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cian, Dr. C. Kellar, of Santa Fe, Kansas, had of the perineum and lower half of the vagina. been consulted in regard to these, as well as Dora S-, aged 16, came under observation the non-appearance of the menstrual flow. His June 2, 1888. The patient had been treated examination disclosed the condition of the for a year by various physicians for violent genital organs, with the gradually increasing attacks of uterine colic occurring at menstrual tumor in the abdomen; operation was advised epochs. She was anæmic and poorly nourUnder the influence of chloroform a trochar ished. Examination disclosed a central tumor was passed through one protuberance diago- within the abdomen, above the pelvic brim, nally through the central depression into the which was evidently the uterus. There was other protuberance. About twenty ounces of an entire absence of the perineal body, the a thick, tenacious dark fluid was slowly exuded. anal orifice being trumpet shaped, its anterior The opening was carefully enlarged and the wall sloping upward to the pubes from a point patient was put to bed, absolute quiet being at about the apex of the perineal body. There enjoined. The uterus gradually emptied its- was a bulging down of this wall within the self, without marked pain, until it could not rectum giving a distinct feel of fluctuation. By readily be felt above the pubes. The operation an exploratory puncture through this wall, as well as the after treatment was strictly asep- about one ounce of a thick black fluid was tic. Hot bi-chloride injections at intervals of withdrawn. It being near the time of her supfour hours, with carbolized compresses of cot- posed menstruation, operation was deferred ton to the external parts. The temperature for the time. At 7 P. M. on the fourth day of the day after the operation rose to 100°, but coming under observation, the patient having fell to normal on the third and remained at been up and about during the day, violent normal on the fourth and fifth day. The inject- attacks of uterine colic set up. Sulphate moring fluid came away clear on the second day. phiæ by hypodermic injection in Ya-grain doses The appetite was good, the bowels regular, no was used with but little relief. At midpain and every symptom indicated a recovery. night the pain suddenly ceased, and the attendOn the morning of tlie sixth day, the patient ing nurses' attention was called to the colstill confined in bed, a chill occurred followed lapsed condition of the patient. When I saw by fever, which continued until the tenth day, the patient an hour later, I found both labia when death closed the scene. The symptoms were enormously distended and black, apparand cause of the fever were those of septicæ- ently with infiltrated blood, the infiltration mia.

extending up over the pubes upon the abdomPost mortem examination disclosed the ab- inal wall. An incision in both labia withdrew dominal cavity filled with pus. The uterus, a large quantity of Auid similar to retained fallopian tubes and vagina were normal in menstrual fluid. Consultation determined their external appearance. On being laid open that nothing was to be gained by operative it was found that there were two uterine cavi- interference. The patient was in a state of ties communicating each with their respective profound collapse, from which it was imposfallopian tube and two vaginal tracts. The sible to arouse her. Death occurred in a few longitudinal central depression spoken of be- hours after being seen. No post mortem was fore was caused by the attachment of the obtained. The thing to be regretted in this. septum to the closed hymen. The diagonal case is that operation was not immediately puncture had emptied both cavities; no pus attempted, when the nature of the case was found in the entire genital tract, that be- rendered certain by aspiration. There should ing remarkably free from any sign of inflam- have been no delay on account of a coming matory action. As was afterwards ascertained menstruation. infection was carried to this patient by a CASE III.-Atresia vagina vith infantile vaginal tube, which used in another uterus. patient suffering from sepsis, the result of an

Kate W- , a well formed and well nourished abortion.

young woman, aged 26, was seen with Dr. CASE II.--Atresia of the vagina with absence Eggers, of Kansas City, October 10, 1888, in




regard to her failure to menstruate and a de- iormed. The vaginal tract led directly into formity of the genital tract. Inspection the bladder, the posterior wall sloping upward showed no vaginal opening whatsoever. Ex- so that the bladder was a cul de sac for the amination by the rectum and bladder disclosed vagina. The ureters had fortunately escaped a line of dense tissue, between the rectum and fnjury. With the vesico vaginal fistula or the urethra and bladder, with a hard round opening, we have nothing to do, although no body high up which was determined to be the operative procedure could be attempted for its

There had been since the age of cure without at first getting rid of the partial puberty definite monthly symptoms pointing atresia vagina. After repeated efforts and perto a menstrual molinien, but so far as any sistent treatment, the upper vaginal vault was objective symptom (that is, accumulation of completely opened and the uterus again left blood) was concerned, no operation was neces- free in the vagina. Nothing especial belongs sitated. The patient, feeling that she was not to this case, save that it is illustrative of a class as other women, insisted upon surgical allevia- of atresiæs which result from injury during tion. A transverse incision was made in the labor. dense septum, between the meatus urinarius CASE V.-Atresia of the vagina with loss of and the anal orifice, and with the finger guard the entire generative organs, as the result of .ed from the rectum and bladder, an opening injuries sustained during labor. was burrowed up to the body which had pre.

