of the vagina, and is most severe on the posterior wall. In other cases it is limited to the posterior vaginal fornix, where it has a tendency to become localized and to persist. In the very early stage the mucous membrane is dry and red. It later becomes covered with a purulent or mucopurulent secretion of a milky color.

If the disease is extensive, severe symptoms may be present. The woman will suffer with burning pain in the pelvis, the pain being increased by any movement.

Acute inflammation of the vagina is usually of gonorrheal origin. A thorough examination of the condition. can be made only by placing the woman in the kneechest position and by exposing the vagina by retracting the perineum with the Sims speculum. The whole vaginal tube, especially the posterior wall near the ostium and the fornices, should be carefully inspected.

Gonorrhea of the vulva may arise primarily, or it may be caused by infection from discharge from the vagina or the cervix. Like gonorrhea of the vagina, it is rare in the adult woman. It is usually seen in girls or in young women. Its occurrence in children has already been referred to.

The disease may extend to the small glands of the vestibule and the fourchette and to Bartholini's glands; in these situations it may lurk for many years, forming a source of infection to men and a great element of danger to the woman. Suppuration of the glands of the vestibule may result in small urethral fistulæ.

In making an examination of the external genitals the parts should always be thoroughly exposed and the physician should attempt to express the fluid from the orifices. of the glands. Microscopic examination of the discharge should be made.

Inflammation of any of the glands of the external genitals is usually the result of gonorrhea.

When the physician examines a woman suspected of gonorrhea, she should not prepare herself beforehand by vaginal douches and washing the external genitals. The

urine should not have been voided for some time. Prostitutes, fearing that gonorrhea will be discovered, often remove all discharges as much as possible before they submit to examination. Other women do the same from motives of cleanliness. As the diagnosis depends upon observation of the origin and character of the discharges, such preparation should be avoided.

As has already been said, it may be advisable in doubtful cases to make the examination immediately after a menstrual period, when the discharges are more profuse and perhaps more virulent than at other times. The examiner should always proceed methodically, and should inspect every portion of the external genitals, the vagina, and the cervix. The vestibule, the external meatus, the urethra, the fourchette, the glands of Bartholini, the vaginal walls, the external os, and the cervical canal should in turn be examined. Discharges obtained from these structures should be saved and submitted to microscopic examination.

Though the gonococcus is by no means always found. in cases the specific character of which is proved by infection of the man, yet it would escape observation much less often if such thorough examination were made.

If the gonococcus is not found, the diagnosis must be made from the consideration of the lesions that we know occur but rarely except in gonorrhea. Thus, urethritis is a strong diagnostic point in favor of gonorrhea; so is inflammation of the glands of the vestibule, of the fourchette, and of the vulvo-vaginal glands. Vaginitis not caused by the degenerations of old age, by traumatism, or by the discharge from a cancer of the cervix or from a vesico-vaginal fistula is usually of gonorrheal origin. This is especially true of vaginitis localized in the vaginal fornices.

Gonorrhea in women should be most carefully treated until all signs of the disease are eradicated. The treatment has already been discussed under the consideration of the different structures that may be attacked. Gonor

rheal cervicitis and endometritis are the most difficult to cure, and it may be impossible to determine with certainty that the disease has been eradicated from these structures. If milder measures fail, the cervical canal and the body of the uterus should be completely curetted, and the raw surface should be treated with pure carbolic acid. The physician should never discharge the patient until she is thoroughly cured.

CHAPTER XXXIX.

THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS.

THE technique of some of the special gynecological operations, such as perineorrhaphy, and trachelorrhaphy, has already been considered in discussing the treatment. of the conditions in which such operations are applicable. The general and local preparation of the patient, the instruments, the dressings, etc., and the technique of the general operations of gynecology that are applicable to a variety of different pathological conditions, such as oöphorectomy and hysterectomy, now demand consideration. The general rules of asepsis that are followed in gynecological operations are the same as those that should be observed in all surgical operations. And although every surgeon should strive to attain perfect asepsis in all operations, yet it is of especial importance for the gynecologist to do so, for he, more often than all others, invades the peritoneal cavity. Of the various structures of the body, the peritoneum is one of the most susceptible to septic influences; and septic infection of the peritoneum, unlike infection of other structures, implies not merely a local disturbance and delay of healing, but general sepsis and death.

Moreover, the gynecologist, operating in the peritoneum, cannot correct any imperfection in his aseptic technique by the use of antiseptic solutions, as can be done in other operations of general surgery. Such antiseptic solutions, if of sufficient strength to be of any value as germicides, are very dangerous in the peritoneum. They may produce fatal poisoning from absorption through the peritoneum; they destroy the delicate peritoneal surface, and thus diminish the very useful power

of the peritoneum to absorb blood and serum after the operation; they cause intestinal and other adhesions; and they so impair the integrity of the intestinal walls that septic organisms may be enabled to pass through and infect the general peritoneum.

The gynecologist, thus debarred from the use of antiseptics during a peritoneal operation, must rely altogether upon the perfection of his aseptic technique.

It must not be forgotten that the danger of peritoneal infection, though very much less in the minor gynecological operations on the perineum and the cervix, is yet never altogether absent. The whole genital tract of women communicates directly with the peritoneum, and infection at any point may extend and cause fatal peritoneal sepsis.

The danger increases with the proximity of the infected point to the peritoneum. The danger of salpingitis and peritonitis from trivial intra-uterine manipulations not performed aseptically, such as the passage of a dirty sound, has already been referred to. Fatal peritonitis has followed trachelorrhaphy.

In the various plastic operations of gynecology disastrous results are, of course, not so likely to occur from imperfect asepsis as in those operations that involve opening the peritoneum. In some of these operations, such as closure of a vesico-vaginal or a recto-vaginal fistula, it is impossible to obtain perfect asepsis.

In minor gynecological operations, however, we may use antiseptic solutions which are inadmissible within. the peritoneum; and the vascularity of the genital tract is so great that healing is usually rapid and perfect even with very imperfect asepsis. This fact, however, should never justify carelessness on the part of the physician. In every surgical procedure, however trivial, the strictest asepsis should always be observed. The practice avoids, at any rate, a minimum danger; it is a useful training. for the physician; and it sets a valuable example to the assistants and nurses. No part of the technique should