Golden Rules Gynecology

GOLD E N RULE S

GYN E COLOGY

PH RISMS OBSER TIONS AND PRECEPTS ON THE A O , VA , PROPER DI GNOSIS AN D TREAT ENT OF A . M DISEASES OF W OMEN

E B NORBE R GEORG . M G , . D .

" NSAS CIT Y MO . A ,

PR F R OF DI OF W M A N D CLI I C L GY C L GY U I V R IT O ESSO SEASES O EN N A NE O O , N E S Y DIE DI CA L COLLE GE ; GY NE COLOGI ST " ANSAS C IT Y GENE RAL - H OSPIT AL ; FELLOW A N D E " PRE SIDENT " A N SAS CIT Y A CADE M Y OF M EDI CI N E

T L UI S . O S

C V M MPA . . OSBY CO NY

1913 COPYRI HT 1 1 B Y MPANY G 9 3 C . . MOSBY CO , , V

Pres s o f

C . V. M o s by Co mp a n y

St. Lo ui s

CI " . A3 4 3 5 3 1 PREFA CE .

The purpose o f this volume is to give its readers those methods o f gynecologic diagno sis and treat f ment, the observance o which is known to produce the best results . The demands made upon the time o f the busy gen eral practitioner are so many and so varied that it is necessary fo r him to eliminate from his reading lengthy dissertations that repeat what has been said over and over again, and that often leave obscure the ideas that they intend to convey . A great many subjects are given considerable

b e space in textbooks on gynecology, which really N long under general surgery . o attempt has been made to cover these subjects . It has been a constant effort to make short , em phatic , and convincing statements that may prove to be of practical v alue . The literature o n gyn ecology has been thoroughly s earched, and what has seemed to be the best meth o ds o f procedure have been incorporated in this lit tle book . In my work on this volume this fact has been in " delibl : Ho w y impressed upon me much is written , ” how little really said . The greatest task is ho w 8 P REFACE . to condense so that every statement means some " thing T O put the nail in the right place and to ” Ho drive it home . w well I have succeeded must I be left to my readers . trust , however , that they will be as much beneﬁted in reading it as I have been

\ f in the preparation o the same .

I Dr A am indebted to . Henry . Cables for his assist I ance in going through the gynecologic literature . am deeply indebted to the publishers for their assist: a nce and patient indulgence .

RB E GE O. B . NO RG.

B l Rialto dg , M O . Ka nsas City, CONTE NT S .

Introduction

A ER CH PT I .

S E T N GENE RAL CON ID RA IO S .

Diagnosis Local Treatment Constipation 1 5 —30

A ER I CH PT I .

I E SE S OF THE UL D S A V VA . Vulvitis Bartholinitis Cysts Of the Vulvovaginal Glands Pruritus Vulvae " raurosis Vulvae E lephantiasis 5 Vulvae Varicose Veins Hydrocele Of the Labium Majus Inguinolabial Hernia Chancroids Chancre Verrucae Adhesions Of the Clitoris Adh esions of the Labia Herpes E czema Thrush Simple Der — ma titi s E rysipelas Vaginismus 3 1 7 7

A E R CH PT III .

DI EASE S OF THE IN S VAG A .

Acquired Stenos is and Atresia — Cystocele and Rectocele Hernia Vaginitis Granular Vaginitis Senile Vaginitis Cysts Cancer Of the Vagina Gonorrhea 7 8— 1 1 1

A E R I CH PT V .

E DISE AS S OF THE UTERUS .

Posterior Displacement — Prolapse Of the Uterus — Inver sion Of the Uterus Fibro mata Cancer Of the Uterus 9 CO T N S 1 0 N E T .

S a rcoma Inﬂamma tio n of the Uterus Metriti s Endometritis E ndocervicitis Subinvolution Of the Uter us Superinvolution Laceration of the Cervix Hypertro phy Of the Cervix Cervica l Polyp i — A c quired Atresia Of the Cervix — Acquired Stenosis Of the — — Cervix Chorioepithelioma 1 1 2 1 7 4

A ER CH PT V .

DISE SE S F THE TUB E S AN D RIE S A O OVA .

Salpingitis — Diseases Of the Ovaries — Chronic Ovaritis Prolapse of the Ovaries — So lid T umors of the Ovaries Ovarian Cysts E ctopic Gestation 1 7 5 — 1 9 6

A E R I CH PT V .

ME N STRU TION AN D ITS DI SORDE RS A .

e O a Pub rty . Menstruation vulation Menop use Pre cocious Menstruation Delayed Menstruation Amenorrhe a Menorrhagi a a n d Metrorrhagia Dys m enorrhea

A ER II CH PT V .

I E F THE ETH A D SE AS S O UR R . Urethritis Stricture Vesicourethral Fissure Prolapse Urethrocele Caruncle 2 1 3-222

I CHAPTER V II .

THE B DDER DisEAsEs OF LA .

— — Cystitis Vesical Calculus 223 227 INTRODUCTI ON .

Remember that one o f the most important prin

r - cip l es in gynecologic practice is ev e y da y asepsis . Cleanliness Of mind is as necessary as cleanliness

Of body .

Remember that , unless your patient has a good reason for an examination being postponed , it is far better to lose the prospective patient than to pre Sh scribe symptomatically . e will return for her ex a mination after a few weeks of internal medication by some other physician . Remember that there are exceptions to this rule ; u no t nless the gravity Of the case demands it , it is wise to examine young girls or single women— if it r should become necessa y, and she is a modest , bash ful person , her nervous system can be maintained in a better condition by administering an anesthetic fo r M such an examination . oreover the examina tion can be made then with perfect satisfaction , on a ccount Of the complete rel axation and freedom from pain . Remember that pelvic examinations should never be undertaken with a wom a n lying recumbent in

re bed . Kno wledge thus gained is usually very un ” n in liable . O e frequently is obliged to use a bed stead Of an examining-table ; but the patient shoul d 1 1 1 2 INTRODUCTIO N . be placed across the bed with the hips on or near the edge and the knees slightly ﬂexed . The annoyance from the sinking-down o f the hips can be obviated by slipping two boards from a dini ng-room table under the mattress .

i f Tables are far super or to chairs for O ﬁce work . Much annoyance can be spared a physi ci an if he would have a relative o r friend accompany the p a

f r tient to his O fice for examination o treatment . E xamine as many women as your opportunity a f e fords , ther by becoming familiar with the normal nd It a the abnormal . requires much practice to educate the fingers to a keen sense Of touch . The exa m i nl ng finger alone gives o ne only an idea Of the c ondition Of the vagina , whether the bladder is sag ging ( cystocele ) , or the rectum bulging (rectocele) , and a general idea Of the condition Of the cervix . It requires the combined examination— v a gino a b do min a l — , the rectoabdominal to ascertain with any degree Of accuracy the true co nditio n i n the pelvis . The speculum is a very useful adjunct where it is desired to bring into view the cervix o r the sur

o ne a rounding vaginal wall , but should never make diagnosis by the use o f the speculum alone— the speculum examination should usually follow the bi manual examination . ’ One must learn to judge his patient ; don t be vacillati ng i n your advice or opinion ; be sure you In are right , and stick to it . such a case informa tion and advice carry conﬁdence a nd co nviction di ‘ IN TRODUCTTON . 1 3 rectly to the patient ; while with the contrary she is soon ﬁlled with distrust . Your conscience should not permit o f wrong—doing

‘ fo r s fo r a l pay ; there i enough legitimate work l .

GOLDEN RULES OF GYNE -OOLOGY

AP E R I CH T .

E RA N GENERAL CONSID TIO S .

DIAGNOSIS .

r l — Gene a . Learn to be Observing ; this comes with e Of a c xperience , course, but is much more easily quired by some than others . Often many things are suggested to the exp eri ence d and Observing physician by the first glance f . A O at his patient woman, near the age fifty, who is anemic , with skin dry and waxy, suggests carci noma Of the uterus o r Of the mammary gland ; o ne who is thin, with a pinched expression, large abdo diffi men, and who walks carefully and with s ome A culty, may suggest ovarian cystoma . woman in

a b the middle period Of life , plump , with a large domen, but with rosy cheeks , who walks with a strong, steady step , suggests normal pregnancy .

Remember that diseases Of the . middle period Of

o life are more frequently inﬂammatory, and due t a - nf ccidents Of child birth , abortions , and i ections, 1 5 1 6 GOLDEN RULES OF GYNECOLOGY . while in the earlier life Of the female the disorders Of the menstrual functions are the ones with which we have to deal . These are mere suggestions at the

ur beginning Of the examination Of o patient , but they will be found to be of great help if properly regarded .

A o f lways keep a full history every patient , with diagnosis , and treatment , whether medical or surgi I cal . t is very embarrassing to have a patient return in two or three years and refer to her former sick

Of fo r ness and treatment , which , course , is entirely If gotten . an accurate history and record are kept , o ne a can refer to them, and the case at h nd will be ’ o ne s fresh in memory . l Don ’ t bother the patient and waste your own time with a number Of unnecessary questions ; remember that the history Of remote ancestors is seldom Of vital importance in gynecologic practice . As a general d rule , it is best to note own the name, address , age , height , weight , whether married or single, etc . , and then allow the patient to tell the nature Of her symp toms and sickness . This soon brings the physician

o f to a deﬁnite plan procedure , when he can proceed with a systematic inquiry and note down at the same time points Of interest .

1 M n tr o n — A ( ) e s ua ti . t what age did it begin ; reg ular o r irregular ; how many days does it last ; nor

o r mal , s canty, profuse in amount ; is it painful ; if " If so , what relation does it have to ﬂow the patient has reached the menopause, inquire at what age ; N L D T N 1 7 GE ERA CONSI ERA IO S . whether it has ever returned ; and any questions per tinent to the case . ( 2) The number Of children ; whether mi sc a r ria ge s o r abortions ; were any Of them Of unusual severity ; were instruments used ; was the c o nv a l es cence delayed beyond the usual time with any Of " them ; and if so , why ( 3 ) Inquire if Sh e has leucorrhea ; whether pro

IS fuse ; color ; Odor . it present during entire inter menstrual period ; does it cause itching or burning " ( 4) Is there irritation o f the bladder causing fr e quent micturition ; or is there difﬁculty in urinating " ( 5 ) Inquire regarding the bowels ; whether consti pated o r not .

6 I s ( ) there pain in the pelvis ; if SO , is it con stant ; does it radiate from hips down thighs and to calves Of legs "

7 Is " ( ) there backache ; if so , where located

8 I s " ( ) there headache ; If so , where Physica l — Remember that it is not safe to omit a thorough examination Of the chest and abdomen b e fore attempting to make a diagnosis Of a pelvic lesion . This is particularly true if an operation is necessary for relief ; although there are now but few patients that cannot take an anesthetic , patients feel better satisﬁed if the physician examines them and assures them that they can take it safely . Remember that the abdomen should be carefully U examined , and ﬁnally the pelvic organs . terine

ﬁb r o ids Of , large cysts the ovaries , and the gravid OF N 1 8 GOLDEN RULES GY ECOLOGY .

uterus can be palpated above the pelvis , but this

i no b should . . -usually be accompanied by the v a g a " i o f do m na l palpation . This means the index ﬁnger o ne hand in the vagina , and the other hand pressing down above the pubis and over the abdomen . The rectoabdominal examination is Often useful

f i dex ne ( r ﬁnger Of o hand in rectum, the other hand above pubis ) in examining for tumors and exudates lo w in pelvis . DO no t attempt an examination if the rectum is ﬁlled with fecal matter o r the bladder full Of urine ; it may change the position o f the pelvic organs very materially and interfere with a correct diagnosis . Don ’ t be in too great haste to give an opinion in

fa t a chronic case , where the patient has a abdomen and where the examination is difﬁcult— it is better to have her come back a second o r third time . ’ Don t attempt to examine young girls or unm a r ried women, especially when it is against their h wis es , without an anesthetic .

Ins r m n — o t u e tal . N w remember that preceding the use o f a vaginal speculum o r perineal retractor the external geni tals are to be inspected . These are usually taken in at a glance without much unne ce s s N ary handling Of the parts . ote if there is any

‘ discharge ; its color and consistency ; whether it causes excoriation o f the parts ; whether there are

o r d s chancre , chancroid , venereal warts , other i eases Of the external genitals ; as adh esions and

‘ o r c a run irritations Of the external meatus , hymen, 9 GENERAL CONSIDERATIONS .

o f c s cula myrtiformis ; laceration perineum , with y o r to o ele and rectocele ; hemorrhoids , or anal ﬁssure

ﬁstula .

Remember that the ordinary bivalve speculum, fﬁ with the patient in the dorsal position, is su cient I for examination o f the cervix uteri . nspect the

’ cervix ; notice if it is swollen o r lacerated ; whether the lateral walls are white and hard with scar tis sue ; whether it is studded with small white cysts , due to the plugging up Of the Nabothian glands . N f otice the amount and character o discharge , ulcer

a tio n s f . , or evidence O malignant disease , etc Remember that the normal color o f the cervix is pink (it has a bluish hue In pregnancy) , it is smooth and conical in shape ; inﬂammation causes it to b e

I S b e . t come large , red, and rough hould also noted whether the external OS is Of the pinhead variety or f whether it is su ﬁciently large .

a Remember that the perineal retractor , with the p tient in either the lateral or semiprone position , is useful where it is desired to pull the cervix down within easy grasp or exposure ; this position is e s p eci a lly useful in removing stitches from the cervix or in removing a polypus from the canal Of the cer vi x uteri . ’ Don t make a practice Of usi ng a sound in the uterus at e very opportunity ; this practice should be c condemned except in very ex eptional cases , for the sake Of clearing up a diagnosis or where some intra uterine treatment is especially indicated , and then 20 GOLDEN RULES OF GYNECOLOGY . with the strictest aseptic precautions ; much harm has been done by the promiscuous use o f intrauterine instrumentation . Micro sco pica l a nd Chemica l — Don ’ t fail to make a thorough examination Cf the urinary organs and

i i their excretions . The modern phys c an is SOskilled tha t he can easily make a tho rough chemical and microscopic examination Of the urine . Cystoscopy and ureteral c a th eriza tio n are SO common and are

S O f accomplished with little di ﬁculty nowadays , that diseases Of the kidneys , ureters , and bladder can be quite accurately diagnosed . Don ’ t fail to make a microscopic examination of the vaginal and uterine discharges , where it is indi

c a te d .

’ Don t make a positive diagnosis Of cancer Of the uterus ( except in advanced cases ) without a micro m scopic exa ination . Don ’ t fail to resort to the microscope in case Of a uv ulceration o r any suspicious appearance of the It cervix . is sometimes necessary to use the curette to get a specimen from the fundus or high in the cervix fo r microscopic examination .

’ - Don t pass over a suspicious looking cervix , and say that it is n o t cancer because the patient is to o young— o ne is scarcely exempt from it at any age ; it is no t rare in the twenties . It is sometimes necessary to make an exploratory incision to clear up a doubtful diagnosis ; when this becomes necessary, the surgeon should be ready to

22 N GOLDEN RULES OF GY ECOLOGY . the pelvic organs cannot be gainsaid by anyone who has tried them intelligently ; but they are seldom ' f O . so used , except in the hands a trained nurse — Effect o f th e Ho t Do uche and Applicatio ns In a great measure this acts in the same manner as Bier ’ s hyperemic treatment— by its local effect it stim u

‘ o f — lates the walls the relaxed blood vessels , causing

If fo r a contraction . this is continued a long time in and frequently, the circulation will improve ; and

Of x i a s tead the rela ed vessels , with stas s and edem

Of the surrounding tissues from exudation , the ves sels contract , circulation is improved , the exudate is absorbed , and the swelling and pain are relieved . Remember that if this line o f treatment is insti tute d fo r early it may prevent adhesions , abscess mation, and general deformity Of the pelvic organs . No w remember that douches for this purpose should be taken lying down ( either using a douche

It no t ne ce s pan Or getting into the bathtub ) . is sary to have a swift stream Of water ; hence the ir E r iga to r o r douche bag need not hang high . nough

0 1 1 0 to water ( at about F . ) should be used make the

douche last for ten o r ﬁfteen minutes . Remember that the virtue Of this treatment lies In keeping th e h ea t and moisture in contact with

S the inﬂamed tissues a long time . This hould be

repeated at intervals of every two hours , day and If h night . t ere is any Odor to the discharges , a f 40 teaspoonful o formaldehyd , per cent , can be

a An dded . y other medicinal agent may be used G S ENERAL CONSIDERATION . 3

that might be suggested for the particular case . Remember that the hot fomentations should be changed as frequently as they cool— every ﬁve to

In c an ten minutes . hospital practice ( and it be

i e done in pr vate practice) , a bag is mad with a stick s ewed in at each end ; the ﬂann el cloth that is used f r e the application is placed in this bag , and the

o f whole placed in the vessel boiling water . This

un o ut Of is wr g by use the sticks , the whole carried

o f to the bedside the patient, when the ﬂannel is

h o t removed from the bag ( steaming ) , and placed ’ o n the patient s abdomen as warm as it can be tol era ted i s , and the cooled application placed into the f bag and pan O hot water . This is repeated back ’ o ne and forth , and it requires about all Of nurse s time to give the douches , and use the hot applica It h h w tions properly. is wonderful , owever, o quickly and completely this plan Of treatment gives relief ; the patient who has been in the throes o f pain in twelve to twenty-four hours begins to hea ve sighs o f relief, the pulse becomes softer and slower , and the temperature drops . Remember that the bowels should be thoroughly evacuated daily by the use Of salines , cathartic waters , or enemata . Remember that in subacute o r chronic diseases Of the pelvic organs tamponade with the various mix tures Of glycerin serves splendidly for temporary relief. Clinical patients are living examples and prove beyond dispute just how far this line o f treat 24 GOLDEN RULES OF GYNECOLOGY .

ment is m eritorious . They are a class Of people whose time Is required every day for the support Of

‘ themselves and their families ; they cannot lie

a around s invalids , nor have they time to go to a o h spital for a s urgical operation . They come to our Cli ’ b nics with the gravest pelvic disease , scarcely a le m i to walk , and if they were wo en Of a h gher plane S in life, they would be conﬁned in bed . omething must be done for them ; so they are given a tampon

i 1 0 Of glycer n and ichthyol , per cent , and instructed

A r in the art Of taking douches . fter three o four visits they return smiling and say that they feel

A ten o r l much better . fter twe ve treatments they t disappear , only o return with a relapse in a few

r C weeks o months . Large numbers ontinue in this way for years , and indeﬁnitely .

Remember that , while the value Of the tampon to some extent i s derived from the medicinal sub t it and s ances that carries to the cervix , as a support to the uterus in some cases vet the greatest beneﬁt comes from the glycerin mixtures , on account Of

DO their hygroscopic properties . not use cotton tampons ; they become too hard and cause pain . L ’ amb s wool , with a piece Of string tied to it , is a A splendid tampon . very convenient tampon is made by cutting plain gauze four or ﬁve inches wide

w o . S o ne by t feet in length aturate about half Of it , and pack around the cervix as desired through an

o ne ordinary bivalve speculum , leaving about inch outside Of vagina so that patient can readily pull it 25 GENERAL CONSIDERATIONS .

I ~ o ut when it has served its usefulness . n withdraw m ing the speculum, gentle pressure ust be made against the tampon with the dressing forceps , so A that it may not become dislodged . tampon should

— be left in from twelve to twenty four hours . Hemo rrhage — Remember that tampons are Often

a se useful in checking uterine hemorrh ge . By the u Of a bivalve speculum or a perineal r etractor small

Of pieces cotton , wrung from warm water are

i packed well up around the cervix , ﬁnally ﬁll ng the vagina . The cotton might be wrung from a boric acid or a weak formalin solution for the antiseptic e effect , or a weak solution Of adrenalin may be us d If for its astringent properties . the hemorrhage is

o ut very great , this entire pack may be forced by the blood—clots and " ﬂuid blood coming from the uterus .

o r sufﬁ Remember that , if the cervix is can be cientl l o f y di ated , strips gauze , wrung from some mild astringent solution , and packed directly into the cavity Of the uterus , are effective when vaginal packing fails . Remember that in ulceration or erosi on Of the cer ~ v ix local treatment must be instituted , but we must not mistake the hypertrophied everted cervical m u ~ cous membrane Of a lacerated cervix for ulceration and erosion . Remember that retention cysts o f the Nabothian glands are relieved by puncture , followed by tam

de o na . p , hot douches , etc 6 GOLDEN RULES OF GYNECOLOGY .

I f r n ection, particularly gonor heal , is met by local In treatment . such a case , remember that rest in bed and vigorous treatment to prevent its spread beyond the vagina are demanded to save her from

i be ng completely ruined .

Local treatment is necessary, effective , and Often entirely sufﬁcient in many o f the diseases Of the

r vulva o external genitals . Intra er ne — D ’ f ut i . on t get into the habit O using

i intrauter ne treatments indiscriminately . Women a s a whole would have been much better off had this plan Of treatment never been instituted . When it o d es become necessary, use it under the strictest , It aseptic precautions . may be Of beneﬁt in cases

Of acute endometritis without infection , when a few applications Of tincture Of iodin may be applied to the endometrium . Remember that the cervix should be well dilated and the applications made two o r three days apart ; if three o r four treatments do not give the effect

i s desired, it better to desist, and let the patient rest from treatment for a time . It is a question whether o r not the beneﬁt derived

‘ in these cases comes from the astringent applica f tion or from the dilatation O the cervix alone , thus establishing better drainage from the uteri ne cavity . Remember that it is necessary to curette and wash o ut é i o r d bris from the uterus , following m scarriage abortion ; but remember that this can be done more thoroughly and safer under a general anesthetic . 2 GENERAL CONSIDERATIONS . 7

Operations of this magnitude Should be done in a ’ fﬁ hospital ; don t undertake them in the O ce . It is permissible to use a uteri ne sound in cases

ﬁbr o ids o r Of uterine (posterior ) prolapse, in order t o clear up an uncertain diagnosis , but these cases

No w are rare . reason, and see if it does not appear

o r quite doubtful whether argyrol , protargol , any Of these antiseptics has any beneﬁcial effect what soever in destroying pathogenic micro -organisms within the cavity Of th e uterus ; the issue almost en tir el n y depends o the antitoxic ability Of the blood ,

No to sa . w with its leucocytes , if it were pos sible y that the infection was limited to the surface Of the

e endometrium , it might do some good , but even th n, we might bruise the otherwise intact endometrium, which was furnishing splendid resistance , and open up new portals for the entrance Of infection to the deeper structures .

NSTIPATION CO .

Remember that most women a r e constipated and that assistance in a general way ( diet , exercise , etc . ) may save her from the necessity Of taking daily cathartics . Remember that the ill effects Of constipation are no t only in the failure to remove the residue from the intestinal tract and its discomforts ; its evil ef fects reach the whole economy . While the seden tary habits Of a woman are no doubt justly blamed

n do i1bt for a part Of her constipation , and o also , 28 GOLDEN RULES OF GYNECOLOGY . may be blamed for the chronic disorders o f the stomach , intestines , liver , and kidneys , yet , on the other hand , there are other anatomical and

i c physiolog al reasons . Remember that the pelvic organs become c o n

e s g ted and engorged at every menstrual period .

‘ Of a nd Lacerations the perineum allow displacement , interference with the function Of the rectum .

U Of th terine prolapse and displacements , tumors e uterus and ovaries in a mechanical way produce co n sti a tio n p , and moreover , it is not always so con v enient fo r a woman to regard and attend the calls

Of N fo r o h ature as it is a man . H wever S e should

ne ce s be taught from childhood that it/ is extremely N d sary to Obey ature promptly in her deman s , and to render assi stance by forming regular habits— to go to stool regularly, just as she has regular hours for meals . A woman who does her own housework o r l O Ok s after her o w n children should not be accused o f

Of sedentary habits . However, when she is guilty l eading a sedentary life , it must be overcome , and

a c co m no doubt , in such a woman it can best be

lish ed p by ordering gymnastics , massage , or some form Of exerci se that is combined with pleasure . No w remember that women do not drink enough water . Water not only furnishes the proper ﬂuid to the body, but taken in proper quantities and at

o f r o proper times , cleanses the stomach mucus , p motes peristalsis , increases perspiration and the

30 N OE N GOLDE RULES GY ECOLOGY.

A glass o r tw o Of water should be drunk between meals , and the same amount taken between the even m f ing eal and bedtime . The temperature o the water need only be that Of ordinarily cool drinking

vva ter .

If o ne— to o ne- the case is ob stinate, a fourth third teaspoonful Of common table salt added to the water taken before breakfast acts almost as well as a saline F b e cathartic . ruit of some kind should be eaten fore breakfast . In very obstinate cases a ta blespoonful of Olive Oil f taken with each meal helps very materially . O

to Of course , in the cases that do not yield this line

nece sa r to treatment , it may become s y divulse the s incter p ani under an anesthetic , and to resort to the various aperient waters or mild cathartics at w times , until e have been able to correct the trouble entirely . CHAPTE R II

EA E F THE L A DIS S S O VU V .

VULVITIS .

Remember that there are three varieties : viz . the simple , the follicular , and the gonorrheal .

Remember that . simple vulvitis found in adults is

Of due to a lack cleanliness , and the colon bacillus and the skin cocci are found . Be careful to eliminate a redness and swelling due to trauma caused by riding, cycling, etc . Remember that in addition to the redness and swelling there will be found an increase in the mucous discharges , and mucopus , red dots marking the site Of the oriﬁces Of the tubular glands ; also , there will be itching Of the parts and scalding dur ing urination . Remember that in women who have diabetes and an ammoniacal urine the sebaceous glands become

r Of inﬂamed and discharge pus , o the mouth the glands becomes plugged, when there will be pro duced an acne-like pustule Remember that a vulviti s W i th intense pruritus - with dry, parchment like skin and mucous mem brane calls for an exami nation Of the urine for

r suga . 32 GOLDEN RULES OF GYNECOLOGY .

Remember that the gonorrheal vulvitis is much more common in the cities and large towns . But remember that the history that can be elicited from the patient makes the task o f differentiation E more simple . ven if the patient is unwilling to give the desired information the Objective symptoms " ” will be o f sufﬁcient tell-tale character to get her to i f adm t the possibility O an infection . Remember that o n inspection the urethral oriﬁce is puffy and red , and by pressure pus may be forced o ut ; the p repuce and clitoris are edematous , and the engorgement o f the erectile tissue causes a semi

’ erection o f the clitoris ; the ducts Of Bartholin s

a n glands are swollen and discharge pus , d the entire gland is tender . Remember that the microscope always Shows the gonococci in the pus and the secretions Should be examined fo r the cocci in all cases Of vulvitis . Remember that cancer o r vesicovaginal ﬁstula by irritating discharges may cause a severe vu lvitis and they should always be excluded by examina tion . n Remember that all varieties are co tagious , and

i n i when occurring institutions , strict isolat on should be enforced . r ent — T ea tm . Remember two things are impera

: . . tive viz , rest in bed and cleanliness The parts Should be thoroughly cleansed with warm water to

Of which is added a little tincture green soap , or a saturated solution Of boracic acid may be used . 33 DISEASES OF THE VULVA .

After a thorough cleansing twice daily (in the sim m ple for ) , a boric dusting powder should be used . In the severe form a hot sitz-bath twice daily will

give relief and be cleansing . Remember that the bowels should be kept freely

open by the use Of salines daily, but later the simple d t laxatives ma y be used . The diet shoul be ligh during the acute stage . Keep the urine bland and non-irritating by the

. S free use Of pure water hould it be strongly acid, potassium acetate and the tincture o f belladonna b e may given ; or, should the urine be alkaline , ben z o a te Of sodium or ammonium should be given . Local medication consists in douching the vulva with bichl o rid of mercury solution ( 1 : 2000 Or 5 000) with the labia separated by a piece o f lint o r cotton

ichl ri pledget soaked in the b o d solution . In the chronic form o r in severe acute conditions

’ l Go ul a r d s int compresses , soaked in solution and warm water equal parts , may be applied to the

o r . o r vulva ; acetate Of zinc gr j to ounce Of water , i f . o sulphate Of zinc , gr j to the ounce water , may be used when an astringent action is needed . When there are excoriations and erosions an Oint f In ment O benzoated oxid Of zinc should be used . the follicular form the vagina should be douched two or three times daily with normal salt solution , and a vaginal tampon used to collect the secretions and thus protect the vulva . The tampon should be medicated with glycerite Of boroglycerin . 34 N N GOLDE RULES OF GY ECOLOGY .

x Paint the affected parts with silver nitrate , gr . x to a n the ounce, every three or four days , d apply compresses moistened with an alkaline solution — bicarbonate Of soda gr . xxx to the ounce continu o usl y over the vulva and between the labia . In the severe cases the follicles should be p unc ture d with a slender bistoury, and the contents squeezed o ut and pai nted with a solution Of silver

fo l nitrate, half dram to the ounce, and apply the lowing Ointment

R I chthyo l i

Ph eno l is

Glycer ini i Unguenti petrolati q . s . ad 3 j et m Misce ﬁat unguentu .

. : Sig Apply locally .

In o r r the gonorrheal form, once twice daily afte

cl ea n sm e hi thoroughly g the parts , a douch of 1 5 000 : . chlorid, to

The area should be thoroughly bathed with a 5 . per cent solution Of silver " nitrate or 1 0 per cent nn protargol at the begi ing , then a daily application 2 Of a per cent solution . Remember in gonorrheal vulvitis to give a good antiseptic vaginal douche and close the opening with cotton soaked in an antiseptic solution to pre vent the extensi on Of the infection along the genital tract . In diabetic vulvitis the vagina should be irrigated

1 : daily with a solution Of corrosive sublimate, SE S S OF TH E L 35 DI A E VU VA .

f ‘ 2000 o r a 1 o . , per cent solution lysol ment of the following may be applied

l i l i R Acidi sa cy ci . Unguenti petrolati et Misce ﬁat unguentum .

Si : g Apply locally .

R Phe no lis

Unguenti z inci o x idi

et Misce ﬁat unguentum .

Si : g Apply locally .

ruri i This will relieve the intense p t s . Where excoriations or abrasions occur they should be painted every three o r four days with a

f . solution o silver nitrate gr . xxv to the ounce

In o f no many these cases , relief will be Obtained

from the wet dressings ; in these cases , after thor

ough cleansing , some dry, mildly antiseptic powder

o f — v iz is great advantage , boracic acid and calo mel , equal parts ; calomel alone ; borated talcum powder .

L N S BARTHO I ITI . Remember that these are racemose glands about

Of the size a bean , located in the labia majora at the

Of junction the middle and posterior third , and the ducts open in front Of the hymen with an oriﬁce

about the size Of a head Of a pin . Remember that the following may be the cause Of a n inﬂammation o f these glands : gonorrhea ; dis 36 N R S GOLDE ULE OF GYNECOLOGY .

charges ; extension Of inﬂamm ation ; suppuration of

o r Of a cyst the gland . Remember that by far the largest majority o f the cases are due to the gonococci and that usually only

o ne a gl nd at a time is involved . Inﬂammation and suppuration Of the glands Of Bartholin are SO common in gonorrheal infections that they are frequently referred to as sufﬁ cient evi

Of f dence Of the character the in ection, when they

‘

are found . Remember ﬁlth may be the cause and the sta p hy l o co c ci may be the pathogenic organisms foun d in

the abscess . Remember that once the gonococci have infected

the gland they may remain dormant , causing a slight watery discharge that will infect the patient

o r others coming in contact with the secretions . Remember the subjective symptoms are : a sense

O f o r burning ; a constant , sharp , lancinating throb

r r i All bing pain with p u it s . symptoms are made

o r worse by standing walking , but the recumbent

posture gives relief . Remember that on examinati on there will be

nd i n e swelling a edema , and severe cases , the sw ll

Of ing extends to the anus . The mouth the duct Of

the gland is inﬂamed , and pus may be squeezed out . Th e evidence Of pus is ﬁrst apparent o n the inner

side Of the labium . The tumor is round or oval ;

o r . ﬁrm ﬂuctuating , and tender on pressure Remember that a hernia into the labium is not

8 GOLDEN RULES OF GYNECOLOGY .

carbolic acid to the enti re cavity with a swab ; pack T- with gauze, and apply a bandage .

If en the abscess has spontaneously opened , then large the opening and proceed as above

Remember that in chronic cases , as well as in the

\ S o ut cystic form, the gland hould be dissected , care

o t being taken n to rupture the cyst . Remember that the nutrient artery enters the

gland at the upper end ; hence the dissection should

a nd be from below upward, and the vessel caught

ligated . Cleanse the cavity, apply carbolic acid ,

pack , and apply dressing . The removal Of the gland is imperati ve i n chronic

cases and those with ﬁ stul o us openings .

N S CYSTS OF THE VULVOVAGINAL GLA D .

Remember that these cysts may be Situated super

ﬁ cia ll Or ~ y deeply . Those Of the duct are always

unilocular, while those Of the gland may be mono

o r locular multilocular , depending upon whether

o ne or more lobules Of the gland are involved . Remember that they may be the result Of inﬂa m

o r mation , usually gonorrheal ; due to an alteration Of glandular secretion that cannot escape through

the duct , thus causing a retention cyst . Remember that while small cysts cause no sym p toms the large ones interfere with walking and sex F ual intercourse . riction to which the parts are

subjected may cause irritation and inﬂammation ,

and eventually suppuration . S S 39 DI EASE OF THE VULVA .

