After free puncture, either with the trochar or knife, the discharge readily takes place, and the patient immediately experiences great relief. If the puncture is made to remove the blood before inflammation has begun, the evacuation may be more difficult, as it is often coagulated; in that case the opening must be made large with a knife, and if the blood does not easily flow, the finger may be introduced to break up the clots and facilitate their expulsion. After the contents are thus expelled as near as it can be, they sometimes reaccumulate and are again discharged, and repetitions of these processes lead to still more chronic suffering, until the patient becomes a permanent invalid or dies from the exhaustion of such long standing. We may, with a good deal of certainty, cause contraction, granulation, and obliteration of the cavity, by injecting it with iodine, wine, or other irritant. The best way to secure efficiency in injections is to introduce through the fistulous opening, or one made for the purpose, a small flexible catheter, so as to reach the bottom of the cavity, and throw the fluid through this tube. We thus place the fluid used in full strength in contact with the walls of the cavity, while the injection thrown out of a common syringe will mix it up with the contents of the sac, and thus dilute it.

CHAPTER VIII.

ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS.

ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS-LOCATION OF INFLAMMATION-CAUSES-SYMPTOMS-DURATION AND COURSE-PROGNOSIS

-DIAGNOSIS-TREATMENT.

ACUTE inflammation, not arising from specific causes, generally affects the fibrous portion or substance of the walls of the uterus. It almost, if not quite always, pervades the whole of the organ, the fundus, body, and cervix. The whole organ is inflamed and tender. Exposure to cold is the most frequent cause. The cold may be applied to the general surface when the uterus is in a state of turgescence from menstrual congestion, sexual excitement, or incomplete involution after labor or abortion. The same agent acting upon a portion of the surface, the feet and legs, under similar condition of the organ, may give rise to the same disease. It is not likely that cold, however applied, would be a sufficient cause, but for the predisponent condition I have mentioned. The excitement of excessive sexual indulgence may be carried so far as to cause a moderately acute inflammation of the substance of the uterus, as also blows upon the abdomen, &c.

It is not a very frequent disease, and yet I do not think it can be regarded as an unfrequent affection.

Symptoms. In speaking of the symptoms of the disease, I wish the reader to bear in mind that their intensity will vary from a mildness that will scarcely confine the patient to her couch to a very severe and grave disease, almost overwhelming the nervous system, with delirium and convulsions, and calling the stomach into excruciating sympathy with it. In considering the subject, I wish to be understood as attaching more importance to the suddenness than the intensity of the attack in determining the nomenclature.

It is somewhat owing to the exciting cause as to the symptom which is likely to usher in the attack. If the cause is a moderate one, as excessive sexual indulgence, pain will generally begin

some time before the general symptoms. If the cause is cold suddenly and extensively applied to a menstruating patient, chills and rigors may precede the pain. However that may be, when the case is fairly developed there is fever, aching in the back, pain in the head and extremities, flushed face, and furred tongue. In addition to these general manifestations there is local pain, indicating the organ affected. This pain may be confined almost entirely to the sacrum and lumbar region if the inflammation is moderate, but generally there is pain in the pelvis behind the pubis, or in one or both iliac regions. Sometimes the pain radiates in several directions up the abdomen, down the thighs, and around the body. The pain is usually of a dull aching, but sometimes of a sharp character. In addition to these symptoms indicating inflammation in some of the pelvic organs, the nervous system is often affected with hysterical symptoms, convulsions, coma, laughing, crying, or unreasonableness of some kind. I should have mentioned among the local symptoms, dysuria, and difficult and painful defecation. Should the peritoneal covering become involved there is swelling, and greater or less tenderness of the abdomen. Nausea and even vomiting are not unfrequent symp

toms.

After a week or more of this kind of suffering the symptoms gradually subside, and the patient slowly recovers her usual health; or sometimes the subsidence of the pains is not complete, and she continues to suffer with a chronic form of inflammation. The termination is almost always in resolution or the chronic form of the disease. Possibly, in some exceedingly rare instances, the force of inflammation is spent in some circumscribed locality, and it proceeds to suppuration. I have seen an instance of this kind where the suppuration was in the anterior lip of the cervix.

