allel appendicitis. Sudden pain, disten-
sion, nausea, vomiting, rapid pulse more
or less rigidity, will call attention imme-
diately to the right side, where will be
found the seat of most tenderness and lead
to the discovery of a sausage shaped tu-
mor in the region of the appendix. This
will call the attention of the medical at-
tendant to the existence of intussusception.
It might be mentioned that absolute con-
stipation in this condition has existed
from the first. In adults a train of symp-
toms which is absolutely identical (with or
without the presence of the tumor) makes
the question of the presence of ileus or
acute intestinal disturbance or obstruction
probable. It may or may not be coinci-
dental with an attack of appendicitis.

The method of abdominal examination
which has been pursued by the writer for
the diagnosis of appendicitis and condi-
tions similating it, might be interesting to
the members of the section. After obtain-
ing the history of the case from the pa-
tient or his friends (in case of a female
a rectal and vaginal examination is in-
cluded), the whole of the abdomen is care-
fully palpated, beginning at the left side
and working towards the right, then
downward. When the point of most
acute tenderness is located, one finger of
the left hand is placed over this point.
Keeping the left hand in this position, the
rest of the abdomen around the tender
area is palpated with the right. As ten-
der »jlaces are encountered, the patient is
asked under which hand the tenderness is
most acute, and in this/^way the definite

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491



point of most acute tenderness is deter-
mined. For example : this point is found
to be within a radius of two inches of
McBurney's point. The finger of the left
hand is placed over this point, and if des-
pite palpation with the right the most ten-
derness still exists under the left hand, it
may be assumed with a considerable de-
^grte of accuracy that this point is over
the seat of the trouble. I have verified
the diagnosis of appendicitis made in this



way over and over again; laparotomy
showing the appendix to extend in a di-
rection from McBurney's point indicated
by the point of most acute tenderness
which was located under the left hand.
It is a simple method and yet my results
have been so satisfactory from following
it, that I am convinced that it will be of
no little service in differentiating appen-
dicitis from these conditions and symp-
toms which similate it.



DYSMENORRHCEA.



JEANNE C. SOUS,
Ann Arbor.



Menstruation being a physiological
function its performance should be with-
out pain. How far this is from the case
every practitioner can witness.

In some investigations made by Engle-
mann in 1900 on this subject among
American girls it was found that dysmen-
orrhcea was present in from 50 to 80 per
cent. Among saleswomen who stand all
day 91 per cent, are afflicted with dysmen-
orrhoea and a large percentage are par-
tially incapacitated for work.

The writings of other authors confirm
these statements. What such suffering
by its frequent repetition through a cycle
of from thirty to thirty-five years entails
upon the individual in the form of secon-
dary nervous and other disorders makes

*Read before the Section on Obstetrics and
Gynecology at the annual meeting of the
Michigan State Medical Society at Grand
Rapids, May 25, 1904, and approved for publi-
cation by the Committee on Publication of the
Council. X



dysmenorrhoea and its treatment impor-
tant subjects.

Etiologically dysmenorrhoea is due to
constitutional disturbances exhibiting
themselves upon the pelvic organs; or to
conditions in these organs themselves.

The constitutional causes may be those
of anaemia, of a rheumatic diathesis, or
of any debilitated condition. These fac-
tors act in producing dysmenorrhoea by
causing an irritability of the nerves of the
pelvic organs through poor nutrition, and
these nerves further irritated by the
monthly congestion, respond by pain. The
local factors in dysmenorrhoea are as vari-
ous as the cases themselves.

In some cases we find a lack of develop-
ment of either the uterus or ovaries, or of
both; in others, a narrowing or stenosis
of the OS uteri — an evidence of lack of
general evolution frequently.

Again we "find the dysmenorrhoea de-
pendent upon an inflanvnation _Qf_ the



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Jour. M.S. M.S.



uterus and adnexa; or there may be a
displacement of the uterus present.

Nearly all these local factors act by
hindering the free escape of the menstrual
discharge from the uterus, thus causing
pressure upon the nerves. The diagnosis
of dysmenorrhoea itself is comparatively
simple. The pain occurring regularly in
connection always with menstruation dif-
ferentiates it from other painful disorders.

