uterus.

An example is a uterine fibroid, either subperitoneal, interstitial, or submucous; also polypi. Other growths inside of the uterus will cause it, as the following case illustrates. The wife of a clergyman living outside of New York, expected to be confined last November; she went to bed, the nurse was engaged, but, on examination, the physician found the uterus only slightly enlarged. I was called in consultation, and after carefully examining the case, came to the conclusion that it was one of moles; the foetus had died and membranes had clung to the uterus and continued to develop. I emptied the uterus of its contents and the patient is now entirely well. Under this head is included fungoid growths of the uterine cavity, which is a very common cause.

IV. Anything that keeps up uterine engorgement. As all flexions; flexions are very likely to occur just after parturition, when the uterine tissues are very soft. The various forms of endometritis, all ovarian irritation, may be accompanied by menorrhagia. If you take a rabbit, etherize it, lay open the uterus so that you can observe the endometrium, then, with a pair of forceps, crush the ovaries, the lining membrane of the uterus will be seen to become intensely engorged with blood. Again, many women think that it is a virtue to have a movement only once a week; these women constantly suffer from menorrhagia, this causes a varicose condition of the uterine veins. Many of the most remarkable cures I have performed, have been done by attention to the simple rules of alvine evacuation. All ovarian tumors, from pressure effects, may cause menorrhagia. To recapitulate, the causes are

I. Blood state.

II. Solution of continuity.
III. Abnormal growths.
IV. Congestion of uterus.

Now, to find out the cause of this patient's menorrhagia. She tells us that she was perfectly well up to two years ago. On examination, I find the cervix lacerated, but this is not enough to account for the hæmorrhage; on pushing the finger further up in the anterior fornix, I feel a short anteflexion. A diagnosis is always a probability, never a certainty. During her last confinement, the cervix was torn, involution went on slowly, patient got up too soon and went about her duties, anteflexion took place, the uterine veins

were interfered with, and fungoid growths were formed in the uterus; this is all that happened, yet it is enough to cause all the trouble.

Treatment. This patient can be entirely cured by simply going backward and correcting each step in the pathological process. Administer an anaesthetic and place the patient in the dorsal decubitus, and thoroughly douche the vagina with 1-2000 bichloride solution; then take a uterine sound and gradually straighten the uterus. Then with a blunt curette (even this is not necessary, for while out of town, I have often curetted a woman with a hairpin and a pair of forceps), carefully scrape out the fungoid growths, and be sure that they are all scraped out. Then take some cotton on a pair of long forceps and swab out the uterus with a 1-1000 bichloride solution, or, preferably, irrigate with an intra-uterine catheter. Next, pare the edges of the lacerated cervix and close it with silver sutures. Take a perforated intra-uterine glass stem and place it in position, so as to keep the uterus perfectly erect. Keep the patient in bed, put her on small doses of ergot to contract the uterine tissue and vessels. In two weeks take out the sutures, but the stem may be left in for some time, and you will find that gradually she will menstruate for only five or six days. Tell them that the first menstruatfon is always profuse. Instead of this woman looking pallid and thin as she does now, in six months she will have some color, weigh fifteen to twenty pounds more, and have no further trouble from syncope.

In all probability if this patient, with her pallid looks and anæmic basic murmur, had gone to an ordinary practitioner, nineteen cases out of twenty he would have given her quinine and iron. Both these medicines are powerful tonics and act as veritable poisons to patients suffering from menorrhagia; in amenorrhoea they should always be given.

REPORTS OF CASES.

To the Editor of the CANADA LANCET.

SIR, I have thought the following case of sufficient interest to report it.

