CASE 6.-Reinicke. A woman, 26 years of age, primipara, was under medical treatment in a hospital for irregular uterine hemorrhage of several months' standing, when she was suddenly seized with violent abdominal pain and symptoms of internal hemorrhage. Immediate laparotomy showed the peritoneal cavity full of blood; the tubes were normal, but in the fundus uteri was a small opening, from which protruded a bit of dark, placenta-like tissue. A supravaginal hysterectomy was performed; the patient recovered, and was known to be well three months later. The author could not find microscopic evidence of chorionic epithelium, either syncytium or Langhans's cells, and therefore did not consider the tumor a chorionepithelioma, but classed it as, in all probability, a “sarcoma telangiectodes hemorrhagicum"; Hörmann, however, thinks it was undoubtedly what would now be classified as an 66 atypical," infiltrating form of chorionepithelioma.

CASE 7.-Zahn. The patient was 43 years of age, V-para. On account of symptoms rather of intestinal obstruction than of internal hemorrhage the abdomen was opened; nothing of importance was discovered in the pelvis, but a portion of the right tube was resected, as the operator thought it appeared somewhat abnormal. The woman died an hour after operation, and at autopsy a small, clean-cut perforation was found in the fundus of the uterus, leading into the uterine cavity. In this region the endometrium was much thickened, and at the adjacent cornu there was a distinct vascular tumor, which the author diagnosed a "placental polyp," but which, from the description and drawings, was evidently a chorionepithelioma. There had been considerable intraperitoneal hemorrhage, with the formation of a retro-uterine hæmatoma.

Summarizing these seven cases, the one reported by Hörmann himself, and our own, we see that of nine patients in whom there occurred an intraperitoneal rupture of a tumor of chorionepitheliomatous nature, three were not subjected to operation, and in a fourth laparotomy was performed, but the seat of the trouble was not discovered. All of these women died in a short time from intraperitoneal hemorrhage or infection. In the remaining five patients hysterectomy was performed, four of them recovering at least from the immediate effects of the operation; in one instance, in which the growth had been incompletely removed, death occurred in a few weeks, however, and the ultimate fate of the other three is unknown. This series of cases, small though it is, is sufficient to indicate the gravity of the condition, the great difficulty at times of making a correct diagnosis, and the importance of immediate operation in the presence of suggestive symptoms.

Our own case emphasizes one point in addition, however, which we consider of the utmost importance, and upon which too much stress

Arch. f. Gyn., 1897, liii, 105.

Virch. Arch., 1884, xevi, 15.

cannot be laid; namely, the potential danger of every case of hydatid mole. This is, we believe, not sufficiently recognized by many practitioners and general surgeons. It is well known that chorionepithelioma is far more apt to develop after a molar pregnancy than after a normal gestation or ordinary miscarriage. It has been estimated that from 35 to 50 per cent. of all cases of chorionepithelioma have been preceded by a hydatid mole, and, conversely, the estimates of the proportion of hydatid moles followed by the subsequent development of a chorionepithelioma range from 7 or 8 to over 30 per cent. Even though the smaller figures may more nearly represent the general average, they are large enough to show the very serious potential danger of the condition, and to impress upon us the necessity for a competent microscopic examination of all material removed by curettement, or discharged spontaneously, in any way suggestive of hydatid mole. If such examination shows this condition to be in fact present, the importance of keeping the patient under frequent supervision should be vigorously impressed upon her family physician, and she herself should be warned of the importance of reporting at once any irregular or excessive bleeding or discharge. Had this been done in the case that we are here reporting, instead of time being wasted with medical treatment, a thorough curettage at least would have been performed when the patient first complained of the renewed irregular bleeding following the original operation, the material would have been carefully examined, and if it had shown any evidences of cellirregularity or of the presence of chorionic elements, immediate hysterectomy would have been insisted upon, and the young woman thereby very probably saved from the development of one of the most malignant types of tumor to which the human body is subject, which came within an ace of costing her her life from acute hemorrhage, and may yet do so from the occurrence of metastatic growths.

[NOTE. Since the above was prepared for publication, the case here reported has presented the following rather interesting developments:

Upon the first attempt at coitus, three weeks after leaving the hospital, the patient was seized with most furious hemorrhage, which necessitated the tightest possible tamponade of the vagina to control it sufficiently for her to be brought in again. On removing the packing, two or three small, soft, papillary excrescences were found in the left vaginal vault. These were removed by the cautery, this procedure being again accompanied by violent hemorrhage, which it was impossible to control by extensive cauterization, so packing was again resorted to. Microscopic examination of the removed particles showed them to consist of VOL. I. Ser. 25-14

vaginal wall, with several areas of typical chorionepithelioma. On removing the packing the following day, another hemorrhage of such violence occurred as seriously to threaten the patient's life, and almost to lead to a suspicion that the iliac vessel had been eroded. This was, however, controlled by acetone gauze, left in place for forty-eight hours more. After the removal of this, there was slight oozing every day, especially after an examination. Soon a distinct mass began to develop in the left parametrium, which shortly reached the size of a large lemon, extended somewhat into the uterovesical space in front, and was immovably fixed to the pelvic wall.

