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 Homoeopathic 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 anesthesia, 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 anæsthetic 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.

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

TH

Brooklyn Homœopathic 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.

A brief account of the laparotomies may not be out of place. Case I. Mr. D., æt. 22. Chronic appendicitis. Complaining since Feb. 8th, 1895. Operation, June 18th, 1895. Appendix enlarged, indurated and adherent. Recovery uneventful. Discharged

July 14th, cured.

Case 2. Miss McF., æt. 23. Ovarian tumor. Suffering for three months. Pain and tenderness in right ovarian region. Operated two years ago for pelvic abscess. Physical examination revealed a large swelling in the right side of abdomen, hard, movable and very tender. Exploratory incision; right ovary adherent and prolapsed. No tumor found. Discharged July 12th, 1895. Case 3. Miss L., æt. 23. Symptoms of appendicitis; irregular and painful menstruation for years. Exploratory incision found left ovary prolapsed and adherent; adhesions broken and ovary replaced; appendix found normal; uterus slightly retroverted. Discharged July 10th, cured.

Case 4. Miss K., æt. 20. Ovarian cyst. A few years ago fell, striking region of left ovary; suffered ever since with pains in left ovarian region shooting to back; examination showed a cystic enlargement of left ovary. Operation June 5th; cyst found and removed; abdomen closed. Discharged July 8th, cured.

Case 5. Miss H., æt. 44. Abdominal sinus; sinus abdominalis following a double ovariotomy four months ago. Operation for its excision, June 9th, 1895. Recovery uneventful. Discharged July 6th.

Case 6. Mrs. J., æt. 38. Married fourteen years. Shortly after marriage, she suffered with prolapsus; three years ago complete procidentia; also severe pain in right ovary. June 21st, operation for ventral fixation; tube and ovary, left side, were also removed; recovery uneventful; operation successful.

Case 7. Miss N., æt.-Resection of intestine-operated in another hospital for abscess of abdomen-communicating with gut; an opening was left in intestine. Operation June 13th; gut resected; Murphy's button introduced. June 15th, had a normal movement of bowels; July 15th, patient still in hospital and doing well.

Case 8. Mrs. N. æt. 38. Ovarian cyst; suffered for years with pain in right ovarian region. Has had two children. Examination shows a tumor the size of a lemon in right ovarian region. Operation June 25th; ovarian cyst removed; July 18th, patient discharged.

Case 9. Mrs. F., æt. 54.

Married for eight years; has noticed a slight swelling in left inguinal region, over internal ring; no

pain; slight impulse on coughing. June 24th, operation; omental hernia ligated and excised; recovery uneventful.

Case 10. Miss N., æt. 22. For eighteen months severe pains left ovarian region; backache, headache, etc.; examination shows left ovary enlarged and firm. June 28th, operation; median incision; left ovary cystic, the size of a walnut; excised; recovery uneventful. Case II. Mrs. K., æt. 36. Married, had three children; prolapsus of uterus for about three years; procidentia complete at present; June 23rd, operation for ventral fixation. July 13th, sutures removed; uterus in good position; recovery.

Case 12. Mrs. V. A., æt. 32. Mother of three children; profuse menorrhagia, losing during each menstrual period excessive quantities of blood, which seemed to be uncontrollable by ordinary methods. June 20th, operated for removal of both ovaries and tubes. Patient made an uneventful recovery.