaiacol carbonate, methylene blue and other antiseptics, inhalation of 
antiseptic vapors, tonics, cough-mixtures, should be used freely, but above all 
as much as possible the so-called open-air treatment must be instituted at 
once. Other constitutional diseases call for appropriate treatment. When 
the leucorrhea is due to local affections these must be treated according to 
the methods described in this book in the various chapters. 



CHAPTER VII. 

STERILITY. 

Case: Some years ago when quite a young practitioner a woman ap- 
plied to me for relief of her barrenness. She had been married six years 
and was suffering keenly. She pleaded that her husband had turned against 
her and unless she became pregnant her existence on earth was not worth 
while. 

I examined this woman as carefully and as systematically as I was thetl 
capable of. I could detect nothing abnormal on bimanual examination or 
with the speculum. She had been treated by prominent surgeons, several 
of whom had promised a cure — all in vain. I tried hard to make a diagnosis, 
but the rosy colored cervix told me : Shame, you dare not say even catar- 
rhal endometritis without lying. 

Borrowing a microscope from a kind colleague I secured some of her 
husband's fresh semen — and behold, there was not a spermatozoon in sight. 
Thinking that my microscopic technique was at fault I consulted my friend, 
whose skill could not be doubted, and he too agreed with me that the man 
was absolutely sterile. 

I requested her to come to an understanding with her husband, with the 
result that the latter knocked her down and called me an insahe imposter. 
Result, divorce. Marriage four months later. Ten and a half months later 
I delivered the woman of a healthy baby girl. 

If this case were the only one in my practice 1 would have omitted it 
from this book. I have seen at least ten similar ones since. 
^ The lesson such cases teach are plain, viz. : in all cases when the physi- 
cian's advice is sought for the relief of sterility, the husband should be ex- 
amined first The number of women suffering from the after-effects of a 
subacute gonorrhea, contracted in wedlock, is enormous. These women are 
regular visitors in the gynecist's office. They are blamed for their barren- 
ness when it is the husbiand first of all who needs the doctor. 

The examination of the man becomes therefore, one of prime importance. 

The following questions, the examination is expected to answer : 

1. Is the husband built normally? 

2. Is he suffering from any constitutional or specific diseases (tuber- 
culosis, diabetes, carcinoma, syphilis, etc.) ? 

46 



46 



DISEASES OF WOMEN, 



3- Has the first morning urme passed p^onorrheal shreds? 

4. Is he capable of performing the sexual act (potentia coeundi) ? 

5. Is his semen free from pus cells and are spermatozoids present, and 
if so, alive? 

AH these questions have got to be ascertained by an oral conversation 
with both husband and wife, for the husband, in the majority of cases, hates 
to tell the entire truth. All answers should be taken by the physician with 
caution, as both man and woman will sometimes lie often with the intention 
to deceive, sometimes out of ignorance. It is for this reason that a physician 
should depend only on what he discovers by means of a physical examination. 
In 95 per cent of all my cases in ra^, gonorrhea was at fault, many of whom 
denied ever having been afflicted. The characteristic shreds exposed their 
statements as falsehood. 

Physicians should remember that tliere is but one truthful thing, and that 
is the microscope. 

Each individual should be examined in regfard to the condition of the 
genital apparatus. The heart, lungs, and kidneys will have to be subjected 
to the most thorough search for disease. 

The cure of sterility of the male naturally depends on the causative 
factor. 

If this can be remedied the prognosis is good, if not the prognosis is bad. 
It is impossible on account of limitation of space to consider the treat- 
ment of sterility in the male, our intention having been only to direct the at- 
tention of the reader towards the husband as the frequent cause of the 
sterility of his partner. When satisfied that the man is healthy, the wo- 
man should be subjected to the most thorough gynecic and general examina- 
tion. 

It is astonishing how frequently insignificant causes are at fault which 
have been overlooked by experts and successfully treated by painstaking 
beginners. At least one such a case has contributed considerably towards 
my reputation as a gynecic surgeon. 

The woman had been married five years, had seen many prominent sur- 
geons who told her that there was nothing wrong with her and that 
eventually she would become pregnant. Disgusted with the profession she 
declined to have anything to do with doctors, until a close friend directed 
her to seek my advice. 

True to my principle, I subjected both the husband and wife to the most 
rigid examination without being able to discover even a trace of an affection 
in either, for which the sterility could be held responsible. Of course, I 



STERILiTV. 



47 



thought of consanguinity, but al! laws, as far as known to science, seemed 
to be obeyed in the pair. 
^f In a sort of aji off-hand way, I took a sHp of litmus paper, and tested a 
very sHg:ht discharge of the vagina, and behold ! the blue paper turned bright 
red, I have done for this woman nothing else, save, the mopping out of the 
entire vaginal canal with a strong solution of bi-carbonate of soda, and she 
conceived promptly, causing no little astonishment in the neighborhood. 

It is needless to say that many envious colleagues were puzzled and 
chagrined, and unless this book falls into their hands they will never know 
what treatment it was which cured the woman. 

It must not be concluded from this case that the cure of sterility is al- 
ways an easy matter, on the contrary it is frequently a very difficult thing, 
•taxing the skill of the surgeon to the utmost, nor can it truthfully be said 
that all cases are curable even when no morbid condition is found. It is a 
well-known fact that occasionally, without any apparent reason, a healthy 

•woman will live for years with a healthy man, and never conceive. 
Death of the husband or divorce will permit this healthy woman to marry 
someone else and may be, a raan who cannot come up to the physical stand- 

Ilird of his predecessor, and the woman will become a mother of several chil- 
|dren. 
I In such cases the underlying causes cannot be discovered by the physi- 
cian, no matter how scientific he may be. There is a something in this, the 
nature of which can only be surmised, but which cannot be scientifically 
demonstrated as yet. 

Almost every disease with which woman may become afflicted has been 
cited by recognized authorities, as the cause of sterility. To enumerate them 
all means really to write a text-book or monograph on the subject, which 
latter the author hopes to present to the profession in the near future. 

The following rules for the guidlance in the treatment of sterility must 
suffice for the present : 

1, Discover whether the woman suffers from constitutional diseases, apt 
to undermine her general health. Diabetes, tuberculosis, anemia, obesity, 
nervous prostration, etc., are all diseases which are known to interfere with 
conception and reproduction and must be remedied if possible. 

It is needless to add that when grave organic diseases of the heart, liver, 
lungs or of the nervous system are present, a cure of sterility should not be 
thought of or undertaken. 

2, Subject the woman to a thorough oral and physical gynecic examina- 
tion and remedy whatever abnormality of her genital apparatus is found. 
It is self-understood that when there is a maldevelopment or absence of im- 



48 DISEASES OP WOMEN. 

portant genital organs, surgery call do little Of nothing'. In a grave organic 
disease such as cancer of the vagina or the uterus it would be folly to think 
of anything else but'to save the woman from this frightful disease. 

Stenosis of the uterine canal has been cited by authors a6 a cause of 
sterility and dilatation is known to have been followed by conception. Since 
the spermato^oids are microscopic organisms, it \i against common sense to 
assume that they cannot find a passage where a sound could pass. It seems 
to the author that in such cases it is not the stenosis itself, a much as the 
retained discharges and, perhaps, the inflamed mucosa, which act as a bar- 
rier and which are removed by dilatation. 

Tumors and flexions may prove, mechanically speaking, real barriers and 
should be removed. 

For further details the reader is referred to the following chapters. 



CHAPTER VIII. 

DISEASES OF THfe VULVA. 

I. ADHESIONS OF THE LABIA. 

Adhesions of the labia majora are often met with in small girls, rarely 
in adults. Mild forms of inflammation, uncleanliness and irritating dis- 
charges may result in labial adhesions. The treatment in children consists 
of forcible separation of the labia, a simple procedure accomplished by 
stretching both labia asunder with both thumbs. In order to prevent recur- 
rence a strip of aseptic gauze should be placed between the labia and ab- 
solute cleanliness maintained, which can be accomplished by sponging the 
vulva with warm water to which any mild antiseptic, such as boric acid, 
can be added. Sometimes the vaginal discharges require attention. In 
children a solution of one ( i ) part of hydrozone to 5 parts of warm water 
injected by means of medicine dropper will prove satisfactory. In adults, 
if there can be found a small opening just under the vagina, which is 
mostly the case, a strong director, the handle of a bistouri or any suitable 
instrument should be inserted and dragged out between the labia, effect- 
ing in this manner, a separation. If an opening cannot be found, await 
menstruation when the labia will be stretched by the retained fluid. The 
bladder should be emptied and the catheter left in situ, a finger introduced 
into the rectum and a bistouri plunged into the fluid mass, in the median 
line, a little below the urethra. The opening should be enlarged with any 
blunt instrument until the finger can be introduced into the vagina when 
separation can be completed. Reunion must be prevented by cleanliness 
and gauze strips until the raw surfaces have completely healed. 

2. HYPERPLASIA OF THE VULVA 

is the smooth and uniform enlargement of either the labia majora, labia 

minora or the clitoris. As a rule the enlargement of the nyniphae is due 

to masturbation, which has been practiced from early youth. In many 

cases this affection produces no symptoms and should be left alone. 

In others the labia, which by the way, are pigmented dark brown, are 

so large as to cover the entrance to the vagina and prove an obstacle to 

49 



50 



DISEASES OE WOMEN, 



sexual mtercoorse or are the cause of irritation when the patient is walk-^ 
ing, riding- a wheel or sewing. ^ 

I have fotind ei^ht out of nine to complain that sexual intercourse had 
lost its charms for them, which however is due to the past overstimulation 
and subsequent nervous exhaustion rather than to the enlargement of the 
riymphae. fl 

The labia can be amputated when they are obnoxious. The operation^ 
is easy. 

After a preliminary thorough douching of the vagina and vulva (thc^| 
pudendal hair should be shaved off) each labium is grasped with any kind^ 
of a self-locking forceps or volsellum and the enlarged portion amp^utated . 
with a stroke of a sharp pair of scissors or with a sharp bistoiiri, Th^B 
raw edge is best served together with fine silk or silkworm gut. Nosophen," 
xeroform, or any other antiseptic powder is blown over each wound and a 
piece of antiseptic gauze placed over the wounds in such a manner that the 
urethral orifice is left exposed. 

The patient should stay in bed for a few days during which time thg 
bladder must be emptied with a catheter. The patient should not be per^ 
mitted to urinate to prevent soiling of the dressings. 

A general anesthetic is not necessary. Local anesthesia is produced by^ 
injecting a drpp or two of a 2 per cent solution of hydrochlorate of cocain 
with a hypodermic syringe along the line in which the incision is to be 
made. 

3. INFLAMMATION OF THE VULVA — ^VULVITIS. 

We have three distinct clinical forms of inflammation of the vulva, 
viz.: simple or traumatic, specific, septic or infectious and finally follicuta 
vulvitis. 

Causes, Simple vulvitis is caused by local irritation and trauma; acrid 
vaginal discharges, dirt, dribbling urine, parasites, scratching, friction, 
masturbation, etc., are causative factors. 

Specific viihntis is caused by venereal (gonorrhea, syphilis) or septic- 
diseases (cancer, erysipelas, diphtheria). 

Follicular vulvitis is the term for inflammation of the glands erf the 
vulva. The causes of this aflfection are about the same as in simple 
vulvitis, but inasmuch as it has been met with in pregnant w^omen and 
patients with a low vitality, these two conditions must be borne in mind 
predisposing factors* 

Diagnosis. The diagnosis is easy. All three forms have the same sn 
jective symptoms, viz. : increased redness with tumefaction and discharges 



i 



t mm* * 
< • 1 » 
' **** ft 



JISEASES OF THE VULVA. 



51 



[of a serous, mticous or mil co-purulent character, elevated local tempera- 
ture and sensitiveness to touch. The objective symptoms are persistent 
itching, burning pain, especially upon the passage of urine. All these 
symptoms are intensified in the specific or infectious form. The diphtheritic 
and erysipeloid forms show the same characteristic appearances as 
diphtheria and erysipelas on other parts of the body* The follicular form 
differs as far as the objective and subjective symptoms are concerned, but 
little from the otherSi and characterizes itself by papillae upon the surface 
of the labia and prepuce, which are nothing else but the projecting 

^sebaceous and peliferous glands. Thus the only difficulty in differentiating 
the different forms of vulvitis is apt to present itself between thfe severe 
forms of simple vulvitis (which occasionally may be very angry looking 
and purulent in character) and a gonorrheal or syphilitic vulvitis in the 
eariy stage. The histoiy of the case as given by the patient, is not always 
trustworthy, as many will deny sexual intercourse for reasons of their 
own. A few days observation of the course of the disease will suffice to 
clear up the difficulty. The microscope is of exceedingly great vahie in 
such cases. 

Treatment consists of rest and local antisepsis. Everything that causes 

[friction, bad habits like scratching and masturbation must be stopped, 
parasites, accumulated secretioffis and other matter should be removed. 
Cleanliness is produced by a rigid employment of mild antiseptics. The 
old way of injecting strong solutions of carbolic acid or mercury is to be 
rejected. Washing with and injections into the vagina of norma! salt solu- 
tions will suffice in most cases of simple vulvitis. In the infectious form 
no better remedy can be recommended than hydrozone, and should be ap- 
plied undiluted. Such irrigations can be made once or twice daily. A con- 
stant application of borated cotton moistened with lead- water will hasten 
healing. Excoriations and ulcerations occurring in neglected cases of 
vulvitis, will heal rapidly under the above treatment. The *'caustic" so 
frequently recommended in modern text-books, in our opinion, is a useless 
drug. 

In the follicular form, the follicles should be opened and touched with 
tincture of iodine. 

The erysipelatous and diphtheritic forms require the same treatment, 
as would be instituted if the affection were anywhere else. Practically we 
have no experience with these two forms and theoretically we are strongly 
inclined to believe that the antiseptic treatment, as mentioned for the other 

(forms will suffice even in the latter two forms. It is self evident that when 



52 



DISEASES OF WOMEN. 



the dia^osis of diphtheritic vulvitis has been established beyond doubt by 
means of the microscope, antitoxin injections can and should be employed. 



GANGRENE OF THE VULVA. 



Definition, An infections affection of young ^irls, similar to noma in 
the mouth> fl 

The diagnosis is difficult in the bcpfinnin,er. when the disease can be mis- i 
taken for vulvitis, although only one labium is affected. The inflammation 
is accompanied by a discharge of ichorous serum. Later sloughs of a 
grayish-gfreen color are formed and gangfrene proceeds rapidly. 

Prognosis. Very unfavorable, unless diag^nosis he made early and 
prompt treatment instituted. 

Treatment Excision of the parts should be made, if the case is see 
and recognized early. It is not advisable to close the wound by sutures, 
as it is rarely apt to heal kindly, A much better plan is to keep a wet 
dressing, moistened with a weak solution of permanganate of potassium 
(i:tooo) or glycozone (diluted with 2 parts of glycerine) constantly ap-_ 
plied to the wound. 

As this disease is most frequently met with in poorly nourished children^ 
living in unhygienic surroundings, care should be taken to remove them, if 
possible, to a clean place where there is abundant fresh air and proper 
ventilation (hospital). The vitality of the unfortunate little patient should 
be sustained and stimulated as much as possible. Remedies that will im- 
prove digestion, tonics and stimulantia are indicated and should be given 
abundantly. 



E a 



A 



5, SEQUELAE OF TNFECTIOUS VULVITIS — ^VULVAR ABSCESS. 