Mrs. M., multipara, was confined on Dec. 29th. Her labor was easy and natural, and the puerperium was perfectly normal until the seventh day, when she complained of having had a severe paroxysmal pain in the right inguinal region at times.

during the preceding night. Upon palpation that region was found slightly sensitive to pressure; pulse 72, temp. 100.5°. Ordered her a saline mixture and vaginal injections of warm water. 8th day. No paroxysms of pain, slight tenderness in right inguinal region; pulse 72, temp. 100.5°; continued treatment. 9th day, 12.30 a.m. Was hastily summoned to see patient; found her suffering intense pain in the lower part of the abdomen, which the nurse said had come on suddenly after the patient had assumed the semi-erect posture to pass urine. Upon examination found abdomen greatly enlarged and tympanitic and tender on palpation, countenance pinched and anxious; temp. 101.5°, pulse 80. Ordered linseed meal poultices to abdomen, quinine sulphate gr. iij. every four hours, morphiæ sulph. gr. % every hour till pain relieved; liquid diet. 10 a.m. Patient feels much easier; temp. 101.5°, pulse 80, other symptoms unchanged. Patient has received four tablets of morph. sulp. % gr since last visit. Morphia to be discontinued unless paroxysmal pain returns, other treatment continued. 2 p.m., temp. 102.2°, pulse 80. 6.30 p.m. 6.30 p.m. Had consultation with Dr. U. Ogden. Temp. 102°, pulse 80. Tympanitis is extreme, the abdomen being fully as much enlarged as before her confinement. Upon palpation tenderness extends as high as umbilicus. It was decided to administer the quimia per rectum and increase the amount given to 7 grains every four hours, in the hope that it would stimulate the coats of the intestines to contract and expel the large amount of flatus.

10th day, a.m. Nurse reports that during the night some flatus escaped, patient has had no recurrence of paroxysmal pain; abdominal distension not as marked as at last visit; temp. 99°, pulse 72. Discontinued quinine and ordered sodæ et potassæ tart. 3j. every three hours, and injections of tepid water to be repeated every two hours. 6 p.m. During the day injections have brought away a small amount of fæcal matter, some flatus also escaping; temp. and pulse same as morning. Abdominal walls were relaxed, and less tympanitic; patient bears ordinary palpation of abdomen without any complaint. Same treatment to be continued, also 3j. whiskey every two hours. 11th day. During the night patient has had considerable rest and taken nourishment well; passed some feculent matter and flatus and appear

ed to be progressing favorably until about 7.30 a.m., when nurse became alarmed at her condition and sent for me. At 8 a.m. I found her in collapse; extremities cold and whole body covered with a cold, clammy perspiration. Pulse 80, very soft and compressible; temp. 97° in rectum. Complained of nausea and faintness; abdomen was much distended, no tenderness. Applied artificial heat by means of bottles of hot water to body and extremities, as well as friction. The perspiration was excessive, standing out in great drops over the entire surface, almost immediately after it had been removed by towels. Administered six syringefuls of whiskey hypodermatically, and gave small quantity by the mouth during first hour. Patient then vomited a large quantity of partially digested food, and this relieved the nausea, so that she was able to take 3ss. whiskey every fifteen minutes by the mouth. This treatment was continued. About two p.m. there were some evidences of reaction, and by 5 p.m. natural heat was restored to the surface and perspiration had abated. At 6.30 had another consultation with Dr. U. Ogden. Pulse 80, weak, temp. 99. Tympanitis was now considerably increased again; no tenderness. Treatment 3iv. whiskey, 3j. egg and milk mixture every hour. Rectal injection of castor oil and turpentine in thin starch. 9 p.m. No action of bowels; repeated injection, omitting turpentine. Injection was retained for two hours and then expelled. Then ordered an injection of four ounces warm castor oil.

12th day, 9 a.m. Bowels have not acted during night. Patient has taken nourishment well, and appears stronger; pulse 72, temp. 99°. Ordered 3j. castor oil and 10 m. turpentine by mouth. At 12 o'clock there was a movement of the bowels, containing some lumps of hardened fæcal matter, but principally composed of softened fæcal matter and oil in an active state of fermentation, the gases making their way to the surface of the mass at all parts while under observation. The amount passed at this evacuation filled the bed-pan, a large amount of flatus also escaped. Bowels continued to act during afternoon, in all, four times, one of the dejections being as large as the above, the others somewhat smaller. 6 p.m. No tenderness, no tympanitis; pulse 72, temp. 99.5°.

