caused death. I am sorry to have had to give you such a history, but I could not otherwise be true to my promise to you. I show you the report kept of this patient, in which you see that the temperature was subnormal prior to the operation. Subsequently the highest temperature was 100, but after the removal of the clamps following the hemorrhage it fell to 97°. She, however, reacted the next day, and following that it remained above normal until just before her death. This case also taught us an important lesson regarding ventro-fixation.

There has been considerable question of late as to the influence of this operation on subsequent pregnancy. Numbers of cases have been reported in which women have aborted, the uterus has ruptured, or dystocia has resulted, owing to the position of the organ. It is important in every operation upon the woman not to lose sight of its possible effect upon her life, or that of her offspring should she become pregnant. Although the operation may give relief from the symptoms the patient experiences, if it causes danger in the performance of the physiological process to which a woman may at any time be subject, we should hesitate as to its performance. I this morning did a ventro-fixation, and in the light of this experience, instead of using buried sutures, I introduced the lower two sutures through the abdominal walls, exclusive of the peritoneum, and the fundus of the uterus, purposely turning back the peritoneum to bring the covering of the uterus in contact with the muscular layer of the abdomen. This procedure will make a pretty firm band of union, but not so resisting as if buried sutures had been placed to keep the parts continuously in apposition. As the sutures only remain ten days, the adhesions become to some degree stretched and the band of union is longer and more likely to give way in subsequent stretching than would the band resulting from a more firm fixation by buried sutures.

CASE II.

The next patient is 63 years of age; she has had four children, with all of which the labors were difficult. She is a laboring woman. She has noticed for the last few years a protrusion from the vulvar orifice, which has increased within the last few months. It is red, inflamed, and as I push it to one side you notice an orifice, the borders of which are denuded and angry. This is the cervix, which has been lacerated and undergone an ectropion. Now, in this patient we have a protrusion from the vulvar orifice, and you naturally ask, what is it? A woman will come to you with such a protrusion and will tell you that it is falling of the womb. It may be a growth in the vagina, a vaginal tumor, a prolapse of the uterus or of the anterior or posterior wall of the vagina. There are numbers of conditions which may cause a projection from the vulvar orifice and should be kept in mind in determining the diagnosis. In a protrusion from the orifice of the vulva, then, we remember the possibility of prolapse of the uterus, prolapse of the vaginal wall, either anterior or posterior, the anterior being known as cystocele, the posterior as a rectocele. We may have a prolapse of the entire vagina, with the cervix protruding from its center, without prolapse of the uterus, a condition known as hy

pertrophic elongation of the cervix, the fundus retaining its normal position. The cervix is dragged upon by the · heavy vaginal walls, which results in its elongation. We may have a protrusion from the vulva of polypoid growths from the uterus, which drag upon the organ until the growth protrudes from the vagina. We may have the protrusion of the fundus of an inverted uterus; so it is important in any condition to make careful examination to ascertain the character of the protrusion, and not take for granted, because there is a protrusion, that it is a prolapsus. Prolapsus of the uterus may arise from a variety of causes. The causes may be divided into three classes; Those which result from decreased support, as in laceration of the vagina or pelvic floor, which no longer affords the proper support for the structures above, and from which the intra-abdominal pressure, having nothing to resist it, drives out the contents of the passage, causing a hernia. Secondly, we may have prolapsus as a result of increased intra-abdominal pressure, the presence of a growth which fills the abdominal cavity or rests upon the uterus, thus pushing it out. In a patient with a large amount of fat, and the abdomen greatly distended, the intra-abdominal pressure is increased, which renders the orifices less resisting, and consequently favors the tendency of the contents to escape. Third, we may have the condition arise as a result of increased weight in the organ itself; thus from subinvolution of the uterus, or growths in its walls, as the presence of a fibroid tumor. The decreased support, the increased intra-abdominal pressure, and the increased weight of the organ may all be associated in the same individual. Taking the first cause into consideration, we can readily understand if we have a laceration of the pelvic floor which extends back to the sphincter ani, or to one side of the sphincter, tearing through the lavator-ani muscle, the vulva stands open, the anus is pulled back, there is a consequent want of support of the anterior segment of the pelvic floor, the constantly filling bladder without support sags, and the intra-abdominal pressure drives it and the uterus toward the vulvar orifice. A portion of the bladder becomes situated below the level of the internal orifice of the urethra. This portion of the sac is consequently emptied of urine with difficulty. Some of the urine will remain unevacuated. In this sac the accumulating urine and the mucus become decomposed, producing an ammoniacal odor, and an irritating fluid which causes a localized cystitis. The salts are deposited, and if there is a small plug of mucus it affords a necleus upon which large calculi may form. The sagging of the anterior segment of the pelvic floor is recognized as a cystocele. As the anus is dragged backward, accumulation of fecal matter in the rectum causes it unsupported to sag until it rolls out, forming a sulcus below the level of the anus. If the patient is lying upon her back, with limbs separated, and is directed to strain, you will see the eversion of the anterior and posterior vaginal walls. If the tumor is confined to one wall you can readily determine between cystocele or rectocele by the introduction of the finger. In the former the finger passes behind, in the latter in front, of the protruding tumor. In this patient the finger en

