rounded by dense white connective tissue, and when the congestion and consequent expansion of these vessels occur at the menstrual period, intense pain arises from pressure on the peripheral nerves in the vessel walls and closely adjacent tissues. A well prepared section of chronic metritis looks pale and shiny, with hard, white connective tissue bundles lying irregularly in the field, interspersed with reddish masses of the muscular bundles. The enlargement of the metritic uterus may be due to the cicatrization of the muscular bundles or hyperplastic growths in the lymph spaces; perhaps both processes occur together.

in the vagina and the other hand on the abdomen, the uterus feels hard, rigid, stiff and solid. A normal uterus should feel like a living muscle in partial tension, in slight activity. It should bend, yield and glide unimpeded in all directions. In short, it should be perfectly mobile, like a normal testicle. The metricic uterus exists in many degrees. It may feel like a muscle in vigorous high tension or as hard as cartilage or a turnip. It will not bend nor glide about normally; it is dislocated because it is permanently fixed. It is fixed by its own rigid, hard walls. The metritic uterus is always in fixed version or flexion, because (pathologic) version or flexion means fixation, it means dislocation. In this relation, four proposiFIG. 4.

The large metritic, nypertrophic uterus consists, to a great extent, of excessive growth of connective tissue in perivascular lymph spaces. Intense congestion and vascular stasis leads to overnourishment, resulting in hypertrophy. Atrophy is but a decadence of hypertrophy. The muscles are crushed out and the vascular supply gradually diminished. The contraction of the shiny, hard, glistening, irregular connective tissue bundles of the uterine muscularis leads to obstructing arterial flow and impeding venous and lymphatic (return) flow, some of the vessels assuming at first a varicose condition, and finally there exists an indurated uterus with but small and weak blood supply. The scene of the metritic uterus is almost constantly connected with endometritis. In the chronic glandular endometritis the glands may enlarge, increase in number, become occluded and dilated and project deeply into the uterine muscularis and absolutely stimulate malignancy by alveolar appearances of the glands. In this manner the glandular endometrium perpetuates metritis indefinitely.

Figure 4 represents the mucous membrane of thirty-five year old multipara in the first day of menstruation. The section of the mucosa is made perpendicular to the long axis of the utricular glands. 1, 2, 3 and 4 are utricular glands; 5. 6,7,8 and 9 represent blood vessels; 11 represents a fasciculus of connective tissue; 12 and 13 represent the ground substance of the uterine mucosa, i.e., connective tissue fibers and connective tissue cells. In this subject the mucosa was about one fifth of an inch thick, i.e., about twice as thick as it is in the normal resting state. First the glands are irregular, elogated and widely dilated with fluid, and the walls are especially folded and sinuous as in Figure 2. Considerable blood is plainly seen in the glandular lumen. The sudden filling of the utricular gland at menstruation does not give them time to distend uniformly; but they expand in the direction of least resistance, as is observed in every gland, but especially in No. 2. The whole mucosa and immediately adjacent muscularis is very edematous. The elements are widely distended by fluids. The lym phatic spaces are very apparent around the glands in the muscularis; leucocytes are numerous. The blood vessels (6, 7, and 8) are widened and filled to distension with blood. The epithelium of the glands is not shed. It is perfectly intact. The muscularis is especially thickened by the distention from fluids. No. 5 doubtless represents a venous sinus cut longitudinally. This section was made near the internal surface of the mucosa, hence no unstriped muscular bundles could be observed dispersed between the glands. The sinuous or folded condition of the walls of the utricular glands is quite a characteristic during the active stage of menstruation. In pregnancy of two to three months the glands are more hypertrophied than in menstruation; also the utricular glands possess a uniform hypertrophy in pregnancy, and do not show a sinuous or folded character of their walls, as is shown in the congested stage of menstruation.

