pulmonary apices and inferior posterior margins to be the seat of nodular masses. The surface of the left hepatic lobe was the seat of two deposits which simulated encephaloid carcinoma. The lymphatic glands were perfectly normal. The uterus was enlarged about one-fourth, and its attenuated walls were easily torn; upon opening it, it was found to be almost entirely destroyed by ulcerative processes which were most marked near the fundus. The cavity of the pelvis was occupied by the morbid mass and the vagina entirely destroyed. The bladder was not involved, but the urethra was sloughed through. Rectum free. The microscope showed a small-cell sarcoma. The pathological laws of which this is an illustration possess especial interest regarding treatment. It is now well known that neoplasms originating in areas that have developed from either the epi, meso, or hypoblast possess certain specific life histories, and while all may closely resemble each other in their incipiency, differ widely, not only in their course, but ultimate results, as they continue to exist. Thus epithelioma of epiblastic structures is local and not subject to metastasis, while the hypoblastic epitheliomata are permanently metastatic. Mesoblastic neoplasms are of connective-tissue type and, in large-cell forms, local, while in small-cell varieties metastatic. Epitheliomata undergo metastasis through the lymph channels; sarcoma by means of the blood-vessels. Either of these diseases when first becoming active, there is good reason to believe, is local, and before retrograde changes occur, can, by total removal of the organ involved, be radically cured. As sarcoma, and especially its small-cell variety, is especially prone to metastasis, its early recognition is a matter of paramount import. In this case its early evidence was mistaken for carcinoma, and from a clinical standpoint alone such an error is unavoidable, but as the discharges contain portions of the neoplasm, readily recognized by the microscope at a time when metastasis has not occurred, its diagnosis and treatment are a matter of simplicity. The later symptoms, absence of lymphatic involvement, and comparatively slow course enable one to know that he is palliating the suffering from a sarcoma.

TRANSACTIONS OF THE GYNECOLOGICAL SOCIETY OF CHICAGO.

Meeting, January 15th, 1886.

The President, DANIEL T. NELSON, M.D., in the Chair. DR. CHARLES WARRINGTON EARLE read a paper entitled:

THE WATERY DISCHARGES OF PREGNANT WOMEN.

Mrs. F. K. consulted me for a profuse watery discharge which had taken place several times during her pregnancy, commencing at the third month. She was the mother of three children, and had always been free from any marked pelvic disease. The first discharge was clear and watery, and she estimates the quantity at about two quarts. This came away in gush, most of it being discharged at once, although there was a slight loss for some days thereafter. At first it was thin and clear, then slightly thicker, of the color of weak coffee. These discharges seemed to occur every two or three weeks, and were frequently attended with considerable pain. There was a decided diminution in the size of her abdomen after each discharge.

On October 30th, I found her in great pain, and examination demonstrated that the fetus was very low in the pelvis, and apparently not surrounded with any liquor amnii. The os uteri was , neither soft nor dilated. She was ordered anodynes and to remain in bed. On the 7th of November I again saw her, and found she had been having more or less pain since my previous visit. There was no dilatation. Two days after, however, she was delivered, her gestation having lasted about two hundred days. The child lived about one hour. She made a good recovery, and resumed her place in the family in the course of two weeks.

Mrs. M., 27 years old; in her ninth pregnancy. At the end of five months she commenced to have a flow of fluid which continued until the end of the seventh month, when she gave birth to twins, one living and the other dead. There was no escape of liquor amnii at her confinement. The same lady, in her eleventh pregnancy, commenced to lose fluid at the end of the seventh month, which continued until the completion of the full term, when she gave birth to a healthy child. She had what her attendants called a dry labor.

Mrs. D. W. R., aged 31, the mother of nine children, has been pregnant since the 1st of July, 1885. On November 20th, she said to a friend who was at her bedside that she was flowing, and asked to be supplied with a napkin. A sheet folded and placed under the patient was thoroughly saturated with fluid; the discharge

being equal probably to at least two pints. She had severe pains, which simulated those of labor, lasting a few hours. On December 15th, she had a similar discharge. The future of this case is yet to be decided.

