ECTOPIC GESTATION, FOLLOWED BY CANCER UTERI, WITH SUBSEQUENT RECOVERY.*

BY CHARLES W. MORSE, M. D.

The case I have chosen to present has a number of interesting features, which I hope will be well worth your consideration.

Mrs. L. M., a strong woman of 30 years, who had been down east on a vacation had a severe attack of uterine colic, intense abdominal pains, cramps, accompanied by profuse menstruation, coming on a few days late. Usually she had but three or four napkins, which lasted but two days.

These pains continued for several days, at times there would be a discharge of dark clots followed by fainting spells.

The physician in attendance advised her to go home where she could receive more attention, for the case was deemed quite serious.

Dr. Bongartz, the family physician, was called immediately on her return, and watched the case carefully for several days, then as the doctor was about to take his vacation the case was turned over to me.

Mrs. M. has been married two years, unusually happy disposition, perfectly healthy, weighing 160 pounds, strong and vigorous, though she was rather poorly while growing up, but no distinct illness.

At the time of my first visit (Aug. 5, '05) the patient complained bitterly of severe pains in the left side, darting down the left thigh, doubling her up with the greatest of agony, followed by marked prostration; had been flowing most of the time since taken (two weeks before) discharge almost black, pungent, ammonical odor, clots, and debris, never clean, always spotting napkin.

Occasionally the pains would subside and she would believe this time they were gone for good, and would try to sit up, but invariably the sudden sharp, cutting pains would return, causing her to immediately resume the knee-chest position and call for the hot water bottles.

Diagnosis: Cessation of menses for a variable period.
Other signs of pregnancy, nausea, change in breasts.

Patients often "feel different" in this pregnancy, expect some. thing wrong. Nullipara cannot furnish this sign.

Blanching, sudden collapse, anaemia, compelling the patient to go to bed.

Repeated attacks and signs of peritonitis.
Constipation and dysuria.

Recurrence of irregular, more or less profuse menstruation.
Discharge of decidual casts.

*Read before the Massachusetts Surgical and Gynecological Society

Hallucination as the patient becomes anaemic, and in some cases nephritis appears.

Enlargement of uterus to the size of two months.
Formation of a tumor on the left side of the uterus.

Decidual membrane; this is often a troublesome symptom, not always satisfactory.

The case continued on in the saine manner until Aug. 24, when she was operated upon by the vaginal route, from which she made. a rapid and uneventful recovery, being discharged from hospital in three weeks.

Flowed two weeks after she got home, but "not any to speak of."

These cases are frequently overlooked in general practice. Grandin wisely insists from a consideration of such cases "that the man who suspects every woman of having this condition is the man who is least liable to err in diagnosis." He further insists upon the importance of giving more careful attention to uterine hemorrhage as a significant sign. And again that the coliky pains which he calls "green-apple pain" is diagnostic of impending or actual rupture, and that in doubtful cases at least an exploratory incision should be made through the posterior cul-de

sac.

Further still-and it is most important-any woman who complains of deviation from her normal condition as regards menstruation-such as a few days more or less than her custom-may be carrying an ectopic gestation, even though amenorrhea, hemorrhage, uterine enlargement, passage of decidua-each and all of these "text-book" accompaniments of ectopic gestation-be absent.

It often happens that the first hemorrhage, even when occuring at the second month, proves fatal. An English actress dropped dead in a cafe in whom a ruptured extra-uterine pregnancy was found when the viscera were examined under the impression she died of poisoning.

In suspected cases of induced abortion, by the use of the catheter, injections of turpentine, emmenagogues, septic infection, abscess, retro-flexed pregnant uterus, etc., symptoms may simulate ectopic gestation.

Recently I had a case of ectopic gestation which was not accompanied by the usual severe pains, although flowing a great deal, clots, dark blood and shreds, anaemic, frequent fainting spells, nausea, vomiting and constipation.

This lady had been married only a year, and I had previously treated her for cystitis and nephritis, still she was quite free from hallucinations.

On opening the abdomen in this case, there was found to be an ampullo-intestino-ovarian pregnancy, which in a measure accounted for the omission of the bursting, tearing, rending, bearing down pains incident to the stretching or rupture of the Fallopian

tube, by the growth of the ovum, or the pressure of blood and blood clots.

Several years ago I reported a case of ectopic gestation accompanied by an X-ray photograph which showed the ovum quite plainly, the faradic current seemed to stop the growth of the embryo. However, for safety the case was sent to the Salem Hospital. Preparations were made to operate as soon as pains appeared, but after waiting a week the patient was discharged and has had no trouble since.

These cases occur frequently in women who have not borne children for several years.

Mrs. M. did not get along very well during the last few months, had a good deal of soreness through her abdomen, severe pains would begin in the pit of the stomach and work down to the uterus, sharp colicky pains, accompanied much of the time with nausea, unable to retain her breakfast. Could digest her dinner, but the upper was rejected during the evening.

Dr. Bongartz attended her several months for localized peritonitis; her flesh rapidly evaporated and the symptoms grew worse.

April 5, when I was called again to see her, she weighed 120 pounds, and there was a marked cachexia.

Examination revealed a uterus the size of a large grape fruit, mostly in the abdominal cavity, the os almost obliterated, hard as cartilage, the uterus firmly fixed, and very tense; on vaginal touch it seemed like a fibroid. Advised an operation.

