Laxatives Avere given daily for two or three days prior ORIGINAL ARTICLES. to the operation, and the last day a purgative dose of salts was administered. Tavo or three thorough baths were given by the nurse, and if a plastic operation CLINICAL REPORT OF CASES OPERATED upon the perineum or vaginal Avails, frequent douches UPON AT THE INDIANAPOLIS CITY of bichloride solution (1 to 10,000) were given. HOSPITAL. Previous to abdominal sections, besides thoroughly the skin upon the abdomen, toAvels BY L. H. cleansing Avrung DUNNING, M.D., out of a bichloride solution Avere laid over the abdo¬ OF INDIANAPOLIS, IND. men for several hours. As a rule, ether was used as The histories of the greater number of the cases an anaesthetic. included in this paper, were presented to the Marion Lacerations of the Uteri.—Of the many pa¬ County Medical Society at different times. A few of tients having this pathological condition, but four them excited such interest and comment, that the presented symptoms of sufficient gravity (in our writer thought it might not be an unprofitable task judgment) to demand an operation. The symptoms for him to collect the histories and present them as Avere hyperœsthesia of the and , disorders a whole to the profession. While the number of cases of menstruation, persistent Avith erosions is not large (but twenty-three in all), they present of the mucous membrane of the cervix, subimrolution quite a variety of pathological conditions and of oper- of the , and reflex symptoms Avhich could not ative methods. be attributed to other causes. The results were uniformly good, except in two in- These four patients had had prolonged and ineffec¬ stances. In one case of procidentia, our efforts were tual treatment for the cure of the erosion. The oper¬ a failure, and in one instance of vaginal hysterecto- ation, in all cases, yielded satisfactory results, both my, death followed in a few hours after the operation. in respect to immediate union and subsequent im¬ With few exceptions, the operations were done in provement in the general health of the patients. the amphitheatre, in the presence of the students of In one instance, interrupted catgut sutures Avere the medical colleges of the city. The others were used with entire success. In another case, silk Avas performed in the surgery of the hospital, in the employed for sutures, and good union resulted. In presence of, and Avith the assistance of the house two cases, silkworm gut Avas used. staff of physicians. In three cases, the perineum Avas closed at the same The instruments, ligatures, sponges and dressings time, and the sutures Avere removed at the end of Avere cared for by the nurses. After thoroughly wash¬ eighteen days. In both cases, union Avas perfect. In ing the instruments, they AArere, just before each oper¬ one case, there Avas an erosion and cystic degeneration ation, boiled for one-half hour, and placed in steril¬ about the os that had resisted local treatment. The ized water, or a 1 per cent, carbolic solution. The dissection Avas carried around the os so as to remove silk for ligatures and sutures was boiled before using, all the eroded tissue. After the laceration had been and laid in a separate dish containing a carbolic solu¬ closed by the sutures, a medium sized, soft rubber tion. The catgut Avas taken directly from the alcohol drainage tube Avas carried into the and juniper oil mixture, and the silkworm gut from a through the internal os, and about \\ inch of the carbolic solution. Sponges were used in all the oper¬ tube left hanging doAvn into the vagina. A silk thread ations. Only the best bleached, aseptic sponges were was attached to the loAver end of this tube and brought bought from the instrument house. When brought out at the ostium vagina, so that at the end of four to the hospital, these sponges Avere placed in jars days the tube was easily removed. On account of containing a carbolic solution (1 to 60). When need¬ having done a perineorrhaphy at the same sitting, ed, they are taken from this solution, Avashed in ster¬ the cervical stitches were not removed until the end ilized water, and placed in the solution used during of two and one-half Aveeks, Avhen union by first in¬ the operation. After operations, sponges used in tention Avas found to have taken place, leaving a good cancer, syphilitic or septic cases, are destroyed. patulous os, which two months later Avas found to be The care of the sponges, after use in a simple case, still of good size, every evidence of inflammation of is as folloAvs : First, they are throAvn into a solution the cervical tissue having disappeared. This method of liquor potassa, and alloAved to remain a few min¬ of dealing with intractable erosions accompanying utes, for the purpose of dissolving the blood clots. lacerations of the cervix, the operator has found, in They are then thoroughly Avashed, and passed through many other cases, to be entirely satisfactory. a bichloride solution (1 to 2,000), and placed in the Lacerated Perineum.—In six cases, operations were carbolic acid solution, there to remain until needed done for the relief of this condition. In tAVO of them again. As dressings, we used iodoform and bichlo¬ there Avas simply an incomplete laceration of the ride gauze, and plain absorbent cotton. The patients perineum vvith . In one of these cases, Tait's Avere prepared for every operation, hoAvever simple. flap-splitting operation was done with excellent re-

Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/24/2015 suits. In the other, Schroeder's operation Avas done ent. In the preceding case, the prolapsus Avas due to with equally as good results. a prolapsus of the vaginal Avails. The active force In two other cases, besides laceration of the peri¬ was from beloAv. When the cervix had reached the neum and rectocele, there Avas also laceration of the osteum vagina, the shape and wreight of the uterus, cervix. The double operation was done in both in¬ favored the dilatation of the vaginal outlet and fur¬ stances. In three the method described by Skene1 ther displacement of the organ. This unfavorable vvas employed, and in each the result Avas the cure of shape, and a part of the weight of the uterus, Avere the rectocele, and the formation of a good perineum. made to disappear by the removal of the loAver seg¬ In two other cases there Avere procidentia and pro¬ ment of the organ. The operation upon the poste¬ lapsus of the vaginal Avails, which presented so many rior vaginal Avail prevented a future prolapsus of that points of interest, that I am constrained to give the tube. treatment in detail. In the last case the prolapsus of the uterus was- Mrs. B., aged 45 years, had complete prolapsus of due to pressure exerted from aboAre combined with the uterus. The anterior and posterior vaginal Avails insufficiency of the uterine supports. The staying, Avere also prolapsed. The bladder Avas dragged doAvn, supporting powers of the broad and utero-sacral liga¬ and spread over the anterior surface of the uterus so ments were incompetent, and the supporting power of that, Avhen partially filled, a pouch containing urine the cellular tissue about the cervix had been over¬ protruded from the vagina. come. The rectal pouch Avas so much distended and dila¬ We were unable to obtain the early history of the ted that, when the patient lay upon her side, and a case, but I am convinced the displacement Avas caus¬ finger Avas introduced into the rectum, it could be ed in the first instance by a heavy lift, a strain, or a. passed upward, then forwards into a dilated portion fall. Either the round did not adhere to· of the rectum, Avhich protruded out of the vagina the tissues to which they were sutured, or else were behind the uterus. As usual in such cases, there Avas not strong enough to sustain the weight of the uterus. hyperplasia of the uterus. Pessaries had been used Should this patient return to my clinic saying she in vain. is unable to Avork, and is suffering much pain or dis¬ Thé cervix Avas amputated in the usual manner. tress, I shall consider the question of removing the The vaginal mucous membrane Avas separated from uterus through the vagina. the cervix by an incision all around it, and pushed Neoplasms of the External Genital Organs. upAvards as in high amputation. The cervix Avas then These occurred in a colored woman 28 years old,,— amputated near the internal os, and a modified He- Avith a history of syphilis. Of the numerous neo¬ gar's method employed in covering the stump. Upon plasms, the largest one invaded the and the remoA7ing the sutures at the end of eight days, it Avas upper portion of the . It Avas pedunculated, the found that union had taken place by first intention. peduncle being about 1^ to 2-J- inches at the attach¬ A feAv days after, Hegar's operation upon the posterior ment, smaller, liOAvever, between the attachments and vaginal Avail Avas done. By these combined methods, the bulk of the neoplasm. The latter Avas lobular in we Avere enabled to cure the procidentia, the patient form and as large as an orange, upon the surface of leaving the hospital at the end of seven Aveeks. Avhich Avere several small superficial ulcers, emitting In the remaining case, the patient had already sub¬ a very foul odor. Scattered over the labia and peri¬ mitted to several operations, one upon the cervix and neum Avere many smaller neoplasms of various sizes two upon the vaginal Avails. There Avas procidentia, and shapes. The operation of remoATing the largest but not to so marked a degree as in the former case. Avas a bloody one. The Avhole mass Avas quickly ex¬ When the uterus Avas pushed back into the vagina, it cised, the numerous bleeding points ligated Avith cat¬ was observed that the vaginal tube had been short¬ gut, and the surfaces of the wound immediately ened by the previous operations. As the organ was brought together Avith deep sutures. By this means not greatly hypertrophied, it Avas thought best to the haemorrhage was arrested. shorten the round ligaments by Alexander's opera¬ Wrhen the Avound was cleansed the configuration of tion, which was done. Some difficulty Avas experi¬ the external organs vvas found to be considerably enced in finding the upon one side. When changed. The clitoris and upper portion of the labia found, it Avas discovered t» be small and fragile, but had disappeared, and an integumentary arch overhung was successfully draAvn out 1-J inch and stitched into the meatus, Avhile