fairly good health, but was rather listless, showing little interest in things about his household, although he would converse, take nourishment, and apparently enjoy walks and rides. The scalp wound healed, except a small opening in the lower angle, which was discharging.

His wife then noticed he became gradually stupid, which grew worse until he became comatose. It was then that an examination was made, and paralysis of the right arm and leg, with rigidity of the right side of the neck, was found. He was in a state of deep coma. Respiration normal, pulse 16, temperature 97°F. Pus was oozing from the opening in the wound.

After the usual preparation of the scalp, the original wound was opened and enlarged. There was a linear fracture of the left parietal bone running from near the angle formed by the saggital and coronal suture downward toward the temporal bone, about two and one-half inches long. There was no depression of the bone.

Upon opening the skull with a trephine, the inner table showed some comminution, but no spiculæ detached. This opening allowed four or five ounces of pus to escape. The dura was found intact and pulsating, so it was not disturbed. The pus cavity, examined with a probe, extended anteriorly to the roof of the orbit, superiorly to the median line, posteriorly to the lambdoidal suture, and inferiorly to a line corresponding with the level of the zygoma. The cavity was irrigated with salt solution and drained with rubber tubing. After he was removed from the table the paralysis began to improve, and in forty-eight hours he was more rational, the rigidity had disappeared, and the paralysis was almost gone.

The temperature remained normal in the morning and subnormal in the evening for five days after the operation, and then began to run a normal course. The wound healed in two weeks, and when last seen, five weeks after the operation, he was in good mental and physical condition.

Case II. J. G., aged 4 years. March 26, 1903, fell, striking his head on the end of a piece of lumber in which there was an eight-penny nail. He was unable to rise without help, so remained several minutes before assistance arrived. The wound of entrance seemed so slight to his parents that no physician was called until the following day. Upon his arrival he learned that the child had been suffering all the previous night with pain in the head, and had some temperature. The wound was opened with an aseptic probe, which was followed by escape of a small quantity of fluid. The wound

was dressed and the child was relieved, which lasted for four or five days. During this time the child was playful and did not suffer any pain. On the fifth day, however, the side of the head commenced swelling and the pain returned. The temperature rose to 100°F. The wound, which had healed, was again opened, and this was followed by the escape of about one ounce of sero-pus which afforded entire relief from all the symptoms. This relief again lasted three or four days, when the pain returned.

When seen April 9th he was crying with pain in the left side of the head and restless. He had no temperature, no vomiting, tongue clear and pulse rapid when crying, but slow when quiet. He was playful sometimes. The pupils were normal and the bowels active, and he had some appetite. The wound, about the size of a small nail-head, was healed, and one and a half inches above the external auditory meatus. near the left parietal eminence, to the examining finger there was a depression in the skull, as if the nail had entered obliquely upward. From the history it was thought advisable to operate. So after preparing the field of operation a horseshoe incision was made down to the bone, and the flap, including the scalp and periosteum, was reflected and a small opening was found in the skull the size of a small nail, from which two or three hairs and the wound in the dura protruded. After removing the hair the opening in the skull was enlarged with hemostatic and Rongeur forceps to one inch in diameter. There was no pulsation in the dura, and when a small probe was introduced into the opening there escaped several ounces of pus. The opening in the dura was enlarged, and fully eight ounces of sero-purulent exudate escaped, which allowed the brain to approach the pening. A silkworm gut drain was adjusted and the flap sutured, leaving in the center an opening for drainage. The wound was dressed daily, the drain being removed on the fourth day. On the seventh day the stitches were removed. At no time was there any fever, and after the effect of the chloroform had worn off he did not complain of pain. There was one small stitch abscess. In one week after the operation there was no symptom of any alteration of health, and he was allowed the freedom of the house.

These two cases show the endurance and ability this important organ has of withstanding the invasion of microorganisms when left to care for itself. In both instances, had the skull been opened immediately, and the spicule of bone from the inner table of the first case been removed, and the seat of

injury in both been drained, doubtless the above-described condition would have been prevented.

The second case illustrates what disproportion may exist. between the actual condition present and the symptoms. This child at no time showed symptoms of compression; the temperature was elevated, but never subnormal. There was no disturbance in the gastro-intestinal or genito-urinary tracts. There was a larger quantity of pus escaped from it than from the first case; the infection was subdural, but there must not have been such a well-defined abscess cavity allowing a more equal distribution of pressure.

There was no irrigation used in the second case, deeming it dangerous, because the force of the fluid may have caused an extension of the infection, and injured the already highly inflamed meninges. In the first case, the infection being epidural, there was not this danger, as the pus was confined within a circumscribed space by an inflammatory barrier.

