purulent changes. In such cases we were led to believe we had arrested or very materially abreviated the attack.

One of our chief objects in reading this paper today is to determine what you and I as general practitioners propose to do with these cases where we are not guilty of railroading them off to the city.

The expectant treatment may be tolerated. where we are certain the patient is rapidly improving but unfortunately these cases are rare; the great majority need sooner or later some form of surgical interference.

The one operation that most of us can do is to reach the pus through the vaginal vault.

The time to do this is as soon as you can satisfy yourself that pus is present in a sufficient quantity to make a target enough to be hit.

It is often possible to locate the pus by means of a long aspirating needle, the needle then serving as a guide in the more extensive operation of evacuation. But we should not wait until the target is too large, until it constitutes about the whole of the abdominal organs for then our markmanship is seldom needed; it is too late.

Occasionally nature will evacuate such an abscess into some of the hollow viscera but the chances are that in such an event the evacuation will be irregular, seriously injuring the rectum or bladder and producing a very incomplete cure.

The safest way is for us to make the drainge canal in surveyed territory, for natures ways are often too devious and dangerous to be tolerated.

An opening through the vault of the vagina near the cervix, generally behind, but often at the side of that organ constitutes the starting point of our canal. This may be cut through the mucus membrane by a sharp knife but not deep enough to wound any important structure, when a long, pointed scissors is made to penetrate the deeper tissues into the cavity of the abscess. The instrument is now spread and thus withdrawn tearing a wide opening through which the pus usually runs quite freely.

Some authors teach curetting the cavity and packing with gauze, but my experience leads me to prefer a plain rubber drainage

tube held by a suture. The gauze drainage I consider a nuisance at almost all times and here it is doubly so on account of the difficulty of introduction and retention.

When thrusting the scissors in quest of the abscess the curve of the pelvis must be followed by the point of the instrument or the rectum may be seriously injured.

On the side of the cervix the ureter and uterine vessels uterine vessels are in danger of being wounded and the less cutting we do in this locality the better, the work can all be done by a penetrating and tearing process.

You will find the whole procedure very much easier, especially when the abscess lies high up, if an assistant will, through the abdominal walls, push with his hands the indurated mass well down into the pelvis.

This procedure not only bringing the diseased tissues closer to the operators hands but fixes them firmly, thereby facilitating our manipulations.

The finger should be introduced into the abscess to determine the absence or presence of other cavities in juxta position to the open one. If any are found the digit may be all sufficient to break into it, as the partition is often very thin.

We are taught to wash out these as well as other pus cavities, but to be frank I cannot say that I think it hastens the healing in the least, provided a good drainage is established.

I have seen many large pus sacs in the pleura, the pelvis, the limbs, the spleen and other tissues heal so rapidly without irrigation that I have almost entirely abandoned the irrigation of them.

Most of these cases so treated will get well, absolutely well, some of them are only more or less benefited and join the ranks of our female invalids who run the red gauntlet of the hospitals in quest of their lost health.

OPERATIVE DYSMENORRHEA.*

BY G. KOLISCHER, M. D., CHICAGO.

As a rule there are subsumed under the term dysmenorrhea quite different conditions and their sequelae, all of which have this in common, that extreme discomfort and severe *Read at 53d Annual Meeting. Chicago, May 30, 1903

pain is noticed immediately before and during menstruation. In this sense, there was distinguished between ovarian tubar, parametrical, peritoneal and uterine dysmenorrhea.

The first three terms serve to express the fact that the symptoms produced by changes at the appendages or at the serosa are increased by the premenstrual and menstrual congestion, while the last one characterizes a condition which arises in the menstruating organ itself. The first three categories as not immediately connected with the process of menstruation, in fact do not deserve the term dysmenorrhea in a strict sense, which name ought to be reserved for these menstrual conditions which are due to certain nervous or mechanic nutritive changes in the uterus proper, and in which always one leading symptom is noticed, that is, the spasmodic painful contractions of the uterine muscle causing the same sensations as actual labor pains.

This latter group shall be the topic of my paper. We call nervous dysmenorrhea the condition which presents the leading symptom of spasmodic contractions, while we are unable to trace any anatomical causes for it, and because the success of a certain treatment points in this direction.

We talk about nutritive dysmenorrhea if the dysmenorrhea is connected with a hypoplastic uterus, or if general anaemia exists. In these cases the flow as a rule, is very scanty and the pain usually subsides after the flow is fully started.

