the uterine septum, or the termination may be the same as in uncomplicated hematometra. The discomfort begins with the occurrence of menstruation, gradually increasing; sometimes disturbances do not appear until long after the onset of the menstrual flow, and the distress may be severe even when there is amennorrhoea of the permeable side (Freund, Freudenberg). The diagnosis is not very difficult; the tumor is closely adherent to the uterus, is firm, elastic, or fluctuating. The os uteri is at the side of the tumor projecting into the vaginal vault, or may be crescent-shaped, the concavity toward the tumor. The diagnosis of hematometra of a rudimentary horn may be made by exclusion, by demonstrating the presence of a firm, elastic tumor with a one-horned uterus, by the connection of the tumor with the horn by means of a cord or band, and by its growth, and the greater discomfort during menstruation; this probable diagnosis may then be confirmed by puncture.

The

Treatment.-1. Stenosis of the external os uteri. narrowed os should be dilated by means of the sound, dilators, knife, scissors or metrotome, or by a special operation. I have had very unsatisfactory results from dilatation by the sound, Ellinger's dilators, and laminaria or sponge tents; as a rule, the stenosis returned in a short time, and the dilatation had no favorable effect upon the dysmenorrhoea though continued for months, at intervals of eight to fourteen days. I have had no experience with the more powerful dilators of Fritsch and B. S. Schultze.

No special knife is required for operative enlargement of the external os; those introduced by Simpson, Ed. Martin, Greenhalgh, Matthieu and Coghill, having the one great disadvantage that the pressure cannot be controlled and modified to suit the individual case; they are also liable to slip or to injure the adjoining tissues. The knife should not be used for stenosis of the internal os, because the depth and extent of the incision cannot be regulated, nor can one ascertain exactly where he is making it. The stenosed portion is usually missed, and injury has been done to the wall of the bladder and even to the ureter from this method of operating, so that it should be discarded. There is no way of permanently preventing reunion; the conditions here are similar to those in dilatation of the external os; when the

dilatation has been discontinued, the stenosed condition speedily

returns.

When stenosis of the external os is associated with the presence of glandular cysts, these may be punctured and evacuated through the speculum, the os subsequently incised in four directions, and the small flaps removed by the scissors with but little loss of blood; next the catarrhal cervical mucous membrane should be thoroughly cauterized, and a small cotton tampon pressed firmly into the cervix.

When the vaginal portion is elongated and resembles a proboscis, it should be constricted by an elastic ligature, the latter fixed by a Carlsbad needle, and the part of the portion below the ligature amputated by the knife. The surface of the wound should be partially or wholly covered by uniting the cervical and vaginal mucous membrane by Lister's catgut. The patient will be confined to her bed for from twelve to fourteen days.

Amputation by the galvano-cautery is less successful, for the os is liable to remain too narrow, and even atresia subsequently

occur.

I

When the lips are thick and hypertrophied, the wedge-shaped excision described in a foregoing chapter, is to be recommended. Kehrer makes a stellate incision with six or eight radiations. have performed a very satisfactory operation during the past ten years in the following manner: A transverse incision into the uterine walls is inade on either side, beginning at the cervix and extending to near the vaginal vault. A small wedge is then excised from the wound made by these incisions, and then the edges of the wound in each lip, right and left, united by fine sutures of catgut or silkworm gut.

2. In atresia of the uterus, the treatment will be governed by the degree of distension and the general symptoms. The distension, either from hydrometra or hematometra, being slight, the introduction of a trocar and evacuation of the contents will suffice. When the distension is great and there is constitutional disturbance, such as fever, rigor or evidences of peritonitis, we should adopt the treatment suggested for hematocolpos on pages

115 to 118.

Most authors agree that free evacuation of the retained blood

or pus must be made, since the danger of septicemia is much greater when the incision is small and putrefaction of the contents may occur. After making a free incision, Emmet advised irrigating the uterine cavity with an antiseptic fluid.* He treated successfully twenty-two patients in this way, but Galabin, who has probably had more experience with these diseases than any other gynecologist, opposes this method. The treatment recommended by Breisky is described on page 117.

CHAPTER VI.

THE ANOMALIES OF MENSTRUATION.

THE ANATOMY AND PHYSIOLOGY OF MENSTRUATION.

