From what has been said one would expect that any disturbances in the circulation, whether arising from increased arterial supply causing overfilling of the capillaries or from nervous obstruction producing over-distension by backward pressure, would tend to produce uterine hemorrhage.

The causes of abnormal uterine hemorrhage fall naturally into the three groups as arranged by E. H. B. Macdonald of Scotland, and from whom I have quoted freely.

I. Abnormalities in the periodic ovarian stimulation.

2. Conditions giving rise to muscular insufficiency, either from (a) actual deficiency of muscular tissue or (b) loss of tone and consequent deficient response to vaso-motor stimulation.

3. Conditions giving rise primarily to continued congestion of the endometrium, either from (a) increased arterial supply or (b) venous obstruction.

Of the ovarian stimulation we know little except that the growth of the uterus is dependent upon ovarian activity, and that menorrhagia occurred in connection with cystic diseases of the ovaries was long ago noted by Tait. From what has been said of the importance of the integrity of the musculature, it is easy to conceive how severe hemorrhages may occur from insufficient muscular development during puberty or from loss of tone throughout

It is the belief of the writer that the most important factor in the causation of these hemorrhages of puberty and young women is venous congestion. To bring this to your attention more forcibly permit me to quote from a paper upon a relative subject read by me before the New York Obstetrical Society last year. "As long ago as 1879 Dr. Emmet described the uterus as an erectile organ surrounded by a mass of blood vessels, pressing in every direction through the loose connective tissue of the pelvis and directly affected by any increase or diminution of the neighboring circulation. In scarcely any other part of the body have we such a network of vessels within the same extent of space. In consequence of the erectile character of the uterine tissues these vessels in time become varicose or overdistended from continued obstruction to the circulation and have an almost incredible venous capacity. As a stream will saturate the ground and lose itself in a marsh, so will the circulation through the pelvic cellular tissue and in diseased conditions become equally sluggish. In attempting after death to inject the vessels in the pelvis of a female who has long suffered from uterine disease, it will be found that the distinctive forms of the veins are frequently lost at different points and with all cases the injection will become extravasated and diffused." The recent histological investigations of Keiffer have furnished ample proof of the correctness of Emmet's views on the subject.

Nothing is so important to the woman and to the human race as the prevention of menstrual abnormalities, and to this end

ous infusion and bandaging of the limbs may be required. That hemorrhages occurring at puberty may be severe and alarming most of us know. Last summer Dr. Milliken of Hamilton, O., related to me the case of a young girl who actually bled to death during the second year of her menstrual life. She began with menorrhagia and in a few months the flow became continuous and resisted all the efforts of the physician to check it. When seen by Dr. Milliken in consultation the patient was moribund. No autopsy was permitted and the cause of hemorrhage never discovered, but the doctor felt justified in eliminating causes depending upon pregnancy.

Emmet's figures show that those women who were abnormal at the beginning of menstrual life and afterwards became normal required eighteen months on an average to become regular and if irregular beyond that time they rarely became regular in after life. Therefore during the first year and a half unless the flow is very excessive the treatment should be general and not local. Beyond that time it is fair to presume that more active treatment will be required and the patient should be examined under an anaesthetic and permission should be obtained to do what is found to be necessary at the time of the examination. The uterus should be thoroughly explored and curetted and a displacement corrected if needed.

Since most of these hemorrhages are the result of pelvic congestion, what can we do to relieve and prevent that condition? The most potent means of equalizing the circulation is by muscular exercise. Assuming that the uterus is an erectile organ, we can note the effect of exercise upon the pelvic circulation of the male.

Trainers have long ago noted that athletes in severe training are practically impotent, and that men of excessive muscular development, the so-called "strong men," are not nearly so active sexually as those who lead sedentary lives and are muscularly weak. The same is true of women, for I have been creditably informed that while undergoing severe muscular exertion such as acrobatic performances and feats of strength that these females have little or no menstrual flow. The knowledge of these facts are valuable hints in the treatment of the cases under consideration. If by reason of pelvic inflammation the patient cannot exercise without pain, then she should be massaged and systematically. By this means the osteopathic treatment has produced some remarkable results. When the uterus is enlarged and the endometrium thickened, curettage gives varying periods of relief by stimulating muscular contractions, but as this does not remove the cause (pelvic congestion) permanent results cannot be expected. That this is true is proven by the many patients upon whom this operation is performed repeatedly. During the past year one case was reported that had been curetted twenty times and the uterus finally removed and no demonstrable lesion found. In patients who have reached the menopause or the latter years of menstrual life it is customary to perform hysterectomy in cases of uncontrollable hemorrhage, but in young women every effort should be made to conserve all of her sexual organs, and with this in view I have been greatly interested in a procedure that aims to relieve this condition with no sacrifice to the patient. Two and a half years ago I saw a young girl under the care of Dr. Jarman of this city, whose bleedings were so profuse and in

tractable that two gynaecologists of national reputation had advised that hysterectomy be performed, since repeated curettings and all other means had failed to give relief. Her uterine arteries were ligated by Dr. Jarman and she made a speedy recovery and has remained perfecly well ever since.

