modic contraction as may arise from any direct exciting cause. Generally all these conditions are in co-operation. As the hyperesthesia is centered in the hymen or its remains, the removal of this structure has been suggested as the most direct means of affording relief, and enabling subsequent dilatation of the vaginal canal to be carried out. I now proceed to illustrate these remarks by the details of the two most recent cases which have come under my notice, together with their treatment and its results.

The first case treated occurred in a lady of a highly nervous temperament. Since her marriage, three years ago, her abdomen had gradually enlarged, giving rise to general expectation of pregnancy existing menstruation was regular, although scanty, and accompanied with slight dysmenorrhoea. At these periods especially, she complained of a pain in her right breast, which was never completely away, and occupied her attention very much, together with uneasiness over the hypogastric region. Notwithstanding these symptoms, she looked well, and was inclined to be stout generally. It was only from her ailments resisting neuralgic and tonic treatment that I was led to examine the uterine organs. This was imperfectly accomplished, for the slightest touch at the entrance to the vagina caused acute suffering and shrinking, followed by shivering, and the vaginal orifice was materially diminished by the hymen being unruptured. I persevered, however, in the digital examination, and felt that the vagina was narrowed, and the os uteri abraded. Leucorrhoea also existed. On subsequent enquiry, I found that connection had been imperfectly performed, and had been mutually abandoned to a very great extent; still, from its imperfect fulfilment, uterine and ovarian congestion had been set up.

The other case of vaginismus was a typical one, and I could judge of the general wearing-out effect on the lady better than in the preceding one, as I had attended her before her marriage. Although never robust she had enjoyed fair health, but soon after her marriage she became so ill, careworn, and had an unhappy or unsatisfied expression, so as to cause much solicitude to her friends. I was frequently summoned to prescribe for her prostrated condition, tendency to sickness, diarrhoea, and frequent and prolonged menstruation. I knew her husband to be a pattern one, and neither the stethoscope nor any other means of investigation revealed the cause of the symptoms. Cerium and Bismuth powders, Easton's syrup, change of air, &c., only gave partial relief, and at last her husband called, and in a general way explained that his

wife was not like other married women, and they had resolved that a thorough examination should be borne. This, however, was almost limited to the vulva, and revealed a most marked example of vaginismus. The hymen was intact, and almost continuous around the vagina, painfully sensitive, and only admitting the tip of the index finger. Penetration had never been effected, and all attempts had been too willingly abandoned. This pitiable picture of conjugal life had been tolerated a year, the day selected for operation, unwittingly, being the first anniversary of her marriage.

Viewing the case as of great delicacy, and the question of treatment as equally so, I requested Dr. J. G. Wilson's advice, and we agreed to excise the hymen and afterwards dilate the vagina. As the method of procedure was virtually the same in both cases, one account may suffice, although in the first case treated, the hymen was not so cleanly excised owing to the patient not taking chloroform, and because the membrane proved to be very friable, like wet paper. In catching it the piece would come away in the forceps; and for some time afterwards I had to introduce the dressings into and dilate the vagina with the forefinger, as the canal would not receive the smallest sized speculum having a diameter of little more than half an inch.

The bowels and bladder having been relieved, the operation was as follows:--Chloroform having been administered, the patient was placed in the lithotomy position accross her bed and drawn to the edge, the labia being well separated. I seized the hymeneal fold and with curved scissors snipped the membrane close off from the vagina all round the orifice, cutting from below upwards and thus avoiding any obscurity from the bleeding, which was moderate in both cases, and easily arrested by touching the cut surfaces with the perchloride of iron, and plugging the vagina with lint soaked in oil and carbolic acid. A half-grain morphia suppository was introduced into the rectum, some lint and a napkin folded over the vulva, kept in position by a T bandage. This concluded the operative procedure. The catheter had to be used once in the latter case, chiefly owing to the position of the dressings. In this instance the hymeneal fold was of strong consistence, and fully more than half an inch in breadth behind the fourchette, from which it tapered round the upper margin of the vaginal entrance.

On the third day, a laxative having been administered, the dressing of the wound and dilatation of the vagina were proceeded with. The vulva being first fomented, the first

as to

pieces of lint were gently removed, the vagina syringed with tepid water, and then strips of lint soaked in oil and carbolic acid as before, were passed through the smallest sized speculum (half-inch in diameter,) and so left separate the raw edges as in dressing a fistula, and distend the vaginal walls slightly. Until this was repeated several times, day by day, it caused acute suffering, almost necessitating chloroform. Still the patients expressed themselves as better able to bear it than that which they had endured formerly. The pain, however, gradually wore off, and as the wound in the vagina healed, I introduced a larger speculum, one inch and a half in diameter, leaving it to be withdrawn by the patient in half an hour. This treatment occupied from three to four weeks, and was continued till the passing of the larger speculum caused no inconvenience.

