demanded, while peritonitis, adhesions and intestinal obstruction, suppuration of the cyst contents, rupture, gangrene, torsion of the pedicle, hemorrhage into the cyst and shock may occur at any time as the result of large or small growths. Solid ovarian growths or dermoids are rare but are considered even more dangerous than cysts. It is estimated that about fifty per cent. of mothers and eighty per cent. of fetuses lose their lives when both pregnancy and the tumor are allowed to remain. Any tumor large enough to be felt may become a serious complication, and it is well to remember they frequently grow very rapidly during pregnancy. The diagnosis during the early months is made by the ordinary signs and symptoms of pregnancy being present and the ovarian growth is made out by palpation and percussion. If the patient or her physician have knowledge of the presence of the tumor before pregnancy began, it may be of great advantage. In the later months it may be extremely difficult or altogether impossible to differentiate between tumor and uterus.

TREATMENT.

All ovarian tumors, cystic or solid, larger than a small orange, known to complicate pregnancy between the second and fifth months, should be removed by laparotomy. I say after the second month because the diagnosis of pregnancy is seldom certain before that time, and before the fifth month because experience has proven it safer and less likely to bring on abortion. If the patient has reached the fifth month, unless the condition renders it imperative that something be done to relieve her, it is better to temporize until the seventh month, after which time the induction of premature labor may be considered. SWAN states that in cases operated between the second and fourth months the maternal mortality is five and the fetal twenty-two per cent.-a clear saving of forty-two per cent. of mothers and sixty of children by early operation. Is anything more needed to show the folly of expectant treatment in such cases?

Ovarian tumors complicating labor may be divided into two classes: (1) Those above the child; and (2) those below the child.

The principal dangers of those above are rupture, hemorrhage into the sack, strangulation and gangrene. Strangulation or gangrene call for prompt action if the patient is to be saved, while rupture, providing the contents of the cyst be not septic, may not demand such prompt operation but will most surely call for it sooner or later.

Ovarian cysts below the child, whether large enough to interfere with delivery or so small as to offer scarcely any obstruction, are exceedingly dangerous. The child may pass by it without great trouble but the tumor becomes bruised and later gangrenous, when only prompt operation gives the patient a reasonable chance for her life. Tumors, if not too large or too firmly adherent, may be crowded up and the child delivered past them; but here again the danger of bruising and gangrene is great. The tumor may be aspirated, freely opened or removed through the vaginal vault, adapting the operation to the case. Aspirating a simple cyst containing thin fluid will prove quite satisfactory, while if the growth be multiloculer or solid and the fluid be thick or purulent, the operation would be dangerous if not useless. The general opinion is that when it becomes necessary to remove the growth the abdominal route is safer for both mother and child, being also easier for the operator. The growth may be removed in this way and the child delivered through the natural passage, or it may be delivered through the abdomen, as seems best. Dermoid cysts are

especially dangerous because of their tendency to suppurate during pregnancy, or after delivery, or become adherent to adjacent structures and rupture.

A tumor that has been above the pelvic brim during delivery of the child may, after the child is delivered, descend into the pelvis and obstruct the delivery of the placenta.

FIBROIDS.

Interstitial, submucous, intraligamentous or subserous fibroids may interfere with pregnancy. Submucous and interstitial growths are likely to cause sterility or abortion. Subserous growths are unlikely to seriously interfere with the development of pregnancy unless they are adherent in unfavorable positions or very large.

Intraligamentous growths unless large generally rise out of the pelvis. as the uterus develops, and permit the passage of the child, so that they are unlikely to interrupt the course of pregnancy. Fibroids and pregnancy complicated by pus-tubes or other septic foci, should be treated from the standpoint of the latter.

When a growth is known to exist that will surely interfere with delivery at full term, the question of premature labor or abortion should be considered; but, it must at the same time be remembered that the mortality from such interference has been as great as, and some claim greater than, Caesarean section at full term.

If the growth be in the cervix, its removal may be possible either before or at the time of labor. In the hospital last week such a one was removed from a patient three months pregnant. The tumor was about the size of a hen's egg, but there was no interference with the pregnancy nor serious inconvenience to the patient.

