Golden rules of gynecology; aphorisms, observations, and precepts on the proper diagnosis and treatment of diseases of women

Front matter

Book JIt-

CoppghtN".

COPYRIGHT DEPOSIT.

Chapter II. Diseases Of The Vulva

Vulvitis — Bartholinitis — Cysts of the Vulvovaginal Glands

— Pruritus Vulvae — Kraurosis Vulvae — Elephantiasis Vulvae — Varicose Veins — Hydrocele of the Labium Majus — Inguinolabial Hernia — Chancroids — Chancre

— Verrucas — Adliesions of the Clitoris — Adhesions of the Labia — Herpes — ■ Eczema — Thrush — Simple Dermatitis — Erysipelas — Vaginismus 31-77

Chapter III. Diseases Of The Vagina

Acquired Stenosis and Atresia — Cystocele and Rectocele — Hernia — Vaginitis — Granular Vaginitis — Senile Vaginitis — Cysts — Cancer of the Vagina — Gonorrhea 78-111

Chapter IV. Diseases Of The Uterus

Posterior Displacement — Prolapse of the Uterus — Inversion of the Uterus — Fibromata — Cancer of the Uterus

10 CONTENTS.

PAGE

— Sarcoma — Inflammation of the Uterus — Metritis — Endometritis — Endocervicitis — Subinvolution of the Uterus — Superinvolution — Laceration of the Cervix — Hypertrophy of the Cervix — Cervical Pohq i — Acquired Atresia of the Cervix — Acquired Stenosis of the Cervix — Chorioepithelioma 112-174

Chapter V. Diseases Of The Tubes And Ovaries

Salpingitis — Diseases of the Ovaries — Chronic Ovaritis — Prolapse of the Ovaries — Solid Tumors of the Ovaries

— Ovarian Cysts — Ectopic Gestation 175-196

CHAPTER VIo

MENSTRUATION AND ITS DISORDERS.

Puberty — Menstruation — Ovulation — Menopause — Precocious Menstruation — Delayed Menstruation — Amenorrhea — Menorrhagia and Metrorrhagia — Dysmenorrhea 197-212

Chapter VII. Diseases Of The Urethra

Urethritis — Stricture — Vesicourethral Fissure — Prolapse

— Urethrocele — Caruncle 213-222

Chapter VIII. Diseases Of The Bladder

Cystitis — Vesical Calculus ...,....,. 223-227

INTEODUCTION.

Eemember that one of the most important principles in gynecologic practice is every-day asepsis.

Cleanliness of mind is as necessary as cleanliness of body.

Eemember that, unless your patient has a good reason for an examination being postponed, it is far better to lose the prospective patient than to prescribe symptomatically. She will return for her examination after a few weeks of internal medication by some other physician.

Eemember that there are exceptions to this rule; unless the gravity of the case demands it, it is not wise to examine young girls or .single women — if it should become necessary, and she is a modest, bashful person, her nervous system can be maintained in a better condition by administering an anesthetic for such an examination. Moreover the examination can be made then with perfect satisfaction, on account of the complete relaxation and freedom from pain.

Eemember that pelvic examinations should never be undertaken with a woman lying recumbent in bed. Knowledge thus gained is usually very unreliable. One frequently is obliged to use a bed instead of an examining-table ; but the patient should

12 INTKODUCTION.

be placed across the bed with the hips on or near the edge and the knees slightly flexed. The annoyance from the sinking-down of the hips can be obviated by flipping two boards from a dining-room table nnder the mattress.

Tables are far superior to chairs for office work.

Much annoyance can be spared a physician if he would have a relative or friend accompany the patient to his office for examination or treatment.

Examine as many women as your opportunity affords, thereby becoming familiar with the normal and the abnormal. It requires much practice to educate the fingers to a keen sense of touch. The examining finger alone gives one only an idea of the condition of the vagina, whether the bladder is sagging (cystocele), or the rectum bulging (rectocele), and a general idea of the condition of the cervix. It requires the combined examination — vaginoabdominal, the rectoabdominal — to ascertain with any degree of accuracy the true condition in the pelvis.

The speculum is a very useful adjunct where it is desired to bring into view the cervix or the surrounding vaginal wall, but one should never make a diagnosis by the use of the speculum alone — the speculum examination should usually follow the bimanual examination.