Mrs. Nettie B—, age 21, married, came under viously been felt. This was ascertained to observation February 18, 1886. The patient be the uterus, but extremely small, though was anæmic in appearance and gave eviperfect in shape as far as could be determined. dence of having passed through a severe course A closed glass vaginal speculum was left in of sickness. The history obtained was that the opening. The patient rallied from the four months previously she had been delivered operation with no unfavorable symptoms. The instrumentally of a child. Her

recovery case passed from observation wearing the

was extremely slow. Vaginal injections glass plug, but it has since been learned that were used after labor took place. About from disinclination on the part of the patient twelve days after delivery a mass of tissue to persist in treatment, an opening only two came from the vagina, about the size of four inches in depth persists, the upper extremity fingers including their bases. This mass, from being closed. The menstrual molimena have the history and description, was neither blood been gradually losing their force and fre

nor placental tissue; but confirmation of this quency. In this case the ovaries evidently

was wanting since it had not been submitted gave the force exciting to menstruation, but to the examination of any physician. Between the uterus being undeveloped there was no the second and third week after delivery, it exudation of blood.

was observed that the vagina injection was Case IV.-Atresia of the upper third of the given each time with increasing difficulty. I vagina, the result of labor.

do not know as to whether the attending playMrs H-, age 27, married,came under obser- sician was consulted in regard to this. Howvation April 4, 1888, for a condition of the ever, according to the history given, the openvagina, which dated back to a labor six months ing gradually decreased in depth, until finally, previous to being seen. The anterior wall of complete occlusion of the vagina resulted. It the vagina had been torn through at about the was for this condition that counsel was sought. base of the bladder, allowing this to fall down Inspection showed that the vaginal orifice becompletely obliterating the anterior and pos- tween the labia was closed completely, a diagterior cul de sacs of the vagina. In fact, the onal line of cicatricial tissue running from the whole upper portion of the vagina was filled right labium at about its middle, upward to with cicatricial tissue, completely concealing the left. Bi-manual examination disclosed a the uterus. At one side a minute opening dense thickened layer of tissue between the was found leading by a tortuous canal to the rectum behind and the urethra and bladder in os, through which menstruation was per- front, extending upward to a small accumula

No spec

tion or body about three inches above the plug was still worn, giving but little discomclosed vaginal orifice, which was diagnosed to fort. Her general health was good, she being be the cervix of the uterus. Through the able to perform all the duties of a farmer's abdominal wall nothing could be felt. I con

housewife. During the two weeks when she fess that the diagnosis was not plain, but was under observation at this time, small portaking the history in consideration, it was de- tions of skin were imbedded in the denuded surcided to make an attempt to open the vaginal face. A year after the operation, removing to canal. No light was thrown on this case by the vicinity of Kansas City, she was seen again, any menstrual molimina, nor did we expect to

when it was found that the entire opening was find what was afterward disclosed. An inci- covered with a membrane, with the exception sion was made with a knife along the line of of a spot at the extreme point of the cul de sac, cicatrix, and with the forefinger we carefully about the size of a silver dime. By dusting burrowed through the tissue, between the rec

this with iodoform and packing the cavity with tum and the urethra and bladder. The finger cotton, a complete covering was obtained at worked upward easily, until the body men- the end of a few treatments. The opening tioned as the supposed cervix was reached,

when seen last, two months ago, was between when the finger was forced upward and a

two and one-half to three inches in depth, of short distance above broke through into space.

sufficient caliber to admit a small vaginal specGoing back to the point of resistance, the ulum and covered by a pink membrane not opening was worked below the resisting body unlike a normal vaginal membrane. and in a short distance again broke into space

ulum or cotton plug had been worn for a year as before. The resisting body was found to be past. By careful inquiry no evidence of a a mass of the cicatricial tissue. With the fin- menstrual molimen has at any time occurred ger of one hand in the rectum, and the fore since her delivery in 1885. The opening on a finger of the other hand passed through the separation of the labii, looks normal and evidilated urethra into the bladder and the fingers dently subserves a useful purpose. Sexual of an assistant meeting these through the aptitude, however, is to some extent lost. The abdominal wall, a careful exploration was conclusion in this case, which, perhaps, is a made for the missing uterus, fallopian tubes unique one, is that the mass of tissue which and ovaries; but nothing could be found; no

came away at about the 12th day after delivuterus, no fallopian tubes, no ovaries.