As any hope of further benefit from operative measures seemed to be gone, the patient was referred to the University Hospital for radium treatment. On January 2, 1915, three tubes of radium, the quantity of whose contents we have been unable to ascertain, were placed in the vagina for 24 hours, following which the patient was allowed to return home. Since then she has been examined at weekly intervals, and has shown, so far at least, a truly remarkable improvement. The mass in the left parametrium has steadily shrunk in size, and become freely movable, the upper portion of the vagina has contracted somewhat, and the tissues have become firm and hard; since the radium application there has not been a drop of blood passed, and now even purposely rough manipulations during examination fail to elicit the least ooze. Two small bosses are still palpable projecting into the vaginal vault, but these are steadily shrinking. Following the radium treatment, the patient complained for a time of severe pains in the rectum, which suggested the possibility of beginning involvement of that organ, but these have now entirely disappeared, and were undoubtedly the result of irritation from the radium. Subjectively, the patient appears entirely well, and is able to lead a perfectly normal life in every way.

Of course, nothing is farther from our purpose than to suggest that an actual cure has been attained here. Only the future can determine that. It seems reasonable to hope, however, in view of what is known of the local destructive action of radium on malignant growths, that if no deep-seated metastases have as yet occurred, sufficient destruction of the tumor may be caused by the radium to permit the natural protective powers of the body to get the upper hand. At the present writing (February 1, 1915) all we can say is that a degree of improvement has followed the treatment such as we believe could have been attained in no other way, even granting the well-known ability of the body at times to overcome this type of growth unaided. Here, however, progression was steadily from bad to worse until the radium application, since which the picture has completely changed. One or more further treatments will probably be given in the near future, according to the progress of the case.]

Medical Problems

MEDICAL ECONOMICS

BY JOHN ASHBURTON CUTTER, M.D.

Secretary of the West Side Physicians' Economic League, New York City

THE first Saturday in March, 1886, the writer boarded a downtown car, moved over worn-out rails by a horse and managed by a compound of driver and conductor in one person, arrived close to the City Hall Park, entered the County Clerk's office, passed in his diploma, of date of a few days before, and was registered as a practitioner of medicine and surgery. Last March he took over the office of secretary to the West Side Physicians' Economic League, and since then has been engaged in more active clerical administrative work than in many years and finds himself associated with men as old, if not older, in a strenuous effort to find some kind of solvent of the economic problems affecting the medical profession.

Here are some of the present-day conditions:

FIRST.-The horse-propelled car is replaced by the application of electricity above, below, and on the surface of the earth. And with this great change have come many others, and among them we find our universities and colleges turning loose annually literally a horde of degreed students, many of whom are going to find a livelihood by working on the problems of regulation before the fact, as if old humanity had not always reeled and staggered along, and can be managed before the fact to only a very limited extent. But the effort is here, and these young people are so filled with their academic vanities that they think they can tell medical men how to practise medicine.

SECOND.-Medical Individualism: Lawyers largely make the laws and execute them, and team-work in the legal profession is highly efficient. The medical man is a hermit; he has friends, yes, and good ones in the profession, but our ideals have been and are so eminently placed that to think of working together financially is to cause a mental cataclysm in the thinker.

THIRD. The decrease in acute diseases is wholly due to the initiative of the medical man, and of it he does not complain, but gives thanks that his own family is less liable to infection and sickness.

FOURTH.-The dispensary and clinical service of the medical men in this city literally means giving to the poor and those not poor millions of dollars annually of unremunerated service. Settlement workers under salary from philanthropists look on with amazement at such altruism. And among other results we find the promotion of pauperization, excessive tiring of the men engaged in this work, and at times their overcharging those who do pay.

FIFTH.-The Health Department in its night clinics, free vaccinations of the children of the well-to-do, and its visiting nurses infringing on medical practice, yet further promotes the idea among thousands that medical services are to be had freely and without cost.

SIXTH.-Medical men have not been blameless-they have chased the man with a dollar, which is one hundred cents and may be half his day's wages, to the clinic, dispensary, or Health Department, and with him have gone many who can pay two and more dollars, to say nothing of his company of thousands who pay only the dollar. The managers of clinics desire large records at the end of the year for publication, whereby more money will be subscribed by people, some of whom have had their arms up to the shoulders in the financial bowels of humanity and who wish to ease their conscience and fatten their self-esteem. And thus the system grows, and the common garden variety of medical men, on whom, in the final analysis, the health of the people rests, suffers from overwork and underpay and is not at his best for his legitimate labor.

SEVENTH.-Mutual piracies are seen-the man on top, called in as consultant or operator, may get enormous fees and leave the attending physician with little or nothing. On the other hand, the financially astute general practitioner, desiring to get even, as he thinks, with the specialist, sends his patients to the clinic and literally hangs round to see what diagnosis and treatment are made and ordered. What a state of affairs in the noblest of professions!

EIGHTH.-Fee-splitting is loudly inveighed against, though naturally arising because the general practitioner has not seen to his getting a proper fee for diagnosis when calling in the operator, and the latter has not always been thoughtful enough to look after the