One must learn to judge his patient; don't be vacillating in your advice or opinion; be sure you are right, and stick to it. In such a case information and advice carry confidence and conviction di-

INTEODUCTION. 13

rectly to tlie patient; while with the contrary she is soon filled with distrust.

Your conscience should not permit of wrong-doing for pay; there is enough legitimate work for all.

Chapter I. General Considerations

DIAGNOSIS.

General. — Learn to be observing; this comes with experience, of course, but is much more easily acquired by some than others.

Often many things are suggested to the experienced and observing physician by the first glance at his patient. A woman, near the age of fifty, who is anemic, with skin dry and waxy, suggests carcinoma of the uterus or of the mammary gland; one who is thin, with a pinched expression, large abdomen, and who walks carefully and with .some difficulty, may suggest ovarian cystoma. A woman in the middle period of life, plump, with a large abdomen, but with rosy cheeks, who walks with a strong, steady step, suggests normal pregnancy.

Remember that diseases of the. middle period of life are more frequently inflammatory, and due to accidents of child-birth, abortions, and infections, while in the earlier life of the female the disorder.s of the menstrual functions are the ones with which we have to deal. These are mere suggestions at the beginning of the examination of our patient, but they will be found to be of great help if properly regarded.

Always keep a full history of every patient, with diagnosis, and treatment, whether medical or surgical. It is very embarrassing to have a patient return in two or three years and refer to her former sickness and treatment, which, of course, is entirely forgotten. If an accurate history and record are kept, one can refer to them, and the case at hand will be fresh in one's memory.

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 rule, it is best to note down the name, address, age, height, weight, whether married or single, etc., and then allow the patient to tell the nature of her symptoms and sickness. This soon brings the physician to a definite plan of procedure, when he can proceed with a .systematic inquiry and note down at the same time points of interest.

(1) Menstruation. — At what age did it begin; regular or irregular; how many days does it last; normal, scanty, or profuse in amount; is it painful; if so, what relation does it have to flow 1 If the patient has reached the menopause, inquire at what age;

GENERAL CONSIDEEATIONS. 17

whether it has ever returned ; and any questions pertinent to the case.

(2) The number of children; whether miscarriages or abortions; were any of them of unusual .severity; were instruments used; was the convalescence delayed beyond the usual time with any of them; and if so, why?

(3) Inquire if she has leucorrhea; whether profuse; color; odor. Is it present during entire intermenstrual period; does it cause itching or burning?

(4) Is there irritation of the bladder causing frequent micturition; or is there difficulty in urinating?

(5) Inquire regarding the bowels; whether constipated or not.

(6) Is there pain in the pelvis; if so, is it constant; does it radiate from hips down thighs and to calves of legs?

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

(8) Is there headache; if so, where?

Physical. — Remember that it is not safe to omit a thorough examination of the chest and abdomen before 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 examined, and finally the pelvic organs. Uterine fibroids, large cysts- of the ovaries, and the gravid uterus can be palpated above the pelvis, but this should usually be accompanied by the vaginoabdominal palpation. This means the index finger of one hand in the vagina, and the other hand pressing down above the pubis and over the abdomen.

The rectoabdpminal examination is often useful (index finger of one hand in rectum, the other hand above pubis) in examining for tumors and exudaites low in pelvis.

Do not attempt an examination if the rectum is filled with fecal matter or the bladder full of urine; it may change the position of the pelvic organs very materially and interfere with a correct diagnosis.

Don't be in too great haste to give an opinion in a chronic case, where the patient has a fat abdomen and where the examination is difficult — it is better to have her come back a second or third time.

Don't attempt to examine young girls or unmarried women, especially when it is against their wishes, without an anesthetic.

Instrumental. — Now remember that preceding the use of a vaginal .speculum or perineal retractor the external genitals are to be inspected. These are usually taken in at a glance without much unnecessary handling of the parts. Note if there is any discharge; its color and consistency; whether it causes excoriation of the parts ; whether there are chancre, chancroid, venereal warts, or other diseases of the external genitals; as adhesions and irritations of the external meatus, hymen, or carun-

GENERAL CONSIDEEATIONS. 19

cula myrtif ormis ; laceration of perineum, with cystocele and rectocele; hemorrhoids, or anal fissure or fistula.