ters the vagina behind the protruding mass, and the cervix is situated just behind and at the base of the tumor. The finger can enter the vagina some distance behind the cervix. This indicates that this is not a case of true prolapsus, but one of hypertrophic elongation of the cervix, and that the elongation is at the expense of the anterior part of the cervix.

Procidentia is complete prolapsus, and this term is only applicable to those cases in which the entire uterus is outside the vulva. That in any mass the uterus is outside the vulva can be readily determined by placing the fingers of one hand in front of, and the other behind the tumor, and press them together until we find that the uterus is below. In a case of elongation of the cervix we will find a thin, attenuated cord passing upward, which is the elongated cervix. Generally in hypertrophic elongation of the cervix we find one or the other vaginal wall remaining partially or entirely undisturbed, while the protrusion involves the other. We may have complete inversion of the vagina and still find the cervix elongated.

In a diagram which I show you, you can see the protruding cervix and the inverted vagina, and a cul-de-sac formed in the bladder, and another in the rectum, and yet the fundus of the uterus is nearly in its normal situation. You can readily understand the distress and discomfort a patient must experience, with a protrusion of the vagina as it settles lower in the pelvis, from the sensation of weight and pressure. In the patient I have just shown you, we have an abrasion of the cervical mucous membrane. This abrasion extends upon the vaginal surfaces about it. In some cases there is complete destruction of the mucous membrane, leading to ulceration. Sometimes the mass itself becomes thickened and inflamed, so that its return is attended with difficulty and occasionally is impossible. A protrusion of this kind may result in secondary inflammation of the peritoneum, which causes adhesions of the prolapsed intestines, so that fixation becomes so definite and determined that it is impossible to reduce and return the uterus to its normal situation. The condition of such a patient is exceedingly uncomfortable.

Having a prolapse or procidentia, we now come to the consideration of the method of treatment. The condition was one recognized by the ancients, and is one of the earliest female diseases described. The earlier authors upon the subject were in the habit of regarding the uterus as a sentient body which could be. frightened back in its normal situation by subjecting it to nauseous odors or bringing it in contact with disagreeable animals. They were in the habit of permitting toads and frogs to be placed in contact with the uterus, allowing lizards to crawl over it, subjecting it to fumigation with unpleasant odors, to drive it back to its normal place. Emmett records the fact that a gentleman from one of the Southern States was in the habit of treating such patients among colored women by placing them in a kind of sling in which the head and upper part of the body were lower than the pelvis, and she was kept in this position for three or four weeks, and her vagina filled with a decoction of white-oak bark, which produced such an astringent effect upon the mucous membrane and