Remember that cysts Of the duct are globular o r ovoid in Shape and located under the mucous mem

Of ae brane at the base the nymph , projecting into the vagina . Remember that a cyst Of the gland is usually about ’ S the ize Of a hen s egg , located in the posterior part

Of the labium majus , and is freely movable under It the overlying tissues . is smooth , ovoid , seldom

o n fr e transparent , dull percussion, and found most quently o n the left side Of the vulva .

o n irr edu Remember that it is elastic pressure , cible, and painless unless inﬂamed . Treatment — The gland and duct should be dis sected o ut , and the wound sutured , unless suppura tion has occurred, when it should be packed .

R U V V PRU IT S UL E .

Remember that this is a sym ptom o f some general o r local lesion and the cause should be sought . Remember that it is a very troublesome symptom

fo r Of in diabetes , and all cases call an examination the urine for sugar . Remember that malignant disease Of the genital organs may cause a severe pruritus from an irrita ting discharge and all cases occurring in elderly women call for a careful vaginal examination . Remember that it may be a reﬂex symptom de

- o r pending upon seat worms , and ﬁssure , it may be n due directly to some anomaly Of the pelvic orga s , I causing an irritating leucorrhea . rritating dis 40 OE GOLDEN RULES GYNECOLOGY . charges are by far the most common cause of this trouble .

o r Remember that the itching is worse at night , r is made worse by wa mth . Remember that it may be due to a neurosis and ma y cause melancholy o r insanity with suicidal tendencies . Remember that pruritus may be caused by diges tive disturbances or it may result from masturba

o r tion sexual excesses . Tr men — ea t t . Remember that in the treatment the cause must be sought and treated , as well as the local condition . The very ﬁrst principle in th e treatment is clean lin e ss , and the next is rest, to prevent , as far as possible , irritating the parts . Remember that nitrogenous food should be r e duce d a n h a e N Or d t t milk diet is b st . O alcoholic other stimulants should be allowed , and the bowels must be kept open by a simple laxative . The free use Of water usually keeps the urine bland , but if

i necessary, potass um acetate and belladonna may be

given to correct an overacidity .

Remember that mild exercise may be advised , but do not forget that friction Of the parts in walking makes the itching worse . Remember that a good general tonic treatment is

i i i th e usually indicated and quin n, arsen c , ron, and

mineral acids are very beneﬁcial . Remember that morphin should not be used but 41 DISEASES THE VULVA . the bromids and cannabis indica allay nervousness and secure sleep .

Sulphonal gr . x to gr . xx ; trional gr . xv to gr .

d xx to xxv ; paral ehyd m xxx, given at bedtime and repeated in two hours , is Often beneﬁcial . Remember that the most important thing in the local treatment is cleanliness . The vagina and vulva should be i rri gated twice daily with normal

bi chlo ri d o r 2 salt solution or solution, a

f o r per cent solution O phenol in glycerin and water, Al a solution Of lead acetate may be used . l dis

Of S o ut charges the vagina hould be cleaned , and a vaginal tampon placed against cervix to protect the vulva from the irritating discharges . Remember that a compress Of lead water and

o r 2 laudanum, per cent Of phenol , Often gives excel lent results . Painting the surface with 1 0 per cent phenol ; di lute hydrocyanic acid 5 ii ; acetate o f lead gr . l . to

Of o n ounce water , a pledget Of cotton held in a dis sectin g forceps , is Often beneﬁcial . Remember that the parts must be protected from the urine and carbolated vaselin is excellent . The following is an excellent Ointment

R Menth o lis Unguenti creosoti Unguenti ca m ph o r ae Unguenti belladonn as Unguenti petrolati et u Misce ﬁat ung entum .

Si : g Apply locally . 42 N S OF N GOLDE RULE GY ECOLOGY .

Or the following

Ph eno lis R gr . m

Menth o l is Unguenti petrolati

Misce et ﬁat unguentum .

Sig . Apply locally

\ Other good solutions are strong solution Of cor r o siv e m sublimate in emulsion Of bitter al onds ( gr . j to ounce ) ; chloroform ( 5 j ) in glyceri n ( g j ) ; di 11 i lute hydrocyanic acid ( 1 j to water 3 j ) .

Fo r Of the pruritus diabetes , diabetic manage n i d me t, local cleanl ness , and the use Of borate tal cum or a boracic acid Ointment to protect the vulva ar e indicated . When pruritus is due to Skin parasites mercurial

i and sulphur O ntments should be used . In cases due to seat—worms the infusion o f quassia should be given in an enema .

A UL E " R UROSIS V V . Remember that this is a progressive atrophy and

contraction Of the vulvar tissues , occurring in mid

Or - advanced life , and resembles , somewhat , senile atrophy o f the parts . Remember that the cause is unknown but malig

nant disease Of the vulva Often develops from it . Remember that the beginning Of the condition is

Of marked by the appearance small , brown spots , e irregular in shape, slightly depressed belo w th

surface. 43 DISEASES OF THE VULVA .

Remember that these spots may be very painful to the touch and may cause a pruritus .

Remember that the labia and nymphae atrophy, forming a Slight ridge upo n either side . The vulva becomes shrunken, dry, and hard, and the normal appearance is lost . Trea tment — Remember that the progress Of the disease is very slow with no tendency to a spon ta ne o s u cure . The treatment is palliative and surgical . " Because Of the resemblance to trachoma , ohn stone recommends the yellow oxid Of mer cury o int m 1 F ent in strength Of from to 3 per cent . irst cleanse the vulva and vagina thoroughly with a h spray of dioxid of hydrogen and apply t e Ointment . in This is done twice a week . The patient is structed to apply the Ointment twice daily to the external parts . The applications are made at longer in tervals as improvement occurs , but the treatment

e is k pt up for months . Strong solution of phenol is used to relieve the pruritus . Lint soaked in a saturated solution o f lead acetate a n d laid over the parts Often gives relief . Cracks and fissures should be touched with silver nitrate stick , and zinc oxid Ointment applied . Remember that the removal Of the diseased tissue is probably the best method Of treatment . Remember that the incision is made along the juncture Of the diseased tissue and the healthy skin 44 GOLDEN RULES OF GYNECOLOGY . along the lateral and posterior margin Of the vulvar orifice . Be sure to get well outside the diseased margin . Remember the urethral orifice in dissecting the diseased tissues , and do not wound it but carry the i i i u nc s on aro nd it .

The diseased tissue is cut away ; the mucosa Of

o ut the vagina dissected loose , pulled , and sutured to the healthy skin .

ELE HAN AS S VULVE P TI I .

Of r Remember that , while this is a disease the t op S th ics , poradic cases are seen over all e world . Remember that the enlargement is due to the hypertrophy Of the skin . Remember that syphilis may cause a hypertrophy similar to elephantiasis but it is no t S O pronounced and mucous patches with other manifestations are present . Remember that elephantiasis occurs in women b e h -ﬁf tween t e twenty th and ﬁftieth years . It is probably due to the F ila ria s a ngumis ho minis and is carried by the mosquito .

Remember that many cases , especially in the trop i cs co nstitu , begin as an acute lymphangitis , with i n t o a l symptoms lasting about two weeks , then

a . subsiding, leaving the vulva slightly enl rged These attacks are repeated' at varying intervals with increasing vulvar enlargement . Remember that the labia majora are most fre

46 GO DEN R L S OL GY L U E OF GYNEC O .

AR SE E N V ICO V I S . Remember that pregnancy is the most frequent cause Of this condition and it is more especially in cases o f gestation associated with small pelvic u t mors . " t Remember that uterine displacemen , chronic constipation, abdominal tumors , and prolonged standing interfere with the venous circulation Of the vulva , hence are Often causative . Remember that symptoms are produced only when the tumor is large enough to interfere with the

o f normal contour the parts , when patient complains

a d Of h ea v i Of aching, itching , burning, n a sensation ness in the vulva . Coitus and walking cause suf ferin g . Remember that it occurs more frequently in the labia majora bii t other parts Of the vulva may be affected .

i s ~ Remember that the tumor an elongated , irreg

Of — e ular , and knotted mass a dark blue color, whil the veins under the Skin are dilated and tortuous : Remember that o n palpation the mass is boggy and can be made to disappear by pressure . Remember that the tumor may rupture into the

o r tissues , during parturition , causing a hematoma , externally causing a serious or perhaps fatal h em o r rh e a g . Varicose veins in the vulva frequently occur in 4 DISEASES OF THE VULVA . 7

pregnancy, owing to the weight and the pressure Of the uterus . Although it is a very troublesome complication in preg nancy, it usually disappears immediately after parturition, and needs no treatment afterward . Tre men — a t t . Remember that the treatment may be either palliative or radical . Palli ative treatment is used only during gestation and consists Of mechanical sup p o rt ' by pad or com T- press Over the tumor, held in position by a band A age . n abdominal binder should be worn to sup port the uterus and relieve the pressure o nthe pelvic R fo veins . est in the recumbent position r a few minutes several times daily. S hould hemorrhage occur , ﬁrm pressure should

’ a i rriv es be made over the bleeding point until d a , when a deep catgut suture Should be inserted to con trol it .

the The radical treatment , where the varix is in

i s fo r labia majora , the same as the operation the

Of i s cure varicocele n the male . The labium i made tense by traction, made by the assistant grasping the tissues ab ove and below the most pronounced M portion Of the tumor . ake the incision over the E varix . xpose the veins by dry dissection and pass a ligature around the vessels at the distal and prox imal ends Of the tumor . Tie and cut the veins at each ligature . The stumps are brought together and held in 48 OF N GOLDEN RULES GY ECOLOGY .

I close apposition by securely tying the free ends Of the distal and proximal ligatures . Close the wound with sutures and cover the vulva T- with gauze held in position by a bandage .

Y R EL F B A S H D OC E O THE LA IUM M " U .

Remember that this is a collection Of serous ﬂuid in the peritoneal sac that forms the canal Of Nuck d I uring fetal life . n the fetus the peritoneal cover ing Of the round ligament extends beyond the inter na l a Of ring , forming pouch which is called the canal

Nuck . The persistence Of this canal after birth

o f fo rms the sac the hydrocele . Remember that it may be Single o r double and c no auses inconvenience unless it becomes large , w when mechanically it interferes with alking , sexual intercourse , and labor . Remember that when seen early the tumor is lo ca ted i i in the ngu nal canal , but later it descends into the upper part Of the labium .

Remember that the swelling is elastic , ﬂuctuating,

a n d o n and translucent , no pain on pressure , dulness

h e e percussion . T tumor may be increased in siz by b earing down or coughing . Remember that i t is important to differentiate i hydrocele from hernia ; and the follow ng points should be borne in mind in making the distinction

1 Th e m . gradual development Of the tu or with no l o r m ocal general sy ptoms . 2 D . n ulness o percussion. F L 9 DISEASES O THE VU VA .

3 . Translucency .

4 A mm S . . bsence of inﬂa atory igns

E o f en 5 . lasticity and ﬂuctuation the tumor, if

cysted .

Keep in mind that an inﬂamed hydrocele and" m strangulated hernia differ. in the absence Of sy p toms Of intestinal o bstruction in the hydrocele . The insertion o f a needle and the withdrawal Of

ﬂuid will settle the doubt in diagnosis . T m n — rea t e t . Remember that when the tumors are

small they cause no trouble and may be left alone , o r the patient given an Ointment Of Oleate o f mer cury to rub into the skin . The tumor may be punctured and the ﬂuid drawn

Off, but it will recollect . A fter the withdrawal Of the ﬂuid, an irritating solution like the tincture Of iodin may b e injected

Ob into the sac , causing an acute inﬂammation and literation, but the danger is in forcing some Of the solution through the abdominal openi ng into the peritoneal cavity . The best treatment is the dissection Of the sac and the closure Of the wound, suturing the individ l f ual ayers O the wall . The incision is made the

Of entire length the inguinal canal , and the sac ex I . t posed is then dissected out , twisted and ligated with a catgut ligature close to the internal abdom

th e i m inal ring, and sac cut Off about half an nch fro

the ligature . When suppuration occurs i n a hydrocele it should 0 N OF 5 GOLDE RULES GYNECOLOGY .

o u be Opened, curetted, and washed t with some anti septic solution . The wound Should be packed with i odoform gauze and allowed to heal by granulation .

N N L B A I GUI O A I L HERNIA . Remember that this corresponds to the scrotal

i I s in variety n the male . t de cends through the guinal canal, following the round ligament . Remember that the contents o f the sac may be in

o r testine, Omentum , uterus , appendages . A hernia containing the uterus is comparatively rare ; it is not nearly so common as scrotal hernia in the male, owing doubtless to the fact that there f is an ab sence o the sp ermatic cord in the female , and consequently the tissues formi ng i n the inguinal canal are stronger ; the pregnant uterus has been

a found in such a herni . Remember that the patient complains o f d i sco m

o r i i a w exer fort gr p ng pain , usu lly follo ing some S tion . There are gastrointestinal disturbances , uch as dyspepsia and constipation .

Remember that the tumor appears ﬁrst as a small , round swelling at the external ring , but after it has descended into the labium it is elongated and con

ri st cted at its upper end . Remember that the contents Of the hernial sac modify greatly the ﬁndings o n physical examination . If m it contains intestine, the tu or is smooth and

h e o n elastic , and t size and tensity are increased ~ c n o r . It disa oughing, sta ding, lifting, straining p F 5 1 DISEASE S O THE VULVA .

o n pears lying down, and when reduced by taxis a gurgling sound i s heard when the gut slips back into the abdominal cavity . The percussion note is

tympanitic , and the characteristic impulse is felt when the patient coughs When the sac contains omentum the tumor is ir regular, feels doughy, and the percussion note is dull . NO g urgling sound is heard when the contents are a replaced into the peritoneal c vity, and the impulse If in o n coughing is slight . the sac contains both testine and omentum, the signs vary over different areas Of the tumor .

c o n Remember that , when the uterus forms the

Of o n tent the sac , the tumor is hard , dull percussion,

i i o w th no mpulse n coughing . Remember that bimanual examination reveals the absence o f the uterus and vaginal examination r e veals the cervix pulled toward the affected side . Keep in mind that when a pregnant uterus forms the contents o f the sac the tumor gradually in

i n S i creases ze as gestation progresses . Remember that hernia must be distinguished from hydrocele , enlargement Of the vulvovaginal glands ,

Of and tumor the labium majus . Trea tment — Remember that treatment may be

o r h en palliative radical . IV the contents Of the hernial sac can be returned to the abdominal cavity a nd -ﬁ ttin s retained by a well g tru s , the palliative treatment may be followed with a certain degree Of 2 N L OF 5 GOLDE RU ES GYNECOLOGY .

But a safety . it should be made very plain to the p tient that it is only fo r the purpose Of temporary relief o r until a more convenient time; when she can submit to a radical cure ; that it is extremely danger o us for a woman ( at least in the child-bearing period

Of e life) t have a hernia . Remember that with incarceration o r inability to prevent the escape o f abdominal viscera with a truss the operative procedure becomes imperative . Remember that the surgi cal procedure Offers the only cure and during the child-bearing period this is o f great advantage fo r the future safety Of the patient . Remember that the steps of the Operation are the

f i r l same as for the cure O i ngu nal he nia in the ma e, with the exception Of the absence of the spermatic f cord, which O course does not necessitate a recon

If sa c struction Of the inguinal canal . the hernial n s contai s the uterine fundus and pregnancy Occur , abortion is more than likely at the third o r fourth month . - Remember that in operation for the cure Of a it hernia Of the uterus , where it is acutely inﬂamed, may necessitate the removal Of the uterus also .

O CHANCR IDS .

Remember that the primary chancroid may occur o n any part Of the vulva but is most commonl y

o n a nd found the fourchette, labia majora, nymphae, vestibule .

4 N S . OF N 5 GOLDE RULE GY ECOLOGY .

No w keep in mind that there is Often great pai n and suffering accompanying chancroids— this pain

and suffering is usually in , proportion to the amount Of ulceration— walking becomes difﬁcult and mic turitio n painful ; these patients will have a Sick and

o f agonizing expression the face . Remember that if not checked the area Of ulcera tion may become quite extensive , the labia may be penetrated from ulceration completely through the tissue, and when ﬁnally it is made to heal the vulva will present a scarred and ugly appearance . Remember that these patients are exceedingly anxious to be assured that they are not the victims o f syphilis ; this is Often quite difﬁcult to do in view o f the facts that promiscuous intercourse may have

o r been indulged in , making a history impossible If worthless , and we may have a mixed infection . in doubt , it is best to wait and anticipate secondary manifestations before instituting g eneral specific r t eatment . Trea tment — Remember that the first thing to do is to convert the sore into a no n-sp e cifi c ulcer and this may be done by cauterizing the ulcer . The thermocautery may be used, but the ulcer should first be anesthetized by a solution of cocain .

The application Of undiluted phenol to the ulcer ,

o r Of followed by alcohol , the use nitric acid, may be used to destroy the infection . The vagina and vulva should be thoroughly

h o douched with a t lysol solution and dried, and the OE 5 DISEASES THE VULVA . 5

w a bi did ulcer dusted ith iodoform, ristol , or the su o o f bismuth . The labia should be held apart by a pledget Of T- cotton, and a bandage applied . The parts should be cleansed daily with ho t lysol

o r bi chl o rid solution, Of mercury followed by saline solution and powder dusted on the ulcer . No w remember that these unfortunate women apply fo r treatment largely o n account Of the pain

o they suffer . Some attempt has been made t treat themselves until the pain becomes unbearable . C ompresses Of lead and opium, frequently change d, are Often useful , and compresses wrung from hot water give relief . Sometimes pledgets Of cotton saturated with 2 per cent cocain solution have to be applied to the ulcers in order that the ’ patient may have a few hours rest . In some the pain and progress Of the chancroids are so persistent that they seem to resist nearly all f o . kinds treatment The author found , by referring

Of r M derm a to l o some these cases to D . H . . Lyle (

l Ob gist ) , that a most instant relief from pain was ta in e d from the use Of the SO—called l euco de scent A light . fter a few treatments the pain will not re turn , the secretions from the ulcers cease , and they present a healthy granulating surface . We now have in o ur clinic a 62—candle-power electric light with a strong reﬂector , with which we treat these

fo r cases , applying heat ﬁve to ten minutes daily,

In co n unc from which we Obtain happy results . j E 6 GOLDEN RULES O GYNECOLOGY .

' ' tion We have used scarlet—red Ointment 5 per cent

’

D Of . (P . . which we believe is much value

When healthy granulations begin to form, discon tinue the powder and apply a stimulating Ointment , such as 2 per cent o f phenol in benzoated oxid Of

o ne z inc Ointment , or part Of the Ointment of mer If curi e nitrate to seven Of vaselin . a bubo de

. v el o s S Of p , it hould be painted with the tincture iodin, and the patient kept in bed ; and should it persist and suppurate , it should be freely incised , u and the gland curetted away . Wash o t the cavity

a i . with hot lysol solution , dry, and p ck w th gauze The general health o f the patient may be such as

Of to demand an iron tonic , rest , and plenty good f d OO .

Remember that there is always danger Of a gen eral sepsis in all these cases , and the gravity Of such

’ in nowise differs from other septic infections . Remember that exuberant a nd unhealthy gra nu lation Of an ulcer demands the application of silver solution, or the stick may be used .

CHANCRE . Remember that the primary lesion or hard cha ncre is frequently no t to be found o n the female

th e genitalia , thus being the opposite to the rule in l It in ma e . is sometimes found on the lips or the

Of mouth . The most common situation the chancre,

o n . however , is the labia majora Remember that chancre is very frequently over OE V DISEASES THE VUL A . 5 7

looked unless the examination is most carefully nf made , owing to the co ormation and the relation

existing between the various parts . Remember that the appearance Of the secondary o r tertiary symptoms may be the ﬁrst intimation Of syphilis and no history Of the primary s ore be Oh in d ta e .

‘ Remember that the primary lesion is , as a rule,

s o r i ingle, but may be multiple m xed with soft

c hancres .

c Of Remember that the ul er is superﬁcial , ﬂat , a

o r reddish grayish color with a smooth ﬂoor . There

o f is an area induration around the ulcer, which is

hard like cartilage , and the edges are never under

mined . Remember that the enlargement Of the inguinal

glands usually occurs but they do not suppurate . Remember that a syphilitic ulcer does no t present the angry appearance and destructive ch a r a cteri s f i o . t cs the chancroid The edges slope inward , and there is not such a marked inﬂammatory reaction in

the adjacent tissues . Remember that the period o f incubation is from

two to three weeks , or even longer , thus differing

markedly from chancroid .

, Remember that the secondary lesions o n the vulva

usually appear as mucous patches , or condylomata . The condylomata vary in size from a split pea to

— a thumb nail and are slightly elevated and ﬂattened, with a shedding o f the epithelium covering the area . 5 8 E S OE GOLD N RULE GYNECOLOGY .

They may appear at any time during the ﬁrst twelve

months and may be single or multiple . They are mo st commonly found o n the labia minora and the u inner s rface Of the labia majora . Remember that the Sp i r o chaata p a llida can be found in all forms of syphili s and it is important to

examine secretions o r pieces Of tissues . Treatment — Remember that it is very important to make a diagnosis before adopting any line o f

treatment that will inﬂuence the clinical picture . After a diagnosis is made the local treatment is

Of simply that cleanliness .

Bichl o rid 2 so as a wash , lysol per cent

tio n A lu . , are excellent fter cleansing use some dust n i g powder . Calomel is frequently used as a dust

in e e . g powder , as it r liev s irritation Where there 1 0 is a tendency to bleed , a per cent solution Of

c opper sulphate is good; o r the use o f the silver

stick . If the case is seen early, it is good practice to excise the sore with a sharp electric cautery .

The chancre usually heals without any trouble , and one o f the greatest difﬁculties is to make the patient understand that she is not entirely well and will not be until She has undergone a thorough c ours e Of general medication . No w remember that it is largely for this reason that no internal treatment should be given , if there is the slightest doubt in the diagnosis , until after At e the secondary manifestations appear . any rat , S OE DISEA ES THE VULVA . 5 9

" the visual demonstration i s the most impressive

to the patient, and then, of course, internal treatment

should be instituted .

E R CZE V R U .

Remember that there are tw o varieties : verruca

vulgaris , or common wart ; and verruca acuminata ,

r l o venereal wart . The vulgaris usua ly is not ten

It r der and Often appears in groups . may o may not be pedunculated and is attached usually by a

broad base .

' Remember that verrucae acuminata are cauliﬂower

r e w a t excrescences . They g very rapidly and may

tain the size Of a ﬁst . Remember that the color will depend o n their vas

cula rit f If y and the condition O the epidermis . the C epidermis is present the surface is dry, and the olor

that Of the surrounding skin or mucosa . When the

epidermis is removed by secretion or maceration ,

- they are deep red or purplish , and the discharge

f . purulent , Of ensive , and highly irritating Remember that they may be found any place on the vulva , around the anus , and on the inner surfaces

Of the thighs . Wh en they are large they interfere with walking and coitus . Remember that in Ol d women they may undergo malignant degeneration or become gangrenous and cause death . Remember that the discharge is virulent and may 60 S OE GOLDEN RULE GYNECOLOGY .

o o r cause purulent phthalmia, following labor , may

o r cause urethritis in male, produce general seps is in the patient . Tr m n — — ea t e t GE N E RAL s In some cas es there is an impairment Of the general system ; especially in

i strumous or anem c children, it will be necessary to

a nd fo l administer a general tonic hematonic . The

: i lowing are recommended arsenic, m neral acids ,

co d— iron, bitter tonics , and liver Oil .

f v Tincture o thuja m ( t . i . tincture Of iodin

x m , twice daily are considered to have a more or less speciﬁc action upon warts . LOCAL — Th e common wart is best treated by ex cising with a pair Of scissors and cauterizing the

o r . base with phenol , the actual cautery Venereal warts require the vaginal discharges r e moved by daily antiseptic douches .

N i i i f . T ext is exc s on , possible , Of the growth his may be done under local anesthesia if growths are

tOO i S not extens ve , when a general anesthetic hould be given . The wound Should be cauterized and dress ed with antiseptic powder , such as calomel or equal parts of

o r bismuth subnitrate and prepared chalk , equal parts o f calomel and salicylic acid .

L OR S ADHESIONS OF THE C IT I .

Remember that the folds Of the nymphae may b e come adherent as a result Of irritating discharges , inﬂammation, and uncleanliness .

OE O 62 GOLDEN RULES GYNECOL GY .

nd S i a if she has to be a sexual lave , without shar ng

in its blessings , it is only considered that it is as it should be ; notwithstanding the fact that Sh e is well

developed , capable Of bearing children, and that there is no reason why she should not be able to p roperly perform the sexual act I Trea tment — Rememb er that the only treatment is

the separation Of the adhesions by blunt dissection . It is very difﬁcult to break up these adhesions in

a satisfactory way, in young girls at least , without l If a genera anesthetic . the patient is a married

i i t woman and can tolerate a little pa n, may be done by cocainizing the parts well with 1 0 per cent cocain

solution, but it is not a very pleasant procedure for

any woman ; hence a general anesthetic is preferable . T horoughly expose the glands , cleanse the parts ,

and smear the raw : surfaces with 2 per cent car

bo lize d r zinc oxid o vaselin . b th e The prepuce should be pushed ack daily, and Ointment applied until there is no longer any danger

o f f the formation o adhesions .

A E ONS OF THE B A DH SI LA I .

Remember that this occurs more frequently in in

fancy, childhood, senility, and the unmarried .

It m ae usually occurs between the ny ph , but the

labia majora, in rare instances , may be united .

s Remember that inﬂammation, irritating di m charges , and uncleanliness are the ost common

causes . E 63 DISEASES O THE VULVA .

Remember that there m ay be all variations from the cementing Of the nymphae by abnormal dis charges to a ﬁrm organic union due to the de struc

a nd so m etim e s . tion Of tissue , it is congenital

' Remember that the pa tient complains Of irritation and o n urination the stream may be deﬂected up

ﬂo w ward . The menstrual may be retained in the f C vagina o r be discharged with di ﬁculty . oitus is impossible o r may be partly accomplished through

the urethra ; and if adhesions take place when a o w man is in the pregnant state , the adhesions will f form an Obstruction to the delivery O the child . Trea tmenu— Where the labia are simply glued to gether they should be forcibly separated with the thumbs , a vaginal do uche given , and the labia kept apart with a pledget Of cotton covered with phenol

e T — a at d vaselin, and a compress with a b andage p plied . The dressing should be changed daily for a

o r n week te days . Where adhesions have become organized or when

to the condition is congenital , it will be necessary do a cutting operation . If there is a partial opening , a grooved director

o is passed into the vagina , being careful to g below the urethra , and the labia are divided with a scalpel along the line o f false union .

When no opening is present , and it can be deter

b ' mined that the closure has been caused y adhesions , the urethra is kept o ut Of the way by a sound . The parts are put upon the stretch by lateral pressure 64 OE GOLDEN RULES GYNECOLOGY .

with the thumb and index ﬁnger , and an incision is made with a scalpel along the line Of adhesions .

AS ﬁ n soon as the opening will admit it , the index

’

' ger should be introduced, and the incision extended

fu o f the ll length the labia . The cut edges on each labium should no w be coapted by chromic catgut

‘ sutures . The dressing to be applied is th e s a m e as described under forcible separation .

Remember, however, that most frequently, when the labia are united and the vaginal oriﬁce is closed,

i s the condition usually congenital, with infantile

r Of o r uterus and appendages , o an absence one all

Of them . Remember that frequently this condition is not appreciated by the mother , and in rare cases by the girl , until she has some thought Of marriage . The

I o f 1 9 fo r author saw an talian girl , who applied

She treatment three weeks after marriage . had no o vagina, and efforts at sexual interc urse had dilated the urethra so that it would admit the index ﬁnger to the depth Of about an inch . If she has not had the menstrual molimen and evidence Of vaginal and uterine distention from the

i menstrual secretions , a very thorough exam nation should b e made to ascertain if she has a uterus and

so ovaries ; and if , if they are fully developed or i nfantile in type . Remember that if they are absent or rudimentary marriage should b e discouraged as well as any effort

o Th e t establish a vaginal canal . disappointment OE 65 DISEASES THE VULVA .

SO im o ssi may be great , but not nearly great as. an p ble married life o r an unsatisfactory attempt to e s

bli s o r ta h a canal , with encouragement that sooner later must be blasted .

E E H RP S . Remember that this acute inﬂammatory affection It is not contagious . is frequently found in connec tion with menstruation i n ﬂeshy or neurotic women . Keep in mind that anything causing irritation and congestion of the vulva Often causes herpes , thus , in prostitutes , pelvic diseases , and pregnancy . Remember that the eruption is preceded by ten derness , pain, burning, or itching , and in some cases , headaches , fever , and chilliness . Remember that the lesion Of herpes begins as a

i i n Si red spot , vary ng ze from a pinhead to a split l pea . These soon change to vesicles ﬁ led with a

Or clear serous seropurulent ﬂuid , with a red base , and usually arranged in groups .

Remember that the presence Of heat , moisture , and friction soon converts the vesicle into an ulcer .

T i . hese coalesce , and the d scharge becomes Offensive

th e ' v e si cl e s Remember that in eczema are smaller ,

Of S les s ﬂattened , there is more swelling the kin , and a tendency Of the disease to extend ; while in herpes the vesicles occur in successive cr Op s and are ar

in On ranged groups . They are situated an inﬂamed

s . base , and the attack i short in duration Keep in mind that chancroids give a history o f 66 GOLDE N RULE S OE GYN ECOLOGY

s l o r r er exua intercourse ﬁve six days , and neve ev t welve days , before the eruption appears . Remember that the chancroid ulcer has a punched

a i Out ppearance , the margins are underm ned, and there is the characteristic involvement of the in

- guinal lymph glands .

R S emember that chancre develops slowly, is ingle ;

Of the base is indurated , and the margins the ulcer n f in are slopi g . There is an enlargement O the

guinal glands , but they seldom suppurate .

Rein e r i mb e that the course Of herpes s short, " a re usually lasting one 0 1 two weeks . The ulcers

generally superﬁcial and rarely cause scars . Treatment — Remember that some Of these cases n eed general as well as local treatment . Th e cause should be sought and removed if possi T ble . h e digestive and urinary systems must be k ept in normal condition . During the acute stage walking or exercise o f any k ind should be forbidden .

A good general tonic should be given . The most m co monly used drugs are the mineral acids , arsenic ,

a n iron, d quinin .

Local treatment should be carefully carried out . Th e vulva and vagina should be douched once o r

twice daily with a hot lysol o r bichl o r id solution .

- A hot sitz bath is very soothing and beneﬁcial . A dry vaginal tampon should be inserted to pro

teet the vulva from uterine or vaginal discharges . After the douche the vulva should be thoroughly E E THE L 6 . DISEAS S O VU VA . 7

l a nd d . co o dried, a usting powder used Talcum, y p

ium r . d , o oxid Of zinc may be used

‘ Fo r severe cases solution Of silver nitrate , gr . x to

o r 5 j , may be painted on the vulval area involved,

2 . phenol , per cent solution in glycerin, is excellent

— A T bandage holds a compress in position .

E A ECZ M . Remember that this is a skin affection that pre sents various forms of lesions o r a combination Of them accompanied with itching, inﬁltration, and Often attended with a discharge and the formation o f scales and crusts .

i s o n Remember that the vulva particularly liable , account o f the frequency o f local and pelvic condi tions that cause chronic irritation and congestion . Remember that a diabetic urine will cause an in tense eczema , as will also the irritation produced by a vesicovaginal ﬁstula . Remember that pruritus vulvae is the most promi nent symptom, while pain and burning are Often com f plained O . E czema may be conﬁned to the labia majora , or it may extend to the mons veneris , the perineal and

o r Of . anal regions , the lower portion the abdomen Remember that the senile changes that occur at the menopause appear to predispose to eczema Of the

ae vulv , and gastrointestinal disorders and gout are strong predisposing factors . — Tre m n . at e t . Remember that the diet is important OE 68 GOLDEN RULES GYNECOLOGY .

A lcoholics , spices , and highly seasoned foods must i be forbidden . The digest ve and eliminating organs must be kept at par . Remember that certain articles Of food— such as

sh ellﬁ sh— i i pork, cheese , and have an nj ur ous effect and should be excluded .

t e Locally, cleanlines s is Of ﬁrst importance in h treatment . The scabs and scales must be thoroughly removed so that the medicament may come in con I tact with the diseased surface . nstruct the patient

ste e to p over a pan Of warm water , and using some good soap , such as sapo viridis , to wash the parts thoroughly with the hand and not to use a sponge

r Dr If o cloth . y the parts thoroughly . this fails

o r — to remove the scales crusts , a bland Oil such as

t - — Olive , co ton seed , or linseed should be applied

l o r freely, and after the sca es crusts have softened , then wash the parts .

a nd r Should the soap water agg avate the lesion, then the alkaline bath must be substituted . This consists o f one ounce Of bicarbonate o f soda in ﬁve

Of In c gallons water . acute ases this bath is very effective and should be used three or four times a da y Of ﬁfteen minutes each . In f the use o lotions distilled water should be used , S as hard water irrita tes the parts . edative and as tringent lotions are Often useful and are applied bv means Of lint compresses which are held in position T -b l with a andage . Lead water and audanum allay E itching and burning . qual parts Of glycerin, lime

0 OE 7 GOLDEN RULES GYNECOLOGY .

u chronic condition , as t berculosis , diabetes , or ma lignant disease . Remember that the s urface is covered with Slightly elevated , whitish spots that have a tendency to

a nd s e . coalesce eventually leave a mall , painless ulc r

Trea men — n t t . Remember that the vulva and vagi a should be douched twice daily with an antiseptic

bi chlo rid solution, as lysol , or A 25 tampon , saturated with per cent ichthyol in glycerin , should be introduced into the vagina . Dust the vulva with a powder composed Of aristol

a b . c lomel , and su nitrate Of bismuth , equal parts T — S . eparate the labia , and apply bandage

a n When the ulcers are slow about he li g, touch

h 2 . t em with silver stick , or silver solution , per cent The patches Should be washed several times daily with peroxid Of hydrogen . The constitutional conditions should receive a p

r ri p o p a te medication .

