Tubercular disease or overwork induce cessation of the menses because the heart, lungs, digestive organs, nerves, and muscles need blood more than the reproductive organs do. I have seen several cases of amenorrhea apparently caused by eating a larger amount of azotic food than the body required. We see the effect of anxiety on unmarried women who have allowed sexual intercourse, followed by menstrual suppression, although conception has not taken place. Occasionally the menopause occurs as early as at thirty-five years of age, and I have treated one case in whom the menses were permanently arrested at the age of twenty-nine years. This lady is married, enjoys excellent health, and has never been pregnant. In all these instances absence of the menstrual flow would be no proof of pregnancy. It also sometimes happens that the menses fail to appear for several months in newly married women, owing to marital excitement, although conception has not occurred.

On the other hand, a moderately large number of cases are on record in which a modified menstruation continued several months

during pregnancy. I attended two such cases and one of regular vicarious menstruation during the whole term. In one case a speculum examination demonstrated that the blood issued from the os uteri.

Nausea and Vomiting, generally called "morning sickness," is often absent in pregnant women, and occasionally occurs in those who are not pregnant. The novel excitement of a "honeymoon" may produce this doubtful symptom. So also may the pressure of abdominal dropsy.

Morning sickness taken alone is of no more importance than cessation of the menses. It is useful, however, as a corroborative sign. The late Prof. Bedford was of opinion that nausea constituted a safetyvalve during the early months of gestation, and that women not thus affected were more likely to miscarry. When vomiting proves severe and persistent I have found a spoonful of hot, strong coffee, without milk or sugar, taken in bed, the best remedy. The patient should remain in bed for twenty or thirty minutes after taking the coffee.

Coloration of the Vagina. We are indebted to Dr. Chadwick, of Boston, for the best account of this sign in a paper published in the Transactions of the American Gynecological Society, Volume XI. A French practitioner, M. Jacquemin, first directed attention to a change of color in the vaginal mucous membrane to a violet hue. Dr. Chadwick says that "the color begins as a pale violet in the early months,

and becomes more bluish as pregnancy advances. . . . It is not due to pigmentation, but to an hypertrophy of the venous plexuses." This coloration does not result from the pressure of fibroid or ovarian tumors, but it may be produced by erotism. The anterior vaginal wall is first affected.

Changes in the Breasts. Toward the close of the second month the mammary glands slightly increase in size, become firmer, and sometimes milk may be expressed by careful manipulation. But the principal sign of pregnancy consists in a darker color of the areolalight to dark brown-and enlargement of the accessory sebaceous glands on its surface. This change of color is more marked on a brunette than on a blonde.

Berhaps I attach more importance to this sign of pregnancy from the circumstance that, while a medical student (1845), I found it on the breasts of a very young girl, lying on our dissecting-table, and was laughed at by several students who found that her hymen was intact. On opening the uterus, however, the presence of a three-months' fetus decided the question in my favor. As the dark color of the areola is more or less permanent, this sign is not of much importance in multiparæ. Blue veins from the nipple outward occasionally appear during the first half of gestation. The areolar papillæ also enlarge in multiparæ. Softening of the Cervix Uteri. The late Dr. William Goodell says, "When the cervix is as soft as one's lips the woman is probably pregnant; when it is as hard as the tip of one's nose the womb is most likely empty." The patient's bladder should be emptied before making a vaginal examination, and the forefinger applied with only slight pressure. Softening of the cervix may result from so many other causes, such as incipient inflammation or from masturbation, that its presence is not of much value as a sign of pregnancy.

Hegar's Sign. This symptom consists in a marked thinning at the junction of the cervix with the corpus, the cervix being tilted backward, which gives the uterus a juglike form. Two fingers of the left hand are introduced into the empty rectum and the thumb into the vagina, while the surgeon's right hand, placed on the abdomen, gently presses the womb downward. As the majority of women object to a rectal examination, this test is seldom had recourse to in the United States, and when employed, an anesthetic should be used. Enlargement and Fluctuation of the Corpus Uteri. The virgin uterus, after puberty, is shaped like a pear, is flattened anteriorly, and

is about three inches long. In an examination for suspected pregnancy two fingers of the left hand are introduced into the vagina, and pressure made on the abdomen by the right hand. The fingers in the vagina will ascertain that the cervix is softened and tilted backward, and, by pressing upward anteriorly, that the corpus is enlarged, rounded like an orange of medium size, and cystic. These changes may be detected in a lean patient as early as the eighth week. When twelve weeks have elapsed the increase of size and the fluctuation are so marked that an experienced practitioner will seldom be mistaken. Only two conditions are likely to mislead him, namely, a cystic fibroid tumor-a rare occurrence-or a retroversion of the pregnant uterus in an obese woman. In the latter case she should be examined bimanually, per rectum, under ether.