beloAv, the free margins of the labia the tissues.about the pubes. The Avound healed Avith- overlapped each other. We feared the act of mic- out suppuration, and the patient kept in bed four turation Avould be interfered Avith, but such did not weeks. When she first arose from the bed, our Avork proAre to be the case. The smaller neoplasms Avere seemed very nearly a success, but in tAvo Aveeks the dealt with in a similar manner to the larger ones. uterus had descended so that, Avhen she Avas on her The patient recovered so as to be around the ward in feet for a time, the cervix protruded at the osteum tAvo weeks. vagina, demonstrating that our efforts thus far were Of the tumor, Dr. A. W. Brayton says : "The neo¬ unsuccessful. Hegar's operation was then done upon plasms agree microscopically Avith the gross clinical the posterior vaginal Avail, good union resulting. characters and history. The group pass from simple While this did not cure the procidentia, the patient hyperplasias of connective tissues and epithelium in¬ was able to get about Avith a moderate degree of com¬ to caruncles and papillary groAvths, culminating in fort Avhen she Avore in the vagina a Peaslee's elastic the fully developed lobulated, and tuberculated, ring pessary. orange-sized growths, on the clitoris and labia. The This case, Avhen vieAved side by side Avith the former latter had become a large fibro-cellular mass suggest¬ one, is very instructive. Why Avere our efforts suc¬ ing a diffuse fibroma. cessful in one case and not in the other? Simply be¬ The case is a duplicate of Fig. 16, of Dr. R. W. cause Ave had different pathological conditions près- Taylor's series in New York Medical Journal of Jan, Skene, Diseases of Women, pp.140 and 141. 4, 1890, on 'chronic inflammation, infiltration and

Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/24/2015 ulcération of the external genitals of Avomen.' The and gland. The operation Avas done at city hospital tumors in this case are the result of chronic syphili¬ Feb. 5th,.1891. The entire breast Avas removed. The tic hypertrophy." line of excision was extended toward the axilla, where Vesico- Vaginal Fistula.—Mrs. Z. gave the folloAv- the enlarged glands AA-ere searched for. One only Avas ing history : As a result of severe attacks of found, which Avas as large as an almond. It Avas re¬ gonorrhoea, a distressing and obstinate cystitis moved. A short drainage tube Avas inserted at each had developed. It had resisted all treatment for extremity of the incision. The Avound was closed by two years. What treatment had been employed deep silkworm-gut, and superficial catgut sutures, we could not definitely learn. She stated that and dressed by dusting iodoform along the line of in¬ she had been treated by several physicians, had taken cision and coArering this with a layer of iodoform a great deal of medicine ; had had the bladder Avash¬ gauze, then by an abundant supply of absorbent cot¬ ed out and medicines injected, yet had steadily groAvn ton and finally a rubber bandage of aseptic gauze. worse. As a last resort a vesico-vaginal fistula had This dressing Avas removed the second day, the drain¬ been established several months previously, which age tubes remoAred and the dressing reapplied. The had relieved her to a slight extent, but not enough dressings Avere not disturbed again until the eighth she thought to compensate for the annoyance and day, when they AA*ere taken off and the stitches re¬ distress occasioned by the constant dribbling of urine. moved. Union by first intention had taken place the She earnestly desired to have the fistula closed. An whole length of the incision, except Avhere the drain¬ examination shoAved some induration of the labia age tubes were inserted. Again the dressings were and other external organs. The vagina had a macer¬ applied and allovA-ed to remain one Aveek when the ated appearance and Avas someAvhat indurated, but wound was entirely AArell. Then only a thin layer of there was no ulcération anyAvhere to be found, neither gauze held in place by a light bandage was applied. Avas there any active inflammation anyAvhere to be The patient Avent to her home in a distant part of seen. The fistula Avas small and situated midAvay be¬ the State at the end of three Aveeks, and I have not tween the meatus and the os. No preliminary treat¬ since seen her. ment Avas instituted except hot Avater douches, to Cystic Tumor of Mammary Gland.—Mrs. K., aged which was added boracic acid ( 3ij to oj). 