I 



Neglected cases of inflammation of a specific or septic character are apt 
to infect the vulvo-vaginal glands, causing a swelling on the inside of the 
lower part of one or both labia, terminating in an abscess. The symptoms 
vary but little from acute abscesses in other places, the pain being perhaps 
more intense here. 

The treatment consists of poulticing at first. As soon as pus is detected ■ 
or even suspected, an early incision will not only relieve the painful CQn-^| 
dition at once, but will prevent its spreading. Occasionally it may be best^^ 
to excise the whole gland, to wash out the wound with hydrozone (full^ 
strength) and to close it with deep sutures. If excision cannot be prac*fl 
ticed the incised wound should be treated with a sharp curette and packed™ 
with iodoform gauze. Hydrozone should be injected into the deep-seated 



I 




DISEASES OP THE VULVA. 

sinuses with a wound syringe, which can he easily improvised by attach- 
ing a closed atomizer hnlb to an eye-dropper. The pus, no matter how 
deeply seated, will be searched for by the hydrozonc and destroyed. 

61 SYPHILIS OF THE VULVA, 

Chancres, chancroids, venereal warts, condylomata, mucous patches 
appear on the vulva. These affections have the same characteristics as 
those appearing on other places. For an exact description we mtist refer 

^the reader to special works on syphilis. 

The irmiment is constitutional and local. Iiitenially, mercury iodide 

, of potassium, or the gold combinations should he p^iven, locally the usual 
treatment should be instituted. Chancres, chancroids and warts may be 
touched carefully with nitric acid and then treated with iodoform, hydro- 
zone, etc. Condylomata, should be cut off and then cauterized with nitric 
acid and treated antiseptically. 



7, PRURITUS VULVAE. 

Definiiion. Itching of the vulvar region (sometimes including the 
vagina) occurring at irregular intervals — paroxysms — ^with remissions dur- 
ing which this inconvenient and troublesome aflfection is altogether absent. 
It is a symptom only and not a disease per se. 

Cause. Many theories have been advanced but nothing definite has 
been offered as yet. Almost every disease of the female generative organs, 
such as flexions and versions of the uterus, ulceration of the os, tumors, 
inflammatory diseases, discharges from the vagina, ascarides of the rectum, 
inflammation of the vulva and certain constitutional diseases (diabetes) 
have been reported by different authors as inimedSaie causes. Others 
classify it among the neuroses. 

Dia^jwsis. There is no diflScuIty in establishing the diagnosis of 
pruritus valvse. But little is gained thereby, however, and a systematic 
search should be made for the cause. Inspection may reveal no perceptible 
change of the parts around the vestibule, although after the affection has 
existed for some time, the frequent scratching, by which the unfortunate 
patients vainly hope to relieve the disagreeable sensation, may lead to ex- 
coriations, induration, inflammation or oedema of the vulva. 

Treatment, If the cause can be found, tht treatment natti rally consists 
in its removal. If it cannot be found, and this is quite frequently the case, 
the treatment can be empirical only. From what was said under "Catises" 
it is plain that any existing local affection should be treated accordingly. 




54 DISEASES OF WOMEN. 

Cleanliness is hygienic treatment and curative sometimes. Everything: that 
causes congestion (heavy bedcovers, tight underwear) friction, sexual in* 
tercourse, should be avoided. Irrigation of the vagina with mild antiseptic 
solutions, do much good. If the pruritus be due to diabetes, the parts 
should be protected from the urine by the application of carbolized vaseline. 

I have observed in my private practice a case in which applications of a 
saturated solution of bicarbonate of sodium has not only relieved each at- 
tack, but finally produced a permanent cure. 

The fallowing two prescriptions offer temporary relief: 

Cocaini muriatici * gr. xxv 

Menthdlis .• , _.......,.,,,..,,. gr. xxx 

Ungt. oxidi zinci, q. s. ad. ...,,,.., S ij 

M, F. Ungt. Sig. Apply externally. 

Or: 

Chloroformii v5 ss 

Tinct. iodii comp .3 j 

Liquor, plumbi. acet. _ , ♦ . .3 iij 

Aquae menth. pip., q. s. ad , g iv 

M. F. Liniment, Sig. Shake and apply on absorbent cotton. 
The nervous system being frequently at fault, strychnin, arsenic, hypo- 
phosphites, bromids are indicated. Sleeplessness must be combated with 
sulfonal. 

Ascarides call for the internal administration of calomel and santonin 
and rectal injections of salt solution, or infusion of quassia (3 ij ad. Oj) 

I warn the readers not to resort to opium. The danger of acquiring the 
drug habit is great in such cases, 

8. TUBERCULOSIS OF THE VULVA. 

Tuberculosis of the vulva which is a very rare affection, occurs, as a 
rule, in the form of lupus. In an extensive private and dispensary prac- 
tice, I have seen only one case in ten years. While it is true that lupus 
here, resembles very much, as regards microscopic appearance the same 
affection as seen, for instance, on the face, the diagnosis, nevertheless, is 
very difficult at times. 

I know that many authors categorically dismiss the subject with a short 
description of the ulcers, but even an expert is very apt to make an error. 

The microscope is unreliable in the majority of cases according to no 
less an authority than Prof. Schroeder of Berlin* 



I 



4 




DISEASES OF THE VULVA, 



55 



Lupus may be suspected when other tubercular lesions are found in the 
genital tract. The diseases with which lupus is apt to be confounded with 
are ; cancer and syphilis. When we are able to exclude both affections with 
certainty, and the ulcers on the vulva, have irregularly jagged ed^es^ with 
a bright red indurated base and very small grayish red spots over it^ ac- 
companied by a purulent discharge, the diagnosis of lupus can be made with 
justification. The presence of tuberculosis In the lungs as demonstrated 
by physical examination and by the microscopic examination of the sputum 
will strengthen our diagnosis. In every instance the discharge from the 
ulcers should be examined for ttibercle-bacilli, according to the method 
described in Chapter IIL 

The prognosis of lupus aUhough spontaneous cures have been reported 
is unfavorable. The ireatmmt consists in the prompt excision of all ulcers. 
The raw surfaces should not be sutured together but dusted over with iodo- 
form. It goes without saying that the constitution of the patient must be 
sustained with tonics, wholesome food, fresh air, etc^ while internally, such 
remedies as are known to possess antitubercular properties should be pre- 
scribed. 

Among those are to be mentioned creosote and carbonate of guaiacol. 

The ultra-violet rays as discovered by Finsen and modified by Minin, 
have yielded excellent results in the treatment of lupus of the face but I 
have no experience with this agent in lupus of the vulva. 

It seems, theoretically at least, sound practice to employ either the violet 
rays or the Roentgen rays when after the excision there is a recurrence of 
the ulcers. All cauterizations with caustics of the Pacquelin cautery, in 
my opinion, are to be condemned. 



9. TUMORS OF THE VULVA. 

Tumors of the vulva are either benign of malignant. Both become 
surgically important for even an otherwise harmless fatty tumor (lipoma) 
of either labium may interfere mechanically with coitus, calling for extirpa- 
tion on that g^round. 

Malignant tumors must be extirpated as soon as seen and recognized. 
Alas, when the practitioner does see them, neighboring glands are as a rule 
already infiltrated. 

The diagnosis of a tumor of the vulva, as such, is child-play* But to 
establish the nature of the tumor requires diagnostic skill. In doubtful 
cases a small particle should be excised and subjected to microscopic ex- 
amination. 



56 



DISEASES OF WOMEN, 



Wfi<?never a tumor is seen to spring from either labium great care shoulc 

be taken in differentiaHng^ it from a |x>ssible inguinal hernia. 

I was once called by a youn|^ surgeon who commenced to operate on 
what he had diagnosed a cyst of the vulva. After the incision was made he 
realized that he had blundered. Tt is needless to add that such an error 
could have never occurred had this young man borne in mind the possi- 
bility of the tumor being a hemia* 

As is well known hefnim which descend into the labium ma jus have the 
same characteristics as ordinary inf^uinal hernias. An attempt at reposition 
will usually confirm the suspicion, the impulse on coughing and the 
tympanitic sound on percussion will leave no further doubt as to tlie 
diagnosis. 

Fatty tumors are as a rule very small, however tumors reaching as far 
down as the knees are reported to have been removed. 

The extirpation of a hpoma olTers no difficulties. An incision is made 
across the tumor, which, as soon as exposed is shelled out with the handle 
of the knife or a Kocher dissector. Tlie skin is united with either continu- 
ous or interrupted silk or silkworm-gut sutures and dressed. Local anes- 
thesia with a 4 per cent cocain solution makes the operation painless. Gen- 
eral anesthesia is* not required. 

Cysts can be easily recognized because of the feel of a sort of fluctuation 
imparted to the palpating fingers. This is due to the liquid contents. 

In doubtful cases a sterile hypodermic syringe should be pushed into 
the mass when, on withdrawing the piston, the barrel will become filled with 
liquid contents. 

The patient gives a history of long standing (sometimes several years) 
during which time the tumor increased gradually. In nine out of fourteen 
of my cases the patients were multipara and had been delivered by forceps. 
I have seen one case in a virgin of about seventeen years of age. 

Aspiration will cause the tumor to shrink only to fill again within a 
short time. 

The entire sac should be extirpated to insure a permanent cure. The 
incision is best made over the tumor, the sac exposed and shelled out with 
a dull instrument. This is not as easy a procedure as in the removal of 
fatty tumors, but should offer no particular difficulties. The raw surfaces 
are united by interrupted sutures. It has been my experience that when the 
sutures are drawn too tight, local inflammation is apt to follow. 

Fibromyomaia, when attaining a large size, on account of their own 
weight form a narrow pedicle with the skin of the labium, not unlike a 



4 



DISEASES OF THE VULVA. 57 

polypus. They can be easily amputated or extirpated in the same way as a 
cyst. 

Sarcoma of the vulva is exceedingly rare. 

Carcinoma can attack either labium ma jus, clitoris or the small labia. 
Pain is more or less constantly present and becomes intense when ulcera- 
tion has taken place. Excision should not be delayed. The line of incision 
should embrace healthy neighboring: tissue. If the neighboring glands ap- 
pear infiltrated they should be removed too. To apply any caustic or the 
Pacquelin thermocautery after excision seems to me superfluous. 

Should there be any recurrence, the x-rays are indicated. 



CHAPTER IX. 



DISEASES OF THE VAGINA. 



:« 



introductory. The vagina is a membranous canal connecting the vulva| 
with the cervix. Normally the vagina, when at rest, is in a collapsed con- 
dition so that the anterior wall lies on the posterior wall. The posterior^ 
wall is the longer one. 

The vagina is always moist with a secretion of slightly acid reaction/ 
which is a natural lubricant for the purpose of sexual congress. 

The examining finger of the surgeon when palpating the vagina will 
find that the mucous membrane forms many wrinkles known as "rugae/* 
which disappear when the vagina is put on the stretch. Thus when the « 
speculum is introduced the vagina is smooth, ^M 

The entrance to the vagina is closed by a membrane called the hymen, 
which normally has a small opening permitting the menstrual blood to^ 
escape. In the majority of cases the well-oiled index finger can be intro-^B 
duced through this opening without rupturing the hymen, provided the^ 
surgeon use a maximum of gentleness. In others the opening may not be 
larger than a pin head. Sometimes, the hymen, which normally has a 
variety of shapes (circular, crescent, etc.) closes the vagina entirely. It is 
then designated as an imperforate hymen. The hymen is a thin membrane, 
easily torn and in the popular mind the proof of virginity. Physicians 
should know better. Personally I know of several instances where frequent 
coition left an intact hymen, because the membrane was originally but 
narrow fold, very elastic, while many women are either without a hymen o; 
with but a rudimentary one- — congenital absence of the hymen. 

When the surgeon is called upon as an expert to establish whether or 
not a girl's claim to have been raped is true, the hymen per se can in no 
way be considered the ''scat of proof." Of course it might be torn ao' 
bleeding— and this certainly would seem to shown recent injury. ' 

While a practitioner in St. Louis the police brought in a girl for ex 
amination before arresting the young man in question. The girl^ who was 
a domestic about nineteen years old told a straight story. The hymen was 
found torn in one comer and bleeding. My suspicions having been aroused 
I asked her whether the young man completed the act? she said yes, for he 



1 

i 



m 



> 




DISEASES OF THE VAGINA. 



59 



held Iier down for fully ten minutes and said afterwards that he wanted 
^her to become pregnant. 

I found no semen or spcrmatozoids. Looking^ at the girl's fingers, 
which I noticed were very clean for a maid of the kitchen and particularly 
after such a struggle and excitement I accused her directly of having 
ruptured the hymen herself. I concluded that she had washed off the blood 
stains from her finger. Sh^ broke down and confessed. She loved the 
young man and had decided to gain him by hook or crook. 



I. IMP.ERFORATE HYMEN AND HEMATOCOLPOS. 

Whenever the hymen Is so tough that the penis is unable to enter the 
vagina, the surgeon is compelled to make a few cross incisions with a sharp 
bistouri. Care should be taken not to wound the vagina. Hemorrhage is 
usually not troublesome but if it prove so, tamponade with sterile gauze 
will arrest it quickly. 

That an imperforate hymen proves an obstacle to the escape of men- 
strual blood goes without saying. 

The following case will illustrate the diagnosis and treatment of im* 
perforate hymen (atresia) producing retention of the menstrual blood in 
the vagina (hematocolpos)* 

Miss S. L., age i8, stenographer, in otherwise good health complained 
of periodic pains in the back and groins. At certain times the pains would 
be worse. She has never menstruated. Her family physician had told her 
that she was anemic and that the pains would disappear as soon as men- 
struation was established ; he had prescribed iron and tonics. 

Her family physician being out of town she visited another physician 
who showed his superior knowledge of gynecology by prescribing a prepa- 
ration containing viburnum pruni folium and advising hot sitz-baths. 

Three months of such treatment failed to accomplish the desired results^ 

I insisted on an examination. Her mother, who was present, consented, 
provided I promised not to "rupture her maidenhead/' 

On separating the labia majora and minora I was astonished to find the 
entrance to the vagina filled by what, at the first glance, appeared to be a 
fluctuating tumor- Careful examination showed that it was the hymen 
closing the vaginal orifice entirely, without any opening, behind which, no 
doubt, there was accumulated blood. The mother grasped the situation 
easily and permitted me lo insert a trocar. Clotted blood came away in 
large masses* I attached a fountain syringe to the canula and irrigated in 
this way until no more blood came away. The puncture was prevented 



DISEASES OF WOMEN. 



from closing by the frequent introduction of sounds and the patient made a 
good recovery. 

Certain authors warn not to make a large incision in such cases, as 
sepsis is very Ukely to occur^-a large opening pernnitting the free ingress 
of pathogenic germs which find a suitable soil in the blood-filled vagina for 
development. Such talk is nonsense and does not reflect much credit on 
the quality of the gray matter of the writers. We might just as well argue 
that in intraperitoneal hemorrhage from^ say, a ruptured, pregnant tube, ihe 
incision through the abdominal wall should be very small for fear of infec- 
tion. On the contrary, we niake an opening sufficiently large to permit the 
insertion of both hands, if necessary, lift out the accumulated blood and 
attend to the source of the hemorrhage. 

