should be used and introduced without speculum. The introduction of the needle may be much facilitated by making it the negative pole of a mild galvanic current. The puncture is made on the point where the uterus bulges most into the vagina. The needle is not pushed deeper in than a quarter to half an inch. It is either used to form a communication with the cervical canal, so that, the artificial canal once made, the usual galvo-cauterization may be performed on the uterine mucous membrane, or goes simply into the tissue of the uterus and perhaps a tumor situated in its wall. Hemorrhage may be stopped by interpolar action alone, without cauterization of the mucous membrane of the uterus.

Galvano-puncture is a more serious interference than galvano-cauterization of the inside of the uterus, and should not be repeated oftener than every eight or fifteen days. It has to be repeated several times before the canal remains open. It may be combined with positive or negative cauterization according to indications.

Galvanism combined with Aspiration, Injection, and Drainage.For the treatment of pelvic abscesses, accumulation of fluid in the Fallopian tubes, or other cystic tumors, instruments have been devised which consist of a trocar and canula. The cyst is punctured, evacuated, and washed out with antiseptic fluids. The canula is used as galvano-cautery, and may be left in situ as a drainage-tube.' This procedure, rational and ingenious as it is, presents the danger of puncturing a loop of intestine, but may occasionally be available.

Thermal Galvano-cauterization. The thermal galvano-cauterization differs from the chemical by using heat as the therapeutic agent. is produced by another kind of battery especially constructed for the purpose. The principle is to produce a large quantity of electricity, which, being led through a comparatively thin platinum wire, that offers great resistance, heats the wire to incandescence. Two sizes of wire are used-a thin and a thick. The former forms a loop that can be drawn round and through a cylindrical body-e. g. the cervix uteri. The latter is shaped into knives and domes for cutting and burning.2 By means of these galvano-cauteries diseased parts may be excised without loss of blood; but in order to obtain this the knife or wire must never be brought to a white heat, and they should be carried slowly and interruptedly through the part to be severed. The knife should be applied cold, in order not to wound the vagina while introducing it. If the wire loop cannot easily be applied, a furrow may first be made for it with the cautery knife. When the wire has

E. C. Gehrung of St. Louis, Amer. Jour. Obst., August, 1888; A. H. Goelet, Med. News, Jan. 25, 1890.

The best instrument of this class is that of John Byrne of Brooklyn, N. Y., who also has constructed a special speculum for galvano-caustic operations (Clinical Notes on the Electric Cautery in Uterine Surgery, New York, 1873, and Trans. Amer. Gyn. Soc., 1892, vol. xvii. pp. 42-46).

entered the submucous tissue, traction may be made with a volsella on the mass to be removed, so as to give to the cut surface the shape of a hollow cone.

Thermal galvano-cauterization does not only present the advantage over other cauteries (p. 177) that it can be applied with a flexible loop, but it has less radiating heat, and is, therefore, less liable to scorch the surrounding parts; it seems to possess a power of modifying the tissue, even at some distance from the cut surface, by diffusion of the electricity; and it has a powerful antiseptic effect, which appears clinically in the remarkable immunity from peritonitis, cellulitis, and septicemia which distinguishes it from other surgical procedures, and has been proved experimentally by direct application to germ-cultures.

Where there are large masses of diseased tissue in the interior of the womb, it is often preferable first to remove some of them with the curette before using the galvano-cautery. But then bleeding must first be stanched by irrigation with creolin, sponging, and the application of the cautery to open vessels. After that every part of the cavity is gone over repeatedly with the dome-shaped galvano-cautery, and each time that blood oozes from the searing tissues the cavity is to be sponged, until finally it is charred all over. The ragged borders of the excavation should next receive attention, and no raw spot should be permitted to escape the cautery. Finally, the cavity and the vagina are tamponed with iodoform gauze (pp. 174–175).

PART VII.

ABNORMAL MENSTRUATION AND METRORRHAGIA.

THE normal process of menstruation has been considered in the chapter on Physiology (pp. 114-119). This process is subject to disturbances which may occur in very different gynecological diseases or without any affection of the genitals. It may be absent (amenorrhea) or scanty; the bleeding may take place from another part (vicarious menstruation); it may be painful (dysmenorrhea); it may begin too early in life (precocious menstruation); or it may be profuse (menorrhagia).

Finally, there may be hemorrhage from the uterus at other times than the menstrual period (metrorrhagia).

CHAPTER I.

AMENORRHEA.

AMENORRHEA is the absence of the menstrual flow. This may either be so that the flow had begun and suddenly stopped, which is called suppression of menses, or so that it does not come on at all— amenorrhea proper.

1. Suppression of Menses. Etiology.-The suppression of menses may be due to exposure during menstruation, by which the feet or the skin becomes wet and cold (compare p. 127); to emotions, especially a fright; or to the appearance of an acute inflammation, such as pneumonia or erysipelas.

Symptoms.-The symptoms are sometimes slight or none, and the courses reappear at the next period; but sometimes the sudden suppression of the menstrual flow gives rise to acute congestion or inflammation of the womb or the appendages, to extravasation of blood into the peritoneal cavity or the pelvic connective tissue, and the amenorrhea may last long or be final.

