may be enhanced by the use of a bath-speculum (Fig. 157), which is introduced into the vagina and allows the water to fill the same.

FIG. 157.

Turkish and Russian baths may sometimes be substituted for warm baths, but are often too irritating or too fatiguing. An artificial steam-bath may be improvised by placing an alcohol lamp under a chair and an open umbrella partly over the chair and partly over the patient lying in bed, and covering all well with blankets and waterproofs. If the patient is well enough, she may sit on the chair covered with a waterproof. Perspiration may also be induced by the hot pack. The patient is wrapped up tightly to the neck in a blanket wrung out of hot water, and covered with several layers of dry blankets. Perspiration should not be allowed longer than from half an hour to two hours.

Sea-baths are often very beneficial as a nerve tonic and to check a disposition to hemorrhage and leucorrhea. A complete hydrotherapeutic treatment may also do good. On a smaller scale cold water may be used to great advantage in the shape of shower-baths, sponge-baths, the wet sheet, or towel-baths. For a sponge-bath the patient stands in a tub and has a pailful of cold water standing at her side-the contents of which she presses all over her body with a large sponge. For a sheet-bath a sheet is dipped into a pail of cold water and thrown from behind over the patient, who is rubbed with it for several minutes all over the body. Thereafter the wet sheet is exchanged for a dry warm one and the rubbing repeated until she is dry all over.

Bath-Speculum.

The towel-bath is less powerful, but by no means without effect, in keeping the skin in order, strengthening the nerves, and brightening the mind. It has the advantage that no help is needed for its administration. All that is required is three Turkish towels and a large basinful of cold water. The patient immerses one of the towels in the water, presses it a little, and washes the upper half of her body with it. Then she dries herself with the two other towels, and finally she repeats the procedure on the lower half of the body, except the feet, which in most people are treated to greater advantage with warm foot-baths.

Some European springs enjoy a particular reputation for their supposed effect on female complaints, such as Franzensbad and Marienbad in Austria, Ems and Kreuznach in Germany, and Plombières in France; but it would be a grave mistake to think that any wateringplace can be more than an adjuvant in the proper treatment of diseases of women.

J. Counter-irritation.-Tincture of iodine is often painted once a

day on the skin over a swelling in the deeper parts. When the epidermis is hardened a little, it is well, in order to avoid cracking, to cover it with a compress soaked in the following wash :

This allows one to continue the use of the iodine indefinitely. (Compare p. 165.)

Spanish fly blisters are sometimes used on the abdomen to combat inflammation in the deeper parts. A large blister is a painful remedy, and it has appeared doubtful to me if it is any better than other means; but half a dozen small blisters, 2-4 square inches, one of which is put on every evening, often relieve pain in chronic cases.

K. Tapping and Aspiration.-The difference between these two operations is only that in simple tapping a fluid is given outlet through the canula of a trocar by pressure from behind, and in aspiration by forming a vacuum in front; but on account of the greater efficacy of the latter method a smaller trocar, or even a needle, may be used instead of the large trocar used in simple tapping. The object is to remove a fluid collected in a normal cavity or a cyst. Tapping is used much less now-a-days as a separate and complete gynecological operation than a decade or two ago. Tumors are seldom tapped, the more radical operation of removal being preferred; but ascitic fluid has often to be evacuated by tapping. Tapping is used during ovariotomy to diminish the cyst, and aspiration is often used as part of a more comprehensive operation-e. g. in removing a pyosalpinx or opening a pelvic abscess. Aspiration through the vaginal roof is used to remove encysted peritonitic exudation or a collection of pus in the parametrium. Straight and curved, fine and large, trocars or needles may be needed. We have already spoken of the use of the aspirator for diagnostic purposes (p. 157).

A patient who is going to be tapped through the abdominal wall should sit on a chair or lie on her side with the abdomen turned toward the operator. The abdomen should be surrounded above and below the point selected for the operation with a sheet, the ends of which are crossed in front and pulled upon during evacuation. The object thereof is not only to produce the necessary pressure for the evacuation, but to avoid a sudden suction of blood to the abdominal viscera, which might cause syncope. A quarter of a grain of cocaine should be injected with a hypodermic syringe into the skin at the place selected, which, as a rule, should be in the mesial line, midway between the symphysis and the umbilicus. Full antiseptic precautions should be used. The bladder should be emptied with the catheter. The trocar is thrust in, the stylet withdrawn, and the fluid

directed into a pail placed on the floor. When all has been removed, the abdominal wall is lifted in a fold around the canula, the latter is withdrawn, the opening is compressed from side to side, and a piece of rubber adhesive plaster placed over it.

In the vagina only the aspirator should be used. So far as possible, the puncture should be made behind the uterus. In front is the bladder and to the sides are the uterine artery and the ureter. The latter organs may, however, sometimes be felt and avoided.

