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the 4th of July. On July 5th took a chair car to Jones City where she was in bed the 5th, 6th and 7th menstruating. July 8th took chair car to Oklahoma City, where she was in bed one week, still flowing. At this time had much gas in the intestines. July 15 took a chair car to Davenport, Okla., where she was in bed two days. Menstruation temporarily ceased; July 18th took a day coach to Shawnee, Okla., where she rested one night, then went to Alderson, Okla., where she rested several days and was curetted-material supposed to be the result of an abortion was obtained-was removed from Alderson to McAllister on a stretcher and placed in the hospital. Her temperature at this time was never above 100 deg. F., pulse 88.

At McAllister, July 25th, she had the first sharp pain since January 31st, though the dull pain with soreness had persisted constantly. In the hospital at McAllister she was examined under an anesthetic and her trouble was thought to be bowel infection and antiphlogistic treatment was instituted. The pain continued to grow worse with an increasing tympany, was unable to void urine voluntarily. July 31st she was removed to the University Hospital, Kansas City.

On August 1st Dr. Jackson made a vaginal incision into a mass discovered posterior and to the right of the uterus. This mass had been observed for at least twelve days prior to coming to Kansas City. An abscess was suspected, but proved to be an accumulation of blood and blood clot, much of which was scraped out and the cavity drained with gauze. Patient remained in the hospital until August 7th, the drainage continued till August 14th. On the 9th of August had an elevation of temperature. On the 10th slept well. On full diet on the 11th. On 11th, 12th and 13th had bad sleep sweats. On the 13th had a copious dejection from the bowels, the result of a saline purge. At 4.30 a.m. on the 13th was taken with acute pain in the left side in the region of the ovary.

The left leg was flexed upon the abdomen and her expression was pinched. At 5 a.m. was taken with a tearing sensation and the flexed left limb went down. Had a severe chill and temperature of 104 4-5 deg. with slight nausea and some headache. She was placed on a stretcher and brought to the University Hospital. The preceding history was furnished by the doctor. On August 13th, Dr. Jackson being sick in bed, I was asked to see her. I found the temperature 102 deg. F., pulse 100, with some pain in left side of pelvis. ing had subsided to such a wait till morning to operate.

The serious symptoms of the morndegree that it was deemed safe to Epsom salts were given prepara

tory to operative interference; in the morning, August 14th, Sunday, assisted by Dr. Howard Hill, at 10 a.m., patient was taken to the operating room, temperature 101 deg., pulse 100. There was considerable tympany with rigidity of the abdominal muscles. Slight bloody discharge from vaginal incision, previously made. Incision enlarged and a large amount of clotted blood and decidual material removed. Thorough irrigation was followed by the packing of the cavity with a large amount of iodoform gauze. The abdomen was then opened. The omen

tum was found bound down to the pelvic organs.

On the left side a ruptured pyosalpynx was found surrounded by old and dense adhesions. The right tube was much thickened and found to be fractured on the lower surface into the broad ligament or pelvic cavity surrounded by organized lymph, as shown in photograph. Upon freeing the adhesions a large cavity was opened into, the site of the hematoma, which two weeks before had been opened. This cavity was lined by a gray necrotic surface yielding a putrid odor. The uterus was

completely removed and the pelvic cavity wiped as clean of debris as possible. Iodoform gauze was packed in each groin over the site of either tube or broad ligament and passed down through the opening left from removal of the cervix. The patient, it must be borne in mind, had been losing blood for some time and, although fat, was clearly anemic and therefore suffered considerably from shock. It seemed that she suffered more than the circumstances warranted, as she lost no blood from the operation; she did, however, lose some from the cleaning out of the cul-de-sac prior to opening of the abdomen. From first to finish she was under the anesthetic nearly two hours. At the conclusion of the operation she was pulseless, and a hypodermic of adrenalin, atropine and morphine was administered, followed after she was returned to bed, by an intravenous transfusion of three pints of normal salt solution. At 3 p.m. temperature IOI 2-5 deg., pulse 120. Adrenalin continued at intervals with strychnia; nutritive enemas were used for several days, as the stomach did not seem disposed to accept nourishment. Physostigma began on second day and continued for some days with apparent benefit in causing an increased peristalsis and escape of gas. Second day salines were administered freely with negative results. Abdomen distended, vomiting, temperature 103 3-5 deg., pulse 144; washed out the stomach with tube, and gave nothing by the mouth. Packed abdomen in ice. Patient from the first had been in exaggerated Fowler position. Gave hypodermically hyoscin, codeine and strychnia. Pulse came down to

120, temperature 102 deg., gradual improvement, though ice pack and treatment outlined was continued for one week. Nourished by enemas. Vaginal gauze was removed for first time on August 18th, four days after the operation. Insufficient drainage in view of the extensive area and material to drain was afforded by the gauze and as a result we had retention and weeping through the lower angle of wound, necessitating the opening of the wound and packing. Tubular drainage should have been employed in conjunction with the gauze. Thorough drainage and irrigation was then practised but found unnecessary.