walls of the vagina as to contract them and retain the organ in place. In looking over the history of the condition, we find patients were operated upon in various ways, mainly for the purpose of rendering the organ unable to escape from the vulvar orifice: thus, one introduced alternate gold and silver rings, and another did a plastic operation upon the perineum, by which the vulvar orifice was narrowed. Another placed a number of forceps on the vaginal wall, which were left in place until they sloughed, and the cicatrization following these sloughs narrowed the canal. We find a very great difference of opinion as to what supports the uterus in its normal position. One believed it to rest upon the upper part of the vagina like a cork in a bottle. Another regarded the perineum as the grand keystone of the arch; others the ligaments of the uterus as the retaining power; others the peritoneum as the structure which retained it in its normal situation. The truth lies not in any one of these, but in all of them: the maintenance of the uterus in its proper position depends upon the peritoneum, the ligaments, the proper condition of the perineum, and the relation of the vagina to the surrounding tissues. If the vaginal walls are torn during labor from their attachment to the levator-ani muscles, and have lost their muscular tissue, they gradually sag until they become heavy; and even if the uterus is retained in its normal situation by the proper muscular tone of its ligaments, we will sooner or later find an elongation of the cervix result. If the ligaments have lost their muscular tone, the uterus itself will be dragged down, and finally result in procidentia. This displacement is increased by the intra-abdominal pressure, by efforts upon the part of the individual in straining, constipation, or if she is obliged to lift heavy weights; anything which increases the intra-abdominal pressure will sooner or later promote the expulsion or displacement of the organ. With this review of the causes which conspire to maintain the uterus in its position, we come to the consideration of the treatment of displace

ment.

It may be divided: (1) into the restoration of the uterus to its normal place, (2) its maintenance. It is quite one thing to replace the organ, another to maintain it after it has been replaced. With the patient upon her back. we grasp the uterus between the finger and thumb, and push it upward, carrying it into the vagina in the axis of the pelvic curve until it is brought to its normal situation. It may be maintained by mechanical means or surgical measures. The former comprise the various pessaries, such as recommended by Hodge (modified by various men); retroversion pessaries, the posterior bar of which passes behind the uterus into the posterior cul-desac of the vagina, carrying it upward; and the doublecurved pessary of Gehrung; the cradle pessary of Graily Hewitt; ring, glass or rubber ball, and glass or rubber disc pessary. All have been made use of for this purpose. It is necessary that these should be of sufficient size to distend the vagina and maintain it above the vulvar orifice. The difficulty of all pessaries is that the vagina is so prolapsed and the vulvar orifice so large that the instrument, together with the uterus, is soon pushed

through. Then, again, we have various pessaries with external support -a pessary ending in a cup or ring, with rubber band attached to it, by which it is held up and which the patient wears continuously. This keeps the organ in place. But all these pessaries, whether with external or internal support, are foreign bodies and produce more or less irritation of the mucous membrane, more or less discomfort, the patient being constantly aware of their presence; so it is desirable to resort to other measures to bring about the relief of the condition and avoid the necessity of continuing mechanical means. To attain these ends, operative surgery must be evoked. The parts are restored to their normal situation, and an effort is made to bring about a normal condition. The difficulty in the various plastic operations on the vagina, whether upon the anterior or posterior or both walls, is that they narrow the vagina at its lower portion, while there is a tendency to rolling out of the uterus and constant pressure upon the newly united tissues. This keeps up until a process of ulcerative absorption results, and the organ is driven through, when the last condition becomes worse than the first. The first consideration should be to decrease the weight of the uterus. This is done by amputation of the cervix; and second, a plastic operation upon the anterior wall of the vagina. This may be adapted to a particular condition, being a denudation of a triangular, circular, or oval area, according to the amount of and the direction in which the narrowing can best be made. An operation which is frequently effective is that of Stolz, which consists in making an oval denudation and introducing a purse-string suture, which, when tied, contracts the anterior vaginal wall in every direction. The plastic operation upon the anterior must be followed immediately, at the same sitting, by the restoration of the posterior segment of the pelvic floor. This may be done in the form of the Hegar operation, in which the triangular denudation is made high up in the posterior wall of the vagina, followed by the narrowing of the vulvar orifice, or a denudation may be made, as has been suggested by Martin; in dissecting up a column on either side of the posterior wall, the edges of each column are united by sutures, and then the vulvar orifice contracted by an operation upon the perineum. Lefort suggested an operation for prolapsus which consisted in making a vertical denudation, about three-fifths inch wide, upon each the anterior and posterior walls of the vagina, and bringing these surfaces in contact by sutures, so that the raw surfaces of the one lay directly in contact with that of the other. This was reinforced by an operation upon the perineum, narrowing the vulvar orifice, upon which this column rested. I had the good fortune to perform the first operation of this kind done in Philadelphia. resulted in a cure of the prolapsus, which had existed for a number of years. The result of the operation is a septum, which divides the vagina into two canals, and consequently is one which is only applicable to those cases in which the probability of conception has passed. As you can readily understand, it would be exceedingly unfortunate for any individual to have such a condition complicated by a subsequent pregnancy, as the band of adhesion

