lation for the proctologist is in the treatment of chronic constipation, and here the results obtained are certainly remarkable. As constipation is often the result of faulty secretion and excretion of the stomach, liver and spleen, also of the small and large intestines, with a weakened or absent peristalsis, we turn our attention to each of these organs in its treatment. We stimulate the gastric glands through pressure on the vagi at the sides of the neck. Irritation of these nerves also produces contraction of the stomach, including the pyloric sphincter, hence the vagi are the motor nerves of the stomach. There are also spinal nerves reaching the stomach through the solar plexus, these nerves pass through the spinal cord in the anterior roots of the nerves from the 6th to the 12th dorsal, passing in the splanchnic nerves to the solar plexus, and hence to the stomach. (Kirke, page 367.)

The activity of the liver may be increased by applying over it interrupted vibration with moderate pressure and a medium short stroke, or by abdominal vibration and spinal stimulation. Dr. Snow, in her book on Mechanical Vibration, pages 214 and 215, says: "Professor Colombo, of Turin, demonstrated in respect to biliary secretion, that 'after ten minutes of trepidation (shaking or vibration) and of tapotement or percussion, the quantity of bile increased considerably in the next four hours. The cholesterin and the biliary soda salts were most abundant. After twenty-five minutes of friction and of petrissage the same results were obtained as after ten minutes of trepidation and tapotement; the maximum result was obtained by combining ten minutes of trepidation and tapotement with ten minutes of friction and petrissage."

The vaso-constrictors of the portal system are the third to the eleventh dorsal, the nerves of the hepatic artery are constrictors contained in the splanchnic, and dilators in both splanchnic and vagus. (Kirke.) From the third dorsal to the first lumbar, the motor nerves of the spleen are given off. The peristaltic movement of the intestines is increased by light stimulations of the vagi in the neck, while a heavy stimulation of the vagi would decrease the peristalsis. The colon, rectum and anus are supplied with nerves from the second lumbar to the fourth sacral. By stimulating these nerve centers, the peristalsis is increased, and the internal sphincter rendered patulous.

In conclusion, I would say that it is necessary to correct any errors in diet, to drink large quantities of water between meals, and at bedtime, and especially to refrain from taking any laxitive or cathartic medicine, as we wish to depend upon the physiological action of mechanical vibratory stimulation.

The technique is as follows:-First the patient lies upon the back with the knees well drawn up, thus relaxing the abdominal muscles. The breathing should be slow and deep. I employ the rubber brush attachment, making medium hard pressure. Begin at the ilio-cecal junction, and pass the brush slowly along the ascending, transverse and descending colon. Repeat this procedure four or five times. Lightly stimulate the vagi at the sides of the neck. Then have the patient turn over on the face, extending the arms upward and around the end of the table, thus

clevating the ribs. We now use the hard rubber ball attachment, medium stroke and pressure, from the fourth to the twelfth dorsal nerve. The impulse reaches the sympathetic through the posterior primary divisions. of the spinal nerves and then along the rami-communicantes. The whole intestinal tract with the exception of the rectum will be influenced by this treatment. Stimulation of the rectum is made with the hard rubber ball attachment, quite heavy pressure and medium stroke, over the 3d, 4th and 5th lumbar, and 2d, 3d and 4th sacral nerves.

Treatments should be given daily until bowels move regularly, then every third day for two or three weeks. As we continue to use mechanical vibratory stimulation, and learn how and when to employ it, I feel confident that as proctologists we will consider it one of our most useful means in relieving and curing our patients.

917 Genesee Ave.

DR. METCALF'S CLINIC.

At Harper Hospital, December, 7th, 8th and 9th, 1904.
REPORT OF CASES-CONTINUED

Case VI. Appendicitis, in which the appendix drained its contents through its distal extremity into the colon. (Dec. 7th.)

Miss H., aet. 11. Family history negative. She has had three attacks of appendicitis. The first attack a year ago last summer, the second last August, and the present one about a month ago. In each attack the symptoms were classic; vomiting and severe pain in epigastrium soon becoming general over the whole abdomen, subsequently localizing itself in region of appendix. The last attack culminated in what appeared to be general peritonitis, which subsided, leaving an area of dullness about McBurney's point. A few days later a large quantity of pus was discharged per rectum. She still has pain and tenderness in the lower right abdominal quadrant, low nutrition, and extreme nervousness. Temperature normal, pulse 120. Operation, 1:15 to 1:45 p. m. Oblique incision through skin and fascia over McBurney's point, muscle fibres separated, and peritoneum incised. Omental adhesions were separated and appendix found pointing upward outside of colon, its distal point adherent to colon and perforated, as was also the colon wall at the same point. This condition accounted for the previous discharge from the rectum. The meso-appendix was clamped with forceps, the appendix was removed, and the stump inverted by a purse-string suture, which passed under the appendiceal artery, thus preventing subsequent bleeding into colon. The mesentery was ligated. The perforation in the colon was closed by continuous Lembert suture and the denuded surfaces covered by peritoneum. Highest temperature after operation, 99.8; highest pulse-rate, 96. She sat up on Dec. 16th, and left the hospital on the 18th, the eleventh day after operation. She made a rapid and complete recovery. The appendix was found, on microscopical examination, to contain a large supply of lymph-glands, a small-cell infiltration of moderate degree in the muscular wall, but more pronounced in the loose tissues of the mesoappendix. There was marked increase in thickness of the adventitia in its blood vessels.