E ER A S SIMPL D M TITI . Remember that this is frequently known to the patient as chafing and is found most Often in fleshy women . Remember that this is produced by the rubbing together Of folds Of the skin . This is especially likely tO occur where there is a leucorrheal dis charge . Remember that the local conditions vary between a simple erythema and a severe inflammation, depend DIS S OE 1 EASE THE VULVA . 7

" ing upon the severity Of the cause and the tender ” f ness O the skin . Remember that the condition gives rise to more

r o f o less burning and itching , and in severe cases there is a serous secretion, which chafes both the

o f vulva and the inner surfaces the thighs . Trea tment — Keep in mind that cleanliness is very important and the parts should be thoroughly

o r cleansed by a carbolic wash, the use Of baking

f tO . soda, a tablespoon ul a pint of water The parts should be dried , and a drying antiseptic dusting powder used . The following make good dusting

: powders boric acid , aristol , rice powder, or

R Z inci o xidi .

M a gnesii c a rbo n a ti s Ph enyl is s a licyl a tis Am yli aa 3 SS

et Misce ﬁat pulvis .

Si : D g ust freely over parts .

This washing Should be done from three to six times daily . In severe cases keep patient in bed and apply gauze soaked in calamine lotion

R Z imei o xidi Ca l a m inae p r aep a r a tae Glyce r in i Liquo r is calcis l Misce ct ﬁat otio .

Si : g Apply externally .

In cases that are requi red to be about their work , an Ointment may be used OE 7 2 GOLDEN RULES GYNECOLOGY .

R Z inci o x idi . Ph enyl is sa l i cyl a tis Adip i s lanae hydr o s i Unguenti aqu ae ro s ae

Misce et ﬁat unguentum . i t S g : Apply o parts frequently .

R Z in ci o x idi

B ism uth i sub ea r b o na tis l i Phenylis sa l icy a t s . Petrolati

Misce et ﬁat unguentum .

Sig : Apply freely to parts .

R B i sm uthi subnitra ti s

Ph enyl is s a li cyl a tis Adip is lan ae hydr o s i Unguenti z inci o x idi t Misce e ﬁat unguentum .

Si : t g Apply freely o parts .

E ELA RYSIP S .

in Remember that this is an acute , contagious

ﬂa mm a tio n Of S tr e to co ccus the skin , caused by the p c r si ela tis y p . There must be a port Of entry through a lesion , however small , and eczema , herpes , and erosions all furnish excellent conditions .

Remember that the general symptoms are chill , The o r . rapid rise Of temperature , nausea vomiting pulse is rapid , soft , but has a good volume .

Remember that locally the parts become swollen,

Of a red , shining appearance , and the margins may

fel b e u f The be t ca se o elevation above healthy skin . OF 3 DISEASES THE VULVA . 7

f line Of demarcation is sharp , but the edges O the inﬂa m m a tio n p rogress daily ; while resol ution occurs

o f a in center or Oldest part the affection . The p

o r tient complains Of pain, heat burning , and V pruritus . esicles may form over the involved

area . Remember that in severe cases abscess formation may occur , or where the edema is great gangrene may follow . Tr n — ea tme t . Remember that the treatment is both local and general .

— Th a GENERAL . e bowels should be moved with c

h r i t a t c o r enema Of water and glycerin .

Where the patient is robust , calomel , followed by

Of . saline , should be the cathartic choice

In V i weak , asthenic cases olent purging does harm

de r e ssm by further p g the vital powers , and the enema Of glycerin and water should be used .

The patient should be conﬁned in bed , and the use o f a bedpan is important , so that the inﬂamed area

n o t will be mechanically injured by friction . Remember that it is important that the patient ’ s

' strength and v ita lity sho uld be conserved by every f means , and stimulants used freely when needed . O the stimulants none are better than strychnin or whiskey given to full effect . The fever should be controlled by the ice cap and E . o r sponging ither water , water and alcohol or vinegar, may be used Rememb er that under no conditions should anti 7 4 OE GOLDEN RULES GYNECOLOGY .

c u i pyreti drugs be sed, because of. their depress ng

effect o n the heart .

Pilocarpin hydrochlorate hypodermatically, gr . to may be used to great advantage in strong h healthy subjects . When used it s ould be early in

the disease . \ " uinin hydrochlorid in two -grain doses every

Of three hours is beneﬁcial , because its power in

small doses Of stimulating the leucocytes , but the

s massive doses hould never be used . Tincture o f the chlorid Of iron has been thought to be very beneﬁcial L —A OCAL . good warm antiseptic douche for the

vulva and vagina is indicated . 1 2 Lysol , to per cent , corrosive sublimate solu

tion o r phenol solution are all good .

The parts should be dried , when either Of the fol lowing may be applied : Crede’ s Ointment rubbed thoroughly into the in

o r ﬂamed area ; equal parts Of ichthyol , tincture Of

iodin, and glycerin painted over the area infected ; o r an Ointment composed Of equal parts Of ichthyol and lanolin may be rubbed well into the parts ; o r a hot strong lysol compress may be applied ; in all c ases a dry dressing as a covering and a T-bandage

are applied . Th e dressing should be changed twi ce daily until the inﬂammation begins to subside and desquama

‘ b enzo a ted zinc n men tion begins , when the oxid o i t t

S hould b e used . S OE 5 DISEASE THE VULVA .

Where the pain and local irritation are severe a lotion Of lead water and laudanum may be a dv a n l ta geo us y used . The hypodermic injection of bichl o rid Of mercury into the healthy skin immediately surrounding the

infe cted area may be used . The solution is in the 0 I . proportion Of 1 to 4 00 Of water . t is very painful

AG N US V I ISM . This affection is due to a hyperesthetic condition v nf Of the vul ovaginal oriﬁce , causing pai ul and spas modic contraction Of the muscles Of the ﬂoor Of the pelvis . Remember that the condition is usually foun d in I . t young, neurotic , hysterical women is frequently

caused by a carbuncle, erosion, ﬁssure, or irritable hymen . Lead poisoning and masturbation are said

to be frequent causes . Remember that the intensity of the symptoms varies . There are cases where the attempted intro duction Of a urethral catheter o r digital examination

will cause a painful spasm . Where the cause is a local lesion the convulsion

will develop slowly, and the patient locates the pain

at the site Of the lesion ; but the sensitive area grad nally extends until the entire surface Of the vulva

becomes hyperesthetic . Remember that many Of the cases suffer from neu

r a l ic g dysmenorrhea , and the bladder and rectum

eventually become irritable . 7 6 OE GOLDEN RULES GYNECOLOGY .

Treatment — Remember that the treatment Should be directed to removal Of the cause as well as fo r the f temporary relief O the symptoms . Remember that cases depending upon brutal o r ineffectual coitus present no local lesion and treat ment demands proper education in the sexual act . \ Remember that a 5 per cent Solution Of cocain a p plied o n a pledget Of cotton for a few minutes will relieve slight cases brought o n by sexual intercourse .

The application should be made just before coitus .

‘ Painting the affected parts twice a week with a 4

Of o r e per cent solution silver nitrate , the use Of r ctal

i n suppositories Of op um and bellado na , is Often bene

ﬁ cia l .

Remember that severe cases demand a more o r less radical procedure . Two methods may be em

to : . o r ployed advantage viz , forcible dilatation ; in extreme cases incising through vaginal mucous membranes and into fascia in each lateral sulcus , producing an artiﬁcial perineal laceration, as it were .

F B — A r e ORCI LE DILATATION . general anesthetic is

o quired , and the patient is placed in the dorsal p i i n s t o . , with the knees ﬂexed on the abdomen

No w , by using the thumb , the vaginal entrance is If thoroughly stretched . the cases require it , a ’ Sims glass vaginal plug may be introduced tO pre vent contraction ( this is rarely necessary if the stretching has been thorough ) . The patient should

fo r o r If be kept in bed a week ten days . it is found

E R CHAPT III .

A E F THE I A DISE S S O VAG N .

E A D RES A AC" UIRED ST NOSIS N AT I . Remember that stenosis means narrowing Of the vagina by cicatricial contraction ; atresia means literation Of the canal by the agglutination Of a p posed granulating surfaces . Remember that this condition may Occur at any

Of " part the vagina or may involve the entire canal . l ~ Remember that lacerations from abor , or for eign bodies— such a s b a dly ﬁtting p essaries— are frequent causes , and from any cause , if enough tis sue has been involved, may produce enough scar tissue during the healing process to cause stenosis . Remember that sometimes a faulty operative

Of o r e o f technic , in the repair lacerations , xcision

o e . labia, may narr w the vagina and caus stricture Remember that Often the sym ptoms are no t p r o no unced until there is sufﬁcient Obstruction to pre vent tii e escape o f vaginal discharges or menstrual

o r . blood , to interfere with sexual intercourse Remember that coitus is only partially interfered with when the Obstruction is situated in the upper 7 8 S OF TH E N DISEASE VAGI A . part of the vagina a nd when there is no tender ness in the parts . The Obstruction will be encountered by ‘ the ex

m inin S a g ﬁnger at the ite Of stenosis , whether near the vul v a o r high in the vagina .

I i f there is a complete stenosis of the vag na , the patient Should be exami ned by the rectoabdominal i route to ascertain the size , posit on, and condition

e o r Of the uterus and appendag s , if there is any retained menstrual ﬂuid in any part Of the canal .

If o r so , the upper part Of the vagina or uterus , h both , will be distended and ave a rather boggy feel . This ﬂuid may have partially escaped through F the allopian tubes into the peritoneal cavity, giv in r g more o less peritoneal irritation . Treatment — Do not attempt any stretching or operative work fo r this trouble with local a ne sth eﬁ A sia . general anesthetic must be given .

With the patient in the dorsal position , do not attempt much cutting , if there is stenosis , without a so und in the bladder and the ﬁnger Of the assistant

s in the rectum to use a guides , thereby protecting these organs from injury . Remember that in atresia a piece Of gauze over

ﬁnger tips will aid materially in dividing adhesions . All raw surfaces should be covered as much a s pos

sible , and if this cannot be completely done, the daily application o f carbolized vaselin must be em ployed to prevent the raw surfaces from agglutina ting . 80 N OE GOLDE RULES GYNECOLOGY .

DO not leave ragged adhesive bands ; they should

to be cut close the vaginal wall , and a suture placed c t a ross o cover raw edges . Bear in mind that sutures should be placed in the

long axis o r parallel with the vagina ; if introduced

transversely, particularly if considerable sewing is dOne n n , they have a te dency to arrow the canal .

Remember that , if there has been much deep scar

it to ring, will be impossible stretch this tough ﬁbrous tissue and -it may become necessary to make

’ several deep parallel incisions ; the mucosa should be dissected loose from the deeper tissues to allow

the cut : mucous surfaces tO be reunited by sutures as

far as possible ; the mucosa, even if thick and

Of made up largely scar tissue , will allow Of con

sider l All a b e stretching . bleeding surfaces and

s points in the deeper tissues mu t be controlled ﬁrst ,

to a and ﬁnally, it may become necessary use glass o r rubber plug to keep the parts dilated to a suf

ﬁ cien t caliber until healing has been perfect . Acquired stenosis must not be confounded with the congenital variety, referred to in a previous I 62 A s C . chapter ( dhesion Of the Labia , hap , page ) where the tr ouble is due largely to a lack Of develop ment instead Of a diseased o r pathological condi tion Remember that these patients suffer much pain fo r the ﬁrst three or four days and will require

a s . opiates , etc . , indicated There will be some vag if inal discharge , which must be kept clean, a E 81 DISEASES O THE VAGINA .

p lug is used that will have to be removed daily .

o r fo rm a lde Saline douches , , if there is some Odor ,

° hyd douches (33 Of formaldehyd to Oiv Of warm water) should be used once o r twice daily .

E ND E C OCELE CYSTOCEL A R T . Remember that lacerations Of the peritoneum may destroy the retaining power Of the pelvic ﬂoor ; there will be a gradual prolapse Of the anterior and p o s

If o f teri o r vaginal walls . it is the anterior vaginal

a wall containing the bladder , it is known s anterior colpocele or cystocele ; if it is Of the posterior vagi

o r nal wall , it is known as posterior colpocele rec

l e A l e ' o th to ce . s ru b a , are found prolapsed in some degree in the same individual .

a nd ‘ o s Keep in mind that, with a deep anterior p terio r f laceration, the daily e forts and straining at stool and micturition will eventually force the p o s terio r wall Of the bladder and the anterior wall Of

o ut the rectum , until they present as pouches with

a f r the vagin l mucous membrane o a covering . Remember that this is a condition found in the woman who has borne children . It is always associated with prolapse Of the uterus

Or in the second third degree , but remember that we

o r o r o may have cystocele rectocele , b th , without the uterine prolapse . There may be considerable sagging Of the bladder

-deﬁ ne d without any well symptoms ; but as a rule , there is more or less vesical irritation from the great 82 OE GOLDEN RULES GYNECOLOGY .

effort o r inability to entirely empty the bladder ; the .

to exa urine has travel up hill , as it were , and in g gerated cases the patient will be obliged to take her hands and elevate the bladder into the vagina in

order to expel the urine . Keep i n mind that in this class Of cases there will w al ays be residual urine , which becomes alkaline in

ra t Of e ction, loaded with sedimen , and is the cause

i i much vesical rr tation . While t here should be no difﬁculty in maki ng a

diagnosis Of cystocele, yet it is well to remember that if there is bulging Of any character from the vagina the patient will speak Of the condition as " ” Of m falling the womb , and while there may be so e

degree Of prolapse , yet the protruding tumor is in r r eality the bladde .

Remember that, if there be a doubt , a curved

be sound may be introduced, when the end will found

tO th e o u ch travel to the lowest point of p , where it can be plainly felt through the tissues with the ﬁ n r ge s . Remember that the vagina may be ﬁlled with ma sterile water , when the tumor y be Observed as it enlarges and diminishes in size when the water is

syphoned away . in Remember that a vaginal hernia , if it contains

o n testine , is tympanitic percussion, gives the char a cteri sti c impulses on coughing , and when returned A the bladder will be found not displ aced . sound may be introduced into the bladder while the tumor DISEASES OE THE VAGINA 83

s h a s i down, when it will be found that it no con

ne cti o n with the bladder . Remember that vaginal tumors do no t vary in size o r n impulse upo coughing , straining, or ﬁlling of the bladder ; they are stationary and cannot be returned , as can hernia or prolapse Of the bladder . Remember that cystocele and rectocele usually o c

: . a n cur together and are due to the same cause viz , terio r and posterior perineal lacerations . Sympto ms — Remember that with the general loss o f f tone , with sagging o practically all the pelvic viscera , there will be a feeling Of fulness and weight in the pelvis ; legs and back tire and ache . Consti p a tio n and difﬁculty in defecation— the force Of the bowel contents— cause the anteri or rectal wall to

o ut bulge Of vagina , and this has to be held back with the hand or ﬁn gers Of the patient to make A defecation possible . utointoxication follows con sti a tio n p , gastrointestinal disturbances , and head aches . Dia no sis — g . The diagnosis Of rectocele is not a fﬁ m di cult matter . With the un istakable perineal

o f laceration in view , there is more or less bulging the posterior vaginal wall ; by introducing the index

ﬁnger into the rectum , it can be hooked around , and the end brought into the vaginal pouch , revealing a relaxed anterior rectal wall with the tissue very thin between the ﬁnger in rectum and the other hand with which the pouch can be held . Treatment — Remember that the treatment for 4 N S OE GOLDE RULE GYNECOLOGY .

cystocele or rectocele must always be radical if a cure is desired ; local palliative treatment consists o f a neffort to keep the parts as well up as possible and by symptomatic treatment to make the patient as

nearly comfortable as possible .

These patients wear pessaries with difﬁculty ; they ar e f to very di ﬁcult retain, and if large enough to

remain within the vagina , produce pressure pain and

i Often ncrease the bladder symptoms . If - — the uterus is prolapsed, a cup and stem pessary w ith an elastic T-bandage may be tolerated and worn w ith some degree Of relief .

o r Tampons Of iodin and glycerin, tannic acid and

glycerin, help to relieve congestion, and by the as tringent effect help to retain the bladder within the

pelvis . Remember that some beneﬁt may be derived from wearing clothing that does no t cause constriction

around the waist ; to keep Off feet as . much as po s si

a a t ble and only do very light work , if ny all ; the

bowels should be moved daily with salines , and the bladder emptied every four to six hours : Remember that any other internal treatment can only be Of beneﬁt to relieve distressing symptoms as

they arise .

R AL M — hen f r e ADIC TREAT ENT . W there is su ﬁcient laxation and prolapse Of the anterior vaginal wall Of to require operation, this should be taken care at the same time that the posterior perineal tear is

repaired .

OE 6 GOLDEN RULES GYNECOLOGY .

is Simpl e and can be d one in ﬁfteen o r twenty min

utes ; there is no destruction of tissue . Either a la teral incision along skin and mucous

o r - membrane line , antero posterior incision may be h made . By blunt lateral dissection t e anterior edges Of the levator ani muscles may be felt and caught " with small tenaculum forceps . The two edges are brought together and held by two catgut sutures

l t tO o n proper y placed , so as not o impinge O much

the vaginal oriﬁce ; the lower suture should catch N some Of the ﬁbers Of the sphincter ani . ext , the

fascia is closed with chromic catgut , and ﬁnally, the

superﬁcial opening closed with the same suture . The author n o w puts in two rather deep silkworm e gut sutures , after all the tissu s have been closed to re -enforce the catgut sutures ; these are removed in

about ten or twelve days .

Remember that , if the cystocele and rectocele were very troublesome , and particularly if there was some

i uterine prolapse , the anterior and posterior per neal f repair may not be su ﬁcient to give perfect relief, and if the uterus pushes down very hard will ﬁnally force its way to the vulva . In these cases a combined laparotomy should be

o ut done , and the uterus raised Of the pelvis and held in place by some operation of shortening the round ligaments . The author prefers the Crossen

- modiﬁcation Of the Gilliam Ferguson operation . The posterior wall Of the bladder being attached to the uterus , the anterior wall Of the rectum, as well , OE 87 DISEASES THE VAGINA .

t is a tached to the uterus behind ; hence , when the

i s i uterus ra sed by shortening the round ligaments , the bladder and rectum are also raised and held in place .

No w remember that, if the vaginal prolapse is very great and the uterus presents itself outside

Of the vulva, the additional operation shortening f the round ligaments will not be su ﬁcient . The se women have given birth to several children and are

- usually near or past the child bearing period .

Remember , then, that in these extreme cases a

E re more radical procedure is necessary . xcellent sults are Obtained by raising the uterus out Of the pelvis into the ab dominal wound, closing the peri to nea l opening above and below, and sewing the sides to the uterus ; the muscle and fascia are also brought around the uterus in the same manner . The point o f thus ﬁxing the abdominal wall to the

Of uterus depends upon the degree relaxation , and the uterus may be raised o r lowered to suit the case A before it is ﬁnally ﬁxed . fter the skin has been closed , the fundus rests in the fat between the skin

Of and fascia . This precludes any further danger prolapse .

E N A H R I .

Remember that a vaginal hernia starts either b e hind Or in front of the broad ligaments . When it starts behind it begins in the cul-de-sac Of Douglas and descends between the rectum and vagina ; then, 88 OE GOLDEN RULES GYNECOLOGY .

n Of separati g the ﬁbers the levator ani muscle , it appears either at th e posterior part of the labium

r f o . S majus , in the perineum tarting in front O the broad lig ament , it pushes the vesicouterine peri to nea l o fold d wn between the vagina and bladder , and appears at the posterior part Of the labium m ajus . Remember that if located in the anterior or pos terio r wall Of the vagina the size Of the tumor in

o n n creases coughing or strai ing . Remember the gurgling sound so characteristic Of the replacement Of the contents Of a hernial sac into the abdomen . Remember that cyst Of the vulvovaginal g land o r tumor Of the labium is smooth and ﬁrm , and does

n o r to not disappear o pressure , is it inﬂuenced as

i r s ze by coughing o straining . Remember that a hernia has a doughy feel to the examining ﬁnger and is tympanitic on percussion .

Tr a tmen — Of e t . Remember that the reduction the hernia is easily accomplished by ﬁrs t emptying the l bladder and rectum, then p acing the patient in

- the knee chest position, and making steady pressure upon the tumor until the contents Of the sac slip back . Remember that a hard-rubber ring pessary large enough to distend the canal may be used to control the hernia . The ring should be as large as can be inserted and Should be carried well up into the fo r

i nices , the ring surrounding the cervix uter . E 89 DISEASES O THE VAGINA .

Treatment o f Vagino labial Hernia — Remember that this variety Of hernia occurs more frequently anteriorly to the broad ligament than it does pos

erio rl It t y. can usually be replaced with the patient

- x str a n u in the knee chest position, e cept in case Of g lation . The operative treatment is practically the same as for hernia elsewhere . VAGINAL ROUTE — If the vagina is room y and the surgeoncan demonstrate to his satisfaction that he can reach and approximate the tissues , this route

i i may be chosen . The overlying tissues are nc sed It and dissected away until the sac is isolated . should be Opened , and the contents well returned ; after which the sac should be loosened from the fascia , surplus cut off and closed . Then the fascia is

Of . closed outside sac , and ﬁnally the vaginal opening D a ng ers — Great care must be exercised SO as no t to injure the bladder ; great difﬁculty may be en co un ter ed in keeping back abdominal contents while sew ing up peritoneum ; great caution must be exercised during the entire operation lest the bladder is pune tur e d by the needle .

Remember that , if there is strangulation , the vagi l na route is out Of the question . ABDOM INAL ROUTE — This is by far preferable to

n the vaginal route . Here o e can get all the tissues o ut Of the way and protect the bladder , closing the h t ernial opening , and hen inverting and closing the peritoneal opening after the excess o f sac has been ff trimmed O . 0 OE GOLDEN RULES GYNECOLOGY .

VA N GI ITIS .

Remember that inﬂammation Of the vagina is nearly always associated with and is frequently the l I cause Of vu vitis . t can usually be traced to some infection \ R emember that, while the normal acid secretion

' Of the vagina is a germicide under ordinary condi

o f tions , yet , in cases pelvic tumors , displacements , o r i i f nﬂammation Of any port on O the genital tract , there will be sufﬁcient alteration o f the vaginal se

" cretion to overcome its germicidal action .

Remember that this is also true in anemia , tuber cul o sis, o r any o f the debilitating diseases when r e sista n c e generally is below par . Simple vaginitis means an irritation and conges tion (which has not quite reached the point o f in

ﬂa m m a tio n ) Of the vaginal mucous membrane , with

No an increase Of the mucous secretion . doubt these cases o w e their origin to the debilitating diseases just mentioned , and the tre a tment must be general as well as local; and direc ted to remove the cause . Remember that while this is a case Of simple vaginitis the patient is n o t proof against infection .

In fact, it is quite the reverse ; with her entire sys tem debilitated from disease , her resistance lowered , and the vaginal mucous membrane i rritated and congested , a severe infection might ensue .

e Remember that in the large cities at least , g nor rhea is doubtless responsible for the greatest num OE DISEASES THE VAGINA . 91

ber ; but remember that unsterilized instruments

o r - used by examiner , a douche nozzle that has been

used by another person, may carry the gonococci ,

o r streptococci , staphylococci , the colon bacilli into

‘ the vagina ; pessaries that are not sterile Or are poorly ﬁtting may produce an irritation ; o r the use o f the various antiseptic tablets fo r the prevention

Of pregnancy may be responsible . Remember that uterine discharges from acute sep tic endometritis will cause vaginitis ; this rarely o c It e curs from a chronic discharge . should be rem m bered, however , that , when a patient with a chronic discharge is conﬁned in bed from any cause , a cleans ing douche should be given once daily ; otherwise the discharges will be retained in the vagina , where they decompose and cause irritation . Remember that frequent sexual intercourse o r a great disproportion between the male and female is sometimes responsible for vaginitis . Remember that at ﬁrst the vaginal walls are red and hot from acute congestion . Remember that early in the disease there is but little discharge but later the parts may become bathed in serum and pus .

. Remember that in neglected gonorrheal vaginitis the discharges are so irritating that there will be found a large area around the vulva extending out o n the thighs and down around the anus , where the

i ﬁSsur es skin will be red and edematous . Pa nful

nd o r a erosions follow, , from continued irritation 92 OF GOLDEN RULES , GYNECOLOGY .

and stimulation Of the skin, numerous papillary growths develop .

Remember that in the acute cases pain is severe , particularly upon manipulation , and if there is also

f o r fo r vulvitis , it is sometimes di ﬁcult impossible

r o the patient to walk o t be on her feet . Rememb er that in chronic vaginitis the discharges e u p rsist , loaded with epitheli m , exfoliated from the vaginal walls . This leaves the papillae exposed and

o n swollen , account Of denudation Of their epithelial covering , giving a rough feeling , or the condition known as granular vaginitis . Sympto ms — The patients have ﬁrs t a feeling or

Of a sensation heat and dryness in the vagina , with slight itching at the vulvar outlet h Remember that , as a rule , t ese patients do not S manifest any general ystemic reaction , although it stands to reason that there is some inclination to mf febrile disturbance ; the greatest disco ort , no

Of doubt , is the sensation fulness and heat communi

a ed t A c t o the rectum and bladder . frequent desire to urinate may be felt .

Remember that the discharge is not great , and sometimes absent , in the beginning ; however , after

b . a few days , it ecomes profuse and purulent Diagno sis — Examine the external urinary meatus which is Often visibly affected and bathed in pus ;

so . if , it may be gonorrheal infection Remember that all vaginal discharges should be f submitted to a pathologist o r examination .

4 OE 9 GOLDEN RULES GYNECOLOGY .

Remember that if the vagina and vulva a re tOO sensitive to admit the use of a speculum hot douches must be relied upon until the acute symptoms sub

o r side the tissues become more tolerant . Remember that constipation contributes to pelvic congestion and salines should be administered as

Often as indicated . Keep in mind the beneﬁts derived from drinking

Of a plenty w ter, and this is especially true when h there is urethral o r bladder complications . W en there i s considerable vesical disturbance use Oil Of

W 1 0 o r intergreen, minims , four ﬁve times daily ; tincture Of belladonna i n 5 -minim doses relieves vesicle irritation . When astringent powders are used instead Of the

o r solutions , boric acid , zinc oxid , calomel , tannin

‘ are the best . Half an ounce Of powder should be

~ in placed in the vaginal vault , and a dry tampon serted to hold it there .

ULAR G N S GRAN VA I ITI .

Remember that this is the most frequent form Of vaginitis and the granular appearance Of the m u cous membrane i s due to the inﬂammatory conges tion Of the papillae . Remember that thi s form may result from Si mple o r gonorrheal vaginitis . Remember that the patient complains Of tender ness with a feeling Of pelvic fulness and a muco t purulen discharge . OE 5 DISEASES THE VAGINA .

Remember that pruritus vulvae is a more o r less constant symptom and eczematous eruption may o c n cur On the exter al genitalia . Remember that the diagnosis is made by insp ec tion Of the vagi nal canal and this is best done with

— the patient in the knee ches t position . Remember that this condition occurs sometimes duri ng pregnancy and at its termination will disa p pear . Treatment — Remember that the bowels should

' il be kept open with a m d laxative . The vagina should be douched daily with a gallon

ho t t Of salt solu ion, followed by a half gallon Of bichl o rid solution o r a gallon Of hot lysol 2 solution, per cent , may be used . When an astringent is needed nothing is better than a 5 per cent solution Of silver nitrate painted over the granulations . A tampon saturated with a 25 p er cent solution

3 b o ro l cerid Of argyrol , protargol per cent , or g y , should be introduced and remain for twenty-four hours . Sometimes the application o f sulphate Of copper

(gr . xxx to 3j) to the granulations will hasten a cure .

SE LE A N S NI V GI ITI . Remember that this is the change brought on by Old age and is found in women who have passed the menopause .

Remember that the symptoms are , as a rule , not 96 S OE GOLDEN RULE GYNECOLOGY .

pronounced . The patients complain Of a thin leu co rrh e a l discharge , usually not profuse , and occa si na ll bl OOd o y streaked with . Remember that this discharge may be very irri tating to the external genitalia and cause a pruritus o r severe burning s ensation . Remember that inspection reveals a mucous mem b rane that is smooth , atrophied, and covered with a

-S scanty secretion . Various ized spots Of ecchymosis and superﬁcial ulcerations are found scattered over the surface . Remember that adhesions are formed from co n

" o r tact between ulcerated surfaces and the vault, even the canal may be obliterated in this mann er Tr m —If d ea t ent . the con ition causes no annoy ance to the patient , no treatment is needed, except a daily cleansing douche .

When the ulcers are present and painful , they should be painted with a 5 per cent solution of silver

A : o ne nitrate . hot antiseptic douche of gallon f 2 should be taken daily . This may consist o a per

o r bi chl o r id cent lysol solution , Where adhesions do no t interfere with secretions and are Old and dense , they should be let alone . A When recent , they are easily broken up . tampon upon which some Ointment has been spread should

E : be inserted . ither Of the following may b e used

to 3 vaselin, zinc oxid Ointment , which is added per

a d cent phenol . This prevents the reforming Of the h esio ns . OE 97 DISEASES THE VAGINA .

Y C STS . Remember that cysts are the most common form

o f neoplasms found in the vagina . While they

r are found usually in the anterior o pos terior wall , they will be found occasionally in other portions Of

A s the canal . a rule , they occur singly, and they

r g e w very slowly and require years to develop . Remember that the cyst is round and Ci rcum t scribed, as a rule, bu exceptionally it may be

- pear shaped and have a pedicle . Remember that if inﬂammation has not occurred the cyst is freely movable beneath the mucous mem brane . Remember that the symptoms vary with the size

and location Of the cyst . Thus it may press upon the urethra and interfere with the voiding Of the

o r urine , by pressure upon the bladder wall lessen its capacity, and thus cause frequent micturition . Remember that a cyst pressing upon the rectum causes a feeling Of weight in the pelvis and produces

constipation and hemorrhoids . It may be so located as to interfere with sexual intercourse by obstructing the entrance Of the penis . Remember that a very important feature in diag nosis is to demonstrate that the tumor is movable x and not ﬁ ed to the wall Of the vagina . This is done by grasping the enlargement with the ﬁngers a nd making traction in different directions in order to

demonstrate by touch its connections . 98 OE GOLDEN RULES GYNECOLOGY .

Remember that the combined rectovaginal touch If must be used if the cyst is on the posterior wall .

o n the cyst is the anterior wall , a sound may be pass ed into the bladder ; and with the exami ning ﬁ nger in the vagina counterpressure is made , and its connection established . Remember that a cyst located high near the cervix requires a general anesthetic , when the examining ﬁnger in the vagina may be met by counterpressure

' o v er th e m abdomen just above the sy physis .

Remember that the cyst is tense , elastic , and is F usually circumscribed . luctuation can be detected in a large cyst . Remember that a cystocele is always loc ated a n terio rly and increases in size by ﬁlli ng the bladder o r in straining and in coughing , and disappears in the recumbent position . Remember that a rectocele is always located pos terio rl n o n y, increases in size O coughing , disappears

s pres sure, and i only in the walls Of the vagina and rectum between the examining ﬁnger in the vagina and the one in the rectum . Treatment — Remember that the treatment is a l ways surgical and consists in removal Of the entire sac . This is best accomplished with the patient under a general anesthetic .

' CANCER OF THE VAGINA

Remember that it is rarely primary ; it is nearly a l It ways secondary to cancer Of the cervix . may be OE 99 DISEASES THE VAGINA .

Of o r secondary to cancer bladder , urethra , vulva , rectum . Remember that the cancer spreads rapidly by lymphatics and inﬁltration Of the surrounding tis sues . Remember that hemorrhage and discharge are the characteristic symptoms . Remember that in the beginning the hemorrhage is slight and may be ﬁrst noticed after sexual inter

b e course or defecation, but that the hemorrhage comes more severe until eventually there is contin uo u s loss of blood . Remember that the discharge is watery and Of

a nd f t fensive early, but as ulceration loss O issue occur the discharge becomes bloody ; pieces Of tis sue , pus , feces , and urine are found in it , and the

Odor is fetid . Remember that pain is not an early symptom and may be absent throughout the course of the disease .

o r When present it is felt in rectum, bladder , pelvis , along the sciatic nerves .

Of Remember that the cancerous cachexia , loss weight , and other constitutional symptoms found in m alignancy elsewhere , are present , but occur late in the disease . Remember that a specimen o f the tissues should

' a a th o l o ist be sent to p g early in the disease , if there

Of is any question doubt , for microscopic examina tion to determine if the growth is malignant, whether carcinoma or sarcoma . 00 OE GOLDEN RULES GYNECOLOGY .

