In chronic cases with long-continued fever, pain and extensive exuda tion iu all directions, no benefit can be derived from baths and resorbents. In these cases tonics, good nourishment and attention to hygiene are indicated.
In cases where large masses remain unaltered for months or years we resort to the same treatment. Locally we treat these cases with tepid and warm irrigations of the vagina. The patient lying on her back has from one to four quarts of water injected into the vagina, beginning with a temperature of 92 to 94° F., raising it every third day 3° F. until from 108° to 110° F. is reached. When a higher temperature is used slight pain frequently follows the irrigation, in which case we tell the patient to remain quiet on the back for one to two hours. Under these conditions the vagina becomes tense, and by digital examination we feel that with the tension there is contraction. According to our idea the douche acts as a mild massage. The mechanical pressure and the contraction of the tissues, which often extends to the uterus and its surroundings, have the masses of exudation in more intimate relation with the circulation, and in this way absorption is promoted.
Iodine and its preparations are frequently used. Suppositories made of cocoa butter, containing from forty-five to seventy-five grains of iodide of potassium, may be advantageously inserted into the vagina. Others prefer applications of glycerine and iodide of potassium tampons, or sponges medicated with the same, or the use of iodide of potassium oint ments, or iodoform liniments, applied to the abdominal walls or to the cervix. Some authors also recommend iodide of potassium internally. Although, shortly after the application of iodine to the vagina it appears in the urine, we are not convinced that it promotes absorption of the exudation; but when there are abraded surfaces on the cervix its applica tion is very useful. Prof. Breisky of Prague introduced the following treatment which has been advocated by Johannowsky: He paints the vaginal portion, and the entire vault with concentrated tincture of iodine through a cylindrical speculum every third day, and assists absorption by vaginal irrigations of tepid water and warm abdominal compresses, under which is a coating of tincture of iodine.
The use of mineral waters containing iodine and bromine has an ap preciable influence on the disappearance of these exudations and on sub involution of the uterus.
We must mention here the treatment for diseases of the female genitals commonly known as " Thur Brand's uterine•gymnastics," also practised by Oskar Nissen and described by Chrobak.
This treatment does not suit cases attended even by the slightest amount of fever, since this is an indication of a still active process, in which case massage will do harm. Its application is useful only in cases where fever has been absent for a long time, and hard masses of exuda tion cause severe pain to the patient for months or even years, making life a burden.
Opening of formation and encapsula tion of serous or sero-bloody exudations occurs frequently in the course of pelvic peritonitis. The most frequent seat is Douglas's sac. The exudations are either separated from the peritoneal cavity by pseudo membranes or by convolutions of intestines matted together, or they communicate by sinuses with cavities situated between the intestines or along the abdominal wall. Now and then large spaces containing exuda tion have their seat above the pelvic inlet, and when existing for a long time without fever, may be confounded with ovarian cysts.
The opening of such exudations is indicated when their contents become purulent, producing high fever and endangering life; or when there is present violent pain situated near the surface.
Incision of abscesses situated in Douglas's cul-de-sac is especially risky and quite simple. The relation of the mass to the bladder and rectum must, of course, be ascertained before the operation is performed. When in doubt of the contents an exploratory puncture should be made.
If the contents are of a sero-sanious nature a simple puncture with a medium-sized trocar and evacuation of the fluid will often suffice, without the use of an aspirator, to effect a cure.