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AMERICAN MEDICINE

, 1910. Complete Series, Vol

, Vol. V., No. 10. The response of the endometrium is also

the body, or a local atony of the uterine interesting. The congestion causes muscle directly, or through fatigue of the definite swelling of the mucosa, and the nerve cells. stroma cells and glands become enlarged. It is the belief of the writer that the The capillaries show a remarkable power most important factor in the causation of of distension and the actual hemorrhage these hemorrhages of puberty and young occurs by diapedesis and by rupture of women is venous congestion. To bring this some of the delicate capillary walls. to your attention more forcibly permit me

From what has been said one would ex- to quote from a paper upon a relative subpect that any disturbances in the circula- ject read by me before the New York Obtion, whether arising from increased ar- stetrical Society last year. “As long ago terial supply causing overfilling of the as 1879 Dr. Emmet described the uterus capillaries or from nervous obstruction as an erectile organ surrounded by a mass producing over-distension by backward of blood vessels, pressing in every direcpressure, would tend to produce uterine tion through the loose connective tissue of hemorrhage.

the pelvis and directly affected by any inThe causes of abnormal uterine hem- crease or diminution of the neighboring orrhage fall naturally into the three groups circulation. In scarcely any other part of as arranged by E. H. B. Macdonald of the body have we such a network of vesScotland, and from whom I have quoted sels within the same extent of space. In freely.

consequence of the erectile character of 1. Abnormalities in the periodic ovarian the uterine tissues these vessels in time bestimulation.

come varicose or overdistended from con2. Conditions giving rise to muscular tinued obstruction to the circulation and insufficiency, either from (a) actual de- have an almost incredible venous capacity. ficiency of muscular tissue or (b) loss of As a stream will saturate the ground and tone and consequent deficient response to lose itself in a marsh, so will the circulavaso-motor stimulation.

tion through the pelvic cellular tissue and 3. Conditions giving rise primarily to in diseased conditions become equally continued congestion of the endometrium, sluggish. In attempting after death to either from (a) increased arterial supply inject the vessels in the pelvis of a female or (b) venous obstruction.

who has long suffered from uterine disOf the ovarian stimulation we know lit- ease, it will be found that the distinctive tle except that the growth of the uterus forms of the veins are frequently lost at is dependent upon ovarian activity, and different points and with all cases the inthat menorrhagia occurred in connection jection will

will become extravasated and with cystic diseases of the ovaries was long diffused.” The recent histological investiago noted by Tait. From what has been gations of Keiffer have furnished ample said of the importance of the integrity of proof of the correctness of Emmet's views the musculature, it is easy to conceive how on the subject. severe hemorrhages may occur from in- Nothing is so important to the woman sufficient muscular development during and to the human race as the prevention puberty or from loss of tone throughout of menstrual abnormalities, and to this end

con

1910.

New Series, Vol. V., No. 10. much can be done by the family physician culation be equalized. In passing allow and the specialist.

me to remark, that if some of the inBefore the girl reaches the menstrual dustrious and well meaning persons of this period she should live as much as possible and other large cities who have interested out of doors and indulge in exercises and themselves and written so feelingly about sports, such as running, skating, jumping the conditions of child labor in the south horseback riding, swimming, etc., side by would only remove their spy glasses long side with the boys. A prominent physical enough to adjust their lorgnettes to view instructor informed me that the records our child labor as seen in the large departmade by the girls of his gymnasium classes ment stores and work shops in our midst under the age of thirteen fully equaled much good could be accomplished. No those of the boys of a corresponding age. more pathetic sight can be seen than the When menstruation begins the

underfed, ill nourished, anaemic and unditions are different, as pointed out by developed specimens of adolescence as repGoffe (in Bovee's Gynaecology). "It resented by these cash girls and apprenseems a strange law of nature that two tices, many of whom never see the light of or three years have been set aside for the the sun and have no opportunity to dedevelopment of the generative organs. This velop physically or mentally. is the designated time for the establish- The treatment of girls and young women ment of menstruation and the power of re

suffering from menorrhagia and metrorproduction. If it is not accomplished at rhagia should be along physiological lines. this time the infantile organs of genera

When called upon to attend one of these tion persist, the normal blood supply is not patients it is most important to take into established, menstruation is not properly consideration her general condition. The performed and the unfortunate ills and af- excessive flow may be dependent upon a fections peculiar to women begin." At cardiac lesion or chlorosis may be the this time is required all the physical energy cause and the possibility of hemophilia that the individual possesses and conse

should not be overlooked. Rest in bed, quently study should be relaxed or sus- careful regulation of the bowels and tonics pended in order that the strength may not judiciously given, especially strychnine, be diverted to the brain and nervous sys

should be the routine. Iron is best avoided tem. Rest, physical and mental, should and unless the uterus is large and flabby be insisted upon before and during the ergot is of no value, as it increases the menstrual period and it would be better