NO physician at the present time should delay a diagnosis waiting for clinical symptoms to complete f the picture Of malignancy, because the hope O the patient rests o n a very early diagnosis and the co m

l ete a p er dication Of the trouble . Treatment — Remember that primary cancer Of the vagina is rather rare , and when such a condition is recognized , early and complete extirpation before it has spread to adjacent organs o r involved th e lym

h a ti cs p is indicated . DO no t depend entirely upon the clean sweep with the knife around this dangerous growth ; use the actual cautery over the edges and base after the

f He growth has been removed . a t has a retrograde inﬂuence upon the cancer cell and is one Of the best agents we have at the present time , at least in cancer o f the vagina and cervix . NO effort should be made to close or approximate the edges after cauterization unless there is an ex

ma tensive surface uncovered , when it y become nec

tO l ea v m essary close the edges , g room for drainage between the stitches . This must b e watched with the greatest care , and any evidence of return should

call fo r another application Of the cautery .

N RR EA GO O H .

Gonorrheal infection Of the female genital organs has reached a Stage where it is almost a universal

calamity . It is such a common disease that it is regarded as

1 02 OE GOLDEN RULES GYNECOLOGY .

and he should give a favorable report before the h patient is disc arged . N o t until then can we hope to control and prevent the sprea d Of this terrible disease Remember that gonorrhea is an inﬂammation Of the

genital organs due to the gonococcus infection, and

r i that , as a ule , it ﬁrst attacks the vag nal mucous

— e membrane except in children , where it usually b gins as a vulvitis— and the exterior mucous mem

brane Of the cervix ; it soon extends to the vulva and .

urethra and may reach the bladder ; if not checked, it to Of will extend the cervical canal , cavity the F i uterus , allop an tubes , and pelvic peritoneum . Remember that it is usually communicated from

o n e to person another through sexual intercourse , although it may be communicated through the use Of an infected towel or closet seat— such an explana tion may be regarded with a little suspicion . We have known it to be transmitted from o n e woman to another by the promiscuous use Of a douche -noz z l e . How children become infected is Often a matter

NO Of much speculation . doubt it is most frequently caused by close proximity with adults in sleeping in

o r the same bed , the handling bathing Of genitals by nurse or mother who herself has gonorrhea , and whose ﬁngers are contaminated by the germs .

A Of b to little girl , eight years age, was rought o ur clinic by her mother fo r what proved to be a S S OE 1 03 DI EASE THE VAGINA . gonorrheal vulvitis ; when the inﬂammation began the child complained to her mother that her father

(a drunkard) had been playing with her genitals ; when he saw the condition Of his child he became frightened and ran away ; examination Of the mother

a reve led that she also had gonorrhea . It is well to remember that gonorrhea in chil dren is usually conﬁned to the vulva and urethra ; consequently with appropriate treatment a perfect

i cure may result without deeper nvolvement . Sympto ms — Remember that in the newly married woman o r girl there will be felt some irritation about the urethra and vulva a few days after intercourse .

Urination becomes painful , being attended with

In u b e smarting and burning . a few days the v lva

Of a t comes bathed with the discharge pus , which is tended with considerable discomfort and distress in both the vagina and vulva ; the vaginal mucous membrane will be found tO be swollen and rather o tender , and c mmunicating to the examining ﬁnger a feeling Of heat and roughness ; if the urethra is pressed upon through the anterior vaginal wall , pus will Often exude from the external meatus . Remember that gonorrheal pus has a yellow ish color during the acute stage and that the cloth ing will bear the yellowish stain ; in chronic go no r rhea this is not always the case . Remember that in th e acute stage there will be a frequent desire to urinate and that urination will be 1 04 OE GOLDEN RULES GYNECOLOGY .

m acco panied by , pain and smarting , the discharge will be profuse , the external genitals will be red and swollen . Dia gno sis — No w keep in mind that gonorrhea in woman is one Of the most serious infections that she may have and that a correct diagnosis is necessary, so that proper treatment may be instituted for a cure and to prevent complications if possible . Remember that vulvitis and vaginitis from any

d so other infection, except gonorrheal , are sel om I acute ri ght from the onset . t reaches its height in a week or ten days , and then, as a rule , begins to

i h a s subside ; the urethra is always nvolved , and it been claimed that infection Of the vulvovaginal glands makes the diagnosis Of go norrhea almost cer i ta n .

However , remember that inﬂammation of the vul v o v a ina l e infec g glands. may take plac from other tions . - Remember that in ‘ vaginitis from any other cause there i s i n all probability a history Of some infection

o r : . opportunity for infection e g , abortion, labor , o r instrumental manipulation . DO no t be decei ved into thinking that because the inﬂammation is not s evere that it may not be go no r rheal . Remember that gonorrheal attacks vary in sever ity ; in the young woman it may be severe ; in the woman wh o has borne children a nd who has been subject tO other Onslaughts there is a more tolerant

1 06 G OE OLDEN RULES GYNECOLOGY .

o f no if the vagina is the seat inﬂammation, t to med

o f dle with the interior the cervical canal , lest the i nf ection, which by natural selection has a tendency to penetrate deeper, is forced into the cervix against r the natu al defense . Remember that the cervix furnishes a considera ble amount o f resistance against the entrance of l irr e i . u nfection The canal is usual y contracted , g

Of s lar on its surface , and closed by a plug mucu .

Th e in more patulous the cervix, the more readily fectio n may enter ; hence after parturition, abortion, o r just following the menstrual period are favorable times for extension . Remember that in the girl o r young woman whose hymen is no t ruptured it is possible to keep the in fectio n conﬁned to the vulva and effect a cure with o ut further extension .

Do not advise vaginal douches in these cases .

Th e u doctor himself sho ld , if possible , see and treat these cases daily ; th e vulva Should be thor o ughly cleansed ( a bichl o rid solution may A h be used) with plain warm water . fter whic an application Of some Of the : various go no co ccicide s

A 1 0 to 25 may be used . rgyrol in a per cent solu tion does well in some ; this is particularly useful in the urinary meatus after the pus has been thor ut oughly cleaned o ; avoid the meatus , however , dur ing the acute stage . Protargol 4 o r 5 per cent and silver nitrate 2 to 4 per cent have given us the best results , and unless OE 1 07 DISEASES THE VAGINA . used strong enough tO burn have no Objectionable If features . the patient is a child, instruct mother o r nec e s nurse , or if a grown woman teach her the sity Of constantly wearing a sanitary gauze pad held T- with a bandage . This should be changed as Often as it becomes soiled . The patient should have a 1 Of dusting powder for this pad , zinc stearate , boracic acid , or borated talcum powder, which keeps the parts moderately dry, and prevents irritation . DO not let the patient come to your Office during the acute period if it is possible for her to stay at home . Remember that rest in bed at this time is a very n important part Of the treatment . Walki g causes friction and more irritation Of the inﬂamed parts . If the discharge is copious the patient may bathe

o r herself two three times daily with a weak , warm

f bi chl ri solution o o d . If there is urethral inﬂammation with a frequent

o il Oil o f desire to urinate , urotropin , santal , or win

r te gr een may be us ed to advantage . We have found the following prescription useful :

R Tinctures belladonnas

S dii nz i o b e o a t s .

Olei gaultheri as ( true ) Fl uidextra cti tritici E lix ir i s aromatici

Misce .

Si : T 2 3 4 . g Shake . easpoonful in water every , , or hours

Remember if the vagina is infected that p ra cti cally the same treatment may be followed, except ’ 1 08 OE GOLDEN RULES GYNECOLOGY .

o that , in connection with the external d uching , a vaginal douche should be taken every four to six hours during the acute period . Be careful in a dv is in i chl r g b o id douches , lest they may be used too strong . Remember th at it is safer to have a bichl o rid SO

e luti n made up for the patient , with directions to

' uSe tO ua rts o f a teaspoonful two q warm water, than

ichl o rid to trust her with b tablets .

DO no t bi chl o rid . advise douches taken several times daily . Once daily of a weak solution is enough . The other douches might be made with 5 j

Of Of zinc sulphate to two quarts water . Boracic

5 o r acid j to two quarts Of water , saline solution, f may be su ﬁcient for cleansing purposes , with the o n i hl r e douche daily o f the b c o id solution . Remember that as the symptoms begin to subside the treatment should be less vigorous .

' DO not fail to emphasize at any time the danger Of carrying the infection to others and the very great nf danger Of eye i ection . After three or four weeks Of treatment the patient

. DO may be apparently well not, however , dis charge her as well without making several micro E scopic examinations Of the secretions . ven if these examinations are negative , the patient should be kept under observation fo r several weeks o r months for the appearance Of unfavorable symp toms . Remember that the day of serum and v accine

1 1 0 OE GOLDEN RULES GYNECOLOGY .

’ ducts Of the vulvovaginal glands and Skene s ducts; an effort must be made to penetrate them with the

o no o ccicid If g c e used . the vulvovaginal glands sup

ur a te p , they have to be enucleated, or incised , and

the walls curetted away, after which the cavity is packed with gauze and allowed to heal by granula A tion . general anesthetic is required . \ Remember that if the wall Of the gland is no t thoroughly removed a suppurating sinus may r e

a main, requiring subsequent operation . A thor ough application Of equal parts Of carbolic acid and tincture Of iodin to the cavity after curettage is

r e splendid treatment . The packing should be

moved every other day, and new packing replaced . An occas ional stimulating application of tincture o f iodin to the closing cavity is good practice .

Let it be emphasized that, during this treatment, the gonorrheal vaccine should be administered every

to ﬁve seven days .

No w n , if the uterine discharge persists , and if upo careful bimanual examination no tubal involvement i s tO found, something must be done facilitate cer vical and uterine drainage , and save if possible the extension tO the F a llopian tubes and peritoneum .

Keep in mind that in such a case , if it cannot be

o r . cured , it will extend sooner later

U i S nder an anesthetic , the cerv x hould be well dilated, and the cavity Of the uterus thoroughly l c eansed by careful curettage, after which the whole surface should receive an application Of equal parts OE 1 1 1 DISEASES THE VAGINA .

Of carbolic acid and tincture Of iodin . A tape Of iodoform is passed into the uterus to favor drainage and to prevent a too rapid contraction o f the cervix .

r This is removed in two o three days . The treat ment should be followed by ho t douches to prevent an acute inﬂammation . AP ER CH T IV.

SEASE S F THE ER DI O UT US .

PO E ST RIOR DISPLACEMENT . Remember that the uterus lies between the bladder and rectum above the vagina and below the a b

o mi na l d cavity . Remember that the long axis Of the uterus forms

i a right angle with the long axis Of the vag na .

Remember that , normally, the uterus is slightly

t ﬂ x d \ a e e e . a n n , with the concavity forward The terio r surface rests upon the bladder , while the cervix points backward toward the coccyx .

Remember that, normally, the uterus is freely movable ; that a full bladder pushes it backward , or forward by a full rectum ; that it moves up and down with respiration .

e Rememb r that the pressure from above , normally, is exerted o n the fundus and the posterior portion Of h t e uterus .

Remember that , normally the abdominal viscera exert their pressure upon the posterior surface , thus forcing the uterus forward upon the bladder . Remember that the question Of displacement Often

Of becomes important in medicolegal affairs , because 1 1 2

OE 1 14 GOLDEN RULES GYNECOLOGY .

e miscarriage, is a very frequent cause Of displac ment .

n S Remember that tight abdomi al binders , or trictly conﬁning the patient to the dorsal position, will

Often cause a retroversion . Remember that nervous symptoms frequently o c r m cur, and neu asthenia is the most co mon . There i s a o f x tired feeling and an utter lack desire to exert o neself . Remember that sterility i s common in retro dis t placement, due to the complica ing endometritis and

o f the malposition the cervix, thus interfering with c the entran e Of the spermatozoa . Remember that it is only by a physical exa mi In nation that a diagnosis can be made . making a

f c bimanual examination, the position o the ervix will be an indication Of the position o f the uterine If b . ody the cervix lies in its normal position , point ing downward and backward toward the second

is to sacral vertebra , the body Of the uterus likely

r n eﬁex d be in its normal pos ition o a t e . Remember that no clinical syndrome will e nable

v a you to make a diagnosis , because Of the great ria tio ns i n i ntensity and character , and it is only by a physical examination that the condition may be diagnosed . Remember that a physical exami nation is made with the patient in the dorsal position, the index ﬁnger Of the left hand being introduced into the Th de vagina . e position Of the cervix is ﬁrst OE 1 1 5 DISEASES THE UTERUS .

ned termi , whether lower in the vagina than normal , and pointing forward instead Of backward toward

‘ the coccyx .

f N r The next step is the locating O the fundus . o mally it is found anteriorly, and it should be sought for in this locality . Push the index ﬁnger into the

— — Of anterior cul de sac the vagina, and at the same time make counterpressure o n the abdominal wall imm ediately above the symphysis . pubis with the

ﬁngers Of the free hand . The fundus can be easily felt between the ﬁngers Of the two hands , if it is in its normal position .

If no t un the uterus be fo d anteriorly, it should be sought fo r posteriorly by carrying the internal finger up into the posterior cul-de-sac ; at the same time counterpressure is made upon the abdominal wall by pushing the structures down along the curve of the f sacrum by the fingers O the external hand . The fundus may thus be caught between the fingers Of the two hands and recognized by its outline . With continued counterpressure with the external hand the tip Of the internal fin ger is passed slowly over the posterior surface o f the uterus from the fundus If to the cervix . the cervix and the fundus lie in a straight line , then the uterus is retroverted ; but

he r r o ﬂexed should the line convex, then it is a et uterus . Remember that in a r etr o ﬂexio n the cervical canal may point in the normal direction but the fundus is bent backward SO that the fundus and the cervix are 1 1 6 N OE GOLDE RULES GYNECOLOGY .

connected by a curved line whose concavity points

downward . Remember that a retrodisplacement m ust be dif fer entia te d from a ﬁbroid o n the posterior uterine

wall . This is readily done by locati ng the fundus

anteriorly and the cervix, normal in position in

case of ﬁbroid . \Remember that a tub e —ovarian mass lying behind the uterus is differentiated by the clinical history and by passing th e uterine sound and demonstrating i the pos tion of the uterus with reference to the mass . Remember that the determination Of the location Of the uterine fundus is always the most important differential point in diagnosticating uterine displace

ments .

Treatment — f . Remember that the length o time

displacement has existed is Of great importance ,

' because in a displacement exi sting for o ne year o r more the tissue changes in the uterine support are permanent and palliative treatment will accomplish

nothing . Remember that in treating recent cases the follow ing must be considered :

1 o f . . Removal the cause

2 . . Replacement Of the uterus

3 o . . Retaining the uterus in normal p sition stimu 4 . Reduction Of the size Of the uterus and f lation o its ligaments .

5 o f n . . Regulation hygie e and general treatment Remember that the removal Of the cause fr e

1 1 8 S OE GOLDEN RULE GYNECOLOGY .

m e the best ethod , becaus when the vagina walls a re

separated air rushes in and balloons out the vagina, which causes the uterus to gravitate to its normal

position . Remember that the bladder and rectum should be nd empty a the clothing loosened .

‘ Th e - patient is placed in the knee chest position, \ a s e culum p introduced into the vagina , and the per

ineum fo r well retracted, when the uterus will drop in S ward tO the normal position . hould the uterus no t o f fall forward at once , the anterior lip the cer V i x should be caught with a forceps and pulled fo r ward se that the uterus will swing clear o f the sacral

promontory . Remember that any o r all these methods will be ineffectual if the uterus is bound down by adhe sions ; sometimes the uterus itself may be free from adhesions and can be more o r less perfectly brought

to a nteﬂex ed forward its normal position , but owing

o r n in to prolapsed tubes ovaries , bound dow by

ﬂa m m a to r to y adhesions , the uterus will drop back

the posterior cul ~ de-sac soon after being released by

r the hands , o when the patient changes her position

— from the knee chest to the dorsal o r upright . A ball Of absorbent cotton held in grasp Of dress ing forceps may be passed into the posterior fornix

and against the posterior uterine wall , and pressed upward while the cervix is pulled down to ward the

vaginal outlet . OE S 1 1 9 DISEASES THE UTERU .

e n Remember that the uterus , aft r bei g replaced , must be held in position for a variable time , and this is accomplished by the use Of the pessary . Remember that a pessary must ﬁt properly or it

mf F o r w . ill be har ul instance , if it holds the uterus

o r a bove below its normal level , it Obstructs the circulation and causes p elvic c ongestion . This trouble may be overcome by changing t h e length

i A and angle Of the poster or curve . long, sharp curve holds the uterus higher than a Short and less

. Or s acute , as the pessary i supported in front by the pubic rami , if the anterior curve is such that the pressure falls upon the neck Of the bladder o r the urethra, it must be changed . Remember that a properly ﬁtting pessary causes no pain and does not interfere with sexual inter course D ’ l on t neg ect a warm soapsuds douche weekly, but

s never use salt olution , as it causes incrustations to form o n the pessary a nd by irritation o f the parts D ’ causes inflammation . on t neglect a weekly ex mi a nation in case Of pregnancy, and at the begin ning Of the fourth month the pessary should be re moved . Don ’ t neglect to examine the patient in the erect position after introducing a pessary, to determine ’ r fin whether o not it fits properly . The examiner s gers should pass between the vagina and the p es - - b sary at all points , the posterior cul de sac should e 2 OE 1 0 GOLDEN RULES GYNECOLOGY .

f taut , and the respiratory movement O the uterus

should be felt . Remember that the method Of introducing the pes sary is as follows : The patient is placed in the dOr sal position ; with the thumb and index finger Of the left hand separate the labia ; the pessary is held by the anterior bar between the thumb and index finger f " t O the right hand, and the pos erior bar is inserted in th e transverse diameter Of the vagina ; push the pessary downward and backward along the pelvic curve until the posterior bar lies close against the N fin anterior cervical lip . o w introduce the index ger Of the left hand into the vagi na below the a n terio r bar of the pessary until it presses against the

i posterior bar . The poster or bar is then pushed downward and backward until it is pressed behind

the cervix . Remember that a routine course Of treatment should be followed to cure the subi nvolution Of the

pelvic organs . This is best carried out by the use Of a vaginal douche Of hot water and the intr o duc tion every other day Of a tampon Of cotton—wool Sa t ura ted with a 25 per cent solution of ichthyol in glycerin . A good general tonic should be administered , and

the clothing kept loose . The patient should take light outdoor exercise . The fo ll o wm g is probably the best depletory that It can be applied to the vaginal vault . causes no

It s pain and is antiseptic . i made as follows

1 22 OE C GOLDE N RULES GYNE OLOGY .

the abdomen is Opened, but all may be accomplished n with o e anesthetic . Remember that the operation will probably be the best that utilizes the proximal part Of the ligaments for suppo rt because Of its greater strength .

Remember that , whatever be the Operation se l ected , it should pull the uterus forward and upward a nd a nd hold it ﬁrmly in position , at the same time be capable o f allowing for the increase in size duri ng pregnancy .

A PROL PSE OF THE UTERUS .

" ” Remember that procidentia uteri o r prolapse o f the uterus is a condition in which the uterus is

o d It i s f un below the normal level in the pelvis . " frequently spoken Of by the laity a s falling Of the ” womb . Remember that this condition is the ﬁrst step that occurs in retro disp l a cem ents ; hence the same causes are found in both . Remember that the extent Of the prolapse deter in mi nes the symptoms . The clinical manifestation e h : lt ludes t e following symptoms Backache , fe usually i n the lumbosacral region a nd made worse

o r e o n by standing walking , but usually r lieved lying

Th e - w down . pain is dragging or bearing do n in character and may radiate down the thighs . Remember that the bladder always accompanies f the uterine descent , because o its ﬁrm attachment

fo r to the cervix . This makes it impossible the blad S OE S 23 DI EASES THE UTERU .

der to completely empty itself , and the residual urine

undergoes decomposition, producing cystitis . Remember that as the uterus descends it drags

down the anterior rectal wall , producing a rectocele , and this gives rise to the rectal symptoms Of difﬁcult a defecation, chronic constip tion , and hemorrhoids . Remember that the patient usually says that the

o r womb is low , drops completely outside , and upon

x e amination, the vaginal opening and all the uterine supports are gre a tly relaxed— the uterus can ea sily

a be pushed out with the examining hands . The p tient herself can force it well out by straining Remember that all women regard the upright p o Si tiou fo r examination as vul gar and extremely em barr a ssin a n g , and should not be pr cticed, u less it is necessary. Remember that the index ﬁnger Of the left hand

should be introduced into the vagina , and the posi

If l o tion Of the cervix determined . found w and pointing forward in the direction Of the long axis f Of the vagina , it may prove to be a prolapse o the w ﬁrst degree . The tip Of the left ﬁnger should no

‘ " a a i st th e to h be placed g n cervix steady it, and wit the right-hand palpation Of the lower abdomen the position Of the fundus will be found to be lower in

r dis l a d R ret e . the pelvis than normal , and o p c e member that in inversion Of the uterus there is a distinct ring completely around the protruding mass

formed by the cervix , while the Opening into the cer

vix cannot be demonstrated . S OE 1 24 GOLDEN RULE GYNECOLOGY .

Remember that in prolapse , unless complete , the fundus uteri can be located by bimanual examina tion and the opening of the cervical canal can be easily seen . Remember that in cervical polypus the uterus is found in its normal position, and a sound may be passed into the uterine cavity .

\ ' Remember that all cases Of prolapse Sh o uld be a ex mined bimanually, because the uterus may be forced out o f the pelvis by a tumor o r by ascites .

Treatmen — t . Remember the ﬁrst s tep in the treat ment is a reduction Of the prolapse : the uterus should be grasped between the thumb and ﬁngers , and steady pressure i s made in the axis of the vagi nal canal . When the uterus returns to the normal position , the patient should then be placed in the k - S ’ nee chest posture , a ims speculum introduced , and the vagina packed with a wool tampon saturated

o r l cer id to with b o g y . This is allowed remain in

fo r — place forty eight hours , and the patient should rem ain in bed three or four days in order that the congestion and edema Of the uterus may be relieved . When the edema is pronounced it may be im p o s f sible to return the uterus . The foot O the bed

— should be elevated , and glycerin and ice water com presses applied to the uterus ; should this fail , then

i multiple incisions Of the cerv x should be made . Remember that the application Of vaselin to the vaginal walls before attempting replacement o f the uterus by taxis is of advantage .

1 26 OE GOLDEN RULES GYNECOLOGY .

Under the ﬁrst class there are two methods tend ing to correct the pathological condition 1 r d . The fastening Of the fundus uteri forwa d an upward by o ne Of the various methods Of Shorten f ing the round ligaments , and the integrity o the

ﬂOOr pelvic restored by surgical p rocedure .

2 i . Ra sing the uterus high and suturing the fundus directly into the abdominal wall , with restoration

Of pelvic ﬂoor . Under the second group come the hysterectomy f and the high ﬁxation o the cervical stump .

E N F TH E INV RSIO O E UT RUS . Remember that the uterus may be partially or completely turned inside o ut. Remember that the cervix is dilated by the in version and forms a callus around the inverted body, and by the contraction Of the circular muscular ﬁbers interferes with the replacement Of the inverted body . Remember that the condition occurs in labor dur

o r ing after the third stage , or is caused by the weight o f a polypoid tumor growing from the fun dus . Remember that traction o n the cord i n attempt i ng to bring away the placenta during labor is very likely to result in inversion Remember that the symptoms depend upon the rapidity Of the inversion , and those cases occurring during labor usually occur rapidly . The patient OE S 1 27 DISEASES THE UTERU .

c complains Of severe pelvi pain , followed quickly by

S profuse hemorrhage and hock . Remember that when the condition occurs in the non-gravid uterus the displacement develops Slowly

and has somewhat a chronic course . There will be

Of hemorrhage, continuous with the daily loss a

Of small quantity blood, and this eventually pro

duces marked anemia and general debility . There will also be leucorrhea, Often purulent and Offensive , suggesting malignancy . Remember that these patients complain o f drag ging pain in the pelvis with pressure upon the rec tum and bladder . Remember that a physical examination reveals a

a - a nd pe r shaped tumor , soft , constricted above by

o r — a rim callus this is the cervix uteri .

o f The surface the tumor is vascular , and the pla centa may or may not be attached .

Remember that rectal touch , combined with pres

re sure upon the abdominal wall above the pubis , veals the absence Of the uterus . Treatment — Remember that the uterus should be

Th e replaced at once in acute cases . patient is anesthetized , placed in the dorsal position , and the reduction made by the hand . Remember that instrumental replacement is no t indicated in acute cases . Remember that the technic Of the procedure is as follows : Form a cone with the ﬁngers o f the left

hand , introduced into the vagina and pressed against 28 S OE GOLDEN RULE GYNECOLOGY .

the inverted fundus , while the ﬁngers Of the other hand make a counterpre ssure from above through

th e If the abdominal wall upon cervical callus . the manipulations are successful , the fundus passes slowly back through the cervical rim .

' A fter the replacement is accomplished, the left hand is kept in the uterine cavity until a douche of tw o gallons Of hot saline solution is given to stim u late contraction . S hould rapid reduction fail , then the slow method

a Of vaginal tamponing must be resorted to . The p

b ed tient must be kept in , and every other day the vagi na i s thoroughly packed with gauze ; o r a grad ual reduction m a y be accomplished bv the use Of u ’ Bra n s colpeurynter , using either air or water to distend the rubber bag Remember that if all efforts fail to reduce the uterus the pos terior lip Of the cervix may be split . This operation relieves the constriction and gives A more space to restore the displaced organ . fter re placement the i nci si on Should be closed by inter r u ted p sutures .

a m When reduction by any method is impossible , putation Of the uterus should be done . This is best accomplished as follows :

1 Of . Seize the inverted fundus with a pair forceps and make strong traction . 2 . The cervix is now grasped by four forceps and pulled down into the vulvar opening .

3 i Of . The fundus is caught by an additional pa r

1 30 N R L S OE N E O GOLDE U E GY C LOGY .

not only destroys the uterus , but cripples and o c cludes F the allopian tubes as well . But it does seem that Nature has intended that the uterus Should

Ma n o perform a given amount Of work . y it t be possible that during this wonderful process of fecun dation and gestation that a certain amount Of some N thing ( say energy) is expended, which, when ature i s d r cheate in her process , is utilized o expended in the formation o f these new growths " Remember that the portion Of the uterus above the internal OS is the part principally concerned in

ﬁ r o id gestation . While b s may be found in the cer vix, yet they are more frequently found above the internal O S .

ﬁbr o ids Keep in mind that are benign, though they r may undergo va ious secondary changes . Remember that they may atrophy at the meno

Or d Of pause , become calciﬁe from the deposit lime

D o f — salts . ilatation the lymph spaces and cyst formations may take place . Remember that submucous ﬁbr o ids may become pedunculated and form what are known as uterine f polypi ; this variety may become in ected, and sup

ra ti p u o n takes place . Remember also that malig nant changes occur in the ﬁbroid, and we have car cine m a to u s and sarcomatous degeneration . i Remember that all ﬁb ro ds are not large , and that they vary in size from a small shot to enormous tu mors weighing several pounds . OF R S 1 31 DISEASES THE UTE U .

e Si Remember that th y may occur ngly, but that

they are usually multiple . Remember that ﬁbro ids caus e a general muscular

Of Of in hypertrophy the walls the uterus , and this

creased weight causes uterine displacement . Remember that large abdominal ﬁb ro ids may

S cause cardiac hypertrophy Of the left ide , and eventually fatty degeneration . The liver may also undergo fatty degeneration .

to o ﬁb r o ids Remember , , that uterine may undergo various degenerative changes . Remember that hemorrhage is a very common symptom and Should always arouse suspicion . Usually there is an increase in the amount and dura tion of the menstrual ﬂow . Remember that the character and location of the tumor will determine the amount and duration Of the A bleeding . polypus generally causes constant bleeding , as well as an increase Of the menstrual

flow . Submucous and interstitial fibr o ids are usually accompanied by menorrhagia ; the subserous and intraligamentous fib ro ids have little if any in

ﬂuence upon menstruation .

Of Clinically we speak them as subserous , inter stitia l E r e , submucous , and intraligamentous : w e quently have all varieties in the same case . Remember that the subserous ﬁb r o ids are under the peritoneum covering the uterus and are found from the size Of a small shot to that Of an enormous 32 N OE 1 GOLDE RULES GYNECOLOGY .

growth ; they have various shapes and occur from

to a single tumor a multiplicity in numbers . The fundus may attain the size Of a three o r four ’ d months pregnant uterus , entirely free from a h e sio ns with the whole surface of the fundus or . t tumor perfectly smooth , and without the his ory, o ne might have considerable difﬁculty in making a d o f . iagnosis , which would b e in favor pregnancy

Remember , however, that , as a rule , these women

menstruate regularly, and quite profusely, although n this is o t invariably the case . They have no other evidences Of pregnancy except the symmetrical en If largement Of the uterus . more convincing proof

to is necessary, then you will be able ascertain from

r A the history o a careful examination . uterine

sound may be used .

R tOO emember , , that in a case of interstitial ﬁb r o ids Of the uterus the early symptoms are rarely so severe that o ne cannot well afford to wait a few

months if there is a ny question in the diagnosis .

to Remember that there is little, if anything , sug gest the development Of uterine ﬁbro ids early in

their growth . There may be a slight hyperemia or

congestion of the pelvic organs , enough perhaps to

produce increased menstrual ﬂow (menorrhagia) .

to o o r Remember, , that there may may not be

no t sterility . Women, as a rule , do call upon the physician for examination and advice concerning their pelvic organs until they are forced to do so

for relief of t heir pain .

1 34 OE GOLDEN RULES GYNECOLOGY .

Remember that these exaggerated cases rarely

give any trouble , so far as making a diagnosis is concerned ; but remember also that should there be Only o ne subserous tumor that does not attain a very ’ e great size , say no larger than a hen s gg , and if that

should be located posteriorly or laterally, and if the

patient is a ﬂeshy woman, positive diagnosis may be f S q uite di ﬁcult , ometimes impossible .

' Remember that in s uch a case we shall h a v e to differentiate between a displacement Of the uterine

r fundus , cyst , or solid tumor Of the ovary, o a broad ligament tumor .

Remember that it is quite possible, in fact it is not

fo r t uncommon, pregnancy o coexist with uterine

ﬁbr m o a .

Remember that we may be ignorant o f the fact that there is a coexisting pregnancy at all and a t

Of Or the time operation discover it . we may have positive knowledge Of a coexisting pregnancy with

1 11 rapidly developing uterine ﬁbroid , due to the creased blood supply during the pregnant state . Remember that in the latter case we have a grave question to decide : o ne that deserves o ur most care

no w ful and honest consideration, because there are

o n o ur tw o lives that are at stake , and all depends advice . Remember that she has sought relief for the rap idly developing tumors which are now producing

o r . serious pressure symptoms , reﬂex disturbances Keep in mind that she may have been married fo r S S S OF S 1 35 DI EA E THE UTERU .

a long time and that this is her ﬁrst pregnancy, and

that she is anxious for an heir . Remember that as gestation advances the ﬁbr o ids

increase greatly in size, and after a while it becomes evident that delivery by the natural route is going l to be extremely difﬁcult and perhaps impossib e . The pain and gastric disturbances are becoming a l i most unbearable , and in all probab lity, she cannot

tolerate her distress until full term . Remember that you have here to consider the wel

fare of both the child and the mother, and undoubt

’ edly the mother s chances for recovery should b e

considered ﬁrst .

s m Remember that , where it is possible to treat y p to m a tica lly and carry a patient like this along until

o r o r the sixth seventh month , later if possible , then

performing a quick supravaginal hysterectomy, hav

ing an incubator handy in which to place the child, the chances may be very good for both mother and

child .

Remember that , even as early as the ﬁfth month , a supravaginal hysterectomy has been done and the

a S1 de tumor laid for several minutes , after which the uterus was opened and a live fetus found , which

fo r was resuscitated , and lived several hours , even

o f 1 ncub a to r If without the use the . proper ar

rangements had been made for an incubator , no doubt this child could have been saved ; at least if a rapid Cesarian section had been performed and fo l

lowed by a supravaginal hysterectomy. S OF 1 36 GOLDEN RULE GYNECOLOGY .

Remember that o ne of the greatest reasons fo r mortality in Cesarian section is that the case has usually been in labor forty—eight hours or more with forceps applied , with considerable local damage to

a nd . the uterus , with an exhausted patient This patient would have little Show for life in any opera tion .

e -deﬁned Remember, th n, that there are no well early symptoms o f uterine ﬁbroid except in the sub mucous variety, where there may be a menorrhagia, and later a metrorrhagia .

co n Keep in mind that, as these tumors develop , f gestion o the pelvic organs increases . Remember that the menopause does ~ not always bring relief from atrophy, as we would hope . Remember also that very frequently in these cases

1 s the menopause is indeﬁnitely delayed , the ﬂow n constant (metrorrhagia) , and accompa ied with much pain ( dysmenorrhea) Remember that the patients are usually sterile m e . and if they beco pregnant , they frequently abort Remember that if congestion and engorgement

ﬁbr o ids continue the develop rapidly, and we must anticipate trouble .

