formly successful. Dr. Sims does not now use chloroform in this operation, but I have been obliged to resort to it in most of my cases. When a patient can be induced to do without it, we will get along better than if she is anæsthetized.

Recto-Vaginal Fistula.-This accident does not so frequently as vesico-vaginal fistula result from puerperal vaginitis. Stricture of the rectum, abscess of the recto-vaginal septum, rupturing into both cavities, and accidents with instruments, as often cause it, perhaps. It is not so common or frequent as vesico-vaginal fistula, nor so distressing. The passage of the faces, if proper cleanliness is observed, although disgusting, is not so productive of inflammation and excoriation as urine, and their discharge may be controlled by appropriate fixtures. A cure is also more easily accomplished; indeed, it is often spontaneous. As the contents of the bowels pass intermittingly, and, when in contact with the raw surface, do not irritate it considerably, the ulcer has time to contract, and healthy granulations, in a good state of the general health, is the result.

The symptoms and diagnosis of this fistula are so obvious, that I need not dwell upon them; but we sometimes meet with cases where the opening is so small and tortuous, that great patience in the use of the probe will be required to satisfy ourselves as to its position and direction. The injection of water into the rectum while the parts are under inspection will generally clear up all doubts.

Treatment. If we are associated with these cases during the ulcerative condition, we may conduct them to a cure with great certainty, and, perhaps, more readily than after the edges of the opening have cicatrized. The important items of treatment at such times are, 1st. Proper attention to the bowels; 2d. Great cleanliness; and, 3d. Maintenance of healthy granulations until the contraction obliterates the opening. The bowels should be kept quiet as much of the time as possible. To accomplish this, the diet should be concentrated and nourishing in character; beef essence, milk, eggs, crackers, coffee or tea, and, if necessary on account of debility, wine, or medicinal tonics; and if the bowels have a tendency to move, opium in such quantities as will restrain them. Every four or five days a gentle alterative, say three grains of massa hyd., followed by a saline cathartic; after the bowels

have moved from this, the opium may be given to restrain them for four or five days again, and so on until the opening is closed. During this treatment, there should be frequent injections in the vagina of water. The part should be examined with the speculum every day, to see that the edges remain raw. When there is any tendency to cicatrize, the edges may be freely touched with pure nitric acid. If the cure is protracted, the acid should give place to the actual cautery. Toward the last, as the opening becomes small, especially if it is tortuous, a piece of twine, or what is, perhaps, better, a silver or iron wire, may be passed through it, and the ends brought out through the anus and vagina. If the case is chronic, and the opening small, the application of the acid may be made every day until the edges are denuded, and then the same course followed as above directed. Of course, these applications must be made through the vagina with a speculum that completely exposes the part touched. If the place is large and chronic, we will very much shorten the process of cure by an operation similar to that for vesico-vaginal fistula. After having thoroughly evacuated the bowels, the patient may be placed in the lithotomy position, and exposing the parts to a strong light, the perineum may be retracted by the rectangular speculum blade of Sims, while the vulva are held open by assistants. The edges are then to be pared thoroughly, and the aperture closed with silver sutures. The bowels will require the use of from two to four grains of opium daily to keep them quiet. They should not be allowed to move for ten days, when a saline cathartic should be given, and after it has operated well, the stitches removed. During the time between the operation and the removal of the stitches, the patient is to remain quiet in bed, and have injections, per vaginam, of tepid water with soap, twice a day. If by this operation there is imperfect closure of any part, the treatment recommended for recent cases will suffice to complete the cure. Even these larger sized fistulæ are sometimes cured by the caustic acids, the actual cautery, or tinct. litta; but it takes a longer time, and is attended with more pain and annoyance. The operations on these fistula will be greatly facilitated by having the breech of the patient projecting somewhat over the end of the table.

CHAPTER IV.

MENSTRUATION AND ITS DISORDERS.

MENSTRUATION AND ITS DISORDERS-GENERAL REMARKS IN REFERENCE TO THE FUNCTION-DIVISION OF THE SUBJECT-AMENORRHOEA-PATHOLOGICAL STATES, OR CAUSING CONDITIONS OF AMENORRHOEA-ABSENCE OF THE OVARIA OR UTERUS-CONGENITAL OR ACQUIRED ATROPHY OF THESE ORGANS DISEASES OF THE OVARIA AND UTERUS, ACUTE AND CHRONICGENERAL CONDITIONS, AS ANEMIA, CACHEXIA (TUBERCULOSIS OR SCROFULA, ETC.)-LOCAL SYMPTOMS-GENERAL SYMPTOMS-CHRONIC AMENOR

RHOEA-RETENTION OF THE MENSES CAUSED BY OCCLUSION OF SOME PART OF THE GENITAL CANAL-OCCLUSION OF THE OS AND CERVIX UTERI, VAGINA, OR VULVA, FROM ADHESION OR HYMEN-SYMPTOMS OF RETENTION -DIAGNOSIS-CASES OF ABSENCE OF THE UTERUS-MODE OF DIAGNOSTICATING THE ABSENCE OF THE UTERUS-DIAGNOSIS OF ATROPHY OF THE UTERUS-PROGNOSIS-DEPENDS UPON THE CAUSING CONDITIONS-TREATMENT OBJECTS ARE TO REMOVE CAUSING CONDITIONS-OF ACUTE AMENORRHOEA: REMOVE THE INFLAMMATION-CHRONIC AMENORRHOEATREATMENT OF-FROM CHRONIC INFLAMMATION-FROM ANEMIA-FROM DEFICIENCY OF GENITAL ORGANS-FROM OBSTRUCTIONS TO THE FLOW.

