Chapter II (1)

OBSTETRICS OR MIDWIFERY INCLUDING NURSING THROUGH PREGNANCY AND CONFINEMENT; PREPARATION, DIET, CARE OF CHILD, ETC., ETC.

"Sickness is the vengeance of nature for the violation of her laws,"--C. Simmons.

Our busy life, our manner of dress, with all its attending demands are causing havoc with the health of women who are under its terrible strain. The number of women undergoing operations in our public and private hospitals from day to day bears witness to the ravages of the strenuous social life and mute testimony of the neglect of the laws of nature. Good health is the fruition of eternal vigilance and a blessing that money cannot buy. The conduct and health of our women represents the life of our nation; individually, in a measure at least, health governs the happiness of the home. Steele says: "All a woman has to do in this world is contained within the duties of a daughter, a sister, a wife, and a mother." But how many girls grow to womanhood untaught; enter wifehood in ignorance, and assume motherhood wholly unprepared for the duties that are thrust upon her. It would be out of place in a work of this nature, a family table book, to take up all the questions involved in such a subject; we can only leave with you a word of warning. Before puberty the girl should be taught to lead a life that will make her strong and healthy to prepare her for the coming strain upon her system. Once she has reached puberty parents should remember, above all things, that HEALTH is far more important than high grades in school. Do not offer prizes for high marks and otherwise add to the pressure of the present school system. Relieve her of worry, do not add to it. A cheerful mind, plenty of fresh air and sunshine is more important at this period than school work. We have paid special attention to "Causes" in this department; may we ask you, Mother and Daughter, to read "CAUSES" of disease and thus render unnecessary in later life, drugs, medicines, headache tablets and, perhaps, operations.

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The Pelvis. It is so called from its resemblance to a basin, is stronger and, more massively constructed than either the skull or chest cavity; it is a bony ring, interposed between the lower end of the spine, which it supports, and the lower extremities, upon which it rests. It is composed of four bones, the two innominated, (nameless), which bound it on either side and in front, and the Sacrum and Coccyx, which complete it behind. Further description will be given in the department of Obstetrics. The cavity of the pelvis contains the bladder, the rectum, and some of the generative organs peculiar to each sex and some windings of the small intestine; they are partially covered by the peritoneum (lining membrane of the abdominal cavity).

Anatomy of the Female Genital Organs.--The external genital organs, to which the term vulva is usually given, consist of the mons veneris, labia majora, labia minora, clitoris, vestibule, meatus urinarius, hymen, fossa navicularis, fourchette and perineum.

Mons Veneris.--This is a rounded eminence surmounting the pubic bones, and is composed of fatty tissue, covered by skin and hair.

The Labia Majora.--There are two more or less prominent longitudinal folds of cutaneous (pertaining to the skin) tissue, covered by hair and mucous membrane, which is continuous with the mucous membrane of the genital organs and urinary tract. They join at each extremity, forming the anterior and posterior commissures (uniting together). Between the posterior commissure (union) and the margin of the bowel is a space of about an inch in extent, the Perineum. It is important to remember this part, for it is often torn in labor, to a greater or less extent.

The labia are the analogue of the scrotum in the male.

The Labia Minora.--These are two smaller folds situated within the labia majora, extending from the clitoris, downward and outward for about one and one-half inches on each side of the vaginal opening. At their convergence at the clitoris each lip (labium) divides into two folds and these surround the glans (clitoris) forming its covering (prepuce) above and the bridle (frenum) below. These lips (labia) are composed of mucous membrane covered by a thin epithelial layer. They contain a network of vessels and numerous large mucous crypts (small sacs or follicles) which secrete a quantity of (fatty) matter.

[WOMAN'S DEPARTMENT 491]

The Clitoris.--This is an erectile structure, the analogue anatomically of the cavernous body of the penis, and is an elongated organ partially covered by the anterior extremities of the labia minora and connected on each side with the rami (slender process of the bone) of the pubic bones and the ischia (two bones) by a band. The clitoris is surmounted by a small tubercle (a small nodule) of spongy erectile tissue, the "glans clitoris," Two cavernous bodies of erectile tissue enclosed in dense fibrous tissue compose the body of the organ.

The Vestibule.--This is the smooth surface of triangular form situated between the clitoris and the entrance to the vagina. The labia minora bound it on either side. It contains the opening of the urethra.

The Hymen is a thin fold of mucous membrane of half moon in shape (semi-lunar) and is spread across the lower opening of the vagina.

The Glands of Bartholin are small oblong bodies, two in number, situated on each side of the commencement of the vagina above the deep fascia band like tissue. Each gland has a single duct and by this duct opens the inner surface of the adjacent labia minoris just external to the hymen. They are made up of mucous glands and a colorless tenacious fluid is secreted by them, which lubricates the vagina. These glands sometimes become diseased. Hence the description.

The Vagina.--This is a membranous canal and extends from the vulva to the uterus (womb) and connects the external and internal organs of generation. It is four to six inches in length, the anterior wall being from one to two inches shorter than the posterior. It lies in the cavity of the pelvis in front of the rectum, behind the bladder and follows first the line of axis of the cavity of the pelvis, and afterwards the axis of the outlet.

The vagina consists of an internal mucous lining (membrane) continuous above with the mucous membrane lining the womb and below with the covering of the labia majora. The next covering (inward) is a muscular coat consisting of two layers--an external longitudinal and an internal circular. There is a layer of erectile tissue between the muscular coat and mucous lining. The lower end of the vagina is surrounded by a band of striped muscular fibers comprising the sphincter muscle of the vagina (sphincter vagina).

The internal organs of generation, more commonly called the pelvic organs. These comprise the womb, fallopian tubes and ovaries.