Viburnum prunifolium were girls taken from school and com- given just before and during menstruation pelled to assume the horizontal position is often of great benefit. In cases of sefor the first days of each period until the vere hemorrhage the feet should be function is well established. Except at the elevated, a very hot prolonged douche times mentioned (just before and during given, adrenalin administered hypodermenstruation) girls and young women dermically and stypticin given by mouth. should be compelled to take out-of-door The vagina may be tightly packed with exercise, for in no way can the uterine gauze and the packing changed in twentymuscle be so well developed or the cir- four hours. In extreme cases subcutane

blood pressure.

ous infusion and bandaging of the limbs Trainers have long ago noted that athletes may be required. That hemorrhages oc- in severe training are practically impotent, curring at puberty may be severe and and that men of excessive muscular dealarming most of us know. Last summer velopment, the so-called "strong men," are Dr. Milliken of Hamilton, O., related to not nearly so active sexually as those who me the case of a young girl who actually lead sedentary lives and are muscularly bled to death during the second year of weak. The same is true of women, for I her menstrual life. She began with have been creditably informed that while menorrhagia and in a few months the flow undergoing severe muscular exertion such became continuous and resisted all the ef- as acrobatic performances and feats of forts of the physician to check it. When strength that these females have little or seen by Dr. Milliken in consultation the no menstrual flow. The knowledge of patient was moribund. No autopsy was these facts are valuable hints in the treatpermitted and the cause of hemorrhage ment of the cases under consideration. If never discovered, but the doctor felt justi- by reason of pelvic inflammation the pafied in eliminating causes depending upon tient cannot exercise without pain, then pregnancy.

she should be massaged and systematically. Emmet's figures show that those women By this means the osteopathic treatment who were abnormal at the beginning of has produced some remarkable results. menstrual life and afterwards became nor- When the uterus is enlarged and the endomal required eighteen months on an aver- metrium thickened, curettage gives varyage to become regular and if irregular be- ing periods of relief by stimulating muscuyond that time they rarely became regular lar contractions, but as this does not rein after life. Therefore during the first move the cause (pelvic congestion) permayear and a half unless the flow is very ex- nent results cannot be expected. That cessive the treatment should be general and this is true is proven by the many patients not local. Beyond that time it is fair upon whom this operation is performed presume that more active treatment will be repeatedly. During the past year one case required and the patient should be ex- was reported that had been curetted twenamined under an anaesthetic and permis- ty times and the uterus finally removed sion should be obtained to do what is found and no demonstrable lesion found. to be necessary at the time of the examina- tients who have reached the menopause or tion. The uterus should be thoroughly ex- the latter years of menstrual life it is cusplored and curetted and a displacement tomary to perform hysterectomy in cases corrected if needed.

of uncontrollable hemorrhage, but in young Since most of these hemorrhages are the women every effort should be made to conresult of pelvic congestion, what can we serve all of her sexual organs, and with do to relieve and prevent that condition? this in view I have been greatly interested The most potent means of equalizing the in a procedure that aims to relieve this concirculation is by muscular exercise. As- dition with no sacrifice to the patient. Two suming that the uterus is an erectile or- and a half years ago I saw a young girl gan, we can note the effect of exercise under the care of Dr. Jarman of this city, upon the pelvic circulation of the male. whose bleedings were so profuse and in

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tractable that two gynaecologists of na- All manner of drugs had been given her tional reputation had advised that hyster- and she had remained in bed for weeks at ectomy be performed, since repeated curet- a time with little or no benefit. tings and all other means had failed to The patient was put under an anaesthetgive relief. Her uterine arteries were ic and the uterus thoroughly explored and ligated by Dr. Jarman and she made a curetted. Nothing beyond a thickened enspeedy recovery and has remained perfec- dometrium was found and as might have ly well ever since.