The true diagnosis is that of the causa-
tive factors, and a local examination is
necessary to determine them.

The symptoms are exemplified in the
following cases:

Case 1. Miss C. H., aged 36 years.
Menstruation was established at about 16
years of age. From the beginning the
patient had great pain every month. Had
cramps, colic and chills. The flow was
always scanty. The pain preceded the
flow and continued through first day. On
the second day of the period there was no
pain at all. At present the patient com-
plains of the occurrence of similar pain
every month, which may precede the
period for one or even twp weeks. She
also complains of severe backache. This
is present all the time, but is aggravated
during menstruation.

Case 2. Miss K. O., aged 20 years.
Menstruation was established at 12 years ;
was normal at first but for one and a half
years she has had some disturbance at
menstruation. Has pain in the pelvis of
a dull aching character, accompanied by a
bearing-down feeling. Has headache and
a dull ache up the length of the spine
during the menstrual periods. Has back-
ache all the time, complains of an exces-
sive leucorrhccal discharge.

Case 3. Miss K. R., aged 34 years.
Menstruation was established at 13 years.



It was normal at first. Then at 18 years
after a fall and exposure to cold, had se-
vere pain at the periods. Pain has varied
in severity, but it has always necessitated
the patient's remaining in bed from a few
hours to one day every month.

The pain precedes the onset of the flow,
sometimes subsiding then, but generally
continuing for a day or so. The patient
has backache at this time, also, and lately
she has been subject to fainting attacks at
this time.

The above are more or less typical
cases. In case one on examination the
uterus was found retroverted, slightly
prolapsed, enlarged, freely movable, the
vagrinal wall and uterine supports as a
whole were relaxed.

Case two showed an endometritis. The
vaginal canal was hypersemic and re-
laxed, the cervix was eroded and inflamed,
while the body of the uterus was hyperae-
mic and enlarged, acutely inflamed, dis-
charging an albuminous secretion.

In case three there was a retroversion
of the uterus, but in this case the organ
was not tender nor enlarged, and was
freely movable.

The treatment of dysmenorrhoea must
meet the pathological indications.

Necessarily it will be of both a general
and local character, for if primarily there
was no constitutional factor, when \\t see
the case some ten or fifteen years after the
beginning of the trouble there will be dis-
turbances on the part of the general state
of the patient which must be met. The
nervous system, digestive, circulatory and
eliminating organs must all be overlooked
and prescribed for as the case requires.

To meet the local conditions we have in
the direct electric current an eflScient
agent.



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493



Let us take case one. A retroversion
of the uterus due to relaxed uterine sup-
ports, dysmenorrhcea and backache as
symptoms of the same. In the negative
pole of the direct electric current we pos-
sess a means of stimulating these sup-
ports, of improving: the circulation which
has become impeded, and of so changing
the conditions that in a number of months
this report was received:

No pain preceding the period in con-
trast to one or two weeks of pain. The
menstrual flow came on without pain and
there was no pain at all during the period.
Neither was there any backache at all.
Previously backache was a constant symp-
tom.

In detail the ti:eatment was as follows :
For ten days preceding every period for a
number of months the patient received
every other day a treatment with the di-
rect current. The negative pole, a round
ball vaginal electrode, was introduced
well up into the vagina and a current of
from 10 to 20 ma. gradually turned on.
Then the electrode was moved gently
about in order to give the interrupted
stimulus of the current to the uterine sup-
ports.

As a part of three of the treatments
in addition to this vaginal treatment the
negative electrode, this time a curved in-
tra-uterine one, was introduced into the
uterus with a current of 10 ma.

This electrode was gently slipped back
and forth through the cervix, never being
entirely withdrawn.

The object in this case was to relieve
the circulation of the uterus and to
straighten the canal.

The vaginal treatments were ten min-
utes in duration, the double treatment
about fifteen minutes long. The third



month, and thereafter for two months, the
patient came for treatment each week pre- •
ceding the period, and finally, after seven
months of treatment of the above short in-
tervals, she was dismissed — a length of
treatment very satisfactory to both pa-
tient and physician, considering the con-
dition was one of twenty years* standing.

While taking treatments, with the ex-
ception of a daily rest for a couple of
hours^ the patient was up and about en-
joying herself.