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The womb is the organ of pregnancy, and receives the fruitful egg (ovum), supports it during its development and expels it at the time of labor (parturition). In form it is pear-shaped, weighs from 12 drams to 3 ounces and is situated in the pelvic cavity, between the bladder and the rectum, with its base upwards and its apex, smaller end downward. Its upper broad extremity is called the fundus--base of the organ, and the lower, constricted, narrowed portion is called the Cervix (neck or constricted portion). The body of the womb gradually becomes narrower from the fundus to the Cervix.

Its anterior surface is covered on its upper three-quarters by the peritoneum, while the lower fourth is connected with the bladder. The peritoneum covers the whole of the posterior surface. The womb is held up (suspended) in the pelvis by ligaments; two anterior, womb and bladder (utero-vesical), two posterior, womb-sacral (utero-sacral), two lateral broad ligaments, and two round ligaments. The womb sacral (utero-sacral) which holds the womb well up in the hollow of the sacrum and the round ligaments which keep the womb well forward enter most actively into the support of the womb. The round ligaments are strong muscular fibrous cords and serve to hold the womb forward. When pregnancy exists they increase in size with the womb, and keep the fundus forward in its excursion upwards into the abdominal cavity, and after confinement, become smaller with the womb, guiding the womb back again to its regular position. The broad ligaments are little more than reflection of the peritoneum serving to support the vessels that nourish, as they go to and from the womb.

The womb has three coats, enclosing a central cavity. This cavity of the womb is small by comparison with the size of the organ and it communicates with the Fallopian tubes by two minute openings at each side of the body, and with the vagina below, through the mouth or opening of the womb.

The external coat of the womb is called servos, derived from the peritoneum; the middle or muscular coat, which forms the chief substance of the womb, consists of bundles of unstripped muscular fibers intermixed, with loose connective tissue, blood vessels, lymphatics and nerves; the internal or mucous coat is continuous through the fringed extremity of the fallopian tubes, with the peritoneum, and through the mouth of the womb (os uteri) with the mucous membrane of the vagina. This mucous membrane is lined in the body of the womb by epithelium arrayed in columns (Columnar Epithelium) which loses its ciliated (eye-lash) movement character during pregnancy. In the lower half of the Cervix, the epithelium (this kind of cell lines all canals having communication with the external air) is of the stratified (arranged in layers) variety. The appendages of the womb are the fallopian tubes, the ovaries and their ligaments and the round ligaments. The fallopian tubes convey the ova (eggs) from the ovaries to the cavity of the womb. They are two in number, one on each side, situated in the free border of the broad ligaments and extend from each horn, an excrescence of the womb that looks like a horn, of the womb outward to the sides of the pelvis; each is about five inches in length, and has a small canal beginning at the womb in a very small opening called the internal mouth (ostium internum). This canal gradually widens to its ending, the abdominal mouth (ostium abdominal) by which it communicates with the peritoneal cavity, the timbrae. A series of fringe-like processes surround this mouth or opening and this farther end is known as the fimbriated extremity. The tube has three coats, serous or external or peritoneal; the middle or muscular, continuous with that of the womb, and an internal or mucous coat continuous also with the lining of the womb and peritoneum (covered with ciliated Columnar Epithelium).

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The Ovaries.--They are analogues, anatomically, of the testes in the male. They are two egg-shaped bodies situated one on each side of the womb on the posterior aspect of the broad ligament, below and behind the fallopian tubes; each is connected by its anterior margin to the broad ligament; internally to the womb by the ovarian ligament, externally to the fringe-like extremity of the fallopian tubes by a short cord-like ligament. They are white in color; about one and one-half inches long, three-quarters of an inch wide and one-third of an inch thick and weigh about two drams each.

The ovarian ligament extends from the inner side of the ovary to the superior angle of the (Uterus) womb. The round ligaments, two in number, are about five inches long and are situated between the layers of the broad ligament, one on each side of the womb in front and below the fallopian tube. They pass forward and outward from the womb through the internal abdominal ring, along the groin canal and out at the external abdominal ring.

I have given a lengthy description of these organs; I think it will repay a careful reading. To understand a disease one should understand the organs that are subject to the disease.

CAUSES OF DISEASES OF WOMEN.

Dr. Child says among primitive people, woman is notoriously free from many of the diseases to which her sister in our present-day civilization is especially prone. As we ascend the scale of civilization, departing from a natural and adopting an artificial mode of life we find nature enacts due penalties for the transgression of her laws. The female among savage tribes has every advantage and opportunity to develop physical perfection, and her endurance suffers little, if any, by comparison with the male. How different is our modern system when the young girls are sent early to school and subjected daily to long hours of study, often in badly ventilated class-rooms, for nine months in the year, and this at the time of puberty, one of the most important periods of their life when they need plenty of out-door exercise. Surely, as Goodell says, "If woman is to be thus stunted and deformed to meet the ambitious intellectual demands of the day, if her health must be sacrificed upon the altar of her education, the time may come when to renew the worn out stock of the Republic it will be necessary for our young men to make matrimonial excursions into lands where educational theories are unknown."

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Menstruation.--Many of the disorders of menstruation are due to carelessness and neglect of this function. There should be rest of both body and mind at this time, and especially at puberty. Rest is seldom allowed, but the daily routine is gone through, regardless of what may happen.

Dress.--The way the abdomen is now constricted, and this is now a prominent feature of women's mode of dress, is without doubt an important predisposing cause in female diseases. This contraction of the normal size of the cavity of the abdomen, with the subsequent compression and displacement of its organs, must of necessity produce dynamic (powerful) changes in the pelvis that cannot be otherwise than injurious to the pelvic organs. Tight lacing or any lacing, aside from the remote effects so unnatural a practice must produce, causes marked atrophy (dwindling) of the abdominal muscles. These are often so weakened that during labor they cannot properly assist the uterus (womb) in effecting delivery, and as a result instrumental interference, with its attendant dangers becomes necessary.