In the first case narrated, as soon as the vagina could bear it, the abrasion of the os uteri was treated in addition to dilating the vagina. The operation was so far successful as to permit of intercourse, and the hysterical pains in the breast and abdomen have disappeared. Pregnancy has not followed, possibly owing to a contraction in the cervix, which may yet be attended to. But the results were still more gratifying in the other case-protracted menstruation ceased, all dyspeptic and other symptoms vanished, to be replaced by a vigorous appetite and high tone of health and spirits, so much so that her friends, not knowing the ordeal she had undergone, were now equally struck by her improved look. Mere gaucherie on either side will not explain the continuance of vaginismus, nor can it be remedied through simply rupturing the hymen by a speculum or otherwise, for even where this has been done at the first parturition, the remains of it are sometimes so sensitive as to necessitate excision.

A COMBINED WIRE SPECULUM AND RETRACTOR. By FRANCIS H. BROWN, M.D., Boston. (Boston Med. and Surg. Jour.) A FEW weeks ago, I was asked by Dr. Waterman to assist him in a vaginal operation, which required the passage to be fully shown, and which promised to be, and, indeed, was quite protracted in its performance. I took occasion to suggest employing a simple wire speculum, which would answer the additional purpose of a retractor, in place of the Sims and Boston (Storer) specula and the copper spatule he

was proposing to use. He carried out my idea by bending a stout wire on itself, and then shaping both folds nearly into the form of the letter S; and thus got a very excellent and serviceable instrument. * Afterward I made, more carefully and after some experiments, the two forms of the instrument which I now describe.

They are made of iron wire, joined by hard solder and then nickelized. The wire used is numbered 10 and 13 of Stubbs's (English) wire guage. The general description of the larger instrument would be that it is a skeleton Sims's speculum; very nearly of the same size, and with the same curves; the two handles turning in opposite, instead of the same direction; and one blade somewhat shorter and narrower than the other. The instrument made from the smaller wire is, generally, smaller, and has one of its ends, proportionally, shorter; otherwise its general shape is the same.

The objects for which I propose these instruments, are the following: Singly, the larger instrument has been found well adapted to take the place of Sims's speculum. It displays the vagina equally well; it is much lighter; equally strong; and no less easy of application. The two together, as retractors or in place of the copper spatula, have served well to dilate the vagina, and bring into view every part of its wall, up to the cervix. Of course, this use presupposes one or more assistants; but, when so employed and guided by the eye of competent helpers, they fill, more satisfactorily than the bivalve and multivalve specula, the place of these instruments, while they are more fully out of the way of the operator. They have, moreover, the additional advantage over the common coppper spatulæ, that they have no sharp edges.

Singly, the instrument may, not infrequently, be used to hold and render tense the vagina, and, by its fenestrum, bring into clear view and make prominent an abscess or small tumor, an ulcer or fistula, on which one desires to operate, much as the fingers of the operator or assistant would do on the external surface of the body. It may, not inaptly, be employed after rupture of the sphincter ani for the display and operations on internal hæmorrhoids and ulcers of the rectum, or the internal opening of a fistula in ano. The retractor will be found a useful aid in searching, by means of

*For sundry suggestions regarding this retractor, I am indebted to Dr. Waterman, and a considerable part of the merit of the instrument--if merit exists-is due to that gentleman.

its fenestrum, for vesico-vaginal fistula-which, as is known, sometimes baffle the search of the surgeon for a considerable time.

The smaller instruments are to be used especially as retractors, to hold aside the edges of wounds during various operations for the removal of tumors, ligature of arteries, &c., and to keep out of danger arteries, veins, nerves, and similar important parts. The smaller retractor answers the purpose of the wire tongue depressor, devised by Dr. Allen, of Cambridge, and serves as an admirable retractor to draw aside the cheek or lips in various operations about the mouth and maxillary bones.

A still farther advantage of these instruments is their very trifling expense; the whole set of four being furnished by our instrument makers at a sixth part the price charged for any of the elaborate forms of specula.

[From the description, it will be an easy matter for many physicians to manufacture them themselves out of stout galvanized iron wire. If any desire the manufactured article they can address the office of this Journal.-Ed. Jour. Obstet.]

ON THE MANAGEMENT OF THE PERINEUM DURING LABOR. By WM. GOODELL, M. D., Clinical Lecturer on Diseases of Women and Children in the University of Pennsylvania. (American Journal Medical Sciences, Jan., 1871.)

[The first portion of the paper is an admirably exhaustive study of this important subject, but the great length of the article necessitated our simply abstracting the Doctor's own suggestions. ED. JOURNAL OBSTETRICS.]

ALTHOUGH I believe that the vast majority of natural labors require no assistance whatever to insure a safe delivery, provided the woman has escaped frequent touching, yet cases do undoubtedly arise which demand intelligent assistance, nor can we always draw the line of demarcation between natural and morbid cases. And let me remark in limine that, by laceration of the perineum, I mean any solution of its continuity, be it small or great. For the loss of every fibre entails a corresponding loss of power in the floor of the pelvis, and a consequent impairment of support to the reproductive organs. Where assistance seems demanded to prevent any laceration, the method which I adopt avoids all pressure upon, and direct support to the perineum, and I can the more confidently re