In forty-four cases of fibroid tumors complicating pregnancy which have come under my care, there was only one in which it has been necessary to interfere by operation during early pregnancy. I believe expectant treatment, in the absence of positive indications for immediate operation, is the safest and best treatment for these cases.

Fibroids complicate labor by interfering with delivery or causing hemorrhage. They may interfere with delivery by forming an obstruction to the passage of the child or interfering with uterine contractions so that the pains are faulty and ineffectual; or, if situated in the lower segment of the uterus, although of insufficient size to obstruct the passage of the child, may interfere with dilatation of the cervix. These complications. may be overcome by artificial dilatation, incision of the cervix, and forceps. When the tumor is so situated that it will not permit of delivery there is seldom any choice or escape from an abdominal operation, and unless the growth can be dislodged and removed Caesarean section and hysterectomy must be performed. Embryotomy with a living child is today scarcely considered a justifiable procedure, while the abdominal operation is considered the safer of the two, offering a good chance to save both lives and at the same time relieve the woman of the tumor.

CANCER.

Cancer of the uterus complicating pregnancy is quite infrequent. This disease occurs most frequently when the activity of the uterus is about exhausted and conception or pregnancy unlikely to occur. If discovered early in its existence and early in pregnancy, hysterectomy is the only

proper method of treatment, the prognosis being as favorable as though. pregnancy did not exist, but if not discovered until the disease is far advanced or the pregnancy beyond the fourth month, expectant treatment should be employed. Hysterectomy under such conditions has proved to be very fatal, usually resulting in the death of both mother and child. It is true that the prognosis is very grave whatever be the course pursued; but I have seen a very badly infiltrated cervix soften and make delivery possible when a few months before it seemed quite impossible. Should delivery through the natural passage prove to be impossible Caesarean section is the proper procedure at this time, if the child be living, the operation being entirely in the interests of the child. If the child be dead, embryotomy or Caesarean section, whichever is deemed the safer, should be performed.

I will now report the following cases as bearing upon the subject under discussion:

A woman, twenty-five years old, who had been married five months, and whose periods were regular, was taken, October 13, with a severe pain in lower part of the abdomen, together with tenderness in right iliac region and other signs of appendicitis. While in bed the patient missed her first period, and had several relapses of the pain and tenderness during the next seven months. She was very nervous and would not consider any operative measures. At about the end of the eighth month she was taken with severe vomiting and all signs of serious trouble in the abdomen. I delivered the child but the mother died twenty-four hours later with every sign of peritonitis. A postmortem was not allowed, but I believe this patient had a focus of septic material about the appendix which ruptured when the serious symptoms began. I also believe an early operation might have saved her.

Another case was that in which the woman had several attacks of peritonitis when she became pregnant, and after she was two and a half months advanced had a severe attack simulating peritonitis. It was thought wise not to operate until the acute symp toms had subsided, and upon the patient becoming convalescent the abdomen was opened,. the appendix, which contained considerable septic matter, removed, adhesions about the uterus were separated and the abdomen closed. The patient made a very good recovery, pregnancy was uninterrupted and she had a normal delivery.

In another case, a woman twenty-four years old, who had suffered from severe dysmenorrhea for several years, had been in bed on four different occasions with attacks of peritonitis. The periods stopped two months before I saw her, and she was then suffering from severe backache, pain in pelvis, nausea and vomiting, and had some edema of the lower extremities. An examination revealed an enlarged uterns, a mass on the right side the size of an orange, which was very sensitive and fixed. The patient readily consented to an operation which revealed a pus-tube surrounded by extensive inflammatory deposits. The tube and ovary were dissected out and removed and the abdomen closed. The patient made a good recovery and pregnancy proceeded normally.

A woman, thirty-two years of age, having regular but very painful periods, complained of severe backaches and pain in pelvis with slight nausea. An examination revealed the uterus slightly enlarged and enlargement on either side which was very sensitive. A diagnosis of pus-tubes was made and their removal advised. An operation revealed extensive inflammatory deposits on each side, the largest being on the left side. The uterus was soft and about four and a half inches in length. The appen

dages were dissected and removed and abdomen closed. This patient was operated on out of town so that I did not see her subsequently, but her physician reported that labor pains came on three days after the operation and something was expelled from the vagina which was supposed to be the products of a conception. The enlarged and softened uterus suggested the possibility of an early pregnancy at the time of operation, but the tubes and ovaries were in such a condition that it scarcely seemed possible. Apart from this complication her recovery was rapid and complete.