Treatment. It is proper to try to bring the flow back by hot applications to the abdomen, hot hip-baths, hot vaginal and rectal injec

tions; but, as a rule, this medication succeeds only in so. far as it relieves pain. The same is accomplished by opiates.

2. Amenorrhea, in the proper sense of the word, is the condition in which the menstrual flow fails to appear, although the patient has reached the proper age and feels as if she would be relieved by its coming, or where it does not reappear at the usual period in persons who have already menstruated.

Etiology. We have seen above that menstruation, as a rule, is absent during pregnancy and lactation. In persons who have never menstruated the cause may be congenital faulty development: absence of the ovaries and tubes; absence or imperfect development of the uterus, such as a rudimentary or infantile uterus; absence or atresia of the vagina. Often, especially in young servants, the cause is overwork, sometimes combined with insufficient food. The causes may also be the same that are at work in making menstruation stop in those who have already menstruated. A common cause is a change of climate and habits. Thus amenorrhea is often found in women who move from the country to large cities, and in those who have recently immigrated from Europe. It is often a sequel of debilitating diseases, such as anemia, phthisis, malaria, typhoid fever, diabetes, or chronic mercurial poisoning. It is not rare in insane women and morphiomaniacs. It is sometimes found in the late stage of chronic metritis, in inflammation of the uterine appendages, in cases of malignant disease of both ovaries, or in women afflicted with a vesico-vaginal fistula. It is a frequent accompaniment of the development of obesity.

About the effect of the removal of the uterine appendages see p. 118. Symptoms.-The symptoms of amenorrhea, besides the absence of the flow, may be insignificant, but it is quite common that the patient complains of headache, flashing heat, heaviness in the abdomen, nervousness, nausea or vomiting, and sometimes she may even suffer from convulsions of the hysterical or epileptic type. If the lack of flow is due to atresia of the genital canal, the fluid accumulates behind the partition, considerable pain is experienced at each recurrence of the menstrual period, and a tumor is felt in the pelvis corresponding to the distended vagina, uterus, or both. The abnormal sensations occurring at the time of the menstrual period are called the menstrual molimen.

Diagnosis. The most important diagnostic question is if the amenorrhea might not be physiological and due to pregnancy, normal or ectopic―i. e. extra-uterine. In this respect every sign of pregnancy as taught in the books on obstetrics must be thought of, especially the early ones, such as the softening of the lower uterine segment, the increased diameter of the uterus in the antero-posterior direction, morning sickness, and small tongues of brown pigmentation shooting

out from the superior external circumference of the areola, the first beginning of what is known as the secondary areola.

In extra-uterine pregnancy we may, besides the signs of pregnancy, find a tumor outside of the uterus corresponding in size to the duration of the amenorrhea.

Treatment-Idiopathic amenorrhea should not be regarded or treated as a disease. In the beginning of menstrual life it is quite common that a period or two are skipped. If the girl is otherwise well no treatment is called for. If the cause of the amenorrhea is anemia, be it from loss of blood, from defective assimilation, or from wasting diseases, the only aim should be to ameliorate the general condition by proper alimentation, tonics (p. 217), moderate exercise in the open air, horseback riding, mild gymnastics, or massage. Aperients have some influence in bringing on the flow, and the one most credited with emmenagogue power is aloes. In malaria quinine and arsenic are the chief remedies. If the nervous system is upset, bromides, antipyrin, or phenacetin is very useful. vaginal and rectal injections, warm hip-baths, warm foot-baths with or without mustard, and long, warm general baths will sometimes bring back the courses. The mere introduction of the sound works as a stimulus to the uterus, and may have the same effect. Electricity in all its forms (p. 220) is a powerful remedy, especially bipolar intra-uterine faradization, with secondary current, and, best of all, galvanism, with the negative pole in the uterus.

Hot

Besides iron, quinine, strychnine, and aloes, the following drugs have more or less well-founded reputation as emmenagogues: Manganese in the form of the permanganate of potassium or the binoxide (gr. ij to iv, t. i. d.); chlorate of potassium (gr. v to xx, t. i. d.) in combination with iron; santonin (gr. ij or iij, t. i. d.); oleum sabinæ (Miij to vj, t. i. d.); oleum rutæ (miij to vj, t. i. d.); oleum tanaceti (miij to vj, t. i. d.); oleum hedeomæ (mij to x, t. i. d.) or a warm infusion made of the herb; ergot (p. 219); radix gossypii (p. 219); tinct. cantharidis (mx, xx, up to f5j, t. i. d.); tinet. hellebori nigri (mxx to xl, t. i. d.); and many others. As their effect is very uncertain, it is wise to combine several in one prescription—e. g.:

R. Strychnine sulph.,
Aloes Socotr.,

Quin. sulph.,

Ferri sulph. exsiccat.,

Ol. sabinæ,

Extr. gentian. co.,

Ft. pill. No. lx.

Sig. Three pills three times a day.

It is also well to use them in connection with the other remedial

agents recommended.