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On withdrawing the stopper of the catheter a few drops of urine run out, and then cease, keeping up an intermittent discharge entirely characteristic. The catheter can be pushed beyond the brim of the pelvis, up to the pelvis of the kidney, by introducing an index-finger into the rectum, and lifting and guiding the catheter while it is being pushed up. Sometimes the ureters may even be catheterized without anesthetizing the patient.

Palpation of the Ureters.-When there is no disease the ureters can usually be felt with facility as more or less flat cords about oneeighth of an inch in diameter, movable to an extent of one-half to three-quarters of an inch, in the loose pelvic connective tissue at the side and in front of the cervix. The patient may be in the dorsal position, and both hands used, the homonymous index-finger in the vagina (i. e. the left for the left ureter, the right for the right), or she may be in Sims's position. In both positions the vaginal roof is pushed well upward, when the ureter may be felt, hooked, brought down, and compressed.

A practical and safe method of obtaining urine from one ureter alone is very desirable in order to locate and treat disease there, and to ascertain the presence and healthy condition of the second kidney, when the removal of one is contemplated.

It goes without saying that the pulse should be counted and its character noted, the temperature measured with a clinical thermometer, and such other investigations made in regard to the condition of other organs and the general health of the patient as the case may call for.

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.

CHAPTER I.

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. Puerperæ 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.

The writer has since 1883 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, as well as in a similar article in the American Text-book of Obstetrics, edited by Norris, Philadelphia, 1895, pp. 683–734. 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).

CHAPTER II.

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. 149). 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. Budd's (Fig. 145), which is a flexible flattened hard rubber stick, is as good as any, recommends itself by its simplicity, and is easy to keep

FIG. 145.

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. 150). If the canal is too narrow it must be dilated (p. 154). 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 position on a bed-pan (Fig. 146). 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

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Bed-pan, holds nearly seven pints: 4, 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

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