13th day. Patient is improving; takes nourishment well, has no pain.

After this date convalescence progressed speedily and uninterruptedly. The remarkable feature of this case was the sudden and unexpected onset of collapse on the morning of the 11th day, which was no doubt due to the absorption of the products of fermentation of the matters contained in the intestinal canal. Patient was unable to account for so large an accumulation of fæcal matters in the intestines, as she says bowels were always regular before her confinement. And subsequent to that time and previous to the onset of the symptoms detailed above, she had taken three doses of castor oil, after each of which the bowels acted freely. The subject of ptomaine poisoning has been receiving considerable attention of late years, and from the variety of symptoms produced by these fermentation products, it is evident that the products themselves are different in almost every case, some slight cause being sufficient to change the type of fermentation. We sometimes see them accompanied by very irritant properties. In the present instance the action seems to have been more that of an antipyretic and depressant. I might also say that repeated examination of urine failed to reveal any kidney trouble.

"A NEW METHOD OF TREATING FRACTURES OF THE PATELLA BY SUBCUTANEOUS LIGATURE WITH SILK."

Prof. Lewis A. Stimson, who is probably the recognized authority on fractures and dislocations in New York, is just now advocating a novel and to all appearances an exceedingly simple and rational method of treating fractures of the Patella. It is known as the subcutaneous ligature with silk method. The great desideratum to be obtained in the treatment of these fractures is some simple appliance whereby the fragments may be held in close apposition, and at the same time one which will not interfere with the nutrition of the patella

by pressure on the articular arteries and thus prevent rapid union; it is now believed that this difficulty has at last been overcome.

The method of procedure is as follows: suppose, for example, the patient has a transverse fracture of the right patella. The patient is etherized and the skin over the part thoroughly scrubbed with soap and water, then douched with 1-2000 bichloride, and finally washed with ether. With an ordinary scalpel, four incisions are made in the following manner: the skin and subcutaneous tissue only being divided, and, for the sake of description, we will suppose the patella to be possessed of four angles. The incisions are so placed, that each angle of the patella has an incision situated a little distance from it, thus; the first is situated a little below the inferior and internal angle, the second a little below the inferior and external angle, the third a little above the superior and internal angle, the fourth a little above the superior and external angle. Then a straight Hagedorn needle armed with a No. 14 heavy braided silk ligature, which has been previously rendered perfectly aseptic by being boiled (one of the essentials of success is that there shall be no suppuration), is introduced into the lower and internal incision and carried deeply through the ligamentum patellæ and brought out at the inferior and external incision. It is then re-introduced and carried deeply through the tendon of the rectus and crureus muscles and brought out at the superior and internal incision. It is again re-introduced and carried beneath the skin along the internal border of the patella, and brought out at the interior and internal incision. The leg is now elevated so as to relax the quadriceps extensor as much as possible, in order that the fragments of the patella may be as closely approximated as possible. Strong traction is now made on the silk and the two ends are firmly knotted deep in the subcutaneous tissue. During this part of the operation considerable force may be used so as to bring the fragments closely together. The cutaneous wounds are then irrigated and dressed with a simple antiseptic dressing, the leg elevated, and a straight posterior splint applied for about three days. At the end of this time the dressings are removed, and if proper antiseptic precautions have been taken, the incisions will be found completely healed. The knee is then encased with a

