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THE BRITISH
GYNAECOLOGICAL JOURNAL
VOL. XX.
Biological
*f Meciical
■Seri n Is
THE BRITISH
GYNt^COLOGICAL
. JOURNAL
BEING THE JOURNAL OF
TN£ BRITISH GYNAECOLOGICAL SOCIETY
VOL. XX.
EOriED BY
J. J. MACAN, M.D.
LONDON
JOHN BALE, SONS & DANIELSSON, Ltd.
83-91, GREAT TITCHFIELD STREET, OXFORD STREET, W.
MCMIV.— MCMV.
\
v.a.0
CONTENTS
OF
VOLUME XX.
PROCEEDINGS OF THE BRITISH GYNECOLOGICAL
SOCIETY.
PAGE
February ii, 1904 (Ordinary Meeting).
Cases and Exhibits : — Dr. William Duncan —
Tubal pregnancy ruptured on the nineteenth day after
conception, and ten days after the uterus had been
curetted ....... i
Discussiofi thereon . . . . .2
Dr. H. Macnaughton-Jones —
Supplementary report on a tubal cyst . . .9
A strange result of iodoform dressing . . .11
Dr. Herbert Snow —
Cyst simulating femoral hernia . . . -13
Paper: — Mr. W. Dunnett Spanion —
One of the causes of bladder irritation in girls . . 14
Inaugural Presidential Address: — Professor John \V. Taylor,
M.D., F.R.C.S.—
The diminishing birth-rate and what is entailed by it . 18
Vote of thanks therefor . . . -43
March 10, 1904 (Ordinary Meeting).
Specimens and Cases .-—Dr. T. Gelston Atkins —
Successful hystero-salpingo-oophorectomy for pelvic sup-
puration . ..... 44
Notes of a case of hystero-salpingo-oophoiectomy for
double ovarian papilloma and carcinoma of the
cervix uteri . . . . . .46
Discussiofi thereon . . . . -47
Dr. William Duncan —
(i) Fibroid removed by vaginal hysterectomy after enu-
cleation had failed .... 47
vi. Contents of the Tiveutieth I'o/ujue
(2) Fibroid of the vaginal wall . . -47
(3) Uterine myoma growmg between the layers of broad
ligament ....... 48
Dr. J. Inglis Parsons —
(i) Fibrocystic tumour of the uterus . . -49
(2) Large fibroma of the broad ligament . . 50
(3) Submucous myoma . . . . -51
Discussion . . . . . • 5^
Dr. Bedford Fen wick —
Fibroid uterus removed for menorrhagia . . -54
Paper : — Dr. Dudley W. Buxton —
Chloroform in surgical anaesthesia ; the Vernon Harcourt
inhaler and e.xact percentage vapours . . -56
Discussion thereon . . . . .68
April 14, 1904 (Ordinary Meeting).
specimens and Cases : — -Mr. J. Furneaux Jordan —
(1) Hydrometra . . . . . -72
(2) Double hydrosalpinx . . . . -75
Discussion thereon . . . . • 7S
Dr. Frederick Edge —
(i) Myoma of the right broad ligament enucleated by the
abdomen . . . . . . .76
(2) Vesical calculus formed on a silk suture . . 77
(3) Successful removal of a displaced spleen simulating
a broad ligament cyst . . . . -77
Discussion thereon . . . . -78
Mr. F. Bowreman Jessett —
Bilateral ovarian dermoid with treble twist and strangula-
tion of the left pedicle . . . . -79
Large fibroid of the cervix displacing the bladder nearly
up to the navel . . . . . .82
Paper .—Dr. T. Arthur Helme—
On the treatment of puerperal convulsions by spinal sub-
arachnoid puncture, with notes of a case so treated . 84
Discussion thereon . . . . .94
Paper : — Dr. H. Macnaughton-Jones —
On the application of pessaries and their dangers . . 97
May 12, 1904 (Ordinary Meeting).
Specimens and Cases : — Professor John W. Taylor —
(i) A loop of gangrenous bowel successfully removed
from a patient with strangulated hernia, the hernia
being one of the cicatrix after abdominal hysterectomy 137
(2) Broad ligament cyst removed by vaginal enucleation . 139
Contents of the Twentieth Volume vii.
(3) Tubo-ovarian cyst removed by posterior vaginal coelio-
tomy . . . . . • .140
Discussion . . ■ • • .140
Adjourned Discussion — Dr. Macnaughton-Jones's paper on the
application of pessaries and their dangers . .142
June 9, 1904 (Ordinary Meeting).
Exhibits: — Mr. Charles Ryall for Mr. Bowreman Jessett —
Giant myoma weighing 261b. . . . -153
Dr. H. Macnaughton-Jones —
The Dovvnes electro-thermic angiotribe . . • 1 54
Paper: — Mr. Stanmore Bishop —
On the prevention of ventral hernia as a sequel to abdo-
minal section . . . • • • • 59
Discus sio?i thereon . . . . .182
July 14, 1904 (Ordinary Meeting).
Specimens and Cases: — Mr. Christopher Martin —
(i) Bone crochet hook removed from the abdominal cavity 241
(2) and (3) specimens of arrested development of the
uterus . . . . . • .241
Mr. Bowreman Jessett —
(i) Gangrene of the leg after hysterectomy . . 246
(2) Myomatous uterus ..... 249
Dr. H. Macnaughton-Jones —
Accessory Fallopian tubes and their relation to broad
ligament cysts and hydrosalpinx . . • 253
Dr. Jervois Aarons —
A new uterine mop . . • • • • -55
October 13, 1904 (Ordinary Meeting).
Specimens and Cases : — Dr. Bedford Fenwick —
Tubal cyst (ectopic gestation ?), with torsion of the pedicle 256
Dr. Frederick Edge —
(i) Glandular ovarian carcinoma
(2) Many-lobed myomatous uterus .
Mr. Furneaux Jordan —
(i) Double tuberculous pyosalpinx .
(2) Ovarian cystoma . . . • •
Dr. William Duncan —
Cancerous uterus removed by combined hysterectomy
Dr. Macnaughton-Jones —
Haemorrhagic endometritis ....
Paper :— Mr. Christopher Martin —
On the treatment of intractable prolapse by extirpation
of the uterus and vagina . . • • ^7
230
258
260
260
266
270
viii. Contents of the Tiventieth Volume
FACiK
KOVEMBER lo, 1904 (Ordinary Meeting).
Exhibits and Cases : — Dr. Macnaughton-Jones —
(i) Adne.xal tumours. . . . . • S^i
(2) Desquamative salpingitis . .... 321
Dr. Bedford Fenvvick —
Ovarian disease associated with uterine fibroids . . 322
Adjourned Discussions — Dr. Macnaughton-Jones's specimen of
htcmorrhagic endometritis .... 326
Mr. Christopher Martin's paper on intractable prolapse . 328
December 8, 1904 (Ordinary Meeting).
Specimens : — Dr. Macnaughton-Jones —
Carcinoma of the Fallopian tube .... 336
Professor John W. Taylor, President —
(i) Fallopian tubes, ligatured twice at previous operations,
and removed at a third Caesarean section . . 338
(2) A large abscess of the ovary .... 340
(3) Cancer of the body of the uterus . . . 342
Discussion ...... 343
Paper: — Dr. William Alexander —
On adenoma htemorrhagica of the endometrium . . 345
Discussion thereon ..... 350
Cases : — Dr. R. T. Smith —
Ectopic gestation ...... 354
Dr. Bedford Fenwick—
An unusual case of degenerating fibroid . . = 354
January 12, 1905 (Annual Meeting).
Election of Officers for the Year ..... 356
The Treasurer's Report and Balance Sheet . . . 357
Votes of thanks to the Treasurer and Auditors . . . 359
The Editor's Report ....... 360
Vote of thanks to the Editor ..... 364
Specimens : — Dr. George Elder —
Ruptured ovarian cyst ..... 365
Dr. J. Inglis Parsons —
Double pyosalpinx ...... 366
Valedictory Presidential Address by Professor John \V. Taylor 368
Vote of thanks therefor . . . 384
British Gynaecological Society : —
New Fellows ....... 188
Nursing Examinations ...... 281
Original Communications :—
Deductions from the study of pelvic diseases in the female
insane, by Ernest H. Kail, M.D., L.R.C.P.Edin. . 120
Contents of the Twentieth Volume ix.
Original Communications — continued.
Belastungslagerung ; elevation of the pelvis as an aid in the
treatment of inflammatory, especially of exudative pelvic
affections by compression, by Ludwig Pincus, M.D.,
Danzig ...... 189, 290
Amenorrhoea following a bicycle accident, by S. L. Craigie
Mondy, MR.C.S. . • 284
Menorrhagia treated with suprarenal extract, by A. F. Tred-
gold, iNl.R.C.S. .... -287
A visit to clinics at Ghent, Bonn and -Brussels, with some
remarks, pathological and practical, by H. Macnaughton-
Jones, M.D. 387
Reviews : —
Reed: .A Text-book of Gynaecology. Second Edition .
Jellett : A Short Practice of Gynaecology. Second Edition
Williams : Vaginal Tumours, with Special Reference tf
Cancer and Sarcoma . . . •
Winter : Die Bekaempfung des Uteruskrebses .
Roberts and Trechmann : Orthmann's Handbook of Gynre
cological Pathology
Edgar : The Practice of Obstetrics
Douglas: Surgical Diseases of the Abdomen
Stoeltzner : Pathologie und Therapie der Rachitis
V. Winckel : Handbuch der Geburtshuelfe. Band I. Zweiter
Haelfte .....
A. Fargas : Tratato de Gmecologia. Fasciculi I., II
Hare : Progressive Medicine, vol. iv., 1903
Schaefer and Webster: Atlas and Epitome of Operative
GynEecology
Sellheim : Der normale Situs der Organe im weiblichen Becken
Monprofit : La Gastro-enterostomie
Montgomery : Practical Gynaecology
Merck : Annual Report for 1903 .
Stacpoole : Ailments of Women and Girls
V. Rein : Twenty-five Years of Teaching Activity
Farabeuf and Varnier : Introduction a la Pratique des
Accouchments . . . . ■
Kermauner : Beitrage zur Anatomie der Tubenschwanger
schaft ....-•
Mandl and Buerger : Die Bedeutung der Eierstoecke nach
Entfernung der Gebaermutter
Stoeckel : Die Cystoscopie des Gynaekoiogen .
Freund and Lancashire : Radiotheraphy for Practitioners
123
124
125
126
128
129
131
134
225
227
229
231
233
-35
237
239
239
-.08
313
314
315
Mitchell and Gulick: Mechanotherapy and Physical Education 31
0'/
Contents oj the Twentieth Volume
Reviews — contimied.
Dudley : Principles and Practice of Gynaecology. Fourth
Edition ... ...
Edebohls : The Surgical Treatment of Bright's Disease
Battle and Corner : Diseases of the Appendix \''ermiforniis
Owen : Cleft Palate and Hare-Lip
Corner: Acute Abdominal Diseases
Macnaughton-Jones : Diseases of Women. Ninth Edition
Schauta and Hitschmann : Tabulae GyncecologiCcC
McKay : The Preparation and After-treatment of Section Cases 422
Publications received .... 135, 240, 318, 424
406
407
411
413
414
416
420
SUMMARY OF GYN^XOLOGY AND OBSTETRICS /, 33, 73, 137
NOTES AND OBITUARY NOTICES 30,70,135,174
THE BRITISH
GYNy^COLOGICAL
JOURNAL.
Vol. XX. — No. 77. May, 1904.
BRITISH GVy. ECOLOGICAL SOCIETY.
Thursday, February ii, 1904.
Professor JOHN W. TAYLOR, M.D., F.R.C.S., President,
IN THE Chair.
Cases and Exhibits.
Rupture of a Tubal Pregnancy on the Nineteenth
Day after Conception, and Ten Days after the
Uterus had been Curetted. By William Duncan,
M.D., F.R.C.S., Obstetric Physician to the Middlesex
Hospital.
Mrs. H., aged 27, was married in 1900. She consulted
me in October, 1901, for menorrhagia. The periods,
which commenced at the age of 12, were quite regular
(lasting four days) until the early part of 1901 (some
months after marriage), when they began to increase
in amount, with pain, the passage of clots, and a muco-
purulent intermenstrual discharge. The patient was a
healthy-looking but pale young lady of very active tem-
perament. On examination, the uterus felt a little en-
larged, was somewhat tender on palpation, was freely
mobile and in normal position. Nothing abnormal could
be felt in either the lateral or posterior fornices. Per
vol. XX. — NO. yy. i
The British Gynecological Society
speculum, the os uteri was eroded and some purulent dis-
charge was seen exuding from it. I diagnosed fungous
endometritis, and recommended that the uterus should
be curetted. The patient went into a nursing home and,
under anaesthesia, I dilated the cervix uteri up to No. 14
Hegar, and scraped away a very hypertrophied endo-
metrium. The uterus, after having been swabbed out
with liquor iodi, was packed with iodoform gauze for
forty-eight hours. At the end of that time the gauze
was removed, and a vaginal douche of i in 4,000 solution
of perchloride of mercury was ordered to be given night
and morning whilst the patient remained in the home.
(This is my usual method of treatment after curetting
the uterus.) The patient made a perfectly uneventful
recovery and returned home well at the end of three weeks.
I saw nothing more of her until the beginning of last
November (1903), when she again consulted me for
a recurrence of the menorrhagia. She then informed
me that she had had a miscarriage at the third month,
at Christmas, 1902, and that since that time the periods
have been excessi\'e and with clots. Since the miscarriage
she has never missed a period. On examination, I found
a similar condition of things to that present when she
consulted me in 1901, except, perhaps, that the uterus
was somewhat more bulky than on the former occasion,
but nothing w^hatever abnormal was found in either fornix.
As the next period was due in a few days it was decided
that the curettage (which I again advised) should be
deferred until a couple of days after the period had ceased.
Accordingly, when this occurred, on November 14, after
a week's loss, I went down to the patient's home on
November 16, and with the assistance of Dr. Gordon
Hogg, of Ealing (under whose care the patient had placed
herself, and to whose skill and unremitting attention the
favourable termination of this most interesting case is
largely due), I again curetted the uterus, removing, as
on the former occasion, a very hypertrophied endometrium.
Duncan on Rupture of a TiLbal Pregnancy 3
but one which did not in the least raise in my mind the
suspicion of its being a decidual lining. The patient pro-
gressed uninterruptedly well, having neither pain nor
rise of temperature, until November 25, when rupture
took place.
At 9 p.m. that evening, Dr. Gordon Hogg rang me up
on the telephone and asked me to go down and see the
patient, as she was bad. He told me that he paid his
usual visit about 2 p.m. that afternoon, when the patient
was apparently quite well, laughing and joking, and
saying she would get up next day. On returning home
from his round of professional visits at 7 p.m., he found
a letter from the nurse asking him to send something to
relieve the patient, who was complaining of pain at the
chest and indigestion. Almost directly after reading
the letter he received an urgent message asking him to
go at once and see our patient. This he did, and on arrival
he found her collapsed, pulseless, semi-conscious, and
tossing about in bed, with gasping respiration. He at
once injected strychnine hypodermically, and put hot
bottles to the extremities in order to remedy the collapsed
condition. As the patient's condition continued serious
he, as I have mentioned, summoned me. On my arrival,
soon after 10 p.m., I found the patient practically mori-
bund, pulseless, blanched lips, and gums very pale, and
extremities cold. On palpating the abdomen, I found
dulness in both flanks and over the hypogastrium. I
also thought there was diminished resonance over the
liver. It was evident that there was internal rupture
of something, with hemorrhage, also that abdominal
section, unless associated with, or preceded by, transfusion,
would be certainly fatal. Not having the necessary appar-
atus and instruments with me, I at once telephoned to
my colleague, Mr. Pearce Gould, and fortunately found
him at home, and got him to come out at once. Whilst
waiting his arrival we prepared in readiness the operating
table, also plenty of sterilised water. Mr. Gould arrived
4 The British Gyiuecological Society
soon after midnight. The patient was at once placed
on the table and skilfully put under the influence of ether
by Dr. Robert Pitcairn Cockburn. Mr. Gould first started
the infusion of saline fluid into the left submammary
cellular tissue, and handed the care of this over to Dr.
■Gordon Hogg, whilst he opened the left cephalic vein and
performed intravenous transfusion (also of saline fluid).
Immediately this transfusion was thoroughly started,
I rapidly opened the abdomen, which was found full of
liquid blood with some clots. The right uterine appen-
dage was brought into view and proved to be normal,
but when the left was drawn out there was seen to be a
small, round perforation of the somewhat thickened tube
near its uterine end (specimen shown). The broad liga-
ment was quickly transfixed and tied with silk in the
usual way, and tube and ovary removed. Most of the
blood was sponged out of the abdominal cavity, which
latter was also flushed with a lot of sterilised water, some
of wliich was left inside. The abdominal wall was sewn
up in three layers. Whilst this operation was proceeding
nearly two quarts of saline fluid had been injected (sub-
mammary and intravenous). After the operation, which
lasted from twenty to thirty minutes, the patient was
returned to bed, still in an extremel}' dangerous condition,
although the pulse was faintly perceptible at the wrist.
Hot bottles were applied, strychnine injected hypoder-
mically, and an enema of brandy and beef-tea administered
per rectum. When Mr. Gould and I left we could only
give the relatives slight hope. Ever^-thing, ol course,
depended on whether the patient could be kept alive for
the next few hours. We left her in Dr. Gordon Hogg's
care, and the ultimate successful issue is greatly due to
his unremitting attention.
At about 9 a.m. Dr. Hogg telephoned the welcome
news that the patient was alive and conscious, that her
pulse was better, her temperature normal, and she was
able to take nourishment. The subsequent history can
Duncan on Rupture of a Tubal Pregnancy 5
be related in a few words. The patient made an un-
eventful recovery and is now (January 30, 1904) quite
well and getting about as usual.
Remarks.
This very interesting case presents several points for
consideration : —
(i) The Duration of. Pregnancy before Rupture took
Place. — This can be accurately stated to be the nineteenth
day, as after her recovery I went to see the patient in
order to make sure of the date. She informed me that
coitus took place on the Friday before her period com-
menced, namely, November 6, and not for some time
previous to then. Before questioning the patient I
expected to hear that coitus had occurred on either of
the two days which intervened between the cessation of
the period and the curettage. This would have given
eleven or twelve days before rupture. However, the
patient was very positive that no coitus had taken place
on either of those dates. As far as I can ascertain, there
is only one other case recorded in which rupture of a tubal
gestation took place as early as the nineteenth day. That
is one reported by Mr. Rumley Dawson in the Obstetrical
Transactions for the year 1898 (vol. xl., p. 155). In that
case the rupture, which was near the uterine end of the
tube, is said to have occurred on the fifteenth day. The
patient was a multipara, and had not missed a period.
Internal haemorrhage was diagnosed, but no operation
was performed, and the ruptured tubal gestation was
onh' discovered post mortem.
(2) .4s regards Diagnosis. — When I first saw the patient
there can be no question but that she was suffering from
fungous endometritis, and although a tubal gestation
was present when I curetted the uterus, seeing that it was
only nine days old, and that the history was totally against
pregnancy, I think it will be considered excusable mv
The British Gyncecological Society
having failed to detect the slight enlargement of the left
Fallopian tube,- which must have been present when I
examined the patient under anaesthesia before proceeding
to curette the uterus. The more I see of cases of extra-
uterine pregnancy, both in hospital and private practice,
the less value do I know can be placed on the history of
a patient having missed one or two periods. In many
of these cases no sucli history can be obtained by the most
careful questioning.
(3) When the Rupture took Place. — When Dr. Gordon
Hogg rang me up on the telephone I confess I did not
attach as much importance as I ought to have done to
his statement that the patient, a few hours after he had
seen her perfectly well, was collapsed and pulseless. I
could not imagine anything having gone wTong with the
pelvic organs ten days after curetting the uterus. How-
ever, on my arrival at the house and seeing the patient
blanched (she was naturally pale), pulseless, and finding
dulness in the flanks and over the abdomen, it was at
once obvious that rupture of something had taken place
with extensive haemorrhage, which would ere long prove
fatal unless operated upon. It seemed to me that the
diagnosis la}^ between {a) rupture of a tubal gestation,
and {h) perforation of a gastric ulcer with profuse bleeding.
I leaned to the gastric ulcer view, as not only was the his-
tory completely against tubal pregnancy, but also I could
not imagine in^^self failing to detect an enlarged tube ;
the fact also that on the afternoon of the accident the
patient complained of indigestion and pain at the epi-
gastrium helped to obscure the diagnosis.
(4) Whatever the cause of the condition was, it was
perfectly certain that the abdomen must be opened, as
no one suffering from rupture of any internal organ with
severe haemorrhage should be allowed to die without an
exploratory operation having been performed. In this
case the patient was too bad to subject her to a severe
operation without first (or, at any rate, simultaneously)
Duncan on Ruptu7'e of a Tubal Pregnancy 7
transfusing her, and as I had not taken my transfusion
apparatus with me, it was indeed fortunate to be within
telephonic reach of skilled help and all the necessary instru-
ments. This case teaches the lesson to always carry one's
transfusion apparatus.
Lastly. — With regard to the parts removed, it will be
seen from the specimen that the thickening of the Fallo-
pian tube was comparatively slight, limited to the uterine
lialf of the tube, and that the rupture took place near
the uterus.
My friend. Dr. Victor Bonney (Obstetric Registrar
and Tutor at the Middlesex Hospital) has made some
excellent microscopical sections across the gestation sac,
and a beautiful drawing of one of these is given. The
section and the drawing made from it, which you see
thrown on the screen with the epidiascope, very clearly
show the gestation sac to be altogether away from the
lumen of the Fallopian tube, and proves that what happens
when a tubal gestation occurs is this : " The minute
embryo burrows through the epithelial lining of the tube
into the muscular coat, where it develops, whilst the
opening into the tube itself closes up again."
Pathological Report by Dr. Victor Bonney.
The specimen consisted of a Fallopian tube and attached
ovary. The tube appeared normal to the naked eye,
except at the junction of the isthmic and ampullary por-
tions. Here was situated a small, hollow enlargement
communicating with the outside by means of a clearly
punched hole through which a small pencil might be
passed. The cavity was principally in the tube wall,
its outer wall being formed of thinly stretched tubal peri-
toneum, whilst its inner boundary was evidently in close
connection with the tubal lumen, though whether it com-
municated with it was impossible to determine without
cutting transversely across the tube at this point. On
a transverse section being made across the tube on the
uterine side of the punched-out aperture it was seen that
8 The British Gyncecological Society
the cavity was situated in the wall of the tube, and did
not communicate with the tubal lumen at any point.
Its outer wall was very thin, consisting practically of peri-
toneum only, but that towards the lumen of the tube
was thicker, and contained muscle elements. The course
of the lumen of the tube was marked in the inner wall
of the cavity as a curved elevated ridge, much in the same
way as the course of the acqueductus Fallopii is indicated
on the inner and posterior walls of the tympanic cavity
when the middle ear is opened up for dissection. The
cavity contained clot and portions of chorionic villi.
Microscopicall}' the following appearances were found :
A considerable section of the tube and its contained
gestation sac was removed, and the continuity of the
specimen restored by sutures. This section was then
prepared and cut in serial sections to the number of about
150. The appearances of individual sections were prac-
tically the same. The tubal lumen appeared intact, and
was separated from the gestation sac by a well-marked
muscular layer (capsularis) of considerable thickness.
The plicae appeared perfect, as was also the case with the
columnar epithelium covering them. The tube was empty.
The gestation sac is situated in the outer part of the tube
wall. It contained well-marked chorionic villi, with a
distinct epithelium consisting of the two layers known
as Langhans and syncytial respectively. In many parts,
however, a much greater thickness of the syncytial layer
was observable, and in those parts of the section where
the villus was applied to the wall of the gestation sac these
proliferating syncytial masses could be seen infiltrating
the sac wall. The sac wall contained many spaces con-
taining blood, part of which appeared to be surrounded
by cells of embryonic origin. Many large cells resembling
decidual cells were seen in the sac wall, but these were
continuous with masses of syncytium, and in all proba-
bility they were of embryonic and not of maternal origin.
There was therefore an absence of any structures which
could be described as " decidual," and it is probable that
such cells are strictly the derivative of the stroma cells
of the endometrium, and therefore do not occur when
the ovum is situated in the midst of muscular tissue as,
in the absence of a subepithelial stroma, it appears to
Duncan on Rnptiire of a Tubal Pregnancy 9
be in tubal gestation. To the absence of decidual cells
is probably to be ascribed the rapidity with which a tubal
gestation erodes the walls of the gestation sac and brings
about early rupture. The specimen is of great interest,
bearing out, as it does, the views put forward by all the
modern German authorities, and lately epitomised in
England by Dr. Russell Andrews, that in all cases the
implantation of the tubal gestation is primarily in the
muscular wall of the tube, and not, as was formerly sup-
posed, in the surface of the tubal epithelium, and therefore
within the tubal lumen.
Dr. Macnaughton-Joxes made a supplementary report
on a tubal cyst shown by him at the December meeting,
in which there had been some question as to the nature
of the haematocele and the relation of the blood sac to
the tube. The patient had gone a fortnight past her
period when he first saw her, but there was no suspicion
of ectopic gestation ; he operated a few days later and
she got perfectly well. The specimen had since been care-
fully examined ; there was no doubt as to the tubal gesta-
tion, as, though there were no products of gestation in
the blood clot, chorionic villi were found in the section
of the tube. The blood sac was a haematocele containing
ovarian tissue and covered by a layer of broad ligament.
There was a communication between the ovarian sac and
that of the ectopic gestation.
The President said that Dr. Duncan's paper and
the beautiful demonstration he had given them of a tubal
pregnancy, not in the lumen of the tube, but invading
the muscular wall, were of extreme interest. In his own
book he had described a case in which rupture followed
almost immediately after dilatation and the use of the
curette. In the clinical diagnosis it was most important
to exclude extrauterine pregnancy before venturing upon
that proceeding, the effect of which, in some cases, had
been to precipitate disaster.
Dr. Herbert Snow congratulated Dr. Duncan on the
lO The British Gynaecological Society
very successful issue of his case. Personally, he thought
that curetting was not a procedure to be lightly under-
taken. It involved risks of serious hsemorrhage, perfora-
tion, septicaemia, even of directly consequent cancer. He
considered that, by swabbing out the cavity of the uterus
with a strong preparation of iodine, as good results could
be obtained as by the most thorough use of the curette,
always supposing there were no placental residua.
Mr. W. D. Spanton said that the issue of such cases
as the one narrated seemed to him to depend very greatly
on the length of the operation. Every minute was of
importance. He therefore demurred to the use of three
layers of sutures, as one layer was, he thought, sufficient,
and should occupy a minute at the most.
Mr. Christopher Martin asked for further explanation
of the separation of the gestation sac from the lumen of
the tube by a distinct muscular layer ; might there not
have been a rupture of the muscle and of the lumen of
the tube elsewhere not shown in the section ?
Dr. H. C. Pope asked for the particulars of any dis-
charge which had occurred before the operation for curetting.
Dr. Duncan, in reply, said that he entirely agreed
with the President that there was danger in curetting if
there was any likelihood of extrauterine gestation. He
did not consider that there was much risk in dilating and
curetting the uterus and swabbing it out, or, as preferred
by himself, pouring in tincture of iodine so as to wash
out the entire cavity. Very little extra time was taken
up by suturing in three layers ; the entire proceeding
need only take a couple of minutes or so. The section
shown was not cut through the rupture, but the number
of sections made proved that the gestation sac did not
open into the lumen. When an ovum attached itself to
the mucosa of the tube wall, it penetrated the mucous
and muscular layers and its port of entry closed up
behind it.
Dr. Macnaughton-Jones showed an aseptic cap to
Macnaughton- J ones on Iodoform Di^essing 1 1
cover the nose and mouth during operations, which he
had devised ; it was very hght and was supported on a
spectacle frame, and was, he thought, more suitable than
other instruments of the kind.
The following cases were then read ; —
A Strange Result of Iodoform Dressing. By H.
Macnaughton- J ONES, M.D., &c.
The local toxic effects of iodoform occasionally result
in cutaneous conditions which are more or less serious,
according to the extent of their invasion of the skin and
their spread to other parts. The more common, which
I have frequently seen, are general redness and swelling
of the skin of the abdomen and down the thighs, some-
times extending from the trunk to the upper extremities,
the eruption being very similar to that of scarlet fever.
In several cases it was associated with a fine vesicular
eruption, principally affecting the region of the wound.
Other observers have had cases in which the vesiculation
has extended into the deeper layers of the skin, resulting
in considerable oedema, and in some instances in a san-
guinolent effusion resembling superficial gangrene.^
A patient, aged 30, on whom I recently operated for
retroversion of the uterus by ventro-suspension, at the
same time resecting an ovary, was progressing favourably
until the third day after the operation. She then com-
plained of irritation, and some smarting in the neigh-
bourhood of the wound, which had been stitched with
celloidinzwirn, a pad of moist sterilised 10 per cent,
iodoform gauze being placed over it, and covered with
coeletin. On raising the dressing, the nurse found some
slight swelling and redness along the area of the incision.
On the following day, when I examined the wound, the
redness had extended to a considerable area, and the
' " Reference Book of Practical Therapeutics," by E. P. Foster,
p. 339, vol. i., 1897. " Taylor's Jurisprudence," p. 427, vol. i.
I 2 The Bi'-ilish GyncBCological Society
entire surface of the skin for a few inches at either side
was vesicated. Attributing the condition to the iodoform,
I had this removed, and the wound hghtly sponged over
with some weak formahn sohition, dried, and dusted with
dermatol (the subgallate of bismuth), covered with plain
sterihsed gauze and protected with colsetin. The distress
continued, and on removing the dressing the next day
I found several large vesicles, like those raised from an
ordinary blister. One or two had burst, and the others
were opened, and a quantity of serous fluid evacuated.
There now appeared on the arms and hands some eczema-
tous vesicles, and also a papillary eruption here and there,
which was attended by great irritation. Much the same
condition followed on the legs. The palms of the hands
became red, and finally desquamated. Some three days
later fresh vesicles appeared in the neighbourhood of the
wound. There were no constitutional symptoms, and
the temperature range shows that there was but a slight
elevation on a few occasions, while the pulse remained
normal. The skin healed by first intention, the sutures
being removed on the eleventh day.
Inquiring into the history of the case, it appeared
that many years previously the patient had had an ulcer
on the leg. This had been dressed with iodoform, when
much the some effects had followed the leg becoming
oedematous, while a slough, extended some distance up,
leaving an extensive cicatrix. The effects of the dressing
were not discovered until after the toxic consequences
had resulted. From her childhood she had had an
eczematous tendency, and there were symmetrical palmar
patches of dry eczematous desquamation of long standing
on the hands.
She left the Home perfectly well at the end of the fourth
week with only some remains of the eczematous condition.
I have not seen a record of any case exactly similar
to this, which is peculiar in the large blebs, somewhat
like those of pemphigus, that appeared in the neighbour-
Snow on Cyst Simtdating Femoral Hernia 13
hood of the incision. One cannot help pondering on the
consequences which would have followed in such a case
had a vaginal fixation been performed, and the vagina
tamponed with iodoform. I had the wound photographed
when the vesiculation was at its height, but unfortunately,
owing to the defective light, the photograph was not suc-
cessful. One thing is clear — it is worth while inquiring,
in any abdominal or pelvic operation in which iodoform
is likely to be used, whether the patient has been subject
to any cutaneous affection, and if so, to substitute another
dressing for that of iodoform.
Note on a Cyst Simulatinx, Femoral Hernia. By
Herbert Snow, M.D.Lond., &c.. Senior Surgeon,
Cancer Hospital.
Mrs. L. S., aged 69, widow, a rather flabby, elderly
woman, consulted me on December 10 last. She had
worn a femoral truss on the left side for seven years, and
now had in the right groin a globular elastic swellinglof
between three and four years' duration. It was of the
size of a pigeon's egg, could not be reduced or diminished
in bulk by pressure, and gave some impulse on coughing.
She had never worn any truss for this. On removal of
the left truss, a similar swelling became apparent, also
with a certain degree of impulse on coughing. On pres-
sure this diminished considerably in apparent size, though
it did not wholly disappear. She considered that the
truss had given her great relief.
An operation was advised. Upon incision it became
apparent that the right tumour was a cyst containing
about an ounce of clear, straw-coloured fluid, and with
a narrow pedicle issuing from the femoral canal below
Poupart's ligament in the usual site of femoral hernia.
It contained nothing but this liquid. The waU resembled
thickened peritoneum. It was slit up, and the interior
carefully inspected. No aperture in the pedicle could
be detected, and attempts to pass a probe failed. The
14 The British Gynecological Society
cyst was excised and the pedicle ligatured. The woman
made an uneventful recovery.
The left tumour was not interfered with, as no per-
mission had been obtained to attack it, and the woman
was quite satisfied with her truss. There can be no doubt
that the condition was exactly identical. The impulse
on coughing was found to disappear when the cyst was
lifted up from its pedicle.
The right femoral cyst excised was evidently a peri-
toneal diverticulum, exactly similar in appearance and
in average size to the common canal of Nuck cyst above
Poupart's ligament. Mr. Cecil Leaf, who kindly assisted
me at the little operation, suggested that a hernial sac
had become nipped (and the lumen of the pedicle thus
obliterated) by the edge of Gimbernat's ligament, the
usual site of strangulation in hernia. The explanation
is to some extent plausible, but we have no evidence that
any intestine or omentum had ever been extruded, and
the cysts were bilateral. I am inclined, therefore, to
consider that the condition was of congenital origin.
I was not, before operating, satisfied that the impulse
on coughing was sufficiently marked to be characteristic
of hernia ; but there certainly was a sufficiently marked
impulse to deceive a hasty observer.
An exactly parallel condition to that presented by the
canal of Nuck cyst, with which we are all familiar, at the
external abdominal ring — not above but below Poupart's
ligament, and with its pedicle issuing from the femoral
canal — seems to me a very unusual state of things.
I shall be glad to learn if any Fellow has encountered
a similar case.
Note on One of the Causes of Bladder Irritation in
Girls. By W. Dunnett Spanton, F.R.C.S., &c.. Con-
sulting Surgeon to the North Staffordshire Infirmary.
Every surgeon must have sometimes met with obscure
cases of bladder irritation or cystitis in little girls, in which
Spanton on Causes of Bladder Irritation
it has been difficult to assign a cause. Some instances
have occurred in my practice which will tend to throw
light on this subject and are therefore, I think, worth
recording.
When a child is brought to the surgeon complaining
of pain in the vesical region, frequent micturition and
urethral irritation, the urine cloudy, perhaps containing
a small quantity of blood and mucus, or muco-pus, without
any constitutional disturbance, one generally would ascribe
it to one of the following conditions : —
Diabetes, azoturia, calculus, or other foreign body
in the bladder, or urethra, or kidney, or possibly tubercle
or malignant growth. The two last are rare and improbable.
Of course the first thing to be done is to examine the
condition of the urethra, and after examining the urine,
to explore the bladder. The urethra may show signs
of urethritis, but insufficient to account for all the symp-
toms ; the examination of the urine may indicate an
excessive amount of uric acid, sugar, mucus, pus, blood,
and possibly such irritating substances as oxalate of lime
or triple phosphates.
If either oxaluria or azoturia exist, simple remedies
will soon suffice to remove the irritation, but the presence
of any inflammatory products will render this less likelv.
Then it will probably be found that the orihce of the urethra
is sore and tender, and there may be discovered a tinv
caruncle — and these will have to be eliminated from con-
sideration. We then explore the bladder and find nothing ;
when the puzzle as to the cause remains unsolved.
It is in such cases that I have found the wisdom ot going
more minutely mto the question, and I will give a short
account of three little patients in whom the same condition
was found to exist, which will serve as an illustration : —
The first was a bright, healthy little girl about 3 years
of age, who cried on micturition, which became very
frequent, only small quantities of urine being passed eacli
time. I found the urethral orifice tender and sore, and
1 6 The British Gyncecological Society
thinking this might be the sole cause of the trouble, pre-
scribed some soothing application and gentle aperient
simply. The urine was examined and found free from
sugar and abnormal elements, but contained a little mucus,
and a few blood corpuscles. The symptoms continued
the same, so I passed a sound into the bladder under chloro-
form, suspecting there might be a calculus or some other
foreign body. This revealed nothing ; but the urine
which was next passed being examined, we found in it
a shreddy-looking mass, with mucous cells, a few blood
corpuscles, and mixed phosphates and urate of soda.
Under the microscope the fluffy mass was shown to consist
of an aggregation of woollen fibres entangled in mucus,
and there were other woollen fibres also found free. Beyond
a few blood corpuscles, crystals of mixed phosphates and
amorphous urate of soda, nothing unusual was seen.
The next point was to discover how this irritating
material had found its way into the bladder. I examined
the child's under-garments, which consisted of thick woollen
combinations, rather rough at the edges. The woollen
fibres of these garments were carefully examined. I
then came to the conclusion that, as the woollen fibres
found in the urine exactly corresponded to those in the
new set of " combinations " the child had been wearing,
that the woollen material had chafed the urethra, some
of the fibres had wormed themselves along it into the
bladder, and so set up the irritation. When we remember
the peculiar barbed edges of woollen fibres, it is quite
easy to understand how they would travel up the urethra
in the same way as an ear of grass or barley does ; and
this also explains why the smooth fibres of flax or linen
fail to do so. The garment was changed for a cashmere
one, diluents were given freely to wash out the bladder,
and in a few days every symptom had disappeared, and
there has never been any since that time. I imagine
that the sounding dislodged some of the woollen fibres,
and as no more entered the bladder, this led to the cure.
Spanton on Causes of Bladder Irritation 1 7
The next case was an older sister of the first, aged about
6. The symptoms in this child began in precisely the
same manner. The urine on examination was found to
contain woollen fibres, as in her sister's case, along with
some mucus, and was of high specific gravity. The
mother described it as containing " a long filmy sub-
stance," which proved to be wool fibres held together
by bladder mucus. I did not, in the light of the former
case, think it necessary to pass any instrument, but
merely changed the underclothing, gave Contrexeville
water freely, and very soon every symptom disappeared —
never to return.
Some time afterwards, in 1901, another instance pre-
senting similar features came under my notice. A merry
little girl, aged about 5, was observed to show signs of
irritation about the bladder, with frequent micturition
and complaints of pain. There was no incontinence nor
retention. I found her apparently in perfect general
health. The symptoms were precisely similar to the
former ones, but the urine was found overloaded with
uric acid and urates as well as containing the minute
woollen threads. The note of urine examination was
as follows : Sp. gr. 1030, no albumin nor sugar, uric
acid and oxalate of lime crystals, mucus and aggregations
of fine woollen fibres.
The first thing to be done was to lessen the amount
of nitrogenous food, to exchange the woollen garments
next the skin for silk, and then give Contrexeville water
freely. The child speedily got well, as in the former cases,
and has had no trouble since.
It is often such little matters as these which, being
overlooked, lead to the discredit of the surgeon, and it
behoves the younger practitioner especially to bear in
mind that such trivial causes may readily simulate more
grave ones. They may then lead to a persistence of symp-
toms which, if unrelieved, may lay the foundation for
gravel, for intractable cystitis, or possibly form, in a tuber-
YOL. XX. — NO. -j-j. 2
1 8 The British GyncBcological Society
culous subject, a focus for tubercle to attack — or, in other
instances, a nucleus for stone. In fact, if we adopt Reginald
Harrison's theory of the formation of calculi, it seems
highly probable that threads entangled in the mucus
of the bladder would readily lend themselves to such an
evil purpose.
I daresa}^ the same observations have been made by
other surgeons, but no mention of them has ever come
under my notice, and I have looked for them in the text-
books in vain.
The President, after thanking Dr. Snow and Mr.
Spanton for their interesting communications, delivered
his Inaugural Address on : —
The Diminishing Birth-Rate and what is
Involved by It.
Gentlemen, — The Presidency of the British Gynae-
cological Society is an honour which I fully appreciate,
and which I would simply and heartily acknowledge.
This Society, from its beginning, has been truly British
in its scope and interests. It has freely and graciously
recognised the work and claims of the provinces as well
as those of the metropolis ; and in representing to some
extent, however unworthily, the work and claims of Bir-
mingham and the ^Midlands, I do joyfully appreciate the
place held by us in the heart of the Society and in the
very centre of its labours.
As I enter upon my duties this evening, I do so with
a sense of great responsibility ; and this is undoubtedly
increased by the recognition of the difficulty and yet
immense importance of the subject which I have chosen
for my Inaugural Address. This — " The Diminishing Birth-
rate, and what is Involved by It " — I purpose now to deal
with, trusting I may count on that consideration, sym-
pathy and interest which so serious an undertaking may
reasonably demand.
The Diminishing Birth-Rate 19
I.
In one of the chapters of Mr. Ruskin's well-known
book on Political Economy, " Unto This Last," he deals
with an inquiry into what he calls the " veins of wealth."
He exposes the fallacy that the wealth of a State lies solely
or essentially in material possessions — showing that apparent
or nominal wealth which fails in its authority over men,
fails in essence and ceases to be wealth at all — that the
true veins of wealth are, as he says, " purple — not in rock
but in flesh," and the " final outcome and consummation
of all wealth is in the producing as many as possible
full-breathed, bright-eyed, and happy-hearted human
creatures."
In his final chapter, " Ad Valorem," Mr. Ruskin writes :
" There is no wealth but life. That country is the richest
which nourishes the greatest number of noble and happy
human beings " — " the nobleness being not only con-
sistent with the number, but essential to it. The maximum
of life can only be reached by the maximum of virtue."
The principles or truths contained in these passages —
passages which bear the strictest examination and criti-
cism— may be, and are, very generally accepted, theo-
retically. But the history of the nation during the last
twenty-five years shows that the principles which govern
its real life are altogether different and directly contra-
dictory.
To-day we are brought face to face with unanswerable
statistics proving that our birth-rate is steadily diminish-
ing. This has already attracted the serious considera-
tion of statisticians and of some of our statesmen, but the
inquiry into its causes has been confused and incomplete.
Here, I hope, we can at least discuss these plainly and
fearlessly, for some of the problems connected with
causation are essentially gynaecological, and can, perhaps,
only be rightly gauged by those who have special
medical and gynaecological experience.
The subject is a great one — so great, indeed, that if
20
The British Gyncecological Society
the nation could only see it in its true proportion, it
would, I think, be found to dwarf all other questions of
the day.
I cannot hope in the time at my disposal to enter fully
into all its phases. I do hope, however, to take the most
salient and striking features of the statistical data at our
command, to inquire what is meant and involved by these,
and to consider how far the profession and the public may
do anything to check the apparently relentless progress of
an evil destiny.
The best tables for our primary consideration are
some of those which have been compiled by Mr. Holt
Schooling, the statistician. In Table i we see the average
yearly number of births to each thousand persons living
in the United Kingdom during five successive periods
of five years each.
Table i. — The average yearly number of births per
1,000 persons living in Great Britain and Ireland, during
the five-yearly
Periods.
1874— 1878
1879-1883
1884 — 1888
1889— 1893
1894— 1898
34*3
32 "6
31*2
29-8
29-1
(Note the steady decrease, 34, 32, 31, nearly 30, 29,
and in 1901 it had come down to 28.)
Now let us compare this with exactly similar statistics
of other countries : —
Table 2. — The average yearly number of births per
1,000 persons living during the five-yearly
Periods.
1874— 1878
1879— 1883
1884— 1888
1889— 1893
1894— I S98
Austria. Germany.
• ■• 39*4
.. 40-1 ..
... 38-4
-. 37-5 ••
... 38-1
.. 36-9 ..
... 37-1
.. 36-3 ..
... 37-3
.. 36-1 ..
Italy.
37-0
368
38-2
36-9
34-9
Great Britain
and Ireland
-. 34-3
... 326
... 3 1 "2
... 29-8
... 29-1
France.
25-8
24-8
23-9
22-5
22-3
If we compare the top line with the bottom we see
that in each case there has been a fall, so that a diminish-
The Diminishing Birth-Rate
21
ing birth-rate is not a feature of our own kingdom only,
but is to some extent European in its scope or effect, and
the lowest birth-rate is that of France.
Of the other great powers and nations — the United
States, Russia, China, and Japan — no certain statistics
are available, but we have very good reason to believe
that the birth-rate is seriously falling in the States, but
notably rising in Russia and Japan. According to Russian
statistics from 1892 to 1894, the birth-rate per 1,000 was
477, and from 1894 to 1897 the birth-rate per 1,000 was
49*5, so that there has been not only no loss or diminution
in the birth-rate here, but the figures are also far above
those already tabulated. So far, the data we have con-
sidered show us that the birth-rate throughout the whole
of the West is diminishing, while that of the East is rather
expanding.
We now want to consider the relative birth-loss of
the various Western nations as compared with one another,
and this brings us to the most important and startling of
Mr. Schooling's tables.
He takes the birth-rate statistics for 1874 to 1878 in
each European nation as the standard for that nation,
and places against this the statistics for 1894 to 1898,
computing from this the loss of birth-force in the twenty
years. The following is the result : —
The yearly
The yearly
The percenta
birth-force during
birth-force during
of yearly loss dur
1874-78 taken as
1894-98 was only
1894-98 was
Norway
100
96
4
Denmark
100
95
5
Austria
ICX)
95
5
Italy
100
94
6
Hungary
100
91
9
Germany
100
90
10
Switzerland
100
90
10
Belgium
100
89
II
Holland
100
89
II
Sweden
100
88
12
France
100
86
14
United Kingdo
m ... 100
85
15
England and W
^ales ... 100
83
17
In other words, while Norway, Denmark and Austria
very nearly keep up their birth-force of twenty years
2 2 The British Gynecological Society
ago, the other nations in their order show an increasing
loss, and England and Wales stand at the very bottom
of the list. None of the other nations have sustained
so great a loss as we have in this definite period of time.
During the same period of time the marriage-rate
in the United Kingdom has not altered much, but during
the last ten years or so has been slowly rising. The figures
in the returns of the Registrar-General are as follows
(Table 44, 1900) : —
1876— 1880
1881— 1885
1886— 1890
1891 — 1895
1896— 1900
Persons married
to 100 living.
14-2
14-1
13-8
14-3
15-2
So that we may take the birth-loss in the United
Kingdom as due to causes operating in the married life
of its inhabitants. It is not simply due to celibacy.
The fertility of marriages appears to have so much
diminished that the decrease in London alone is said to
" equal 26,000 births yearly, or about 500 weekly." (Mr.
T. A. Welton, at a meeting of the Royal Statistical Society,
June 17, 1902.)
But some may say, England and Wales are only a
small part of the Empire, and the statistics of Great Britain,
where there is but little room for expansion and increase,
form no criterion of the birth-rate in our Colonies. Un-
fortunately, what statistics are available on this point,
and notably those of x\ustralia, offer no encouragement
to the hope that the Colonies are much better than our-
selves.
In Australia the birth-rate has fallen with an even
still greater rapidity than in England. In 1861 to 1865
the rate was 41-9 per 1,000, but had diminished in 1871
to 1875 to 37-3 ; in 1881 to 1885 to 35*2 ; and in 1891
to 1895 to 31-5 ; while in 1896 to 1899 the rate was only
27'35, or actually below the rate of increase at home.
If we work out these figures in harmony with Table 3,
The Diminishing Birth-Rate
we find Australia a long way below all the European nations,
with a birth-force down to 703 and a percentage of 3'early
loss amounting to nearly 30.
Regarding this, Mr. H. W. Wilson writes : " The
decline in Australia is great in every position of life, among
the poorest and the richest alike, and it is the more ex-
traordinary because the greatest want of Australia is a
teeming population."
But any statistical inquiry, to be of value, must be
considered in all its bearings. It has been said, and with
considerable reason, that there is nothing so unreliable
as statistics, and this may be the case when these are im-
perfectiy considered. In the present instance, if we are
desirous of estimating the true wealth or value of the popu-
lation we possess, there may be a fallacy in mere numbers.
It may well be that twenty children better clothed, better
fed, better educated, better trained, may develop into
men higher socially and morally, stronger and better
able to hold their own than 100 children less advanta-
geously brought up. Can we hope that the type of man
is improving ? — that the generation of Englishmen to-day,
though falling short in birth-force, is yet greater than
the generation preceding it ?
Again, unfortunately, we must sorrowfully admit that
we have not sufficient ground for believing this. The
criminal statistics, though showing a general and steady
reduction in the whole criminal population of the United
Kingdom, during the last twenty years (a fact which is
very encouraging), do not show a corresponding diminution
in juvenile criminality, and it is necessarily the youth
of our country to which any estimate of the last twenty-
five years would more particularly apply.
According to August Brahms, in his work on " The
Criminal " (p. 272), " Juvenile criminalism is on the
increase. Forty per cent, of the convictions in England
every year are against young persons under 21 years of
age." And on p. 281 he appends a table which shows
24 The British Gyncecological Society
a higher percentage of criminals under 20 years of age
in England than in any of the other European countries
there tabulated.
The Lunacy statistics of England and Wales show a
steady proportionate increase of lunatics and idiots,
especially during the last few years.
In 1869 there were 23-93 lunatics, idiots and persons
of unsound mind to 10,000 of population.
10,000 of population.
1879
27-54
( 1889
5 1894
2965
30-58
y!,^'" ' 1899
ending ^^^^
32-96
34-14
(From the 57th Report
of the Commissioners in Lunacy,
1903.
Parliamentary
Blue Book.)
Or in other words, the increase of lunatics and idiots
in England and Wales has, during the last fifteen to twenty
years, been very nearly double the old rate.
The natural deduction from these figures that insanity
and idiocy are increasing seems also to be proved by the
recent statistics of the new admissions to asylums and
licensed houses. The ratio of first admissions to 10,000
of population has been as follows : —
In 1S99 4'94
,, 1900 ... ... ... ... ... ... ... 5'02
,, 1901 5-28
,, 1902 5-76
{Ibid., p. 95-)
It is very difficult to obtain trustworthy statistics
regarding alcoholism, but those given in the " Temperance
Problem," by Messrs. Rowntree and Sherwell, are probably
the best. According to these the consumption of wine
per head of the population has varied but little during
the twelve years from 1885 to 1897, but during the same
time, the consumption of beer has gone up from 27-5
gallons to 31-3 gallons, and of spirits from -93 gallons to
1-02 gallons ; and the " National Drink Bill " (p. 437),
which was estimated at £3 7s. lod. per head in 1885, came
to £3 i6s. lo^d. in 1898. In London (Metropolitan Police
The Duninishing Birth- Rate
Area) there were, from 1885 to 1889, 4-33 arrests for drunk-
enness to 1,000 of the population. Tn 1897 the proportion
had risen to 7-35 (p. 499).
So, in juvenile criminalism, in mental disease and
brain weakness, and even in alcoholism, the restricted
population of the present day compares unfavourably
with that of a former generation.
If we try to go on and trace this comparison further,
and compare the general culture of the more intellectual
classes of the two generations over a limited field — for
no general statistics are available — still the investiga-
tion (though necessarily imperfect and tentative) seems
to point to an unfavourable conclusion.
In my own city of Birmingham, a critical survey of
its chief semi-public literary and artistic institutions has
been recently made by ]\Ir. Howard S. Pearson, and he
publishes a tabulated statement showing the support
given to these twenty years ago, ten years ago, and to-day.
{Central Literary Magazine, November, 1903.)
His figures show as a net result that in the course of
twenty years there has been a loss of 366 subscribers,
or about one in fourteen. " This would be discouraging,
but it is by no means all. The population of the city and
district has vastly increased, while this care for intellec-
tual and artistic culture has materially diminished. In
brief, the population has increased by more than one-
fourth, while the interest in the institutions named has
decreased by one-fourteenth." Later on, Mr. Pearson
writes : " These institutions are not some among many ;
they have actually no rivals at all. Neither in the city
nor in the neighbourhood is there anything which even
pretends to touch their special work. They stand, each
in its own way, for the general and intellectual culture
of the educated classes. The very aim and intent of all
our strenuous efforts in the cause of education is to increase
the proportion of the educated classes and to lead to a
life-long interest in culture. And as the population rises,
26 The British Gynaecological Society
as education becomes more far-reaching, as art is more
and more talked about, even so must grow the discourage-
ment of all who might have hoped to gather from the
changed conditions a larger sympathy in their work."
It must be confessed that the more deeply and
thoroughly one goes into this matter the more serious
does it appear. Prof. Karl Pearson (Huxley Memorial
Lecture, 1903, and British Medical Journal, October 24,
1903), who has approached it from an altogether different
standpoint — from a careful studv of the inheritance by
children of the mental and moral, as well as the physical
characters of their progenitors — comes to much the same
conclusions. He notes that there appears to be a want
of intelligence in the British merchant, workman and
professional man of to-day, and sees but little hope in
the usually proposed remedies of foreign methods of in-
struction and the spread of technical education. " The
reason for the deficiency," he states, " is that the mentally
better stock in the nation is not reproducing itself at the
same rate as of old — the less able and the less energetic are
the more fertile. Education cannot bring up hereditary
weakness to the level of hereditary strength, and the only
remedy is to alter the relative fertility of the good and
bad stocks of the community. The psychical characters
which are the backbone of a State in the modern struggle
of nations are not so much manufactured by home and
school and college ; they are bred in the bone, and for
the last forty years the intellectual classes of the nation,
enervated by wealth or by love of pleasure, or following
an erroneous standard of life, have ceased to give in due
proportion the men wanted to carry on the ever-growing
work of the Empire."
All this tends to show that the marriages of to-day
are not only relatively infertile, but, also, either : (i)
" That the children born of such marriages are weak,
neurotic, specially liable to alcoholism, criminality and
insanity, and so far unfit for the battle of life, or (2) that
The Diminishing Birth-Rate 27
marriages of the middle and better classes are now so
sterile that quite an undue and dangerous proportion of
the rising generation is recruited from the lower, the more
ignorant, the more vicious and semi-criminal population.
In any case the conclusion is one of the utmost gravity,
and almost paralysing in the seriousness of its import. It
is indeed a "handwriting on the wall" which claims the
fullest and wisest interpretation to be found throughout
the Kingdom.
II
We now pass on to the consideration of the cause and
life-history of these relatively sterile marriages. Some,
and notably M. Arsene Dumont in his work on the age
of marriage, profess to consider the elevation of the age
when marriage is entered into as mainly responsible for
the deficit in the birth-rate. It does undoubtedly account
for some of the loss. Obviously, if marriage be deferred
until 35 or 40 j^ears of age, there must be less expectation
of progeny than in a marriage contracted some ten years
earlier. It is, however, idle to suppose that this touches
more than the fringe of the nation's loss. The main cause,
and we who are in gynaecological practice must know it,
is the deliberate prevention of conception. This, which
was first encouraged and taught in England some thirty-
five years ago, has gradually spread like a blight over
the middle-class population of the land, and the true
wealth of the nation, the " full-breathed, bright-eyed.
and happy-hearted children " of Ruskin, have more or
less gone down before it. It is this which has so altered
the family life of our country that the most superficial
observer of middle or advancing age must be struck by
the difference. Instead of the families of six or twelve
to eighteen children, we see more often the so-called family
of three or two or one, and that which used to be — and
still should be — the highest and noblest function of the
28 The British Gyncecological Society
married woman, the rearing of sons and daughters to the
family, the nation and the Empire, is very largely handed
over to the lower classes of our own population and to
the Hebrew and the alien.
For a long time it appears to have been assumed that
whatever might be the loss to the nation and the race
by such a practice, the individual must gain. The avoid-
ance of the troubles of pregnancy, the dangers incidental
to parturition, the confinement of the lying-in, the worries
of lactation, the expense of another child, and the extra
work which this entails — all of this avoided — seems at first
to be an undoubted gain to the struggling husband and
over-anxious wife, and it would ill become me, with the
knowledge I possess, if I failed to appreciate the difficulties
of the position or to under-estimate the power of that
current advice which seems only to be dictated by common
prudence.
But the question arises whether this immunity from
pain and trouble may not be too dearly purchased, even
by the persons themselves who are primarily concerned.
It would be strange indeed if so unnatural a practice
— one so destructive to the best life of the nation — should
bring no danger or disease in its wake, and I am convinced,
after many years of observation, that both sudden danger
and chronic disease may be produced by the methods of
prevention very generally employed.
In one or two instances I have known acute periton-
itis to immediately foUow the use of an injection after
sexual intercourse. The cervical canal appears to be
often unusually patent at this time, and the danger is
neither an unimportant nor isolated one.
In another instance I was consulted for an acute purulent
vaginitis directly following the use of a mechanical shield,
and as both parties were free from any disease previously,
there could be no doubt that the infection or cause of
irritation arose from this.
These are casual instances of sudden danger or acute
The Diminishing Birth- Rate 29
illness that have come under my own notice, but none
the less real and far more common is that chronic impair-
ment of the nervous system which frequently follows
the long-continued use of any preventive measures, whether
open to hostile criticism or not as immediately dangerous.
This chronic impairment of nervous energy of which
I am now speaking, often referred to under the name
of neurasthenia, and still more recently under that of
" brain-fag," has many causes, and may be produced
whenever there has been too great a tax or drain upon
the nervous system, and too short a time for real recupera-
tion ; but it is especially marked in many of these cases
of sexual onanism.
The inability to fix attention, the unreasonable fears,
the loss of memory, the loss of emotional control, the
mental depression and abject misery often felt by the
sufferer — himself or herself — and shown more or less in
countenance, word and act, these are symptoms well
known to all of us, and symptoms that may be studied
exceptionally well perhaps in the school-boy addicted
to the habit or vice of self-abuse. With the reform of
this habit in the boy, all of these symptoms quickly dis-
appear. It is difficult, therefore, to escape from the con-
clusion that the storing-up of semen in the male is of value
in the economy. It is undoubtedly a source of strength
both in man and in the lower animals, and it appears
as if the seminal fluid must therefore have some function
beyond and in addition to its power in the reproduction
of species. Its loss is often followed immediately by
loss of strength and staying power, and this loss of strength
or vitality after the process of reproduction is noticeable
throughout all the animal creation, man being no exception
to the general rule.
Further, the artificial injection of " testicular juice "
in senility, though a means of treatment by no means
free from objection, and one of which I have no personal
knowledge, is stated by many competent observers (from
The British Gyncsco logical Society
Brown-Sequard to Boy Teissier in the "Twentieth Century
Practice of Medicine ") to be attended by very marked
results, and this, I beHeve, quite irrespective of the sex
of the patient submitted to the treatment.^
Do we understand the whole of the physiology of the
act which often ends in conception ? Is it limited, as
most have too readily assumed, to the carrying of sper-
matozoa for the fecundation of the ovum, or is some
portion of the fluid retained by the uterus and absorbed ?
Modern investigation shows that traces of the seminal
fluid may be found quite high in the female genital tract,
beyond the confines of the uterus, and the ever-varying
mucous surface of the body of the uterus can, as we know,
under certain conditions easily absorb septic poisons and
mercurial salts.
Beyond this, it is by no means certain that the endo-
metrium and so-called uterine glands are inactive. Except
during menstruation there is no visible discharge from
the body of the normal uterus, and if the theory of Arthur
Johnstone be accepted, that the cavity of the corporeal
endometrium is essentially an open lymph-gland, the
channel of absorption may be immediate and direct.
It is quite possible, then, that in one or both of these
suggested ways some tonic constituent of the seminal
fluid may be taken up by the uterus, and thus affect the
general organism ; and there is nothing unreasonable
in the suggestion that such absorption may allay the
exhaustion which, without it, is liable to follow the act
of connection.
It is very noticeable that exactly the same train of
neurasthenic symptoms are nearly always to be observed
^ Dr. Boy Teissier writes : " I have employed injections of
testicular juice in certain cases of irregular and sometimes very
advanced senility, and the very favourable results thereby obtained
are of such a nature as to make me regard this substance as an
agent of real power, the emploj'ment of which is rarely contra-
indicated."
The Diminishing Birth-Rate
in the worst cases of cervicitis, where the cervical canal
is effectively plugged by thick mucus, and the patient,
though married, is temporarih^ but necessarily sterile.
In both cases the resulting imperfect acts of sexual con-
gress appear to be directly harmful.
But apart from this, is the prevention of pregnancy
the gain to the woman that so many imagine ? It may
well be questioned whether in the study of pregnancy
sufficient attention has been paid to the period of ovarian
rest which appears to accompany the growth of the preg-
nancy. The raising of the ovaries out of the pelvis into
the abdomen, the diversion of the main blood stream
for nine months directly to the uterus, and the absence
of menstruation, through pregnancy and lactation, argue
a time of rest and comparative inactivity for the ovaries
which cannot but have an important value in the life of
the woman who is married, and at the same time physio-
logically ready for conception and for pregnancy.
During this time of uterine activity, but of ovarian
rest, there is ample opportunity for the nervous supply
of the ovary to recover from any undue stimulus, and
it is perhaps worthy of notice that this period is usually
attended by improvement in general nutrition and increase
of fat. This comparative suspension of ovarian activity
also coincides with the time when the uterus is filled and
unable to retain the secretion of the male.
When this period is fully over it is only reasonable
to suppose that the ovaries have gained by this alterna-
tion in the sexual apparatus, and that the maturation
of the follicle may proceed more healthily, and even the
ovum itself may be more perfectly formed, than in the
case of a woman in whom this natural cycle has been arti-
ficially prevented. In this case the ovaries suffer and
the woman suffers with them — far more, as a rule, than
she would by repeated child-bearing. Widely as the
practice of prevention has spread, you will still have to
go to the mothers of large families if you want to point
2,2 The British GyncBco logical Society
to the finest and healthiest examples of advanced British
matronhood. The natural deduction from this reasoning
is, that the artificial production of modern times — the
relatively sterile marriage — is an evil thing even to the
individuals primarily concerned, injurious not only to
the race, but to those who accept it.
Much that I have said regarding the married life of
the mothers of our race has a very similar bearing on that
of the fathers also. The incomplete act of sexual congress
is but slightly removed from that of self-abuse and is
open to much the same criticism and strictures. The
lower passions are usually stronger in man than in woman,
and demand a firmer control. This is encouraged by the
natural progress of the healthy married life. The recur-
ring periods of abstinence and restraint induced by each
pregnancy, at the confinement and lying-in, not only
tend to raise the man himself, but the power obtained
by this we may expect (as Prof. Pearson has demonstrated
regarding other moral faculties) to be mathematically
transmitted to his children.
The increased work and self-sacrifice also necessitated
by the growth of the family, the simpler and plainer
standard of life corresponding to this, all have their en-
nobling effect on parents and children. But when the
opposite of this obtains then, indeed, there follows not
only a moral deterioration of the individual, but a step
has been taken reversing the great order of progress from
the brute. For then the higher powers of the race, know-
ledge and the intellectual application of it shown in
" prevision " and " precaution " have become systematically
subservient to the lower and the animal. And when
this is the case decadence has begun.
There is no method of prevention, whether by with-
drawal or by the use of injections, or shields, or medicated
suppositories, that can be regarded as innocuous.
The health, and especially the mental and moral
stamina of those who use these " checks " is slowly under-
The Diminishing Birth- Rate ^iZ
mined. The very life of the nations, as we have seen,
is seriously imperilled, and there is increasing reason to
believe that such isolated children as are " arranged for "
and produced under these conditions may themselves
suffer and be degraded by their antecedents.
To the evils of disease, race-limitation, or destruction
and hereditary weakness which appear to inevitably
follow the artificially sterile marriage, we have to add
the accompanying evil of a debased and stunted education
for the children.
In the most plastic period of the child's life, in its
earliest years, the more or less solitary child brought up
in a land of solitary children is necessarily isolated and
self-centred. Reared in greater comfort or comparative
luxury, with no brothers or sisters of similar age to rub
off its angles and selfishness, it is ill-prepared for ever}-
step of the succeeding battle of life, and it is very generally
the child of the larger family and poorer parents, and
very often the child of a lower class, who pushes his way
in front of him and elbows him to the wall. I have no
time to dwell on this, which opens out an important field
for further observation and study, but you, gentlemen,
who have necessarily been students of human nature
all your lives, will know how much there is to bear out
every word that I ha\-e said.
III.
What will be the outcome for England in the future
if nothing be done to check this and allied abuses of
so-called modern civilisation ? If I shall not weary you
with statistics I would ask you to turn your attention
for a short time to our sister nation, France, where (as
in a magic mirror) one can apparently see the future of
those countries in which the birth-rate tends to fall until
VOL. XX. — NO. -]■]. 3
34 ^■^^ British GyncBcological Society
the population becomes stationary, or even less than
stationary, as it is in France to-day.^
In a remarkable paper written by M. Alfred Fouillee,
of the School of Moral Sciences, in the Revue des deux
Monies of January 15, 1897, we find the following account
of the criminal statistics of France : " Since 1881 — that
is, from 1881 to 1896 — the number of prisoners before
the Correctional tribunals has risen from 210,000 to 240,000.
Since 1889 — or in seven years — manslaughter has risen
from 156 to 189, murder from 195 to 218, and sexual
crime from 539 to 651.
" In addition to the general increase in criminality
of all kinds, a sort of specialisation of crime, especially
for acts of violence, is to be noticed. These belong more
and more to a certain class, that of the old offenders. The
number of these, which was 30 per cent, in 1850, is now
65 per cent. In short, during the last fifty years crimi-
nality has trebled itself in France, although the population
has hardly increased at all.
" The saddest side of the criminal statistics is that
regarding children and young people. From 1876 to 1880,
while the misdemeanours of common law had trebled
among the adults, the criminality of youths (from 16
to 24) had quadrupled, that of young girls had nearly
trebled, and the number of children prosecuted had doubled.
In the period 1880 to 1893 criminality has increased still
more rapidly. To-day child-criminality is nearly double
that of adults, notwithstanding that minors from 7 to
16 years only represent 7,000,000, while adults amount
to more than 20,000,000. In Paris more than half of
• " In France during the past year, according to the returns of
the Bureau of Vital Statistics, there were 25,998 more deaths than
births, and 20,000 fewer births than during the previous year. The
record shows only 827,297 births for a population of 39,000,000,
though there was a slight increase in the number of marriages, and
a slight decrease in the number of divorces." — Montreal Medical
Journal, December, 1903.
The Diminishing Birth- Rate 35
the individuals arrested are under 21, and nearly all have
committed the more serious offences." According to
M. Adolphe Guillot, the acts of the young prisoners are
marked by an exaggerated ferocity, a special refinement
of lust, and a bragging of vice that are never met with
to the same degree at a more advanced age.
" Child prostitution is growing, and in ten years the
number of children charged with prostitution was esti-
mated at 40,000. In 1830 the number of suicides was
5 in 100,000 ; in 1892 there were 24 to the same number.
By 1887 the suicides of children under 16 years (formerly
extremely rare) amounted to the number of 55. In 1896
we had 375 suicides of young people between the ages
of 16 and 21, and the suicides of children under 16 were 87."
These are facts written by a Frenchman for French
readers in the best known French magazine of the day.'
If we like to extend our inquiry we find that these
figures are taken from the national statistics, and are
in harmony with other observations. " Since 1880 —
that is, during the last twenty years — the consumption
of alcoholic drink in France has trebled, and France has
passed from the seventh place in order of consumption
of alcohol to the first." (Mr. Yoxall, M.P.)
The figures in Mulhall's " Dictionary of Statistics,"
though varying to some extent, are in rough accordance
with these. According to this authority, we find that
insanity is steadily increasing in France, and that the
ratio of suicides has risen from 112 per million in 1880
to 205 (or nearly double) in 1885.
I do not want to press these figures beyond their
bare legitimate application. In particular, with regard to
alcoholism, this depends on many factors, and is very
' A very similar or parallel article on the Increase of Crime in
the United States (where " prevention" is exceedingly common") is
written by Dr. Buckley in the Century Magazine for jNovember,
1903.
36 The British Gynceco logical Society
much governed by the legislation of the country regarding
its sale. In England, for instance, there was a marked
diminution in national expenditure after the Early Closing
Act of 1872, and in France there has been a great increase
since 1880, when, as I understand, the facilities for obtain-
ing it were much increased.
But this does not alter the fact that after half a century
of trial with an increasingly limited population France
shows more and more a lowered and still falling moral
average, a lessening virtue and strength, and an increasing
national neurasthenia, which seems to crave and to need
the help of constant stimulation in order to face the ordinary
routine of life.
Here we see a great nation, a people and a land which,
next to my own, I think I understand, appreciate and
love better perhaps than any other, and to which I wish
nothing but good ; but a nation so bound by the fetters
she has forged for herself that nothing but the life she
has deliberately cast aside could apparently save her
from her slow decay.
And is not this refusal of life by the French at the
root of the deep anti-Semite feeling which otherwise would
be so contrary to the frank spirit of the French ? The
Hebrew race, to their lasting honour, with very few excep-
tions, have not only kept themselves free from the vice
of which I have been speaking, but, by reason of their
laws and customs, are the most systematically temperate
in their sexual relations of any nation or people I know.
Consequently, among them, the natural breeding of
the better stock has never been interfered with, and in
a country like France, the Hebrew seems to rise not only
individually, but racially, among the people with whom
he has his dwelling, until what appears to be an unfair
proportion of responsibility and power and wealth rests
in the hands of an alien race. When this is discovered,
and the cause of it but dimly recognised, there cannot
but be bitter feelings of jealousy and even hatred in
The Diminishing Birth- Rate T^y
the great mass of the nation among whom the Hebrew
dwells, and it is not surprising that the power of combina-
tion and of number is sometimes unjustly used to over-
come (if possible) the disadvantage.
So far, I have been dealing only with what is open
to observation and experience. But may we not reason-
ably go a step further ? What must be the future of
such a society if degeneration goes on and the power of
the democracy remains as at present or increases ? So
long as the race progresses the people can be trusted with
the powers of Government, but when decadence has been
going on for years, or even ages, what can be the final
outcome of such democracy but anarchy and confusion ?
IV.
In dealing, or attempting to deal, with the treatment
of this grave national evil, it is necessary to take a broad
and yet sympathetic view of the problem.
It is one belonging essentially to the higher gynaecology,
in which no false sympathy or lower obstetric platform
must be permitted to interfere with what is really best
for the individual and the race. And yet when we recog-
nise that the whole force of modern civilisation, its honour
paid to riches, its luxury, its frivolity, its impatience,
its society, its manner of life, its very " neurasthenia,"
seems all more or less opposed to the cultivation of that
true family life which is its best safeguard against decay,
one needs indeed to temper judgment with a quick appre-
ciation of all the difficulties encountered by every modern
wife and mother, and to recognise the almost insurmount-
able obstacles for the Church, the State, and the Profession
of Medicine to slowly overcome.
For I think the help of all is needed. The Roman
Catholic Church teaches that prevention is a sin, and
though this is altogether beyond my province, I would
submit that no lower standard of sexual morality should
The British GyncBcological Society
beTallowed by those who belong to another communion,
and that every effort should be made by the religious
and the moralist to inculcate a higher ideal and a plainer
and simpler standard of life.
In the State it might be possible to encourage this
higher ideal by regarding the well brought-up family
as one of the attendant qualifications for high distinction
and honour, and, in addition, by some wide scheme of
old-age insurance or pension, by better facilities for the
higher education of children, and by some special remis-
sion of taxation to hghten the burdens of those who are
bringing up large families to be a credit to themselves,
and a lasting benefit to the nation.
Again, where further education is demanded, and
legitimately demanded, by any profession or calling as
necessary to full qualification, I would have the State
rather jealuously guard the earliest possible date at which
productive work may begin. Part of the difficulties of
our modern life seems to be caused by the ever-receding
age at which such work is possible. In my own student-
days many of us qualified at 21, were earning our own
living at 22, and yet managed to keep up study and hos-
pital attendance until taking the higher degrees at 25
or 26. This may have been mistaken, but I am convinced
it is a far greater mistake to keep a young man, with a
man's vigour and ambition, from any real independent
work through most of the years from 20 to 30.
In the Medical Profession itself the evils of prevention,
both immediate and remote, should be studied more
closely, and explained to such patients as need direction
and advice. No advice should be given in favour of it
without special consideration of the subject in aU its
bearings and due consultation.
My own opinion is that while occasional abstinence
in married life is perfectly allowable and may have, as
I have suggested, a high moral hereditary value, no arti-
ficial prevention is advisable save that which is produced
The Difninisking Birtk-Rate 39
by operation, when deformity or grave disease imperatively
demands it.
Certainly in the present day when septic diseases, as
we know, can be reduced to a minimum and should be
almost entirely avoided, when surgery can so effectually
and safely deal with nearly every kind of difficult or
dangerous labour, it is not the time for the fairly healthy
parents of one child to shelter themselves behind the
terrors and troubles of a first confinement, and demand
some easy but evil way of further immunity.
But as civilisation increases, there can be little doubt
that the susceptibility to pain increases also, and it may
be that the mothers of to-day need a greater consideration
and help, during the progress of pregnancy and lactation,
than the mothers of former years. Very much more
may be done during these periods by suitable advice,
management, and diet than many imagine. In some
cases, as I showed last year, repeatedly disastrous preg-
nancies may be changed into ones of healthy type and
character solely by what amounts to a special and more
liberal dietary before and during pregnancy ;^ and much
of the partial collapse and ill-health that is apt to follow
parturition and accompany lactation may be modified
or altogether avoided by due provision and direction for
the hygienic requirements of mother and child, particu-
larly as regards rest and food.
In these ways, and especially by personal influence
and example, the medical practitioner may do more perhaps
than anyone else to reform the judgment and correct the
practice of this and coming generations.
But when all this is said and done, there still seems
to be needed some general awakening of the national
conscience if any thorough and lasting change is to be
hoped for. Let us be careful that the awakening is in
the right direction.
' British Medical Journal, Apriri i, 1903.
40 The Brittsk Gyncecological Society
One word of caution may be needed. Whatever may
be the merits or demerits of cehbacy as compared with
marriage, statistics show, as I have already stated, that
it has but very httle practical bearing on the subject
before us. '■ The birth-loss in the United Kingdom must
be due to causes operating in the married life of its inhabi-
tants." True celibacy, maintained, as it often is, for
the sake of the better service of mankind, is worthy of
the highest honour and may well be subject to a higher
law than that of physiological increase. Many noted
examples of this will occur to all as I speak, in every pro-
fession and of both sexes. These are vicarious fathers
and mothers whose children far out-number the limits
of a physiological family, and the lives they protect or
encourage or save make for that " maximum of life "
which is associated with the '' maximum of virtue."
