diminished, so much so that if I had not had my attention called to it I should hardly have found it. There is still, however, a little thickening behind and to the right of the uterus, and as I press directly backward there is some tenderness. At the time the patient was at the dispensary neither elevation of temperature nor acceleration of pulse were found.

From the history, perhaps the first thing of which we should think would be extra-uterine pregnancy, with a ruptured tube. It might also be an inflammatory condition in the tubes, with a certain amount of pelvic peritonitis, or some growth which had existed there; for example, a small dermoid cyst of long duration, which had given no previous trouble and had suddenly become irritated and had caused this pain. Or the case might simply have been one of dysmenorrhoea, with the inflamed condition of an old dermoid cyst or some other tumor. Some of these diagnoses are thrown out at once by the examination to-day. If there had been a dermoid or ovarian cyst or other tumor, it would remain to-day, and we can safely exclude these suggestions. With regard to the diagnosis of inflammatory trouble, there was no rise of temperature, and the woman had been previously in good health, with no reason for inflammation in the pelvis. Although the result of the digital examination would correspond with inflammation and the formation of an exudate, the lack of febrile symptoms does not correspond, nor should we expect an inflammatory mass to have disappeared so rapidly. The case might also have been an abortion at one month, and the expulsive pains would lend credence to this view; but there would not have been the mass behind the uterus unless there had been retained secundines and septicemia with septic salpingitis and peritonitis, and these conditions would not have passed away in three days; so I think we can throw out that idea also. There might have been an abortion and possibly a hæmatocele, a certain amount of blood escaping from the tube without any tubal pregnancy, but we have no proof that such a condition can exist, and tubal pregnancy is much more likely to be the true diagnosis than the regurgitation of blood from the tube and a consequent hæmatocele. I think, therefore, that we are brought down to the diagnosis of ruptured tubal pregnancy. As I have told you in the didactic lectures, I believe tubal pregnancy is very much more common than has ordinarily been supposed. I have no doubt that there was blood in the peritoneal cavity, and that the extreme tenderness was due to irritation of the peritoneum and slight peritonitis, but not of a septic type. In the mean time almost all the blood has been absorbed and there is left only a little

thickening, which can be explained as being a little remaining blood, and a certain amount of exudation into the peritoneum, which exudation will be absorbed much more slowly than the blood itself. The amount of hemorrhage was very slight.

These cases of ruptured tubal pregnancy almost always have a bloody discharge from the vagina soon after rupture,—within a few hours or sometimes after a day or two,-and they flow almost continuously. The books do not state this, but describe gushes of blood and stoppages, which I do not find to be the case in my experience. I have seen patients who have flowed six weeks, dating from the time of rupture. In such a case as this there is nothing to do; nature has taken charge of the affair; the hemorrhage has ceased and the blood has been almost entirely absorbed. The patient will doubtless entirely recover, and the tube may even regain its normal condition, as the rupture at so early a time in pregnancy is slight, and perhaps in a year from this time, if we had an opportunity to examine the pelvic organs, we might find nothing more than a little scar showing the place of rupture.

Only the other day I saw an undoubted case of ruptured tubal pregnancy. The patient was operated upon by another operator, and, unfortunately, died, but the diagnosis was confirmed. I have seen twenty cases of tubal pregnancy in the last eighteen months. Half of these have been subjected to operation and the diagnosis confirmed; the others were either treated by electricity and cured, or their condition was not such at the time that I saw them as to demand any treatment whatever.

UMBILICAL HERNIA, EARLY MENOPAUSE; LACERATED CERVIX AND VAGINAL ENTEROCELE; RECTOCELE, LACERATED CERVIX, AND RETROVERSION.

CLINICAL LECTURE DELIVERED AT THE NEW YORK POLYCLINIC.

BY PAUL F. MUNDÉ, M.D.,

Professor of Gynecology in the New York Polyclinic.

UMBILICAL HERNIA; EARLY MENOPAUSE.

GENTLEMEN,-This patient is forty-one years old. She has been married about eight years, and has had three miscarriages, the last at the third month, one year ago. She complains of pain in the lower part of the back and in the ovarian regions, and of hot flashes through different parts of the body, followed by profuse perspiration. You notice the woman has a large abdomen, which is very tense and which closely simulates an abdominal tumor. On percussion it is found to be resonant throughout, and on lifting up the abdominal wall with the hand we find she has a great deal of adipose tissue. Besides this, on allowing her to lie quietly for a moment with her mouth open, the parts are relaxed and the abdomen is gradually reduced in size, thus showing that there is no abdominal tumor, but that the distention is due to fat, flatulence, and muscular resistance. This, then, is a false tumor. In addition to this you notice a protrusion at the umbilicus, which is increased on coughing, and on gently inserting the finger into the centre of this protrusion we find it can be replaced, and that the finger encounters a sharp, tense ring about half an inch in diameter. This is the umbilical ring, and the protrusion is an umbilical hernia. As there is considerable discomfort and pain on pressure, we shall advise her to get an abdominal supporter with a hard rubber or wooden pad, which will gently press down the protruding intestine and close the ring. Such bandages, however, are very apt to slip, and if the pressure be great the pain will be more severe than the condition which they are expected to relieve. I have seen the intestines