A ery, was the uterus which was sloughed off on Linus closed glass vaginal speculum or plug, account of death occurring in it as the result three inches in length by one and one-half in of injuries sustained at the time of delivery. diameter was inserted along the tract of the That the patient was delivered of a child at lower opening and the patient put in bed on the time stated, is corroborated by a letter appropriate treatment. No unfavorable reac

which I have in my possession, from Dr. E. E. tion occurred, the patient being up and ready Hamilton, of Wichita, who was called in conto return home by the ioth day. On account sultation at the time of delivery. That the of the profuse discharge of pus from the open

internal organs of generation were not present ing, a gutta percha plug with holes bored in its at the time of operation is evidenced by the closed extremity to allow of drainage, was sub- thorough search of the pelvic cavity, as well as stituted in place of the glass instrument. The the subsequent absence of symptoms pointing patient was instructed to retain the plug con

to their presence. stantly in situ, and only to remove it morning

From these cases it is not difficult to draw and evening when a disinfectant wash

the following conclusions: used for cleansing purposes.

Six months 1. The necessity of operative interference in after the operation, the patient was seen again. all cases where there is an establishment of the The opening was patulous, being covered for an menstrual function and an accumulation of inch and a half over its lower extremity with blood. mucous membrane; the remaining portion 2. The great danger of septic infection, even being still denuded and secreting pus. The more so than in other operations. Hence here


if nowhere else, the necessity of every aseptic if not relieved, lead to death in a few hours or, precaution.

at most, in a few days, is called acute. 3. The possibilities of success, under circum

While the form which gradually develops, stances in which it might seem impossible.

is unaccompanied by sudden and great depres4. The necessity of persistence in treatment, sion of the vital forces, and which leaves the both on the part of patient and physician.

intestine pervious, but of diminished calibre,

may exist for several months but usually proIntestinal Obstructions,

duces death in time, is called chronic.

The following case which recently fell unRead before the Northeast Kansas Medical der my notice, illustrates the chronic form: Society, at Horton, December 3, 1889. Patient a little girl aged twelve, had been

sick about two months when I saw her, and BY L. REYNOLDS, M. D., OF HORTON.

was greatly emaciated. In fact I regarded her as the poorest person I had ever seen alive.

As nearly as I could get the history of her This term comprehends conditions widely different in their pathology.

illness, it began with slight indisposition, I shall not attempt to enumerate all of the poor appetite, didn't want to go to school, ocdifferent pathological conditions that may

casionally vomited, was without fæcal movedirectly or indirectly interfere with intestinal ment for two weeks and but little for four calibre.

weeks. No medical aid was sought during the As intussusception is the most frequent and first two weeks of her sickness. fatal and consequently of greatest interest to

Her attending physician first found the the general practitioner, this paper will be abdomen considerably distended, but, as I confined to the consideration of this form of understood could find no tumor other than the obstruction.

general abdominal distension. Later on, perThe small intestine is a cone about twenty haps two weeks later, an injection of soap suds, feet long of which the upper end forms the base one-half gallon was given and retained twentyand the lower the apex. The same is true of six hours. Following the injection the little the large bowel, except that it is only about girl got easy and slept well without an anofive feet long

dyne. The majority of cases occur under the age

After the lapse of the twenty-six hours her of twelve, and one-fourth of all cases occur bowels began to move and a tendency to between the ages of three and fifteen months. diarrhæa developed and continued until the

