1270.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF OBSTETRICS AND GYNECOLOGY.A MEETING of this section of the Royal Society of

Medicine was held on June 4th, Mr. J. D. MALCOLM,the President, being in the chair.

TftHM)t(tMc Laceration of Pediele of a Fibroid.In the absence of Dr. PHILIP TURNER Dr. HERBERT

WILLIAMSON read his communication on a case of Trau-matic Laceration of the Pedicle of a Fibroid, following abicycle accident. A woman fell off her bicycle on to herleft hip, which was bruised, and she was taken homein a bath-chair. The following day she had a risingpulse; the abdomen was tumid, with dullness in theleft flank, and a hard tumour was felt rising out of thepelvis in the mid line. The diagnosis made was intra-abdominal haemorrhage, probably connected with a

calcified fibroid, and a laparotomy was performed24 hours after the fall. The abdomen was found full ofclots and blood, and on raising a hard, calcified, peduncu-lated fibroid attached to the fundus of the uterus the

pedicle was found to be torn and bleeding, and wasremoved. The bleeding of two small arteries was

checked, and the wound in the fundus closed. The

patient made an uninterrupted recovery.R2aptiore of the Z’te7°ues.

Dr. J. FORD ANDERSON described a case of Rupture ofthe Uterus followed by Recovery.Mrs. E., aged 33, a 4-para (one miscarriage), was sent

to a maternity institution, in a collapsed condition andlosing blood freely, by a doctor who had been called in andhad found her in labour, with the feet of a foetus ofapproximately four months presenting. He said that therehad been no contraction of the uterus, but expression andtraction had been used, and that after the easy removal ofthe foetus he had discovered a tear of the cervix extendingoutwards on the left side. The doctor stated also that hehad removed the placenta "with the fingers," and in doingthis had found coils of intestine lying in the uterus. Dr.Ford Anderson saw the patient for the first time 14 hoursafter delivery, when she was still extremely collapsed, andon examination under anaesthesia he found a coil of intestinein the uterus and a transverse rupture 3 to 4 inches long at thefundus, quite independent of the tear of the cervix. Operationwas deemed inadvisable in the patient’s collapsed condition,so the bowel was replaced under anaesthesia, and, contractionof the lax uterus being stimulated by pressure on the fundus,the uterus was packed with sterilised gauze. Thirty hoursafterwards the packing was changed, and 30 hours later thegauze was finally removed. The patient was given pituitrin,morphine, saline solution per rectum, and douches of 1 in320 lysol, as well as oxygen inhalations. From the firstthere were swelling and tenderness in the left iliac region,and during the first few days the temperature varied from103° to 104° F. ; the lochia were foetid. By the eighteenthday the cervical and uterine tears had healed and dischargehad almost ceased; pyrexia and evidences of left pelviccellulitis were still present, when, on the twenty-fifth day,the patient insisted on leaving hospital. A pelvic abscessafterwards had to be opened, but two months later she wascompletely well.In Dr. Anderson’s opinion convalescence would havebeen much speedier but for the cervical tear. Hesaid that probably the majority of medical menwould hold that in these cases operation offers thebest prospect of cure, but it was not consideredpossible on account of the extremely bad conditionof the patient, and the procedure adopted was

carried out with but little hope of success. As aresult of the present case, and after reading Dr. HerbertSpencer’s account in the Obstetrical Society’s Tran-sactions for 1900 (Vol. XLII.) of four cases successfullytreated by packing with iodoform gauze, Dr. Andersonwas inclined to modify his views, and would beinterested to know if Dr. Spencer still adheres to theopinion then.,expressed.In the course of the discussion on Dr. Ford Anderson’s

paper Dr. FLETCHER SHAW recalled an article in whichDr. W. E. Fothergill had collected a series of cases ofrùptu’1’êd utei°i at St. Mary’s Hospital, Manchester, andhad concluded that in genera.] operation was advisable.