Frequency. These cases evidently take place with more frequency than we have, up to this time, supposed; but the older obstetric authors have noticed peculiarities of this kind, and given very fair descriptions of the complication.

Smellie says (page 179, Vol. II.): "Dribbling of fluid may go on for weeks, but a sudden gush is invariably followed by parturition; the longest interval between a sudden gush and labor being seven days." In this he is certainly mistaken, as the history of many recorded cases and some of mine will demonstrate.

Denman, 1815, says: Instances have been recorded in which the waters of the ovum are said to have been voided as early as the sixth month of pregnancy without prejudice either to the child or the mother. The truth of these reports seems to be doubtful, because where the membranes are intentionally broken, the action of the uterus never fails to come on. A few cases of this kind, somewhat similar, have occurred to me. A discharge of colorless fluid takes place daily from the vagina for several months preceding labor, which is due to the rupture of some lymphatic. Such labors are usually premature and the fetus small."

The same authority also cites a case where, after the delivery of the placenta several pints of lymph were discharged.

Burns, 1822, page 238, says that the discharges of watery fluid from the vagina are not infrequent, and generally depend upon the secretion of glands about the cervix, the rupture of lymphatics, or from fluid collected between the chorion and amnion, or water from blighted ovum in the case of twins.

Dr. Pentland relates a case where coughing produced a discharge, the water being discharged at the fourth month; but labor only occurred at full term.

Merriman, in his work entitled "Difficult Parturition," 1826, relates the case of a lady-six months pregnant-from whom a profuse watery discharge occurred. She summoned a physician, who assured her that if pains came on she would soon be delivered. She continued, however, to the end of pregnancy, having a profuse discharge each day. At full term she was delivered, her attending physician rupturing a bag of waters which appeared in no way different from usual cases. No opening was discoverable in either the placenta or the membranes, and he concluded that the discharge must have come from the outside of the membranes.

Chailly, edited by Bedford, 1844, gives a rather full account of hydrorrhea, the description not being different from those I have already related. He says, however, that these discharges are more frequent than are generally supposed, but makes the erroneous statement that in nearly all these cases pregnancy is carried along to its full term.

Nearly all modern authors devote a short section to the consideration of this subject, giving different names, as their ideas of its origin and pathology are different.

Three separate pathological conditions seem to be, in many cases, confounded, and I see no way by which a differentiation can be made.

1st. A discharge of the liquor amnii.

2d. Discharges from increased glandular action.

3d. A possible collection of fluid between or outside of the membranes, and its irregular evacuation.

In my teachings I have been in the habit of speaking of hydrorrhea, but never, up to a few months ago, had I seen a marked case. A study of this case with others collected from my own experience, and the perusal of the article written by Dr. Thomas C. Smith, of Washington, D. C., which appeared in the AMERICAN JOURNAL OF OBSTETRICS in May, 1885, has caused me to go over the subject carefully and to present what I can obtain from the authorities in regard to these peculiar discharges.

Great numbers of cases have been recorded, but no one, up to this time, has demonstrated conclusively the source of the flow.

The etiology of these discharges has been the subject of very different opinions by different obstetric authors.

Chailly says that authors have attempted to show that these discharges are due to the accumulation of fluid between chorion and amnion; to rupture of lymphatic vessels; to transudation through amniotic membranes; to rupture of the membranes at some remote point from the orifice of the uterus, and finally to dropsy of the womb.

Lusk says the pathological processes involved in the disease are vascularity, hyperemia, and hypertrophy of the interstitial connective tissue, and of the glandular elements of the decidua.

Barnes, in the "System of Obstetric Medicine and Surgery," 1885, says in regard to these discharges, without entering into a critical discussion of the several theories, that it seems to be well established that there are five sources from which this fluid may come :

1st. A discharge from the cervical canal.

