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inflammatory conditions they may be lost, so that | bowel. In those cases in which the uterus has it presents a smooth, glazed appearance. Below not accompanied the displacement, the traction the point of attachment to the peritoneum, downward and forward upon the cervix leads we have the vagina closely associated with the the other end of the lever, the fundus, to fall rectum, but not so intimately as with the blad backward until the uterus is parallel in its axis der. About 1/2 inches from the lower ex with that of the vagina; when this takes place tremity it is separated from the rectum by a the intra-abdominal pressure is directed against muscular structure, which is known as the the fundus and anterior wall of the uterus, inperineum. The uterus is situated at nearly a creasing its tendency to displacement. The right angle to the vagina, so that as the patient interference with the circulation develops an stands in an erect position the intra abdominal increased size of the uterus, and by this propressure is exerted upon the posterior surface motes its further displacement. of the uterus. This pressure drives the uterus In those rare cases in which the uterus is against the posterior wall of the vagina. firmly fixed in its place by the maintenance of

With this preliminary consideration we can its normal ligaments, or where inflammatory readily see how any rupture of a portion of this conditions have shortened the ligaments so that pelvic floor or a weakened condition of the it cannot be displaced, the traction of the muscular structure must exert an influence int heavy vaginal walls leads to the production of the support of the vagira and superjacent a condition which is known as hypertrophic structures.

elongation of the cervix. In such cases we In order to maintain a proper support of the may find the os forming the centre of a proanterior segment of the pelvic floor, we must trusion, and suppose that we have to deal with have its posterior segment in a normal and a prolapsus uteri. Careful examination, howhealthy condition. Now, this segment may be ever, discloses the fundus of the uterus in its interfered with by any state of health which normal position, and the cord-like continuation produces a weakened condition of the muscu- between it and the cervix shows that the latter has lar system, by causes which increase the intra- been drawn out under the influence of traction. abdominal pressure, such as abdominal growths, This is a form of trouble most difficult, indeed, hypertrophy of the uterus, and so on; or by to relieve. In this displacemert of the vagina, lesions of parturition, in which a part or the the cystocele, or rectocele, is readily recognized, whole of the pelvic floor has been lost. If the and the patient complains of some protrusion perineum, in part or whole has been destroyed, from the vulvar orifice when in an upright we have to that extent a loss of the resistance position, in coughing or in straining. When to the intra abdominal pressure, so that soon the the protrusion is a cystocele it will be found to anterior segment, no longer finding its support, be continuous backward from the urethra. drags downward; with this downward dis. When the finger is introduced into the vagina placement of the anterior wall of the vagina, it passes posteriorly to the mass; on the conby the intimate relation already named between trary, in a rectocele it passes anteriorly to the it and the bladder, we find the posterior wall projection. In this patient you will notice the of this viscera displaced, and the distress and projecting portion is from the anterior wall, , discomfort of the patient will be increased ac- and that the uterus is but slightly prolapsed. cording to its extent. As the anterior segment Upon examining the literature of the subject sinks below the level of the internal meatus, we we find that prolapsus of the uterus and vagina find that the bladder is not completely emptied; was among the earliest diseases recognized by the retention of a portion of the urine, with the the ancients. They, however, had peculiar formation of increased secretion of mucus, ideas regarding its pathology and the manner leads to the development of cystitis and the of replacing and retaining the organ in place. production of ammoniacal urine. This irrita- Thus, we find Soranus criticizing his confrères tion may lead, subsequently, to deposit of the for suspending patients head downward for salts of the urine, forming a calculus.

twenty-four hours; others considered the uterus A protrusion of the anterior wall may or a sentient body, and attempted to frighten it may not be associated with the rolling out of back into place by placing it in contact with the posterior. The latter is usually accom- lizards and disgusting insects, or subjecting it panied, but not always, with protrusion of the to disagreeable odors.