I attach more importance to this last sign than to any other. Next in value in primiparæ are the changes in the breasts. It is scarcely necessary to add that the age of the patient, the state of her health, condition in life, as single or married, and all ascertainable surrounding circumstances should be taken into account. In other words, the eye and touch must be governed by the brain. We sometimes meet with cases where the patient is so anxious to bear a child that the mere stoppage of menstruation is enough to convince her that she is pregnant, and the obstetrician who tells her that she is mistaken is set down as an incompetent pretender. Time, which tries most things, is sufficient to try that. There are also women, even five or six months along, who stoutly deny the possibility of conception, about whose cases we can afford to wait till time tries them too.

STONEHAM, MASS.

X-RAYS IN SURGERY, WITH REPORTS OF CASES.*

BY J. T. DUNN, M. D.

Though it is now more than a year since Prof. Roentgen astonished the world with the X-rays and their wonderful penetrating power, interest has not abated. True, it is not now the novelty it was at the Lebanon meeting last year, but its demonstrated utility and practical application in medicine and surgery make it still a subject of momentous interest. The experiments of other scientists quickly and fully con

*Reprinted from the Volume of Transactions of the Kentucky State Medical Society, 1897.

firmed all that Roentgen claimed, and, I am sorry to say, have been able to add but little to the discovery in its scientific aspects. But such a host of inventive minds and practical hands were called into the field that the improvements in means and methods have been remarkably rapid and satisfactory, until now we are able to do work that seemed impossible a year ago. Much credit belongs to Edison and Tesla.

I began experimenting with the X-rays in February, 1896, soon after the discovery, and on the 29th of that month I succeeded in making a shadowgraph of a half-dollar which was concealed in a box. This was the first shadowgraph made in Louisville. The chief objection to the use of the rays at first was the length of time required for an exposure, it requiring at least thirty minutes for the hands, and it was impossible to penetrate the trunk of even a child. Scientists, however, soon overcame this objection, and now the hand may be shadowgraphed in one minute, and the trunk in fifteen, thus rendering the X-ray instrument an indispensable part of the surgeon's outfit. Proper surgery can not be done in a certain variety of diseases without first using the X-rays. It is as frequently consulted by those surgeons having access to it as is the microscope or test-tube. It is to the surgeon what the microscope is to the pathologist and bacteriologist. Perfected, as is the instrument I am now using, it is with the greatest ease that a dislocation is differentiated from a fracture, and a fracture from a sprain, true ankylosis from false ankylosis, foreign bodies located, deformities detected, and a host of other conditions made visible which would otherwise remain in darkness.

Think of a fractured limb dressed in a wooden'splint, or even in a heavy plaster-of-paris bandage, placed beneath the rays and the fragments seen to be in perfect apposition or otherwise, as the case may be! What could be of more practical and satisfactory use to the surgeon than such a powerful instrument? Think of the embarrassment it would have saved many a surgeon who has dressed a fracture with fragments in bad position, and was sued for malpractice; or one who has examined a dislocated joint and given the opinion that "nothing is wrong," or that "it's only a sprain." They may have used all the means known to surgical science, but were unable to diagnose the true condition, hence they were not to blame. But the courts. have given large judgments against them. The free use of X-rays will eliminate a large percentage of such cases from our courts. On the

other hand, a surgeon who has a bad result and has not used the X-rays to detect the trouble and direct his treatment will be more liable to suits for malpractice than his neighbor who makes free use of the X-rays.

It seems that surgery is destined to become a powerful science, for, perfect as it seemed to be a few months ago, advance seeming almost impossible, Roentgen gave to it free of charge a stimulus, the X-rays, which sends it higher and higher. The question is often asked me, if I have had any injurious results from the use of X-rays? The daily press has prejudiced some people against the use of the rays by announcing some formidable lesions arising soon after an exposure to the rays, such as dermatitis, falling of the hair and nails. I have carefully reviewed the literature of these cases, and find it true that these results have been produced, but in every instance the part to be shadowgraphed was placed very near the Crookes tube and a very long exposure made. I have had no such results, and I explain this by the fact that I always place the Crookes tube at least eighteen inches from the part to be shadowgraphed and make a very short exposure. This I find to be most successful, giving me a sharp outline with least distortion. I have as yet experienced no personal injury, although I have worked with the rays for more than a year.

The Edison fluoroscope, that most valuable accessory to the X-rays, enables the surgeon to see the interior of man as if his skin and muscles and bones were glass. The bones, being more dense than the muscles and skin, can be seen as distinct as the bones of the dry skeleton in the surgeon's closet, thus enabling him to see a fracture, dislocation, deformity, bone tumors, and fetus in utero, also to locate foreign bodies, such as bullets, pins, needles, iron, and glass; but a wooden splinter can not be seen, because it is transparent to the X-rays. The surgeon can daily watch the repair of the fracture, and it is not necessary to remove the splints nor plaster-of-paris dressing. Enlarged bones, hardening and softening of the bone, can also be diagnosed. The liver can be seen, thus its size determined. I have seen the throbbing of the heart itself in a fair-sized man.

Report of Cases. The first case I wish to call attention to is that of D. N. Nelson, of East Bernstadt, Ky. He was accidentally shot with a 38-caliber ball in the median line, two inches below the ensiform cartilage. He fell instantly, being paralyzed in his legs, bowels, and bladder. Seven months later he heard of the X-rays in Louisville,