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think she is menstruating, and often misleads the physician who may not be on the look-out for it.
The disease is ushered in by a chill followed by fever, pulse increased, pain or uneasiness in the lower portion of the abdomen. If the peritoneum is not complicated, the disease may last some time without being seen by a physician, but very few if any cases exist without the presence of peritonitis, owing to the intimate relation of the peritoneum to the cellular tissue. In these cases the tenderness and pain are more severe, extending over the whole lower portion of the abdomen. Perhaps tympanitis is present, the patient lying on her back with the knees drawn up, the pulse will be indicative of an inflammation in the serous membrane and the temperature correspondingly elevated. These symptoms may accompany nervous diseases, but the elevation of temperature will diagnose between them. Nausea and vomiting are present in severe forms of the disease complicated with peritonitis, and in those cases the temperature may be below normal. The signs are a perfect guide. The period of chill marks the venous congestion. The seruin of the blood exudes through the walls of the blood-vessels into the cellular tissue. A digital examination in this stage shows a doughy condition of the tissues at some point, and increase of pain upon slight pressure. As the disease advances the exudation continues filling up the interstices; if the disease is slight a portion only of the pelvic tissue is infiltrated; usually the whole vaginal vault is put upon the stretch, the surface becoming incapable of indentation, the uterus becomes immovable and frequently pushed from the side of invasion, in milder cases nodules may be felt. The greatest care must be exercised in making a digital examination, as much harm may be done through carelessness. In the milder cases absorption of the exudation takes place, the symptoms subside, the uterus becomes movable, and all hardness in the pelvic cavity disappears. In a large number of cases without treatment, symptoms of bloodpoisoning become prominent; the exudation is changed into pus, which if not removed will burrow or escape through the point of least resistance, usually the rectum, less often through the vagina, bladder or small intestines. The wife of a prominent Chicago physician who came under my notice a year after an acute attack, passed fecal matter and gas with the urine. Her husband subsequently informed me, an autopsy revealed five openings between the bladder and intestines. The period of restoration to health will depend on the size and form of the suppurating surface and the location of the point of exit. One case came under my notice which had discharged at intervals for three years and finally recovered.
Treatment: During the period of chill the patient should be placed in bed, heat applied to the extremities, an opiate administered if necessary, I prefer the Dover's powder on account of its action on the skin, hot flax-seed meal poultice over the abdomen. A large dose of quinine is often of great value in arresting its progress, and what is of more value than all the other remedies, the continued use of the vaginal douche, the patient lying on her back with the knees flexed. I find a common chamber vessel better than a bedpan. A pillow is placed under the small of the back, the vessel placed under the patient takes a slanting position, the back of the patient forms a perfect cover and prevents the water's running outside the vessel. Water at as high a temperature as the patient can bear, should be put into the vessel before it is placed in position. An attendant using a Davidson syringe, or one made on that plan, can sit beside the bed and gently but constantly keep the hot water flowing into the vagina. Using a vessel of this kind places the vagina on the proper slant; making the os vaginae the highest point, and keeps it full. The water should be changed sufficiently often to preserve the heat. Another syringe may be used to add hotter water or remove some of the cool without changing the vessel thereby preserving the patient's strength. As short an interval of time as possible should be allowed for the patient to become rested when the douche should be again used. I make a practice of using it once an hour and continue it as long each time as possible. This routine treatment should be kept up till the temperature in the vagina is normal and remains so; afterward it need be used only through the day until all doughy feeling and tenderness have disappeared, then three or four times daily for a week or more according to the case, to prevent if possible a recurrence at some future time. The continued use of hot flax-seed meal poultices over the entire abdomen should be kept up. A tablespoonful of pulverized willow charcoal stirred into the poultice when ready to spread, will relieve the patient of the sickening odor and may do some good by absorption. A comparatively thin poultice covered with oiled silk is preferable to a heavy thick one. If the case goes on to suppuration, the hot douche should be used as often through the day as possible without tiring the patient. After pus has formed as shown by the symptom of blood poisoning or by palpation the cyst should be opened at its most dependent point, if possible into the vagina, and the cavity washed out gently but thoroughly with some antiseptic fluid.