Various pessaries and mechanical means the vagina laterally and vertically, and take up have been used. Some, mechanical means, in the tissue that has been so abundantly displaced the form of tampons, which combined the outward. This operation alone, however, astringents for their influence upon the mucous would be a failure, and must be supplemented membrane or the walls of the structure. These, by one upon the perineum in such a way as however, acted upon the principle that the to bring the posterior segment in contact with vagina is a retaining power, and when it was the newly replaced anterior segment, thus contracted the uterus was held up by it. All | imitating the normal condition of the vagina. these mechanical means, whether in the form of Having freshened a triangular surface upon the tampons or pessaries, act by so dilating the upper posterior commissure, deep sutures are intropart of the vagina that it, together with the dilat- duced and the mucous membrane is brought ing body, cannot slip through the inferior pelvis together by a continuous suture, to make ceror the orifice of the vagina; in cases, however, tain that the union is complete from within. in which the outlet of the vagina has been greatly This patient will be kept quietly in bed, fed lacerated or enlarged, it is difficult to maintain on an animal-broth diet, avoiding the use of a foreign body of this character in place; and milk on account of the casein it contains. in other cases, what little elasticity the vagina After forty-eight hours the vagina will be may still retain is lost through the distending irrigated twice daily, with an acid sublimate influence of the foreign body. A variety of solution. The perineal sutures will be resurgical procedures have been devised, as the moved at the end of one week; the sutures in application of caustic agents to the surface, the vagina will be permitted to slough out producing sloughing and the subsequent con- themselves. As you have noticed, we have traction of the vagina. Dieffenbach applied used silk in the whole surface, so that she is forceps to the vagina, grasping folds of the not likely to experience any discomfort from tissue, which were permitted to remain until them. By this plan of procedure we conthe tissue sloughed away. Introduction of a fidently expect to remedy the distress from ligature encircling the vagina, drawing this which she has been suffering, and to make her tight, and in this way creating vaginal stricture, a well woman. closing the perineum, imprisoning the uterus and vagina within the canal with alternate gold

ORIGINAL COMMUNICATIONS. and silver rings, were plans practiced.

All of these methods of procedure, how-A SYNOPTIC REVIEW OF THE ever, fail to support the vagina throughout its PHYSIOLOGICAL AND THERAwhole length, permitting the heavy organ to PEUTIC ACTION OF ARSENIC. press upon the vulvar outlet, and permitting

By EDWARD STERNE SHARPE, M.D., absorption of what union has been gained. Marion Sims recognized the importance, in

N an excerpt from Le Progrès Médical any operative procedure, of retracting the of July 27, 1889, in THE MEDICAL anterior wall of the vagina. This he did by BULLETIN of November last, it is stated that freshening the surfaces in the shape of a letter at a meeting of the Academy of Medicine, V” and bringing the arms of the “V” to- July 16, 1889, M. Marty read a note of M. gether; this resulted in holding the uterus up, Ballaud, according to which Roussin had anforming a sulcus in the anterior wall, into nounced, in 1863, that arsenic is deposited in which the cervix would sometimes slip and the bones, taking the place of phosphorus,' give rise to pain and discomfort to the patient which was suggested by a communication of To obviate this, Emmet freshened a surface M. Bruardel “ upon the subject of arsenical upon the upper part of the “V," so that he chronic poisoning," the latter confessing his had but a slight opening left. Other forms of ignorance of said osteo-chymic metamorphosis, denudation have been practiced. In the as it was not "mentioned in the book M. Rouspatient we operated upon to-day we make a sin had written in collaboration with Tardieu.”' star-shaped denudation, or vertical and Although the consequences of the prolonged lateral bar crossing each other, and bring these administration of arsenic upon the human together so that we have a vertical and hori- system, and also observations of the symptoms zontal line of sutures; in this way we retract I in cases of severe poisoning, either intentional