Another woman, twenty-five years old and married six months, sent for me on account of severe pain in the abdomen. She had the appearance of a very large woman at full term. I suggested, not then knowing her history, that it was approaching labor, adding that she looked as though it was about time for her confinement. The woman then gave me her history of being married six months, missing four periods with rapid enlargement, and although she was rather large before being married had never suspected there was any growth present.

The patient was suffering from severe pressure symptoms as well as the pain in the side, on account of which I was sent for. Examination revealed in this case a large fluctuating growth in the upper part of the abdomen and corresponding to the history an enlarged uterus in the lower part. I advised immediate removal of the tumor and ten days later removed an ovarian tumor weighing twenty-three pounds. The excision of the tumor necessitated the removal of the ovary and tube on that side. The patient made a perfect recovery, had a nice girl baby at the proper time, and eighteen months later was delivered of a second child. The abdomen remains firm and the patient is well in every respect.

PREGNANCY COMPLICATED BY MULTIPLE DERMOIDS.

A very unusual case was that of a woman aged twenty-seven years and married four years, who had one child three years old. There had been no abortions. Nine years ago, after an attack of la grippe there had been a dull, painful sensation in the right side. The patient knew she had a growth in the abdomen some months ago, and it was as large as a child's head. The woman said she became pregnant three months ago, and was very weak, being able to walk very little, and having nausea with vomiting and a great deal of pain in the abdomen. An examination showed the breasts to be enlarged, the areola darkened and glands active, while the abdomen was enlarged to the size of full term. Palpation revealed the fact that at least two separate enlargements were contained in the abdomen, each being about the size of an adult head, one filling the upper part of the abdomen, freely movable; the other, filling the lower zone and not so freely, but still quite movable. Vaginal examination proved the pelvis also to be filled by a dense mass firmly fixed therein, which could not be moved up or down and which filled the pelvis so closely that a finger could not be passed between the growth and the pelvic wall. The cervix was high up under the pubic arch and pointing forward. The mass felt not unlike a pregnant uterus and seemed a part of the lower growth in the abdomen. The diagnosis was multiple growths, probably ovarian, which complicated pregnancy, while the uterus was apparently retroverted and incarcerated in the pelvis. There was nothing to advise but laparotomy. Five or six days after the first examination I opened the abdomen and found the pregnant uterus in the lower part of the cavity with a large, hard growth above it, another below it, filling the pelvis, and a smaller one on either side; all hard growths and all ovarian. I removed all the growths intact, although there appeared to be fluid in portions of them. The one in the pelvis gave me much trouble, as it was packed in so tightly and adherent in so many places that even with combined pressure from below and traction from above it seemed as though it could not be removed without diminishing its size. Both ovaries and tubes together with the tumor were tied off close to the uterine horns and removed. The patient had some infection and suppuration in the wound, but made a good recovery and went home six weeks after the operation, feeling well. The uterus had developed so that the fundus was above the umbilicus, while the fetal movements were vigorous and the heart distinctly heard.

This woman could not speak English and seemed to lack any kind of judgment or knowledge in caring for herself. Two days after the operation, during the temporary absence of the nurse, she arose from her bed and walked across the room, and it was only by keeping a nurse constantly at her bedside that she could be kept in bed.

About six weeks after the patient went home she did a laborious day's work, lifting some heavy articles which brought on an abortion. She recovered and is well, but the abortion was absolutely unnecessary.

The tumors that were removed proved to be four dermoids, three attached to the right ovary and one to the left. Those attached to the right side were in the form of a three-leaved clover with a small middle leaf. One large growth was in the pelvis below the uterus, the other large one in the upper part of the abdomen above the uterus, and the small middle one lying between them by the side of the uterus. Multiple dermoid tumors are rare and I know of no other case wherein so many have been found to complicate a pregnancy.

