intestines. Kidneys, thyroid gland and liver may become involved. Fever is not unusual, varying from 100° to 104° F., and a pulse characteristic of anemia. Digital examination shows the os uteri dilated, so as to admit of one or two fingers. The cervix is soft and patulous. Conjoined manipulation reveals an enlarged, somewhat tender, freely movable uterus. The surface may present irregulari

ties. Within the uterus is a soft, pliable mass, which feels like placental tissue, is friable, and bleeds easily. Microscopically these tumors are dark red or purple, soft and spongy, and the tissue bulges on a cut surface. The disease develops very rapidly, and after curettage the hemorrhage returns and tumor masses fill the uterine cavity. Metastases develop rapidly, except those in the vagina. Positive diagnosis is only made by the microscope. The prognosis is unfavorable. Deciduoma malignum is the most fatal of all neoplasms. The only hope lies in early diagnosis and complete removal, preferably by the abdominal route. To illustrate the rapid course the disease may take I will recite in brief the history of my patient :

Mrs. W., age 29. Family history negative. Has borne six children and had no miscarriages. Oldest child was eight years of age, youngest eighteen months. Menstruation was always irregular, always free, and recently, before last pregnancy, rather profuse.

In the second month of her last pregnancy an effort was twice made to produce an abortion by, as the patient expressed it, an electric needle and shock. Since this treatment the patient claimed she had never been free from pain. This she described as a continual distress in the abdomen. As pregnancy advanced the abdominal pain and distress become more severe, notwithstanding medicine and treatment from several competent physicians. These pains were aggravated at night, and in the later months very severe. Her physician had noticed a peculiar sallow, yellow, anemic condition of the skin. A slight cough and night sweats developed during the last months of pregnancy. Examination of the lungs was negative.

On February 11, 1902, she was delivered of a healthy male child weighing 8 pounds. Labor was prolonged, apparently owing to weakness of patient and lack of uterine contractions. Otherwise the labor was normal. The placenta came away completely in thirty minutes. The immediate hemorrhage was not unusual. The next day the flow was not diminished; the abdomen became sore and tender. This continued for three days. Shreds, mucus, and pieces of tissue resembling somewhat retained secundines were frequently passed. The temperature and pulse, without any chill,

gradually rose until on the third day the temperature was 101° and the pulse 110 and weak.

case.

On this third day, February 14, 1902, with the above history given me by the patient and attending physician, I first saw the She impressed me at once as being anemic and cachectic, but not septic. Examination showed the uterus large, fundus on level with umbilicus; os wide open admitting easily two fingers. By conjoined manipulation pieces of tissue, as I thought at the time resembling retained placenta, were easily drawn out. I advised curettage at once, which was performed under chloroform. In the right upper segment of the uterus a soft spot was located which continued curettings failed to remove. The remainder of the uterine mucosa appeared of normal firmness, and fearing a perforation of the uterus if curetting of the soft area were continued, I desisted and packed the uterus. The patient rallied well from the curetting. The following is the microscopical report of the curetting:

"The tissue from the uterus sent for examination is from a ma

lignant growth, sarcoma, of the mixed-cell type. In some respects, but not perfectly, it resembles the deciduoma which has been recently described as developing from chorionic villi. The deciduoma is malignant, grows rapidly, and forms metastases, and resembles sarcoma in its clinical course. Early extirpation of the growth and a wide margin of surrounding tissue is advisable.

On the day following curettment, February 15, 1902, the patient was no better, although the bleeding was less. Hysterectomy was advised, and, as the home surroundings were not suitable for an abdominal operation, she was removed to the hospital on February 16, and abdominal pan-hysterectomy performed early on the morning of February 17.

On admission to the hospital the patient's pulse was 120, temperature 103; and this was the record when she went to the operating room the following morning. There was slight distention of the abdomen. Gas was passed per rectum and bowels had moved. I mention these records of temperature, pulse, and condition of the abdomen and bowels to show that there were no signs of septic peritonitis, which was later confirmed on opening the abdomen. We did find that the growth had infiltrated the right broad ligament, and excision wide of the infiltration was necessary. The operation would have been simple and short had it not been for the difficulty in controlling the hemorrhage, due to the friable, spongy condition of the tissues to the right of the uterus. As it was the operation was less than two hours.

The patient died thirty-six hours after the operation; not from

shock, not from septic peritonitis, but apparently from sepsis due to metastasis, which had taken place prior to the operation. Permission for an autopsy could not be obtained, but I firmly believe metastasis to other parts of the body had taken place.

Microscopical examination of the uterus showed it enlarged. In the right cornu surrounding the right fallopian tube there was an area of degeneration 11⁄2 inches in diameter.

the syncytium and Langhan's cells were found.

I. Central. bl. fur Gyn. 1889.

Monatich f. Geb u. Gyn. Bd. I, 1895.

5. Zeit. f. Geb. u. Gyn. Bd. XXXIX, 1898.

Microscopically,

6. Am. Journal of Obstetrics and Diseases of Women and Children. March, 1902.

7. Am. Journal Obs, and Diseases Women and Children, April, 1902.

8.