All these categories never call for any operative interference and appropriate treatments are almost uniformly successful. As such, I mention the administration of nervina and hydro therapeutic treatments in nervous cases. The fighting of general anaemia by the very well known methods, the administration of Thure Brandt massage of the back bone, resistance gymnastics, bicycle riding, repeated sounding and hot douches in cases of hypo-plasia.

Apostoli's electric method although undoubtedly successful in many of these cases. has no advantages over the above mentioned methods but some rather serious objections can be raised against it. At first, it neces

sitates the destroying or at least the considerable dilating of the hymen in virginal indi viduals who furnish the majority of patients of this kind. Second, this method is not free from danger, inasmuch as serious infections and inflammations have been observed as sequelae of the application of the electric sound. Only in cases of dysmenorrhea membranacea it might be indicated but this abnormality as a rule, does not, cause uterine contractions and pain so that it does not belong to todays discussion.

More serious problems for diagnosis and therapy offers the mechanic dysmenorrhea. The mechanic dysmenorrhoea may either be based on the fact that the internal os is abnormally tight so that it offers a great obstacle to the flow of the menstrual secretion. Of course, an absolute obstruction does not take place but the outflow is not in proportion to the rate at which the blood is extravasated into the uterine cavity.

The consequence is, that blood accumulates inside of the uterine cavity and stimulates the uterine muscle to contractions which are perceived as painful. In other cases, the cervical canal in toto is so narrow or the cervical tissue so rigid that there is not enough room for the congested mucosa so that this impacted mucosa and the consecutive stretching of the cervix starts spasmodic uterine contractions, while on the other hand, the outflow is impaired by this swelling.

In very pronounced cases we actually see the cervical mucosa bulging out of the external os red and swollen, if we examine the cervix during the earliest stages of menstruation. After the menstruation is in full go and the extreme congestion relieved, the pains cease; although there are cases where spasmodic contractions and excruciating pains persist during the whole time of menstruation.

I want to call attention to the fact that it is quite a general erroneous teaching that the mechanic dysmenorrhea is due to extreme ante-flexion. That is absolutely wrong. All the above mentioned conditions are just as frequently observed in retroflected or absolutely straight uteri. It is furthermore a matter of experience that, when the menstrual congestion begins the angle between body and

pregnancy and smooth confinement followed the operation.

I want distinctly to be understood that I do not recommend the indiscriminate use of this operation in dysmenorrhea, that only after all the other bloodless methods have failed and the diagnosis of mechanic obstruction is established we may resort to it. I consider it a particular duty of the gynecologists to make use of surgical methods of this kind in virginal individuals only, after the conditions have been fully explained to the patients and they have been given to understand the importance of such a step as destroying the hymen.

NOTES ON THE TREATMENT OF
PUERPERAL INFECTIONS.*

BY THOMAS J. WATKINS, M. D., CHICAGO.

The treatment of cases of puerperal infection is the treatment of an infected wound. Infection of the puerperal uterus is, however, relatively more serious than most wound. infections because the wound is comparatively inaccessable to treatment; the uterus contains numerous thrombosed vessels; absorption is rapid because of the large supply of lymphatics; and the organ, is poorly prepared to resist infection because it is in a process of atrophy or involution.

Bacteriological examinations have been of great value in the study of the disease but as yet have not been of much service in its treatment. It is of interest to know the kind of infection but it does not assist materially in the treatment.

Blood examinations are also of very little value in the treatment of these cases.

The author, however, believes that bacteriological and blood examinations should be persisted in as they are of interest, tend to cause more accurate study of the cases and they may lead to valuable discoveries.

INTERNAL MEDICATION.

The result of serum therapy in cases of streptococcus infection has been disappointing and one seldom obtains much benefit from its use. The chief difficulty is that there are numerous varieties of streptococci and only one variety of streptococcus serum.

*Read at 53d Annual Meeting, Chicago, May 30, 1903

After the use of the serum in numerous cases and from reports of cases the author believes the serum should be tried in all severe cases of streptococcus infection. The writer's experience has been that its use occasionally followed by improvement and in no case has it seemed to do any injury. If its use is not followed by a "reaction" it is not repeated and if reaction is obtained it is repeated in 12 hours for one or more times.

Ergot I believe to be of service in cases where the uterus does not remain well contracted as it tends to increase uterine drainage and by increasing the tonicity of the organ it tends to diminish the amount of absorption and to hasten involution.

