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 Hot bi-chloride injections at intervals of withdrawn.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 1⁄2-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 the 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 septica- 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 fluid 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 longitudinal central depression spoken of before was caused by the attachment of the septum to the closed hymen. The diagonal puncture had emptied both cavities; no pus was found in the entire genital tract, that being remarkably free from any sign of inflam matory action. sible to arouse her. Death occurred in a few hours after being seen. No post mortem was obtained. The thing to be regretted in this case is that operation was not immediately attempted, when the nature of the case was rendered certain by aspiration. There should have been no delay on account of a coming CASE III-Atresia vagina with infantile As was afterwards ascertained menstruation. infection was carried to this patient by a vaginal tube, which was 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 uterus. 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 molinten, 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 atresias 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 frenor 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 phyMrs 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. 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 face. A year after the operation, removing to the vicinity of Kansas City, she was seen again, when it was found that the entire opening was covered with a membrane, with the exception of a spot at the extreme point of the cul de sac, about the size of a silver dime. By dusting this with iodoform and packing the cavity with 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 canal. No light was thrown on this case by any menstrual molimina, nor did we expect to find what was afterward disclosed. An incision was made with a knife along the line of cicatrix, and with the forefinger we carefully burrowed through the tissue, between the rectum 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 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. No specand 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 dilated urethra into the bladder and the fingers of an assistant meeting these through the abdominal wall, a careful exploration was made for the missing uterus, fallopian tubes and ovaries; but nothing could be found; no uterus, no fallopian tubes, no ovaries. Aery, 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 10th 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 to their presence. patient was instructed to retain the plug constantly in situ, and only to remove it morning and evening when a disinfectant wash was used for cleansing purposes. Six months after the operation, the patient was seen again. The opening was patulous, being covered for an inch and a half over its lower extremity with 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 separation of the labii, looks normal and evidently subserves a useful purpose. Sexual aptitude, however, is to some extent lost. The conclusion in this case, which, perhaps, is a unique one, is that the mass of tissue which came away at about the 12th day after deliv From these cases it is not difficult to draw the following conclusions: 1. The necessity of operative interference in all cases where there is an establishment of the menstrual function and an accumulation of blood. 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 circumstances in which it might seem impossible. 4. The necessity of persistence in treatment, both on the part of patient and physician. Intestinal Obstructions. Read before the Northeast Kansas Medical BY L. REYNOLDS, M. D., OF HORTON. This term comprehends conditions widely different in their pathology. I shall not attempt to enumerate all of the different pathological conditions that may directly or indirectly interfere with intestinal calibre. As intussusception is the most frequent and fatal and consequently of greatest interest to the general practitioner, this paper will be confined to the consideration of this form of obstruction. The small intestine is a cone about twenty feet long of which the upper end forms the base and the lower the apex. The same is true of the large bowel, except that it is only about five feet long. While the form which gradually develops, is unaccompanied by sudden and great depression of the vital forces, and which leaves the intestine pervious, but of diminished calibre, may exist for several months but usually produces death in time, is called chronic. The following case which recently fell under my notice, illustrates the chronic form: Patient a little girl aged twelve, had been sick about two months when I saw her, and was greatly emaciated. In fact I regarded her as the poorest person I had ever seen alive. illness, it began with slight indisposition, As nearly as I could get the history of her poor appetite, didn't want to go to school, occasionally vomited, was without fæcal movement for two weeks and but little for four weeks. No medical aid was sought during the first two weeks of her sickness. Her attending physician first found the abdomen considerably distended, but, as I understood could find no tumor other than the general abdominal distension. Later on, perhaps two weeks later, an injection of soap suds, one-half gallon was given and retained twentysix hours. Following the injection the little girl got easy and slept well without an anodyne. After the lapse of the twenty-six hours her bowels began to move and a tendency to diarrhoea developed and continued until the child's death three or four weeks later. The majority of cases occur under the age of twelve, and one-fourth of all cases occur between the ages of three and fifteen months. The frequent occurrence of this form of obstruction 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 the mucous and muscular coats and connective tissue. The intestinal supports are also more relaxed,and the larger bowel in which this form of obstruction usually occurs, is crowded into a smaller proportionate space than in older subjects, thus throwing the gut into closer folds. Intussusception may be acute or chronic and involve any part of the intestinal canal. The form with sudden and violent onset accompanied by great suffering, and which may, gion. Subsequently the same tumor was found in all of the abdominal regions whereever gravity happened to place it. It was pretty firm but elastic, could be rolled about in the abdominal cavity with ease, and usually without much pain to the patient. All motions of the bowels contained pus and most of them both blood and pus. About ten days before death pus began to discharge by the vagina. We were unable to make a positive diagnosis and as the progress of the case indicated a speedy, fatal termination, made a 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 is poured out glueing together the contiguous portions of its surface. na. Although the adhesions were slight the intussusception had evidently existed a number 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 tissue to the favorite seat of acute intestinal pathology. seriously abridge the intestinal canal. The two most common forms of invagination involving this part, are prolapse of ilium through ileocæcal valve and inversion of the cæcum into ascending colon. It has been experimentally demonstrated on animals that a contraction equal to one-half of the intestinal calibre is not incompatible with life and health if it involve only the convex surface of the bowel. Any marked contraction of its concave or mesenteric border seriously interferes with the nutrition of that part of the intestine. The severity of the symptoms is in proportion to the amount of Occasionally the cæcum is primarily inverted and invaginated and descending along the colon, it draws after it the ilium which sustains its natural relation to the ileocæcal valve. Usually as the intestine becomes invaginated 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 reference to the causation of gangrene, Dr. Senn asserts, and apparently proves in his experiments on animals, that it is due to venous stasis rather than to an interruption of the arterial supply as formerly taught. A symptom which is always present and of great importance is pain. This is very severe in most acute cases and a source of considerable exhaustion, is felt principally at firstabout the umbilicus but spreads as peritonitis. 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 distenappears externally in the way of scanty sion of bowels and vomiting are common to motions from the bowels. nearly all forms of intestinal obstruction. blood 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 |