months, and pain during the last two or three months. The temperature and pulse range the first day in hospital was as follows: 9 A.M., 101° F., and 86; 12 M., 100.6° and 90; 4:30 P.M., 101.6° and 80; 7 P.M., 102.2° and 94.

Physical examination: Abdomen greatly distended and tense, as from ileus low down. Below the umbilicus was a tense, tympanitic swelling the size of an orange and a similar swelling occupying the normal position of the cecum. These were taken for intestinal loops, although they were much more tense than any distended intestinal loop I had ever observed. Vaginal examination revealed a rounded mass pressing downward and filling the whole pelvis. This was diagnosed as the retroverted and probably gravid uterus. The os could not be palpated, nothing presenting excepting this smooth, globular mass. The pain and soreness were but moderate in degree.

The picture was in part one of ileus. A high enema containing asafetida was given, with the result of obtaining two free bowel movements within three hours. The tympany, however, was but partially reduced. An enema of magnesium sulphate, 125 grams; glycerin, 125 c.c.; water, 1,000 c.c. was given in the afternoon, with the result of producing a free, loose movement. There still remained some tympany, but it was less diffuse. After preparation for celiotomy, an abdominal dressing of turpentine and olive oil was applied and left on over night.

Sept. 3, 6:30 A.M.; temperature 100, pulse 90.

Operation: Ether anesthesia. Median incision to the umbilicus. The tympanitic swellings proved to be the anterior uterine wall unevenly dilated, greatly congested or inflamed, and very thin. The uterus, which was extended nearly to the umbilicus, was adherent everywhere except to the anterior parietes. The fundus and the posterior and lateral walls were literally dug out of the pelvis. During the process the uterus was unavoidably ruptured, giving exit to extremely fetid gas and a quantity of dark red fluid, which was also fetid. As much of this fluid as possible had been aspirated after opening the abdomen. Although the general peritoneal cavity was packed off with gauze, there was necessarily some contamination of the peritoneum contiguous to the wound. The uterus was completely retroverted and the cervix was pulled up above the pubis and flattened out ribbonlike, as well as greatly elongated. After supravaginal amputation of the uterus careful toilet was made, and the abdomen closed without drainage. The patient was in the operating room nearly

two hours and during the operation was given about 1,000 c.c. of physiologic salt solution subcutaneously. On return to bed the patient seemed in very good condition, although the pulse rate was 140. At 12 M. the temperature was 99.8, pulse 134; at 4:30 P.M., 102.8 and 124.

Sept. 5, 6:30 A.M., temperature 100, pulse 120. The patient had been comfortable, had not vomited and appeared to be improving. The bowels moved well spontaneously. She drank water freely and took nourishment in the form of beef juice and malted milk. Late in the forenoon she became worse, sank rapidly and died at 11 P.M. Abdominal autopsy showed that she died of septic peritonitis or septic absorption from the peritoneum. There was a considerable quantity of fetid serous fluid in the cavity, but no tympanites.

Specimen: The uterus, which was very friable and presented large areas of blood extravasation into its tissues, contained a decomposing fetus which appeared to have advanced in gestation to six or seven months. It was undergoing liquefaction and all bones were nearly separated from the soft tissues. There was gas beneath the integument and in the skull cavity. Besides the products of conception, the uterus contained a considerable amount of semiliquid blood.

The cause of the condition in which this patient was found was probably it might be said undoubtedly-a retroverted uterus which became incarcerated. The larger the uterus became the less possible was it for the contents to be extruded normally, because the cervix became increasingly flexed and finally rose to a position above the pubic bone.

Physometra is a somewhat rare condition. In the majority of text- and reference-books I have seen it is not mentioned. Howard Kelly, in his Operative Gynecology, mentions that he had seen. three cases, two complicating large sloughing fibroids, and one associated with a pyometra due to a cancerous cervix. Kelly also describes a case reported by George W. Dobbin,1 the first case in which the bacillus aërogenes capsulatus, the usual cause of the tympany, was demonstrated antemortem. In the case here reported we were unsuccessful in cultivating the bacillus. Putrefaction of the products of conception is probably the most frequent cause of physometra.

Pyometra.-Mrs. X., aged 65, mother of several children, en'Puerperal Sepsis due to Infection with the Bacillus Aërogenes Capsulatus, Johns Hopkins Bulletin, Feb., 1897.

tered the Augustana Hospital, Chicago, in April, 1894, while I was acting surgeon during the absence of Dr. A. J. Ochsner. The patient was sent to the hospital with a diagnosis of osteosarcoma of the sacrum. No history was obtained, beyond the statement that she had suffered a moderate amount of pain in the pelvis for many months and had experienced an increasing amount of discomfort accompanied with malaise. She was a large woman and seemed well nourished. There was a slight elevation of temperature.