It

would be sufficiently firm to render the delivery of the patient exceedingly difficult, if not dangerous.

If the uterus is turned backward, so that the intra-abdominal pressure is directed upon its fundus or posterior surface, constantly driving it down upon the newly-united surfaces, the treatment will be incomplete unless measures are taken to bring the uterus forward. The Alexander operation, shortening the round ligaments, will be found to serve a useful purpose, as the organ is held forward, and consequently in a position in which the tendency to displacement is greatly decreased. In the patient I have had before you this morning, a woman sixty-three years of age, in enfeebled health, in whom operation would be attended with more or less shock, possibly in whom there would be danger in the administration of an anesthetic, it becomes a question whether any other procedure of less danger would afford relief. An operation has been recently devised which consists in passing beneath the vaginal mucous membrane a number of circular sutures, preferably wire or silk-worm gut, the first passed just below the cervix, introducing the needle beneath the vaginal wall, carrying it as far as can be reached, bringing it out, reintroducing it at the point of exit, and so on until the vagina is encircled, bringing it out at the point through which it was introduced; a second suture is introduced about half to three-fourths inch below this, and so on until the last suture is passed above the vulvar orifice. These sutures are then drawn comparatively tight and fastened, pushing them back through the opening, so each is a completely buried suture. The result is a narrowed canal, through which it will be impossible for subsequent displacements to occur, and yet sufficiently large to favor drainage. Under the influence of cocaine these sutures may be introduced without the administration of a general anesthetic.

CLINICAL MEMORANDA.

TOXIC ERYTHEMA.

BY CUTHBERT R. BARHAM, M.D.,

OF PITTSBURGH, PA.;

ATTENDING PHYSICIAN TO THE SKIN DEPARTMENT OF THE PITTS-
BURGH FREE DISPENSARY; CONSULTING DERMATOLO-
GIST TO THE ROSALIA FOUNDLING AND

MATERNITY HOSPITAL.

UNDER this designation I wish to call attention to a form of erythema occurring in the course of pus formation. It is most commonly encountered in young children. Its form is usually macular or punctate, though occasionally of the papular or vesicular variety, and its course mild and of short duration, accompanied by moderate rigors, with rise of temperature and subsequent desquamation. The eruption itself is of slight importance, except in those rare cases where the subjective sensations of burning and itching are distressing to the patient.

The common form of small discrete macules of faint pink color, appearing first upon the abdomen and sides of the chest, few in number and widely distributed, are seen in the milder forms of endocarditis and empyema, tubercular abscesses, etc. In some cases of abscess of

the middle ear or of mastoid this form is seen, but usually attendant upon these conditions we find the macular eruption rapidly changing to a papular, and in the severer cases to a vesicular form, with rigors of moderate severity, headache and backache at the beginning, followed by rise of temperature. These symptoms may follow an infected wound, accidental or intentional (as in vaccination), where there is rapid formation of pus and absorption of the toxic products of the same.

The following cases will illustrate a few of the features noted above:

CASE I.-Male, aged 18 months. Had suffered from empyema. Chest had been drained, child improved, and drainage tube removed, the wound being allowed to heal. Rigors and rise of temperature developed one week after the tube was removed, followed next morning by a macular erythema over a greater part of the body. The chest was again drained, the fever subsiding and erythema disappearing the next day.

CASE II.-Male, aged 6 years. Suffering from tubercular abscess of hip-joint. The abscess had been opened, but owing to carelessness of the nurse had later not received proper attention, and was partially closed. A diffuse erythema developed, which rapidly disappeared after the abscess had been thoroughly cleansed.