2d. The decidual origin.

3d. Transudation through the amniotic membranes.

4th. Hydatidiform degeneration of the ovum.

5th. Cauliflower excrescences.

The differential diagnosis must rest between the following similar discharges:

I. From the discharge from hypertrophied cervical glands.

II. Fluid collecting between chorion and amnion, occurring only once. III. Escape of fluid from amniotic cavity.

I. The fluid escaping from the hypertrophied glands must be small in quantity, and we would expect that it would continue for a considerable length of time. There would be no diminution in the amount of liquor amnii, and the child would be found floating in the usual amount of fluid. II. If the fluid collected between any of the membranes, and adhesive inflammation around it followed, a considerable amount of fluid might collect, and the discharges would be considerable at once, and might or might not be repeated. In such a case there would be no evidence of escape of true amniotic fluid, although there might be a lessened size of the abdomen.

III. Where the liquor amnii escapes, there would be a greater tendency to uterine contractions; a more perceptible diminution in the size of the uterine tumor, and a microscopical or chemical examination would certainly reveal some evidence of urine, as we know this exists in variable quantities in the liquor amnii.

Transudation through the amniotic membrane, although recently noticed by Barnes, and mentioned by older authors, would give rise to the discharge of a very small amount of fluid.

This could hardly be differentiated from a slight discharge taking place from the cervical glands. Fluids discharged from hydatidiform degeneration of the chorion or from cauliflower excrescence would be so associ

ated with the diseases which cause them that the diagnosis would not be difficult.

Prognosis.-As far as my observation goes, the life of the woman is not jeopardized, but she suffers from the constant discharge and becomes anemic. The pain is sometimes severe, as I have before remarked, and the patient is full of gloomy forebodings and anxious in regard to the final result.

The fetus is usually born prematurely, and, in many cases, only lives a short time.

The treatment must necessarily be very simple-rest and anodynes being about all that can be suggested.

DR. H. P. MERRIMAN.-Mr. President, I had one case of this kind about a year ago. The woman had a sudden gush of water when she was not quite five months pregnant. I thought it might presage labor, and told her to let me know of any symptoms of labor-that I expected it would come on. But she felt better after having the gush of water. She had, in the course of two or three weeks, another, and said she could tell when they were coming on, because she felt so full before they came. When the second came I began to think that perhaps she was not going to have labor at the present time after all; that it probably was not a loss of the amniotic fluid, and I examined her and found the os not dilated. I could feel, however, by carefully introducing my finger, that there was water still remaining there-the amniotic bag remaining apparently intact. I gave her opiates, thinking that labor might possibly be prevented. She went along for nearly a month after that, before she finally miscarried. She had three separate gushes of water at intervals of two or three weeks before her miscarriage finally came on. The fetus had perhaps a little over six months of intrauterine life at the time of its expulsion.

It strikes me that we might learn, by careful examination of the placenta and membranes after delivery, a great deal more than we have yet learned about this subject. I cannot help thinking that there must be some defect in the fetal envelopes to have a thing like this occur. It could not have been a rupture of the amnion, but there may have been a separation between the amnion and the chorion, as I have seen in one other case in my own practice, in which the infant or fetus enveloped in the amnion came away, leaving the chorion within the uterine cavity. And we had a similar case presented to the Society a year ago, by Dr. Sawyer. The amnion had been separated from the chorion, and came away intact by an effusion of liquid between the chorion and amnion. Now, if that takes place, why of course there may be a separation in part and then adhesion again after the occurrence of the rupture. Any gush of this kind indicates, to me at least, some disturbance of the fetal envelopes, either of the chorion or amnion, or a cystic degeneration of the placenta; and it strikes me that in every case of this kind the placenta and membranes ought to be carefully observed after the delivery, to see what pathological cause brought on the abortion.

I would like to state, in addition to my case, that the woman finally had her miscarriage quite suddenly. I was not present, and another physician was called.