In September of last year a girl of seventeen came under my care with the following history: Menstruation first appeared at 131⁄2 years. She then missed three months and menstruation returned profusely and irregularly, lasting from 7 to 8 days and never remaining away a full month. Then during the summer of 1908 she missed three months, in September began a continuous flow for 40 days. Then relief for 12 days, to be followed by profuse flow for two weeks. In January she was free for nearly a month and then began a continuous and profuse flow for 35 days, when she was curetted. By the operation she was relieved for a month and then the same condition returned and the flow became almost continuous during the summer. In August while at a summer resort she had such a profuse hemorrhage for two weeks as to necessitate the constant attendance of two physicians. After this she was brought to the city. She seemed very pale and complained of shortness of breath, but was well nourished and well developed. There was no cardiac, pulmonary, nor kidney lesion and no history of constipation and no pelvic pains or dysmenorrhoea. Her hemoglobin was found to be 602.

The uterus was larger than normal and of softer consistency and rested upon a lower plane in the pelvis, but was otherwise in good position. The ovaries and tubes appeared to be normal.

All manner of drugs had been given her and she had remained in bed for weeks at a time with little or no benefit.

The patient was put under an anaesthetic and the uterus thoroughly explored and curetted. Nothing beyond a thickened endometrium was found and as might have been expected the pathological report was "hyperplastic endometritis."

By means of a horizontal incision just above the cervix the bladder was separated from the uterus sufficiently to enable the uterine arteries to be demonstrated and ligated. The vessels were tied just above the ureters and with 40-day catgut. The flap was then sutured in place and the patient put to bed. She had no reaction and little pain after this simple procedure. She was out of bed in two weeks and menstruated for the first time five weeks after the operation. The duration of the period was four days and rather scanty, otherwise normal. Since then her periods have been normal both in time and duration and her physician informs me that she seems to be in perfect health. In a letter received a few days ago she says that she has never felt better.

This, I take it, was a case of pelvic congestion and by diminishing the arterial supply the veins were able to empty themselves and the circulation was equalized. Of course little can be claimed for this operation, because the cases are too few in number and time too recent after its performance to prove anything. It is merely offered as a suggestion, in the hope that others will try it in those cases of menorrhagia that are dependent upon venous stasis.

In closing let me urge upon every practitioner who has one of these young women under his care, the importance of correct

ing menstrual irregularities and to assure him that he has not done his duty or merited the trust imposed in him if he neglects the opportunity to save a woman from a life of semi-invalidism.

244 West 73rd St.

GASTRIC JUICE FROM THE LIVING PIG AND ITS THERAPEUTIC. APPLICATION.

BY

MAURICE HEPP, M. D.,

Paris, France.

My experiments for the obtaining of natural gastric juice were begun in 1899, and were inspired by the favorable effects observed during seven years with the gastric juice of dogs (Tremont). It was my desire to suppress the disadvantages of the gastric juice of the dog as regards its exaggerated acidity and unpleasant odor. Tremont's idea appeared to me a fertile one, and offered an interesting field to surgical activity. A series of the most varied operations were performed by me, first the isolation of the stomach; then transverse division, with the transposition of the oesophagus into the pyloric pouch; next longitudinal division; then the making of a small stomach, at the expense of the greater curvature, according to Pawlow's method with which I was unacquainted at the time; and finally sequestration of the stomach, according to Tremont's plan. All these operations were productive of some results, all provided for the juice from a closed pocket, which juice being very acid, often gave rise to very extensive ulcerations in the pouch. I then decided to simply exclude the stomach from the alimentary route, by implanting the oesophagus into the duodenum, leaving

the pylorus open and to collect the secretion from the organ isolated in this way, but still maintaining its physiological relations, with vessels and nerves intact. By these means I succeeded in regularly collecting the gastric juice of the animal, which remained in excellent health, without developing any complicating ulceration and which continued to grow like a normal animal.

After various experiments upon the dog, I decided to perform this operation upon the pig, for the theoretical reasons that this animal is omnivorous and has a perfect assimilation, furthermore for the practical reason that the gastric juice from its entirely isolated stomach is in its chemical composition identical, from all points of view, with human gastric juice.

In order to make of the pig a producer of gastric juice, I perform my operation as follows: I make a median laparotomy, from the xiphoid process of the umbilicus. I grasp between the thumb and forefinger of the left hand, the protuberance caused by the abdominal end of the oesophagus, this protuberance is then brought forward; the peritoneum in front of the duct is split longitudinally with a grooved director; the index finger is inserted into the slit, and the oesophagus is separated from the pneumogastric nerves which accompany it. This separation being carefully accomplished, the index finger is passed under the oesophagus which is enclosed in very loose cellular tissue, and as long a segment of the oesophagus as possible is drawn downward into the abdomen. It is then seized transversely, in a large clamp, and divided above the cardia, which latter is at once grasped, passed grasped, passed through an accessory lateral incision and is fixed outside of the larger laparotomy wound; the cardia is