Eemember that the ordinary bivalve speculum, with the patient in the dorsal position, is sufficient for examination of the cervix uteri. Inspect the cervix; notice if it is swollen or lacerated; whether the lateral walls are white and hard with scar tissue; whether it is studded with small white cysts, due to the plugging up of the Nabothian glands. Notice the amount and character of discharge, ulcerations, or evidence of malignant disease, etc.

Remember that the normal color of the cervix is pink (it has a bluish hue in pregnancy), it is smooth and conical in shape; inflammation causes it to become large, red, and rough. It should also be noted whether the external os is of the pinhead variety or whether it is sufficiently large.

Eemember that the perineal retractor, with the patient in either the lateral or semiprone po.sition, is useful where it is desired to pull the cervix down within easy grasp or exposure; this position is especially useful in removing stitches from the cervix or in removing a polypus from the canal of the cervix uteri.

Don't make a practice of using a sound in the uterus at overy opportunity; this practice should be condemned except in very exceptional cases, for the sake of clearing up a diagnosis or where some intrauterine treatment is especially indicated, and then with the strictest aseptic precautions; much harm has been done by the promiscuous use of intrauterine instrumentation.

Microscopical and Chemical. — Don't fail to make a thorough examination of the urinary organs and their excretions. The modern physician is so skilled that he can easily make a thorough chemical and microscopic examination of the urine. Cystoscopy and ureteral catherization are so common and are accomplished with so little difficulty 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 indicated.

Don't make a positive diagnosis of cancer of the uterus (except in advanced cases) without a microscopic examination.

Don't fail to resort to the microscope in case of any ulceration or any suspicious appearance of the cervix. It is sometimes necessary to use the curette to get a specimen from the fundus or high in the cervix for microscopic examination.

Don't pass over a suspicious-looking cervix, and say that it is not cancer because the patient is too young — one is scarcely exempt from it at any age ; it is not rare in the twenties.

It is sometimes necessary to make an exploratory incision to clear up a doubtful diagno.sis ; when this becomes necessary, the surgeon should be ready to

GEN"EKAL CONSIDEKATIONS. 21

meet any condition that presents itself and to do a finished operation.

Don't fail to make a blood examination whenever it is indicated for an index, or to help to clear up a doubtful diagnosis.

LOCAL TREATMENT.

While there is much to be accomplished by local treatment in gynecologic cases, yet in no class of diseases, perhaps, has local treatment been miscarried farther than for ailments peculiar to women. It is doubtful if there is any inflammatory disease (at least chronic) of the pelvic organs of a woman that cannot be relieved temporarily by the use of tampons of glycerin and ichthyol, or borogiycerid and glycerin, with daily hot douches. Remember that this practice is perfectly proper and .should be highly endorsed when it is done for temporary relief, and when it is so understood by the patient; but when undertaken as a curative measure in all the distorted conditions of the pelvic organs, with adhesions and even pus collections, too much cannot be said against it; and if one will only familiarize himself with the anatomy of these parts, as well as acquire an accurate knowledge of the pathology of pelvic disease, he will need no further proof to convince him of the exact limitations of local treatment.

The efficiency of rest in bed, the hot douche, and hot fomentations in acute inflammatory disease of the pelvic organs cannot be gainsaid by anyone wbo has tried them intelligently; bnt they are seldom so used, except in the hands of a trained nurse.

Effect of the Hot Douche and Applications. — In a great measure this acts in the same manner as Bier's hyperemic treatment — by its local effect it stimulates the walls of the relaxed blood-vessels, causing a contraction. If this is continued for a long time and frequently, the circulation will improve ; and instead of the relaxed vessels, with stasis and edema of the surrounding tissues from exudation, the vessels contract, circulation is improved, the exudate is absorbed, and the swelling and pain are relieved.

Eemember that if this line of treatment is instituted early it may prevent adhesions, abscess formation, and general deformity of the pelvic organs.

Now remember that douches for this purpose should be taken lying down (either using a douche pan or getting into the bathtub). It is not necessary to have a swift stream of water; hence the irrigator or douche bag need not hang high. Enough water (at about 110° F.) should be used to make the douche last for ten or fifteen minutes.