It is but reasonable to assume that in cases of accumulated blood due to 
an imperforate hymen, this organ should he opened ^ and if necessary a 
piece of it excised, the accumulated, clotted and decomposed blood removed^ 
the vagina copiously irrigated with a warm, antiseptic (mild) solution and 
packed with iodoform gauze, until the wound has mitirely healed* 

2. ABNORMALITIES OF THE VAC, IN A, 

Limit of space prevents us from discusing the many abnormalities 
the vagina. Sometimes there is only a rudimentary one, sometimes not only 
the vagina, but the uterus and adnexa are absent, again I have seen a wo- 
man who was blessed with two vaginae and several who had that organ 
divided into two compartments, a membrane — ^septum — crossing the vagina 
in a similar manner as does the septum of the nose. In the latter class 
of cases, small retractors expose this partition to full view and it can then be 
excised with knife or scissors alongside its two attachments to the vaginal 
walls. The after treatment consists in the packing of the vagina with a 
strip of iodoform gauze with frequent douching, I have found it necessary 
to administer chloroform for this trivial operation, to insure absolute quiet 
on the part of the patient. 




4 



3. ATRESIA OF THE VAGINA. 

Any portion of the vaginal walls or the entire vagina may be firmly ad- 
herent, as if glued together » A vaginal atresia may be easily confounded 
with a congenital absence of the vagina. 

When the diagnosis of atresia has been established, three questions must 
be answered before any intelligent plan of treatment can be decided upon: 

1, Is the atresia congenital or acquired ? 



DISEASES OF THE VAGINA. 



2, If acquired what was the cause? 

3, If congenital^ is there a uterus and ovaries fully developed and 
functionating^? 

If the atresia be congenital and no functionating uterus can be detected, 
nothing can and should be done. It is self evident that such persons are 
practically sexless and shotdd not marry. 

I knew oi one married woman in Europe. Her husband loved her in- 
tensely and copulated per rectum. 

If, by rectal examination or laparotomy, a functionating uterus and 
ovaries are detected the question of operation becomes a vital one. 

I would not advise a beginner to undertake the operation, who had best 
refer the case to a competent man, should he be fortunate enough in ever 
seeing one, for vaginal atresia is rare. 
. Acquired atresia is ascribed to inflammatory diseases, violence, injuries 
of all sorts, hot douches (?) caustics, etc. 

The operation has as its object the separation of the existing adhesions. 
To prevent injury to the bladder and rectum, a catheter is introduced into 
the bladder and a rectal bougie into the rectum, which objects serve as 
"landmarks" or "guides" during the forcible separation of the adherent 
walls. This should be accomplished best with the fingers of both hands or 
dull instruments. 

The vagina must be kept open and the walls prevented from becoming 
adherent anew by the introduction of suitable glass or hard rubber tubes, 
which should be kept in the vagina a few weeks. After the first week it 
will suffice if the plug is kept but several hours daily* Cleanliness should be 
insured by frequent removal and sterilization of the tubes and irrigation of 
the vagina with hot salt water (a teaspoon ful of salt to each pint of hot 
water), 

4- VAGINISMUS, 

Vaginismus is the term for a condition of hyperesthesia and painful 
spasm of tlie sphincter vaginse particularly when an attempt is made to enter 
the vagina for purposes of coitus. A similar result is observed by the 
surgeon when attempting to insert the fingers for examination. The condi- 
tion is met with in women of a neurotic predisposition. Cold, heat, excite- 
ment, in fact anything apt to irritate the vulva and vagina may produce 
such spasms. 

Coitus becomes horrible to these women* 
In some cases the spasm ceaseg as soon as the penis 1 
ihe vagiHtt, 



62 



DISEASFS OF WOMEN. 



The dia^^nosis, as can be seen from wViat has been said, is easy. 

The prognosis as regards life good. 

Cures can be expected when the patient is billing to submit herself to 
systematic treatment for a prolonged period. 

The treatment is constitutional and local. 
The constitution must be built up by such tonics as strychnin and the 
hypophosphites, sedatives in the form of bromids should be administered 
freely* 

The value of general galvanization and faradization cannot be over- 
estimated in such cases. The subjection of the patient to the "static charge'' 
has proved highly satisfactory to me. 

The local treatment consists in forcible stretching of the vagina with a 
large bi-valve speculum and the introduction of large glass plugs, which 
should be worn for some time. 

Hot antiseptic douches do good. Cotton tampons saturated with a lo 
per cent ichthyol-glycerin solution are invaluable. 

General anesthesia may become necessary the first few times to accom- 
plish complete dilatation. 



IlJfFLAMMATION OF THE VAGTNA-COLPITIS^VAGINITTS. 



Much that has been said about inflammation of the vulva holds g 
for inflammation of the vagina. 

The practitioner, as regards treatment, need only answer one question 
when treating a case of colpitis, viz.: is the inflammation acute or chronic? 

The majority of cases of acute colpitis are due to infection by the 
gonococcus, and may be primary or subsequent to a gonorrheal vulvitis. 

Though the microscope can settle the diagnosis without much difficulty 
I am frank enough to admit that not much is to be gained by such "scientific 
investigations." 

My advice to every physician is: make your diagnosis of acute colpitis 
and proceed to treat the affection as if you were positive it is gonorrhea, 
for then the physician will do real good not only by curing the disease but 
by preventing its spread to the uterus and what is worse — to the tubes and 
ovaries. 

The diagnosis is easy. It is based on the symptoms and local findings. 

The vagina is very sensitive and hot The wom^n cannot bear the ex- 
amining finger. She complains of a burning sensation. There is a yellow- 
ish purulent discharge, which again infects the vulva and urethra, produ' 
mg a desire to micturate frequently. Urination is painful and describee" 



4 

I 

I 
4 



• 



DISEASES OF THE VAGINA, 63 

burning. The patient may have chills — temperature rises several degrees 
and the pulse is increased in frequency correspondingly. 

Treatment. Internally an antipyretic — pulvis acetanilid compositus in 
five grain doses every three hours is best — and a urinary antiseptic should be 
prescribed. Urotropin in eight grain doses three to four times daily in 
half a glass of water is the best remedy yet discovered. 

The patient should be advised to drink alkaline drinks to render the 
urine bland. ^ 

Bushong recommends the following prescription for the irritability of 
the bladder : 

Tinct. hyoscyam S J 

Potass, acet 3 vj 

Tinct. gent, comp., ad 5 vj 

M. S. Two teaspoonfuls three times daily in half a glass of water. 

That the patient should be ordered to bed and only liquid diet allowed 
need hardly to be mentioned. 

The local treatment consists in copious vaginal irrigations with certain 
antiseptic solutions, which should be administered by the physician, his 
assistant or a competent nurse, and then, as a matter of precaution, the at- 
tending doctor should supervise the work at least the first time. 

My own method is as follows: 

First day: Irrigation of the vagina with a gallon of a 3 per cent solu- 
tion of lysol at 115° F. 

Injection with a glass vaginal syringe of ful strength peroxide of 
hydrogen, preferably hydrozone. I await a few minutes until the liquid 
has about ceased bubbling. Irrigation with a hot normal saline solution. 

Introduction into the vagina of a narrow strip of moist bichloride gauze. 

The above precedure is repeated every three hours. 

Second day : Same treatment, only twice, at about 8 a. m. and 3 p. m. 

Third day : Same treatment as second day. 

Fourth day: Treatment is changed somewhat. Instead of lysol solu- 
tion I irrigate the vagina with a quart of i-iooo formalin solution and stop 
the gauze-packing. 

The formalin is apt to produce pain for a few minutes, but a sort of 
Anesthesia takes place after the pain ceases. 

Fifth day: Treatment as on 4th day administered only once, which 
trttti"^*^ Tccovery takes place. 



64 



DISEASES OF WOMEN. 



Special symptoms call for symptomatic treatment. T cannot close tne 
treatment of acute colpitis without %vaiTiin^ the reader to look after the con- 
dition of the bowels — ^and to insure daily evacuations either with effervescent 
magnesium solution or with enemata. 

Chronic colpitis either follows an acute attack or starts as such from the 
begmning. Infection may occur from without or from a discharge from the 
tubes and uterus. 

The symptoms are son^what similar to those observed in acute colpitis, 
but of course much milder. The discharge is as a rule thin. In short we 
have to deal with a milder form of infection. 

The diagnosis is based on the clinical history and on direct examination 
The mucous membrane, as observed by a speculum, is somewhat reddened 
and may show small follicles or ulcers. 

The treatment consists of douches with warm solution of permangaiiat 
of potassium. Solutions should be prepared fresh every time. 

Patients should be instructed to dissolve a few crystals in a glass pitcher. 
When the solution assumes a deep red color the proper strength has been 
achieved. These douches can be administered by the patients themselves. 
The patients should be instructed to douche only when in the reclining 
posture. 

In the office the physician starts to swab out the vagina with a 2 pe; 
cent solution of silver nitrate and increases the percentage up to five eve 
other treatment. Treatments should be given thrice weekly. 

After a while the treatment with silver nitrate should be stopped and in 
jectiotis of the following mixture made : 

Hydrozone ^ ss 

Aquae menth* pip , .5 iss 

M. S. For injection. 

The injections are best made with a glass vaginal syringe. 

The patient should be admonished not to exert herself too much and toj 
abstain from sexual intercourse. 

The general condition should be looked after. 

If on examination with the speculum it is demonstrated that the Infec- 
tion is due to a discharge coming from the uterus or tubes, these organs 
must be treated so as to remove the cause. 



4 



6. TUMORS OF THE VAGINA. 

Diagnosis and treatment same as described in tumors of the vulva. 



DISEASES OF THE VAGINA. 65 

Only one word in addition concerning cancer. When seen by the physi- 
cian, as a rule, either the cervix or the parametrium are already attacked. 
The most radical operation only holds out some hope for the prolongation 
of life. 

If a radical operation is refused, curetting the ulcerated area, applications 
of very strong antiseptics and the use of the galvano-cautery or Pacquelin 
thermocautery should precede a systematic course of treatment with the 
x-rays. 



CHAPTER X. 

DISEASES OF THE UTERUS. 

r. Malformation. The utems, with or without the tubes and ovaries, 
may be totally absent or present only in a rudimentary way. In such cases 
the bladder rests on the rectum, as there is practically no organ between. 
That the sexual function of the woman remains undeveloped can be easily 
imagined. The physician must make a dia^osis after a thorougfi bi- 
manual examination only. Frequently it becomes necessary to introduce a 
catheter into the bladder and a sound in the rectum when tlie absence of a„ 
uterus and adnexa can be recognized with certainty. 

There can, of course, be no question of therapy. Not much more can be' 
done for an infantile uierus or for the primary atrophy of the uterus, as de- 
scribed by Virchow. Their main feature is arrested dev^opment so that the 
adult patients have organs of the same size as found in infants — Whence thi 
name infantile nterus. 

2. Atresia uteri, which can only be diagnosed after puberty has teci 
established, resembles clinically the atresia vao^inse. Atresia uteri may 
present even though the vagfina be normal. In such cases an examinatio 
per vaginam will reveal the presence of an occluded uterine canal 

There is great danger from the accumulated menstrual blood which nol 
only dilates the uterus but also the tubes — hematometra. These enlarge 
organs can be palpated as tumors in the pelvis. The diagnosis is clear whe; 
there exists also an atresia of tlie vagina, in which case a rectal examinatv 
will warn us of the enlargement of the uterus and tubes. 

If the blood is not permitted to escape, rupture of either the uterus or th 
tubes is bound to follow sooner or later with effusion into the periton 
cavity with subsequent sepsis and death. 

The operation for the relief of hematometra requires considerable ski 
and should be undertaken only by men who are prepared to do abdomina 
surgery- Not that an operation through the abdominal wall is always neces 
sary, but such a one may become imperative any time. The opening of the 
blood-mass requires an exact knowledge of the anatomy of the female 
pelvis. If certain precautions are not observed, the tubes may rupture^ an 
accident which will prove disastrous if the surgeon be familiar only with 
the minor gynecic operations. 

68 



n 




DISEASES OF THE UTERUS, 



67 



3, StefWsis of the uterus. When the ordinary uterine sound with a 
head not thicker thun three mm. cannot pass either the interna! or the ex- 
ternal OS or any portion of the uterine canal without the employment of 
undue force, that is to sav when the lumen of either mouth of the cervix or 
portion of the uterine canal is so narrow in calibre as not to permit the free 
passage of the ordinary uterine sound, then we have an either congenital or 
acquired stenosis of the cervix or uterus. 

On examination with a speculum the vaginal portion of the cervix, in the 
majority of cases, appears rather peculiar, the organ beings elongated and 
terminating in a narrow point. The external os looks not much larger than 
a pin head. The diagnosis can usually he made when such a cervix is seen, 
although it should never be made without an attempt to pass the sound. 

Stenosis per se has no symptoms, though many authors associate it with 
anemia, neurasthenia and a host of constitutional troubles, 

I believe the relation of stenosis to constitutional diseases has been over- 
rated. 

It is a fact, however, that it causes mechanical dysmenorrhea and is fre- 
quently responsible for sterility, as has been alluded to in the respective 
chapters. 

The frequent dysmenorrheic attacks, retained secretions, etc., may 
eventually lead to inflammation of the uterus. 

The treatment of uterine stenosis is mechanical and electrical, 

Among^ the mechamcal methods the following are popular: (t) Forci- 
ble dilatation with Palmer's and Goodeirs dilators, (2) Gradual dilatation 
with (a) steel sounds, (b) sponge or slippery elm tents, (c) inflatable rub- 
ber bags, (3) Introduction of stem pessaries and drains. 

But two of these methods need be considered here, the others, for one 
reason or another being either impracticable or risky, vi^. : forcible divulsion 
or gradual dilatation with steel sounds. The forcible method requires, gen- 
eral anesthesia and intra-uterine treatment, frequently curettage after the 
completed divulsion, for the tissues are sure to be injured by the great force. 
Surgeons of great experience, can afford to resort to this method, which, 
has one advantage, in that it does not consume as much time as the gradual 
method, which latter should be the treatment of choice by beginners. 

The technique is simple. The vagina, hands of the surgeons and instru- 
ments must be rendered as aseptic as possible. The cervix is grasped with a 
fine volsetlum hcn^k or forceps and steadied and the smallest size sound in- 
serted into the uterine canal. By palpation through the abdomen we can 
ascertain whether the sound has reached the fundus. Great care should 
be exercised not to push the instrument too hard when trying to pass the 



m 



DISEASES OF WOMEN. 



Ifiner os .as the fundus of the uterus can be easily perforated* There 
astially fjuite a resistance at the inner os and the passaiT^ f^f the souncl 
easily felt in the fingers, even though one does not see the instrunie 
slip in. 

Treatments should be ^iven every other day. At each subsequent m\tin. 
a gonnd of the next larger number should be chosen. It is prudent to advjs#' 
the patient to rest as much as possible after such treatments and to employ 
a hot vaginal douche every evening to counteract the effects of the irrita 
tion. 

For the description of the electric treatment see Qiapter XIT- 

4. Inflammaiion of the uterus or metritis is either ^cute or chronic, Tn 
the acute form as a rule all structures of the uterus including: the peritoneal 
covering are involved* Depending which part of the uterus b attacked by 
the inflammation, we distinguish between endometritis, when the mucous 
membrane only ig attacked, parenchyniatous metritis when the muscular 
layer and pcrimeiritis (as the word implies) when the peritoneal covering 
is inflamed. 

Sympiofns. Acute inflammation of tlie uterus, no matter to what cause 
it may be due is always accompanied by fever. Tlie author has ohsarv^il 
that many cases of acute gonorrheal infection of the uterus are ushered in 
by chills. The patient complains of a sensation of heat in the pelvis, uterine 
"cramps," pain in the small of the back, painful urination and frequently of 
nausea and vomiting. 

