spreads both laterally and deeply; the periosteum, cartilage and bone are gradually affected. The discharge increases and becomes purulent, sanious and very offensive. At the breaking down of the gumma, the nightly boring pains cease and the most prominent symptom is the offensive discharge. The sense of smell is impaired. The discharge shows a tendency to dry in the nose, forming thick crusts or scabs, which stick to the septum and turbinates with great tenacity, at times requiring forcible removal with the forceps.

When the cartilage or bone becomes affected, these crusts are horribly offensive, differing from those found in atrophic rhinitis, in which the odor is due to decomposition of mucous, while in the former it is due to decomposition of animal matter The cartilage of the septum is usually first to be attacked, then the vomer and the turbinated bones. Destruction may continue until the floor of the nose is partially destroyed.

A characteristic feature of this ulceration is that it seldom ever affects other or adjoining parts, does not extend to the mouth, pharynx or skin, the ulceration being limited to the original gummy deposit. In some cases the cartilaginous and bony septum is entirely destroyed, thus converting the two nostrils into a single cavity. I have a patient in charge at present with this condition. The lower and middle turbinated bones are entirely gone, the hiatus semilunaris is in full view, and a probe can be easily introduced through it into the antrum of Highmore. There is not much deformity in this case, as the nasal bones and upper portion of the cartilaginous septum forming the bridge of the nose are still intact; the tip of the nose is somewhat broadened and flattened. This patient, now thirty years old, had syphilis six years ago. His nose began troubling him a year ago but he received no treatment for it until about three months ago, when I found the condition described above. The nose was so sensitive from cracks and fissures in the ala nasi, and a large ulcer at upper junction of the ala nasi with the triangular cartilage that he was unable to blow it; the cavity was full of crusts and scabs with no especially bad odor, and the patient says there never was any odor. At the present time, the original seat of the gumma having sloughed away, there is little tissue left for ulceration unless new parts are invaded. How so much of the bony and cartilaginous tissue could be destroyed without any odor, is unexplain

able to me.

In the advanced stage of the disease, there is, at times, difficulty of making a differental diagnosis between syphilis and lupus; a

In

few characteristics of lupus, will serve to show the difference. lupus the mucous membrane is attacked secondarily, the disease extending from the skin. Lupus progresses slowly attacking only skin, mucous membrane and cartilage. Syphilis attacks bone also. Lupus does not invade the hard palate. The odor is not especially

offensive and it attacks subjects predisposed to tuberculosis.

The treatment of tertiary nasal syphilis is very similar to the inherited form but larger doses are used. If the case is seen and the gumma recognized before it breaks down, kali iod. in saturated solution, beginning with ten drops well diluted with water three times a day, and increase a drop a day until 30 drops three times a day are taken, (then reduce the dose the same way) will often cause absorption without ulceration occurring. The terf drops should be continued three times a day for ten days after all vestige of the deposit has disappeared.

X 2

can

Merc. biniodide 1x or meri. protoiodide 1 x merc. corr. be given in connection with the kali iod. until disappearance of gumma, then the potash can be stopped but the mercury continued for one and a half or two years unless contraindicated.

Aur. mur.; nit. ac.; kali bi.; and a few other remedies may come in to meet special symptoms, but kali iod., and mercury are the principal remedies to be relied upon.

The local treatment of this condition is very important after ulceration has begun. The nose should be thoroughly cleansed by means of douche or atomizer with a carbolized or alkaline spray, or peroxide of hydrogen solution, all crusts and scabs removed by probe with cotton attached, or by the forceps. When a bone becomes necrosed as revealed by the probe, it should be removed, as it keeps up the suppuration and discharge by its presence. A careful differential diagnosis should be made between necrosed bone and exposed bone. A necrosed bone will have a hard, dry, gritty feel when touched with a probe; an exposed bone will have a softer, smoother feel. If the sequestrum is not fully separated from the surrounding tissue, it is well to wait a few days as separation soon occurs after the necrosis. After the parts are thoroughly cleansed the necrosed tissue removed by forceps or curette, the fissures or cracks in the alae should be touched with Tr. Benzoin. Comp. or Argentum Nitricum 10 grains to the ounce and the edge of the ulcer also, then the ulcerated surfaces should be covered with a powder of Stearate of Zinc and Iodoform. The powder is so light and odorless I prefer it to the pure iodoform. Aristol and Europhen are prepared in the same way and can be used instead of the

iodoform if preferred. As it is necessary for the patients' comfort that the nose should be cleaned two or more times a day, I have them use some carbolized or alkaline solution at home followed by spray of Calendula, Hydrastis or Plantago oil, or one of the powders. mentioned.

BILATERAL RUPTURE OF UTERUS; OPERATION, WITH AMPUTATION OF CERVIX.*

J

BY FRANK S. ABY, M.S., M.D.

Chicago.

Professor of Embryology and Histology, Chicago Homœopathic Medical College.

UNE 30th, 1895, I was called to see Mrs. T-, to relieve her insomnia and loss of appetite. Patient had practically no sleep for three weeks preceding my visit. She had eaten little

for two weeks. It was to prescribe for these two symptoms that I was called.

Instead of attempting to collate the symptoms with a view to ascertaining the indicated remedy, I set about ascertaining the cause of her insomnia and loss of appetite.