In about two weeks granulations sprung up and secondary sutures were introduced with perfect results. Patient, after the first ten days, made an uninterrupted and perfect recovery, walking about in two days less than four weeks, and going home in five weeks from the day on which she came to the hospital. The results to those of us who have been intimately associated in the case, seem little short of marvellous, much more so than seems possible to one listening only to the story. So satisfactory has the treatment seemed in this case that I have chosen to enter quite extensively into detail.

While the features of treatment possess principles of interest and might admit of special observation, it is not that feature which I think this case most emphatically displays. We have in the history circumstances which suggest, at least now, very strongly ectopic gestation and yet we can see how easily they might be mistaken. The first question we ask is, what was the nature of her attack last January 31st? Was there a rupture with extrusion of the embryo then, with subsequent hemorrhages from time to time? Her recurring menstrual period and the high temperature at the time would seem to be against such a theory, and yet, I am disposed to think that such was the case. However, of that point we have no way in which to prove or disprove it. High temperature, though not common to these cases, may exist at the time and prior to rupture.

Passing then to the later manifestations with a swelling in the cul-de-sac and to the right, believing possibly that we had a broad ligament pregnancy there, we would ask, is the vaginal incision and drainage the choice of operation? It is true we have most excellent authority advising it, but from my personal experience I am convinced that though the hematoma may be removed quite perfectly in a certain per cent. of cases, even then we have left a fractured tube which may leak more blood, as I have several times seen, or if not, it is left in an imperfect condition, or at least in a condition which we cannot fully appreciate,

through the vagina.

This case then, with several others I have in mind, would teach me the best procedure is to go directly through the abdomen, remove damaged structure, clean properly, and get a more perfect recovery.

My reasons for believing that the primary rupture occurred on January 31st are that we have not subsequent history indicating a rupture, at least far enough removed from the time of the operation to give the necrotic and well-organized appearance found in the hematoma site and, moreover, she complained constantly of tenderness in that side. The appendix was found to be normal. The flatulence and intestinal irritation were probably due to the pressure of the hematoma upon the intestinal

tract.

The menstruation which appeared to return did so with much physical disturbance and irregularity in time and quantity.

Although there was an apparent or possibly a true menstrual return after the attack in January, still I feel that we had a ruptured tube which may possibly have sustained a second pregnancy and a renewed escape of blood. Certainly the history does not show usual paroxysm of pain of later date than January, when she is said to have had severe lancinating pain coming on during sleep. That we had the rupture at some time is clearly shown in the specimen and the resulting hematoma, and one of some standing, more than a few days, as evidenced by its organized periphery.

I am fully persuaded, that it is possible for such an occurrence even as long as this seems to have been, say seven months. The only history of pain we had since January was on July 24th or 25th, only one week prior to the first operation done by Dr. Jackson.

We also note that the swelling had been observed for at least twelve days prior to this time, that she had been curetted for a supposed abortion on July 19th. Had the rupture with the formation of the hematoma occurred as late as July 24th or July 19th, the clot and debris found in the broad ligament would have left only a roughened surface from the agglutination, while the facts are, we had a well organized cavity in which rested the hematoma.

Had a subsequent rupture taken place as the result of necrosis as it must have been, not to have been attended with more pain, then instead of a hematoma pure and simple we should have had an abscess. As it was, I am told that besides the organized blood there was quite a quantity of free blood when the vaginal incision was made.

The embryo was not found, quite likely having been digested or absorbed, as often happens in old cases. The case has been pregnant with features of interest to me, whether pregnant in the tube last January, or since, or both.

A Case of Acute Leukemia, with Remarks on its Clinical Features and Diagnosis. W. MITCHELL STEVENS, M.D. (LOND.), M.R.C.P. (LOND.), Fellow of University College, London; Assistant Physician and Pathologist to the Cardiff Infirmary, in The Lancet.

Cases of acute leukemia which are usually of the lymphatic type are especially prone to occur in young subjects and they are of much clinical interest as the difficulties in diagnosis may be very great. The case which I am about to record occurred some months ago in the practice of my friend, Mr. F. Temple Morris, to whose kindness I am indebted for seeing it.

The patient, a boy, aged seventeen years, complained of general weakness, slight headache, loss of appetite and painful priapism. The family history was good. The lad himself had enjoyed excellent health until his present illness which commenced one week before sending for his medical attendant with the above-mentioned symptoms. Six months previously the patient had fractured his thigh but he had rapidly recovered from this accident. When first seen on the eighth day of his illness he showed marked pallor and weakness; the temperature was 102 deg. F., the pulse was 84, and the respirations were 24, and a careful physical examination failed to discover anything except very marked and continuous priapism. On the tenth day of illness the blood was tested for Widal's reaction with a negative result. On the thirteenth day of illness I saw the patient in consultation with Mr. Temple Morris and his condition was as follows. He was dull, apathetic, and irritable and complained of headache, weakness, loss of appetite, and great pain in the penis, with difficulty in passing his urine. He was pale, prostrated and wasted. His temperature was continuously raised and varied irregularly between 100 deg. and 103 deg., the pulse was 98 and regular though weak, and the respirations were 26. The skin was dry and sweatings were absent and a careful inspection showed a few small hemorrhagic spots on both flanks. There was no glandular enlargement. The appetite was very poor but there were no gastro-intestinal symptoms and the bowels were regular and the stools were normal.

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