Causes. Exposure to wet and cold during menstruation. In Buch cases 
there is also a suppression of menstruation. Recent abortion, injuries of all 
sorts, irritation following foreign bodies, such as pessaries, any and all 
operations and instrumental manipulation of the cervix and uterus by the 
surgeon, partictdarly when the strictest asepsis has not been maintained and 
infection by pathogenic micro-organisms. 

Acute metritis is frequently observed accompanying certain acute in- 
fectious diseases, hut this is so rare as to lose all practical importance. 

Diagnosis. The diagnosis of acute metritis is very easy. The symptoms 
point to pelvic trouble, the presence of fever and increased pulse show that 
whatever inflammation exists — ^it is of recent date, hence acute. The ab- 
domen is tender (palpation causing pain) and tympanitic. The tongue is 
furred. 

Examination with the cleansed finger shows a hot, tender vagina h 
very moist by the discharges. The cervix feels soft ftnd swollen, the 
patulous. 



.4 



i 



DISEASES OF THE UTERUS. 69 

In thfe iliajbrity df caSfes the digital examination is sufficient. Examina- 
tidil with the speculum causes a great deal of pain and must frequently be 
ortlitted brl that addduht; In doubtful cases the microscope must be used' to 
establish the diagno.sis of gonorrheal infection. 

The treatment of acute metritis depends on the cause and sometimes also 
on the individual. 

For purposes of treatttiellt acute metritis Can be divided in four classes : 

1. A. M; due to suppression of menses subsequent to exposure of cdld 
and wet. 

2. A. M* folloWitig aboftiori arid instrumentation (sepsis). 

3. Infection by the gonococcus* 

4. A. M; accdrtipatiyltlg constitutional diseases. 

Ih A. M. due to suppression, heat is our mainstay. Hot douches should 
be admiiiistercdj a hot water-bag applied to the hypogastrium, and hot sitz 
baths advised* The douches can be made every two to three hours. Two 
sitE baths daily one in the mornirig and one in the evening will suffice. Hot 
lettidnade should be given freely. The bowels should be kept open with 
laxatives, the painfe relieved by opium and hyoscyamus rectal suppositories. 
Internal medication is unnecessary, unless the fever is very high, when an 
antipyretic can be resorted to. 

In metritis due to abortion, we have frequently hemorrhage from the 
uterus caused by retained membranes ; in such cases currettage is a rational 
procedure In feepsis following operation, uterine irrigation with a hot 2 
per ceht lysol solution, Cauteriieation of the endometrium with equal parts 
of carbolic acid and iodine are useful. In inetritis due to gonococcic infec- 
tion, the author irrigates the Vagina in the manner described under the head- 
ing! acute colpitis, the endometrium is then mopped out with a cotton ap- 
plicator dipped in tincture of iodine. A strip of iodoform gauze is packed 
loosely in the uterine canal and changed every day following each treatment . 

The acute metritis accompanying constitutional diseases requires but 
little local attention. Vaginal douches with a hot 2 per Cent lysol solution 
is all that is necessary. It is needless to add that all our attention should 
be directed td the constitutional treatment. 

Probably no infection of the female sexual apparatus is of greater interest 
to the ambitious gynecist than chronic metritis. 

Volumes could be easily filled with a description of the symptoms, local 
and reflex, the pathology, macro- and microscopic appearances of the struc- 
tural changes, the causes, varieties and last but not least the diagnosis and 
treattnent. 



70 



DISEASES OF WOMEN. 



The writer admits that he considers the discussion of this particular sab- 
ject his most difficult task. Compelled to use as little space as possible, how 
is he to simplify so important a subject, at once so complex and yet very 
simple? 

The subject is of particular interest to the ^ynedst because 95 per cent of 
all office consultation^ will undoubtedly be cases of chronic inflammation of 
the uterus. On the cure of a lar^e number of such clients depends his suc- 
cess as a p^ynecist, if he wishes his services to be eagerly sought by a large 
clientele — after all a beginner s fondest dream. 

And yet chronic metritis of whatever form, is far from being an affection 
easily cured, though not an incurable one. 

Everything depends upon the surgeon's tact, keen insight and above all 
patience and systematic work. 

In trying to simphfy the classification, diagnosis and treatment of chronic 
inflammation of the uterus^ the author must necessarily sacrifice a great deal 
of what ought to be said, but these omissions must not be criticized too 
harshly, for after all I have in mmd the most urgent needs of the gynecist 
who intends to practice gynecic surgery and not to make pathologic investi- 
gations. 

It may help to quiet our conscience somewhat when we know that the 
greatest authorities fail to agree that the term '"chronic inflammation" is a 
correct one "areolar hyperplasia/* ''sclerosis'* "diffuse interstitial hyper- 
trophy/* "uterine infarct'* having been advanced as correct designations and 
of course, representing the diverse views held by the various authorities in 
regard to the pathology of this affection, 

Schroeder is satisfied with the words: ''chronic metritis*' and cares little 
whether we have to deal with a real chronic inflammation or a connective 
tissue hyperplasia of the hvpcremic uterus. 

The knowledge of the causes of chronic metritis is essential. Here arc 
the most frequent ones : 

1. Poor involution of the puerperal uterus. 

2. Abortions and miscarriages. 

3. Congestions, produced by excessive masturbation, frequent interrupted 
copulation (premature completion on the part of the husband, withdrawal of 
the penis before ejaculation to prevent conception). 

4. Dysmenorrhea when due to stenosis or flexion of the uterus, the re- 
tained blood producing irritation and indirectly contractions of the uterine 
walls. 

5. Neglected or poorly treated acute metritis. 



4 



DISEASES OF THE UTERUS, 71 

6. Venous stasis due to retroflexion and prolapsus, tumors, habitual 
constipation and prolonged retention of urine in the bladder (not infre- 
quently due to faulty habits of the patients). 

Symptoms. The patients, particularly such who recently gave birth or 
had a miscarriage, complain that their previous good health is gone and that 
they suffer either constantly or especially about the time of menstruation 
from a variety of symptoms, not severe enough to compel them to go to bed 
and yet sufficient to make their lives miserable. They complain of pains in 
the sacral region, abdomen, groins which sometimes radiate to the thighs, a 
sensation of pressure in the pelvis, constipation, leucorrhea, excessive men- 
strual flow (menorrhagia) and a desire to micturate frequently (irritable 
bladder). The reflex symptoms are many. The patients have headache, are 
at times nauseated, have loss of appetite, bad digestion, eructations, neuras- 
thenia and frequently "spells of melancholy." 

The examination shows a large, congested uterus, and in the early stages 
of a soft consistency, resembling very closely a uterus pregnant about eight 
or nine weeks. The introduction of a sound in the uterine canal produces 
pain and frequently causes the membrane to bleed. The examining finger, 
aided later through a speculum, easily detects lacerations and erosions of the 
cervix. 

Treatment, A glance at the causes of chronic endometritis and metritfa 
(inflammation of the uterine mucosa alone does hardly exist — we always 
have to deal with a metritis) suggests the treatment of uterine stenosis, re- 
troflexion, prolapsus, if such exist, and the regulation of the patient's faulty 
habits as the first rational steps to be taken whenever the cause has been 
ascertained. 

The local treatment of the inflamed or hyperemic uterus is either anti- 
phlogistic, antiseptic or electric. 

We frequently find the cervix studded with little cysts (ovula Nabothi) 
which are best pricked open with a sharp bistouri and then painted over with 
tincture of iodine. 

The same treatment can be employed for the relief of the congested 
cervix. Instead of scarifying the cervix I prick the tissues with a sharp 
pointed knife and permit the escape of several drachms of blood. 

Glycerin-tampons are then inserted against the punctured cervix and 
permitted to remain for twenty-four hours. 

Tincture of iodine, painted around the cervix has a slight revulsive ef- 
fect. Its antiseptic value is doubtful, when applied in this manner. 

A{>plications can be made directly to the endometrium by cotton appli- 
ed with the liquid we may desire to distribute. 



72 



DISEASES OF WOMEN. 



I apply one day tincture of iodine, the next ireatmetit is change 
silvcr-nitrale solution (5 to 5 per cent). If there is a tendency to hemor- 
rhages (menorrha^'a and metrorrha^) applications of tinctura ferri 
chloridt are to be made. 

1 have seen bad results from the use of llie inira*uierinc syringe aiid 
from the uterine irrigator. These instruments sfiould be used only when the 
entire uterine canal has been thoroughly dilated. 

When the cervix appears spongy, tampons of tannic acid and j^lycenn 
prove eflBcient, 

A lacerated cervix should he repaired, a granulating endometrium re- 
quires curettage (sec Chapter XIII). 

The galvanic current however, acts better than any astringetit drug in the 
treatment of erosions of the cerv^ix and the s%\t>llen endometrium (see 
Chapter XII). 

Hot douches are useful and should be recommended, I use a powderj 
containing thymol, bicarbonate of soda and tannic acid (see Appendix)* 



4 



5, MALPOSITION OF THE tJTI^RUS. 



A great deal has been written on the subject of abnormal positions of the 
uterus. The tium?>er of theories especially dedicated to these conditions, the 
number of theories advanced, the number of methods of cure announced^ the 
number of operations and mechanical devices for the cure of the forward and 
backward dislocations of the uterus described, is countless. 

After several years of experience the physician trained to use his faculties 
for purposes of critical observation must ask himself two main questions: 

First, what really is the normal position of the uterus? and 2nd, when 
must digression from that position be corrected? 

The first question is very difficult to answer in spite of the fact that many 
well-known authorities have arbitrarily agreed on a certain position as the 
normal standard. 

The second question permits in my estimation of only one rational 
answer, viz,: if there are no other pathologic lesions and conditions present 
save a pronounced deviation from the uterus, commonly accepted as normal, 
and if there are symptoms present inconveniencing the patient and pointing; 
to trouble in the pelvis then only should such a malposition be corrected. 

The diagrams of the normal uterus and its relation to adjacent organs 
as found illustrated in most text-books on diseases of women are palpably 
false and untrue to nature. 

It would require too much space and useless labor to copy some of these 



i 



DISEASES OF THE UTERUS. 73 

diagrams and ask the various authors whether they have ever seen a living 
woman as represented in their drawings. 

Sections made through frozen bodies, while of great interest to th^ 
anatomist have no practical value to the practicing gynecifet. 

The conception most young graduates have in regard to displacements 
of the uterus are so erroneous that at the least provocation they hasten to 
irritate the vagina and uterus with all sorts of useless and nonsensical 
pessaries only to produce infection and inflammation. I consider it mjr duty 
to warn my readers to be more independent in their own conclusions and 
to be conservative in the treatment of the conditions referred to. 

We speak of a normal uterus when the cervix is situated almost in the 
same axis as the vagina, while the body itself is slightly curved forward. It 
must be remembered that this position is apt to vary, depending whether the 
bladder and rettum are full or empty. In order to appreciate the character 
of malposition of the uterus we must recapitulate the support of this organ 
as we have learned it in our anatomy. We know that the uterUs is held 
in position by ligaments, the strongest and least yielding of which are the 
utero-sacral ligaments. These are attached to the sacrum at their posterior 
ends, and to the uterus on either side at about the place where the internal 
OS can be found. 

Next in importance are the broad ligaments which are attached to each 
side of the uterus and the bony pelvis ; the round ligaments act like a pair 
of cords also springing from the sides of the uterus and losing themselves in 
the labia majora. 

The piece of peritoneal fold between the uterus and bladder amounts tc 
very little as a support. Motion of the utetus is possible in every directiohi 

The displacements are called flexions, when the body of the uterus is 
bent on its own axis, versions, when the entire uterus is displaced. Depend- 
ing upon which direction the displacement takes, we speak of : 

A. Anteflexio (forward bending). 

B. Anteversio (forward turning). 

C. Retroflexio (backward benditig). 

D. Retroversio (backward turning). 

E. Latero-flexio (sideward bending). 

F. Latero-versio (sideward turning). 

G. Prolapsus (downward displacement). 

A. ANTEFLEXION. 

Normally the uterine canal from the os to the cervix is either absolutely 
straight or curved but slightly. If the body of the uterUs is so tilted for- 



H 



DISEASES OF WOMEN, 



ward that the canal of the uterus forms an exaggerated curve or an angTeT 
we speak of anteflexion or a forward bending of the uterine body. 
. In many text-books these flexions are described as being: iii either the 
first, second or third degree, depending upon the angle formed bv the body 
and cervix. This is neither scientific nor exact- 
Acquired anteflexion is caused by inflammation of the uterus or its 
adnexa, fibroid tumors, within the uterine wall or is the result of general 
mahiutrition. 

The symptoms do not diflFer from those which are produced by uterine 
inflammation. Anteflexion is frequently responsible for habitual abortion 
and unpleasant reflex phenomena during pregnancy. 

The diagnosis must be made by a careful bimanual examination. The 
position of the cervix alone will not be suflicient to enable us to form an 
opinion concerning the position of the body of the uterus. The body must 
be felt by the hand placed on the hypogastrium, while the fingers of the 
other hand steady the organ by pressing on it from within the vagina. 
Finally the uterine sound, bent to an angle approximately equal to that 
formed by the uterine canal, will leave no doubt. The sound has also the 
additional diagnostic value in that the uterus can be differentiated from 
fibroid tumors, whose size and position may stimulate a displaced uterus. 
Care should be taken not to introduce the sound after a recent acute attack of 
inflammation of the uterus or its adnexa, as the extinguished fire may be 
rekindled, 

Treatmeni should be directed towards the inflaiiunation. When there is 
no excessive sensitiveness, that is to say^ when the inflammatory process has 
subsided 1 commence massaging the uterus back to a more normal position. 
Intra-uterine galvanization and faradization is very helpful. 
Pessaries, whether vaginal or intra-uterine are worse than useless, be- 
ing not infrequently the cause of additional irritation, consequently intensify- 
ing the inflammation. 



B. ANTEVERSION. 

Uterus and cervix form one line, the entire organ assuming the appear- 
ance and position of a straightened finger. There is no bend in the canal. 
On digital examination with the finger the cervix is found pointing against 
the rectum (promontory), the finger striking the posterior lip of the cervix, 
the body leaning more forward than is conceded to be normal, thus the body 
has tilted forward and the cervix correspondingly backward. 

Causes and symptoms are practically the same as in anteflexion. Perhaps 
the bladder becomes more irritable than is usually observed m anteflexion. 




DISEASES OF THE UTERUS. 75 

Treatment. Sims sug^gested an operation for the relief of anteversion 
and many pessaries have been devised for the relief of this malposition. 
Personally I have no faith in either. In the light of clinical experience the 
pessary is becoming an obsolete instrument in almost all uterine dislocations. 

The first thing our attention must be directed to is the existing inflamma- 
tion. All that has been advised for the treatment of chronic metritis should 
be instituted. Depletion, hot douches, iodine painted around the cervix, will 
do good. Right from the beginning pledgets of cotton soaked in 5 to 10 per 
cent itchthyol-glycerin can be placed behind the cervix, with a view of exert- 
ing a mild but prolonged pressure on the cervix in the direction toward the 
vulva, at the same time utilizing the antiphlogistic and dehydrating prop- 
erties of the two drugs. 

Of course, when the inflammatory condition has improved, more forcible 
methods may be cautiously employed consisting mainly in a sort of pressure- 
massage with the fingers. If it is found that there exist adhesions, great 
care is necessary to prevent a relighting of the old inflammation. 

Our mainstays are, however, the tampons, properly inserted. It goes 
without saying that the tampons should be made larger from time to time, 
depending on the amount of reduction achieved in the course of treatment. 

C. RETROFLEXION AND RETROVERSION. 

Owing to the similarity of both conditions as regards diagnosis and 
treatment they are considered together. 