been expected the pathological report was In September of last year a girl of seven- “hyperplastic endometritis.” teen came under my care with the follow- By means of a horizontal incision just ing history: Menstruation first appeared above the cervix the bladder was separated at 1372 years. She then missed three from the uterus sufficiently to enable the months and menstruation returned pro

uterine arteries to be demonstrated and fusely and irregularly, lasting from 7 to 8 ligated. The vessels were tied just above days and never remaining away a full the ureters and with 40-day catgut. The month. Then during the summer of 1908 flap was then sutured in place and the pashe missed three months, in September be- tient put to bed. She had no reaction and gan a continuous flow for 40 days. Then little pain after this simple procedure. She relief for 12 days, to be followed by pro- was out of bed in two weeks and menfuse flow for two weeks. In January she struated for the first time five weeks after was free for nearly a month and then be- the operation. The duration of the period gan a continuous and profuse flow for 35 was four days and rather scanty, otherwise days, when she was curetted. By the op- normal. Since then her periods have been eration she was relieved for a month and normal both in time and duration and her then the same condition returned and the physician informs me that she seems to be flow became almost continuous during the in perfect health. In a letter received a summer. In August while at a summer few days ago she says that she has never resort she had such a profuse hemorrhage felt better. for two weeks as to necessitate the con- This, I take it, was a case of pelvic constant attendance of two physicians. After gestion and by diminishing the arterial this she was brought to the city. She supply the veins were able to empty themseemed very pale and complained of short- selves and the circulation was equalized. ness of breath, but was well nourished and Of course little can be claimed for this well developed. There was no cardiac, operation, because the cases are too few in pulmonary, nor kidney lesion and no his- number and time too recent after its pertory of constipation and no pelvic pains formance to prove anything. It is merely or dysmenorrhoea. Her hemoglobin was offered as a suggestion, in the hope that found to be 602.

others will try it in those cases of menorThe uterus was larger than normal and of rhagia that are dependent upon venous softer consistency and rested upon a lower stasis. plane in the pelvis, but was otherwise in In closing let me urge upon every pracgood position. The ovaries and tubes ap- titioner who has one of these young women peared to be normal.

under his care, the importance of correct

BY

ing menstrual irregularities and to assure the pylorus open and to collect the secrehim that he has not done his duty or tion from the organ isolated in this way, merited the trust imposed in him if he but still maintaining its physiological relaneglects the opportunity to save a woman tions, with vessels and nerves intact. By from a life of semi-invalidism.

these means I succeeded in regularly col244 West 73rd St.

lecting the gastric juice of the animal, which

remained in excellent health, without deGASTRIC JUICE FROM THE LIVING veloping any complicating ulceration and

which continued to grow like a normal PIG AND ITS THERAPEUTIC.

animal. APPLICATION.

After various experiments upon the dog,

I decided to perform this operation upon MAURICE HEPP, M, D.,

the pig, for the theoretical reasons that this Paris, France.

animal is omnivorous and has a perfect My experiments for the obtaining of assimilation, furthermore for the practical natural gastric juice were begun in 1899, reason that the gastric juice from its enand were inspired by the favorable effects tirely isolated stomach is in its chemical observed during seven years with the gas- composition identical, from all points of tric juice of dogs (Tremont). It was my view, with human gastric juice. desire to suppress the disadvantages of the In order to make of the pig a producer gastric juice of the dog as regards its of gastric juice, I perform my operation exaggerated acidity and unpleasant odor. as follows: I make a median laparotomy, Tremont's idea appeared to me a fertile from the xiphoid process of the umbilicus. one, and offered an interesting field to I grasp between the thumb and forefinger surgical activity. A series of the most of the left hand, the protuberance caused varied operations were performed by me, by the abdominal end of the oesophagus, first the isolation of the stomach; then this protuberance is then brought forward; transverse division, with the transposition the peritoneum in front of the duct is split of the oesophagus into the pyloric pouch; longitudinally with a grooved director; the next longitudinal division; then the mak- index finger is inserted into the slit, and ing of a small stomach, at the expense of the oesophagus is separated from the pneuthe greater curvature, according to Paw- mogastric nerves which accompany it. This low's method with which I was

separation being carefully accomplished, quainted at the time; and finally sequestra- the index finger is passed under the tion of the stomach, according to Tremont's oesophagus which is enclosed in very loose plan. All these operations were produc- cellular tissue, and as long a segment of tive of some results, all provided for the the oesophagus as possible is drawn downjuice from a closed pocket, which juice be- ward into the abdomen. It is then seized ing very acid, often gave rise to very ex- transversely, in a large clamp, and divided tensive ulcerations in the pouch. I then above the cardia, which latter is at once decided to simply exclude the stomach grasped, passed through an accessory from the alimentary route, by implanting lateral incision and is fixed outside of the the oesophagus into the duodenum, leaving larger laparotomy wound; the cardia is

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