CASE III.-Female, age 13 years. A punctate eruption appeared twelve hours after a rather severe headache and pain in the back; temperature rose to 102° F. The rash was located on face and chest, and later extended to the abdomen and extremities, at first macular, rapidly (within twelve hours) becoming papular in character, vesicular in places. The diagnosis of measles had been made before the writer saw the case. Improvement was followed by three exacerbations in ten days, when pus discharging through the outer ear disclosed an abscess of the middle ear. Treatment was instituted for this, and resulted in the prompt healing of the abscess and the complete disappearance of the erythema in two days; desquamation slight.

Dr. G. H. Fox (MED. NEWS, January 4, 1896) reports the following case:

Male, age 2 years. Eruption appeared one week after vaccination; became generalized after twelve hours. There was considerable redness and swelling around the pustule, but no signs of injury or external irritation. Eruption began to fade on the third day.

In all except the last of these cases the absorption of some toxic product of the existing inflammation was evidently the main etiological factor, since removal of the pus resulted in the disappearance of the eruption, no local application or other treatment of the eruption having been employed. In the last case both local treatment and a laxative were employed.

Dr. Fox touches lightly upon the etiology in his report, from which I quote as follows:

"These eruptions (seen after vaccination) may depend upon some abnormal condition of the patient, in which case the vaccination cannot be regarded as the prime cause of the rash, inasmuch as it merely evokes an eruption which was already latent, and might have

appeared spontaneously, or from any one of a variety of causes."

This I consider a misleading use of the word latent, inasmuch as many diseases, eczema for instance, may be due to a variety of causes; yet it behooves the physician to seek the exciting cause in each separate case.

Again: Frequently, however, the vaccinated subject. is in normal health, and the vaccinal eruption, like a drug rash, can only be attributed to idiosyncrasy.'

The symptoms noted-headache, malaise, febrile reaction, etc.-indicate that these cases should come under that class designated "erythema scarlatiniform." The phenomena are due to the action of some poison on the nervous system, frequently, as in these cases, the toxins produced at the foci of suppuration. The erythema is only a part of the general process, representing the action of these toxins on the vaso-motor centres. As in all diseases due to such causes, the intensity of the reaction depends to a certain extent upon the normal resisting power of the tissues or organs affected. To this extent we may ascribe its occurrence to idiosyncrasy. In other words, we may regard the toxin absorption as the prime or exciting cause of the rash, the lowered state of health, and consequent subnormal tone of the nervous system as secondary or contributing etiological factors.

A consideration of this class of cases and their etiology is presented, not so much on account of the skin and nervous phenomena as to call attention to a condition which may frequently lead to the diagnosis of an unsuspected pus foci.

32 WESTINGHOUSE BUILDING.

SARCOMA OF THE LARYNX-FINAL REPORT OF A CASE.

BY JOHN A. THOMPSON, M.D.,
OF CINCINNATI, OHIO.

IN the MEDICAL NEWS for October 24, 1895, I reported a case of sarcoma of the larynx, operated upon by a method radically different from that usually followed in laryngectomy. In the interest of truthful medical statistics, I wish briefly to report the further history of the case. At the time the article was written the patient had resumed work and was gaining rapidly in weight and strength. A little later he had a small abscess in the neck which discharged spontaneously through the opening where the tracheotomy tube was worn. After the inflammation and thickening had subsided, no trace of any neoplasm could be found in the tissues of the neck.

Early in November a second abscess developed near the median line, and this abscess was accompanied by a very rapid growth of a sarcomatous tumor in the connective tissue of the neck. The point of origin was at the level of the upper border of the thyroid cartilage on the right side, where the original growth had protruded above the larynx. The growth of this tumor was exceedingly rapid, and attended by a great deal of pain.