Eemember that the virtue of this treatment lies in keeping the heat and moisture in contact with the inflamed tissues a long time. This should be repeated at intervals of every two hours, day and night. If there is any odor to the discharges, a teaspoonful of formaldehyd, 40 per cent, can be added. Any other medicinal agent may be used

OENEKAL CONSIDEBATIONS. 23

that miglit be suggested for the particular case.

Eemember that the hot fomentatious should be changed as frequently as they cool — every five to ten minutes. In hospital practice (and it can be done in private practice), a bag is made with a stick sewed in at each end; the flannel cloth that is used for the application is placed in this bag, and the whole placed in the vessel of boiling water. This is wrung out by use of the sticks, the whole carried to the bedside of the patient, when the flannel is removed from the bag (steaming hot), and placed on the patient's abdomen as warm as it can be tolerated, and the cooled application is placed into the bag and pan of hot water. This is repeated back and forth, and it requires about all of one nurse's time to give the douches, and use the hot applications properly. It is wonderful, however, how quickly and completely this plan of treatment gives relief; the patient who has been in the throes of pain in twelve to twenty-four hours begins to heave sighs of relief, the pulse becomes softer and slower, and the temperature drops.

Eemember that the bowels should be thoroughly evacuated daily by the use of salines, cathartic waters, or enemata.

Remember that in subacute or chronic diseases of the pelvic organs tamponade with the various mixtures of glycerin serves splendidly for temporary relief. Clinical patients are living examples and prove beyond dispute just how far this line of treatment is meritorious. They are a class of people whose time is required every day for the support of themselves and their families; they cannot lie around as invalids, nor have they time to go to a hospital for a .surgical operation. They come to our clinics with the gravest pelvic disease, scarcely able to walk, and if they were women of a higher plane in life, they would be confined in bed. Something must be done for them; so they are given a tampon of glycerin and ichthyol, 10 per cent, and instructed in the art of taking douches. After three or four visits they return smiling and say that they feel much better. After ten or twelve treatments they disappear, only to return with a relapse in a few weeks or months. Large numbers continue in this way for years, and indefinitely.

Eemember that, while the value of the tampon to some extent is derived from the medicinal substances that it carries to the cervix, and as a support to the uterus in some cases, yet the greatest benefit comes from the glycerin mixtures, on account of their hygroscopic properties. Do not use cotton tampons; they become too hard and cause pain. Lamb's wool, with a piece of string tied to it, is a splendid tampon. A very convenient tampon is made by cutting plain gauze four or five inches wide by two feet in length. Saturate about one half of it, and pack around the cervix as desired through an ordinary bivalve speculum, leaving about one inch outside of vagina so that patient can readily pull it

GENEEAL CONSIDERATIOl^S. 25

out wlien it lias served its usefulness. In withdrawing the speculum, gentle pressure must be made against the tampon with the dressing forceps, so that it may not become dislodged. A tampon .should be left in from twelve to twenty-four hours.

Hemorrhage. — Remember that tampons are often useful in checking uterine hemorrhage. By the use of a bivalve speculum or a perineal retractor small pieces of cotton, wrung from warm water, are packed well up around the cervix, finally filling the vagina. The cotton might be wrung from a boric acid or a weak formalin solution for the antiseptic effect, or a weak solution of adrenalin may be used for its astringent properties. If the hemorrhage is very great, this entire pack may be forced out by the blood-clots and fluid blood coming from the uterus.

Eemember that, if the cervix is or can be sufficiently dilated, strips of 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 erosion of the cervix local treatment must be instituted, but we must not mistake the hypertrophied everted cervical mucous membrane of a lacerated cervix for ulceration and erosion.

Remember that retention cysts of the Nabothian glands are relieved by puncture, followed by tamponade, hot douches, etc.

Infection, particularly gonorrheal, is met by local treatment. In such a case, remember that rest in bed and vigorous treatment to prevent its spread beyond the vagina are demanded to save her from being completely ruined.

Local treatment is necessary, effective, and often entirely sufficient in many of the diseases of the vulva or external genitals.

Intrauterine. — Don't get into the habit of using intrauterine treatments indiscriminately. Women as a whole would have been much better off had this plan of treatment never been instituted. When it does become necessary, use it under the strictest aseptic precautions. It 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.

Eemember that the cervix should be well dilated and the applications made two or three days apart; if three or four treatments do not give the effect desired, it is better to desist, and let the patient rest from treatment for a time.