plaster paris dressing for two weeks, when it is taken off, and the patient allowed to hobble around the ward on crutches, and gradually use his leg. As to the length of time the plaster bandage should be worn in order to secure the best results, it may be stated that this point has not been determined, as the method has not yet had sufficient trial in order to decide this point. So far, however, the cases in which it was discarded after two weeks' use appear to have done the best, as the union seemed quite as firm as those cases in which it had been worn for four weeks, and there was less stiffness of the knee. In every case, so far, very satisfactory results have been obtained, and in one case which your correspondent had the opportunity to examine, after three weeks the separation was less than of an inch. It is recommended that if the case comes under observation before inflammation and effusion into the joint have taken place, to at once perform the operation; but if inflammation and effusion have taken place, it is better to wait until they have subsided. Some may ask, what eventually becomes of the silk. In the cases so far nothing has been seen of it, which is due to antiseptic precautions, and it remains under the skin, acting as a firm splint, holding the fragments together, and this explains why the plaster paris dressing can be discarded so early. To contrast the results obtained by this method and those by wiring, would be premature, as the method has only been on trial for a short time, but it may be stated that wiring the patella has fallen into disrepute in New York. In nearly every case it has resulted in a stiff knee joint, and in some suppurative synovitis has followed, so that the joint was completely anchylosed, and many surgeons here have almost abandoned the operation and fallen back to the old method of splints, etc., except in those odd cases where the separation of the fragments has been so great as to render the limb almost useless. The one is a grave operation, the other a simple procedure, and the general impression is, that it is the best plan yet proposed, and is destined to completely revolutionize the treatment of this important fracture.

FOR HICCOUGH.-Dr. Wm. C. Wood, writing to the Med. Reg., speaks in high terms of viburnum prunifolium in singultus. He states that drop doses of the fluid extract never fail to relieve.

Selected Articles.

MENSTRUATION, ITS NERVE-ORIGIN— NOT A SHEDDING OF MUCOUS

MEMBRANE.

In every healthy human female, during the socalled childbearing epoch, which extends, on the average, over a period of thirty-two years, the uterus becomes the seat of a periodically recurring functional disturbance, evidenced by the emission of a more or less marked hæmorrhagic discharge. As the initial establishment and each subsequent recurrence of this monthly phenomenon is frequently accompanied by symptoms of a general as well as local character, we shall designate under the appellation menstruation the whole essential train of events, and not its mere outward manifestation.

The molecular world, organic as well as inorganic, exists in a perpetual state of trepidation, and equilibration of a vital character is the outcome of an inherent power of adaptation. Normally the structural and functional integrity of the organism is maintained by a mutual dependence of the organs upon each other, and according to the manner in which these, each and all, respond to those multifarious changes which, from time to time, arise in the environments of the individual. The variations in the waves of molecular motion occurring in every organ, and associated with physiological activity, are radiated to, and affect, however feebly, every ultimate tissue of the body. So completely is this intercommu nication, through the medium of the nervous system, carried on, and so apt are the different other than those for which they have apparently structures of the organism to perform functions become specialized, that vicarious compensation may be readily established. In the case of double organs it is a noteworthy fact with which everyfect but little, if at all, the well-being of the body; one is familiar, that the removal of one may af generally the remaining organ at the same time becomes of augmented functional activity, undergoing slight or even well-marked enlargement. This compensatory change will be manifested, not only by organs recognized as active, but also by such as have hitherto been viewed as obsolete. In many of the lower organisms, where structural differentiation is ill defined, vicarious function is readily fulfilled. The animal may, for example, be turned outside-in with impunity, the vital integrity of the organism being still maintained unimpaired-the endoderm, already but feebly specialized, although set apart for assimilation, performing with ease the function of the ectoderm, that of elimination; while the ectoderm, in turn, assumes forthwith the power of assimilation, and

discharges effectually a function hitherto foreign to it and performed previously by the inner layer. In the animal economy we see constantly enunciated the fact, too frequently ignored, that functional activity and structural integrity proceed together, hand-in-hand, and are regulated by a mutual action and re-action upon each other.

