217 571 602 Paducah Medical Club... Rheumatic fever, treatment of, by sali- REVIEWS AND BIBLIOGRAPICAL NOTICES- Ziemssen's Cyclopædia of Medicine. Vol. X. Diseases of the Female Sex- ual Organs. By Prof. Carl Schroe- Medical and Surgical Memoirs. Con- taining investigations on the Geo- graphical Distributions, Causes, Na- ture, Relations, and Treatment of various Diseases, 1855-1876. By Pro- fessor Jones, M. D... Lectures on Syphilis and on some Forms of Local Disease affecting principally the Organs of Genera- tion. By Henry Lee, M. D., Lon- Phthisis. Its Morbid Anatomy, Etiol- The Relation of Medicine to Modern Unbelief. By Richard O. Cowling, The Mucous Membrane of the Uterus, with special reference to the devel opment and structures of the de- Central Ky. Medical Society...... 59 154 157 272, 581 Medico-Chirurgical Society of Louis- ville.. Michigan State Medical Society.......... 590 189 74, 194 Spinal anæmia.... 343 192 Stealing as a symptom of general paral· 128 297 Strapping the breasts to prevent and ar- 57 Stricture... 450 Subcutaneous injection of water. 93 warm water; 196 osteotomy, 509 391 Uterus after pregnancy, the walls of the 91 595 Sarcoma, remarkable case of. 525 Vibration, experiments in.. 76 Scarlet fever.. 142 Scientific execution of the death pen- Vivisection question in England, the..... 91 509 197 Sea-sickness two hundred years ago, What birds sometimes do to their own 90 ART. I.-Pelvic Hæmatocele and Pelvic Cellulitis. A Clinical Lecture delivered at Bellevue Hospital, New York City. By Professor FORDYCE BARKER, M. D. [Phonographically Reported for the "Richmond and Louisville Medical Journal" by WESLEY M. CARPENTER, M. D.] Gentlemen,-I bring before you to-day two cases which I think may be usefully studied together, as there are many points of resemblance between them, yet they are quite distinct as regards their causes, diagnosis, progress, termination and treatment. Dr. Farrington will read to you the history of the patient now before you. CASE I.*--Ellen B., aged twenty five; born in Canada; widow; seamstress; admitted November 28th; family history unimportant. Patient has always enjoyed excellent health; she began to menstruate when twelve years of age, but her courses shortly afterwards ceased; and when they returned again, two years later, they recurred frequently twice a month, very profuse, usually lasting a week, but unaccompanied by pain. At the age of seventeen she became pregnant, but not wishing to have a child, took medicine, producing a three and one-half month's abortion. This does not seem to have affected her injuriously at the time. Four years ago she had what she calls "inflammation of the womb," due to exposure to cold and damp while * Case reported by W. H. Farrington, M. D., House Physician menstruating. Her next period returned in proper time, but was attended with considerable pain in the loins, and since then she has been subject to leucorrhoea in the intervals of her courses. In the early part of the present month, patient, while overheated from work, incautiously sat in a draught. She was menstruating at the time. Her discharge suddenly ceased, and she experienced pain in the abdomen quite diffuse, which she regarded as due to intestinal derangement, and treated as such. But as the pains persisted in spite of treatment, lasting for several days, she applied to a physician, who told her to remain in bed. She now developed well marked hypogastric and iliac pain and tenderness, painful defecation and micturition, constant nausea and vomiting. A hard mass appeared in the lower abdominal segment, and from its first appearance she suffered pains in the lower extremities, most severe in the left. One day later (November 15th) she had a chill, with high fever, distension of the abdomen and diffuse pain and tenderness. Her bowels became constipated. These symptoms persisted up to the date of her admission here, the chill recurring two or three times. She became very weak and pale. On admission: patient is of moderate nourishment, anæmic, her abdomen is considerably distended, tympanitic above, hard and dull on percussion in the lower portion. The swelling, she says, is not as great as before. Complains of pain most marked in the left iliac region, and tenderness on pressure corresponding with the extent of the induration. Has no dysuria at present, but she suffers great pain when her bowels move. Appetite poor, tongue coated, pulse quick, respirations increased in frequency, skin hot and dry. December 1st.-Condition about the same. Has used opiates. and poultices to abdomen. The distension is subsiding; pulse 120; respiration 30; temperature 103°. December 2d.