uterus was discovered, behind which, in Douglas's Pouch, was a hard mass buried in dense adhesions. It was found very difficult to separate down to this stony-like tumor, because of its intimate adherence to surrounding tissues. When it was reached it was found to be like a stone in consistency, and as large as a good sized orange. In order to remove it, it had to be forcibly stripped out of its bed, much care being used in separating it from the rectum that the latter should not be opened. The uterus was amputated at the level of the internal

OS.

This

This patient's recovery was very slow and unsatisfactory for a long time, but at this writing (one year after the operation) her condition is more gratifying, and she continues to improve. There was great mental derangement following the removal of the tumor, which proved to be a calcified myoma, and I have no doubt that the colitis from which she had been suffering for about four years was entirely secondary to this growth. Another case of unusual character was Mrs. case is included here although the myoma was a complication rather than the cause of the crisis. Nearly two years ago she began to have trouble with the rectum, although she had been constipated for years. Menstruation had been regular. A year ago she first saw shreds of membrane in stool but thought it came from the vagina. Until recently a cup of coffee in the morning always resulted in a good stool, but last summer constipation became obstinate in spite of coffee. In August with the escape of flatus came much blood and mucus. Following this there was much trouble in the rectum, with a great deal of pain from flatus, and during the last two months both pain and discharge from the rectum have been worse. There was not a bloody discharge every day, although it was frequent, and after a stool she was fearfully exhausted. Movements of the bowels became more and more difficult. Menstrual flow has always been very profuse. An examination showed an occluding mass high up in the rectum just beyond the reach of the finger, and movable. Also a fibroid of the uterus nearly filling the pelvis. Immediate operation was advised, but it was somewhat of a problem to determine the best method of procedure. The growth was too high to be dealt with through the rectum. Under any circumstances which I have seen, I am opposed to a Kraske operation. To attempt removal through the abdomen would necessitate the removal of the fibroid in order to gain access to the pelvis. No matter what was undertaken, it seemed necessary to get the fibroid out of the way in order to give room for manipulation of the intestinal growth. It was therefore determined to make an hysterectomy through the vagina, and then split the posterior wall of the vagina the whole length, beginning above, downward, and attempt to enucleate the rectal growth through the vagina. The operation

was carried out in this order. The vaginal hysterectomy was simple and uncomplicated. Before closing the top of the vagina, the posterior vaginal wall was split from above, down. This gave access to the growth in the rectum, which was enucleated by blunt dissection until it was entirely separated in its whole circumference. The bowel both above and below the diseased area was separated in like manner, and sufficiently far so that a clear line of incision in non-affected tissue both above and below the growth could be obtained. After the enucleation was complete, the growth was excised above the sphincter muscle, yet sufficiently below the diseased area to insure an incision of the whole circumference of the bowel in healthy tissue. Traction was then made to bring down the bowel from above, when a like incision was made above the diseased area. After the growth was cut away, there was some doubt about the incision having been made in healthy tissue, and a further section of the bowel half an inch in length was made. Then an end to end anastomosis was undertaken with fair success, there being no undue tension upon the line of suture. After this the posterior line of of the vagina was closed as well as the top of it, free drainage being instituted below. The operation was long and tedious, taking over three hours for its completion. Considerable blood was necessarily lost and the patient was put to bed fearfully shocked and bled out, with a pulse of about 120. She rallied remarkably, however, suffered more than the usual amount of pain following an abdominal operation, but in about forty-eight hours passed gas naturally through the rectum, and within six hours more was passing it very freely, and from that time on she had no difficulty in expelling gas from the rectum. Everything went well until the seventh day, when some of the enema came back through the vagina. This was the first intimation we had that the whole thing had not healed by first intention, and very naturally it caused great anxiety as to what the outcome would be. For several days there was a slight fecal discharge through the vagina, although most of the bowel contents came through the anus proper. Sterile douches were given every three hours, and constant attention to cleanliness. The discharge lessened very rapidly, and a week later nothing from the rectum was coming through the vagina, nor has anything come since. The next stage was difficulty in obtaining any movement from the bowels, and at first the movements were very small. Improvement, however, was continuous, and the final outcome of the case has been most satisfactory. The pathological report classed the tissue removed as an adeno-carcinoma, and what was most satisfactory about it was that "sections of the mucosa at both ends of the intestines resected" showed "that no malignant process has yet

invaded those parts." I would lay emphasis upon the necessity in all these cases of going wide of a diseased area, if any promise of a permanent result is to be given.