28 years, Avell nourished, the mother of several chil¬ The operation Avas a simple one; a strip of tissue dren, the youngest of which Avas eighteen months of one quarter inch in width, Avas removed from around age. The tumor had been pronounced malignant and the fistula. Six sutures of silkworm-gut AA^ere used, she came to the hospital to have it removed. An ex¬ three deep, and three superficial. A Skene-Goodman amination of the breast revealed a tumor about the catheter Avas left in the bladder, Avhich Avas remoAred size of a hen's egg,located in the substance of the gland, and cleansed every eight hours. A small rubber tube midway between the nipple and axillary border. It was fastened over the external end of the catheter Avas deep-seated, rather hard, movable, and not nod¬ which conveyed the urine to a small earthen dish in ulated. Pressure upon it caused a sanguinolent fluid the bed. The bowels Avere moved the third day and to discharge from the nipple. So profuse Avas this every second day subsequently. \raginal douches of discharge that the patient stated she AA-as compelled boracic acid solution Avere given regularly twice a to wear cloths over the nipple to protect her clothing day. On removing the stitches on the tenth day per¬ from the discharges which occurred every day. The fect union had taken place. nipple Avas not extracted, nor was there SAvelling of The catheter Avas discarded and the patient alloAA'ed the superficial veins. She suffered but little pain, to void urine in the natural way. At first there Avas and no impairment of general health. The tumor, a frequent and irritating desire to micturate, but it which she thought due to an injury, had developed gradually became less frequent. She left the hospi¬ within six months. tal in two weeks after the stitches were removed. At I diagnosticated the tumor an adenoma,and removed that time she was able to retain her urine one hour, it in Nov., 1890. A thick layer of adipose tissue over¬ and sometimes, two hours. The urine contained no lay the gland. By an accident the tumor Avas cut blood and but little mucus. into, when there Avasagush of sero-sanguinolent fluid. She did not complain of much pain. Unless she Under the circumstances it Avas difficult to estimate greatly overstated her sufferings before the fistula the amount of this fluid, but there was not less than vvas formed, the drainage was beneficial. I have not an ounce nor more than two ounces. The tissues been able to see the patient since she left the hospital, about the cyst walls Avere so hard the operator thought so do not knoAv her present condition. he was dealing with an adenoma which had undergone Two Cases of Amputation of the Mammary Gland.— partial cystic degeneration. He therefore decided to Mrs. J., aged 35 years. Mother of one child, 5 years remove the AA'hole gland, Avhich Avas done. The Avound of age. About one year ago noticed a small tumor in Avas closed and dressed in the same manner as in the the breast. When first noticed it Avas not larger than preceding case. There was slight suppuration in the a hickory nut : Avas hard, tender and movable, but loAver angle of the wound ; the temperature reached deap seated. It gradually greAv and became nodular 101°F., the third day, then fell to normal and remain¬ and painful. When first seen by the operator it was ed so until recovery was complete. She left the hos¬ the size of a large orange, apparently involving nearly pital in three Aveeks, well. the Avhole gland. Irregular in outline, nodular and Dr. Brayton, Avho witnessed the operation and ex¬ flattened upon the under surface, it Avas attached to amined the specimen, makes the folloAving statement : the skin, but movable. The axillary border of the "In this case the microscopical examination confirms nipple was retracted, and two small areas of skin the clinical history. There Avas a AArell marked inflam¬ were attached to the upper surface of the tumor. The matory Avail surrounding the cyst, which probably tumor was quite painful, and one axillary gland Avas arose from an injury. The tumor on excision and found involved. I did not hesitate to pronounce it a examination exhibited none of the character of ade¬ case of carcinoma and advised extirpation of tumor noma, carcinoma, or fibroma. The tumor proved to be

Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/24/2015 a benign lacteal cyst maintaining through the ducts and as this Avas folloAved by an attack of peritonitis' its connection Avith the nipple." rupture of the cyst probably took place at that time- Ventral Hernia.—Six months previously the patient Operated Dec. 12, removing a 38-pound tumor. There had had the removed, by the Avas a large rent in the anterior Avail of the cyst, while writer, for chronic inflammation of the appendages the lower abdominal cavity Avas filled Avith a colloid Avith . Her recovery had been a speedy one. material. Many soft and extensive adhesions were The union in the abdominal incision had been by found ; more extensive and firmer within the right first intention, except at the lower angle, where a finer inguinal region. A large glass drainage tube was cicatrix had formed. She left the hospital eight inserted and allowed to remain for twenty-four hours. Aveeks after the operation, and Avent to Avork, leaving Temperature reached its highest point, IOI-3-0, and off the abdominal bandage. A few months later she pulse 136, upon the third day. Upon the eighth day came to me, complaining of pain and Aveakness in the she seemed to be convalescent, but upon the twelfth lower part of the abdomen, where a hernia Avas found. day the temperature began gradually to rise, when it She Avent to the hospital, and in due time was oper¬ ranged from 99° to 100.6°. The tongue became dry ated upon for radical cure of the hernia. It was and furred and the countenance anxious, but there small and easily reduced. Over the prominent point Avas no tympanitis. On the fifteenth day the pa¬ of the protrusion