which was followed by bladder distress, leucorrhea, and a gradual running down. Not till the second winter after the operations men. tioned were the kidneys questioned. It was found that two hundred and ninety-eight grains only of urinary solids were passed, where she ought to have voided eight hundred and fifty grains. This discovery was made in 1890. She was at once put upon a stimulating diuretic, tonics, and a laxative. In thirty days her urinary solids were increased to nine hundred and fifty grains, the cough had entirely disappeared, and she was on the high road to recovery. After March 1st she had resumed her social obligations, every old symptom had disappeared, and she reached a degree of health she had not known for years.

The only explanation of cure of this patient is to be found in the removal of the conditions of renal insufficiency. The bronchial mucous membrane was apparently attempting to play the part of the kidney, and the irritating quality of the sputum perpetuated the cough. The vesical mucous membrane, irritated by the acrid character of the urine that was passed, as well as by the violence of the contractions of the abdominal muscles in coughing, caused the irritability of that viscus. The increased leucorrheal discharge could be produced by the vicarious attempt of the endometrium to discharge urinary solids in its imperfect way, aided by the continual engorgement of the uterus incident to the sudden and violent retardation of the venous blood flow that always accompanies the effort of coughing.

Almost numberless illustrations of cases of renal insufficiency in gynecological cases can be cited. Not all gynecological cases present it by any means. When it is detected it should receive our most careful consideration. No intimation is here given that it is the most important factor in diseases of women. To set up such a claim would be most absurd. The aim of this article is solely to call attention to one line of treatment that has been all but universally neglected heretofore, and to invite observations. and original investigations.

There is the gravest reason for thinking that a very close relation, even that of cause and effect, exists between renal insufficiency and pelvic disorders. The developmental phase of the renal and generative organs constitutes that reason. Embryologically these two sets of important organs arise from the same source. The mesoblast in the ovum gives rise to the muscles, bones, circulatory and lymphatic systems, the urinary and generative organs. From this fact it becomes an easy matter to infer

that derangements in one set of these organs can produce, reflexly, if you please, or at least are very frequently associated with derangements of the other.

Since observation shows the numerous cases of coexistence between renal insufficiency and neuralgias, mucous membrane disorders and serous membrane inflammations, one cannot but question the possibility of this insufficiency producing or permitting amenorrheas, dysmenorrheas, leucorrheas and attacks of pelvic peritonitis. It is strongly emphasized that the position is not assumed that all cases of these disorders are produced by renal insufficiency, but from the fact that many of them are relieved by including in the treatment remedies that increase the urinary solids, the conclusion cannot be resisted that cause and effect actually exist between many of them and the deficiency of urinary ingredients.

FIELD BUILding.

SARCOMA OF THE NOSE TREATED WITH THE
TOXINS OF ERYSIPELAS AND BACILLUS
PRODIGIOSUS.

BY NORVAL H. PIERCE, M. D.

PROFESSOR OF OTOLOGY POST GRADUATE MEDICAL SCHOOL AND HOSPITAL; SURGEON TO NOSE AND THROAT DEPARTMENT. MICHAEL REESE HOSPITAL; LARYNGOLOGIST AND RHINOLOGIST

TO THE EMERGENCY HOSPITAL, CHICAGO.

I will not detain you with a review of the faults and theories of serum therapy. My object in the present modest contribution is to lay before you the results of treatment by toxins upon three cases of sarcoma involving structures within the nasal cavity, or rather two cases, for in the third was a mistake in diagnosis. I embrace the third case in this report for the reconciling light it may throw on the varying reports as to the efficiency of toxins in the cure of sarcomata, and also to call attention to a peculiar neoplasm which lies typically in the domain of rhinology.

No Complains of

CASE I. Myxosarcoma beginning in the middle turbinated body. October 1, 1894. M. J.; female, aet. thirty-seven; married. history of importance either in herself or family. stoppage of nose. Has been treated by advertising seven months for simple catarrh by means of sprays. nose began two months previous. Patient complains of intermittent pains through left eye and difficulty of seeing. There is epiphora. During last two weeks has had pains over bridge of nose.

specialist for Stoppage of

Four years ago patient had total amenorrhea for two months with vicarious epistaxis.

