PART VI.

TREATMENT IN GENERAL.

THE treatment of gynecological diseases is preventive and curative, the latter again is carried out by external manipulations, by the internal use of drugs or by electricity.

Preventive Treatment.-What can be done and is to be attempted in the way of preventing gynecological diseases, can easily be inferred from a study of the chapter on etiology, but the beginner must not be too sanguine in his expectations or too positive in his demands, if he will avoid disappointment or the loss of his patient. As soon as his advice clashes with that of the dressmaker or social habits, ninetynine women will be decided by these last two factors for one who will follow the first. Where this antagonism does not come into play, much good may, however, be done by timely warning.

At puberty girls should not be exposed to mental overwork, and at no time should the practice of music be carried so far as to engender nervousness. All sexual excesses and unnatural practices should be avoided. The skin should be kept clean. The muscles should be strengthened by exercise and games. Some time, at least an hour every day, should be spent in the open air. Good, wholesome food should be taken at proper times, and in sufficient quantity to make up for the physiological tissue-consumption. The bladder should be emptied when a desire is felt to do so. An evacuation from the bowels should take place once or twice a day. The body should be sufficiently covered, especially in the cold season. In winter time women should wear woollen drawers, but they should not be "closed," as this tempts to neglect proper evacuation of the bladder. Corsets ought to be banished from the dress of children, girls, and young women. All of them ought to go early to bed-as a rule, not later than ten o'clock. During menstruation they should carefully avoid exposure, violent exercise, or sexual intercourse. If suffering from chronic pelvic inflammation they had better abstain from marriage. Good midwifery, both as to surgical help and conscientious use of antiseptics, not only in hospitals, but in private practice,' goes far to prevent later disease. Puerpera should be kept in bed until the uterus has receded into the pelvis.

Lacerations of the cervix and the perineum, if not healed immediately after delivery, should be repaired by the proper operations before the bad effects consequent upon them make their appearance. Women should be told to what enormous dangers they expose themselves by availing themselves of abortionists, and miscarriages should

be treated with great care according to the tenets of modern midwifery, and especially all the products of conception should be removed. Antiseptic precautions should be taken as far as feasible, even in minor gynecological operations and examinations. A man who has had a gonorrhea should not marry before a careful examination by a competent judge has ascertained that he is perfectly cured.

EXTERNAL TREATMENT.

A. Applications.-Applications of medicinal substances are made to the vagina or to the uterus. The patient is in Sims's position, the parts are exposed with Sims's speculum and my depressor (p. 147). After having wiped the mucus off with absorbent cotton, the vaginal vault is painted with common tincture of iodine, by means of a large camel's-hair brush on a long handle. The throat-brushes with wooden handle that are found in the drug-stores, are quite serviceable for this purpose. As the iodine smarts when it reaches the vulva, care should be taken not to fill the brush too much, and to wipe the superfluous fluid off with absorbent cotton before the patient rises. In the vagina I prefer the common tincture of iodine to Churchill's, as I have seen the latter produce ulceration.

For applications to the interior of the uterus an applicator is needed.

The writer has for the last ten years repeatedly called the attention of the profession to the importance of aseptic and antiseptic midwifery. He was the first to introduce strict antisepsis in this country. On the first day of October, 1883, the whole arrangement of the New York Maternity Hospital was changed, and the results were so striking that the example was soon followed by others, and that the treatment then inaugurated has been kept up ever since with insignificant modifications. His first report was given in a paper on "The Prevention of Puerperal Infection" read before the Medical Society of the County of New York, and published in the Medical Record, December 29, 1883, vol. xxiv., pp. 703-706. Soon followed an article under the same title, especially on the use of injections, published in the New York Medical Journal, March 1, 1884. Then came a paper on "Puerperal Diphtheria" published in Transactions, Amer. Gynecol. Soc., vol. x. 1885, pp. 96–113. Next, he treated the whole subject of puerperal infection at greater length in bookform in his Practical Guide in Antiseptic Midwifery, Detroit, Mich., 1886, and in a long article on "Puerperal Infection" in the American System of Obstetrics, edited by Hirst, Philadelphia, 1889, vol. ii. pp. 290-378. The article on "Corrosive Sublimate and Creolin" in Amer. Jour. Med. Sci., August, 1889, contained the only change he in the course of time found it advisable to make.

In hospital practice strict antisepsis is now used everywhere, but in private practice we lag yet in a deplorable way behind other countries, and the result is to be found in frequent disease and death among the well-to-do, which have nearly disappeared from the lying-in hospitals. It is to be hoped that the general practitioner soon will follow the lead of the expert obstetrician in this field. At my motion the following resolution was unanimously adopted on October 27, 1892; "In the opinion of the Section on Obstetrics and Gynecology of the New York Academy of Medicine, it is the duty of every physician practicing midwifery to surround such cases in private practice with the same safeguards that are being used in hospitals" (Garrigues, "Reprehensible, Debatable, and Necessary Antiseptic Midwifery, Med. News, Nov. 26, 1892).

Budd's (Fig. 139), which is a flexible flattened hard rubber stick, is as good as any, recommends itself by its simplicity, and is easy to keep

FIG. 139.

Budd's Uterine Applicator.

clean. It is sold straight, but it ought to be curved like a sound. This is easily done by warming it over an alcohol lamp and bending it.

A little absorbent cotton is fashioned so as to form a thin rectangular pledget, 3 inches long by 1 wide. The applicator is held at right angles a little inside of one of the ends and one of the sides, and the cotton is rolled round it with the fingers of the left hand, going down in a spiral line toward the handle. By a little practice it becomes easy to put it on smoothly and of variable thickness, according to the caliber of the cervical canal. The thick mucus that is often found in the cervical canal must first be wiped off with dry cotton, or, if this proves impossible, it is coagulated by applying a mixture of equal parts of tincture of iodine, tannin, and carbolic acid.