Prevention of Conception.--This is a very common practice among civilized women, and it has a most destructive effect upon the pelvic organs, as well as upon the general system.

Criminal abortion.--The chief danger from the criminal interruption of pregnancy is sepsis (absorption of poisons) into the system. This may be acute in character and have a fatal termination, or chronic in nature, leading to permanent injury of the womb and fallopian tubes, sterility and chronic invalidism.

Child birth.--Pelvic diseases frequently come from injuries received during labor.

Venereal diseases.--Dr. Child says, "Syphilis exerts its usual baneful influence, but gonorrhoea is responsible for more pathological (diseased) lesions (conditions) in the female pelvis than any other one factor. Its attack, if not resulting in ultimate loss of life, always leaves the tissue in an impaired condition, from which resolution (returning to natural condition) is rare. It is doubtful if a woman once infected with gonorrhoea ever recovers from its ravages. As a cause of sterility its power is beyond estimation."

INFLAMMATION OF THE VULVA.--(Vulvitis).--An acute or chronic inflammation of the vulva (external genitals) either from a specific, like gonorrhoea, or non-specific cause.

Causes.--Veit says, "Seventy-five per cent of the cases are caused by gonorrhoea."

Other Causes.--Accumulation and decomposition of discharges from the womb and vagina, inflammation of the inner lining of the womb and of the vagina. Foul, putrid discharges from neglected supports (pessaries) and tampons in the vagina; sloughings from cancer may act as exciting causes. Contact with ammoniacal and sugar urines has a similar effect.

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In Infants.--It is usually due to want of cleanliness in failing to remove decomposing urine and feces. Mothers often allow soiled, foul smelling diapers to remain for a long time on the baby.

Symptoms and Condition of the Parts.--In the acute stage the mucous membrane around the opening of the vagina is red, swollen, painful and bathed in pus. The glands in the groin and glands of Bartholin are usually enlarged and tender. The glands of Bartholin and those around the urethra may become infected and fill with pus. The fatty glands of the labia majora are also sometimes affected and then appears the disease called Follicular Vulvitis (in the chronic stage secretion is abundant). The parts feel hot and there is more or less burning and itching. Walking makes the trouble worse, due to rubbing of the parts. Passing of urine increases the distress.

When the disease is caused by gonorrhoea it is more extensive and involves the vagina, urethra, the glands around the urethra and glands of Bartholin. This gland infection frequently results in an abscess.

Treatment.--In the acute form the patient should go to bed and remain there for some time. The parts should be kept constantly moist with a wet antiseptic dressing, listerine, hot water, etc., applied to the vulva and kept there.

1. If there is much pain the following solution may be used:

Acetate of lead 1 dram
Laudanum 1/2 ounce

Water enough for six ounces.

Mix and apply constantly with sterile cloths.

2. For chronic form Dr. Child says, "The vulva should be shaved, thoroughly cleansed and a mild ointment applied daily thereafter," such as:

Salicylic acid 20 grains
Oxide of zinc 2 drams
Petrolatum enough for 1 ounce

Mix and make an ointment and apply daily.

If it is due to irritating discharges that cannot be checked, cleanse the parts thoroughly and use the Zinc ointment to protect.

ITCHING OF THE VULVA.--Vulvae or Pruritus.--This intense itching is the characteristic symptom. With the itching there is more or less swelling of the parts and extreme nervous irritability.

Causes.--This is doubtful; some think it is a purely nervous condition.

Parts irritable.--The upper angle of the labia majora and the mons veneris are the usual locations. The skin is inflamed thickened, raw, from the continual scratching."

Symptoms.--The itching and burning are almost unbearable at times, beginning most often around the clitoris, coming in paroxysms and made worse by warmth and motion.

In chronic cases the skin is a little thickened and looks dull and dry and is covered with small cracks and scratches, the result of the patient's efforts to stop the itching.

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Treatment.--Systematic, general tonic treatment. Diabetes, gout, irritating discharges from the vagina and rectum should be removed. Pin worms and highly acid urine sometimes cause it in children. Internally the bromides to quiet the nerves and arsenic to build up the system should be given.

Local.--Strong solutions of corrosive sublimate (1 to 1000), nitrate of silver, tincture of iodine, and cocaine ointment give temporary relief.

Sometimes an operation is necessary.

CYSTS OF THE VULVA.--A cyst is a cavity containing fluid and surrounded by a covering (capsule). The duct (canal) of the gland of Bartholin, situated in the labia majora, sometimes closes and the secretions of the gland are not cast out, thus forming the cyst.

Cause.--The closing is nearly always the result of gonorrhea.

Condition.--The cyst is formed in the duct, the gland itself being affected rarely. It contains a thin sticky mucus. If the cyst arises in the gland, the swelling is more deeply situated. These cysts may be attacked with an acute inflammation and finally pus is formed in them, and a very painful abscess is the result,

Symptoms.--There are no symptoms except from the size of the swelling unless an abscess occurs. Then there is an acute local pain, quite tender on pressure, and often high fever.

Treatment.--If the cyst is large it should be removed, especially if it causes annoyance. If it becomes inflamed, rest in bed and cold applications are indicated. If it goes on to an abscess, a free cut should be made, the abscess scraped and good drainage given. Sometimes it is best to use pure carbolic acid in the walls of the cyst.

INFLAMMATION OF THE VAGINA, (Vaginitis).--Vaginitis is an inflammation of the mucous membrane of the vagina.

Varieties.--l. Catarrhal or simple 2. granular; 3. gonorrheal; 4. diphtheritic, and 5. senile.

1. Catarrhal or simple form.--This is the most usual form. There is a general redness of the membrane with swelling and increased secretion.