-A. M., pulse 120; respiration 30; temperature 10110; pain continues; treatment same. December 3rd.-A. M., pulse 120; respiration 32; temperature 9910. P. M., pulse 120; respiration 32; temperature 103°. December 4th.-A. M., pulse 136; respiration 28; tempera ture 1014. Feels better, but still suffers from sharp pain, especially in the left iliac region, with tenderness on pressure. By vaginal examination, the presence of a hard resistant mass, rather tender on pressure, is found anterior and posterior to the cervix, raising the uterus up and diminishing the calibre of the vagina. December 5th.-A. M., pulse 124; respiration 26; temperature 100°. P. M., pulse 120; respiration 28; temperature 10410. Inunction of ung. belladonnæ is made into the lower portion of the abdomen, and hop poultices when the pain is severe, and opiates internally. December 6th.-A. M., pulse 124; respiration 24; temperature 1021. P. M., pulse 124; respiration 32; temperature 103°. December 7th.-A. M., pulse 120; respiration 28; temperature 1021°. P. M., pulse 124; respiration 32; temperature 103°. December 8th.-A. M., pulse 116; respiration 24; temperature 101°. P. M., pulse 108; respiration 30; temperature 1011. Patient has had diarrhoea for three days past, partly controlled by powders of opium and bismuth. Pains persist in abdomen; no dysuria, and but slight pain in defecation. Suppositories of morphia and belladonna ordered. December 11th.-Pulse 116; respiration 32; temperature 101. General condition about the same. Is still weak and anæmic, but her appetite is improving. Now if you look at the abdomen, you see that it is moderately tympanitic; that it is sensitive to percussion, and that there is well-defined tumefaction in the left iliac fossa, which gives a dull sound on percussion, quite a contrast with the resonance of other parts of the abdomen. In making a vaginal examination, I find in the pelvic cavity two distinct tumors, one posterior and on the left of the cavity, quite firm, I may call it hard; painful on pressure and immovable; the other is anterior, the greater portion of it is on the right of the median line, which from its form, density, and contiguous relations, I recognize as the uterus. The one on the left is much harder and longer than the uterus, it can be distinctly felt in the left iliac fossa, and from bimanual palpation I should judge it to be about the size of the egg of a goose. Rectal touch shows me that it compresses this portion of the intestine; that the tumor has pushed the uterus forward and to the right, and confirms my impression as to its size. I should have mentioned that the cervix is very high up and points backward toward the sacrum, so that to one unaccustomed to make vaginal examinations, it might be difficult to find the os, as I have often known to be the fact. Now, you ask, what is this tumor in the left side of the pelvic cavity which has pushed the uterus forward and to the right? I answer that I believe it to be blood which has been extravasated between the peritoneum and the left and posterior part of the uterus. This blood tumor, with its attendant symptoms and consequent results, constitutes a disease now almost universally denominated pelvic hæmatocele. Early writers on the disease used other names, as retro-uterine hæmatocele, pelvic hæmatoma, or peri-uterine hæmatocele, and other similar terms, but pelvic hæmatocele is now generally accepted as the best name, for it is anatomically correct, and includes both forms of the disease; that is, the intra and supra-peritoneal. The occasional recurrence of these bloody tumors had been recognized in making post-mortem examinations even as early as 1761 by Ruysch, and subsequently by Frank, Dr. Bright, Velpeau, and Sir Benj. Brodie; but it was first described as a special affection by Bernutz in 1848, and after that Nélaton and his pupils, Vignes and Voison, made this a subject of special clinical research. It is not a very rare affection, for I am quite sure that I have seen more than fifty cases within the last twenty years. I do not think it is often met with in hospitals, for during the same period this is only the fifth that I have had in my service in this hospital. This extravasation is a result of rupture of blood vessels connected with the uterus and its appendages, and most frequently occurs in connection with some disturbance of the menstrual function. We have reason to believe that it is preceded by congestion of the uterus or its associated organs, and that any shock, physical or emotional, may cause rupture of the vessels, |