There is no reason to fear any high ideal of chastity
or continence, and especially none when it is associated
with the care of those forces which go for the defence of
the nation and that child-life which is its future hope.
On the other hand, there is every reason to fear that
debased ideal of married life which is secretly and in-
sidiously working for the ruin of the nation's power and
for the destruction of its hope.
Artificial prevention as an evil and disgrace — the im-
morality of it, the degradation of succeeding generations
by it, their domination or subjection by strangers who
are stronger because they have not given way to it, the
curses that must assuredly foUow the parents of decadence
who started it — all of this needs to be brought home to
the minds of those who have thoughtlessly or ignorantl}-
accepted it. For it is undoubtedly to this that we have
to attribute not only the diminishing birth-rate, but the
diminishing value of our population.
No truer words were ever said than those by Ruskin :
" The maximum of life can only be reached by the maxi-
mum of virtue." Do they not carry with them another
The Diminishing Birth-Rate 41
truth which has now become almost a demonstrable fact,
that the prevention of life is always accompanied by moral
deterioration ?
And this evil harvest, for ourselves and for our chil-
dren, is of our own sowing. Some, looking back on past
history and bygone civilisations, have imagined that the
rise and fall of empire follows some unalterable law, and
that nations, like individuals, must necessarily suffer from
senility and decay.
But it is not so. National decay or degeneration is
by no means the inevitable consequences of age. Our
modern ally, Japan, is an evidence of this. After a long
and chequered history, quite as long or longer than our
own, she has emerged in all the activity and strength
of a second youth.
And it is interesting to note that this new-found power
is directly associated in the mind of the Japanese with
the knowledge of their own racial strength and power
of increase ; indeed, it is this which gives them — youth.
This is well shown by some recent remarks of one
of their more prominent men. He writes : " Japan is in
no danger of race-suicide. . . . The mothers are not
shirking maternity as in other lands, and the result is
that we can spare half a million of men a year for an
indefinite number of years and not miss them.
" Barring Formosa and the Pescadores, we have less
than 150,000 square miles of territory, of which eleven-
twelfths is unproductive of food. Nevertheless we have
close to 50,000,000 folk to feed. Do you wonder that
we are land-hungry — that we want elbow-room ? " (Re-
ported by Stephen England in the Daily Mail of December
23, 1903-)
In a somewhat different way the Hebrew race, to whom
I have already referred, may also be cited as an example
of an ancient people, old in every sense, and still not dying
out. Conquest and dispersion have left their ineffaceable
impress on the race, but they are with us to-day, not in-
42 The British Gynceco logical Society
frequently showing evident traces of centuries upon cen-
turies of nervous training and development, of nervous
wear and tear ; possessing, too, a history of great
achievement in music, art, and literature, corresponding
to that development, and yet showing, so far as I am able
to ascertain, no sign of real decay or loss of reproductive
energy.
We have the same power with far better opportunities
and a much brighter outlook. At no period in our history,
perhaps, was there less reason for racial suicide, and, apart
from this, for pessimism. All of us, both men and women,
need a truer and braver conception of life. Life is entrusted
to us — ^life and the power of life — and we should be ready
to work, to suffer and to adventure greatly and cheer-
fully, for the honourable and wise employment of the
entrusted capital.
" Then welcome each rebuff
That turns Earth's smoothness rough.
Each sting that bids, nor sit, nor stand, but go.
Be our joys three parts pain !
Strive and hold cheap the strain ;
Learn, nor account the pang ; dare, never grudge the throe."
I must confess when I hear of thoughtful men among
the Boers in South Africa, military authorities in St.
Petersburg, and Japanese in far Japan, noticing and
counting on their own racial increase, and comparing
this, kindly or unkindly, with our own comparative stag-
nation, I would like, if I could, to sting my fellow country-
men into some proportionate sense of shame and duty.
My voice is weak, but in the responsible position in
which you have so generously placed me, as the tem-
porary head of a great British Society, which may well
claim to be the greatest British authority on such ques-
tions, I am surely not overstepping my province if I ask
for the grave interest of every Fellow in this important
subject ; if I ask, not so much for any following of my
leadership as for the fullest independent investigation
The Diminishing Birth-Rate 43
into all the facts, figures and arguments I have brought
before you. For with us lies a great responsibility, and
ours will be to a very large extent the blame if, in after
years, the lamp of the Anglo-Saxon is found to be burning
dimly.
Dr. Heywood Smith proposed that a vote of thanks
be given to Prof. Taylor for the masterly address, and
that it be published in the Transactions of the Society.
The attention of the whole nation should be drawn to
this most serious question, and he thought it would be
well to have it printed and brought definitely before the
Government, and circulated among members of Parlia-
ment. He was quite sure that, if unchecked, the evil
which it put before them would go on spreading, and
he thought that the British nation should set an example
to the others in trjdng to arrest it.
Dr. Macnaughton-Jones, in seconding the motion,
said he thought it a great honour to the British Gynaeco-
logical Societ}' that Professor Taylor, coming as he did
from the Midlands, which were associated with such well-
known names as Clay, Lawson Tait, and others, should
occupy their Chair. The subject brought before them
was one which touched the physical, moral, and intellectual
welfare of the country, for as so lucidly exposed in the
address, crime, lunacy, alcoholism, and other evils tending
towards the deterioration of the race were undoubtedly
intimately connected wdth the matter. He thought the
Fellows of the Society were additionally indebted to the
President for breaking new ground in his address. In
medical matters they were to a certain extent responsible
for the safety of the national health, and Professor Taylor
had shown them a direction in which it was in their power
to fulfil that function.
Professor Taylor, in responding to the vote of thanks,
said the subject of his address had occupied his thoughts
and attention for many years past. He added a hope that
the Society might have a useful and prosperous year.
44 The British GyncEcological Society
BRITISH GYNECOLOGICAL SOCIETY.
Thursday, March io, 1904.
Pkofessor JOHN W. TAYLOR, M.D., F.R.C.S., President, kn
THE Chair.
Specimens and Cases.
By request of the author, Dr. H. Macnaughton-Jones
read the following notes accompanying the two specimens : —
Notes of a Case of Successful Hystero-Salpingo-
OoPHORECTOMY FOR PeLVIC SUPPURATION. By T.
Gelston Atkins, M.D., M.Ch., Surgeon to the South
Charitable Infirmary and County Hospital, Cork.
Mrs. L., a woman aged about 35, consulted me in
October, 1903, stating that early in January she had been
confined of a large male child after a slow labour. All
seemed to go on well for the first five days, when she had
a shivering attack with acute pain in her left side. After
some days of very severe pain she felt something give
way, a gush of discharge took place, and she felt greatly
relieved. She remained in bed for six weeks, during which
time the discharge diminished considerably, but never
ceased, and when I saw her early in October, and made
a vaginal examination, a torrent of pus, fully one pint,
was passed, and could be seen coming out of the os uteri.
On each side of the uterus there was a swelling, and
pressure on either of these caused the pus to flow more
abundantly. It was therefore clear that there were pus
sacs communicating with the uterus. A Sims's probe could
be easily made to enter the sac on the left side, but not
the one on the right. I therefore concluded that these
Atkins on Hystero-Salpingo-Obphorectomy 45
sacs were either pus tubes or broad ligament or ovarian
abscesses opening directly into the uterus, and advised
an exploration and the adoption of the proper course
when the exact condition was made out. On opening
the abdomen, I found that the omentum was adherent
all round, and presented the appearance of a cover to the
pelvic roof. When this had been tied off, the swellings
were seen to be the ovaries embedded in a dense mass
of adhesions to the bladder, bowel, uterus and pelvic walls,
and it was evident that nothing short of clearing out the
pelvis would be of any use. This proved to be a very
difficult proceeding, as the tubes and ovaries had literally
to be dug out of the dense mass of adhesions. The first
step consisted in tying the ovarian arteries ; the bladder
was then detached from the uterus, and the separation
of all the adhesions was completed by working upwards
from below ; total hysterectomy was preferred to supra-
vaginal, as the cervix seemed to be infected, though exami-
nation proved that the pus from the abscesses was sterile.
The patient made an uneventful recovery, and left the
hospital quite well in four weeks. Referring to the speci-
men, the opening of the abscesses, into which a bristle
is ' passed, can be seen in the uterine canal. The case
is the first of the kind that I have seen, and I believe,
from the literature I can lay hands on, that the condition
is a very rare one. It is an interesting question how both
ovaries became infected. From the severity of the puer-
peral attack the infection must have been streptococcic,
and it must have passed through the uterus and tubes
and lodged in the ovaries, but there is no sign that either
uterus or tubes were involved. If the mode of infection
had been through the lymphatics, through the uterine
wall and parametrium, one would have expected an endo-
metritis or metritis, and then a parametritis. From the
extent and density of the adhesions there had evidently
been a considerable amount of pelvic peritonitis.
46 The British Gyncecological Society
Notes on a Case of Hystero-Salpingo-Oophorectomy
FOR Double Ovarian Papilloma and Carcinoma
OF the Cervix Uteri. By T. Gelston Atkins,
M.D., M.Ch.
Mrs. C, aged 53, was admitted under my care to the
South Infirmary, on December 6, 1903 ; she had been
kindly sent by Dr. Orpin, of Youghal, with a diagnosis
of uterine cancer. He had only seen her a few days before,
but feeling sure of his diagnosis, sent her to hospital. On
admission, she was greatly attenuated and pallid, and
complained of shortness of breath and general abdominal
discomfort. Her pulse was 150, and the vessel was not
well filled. She stated that she had had a coloured dis-
charge for three or four weeks, but otherwise, except for
the gradual abdominal enlargement, she had no symptoms.
There was ascites, and two large growths could be felt,
one in each iliac region, which were freely movable in the
ascitic fluid. The cervix was hardish, with a patulous
OS which bled easily. A scraping of the cervical canal
gave unmistakable evidence of malignant disease. There
did not seem to be any adhesions. A few days' observa-
tion showed that she had decided tachycardia. The urine
was normal. I decided to explore, and on opening the
abdomen, a large quantity of ascitic fluid came away,
and the swellings in the pelvis floated up into the abdominal
incision, and proved to be malignant papillomata. I
therefore determined to remove them and the uterus,
which I did by the ordinary operation of hystero-salpingo-
oophorectomy, as in the preceding case, without meeting
any difficulties. She bore the operation well, but her
pulse remained between 150 and 160, and her tem-
perature was from 99° to 99-6° F. For the first seven
days she seemed to be making an uneventful recovery,
and on reference to the hospital notes, I find that on the
fifth day she had boiled fish, light food which she digested
well, the bowels moving regularly. On the evening of
the seventh day her breathing quite suddenly became
Oh
a
<
a- ?, S
13 tu S
- ^ I
p _a; -5 X
Discussioit on Hystero-Salpingo-Oophorectomy 47
very irregular, short and jerking, and the pulse rose to
165. On the eighth day, when the stitches were removed,
the abdominal wound was quite healed and aseptic, but
the rapid breathing and pulse never went down, and she
died on the night of the ninth day after the operation.
The cause of death was in no way connected with septic
processes, but simply due to the tachycardia. The speci-
men is a beautiful example of double papilloma -of the
ovaries, and of cancer of the cervix. It is an interesting
point whether the cervical cancer was due to infection
from the ovaries.
Dr. Macnaughton-Jones remarked that, seeing how
frequently papilloma of the ovary partook of the nature
of adeno-carcinoma or carcinoma, or was associated with
such disease, he was not surprised at the cervix being
cancerous in this instance. As regarded the SQurce of
infection in the other case, the occurrence of suppuration
of the adnexa during pregnancy or childbed was un-
common and difficult to account for ; it was no doubt
in some instances due to latent gonorrhoeal infection or
other disease of the tube or ovary present before
pregnancy.
The President said that Dr. Atkins was to be warmly
congratulated upon his successful operation. It was a
very bold undertaking to remove the uterus and ovaries
in the condition described by him.
Dr. William Duncan thought the question whether
the papilloma was the source of the cancer of the cervix
was a very pertinent one. He had never seen the two
conditions associated.
Dr. Inglis Parsons said that the combination must be
a very rare one, as he had never met with it.
Dr. William Duncan exhibited the following speci-
mens : (i) Fibroid uterus removed by vaginal hysterec-
tomy after enucleation had failed. (2) Fibroid of the
vaginal wall. (3) Uterine myoma growing between the
48 The British Gynceco logical Society
layers of the broad ligament, and completely filling the
pelvic cavity ; hysterectomy ; recovery. He read the
following notes : —
Large Uterine Myoma in the Left Broad Ligament,
Completely Filling the Pelvic Cavity — Hysterec-
tomy— Recovery.
The patient, aged 53, was seen by me in consultation
with Dr. Tom Godfrey, of Finchley. Married in 1875,
she had had seven children, the youngest aged 13, and
five miscarriages, the last two years ago. The catamenia
were regular up to 1902, when they began to be erratic,
and sometimes a flooding took place ; the patient also
complained of much backache and frequent micturition.
On examination, a central firm tumour could be felt extend-
ing upwards midw^ay between pubes and umbilicus, and,
per vaginam, a tumour was felt, filling the pelvic cavity
and displacing the cervix downwards and to the right.
This tumour was evidently part of the one felt in the abdo-
men, and movement of it moved the cervix. The sound
was not passed.
Hysterectomy was recommended, and was performed
on September 24, 1903. When the abdomen was opened,
the tumour was found to be attached to the posterior
wall of the uterus, and to be growing between the folds
of the left broad ligament. The ligament was incised
and the tumour, with some difficulty, shelled out of the
pelvic cavity ; the ovarian and uterine arteries were
secured in the usual way ; the left ovary only was removed.
The cervix was divided in the usual way, and a huge
cavity could then be seen extending between the layers
of the broad ligament down to the floor of the pelvis.
After all the oozing vessels had been secured, the walls
of this cavity were whipped together, from below upwards,
by a continuous suture of fine silk, the peritoneal flaps
were united over the stump of the cervix, and the abdo-
minal wound was closed with three layers of suture, fine
specimens and Cases 49
silk for the peritoneum, interrupted silkworm-gut sutures
for the sheath of the recti muscles, and strong continuous
silk suture for the skin.
The patient made an absolutely uneventful recovery,
without rise of temperature, sickness, or trouble of any
kind, and now, five months after the operation, feels per-
fectly well and can take long walks without fatigue.
The interest of this case lies in the manner of closing
the large cavity left between the layers of the broad liga-
ment after the tumour had been removed, a method which
is infinitely better and safer than packing with iodoform
gauze, as recommended by some operators.
Dr. Inglis Parsons exhibited three uterine tumours
and read the following notes : —
I. — Fibrocystic Tumour of the Uterus.
The patient, a single woman, aged 40, complained
of difficulty in passing water for the last three years, and,
latterly, of complete retention, necessitating the use of
the catheter. For the last eighteen months she had
noticed a swelling in her abdomen, accompanied by pain.
Her menstruation had been regular, every twenty-eight
days, lasting for five days and very free and painful for
the first three days.
Dr. Cameron, the house surgeon, described the abdo-
men as much distended by a large tumour with a more
or less uniform surface, movable and not tender, of a
doughy consistence, and with a contour like a bullock's
heart, such as Professor Murdoch Cameron has described
to be characteristic of fibrocystic tumours. The cervix
was obliterated and almost the whole of the lower pelvis
was filled by the tumour. The sound, passed with some
difficulty, showed the uterine cavity to be seven inches
long.
On opening the abdomen on January 12, 1904, I found
the pouch of Douglas entirely obliterated, the peritoneum
VOL. XX. — no. 77. 4
50 The British Gynecological Society
which usually forms it, with part of the rectum and sig-
moid flexure, lying on the back of the tumour. After
tying off the broad ligament at each side, and removing
the appendages, as both ovaries were diseased, I cut
through the peritoneum on the posterior wall and stripped
it and the bowel down away from the tumour, until I
came to a point where it was firmly adherent.
The round ligaments were then tied, and the anterior
layer of the peritoneum cut across from side to side and
stripped down, taking the bladder with it. The sides
of the tumour were then carefully examined, and, as the
ureters seemed to be below, both uterine arteries were
tied. The tumour was then cut across low down and
removed, a piece of the adherent capsule being left on
the bowel. Finally, the remains of the cervix containing
a portion of the tumour were completely removed, thus
opening the vagina. One or two small vessels had to be
tied. The vagina was then closed by a mattress suture and
the anterior and posterior flaps of peritoneum were united
by a continuous silk suture, though, on account of the
adhesions on the right side, there was not enough of the
posterior flap to meet the anterior. The abdominal wall
was united in three layers. The patient made an un-
interrupted recovery without a single bad symptom.
I have brought this case forward because fibrocystic
tumours are rare in women of 40 and, on account of the
amount of the growth in the lower part of the pelvis, the
removal of the tumour presented unusual difficulty, and
also, because Dr. Cameron, the house surgeon, made a
correct diagnosis based on his father's observation of the
bullock's heart shape of fibrocystic tumours.
II. — Large Fibroma of the Broad Ligament.
The patient, a single woman, aged 35, for two years
had suffered from pelvic pain, especially at her menstrual
periods, which were regular, and lasted three days with
a scanty discharge.
Specivieiis and Cases 5^
On examination, a large tumour was found iilling
the pelvis and extending above the pubes. It was hard,
nodular and movable, and gave a sense of fluctuation.
The uterus, displaced upwards and to the right, was normal
in size, the sound passing 2-5 inches. Abdominal section,
on February 23, 1904, showed that the tumour was a
large iibromyoma of the right broad ligament. After
tying the left ovarian and uterine arteries in the usual
way, and tying the right broad ligament, the peritoneum
was cut across before and behind the tumour, and the
flaps stripped downwards ; the cervix was then divided
from the left side until the right uterine artery was exposed,
and when this vessel had been caught and tied by Dr.
Bonney, who was assisting me, the tumour was rolled
up out of its bed. In doing this the bladder, which was
closely adherent to the tumour, was unavoidably opened,
and a large raw space was left in the bed of the tumour,
from which there was a great deal of oozing. After several
small vessels had been secured and the oozing checked
by hot sponges, this space was brought together with
fine silk and the bladder sewn up. The peritoneum was
then united, and the wound closed. A soft rubber catheter
was kept in the bladder. Three hours after the operation
the patient coUapsed from shock, but Mr. Rose, the house
surgeon, promptly transfused a pint and a half of saline
fluid, and injected ^-V gr. of strychnine. The bladder was
drained for ten days, and beyond passing some blood in
her urine, she has had no bad symptoms. She can now
retain her water for some hours, and in a few days will
be able to get up.
III. — Submucous Myoma.
The patient, aged 31, married for eighteen months,
but childless, was sent to me by Dr. Lauchlan on account
of profuse menorrhagia of four or five years' duration.
She was very anaemic from loss of blood, and on examina-
tion, I found a large, hard, irregular, nodular swelling
The British Gymcecological Society
involving and forming part of the uterus, and reaching
to the umbiHcus ; the sound passed 4'5 inches.
On February 23, 1904, I performed a supravaginal
hysterectomy, removing the left ovary, which was diseased,
but leaving the other. The patient made a good recovery,
and was able to sit up on March 10.
Mr. BowREMANX Jessett dissented from Dr. Duncan's
opinion about closing such a cavity as the one described.
His own practice was to put some gauze into the cavity,
bring the gauze through a drainage tube into the vagina,
and withdraw them both on the second or third day.
Dr. J. J. Macax, in relation to the absence of any
capsule and the general condition of fibrosis of the uterus,
described by Dr. Duncan, drew attention to a recent dis-
cussion in the French Surgical Societ}?-, on a paper by
Richelot on malignant degeneration of the stump after
supravaginal hysterectomy, in w^hich he insisted that
uterine sclerosis, of which fibromata were merely incidental
modifications, was an initial stage preceding cancerous
degeneration. An epitome of the paper and discussion,
prolonged over six meetings of the Society, would be found
in the February number of the Society's Journal (Sum-
mary, p. 756).
The President remarked, in regard to enucleation,
that when there was a good capsule and no sepsis there
was no reason that course should not be adopted if it could
be carried out without difficulty, but in a case such as
the one described, especially where there was sepsis, it
was infinitely better to remove the uterus altogether,
as Dr. Duncan had done, with marked success. As to
myomata of the vaginal wall, he (the President) had met
with five or six, most of them in the anterior wall. The
largest was close to the cervix ; the others were near the
urethra, and in enucleating one of these there was
some risk of damaging the urethra. Cavities such as
those left by the removal of a tumour of the broad liga-
specimens and Cases 53
ment he had himself been in the habit of draining with
iodoform gauze without any tube.
Dr. Duncan, in reply, said in regard to the possibility
of enucleating the tumour from the broad ligament, the
uterus was a fibroid one, and the patient was over 50 years
of age, there was no extra risk in removing the uterus,
and the patient was left in a much better condition than
if it had been allowed to remain. He upheld his own
method of treating the cavity, from which, in his own
experience, and in that of others, he had never known
of any ill result, always provided care was taken to arrest
all oozing before whipping the sides of the cavity together,
and considered it a far safer proceeding than draining^
into the vagina, and thereby risking septic infection.
j\lr. Charles Ryall said he thought it was a pity
that the specimens brought before them from time to
time were not classified and shown together, so that they
might have some idea of various operators' methods in
similar cases. As to Dr. Parsons' remark about drainage
keeping the so-called abdominal cavity open, he had
always regarded draining in such cases as hasmorrhagic
oozing, following breaking down of adhesions, or enuclea-
tion of tumours as the safest course to follow in gyuceco-
logical operations. He was not at all in favour of drainage
through the usual suprapubic abdominal incision, and
always preferred the vaginal route, and in fact he had
never yet come across a case where he regretted carrying
out this latter procedure ; but such was not his experience
with former methods of abdominal drainage.
Dr. Macnaughton-Jones remarked that there had
been much divergence of opinion as to the pathogenesis
of fibrocystic tumours. The cyst may be due to (i) the
deliquescence of a portion of a fibroma ; or (2) the dila-
tation of the lymphatics and the formation of sinuses
at the extremities of the lymph vessels. The first of
these views was accepted by Virchow. Klebs attributed
them to hydropsia and oedema. The view of lymphatic
54 The British Gyncecological Society
dilatation was advocated by Billroth and Koeberle, the
lymphangiomatous nature of the tumour lending force
to the supposition, as also the rich peripheral supply of
lymphatics. Dr. Mary Dixon Jones, who has recently
discussed the subject, does not accept this explanation,
and she regards the new cystic formations as a conse-
quence of medullary changes in the tissues, and new forma-
tions eventuating from this medullary condition. The
cyst is a development from the medullary material. She
takes the view that a fibroid tumour is a diseased condition
arising out of an inflammatory corpuscular change in
the tissues of the uterus ; that fibroid tumours do not
cause degeneration, but that the degeneration arises from
the secondary processes of disease developed in the tumour
or in the uterus ; and, further, she believes that infection
of the adnexa is carried from the tumour to the ovaries
and tube. She supports her contention by a number
of microscopical researches into the nature of fibrocystic
degeneration, in which she found inflammatory changes
in the tissues associated with sinuous cystic canals or
irregular cavities, sometimes with the presence of granules
and inflammatory corpuscles, sometimes with osseous
degeneration, at others with pus. In some the changes
partook of the endotheliomatous nature, and the blood
cysts were present.
Dr. Inglis Parsons thought that the gelatinous matter
in fibrocystic tumours resembled that found in malignant
ovarian cysts, and that it would probably be found some
day that it was due to micro-organisms, as it is a well-
ascertained fact that gelatinous material in large masses
is formed by certain saccharomyces in symbiosis with
certain bacteria.
Dr. Bedford Fenwick read the following notes and
exhibited the specimen : —
A Fibroid Uterus Removed for Menorrhagia.
The patient was a governess, single, aged 33. Her
catamenia had been established at 14, and had been
specimens and Cases 55
regular, lasting four or five days with normal loss and
without pain, until two years ago, when they began to
be more protracted with more discharge. For the last
nine months the periods have lasted from eight to ten
days, the discharge has gradually become more profuse,
and large and small clots have been passed with great
straining pain ; for the last month the loss has been almost
continuous. She has, for some months, been suffering
from increasing giddiness, muscular weakness, dimness
of sight, palpitation, dyspnoea, and faintness on exertion.
When she was sent to me, on February lo, 1904, her skin
and mucous membrane were waxy and yellowish ; her
pulse was 120 ; her first heart sound was almost inaudible
at the apex, which was most perceptible in the nipple
line. The cervix was small with a pin-hole os ; the uterus
was slightly enlarged, soft and mobile ; the ovaries and
tubes felt normal. She was at once admitted into the
Hospital for Women, Soho Square, and after a week's
absolute rest, I dilated the cervix, and found several fibroid
growths in the canal too deeply situated to be enucleated
with safety. On March 8, I therefore performed hys-
terectomy, leaving the ovaries, as they were perfectly
healthy. This afternoon, only forty-eight hours after
the operation, her pulse is only 75, and there is a faint
tinge of colour in her lips and eyelids. The case is inter-
esting because the uterus measures only three inches ni
length by two and a quarter in thickness, but it is simply
studded with small fibroid nodules, and the canal is full
of submucous growth. I may call special attention to
the facts that there are no growths at the cornua of the
uterus, and that the ovaries and tubes are perfectly
healthy, which supports the theory I have advanced that
the disease of the appendages, so frequently found asso-
ciated with uterine fibroids, is due to the presence of such
growths at the fundus causing hypertrophy of the ovarian
arteries and consequent hyperasmia of the ovaries and
tubes, a condition which is certainly an ordinary ante-
cedent to chronic disease and degeneration of structure.
The British Gyncecological Society
Dr. Duncan said that the appearance of the specimen
suggested to him that there might be mahgnant disease,
and he thought that a proper pathological report would
be of much value, as the case was most interesting.
Mr. BowREMAN Jessett concurred, and on the invita-
tion of the President —
Dr. Fenwick undertook to have a pathological report
prepared, and bring it before the Society on some future
occasion. In reply to Dr. Heywood Smith, he said that
on introducing the sound he could feel it quite distinctly
pass over the nodule ; there was no question as to the
presence of intrauterine growth.
Paper.
Chloroform in Surgical Anesthesia : the Vernon
Harcourt Inhaler and Exact Percentage Vapours.
By Dudley W. Buxton, M.D., B.S., M.R.C.P., An-
aesthetist and Lecturer on Anaesthetics in University
College Hospital.
The apparatus which I have been asked to explain
to you this evening owes its origin to the ingenuity of
Mr. A. Vernon Harcourt, F.R.S., sometime Reader in
Chemistry at Christ Church, Oxford. The British Medical
Association in 1901 appointed a Committee, of which I
was a member, to carry out certain investigations with
regard to chloroform, and Mr. Vernon Harcourt was co-
opted a member of that Committee. In the course of
our investigations, it became apparent that we must obtain
some method of exactitude by which we could ensure
a definite amount of chloroform being delivered, in other
words, a definite dosage by a known percentage of chloro-
form vapour in air. Now, in 1899 Mr. Vernon Harcourt
published, in the Transactions of the Chemical Society,
a description of a method whereby a current of air could
be mixed with any desired proportion of chloroform
Dudley Buxton on Chloroform in Ancesthesia 57
vapour. This method was, however, only apphcable to
small animals, and was supplemented in June, 1902, by
a communication by Mr. Harcourt to the Royal Society.
In the paper in question reference is made to two methods,
both of which were demonstrated before the Committee
of the British Medical Association, and the second was
adopted by them, after various experiments and trials,
as being applicable to human beings.^ The apparatus
shown to-night is the outcome of these experiments, and
is a remarkably ingenious application of chemico-physics
to the service of suffering humanity.
While the Committee of the British Medical Associa-
tion were studying the accepted methods and apparatus
for giving chloroform, I was requested to report upon
various inhalers, and among them upon Mr. Vernon Har-
court's Chloroform Regulator. Let me, before going
into detail, explain that the principle of this apparatus
is that air passes over the surface of chloroform b}^ the
aspiration of the patient's respiration, and that b}' its
construction the apparatus delivers a maximum strength
of 2 per cent. I was first uncertain whether this 2 per
cent, strength would satisfy the requirements of sur-
gery, although possibly adequate for physiological work.
Probably those of you who have not used, or seen the
apparatus used, will be inclined to take this view. I
mention my own mental attitude at the commencement
of my research. However, experience has convinced
me that, like many theories based on a 'priori reasoning,
this one is entirely wrong. The great bugbear of this
chloroform question has always been a priori reasoning,
coupled with a confiding faith that chloroform as an
anaesthetic obeyed no laws like other drugs. Like the
blessed word " Mesopotamia," the much-abused word
* Mr. Harcourt formulated a Report on these methods, which
the Committee duly presented to the British Medical Association.
See Brit. Med. Journ., July 18, 1903, cxlu.
The Bi-itisJi Gyncecological Society
" idiosyncrasy," has consoled many an aching heart and
ministered to the amour propre of not a few chloroformists.
But if you will bear with me, I hope to convince you
that there is overwhelming evidence in favour of the state-
ment that chloroform is not only a most law-abiding body,
but is impeccable in the matter of idiosyncrasy, while
no evidence exists in support of the contrary view save
various ipse dixits, which are inadmissible as against
definite experimental and clinical observations.
Snow, who in 1858 was the voice of one crying in the
wilderness of inexact experimentation, conducted researches
on chloroform, which succeeding workers have elaborated
and confirmed, but have not disproved. His conclusions
were that 12 minims of chloroform in the body produces
the second degree of narcosis ; 18 minims the third degree,
24 minims the fourth degree, and 36 minims the fifth degree.
Thus 18 minims is 2 per cent., 36 minims equals 4 per
cent. (Fluids of body, 30 lbs. equals 15 litres, or 300
litres of vapour in 15,000. The figures are given by Waller,
Brit. Med. Journ., April 23, 1898, p. 1059.)
Paul Bert, although working on somewhat different
lines, and without any knowledge of Snow's views, arrived
at the same figures, i.e., 2 per cent, vapour will produce
anaesthesia. It is true that Snow speaks of a safe 5 per
cent, vapour, but his methods of giving chloroform were
so inexact that the actual vapour inhaled was never any-
thing like the dangerous 5 per cent, spoken of.
When Clover adopted a dosage method of giving chloro-
form, he fixed his maximum at 4*5 per cent., which was
too dangerous for operations lasting any time, and even
in his skilled hands actually proved fatal. His, like other
methods based upon the principle of mixing large quanti-
ties of air and chloroform vapour, was fallacious. In the
first place, the gases do not remain equally intermingled,
and the heavy chloroform vapour sinks, so that the first
portion inhaled possesses a lower tension than the last.
An apparatus I have seen used in France, invented by
Dudley Buxton on Chloroform in Ancesthesia 59
Dr. Dubois, and which was described in the press recently
by Dr. Waller, who showed it in London and at Hereford,
gives a 2 per cent, vapour, and produces anaesthesia.
Thus we see that experiment shows 2 per cent, of
chloroform vapour is safe, and clinical experience reveals
that it is effectual certainly in some cases.
Further, we may dismiss most of the methods sug-
gested, such as are inapplicable for general use on account
either of their inaccuracy or, in the case of Dubois' machine,
as being too cumbersome and costly.
The next question is — What are the requirements of
the surgeons of to-day, and how far can these require-
ments be met by low-tensioned chloroform vapours ?
All admit it is a very different matter to undertake the
conduct of the anaesthetic for the more serious operations
in vogue at the present time than it was in the case of
such surgical proceedings as were performed a generation
or so back. The anaesthetist is expected not only to
make and keep his patient unconscious, but he is asked to
insure muscular relaxation, and the abeyance of as many
of the reflexes as is consistent with his patient's ultimate
recovery. Indeed, in many instances, the inability of the
chloroformist to accomplish this must result in the failure
of the operation and jeopardise the patient's chances of
after-recoverj^
You ask, then, Can 2 per cent, of chloroform vapour
effect this ? And I am bound to say that, with Mr. Har-
court's inhaler I must answer, It will do so. But before
I tell you in a few words what I have done with it, I am
anxious to point out what will explain the apparent dis-
crepancy between myself and others with regard to " light "
and " deep " narcosis. In the teaching and in many of
the books of trustworthy men, you will find that they
emphatically caution against " light anaesthesia," and
point out the many reflex dangers liable to accrue if
their directions are unheeded. I am convinced, however,
that a common, if not general, misapprehension exists
6o The British Gynecological Society
with regard to so-called "light anaesthesia." It is this.
The patients who reveal these reflex troubles are not
anaesthetised at all. There are two conditions ; one is
incoinplde or irregular narcosis or anaesthesia, and the
other is light ancesthesia, and these are absolutely different
things. In practically all cases the patient must pass
definitel}' into the third degree of narcosis before the
anaesthesia is complete. Then, and not until then, if in
the view of the anaesthetist a light phase of anaesthesia
is best for the patient, and is sufficient for the require-
ments of the surgeon, the anaesthetist can, by lessening
the dosage of the anaesthetic, diminish the depth of the
narcosis without running any risk of reflex dangers. He
will, of course, have to expect the phenomena charac-
teristic of the particular phase of narcosis, but of none
other. The incomplete anaesthesia is the type one com-
monly hears of, and sometimes sees, in the hospitals
among learners. The patient is hurried often with a too
strong vapour of chloroform into a drugged state, the
mixture -of chloroform in the blood stream is irregular,
some tissues are over-dosed, others are under-dosed. The
operation is commenced and the patient moves or vomits,
then the anaesthetic is pushed, and disaster may, and
commonly does, occur.
Will you forgive me if I pursue this matter a little
further and compare the physiology of " incomplete "
with " light " narcosis ?
We have to deal with the vasomotor system, the lungs,
their nerve mechanism, the pulmonar}' circulation, the
heart, and the vagus control. To insure safety, all these
must work in harmony. What may occur, however,
and I am afraid often does occur, is that in this irregu-
lar anaesthetisation — first one strength then another — the
machinery is put out of gear.
The work of ]\lc\Mlliam has recently been extended
by Miss Sowton and Professor Sherrington, and we now
know by their research on the isolated mammalian heart
Dudley Buxton on Chloroform in Anccsthcsia 6i
that not only does the heart undergo acute dilatation
when chloroform perfuses the coronary vessels, but that
even i in loo.ooo in artificial circulating fluid produces a
weakening of both the auricular and ventricular beats by
30 per cent, and 49 per cent. When more concentrated
solutions were perfused the effects were even more marked,
and were ultimately destructive to the structure of the
muscle. But equally important researches in this con-
nection are those of Rudolph and Embley, who have in-
dependently worked out the part played by the vagus
control in chloroform narcosis. The first point is that the
vagal centre becomes unduly irritable under chloroform,
and the more so when the vapour is strong. In early
narcosis Embley, working with over 2 per cent, vapour,
repeatedly obtained complete and fatal vagal inhibition of
the heart. With lower dilutions the inhibitory action was
not fatal. The point I desire to emphasise is, that the
dilatation of the heart and the vagal inhibition are not
fatal when a lower tension of chloroform is uniformly
acting upon the tissues of the body, but are unavoidably
fatal when the uniform tension is high or an irregularly dis-
tributed amount of chloroform finds its way to vital points.
Then, as regards vasomotor action. All observers agree
that under chloroform the blood pressure falls. This fall
is proportional to the actual tension of the chloroform
and always makes for danger both by depriving the nerve
centres and heart of their necessary blood supply, and
by draining the blood generally from the arteries into
the veins, more particularly into the large abdominal
veins, felicitously called by Leonard Hill " the abdominal
pool." One sees in abdominal sections, especially under
chloroform, that as soon as the abdominal walls are opened
there is some shock, which steadily increases, and is most
marked in deep narcosis. This is easily explained. The
vessels are no longer protected by the parietes. and the
thin-walled vessels dilate and receive more blood. The
reverse is seen when the abdomen is closed. The shock
62 The British Gynaecological Society
lessens, the patient gradually rallies, because the h?emo-
dynamics of the abdomen have again resumed their normal
condition. Now, with a low percentage of chloroform,
these dangers are lessened or even annulled. To put it
in another way, if dangers arise when the chloroform in
the body is uniformly distributed and is of low tension,
remedial measures result in the safety of the patient ;
if the tension is high the patient dies. It would be worth
much discomfort to the operator to ensure this maintenance
of safety, but I think that my cases will show no discomfort
to the surgeon need arise when a low tension of chloroform
is employed.
With high-tensioned vapours, my past experience
goes to show that it is extremely difhcult to ensure a uni-
form distribution of chloroform, and it often happens
that a patient, seemingly narcotised, is in fact incompletely
aucTSthetised, and, even if he safely emerges from the
stage of induction, is in greater peril of reflex, shock,
respiratory failure and death. It must never be forgotten
that unlike other anaesthetics, chloroform is a protoplasm
poison, and that at a certain strength it not only paralyses
nerve and muscle, but absolutely kills them. This destruc-
tive power actually increases with the strength of chloro-
form which is carried through the tissues by the blood
stream.
Now if we admit that a 2 per cent, vapour of inhaled
chloroform, even taken for a prolonged period, is not
destructive to nerve and other tissues, that it does not
render the dilated heart unable to contract sufficiently to
maintain the circulation, that it does not involve risk of
fatal vagal inhibition, that it does not cause a dangerous
fall of blood pressure, we have at least got to know what
haven of safety we should seek. For the present we are,
I submit, warranted in believing that possibly as our
methods improve and our knowledge increases we may
recognise that 2 per cent, is too high a concentration.
I will not attempt here to suggest what 2 per cent, inhaled
Dudley Buxton on Chloroform in Anesthesia 63
chloroform represents in the residual air of the lungs or
in the blood or tissues. The data at present is wanting.
I propose rather to explain how, by means of Mr. Har-
court's simple apparatus, we can obtain this 2 per cent.,
and lessen it as the necessities of the case require. The
apparatus consists of a two-necked bottle, which is filled
with chloroform to near the top of the conical part, and
two coloured glass beads are dropped into the liquid to
Mr. Vernon Harcoukt's Inhaler— The index point is i per cent.
indicate when the temperature is within the range 13°
to 15° C. If the temperature of the chloroform is below
13°, both the coloured beads will float ; if it is above 15°
both will sink ; in the former case the proportion of chloro-
form inhaled will be less than the pointer of the stop-cock
indicates ; in the latter case it will be greater. During
inhalation the chloroform is cooled by evaporation ; its
temperature may be kept between 13° and 15° by now
^4 The British GyncBCological Society
and then holding the bottle in the hand till the red bead
has floated up and the blue bead is beginning to rise.
The stop-cock is so made that when the pointer is at
the end of the arc nearest the bottle of chloroform the
maximum quantity is being administered — namely, 2 per
cent. When the pointer is at the opposite end only air
will be inhaled ; and when it is midway dilution of the
2 per cent, mixture with an equal volume of air will make
the proportion i per cent. The shorter lines on either
side indicate intermediate quantities, namely, o-8, o-6, 0'4,
0-2, and towards the chloroform bottle, i-2, 1-4, i-6, i-8.
The valves on the two branches prevent the entrance
into the apparatus of expired air, and also serve to show
whether the stop-cock is working rightly. Only one valve
opens when the pointer is at either end of the scale, both
equally when the pointer is midway, and for all other
positions one valve opens more and the other less, in the
degree indicated by the position of the pointer on the scale.
The movement of the valves shows also how full and
regular the breathing is.
It is generally found that beginning with the pointer
at 0-2, and moving it on towards the chloroform bottle
at the rate of one division about every half- minute up
to 1-6 or 1-8, produces narcosis as quickly as is desirable.
For the maintenance of narcosis it is believed that
I per cent, or even less will be found sufficient. The stop-
cock can be moved by a touch of the finger so as at once
to increase or diminish the dose.
The face-piece, which is provided with an expiratory
valve, and can be fixed in any position, is either attached
directly to the inhaler, which in this case is held in the
hand, and should be kept as nearly vertical and as steady
as possible, or can be connected by about twenty inches of
half-inch rubber tubing, the inhaler in this case being sup-
ported on a stand or hung on to the back of the bed.
The mask is made of solid toughened rubber, fitted
with a rubber air-cushion. It can be washed or boiled, and
Dudley Buxton on Chloroform in AncBsthesia 65
as it becomes plastic in hot water the shape can easily be
modified, if required, so as better to fit the patient's face.
Now any apparatus must differ in the hands of various
men, for, happily, none can even invent " a penny-in-
the-slot chloroform machine." There must be the con-
trolling mind behind the mechanism ; in the first place
the hand must acquire the dexterity necessary to get
the full use of the contrivance, and, secondly, as the user
has the power of altering the strength of \'apour his know-
ledge must guide him in selecting the requisite strength
of vapour for each patient.
It would be tedious to read lists of cases to you, so I
will only mention a few, and in passing say I have now
used this inhaler for some hundreds of cases, including the
graver abdominal operations involved in partial resection
of the stomach, pylorectomies, enterectomies, gastro-
enterostomies, hysterectomies, colectomies, appendicoto-
mies ; with cholecystectomies, and other very complex
operations involving the liver and intestines. I must
add to my list removal of cerebral growths, Hartley-
Krause's resection of the Gasserian ganglion, the dissection
of the nerves in the suboccipital triangle for torticollis,
and a number of other operations more severe to perform
in some cases than their mere names might indicate. In
most of these, although employing a 2 per cent, for induc-
tion, I have worked with a i per cent., or in some cases,
a -5 per cent, vapour. Now I think these operations
require two things from the anaesthetic ; they call for
a complete and absolute narcosis, and a freedom from
reflex movements. These cases tax the skill of the sur-
geon, and induce him to look for and demand from his
chloroformist that such desiderata are given him, and
when I say that in only one case have I supplemented
the Harcourt inhaler, and then only for a minute at a
critical moment in a gall-bladder case, when there was
some rigidity, I think I may say that I have some reason
to believe that the narcosis offered was satisfactory from
VOL. XX. — NO. TJ. 5
66 The British Gyn<2Cological Society
the point of view of the surgeon. In none of these cases
have I been caused any alarm by conditions arising from
the anaesthetic.
But there are other cases in which the operation is
not so much to be dreaded as the actual condition of the
patient. Into this category come bad empyemas and
liver abscesses, communicating with a bronchus, exten-
sive goitres with tachycardia, and fat, feeble people with
an addiction to alcohol.
I have used the inhaler now for several goitres and
several empyemas, and with these have found the greatest
comfort from being able to diminish my percentage of
chloroform. You may say that a skilled man with a
Skinner's mask and a drop bottle can do this. Possibly,
but how many can ? And if you try even your skilled
men and test them by accurate methods I venture to say
that their percentages will be wildly wide of the wished-
for amount.
I wish, if I may, to mention a few cases.
A lady of extreme obesity, over 60, puffy, had cancer
of the body of the uterus, and as abdominal section through
many inches of fat was thought impossible, it was decided
to perform a vaginal hysterectomy. Her condition was
so unsuitable for any anaesthetic that I had to warn the
friends that her life was in danger. As a matter of fact,
she not only gave me no trouble, she was not sick, had
no headache, and told me subsequently she had no idea
that she had taken an anaesthetic.
A lady of over 40, a chronic asthmatic, with grave
aortic lesions, kidney trouble, and bronchial catarrh, was
another case so bad that I was seriously anxious about her.
The result of the chloroformisation was absolutely perfect.
There was no trouble during the narcosis or afterwards.
But an even worse case was that of a gentleman whom
I was asked to see to determine whether he could take
an anaesthetic. 1 am allowed to mention this case by
the courtesy of one of the Fellows of the Society. The
Dudley Buxton on Chloroform in Ancssthesia 67
patient, aged 60, about 5 feet high, and weighing over
17 stone, had rolls of fat all over him. He suffered from
bronchitis and emphysema, with a feeble fatty heart with
dilated aortic and mitral orifices, and albuminuria. I
expressed the opinion that unless the operation were
imperative with a view to saving life he ought to be spared
what I regarded as a grave risk, especially as previously
he had taken an anaesthetic with, I was told, extreme
difficulty, and was placed in some danger. However,
as the operation had to be done, I used the Harcourt
inhaler, and had no difficulty in maintaining anaesthesia,
after obtaining full narcosis, by a i per cent, vapour.
Another class of cases is that of intestinal obstruction
with vomiting. With some grave cases of this sort I have
used the inhaler successfully because I was able to limit
my doses so accurately. In the same way patients with
a cerebellar tumour, since there is commonly pressure
in the region of the medullary centres, are among the
most dangerous with which chloroformists have to deal.
When we employ a low percentage vapour these dangers
are lessened, and with Mr. Harcourt's inhaler I have satis-
factorily dealt with several of these cases.
The dangers met with in using this inhaler have been
in no case serious. I have never had to employ arti-
ficial respiration or tongue traction, or indeed, any heroic
treatment whatever. As to after-effects, vomiting has
often been absent, and I believe generally less severe than
when other methods are adopted. In many instances,
delayed vomiting foUows chloroform in cases where mor-
phine has been given, and it is, I believe, often the
combination of these two drugs which occasions this
troublesome symptom.
In conclusion, I would say that the gist of this com-
munication is to be found in the statement that a vapour
of chloroform not exceeding 2 per cent, is quite adequate
for surgical anaesthesia, and its use avoids most of the
grave dangers of this anaesthetic ; that such a percentage
68 The British Gyncecological Society
can be obtained by the proper use of Mr. Harcourt's
inhaler, and this, with experience, will be found sufficient
for all requirements. Like all apparatus, its technique
must be mastered, and it must be used with intelligence
and a knowledge of the powers and limitations of chloro-
form in order that the most satisfactory results may be
obtained.
The President said that before declaring the discus-
sion upon the extremely interesting paper, for which they
were indebted to Dr. Dudley Buxton, open, he desired
to welcome, in the name of the Society, the several dis-
tinguished visitors present, especially Mr. A. Vernon
Harcourt, F.R.S.
Mr. Mayo Robson said that when he first came to
London it was seldom that he would have any other anaes-
thetic administered but ether, but having such a very
competent anaesthetist as Dr. Buxton, he felt that he
might place implicit reliance upon his judgment, and Dr.
Buxton had given chloroform for him with the Vernon
Harcourt inhaler in a large number of serious cases, in
some of which practically the whole of the danger depended
on the anaesthesia. In no single instance had there been
the slightest difficulty, and he could bear out every word
Dr. Buxton had said with regard to the use of the apparatus,
which, so far as he could see, would, by giving the operator
complete control of the dose administered, completely revo-
lutionise the administration of chloroform.
Dr. Inglis Parsons remarked that in the adminis-
tration of chloroform there were many points that were
surprising. A well-known Fellow of the Society, in the
habit of giving the anaesthetic for their Honorary Presi-
dent, employed an enormous inhaler, containing a sponge,
upon which he used to pour one or two drachms of chloro-
form, and then putting it over the patient's face, entirely
exclude the air for a time. When asked to adopt this
method himself, he (Dr. Parsons) had decidedly refused,
though the Fellow referred to had never had an accident
Discussion on Chloroform in Ancsstkesia 69
from it. On one occasion, when he was a dresser, the
lioiise surgeon was using Junker's apparatus upon a patient
whose tongue was to be removed for epitheUoma ; un-
fortunately the tube which should have been in connection
with the air space was inserted in the fluid, and a con-
siderable amount of chloroform was pumped down the
man's throat. He (Dr. Parsons) took the opportunity
of observing whether the respiration or the heart's action
was first arrested, and by keeping his finger on the temple
found that the pulse continued after the respiration had
immediately stopped. That was perhaps a unique case,
but there was no doubt that in it the respiratory centre
was first affected.
Dr. Macnaughton-Jones said that he had had the
advantage of having chloroform administered for him by
Dr. Buxton with the Vernon Harcourt inhaler on several
occasions, mostly for abdominal sections, and once for
a deep operation on the posterior triangle of the neck,
and in his experience the apparatus was altogether satis-
factory. The time taken to induce the requisite amount
of narcosis had not been greater than with the Junker
inhaler, and in no case had the full 2 per cent, vapour
been required to maintain unconsciousness ; moreover,
the post-operative condition of the patients had been,
on the whole, more satisfactory than with any other
chloroform inhaler with which he was acquainted. The
success of an operation depended greatly on the judgment
and self-reliance of the administrator, and they were
therefore much indebted to Dr. Buxton for his paper,
and to the other anaesthetists for their presence at its
discussion.
Dr. Aarons said that so far as he could judge, the
Vernon Harcourt inhaler answered its purpose perfectly,
but whatever form of apparatus was employed, the suc-
cessful administration of an anaesthetic was a question
of brains.
Dr. Bakewell said that the present form of the instru-
70 The British Gyiicecological Society
ment was an improvement on an older one, with which
he had had some difficulty on account of the buckling of
the valves. He had, however, used the improved instru-
ment with great success in a large number of cases, and
was sure that the after-effects of the chloroform were
less when this inhaler was employed. It was splendid
for children, and he had used it many times at Great
Ormond Street, but as children disliked anything in the
form of a mask over their faces he found it better to begin
with a few drops of chloroform on lint. It was a great
advantage that, with a little manoeuvring, the apparatus
could be satisfactorily adjusted for laminectomies, in
spite of the difficult position in which the patient had to
be placed. The importance of knowing the exact amount
of chloroform being administered at every time during
the anaesthesia certainly made the use of this inhaler
desirable.
Mr. A. Vernon Harcourt (a \dsitor) explained that
originally the valves were of celluloid, which gave a beau-
tiful flat and very elastic surface, but, unfortunately,
the vapour of chloroform acted upon it, and caused a
deformation which no doubt was the cause of the failure
mentioned by Dr. Bakewell. He afterw^ards had the valves
made of metal, so light as to be quite easily moved ; it
was also an advantage that the action of the metal valves
was more easily inspected than that of the more trans-
parent celluloid. He thought that for childbirth or pro-
longed operations it might perhaps be well to have some
sort of a stand to hold the instrument upright so that
there would be no splashing of the contents ; a tube
twenty inches or so could be used to connect it with the
mouth- and nose-piece, and the administrator would be
spared fatigue in prolonged cases. On this point he would
be glad to have Dr. Buxton's opinion. He had been
gratified by hearing those gentlemen who had spoken
of their successes in using the apparatus.
Dr. Dudley Buxton, in reply, said that in regard
Discussion on Chloroform in Ancesikesia 71
to the case of chloroform poisoning when the Junker
apparatus was employed, it was quite possible that the
overwhelming amount of chloroform swallowed had pro-
duced conditions which had led to the respiration ceasing
before the circulation ; no doubt by vagal reflex inhibi-
tion. He was in the habit of taking from six to ten
minutes to induce chloroform anaesthesia, and he might
say that if an anaesthetist knew how to give chloroform by
Junker's inhaler he could always get a patient under it.
A propos of " failure " of methods, he mentioned a case in
which an attempt was made to give ether by pouring it
on to a towel, which was held over the patient's face ;
the patient naturally got excited, and the administrator
said, " This gentleman cannot take ether, I will give him
chloroform." The failure was, of course, the result of a
faulty method. He insisted on the importance of surgeon
and anaesthetist being in perfect accord with each other.
He thought the stand and tubing suggested by Mr. Vernon
Harcourt might be advantageously adopted in some cases,
but as a matter of fact, the fatigue of holding the instru-
ment when one was accustomed to it was not great, even
in a long operation.
72 The British Gynccco logical Society
BRITISH GYN.ECOLOGICAL SOCIETY.
Thursday, April 14, 1904.
Professor JOHxV W. TAYLOR, M.D., F.R.C.S., President,
IN THE Chair.
Specimens and Cases.
]\Ir. J. FuRNEAUX Jordan read notes of the following
cases, exhibiting the specimens : —
(i) Hydrometra.
Mrs. K., aged 63, was first seen by me on August 23
of last year, in consultation with Dr. Ware, of Kings
Heath. Her history was that she had been married forty-
three years, had liad live children — youngest aged 28 —
and had alwaj^s enjoyed good health until she was 50,
when a large tumour developed in the abdomen. She was
admitted into the Birmingham Hospital for Women by
Dr. Savage, and had a large ovarian cyst removed. Five
and a half years ago a second tumour formed ; she was
operated upon in Dr. Savage's pri\'ate hospital. She was
told that she had a cystic tumour of the womb and that
an abscess had been opened. The tumour was not removed,
but has been growing slowly ever since. For the last two
or three weeks the tumour had been excessively painful
and tender, and a localised swelling had formed at the
seat of the old scar. This was the history I got when I
saw her, and I found a thin, almost emaciated little woman
lying on her back, knees fully drawn up, and abdomen
enormously distended. Below the umbilicus there was
a tense, red, cedematous swelling, obviously an abscess
nearly about to burst. The abdominal swelling — larger
Furneaux Jordan on Hydrometra
than a full-sized pregnancy — was very tense and tender,
and a distinct thrill could be detected all over it. On
internal examination the large cystic swelling was found
to bulge down into the pelvis. The cervix of the uterus
could not be felt, nor could I make out any distinction
between the tumour and any uterus. Her general con-
dition was bad — temperature over 102°, quick pulse, thick,
dry fur on the tongue, and constipation.
I admitted her to the Women's Hospital on August 25,
and when I saw her the next day found that the abscess
in the old scar had burst, whereby she was much relieved,
and through the small opening (formed by its bursting)
a watery fluid containing cholesterin crystals exuded.
Her general condition was improved — bowels open, pulse
slower and regular, temperature normal. Urine acid, and
no albumin. Through the courtesy of Dr. Smallwood
vSavage I was able to see his father's notes on the case.
These showed that she had had a pyometra, which had
been opened, and the opening into the uterus had been
sutured to the abdominal wound and the cavity drained.
I still could find no sign of any cervix, the vagina being
stretched underneath and behind the lower part of the
tumour. You, Mr. President, very kindly saw the patient
with me, and we decided that it was a hydrometra, and
that it should be removed.
On August 27 I operated, assisted by Dr. Smallwood
Savage. Even in the lithotomy position I failed to find
any trace of cervix. The bladder was small and pushed
away to the right side behind the pubes. I tapped the
cystic swelling through the anterior vaginal wall to ascer-
tain the nature of its contents, which proved to be a light
brown fluid with abundance of cholesterin crystals. I then
opened the abdomen, and after dividing some dense adhe-
sions of omentum and bowel to the upper part of the
tumour, found the tumour firmly adherent to the old place
of suture, and this necessitated the removal of that part
of the abdominal wall containing the old scar. The dis-
74 ^■^^ British Gynaecological Society
tension of this uterine tumour was so great that the upper
part of it appeared as bUiish, fibrous tissue, almost like
an ovarian cyst. I tapped it, and then was able to pull
the bulk of it through the incision. But the whole of the
lower part was embedded in dense fibrous adhesions,
which it took a long time to separate. I ligatured the
broad ligaments and the uterine arteries, and, just above
the level of the ureters, amputated the uterus. After
establishing a gauze drain from the remains of the cavity
into the vagina, I sutured the edges of the cut uterus with
fine silk. The part remaining was about the size of a
smallish virgin uterus. The left ureter was dilated to
the size of one's finger, the right one appeared normal.
She stood the operation remarkably well, and the next
day, when I saw her, the temperature was 99°, pulse 100 ;
the bowels had acted, there was no sickness, and she felt
very well. This good progress was maintained until the
fifth day, when she complained of feeling very weak and
unable to sleep. She had had very little sleep the night
before. On the sixth day she passed less urine than before,
and on examining it I found albumin and a small quantity
of pus. The condition of the urine did not improve in
spite of treatment and washing out of the bladder ; in
fact, the quantity of pus increased. She gradually got
weaker and weaker, and on the eleventh day became
semi-comatose. She continued in this condition until the
fourteenth day, and then died. Temperature only once
rose to 100°, and never above it.
Post mortem. — No peritonitis. On the left side, the
stump of the appendages shows a stitch abscess contain-
ing 15 minims of pus. The remnant of the uterus closely
adherent to bladder, the ca\-ity very wide, substance of
walls thickened and fibrous. Kidneys unequal in size,
left one two-thirds of the normal size, the right one nearly
double the normal size, both greatly diseased, with adherent
capsules, rough surfaces showing many cysts, some of
which are suppurating, dilated calices lined with a thick
Furneaux Jordan on Double Hydrosalpinx 75
pyogenic membrane and containing urine and pus, and in
the left kidney numerous small concretions. The renal
tissue shows evident degeneration, but little fibrosis.
Bladder, chronic cystitis. Cause of death, renal disease,
result of long-continued suppuration previous to operation.
(2) Double Hydrosalpinx.
Mrs. P., aged 39, married fifteen years, two children —
youngest aged 13. For ten years has suffered from
attacks of pain in the abdomen, and has been told several
times that she has inflammation of the bowels. Menstrua-
tion for the last two years too often and loses far too much .
Acute pain causing her to lie up on the third day of the
period. On examination, a distinct, freely movable tumour
is to be felt in the lower left part of the abdomen. No
connection with the uterus and entirely above the pelvis.
Pain on pressure in the right fornix of the vagina. I
thought it was an ovarian tumour with a long pedicle.
On March 10 last I operated and removed a hydro-
salpinx from each side ; this larger one, from the left
side, was lying above the level of the uterine fundus and
had no adhesions. The small right one was adherent to
the back of the right broad ligament. She made an unin-
terrupted recover}^ and went home on March 28.
The President said that Mr. Jordan's case of hydro-
metra following pyometra (apart from its operative interest)
was of some value as bearing on the analagous diseases of
pyosalpinx and hydrosalpinx. Hydrosalpinx was a condi-
tion very difficult to explain, and he thought it might
sometimes be accounted for by the very virulence of the
gonorrhoeal or other endometritis starting the disease. It
was possible that this might cause early and complete
occlusion of the uterine end of the tube while the disease
was limited to the uterus and before the tube had been
invaded by micro-organisms. If so, it was quite con-
ceivable that the inflammation, which was purulent in
the uterus, might be only represented by a sterile watery
76 The British Gy^icecological Society
exudation in the tube. The interesting cases brought
forward by Mr. Jordan seemed rather to bear out the old
idea that hydrosalpinx might be simply a later stage of
pyosalpinx. It should be noticed, however, that in the
hydrometra the fluid contained cholesterine ; in hydro-
salpinx the fluid was generally limpid. The President
then alluded to the presence of several distinguished
visitors, including the President of the Obstetrical Society,
Dr. Prochownic, of Hamburg, and Dr. Fellner, of Franz-
enbad, and welcomed them in the name of the Society.
Dr. Frederick Edge exhibited three specimens and
read the following notes : —
(i) Myoma of the Right Broad Ligament Successfully
Enucleated by Abdominal Section.
The patient is a multipara, aged 43, well nourished
and generally healthy, except that she is anaemic and care-
worn ; last child, aged 12.
She has suffered from painful and profuse menstrua-
tion, which has become worse and worse. There was
pressure on the bladder and consequent frequent micturi-
tion with tenesmus. On examination there was found, per
vaginam. a round, cystic swelling of the anterior vaginal
wall about the size of a walnut. This w^as diagnosed as
a retention cyst. The uterus was found to be enlarged
irregularly, chiefly to the right, and a sound passed four
and a half inches, which was about half the distance it
would have entered had the uterus been continued to
full extent of the tumour. Therefore, it was considered
that the myomatous mass was chiefly subperitoneal, but
it was not diagnosed as intraligamentary. As the tumour
was growing, the bleeding increasing, and the pressure
symptoms causing great suffering, especially from the
bladder, I advised operation.
On opening the abdomen, the parietal peritoneum was
found to have been carried up the front wall, and this
for a moment obscured matters. However, by noticing
Edge on Displaced Spleen jy
the size of the uterine fundus it was evident at once that
the myoma was intrahgamentary. I shelled it out, but
found that it had a very intimate union with the right
anterior lower uterine wall, where its vessels entered.
There was severe bleeding when I divided this, but only
one or two arteries spouted, and were tied. The venous
bleeding was controlled by sutures drawing together the
uterine tissue. The cavity in the broad ligament shrank
a good deal, and its peritoneal coat was sutured to the
parietal peritoneum at the lower angle of the wound.
The rest of the operation was finished as usual. The
retention cyst in the vagina was emptied. The patient
recovered uninterruptedly and without any reaction.
I have removed several broad ligament m3^omata,
where no connection with the uterus was present, but
it is a question whether the majority of broad ligament
myomata are not originally pedunculated uterine growths.
(2) Calculus of the Bladder Formed on Silk Sutures
Used in Pekporming Hysterectomy.
This calculus was removed by vaginal lithotomy three
years after panhysterectomy of a myomatous uterus.
It was encysted and not easy to sound. Dilatation
of the urethra and traction with forceps failed to remove
it. I therefore incised the base of the bladder pervagincm,
and removed it with the linger. The vaginal incision was
not sutured, but the bladder was drained. The wound
healed within the week, and there was no leakage. I have
treated several cases in this way, and consider that where
there has been considerable alteration of the parts by
contraction of cicatrices, it is best not to suture, especiallv
if the bladder is septic or in a doubtful condition.
(3) A Displaced Spleen Simulating a Broad Ligament
Cyst Successfully Removed by Abdominal Section.
The patient, a school teacher, aged 24, and unmarried,
in August suffered from peritonitis and was sent to Bir-
mingham b}^ Dr. Wilson, of Barnsley. To me she com-
78 The British GyncECO logical Society
plained of parox^^smal pain in the abdomen. She had had
amenorrhoea for three months, and before that time scanty
menstruation ; she was costive, but had no swelling of
the feet, and her general organs were normal. A rounded
tumour was to be felt on the right side of her small uterus ;
the hymen was intact. Fer rectum the tumour was diag-
nosed as a cyst of the broad ligament.
After abdominal section and the separation of adhe-
sions I enucleated a reniform tumour from between the
broad ligament and omentum. Owing to twisting of the
pedicle, the mass was black with extrava sated blood, and
as it seemed doubtful of vitality if left, it was therefore
removed. There was, however, some question as to how
to treat the pedicle, as from its shape the tumour appeared
to be a kidney. On cutting into it, the mass proved to
be a spleen, and the pedicle was therefore ligatured and
dropped.
The blood, examined after the operation, showed some
deficiency in the red cells (4,000,000), a slight increase in
the leucocytes, and a good many polynuclear cells. A
week later the blood was normal. The patient did per-
fectly well, and has returned to her work.
Dr. Heywood Smith remarked that it was but rarely
that the spleen became a pelvic tumour. Some years ago
a case sent to him as an ovarian growth turned out on
examination to be splenic. Mr. Bland Sutton operated
and found it behind the uterus on the left side.
Dr. Bedford Fenwick, referring to the first specimen
shown by Dr. Edge, said that myomata of the broad liga-
ment were always muscular or fibroid growths, and different
in structure from the tissue of the broad ligament ; in
such cases — and he had operated on several within the
last few months — he had invariably been able to trace
some connection with the uterus. In one case, quite
recently, a calcareous fibroma, attached to the omentum,
had a fine pedicle projecting downwards which had evidently
at some time been connected with the uterus and after-
Jesseit on Bilateral Ova7'ian Dermoids 79
wards become detached. It was, of course, not unusual to
find calcareous degeneration in a fibroid with a very slender
pedicle. He thought the spleen shown most interesting ;
the entire removal of the spleen was sufficiently rare to
make the blood condition of the patient, when some
months had elapsed, an important point, and he hoped
that Dr. Edge would report upon it.
Dr. Macnaughton-Jones maintained that myomata
of the broad ligament were sometimes quite independent
of the uterus. In regard to what the President had said
about hydrosalpinx being a sequence of pyosalpinx, Dr.
Charles Hanley had recently published a very able paper
which showed that hydrosalpinx might be quite independent
of any pyogenic invasion whatever.
Dr. Edge, in repl}', said that he should not think of
removing a displaced spleen if there was no torsion, but
would replace and fix in with a few sutures. Many cases
had been successfully treated in that way. In myomata
of the broad ligament, in the majority of cases, there was,
in his experience, a certain connection with the uterus
which led him to think that they had their origin in that
organ. They sometimes became detached, but it was a
mistake to suppose that there was no tissue in the broad
ligament itself of the kind from which a fibroma might
arise. Every opportunity would be taken to ascertain the
condition of the blood in the patient, who had gone back
to Warwickshire without her .spleen.
Mr. F. BowREMAN Jessett read notes of the following
cases : —
Bilateral Dermoid Ovarian Cysts with Treble Twist,
AND Strangulation of the Left Pedicle.
I am indebted to Dr. Balgarnie, who kindly called me
in to see the patient with him, for the note of this case
until the date of our consultation.
B. B., aged 21, had always enjoyed good health. Cata-
menia regular and without pain. One child bom, May,
1903.
8o The British Gyncsco logical Society
In November, 1903, she had a sudden attack of pain
referred to the left hip, causing faintness and sickness ;
she was in bed for four days, but saw no doctor. About
noon on February 24, 1904, just at the termination of an
uneventful period, she again had severe pain referred to
the left hip, accompanied by faintness and sickness. Dr.
Balgarnie was called in to see her in the evening of the
25th. She was then in bed and complained of '" sciatica."
She had a rapid pulse, 120. Temperature normal. On
examination of the abdomen a tumour was noticed in the
lower abdomen, slightly tender. ]Morphia was given by
the mouth, but was rejected at once. Fomentation and
a second dose of morphia gave relief. On February 26
her condition was much the same — pain, very severe, was
relieved by hypodermic injection of morphia. On the
27th, unknown to Dr. Balgarnie, she was led into another
room ; by the e\-ening her symptom.s were much more
severe, with a rising pulse, temperature 101°, increased
sickness, tenderness much more marked over tumour, which
until now had been more or less defined. Its outline was
obscured by obvious peritonitis ; subsequently the symp-
toms gradually abated. On February 29 I saw the patient
with Dr. Balgarnie. She had a rather anxious expression,
and some tenderness over the lower abdomen. The abdo-
minal muscles were tense and it was with difficulty that
anything like a defined tumour could be felt. Fer vaginam
there was distinct fulness in the left fornix, tender on
pressure, and somewhat tense. Bimanually this fulness
was distinctly connected with that of the lower part of
abdomen. On tlie right side the right ovary was prolapsed,
distinctly cystic, and about the size of a Tangerine orange.
The uterus was somewhat fixed and tender. The diagnosis
was rather obscure, but I arrived at the conclusion that
we had to deal with a ruptured tubal gestation, or an
ovarian tumour with a twisted pedicle.
I advised early operation ; as, however, the symptoms
had abated and the patient was in every way better than
yessett on Bilateral Ovarian Der^noids 8i
she had been, and it was necessary to remove her to the
Cottage Hospital, because no convenience existed at lier
own home, we decided to wait and continue the treatment
she had been having.
On March 7 she was removed to the Cottage Hospital,
and on the 12th T operated, with the assistance of Dr. Bal-
garnie. Dr. Adams administering the anccsthetic.
On opening the abdomen in the middle line by an inci-
sion about three inches in length, between the pubes and
umbilicus, I found the omentum adherent to the parietes
by recent adhesions ; on carefully separating these the
omentum was found to be adherent to the tumour. Tliis
was carefully detached. On endeavouring to pass my hand
around the tumour I found it wedged into the pelvis and
^ery adherent to the parietal walls in front and the intes-
tines above and behind. These adhesions were separated
by sweeping the hand carefully round the tumour, which
extended quite down into the pouch of Douglas. I next
extended my parietal incision upwards as high as the
umbilicus, and by passing my hand into the pouch of
Douglas, lifted the tumour bodily out, not, however, without
tlie rupture of a small cyst on its posterior surface. The
pedicle was then seen to have three distinct twists and
^^as quite black, and very shortly would have become
gangrenous. I transfixed the pedicle and tied it in the
usual manner.
T next examined the uterus, which was normal, and
drew up the right ovary, which was, as I had discovered,
cystic and enlarged. I removed this. The patient, with
the exception of a stitch abscess, made an uneventful
recovery.
On cutting into the larger tumour it was found to be
a dermoid, and on bisecting the smaller right cystic ovary
a distinct dermoid cyst is seen in the centre.
I have ventured to bring the case forward as ovarian
dermoids are sufficiently rare to make them of interest.
Thus Olshausen has collected a series of 2,275 ovariotomies
VOL. XX. — NO. 77. 6
82 The British Gyncscological Society
performed by various operators, and among them there
are only eighty cases of dermoid cysts (3-5 per cent.),
and to find both ovaries so affected is still more rare. The
case is also remarkable on account of the treble twist of
pedicle. In my experience the pedicles of dermoid or
solid tumours are much more liable to become twisted
than those of ordinary cysts of the ovary. The diagnosis
was also somewhat uncertain, as although the sudden pain
experienced pointed to ovarian tumour with a twisted
pedicle, yet the fact that per vaginam a distinct fulness
was felt in the left fornix rather suggested the possibility
of a tubal pregnancy.
Case of Large Fibroid Springing from the Anterior
Surface of the Cervix Uteri, Pushing up the
Bladder and Peritoneum to Within an Inch of
the Umbilicus.
Mrs. D., aged 48, married, no family, was sent to me
by Dr. Case, of Fareham, suffering from an abdominal
tumour. About five years ago she first noticed pain in
the lower abdomen, for which she consulted Dr. Case ;
there was then no tumour to be felt. A year later she
suffered from menorrhagia, with pain in the back and right
side, which continued with greater or less severity until
about a year ago, when, notwithstanding treatment, it
increased considerably, and the tumour, which had been
noticed for some time, began to enlarge. When she con-
sulted me on March 3, I found a tumour in the lower
abdomen, extending as high as the umbilicus and ver\'-
slightly mobile. Bimanually, I found it extended to within
two inches of the outlet of the vagina, and the os uteri could
not be clearly defined, but was pushed backwards by the
growth. The whole tumour seemed to be somewhat fixed.
The patient suftered from rather frequent desire to mic-
turate, menorrhagia and pain. She was blanched, and
moved about with decided discomfort. I advised opera-
tion, and on March 13, with the assistance of Mr. Hugh
yessett on Cervical Myoma
Case, I operated, Dr. Hanson giving the anaesthetic, Dr.
George Case being present.
On making the usual incision in the middle line between
the pubes and umbilicus and dividing the parietes, I failed
to lind the peritoneum, but came down upon what was
apparentl}^ the bladder, and had to extend my incision
upwards to the umbilicus before I could get into the
peritoneal cavity. On passing my hand downwards into
Douglas's pouch behind the tumour, and endeavouring to
lift it out, I found it was firmly bound down. I then
separated the bladder from the tumour and introduced
Doyen's myoma screw, and by firm traction upon the
tumour and digging around it with my disengaged hand,
I succeeded with difficulty in drawing it out of the pelvis.
Having ligatured the arteries on that side, I enucleated
the tumour from the fibres of the uterus. The body of
the uterus, of normal size, was then seen to be in the
abdominal cavity covered by its peritoneum. As there
was very considerable oozing from the surface of the uterus
from where I had peeled the tumour I thought it advisable
to remove it. There was a considerable cavity left from
where the tumour had been extracted ; this I laced over
b}^ several strands of catgut in the manner described by
Dr. W. Duncan at our last meeting. By this means the
cavity was closed and much of the oozing stayed. I,
however, introduced a gauze drainage into the lower angle
of the wound, and having carefully closed the divided
peritoneum in the abdominal cavity I closed the parietal
wound by means of three layers of ten-day gut sutures.
The patient made a good, although rather slow, convales-
cence.
Remarks. ^This tumour evidently sprang from the
anterior surface of the cervix uteri and extended laterally
to the right, splitting up the right broad ligament. It
thus extended forward and upwards, carrying the bladder
and the peritoneum before it. The notable points about
the operation were, first, the bladder, being directly under
^4 The British Gyncecological Society
the parietal wound and stretched over the tumour, was
in great danger of being wounded ; and, secondly, the
difficulty of extracting the tumour was very great, and
had I not had the myoma screw would have been very
much more so.
In reply to a question from Dr. Edge, Mr. Jessett
said that the bladder had not been injured in any way.
A Suggestion fok the Treatment of Puerperal
Convulsions by Spinal Subarachnoid Puncture,
WITH. Notes of a Case so Treated. By T.
Arthur Helme, M.D., M.R.C.P.(Lond.), F.R.S.E.,
Hon. Surgeon for Women to the Northern Hospital
for Women and Children, Manchester.
Our knowledge of the etiology and pathology of
■eclampsia of pregnancy and the puerperium is so unsatis-
factory as to afford no rational basis for treatment. In
the present state of affairs we must turn to clinical study
and to the results of personal experience for guidance.
No apology is needed, I think, for venturing to suggest
any means of treatment which offers the possibility of
relief in this distressing condition.
Whether of mechanical or chemical origin, it is now
agreed that the phenomena of eclampsia are largely depen-
dent upon the presence of toxic material in the blood,
discussion still going on as to whether this accumulation
is the result of deficient elimination, imperfect metabolism,
or increased production, or of the introduction of some
new toxin foreign to the non-pregnant state. The nature
of the toxin is still unknown, nor is there more certainty
as to the way in which it produces the eclamptic state.
In the matter of treatment it is agreed that there are
three chief indications : (i) To prevent the accumulation
and assist the elimination or destruction of the poison ;
(2) to deal with the pregnancy ; (3) to control the con-
vulsions ; and upon each of these there exists a diversity
of opinion as bewildering as in the question of causation.
Helme on Eclaiiipsia 85
The first is scientifically the important one, but at
present our methods are purely empirical. It is to the
last of these three principles that I wish especially to draw
attention, but I may say that my experience coincides
with what I believe to be the experience of others, viz..
those cases have in my hands done best where the preg-
nancy has come to an end, and the convulsions have been
controlled ; the worst cases have been those in which the
convulsions could not be controlled and where coma super-
vened ; and I have come to regard the extent to which the
nervous system is involved and the success with which
this can be controlled as the key to prognosis.
The questions of the management of the pregnancy
and of the toxaemia must be dealt with equally whether
we see the case before the occurrence of convulsions or
afterwards.
(i) In the pre-eclamptic stage {i.e., the stage in which
the albumen in the urine may be increasing while the
urea is diminishing in amount, and certain signs and symp-
toms are appearing, as e.g., headache, oedema, respirator}^
distress), the first indication is to combat the accumula-
tion of the toxin by dietetic and hygienic measures, atten-
tion to the excretions, and possibly the administration
of extract of thyroid gland, based on the theory that,
owing to thyroid deficiency, tissue metabolism is imperfect.