2. Granular.--This is an advanced stage of the simple type, and is due to long continued or repeated attacks.

3. Gonorrheal form.--Is due to infection by the gonococcus of Neisser (due to gonorrhea). This form is hardest to cure and may continue for years or life, The infection may extend to the womb, fallopian tubes and peritoneal cavity and produce inflammation of the womb (endometritis) pus in the tubes, (pyosalpinx) and peritoneal cavity. This is more common than even some physicians realize.

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4. Diphtheritic--Due to diphtheria, not frequent.

5. Senile type.--This comes only after the change of life.

Symptoms.--There is pain in the lower abdomen. Passing of urine is frequent and is attended with smarting and burning pain. There is a feeling of heat and burning in the vagina, and a copious discharge of mucus and pus. In the gonorrheal variety the urinary disturbances are most marked.

In gonorrheal variety the symptoms date from a distinct onset, last longer, do not yield so rapidly to treatment, and complications, such as enlarged glands in the groin and in the vulva and vagina, inflammation of the lining of the womb and fallopian tubes, inflammation of the bladder, often make their appearance early.

Treatment (in acute cases).--Rest in bed and prolonged vaginal injections of a solution of corrosive sublimate (1 to 4000 strength) three times a day. If the gonorrheal poison is present in the pus, the walls of the vagina, cervix and cervical canal should be dried and thoroughly painted with a twenty per cent solution of nitrate of silver. The patient should be in the knee-chest position for this treatment.

In chronic cases the gonorrhea poison (gonococcus) is found most frequently just behind the posterior lip of the cervix and here the silver solution should be applied very thoroughly.

VAGINISMUS.--This is a painful reflex muscular contraction of the vaginal orifice, and is most often observed in patients of a nervous and sensitive temperament. Treatment.--Any local cause of irritation should be removed. If there is no local irritation, the opening should be dilated under an anesthetic. Tonics, exercise, and a complete change of scene are beneficial.

DISEASES OF THE CERVIX.

TEAR OF THE CERVIX (Laceration).--This is a tear in the lower part of the cervix. There may be one or more. The left one-sided tear is the usual form. Next comes the tear on both sides (bilateral). Tears on front and behind are not frequent. Tears are found in about thirty per cent of women who have had children.

Causes.--The majority of cases are caused by labor, and is due to a cervix that is not perfectly dilated. Very hurried, quick labors cause it sometimes, but the greatest injuries are due to the various operations for delivering the child through a cervix that is not fully dilated.

Symptoms. Immediate and remote.--On the immediate, when the tear is severe, there is bleeding; later, sub-involution, that is, the womb does not return to its normal size and weight.

Remote symptoms.--Leucorrhea, thick and mucus in character; profuse menstruation and inability to become pregnant. When the tear has extended through the internal opening the woman win not be able to carry the child to full term, even if she becomes pregnant.

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Treatment.--Tampons of ichthyol (ten per cent), mixed with glycerin, introduced twice a week against the cervix and permitted to remain forty-eight hours will often afford relief.

The tear should be repaired after child-birth, if possible. If not then, and if it does not heal, it should be repaired later when the tear extends through the internal (opening) or in case of extensive raw surface on the cervix.

INFLAMMATION OF THE CERVIX.--This is an inflammation of the mucous membrane lining the canal of the cervix (cervical canal), known as Endocervicitis; it may be acute or chronic. The acute form is seen most often as a part of a general infection involving both womb and cervix, and will be described later. The chronic form is a very common condition and it is difficult to treat.

Cause.--Injury and tear of the cervix.

Symptoms.--Leucorrhea, profuse and frequent menstruation, pain in the back and loins. On examination a string of thick mucus is seen at the external opening (os) of the cervix; and of women who have borne children there are usually signs of tear and rawness of the cervix present; (Endometritis usually produces a thin watery discharge, while gonorrhea produces a thick, pus-like discharge).

Treatment.--Hot vaginal douches, containing one dram of sulphate of zinc to one pint of water, used every night for ten minutes. Hot water with witch-hazel, about four drams to the pint, is also good. Tincture of iodine applied locally twice each month. White oakbark tea used as an injection once a day for this trouble; also good for vaginitis.

INFLAMMATION OF THE LINING OF THE WOMB. Endometritis.--Endometritis is an inflammation of the lining membrane of the womb, with a tendency to extend to the lining membrane of the fallopian tubes and to the peritoneum. These are the acute and chronic varieties.

Causes.--It may occur during an acute skin disease eruption, like that of scarlet fever, and occasionally upon exposure to cold during menstruation. The most frequent exciting causes are the microorganisms, like the gonorrhea poison, etc.

Acute Variety.--The whole mucous lining is inflamed. In severe cases the whole mucous lining is destroyed and the deeper muscular tissues of the womb are invaded.

Gonorrheal Variety. Symptoms.--There is general pain in the lower bowel region, in spells at first, later constant, with rapid rise of temperature and pulse. A purulent (pus) discharge appears early from the cervix, usually about the second day, and difficult and burning passing of urine are early symptoms. There is inflammation of the vagina accompanying it in about fifteen per cent of the cases, while inflammation of the fallopian tubes, pus in the tubes, and local peritonitis are common results.

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MOTHER'S REMEDY. Inflammation of the Womb. 1. A Good Tonic for.--"For inflammation of the uterus or ovaries try a hot sitz bath every day for a week, and then every other day. In case of hemorrhage this bath is invaluable, and will relieve when all other means have failed. It can be taken during the hemorrhage, or at frequent intervals between times. Remember, one should always lie down after a sitz bath. If desired you may give aconitum tincture. Dose:--Two drops in a half glass of water, tablespoonful doses every ten to thirty minutes according to the severity of the case." If a woman has taken a severe cold, then the aconite should be given, but under no other condition.