In the case of metritis the opposite pole,
the positive, for the intra-uterine electrode
is the choice. Otherwise the treatment is ^
similar. In this case we want to constrict
the dilated blood vessels, reduce the blood
in the parts, overcome the sensitiveness
and prevent the hypersecretion.

Wherever we have inflammation, there
we have bacteria. This factor is also met
by the direct current. The positive pole
in this case will exercise a microbicidal in-
fluence in the tissues to which it is ap-
plied.

This effect can be heightened by amal-
gamating the positive electrode with a
mercury preparation, or by using a copper
or zinc electrode, the electrolytic action of
the current causing a disengagement 'of
the various metals in nascent state, and
the cataphoretic power of the same carry-
ing these metals deep into the tissues, in-
creasing the range of their action.

Treatment in the cases of metritis
should be given at least as often as three
every week.

The current strength should be from 10
to 20 ma. and the duration of each treat-
ment from 10 to 15 minutes. The
current should never be turned on till both
electrodes are fully in position.

The large electrode iif most cases is



494



DYSMENORRHCEA— SOUS.



Jour. M.S. M.S.



preferably placed under the patient's hands
after it is ^ell covered and moistened, the
patient being cautionc J as to the removal
of rings from her fingers. Then the other
electrode is introduced well up in the
uterus, the patient lying in the dorsal
position. Now the current should be
turned on gently till the desired quantity
is obtained, and gradually withdrawn in
the same manner later. In this way the
patient experiences no shock, and ai\y ner-
vous apprehension of the treatment is
avoided.

Treatment should be continued in this
manner till the inflammation subsides and
the dysmenorrhoea no longer is present.
The usual internal medication and the use
of douches should be advised in connec-
tion with the direct current treatment.

Dysmenorrhoea due to constriction of
the tubes by adhesions is better treated by
the direct current than by any other
method.

The only permanently successful treat-
ment of dysfnenorrhoea due to stenosis of
the cervix is that by means of the direct
current.

The method here consists in the use of
the negative pole by means of a set of
olive-tipped intra-uterine electrodes of
varying sizes. The smallest is used first.
It is introduced as far as it will enter the
cervix, then the current is turned on to a
strength of about 10 to 15 ma. and the
electrode gently slipped back and forth
till the obstruction yields and the -elec-
trode enters the constriction.

At the same sitting, or at the next one,
depending upon the patient's condition,
the second sized electrode is inserted in
the same manner, and following this the
third one. There is no need for an anaes-
thetic, there is no hemorrhage, the patient



suffers less pain, at least in duration than
at every month, and leaves the office to
walk home and to be about her daily duties
without interruption.

This treatment may need to be re-
peated ont or two months just preceding
the menstrual period. But after that noth-
ing further is required.

Sometimes we find through long con-
tinued obstruction to the free escape of
the menstrual discharge inflammation or
passive congestions have been set up ; if so,
further treatment with the direct current
is indicated either with the positive or the
negative pole according to the conditions
found.

The general rule to follow is that when
we find^ relaxations, exudates, constric-
tions, passive congestions, the negative
pole with its stimulating,, liquefying and
dissolvent properties is required. If, on the
other hand, we find active h)rperaemia,
acute inflammations, sensitiveness, ero-
sions, increased secretions, it is the posi-
tive pole we must choose for its constrict-
ing and sedative actions.

If the stenosis of the cervix is but one
evidence of a general lack of evolution on
the part of the generative organs, a con-
tinued use of the direct current with the
neeative electrode for about three months
is indicated. During the intermenstrual
period give intra-uterine treatments three
times a week, thus stimulating the nutri-
tion in these parts.

DISCUSSION. .

H. H. Cook, Detroit: I agree with Dr.

Solis in regard to the electrical treatment of
these conditions because I believe it offers
the best results,

Dysmenorrhoea, in a majority of cases, is
due to either a displacement of the uterus, or
a stenosis of the cervical canal or both, be-
cause the displacement, if it be a flexion, may
cause a stenosis. Some few c^ses are doe to
a lack of developmcnfi^ed by VjOO QIC



r



NOVHMBER, 1904.



DYSMENORRHCEA— SOUS.