Keep in mind the close proximity of the bladder ,

n urethra , ureters , pelvic vessels , and erves , and the effect of direct pressure which is responsible fo r nu m er o u s complications . Keep in mind that anterior and posterior displace

1 38 S OF G GOLDEN RULE YNECOLOGY . there will be exacerbations of acute symptoms o f in fectio n occurring at frequent intervals . Treatmen — t . ﬁbr o ids Remember that, if the are

’ quite small , and produce no symptoms , and espe cia ll y if near the menopause, they should be let a lone .

— Remember that in a woman, near full term preg n r i ancy, o perhaps dur ng delivery, a ﬁbroid as large

' as a walnut may be felt on the fundus o f the uterus .

T S e his hould not necessitate operative interfer nce , as in all probability this tumor will disappear as the uterus undergoes involution . Do not undertake palliative treatment by local medication with any hope to yourself o r to the p a tient that you will effect a cure in ﬁbr o ids that are producing symptoms o f a ny character .

o u Remember that, if you do , y will fail , and your patient as well as yourself will be greatly disa p pointed . Keep in mind that local treatment is only o f bene

ﬁt for cleansing purposes , and the temporary control o f hemorrhage . Remembe r that the r emoval o f the polypus pre senting through the cervix gives temporary relief

Do from pain and hemorrhage . not promise perma nent relief from this , if the fundus is also nodular .

Remember that curettage is not curative , and is

‘ sometimes followed by sloughing of th e ﬁbroid tu m o r ns to deal , which gives us dangerous complicatio with . OF S 1 39 DISEASES THE UTERU .

Remember that myomectomy may be safely done

ﬁbro ids where the are purely subserous , and in many f o these , operation is not necessary .

‘ Remember that where there is a mi xture of tu - mors , which is so often the case ( some deep seated

S o ut intramural ) , and when these are helled , it necessarily leaves a much-weakened wall of the uterus at that point which Is In danger, should preg nancy subsequently occur . Remember that there is o ne very important thing fo r us to consider, and which will become very plain to us after incising a uterus that has been removed fo r ﬁb ro ids : that is , the great possibility of overlook ing some o f the new and smaller ﬁb r o ids within the u terine wall , which means further trouble , and per haps another operation for our patient .

e o f R member, however , that the plan treatment may be greatly modiﬁed by the age and wishes o f the patient .

Remember and always discuss with the patient ,

o f and her husband , the possibility and advisability

- - child bearing, if she is in the child bearing period f b life . Keep in mind that if the ﬁbr o ids are numerous a nd large , and we have reason to believe that the

o f function the uterus is beyond hope , myomectomy

o f is entirely out the question , and hysterectomy should be done . e Rem mber that , when it comes to a matter of hys terecto m o f a b y for the cure uterine fibroids , the 1 40 OF GOLDEN RULES GYNECOLOGY.

do m ina l route is by far the best and safest , and can T h be done in less time . e argument that the vagi

1 W l ll nal route s safer not hold good . f Remember that , if the tumors are o any co nsid era bl e S ize , the vaginal route is entirely out of the

An o f question . operator skill can do an abdom inal operation in less time, complete the work to hi s a o f h em o r entire satisf ction , with much less fear ’ rha e g following , and his patient s convalescence will be just as short . If the cervix is large and hard , a complete (pan M hysterectomy) hysterectomy Should be done . any o f - a these patients remain semi invalids , after supravaginal hysterectomy, owing to the fact that n they have a large , heavy cervix remai ing , which T will not atrophy . hey have a constant , copious leucorrhea , and often bloody discharges almost equal to a menstruation .

o r Remember that , whether the cervix is removed not , the vagina may and should be raised , by ﬁxing

o f h the stumps t e broad ligaments at this point , after which the wh o le is covered entirely by peri

ne m n o u . a t This raises the vagina , keeping the ter io r and posterior walls o f the vagina from sag

o f ging , and adds materially to the success the O n a d peratio , n to the future comfort of the patient , the end desired by both the patient and the surgeon . E Remember that delay is dangerous . arly opera to tion , under proper conditions , means small risk the patient , while late operatio n means great risk .

1 42 GO N S OF LDE RULE GYNECOLOGY .

Remember that frequently glandular hyperplastic

a endometritis , associated with free hemorrhage and

‘ watery discharge following repeated curettage , should demand a miscr o sco p ic examination of the scrapings and the uterus extirpated if it is found to be malignant .

f fo llo wm Remember that a show o blood g coitus ,

o r r straining at stool , walking, any active exe cise

1 s usually the ﬁrst evidence noticed . Remember tha t the presence of a Slight watery d ischarge , even though odorless , is very suggestive , ut b if the discharge has a foul odor, the evidence of cancer is very strong Remember that the following p o m ts differentiate carcinoma from sloughing submucous myoma 1 . Cancer causes cachexia , hemorrhage , and very d foul ischarge . 2 Th e . . sloughing tissues are very friable

3 . E i pithel al proliferation seen by microscope . Remember that in case o f retained placenta there will be history o f recent pregnancy ; the scrapings

o f o f are composed myriads long , slender threads ; and the microscope Shows products of conception . Remember that tuberculosis o f the endometrium presents a mucosa that at ﬁrst is smooth , yellowish

- white , and glistening , later becomes yellowish white with nodules both o n the surface and below the sur f o . s face the endometrium These nodule , undergo a s c eous degeneration . S S OF T T S 43 DI EA ES HE U ERU .

Remember that the tuberculin test in the cutane o us reaction will greatly assist in determining the f presence o a tubercular infection . Never omi t the submission o f scrapings from the mucosa o r a piece excised from the cervix to a com

mi i petent croscopist for exam nation, to furnish the

ﬁnal evidence o f malignancy .

— Treatment . Remember that treatment is radical when all the cancer can be removed ; hence the great importance of an early di agnosis . Palliative treat ment is to be followed only when it is impossible to remove all the malignant growth . When the blad der and rectum are involved , the vagina invaded, or

- when the uterus is ﬁxed, hysterectomy is extra dan

ero us g and useless . Remember that the cancer may extend through

o r the bladder, rectal , uterine walls , and that great

to care must be used avoid opening the bladder,

o r bowel , peritoneum .

In he inoperable cases , thorough cauterization is t best treatment today.

This is accomplished with the cautery, either

Pa uelin o r - o r . q galvanic , the red hot iron The sear ing of the exposed surface must be thorough to o b tain the most beneﬁt . The cautery should be reap plied with the return of pain or hemorrhage . Remember that the general treatment consists o f

o f good tonic , plenty good food , light exercise . The b u owels m st be kept open and the kidneys active . 144 OF GOLDEN RULES GYNECOLOGY .

D a aily cle nsing douches , and an occasional applica

i o tion of astr ngents t the cavity, such as acetone or f tincture o iodin . Remember that hysterectomy is indicated if

Th e m m etri 1 . uterus is normally movable and sy cal . 2 The . uterus is not excessively enlarged . 3 . The iliac and lumbar lymphatic glands are not f e . nlarged, and this is di ﬁcult to determine

4 . The vaginal wall is not Involved . Remember that vaginal hysterectomy is not the ’ o f bes t procedure , because the operator s inability to remove all cancerous tissue and the statistical fact that practically all have a recurrence . Remember that any operation that does not re move the parametrium IS not admissible as a cura

i tive operation for cervical carc noma . Remember that in the inoperable cases the hem o rrh a ge and discharges must be checked and this is best accomplished by sharp curettage o f the ul

o f cerating surface the cancerous growth , followed by the application o f the cautery as previously stated.

SARCOMA .

R but emember that sarcoma is usually primary, rarely, it may be secondary, and then it generally starts in one o f the ovaries and extends to the uterus b v continuity . Remember that age is not so important a factor

146 OF G GOLDEN RULES YNECOLOGY .

same as it is for cancer , with this warning : unless

all the disease can be removed, Operation will hasten death because it opens the venous channels and thus If favors metastasis . the cancer is conﬁned to the

o f cavity the uterus ( endometrium) , the prognosis

s after hy terectomy is favorable .

INF AMMATION OF THE UTER S L U .

Remember that the female g enital tract is patu

lous from the vulva to the peritoneal cavity ; it will at once emphasize the great danger of infection any

h o f w ere along the tract, and the importance proper and even drastic measures that are necessary to f check the progress o microbic invasion . Remember that if the infection reaches the peri

to neum it may cripple the woman for life , if it spares

life at all . Remember that the natural secretions o f the

vagina are acid in reaction , and possess germicidal

properties to some degree . They are no doubt able

o f to hold the fortress during time peace , but during

active inﬂamm ation due to microbic irritation , these secretions are so diluted that their germicidal action

s i greatly diminished . Remember that it is seldom that an infection of such virulence as the gonococcic stops Short o f com p l ete destruction o f the whole genital apparatus ; hence inﬂammation anywhere along the genital tract ( whether it is known to be dangerous in origin o r

not ) must be regarded with gr eat suspicion . D OF T S 1 4 ISEASES HE UTERU . 7

METRITIS .

Study the anatomy of the uterus carefully ; study it minutely, SO that it will not appear as a mere hol low thing with a lining called the endometrium . m n Happily for women, the once popular ter e

o m etritis . d is not now so much abused, and with its

i o f decrease n popularity, the common use the curette as o f some years a go is almost a rare pro c edur e nowadays . Remember that an acute inﬂammation of the en do metrium alone is seldom foun d ; it no doubt occurs in the beginning of some mild inﬂamm atory proc

no t d i esses , but it is etected until the deeper t ssues o f the uterus are Involved . Remember that there are some cases of endo metritis that run a short course and recover co m

l e tel e v en p y, without treatment ; however , many of the so -called cases o f endometritis are decidedly f o a nd e . cases metritis , sometim s perimetritis m Reme ber that , in the cities at least, the most

f . common cause o metritis is gonorrhea , next sepsis T here can be no doubt that , in years gone by , when the uterine sound was commonly used without any thought of asepsis and without the use o f a vaginal

i speculum, infection was frequently carr ed into the I uterus by the physician . t seems reasonable to sup pose that the colon bacillus was a frequent intruder then . Remember that inf ection in the uterine cavity rap 1 48 N L S OF O GOLDE RU E GYNECOL GY .

- idly extends beyond it , by way of blood vessels ,

o r lymphatics , by continuity of tissue . Remember that occasionally cases of known go no r rheal infection In women do to all appearances com

l etel b e p y recover, and remain well , and they later

come mothers . It is a happy fact that puerperal sepsi s i s not so

a common as formerly, since all physici ns have a proper knowledge and regard of the necessity o f

i aseps s . But remember that it does occur , and some times when the physician has taken every precaution against it . Remember that the infection must gain entrance

o r in s ome way through the vagina , perhaps from a perineal tear . Remember that it does not conﬁne its elf to the uterine cavity o r to the uterus . The recently preg nant uterus takes up the infection rapidly, until the

- entire blood stream is virtually charged . Remember no w that this is a general and not a

so . local condition , and must be treated Remember that the onset is usually gradual ; the temperature in twenty-four hours after delivery may 9 0 100° F 9 . be to , while the pulse will range from 1 00 90 to . Da y by day, the temperature and pulse

S how a steady increase , and the general condition becomes more alarming . Remember that the abdominal tenderness is not always great ; there will be more or les s abdominal pain and rigidity with tympanitis .

5 0 OF 1 GOLDEN RULES GYNECOLOGY . every day with salines or enemata; forced feeding with nutritious food , eggs , milk , etc . Remember that when the heart begins to run rap idly and shows signs of weakening there is no tonic that equals strychnin, given hypodermatically in 1 . to e . from % 0 4 0 grain, very six to four hours The

f o f e ﬁcacy quinin in these cases is doubtful , except fo r S its light tonic effect . Remember that whiskey sometimes increases the l de irium . Phenacetin is usually condemned in i febr le conditions , but it often gives excellent remis m sions in temperature without any har whatever . It should not be given continuously, but the nurse can be given a certain mark in temperature , at which time she should give ﬁve grains o f p henacetin and o ne- o f re half grain codein . This should not be

e a ted fo r o r p then some hours , until the temperature h If a s . reached the high mark again pain is great , it may be necessary to resort to an occa sional dose o f codein or morphin .

Remember that sleep is quite necessary, and as the patients are frequently restless and nervous , it may be necessary to give the various hypnotics , with which we have had the best success . Remember that the temperature bath i s indis pensable . Remember that the curette o r ﬁnger Should be used early to ascertain if any remnants of membrane

Do are remaining in the uterus . not scrape the OF S 1 5 1 DISEASES THE UTERU .

— it Si uterus unless something is there , mply opens s new avenues for ab orption . Remember that many o f these cases die in spite D o f treatment in ten to fourteen days . o not mis

take sapremia for septicemia . Remember that in sapremia the onset is delayed ’ several days ; the patient s convalescence after con

ﬁ nem ent has been practically normal , and suddenly there is a chill a nd an elevation of temperature to 1 03 0 05 ° F or 1 . Remember that there is not a cor responding increase in the pulse rate . Remember that the patient does not seem gravely

n o r ill is there delirium . Remember that this is

- usually due to a retained blood clot or membrane , which has undergone decomposition , and the dis turb a nce is due to absorption o f the products of de composition . Remember that a saprophytic infection may b e

i come septic , by furnishing a med um for the devel o m ent - p of septic micro organisms .

- Removal of blood clots or membranes , and wash ing o ut the cavity are usually followed by recovery These may have to be repeated daily for two o r three davs .

ENDOMET ITI R S .

Remember that the starting-point o f inﬂammatory

f o f af ections the uterus is , usually, the endometrium ,

o r and may extend , eventually, to the muscular wall 5 2 OF GOLDEN RULES GYNECOLOGY .

h to the peritoneum . Thus t e uterine mucosa is the origin o f nearly all of the inﬂammatory lesions of the pelvic organs . Remember that all inﬂa m m a tio n s o f the endome trium may be divided into the infectious and non infectious . Remember that septic endometritis is nearly a l It ways found following abortion and labor . may follow insertion o f instruments into the uterine ca v

r ity o operative procedures upon the cervix . Remember that in acute endometritis there is a

o r leucorrhea, sometimes profuse , it may be thin and serous . Remember that the history of a previous opera tion on the uterus o r instrumental treatment should suggest endometritis . Remember that sterility and abortion are very — comm on in endometritis caused by the changes pro duce d in the mucosa by the disease . Remember that the general physical condition of

Sh e the patient varies . may experience no ill feel

o r o f ing , she may be hysterical , complain dyspepsia ,

o f . ﬂatulence, and loss appetite Remember that the Speculum reveals the origin o f the leucorrhea and usually the cause of the en d m etriti s o . , such as a torn cervix Remember that the gonorrheal variety of endom e tritis is due to the presence o f the gonococci in the endometrium . Remember that in the normal state the cavum

5 4 OF GOLDEN RULES GYNECOLOGY .

o r r and stenosis , lacerations of the cervix, should e ceiv e appropriate treatment . Remember that in chronic cases constitutional f measures are o more value than local treatment . Remember that in the non-i nfectious variety with a violent onset it is better to defer local treatment, in the absence of positive indications to the contrary . Remember that in chronic gonorrheal cases a curettage will be necessary and especially Should the cervical mucosa be thoroughly removed because f o the many glands contained .

r e Remember that in septic cases , where there are ta ine d membranes , the uterus should be thoroughly curetted and washed with some hot antiseptic so

‘ lutio n cr e so lis 2 o r , such as liquor per cent , a solu tion o f bichl o rid o r wiped o ut with tincture

f The S a o iodin . douche hould be given through reﬂex Irri gator unless the cervical canal be very

to o f . patulous , insure unimpeded outﬂow solution Remember that no t attempting to do to o much 10 l A cal y in septic cases will insure better results . good intrauterine douche at the time o f dilatation f and curettement is su ﬁcient, followed by hot vagi nal douches several times daily, and hot fomenta tions over the abdomen .

Th e patient should receive a good tonic treatment, N F o f . . o r elixir iron, quinin, and strychnin ( ) pep tonate of iron and manganese, quinin bisulphate gr .

ii . j, t . i . d D S OF S 1 5 5 I EASES THE UTERU .

Th e diet must be nutritious , and fever should

A a m be controlled by bath . lcoholic stimulants and monia Should be used freely In severe septic cases . Remember that Wright ’ svaccines should be tried th in general sepsis . Wh ere possible e vaccines

’ — should be from patient s germs autogenous . Remember that injection o f polyvalent serum should no t be neglected when a general s eptic con dition develops .

ENDOC RVICITIS E .

Remember that this condition i s usually sec o nda rybut may be primary . Gonorrhea is the most f frequent cause o the primary . The secondary form usually results from ‘ an extension upward from the vagina but may be caused by downward extension from the uterus . Remember that the cervical canal is especially ex posed to various forms of infection because of the anatomical relation between the cervix and vagina . A gain, the canal usually contains germs , and any

‘ co n alteration in the canal , such as traumatism or gestion, allows the bacteria to gain entrance , mul ti l p y rapidly, and become pathogenic .

o f Remember that, owing to the presence the glandular crypts that afford a lodging place and pro tectio n fﬁ s , it is very di cult to de troy an infection . Remember that the internal OS uteri offers a bar

o f rier to the passage the germs to the uterine body. 1 5 6 N OF GOLDE RULES GYNECOLOGY .

Remember that leucorrhea is often the only com plaint . The discharge is thick , clear, and tena

io us f c o . , like the white an egg

b e When the infection is pyogenic, the discharge comes opaque and creamy in color . Remember that vaginal examination reveals a

o o f patul us OS , the vaginal portion the cervix swollen, and frequently a laceration, if the patient be a multiparous woman . Treatment — Remember that cervical injury should be repaired by trachelorrhaphy o r by a m p u ta ti n o of the cervix . Remember that a thorough curettement of the s canal is trongly indicated , unless the gonococcus be U a the infecting organism . su lly the internal os f uteri is su ﬁcient , for a time at least , for preventing the involvement o f the uterine cavity in gonorrheal

a d no t endocervicitis , and c re shoul be exercised to carry the gonococci through in the treatment . The application to the canal o f a solution o f silver

S nitrate , ixty grains to the ounce , or iodin is excel lent . In gonorrhea some variety of silver salts should — 5 be used silver nitrate , protargol , per cent , or ar

o l 5 0 gy, , per cent solutions . Th e application o f phenol for o ne minute followed by alcohol gives excellent results . The vagina should be douched daily with some li 2 creso s . a ntiseptic, such as liquor comp per cent .

15 8 OF Y GOLDEN RULES GYNECOLOG .

large uterus , perhaps displaced, the depth of the cav t i y increased . The enlargement o f the uterus is symmetrical , and there is no tenderness . Treatment — Remember that there is usually an t endome ritis , as well as the enlarged uterus , to treat . Remember that when subinvolution is as sociated with either retrodisplacement or lacerated cervix o r perineum no cure can result until the associated l e sions are corrected . m Reme ber that curettement, performed as under endometritis , is indicated . The reducti on In the s ize of the uterus is a c co m

lish ed p by both general and local treatment .

O AL — A h o u S L O . gallon of t saline sol tion hould be given slowly as a douche just before going to bed .

F b e ollowing this , the vaginal fornices should packed with gauze saturated with the following

R Glyceri ni 3 Viij Ma gne s ii sulph a tis 5 v

Ph eno l is 5 S S M isce .

to r Heat until all is dissolved , being careful not add any wate .

I chthyol may be added to the above . This is an e excellent depletory, and thus reli ves the local con gestion and hastens venous circulation . Once o r twice a week half to an ounce o f blood h All from the cervix with a s arp bistoury . local treatment must be stopped during the menstruation .

A — A GENER L . nourishing and easily digested diet

should be given . OF T HE S 1 5 9 DISEASES UTERU .

f S a Plenty o pure water hould be drunk daily, s this relieves constipation . b e Should constipation exist , the bowels must

opened by use . of cathartics , and those producing watery evacuations are best . The salines are good,

mi U . ae e t . S but if ane a be present , pilul aloes ferri (

m a o n ce . P . ) y be given daily and salines a week

s Light exercise daily in the open air and unshine ,

reco m such as driving and walking, should be mended .

SU ERINVO UTION P L . m h Reme ber t at this is a rare condition, occurring more often, probably, after abortion than labor . Remember that the atrophic changes occurring in the uterus cause amenorrhea and sterility . Remember that the history of the case i s Impor tant, as it shows the patient in good health previous to her last conﬁnement and the puerperium cOm

o r . plicated by hemorrhage , septic infection Remember that examination reveals a uterus that is greatly reduced in size , and indeed it may be so reduced that nothing remains to mark its presence except a small knob in the dome o f the vaginal vault . Trea tment — Remember that the basic principle in

s treatment i to increase pelvic blood supply . This is accomplished in the following manner 1 D . ilate and curette the uterus .

~ 2 . us Warm vaginal douche night and morning , 1 60 OF GOLDEN RULES GYNECOLOGY . ing one gallon of water at temperature between 95 ° 1 02 ° F and .

3 One f . o the following drugs should be admin i ster ed : M ino xid anganese b gr . j to v thrice daily ; a piol miv to viii thrice daily ; o r potassium perman

a n a te ss g gr . to j thrice daily . 4 r . o C nstipation, when it exists , is best elieved by aloes combined with podophyllum . 5 D . aily exercise in the open air and general mas sage and electricity should beused . 6 S . exual intercours e Should be forbidden .

ACERATIONS OF THE CE VI" L R .

Remember that lacerati ons are very common and in many instances are caused by meddlesome o b

tri ste c s .

‘ o n o ne The tear may be only side , when it is

S o n poken as unilateral ; or both sides , when it is

o r o r called bilateral ; multiple stellate tears , when there are several lacerations . Remember that there are no symptoms p a th o g n o m o nic of the condition and those present are due to lesions caused by the laceration . These patients usually complain o f beari ng-down

i i pa ns in the back n the sacral region, and disturb ano es of menstruation . Remember that examination by both sight and l touch revea s the pathologic condition . Although the cervix uteri is susceptible of great

l o f distention , especial y with the bag water preced

1 62 N OF GOLDE RULES GYNECOLOGY . o n backache , feeling of fulness , dragging sensation, o r weight in the pelvis . Vesicle o r rectal symptoms may be caused by

o n An either pressure or tension their walls . irri tating salpingitis may result in closure o f the ﬁm

se fﬁ bri , or the uterine discharge may be su cient to prevent pregnancy . e Ke p in mind, then, that cervical lacerations alone do n not as a rule cause grave symptoms , but ofte a multiplicity o f symptoms arises from cervical lacera tions and the common complications . Remember that an obstetrician shoul d not dis charge his patient after she has been conﬁned, until

ex two or three months have elapsed ; then , upon amination, if he ﬁnds that the cervix is entirely healed, with perhaps only a slight depression at the

o f site the tear , he may safely discharge her , but if it is still unhealed , he should advise repair within a reasonable time . Do not content yourself with a speculum exami So nation . metimes the speculum will turn out the anterior and p o s terior lips ; when there is a bilateral laceration , this will make the cervix appear smooth and perfectly intact . M ake a digital examination ﬁrst, at which time o ne can examine the entire pelvis and see if there is any other trouble ; a laceration of the cervix can be readily felt with the examining ﬁnger . ’ Don t fail to examine with the speculum also ; that will bring into view the character o f the discharge ; SE ES F T H E U R S 1 63 DI AS O TE U .

the condition o f the cervical mucosa ; it will Show if

there is cervical hypertrophy, ulceration or erosion,

or cystic degeneration .

Remember , while examining with the speculum, that it is a splendid idea to catch the anterior and posterior lips with hooks and draw them down ; this brings to view the extent and character of the

laceration . Treatment — l Remember a ways that cancer does ,

a in many c ses , develop at the site of laceration .

' Remember that the treatment is operative ; but no t every cervical laceration needs to be operated o n . Every woman with a lacerated cervix would

o f be safer , if it were repaired, and all them bear watching . The following rules furnish a guide as to what cases to operate o n : 1 All . lacerations complicated with indurations and hypertrophy o f cervical tissues or eversion of the cervical mucosa ; cystic degeneration ; and ero sion . 2 . u Laceration ca sing subinvolution o f the uterus , m displacement , and endo etritis . 3 . Lacerations with a sensitive plug o f scar tis in f sue the angle o the wound . Remember that if there is endometritis the cav ity o f the uterus should be curetted before tear is repaired . The lips o f cervix should be caught with two for ’ ceps after a Sims perineal retractor has been in serted into the vagina . 1 64 OF E Y GOLDEN RULES GYN COLOG .

The surfaces to be denuded are marked out with a scalpel on the torn cervical margin , in such man ner that the i ncisions pass beyond the angles o f

o f laceration externally, and a strip mucous mem brane about o ne —fourth inch wide is left in the mid dle o f each lip for reconstruction of the cervical canal . The surfaces thus outlined are entirely cut o ut beyond the scar tissue . The raw surfaces are coapted and held by interrupted sutures , care being taken in inserting them no t to pass through the cer vical mucosa . Remember that it is important that all o f the scar tissue be removed , and especially that at the angle

f s o the wound . This tissue i easily recognized by touch . Remember that in multiple or stellate tears am p u ta tio n of the cervix may be indicated instead o f an r n attempt to epair , owi g to the fact that too much

s tis ue would have to be sacriﬁced , leaving a very small cervix with an uncertain cervical canal .

A h a s un gain, when the cervical mucous membrane der o ne b e g cystic degeneration, amputation may come necessary. Remember that lacerations o f the cervix should

co n not be repaired at the time of occurrence , as the dition o f the tissues following labor i s such as to pre clude f a correct determination o the tear , and there is great danger of infection .

A S in fter operation, the patient hould be kept

66 N OF 1 GOLDE RULES GYNECOLOGY . with equal parts o f tincture o f iodin and carbolic acid ; the vagina should be protected with cotton or

S gauze , and both the cervix and vagina hould be cleaned o ff immediately with alcohol o n a gauze sponge to prevent burning with the carbolic acid . No w the anterior and posterior lips o f the cervix are grasped with Single tenaculum forceps and held by an assistant, the perineum being retracted with a self-retaining retractor ; the scar tissue in each lac er a tio n d o ut is now well trimme , extending it as

A s high as necessary into each vaginal fornix . a

o ut su rule , both sides may be trimmed before any If tures are introduced . there should be severe hem o rrh a e g on account of deep excision of scar tissue , it may be necessary to sew up that side to prevent too much loss of blood before proceeding to the

It a b so lutel v f other . is necessary to have a slip o cervical mucous membrane o n both the anterior a nd posterior lips to make the future patulous c ervical If l canal . the acerations necessitate the excision of

a r co ntinu much tissue , it is a splendid rule to place

us o buried catgut suture ﬁrst , just as in sewing up a deep wound elsewhere , and ﬁnally bringing the ' If a . surf ces nicely together not too extensive , two

r e o n S o thre sutures each ide , which include all the f i . A t ssue , are su ﬁcient bsorbable suture material Should be used unless conditions may entirely co n

r indic ifﬁ t a a te their use . Silkworm gut is rather d cult and painful to remove , especially if the peri A — neum, too , has to be repaired . forty day chromic D S S S OF 67 I EA E THE UTERUS . catgut is perfectly reliable and will last twelve to

ﬁfteen days in the cervix . Van Horn prepares an obstetrical catgut tested to last against the action of

e the lochial discharge for t n days . A stellate laceration should be -handled just as a

o r mi unilateral bilateral laceration, keeping in nd, however, that care must be exercised not to remove t o o much cervical tissue , so that there may follow

r i an acquired cervical stenosis o atres a .

o f Remember, if there has been a great deal dam age to the cervix and it is plain that much tissue has

o f to be sacriﬁced to get rid all the scar tissue , that it may be decidedly better and safer to do an a m p u

a io n f t t o the cervix than to attempt its repair .

E TR OF THE CE HYP R OPHY RVI" .

Remember that hypertrophy may be of either that

o f o r part the cervix above the vaginal junction, the part below . Remember that this is the only form of uterine

" o r prolapse met in virgins sterile women , except in the rare acute cases , where the prolapse may be due to injury o r V i olence Remember that supravaginal hypertrophy cause s

s o f di placement the uterus , due to the increased weight on the uterine ligaments . Remember that exami nation reveals an elongated

r cervix, perhaps protruding at the vulvovaginal o i

ﬁ ce ; the vaginal dome is no t obliterated ; and the fun 1 68 GOLDEN RULES OF GYNECOLOGY .

dus uteri is found , either in its normal position or occupyin g a higher position than is consistent with

f i the degree o cerv cal descent . Remember that this condition occurs in virgins

w o f and sterile omen also , while prolapse the entire uterus occurs only in those who have borne children . Remember that there may be no evidence of trau m a ti sm in the cervix o r perineum and the vaginal dome may be normal . Remember that the knee—chest posture causes an apparent elongation to disappear if due to prolapse o f o f the uterus , but will have no effect in cases hypertrophy . Trea tment — Remember that a cure can only be ef fe te d c bysurgical measures . Re member that if the hypertrophy is slight and causes no s ymptoms o r discomfort nothing should be done . The best treatment is high amputation of the cer vix . The incision is made above the v a gino cerv ic a l junction, through the wall of the vagina down to the cervical tissue . The cervix is then pulled down by forceps , and the cervical tissues are separa ted from the surrounding structures i n front of and behind

the ﬁnger,as far as the uterine vessels . The arteries should be ligated with ca tgut liga tures , carried around then by a curved needle . The c ervix is now divided o n each side down to the ligated A vessels . curved Hagedorn needle is threaded with Silkworm gut and passed through the center of the

0 OF 1 7 GOLDEN RULES GYNECOLOGY .

t very common, due to irri ation and consequent uter

o r ine congestion , to the effort of the uterus to expel the polypus . Remember that physical examination by both touch and Sight yields the only positive information .

It m a t ybe necessary o dilate the cervical canal , but usually it is soft and patulous . Remember that it should be a routine rul e o f

’ practice to examine m icr OSOOp i ca lly every polypus tha t is removed to determi ne the question of malig N . t nancy ever fail o Observe this rule, that when necessary the patient may have the beneﬁt o f an early hysterectomy . Trea tment — The treatment is always surgical and consists in the removal o f the growths .

ED A E F H E I" AC" UIR TR SIA O T E C RV .

Remember that atresia of the cervix prevents the escape o f the menstrual blood and uterine secretions . These gradually accumulating within the uterine cavity produce the following conditions

Hematometra , when the uterus is ﬁlled with blood .

Hydrometra , when the accumulation is mucus .

Pyometra , when pus .

Physometra , when there is a collection of gases . Remember that after the climacteric there will be no retention ; hence no symptoms . Remember the importance of the history detailing an operation on the cervix ; vaginitis caused by diph~

r . theria , scarlatina, o variola OF 1 7 1 DISEASES THE UTERUS .

Remember that amenorrhea accompanied by a f menstrual molimen is very signiﬁcant o atresia . Remember that phys ical exami nation reveals a

If no round , symmetrical , elastic tumor . there is uterine hypertrophy, ﬂuctuation may be elicited . The uterine sound introduced by sight through a vaginal speculum determi nes not only the atresia but

also its location . Trea tmen — t . Remember that the treatment con

sists in opening the canal and keeping it patulous .

This is accomplished by either inci sm g or divulsing . A speculum is introduced into the vagina , and the anterior and posterior cervical lips are seized -by forceps and pulled down toward the vulvar oriﬁce .

S o s hould the obstruction be seen at the external , it is incised by a straight bistoury . If higher up in the canal a dilator is pa ssed into the cervical canal until it meets the obstruction ; the cervical canal is then forcibly dilated , for a short time , when the blades will pass farther into the canal upon relaxing the pressure . A new position of dila tors farther up , and again dilating forcibly, tears apart the canal farther up . This intermittent dila ta tio n is continued until the uterine cavity is reached . The uterus is then washed Out thoroughly with

ho t 2 some antiseptic solution , as per cent lysol solu n tio . The canal is packed tightly with strips o f e - gauze , which should r main for forty eight hours . Every second day the vagina Should be thor 1 2 OF 7 GOLDEN RULES GYNECOLOGY .

oughly douched with antiseptic solution, and the

re pack in the canal changed . The patient should h main in bed ten days . S e should use hot vaginal douches daily fo r several weeks after being allowed u f o t o bed . In cases of pyometra the pack Should be changed daily, and the uterine cavity thoroughly cleansed with a hot lysol douche . Toni cs containing quinin and s trychnin should be g iven when needed .

ED TE F E E " AC" UIR S NOSIS O TH C RVI .

Remember that this condition i s often produced by uterine displacements and most often caused by ﬂ i n a nte ex o . Remember that obstructive dysmenorrhea is a prominent symptom , produced by the interference

a nd c o n se with the escape of the menstrual ﬂuid , quently painful uterine contractions to force o ut the

ﬂuid . Remember that sterility a nd leucorrhea are pres ent and when a ssociated with painful menstruation

i i should arouse susp c on . Remember that the passage o f the uterine sound under strict aseptic precautions will determine not

only the stenosis but location and probable cause . Treatment — Remember that dilatation and

curettement of the uterus cure stenosis , but they Should be followed by dilatations every week o r two

fo r ﬁve or six months to prevent recurrence .