The course and prognosis of metritis is absolutely indefinite. I have treated scores of cases for at least five years. I carefully treated one case ten years for a large metritic uterus, and finally assisted Dr. Lucy Waite in performing an abdominal hysterectomy, whence the patient, from over ten years of invalidism, became well and fat in a few months. The prognosis of the metritic uterus following gonorrheal endometritis is often hopeless, because the gonorrheal infection is so persistent and continuous, inviting mixed infection, that both the mucosa and muscularis are structurally crippled beyond repair. However, many metritic uteri can be repaired so that the patient is partially well, and some perfectly well (symptomatically).

The diagnosis of metritis is easy to make (omitting the acute). With the index finger

tions may be well remembered, viz.: 1. Anteversion is where the uterus lies ex

tended forward and is abnormally fixed. 2. Anteflexion is where the uterus is curved on its anterior surface and is abnormally fixed. 3. Retroversion is where the uterus lies extended backward and is abnormally fixed. 4. Retroflexion is where the uterus is curved on its posterior surface and is abnormally fixed.

The symptoms of metritis occupy wide fields according to its intensity and the individual susceptibility. In women the ganglionic system is developed to a greater extent than it is in men. The ganglia are not only large and more numerous, but they are richer in nerve distribution. This makes women more enduring and tenacious of life, but also it makes her more subject to reflex neurosis. The irritation arising in the uterus, an organ dominated by a rich supply from the sympathetic, like electricity streams to all other viscera. The genitals are like an electric bell button, which being pressed rings up the whole system.

Now, the learned neurologist will gravely announce that reflexes do not create deepseated disease, and the reverse, that deepseated disease will not be cured by removing the reflexes or its cause, to which we lend an attentive ear. However, we will claim that irritation in the (genitals) uterus, creates by reflex action disturbance in function in distant viscera. The disturbance in function soon begins a train of suffering, an impairment of health. We must say first that metritis produces symptoms of reflex irritation in various viscera, especially the stomach (digestive apparatus), and second, symptoms of pain. The manifest pain of metritis is in the pelvis, back and head. The systematic train of evils following metritis are: 1, irritation; 2, indigestion; assimilation; 4, Anemia, and 5, neurosis. In many cases this evil train is very slow in arising.

3, non

Again, it must not be forgotten that many women have metritis with insufficient symptoms to make them conscious of its presence. I have examined many such women. The treatment of metritis is medical and surgical.

First, so many women are afflicted with metritis that surgical application could not and should not be applied to but a comparatively few. The medical side of metritis is the chief one and in the majority of cases we can do much. The object is to restore the uterus to normal or to repair the damaged organ as much as possible, to relieve the patient from the accompanying reflex action and disturbing symptoms. Fortunately, for physicians, most diseases tend to get bet

ter. We can do but little for the atrophic, indurated uterus, except to relieve pain, and fortunately the atrophic indurated uterus is not afflicted with much pain. It is in the hypertrophied metritic uterus where we can do the most practical good. To treat it we attempt to limit its blood supply, in other words, to starve out the excess of tissue. This is accomplished by hot fluids, astringents and hygroscopic materials. A douche may consist of 16 quarts twice daily, a handful of salt and a teaspoonful of alum for a gallon. For directions to use douche see my article in Jour. Am. Med. Assoc., Oct., 1897.

Figure 5 represents a section of the uterine mucosa of a ten weeks' pregnancy. The section is made at right anles to the long axis of the utricular glands. 1, 2, 3, 4 and 11 represents glandulæ uterinæ. Observer the glands are large, but uniformly hypertrophied and distended. The epithelia of the glands appear to be elongated. No 11 represents a partial utricular gland with parts of its epithelia fallen out: 5, 6, 7, 9 and 10 represents blood vessels which are enlarged. but especially show thickened walls; 13 and 18 represent a fasciculus of connective tissue traversing the uterine mucosa between its glands. The ground substance, 14 and 15, show connective tissue cells and fibers, all enlarged, but it does not show the edema of menstruation. The special characteristies of pregnancy are in the uterus, uniform thickening of the vessel walls, uniform enlargement of the glands, elongation and apparently multiplication in the form of diverticular building. The mus cular cells are thickened and elongated and increased in number, and the connective tissue of the mucosa is increased in its cells and fibers; in short, the glandular (lymphatic) vascular connective tissue and muscular elements seem to be not only hypertrophied, but increased in number.