Retroversion and retroflexion, roughly speaking, are the opposites to 
anteversion and anteflexion, although not quite so as regards the cervix. 
In retroversion the fundus inclines backward without any bend of the^ 
uterus — in retroflexion ihe uterus bends over its posterior surface. The 
cervix in either condition may remain in a fairly normal position or be tilted 
upwards. 

The diagnosis is to be made by a careful bimanual examination. In ag- 
gravated forms of retroflexion the fundus can be felt in Douglas' cul-de-sac 
by the examining finger in the vagina, but care should be taken not to con- 
fuse the uterus with a possible tumor, mistakes which have often been made 
by competent gynecists and which could have been avoided, had they used 
more care in the examination. Like in all other malpositions a diagnosis can 
be made with certainty only, when the entire uterus has been mapped out 
with the examining fingers of both hands. 

In retroflexion this is not an altogether easy task, much depending how 
relaxed the abdominal muscles are during the examination, for the fingers 



76 



DISEASES Of WOMEN- 



must be pressed m deeply in order to feel the bcnly of the retrafiexed uterus. 

In ckiubtful casest particularly when we do not know whether we hare 
to deal with a simple case of rctroflexed uterus or a fibroid tumor springing 
from the posterior ntcrine wall, we may have to resort to general aitestbesiA 
to clear up the diap^osis. 

As regards the causes of retroflexion and retroversion, the acquired 
form, in most instances seems to follow parturition. An overfilled bladder 
will easily crowd the fundus downwards while relaxed utero-sacral ligaments 
and a pelvic fioor, weakened in its tone by traumatic injury during child- 
birth will keep the uterus in the abnormal position or at least penult it to re- 
main so as they offer no support. Add to this inflammation of the uterus 
and its neighboring space, and adhesions are soon formed so that the uterus 
becomes firmly inbedded in a mass and camiot be lifted out. 

The treatment is not based so much on the cause of the trouble as on the 
question; can the uterus be replaced or not? keposition is possible, if there 
are no adhesions. Great care must be exercised in manipulating the uterus 
with or without instruments when recent infiamniatory disease of the adnexa 
and parametrium is suspected. 

All attempts at reposition should be very gentle at first. 

Reposition can be accomplished in two ways. The woman is in the 
dorsal position with somewhat elevated liips. The index and middle finders 
of the left hand are introduced in the vagina and press ag^ainst the retro- 
verted or retrofiexed itteruSp while all fingers of the right hand, pressing 
deeply through the abdominal wall, try to grasp and lift up the uterus. In 
order to aid somewhat this procedure, one of the fingers in the vagina can 
depress the cervix to secure a sort of lever action. 

Another way is to place the patient in the knee-chest position. All con- 
stricting garments particularly corsets and corset-waists should be loosened, 
If we now retract tlie perineum either with fingcrs'or with a retractor, air 
is allowed to enter and fill the vagina and in ordinary cases the uterus will 
now gravitate towards the abdomen without any trouble. In some cases we 
must introduce a finger in the vagina or rectum and give the uterus a push. 

If we have succeeded in reducing the uterus the therapy is directed 
towards the repair of any existing pathologic condition of the uterus or 
cervix and towards the retaining of the uterus in a normal position* 

If, however, reduction is impossible, that is to say if the uterus is bound 
down by adhesions, then our first aim, naturally is to try to overcome these 
adhesions. In order to cause the adherent mass to absorb we must paint the 
vaginal vault three times a week with liquor ferri persulphatis, followed by 
tampons of glycerin. If the iron produces inflammation or ulceration of the 



I 



i 



DISEASES OF THE UTERUS, 



w 



skin, treatments should be ^iven less often and tincture of iodine applied 
instead. 

Much srood can be expected from the i^alvanic current. Inflammation of 
the uterus is treated in the usual way. 

We know of hut one recommendahle way to prevent the reduced uterus 
from falling back to its abuomial positiQU find that is by the insertion of 
cotton pledgets, press! np^ a^ahist the lower vap^nal fornix and over the 
cervix. 

I am decidedly opposed to the use of any pessary even for a few weeks, 
for the simple reason that when the woman wears one she im3p:ines she caij 
keep away from the doctors care for some time, meanwhile tha pessary can 
do all sorts of miBchief. The safest amonf^r all pessaries is the inflatable ring 
pessary* T have seen a woman in whom a Hod^e pessary, so much made of 
in many hooks, ulcerated almost through the vas:ina. 

The physician who introduced the instrument enjoyed an excellent repu- 
tattQu, This happened in Detroit 

In many cases, however, in spite of prolonged systematic efforts with non- 
surfi^ical methods no success is achieved. It is in mch cases, particularly 
when the symptoms have not abated that we must resort to surg^ical measures. 
Many are the methods sugfifested but not all are equally usefuL I invariably 
open the abdomen preferring this to the so-called Alexander operation in 
which the round ligaments are shortened by extraperitoneal operation. 

Plastic operations, in which an incision is made through the vagina and 
the anterior wall of the uterus sutured to the vagfina are, of course less risky, 
but are apt to cause disturbances as soon as the patient ^ets pregnant. The 
mortality of the abdominal operation, however, almost being nil, it is my 
operation of choice. 



D- LATEROFLEXIO AND LATEROVERSIO- 

I recollect to have seen but one case of lateroversio. 

This was a young:, slim Jewish woman, born in Russia but raised and 
educated in this country. She was married about four years and was 
sterile, for which she had had her jiterus dilated and curetted by a New York 
surgeon. 

The cervix in her case pointed in an oblique direction towards the left 
side of the pelvis while the fundus proGeeded in a direct line opposite. As 
I did not promise relief for her sterility positively, she did not come again. 

I cannot say whether the malposition was congenital or due to trauma. 

As I have no personal experience with such cases I can express no 
opinion. The literature is very scant on the subject. 



DISEASES OF WOMBM. 

Sfioiild msf oi mf icadefi mctt with ^mA a case I v9 be ^ratefts) for a 
ffetaited report. 

It seems to me tlmt tlie tr e j ituieiil. AtatU not be bbj ifiSereiit than the 
one described in the prerioai sedian. 



» 



E. PBOLAPSI]5 DT^BL 



Downward smldng of the titcnss is tisitaify dirooic and rarelv met with 
in ntillipara. The injuries sustained dnring^ cliil<!biith, enUr^^ement of the 
utems makinif this organ hcaricr than normal, loss of tone of the ligant^its, 
a torn pertnetim. are all causative factors. Tbe sitppoft of the litems weak- 
ened above and below — the organ itself is drircn dowtiward by abdominal 
pressure* 

The uterus In its downward descent drags alan|f tbe vagina, which, too 
in the severer forms might become inverted and prolapised. 

It is frequently impossible to reco^ize a descent of the uterus, when 
such displacement is not very ^reat, while the patient is in the recumbent 
posture* Such cases can be easily recp^tzed when the woman Is examined 
while standing. 

The prolapsus may be so severe that the entire uterus comes out of the 
vulva and han^s between the thig^hs. Such a condition is met with mostly 
in old women. In younger women the uterus is usually observed to be at the 
vulva* 

The diagnosis is easy enoug^h. .^n unusually elongated cervix might 
simulate prolapse, though the fundus be in about the normal position, a 
polypus mi^ht occasionally mislead. The uterus might be inverted, that is 
to say the fundus might go through the uterine canal not unlike a glove 
turned outside in. To differentiate from these conditions should not be 
difficult. 

A good rule to follow is never to make a diagnosis of uterine prolapse 
until tlie protruding mass shows the external os. permitting the introduction 
of a sound, while the fundus should be palpated bimanually. 

Treatment is either mechanical or surgical. 

Reduction of a prolapsed uterus being very easy in almost all cases, 
peiairies of all sorts have been devised to hold the uterus back. The only 
one to be recommended is a cup-shaped pessary attached to a rod-like piece 
from which several strings lead to an abdominal belt, 

ITie greatest cleanliness must be observed* The pessary should be re- 
moved and disinfected every evening. A hot, antiseptic douche administered 
every day la essential 



DISEASES OF THE UTERUS. 79 

It IS needless to say that any ulceration or other pathologic condition 
found in a prolapsed uterus should receive due attention. 

Surgical treatment consists in the repair of a lacerated perineum, or 
colporrhapy and a surgical operation to fasten the uterus by similar methods 
as mentioned under retroversion. If a large hypertrophic cervix was one 
of the primary causes — the cervix should be amputated. 

The result of all operations mentioned, singly or combined are far from 
ideal. 

In old women, hysterectomy, or extirpation of the uterus may .become 
justifiable. 

3. TUMORS OF THE UTERUS. ^ 

Mucous polypus are frequently seen protruding from the os externun 
on examination with a speculum. They are very soft in structure. The 
patients complain of "whites" and the frequent appearance of "a flow." 
Sometimes they cause pain. 

They are easily recognized as such, as they resemble in structure and ap- 
pearance the polypus seen in the nasal passages. And who has not seen 
a nasal polypus ? 

They are attached to the mucous membrane of the cervix or uterus by a 
narrow pedicle. 

There is only one treatment for them, viz. : to seize them as near their 
seat of attachment as possible with a pair or artery or clamp forceps and 
twist them off. 

If their base is very broad the uterine cavity should be thoroughly 
curetted with a sharp curette when they will come away. 

Fibro-myoma, Small tumors may be present in the uterus without giv- 
ing rise to any symptoms. The shape of the womb is not sufficiently altered 
to be detected by any of the methods of examination. 

Sometimes the presence of a tumor must be suspected on account of 
certain symptoms. When the tumors reach any considerable size they can 
be easily detected. 

Depending on the locality of their growth fibro-myomata are described 
as submucous, intramural and subserous. 

They have either a broad base of attachment or a narrow pedicle. The 
submucous ones, as a rule grow into the uterine canal, the subserous ones 
into the abdominal cavity. 

The intramural fibro-myomata enlarge the uterus itself. If several 
equally formed tumors be evenly distributed in the uterine walls the en- 
largement will appear to the examining finger uniform, not unilke the en- 
largement observed in pregnancy. 



m 



DfSEASBS OF WOMEN, 



From this condition it can be easily differentiated by the absence of the 
^classical objective (soft, purple cervix, purple vulva, etc.) ant! subjective 
symptoms (cessation of menstruation, morning sickness, etc.) and the hard- 
ness of the uterine wails. This hardness has a special diagjiostic value. 

There are no symptoms especially characteristic of uterine fibroid — in 
fact symptoms may be absent altogether. The symptom wliich drives the 
patients to seek medical aid Is : metrorrhagia. These hemorrhages may be- 
come so frequent and excessive that, unless arrested, they may lead to com- 
plete exsangulnation. 

Painful urination (dysuria), painful sexual intercourse (dyspareunia), 
backache and leucorrhea are frequently observed in fibroid of the uterus. 

As regards the prognosis it must be borne in mind tliat fibroid per sc 
Js a conp^ratively harniless growth. I do not knovvr of otie authentic instance 
in which the tumor itsejf has become malignant. Of course, mahgnant dis- 
ease may come on as if there was no fibroid. 

The hen^orrhages, however, must b^ stopped. This can be accomplished 
by the administration of the fluid extract of ergot internally and the topical 
application to the uterine mucosa of the tincture of iron. 

Curettage, whenever this can be done, should be perforrped. I say, ad- 
visedly, whenever this can be done, for frequently the irregularly shaped 
tumor or tumors make the uterine canal so tortuous that not even a sound 
p^n be successfully passed. 

The methods of treatments for the growth itself are many. 

Among the medicinal ones ergot is the oldest. Its value is doubtfuK 

Prof, Garrignes of New York kindly advised me in a private letter that 
mammary extract in 5 grain doses (prepared by Armour & Co,) has been 
successfql in his hands in at least one case. The patient, a relative of a 
physician had already determined to undergo hysterectomy by a surgeon of 
national reputation when Dr, Garrigues suggested the use of this extract. 
The results were astonishing. In a few months the tumor slirunk two- 
thirds, 

Dn Garri.efues is too great a surgeon not to command the respect of every 
physician and though this information came at so late a date that I have 
had no opportunity of testing it personally, I strongly urge the readers to 
remember this agent when they undertake to treat uterine fibroid and to g-ive 
it a thorough trial, 

ApostoH has suggested a method of treating by galvanic electricity, A 
sharp, spear-shaped electrode is pushed into the tumor at its most prominent 
place (either through the vagina or abdomen) and an iinditferent, dispersing 
electrode applied to the back and hypogastric region. 



DISEASES OF THE UTERUS. 81 

This method, which caused quite an excitement in the surgical world 
soon after its birth, has lost considerably the confidence it once enjoyed. The 
method permits of many objections. The value of the galvanic current, pro- 
viding it be applied differently, however, cannot be denied. .It will be more 
fully discussed in Chapter XII. 

The surgical treatment consists in either the extirpation of the tumors — 
myomectomy, or the removal of the entire uterus — ^hysterectomy. 

Myomectomy is the operation which should be preferred, if an operation 
be decided upon at all, but alas, is not always possible. Hysterectomy is so 
formidable an operation that the practitioner might well think twice before 
suggesting such a step. 

The comparatively less harmful operations of ligating the uterine arteries 
atid of oophorectomy are still favored by some surgeons, particularly when 
extirpation of the uterus on account of extensive adhesions is impossible. 
The former operation is performed with a view of shutting off the blood 
supply of the uterus and thus ''starve" the tumor or tumors, the latter 
produces an artificial menopause and with it — cessation of the menstrual 
function and — it is believed — an impossibility for the occurrence of uterine 
hemorrhage. 

That these two operations do not always arrest the hemorrhages produced 
by uterine fibroid is now a well-established fact. The theory that the natural 
menopause will silence these growths has also proved to be erroneous. 

When should the patient be operated on? is the question of vital im- 
portance. 

There can be but one answer, viz. : when with the medical methods or 
electricity we have failed to arrest the hemorrhages. 

In those cases in which the tumor grows very rapidly in spite of all treat- 
ments, operation is the only rational procedure. 

Finally repeated attacks of peritonitis call for the surgeon's knife. 



Among malignant growths cancer is the most frequent one. Other 
malignant growths, sarcoma for instance, may attack the uterus, but they 
cannot be considered here. 

The best description of cancer I have seen is given by Dr. Chas. H. 
Bushong in his book "Modem Gynecology." It reads as follows : 

"Cancer of the cervix has some peculiar characteristics that will at least 
lead to a more thorough investigation. The cervix is usually the seat of 
laceration which has been neglected for a number of years. There is 
hypertrophy, which is frequently at the lowest point, giving a "cauliflower" 
shape to the cervix. The consistency is not so dense as that of simple 



82 



DISEASES OF IVOMEN. 



hypertrophy, and the hard resistance ^iven by fihrous growth is absent, 
stead of these there is a spongy impression given by the examining finger, 
as if the parts were saturated with fluid and ready to break down at any time* 
At the highest limit of this softer tissue a zone of quite hard tissue is fre- 
quently felt. The canceron^ growth in the cervix may be hmited to a small 
spot or it may involve its whole circumference. When the body of the uterus 
is invaded by the disease it is hard and unyielding to the finger at the side, 
and nodules and irregularities are frequent. These must not be mistaken for 
multiple fibroids of the uterine wall, which are smoother over each individual 
tumor, while the malignant tumors are irregular in form and broken by de- 
pressions and elevations. When the entire uterus is involved in a cancerous, 
growth it may be smooth and uniform in size/' 

A positive dia^^nosis, in all doubtful cases, can be made from the micro- 
scopic findings of a small piece, removed for that purpose. 

