they produce, or of the importance of recognizing and correcting these symptoms?

Does not the improper habits of life have much to do with it? It is not an uncommon occurrence for a young girl, especially the society girl, who keeps late hours, eats midnight lunches, dances every dance, improperly dressed (not so much for dancing but sitting in the windows to cool off), whereby the blood is driven into the interior of the body, congesting the uterus along with other organs; tight lacing, which interferes with respiration and circulation, also displacing abdominal organs, to consult her physician for relief from, that tired feeling increased with the least exertion, nervousness, changed disposition, headache, insomnia, lessened mental activity, backache and one of her worst troubles, a thick, dense, opaque and tenacious or serous, non-tenacious and somtimes a purulent leucorrheal discharge, or disturbed menstruation. Not only the society girl is heiress to these symptoms, but in the shop girl, school, teacher, servant, the constant standing, undue exposure, and excessive fatigue serve as an efficient exciting cause. With such a list of symptoms it is not difficult for the physician to know that some uterine affection exists, which, if it does not yield promptly to constitutional treatment, demands further investigation in order to settle definitely its source. universal practice, and with which on the whole, within proper limits I concur, that the sexual organs of a young girl should not be subjected to local interference by the gynecologist, and still there are limits to this rule. In all ordinary cases first try to find all that can be found of the patient's life, her surroundings, her inclinations, her troubles and anxieties and then her general health. Remove as far as possible the cause, if found, and then give constitutional treatment. Constitutional remedies, as we know, act upon the uterus only so far as they improve the general nutritive and nervous systems. But when more severe symptoms present themselves which cannot be controlled by such treatment, then a local examination should be made. A digital examination while very useful to detect position and tenderness is not a sufficient means for a perfect diagnosis. Speculum examination following a digital, affords the best means of ascertaining the lesion. A slight inflammation may be seen just within the external os, there may be eversion,

redness and erosion with little or exersive secretion. The lips. of the eroded cervix may be broad and separated, presenting a distinct bilateral cleft simulating closely a puerperal laceration or may be attributed to be a congenital malformation of which Fischel of Prague, Mundie, and Penrose speak. There may be no lesion visible, but passing a sound, shows abnormal tenderness, dilatation of os, enlargement of uterine cavity and increased vascularity of mucous membrane, which bleeds readily upon touch. The most important symptom by which the differential diagnosis between cervical and corporeal endometritis can be made is derangement of the menstrual function. This flow may be scant, profuse, of long duration, too frequent, prolonged intermission, or painful. The profuse, prolonged and painful more often occur. In this, careful examination must be made in the differentiation of fibroid, polyp, cancer and endometritis. This is best made by the use of the probe, curette and microscope.

Not only is the diagnostic skill of the gynecologist brought to bear upon these cases, but the practitioner's skill as a physician in the widest possible sense of the term is called into requisition.

In women of a lymphatic type of organization, a relaxed state of the mucous membranes with constant hypersection is not an uncommon symptom of slight constitutional disturbances, but when this is observed in connection with the uterus it is too often considered as a symptom of endometritis, while really a true endometritis does not exist. Then again, curettement has even been resorted to, to cure chronic catarrhal discharges; these as we know are not infrequently associated with corresponding conditions of other mucous tracts depending upon some constitutional dyscrasia such as anaemia, tuberculous disease or some other disorder that tends to a generally lowered state of vitality.

A correct diagnosis is of first importance to a successful treatment. The careful and conscientious practitioner will constantly bear in mind the interdependence of all the organs and tissues of the body in health and disease. The cause of the disease having been recognized, the proper treatment suggests itself. The improper or faulty habit of life, must if possible, be corrected. If patient is anemic the iron preparations and arsenic are indicated

together with plenty of fresh air or perhaps change of climate. Rest in bed should be inforced if symptoms are acute and exercise gives pain. The nutritive and nervous systems must be improved first and if these measures faithfully employed does not cure, then local treatment must be resorted to.

Many of these office cases can be cured within a short period, but again it requires a longer time and in the severer forms of the disease nothing but curettment will produce a cure. The non-operative treatment is practically confined to direct applications to diseased areas. There does not seem to be as much difference of opinion to the direct application in cervical endometritis as in that of corporeal.

Am sure many satisfactory cures have been effected by local treatment especially in cervical endometritis.

One of my most successful cases was that of a school teacher who had suffered for ten years with such severe dysmenorrhoea that she was often compelled to be absent a half day from school each month, or, if at school taken home in a cab. After four local treatments, two each week, with Battey's sol. for an eroded cervix, the dysmenorrhoea ceased, there has never been any pain since and no leucorrhoea, which had formally been profuse.