1 4 G R OF 7 OLDEN ULES GYNECOLOGY .

touch like ﬁbroid nodules . Later, they break down

—o ut and slough, leaving scooped areas of necrotic Th tissue . e cervix is soft and dilated so that the

A f co n si s finger may be introduced . tumor o the ten c o f y a fibroid growth , sharply defined and nodu l l a r . in character, may be felt upon the uterine wal

r h La te . t e , growth softens and bleeds easily, and eventually sloughing occurs . Remember that microscopic examination o f scrap ings should always be made by a competent micros copist . Remember cancer differs in the following

1 O . N connection with pregnancy .

2 O — a t . ccurs in advanced life or near the meno pause .

3 . i Uter ne colic occurs late or not at all . 4 . Uterine wall becomes hard and indurated . 5 D f — . uration o disease much longer one to two years . M 6. icroscopic examination shows characteristic structure s differing from those found in ch o rio ep i

h eli t o m a . Trea tment — Remember complete abdominal hys

er ec i t to my and removal of m eta sta t s if possible . Remember that the value o f an early diagnosis lies in an early radical tre atment if the patient is to be beneﬁted . CHAPTE R V

E E D A I DISEASE S OF TH TUB S AN OV R E S .

A PINGITIS S L .

i s Remember that this very common disease due ,

o f in the vast majority of cases , to extension upward an endometritis . Remember that there is such a condition as c a ta rrh a l salpingitis , but the symptoms are so slight

no as t to be noticed . Remember that purulent salpingitis is caused by septic and gonorrheal endometritis . Remember that the gonococci mos t fre quentlv are the cause o f pus —tubes and this fact renders go no r rhea such a serious complaint in the female . Remember that in additi on to the symptoms caused by the tubal lesion consideration must be given to those that are dependent upon the coexist ing endometritis . Remember that pain is an important symptom and m a y result from mechanical pressure and displace ment o f the uterus and appendages ; o r it may be caused by tractions upon adhesions that have formed a between the tube and djacent structures . Remember that the character and severity of the 17 5 1 7 6 OF GOLDEN RULES GYNECOLOGY .

pains vary from a dull heavy sensation to acute , In m agonizing paroxysm . so e cases the pain takes the form of colic . Remember that the pain is usually constant but is inﬂuenced by position . Thus the recumbent posture relieves the pelvic weight and also pain ; hence these patients , as a rule, are better on arising in the morn

. W ing alking , exercise , coition, constipation , and A often urination make the pain wors e . t the menstrual period the congestion of pelvic organs in creases the pain . Remember that the pain is located in o n e o r both iliac regions and may extend to the lumbosacral region or radiate down the thighs . Remember that dysmenorrhea is a somewhat con It l stant characteristic symptom . usual y begins a week prior to the ﬂow and does not cease for several I days after it stops . t radiates from the iliac region into the pelvic cavity and down the thigh; l Remember that sterility is the ru e in these cases , due to the closure o f the ﬁmb riae o f the tubes or the

o f thickening of the external coat the ovary, thus preventing the rupturing of the Gr a a ﬁ a n follicles f and the escape o the ovum . Remember that physical examination reveals a n All enlarged tube or a tumor in the ovarian region .

i tumefact ons should be traced, by deep palpation,

n from o e o f the uterine cornua . Remember that adhesions can be determined by

i the latitude of uter ne motion . When the pelvic

1 7 8 OF GOLDEN RULES GYNECOLOGY .

o f um pression the menses , exanthemata , acute rhe a tism , or poisoning from arsenic or phosphorus , there are pain and tenderness in the iliac regions , fever , and a rapid pulse . Remember that the pain radiates to the lumbo sacral region, bladder, thighs , and occasionally to the breasts . Remember that the parotid gland may become swollen . The patient lies with her knees drawn up . Remember that physical examination reveals an e nlarged and tender ovary ; and the organ is usually

If a b found prolapsed and adherent . an ovarian sce ss has formed, it will be felt as a round or globu lar mass , and in some cas es ﬂuctuation may be elicited . Remember that the non-puerperal ovaritis and appendicitis must be carefully differentiated . They both have sudden onset, pain, and tenderness and i fever . Vomiting with nausea s very common in M appendicitis . uscular rigidity of the right rectus , ’ McB urne s with especial tenderness over y area, is

f In somewhat characteristic o appendicitis . appen diciti s the onset is more o f a general abdominal pain ; while in acute ovaritis the pain is conﬁned to the

w y lo er pelvic region , and the general s stemic dis turb nc n a e is not early so great . Treatment — Remember that puerperal cases are

: i . e . treated the same as acute purulent salpingitis , the septic endometritis is treated , and the tubal and ovarian troubles allowed to take care o f themselves . OF B S 1 7 9 DISEASES THE TU E AND OVARIES .

The non—puerperal cases are treated by absolute

u sm rest in recumbent posture, g the bedpan when

the bowels and bladder are to be emptied . The vagina is douched several times daily with a

o f Ho t gallon hot normal salt solution . compress es

o r an ice bag are placed over the affected organs . Bowels should be opened thoroughly with a sa linepurge and kept opendaily by half-bottle of mag

ne siu m citrate .

i The diet should be l quid for two or three days ,

o f then semisolid until patient is out bed . Morphin should be used if much pain and restless

ness are present .

F su ever is controlled by sponging . The attack u i ally yields n twelve or fourteen days .

NIC O ARITI CHRO V S . Remember that the symptoms may vary when the

ovarian trouble is associated with endometritis , sal

in itis p g , adhesions , and pelvic tumors . Remember that pain is the most constant and sig

iﬁ a n In n r n c t . o e o symptom both iliac regions , it i s usually more severe at menstruation . The pain

radiates to back , bladder , and down the thighs . o Like the acute c ndition , the pain is worse in the n erect posture , walking , pressure of clothi g at the

waist , sexual intercourse , during defecation or uri

nation .

Remember that menstrual disturbances vary .

T likelv m etro r here will be , most menorrhagia and 1 80 GOLDEN RULES OF GYNECOLOGY rha gia in cystic ovaries ; while the Oi rrhotic ovary produces an opposite condition . Remember that a large cystic ovary may be recog niz e d o n m palpation as a large , oval , or globular ass located o n either Side of the uterus in the cul—de —sac o f D ouglas . Remember that the cirrhotic ovary is not so easily

' th e ﬂe sh palpated in y patient , but can be palpated n through the thi and relaxed abdomi nal wall . Treatment — Remember that the treatment may be palliative or radical . Remember that the palliative treatment is no t a p

A o f plicable to every case . careful study pelvic conditions should be made , and if complicated with salpingitis or the ovaries are greatly enlarged and prolapsed and the adhesions present , the palliative treatment is only temporary in effect . Patients that are dependent upon their work fo r a living should b e told h o w much o r h o w little beneﬁt can be

t S expected from his line of treatment . They hould not be encouraged to pursue a line o f treatment which requires much time and money, without a rea f sonable hope o success . Remember that after the palliative treatment is stopped the pain and other symptoms usually return — and a cure is not permanent . Remember that co mplete rest i n ‘bed for ﬁve o r six weeks should be insisted upon . The vagina should be douched several times daily with a gal Th lo n of hot normal salt solution . e patient should

2 OF 1 8 GOLDEN RULES GYNECOLOGY .

The severe menstrual pains may be relieved with

o f r th e tincture cannabis indica , antipyrin, bromid , o tincture of pulsatilla .

Light exercise in open air may be permitted . The clothing Should hang from the shoulders and not from the waist . Remember that almost all cases eventually demand surgical intervention . The operation varies from partial to complete removal o f the ovaries . Remember that it is best to leave as much ovarian i f n e . t ssue as possible , if only a part o o ovary

Remember that where there is any uterine . dis placement it should be corrected at the operation .

RO A SE OF THE OVARIES P L P .

Remember that where there is a prolapse o f the uterus it will eventually pull the ovaries down . Remember that prol apse o f the ovaries sometimes occurs in persons suffering from a chronic disease in which there is los s o f weight . The displacement is due to the lack o f pelvic fat a nd the relaxed condi tion of the pelvic organs and their support . Remember that the left ovary is more often pro lapsed than the right . This is due to the following reasons : 1 . There are no valves in the left ovarian vein , and it opens at right angles into the renal . 2 . The rectum lies to the left of the median line ; hence chronic constipation will produce its m e ch a ni cal effect upon the left ovary . S OF B R S 83 DI EASES THE TU ES AND OVA IE .

3 . There is greater hypertrophy of the left ovary in during pregnancy, and its weight is thereby creased . Remember that there are no pathognomonic symp

' to m s a nd they are often combined with those caused

n o r by chro ic ovaritis subinvolution of the uterus . Remember that pain is the most prominent sym p It tom . is increased by exercise , upright position, It defecation, urination , and coitus . is felt in the iliac region o r deeply located in the pelvis near the

o r sacrum, and it may radiate to the hips , rectum, down the thighs . Remember that menstruation is affected and dysmenorrhea is very common, and ovarian pain is r increased du ing periods because o f the congestion . Remember that physical examina tion furnishes the only conclusive evidence , when the ovary may be It felt . may be recognized by its shape , and its con nectio n with the cornu uteri . Treatment — Remember that when the prolapse is due to subinvolution o r to debilitating diseases the palliative form of treatment should be followed , but if the ovary be greatly enlarged or adherent , this form of treatment is contraindicated . Remember that rest is very essential and during menstruation the patient should be conﬁned in bed .

Coitus should be forbidden . The vagina Should be douched twice daily with a gallon o f hot normal D . o f n saline solution aily a tampon , either glyceri o r of phenol-magnesium-sulphate -glycerin combina 1 84 OF GOLDEN RULES GYNECOLOGY .

s r e tion, should be inserted until the congestion i duc e d , when it is u sed less frequently . The bowels should be kept open by the use o f sa lines . The patien t should a ssume the knee-chest posi tion for ﬁfteen or twenty minutes daily, to allow the pelvic organs to drop back into their normal posi tion . Remember that radical treatment always calls for a conservative operation on the ovary .

S D T S F THE O RIE OLI UMOR O VA S .

Remember that ﬁbro m a ta are very rare and do not attain large size and are usually unilateral . Remember that there are no characteristic symp toms . The tumor is not painful , unless it should attain a large size and become wedged in the pelvis . Remember that bimanual examination reveals a round , pedunculated tumor that is freely movable and not connected with the uterus . Remember that removal o f ﬁb r o ids is th e only

' a nd del a im treatment y is dangerous , because it is possible to exclude malignancy . Remember that cancer o f the ovary is usually found in both ovaries and usually occurs in a cystic o r solid ovarian tumor . Remember that the early symptoms W i ll be those

‘ f r o w h in o the benign g t the ovary , but later when malignancy occurs the clinical picture changes ma

ria ll te y . The tumor takes on a rapid growth ,

OF 1 86 GOLDEN RULES GYNECOLOGY .

era tio n o f um i n t in the shape the t or , and septic

ni . cysts , acute perito tis Remember that the increased weight o f the ovary causes displacement ; hence bimanual examina

l o w tion reveals the cyst down in the pelvis , either

- — o f D o r in the cul de sac ouglas , , if in the broad liga f l o w o . ments , then down and to the side the uterus Remember that the tumor is round o r ovoid in shape with a smooth surface, and regular outline . Remember that great cafe should be used in dis t in uishin g g between pregnancy and ovarian cysts . Remember that time is an important aid in differ entia tin f g pregnancy, and the signs o pregnancy should be given plenty o f time to manifest them selves before deciding the question . Remember of course that fetal movements and n heart sounds can mean but o e thing . Remember that in ascites an area o f ﬂuctuation changes with position of the body and no resistance f is Of ered to the palpating hand . Remember that in ascites the areas of resonance and dulness change with the pos ition o f the patient . Remember that the upper line o f dulness o n per cus sio n with the patient in the upright posture will

c n in scite s . be o cave a , but convex in an ovarian cyst Trea tment — Remember that early operation fo r the removal o f the cyst is the only treatment . Remember that when operati o n would be almost certainly fatal , the patient may be made temporarily more comfortable by tapping the cyst with a trocar . OF E S 87 DISEASES THE TUBES AND OVARI .

TO IC GEST T N EC P A IO .

E ( xtrauterine Pregnancy . )

Remember that, normally, the ovum is fertilized by the spermatozoa somewhere in the tube , after which the ovum is carried to the uterine cavity by the peristaltic action of the tube and by the cilia i with n the tube , where it attaches itself ; and normal pregnancy ensues . No w remember that extrauterine pregn ancy is fertilization of the ovum and continuation o f gesta tion outside the cavity of the uterus .

Remember that ectopic gestation , extrauterine pregnancy, and tubal pregnancy are synonymous It terms . is safe to say that nearly all extrauterine pregnancies are tubal in the beginning ; the sub se quent history and development of the ovum may

tlf ir change e location . No w remember that the cause o f extrauterine preg nancy is something that prevents the fe rtilized ovum from passing through the Fallopian tube to the uterus ; and this is usually found in women who at s ome time have suffered from pelvic inﬂammation, where adhesions may have produced kinks in the tube , where tumors may have compressed the tube , where displacements o f the tubes have formed an

o r o r acute angle twist , where there is chronic sal p ingiti s with swollen mucosa o r strictured lumen : there may be a diverticulum in the Fallopian tube : 1 88 OF GOLDEN RULES GYNECOLOGY . and it is also said to occur in cases o f congenital mal formation, where the tubes are long and tortuous with a small canal . Many textbooks say " that it occurs after a long ” f i N w period o steril ty . o these women are doubt less sterile by virtue o f the fact that the pelvic o r fﬁ gans have been crippled by disease , and it is di cult for pregnancy t o take place at a ll ; and if the sperma to z o a l can meet the ovum at all , tuba pregnancy results . These women may perhaps only ovulate occasi onally through the thick capsule covering the ovaries . Remember that the fertilized ovum may lodge in any portion o f the tube that furnishes sufﬁcient r e

is n e I o f s ta c . t may lodge in that portion the tube that passes through the cornu of the uterus ; this is If known as interstitial pregnancy . near the distal end of the tube , it is called ampullar pregnancy ;

- tubo ovarian pregnancy may occur . No w remember that in interstitial pregnancy rup ture is likely to be later than in the other forms o f tubal pregnancy ; it may take place at any time from one to four months . Rupture in the other portions

f a l o the tube usually occurs in six to eight weeks , though it may occur as earlyas the fourth week and as late a s the twelfth week . N o w keep in mind that in the beginning the tube

a nd y a scu becomes hypertrophied swollen, and the l a r ity o f the tube and broad ligament is greatly in

If ﬁmbria ted creased . pregnancy is near the ex

1 90 OF GOLDEN RULES GYNECOLOGY .

No w o f ~ remember that, as a rule , the product con ce tio n a sufﬁ p perishes , but the placenta may retain

unru cient attachment , and with the membranes p

ur t e d . the fetus may develop to full term . Remember that the fetus dies at full term i f left alone . Remember that such a child is ' usually imper fe ctl i l y developed , both mentally and phys cal y, and b if removed y operation while still alive , will often m die im ediately or in a very few days . Remember the interesting secondary changes that I . t may take place in the fetus , after its late death

i may become calcified , form ng a lithopedion ; it may become mummified ; o r it may be found that nothing In in remains except the skeleton . the first two stances the fetus may become encapsulated and r e main for years without disturbing the patient greatly ; in the last case it is frequently a cc o mp a nied by suppuration and rupture (usually into rec tum) , and the skeleton is expelled piece by piece . Sympto ms Befo re Rupture — Remember that the early symptoms of extr auterine pregnancy are those f : . o normal pregnancy viz , amenorrhea ; morning nausea ; changes in the breasts , etc . ; and the patient believes herself normally pregnant . Although many will complain of pains in the a b

n r e domen and in o e of the inguinal regions , yet member that some go o n with no special discomfort f until at the time o rupture . Remember this : that when a patient employs you OF AN D S 1 91 DISEASES THE TUBES OVARIE .

r i o r fo her phys cian early in pregnancy, if she con sults you fo r any irregularity in early pregnancy,

Re a careful and thorough examination be made . member that the uterus will be enlarged and have the same characteristics as in normal pregnancy . ’ Don t lay to o much stres s on the blue discolora tion of the vaginal mucous membra ne ; that may not be noti ceable until the second o r third month o f gestation .

Remember that the cervix will be soft , the os patulous , the vagina will be moist , and the pulsating vessels may be felt . No w carefully examine the tubal regions ; the tube may be posterior to the uterus or clinging to the f side o the uterus . Remember that the mass is usually elongated and rather ovoidal in shape . Remember that it is usually soft and boggy to the feel , and rather sensitive to the touch ; the mass may ’ f give the sensation o contracting . Remember that the greatest care must be ex er cise d , lest the tube may be ruptured during examina tion . Remember that often a history of long sterility is F present , indicating abnormality in the allopian tubes . Sympto ms at Time o f Rupture — No w remember that , although tubal rupture may be preceded by a

o f few days abdominal discomfort and pain , it

o n usually comes suddenly and without warning . 92 OF GOLDEN RULES GYNECOLOGY .

Remember th at it does no t always follow great strain or exertion ; it Often comes with the slight

o f effort rising from bed or a chair .

Remember that the patient is seized by sudden, severe , abdominal and pelvic pains , which are usually followed by pallor and collapse . Remember that the pain and shock may be so se vere that the patient becomes unconscious ; Sh e will be deathly pale , with lips blue , pupils dilated, and a cold perspiration covering body ; very restless

n o t (if unconscious ) , with a shallow sighing respira N tion and a subnormal temperature . ausea and c vomiting are not un ommon .

Remember that , while conscious , the patient will be aware o f the gravity of h er symptoms and will

She . express great fear, lest will not recover Remember that the feeling o f such a patient must be dreadful ; s eized suddenly in the midst of health , with agonizing pain ; ears ringing and vision im paired , until Objects become hazy and dance before her ; nausea and vomiting that only tend to increase

o f the gravity the whole Situation . Remember that the decidua is usually thrown off e i and there is vaginal ble ding , wh ch may be mis

; taken for miscarriage . Remember that if the rupture has been intr a p eri to nea l - , bimanual examination will reveal the cul de

’ sac distended into the vagina ; further palpation will no doubt reveal the enlarged tube ; the indications o f free ﬂuid will be found in the pelvis and abdom

4 OF N 1 9 GOLDEN RULES GY ECOLOGY . make a careful examination o f his case as soon as

to he is retained, ascertain if the pregnancy is nor mal , or if conditions call for frequent examinations in the future .

o r tw o o f Remember that, if in the ﬁrst month pregnancy the patient complains o f pelvic distress o r pain , and if upon examination a small mass may be felt in the region of either tube o r perhaps pos

ri r If te o . to uterus , it will need special watching it increases rapidly in size , it should call for prompt D ’ treatment . on t be rough during these examina tions . Handle the patient gently . Diagno sis a t Time o f Rupture — Remember that the history is of great importance ; the patient has had sudden and severe pain followed by weakness

S and hock , which often seems as though it would prove fatal in a short time ; there will be ﬂuid blood clots and pieces of membrane expelled from the uterus . Remember that the hemorrhage is not fatal in all

cases ; the patient revives in a way, only to have a

recurrence of the acute symptoms in a few days ,

with more hemorrhage , and membranes expelled

from the uterus . Don ’ t fail to make a thorough bimanual examina tion before resorting to curettage for a supposed

i i n l a miscarr age . Remember that this c ass of c ses the pelvis and part of the abdomen will be ﬁlled w ith hard blood— clots and the patient will often present

symptoms of peritonitis . OF B AN D AR 1 95 DISEASES THE TU ES OV IES .

Treatment — Remember that there is but o ne line o f treatment and that is operative ; the operation should be performed as early as the condition is

o r recognized strongly suspected . While waiting ’ o r for the surgeon, don t use proctoclys is any other form o f normal saline therapeutics ; it will tend to I increase the hemorrhage . t is better to administer morphin to quiet the restless patient and relieve her pain than to resort to stimulation . Let her have plenty o f fresh air ; she will complain of bei ng warm f and have di ﬁculty in breathing . Remember that the ideal time to operate is before rupture , when the tube may be removed without damage to the other structures . Arguments have been presented from time to time for and against operations during extreme shock f . No w from hemorrhage , o course , if it were possi ble to state that in a certain number o f hours or davs the patient before us in a condition o f collapse would cease bleeding and recover from h er extreme

no condition , it would doubt be safer and quite proper to wait ; but remember that while waiting for the patient to grow stronger the golden moments may be lost and the patient gradually Si nks and

e o r to o di s while we sit by, we may wait long , so that o ur patient is unable to stand the operation later, when we ﬁnally make up our minds that it is useless to wait longer . To one who has had considerable experience with these cases there can be no doubt that an imme 1 96 N S OF Y GOLDE RULE GYNECOLOG .

diate operation is indicated in a ll cases ; in the class where the hemorrhage has not been severe , they can

go through the operation safely, and doubtless are saved from a subsequent severe hemorrhage ; in the class where the bleeding continues and ﬁlls the whole

" abdominal cavity, they will surely die unless the

o c hemorrhage is stopped . We have never had casion to reg ret operation in these cases at the earliest possible moment . Remember that o ne o f the great elements of suc cess in operating o n a grave case of hemorrhage is to do the work rapidly, using intravenous trans

r fusion o hypodermoclysis during the operation , and proctoclysis and heat applied around patient after

she Is returned to bed .

1 98 OF GOLDEN RULES GYNECOLOGY .

Great care should be exerci sed during the ﬁrst few periods . Keeping the feet as well as the body dry

w a rm m a . and , y save her from a life of suffering

MENSTRUATION Remember that menstruation is a physiological

ﬂow of a bloody discharge from the uterus , begin ning with puberty and ceasing with the menopause , O 28 and ccurs about every days . Remember that we have a physiological a m eno r

Re rhea during pregnancy and during lactation .

‘ member also that there may be exceptions ; some women have occasional bloody discharges during pregnancy ; and some will menstruate during lacta tion . Remember that they have premenstrual symptoms (more pronounced in some than others ) : Slight swelling of the vulva ; more o r less engorgement of all the pelvic organs , which occasions a mucous dis charge that Often bathes the vulva ; the breasts often become more o r less tender and swollen ; and there f is a Slight swelling o the thyroid gland . Remember that this hv p er em ic condition o f the genit al organs is responsible fo r the feeling of ful S ness and slight distress . oon the mucous ﬂow is w mixed ith blood , and after the active period is on , there is usually a feeling of relief .

c l Remember that mucus , epithelial e ls , and blood compose the ﬂow and this continues actively for M N S N AN D IT S 1 99 E TRUATIO DISORDERS .

three to four days ; after which it begins to subside

and again becomes mucus . Remember that there is a considerable difference

o f in the duration, time , and quantity menstruation f in di ferent women . Remember that some women

menstruate every three weeks , while some may go f r f o a number o weeks . Remember that each woman mus t be governed by What seems to be normal in her individual . case . Remember that what is physio logical in o n e might be pathological in the other . Remember that the average length of a woman ’ s

i 3 menstrual life s about 5 years .

V TION O ULA .

Remember that ovulation is the maturing and rupturing o f a Gra a ﬁ a n follicle and the throwing

r o ff o escape o f the ovum .

Remember that , according to recent investiga

th e ‘ im ul se tions , there is no doubt that p that con l tro s the menstrual cycle is supplied by the ovaries . Remember that the corpus luteum is directly con cerned in the elaboration o f the internal secretion

- that is thrown into the blood stream . i Remember that , accord ng to Leo Loeb (who

i ts speaks of this secretion as hormone ) , function is twofold : o ne is to regulate thetime between ovula tions ; and the other is to prepare the endometrium for the reception of the fecundated ovum and to form the maternal placenta . 200 OF GOLDEN RULES GYNECOLOGY .

MENOPAUSE .

o f Remember that the menopause ( change life ,

dodging point , climacteric ) is that period in a woman ’ s life when menstruation and child-bearing

cease . n Remember that the me opause occurs , as a rule ,

o f 42 48 i s d from the ages to , although there a wi e i It variat on from this general average . has been kno w n / to occur as early as in the twenties , and to be delayed as late as the Sixtieth o r seventieth years . w Remember that pelvic disea ses , ith congestion

o and engorgement of pelvic rgans , is often responsi ble for the indeﬁnite delay o f the menopause . Remember that a woman with uterine prolapse

r - ( of the third degree ) , o with tubo ovarian disease , t will continue o menstruate indeﬁnitely, unless the uterine or pelvic lesion is cured . No w remember that menopause is the reverse of puberty, with a local and general atrophy and shrinking . The symmetrical Outlines of the ﬁgure

to . are lost , due either atrophy or obesity The breasts become shapeless and ﬂattened ; the vulva becomes wrinkled and ﬂat ; the vagina becomes pale and narrow ; the uterus atrophies until it is a mere

e m hard r mnant , and someti es disappears altogether ; the hair over the genitals becomes thin and turns

r g ay early .

no t Remember that , as a rule , the menses do cease

02 OF GOLDEN RULES GYNECOLOGY .

disorders . The nervous and mental troubles have

to o f be relieved by improvement surroundings , if they are not cheerful and pleasant ; agreeable and pleasant occupation o f time ; careful attention to hy giene ; cleanlines s o f the body ; careful attention to k diet , idneys , and bowels ; a moderate amount of

‘ o ut exercise of doors , when the weather permits . Remember that local disorders must have atten

tion .

RECOCIO S MEN TRUATION P U S . Remember that precocious menstruation means the ﬂow o f blood from the uterus in a girl before the

o f age puberty . No w remember that it is not uncommon to ﬁnd girls whose menstrual periods begin at eleven o r twelve years o f age ; these gi rls are precocious in

other respects ; their form and general appearance assume that of a matured woman very early ; they l simply mature early, menstruate regularly, fee no s pecial inconvenience o r discomfort from it ; matur

a nd ing early, they often marry become mothers

early .

o f While it may occur , and cases are recorded per iodic bl oody discharges in very young girls and ’ to o o f in infants , don t be sure that the presence a little blood o n the napkin or underwear is a pre co cio us menstruation— it may c o m e fr o m the vulva

o r vagina . Remember that it may be due to irrita M AN D ITS 203 ENSTRUATION DISORDERS .

o o f u tion and adhesi ns the clitoris , or abo t the vulva I i or hymen . t may be due to itch ng and rubbing

o f o r the parts , to masturbation . Trea tment — Remember that a thorough insp ec tion of the parts is necessary ; look fo r caus es o f irri i ta t o n . and inﬂammation, and remove them The proper treatment at this time m a y sa v e this child '

i from sexual excesses and pervers ons .

c o ld Remember , if this hild is enough and has

th e acquired precocious habits , that she will require greatest care and teachings along the lines o f mo

r a lit co m y ; keeping good hours , abstaining from bad

panions (boys and girls ) , bad books , etc . will do m uch for these girls .

DE A ED MENSTRUATION L Y .

Remember that , if menstruation is delayed as late

o f as the ﬁfteenth year life , it is known as delayed ,

o r retarded , menstruation . Remember that menstruation may be dela yed this n u lo g in some girls , when it will begin and occ r at

regular intervals ; sometimes in these delayed cases

the pelvic organs are poorly developed , and men strua tio n that starts la ter than usual occurs at ir regular and prolonged intervals afterward .

Remember that , should menstruation be delayed and the menstrual molimen occur with a feeling of

o r fulness and distress in the vagina or uterus , both , f with perhaps a distention o the bladder , the case 204 S OF GOLDEN RULE GYNECOLOGY .

should be thoroughly investigated fo r congenital malform ation o r occlusion of some part o f the geni

tal tract . Remember that menstruation may be delayed by some debilitating disease Trea m n — If t e t Treat the cause . the genital a p paratus is normal and the girl is not ill as a result

do of the delayed menses , not give emmenagogues ;

h er let alone , and the menses will appear in due

time .

i Remember , if she is suffer ng from some general

to d disease , treat that condition ; o not undertake to i nﬂuence o r produce a menstrual ﬂow directly

If n o t the canal is patulous , it should be treated

he as t condition requires .

AMENORRHEA .

Re~ Amenorrhea is an absence o f menstruation . m ember that we may have a physiologic and a

pathologic amenorrhea . Remember that p hysml o gi c amenorrhea occurs in

the human female before puberty, during pregnancy

and lactation , and after the menopause . Remember ,

there will also , that occasionally be found women w h o have a slight ﬂow duri ng pregnancy and during l the atter months o f lactation . Remember that in imperforate hymen o r imp erfo r

ated cervix the menstrual molimen occurs , but there ﬂ i is no visible o w . The menstrual ﬂuids rema n in

the uterus (hematometra) , back up in the tubes

N OF G Y GOLDE RULES YNECOLOG .

f rudimentary organs , or an absence o a part o r all

o f fo r the genital organs , the prognosis improve

ment of her condition is very bad . Much care must be exercised regarding advice I about matrimony . t is much better not to marry at

all than to marry and make a complete failure .

Treatment — to Remember that , in the cases due acute or chronic systemic diseases or to nervous o r l menta disorders , these conditions must be treated , If and the amenorrhea will take care o f itself . there is some acquired stenosis o r atresia of any

o f en part the genital canal , it must be treated

ir l t e y o n the merits o f the individual case . Remember that the treatment must necessarily

depend upon the cause . Rest , with proper hygienic s surroundings , fresh air , judiciou exercise , good t nourishing food , etc . , consti ute about the routine general treatment

Remember that , in young girls who are crowded " with work in school and at the same time doing so ” ciet y, a very important part of the treatment is to relieve this poor girl o f some o f the nervous strain ; ﬁrst o f the social strain ; and if her condition does not

o ut . promptly improve , she should be taken of school

This girl requires rest , and in addition a good iron tonic , cathartics , etc . , as indicated .

f: O the various drugs used in amenorrhea, may be e named iron, strychnin , rgot , manganese , aloes , apiol , oxalic acid , etc . But use direct emmena

o ues g g with caution , and if the cause can be found AN D ITS S 207 M ENSTRUATION DISORDER .

and treated , these emmenagogues in all probability

will no t be needed .

M A ENORRHAGI AND METRORRHAGIA .

Remember that , although, theoretically, menor rha gia means an excessive ﬂow at the menstrual p e rio d and metrorrhagia means a ﬂow o r hemorrhage

that does n o t correspond to the menstrual period,

o r yet a metrorrhagia, excessive menstrual ﬂow , is

practically always prolonged, and sometimes rather irregular by ceasing slightly o r almost completely fo r a few hours or a day, to begin freshly again with a little exertion ; hence , practically speaking , it is ff often di icult to differentiate one from the other , and fo r practical purposes the term menorrhagia will answer very well in both cases . Remember that any pathologic condition that pro duces congestion o f the pelvic organs will cause e m norrhagia , viz . , chronic pelvic inﬂammation , ma

o f lignant disease the uterus , displacement ( espe cia ll y prolapse) , inversion, tumors of either uterus o r ovaries . Remember that menorrhagia may also occur in It hemophiliacs , in scurvy, purpura , or syphilis .

o f may occur with splenic hypertrophy , diseases the

o r o f liver kidneys , and sometimes in cases mitral i f nsu ﬁciency . Remember that pieces o f retained membrane or clots after parturition o r abortion may be the cause . We found a woman in our clini c who had worn a 208 G U OF G OLDEN R LES YNECOLOGY . wire spring in the uterus fo r over two years to pre

n o n vent pregnancy and to bri g the ﬂow . Her ﬂow had been excessive and almost constant . When we saw her, the uterus and appendages were destroyed by ab scess formation, necessitating a complete hys ter ecto m y. Treatment — Remember that there is always a cause , which must be sought and treated ; whether

a o r gener l local , if corrected , the menorrhagia will

all f in probability take care o itself .

t fo r Remember, however , hat temporary relief from excessive ﬂowing rest ( absolute rest) in bed is

ﬂo w o f necessary ; if the continues , the foot the bed may be elevated ten to twelve inches ; this in itself

l s wi l check any ordinary hemorrhage . The bowel Should be moved daily with salines ; the diet Should If be liquid ( soft diet) . there is evidence o f pelvic

n - i ﬂammation, frequent hot water douches should

At o f be given . sleeping time a tampon glycerin 1 0 . and ichthyol , per cent , may be inserted This can be removed by the patient herself o r the nurse the following morning ; after which give a hot douche . Remember that if there is evidence o f retained membrane o r clots a thorough dilatation and curet

Re tage must be done , using a general anesthetic . member that drugs alone are no t to be depended A upon ; they will probably fail . mong valuable drugs that may be used in connection with general

V treatment are mineral acids , iburnum prunifolium, hydrastis , ergot, hamamelis , etc .

N OF 1 0 GOLDE RULES GYNECOLOGY .

Remember that in the cases due to systemic troubles these must be treated as indicated .

Treatment -A a c . scertain the cause and treat c r din l o g y. Remember that it is a very common habit o f many women with pai nful menstruation to numb their sensibilities as much as possible with drugs and whiskey ; and frequently they acquire the morphin o r whiskey habit in this way . There are very few cases of dysmenorrhea that cannot be relieved if the cause is found and properly treated .

n eﬂex e d Remember, if the uterus is a t or the canal is small , that a thorough dilatation under an anes I thetic will relieve this . t may return in a few If . months , when it should , be repeated both dila

a tio s t n are well done, the trouble in all probability

no will t return .

Remember , if there are uterine displacement , pel vic tumors , etc . , they must be handled as indicated . Remember that it is very i mportant that a girl o f should be educated in the proper manner dress , and her clothing should always be sufﬁcient to keep her dry and warm ; disregard of this rule may be the means of starting the young girl o n a life o f suffer ing . Remember that constipation adds to pelvic con

S t neces gestion . Women hould be taugh the great sity of regularity in their daily stools . Remember that local treatment o f daily hot douches and tampons of some glycerin mixture two M N S N AN D IT S 1 1 E TRUATIO DISORDERS .