In many cases treatment on these lines succeeds and
pregnancy may run to term ; but the anxious cases are
those in which the deficiency of urea excretion and albu-
minuria persist and untoward symptoms intensify. In
these cases we have to face the important question of
interfering with the pregnancy. If, on the one hand,
it is the fact that there is deficient excretion or increased
production of effete material directly dependent upon the
pregnant state {i.e., upon the fact that the maternal organism
cannot meet the strain put upon her metabolic processes
by the life and growth of the foetus and their consequences),
and by appropriate means we are unable to restore the
86 The British Gynceco logical Society
balance, we must consider termination of the pregnancy
as an important and integral part of treatment ; or, if
the toxin is some special toxin generated in the gravid
womb from placental or foetal faultiness, or some toxin
formed in association with the dissolution of deported
placental cells, the same rule holds, though possibly we
must eventually rather look to serumtherapy or treatment
by antitoxin injections. If, on the other hand, it could
be shown that the fault lies in some distant organ of the
thyroid gland, and a remedy can be found by supplying
some deficient element of its secretion, a great point would
be gained, for interference with pregnancy would become
unnecessary.
If it should become necessary to terminate the preg-
nancy, the choice of method is of importance. Formerly
I have induced labour by the introduction of bougies and
also by the glycerine method of Pelzer ; but recently I
have employed the more rapid method of dilating by
Bossi's dilator.
The first and second principles of treatment are bound
up together and are of special importance in the preventive
treatment of eclampsia, but, once convulsions have set in,
the third principle becomes of instant and of first importance.
(2) Eclamptic stage. The first principle of treatment
remains in force ; it is necessary to get rid of the toxin,
and now more active measures must be taken — hot packs,
saline injections and rectal irrigation are of use.
With regard to the second principle — the management
of the pregnancy — there is great diversity of opinion.
Looking upon the continuance of pregnancy as a vital
factor in the production of the poison and the causation
of the disease, my own practice is to end the pregnancy
whether labour has commenced or not. Truly, the onset
and progress of labour by the unaided natural powers,
involving much unwonted muscular work and nervous
strain, must throw into the system an additional amount
of effete material, with which the excretory organs, if
Helme on Eclampsia 87
already damaged, may be unable efficiently to cope, or the
violent uterine contractions may conceivably give rise to
further escape of placental cells into the maternal blood-
stream, and so intensif}'^ the danger ; and it is on this
account that I personally am of opinion that the right
course is not to leave the matter in the hands of the
maternal powers, but to terminate the labour as expedi-
tiously and as safely as possible by artificial means.
Though much has been said (and possibly rightly said)
in favour of abdominal or vaginal Caesarean section, my
own practice is as follows : —
(i) Where labour has commenced and the os is dilating
I chloroform and deliver, if necessary completing dilata-
tion artificially by hand or instrument.
(2) Where labour has commenced and the os is not
dilating, or when labour has not commenced, I chloroform
and dilate by means of Bossi's dilator, and deliver ; formerly
I dilated manually or by hydrostatic bags, but now I
prefer Bossi's instrument which, I believe, if carefully
used, may be safely used. Possibly the fact that my
muscular development is not too great has preserved me
from inflicting those serious injuries which apparently have
been met with in its use. If dilatation be performed slowly
and the cervix carefully watched, there should be little
danger.
But, as I said before, when once convulsions have
occurred, whether before, during, or after labour, the
third principle becomes of instant importance. It is now
essential to control the convulsions, and this is the special
point to which I desire to call attention.
The Convulsions. — How are the convulsions caused ?
Several suggestions have been offered : —
(i) That they are produced by direct action of the
toxin upon the nerve cells.
(2) By cerebral anemia, the result of constriction of
arterioles.
(3) By cerebral oedema, the result of increased arterial
tension.
SS The British Gynceco logical Society
(4) By coagulation and capillary thrombosis.
A suggestion which I now advance is tliat the eclampsia
is due to increased cerebrospinal tension.
If we look at the clinical aspect of a case we see at
once that this suggests intracranial pressure. The pre-
monitory signs of headache, dizziness, irritability and
sudden blindness, the clonic, tonic and tetanic spasm,
the stupor and coma, all are consistent with the existence
of increased intracranial pressure. Whether this be the
cause or not, the continuance of the violent convulsions
will increase the pressure by causing congestion of the
cerebral vessels and, if continued, serous effusion and even
haemorrhages may occur.
We have only to think of the picture of the eclamptic
woman to see how grave must be the congestion resulting
from each attack. If this intracranial pressure be present
and if it be allowed to continue unrelieved or to increase,
it will in ail probability lead to death. If the convulsions
continue unrelieved, small or large hcemorrhages or other
vascular disturbances may occur, and, once this state is
reached, the patient will almost inevitably die — these are
the cases that end in death, whatever treatment be adopted,
and m}^ experience has led me to the conclusion that the
tendency to death is proportionate to the extent to which
the nervous system is involved.
Whilst, therefore, dealing with the questions of the
toxaemia and the frequencj^ it is essential to control the fits.
What means have we ? Up to the present time we have
been dependent chiefly upon drugs. It has lately been
suggested that saline injections may be of use by washing
out minute capillary thrombi — an unsatisfactory theor\-.
Venesection, too, has been thought to influence the fits
by reducing arterial tension ; but it is chiefly upon drugs
that we depend. I must confess to employing drugs,
especially morphia, with a feeling of anxious doubt. We
have yet no rational basis for their use ; we are acting
altogether in the dark and are introducing into the body.
Helme on Eclampsia 89
once and for all, substances, which, whilst they may do
good, offer for all we know an equal chance of doing-
harm.
Most of these drugs are cardiac depressants, and their
actions require to be carefully watched. Morphia, if given
in sufficiently large amount, whilst certainly paralysing
the nerve centres, with equal certainty interferes with and
checks metabolism and arrests the excretions ; the inter-
ference with the latter being the antithesis of what we
want. To illustrate the difficulty of the present position
it is only necessary to refer to the fact that whilst one
school recommends morphia to control the fits and inhibit
metabolism, another would exhibit thyroid extract because
it enhances tissue change.
If it could be shown, on the one hand, that the toxccmia
is not due to the accumulation of effete materials usualh"
present in the body, which are now in excess and capable
of being eliminated by the natural channels if these could
be got to work, and, on the other hand, that the toxsemia
is due to the presence of some new toxin entirely peculiar
to the pregnant state, e.g., a toxin formed during the pro-
cess of dissolution of placental cells (syncytiolj-sin or s\n-
cytiotoxin), and that this toxin chiefly acts as a poison to
the nervous centres, then, until the discovery of a specific
antitoxin, there might be ground to encourage us to push
the administration of morphia, even though it blocked the
excretions.
Recent experimental researches have been conducted
in this direction. It has been shown by Schmorl and
others that during pregnancy fragments of villi or syn-
cytial cells escape into the maternal blood stream, and
upon this fact has been built the following theory : these
foreign cells act as a poison to the maternal system ; the\'
give off a toxin (cytotoxin), for the neutralisation of which
an antitoxin (cytolysin), which has the power of destroying
these cells, is produced by the maternal tissues. Veit
suggested that if this antitoxin, which he named syncytio-
90 The British Gyncpcological Society
lysin, is formed in insufficient quantity, the placental
cells are not destroyed and act as the direct cause of the
eclampsia. Ascoli, as the result of experiments, concluded
that the convulsions were due to the over-production of
this syncytiolysin, whilst Weichardt propounds the theory
that in the dissolution of the placental cells by the maternal
antitoxin (syncytioh^sin), a new toxin is set free, which,
if not neutralised, will give rise to eclampsia, and this he
calls syncytiotoxin. His conclusions are the result of
experiments upon rabbits and guinea-pigs, in which he has
induced all the phenomena of eclampsia. Recently these
experiments have been repeated by Wormser, of Bale,
who has failed to confirm the results obtained by Weichardt.
Unfortunately, then, this interesting and promising
theory remains a theory ; we have no substantial evidence
of the existence of this specific toxin, and our hopes of
a specific antitoxin are unrealised.
We must return, therefore, to our present means of
controlling the convulsions for w^hich, as I have said, we
are chiefly dependent upon drugs. It would be of ines-
timable value if we had some means whereby we could
control the fits without introducing into the system new
substances or drugs, which may do harm ; some means to
control the fits with certainty, averting, as it were, the
immediate menace of death and allowing time to bring
the pregnancy to an end and to get the excretory powers
to work.
If my view, that the convulsions and stupor are depend-
ent upon an increased intracranial pressure, be correct,
we have a most satisfactory and certain means of obtaining
immediate relief.
In 1872, Quincke noted the free communication of the
subarachinod spaces of the brain and spinal cord, and
again in 1891 he called attention to this fact and to the
possibility of tapping the spinal cord in the lumbar region.
Since that time many cases have been recorded, chiefly
of meningitis in children, but also some cases of persistent
Helme on Eclampsia 91
headache and coma in lead poisoning and chronic Bright's
disease, in which the method has been employed and relief
lias been obtained.
It was in November of last year that I decided to apply
this method of treatment to puerperal eclampsia. The
first two cases seen by me after coming to this decision
I now record for the sake of contrast ; in one the method
was not employed, in the other it was. Both were cases
of puerperal eclampsia, the convulsions following confine-
ment ; the question of treatment was simplified, for the
first principle (the management of pregnancy) was not
involved, the pregnancy having already come to an end
before the fits appeared. Treatment then lay in the
direction of controlling the convulsions and eliminating
the poison ; it was a matter of energetic action.
The first case was that of a primipara, over 30 years
of age, the wife of a member of the medical profession.
During pregnancy, her health was good, and a fort-
night before confinement, noticing that her ankles were
a little swollen, she called her husband's attention to the
fact : he thought little of it, but examined the urine,
which contained no albumin. Labour was quite straight-
forward, but, as the perineum was somewhat resistant,
chloroform was administered and low forceps applied.
Everything appeared satisfactory, the only noticeable
feature, to which no great importance was at the time
attached, being that the patient was somewhat excited
and lively. Delivery took place about 10.30 p.m., and
during the night the doctor was summoned because of
some slight attack, the nature of which was not quite
evident. This recurred two or three times ; no urine
was obtained. In the morning the patient had a more
definite eclamptic attack, and I was sent for. On my
arrival I witnessed a most violent and prolonged eclamptic
seizure. By catheter I obtained a very small amount of
urine (a few drachms) which was deeply mixed with blood.
Chloroform was administered and a pint of saline solu-
92 The British GyncEcologual Society
tion injected beneath each breast, chloral and croton oil
were given by mouth, and hot saline solution injected
into the bowel. The question of lumbar puncture was
mentioned but, owing to its experimental nature and
the surroundings of the case, was not employed. In spite
of the treatment adopted I regret to report that death
occurred about twelve hours after the first violent attack.
The second case was one which I saw in consultation
with Dr. Henry and Dr. McMaster, of Rochdale, on Decem-
ber ig, 1903, and to the latter I am indebted for the notes
of the case. The patient was aged 29. Morning sickness
had persisted all through pregnancy, and from the sixth
month onward the patient had suffered from headache
and swelling of the ankles, the urine being scanty. Labour
was natural, lasting only a few hours, and, a midwife being
in charge, the child was born at 6 a.m. and the patient
was then quite comfortable ; but two hours later she com-
plained of headache, vomited, had a fit, and suddenly
lost her sight, the blindness being complete. During the
day the fits recurred with increasing severity and fre-
quency. At first during the intervals the patient was
irritable, but the irritability gradually gave way to stupor :
the stupor deepened, until towards 5 p.m., when I first
saw her, the patient was almost comatose between the
fits. In ten hours there were fifteen fits ; and as the
day advanced the patient was progressively becoming
worse.
Treatment. — During the day chloral h^^drate and a
diaphoretic mixture were given by Dr. Henry and Dr.
McMaster ; at 3 p.m. Dr. Henry telephoned to me and
on my suggestion the chloral was repeated, 5 grains of
thyroid extract and two minims of croton oil were adminis-
tered, and normal saline solution was injected into the
rectum. At 5 p.m. I met Dr. Henry and Dr. McMaster
in consultation. The patient was very ill ; her condition
had steadily got worse in spite of the treatment employed,
the fits were very violent and prolonged, and in the interval
Helme on Eclampsia
tlie patient maintained a semi-comatose state ; it looked
as if she must die. We decided upon energetic action,
the patient was put under chloroform by Dr. McMaster,
and a pint of warm saline solution (made up from Burroughs
and Wellcome's tabloids, a most convenient preparation)
was transfused beneath each breast ; whilst Dr. Henry
attended to this, I performed spinal subarachnoid punc-
ture in the lumbar region, and withdrew a drachm and
a half of cerebrospinal fluid. The fluid escaped rapidly,
as if under considerable pressure, and not drop by drop
as occurs, for example, in health when the needle is inserted
for cocaine anaesthesia. A rectal injection of hot normal
saline solution was also given.
We stayed with the patient till 7.30 p.m., and as no
farther convulsion occurred and as the patient was per-
fectly quiet, she was left in charge of the midwife. At
10 p.m. we again visited the patient, and was informed
by the midwife that the patient had had " two very slight
fits " during our absence ; the patient was, however,
in a very satisfactory state ; she spoke to us, recognised
the voices of the doctor and her friends, and sat up in
bed to drink some water and take the medicine given to
her ; there was, however, still total blindness.
From this time onwards there were no more fits, the
patient steadily improved, and is now quite well and has
completely recovered her sight ; the albumin disappeared
from the urine six weeks after labour. For four days the
extract of thyroid (5 grains three times a day) was con-
tinued, large doses of acetate of potash were given at
frequent intervals, with plenty of barley-water to drink,
and the bowels regulated by sulphate of magnesia for a
week. Thereafter she was given a mixture of liq. ferri
perchloridi, acetate of potash and aq. chloroformi. The
method of operating employed w^as as follows : The patient
was placed upon her left side and the trunk flexed as far
as possible ; the skin of the lumbar spinal region was
washed with ethereal soap and water, and then with per-
94 The British Gyncsco logical Society
chloride of mercury solution (i in 2,000). The highest
points of the iliac crests being determined, an imaginary
transverse line was drawn between these points ; the left
index finger was placed upon the point where this imaginary
line crossed the spine, this point coinciding with the tip
of the spinous process of one of the lumbar vertebrae. A
hollow needle, 3 J- inches long, held in the right hand, was
made to pierce the skin lialf an inch to the right of the
point held b}^ the operator's left index finger, and was
then pushed onwards, being directed slightly upwards
and towards the middle line, so as to pass beneath the
lower edge of the vertebral lamina, and so enter the sub-
arachonid space.
Such is the history of these two cases, and the successful
issue, of the second case, which seemed quite hopeless,
gives me a feeling of the deepest regret that lumbar punc-
ture was not performed in the first.
I have only one case to record, and on that account
I have hesitated to bring this matter forward. The
importance of the subject, the peculiarly distressing nature
of the occurrence, the absence of definite knowledge, and
the feeling of uncertainty and semi-helplessness in our
present treatment, together with the hope that this sug-
gested method ma}^ receive extended trial and prove of
value, must be my excuse, if apology be required, for
bringing the matter forward at this stage.
Discussion.
The President described the paper as a very valuable
communication on a most important subject.
Dr. Macnaugkton-Jones said that it would be pre-
mature to express any opinion on a mode of treatment
the action of which had been ascertained in one case onlv.
If further experience substantiated Dr. Helme's viev.\
puncture of the spinal canal would be recognised as a most
valuable method of dealing with one of the most terrible
contingencies which medical men had to face. Personally,
Discussion on Eclampsia 95
he thought that in pilocarpine they had a means of relieving
eclampsia, the value of which was not sufficiently recog-
nised, and he instanced two cases of its successful use.
The first was one occurring at mid-term ; the patient was
brought to him one day complaining of loss of sight, and as
there was incipient choking of the disc and the urine was
loaded with albumin, he advised the induction of labour.
This course was adopted, and, labour coming on at night
in his absence, delivery was effected by Dr. Bland Sutton,
but eclamptic convulsions ensued and continued the whole
of that night and part of the next day, when he administered
a hypodermic injection of pilocarpine, which induced profuse
diaphoresis ; the convulsions immediately ceased, and the
woman made a perfect recovery. The second case was
a woman who, during pregnancy, had suffered from much
gastric disturbance and hyperemesis, and, after delivery,
from post-partum haemorrhage. A quantity of clots were
removed from her distended uterus, and she seemed to
be doing perfectly well, but after a time was attacked
with rapidly succeeding convulsions : on the injection of
10 minims of a 2 per cent, solution of pilocarpine the con-
vulsions ceased for some hours, and an injection of 5 minims
more was followed by total cessation of the fits and perfect
recovery.
Mr. J. FuRNEAUX Jordan asked what the total amount
of the cerebro-spinal fluid was supposed to be. It was
an important point what quantity of the fluid should be
withdrawn, and he hardly thought that the removal of
merely a drachm and a half would relieve the intracranial
pressure as much as venesection to, say, 15 ounces.
Dr. Bedford Fenwick agreed that, as Dr. Helme had
clearly explained, the real cause of the fits in puerperal
eclampsia was intracranial pressure, and that the treat-
ment should be directed to the vascular system. '' He
(Dr. Fenwick) thought that it was an error to suppose
that it was entirely the nervous system which was at fault,
and that more attention to the condition of the heart and
96 The British Gyncrcological Society
to the vascular cr)ndition of the brain and nervous system
generally would lead to a clearer perception of the proper
lines of treatment of the eclamptic condition, and to an
increase in the recoveries from that condition. Some years
ago, on the supposition that the convulsions were due to
intracranial pressure, he treated a succession of cases by
bleeding to from 15 to 25 ounces, without dnigs or injec-
tions of any kind, and they all recovered. Even without
bleeding to such an extent, he thought that better results
than hitherto might be obtained by tapping the pelvic
circulation by means of sulphate of soda, and reducing
the heart pressure by the use of nitrate of amyl.
Dr. R. H. Hodgson remarked that the convulsions of
epileps}^, in which it was not asserted that there was any
increase of the cerebrospinal fluid, were \-ery like those of
puerperal eclampsia. From personal experience he could
confirm all that Dr. Macnaughton-Jones had said as to
the beneficial effects of pilocarpine.
Dr. Edge asked what position the patient was put
into for the spinal puncture.
Dr. Helaie, in reply, said that his paper was in no way
intended as a criticism of the action of any drugs indi-
\'iduall3', but simply to suggest the employment of a
method independent of drugs. Pilocarpine was a remedy
of great value, but one that required careful watching,
because of its depressing influence upon the heart, and
though in some cases of eclampsia there was a robust,
bounding pulse, in others the pulse was weak, and in the
latter he would prefer not to give pilocarpine. He was
not aware that the amount of cerebrospinal fluid in the
human body had been ascertained, but just as the removal
of a few drops from an india-rubber ball full of water
would materially diminish the tension of its wall so, he
had no doubt, the abstraction of a drachm and a half of
fluid from the cerebrospinal canal would profoundly in-
fluence the tension in the cerebrospinal system. There
was an element of danger in withdrawing too much ;
Macnmighton-yones on Pessaries 97
though he knew of one case in which an intense head-
ache, associated with chronic Bright's disease and lead
poisoning, had been reheved after puncture and allowing
the drainage to go on till it stopped, so that perhaps the
whole of the fluid might, in some cases, be removed
without a fatal result ; in other instances of coma, the
abstraction of six drachms had been followed by relief.
For the operation, which was quite easily performed, the
patient was placed under chloroform on her left side, so
bent as to arch her back ; the needle was inserted at a point
about half an inch to the right of the line of the spinal
processes at the level of an imaginary line joining the
highest points of the iliac crests, and with a simple upward
movement was passed between the laminae of the two
vertebrae.
On the Application of Pessaries and their Dangers.
By H. Macnaughton-Jones, M.D., M.A.O., F.R.C.S.I.
and Edin.
It might appear that nothing further remains to be
said on the subject of pessaries. Their use and abuse
have been so frequently discussed, and so much has been
written with regard to them, that it might be concluded
that the question had been exhausted. I hope to-night to
prove that this is not so, and that the time has arrived
when more definite ideas should prevail as to the objects
to be attained by, and the dangers which may follow, this
method of treatment. Such accuracy of idea comes to be
more necessary when we reflect on the fact that in general
practice treatment by pessary is probably more resorted to
than is any other therapeutical step in the conduct of a
gyneecological case. It is true that the more barbarous
contrivances of the past have disappeared, though, indeed,
some still figure in the catalogues of instrument-makers.
Also, with the advance of surgical measures for the relief
of uterine displacements, and the better understanding of
vol. XX. — NO. 77. 7
98 The British Gyncsco logical Society
their causation, as well as the various anatomical points of
departure from the normal relations of the pelvic viscera
involved in their stages, pessaries are not now so indis-
criminately used, nor does every other woman who happens
to have a backache move about with an internal prop. Time
was, and not so long since, when for every pain in the back,
every sense of weight or bearing down, every vesical trouble
attributable to the uterus, any descent of the latter, a
commencing rectocele or vesicocele, a pessary was at once
adjusted as at least affording a temporary means of relief.
It was not considered how far such a temporising with
the commencement of affections which, should they increase
in magnitude or extent, must entail in their ulterior conse-
quences far greater suffering on the woman, and involve
her in operative procedures of much greater severity than
those which might have rectified her trouble had they been
adopted in its early stages, would go. Prolapse of the
vagina, before involving either rectum, bladder, or uterus ;
relaxation of the vaginal outlet or defect in the perineum,
before it brings about descent and retrodisplacement of
the uterus ; hyperplasia and subinvolution of the uterus,
before procidentia and ultimate retroversion and prolapse ;
interstitial myomata leading to displacement and haemor-
rhage, are some examples of the effects of such procrastina-
tion and expectant treatment.
To clear the ground of misapprehension, let me dis-
tinctly say that no one appreciates the utility and thera-
peutical value of pessaries more than I do, and if I do not
adhere to everything I have elsewhere said and written
with regard to their use, I still believe " that in all forms
of displacement, where its employment is clearly indicated,
a pessary generally gives material relief. I know few steps
in gynaecological therapeutics attended with such obvious
and immediate benefit and comfort to a patient as the
restoration of a retroverted uterus to its normal position,
and its support and retention by a well-fitting pessary."
Or, again, " that b}' replacement of the uterus, the use
M acnaug Jit on-y ones on Pessaries 99
of a pessary, and the adoption of the postural plan and
periodical reposition in the knee-elbow position, in cases
of retroversion, the uterus and its supports can be restored
to a healthy state, so that in time the necessity is obviated
for any mechanical appliance."
Also, " a very large proportion of cases of retroversion
can be treated and cured by the aid of a pessary ; that a
smaller number, assuming that the patient may have time and
opportunity to avail of the treatment, can be cured not only
of the displacement, but of its complications, in the same
manner."
" Every mobile and reducible uterus should be treated
in the first instance by a support, which should be worn
for a space of time proportionate to the tendency there
is on the part of the uterus to revert to the backward
position. Associated adnexal conditions are frequently
amenable to treatment in such cases, and it should follow
the reposition of the uterus."
To prove that some of the most distinguished pioneers
in gynaecology recognised not only the futility, but also
the danger, of the misuse of pessaries, it is sufficient to
mention the names of Marion Sims, Matthews Duncan,
and Gaillard Thomas. Marion Sims recognised in their
use a necessar}^ evil. " We should," he says, " always do
without them if possible, but if it be impossible, then it
is the part of wisdom to resort to such appliances as will
best answer the indications of the individual case." . , .
"The man who is not a mechanic should not trust himself
to use a pessary."
" Think twice," says Matthews Duncan, " before begin-
ning the often baneful practice of using any instrument,
teaching a woman to depend on what, if not positively
useful, is positively injurious, though perhaps not much.
Many a woman has suffered from, and many a woman has
died of, a pessary ; but most pessaries, as I find them,
are nearly innocuous for evil or for good. . . . When
every-day experience teaches that every kind of pessary
lOO The British Gyncecological Society
in cases of anteversion or retroflexion frequently fails to
give relief, and often only creates distress, we shall hesitate
before we place in the vagina for this variety of uterine
displacement a pessary of any kind."
' Fig. I. — Schultze's figure-of-eight
pessary in position. (Schultze. )
Fig. 2. — Schultze's sledge-shaped
pessary in position. (Schultze.)
A. B.
Two of Schultze's sledge shapes. A and B, moulded from ring.
Writing as far back as 1876, GaiUard Thomas, referring
to the general use of pessaries, says : " Were I asked at
the present moment whether I believed that in the aggre-
gate they accomplished more good or evil, I should be
forced to give a doubtful reply." He goes on to attribute
the injurious consequences not so much to the instru-
ments themselves as to their mode of application.
" I myself believe," says Schultze, " that anyone who
Mac7taughton-y ones on Pessaries loi
is able to replace a retroflected uterus in its normal posi-
tion by the bimanual method can manage to make out
of a rubber-covered ring of wire a figure-of-eight or sledge-
shaped pessary of a suitable shape, and can afterwards
introduce it properly. Anyone who is unable to replace the
uterus in its normal position requires no pessary to retain
it there, but may go on sticking some indiarubber ring,
or one of Hodge's pessaries, under the somewhat elevated
but still retroflected uterus.
" There is still a very widespread misconception that a
uterus can be brought out of an anomalous position into
the normal one l:)y the pessary. No pessary in existence
can do this. The normal position must first be restored
bimanually ; a pessary may afterwards maintain it."
Referring to the introduction of a Hodge or ring, he says
that for those who can content themselves with giving
a little relief, these will always remain in use, though all
they can possibly do is to diminish the painful mobility of
the uterus. " The troubles and inflammatory complica-
tions arising from an unreposed retroflected uterus are,
however, very often made decidedly worse by the intro-
duction of a pessary underneath it."
The questions I should like discussed are these : (i)
What is the action, and what the purpose of a properly
designed and adjusted pessary ? (2) What are the patho-
logical conditions which make the use of a pessary
dangerous ? (3) What are the best forms of pessary
for use under the different circumstances in which
their application is indicated ?
I cannot improve on the description given by Goodell
of the principle of the ordinary Smith-Hodge or lever
pessary, whatever the material be of which it is made : and
this description refers, of course, also to the same class
of pessary which has a cushion posteriorly. To a certain
extent it also applies to Fowler's cradle pessary and to
Schultze's figure of-eight support.
" As its name indicates, this pessary acts on the prin-
I02
The Bi'itisk Gynceco logical Society
ciple of a lever ; but the mechanism of its action is twofold.
By stretching the vagina upward and backward, it draws
the cervix in the same direction. The womb then turns
on its central point of ligamentous attachment as on a
fixed pivot, and the fundus is consequently tilted forwards.
The womb itself thus becomes a lever, of which its point of
attachment to the bladder is the fulcrum. The power is
applied to the cervix and the fundus becomes the weight
or resistance. This action remedies retroversions, but not
retroflexions unless complicated with retroversion, as they
Fig. 3. — Position of curved celluloid
cushion (Smith - Hodge), keeping
uterus in fairly normal position.
(H. M.-J.)
Fig. 4. — Uterus restored to the
normal position— the S. pessary of
author applied. (H. M.-J.)
usually are. The anterior vaginal wall, with the visceral
pressure above it, now becomes the power applied to the
lower limb or ' long arm ' of the lever ; the posterior
vaginal wall is the fulcrum, or support ; and the upper
limb or short arm lying behind the cervix directly pushes
the weight or fundus uteri. This action tends to remedy
both retroflexion and retroversion. For instance, during the
act of inspiration the descending diaphragm crowds down
the abdominal viscera upon the bladder to which are
attached the cervix uteri and the anterior wall of the
Macnaughton-y ones on Pessaries 103
vagina. These organs therefore descend. As a result,
the lower or fore end of the lever is necessarily pushed
down by the descending anterior wall of the vagiuci on
which it rests, while its upper or hind end proportionately
rises up and tilts fonvard the retroverted or the retroflexed
fundus. In expiration, the reverse takes place. The pres-
sure is, therefore, not a steady but a gentle rocking one,
which is the most efficient of all. This, also, is one least
liable to inflict injury on the soft parts, because the points
of pressure are varying ones. But to attain these ends
the pessary must be mobile, and never so long as to put
the vagina on the stretchy otherwise it loses its distinctive
character of a lever, and degenerates into an ordinary ring
pessary. It should further impinge on the soft parts only,
Fig. 5. — Celluloid cushion pessary. (Author's.)
and take no bearings on the solid structure of the pelvis. . ."
A certain degree of stretching is, however, inevitable in
the drawing back of the vaginal portion.
Schultze is naturally somewhat prejudiced in favour
of his figure-of-eight and his sledge-shaped pessaries. We
may therefore in some degree qualify what he says, but
it is in the main true.
" Both by Hodge himself," he remarks, " and by Braun,
\\ho first introduced it to us, the instrument was extolled
distinctly upon the ground that it rendered reposition by
the sound, the method at the time practised, unnecessary.
. . . . The question remains whether this pessary can
keep the uterus in its normal position after reposition, an
effect attributed to it by many gynaecologists.
I04 The British Gyncscological Society
" As a matter of fact, if the uterus has been previously
replaced, Hodge's pessary does in some cases keep it in its
normal position, and does so because, by extending the
posterior ^^aginal vault backwards and upwards, it com-
pels the vaginal portion to keep in its proper position,
well at the back of the pelvis.
" But the posterior vaginal vault, if tender, as it very
often is directly after the elevation of a retroflexion, cannot
be put sufficiently upon the stretch to fix back the portio
vaginalis. If the upper and back part of the vagina be
roomy and relaxed, a condition in which it very commonly
Fig. 6. — (A) Complete retroversion. Pouch of Douglas occupied by fundus,
\\ ith pedunculate polypus in the cavity. Rectum encroached on and the bladder
drawn upwards and backwards.
(B) Same uterus with fungoid or carcinomatous mass in fundus. (H. M.-J.)
is in retroflexion, we may stretch the vaginal vault as far
backwards as ever we like without thereby compelling the
vaginal portion to remain in the back of the pelvis ; it
slips forward in the loop of pessary, and though the latter
is in a proper position, the uterus falls back over it into
retroversion, just as if it were not there at all.
"It is only when the vagina is fairly rigid as well as
long, and where there is no tenderness in the posterior
vaginal vault — a combination of circumstances not often
found with retroversion — that Hodge's pessary actuallv
Mac7iaughton-y ones on Pessaj'ies 105
replaces the uterus, forces the vaginal portion into a pos-
terior position, and thereby transfers the intra-abdominal
pressure on to the posterior surface of the uterus."
There are certain points which must be remembered
in regard to all pessaries : First, the consequent stretching
of the vaginal walls and the distension of the canal,
especially at its uterine end. Secondly, the necessity for
perfect mobility of the pessary. Thirdly, the need for
adaptation in size and shape of the pessary to the dimen-
sions of the canal, and to the length of the portio vaginalis-
The support should not interfere with the normal acts of
Fig. 7. — Large retroflexed uterus, obliterating the pouch of Douglas and
pressing on the rectum, drawing the fundus of the bladder backwards. (H. M.-J.)
defaecation, nor impinge on the neck of the bladder or
urethra so as to cause either distress to the bladder or
impediment to micturition. The main points to be con-
sidered are — the capacity of the vaginal fornix, the length
of the canal, and the size of the portio vaginalis ; after
the application of the pessary, the comfort with which it
is worn while standing, walking, and sitting in different
positions, and the absence of any sense of distension or
pressure. In order to fulfil its action in retrodisplacement
and support the uterine fundus, while it retains it in posi-
tion, its posterior curve should be such as to so occupj^ the
io6 The British Gynaecological Society
posterior fornix as to prevent a doubling over of the uterus
on the pessary during such acts as those of defaecation,
any strain of the abdominal muscles in lifting weights or
during fits of coughing, and the unavoidable pressure result-
ing from over-distension of the bladder. A pessary also
should be as light as possible consistent with its strength
and hardness. The material should resist the corroding or
solvent action of the vaginal secretions, and be one which
can be easily kept clean. The rmgs I show are of two
kinds ; the first are my own celluloid and wire rings, made
for me many years since by Arnold. They can be moulded
into any form desirable. The others are Schultze's celluloid
rings. These are the most perfect that can be conceived.
Fig. 8. — Celluloid wire ring finally moulded.
They are so hght that the weight of the ring is hardly felt.
On the other hand, w^hen moulded by means of boihng
water they become very hard, and though elastic never
alter their shape.
When the position of the uterus is such that a pessary
can be taken out and replaced by the woman herself, it
is ^^•ell that it should then be of a kind that will enable
her to do this easily. Obviously she cannot replace any but
the simpler forms, such as a glycerine ring or simple Hodge.
The more sharply curved pessaries, a Fowler's or Gala-
bin's, she cannot replace on, but she ought to be taught
how to remove any pessary. Such conditions involving the
application of an ordinary lever pessary cannot be fulfilled
unless it be moulded at the time according to the anatomi-
cal peculiarities of the vagina and uterus. Nor can this
Macnaughton-yones on Pessaries \oj
frequently be decided on its first adaptation. It has to be
worn for a certain time before its efficacy and comfort
can be finally determined. The application of a pessary
without such determination as to its suitability from these
points of view is obviously wrong. What we want
speciall}^ to avoid is that over-distension of the vaginal
walls which leads to an atonic condition of the muscular
structure and subsequent relaxation of the vesical and utero-
rectal supports. Even supposing that a uterus be kept in
position temporarily by such over-stretching, when the
pessary is removed the tendency is to recurrence of the
Fig. 9. — Fowler's cradle pessary in position. (H. M.-J.)
deviation, and the last state of the woman is often worse
than the first, relaxation of the vagina assisting in the
downward and backward movement of the uterus.
If we look at a Fowler's pessary, we see that its posterior
projection rests against the junction of the infravaginal
with the supravaginal cervix, tilting the latter, with the
fundus, forwards, while the smooth and convex surface
of the bowl fills the posterior fornix. The narrow end of
the cradle lies in front of the cervix against the vaginal
wall, and should not press on the urethra. The pessary
itself should be made in one piece, so that there can be no
chance of any want of continuity which would permit
io8
The British Gynceco logical Society
the entrance of vaginal secretions into the hollow space
between its walls.
Such pessaries as those I have mentioned, if properly
adjusted to the individual case of retrodeviation, assum-
ing that any form of pessary will maintain the uterus in
anything approaching its normal axis, exert their action by
tilting forward and at the same time supporting the fundus,
the cervix being thrown backwards. No bad effects follow.
A ring of any kind is quite different. It is not a lever
in the sense of the Smith-Hodge, and does not support
the uterus in the same manner. A movable ring lying
Fig. io. — (A) Glycerine ring in position in the vagina. Uterus has been
replaced, but not quite in the normal position.
(B) Effect on same uterus by over-distended bladder. (H. M.-J.)
obliquely in a rigid unrelaxed vagina is useful, but in the
majority of cases of retroflexion in a relaxed vagina it is
absolutely useless. It plays as active a part in retaining the
uterus in position as the ring on the woman's finger.
With regard to stem pessaries, I can only repeat what
I have several times said and written. For years I have
not inserted one into the uterus save after an operation
for stenosis and anteflexion, and then only rarely. In few
cases is the use of a stem required, and the risks incurred
during the time it is worn, the constant supervision required
Macnaughton-y ones on Pessaries
109
from the medical attendant, and the unpreventable care-
lessness of patients, render its employment particularly
hazardous in busy general practice. I am always uneasy
while a stem is in the uterus, and in applying it give
the patient strict injunctions regarding rest and medical
supervision. I never place one in the uterus immediately
before a menstrual period, and, when one is worn, I remove
it on the approach of a period. I always teach the patient
how to remove the instrument by means of a string
attached to its lower end, and direct her to do so on the
least indication of uneasiness, pain, chill, or a feeling of
Fig. II.— Celluloid stem of author.
Fig. 12. —Method of moulding the
tigure-of-eight ring. (Schultze.)
general malaise. No stem should be placed in the uterus
if there be signs of recent perimetritis, or during an inflam-
matory state of the endometrium. I use a smooth, straight,
or slightly curved stem, such as my celluloid bulbous
one. The stem should not reach the fundus of the uterus.
.: I have removed stems which had been worn in the uterus
for months, and, apart from my pity for the patient, my
regret was that the person who had placed the stem in
position was not present to learn a lesson from the effects
of its sojourn there.
J_' Schultze, speaking of intrauterine stems, in connec-
no The British Gynaecological Society
tion with flexions, regards one as a suitable addition pro-
vided there be no active inflammation present, preferring
the independent stem to the combination of pessary and
stem, and only using it where the flexions are such that
they cannot be permanently adjusted.
" They are," he says, " the only cases in which, with
our present knowledge of the normal and abnormal posi-
tions of the uterus, there can be any indication for their
application.
" The more cases of retroflexion I have to treat, the
fewer are those in which I meet with this exceptional indica-
tion for the use of intrauterine pessaries. Years have
repeatedly passed without my coming across it, because
in all cases of the sort coming under my observation, in
which the circumstances were not such that I had for the
time to abstain from reposition, either the peritoneal
adhesions which caused the anomalous position of the
uterus were discovered and removed, or the action of the
parametric cicatrices could be compensated with vaginal
pessaries of appropriate shape."
The views Professor Schultze held some years since are
practically those he advocated in 1898, which, he says in
a letter to me, " hold as good now as when they were
written."
In regard to anteversion and anteflexion, though we
still have to include degrees of the former condition in
our text-books, we all now know that it is not correct to
speak of an anteverted womb as a displacement. If the
womb leans forward at an angle of forty-five degrees and
upwards, it is then out of the normal plane and has an
abnormal relation to the pelvic axis, and may then require
support. Anteflexion is a different state. Most frequently
it is not merely the abnormality we have to deal with,
but we have also present stenosis of the uterine canal,
possibly enlargement from hyperplasia, or tumour in the
anterior wall of the fundus.
" I have learned to unlearn," says Goodell, " that
Mac7iaughton-y 07tes on Pessaries 1 1 1
anteflexion and anteversion in themselves, that is to say,
as displacements merely, and without narrowmg of the
uterine canals, are necessarily pathological conditions of the
womb " ; and he goes on to urge the mistake of attributing
to this natural position of the womb such an affection as
irritability of the bladder, naturally dwelling on this fre-
quently occurring symptom, which is often attributed to
pressure of the uterus when it is in reality due to an
impaired nervous system with lack of brain control. " Upon
making a vaginal examination, the fundus of the womb is
found resting on the bladder, where it naturally should
Fig. 13. — Anteflexed uterus with elongated cervix pressing on bladder,
altering the position of the pouch of Douglas, and drawing on the rectum.
Ovary prolapsed anteriorly. (H. M.-J.)
rest, and the conclusion is jumped at that the whole trouble
is due to the existing natural anteflexion or anteversion, as
the case may be. The surgeon racks his brains to adapt or
devise some pessary capable of overcoming the supposed
difficulty, heedless of the dilemma that the upward or
shoring pressure of the pessary on the bladder must be
greater than the counter or downward pressure of the
womb to which he attributes the vesical irritability."
For m}^ own part, I have not, in anteflexion, for years
used any pessary save one which I have either moulded
I 12
The British Gyncscological Society
myself from a ring, such as I show here, or a Galabin, which
it practically resembles.
Ventrosuspension of the uterus, or the enucleation of
Fig. 14. — Myomatous uterus— nucleus in anterior wall pressing on bladder —
pedunculated tumour in the pouch of Douglas. (H. M.-J.)
Fig. 15. — (A) Pouch of Douglas occupied by a large pyosalpinx adherent to
the uterus or incorporated with it and altering its position — mistaken for retro-
flexion. This may be a myoma, an ectopic sac, an ovarian cyst, or a tumour
of the mesosalpinx or Fallopian tube.
(B) Idea of the nature of tumour conveyed on examination by vagina and
rectum, confusing it with myoma. (H. M.-J.)
a myoma, will rapidly and completely cure symptoms of
bladder trouble, even in cases where a urinal has to be
worn.
Macnaughton-y ones on Pessaries
ii3
I may now briefly summarise the pathological condi-
tions which contraindicate the use of any pessary, and
where its presence constitutes a distinct danger, (i)
Displacements which are associated with inflammatory
states of the endometrium, until such endometritis be
cured. (2) Those which are complicated by adhesions,
rendering restoration of the uterus to its normal position
impracticable. (3) Those associated with adnexal tumours
and inflammatory conditions of the ovaries and tubes.
(4) Those complicated by other than adnexal tumours in the
pouch of Douglas, such as an enlarged, sensitive, and pro-
FlG. 16. — (A) Large uterus encroaching on the bladder, which is elongated
as the result of pressure and over-distension. Loaded rectum pressing on adnexa
in the pouch of Douglas.
(B) Galabin's pessary supporting the uterus.
(C) Galabin's pessary supporting uterus with myoma in anterior wall.
(H. M.-J.)
lapsed ovary, cysts of the ovary or mesosalpinx, pus
cysts of tube or ovary, ectopic sacs, pedunculate myomata,
solid tumours of the ovary or Fallopian tube. (5) All
cases in which, after reasonable trial of a pessary and
palliative treatment of the displacement, the prolonged use
of a pessary is necessitated, inasmuch as without the latter
the displacement recurs, and when, even with the pessary
in situ, the uterus cannot be kept in the normal position.
VOL. XX. — NO. 77. 8
1 1 4 The British Gynecological Society
It is altogether unsurgical to consign a woman to the
life-long burden of an irksome appliance in the vagina.
In my own experience I have seen, not once but several
times, pessaries worn when one or more of those patho-
logical conditions I have enumerated have been present.
It is not necessary to dwell on the risks and dangers thereby
entailed. Nor is it any matter for surprise that such
conditions have not been detected when complicating a
retroflexion, for they are out of reach, and, save under an
anaesthetic and by the bimanual method, it is impossible
Fig. 17. — (A) Myoma in posterior wall of retroflexed uterus. Ovary and
tube in the pouch of Douglas.
(B) Myomatous anteflexed uterus, which has become retroverted. (H. M.-J.)
to detect their presence. And even with this advantage
the most experienced gynaecologists are liable to err in
diagnosis. It may be thought more inexcusable to con-
found the occurrence of any of these conditions with a retro-
flexion, but here, again, so intimately associated are certain
growths — C3'stic tumours, pus sacs, and solid tumours — with
the uterus, so hard and resistent do they become, and so
difficult is it to dissociate and define what is uterine from
that which is extrauterine, that it is a matter of common
knowledge that operators of the highest skiU and the
widest experience have not detected the error of diagnosis
until the abdomen has been opened. How much less, then,.
Macnaughton-y ones on PessaiHes 1 1 5
is the surgeon in general practice to be blamed if he fail
occasionally to differentiate a mass in the pouch of Douglas !
I have elsewhere recorded some such " pitfalls " in my
own practice, and have been present when even the most
wary have slipped. Only lately I saw a case in which
a pessary had been worn for some time, an opinion after-
wards being given that there was nothing seriously wrong.
Finally, a distinguished surgeon pronounced the case to be
one of myoma, another experienced gyneecologist viewed
it as a case of inoperable carcinoma. I came on the scene,
and concurred in the view of myoma. It turned out to be
one of old infiltration with pyosalpinx.
Quite recently I operated upon a case the full par-
ticulars of which I intend soon to report, with a peculiar
history. The facts would fit in with the presence of an
ectopic gestation sac, a molar pregnancy, or a long-standing
pyosalpinx, forming a hard adnexal tumour in Douglas's
pouch. The latter was the view I took in the first instance.
Under aucesthesia, before operation, by bimanual examina-
tion, different views were expressed as to the nature of
the tumour. Before proceeding to open the abdomen, I
proved with the sound that the uterus was in its proper
position, and that the mass was not part of the uterus,
though closely incorporated with it. One of the most
experienced of Continental gynaecologists was present at
the operation.
On exposure of the pelvis, an old infiltration was found
extending from side to side, raising the broad ligaments
and extending as far as the second lumbar vertebra ; the
mass behind the uterus, which was firmly incorporated
with it, proved to be a large infiltration, communicating
with a pyosalpinx, and tunnelled through by a portion of
the bowel.
When we ourselves trip and stumble into one of these
pitfalls, we usually feel what an American cells " pretty
bad." Is it a brotherly feeling that makes us so sympathetic
to a fellow-traveller on the same road that we cannot
1 1 6 The British GyncEcological Society
restrain the desire to talk of his misfortune ? Or, is it the
philanthropic motive to make him serve as an object-
lesson which may prevent others from following in his
rash footsteps ?
An ovum of half truth, when impregnated by the dual
germs, insatiable love of gossip and cancrous jealousy,
develops not infrequently into a twin monster of insinua-
tion and falsehood, which even its original generative force
would not recognise as its own conception. Let, then, the
.Gods of gynaecology be lenient in their judgment on the
errors of the less infallible mortals, who, treading the
rougher highways and byways of general practice, occa-
sionally make such mistakes as those I have referred to —
mistakes to which even the immortals themselves have been
proved to be liable.
All I have here said with reference to my second ques-
tion tends to show that a pessary is not the harmless
appliance it is generally thought to be, and that before
it be applied it is our duty, by bimanual examination, and,
should doubt exist, under anaesthesia, to exclude those
often obscure pathological conditions which altogether
contraindicate its use,
I need not refer to the dangers of allowing a pessary
to remain too long in the vagina without being cleansed
or changed. I once showed at this Society a ring pessary
which had been worn for nine years ; it was covered with a
calcareous coating, and had worn a deep groove in the
walls of the canal. It is not so very long since that I removed
a pessary which had been worn without change for five
years. Such occurrences should not be possible were the
dangers emphasised to the patient when leaving the imme-
diate care of the surgeon who inserts the pessary.
As to the best forms of pessary for application under
the different circumstances in which they are indicated, I
believe that for retroversion or retroflexion the well-curved
S pessary, which the practitioner himself moulds for the
vagina in which it is to rest, and adapts for the uterus
Macnaughton-J ones on Pessaries' 1 1 7
that it has to keep in position, is the safest and best. After
the uterus has been replaced, and where we suspect that
it will not remain as we have replaced it, a Fowler's
pessary, carefully selected as to its size, is an admirable
one. So, also, are the celluloid cushion and Schultze's
figure-of-eight.
When we require a pessary for anteflexion or extreme
forward displacement of the uterus, Galabin's pessary,
which can easily be kept clean and be worn without change
for some months, I consider the best. Here, again, the most
important points are its width and length, as if these be
not attended to the pessary is certain to cause distress.
Also, care must be taken in its removal, for if roughness
be used in abstracting it, considerable pain will be caused,
and the outlet may be bruised and injured. The pessary
has to be turned by the finger with the long axis of its
arched portion corresponding to the long axis of the outlet,
and the perineum should be well drawn back so as to
permit of the escape of the broad portion of the pessary.
Where the uterus is anteflexed, and there is a myoma
in its anterior wall, or where there is relaxation of the
vagina, with tendency to cystocele and prolapse, with atten-
dant reversion, it is as good a support as we can use. It
does not prevent conception. If a Galabin be not at hand,
a pessary much on the principle of Schultze's sledge-shaped
one can be fashioned from a celluloid ring and adapted in
size and shape to the anatomical conditions of the indi-
vidual case. It acts much in the same way as Galabin's
and is useful under similar conditions.
With regard to prolapse, in its earlier stages, when
retroflexion is the first consequence of relaxation of the
utero-sacral folds, and where reposition of the uterus is
called for as a palliative measure, a pessary is of use, and
a celluloid cushion support or one moulded for the case
from a ring is indicated ; a glycerine ring of suitable size
often affords considerable relief. But when both the uterus
and vagina begin to descend, when the uterus is retro-
ii8
The British Gyncscological Society
fleeted, while the vaginal outlet is relaxed, and there is
prolapse of some portion of the vaginal wall, operative
measures are called for, and a pessary of any kind is
injurious, and becomes more so in proportion as the vagina
is stretched by it. By early operative measures, those
more serious ones which have to be considered in the later
stages of procidentia will, in all probability, never have
to be undertaken. Hardly any of those cases in which
B
Fig. 1 8. — Moulding of Schultze's ring into an S-shaped pessary. {A) first
shape ; {B) second shape ; (C) third shape ; (Z?) fourth shape.
operations on the utero-sacral ligaments, extirpation of the
vagina, in whole or part, or removal of the procident mass,
are indicated, would ever occur were suitable operative steps
taken, instead of the attempt being made to palliate the
woman's troubles by resort to an appliance which is not
intended to cure, and, as a rule, aggravates the mischief.
For those who will not consent to operation, the best sup-
port will be that which is moulded by the surgeon himself
to suit the degree of the prolapse, and in some extreme cases
under the same circumstance, Godson's wire modification
of Zwancke's pessary, if care be taken with regard to clean-
liness, I have known to afford the greatest relief.
Macnaughton-y ones on Pessa^Hes 119
I trust that I have shown that a pessary, whether we
view it from the point of view of the positive mischief
it may do or the negative consequences that follow its use
by delaying suitable and efficient treatment, is not the
harmless agent it is often thought to be.
The moulding of the ring is accomplished thus : Having
carefully examined the vaginal roof, and noted the size
required, a few rings are taken and thrown into a basin of
very hot water ; when they are phable one is given the
shape shown in fig. 18 — A. The ring is again thrown back
into the water for a few seconds, and on being withdrawn
it is given the form shown in fig. 18 — B. It is again im-
mersed, and after removal the second curve is made (fig.
18 — C). After a few seconds' final immersion, the pessary
may be made to assume the exact shape desired, and the
arms of the lever brought to the proper length and angle
required (fig. 18 — D, shape advised). The pessary is next
thrown into cold water, and left in it for a few minutes to
set. The red celluloid rings are not so liable to crack in
moulding, and possibly they keep better than the trans-
parent kind.
On the motion of Dr. Heywood Smith, it was agreed
to postpone the discussion of the paper to a future meeting
of the Society.
I20 Original Communications
ORIGINAL COMMUNICATIONS.
Deductions from the Study of Pelvic Disease
IN THE Female Insane.^
By Ernest A. Hall, M.D., L.R.C.P.Edin.
Fellow of the British GyncBcological Society.
It is not my purpose to give a resume of all that has
been done in investigating the causes of mental disease
associated with abnormal conditions of the pelvic organs,
nor to endeavour to attempt any solution of the problem
of the correlation of the physical with the psychic disorders,
but to offer you a few deductions which are the product
of several years of careful study of pelvic diseases as causa-
tive of abnormal mentality. My point of view is that
of a general practitioner, and I shall deal with this matter
as it has appeared to me in private practice. It is, I
know, only necessary to call your attention to the alarm-
ing increasing prevalence of insanity upon this continent,
and the ever-increasing burden that is thus entailed upon
the State, and to the shadow cast upon many of our
best families by a history of mental disease, to arouse
your interest in any measures whose object is alleviation
of the sufferings or diminution in the number of those
unhappily so affected. In the etiology and treatment of
insanity we have a problem second in importance only to
the eradication of cancer and the control of tuberculosis.
That the attention of the profession has been aroused
on this point is shown by the fact that in many recent text-
' A Paper read at a meeting of the British Columbia Medical
Association in Vancouver (c/. ante, vol. xvi., p. 242). Dr. HaU's
work is alluded to by Fredericq (infra, Summary, p. i).
Pelvic Disease in the Fe^nale Insane i 2 1
books on gynaecology, a chapter is devoted to the relation-
ship between abnormal mental conditions and pelvic
disease. The necessity of such investigation will be brought
home to you, perhaps to your surprise, when I state that
of 109 patients examined by me who were suffering from
well-marked mental abnormality, I found decided patho-
logical conditions of the pelvic organs in 99, or 90 per cent.
Other investigators have had the same experience :
Dr. Tyler, of Denver, reports that less than 10 per
per cent, of female lunatics have normal organs ; and
Dr. Hobbs, of Guelph, and formerly of London Asylum,
found that 89 per cent, had pelvic lesions. Reports from
other asylums, where careful examinations are made, give
somewhat similar results.
Without going further into statistics, which would
tend to show, in the first place, that pelvic disease and
insanity are frequently associated, and secondly, that
such disease should receive appropriate treatment, in the
insane, just as in those who are not mentally affected, and
that insanit}^ is no excuse for neglecting the treatment of
pelvic disease — matters upon which I shall assume that
we all agree — I have now to make some statements
which I cannot expect you to accept unanimously.
(i) Whenever the physical condition of an insane
woman, owing to pelvic or other disease, necessitates
abdominal section — should the surgical interference, other-
wise necessary, not render her inevitably sterile — it is the
duty of the ■ surgeon, with the consent of the husband
or friends, to render her incapable of reproduction by the
slightest operative procedure necessary to accomplish the
purpose.
(2) Given a history of recovery from one or more attacks
of insanity in a woman exposed to conception, we are justi-
fied, with the consent of the interested parties, in rendering
her sterile, more especially so if the mental trouble has been
associated with childbed.
(3) Given a first attack of insanity in a woman of good
family history, even if a thorough examination by the
1 2 2 Original Communications
best skill obtainable fails to detect any physical lesion,
considering the surprises often met with upon abdominal
section, and the many pathological conditions within
the abdomen that cannot be determined by external
methods of examination, considering also the fact that
persistent insanity may doom the patient to a condition
worse than death, while the risk of the operation is
little more than that of the anaesthetic, we are justified
in opening the abdomen for the purpose of examination.
(4) Considering that, on the somatic basis of insanity,
mental disease is but the psychic sum of physical abnor-
malities, that the recovery rate is greater when the habit
of vicious cortical metabolism has not yet been estab-
lished, we should concentrate our efforts upon the treat-
ment of recent cases, and endeavour to remove the
underlying lesion or lesions as early as possible. To
facilitate this, provision should be made in connection
with each of our city hospitals for the reception and
treatment of recent cases of insanity ; they should remain
there, for a few months, under the care of their family
physician, associated preferably with specialists in in-
ternal medicine, nervous diseases, and a surgeon (which
latter term now includes a gynsecologist) ; and if after a
time there was no indication of recovery, they should be
transferred to the Provincial Hospital. It would, of
course, be folly to detain cases of general paresis or
senile dementia.
This suggestion is not made with the purpose of reflect-
ing upon our provincial asylum, which is as good as it
can be under the present system, while the superintendent
is one of the ablest in the dominion ; but the associations
of the asylum are not those in which any of you would
care to see your mother, wife, or daughter placed, except
as a last resort ; nor are such associations calculated to
restore weakened bodies or to recuperate exhausted nerves.
Until all other methods of treatment at our disposal have
been exhausted, we should not desire such an environment
for, any one dear to us.
Reviews 1 2
REVIEWS.
A Text-Book of Gynaecology. Edited by Charles A. L.
Reed, A.M., M.D., Professor of Clinical G5ni8ecology
in the Medical Department of the University of Cin-
cinnati ; ex-President of the Medical Association, &c.,
&c. Illustrated by J. R. Hopkins. Second Edition,
revised, royal 8vo, pp. xxv. and 900. New York and
London : D. Appleton and Co., 1904. Cloth. Price
25s.
Since its first appearance, about four years ago, this
book has been reprinted several times without alteration.
In the present issue room has been obtained by the omis-
sion of relatively unimportant paragraphs to give more
details in regard to some points of treatment and technique —
but no complete revision has been attempted ; the printer's
errors, mostly misspelling of foreign names, continue the
same. Professor Cameron is still allowed to make it a
condition for Caesarean section that the conjugate diameter
should be " not under " instead of " not over " i-i- inches,
though we know that this lapsus calami has been corrected
in another publication of his paper ; and Dr. Ballantyne to
imply that the sexual glands do not appear till the fifth
or sixth month of utero-gestation. Owing to the rewriting
of part of the chapter on Abdominal Section, Dr. Clark is
more fortunate, for he is no longer charged with the state-
ment that " Great quantities of organisms which ordinarily
produce no disturbance may give rise to a general asepsis.
124 Reviews
if the absorptive ability of the peritoneum is impaired.'*
In the same chapter Dr. Reed has rewritten the remarks
on Drainage very strongly in favour of the vaginal route,
and of sterile, in preference to iodoform, gauze, and has
added some pages on treatment after abdominal section.
He has greatlv improved the chapter on the Pelvic Floor
and its Injuries by considerable alteration and the addi-
tion of three new illustrations. In the chapter on Dis-
placements of the Uterus, a new paragraph is inserted
laying stress on the disadvantages of ventrofixation during
child-bearing age, and some remarks on the technique for
operating on ectopic pregnancy when the child is viable
have also been rewritten.
For more detailed appreciation of the book as a whole
we must refer our readers to the review of the first edition in
this Journal (vol. xvii., p. 165). The book is undoubtedly
a good one, rich in good pathology, and well-illustrated
details of operative technique, and its value to the practical
gynaecologist is considerably enhanced by the chapters on
the Urinary Apparatus and Rectum, with directions for
the necessary physical examination of bladder, ureter and
lower bowel. But though re-reading it has been a pleasure,
the revision has not materially altered the book, and its
merits and demerits remain much the same as those of
the first edition.
A Short Practice of Gynecology. By Henry Jellett,
M.D., F.R.C.P.I., ex-Assistant Master, Rotunda Hos-
pital ; Examiner in Midwifery and Gynaecology, R.U.I.
and R.C.P.I., and late Examiner, Dublin University,
&c., &c. Second Edition, revised and enlarged, with
223 Illustrations. Demy 8vo, pp. xiv. and 406.
London : J. and A. Churchill, 1903. Price los. 6d.
It is not surprising to find that a second edition of
Dr. Jellett's " Short Practice of Gynaecology " is necessary
Reviews 1 2 5
little more than three years after the publication of the
first, but it is by no means the same book. Though he
has omitted all detail that he could consider unnecessary
or irrelevant, and is as we have noticed, as concise in style
as is compatible with clearness, in order to make the book
as complete and modern as might be, he has had to make
considerable additions to the text, and very nearly double
the number of the illustrations. We reviewed the iirst
edition shortly after it appeared {ante, vol. xvi., p. 263)
and on comparing the two must congratulate Dr. Jellett
on the additions he has made, particularly as regards the
original pathological illustrations, and those which by the
courtesy of Dr. Roberts and others he has been able to
reproduce, and which render the study of gynaecology at
its commencement so much more interesting to the student.
The additions to the text are valuable, the index, however,
is not complete, and would lead one to suppose that neither
cystoscopy not atmokausis were properly recognised.
From Dr. Jellett's connection with the Rotunda and the
prefaces to the two editions, the book may be accepted as
an exposition of the gynaecological practice at the Rotunda
Hospital, under the masterships of Sir Arthur Macan and
Dr. W. J. Smyly, and we can heartily recommend it to
the student as an excellent introduction to the practical
study of the diseases of women.
Vaginal Tumours, with Special Reference to Cancer
AND Sarcoma. By W. Roger Williams, F.R.C.S.
With 5 Illustrations, demy 8vo, pp. x. and 92. London :
John Bale, Sons, and Danielsson, Ltd., 1904. Price
5s. 6d.
In this monograph Mr, Williams endeavours to co-
ordinate and arrange in a concise and accurate manner
the immense accumulation of details relating to the etiology,
pathogenesis, minute anatomy, general pathology and life-
history of vaginal tumours, and few men, as his articles
1 26 Reviews
in the Medical Record, 1901, and in other journals in 1902,
are better fitted for the task, formidable as it is.
Though cancer and sarcoma are made so prominent
in the title, nearly half the book is devoted to myoma
and other non-malignant tumours, including cysts. The
latter part has proved the most interesting to ourselves, as
in nearly all cases the origin of these cysts is to be referred
to " inclusions " or " rests " of the ducts of Wolff or
Gartner. The monograph does not aim at including all
that has been brought forward, or at affording any original
work, but is a convenient condensation of what is accepted
in regard to vaginal tumours.
Die Bekaempfung des Uteruskrebses, ein Wort an alle
Krebsoperateure. Von Dr. Georg Winter, Ord.
Professor und Director des Universitaets-Frauenklinik
in Koenigsberg, i. Pr. Royal 8vo, pp. 76. Stuttgart :
Ferdinand Enke, 1904. Price 2 M.
Der Erfolg der Bekaempfung des Uterus Krebses
IN Ostpreussen. Von Dr. Georg Winter, &c., &c,
{Zentralhlatt juer Gynaekologie, 1904, No. 14.)
The mortality of uterine cancer, due to the fact that
so many cases are allowed to advance too far for operation,
is admittedl}/ enormous. In 1895, at the meeting of the
British Medical Association, the late Mr. Knowsley Thornton
appealed to the members in general practice never, in case
of irregular haemorrhage or vaginal discharge, to neglect
internal examination and never to treat any suspicious
case expectantly, but to refer it at once for operation.
Dr. Lewers, in an article in the Practitiojier in 1902, in order
to promote the early diagnosis of cancer of the uterus,
urged that women, generally, should be made acquainted
with the early symptoms of the disease, especially with
the significance of anomalous haemorrhage, and suggested
that the cancer commissions of the Royal Colleges of
Physicians and Surgeons might well issue leaflets, conveying
Reviews 1 2 7
the necessary information, to all medical men, for distribu-
tion to suitable persons, and to the matrons of all hospitals
to give to ever\^ nurse trained under their authority. In
the same year, Professor Japp Sinclair, in his address on
obstetrics at Manchester to the British Medical Association,
attributed the vast number of cases in which uterine cancer
was allowed to advance too far for operation, to the preva-
lence of the idea that haemorrhage after the menopause
was not any cause for alarm, to the belief that pain was an
early symptom, to delay on the part of the patients in
seeking advice, and to the negligence of general prac-
titioners about making an internal examination ; he
quoted with approval the suggestions made by Dr. Lewers.
Professor Winter began to do battle with uterine cancer
in 1891, at Berlin, and by investigation of the histories of
the cases at the University Poliklinik was able to assign
three factors as the chief causes of neglected and advanced
cancer of the uterus : (i) Deficient knowledge on the part
of medical men ; (2) unconscientiousness on the part of
midwives ; and (3) the conduct of the patients themselves.
In his present sphere of work he has commenced an active
campaign against these evils, and in December, 1902, he
sent to every practitioner in East Prussia a pamphlet (in
a covering letter) describing the symptomatology and
diagnosis of cancer, impressing upon them the absolute
necessity of internal examination in every suspicious case,
givmg details of the technique for securing specimens for
diagnosis, and placing his laboratory at their disposal so
that their patients might, if possible, be spared the pains
and expense of an unnecessary journey, and the practitioner
still have the credit of understanding the case. To every
midwife he sent a flysheet pointing out that gynaecological
disease was outside their province and that it was incum-
bent upon them to refer all such cases to a medical man,
giving also the characteristic symptoms of uterine cancer,
and urging them to insist upon any woman, who com-
plained of such, consulting a doctor forthwith.
128 Reviews
But Professor Winter found that the conduct of the
patients themselves was far the most potent cause, and
feeling that every woman should know that cancer can
be cured by operation, but only in its earliest stages, he
published, early in 1903, in all the leading newspapers of
the pro\-ince, " A Word of Warning to Womankind," a
popular exposition of the Dangers of Cancer of the Uterus,
so worded as to be easily understood and yet not excite
morbid fear of the disease. These three documents are
reproduced in the notable monograph before us, as also
a circular interrogatory letter addressed to the medical
profession. In his article in the Zcntralhlati he is able to
report the very satisfactory results obtained by these
measures even in 1903, the first of his campaign. In that
year, no single physician, save one homoeopath, laid
himself open to blame by neglecting to make an immediate
internal exammation of a suspected case ; microscopical
examination for diagnosis was resorted to in thirty-nine
cases more than in the previous year ; out of seven mid-
wives consulted by patients, only one behaved improperly ;
the proportion of patients who sought advice within three
months of the earliest symptom rose from 32 to 57 per
cent., and that of those who followed the advice for opera-
tion within fourteen days of receiving it, from 78 to 90
per cent., and the operability of cancer of the uterus in
East Prussia increased from 62 to 74 per cent.
In a review of this very remarkable monograph, in
the same number of the ZentralblaU, Baisch, of Tuebingen.
mentions that in Wuertemburg, 77 per cent, of the women
with uterine cancer consulted their family doctor ; that
I4"6 per cent, of these doctors made no internal examination
at all ; that of those who on doing so found operable cancer,
only 57 per cent, advised operation immediately, and
though 30 per cent, more did so later, sometimes not for
months, 13 per cent, never did so at all. Midwives were
consulted by 16 per cent, of the patients, and kept more
than half the cases under their own care.
Reviews 129
It is earnestly to be hoped that the Royal Commis-
sioners, and the Central Board of ^lidwives, may consider
these facts, and that measures not less active than those
suggested by Dr. Lewers and Professor Japp Sinclair
may be taken to " stay the plague " in the United
Kingdom.
Orthmann's Handbook of Gynecological Pathology,
FOR Practitioners and Students. Translated by
C. Hubert Roberts, M.D.Lond., F.R.C.S., M.R.C.P.,
Physician to the Samaritan Hospital, &c., &c. ; assisted
by Max L. Trechmann, F.R.C.S., M.B., CM. Demy
8vo p,p. xvi. and 128, with 36 Plates. London : John
Bale, Sons and Danielsson, Ltd. Price 5s.
We reviewed Dr. E. G. Orthmann's " Vademecum fuer
histopathologische Untersuchungen in der Gynaekologie "
just three years ago, so may refer our readers back to
vol. xvii., p. 89, in regard to the matter of his excellent work.
The translation before us forms an admirable supplement to
Dr. Roberts's " Outlines of Gynaecological Pathology."
The diminished number of pages is accounted for by the
figures appearing on plate paper instead of in the text
as in the original. This is an improvement as regards
the microscopical sections, but must have very materially
increased the cost of publishing the work, which is never-
theless issued at the same price as the German edition.
The English text reads well, but in the preface there
is a mistranslation which implies not only that there is
such a thing as normal pathology, but also that the normal
histology of the female sexual organs is dealt with in the
second part of the book ; Dr. Orthmann, on the contrary,
saying that " in order not to overstep the prescribed
limits of the book he must presuppose the normal histology
known." We wish we could say this was the only
instance of carelessness in the translation.
VOL. XX. — NO. •]■]. 9
1 30 Reviews
The Practice of Obstetrics : Designed for the Use of
Students and Practitioners of Medicine. By J.
Clifton Edgar, Professor of Obstetrics and Clinical
Midwifery in the Cornell Univ^ersity Medical College ;
Attending Obstetrician to the New York Maternity
Hospital. Imp. 8vo, pp. i,iii, with 1,221 Illustra-
tions, many of which are in Colours. London :
Rebman, Ltd., 1904. Half Persia leather. Price 30s.
net.
In this large and handsome volume Dr. Edgar gives the
results of fifteen years' experience in practical midwifery
and clinical and didactic teaching. Our notice of it has
been unavoidably delayed, and we can now heartily endorse
the warm approval with which it has been received on
both sides of the Atlantic. No single work on Obstetrics
in the English language has appeared so well calculated to
meet the requirements of those engaged in, or in course of
training for, the practice of midwifery. It is clearly written
without prolixity and is eminently readable, the arrange-
ment of the matter is at once logical and practical.
To avoid repetition, Dr. Edgar begins the first of the ten
parts into which the book is divided, with the physiology of
the female genitalia ; indeed, except what was necessary in
regard to the pelvis and its contents in connection with
pregnancy and labour, anatomical descriptions have been
omitted. Eight parts are devoted successively to the
physiology and pathology of pregnancy, labour, child-bed
and the new-born, and the last to Obstetric Surgery, fol-
lowed by an appendix on case taking.
In the pathology of pregnancy much space is devoted
to the diseases of the decidua, membranes, umbilical cord,
and to the antenatal pathology of the foetus. The classi-
fied table of monstrosities is supplemented by a large
number of illustrations, chiefly from Ahlfeld's Atlas, and
by a convenient etymological key. Deformity of the
pelvis and cephalometry are very completely discussed,
and though Dr. Edgar is not unduly narrow as to the indica-
Reviews 1 3 ^
tions for the induction of labour, even admitting that the
question merits consideration in the " Candidate for tuber-
culosis," as well as for serious maternal, general, or local
diseases, he condemns any prophylaxis against conception
except chastity or excision of part of each tube.
The necessity of asepsis and antisepsis, as might be
expected, is urgently advocated; the author cannot too
strongly recommend the use of sterile rubber gloves, as
a routine practice in all confinement cases. Though, in his
opinion, no internal examination may be required in normal
cases, and meddlesome midwifery is bad, the physician's
object should not be to do as little as possible, but to watch
the course of labour so carefully as not to lose the proper
opportunity for interference ; one internal examination is
desirable before, and perhaps one after, the rupture of the
membranes, and in a normal case should be sufficient. In
the third stage, care against infection is still more imperative,
and no internal manipulation which is not absolutely
indispensable should be undertaken; we, therefore, are
rather surprised that the author, who discountenances
vaginal douching before labour, allows a single douche
after it, to promote the patient's comfort. An intra-
uterine douche he never employs unless an instrument or
the hand has been introduced into the cavity.
Nearly a hundred pages are given to the physiology
and pathology of the new-born ; artificial feeding is carefully
discussed, and a useful table of formula given for the home
medication of milk. In the treatment of asphyxia neona-
torum, Byrd's method, varied in the apoplectic form with
a few swingings in Schultze's way, is recommended.
The barbarism, " choriitis," on p. 211, is probably a
printer's error, if not it has been repented, as is shown
in the index, but there are few such mistakes, and the type,
paper, and binding, leave nothing to be desired. The
numerous illustrations, generally well chosen and well
executed, are hardly ever superfluous. Altogether, we can
heartily congratulate the author on his work, and on the
way his publishers have produced it.
132 Reviews
Surgical Diseases of the Abdomen, with Special
Reference to Diagnosis. By Richard Douglas,
M.D., formerly Professor of Gynaecology and Abdo-
minal Surgery in the Vanderbilt University, Nash-
ville, &c., &c. Large 8vo, pp. xii. and 884, Plates xx.
London : Rebman Ltd., 1903. Price 30s. net.
Now that the surgeon is daily more and more invading
the domain of the physician, and nowhere more so than
in abdominal affections, one would expect that in a treatise
on surgical diseases of the abdomen a large field of work
would be covered, and so it is in the volume written by
Dr. Douglas, for almost every abdominal organ is treated
in his book.
With the exception of the suprarenal capsule, the
book deals more or less exhaustively with every lesion
in the abdomen which a surgeon can be called on to treat,
and the work not only demonstrates the careful observa-
tions of the author, but its extensive bibliography reveals
the pains taken in comparing the work of others with
his own.
The author prefaces by remarking that he has refrained
from giving operative technique in detail because so many
manuals of practical surgery can be found now-a-days,
yet one cannot but feel that it is a misfortune that a sur-
geon of his experience has not given us somewhat more
of the practical details of operative treatment. The work
almost entirely deals with causation, pathology, symptoms
and diagnosis, differential and otherwise, and these are
aU described most minutely, and leave little room for
improvement ; yet in a surgical manual one ought to have
more practical definitions of the indications for operation
and of the operative measures themselves.
In regard to the diseases of the pelvic organs, fibro-
myoma of the uterus is discussed in an excellent but
somewhat brief chapter for such a subject, and we are
glad to see such a good description of the changes and
degenerations that may take place in these tumours, and
Reviezvs i 3 3
also on the very important question of pregnancy com-
plicating fibromyoma. A very good description is also
given of various cystic troubles in the ovary, but the
account of broad ligament cysts and diseases of the Fal-
lopian tube scarcely does justice to two such important
subjects.
The importance of ectopic gestation,, and the light which
has been thrown on this subject in recent years, is dealt
with in an admirable manner, especially in relation to
its pathology, symptoms, and diagnosis.
The book contains some "very good tables showing
the differential diagnosis between the various abdominal
affections,' and some of the plates, especially those showing
position and distribution of pain, are very explicit and
somewhat original.
Appendicitis is a subject to which the author has
devoted much space and much detail. To trauma as the
exciting cause of an attack he attaches some importance,
and no doubt owing to the position of the appendix on
the psoas, this may frequently occur during muscular
strain, and especially when the caecum is loaded. Like
many other modern writers, he distinguishes several kinds
of appendicitis ; indeed, according to his classification
htere are four various kinds with five sub- varieties. As
these are all practically merely degrees of appendicitis
and not distinct varieties of the inflammation, we think
this classification is not only clumsy but misleading. He
does not advise immediate operation in every case, but
recommends surgical interference if improvement has not
taken place in twenty-four hours.
In the chapter on intestinal obstruction the various
causes are not fully dealt with, nor does the author men-
tion the almost equal importance of evacuating the bowel
as well as relieving the obstruction. We cannot agree
with him that it is advisable to delay as much as twenty-
four hours while trying to reduce an intussusception by
distension, when any waiting leads to greater difficulty
134 Reviews
and greater risk in dealing with the bowel, should opera-
tion be afterwards found necessary. Peritonitis and the
various phenomena associated with it are all very clearly
dealt with, and also the question of gonorrhcea as a cause.
The author gives a most valuable and interesting
chapter on perforating typhoid ulcer, and deals in a mas-
terly way with gastric and duodenal ulcer, as well as with
gall-stones, abscess, and hydatids of the liver.
On the whole, the book is very well written, has a good
index, deals very minutely with the question of symptoms,
and above all with diagnosis ; and this, with an extensive
bibliography attached to each chapter, makes it a most
valuable work of reference.
Pathologie und Therapie der Rachitis. Von Ur. Wil-
HELM Stoeltzner, 1. Assistenten an der Kinder-
Poliklinik der Kgl. Charite und Privatdocenten an
der Universitaet zu Berlin. Mit drei Tafeln. Royal
8vo, pp. 176. Berlin : S. Karger, 1904. Price 4s.
This extremely well -written and well- arranged mono-
graph commences with a masterly summary of the develop-
ment of our knowledge of rickets, from the classical work
of Glisson in 1650 to the last important treatise by Vierordt
in 1896. After a short chapter on its geographical and
racial distribution, the author sketches the symptoms as they
affect — at first the general system — -and in the subsequent
course of the disease the bony skeleton, and the viscera and
their functions. As regards the time of onset, he holds that
the skeleton is not materially affected till some weeks after
birth. He estimates that in Berlin upwards of 90 per cent,
of all children are more or less rachitic, and though he
cannot assert that the disease, in itself, is ever fatal, it is
certainly indirectly a very important factor in infant mor-
tality. It is apt, particularly during teething, to be attended
by complications, by thoracic, intestinal, or nervous dis-
orders. As regards the pathology of the disease, Stoeltzner
differs from Dickinson, and does not admit the existence of
a visceral form of rachitis, holding that as yet no patholo-
Pitblications Received 135
gical changes analogous to the rachitic derangement of the
development of the bones has been demonstrated in other
organs, and he ventures to differ from Virchow, and defend
the pathological identity of rachitis and osteomalacia, while
admitting that they may be due to different causes.