SEVERAL Conditions are necessary to the healthy performance of the functions of menstruation.

1st. The ovaria must be present, and sufficiently healthy to produce ova.

2dly. The uterus must be sufficiently perfect, anatomically and physiologically, to be the medium of this elimination.

3dly. A certain, but not as yet very well-defined, state of the blood and nervous system.

I do not think that these are all the conditions necessary to perfect menstruation; but they are the obvious and undoubted

ones.

The physiological chain of circumstances that give rise to menstruation may be given thus: the organs concerned being fully developed, the blood and nervous system matured to a certain degree, an ovum is produced, and during the time it is being matured and cast off from the ovary, all the organs of generation are

intensely congested by the increased energy of the capillary circulation; the congestion and stress of blood upon the delicate capillaries of the mucous membrane of the uterus become so great, that the walls of some of these vessels are ruptured, and an effusion of blood takes place in the cavity of the uterus, which, finding its way out of the vagina, is called menstruation. If ovulation does not take place, the congestion does not occur, and in the absence of the congestion there is no effusion. All these processes which accompany menstruation should be painless, and only of a certain grade of activity to be healthy. When absent, deficient, painful, or in excess, the function is deranged.

This very brief summary of the general physiological principles of healthy menstruation, will do for a starting-point, in the consideration of the disorders of them. And as I proceed, I shall have occasion to mention pathological states, which are superadded to a deviation from the above conditions, as also some that induce derangements of menstruation, notwithstanding the presence of them in a healthy degree.

I shall consider the disorders of menstruation under five different divisions:

1st. Amenorrhoea.

2dly. Menorrhagia.

3dly. Dysmenorrhoea.

4thly. Misplaced menstruation (Metatithmenia).

5thly. Vicarious menstruation.

Under these five heads may be included all the deviations met with in ordinary practice. It is usual with authors to make only three distinct divisions, not treating the last two as worthy of separate mention. My fourth division is spoken of by those who have described it as uterine hæmatocele, hæmatoma, &c.; but I shall give what I consider good reasons for classing it under the general head of menstrual disorders.

Amenorrhoea.-Amenorrhoea simply means the absence of menstruation, and may appear under several different circumstances.

1st. Menstruation may never make its appearance in the individual. 2dly. After having occurred it may cease, or, as the term is, be "suppressed;" and this suppression again may be suddenly brought about, and attended with acute symptoms, and hence properly denominated acute suppression; or it may not be attended

with acute symptoms, and last long enough to be called chronic. 3dly. I should think it right to consider deficient menstruation as suppression, although but partial. This partial suppression assumes two forms, viz., infrequency, when the intervals are uncommonly long; and scantiness, the return being regular, but the quantity of the discharge much less than it should be. Or there may be both scantiness and infrequency. 4thly. The menses may be retained in the cavities of the uterus or vagina, or both, after having been effused. This retention is very different in many respects from the suppression; giving rise to quite a different set of symptoms, and requiring a separate sort of treatment, agreeing with it only in the non-appearance of the blood externally.

The pathological states upon which the symptom amenorrhoea is based are very numerous, and sometimes inscrutable. The more obvious are the following: congenital absence of the uterus or ovaria, or both; congenital non-development, or acquired atrophy of these organs; diseases of the uterus and ovaria, acute or chronic. These are the ordinary local causing conditions. The general are, anemia, cachexia (as tuberculous, scrofulous, etc.), pregnancy, and nursing. Serious diseases of any of the vital organs may, under certain circumstances, give rise to amenorrhoea.

The local symptoms which attend the absence of the menses will differ according to the conditions which give rise to it. In acute amenorrhoea, we shall have signs of great congestion, or inflammation of the uterus. The patient, after commencing to menstruate, being subjected to the causes necessary to suppression, such as the partial or general application of cold, is seized with pain in the back, hypogastric region, and hips, attended with a sense of chilliness more or less intense. These symptoms are usually succeeded by febrile reaction, headache, pain in the limbs, general languor, white tongue, and a persistent pain of varied severity in the region of the uterus. There is, in this state of things, as there seems to be, inflammation of the uterus. The symptoms may subside, and generally do in a very few days, leaving more or less local discomfort in the pelvis and neighborhood. At the next menstrual period, if the uterus is not much inflamed, and the system not greatly deranged, the blood is effused, but seldom with the same naturalness in quantity, quality, and painlessness, as before; but there is more