On opening the abdomen the uterus was a dark leaden color, presenting on its anterior aspect a single vesicle-a probe was inserted which easily dropped in six inches, this was followed by a grooved director which produced a copious flow of pus, and degenerated tissue. The bowels were protected, the opening enlarged, the uterine cavity was carefully cleaned of a quart of pus grumous matter, and most of the endometrium, the walls of the uterus were irregularly hypertrophied; in some few places the musicles were attenuated.

The organ was firmly fixed, an inflammatory process had infiltrated the broad ligament and surrounding tissues.

Report of specimens miscroscopically examined was adenocarcinoma.

No attempt was made to excise any part of the uterus; it was washed out with a 2 per cent. sol. of formalin, fastened by a number of retaining sutures to the abdominal walls. The uterine tissue was so friable that it took a large number of sutures to fix it securely.

A uterine sound was forced with difficulty into the cavity of the uterus through the cervix for the atresia that existed, and to establish drainage.

The abdominal opening was of sufficient size to treat the cavity of the uterus.

Owing to her collapsed condition two quarts of normal saline was given intravenous.

X-ray treatment was given to her the next day and twice a week thereafter. For 10 minutes, every day, except when the Xray was used, she was treated with a high frequency tube in the cavity of the uterus. The internal surfaces of the uterus were kept well covered (iodoform and olive oil 10 grains to the ounce).

She remained at the hospital twenty days, the uterus contracted finely, the discharge from the opening in the abdomen was very copious, necessitating a change of dressings every few hours. In a few days she went on full diet. No hope was expressed at the time of the operation that she would ever get home alive, but still she got into the carriage very comfortably alone, and continued to improve every day.

The X-rays were regularly given twice a week for six months, the patient continued to mend, became regular at menstruation, and free from pain. At the present time, thirteen months after her second operation, she has done all her housework, except the washing; has had a boarder a part of the time, and is as healthy specimen as you would wish to see, weighing 212 pounds of apparently healthy tissue, a gain of 97 pounds in thirteen months.

No claim is made of a radical cure, but the query arises, may not the above treatment act as benignly as opening the abdomen in tuberculous peritonitis or colotomy in cancer of the rectum.

LET IT BE RESOLVED.

That we strive to carry to every patient a more pronounced spirit of hopefulness and good cheer; to know more about disease, exhausting, so far as we may, every possibility of relief or cure; to search for medical truths and accept them wherever they may be found, regardless of source; to meet our defeats like men and fight our battles with undiminished courage; to hate evil and have no commerce with hypocrisy nor with those who fatten on the misfortunes, the ignorance and the appetites of the weak; to give every man a square deal and demand the same for ourselves; to be kind to all but especially the unfortunate; and, finally, to dedicate our energies and our talents to the service of our fellow men, aiming to make Medicine, as we practice it, so helpful, so efficient, so scientific, that there shall be no abiding place in the communities in which we work, for quackery in any of its many forms. DR. W. C. ABBOTT.

According to the annual report of the State Board of Medical Examiners of the State of New York for the year ending August 1, 1906, the percentage of failures was as follows: Allopathic, 22.9 per cent.; homeopathic, 22.2 per cent.; eclectic, 42.8 per cent. Of the honor men for the year there were nine among the 379 allopathic candidates, three among the 27 homeopathic candidates, and none among the 14 eclectic candidates. Cleveland Medical and Surgical Reporter, April, 1907.

INCREASE OF PHYSICIANS' FEES.-The physicians in AustriaHungary have recently suffered so much by the increase in the cost of living that they have decided to raise their professional fees not less than 50 per cent.

CAESARIAN SECTION.*

G. FORREST MARTIN, M. D.

The history of this operation makes reading of the most interesting type, and the various changes which have been brought about by time, both in the manner of operating this condition, and in the decision of the question of operation, illustrate, as perhaps no other single operation can, the tremendous advances of modern surgery, and of its technique.

It is interesting to note that back in the days of Numa Pompelius, that potentate "forbade the burial of pregnant women in whom the operation had not been performed." It was not until 1500 that it is authentically reported as being performed on the living woman.

Since that date, the sentiment for and against the operation, and the changes of opinion as to what class of cases should and should not be thus treated, have undergone many variations.

The death rate, both to the mother and the child, has been gradually coming down from the old figures of 84 per cent. to 100 per cent. of the early days, until now we find numerous operators claiming a death rate below 10 per cent. for the mother and 1-2 of that for the child. And a few claim much better results. Suffice it to say, in this connection, that, in the opinion of the best operators, the operation is now firmly established as a valuable and a justifiable obstetric procedure in suitable cases, and one which is the means of saving many a valuable infant life, to say nothing of the immense relief from suffering afforded to the mother. For I can assert, with the utmost assurance, after watching a number of cases carefully, that the post-partum condition of the mother is one of ease and comfort compared to her state after she has been subjected to a severe instrumental delivery following a long period of extreme pain and ineffectual attempts at self delivery. The tears and stitches, the long period of catheterization, the bruised and helpless rectum, etc.. are all avoided, and a comparatively comfortable convalescence takes their place.

Page after page has been written in discussing the size of the pelvis which justifies this operation. But it is a problem which cannot be settled by figures alone. Like the selection of our remedies, every patient must be a law unto herself. The size of the foetal head, or even its position, may be the determining factor. A shelving brim, a kyphotic pelvis, or any one of many varieties of pelvic deformity, or a fibroma of the uterus may demand the procedure. I think that Dr. Briggs of this city, has recently reported two such cases. From my own experience, I am strongly of the opinion that we should add to the common list of indications, the cases of mothers who have had one or more fatal labors, from in

*Read before the Massachusetts Surgical and Gynecological Society, June 12, 1907.