The chapter on the Aetiology and Pathogenesis is the most
interesting in the book. Stoeltzner, after a critical review,
concludes that the first cause of rickets lies in the functional
insufficiency of an organ analogous to the thyroid gland,
and probably of the cortical substance of the suprarenal
capsules, an opinion in which he is supported by the
therapeutical use of the substance of these bodies in a long
series of cases.
After discussing the diagnosis, prophylaxis and treat-
ment, including that of children in public institutions,
Stoeltzner points out that the diseases of the bones, in the
foetus and new-born, which on superficial exammation
resemble rickets and have been called foetal rachitis, may be
classed in two groups : (i) Osteogenesis imperfecta (Stilling)
or fragilitas ossium (Klebs) or osteoporosis (Kundrat) ; or
(2) the cases of chondrodystrophia foetalis (Kaufmann) or
cretinoid dysplasia (Klebs), cases undoubtedly closely allied
to cretinism, and of which in his opinion the most marked
cases may be regarded as foetal myxoedema. A list of
literature, which though long does not pretend to be com-
plete, and three microscopical sections, are appended.
An interesting discussion took place at the American
Paediatric Society last year (Archives of Pa'diatrics, April,
1904), of a paper on rachitis in which Stoeltzner's previous
work is recognised.
PUBLICATIONS RECEIVED.
Owing to the length of the Proceedings in this number of the Journal, we
are compelled to hold over reviews of several of the following works : —
From J. F. Bergmann, Wiesbaden, by F. Bauermeister, Glasgow :
Handbuch der Geburtshuelfe ... In drei Baenden herausgegeben von
F. von Winckel, in Muenchen. Erster Band, II Haelfte, mit zahlreichen
Abbildungen im Text iind auf 21 Tafeln. Large 8vo, pp. x. and 645.
Price 13s. 9d.
136
Publications Received
Der normale Situs der Organe im Weiblichen Becken und ihre hauefigsten
Entwicklungshemmungen. Auf sagitallen, queren und frontalen Serien-
schnitten dargestellt von Professor Dr. HUGO Sellheim, I. Assislengarzt
an der Frauenklinik der Universitaet Freiburg i. B. , mit 40 lithographischen
Tafeln und 11 Figuren im Texte. Long quarto, 18 X 13 "5 inches. Price ;^3.
From Rebman Ltd., London :
A System of Physiologic Therapeutics. A Practical Exposition of the
Methods, other than Drug-giving, useful for the Prevention of Disease
and in the Treatment of the Sick. Edited by Solomon Solis Cohen,
A.M., M.D. Vol. VIL, Mechanotherapy and Physical Education, in-
cluding Massage and Exercise, by John K. Mitchell, M.D. ; and
Physical Education by Muscular Exercises, by LuTHER Halsey Gulick,
M.D. 1904, Eleven volumes. $27 '50.
From Breitkopk und Haertel, Leipzig:
Die Cystoscopie des Gynaekologen von Dr. Walter Stoeckel, Oberarzt
an der Universitaets-Frauenklinik zu Erlangen. Mit neun farbigen Tafeln
und vielen Abbildungen im Text. Demy 8vo, pp. x. and 321. Price 8 M.
From Franz Deuticke, Leipzig and Wien :
Die biulogische Bedeutung der Eierstoecke nach Entfernung der Gebaer-
mutter ; experimentelle und klinische Studien, von Dr. Ludvvig Mandl,
Privatdozent fuer Geburtshuelfe und Gynaekologie an der Universitaet in
Wien, und Dr. Oscar Buerger, i. Assistent der ersten Universitaets
frauenklinik in Wien; mit 6 Abbildungen und 14 Kurven in Text, sowie
13 Tafeln im Anhang. Royal 8vo, pp. iv. and 240. Price 7 marks.
From W. B. Saunders and Co., Philadelphia, New York, and London :
Atlas and Epitome of Operative Gynaecology, by Dr. Oscar Schaeffer,
Privatdozent of Obstetrics and Gynecology in the University of Heidel-
berg. Authorised translation from the German, with editorial notes and
additions by J. Clarence Webster, M.D., F.R.C.P., F.R.S.E., Pro-
fessor of Obstetrics and Gynaecology in Rush Medical College, &c., &c.
W^ith 42 coloured lithographic plates and many text illustrations, some in
colours. 1904. Cloth. Price 13s. net.
Transactions of the North of England Obstetrical and Gyneco-
logical Society, Fasciculi ii. and iii., 1904.
From the Authors :
Ovariotomy and Hysterectomy in Martha Ward, St. Bartholomew's
Hospital, by Harrison Cripps, F.R.C.S.
Primary Sarcoma of the Vagina in the Adult, with the Notes of a
Case by Henry Jellett, M.D., F.R.C.P.L, Gynecologist to St. Steevens
Hospital, and H. C. Earl, M.D., F.R.C.P.L, Pathologist to the
Richmond Hospital, Dublin.
Notes on the Occurrence of Gall-stones in Insane W^omen ; Advances
IN Pelvic Surgery during the past ten years; The Mischievous in
Midwifery ; and Acute General Staphylococcic Infection through the
Puerperal Breast ; by W. P. Manton, M.D., Adjunct Professor of
Obstetrics, and Professor of Clinical Gyncecology in the Detroit College
of Medicine, &c., &c.
Lehrbuch der Hebammenkunst, von Dr. Bernhard Sigmund Schultze,
wirkl. Geheimer Rat, off. ord. Professor der Geburtshuelfe zu Jena,
Mitglied der Medizinalkommission des Grossherzegtums Sachsen. Drei-
zehnte (13th) Auflage, mit 102 Abbildungen. Leipsig Verlag von
Wilhelm Engelmann, 1904.
The Closure of Laparotomy Wounds as Practised in Germany and Austria,
from upwards of fifty reports, edited and translated by Walter H. Swafijield,
M.D., F.R.C.S. Edin., dc. 1904.
THE BRITISH
GYNECOLOGICAL
JOURNAL.
Vol. XX. — No. 78. August, 1904.
BRITISH GYNAECOLOGICAL SOCIETY.
Thursday, May 12, 1904.
Professor JOHN W. TAYLOR, ^LD., F.R.C.S., President,
IN THE Chair.
Specimens and Cases.
The President exhibited : —
(i) A Loop of Gangrenous Bowel Successfully
Removed from a Patient with Strangulated
Hernia; the Hernia being one of the Cicatrix
AFTER Abdominal Hysterectomy.
My first specimen, gentlemen, is a loop of semi-gan-
grenous intestine (together with its solid, undigested con-
tents) successfully excised from an old lady, aged 77, who
had been suffering for twenty-four hours from a strangulated
hernia in the middle line of the abdomen. The hernia was
one of the cicatrix after abdominal section and partial
hysterectomy for fibroids, performed by one of my old
colleagues twenty-three years previously (April 22, 1879).
This original operation was regarded, and most rightly
regarded, as one of the most signal triumphs of abdominal
surgery at that date. I have assumed in my notice tiiat it
VOL. XX. — no. 78. 10
138 The British GyncEco logical Society
was done by the clamp or " serre noeud," but the old records
are imperfect, and the exact method of operation employed
appears to be doubtful. In any case, whether by clamp or
otherwise, in the course of several years the bowel became
very adherent to the scar, and at the lower end of this
a large callous opening was to be felt in the abdominal-
wall, through which a certain amount of bowel frequently
protruded. No appliance could apparently be worn with
comfort, or even endured, and at the time the strangulation
occurred nothing was being worn except a belt bandage.
About 4 p.m. on April 4, 1902, the patient was seized with
severe abdominal pain and vomiting, which continued all
night. On the 5th she was seen by Dr. Clark, who found
a very tense, red, hard and glazy swelling (like a coil of
distended bowel), projecting from the abdomen across the
lower part of the cicatrix. It was quite irreducible. No
time was then lost in arranging for the patient's admission
to hospital, where I saw her at 4 p.m., and operated. On
opening the sac it was seen that the tumour was formed by
one loop of bowej bent into the shape of a capital T. It
was distended, black, at one part papery and apparently at
the point of bursting. It had, too, the faint sour odour of
commencing decomposition. After thoroughly freeing the
loop, the ends were clamped, the bowel cut through, the
mesentery nipped off, its vessels tied, and the loop removed.
The cut ends were then joined together by continuous
suture without any bobbin or artificial aid. The primary
suture was closed in by two other circles of continuous
suture. An effort was made to close the hernial opening,
but this was found to be impossible. The old circle of
cicatricial tissue was quite rigid and unyielding, and an
extensive excision of the abdominal wall could alone have
resolved this into its separate constituents.
The patient was very ill for two days, but made a perfect
recovery, and when she was fully convalescent a rubber
air-pad fitted underneath an abdominal truss, gave her relief
and safety. 1 have seen her several times during the last
two years, and siie continues well and is fairly vigorous.
specimens and Cases 139
The specimen of intestine removed, on being opened,
was found to contain a large quantity of nodules of un-
digested meat, which appeared to be the remains of a
kidney pie. These seem to be partially responsible for the
obstruction and strangulation. At first (in all probability)
they were able to enter the loop of bowel, but none could
be passed on through the distal end of the loop. Then, as
the loop became distended and inflamed, both ends were
tightly nipped by the callous margins of the ring, and
strangulation became complete.
The case seems to be one of some interest, first, as
a successful enterectomy under difficult circumstances ;
secondly, as illustrating the far-reaching danger to which
a patient is exposed after abdominal section, with that
imperfect closure of the wound which was so common a
feature of the old operation ; and thirdly, as an illustration
of the method by which an acute strangulation may take
place even with a large hernial opening.
(2) Broad Ligament Cyst Removed by Vaginal
Enucleation.
The other two specimens were removed by vaginal
section. The first is one of broad ligament cyst removed
by vaginal enucleation. P'or some years I had been rathei^
looking out for a suitable broad ligament cyst to remove
fcr vaginam, but it was not until three months ago that I
found the case. This was a fixed, tense cystic tumour to
the left of the uterus reaching about half-way to the
umbilicus above, displacing the uterus to the right, and
coming down low enough somewhat to depress the left
lateral fornix. The patient was a single woman, aged 51,
who had ceased menstruating for several years. On January
12, 1904, I opened the vaginal vault on the left side, extend-
ing the incision rather behind the cervix, and readily found
the lower limit of the cyst. I tapped the cyst, removing
from one and a half to two pints of fluid containing choles-
terin crystals, and then finding that I could differentiate the
140 The British Gyiuccological Society
true cyst wall from its outer coverings, I enucleated the
cyst from its bed by my fingers. The chief difificulty was
about the higher middle zone of the tumour. When this
was passed the upper part of the broad ligament appeared
to invert on traction, and the manipulation was rendered
easier.
In the course of the operation I made a small opening
inadvertently into the peritoneum just anterior to the open-
ing into the broad ligament, so that I could easily verify the
peritoneal relations of the envelope. Both cavity and peri-
toneum were drained with separate drains of iodoform
gauze.
The patient did well, but developed a high temperature
— 104°, W'ith rapid respiration (40), and quick pulse (128),
on the night following the operation. This came down in
the course of the following day, and it was a question
whether the transient attack may have been due to iodoform
poisoning. The patient went home convalescent on
January 30.
{3) TuBO-OvARiAX Cyst Removed by Posterior Vaginal
CCELIOTOMY.
The third specimen is a real tubo-ovarian cyst of the left
side, removed from a married woman, aged 31, on January
21, 1904, by posterior vaginal coeliotomy. I had removed
a smaller tubo-ovarian cyst of the right side some five years
previously, from the same patient, by the same method.
There were no adhesions. The fluid removed from the
cyst was brownish, and rather turbid, as if mixed with some
blood or secretion from the tube. The patient was dis-
charged on February 5, 1904.
Dr. Heywood Smith asked what hindrance there had
been to cutting away the cicatricial ring of the hernia and
bringing the parts together ; would that have involved the
sacrifice of too much of the abdominal wall ?
Specimens and Cases 141
Dr. Macnaughton-Jones said that the important point in
regard to the President's second case was that of diagnosis.
If we were certain beforehand that we had to deal with
a simple cyst of the broad ligament, we might no doubt, b\-
attacking it by the vagina, avoid an abdominal coeliotomy,
and that would be an obvious advantage ; but should there
be adhesions or other complications above the broad liga-
ment, there might be great difficulty in operating by the
vagina, just as there was in the vaginal removal of some
forms of ovarian cyst. He had seen Schauta remove bv
the vagina an ovarian cyst of considerable size, but he had
known most experienced operators meet with complications
that they had not detected in making their diagnosis, and
who were compelled to abandon the vaginal for the abdo-
minal route. The diagnosis was much harder in the
instance of a broad ligament cyst, and, bearing in mind
the risks of unknown complications and the many points
that made the diagnosis obscure, he, personally, would
prefer to attack a broad ligament cyst by the abdominal
route.
The President, in answer to Dr. Heywood Smith, said
that there were two reasons for not doing more than he
did in the case of hernia : First, the condition of the
patient, with a gangrenous bowel strangulated for four-and-
twenty hours, was necessarily most critical ; indeed, it was
a question whether there was time to do the excision of
the bowel while she was alive ; secondly, the induration
and thickening of the scar tissue after the first operation
was so marked and so extended (as it often was in such
cases), that it would have been necessary to excise some
inch or more on both sides of the original wound in order
to distinguish the various constituents of the abdominal
wall, and there would not have been enough tissue left to
close the abdomen afterwards. He did not think, after the
lapse of so many years, there was any possibility of restor-
ing the condition as it was at first, unless the abdomen
had been so lax that a considerable amount of the wall
14- The British Gynecological Society
could have been sacrificed. With regard to the broad
ligament cyst, and Dr. Macnaughton-Jones's remarks on
its removal by the vagina, he might say that the operator
could very easily recognise any complications not detected
beforehand through the vaginal roof, and could, if neces-
sary, alter his route to the abdominal one ; moreover, in
nearly every case in which there were such complications,
the opening of the vaginal vault would be of help, for the
vaginal drain would be of service. No simple uncompli-
cated case treated by abdominal section required drainage,
but if the route had to be altered from the vaginal to the
abdominal one, the operator would probably be glad of
the vaginal drain.
Discussion on the Application of Pessaries, and
THEIR Dangers.
Dr. AIacnaughton-Jones, before the opening of the
discussion upon his paper (see ante, p. 97), illustrated the
method of shaping the supports suitable for individual cases,
by moulding several pessaries from the semi-transparent
celluloid rings recommended by Schultze, which he pointed
out were not only the lightest and strongest made, but
never after application altered in form from the shape so
given them.
Dr. Heywood Smith thought that as regarded the
dangers of pessaries the great pitfall open to practitioners
was the mistaken idea that the application of a pessary in
a case of retroversion, was sufficient to cure the displace-
ment ; indeed, it was not unusual to meet with cases of
backward displacement in which pessaries had been in-
serted without any previous attempt to place the uterus in
its proper position. All that a pessary could do was to
support the uterus during the process of cure, which some-
times took eighteen months or two years, during which time
the patient had to be kept fairly quiet so that no relapse
should occur. The Hodge pessary and its modifications
were the instruments most used in this country. The
Discussion on Pessaries and their Dangers 143
Smith-Hodge, when first brought out, though almost flat,
had a shght curve at each end. Unknown to each other,
Dr. Albert Smith, of Philadelphia, and he himself, had
devised the curve, which Dr. Macnaughton-jones, in a
slightly exaggerated shape, called his S-shape. There were
cases in which the uterus could not be kept in position by
the Smith-Hodge pessary unless the vaginal wall, especially
the upper portion of it, was put upon the stretch ; if the
pessary were too short, on the least strain or exertion by
the patient the uterus would bend over the upper arm of
the instrument into an increased retroflexion, and there
would be irritation and congestion at the seat of the bend.
When there was congestion and endometritis, it was often
best to put the patient to bed, bleed the uterus, and apply
tampons and use hot douches until the uterus would bear
reposition and the support of a pessary. Dr. Macnaughton-
jones seemed to imply that bimanual replacement had
altogether superseded reposition by the sound ; in that he
could not concur, but considered that when the uterus had
become fairly insensitive and the sound could be passed
without causing any discomfort, reposition by the sound
was a great advantage, as by it the fundus could be brought
on to the pubes and the uterus placed in a position of
exaggerated anteversion, from which it was less likely to
fall back into retroversion. Every woman wearing a pessary
should be kept under observation to make sure that the
instrument kept its place. The patient should not be
encouraged to remove and replace it herself ; no doubt, if
carefully instructed, she might take out and replace a ring,
but a Smith-Hodge was a different matter ; even medical
men sometimes put them in wrongly. Moreover, if the
uterus had fallen back, the patient could not replace it, and
the introduction of a pessary below a displaced uterus was
worse than useless. For anteflexion he was sure that no
pessary outside the uterus was of any benefit ; some form
of intra-uterine stem must be employed. The patient should
be prepared by a week or two in bed, the cervical canal
144 ^-^^^ British GyiKTco logical Society
incised slightly and forcibly dilated, and a stem, preferably
of glass with a large button, slipped in. The stem should
be neither too long nor too short, and should be retained
in the position by rest in bed till after the next period was
passed. He disapproved of any string being attached to the
stem, as, when soiled by discharges, it would form a likely
source of septic trouble. For prolapse, an elastic ring was
the best support, and, if sufficiently large, would often
obviate the necessity for a serious operation.
Dr. C. H. F. ROUTH had no doubt that the ingenious
method described by Dr. Macnaughton-jones would be
very useful in many cases, but there was an objection in
the fact that celluloid w^as a very inflammable substance
and dangerous to be handled by servants. He exhibited
several specimens of the pessary he preferred himself — a
Hodge pessary, which he had supplemented with a ring
carrying a hollow stem, the ring being on an axis, which
allowed it to play for the movements of the uterus, but the
instrument could not fall out. His plan was to reduce the
congestion by bleeding, by puncture, or even by leeches,
and to introduce a sea-tangle tent adapted to the curve of
the uterus and sw^athed in cotton wool dipped in pure
carbolic acid. This caused some bleeding for a few days,
and when he found that the inflammation had passed away
and the size of the uterus had diminished, he applied the
instrument and generally left it /// 5/7// for six months. He
had never had any evil results from this method, which had
with him been very successful, and especially so in curing
sterility. Seven women out of eight from one town, who
had been previously sterile, conceived after being so
treated.
Dr. Herbert Snow said that some objection might
be taken to the title of the paper for which perhaps Dr.
Macnaughton-Jones was not altogether responsible, as it
seemed to be rather a laudation of pessaries than otherwise.
He did not think that the mischief arising from pessaries
improperly introduced, owdng to a wrong diagnosis, should
Discussion on Pessaries and their Dangers 145
be attributed to the pessaries, but of course the dangers
attending their use were real. As a student he had seen
a large ring shaped like a cart-wheel, with two ridges on
its circumference, dug out of a woman's vagina, where it
had lain nearly a dozen years, and caused ulceration before
and behind. He thought that the forms of pessaries used
were unnecessarily numerous and complicated. They were,
he thought, used for three purposes : hrst for the relief of
pain ; a ring pessary would relieve the pain of a prolapsed
ovary certainly for a time ; it kept the vagina taut and gave
the needful support to the relaxed muscular walls. It no
doubt had often some effect by hypnotic suggestion, though
it was not desirable to dwell too much on that. The second
purpose was to retain in their place organs which otherwise
would prolapse, and he was glad to hear Dr. Heywood
Smith favour the treatment of uterine prolapse by the same
instrument — an elastic ring. Thirdly, a pessary was used
to rectify the position of a retroflexed or retroverted uterus.
Happily, anteversion was not now, as in his student days,
looked upon as a pathological condition. Personally, he
thought that no pessary should ever be employed for the
rectification of a flexion, seeing that the pain and other
ill-sjmiptoms almost wholly resulted from internal adhe-
sions which could not be dealt with instrumentally. Xo
harm attended an ordinary flexion or version when the
uterus was mobile, and in the absence of previous peri-
metritis. Moreover, the natural movements of the organ
with the varying distension of bladder and rectum, in
addition, the frequently short intravaginal cervix, commonly
precluded rectification by the best intentioned pessary. He
thought the simple elastic ring, while perfectly innocuous,
effected every benefit possible, and that the true principle
for pessaries in general should be that of support to the
relaxed vaginal wall and pendulous pelvic viscera, but
nothing more.
Dr. R. H. Hodgson said that m an experience of
twenty years he had never met with an instance in which
146 The British Gyncecological Society
the introduction of a suitable pessary, or stem, in a suit-
able case had been followed by serious consequences. Of
course, before any pessary was introduced, the congestion
which had probably contributed to the displacement should
be relieved. A neglected pessary might cause mischief ; he
had known many instruments retained for long periods, the
worst case being one in which an instrument inserted by an
eminent surgeon in Paris had been left in for several years
and had caused a vesico-vaginal fistula. There was some
contradiction in the paper in regard to the "stretching"
of the vaginal walls. It was no doubt indispensable that
the pessary should keep the walls of the vagina taut, <md
the omission of the word " stretch " would probably put
the description right for both classes of cases. He did not
see how even an S pessary properly introduced could press
against the fundus uteri. It would only be in a very
extreme backward displacement that the fundus uteri could
come in contact with the floor of Douglas' pouch, and if,
as was to be presumed, the normal position of the uterus
had been restored before the pessary was inserted, the
pessary would not even press against the body of the
uterus. The action of an S pessary is to raise the vault of
the posterior cul-de-sac and thereby draw backwards the
cervix, to raise the floor of Douglas' pouch, and thus, by
lessening the curve therein, to lengthen the antero-posterior
diameter of that pouch, whereby the back traction on the
fundus is lessened, to push back by means of the convex
surface of the upper end of the pessary the posterior vaginal
wall and correspondingly draw backwards the anterior wall ;
and as the lower end of the anterior wall is prevented from
rising by the lower end of the pessary, the drawing back-
wards of the upper end of the anterior wall of the vagina
draws down the anterior vault and with it the anterior
surface of the uterus, the lessening of the backward tension
of Douglas' pouch and the drawing downwards of the
anterior cul-de-sac being in his opinion the chief factors
which enable an S pessary to retain the uterus in its
Discussion on Pessaries and their Dangers 147
normal position. Therefore it follows that an ill-fitting
pessary, or a pessary in an abnormally relaxed vagina, fails
to give the relief sought. He was sorry to hear the use
of stems denounced, because, while he had never seen any
harm from them, he had in a number of cases known them
relieve pain that had been of years' duration.
Dr. J. A. Mansell Moullin agreed with much that
had been said by Dr. Heywood Smith and by Dr. Hodgson,
but did not think they had been quite correct about the
exact action of the pessary. The first effect of the instru-
ment was as described in the paper. In almost every case
of retroflexion or retroversion there was more or less
sinking of the vagina, and the first action of the Hodge
was to elongate and restore the vagina to its normal shape,
but not to stretch it or even make it taut. The second
action was merely mechanical. If the posterior vaginal
vault was deep enough for the pessary to rise well behind
the uterus the fundus could not fall backwards. A tampon
of cotton wool would act in the same way. He thought
that the effect of the pessary as a lever had been greatly
exaggerated ; the idea of respiration acting first on one and
then on the other end of the pessary was very far-fetched.
Mr. Stanmore Bishop said he was disappointed not
to see more general practitioners present, for he thought
that they saw more of the evil results of pessaries, and
were certainly more tempted to use them than hospital
surgeons. He entirely believed in the lever action of
pessaries, but thought that as regarded their use a dis-
tinction should be drawn between flexion, version and
prolapse. A flexion was often due to softening of the
uterus from endometritis, and associated with inflamma-
tion of the adnexa, and he thought that pessaries in such
cases could do very little good and were likely to do much
harm. Yet it was in flexions that the practitioner seemed
most inclined to apply a pessary and omit to impress on
the patient the necessity of medical control. Version pre-
supposed a firm body, against which a lever could act with
148 The British Gyncecological Society
effect. He was glad to tind that anteversion, as a patho-
logical condition, was practically ignored, and thought it
should be known that the British Gynascological Society
condemned the use of pessaries in young women supposed
to be suffering from anteversion, but whose trouble was
either hysterical or due to some totally different cause.
He had the strongest objection to the use of a pessary
merely as a means of hypnotic suggestion. He had seen
much evil result from the use of pessaries in young
unmarried women for supposed pathological anteversion.
As regarded anteflexion, if its effects were so serious as
graphically described by Dr. Routh, should the operations
of Duehrssen and Mackenrodt be countenanced for any
displacement of the uterus ? The most difficult cases of
prolapse were in women who would not submit to opera-
tion, and if one put in a ring big enough to retain the
uterus, the woman probably failed to report herself till the
instrument was coated with foul deposit.
These rings acted by still further distending the already
over-dilated vagina, and he had seen uteri descend through
them. In these cases pessaries of any kind were useless,
and operation was the only reasonable resource. Since
advocating his own operation before the Society in De-
cember, 1902, which aimed at reproducing the sacro-uterine
attachments, he had operated on several others, in all
with good results. He thought age w'as no bar to opera-
tion since one of the later cases was that of a woman aged
61 years.
The President, speaking of the difficulties of diagnosis
referred to by Dr. Macnaughton-Jones, admitted that such
difficulties were met with, but said they should maintain
a high ideal, and it w^ould ill become the Society to admit
that these difficulties were at all insurmountable save in the
most exceptional cases. He had little doubt that it was
some negligence, some want of observation of symptoms
as well as physical signs, which was mainly responsible for
the mistakes. He was sorry that more had not been said
Discussion on Pessaries and their Dangers 149
as to the real dangers of pessaries and their continued use,
which in his opinion were twofold. In the first place, after
a pessary had been worn for some time pelvic disease was
apt to develop, either from the rekindling of an old inflam-
mation, possibly the original cause of the displacement, or
from the onset of some new infection. In the latter
instance the pessary itself might be the means of infection
from without ; in other cases its presence had undoubtedly
disturbed normal marital relations and suggested to the
liusband some excuse for occasional unfaithfulness. A
pessary might be worn for years, by one who was past the
change of life, without any harm resulting, but in young
women the use of a pessary was apt to lead to some form
of infection. The second danger he would mention was
from stretching. He held with Dr. Heywood Smith that a
pessary, to be of use in retroversion, must elevate the vaginal
vault behind the cervix, and by doing so, it hangs up the
cervix, like the prop does a clothes-line, and the fundus
falls forwards. As a temporary measure that is very useful,
but by stretching the sacro-uterine ligaments it does exactly
the wrong thing. In his own opinion pessaries might be
applied in middle life in order to ascertain whether the
symptoms complained of were due to displacement of the
uterus or not. If they were found to be so, the case was
one for operation. Many years ago, when Schultze's book
was first published, he had procured celluloid rings from
abroad and made pessaries in the way described by Dr.
Macnaughton-Jones. He had used them extensively, but
had not found them satisfactory. The figure of 8, especially,
seemed to cause much trouble with the rectum, and, like
Dr. Macnaughton-Jones, he had reason to prefer the Smith-
Hodge or the "S" pessary. Moreover, though he got his
rings from abroad, he found that after lying for four or five
weeks in the vagina, they altered considerably in shape.
The celluloid now supplied might possibly be better. He
had found that for prolapse in oldish women the best
pessary for keeping up the uterus was Tait's modification
I 50 The British Gynaecological Society
of Simpson's shelf pessary, which had all the advantages,
without the demerits, of Zwanke's.
Dr. Macnaughton-Jones, having thanked the Fellows
for the way in which they had received his paper, said, in
reply, that the dangers arising from pessaries might be
either of a positive or negative nature. The former he had
not dwelt on much, because they were obvious to everyone,
but rather on the latter. His contention was that pessaries
were often applied under conditions in which not only
were they useless and possibly mischievous in themselves,
but were dangerous, because they encouraged an expectant
treatment of inflammatory states which might be arrested
and cured by operative measures, the woman's mind being,
as had been suggested, " hypnotised " into the belief that
in some measure her affection was being cured and her
sufferings mitigated, by the insertion of a pessary. Serious
pelvic complications thus increased in severity, endangering
the woman's life and increasing her risk from the final
operative interference. As to the term " letter S," which
Dr. Heywood Smith had referred to, much ingenuity could
not be claimed for simply altering the shape and curve of
the original Smith-Hodge. It decidedly was not well, in
the case of certain pessaries, such as Fowler's or Galabin's,
to leave it to the patient to remove or replace them, espe-
cially the latter, nor could she replace the modification of
the hoop pessary he had moulded. Those to which he
was referring were such as the ordinary glycerine ring, or
the Smith-Hodge. There were many circumstances under
which patients might find themselves when any pessary
ought to be removed, and under these conditions they
should at least be able to withdraw it, and they should be
taught how to do this. William Goodell was one of the
most practical and discreet American gynaecologists of
his day, and he (Dr. Macnaughton-Jones) had purposely
taken his amplification of Hodge's view of the action of
his pessary, and had quoted this as he believed it to be
complete and correct. The opinion of Matthews Duncan
Discussion on Pessaries and their Dangers 1 5 1
in England, of Gaillard Thomas and Marion Sims in
America, as to the dangers which accrued from the misuse
of a pessary, was expressed in much stronger language than
that used by him. All he had to say of stem pessaries was,
that he did not use them, save, as he stated, only occasion-
ally and under exceptional circumstances, and then only as
a post-operative aid in maintaining dilatation after division
of the uterine canal. They were worn but for a very short
time. The celluloid stem was safe and clean, and the
string of silk or non-absorbable cotton {Celloidinzwirn)
attached for withdrawal, if necessary, did no harm. As to
the action of the Smith-Hodge or its modification, which
he had depicted as the " S " pessary, he totally differed from
the opinions which had been expressed as to its mode of
action. He still looked on it as a lever when properly
applied, as explained by Goodell, and this view was also
that of Schultze. The celluloid cushion was an admirable
pessary, easily kept aseptic, and worn after the uterus had
been retained in proper position for some time, but where
there was a tendency again to retrovert. Robert Barnes it
was who first adopted the rubber cushion of air or glycerine.
Braxton Hicks also used a pessary with a celluloid cushion.
He (Dr. Macnaughton-Jones) repeated that Galabin's ante-
version pessary was one of the most valuable of all means
of relieving certain symptoms due to exaggerated and
abnormal anteversion or anteflexion of the uterus. It was,
as he had shown in the diagrams, of special service in an
anteflexed uterus, or one in which there was a myoma in
the anterior wall, also in cases of cystocele. It could be
closely imitated, as he had shown, by the moulding of a
Schultze's or wire celluloid ring. He did not agree with
what had been said as to the softness of the uterus in
flexions, and how far we should be influenced by this in
the application of a pessary, for in an old flexion there
v/as frequently a greater degree of hardening than in the
simple retroversion. As to prolapse, he felt strongly that
pessaries should only be used in the earliest stages, and
152 The British GyncBcological Society
never advised when the descent became more apparent,
unless the patient absolutely refused operation. The very
class in which prolapse most frequently occurred was that
in which operative measures were most demanded in order
to enable the sufferer to earn her bread. If we urged
operations of different kinds in other forms of displacement,
it was equally, if not more important that the woman who
suffered from prolapse should be made aware of the
probable if not inevitable misery before her should she
decline operation, and urged not to postpone it until far
graver and more serious procedures would have to be
carried out. With regard to ideal diagnosis, while this was
doubtless always to be aimed at, it was frequently not
attained, and several of the conditions mistaken for retro-
displacements were difficult to differentiate, and not possible
without an anaesthetic. As he had stated, he had seen
every complication he had mentioned or depicted, where a
pessary had been worn up to the time of an operation,
during the performance of which the actual nature of the
condition present was for the first time disclosed.
specimen 1 5 .
BRITISH GYNECOLOGICAL SOCIETY.
Thursday, June 9, 1904.
Professor JOHN W.TAYLOR, M.D., F.R.C.S., President, in the
Chair.
GlAXT Myomata.
Mr. Charles Ryall, in the absence of Mr. Bowreman
Jessett, exhibited an enormous soft myoma undergoing cal-
careous degeneration. The patient was past the meno-
pause, but as tlie tumour was continuing to grow Mr. Jessett
decided to remove it, though an attempt to do so in one of
the London general hospitals had been abandoned. The
tumour was adherent for at least three inches on each side
of the middle line from the pubes to above the umbilicus,
the capsule being intimately blended with the parietal peri-
toneum. The patient suffered from considerable shock,
for which she received intravenous transfusion, and saline
solution was also left in the abdominal cavity. Otherwise
she bore the operation well. The tumour weighed about
26 lbs.
Dr. Macxaughtox-Joxes said giant myomata were not
always more difficult to remove than small tumours. Four
years ago he had removed one weighing 28-5 lbs., which,
besides its attachment to the uterus, had a large pedicle to
the broad ligament, and was also adherent to the bladder.
The bladder was opened during the operation, but imme-
diately stitched up, and the patient did well, and is now in
perfect health.
Dr. C. H. F. RouTH mentioned that he had successfully
removed a tumour weighing 22 "5 lbs.
The President asked whether the pelvis was free, or
VOL. XX. — NO. 78. II
'54 The British Gynceco logical Society
whether any portion of the tumour, which was interesting
not only from its size but from its situation, had to be
enucleated from the pelvic cavity.
Mr, Ryall replied that the tumour was not at all
adherent to the pelvis.
The Downes Electro-Thermic Angiotribe. By H.
Macnaughton-Jones, M.D.Q.U.I., M.A.O.R.U.l. (Hon.
Causa), F.R.C.S.Irel. and Edin.
I show these appliances for Dr. Andrew Downes of
Philadelphia, and you will agree wuth me that they are as
skilfully devised and as beautifully constructed instruments
as one can well conceive. It will be remembered that so
far back as 1862 Baker Brown used the cautery in the treat-
ment of ovarian pedicles. Keith also adopted this method,
and so did Lawson Tait. Byrne adopted the galvano-
cautery with considerable success for operations on the
uterus, especially in malignant conditions. To Skene of
Brooklyn, however, is due the credit of introducing the
practice of electro-ha^mostasis — that is, the control of
haemorrhage by the combination of forcipressure with heat
produced by electricity.^ Jacobs of Brussels in 1899 advo-
cated it instead of ligature, clamp, or forcipressure by lever,
the advantages claimed being that there is no sloughing of
the tissues, that it enables us to act on a large surface,
occluding the lymphatics, and opposing an obstacle to the
spread of mfection. Also, no bleeding surface is exposed
which is calculated to form adhesions with surrounding
structures. Again, w-here tissues are friable and the appli-
cation of a ligature is risky, the application of haemostasis
is safe. Jacobs used various haemostatic clamp forceps and
indicated their use in cases of ovarian cystoma and pan-
hysterectomy, as well as in appendicectomy and resection
* Revue de Gynecologic, July— August, 1889.
Macnatighton- J ones on the Downes Angiotribe 155
of the omentum.' He had then (August, 1899) performed
six abdominal hysterectomies and two ovariotomies, besides
other operations without an accident, and Skene had carried
out over 200 coeUotomies without any haemorrhage. The
strength of the current was regulated by the interposition
of a galvanometer, the time necessary for the desiccation
being from half a minute to two minutes.
PUnnu
connecCi with ^adt
Inner surf a.ce of ^orcepi (scretj
( fteaCinf ila.de) \
^mutation {Mica.}
Coin^cti luiC/t Transformer
or sCtra^t SatCeri^
Fig. I. — Section of the heating blade.
Fig. 2. — Protecting shield.
The main improvements aimed at by Dr. Downes were
the ability to raise the heating point to 212° F., the insuring
of cool shafts and handles to the instrument, greater security
in the construction of the blades for the resistance of heat,
and increase in the degree of pressure exerted.- The outfit
consists of three angiotribes with blades of different widths,
' Macnaughton-Jones, "Diseases of Women and Uterine Therapeu-
tics," Eighth Edition, 1900.
- American Medicine^ May 24 and November 28, 1903 ; also American
Gyncccology^ July, 1903.
156
The British Gynecological Society
a quarter, three-eighths, and half an inch, one of the angio-
tribes being curved ; a shield to protect the surrounding
parts, a cautery knife, cable, transformer for use with the
continuous or the alternating current, and the necessary
electric supply. A maximum current of 60 amperes is
Fig. 3A. — Lever electro-hremostatic angiotribe with straight blades. The blades
open on releasing the lever.
Fig. 3B. — Lever electro-hsemostatic angiotribe with curved blades.
Fig. 3c. — Electro-hremostatic forceps without lever.
necessary, and the platinum in all the instruments should
be of the same weight. The advantage of this high am-
perage is that the heat developed in the platinum causes the
blades to heat more rapidly and effectually than with the
lesser current, while there is less risk of burning out the
platinum. The cable used is composed of mineral and
Macnaughton- [ones on the Doivites Angiotribe 157
rubber and will stand indefinite boiling, while it can be
made in two portions, so that the coupler alone need be
sterilised for each operation.
Fig. I shows the section of the heating blade, the inner
surface being made of steel, inside which are the layers of
mica insulating the platinum. It also shows the connections
with the transformer of a storage battery. Fig. 2 illustrates
the protecting shield. Fig. 3A shows the lever angiotribe
Fig. 4. — The cable and coupler.
Fig. 5. — Thermo-cautery knife.
closed, and fig. 3B the same with curved blades. On releas-
ing the lever the handles spring open. On reclosure, when
the lever is adjusted, greater pressure is exerted on the blades.
Fig. 3c shows the angiotribe without the lever. It is less
powerful in its forcipressure action than that with the lever.
Fig. 4 shows the cable and coupler. Dr. Downes has
devised a foot breaker for the control of the current, so
that it may be turned on when required by pressure of the
foot. All that is necessary to heat the instruments is gradu-
ally to turn on the rheostat of the transformer until the
158 The British Gyncecological Society
platinum in the cautery knife (fig. 5) or in the heater is a
bright red. The transformer may be set at this point in
the operating room, thus securing the necessary electrical
supply by pressure of the foot at the required time. Water
placed on the pressing surface of the blades will boil in ten,
fifteen or twenty seconds, according to the width of the
blades already mentioned. From ten to thirty seconds
longer must be allowed after the application of the instru-
ment for the haemostasis.
In the latest reprint of his pamphlet on the subject, Dr.
Downes enters into details of the various operations — such
as ovariotomy, salpingo-oophorectomy, herniotomy, appen-
dicectomy, and various intestinal operations, as well as those
on the stomach — which may be performed by this method.
He also describes the particulars of operations of hysterec-
tomy, abdominal and vaginal. He has collected the particu-
lars of 80 hysterectomies, 200 salpingo-oophorectomies, i
nephrectomy, 200 appendicectomies, and 20 ovariotomies
for ovarian cysts, 16 of the hysterectomies being for cancer.
Amongst those who have specially written on this method
of haemostasis are Hirst and Charles Noble of Philadel-
phia, Bovee of Washington, and Goldspohn and Murphy of
Chicago.
I have no experience myself of this method, as I have
never adopted it, but the results reported by a number of
operators who have used these appliances prove that it is
one which can be followed with perfect safety. " Intes-
tinal resection and anastomosis," says Dr. Downes, " by
these instruments can be ideal." He has yet to hear of
haemorrhage after an operation in which these instruments
have been used. At the time of writing (November, 1903)
the only accident that he was aware of was the clamping of
the right ureter in hysterectomy for cancer in an operation
in which he himself assisted. He has operated upon mori-
bund cases, and during sixteen months he had but one
death in any case in which his appliances were used, and
that was not connected with the method of operation.
Messrs. Arnold and Sons have the appliances.
Bishop on Ventral Hernia 1 59
On the Prevention of Ventral Hernia as a Sequel
TO Abdominal Section. By E. Stanmore Bishop,
F.R.C.S.Eng.
Gentlemen, — Although it is fortunately true that in the
great majority of instances no hernia follows abdominal
section, and that every variety of incision and method of
closure can count its successful results by hundreds, yet it
is equally true that post-operative ventral hernia does occur
at times in a small percentage of cases, and one of the
greatest disappointments that can fall to the lot of any
abdominal surgeon is to find that after a successful opera-
tion upon some of the internal structures, the outer wall of
the abdomen, which had apparently perfectly united, yields
soon after the subject gets about again, or during the next
few years, and his patient returns later with a large ventral
hernia. The discomforts arising from this discount heavily
the advantages obtained from his work, and unless the
primary operation was performed for something which was
evidently risking the life of the sufferer, or making that life
unbearable, she is apt to consider that the last stage is
infinitely worse than the first, and to wish that she had
never consulted a surgeon at all. Such an occurrence does
much to mar the reputation not only of the operator but
of the operation itself, and to dissuade others whose condi-
tion requires it from having recourse to the benefits it is
otherwise able to confer.
It is difficult to get any clear idea of the relation between
successful aud unsuccessful cases of union of the abdominal
wall. Unsuccessful cases, as Owen says, are apt to be
quietly interred, and one hears nothing of them. But my
friend, Mr. Rutherford Morison, estimates the number
occurring in his own very large practice at about 2 per
cent., and in my own list of over 550 abdominal sections
I can find 4, a little over i per cent. Every abdominal
surgeon will, 1 think, admit that he sees them from time to
time. Allow me to mention briefly the details of these
cases.
i6o The British Gyncecological Society
Case i. — Mrs. H., aged 29, who in 1892 was operated
upon in another town by another surgeon, who removed
an ovarian cyst. As soon Ss she began to get strong she
sutiered from a hard dry cough, wliich persisted for a long
time. This continued, according to her account, more or
less for over two years. No yielding of the scar was noticed
until the middle of 1895, about three years and a half after
the first operation. This went on slowly for si.x months,
when she presented herself at Ancoats Hospital. At that
time — January, 1896 — there was yielding of the lower two-
thirds of the scar ; there were present two or three openings
in the fascia through which the internal contents, consisting
chiefly of omentum, could be felt protruding beneath the
skin, one slightly to the left and about midway between
the pubes and umbilicus being larger than the rest.
On January 23 the skin was divided by a straight in-
cision parallel to and to the right of the old scar. The
patient took the anesthetic very badl}^, and the operation
was therefore hurried. After freeing and removing the
omentum the fascial edges were approximated by buried
silkworm-gut sutures, the skin by horsehair. There was
continuous vomiting for four days, nevertheless firm union
apparently resulted, and the patient was discharged on
February 8, that is, in sixteen days after the operation.
She was firmly strapped up.
In March, 1897, that is, fifteen months later, she pre-
sented herself again. She said that in the previous June,
whilst travelling by train, she was assaulted by some man,
and as soon as the train stopped she jumped out of the
carriage. In doing so she fell on her knee, and was aware
of some yielding of the abdominal wall, which had since
increased. She was found to have two medium-sized
herniae, rather outside the median line, one above the other,
the highest being about one inch from the umbilicus. This
time she took the anaesthetic better, and both sacs were
carefully dissected free from the edges of the openings, and
removed with some extruded omentum. The fascial edges
were split, after Grieg Smith's method in umbilical hernias,
so as to obtain a wider union, and united by buried silk-
worm-gut. She W'as discharged on March 24, three weeks
after operation, apparently firm. She was again firmly
strapped up.
Once more she returned in 1899. This time no apparent
reason had existed for the reappearance of the hernia, but
Bishop on Ventral Heiniia i6i
again three distinct spaces were to be felt, each more or less
in the line of the scar, and each containing omentum. This
time frayed-out bands of fascia were found in the coverings
of the herniae, partially subdividing them. The whole scar
was excised and all the spaces thrown into one. The fascia
was very carefully bared above on one side, and below on
the other, for a distance of 2 to 3 cm. on either side.
Mattress silkworm-gut sutures were placed in such a way
as to draw one layer of fascia over the other and to tix it
there. These sutures were buried and the skin united over
all. She was kept on her back for two months. Twelve
months later the union was still firm and secure, and as
nothing further has been heard of her, it may be supposed
that the hernia has not again recurred. Five years have
now elapsed.
Case 2. — ^Mrs. B., aged 31, a heavy, phlegmatic woman,
with great development of fat, enteroptosis, and prolapsus
uteri, was operated on for ventrofixation on May 22, 1900,
apparently successfully, and she was discharged well on
June 15, three weeks after operation.
The next year, February 7, 190 1, she appeared with a
large median ventral hernia, which 1 have operated upon
three times since, always without lasting success, and she
has now a large hernia, which can only be supported by a
heavy belt.
Case 3. — Mrs. K. H., aged 33, in July, 1893, had a
parovarian cyst removed, and as was the custom at that
time, a Keith's drainage tube was inserted into Douglas's
pouch. The peritoneum was united around this with
catgut, and the skin and muscles, including the fascia, by
through-and-through sutures of silkworm-gut. The tube
was removed on the third day, and a small amount of
omentum plugged the opening. She recovered apparently
completely, and left the hospital with the wall lirm two
months after operation.
Four years later she returned with two small gaps in
the line of incision. Omentum was found adherent to
their edges and was freed all around. The edges of the
fascia were brought together and united by buried silkworm-
gut sutures. Two days later, there having been almost
persistent vomiting, the abdominal wall gave way, and a
loop of intestine could be seen below and between the skin
sutures, which were cutting into it. The loop was washed
and returned, and the muscular wall reunited by silkworm-
1 62 The British GyncBcological Society
gut sutures which passed through them, the fascia and the
peritoneum ; the skin and subcutaneous layer was left open,
to permit of free exit to any discharges. Healthy granula-
tions being present seven days later, the outer layers were
drawn firmly together by strapping. She left the hospital
one month after the operation apparently soundly healed,
and was seen a month later still, when she was perfectly
firm. This was in 1897.
Once more she returned in 1903, that is, six years after
the last operation, and ten years after the first. This time
there was a large ventral hernia, extending over very nearly
the whole extent of the scar. She could give no very
definite reason foi- its reappearance, but said that it had
gradually opened up, and had been present for at least a
year — it might be more. She was never very clear in her
statements. This time the operation took a long time.
Adhesions were plentiful and firm, omentum and large
intestine were adherent to the edges of the opening, espe-
cially near its upper end, and the latter had to be separated
with much care. The outlying cavities of peritoneum
seemed never ending ; when one was cleared out, a small
tag of omentum led into another, which in its turn had to
be opened up ; and when at last the whole tangle was
straightened out and the muscular wall properly united,
the patient was much collapsed. Transfusion was done on
the table during the operation, 20 minims of liq. strych.
and ID minims of adrenalin were injected subcutaneously ;
but the length of exposure and the severity of the operation
itself were too much for her, and she died within twenty-
four hours.
Case 4. — H. F., aged 47. A large fibroid uterus was
removed by the abdominal route on November 23, 1897.
The fascia was united by buried silkworm-gut mattress
sutures. Suppuration occurred around one of these, and
a sinus formed. From this, on the 31st, the suture was
removed and the sinus healed. She was discharged on
January 15, 1898, seven weeks after the operation. She re-
mained perfectly well until 1902, that is, for four years. She
was then nursing a sister ; the scar began gradually to yield,
and a hernia appeared. This slow'ly increased, and on her
return to hospital in May, 1904, there was a circular opening
in the fascia about two inches in diameter ; through this
bowel and omentum had escaped, and formed two bluntly
acuminated masses, separated by the firm, thick, skin scar.
Bishop on Ventral Hernia 163
which stretched hke a tough cord above and between them.
On operation omentum was found firmly adherent to the
edges of the opening, and spreading widely in peritoneum-
lined cavities above the fascia in the subcutaneous tissues.
It is too early to say anything as to the result in this
case, but of the three others it will be seen that one was
apparently cured, one is still uncured, and one ended in
death. Such occurrences makes one, as the French say,
furiouslv to think.
Many abdominal operations are not of a simple kind.
A firmly adherent double pyosalpinx cannot be removed
safely in a few minutes, whatever the advocates of extreme
speed may say. When small and large intestine are
adherent above and behind, when adherent omentum covers
in the whole mass, when the tubes themselves are tense and
thin, separation must, if it is to be safe, also be quietly,
slowly, patiently carried out, and such patient work takes
time. An intraligamentous fibroid cannot be enucleated
with safety at express speed. It is therefore inevitable that
when all the primary and essential work is done, the patient
will be feeling the shock of the operation, and that the
surgeon, possibly urged thereto also by remarks from the
anaesthetist, will take the readiest means possible of closing
the abdominal wall, and risk the possibility of this not
being the one most likely to ensure a satisfactory and
permanent union.
So forcibly had this impressed some surgical minds that
some years ago there was a strong current in favour of
doing all pelvic operations in women by the vaginal route.
Incisions in the upper half of the abdominal wall are by no
means so likely to be followed by hernia as are those m the
lovvcr half. Very rarely indeed are operations upon the
gall bladder or stomach succeeded by ventral hernia, and of
course this might have been anticipated. The main weight
of the abdominal viscera rests upon the lower half of the
abdomen ; the structures found there — the small intestinal
loops — are more movable, and are more likely to undergo
164 The British Gynecological Society
variations in size owing to distension, than those found in
the upper half, and therefore the internal tension upon this
segment alters more rapidly, more frequently, and more
forcibly. In the lower segment, moreover, is found the
free extremity of the omental curtain, and experience has
shown that this structure has a most perverse tendency to
insinuate itself into any opening which may have been left,
and that when once it has gained an entrance it gradually
but persistently tends to widen this, pushing the peritoneum
before it, and to burrow amongst and between the super-
jacent structures. Any one who has operated upon a few
ventral hernise knows how far more extended they are m
the subcutaneous fat than w^as apparent before the skin
was divided ; that outside the apparently rounded and
defined limits of the protrusion as felt through the skin, will
be found small loculi of peritoneum, each occupied by its
own httle omentum tag, evidently the outposts and pioneers
of the ever-invading structures of which they are the ex-
tremities. When once this process has gained any ground,
nothing appears to stand before it. Peritoneum is ex-
panded, fat is absorbed, muscular fibres pushed aside, even
the resistant fascia will be found frayed out over the mass, or
with some few more obstinate bands stretched tautly between
adjoining lobes. If, then, internal pelvic viscera could be
reached and dealt with from the vagina, leaving the abdo-
minal wall intact, much after-misery would be avoided.
And, greatly to the satisfaction of workers in this direction,
many other advantages have been proved to be gained in
surgical work by this route. Shock is very materially
lessened, after-recovery is more rapid, peritonitis is evidently
not so great a danger, and many more operations turn out
to be practicable through this canal than li priori would
have appeared possible. But some things still remain, in
treating which it is most convenient and safest to adopt
the abdominal route. Ovarian cysts, even if mullilocular,
may be evacuated and removed through the vagina ; but
when these are adherent, and no pre-operative signs exist
Bishop on Ventral Hernia 165
by which the extent of these adhesions can be estimated,
it is wiser to attack them from above. Some adhesions,
such as those to the lower end of the omentum, can be
detached from below, but adhesions to the transverse colon,
to the outer borders of the broad ligaments, to the sigmoid
flexure, &c., are almost impracticable without a free entry
through the abdominal wall. Ectopic pregnancies have
been removed through the vagina, but cases are on record
where the ovarian artery has slipped from the ligature placed
upon it under tension from below, when once that tension
has been removed, rapid and very dangerous haemor-
rhage has followed. Abdominal section, then, is the only
means by which the vessel can be secured, and this has to
be carried out immediately under very unfavourable con-
ditions. Fibroid tumours have been frequently removed
with or without the uterus per vagiiiam, but if the tumour
is subperitoneal, if it is calcified, if the entire tumour is
larger than a child's head, or if it is adherent to any extent,
the advantage of being able to see and reach the whole
working area afforded by abdominal section, especially
when performed in the Trendelenburg position, completely
counterbalances by its safety the advantages which belong
to the vaginal route.
Surgical opinion, therefore, without denying the force
of the manifest arguments in favour of vaginal section,
recognises that abdominal section has, and must continue
to have, a distinct place in pelvic surgery, and the problem
of how best to reunite the abdominal wall after an
abdominal operation presses once more for a solution.
It could scarcely be said until lately that of all the many
ways in which this had been done there existed one method
which was ideally perfect. Methods which were rapid were
not secure, and those which give a demonstrably secure
result were not rapid. As has been pointed out above, the
temptation to sacrifice all else to rapidity when the operator
had reached the stage at which this had to be done, was
very great indeed.
1 66 The Bi'itisli Gyncecological Society
Various opinions are held as to the cause of sequent
hernia ; of these, two appear to be most worthy of con-
sideration. Although nowhere definitely stated, so far as
I know, the idea of the importance of the action of the
recti muscles would appear to underlie the practice of some
surgeons. The incision must not lie in the linea alba ; it
must separate the muscular bundles of these muscles, or
the incision in the skin must not be directly over that in
the deeper fascia, whilst that must not coincide with the
line of separation of muscular fibre, or the muscle must be
dragged to one side, and the deeper incision through the
transversalis fascia must be on another plane than that
which had opened the muscular sheath. If the muscular
fibres are separated they are to be sewn together again.
One surgeon makes a crescentic cut through the skin, with
its convexity towards the pubes ; then turning up the flap
thus formed of skin and subcutaneous fat, he makes a
vertical incision through the rest of the abdominal wall into
the peritoneal cavity. Those who advocate the first three
of these plans evidently trust to the presence of the more
or less bulky mass of the rectus muscle and to its contrac-
tions for a restraining force ; those who advocate the last
to the support of a flap of skin and subcutaneous fat as a
reinforcement to the divided and reunited tissues below.
But any one who will study these cases will readily
recognise that these openings increase in size primarily in
a lateral direction and not vertically. The muscular fibres
of the rectus have a vertical pull ; they cannot antagonise
to any degree a force acting in a transverse direction.
Moreover, it is of little use suturing parallel muscular fibres
together. Such fibres never unite to form a resistant scar.
It is hardly necessary to point out the futility of relying
upon such essentially yielding tissues as skin and subcu-
taneous fat for the supply of a force sufficient to hold in
check the burrowing tendencies of omentum or the pressure
of internal abdominal tension.
The alternative opinion would appear to be founded on
Bishop 071 Ventral Hernia 167
sounder principles and to offer the really true basis for
action.
Surrounding the recti muscles above the fold of Douglas
and passing entirely in front of them below this fold, is the
deep fascia of the abdomen. The name is misleading, since
this structure is in no sense a fascia, such, for instance, as
is the fascia lata of the thigh. It is a tendon, broad and
flattened out : the combined tendon of the external and
internal oblique and transversalis muscles. It arises from
these muscles on one side, and is inserted at the linea alba
into the tendon of the muscles of the opposite side. When
this insertion is intact the two opposing sets of muscular
fibre antagonise one another. Should the one side only
contract it pulls the linea alba — the line of insertion — with
the inclosed rectus over towards its own side, but it cannot
pull it far owing to the resistance of the opposite set. If
both contract they draw the linea alba closer to the spine.
If, however, this combined tendon is divided, as it is in
ordinary laparotomy in the median line, or in Langenbuch's
line on either side, each set of muscles, so far as their tendon
is free, pulls its segment further and further away from its
fellow of the opposite side, until the normal tension is taken
off their fibres, so leaving a gap which any further contrac-
tion of these fibres still further enlarges. That the true gap
through which a hernia escapes is in this layer and formed
by this structure can be demonstrated easily in any ventral
hernia which will allow of the entrance of a finger. The
firm string-like edge of the gap can be traced all round,
with no resistance from any other tissue, peritoneum, skin,
subcutaneous fat or muscle, except outside this fascial ring.
The fingers easily depress all other tissues before them, and
enter the abdominal cavity. On operation everything which
has escaped from that cavity is found to be within this ring,
and not to pass beyond it until, having reached the looser
tissues above, these intra-abdominal contents spread out
widely and apparently without hindrance in the easily-
yielding subcutaneous tissues. Although the skin does not
1 68 The British GyncBcological Society
give way it stretches enormously, so that on reduction of
the hernia once more through the fascial gap, such skin
lies in loose redundant folds, and may be largely removed
without being missed. The skin and subcutaneous tissue
have evidently been no restriction to freedom of escape of
the abdominal contents ; nor, it is equally demonstrable,
have the recti muscles. The rectus of either side has simply
been deflected from the middle line and lies outside the
edge of the gap. If this edge is divided the recti fibres will
be seen curved around outside. They are never found
spread over the hernia itself. The integrity of the recti
muscles themselves and their power of contraction have
been no bar to the post-operative hernia.
It is, of course, perfectly well known, though practically
the importance of the fact would appear to be usually
ignored, that normal muscular fibre contracts at once if
the tendon to which it is attached is divided, and that if
such division is allowed to continue the muscular fibre
itself becomes shortened as time elapses. Reunion of the
tendon becomes progressively more and more difficult
owing to this ; if the statements previously made and their
obvious corollary be admitted, this is a very strong reason
for early interference in any ventral hernia, but, putting
this aside for the moment, it naturally follows from what
has been said that the most important structure in the
abdominal wall from the standpoint of the surgeon is this
so-called deep fascia, this tendon of the lateral muscles;
and that the risk of or security from post-operative hernia
depends entirely upon the thoroughness with which this
has been reunited after division.
Although peritoneum will and does yield to a surprising
extent when once its outer support has given way, there
can be no doubt that a gap in it enables the omentum to
find an exit and so to exert its wonderful po\\'er of burrow-
ing amongst the tissues of the abdominal wall. Therefore
next in importance to the security of the fascial union, must
rank the importance of complete closure of all gaps in the
Bishop on Ventral Hernia 169
peritoneum : other reasons, of course, exist for this pro-
cedure, but this is from this particular point of view the
most important. This closure is in this region usually very
easily done. When this is complete and the fascia also
firmly united, the muscular fibres of the rectus then assist
in the only way they can, by their bulk as a pad between
the two, to reinforce the pressure from without, and to fill
any dead spaces which might otherwise exist.
The essential thing then is to unite the tendons of the
oblique and transversalis muscles in such a complete manner
as once more to restore their mutual antagonism and to
keep them firmly united long enough for firm organic union
to take place between them — a process which, according to
Macewen, takes six weeks, but which some observations of
my own tend to show is sufficiently firm in a month — by
some material which can be trusted to do this, and to
remain firm and strong for that period. If at the end of
that time all foreign material can be eliminated or removed
from the tissues, the ideal method, so far as permanency is
concerned, will be attained. If this is not possible the
material used should be such as to cause no after-discom-
fort. It will be seen that this is by no means the simple
problem that earlier operations suggest, nor the least im-
portant that the surgeon has to consider when planning
an abdominal operation.
The ideas which dominate an operator's mind with
reference to the structures with which his operation deals,
can be fairly deduced from the steps of the operation he
performs, judged in this way, the earliest operators must
have looked upon the abdominal wall as practically a homo-
geneous layer of tissue, which, when union of any sort had
taken place, would be equally strong in all its parts.
Sutures were introduced th';ough all the tissues, and
these were simply drawn and held together for a certain
length of time, which appeared mainly to depend upon the
time required for the union of the skin. This method even
yet is often adopted for the sake of speed. It is no doubt
VOL. XX. — NO. 78. 12
170 The British Gyncecological Society
the quickest and readiest method, but it will be seen that
the union of the definite layers of this covering must be
merely a matter of chance. Peritoneum will unite to any-
thing to which it happens to be apposed — to fat, or muscle,
fascia, or connective tissue. In most hernias of any dura-
tion, the union between the fascial edge and the peritoneum
is very intimate ; the thin covering which alone exists
between the external world and the peritoneal cavity in an
old ventral iiernia is composed exclusively of skin and
peritoneum, with perhaps a few strands of frayed-out fascia
near its periphery.
These unions are not merely useless to prevent escape of
intra-abdominal contents, but they are distinctly harmful as
rendering impossible the union of the more resistant struc-
tures until they are once more freed. Union of skin to skin
is frequently one of the most rapid of all ; and it has not
been an infrequent experience to find that this skin union
has had to be broken through again to permit of the exit
of banked-up blood, serum, liquefied fat, or pus, which has
collected in some space between deeper tissues which have
been some distance apart. Such a method stands theoreti-
cally and practically self-condemned from the point of view
of permanency, however it may appeal to the surgeon from
the point of speed.
Spencer Wells was the first to point out the necessity of
union of peritoneal surfaces, but he only laid stress upon
this. The importance of such union has been emphasised
by other writers since, for other reasons ; notably by Clark,
on the score of the advisability of once more producing
a closed peritoneal cavity, so as to favour peritoneal currents
by means of which bacteria and other foreign material in
the abdominal cavity may be carried into the lymphatic
spaces, and to prevent adhesions between internal viscera
and connective tissue outside this layer ; but the other
structures of the abdominal wall were still treated as though
they all were of equal importance.
It is curious to note the swing of the surgical pendulum
Bishop on Ventral Hernia i 7 i
between this method of laisscr /aire and the opposite ex-
tremity in a method lately advocated in some of the surgical
journals. In this latter every layer has its own continuous
suture. Not only peritoneum, fascia, and skin, but parallel
muscular fibres, and even the subcutaneous fat, are each
united by a continuous silk thread. It is difficult to see the
use of this. Parallel muscular fibres do not unite, however
long they are apposed to one another. If they did, every
muscle in the body would soon become rigid. As to fat,
it is of all tissues the most lowly vitalised ; the cells which
contain it are most easily crushed, and free fat exudes. The
passage of a thread through them opens up a way for the
exit of their contents, the thread itself becomes soaked in
this oily fluid, now practically dead material, and can then
only act as an irritant, sooner or later requiring elimination
from the living structures. If the intention is to bring the
divided fatty surfaces together, and to prevent dead spaces,
this can be done equally well by the pressure of the united
more solid structures above and below, owing to the
elasticity of the material between, which now will not have
been crushed or bruised, nor will it contain any dead
foreign substance. A dead space is none the less a dead
space because it is filled by dead fluids, such as exuded oil.
It is thus demonstrable that the only tissues as to the
union of which the surgeon need interfere are the perito-
neum, the fascia, and the skin. If these are secure, all the
rest fall naturally into their own place, and are far better
left untouched.
The union of peritoneum otters no difficulty. The
rapidity of its union and its powers of absorption permit of
the use of fine catgut, which is readily elimmated as soon as
its work is done — as it is within forty-eight hours — and this
has never given rise to any evil results.
The union of the skin is equally simple. Sutures or
Michel clamps are readily applied and as easily removed
when this layer is united. But the union of the combined
tendon of the lateral muscles is by no means such a simple
172 The British Gyiuccological Society
matter. Some material must be used which shall be strong
enough to resist, not only the natural pull of the three
strong muscles attached to this tendon on either side, but
any extraordinary strain which may be placed upon them
by chloroform or other vomiting, by cough, or by move-
ments of the patient. Incidentally, it will be recognised
how futile it is to depend upon the pressure of strapping,
binders, or belts, as a counter-force to this internal muscular
contraction. They are useful for the purpose of keeping
external dressings in place, or for the feeling of support and
comfort which they undoubtedly supply ; but the force they
can exert does not, and cannot, effectively act in a contrary
direction to the muscular contraction of the obliques and
transversales.
And this material must remain strong and firm for a
month or six weeks. It is not sufficient to claim for it, as is
often done for chromicised gut, that it is not absorbed for
that length of time. Long before any material is absorbed
it has ceased to have any restraining power. It has become
soft, frayed-out, and powerless. It may have held the
tissues safely enough for a fortnight, but at the end of that
time the patient may cough or strain in urination or defae-
cation, the lateral muscles contract strongly, perhaps
suddenly, the weakened suture stretches or snaps, and the
plastic material between the uniting edge of the tendon
yields slightly. A repetition of the strain occurs, or several
repetitions, and a weak yielding gap between the rigid
fascial edges is the result. It needs only some increase in
abdominal tension from flatus or other cause to start a
small hernia, which will steadily increase from that time
onwards.
But any material which will remain strong and firm for
six weeks will, on the other hand, probably remain un-
absorbed during the life of the patient. Silver wire,
bronze aluminium wire, Pagenstecher's thread, celloidin
thread, silkworm gut, are all capable of withstanding the
strain, but they are all totally unabsorbable, and sooner or
Bishop on Vejih'al Hernia 173
hiter are almost certain to give evidence of their presence.
Prickin<4, stabbing pains, especially when the recti muscles
are in action, slow movement towards the surface, accom-
panied or not by suppuration around them, have been fre-
quently observed. Buried sutures, therefore, are to be
avoided if possible. If, however, a suture must be buried,
nothing appears to serve so well as plain silver wire, the
ends of these being twisted, and pressed flat against the
surface of the fascia.
Since this was written, however, I have had the pleasure
and advantage of watching Mr. Rutherford Morison
operate on several cases. He uses chromicised catgut of
unusual thickness — No. 8 for uniting the fascia — and claims
for it that it does remain effective for a sufficient period.
I notice, however, that in a very valuable paper contri-
buted by him to the Edinburgh Medical Journal this year,
he says that in a certain percentage of cases ventral hernia
is inevitable, and that the evidence of a surgeon who says
that he never sees it may safely be put aside, for he does
not care for the after-history of his patients. It occurs, he
says, most frequently in very fat and very thin persons. I
cannot agree that this condition should be deemed inevitable,
even in a small percentage. The word itself suggests that
surgeons should be content to accept it as such, and to
make no effort to eliminate its possibility. It is with a
hope of doing something towards so desirable a result that
I have brought forward this subject for discussion. Dr.
Macnaughton-Jones also uses this material for this purpose,
and so doubtless do others. I am very anxious to obtain
their evidence as to its reliability.
I have used glass stretchers for preparing gut and silk.
When silk or catgut is used after having been sterilised on
reels, I have usually found that it is very apt to become
entangled or kinked, so that for a long time I have sought
for some means by which a perfectly straight thread might
be obtained. With these glass stretchers (fig. A), made for
me by Messrs. W^ooUey, Sons, and Co., of Manchester, I
174
The BritisiL Gynaecological Society
have been able to obtain them. The silk or gut is fastened
securely to one end, and then wound upon them so as to
obtain only one layer ; the opposite end is again securely
fastened. Threads of the same material are then tied
around, enclosing the sutures at each of the two points
where notches have been cut in the uprights, and where
the frame has been strengthened by crossbars of glass. If
the material is silk, it can easily be boiled, frame and all,
in an ordinary steriliser. If catgut, it requires to be boiled
under pressure in cumol or xylol, and must be enclosed in
some watertight receptacle, such as the gun-metal cylinders
of Mayo Robson. But those cylinders will not take these
^i^==^
Fig. a.
stretchers, and 1 have had a rectangular one made by the
same firm which supports the glass frame in such a position
that the sterilising fluid can act upon every part of the
suture. This is, indeed, one of the main advantages of
using these glass frames. All parts of the suture — that
turned to the frame, as well as that outside — are equally
exposed. When a suture is wound upon a wooden or glass
plate, tlie side next to the plate is to some extent protected ;
it is not so in these open stretchers. Glass has been used
because it is so easily cleansed, and will itself resist the
action of boiling fluids. When sterilisation has been done,
the threads are cut across at one end of the stretcher,
and each double thread can be drawn oi^' from the other
end without disturbing the rest. After they have been cut,
the advantage of the two cross threads which keep them
in place against the stretcher will be appreciated. The
stretchers are then kept in wide-mouthed bottles — silk in
I
Bishop on Ventral Hernia 175
Bergmann's solution, catgut in absolute alcohol with \ per
cent, sterile glycerine.
The way in which the sutures are placed is of impor-
tance. Inasmuch as they have to resist a constant and
persistent pull, it is essential that they should not cut
through the tissues and so become loose. If applied in the
ordinary way this is very likely to happen, especially when
the material used is wire of any kind. Moreover, if the
fascial edges only are approximated the area of union is
but a thin line, and is consequently stretched or torn
through wath comparative ease. Noble, whose example I
have followed for a considerable time, carefully clears the
upper surface of the fascial layer for a distance of 2 to 3
cm. on one side, and the under surface of its opposite
for a similar distance, from all fat, and then places mattress
sutures in such a way as to draw one side of the fascia
beneath the other and fix it there, so obtaining a broad
double union, which is correspondingly stronger, and more
likely to be permanent.
But a method which leaves behind foreign material in
the living tissues which cannot be absorbed cannot be
considered ideal, and it would be a great advantage if at
the end of six weeks this could be removed without reopen-
ing the wound. Lately, three or four ways in which this
may be done have been proposed and carried out with
success. In the first the two ends of the wire sutures
placed as above described in the fascia have been made to
penetrate the skin and superficial fascia above, and have
been twisted over the bridge of skin between ; or, better
still, since such wires tend to cut through the skin, over a
pad of gauze placed between them ; but in some cases,
where the subcutaneous layer of fat is very thick, it is
useless to attempt to fix the wire outside, the pressure
exerted by the pad being rendered nugatory by the con-
sequent absorption of this layer, the wire loop becoming
loose, and permitting the fascial layers to separate once
more, omentum to insinuate itself between them, and the
176
The Bi'itish Gy7icecological Society
hernia again to recur. In such cases two courses are open ;
first, to tighten the loop from time to time ; or, second,
to apply the wire suture in a figure-of-eight fashion, allow-
ing the lower loop simply to grip the fascial layers. Of
the two methods the latter is often to be preferred, it
seems impossible accurately to gauge the rate of absorption
of the fatty layer ; the loop may possibly be left too long
untightened, and if once omentum has gained a foothold
between the fascial edges, it will continue to enlarge the —
often minute — opening thus formed.
If the figure-of-eight method is used, the wire is intro-
duced through the skin on owq side, penetrating the sub-
cutaneous fatty layer in an oblique manner, and emerging
in the wound just above the fascia. It is then carried to
Fig. I.
the opposite side, reversed and made to pierce the fascia
of that side from above downwards about a centimetre
from its edge. Both layers of fascia have previously been
cleared of fat on their Iov\'er surface for that distance.
Passing beneath this, the needle is carried through the
fascia on the original side from below upwards at a point
the same distance from its edge. The needle is again
reversed, and carried through the subcutaneous tissue and
fat obliquely upwards to emerge through the skin at a
point corresponding to that by which it first entered, but on
the opposite side of the wound. By pulling upon both
ends of the wire in a direction from the wound, the two
fascial under surfaces are brought together and held firmly
opposed to one another. The skin edges are then adjusted,
\
Bishop on Ventral Hernia
177
a layer of gauze laid over them, and the ends of the wires
are brought together over this and twisted together, so
closing the skin wound and bringing the divided subcu-
taneous tissue surfaces in contact. When it is required to
remove the wire this is slightly pulled out on one side and
divided close to the skin. A steady pull upon the other
end draws it out. Thus in figs, i, 2, 3, c marks the skin, d
the subcutaneous fat, e the fascia,/ the rectus muscle, g the
Fig. 2.
Fig. 3.
subperitoneal fat, // the peritoneum. In fig. i the peri-
toneum is united ; the wire sutures are placed but not
drawn up. In fig. 2 the fascia is drawn together by
tightening the loop a, by pulling upon both ends of the
wire in a direction obliquely from the wound as indicated
by the arrows. In fig. 3 the loop h is completed, and by
tightening this over the pad /c, the skin and subcutaneous
fat are thus approximated. It will be noticed that the
tightening of loop a has approximated the muscular layer
/ and the transversalis fascia g.
178
The B7'itisli Gyncecological Society
With this method it is evident that absorption of the fatty
layer enclosed in the loop h will have no influence upon
loop a, which will still remain tight, owing to the rigidity
of the silver wire. Silkworm-gut is not so effective, as
with it the firmness of the loop a will depend on the tension
in both loops. This method is probably the quickest of
all those which permit removal of the foreign material
uniting the fascia, and therefore will be preferred by many
surgeons, and probably by all in cases where the rapid
-=Y==V^=="'^
c'
^
*=
Fig. 4.
closure of the abdominal opening is important. But the
removal of these wires is sometimes painful, and another
method has lately been introduced by Alilton, of Cairo,
which is neater, and renders after-removal less painful.
The central idea of his method is the use of the lock stitch,
and he uses it in the following way, which fig. 4 may help
to render clearer. Two threads are used : a, the primary
thread; and 6, the secondary thread. In the figure, which
represents the wound looked at from above, c d represent
the two edges of the fascia which are to be united. A
sharp-eyed needle carrying a long silk thread is carried
through fascia c on one side from above downwards, and
through the fascia c' on the other side from below upwards ;
as it protrudes on this side, a loop of silk is pulled out and
the needle is withdrawn, still carrying the thread. This is
again carried through both layers of fascia in the same
I
Bishop on Ventral Hernia 179
way, a third of an inch further on, a loop drawn out, and
so on. Through each loop the secondary thread h is
passed ; when all the loops are placed they are drawn up
in turn, so tightening around the secondary thread and
approximating the two under surfaces of the fascia. At
each end of the wound the respective ends are brought up
through the skin, and the end of a is tied to the correspond-
ing end of h. When it is desired to witlidraw the threads,
the ends of both are cut through close to the skin at one
end of the wound, and the secondary thread h is drawn
out ; this sets free all the loops, and traction upon the end
of the primary thread will draw it also out of the wound,
leaving in this way no buried suture.
This is a very admirable method, but it has certain
drawbacks. 1 have found that however tightly both ends
may be held, during the process of tightening up, the
secondary thread is almost unavoidably bent at the points
embraced by the primary thread. When the time comes
to withcjraw the threads, it is evident that if applied as
Milton advises, the secondary thread must be first removed
in order to set free the other. If the secondary thread is
silver wire this is almost impossible ; the slight kinking
produced is sufficient to render it extremely difficult to
release the wire from the bite of the primary thread ; if it
is of silkworm-gut this is apt to break at these points, and
so a foreign body is left behind, and the main object of
the method — the removal of all buried foreign bodies when
deep union is complete — is not obtained. In order to
avoid this I have modified the plan in the following way,
so as to be able to remove the primary thread first, so
setting free the secondary, which can then be easily drawn
out.
The secondary thread h may be either wire or silkworm-
gut ; the latter, I think, is preferable. The primary thread
a is interrupted, and made up of several silkworm-gut
threads introduced as single loops by means of an eyed
needle. Each loop is passed through the skin, subcutaneous
i8o
The British Gyncecological Society
tissue and fascia of the right side of the wound, emerging
in the wound below the fascia of that side ; it is carried
onwards below the fascia on the left side, and penetrates
this layer from below, emerging on its upper surface ; the
secondary thread is passed through each loop. When all
the loops are in place, and the skin wound united by other
I I
4
Fig. 5.
c'
b
Fig. 6.
sutures, the secondary thread is held tight at each end to
prevent kinking, whilst each loop is drawn taut, the two
ends of it which emerge from one opening on the right side
of the wound are separated, a gauze pad k placed between
them, and they are then tied over this pad.