Physical examination revealed the presence of a large globular tumor filling the pelvis and encroaching on the abdominal cavity. There was no special sensitiveness to bimanual pressure. There was distinct fluctuation, although the tumor was very tense. It did not involve any of the pelvic bones. At first it seemed as though there was no sign of an os to be found, but soon a slight crescentic ridge was made out near the anterior fornix of the vagina which I diagnosed the remains of the anterior lip of a lacerated cervix. This gave the clue to the nature of the tumor, which was then diagnosed as pyometra.

Operation Without anesthesia, free crucial incision was made posterior to the crescentic ridge, giving exit to a large quantity of non-fetid pus. For a few days a rubber drain was employed and then a glass dumb-bell drain was substituted. The patient left the hospital in good condition about three weeks after the operation. There was a small discharge of pus for a few days after operation, after which there was only a slight watery discharge for a short time. The patient was instructed to return if anything unfavorable occurred. We heard nothing further from her, and a year or two later I was unable to trace her. This case of pyometra was probably due to senile endocervicitis with ulceration and adhesion.

Pyometra, with Fibromyoma of the Cervix.-Mrs. R., aged 35, octoroon; a little above medium size and well nourished. Mother died of unknown cause; father died of cholera, and eight brothers and sisters of yellow fever; one brother living and well.

The patient had always been healthy until present trouble began, excepting for an attack of pneumonia when she was 15. She menstruated at 14 and continued to menstruate normally until after marriage. She was married at 21, became pregnant almost immediately, and aborted at five months, since which time she has not conceived.

The first she noticed of her present trouble was five years ago,

when she menstruated profusely during one regular period, immediately after which she discovered a tumorous enlargement in the hypogastrium. The tumor increased in size slowly until two or three months ago, when it seemed to rise suddenly in the abdomen. Until three months ago menstruation had continued normal, with the exception mentioned. Since then the flow has been more profuse and has lasted four days instead of three. Two years ago the patient had "rheumatism," affecting the right lower extremity for three months, and then changing to the left. This trouble continued in varying degree until about three months ago, since which time she has had no pain in the extremities. During the time she had the pain it was always worse when she was on her feet. The last three months there has been much soreness and pain in the lower part of the abdomen and in the pelvis, especially on riding or walking.

Examination demonstrated the presence of a uterine tumor extending to the level of the umbilicus. The upper part of the cervix projected into the vagina as a globular, hard body, while the fundus seemed somewhat boggy, and regular in outline. There was moderate tenderness of the tumor and pelvic structures to pressure, and relative immobility of the tumor.

The patient was admitted to Hotel Dieu Hospital Aug. 27, 1904, with a temperature of 99.6° F and a pulse rate of 90. The next day the temperature ranged from 99 to 99.8°, and the pulse rate 84 to 88, with the patient in bed. At 7 A.M., on the 29th, the temperature was 99° and pulse 84.

Operation: Aug. 29th; ether anesthesia; incision through left rectus up to umbilicus. The tumor could not be lifted out of the pelvis until a rather difficult dissection of its lateral attachments had been made. About three-fourths of the cystic left ovary was removed with the tumor. After amputating the cervix close to the tumor the cervical canal, which was small and difficult to locate, was cauterized with 95-per-cent. phenol and buried in the stump by means of catgut sutures. Before completion of this step of the operation the right ovary, buried in adhesions, was located, and several small cysts incised and treated with tincture of iodine. The dilated right oviduct, the distal extremity of which constituted merely a thin-walled, egg-sized cyst, was found deep in the pelvis and was dissected out with considerable difficulty. It extended downward as far as the internal anal sphincter. The peritoneum was sutured over the entire wound with a continuous suture of catgut. No ligature was used.

During the first and second days the patient was quite comfortable, but on the third she had persistent epigastric pain and the temperature reached 102.6°; pulse, 128. This pain may have been pulmonary or diaphragmatic, as she had a severe bronchitis for a few days after this, with a temperature range of 99.8 to 103° and and the pulse 110 to 130. There was a thick abdominal adiposus and serum collected between the cut surfaces. After the cavity

Uterus, laid open anteriorly, from case of fibromyoma with pyometra. I. Fibro-myxomatous tumors. II. Fibromyoma blended closely with uterine tissue and presenting a submucous lobe. III. Cervical fibromyoma. IV. Uterine tissue. V. A fatty, mucoid tissue. VI. Partially degenerated mucous membrane. (Free-hand drawing, 1⁄2 natural size.)

had been open a few days there was a show of pus. Otherwise the recovery was uneventful.

The specimen weighed a little less than three pounds. On examination of the cut surface of the cervix at the point of amputation it was found that the amputation had been made close to