The effect of a vaginal douche is: 1, to contract tissue, i. e., muscle, connective, elastic; 2, to contract vessels, i. e., arteries, veins, lymph; 3, to absorb exudates; 4, to relieve pain; 5, to check secretion; 6, to stimulate (tonic); 7, to cleanse parts.

A second form of medical treatment for metritis consists in the use of cotton (or wool) tampons soaked well in boroglycerid (glycerin, 16 ounces; boracic acid, 2 ounces). The tampon is distinctly hygroscopic and an excellent mechanical support; otherwise it has a similar effect with the vaginal douche. The tampon may be used three times a week and allowed to remain in the vagina for ten hours. With six months or more of such treatment the hypertrophic uterus is nearly always benefited and frequently so much improved that the patient is comfortable. Sometimes she is cured symptomatically or perfectly. Pregnancy often cures it perfectly. Painting the cervix with various materials is, so far as my observation goes, of very limited benefit.

The surgical treatment of metritis consists in dilatation, curettement and the application of a caustic, Alexander Adams' operation or hysterectomy. A fixed uterus should always be curetted with caution. Dilatation of a metritic uterus is accompanied with dangerous trauma. Some metritic walls are so thick, that they can not be dilated and often vastly more damage than good is done to a metritic uterus by dilatation. The solid, metritic walls will not dilate without thousands of localities of trauma, which prepare the way for wider and more intense infection. Some may be curetted with a small curette without dilatation and endometrium cauterized, pure carbolid acid being one of the best caustics. However, from experiment with the curette on recently removed uteri, I am convinced the curette is not what accomplishes the good effect, but it is the applied caustic, the pure carbolic acid which sloughs off the old chronically inflamed endometritis and allows a new endometrium to appear, giving nature a chance to rejuvenate itself. use a rubber tube stitched in the uterus to drain for a week, washing it out with alcohol and sterilized water from the third day on. Some use gauze, but gauze is a poor drain. It may be borne in mind that it is dangerous to curette a fixed metritic uterus and it is even more dangerous, from trauma, to dilate a thickwalled metritic uterus. Hence, the douche and tampon are often more successful than the dilator and curette in a large metritic uterus. The Alexander Adams' operation is often of value in the hypertrophic metritic uterus. Its upright position will allow vascular depletion. The hard ring and intrauterine stem pessary are a traumatic evil and are mentioned only to be, in general, condemned.

To say that metritis calls for hysterectomy to cure a patient, would doubtless call anath

emas on my head from many physicians whom I respect. But I have cured absolutely, from metritis, so many patients by hysterectomy who were invalids for years previous, that I dare to follow the operation and abide by the result to tell its own simple story. Of course, only selected cases of metritis call for hysterectomy, after which patients get well and fat. I now nearly always remove the uterus when both appendages require removal. Dr. Lucy Waite and myself have now practiced the removal of the uterus with bilateral disease of the appendages for some four years and our satisfaction grows with improving results. The hard, solid, hypertrophic, metritic uterus can be sometimes cured only by extirpation; the safest route is per vaginam.

There is a significant question as to how far the frequent metritis enters into the etiology of uterine myomata. Doubtless many myomata are due to local disturbances in uterine circulation.

Finally the predisposing causes of metritis are: Labor; abortion; lack of submucosa; menstruation; sexual irritation; the mucosa and muscularis do not move independently; traumatic lesion; vascularity; excess of lymphatic elements; muscular trauma on infected utricular glands.

Pathologic results: Deposit of connective tissue; hypertrophy; atrophy.

Clinical results: Pain; menstrual disturbance; sterility; hemorrhage; prolapse; reflex irritation.

The predisposition of the uterus, over other hollow organs, to inflammation is because the uterus has no submucosa and hence the mucosa and muscularis do not move independently as in the stomach. The utricular glands penetrate the muscularis directly by muscular contractions and induce consequent direct infection.

