two weeks (before a firm callus could have formed), can be explained in no other way.

CASE V.-A lineman fell from a telegraph pole and injured his pelvis. He was unable to walk because of the exquisite pain deep in the left hip. Physical examination was negative. The movements of the hip were unimpaired, and there was neither shortening nor crepitus. He was confined to his bed for one week, after which he was allowed to walk about. He could walk with the aid of a cane, but complained of deep-seated pain in his pelvis. Owing to his well-developed musculature no special points of tenderness about the pelvis could be obtained.

A skiagram taken several weeks after the injury revealed a linear fracture in the left side of the pelvis, which began at the tuberosity of the ischium and extended through the thyroid foramen into the left acetabular cavity, but the separation of fragments was so slight that the fracture was represented by a faint line that might easily be overlooked upon any but the most perfect skiagram. This was apparently a subperiosteal fracture.

CASE VI.-J. R. was admitted to the Cincinnati Hospital with the history of having fallen upon his elbow. The injured joint was very much swollen and all movements very painful. The swelling subsided in twenty-four hours

under cold applications, and a most careful examination at this time failed to reveal anything abnormal about the joint, except for the existence of a certain amount of pain upon extending the arm, and some tenderness over the olecranon. The patient could voluntarily extend the arm without much difficulty, and could flex and rotate readily.

The skiagram revealed a sub-periosteal fracture of the olecranon, with practically no separation of the fragments.

CASE VII.-Miss H., aged about ten years, had several weeks ago suffered some injury to her arm and shoulder, the result of a fall, the details of which were not obtained. Her physician could not establish the diagnosis of a fracture, and he put the arm in a sling expectantly. The patient failed to recover the full use of her arm, all movements being more or less painful, especially abduction. After several weeks a surgeon was consulted, who, after a painstaking examination of the arm and shoulder, could find no cause for the pain and the limitation of movement.

The patient was therefore referred for an X-ray examination, which disclosed an incomplete subperiosteal fracture of the shaft of the humerus at about the junction of the middle and the upper thirds. The line of fracture was a faint oblique one, and there was of course no separation of fragments.

Since my earliest study of the symptoms of cholecystitis upon a poor woman with a gall-bladder reaching down to the crest of the ilium, that I cared for and carefully autopsied at the Cook County Hospital in 1885, I have always sought for and often found regurgitation of food. This symptom is at least worthy of recognition and study. It will often assist in excluding ulcer of the stomach and even carcinoma, and lead to diagnosis when time may be an important element.

The immediate cause of regurgitation is not always clear. It occurs when the cardia is large without any remote cause. It appears in perfectly healthy persons as a result of emotion while the stomach is full. When there is a congenital defect of the stomach, giving rise to an antrum or proventriculus like that of the beaver, regurgitation may be habitual and without pathological significance. E. M. Brock

bank (British Medical Journal, February 23, 1907) recounts a case of this kind which seems to be a true variation, for it occurred in a family which had presented the symptom for five generations. When the symptom occurs in cholecystitis we may surmise that it is due to a wave of reversed peristalsis returning from the pyloric end of the stomach, against which the intoxicated gall-bladder lies in contact. In one patient, where regurgitation was very prominent and troublesome and accompanied by pain, I found, on operating, that there was a band of peritoneal adhesions between the side of the gallbladder and ventral wall of the pyloric end of the stomach. After its removal and the drainage of the gall-bladder, all symptoms disappeared and with them the troublesome regurgitation.

In another case, a member of my own family, where naturally I had unusual op

portunities of observing the symptom, the food came up for half an hour after almost every meal, and was said to taste just as it did when swallowed. A little chunk of ice or a walk out of doors was often useful in stopping the regurgitation. When the gall-stones were removed and the gall-bladder drained, the symptom disappeared.

A number of cases where tachycardia was the most pronounced symptom had a troublesome regurgitation or merycism. In those that submitted to cholecystostomy the regurgitation disappeared.

Cholecystitis does not always give rise to biliary colic. The disease may be present, however, and should be diagnosed. The symptoms may be constitutional only, that is, those of toxemia. At present our laboratory friends cannot make a urinalysis or other chemical examination which will indubitably point to the infected gallbladder, though the leucocytosis and the indicanuria may be consistent with such a possibility. Therefore we must still follow Sydenham, and study the symptoms of our patient. The result may be quite as satisfactory. We may make the diagnosis and thus cure the patient before the disease has extended beyond this appendix. The marvelous not to say terrible operations for stone in the common duct or for pus in the upper abdomen may be avoided by the early diagnosis of cholecystitis.