Treatment, When cancer of the uterus is seen and recognized in it 
earlier stage, while the growth is localized, and before adjacent structures 
are involved or a cachexia due to general infection present, there can be but 
one advice to give: to secure the services of a conscientious and skillful 
operator and have the uterus totally removed. An ordinary hysterectomy 
will not suffice, for the operator will have to carefully scrutinize the vessels 
and lymphatics, which, if in the least involved will need careful dissection 
and removal. 

When the disease, however, has become too far progressed, or when^ 
operation, though advisable, has been dechned, then palliative measures must 
suffice. 

Curettage of all diseased tissues, followed by application of strong anti- 
septics, particularly with a sohition of equal parts of creosote and tincture of 
iodine, destruction of the ulcerated and sloughing tissues with the PacqueJin 
thermo-cautery, followed by the creasote-iodine solution have proven veryj 
useful 

Of course a good many drugs, such as strong solution of carbolic acid, ] 
silver-nitrate, zinc sulphate can be used. Dusting powders, such as iodoform, 
nosophen, aristoi, dermatol, xeroform, etc., may be frequently blown on the 
raw surfaces. 

There is no internal remedy for cancer. The treatment is purely sjmip- 
tomatic. Pain and sleeplessness should be combated with codein, morphin, 
sulfonal, etc., while the strength of the patient should be supported by tonics 
and judicious diet 

The x-rays directed towards the uterus through cylindrical vaginal 
specula of celluloid should be tried in every instance of inoperable cancer 




CHAPTER XI. 



DISEASES OF THE OVARIES AND FALLOPIAN TUBES, 



As even skilled and old j^necic practitioners are in the majority of cases 
unable, by physical examination, to positively demonstrate whether it is the 
ovaries or tubes which are afflicted by inflammatory disease, we deem it best 
to describe inHammatlon of both organs together in one chapter. Inflam- 
mation of the ovaries is technically called ovaritis or oophoritis, inflamma- 
tion of the Fallopian tubes salpingitis. If the tubes are filled and distended 
by pus we speak of pya-saipinx and if there be serum instead of pus, hydro- 
salpinx. 

Practically all that has been said in regard to metritis holds good !n both 
ovaritis and salpingitis. Both conditions can be acute or chronic. The 
acute cases are usually extensions of uterine disease, which has been per- 
mitted to exist without appropriate treatment. 

The chronic forms are sequelae to acute inflammation of the tubes and 
ovaries. They seldom start as such. 

The symptoms of acute inflammation are practically the same as those 
described in acute metritis, save that they are more intense. The "uterine 
•cramps" are substituted by "tubal colic" in salpingitis. 

Digital examination through the vagina establishes the presence of in- 
flammation. That is as much as can be done, for any attempt to make a 
bimanual examination, produces intense suffering. It leads to nothing and 
should not be undertaken, I would not even give chloroform for the sake 
of a correct diagnosis. It must be remarked that even while the patient is 
under the influence of the anesthetic, the palpation of the ovaries and tubes, 
should one succeed in this, will not aid us materially, even though we suspect 
and establish so grave an affection as pyo-salpinx. 
^ Operation of any sort is not to be undertaken during an acute attack so 
that instead of wasting time \vith examinations the physician had better 
make a provisional diagnosis resting between, pelvic peritonitis, ovaritis, 
salpingitis, or metritis, or two or more together and proceed to local and 
general treatment. 

Rest is absolutely essential. An ice-bag should be placed on the hypo- 
gastrinm. Nothing but a piece of flannel should intervene between the skin 
and the bag. 

B3 



84 



DISEASES OF WOMEN. 



To relieve the intense pain nothing is better than the hypodermic injec- 
tion of morphin and atropin. Tmmed lately afterwards saline laxatives should 
be freely administered. Perhaps it is best to at once catheter ize tlie patient 
and administer a soapsud enema. 

No vaginal applications of any kind should be made during the first four 
or five days. 

Throughout the entire attack the bowels should be kept open by magne- 
sium sulphate and enemata. Instead of morphin injections suppositories con-j 
taming opium and hyoscyanuis should be inserted in the rectum. 

The ice-bag should be applied for an hour and then removed for an hourj 
to be replaced again for another hour and so on. 

The diet should be light Milk is sufficient wdiile there is fever. When 
the fever has subsided soups, oat meal and soft eggr^ are permissible. 

Chronic ovaritis and salpingitis are treated in the same way as a chronic 
endometritis, which, usually co-exists. Glycerin or better still ichthyol- 
glycerin tampons should be applied to th^ vaginal fornix every other day. 
The bowels should be kept open. Hot douches can be administered wh&n 
there are no tampons. The vaginal vault and cervix should be painted w^ith 
tincture of iodine several times a week. 

Internally the so-called "mixed treatment*' can be given. It consists of , 
solution containing bichloride of mercury and potass, iod* 

When, in spite of careful and conscientious prolonged treatment the re-«^ 
suits are not satisfactory or the patient is subject to repeated exacerbations,^ 
the question of surgical operation has arisen. As it usually means the un- 
sexing of a young w^oman, consultations with surgeons known to be con- 
servative and painstaking should be held. That tlie practitioner must aid the 
consultant by submitting to him an exact history of the case goes without 
saying. The patient should be fully advised in regard to the seriousness of 
the step. 

In such cases I always favor laparotomy, for when the abdomina! cavitj 
lias ben opened the adnexa are open for direct inspection and palpation 
More than once has the abdomen been closed again, because the finding 
were at variance with the symptoms, without operating on the adnexa, andj 
non-surgical methods advised continued— to the great benefit of the patient 

Thus every abdominal operation can be considered to be preceded by 
exploratory laparotomy. 



ELECTRO-THERAPY, 87 

Static machines at this date are no "rare bird" any longer, enterprising 
manufacturers having distributed, broadcast circulars all over the continent. 
Competition has bought down the machines from high prices to sums within 
the means of every successful physician who cares to completely equip his 
office. Nevertheless, I would not advise to expend any money on a static 
machine if it was to be used in gynecic practice exclusively. 



^ 



Fig. 22. — Fitzhugh's electrode for erosion of cervix. 

The main value of the static machine lies in its usefulness as a producer 
of x-rays and is undoubtedly the best means for malignant growths. In 
these respects the static machine is even superior to the x-ray coils. 

The fnalvanic current is the most important one. 

The galvanic battery used by the author can be connected with the no 
volt direct current by means of a special attachment furnished with the ap- 



^ 



Fig. 23. — Goldspohn's vaginal ball electrode. 

paratus, or the source of electricity can be obtained from a number of dry 
cells which can be conveniently placed in a compartment of the cabinet. 

It is a stationary office battery but can be easily moved about the room, a 
feature which must not be underrated. 



^ 



Fig. 24. — Block tin electrode (uterine) for positive galvanic current. 

The battery has a graphite rheostat, a milliamperemeter, a pole-changer 
and a galvanic interrupter. The last-named feature, though very useful in 
the treatment of nervous affections, is seldom, if ever, required in gynecic 
practice, for on the contrary, in the use of the galvanic current on the female 



8S 



DISE.4SES OF tVOMEN. 



genital apparatus great care must be exercised to avoid "shocks" or interrup- 
tions of the galvanic current. Both an increase or decrease of the current 
must be as gradual as possible, which can be accomplisbed with the rheostat. 
My experience ^\^th rheostats in the past has not been a very pleasant one. 
The composition has been poor, the graphite became soft and brittle and 
after some time the current could be increased only in jerks. The rheostat 
oa my present battery is far superior in every respect to any I Iiave had — 



Fia 25.— Vaginal electrode. 

being durable, hard in consistency, smooth and permitting of fine, uniform 
gradation of both the galvanic and faradic currents. 

The pole-changer is certainly a great convenience. By means of a simple 
svvitcli either electrode can become the positive or the negative* at the will 
of the operator. Thus if we wish to change for instance the uterine electrode 
from negative to positive or vice versa, this can be easily accomplished with- 
out disturbing the position of the electrode or its connections with the bat* 




Fig. 26. — Goelet's bi-polar vaginal electrode. 



tery by simply changing the switch on the board. Care should be taken to 
first turn oflf the current, that is to say, to put the handle of the graphite 
rheostat on the starting point, before making the change, as otherwise the 
current is suddenly interrupted and just as suddenly turned on, producing 
two *'shocks" which are as painful as they are unpleasant. 

The milliamperemeter is to the electro-therapeutist what the scales and 
graduate are to the chemist — an instrument for the purpose of measuring 
the galvanic current. 

In the older batteries so-called * 'cell-selectors*' have been attached, con- 
sisting of a number of buttons arranged in a circle, each connected with 




ELECTRO-THERAP V. 



89 



cell. Al! of tlie buttons used meant that all the cells were employed. By 
means of special handles any desired number could be utilized. We there- 

Ifore frequently read in older articles of estimates of the intensity of the 
current by the number of cells employed, 
L This is as unscientific as it is unreliable. Five cells used to-day will give 



Fig. 27,^Apostoli's bi-pokr uterine electrode. 



off a stronger current than after a few days, because these cells lose their 
strength. Different portions of the body are differently affected by the 
galvanic current, depending of course on the amount of resistance to the 
current. The nature of the electrodes and rheophores is also to be reckoned 
with. 



(■>7^/- 



Fia 28.— Faradization of vagina with bi-polar electrode. 



The milHaniperemeter, which registers the amount or intensity of the 
current is the only reliable guide, and these facts are appreciated by manu- 
facturers of electrical apparatus and the cell-selectors are done away with. 
The rheostat has taken its place. When cells are used, they are now con- 



DISEASES OF WOMEN. 

nected amongf themselves the zinc of the first and the carhon of the last beln^ 
connected by two wires with the ** switchboard/' The rheostat can be com- 
pared to a damper on a piano. Though all cells %VDrk whenever the current \ 
is used each one is called upon to furnish an equal share. fl 

In order to demonstrate the use of the g:alvanic battery let us assume that 
we have a case of fibroid tumor, which g^ives rise to hemorrhages and which , 
we desire to destroy. 

Two electrodes are needed for that purpose, a dispersing or indtfferetti^ 
abdonma! electrode and a suitable intra-nterine electrode. 



m^ 



Fig. 29." Faradization of endometrium with bi-polar electrode. 



The dispersing electrode must be wide and large to minimize the local 
eflfects of the current. It is usually made of a sort of felt attached to a 
tneta! sheet. Clay-electrodes have also been manufactured. 

In the selection of an intra-uterine electrode we must remember that the 
negative current does not affect the metal, if we use thS positive current all 
metals will be decomposed save platuium and carbon. 

Of course sometimes the decomposition of the metal is what we are after. 

The patient is now placed on the operating table. The vagina is disin- 
fected and a vaginal speciilum introduced and the cervix exposed. The 
dispersing electrode is now made wet with a warm solution of bicarbonate, 



ELECTRO-THERAPY. 



91 



>f scxia (5j:0]) and applied over the hypogastrium or sacrum, a$ the 
operator sees fit 

The disinfected intra- uterine electrode, made of copper is put into the 
uterine canal as far as it will go without any undue force. If there be re- 
sistance we stop and throw the switch so that the dispersing electrode is 
positive. The current is now started by means of the graphite rheostat 
handle. It is of course essential that all switches are in their right place. 

The milliamperemeter needle begins to move which shows that the 
^galvanic current is actually flowing. It can be noticed now that the \:iterine 
electrode enters the uterine cavity much easier and soon it has reached the 
fundus. 



Fig. 30*— Tripier's method of faradization for anteHexion. 



We now continue to move the rheostat handle until the milliamperemeter 
shows the desired strength. 

Sometimes the patient cannot tolerate what we consider even a weak air- 
rent and complains of a burning pain. It is best to desist for a while and 
perhaps to decrease the current one or two milliamperemeters, %vhen the 
patients will be satisfied. 

We now wish to make the intra-nterine electrode positive with a view of 
arresting the hemorrhages, that is to say we wish to influence the mucous 
membrane of the uterus. 



92 



DISEASES Of WOMEN. 



The current must be turned off gradually hy means of the rheostat 
handle first of all. When the current is off whatever chang^es we see fit to 
make can Se made without dangler to the patient. 

The pole-changer is now switched to the opposite side — the uterine 
electrode is now positive. The current is turned on as before. After the re- 
quired time Is over the current is turned off again* 

Now it win be found that the uterine electrode cannot be removed from 
the uterus. The decomposition of the electrode has "glued*^ the instrument 
to the uterine mucosa. 



Fig, 31. — Tripier's mtthod of faradization lor retroflexion. 



In order to "loosen" the electrode, it is changed again so as to become 
negative, a weak current turned on for a few minutes when it will be found 
that it can be easily removed. Of course the electrode should not be re- , 
moved until the current is completely shut off, to avoid shocks. 

^ The above case represents the technique of inira-nterine galvanization, in I 
all its details, at least as far as the handling of the battery and electrodes 
are concerned. It can thus be seen that those gentlemen who m^ke a spe- 
cialty of electro-therapy surroimd their work with a halo of mystery that 
tends to frighten away the novice. In reality, however, the technique of 
electro- therapy is very simple indeed. If any special skill is needed at all it 



ELECTRO-THERAPY. 



93 



is required in the determinaftion what particular electrode to use, how long 
and at what strength. 

Gradually a sort of electric "materia medica" has been evolved by certain 
writers. 

Lists of diseases have been published, along side of each an enumeration 
of the particular current, strength, length of time, etc. 

An example of such a list follows : 

"Chronic endometritis : galv. neg. 15 ma. 10 minutes three times a week." 

Nothing tends more to undermine the value of a given therapeutic agent 
than an attempt to prescribe for its use iron-clad rules. 

All such writings are misleading and unscientific. 

Though, we know for instance, the difference of the action of the negative 
and positive currents, it frequently happens that no results are achieved, with 




Fig. 32. — Different forms of uterine curettes. 



the one which seemed indicated while excellent progress is made after a 
change of treatment with the other pole has been instituted. 

Thus, it can be seen, that a little experimentation to which should be 
added a little common sense, will do more good than all rules and regulations 
laid down by so-called authorities. 

The trouble seems to be that electro-therapy has become a specialty in 
the hands of many physicians, whose education and abilities or rather lack of 
both, unfit them for any other scientific work. 

These men are usually not pathologists, not even good diagnosticians. 
They never dare to take a surgical instrument in their hands and have be- 
come regular monomaniacs on the subject of electricity. 

Electricity, like any other agent, has its limitations, but in the hands of 
a liberal-minded man it will do real good in selected cases. 

It is first of all important to know the contra-indications to galvanism 
and faradism. 



DISEASES OF WOMEN. 



Electricity should never be applied in acute inflammatory disease of the 
sexual apparatus. This is an axiom. j 

It is also contra-indicated in pyo-salpinx (chronic), • 1 

Of course the presence of a chronic pyo-salpinx cannot always be sur- 
mised, 

A e^ood rule is that when a woman complains of chills and fever^ and has 
an increased temperature a day of two after intra^uterine galvanization or 
faradization, the presence of pus somewhere In the pelvis is established be- 
yond a doubt. Further treatments are decidedly contra- indicated. 



The galvanic current is an excellent a^ent in the treatment of stenosis 
of the uterine canal Goelet's dilating electrodes consist of an insulated 
handle with nickel -plated intra- uterine stems of three different sizes. The 



Fig, $$. — Skene's volscUum forceps. 

smallest one is used at first. The indifferent electrode is connected with the 
positive pole. The uterine electrode is naturally connected with the negative 
pole. The electrode is introduced through the external os as far as it will 
go and the current turned on to 15-35 milliamperes, depending on the sensi- 
bility of the patient The first two or three treatments should not last longer 
than three minutes. Tfce first half minute is devoted to the gradual turning 
on of the current. When the seance is over the current is turned off in a 
few seconds. 