The pressure of the secondary thread on one side is
thus opposed by the pressure of the pad on the skin above,
and the two surfaces of the fascia are drawn together and
held in position by them.
Fig. 5 shows the position of the wound and threads ;
Bishop on Ventral Hernia
i8i
looked at from above, c c are the two edges of the divided
fascia, h the secondary thread, a a a the interrupted loops
of silkworm-gut. Figs. 6 and 7 represent a vertical
section through the abdominal wall, the various layers of
which are lettered as before. In fig. 6 a loop is placed
a a\ and through its extremity is seen the cut end of the
secondary thread h. In fig. 7 it is tightened up, and a pad
k is placed between the two ends of the looped thread ;
when tied it brings the two under surfaces of the fascia
firmly together.
Fic. 7.
b
The same objection holds good with this modification
in cases where the fatty layer is thick and may become
absorbed, so loosening the grip of the loops. In all such
cases it will be advisable to use Milton's original plan of
application, but in cases where this layer is thin I have
found the modification easy of performance, and giving a
perfect result. The loops should be applied at distances of
one-third of an inch from each other, and should so pierce
the fascia as to bring together a corresponding width of
fascia on both sides. Removal is easy ; one-thread of each
loop is divided close to the skin beside the gauze pad ;
pulling on the other end quickly releases it, and it is drawn
out. When once all the loops are free, the secondarv
thread is easily withdrawn whether slightly kinked or not.
Care must be taken in all cases to carry the suturing for
at least half an inch at each extremity beyond the line of
1 82 The British Gyncecolooical Society
fascial division, so as to produce a fold in the yet undivided
tissue.
By the use of one or other of these plans it will be
evident that we possess means by which the all-important
tendinous expansion known as the deep fascia may be
reunited safely and permanently, and that the hitter methods
also enable us, when organic union is firm, to remove all
foreign material from the interior of the wound.
Something more might be said as to the different
behaviour of the tissues in different parts of the abdominal
wall, especially as to the difficulty experienced in the
reunion of peritoneum near the epigastrium as compared
with the ease of this manoeuvre below the umbilicus, and
certain modifications which thereby become necessary, but
this paper is already too long, and they must be left for
future statement.
When a large hernia has to be closed, and the fascial
edges are widely separated, the method adopted by both
Dr. Macnaughton-Jones and Mr. Rutherford Alorison, of
placing stay sutures so as to embrace the whole rectus
muscle, and so obtain a firmer and more comprehensive
grip of the tendon on either side, is an admirable one, but
does not, in my opinion, dispense with the necessity for
obtaining a broad imion of the actual opposing portions
of this tendon such as is produced by the Noble method.
It is an accessory of very great use, but not the primary
requisite. Dr. Macnaughton-Jones uses strong silver wire ;
Mr. Rutherford Morison strong chromicised gut. After
all, these are measures for the cure, not for the prevention
of post-operative hernia.
Discussion.
Dr. Macnaughton-Jones said that while all operators
acknowledged the importance of securing as perfect an
abdominal toilet as possible, different surgeons gave
Discussion on Venti^al Hernia 183
preference to different methods, and each generally con-
sidered his own the best. Mr. Stanmore Bishop accurately
represented in his diagram the method he (Dr. Mac-
naughton-Jones) usually followed of closing the abdominal
wall. It was practically the same as that originally advised
by Noble, of Philadelphia. He showed by diagram another
method of mattress suture recently introduced by Noble.
His (Dr. Macnaughton-Jones) method included closure of
the peritoneum by a fine continuous cumol-gut suture, and
the fascia, after dissection from the rectus muscle, was
united by a continuous suture passing through it and loop-
ing up the muscle at either side before penetrating the
fascia at the opposite side, and thus closing the wound
either by complete adaptation or slight over-lapping of the
aponeurosis through its entire extent. Any apparently weak
points were then secured by an interrupted suture, the skin
was stitched with celloidinzwirn. In the largest ventral
hernia he had ever seen, in which there was a huge protru-
sion over the pubes, he had adopted the following plan
with complete success : the necessary dissections having
been made to sever the adhesions of the bowel and omen-
tum to the skin, and to separate these from the dense fascia
which had formed underneath in the middle line, as also to
clear the recti muscles, mattress sutures of silver wire were
carried alternately from one side to the other, from the
outer border of the rectus at one side, including its fascia,
under the dissected central fascia and including it, and were
brought out through corresponding points on the opposite
side. There were thus three loops and three double strands
at either side, and a strong suture, also of silver, was passed
at the upper and the lower ends of the wound, which
extended from just below the umbilicus to the pubes.
These silver sutures were buried, and the skin closed over
them with silkworm-gut. The closure was complete and
permanent, and has remained so up to the present time
without giving rise to any trouble. Bumm, of Berlin, lays
special stress in these cases of large hernia on the impor-
184 The British Gyncecological Society
tance of flexion of the trunk while suturing, and of com-
plete separation of the rectus sheath from the muscle, so as
to relieve the tension in the adjustment of the fascia. His
own (Dr. Alacnaughton-Jones) experience of post-operative
hernia was limited to three cases. In the first case the
wound had been twice deliberately opened by the patient,
who was mentally afflicted, but was Anally and perfectly
closed by a third operation. The second was a very small
protrusion, so slight that the patient refused to have it
interfered with, three years after the operation ; and the
third he had seen this year, in which there was an opening
at the lower end of the wound, in a case in which the opera-
tion was performed under desperate conditions, and where
it was absolutely necessary to close the wound with through-
and-through sutures. If there had been hernia in any other
cases of his, he had never heard of it. In 872 cases of
abdominal section reported by Charles Noble, there was
suppuration in only 10, and hernia in only 2. Paul Zweifel,
in cases of fat women and where there was a doubt as to
the security of his special mterlacing suture, passed with his
large needle three strong strands of chromicised cumol-gut
as through-and-through sutures, at even distances, and tied
these finally. He (Dr. Macnaughton-Jones) had himself
pursued this method in some similar cases.
Mr. Charles Ryall remarked that while our aim in
closing the laparotomy incision must be to bring the parts
as nearly as possible into their original anatomical position
by uniting each layer, the essential thing was to see that the
aponeurosis was united throughout the whole length of the
w^ound. The union of muscle would not prevent hernia,
and that of the peritoneum did not add much strength to
the cicatrix, though it was important in preventing
adhesions. The posterior sheath of the rectus w-as prone
to retract with, but more than, the peritoneum, and this, he
thought, led to imperfect union and consequent hernia in
some cases. An important prophylactic measure was pro-
longed rest, and this the hospital surgeon could not always
Discussion on Ventral Hernia 185
give his patients. He thought that post-operative hernias
were not by any means invariably reported to the operator.
Dr. Macxaughton-Jones, jun., remarked that as both
ends of the sutures passed through the skin on the same
side, in the method of suturing suggested by Mr. Stanmore
Bishop, the edges of the fascia would be drawn beneath
the skin on that side, and the operator would have a
difficulty in seeing whether they were in accurate apposition.
This difficulty would be greater when securing sutures after
a number had already been tied.
Dr. J.J. Macan said that it was a matter for regret that
those Fellows of the Society who were in the habit of using
the through-and-through suture, and who were known to
obtain good results by it, were not present to take part in
the discussion. A recent inquiry by Dr. W. H. Swaffield
had shown that among upwards of fifty of the most dis-
tinguished surgeons in Germany and Austria, less than a
dozen adhered to the simple through-and-through suture
in median laparotomies, and three of those moditied the
practice in some way. The remaining forty-six preferred
some method of suture in layers. There could be little
doubt that since the almost general adoption of suture in
layers, post-operative hernia had been less frequent and less
severe than formerly.
The President expressed his appreciation of the prac-
tical manner in which Mr. Bishop had treated a subject of
extreme interest to all operating surgeons, and said that he
concurred in the opinion that immediate union of the
peritoneum, as well as of the tendon, was of service in the
solidity of the abdominal cicatrix. On that point he must
join issue with Mr. Ryall, for he had found in the posi-
mortem room that a union which externally appeared perfect
might be absolutely incomplete on the peritoneal surface,
and the only points of union be where each suture passed
through the abdominal wall, gaps being left between the
sutures almost inviting the omentum to protrude. For the
last eight or nine years he had employed a simple method,
VOL. x.x. — NO. 78. 11
1 86 The British GyncEcological Society
which in his experience had not been followed by hernia.
He united tiie peritoneum with a continuous suture of the
finest silk, generally figured No. ooo, and sterilised by
boiling in a solution of biniodide of mercury. He then
passed sutures of silkworm-gut at short intervals of about
half an inch through skin, fascia and muscle, without
including the peritoneum, but, before tying these, he united
the fascia for the whole length of the wound, with a close
continuous suture of the same fine silk as that used for the
peritoneum. The silkworm-gut sutures were then tied.
The interrupted sutures remained, to support the fine ones,
for ten days, and were then withdrawn ; the silk ones were
left. He had found slight indications of these two months
after the operation in a patient who died of slow sepsis
after a supra-vaginal hysterectomy, but in another, in whom
he reopened after about a year for obstruction by a band,
the silk had been completely absorbed. In only three
instances had the silk given any trouble, and these occurred
before he knew the best mode of sterilising the silk by
boiling in biniodide solution, of a strength approximately
one per mille, made by adding one soloid of mercuric
potassium iodide (875 gr. ; B. and W.) to one pint of
water in a steriliser.
Mr. Stanmore Bishop, in reply, said that in his
experience cases of hernia after operation did come back
to the operator, and he had no reason to suppose that he
had failed to hear of any single case of his own. In regard
to the material for sutures they were all agreed that all
buried sutures should be absorbable, that is to say, after
they had done their work. Neither silkworm-gut nor wire
were so ; and catgut was apt to give way, or, if used of
the thickness (No. 8) sometimes employed, was almost
impossible to sterilise. Within the last few days he had
heard of a case of tetanus following the use of imperfectly
sterilised catgut. Of course, if one could rely on catgut
being absolutely germ-free, the difficulty would vanish. The
view that post-operative hernia might be due to overlooking
Discussion 07i Ventral He7'nia 187
the posterior sheath of the rectus merited serious con-
sideration. It was a mistake to suppose that in his method
there was any difficulty in obtaining a clear view of the
fascia ; it was perfectly easy to assure one's self by sight, still
more satisfactorily by touch, that the aponeurosis had been
properly united for the whole of its length.
1 88 The British Gyncecological Society
XEW FELLOWS.
Their names having been previously submitted to the
Council and posted at an Ordinary Meeting of the Society,
after having appeared on the Agenda Paper summoning
that meeting, the following candidates for the Fellowship
have been duly elected : —
Bale, Rosa Elizabeth, L.R.C.P. & L.R.C.S.Edin.,
L.F.P.S.Glasg., 24, Portland Square, Plymouth.
Jones, Mary Dixon, M.D., 62, East 86th Street, Xew
York.
Phillips, Mary Elizabeth, M.B.Lond., Presbeli, Merthyr
Cynog, Brecon.
Campbell, Ernest Alexander, L.R.C.P. & L.R.C.S.
Edin., L.F.P.S.Glasg., 25, Bow Road, E.
George, Jessie Eleanor, L.R.C.P. & L.R.C.S.Edin.,
L.M.Dub., Ishwari Memorial Hospital, Benares, India.
Phillips, Miles Harris, M.B., B.S.Lond., M.R.C.S.Eng..
Avon View, Portishead, Somerset.
Smith, William Robert, M.D., B.S.Lond., F.R.C.S.Eng.,
Beeston, Notts.
Clark, Ann Elizabeth, M.D.(Berne), M.R.C.P.I., and
L.M., 4, Calthorpe Road, Edgbaston, Birmingham.
Sturge, Mary Darby, ^LD.Lond., 45, Hagley Road,
Edgbaston, Birmingham.
Bernard, Claude Abel, 1\LD. Bordeaux, Roc Maria,
Dinard, Brittany, France.
Chipman, Walter William, McGill University, Montreal,
M.D., F.R.C.S.Edin., Professor of Obstetrics and
Gynaecology in McGill University.
Belastungslagerung 189
ORIGIXAL COMMUNICATION.
Belastungslagerung.
Elevation of the Pelvis as an Aid in the Treat-
ment OF Inflammatory, Especially of Exudative,
Pelvic Affections by Compression.^
By LuDWiG Pincus, M.D., &c., Danzig.
With more matured experience I again venture upon
the consideration of this subject, which an extensive htera-
ture and the active interest of my gynaecological colleagues
show is one of essential importance in the treatment of
diseases of women in hospital, and even more particularly
in private practice.
My article on "Belastungslagerung" in the Festschrift,
dedicated to Heinrich Abegg (i.) upon the fiftieth anniver-
sary of his doctorate, very soon became widely known,
even among general practitioners, in consequence of
numerous communications to medical societies, and an
article upon the subject published in the Therapeiitische
Monatsheftr
It was seen that in successfully contending with and
curing disease, one had to rely upon sound empiricism, and
practitioners were taught much by the lack of therapeutical
^ The author in his original article {Zeitschrift J. Geb. u. Gyn., Bd.
xxxix., S. 13) defines his method as "Treatment by position on an
inclined plane while continued or intermittent compression is applied to
the exudation or inflammation, from the surface of the abdomen, or
from the vagina, or at the same time from both, ' Positio in pla7io
inclinato cum Cotnpressione.' "
- An address to the Munich Congress of Naturalists and Physicians,
September, 1899, elaborated on the ground of further experience. Fest-
schrift, on the twenty-fifth anniversary of the foundation of the Dantzig
Medical Society, December 19, 1901.
190 Original CovmiMnication
means at their disposal. There was even then a real and
evident want for this new method of dealing with gynae-
cological disease. The treatment of inflammatory affec-
tions of the abdomen ordinarily adopted, by no means
corresponds with the knowledge and improved possibilities
now available. From physiology and morbid anatomy
we have learned facts and principles which must be applied
to the pathology and treatment of the diseases in question,
with better and more permanent results.
The subject has become in every respect of more prac-
tical importance than it was, for during the last few years
a most gratifying reaction has taken place in the opinions
held upon the efficacy of so-called adnexal operations.
This was inevitable, for conservative treatment has proved
to be efficient and indispensable.
In reporting the proceedings of the Munich Congress,
the writer in the Thcrapcutische Mouatsheft said very justly
(II.) : " It is to be noticed as an encouraging fact that at
this Congress the opponents of indiscriminate operative
interference in adnexal disease, in opposition to those who
extirpate every tube and ovary that exhibits the slightest
pathological change, for the first time advocated con-
servative measures under general approval." This conser-
vative principle, was again put forward at the Aix meeting
in 1900, and is the nova Veritas expressed in the conclusions
of my original article.
There can be no longer any doubt that in adnexal
disease some means of treatment other than the operative
measures hitherto adopted is absolutely required, especially
in private practice. It is evident from reliable observations
of others beside myself that the fact must be faced that
far better and more immediate results may be obtained by
" Belastungslagerung " than by any other resorbent method
hitherto known, and that under it women in whom, under
the principles formerly accepted, mutilating operations
would, a priori, have appeared to be indispensable, become
functionally not merely capable but active.
Belastungs lager ung 1 9 1
But this in no way implies a declared opposition to
operation on principle. It is clear that in hospital practice
as long as " incapability for work " has to be accepted as a
direct indication, operative treatment must prevail, and this
must continue to be so until the movement, promoted by
V. Winckel, Fritsch, G. Klein and others, to build asylums
for women with pelvic diseases is actually carried out.
In 1898, shortly after the appearance of the Festschrift,
Funke, of the Strassburg University Frauenklinik, published
his esteemed article (ill.) on " Schrotbelastung," a lucid
elaboration of the principle of treatment enunciated by
\V. A. Freund, at the Meeting of German Naturalists and
Physicians at Brunswick, in the previous year (Resorption-
skuren, iv.).
It would be futile to raise any question as to " priority "
which does not depend merely upon the order of publica-
tion as regards date, but also upon fundamental facts. It
will be shown further on that in many respects there is
a surprising accordance in the views expressed, but that
the two methods of cure, developed quite independently
though finally absolutely complementary to each other,
exhibit fundamental points of difference.
The points of accordance are so remarkable, that Funke
added as his closing phrase : " For the rest, I have pleasure
in the fact that the views of Herr Pincus in many respects
agree with mine. That some of the principles I have enun-
ciated are, almost word for word, identical with his, seems
to be a proof that those principles are correct."
I shall try to make clear in the present work that
Funke's article and mine supplement each other in the
happiest way, though the literature of the subject shows
that, from circumstances not entirely depending on myself,
some misunderstandings arose which, however, can be
easily and quite satisfactorily explained.
The consideration due to my fellow-workers in the
Festschrift led me, at the last moment, owing to the great
length of my article, to recall from the press the case
192 Original Conwmnicaiion
histories, which, with the critical remarks upon them, the
editor had designed to print in cxtenso, as an appendix.
An incompleteness in the treatise was therefore unavoid-
able, though perhaps not at first very remarkable.
The misunderstandings affected the indications for
treatment, as well as the technique of my method. For
instance, in acute affections I advised that a nominal eleva-
tion (15 but not exceeding 25 cm.) with an intermittent
and limited external compression, should be tried in the
gentlest way possible and under the most careful pre-
cautions, and that no intravaginal treatment should be
attempted until the period of fever could be considered
overpast. This view, though clearly explained in the treatise,
was more precisely set forth in the case histories.
In regard to the methods of intravaginal compression
and its technique, a sharp distinction was drawn betw^een
the action of the shot bag and that of the air pessary, and
between the colpeurynter and the graduated tampon (Staff'el-
tamponade) ; some indications were given for the shot bag,
others for Gariel's air pessary, and so forth ; the different
ways of applying intravaginal compression were treated not
as equivalent, but as complementary factors which, with the
inclined plane, contributed to form the typical method of
" Belastungslagerung."
The inclined plane was employed not merely as a means
of accelerating the circulation of the blood, but as an im-
portant way of making the action of the shot bag as effective
as possible, and also of bringing into action and utilising
the traction effect of the organs when they gravitated out of
the pelvis. The " Belastung," the compression, is partly
direct from the pressure employed, partly indirect from the
traction of the pelvic and abdominal viscera, according to
the laws of gravity.
It must be clearly understood that in regard to the
indications, there is a fundamental difference between intra-
vaginal compression with the shot bag, as practised by me
more than ten years ago, and the use of Gariel's air pessary
Belastu7igslagerung 193
or other equivalent factors ; that it is just when intra vaginal
compression with the bag of shot, or quicksilver (Schauta)
ceases to act, that the air colpeurynter and such like become
beneficial in the treatment. This also, though mentioned,
was not so definitely expressed in the text of my article as
it was in the appendix of case histories.
It must, moreover, be once more clearly stated that the
colpeurynter and its modifications or substitutes, such as the
graduated tampon, are not merely indispensable elements
in typical position-treatment, but that in a very remarkable
manner they also afford the only possible means of treating,
with the best and most rapid success, chronic exudative
processes in the pelvis, in suitable cases even while going
about [ainbttlant). The fact that these modifications of
position-treatment allow one to deal successfully with
chronic, high-seated exudations and their consequences in
the out-patient or consulting room, is overlooked by almost
all authors.
Quite apart from this, there should be no conflict of
opinion, no question as to whether the bag of shot, or
some modification of it, is more useful than the air pessary
or anything of that kind ; the gist of the matter, as I put it
in definite words in my address at Munich (1899), is that
in the new force, Belastungslagerung, which must be
accepted as a perfectly typical therapeutical method, these
individual and essentially complementar}^ factors mutually
and profitably supplement one another.
For some reasons it might have been desirable to make
this view — the one I have held from the first, and which 1
hope to establish in this paper — more fully known sooner ;
but it seemed more scientific and at the same time more
convenient, to wait for the publication of other articles on
the subject, so that everything that after careful testing in
hospital practice had proved beneficial or useful, might be
adopted into the method. Apparently this course has been
justified, for owing to publications by Halban (v.) of
Schauta's Klinik, by Funke (vi.) of W. A. Freund's, and a
194 Original Communication
recent dissertation by E. Wolff (vii.) from the Klinik of
Olshausen, tliere is now some prospect of presenting the
subject in a complete form. The task is assisted by some
remarks in Fritsch's Text-book (viii.), by the discussion
following Halban's address (ix.), and that after Steffecks (x.),
and some remarks in the discussion at the Meeting of
German Naturalists and Physicians at Aix (1900) ; an article
by Manswetoff (xi.), and one by Beckers (xii.), with an
epilogue by Adler (xiii.), may also be mentioned. As I
am aware that other special treatises on position-treatment
are in course of preparation, it seems for various reasons
unpractical to delay the publication of the present article
any longer.
A few remarks are necessary on the development of my
method. I have given in my former articles details of the
profound literary research which I felt it my duty to imder-
take (Hippocrates), merely to avoid the question of priority,
before bringing forward my new method. These researches
showed that some of the factors in position-treatment were
no doubt well known and esteemed therapeutically, but
that their complementary significance to each other was
unknown or at all events ignored. Now, as Wolff puts
it in his dissertation (/. c. p. 37), " One must admit that
of the two factors, elevation and compression, neither is
very effective when employed by itself, and that it is
entirely to their happy combination that the favourable
results are due."
Auvard (xiv.) employed compression, both external and
intravaginal, but not elevation. Aveling (xv.) and Emmett
(xvi.) recommended elevation of the pelvis to diminish
uterine haemorrhage and to oppose inflammatory processes
in the pelvis, but do not mention compression. Lobingier
(XVII.) again recommended the mechanical force of gravity.,
the suction effect of respiration and the use of abdominal
binders ; Wernitz (xviii.) elastic abdominal bandages for
compression. Donaldson (xix.), Campbell (xx.), Courty
(xxi.), Bozeman (xxil.) (xxiii.), and others, advised the
Belastungslagertmg 195
knee-elbow or knee-breast position, which, however, as will
be explained in detail, are useless for our purpose. Oliver
(XXIV.) and others reinforced the resorbent power by stimu-
lating the tone of the muscles and vessels ; and so forth.
Indeed, as Goethe said : " Everything worth knowing has
been thought of already."
The historical development of the therapeutical use of
compression I naturally made a subject of personal study,
in regard to which I must, for independent reasons, refer
to my former article, merely mentioning that researches
made in the Royal Library in Berlin during 1895-6, in
preparing it for publication, showed that no method appre-
ciating the complementary significance of the factors above
mentioned had been described. The only thing of the kind
were a few remarks by myself in an article upon muscular
constipation, which had appeared about a year earlier in tiie
Archiv f. Gyiuvkologic (xxv.), pointing out the usefulness of
elevation and compression with wet potters' clay. The
word " Belastungslagerung " had not at that time been
intentionally used ; it appeared first in an article upon
atmokausis in 1898 (xxvi.). I should like the term retained
rather than replaced by Halban's " Belastungstherapie " ; it
is more significant, as " Lagerung," that is, " position," is
a typical factor in the treatment.
In position-treatment we have nothing whatever to do
with stereotyped prescriptions ; " what is to be done and
what to be left undone" must be decided most carefully in
each individual case. The therapeutic combination disclos-
ing itself in each single instance is that which will be useful.
The natural resorbent powers of the system must be brought
into action, supported and reinforced, while the local pain
and consequent congestion are diminished by placing the
diseased organs in the position of most complete rest
possible. The only typical elements in the method are a
moderate elevation of the pelvis and lower extremities, and
compression in the various forms employed.
The inclined plane is never elevated to the acute angle
196
Oj'iginal Communication
of the typical Trendelenburg position, and differs also from
that position in the legs being extended. In the patient's
house the simplest arrangement is to raise the foot end of
the bed on props of some kind, blocks of wood, bricks,
or such like. For hospital and intermittent use hammock
cloths in iron frames are most convenient. They must be
made of strong ticking of the width of the bedstead and
passed over a roller at the foot, so as to be made fast at
any desired elevation.
One may also, as a makeshift, even for intermittent use,
fit a strong hook at each side of the foot-end of the
Fit;. I.
mattress, so that it can be raised up. All that is then
wanted is a crossboard under the head of the mattress.
The patient's head must always be somewhat high, prefer-
ably upon a horsehair bolster. As Fritsch says (/. c. p. 470) :
" The patient, for this treatment, must lie with her pelvis
from 10 to 15 cm. higher than her thorax, a position which
is well borne." For ordinary cases, that is to say, decidedly
chronic affections, it is sufficient to raise the foot end from
20 to 30 or 35 cm., and from numerous carefully made obser-
vations we find that the extreme height admissible for our
present object is no more than 40 cm. Greater elevations
are seldom endured, even by not very sensitive women, for
more than a part of an hour, and, though used inter-
mittently they are sometnnes very beneficial, are seldom
Belastungslagerimg 197
necessary. They often cause cramps in the calves and
cerebral oppression, though here also there is no universal
rule. During the night the elevation should not exceed
25 cm., in order that the patient may lie comfortably and
sleep undisturbed. In this respect, however, a few days'
practice makes a great difference. In women who suffer
from cramps in the calves of the legs and varicosities, the
bandages worn during the day time may be left on at night,
but should be changed daily, and before the bandages are
applied the blood should be encouraged to flow away by
lifting up the legs. For our purposes the best bandages are
of Japanese Picot,
The rules laid down by me have always been identical
with those just given. In nearly every case the elevation of
the foot end of the bed above the horizontal has been from 20
to 35 cm., and it has been quite an exception for a height of
40 cm. to be used, even intermittently, and such an eleva-
tion is only possible in insensitive women, suffering from
old and distinctly chronic processes. In acute cases, always
provided there were no symptoms of peritoneal inflamma-
tion, or very slight ones only, elevation was tried with great
caution and the foot end of the bed was never raised more
than from 15 to 25 cm., just enough to facilitate flow of the
venous blood and lymph away from the uterus.
Everything described in my former article was derived
from the experience of many years' careful and critical
study during busy practice. Never, even in chronic cases,
was any foolhardy attempt made to raise the foot end
of the bed so high that it could be supported by a chair set
underneath it. Clinical experience has recently shown
(Halban, Wolff) that, as regards chronic inflammation, this
caution was perhaps excessive. That women with acute
inflammation of the parametrium could not endure such an
elevation of the pelvis is self evident (Halban).
I am, however, firmly convinced that the method can-
not be generally recommended, in acute inflammations,
simply because it is not possible to lay down strictly
198 Original Connnunication
limited indications in a few words. Too much depends
on momentary observation and effects and, therefore, upon
accidental circumstances too much dominated by the sub-
jective opinions of the individual. Moreover, it would
necessarily pre-suppose such an intimate acquaintance with
the subject as can only be expected from an experienced
specialist.
A moderate elevation of the bed (15, 20 or 25 cm.)
should also be the rule, in order to guard against congestive
thromboses as far as possible and to ameliorate such as
are due to infection. Further precepts in regard to com-
pression must for the present be held in reserve, attention
may, however, again be drawn to the fact, very clearly stated
already in the Festschrift, that intravaginal compression is
never to be prescribed until the period of fever may be
considered quite passed away.
just as in atmokausis, in order that the method may
be assured a permanent place in therapeutics, one must, in
position-treatment, depend entirely upon what is absolutely
certain from experience, so I shall continue to collect suitable
observations and if they should, on analysis, yield any useful
results not dependent on accidental circumstances, will
describe them hereafter for my fellow-labourers in gynae-
cology. With this in view, I would beg those with hospital
opportunities to institute further trials, since observations
suitable for such analysis can seldom be made in private
practice or without the collective responsibility of the
hospital staff.
Si ilium objurges, vitae qui auxilium tulit,
Quid facias illi, qui dederit damnum aut malum
(Terentius, in Andria, Act I., i.)
As already prominently set forth in the Festschrift, the
guiding principle to be insisted on is that the peculiar
domain of Belastungslagerung is the treatment of distinctly
chronic exudations.
By such moderate elevation as above described one
may in chronic inflammatory processes succeed in greatly
BelastiLngslagei'ung 1 99
relieving the pelvic organs, and so far as those viscera are
at all movable, lift them out of the pelvis to an extent
quite sufficient for our purpose. At the same time the
acceleration of the return flow of the blood and lymph
causes mechanically a material improvement in the circu-
lation, and an auto-transfusion to the medulla oblongata
and to the heart of patients anaemic from many causes,
which invigorates the circulation and enlivens the vital
processes. We should remember how often the action of
auto-transfusion in the acute an?emia of recently delivered
women is extremely beneficial, and that from inflamed parts
of the body the lymph poured out is not only more
plentiful in amount, but also richer in cell elements than
usual.
There can be no doubt that moderate elevation of the
pelvis, such as I recommend, constitutes an important factor
in the treatment of inflammatory pelvic affections. This
is entirely in harmony with the theoretical view and is
taught with absolute certainty by the observation of
cases in practice ; it has, to my great satisfaction, been
demonstrated by trials in Olshausen's Klinik, and requires
no further proof. But one remark may be permitted :
"Pain in the hypogastric viscera, apart from strangling or
dragging adhesions, for the most part arises from haemal
congestion. Whether it be cause or effect, such con-
gestion will always be diminished and relieved, to the
subjective and objective benefit of the patient, by repose
upon the inclined plane, and this quite independently of
the action of complem.entary compression. The return of
the venous blood is accelerated and the arterial circulation
thereby stimulated, for normal blood is an excellent stimu-
lant for the healthy endocardium ; an influx of blood will
rouse even the paralytic heart indirectly to activity, directly
to rhythm." To this passage from the Festschrift I may
here add that by moderate elevation of the pelvis one can
to a certain extent paralyse the deleterious influence of
defective bodily nutrition upon resorption. This observa-
tion, made in practice, is necessarily of practical importance.
200 Original Communication
The inclined plane has been compared with the elevation
and swathing of an extremity, a method which surgeons
successfully employ to subdue declared lymphangitis, or
lymphadenitis, but the statement must not be taken too
literally. An analogy only should be sought in the com-
parison. Moreover, it is always wiser not to express an
opinion on any new method of treatmeiit until one has
tried it.
Although great importance is attached to improving the
circulation of the blood, our treatment should never be
directed to this object alone, but the irritated and in-
flamed adhesions should, as already pointed out, be relieved
by the traction of the viscera themselves as soon as, under
the laws of gravity, the latter begin to fall towards the
abdominal cavity or, as it were, to be drawn away from
their beds. That this takes place to a notable extent, even
when the bed-foot is raised to no more than 30 cm., is
easily proved by an internal examination, in conducting
which, however, care must be taken that as little air as
possible enters the vagina, for otherwise the examination
will be misleading.
Finally, elevation of the pelvis is employed, is, indeed,
specially devised as the only possible means of applying
intravaginal compression rationally in the first place, and
of obtaining any gradual increase in such compression
in the second. This is as self-evident as the fact that,
just like the quicksilver, the mobile grains of shot always
find their way where the opposed resistance is weakest.
The weight does not act directly until the equilibrium
has been established. More will be said on this point
hereafter.
The value which, on the ground of my own clinical
observations and experience, I think should be ascribed
directly to the relieving traction of the weight of the viscera,
is shown by the view above quoted, which with deliberate
intention was prominently set forth in the introductory
words of my original article.
Belastungs lager ung: 20'i
To some extent, the action of the inclined plane is de-
pendent on compression, the second complementary factor
of typical Belastungslagerung. The effect of elevation of
the pelvis, alone, is often not sufficiently intense, and the
same may be said of compression. But while the inclined
plane alone was never the cause of any noticeable deteriora-
tion or bad effect of any kind in inflammatory pelvic
affections, the same cannot be said of compression. Indeed,
as has already been mentioned, compression by itself is as
a matter of fact now and then directly injurious. When
used alone it has, in several cases, caused severe pains,
which were immediately relieved as soon as the simul-
taneous use of the inclined plane was prescribed.
It is the observation of cases in practice that has
established the different therapeutical value of the two
factors, and demonstrated, with absolute certainty, that
each is complementary to the other. Whether this can be
explained theoretically or not, is of no consequence. The
merits of any therapeutical method depend on its results.
All that sound empiricism has gained for us is of permanent
value. I must, however, confess that in this instance I do
not find the slightest difficulty in reconciling theory and
practice most happily and harmoniously. The matter is
not one that requires any argument. Everyone in surgical
practice, or who has had experience in surgical wards, is
well aware that in simple elevation of the part we have
a most effective antiphlogistic method of treatment, and
that this effect is greatly increased when compression
(bandaging) is associated with the elevation. The method
is in daily use in practice. Why should it not be so also in
pelvic affections ?
The analogy to an elevated extremity, drawn by the
author, is accepted by Wolff in his dissertation (/. c, s. 36)
as appropriate. Funke objects that one cannot suspend
the pelvis as one can an extremity ; that is quite true, and
in Danzig we never attempted to do so ; yet, though the
elevation employed has been quite a moderate one, the
VOL. XX. — NO. 78. 14
20:? Origi7tal Communication
results have been remarkably good. Suspension, therefore,
is quite unnecessary, and the unnecessary is to be avoided.
Compression is used in two forms : external, through
the abdominal walls, and internal, that is intravaginal ; it is
most effective when both forms can be used at the same
time. Either form may be used continuously, or inter-
mittently.
Intravaginal compression, used alone, is a valuable means
of cure, and more so than external compression, as during
the latter symptoms of congestion in the depressed abdo-
minal and pelvic viscera are not unusual. This may be
ascertained by direct examination. It follows directly, that
compression through the abdominal walls can only be
employed with real benefit when there is from the vagina
an opposing force to serve partly in compressing, partly in
elevating and fixing the organs. As will be shown, the
indications for elevation of the pelvis and immobility of the
organs on the one hand, and for intravaginal pressure on
the other, are not altogether the same.
In subacute stages, the compression should be external
only (possibly with an ice-bag) and is essentially more
effective when applied to the patient on an inclined plane
(15 to 25 cm. elevation). Peritoneal irritability is a valid
contraindication. Moreover, the compression must be inter-
mittent and is not suitable unless it diminishes both fever
and pain, a condition suspended at the first trial.
In the chronic stages of disease, compression, whether
external, or intravaginal, may be continuous if the patient
remains free from pain and fever. Should pain or any rise
of temperature (evening) occur, the compression must be
intermittent. Great caution and careful observation is then
indispensable, so as to avoid exacerbations. Slight rises in
temperature do not necessarily forbid compression ; pain
is of more importance, but even in the chronic stage, the
occurrence of both pain and fever is a contraindication.
There is then certainly some focus of suppuration which
demands milder measures (never massage). In the first
Belastungs lager ung 203
instance, warm poultices and the inclined plane will be
beneficial, without compression.
If on renewed application of the typical Belastungs-
lagerung no improvement should occur, it is well to inform
the patient's relatives that the course of the disease will
probably be very protracted, and, if the patient at the same
tune loses strength, an incision must be made, and the sup-
purating focus sought by blunt dissection and opened as
freely as possible in all directions by digital pressure ; this
applies, however chronic the case may be.
Abdominal compression is obtained by a shot bag,
(Auvard xiv.), from i to 5 kilos in weight, or by from 2 to 5
kilos of damp potters' clay. Many women bear the damp
clay (pelite='TJion =^c\ay) much better than the shot bag, and
for this reason the minimum weight is put at 2 kilos. It is
probable that there is some simultaneous beneficial effect
from the moisture and perhaps also some chemical irritation
of the skin. In any case the use of shot or clay is to be
preferred to that of sand bags, and also to compression with
stones, such as used to be frequently prescribed. Compres-
sion with bags of stones is often beneficial in constipation
(xxv.). The extreme weight of 5 kilos is seldom necessary.
For intravaginal compression the author formerly made
most use of the shot bag. The bags were made of iodo-
form gauze, with a lumen larger than that of the completely
dilated vagina. They were introduced into the vagina by
means of a short cylindrical speculum while the woman's
pelvis was elevated, and from 500 to 800 grammes of shot was
poured into the bag while the speculum was slowly with-
drawn. The bag was then tied up and pushed in as deep as
possible, so that only the string protruded. The grains of
shot exercised their effect in the vagina unrestrained by the
gauze, for the gauze capsule accommodated itself to the walls
in every direction, and was only intended to facilitate the
removal of the shot. The shot really lay almost free in the
vagina, and could be easily removed at any time, even by the
patient herself. Indeed, the patient did as a rule remove it,
204 Original Communication
for as soon as it had been ascertained that the treatment
could be carried out without danger, the compression was
generally applied in the patient's own house or in a private
hospital. Of course, unwearied pains were taken in giving
exact directions ; above all, the patient or nurse was most
carefully instructed to remove the shot directly the com-
pression gave rise to pain, or to any increase of existing
discomfort. The temperature (evening) was always taken
most systematically, and compression was never applied
during the menstrual period.
Freund's method of intravaginal shot compression by
means of a special condom, was thoroughly tested in practice,
and the more so because, a priori, it seemed better than my
own, but it was not found to be so in application. Though
very convenient, the method has serious practical disadvan-
tages. There is great uncertainty in the use of a condom,
and constant trouble from its rupture. However careful,
however expert one may be, just when least expected the
rubber bag breaks. You may perhaps carry the matter
through successfully ten or a dozen times, and yet in the
next two the bag will break. Is that so serious ? Indeed,
in private practice it is a ticklish matter. In itself of no
great importance, it causes both doctor and patient a
certain annoyance, and the peculiarities of nervous women
must not be forgotten. With innate instinct, the patient
at once notices that something strange has occurred ;
no doubt many a young colleague has gained some
reputation by a novelty, but if, when such an accident
happens, the doctor has not a plausible story ready, the
nervous woman loses confidence, and will not allow him
to make any more experiments with her. This is worth
consideration, for it is taken from cases which have occurred.
This particular method, however, has merely a theoretical
interest, for as regards intravaginal compression, the use
of shot has been altogether abandoned for that of quick-
silver, as suggested by Schauta {v. Halban).
1 no longer use the gauze bag myself, and the last time
Belastungslagerung 205
I employed Freund's method it was upon the wife of
a colleague to whom I wished to demonstrate it ; the
rubber bag broke, and the colleague was shown that this
application was by no means a perfect one.
The introduction of quicksilver for compression by
Schauta and Halban was a great improvement. Its use is
more convenient and sure, and its therapeutic elTect more
uniform and intense. That is apparent, a priori. Halban
(/. c, p. 132) ascertained by experiment on the cadaver
that, under similar circumstances, more powerful effects
can be got with quicksilver, because, in the first place,
we can use a greater weight (1,000:600), and secondly,
because the quicksilver adapts itself to the form of the
vagina even better than the shot. In a cadaver with open
abdomen, it appeared that "the vaginal vault was more
completely distended and tensely stretched, and the uterus
more forcibly elevated than was the case when the shot bag
was employed."
I do not see, however, that there is any distinction in
principle to be drawn between the use of shot and that of
quicksilver for producing compression. If an examination
be made directly after the withdrawal of the condom or
colpeurynter, it is at once apparent that there has been a
direct pressure upon the exudate, but that the chief amount
of the compressing agent, as is quite natural, has found
its way into the parts where it encounters least resistance,
in the manner already alluded to.
In the appendix of case histories the author had de-
scribed many instructive examples of intravaginal compres-
sion with shot, and the critical review showed that this
method of compression, though it must be admitted to be
very efficacious, was only suitable for certain definite affec-
tions. It was pointed out in particular that a fundamental
distinction must be drawn between compression with the
shot bag and the use of the air pessary, which was described
in detail in the text. This distinction of course holds in
regard also to the use of quicksilver, though the action
of the latter is more intense.
2o6 Original Communication
Before discussing the use of quicksilver a few necessary
words must be said about the air pessary, the colpeurynter
and Staffel-tamponade, which are therapeutical factors of
nearly equal value. Staffel-tamponade was the name 1 gave
to a certain modification of my own, of the original
columnisation devised by Bozeman (XXII.)^ I had often
noticed in practice, that in the chronic stages of inflam-
matory exudative pelvic affections women could be pro-
tected from relapse with much greater certainty if, before
they got up, an elastic binder was applied round the
abdomen, and one of Gariel's air pessaries, or a colpeu-
rynter, was introduced into the vagina.^
The binder exercised a beneficent compression, and to
some extent exonerated the uterus and itsadnexa from intra-
abdominal pressure, and the support introduced into the
vagina gave some relief to the affected organs by placing
them in a position of elevation and absolute rest. The
therapeutical value of this treatment is generally acknow-
ledged, and, as regards cases of this particular kind, admitted
by Halban (/. c, p. 135), Steffeck, Broese (xxviii.), and
others. No one can contend that there is any serious
difficulty in the theoretical explanation of its indubitable
practical benefit in these cases.
As will be presently explained, the technique in regard
to the air pessary is, now that the quicksilver air col-
peurynter has been devised, different from what it was three
years ago.
' Although the air colpeurynter (Gariel's air pessary) is fitted chiefly
for the fixation of the organs, it cannot be denied that it exercises
a certain amount of compression. Accordingly, all cases treated with
Mirtle's apparatus for the vaginal application of heat (Manswetofif, XI.),
and Pflanz (xxvn.), must be controlled by adequate recognition of the
effect of the colpeurynter, as Schauta has very properly pointed out
{Zeniralb. f. Gyn., 1892, No. 42). von Erlach (/. c, i) endeavoured, indeed,
to utilise this effect directly, inasmuch as he used the colpeurynter under
high pressure, a proceeding that, a priori, was commendable. See also
Foges (xxxni.).
^ Fuller details of plugging or columning the vagina will be found in
Pozzi, N.S..S., vol. i., p. 98.
\
Belastttngslagerzmg loy
The technique of the Staffel-tamponade is unchanged.
Its action is often more prompt than that of the air
pessary, for the pressure is exercised all round it and more
energetically. It is particularly useful when the air pessary
cannot be borne. This tamponade elevates the uterus,
relieves the ligaments, and lessens the passive hyperccmia,
in short, has an eminently antiphlogistic action.
It is not desirable to use the knee-elbow position recom-
mended by Bozeman. This position is most distressing
to the modesty of women, especially when, as here, the
treatment has to be carried out with the aid of sight.
The elevated pelvis position is just as convenient, but it
is then desirable to use a short cylindrical speculum. The
modification which I call Staffel-tamponade is carried out
as follows : —
The vagina, after careful disinfection and drying out
is firmly plugged with dry sterile material (strips of gauze
5 cm. broad and 80 cm. long and Walcher's woodwool)
introduced by successive steps or layers.
Especial care must be taken to make the pressure in the
vaginal vault, especially in the neighbourhood of Franken-
haeuser's cervical ganglion, not only tolerably firm, but
uniform ; for this large complex of ganglionic cells is
undoubtedly the cumulative centre for the whole of the
female organs of generation, from which, as numerous
researches on this particular point have shown, beneficial
influence may be exerted on the circulation, and on sub-
jective impressions of pain, in the pelvis.
This modification has the advantage that the tampon has
not to be removed so often, as in consequence of the
dryness of the material used, the remarkable power of
absorption of the woodwool, and its being absolutely free
from bacteria, maceration of the vaginal mucous membrane
is, as far as possible, prevented. This maceration is a very
inconvenient trouble when glycerine and such like applica-
tions are used, as was formerly recommended by Auvard
(xxvilirt.) and others.
2o8 Original Covimunication
If, nevertheless, maceration should occur in sensitive
women, the process must be carried out intermittently, in
suitable cases, alternately with massage or other treatment.
If the tubes are thickened to any considerable extent, or
swollen in the form of tumours, Stafifel-tamponade, unless it
is absolutely painless, is out of place.
This contraindication however, must be further con-
stricted. It is absolutely necessary, at all events in inflam-
matory affections, that after the first application the patients
should repose for about twenty-four hours on the inclined
plane. This in regard to Staff el- tamponade may be con-
sidered an equivalent factor, since plugging is merely a
complementary, though important, element of the typical
method of compression-position.
If in spite of apparently correct indications, and repose
on the inclined plane, on the insertion of the Staffel-tam-
ponade in the proper way pains do come on, or existing
pains are increased, the proceeding is contraindicated. It
is therefore well in painful affections to simplify matters by
first introducing an air colpeurynter as a test. The expres-
sion "Stafifel-tamponade" has met with approval in the
writings of Halban, Wolff and others. The particular modi-
fication of Bozeman's "Columning" above described, should
therefore be so designated.
The effect of the Staffel-tamponade is increased and
strengthened by the inclined plane, but it is by no means
necessary, nor indeed desirable, that the patients should
be always lying down on it. In all cases its use should
be intermittent, and in very many may be limited to the
night. In other respects, in the interests of the patient, the
treatment should and must be undertaken while they are
going about.
It will be well for me to define here my views in regard
to the ambulatory treatment of chronic inflammatory,
especially of exudative, pelvic affections. As may be seen
from what has been already said, they may be divided
into two essentially different groups : first, those inflam-
Belastu7igs lager ung 209
matory and especially exudative affections which extend
to or lie near the pelvic floor and require resorbent treat-
ment ; that is to say, parametric exudations, haemorrhagic
cellulitis, exudations in Douglas' pouch and the like, and
all cases of disease of the adnexa and pelvic peritoneum
in which it can be determined without difficulty that the
organs are low down. All these conditions are accessible
to intravaginal compression proper, that is to say, that
pressure can be so applied in the vagina that it will
actually work as compression, while any external pressure
will serve rather as an adjuvant. During the application
of the intravaginal pressure the patient must lie down.
In the second group, the diseases of the adnexa and
pelvic peritoneum other than those just mentioned, the
organs, or the mass containing them, lie, so to speak, in
the normal position ; they are less accessible from below
and spread themselves in the plane of the pelvic inlet, or
even further into the abdominal cavity and, commonly,
there are adhesions to the upper margin of the pelvis
(ovarian), to the bowel, the fundus uteri or elsewhere.
It is difficult and sometimes quite impossible to deal
with the conditions in the second group by intravaginal
compression proper. Pressure maybe applied in the vagina
in these cases also, but cannot be considered as true com-
pression. All that in general can be obtained is a position
of rest and elevation for the diseased organs, a relief, a
diminution of the /tux iona I congestive hyperasmia and such-
like. The true " compression " is exercised from outside
through the abdominal walls. Apart from the inclined
plane, external pressure is the essential therapeutical agent,
while the opposing object inserted in the vagina fulfils the
part of adjuvant. When in these cases the compression
from outside can be obtained by elastic bandages, adhesive
plaster and such-like, ambulatory treatment may be success-
fully adopted.
This has been overlooked even by Funke, for after his
quotation from the Festschrift describing my method, he
2IO Original Communication
questions whether directly or soon after the termination
of an acute exudative process in the pelvis the woman
could be allowed to get up without any danger of a relapse.
Now on the previous page I had been writing about the
intravaginal pressure with the shot bag. My exposition had
become deficient in clearness, simply from the omission of
the case histories.
From what has been said it is evident that, from the first
trials of compression-position, a fundamental distinction was
drawn as to the mode of action of compression in the two
groups of diseases just described. The trials were always
made under the guidance of this distinction, and as the
theoretical deductive conclusions were confirmed by the
informing exigencies of practice, the path of treatment
became clearly outlined.
It was of deliberate purpose and by no means an accident
that the use of the shot bag was described in detail in
connection with the parametritic and perimetritic affections
of childbed, inasmuch as it is in these and similar condi-
tions that intravaginal compression not only appears to
be theoretically rational, but has proved to be especially
successful. For this reason also the words, " especially the
exudative," were, perhaps with unnecessary intention, added
in the title of the Festschrift.
The fundamental principles and the practical results
I have related have been confirmed in many quarters ; I
need only point to the writings of Halban, and to the
discussion in the Berlin Obstetrical and Gynaecological
Society (x.).
Belastungslagerung, therefore, meets all the demands of
practice. It is not a competitor with compression by
means of the shot bag (Freund, Pincus) or quicksilver
(Schauta, Halban), but claims and utilises both these
proceedings as integral parts of itself of remarkable
complementary significance.
In the other component parts of this method (air pessary,
Staffel-tamponade), we have means and ways which will
Belastungslagerung 211
most effectually subdue the exacerbations always immi-
nent in adnexal disease, and likely to supervene upon
compression, provided they do not depend directly upon
existing foci of suppuration. Workable ways are thus
available to set upon their legs more quickly the women
suffering from these tedious adnexal affections, graves of
the joy of existence and the happiness of home, and till
now so refractory to conservative treatment, without elicit-
ing the sudden thunderbolts of relapse. This has been
rendered possible simply and solely, as numerous parallel
observations in practice have shown with certainty, by the
therapeutical measures described in detail in the Festschrift.
Attention must be drawn to another point of funda-
mental importance which as yet has not been considered,
or even mentioned, by any author. It is that the com-
pression should be not only applied, but also relaxed,
gradually. With this postulate this method, though built
up on empiricism, assumes a true scientific form ; it
becomes more sympathetic and satisfactory to medical men
with logical ideas.
As a necessary consequence of this advance the technical
side of the method has also had to take on a scientific
dress. An apparatus had to be provided enabling us to
apply the compression, and also to conduct the relaxation
by degrees and with exact control, so that the shocks,
which seemed otherwise unavoidable, and only too well
calculated to induce aggravations in the objective and
subjective sufferings of the patients, would be avoided, or at
all events reduced to the minimum.
There can be no doubt that compression is followed
by an increased and more rapid resorption of pus, &c.,
(Fritsch viii., S. 470), and that the reactive fluxion after
irregular and sudden relaxation, induces an abnormal absorp-
tion of stirrers up of inflammation.
Both these statements are theoretically sound and both
are supported by practical observations. By gradually
relaxing the compression we have been able to employ the
212 Original Communication
method with the happiest results in conditions in which it
would have appeared impossible and contraindicated if, as
formerly, and without regard to the inevitable, and indeed
in many ways desirable, reaction, the relaxation was to be
carried out forthwith, and the patients, each time they sub-
mitted to the method in the out-patient department, were
to be sent home without any safeguard. The reactive
fluxion is certainly very desirable and to be utilised as much
as possible, but must not be allowed to escape from medical
control, without which the harmless ambulatory treatment
of chronic exudative pelvic affections which is such a
desideratum, cannot be ensured.
The apparatus suggested by Funke (vi.), a combination
of two colpeurynters, does not meet the case. The admitted
practical want and the technical demands it implies may,
the author hopes, be satisfied in a simple way by
The Quicksilver Air Colpeurynter.^
By the use of this instrument the method of Belastungs-
lagerung should obtain more rapidly than hitherto general
acceptance among my gynaecological colleagues and the
recently educated practitioners, inasmuch as it makes
the method more scientific, and doubtless more safe in
application.
The hollow glass sphere {a) intended for the temporary
reception of the quicksilver, and graduated for from loo to
500 grammes of mercury, is provided with 4 hollow projec-
tions, each 2 cm. long (6), which are allowed for in the
graduation, and each of these projections is inserted into
short rubber tubes (c), which again are connected with short
4 cm. glass tubes (^) with rounded edges, over which the
tubes of the colpeurynters (/ and £) and the air bag (A) can
be drawn. The fourth projecting glass tube {v) has an open
mouth acting as a valve. Each rubber tube (c) is fitted with
a spring clamp {e) which can be set tight. There is a fifth
To be had from Hahn and Loechel, Danzig.
Belastungslagerung
2 I
clamp on the pipe of the colpeurynter (/), which is designed
to hold i,ooo to 1,500 grammes of quicksilver.
Before the induction of the intravaginal compression,
the rectum and bladder should have been emptied, and the
patient invariably placed upon the inclined plane. The
woman, lying with her legs drawn up, the valve is opened
Fig. 2.
and the colypeurynter {g) emptied of air and by means of
a short cylindrical speculum or colypeurynter forceps, is
introduced as high as possible into the vagina, which has
been carefully disinfected beforehand. All the clamps are
then closed up to the ones leading to/. A chosen quantity
ofiquicksilver, not exceeding 500 grammes, is then admitted
from / into the glass sphere {a), and after the suitable
214 Original Communication
clamps are loosened this amount of mercury is emptied into
the colpeurynter {g). In this way one can, either slowly or
quickly as may be desired, fill the colpeurynter {£) with 800,
1,000, 1,200 grammes of quicksilver, or even more if neces-
sary, but that is rarely so.
The emptying of the colpeurynter, when undertaken, is
also done gradually, but in order not to submit the patient
at once to the uncontrolled effect of the reactive fluxion
from the diminished pressure, after emptying out all or part
of the quicksilver, one must open the clamp belonging to
{h) and blow up the colpeurynter (^) with air from iji) ; any
annoyance to the woman is thus absolutely prevented.
Until one has had some practice in the method, it is well to
control the injection of air by a finger in the vagina, because,
just as with the water colypeurynter, vaginal lacerations may
be caused by pumping in air in too great quantity, or still
more easily by doing it too rapidly. With the finger in the
vagina all danger can be avoided, so long as one remembers
the principle that a pessary is too large unless the examin-
ing finger can easily pass between it and the vaginal wall.
If the distended air bag causes any distress or pain it is
only necessary to open the air valve (v) a little. In general
it is better to introduce the air quite gradually, for the
reactive fluxion in itself is desirable.
A point of fundamental importance in the ambulatory
treatment of exudative pelvic affections is that the col-
peurynter, after it has been closed by the clamp [c) should be
detached from the glass sphere, and secured upwards to some
part of the woman's dress before she is allowed to go home.
One must not neglect to impress upon each individual
patient the precautionary rule, that in case of pain coming
on, the clamp is to be somewhat loosened, but the woman
should be on the inclined plane when this is done, other-
wise the pressure from above will be too strong, and the air
will escape too quickly and too completely.
In all these cases it is well to keep the abdomen as far
as possible at rest, and lessen the intra-abdominal pressure
Belastungslagerung 2 1 5
on the pelvic viscera by elastic bandages. In private
practice it is of course desirable to prescribe a colpeurynter
for each patient [for many women are " sensitive " when
they reflect at home that other women have worn the same
instrument]. The colpeurynters fitted to the apparatus are
the most suitable in size and resistance, and the air pump
also is adapted to what is required.
Many women will wear the moderately distended air
colpeurynter till the next day when the compression with
quicksilver is to be repeated. In that case it is not neces-
sary to remove it. In many others the bag has to be
removed by the patient at home after it has been worn for
some hours. It must then be cleansed with soap and brush
and sublimate, and kept in a 2 per cent, lysol solution. If
the bag has remained in sublimate it must, of course, be
washed in sterile soda solution, or in sensitive women it
may cause symptoms of irritation in the vagina (burnings,
and such like).
The little apparatus may be used in a different way.
For instance, if another colpeurynter Qi) be fitted at (y),
[or if (/) be emptied in the first place], one may, after
loosening the corresponding clamps, blow up / and g
(or k and ^) at the same time. Then, after stopping off
the air pump {h) by squeezing and relaxing / (or k) one
may institute with (^) an intravaginal massage which has
a beneficial effect on the tone of the walls and immediate
surroundings of the vagina, and this massage can be
practised for any time desirable without the least in-
convenience to the woman. The colpeurynters, however,
should be only a little more than half full. This proceed-
ing may be appropriately termed colpeurynter massage, and
is a new suggestion, at least, as far as I can discover, nothing
of the kind has yet been described in the literature. The
indications for it have been discussed in the Zentralblatt
(XLII.), and must therefore find mention here. The method
must be further tested, and within certain limitations will
be appreciated as a welcome addition to the therapeutical
measures available hitherto.
2'i6 Original Communication
The various technical and mechanical precepts and in-
structions above given by no means completely describe
the method. The importance of careful nourishment, and
systematic respiration gymnastics must still be insisted upon
as indispensable and integral components of Belastungs-
lagerung, without which it cannot be recognised as typical.
By these complementary factors the forces of Nature are
mobilised for our objects, and none more effective to
promote resorption could be imagined.
It is absolutely necessary that the paniculus adiposus
of the pelvic viscera should be effectually preserved by
prophylaxis. It is therefore necessary, a priori, to pay great
attention to the general condition. The fat packing in the
pelvis is no mere storehouse of superfluous fuel, but is
wanted to keep the organs in their natural position, to act
as a protection and mutual support. When it has perished
from long confinement to bed, one must endea,vour to
restore it as quickly as possible by such hypernutrition as
is administered in the Weir-Mitchell treatment.
Finally, that an improvement in the circulation goes
hand in hand with the increase in bodily powers, requires
no argument, and no well-educated physician would require
proof that an energetic circulation is of importance for
resorption.
For this reason, even in the Festschrift, attention was
specially directed to the utilisation of the exhaustive effect
of respiration by methodical respiratory gymnastics. Slow
forcible inspiration through the nose is all that is necessary,
but this must be practised systematically and regularly, from
ten to twenty times every hour. In private practice, these
respiratory gymnastics are the more important because most
of the women wear tight stays, and they offer the only possible
method of successfully increasing the capacity of the thorax.
A rapid balance is obtained in the differential pressure of
the arterial and venous system. While the arterial pressure
is raised the venous is diminished and the lymph stream is
accelerated, a valuable preliminary for the desirable resorp-
Belastungslageriing 1 1 7
tion. And since the variations in the blood pressure caused
h)^ respiration, not in the arteries only, but in the veins and
even in the lymphatics also, are greatest in the vessels in
and near the thoiacic region, and their hmits are in propor-
tion to the intensity of the breathing, not even theoretically
can any doubt be raised as to these recommendations being
wise and necessary.
Method in these exercises is very im^iortant, as without
it the heart cannot adapt itself to the increased work thrown
upon it. Isolated forcible inspirations are detrimental
rather than improving to the cardiac function. If anaemia
be present, but only to a moderate extent, the inclined
plane alone will prove efficient, but if the anasmia be extreme
one must also try to improve the circulation in a purclv
mechanical way by hypodermoklysis, or perhaps clysters.
Finally, it must be remembered that one-sidedness, as
well as generalisation, is to be avoided. In many cases the
permanent success of Belastungslagerung is only secured
when the method is combined with other measures ; hot irri-
gation, in the excellent way recommended by Stratz (xxix.)
peat baths, hot sand baths, advised by v. Winckel (xxx.),
and such like. In many women, though the continued
use of the method is well borne, its intermittent emplov-
ment has a better effect. This agrees with Halban's ex-
perience that a long course of the treatment is not always
more effective than a shorter one. Massage is not indicated
unless movable organs are cemented together (ovaries and
tubes). One must individualise and carefully watch the
cases and so get a true diagnosis.
My investigations in connection with compression-methods
were not perhaps originally due to any very noticeable gaps
- in our available means of treatment, but were instituted
rather upon diagnostic grounds, because in these particular
cases it must always be desirable for the beginner to avoid,
as far as possible, the use of narcosis merely for diagnostic
purposes. This was mentioned in the Festschrift, but it is
VOL. XX. — NO. y^). 15
2i8 Original Cofnmunication
to be understood that afterwards, in the exposition of this
new method of treatment, the therapeutical moment pre-
vailed.
Yet the more the author has to do with this method
the more is he impressed with its practical value in
diagnosis. At Munich the time limit on the speakers
was absolute, and I confined myself to merely mentioning
the advantages of the method in this respect ; but these
very advantages merit the special consideration of specialists
and practitioners, and would materially promote the general
acceptance of the method.
Freund, in his own report of his address at Brunswick
(see also in the Proceedings, xxxi.), made no allusion to
the value of the method in diagnosis, and when the Fest-
schrift appeared nothing further had been published, though
Funke soon afterwards made some contributions on the
subject, and Halban also. In the discussion at Aix of
Fritsch's address " On Vaginal Coeliotomies," VV. A. Freund
characterised the compression treatment as an aid to dia-
gnosis/or which there was no substitute. We should, therefore,
endeavour to secure that in every case before and with
the employment of this method for therapeutical purposes,
it should also, and previously, be utilised for diagnosis.
It may therefore be permissible to add a few funda-
mental diagnostic rules, which are the result of practical
experience, and promise to be useful.
It is the duty of every practitioner to avoid all that is
useless, especially any proceedings not free from danger.^
Narcosis merely for diagnostic purposes, therefore, should
never be employed unless it is actually indispensable, or
unless as I recently pointed out (xxxiv.), the diagnosis in
any case must necessarily be followed by an immediate
operation (xxxiv.).
On leavmg hospital work a man is too apt to carry out the
1 Cf. Borntraeger's Classical work : " On the Criminal Responsibility
of the Physician in the Use of Chloroform, &c." Berlin : 1892.
Belastungslagerung 2 1 9
things that he has seen there in private practice ; but there
is a fundamental difference between hospital and private
practice, and especially so in regard to the necessity or
propriety of narcosis for diagnostic purposes. This dis-
tinction should be more prominently set forth, as it was
constantly by v. Winckel in Dresden, so that physicians
attending hospital practice should take it to heart.
In hospitals didactic teaching is appropriate. The
students have to be prepared for their profession, and in
general for the first time be taught to know how to make an
examination. The morbid condition must be felt not only
thoroughly, but as quickly, and by as many persons, as
possible. In hunting haste one instructive case follows
another, and it is the duty of the superintending clinical
teacher to utilise to the utmost possibility, for the purpose
of education, all the material at his command. The object
of hospital study is to wake up the power of combination,
to call out and form the capability of the student to come
to a decision. The power of combination is only acquired
after frequent observation, palpation and recognition.
Furthermore, in hospitals the patients come from classes
whose only wealth is represented by good health and
capability for work. The women submitted to examina-
tion and observation wish, and are obliged, to be capable of
work quickly, or they must from material reasons succumb.
In hospital, therefore, important distinctions have to be
drawn in a moment, and one must therefore admit that
narcosis for diagnostic purposes is directly indicated in
various ways ; but in private practice it is very different ;
narcosis for diagnostic purposes is only justifiable when
threatening symptoms are present or an important distinc-
tion in prognosis must be promptly arrived at. One is by
no means compelled so to proceed, in every case, that a
complete diagnosis may be arrived at on the first examina-
tion ; if one were, one would be compelled to use narcosis.
It is much more correct in difficult cases to make
repeated examinations ; one can in that way proceed much
2 20 Original Communication
more cautiously and obtain nuicli more information with-
out doini^ any harm. By comparing with one another
the conditions found on two or three successive days, one
may, by combining the results, learn just as mucli as by a
forceful examination under narcosis. Of course there is
little use in saying that narcosis should not be so often
employed. He who condemns it must offer something
better, or he will not be listened to ; for who can deny that
there is a much felt and well recognised want. The sub-
stitute for narcosis, however, is in many respects provided
by the typical method of Belastungslagerung (xxxiv').
In Germany we have two excellent text-books on Gynae-
cological Diagnosis, Winter's (xxxv.) and Veit's (xxxvi.).
Each has had a large circulation, and each in the happiest
way supplements the other.
Too much importance is still attached in family practice
to chronic parametritis. " Under this collective expression
all sorts of affections, inflammations, callosities and exuda-
tions in the parametrium, inflammations and exudations in
the peritoneum, perisalpingitis, perioophoritis ; tubal tumour-^
are very often included (i.)."
In Strassburg Funke's experience was much the same,
he writes (/. c, p. 269) : " Examiners without experience
wrongly refer to the parametrium both acute and chronic
affections the localisation of which they are unable to
determine exactly."
This circumstance is important inasmuch as Belastungs-
lagerung can only be recommended, generally, on the
supposition that the differential diagnosis, especially as
regards the tubes, has been most carefully established ;
moreover, exact observation, including the taking of the
temperature, must be guaranteed in every case.
The extreme importance of an exact anamnesis, in
regard to diagnosis, must not be disregarded. From a
careful case history one may often get more valuable
hints than from a thorough combined examination. If,
for instance, it is recorded that an exudation occurred in,
II
Belastu ngslage ru no 2 2 i
or in immediate connection with, child-bed, and if from
the symptoms and data given septic endometritis and
gonorrhoea can be excluded in the great majority of cases,
one may take it for granted, // priori, that one has to deal with
an exudate in the parametrium, at all events with one in
which the perimetrium, if affected, is only so secondarily.
On the other hand, if there has been no child-bed, or
only one absolutely normal and free from fever, or if the
exudate is to all appearances entirely independent of puer-
pery, perhaps occurring many years after anything of the
kind, and if, also, it is known that no gynaecological opera-
tions have been performed, one may then suppose that
the exudation has its seat in the pelvic peritoneum.
I have invariably found it well to attach importance to
such fundamental differences. Every differential charac-
teristic must be given its full value in the history. Above
all the anamnesis should show whether relapses or exacerba-
tions have been of frequent occurrence and whether the
inflammation has been in any way of a remittent character,
for if so one has generally to deal with pelio-peritonitic pro-
cesses, or with tubal affections. Parametritis seldom takes
this course, but is chronic and tedious, with the formation of
abscesses. As Kuestner well says (xxxvii.) : " Infiltrations
low down in the pelvis are generally phlegmons of the
connective tissue ; those lying near the uterus in the pelvic
inlet are generally connected with the tubes or ovaries ; an
exudate palpable behind the uterus and extendmg towards
one side, is generally connected with the tube, ovary, or
pelvic peritoneum.
Even with the constant aid of narcosis, an exact and
complete diagnosis in every single case, as Fritsch (xxxviii.)
puts it very appositely, is only to be established by a
diagnostician at once optimistic and fanciful.
It is often very difficult in nervous hysterical women, in
whom examination causes much pain, to arrive at any
definite conclusions. In such cases the uterine elevator
I devised and originally used for the purpose of gynae-
222 Original Communication
cological massage in order to lift the uterus upwards and
forwards (Luftungen) {v. Archiv f. Gyn., Bd. xiii., p. 456) has
proved very useful.
The cup-shaped extremity, which is screwed on, and is
made in various shapes and sizes, is introduced like a
speculum, and after it has received the portio vaginalis
under the guidance of the fingers, the straps through the
movable lateral branches are passed below the woman's
thighs and gradually drawn upwards by the patient herself.
Fig.
The convexity of the lower curve of the instrument is then
guided and supported on the perineum, so that the uterus
is raised directly upwards and forwards right against the
abdominal wall. The uterus is then accessible for massage.
The dotted lines show how in special cases an interposed
crook may be used to give a different direction to the cup.
If the patient is entrusted with the instrument there
need be no further anxiety, and one can ascertain with
perfect certainty whether pains on ballottement are of
nervous origin or otherwise.
Proceeding on the diagnostic principles just set forth,
which are founded on sound clinical and anatomical facts,
and utilising all the advantages given by the method of
Belastungslagerung, in the majority of cases it will not be
Belastu7igslagerung 223
difficult, even without narcosis, to form a clear opinion upon
the nature of the affection and its prognosis. It is quite
wonderful to what a high degree combined examination is
simplified by Belastungslagerung. The difference is par-
ticularly striking in young women with rigid abdominal
walls, especially when such persons are anxious and
nervous.
The reason the difference is so great in nervous women
is because the reflex spasm of the abdominal wall, which is
so easily induced in such persons, is excluded by the
compression. For this particular object, especially in
hysterical women with hyperaesthetic zones of the abdo-
minal wall and hypersesthesia of nerve trunks, compression
with moist clay acts even better than with shot.
In hysterical, erethismic and erotic women, the appli-
cation of cocaui to the vestibulum vaginas before each
internal examination, an artifice already described in the
Archiv (xxv.), has proved useful.
Cocainisation, desirable in young persons and those that
are nervous, is indispensable in the erotic and hysterical.
Of course the patient is not to be told the object of the
solution, indeed it is best if her attention is not drawn to it
at all. It not only prevents excessive sensations, but also, to
a great extent, the reflex spasm of the abdominal muscles.
The shot bag or clay is not removed during the
examination. The vaginal examination is easier if the
pressure from above is maintained. By gentle palpation —
not with rustic hands — one then often feels as distinctly as
during narcosis, and one learns more, because the con-
figuration of the tumours is not infrequently made clearer
and more definite by the more prolonged compression.
Repeated narcosis for diagnostic purposes is seldom bene-
ficial, but the repetition of Belastungslagerung is much to
be recommended. In a favourable case repetition of nar-
cosis may do no harm, but repeated compression for
diagnostic purposes will, in the majority of cases, do good.
If after repeated compression, as usually is the case, the
224 Original Conimimication
diagnosis becomes iiK^re exact and instinctive, this often
signifies only that resorption has been actively going on.
I can now from additional experience confirm my
original statement that "So long as the general mass of the
adnexal tumours has not assumed any definite form, sve
should abstain, on principle, from narcosis." This of
course refers to private practice only. The treatment in
the beginning remains, generally, the same. If under it
any shrinking has taken place, one can in almost all cases
easily determine the nature of the disease."
When, owing to some vaginismus, the introduction of
a speculum is difficult, if the point of the speculum is intro-
duced into the cocainised introitus a little beyond the pro-
tuberance of the levator, and the patient is then told to
give a strong cough, the instrument will slip in almost of
itself. This method is also very useful in virgins if the
point be passed beyond the lower edge of the hymen, and
pressed somewhat backwards towards the rectum.
External compression, and, inntntis iniitaiidis, as regards
facilitating the examination of a case, the same may be said
of intravaginal compression, acts not merely by greatly
relaxing the abdominal walls, but also by very materially
diminishing sensibility. On this point there can be no
doubt. Anyone who takes the trouble to test it will
assuredly confirm my observations and remarks.
{To be contimied)
Revieivs 225
REVIEWS.
Haxdbuch der Geburtshuelfe. In chei Baendeii
herausgegeben, von F. WixcKEL, in Aluenchen.
Erster Band II., Haellte, mit zahlreichen Abbildungen
im Text und auf Tafeln. Large 8vo, pp. x. and 646.
Wiesbaden : J. F, Bergman n.
A notice of this very important work appeared in our
last volume (p. 357). The second instalment now before us
is divided into two parts, dealing respectively with Preg-
nancy and Labour, as regards their physiology and dietetics,
but, especially in regard to multiple pregnancy, it has not
been convenient to omit pathological conditions altogether,
and the term dietetics, which in the tirst part includes all
regulations for the general conduct of a pregnancy, in the
second seems to embract" nuich more — diagnosis, as well
as the entire conduct of labour, including protection of
the perineum, and the ligature and division of the cord.
Under the heading of Physiology, F. Skutsch, of Leipsic,
describes the investigation and diagnosis of pregnancy, as to
its existence, period, and whether it is primary, multiple or
otherwise ; the size and condition of the foetus, and the
dimensions of the pelvis, &c., &c. Strassmann, of Berlin,
treats of multiple pregnancy, and crossing the border line
of physiology (twins, triplets) discusses the effect of the death
of one (or more) of the embryos on the remainder ; oligo-
and poly- hydramnion ; the circulation of uniovular twins,
and acardia. He gives due appreciation to Schatz's work,
and among a large number of excellent illustrations, many
of them coloured, reproduces some good diagrams from
Professor Bumm's " Outlines." " The Dietetics of Preg-
2 26 Reviews
nancy" conclude the first part : von Herff, of Basle, writes
on the general care of the pregnant woman, including the
treatment of the slighter maladies incidental to her condi-
tion, while Bumm contributes a chapter, supplementing,
and to some extent overlapping, Sarwey's subsequent
remarks, "On the Preparations for Labour."
Four chapters of the second part are from the pen of
Oscar Schaeffer of Heidelberg, who deals with the nervous
centres of the uterus, the causes determining labour, the
expulsive forces and the resistance they have to over-
come, and also with the course and stages of labour.
Hugo Sellheim, of Freiburg, describes the bony pelvis, its
joints and ligaments, the anatomy of the pelvic fasciae and
muscles, including their condition when at rest and during
delivery, introducing much from his excellent Atlas (v. autCj
vol. xix,, p. 393).
L. Seitz, of Munich, writes a most interesting chapter on
the development of the attitude (luibifiis) and presentation
{situs et posit io) of the foetus, and M. Stumpf, also of
Munich, discusses "The Mechanism of Labour," prefixing
his work with a list, extending to more than seventeen pages,
of publications on the subject more recent than Mueller's
" Handbuch " in 1888.
O. Sarwey, of Tuebingen, writes on the Dietetics (Diag-
nosis and Conduct) of Labour, except as regards the third
stage, which is dealt with later by A. O. Lindfors of Upsala.
Menge, of Leipsic, undertakes Asepsis and Antisepsis, and
holds strongly that in midwifery antisepsis is useless if not
harmful, and that for the prophylaxis of puerperal fever we
must depend on such asepsis as will exclude infectious
germs from the genital canal, and upon such measures as
will fortify the resistance, local and general, of the system of
the parturient woman to such germs. In the next chapter
G. Klein, of Munich, gives an historical sketch of the
dependent-leg position (Hdngelage), and points out that its
essential effect was known and appreciated by Albucasis in
the 12th century, by Mercutio in the 17th, and by Melli in
Reviews 227
the i8th, but it was so ridiculed and neglected that it might
be said to be rediscovered by Walcher in 1889. He gives
some remarkable pictures from Mercutio and Mulli.
Lindfors, in connection with the third stage, discusses
the various methods of dealing with the placenta, and the
differences that from time to time took place in the so-called
Crede, and in the Dublin method of expression. He himself
leans to the milder form of the Dublin method (as described
b}'' Byers), and includes the idea of marking the cord off at
the vulva by a thread (or small clamp).
Labour in Multiple Pregnancy is undertaken by Strass-
mann, who here again, as might be expected from the
greater liability in such births to faulty positions, prolapse
of limbs or of the cord, haemorrhage, eclampsia, &c., &c.,
has a good deal to say about pathology.
In a work of this kind by many writers, it is practically
impossible to devise and preserve an absolutely systematic
arrangement, and to avoid overlapping and repetition, but
we have no hesitation in saying that this second instalment
of von Winckel's Handbuch fully maintains the high
standard of the first.
Tratado de Ginecologia. Por Miguel A. Fargas, Cate-
dratico de Obstetricia y Ginecologia de la Facultad
de Medicina de Barcelona ; Miembro honorario de la
Sociedad de Obstetricia y Ginecologia de la Universidad
Imperial de Moscou, &c. Illustrado con gran niimero
de Grabados y Laminas. Large 4to (10 x 7). Fasci-
culus I., Generalidades. Pp. viii. and 300 (with 174
Illustrations and 8 Plates). Price 9s. 6d. Fasciculus 11.,
Enfermedades de la vulva y vagina. Pp. 301 — 51O
(with 296 Illustrations and 12 Plates). Price 7s. 6d.
Salvat y C^. : Barcelona, 1904.
