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Exciting Causes may be enumerated, prin- symptom of trouble in the cervical canal, uncipally as follows:

less associated with cervical hyperplasia or Excessive or intemperate coition.

other form of inflammatory disease. The use of pessaries, especially stem.

Menstruation may be deranged, more freEndometritic puerperal or non-puerperal. quent, less excessive, frequent, painful with

Hard labor and constipation, with a subin- varying character and quantity. As to the involuted uterus.

fluence of the local disease on the constitutional Efforts at production of abortion and pre-condition, it will be plainly manifest in time, vention of conception.

some sooner than others. All the vital funcVaginitis, simple or specific.

tions are disturbed. Yet notwithstanding the Excessive manipulation during labor in aid diseased mucosa, the deranged menstruation of dilatation.

and disordered general health, conception Laceration of the cervix.

frequently takes place and healthy children In addition to the usual list of predisposing are born at quite natural labors. and exciting causes we have to add the sug- Physical Signs.-By touch. The uterus is gestion of a third. Boleris in An. Uni. Med. usually found very nearly in its normal posiSci. for 1889, considers that it may be due to tion, though often depressed to the utmost, exterior causes, represented by certain patho- with the os almost out of neck and patulous. genic organisms or traumatism. Verchère, Tenderness is not marked in cases where no Annual, as above, holds that all forms of en- complication exists. The cervix may be dometritis are infectious, and that they take found enlarged, puffy, nobular and irregular their origin from a point of infection from from lacerations. If pain or tenderness is some pathogenic organism introduced into the evinced, to any marked degree, a certain vagina or uterus, and his views are, in a meas- amount of inflammation or cervical hyperpla ure, supported by the researches of Winter, sia must be present. who has determined that, while micro-organ

By speculum. The cervix well exposed, isms are always found in the vaginal and cer- the os will be found bathed in secretion, from vical canal, they do not exist above the inter- the typical white-of-egg looking glairy mucus nal os except with a diseased mucosa.

to that closely resembling pus,with occasional Chronic cervical endometritis is often so mixture of sanies or shreds of mucous memslow and insidious in its inception and prog-brane from the body of the womb. An effort ress, that it may exist for considerable time at removal of the first described product will and the woman be unaware of its presence. confirm the former opinion, if additional Even an abundant leucorrhæa fails to attract proof is necessary, as it will be found very attention, and when she is questioned in re difficult of removal. If the disease has passed gard to its existence her answers will be main-on to one in which pus is found, we will probly negative, only just enough admitted to ably find abrasion or erosion of the mucous keep the physician on his guard and cause membrane, by removal of epithelium, leaving him to seek a full investigation, when all the a reddened and raw looking area---it may be facts necessary to a definite diagnosis are only a limited space, or it may cover a large easily obtained. One of the first symptoms share of the most dependent part of the cerwhich usually attracts attention is an exces- vix. The cervix may present an extreme sive leucorrhæa, acompanied by a sense of puffy condition even to the extent of two dragging weight with bearing down sensa- inches or more in diameter, without ulceration tion in the pelvis, incurred by standing or or abrasion. walking This may be accompanied with The sound. If the sound passes freely into pain in the back, pain on the top of the head, the body of the womb, it inay be safely asand all of the above may be aggravated during serted that the morbid action extends to that menstruation.

cavity as well. It is certainly proper, in every Tenderness and pain during coitus, or an case, to make intelligent use of the sound. instrumental examination is not necessarily a Where much tenderness is manifest, great care should be taken not to do harm, but it is al- either of which conditions are sufficiently ways good practice to make every examination rare to elicit surprise. just as full and complete as possible, thereby

Treatment.-It might almost be written as preparing ourselves for any complication that an axiom that all chronic diseases, however may arise in the treatment of the case. If

local, soon leave their impress on the constigreat tenderness' is found, with hemorrhage tution, and this being so very true of the diseasily started, and increased weight of womb, ease under consideration, it is eminently proper we may be positively certain that, while we

to first look to the constitutional condition, may have chronic endometritis, we also have

and its treatment. As a rule we will find a general utritis, or, more concisely, one of are weak condition of stomach, poor appetite and olar hyperplasia according to Thomas; or, if poor digestion, and poorer assimilation, and a within one or two years after labor, one of sub. consequently defective sanguification. The involution as a farther complication. I would nervous system will frequently be as manifestsummarize the most prominent symptoms uni

