Exciting Causes may be enumerated, prin- symptom of trouble in the cervical canal, uncipally as follows: Excessive or intemperate coition. less associated with cervical hyperplasia or other form of inflammatory disease. Menstruation may be deranged, more frequent, less excessive, frequent, painful with varying character and quantity. As to the influence 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. Vaginitis, simple or specific. some sooner than others. All the vital functions are disturbed. Yet notwithstanding the Excessive manipulation during labor in aid diseased mucosa, the deranged menstruation of dilatation. Laceration of the cervix. and disordered general health, conception frequently takes place and healthy children are born at quite natural labors. In addition to the usual list of predisposing and exciting causes we have to add the sugPhysical 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 some pathogenic organism introduced into the vagina or uterus, and his views are, in a measure, supported by the researches of Winter, who has determined that, while micro-organisms are always found in the vaginal and cervical canal, they do not exist above the internal os except with a diseased mucosa. Chronic cervical endometritis is often so slow and insidious in its inception and progress, that it may exist for considerable time and the woman be unaware of its presence. Even an abundant leucorrhoea fails to attract attention, and when she is questioned in regard to its existence her answers will be mainly negative, only just enough admitted to keep the physician on his guard and cause him to seek a full investigation, when all thè facts necessary to a definite diagnosis are easily obtained. One of the first symptoms which usually attracts attention is an excessive leucorrhoea, acompanied by a sense of dragging weight with bearing down sensation in the pelvis, incurred by standing or walking. This may be accompanied with pain in the back, pain on the top of the head, and all of the above may be aggravated during menstruation. Tenderness and pain during coitus, or an instrumental examination is not necessarily a from lacerations. If pain or tenderness is evinced, to any marked degree, a certain amount of inflammation or cervical hyperpla sia must be present. By speculum. The cervix well exposed, the os will be found bathed in secretion, from the typical white-of-egg looking glairy mucus to that closely resembling pus, with occasional mixture of sanies or shreds of mucous membrane from the body of the womb. An effort. at removal of the first described product will confirm the former opinion, if additional proof is necessary, as it will be found very difficult of removal. If the disease has passed on to one in which pus is found, we will probably find abrasion or erosion of the mucous membrane, by removal of epithelium, leaving a reddened and raw looking area-it may be only a limited space, or it may cover a large share of the most dependent part of the cervix. The cervix may present an extreme puffy condition even to the extent of two inches or more in diameter, without ulceration or abrasion. The sound. If the sound passes freely into the body of the womb, it may be safely asserted that the morbid action extends to that cavity as well. It is certainly proper, in every case, to make intelligent use of the sound. Where much tenderness is manifest, great care should be taken not to do harm, but it is always good practice to make every examination just as full and complete as possible, thereby preparing ourselves for any complication that may arise in the treatment of the case. If great tenderness is found, with hemorrhage easily started, and increased weight of womb, we may be positively certain that, while we may have chronic endometritis, we also have 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 unly 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: a decided leucorrhoea extending from one period to another; pain on top of head, disturbed stomach, dragging weight and bearing down of pelvis, tenderness and pain during either of which conditions are sufficiently rare to elicit surprise. Treatment. It might almost be written as an axiom that all chronic diseases, however local, soon leave their impress on the constitution, and this being so very true of the disease under consideration, it is eminently proper to first look to the constitutional condition. and its treatment. As a rule we will find a coition, and may be vesical disturbance, also deranged menses, or not. Second, upon an examination, digital-the os commonly low down and womb in condition of anteversion, os frequently soft and puffy to feel, or may be of a nobular feel from laceration or enlarged Nabothian glands, tender to touch. Examination with speculum, vaginal walls frequently dark and flabby from loss of tone; os sometimes enlarged to a degree making it difficult to bring into the speculum. May be puffy or very puffy-nodular or hard. Secretion pro. fuse; that already in the vagina being white, a floculent or lumpy, that hanging from the os of a glairy, white-of-egg appearance and very difficult of removal. The mucous membrane may be eroded or ulcerated, most commonly the posterior lip of the cervix has the most extensive erosions. If a puffy cervix is found there is generally a patulous os, and where the cervix is hard, or free from cervical hyperplasia, there is most commonly a more natural condition of the os or even a constricted one. The above comprise the principal features of an uncomplicated case of cervical endometritis. Many peculiarities will be met in this line of investigation. We may find a conical cervix, or a pinhole os, with disease confined strictly to the cervical canal, an outgrowth of constitutional poverty, or as one of its prime factors. The above, with obstinate constipation added, will all demand attention. I will give my treatment in a typical case as above enumerated, hoping some one will present a better line than the one here indicated. Sig. One after each meal, or three a