the scar tissue widened so that it tient seemed very sick, and I became convinced that Avas one-half inch across, and very thin. An incision there was pus forming at some point, and upon was made through this and the tissues divided searching found an accumulation in the pelvis, upon through to the hernial opening. This opening read¬ the right side. I could outline a distinct abscess ily admitted the tip of the index finger. The edges Avith tense Avails bulging toward the rectum, the loAver of the ring were pared doAvn to the peritoneum, Avhich portion of Avhich could be outlined by vaginal ex¬ Avas not opened. Three rows of stitches were intro¬ amination. Distinct fluctuation was elicited by ex¬ duced, the first extending from the skin one-quarter amination with one finger in the rectum and another inch from the line of the incision, and were passed in the vagina. A trocar Avith cánula Avas thrust into through all the tissues to the bottom of the opening, the abscess through the A^agina, an aspirator attached, but not including the peritoneum ; they Avere then and little more than a pint of thick pus draAvn off. passed upward from the bottom of the wound through The cavity of the abscess was then Avashed out with all the tissues, emerging through the skin at a point a 1 per cent, solution of carbolic acid. At this time corresponding to the points of entrance. Of these —8:30 a. M.—the pulse Avas 112 and the temperature there Avere three. The second row of stitches were of 100° ; at noon the temperature Avas 100-|°, pulse 120 ; catgut, and included only the muscular and fasciai at 5 p. M., temperature 99°, pulse 103 ; at 9 p. m., tissue. The third and superficial roAV, four in num¬ temperature 98f°, pulse 96. From this time fonvard ber, included only the cutaneous and sub-cutaneous the temperature never Avent above 99°, though the tissues. The catgut stitches were tied first, then the pulse Avas several times as frequent as 120 per minute. deep suture (silkworm-gut), and lastly the superficial The patient made a good recovery. A feAv days after ones. The sutures were removed on the ninth day, the evacuation of the abscess there could be found when perfect union Avas found to have taken place. upon digital examination no trace of indurated The patient begged to leave her bed on the tenth day, tissue in the pelvis. but Avas not permitted to do'so until the end of two High Amputation of Cervix Uteri for Epithelioma. Aveeks. She Avore continually a firm, well-fitting ab¬ —This patient was a young married woman, Avho dominal bandage. Three months subsequent to the four months previously had been delivered of a operation there was no evidence of the return of the healthy child. There was an extensive laceration of hernia. the cervix. The epithelioma sprang from the cervi¬ Pyosalpinx and Chronic Peritonitis. Laparotomy cal , involving the anterior lip of the and removal of tubes and ; —irrigation and cervix. A microscopical examination of the removed drainage; recovery. Miss B. B., aged 24 years, was portion of the neoplasm pointed unmistakably to its admitted to hospital during an attack of pneumonia. malignancy. The cervix Avas removed at its Two weeks later complained greatly of pelvic pains. junction Avith the body of the uterus. We experi¬ On examination found an irregular mass upon either enced some little difficulty in arresting the haem¬ side of and posterior to the uterus. Pronounced these orrhage from the uterine artery upon one side, but as distended tubes. A few weeks later, Avhen she had otherwise the operation was quickly and easily ex¬ sufficiently recovered from her acute sickness, the ecuted. The mucous membrane of the vagina and the appendages were removed. Both tubes were found stump were stitched together so that the stump was distended with pus and the ends occluded. The nearly covered by the flaps. Union by first intention ovaries were found in a state of parenchymatous took place. For two months the patient was Avell, chronic inflammation. There was also chronic peri¬ Avhen she began having irregular sanguinous dis¬ tonitis, limited chiefly to the pelvis and loAver part charges and much pain, intermittent in character. of abdomen. Irrigated thoroughly and drained. The A feAv weeks later an examination shoAved the stump patient made a quick recovery, both from the effects apparently healthy, but the Avail of the vagina exten¬ of the operation and from the chronic peritonitis. sively invaded. Ulcerative processes beginning in a I saw her at the end of two months, when she was line reaching from a distance of one-half inch in apparently Avell. front of the os forward to near the meatus urinarie. Ovarian Tumor. Mrs. H., aged 49 years ; This operation, though carefully done and all of the AvidoAv one year; married— at 40. Menopause was cancerous tissue thoroughly removed, gave but a two established at 47. She enjoyed fair health until months' respite. Does another such case present within the last few months, but had noticed bloating itself in Avhich there shall appear as great evidence of the abdomen for some months. She was taken of malignancy, I shall not stop short of the removal •.suddenly sick eight weeks previous to my seeing her, of the entire organ.

Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/24/2015 Large Fibroid Tumor of Uterus.—Mrs. W., aged 29 found all the characteristics of adenoid cancer in the years; colored. She had noticed a tumor in the specimen. loAver part of the abdomen for four or five years, The patient and her husband desiring it, the uterus Avhich had gradually groAvn in size until it reached was removed through the vagina. The operation was from Ioav down in the pelAris to a point one inch above not difficult, requiring but forty minutes for its com¬ the umbilicus. The tumor had developed so low in pletion. Forceps Avere used, two to each broad liga¬ the uterus that the cervix Avas very nearly obliterated. ment; two others Avere required to close bleeding As no pedicle could be formed, permitting extra-peri¬ points. There Avas but slight haemorrhage during toneal treatment, it Avas decided to remove the ap¬ the operation, the vagina being dry where the tampon pendages from the uterus. An incision was made, was placed. extending from a point one inch above the umbilicus The patient Avas put to bed in good condition and in the median line doAvn Avithin two inches of the rallied well. Five hours after the operation, upon pubes. The tumor Avas exposed and search made for my return to see the patient, the house physician the ovaries and tubes. These not being found, the informed me he had just discovered the patient Avas incision Avas enlarged above and beloAv, and the tumor bleeding. Upon examination there Avere found slight lifted out of the abdominal cavity, Avhen Ave were signs of haemorrhage, and upon removing the cotton able to find the right and tube. The uterine from around the forceps, the lower portion of the end of the latter was enveloped and altogether in¬ vagina could be seen filled with clots of blood. The volved in a small fibroid which sprang from the patient showed signs of exhaustion, but the bleeding uterus. This mass, together Avith tube and ovary, was still going on. Though I appreciated the danger was removed after ligating the tissues, uniting them from shock in opening the vagina and attempting to to the uterus with chain-stitch ligatures. The left arrest the haemorrhage, hasty preparations Were made ovary and tube could not be found. The bladder Avas to do so. adhesent to the under surface of the abdominal wall, The patient was brought across the bed, the cotton just above the pubes, and Avas accidentally cut removed from around the forceps and the vagina through the serous and muscular coats. The length tampon Avithdrawn. The forceps Avere pressed aside of the incision being about one and one-half inch. so that the way was clear to enter the vagina. The This incision Avas sutured Avith a continuous catgut, clots were removed by the finger, while two fingers of A careful toilet was made of the peritoneum, after the left hand depressed the posterior vagin. 1 wall, Avhich the tumor vvas returned to the abdominal the blood was carefully mopped away Avith cotton cavity. Tavo gallons of hot sterilized Avater were probangs. poured into the cavity and allowed to run out, No Fortunately the bleeding point Avas found. It Avas drainage vvas employed. The patient made a speedy not in the broad ligament stump, but in the tissues and uninterrupted recovery. On the 11th of May severed from around the os. The tissues had pulled last I saw the patient and examined the tumor. I out from the end of the forceps, leaving the open end found it much smaller, probably about one-half the of the artery free. I saw I could not ligate this small size it was when operated upon. She had menstru¬ vessel Avithout removing the forceps. This I feared to ated but once since she left her bed, two and one-half do lest other points Avould be exposed and more bleed¬ months previous. She expresses herself as feeling ing follow. strong and well. The only thing to do Avas to cauterize Avith thermo- Adenoid Cancer oj the Uterus.