ly faulty. A tender spine, with perverted der two heads: first, those' necessary to call sensation, neuralgic pains, and loss of memfor and justify an examination, and those ory, and inability to secure good sleep, will found by an examination. The first class clearly point to cerebral and spinal anæmia as comprises those elicited by inquiry, as follows: an outgrowth of constitutional poverty, or as a decided leucorrhæa extending from one

one of its prime factors. The above, with obperiod to another; pain on top of head, dis- stinate constipation added, will all demand atturbed stomach, dragging weight and bearing

tention. I will give my treatment in a typical

case as above enumerated, hoping some one down of pelvis, tenderness and pain during coition, and may be vesical disturbance, also

will present a better line than the one here

indicated. deranged menses, or not. Second, upon an examination, digital--the os commonly low

For the constitutional wants, down and womb in condition of anteversion, R. Syr. hypophos comp. with iron, 3 iv. os frequently soft and puffy to feel, or may be

Dil. phos. acid

3j of a nobular feel from laceration or enlarged

Pepsin, scale,

grs. XXX Nabothian glands, tender to touch. Examin

Liquid malt qs. ad.

3 viij ation with speculum, vaginal walls frequently

M. Sig. Teaspoonful in water before meals. dark and flabby from loss of tone; os some- Also R. Quinia sul. times enlarged to a degree making it difficult

Ferri phosphus,

grs. xx to bring into the speculum. May be puffy or

Zinc phosphite,

grs. x very puffy-nodular or hard. Secretion pro.

Ext. nux. vom. fuse ; that already in the vagina being white, M. ft. capsules No. 40. a floculent or lumpy, that hanging from the Sig. One after each meal, or three a day. os of a glairy, white-of-egg appearance and Electricity (galvanism) to spine. Good food, very difficult of removal. The mucous mem- nutrient qualities, and ease of digestion to be brane may be eroded or ulcerated, most com- considered. monly the posterior lip of the cervix has the Or again : Adopt such treatment as will inmost extensive erosions. If a puffy cervix is crease the tone of the stomach, improve difound there is generally a patulous os, and gestion, promote assimilation, and thus secure where the cervix is hard, or free from cervical good blood, meet the wants of an impoverhyperplasia, there is most commonly a more ished spine and nervous system, secure rest natural condition of the os or even a con- and relieve pain. In the above nothing has stricted one. The above comprise the princi: been taken note of directly pertaining to the pal features of an uncomplicated case of cer- condition of the womb. In some cases some vical endometritis. Many peculiarities will be form of alterative may be needed ; abdominal met in this line of investigation. We may support, massage, stimulants, bitter tonics, etc. find a conical cervix, or a pinhole os, with The above coupled with such hygienic measdisease confined strictly to the cervical canal, ures as are called for, in dress and local sur

grs. xl

grs. x

case.

roundings, and the freeing the mind from the using a cone of my own preparation, composed depressing influences will do much to build as follows: up and invigorate the enfeebled system and R. Calomel,

3 iij thereby give better tone to the uterine organs

Iodoform,

3 i as well as to the nutritive system. While in

Ox, zinc,

zij the general or constitutional treatment, regard

Sal. ext. belladonna, 3j] has mainly to be had to the condition of the

Pow'd gum acacia,

3j system in a general way; in the local treatment

Aqua qs. we enter another field, one where we must de- M. Ft. cones No. 12. termine exactly what we have to treat and

These when placed in water for a few minwhat there is to immediately complicate the utes are sufficiently elastic to yield to a slight