Gradually the treatments can be made stronger and longer in duration. 
The size of the electrode should be increased as soon as the smaller one is 
found to pass without difficulty. 

, Chronic metritis is treated in a similar way as stenosis, aided of course 
by other agents. When there is leucorrhea and a tendency to hemorrhages 
the positive current is to be applied to the uterus. 

^ For this purpose special electrodes made of platinum, carbon or block tin 
are to be chosen. 

Copper and zinc electrodes are chosen when we wish to deposit either 
chemical on the uterine mucosa which is accomplished by electrolysis. 



ELECTRO-THERAPY. 95 

The technique is the same as described for fibroid tumors. 

The immediate effects of intra-uterine galvanization are not always 
pleasant. In many cases the patients complain of colic a few hours after the 
treatment, sometimes as late as the following day. 

Patients should be forwarned against such complications which is of 
little moment. All that is needed is rest and the pains will disappear. 

The patient should also be advised that the first few treatments are apt 
to aggravate the trouble, the pain, leucorrhea, etc., becoming worse. 

It is only after four or five treatments have been administered that im- 
provement commences. , , 

In the treatment of chronic ovaritis, the negative electrode should be the 
vaginal-ball electrode, which should be covered with cotton. It is introduced 




Fig. 34. — Heavy uterine volsellum forceps. 

into the vagina and pressed towards the affected ovary. The indifferent 
. electrode is best placed on the abdomen. 

The faradic current is either primary or secondary, depending whether 
the current is going through the outer-primary coil or whether it is induced 
in the inner-secondary-coil. 

As regards the application of the faradic current, the same electrodes 
used for the galvanic current can be used. 

The following description of the therapeutic action of faradism is taken 
from Garrigues masterly work on Diseases of Women : 

"If the primary current goes through a thick and short wire, it has a 
great quality of electricity ; and if the second current is induced in a very 
long thin wire, it requires a very high degree of tension. Such a current 
of tension has great power in subduing pain (ovarabfl^ ^iibdominal pain 
in hysterical women, vaginismus and pain aHAi*w nam- 

tions). It is also an emmenagogue. 



96 



DISEASES OF WOMEN. 



'The faradic current is, as a riile» applied three times a week, sometmies 
daily; each sitting lasts from ten to thirty tninntes. The electrodes should 
be applied first, and then the current turned on very slowly, the patients 
feelings servingf as a giiide as to the strength applied. At the end the 
strength of the current is again g:radually decreased until it stops before 
the electrodes are withdrawn. The reason for so doing is that the vulva is 
much more sensitive than the vagina or uterus and that a strong current is 
more endurable when it is increased and decreased gradually than %vhen tt 
begins and ceases suddenly. The cervix is also much more sensitive than 
the body of the womb." 

The so-called bi-polar electrodes are so constructed that both the posi- 
tive ajid negative poles are connected witli the same electrode. As they are 
usually made of ordinary metal they cannot be utilized for t!ie galvanic cur- 




FiG. 35. — Palmer's uterine dilator. 



rent. They are therefore intended for the faradic current exclusively. ITieir 
advantage over an ordinary vaginal or uterine electrode (which requires 
the use of an indifferent or dispersing electrode in order to produce a com- 
plete circuit) lies in the fact that the faradic current can be better localized, 
and is therefore to be used when a localized, topical application of the faradic 
current is desired. 

Goelet's bi-polar vaginal electrode (Fig. 26) is the best because it per- 
mits of an application of faradism to the most proximal and distal ends of 
the vagina. Unless a given vagina is very roomy and relaxed, it is an ahno^^t 
self -retaining instrument, a feature which is not without some importance, 
as it is very desirable not to shift a bi-polar electrode after a current has 
been turned on. This holds good also for applications to the endometrium, 
for which purpose ApostoH's bi-polar uterine electrode (Fig, 27 J is the 
most popular and perhaps the only one in vogue. Figs. 28 and 29 illustrale 
the faradization of the vagina and uterus with the bi-polar electrodes. 

It is needless to say that all electrodes should be disinfected before use. 
As the insulating material will not stand boiling, they can be sterilized by 



ELEC TRO- THERAPY, 



97 



trodes shoitld first be rinsed off with sterile (boiled) water before use, in 
off the current, threw the switch on the galvanic hottdhi and turned on the 
order to prevent the contact of the irritant and toxic diernicab with the 
mucous membrane. 

I have seen oa^ physician lubricate an electrode with oil. The patient 
seemed to like the treatment very well in spite of the fact that he had 
brougtit the handle of the rheostat to the extreme end. I sug-^sted that he 
use the galvanic current. He objected on the grotmd that one metal part of 
the electrode connected with the positive rheophore wtH become deccwn- 
posed and ^'stuck/' I told him to go on and try. With a smile he turned 
formaldehyde g^s or by antiseptic solutions. If the latter be used the elec- 
galvanic current. Imagine his surprise when the milliamperen'tetcr refused 
to register, although all connections proved to be correctly made. 

The dcxrtor will now remember that oil is a non-conductor as long as he 
lives. 

The best lubricant is a mild solution of bicarbonate of soda, which has 
the advantage that die current becomes more intense. Soap foam is ideal 
.when mildSess of the current is desirable. 

As regards the indications for the employment of the bi-polar instru- 
"ments they have proven serviceable in my hands in : 
Subinvolution, 

Relaxed vaginal outlet, not due to a torn perineum, 
Cystocele, 
Rectocele, 

In chronic uietro-endometritis producing '"neuralgic" pain. 
Dyspareunia, when not due to inflammation or ulceration of the 
ia, aiid 

Vaginismus, 



A method of treating anteflexion and retroflexion of the uterus by means 
of the faradic current, which has been introduced by Tripier, and which is 
well worthy of a trial in such cases in which inflamnmtion is absent, is 
depicted in Fig^s, 30 and 31, 

The reader must, however, not expect too much from this treatment as 
it is hardly likely that tlie malposition will be corrected by the faradic cur- 
rent. Symptomatic cures have been reported. 

His directions are as follows: 

The first thing to be done b to lubricate the rectal probe, although it is 
the last thing to be used, as later the operator would have no disengaged 
hand to do so. Then a towel should be placed within reach. 



98 DISEASES OF WOMEN. 

"The uterine exciter, havin.s: been dried by the left hand, is inserted into 
the uterus, using" for" this purpose the left forefinger as a conductor. After 
this the rectal probe is inserted ; this is the most delicate part of the opera- 
tion ; if not well done ifc might be ver}' painful. The olive must pass the 
internal sphincter, leaning a little on its upper edge, the concavity of the in- 
strument pointing downward: after this it should be pushed 'forward, be- 
low, and a little to the left. When the olive has thus reached the bottom of 
the concavity of the sacrum a pause -should ensue, then turn the probe while 
elevating its pavilion so that the concavity of the curvature is turned uoward, 
and in this way cause the olive to face the rear wall of the uterus. It would 
naturally seem that, on account of the development to the left of the rectal 
ampulla, the rotation would be easier on that side, but this is not the case ; I 
have always found it infinitely easier to the right, and I have tried it both 
sides. After pushing- the olive from right to left in the concavity of the 
sacrum, it must be brought back to the right, while turning the concavity of 
the probe more and more toward the right. The pavilion, being held in the 
hand of the rectal probe, must be slowly elevated during this rotation move- 
ment until it has been completely eflfected. This precaution i# necessary, 
first in order not to use the uterus roughly ; then, that the movement of the 
rotation may be more freely eflfected. 

"When the curvature of the probe has been brought parallel to that of 
the sacrum, then only can the hand be gently lowered, pushing lightly so 
that the olive may come up, sliding against the wall of the uterus. 

"This last motion, however, must only be accentuated when the farad- 
ization has begun, in order to give it strength and assure a sufficient con- 
tact. The rotation movement just described is not always accomplished 
without meeting with some resistance: this is sometimes easily overcome, 
but at other times it may be difficult. The operator should be able to judge 
according to the impression received by the hand controlling the probe. 
The most ordinary obstacle to this maneuver is the presence of a fecal mass, 
hard or soft, and it is something that cannot be foreseen. The best way to 
avoid it is to give the patient an injection of oil before the application. 

"The rectal exciter, once placed, should be held in position; then the 
conducting-cord must be attached with the right hand, which must, at the 
same time, hold the uterine exciter. It is necessary to get accustomed to 
manage these two exciters with the same hand, the other being free to con- 
trol the faradic battery and to govern its action. This hand directing the 
apparatus must, however, be able now and then to assist the other one, if 
any cause should present itself to modify the connection of the two probes, 
in accentuating the motion of the rectal probe. The fact is that a definite 



ELECTRO-THERAPY, 99 

position cannot always be given at' once to the rectal probe. I have already 
described one obstacle to its progress : the existence of the fecal mass in the 
intestine. If this should happen to be of any considerable size and a little 
soft, it might cover the posterior wall of the uterus as with a plaster, which 
could only be penetrated little by little during the application. Muscular 
contractions form another obstacle to placing the probe. These alter the 
form of the cavity where the evolutions take place. They are of a flexible 
nature, and give way under the influence of faradization ; however, the re- 
sistance they present cannot be overcome at once, and it is by interrupting 
the rotation during the application that this can be avoided. 

"In retroversion and retroflexion the anterior wall of the uterus must be 
acted upon and vesico-uterine faradization employed. The patient being in 
the dorsal position, the uterine exciter is first inserted, then the positive 
vesical, which is previously lubricated. After this the contacts are estab- 
lished and the apparatus put in action'?, the same hand then places the two 
probes in the required contact. The insertion of the vesical exciter is made 
like that of any ordlinary probe, the handle must be raised at the time of 
operating, but only at that timej so to lean the active tips on the anterior 
wall of the uterus. 

"The application should not last longer than three minutes, to avoid 
fatiguing the muscular structures." , 



CHAPTER XIIL 



CURETTAGE, 



Curettage Is an operation consisting of scraping of the uterine mt 
by means of long handled, spoon-shaped instruments, known as curettesj 
Many varieties of curettes have been offered to the profession, seme 
which, such as the Recamier curette, are not only impractical but dangerousT 
The accompanying iUustrations show the most frequently-employed curettes. 

There has been going on quite a controversy in current medical litera- 
ture whether the dull or sharp instrument should be used. In my opinion 
the dull instrument has no place in gj^necic surgery and I have discarded it 
long ago. The sharp instruments are "dull" enough to prevent too much 
tissue being scraped off. 

The curette is frequently used as a diagnostic instrument when we wish 
to obtain scrapings for miscroscopic examination as for instance in cases of 
suspected carcinoma. 

The operation is usually described as a minor operation and the belief 
IS prevalent among general practitioners that it can be performed by anyone 
without special training. While it is true that it is not a major operation it 
IS, nevertheless, a very important one. In the hands of a competent surgeon, 
who knows the indications and contra-indications of curettage the benefit to 
the patient is immense, if, however, performed in a haphazard way, without 
a previously made careful diagnosis, it will not only do no good but fre-, 
quently prove the cause of much harm. 

The operation itself cannot be taught by ocular demonstration^ for no" 
teacher can impart manual dexterity and delicacy of touch to his student^ 
in the amphitheatre. 

Practice, a desire to do right and careful observation are the requisites" 
for the achievement of successful surgery. The following is the techniq 
^employed by me. 

Anesthesia. General ether or chloroform anesthesia is always to 
used, save when there is grave organic disease of the heart or profound 
sepsis followmg incomplete abortion. 

Asepsis. The most rigid antisepsis is to be maintained from beginninj 
to end. The hair of the pubes should be shaved or removed b}!^ means of : 
chemical depilatorj^ The external genitalia and neighborhood should 

100 



CURETTAGE. 



101 



scrubbed with green-soap and warm water, which procedure must be fol- 
lowed b}^ ablution with antiseptic solutions. The vagina should be cleansed 
in a similar way by an assistant who introduces several fing^ers in order to 
thoroughly remove all the discharges which can be better accomplished whea 
|he vaginal canal is put on the stretch. 

As soon as the antiseptic preparations are finished, the surgeon, who in 
the meantime has disinfected his hands and forearms, makes once more a 
final bimanual examination, which can now be made much better* as the 
w^oman is completely under the influence of the aneiithetic and the abdominal 
muscles are relaxed. It is very important to know whether there are present 
pus-tubes or other evidences of pelvic inflammation or not 



Fig. ^6. — Goodeirs dilator. 



The surgeon dips his hands once more in an antiseptic solution for a 
minute, rinses them in sterile water, puts on a pair of sterilized gloves and 
is now ready to begin the operation proper. 

Operatiofu In order to expose the cervix, I use either a bivalve 
speculum or two vaginal retractors. If the latter be used the assistant sits 
or stands to the operator's left and grasping the handles of each retractor 
with several fingers, inserts one retractor handle, presses down the 
posterior wall of the vagina and executes the same manoeuvre on the an- 
terior wall in the opposite direction with the other retractor. 

When the cervix is brought into view a fine tenaculum forceps is hooked 
on the posterior lip of the cervix and by means of an applicator, on the end 
of which is w^ound a piece of sterile absorbent cotton, the uterine canal is 
mopped out with any desired antiseptic. (In my own practice, I prefer the 
compound tincture of iodine.) 

This procedure is of additional value to the surgeon for it enables him 
lb form an estimate of the direction of the uterine canal as well as of its 
depth. 



102 



DISEASES OF WOMEN. 



Should the surgeon encounter difficulties in the passage of the applicator 
behind the inner os on account of flexion, the appHcator must he bent to a 
suitable angle. 

Frequently small fibroid tumors will stand in the way in which case, of 
course^ only the canal of the cervix can be disinfected. 

The small tenaculum forceps is now withdrawn and each lip of the cervix 
firmly grasped with a heavy tenaculum forceps. 

The uterus is now pulled down gently hut firmly as far to the front ag' 
can be done without undue traction. The speculum or retractors can then be 
removed. , 

The assistant keeps the uterus firmly in front of the vulva holding the 
tenacula in such a way that the upper one rests on the os pubis and the 







Fig. 37. — Uterme ^'irrigator.' 



lower on the perineum which position of course must be moved from time 
to time in order to enable the surgeon to introduce his fingers whenever he 
so desires. 

Palmer *s uterine dilator is now introduced into the uterine canal a little 
behind the inner os and the blades expanded sidewards as far as they will 
go. Care should be taken not to press the blades apart suddenly in order 
to prevent injury to the mucous membrane and to the other tissues of the 
uterus. 

The blades are now closed again and the instrument turned ninety de- 
^ees and opened in the new position in a similar way, Goodell's dilator, 
which is much larger and heavier, is now used the same way as described 
for the small dilator* 

The dilatation with the larger instrument should be more gradual yet 
and no surgeon will regret having spent an additional minute or two, for 
the desired results will be better while the injury to the tissues will be re* 
duced to a minimum. 

The uterine canal is now ready to be curetted. The curette is grasped on 
the handle with four fingers of the right hand, the index fingers resting on 



CURETTAGE. 



103 



le shaft in a similar way as one holds a pencil when writing. The curette 
IS mtrodiiced carefully up to the fundus, the sharp edge pressed on the 
posterior wall and pulled out, maintaining the same amount of pressure 
throughout. Surgeons, who have had an extensive experience can tell by 
this first stroke the pathologic condition of the uterine mucosa. The '*feer* 
imparted to the fingers on the handle, is something that can be appreciated 
only and not described. Surgeons, can judge w^ithout difficuhy whether they 
have to deal with healthy mucosa, granulations, fungosities, etc. If retained 
membranes be in the way of the curette they %vill be brought out without 
difficulty. Proceeding either to the right or left, as the surgeon sees fit, 
strip after strip of the uterine walls is thus subjected to the scraning of the 



Fig. 38. — Kdly's Perineal and operating pads. 