’ o r three times a week helps materially if there is uterine or pelvic inﬂammation . Don ’ t undertake intrauterine applications for the ‘ relief o f this trouble ; it is doubtful if any good can

m A fa be acco plished, and harm might be done . v o rite plan o f ours has been to institute treatment

a with hot douches and tampons , and then at the p proach of the menstrual period the patient is put in bed, if possible ; the diet should be soft and easily

r escri digested . The following is a very favorite p p tion a nd is given three o r four times daily for two o r three days prior to the appearance of the ﬂow .

At o f the advent the ﬂow , if the pain is great , it

o r may be given every hour two , until the patient feels relieved , when the doses may be made much farther apart

Tinctur ae cannabis indicae Fluidextr a cti s a li ci s nigrae Fl uidext ra cti ergotas

E l i i r is a x arom tici q . s . ad

Misce .

: - Sig . Teaspoonful in one third cupful o f hot water every o ne

to ﬁve or six hours until relieved .

If the case is severe , three to six grains of codein A may be added . mong other drugs are aspirin , sodium salicylate , phenacetin , apiol , camphor, pulsa

um V tilla, sodi and potassium bromid, iburnum prunifolium , etc . A case o f dysmenorrhea of the neuralgic type will test one ’ s skill to the utmost and call upon all of one ’ s therapeutic acumen . We have relieved this hys 2 OF 21 GOLDEN RULES GYNECOLOGY .

rica l to . te spasm with gr . gr of apomorphin ; this relaxes quickly, and does no harm . The unsexing of a woman must be advised with the greatest caution , and not until other means have been exhausted and after advice with able counsel .

1 4 N OF GOLDE RULES GYNECOLOGY .

o r citrate of potash ; if it is alkaline , give ammonium

b a en te, boric acid , salol , combined with the infu

sion o f buchu . The o il of sandalwood Should be given as a rou

Of tine , because its beneﬁcial effect upon the ure

hr l t a mucosa . In gonorrheal urethritis local treatment is im

era tiv e p , and the following technic should be fol lowed ' 1 . With the patient in the dorsal position douche A the vagina with 3 per cent lysol solution . nother good method for cleansing the vagina is the follow

: I l ing ntroduce biva ve speculum, make round, soft

balls with absorbent cotton , and use a long dis Di f secting forceps . p the balls o cotton in hot lysol o in s lution, and by means of the dissecting forceps

r t o duce it into the vagina through the speculum , and

m o . p thoroughly back behind the cervix Remove , a dry with dry cotton, and again introduce ball fter

dipping in solution . This is continued until the e vaginal mucosa has been perfectly cleans d .

2 4 er l . Cocain solution , p cent , is app ied to the

urethra o n an applicator wrapped with cotton, and

allowed to remain ﬁve minutes .

3 A i s . reﬂex catheter introduced , and the urethra thoroughly washed o ut with hot normal salt solu

‘

tion . 4 . A bivalve urethral speculum is introduced as

far as the internal meatus , and an app licator wrapped with cotton and saturated with a 25 per S OF 1 5 DISEA ES THE URETHRA .

1 o f - cent argyrol s olution, or a per cent solution

protargol , is passed into the canal . The speculum t h e . is removed , and applicator slowly withdrawn

This treatment Should be given daily until cured . When the discharge changes from purulent to

f — that o egg albumin in color, it is better to discon tinue the silver solution and use o ne o f the follow i ing astringents : zinc sulphate gr . j or j to the ounce ; i to . zinc acetate gr . x the ounce ; lead acetate gr j

to the ounce . In chronic gonorrheal conditions of the urethra

the canal is cocainized , and the entire canal painted

S . . with a solution of ilver nitrate, gr v to the ounce This is followed by the application o f weaker so

lutions twice a week , until discharge stops . Ulcers occurring along the urethra re ceive the fol lowing treatment ° Cocainize the urethra ; introduce the urethroscope to the internal meatus; wind cotton on an applicator

o ne and dip into a solution of silver nitrate , dram to

the ounce , and touch each ulcer with the solution .

This is repeated once a week until cured . S ’ Where kene s glands are chronically involved ,

the meatus is dilated , and probe inserted ; each duct

is slit open on the urethral surface . The raw sur

face is cauterized with 95 per cent phenol .

STRICTURE .

Remember that stricture of the urethra in the fe

no t I male is nearly so common as in the male . t 21 6 OF GOLDEN RULES GYNECOLOGY .

o r may follow acute gonorrheal inﬂammation ,

o r f chancre , chancroid , or tumors o the tract or trauma resulting from childbirth .

' Remember always th a t th e incontinence o r reten tion that is observed in the male may also be found in the female . Remember that the mos t common symptom is difﬁ cult and frequent urination . The induration at the Site o f the stricture may be e palpat d . T e m nt — r at e The treatment is dilatation , either forcible or gradual . Forcible dilatation is indicated in the majority of I cases . t should not be used where the cicatricial tissue is so dense that too much trauma will result from force necessary to dilate . Remember that forcible dilatation must be done

no t to o carefully and rapidly, s o as to avoid tearing the urethra . Remember that a general anesthetic should be given and the dilatation done at one Sitting . The l patient is p aced in the dorsal position , and a small

’ S He ga r s uterine dilator is pass ed . The size hould l be increased until the urethra i s fu ly dilated . After the operation p a ss a dilator every third or

w o r fourth day for t o three weeks . Gradual dilatation is done under a local anes the Si a — d , and beginning with a small size dilator , the size is increased every third day until full dilatation is accomplished .

D S OF GOL EN RULE GYNECOLOGY .

RO A SE P L P . Remember that slight eversion or pouting of the urethral mucosa is found in women who have borne children, and has no pathologic signiﬁcance . Remember that the size and extent vary from only o ne part o f the urethra to others where the entire

mf o f circu erence the canal is involved .

co n Remember that inspection reveals a dark , gested mass protruding from the external meatus , i n the center o f which can be seen the urethral open ing . When the eversion is limited to a part o f

o f the circumference the urethra, there will be a small tumor apparently attached to the margin of the urethral opening and resembling a caruncle in appearance . Trea tment — Remember that the ﬁrst indication in treatment is to discover the cause , if possible , and remove it When the condition is recent and the mucosa

r e hypertrophied , overstretched , or relaxed , good sults may follow a non-operative treatment ; but

l o r when atrophy resu ts from chronic changes , the m urethra is torn fro its normal attachments , there is nothing but an operation that will accomplish any good . Rest in bed is necessary in non—surgical treat In in ment . anemic women a good iron tonic is

dic a ted .

If the prolapse is dependent upon i rri tation in the OF 21 9 DISEASES THE URETHRA .

r rectum o bladder, it is often restored when the tenes

mus is relieved . The bowels Should be kept loose by the use of sa

ex a m eth l enamin lines and potassium acetate and h y ,

administered to render the urine bland or innocuous . A , fter the swelling and edema subside , an attempt

should be made to reduce the prolapse , and if success

ful , astringent injections should be used .

A o f 5 iiss o r pint of solution alum ( ) , tannic acid

ii r e ( 5 i to j) , should be injected daily through the -ﬂ turn o w catheter . Once every ten days the urethral mucos a sh ould

i to be painted with a solution of silver nitrate ( gr . j 3 i) This line of treatment should not be continued e longer than three months , when surgical interferenc should be resorted to if no beneﬁcial results have been attained . The best surgical procedure is obtained by r e f moval o the prolapsed mucosa . Th e patient should be given a general anesthetic . The prolapsed mucosa is seized with tissue forceps A and made taut by traction . chromic catgut liga ture is carried through the upper edge o f the ex

o ut ternal meatus , directly across the canal , and through the lower margin of the urethral oriﬁce .

. The prolapsed mucous membrane is cut away in front of the ligature with a pair o f curved scis

tra n sﬁ xio n sors , and the suture is caught with a pair o f dissecting forceps and pulled part o f the way o ut GOI DE N OF , RULES GYNECOLOGY .

of the urethral canal . The loop thus formed is cut , thus leaving two sutures , which are tied . This controls the edge of the wound at opposite points , f and thus prevents retraction o the mucosa .

N o f ext , a series interrupted catgut sutures are introduced about a quarter o f an inch apart com

‘ l e tel a r o und p y the external meatus . The continu o us c f suture should not be used , be ause o the tend ency -to pucker the meatus and eventually cause a stricture . The wound should be douched daily with some h o t 2 antis eptic solution, as a per cent lysol , and a

T — pad and bandage are applied . The pad should be removed for urination o r de f a i n e c t o . , and the wound should be washed Keep the patient in bed a week o r ten days;

RET ROCE E U H L .

Remember that this is a sacculation o f the middle third of the posterior wall of the urethra , most often produced by traumatism during labor . Remember that partial incontinence o f urine in a woman who has borne children should arouse sus i n p ic o . Remember that a very frequent complication o f urethrocele is a urethritis , and this causes frequent i m and pa nful icturition . Remember that inspection reveals a bulging o n the anterior vaginal wall , which is easily compres f sible . The introduction o a sound into the urethra

222 OF GOLDEN RULES GYNECOLOGY . thritis an opening is made between urethra and v a gina at the bottom of the urethrocele and the excess

c . tissue cut away at on e The wound is sutured , and S ’ when the patient leaves her bed, a kene s pessary

fo r should b e worn several months .

R NC E CA U L . Remember that these tumors usually occur late in

- the child bearing period . They are , as a rule , found

o f at the margin the external meatus , but may be

ur e r l l located in other parts of the th a c a na . Remember that these are the most frequent tu

o f i a mors the urethra , and wh le they are usu lly sin gle , they may be multiple . — k Remember that a small , red, raspberry li e growth attached to the margin of the external meatus that is painful o n touch o r urination is nearly always a caruncle .

m m r Tr atment . Re e b e e f that a general anesthesia i s i o f is indicated . The tumor se zed with a pair for c eps , and the pedicle cut close to the urethra with a

o f pair s cissors . These growths are liable to return ; therefore it is a good plan to cauterize the base with 11 electric cautery and allow it to heal by granula tion . E I I CHAPT R V I .

E DE DISEASE S OF TH BLAD R .

TITIS CYS .

Remember that the severity o f the symptoms d e pends upon the degree o f inﬂammatory changes o c in - curring . Thus , a mild type the symptom group

is : frequent micturition, vesical tenesmus , pain, and

urinary changes . There is usually a feeling o f tenderness over the

base of the bladder , made more acute by standing .

Remember that in the severe type , in addition to

the above , there will be hematuria . The urine is

o r turbid, opaque , and contains pus , mucus , and i epithel al cells , also many bacteria . The reaction m a b e y alkaline , when there will be present trip le phosphates , ammonium urate , and amorphous phos phate . Remember that in the virulent type there will be th e o f foregoing group symptoms , and in addition,

: the following general symptoms rigors , fever , rapid pulse , and in some neurasthenia ; sometimes we have the manifestations o f a profound septic infection Treatment — . Remember that rest in bed is very 223 G D S OF OL EN RULE GYNECOLOGY .

important , and the more severe the attack the more urgent is absolute rest .

The diet must be concentrated , nutritious , and bland .

The bowels must be kept open , and daily admin i str a tio n o f Rochelle salts o r magnesium citrate is excellent .

S The urine hould be rendered bland . The regu lation o f the diet and drink is often sufﬁcient to a o

i complish this . When the ur ne is strongly acid,

S ul then alkaline mineral waters ho d be drunk , and in addition, potassium acetate or citrate combined f with the infusion o buchu should be exhibited .

l o ta ssii c et i N The e ixir buchu et p a a t s ( . given in tablespoonful doses , is an excellent diuretic and urinary sedative .

If i the urine is alkaline , then ammon um benzoate ,

i salol , or benzo c acid should be given . Hex a m ethyl ena min i n ﬁ v e —grain doses night and morning should be given to check bacterial growth and extension along the ureters to the bladder . Af ter th e acute symptoms sub side oil o f sandalwood should be given for its beneﬁcial effect o n the m u cosa .

Locally, the bladder should be irrigated with

o f some antiseptic solution , and a solution perman A a na te Of 1 4 . g potash , to per cent is the best sat ur a te d solution of boracic acid o r 1 to 2 per cent

u f o r 1 sol tion o silver nitrate , to per cent solution

o f l . ysol , may also be tried

226 N OF GOLDE RULES GYNECOLOGY .

l o re p the bladder, and when it comes into contact

a with the calculus , a peculiar click is heard , and grating sensation is imparted to the ﬁngers a s the

o f tip the instrument scrapes over it . Remember that it is not always possible to recog

e S b e niz a tone with a sound, because it may have

r come encysted o may be covered by a clot of blood , o r again it may have become attached to the anterior

o f wall the bladder , thus eluding the instrument . Remember that cystoscopic examination should be made not only to conﬁrm the diagnosis but also to determine the condition o f the mucosa of the blad

c stitiS ’ s o der , because y i a c nstant symptom when

Si there is a foreign body in the bladder , and nce the cystoscope is such a substantial help from the stand

o f point both diagnosis and treatment , it should be used in practically all bladder affections .

Treatment — to Remember that , owing the short f ness and dilatability o the female urethra, small stones may be removed safely through it , by either forceps o r manipulation . The patient should be placed in the dorsal posi tion, and the bladder thoroughly washed out with a

i i s hot borac c ac d solution . The next tep is to dilate the urethra and inject three ounces of warm normal salt solution into the bladder . Locate the stone either by bimanual palpation or by the cystoscope .

The forceps are then introduced into the bladder ,

i n is and guided by the ﬁnger the vagina , the stone grasped by the forceps and Slowly withdrawn . D SE S S OF THE BLADDER 22 I A E . 7

n me ca se r I so s , by the vaginal ﬁnge s and counter e pressure over the symphysis , the stone may b worked along into the urethral opening , whence it may be pushed along by the vaginal ﬁngers through the external meatus . Remember that litholapaxy Should be attempted on moderate-Sized stones that are soft and easily Af crushed . ter thoroughly crushing the stone , the bladder should be thoroughly irrigated through a glass catheter . Remember that suprapubic cystotomy is the o p era tio n indicated in girls not having reached the age f o puberty, and in women when the stone is very large .

0 D A S I " 23 I GNO TIC NDE .

— ’ co n t d . a 222 Bartholinitis C runcle of the urethra , a 3 5 1 7 5 disch rges as , Catarrhal salpingitis , a s 36 1 24 1 69 filth , Cervical polypi , , 35 1 69 gonorrhea as , discharge in , s a 1 69 inflammation and uppura dysmenorrhe in , n 36 1 69 tio as , endocervicitis with , ' r ntia t d 36 difl e e e from hernia, examination for, 1 7 0 3 7 1 69 from hydrocele, fibroid , 3 6 m 1 69 edema in , he orrhage in , 36 1 69 symptoms of, leucorrhea in , a a 1 69 with pruritus , 36 menorrh gi in, S m 1 69 Bivalve peculum in instrumental ucous , n 1 9 diag osis , Cervix, acquired atresia of the, 1 7 0 Bladder, descent of, in prolapse 1 22 1 7 2 of the uterus , stenosis of the, 22 3— 22 7 14 1 diseases of the , cancer of the, 226 1 9 stone in the, color of the, 22 5 1 61 1 67 vesical calculus in the , hypertrophy of the , , m n in in Blood exa inatio diagnosis , imperforate, amenorrhea, 204 1 60 lacerations of the, 1 69 polypi of the, 7 0 Chafing of the vulva, v a 5 6 Cachexia , cancerous, of the Chancre , i a 99 a 5 g n , char cter of, 7 1 4 5 f in sarcoma of the uterus , dif erentiated from chancroid, 22 5 5 7 Calculus , vesical , 32 66 Cancer as cause of vulvitis , from herpes of the vulva , ff e cho rio e i o a o f 5 di erentiat d from p peri d of incub tion , 7 th elio m a 17 4 , primary, 5 7 1 4 1 5 of the cervix, secondary lesion of, 7 1 84 5 2 of the ovaries , Chancroids, 14 1 5 3 of the uterus , appearance of, ’ a e 1 41 difl erentia ted 5 7 g in , from chancre , 1 42 65 blood following coitus in , from herpes of the vulva , ff m 5 3 di erentiated fro myoma , discharge of, 142 5 4 pain of, 1 4 2 a 5 2 from retained placenta , prim ry, Of 5 3 from tuberculosis the secondary, 1 42 e 3 endometrium , time of appearanc of, 5 142 200 discharge in, Change of life , m 1 42 2 0 endo etritis with , Chemical diagnosis,

irregularity of menstruation Chest, physical examination of, 1 in , 41 1 7 i 9 8 1 7 3 of the vag na , Chorioepithelioma, 99 cachexia in, after expulsion of hydatid n m 9 9 1 7 3 pai as sympto of, mole, ff 1 7 4 with hemorrhage and dis di erentiated from cancer, 9 9 m m hem o r charge, fro postpartu f rha e 1 3 Carcinoma dif erentiated from g , 7 a ae 45 1 7 3 elephanti sis vulv , discharge in , u e 1 41 e a m n fo r 1 3 t ri, x inatio , 7 DIA S D 231 GNO TIC IN EX .

— ’ — ’ on t d c nt . Chorioepithelioma c . Cysts of the vagina o d 1 7 3 ff m hemorrhage in, di erentiated fro cystocele, a 1 3 9 8 leucorrhe in, 7 1 7 3 9 8 pain in, from rectocele , 1 7 3 t 9 7 pregnancy as cause of, interfering wi h coitus , C 1 80 t 9 7 irrhotic ovary, symp oms of , 200 th e 3 9 Climacteric, of vulvovaginal ducts , s 60 3 9 Clitoris , adhe ions of the , character of, t 3 8 Coi us, blood following, as evi glands , 39 dence of cancer of uter character of , 1 42 38 us , result of gonorrhea , 1 85 frequent , as cause of vaginitis , ovarian, 9 1 differentiated from uterine ﬁb ro ids 1 3 7 interfered with by adhesions of , 63 labia , t i 9 7 by cys s of the vag na , o 7 8 by sten sis of the vagina , o f D 2 03 Colpocele the vagina, anterior, elayed menstruation , 8 1 D ermatitis of the vulva , simple, 8 1 7 0 posterior, Condylomata as secondary l e Diabetes as cause o f eczema of 5 7 67 sions of syphilis , vulva , 2 7 3 1 Constipation , Of vulvitis , ae ’ caused by cysts of the vagina , pruritus vulv as symptom in, 9 3 3 9 2 7 D 1 5 — 2 1 causes of, iagnosis, 8 3 a t 1 5 in cystocele and rectocele, ﬁrst glance , t 1 8 0 2 1 Cys ic ovary, blood examination in , C t 22 3 20 ys itis , chemical , 223 t 20 frequency of urination in , explora ory incision in, 223 1 5 hematuria in , general , 223 1 8 symptoms of , instrumental , 223 u 1 9 urine in, bivalve specul m in, c 8 1 tr 1 9 Cysto ele , perineal re actor in , 1 9 associated with prolapse of the use of sound in, 8 1 uterus , menstruation in reference to , 83 constipation in , 1 6 8 3 20 diagnosis of, microscopical, 1 7 differentiated from cysts of the physical , V 9 8 1 7 agina , of abdomen , 1 from prolapse of the uterus , of chest, 7 82 1 7 of pelvic organs , 8 2 in 1 6 from vaginal hernia , questions to ask patient , 8 3 D f i tumors , if erentiating appendicit s from no n- improper repair of, cause of puerperal ovaritis, 22 5 1 vesical calculus , 7 8 O f 8 3 1 8 6 symptoms , . ascites from ovarian cysts , t o f 36 Cys oscope , use , in vesical cal bartholinitis from hernia , cul us 2 26 C , cancer from horioepithelioma , 9 7 1 7 4 Cysts of the vagina , 9 7 o f m causing constipation , the uterus from yoma, 9 1 2 hemorrhoids , 7 4 D A S I N DE x 232 I GNO TIC .

D f h — n t’ Differentiating cancer of the if erentiating ernia co d . ’ — t a o f uterus co n d . of the v gina from cysts a a from retained placenta , the vulvov gin l glands , 1 42 8 8 t from uberculosis of the from tumor of the labium , 1 42 8 8 endometrium , ca r cim o m a a u from elephanti sis herpes of the, v lva from ae 45 66 vulv , chancre , 5 7 65 chancre from chancroid , from chancroid, 65 from herpes of the vulva , from eczema , 65 3 7 hydrocele from bartholinitis , 5 7 chancroid from chancre, of the labium majus from o f 48 from herpes the vulva , hernia , 65 hypertrophy of the cervix from h o rio é ith elio m a c p from cancer , prolapse of the uterus, 1 7 4 1 68 from postpartum h em o r myoma from cancer of th e r ha e 1 3 e 1 42 g , 7 ut rus , - cirrhotic ovary from cystic no n puerperal ovaritis from a p 1 8 0 endi citi s 1 8 ovary , p , 7 c m 1 86 ystic ovary fro cirrhotic ovarian cysts from ascites, 1 8 0 fi br o ids 1 3 ovary , from , 7 1 8 cystocele from cysts of the from pregnancy, 6 V 9 8 fibr o ids h agina , polypi from of t e o f 1 3 1 from prolapse the uterus , uterus , 8 2 postpartum hemorrhage from 8 2 Ch 1 3 from vaginal hernia, orioepithelioma , 7 8 3 fi bro id tumors , pregnancy from s of the 1 3 7 cysts of the vagina from cysto uterus , 9 8 1 cele , from ovarian cysts , 86 9 8 from rectocele , prolapse of the uterus from o f 8 2 the vulvovaginal glands cystocele, 8 8 from hernia , from hypertrophy o f the cer 1 68 displacements of uterus from vix, fibro ids 1 37 , rectocele from cysts of the va fi b ro ids 9 ectopic gestation from gina , 8 1 3 7 ~ of uterus, retained placenta from tubercu eczema from herpes of the l o sis of endometrium , u 65 1 42 v lva , ‘ elephantiasis vulvae from carci retrodisplacement o f the uter 45 fib ro ids 1 1 noma , us from , 6 44 - f , tubO a 1 1 6 rom syphilis from ov rian mass , fib ro ids of uterus from dis suburethral abscess from ure m 1 3 p , 7 th ro cel e 22 1 lace ent , c 1 37 from ectopi gestation , syphilis from elephantiasi s 1 37 ae 44 from ovarian cysts , vulv , 1 3 1 s o f from polypi , tuberculo is endometrium 1 37 from pregnancy , from cancer o f the uter 1 1 6 p , 1 42 from retrodis lacement us , t 36 - hernia from bartholini is , tubo Ovarian mass from retro from hydrocele of the labium displacement o f the m 48 e u 1 1 ajus, ut r s, 6

34 S " 2 DIAGNO TIC INDE .

— ’ F — ’ E o n t d . n t d ndometritis c ibromata of the uterus co . 1 5 3 e gonococcus in , as caus of uterine displace 1 5 2 1 3 1 gonorrheal , ment , 1 5 2 f infectious , dif erentiated from displace - 1 5 2 1 37 non infectious , ments , 1 5 2 1 3 pregnancy in , from ectopic gestation , 7 t to o f 1 3 salpingi is due extension , from ovarian cysts , 7 1 7 5 1 3 1 from polypi , s 9 1 1 3 7 eptic, as cause of vaginitis , from pregnancy, s o 1 5 3 o 1 taphyl coccus in, dysmen rrhea in; 36 1 5 3 1 3 1 streptococcus in , hemorrhage in, c t 1 42 1 33 with can er of the u erus, hydronephrosis in, E 1 3 1 1 32 ndometrium , inﬂammation of interstitial , , 147 1 3 1 1 33 the , intraligamentous, , c f m 1 3 1 1 32 tuber ulosis of the , dif erenti enorrhagia in , , , ated from cancer o f the 1 36 142 m 1 36 uterus , etrorrhagia in, E 7 2 a 1 33 rysipelas of the vulva , p in in, 7 3 n 1 34 abscess formation in , pregna cy with, S tr e t c ccus er 1 30 caused by p o o y size of, s i e la tts 7 2 1 29 1 32 1 36 p , sterility in , , , 7 3 1 2 9 1 3 1 1 36 gangrene in, submucous , , , 2 1 3 1 1 32 symptoms of , 7 subserous , , w 7 3 F m 1 29 ith pruritus, ibromyo a of the uterus , ’ E fo r Fi la ma sa n uin is h m i nis xamination cervical polypi, g o , ele 1 69 ha ntia s is a p vulv e due to, C ma 1 7 3 44 for horioepithelio , fo r 1 94 V 2 1 7 ectopic gestation , Fissure, esicourethral , fo r i s 1 83 F prolapse of the ovar e , istula , vesicovaginal, as cause 1 23 o f v 67 of the uterus , of eczema ulva, f r 1 6 o f 3 2 o salpingitis, 7 vulvitis , 2 0 F 3 1 of urine , ollicular vulvitis , i n vulvitis , 3 1 of young girls or unm a rried 1 women , 8 1 8 rectoabdominal, E 18 e xtrauterine pregnancy, 7 Gangren in erysipelas of the v u 3 lva , 7 o f Glands , vulvovaginal, cysts , 38 Gonococcic inﬂammation of the F th e 1 22 1 45 alling of womb, uterus , F o 1 5 3 allopian tubes , diseases of the , Gonoc ccus in endometritis , 1 5 1 00 7 Gonorrhea , 1 90 1 03 Fetus in ectopic gestation , acute , F 1 69 a t 36 ibroid cervical polypi , as cause of b rtholini is , o f 1 29 Fibroids the uterus, of cysts of vulvovaginal f retro dis 38 dif erentiated from glands , e 1 1 6 s 1 5 5 placem nt , of endocerviciti F i 1 84 1 47 ibromata of the ovar es , of metritis , 1 29 9 0 of the uterus , of vaginitis, a 1 36 1 03 bortion in, character of pus in , D A S D 235 I GNO TIC IN EX .

— ’ - — ’ o n t d Of co nt d. Gonorrhea c . Herpes the vulva 1 03 65 chronic, from chancroid, o f 102 65 communication , from eczema, 1 04 65 diagnosis of, pregnancy causing, 102 h 65 in children , wit menstruation , 1 01 seriousness of , History and record of patient , o f 1 03 o symptoms , imp rtance of keeping, 1 5 2 1 6 Gonorrheal endometritis , 1 7 5 n as cause of salpingitis, Hormone, a secretio in ovula 2 1 3 1 9 9 urethritis, tion , " 9 1 1 04 H o a vaginitis, , ydatid m le , chorioepitheliom 3 1 32 1 04 o f 1 7 3 vulvitis, , , after expulsion , H f Gout as cause of dysmenorrhea , ydrocele dif erentiated from 209 37 bartholinitis, 94 48 Granular vaginitis, of the labium majus , ff di erentiated from hernia , H 48 S o 48 ingle or d uble , 205 a Hematocolpus, Hydrometra in acquired atresi 204 1 7 0 Hematometra , of the cervix, in acquired atresia of the cer Hydronephrosis in uterine fi 1 7 0 b ro ids 1 33 vix , , 2 05 m e a m eno r Hematosalpinx , Hy en , imperforat , in 223 204 Hematuria in cystitis, rhea , 225 1 67 in vesical calculus , Hypertrophy of the cervix , Hemorrh a ge as symptom of ca n causing displacement of the o f 9 9 1 6 cer the vagina, uterus , 7 m 201 f at enopause, dif erentiated from prolapse 1 69 1 68 in cervical polypi , of the uterus , C 1 7 3 1 6 1 in horioepithelioma, from lacerations , 1 89 1 94 in ectopic gestation , , occurring in virgins or fib ro m a ta 1 3 1 n 1 67 1 68 in of the uterus , sterile wome , , o f 127 1 67 in inversion the uterus , supravaginal, 1 45 in sarcoma of the uterus , Hemorrhoids ca used by cysts o f 9 the vagina , 7 1 85 a m e no r by ovarian cysts , Imperforate cervix in n ff 2 04 Her ia di erentiated from bar rhea , tho l initis 36 204 , hymen in amenorrhea , from hydrocele of the labium Incontinence of urine in. strie m 48 2 1 6 aj us , ture of the urethra , 5 0 2 1 6 inguinolabial , in urethrocele , 87 of the vagina, Inflammation of the endome f m trium 1 47 dif erentiated fro cystocele, , 82 146 of the uterus , v ul v o i 146 from cysts of the gonococcic , 8 8 209 vaginal gland , pelvic, with dysmenorrhea , 5 0 from tumor of the labium , Inguinolabial hernia , 8 8 5 0 containing intestine, v 65 5 1 Herpes of the ulva , omentum , f m 5 0 1 dif erentiated fro chancre , the uterus , , 5 66 a 18 Instrument l diagnosis, 236 " DIAGNOSTIC INDE .

ﬁbro ids e n a v a Interstitial of the uterus , L ad poisoni g as c use of 1 3 1 1 32 in ism us , g , 7 5 1 88 e pregnancy, L ucorrhea causing dermatitis of 1 88 0 rupture in, the vulva , 7

Intestine , inguinolabial hernia in acquired stenosis of the cer 5 0 1 7 2 containing , vix, ﬁ br o ids t 1 5 2 Intraligamentous of the in acute endome ritis , 1 3 1 1 33 1 69 uterus , , in cervical polypi , 1 9 3 1 7 3 pregnancy, in chorioepithelioma, 1 9 3 1 5 6 Intraperitoneal pregnancy, in endocervicitis , 1 2 6 12 7 Inversion of the uterus , in inversion of the uterus, 1 26 o 1 90 complete, Lithopedi n , a 1 27 e e h a ntia hemorrh ge in , Lymphangitis , acute , l p ' - 1 27 a 44 in non gravid uterus, sis vulv e begins as, 1 27 leucorrhea in , 12 6 partial, ca o f polypoid tumor as use , 12 6 Masturbation as cause o f v a 1 26 inism us 5 pregnancy as cause of, g , 7 m o f 1 26 sy ptoms , due to adhesions of the clitoris, 6 1 u ae 40 to pruritus v lv , 200 Menopause , 200 age occurring at, " ae 42 raurosis vulv , o f 2 00 42 characteristics , a progressive atrophy , 20 1 emorrhage at , m a h atrophy of labia and ny ph e m 201 4 3 sy ptoms of, in , 2 0 enorrhagia, 7 m a 43 M y cause pruritus , o f 20 causes , 7 1 69 in cervical polypi , 1 7 9 in chronic ovaritis , ﬁbro ids 1 31 1 32 in uterine , , , 1 36 Labia , atrophy of the, in krau a 43 1 9 8 rosis vulv e, Menstruation , o f 62 o f 2 04 majora , adhesions the, absence , 48 f o f the hydrocele of the , af ected by prolapse o f 1 83 most common situation ovaries , 5 6 1 9 — 2 12 chancre, and its disorders , 7 m ff 1 9 9 ost frequently involved in di erences in , ae 44 1 9 8 elephantiasis vulv , discharge during, 46 o f a 6 in varicose veins , herpes vulv with , 5 1 60 to 1 6 Lacerations of the cervix, in reference diagnosis, 1 60 1 6 1 th bilateral , , irregularity of, in cancer of e 1 60 1 41 causes of, uterus , na 1 62 a 2 09 exami tion for , p inful , to 1 61 leading cancer, in acquired stenosis of the 1 61 17 2 to hypertrophy, cervix, 1 60 2 02 multiple , precocious , 1 62 a 2 03 salpingitis from, ret rded, 1 60 1 61 o f 1 9 stellate , , symptoms , 8 1 6 1 14 symptoms of , Metritis , 7 u 1 60 1 61 s in 149 nilateral , , di charges ,

3 D GN T C E" 2 8 IA OS I IND .

1 o — n t’ 7 c d . Physical diagnosis , Pr lapse of the ovaries o Physometra in acquired atresia with s ubinvolution of the 1 7 0 1 83 of the cervix, uterus, o f 2 1 8 Placenta, chorioepithelioma de the urethra , v el o in 1 22 p g at the site of of the uterus , 1 7 3 ff the , di erentiated from cystocele , Polypoid tumor as cause o f in 82 o f 1 2 6 h version uterus , from hypertrophy of t e 1 24 1 69 168 Polyp us , cervical, , cervix,

1 30 fo r 1 23 . uterine , examination , f fib ro ids o f 1 22 dif erentiated from , falling bladder in, 1 3 1 23 producing rectocele , 1 o f m 1 22 Posterior displacement the sy ptoms of, 1 1 2 uterus , with cystocele and rectocele, Postpartum hemorrhage differen 8 1 tia te d cho r io e i ae 39 from p Pruritus vulv , th el io m a 1 7 3 3 9 , a reflex symptom , 202 36 Precocious menstruation , bartholinitis with , t Pregnancy , adhesions of labia caused by diges ive disturb 63 a nces 40 hindrance to, , u 1 8 8 amp llar , due to a neurosis , 40 6 as cause of chorioepithelioma , eczema with , 7 1 7 3 3 erysipelas with, 7 65 ae m a of herpes of vulva, kraurosis vulv y cause, o f 42 of inversion the uterus, 1 26 o f as 4 result m turbation, 0 220 40 of urethrocele , of sexual excess , o f r 46 e 39 va icose veins, symptom in diab tes , ff m s 3 1 di erentiated fro ovarian vulviti with, 1 86 5 cysts , with granular vaginitis, 9 fib ro ids 1 37 u 1 9 from uterine , P berty, 7 1 8 7 Of 1 9 7 extrauterine , age , 9 5 1 9 granular vaginitis in, changes in, 7 1 5 2 a 148 in endometritis , Puerper l sepsis, 1 8 8 1 7 5 interstitial , Purulent salpingitis , t 1 9 3 36 in raligamentous , Pus in bartholinitis, 1 93 1 03 intraperitoneal , in gonorrhea , character of, 1 8 7 3 1 normal, in vulvitis, physiological amenorrhea dur Pyometra in acquired atresia of 1 98 the i 1 0 ing, cerv x, 7 1 8 7 tubal , - n 1 8 8 tubo ovaria , 4 varicose veins in , 7 fi b r o ids 1 34 m n 1 8 with uterine , Rectoabdominal exa inatio , 1 22 8 1 Procidentia uteri , Rectocele , 1 82 ff the Prolapse of the ovaries , di erentiated from cysts of a 1 8 3 9 8 dysmenorrhe in , vagina, 1 83 o examination for, pr duced by prolapse of the f 1 23 menstruation af ected by, uterus, 183 Reta ined placenta differentiated 1 8 3 er u pain in , from canc of the ter n a 1 83 us 142 with chro ic ov ritis, , DIA S D 239 GNO TIC IN EX .

instru S Retractor , perineal , in tenosis of the cervix, acquired, 1 9 1 7 2 mental diagnosis , th e 7 8 Retrodisplacement of the uterus of vagina , acquired, differentiated from fi Sterility in acquired stenosis of b ro ids 1 1 6 1 7 2 , the cervix, - fi b ro m a ta the t 1 2 9 from tubo ovarian mass, in of u erus , , 1 1 6 1 32 , 1 36 Retr o fl ex io n 1 1 5 of the uterus , in retrodisplacement of the w t 209 t 1 1 4 i h dysmenorrhea , u erus , 1 1 3 1 7 6 Retroversion of the uterus , in salpingitis , Rheumatism as cause of dys in superinvolution of the uter 209 1 9 menorrhea , us , 5 St in 226 one bladder, S tr e to co ccus S p in endometritis , 1 5 3 S a cch a r o m ces a lbi ca ns cr s t e la ti s y as cause y p causing erysipelas ,

69 . 2 of thrush of vulva , 7 1 7 5 2 15 Salpingitis , Stricture of the urethra , t 1 7 t ca arrhal , 5 difficul or frequent urina to 2 1 6 due extension of endometri tion in , 1 7 5 ' 2 1 6 tis , symptoms of, 1 7 6 S u t t 1 1 3 1 5 7 dysmenorrhea in , binvolu ion of u erus, , 1 7 6 1 5 7 examination for, causes of , t s t from lacera ion of the cervix , wi h prolapse of the ovaries , 1 62 1 8 3 1 5 fi b ro ids pain in, 7 Submucous of the uterus , 1 7 5 1 30 1 3 1 purulent, , 1 7 6 S fib ro ids o f sterility in , ubserous the uterus , 144 1 3 1 Sarcoma of the uterus , 1 44 S o age in , uperinvoluti n of the uterus , 1 45 1 5 9 ascites in , 1 4 5 1 5 9 cachexia in , abortion as cause of , 145 1 5 9 hemorrhage in , amenorrhea in, - 145 1 5 9 round celled , large, causes of , 145 t 1 5 9 small, s erility in , - 145 Subr a v a ina l spindle celled , g hypertrophy of the t 1 45 1 67 symp oms of, cervix, 9 5 S t Senile vaginitis , yphilis differentia ed from ele 1 47 h a ntia s is ae 44 Sepsis as cause of metritis , p vulv , 148 puerperal , Sexual excesses resulting in pru ae 40 ritus vulv , T 69 Sound in instrumental diagnosis, hrush of vulva, 1 9 most frequent in nursing S instr um en 69 peculum , bivalve , in women , 1 9 S a ccha r o m ces a l bi ca ns tal diagnosis , y t 69 examina ion with , for lacera cause of , 1 63 T 1 89 tions of cervix , ubal abortion , ir o chce ta a l lida 5 8 1 8 Sp p , pregnancy, 7 t t T S aphylococcus in bar holinitis, uberculosis of the endometrium 3 6 differentiated from ca n m 1 5 3 cer u 142 in endo etritis, of the uter s , 240 " DIAGNOSTIC INDE .