If the functional activity of any organ be augmented, but not unduly, the structural integrity will be maintained and be rendered more perfect. Again, the more complete the structural arrange ment has become, the more likely we are to find the function actively performed. All visceral activities are now, through habituation, fulfilled in a somewhat automatic manner; and although these transitional states may at one time have excited a conscious sensation, they are at the present stage of evolution wholly ignored by the higher cells of the cerebral lobes which participate in feeling. What is true of one organ of the body is likewise true of all the others. It is, therefore, more than probable that the physiological changes recurring from time to time in the uterus are anticipated by, and in reality the sequence of, a molecular disturbance arising spontaneously in some center located in the higher part of the cerebro-spinal tract, possibly somewhere in the medulla oblongata. The mere fact that the functions of the uterus may be revealed uninterruptedly after the spinal cord has been completely severed in the dorsal region is no criterion, and cannot justify us in concluding that there exists no representative higher centre. Structural evolution itself forbids the acceptance of such an hypothesis. Like all other nerve centres fulfilling a similar dispensation, this uterine centre is undoubtedly beyond all volitional control, but is, nevertheless, capable of being disordered by emotional impressions. With this fact everyone is familiar. A sudden shock experienced during menstruation, and apart from any bodily injury, will produce, as I have frequently noted in some females, immediate cessation of the flow, and even interrupt for a more or less indefinite length of time thereafter, its amount and periodic regularity. The resulting disturbance will depend essentially upon the state of the nervous system and its proneness to molecular instability.

With the approach and appearance of the monthly flow the whole frame, as one would naturally expect, participates more or less in the change, and the amount of disturbance experienced, as well as manifested, is commensurate with the power the organism possesses of adaptation, and hence of equilibration. The simple determination of blood, because of increased functional activity, to the genital and, in many cases, to the other pelvic organs, of itself produces a definite alteration in the waves of molecular motion proceeding therefrom, and which, radiated in all directions,

must necessarily affect the vascular state of other very important structures. In many chronic disorders, of whatever system, affecting the female, every observer must have remarked that, according to the menstrual type of the individual, there is often, either in anticipation or with the appearance of flow, a proneness to aggravation, or in some very exceptional cases, it may be, to alleviation of symptoms; and with the cessation or disappearance a corresponding gradual reversion to the original already stationary or slowly progressive state. In some few cases the loss of blood may account for much of the disturbance manifested, yet it cannot be the sole factor. In many women, where, from some inexplicable cause, there is for a more or less indefinite period a total suppression of the characteristic discharge, we may detect frequently such a regularly recurring alteration in the symptoms or manner of the patient as to place beyond denial a direct relationship. In no class of functional disorders do we find so regularly and markedly an interference with the outward manifestation of uterine activity as in epilepsy, a disease the pathology of which is still undetermined. It is more than probable, however, that as we may consider the epileptic female as epileptic throughout, even to the finger-tips, the interruption of the periodically recurring functional change in the uterus is the result of some occult condition of the corpuscular elements governing the activity of this organ, and wholly independent of any defective structural state of the viscus itself. The structural integrity of the uterus, may, however, eventually suffer, for inaction and overaction alike tend to exert a prejudicial influence.

Gestation, as a rule, although not invariably, determines for a period of nine months a cessation of the monthly recurring flow. Not infrequently, however, we see women who throughout one or more pregnancies continue perfectly regular, the amount or character of the flow being unaltered by the physiological process going on in the uterus. Usually the fertilized ovum affects in some unknown manner the uterine organ, thereafter destined to be its source of nutrition, and the gradual molecular variations so produced are radiated to the uterine centre, after the corpuscular state, and determine the sequence of events. During the period of lactation, and consequent activity of the mammary glands, we find not only the manifestation of the monthly recurring functional change of the uterus held in abeyance, but also the activity of the generative glands, as impregnation rarely occurs while the mother continues to suckle the offspring. Should, however, lactation be prolonged indefinitely, the secretion of milk may become more or less habitual, as in the case of the cow, and the generative glands regain their activity. The life of every organism is twofold: first,