—Vaginal hysterec¬ cautery, Avhich was done. An iodoform tampon Avas tomy. Death, of hœmorrhage, ten hours after the introduced and the patient changed in bed and made operation. Mrs. Gr. G., aged 27 years. Had been an as comfortable as possible. Our efforts, though not invalid nine years. Confined to her bed most of the continuing over ten minutes, had added greatly to time. her exhausted condition. For a time she vvas almost Nine years ago she gave birth to her first child. pulseless. Under the influence of rest, stimulants, Soon after this confinement her physician informed and external heat she partially rallied for a time, her she had a cancer of the neck of the Avomb. This then gradually sank until her death at 2 a.m., ten he thought to destroy by the application of caustics. hours after the operation. No haemorrhage occurred One year ago she gaATe birth to a Avell-developed after the cautery. Haemorrhage is one of the chief child, and had nursed until the day of her arrival at causes of death resulting from a vaginal hysterec¬ the hospital, Feb. 23, 1891. tomy. The forceps giving the trouble vvas a large I examined her the day of her arrival. She was one with a short bit, and hung loosely when not much emaciated, scarcely able to sit up. She com¬ stayed. I do not believe haemorrhage occurs any plained of a continual burning pain through the pel¬ more frequently from the use of the forceps than the vic regions, and much irritation of the bladder. She ligature. I have used them several times since the had not menstruated since the birth of her last child. above operation Avithout secondary haemorrhage, the There was a slight, thin , which patients all recovering, but have not used them Avith¬ irritated the external organs. A physical examina¬ out the folloAving precautions : For clamping bleed¬ tion showed the vagina large and relaxed, the uterus ing points in the tissues nearest the vaginal outlet movable, of normal size and in normal position. There only, small forceps are used and these are tied to the was an absence of the vaginal portion of the cervix. large clamps, Avhich include the broad ligaments. The cervix could be felt in the center of the vaginal Cystic Temor ofAnterior Vaginal Walls.—The patient, vault, and had an excavated feeling and appearance, Miss H., Avas a subject of valvular heart disease. Within the os could be seen a small, irregular pout¬ The tumor Avas oblong about the size of a hulled ing mass of a deep red hue, which bled upon touch¬ butternut. The centre of the tumor Avas to the right ing it Avith the probe. A portion of it was removed of the median line, overlapping the . It had and submitted to Dr. Hessler for microscopical ex¬ been mistaken for a uretlirocele, but from this it Avas amination. He reported two days later that he had easily differentiated. The tumor was elastic and

Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/24/2015 fluctuating, and did not diminish by pressure. A the ulcerated surfaces touched Avith carbolic acid and sound introduced into the urethra found no pocket dusted with iodoform. A copious rectal injection of between tne meatus and bladder. On the contrary it hot water Avas ordered once a day, and a bichloride pursued a normal course and direction until the (1:10000) Araginal injection twice a day. Every third bladder Avas entered. On account of the acute sick¬ day the ulcerated parts were to be touched Avith car¬ ness of the patient no attempts at radical cure were bolic acid and dusted Avith iodoform. She was ordered admissible. So we aspirated the tumor, drawing off to take internally large doses of iodide potassium, and one-half ounce of the colorless fluid. The patient moderate doses of deodized iron, vvhile a liberal diet died of the effects of paralysis and heart disease a Avas directed. This treatment Avas followed for two fevv Aveeks later. At the time of her death the tumor months, by Avhich time the fistulous opening had Avas refilling. become so small as to scarcely admit the point of a Hypertrophy and Elongation of the Infra- Vaginal uterine sound. The healing Avas by granulation, and Cervix.—Amputation with knife and scissors. Mrs. Avas gradual. Twice during the time she was under P. P. Avas aged forty years ; had never borne children. treatment she had quite profuse haemorrhages from Stated she had had "falling of AAromb" for fifteen the vaginal ulcerated surfaces. Once Avhen most years, and that it had been gradually becoming worse, profuse itAvas arrested by the administration of a hot until the Avomb protruded so far as to make Avalking vaginal douche. She left the hospital before the painful. In other respects the patient appeared well, healing was complete, yet her general health was fully nourished, and able to do the housework for a much improved, and the feces passed in the nat¬ large family. ural manner. Upon examination the os Avas found protruding Endometritis and Painful Menstruation.