PHYSICIANS' TREATMENT.--Dr. Child advises that the cervix be dilated, and the interior of the womb, cervical canal and vagina swabbed out with a ten per cent silver nitrate solution. Subsequently vaginal douches (1 to 5000) corrosive sublimate solution followed by a salt solution, one dram of salt to a pint of water, should be given for at least one week. Keep the bowels open.

SEPTIC PUERPERAL ENDOMETRITIS.--This is an inflammation of the inner lining of the womb that occurs after child-birth during the first few weeks, and is due to a poison.

Symptoms.--The attack usually begins with a chill, preceded by a regular increase of the temperature and pulse. The face looks flushed at first, but it soon becomes pale and the patient has an anxious look, as the disease goes on. There is very little pain, if any. The discharge that always follows labor is diminished or stops and has no odor, if there is any discharge.

The death rate is from five to twenty-five per cent.

Treatment.--Never scrape out (curette) the womb for this disease. The womb should be washed out with a hot salt solution, one teaspoonful of salt to one pint of water, and then packed with ten per cent iodoform gauze. This solution should also be injected hot into the rectum and frequently. The bowels should move freely, and if necessary injections may be given for that purpose.

The strength must be kept up by a liquid diet. Milk, brandy and strychnine, if necessary; 1/100 of a grain of strychnine can be given every four hours. Milk should be given every half hour, about two ounces at one time: or more if it agrees well.

The gauze should be removed gradually, beginning on the third day and ending on the ninth day.

In this disease the interior of the womb is smooth and contains no broken down or foreign tissue. In the next disease, Putrid Endometritis, it is far different, for this is caused by the presence of dead material, such as parts of the after-birth, left in after labor, or sloughing tumors. This material becomes putrid (rotten), and thus causes the disease called "Putrid Endometritis."

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PUTRID ENDOMETRITIS.--An inflammation of the inner lining of the womb caused by putrid (rotten), decaying material.

Symptoms.--A chill is sometimes present at the beginning. The fever is high, pulse bounds and feels hard and strong, the face is flushed but there is little or no pain. The discharge from the womb, unless it is blocked by a clot, is foul smelling. The flow after childbirth is scanty, sometimes suppressed. The womb and ovaries are not very tender.

Treatment.--The first thing to do, of course, is to get the dead material, such as parts of an after-birth, clots, shreds, etc., out of the womb, and then scrape the rough surfaces. This must be done carefully and with perfectly clean tools and liquids of every kind. Then wash the womb thoroughly with the hot salt solution. One teaspoonful of salt to one pint of boiled water. After this pack the womb with ten per cent iodoform gauze, which may be bought in this strength. Remove this from the womb about the third to the ninth day. The bowels should be kept open.

Diet.--Should be of milk or at least of liquids only. The patient can be given whisky or brandy and 1/60 grain of strychnine every four hours if needed.

MALIGNANT DISEASES OF THE WOMB.--Cancer or carcinoma is a malignant disease of the neck (cervix) of the womb.

Causes.--The immediate cause is not yet known. Tears and erosions (scraping off and making raw) are supposed to act as direct causes.

Symptoms.--Bleeding is the early and very important symptom. After the change of life (menopause) is over if bleeding occurs and continues it is a very bad sign and the womb should be examined immediately. Later, a watery bloody discharge appears, with pain, loss of weight and general weakness. Pain is not an early symptom. It appears when the disease has spread to the nearby tissue.

Treatment.--The only thing to do is to operate and the earlier the better. The womb and all its belongings should be removed. If this is done early it is very successful. If the case is too far advanced, the only thing to do is to make the patient as comfortable as possible.

For the pain, morphine or opium should be given.

For the discharge, hot water and corrosive sublimate (1 to 2000) is the strength to be used. This should be used daily as an injection into the vagina.

Cancer of the Body of the Womb is found in only about two per cent of womb cancers.

Treatment.--An early operation is then necessary. The chances of obtaining a cure if operation is done is better even than in cancer of the neck of the womb. There is less chance for the adjoining structures to be affected so early and readily.

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FIBROID TUMORS OF THE WOMB or Fibromata, Frequency.--Some observers state that twenty to forty per cent of all women over thirty-five years have one or more of these tumors. They are not malignant. They are more common in women who are sterile, unable to become pregnant. They appear early in life and attack all classes. They appear oftener in the body of the womb than in the neck. When in the body of the womb the back wall is the common site. A covering of loose fibrous tissue surrounds the growth. Few blood vessels appear in the tumor, nourishment being received from the surrounding tissues. Their growth is slow, except during pregnancy, when they grow rapidly. There are three varieties named according to their location and the structure covering: or surrounding them. 1. Interstitial; 2. sub-mucus; 3. sub-peritoneal or sub-serous.

1. Interstitial.--They are in the substance of the womb wall. They are usually many and vary in size.

2. Sub-mucus (under the mucous membrane).--They project into the cavity of the womb, are covered by mucous membrane and are attached to the womb by a broad base or pedicle. This is sometimes cut off spontaneously, and then the tumor is expelled from the womb.

3. Sub-peritoneal.--They are under the peritoneum, which forms its outer cover.

Causes.--Are not known. They are more frequent between thirty and forty.

Symptoms.--Difficult monthly sickness, too much blood flowing from the womb, unable to become pregnant, sometimes, and abortion. Bleeding comes more from the sub-mucus variety generally. Pain is caused by the size and weight and by pressure upon the bladder, rectum and the nerves. Death rarely results except from the complications.

MOTHER'S REMEDY. 1. Ulcers of the Womb, Common Wood Cactus for.--"Common wood cactus tea. Take wineglassful three times a. day." Should remove all thorns, chop fine and boil in sufficient water; add gin to make dose more pleasant.

Treatment.--Operation is needed when the symptoms are pressing. The sub-mucus variety may make an early operation necessary on account of their location.