or accidental, have become familiar topics, the longed extraneous residence, Professor Gubler details of which are described in the text having disengaged it from the hair eight books and published lectures of various authors months after the date of the ingestion of the accessible to the student, together with its ratsbane with suicidal intent. In this instance physiological and pathological effects, as dem- the quantity taken was enormous, and when, onstrated by experiments upon man and the after several weeks, the poison was no longer inferior animals, when we consider that the found in the urine, it re-appeared immediately peculiar interchange alluded to above is prac- under depuration from potassium hydriodate, tically ignored by almost all writers, it is not in quite moderate doses. surprising that M. Bruardel, his resources When given medicinally, the renal function limited to a single monograph, was not ap- being normal, accumulation to any great extent prized of that substitution, à propos of which, rarely occurs, it being rapidly excreted through inter alia, I take the liberty of asking space in the urinary channels, having been found in the your instructive columns.

urine of individuals accustomed to taking it Prof. Adolph Gubler, in his lectures upon shortly after an unusually large amount was arsenic, discusses this matter more fully tlian Iswallowed; hence the importance of inquiring have seen elsewhere. He there states that M. | into the condition of the kidneys when we Paul Thenard, proceeding to experiment upon prescribe arsenic; if they are free from dethe dogma of the substitutive action of this generative change it may prove beneficial, drug, as promulgated by Roussin in 1863 and otherwise toxic symptoms inay arise and decorroborated by himself in 1865, had added mand a suspension of the treatment. the tribasic arseniate of lime to the food of Although the chemico-vital reaction of certain young animals after they were weaned, arsenic with phosphorus in the living organand, having afterward killed them, he found in ism seems to admit of proof, the manner “the new layers of the bony tissue the tri- thereof, equally with that of its general conbasic phosphate of lime was replaced by the stitutional action in health and sickness, is intribasic arseniate," thus confirming not only volved in obscurity. We see the result, but the his own theory and that of M. Roussin, but process is not revealed to us; therefore, its also “ine great law of substitution advanced esoteric operations become a matter of conand defended by M. Dumas."

jecture. Of the numerous theories advanced, This vito physical transposition can, of are remarkable' for the imaginative course, happen only where phosphorous fertility they evince, as that of M. Padey, naturally exists, and, as the phosphatic salts who (in popular fashion) solves the problem are found in all the tissues and humors of the as regards pernicious anæmia “en montrant economy, the correspondently extensive affini que les leucocytes peuvent étre considerés comme ties therein implied would explain the wide des parasites, les arsenicaux a dose modéré range of the agency, curative as well as toxic, les attaquent en respectant les hématies,". of this interesting substance; and as its elimi- supposititious discrimination not unlike that nation from combination in situ is regulated formerly spoken of as “almost intelligent " by the longevity of the parenchyma of the between sound and diseased structures likewise organs where it may have usurped the place of ascribed to this agent, when used externally as the homologous element, it is to be sought for a caustic by means of the arsenical pastes, but with reliance in them, particularly the nervous now known to be due to the feeble resistance and osseous systems, and in the latter may be of the neoplasm from deficient vascularity, detected after the softer textures have entirely causing it to succumb before the adjacent disappeared,-a circumstance of importance in healthy parts, which, being plenteously furcriminal jurisprudence, as regards the inno nished with vessels and blood that absorb and cence or guilt of one accused of crime com remove the redundant poison before its charmitted long before,-although the antiseptic acteristic effects can be produced, remain preservation of the gastric parietes usually unaffected. suffices, together with other physical signs, to M. Lemarie Piquot recommends it, "contre sustain incriminating charges.

les congestions appoplectiques," without further Moreover, the tegumentary decidua are in comment, except some statistics of cases where evidence of its wide dissemination and pro- he supposed it the cause of improvement, him



self included in the category, although (had he | when pledgets of lint, saturated with Fowler's been aware of them) allusion might not have solution, are applied, an eschar forms, which, been deemed irrelevant, to the histological being detached, a healthy, granulating surface changes already mentioned, resulting from the remains, that speedily heals. introduction and incorporation of this element But as a peptic tonic we have a clue to the in the cerebrum (as in the osseous skeleton), secret, and it becomes apparent that arsenic, by protracted and made permanent by continued facilitating the concoction and assimilation of dosage, obviating degenerations to which that the food, can be of indubitable service in anorgan might be from idiopathy predisposed. æmia and the debility incident thereto; indeed,

