no offensive odor, and but little pain. The cervix was hard, and examination by touch or speculum was followed by hemorrhage. I curetted the cervical mucous membrane and sent the scrapings to Dr. Simon Flexner for microscopical examination. He pronounced the growth malignant, the nature of which was spindle-cell sarcoma. The vagina and adjaThe vagina and adjacent parts gave no evidence of infiltration by the morbid process, and vaginal hysterectomy was determined upon. The operation was done on May 2d, in the presence of Drs. George W. Griffiths, T. P. Satterwhite, Julia Ingram, Watkins, and Lucas. Dr. J. Ford Barbour administered ether. The broad ligaments were secured with Greig Smith's clamps, which were removed at the end of fifty-two hours.

The difficult point in the operation is the dissection beneath the bladder, great care being necessary to avoid injury to the ureters and bladder. The patient made a quick and uninterrupted recovery. The parts healed firmly. Her general nutrition is good, and she returned to her home at the end of five weeks in excellent health. In presenting the excised uterus for examination, I particularly ask attention to the extent of invasion of the organ by the disease. From the history and the symptoms in this case the malignant degeneration was in its incipiency and apparently limited to the cervix. Yet an examination of this specimen shows that the entire length of the body of the uterus had been invaded by the disease. To have removed the cervix by the highest possible amputation could have done the patient no good. The only rational treatment of uterine cancer is total extirpation of the whole uterus. No matter if the cervix exhibits only limited infiltration, we can not assume that the body of the uterus is healthy.

Total extirpation is the only thorough and trustworthy operation, a fact demonstrated by the specimen I here present for your examination. The gratifying result in this case is due to the early recognition of the nature of the disease by the family physician, and the successful execution of the operation.

CASE 7. Acute Intestinal Obstruction; Abdominal Section; Recovery. I was called by Dr. J. A. Larrabee on May 8, 1890, to join him

in a case of intestinal obstruction. The patient, a male, aged forty, had for years had an inguinal hernia on the right side, and wore a truss. During the night he had been seized with pain and vomiting. Dr. Larrabee discovered the tumor and recognized the hernia, gave chloroform, and applied taxis. He succeeded in reducing the mass in part, but felt that the reduction was not complete. The patient was for a time relieved, but in the early morning vomiting recurred. When I saw him at 10 A. M. the belly was tender and tympanites was developing. The inguinal canal seemed clearer, but a boggy mass could be felt external to the inguinal ring, and seemed as if it were incorporated in the abdominal wall. The ejected matter from the stomach was the green serous vomit characteristic of peritonitis. The symptoms of obstruction were less urgent, the pulse was eighty, the vomiting had ceased, and we decided to await further symptoms. The patient had received a dose of morphia during the night. On the following morning Dr. Morgan Vance joined the consultation. The patient's condition was like this: slightly impressed with morphia; patient indifferent; tympanites slightly increased; vomiting had recurred in the early morning. The boggy mass on the right side, already described, remained the same; we believed it to be impris oned omentum. The pulse was good, vomiting had again subsided, and, thinking the symptoms might be due to traction of retained omentum after reduction of the gut, we decided to wait a while longer before deciding upon interference. The patient referred all pain to the epigastrium.

During the night symptoms of obstruction. were intensified, and on the following morning, the 10th inst., Dr. Vance again joined Dr. Larrabee and myself in consultation, and we decided to operate. Dr. Larrabee administered chloroform and Dr. Vance assisted me in the operation. An incision of three inches was made in the median line. The abdomen contained a quantity of serum, and other evidences of active peritonitis were apparent. The seat of obstruction was readily found. A loop of the ileum was imprisoned and strangulated in the femoral canal. By dilating the band en

circling the gut at the femoral ring with my fingers, the strangulated gut was liberated. The gut was of a deep rosy hue, with good vitality.

Irrigation of the peritoneum brought away a great deal of lymph and debris. A glass drainage-tube was placed in the recto-vesical pouch, and discharged a quantity of lymph and bloody serum for two days. It was removed on the third day.

The patient was put to bed without shock, pulse 80°, and all the untoward symptoms rapidly disappeared. The bowels moved freely in response to an enema, and an uninterrupted convalescence was promptly inaugurated.