THE terms menstruation, catamenia, menses, periods, and "regel" signify a periodically recurring discharge of blood from the genital tract of adolescent girls and women, chiefly depending upon a peculiar action of the ovaries which we term ovulation. The close connection of these two processes is proved by the fact that castration of the female is, in the great majority of cases, followed by permanent cessation of the menstrual flow. The view hitherto accepted with regard to menstruation is as follows: From the twelfth to the thirteenth year the ovaries are more vascular, and the Graafian follicles gradually ripen, one or more slowly growing toward the surface of the ovary, the tension thus produced causing an irritation which leads to congestion of the whole genital apparatus. With this congestion there is an increase in the quantity of fluid in the Graafian follicles, one of the latter finally rupturing at the thinnest non-vascular portion of its wall, and evacuating its contents, including the ovule, into the abdominal cavity. The latter is now carried into the hyperemic Fallopian tube and thence into the uterus by the action of the ciliated epithelium of the tube and its fimbriæ. In the mean

* Principles and Practice of Gynecology, 1881.

time the tissue of the uterus has become relaxed, its mucous membrane thicker and darker, and a moderate quantity of blood appears upon its surface, apparently without lesion of its vessels, by diapedesis. Ruge and Moericke, however, have recently found intact ciliated epithelium upon the mucous membrane of the menstruating uterus, an observation which we have repeatedly confirmed, and this proves the falsity of the former views, that menstruation was caused by a fatty degeneration of the superficial layers of the membrane (Kundrat and Williams), that these degenerated portions were exfoliated and regenerated; and, furthermore, that even without the fatty degeneration from hemorrhagic extravasations, this blood may exude from the surface, the exfoliation occurring later (Leopold).

Different views are entertained concerning the connection between ovulation and menstruation with regard to time. According to Leopold's investigation, it is very probable that ovulation may occur between two menstrual periods, and it may be accepted as the general rule, that the rupture of the follicle and the liberation of the ovule usually occur at the time when the distension of the follicle is greatest from the new congestion, i. e., just before the discharge of blood from the uterus. If conception does not occur, menstruation now proceeds in the usual manner. If the ovule be impregnated before the hemorrhage takes place, the latter is either entirely checked or is less and continues for a shorter time than usual. If impregnation occurs during the menstrual flow, the menstrual decidua becomes the decidua graviditatis, or, if the ovule is not impregnated until after the flow has ceased, the next menstruation does not appear.

Loewenthal has recently proposed an hypothesis which is not in harmony with the above.* According to this hypothesis, the ovule first reaches the uterus unimpregnated; its presence causes an irritation leading to the formation of the menstrual decidua, which is transformed into the decidua of pregnancy if the ovule be impregnated. If not impregnated, the ovule dies, and its death (!) causes an active congestion, as well as the degeneration of the menstrual decidua and the menstrual hemorrhage. The

* Archiv f. Gynäkol., xxiv., p. 2.

congestion produced in this way favors the ripening of younger Graafian follicles in the ovary, and so the circle is completed. This daring hypothesis has its weak point-its Achilles' heel, and this is certainly found in the assertion that the death of the ovule must cause the congestion.

It is beyond cavil that, while the ovule perishes unimpregnated, there is a return of the uterine mucous membrane to the normal condition during and subsequent to the discharge of blood, and also, that ovulation may occur independently of this discharge of blood. The proofs are, first, that conception is not infrequent before the appearance of the menstrual flow; second, s woman may conceive while nursing, and before the menstrual flow has reappeared subsequent to the last confinement; third, that ruptured follicles from which the ovule has just been expelled, have been found in the non-menstruating female in cases of sudden death; and, fourth, that there are women who, having once menstruated, may conceive during a period of amenorrhoea (Petit). Finally, conception has occurred subsequent to the menopause, in which case ovulation must have outlasted menstruation.

In connection with the changes just described, transpiring in the ovaries, tubes and the uterus, there is present hyperemia of the vulva, vagina and mammary glands. There is also an increased genital secretion, and the breasts may be so considerably enlarged at the first menstruation that numerous striæ appear upon their surface.

Symptoms, Course and Duration.-When a perfectly healthy girl menstruates for the first time there are no premonitions, and she is usually surprised by a discharge of blood from the genitals. In our climate this occurs at the average age of 16 years, very rarely before the thirteenth, and not often later than the eighteenth year. It occurs earlier in girls who live in cities, and in strong, vigorous persons. In tropical climates it may appear as soon as the twelfth or even the eighth year.

The duration of the flow is from three to six days, but the va riations in the same female are great, and often without apparent cause. It may last but one or two days, and at the next period be profuse and continue from six to eight. The quantity of the discharge is with difficulty determined; one is forced to make a