— Dilation from the ostium vagina about one inch. The examin¬ of cervical canal, curettement of uterus and drainage. ing finger Avas easily introduced into the vagina both Mrs. B., aged 40 years. She complained of con¬ before and behind the cervix. The cul-de-sac was siderable pain in the loAver part of the abdomen, normal, there Avas no prolapsus of the bladder, and but Aresicle irritation and severe intermittent pains during little if any descent of the body of the uterus. It menstruation. The flow, Avhich was scant, contained was clearly a case of infra-vaginal elongation of the small clots of blood, the discharge of which Avas cervix uteri with hypertrophy. always preceded by pain. There Avas a moderate The sound passed into the uterine canal five inches. amount of uterine discharge aaLucIi Avas irritating to The protrusion of the cervix Avas greater during men¬ the external organs. She stated that several years struation. Menstruation, though profuse, was never before she had been operated upon for the cure of painful. The patient Avas placed upon the side and lacerated cervix uteri. A physical examination a Sims' speculum introduced. The cervix was am¬ shoAved stenosis of the os, and an enlarged and sensi¬ putated with knife and scissors. Excessive haemor¬ tive uterus. rhage Avas prevented by an elastic ligature tied around The vagina Avas Avashed out Avith a bichloride solu¬ the cervix at the vaginal junction, While the cervix tion, the os dilated Avith Goodell's steel dilator, under Avas severed just beloAv the ligature. the influence of ether narcosis. The The sutures Avere placed after Hegar's1 methods, was large, the sound moving about as in a small the parts irrigated with a hot bichloride solution abscess cavity. It Avas found to contain a small (1:1000), and a vaginal tampon of iodoform gauze amount of tough mucus. The dilation of the uterine left in the vagina. There was but little loss of blood. cavity Avas probably due to the presence of secretions The patient reacted well, and made a comfortable from the uterine mucosa and the accumulation of and easy recovery. menstrual fluid from the cavity with difficulty. The On the ninth day the sutures Avere removed, when cavity Avas swabbed out with cotton dipped into a perfect union was found to have taken place. The bichloride solution. A light curetting Avas done with amputated portion of the cervix Avas three inches a dull curette and the cavity again swabbed out, and long, and one and three quarters inches in diameter. a thorough application of carbolic acid made to the I have examined this patient several times since the mucosa. A soft rubber drainage tube was carried operation. The lower end of the stump is three Avell up into the uterus, and the vagina lightly tam¬ inches above the ostium vagina, and the symptoms poned with iodoform gauze. The patient was kept of prolapsus have entirely disappeared. in bed four days. The third day the drainage tube Recto Vaginal Fistula.— . ., colored ; aged 50 years. Avas removed and the vaginal douches given twice a Patient much emaciated, had suffered from syphilis day. She made a satisfactory recovery, and remained for several years. Complained of Aveakness, and at the hospital until she had passed through one men¬ stated that "passages from bowels come from wrong struation, Avhich was painless. The pain in lower opening." part of abdomen had gradually disappeared. A physical examination showed syphilitic ulcéra¬ tions about the external genitals, and a large recto- vaginal fistula. Tavo or three fingers could be readily passed from the rectum through the fistulous opening OSTEOMALACIA. into the The stated that there had BY D. S. LAMB, M.D., vagina. patient D. C. been soreness in that region for a year and that dur¬ OF WASHINGTON, ing the last six months she had noticed the fecal pas¬ The following is a description of the skeleton of a sages coming through the vagina. The tissues about woman Avho died of osteomalacia ; it was obtained by the opening Avere ulcerated, and beyond the ulcéra¬ me for the Army Medical Museum, where it is cata¬ tion there Avas much induration. For obvious rea¬ logued as No. 10,010, Pathological section. Its entire sons the idea of a plastic operation could not be en¬ Aveight is only 2 lbs. 13 oz. tertained. The parts Avere ' thoroughly cleansed and The bones generally shoAv extreme rarefaction ; the tissue reduced to almost thinness. 1 Gordel's Lessons in Gynecology, p. 214. Fig. 74. compact paper-like

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