flexion or to follow the canal without injury Local treatment.- As an examination with to the delicate and hypersensitive tissues. a speculum is necessary to ascertain the exact This is maintained in position by absorbent condition of the parts, so is the instrument cotton, or antiseptic wool saturated with boronecessary in order to apply treatment. The glyceride or carbolated glycerine. The panatural aversion to an instrumental examina- tient is instructed to allow this dressing to tion by most females, and especially the remain until the next morning, then to remove younger ones, is bereft of most of its fear if it and use the syringe with water as hot as they can be convinced of two things: that can be borne with comfort. The ladies' syrthey will not be needlessly exposed nor hurt. inge to be preferred. And a digital examination should always ena- This treatment to be repeated once in four ble the physician to know whether an instru- or five days, and not to be begun until three ment could be used without severe pain or not. or four days after menstrual period ends and If not, then the patient should be directed to the same interval to be observed in approachuse water just as hot as she could bear, with a ing the period. If the cervix is found puffy, syringe, several times a day for two or three enlarged and highly sensitive, the entire infradays before making an examination. I have vaginal cervix may be penciled over with made examinations where it was necessary to iodized phenol or the dark pinus canadensis use cocaine solution before an instrument (Kennedy's). If much sensitiveness, is manicould be introduced. These precautions will fest rest in horizontal position is advised, well repay the practitioner. After the instru- and irrigation with hot water is ordered once ment has been introduced, and the blades or twice each day. Where the womb is pressed moderately expanded, with the cervix brought low by superincumbent viscera, a proper abfully in view, carefully remove the secretions dominal support is advised, and the patient is from the vagina and os-remembering that di- directed to assume the knee-chest position for agnosis and treatment are intimately asso- a few minutes when ready to lie down for the ciated. If there is but little secretion in the night. The new treatment of gonorrhea vagina and around the cervix, with a normal opens a new thought in the treatment of encondition as to size and form of the cervix, docervicitis, and one from which much good with the usual plug of glairy mucus hanging may be reasonably expected--that is the packfrom the os, the case is probably without coming the cervical canal with dry powdered plications and will readily yield to treatment. agents, as bismuth, boracic acid, iodoform, Remove the mucus with pleget of cotton or calomel, or other alteratives or astringents. rubber dressing probe or with a long nozzled The various agents to be properly reduced hard rubber syringe, by suction. Be very with starch other neutral substances. careful about the use of water to wash this From the valuable results claimed for Resormucus away, as water might be thus forced cin in various cutaneous and ulcerative affecthrough the fallopian tubes and cause danger- tions, and its ready disinfectant properties, I ous prostration. After all mucus and secre- would expect some very valuable effects from tions have been removed I am in the habit of its use in ulceration of the cervix and from

or

glandular involvement of its canal. Galvanic wrapped rubber, the cotton saturated with and Faradic currents properly applied are use such agents as it is desired to use ; such as ful in some cases.

Also the scarification of solutions of silver, zinc, copper, iron, chromic the cervix when much inflammation and indu- acid, comp. tr. iodine, pinus can. or hydrastis. ration exists. Where extensive lacerations where a chronic metritis, hyperplasia or subexist, Emmet's or some other form of opera- involution exist as complications of the certion may be performed after due attention has vical, they should receive proper attention in been given to the diseased tissues and glands. connection with the treatment of the other With the less grave cases, where there is but conditions. little eversion, I am inclined to agree with

There is one agent that I cannot pass unHogarath, that it is a question as to its pa- noticed at this place, viz. the curette. There thological influence and the operation is of may be a class of cases of corporeal or general doubtful propriety.

metritis where its judicious use would result Where the case is one of corporeal, as well in good, but in the majority of cases it is used as cervical endometritis some distinct meas

because the doctor cannot think of anything

But let the local treatures have to be adopted. This extension to else to do for his case. the corporeal endometrium may be of any

ment be with the curette or without it, with grade from the lightest form of exaggeration solid caustics or liquid astringents, with mild of the secretory function of the utricular local alteratives or gentle emolients, unless the gland, causing uterine leucorrhoea, through all constitutional conditions are carefully looked shades of severity and epithelial destruction after, and every vice and defect remedied, to that of complete exfoliation of the lining failure will be oftener the reward of our labor membrane, and the destruction of the glandu- than otherwise. And every physician, after lar structure and development of small cysts, making himself perfectly familiar with all the by closure of duct orifices. In addition to the minutia, of diagnosis and treatment, should constitutional measures directed heretofore,

demand perfect advisory control of his case we may add such agents as will help to reduce before undertaking its treatment, to make the irritation and inflammation of the mucous

success assured. structures and other tissues that are more frequently involved than in cervical disease alone. Locally several plans have been adopted: The