It is presumed that carcinoma of the gall-bladder may be averted by the early cure of the infected gall-bladder. In calling attention to the possibility of cholecystitis before biliary colic has appeared, regurgitation should not be forgotten. It is like the "chug-chug" of the automobile, the recognition of which may preclude

serious accident.

AMONG the accepted, but sometimes not recognizable, contra-indications to the use of pelvic massa e are acute inflammatory processes, the presence of Fallorian tubes, ovarian enlargements, cystic degeneration in either the ovaries or parovarium, and, above all, the presence of pus in the pelvis.

IN the cysto-adenomata of the ovary we have epithelial neoplasms which differ greatly in some respects from adenomata found elsewhere. The latter, as a rule, have a great tendency to become malignant and to change into true carcinomata..

Society Reports.

THE OBSTETRICAL SOCIETY OF

PHILADELPHIA.

OFFICIAL REPORT.

Meeting of March 5, 1908.

THE PRESIDENT, DR. J. M. BALDY, IN THE
CHAIR.

Myxosarcoma of the Round Ligament.—Fibroma

of the Anterior Abdominal Wall.

DR. WILMER KRUSEN reported two cases, one a myxosarcoma of the round ligament removed from a woman thirty-six years of age. The growth was 9 c.m. in the long diameter and 5 c.m. in the short diameter. The tumor was a

firm, solid growth enclosed in a capsule, and had a rounded smooth surface, resembling the

cut surface of cheese, and not the circular arrangement of fibres peculiar to fibromata.

Microscopically, the characteristics were areas of abundant spindle-shaped cells, nearly all of one type. The blood vessels were thin-walled. Areas of stellate connective tissue cells, which lay within a matrix of myxomatous material, were noted. No cystic spaces, glands, or muscular tissue were to be found. Diagnosis, myxo

sarcoma.

Dr. Krusen reviewed the differential diagnosis between neoplasms of the round ligament and other affections of the inguinal canal.

The second case reported was a fibroma of the anterior abdominal wall removed from a patient twenty-nine years of age. The growth was extirpated from the left rectus muscle and presented the following characteristics: The tumor was 8 c.m. long, 6 c.m. short diameter, round in outline, hard, smooth, encapsulated, not lobulated. The section of the mass revealed its fibrous nature in the distinct concentric arrangement of the fibres. The color was white. Mi

croscopically, it was made up of connective cells, elongated and spindle-shaped and closely packed.

The intercellular substance contained blood-vessels of distinct but thin walls.

According to Binnie, fibromata occurring in the rectus abdominis are uncommon. Pfeiffer found that 89.8 per cent. of these tumors occurred in women, and that all of these women had borne children. He believed that the normal proliferation of the abdominal wall which is found during pregnancy is, in these cases, kept up in limited areas, and thus tumors arise. According to Olshausen, their place of origin is for the most part in the posterior sheath of the rectus in ruptures which take place during pregnancy. In three-fifths of all cases they arise in women during pregnancy, and are usually found between the years of twenty-five and thirty-five in women, while in men they occur at a later

period, that is, between thirty-five and fifty years of age.

Occasionally a case is reported as congenital, or in advanced life. Most of these tumors are single, but at times they are multiple or appear in succession in different localities. Their rate of growth may be slow, or, if occurring during pregnancy, rapid; and in the latter case they shrink after partur ̊tion.

DISCUSSION.

DR. WM. R. NICHOLSON: I have nothing to say concerning the second case. Regarding the first case, that of tumor of the round ligament, I have seen one case of fibroma of the ligament diagnosed before operation, and, strangely enough, it was very evident what the tumor was. The diagnosis was made without much doubt. The growth was benign, and was removed by a perfectly simple operative procedure, and there was no further trouble. The case did not occur in my own practice.

I think the second case was particularly interesting, because of the liability of confusing the tumor of the wall with an intraperitoneal growth. I can imagine how a case might arise in which such a growth would be absolutely indistinguishable from an intra-abdominal condi

tion.

DR. C. C. NORRIS: I have seen only two cases of this kind that I recall. One was a small lipoma of the inguinal canal, in which the diagnosis was made by the microscope. The other case was a small fibroma of the round ligament. Both these operations were uncomplicated, and the result in each was good. I have also seen a fibroma of the abdominal wall, small and pedunculated, springing from the rectus muscle and growing inward. This was an almost pure fibroma. The convalescence was uncomplicated.

DR. E. E. MONTGOMERY: I have never had the fortune to see a tumor of the round ligament. I have seen several fibroid tumors of the abdominal wall. The majority of these occurred in the rectus muscle. I have seen two situated at a considerable distance external to the rectus muscle, having developed in one of the oblique muscles.