^ 

^^A 



curette until the original starting place is reached. The greatest care must 
be exercised in starting on **the next tour" for frequendy it is essential 

■or success that the entire endometrium be removed and no strips of the 
mucosa left. The fundus must next be subjected to the same procedure. 
But even with the greatest care it is utterly impossible to curette the 

ornua. This is to be deplored, particularly when it is desired to permit 
drainage for the Fallopian tubes. To overcome this difficulty I have devised 
a uterine comua curette, which has a thin oblong, narrow spoon bent in 
such a curve that the corners of the uterus around the opening of the Fal- 




104 



DISEASES OE WOMBM. 



lopian tubes can be easily reached. It has been manufactured for me by 
Frank S. Betz & Co,, of Chicago. The curettagne finished, the uteriiM: 
cavity is irrigated with any mild, hot antiseptic solution by means of a 
doiible-curTent uterine im^tor. attached to a g^lass-cofitainer or fountaia 
syringe by means of a long rubber- tnbing. Care should be taken to permit 
fir&t a Httle solution to flow out before inserting: the irrigator, in order to 
expel all air, dust and rubber particles. 

If curettage be properiy performed with due regard to antisepsis, there 
should be no bad con sequences, I have seen reports that curettes have been 
pushed through the frnidus into the peritoneal cavity. Such an accident, the 
reporters claim, were rarely if ever foUowed by bad results, 

I can only warn my readers to look out for such accidents. Peritonitis 
and death may be the consequences. That many women have died from an 
improperly performed curettage there can be no doubt. , 

To avoid this accident I can oflfer but one suggestion, viz, : that through- 
out the operation the surgeon utilize his free, left hand to acquaint himself 
with the position and size of the uterus by pressing the hand agia^inst the 
uterus through the abdomibal wall in the hypogastric region. 

The operation of curettage is best performed with the patient in the re- 
cumbent posture and the legs securely fastened with any desired leg-holder. 
The buttocks of the patient should rest on a Kelly-pad, which permits the 
escape of blood and fluids into a slopjar without soiling the patient, tabic ofl 
floor. 



CHAPTER XIV. 

MASSAGE IN DISEASES OF WOMEN. 

MasscDfne (from the Greek word "masso," to knead [dough], to work 
manually, or frcxn the Arabian "masso/' to press [softly]) is best defined 
as a therapeutic method of treating certain affections by means of systematic 
manipulations. In the majority of instances the physician's or attendant's 
hands are the "instruments" used — ^but of late machines have been invented 
to replace the human hand. 

It is self evident that all mechanical devices can be used only in cases 
not requiring special delicacy of touch. 

Massage is not a very popular remedy with physicians, probably because 
it requires time and physical exertion. In larger cities special masseurs and 
masseuses abound, among whom can be found good and reliable attendants, 
ready to execute the ccMnmands of the physician. 

Since the introduction of massage in diseases of wcxnen by Major Thure 
Brandt of Sweden (who was a layman) surgeons of g^eat repute, stimulated 
by the many cures brought about by the major and his pupils, have in- 
vestigated the method and have put it on a rational basis. 

The man who has done more in this direction than anyone else is Prof. 
Robt, Ziegenspeck of the University of Munich, who has written an excel- 
lent monograph on the subject. My friend, Dr. F. H. Westerchulte of Chi- 
cago has translated his work in English, from which I have freely quoted 
in the preparation of this chapter. A persual of the work will prove of 
great benefit to those who desire to attain the best possible results with 
massage. 

Indications and contra-indications. In order to better appreciate when 
massage is indicated I deem it best to first enumerate the contra-indications. 

Acute inflammatory affections* mahgnant diseases, acute infectious and 
septic diseases and pus. 

Pus offers an obstacle to the employment of massage only when accom- 
panied by an acute inflammatory process. 

In chronic cases of pyo-salpinx massage is not absolutely contra-in- 
dicated, but should be employed with great care. If the pain becomes in- 
tense and there is a rise of temperature, further treatment has to be 

106 



106 DISEASES OF WOMEN. 

suspended for a few weeks; an ice-bag should be applied over the hypo- 
gastrium and opium suppositories (see Appendix) inserted in the rectum. 

Pregnancy is no contra-indication for massage. Ziegenspeck says that 
massage is indicated in every case in which pressure on any part of the 
internal genitals causes sudden and perhaps persistent pain, or in which 
we want to disperse a swelling or effusion. 

The patients should always be warned that massage treatments are apt 
to increase the pain at first. If after the first few sittings the pain dimin- 
ishes, recovery can be looked for. 

If fever is provoked after a second seance, as described above, the treat- 
ment must be postponed for at least a month and meantime other measures 
resorted to. 

Judiciously employed, massage is a harmless remedy and invaluable 
particularly in chronic, painjFul affections of the uterus, ovaries, tubes, 
parametrium, and peritoneum (pelvic). 

It is decidedly indicated in subinvolution of the uterus. 

In chronic inflammatory processes resulting in shrinking and adhesions, 
massage should be combined with "stretching." 

Technic. The patient is best placed on an ordinary examining table or 
-chair in the recumbent posture. The heels are placed in the stirrups to relax 
the abdominal wall. 

Special massage tables, couches or benches as recommended by Brandt 
are unnecessary. ^ 

The patient's corset and garments should be so loosened to permit easy 
access to the abdominal wall. Rubber gloves are not to be recommended, 
"hut the fingers which are to be introduced into the vagina can be protected 
l)y soft rubber cots. 

Strict cleanliness should be observed. Long finger-nails of the physi- 
cian's hands are apt to cause injury. It is well to lubricate the right hand 
with some fatty substance. I prefer ordinary olive oil to which a few drops 
of .peppermint oil has been added. Most patients like the cooling effect of 
the peppermint. 

The index ahd middle fingers of the left hand are introduced into the 
vagina and remain stationar\^ after pressing the organ to be massaged 
against the right hand, w^th which all manipulations on the abdominal wall 
are performed. 

The position of the surgeon is immaterial. Some prefer to stand at the 
left side of the patient, others in front of the table between the patient's legs. 
The physician soon finds out which position permits the greatest convenience 
-and will change position whenever he likes. 



MASSAGE IN DISEASES OF WOMEN. 107 

The rig^ht hand is placed very lightly upon the abdominal wall and with 
the fing^er tips, describes large circles in the beginning, gradually the in- 
testinal coils give way and the hand penetrates deeper and deeper into the 
pelvis. The circles become smaller the deeper the hand advances and de- 
pend finally upon the size of the organ, which we intend to massage. Each 
seance should last about ten minutes, and brought to an end by gradually 
relaxing the pressure, at the same time increasing the size of the circles. 

The force of the pressure to be used depends upon the sensitiveness of 
the patient. Too much pressure should be avoided by either hand, as we 
cause unnecessary pain and only aggravate the trouble. If, however, we 
use too little pressure, the patient gains nothing from such treatment. 

Ziegenspeck recommends to increase the pressure until some pain is felt, 
when the patient shows that the milder treatment is sexually exciting her. 

Stretching is employed for the separation of parametritic adhesions, 
which appear to the fingers in the vagina as bands which run along the 
uterine or spermatic veins or both. Before resorting to stretchings, a few 
massage treatments should be given. 

We place both fingers of the left hand against the left side of the uterus 
in the left vaginal vault and do the same with the finger tips of the right 
hand from above. We then push the uterus with both hands to the right as 
far as the sensitiveness of the parametric band will permit. This stretch- 
ing of the band produces renewed pain, which we remove by massage. By 
alternate stretching and massage (for the removal of sensitiveness and 
swelling) we stretch the band, although it may require a great many sittings 
sometimes, and remove it finally, perhaps in its entirety, by massage. One 
can be satisfied if he succeeds in pressing the uterus, without any special 
effort or without causing pain against the opposite pelvic wall. 

The above description is intended for a left parametritis. 

If the pathologic condition is met with in the right side, the right side 
of the uterus is to be treated and pushed against the left side. 

After some sittings the bands can be stretched by the two fingers in the 
vagina while the external hand is describing circles over the band, as in 
ordinary massage. 

Massage is also an invaluable remedy in constipation. Stroking, squeez- 
ing and rubbing movements can be employed along the course of the as- 
cending, transverse and descending colon. 



APPENDIX. 

I. Lfrugs, which are needed in the oifice for applications to the vagina 
and uterus: 

a. Tinctura lodii. 

b. Tinctura lodii cotnposita. 

c. Tinctura iodii. 
Acidi carbolici aa. 

d. Tinctura iodii. 
Creosoti aa. 

e. Sol. argenti nitr. 3 per cent. 

f. Sol. argenti nitr. 5 per cent. 

g. Sol. argenti nitr. 10 per cent, 
h. Acidum aceticum. 

1. Tinct. ferri. chloridi. 
j. Glycerin, 
k. Ichthyol 10 parts. 
Glycerin 100 parts. 

1. Boracic acid gr. xv. 
Glycerin 5 j. 

(Note: Boro-glyceride is expensive — this formula is sufficient.) 
m. Acid, tannic. 3 j. 

Glycerin. §j. 
n. Dusting powders: 

Sod. bicarb., acid, boricum, nosophen, xeroform or aristol. 

2. Some prescriptions, not given in detail in the text: 
A. Vaginal Douche-Powders. 

a. Alkaline, antiseptic 

Thymolis gr. xv 

Natr. biborat 

Natr. bicarb., aa 5 ij 

M. f. p. S. Teaspoonful to quart of hot water. 

b. Antiseptic, cleansing. 

108 



APPENDIX, 109 

Zinci sulphurici gr. x 

Acidi borici -S ij 

M. f. p. S. Teaspoonful to quart of hot water. 
c. Astringent, 

Alum 3 jss 

Acidi tannici 3 j 

Acidi borici 5 ij 

M. f. p. S. Teaspoonful to quart of hot water. 

B. General Tonics. 

a. Nerve tonic and tissue-builder 

Strychnin sulph gr. J4 — g^- ss 

Syr. hypophosph. comp S ij 

M. S. 3j, t. i. d. before meals. 

c. Appetiser: 

Tinct. nucis vom gtt. xx 

Tinct. cinchonae comp 5 ij 

M. S. 3j before meals. 
c Fat-builder, 

Any palatable cod-liver oil preparation. 

Russel's Emulsion. 

d. Sedatives 

Syrup bromid. comp. ; trional, sulfonal, etc. 
(Note: When we wish to relieve pain, whenever there is no unusual 
urgency the hypodermatic syringe should not be used but cod«in sulphate 
prescribed in doses of 2 grains every 3 hours, or the following rectal sup- 
pository:) 

Extr. gelsemii gr. iv 

Extr. opii g^"- ^i j 

01. theobrom. qu. s. ut. fiat suppos No. vj. 
Sig. Insert one every 2 — 3 hours. 

e. Anti-constipation. 

To insure a thorough evacuation of the bowels, a tablet containing aloin, 
belladonna, podophyllin and strychnin, as put up by manufacturing chemists, 
IS ideal in gynecic practice. Its prolonged use is to be rejected, however, 
because a tolerance for the drug or drugs (aloin is the main ingredient) is 



110 DISEASES OF WOMEN. 

soon established. In chronic constipation, the tone of the intestines must be 
improved by massage, faradism and galvanism. 

Patients suffering from chronic constipation should be instructed to take 
a glass of cold water or seltzer the first thing in the morning and make it a 
a rule to go to the closet at a given hour every morning and at least make 
an attempt to have a bowel-movement for a few minutes. Even if they 
obtain no results, this regularity should be observed for a prolonged time 
when, in the majority of instances, it will be found that the bowels will be- 
come accustomed to move at the fixed hour. 

A semi-liquid diet should be tried for several weeks. Fruits of all sorts 
should be partaken of freely while tea is to be interdicted. 



BIBLIOGRAPHIC LIST. 

The following is a list of the books from which the author has freely- 
drawn in the preparation of this work. Those interested in special subjects^, 
or desirous of widening their knowledge in gynecology will find the list suf- 
ficiently large for their purpose : 

1. A Manual of the Modem Theory and Technique of Surgical Asepsis, 
by Carl Beck. (W. B. Saunders, Philadelphia.) 

2. The Venereal Diseases including Stricture of the Male Urethra, by 
E. L. Keyes. (William Wood & Co., New York.) 

3. Excessive Venery, Masturbation and Continence, by Joseph W.. 
Howe. (Bermingham & Co., London.) 

4. The Pathology and Surgical Treatment of Tumors, by N. Senn. 
(W. B. Saunders, Philadelphia.) 

5. Atlas and Epitome of Gynecology, by Oscar Schaeffer. (W. B^ 
Saunders & Co., Philadelphia.) 

6. Sexual Impotence in the Male, by William A. Hammond. (Ber- 
mmgham & Co., New York.) 

7. The Technique of Surgical Gynecology, by Augustin H. GoeleL. 
(International Journal of Surgery Co., New York.) 

8. Conservative Gynecology and Electro-Therapeutics, by G. Bettoir 
Massey. (The F. A. Davis Co., Philadelphia.) 

9. Massage Treatment in Diseases of Women, by Rob. Ziegenspeck^ 
(F. H. Westerschulte, Chicago.) 

10. The Pathology, Diagnosis, and Treatment of the Diseases of 
Women, by Graily Hewitt. (Bermingham & Co., New York.) 

11. Modern Gynecology, by Charles H. Bushong. (E. B. Treat, New 
York.) 

12. Operative Gynecology, by Howard A. Kelley. (D. Appleton &r 
Co., New York.) 

13. Minor Surgical Gynecology, by Paul F. Munde. (William Wood 
& Co., New York.) 

14. Medical Gynecology, by Alexander J. C. Skene. (D. Appleton & 
Co., New York.) 

15. A Text-book of the Diseases of Women, by Henry J. Garrigues.. 
(W. B. Saunders, Philadelphia.) 



112 BIBLIOGRAPHIC LIST. 

i6. Manual of Gynecology, by Henry T. Byford. (P. Blakiston, Son 
& Co., Philadelphia.) 

17. Handbuch der Krankheiten der Weiblichen Geschlechtsorgane, von 
Carl Schroeder. (F. Vogel, Leipzig.) 

18. Medical Microscopy, by Frank J« Wethered. (P. Blakiston, Son 
& Co., Philadelphia.) 



LANE MEDICAL LIBRARY 



To avoid fine, this book should be returned on 
or before the date last stamped below. 



Ity. 

rent Alternating: Currents. 

int and as a Therapeutic 



5s of Fibromata, with De- 



B. 

ses of Catarrhal Disease 



:W REVIEWS. 

animations, menstrual de- 
, and that on malignancy, 
Zbicago Clinic. 



Juable one upon the sub- 
ilts It contains are backed 
e histories.— Nm- England 



■t electricity is discussed 
as a specific for every- 



' physician's library, not 
treatise, but also for the 
iclples and application of 



This book should be in the hands of all Gynecologists and 
those interested In diseases of women. Physicians interested in 
insane-hospital practice should also have It as a reference-work.— 
Medical Fortnightly (St. Louis, Mo.). 



As a treatise on gynecology the work is good, and, to those 
Interested in the electrical treatment of the diseases of women, 
invaluable.— C»»«»«rt/# Lancet-Clinic. 




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