Atresia Hymenalis et Vaginas. applications of solids; applications of fluids; injections and the use of ointments. The ap- Read before the South Kansas Medical Society, plications of solids is attended with too many Newton, Kansas, November 11, 1889. dangers to ever become popular. The use of fluid agents with the silver or rubber dressing BY CHARLES W. ADAMS, A. M., M.D., PROFESSOR probe certainly meets all the requirements and OF DISEASES OF WOMEN AND CHILDREN, is not attended with the dangers of either sol- UNIVERSITY MEDICAL COLLEGE, KANSAS ids or the injection of fluids--the latter being CITY, MO. the most dangerous of any of the different forms of treatment. If to be applied at all, it The cases which we meet, that fall under should be with the Molesworth syringe or the head of the gynatresiæ, may practically some form of double canula, allowing free re- be divided into the following classes. turn of fluid. Ointments are not satisfactory Those in which we have an arrest in develand seldom used. Where this condition ex- opment either in a whole or in a part of the ists, as discovered, or suspicions confirmed, by genital tract. the ease of passing the cotton wrapped probe

Those in which the genital organs are fully or application through the os internum and into developed, but where there has been an arrest the womb, an effort should be made to remove in their growth. gently all secretions and then pass through Those in which, either before or after comcervical canal, patulous or dilated, the cotton ing to maturity, there has been an obliteration or a loss of the whole or a part of the genital in the bladder to guard these organs from inorgans either from disease or injury.

jury. If it be impossible to reach the blood Cases which fall under the first class can cysts in this manner, it is recommended that only be explained by a reference to the course the urethra should be dilated, and an openof development during intra-uterine life. For ing made through the bladder for the prethe second class intra-uterine development sent escape of the menstrual fluids. The may be perfect, but for some reason the further complete evacuation of the fluid is in most change or growth which occurs at puberty cases impossible, on account of the viscid does not take place. Under these conditions character of the blood. I believe therefore it the organs are infantile and incapable of per- is a good rule, to allow of the gradual emptyforming their normal function. The first and ing of the fluid, striving by repeated injecsecond classes may be combined in various de- tions of carbolized water to keep the parts grees.

aseptic. The dangers to be apprehended, are For the third class if during childhood as the sloughing of the blood cyst, rupture of a tube result of scarlatina, measles, diphtheria, ty- into the abdominal cavity, or septic infection. phoid fever or injuries, adhesive inflammation The last, unless the greatest precaution be occur, we have an atresia of the vagina or taken is apt to occur, and renders the operastenosis of the os uteri. This may entirely tion one justly to be dreaded. The organs are escape observation, until attention is called to in the highest degree subject to metamorphic this condition at the age of puberty. After changes, hence every aseptic precaution should puberty the same result may be set up by be taken before, during and after the operainjuries, which may be so extensive as even to tion. Pressure on the abdomen after the punccause the entire loss of the generative organs. ture should be carefully exercised or even not

In a majority of cases attention is first called allowed, and every violent action on the part to a generative defect by various occuring men- of the patient which may lead to rupture of strual mollimina without the appearance of the tube, should be guarded against. blood and the presence of an increasing ab- The following cases which have come under dominal tumor, with pain. This pain dur

my

observation may serve better to illustrate ing the time of menstruation has the character the subject : of a most violent uterine colic. If the defect

CASE I.-Atresia hymenalis with normal be of the hymen alone or even the vagina, in- external formation, internally two vaginal and spection and palpation will easily determine two uterine canals, (bilocularity.) the cause of the trouble. If the trouble lie in

Mary W—, came to me for treatment Octothe uterus, diagnosis will be more difficult. ber 20, 1887. The patient was fifteen years However by combined examination and a care- old, was well developed and in good general ful method of exclusion certainty may soon be health. Examination showed the external reached. In cases admitting of this, an ex genitals well formed but there was a complete ploratory puncture with a fine aspirating needle closure of the vaginal orifice. Between the has been advised as perfectly safe. The labia was a longitudinal depression in the presence of the thick, tenacious black blood

center, with a bulging out of the closed memwill render the diagnosis certain.

brane on either side. Palpation of these In defects involving the hymen and lower prominences and rectal examination gave a end of the vagina, simple puncture with a distinct sense of fluctuation. Palpation over large trochar to allow the retained fluid to the abdomen, showed the uterus to be enlarggradually flow out, care being taken to prevented as if at about the seventh month of septic decomposition, will suffice. Subsequent pregnancy, with a smooth normal round feelenlargement of the opening may be made. ing to the hand. The history given was that When however the atresia of the vagina is the patient began to have symptoms pointing complete, a transverse incision is first made between the rectum and urethra, then with to menstruation at the age of fourteen and the finger we slowly burrow upward, being that these had been regular and monthly up careful with a finger in the rectum and sound to the date of being seen. The family physi

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