EARLY PREGNANCY COMPLICATED BY LARGE FIBROID.

A woman, thirty-two years old, who had been married five months, said that she had noticed a gradual enlargement of the abdomen for four years, which has been growing very rapidly for the last two months. The ime of her last period was eight weeks ago, and the patient had nausea with vomiting. A severe attack of peritonitis occurred six weeks ago and a other two weeks ago, from which she had not fully recovered, being still unable to sit up. Her physician gave me the following additional history: A hard, movable tumor the size of a fist was discovered four years ago, and at that time the patient was advised to have it removed. Six months ago the patient consulted him relative to the advisability of entering matrimony. He examined her then and found a hard

growth filling the abdomen to the size of a full-term pregnancy. The advice was emphatically against marriage, and he also told her that the most favorable time for an operation had passed, but urged her to have it done, as the only possible help. The patient entirely ignored his advice, refused to have anything done with the growth and was married. Six weeks before consulting me she had a very severe attack of peritonitis and had not entirely recovered before another attack occurred. She had been very ill, her life being despaired of a good part of the past two weeks.

The woman was brought to the hospital on a stretcher, complaining of a severe pain and tenderness in the abdomen, and having a temperature of 101° and a rapid pulse. Examination showed a large abdomen filled to the ensiform by a hard, nodular and very sensitive mass. A vaginal examination revealed the purplish color of the mucous membrane, a scftened cervix, with a uterus enlarged and softened. A diagnosis of pregnancy, two months advanced, complicated by fibroid tumors, peritonitis andsome septic foci was made. I consented to operate, as it seemed her only possible chance of life. She certainly had nothing to lose and everything to gain. On August 22 I opened the abdomen and found a large, solid fibroid, filling the abdomen from pelvis to ensiform, adherent to abdominal walls, omentum, intestines and liver. The adhesions were, for the greater part, not firm and I succeeded in separating them without injuring any impor tant structure, but with difficulty delivered the tumor through an incision extending from the ensiform to the pubes. The tumor was attached to the fundus of the uterus by a round, hard, half-twisted pedicle, four inches through, which connected it directly with some other growths in the uterine wall. This pedicle was divided, but, as it was found impossible to control the hemorrhage by ligatures, and leave the two months pregnant uterus behind, I was compelled to do a hysterectomy. The extirpated uterus contained several small-sized fibroids besides the two months' fetus. An examination of the large tumor showed several necrotic areas, some of which were quite large, having small spaces containing virulent fluid. The patient stood the operation very poorly, but reacted quite promptly when put to bed, doing very well for three days, at the end of which time death occurred quite suddenly and unexpectedly; which appeared to be caused from sudden heart failure.

It has been well said that women having fibroids and entering matrimony are entering upon an interesting and venturesome experiment.

These are a few of the many cases of neoplasms complicating pregnancy that have come under my care and observation, which are fair illustrations of the worst cases I have met with. Out of the forty-four cases of fibroid tumors which I have recorded, I find eleven have had abortions, two Caesarean section, six have been confined more than once, and nearly all having tumors of any size have had severe hemorrhage whether delivery occurred prematurely or at term.

RECTAL OBSTRUCTION.*

BY JAMES A. MACMILLAN M. D., DETROIT, MICHIGAN.

LECTURER ON MATERIA MEDICA IN THE DETROIT COLLEGE OF MEDICINE.

[PUBLISHED IN Che Physician and Surgeon EXCLUSIVELY)

THE whole subject of intestinal obstruction is one of great importance, but this discussion is restricted to a consideration of rectal obstruction, a condition to which this portion of the bowel is for several reasons peculiarly liable.

First, the rectum is situated in a bony cavity where it has a comparatively fixed position; second, it is in intimate relation with organs disposed to displacements, enlargements, and disease, that tend to monopolize pelvic space, thereby causing occlusion of the bowel; and third, either on account of the extraordinary pressure to which it is exposed, or on account of its innate susceptibility to disease, the terminal portion of the intestinal tract is very frequently the location of lesions which produce obstruction.

*Read before the MICHIGAN STATE MEDICAL SOCIETY at its Battle Creek meeting.