Symptoms Calling for an Operation.--Size of the tumor; from the pressure symptoms; persistent bleeding from the womb. Sometimes it is necessary to remove the entire womb, especially in the interstitial variety, for the walls of the womb may be filled with the tumors.

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SUBINVOLUTION OF THE WOMB.--This simply means that the womb, after miscarriage or child-birth, fails to return to its normal size and weight.

Causes.--This is frequently due to getting up too soon after labor.

Symptoms.--Menstruation or too much flow of blood (menorrhagia), dull, heavy feeling in the pelvis, backache or leucorrhea.

Results.--The womb frequently becomes misplaced.

Treatment.--Proper supports should be put in after the womb has been placed in its proper position.

If seen early enough some cases can be cured by tampons of ichthyol used three times a week and prolonged hot water injections at bed time. Cotton soaked in ichthyol and glycerin are frequently of benefit three times a week used as a tampon. The patient should not be on her feet much, or be active. Witch-hazel water can be added to the hot water injection if so desired.

DISEASES OF THE FALLOPIAN TUBES.--These are named after their discoverer, Fallopian, an Italian anatomist. These tubes begin at the part of the body of the womb that extends out like a horn. This is on the sides near the top of the body of the womb. They are two in number and extend outward on each side for about four inches; each end forms a fringe or finger shape to catch the egg, as it emerges from the ovary. Through the center there is a tube or canal, and the inner lining of the womb continues on and lines this canal, the mucous membrane of the Fallopian tubes. When this lining or membrane becomes inflamed it is called Salpingitis or Inflammation of the Fallopian tubes. Salpingitis is derived from two words: Salping, meaning tube; ltis, meaning inflammation; Fallopian was the discoverer. Thus we have Salping(x)itis, or Inflammation of the Fallopian tubes. Unfortunately in medical description it is generally called Salpingitis.

SALPINGITIS. Inflammation of the Fallopian Tubes.--It may be either acute or chronic in character.

Condition.--The tissues of the tubes become swollen when the inflammation runs into the pus stage; the finger-shaped end (outer end) is usually closed by adhesions, the pus accumulates in the tube and we have pus in the tube, or what is technically called [pyo. (pus) Salpinx (tube)] Pyosalpinx. In long standing cases the pus is absorbed or degenerates into a thin watery fluid, forming watery fluid in the tube or [hydro (water) Salpinx (tube)]--hydrosalpinx.

The tube may become attached to neighboring organs. The pus or fluid may drain occasionally into the womb and vagina. It may go into the bladder or bowels.

Causes.--It is usually caused by invading germs from the womb. Gonorrhea is the cause of the most cases.

Symptom.--This disease follows the same kind of an infection in the womb and vagina; the patient complains of pain in the region of the tube, a little to the side or sides of the womb, and the pain is made worse by motion, exercise or long standing. If it is the acute variety, the temperature rises, the pulse grows faster, and sometimes there is nausea and vomiting.

[WOMAN'S DEPARTMENT 503]

The Symptoms of the Chronic Variety are due to congestion and adhesions. There is a constant pain in the region of the tube and the patient protects herself when she walks, rides or sits down. There are difficult, painful monthly periods and too much flow. The history shows gonorrhea or septic infection, that is, disease caused by the absorption of products of putrefaction.

Treatment of the Acute Kind.--First thing is absolute rest and quiet in bed. Then prolonged hot injections in the vagina of hot water, and if you wish, one teaspoonful of listerine, etc., in each injection. Put a hot-water bag to the sore side, or fomentations of different remedies, like hops, catnip, pennyroyal, smart-weed. The applications should not be of great weight. The bowels should be kept open.

For Chronic Variety.--This frequently calls for an operation. When the symptoms are due to inflammation in the tube alone, ten per cent strength of ichthyol and glycerin tampons placed behind the lower part of the womb three times a week do much to improve the condition.

This is an unfortunate disease, and it must be closely watched for symptoms that may arise from a pus condition. There are many cases of this kind in our public hospitals, and when they are due to gonorrhea they may have been caused by the husband who had an acute or latent gonorrhea--an attack he thought cured.

DISEASES OF THE OVARY.

Inflammation of the Ovary or Ovaritis.--This is an inflammation of the ovary and it may be either acute or chronic.

In the acute form the ovary is slightly enlarged and the follicles on the circumference are distended and filled with thick fluid or pus.

In the chronic variety the ovary may be small and contain cysts; there is a destruction of the follicles and a hardened condition develops. The function of the ovary is then impaired.

Causes.--Gonorrhea, septic infection from adjacent tissues, acute fever diseases, mumps, and peritonitis. Falling (prolapse) often gives rise to chronic inflammation.

Symptoms.--Pain in the lower abdomen (pelvis), difficult and painful menstruation, too much monthly flow (menorrhagia), and painful intercourse.

Treatment.--Ichthyol (ten percent) and glycerin tampons placed behind the lower back part of the womb three times a week. The bowels should be kept open with salts. The diet should be milk or liquid. Sometimes an operation is necessary. In the department on operations this subject will be touched upon in regard to operations.

PHYSICIANS' TREATMENT.--Change of the mode of life, and proper hygienic measures will generally be all that is needed.

[504 MOTHERS' REMEDIES]

TUMORS OF THE OVARY.--Cystoma is the most common tumor of the ovary. The word "cystoma" means a cyst tumor, or cystic tumor. A cyst means a cavity containing fluid and surrounded by a covering (capsule). Ovarian cyst or tumors is often seen in print these days. Ovarian tumor takes in the cystic variety, cancer and sarcoma, two malignant tumors.