In

The case referred to by Dr. Krusen was in a colored woman in the Jefferson Hospital. The outline of the abdomen, and general appearance of the patient, led me to proceed to operation with the idea of the presence of a fibroid tumor of the uterus. Of course, careful examination of the pelvis should have excluded this, but the appearance of the tumor, the shape and size of the abdomen, led us to overlook the possible absence of relation to the uterus. Upon attempting to remove this tumor, I went directly into it before entering the peritoneal cavity. fact, it developed from the posterior sheath of the right rectus muscle, and as it enlarged it pushed into the abdominal cavity, filling the cavity from the pelvis to the ribs, giving the shape and outline to be expected from a uterine tumor of that size. The entire posterior surface of the tumor, and even the lateral surface, was covered with peritoneum. Consequently, when we removed the tumor we had to remove a portion of the abdominal wall and a large portion of peritoneum. This made the closing of the opening a problem. Fortunately, I was able to

use the left side of the abdominal wall, and had a very satisfactory result. The patient recovered without difficulty, and so long as she was under my observation there was no discomfort following the operation. The structural appearance of the tumor, which weighed nineteen and one-half pounds, was that of an ordinary fibroid tumor. I have never seen any of these cases show sign of malignancy under the microscope.

DR. KRUSEN (closing): I made the diagnosis of fibroma of the ovary because upon examination of the tumor I found the uterus movable and not closely connected with it, and the entire thickness of the abdominal wall, except the peritoneum, was involved with the growth. When I made the incision I found the growth anterior to the peritoneum, and made a bimanual examination to exclude the uterus. It was the most satisfactory bimanual examination I have ever made, having only the peritoneum between the examining hand and uterus.

Syncytioma or Chorio-Epithelioma of the Pla

centa.

DR. EDWARD P. DAVIS: The patient reported was a primipara, with a negative family history, delivered at the Jefferson Maternity. The placenta was evidently abnormal, containing several areas of grayish pink sponge-like substance. The report on the placenta from the pathological laboratory was detailed. Pathological diagnosis, chorio-epithelioma or placentoma. In view of the pathological findings in the placenta, dilatation and curettement were done under ether one month after labor. Laboratory examination of the scrapings showed normal endometrium with no evidence of malignant disease. Upon receipt of the result of the examination of the placenta, it was first determined to subject the patient to hysterectomy, and she gave her consent to this operation. It seemed, however, possibly not justifiable to sacrifice the uterus because of the diseased condition of the placenta, especially as the author could not find in the literature of the subject a precedent for so doing. Accordingly it was determined to curette the uterus instead, and if the scrapings proved malignant, then to perform the hysterectomy. As the scrapings showed no evidence of malignant disease, the patient was discharged.

The author raised three points for discussion: (1) The importance of examining the placenta as far as possible in all cases where pregnancy is interrupted after the fourth month. (2) Shall the operator who detects chorio-epithelioma of the placenta proceed immediately to hysterectomy so soon as the patient's condition justiñes it, or shall he content himself with a thorough examination of the patient under ether, including curetting and the microscopic examination of the scrapings? (3) If these procedures give no evidence of chorio-epithelioma, is he justitied in allowing the patient to pass from observation without hysterectomy?

DISCUSSION.

DR. JOSEPH MCFARLAND: I am afraid I shall be unable to discuss the three points raised by Dr. Davis, as my province is that of a pathologist.

The tumor is one which has been attracting attention for a good many years: first, because of the obscurity of its etiology; second, because of the fact that it so frequently succeeds pregnancy; and third, because it occurs in all countries, in persons of both sexes, at all ages, and, of course, entirely apart from pregnancy.

It has been called syncytioma malignum, under the supposition that it developed essentially from the syncytium. This cannot be, because in many cases the syncytium was scarcely at all in evidence. It has also been called deciduoma malignum and chorio-epithelioma. The earlier cases were described as sarcoma, and it is impossible to tell when it was first observed, because we cannot trace it out by name. So far as I can tell, the first case observed in this country was that of Dr. Charles P. Noble, operated on at the Kensington Hospital for Women. The history was metrorrhagia. The uterus was curetted and the fragments removed sent to me for microscopic examination. This examination revealed nothing. The fragments of tissue were so completely necrotic that nothing could be made out of them, and I reported that the growth was probably a necrotic fibroid. But the clinical signs of malignant tumor were so positive that the uterus was removed and sent to me for examination. The uterus was enlarged, and from one wall a rounded tumor, with a hemorrhagic and necrotic surface, projected. Large sections were made through the entire mass, and it was found that the greater bulk of it seemed to consist of muscular tissue resembling that of the uterus and continuous with it. On the surface of this tumor, however, there were spaces filled with masses of cells of various size, many of them giant cells, and some large enough to constitute masses of nucleated protoplasm. I never saw anything like it, and had read of nothing of the kind in the literature. After a long period of deliberation it was diagnosed large roundcelled sarcoma of the uterus and published under that title. Those of you who are familiar with the literature will remember that Dr. Noble corrected the diagnosis in later years when he had another case.