This case is a demonstration of the value of exploratory operation in intestinal obstruction, and a confirmation of the principle of early interference in such grave conditions, wherein expectancy and so-called conservatism invariably end fatally.

LOUISVILLE.

GOUT.*

BY C. J. RADEMAKER, M. D. The nitrogenous compounds that are derivatives of decomposed nitrogenous matter found in the urine of healthy persons are urea, uric acid, ammonia, kreatin and coloring matter. A quantitative analysis of the urine reveals the fact that a healthy young man produces daily about thirty-three grams of urea, seven decigrams of ammonia, six decigrams of uric acid, seven decigrams of kreatin, and eleven decigrams of coloring mat

ter.

The relations of these bodies differ during different hours of the day. Directly after a meat diet the urine contains more uric acid, kreatin and coloring matter, and is poorer in urea and ammonia. Twelve hours afterward the urine becomes richer in urea and ammonia. But if the urine that is passed in twenty-four hours is collected, mixed, and examined, we find a constant relation existing between the urea and uric acid, and namely in the relation of one gram of uric acid to fifty-five grams of Uric acid in its pure state is white

a

urea.

*Read before the Medical Department of the National Life Insurance Company at the Metropolitan Hotel, New York.

crystalline powder, noted crystalline powder, noted for its sparing solubility in water. solubility in water. One gram of uric acid

requires fifteen liters of cold, but only two liters of hot water for solution. In alcohol uric acid is insoluble.

The chemical relation of uric acid is as yet not very clear. Its empirical formula is given as C,H,N4O3, and contains 33.3 per cent of nitrogen. By name it is called an acid, but its aqueous solution has no acid reaction to litmus. It combines with concentrated H2SO4 as well as metals to form salts. The salts of the alkaline metals are neutral and acid. In the neutral salts we have two atoms of alkalimetal with one molecule of acid; in the acid salts we have one atom of metal with one molecule of acid. The neutral alkaline salts are readily soluble, while the acid salts are but sparingly soluble in water. Uric acid is much more soluble in an aqueous solution of caustic potash or soda, or their carbonates, and also in a neutral solution of phosphate of soda, than in water. In these solutions urates of the metals are formed. Uric acid exists in the urine as urates, either neutral or acid salts. It is for this reason that a liter of urine contains more uric acid than a liter of distilled water will dissolve. One liter of urine can contain six decigrams of uric acid in solution. If to this a little hydrochloric acid is added, the uric acid will be precipitated, as chlorides of the metals are formed. In dilute urine no uric

acid is precipitated if hydrochloric acid is added; why this is so has not been explained. Hydrochloric acid was formerly the adopted method for estimating uric acid in urine, but now the more accurate silver method is used. This method was first introduced by Camerrer.. (Zeit Schrift für Biol.) He precipitates uric acid by means of a solution of ammoniated nitrate of silver. The process is as follows: 300 c. c. of urine is diluted to a specific gravity of 1.010; this is treated with 50 c. c. of magnesia mixture to precipitate the phosphates, and then filtered to 200 c. c. of the filtrate, 0.5 of CaCo is added, and then treated with 5 c. c. of a three-per cent solution of silver nitrate. The precipitate is thrown on a filter, washed, pressed, and rolled together and put in an iron combustion tube, and the nitrogen estimated by

It was supposed that gouty persons produce more uric acid than people not suffering with this disease, and that the nitrogenous matter was first converted into uric acid, and by further oxidation into urea. In other words, that the albuminous substances taken by gouty persons was not completely oxidized. As a proof of this theory, it was asserted that gout was only produced in people who lead an easy life, and who took a good deal of albuminous, fatty, and starchy food, and who consumed a great deal of alcohol. These last named substances are readily oxidized in the body. It was supposed that not sufficient oxygen entered the body to oxidize all these substances, hence the accumulation of uric acid. But this theory is antagonistic with all modern theories of the decomposition of matter in the body. According to Garrod, it is not the production of uric acid that produces gout, but that its elimination is not complete. He argues that the same quantity of uric acid is formed, but that it is accumulated because the kidneys are almost always diseased, which is the cause of its not being properly eliminated. But Garrod says nothing about the relation of urea and uric acid. As stated before, these relations are constant. Consequently, if a patient eliminates only sixteen grams of urea in a day, it is quite natural that he will only eliminate three decigrams of uric acid. This leads to the conclusion that too little albuminous matter has been decomposed. But if only three decigrams of uric acid and thirty-three grams of urea were eliminated during the day, we should conclude that too little was produced, or that it was not eliminated. Besides, Garrod's method for estimating uric acid by means of hydrochloric acid is not very accurate.