In this article I have made free quotations from my article in the Journal of the American Medical Association of October, 1897. 100 State Street.

MONEY MORE VALUABLE THAN LIFE. It is said that since John W. Mackay recently refused to pay the bill of the physicians who extracted the assassin's bullet from his body, amounting to $12,500, he has paid an attorney's bill of $20,160 for taking a will of which he was executor through the probate court-an automatic procedure requiring neither skill, great ability, learning, nor judgment.

The California press was unanimous in condemning the physicians for rendering so large a bill, and in congratulating the lawyer upon receiving a handsome fee.

There are three conditions in which excessive tympanites becomes a symptom of considerable importance, namely, typhoid fever, intestinal obstruction in its various forms, and in forms of pulmonary disease, chiefly pneumonia, in which the pressure of the gas upon the diaphragm and the thoracic viscera gives the patient much aistress. Of course there are many other diseases in which a considerable quantity of gas may form at times in the stomach and intestines, yet it is in these three instances that we have named that it most frequently gives rise to serious discomfort or even danger. Under these circumstances the question at once arises as to what is the best method to give relief to the patient. In the majority of cases of typhoid fever this condition can be prevented, if the patient is seen early in his attack, by a proper direction of the diet and control of the bowels, using mild purgatives when they are needed to overcome constipation and mild antiperistaltics when diarrhea becomes excessive. In a proportion of cases, however, even these precautions are not successful in warding off this complication, and under these circumstances it is our custom to direct that a turpentine stupe as hot as the patient can bear shall be placed over the abdomen and allowed to remain until it produces considerable counter-irritation. The period during which it remains in contact with the skin varies of course with the susceptibility of that patient's skin to this irritant.

It may be that other counter-irritants are equally useful, but experience has seemed to indicate to us that turpentine is the most efficient.

If the tympanitic distention is not relieved by this application, a rectal injection of two to four ounces of milk of asafetida, pure or diluted half with water, is resorted to, and if this does not give relief a few drops of turpentine are added to a fresh injection of milk of asafetida, care being taken that the Lurpentine is thoroughly broken up in the asafetida emulsion so that no separate drops of the irritant oil will come in contact with the rectal mucous membrane. In other cases turpentine made into an emulsion with starch water, or thoroughly mixed with sweet oil, and given by rectal injection is equally efficient; but if all these remedies fail, then the rectal tube passed well up into the sigmoid flexure, as far as possible and as gently as possible, will generally allow the passage of the wind. Should these com*Theraputic Gazette.

paratively moderate means fail to give the patient relief, the question at once arises as to what other means there are at our disposal, and in this connection it is interesting to recall the very careful and able studies made by Ogle, of London, a number of years ago upon the subject of puncture of the abdomen for excessive tympanites. This investigator has collected from the experience of a large number of medical and surgical friends a great number of cases, which he has placed together in a complete essay. The result of his study is that in a certain proportion of cases puncture of the abdominal wall and intestine is safe and expedient and often followed by good results, and that in cases which are necessarily fatal its use will often render the patient's death much more easy than had the distention been allowed to remain or increase.

In Ogle's studies it was found that the operation is suited chiefly to those cases which have distention of the colon and stomach, for the numerous coils and kinks of the small intestine and the fact that its caliber is much less than either of the viscera which we have named render accurate puncture difficult unless the knuckle of distended gut is particularly prominent. It seems evident, too, that puncture of the stomach is rarely if ever justifiable, because great distention of this viscus can nearly always be relieved by the use of the stomach tube or esophageal tube. It is only when grave obstruction to the esophagus or cardiac orifice exists that puncture for distention of this organ is permissible. Ogle believes that incurable cases of bowel obstruction are relieved of their most distressing symptoms by this means, and that curable cases are greatly aided by it since by this means vital organs are relieved from pressure and purgative drugs which before the gas was withdrawn could not move the bowels have an opportunity of unloading them.