Examination of nose, anterior. Presenting at the mucous margin of the vestibule on the left side, and completely shutting off anterior rhinoscopy was a tumor rather angular in its contour having three borders and three surfaces, grayish yellow in color, slightly movable, and apparently springing from the middle turbinated body. In situ the tumor resembled very much an ordinary mucous polypus. A piece the size of a filbert was snared off, and then it was found that the mucous membrane presenting at the vestibule was edematous while the tumor back of this was hard, denuded of mucous membrane in spots; the denuded spots being covered with fine granulations. The tumor seemed to be confined to the middle turbinated body. Microscopic sections were made by Dr. Oscar Dodd, and showed typical myxosarcoma. Operation was advised through the natural orifice, but the patient did not present herself again for about a month afterward. At this time the nose was deformed externally, was filled internally with the same mass as before described. The left half of the post-nasal space was occupied by the same sort of tissue. At the inner angle of the left eye was a hard immovable tumor. Patient was admitted to Michael Reese hospital, and on November 13, operation for removal performed. We were prepared to remove the superior maxilla. Langenbeck's incision was made, the nose laid back, but on account of the encroachment upon the structures in the post-nasal space and because the sarcomatous tissue spread up to the cribriform plate, we simply scraped away all tissue that had the appearance of sarcoma, opening the antrum which was filled with the same tissue, scraping this out, ditto the lachrymal canal, packing and closing, depending upon the toxins for a permanent cure. Owing to delay in procuring a reliable supply the injections did not commence before December 15, 1894. At this time there did not appear to be any return in the nose. Injections were made every day or every other day for two months. The supply was obtained from Von Rheim and consisted of the latest product of Coley, consisting of toxins of bacillus prodigiosus and bacillus erysipelas. The quantity used each time varied from two to ten miniums. The reactions were marked not so much by height of temperature as by the depression of the vitality of the patient. The temperature varied from 101° to 103° F. and was preceded by a chill. Dr. P. H. Conley carried out this portion of the treatment. I examined the patient January 15, and the nose presented small foci of sar

comatous tissue along the line formerly occupied by the middle turbinated body.

Examined February 1.

These had increased and the tumor

at the inner angle of the eye was beginning to reappear.

March 23. There was an enormous advance in the whole territory, the increase of the tumor involving the nasal process of the superior maxilla being especially noticeable.

Now, it must be said that after an unusually large injection about March 1 the reaction was so severe, the patient being much prostrated, nauseated, with pains in the joints and back, that she absolutely refused any further treatment with the toxin. Whether it is a coincidence or not the advance of the disease was much more marked after this cessation. The patient took in all two drachms of the toxins in three months. I believe the upper jaw has since been removed.

CASE II. Post-Nasal Fibrosarcoma. B. Male, Nineteen years. Referred to me with diagnosis of tuberculosis. He was emaciated, extremely anemic, and very weak. Temperature, 100. Pulse 120. I could find no trace of lung trouble. In the postnasal space, was a tumor the size of an egg, lobulated and furrowed, which rested upon the soft palate and touched the lateral walls, the septum and posterior wall of the pharynx. Its surface. was mottled, with foci of corticle hemorrhages more or less decomposed. The tumor was immovable and bled freely at the daintiest touch of the probe. There was an offensive necrotic odor. Anteriorly the floors of both nostrils were raised evidently by the submucous encroachments of the same neoplasm. Microscopic examination proved it to be a fibrosarcoma. I advised against operating in the condition the patient was then. He had had frequent hemorrhages from the growth and the shock and unavoidable. hemorrhage incidental to any operation for the removal of such a growth is very great, and in my opinion would, in this case, have been fatal. For the purpose of temporizing, the toxins were tried. A supply was produced from von Rheim, of the prodigiosus and erysipelas toxin. From two to fifteen mm. were injected every other day. The patient declared that he could hear better, swallow better and felt generally improved. The fever in this case rarely went above 101° F., but as I examined the case from time to time I could not notice any marked diminution in size of the tumor. On account of the hemorrhages having ceased the young man gained in weight and blood. To-day I examined the growth and can affirm positively that it is increased in size. The hemorrhages have

recommenced and the anemia is returning. the end of the second half drachm of toxin.

He is now nearly at

The next case is interesting as it is one in which the toxins were supposed to have been of service. The history of the case is as follows: The patient was a male child, six years old, living in the southern part of Illinois. Six months before I saw him he had been operated on for a tumor of the septum, which had bled at frequent intervals for two months previously. The neoplasm was diagnosed sarcoma, was removed with a snare, and the toxins used. There had been the usual reactions and after two months the child was pronounced cured. But the bleeding having returned, the case was brought to me. On examination I found a tumor the size of a large pea projecting from the septum on the left side two mm. from the floor of the nose and about at the point where the triangular cartilage joins the vomer. The attachment was pedunculate. The color of the tumor was dark bluish, intermingled with red. It bled freely 'when touched with a probe. The tumor was removed with the cautery snare. The bleeding was unusually profuse, but was easily controlled by pressure. As I suspected the nature of the case I did not cauterize the base any further. The subsequent microscopic examination confirmed my diagnosis. It was what is known as a "bleeding polyp of the septum" or "fibroma polyposum fungoides taleangiectodes (septi narium,)" a growth which is not infrequent at this place, which is sometimes mistaken for a sarcoma and which possesses histological characteristics sufficient to give it a special place in pathological classification.

In describing the histology of the growth I can do no better than translate a description given by Dr. Langerhans in a recent paper on the subject by Schadewaldt in the Archiv fur Laryngologie, Erster Band, Heft 3.

"Beneath the epithelium is found connective tissues very rich in cells and vessels. In the neighborhood of the prominent vessels are thickly clustered small round cells which possess round nuclei. Toward the periphery of these groups the cells are larger and some more angular than those near the vessels, while their intercellar substance becomes more abundantly thready. At the base of the tumor the vessels are numerous and their walls relatively thin, and surrounded by dense connective tissues poor in cell elements."

Moreover, we find both in the interior of the tumor, and near the surface small clusters of cells which seem to be independent of