In the large majority of cases of puerperal infection alcohol does much more harm than good, as it often interferes with the administration of food, causes the tongue to become dry, diminishes the secretion of urine, tends to prevent sleep and often excites delirium.

The use of nucleins seems at times to be beneficial. The most important internal remedy in the treatment of puerperal infec

tion consists in the free administration of

large amounts of nutritious food preferably

milk, beef juice, eggs, etc., and in the copious use of liquids to keep the toxines diluted and to force the excretions. This is often best done by the use of normal saline solution in the rectum or under the skin.

EXPLORATION OF THE UTERINE CAVITY.

In every case of puerperal infection the uterine cavity should be thoroughly explored for remnants of the products of conception.

This can always be done with the finger, when the cervix is sufficiently dilated, and it is the only way one can accurately determine the condition of the uterine cavity.

CURETTAGE.

If the uterine cavity is empty there is no need of curettage. If it contains placental or decidual debris it should be curetted preferably with the finger. In cases of abortion. when the cervix is not sufficiently dilated to permit use of the finger, I believe the placenta forceps much preferable to the curette for this purpose as it is more certain in action, less dangerous and causes less abrasions. When the uterine cavity is empty the use of the curette is not only of no use but it is

harmful as it tends to break down the leucocytic wall which is nature's fortification against the invasion of bacteria and it produces abrasions which increases the absorptive power of the uterus.

It is only necessary to mention repeated curettage of the uterus, which is frequently practiced, in order to condemn it as an aimless, useless and dangerous procedure.

INTRA UTERINE IRRIGATION.

Intra uterine douches do as a rule much more harm than good in the treatment of puerperal infection. When debris is removed from the uterine cavity a single intra uterine douche is permissable to flush out loose particles of necrotic tissue, but after the uterine cavity is empty and when it drains itself there can be no apology for the use of an intra uterine douche. Numerous cases of puerperal infection are successfully treated by discontinuing douches especially intra uterine ones. The common method employed in giving intra uterine douches is almost certain to carry infection into the uterus.

Vaginal douches may be given under low pressure if the lochia tends to accumulate in the vagina and especially if it is offensive. Even under these conditions it is questionable if it is not better to occasionally change the position of the patient than to assume the dangers coincident to the use of vaginal douches, especially in the absence of a well trained nurse. The occurrence of a chill which frequently follows the use of douches, and which is probably often due to dislodgement of thrombi in the uterine sinuses emphasizes their danger.

DRAINAGE.

The use of gauze in the uterus or vagina is probably as apt to obstruct drainage as it is to promote it. The presence of the gauze increases the decomposition as is frequently proven by leaving sterile gauze in the vagina. for 24 or 48 hours when it is always found to become offensive. The vaginal secretions in the same cases in the same length of time do not become offensive in the absence of sterile gauze. It seems to me that too much is usually expected from the use of drainage. One cannot expect that the infective bacteria will travel out along the gauze drain. The only function that the gauze can perform is to

prevent the accummulation of serum sanguineous or purulent in the wound. Such accummulated serum forms an excellent culture medium for the infective organisms and increases the amount of the toxines which they produce.

MAJOR OPERATIONS.

Until more is known about the treatment of puerperal infection, no definite rules can be laid down as indications for major operations for all cases.

It can probably be said without danger of contradiction that major operations are not indicated in the absence of peritonitis and pelvic tenderness and when no swelling can be found in the pelvis. In the presence of these conditions major operations are not indicated if the general condition of the patient indicates improvement, and as long as the patient continues to get better. One should continually bear in mind that, in the large majority of cases, the infection becomes less and less virulent until it becomes a negative quantity; that large puerperal pelvic exudates frequently disappear by absorption, and that the facial expression is often the most important prognostic symptom.

VAGINAL SECTION.

This is at times an important procedure for the purpose of determining with accuracy the condition of the pelvic organs. It is also occasionally life saving for the purpose of draining cavities filled with infected serum or pus.

The incision should be made as a rule posterior to the cervix into the cul-de-sac of Douglas because this is the best location for drainage as it is the lowest point in the pelvic cavity and gives the most ready access to palpation of the pelvic organs. With this incision one should always be able to determine the condition of the pelvic peritoneum and the uterine appendages. When distinct abcesses are found this method of drainage will frequently result in a complete recovery without the sacrifice of organs and without resorting to a dangerous operation. One should continually bear in mind that pelvic puerperal exudates in the absence of pus tend to completely disappear by absorption. This statement will be verified by any one who has observed a large number of cases of puerperal