Erbstein is of the opinion that uric acid is formed in the muscles of gouty persons, while other people do not produce it, and that this is carried through the circulation and precipitated in the tissues. The fourth theory is, that as uric acid is but sparingly soluble, and that

gouty persons have not the proper solvents for it that healthy persons possess, consequently a precipitation of uric acid in the tissues. A chemical and microscopical examination of urine reveals nothing abnormal, only that the organic nitrogenous constituents are not of the normal quantity-hence we find the urine of gouty persons having a very low specific gravity (1.010). This condition of things is due (according to Garrod) to plugging up of the uriniferous tubules by urates. But suddenly the urine is passed in a very concentrated condition, of a high specific gravity, and the patient gets well almost as suddenly as the attack came on. At the same time there is almost an immediate precipitation from the urine of a free acid. To this acid, which is not uric acid, I contend that the attack of gout is due.

Normal urine has a specific gravity of 1.020 to 1.024, and an acid reaction to litmus paper. The reason of this acidity is due to the fact that the acids of urine are not completely neutralized by the alkaline metals and metals of the earths.

The hydrochloric and sulphuric acids are always saturated, but the uric and phosphoric acids are not. The phosphoric forms three varieties of salts, namely, acid, neutral, and basic.

If

The urine generally contains acid and neutral phosphates, and acid and neutral urates. the urine contains much acid phosphates it is likely that the urate of soda will be decomposed by it, and a precipitation of uric acid takes place.

Persons suffering with gout, acute or chronic, have almost an immediate precipitation in the urine after passing it. If this precipitate is examined chemically it will be found to differ from uric acid in its ultimate composition. This acid is only found in the urine during an attack of gout, and always in a free or uncombined state, while the uric acid remains in the urine as a urate, and in solution. This acid was prepared in its pure state by the following process: The precipitate in urine was collected on a filter and washed with distilled water. It was then transferred to a beaker and neutralized with a dilute solution of caustic soda, and filtered through animal char

coal. The filtrate was treated with pure dilute hydrochloric acid, the precipitated acid again washed with distilled water, re-dissolved in a solution of caustic soda, and again precipitated with pure dilute hydrochloric acid, washed and dried. This acid, prepared by the above process, is a white crystalline powder but sparingly soluble in water. Its aqueous solution has a decided acid reaction to litmus (which uric acid has not). Its formula from an

mate analysis is C,H,O,N,, its molecular weight 200, and it contains 28.28 per cent of nitrogen.

A barium salt of this acid was prepared by dissolving the pure acid in a dilute solution of caustic soda, filtering the solution, evaporating and crystallizing. A solution of this salt was decomposed by a solution of chloride of barium. The precipitated barium salt was washed with distilled water, dried over sulphuric acid in a drying oven, and weighed. .0221 grams of substance left after incineration .0122 grams of BaCo=40.87 per cent of barium. The empirical formula of urate of barium, CH4N BaО ̧=305 requires 44 90 per cent of barium. The barium salt was calculated for

4

The connection between gout and this acid is the following: This acid being but sparingly soluble in warm water, it is, under certain conditions, such as a rapid change in temperature and exposure to cold, precipitated in the tissues. If this precipitation takes place in the muscular coat of the trachea and bronchus, we have asthmatic gout; if in the heart, we have cardialgia, with disturbances of the functions of this organ; if in the joints, we have arthritis. All these conditions produce inflammation of the parts in which the precipitation takes place, consequently the pain and fever, but as a rule no suppuration takes place. Why this acid in its uncombined state is precipitated in the tissues of some people and not in others is not known. What produces this acid in some people and not in others has never been discovered. But as gout is generally produced in people who eat a great deal of nitrogenous food, and drink wine and beer regularly, its production must be attributed to their mode of living. Under these conditions all the nitrogenous matter is not converted into urea, uric acid, kreatin, coloring matter, and ammonia. Hence the chemical changes into abnormal compounds, some of which are precipitated in the tissues.