The conjestions, the cystic degenerations, the erosions and the accompanying enlargements are all favorably influenced by local depletion and local alteratives such as hot vaginal douches, pledgets with boroglyceride, glycerin or ichtholdine and, in selected cases, puncture. The alteratives, Churchill's tinct. iodine, tr. iodine and carbolic ac. are perhaps used more often than any other preparations. But silver nitrate must not be overlooked.

One of the most essential things in connection with local treatment is rest, and yet, it is usually the most difficult to secure. If all these measure fail, then curette.

Curettement alone may not cure all of them, but followed by local and constitutional measures as are indicated, will.

The hemorrhagic form while the most obstinate to cure by local treatment sometimes is cured as if by magic by curettement, and while I protest against the tendency to curette every girl that suffers with even a severe endometritis yet, when it is indicated, I do not hesitate to do it. And yet there is no pelvic symptom that is so frequently taken as an indication of the presence of disease demanding curettement, and yet none that in more instances may

be merely a uterine expression of a general condition, or of a diseased state of some distant or neighboring organ, than hemorrhage from the uterus. Have seen case of villous endometritis which were not cured until after two or three curettements. One case, a young lady 20 years old, blond, slender build, tall, consulted her physician on account of profuse menstruation at various periods. Sometimes the hemorrhages would be so great as to prostrate her and she would become quite anemic. Constitutional remedies in no way controlled flow. Even rest in bed seemed to do no good. Upon examination, uterus was found slightly retroflexed, no enlargement, no ovarian tenderness, external os gaping with some erosion. While a curettement was advised but not strongly pushed at the time it was not accepted and at the next period the physician was hastily called on acocunt of patient's condition, she had been menstruating about four days. and flow still increasing; she was very enemic, pulse so feeble that curettement was strongly urged and accepted. The uterus. was then greatly dilated, external os presented a picture of puerperal laceration, eroded and everted lips. A quantity of adenoid vegetations were removed. After treatment was not given as she left the hospital in ten days but in four or five months there was hemorrhage again but only slight with a persistent discharge tinged with blood. Local treatment was then given for a year, not constantly or regularly but once in awhile when discharges became enough to worry her. Not being able to cure her entirely she was persuaded to have a second curettement, followed by intrauterine swabbing of iodine and carbolic acid and packed with iodoform gauze. This not only cured her menorrhagia but the external os resumed its natural appearance, after using hot douches for a few months together with iron tonics.

I have not spoken of septic and gonorrheal endometritis as I have confined myself more especially to virginal endometritis and in this we are not expected to find either.

I believe every gynecologist will confess that chronic endometritis is one of the most discouraging and obstinate affections to cure. It is impossible to control the patient's habits of life and her environments. I find that some women are satisfied to simply feel better than when at their worst, and will not continue faithfully the treatment, but if one is determined to get well and will put herself under the care of her physician and obey orders, her recovery as a rule is more speedy and permanent.

A REVIEW OF ONE THOUSAND OPERATIONS FOR GALLSTONE DISEASE, WITH ESPECIAL REFERENCE TO THE MORTALITY.*

BY WILLIAM J. AND CHARLES H. MAYO,

Surgeons to St. Mary's Hospital, Rochester, Minnesota.

In one thousand operations for gallstone disease there were fifty deaths (5%), counting as a death every patient operated upon who died in the hospital without regard to cause of death or length of time thereafter. Nine hundred and sixty for benign disease, with 4.2% mortality. More than one procedure through a single incision, only the major was counted, therefore 101 cholecystostomies and 44 cholecystectomies in connection with common duct operations are not included.

Cholecystostomies: 673 cases-mortality 2.4. This group includes most of the acute infections. In no case did stones reform in the gall-bladder. This is the operation of choice in the average uncomplicated case, and especially if there is or has been cholangitis.

Cholecystectomy 186-mortality 4.3% employed for special indications such as cystic duct obstruction, thick-walled gallbladders, suspicious of malignant disease and cholecystitis without calculi. One hundred and thirty-seven operations for stone in the common duct-mortality 11, 7% from operation, 4% from secondary complications after more than three weeks. Cases operated upon during quiescent period with little jaundice and slight infection, all recovered. Four cases with extreme icterus from obstruction, who had subcutaneous hemorrhage at the time of operation (purpura), all died; four cases of complete biliary obstruction in which common and hepatic ducts filled with clear cystic fluid and no bile, all died. Including malignant disease, 14.6 of total were upon common duct. Forty cases of malignant disease with 22.5% mortality, two cases with cancer of the gall-bladder now alive and well more than two years after; two additional favorable cases of more recent date. Of the remaining malignant cases a few received marked palliation, but the majority were but little benefited.

Abstract of paper read before the Southern Surgical and Gynecological Association, Birmingham, Ala., December 15th.