Symptoms.--These depend upon the size of the tumors. The large tumors are generally cystic. Examination of the vagina shows the pelvis filled by a tense, watery, fluctuating mass. Examining the abdomen, the abdomen is seen more or less distended by a regular swelling, and sometimes this is enormous. The abdomen is rounded and there is no bulging at the sides like there is in ascites (dropsy). The navel is not prominent. The tumor can be outlined. It cannot be in ascites.

Treatment.--In bygone years tapping was done for these tumors. If it gets large or the health fails, an operation should be performed. This is very successful in uncomplicated cases. Inside of two months the patient is about well. I know I have saved many lives of women by recommending an operation for such tumors.

For the congested ovary, treatment by tampons and medicine often helps. I have frequently given a medicine called Apis-Mel for this condition and with success. I give it in tablets of 1/100 of a grain regularly four times a day.

MENSTRUATION AND ITS DISORDERS.--Normal menstruation occurs monthly in the female. There is a flow of blood from the cavity of the womb. The time for its beginning is different in different countries, it being earlier in warm climates, ten to twelve years, and later in cold ones (fifteen to seventeen years); the average is fourteen years.

Pregnancy suspends menstruation and often nursing the child does, also. Menstruation continues longer in robust, healthy women. Change of life (Menopause) occurs usually between forty and fifty years. The healthy girl and woman comes around every twenty-eight to thirty days. This is the usual time. The flow lasts from two to eight days and the quantity is about one ounce each day. A slight feeling of weight and fullness in the lower abdomen (pelvis) should be the only symptom present in a healthy female. The blood lost should not cause any special degree of weakness.

PREMATURE MENSTRUATION. Too early menstruation.--Premature or precocious menstruation is when it occurs before puberty. This is in part hereditary, but bad associations may be a cause of this early menstruation.

Treatment.--The cause, if possible, should be removed. The nerves should be kept quiet by rest and, if needed, general tonics like iron, arsenic, and nux vomica prescribed and given.

[WOMAN'S DEPARTMENT 505]

DELAYED MENSTRUATION.--This is often caused by slow development of the generative organs. The girl may not come around until seventeenth to nineteenth year.

Causes.--It may be due to heredity. Lack of proper nourishment and proper exercise are the most important causative factors.

MOTHERS' REMEDIES.--l. Obstruction of Monthly Flow.--An herb combination for.

Poplar Bark 2 ounces
Ginger 1/2 ounces
Bayberry 1 ounce
Cinnamon 1/2 ounce
Anise Seed 1/2 ounce
Golden Seal 1/4 ounce

Mix well and give a teaspoonful in a cup of boiling water sweetened with sugar two or three times a day. Excellent in obstructions of the monthly periods, debility, loss of appetite, etc. This combination is fine when used as a tonic. It is stimulating and has been known to cure many severe cases.

2. To Promote the Menses, Smartweed for.--"Smartweed is good to promote the menses. Always steep in cold water; never boil. Dose.--Two teaspoonsful every hour. Be sure to take warm."

VICARIOUS MENSTRUATION (In place of).--When menstruation is absent or suppressed, bleeding sometimes occurs periodically, from the ear, nose, any existing raw surface, leg, ulcer, and from the respiratory (breathing) tract, and also from the bowels.

AMENORRHEA.--This is absence of menstruation.

Causes.--Delayed puberty, anemia (want of proper blood) chlorosis (green sickness). diabetes, malaria, tuberculosis and acute illness may cause it. Sometimes change of climate causes it and nursing baby too long.

Symptoms.--If it is associated with atresia, that is, want of the normal outlet, of course no signs of flowing can show, but colicky, cramp-like, monthly pains appear in the lower abdomen. These increase in severity as the retained blood distends the womb.

Treatment.--If there is no opening for the vagina or cervix one must be made, by operation. If it is due to anemia or chlorosis, Blaud's pills will benefit. The following is the formula:

Dried Sulphate of Iron 2 drams
Carbonate of Potash 2 drams
Syrup--Sufficient quantity to make forty-eight pills.

Take one to three pills three times a day, after meals.

MENORRHAGIA.--Too much bleeding at the monthly periods. If it occurs between the monthly periods it is called Metrorrhagia, womb-bleeding at any time, especially between the periods.

Causes.--These may be constitutional or local, the latter being the most important.

Local Causes.--These are inflammation of the womb, displacements of the womb, malignant disease of the womb, fibroid tumors and disease of the ovaries.

[506 MOTHERS' REMEDIES]

Symptoms.--Sudden or gradual increase in the amount of blood lost at the monthly periods. Then secondary anemia, weakness and run-down feeling.

PHYSICIANS' TREATMENT. 1. Profuse Menstruation, an Easily Prepared Herb Remedy for.--

"Cranesbill Root 1 ounce
White Poplar Bark 2 ounces
Bistort Root 1 ounce
Golden Seal 1 ounce
Geranium 1/2 ounce
Cloves 1/2 ounce
Ginger 1/2 ounce
Ground Sugar 1/2 pound

Mix. This compound is excellent for complaints of weak females, such as leucorrhea, bearing-down, or profuse menstruation, etc. Dose: One teaspoonful of the powder, in a half cup of boiling water three times a day. Drink the clear liquid only." Any woman suffering with, female trouble will find the above combination very beneficial.

2. In young girls and women who are not married, thirty drops of the fluid extract of Ergot three times a day. This medicine will cause the womb to contract. Hot douches can be given to married women. If the bleeding is severe it may be necessary to pack the vagina with sterile gauze. Ergotin ten to twenty drops, may be needed, given hypodermically. If it is due to constitutional causes, like anemia, a played-out feeling, paleness. weakness, etc., a tonic treatment is needed.

3. Blaud's pills will do well. This is the formula:

Dried sulphate of iron 2 drams
Carbonate of potash 2 drams
Syrup enough to make a mass

Mix and make forty-eight pills. Take one to three, three times a day after meals.