forced out through an opening even smaller than this until the protrusion was as large as an egg, and the part becoming incarcerated, it was necessary to give an anæsthetic and freeze the tissues before the protrusion could be returned. If this had not been successful, an incision would have had to be made down to the ring and the latter slit upward and downward, to allow of the reduction of the hernia. It would be desirable, then, to freshen the edges of the ring and unite them by deep sutures passed through the peritoneum and the whole of the abdominal wall. Sometimes these umbilical hernias are very large. The largest abdominal hernias we find are not umbilical hernias proper, but are really ventral hernias, from the separation of the recti muscles as a result of numerous confinements, or after a laparotomy. The scar from such a wound often weakens the abdominal wall, allowing the formation of such a hernia. In operating upon one such case I removed an intra-ligamentous ovarian tumor. She had had two previous laparotomies done. I freshened the parts on either side and brought them together by deep sutures after removing the ligamentous cyst.

This woman, who is forty-one years of age, has not menstruated for nine months, and complains of hot flashes or waves followed by profuse perspiration. This is one symptom of the condition which I presume is already here established,-viz., "the change of life." You might look for pregnancy at her age, but menstruation has already ceased for a time equal to the normal period of gestation, and an examination negatives this theory. The uterus is, however, enlarged, hard, and slightly anteflexed. The enlargement of the uterus is due in all probability to a fibroid in the anterior wall and towards the left side. One would expect, under such circumstances, that the patient, instead of being amenorrhoeic, would be menorrhagic; but subperitoneal fibroids do not, as a rule, have any such effect upon menstruation. Almost all women who are passing through the period known as "the change of life" suffer more or less from hot flashes and perspiration, and also from a great variety of other neurotic symptoms, which disappear when the menopause is fully established. The cervix is so far behind in this case, and the patient so nervous, that I shall make no further attempt to introduce the sound. Usually in cases of uterine fibroids the menopause is postponed, yet in this patient the menopause seems to be rather earlier than common. I am unable to explain her reaching the menopause so early. I have two patients (sisters), one about forty and the other forty-four years of age, who have told me that they have at times skipped long periods-at one time six years and at another nine years -without being unwell at all, and then menstruation has returned

naturally. The sister who is forty-four years of age conceived about one year ago, and was four months pregnant when she came under my care on account of diabetes. Some years before she had had a dead child, and had nearly lost her own life from the debility consequent upon the confinement complicated with the diabetes. She came to get my advice as to the advisability of allowing pregnancy to go on to term. There is very little literature upon this subject, but I found in Lusk's book a brief résumé of the statistics of the subject, showing that about fifty per cent. of the diabetic women who went to term died. The family physician not agreeing with me about advising abortion, the case was referred to Dr. T. G. Thomas, who also advised abortion, and this I produced. She is now in good health. The case is interesting as showing that a person may, under certain circumstances, go for nine years without menstruating and yet afterwards conceive. An early menopause is sometimes due to excessive involution of the uterus and ovaries following confinement. I have seen it occur as early as the twenty-sixth year. I have been told by one of my patients that she ceased menstruating at the age of twenty-five, after a difficult confinement. Both uterus and ovaries might atrophy as a result of pelvic peritonitis and a consequent shrinking of the peritoneal adhesions, and of course such a condition is not amenable to treatment; but so long as there is a menstrual molimen, even without any flow, the local use of electricity, intra-uterine applications of carbolic acid, hot douches, and measures directed towards building up the general health may prove successful.

LACERATED CERVIX AND VAGINAL ENTEROCELE.

The next patient is twenty-six years of age. She has been married three years, and has had two children and one miscarriage. The last delivery was six months ago. She flows every four weeks for six days, the last time being two weeks ago. She complains of pain in her back and on the left side of the abdomen, and of profuse white vaginal discharge. After the birth of her first child she says she had "blood-poisoning," and was sick in bed for some time.

This is a case in which the finger detects a rather peculiar condition. The uterus is in the first degree of prolapsus, the cervix being two inches within the vulva, and, as is usual in such cases, it is also retroverted in the first degree, the axes of the uterus and the vagina being about in the same plane. The external os gapes so as to allow the passage of the finger one-half inch into the canal; the cervix has evidently been torn, but this laceration has been intra-cervical, and