In his formulated system of arsenical medi- the improved appetite and eupepsia it occasions cation for intermittent fever, M. Boudin does readily explains the respiratory tonicity and not favor us with the ratio medendi ; yet here muscular strength of the arsenicophagi of Carthe theory of M. Padey, with slight modifi- niola and Styria, as observed and described by cation, would apply, simply by diverting the Tchudi and others; also, the heightened comcytocidal proclivity of the arsenic from the plexions and embonpoint of those of gentler leucocytes toward the protophytum held by sex who resort to it amongst their cosmetic some to be the etiological factor in ague; and juvantia. Unfortunately, these flattering con(were the above hypothesis true), could it escape comitants are not only factitious, but transitory, from the albumen and plasma in which we are and disappear with the withdrawal of the drug, told it is incarcerated whilst in the circulation, the robust aspect of persons during a course of there would be ample scope forsuch antagonism, arsenical medication being probably largely due no form of organic life, with one exception, to the ædema arsenicalis, as when treatment is surviving its mortal touch, under certain cir- interrupted or stopped a changed and haggard cumstances the blood itself not escaping, even appearance quickly ensues, an emaciation caused that vital Auid feeling its baneful presence, as by the rapid absorption of the effused serum shown by its sinister effect on the hæmoglobin, held in the connective-tissue of the muscles of embarrassing the function of hæmatosis, and the face and neck. impeding tissue-respiration and the progress of The illustrious predecessor of Professor the current through the capillaries, and so, Gubler, the profound and eloquent Trousseau, probably, causing the effusion constituting the “ in verba magistri jurare, 'a:Imits the good specific anasarca, which occurs when, for what recorded of arsenic when properly taken, but ever purpose, it may be indiscreetly taken. affirms that simultaneous active exercise in the

We must, however, acknowledge our igno. open air is requisite to produce it, as with codrance of these occult matters, and admit that liver-oil and other hystogenetic analeptics; he in them, as in cutaneous diseases, in asthma, in also indirectly intimates that minute doses of it dyspnea, in chorea, in angina, in gastralgia, may prove advantageous in chronic digestive disin ague, in neuralgia, in rheumatoid arthritis, orders, by asking whether the alterative action of in chronic adenitis, and in intestinal catarrh, certain natural mineral springs, hitherto attribits use is purely empirical, the therapeutic uted to their alkaline ingredients, might not in rationale being unknown.