4. If the appetite is poor, bitter tonics such as gentian, quassia, cinchona, or nux vomica are needed.

Compound Tincture Cinchona 2 ounces
Compound Tincture Gentian 2 ounces

Mix. Take one teaspoonful before meals, in a little water.

5. Tincture of nux vomica in doses of two to three drops after meals is a good stomach and bowel tonic.

6. Golden seal root made into a tea is good in some cases, especially if the tongue is much coated.

7. Oil of Erigeron or flea-bane is good for oozing bleeding. Dose: Three to five drops in a capsule every four hours.

8. Oil of cinnamon in one dose of one-half dram is good where flea-bane oil cannot be used or obtained; usual dose, one to five drops. An infusion can be made of the cinnamon bark and drank freely.

[WOMAN'S DEPARTMENT 507]

9. Cranesbill (Geranium maculata). The fluid extract is splendid when diluted three or four times with boiled water, used locally for bleeding from the womb, or as an injection for the same; or an infusion can be made of the plant and injected into the vagina. The local cause mentioned should be treated. The displacement should be corrected.

DYSMENORRHEA or Difficult Menstruation.--This term means difficult and painful monthly periods. The pain may occur before, during or after the periods.

Causes.--It may be caused by a narrow cervical canal, the canal from the inner womb to the vagina. This is often very narrow and almost closed. Again it is produced by the womb being turned back and bent on the canal, thus partially closing it. This causes the blood to be retained in the womb and then the womb contracts to expel the blood, pains being the natural result. Diseases of the womb and ovaries also cause it. Sometimes the membrane of the womb is cast off in the form of shreds or even a cast of the inner womb.

Symptoms.--The flow may be scanty, moderate or profuse, often clotted. The pain varies. It may be slight before the flow, or the first day or two, or it may be severe, agonizing and continuous for one or two days, or during the whole period and sometimes for some days after there may be pains.

MOTHERS' REMEDIES. 1. Painful Menstruation, a Good Tonic for.--"This may be relieved by sitting over the steam of a strong decoction of tansy, wormwood, and yarrow, and fomenting the abdomen with the same. Then take the following in wineglassful doses:--One ounce each of ground pine, southern wood, tansy, catnip and germander, simmering in two quarts of water down to three pints and pour boiling hot on one ounce of pennyroyal herb, strain when cold and take as per dose above."

2. Painful Menstruation, a Home Remedy for.--"Let the patient take an active cathartic; then when put to bed let a half cup of hop tea be given; and a douche of one quart of hot water into which ten drops of laudanum have been dropped, be injected." A cathartic is not necessary in all cases. If the bowels have been moving freely do not take one. The douche will give great relief providing the woman can take one while menstruating. Some women can and some cannot.

[508 MOTHERS' REMEDIES]

PHYSICIANS' TREATMENT.--If the womb is displaced it should be corrected. Any disease of the womb or ovaries should be treated. If the canal is too much closed, gradual and careful dilation between the periods, will often remove this cause in time. The bowels should be kept regular at all times.

1. For the attack.--Never take opium or alcohol for it in any form; it is so easy to form the habit and a doctor who gives it is simply dodging effective general and local treatment between the periods. If it is due to taking cold, or from any local cause, the following treatment is good: The patient should take a hot sitz bath, being well covered by a blanket, while in the tub and afterwards, and should immediately get into bed as soon as the buttocks are dried and remain there well covered. A turpentine stupe is now to be used, prepared as follows: Place a tin cup containing the turpentine in a vessel containing hot water. This will keep the turpentine warm. Dip a piece of flannel into very hot water and wring it out in a twisted towel, and after it is perfectly dry and no dripping, dip it into the hot turpentine and wring it out again to free it from too much of the drug. Apply the cloth while hot and allow it to remain until it causes discomfort. Then withdraw it or it will blister the skin if left on too long. Fomentations wrung out of teas like hop, pennyroyal, smart-weed, etc., applied and kept warm often do much good. At the same time pennyroyal tea can be drank freely. A five-cent package can be bought at any drug store. Hot lemonade will help also. The object is to produce relaxation of the tissues through the local applications and tea drinking. If there is constipation, the bowels should be moved freely with epsom salts, half ounce dose, in the morning before breakfast. If there is much pain a belladonna suppository, one-half grain of the extract, can be inserted into the rectum.

2. If the patient's nervous system is run down the "Rest Cure" will be of benefit, and medicines to strengthen the nerves. Exercise, outdoor life, horseback riding are of great benefit in toning the system.

3. Fluid extract of blue cohosh is a good medicine in this disease, especially if there is some rheumatism during the interval. One or two drops every hour will be enough.

4. Tincture of Pulsatilla in doses of three drops every hour is good for the pain, especially in blonde girls and women.

5. Tincture of Cocculus I have found to be of great benefit. Put five drops of a good pure tincture into a glass half full of water and give two teaspoonfuls every ten to fifteen minutes until relieved. This I give in cases I am called to and have not the time then to find out what the real cause may be.

DISPLACEMENTS.--Turning back or retro-displacements. This includes retro- version and retro-flexion. Retro-version means turning back, in plain terms. Retro-flexion means bending back, bending of the body of the womb, or the neck, backward. Retro-flexion is more common than retro-version.

Causes.--Some are congenital, that is, from birth, and a few are the result of some injury, falls or blows. It is more often found in child-bearing women, and this may be due to the fact that the womb has not returned to its normal size and weight, and therefore there is more weight for the ligaments to hold up. The ligaments often relax and do not support the womb as thoroughly as before.

Symptoms.--Backache, a sense of weight in the lower abdomen, difficult menstruation, leucorrhea, sterility, or repeated abortion and constipation. The constipation is often due to the womb lying on the rectum.

[WOMAN'S DEPARTMENT 509]