495



The usual plan of treating cases of stenosis
has been to give the patient an anaesthetic and
produce a rapid dilatation. By this opera-
tion you practically tear the tissues, and in
the course of six months or a year you get a
secondary construction on account of the con-
traction of the scar tissue which is formed,
and the trouble may become even worse than
it was before the dilatation.

When the galvanic current is used in these
cases it has a peculiar softening effect and
when the stenosis is dilated in this manner
the canal becomes soft and patulous and re*
mains open.

If there are any adhesions present they also
become softened.

Dilatation of a stenosis by electricity causes
no pain, hence there is no necessity of giving
an anaesthetic, and the patients can go about
their usual vocations without the least dis-
comfort.

There have been various plans of correct-
ing displacements of the uterus by operative
^measures but the results are not promising.
When the round ligaments are shortened for
A posterior displacement you do not stimulate
the relaxed ligament, but simply stretck^ a
ligament whiclx is already relaxed. By using
the electricity the individual fibers of the liga-
ment may be toned up and the ligament
placed in a position to exert its own healthy
influence in holding the organ in its normal
position.

W. F. Metcalf, Detroit: I do not wish to.
have it pass leaving the impression that the
application of electricity will cure all cases of
dysmenorrhoea. It seems those who at times
find operative procedure necessary have kept
quiet. I think that one of the most difficult
problems that the clinician meets is the treat-
ment . of dysmenorrhoea, it being simply a
symptom of a variety of conditions. In the
majority of cases the patient does not consult
her physician until she has suflFered long,
and although the original cause may have been
constitutional or in her environment, yet local
conditions have arisen which in many cases
demand mechanical correction. I know that
the passing of or the dilatation by a charged
sound is less pain{ul, and I know that in cases
of hyperthesia of the endometrium we may
get cures from the use of electricity. But to
make a universal application to all cases of
dysmenorrhoea would, I think, be hazardous
practice.



First we must determine whether there is
suppuration in the tubes. One who treats
dysmenorrhoea must be so familiar with the
pelvic organs that he can determine the exact
condition, or as nearly as possible determine
the exact condition, before he institutes any
local measures of treatment.

The cause in many cases undoubtedly, is
lack of development The blood vessels are
engorged. Matrimony helps many of this
class. The stimulation of the marital rela-
tions is helpful to the development. The bear-
ing of children subsequently will remove
naturally that hypersensitive endometrium, a
new one will form, and the whole trouble will
be overcome. But the discussion of the sub-
ject of dysmenorrhoea really means the dis-
cussion of all the ailments that affect the
human body in women.

L. J. Hirschman, Detroit: The discussion
of dysmenorrhoea, or the treatment of it, it
seems to me is just about as logical as to
speak of the treatment of pain, or the treat-
ment of cough, or the treatment of any one
symptom. I think too' many books are wont
to say that dysmenorrhoea is a distinct dis-
ease, when it is merely a symptom of a dis-
ease of the organism.

Now I don't think that all cases of dysmen-
orrhoea should be treated by electricity, nor
do I think all cases which show dysmenor-
rhoea as one of the symptoms should be
treated surgically. There are a great many
young women who present dysmenorrhoea as
a symptom of other things than diseased or-
gans which may be a lack of exercise, or
wrong environnvpnt. A great many cases of
dysmenorrhoea as a symptom occur in young
school girls, clerks, teachers, stenographers,
shop girls, young women who are engaged in
some occupation, in which they are confined
too much indoors. A great many cases of
dysmenorrhoea are due simply to systemic im-
poverishment; due to not getting enough
fresh oxygen. A great many girls who work
on sewing machines, operated by foot power
have dysmenorrhoea. They sit in a cramped
position. Although they may have some
stenosis, if they are taken into the country
out of the shops, and poorly ventilated school
rooms, and made to walk three or four miles
a day they will need no electricity or surgical
interference. They are a class of cases that
have been overlooked to a large extent, those
in whom, simple outdoor exercise will do the

whole business. ( ^ r\r\nl^

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RADIOGRAPHS—HICKEY.



Jour. M.S. M.S.