When a competent surgeon is available, in all cases of appendicitis, before the beginning of peritonitis, the appendix should be removed. In the majority of cases when general peritonitis has developed, the surgeon should wait for its subsidence and a localization of the infection before resorting to operation. In the meantime no food should be given by the mouth and the vomiting should be controlled by irrigation of the stomach. Physic should not be given in such cases.

Case VII. Dermoid cyst, symptomatically resembling ectopic gestation. (Dec. 7th.)

Marked tenderThe uterus was The pains pro

Mrs. K., aet. 23. Wife of a Polish laboring man. Family history negative; menstruated normally at 14; married at 21. Has had 2 children, one still-born, and the other died when one month old. Had always been well except for nervous spells. Four weeks previous to entering hospital she had been seized with severe cramps in left inguinal region, with great distress in pelvis and lower abdomen. Entered Harper Hospital Dec. 2nd, with temperature 100.8 and pulse 120. Delirium was such that she required constantant watching. ness and tension of muscles were noted over entire abdomen. fixed, with a large mass apparently in the left broad ligament. duced by the administration of cathartics or enemata suggested partial intestinal obstruction. Blood examination revealed a moderate leucocytosis and a slight reduction in hemoglobin. Operation, 1.45 to 3:30 p. m., disclosed the pelvic contents matted together, with small pus-pockets throughout. Intestines and omentum were extensively adherent to pelvic mass. The uterus was large and boggy; the tubes were filled with pus; the right ovary was the size of a small egg and contained several numerous infected cysts. There was a suppurating dermoid cyst of the left ovary, containing hair and other debris. The adhesions were freed and the intestine repaired where injured. The uterus and adnexae were removed. To assist drainage and to lessen subsequent formation of adhesions, the pelvic cavity was loosely packed with iodoform gauze, one end being pushed down into the vagina. The abdominal incision was then closed. Two days after the operation, the pulse reached 140, and the temperature 103. The gauze was removed through the vagina on the fourth day. The improvement was then gradual and she became rational, the temperature falling to normal on Dec. 14th, with a pulse of 100. Pathological report: Uterus. Relative increase of interstitial cells in mucosa. Fallopian tubes: Purulent salpingitis. Epithelial lining in a state of disintegration, especially in the right tube. Folds greatly congested. Muscular wall infiltrated with leucocytes. Right ovary. Hyaline degeneration. Graaffian follicle cysts. Corpus luteum. Thickening of arterial walls. Thick layer of loose connective tissue surrounding the ovary and containing fluid and leucocytes. On Dec. 17th, she began to cough; an area of consolidation appeared in the middle lobe of the right lung anteriorly; her temperature rose to 100. the pulse to 108, and the leucocytes to 18,000, with 82 per cent polymorphonuclear. Subsequently the temperature ran from 99 to 102, with pulse 100 to 110. The area of dullness increased and a few days later there was a large accumulation of fluid in the right pleural cavity. The husband would not permit aspiration, although he was told that the cavity was filling with pus, and no argument could overcome his fears and prejudices. January 8th, on his own responsibility, the man removed his wife from the hospital. At this time the patient had a temperature of 101.8 and pulse of 100. She died at her home Jan. 20th, refusing surgical aid. Throughout the case the husband blindly opposed our efforts to do for his wife. Early drainage of the pleural cavity would likely have saved her life. No autopsy was permitted.

Case VIII. Complete inversion of the uterus. (Operation, Nov. II, 1904; exhibition of patient and specimen in clinic, Dec. 7th.)