History.-Age twenty-four, married; began menstruating at twelve; always irregular; usual period about three weeks; never went four weeks; flow usually lasted one week or longer; no dysmenorrhoea; married at fifteen. Her first child born October, 1889, at full term. Duration of labor, twelve hours; instrumental delivery. Second child born May, 1891, at full term; duration of labor, fifteen minutes. Third child born December, 1892, at full term; duration of labor, thirty minutes. Fourth child, June 1893, miscarriage at third month. Fifth child, August, 1894, miscarriage at third month. Family history good.

In addition to this I obtained a history of excessive menorrhagia, pains in the lumbar region, distressing sensation in pelvis as if pelvic organs would fall through the vagina; almost constant nausea; incessant headache, and mental symptoms pointing toward insanity. In fact, incipient insanity was present. She was a

chronic invalid.

Two days after this, I made as thorough an examination of the pelvic organs as possible with such a nervous and irritable patient. Found a very extensive bilateral laceration of the cervix, extending apparently almost to the internal os; lips everted and eroded, raw * Written especially for the NORTH AMERICAN.

and bleeding; uterus twice its normal size. Perineal body entirely destroyed, separation of left band of levator ani muscle, rupture of external sphincter ani muscle, with hard cicatrix at anterior wall of anus, slight prolapse of anterior wall of anus and beginning rectocele.

July 6th, operation at the Chicago Baptist Hospital. When the patient was on the operating table under complete anæsthesia, a more thorough examination was made. Then the full extent of the work on hand dawned upon us. Upon introducing a sound, the uterus was found to be fully five inches in depth. The conditions were such that the advisability of vaginal hysterectomy was seriously considered. Conservatism prevailed, and I decided to save the uterus if possible, and restore the functions of the reproductive organs.

Dilatation of the curettement followed, with application of carbolic acid to the lining of the uterus, then packing with iodoform gauze. The gauze was left in the uterus until after trachelorrhaphy when it was removed--before patient left the table.

The separation of the anterior and posterior cervical lips was now found to extend to within one-fourth of an inch of the internal os uteri. A large plug was felt on each side above the internal os. This was evidently more than a bilateral laceration of the cervixit was a bilateral rupture of the walls of the uterus itself. Seizing the plug on the left side with Pratt's plug forceps, and tunneling it with scissors, it was found to extend fully two inches above the internal os.

Both cicatricial plugs were entirely removed, and the scissors traveled through healthy tissue. Many fair sized arteries were severed, but at no time was the hæmorrhage alarming. Tunneling was performed through both plugs, and afterward the walls of the tunnels were removed. The edges of the cervix and fundus were united by five sutures of chromicized catgut on each side. As the patient had already been under the anesthetic three hours, it was decided not to do the perineal work at that sitting. As the sequel will show, this was a happy omission.

The immediate effects of this treatment of the uterus were astonishing. The patient slept soundly all the night, and continued to sleep soundly each night afterward, the appetite also improved. No nausea. Patient cheerful and happy. On the seventh day following operation, menstruation set in; on the eleventh day the discharge became somewhat offensive, then gradually abated. On the fourteenth day, just two weeks after the first operation, patient was anesthetized and brought to the operating table.

The wounds in both angles of the wound from the previous operation were healed well down past the internal os, the cervix itself had failed to unite, and large black clots filled the dilated os. Sounding the uterus, the depth was found to be about two and one-half inches. The uterus was thoroughly curetted a second time with Holbrook's douche curette, and a quantity of blood clot and membranous or fungoid material removed. I had curetted only two weeks previous. It demonstrated the fact, however, that I had not curetted thoroughly at the previous operation, and that I had not succeeded in removing all foreign matter. I applied carbolic acid, swabbing the fundus thoroughly thrice, and packing with iodoform gauze, which was removed after amputating the cervix.

With the sharp curette I vivified the ununited edges in the angles of the cervix, introduced three silk sutures on each side, tied two upper pairs and approximated the lips, leaving the third pair untied.

The cervix was then amputated about one inch from the anterior lip and half an inch from the posterior lip. The cut surfaces were then inverted, sutured with two additional silk sutures, and the uterine packing, which had been allowed to remain through all this work was removed. This was followed by the perinæorraphy. Professor Streeter's flap-splitting submucous operation, with some modifications suggested by Professor James C. Wood, was performed.

Three weeks after the second operation the silk sutures were removed from the uterus. The results of the trachelorrhaphy, as well as the perinæorraphy, were exceedingly satisfactory.

The testimony of the patient herself is the best evidence of the result from a therapeutical standpoint. She states that she is free from aches and pains, has slept soundly every night since the first operation, that her head is as clear as when she was a girl, and that her appetite is perfect. A number of times she has said that she never felt so well since girlhood as she does now. The relief is perfect, and from a sour, snarling, whining, chronic invalid she is converted into a pleasant, agreeable and useful member of society.

T

REPORT OF ONE MONTH'S SURGICAL WORK.
BY GEO CLINTON JEFFREY, M.D.

Brooklyn Homeopathic Hospital.

HE month of June marks one of the most successful and profitable months in the surgical history of the hospital; there having been one hundred and nine operations performed without a single death having occurred during this period.