It goes without saying that in making the puncture careful antiseptic precautions as to the condition of the nails and the patient's skin over the abdominal area are to be taken. The skin should be as carefully prepared as it would be for an abdominal incision, and the cannula or hypodermic needle which is used for puncturing purposes should be as small as possible in order that the wound in the abdominal parietes and particularly in the wall of the gut may be so minute that the muscular fibers will immediately close it when the needle is withdrawn. Further than

this, if a large needle is used which has to be reinforced by a trocar passed through it, this trocar, the point of which should be sharp, should not have triangular edges but be perfectly round, in order that the puncture can remain open; and again, as there is a certain amount of danger in withdrawing the needle of infecting the peritoneum or the abdominal wound by minute portions of the intestinal contents which may adhere to the needle, it may be advisable to allow a small quantity of saline fluid to flow inwards through the needle while it is still in situ after gas has ceased to come away from it, in order that any intestinal contents in its caliber may be washed back into the bowel and not withdrawn into the wound. When it is considered what grave insults the peritoneum will receive without resentment when it is in a healthy condition, the danger of infection in the way that we have hinted at cannot be very great. On the other hand, it is not to be forgotten that in case of intestinal obstruction in particular the susceptibility of the peritoneum to infection is greatly increased. It is better to make a number of punctures in various portions of the bowel for the purpose of relieving the gas, using in each instance a fine cannula or needle, than it is to use one or two punctures with a large cannula. Ogle asserts that fecal extravasation has never in his experience followed such punctures, nor have they

given rise to adhesions; and, further, that should more serious operative procedure be required these punctures in no way increase the danger to the patient. In an editorial which was published in the Medical News some years ago the writer mentioned a case in which the ingestion of a number of pigs' feet which lodged in the lower colon caused intestinal obstruction to such an extent that all purgatives and injections were futile, and yet the cardiac distress was so great as to force the writer to the use of hypodermic needles, which were inserted at various points along the course of the colon. Gas rushed through these for fifteen minutes before the colon became entirely collapsed, but after its collapse the purgatives, which had been administered, acted and the obstruction was removed. Recovery followed.

We have called attention to this means of treatment of severe tympanites not because we think it should be used in many, cases, but because it seems a justifiable operation in some instances. It is not to be resorted to carelessly, nor until every other means of greater safety for the removal of the flatus has been carried out; but as a last resource which will sometimes succeed, sometimes fail, in relieving the distention, and which is not so dangerous as to seriously imperil the patient's recovery. We believe that the physician should always remember this method of giving relief.

There can be no doubt that (Boston Medical and Surgical Journal, Am. Journ. of Surgery and Gyn'y) the trend of medical opinion of late years has been pretty steadily against the efficacy of operations upon the pelvic organs, especially oophorectomy, as a cure for nervous or mental affections always excepting those cases where disease of those organs demands such operation, independently of the nervous condition. At a meeting of the Association of American Physicians, Dr. Wharton Sinkler, of Philadelphia, took the ground that it was unjustifiable to remove healthy ovaries in cases of nervous disease, and the late Dr. Lusk, of New York, said that he was tempted to regard such a proceeding as malpractice. A recent inquiry conducted by Drs. Angelucci and Pieraccini of the provincial asylum at Macerata, Italy, has afforded considerable information in the way of the accumulation of statistics of cases in sufficient number to warrant certain definite conclusions. The

data which they present are based upon reports made to them by the heads of public and private asylums and psychiatric clinics 115 cases in which surgical operations were in various countries, embracing a total of performed upon the female sexual organs, either healthy or diseased, to combat some nervous disorder or to remove diseased organs. One hundred and thirty-seven of the asylums and clinics interrogated had had no cases of the sort. Out of seventy-six alienists, directors of asylums or clinics, fifty-six more or less strongly disapproved of such operations, twelve had not had sufficient experience to warrant a personal opinion, five were uncertain, and only three favored such operations in the treatment of hysterical conditions. Of the 115 cases, six were subjected to a simulated operation for the relief of hysterical conditions. Of the remaining 109 cases, sixty-five had healthy organs removed for the cure of nervous conditions, eighteen nervous patients had diseased or