As no metastatic growths could at this time be located anywhere else in the body, a second operation was done November 15th. Drs. Oliver and Castle were present and

=

assisted at the operation. The patient was anesthetized by chloroform inhaled from a bit of gauze held over the opening of the tracheotomy tube. This simple method was more satisfactory than any of the more complicated appliances used for this purpose. The growth removed from the neck was about three inches in length, two inches in width, and one and a half inches in thickness. As all the usual landmarks except the anterior border of the sterno-cleido-mastoid had been destroyed at the previous operation, the dissection was necessarily tedious and difficult. The growth had apparently pushed the tissues before it so that only two important structures were involved. The facial artery and descendens noni nerve had to be cut in the removal of portions of the growth. After the large mass of the tumor was removed, it was found that the chain of lymphatic glands lying beneath it had become involved. The highest gland was three-fourths of an inch in diameter. The glands immediately below it were smaller; but after following down the chain until we had reached the sterno-clavicular junction without being able to remove all of the involved structures, the operation was completed with the knowledge that secondary developments in the lungs or mediastinum would soon follow. The growth was suppurating at the time of the operation. The amount of tissue removed from the neck was so extensive that it was impossible to entirely close the wound. Skin-flaps were formed so as to close as much of the wound as possible, and the remaining portion was packed with iodoform gauze.

The patient rallied rapidly after the operation. The wound healed with very little suppuration, and the patient was able to leave the hospital on the seventeenth day.

MEDICAL PROGRESS.

Nasal Tuberculoma.-At a meeting of the Hungarian Society of Otologists and Laryngologists, POLYAK (Revue de Laryng., d'Otol., et de Rhinol., 1896, No. 4, p. 115) reported the case of a woman, 49 years old, who consulted him for an affection of the right nostril, with hemorrhage and gradual obstruction commencing six months before; later the left had become implicated.

The right nostril was completely filled by an irregular tumor, bleeding easily and resembling granulations. In the left, on the anterior part of septum, there was a tissue partly covered with dry crusts, of a dirty white color, of the size of a dollar, flattened, here and there granular, projecting but slightly, and bleeding easily. The tumor of the right nostril was immediately extirpated by means of the hot snare, and it was found that the neoplasm had its base on the right part of the septum corresponding to the lesions described on the left. Hemorrhage was slight.

The tumor consisted of fine reticular connective tissue, with fairly thick fibrous layers, and a few greatly dilated blood-vessels, but altogether it was but slightly vascular. Between the fibres there were numerous tubercles, presenting in the center traces of beginning necrosis. The cells were badly colored, and indistinct, the nuclei small, shriveled, and decomposed. The tubercles contained some very characteristic giant cells of Laughan.

The surrounding tissue was infiltrated with round and migratory cells, and a small number of tubercle bacilli were found, usually appearing in the giant cells.

This was therefore an undoubted case of tuberculosis of

the nasal septum. There were no signs of tuberculosis in the lungs or elsewhere. The patient was well-nourished, without the slightest sign of cachexia, and was only troubled by this affection.

This disease presents itself in two forms: as granular ulcers, and the rare form with formation of a tumor, like the case above related. It seems that the disease attacks women especially, has a strong tendency to recurrence, but seldom leads to general tuberculosis.

nea.

The patient had acquired the art of talking by motion of the lips and cheeks so that he could readily carry on a conversation with those associated with him.

After the closure of the wound, made at the time of the laryngectomy, there was never any difficulty in swallowing. The patient ate all the ordinary foods with as much ease as before the beginning of the malignant growth.

In the discussion following, IRSAI pointed out the importance of not confounding tuberculosis with lupus. The bacillus is identical in both affections, but the clinical symptoms are very different. In pure tuberculom, tuberculosis may also be found elsewhere; and although a tuberculoma may heal spontaneously, recurrences are very frequent, and therefore it is important to destroy all the morbid products, with lactic acid, after complete extir

KREPUSKA recalls two cases in which the nose and the ear were similarly affected at the same time. The tissue extracted from the cavity of the middle ear showed in both cases giant cells and tubercle bacilli.

V. NAVRATIL said that secondary tuberculomata are much more frequent and are often taken for syphilomata, just as tubercular ulcers of the mouth and of the pharynx are often considered syphilitic.

POLYAK concluded by saying that the facts recited show clearly the importance of a histological examination, because a simple microscopical examination of the exu