The frequent occurrence of this form of ob- child's death three or four weeks later. struction in infancy is thought to be due to Immediately after the action of the enema greater frequency of intestinal irregularities a tumor a little larger than an adult kidney, in the intestinal movements than in older but of about the same outline, could be felt children. Also to the thinness of the intesti- in the upper portion of the right lumbar renal wall due to the lack of development in gion. Subsequently the same tumor the mucous and muscular coats and connective found in all of the abdominal regions wheretissue. The intestinal supports are also more ever gravity happened to place it. relaxed,and the larger bowel in which this form It was pretty firm but elastic, could be rolled of obstruction usually occurs, is crowded into about in the abdominal cavity with ease, and a smaller proportionate space than in older usually without much pain to the patient. All subjects, thus throwing the gut into closer motions of the bowels contained pus and most folds.

of them both blood and pus. About ten days Intussusception may be acute or chronic before death pus began to discharge by the and involve any part of the intestinal canal. vagina. We were unable to make a positive

The form with sudden and violent onset ac- diagnosis and as the progress of the case incompanied by great suffering, and which may, dicated a speedy, fatal termination, made a

was na.

request for a post mortem examination in case the intussusception and is more or less stretchdissolution occurred.

ed and compressed, venous return is impeded Autopsy made in the presence of Drs. Fish- or interrupted, swelling ensues, the invaginater, Stivers and Hackadorn, revealed an en- ed portion is infiltrated with bloody serum, an largement in the ascending colon produced by acute catarrh of its mucous membrane is estaban invagination of ilium and ileocæcal valve, lished, the peritoneum becomes intensely drawing after it the cæcum.

hyperæmic and an abundant plastic exudation Although the adhesions were slight the in- is poured out glueing together the contiguous tussusception had evidently existed a number portions of its surface. of weeks as the bowel had become so adjusted These are the usual steps of acute intussusto its new relation that it required considera- ception. The compression of the mesenteric ble force to dislodge the invaginated portion. vessels may cause necrosis of the incarceratThe valve formed the apex of the intussuscep-ed bowel which may slough and restore contion and a perforation existed near its base tinuity, but there are various dangers attendwhich ended in a fistula opening into the vagi- ing this process that must be borne in mind,

The mesentery of the intussusception such as sloughing with insufficient adhesion was tightly drawn and caused flexion of the of the remaining opposing surface allowing an invaginated portion towards mesenteric side opening into the peritoneal cavity as occurred of its receiver or the intussuscepion thus in- in the case above reported, and if this does creasing the tendency to complete occlusion. not occur the ulceration accompanying the The junction of the large and small bowels is slough may leave enough cicatricial tisşue to the favorite seat of acute intestinal pathology. seriously abridge the intestinal canal. The two most common forms of invagination It has been experimentally demonstrated on involving this part, are prolapse of ilium animals that a contraction equal to one-half of through ileocæcal valve and inversion of the the intestinal calibre is not incompatible with cæcum into ascending colon.

life and health if it involve only the convex Occasionally the cæcum is primarily invert- surface of the bowel. Any marked contraced and invaginated and descending along the tion of its concave or mesenteric border colon, it draws after it the ilium which sus- seriously interferes with the nutrition of that tains its natural relation to the ileocæcal valve. part of the intestine. The severity of the

Usually as the intestine becomes invaginated symptoms is in proportion to the amount of its mesentery or mesocolon is also invaginated constriction of intestinal calibre and interrupand its veins compressed, causing venous tion of circulation in the vaginated portion. stasis and the condition of the incarcerated

Duration and location of the intussuscepmass becomes that of intense congestion which tion also influence the symptoms. may be followed by gangrene.

With refer- A symptom which is always present and of ence to the causation of gangrene, Dr. Senn as- great importance is pain. This is very severe serts, and apparently proves in his experiments in most acute cases and a source of consideraon animals, that it is due to venous stasis ble exhaustion, is felt principally at firstrather than to an interruption of the arterial about the umbilicus but spreads as peritonitis supply as formerly taught.

develops. In infants, after a few hours, the capillaries

One or two natural passages may occur become so distended in the invaginated por- after the intestinal canal is completely occludtion that they generally give way and the ed. Tenderness to pressure, gaseous disten

appears externally in the way of scanty sion of bowels and vomiting are common to motions from the bowels.

nearly all forms of intestinal obstruction. Generally the portion of the intussusception The point of tenderness may, at first, indiforming the exterior of the invaginated mass cate the seat of obstruction, but later peritoniis much drawn together or contracted into tis is apt to develop and extend the region of folds.

tenderness. The mesentery necessarily forms a part of The above symptoms may be so intense as


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