I have seen but one case in which the cavity when opened discharged serum instead of pus, and but one which was complicated with pregnancy. The patient was commencing the fourth month, fearing to give her quinine on account of its great oxytocic properties and not being able to find any help in the literature at my command, I lost several hours before I could get counsel; at that time hardening in the vagina had increased from a painful point with slight cedema, to half the vaginal vault. According to the instructions received I used the hot douche and poultices; the oedema was kept in check and pain very much lessened, but labor came on the third day with the temperature at 1050 and pulse 120. Very little if any blood was lost, but the pain during labor was excruciating and was relieved by hypodermatic injections of morphine. She made a good recovery, all tenderness and ædema having disappeared in a week. The treatment was kept up regularly for a week longer to prevent a recurrence. Tonics should be exhibited throughout, Sedatives for nervous indications, Opium if the pain is severe, Stimulants if the symptoms indicate great nervous prostration.
The diet should be in as concentrated a form as possible to prevent the peristaltic action of the bowels, the probabilities being that they are united by inflammation to some of the other organs or tissues. If Scybala form in the rectum they should be gently removed with the fingers of the attending physician. A small enema of oil or an emulsion of oil or oxgall will help to soften the hardened mass.
The result of cellulitis is an item of grave importance, What physician has not met case after case of so called uterine trouble which has grown worse with ordinary "local treatment?”
Those cases may be described as having some tightened ligaments drawing the uterus out of position, a displacement of the ovaries with great tenderness in conjoined manipulation and perhaps such a thickening of the pelvic tissues as to prevent an examination of them at all, or the ovaries and uterus may be bound down, being extremely
sensitive upon pressure with the finger, preventing the woman from fulfilling the duties of a wife, without great suffering, and perhaps a recurrence of active inflammation, and in the majority debarring her from the joys of maternity.
These cases are common to all of us, but how few have seen as many cases of the acute variety. It is hardly necessary to call attention to the fact, that there must have been as many acute cases as there are chronic, which were unrecognized in time.
Some physicians are, shall we call it self-conscious or bashful, and cannot forget sex when in the presence of a female patient. No woman will call a physician in whom she has no confidence and no suffering female will deny her physician the privilege of an examination if he asks it in a business way as a necessity to the proper understanding of her case, on the contrary if he insists upon it or gives up the case her confidence in him will be greatly increased.
The object of this paper is to bring before the physicians in general practice the necessity of always keeping this disease before their minds, when called to a female patient who complains of pain or uneasiness in the pelvic or abdominal cavities and if the symptoms are not sufficiently well marked to class the trouble among the other many diseases, which might be located there, and is one which must be treated on the expectant plan for a day or more, by all means insist on a digital examination, when you will in the greater number of cases find a tenderness at some place in the vaginal vault, which the proper application of hot water will change from a most dreadful disease if allowed to progress into a few quiet days in bed, where the patient says she feels rested and ready for her work again.
OPERATION OX SIX CASES OF LACERATION OF THE CERVIX UTERI WITH
In these days of enlightened Gynecology, I believe it is perfectly safe to assume, that a Cervix Uteri, suffering from a loss of continuity, should always be restored to its former shape of perfect integrity,especially if ectropion of the cervical mucosa is well marked and productive of discomfort. This, I believe, is a sound, safe, as well as conservative Gynæcological doctrine, and in full accord with the opinion of the acknowledged leaders in uterine surgery. The operation for laceration of the cervix uteri has long since passed beyond the pale of justifiable procedures, for it is now an established necessity. It is not too much to say that hundreds, yes thousands, of cases have been reported with such beneficial results as to preclude even a doubt as to the necessity of the operation. It is not intended by this admission that all cases of cervical laceration are suitable for operative procedure, especially if there be no erosion present; but if there be a well-marked ectropion, no question as to the necessity for an operation should be entertained for a moment, for ectropion cannot be cured by any other means short of a surgical interference. No doubt is entertained by some of the leading Gynæcologists as to the propriety, the necessity of surgical aid, even in simple cases of lacerated cervix, where no constitutional symptoms are present, for they believe, and their belief is sustained by experience, that a constantly raw and excoriated surface of a cervical rent is predisposing to cancerous growths, whether that disease be hereditary in the family or not. That the symptoms of laceration requiring surgical interference are not always in proportion to