Tapping has occasionally proved fatal by lesion of a blood-vessel in the abdomen. Septicemia may be avoided by antiseptic precau

tions.

Sometimes the canula is left in as a drainage-tube, and has for that purpose two eyes for the insertion of cords or wire. The puncture may be followed by incision or dilatation; then the pointed stylet

FIG. 158.

Trocar, composed of canula with cap, pointed stylet, and blunt staff.

is withdrawn, and a blunt guide with a longitudinal furrow substituted, over which the canula is withdrawn (Fig. 158).

L. Abdominal Belts.-An elastic abdominal belt (Fig. 159) is often

useful, especially in fat women, to take off some of the pressure on the pelvic organs, and is used during the first year after laparotomy to take off the strain on the cicatrix.

When a special pressure above the symphysis is required, an abdominal supporter, with a solid hypogastric pad, is used (Fig. 160).

M. Massage. Certain manipulations inside of the pelvis and through the abdominal walls constitute a valuable mode of treatment in many diseases of women, especially chronic metritis, cellulitis, peritonic exudations, adhesions, hematoma, and oöphoritis. Often a general massage of other parts of the body or the whole body is added. In this way exudations, infiltrations, hypertrophies, and adhesions are made to disappear, weak ligaments and muscles strengthened, and displaced organs brought back and kept in their normal position. The procedures being rather painful, there is no danger of causing sexual excitement. The manipulations are quite complicated, have to be adapted to the special abnormal conditions obtaining, and can hardly be learned except by seeing them carried out by an expert. Unfortunately, this treatment requires so long sittings that a gynecologist or general practitioner will hardly find time to use it himself, and, on the other hand, such fine diagnosis is necessary that nobody who has not a large experience in abdominal examinations can be entrusted with it."

1 Up to three-quarters of an hour! The length of the sittings is, however, partially counterbalanced by the great efficacy of the treatment, which often leads to a cure in a short time.

2 The limits of this work forbid me even to give an outline of the different manipulations used in massage. Those interested in it are referred to the paper by

N. Gymnastics.-Gymnastic movements, active and passive, are sometimes a direct cure for certain diseases, perhaps even the best of all-e. g. Thure Brandt's' wonderful cure for procidentia uteri.

In other cases the Swedish movement cure may be a valuable adjuvant, combined with other methods, and even common gymnastic exercises, if not too violent, are not only an excellent preventive of pelvic diseases, but may be used to advantage toward the end of a cure begun on other lines.2

O. Operations in General.-1. Time for operating. If we have a choice, operations should be avoided in this climate during the hot season. It is no small discomfort for the patient to lie in bed for weeks, when not even the nights bring coolness, and it is rather trying for the operator to work when the thermometer is in the nineties in the shade. But I have had hospital-service during the hottest time of the year, and performed both laparotomies and plastic operations without the slightest disturbing influence on perfect success.

In general, operations should not be performed on pregnant women, on account of the danger of producing miscarriage. It would seem that interference with the rectum is particularly liable to have this effect. As to the genitals, we may say that the farther the seat of operation is removed from the uterus the less is the danger of provoking abortion. Sometimes the very presence of pregnancy may call for operative interference. Vomiting in pregnancy, which may lead to the patient's death, may be treated successfully by applying nitrate of silver in substance or in solution to a granular os, or by stretching the os and lower part of the cervical canal (Copeland's method) with the index-finger. Large polypi hanging from the cervix may be the source of hemorrhage or become an obstruction during labor. It may, therefore, be wise to remove them with the galvanocaustic wire. Ovarian cysts should be removed if discovered early. If the patient is far gone or in labor, tapping may be preferable. If a cancer of the cervix can be removed, it is better to do so even with the risk of causing abortion, as the cancer, as a rule, grows rapidly during pregnancy, and may cause an obstruction during labor that may cost the life of both mother and child.3

A. Reeves Jackson of Chicago, on "Uterine Massage as a Means of Treating certain Forms of Enlargement of the Womb," Trans. Amer. Gyn. Soc., 1880, vol. v. p. 80; to that by H. J. Boldt of New York, on the "Manual Treatment in Gynecology," Amer. Jour. Obst., June, 1887, vol. xxii. p. 579; to that by H, N. Vineberg on "The Treatment of Retrodisplacements of the Uterus with Adhesions by Brandt's Method," N. Y. Med. Record, July 11, 1891; and to Profanter's pamphlet, Die Massage in der Gynäkologie, Vienna, 1887.

This is the name of a Swedish layman who is the inventor and successful performer of most of the special massage and gymnastics applied in gynecology.

2 The value of gymnastics as preventive of and cure for pelvic disorders has been inculcated by John H. Kellogg, Med. News, November 8, 1890, No. 930, p. 468. 3 Further information may be found in a paper by M. D. Mann of Buffalo, N. Y.: