IN CHARGE OF ADAM H. WRIGHT, K. C. M'ILWRAITH, FRED. FENTON

AND HELEN MACMURCHY.

A Case of "Fleshy Mole." BY J. W. BROWNE, B.A., M.B.,
B.Ch., Adelaide.

The patient, Mrs. M., was first seen by me on December 26th of
last year.
The history was as follows: She had been married
about a year; was last unwell on October 9th; on Christmas Day
she noticed that she was bleeding, and sent for me on the 26th.
I found, on examination, that the uterus was enlarged, about the
size one would expect at two and a half months, and that there
was blood coming away from it. There was no pain. I diag-
nosed threatened abortion, and prescribed rest in bed, and gave a
little opium. The patient stayed in bed altogether nine days, by
which time the bleeding had stopped. Only blood was passed
during this time. She then got up and went about her work as
usual, and I congratulated myself on having prevented a threat-
ened abortion. I may remark in passing that this is a thing I
have always tried to do in any case of threatened abortion I have
had occasion to treat, but have never yet succeeded in doing,
with the possible exception of the present case.

I heard nothing more from the patient until May 6th, when she came to see me. Her complaint was then that she was not feeling altogether well; that she had "no life and felt no interest in anything"; also that she had not noticed that alteration in figure she was entitled to expect. The bleeding had not returned, and there had been no discharge of any kind. I examined again, and was a good deal surprised to find that the uterus had apparently not increased in size since the last examination; it was, so far as I could judge, exactly in the same condition. I told the patient that the child was dead; that it must have died at the time she had that threatened miscarriage, and that it had not come away as it should. I recommended operation, and explained to her that she would not be well until everything left behind had been removed. The family, however, had had a most unfortunate experience of operations in the past, and were strongly disinclined to submit to another, of the necessity of which they were not entirely convinced. They decided to await the healing influences of time and nature. I told the patient to come again in a month. She did, with the same story as before, and I again strongly recommended operation. This time she

consented, asking, however, for four weeks' grace, to give those healing influences another chance.

On July 21st bleeding recommenced, accompanied by severe pain. There had been a slight brownish discharge for two weeks before this date. On the 22nd I found a mass protruding from the os uteri, which I withdrew, and then curetted the uterus. The mass referred to was about the size and shape of a small orange. It contained a cavity, opening to the exterior. The wall of the mass was about an inch thick; the material of medium toughness, and fairly uniform texture. No fœtus recognizable. It was, I think, a well-marked specimen of the so-called fleshy mole.

The patient was quite well in a week, and has remained so since. The catamenia returned in four weeks after the expulsion of the mole.

The points of interest in the case seem to me to be the long time, nearly seven months, the mole was retained; the total absence of bleeding during that time; the aseptic condition of the mole; and the comparatively trivial symptoms its presence occasioned. The mole was expelled almost exactly at the time the fœtus would have attained to term had it survived.—Australasian Medical Gazette.

Monstrosity.

Dr. M. V. Mulcahy, of San Jose, Cal., reports a peculiar case, under date of May 3rd, 1908:

Parents both healthy, no abnormality; they have two children, both girls, one six, the other four, perfectly normal and quite pretty.

The mother gives no untoward history during pregnancy except she had scarlet fever in March last. I attended her; the attack was light, highest temperature 103 degrees, lasted only five days.

I was called at 1 p.m. April 25th, she saying that she was flowing some. I examined; found a breech presentation; os patulous slightly dilated, no pains; ordered her to bed; was called again at 4 p.m., she having hard pains; on examination found os dilating nicely; membranes ruptured. Labor was normal and easy; fœtus delivered at 5.30. The placenta, which was expressed without aid five minutes after, was small but normal, cord very small and flaccid. Foetus breathed about once in a minute for half an hour. Monday a.m. mother's temperature 103.6 degrees; lochia scant and very light color, some odor.

Evening temperature, 102; pulse, 120; tympanitis. Tuesday a.m. temperature, 102; evening, 100.4. Wednesday temperature, 98.6, and has been normal since. No cause could be found for rise of temperature, as no part of placenta or membranes were left in utero, and thorough asepsis on my part would preclude from that source. I believe cause to have been infection from

fluid in foetal nose, or whatever it was.

The foetus was as you see it. There was no nose or prominence between the mouth and eyes. The eyes were, as you see, both evidently in one orbit, and, staring at you, were a very uncanny object. The picture makes them appear white, but the conjunctiva was very much injected. The horn on the forehead had a small opening, central, like a meatus urinarius, and on probing a few drops of a muco-purulent nature were discharged from it. The right arm was like a seal's flipper, jointed back, and terminated in two fingers, middle and little fingers, but they were only about 1 1-2 inches from the elbow; left had thumb located near median line of palm and appearing between middle and ring fingers. Both feet were very marked cases of talipes varus. The ears were of tremendous size for a child, but presented no abnormality. The child was a male and weighed 8 1-2 lbs. It breathed for half an hour with a peculiar noise which was indescribable.

THERAPEUTICS.

Treatment of Angina Pectoris.

Sir Clifford Allbutt, F.R.C.P. (Folia Therapeutica, Jan., p. 3): Too often angina pectoris is regarded as inevitably fatal. On the contrary, of all perilous maladies it is, perhaps, the most curable. The writer thinks that it is usually a painful lesion of the first part of the aorta due to tension. Sometimes it may be produced by stretching of the pericardium, as in aneurysm of the left venticle, or by inflammation of that part of the tunic which invests the root of the aorta; very rarely it may depend on some extraordinary kind of disturbance in the mitral area. The innervation of all these parts is approximately the same, and the disease even in these rare points scarcely deviates therefore from the common formula. This tenderness may be due to aortitis of any kind, e.g., rheumatic, influenzal, or atheromatous. In the first two the tensile stresses may be about or even below normal; in the third, normal or excessive. Primarily angina pectoris is not a fatal disease; secondarily, by reflex inhibition of a frail heart it frequently proves fatal. Even in the case of an infirm heart complete recovery often comes about. In young subjects recovery is the rule.

In treatment there are three purposes: to mitigate, if possible, the lesion of the aorta; to reduce the stresses; to block the inhibitory influence on the heart. In many cases to reduce the stresses may be our only means of compassing the restoration or quiescence of the vessel. To combat the local affection directly we may use antidotes, as in acute rheumatism for instance, salicylates, and perhaps the iodides. The iodides with or without. mercury would be required in syphilis. In aortitis arising from other toxins, such as influenza, antidotal means may be lacking, and we have to trust in the recuperative methods of "Nature." There are, however, intermediate cases, such as gout, in which we may not have antidotes so direct as the salicylates, but tolerably efficacious empirical methods nevertheless, on which we may place no little reliance. Indirectly we may do much by reducing the tension. In many, perhaps in most cases, the tension depends on pressures exceeding the normal. In elderly persons angina pectoris is commonly attended with atheroma and often with increased arterial pressures; but in not a few cases it seemed

to be of infective origin, especially of influenzal origin. In these the arterial pressures were not persistently enhanced, and they ended favorably. It may be difficult to distinguish between means used simply to reduce pressure and similar means for the elimination of gout or goutiness; but the distinction is unimportant. Gentle and frequent mercurials, such especially as calomel, in persons who tolerate it easily, laxative waters, at a spa or otherwise, colchicum, salicylates, iodides, strict diet are some such means. Flatulent or catarrhal states of the stomach must be relieved. In obscure cases of heart disease the morbific element may be syphilis, so in angina pectoris likewise give the patient the benefit of this doubt. To promote normal metabolism exercise is important; but as exertion raises arterial pressures, at any rate at the beginning, we shall have to balance tentatively in the individual one indication against the other. Meals should be restricted in quantity. If appetite be defective, it may be solicited by a draught composed of hydrochloric acid, pepsine, and perhaps a little strychnine or other bitter stomachic of a more carminative kind, not so much to aid in the digestion of the meal as to arouse the languid viscus by its customary excitants. Carbohydrates are the kind of ingestum most concerned in the disengagement of flatus, and must be ordered sparingly and with discretion of form and cooking. Alcohol, strong tea or coffee, and other excitants of the heart must be forbidden.

Rest in bed is essential and is sadly neglected. From the first attack of angina the patient should be sent to bed as if he had an aneurysm, so as to reduce the work of the heart as much as possible. The pressure should be reduced as low as may be consistent with health by vaso-dilators, in co-operation with the measures described. On the other hand, the physician must be cautious in ordering an elderly patient to bed, or bed and couch, even for three months. To send an old man to bed for some weeks may be to consign him to a living grave; his lungs may become œdematous, his energies may flag, and he may never get about again. Or a perishing heart may be kept agoing only by a certain activity of oxidation, and in muscular idleness it may dwindle more and more. In young subjects with sound cardiac muscles and arteries this deterioration is less menacing. Nevertheless the writer constrained a man over 80, wiry, cheerful, with the decrescent form of atheroma, to keep bed and couch for many weeks, and cured an angina pectoris which had lasted a considerable time.

The value of the nitrites in reducing aortic pressure is well known; still we are always learning, even in well-worn subjects.