Am. Journal Obs. and Diseases Women and Children. March, 1902.

LAMINECTOMY

FOR GUN-SHOT

WOUND OF THE

FIFTH CERVICAL VERTEBRA.

By H. T. MILLER, M.D.

Springfield, Ohio.

Surgeon to the City Hospital.

HIS case, a burly negro, was shot while engaged in a game of

THIS

craps, and immediately taken to the hospital. It was found that the missile, 38-calibre, had entered immediately below the right ear and lodged in the outer third of the left clavicle. Cerebral function undisturbed, temperature and pulse normal, and motor and sensory paralysis below clavicle and upper third of arm complete. Breathing diaphragmatic. Retention of urine and feces. Patient able to take nourishment.

Under X-ray examination the bullet was located in the outer third of the left clavicle; of the spine, however, we could not define which of the vertebræ was injured. There being faint sensation over the biceps and more marked over the deltoid muscles, and as these muscles were supplied by the circumflex, a branch of the posterior cord of the brachial plexus, the fibres of which may be traced, in common with the muscular spiral nerve, to the fifth, sixth, seventh and eighth cervical, the conclusion was, that if the injury had been to the fifth cervical, the outer cord of the brachial plexus, the paralysis of the muscular tissue around the shoulder joint would have been complete.

The sixth cervical nerve joins with the fifth to form the outer cord, and as the sensation of the muscular and cutaneous tissue

around the shoulder joint (supplied by the circumflex and muscular cutaneous nerve), and the muscular and cutaneous tissue above and immediately below the clavicle remained normal (tissue supplied by the sub-clavian, supra-scapular, external anterior thoracic-branches of the outer cord-and upper sub-scapular and scapular, branches of the posterior cord, which receive filaments from the fifth nerve), we concluded that the greatest pressure on the spinal cord must be in the neighborhood of the sixth cervical nerve, which is opposite the fifth cervical vertebra-the vertebra supposed to be fractured.

As there had been no improvement at the end of forty-eight hours, we concluded to operate. Using the spinous process of the seventh cervical vertebra as our landmark, an incision was made exposing the spines of the fourth, fifth and sixth, and the laminæ of the fifth and sixth cervical were exposed. The course of the bullet was found to have gone through the laminæ of the fifth cervical near the spinous process. The spinous process and the laminæ of the fifth and a portion of the fourth were removed with bonegnawing forceps and the cord exposed. A clot about the size of a pea was found and removed. Otherwise the cord seemed normal. The canal for some distance above and below the exposed portion of the cord was probed, and no projection of bone found. While probing the canal the nerves supplying the muscles of the chest and arm were touched, being manifested by marked convulsive movements of these muscles. Gauze was used for drainage and the wound closed. The missile and a portion of the fractured clavicle were removed.

For forty-eight hours following the operation the symptoms did not change. At one time the patient felt that the bowels would move, which they did a few hours later. On the third day the temperature rose to 103° F. and pulse to 120. Breathing diaphragmatic and labored, death following.

We removed post-mortem the fourth, fifth, sixth and seventh cervical vertebræ. The cord was carefully removed from the detached vertebræ, and found to be in a normal condition. It is to be regretted, however, that the cord had not been more carefully dissected, for in all probability we would have discovered a hemorrhage within the substance of the cord. The surgical wounds were found in a healthy condition. A small quantity of pus was found where the missile had entered. Hypostatic pneumonia was found in both lungs. Both lungs were intensely engorged, and on section had the appearance of liver. The tubes, particularly the bronchioles, were filled with a substance closely resembling pus. Many old pleuritic adhesions were found.

EUGENE H. PORTER, A.M., M.D.

ASSOCIATES,

EDITOR.

GEORGE F. LAIDLAW, M.D

WALTER SANDS MILLS, M.D.

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IN

THE HIGHER DUTY.

N addition to problems of diagnosis, prognosis, and therapeusis, and the responsibilities resting upon the medical attendant of a sick member of a family, and the anxieties which press upon him as he sees one in whom he takes more than a professional interest pass downward to the grave in spite of all that medical or surgical science can do, the practitioner of medicine is often called upon to face grave questions of moral conduct. In these cases he very frequently has to decide some nice points of duty on the spur of the moment; and if he makes an error of judgment, abundant charity. should be meted out to him. Rarely do we find him deliberately casting his lot for the lower of two courses.

If in times of peace one should prepare for war, it is well for the medical man occasionally to discuss impassionately hypothetical or actual situations, so that, when confronted with a similar condition of affairs, he may be the better prepared to make a right, if necessarily hasty, judgment. With this end in view we desire to draw the attention of our readers to one or two cases calling for a choice of procedures in which, as it appears to us, the wiser course was not chosen.

When called upon to make a hasty judgment we are apt to overlook a defective ultimate result, if what appears to us to be a sufficiently satisfactory solution of a present difficulty is offered to us. This may be excusable in the untrained critic acting on the spur of the moment; but it ought not to be expected that physicians would deliberately shut their eyes to future possibilities of very grave nature when there is ample time for mature judgment. In view of the epidemic of typhoid at Ithaca, the Faculties and Trustees of