Another point: Dysmenorrhoea we have
occurring in young girls just starting to men-
struate, and every case, as Dr. Solis suggests,
should be examined to see if there is a phys-
ical q^use. I would say in cases where it is
difficult to examine the girl, that a combined
rectal and abdominal examination will dis-
close the condition, without embarrassing her
by making a vaginal examination or rupturing
the hymen. If we look at young girls in
school and find out if they are anemic, and
run down we will cure 50 per cent, of the
cases without any surgical or electrical treat-
ment whatever, simply by making them take
regular out-of-door exercise.

J. H. Carstens, Detroit: As has been said,
this is a broad subject, but if there is a class
of cases that cause a great deal of trouble
they are these cases of dysmenorrhoea, and
we seem to get them more and more with
advancing civilization. It seems to me we
have more of them in the large cities than
in the country, due to the condition Dr.
Hirschman spoke of. Now we very often get
dysmenorrhoea outside of diseases of the
ovaries or tubes, as mentioned by Dr. Met-
calf. A great cause of dysmenorrhoea h a
small undeveloped uterus in a young girl, and
that small undeveloped uteru^ is caused by
forcing or using up, rather, all the nutrition
and energy of the body in the development
of the brain by hard study, hard work in
school, especially when the girl has not got
the mental capacity to quickly grasp ideas.
That alone often causes it. They have got
to stop this mental forcing and do something
eke. You have another case where they have
that mental capacity, learn easy, go through
school just as easy as anything; their men-
strual functions are established, they are per-
fectly well and healthy. They go along — espe-
cially school teachers — they go along for ten,



twelve or fifteen years, perfectly well, men-
struate regularly, but g^'sidually it becomes
more scant, gradually painful, and then they
have dysmenorrhoea.

Now you examine this kind of a woman and
see what is the trouble, and what do you find?
You find they have also an atrophied uterus, a
small uterus, a uterus that has not fulfilled its
function. That woman ought to have been
married and if she had she would never have
had any dysmenorrhoea. She has led an abnormal
life, that is the reason she has a small uterus.

Now this treatment of Dr. Solis is the cor-
rect one. If you haven't used your arm and
you allow it to be idle year in and year out,
it becomes atrophied, and the only way to get
it strong is to use it. The same thing you do
by applying electricity; you cause a contrac-
tion of those muscles of the uterus, the broad
ligament and the round ligament^ and gradu-
ally bring about a development, an increase
in size, stronger circulation, better nutrition
and a better organ, and when you have done
that your patient won't have dysmenorrhoea.
That is a good way to do. Sometimes you can
use electricity; I sometimes accomplish the same
thing by using a stem pessary, and i leave it
in there for six months or a year.

Jeanne Solis, Ann Arbor: I will first state
that a pus-tube would be a contra-indication,
for we know that pus is always a contra-indi-
cation, and electricity would not in those cases
be the remedy. If we have a case with such
a. chronic history that none of the usual
jnethods would avail, then we can examine it
and find out the condition^ In the class of
cases I referred to I claim electricity is an
efficient agent, not overlooking giving the
patient advice as to exercise, dress, diet, etc.,
but electricity in connection with these ordi-
nary methods is an efficient means in curing
dysmenorrhoea.



THE INTERPRETATION OF RADIOGRAPHS.*

P. M. HICKEY,
Detroit.



As with all new branches, it is well to
pause and consider the limitations, possi-

*Read before the Section on Surgery,
Ophthalmology and Otology at the annual
meeting of the Michigan State Medical So-
ciety at Grand Rapids, May 26, 1904, and ap-
proved for publication by the Committee on
Publication of the Council.



bilities and proper precautions to be ob-
served in this new art.

It is safe to assume that radiography is
now recog^iized as one of the important
aids in medical and surgical diagnosis.
While there may be occasionally met iso-
lated individuals who still ^dj^^^^pg-



NOVBMBER, 1904.



RADIOGRAPHS— HICKEY.



497



nize the help which may be derived at
times from proper radiographic studies,
yet the main body of the medical profes-
sion recognize radiography as a diagnos-
tic aerent whose value is not to be' dis-
puted.

We may consider the subject of this
paper, viz., the interpretation of radio-
graphs, from two standpoints: First, the
technical quality of the radiograph; and
second, the experience of the interpreter.

A radiograph may be defined as the
record of the density of objects interposed
between an energized Crook's tube and
the photographic plate. It is important