Though many of the best books on Gynaecology have
been translated into Spanish, few original works on the sub-
ject have been written in that language. Some years ago
Dr. Corolen and Dr. Soler published Notes of Lectures
2 2 8 Reviews
delivered by Professor P^ir^as, but the work wum concise,
and since its appearance he lias felt impelled to write a
treatise on the subject. The present book may indeed be
considered as a revised and enlarged second edition of the
former set in a didactic form. Professor Fargas has not
only his experience in the Chair of Obstetrics and Gynae-
cology to lit him for writing such a book, but that of twenty
years' practice witli a clientele of 18,000 patients, and labora-
tory work in his beautifully installed private hospital, which
is fully described and depicted in the first part of this book.
He has been a regular attendant at the International Con-
gresses, Berlin, Moscow, Paris, Madrid, and the Special
Congresses at Geneva, Amsterdam and Rome, and has
visited most of the Gynaecological clinics in Europe and had
personal relations with the most distinguished of his col-
leagues in many countries. His book is to be completed
in four parts, and judging from the two before us, while it
will not serve a student to cram for examination, it is free
from the prolixity that is wearisome to a well-educated
reader, and its clear and practical character throughout is
the patient outcome of the wide knowledge and practical
experience of a strong personality. The illustrations are in
great part original, the photographs and microphotographs
being the work of Dr. Terrades, the chief of Professor
Fargas' laboratory and himself a skilled gynaecological
pathologist.
Professor Fargas insists that surgery is more advanced
than diagnosis and the study of the indications for treat-
ment ; that there has been too great a tendency to improper,
premature or excessive intervention, and he holds to the
standard of conservatism that he has for ten years set forth
in his lectures, his annual reports and his communications
to the International Congresses at Moscow, Amsterdam,
Rome, and Madrid. He warmly advocates Apostoli's
electrical treatment.
The first fasciculus of the work deals with generalities, is,
in fact, a general introduction to the study of the Diseases
Reviews 229
of Women, including the necessary anatomy, phvsiologv,
hvgiene, general aetiology and pathogenesis, symptoms,
methods and instruments for examination, general and
special therapeutics, tonics, specifics, opotherapy, sero-
therapy, local applications and anaesthesia. Antisepsis and
asepsis are thoroughly discussed and eyidently thoroughly
carried out, the installation of Professor Fargas' clinic,
in this respect, being yery complete. The first part con-
cludes vyith the description of yaginal and abdominal
operations and the consecutiye treatment, and the accidents
and complications, prognosis, indications and contraindica-
tions for laparotomy.
For the remainder of the work Professor Fargas has
chosen the anatomical arrangement, and deals in Part II.
with Diseases of the Vulya and Vagina; in Part III. with
Diseases of the Uterus ; and in Part lY. with Diseases of
the Adnexa. This arrangement, though it entails some repe-
tition, has the adyantage of being more instructive, and in
the first part he has done much to minimise the repetition.
The remaining parts, making the second and concluding
volume, are promised shortly, and we congratulate Professor
Fargas on having given to our Spanish colleagues such an
excellent work. To the publishers, Messrs. Sal vat y Ca., we
offer our cordial compliments on the elegant production of
the work as regards paper, type and illustrations.
Progressive Medicixe : A Quarterly Digest of Advances,
Discoveries, and Improvements in the Medical and
Surgical Sciences. Edited by Hobart Amory Hare,
M.D., Professor of Therapeutics and Materia Medica
in the Jefferson Medical College of Philadelphia, &c.,
&c. ; assisted by H. R. M. Landis, M.D., Assistant
Physician to the Medical Dispensary of the Jefferson
Medical College, &c., &c. Vol. iv., December, 1903.
Large 8vo, pp. viii. and 444, with Plates and Illustra-
tions, cloth. Price 15s. (annually, 52s.).
This handsome volume is one of a series to which a
Grand Prize was awarded at the Paris Exposition 1900.
2 30 Reviews
The list of collaborators, in addition to the names of some of
the best known professors in America, includes those of
Dr. Rose Bradford, of University College, and Dr. William
Ewart, of St. George's Hospital, London, and that of Dr.
Logan Turner, of Edinburgli, and in this volume Dr. Rose
Bradford undertakes the Diseases of the Kidneys. The
other subjects treated of are none of them, except, perhaps,
Practical Therapeutics, very directly connected with our
Gynaecology and Obstetrics, and it is probably owing to the
carelessness of a clerk that the volume sent to us does not
deal with these branches of medical science. We have,
however, found mucii pleasure and profit from a study of
the book, and incidentally may mention as points worth
noting : the use of compresses of alcohol in peritonitis
(Ssaweljew) ; intravenous injections of a solution of
adrenalin in surgical shock (Crile), with caution on
account of its inhibitory action on the heart ; to its use
also in profuse uterine haemorrhage, and to increase the
effect of cocain in local anaesthesia. In connection with
vaporisation, a steam saw, devised bv Koslensko, which
checks parenchymatous haemorrhage as it makes the incision.
The occurrence of gangrene after the subcutaneous injec-
tion of Tavel's solution — it is apparentlv better not to add
bicarbonate of soda. One death after scopolamine recorded
by Bios in 105 cases — the danger is from the morphia, but
in six cases the patient was found by the test dose given the
previous evening to be a bad subject, and in twent}'-nine
the supplementary administration of ether was necessarv.
Spinal anaesthesia is not recommended. The treatment of
general infections by intravenous injections of collargol,
formalin, or nitrate of silver, seems justifiable in desperate
cases ; the good effect of saline solutions is beyond doubt.
An important article by Patella records good results from
the intravenous use of corrosive sublimate in anthrax, car-
bolic acid in tetanus, cinnamic acid in tuberculosis, and
collargol in various affections. Jaenicke reports a case of
severe puerperal sepsis treated with collargol.
I
Reviews 231
Four cases of fibroma of the abdominal muscles directly
associated with pregnancy are recorded by Fabian. Reflex
vesical irritation, according to Hahn, may be caused by, and
first draw attention to, uterine myomata, and may indicate
operation. Morphia is found to be beneficial in uraemic
convulsions, in pregnancy or otherwise, when the nephritis
is acute, but is less so, or even dangerous, when the nephritis
is chronic. Garsig records the piecemeal extraction through
the urethra of a three months' foetus from the bladder.
Harrington and Walker declare that corrosive sublimate is
much overrated as a skin disinfectant, and should be aban-
doned, alcohol (70 per cent.) being much better. Link, in
connection witii a death caused by the administration of
50 cc. of lysol in an enema, has found by experiments that
poisoning depends on the total dose, not on the strength of
the solution.
Our notice has been unwillingly delayed ; judging from
the present volume we think that this Digest would be a
most valuable help to any medical man in keeping abreast
wath the progress of medical science.
Atlas axd Epitome of Operative Gynaecology. By
Dr. Oscar Schaeffer, Privatdozent of Obstetrics and
Gynaecology in the University of Heidelberg. Authorised
translation from the German, with Editorial Notes and
Additions by J. Clarence Webster, M.D., F.R.C.P.,
F.R.S.E., Professor of Obstetrics and Gynaecology in
Rush Medical College, &c., &c. Crown 8vo, pp. 138,
with 42 Coloured Lithographic Plates and manv Text
Illustrations, some in Colours. Philadelphia, New York
and London : W. B. Saunders and Co. Cloth. Price
13s. net.
This little book is one of the translations of Lehmann's
Series of Hand Atlases, which are being issued by Messrs.
Saunders. It mav be considered a supplement to the ''Atlas
and Epitome of Gynaecology," which we were able to review
so favourablv in igoi {ante, vol. xxii., p. 88), but, though less
232 previews
tliiin half the size, the price is nearly the same, and while the
plates on the whole are as ,u;()ocl and will win the admiration
of even an experienced operator, it is not so with the text.
The distinguished editor disclaims any responsibility for the
plan or details, and one niav almost assume that the notes
he has interspersed in brackets were made by him in a
German copv, and that he had no opportunity of reading
the translation. In the " Atlas and Epitome of Gyncecolog}^"
edited by Dr. Richard C. Xorris, the name of the translator,
Dr. W. Hersev Thomas, was given in the preface, and {c.i^.,
p. 236) he did not hesitate to correct a lapsus calami in the
original. The translator of this book seems to have been
neither an anatomist or gvna^cologist, and though no
doubt able to read German cannot write good English.
One perhaps should justify such a statement. On page 71,
" vaginal portion" is used instead of vaginal canal ; on page
74, '' diverticulum," in itself an improper description, is
applied to a portion of the bladder which is not as there
stated anatomically " contiguous above " the trigone. The
use of the word " atrium " on page 119, cannot be justified,
even if transcribed from the original ; the only atrium in
the genitalia known to English or American g)aiaecoIogists
is the vestibule. On page 61, "urethra "is substituted for
bladder, though in the preceding sentence a warning is
given against openuig the urethra. Kolpocoeliotomy is a bar-
barism that mav have been taken from the German original.
In the descriptions of figures 16, 20 and 21, "mucous mem-
brane," "in the direction of the incisions," and "forward,"
are entirely wrong, and a reference given to plate 9 on page
56, should have shown the translator that " in the median
Hne " was not correct. Vaginofixation is sanctioned bv
use and euphonv ; if another form of the word had been
necessary no educated man would have chosen vaginifixation
instead of vaginae fixation, nor have written " urocervical."
The amount of the text actually devoted to gynaecological
operations is considerably less than 100 pages, and could
therefore be merelv an epitome ; as the German book is
Reviews 233
not before us and as no dates are given, we cannot say
whether it might have been more up to date than it is.
The Editor's notes are brief, and there is hardly one to dis-
sent from. He " emphaticallv " favours panhysterectomy in
cancer of the vaginal portion, and also in infected myo-
matous uteri ; he characterises half a page in regard to the
surgeiy of ectopic gestation as scanty and inexact, as indeed
it is, but this subject has been dealt with in the *' Atlas of
Obstetric Diagnosis and Treatment." It is a great pity that
carelessness such as we have shown should detract from the
value of the book to the student and practitioner, for the
illustrations are excellent both in design and execution.
Dee, normale Situs dek Organe im Weiblichex
Becken uxd ihre Hauefigstex Entwickluxg-
SHEMMUXGEN. Auf sagitallen, queren und frontalen
serienschnitten dargestellt von Professor Dr. HUGO
Sellheim, I., Assistentarzt an der Frauenklinik der
Universitaet Freiburg i. B., mit 40 lithographischen
Tafeln and 11 Figuren im Texte. Long quarto, 18 by
13*5 inches. J. F. Bergmann, Wiesbaden ; F. Bauer-
meister, Glasgow. Price ^3.
We had last year (vol. xviii., p. 393) the pleasure of
reviewing a most excellent and laborious work in which
Professor Sellheim dealt with the Anatomical Relations of
the Muscles of the Female Pelvis when at Rest and during
Labour. He had previously published (Giorgi, Leipsic,
1900) an Atlas of the Topographical Anatomy, Normal and
Pathological, of the Female Pelvis, in the preparation of
which he had been much hampered by the difficulty of
obtaining normal specimens. The material for the present
work, with the exception of one abnormal case lent by
Professor Wiedersheim, has been derived from the Patho-
logical Institute of the German University at Prague, and in
gratitude the author has dedicated the work to Professor
Hans Chiari, the Director.
The work consists of two parts : in regard to the first, on
VOL. XX. — NO. 78. 16
234 Reviews
the Normal Situation of the Pelvic Viscera, the cases
were most carefully selected, and any specimen that, though
apparently normal at first, showed after fixation or even
after section any considerable deviation therefrom, was
rejected.
In the introduction the manner in which the specimens
were hardened, and finally, after several months, prepared
for section by embedding in celloidin and soaking in
alcohol, is given in detail. The sections were made in three
dimensions, sagittal, transverse and frontal, in the way
originally adopted by Hodge, and employed by Sellheim in
his earlier work. Moreover, in regard to the sagittal sections,
the pelvis was placed at an angle of 20° to the horizon,
corresponding to the position in which examinations are
generally made, and many operations performed. In the
text (34 pp.) which precedes the plates, the anamnesis,
detailed autopsy and post-inortcin diagnosis of each case is
given before the description of the plates taken from it.
In the text as well as on the plates the direction of the
sections is given by smaller figures, and the study of the
plates is greatly facilitated by the position of various parts
named on the margin being indicated by pointing lines.
Sellheim claims that while his work corroborates gene-
i-ally the accepted view as to the situation of the pelvic organs,
he has by these studies of the anatomy in women who
have, and have not, borne children, in both young and old,
and with varying conditions as to distension of the bladder
and rectum, succeeded in correctly determining the play
room allowed to the pelvic viscera under normal conditions.
Apart from this the variations in form and position within
the normal are exposed in the most instructive way, the
extramedian position of the uterus and consequent asym-
metry of the adnexa, the effects of the full and empty
bladder and rectum, the variety in the relation of the vermi-
form appendix to the right adnexa, the variable depth of
the utero vesical pouch, &c. Moreover, if the course of the
ureters be followed in successive plates, one can understand
I
Reviews 235
how in a hysterectomy one of them mav not be in any
danger while the other can hardly escape injury.
The last ten plates, all instances of deficient development,
offer good examples of retroverted infantile uteri, twisted
tubes, functionless displaced ovaries, deep Douglas and
anti-uterine pouches, a remarkable instance of displacement
of the bladder to the right, and of supernumerary folds
(transverse, vesical and others) of the peritoneum, incom-
plete perineum, tuberculosis of the peritoneum, tubes and
uterus, &c., &c.
The accurate record and depiction of such laborious,
persevering and intelligent research, must aid in the progress
of gynaecology. Altogether this work is worthy of Sellheim's
established reputation, and has been produced by the
publishers in a most excellent manner.
La Gastro-Exterostomie. Historic generale, Methodes
Operationes. Les cent cinquante premieres operations
de la clinique chirurgicale d'Angers, par A. Monprofit,
Professeur de Clinique chirurgicale a I'Ecole de Medi-
cine, Chirurgien de I'Hotel-Dieu d'Angers, Membre
correspondent de la Societe de Chirurgie, Laureat de
ITnstitut (Academic des Sciences ; Prix Mege, 1903).
Large octavo, pp. xvi. and 375, with 300 illustrations.
Paris : Institut International de Bibliographic Scienti-
fique, 1903. Price 15 francs.
We are pleased to see a work of this nature from an
experienced surgeon who has distinguished himself not only
in the field of general surgery but also in gynaecology, for
last year the Prix Mege was bestowed upon him for his
work on the "Ovaries and Fallopian Tubes" {Chirurgie des
Ovaries et des Troinpes), which was reviewed about eighteen
months ago in this Journal {ante, vol. xviii., p. 397), and he
has also written and published much on the surgery of the
female pelvis. To those more particularly concerned with
the progress and increasingly satisfactory results of gastro-
enterostomy, the book before us will prove most interesting.
236 Reviezvs
and indeed fascinating, because the author writes with all
the fervour of an enthusiast.
In the preface he refers to the invasion of the domain of
medicine by the surgeon, and to the changes that have
already occurred, and that are taking place, in regard to the
treatment of chronic affections of the stomach. Too fre-
cjuently medical measures are resorted to and continued too
long, often with the result that the patient's health has so
deteriorated and the disease has so much further progressed
when surgical aid is ultimately sought, that the delav has
robbed both the patient and the operator of the best oppor-
tunity of attaining a satisfactory result. Monprofit justly
and rationally claims that such cases should be handed over
to the surgeon in an early stage, and points out that with
increasing knowledge of these affections surgical treatment is
happily becoming less and less postponed, and is daily giving
better results. We can sympathise with the author, for it
is especially in malignant disease that operative treatment
is too frequently deferred until the patient is in the worst
possible condition for such treatment. He believes that
with earlier operative interference, and with the great im-
provement in operative technique, the operation of gastro-
enterostomy will soon be as safe and as easy of performance
as that for radical cure of hernia. He confesses to being
a confirmed "suturist," and is altogether opposed to the
employment of buttons or any mechanical appliance for
obtaining anastomosis, and states that good results can onlv
be attained by good operative measures, with which the
surgeon must be thoroughly conversant, and that the next
most important point for him is to learn to sew rapidly.
The most interesting part of the book relates to his
description of the operation which he considers is the
nearest approach to the ideal, and that is the posterior im-
plantation method, or '' Y operation," as advocated by Roux,
where end to end anastomosis is made between the stomach
and the jejunum, and at the same time the duodenum is
made to anastomose with the jejunum below this junction.
Reviews 237
As the impossibility of regurgitation of bile and pancreatic
juice into the stomach is practically assured by this method,
the restoration of the digestive function takes place at once
and the patient's condition begins to improve immediately
after operation. Although he has had extensive experience
of gastric surgery, he has only practised the modified opera-
tion of Roux in some of his recent cases, and in which
the trouble was non-malignant, so that undue importance
should not be attached to them in comparison W'ith results
by other methods. He gives some excellent tables, classify-
ing the cases and operations, and full notes of all patients
that come under his care. The immediate and remote
results of operative treatment are well dealt with, likewise
the after-treatment of these cases, and we are glad to note
his recommendation of the early administration of food,
as we are convinced that, in the past, as many cases
have died from starvation after operation as from faulty
technique.
The work on the whole is an excellent text-book, and
contains a profusion of descriptive and useful illustrations.
Each chapter is well written, and that which particularly
deals with the various methods of performing gastro-
enterostomy is so descriptive and so full of details that it
cannot fail to be of the greatest value as a reference.
Practical Gynecology, a Comprehensive Book for
Students and Physicians. By G. G. Montgomery,
M.D., LL.D., Professor of Gynaecology Jefferson
Medical College; Gynaecologist to the Jefferson Medi-
cal College and St. Joseph's Hospitals ; Consulting
Gynaecologist to the Philadelphia Lying-in Charity and
the Kensington Hospital for Women. Second Revised
Edition, with 539 Illustrations. Royal 8vo, pp. xxxiv.
and 17 to 900. London : H. Rebman, Limited, 1894.
Price 25s.
When a book is beyond the size of an epitome for examina-
tion purposes, or even an ordinary student's manual, and also
238 Reviews
is nither costly, the fact that a second edition is called for
little more than three years after the first, is practically a
proof of its excellence, and certainly there are few works on
Practical Gynaecology that are more comprehensive than the
one before us, or which, while instinct with the experience
of personal woik by the bedside and in the lecture room,
give a better summary of the practice of other gynaecolo-
gists. The arrangement is somewhat unusual, for the
matter is not divided into chapters but into 654 sections,
and after a short introduction and the consideration
of diagnosis, the author passes to methods of examina-
tion, both pelvic, including curetting, microscopic and
bacteriological investigations, and abdominal, including
exploratory puncture and incision ; therapeutics, general
and local, medical and surgical, preventive and curative,
and the embryology, anatomy and physiology of the
genito-urinary organs in women, and then deals seriatUn
with malformations, traumatisms, inflammations, deviations,
genito-urinary haemorrhage and ectopic gestation and genital
tumours. As symptoms, diagnosis and treatment have to
be dealt with again, there would be some difficulty in refer-
ence, but that the verv full table of contents indicates the
subject of each section, and there is a good index of sub-
jects and also one of authors quoted. Dr. Montgomery's
general standpoint is not to sacrifice any organ whose phy-
siologic integrity is capable of being restored ; he is very
decidedly in favour of electrical treatment, especially of
fibroids in women near the menopause. In regard to the
vaginal methods of removing the cancerous uterus, from
which many of the best authorities hope so much, we agree
with him that, considering the ease with which the uterus
can be reached from above, there is too great a tendency to
extend the vaginal incisions and disregard the increased
danger of infecting the parametria. He is, of course, sound
on asepsis and insists on continued watchfulness, mention-
ing that, after careful and painstaking preliminaries, he has
seen an operator place his sutures on a syringe box, an
Reviews 239
assistant stroke his moustache, and a nurse use her handker-
chief.
The type, paper and binding are excellent and the illus-
trations for the most part well executed and well chosen.
The greater number are said to have been drawn and en-
graved specially for this work, for the most part from original
sources. Still there are a large number of figures judiciously
selected from older works, e.g., those of Savage and Deaver,
and others modified, and certainly not improved, e.g., figs.
382, 383, and 384, where, moreover, fig. 382 should come
after the others.
Annual Report on the Advancements oy Pharma-
ceutical Chemistry and Therapeutics. Vol. XVII,
for 1903. Demy 8vo, pp. 220. Darmstadt : E. Merck,
1904.
We have for several years had pleasure in noticing these
reports and the present volume is as good as its predecessors.
The preparations are arranged alphabetically, and in addition
to the general index there are others of the bibliography,
of the authors quoted, and of Diseases, Symptoms and
Indications for Treatment, which greatly facilitate reference.
Ailments of Women and Girls. By Florence Stac-
POOLE, Lecturer for the National Health Society, &c.,
&c. Crown 8vo, pp. viii. and 220. Bristol : John
Wright and Co., 1904.
This little book is full of good sense, exceedingly well
conveyed. We are glad to notice it for two reasons : first,
because as we heard at our first lecture on " Obstetrics," in
reference to some very popular works for wives and
mothers, it is well for medical men to be acquainted with
the source of their patients' information, and secondly,
because of the chapter on " Cancer of the Uterus," which,
if it were taken to heart by English women in general,
would do much to aid us in dealing more successfully
with that terrible disease.
PUBLICATIONS RECEIVED.
From Baii.mkke Tinuall and Cox, London :
Cleft-Palate and Hare-lip : the Earlier Operation on the Palate, by Edmund
Owen, M.B., F.R.C.S., Surgeon in Chief to the French Hospital, Con-
sulting Surgeon to St. Mary's Hospital and to the Hospital for Sick
Children, Great Ormond Street, London. Medical Monograph Series,
No. 10. Crown 8vo, pp. 112, with illustrations, 1904. Price 2s. 6d. net.
From Archibald Constable and Co., London :
The Clinical Causes of Cancer of the Breast and its Prevention, with Analyses
of a Hundred Cases, by Cecil H. Leaf, M.A., M.B.Cantab., F.R.C.S.
Eng. , Assistant Surgeon to the Cancer Hospital and the Gordon Hospital
for Rectal Diseases. Demy 8vo, pp. 64, 1904. Price 2S. net.
From S. Karger, Berlin ; Williams and Noroate, London:
Beitrage zur Anatomie der Tubenschwangerschaft, von Dr. Fritz
Kermauner, Assistent ander Universitaets, Fiauenklinik zu Heidelberg,
mit 44 Abbildungen. Large 8vo, pp. 137, 1904. Price 4s.
From E. Merck, Darmstadt and London :
Report on the Advancements of Pharmaceutical Chemistry and Therapeutics.
Vol. XVH. for 1903. Demy 8vo., pp. 216.
Fro.m Rebman, Ltd., London and New York:
Elements of General Radiotherapy for Practitioners, by Dr. Leopold
Freund, Vienna. Translated by G. H. Lancashire, ^LD.Bru^'., &c..
Assistant Physician to the Manchester and Salford Hospital for Skin
Diseases. With 107 illustrations in the text and one frontispiece. Royal
8vo, pp. xxii. and 538. With Notes on Instrumentation by Clarence A.
Wright, F.R.C.S.(Edin.), F.F.P.S., &c. Illustrated, pp. 60. Price £1,
cloth ; £1 5s. half bound.
From Georges Steinheil, Paris :
Introduction a I'etude clinique et a la pratique des Accouchements, par le
Professeur L. H. Farabeuf et le Doctevir Henri Varnier. Preface du
Professeur A. Pinard. Avec 362 figures. Nouvelle edition revue et
corrigee. Large 8vo (11 x 7 '5), pp. x. and 480. n.d.
And the following Pamphlets and Reprints : —
Gastrotomia primativa per gravidanza ectopia a terniine con forzato abban-
dono della placenta (madre e bambino viventi), pel' Professor GIOVANNI
Calderini, Direttore della R. Clinica Ostretrico-ginecologica di Bologna
(and others ; a full list will appear later).
Rara associazione neoplastica del collo uterino (Epitelioma Malpighiano-
Angioneoplasma complesso con metaplasia del connettivo e del mometrio),
pel Dott. GuisepT'E Cristalli, Assistente, Instituti O. G. della R.
Universita di Napoli, direlto dal Prof. O. MORISANI.
Extracts from the works of Professor T. E. Rein, published in Russian
by his pupils on his removal from Kief after sixteen years' service, to
occupy the Chair of Clinical Obstetrics and Gynaecology at the Imperial
Military Academy of Medicine at St. Petersburg, in 1899, with a portrait.
Tuberculosis of the Urinary Tract, by Edmund Garceau, M.D., &c., &c.,
Boston.
Tuberculosis of the Urinary System in Women, Report of thirty-five cases,
and Surgery of Urinary Tuberculosis in Women, by GuY L. HuNNER,
M.D., Associate in Gynaecology, Johns Hopkins Hospital, Baltimore.
Zum Problem vom Geschlechteverhaeltnis der Geborenen, von B. S.
ScHULTZE, in Jena.
THE BRITISH
GYNAECOLOGICAL
JOURNAL.
I
Vol. XX. — No. 79. November, 1904.
BRITISH GYNECOLOGICAL SOCIETY.
Thursday, July 14, 1904.
Dk. H. MACNAUGHTON-JONES, Vice-President, in the Chair.
Mr. Christopher Martix exhibited the following
specimens : (i) Bone Crochet Hook removed from the
Abdominal Cavity ; (2) and (3) Two Specimens of Arrested
Development of the Uterus; and read the following notes : —
(i) My first specimen is a foreign body, which I removed
from the abdominal cavity in December last. It is a por-
tion of a bone crochet hook about five inches long. The
patient was a widow, aged 48. She had missed her periods
for a few months, and believed she was pregnant. With
the object of procuring abortion she got a bone crochet
hook, and having sharpened it to a point, pushed it up into
the uterus. It slipped from her fingers and she was after-
wards unable to get hold of the end of it. It worked its
way right through the uterus and became free in the peri-
toneal cavity. She became alarmed, and consulted her own
medical man who sent her to me. When I examined her
a fortnight after the occurrence, I could feel the foreign
body lying in the left iliac fossa quite apart from the uterus.
She was a very thin woman, so that it was easy to palpate
vol. XX. — no. 79. 17
242 The Brilisli Gymecological Society
it. She was not pregnant. 1 opened her abdomen and
found this bony rod lying in the left iliac fossa, com-
pletely embedded in the omentum. It was easily removed,
and she made a good recovery from the operation. On
looking at tiie uterus I could see on the posterior aspect
just above the level of the internal os, a round, depressed
scar — evidently the spot through which the rod had passed.
There were a few adhesions between the omentum and the
small intestine, but there were no signs of infiammation in
or around the uterus itself. When I saw her she was in a
very strange mental condition, bordering on insanity. She
was firmly convinced that she was pregnant and that she
would still have to be confined, and would have to go to
prison for attempting to procure abortion. I saw her again
about two months ago, and then found that she liad de-
veloped cancer in the breast, which, however, she refused
to have removed.
(2) The next specimen illustrates one variety of arrested
development of the uterus. The patient was a smgle girl,
aged 18, who had never menstruated. About the age of 15,
the usual external signs of puberty appeared, and she began
to have monthly attacks of pain in the pelvis, lasting for
a few days. These monthly pains gradually increased in
severity until she saw me. When I examined her I found
her a well-developed girl as regards figure and mammae.
The vulva was normal, but there was no vagina except a
small cul-de-sac about half an inch deep. On passing the
sound into the bladder and finger into the rectum, it was
evident that nothing intervened except the vesical and rectal
walls. 1 opened her abdomen and found that the uteius and
rectal walls were represented by two small solid muscular
bodies, one on each side of the pelvis. Each of these bodies
received at the upper end a small Fallopian tube and a
well-marked round ligament. Below, each body faded
away in the cellular tissue between tlie l")ladder and the
rectum. The right body was better developed than the left.
The ovaries were well developed and apparently normal.
specimens 243
There was no structural connection between the uterine
body of one side with that of the otlier, they were, indeed,
separated by a gap of two inches. As 1 was anxious to stop
the monthly paroxysms of pain, I removed both the ovaries,
together with the Fallopian tubes and the representatives of
the uterus. The patient made a good recovery. She has
since remained well and is quite relieved of her old pains.
It is evident that in her case the two ducts of Miiller did
not coalesce, whilst the uterine and vaginal portions were
arrested in their development and did not form mucous
canals. A week or two ago the patient came again to see
me, looking very well, and she informed me that she was
thinking of getting married, and was anxious to know if 1
could make her a vagina.
(3) The third case is one in which the uterus was bicor-
nuous — the right horn being distended with menstrual fluid
and not communicating with the rest of the uterine cavity.
The patient was a single girl, aged 21, anaemic and delicate,
who consulted me on June i, 1904, complaining of violent
pain in the right lower abdomen at each period, lasting the
whole of the time and continuing some days afterwards.
Menstruation occurred every three weeks, was scanty and
only lasted three days. On examining her 1 found a mass
about the size of an orange in front of and to the right of
the uterus — a mass which I took to be tubal or ovarian. I
took her into the hospital and on June 18 I opened her
abdomen. I found the mass to be the right horn of a
bicornuous uterus. It was tense and globular, and evidently
contained fluid. It was attached to the rest of the uterus by
a broad fibrous and muscular pedicle. The distended right
horn, right tube and ovary were very adherent. I removed
them by dividing their attachments in sections and was able
to save the rest of the uterus with the left ovary and tube.
The patient made a good recovery and returned home on
July ID.
Dr. Heywood Smith said that it was remarkable how
often sounds or other instruments passed through the
244 The Bi'itish Gyncscological Society
uterine wall without setting up an\' mischief. Referring
to induced abortion, one lady he knew had brought on her
own miscarriage thirty-five times and on several occasions
nearly lost her life from severe flooding ; she used a long
knitting needle for the purpose. Malformation or displace-
ment of the kidney was so often associated with arrested
development of the uterus that he would like to know
whether Mr. Martin had examined the position of the
kidneys ?
Mr. BOWREMAN JESSETT suggested that the last specimen
might possibly be a fibroid or myoma of the Fallopian tube^
it did not in his opinion resemble a bicornual uterus.
Dr. Robert Bell mentioned a case which he had
operated upon for a tumour he supposed to be a subserous
fibroid of the uterus, or possibly, as its attachment was at
the cornu, of the P'allopian tube, and he removed it under
that impression. The woman had been pregnant two years
previously, and the pregnancy had terminated suddenly, a
fact which he did not ascertain till after the operation. On
a section being made of the tumour it was found to contain
a four and a half months' foetus in perfect preservation.
The tumour weighed four pounds and had all the appear-
ances of a fibroid.
Dr. Macnaughtox-Jones (Chairman), said that it was
remarkable what a variety of instruments could be used to
procure abortion ; he had known the handle of a toothbrush
successfully employed for the purpose. One of the un-
pleasant consequences which might follow such attempts,
was that imputations, quite unfounded, might be cast on
the ordinary medical attendant. In a uterus examined by
Mr. Bland Sutton and himself there was a perforation, and
a portion of cotton wool was found in the abdominal cavity.
The woman had been attended by a midwife, but the con-
sequence to her ordinary medical man was very disastrous.
Mr. Martin's second case was of much interest ; among five
cases of total absence of the uterus and ovaries he (Dr.
Macnaughton-Jones) had himself published, two were in
specie le US 245
children, and in one of them he had succeeded in making
a very fair artificial vagina; in the other, particulars of which
he had read to the Society at a former meeting, the abdomen
was opened for inflammation of the appendix, which was
bound down to the floor of the pelvis. Before the opera-
tion he had been able, by a vesico-rectal examination, to
determine the absence of the uterus and ovaries. He might
refer to one of the three other adult cases, as it had a bearing
upon the question of making an artificial vagina, as von Ott
and others were reported to have done successfully. In his
own case he had not been able to make a good vagina,
and a rectal fistula was left. He was able to close the latter
successfully, but had to sacrifice the substitute for the vagina
he had made. Before the operation the mental condition
of the patient was such as to cause grave anxiety ; she had
become hysterical and almost delusional, and was greatly
reduced in strength ; after the plastic operation, her health
improved greatly and she became, and has remained, robust
and well. It therefore seemed that the production of even
a small artificial vagina might have a good effect. He
thought there was no certainty that Mr. Martin's third
specimen was a uterus, and suggested that it should be
examined by a pathologist.
Mr. Martin, in reply, said that there was nothing to
lead him to suppose anything anomalous about the kidneys.
A manual examination of their position would have in-
volved a larger incision than he cared to make, A section
had just been made of the third specimen and the centre
evidently consisted of inspissated blood-clot, w^hich he held
supported his view that it was the occluded horn of a bi-
cornuous uterus filled with retained menstrual blood. The
specimen had been hardened by the formalin and now felt
solid, but when removed the tumour was soft and fluctua-
ting. Dr. M.icnaughton-Jones had referred to the medico-
legal aspect of the first case. If it had proved fatal, it might
have been his duty to decline to certify. It was remarkable
how little irritation the very sharp piece of bone had
246 The British Gyncecological Society
caused ; perhaps it had been cleansed of germs in its
passage through the muscular wall of the uterus. The
mental state of the woman might partially account for her
immunity. Insane women were curiously tolerant of ab-
dominal injuries, and in many instances had opened their
own abdomens and yet recovered without any bad symp-
toms from legions that in all probability would have led to
fatal peritonitis in others. He was convinced that the third
specimen was an occluded horn with retained menstrual
blood, but he would be pleased to have it examined by a
pathologist, as suggested, and would submit a report to
the Society,
Mr. BowRi'MAX (ESSETT read the following notes upon
A Case of Gaxgrexe of the Leg after Abdominal
Hysterectomy for the Removal of a Large
Fibro-Cystic Tumour, weighlxg Twenty-eight
AND a half Pounds.
E. G., aged 54, married thirty-three years, five children,
youngest aged 22 ; has not, so far as she can perceive,
reached the menopause.
Six years ago an exploratory operation was performed at
a London hospital for " flooding and tumour." According
to the report from the surgical registrar, "a large uterine
fibroid was found. Nothing further was done." Soon after
leaving the hospital she had two fioodings, more since.
Now, the abdomen gets very big, no pain, but patient is
unable to get about with any degree of comfort.
Varicose veins in legs for last three years, and occasional
ulcers. General health fair, but is losing flesh. Constipated ;
menstruation regular every four weeks, lasting about a week ;
complains of loss of sight.
On Admission. — Florid, but thin. Abdomen enormously
distended, umbilicus flattened, old median scar below it.
Large mass occupving practically whole abdomen, dull on
r
specimens 247
percussion, no thrill, not tender. Superficial veins dis-
tended.
Per vniiliiimn. — Uterus low down and cervix directed to
ri,^ht. Mass felt through posterior fornix.
She was admitted into the Cancer Hospital on Wednes-
day, June I, and on the 7th Mr. Jessett operated. An
opening about three inches in length was made in the
middle line below the umbilicus for explorations. The
tumoiw was found to be firmly adherent to the parietes over
its whole surface, but by using some considerable force the
parietes were peeled off. The whole scar tissue was removed
by an elliptical incision, and the abdominal incision enlarged
to enable the hand to pass round the tumour, when it was
found to be quite free behind and the intestines well pushed
up and not adherent. Mr. Jessett then, by bringing his
hand up from behind, was enabled to peel the parietes quite
free from the tumour, which was then readily shelled out,
not, however, until the parietal incision had been prolonged
from the pubes quite to the ensiform cartilage. The
omentum was adherent to the tumour and had some very
large veins. This was ligatured in segments and cut across.
The broad ligaments were then tied and divided; the uterine
arteries secured, and the cervix uteri cut across, after having
stripped down an anterior and posterior flap of peritoneum.
There was a considerable amount of oozing, so Mr. Jessett
packed the cavity with iodoform gauze and brought the end
out of the lower angle of the parietal wound.
The patient suffered a good deal from shock during the
operation and after the removal of the tumour, which
weighed 28^ lbs. ; Mr. Keyser injected four pints of saline
fluid into the median basilic vein, and a subcutaneous
injection of strychnine was also given. After stitching up
the peritoneum, two pints of saline fluid were introduced
into the peritoneal cavity before finally closing the parietal
wound.
The patient was returned to bed and seemed as well as
could be expected. She. however, complained of a good
248 The British GyncBCological Society
deal of pain in her right leg, which was somewhat dusky
and cold. This was wrapped in cotton-wool and flannel
bandages. Had a fairly good night, but saline fluid was
given by the arm, and small quantities of saline fluid and
brandy and beef-tea given by the rectum.
June 8. — Pulse small but good ; temperature normal.
No distension ; gauze drainage removed. No sickness or
vomiting. Ordered brandy, milk, and lime water by the
mouth, which she retained. General aspect fairly good.
Leg still somewhat discoloured but warm. Not so painful.
Rectal feeding continued.
The patient gradually improved from day to day, the
abdomen keeping quite flaccid, bowels opened, kidneys
acting well, and she takes plenty of nourishment.
June 13. — Patient expresses herself better and strongei",
takes all nourishment. The leg, however, is quite gangren-
ous from the knee downwards, being discoloured and cold,
due undoubtedly to impeded blood supply, the skin being
dry and shrivelled. No sensation below the knee. There
are a few blebs. The limb is kept wrapped in boric lint,
dusted with boric acid powder and the whole enclosed in
a quantity of cotton wool.
The hne of demarcation is just above the patella, verging
downwards and backwards to about two inches below the
joint posteriorly. The patient continued to improve daily,
and on June 21, fourteen days after the operation, with the
assistance of Mr. Churchill, I amputated the leg at the
junction of the upper and middle third of the thigh. She
bore the operation remarkably w^ell, and suffered very little
from shock. Before the operation she had a nutritive
enema of brandy 5J., with beef-tea giij., administered.
June 12. — Has passed a good night and taken a small
amount of nourishment. She has also been sustained bv
nutritive enemata. Ordered beef-tea, egg and brandy, milk
and champagne.
June 23. — Stump dressed, a good deal of oozing from
the drainage tubes ; stump looks well. Patient's condition
specimens 249
generally satisfactory. Pulse good quality, but very quick.
Temperature normal.
Patient gnidually lost ground and died on Sunday, the
J5th, four days after the amputation, and nearly three weeks
after the removal of the tumour.
Post-mortem. — The abdominal wound was quite healed
and tirm. There was some suppuration in the stump. The
external iliac was found to have a firm clot in it extending
from its junction with the common iliac for about one inch
downwards.
The kidneys were both much diseased and degenerated,
this was not suspected, as the urine was tested before the
first operation, and only showed very slight trace of albumin ;
possibly the pressure of the tumour may have had some-
thing to do with this.
This case is of interest on account of the size of the
tumour and also in respect to the gangrene of the leg. That
this was caused by the plugging of the external iliac there
can be no doubt, but it is difficult to understand why this
artery was plugged, as there was no sign of its being involved
in the ligature or twisted. Could it have been caused by
the pressure of the tumour : But even then, why was not
collateral circulation established ? It has been suggested
that these clots may be the result of bacterial infection. In
this case it could hardly have been so, as the patient com-
plained of pain, and the leg was somewhat dusky within an
hour of the comp'etion of the operation. I shall be glad
if any Fellow who may have had a similar experience will
explain the cause.
Mr. JiiSSETT also showed a
Myomatous Uterus, removed by Abdominal
Hysterectomy,
illustrating the presence of sub-mucous, mterstitial and
sub-peritoneal growths, and read the following note : —
A. H., aged 50, married, no children or miscarriages,
was seen by me in consultation with Dr. Smyth, Colebrook
Road, on June 2, 1904.
250 Tht British Gxtuccological Society
History. — For about two years has had achin<^ pains
in the groins, especially the left, and in the back. Of
late has noticed a swelling in her abdomen. Has had a
brownish discharge for last six months. Complains of
morning sickness, nausea, and pains in the upper abdc^men
after meals. No ha?matemesis ; no increase in micturition ;
menstruation regular monthly, lasting a week, less copious,
with pain for one or two days.
Exauiination. — The abdomen is distended at the lower
part by a large very hard mass, extending to within one inch
of the umbilicus, and not mobile ; no tenderness ; a hard
knob is felt in the right side ; the rest of tumour smooth,
and apparently wedged into the pelvis.
Per vaginain. — Cervix high up and to the left. Body of
uterus not distinguishable. Mass filling both fornices con-
tinuous with abdominal tumour. On bimanual examination
the tumour is found to be very fixed, only very slightly
mobile. On June 14 I opened the abdomen by the usual
incision, and bv means of Doyen's hysterectomy screw with
some difHculty lifted the tumour out of the abdomen, and
removed it bv the sub-peritoneal method. The patient
made an uninterrupted recovery. On section of tumour
it was found to contain several large sub-mucous, intra-
mural and sub-peritoneal fibroids.
Mr. Charles Ryall said that Mr. Jessett was to be
thanked for showing this giant myoma again, and for the
further history of the case, especially as it had turned out
unsuccessfully, for much more was to be learned from one
failure than from many successes. Apart from the immense
size of the tumour, the remarkable point was the extent and
extreme intimacv of its adhesions to the abdominal wall.
The cause of the gangrene was very obscure ; the early
onset of the symptoms contradicted the idea that it was
due to bacterial invasion at the time of the operation. He
thought that the gangrene might possibly be due to throm-
bosis of the common iliac extending down to the bifurcation
and then along the external iliac, or to dislodgment of an
specimens 2 5 1
embolus in the aorta, owing to the manipulation of the
tumour at the time of the operation.
Dr. Heywood Smith mentioned that many years ago
a patient of his did perfectly well after hysterectomy for
nearly a tortnight after the operation, and then fell back
dead while sitting up to have her dinner, the cause of her
death being a pulmonary embolus. In that case the tumour
had been a very large one. The occurrence of embolism
after abdominal operation was a question of deep interest.
Possibly it was more frequent in connection with large
tumours where the blood supply was great and the vessels
had been subjected to pressure, and perhaps, afterwards,
to ten--ion, at the time of the operation.
Dr. J. J. Macax' reminded the Fellows that though
gangrene was uncommon, if not unique, after abdonunal
operations, it was by no means so after childbirth, affecting
various parts of the body, but most commonly the lower
extremities. In a recent number of the Zcntralhlait there
were abstracts of articles on the subject by Schaeffer and
Wormser, and both of them agreed in attributmg it to
infection. In Mr. Jessett's case it seemed that infection, if
it had any influence, must have existed before the first
operation.
Dr. Richard Smith asked whether there had been any
oedema of the leg, and what had been the after treatment.
Dr. Macnaughton-Joxes, junior, suggested that the
pain complained of by the patient two hours after the
operation could hardly have been due merely to local
anaemia, and that there might have been some pressure
on the nerve as well as on the artery.
Dr. Robert Bell remarked that in a bood-vessel,
so far as he understood it, coagulation could only occur
in the presence of a foreign body. In healthy blood-
vessels coagulation would not take place, but inflanuua-
tion in a vein or artery would act as a foreign body,
and wuuld produce the catalytic effect which caused the
formation of a clot. In a case such as the one Mr. Jessett
252 The British Gynaecological Society
had brought before them, some injury might have occurred
to either the innominate vein or artery, but if to the former
the embolism would have been in the pulmonary artery
rather than in the iliac, and he therefore thought that
there must have been some lesion of the iliac artery to
account for the clot.
Mrs. SCHARLIEB mentioned a case in which arrange-
ments had been made to remove a very large fibroid, but
two days before the proposed operation the patient was
taken exceedingly ill with thrombosis of the left femoral
vein, and the operation had to be postponed sine die. The
patient had not suspected any phlebitis or other trouble in
her leg, and there had not been any recent operation or
manipulation in her case.
Dr. Bell explained that he by no means suggested that
Mr. Jessett had injured the artery. Mrs. Scharlieb's case
supported his own theory that the pressure of a large
libroid upon the iliac vessels might cause sufficient irrita-
tion to induce the formation of a clot, and thus produce
the same effect as a foreign body.
Dr. Macnaughtox-Joxes said that he did not under-
stand that there had been any injury to the vessels during
the removal of the tumour. Large tumours pressing upon
the great vessels of the pelvis undoubtedly sometimes affected
these vessels injuriously, and it was more than possible that
in the present case, especially considering the co-existent
kidney disease, there had been an obstructive arteritis, and
that the manipulation necessary during the operation had
loosened an embolus already formed.
Mr. Jessett, in reply, said that there had not been
before the operation any swelling of the legs, such as
would naturally have been attributed to pressure of the
tumour. The patient, it was true, had varicose veins, but
not to any extent worth noticing. Pressure sufficient to
interfere with the arterial circulation must, he thought, have
interfered with the venous also, and would then have caused
considerable swelling of the legs. Although the clot in
I
specimens 253
the external iliac extended about an inch up to the bifurca-
tion, the internal iliac was free, and it was difficult to under-
stand why the collateral circulation was not sufficient to
carry on the nutrition of the limb. In his opinion, the
only explanation of that was that during the operation,
perhaps owing to nervous shock, the woman lost very little
blood, the general circulation was impeded, and the vis a
icrgo was insufficient to drive the blood through the leg,
and a clot gradually formed, which increased the difficulty.
It had also crossed his mind whether the saline solution,
of which the patient received a considerable quantity, had
been absolutely sterile. There was no moisture in the
gangrene whatever, the leg was simply dried up for Vv-ant
of nourishment. Dr. Macnaughton - Jones, junior, had
suggested that there had been pressure on the nerve as
well as on the blood-vessels to account for the pain. It
was possible ; we were all familiar with the sensation of
" pins and needles " which supervened on pressure on a
nerve. Still, in his own opinion, the arrest of the blood
supply was the cause of the pain from the commencement.
Dr. Hkywood Smith (Vice-President) having taken the
chair. Dr. Macnaughtox-Joxes read some notes on
Accessory Fallopiax Tubes and their Relation to
Broad Ligament Cysts and Hydrosalpinx,
and showed specimens illustrative of the origin of
hydrosalpinx from accessory Fallopian tubes. Sampson
Handley had criticised Kossman's view that broad ligament
cysts were neither parovarian, nor cystic dilatations of the
Wolffian diverticula or ducts, but are derived from accessory
Miillerian ducts (sacro-parasalpinx serosa). Handley and
Shattock had demonstrated, from specimens in the College
of Surgeons' Museum, the origin of accessory hydrosalpinx
from the pronephric funnels of the Miillerian duct. Handley
also showed that enucleable broad ligament cysts, developed
above the tube, were derivable from accessory F'allopian
2 54 The B7'-itish Gyncecological Society
tubes. Alban Doran had anticipated Kossmann in his
surmise that such cysts were of Miillerian origin. Hamilton
Bell, from the examination of a cyst removed by Culling-
worth, supported Handley's contention. The histological
analogy between the accessory and the ordinary hydro-
salpinx was complete.
These histological analogies were typically shown in the
first of Dr. Macnaughton-Jones' specimens. The cysts were
derived from the Fallopian tube. The ovarian fimbria was
absent, and its place was taken by two cysts.
The second specimen Dr. Handley reported to be un-
doubtedly an accessory Fallopian tube, the important point
in this instance being that both the pedicle of the cyst and
its wall were muscular, and the cyst was lined with ciliated
and columnar epithelium.
The third specimen was very interesting, and though
not microscopically examined, there was little doubt of the
natiu-e of the cysts. When one of these was held up against
a strong light, the plicfe could be seen through its wall. In
this instance there was a cyst in the free edge of the broad
ligament, attached to whicii were two small flattened cysts,
w'hile hanging from the peritoneal folds there were two
small cysts and an accessory Fallofiian tube. These latter
Dr. Handley considers represent in abnormal number the
pionephric funnels. Other specimens illustrating the paper
were shown with the epidiascope.
He exhibited a form of clip to which a small weight w^as
attached by aluminium bronze w'ire, or any sterilisable
string, intended to supersede the use of forceps in keeping
the cut edges of the peritoneum in position after o^iening
the abdomen.
Dr. Heywood Smith said the only criticism he would
offer of the cases described by Dr. Macnaughton-Iones was
as to the word " accessory." When speaking of accessorv
organs one had in mind an organ parallel in function to the
one described, such as an accessory mamma or accessory
kidney. He suggested that in the case mentioned by Dr.
Spcaniois 255
Macnaughton-Jones the word diverticulum or aneurysm of
the duct >hould be used. Tliey were really excrescences
which seemed to be cut o^, but evidently had the same
foundation as the tube itself.
Dr. Macxaughtox-Joxes said he could not agree with
Dr. Heywood Smith in his view of the term "accessory."
Dr. Jervois Aaroxs showed
A New Uterixe Mop,
reading the following note : The dilftculty and
length of time wasted in removing the wool from
the ordinary Playfair's probe after it has been used,
led me to try and devise some means by which the
mop might be more easily and quickly removed.
It occurred to me that a cap of some absorbent
material which would iit over a conical sound would
serve the purpose, and such a cap or mop 1 have
had made ; this slips over a conical or tapering metal
sound, and is held in position by a small bayonet
catch, which eli'ectually prevents it from leaving
the sound. The dry mop weighs 13 grains (79
grammes) ; after being used they weighed 39 grains in
(2*5 grammes) ; they are, therefore, sufficiently ab- Q
sorbent for the purpose. The advantages over the 1
ordinary Playfair's probe are: (i) Ease and rapidity of || •
dressing the probe ; (2) ease and rapidity of remov- ^
ing the mop after use ; (3) they are easily sterilised ; |
(4) the tapered part of the sound being made of plated |i
copper can be bent to any desired shape. The caps «■;
and the probe were made for me by the Galen Manu- '^
facturing Co., Ltd., and I am indebted to them for |'
the way in which they have carried out my ideas. 1
Dr. Heywoi^d Smith concurred as to the difficulty in
getting the cotton wool off the Playfair probe, unless one
had tlie knack of rotating it in a direction contrary to that
adopted when putting it on. The present device was useful
because the ring fixed the swab securely, and after use
released it.
!!
256 The British Gynaecological Society
BRITISH GYNAiCOLOGICAL SOCIETY.
Thursday, October 13, 1904.
Professor JOHN W. TAYLOR, M.D.. F.K.C.S., President,
IN iHK Chair.
Specimens and Cases.
Dr. Bedford Fenwick showed a
Cyst of the Right Fallopian Tube ( ? Ectopic Gesta-
tion), WITH A Double Twist in the Pedicle and
commencing Necrosis of Cyst Wall
and gave the following account of the case : —
The patient was 46 years of age, unmarried. Menstrua-
tion commenced at 14, and has been perfectly regular every
twenty-four days, lasting three days, and otherwise quite
normal. She came to the Out-Patient Department of the
Hospital for Women, Soho Square, on October 6, stating
that in August last the period was fifteen days late, lasted
four days, and was very scanty, ceasing on September 5,
since which time she had seen nothing. On September 30
she had a sudden, severe pain in the lower part of the
abdomen, lasting three or four hours, and gradually passing
off. On the morning of October 6 the same pain suddenly
returned, and became very severe. On examination, the
vagina was found to be large and lax, a tense swelling was
felt in front of the uterus, fixed and extremely tender. Her
temperature was 103° F., pulse no. She seemed very ill,
and was at once sent into the wards, and I performed
abdominal section the next day. The uterus was pushed
down into the pelvis by a cystic swelling, thick-walled and
perfectly black in colour ; it was attached by soft recent
Speci?nens and Cases 257
adhesions to the bladder in front, and the uterus behind.
A pint of black blood was drawn off from it, and the cyst
lifted out of the abdomen, and it was then found to have
a long pedicle twice twisted. On removal, a small, bhck
ovary was found adherent to the outer ed<^e of the cyst
wall, and the cyst itself was found to be a dilatation of the
outer third of the right Fallopian tube. There was no
rupture but there was commencing peritonitis. The left
tube and ovary were perfectly normal. It will be observed
that the sac is lined with membrane, and contains apparently
some firm, organised clots ; but as it may be the wish of the
Society to refer the specimen to the Pathological Committee,
1 have not distiubed the latter in any way. It will be
noted that the tube is extremely constricted about one
inch from the cornu of the uterus, where the double twist
was found, and that the surface of the cyst is perfectly
black, and shows signs of commencing sloughing of its wall.
The impoitant question arises as to whether this is a simple
haematosalpinx, or an ectopic gestation. In favour of the
latter is the dilated condition of the vagina, the definite and
large dilatation of the outer third only of the tube, not of its
whole length, and the considerable quantity — at least one
pint — of blood which it contained. Presuming that further
investigation proves this supposition to be correct, I need
scarcely point out the raritv of the case. I can remember
having seen only one such example, and it rimst, therefore,
be most unusual ; and it is further interesting to observe the
rapidity with which necrosis and peritonitis were being
induced, and the extreme danger which the patient would
have suffered if she had not been immediately operated
upon. She made an uneventful recovery.
After some remarks from Dr. Dauber and the President,
it was agreed that the specimen should be referred to a
Patholo^iical Committee.
Dr. Frederick Edge showed the following speci-
mens : —
VOL. XX. — NO. 79. 18
258 The British GyncBco logical Society
(i) Microscopical Section fkom a Case op^ Glandular
Carcinoma of both Ovaries removed with perfect
Imimkdiate Result, but with Fatal Recurrence
WITHIN Four Months.
The patient was 48 years of age, and, apart from the
tumours, was in good heaUh and condition. The operation
was performed at the Women's Hospital, Birmingham, on
May 26, 1904. The tumour on the right side extended to
the hver, and was of peculiar shape, resembling a vegetable
mairow with one side pushed into concavity. The pedicle
on this side was broad and fleshy, no doubt owing to
increase in the muscular tissue of the broad ligament, and
he therefore divided it and secured the vessels separately.
The other tumour was much smaller, and was tied straight
off. Any adhesions were omental, and all bleeding points
were secured ; no drainage was used, and the patient made
an easy and uninterrupted recovery. On August 17, in
Dr. Edge's absence, the woman was readmitted into the
hospital by his colleague, Mr. Furneaux Jordan, on account
of pain and intestinal obstruction, but as this was found to
be incomplete and intermittent, the abdomen was not
opened. Large masses of growth could be felt in the pelvis
and omentum, and these rapidly increased and she died on
September 7, three weeks after her re-admission, that is,
within three and a half months of the ovariotomy. The
section, which was prepared by Dr. Small wood Savage,
showed that the tumours were glandular carcinoma.
(2) A Large, Many-lobed Myomatous Uterus Success-
fully Removed by Supra-vaginal Hysterectomy.
The patient was a small, thin woman, aged 42, and the
operation had been performed on account of pain, symptoms
of pressure on the bladder and bowels, and enlargement of
the growth. The lobular masses ran under the peritoneum
in several directions and were enucleated from their beds.
The peritoneum and floor of the pelvis were injured to such
Specimens and Cases 259
an extent that the abdominal cavity could not be closed by
a complete transverse suture, and as the extensive opening
up had led to free oozing, Dr. Edge thought it better to open
the vagina and drain. During the following night there was
sudden and very severe haemorrhage, and it seemed that
he would have to reopen the abdomen. Fortunately the
bleeding ceased and did not recur, and there was no other
disturbing symptom. Though there had been such exten-
sive laceration of the tissues there was no fever, and this
absence of reaction after such severe surgical wounds he
attributed to the use of antiseptically impregnated sutures
and the prevention of the so-called " implantation infec-
tion," more than to any other factor. His silk sutures are
boiled in solution of corrosive sublimate or of biniodide of
mercury, and used straight out of the solution ; silkworm
gut is treated in the same way ; catgut is boiled in xylol,
preserved in alcohol and corrosive sublimate (i : 1,000) and
used out of the preserving medium. Even if the outer
surface of the ligature or suture be soiled by the hand, the
antiseptic material is afterwards given off and kills the
germs, or inhibits their infective action until the normal
currents are re-established and the phagocytic agents are
able to destroy the micro-organisms.
Mrs. SCHARLIEB mentioned a case similar to the one
first related by Dr. Edge. She removed two solid malignant
ovarian growths with thin, ordinary pedicles, and had no
reason to suppose that the operation was in any way incom-
plete, but the woman died about six months later from a
secondary growth affecting the transverse colon.
Mr. FuRXEAUX Jordan said that when, in the absence
of Dr. Edge, he was called to the case, he expected to have
to operate for intestinal obstruction, but by the aid of injec-
tions the bowels were freely relieved and he could then feel
a small lump behind the cervix. As the only history he had
was that the tumour removed was a solid ovarian one, and
he had no hint of its malignant nature, and as the obstruc-
tion had been relieved, he did not interfere, and in a few
26o The British Gynecological Society
davs was glad he had abstained from doing so, for in those
few days the growth had increased so rapidly in size that
it rose right out of tiie pelvis and could be felt under the
abdominal wall.
Dr. Edge said that it would have been natural for Mr.
Jordan to suppose that after such a recent operation the
obstruction was due to intestinal adhesion to the stump or
pedicle. A fatal termination from the recuirence of such
a malignant growth within three and a half months after
a complete operation, had not, so far as he knew, been
previously recorded.
]\Ir. J. FuRNEAUX Jordan showed : —
(i) Double Tuberculous Pyosalpinx.
A. H., aged 21, single ; general health good. For some
four montiis had indefinite pain in the lower part of the
abdomen, but did not think it was anything serious. One
day, wlien having her bath, felt a lump in the lower left part
of the abdomen. The pain becoming worse, she went to
her doctor, who asked me to see her. On examining her
I could feel the top of two distinct swellings above the
pelvic brim. Since, apart from the pain, she complained
of nothing and there was no interference with her general
good health, 1 thought it was an ovarian cyst. It was two
or three weeks before 1 could admit her into the Women's
Hospital, and by that time the pain had become very severe.
On April 19 last I removed by abdominal section the two
tubes you see here — the larger one from the right side. A
few tubercles were dotted about the peritoneum of the broad
ligament. One ovary, quite free from tubercle, 1 left alone ;
the other I removed. The patient now, six months after
the operation, is in excellent health.
(2) Cystoma of Left Ovary.
Mrs. H., aged 28, was four months' pregnant and com-
plained of excessively frequent micturition and constant
specimens and Cases 261
bearing down pain. On examination I found the uterus
pushed up into the abdomen and the pelvis completely tilled
by a tense elastic tumour. On May 8 last I operated at the
Midland Nursing Home by the vaginal route, and through
a small incision into Douglas' pouch 1 tapped the cyst,
pulled it out, and ligatured the pedicle. The cyst was a
good bit larger than it appears to be, the walls being
stretched and thinned. Fortunately there were no adhe-
sions. Pregnancy was uninterrupted.
Mr. Jordan said that he was not now so keen on the
vaginal route for operating as formerly ; but this case of the
removal of a cystoma from a pregnant woman without any
interruption of the pregnancy, showed that there were cases
in which the vaginal route had very great advantages and
should certainly be chosen.
Dr. William Duxcan said that tuberculous pyosalpinx
was met with in some women who appeared to be the picture
of health, and it was remarkable how well such cases did,
even though, at the time of the operation, they might seem
to be most unfavourable, and the whole of the peritoneum
might be studded with millet-seed tubercle. He instanced a
case in his own practice which afforded a typical specunen
of double tuberculous pyosalpinx, now in the museum of the
Middlesex Hospital, both tubes bemg distended with cheesy
pus. P'ive years after the operation the patient was in perfect
health. Tumours complicating pregnancy were always of
very great interest, and, when ovarian, should invariably be
removed at whatever period of the pregnancy they might be
detected. But he mu^t join issue with Mr. Jordan as to the
vaginal route, for he thought the abdominal route should
always be chosen. He would be very sorry to open the
vaginal vault, hoping, but by no means sure, that there were
not adhesions that might make the removal of the tumour
difficult or even impossible. As a good example of the
superiority of the abdominal route and of the tolerance of
the womb, even during labour, to surgical proceedings, he
mentioned that in a young married woman in whom a con-
262 The British Gyncecological Society
tracted pelvis was suspected, he found not only a pelvis justo
minor, but a hard tumour fixed to the sacrum, which would
have prevented delivery by the natural way. At term, labour
having begun, he opened the abdomen and determined to
try and remove the tumour. Before deciding to open the
uterus, he extended the incision to the ensiform cartilage^
drew out the uterus, and was then able, with much difficulty,
to remove the sacral tumour, a dermoid. He returned the
uterus to the abdomen and closed the wound at ten in the
morning, and the patient was delivered by forceps at two
o'clock the same afternoon, and made a perfect recovery
without any rise of temperature.
Dr. Macxaughtox-Jones said that it was not un-
common to have absence of pain in pyosalpinx, and
instanced some cases in which this immunity was present,
notably one he had recorded at the Obstetrical Society, in
which there was a large double pyosalpinx. The pelvis was
filled by a large effusion containing two pus sacs, and the
bladder was distended from pressure. The patient had
never complained of pain, and the symptom for which she
sought relief was incontinence of urine. He had brought a
case of tuberculous salpingitis before the Society three years
ago, which was unilateral, and the sac similar to one of those
shown by Mr. Jordan. It was primary tuberculosis, and the
lady had since had two pregnancies, one of which was
a twin birth. The lesson to be learned from these cases
was that the risk entailed by the non-removal of such pus
sacs was very serious. As to the second specimen, the
choice of operation for ovarian cystoma by the vagina
would depend upon the diagnosis, the unilocular nature
of the cyst and the absence of adhesions. Given accuracy
of diagnosis on these points, and there could be then no
doubt that the vaginal route would be the preferable one,
but such diagnosis was sometimes extremely difficult.
Operation on ovarian cystoma in pregnancy was now the
accepted rule, but the time of selection was from the end of
the second to the fourth month.
specimens and Cases 263
Dr. Bedford Fenwick said the case of tuberculous
tubes shown by Mr. Jordan was one in which he felt the
greatest interest, because, apart from the excellent results
obtained by Mr. Jordan, the case opened up a very large
and important question. He had operated on a considerable
number of these patients, and with results which had im-
pressed him more and more with the advisability of early
operation in all cases of pelvic disease which appeared to be
tuberculous in character. Most abdominal surgeons had
met with cases of tuberculous peritonitis in which the mere
opening of the peritoneal cavity, even if nothing else was
done, had been followed by the disappearance of the peri-
toneal mischief and more or less rapid improvement in the
patient's health. But it appeared almost as if the logical
lesson of that fact had not been entirely appreciated ; his
experience compelled him to believe that there were a large
number of cases of tuberculous disease in women which
originated in the ovaries or tubes, and that the early removal
of the primary disease, even if secondary mischief had
appeared, must be productive of some good, and might even
lead to cure. At any rate, he had seen a number of cases in
which the latter event had occurred, and might mention one
excellent illustration of it. A woman, aged about 33, had
been admitted into his wards for ovarian and tubal disease
and general peritonitis. It was evidently tuberculous in
character, and the apices of both lungs contained cavities,
whilst the patient was reduced to a state of extreme emacia-
tion and exhaustion. Before operating, he pointed out that
his hope in these cases was, by removing the original source
of disease, to prevent further general infection, and certainly
to cure the tuberculous peritonitis, and assist the patient
in fighting against the pulmonary extension. In that case
both ovaries and tubes were found to be extremely diseased,
and the whole pelvic contents matted together, whilst the
intestines and peritoneum were thickly studded with miliary
tubercles. He removed the diseased appendages, the peri-
tonitis completely cleared up, the lungs commenced to
264 The British Gyiuecological Society
improve at once, and when she left tlie hospital she had
gained more than a stone in weight, and the pulmonary
cavities were healing. Some months afterwards, when she
reported herself, her general condition was excellent in every
way. It was almost needless to say that equally good results
could not always be obtained. When, for example, the
lumbar or thoracic glands had become infiltrated, so that
secondary foci of infection had developed, one could not
hope for complete cure ; but as it must take some time foi"
secondary developments, he was convinced that early opera-
tion afforded the best ground for hope that a complete cure
might be effected, and that it was not only common-sense
and surgical science in these, as in every other case, to
remove as speedily as possible Xho, fon^ et origo mali, but that,
in cases of tuberculous pelvic disease, there was a great
possibility, by early operation, not only of removing the local
dise.iss from which the patient suffered, but also of saving
her fi om the gravest second. iry developmetits.
Dr. E. Tenison Collins agreed with Dr. Macnaughton-
Jones that, if in diagnosis one could be sure that the cyst was
unilocular and non-adherent, operating by the vaginal route
was both simple and rapid. He recalled two cases of his
own ; in one the cyst was large, and in the other though not
so, was rapidly increasing in size ; in each case he opened the
abdomen by a small incision ; both went on to term and
did well. As it turned out, there were no adhesions in either
case. He was glad to hear Dr. Duncan speak so emphaticallv
in favour of the abdominal route.
Dr. Edge remarked that though much of his experience
accorded with that of Dr. Bedford Fenwick, he could not be
so enthusiastic about the elTect of removing tuberculous
appendages upon tuberculous lesions already present in the
lungs. On the whole the results of his operations had been
favourable, but by no means so brilliant as described that
evening. For instance, after an opeiation of the kind last
summer, the wound healed well, and all seemed satisfactory
for a fortnight, when, suddenly, the patient's mental condi-
specimens and Cases 265
tion changed, miliary tuberculosis set in, and she died in a
fortnight. There was, it is true, an abscess cavity in the
lung.
The President said that he entirely agreed with Dr.
Edge. iNot very long ago he obtained a good immediate
result after a difficult case of operation for removal of a
double tuberculous pyosalpinx, but the patient afterwaids
succumbed to tubercular meningitis. In the worst cases of
tubercular disease it by no means followed that the removal
of one local manifestation of the disease was necessarily
attended by improvement in another.
With regard to the question of vaginal ovariotomy during
pregnancy, he would like to draw attention to the fact that
an ovarian cyst which gave distinct fluctuation — a cyst
therefore that was probably a simple cyst and not a dermoid
— was very rarely adherent when pregnancy was found co-
existing; and if the cyst was blocking the pelvis below the
pregnancy it was, as a rule, better and safer to attack it from
the vagina instead of from the abdomen.
In a case very similar to Mr. Jordan's which he brought
before the Obstetrical Society a few years ago, the tumour
was not discovered until the patient was in labour, and the
cyst was met with as an obstruction to delivery. In this case
he removed the cyst by vaginal section and delivered the
patient at the same operation, both mother and child doing
well. No abdominal wound was made ; no eventration of
the uterus was necessary to get at the tumour ; but the cyst
was removed according to the best surgical standards, by the
nearest, quickest and safest route. In such cases, he con-
sidered the vaginal route ideal.
Mr. i'UKNEAUX JOKDAN, in reply, said that the President
had to a great extent answered all that had been advanced
against operating by the vagina. Dr. Duncan, however,
seemed to think that if the cyst had been adherent, he (Mr.
Jordan) would have been in a serious difficulty, and in this
he could not agree. He could have proceeded at once to
operate from the abdomen and the patient would have been
!66 The British GyncBcological Society
none the worse for the small opening that had been made in
the vaginal vault. The case was an excellent illustration of
the fact that, as the President had said, when there were no
adhesions and the tumour was below the pregnancy, the
vaginal route was the right one. To say or infer that he
would adopt the vaginal route in every case would be
absurd. The President and Dr. Edge had also answered
some of the remarks that had been made as to the effects of
operations for pelvic tuberculosis. The benefit upon tuber-
culous peritonitis of merely opening the abdomen was well-
known, but, as regards the wider operation for the removal
of tuberculous pyosalpinx, it was most difficult to give any
prognosis, especially where there was general peritonitis and
extensive deposits in the mesentery. One case would get
well, and perhaps the next, apparently quite similar, would
not. One could not say why ; one could only hope for
success knowing one had done one's best.
Dr. William Duncan showed a
Cancerous Uterus removed by Combined Vaginal
AND Abdominal Hysterectomy,
and read the following notes : —
The uterus shown was removed from an exceedingly
stout nulliparous lady, 42 years of age, who had been twice
married, and consulted Dr. Duncan in July last for menor-
rhagia, which had lasted four months. Fifteen years ago
she consulted Dr. Duncan for the same condition, when
the uterus was dilated and curetted. A mucous polypus
was removed, and a complete cure resulted. On examina-
tion the vagina was found to be very small ; the cervix
uteri was healthy, the sound passed 3-5 inches, and caused
bleeding. The patient was so stout that a bimanual examin-
ation was not possible. She looked healthy and well, and
suffered no pain or offensive discharge. On dilatation of
the uterus under anaesthesia, the curette brought away a lot
of cheesy material ; this was examined by Mr. Targett, who
specimens and Cases 267
reported : " these curettings from the interior of the uterus
are thickly infiltrated with a soft columnar-celled carcinoma
of the villous type." A week later Dr. Duncan removed the
uterus by hysterectomy, and as the vagina was so small and
the patient so stout, he adopted the combined method.
When anaesthetised the patient was placed in the lithotomy
position and an incision made all round the cervix ; the
bladder was separated up, and Douglas' pouch opened.
Next the abdomen was opened, and the uterus removed
in the usual way, but with the greatest difficulty owing to
the excessive thickness of the abdominal walls and also to
the fact that the broad ligaments w^ere very short and did
not allow the uterus to be pulled up much. The patient
had a normal temperature on the eighth day. Dr. Duncan
thought that perhaps it would have been easier to have
cut through the perin?eum to the anus, and then have per-
formed vaginal hysterectomy (as he has done on other
occasions), rather than to have adopted the combined
method.
Mr. BOWREMAN Jessett did not understand why a
combined vaginal and abdominal operation should have
been necessary ; a uterus of the size shown was, in his
opinion, comparatively easy to remove by the vagina. Of
course, in very fat women there was more difficulty, but
that could be overcome by making a deep incision on one
or even both sides of the rectum through the perinaeum
and para-vaginal tissue, extending to the fornix. He had
practised this method for several years, and believed he
adopted it before it came to be known on the Continent as
Schuchardt's incision.
Dr. Heywood Smith said that in the hands of one
accustomed to use it, the sound would give information
of any tortuosity of the canal or roughness of the internal
surface of the uterus ; if it were possible to diagnose
malignant disease in that way it might be better to remove
the uterus at once without curetting.
Dr. F. A. PURCELL said that at the Cancer Hospital,
268 The Brilisk Gynccco logical Society
where they had to remove many uteri, they had found that
in a patient such as Dr. Duncan had described the abdo-
minal route was practically out of tlie question. With the
aid of the incisions Mr. Jesselt had described, and which
Mr. Jessett and he himself had developed independently,
ample room could be got to secure the broad ligaments and
bring down the uterus.
The President said he thought Duehrssen was the first
advocate of the lateral incision, and the rule was simply an
incision from one side of the vagina prolonged to a point
half way between the rectum and the tuberosity of the
ischium. This could be done on either side.
Dr. Macxaughtox-Jones said that he could not agree
with Dr. Purcell's remarks as to the removal by the abdo-
minal route being out of the question in any case of uierine
cancer. Wertheim, v. Roslhorn, and a considerable pro-
portion of the most distinguished gynaecologists operated
by the abdomen, though a large number of men of equally
high reputation thought the best results were to be hoped
for from early vaginal extirpation. The contrast in prac-
tice had been well reviewed by Olshausen at Oxford quite
recently.
Mr. Charles Ryall said that in some cases in which
vaginal b.ysterectomy seemed almost impossible, it was found
that the abdominal operation was not any easier. For the
patient's sake the best operation was the quickest, and
where time was the object he would pull down the uterus,
and having opened the anterior and posterior fornices,
would split it, and to avoid the loss of half an hour in
trying to get ligatures on the broad ligaments, would apply
forceps.
Dr. J. J. Macan asked whether anyone would now
seriously advocate the bisection of the body of a cancerous
uttrus ?
Dr. Herbert Sxow asked for the grounds upon which
Dr. Duncan had based his diagnosis, and what were the
clinical symptoms ? He thought the use of the sound
specimens and Cases 269
unnecessary and undesirable for the diagnosis of uterine
cancer.
Dr. Edge asked Dr. Duncan what degree of elevation he
was able to obtain ? It seemed hardly possible for any
woman to be so stout that, with full elevation and complete
retraction, one would not have a better attack on the fundus
from the abdomen than by any vaginal route.
Dr. DuxCAN, in reply, pointed out that he had laid
much stress upon the extreme narrowness of the vagina of
this patient as the reason why he had not in the first place
undertaken a vaginal operation, which he agreed with Mr.
Jesselt to be the way of best attacking a cancerous uterus.
In answer to Dr. Snow, he said that he used the sound
because, owing to the woman's obesity, it was impossible
to ascertain the size of her uterus by bimanual palpation.
There were no clinical symptoms pointing to malignant
disease, but, as he had mentioned, Mr. Targett had made a
report upon the microscopical examination of scrapings
from the cavity, and he had no doubt as to the diagnosis.
He hardly ever made use of the sound either for diagnosis
or treatment, and naturally would not have done so had
he had reason to suppose that there was cancer of the
fundus. Time was no doubt most important, and more
than an hour taken ov^er an abdominal operation certainly
militated against the patient's recovery ; but, as long as the
time did not exceed an hour, he thought it did not much
matter. He felt sure that Mr. Ryall would not advocate the
bi-section of a cancerous uterus, and that if he had had
the same unfortunate results from forceps that had occurred
to liim-elf, Mr. Ryall would give up forceps in favour of
ligatures. Replying to Dr. Edge : He was not able to
obtain satisfactory elevation as the operation took place at
the panen.'s house, and no table suitable for the Trendelen-
berg position was to be had.
Mr. Kyall said that he would prefer bisecting even a
cancerous uterus to leaving it behind unremoved. With
regard to Dr. Duncan's remarks about forceps : Forceps
2'jO TJie British Gyncccological Society
when applied to blood-vessels did not act like a string tied
round an indiarubber water tube, but, by causing stasis,
led to the coagulation of the blood in the vessels, and
when coagulation had occurred there w'as no reason, if
ordinary care was employed, why they might not be taken
off without any haemorrhage. They had been successfully
used by gynajcologists in thousands of cases.
HEMORRHAGIC ENDOMETRITIS.
Dr. Macnaughton-Jones showed the uterus and adncxa,
with microscopical sections of the endometrium, from a
case of hystero - salpingo - oophorectomy, performed for
hasmorrhagic endometritis. He said that the case was in-
teresting more from a clinical and pathological than from
an operative point of view. The differentiation of the
various forms of endometritis was most difficult. He hoped
on a future occasion to indicate the histological differentia-
tion of the various forms of endometritis which lead up to
what is called " hasmorrhagic endometritis." In addition
to this specimen there was another on the table, which he
had shown at the Society before ; he had brought it in
order that the uterus and adnexa might be compared with
the present one. Here the adnexa of one side had been
first removed, and subsequently those of the other, for cystic
disease ; finally the uterus, for h^emorrhagic endometritis.