day. Electricity (galvanism) to spine. Good food, nutrient qualities, and ease of digestion to be considered. Or again: Adopt such treatment as will increase the tone of the stomach, improve digestion, promote assimilation, and thus secure good blood, meet the wants of an impoverished spine and nervous system, secure rest and relieve pain. In the above nothing has been taken note of directly pertaining to the condition of the womb. In some cases some form of alterative may be needed; abdominal support, massage, stimulants, bitter tonics, etc. The above coupled with such hygienic measures as are called for, in dress and local sur 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 thereby give better tone to the uterine organs as well as to the nutritive system. While in the general or constitutional treatment, regard has mainly to be had to the condition of the system in a general way; in the local treatment we enter another field, one where we must determine exactly what we have to treat and what there is to immediately complicate the case. These when placed in water for a few minutes 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 gonorrhoea 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 com- ing 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 or 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 through the fallopian tubes and cause dangerous prostration. After all mucus and secretions have been removed I am in the habit of cin in various cutaneous and ulcerative affections, and its ready disinfectant properties, I would expect some very valuable effects from its use in ulceration of the cervix and from glandular involvement of its canal. Galvanic wrapped rubber, the cotton saturated with and Faradic currents properly applied are useful in some cases. Also the scarification of the cervix when much inflammation and induration exists. Where extensive lacerations exist, Emmet's or some other form of operation may be performed after due attention has been given to the diseased tissues and glands. With the less grave cases, where there is but little eversion, I am inclined to agree with Hogarath, that it is a question as to its pathological influence and the operation is of doubtful propriety. Where the case is one of corporeal, as well such agents as it is desired to use; such as solutions of silver, zinc, copper, iron, chromic acid, comp. tr. iodine, pinus can. or hydrastis. Where a chronic metritis, hyperplasia or subinvolution exist as complications of the cervical, they should receive proper attention in connection with the treatment of the other conditions. There is one agent that I cannot pass unnoticed at this place, viz. the curette. There may be a class of cases of corporeal or general metritis where its judicious use would result in good, but in the majority of cases it is used because the doctor cannot think of anything else to do for his case. But let the local treatment be with the curette or without it, with as cervical endometritis some distinct measures have to be adopted. This extension to the corporeal endometrium may be of any 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 structures and other tissues that are more frequently involved than in cervical disease alone. Locally several plans have been adopted: The applications of solids; applications of fluids; success assured. Atresia Hymenalis et Vaginas. injections and the use of ointments. The ap- Read before the South Kansas Medical Society, plications of solids is attended with too many dangers to ever become popular. The use of Newton, Kansas, November 11, 1889. OF DISEASES OF WOMEN AND CHILDREN, fluid agents with the silver or rubber dressing BY CHARLES W. ADAMS, A. M., M.D., PROFESSOR probe certainly meets all the requirements and is not attended with the dangers of either solids or the injection of fluids-the latter being the most dangerous of any of the different. forms of treatment. If to be applied at all, it should be with the Molesworth syringe or some form of double canula, allowing free return of fluid. Ointments are not satisfactory and seldom used. Where this condition exists, as discovered, or suspicions confirmed, by the ease of passing the cotton wrapped probe or application through the os internum and into the womb, an effort should be made to remove 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 The cases which we meet, that fall under the head of the gynatresiæ, may practically be divided into the following classes. Those in which we have an arrest in development either in a whole or in a part of the genital tract. Those in which the genital organs are fully developed, but where there has been an arrest in their growth. 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. In a majority of cases attention is first called to a generative defect by various occuring menstrual mollimina without the appearance of blood and the presence of an increasing abdominal tumor, with pain. This pain during the time of menstruation has the character of a most violent uterine colic. If the defect be of the hymen alone or even the vagina, inspection and palpation will easily determine the cause of the trouble. If the trouble lie in The ture should be carefully exercised or even not allowed, and every violent action on the part of the patient which may lead to rupture of the tube, should be guarded against. The following cases which have come under my observation may serve better to illustrate the subject: CASE I.-Atresia hymenalis with normal external formation, internally two vaginal and two uterine canals, (bilocularity.) Mary W, came to me for treatment October 20, 1887. The patient was fifteen years old, was well developed and in good general health. Examination showed the external the uterus, diagnosis will be more difficult. However by combined examination and a careful method of exclusion certainty may soon be 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. 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 prevent ed 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 |