Some prefer to make applications to the inside of the uterus by means of a glass pipette, or through a cervical speculum (p. 148). If the canal is too narrow it must be dilated (p. 152). For the endometrium, I use mostly Churchill's tincture of iodine, liquor ferri chloridi undiluted, chloride of zinc (20 to 50 per cent.), and occasionally sol. argent. nitrat. 1 to 12, or pure carbolic acid.

As some patients are very sensitive to intra-uterine applications, it is best to restrict the first application to the cervix, and gradually penetrate into the cavity of the body up to the fundus.

Drugs may also be made up as ointments, and applied in the interior of the womb by means of Barnes's ointment carrier, a silver tube with large side openings and a piston. Or they may be incorporated in small rods, so-called bacilli, made with cacao-butter or althæa, which are pushed through a metallic tube with open end (E. Martin's pistol). Powders, especially boracic acid, iodoform, and aristol, may be applied in the interior of the uterus by means of a similar instrument. All these tubuliform instruments have, however, the grave drawback that it is next to impossible to keep them clean. I have, therefore, of late years, discarded them all in favor of the applicator wound with cotton.

Applications are, as a rule, repeated twice a week.

B. Injections.-Injections are made into the vagina, the uterus, the rectum, and the bladder, with plain or medicated water, by means of a syringe.

Vaginal injections are used to greatest advantage in the dorsal posi

tion on a bed-pan (Fig. 140). A good bed-pan should be large, and have an opening near the bottom with an attached rubber tube to carry off the water into a larger vessel placed under the bed. If it does not have such a contrivance, and is not large enough, the water may

Bed-pan, holds nearly seven pints: A, tube closed with plug, B, unless used to make connection with rubber hose leading to vessels placed under the bed; C, tube for emptying pan; D, cover to be screwed on the same when not in use.

be gradually pumped out by means of a bulb-and-valve syringe (Davidson's syringe) while running into the bed-pan.

Patients who are obliged to help themselves may also take their vaginal douche standing over a chamber-pot placed on a chair, or sitting on a bidet.

It is best to use a fountain syringe; that is, a bag of soft rubber, or a metal pail, a so-called douche-can, with a long soft rubber tube and a nozzle of metal or preferably hard rubber. The nozzle should only have holes at or near the end, and it should be pushed in so far that the openings are behind and above the os uteri. If there are side openings lower down or the nozzle is not introduced to the proper depth, an opening may face the os and some fluid be injected into the uterus, which gives rise to a very painful and alarming uterine colic.

If the chief aim of the injection is to combat inflammation and cause absorption of inflammatory exudations, plain hot water is the best. The amount should not be less than two quarts. The temperature should be as high as the patient can stand it-i. e. so that she just can hold her hand in it (110° to 115° F.). In exceptional cases hot water increases instead of relieving pain, and is then advantageously replaced by lukewarm water. Cold injections are injurious.

For merely cleansing the vagina-for instance, when a pessary is worn-a pint of tepid water suffices, and its effect may be increased by adding a heaping teaspoonful of common salt or bicarbonate of sodium.

If an astringent is called for, alum, borax, or equal parts of sulphate of copper and alum are dissolved in the water. Of alum or borax, a teaspoonful is added; of the mixture of copper and alum, only half a teaspoonful.

If there is a spongy os uteri giving rise to hemorrhage, I use half a teaspoonful of the liquor ferri chloridi to a pint of water.

For antiseptic injections carbolic acid (1 to 2 per cent.) or creolin (to 1 per cent.) are used. The latter is also an excellent hemostatic, but in some patients it produces a smarting sensation. Bichloride of mercury should be avoided, except for gonorrhea, on account of its poisonous properties,' and the solution should not be stronger than 1 to 3000 or even 5000.

As an emollient injection a decoction of flaxseed tea or slippery-elm bark, a heaping teaspoonful to each quart of water, is good.

Vaginal douches are, in chronic cases, as a rule, used morning and evening, and in acute three times a day, or even every three hours. Intra-uterine injections are much more dangerous than vaginal injections, and should always be administered by the physician himself. We distinguish between small and large intra-uterine injections. The former are really only applications of drugs made on a larger scale. The injection is made by means of a small glass syringe with a long nozzle, with one or more fine openings near the end (Fig. 141). Having seen several cases of alarming collapse follow the use

FIG. 141.

Braun's Uterine Syringe.

of this method, and knowing that it has been fatal in the hands of others, I have entirely discarded it.

Large uterine injections are used for cleaning and disinfecting the uterus and for checking hemorrhage. If the cervix has been thoroughly dilated before injecting, a single-current tube is preferable, as it leaves more room for evacuation of large débris. For this purpose I find the so-called soft-metal male catheters sold in the stores of the instrument-makers very convenient, as they are easily bent so as to adapt themselves to any shape of the uterine canal. By adding a flange at the open end, connection is easily established with a fountain syringe. If the cervical canal is not so wide, Bozeman's double-current uterine tube (Fig. 142), or its modification by Fritsch, which is easier to clean, should be used.

The patient is placed on a table, unless she is so weak that it is deemed better to leave her in her bed, and only move her sufficiently beyond one edge to have a free back-flow from the vagina. The outer

1 Garrigues, “Corrosive Sublimate and Creolin in Obstetric Practice,” Amer. Jour. Med. Sci., Aug., 1889, vol. xcviii. pp. 109-128.