DENVER MEDICAL TIMES VOLUME XVIII. AUGUST, 1898. NUMBER 2. ORIGINAL COMMUNICATIONS. SOME COMMON ERRORS IN GYNECOLOGICAL By HENRY P. NEWMAN, A.M., M.D., Carelessness in handling routine cases is one of the commonest errors in the practice of this branch of medicine. This embraces mistakes in diagnosis, negligence in taking case histories, lack of attention to the details of treatment and instructions given to patients, and failure to appreciate the importance of prophylactic supervision over the life and habits of women. It is a common error to make a superficial diagnosis. A certain train of symptoms is presented by the patient, an examination made and a laceration of the cervix discovered. To take this as the cause of the patient's trouble, and direct treatment solely to the laceration is careless diagnosis, and yet too often this is the course pursued. Local treatment or surgical procedure is directed solely to this indication and as a result the patient is more often injured than benefited. Whereas, a cervical laceration may primarily give rise to a series of complications and changes in the surrounding structures which break down a woman's health, it by no means follows that to repair the laceration will cure the resulting evils. On the contrary, the operation of repair, if unaccompanied by auxiliary operations upon the pelvic structures, may be positively mischievous. Thus I have not for many years found a case of cervical tear which had existed for any length of time, where there had not also occurred other structural changes demanding operation, and where to sew up the cervix and leave a large. heavy and displaced uterus, with chronic metritis and endometritis, and probably more or less inflammatory implication of the adnexa, would be to hamper Nature's efforts rather than help. Before the canal is lessened as an avenue for drainage, the endometrium should be thoroughly curetted, the uterus replaced and kept in place by the method best suited to the individual case, and all other pelvic lesions presenting should be repaired. This should all be done at one sitting, and I may say confidently that in all cases of laceration presenting symptoms, it will be found that nothing short of such multiple operating will produce a cure, for the symptoms are not the result of the laceration in itself but of the complications to which it has given rise. It is an error to rely on any single plastic operation to cure a generally disordered pelvis. In this connection it is well to emphasize a warning against another common error, that of relying on the diagnosis of another without personal verification. What I have said in regard to carelessness in diagnosis and plastic surgery is well illustrated by a case which came under my observation recently. I was asked to advise in the case of a woman who had been under the care of a physician at a distance. I did not see the patient, but this history was given me. The physician in charge had made out a laceration of the cervix and had called in a surgeon to operate. After the operation, which was a simple one, the patient did not rally as had been expected, but seemed to be much worse, and in the course of a few days presented alarming symptoms. The surgeon applied to me and I suggested that there was probably some pelvic complication which had not been observed. An examination was made with this view, and a ruptured tubal pregnancy discovered. Another man, a young physician, consults me in regard to a member of his family who is lying ill in bed and rapidly losing ground and yet the only diagnosis made, the only treatment used, is of and for lacerated and eroded cervix. Such incomplete operating and careless diagnosing is worse than useless to the patient and brings more or less discredit or adverse criticism upon the profession. And here let me say that a very common error is an error of judgment as to what constitutes conservatism and what radicalism in surgery. The saving of life alone is not all of true conservatism, nor the end and aim of medicine. By one well-directed procedure to save to a patient years of health and opportunity may be radicalism, but it is in many cases better conservatism than that which hesitates and palliates and delays at the expense to the woman of months and years of invalidism and suffering. Invalidism is bad for the individual, the family and the nation. Neglect of the proper opportunity for surgical help has not only cost many lives, but it has added to this great army of helpless members of society, many who might have been restored to health. The years which the elder Keith has added to the sum of human usefulness have been computed in the thousands, and they stand as a monument to the glory of true conservatism. Of course, a certain proportion of invalid women owe their condition to their own neglect or wilfulness and not to that of the physician who may have done his best to persuade them against their disinclination or fear. Neither do I wish to be understood as implying that topical and palliative treatment have no place in gynecological practice. But that they have grown to assume too great prominence in this branch, particularly in the view of the laity, I am quite convinced. The average office patient is apt to rely upon the ingredients of the various injections and douches she may be ordered to use, and upon the various manipulations of the physician rather than upon the principles underlying the applications. For instance, the more common agents