Another case of special interest in this same connection was Miss B. M. P., aged fifty-five, who had been ailing for several months. Menstruation had never stopped, and for several months there had been a constant watery discharge. There had been a period of much abdominal pain, but none lately. She had lost both weight and strength, was constipated, but urination was normal, appetite good, and she slept well. Examination showed a freely movable tumor high in the abdomen as large as a child's head, and a diagnosis made of a myoma of the uterus, for which abdominal hysterectomy was advised, and accepted. When the operation was undertaken, it was quickly discovered that besides the uterus, there was a carcinoma of the rectum at the junction of the sigmoid. The tumor was removed with no unusual difficulty presenting, but the intestinal growth was much more difficult of manipulation. Enucleation of it was not wholly satisfactory, and considerable difficulty was found in bringing the ends of the intestine together so as to make an anastomosis without tension. She bore the operation very well, but her condition never became satisfactory, and she died on the fifth day.

One could indulge in much speculation over a case of this kind but it would be fruitless. It is certainly one point more in the argument that all cases of fibroid should be studied most carefully. While in this case the uterus and tumor were free from any malignant invasion from the seat of the malignancy, it would seem a fair suggestion that the constant irritation of the tumor may have been a predisposing, if not an exciting, cause for such a growth to develop. Had this tumor been removed at an earlier date, the condition would certainly have been improved to such an extent that possibly, and I believe probably, that the growth of the intestine would not have occurred.

(Continued in June.)

THE SCALENUS ANTICUS AND THE RADIAL PULSE.

BY W. K. S. THOMAS, M.D.

The writer of this short paper has for some time noticed, first in regard to himself and subsequently in numerous others, that the character of the radial pulse is often affected by deep inspiration, especially if the inspiratory effort be forced and followed by a period of holding the breath. In such a case, the pulse beat at the wrist can be frequently stopped so as to be indistinguishable to the tactile sense from one or two pulsations to several in number. Of this fact, after a faithful study of the subject, there has been found no mention, and the explanations of the effect of inspiration upon the pulse have been intangible and far from satisfactory.

While assisting the demonstrator of anatomy in Boston University during the current winter, the writer has had ample opportunity to investigate the subject, and believes he can explain the raison d'être of this peculiarity by the following anatomical facts. First in order to prove that obstruction to the blood stream really does take place, the reader is asked to compare and note the similarity between the sphygmographic tracings herewith presented.

The tracing above illustrates the effect of an aneurysm of the brachial artery on the sphygmogram. An aneurysm, it is well known, acts as an obstructive element to the pulse wave,

in fact it is by causing a disparity in the strength of the beat at the wrists that gives us our chief clue to the situation.

The one below is a fair representative of many taken in pursuing this study. It will be seen here that the sharp upstroke is absent, thereby indicating a sluggish movement of the blood stream. To show how and why the current is retarded, the reader is once more asked to examine the enclosed cut from Gray's Anatomy.

It will be observed that the Scalenus Anticus muscle arising from the third to the sixth transverse cervical processes and inserting at the tubercle of the first rib, bows slightly forward. to allow transmission to the Subclavian artery and the brachial plexus in front of the Scalenus Medius. These muscles, part of the accessory muscles of respiration, in anything stronger than normal breathing are brought into violent use. The Scalenus Anticus by this means, is straightened out, thereby causing the Subclavian artery to be compressed hard against the scalenus medius posteriorly.

The blood current is thus shut off in direct proportion to the muscular effort expended. Applying what we have seen above to our clinical observations, we can hope to explain satisfactorily why in cases of severe air hunger or dyspnoea the radial pulse would be varying and weak in quality and at the same time be not a true indication of the condition of the heart itself.