reality result from the infinitesimal modicum It is said that during arsenical treatment for of arsenic then recently detected in them,—an chronic squamous eruptions, deposits of this inference worthy of consideration, in its relametalloid become visible upon the inflamed tion to hygiene and the salutary consequences surfaces, and cures have been credited to that of its imbibition in extremely dilute solution, circumstance, to an Ďuotos nábos from its as found in the waters of the surface of the specific phlogosis, which, superseding the earth. pathognomonic, modifies it to the end of its Sulphur has also been accused of “stealing ultimate disappearance; a surmise fortified by the thunder" of arsenic, from the frequency the not infrequent sudden aggravation and sub- with which the latter has been found combined sequent amelioration of these diseases, follow- with it as an adulterate,—a charge doubtless uning the adoption of this potent medicament for warranted, yet showing the estimation in which relief, together with its well known local action it (the arsenic) is held when administered in in intractable ulcerations; as in onychia maligna imperceptible quantity; and, though it may be and indolent ulcers of the inferior extremities, I prized more highly than sulphur in cutaneous and other diseases when introduced through for long periods, or during life, in astonishing the primæ viæ, employed externally, the latter quantities and with equally astonishing results, claims our unreserved confidence, its virtues there seems to be considerable discrepancy of having been recognized for centuries ; since, as testimony regarding its actual effects, even upon Alibert remarks, "Naaman ce chef des troupes them; and, admitting that some persons can de Syrie merveilleusment queri par le prophete take it in relatively large doses with impunity, Elisee pour s'être baigne sept fois dans les flots as they are said to do in health, as a general sulphureux du Jourdain," until the present tonic, its consequences, under such circumday, and it will scarcely fail to reward the phy- stances, though interesting, are unimportant in sician who prescribes it, alone or combined, in our consideration of it, in morbid states of the baths or by inunction, especially the latter, not system. Its chronic (toxic) signs are, however, only in scabies in which it is regarded a specific, readily observed, and, when appearing, demand but also in prurigo, scaly eczema, and psoriasis, its immediate cessation. They consist of an palliating and accelerating the cure by its emol- accelerated pule, a metallic tas'e, ædema of lient, sedative, resolvent, and antipruriginous the eyelids, congestion of the conjunctiva and properties. In the latter affections some form psorophthalmia, præcordial distress, anorexia, of arsenic should at the same time be given by nausea; silvery tongue, from mucous slime; the mouth, the consensus of contemporary der- diarrhea and colicky pains, caused by gastric matological judgment being in its favor. and intestinal irritation; restlessness during

As regards its topical employment as a cor- sleep, frightful dreams; dry, furfuraceous skin; rodent in the carcinoses, M. Lebert, in his eczema and prurigo arsenicale, loss of sexual "Traité Pratique des Maladies Cancéreuses," appetite and power, impaired memory, paralywhile granting the conservative action of ar- sis, progressive emaciation and weakness, and senic as an escharotic in chancroid ulcerations, finally death. denies that in true cancer it is of any radical Many of the above disorders, when arising service, and promises to prove it, Mais nous spontaneously, are counteracted by this very prouveron bientôt que les ulcers que l'on guerit remedy which, under other circumstances, will par la pâte årsenicale ne sont pas vraiment produce them,-a therapeutic fact now well cancereux et que'en outre son action locale est authenticated, and of broad application to purement caustique." Gubler, however, dis- analogous symptomatic conditions. sents from this estimate of it as a caustic. He Arsenic is one of the most reliable weapons says: “It is not a caustic substance, but pro- we possess, in combating many of the diseases duces a scar like a caustic; it does not produce of children, to whom it is peculiarly applicable; an eschar by carbonizing the substance of an they bear it well, and as it is tasteless, and may organ or by transforming it into zantho proteic be given in plain or sweetened water, there is acid or into a soap, it kills it.” Also, “the never any difficulty in induciug them to take it; eschar produced by arsenic contains the histo- they appear to enjoy complete immunity from logical elements of the tissues, when, on the its deleterious consequences, an infant at the contrary, the eschar has been produced by sul- breast taking it in the dose of 2 minims withphuric acid; nothing remains but a magma out inconvenience, and little, shrunken, puny, without form."

weak, cadaverous, and aged looking babies When we attempt to speak from the book of become marvelously healthy, rosy, and strong, the protracted administration of arsenic, we under its sanatory manifestations. realize the dearth of information upon this At whatever age it may be given, the proper important phase of our subject; and although time is, invariably, directly after meals, as it is there is enough and to spare of literature on its then taken up by the lacteals, and by way of tentative use, for the relief and cure of acute the thoracic duct enters the general circulation, and chronic ailments, we find little to enlighten thus avoiding the liver (the organ, according us in respect to its sequelae, if any, when given to Ludwig, that confines and conserves it the in moderate doses for months and years, with most and the longest, after its internal use has out intermission or change, in the quantity been discontinued), which, in the intervals of prescribed.

digestion, it would otherwise reach through the Although the mountaineers of the Tyrol, vena portæ, and there be arrested. already alluded to, are reputed to eat arsenic An additional reason for giving this active

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