employed in routine treatment are the hot vaginal douche and the tampon. The use of hot water is valuable when properly applied, as a vaso-motor stimulant and as a cleansing agent. The requirements for its use are the recumbent position of your patient with the hips elevated so that the water is retained in the vagina sufficiently to distend that organ to its utmost, before discharge; the length of time not less than twenty minutes, twice daily; the temperature should be gradually increased from day to day; the recumbent position should be maintained for at least half an hour after the douche, and its use continued for weeks or months, persistently. As commonly used, in the sitting posture, at irregular intervals, with water at indifferent temperature and in small amounts, with no rest afterward, the woman believing that the antiseptic used with the water contains the healing virtue, the douche is of little benefit. Its misapplication as a therapeutic agent may also be positively disastrous, as in those cases where there is local infection of the external genitals. The douche point may be the means of carrying the infection to the upper canal and thereby inflicting grave injury on the pelvic structures. Also, whereas in many cases of inflammation the accumulating secretions require washing away with some mild antiseptic solution, there are many cases where the safeguard of the normal vaginal secretion with its bactericidal power is essential and constant flushing with water is mischievous. The improper use of the tamponade is a frequent cause of failure in gynecological treatment. The tampon is indicated as a hemostatic, as a support or compress and as a carrier of medicinal agents. For hemostatic purposes within the uterus the first requisite is a patulous or dilated cervical canal. Iodoform gauze or wicking should be packed firmly in the upper part of the uterus with an appropriate instrument, a pair of dressing forceps such as these which I have devised for the purpose, with slender and tapering blades. The lower segment of the cavity should be less firmly packed, and a strand or two of the material should project through the cervix into the vagina. A tampon so placed is efficient in controlling hemorrhage from the uterine cavity, in securing contraction of the organ and in providing limited drainage. When used in the vagina the same precautions should be taken, firm packing in the upper portion around the cervix, and looser folds in the lower, otherwise it may be expelled or become exceedingly painful and interfere with the functions. of bladder and rectum. Its usefulness depends entirely upon its proper application. As a carrier of medicinal agents, and as a support it is equally valuable or useless according to the manner of applying, the material used and the aseptic and antiseptic care of the operator. In most instances it is a mistake to allow it to remain in situation more than twentyfour hours, as it may become a hot-bed for germ propagation, and the common method of applying, once or twice a week, can accomplish little good and much harm. The same applies to topical applications in general. To paint over the endometrium, cervix uteri or vaginal vault with the usual medicinal agents, iodine, nitrate of silver, carbolic acid, etc., once or twice a week is a delusion and can not, beyond its germicidal action, produce any results other than destruction of tissue by cauterization. It is claimed that the electric current has especial virtue as a topical application, but it is in the same category as those just mentioned and depends for its effect upon its cauterizing power. Better results can be obtained if curette is substituted for all of these things, and more safely, as the operator can better control the technique of the procedure and regulate the amount of action he wishes, whereas with caustics, electricity, etc., the extent of the effect is uncertain and hard to limit. Making local applications to the endometrium except following full dilation of the cervical canal is a very questionable procedure, and yet a few years ago electricians recommended the use of a very small, flexible, intra-uterine electrode for the tortuous canal leading to the large cavity of a myomatous uterus. The usual result of this kind of work was infection of the endometrium with extension to the tubes, ovaries and pelvic peritoneum, complicating a condition already grave enough. It should not be necessary to say very much upon aseptic and antiseptic methods in gynecological practice at the present day, and yet we know that many women are still infected by septic instruments and appliances used in the general tract. The respon sibility for this state of things is no doubt in careless preparation of the patient before treatment, and a too superficial cleansing of the hands and instruments of the physician. Unremitting aseptic and antiseptic vigilance should be as much the rule in the office as in the operating room. The same may be said in regard to obstetrical work. One of the gravest errors that can be listed is the careless handling of obstetrical cases and abortions. This may not seem to be strictly in line with a gynecological subject, but as I wish to speak particularly of the importance of prophylaxis in gynecological work, I can not avoid mention of the great part this plays in the causation of gynecological disease. Clean obstetrical work is of prime importance in eradicating many of the diseases common to women, all meddlesome |