of the peritoneum behind the posterior vaginal wall may have existed; but of this there is no evidence.

Treatment. If an ordinary Albert Smith or anteversion pessary fail, an operation may be tried. In the posterior vaginal enterocele, for

example, the protrusion should be replaced; a raw surface is then made on the posterior lip of the cervix and a portion of the posterior vaginal wall about its middle; these surfaces are then stitched.

Prolapsus uteri and both forms of vaginal enterocele are therefore essentially the same in nature, viz., hernial. Intra-abdominal pressure usually displaces all in front of the anterior rectal wall; but may also force intestine in front of the anterior vaginal wall, or behind the posterior one.

SECTION VIII.

DISTURBANCES OF THE MENSTRUAL FUNCTION.

CHAPTER XLVIII. Amenorrhoea Menorrhagia Dysmenorrhoea.

SECTION IX.

DISTURBANCES OF THE REPRODUCTIVE
FUNCTION.

CHAPTER XLIX. Sterility: Abortion: Retroflexion of the Gravid

Uterus.

L. Extra-uterine Gestation.

CHAPTER XLVIII.

AMENORRHOEA: MENORRHAGIA: DYSMENORRHOEA.

THE three subjects to which this section is devoted are not diseases, but are symptoms of a large number of the more or less well ascertained pathological conditions already considered. Theoretically, therefore, they should not come up for special consideration; practically, however, it is of use to the practitioner to summarize the conditions causing these symptoms, and to give some special hints as to their treatment.

AMENORRHOEA.

This means cessation of menstruation during the period between Puberty and the Menopause. It is normal to have Amenorrhoea during pregnancy and lactation.

Local conditions:

Congenital

Acquired.

Amenorrhoea may be caused by the following

Absence or incomplete development of uterus and annexa, atresia of the genital canal (with or without accumulation of the menstrual blood), state of Cretinism;

Superinvolution, simple atrophy of uterus, cystic ovarian disease, extensive inflammatory conditions of uterus and ovaries. Constitutional conditions-such as phthisis, chlorosis (v. Appendix), prematurity of menopause also cause amenorrhoea.

The local conditions have already been fully described under the various heads; we give here only a few hints as to the investigation of the causes of this symptom. When the patient complains of never having menstruated and there is no constitutional cause for the amenorrhoea, the question of examination should always be entertained; abdominal palpation and rectal examination are employed to ascertain that there is no retention from atresia. To ascertain the condition of the uterus, a vaginal examination may be necessary. Sudden cessation of the menstruation in a girl neither phthisical

nor chlorotic is usually due to pregnancy; early sickness, mammary and other signs should be looked for. Nothing is a sure sign of pregnancy except the characteristic increase in the size of the uterus, agreeing with the number of periods passed.

MENORRHAGIA.

Menorrhagia is the term applied to excessive hæmorrhage at the menstrual periods; when the hæmorrhage is intermenstrual, it is termed metrorrhagia.

The causes of menorrhagia are the following:

Constitutional

Local.

Hæmorrhagic diathesis, scorbutic conditions; ́Endometritis, metritis, subinvolution, retroversion of uterus, inversion of uterus, submucous and interstitial fibroids, polypi, carcinoma uteri, sarcoma uteri, incomplete abortion. It should not be forgotten that we may have menorrhagia in cardiac disease, and also in hepatic congestion (Matthews Duncan, Warner).

The treatment of menorrhagia is the treatment of the condition producing it. In cardiac disease we give digitalis; and in hepatic disease we may try chloride of ammonium, euonymium or iridin.

In cases where there is menorrhagia due to a simple congested condition or to a flabby state of the uterine muscle, we may give the following at the menstrual periods :

В Ergotinæ
Argenti oxidi

Mica panis

:

Fiat pilula mitte tales xij.

Sig. One thrice daily as directed.

gr. iv.

gr. 1.

q. s.

Note that it is well not to write "at the menstrual period" on the prescription, but to put "as directed." When the practitioner is consulted as to menorrhagia in unmarried ladies or young girls, he should first try the ergotin and oxide of silver pill. If this fail and the case