In his reply, Dr. FORD ANDERSON read a letter fromDr. Herbert Spencer expressing the opinion that rupturewas usually best treated by packing, as the patients wereas a rule too ill to stand a hysterectomy.Dr. W. FLETCHER SHAW and Dr. A. BURROWS read a

paper on

11’e)-th.eigit’s fI-rtste7°ectorrz for Advanced Ca1’Cinoma of theCervix made Possible boy the Use of BaclÙlm.

Dr. Fletcher Shaw said that the greatest advancehitherto made in the treatment of carcinoma of thecervix was the general adoption of Wertheim’s operationin place of the old-fashioned vaginal or pan-hysterec-tomy. The next great advance was the discoverythat radium acted beneficially on the growth. Althoughon some types of growth and in some situations radiumhad little effect, in carcinoma of the cervix its actionwas wonderful.The first time he had the opportunity of observing

this action was in 1914, when an inoperable growth ofthe cervix with a secondary pelvic mass the size ofan orange, in a patient 53 years of age, yielded toradium treatment (three applications) in a remarkablemanner. At the end of 12 months there was no

growth or mass to be felt; her general condition hadgreatly improved and she was free from pain, but, unfor-tunately, the pelvic mass reformed and continued to growin spite of further applications, and the patient diedat the end of the second year. Since that time_Dr. Burrowshad treated a large number of cases with radium. A largepercentage showed a temporary marked improvement, manyeven complete local disappearance, but in no case of Dr.Fletcher Shaw’s had the improvement lasted for morethan one year, even with repeated applications. However,the combined treatment by radium and subsequentoperation had given good results. In an inoperablecase seen by the speaker in November, 1916, theapplication of radium was advised as a palliative.Three months later, after two applications by Dr.Burrows, the cervix had contracted to little abovenormal size, had lost all friability, and did not appearto be fixed, so it was decided to attempt operation. Theureters were separated from the adjacent and partlysurrounding hard tissue only with the greatest difficulty,since the growth had contracted down under the influenceof radium into a smaller mass as hard as cartilage.Dr. Fletcher Shaw had last seen this patient over threeyears after the operation, and she was then very well,doing all her housework and putting on weight. When hefirst saw her he did not think she could live one year. Sincethat date he had operated upon 13 other patients withcarcinoma of the cervix too advanced for operation whenfirst seen, but apparently operable two months after theapplication of radium. In six of the cases he had to abandonthe operation owing to the impossibility of separating theureters or bladder from the hard tissue which had replacedthe growth, but in the remaining seven cases he was ableto do a complete radical operation.Dr. Fletcher Shaw then gave details of these cases, all

women over 38, of whom five were very well respectively9 months, 14 months, 19 months, 2 years, and 3 years afterthe operation. Unfortunately all these cases had been doneduring the war, and several of the specimens had been lostbefore examination. In case No. 7 no trace of malignanttissue could be found in the cervix, only in one of the glandsremoved with it. As all the cases were considered inoperableon first examination, the application of radium evidentlydefinitely increased the operability.Dr. BURROWS then read the part of the paper con-

cerned with the methods employed at Manchester inradium treatment and with the estimation of the

proportion of inoperable cases of carcinoma of thecervix likely to become operable after this treat-ment. Much depended upon the technique and thequantities of radium employed. Occasionally cases

were rejected because they were too advanced, buttheir number was relatively small. The main points intreatment were that-

’

(1) Many tubes must be buried in the cervix and surround-ing tissues; and (2) the largest possible dose must beemployed. The large number of tubes (five or more) allow abig dose to be given with a minimum of local necrosis.Radium emanation tubes are small in bulk, and whenscreened by pointed tubes of platinum, the walls of whichare 3/10 mm. thick, are easily pushed into place. Othermetals are less convenient. Dr. Burrows usually placeda larger central silver screened tube up the cervicalcanal towards the upper end of the growth. No uniformlygood results could, as a rule, be obtained by less than120 mg. of radium metal, or milleaines of emanation,for 24 hours. Larger. doses might be employed and, if