TREATMENT.

The majority of physicians state that it is absolutely necessary to prescribe precisely the form, quantity and quality of food that a gouty He should be forbidden to person should eat. attend dinners, drink no wine or beer, eat but little nitrogenous food, and live principally on soups and vegetables. If this treatment is followed, I have no doubt that a gouty person will be free from all future attacks. But my opinion (and this opinion is founded upon individual experience) is that a gouty person should be fed like a healthy person. Gouty people have generally been reduced by fever, pain, insomnia, and loss of appetite, and left in a very enfeebled condition. If they are deprived of

meat, fat, and stimulants, there is more harm done than good. An excess of any of these substances should be forbidden, but if you limit them to a minimum quantity you are liable to have indigestion, a condition that gouty patients readily acquire when subjected to this treatment. The medicine from which I have derived the most benefit is a combination of colchicia, decandria, and solania combined with iodine.

If there is such a thing as a specific for a disease, this combination can be classed as such : Colchicia (C17H19 NO5) as is generally known, is extracted from the meadow saffron, colchicum autumnale, and has been used in gout since the days of Hippocrates. Iodine in the form of iodide of potassium has also been extolled for the cure of this disease. Decandria

87

is a more modern alkaloid, being first isolated by me in 1889. from phytolacca decandria (Linne) or poke root. (See Medical Herald for April, 1889.) Decandria (C,H,N) molecular weight 57, is a volatile base, and is classed with the amines. Solania (CH, O16N) is obtained from solanum dulcamara or bittersweet. These alkaloids are neutralized with dilute hydriodic acid, and then salicylate of soda added, and the whole made into an elixir of proper strength. It is found in the market under the name of the "Solution of Triple Hydriodides, with Salicylate of Soda." These medicines are all known to the profession, but I claim originality for the combination. I have also used this combination in acute and chronic rheumatism with great success.

The only objection that I have found to this combination is that it produces iodism in people that are very sensitive to the use of iodine. The alkaline carbonates are only indicated when there is an acid condition of the stomach and bowels. It has never been proven that gouty people are deficient in alkali, consequently, if the alkaline carbonates are given they should be given in doses of about thirty grains daily, largely diluted with water. Given in this quantity and in this condition, they will not interfere with the action of the stomach. The mineral and vegetable acids should under all conditions be avoided, as they increase the liability of precipitating this acid

in the tissues. A proper diet should be prescribed for all gouty people. They should eat meat only once a day. Stimulants, if taken at all, must be used very moderately. This applies to both acute and chronic gout. In the chronic stage, as much exercise should be taken as the strength of the patient will admit, this being the best way to hasten absorption.

LOUISVILLE.

LAPAROTOMY FOR STRANGULATED HERNIA.*

BY W. L. RODMAN, M. D. Demonstrator of Surgery in the University of Louisville. Mr. Casey, a robust young man, twenty-one years of age, who was the subject of inguinal hernia-but did not wear a truss-was taken

suddenly ill with strangulated hernia on Friday morning, March 21st. Drs. LaRue, Ewing, and Wooten, of Smith's Grove, Warren County, were called in. Putting patient under the influence of chloroform they succeeded, after manipulating the tumor for more than an hour, in causing its disappearance. Symptoms of strangulation continued, the patient vomiting fecal matter freely after the reduction of the hernia. Constipation was as obstinate as before, the bowels failing to act from purgatives of various kinds. He went on from bad to worse until Monday the 24th, when Dr. Wright, of Bowling Green, was added to the consultation. A diagnosis of intussusception was made and an immediate operation urged. The grandfather of the patient, Dr. Arnold, did not concur in the diagnosis, and insisted that the young man had "had colic." He refused to allow any operation. Monday night, when the case was "in extremis," and every one thought death would result before morning, Prof. D. W. Yandell was telegraphed to come at once, prepared to operate for intussusception. He was unable to leave the city and asked me to make the trip. I did so, reaching Smith's Grove at 5 A. M., Tuesday.

I found Drs. Arnold and Ewing with the case; they told me that he was much better— they thought he would die before midnight, but since then had rallied.

*Read before the Louisville Surgical Society, April 14, 1890. For discussion, see p. 412.