’ T - ff — co n t ubo ovarian mass di erentiated Uterus d . 1 2 6 from retrodisplacement inversion of the, 1 1 6 no n- 1 2 of the uterus , gravid , 7 1 88 147 pregnancy, metritis of the, T th e m f the 1 2 9 umors of labiu dif erenti myoma of , 8 8 m fi b r o m a 1 2 9 ated from hernia , yoma of the, o f 1 84 the 1 1 2 the ovaries , solid , normal position of , V ff t 1 30 aginal , di erentia ed from polypi of the , 8 3 t cystocele , pos erior displacement of the, 1 1 2 1 2 2 U prolapse of the , r etro fl ex io n o f 1 1 5 the, a 222 t 1 1 3 Urethr , caruncle of the, re roversion of the , 2 1 3— 2 22 1 44 diseases of the, sarcoma of the, 2 1 8 1 1 3 1 eversion of the , subinvolution of the , , 5 7 2 1 8 1 pouting of the, superinvolution of the, 5 9 2 1 8 prolapse of the , 2 1 5 stricture of the , V 2 1 3 Urethritis , 2 1 3 t causes of, Vagina, acquired s enosis and 2 1 3 th e 7 8 gonorrheal , atresia of , 2 1 3 9 8 symptoms of , cancer of the , 22 0 th e 8 1 with urethrocele, colpocele Of , anterior , 2 20 8 1 Urethrocele, posterior , 22 0 8 1 as caused by pregnancy, cystocele of the , f subur e 9 dif erentiated from cysts of the , 7 th ra l s e 22 1 7 8— 1 1 ab c ss , diseases of the, 1 22 0 o f 1 00 incontinence of urine in , gonorrhea the, 2 2 0 8 w th urethrit s , hernia of the, 7 i i " f 8 1 Urination , dif icult and frequent, rectocele of the, 7 5 in stricture of the ure Vaginismus , 2 1 6 7 5 thra , causes of , 225 7 5 in vesical calculus , lead poisoning as , in 7 5 vesicourethral fissure, masturbation as , 2 1 7 neuralgic dysmenorrhea with, 2 23 7 5 frequency of, in cystitis , 2 0 7 5 Urine , examination of, symptoms of, 3 1 9 0 in vulvitis , Vaginitis , 22 3 9 1 in cystitis , chronic, 9 1 incontinence of, in stricture of diagnosis of, 2 1 6 9 1 the urethra, frequent coitus as cause of, 2 20 9 in urethrocele , gonorrhea as cause of, 0

14 1 n 9 1 . 1 04 Uterus , cancer of the , go orrheal , 1 4 1 9 4 carcinoma of the , granular, s 1 1 2— 1 7 4 9 5 disea es of the , in pregnancy, flb r dids 1 29 ur itus ae 9 5 of the , p vulv with, fib ro m a ta o f 1 29 9 5 the, s en le, ‘ i fib ro m o m a the 1 29 95 y of , brought on by old age, 1 46 inflammation of the , septic endometritis as cause of, inguinolabial hernia contain 9 1 5 0 5 1 9 0 ing, , simple,

THERA E P UTI C INDE" .

Fo r D s ee 22 9 ( iagnostic Index page . )

A Anteﬂex io n of uterus with dys 2 1 0 menorrhea , 26 n o c Abortion , curettement for, Antipyri in chr ni ovaritis Acetate of lead for gonorrheal 1 82 1 . 2 5 n urethritis , Antiseptic solution in septic e a 4 3 do m etr itis 1 5 4 for kraurosis vulv e, , fo r ae 4 1 pruritus vulv , Antistreptococcus serum for m e 1 49 of potash for acid urine in ure tritis , th r itis 2 1 3 fo r 206 , Apiol amenorrhea, u r ethr i - 2 1 1 of zinc for gonorrheal for dysmenorrhea , 2 1 5 tis, for superinvolution of the uter 3 3 1 60 for vulvitis , us, fo r Acquired atresia of the cervix, Apomorphin neuralgic dys 1 7 1 2 1 2 menorrhea , o f 7 9 t the vagina , Applications, local treatmen 1 2 22 stenosis of the cervix, 7 with, 7 9 fo r 106 of the vagina, Argyrol gonorrhea, h ‘ 62 1 09 Ad esions of the clitoris, chronic, 63 r of the labia, for gonorrheal endoce vicitis, 63 64 1 5 6 congenital , , Of 1 1 8 2 1 5 the uterus , urethritis, h em o r 95 Adrenalin solution for for granular vaginitis , rh a e 25 A fo r 2 1 1 g , spirin dysmenorrhea , o S en fo r Alc holic timulants in septic Astringent powders vaginitis , tr i 1 do m e tis , 5 5 94 fo r 2 06 Aloes amenorrhea , Astringents for cancer of the m o f 1 44 Alu for prolapse the urethra, uterus , 2 1 2 1 5 9 for gonorrheal urethritis, 2 06 fo r o f Am enorrhea , prolapse the urethra, with acquired stenosis or atre 2 1 9 206 fo r 22 1 sia , urethrocele, a Ammonia in septic endometritis, Atresi of the cervix, acquired, 1 5 4 1 7 1 m o f 7 9 A monium benzoate in cystitis, the vagina , acquired, 224 Autogenous vaccines fo r septi c 2 1 4 o 1 5 5 in urethritis, end metritis, Am putation of cervix fo r endo 1 5 6 cervicitis, B o 1 68 f r hypertrophy, 1 67 3 7 for lacerations , Bartholinitis, 1 28 a n 37 of uterus for inversion , with abscess form tio , AP D 243 THER EUTIC IN EX .

’ fo r n Bath, alkaline, eczema of the Brau s colpeurynter for inver 68 th e 1 2 vulva , sion of uterus , 8 1 5 3 t 1 82 sitz for endometritis , Bromids in chronic ovari is , fo r o f l 66 ae 40 herpes the vu va , in pruritus vulv , . 3 3 for vulvitis , Bubo developing in chancroids , ae 6 Belladonna for pruritus vulv , 5 40 o f Buchu , infusion , in cystitis , 9 4 224 tincture of, for vaginitis, 33 in 2 1 4 for vulvitis , urethritis , Benzoate of ammonium for vulvi 3 3 tis, o f 33 sodium for vulvitis, 2 14 a fo r s Benzoic acid in cystitis , Cal mine lotion dermatiti a fo r 7 1 Bicarbonate of sod follicular of the vulva, 34 el e h a ntia vulvitis , Calcium sulphid for p Bichlo rid fo r ae 4 5 of mercury solution sis vulv , 37 C 22 6 bartholinitis, alculus , vesical, 5 8 fo r the for chancre, Calomel erysipelas of 5 5 7 3 for chancroids, vulva, fo r -1 8 1 o f 1 44 chronic ovaritis, Cancer the cervix, fo r 143 erysipelas of the vulva , of the uterus, 4 1 44 7 hysterectomy for , fo r 1 06 1 08 o f 1 43 gonorrhea, , palliative treatment , a 66 143 for herpes of the vulv , radical treatment of, fo r ae 41 1 00 pruritus vulv , of the vagina , 1 5 4 for septic endometritis , with lacerations of the cervix, o f 7 0 1 63 for thrush the vulva , 9 5 nn fo r for vaginitis , granular, Ca abis indica chronic 9 6 1 8 2 senile, ovaritis , 33 ae 4 1 for vulvitis , for pruritus vulv , 34 a diabetic, Carbolic acid solution for eczem 34 o f 69 gonorrheal, the vulva , t o f 1 44 Bimanual replacement of u erus , Carcinoma the cervix, 1 1 7 o f 1 43 the uterus , a 1 00 Blackwash for eczem of the of the vagina , 69 22 2 vulva , Caruncle of the urethra , t 2 06 Bladder , stone in , removal of, Ca hartics for amenorrhea , 22 6 fo r 7 3 erysipelas of the vulva , c for o f Bora ic acid ointment pruri for subinvolution the uterus , 42 1 5 9 tus of diabetes, o f solution , saturated , for vul Cauterization for cancer the 32 1 43 vitis , uterus ; o f 1 00 Borated talcum powder for pruri the vagina , o f 42 tus diabetes , for caruncle of the urethra , 222 Boric acid solution for cystitis , fo r 5 8 chancre , fo r 5 4 eczema of the vulva , for chancroids , 69 fo r ae 60 verruc , 1 08 ~ 1 7 7 for gonorrhea , Celiotomy for salpingitis , 2 5 o 1 7 0 for hemorrhage, Cervical p lypi , 2 14 for urethritis, Cervix, acquired atresia of the, 3 3 17 1 dusting powder for vulvitis, 4 AP T N E" 2 4 THER EU IC I D .

— ’ — ’ t d n t d . Cervix con . Constipation co 1 stenosis of the, 7 2 with superinvolution of the m t endo ce r 1 60 a puta ion of, for uterus , ’ v icitis 1 5 6 , Crede s Ointment for erysipelas t 1 68 4 for hyper rophy , of the vulva, 7 1 6 for lacerations , 7 Cresol , compound solution of , o f 1 44 fo r endo cer cancer the , gonorrheal

‘ h ertro h o f 1 68 v icitis 1 5 6 yp p y the , , 1 63 m lacerations of the, for septic endo etritis, o f the 1 0 1 5 4 polypi , 7

splitting lip of , for inversion Crossen operation for shortening 1 28 o f t 8 6 of the uterus , round ligamen s, Cesarian section fo r pregnancy Curettement for acquired steno ﬁb ro ids 1 3 5 o f 1 7 2 with , sis the cervix, 5 8 o f th e t 1 44 Chancre ; for cancer u erus , 5 4 fo r 1 5 6 Chancroids , endocervicitis , 5 6 fo r 1 1 7 bubo in, endometritis , chronic , fo r 1 5 4 Chlorid of gold and sodium gonorrheal , 1 8 1 fo r ﬁ b ro ids o f u 1 38 chronic ovaritis , the uter s , 1 7 4 Chorioepithelioma , for lacerations of the cervix o f s 1 63 Citrate potash for cystitis, with endometriti , 224 fo r 2 08 menorrhagia , 2 1 4 1 5 0 for urethritis , for metritis , Or n 26 Cleanliness in eczema of the for miscarriage abortio , 68 vulva , for subinvolution of the uter ae 40 u s 1 5 8 in pruritus vulv , , u 32 r in v lvitis , for superinvolution of the ute 62 1 5 9 Clitoris, adhesions of the , us , fo r 22 3 Cocain solution adhesions of Cystitis , 62 224 the clitoris , acid urine in , fo r 5 4 5 5 224 chancroids , , alkaline urine in, fo r o 8 3 gon rrheal urethritis, Cystocele , 2 1 4 84 palliative treatment of, 7 6 o f 84 for vaginismus , radical treatment , 2 1 1 s ves Codein for dysmenorrhea , Cy totomy, suprapubic, for 1 5 0 22 7 for metritis , ical calculus , ’ e fo r a Colp urynter, Braun s , inver Cysts of the Nabothian gl nds, 1 2 8 o fo r sion of the uterus, retenti n, puncture , 8 5 25 Colporrhaphy, anterior, fo r o f 9 8 Compresses diseases of the the vagina , 1 7 9 o f 39 ovaries , the vulvovaginal glands, r a 1 86 of glycerin and ice wate for ovari n , edema in prolapse o f the 1 24 uterus , of ead and opium han l . for c c ro ids 5 5 De u 204 , layed menstr ation, fo r the D s of lysol erysipelas of epletory in chronic ovariti , 4 1 8 1 vulva , 7 2 7 — 30 o f s Constipation , in displacement the uteru , 2 1 2 1 with dysmenorrhea, 10 n u with subinvolutio of the ter in subinvolution of the uterus,

us, 1 5 9 15 8

AP D 246 THER EUTIC IN EX .

E ae 45 F lephantiasis vulv , ormula for chronic ovaritis, h 45 1 8 1 c ronic, 4 5 fo r 7 1 hemorrhage in , dermatitis of the vulva , , E 2 mmenagogues for amenorrhea , 7 2 06 fo r displacement of the uterus, E 1 5 6 1 2 1 ndocervicitis , 1 5 6 fo r 2 1 1 gonorrheal, dysmenorrhea , E 1 5 3 69 ndometritis , for eczema of the vulva , 1 5 4 1 07 chronic, for gonorrhea , t 1 1 7 r t ae 4 1 42 curet ement for, for p uri us vulv , , 1 5 4 fo r 34 35 gonorrheal , vulvitis , , 1 5 3 in virgins , 1 5 4 septic, 1 5 fever in , 5

with lacerations of the cervix , Glands , vulvovaginal , cysts of 1 63 3 9 the , l o with subinvolution of the uter Glycerin , tamponade with , in us 1 5 8 2 3 , cal treatment, E nemata for erysipelas Of the Goddard pessary for prolapse of 7 3 1 2 5 vulva , the uterus , f o r 1 5 0 Go no co ccic ides fo r metritis , gonorrhea, E 206 1 06 rgot for amenorrhea , 208 1 05 for menorrhagia , Gonorrhea , E r i el a s 7 3 1 09 yS p of the vulva, chronic , 7 3 6 fever in , local treatment for, 2 3 1 07 general treatment of, 7 of vagina, t 1 7 4 1 06 local treatmen of, of vulva , E 60 1 1 0 xcision of venereal warts , of vulvovaginal glands , E 1 95 5 6 xtrauterine pregnancy, Gonorrheal endocervicitis , 1 1 5 4 endometritis , 2 14 urethritis , 34 vulvitis , ’ F o f Go ul a r d s ever in diseases the ovaries, solution for vulvitis, 1 7 9 3 3 7 3 9 5 in erysipelas of the vulva , Granular vaginitis, 1 5 5 in septic endometritis , F 1 3 8 ibromata of the uterus , 1 38 curettement for , c 1 39 m 208 hystere tomy for, Hamamelis for enorrhagia , ’ 1 39 He a r s t intramural , g Operation for cys ocele 1 39 t 8 myomectomy for, and rec ocele, 5 fo r 1 40 r t panhysterectomy , ute ine dila or for stricture of 1 3 5 1 3 8 2 1 6 with pregnancy, , the urethra , F‘ 2 17 t issure , vesicourethral , for vesicoure hral ﬁssure, Fo ll icul a r v ul v itis 33 2 1 7 , , H Fomentations , local treatment emorrhage , adrenalin solution 2 3 fo r 2 5 with , , F 2 5 ormaldehyd for odor of dis boric acid solution for, 2 2 2 charges , formalin solution for, 5 F fo r h em o r 1 ormalin solution in ectopic gestation , 95 r ha e 25 a s ae 4 g , in eleph ntiasi vulv , 5 AP D 4 THER EUTIC IN EX . 2 7

’ ’ — d — c o n t n t d . Hemorrhage co . Inguinolabial hernia 47 t 5 2 in varicose veins , radical trea ment of, t 25 5 1 ampons for checking, truss for , n 5 1 t th e Hernia , ingui olabial, Injec ions for prolapse of ure l 8 8 t 2 1 9 vagina , hra , o f 8 8 26 reduction , Intrauterine treatment, 8 9 e c vaginolabial , Intravenous transfusion in t 1 9 6 treatment by abdominal topic gesta ion , 8 9 1 2 7 route, Inversion of the uterus, 8 9 fo r 1 2 8 by vaginal route , amputation , 66 S Herpes of the vulva, plitting of lip of cervix for, Hexa m eth l ena m in t 1 2 8 y for cysti is, 224 technic of replacement in, fo r 1 0 1 2 gonorrhea , 7 7 fo r en prolapse of the urethra , Iodin, tincture of, for acute 1 m tr iti s 2 9 do e , 2 6 w 5 6 Hill, Ho ard , operation of peri for bubo, n eo r r a h 144 p y for cure of for cancer of the uterus, t 8 5 1 8 1 rec ocele , for chronic ovaritis , t 208 1 09 Hydras is for menorrhagia , for gonorrhea ,

Hydrocele of the labium majus , for hydrocele of labium ma 49 49 jus , 4 9 1 5 4 suppuration in , for septic endometritis , t 1 68 ae 60 Hyper rophy of the cervix, for verruc , fo r 1 68 I t amputation , odoform gauze for bartholini is, Hypodermoclysis in ectopic ges 3 7 t a tio n 1 9 6 2 06 , Iron for amenorrhea , c t 224 Hystere tomy for cancer of the Irriga ion for cystitis , 144 a 4 1 uterus , for pruritus vulv e, 1 4 2 2 7 for chorioepithelioma , 7 for vesical calculus , ﬁ bro ids t 1 39 for of the u erus , 1 26 for prolapse of the uterus , - 1 7 7 for pus tubes , ﬁ b r o ids " - supravaginal , for with nee chest position for prolapse 1 35 1 84 pregnancy, of the ovaries , for replacement of the uter 1 1 7 I us , " ae 43 raurosis vulv , fo r t 43 Ice bag diseases of the pruri us with , 1 7 9 ovaries , 1 8 1 Ichthyol for chronic ovaritis ,

for subinvolution of the uterus , 1 5 8 a o f 63 L bia , adhesions the , o no r tampon of, for chronic g Labium majus , hydrocele of the, 1 09 49 rhea, fo r a 1 63 displacement of uterus , L cerations of the cervix, 1 2 1 1 64 multiple, fo r 1 64 Incision acquired atresia of repair of , 1 7 1 1 67 the cervix, stellate , In uinOl a bia l 5 1 t ra che l o r r a h 1 6 g hernia , p y, 5 n 5 2 1 63 in preg ancy, with cancer , 5 1 1 63 palliative treatment of, with endometritis, 248 AP D THER EUTIC IN EX .

M Laxatives for granular vaginitis , 9 5

Lead acetate for gonorrheal ure Magnesium citrate for cystitis , 2 thr itis , 2 1 5 2 4 fo r ae 43 kraurosis vulv , for diseases of the ovaries, t ae 4 1 17 9 for pruri us vulv , Le uco des cent 2 06 light for chan Manganese for amenorrhea , cro ids 5 5 t , for superinvolu ion of the uter t in 1 60 Litholapaxy for s one bladder , us , 2 2 7 Massage for superinvolution of 2 1— 2 1 60 Local treatment , 7 the uterus , 5 8 201 of chancre , Menopause , 2 1 2 08 of dysmenorrhea , 0 Menorrhagia, the 7 4 M t 206 of erysipelas of vulva , enstrua ion , absence of, h t 1 e 2 o f ﬁb r o ids t e 38 04 . Of u erus, delay d, 2 6 2 08 of gonorrhea , excessive , 2 14 2 1 0' of gonorrheal urethritis, painful, 25 2 03 of hemorrhage , precocious, o f ae 4 1 t 1 49 pruritus vulv , Me ritis , o f s 15 1 of subinvolution the uter apremia in , 1 5 8 t 208 us, Me rorrhagia , a 60 26 of verruc e, Miscarriage , curettement for, 33 of vulvitis , Morphin for diseases of the t 1 7 9 tamponade wi h glycerin in, ovaries , fo r r 2 1 23 dysmenor hea , 0 22 1 9 5 with applications , for ectopic gestation , 2 2 fo r 1 5 0 with hot douches , metritis , 23 fo r ﬁ b ro ids fomentations , Myomectomy of the 2 1 24 1 39 with tampons , , uterus, o f vu Lotions for eczema the lva , 68 7 5 for erysipelas of the vulva , t fo r Lysol solu ion acquired atre Nabothian glands , retention 1 7 1 sia of the cervix, cysts of the , puncture fo r 5 8 2 5 chancre , for, 5 4 5 5 for chancroids, , Neisser vaccines for gonorrhea, fo r 2 24 1 09 cystitis , 35 eura l i c 2 1 1 for diabetic vulvitis , N g dysmenorrhea ,

f , 5 4 or erysipelas of the vulva Nitric acid for chancroids , 7 4 Normal salt solution for fo llicu fo r t 3 3 gonorrheal urethritis , lar vulvi is , 2 1 4 66 for herpes of the vulva , o r o f a f prolapse the urethr , 2 9 Oil fo r 1 of sandalwood cystitis, 1 2 224 for pyometra , 7 fo r h 7 0 fo r 1 thrus of the vulva, gonorrhea , 07 9 5 fo r 2 1 4 for vaginitis, granular, urethritis , s 9 6 W enile, of intergreen for gonorrhea , 1 07 94 for vaginitis , fo r n 3 olive, co stipation , 0

25 0 AP D THER EUTIC IN EX .

— n ’ Potassium perma nganate co t d . for superinvolution of the t 1 60 8 3 u erus , Rectocele, t 84 Powders , an iseptic, for diabetic palliative treatment of, t 35 a fo r 8 5 vulvi is, perineorrh phy , 94 84 astringent, for vaginitis , radical treatment of, m 203 h Precocious enstruation , Reduction of prolapse of t e P 1 9 5 1 24 regnancy extrauterine , uterus , ﬁ b ro ids 1 3 5 1 38 1 1 with , , Replacement of uterus, 7 5 2 1 1 inguinolabial hernia in, bimanual , 7 Pfo ct o cl sis n - y in ectopic gestation, by the k ee chest position, 1 9 6 1 1 7 o f 1 83 1 27 Prolapse the ovaries , in inversion, to 1 83 1 2 1 due subinvolution, surgery for, Of - 2 1 8 n 206 the urethra , Rest in ame orrhea , 124 1 8 0 of the uterus , in chronic ovaritis, 1 24 223 edema in, in cystitis, t fo r 1 2 5 o f 1 7 9 opera ions , in diseases the ovaries , a fo r 1 06 1 5 3 Prot rgol gonorrhea, in endometritis , endo cerv ititis ” 1 0 for gonorrheal , in gonorrhea , 7 1 5 6 208 in menorrhagia , 2 1 5 o f 1 83 urethritis, in prolapse the ovaries, 34 2 1 8 vulvitis , of the urethra, f r 9 5 ae 40 o granular vaginitis , in pruritus vulv , t 42 2 1 3 Pruritus of diabe es , in urethritis, r - 42 t 9 3 f om seat worms , in vagini is, S 42 32 from kin parasites , in vulvitis , ae 224 vulv , Rochelle salts in cystitis, ae 43 with kraurosis vulv , o f Puerperal diseases ovaries, S 1 7 8

a o f fo r 224 Puls tilla , tincture , Salol in cystitis , 1 82 2 1 4 chronic ovaritis , in urethritis , 2 1 1 1 7 7 for dysmenorrhea , Salpingitis , 1 80 Puncture of follicles in vulvitis , with chronic ovaritis , l a 34 Salt, tab e, in obstinate constip 3 0 of hydrocele of the labium ma tion , 49 fo r 224 jus , Santal oil cystitis , 1 07 of retention cysts of the Na for gonorrhea , b th ia n 25 2 1 4 o glands , for urethritis , - 1 7 7 S 1 5 1 Pus tubes , hysterectomy for, apremia in metritis, 1 7 2 S 1 45 Pyometra , arcoma of the uterus , Scarlet-red ointment for chan ro id 5 6 c s , 96 Senile vaginitis, S t " uassia , infusion of, for pruri erum , antis reptococcus, for me - 4 2 t 149 tus from seat worms , ritis , u u t " inin for acq ired atresia of polyvalen , for septic endome ‘ 1 7 2 1 5 5 the cervix, tritis , fo r 15 0 S fo r metritis , hortening round ligaments fo r hydrochlorid erysipelas of prolapse of the uterus , a 4 1 26 the vulv , 7 T AP DE HER EUTIC IN X . 25 1

Shortening n ligaments Sulphate o f copper for granular . rou d ’ t co n t d . 9 5 vagini is , 8 6 o f Crossen Operation for, zinc for chronic ovaritis, 1 2 1 1 8 1 operation for, a Silver nitrate solution for cysti for gonorrhe l urethritis, 224 2 1 5 tis , 0 fo r 3 for gonorrhea, 1 6 vulvitis, 3 fo r a e ndo cerv i ci gonorrhe l Superinvolution of the uterus, 1 5 6 1 5 9 tis , 2 1 5 1 60 urethritis , with constipation , h o f 67 S fo r 7 6 for erpes the vulva , uppositories vaginismus, k ae 43 for raurosis vulv , Suprapubic cystotomy for vesical o f 2 2 for prolapse the urethra , calculus , 7 2 1 9 Supravaginal hyste rectomy fo r 6 ﬁb ro ids for vaginismus , 7 with pregnancy, fo r a 9 3 1 35 v ginitis , u 9 5 gran lar, 9 6 T senile , fo r 3 5 vulvitis , diabetic, ‘ 34 l o follicular , Tamponade with glycerin in S ’ 2 3 ims glass vaginal plug for cal treatment, 7 6 T m h em o r vaginismus , a pons for checking - fo r 1 3 rh a e 2 5 Sitz bath endometritis , 5 g , fo r 66 1 09 herpes of the vulva, for chronic gonorrhea , 33 1 8 1 for vulvitis , ovaritis , . ’ 8 ’ Skene s pessary for urethrocele, for cystocele and rectocele , 4 2 2 1 2 1 0 for dysmenorrhea , 3 3 Sodium bromid for chronic ovari for follicular vulvitis , 1 8 1 fo r 66 tis , herpes of the vulva , fo r 2 1 1 dysmenorrhea, for inversion of the uterus, 2 1 1 1 28 salicylate for dysmenorrhea , ae 42 2 08 Solutions for pruritus vulv , for menorrhagia , o f Stenosis of the cervix, acquired, for prolapse the ovaries, 1 7 2 1 8 3 7 9 1 24 of the vagina , acquired, of the uterus , S t ae 4 1 tone in the bladder, removal of, for pruri us vulv , 226 for subinvolution of the pelvic o 1 20 Strangulati n of vaginolabial organs ; n 89 0 her ia , for thrush of the vulva , 7 o f 2 1 6 9 3 Stricture the urethra, for vaginitis , fo r 9 5 Strychnin acquired atresia of granular , ' 1 7 2 9 6 the cervix, senile , 206 t 2 1 24 for amenorrhea, local trea ment with , , 7 3 for erysipelas of the vulva , Tannic acid for prolapse of the t 1 5 0 2 1 9 for metri is , urethra , o r T o f Subinvolution of the pelvic axis in prolapse the uterus, 1 20 1 24 gans, ‘ o f 1 5 8 T the uterus , hermocautery for chancroids, 1 5 8 5 4 general treatment of , 1 5 8 T o f th e u 0 local treatment of , hrush v lva , 7 n 1 5 9 T a fo r ae with co stipation , huj , tincture of, verruc , 1 5 8 60 with endometritis , 25 2 AP D THER EUTIC IN EX .

T 22 1 hymol solution for eczema of Urethrocele , 69 2 2 1 the vulva , from stricture , T fo r t 22 1 incture of belladonna vag with ure hritis , t 94 224 ini is , Urotropin for cystitis , fo r 33 1 07 vulvitis , for gonorrhea , er s i e a of chlorid of iron for y p for prolapse of the urethr , a 4 2 1 9 las of the vulv , 7 5 6 1 1 8 of iodin for bubo , Uterus , adhesions of, 1 44 1 4 3 for cancer of the uterus , cancer of the , fo r 1 8 1 ﬁ br o ids o f 1 3 8 chronic ovaritis , the , 2 6 ﬁ br o m a ta 1 38 for endometritis , of the , fo r 1 09 1 2 gonorrhea , inversion of the , 7 fo r 1 28 hydrocele of labium ma amputation for, 49 the jus, posterior displacement of , fo r 1 5 4 1 1 6 septic endometritis , ae 60 a 1 24 for verruc , prol pse of the, o f o f 1 1 pulsatilla for chronic ovari replacement the, 7 1 8 2 a 1 1 tis , bim nual , 7 a 6 - 1 1 of thuja for verruc e, 0 knee chest position for , 7 ‘ T o f 1 45 onics for acquired atresia sarcoma of the , 1 7 2 t 1 5 8 the cervix, subinvolu ion of the , 206 1 5 9 for amenorrhea , superinvolution of the, 1 8 1 for chronic ovaritis , 66 for herpes of the vulva , fo r prolapse of the urethra , 2 1 8 fo r Vaccines , autogenous , septic ae 40 1 5 5 for pruritus vulv , endometritis , t 1 5 4 1 09 for sep ic endometritis , Neisser , for gonorrhea , , a 60 1 1 0 for verruc e , ’ T endo cer v ici W t rachelorrhaphy for righ s , for septic endometri 15 6 1 5 tis, tis , 5 nd for lacerations of the cervix, Vagina , acquired stenosis a 1 65 7 9 atresia of the, T c c 1 00 ransfusion , intravenous , in cancer of the , 1 9 6 8 3 topic gestation , cystocele of the , T fo r 9 8 russ inguinolabial hernia, cysts of the , 5 1 o f 1 0 gonorrhea the, 7 T o f 1 8 5 8 8 umors the ovaries , hernia of the, r eto ce l e 8 3 of the , 7 6 U Vaginismus , fo r 7 6 forcible dilatation , 222 7 7 Urethra , caruncle of the , operation for , 2 1 8 9 3 prolapse of the , Vaginitis , 2 16 9 5 stricture of the, granular , 2 1 3 9 6 Urethritis, senile , 2 1 3 89 acid urine in , Vaginolabial hernia , ’ e 2 14 H t alkalin urine in, Van orn s obste rical catgut for 2 14 c o f gonorrheal , la erations the cer s 2 15 1 67 ulcer in , vix , ’ 4 7 with involvement of Skene s Varicose veins, 2 1 5 4 7 glands , hemorrhage in , 22 1 47 with urethrocele, palliative treatment in,