trical school; they tell us about their bitter experience and lessons. For years you could not get one of them to witness legitimate work. They tell us now "they were honest," and ask for our sympathy. I notice that group of men are never out of mischief; that they are always meeting obstructions at some point.

You will notice, in referring to these tumors, that the hard tumors were removed by one of three methods, the Koeberle, or the clean extirpation from above or below. The Koeberle always gives the best results. If you will study the reports of cases throughout the journals, you will find that about every hysterectomy done by a beginner-an emergency operation—and finished by the extraperitoneal method, recovers. In one of our August journals you will find illustrated an extraperitoneal hysterectomy done for triplets-recovery. If a beginner can save everything by the Koeberle method, why try anything else?

Ectopic pregnancy, you see by these reports, has been as common as in previous summers-it is largely a summer accident.

We have rather a new group of cases in suppurative forms of tubal and ovarian disease, in patients more advanced in years and a more unfavorable class of patients-the wives of professional men and merchants; after the birth of two or more children the contamination occurs. The wife is the victim of some nervous disturbance or some accident incident to parturition, and under treatment. The husband finds it more convenient to fish in disturbed waters, and he gets what I commonly call a typewriter's disease. The disease has really increased my work in a new class of patients, and it is going to spread.

Mr. President, it remains for us to refine our present methods and environs to give us a nil mortality. It is my impression there is not an organization in existence doing more in that direction than the one now assembled. We are always alluding to fuss, feathers, and foolishness, complicated tables and instruments. I am always reminded, Mr. Chairman, when I see a man hampered and embarrassed by his seven assistants and nine nurses, two or three of them working at cranks and turn-tables to get his patient in position, of an interesting picture apropos of results. (Picture presented.)

SENILE IRRITABLE UTERUS.

BY THOMAS J. MAXWELL, M.D.,

KEOKUK.

It

THE procreative power of the genus homo is not necessary to the existence of the individual; it is engrafted upon the individual for the sole purpose of propagating and conserving the race. is prevalent and active in the female during the period of greatest physical vigor, in order that her progeny may be numerous and strong. The Greek matrons could boast "they brought forth men." This new life-giving power comes to the girl at fifteen years of age, and like a tidal-wave lifts her into a new and higher plane of existence that of womanhood. This new force continues to ebb and flow, its waves of quickening power breaking upon the shores of her whole physical existence until she reaches the age of change, which comes at forty-five to fifty. Then this ebb and flow gradually subsides, leaving her dizzy and distraught until nature adjusts herself to the calm. If the woman passes safely over the rapids into and through the eddying currents of the menopause, her life then flows on in a peaceful, even current, she taking comfort and pleasure in reminiscence and in her children. Unfortunately, this is not always the happy ending of this wonderful superadded life.

I do not propose to give in this short paper-and the time allotted to it will not permit-a detailed account of the many diseases, malignant and benign, that render this period of female existence extremely critical. My attention has been directed to a class of cases that, having passed the menopause, still suffer from uterine irritation or irritability and the attendant nervous reflexes whose name is legion. The uterus usually has undergone atrophy; in some cases there is evidence of chronic endometritis, with scant, thin, corrosive discharge that irritates and sometimes excoriates the surfaces with which it comes in contact, causing vaginitis and vul

vitis, or pruritus vulvæ, which at times becomes intolerable, driving the unfortunate patient to the very verge of distraction. Many of these cases in my hands have defied all my efforts and resources to cure. I have utterly failed in some of these cases to cure after applying various astringent, antiseptic, and anesthetic, strong and mild, washes to vagina and uterus.

Dilatation of the cervix, curetting away the entire endometrium, and, in one case, the actual cautery applied to the entire surface of the uterus, failed to relieve the numerous reflexes that had deranged every function of the body and driven my patient to the borderland of insanity. I have already stated that some of these patients had uterine discharges and some of them had no discharges, and yet both classes suffered alike from neuroses.