I had expected that Dr. Davis would refer to two papers on the subject, one by Dr. Carl Fisch, of St. Louis, speaking of the occasional occurrence of the tumor in the male; the other, published in the Journal of the American Medical Association in 1907, by Dr. Frank, of Columbia University Medical College, New York. Both are interesting and important, the latter going into the etiology and relations of the tumor from the critical point of view.

The etiology of the tumor is not known. Its frequent occurrence with pregnancy, and its almost invariable primary occurrence in or near the sexual organs, seem to indicate that it has something to do with the germinal cells, and its occasional occurrence apart from these organs does not disprove that view, because of the fact that germinal cells detached in the earliest developmental process may find lodgment here or there, in this or that organ. Whether syncytium is formed in the development of these cells is uncertain, but we do know that in the uterus

the syncytium descends from the cells of the trophoblast, whose object it is to dissolve the endometrial tissue and facilitate the embedding of the ovum.

DR. BROOKE M. ANSPACH: Chorio-epithelioma is the most interesting form of cancer that the obstetrician and gynecologist meets. One peculiarity which has always impressed me concerning it, is the difficulty sometimes encountered in making a diagnosis from a curettement alone. As Dr. Davis has indicated by his reports of cases, and as Dr. McFarland has mentioned of a particular case, the tissue removed by curettement may be necrotic and not present a typical histologic picture of a chorio-epithelioma, even though such a tumor exists. There have been cases, on the other hand, and one of them I know of positively, in which, although a diagnosis of chorio-epithelioma was made by a competent man, the uterus, after hysterectomy, was found entirely free of any such disease. I think the difficulty in making a diagnosis from the scrapings alone is attributable to the nature of the growth. As Dr. McFarland has pointed out, the chorion epithelium normally destroys to a certain extent some of the maternal tissues in order to form the placenta. This destruction and penetration of the chorion epithelium goes only to a certain distance physiologically, but under pathological conditions it becomes unlimited.

The line between the normal corrosive action of this epithelium and the pathological is rather a fine one; so that, practically, I think it is a mistake to make a diagnosis from curettings alone, without a digital examination of the interior of the uterus, because even though the curettings show muscular tissue infiltrated by chorio-epithelial cells, it is by no means positive evidence of a malignant growth. This fact has been well illustrated in two cases I have seen. One was found in a uterus removed with the appendages for pelvic inflammatory disease, in which an early pregnancy had not been suspected. The chorio-epithelial cells had penetrated into the muscular tissue for a considerable distance, and the picture was taken to be that of a malignant growth by the first examiner. If this patient had suffered from hemorrhages following abortion, and a curettement had been done, from the scrapings alone the case might easily have been diagnosed chorio-epithelioma. In another uterus removed at autopsy, a woman who had died from pernicious vomiting, microscopic sections had the same appearance. In all cases, in conjunction with the microscopic examination, it is important to feel inside the uterus to see whether there is a palpable tumor or a sloughing necrotic mass. In the only case of chorio-epithelioma which I have seen clinically, one occurring at the University Hospital, the clinical diagnosis was, "sloughing fibroid tumor." There could be felt a distinct mass inside the uterus which was not entirely removed because the uterine wall seemed very thin at the site of the pedicle. Histologic examination at once revealed the true nature of the growth, and the uterus was removed by a panhysterectomy.

As 50 per cent. of the cases of chorio-epithelioma are preceded by hydatid mole, every case of that sort should be watched with special care. The interior of the uterus should be examined and scraped immediately after the mole has been expelled. It has been advised by a

number of gynecologists to curette the patient again within fifteen or thirty days. Such patients should be watched very carefully, and if there is any suspicion of a chorio-epithelioma, either from curettings or from a nodule, or an ulcerated surface in the uterus, immediate hysterectomy is indicated.

One of the interesting things about a chorioepithelioma is that it may be congenital in origin, a tumor of this sort having been found in the testicle by Schlagenhaufer, and in the Ovary by Pick.

Another noteworthy fact is the comparative frequency of the spontaneous regression of the growth. Gaylord was able to find but fourteen well authenticated cases of spontaneously disappearing cancer, and seven of these were chorio-epithelioma. For this reason I should be inclined to operate in any case where it seemed possible, by this means to check the hemorrhage and increase the resisting powers of the individual. Noble and others have reported cases of recovery after an incomplete removal of the growth.