The patient was now perfectly well. The pathological
report was that the adenomatous change was extending from
the endometrium into the substance of the uterus. In the
case now for the first time before the Society, the patient,
who consulted him in November, 1902, was in her 43rd
year, and was over six feet in height. She had cardiac
complications, and was completely blanched from constant
haemorrhage. After a month's rest she was curetted, and
the report stated that there was nothing malignant, and
only some slight glandular changes in the endometrium.
Her health improved, and the haemorrhage ceased for a
specimens and Cases 271
time. It recurred later, and she consulted him again in
April of the present year. She was again curetted. The
report then furnished to him by Dr. Cuthbert Lockyer was
that the endometrium presented much round-celled infil-
tration of the stroma, the tubules having in many instances
become distended into small cysts. A few of these were
large enough to be distinguished by the naked eye. The
currettings were under the microscope, and the changes
described by Dr. Lockyer were quite evident. After a brief
respite, the patient again suffered from recurrence of the
haemorrhage, and in August he performed hystero-salpingo-
oophorectomy, from which she completely recovered.
There was an interesting point with regard to the specimen.
After removing the uterus, he split and cut up either cornu
in the usual fashion, and out of one what appeared to be
pus exuded to the extent of about one and a half tea-
spoonfuls. He thought the case one of suppurating
endometritis, but a further examination showed that the
exudation was not pus. An abstract of the histological
report is of interest : "The uterus has been slit open towards
the left cornu, as directed, and sections cut in this situation.
They reveal a healthy fibro-muscular wall, but a thickened
endometrium covered by a pultaceous deposit consisting
of epithelial debris. The endometrium shows two patho-
logical changes, advancing pari passu, viz., interstitial fibro-
sis and desquamation of the gland tubules, both changes
being well marked. There was no sign of an abscess cavity.
The extreme desquamation of the glands amply accounts
for the mass of shed epithelium and debris, which looked
not unlike true pus. The wall of the uterus at its thickest
part measures one inch. There is a small circular fibroid
the size of a marble in the left uterine wall, just above the
line of amputation." The right ovary was cystic, the left
also ; there were also in the latter two small blood cysts,
and both tubes showed evidence of chronic salpingitis.
The second was a rather unique specimen, which
he had brought from Bonn that week, from Professor
272 The British Gyncecological Society
Schroeder, assistant to Professor Fiitscli, of that University.
It was the section of an ovarv from a still-born cl ild dying
in birth, and showed typical commencin;4 ovarian cystoma.
Owing to the lateness of the hour these specimens were
not discussed.
Ox THE Treatment of Ixtkactable Prolapse by
EXTIKPATIOX OF THE UtERUS AND VaGIXA. By
Christopher Martix, M.B., F.R.C.S.
Every gynaecologist who has much hospital experience
must have had cases of severe total prolapse of the uterus
and vagina, which are intractable to ordinary measures,
cases in which no pessary can be retained, and in which
the ordinary plastic and suspensory operations fail to give
more than temporary relief. It was such a case that led
me, in 1899, to devise and perform the operation of extirpa-
tion, not only of the uterus but also of the whole of the
vaginal canal, as a radical cure. I have now carried out
this proceeding in four cases. The final after-result has
been excellent, and the cure of the prolapse complete. It
is, however, a severe remedy. The operation is a long,
tedious and bloody one, and attended with a good deal
of shock. There is a considerable danger of wounding
the bladder, the ureters and the rectum. Convalescence,
in all my cases, was slow and complicated with suppura-
tion in the depth of the pelvis. I should only, therefore,
feel justified in recommending this operation in cases
where other measures have been tried and have failed,
and where the patient's discomfort is very great. It is to
be kept in reserve as a dernier ressort and not performed
as a routine line of treatment. For obvious reasons it
should not be performed in married or marriageable
w^omen.
1 do not propose to discuss at length the treatment of
ordinary prolapse. In a great majority of cases all that
is required is a well-titting pessary, and for marked proci-
Christopher Martin on Intractable Prolapse 27
^16
denlia I know of no instrument so satisfactory as Simpson's
shelf pessary. Where no pessary can be retained, or where
the patient objects to its use, a plastic operation should be
perfcjrmed to support the uterus. In such cases I am in
the habit of doimj ventrofixation of the uterus comloined
with an extensive colpoperinaeorrhaphy. The results as a
rule are very satisfactory. Occasionally, however, it will be
found that the uterus breaks away from the abdominal
wall, or remains attached to it merely by a long, thin band
of adhesions, or becomes elongated and stretched, so that
whilst the fundus is still adherent to the anterior abdominal
wall, the cervix i-> outside the vulva. At the same time the
vagina graduallv dilates, the perinical scar stretches, and
slowly the condition of total prolapse becomes re-established.
In such cases vaginal hysterectomy may be performed. But
whilst it is obvious that if the uterus be removed it can no
longer be prolapsed, the operation does not cure the
rectocele and cystocele. In one case in which I performed
vaginal hysterectomy for prolapse, the vagina afterwards
protruded as a large polony-like swelling and turned com-
pletely inside out.
We may now pass on to a brief description of the object
and the steps of the operation of extirpation of the uterus
and vagina. The main aim of the proceeding is, after
removal of the uterus and vagina, to bring together the
fascia of the pelvis in such a way as to make a firm fibrous
diaphragm extending from one side of the pelvis to the
other, and having adherent to it the bladder in front and
the rectum behind. In this wa}' a firm, solid pelvic floor
is built up, measuring in depth from peritoneum to peri-
naeum some three or four inches. We produce, in fact, a
pelvic floor closely resembling that which obtains in the
male pelvis.
In its broad outlines the operation resembles that of
the radical cure of hernia. Thus the contents of the hernia
are removed, the peritoneum is closed, the fascia is brought
together with buried sutures, and finally the cutaneous
wound is closed.
VOL. XX.— NO. 79. 19
2/4 -i he British GyncBCO logical Society
The patient should be kept in bed for several days before
the operation, the functions of the stomach and the bowels
regulated, and the general health improved as much as
possible. The vagina should be rendered as aseptic as
possible by frequent antiseptic douches. Should the pro-
lapse be irreducible the parts should be well washed with
soap and water and lysol, swabbed with methylated spirit,
and then wrapped in gauze or lint soaked in a solution ot
biniodide of mercury. If, as is often the case, the cervix
or vagina be ulcerated from friction against the patient's
clothes, an attempt should be made before the operation
to get the ulcers healed by keeping the patient in bed and
applying antiseptic dressings. If any ulcers remain they
should be swabbed with pure carbolic acid at the com-
mencement of the operation.
The patient having been anaesthetised and placed in the
lithotomy position, the vulva, the vagina and cervix arc-
again thoroughly cleansed with lysol, followed by spirit and
biniodide of mercury.
The cervix is seized with vulsella and drawn forwards.
An incision is made in the mesial line through the vaginal
mucous membrane from the posterior lip of the cervix to
the edge of the perinseum. From the latter point two
curved incisions are carried forward, one on either side at
the junction of the vaginal mucous membrane and the skin
of the labium, meeting in front about half an inch behind
the meatus urinarius, that is, near the posterior edge of
the vestibule. It will be seen that these lateral incisions
completely encircle the ostium vaginae, and roughly corre-
spond to the Ime of attachment of the hymen.
The mucous membrane of the posterior and lateral
vaginal walls is now dissected off with scissors and turned
forwards, but at this stage the mucous membrane of the
anterior vaginal wall is not interfered with. The peri-
toneum of the pouch of Douglas is next opened by a trans-
verse incision, and the fundus of the uterus exposed and
drawn downwards. The broad ligaments are ligatured
Christophei' Martin on Intractable Prolapse 275
and divided from above downwards, either internal or
external, to the ovaries and tubes. Should a ventrofixation
have previously been performed, the attachment of the
fundus to the abdominal wall must be severed with scissors.
The fundus having been seized with forceps is drawn
downwards, acutely retroflexing the uterus, and exposing
the bottom of the utero-vesical pouch. The peritoneum at
the bottom of this pouch is divided transversely, and the
bladder stripped off the cervix with the finger. The mucous
membrane of the anterior vaginal wall is next dissected
off the bladder and urethra with scissors and removed,
together with the uterus, in one piece. This separation of
the anterior vaginal wall is the most difticull and tedious
part of the operation, and unless great care is exercised the
bladder or ureters may be wounded. It usually causes free
haemorrhage from the veins of the vaginal plexus.
Each bleeding point must be seized and ligatured with
fine silk or catgut. It is important to control all hasmor-
rhage completely before proceeding with the next step
of the operation. In every one of my cases there has
formed a collection of grumous pus, due, I think, to the
breaking down of blood effused from these numerous small
veins. All bleeding having been controlled, the abdominal
cavity is closed by a purse-string suture of fine silk, passed
through the peritoneum of the pouch of Douglas, the back
of the bladder, and the top of the broad ligaments.
Below this purse-string suture the broad ligament of one
side is sutured to that of the other with fine chromicised
catgut. Below this the pelvic fascia of one side of the pelvis
is sutured to that of the other side of the pelvis with fine
interrupted chromicised catgut, beginning above at the
base of the broad ligaments and working gradually down
to just above the vulva. In this way a firm diaphragm
stretching from one side of the pelvis to the other and
supporting the bladder m front and the rectum behind, is
built up of pelvic fascia. This is a most important part of
the operation. 1 do not attempt to suture ihe bladder or
276 r/ic British Gyiuecologicai Society
the rectum to this fascia. They afterwards become firmly
attached to it.
Tlie vulva and wound is then closed with line silk-
worm gut sutures which approximate the posterior halves
of the labia.
If the iiiemorrhage from the deeper part of the wound
has not been completely arrested, 1 should recommend the
insertion of two small rubber drainage tubes, one in front of
the fascial column, and one behind it. These should be
removed at the end of twenty-four hours.
The vulva is dusted with iodoform and a pad of iodoform
gauze is applied. The patient's urine should be drawn off
with a catheter for about a week, and she should be kept
in bed for about three weeks.
As I have already said it is a long and difiicult operation,
and is attended with a good deal of risk to the patients,
who are, as a rule, elderly women and often in feeble health.
The prolapsed cervix and vagina is apt to be ulcerated from
friction against the patient's clothes, and the discharge from
these ulcers may lead to infection of the wound and suppura-
tion. There is free haemorrhage during the course of the
operation, not so much from a few arterial trunks as from
the numerous veins of the vaginal plexus. There is con-
siderable ri^k of wounding the bladder, the ureters and the
rectum. Alter the operation there is a good deal of &hock,
and shock in old, feeble women is a serious matter. The
convalescence is apt to be a tedious one, and in all my cases
was complicated with deep-seated suppuration in the wound.
The after results, however, are excellent, and to my mind
justify me in recommending this operation in suitable cases.
Let me now very briefly refer to the four cases in which
I have perlonned the operation.
Case i. — Mrs. K., a widow, 53 years of age, was sent to
me by Dr. Leech, of Bu'mingham, sufleiing from stone
in the bladder and complete prolapse of the uterus. She
had evidently had the stone for a long time, and the strain-
Christophei' Mai'tin ojt Intractable Prolapse 277
ing to which it gave rise no doubt aggravated the prolapse.
I took her into the Women's Hospital at Birmingham, and
on July 22, it^95, removed a large calculus by the operation
of vaginal cystotomy. The incision healed by first
intention. On August 16 in the same year I performed the
operation of ventrofixation, together with perin:i3orrhaphy.
The wounds healed well, and the result was satisfactory for
about two months. In November, 1895, she began again
to have some cystocele, and I inserted a small pessary.
Gradually the prolapse of the interior and posterior vaginal
walls recurred, and in spite of pessaries of all shapes and
sizes became total. In October, 1896, the vaginal prolapse
was so marked that I again took her into the hospital and
performed extensive anterior and posterior colporrhaphy,
together with perina^orrhaphy. As before, the immediate
result was satisfactory, but it was only for a time. In
January, 1897, the cystocele recurred, and I had again to
resort to pessaries. From this time onwards she attended
as an out-patient with steadily increasing prolapse, until,
in 1899, the uterus was once more quite outside the vulva,
the vagina turned completely inside out and ulcerated from
friction against the clothes. I then decided to perform
total extirpation, not only of the uterus, but of the whole
vagina. I explained to the patient exactly what I proposed
to do, and she readily consented to have anything done that
would afford her relief and enable her to carry on her work
— that of a charwoman. The operation was performed on
May II, 1899. '^1^^ patient was put back to bed in a slate of
collapse, but rallied after free stimulation with ether, brandy,
and strychnine. After this she continued to progress satis-
factorily until about the tenth day, when her temperature
began to show a marked evening rise and morning fall.
This continued until the fourteenth day, when it reached
10-5° F. A pair of sinus forceps were then thrust into the
depth of the vaginal wound, and a large collection of gru-
mous pus (evidently broken down blood) evacuated. After
this she made a straightforward recoveiy, and left the
hospital on the twenty-fourth day. After leaving the hos-
pital she continued to improve, and w^hen I saw her again
on June 30 she was quite well. I examined her in the early
part of July, 190 1, and found her condition most satisfactory.
She was perfectly comfortable, and had complete control
of the bladder and rectum. The vulvar scar was firm and
quite painless, and in her own words, " Life was now a
2/8 The British Gyncccological Society
pleasure instead of a continual misery." Since then 1 have
seen her from time to time (the last occasion being October
10, 1904). She has remained perfectly well and is very
comfortable.
Case 2. — Mrs. J. L., 56 years of age, was sent to me by
Dr. Simpson, of Kugby, suffering from extreme prolapse.
She was a widow and earned her living as a cook. She
had had one child over thirty years ago. There was a his-
tory of gradually increasing prolapse for over twenty years.
She had worn in turn mstruments of various kinds (Hodge,
ring, cup and stem, shelf, and Gariel's ball pessary). Finally
nothing would stay in, and she had to support the totally
prolapsed uterus with a diaper. In June, 1901, she under-
went a plastic operation on the perinaeum at one of the
London hospitals, but this gave only a very temporary
benefit. On October 17, 1901, I performed total extirpa-
tion of the uterus and vagina. For the first ten days the
patient made a good recovery. Then her temperature
began to go up at night to 101° to 102°, with morning
remissions. Her pulse was never over 95. I evacuated
some pus with the sinus forceps on the fifteenth day. After
this she did well and went home on November 19, four and
a half weeks after the operation. I saw the patient on
December 17, and again in February, 1902. She could
walk well, and go up and downstairs without any discom-
fort. There was no feeling of bearing down. She had no
discharge, and the bowel and the bladder acted normally.
The vulvar wound was strong and firm, and showed no
signs of bulging when she strained. She returned to her
work as a cook, and I hear has since remained well.
Case 3. — Mrs. E. M., a widow-, aged 45, was sent to
me by Dr. Baldwin, of Birmingham. The uterus was
totally prolapsed and the cervix ulcerated. There was a
constant discharge of blood and of muco-pus. Thirteen
years before she had been operated on by another Bir-
mingham surgeon, who lepaned her perinaeum. 1 found
it impossible to insert any pessary, and her condition was
so bad that 1 decided to extirpate her uterus and vagina.
The operation was performed on November 22, 1902, when
I removed her uterus, ovaries and tubes, and the whole of
the vagina. The operation was performed in the method
already described. The broad ligaments were ligatured
Christopke7'- Martin on Intractable Prolapse 279
with silk, the pelvic fascia sewn with chromicised catgut and
the vulvar wound with silkworm gut. The patient did not
make a good recovery. Her temperature went up the
second day and fluctuated for some days between 99° and
102°. The deeper part of the wound became infected.
Finally, a pair of sinus forceps were thrust in and a deep
collection of pus evacuated. After this she progressed quite
satisfactorily, and left the hospital on December 28, five
weeks after the operation. The wound had then healed and
all discharge had ceased. I saw nothing of her until April,
1903, when she came to the hospital complaining of
discharge from the vulva. On examining her 1 found a deep
sinus in the perinjeum. I took her into hospital again ana
explored this sinus under chloroform, and was able to fish
out some buried chromicised catgut sutures, which had
become infected and had not been absorbed. After this
the sinus healed up and the patient's condition improved. I
last saw her about a week ago, and then found she had still
a little discharge and that the vulvar cicatrix was red and
irritable. Although she was infinitely better than she was
before the operation, I suspect there is still a buried
suture in the septum between the rectum and the bladder
causing irritation. This case was the least satisfactory of
the series.
Case 4. — Mrs. J. L., a widow, aged 63, was sent to me
by Dr. Cowen, of Malvern. She had had prolapse for over
twenty years. Many years ago Mr. Lawson Tait repaired
her perinasum, but in about a couple of months the cicatrix
stretched, and she was as bad as ever. She wore numerous
instruments (such as rings, balls, cup and stem, and shelf
pessaries), but nothing would keep in. During the last few
months the parts have been badly ulcerated from friction.
When I examined her I found the uterus totally prolapsed,
and the vagina turned inside out and ulcerated. On
February 29, 1904, I performed total extirpation of the
uterus and vagina, but did not remove the ovaries or tubes.
The peritoneum and broad ligaments were sutured with fine
silk, the pelvic fascia with gossamer gut, and the vulva with
silkv^orm gut. A small rubber drainage tube was inserted
into the posterior angle of the wound. It was a tedious
and bloody operation and the patient was put back to bed
rather collapsed, but rallied after free stimulation. Her
temperature remained normal for the first fortnight. On
2 8o The BritisJi Gyncecological Society
tlie fifteenth day it rose to ioo"6', and two days later a free
discharge of blood and pus took place fi^om the wound.
After this she made a straightforward recovery ; she got
up on the twenty-third, and left the hospital on the twentv-
sixth day after the operation. I last saw her on April 25,
about two months after the operation. The wound was
completely healed, she had no discharge, and no pain or
discomfort of any kind.
In relating the cases I have ntjt attempted to minimise
the dangers and difficulties of the operation. I shall be
glad of any suggestions or criticism from members of the
Society which would improve the technique. In particular
I shall welcome any suggestions which will help me to
prevent the occurrence of the troublesome suppuration
which has complicated the convalescence of all my cases,
and which is the chief drawback of the proceeding. I
hope, however, in any future case to avoid this suppuration
by more careful disinfection of the field of operation, by
more careful arrest of haemorrhage, by the use of drainage
tubes to prevent discharges collecting, and by the employ-
ment of perfectly sterile absorbable suture material.
Curiously enough, Dr. Edebohls of New York, devised
and performed an almost precisely similar operation in
April, 1900. His description of the operation appeared in
the Neiv York Medical Record on October 12, igoi ; whilst
I published an account of my lirst operation in the British
Medical Journal on October 5, 190T, just one w^eek before
Dr. Edebohls, So that I feel that whatever merit there may
be in the operation must be shared with Dr. Edebohls, who
quite independently planned and carried out the same
surgical proceeding.
The discussion of this paper was postponed.
Nursino- Bxamifiaiions 281
BRITISH GYNAECOLOGICAL SOCIETY.
NURSING EXAMINATIONS.
Examinations for the Nursing Certificates of the Society
were held on June 2 and 7, the written part on the former
and the viva voce part on the latter date.
The following were the questions for the written
papers : —
Maternity Nursing Examination.
(i) What are the reasons for giving vaginal injections
after a confinement ? And what are the most usual pre-
parations employed for that purpose ?
(2) If a patient 8 months pregnant is seized with profuse
flooding, what condition would you suspect ? And what
would you do until the doctor came ?
(3) What are the methods by which septic infection can
be conveyed to a puerperal woman ? And what precautions
would you take to prevent such infection ?
(4) What is "White Leg" ? What symptoms would lead
you to suspect its onset ? And what nursing would be
required in such a case ?
(5) What do you understand by '' after-pains " ? What
is their usual cause ? And what remedies are, as a rule, used
to control ihem ?
(6) What is ophthalmia of the new-born ? And what
precautions should be taken to prevent its occurrence ?
Gynecological Nursing Examination.
(i) What instruments are required for the operation of
curetting ? And how would you make them ready for the
operator's use ?
282 The British Gyiicecological Society
(2) What aie the iirst symptoms ol " Sliock," " Internal
Haemorrhage," and " Peritonitis," after an abdominal section
has been performed ?
(3) Describe fully how you would prepare a patient for
an operation upon the cervix ?
(4) What are the different positions in which you might
be required to place a patient for a gynaecological operation ?
And for which operation is each position most suitable ?
(5) What are the most frequent causes of retention of
urine after an operation ? Describe fully what you would
do for the patient's relief in such a condition.
(6) Describe fully the different kinds of enemata which
are employed in gynaecological nursing.
The following candidates were successful in obtaining
the Society's Certificate in Gynaecological Nursing :—
Miss Alice Butcher, certificate from Ipswich General
Hospital (3 years).
Miss Maude Mary Brett, certificate from Royal Hants
County Hospital (4 years), and New Hospital for Women,
Euston Road.
Miss Frances Marie Barker, certificate from St. Bartholo-
mew's Hospital (4 years).
Miss Minnie Morris, certificate from Royal Infirmary,
Bristol (3 years).
Miss Charlotte Naylor, certificate from Bedford Union
Infirmary (3 years).
The following candidates also gained the Society's Certi-
ficate in Monthly Nursing : —
Miss Maude Mary Brett, certificate from City of London
Lying-in Hospital.
Miss Alice Butcher, certificate from General Lying-in
Hospital, York Road.
Miss Minnie Morris, certificate from London Obstetrical
Society.
The following were the questions for the written paper
in an examination which was held in London, Nottingham,
]Vursin£- Exami7iations 28
3
Grimsby, and Whitehaven on September 15 ; the viva voce
examination being held in London on September 22.
Gynecological Nursing Examination.
(i) Describe fully how you would make and apply
.j^lycerine plugs
(2) Describe exactly how you would pass the catheter
after {a) an abdominal section, (b) an operation for ruptured
perinaeum, had been performed.
(3) How would you prepare a patient for amputation of
the breast ? and what subsequent nursing would she
require ?
(4) Describe fully how you would prepare {a) the instru-
ments, and (6) the dressings, for a case of abdominal
section.
(5) Give a brief report of some gynaecological case which
you have nursed,
(6) Describe fully the usual dietary for a patient for the
first week after abdominal section has been performed.
The following candidates were successful in obtaining
the Certificate in Gynaecological Nursing on that occasion.
Miss E. M. Halliwell, Matron of the Samaritan Hospital
for Women, Liverpool ; certificate from Royal Infirmary,
Newcastle-on-Tyne.
Miss Eveline Marcon, certificate from St. Bartholomew's
Hospital, London.
Miss Etty Moorhouse, certificates from South Devon
Hospital, and Jessop Hospital for W^omen, Sheffield.
Miss Kitty Read, certificates from Grimsby Hospital, and
Hospital for Women, Brighton.
Miss Sarah Radford, certificates from Bagthorpe Infir-
mary, Nottingham.
Miss Kate Sanderson, certificate from Bagthorpe Infir-
mary, Nottingham.
Miss Lucy Scott, certificate from Bagthorpe Infirmary,
Nottingham.
284 Original Comnmnicalious
ORIGIN A L COMMUNICA TIONS.
Amenorrhcea of Four Years' Duration following a
Bicycle Accident : Recovery.
By S. L. Craigie Mondy, M.R.C.S., &c.
The following notes on a case of amenorrhcea which
was under my care from January to June, 1903, may prove
of interest to my colleagues in the British Gynaecological
Society.
Miss A., single, aged 21 years, consulted me on January
8, 1903, for amenorrhcea, which had lasted about four years.
The history she gave was that she had been perfectly regular
until some four years previously, when, while cycling, she
collided with a cart, the shaft striking her in the region of
the left kidney. She was taken home unconscious, and put
to bed, and her doctor was called in. For some days she
remained unconscious, and passed blood in her urine. The
haematuria cleared away, but she was confined to her bed
for some weeks. She said she had menstruated for one
day only after the accident, but I am inclined to think that
she mistook the blood of the urine for menstruation. She
had been treated for amenorrhcea off and on durmg the
four years, but the menses did not return. In tiie interval
she had suffered more or less from headaches, mainly at
the times when she imagined her periods were due. Her
habits had been somewhat sedentary, as she was a school-
mistress, and was also studying for examinations. I sug-
gested an examination at her home, and accordingly
visited her the next day. She was in an excellent general
physical state, there being no signs of cardiac, pulmonary
or renal affection.
Anienoi-rhcca of Four Years Duration 285
Vaginal Exaiin'iialioii. — Vagina was normal, except for a
very slight leucorrhoeal discharge. The cervix uteri was
normal and its canal pervious, but the body of the uterus
was unusually small, a condition which might have been
due to the prolonged absence of the menstrual function.
The Fallopian tubes, so far as could be made out, were
normal. The right ovary was not felt, the left ovary was
slightly enlarged and felt semi-cystic. She complained of
no tenderness nor pain in either the uterus or ovaries.
There was no thickening of the pelvic cellular tissue or
uterine ligaments, and no prolapse of any of the organs. I
decided to try medicinal treatment, and gave her a pill
containing pil. phosphor., acid, arsenios. and strychnin,
hydrochl., to be taken every night, and one containing
fuchsin to be taken three times a day. She took these regu-
larly for one week, and on January 17 was suddenly seized
with fainting and giddiness which lasted about an hour,
accompanied by vomiting and pains in the stomach, and a
menstrual discharge lasting one day. Thinking that her
sudden illness was due to the pills, she stopped taking them
for two weeks and called in a local doctor — she lived some
miles from me — who said she had influenza and treated her
for it. The sudden onset of the severe disturbances was, in
my opinion, due to a re-establishment of the menstrual
function, but it is quite conceivable that she had contracted
influenza as well.
On February i, having previously written for my
advice, she resumed taking the pills as before, with the
result that menstruation reappeared on February 10. This
time there was no great disturbance, but the flow was
accompanied by the usual feeling of fulness in the lower
abdomen, and slight pain. It was also equal in amount to
what it had been previously to the accident. On February
14 she came to see me, and was looking and feeling well,
I advised the continuance of the pill containing phosphorus,
&c., as before, but suggested that the fuchsin pill might be
taken twice a day only until seven to ten days before the
286 Original Connumucatwns
next " period " was due, when they might be taken three
times a<^ain. The menses appeared, accompanied by severe
backache, on March 12. On March 21 she came to see me
again, and I made a vaginal examination to see what changes,
if any, had occurred in the organs. I thought the left ovary
less cystic and the body of the uterus somewhat larger,
and it was now retroflexed and slightly retroverted. The
patient was in excellent health and spirits. The menses
recurred on April 2 and lasted three days, though the flow
was somewhat less in amount. Both pills were now stopped
altogether to see if the function would occur without them,
and on April 26 the flow began without any disturbance
or pain, and continued for three days. The next period
occurred at the end of May and was more copious. With
occasional irregularities in the amount and the dates, men-
struation had come on every month up till the end of
December, 1903. I heard from her again at the end of
May. She informed me that she had only taken two of the
pills (fuchsin). since January, i.e., just before one of her
" periods " was due, as the previous flow had been some-
what scanty. The menses had recurred each month, lasting
on an average three days each time. Considering that the
patient was still leading a sedentary life, 1 think this result
very satisfactory.
That menstruation depends on ovulation is now, I
believe, an established fact. I therefore felt justified, when
asked, in informing the patient that, in the event of her
marrying, she might reasonably hope to have children.
Whether or not any pathological change was brought about
in the ovaries in this case, of course, one cannot say for
certain, but I imagine the severe shock was in itself suf-
ficient to cause amenorrhoea. What effect fuchsin has on
the ovaries I am unable to sav, but as clinical assistant at
Soho Square Hospital for Women I had seen it prescribed
by Dr. Oliver in cases of amenorrhoea with good results.
The only literature I had seen on the drug is in Martin-
dale's " Extra Pharmacopoeia," but this use is not men-
tioned.
Violent Menorrhagia of Puberty
A Case of Violent Menorrhagia of Puberty,
SUCCESSFULLY TREATED WITH SUPRA-RENAL EXTRACT.
By A. F. Tredgold, M.R.C.S., &c., Guildford.
It is sufficiently uncommon for the beginning of men-
struation to be attended with such severe haemorrhage as
to threaten the patient's life, to make the following case
worth recording.
On the morning of February 20, 1904, 1 was called into
the country to see a girl 13 years and 9 months old, suffering
from menorrhagia so profuse as to cause her parents great
alarm. The history was that her first menstruation had
occurred 4 months previously, lasting 5 days. Her second
a month previously, also lasting 5 days. On each of these
occasions she had lost a considerable amount of blood, but
not sufficient to alarm her mother or to cause her to seek
advice. On the present occasion the flow had appeared
three days ago, but within the last 24 hours had increased
to such an extent as to render her blanched, dizzy, and quite
unable to stand without support.
There was no family history of hajmorrhagic diathesis
or other disease ; there was, however, a pronounced Jieuro-
pathic tendency in both paternal and maternal stock. The
girl was somewhat small for her age, and had been delicate
and ailing in early infancy, but had afterwards always had
good health.
On my arrival I found the girl lying in bed in an
exceedingly weak condition. Her face, usually very ruddy,
was white and pinched ; her tongue and mucous membranes
were very pale, and her pupils were dilated. The pulse was
rapid (about 160) and very compressible ; the heart sounds
2 88 Original CoiiinnLuications
were clear ; the lungs were normal, and nothing unusual
could be detected on abdominal examination. She com-
plained much of headache and dizziness. Her mother told
me that she must have lost " several pints" of blood, and
showed me several large pieces of black blood clot and half
a dozen saturated diapers. As there had been no treatment,
1 thought the haemorrhage might yield to ergot and opium,
and accordingly gave her these in large doses, at the same
time raising the foot of the bed and enjoining perfect
rest.
Early the next morning 1 leceived an urgent request to
go at once, as the bleeding, which had seemed to be abating,
had again come on worse than ever. I found the girl abso-
lutely blanched, with an almost imperceptible pulse, con-
siderable dyspnoea, and dimness of vision. She was
restlessly tossing about, at times delirious, and was utterly
unable to keep down any food. Her mother said that she
had twice lost consciousness for a few moments, and that
the blocd had "simply poured out of her, and she must
have lost every drop in her body." She showed me several
saturated napkins, in addition to about a pound of clot, and
the sheets under the girl were also saturated. It was obvious
that she was in an extremely critical condition.
Abdominal examination revealed a distended bladder,
which I emptied. 1 then examined bimanually, but beyond
a patent os, and considerable tenderness of the uterine body,
there was nothing whatever abnormal. This examination
caused so much screaming and struggling that I gave up the
intention I had had of plugging, and decided to try the effect
of supra-renal extract. I accordingly prescribed 15 minims
of Parke Davis' solution of adrenalin chloride with 10
minims of tincture of cannabis indica, to be given every
2 hours ; at the same time making arrangements for local
treatment under an anesthetic if this should not succeed.
After the second dose, her pulse rate had fallen to 128, and
the tension had greatly increased, the vomiting had ceased,
and she was able to keep down copious draughts of milk
Violent Menorrhagia of Puberty 289
and water ; there was less breathlessness, and the haemor-
rhage had practically ceased. During the 12 hours following
she passed no more than about i oz. of black clot, her pulse
continued steady, and the symptoms of cerebral anaemia
began to abate. At the end of another 12 hours haemor-
rhage had completely ceased, and I accordingly diminished
the dose of adrenalin and cannabis indica to one half of
that first given. Within a few hours, however, bleeding
again came on, but was at once arrested on going back to
the dose originally prescribed. At the end of another 24
hours the dose was again reduced, and this time the hccmor-
rhage did not recur, and after another 48 hours the mixture
was discontinued, there being no further haemorrhage. The
only troublesome results which followed these doses were
the secretion of very large quantities of urine, which had to
be drawn off by catheter ; and much mental confusion with
hallucinations, doubtless the result of the Indian hemp.
Convalescence was naturally slow, but quite uneventful ;
the patient has since had 3 catamenia which were perfectly
normal in every way, although during the first one she was
kept in bed as a precautionary measure. She has now
completely recovered from the anaemia, and is in excellent
health.
VOL. XX. — NO. 79 20
290 Original Communications
Belastungslagerung.
The Application of Compression in the Raised Pelvic
Position in the Treatment of Inflammatory,
Especially of Exudative, Pelvic Affections.
By LUDWIG Pincus, M.D., &c., Danzig.
{Conclusion^
It was stated in the Archiv (xxv.) that local hypei-
aesthesia was favourably affected by compression. In a
rude, empirical manner compression was recommended and
much used hundreds of years ago to relieve pain. In the
Festschrift I pointed out how not only the reflex spasm in
the muscles, but also the pains in the inflamed parts, were
relieved or altogether dissipated. This can now be entirely
confirmed.
Nor is this at all surprising. Two factors have to be
considered : the pressure itself, and the anaemia, the latter
being a consequence of the former. The effect of the
pressure, when its constant or vibrating action is exercised
upon the diverse plexus of nerves of the abdomen, is in
the majority of cases sedative and pain-stilling. Moreover,
the anaemia caused by the pressure no doubt depresses
the vital energy of the affected parts.
Pressure exercised on larger fields, as just described,
confirms the empirical observation of every day in regard
to individual nerves (supra-orbital neuralgia) or individual
plexus (Frankenhaeuser's "Cervical Ganglion"). In the
abdomen the action is facilitated by the fact that here
nature has provided the resistance, the vertebral column and
the promontory, on the anterior surfaces of which the
nervous plexus are distributed.
Be las tungs lager ung 2 9 1
If the pressure is to be made as intense as possible at
once, one must in order to bring the resistance into full play
press the interposed intestines upwards towards the dia-
phragm by slow massage. One can easily recognise that
a considerable force has been at work by noticing, after
removal of the weight, the configuration which the abdo-
minal wall assumes in a short time. To facilitate exami-
nation, however, the external weight should, as I have men-
tioned, be left in position.
As Funke remarks : " Loops of intestine merely lying in
front of the tumour can be massaged out of the way, but
not such as are adherent to the tumour. The contents of
the latter, whether fluid or gaseous, will be very soon
pressed out by the shot bag, and when this has been done
the pressure will act directly upon the exudation."
Of course all the varieties of compression which have
been mentioned can be used for diagnostic purposes. It
must, however, be remembered that external pressure is not
of any real use unless the inclined plane is used at the same
time, though perhaps at only so moderate an elevation that
the pelvis and lower extremities are raised just enough for
the venous blood and the lymph to have a slight fall from
the pelvis towards the abdomen.
Another important point is that Belastungslagerung
utfords an excellent method of ascertaining whether a retro-
flexion of the uterus is fixed or mobile : a question which
lies on the borderland of diagnosis and treatment. Indeed,
as has already been pointed out, the diagnostic significance
of Belastungslagerung in reality always plays on this
boundary line. Funke repeatedly mentions the reposition
of a retroverted, and especially that of a gravid retroverted
uterus. Halban {I.e., p. 140) writes : " One was often under
the impression that one had to deal with a fixed backward
displacement. Narcosis was, naturally, then often called
to our assistance. It proved, however, that when the
abdominal walls were quite relaxed, the uterus could easily
be brought forward and was not in any way adherent.
292 Original Coninimiications
" In such cases, if one introduces a colpeurynter filled with
quicksilver, one can almost always, after one or two sittings,
draw the uterus forwards without any force, and thus avoid
the exertion of attempts at reposition for oneself, the con-
sequent pain for the patient, and the narcosis and its risks
for both."
No doubt every colleague who may hereafter practise
Belastungslagerung will meet with surprises. For example,
a case may have been ascertained by a careful examination
to be one of retroflexion with inflammatory complications
in Douglas' pouch, and if in order to see whether the
intravaginal compression can be borne a quicksilver col-
peurynter is introduced, the uterus is set up again in the
very first sitting.
Cases of this kind must of course be appreciated in
regard to the effect of compression in the reposition of a
retroflexed uterus, and Freund, more than anyone, has
insisted on this happy result. Intravaginal compression
will, without question, be the means chiefly employed for
the elevation of a retroflexion of the gravid uterus. Thera-
peutical success in this respect will be one of the principal
acquisitions of the new method ; it is an acquisition of
permanent value, and the merit of drawing attention to it is
W. A. Freund's. It will in most cases be substituted
successfully for reposition in narcosis. As Fritsch very
properly remarked (XXXIX.) in the conclusion of his address
upon vaginal coeliotomies at Aix, " the compression treat-
ment is a reliable and elegant means of relief, especially in
retroflexion of the gravid womb."
But here also there is no absolute rule ; things do not go
so easily in every case. In one instance the author had to
apply compression eleven times, for an hour each time, to
repose a uterus. In that case the anterior vaginal wall was
abnormally short, a condition discussed in the Festschrift,
and it was not until it had been stretched by the prolonged
compression that the abdominal pressure was equal to main-
taining the uterus permanently in anteflexion. Funke also
Belasticngslagerung 293
speaks of the good effect of intravaginal compression in
stretching an abnormally short anterior vaginal wall, and of
its consequent beneficial influence upon the reposition of
a retroflexed uterus, and upon the ligamenta vesico-uterina
and the retractors of Douglas' pouch ; but these are points
that are self-evident and require no argument.
The diagnostic value of Belastungslagerung is prominently
shown in cases like the following, which are occasionally
met with in practice. On examination one finds an appar-
ently fixed retroflexed uterus, sometimes unaccompanied
by any distress or pain. The adnexa and uterus seem to
form a single mass. Advice is generally sought for some
irregularity in the menstrual periods, perhaps also for
sterility. By intravaginal compression an apparent reposi-
tion is effected without difficulty. Nevertheless the case is
not one of retroflexion, at all events, not of fixed retro-
flexion, but a conglomerated tumour of the tubes situated
in Douglas' pouch, and superficially cemented to the
uterus.
Funke alludes to the value of the method in facilitating
the differential diagnosis between acute haematocele and
incarcerated retroversion of the gravid womb. Of this I
have no personal experience to report. Funke, however,
points out that while in hasmatocele intravaginal compres-
sion causes or increases pain, in incarceration of the
retroverted gravid womb the reverse is the case, and after
reposition the tumour is no longer found in the pelvis. He
also mentions an important case which was necessarily
suspected to be one of malignant tumour, but which the
compression proved to be a resorbable exudate : a chronic
pelvic peritonitis had caused a nodular tumour in the pouch
of Douglas, but in the course of seventeen days the tumour
was entirely absorbed and the uterus perfectly mobile.
Ovarian tumours, myomata (Funke), or other growths
which, having sunk from the larger into the smaller pelvis,
on manual examination appear to be quite fixed there, as
in the observation above mentioned, may be raised up again
by compression.
294 Original Conn?iunications
Moreover, as I explained in the Festschrift, the value of
the method as facilitating the diagnosis and prognosis in
cases of exudation is increased by the fact that it enables
one to know m an early stage whether there is any pus
in the exudation, and whether the case will be one for
perforation.
One of the conclusions drawn in the Festschrift (No. 15,
p. 58) was : " If in spite of the employment of typical
Belastungslagerung any exudate, especially one due to
puerperal perimetritis or parametritis/' . . . "should not
diminish in size, and if though the range of temperature be
limited the patient is evidently losing strength, not only is
pus present in the exudate, but most probably perforation
is about to take place, and must be anticipated by a pre-
paratory incision after an exploratory puncture" (even if
such be negative).
Halban is not altogether sound in writing upon this
point (/. c, p. 135). "It would therefore seem absolutely
imperative to ascertain whether any virulent bacteria are
still present in the adnexal tumour to be dealt with. The
acquisition of this criterion is not yet absolutely within our
powers, and we therefore have rather to rely upon the
objective impression, which only too often gives rise to a
mistake."
In my experience the required criterion is afforded by
the fact above mentioned, that an exudation docs not diminish
in size when it contains a virnlent pns. The limits may be
drawn closer : Belastungslagerung must always, in the first
instance, be looked upon as a test, and whenever possible
be commenced after a menstrual period, during which the
behaviour of the temperature and the status gynaecologus
has been most carefully observed. If during the menstrua-
tion there have been slight elevations (0-5° to i'o°) in the
temperature, that does not imply more than that the case
must be treated with caution. Under such circumstances,
however, one should wait till the menstrual high tide has
passed, and till in the subsequent ebb the relaxation of the
Belastungs lager iiiig 295
tissues of the smaller pelvis has decreased. If the elevations
of temperature during the period, though moderate, have
been attended with pain, or if there be pain or swelling in
the tubes, a milder treatment than intravaginal compression
must be instituted, best of all hot irrigation, as recommended
by Stratz. Even if from independent reasons one has not
the opportunity of watching the course of a previous men-
struation, one should still regard the Belastungslagerung as
a test ; as a rule it answers the purpose, and as Fritsch so
well says (/. c, p. 470), when carefully watched does no
harm.
If the case stands the test it may be given out-patient
treatment. Hospital treatment is so far better, in that it
is more convenient for combining with the Belastungs-
lagerung other factors, such, for example, as hot irrigation,
as adjuvants. In old chronic processes, however, the
ambulatory treatment is to be preferred ; moreover, when
the quicksilver-air-colpeurynter is used and the case is well
watched, it is free from danger. In this respect, as the
method has been made more scientific it has gained in
safety, and therefore everyone who employs Belastungs-
lagerung in private practice will, as a rule, use the quick-
silver-air-colpeurynter.
If there be no pus in the exudate, or, to speak more
deductively, if the course be favourable, the size of the
exudate will decrease ; and often after a few days, after the
combined use of intravaginal compression and the other
factors of this treatment, the various constituents and the
individual organs forming the conglomerate mass become so
prominent that the diagnosis is possible without narcosis.
In old, hard, conglomerate tumours, essentially para-
metritic in their nature, and which, as is well known,
are obstinately refractory to other resorbent treatment,
Belastungslagerung is especially successful. Halban him-
self states (p. 138) that even after two or three applications
of the compression there may be " a complete alteration
in the condition found on palpation." This apparently
296 Original Couuuunications
depends on the fact already mentioned, that it is especially
in these cases that the colpeurynter has a good effect in
every direction round it (p. 139). Halban also confirms
some earlier observations of mine : " It appears to me
that the compression treatment may also be of valuable
assistance in investigating the pathology of these hard
exudates, inasmuch as the slight extent to which they
yield to pressure shows with tolerable certainty that one
has to do with a chronic indurated oedema, which by its
cartilaginous hardness resembles firmly organised hard
tissue."
It is a fact, however, that with these old conglomerate
parametritic tumours one gets better results, especially
subjective results, if one combines hot irrigation with the
compression, because, as has been noted in Schauta's
Klinik, the adhesions and cords attached to the resorbed
mass may cause what I may call "shrinking pains," well
calculated to obscure the excellent objective result. Finally,
one must not forget that every sufferer from such exudates
is exposed to all sorts of accidents and dangers, which
are set aside by Belastungslagerung ; and when there are
no more to be found, one is in a position to deal success-
fully with the remaining and sometimes really consequent
" shrinking pains."
In these cases it is not massage (Halban), but the
graduated tamponade that is suitable. At all events, in six
cases in which everything else had failed I have had good
results from the tampon. The chief and essential point is
to keep the parts at rest, as is shown by the previous test
use of the air-colpeurynter.
Practice will soon prove to anyone that the treatment of
these old chronic exudates of a predominating parametritic
character is sooner and more successful, in regard to both
objective and subjective results, if that treatment is an
ambulatory one, always with all the precautions recom-
mended by the author, so that the patient is never exposed
without safeguard and watching to the reactive fluxionary
Belastungslagerung 297
hyperaemia consequent upon the artificial anaemia. There
is no difficulty, with the help of the quicksilver-aii-
colpeurynter, in preventing any such exposure.
In a discussion on Halban's address on the " Conserva-
tive Treatment of Old Pelvic Exudations " in the Vienna
Obstetric and Gynaecological Society, which bears closely
upon our present theme, Fabricius said that compression
treatment was not adapted for lar<^e exudations of the
kind just spoken of, that incision and search for the
purulent focus was the treatment which was indicated.
That is not correct ; I repeat what 1 said in the
Festschrift (p. 26) : i am convinced from personal observa-
tion that circumscribed collections of pus may condense
and disappear, leaving merely a slight callosity ; indeed,
in every case of pelvic exudation one must, a priori, start
with the opinion that the largest exudations, such as
contain pus, may undergo complete involution ; and as
a rule in such cases one finds that involution is induced
by Belastungslagerung.
But should it not be so, and this is the crucial point,
it is then — and then only — that incision is indicated. If by
incision one could obtain quicker and thereby more certam
results it would be silly to write against it ; but that is not
the case. There is a want for other methods of treatment,
and none more effectual than Belastungslagerung has been
found. V. Winckel, in his Textbook, says (p. 719), *' Even
in very large exudations one must count upon complete
resorption," and this should always be borne in mind
above everything (c/. R. v. Braun's remarks in the
discussion (ix.).
It has already been shown that the view taken by von
Erlach cannot be accepted as correct. He said {Ibid.) .- " If
there is any suspicion of suppuration, the compression treat-
ment is, // priori, to be excluded." Since Belastungslage-
rung has been introduced into gynaecological therapeutics
there is no longer any such indication as "suspicion of
suppuration." One has to reckon with "actual suppura-
298 Original ComniiiuicatiotL^
tion," and for this statement the author accepts entire respon-
sibihty. The criterion ah-eady repeatedly laid down is at
everyone's disposal, and runs : If tJic coiiipirssioii is not bene-
ficial, pus — one may indeed say virulent pus, is present in the
exudation ; if the compression is ineffectual, and if at the same
time, even ivitli only moderate feverish ciiauifes, the patient loses
strength, perforation is imminent.
It is satisfactory to notice that in closing the discussion
Schauta insisted on the importance of compression in these
old " stony-hard " perimetritic and parametritic exudates,
saying : "In these cases particularly the compression treat-
ment seems to fill a gap in our therapeutics."
After the foregoing searching discussion, there is but
little to be said on the remaining indications. All inflam-
matory, especially all exudative, processes in the para-
metrium or in the pelvic peritoneum are grateful objects for
Belastungslagerung ; but no rule is absolute, even here.
It has been explained above that sometimes this and some-
times that complementary factor stands in the forefront of
the attack, and that a less dangerous, and at the same time
more successful, ambulatory treatment is rendered possible
by the use of the quicksilver-air-colpeurynter and the Staffel-
tamponade. It may here again be pointed out that our
method in no wise impugns the importance of the thera-
peutic change between anaemia and fluxion, but implies
that sudden extremes should be avoided until careful obser-
vation has proved that exacerbations are not to be feared.
We are concerned to cure, cito into et jncnnde.
I have already repeated the statement made in the
F'estschrift, that in applying the tamponade, care must be
taken to exercise compression in the neighbourhood of
Frankenhaeuser's ganglion. This precept proves itself with
the certainty of an experiment if intravaginal compression
is employed in the treatment of a certain form of dys-
pareunia, affecting women, in whom some degree of hysteria
is present, but no objective palpable lesion is to be found.
As Funke remarks (p. 279) : " One finds a point in the pos-
Belastungslagerimg 299
terior vaginal vault not larger than the tip of the finger, a
touch upon which ehcits a loud scream from the woman."
The method is also useful in that form of dyspareunia
which depends on the tenderness, inflamed and thickened
retractors, or inflammatory contracting processes in the
parametrium ; such, for instance, as result from cervical
lacerations.
I may here also allude to the successful treatment of
cases of spastic contraction of muscles in the pelvis, which
are occasionally met with in practice in erethismic and
erotic women, and in those w^ho are hysterical by nature,
or have become so from prolonged use of preventives to
conception, I have already discussed this affection in an
earlier work (xxv.) under the title of " Myodynia intrapel-
vica." It is characterised by noticeable spastic contractions
in the pelvic muscles (and reflex contractions in those of
the abdominal wall), the former on being touched (coitus)
become very painful indeed, so much so as finally to lead to
vaginismus. In the anamneses the use of that unholy thing,
the occlusive pessary, and of coitus interruptus, has a pre-
dominant part. The hysteria seems rather result than cause,
but the point needs further confirmation.
Of course, rcsiitiiiio ad integrum is by no means to be
obtained by Belastungslagerung in every instance. Coe,
(XLI.) years ago pointed out that the strongest pressure that
could be exercised through the posterior vaginal vault was
not enough to separate parts cemented together, and that
intravaginal pressure, therefore, was not capable of separat-
ing adhesions. This, however, is not correct except as
regards adherent organs movable as a whole. If there is
any point fixed to the bony pelvis stretching will take place,
as can be proved clinically. At all events, by Belastungslage-
rung one can alleviate any pains in the residual exudation ;
ovaries attached to the edge of the pelvis are loosened and
become less painful, &c., and, without exception, the reflex
fluxion to the uterus is diminished, if not done away
with. The cure, if not truly anatomical, is at all events
a symptomatic one.
)00 Original Comimmications
Our object is attained if the function of the organ har-
monises with the good health of the individual. As Virchow
said, "To be well means that no part of the body is more
distinctly felt than the rest."
In many cases Belastungslagerung induces such perfect
resorption that even the most thorough combined palpation
can detect nothing in any way morbid.
Another consideration of fundamental importance is
revealed by comparing the symptomatic cures obtained by
operative measures, and those due to Belastungslagerung.
To the eight instances of pregnancy after the symptomatic
cure of adnexal disease, recorded in the Festschrift, I can
now add another. In four instances there had been bilateral
perisalpingitis and perioophoritis ; in two a tubal tumour
on the left side ; once inflammation in the ligaments on
the right side, and in three bilateral perimetritis and para-
metritis. This wall explain the perseverance and constancy
witli which I have striven to get the method more extensively
used.
Even when the method is not entirely successful nothing
is lost, but a good deal gained, merely in the fact that
one has much greater assurance in recommending an
operation either of utility or urgency. And in many
instances in hospital practice in which " unfitness for work "
is the prominent indication, Belastungslagerung prepares
the conglomerate tumours for the operation finally to be
decided upon. It is like Eduard Martin's handgrip in
obstetrics ; even though that fail, the head, though not born
spontaneously, nevertheless becomes engaged in the proper
way for expression by v. Winckel's method.^
In private practice one is not justified in operating for
inflammatory pelvic affections, especially not for exudative
inflammations, until treatment by Belastungslagerung has
been tried and failed.
It does not seem necessary to add more than a short
' Cf. Pincus, Abhaiidl. Berli?ier Klinik^ Heft 92.
Belastu ngs lager u ng 301
summary and review of the most important cases that have
come under my notice. The complete consideration of the
whole in their clinical aspect may be reserved for the
present.
Between 1886 and 1900, 229 cases came under treatment.
This relatively small number shows that in the earlier years,
during which it was still more or less on trial, the method
was only employed occasionally in specially selected cases,
and, even later on, generally only when simpler measures,
for which the patients were less dependent upon the doctor
(hot irrigation, baths, &c.), were not rapidly enough effica-
cious. Importance, however, was, a priori, always attached
to the employment of combinations of approved value.
These have been already thoroughly discussed.
The diagnosis throughout was established on the
scientific principles of Freund and v. Winckel, and the
cases treated were as follows : —
Parametritis (exudates and cord formations! ... ... 23
Perimetritis (cord formations) ... ... ... ... 36
Pelioperitonitis (diflfuse form, affecting many organs, adhe-
sions and small exudations) ... ... ... 47
Perioophoritis-perisalpingitis (circumscribed form affecting
only the ovary or the tube) .. ... ... ... 2i
Painful and generally enlarged ovaries fixed to the brim of
the pelvis (thirteen times on the left side) ... ... 18
Retroversio-flexio uteri (fixata twenty-one, mobilis twelve)... }^2,
Tubal tumours (pronounced chronic stage) ... ... 19
Cicatrices in the cervix and vaginal roof extending into
the parametrium ... ... ... ... ... 11
Dyspareuma (thickening of the sacro-uterine ligaments),
V. text ... ... ... ••• ... ... 13
Myodynia intrapelvica sexualis ... ... ... 8
229
In the cases here referred to, in some exceptional in-
stances the affection was chronic and without fever. The
temperature was regularly taken, especially during the
catamenia, and no treatment was applied at those times.
Fever was regarded as a danger signal, fever with pain as
302 Original Commtmicaiions
a contraindication. Moreover, if after three or four sittings
no decided improvement appeared, or if the tumour in-
creased in size, compression was considered to be contra-
indicated. Ambulatory treatment was invariably conducted
with especial caution, and the women, when allowed to go
away after the compression, were invariably fitted with a
moderately distended air pessary with the graduated tampon,
or in the simplest cases with Mever's india-rubber ring.
The duration of the treatment varied between five days
(parametritis) and two months. The most obstinate cases
were two exudates in the parametrium, which, from their
eccentric position, and the fact that with the return of the
appendicitis the exudate enlarged also, were doubtless to
be referred to an appendicitis. The treatment lasted for
almost four months, but was by no means regular.^
In twenty-three instances (lo per cent.) the treatment
had to be interrupted, or altogether abandoned (4 per cent.)
because of pain or fever, and this shows that the method is
not universally applicable. Its employment demands com-
plete knowledge and earnest circumspection, and then yields
excellent results. It must, however, be pointed out that a
higher percentage of the cases could undoubtedly have been
successfully treated in the hospital. There are matters in
private practice that cannot be exactly estimated, and yet
cannot be at all neglected.
In the 17 cases of disease of the pelvic peritoneum,
although there were extensive adhesions, subjectively the
' Wolff (Olshausen's Klinik) also saw good results in appendicitis
which are worth notice. An exudation that had existed for six years,
caused constant pain and frequent confinement to bed, and for which
many physicians had for years tried most various forms of resorptive
treatment without much relief, was, after thirteen applications of com-
pression, the only treatment the patient had in the hospital, dissipated
except a very slight residue. " The most important point, however,
was that the subjective condition of the patient, who had previously been
a constant invalid afflicted with pain, became and remained excellent.'"
. . . This was at all events an encouragement to further trial, and
shows that in practical therapeutics there is no universal rule.
Belastungslagerung 303
cure was complete ; in five instances only massage, after-
wards employed on account of sterility, was without perfect
success in dissipating the residua. In four instances,
although the objective cure was complete there was nothing
pathological to be detected by palpation ; there was some
persistent pain. Apparently these were not merely adnexal
lesions but some circumscribed pelio-peritonitis, which it
would have been difficult to cure even by extirpating the
adnexa. Prolonged hot irrigation, Priessnitz' compresses
and belladonna suppositories finally gave relief. In one case
also e.xtensive use was made of the knee-breast position.
In four instances of parametric exudation after the
failure of Belastungslagerung, an incision had to be made
and enlarged by blunt dissection with the fingers ; three
times from the vagina, once above Poupart's ligament.
Cicatrices left by laceration of the cervix and vaginal
roof, often extending deeply into the parametrium, were,
without exception, much benefited. The relaxation and
extension were often so complete that there was nothing
left palpable even by bimanual examination.
We may conclude our lucubrations with the words
Wolff wrote from Olshausen's Klinik : " The experiences
already published, and that reported in this work, show that
the introduction of compression into gynrecological thera-
peutics constitutes a material advance in simplicity and
harmlessness ; when circumspectly and carefully employed,
it surpasses all other resorbent measures in the rapidity of
its success, and is efficacious in cases in which other means
leave one in the lurch. Compression treatment must, from
the observations here recorded, therefore, be most warmly
recommended for dealing with chronic inflammatory affec-
tions of the female pelvic organs, especially for exudations.
COXCLUSIOXS.
(i) Belastungslagerung is to be accepted as a successful
and typical method of treatment which fills a gap in gynae-
cological therapeutics.
304 Original Covuiiunicalions
(2) It forms in various ways an appropriate substitute
for narcosis for diagnostic purposes, and is therefore to be
welcomed as a typical diagnostic method. The diagnostic
and therapeutical results pass indefinitely into one another.
(3) The fundamental type of Belastungsiagerung is
formed by the inclined plane {plamiiii iiicliiiatuin), and
compression {Bclastniig) — factors which are each of com-
plementary significance. An adjuvant in regard to the
maintenance of the bodily strength is found in methodical
respiratory gymnastics.
(4) The inclined plane, used alone, is less effective but
never harmful ; it successfully paralyses the prejudicial
influence of deficient bodily nutrition upon resorption.
Compression is never to be employed except in association
with the inclined plane. Either factor may be used con-
tinuously or with intermissions. Compression may be
intravaginal or abdominal, but is better when both forms
are combined.
(5) The peculiar field for Belastungsiagerung is formed
by those exudations of pronouncedly chronic nature which
do not exhibit any rises in temperature, even during men-
struation. It also, according to W. A. Freund, offers the
best means of reposing a retroflexion of the gravid womb.
(6) In exudates in the parametrium and all such exu-
dative processes as are situated near the pelvic floor,
intravaginal compression by means of the quicksilver
colpeurynter is to be employed ; an adjuvant is found
in abdominal compression. When exudates and similar
lesions are situated high up in the pelvis, intravaginal com-
pression is rather equivalent to a resistance interposed to
elevate and fix the organs in a position of rest (air-col-
peurynter, Staffel-tamponade), and it is then the adjuvant,
while the abdominal compression (shot bag, potter's clay)
forms the active therapeutical agent.
(7) Belastungsiagerung, therefore, is not identical with
compression either with the shot bag or with the quicksilver-
air-colpeurynter, but a method which claims and utilises
Belastungslagerimg 305
both these modifications as integral factors, of itself of
notable complementary etficac}'.
(8) Ambulatory treatment is to be accepted as the ruling
principle in dealing with old chronic pelvic exudations. It
may be carried out without danger and in an effective
scientific way, by means of the author's quicksilver-air-
colpeurynter. A complementary factor is found in the
elastic abdominal bandage.
(9) The scientific postulate of Belastungslagerung is
fulfilled by the quicksilver-air-colpeurynter : gradual com-
pression, gradual relaxation. This instrument also permits
the use of colpeurynter massage, facilitates the general use
of the method and is indispensable to every gynaecologist.
(10) The surgical treatment of chronic pelvic affections
is not justifiable until Belastungslagerung has been tried.
(11) A negative result from the use of Belastungs-
lagerung is the most reliable scientific criterion that virulent
pus is present in an exudation, and, in private practice, this
criterion only gives the indication for surgical treatment.
REFERENCES.
(l.) Pincus, L., Eine neue Methode der Behandlun.i^' entziindlicher,
namentlich exsudativer Beckenaffektionen mittels " Belastungslagerung,'"'
Ztschr. f. Geb. und Gyn., 1898, Bd. xxxix., Hft. i. Zugleich Festschrift
zu Heinrich Abegg's 50 jahrig. Doktorjubilaum. Desgl. Vortrag, fiir
die Diisseldorfer Naturf-Vers (1898) angemeldet. Therapeut. Monats-
liefte, 1899, j\lai ; und Vortrag auf der ^liinchener Naturf-Vers., Sept.,
1899.
(n.) Falk, E., Therapeutisches aus der Sektion f. Geb. u. Gyn. der
71. Vers, deutscher Naturf. u. Arzte in Miinchen, Sept., 1899. Therapeut.
IMonatsh., 1900, April, S. 207.
(ni.) Funke, A., Uber die Behandlung chronischer Aftektionen der
vveiblichen Beckenorgane, spec, der chronisch entziindlichen, mittels
Schrotbelastung. Aus der Frauenklinik der Universitat Strasburg.
Beitrage zur Geb. u Gyn. (A. Hegar), 1898, Bd. i., Hft. 2.
(IV.) Freund, W. A., Uber Resorptionskuren. Vortr. in der Sekt. f.
Geb. u. Gyn. der 69. Vers, deutscher Naturf. u. Arzte zu Braunschweig,
1897. Ref. Centralbl. fiir Gyn., 1897, Nr. 40, S. 1195.
(v.) Halban, J., Uber Belastungstherapie. Aus der Klinik Schauta,
Wien. Monatschr. f. Geb. u. Gyn., 1899, Bd. x., Nach einem in der
Wien. gyn. Ges. am 21. Febr., 1899, gehalt. Vortrage.
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3o6 Original Commu^tications
(vi.) Funke, A., Beitrag zur Bclastungstlierapie bei Retroflexio uteri
gravidi. Aus cler Univers.-Frauenklinik Strasburg. Cenlralbl. f. Gyn.,
1900, Nr. 8.
(vii.) Wolff, E., Beitrag zur Belastungstherapie. Dissert., Berlin, 1900.
(viii.) Fritsch, H., Die Krankheiten der Frauen. 9. Aufl. Braun-
schweig, 1900, S. 470.
(IX.) Halban, J., Diskussion. Centralbl. f. Gyn., 1899, No. 35,
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Juli, 1900. Ref. Centralbl. f. Gyn., 1900, No. 46, S. 1237.
(XI.) Manswetoff, A., Uber die Behandlung der entziindl. Zustande
des Uterus, iS:c. Wratsch, 1900, No. i. Ref. Deutsch. med. Wochenschr.,
1900, No. 4.
(xil.) Beckers, Meine (!) " Lagerungsbehandlung," &c. Miinchen.
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(xiv.) Auvard, A., Behandlung der Salpingo-ovariitis durch inter-
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(XV.) Aveling, J. H., The Use of the Inclined Plane. The Americ.
Journ. of Obstetr., &c., 1892, vol. xxv., S. 782.
(xvi.) Emmet, Th. A., The Inclined Plane as an Important Aid in
the Treatment of Diseases of Women. The Americ Journ. of Obstetr.
&c., 1892, vol. xvi., S. 365.
(xvil.) Lobingier, K. R., Mechanical Influence in Pelvic Disorders.
Philad. Medical News, 1892, 16, vol. i., S. 63.
(xviii.) Wernitz, J., Zur Behandlung von Beckenexsudaten. Cen-
tralbl. f. Gyn., 1889, No. 43.
(XIX.) Donaldson. Bodily Posture in Gynaecology. The Americ.
Journ. of Obstetr., &c., 1885, May, S. 4S1.
(XX.) Campbell, H. F., Resume of a Report on Poitrine, Pneumatic
Pressure and Mechanical Appliance in Uterine Displacements. Atlanta,
Georgia, 1875. Ref. Virchow-Hirsch, Jahresber. f. 1875, Berlin, 1876,
Bd. ii., and Transact, of the Amer. Gyn. Soc, 1876 u. 1877.
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par introduction de I'air dans le vagin, &c. Annal. de Gynecol., 1880,
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(xxil.) Bozemann, " Columning " the vagina in Pelvic Adhes. The
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(XXIV.) Some Points in Uterine Pathology. The New York Med.
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(xxv.) Piiicus, L., Uber die Constipatio myogenita s. muscularis
Belastungs lager mig 307
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Archiv, Bd. cliii.
(xxvi.) Derselbe, Weiteres zur Vaporisation, &c. Centralbl. f. C]yn.
1898, No. 10.
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1898, No. 12, S. 303.
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(xxxi.) V. Winckel, F., Lehrbuch der Frauenkrankheiten, 1886, S. 719.
(xxxil.) Freund, W. A., Verhandl. der 69. Vers, deutsch. Naturf. u.
Arzte zu Braunschw., 1897, Leipzig, 1898.
(XXXIII.) Derselbe, Diskussion, 72. Vers, deutsch. Naturf. u. Arzte
zu Aachen, 1900. JMonatsschr. f. Geb. u. Gyn., 1900, Bd. xii., Hft. 4,
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(xxxiv.) Pincus, L., Praktisch wichtige Fragen zur Nagel-Veit'schen
Theorie. Volkmann'sche Samml. klin. Vortr. N. F., 1901, No. 299-390,
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(XXXV.) Winter, G., Lehrbuch der gynakol. Diagnostik, 2 Aufl., 1898.
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(xxxvil.) Ktistner, O., Grundziige der Gynakologie, 1893, S. 297.
(xxxviii.) Fritsch, H., Aus der Breslauer Frauenklinik. Bericht
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(XXXIX.) Derselbe. Uber vaginale Koliotomieen. Vortrag. auf der
72. Vers, deutsch. Naturf. u. Arzte zu Aachen, 1900, Ref. Monatsschr. f.
Geb. u. Gyn., 1900, Bd. xii., Hft. 4, S. 51S f., " Schlusswort,'' S. 520.
(XL.) Schauta, F., Diskussion zu Halban (5). Siehe Litteralurverz.
No. 9.
(XLI.) Coe, H. C., Can Old Intrapelvic Adhesions be Stretched by
Continuous Pressure apphed through the Vaginal Fornix.? The Amerir.
Journ. of Obstetr., &c., 1S87, S. 60 f., and The Vaginal Tampon in
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(xlii.) Pincus, L., Der Quecksilberkiftkolpeurynter. Kolpeurynter-
massage. Centralbl. f. Gyn., 1901, No. 32.
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1901, No. 9.
\oS Rcvicivs
REVIEWS.
Twenty-five Years of Teaching Activity, a tribute to
Professor von Rein from his pupils and a record of his
Hfe and work. Large Quarto, with Portrait, Plates and
Ilkistrations. Pp. 368. Kiew, Russia, 1900.
This work is not quite on the hnes of the Festschrift
so commonly presented to a German professor on the com-
pletion of his 25th or 50th year of academic life or other
suitable occasion ; it is, rather, based on Professor v. Rein's
work as Director of the Obstetric and Gynaecological
Hospital and School at Kiew, and is, as it were, a fare-
well token of the congratulations and good wishes of those
who have studied under him there, on the occasion of his
appointment to a similar post at the ^Military Academy of
Medicine at St. Petersburgh. The subject matter is divided
into four sections : the first describes the Obstetric and
Gynaecological Clinic at Kiew, as it has been built up and
developed by Professor v. Rein ; the second contains a
review of the work of the Professor and his pupils ; the
third is an index of all the memoirs issued from the
clinic during the sixteen years for which he occupied the
professorial chair ; and the last is a list of all his addresses
and published works, including the Proceedings of the
Society of Obstetrics and Gynaecology at Kiew, from 1887
to 1899, forming twelve volumes, each of two parts. The
book is thus rather a record of v. Rein's work and of its
active and permanent influence upon his pupils than like the
usual Festschrift, a collection of original articles specially
written in honour of their master by his pupils and dedicated
to him on a special occasion.
Revieivs 309
The direction in which v. Rein's hfe-work would He was
foreshadowed in his Dissertation for his Degree published in
St. Petersburg in 1896, for he chose as his subject ''The
Removal of Fibro-myomata by Abdominal Section." It is
significant that the mortality of all cases then published was
6072, while that of enucleation was not very much less, being
55*0. V. Rein wrote and worked much on Caesarean sec-
tion, devoting himself especially to improving the methods
of removing the pregnant uterus as regards loss of blood.
Under Professor Waldeyer of Strassburg, he studied the
development of the mammary glands in the embryo and the
maturation, impregnation and early changes in mammalian
ova, and under Ranvier of Paris, the sources and distribution
of the nerves of the uterus. He published many papers on
asepsis and anti-sepsis, and his own methods were so rigidly
observed that his mortality for uncomplicated abdominal
sections was only from i to 3 per cent. Without entering
into details, we may say that his work as recorded in this
book covers the whole field of obstetrics and gynaecology,
both as to theory and practice. To him in no small measure
was due the increase in the number of students of medicine
at Kiew, from 416 to more than 1000 while he was there.
Owing to his influence and exertions the old Frauenklinik
at Kiew, dating from 1844, was rebuilt in 1888, and by
various additions in 1893 and 1898, is now completely up to
date, both for midwifery and the diseases of women. The
material at his disposal for clinical purposes increased
enormously, and his lectures and classes for midwives,
students and graduates were up to the best standards.
In 1881, Professor v. Rein read a paper on the develop-
ment of the breasts in the Anatomical Section of the Inter-
national Congress in London, and he has spoken and read
papers at several similar meetings since then. He is still
full of energy, and in the wider sphere at St. Petersburg
where he is now Professor, may be confidently expected to
continue his excellent work.
F. E.
3IO Reviews
Introduction a l'Etude Clinique et A la Pratique
DES Accouchements : Anatomic, Presentations et
Positions, Mecanism, Toucher, Manoeuvres, Extrac-
tion du Siege, Version, Forceps. Par le professeur
L. H. Farabeuf, et le docteur Hexri Varxier ; Pre-
face par M. le professeur A. Pixard. Dessins demon-
stratifs de L. H. Farabeuf, donnant avec les repetitions
necessaires 362 iigures. Nouvelle edition, revue et
corrigee par le professeur L. H. Farabeuf. Super royal
8vo (11 + y5 in.), pp. x. + 478. Paris : G. Stcinheil,
n.d. Price, 14 francs.
The late Professor Varnier was interne to Professor
Pinard at the Lariboisiere ]\Iaternite and followed him to
the Baudeloque. He watched and verified all the ana-
tomical experiments which Professor Farabeuf made the
basis of his figures, and which were carried out on what he
describes as "natural mannikins," bodies embalmed with
glycerine and therefore plastic, and whenever possible those
of eclamptics dying in labour, or just delivered in the final
coma. In the very eulogistic preface which Professor
Pinard wrote to the first edition of this book in 1891, he
says that the chief difficulty in the clinical teaching of
obstetrics is the student's ignorance of indispensable pre-
liminary anatomical and mechanical knowledge, and that it
is not superfluous for the authors to have given a text lucid
enough to be understood even without figures, and figures
so accurate and instructive as to make the text seem
unnecessary.
The book has long been out of print, and was so highly
appreciated in France that the few copies occasionally met
with commanded high prices. A new edition was wanted,
and owing to the lamented death of Professor Varnier, the
revision has been undertaken by Professor Farabeuf with
the support of Professor Pinard. This revision was particu-
larly necessary in regard to the chapter on the forceps, as
during the fifteen years since the book was composed, owing
to the practice of symphyseotomy and Caesarean section, the
Reviews 311
treatment of labour arrested in the superior strait has been
much changed and the high apphcation of the forceps
become less and less resorted to.
The scope of the work is limited, as indicated by the
title, but we can endorse Professor Pinard's eulogium of
text and illustrations. With many of the latter every
obstetrician will be familiar, as they have been adopted into
one manual after another. It is a real pleasure to study
them, for they are drawn by one who is both an anatomist
and an artist. The text is essentially didactic with inten-
tional repetitions, but is also a record of practical research,
and is concise considering all it contains.
Beitrage zur Anatomie der Tubenschwangerschaft.
VON Dr. Fritz Kermauxer, Assistent an der Uni-
versitaets- Frauenklinik zu Heidelberg. Royal 8vo,
pp. 137, witii 44 Illustrations. Berlin : S. Karger, 1904.
Price 4s. net.
This excellent monograph on the anatomy of tubal
pregnancy is based on 40 cases operated upon by von Ros-
thorn or his assistants, 36 at Graz, and 4 at Heidelberg.
Though for various reasons some other specimens obtained
during the same period were not available for his researches,
the author is justified in attributing greater value to con-
clusions drawn from a series so connected, than to any
drawn from specially selected cases. His investigations
extended to the placenta — when possible to its entire extent ;
to sections, sometimes serial in order, of the tube, especially
of the uterine and abdominal portions ; to the ovary on
the same side ; and when desirable to the uterus and
adnexa of the other side ; to the mole and to the capsule
of the haematocele. The results, illustrated by most in-
structive, explanatory, and partly diagrammatic, drawings,
and by abbreviated anamneses, form the earlier part of the
work. One case was bilateral, and he points out that the
fact that in 25 cases the tube affected was on the right side
and 14 on the left, implies nothing, as the statistics of larger
3 1 2 Revieivs
numbers show that both tubes are equally liable. The seat
of the ovum is described as ampullary in i8 instances,
isthmical in 19, not exactly determined in 4. The dis-
crepancies of statistics on this point are no doubt due to
the limit of the ampullary portion being quite arbitrary,
even in the non-pregnant tube, a pregnancy that would be
termed ampullary by one observer being called isthmical by
another.
Of the 19 isthmical pregnancies, 10 ended in rupture,
9 in abortion. From all the cases he concludes that
the tendency to abortion rather than rupture varies with
the distance of the seat of the ovum in the tube from
the uterus, and vice versa. The diagnosis w^as possible
macroscopically in 16 cases, microscopically in 25, but
sometimes only with difficulty. In 11 cases only was there
any definite period of amenorrhoea before the onset of
haemorrhage. Apart from typical cases of rupture, bleeding
from the genitals, either continuous or intermittent, had
occurred for weeks, even for 3 months, before special in-
dications led to operation ; in 25 instances blood was found
in the uterine end of the tube ; bleedmg from the genitals,
especially when profuse, comes no doubt from the uterus,
but may be in part derived from the tube.
When the ovum buries itself in the tube wall, owing to
the tenuity of the mucosa, it finds itself at once in the
muscularis, and even from the beginning of pregnancy the
latter forms a membrane, shutting the ovum out of the
lumen of the tube. For this membrane Kermauner accepts
Petersen's name, " membrana capsularis " ; it contains no
decidual cells, and is in no sense a decidua refiexa. Remains
of this m. capsularis were found in 35 out of 36 cases. The
thinning of the tube wall at the seat of the ovum, especially
of the site of the placenta, and the formation of isolated pro-
trusions, may be due to the action of foetal elements (Aschoff),
or to extravasation of blood owing to stasis and subse-
quent destruction of the tube wall, but both are secondary
processes, and have nothing to do with the nidation of the
ovum.
Reviews
o^o
The term columnar implantation (Werth), that is the
settlement of the ovum in a fold of ihe tube, should be
abandoned, as the fact has not been demonstrated, and cer-
tain secondary processes can cause its apparent occurrence.
Nor has the nidation of the ovum in a diverticulum of the
tube been proved in a single case. In only 6 of the 41 tubes
examined could Kermauner hnd unmistakable decidual
changes, generally at the uterine side of the ovum. Even as
regards the formation of decidua in the uterus there are
too many negative cases for it to be laid down as certainly
demonstrable.
In regard to the aetiology, Kermauner points out that a
certain connection between salpingitis and tubal pregnancy
must be accepted as proved, and that the simple mechanical
theory, of which indeed no absolute proof has been given,
must, therefore, at all events undergo some restrictions.
Die biologische Bedeutuxg der Eierstoecke xach
Entfernuxg der Gebaermutter : experimentelle
und klinische studien von Dr. LUDWIG Maxdl,
Privatdozent fuer Geburtshilfe und Gynaekologie, und
Dr. Oskar Buerger, I. Assistent der ersten Frauenklinik,
an der Universitaet in Wien. Mit 6 Abbildungen und
14 Kurven im Text sowie 13 Tafeln im Anhang.
Royal 8vo, pp. 4 and 240. Leipzig und Wien ; Franz
Deuticke, 1904. Price 7 marks.