It is a question whether or not the benefit derived in these cases comes from the astringent application or from the dilatation of the cervix alone, thus establishing better drainage from the uterine cavity.

Eemember that it is necessary to curette and wash out debris from the uterus, following miscarriage or abortion; but remember that this can be done more thoroughly and safer under a general anesthetic.

GENEBAL CONSIDEEATIONS. 27

Operations of this magnitude should be done in a hospital; don't undertake them in the office.

It is permissible to use a uterine sound in cases of uterine fibroids (posterior) or prolapse, in order to clear up an uncertain diagnosis, but these cases are rare. Now reason, and see if it does not appear quite doubtful whether argyrol, protargol, or any of these antiseptics has any beneficial effect whatsoever in destroying pathogenic micro-organisms within the cavity of the uterus; the issue almost entirely depends on the antitoxic ability of the blood, with its leucocytes. Now, if it were po.ssible to say that the infection was limited to the surface of the endometrium, it might do some good, but even then, 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.

CONSTIPATION.

Eemember that most women are constipated and that assistance in a general way (diet, exercise, etc.) may save her from the necessity of taking daily cathartics.

Eemember that the ill effects of constipation are not only in the failure to remove the residue from the intestinal tract and its discomforts; its evil effects reach the whole economy. Wliile the sedentary habits of a woman are no doubt justly blamed for a part of her constipation, and no doubt also.

may be blamed for the chronic disorders of the stomach, intestines, liver, and kidneys, yet, on the other hand, there are other anatomical and physiological reasons.

Eemember that the pelvic organs become congested and engorged at every menstrual period. Lacerations of the perineum allow displacement, and interference with the function of the rectum. Uterine prolapse and displacements, tumors of the uterus and ovaries in a mechanical way produce constipation, and moreover, it is not always so convenient for a woman to regard and attend the calls of Nature as it is for a man. However she should be taught from childhood that it is extremely necessary to obey Nature promptly in her demands, and to render assistance by forming regular habits — to go to stool regularly, just as she has regular hours for meals.

A woman who does her own housework or looks after her own children .should not be accused of sedentary habits. However, when she is guilty of leading a sedentary life, it must be overcome, and no doubt, in such a woman it can best be accomplished by ordering gymnastics, massage, or some form of exercise that is combined with pleasure.

Now 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 proper times, cleanses the stomach of mucus, promotes peristalsis, increases perspiration and the

GENERAL CONSIDERATIONS. 29

quantity of both solid and watery constituents of the urine, aiding the excretion of carbonic acid and ab- .sorption of oxygen; thus, all the tissues in the body are relieved of salts and waste material, and the tendency to calcareous degeneration of blood-vessels is lessened.

To say that distilled or boiled water is dead and has no virtue is a mistake. Boiled water contains but few salts and distilled water no salts, and therefore they have greater absorbing power when filtering through the system. While it is also free from pathogenic micro-organisms, the food that we eat furnishes enough of the earthy salts to our system, so that they do not have to be taken in the water we drink.

To get a woman to drink enough water daily, the amount and time must be specified until she has acquired the. habit, so to speak. A woman who is in normal health should drink from one and a half to two quarts of water daily. A good practice, I believe, is to have her take a bottle or pitcher of water to her bedroom at night; advise her to drink one or two glasses full while she is dressing in the morning; this washes the mucus from her stomach, improves the appetite for breakfast, and aids the peristaltic action of the bowels.

Large quantities of water should not be taken during meals, as it dilutes the digestive fluids and predisposes to indigestion. The drinking of several glasses of iced tea with meals should be condemned.

A glass or two of water should be drunk between meals, and the same amount taken between the evening meal and bedtime. The temperature of the water need only be that of ordinarily cool drinking water.

If the case is obstinate, a one-fourth to one-third teaspoonful of common table salt added to the water taken before breakfast acts almost as well as a saline cathartic. Fruit of some kind should be eaten before breakfast.

In very obstinate cases a tablespoonful of olive oil taken with each meal helps very materially. Of course, in the cases that do not yield to this line of treatment, it may become necessary to divulse the spincter ani under an anesthetic, and to resort to the various aperient waters or mild cathartics at tim.es, until we have been able to correct the trouble entirely.