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necessary, the time correspondingly reduced. Cautery andcurettage were not necessary, but the growth must becleaned as much as possible before the treatment andthe part should be douched daily for six weeks after thetreatment to prevent the formation of vaginal adhesions..Recently Dr. Burrows had treated some cases by Viol’smethod (burying and leaving in the cervix small unscreenedemanation tubes), but was not yet disposed to give a definiteopinion upon the method, although it appeared to promiseeven better than the older ones. When the question ofoperation following radium treatment had first been con-sidered Dr. Burrows was not using the present adequatedosage, but the following details of his first 150 cases inManchester, the last application of radium to which wasgiven early in 1917, would indicate in some degree thepossibilities of increasing the number of operable cases ofcarcinoma of the cervix by radium.G1’OUP (a).-One has been well over four years. Four have been

well between two and three years.Gro,ttl) (b).-Eight cases were observed for periods of one to two

years, during which they remained well, but have not recentlyreappeared for examination. Four cases similar to the last keptwell from six to ten months.Gro2cp (c).—Thirty-four did not return for examination after one

treatment. This commonly happens because the patients are freeof all symptoms and think that they are cured. !

Group (d).—Forty-four had signs of disease, but no symptoms forsix months or more. Five were operated upon by Dr. FletcherShaw, and two by other surgeons.This gave a total of 102 cases accounted for. The remaining48 cases were benefited imperfectly or for less periods than sixmonths, or not at all. Nearly half the cases reported as wellat the end of the year in his annual reports recurred subse-quently. Dr. Burrows emphasised the fact that all these casesbefore radium treatment were regarded as hopeless andinoperable. He thought we might safely assume that groups(a) and (b) became operable, also, perhaps, 10 per cent. of group(d) 7 7 of group (d) were actually operated upon, making up atotal of 28, or nearly 20 per cent. For the last 2t years, withimproved radium, methods he had been able to report 20 percent. of cases as being well at the end of the year. Nearly allof these had clearly become operable in the hands of anexperienced surgeon, and if for any special reason a few hadnot, the number would be more than made up by theimproved cases, not included in the 20 per cent., in which thegrowth, though not completely atrophied, had sufficientlyreceded for operation to be performed. It would thus seemthat 20 per cent. of inoperable cases of carcinoma of thecervix of the uterus come within the range of surgery afterradium treatment.

Mr. COMYNS BERKELEY congratulated Dr. FletcherShaw and Dr. Burrows on their results. He had had a

large experience of radium treatment, but had found itdifficult to follow up cases in London. He found that adose of 250 mg. relieved symptoms, and that the palpablegrowth disappeared, but the ultimate result was dis-appointing, as in most cases the growth recurred

internally. In one case in which operation had beenattempted and abandoned two applications of 250 mg.each had been given, and after two years no trace ofgrowth could be seen, either locally or internally, whenthe abdomen was opened for the cure of a ventralhernia. Mr. Berkeley confirmed the fact that the

operation was very difficult after radium. He said thatthe duration of life after removal of the growth byoperation was about three years in any case, so that asyet the effect of the radium was difficult to estimate.Dr. DRUMMOND ROBINSON quoted a satisfactory cure

by radium only in a woman of 54, who had refused ’,operation. He said that most of the satisfactory cases z,

reported by the Radium Institute were women past the ’menopause. He asked for details of time of exposure,and whether Dr. Burrows considered that an expertradiologist only should use the treatment.

Dr. AMAND RouTH congratulated the authors on suchexcellent team-work. He recalled one case which hehad treated at Charing Cross Hospital by a weak tubeapplied for 20 minutes twice a week.-Mr. W. GILLIATTasked whether the interval between applications andoperation had a bearing on the difficulty of the latter.At the Middlesex Hospital radium bromide, not themetal itself, was in use.-Mr. GORDON LEY suggestedthe intraperitoneal application of radium.-Dr. J. P.HEDLEY approved of radium if only as a palliative. Onthe advice of the Radium Institute he had removed someof the cervix so as to let the emanation get farther in.