In all of these cases there was one symptom common to all—that was extreme sensitiveness or irritability, manifested on introducing the probe or sound. The patient would invariably shrink and cry out with pain as the probe or sound entered the cavity of the uterus ; the contact of the sound would bring into painful prominence one or more of the nervous reflexes from which she was suffering. This would sometimes take the form of a gastralgia, pain under the heart in the sixth intercostal space, or it may be that of the rectum, spine, or vertex. There is one prominent symptom always present: that is extreme sensitiveness of the endometrium, the contact of the probe or sound causing acute pain. I have found this the case with or without discharge from the uterus. It is present with granulated os and when there is no appearance of inflammation.

I cannot give more than a hypothetic pathological cause for this extreme erethism of senile atrophied uterus. May not this condition depend upon a starved state of the nerves in the anemic uterus, with atheromatous arteries, or may they not have been caught in the vise-like grip of muscular tissue undergoing fibrotic degeneration? These questions arise in my mind, and I propose them for future solution.

I have made numerous inquiries among my professional brethren as to their experience with such cases, and find that treatment has availed but little in the way of relief, and failed to cure in almost every case. My friend Dr. Hornibrook, President of the Iowa State Medical Society, kindly gives me somewhat in detail the clin

ical history of three cases, and, summing up his experience with these and others not reported, he says: "The treatment was always unsatisfactory, and it did not occur to me to propose hysterectomy." Having failed to relieve the class of cases just described, and having exhausted all the ordinary resources at my command, I determined to adopt radical treatment-that was, the complete removal of the offending, useless organ. A case presented itself for the new departure in the person of Mrs. M., of C, Mo., the latter part of August, 1895. Mrs. M. passed the menopause at fifty-two, but continued to suffer increasingly, as the years went by, with pelvic, stomachic, and spinal pains. These pains were accompanied with indigestion, constipation, insomnia, and all that train of symptoms which, grouped together, we call neurasthenia. This nervous condition had existed so long that she was almost driven to insanity. Her uterus was atrophied and the endometrium exquisitely sensitive. The introduction of the sound into the body of the uterus would provoke numerous reflex sensations and cause her to cry out with the intolerable pain. On September 5, 1895, I performed vaginal hysterectomy, from which she made a good recovery. It required about twelve months for the perturbed nerves to settle into a state of quiescence. At the last report, less than a year since, she was enjoying good health.

CASE II. Mrs. W., aged sixty years, a counterpart of first case, had acquired the opium habit from resorting to it for relief. May, 1896, I removed the uterus per vaginam. Recovery from the operation was uninterrupted, but she had quite a struggle with the opium habit, which, at last report, she had almost conquered, and is at the present time enjoying freedom from all those neurotic symptoms resulting from an irritable senile uterus.

CASE III.—Mrs. B., aged sixty-three years, had been a sufferer from uterine disease for twenty-five years, having had one or two small submucous fibroid tumors removed. She continued to suffer from uterine pain and reflexes after the menses ceased, and there was, the last two or three years, a discharge from the uterus, reported to be of an irritating nature to the vulva. She did not come under my care until just before operation. The physicians in charge-for she had been under the care of quite a number of them-had used washes and douches, had curetted the uterus and mopped it out with carbolic acid and iodine, all of which treatment

failed to give her relief. She came to St. Joseph's Hospital, and I made a vaginal hysterectomy. No shock followed the operation, and the temperature never rose above 100° F., and that only for two days. Pulse remained in the 70s. She at this writing is in good health, but it has been attained after a hard fight with the chloral habit. This case was somewhat different from the first two so far as the pathology of the uterus was concerned. The uterus in her case was filled with small, round fibroid tumors. On the posterior aspect of the fundus there was a small subperitoneal, pedunculated tumor the size of a small hazel-nut. The other tumors were interstitial.

I have grouped these cases under the head of what I am pleased, for the lack of a better name, to call irritable senile uterus.