DR. RICHARD Č. NORRIS: This subject seems to be mainly a study for the pathologist. Its mysteries leave the clinician in the dark. I was very glad to hear what Dr. Anspach said with reference to the failure of curettement to recognize the malignant potentialities of this disease sufficiently to warrant operation. That statement of the case agrees with my own personal experience. The subject illustrates one of the curious phases of certain body tissues running riot without any possible explanation. Some women will have this tissue penetrate to varying extent the uterine wall, and exhibit no malignant tendencies. In others there will be widespread metastatic deposits, the disease assuming the most malignant characteristics.

From a clinical aspect I think with Dr. Davis that it is very important for us to examine the placentæ in all labor cases; and yet, even with microscopic study, as in his case, there is no warrant that this growth will penetrate the uterine wall and exhibit malignant tendencies. Since the microscopic study of the tissues removed by curettement fails to show more than the characteristic tissue, and cannot determine malignant potentialities, we are helpless, and must depend upon the clinical history of this disease. Hemorrhage, with the detection of a sloughing mass in a puerperal woman, should decide the necessity for operation. Microscopic study should confirm the diagnosis. Until the pathologist can give us a clearer idea of what the disease is, we must base our practice upon clinical grounds, and the sum and substance of the matter is that when we feel a growth in the uterus which is necrotic and causes severe bleeding, an operation for its removal is justifiable. Whether that operation should always be a removal of the uterus is sometimes questioned, since curettement has been sufficjent in some cases.

The clinical history of the disease, so far as I am informed, is such that it is my conviction that in a series of cases hysterectomy will save cases that will otherwise be lost, although some cases, with our present limited knowledge, will doubtless be subjected to that operation unnecessarily.

DR. W. REYNOLDS WILSON: I have had no practical experience with this growth. It seems curious that in conducting my service in the Lying-in Hospital for some years I have never

come in contact with a case which could be suspected of chorio-epithelial development, with the exception of one case, and that was so doubtful that it can scarcely be included. Of course, the obstetrician is not always liable to meet with these cases, especially in a hospital of such a character, where the patients are discharged more or less promptly after delivery. At the same time, I have been impressed with the thought that possibly the early diagnoses in this affection have been rather hastily made, and this seems to be the case from the recent studies, which show that in a great many instances chorio-epithelial deposits have been found which have been unexpectedly benign. I think this discussion and the literature show that there is not always malignancy in cases in which this condition is found. I concur fully with Dr. Norris as to the impossibility of proceeding in any methodical way in making up our minds as to what should be done in these cases. Certainly the intrauterine aspects are not diagnostic. The clinical history is apt to be confusing. It seems to me that emphasis should be laid upon the metastasis in the disease, which occurs very promptly and which is accompanied with marked clinical manifestations, such as anemia without earlier symptoms, the continuous hemorrhage after abortion or after discharge of hydatid mole or interruption of pregnancy. The sudden development of metastases means that there has been extensive deportation of villous infarcts throughout the body, and that it is really too late to do anything for the case. From the surgeon's point of view, it brings us to the point of either waiting for these manifestations, or operating promptly where there is the slightest suspicion, in order to avoid the metastasis and ultimate development. This, of course, means a very radical position to take in connection with the case. If we wait for clinical manifestations it is often too late to operate. If we operate early we will often extirpate the uterus in cases where the growth is benign.

DR. GEORGE W. BOYD: I desire to express my appreciation of the splendid review of the subject which I have enjoyed. I have had a number of cases in which chorio-epithelioma has been suspected, have had repeated curettings examined, and have failed to find the trouble. The paper brings out strongly the necessity of careful microscopic examination of uterine scrapings in cases of mole and of patients delivered at term, and the necessity of carefully studying our cases from the clinical standpoint. It is the early and careful diagnosis that will enable us to more intelligently study these cases.

DR. WM. R. NICHOLSON: I was extremely interested in Dr. Davis' paper because of the fact that the placenta was the site of the disease without any, extension to the uterine tissue. I cannot agree with Dr. Wilson in his opening remark. It seems to me that if syncytioma malignum is diagnosed by a curettement, that the uterus ought to come out, without waiting for any further investigation, because the literature shows many cases on record in which one would not find on digital examination any definite growth. Therefore, it seems to me, there is somewhat the same condition as in cervical carcinoma-we operate with the idea of curing the disease. If we wait for the development of metastasis, no operation will do any good. The probability is that in those reported cured there was some peculiarity that we do not know any