Mrs. S., aet. 47. Family history negative. Menses at 14; regular and normal. Married at 18. Has 11 children. One miscarriage at 4 months, 10 years ago, following which her flow was excessive. Seven years ago a hard tumor was removed through the vagina; recovery was slow. Her menstruation then became irregular for about four years, when excessive irregular flowing returned. Aching in back and lower abdomen became more and more troublesome. During the last 3 years there has been a constant profuse discharge from the vagina. Four weeks ago she suffered severe strain from lifting. Profuse flowing at once began, with frequent desire to urinate. The vagina was found to be filled with a large oval mass, with apparently no pedicle. A diagnosis of inversion of the uterus was made, because a depression could be felt where the uterine body should be. Blood examination: Hemoglobin, 50 per cent. The red cells show deformity and variation in size. Leucocytes not increased in number, but the polymorphonuclear cells are relatively increased. The laboratory diagnosis was given as a secondary anaemia, with a polymorphonuclear leucocytosis. (The absence of leucocytosis in the presence of infection, with only a relative increase of polymorphonuclears points to a lowering of the patient's resistance.) Operation, Nov. 11th, the tumor mass was removed per vaginam, together with the uterus and its appendages. The specimen shows the in-drawing of the ovaries and tubes, a useful point in

diagnosis. (Photograph I.) Her temperature preceding operation was 103, pulse 110. Within a week her pulse and temperature became normal and remained so. Left the hospital Dec. 7th and on June 2nd she is reported to be well.

I have shown this specimen because complete inversion of the uterus caused by extrusion of a submucous fibroid is not common. More

T-Tumor

J-Junction of tumor and body of uterus

M-Muscularis

C-Cervix

O-Ovary

F. T.-Fallopian tube
C. C. Cervical canal

rarely, however, does it occur following delivery at term. In the Rotunda Hospital, Dublin, only one case of complete inversion was observed in 190,800 deliveries, and at the Vienna Lying-in Hospital only one in 250,000.

Cases like the one here shown must be rare, but it is interesting to observe that in case X. of this clinical series we have the beginnings of a condition perhaps identical.

Case IX. Chronic metritis, subinvolution and double pyosalpinx, after streptococcic puerperal infection. Abdominal hysterectomy. (Dec. 8th, 9 to 10 A. M.)

Mrs. M., aet 34. Father died at 45 of bronchitis. Mother died at 42 of tuberculosis. One brother died of typhoid. Has one brother and one sister in good health. Menses began at 12; duration 5 days; severe pain during first day. Has one child 16 months old. Miscarriage Oct. 10, 1904, followed by sepsis. Entered Harper Hospital four days later with a temperature of 105.2 and pulse of 120. I then disinfected uterine cavity and drained through Douglas' cul-de-sac an abscess in right broad ligament. The cul-de-sac was found to be filled with a brownish fluid, the growth from which, after inoculation of sterile media, showed pure cultures of streptococci. The patient made a fairly satisfactory recovery, except that local symptoms remained and headaches were troublesome.

Here was a case where the vital forces were not building a limiting wall either in the endometrium or in the pelvis outside the uterus. The incision through the vaginal vault, which was carried freely from one uterine artery to the other, opened the lymphatic channels about the infected uterus and favored the direct disposal of the toxins being generated. At the same time the contact of the gauze left in the pelvis may be supposed to attract leucocytes to the locality and to favor thus the formation of a protecting wall.

Having been advised to return for examination, the patient presents herself in a condition of imperfect recovery. Exploratory abdominal section is made (Dec. 8th), and the uterus is found one-half larger than normal, with a consistency such that the tenaculum-forceps cut through the tissue and are useless in the operation. Both ovaries are found enlarged and cystic. These conditions, considered in the light of the patient's social necessities, as stated below, made abdominal hysterectomy the only reasonable course. Accordingly this was done; the highest subsequent temperature, except for a few hours on the 9th day, was 100. The pulse remained normal throughout. The gauze drainage was removed from the vagina on Dec. 10th and a lysol douche was given twice a day after the 11th. She left the hospital on the 14th day after operation. Pathological report: Both Fallopian tubes, were filled with pus, which was in part made up of the debris of their epithelial lining. Their plicae were densely nfiltrated and adherent, while the low-staining character of their epithelial covering marked the beginning of necrosis. Muscular walls of the tubes were, in section, studded with patches of leucocytes. The uterus was the seat of marked increase in blood-supply. Lymph-spaces were distended. Mucosa of corpus uteri showed some increase of interstitial cells, but this was much less pronounced than the glandular hyperplasia. The ovaries contained many follicular cysts and areas of hyaline degeneration as well as relative increase of connective tissue.

The pockets formed by the increase of uterine glands serve as incubators for bacteria and the inflammation induced naturally becomes chronic. This uterus in its condition of subinvolution, complicated by the local hypertrophy and infection, together with the tubal conditions, has caused the patient continual suffering. Later the fibrous tissue resulting from the continued irritation might be expected to contract and leave a small hard organ, with another train of reflex symptoms. The