In reply to Mr. BERKELEY, Dr. HEDLEY said he had’no serious results, though in one or two cases he hadhad a small fistula or a leak through the bladder orureter,

Dr. HERBERT WILLIAMSON agreed with Mr. Berkeley’sviews on the temporary value of radio-therapy in thesecases. He wondered whether too large doses werebeing used, and asked about the possibility of usingsub-lethal doses sufficient to prevent reproduction butnot to kill the cell. He hoped a collective investigationwould be undertaken on the subject.The PRESIDENT asked Dr. Burrows for his views

on the possibility of harm resulting from radiumtreatment.In reply, Dr. FLETCHER SHAW hoped that in time the

operative treatment of carcinoma of the cervix wouldbe supplanted altogether. Concerning the time of

interval, he considered that the operation only 24 hoursafter treatment would be less difficult than aftertwo months.Dr. BURROWS said that radium should be put in and

around the cervix and not in the middle of the tissues.He considered that if more than three applicationswere required the treatment would be a failure. Thetime of exposure was fixed at 24 hours and the dosagewas varied in screened treatments. Weil, of NewYork, was using unscreened glass tubes left in thecervix. If was difficult for an expert to say that he wasessential, but he deprecated the lack of standardisationin the treatment used. Dr. Burrows gave variouscontra-indications against the use of radium. A reallysatisfactory cure was only obtained when no indura-tion was present round the growth. The risk of too earlyoperation was that of sloughing. The therapeuticdistance was actually about 1 cm. only, and this was anargument in favour of the use of many tubes. He hadhad no immediate bad results after the intra-abdominaluse of radium, and had commonly placed radium tubesadjacent to blood-vessels with impunity. As tothe dangers of radio-therapy, he had seen some badnstulae, but had also seen terrible results afterunsuccessful Wertheim operations, and it must beremembered that the cases were considered hopeless tostart with. In women under 33 or 34 the results werenot permanent. The question of sub-lethal dosage wasentirely theoretical at present.Mr. A. W. BOURNE described a case of

Spontaneous Ruptacre of the Ute1’U8 following Pit-tcitrin.The patient was a 12-para whose last child was born two

years ago. Labour started at 4 A.M. on May 13th, but painswere sluggish during the day, and in the afternoon a sedativewas given on account of primary inertia. At 9 P.M. the oswas fully dilated, and the head was bulging the perineum,but as pains seemed ineffectual c.cm. of pituitrin was givenhypodermically. No apparent progress was made till10 P.M., when the pains suddenly became extremely violent.Just as the head was being born the patient suddenly gave asharp cry and collapsed. The head receded, pains ceased,and the pulse was not perceptible. Mr. Bourne saw the patientfirst on admission to St. Mary’s Hospitaff Paddington, at11 P.M., when she was still pulseless and profoundly shocked,with very slight hsemorrhage. The abdomen was soft, render-ing the palpation of the foetal parts very easy, and fluiddullness rose high in the flanks. After an intravenous injec-tion of gum, gr. of morphia, and other restorative measures,the pulse returned. The head was perforated and removed bycutting through the neck. It was in the permanent occipito-posterior position, but small, and came away withease, but it was not possible to extract the wholechild by gentle traction. A further sudden collapseensued, and in spite of blood transfusion, carried out

by Mr. C. W. G. Bryan, the patient did not rally anddied at 1 A.M. The post mortem showed the child’strunk and placenta free in the abdomen, with theuterus retracted behind it, and much free blood. Therewas a tear of 7 inches in the peritoneum of the anteriorleaflet of the broad ligament, opening up the utero-vesicalpouch anteriorly. The rent in the uterine wall was

5 inches long, beginning at the left lateral wall of thelower segment and extending downwards and inwards toinvolve the cervix. The bladder was uninjured.Mr. Bourne considered the case noteworthy on accountof the rupture occurring in the absence of any obstruc-tion whatever, after a sluggish and short labour, andwhen the head was in the act of being born.Dr. WILLIAMSON, Dr. FLETCHER SHAW, and Mr.

EARDLEY HOLLAND all quoted cases of ruptured uteruswithout obstruction, following the use of pituitrinbefore the birth of the child, and emphasised thedanger of this procedure.