There was a difference in the two purulent products. In the first case the liquid was thick and creamy, with uniform consistency, while in the second case the larger portion was serous, with flakes of fibrin and pus, the smaller portion being sero-purulent.

The ultimate recovery in all such cases is not always good. For months after they may again show symptoms of intercranial disturbance, and undergoing a second operation may not be relieved, as in the first instance, and then again they might develop epilepsy, monoplegia, or some mental alteration. In other instances, weeks and months have elapsed after a slight injury to the head, and the patient developing symptoms is operated upon and pus found. It is not likely that this purulent inflammation has been active for the whole time, but the seat of injury may be a small contusion of the brain or a small hemorrhage; being a place of least resistance it affords a suitable nidus for microorganisms, should they gain entrance into the body.

It has been shown by experience, and pointed out forcibly by Dr. Crook, in this association, that it is always advisable to open the skull after injuries to the head, and especially is it so when there exists even a linear fracture without depression or symptoms.

TREATMENT OF MENSTRUAL DERANGEMENTS.

J. SMITHLINE, M.D.

BAYONNE, N. J.

IN outlining a method of treating menstrual disorders, I shall not enter into the detailed consideration of the theoretical side of my subject, but shall confine myself to recording the series of cases which I have observed, and in which I have employed the treatment which I shall discuss. As almost every practitioner uses a different method of treatment for the same condition, it is always interesting to compare notes and to glean from the experience of others what we may have been looking for in our own. For this reason every contribution to the clinical study of an important and common disease offers some points of interest to the practitioner.

The class of cases of which I am about to speak includes the menstrual disorders commonly met with in general practice, namely, amenorrhea, dysmenorrhea, excessive and scanty menstruation. We know theoretically, as well as practically, that the regular recurrence of the menstrual period from puberty to the menopause is not only an evidence of health, but is essential to health. The normal recurrence of the menstrual function is an index to the state of the genital apparatus, as well as of the general health of the patient. Derangements of menstruation, on the other hand, constitute valuable symptoms of disease.

In practice it is more convenient to study the clinical characters of the menstrual derangements rather than their causes. Yet the natural history of menstruation should be borne in mind and the rules that govern normal menstruation should be remembered. Menstruation should begin at puberty and should recur at intervals of twenty-eight days, with a fluid, sanguineous discharge, which should remain about the same in quantity throughout. But if the recurrence of menstruation be irregular, the color of the discharge dark, the quantity either profuse or scanty, then we have affections that we are called upon to treat. Of these the first and most important to be considered is amenorrhea.

AMENORRHEA. This denotes the absence of menstruation during the period of sexual activity, i. e., between puberty and menopause. During pregnancy and lactation amenorrhea is physiological. Amenorrhea may be due to local causes, such as nondevelopment or maldevelopment of the generative organs, atrophy of the uterus and ovaries, or to an occlusion of some portion of the genital tract. The constitutional causes of amenorrhea include a variety of general diseases which affect the nutrition of the body and which incidentally impair the health of the generative organs. A good example of this class of affections is pulmonary tuberculosis, in which the menstruation may be arrested during any stage, especially in the advanced phases of the disease. A temporary interruption of menstruation may also occur in acute constitutional diseases such as pneumonia and typhoid fever, but the function is reestablished with the full onset of convalescence. A variety of nervous shocks, such as fright, grief, mental worry, etc., may also induce a temporary cessation of the menses.

After we have obtained the history of the patient, and after we have made a thorough physical examination, and have, if possible, determined the cause of the amenorrhea, we are prepared to apply the necessary treatment. It is impossible to treat a case of this kind intelligently, however, unless the practitioner is aware of the cause of the absence of menstruation. The man who seeks and finds the cause of each ailment is able to predict the possibility of an ultimate cure. This is especially true in the disorders of menstruation.

In the cases of amenorrhea due to anomalies and malformations or atrophies of the genitals, scarcely anything can be done in the way of treatment. In amenorrhea due to anemia and chlorosis, the use of tonics, fresh air, good food and exercise are beneficial to a certain degree, inasmuch as all these remedies improve the patient's general health; yet I have found that in some of my cases the menstrual flow did not reappear after this treatment. Ferruginous and laxative prep arations failed to restore the menstrual function, and I therefore began to try the use of drugs that acted directly upon the generative organs. In this class I have used potassium permanganate, quinin, valerian, camphor and many other drugs. Vol. 23-31