Prognosis.-The termination is so frequently in resolution or a moderate form of chronic inflammation, that we may almost always 'expect complete or partial recovery. Death probably never results in uncomplicated cases of acute metritis, but unfortunately we occasionally meet with grave and even fatal peritonitis, apparently resulting from extension of the disease from the uterus. It has been my misfortune to have lately met, in consultation, with two instances of this sort. Although the prognosis is favorable as a general rule so far as the recovery of the patient from the attack

is concerned, it is not so favorable for the complete re-establishment of health, as the patient is likely to be affected with chronic inflammation in the body or cervix. Not unfrequently we trace chronic inflammation back to a moderate attack of the acute.

Diagnosis.-Inflammation of the cellular tissue beside the uterus, metatithmenia, rectitis, or cystitis, cause symptoms which may be mistaken for metritis. When doubt exists it may be easily and certainly solved by a digital examination. If the bladder is the seat of disease, the tenderness complained of by pressing it between fingers in the vagina and others above the pubis will be sufficient proof; pressure may be made upon the rectum by including it between the introduced fingers and the sacrum. The inflammation at the side of the uterus, or cellulitis, causes tenderness and hardness close to the iliac bones on the side, and the hardness seems to be continuous with the bones. The greatest tenderness is, therefore, close to the side of the pelvis. In all these cases the uterus may be touched, provided it is not moved so as to press upon the inflamed part or organ without causing pain. If it is the seat of inflammation the tenderness will be confined to that organ, while all the rest are free from it, and may be handled freely. We should not forget that all these organs may be implicated in one great mass of acute inflammation, and all the pelvic contents be intolerably tender to the touch. In an examination to diagnosticate inflammation of the uterus, I need hardly say that a resort to instruments is unnecessary.

Treatment. The intensity of the inflammation will govern us in the activity of treatment. If it is not attended with great pain or febrile reaction, although our remedies must be the same, there is no need of using them with the same energy. We should, however, bear in mind the great likelihood of leaving the chronic form behind, and be diligent in our medicinal and hygienic appliances, until every vestige is gone, when practicable. If the attack is moderate, it may sometimes be interrupted in the beginning, by measures to induce a copious perspiration, more particularly if caused by an exposure to cold. Even a smart attack may sometimes be relieved by a large dose of opium and a steam bath, used within a few hours after the commencement of the symptoms. After the symptoms have become fairly established and have lasted for twenty-four hours, we must not expect to find immedi

ate relief, and should begin the systematic use of antiphlogistic treatment. In the subacute form, a brisk cathartic, foot-bath, and fomentations over the uterus, should be followed by tart. antimony, muriate of ammonia, and calomel. R. ammon. hydrochloras, 3ij; ant. et pot. tart. gr. j; ext. glycyrrhiza, 3ss; aqua bull., 3viij. Mix and dissolve. This is a good old formula, and may be taken in tablespoonful doses every four or six hours. Perfect quietude should be enjoined also, and rest at night may be insured by giving one grain of calomel, with twice the amount of opium, in a pill at bedtime. Continued for five or six days this will generally induce slight mercurial effect, when the pain and other symptoms will pretty surely subside. If it does not do so, a blister over or a little above the pubis will aid in banishing them. If the attack is severe, we ought to add to the above remedies the more immediately depressing. The patient may be bled from the arm until a decided impression upon the pulse is produced, or we may apply from ten to twenty leeches to the vulva and groins, as the depletant measure. In the country, where leeches cannot be had, scarification and cupping can be profitably substituted for them. Should arterial excitement be high after the depletory measure, the tinct. of verat. viride, in doses from four to six drops every four hours, with the ammon. mixture, will be an efficient adjunct to our remedial measures. The calomel should be withheld as soon as its specific effects are produced.

I should not discharge the obligation I feel to the student, in the treatment of this disease, were I not again to caution him against an imperfect cure of it. Very often it becomes chronic, and renders the patient miserable for years. We should try to avoid this consequence. Too early a resumption of duties and active exercise should be especially prevented. When practicable, a continuation of treatment and avoidance of the causes which produced the inflammation, are of equal importance. As a means of perfecting the cure which the more active treatment has brought about, the sedative effect of water affords us valuable aid. sitz bath and vaginal injections are the modes of using it. The sitz bath ought to be used as much as the time and patience of the patient can be made to allow. An hour is short enough time, and two hours is better, twice or thrice in twenty-four hours. The injections should be copious, and may be used in the bath and of the

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