This important monograph is based upon experiments
on rabbits and apes, which proved that after the removal of
the uterus the ovaries preserved their function to some
extent, but not completely ; degenerative processes (atresic
and cystic degeneration of the follicles, &c.) becoming
established, so that by degrees the function was lost. The
authors also had at their disposal the rich material of
Schauta's Klinik, 550 cases of hysterectoni}-, of which 405
were followed up and examined by the authors them-
selves, or by some other physician, as to the presence
and intensity of the menstrual wave, the occurrence and
3 1 4 Reviews
severity of omission symptoms and the time of their onset
after the operation, the degree of sexual desire and enjoy-
ment remaining, the alterations in body-weight, in memory,
power of recollection, flow of spirits, and finally the phy-
sical change in the external genitals and vagina. In all these
respects the condition of those women who still possessed
one or both ovaries was better than that of those Vv'ho had
lost both. On the other hand it seemed that, not infre-
quently, tliose of the former class suffered sooner or later
in the same way as the otliers, probably because the ovarian
circulation had been injured by the operation ; moreover,
cystic and even malign degeneration of the unremoved
ovaries was not uncommon. The authors give curves of the
temperature, pulse, blood-pressure and muscular power in
three healthy women, showing the well-known form before,
during, and after menstruation. In live women completely
castrated there was no such wave ; in only three out of six,
who still had ovaries but no uterus, was there any wave, so
that in the other three the ovarian function was already
inactive. The cases arranged in tables are convincing
enough in spite of such a lapsus calami as at the bottom
of page 59, where a displaced entry of Virgo, Libido und
\"oluptas unveraendert Koitus schmerzlos, is appended to a
case of a woman who is credited with i partus, 3 abortus.
The work is, however, a valuable contribution to the
evidence in favour of conservation of the ovaries in hyste-
rectomy, total or supravaginal, abdominal or vaginal.
Die Cystoscopie des Gyxaekologen. Von Privatdozent
Dr. Walter Stoeckel, Oberarzt an der Universitaets-
Frauenklinik zu Erlangen. Mit neun farbingen Tafeln
und vielen Abbildungen im Text. Demy 8vo, pp. x.
and 322. Leipzig : Breitkopf und Haertel, 1904.
Price, 8 marks.
Dr. Stoeckel has recently become Oberarzt at the Charite
Frauenklinik at Berlin, but he developed his interest in
cystoscopy at Bonn under Professor Fritsch, to whom he
dedicates his book. It was at the Bonn Frauenklinik that
Reviews 315
the diseases of the uropoietic system in women were first
seriously studied in Germany in connection with gynae-
cology. The bearing of cystoscopy upon the diseases of
women has recently been much more recognised ; this
means of diagnosis has, indeed, a much wider field in
women than in men. Urinary diseases offer conditions in
the former that do not exist in the latter, and genital affec-
tions in women lead to changes in the ureters and bladder
that have no analogues in man. Moreover, diseases of the
bladder tend to fall under the observation of gynaecologists,
because they are accompanied by symptoms which, rightly
or wrongly, the patients associate with their genital organs.
More than half of the book is taken up with describing
cystoscopes for examination, for catheterisation of the
ureters, for operation, for irrigation (washing the prism),
and for photography ; the bladder phantom for practise, and
other apparatus ; and the technique itself and the descrip-
tions are so detailed and clear that they will be most useful
to any gynaecologist for self-instruction. Stoeckel, on the
whole, prefers Nitze's instrument to Caspar's, and recom-
mends the combination devised for examination, irrigation,
and catheterisation of the ureters, an expensive instrument
costing nearly Xy — a sum serious to any but specialists.
After insisting on asepsis and antisepsis, and the dangers
of catheterisation of the ureters, Stoeckel, in the last six
chapters, describes the results of cystoscopy in such patho-
logical conditions of the urogenital system as vesical affec-
tions, fistulae, and injuries of the urinary passages. The
book is extremely well printed and illustrated, the coloured
plates being beautifully executed.
Elements of General Radio-therapy for Practi-
tioners. By Dr. Leopold Freund, Vienna. Trans-
lated by G. H. Lancashire, M.D.Brux., &c.. Assistant
Physician to the Manchester and Salford Hospital for
Skin Diseases. With 107 illustrations in the text and
one plate. Supplemented by Notes on Instrumenta-
tion by Clarence A. Wright, F.R.C.S., &c., Member
3 r 6 Reviews
of the Roentgen Society. With 86 illustrations. Royal
8vo, pp. xxii. + 538 + 60. London : Rebman, Ltd.
Price : cloth, 21s ; half bound, 25s, net.
The author, who was recently granted the " venia
legendi " for radiology, includes under radiotherapy the
application of any form of radiation to the treatment of
disease ; that is to say, electro-magnetic, heat, light and ultra
violet rays, and also Kathode, Roentgen, glow-ivonn (!) and
Becquerel rays, and those emitted by such substances as
radium and polonium. The subject is comparatively so new
that most of the knowledge acquired about it is scattered
throughout the publications that have appeared during the
past seven or eight years, and this book will be welcomed as
a comprehensive summary of what is known on the matter,
made by one w-ho has been consistently working at it for
several years, and who, as regards the Roentgen rays, is an
acknowledged authority. As he presupposes but little
knowledge on the subject on the part of the reader, his first
chapter of over eighty pages is devoted to the Elements of
Electricity. The second deals with High Frequency Cur-
rents, the bactericidal, desiccating and antipruritic effects
of which, though real, he does not consider so pronounced
as those of other methods. The third chapter gives the
details of treatment with the X-rays, which he considers
indicated in diseases of the hair and hairy skin, in ulcerations,
acute and chronic exudative dermatitis, morbid changes in
the blood-vessels and progressive disturbances in the
nutrition of the skin. The Becquerel rays have for him
but a scientific interest at present. In the last chapter on
Heat and Light Rays, Finsen's concentrated arc light is the
most interesting part of the book and seems to offer the
widest field for success ; success which Freund attributes
less to the bactericidal action of light than to inflammatory
processes and lasting hyper^emia induced in the diseased
area. In this chapter there are a few pages on treatment
by sunlight. The appendix is a well illustrated eclectic
catalogue of instruments by various makers.
Reviews 3 1 7
A System of Physiologic Therapeutics. A Practical
Exposition of the Methods, other tlian Drug-giving,
useful for the Prevention of Disease and in the Treat-
ment of the Sick. Edited by Solomon Solis Cohex,
A.M., M.D. Eleven volumes. Vol. vii., Mechano-
therapy AND Physical Education, including Mas-
sage and Exercise, by John K. Mitchell, M.D. ; and
Physical Education by Muscular Exercises, by Luther
Halsey Gulick, M.D. Large 8vo, pp. 420. London :
Rebman, Limited. Price 12s. 6d,
The frequent abuse of massage by unauthorised or
unqualified persons, its exploitation under some fanciful
name as an exclusive form of treatment, and the indiffer-
ence of some phvsicians to the details of the manipulations
they may order, make it very desirable that the medical
profession should have a clear and explicit statement of
what can and cannot be done by massage, and how its
ends are accomplished. Such a statement Dr. Mitchell
gives us with very great authority, for as lecturer on massage
at the Orthopaedic Hospital he has had wide experience in
teaching the nurses and pupils of that institution. More-
over, in the descriptions of the movements and in the
directions for carrying them out, simplicity and exactness
are guaranteed by their having stood the test of use in
instruction. Dr. Gulick's scientific views on the correlation
of the development of the race and that of the individual,
and his long experience in physical education, are well
known, and, as might be expected, his consideration of
education and remedial therapeutics is precise, rational
and practical.
In addition to the subjects in the title, this volume
contains chapters on Orthopcedic Apparatus, by Dr. James
K. Young ; on Corrective Manipulations in Orthopaedic
Surgery, including the Lorenz Method of Reducing Con-
genital Dislocation of the Hip ; and one on Ph^^sical
Methods in Ophthalmic Therapeutics, by Dr. Walter L.
Pyle, of peculiar interest, and most instructively illustrated.
PUBLICATIONS RECEIVED.
From Archikald Constable and Co., Ltd., London :
Clinical and Pathological Observations on Acute Abdominal Diseases. The
Erasmus Wilson Lectures, 1904, by Edrkd M. Corner, B.Sc.Lond.,
IVI.A., M.B., B.C.Cantab., F.R.C.S.Eng., Surgeon to Out-patients, St.
Thomas's Hospital, &c.,&c. Demy 8vo, pp. 98, 1904. Price 3s. 6d. net.
The Surgery of the Diseases of the Appendix Vermiformis and their Complica-
tions, by William Henry Battle, F.R.C.S., Surgeon to St. Thomas's
Hospital ; Hunterian Professor of Surgery at the Royal College of Surgeons
of England, &c., &c. ; and Edred M. Corner, Assistant Surgeon to
the Great Ormond .Street Hospital for Sick Children, Erasmus Wilson
Lecturer at the Royal College of Surgeons, &c., &c. Demy 8vo, pp. xii.
and 208, 1904. Price 7s. 6d. net.
From W. and A. K. Johnston, Ltd., Edinburgh and London :
Manual of GyN/^cology, by D. Berry Hart, ]NLD., F.R.C.P.,
F. R.S.Edin., Lecturer on Midwifery and Gynaecology, School of the
Royal Colleges, Edinburgh, &c., &c., and A. H. Freeland Barbour,
M.A., B.Sc, M.D., F.R.C.P., F.R.S.Edin., Lecturer on Midwifery and
Diseases of Women, School of the Royal Colleges, Edinburgh, &c., &c.
Sixth Edition. Demy 8vo, pp. xxxiv. and 736, with 12 lithographs and
359 woodcuts, 1904, price 21s.
From H. K. Lewis, London :
Deaths in Childbed, a Preventable Mortality ; being the Milroy Lectures
delivered at the Royal College of Physicians, 1904, by W. Williams,
M.A., M.D., D.P.H.Oxon, Medical Officer of Health to the Glamorgan
County Council, &c., &c. Demy 8vo, pp. vi. and 99. Price 2s. 6d. net.
From Frank F. Lisiecki, New York :
The Surgical Treatment of Bright's Disease, by George RL Edebohls,
A. AL, ALD., LL.D., Professor of the Diseases of Women in the New
York Post-Graduate Medical School and Hospital ; Fellow of the New
York Academy of Medicine and of the American Gynaecological Society ;
Honorary Fellow of the Surgical Society of Bucharest, &c. Royal Svn,
pp. iv. and 338, 1904.
From Simpkin, Marshall, Hamilton, Kent and Co., Ltd., London ;
Cornish Brothers, Birmingham:
On the Sterilisation of the Hands ; a Bacteriological Enquiry into the Relative
Value of the Various Agents Used in the Disinfection of the Hands, by
Charles Leedham-Green, M.B., F.R.C.S., Surgeon to Out-patients,
Queen's Hospital ; Assistant Lecturer in Bacteriology, University of
Birmingham, &c. Demy 8vo, pp. 102, 1904. Price 2s. 6d. net.
From J. Wright and Co., Bristol; Simpkin, Marshall, Hamilton,
Kent and Co., Ltd., London :
Our Baby : for Mothers and Nurses, by Mrs. J. Langton Hewer. Ninth
Edition, Revised, 1904.
Transactions of the American Association of Obstetricians and
Gynaecologists, vol. xvi., for the year 1903. Royal 8vo, pp. Iviii.
and 483. New York, 1904.
Transactions of the North of England Obstetrical and Gynaeco-
logical Society, 1904, Fasciculi iv. & v.
Transactions of the Canadian Institute : —
The Palceochemistry of the Ocean in Relation to Animal and Vegetable
Protoplasm, by A. B. Macallum, M.A., M.B., Ph.D.
Publications Received 319
Transactions of the Italian Society of Obstetrics and Gynecology :
Guiseppe Vespa e la Clinica Ostetrica di Firenze, discorso pronunciato dal
Professor Ernesto Pestalozza, all' inangurazione dei locali rinovati
della Clinica, 1904.
We have to acknowledge, also, the following Pamphlets
and Reprints : —
Dal Dottore Giuseppe Cristalli, Napoli, 1904 :
A proposito delle nuove vedute di Zweifel sulla prevenzione della febbre
puerperale.
von Elis Essen-Moeller, Lund :
Beitrag zur Kenntniss von Hjeniatometra in Nebenhorn.
von A. KoBLANK, Berlin :
Ueber entzuenliche Erkrankungen der Eileiter.
Erkennung und Behandlung der Eierstockskranheilen.
Kraniotomie und Embryotomie.
By H. Macnaughton-Jones, M.D., M.Ch., M.A.O. (Hon. Causa), &c., &c. :
Tuberculosis of the Female Genitalia. A Brief Resume of our Present
Knowledge.
Accessory Fallopian Tubes and their Relation to Broad Ligament Cysts and
Hydrosalpinx.
Sclerosis and Cirrhosis of the Ovaries as Causes of Adne.xal Pain and other
Symptoms.
The Treatment of Fibroid Tumours of the Uterus.
By Charles P. Noble, M.D., Philadelphia :
Some of the More Unusual Results of Movable Kidneys.
Invasion of a Fibromyoma of the Uterus by an Adenocarcinoma, which by
Metaplasia had Assumed the Appearance of a Squamous Cell Carcinoma.
And also copies of the following works by our recently
elected Fellow, Professor Giovanni Calderini, Director of
the Royal Obstetrical and Gynaecological Clinic at Bologna.
Saggio di pratiche osservazioni intorno alia aspettazione nelle operazioni
ostetriche, Torino, 1865.
Relazione clinica e statistiche della Clinica Ostetrica di Torino, Torino, 187 1.
L'istituto ostetrico di Parma, Torino, 1873.
Illustrazione di un feto umano abortivo, Torino, 1874.
Fibro-mioma uterino esportato felicemente coUo schiacciatore lineare ; and
Le dimensionidel feto negli ultimi tre mesi della gravidanza, Torino, 1875.
Primo rendiconto del R. Istituto ostetrico di Parma, 1877.
Dispareunia da vaginismo, Torino, 1878.
Secondo rendiconto del R. Istituto ostetrico di Parma, anni 1875- 1877,
Torino, 1879.
Ranula in un neonato, Milano, 1881.
Le precauzioni antisettiche nella pratica ostetrica, Torino, i8Sr.
Sulla questione dell' insegnamento pratico della ginecologia e della pediatria,
Milano, 1881.
DecoDazione colla fune, Milano, 1881.
Una cretina ed una microcefala nell' Istituto ostetrico di Parma, Milano, 1882.
Contributo alia diagnosi delle mostruosita del feto ed alia eziologia dell'
idramnios, Milano, 1882.
Esportazione dell' utero dalla vagina, Milano, 1882.
Alcuni vizi congeniti dell' apparato genitale, Bologna, 1882.
L'Ostetricia e la Ginecologia nelle Universita tedesche, Roma, 1882.
Note cliniche di ostetricia ; and Note Cliniche di ginecologia, Torino, 1882.
L' esame del latte delle nutrici nella pratica medica coll' apparecchio di
Conrad, Parma, 1882.
I bacini asimetrici, Parma, 1882. Uterus septus duplex, Parma, 1887.
•2 20 Publications Rcccrucd
Embriotomia, una decollazione e una detroncazione coU' uncino a chiave di
G. Braun, Parma, 1887.
Distocia per idrocefalia, Milano, 1887.
Un' altra detroncazione eseguita coll' uncino a chiave di Braun, Parma, 1888.
Cellule simili a quelle della decidua, Torino, 1888.
Di alcune laparatomie (37) state eseguite nell' Islituto ostettico-ginecologico
di Parma, 1889.
II quinquennio 1884-85 — 1888-89 nel R. Istituto ostetrico-ginecologico di
Parma, 1889.
Comunicazioni e dimostrazioni fatte al Congresso di Berlino, Torino, 1890.
L'accouchement premature artificiel, ses indications el methodes, Berlin,
1891-92.
II parto premature artificiale in Italia, sue indicazioni e metodi operativi,
Milano, 1890.
Un met'iilo di spaccatura della cervice uterina per cura della dismenorrea e
della sterilita, Bologna, 1893.
Laparatomie, Milano, 1S93.
II triennio 1889-92 nel R. Istituto ostetrico-ginecologico di Parma, Torino,
1893.
Due casi di utero bicorne con ematometra unilaterale, Roma, 1894.
Beitrag zur Diagnose und Therapie des Uteruskrebses, Berlin, 1894.
Sviluppo storico dell' ostetricia e della ginecologia, Napoli, 1895.
Stenosi del collo dell' utero in donna affetta da isterismo, Firenze, 1896.
La Gonorrea in relazione colla ginecologia e colla ostetricia secondo i piii
recenti studi, Milano, 1896.
La pratica ostetrica a domicilio, Bologna, 1896.
Contributo alio studio della ossificazione dellb scheletro embrionale e fetale
coi raggi Rontgen, Roma, 1896.
Della endometrite decidua da gonococco, Firenze, 1897.
Manuale clinico di terapia e di operazioni ostetriche, Torino, 1897.
Malattie delle mammelle e del bambino in rapporto coU' allattamento,
Bologna, 1S97.
Rivoluzioni nel campo dell' ostetricia, Bologna, 189S.
Innesto dell' uretere in vescica per via transperitoneal, Bologna, 1898.
Sulla inclinazione del bacino nei varii atteggiamenti della donna sotto
r aspetto ostetrico ginecologico, Roma, 1S98.
Fistule uretero-uterine guerie par I'implantation de I'uretere dans la vesie ou
moyen du boutou du Dr. Boari, Marseille, 1898.
Innesto transperitoneale dell' uretere nella vescica per cura di fistola uretero-
uterina, Milano, 1899.
Ostetricia e ginecologia. Loro fondamenti, legami, confini, insegnamento,
Napoli, 1899.
Transperitoneale Einpflanzung des Ureters in die Blase behufs Heilung der
Ureter-gebarmutter-tistel, Berlin, 1899.
Intorno alia assistenza del parto podalico, Bologna, 1899.
I tumori interlegamentosi, Roma, 1899.
Sulle indicazioni della operazione cesarea della sinfisiotomia, della cranio-
tomia e del parto premaluro, Napoli, 1899.
Importanza della patologia degli annessi fetali e specialmente delle anomalie
del cordone, Bologna, 1900.
Des injections intraveneuses de serum artificial dans des cas d'infections
puerperales, Turin, 1900.
Diagnostic et trailement du cancer du corps de I'uterus, Paris, 1900.
Sulla diagnosi e sulla terapia del cancro del corpo dell' ulero, Napoli, 1900.
Relazione possibili fra la mola vescicolare e la degenerazione, Napoli, 1901.
L'eclampsia puerperale, Bologna, 1901. Cancro dell' utero, Bologna, 1901.
Tumore della placenta, Roma, 1902. Ueberein placentartumor, Berlin, 1903.
Gastrotomia primitiva per gravidanza ectopica, Firenze, 1903.
Commemorazione del Dott. Emanuel Bruers, Roma, 1904.
THE BRITISH
GYNECOLOGICAL
JOURNAL.
Vol. XX. — No. So. February, 1905.
BRITISH GYN. ECOLOGICAL SOCIETY.
November io, 1904.
Professor JOHN W. TAYLOR, M.D., F.R.C.S., President,
IN THE Chair.
Exhibits.
Dr. Macnaughton-Joxes read the pathological reports
on two cases of embedded adnexal tumours, which had
been completely hidden by perimetritic exudation, and later ^
exhibited with the epidiascope sections of the tube illustra-
tive of desquamative salpingitis. He raised the question
of the necessity of hysterectomy if the uterus were not
materially affected.
Dr. R. H. Hodgson asked whether he correctly under-
stood Dr. Macnaughton-Jones to attribute all the pain in
salpingo-oophoritis to peritonitis. Surely pain in an ovary
or tube did not necessarily imply the presence of any
peritonitis.
Dr. Heywood Smith said that in deciding as to the
removal of the uterus in ovarian disease one had to consider
the age of the patient and whether she was, or was not,
married. In his experience, the removal of the ovaries alone
VOL. XX. — no. 80. 22
322 The British GyncBcological Society
did not interfere with sexual appetite, which, when the
uterus was also taken away, became very much deteriorated.
The President concurred with Dr. Macnaughton-Jones
in the opinion that it was, as a rule, an advantage to retain a
uterus that was comparatively healthy ; at the same time,
even in abdominal operations, he found himself more and
more inclined to begin his work by curetting the uterus if he
had any reason to think there was endometritis present.
Dr. Macnaughtox-Joxes, in reply, said that he had
expressed no opinion in regard to the pain ; Dr. Cuthbert
Lockyer's report did, however, refer to the considerable
influence which contractions of the hypertrophied muscular
tissue of the so-called uterine platysma had on the clinical
aspect of such cases. He had been recently informed by a
patient from whom he had removed both ovaries, and on a
subsequent occasion the uterus also, that her sexual sensa-
tions had not been in the least affected.
Dr. Bedford Fexwick read notes on a case of
Ovarian Disease Associated with Uterine Fibroids.
The specimen which I now show was taken from a
patient, aged 44, and unmarried, who was sent to me by
Dr. Richmond, of Wimbledon. Ten years ago, she was told
by a well-known obstetric physician that she had a fibroid
tumour, but it would disappear at the change of life. It
almost seems too much to hope that this antediluvian
superstition will ever be decently buried, because one is
constantly meeting with it in the case of patients with
uterine fibroids who have passed through years of needless
suffering and danger whilst waiting for a menopausic
millennium. For the past six months, the patient has
suffered from increasing pain in the abdomen, especially
on the right side, and from increasing loss of flesh and
strength. 1 performed abdominal section on October 24,
and had some difficulty in lifting up the mass as it was com-
pletely moulded into the shape of the pelvis. It was also
exercising considerable pressure on, and causing some
displacement of, the left side of the bladder. I performed
specimens
j^j
hysterectomy in the usual manner, and as both ovaries were
grossly diseased, removed them with the tumour. I then
observed that the left ureter was greatly dilated, being about
three times its normal calibre, evidently due to the effect
of compression on the base of the bladder by the tumour. I
had predicted this condition before operation, and had the
urine measured carefully for a week previously, the average
amount being only 35 oz. a day. Directly after the tumour
was removed, the bladder rapidly filled, proving that there
must have been a considerable collection of urine in the
ureter and calyx of the left kidney, and after the operation
the average amount of urine per diem rose at once to 55 oz.
I feel confident that sufBcient stress is not laid upon the
danger to the kidney caused by pressure on the ureter by
fibroids of the uterus. Indeed, I regard this as one of the
most serious and insidious complications to which these
patients are liable. 1 desire to call special attention to the
gross disease in both the ovaries attached to the tumour.
The left ovary was converted into a blood cyst containing
8 oz. or 9 oz. of black blood. The right ovary contained
about 4 oz. of congealed blood, about half its cavity being
filled with a dense nodular growth, which has thinned the
capsule at one part to a thickness of only one-tenth of an
inch. The growth cut like scirrhus, and I am indebted to
Dr. Aarons for the sections which are shown to-night, and
which prove that the growth is a fibro-adenoma. In the
next place I wish to call attention to the remarkable size
of the ovarian arteries, which are four or five times their
normal calibre. Dr. Aarons has kindly also made sections
of these, and it will be observed that the middle coat of
the artery is greatly hypertrophied. It will be within the
memory of the Society that a distinguished Fellow, at a
meeting some two years ago, showed a number of micro-
scopic sections proving that the uterine arteries are greatly
thickened in cases of fibroid disease of the uterus, and that
he expressed his belief that this condition was the cause
of the fibroid change. I then, and have since, ventured
324 The British Gyncecological Society
to point out that there is reason to beheve that the increased
hypertrophy of the uterine arteries is the consequence and
not the cause of the fibroid change, and precisely resembles
the hypertrophy of the muscle of the heart or of other
arteries in the body where the circulation is called upon to
overcome an increased difficulty or obstruction to the blood
stream. And this case, and others which I have shown, in
which the similar hypertrophy of the ovarian arteries occurs,
goes further to prove my argument. But there is a practical
point to which I have also drawn attention, and which this
case strongly supports : that whenever we have fibroid
thickening to any marked degree at the fiuidus of the uterus
— that is to say, where the ovarian arteries enter the uterine
tissue — then, and then only, will there be much obstruction
to the flow through the ovarian vessels ; then, and then only,
do we find hypertrophy of the muscular coat of the ovarian
artery; and then, and 1 am inclined to believe then only, do
we find ovarian disease associated with the presence of the
uterine growth. 1 would venture to emphasise these facts,
because they have assisted me much in practice in this way :
that when I find the fundus fairly free from fibroid growths
I always leave the ovaries with an easy conscience, but when
there are fibroids on one or both sides of the fundus, and
considerable enlargement of the ovarian artery, I have
always found sufBcient disease in one or both ovaries to
make it evidently advisable that they should be removed.
The President said that he had occasionally, but only
occasionally, found large blood-cysts of the ovary in associa-
tion with myoma of the uterus ; in one instance the tumour
was as large as an ordinary water bottle, and in another
as large in diameter as an adult arm, and contained a
quantity of black blood. In the cases he could call to
mind the tubes had been quite free, and it did not seem
that such cysts could be directly connected with menstrua-
tion, or explained by regurgitation of blood from the tubes.
The pathogenesis of these cysts was obscure, and he would
be glad to hear if Dr. Bedford Fenwick had formulated, or
knew of, any theory on the subject.
Discussion on Specimens 325
Mr. Christopher Martin said that, in his opinion, the
most urgent of all indications for operative interference in
fibroids was pelvic pressure, especially pressure upon the
bladder and ureters. But pressure on the ureter in many
cases added greatly to the risk of the operation, especially
when the tumour was very adherent in the pelvis. In
removing such a tumour not long ago (a fibroid embedded
in the pelvis) he found he had removed one and a-half inches
of the ureter lying in a groove at the side of the mass. He
performed nephrectomy on the corresponding side, but the
patient died from shock. With regard to Dr. Fenwick's
theory of the causation of ovarian disease by pressure of a
fibroid on the ovarian artery, that would not, he thought,
justify the removal of an ovary apparently healthy ; it was
reasonable to suppose that when the tumour and the pressure
were removed, the circulation in the ovary would become
normal again. Except for gross disease, it was better not to
remove an ovary.
Dr. Fenvvick, in reply to the President's question, said
that he had looked up the text-books on this very point some
two or three years ago, and had been unable to find any
explanation given, and in several no mention was made
of the ovarian chan<jes in fibroid disease of the uterus. The
theory he had ventured to advance at this Society was,
of course, only a theory, and nothing more ; but it seemed
to him to be not only plausible, but sufficient to explain the
pathology. Increased power in the ovarian artery, combined
with increased difficulty in the ovarian circulation at the
uterine fundus, must inevitably mean a constant hyper-
congestion of the intervening tissues, that is to say, in the
ovary itself ; and the effect of such congestion must be not
only the production of inflammatory changes, but, in the
case of such an organ as the ovary, a greater likelihood
of cystic degeneration ; and, given the formation of a cyst,
the greater probability of rupture of a vessel, or of exudation
of serum into the cavity, of rapid increase in the cystic area ;
or in other words, of the production of the very conditions
The British Gyncecological Society
shown in the specimen he had just brought before the
Society, and he would point out that even if there was
no rupture of a blood-vessel, the vascular changes would
still explain the production of other forms of degeneration
which are known to be associated with ovarian disease. -
Dr. Heywood Smith showed a uterus containing
numerous fibroid tumours, one in process of sloughing ; the
right ovary was converted into a large blood-cyst, the left,
though slightly enlarged, had not been removed, as the
patient was young. An interesting point in the case was
that the patient's temperature had been persistently sub-
normal, and that, in spite of the sloughing tumour, there
had been no symptom to suggest suppuration.
Dr. Heywood Smith also showed, for Dr. Alexander
Duke, a device for the removal of wet wool from a Play-
fair's probe, often in some hands a difficult proceeding. It
consists of a little metal frame with a slot wider at one end.
The probe is passed through the wide end, and on being
pushed towards the narrower part, the wool is then easily
stripped off.
Dr. Bedford Fenwick pointed out that in Dr. Hey-
wood Smith's specimen the ovarian artery was greatly
hypertrophied, being at the point where it was divided
nearly double the normal size.
The President said that the discussion on Dr.
Macnaughton-Jones' specimen of hcemorrhagic endome-
tritis (which was postponed at the last meeting) would
now be taken, and he invited all who were present to take
part in the discussion.
Dr. Macnaughton-Jones said he had brought the
specimen again, but had little to add to his remarks at the
last meeting. Cases of glandular endometritis attended
with persistently recurrent haemorrhage might pass into
what was practically a form of pernicious anaemia, in which
the condition of the woman was almost as bad as if she
were suffering from malignant disease, and if bleeding
recurred there was no alternative save removal of the
uterus.
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Discussion on Speci77tens 327
Mr. Charles Ryall said that some years ago he had
shown to the Society two specimens removed by hysterec-
tomy, and his treatment met with a good deal of adverse
criticism at the time, but in the condition described by Dr,
Macnaughton-Jones, extensive hyperplasia of the endo-
metrium with increase of the muscular and fibrous tissue,
and general thickening of the uterine wall and some
endarteritis, the curette, though repeatedly resorted to,
seldom gave relief, indeed, generally made things worse ;
and for obstinately recurring haemorrhage in such cases,
removal of the uterus was the best treatment.
Dr. J. J. Macan reminded the Fellows that the term
" h^emorrhagic endometritis " was originally applied by
Slaviansky some fifteen years ago to cases of profuse uterine
haemorrhage associated with inflammation, affecting chiefly
the glandular elements of the endometrium, during an
epidemic of cholera. The term, as Veit mentions, had been
also appHed to uterine haemorrhages occurring during the
course of the exanthemata. A report of one such case
would be found in the November number of the Society's
Journal {Summary, p. 81.)
Dr. Macnaughton-Jones, in reply, said that he could
understand the term hcemorrhagic endometritis being used
in connection with the exanthemata, for during eleven
years' work in a large fever hospital he had seen many cases
of haemorrhage from the uterus, more especially in typhus
of a malignant type, but he attributed that haemorrhage to
a change in the blood rather than to any affection of the
uterus. The condition he had brought under the notice of
the Society was generally the result of long pathological
change, and the question was, not so much the cause of the
haemorrhage, as the passing of some of these cases of
glandular hypertrophy and desquamation into a state
approaching malign adenoma.
328 The British Gyiicecological Society
Discussion ox Mr. Christopher Martin's Paper on
THE Treatment of Intractable Prolapse by
Extirpation of the Uterus and Vagina. {Vide
ante, p. 272.)
Dr. J. A. Mansell Moullin said Mr. Martin had
brought before the Society a new operation for the treat-
ment of this distressing condition. Mr. Martin recognised
the futiHty, or at any rate, the temporary nature of the
benefit to be derived from the many operations hitherto
devised for the correction of prolapse. The operation now
proposed did not rest on the cutting away and suturing of
tegumentary structures, but on a more soHd and scientific
basis, namely the union and reconstruction of the fascia
to form a pelvic floor resembling that of the male pelvis.
It was well known that to repair a hernia occurring in the
cicatrix of an abdominal incision it was essential to expose
and unite the cut edge of the transversalis fascia. If this
was done effectually, a good result was certain, otherwise
the operation was in vain. Mr. Martin tells us that the
pelvic fascia, which splits to enclose the upper portion of
the vagina, does not itself become prolapsed, but that the
uterus and vagina are prolapsed and stretched away from
it. When these latter are removed, the cut margin of the
fascia can be readily distinguished and united with sutures
to the opposite side, thus obliterating the opening through
which the vagina passes, and forming a continuous pelvic
floor. Mr. Alartin does not conceal the fact that the opera-
tion is a formidable one, and attended by many risks. An
improved technique may possibly enable us to add it to our
remedies for use in severe cases.
Dr. R. H. Hodgson, after complimenting Mr. Martin
on the frank way in which he had given the details of his
cases, said that it was noticeable that the fever and suppura-
tion which in three cases did not occur till after ten days, in
the fourth appeared on the second day after the operation.
It seemed, therefore, probable that this fourth case was one
Discussion on Intractable Prolapse 329
of infection at the time of operation ; the others, due to
some change in blood-clots formed in the wound. The
great tendency of blood-clots in the pelvis to undergo
decomposition might, he suggested, be due to their
proximity to the rectum, and to the difference between
the coverings of the intestine outside and within the abdo-
minal cavity. He had himself suggested some years ago
that prolapse might be remedied, or prevented, by amputat-
ing the uterus at the internal os, drawing down the free
edges of the broad ligaments through the cervix, and so
making all the parts taut. This would save the vagina,
which it was desirable to do, even in a woman getting
on in years. He suggested that the suppuration might be
avoided by preventing the collection of blood, a conse-
quence of the failure to obtain accurate apposition of the
raw surfaces. He thought that the introduction into the
rectum of one of Cooper's tubes, for arresting hajmorrhage,
might have the desired effect.
Dr. Bedford Fenwick said that he considered the
Society owed a debt of gratitude to Mr. Martin for the
excellent paper he had brought before them, and personally
he much admired the skill and courage displayed in the
operation Mr. Martin had described, because, to anyone
who was constantly accustomed to operate on the abdomen
or vagina, it needed no words to explain the difficulties of
the operation in question. There were one or two matters
which had particularly struck him in Mr. Martin's descrip-
tion. In the first place, he could not understand the special
advantage of removing the mucous membrane from the
anterior wall of the vagina, but as Mr. Martin did it, it
seemed to him to explain all the suppuration to which Mr
Martin referred ; for example, he apparently left an entirely
raw surface in the canal, which must be closed by granula-
tion, which involved the formation of pus. If the lower
part of the canal closed first, as it most probably would do,
then the pus must collect at the top of the canal, and of
course the septic conditions to which Mr. Martin referred
»50
30 The British Gynceco logical Society
naturally followed. Mr. Martin, indeed, seemed to have
realised this, because he in each case passed a pair of forceps
along the canal, liberated the accumulated pus, and the
patient at once recovered. If he (Dr. Fenwick) were going
to perform this operation, he would certainly feel inclined
to modify it, therefore, to the extent of leaving the mucous
membrane on the anterior wall untouched, and thus saving
what everyone would know to be the most difficult part
of the operation. Then by stitching its edges together one
could reduce the canal to the diameter of an ordinary
pencil, and in the great majority of severe cases he could
not but think that colporrhaphy to this extent would be
sufficient to entirely cure the patient. Moreover, it would
leave no suppurating surface, it would not interfere with the
relations of the uterus and ovaries, but it would to all
intents and purposes close the canal into and through which
prolapse of the rectum or bladder could occur. Then,
again, in Mr. Martin's operation he could not but think that
there must be a great practical difficulty sometimes in find-
ing the pelvic fascia, and when it had been found in draw-
ing it together sufficiently to close the base of the pelvis,
which, as he understood the procedure, was the scientific
principle on which Mr. Martin's operation was founded,
and which, as a principle, both anatomical and pathological,
he cordially accepted. Nature had created a wide separa-
tion between the fascia, and in his experience it was in
some cases not easily found. He, therefore, was inclined
to believe that cases might occur in which the edge of the
fascia could not be defined, and others in which it would
not be possible, by any permissible traction, to draw the
edges of the fascia into a sufficiently accurate position to
obtain firm union.
Dr. Macnaughton-Jones commented on the fact that
only on the rarest occasions was such an operation called
for, as acknowledged by Mr. Martin himself. He (Dr.
Macnaughton-Jones) had on three occasions removed the
uterus and then performed free colporrhaphy. In these
Discussion on Intractable Prolapse 331
cases the bladder and bowel were down in the procident
sac. They were all permanently relieved. It was rarely
indeed that even this step was necessary. A Schroeder's
operation, consisting of a free anterior and posterior colpor-
rhaphy and high amputation of the cervix, with a deep
perineorrhaphy, was sufficient in the majority of instances,
combined, if need be, with a ventrofixation, or better still,
an Alexander-Adams operation. So far back as 1889, Pro-
fessor A. Martin (now of Greifswald) had performed com-
plete extirpation of the vagina and uterus for both cancer
and procidentia. The operation differed in the two
instances. In 2,000 cases of procidentia, up to the end
of 1903, Professor Martin had performed total extirpation
nineteen times. He removed the adnexa also. In all such
operations a good deal of bleeding might be avoided by
early ligature of the uterine trunks or the vaginal branches.
The rarity of the operation did not detract from the bold-
ness or ingenuity of the procedure.
Dr. Jervois Aarons said that he was much struck with
the ingenuity of Mr. Martin's operation. He had, since
the paper was read, seen a case of prolapse which recurred
after hysteropexy, perineorrhaphy and anterior and posterior
colporrhaphy, and for such a case, especially in a woman
past the menopause, the method promised relief otherwise
unattainable.
The President said : I have watched with very great
interest the work of my colleague, Mr. Christopher Martin,
on the extirpation of the uterus and vagina for the treat-
ment of severe prolapse, and can, from my own observa-
tion, confirm a good deal of what he has told us. But
while I can and do most heartily admire the use of thought
and skill which are united in the performance of this long
and difficult operation (for there is one part at least in its
performance when, if I remember rightly, as the uterus
is turned downwards and backwards, all ordinary relations
are more or less reversed, and every attention and care
is necessary to understand as well as to perform the work),
^2,2 The British Gynceco logical Society
1 am not fully satisfied after all is completed that the best
has been done for the patient. The loss of the vagina is a
serious loss, and what Air. Martin regards, and rightly
regards, as the essential part of the operation — the rebuild-
ing up of the stretched pelvic fascia — can be obtained in
another way, I think, without the loss of the whole vagina.
If, after starting to repair a perineum by Mr. Tait's method
of flap-splitting, the upper flap of the posterior vaginal
wall be grasped by the left thumb and forefinger and
the scissors dissection be carried up higher and higher
between the rectum and vagina, a plane is finally reached
where there is only the flimsiest union between the vagina
and rectum, and the finger can bluntly separate the two
right up to the cervix if necessary. Now, if this be done,
the separation being not only carried high enough but
extended (by dissection) freely on both sides, and the long
triangular flap of vaginal membrane thus produced be fully
excised, you find a condition exactly similar to that pro-
duced by Mr. Martin in its free exposure of the pelvic
or recto-vesical fascia. Some of this has been already
removed b}^ the removal of the vaginal floor above it, and
you can see the edge of the fascia as a distinct structure
on each side, a divided membrane, which can be still
further excised or united at once, at the discretion of the
operator. It is the repair and firm suture of this, confining
the rectum backwards, that is the essential in the cure of
every rectocele, but I question whether it is of much use
in the prevention of a cystocele. The accompanying cys-
tocele in cases of bad protrusion needs separate treatment.
The usual operation 1 have done for some years in cases
of severe prolapse, is, first, a repair of the cystocele by
anterior colporrhaphy, with a buried tier-suture of the base
of the bladder, so as permanently to contract its capacity
and cure all anterior bulging. The suture is a continuous
one of the finest silk, carried from urethral orifice to cervix,
back again from cervix to urethra, and still back again from
urethral orifice to cervix, enfolding more and more of the
Discussion on Intractable Prolapse '^,'^'i,
dilated and redundant bladder, until the base of the bladder
and anterior wall of the vagina are perfectly taut and firm.
Here the fascia is sometimes recognisable, more often it
is not ; but the remains of it are taken up with the floor of
the bladder in the silk suture. This suture is buried. A
separate running silk suture unites the vaginal wound over
this. The uterus is then fully replaced, and the posterior
dissection between the rectum and bladder carried out as I
have described. As much of the posterior and lateral
vaginal wall as is considered advisable is then removed
through nearly the whole length of the vagina. Deep
sutures of silkworm gut are passed to bring the raw surfaces
into close apposition, and a separate fine silk buried suture
is often used for the fascia only. It may help to explain my
description if I show the parts removed in a recent case,
occurring about two weeks ago, after the meeting is con-
cluded. The operation is, of course, a minor one, and the
wounds heal readily without any suppuration or tempera-
ture. By this means the vagina is contracted through its
whole length ; the recto-vesical fascia is repaired, the
bladder is kept up, but the vagina is retained, and no
definite function or organ is necessarily lost. I cannot say
whether all of the cases operated on in this way will stand
the test of time, but so far I have not met with any real
failure. In one respect, even as regards the protrusion, I
am inclined to think that the method I have described may
compare very favourably with that of total extirpation of the
vagina. Some cystocele-bulging or impulse was present
in the cicatrix of one of the cases Mr. Martin kindly showed
me, and this, I think, may be avoided by the cure of the
cystocele before repairing the fascia posteriorly. I should
like to suggest that even in extirpation of the vagina it might
be advisable (if time permitted) to enfold and narrow the
base of the bladder by a buried suture before bringing the
rest of the wound together.
I think that the Society is to be congratulated in having
such an original and bold innovation in surgery, and such
334 ^'^'^ British GyncEcological Society
a valuable and interesting paper brought before it by one of
our Fellows. As your President as well as his colleague,
in thanking him for his communication, 1 would like
especially to notice the fine and virile restraint which has
marked his practice. The treatment is, as he has acknow-
ledged, a severe and even dangerous one. He has used
it with rare judgment and discretion.
Mr. Christopher Martin, in reply, said : First let mc
thank the President and members of the Society for the
kind manner in which they have received and discussed
my paper. In reply to Dr. Mansell MouUin, I have never
found any difficulty in recognising the pelvic fascia and in
sewing its edges together. It is a very distinct and definite
layer. In reply to Dr. Hodgson, who asked why the
bloody effusion broke down into pus, I would point out it
was exposed to two sources of infection — bacteria from the
rectum and bacteria from the ulcerated cervix and vagina.
Dr. Fenwick asks " Why not leave the anterior wall of the
vagina and be content with removing the posterior vaginal
wall and sewing up the fascia ? " I would point out that
this would not cure the cystocele. Ergot and strychnine
given with the idea of reducing the size of the uterus would,
I am sure, be perfectly useless in bad cases of total prolapse.
Moreover, most of these women are past the menopause. I
am interested to learn from Dr. Macnaughton-Jones that
Professor Martin, of Berlm, has devised and carried out
a somewhat similar proceeding. I appreciate the value of
the suggestion of Dr. Macnaughton-Jones that the uterine
arteries should be ligatured before the vaginal mucous
membrane is dissected off. It would no doubt tend to
diminish the arterial bleeding. The most troublesome
bleeding, however, comes from the veins of the vaginal
plexus, and I do not think that it w^ould prevent this. I am
very grateful to the President for his generous remarks. I
am pleased to know that he agrees with me in insisting on
the importance of suturing the pelvic fascia in operating for
uterine prolapse. In all these cases of plastic operations
Discussion on Intractable Prolapse 335
for prolapse, it will be found that the more thoroughly the
vaginal mucous membrane is removed, and the more com-
pletely the pelvic fascia is brought together, the better will
be the ultimate result.
Dr. Macnaughton-Jones read notes of the condition
Tuberose Subchorial Decidual Haematoma, and touched on
the etiology of the condition as advanced by Breus,
Goldspohn, Newman, Davidsohn, and H. Schroeder. He
showed with the epidiascope a specimen of Professor H.
Schroeder's of this condition, which he (Dr. Macnaughton-
Jones) had recently brought from Professor Fritsch's klinik
at Bonn.
"''6 The British Gynaecological Society
03
BRITISH GYNAECOLOGICAL SOCIETY.
Thursday, December 8, 1904.
Professor JOHN W. TAYLOR, M.D., F.R.C.S., President, in
THE Chair.
Specimens.
Carcinoma of the Fallopian Tube.
Dr. Macnaughton-Jones said that he exhibited this
specimen solely for its pathological interest. For some
years he had lost sight of the case from which the tumour
was removed, and it was only recently that he had discovered
the latter amon^ others in his collection. When he had
sent it for examination and report to Dr. Cuthbert Lockyer,
it proved to be one of exceptional interest. The report
was as follows : " The tumour is oval in shape, and measures
10 inches in its greatest and 8 inches in its shortest circum-
ference. It has a lobulated surface ; some of the lobes are
smooth, the growth being enclosed in a highly-stretched
fibrous-looking shiny capsule. Other lobes are rough and
papiliform, consisting of growth which has burst through
the containing capsule. The smooth thin capsule has been
peeled off, the greater part of one portion of the growth
revealing a rough surface studded with nodules the size of
a pin's head. A further portion of the tumour has been
cut through its greatest diameter, the cut surface has a pale
yellow colour, and consists of soft friable granular-looking
material. At one point there was a small projection which
admitted a fine bristle. This on transverse section proved
to be the cut end of the Fallopian tube. On following this
up it was found to lead through the capsule into the cavity
Specimens and Cases
containing the new growth. Sections have been prepared
at various levels to show that the capsule of the growth
is continuous with the wall of the undilated tube. These
sections prove that the smooth capsule enclosing the
tumour consists of fibro-muscular tissue continuous with
that forming the wall of the unexpanded tube. The tumour
is, in fact, of tubal origin." Section i shows a thickened
tube-wall with intact lumen and with swollen, but perfect,
plicae. The vessels are thickened and contain thrombi.
The main lymphatics are injected by leucocytes, but contain
no deposit of new growth. Section 2, taken a little further
on, shows a portion of tube wall with carcinomatous growth
arising from and distorting the still existent plicae. Section
3 shows a few plicae, but the majority have disappeared,
giving place to columns of cancer cells densely packed
together, and which have lost their columnar shape and
have become more or less spheroidal. These lie lin close
apposition to the stretched wall of the tube ; the latter is
here invaded by cancer cells which occupy alveolar spaces
(lymphatics) between the fibro-muscular layers. Section 4,
taken furthest from the non-dilated end of the tube, shows
a much thinned-out tubal wall, forming the capsule to a
dense solid carcinomatous growth composed of densely
packed spheroidal cells arranged in long columns and
concrete masses.
Dr. Macnaughton-Jones remarked that unfortunately
the clinical history of the case had been lost sight of, and
he could not say what the ultimate issue was. In Mr. Alban
Doran's recent paper in the Journal of Obstetrics and Gyne-
cology, October, 1904, there was a table of over 50 complete
cases of primary cancer of the Fallopian tubes. Up to 1902
Graef of Halle had found 52 recorded cases. From Mr.
Alban Doran's table it would appear that married life had
not much influence on the disease, 34 cases occurring in
married, and 29 in unmarried women. Twenty-seven had
been pregnant, and 9 were sterile. As to the involvement
of other organs, the uterus was involved in only 6 cases,
VOL. XX. — NO. 80. - 23
22,8 The British Gynceco logical Society
and in i tliere did not appear to be any relation between
the cancer of the tube and that of the uterus, inasmuch as
the cervix only was diseased. In only lo cases was the
ovary involved ; in i8 cases no other parts were involved.
As regards the nature of the cancer, 40 were papillomatous,
4 medullary, i adeno-carcinomatous, i alveolar, i a villous
endothelioma, i a sarcoma, i a carcinoma of a nature not
stated, and in 3 the type of malignancy was not described.
Of all the cases only i survived over three years, and i two
years and two months. It will be seen from Dr. Lockyer's
report that the nature of the solid tumour in the present
instance was spheroidal-celled carcinoma. Dr. Alban
Doran's paper, with the interesting clinical facts which he
records, is worth perusal.
Mr. BOWREMANN Jessett said that he had never met
with a case of primary columnar-celled carcinoma of the
Fallopian tube, and suggested that the specimen might
possibly be a secondary growth of carcinoma of the bowel.
Dr. F. A. PuRCELL also spoke of the extreme rarity of
primary carcinoma of the tube, and suggested that there
might have been primary growth in the uterus.
Dr. C. F. H. ROUTH asked what was the age of the
patient ?
Dr. Macnaughton-Jones, in reply, said that the capsule
of the tumour was a direct extension of the Fallopian tube ;
the analysis of Mr. Doran's cases showed that the uterus
was involved in only 6 out of 53 instances.
The President (Professor J. W. Taylor) then showed
the following specimens, reading the notes appended : —
(i) Fallopian Tubes, Ligatured twice at Previous
Operations, and removed in the Case of a Third
CiESAREAN Section.
M. S., a strumous dwarf, aged 25, with both curvature
of spine and contracted pelvis, was married in July, 1900.
She immediately became pregnant, and was sent to me for
specimens and Cases
operation by Dr. Darroll, of Leintwardine, in February,
1901.
Labour commenced on the morning of March 29, when
1 operated by Caesarean section, removing a healthy female
child, which is still living. After suturing the uterine wound,
I tied each Fallopian tube by a single ligature of silk as
some bar to further pregnancy. The mother and child both
did well, and left the hospital on April 17, but remained at
our Convalescent Home for some time longer. The follow-
ing year, 1902, the patient developed tuberculous disease of
the right knee-joint, and her leg was amputated above the
knee at Shrewsbury Infirmary, on September 22, 1902. In
1903 she again became pregnant, and was sent up to me
once more by Dr. Darroll towards the end of August. I
did a second Caesarean section on September 14, 1903,
removing again a living female child, which, however, was
very feeble, and only lived about half an hour. After the
suturing of the uterine incision was completed, I carefully
examined the Fallopian tubes, and found considerable
atrophy at each site of ligature. The atrophy was most
marked on the right side, where the tube seemed narrowed
to a point. The silk had been absorbed. I placed two
fresh ligatures of silk on each Fallopian tube (four ligatures
in all, but without any cutting or removal), and closed the
abdominal wound. The patient did well after the operation
so far as the section was concerned, but during the whole
of the time of her stay in hospital she was troubled with
chronic strumous conjunctivitis and ulceration of the cornea,
an affection from which she had been suffering for nearly
two years, in spite of the free administration of cod-liver
oil. She went to the Convalescent Home on October 8,
1903.
Early in this year I heard from Dr. Darroll that from
the date of her return home she had never menstruated,
and was evidently again pregnant. She came up in July
last, and I found that this was indeed the case. On this
occasion I determined to remove the uterine appendages,
340 The British GyiKTCological Society
but was anxious not to hurry the performance of the opera-
tion so as to obtain a living child, if possible.
On August 4 I went for a holiday, and two days later,
the patient beginning to be in labour, my colleague, Mr.
Christopher Martin, kindly operated for me, removing a
living child, which, like the preceding one, only lived about
three quarters of an hour.
Mr. Martin, before closing the abdomen, removed the
whole of each tube, and a small portion of each correspond-
ing cornu of the uterus. He also removed one ovary. The
patient made a good recovery, and left the hospital soon
after my return on September 7.
On looking at the tubes removed, it may be seen that
one tube is as completely divided by the double ligature as
if a piece had been cut out of it, while in the other the
whole of the muscular coat appears to be gone, but (in all
probability) the mucous channel is still pervious.
In addition to the direct interest of these specimens as
contributing to the general sum of knowledge regarding
Cesarean section, and the utility or non-utility of ligature
of the tubes as a bar to future pregnancy, I must confess
that they have a very considerable interest to me as bearing
on the question of the causation of tubal pregnancy.
It would, I suppose, be difticult to find two Fallopian
tubes in which an ovum would be theoretically more likely
to be stopped on its journey to the uterus, yet the pregnancy
on each occasion after ligature was uterine and not tubal.
It seems to suggest that the cilia of the epithelial coat,
even within the lumen of the tube, have more to do with
the progress of the ovum than any peristaltic muscular
contraction.
(2) A L.ARGE Abscess of the Ovary.
This specimen is, I believe, a rather rare one, it being
unusual to find so large an abdominal tumour due to ovarian
abscess. The history is interesting : The patient, Mrs. C. C,
had been married five years, but had never been pregnant.
specimens and Cases 341
when in August of this year she developed a rising tem-
perature with obscure abdominal pains and, rather naturally,
was supposed to be suffering from typhoid fever.
She was seen on August 21 by another consultant, who
diagnosed suppuration, and opened an abscess by the vagina
on the 23rd, over a pint of pus and blood being evacuated.
This undoubtedly gave her very great relief, and she was
able to get up and go out of doors a little later; but since
this date an increasing enlargement was noticed in the lower
part of the abdomen — the catamenia had ceased from the
date of her illness.
When she was sent to me by Dr. Kingsland, about the
middle of November, I found a remarkably prominent
cystic swelling reaching to the umbilicus, and looking like
a five months' pregnancy, or a very distended bladder.
On examination, however, I found it was due to neither
of these conditions, but to a tumour of the left ovary or
left broad ligament pushing the uterus to the right. The
lower pole of the cyst came down to the level of the
vaginal cervix on the left side, the side of the uterus being
apparently lixed to the wall of the cyst, and a diagnosis was
made of adherent ovarian tumour or broad ligament cyst.
The patient's temperature was never quite normal, but
usually slightly raised ; on the evening of admission into
hospital it was 101° F. Under anaesthesia, on November
19, I came to the conclusion that the tumour must be
intraperitoneal, and operated by abdominal section, remov-
ing a large single abscess of the left ovary, with dense
adhesions to the pouch of Douglas at the site of the first
tapping, or incision. As there was necessarily some fouling
of the pelvis in the separation of these adhesions, I finished
the operation by posterior vaginal coeliotomy and gauze
drainage. The pus removed was examined by my assistant,
Dr. Smallwood Savage, and showed a pure growth of
bacillus coli, but at no time during the operation was there
any visible adhesion or channel of communication found
between the ovary and the rectum. The patient made a
342 The British Gyncecological Society
good recovery, and went to the Convalescent Home two
days ago.
The President also exhibited a series of three cases of
Cancer of the Body of the Uterus,
all removed within the preceding four or five weeks : —
The first was a simple case of cancer of the body,
occurring in a married woman, aged 56, four years after
the menopause, and attended by the classical symptoms
of watery, foul-smelling and bloody discharges, for three
months before operation. The uterus was removed by
vaginal hysterectomy on October 31, and on being laid
open, disclosed a fairly typical and very pretty specimen
of the disease. The patient made a good recovery.
The second case appeared, clinically, to be one of
ovarian tumour, complicated by a small uterine polypus or
fibroid. The patient was single, aged 43, never regular, the
last normal period having taken place some three years
previously ; since then she stated that she had suffered
from a daily coloured discharge, never profuse, and never
amounting to more than a " show." On examination, she
was found to have a large abdominal tumour reaching well
above the umbilicus. The uterus was pushed backwards
by the tumour ; the cervix was open, and a small growth,
like a polypus, which did not break down or bleed on
examination, was just to be felt by the tip of the examining
finger. I operated on November 17, and on first attending
to the condition of the uterus under anaesthesia found that
the growth presenting at the cervix was soft, brain-like, and
almost certainly malignant. I therefore proceeded to remove
the whole of the uterus as well as the ovarian tumour and
the uterine appendages of the opposite side, hoping in this
way to obtain freedom — or a longer freedom — from re-
currence. The patient has done well, and is now con-
valescent. The uterine growth has been examined by
Professor Leith, who reports upon it as malignant. The
Discussion on Specimens 343
ovarian tumour is still under examination, but presents the
rough general characters of malignancy.'
The third case was originally one of myoma of the
uterus, attended for several years by menorrhagia. The
patient, a midwifery nurse, single, aged 52, appeared to
pass through the menopause eighteen months ago, and the
haemorrhage ceased. For six months an irregular foul-
smelling discharge returned, and in September and October
last she suffered from severe haemorrhage, with " floodings."
The patient was virginal, and the vaginal cervix was free
from any tangible ulceration. The tumour filled the pelvis,
and therefore no estimate could be made of fixation. The
abdominal characters of the tumour were those of a fibroid.
The diagnosis was made of cancer of the uterus or a
"sloughing" fibroid, and I operated on December i, doing
a panhysterectomy by the combined method. There was
pyometra and right pyosalpinx, and the extraction of the
tumour was by no means an easy one. During its removal
the uterus tore at the junction of the body with the cervix,
and the latter, which was removed separately, was un-
fortunately not preserved. The pathological examination
appears to show that a malignant adenoma is invading a
myomatous uterus, but the case is too recent to obtain a
full report. The patient (to-day) is doing well.
Dr. Heywood Smith said that as the ligature allowed a
certain amount of patency in the lumen of the tube, more
radical measures were required to ensure sterility.
Dr. J. A. Mansell Moullix concurred as to the
inadequacy of ligature ; the easiest and best course to
adopt is to remove the whole of the tube at the primary
operation.
Dr. J. H. Dauber remarked that cases had been recorded
in which both ovaries had been removed, and yet the patient
had become pregnant.
Dr. J. Furneaux-Jordan said that Cajsarean section was
' This has since been reported upon as being decidedly malignant.
344 ^■^^ British Gyncecological Society
now attended with such jL^ood results that he did not see
the necessity of steriHsing a young woman merely because
she could not have a child born through the pelvis.
Dr. Macnaughton-Jones remarked that in some of
these cases the method introduced by Pincus had been
successfully employed to seal up the uterine canal by
atmocausis. In regard to his specimen of carcinoma of
the fundus, it was precisely similar to a case brought
forward by him before the Society, and from the appear-
ance of the uterus it did not seem that the cervix uteri was
involved. In his case it was proved microscopically not to
be so. It would be well that the specimen were examined
to settle this point.
The President, in reply, said that though they now
knew that ligaturing the Fallopian tube was a very poor
bar to future conception, his critics must remember that
in 1900, which was the date of his case, their knowledge
was by no means so complete. However tightly a ligature
was tied, the serous membrane and muscular tissue appeared
to offer such resistance that in spite of the ligature, a minute
aperture was left through which the ovum could pass. The
surest method of ensuring sterility was, he thought, that
adopted by his colleague, Mr. Martin, viz., to remove not
merely the tube, but also the corresponding cornu of the
uterus by a wedge-shaped or triangular incision, and to
bring the edges of the wound together, so as to close the
channel effectually by some depth of muscular tissue. For
closing the wound in the uterus, he always used sterilised
silk, and had not employed gut for that purpose for many
years. The large ovarian tumour removed with the uterus
diagnosed to be cancerous after curettage, had all the micro-
scopic characters of a carcinomatous tumour, and if proved
to be one, must have existed for several months before
anything was known to be wrong with the uterus.
Photograph of interior of uterus in Case i.
Alexander on Adenoma HcBinort'kagica 345
Paper.
Dr. William Alexander then read the following
paper : —
Adenoma Hemorrhagica of the Endometrium.
It is very strange how frequently students of medicine
have to search in vain for assistance from books in regard to
conditions that they meet with in their practice, conditions
that they have seen with comparative frequency, and that
have apparently been overlooked by other observers, or if
seen have not been considered of sufficient interest to secure
a record. Some conditions seem to be recorded too
frequently, others are perhaps mentioned by some old
writer, but not a modern pen is raised to rescue them from
obscurity. Such are the cases I bring before you to-night in
the hope that I may obtain more information than I have
been able to derive from books : —
Case i. — In 1899, a lady, aged 34, consulted me for
metrorrhagia of eighteen years' duration. During one of these
years she had no bleeding, not even at menstruation. This
year of freedom was early in the disease. Like the lady
in Scripture, she had consulted many physicians without
lasting benefit. She had been curetted by an eminent
gynaecologist, now dead, but the relief was only for two
months, when the metrorrhagia i appeared as before. She
was frequently bed-ridden, and at all times a useless invalid,
although she had strong aspirations after a useful and busy
life. Oophorectomy had been recommended quite recently.
This she felt inclined to have performed, but her medical
attendant on hearing of the proposal warned her against it,
telling her that removal of the ovaries was frequently
followed by insanity. Such a possible, or rather probable
result naturally frightened her, and she reluctantly refused
that operation, resumed her couch, her bed, and her ergot,
without much hope of ever being cured, and with the pros-
pect of spending her life, up to the menopause at any rate, as
346 The British Gynceco logical Society
an invalid under medical supervision. She knew all about
it, having had a large experience of medical men and
medical subjects. Finding that after a more prolonged
trial such a life was intolerable, she, without consulting
either her doctor or her relatives, came to the out-patient
gynaecological clinique at the Royal Southern Hospital.
The patient was fairly nourished, but pallid and flabby, the
result of repeated haemorrhages and of her sedentary life.
A walk, or even slight movements about her room would,
she said, bring on the bleeding, and sometimes she had
to remain in bed altogether for days. The uterus was
slightly enlarged and congested, but there was no sign of
malignant disease, and the patient's age did not favour such
a serious diagnosis. There were no palpable fibroids,
although the existence of small fibroids was the diagnosis
arrived at. The previous history of the disease and its
treatment did not permit the hope that further curetting
would be more permanently successful than before, and her
wish was to have the bleeding stopped, at any cost but that
of her sanity and her life. She had no intention of marrying,
but wished to live an active, useful life, and did not mind the
loss of any of the child-bearing organs. She was advised
to have a vaginal hysterectomy performed. This operation,
she was told, was certain to stop the metrorrhagia and the
ovaries being left behind, was not likely to produce such
serious symptoms as were alleged to follow oophorectomy.
After consulting with her friends, she came into the private
ward of the Royal Southern Hospital ; hysterectomy was
successfully performed on July 6, 1899, and the patient left
the hospital well on August 8, 1899. On opening up the
uterus after its removal, we found the mucous membrane
replaced by a soft, white, gelatinous-looking substance about
one-sixth of an inch thick, spreading up into the Fallopian
tubes on each side, where it was specially luxuriant and
almost polypoid, becoming scanty below and not so even on
the surface. It looked as if the growth was reforming
below after having been torn away there by the curette.
''■\^^
Alexander on Adenoma Hemorrhagica 347
The uterine walls seemed normal, and there was no
induration.
Case 2. — In 1900, a Miss G., aged 39, was seen by me
with Dr. George Johnston, of Liverpool, on account of
persistent and profuse metrorrhagia extending over eight
years. She was very anaemic, but did not seem to have
lost much flesh. She had been curretted about five years
ago, but not only without lasting benefit, but she said the
haemorrhage had been worse since the curetting. I per-
formed the curetting myself most carefully and thoroughly.
Her family history was distinctly phthisical, and the dread of
the onset of phthisis that possessed the minds of her relatives
and of her medical attendant was naturally intensified by
the haemorrhage, especially as she had been losing weight. I
described my experience with the former case, and the same
treatment was readily agreed to both by the patient and her
friends, and by Dr. Johnston. On April 5, 1900, vaginal
hysterectomy was performed. The uterus presented exactly
the same appearance as in the previous case. The results of
the operation were all that could be desired, the anaemia was
gradually recovered from, and no signs of phthisis have
so far appeared.
Case 3. — Miss C, aged 38, single, had been quite regular
and normal as regards menstruation up to five years ago, when
she became the subject of frequent uterine haemorrhages at
all times, and sometimes to a great extent. The haemorrhage
was checked at first by ergot. When this failed curetting was
performed, and the haemorrhage abated for a few months.
It then came on again more vigorously than ever, and in the
meantime one sister had died from recurrent cancer of
the breast, and the second had been recently operated upon
for the same disease. The patient was also the subject of a
nervous twitching of the muscles of the head and neck,
which was made much worse by the hemorrhage. Marriage
and child-bearing were not likely events. She was in the
meantime much reduced by the repeated losses of blood.
From every point of view it seemed to be desirable to have
348 The British GyncBCological Society
the uterus removed. This was done on September 18, 1900.
The ovaries were left behind. The patient is now (1904) in
excellent health. The uterus presented the same appearance
as the other cases.
Case 4. — Mrs. H., a<;ed 36, married, one child sixteen
years ago, from the birth of which she recovered satis-
factorily. Ten years ago she had an ovarian tumour
removed, and soon afterwards began to suffer from leu-
corrhoea and occasional metrorrhagia. Neither of these
symptoms ever became severe, but they persisted in spite
of treatment of different kinds. Twelve months ago she
began to suffer pain in the right side of the pelvis, which
continued ever since uninfluenced by any drugs, except
sedatives. Six months ago dyspareunia set in, and was
accompanied by blood-stained, foul-smelling discharge.
Patient is cachectic-looking. On examination, the os uteri
was found elongated, eroded, and very hard, but not
apparently the seat of malignant disease. The canal of the
uterus was normal in depth. Microscopical examinations of
curettings did not give a decided diagnosis of any kind.
Clinically the disease looked so malignant in its nature that
removal of the uterus was advised, and was readily agreed
to both by the patient and her husband. The operation was
performed on November 3, 1904. On cutting the uterus
open, the pathologist remarked, " The whole endometrium
was infiltrated with a white, fibrous-looking formation that
merely thickened the walls of the uterus without altering
their contour." It was an exact counterpart of the condi-
tions found in the other cases. On November 29 the patient
was discharged, quite well.
Case 5. — Emily E., aged 41, admitted to hospital
November 13, 1903. She was confined eighteen months
ago. Soon after convalescence from the confinement she
began to suffer from pain in the lower part of the abdomen
and back, and from intermittent attacks of bleeding, which
were not amenable to treatment. Two days before admis-
sion she had severe haemorrhage, and was bleeding profusely
Alexander on Adenoma Hcemorrkagica 349
when admitted to hospital. Ergot was given, and the haemor-
rhage stopped. Examination showed an enlarged, eroded
anterior os, uterine cavity normal in size. A curette passed
in did not show any growth or irregularity ot the uterine
wall. As the state of the os was considered suspicious, a
small piece of the anterior lip was removed for examination,
and a section showed dense fibrous tissue with cystic dilata-
tion of the cervical glands. No evidence of malignancy.
She was douched with creolin. Ergot and hydrastis were
prescribed. The haemorrhage continued, and was frequently
accompanied by so much pain that nepenthe had to be
resorted to. On December 16, 1903, the os was dilated up to
22, and the cavity thoroughly curetted. The pathologist did
not make anything definite out of the curettings, except that
the glandular tissue was increased. Vox a few days she was
relieved, when the haemorrhage began again, and continued
at frequent intervals. On January 21 she had a severe
attack of metrorrhagia, accompanied by severe pain in the
pelvis. She was evidently losing ground so rapidly that,
being convinced that the disease was probably malignant,
I advised vaginal hysterectomy, which was performed on
January 25, 1904. The patient made a good recovery, but
some troublesome pains m her back continued more or less
till May, when she reported herself as quite well. She has
not been seen since. The uterine cavity presented an exactly
sunilar appearance to the previous two cases, where a fine,
soft, gelatinous substance was spread over the surface of the
uterine cavity.
It will be seen that the chief symptom in all these cases
was persistent haemorrhage recurring after curetting and
after all treatment ; not so great as to destroy life, but
sufficient to keep up a condition of anaemia and invalidism.
The size or shape of the uterus did not differ materially from
that of a normal uterus, and the curettings did not present to
the pathologist anything abnormal. The glands were, per-
haps, more numerous, but nothing more. One had a child
sixteen years ago, and another had a child one year and a-half
350 The British Gyncecological Society
ago ; the rest were all nulliparous women. After removal,
the uterine cavity presented very distinct and uniform
features in a thick, semi-gelatinous, semi-fibrous membrane,
running into folds or polypoid masses affecting the whole
mucous membrane of the uterus and the beginnings of the
Fallopian tubes. Little points of blood appeared here and
there in some of the specimens. I am sorry not to be able
to show a recent specimen, as hardened specimens become
quite different in appearance. I can, however, show slides
which will give some idea of the appearance of recent cases.
I have only recently had Case 4 thoroughly examined
by Dr. F. Griffith, one of the pathological Fellows at the
Thompson Yates Laboratories, Liverpool. He reports the
disease to be an adenoma of the endometrium, and the two
photo-microscopic lantern slides he has prepared for me will
show you at a glance the nature of the change. You will
then see how the glandular tissue has dipped down between
the bundles of muscular fibres of the wall of the uterus, and
it is probably the presence of these downgrowths of adeno-
matous tissue that produces the haemorrhage, and hence the
disease.
Hysterectomy was successful in all these cases, and a
cure resulted in them all. That resource is only to be had
recourse to when all well-known methods have failed, and
when sufficient time has clasped. Eighteen years is, how-
ever, too large a slice out of a human life to let pass before
using curative means.
Dr. F. A. PuRCELL noted that in some of the cases the
ovaries had not been removed with the uterus. It was only
of recent years that due consideration was being given to
a conservation of the ovaries on account of the value of
their internal secretion. He thought that the ovaries, if
apparently normal, should never be removed.
Dr. Macnaughton-Jones said that, on different occa-
sions, he had brought cases precisely similar to those
described by Dr. Alexander, before the Society, in which
the adenomatous changes mentioned by him had been
Microphotographs showing downgrowths of adenoma.
Discussion on Adenoma Hcsmorrhagica 351
present. In the new edition of his book, the macroscopical
and microscopical appearances mentioned by him were
fully illustrated, and at the last meeting he had shown a
uterus in which the cavity was filled with the same gelati-
nous and mucoid substances as that described by Dr.
Alexander. It was due to the breaking down of the
epithelial debris, and the haemorrhage w'as caused by necrosis
of the vessels, brought about by pressure due to the glan-
dular change. The subject was a very important one, as
the recurrence of the haemorrhages brought about a most
serious condition, and at times a profound anaemia.
Curettage was useless as a means of treatment, and the
proper course to pursue in these cases, when the diagnosis
was made, was to remove the uterus. In certain of these
cases the ovaries were also diseased, and if so, they should
be removed with the uterus.
Mr. BOWREMAN Jessett, alluding to the gelatinous
condition of the uterine mucous membrane, said he had
not the slightest doubt that it was a pre-cancerous condition,
and that certainly in the first case referred to, if left alone,
it would have developed into malignant disease of the fundus
of the uterus ; he had seen several cases of the sort, but the
diagnosis of such pre-cancerous condition was still obscure.
It was a question whether in a woman, aged 40, suffering
from persistent uterine hzemorrhage, one would be justified
in removing the uterus, if microscopical examination of the
scrapings by the curette did not show malignancy ? He
thought not in the majority of cases. But he was certain
that he had seen cases pronounced to be non-malignant
after such examination, which afterwards proved to be
malignant. If these pre-cancerous conditions could be
detected earlier, and the uterus removed in time, many a
woman's life would be saved.
Dr. J. A. Mansell Moullin said that though the
curette in these cases was not an efficient cure, it was still
of great value in diagnosis. When it brought away malig-
nant tissue, the removal of the uterus was clearly the right
course to adopt.
352 The British Gynecological Society
Mr. FURNEAUX-JORDAN stated that in the tirst five cases
he had operated upon for this disease he had previously
tried in vain to stop the haemorrhage by the use of the
curette, but in the last three cases he operated on had not
done so, as he had come to the conclusion that it was not
advisable. If profuse haemorrhage, such as occurred in
this disease, was allowed to continue, the patient would
probably die before malignant disease had time to show
itself. The condition was a most serious one, and required
radical treatment.
Dr. ROUTH confessed that in the course of his practice,
rather a long one, he had never had occasion to remove a
non-cancerous uterus. He had not found scraping of the
uterus of much use ; much better result would follow the
intrauterine application of the strongest carbolic acid. In
several cases of persistent bleeding, even with a bad odour,
he had cauterised the uterus with a red-hot iron ; this had
never caused any bad symptom, and the patients had got
perfectly well. There was no justification for removing the
uterus for haemorrhage, unless it was certain that the case
was one of malignant disease.
Dr. Heywood Smith thought that in cases met with
sufficiently early, intrauterine measures should be tried.
Chloride of zinc might destroy the ha^morrhagic condition,
and give the uterus a chance to recover itself, nor did he
see why the actual cautery should not be applied. Such
an application might stop the haemorrhage, but if not he
would then consider the advisability of removing the uterus.
The President, after cordially thanking Dr. Alexander
for his paper, said that the question of glandular inflamma-
tion was certainly one that at present was attracting great
attention from gynaecologists, and the more it was studied
the less possible it seemed to draw a definite line between
that condition and cancer. There was much in what Dr.
Routh had said regarding the treatment of the disease in
its early stages. Mr. Lawson Tait employed the actual
cautery extensively, and with good results, but it was
Discussion on Adenoma Hcsniorrhagica 353
questionable whether the condition of the patient after such
treatment was better than after the removal of the uterus.
He asked Dr. Alexander whether he considered that adenoma
of the endometrium was responsible for all the cases of
persistent metrorrhagia in middle life for which no tangible
cause could be found ? He had himself met with cases in
which microscopical examination disclosed a growth in the
tubes after the removal of the uterus ; in others a fibroid
thickening of the uterus was all that appeared. The
diagnosis was a matter of great difficulty, especially when
one had to rely entirely on the symptoms of the patient
and the haemorrhage ; he had known instances in which
bleeding had been profuse and almost continuous for two
or three years, in spite of repeated curettings, and without
any assignable cause the haemorrhage had diminished, and
normal menstruation had been re-established. Some years
afterwards the patient had continued quite well.
Dr. Alexaxder, in reply, said that he always left the
ovaries behind, as he believed this made the convalescence
more satisfactory. He did not think that the disease was
malignant ; at all events, in his experience it seldom became
malignant. His first patient, after eighteen years, did not
seem to have any more of the growth than she had at the
beginning of that time. In another case the bleeding has
been going on for twenty years ; the patient is still alive,
waiting for the menopause, and probably not any worse
now than she was many years ago. Hysterectomy should
only be performed in these cases when all other means
have been fairly tried and have failed. When this is the
case, the treatment, nowadays, of removing a uterus that
had become useless and only a source of weakness to the
patient, can hardly be called heroic. In these cases the
operation is a very simple and safe operation for a very
grave disease. He always removed the uterus in these cases
per vaginam, and did not think there was any reason why
it should ever be removed through the abdomen. He
thanked the President and Fellows for their very kind
remarks on his paper.
VOL. XX. — NO. 80. 24
354 ^/^^ British GyncEco logical Society
Ectopic Gestation.
Dr. R. T. Smith showed a specimen and read the
following notes : The patient was a Polish Jewess, aged 30,
married two years, with a child one year old, and the facts
elicited were simply that four weeks ago, after two months'
amenorrhcea, she was seized with sudden pain in her left
side, and from that time had had a sanguinueous discharge
with clots. Examination revealed a soft swelling in the left
side of Douglas's pouch, an old retro-uterine haematoma.
At the operation, the tumour forming the adventitious
sac, so well shown in the specimen, was surrounded by a
considerable amount of blood, the escape of which had pro-
bably caused the pain. The anterior wall of the tube was
extremely thin, and evidently on the point of a second
rupture. The patient made an uninterrupted recovery. The
interest of the specimen lay not so much in any special
pathological feature as in its structural completeness ; the
tumour was entirely tubal, the foetus with the head towards
the uterus filling the whole tube, and also in the fact that
the diagnosis depended almost entirely on the physical
examination, the patient knowing so little English as
practically to be unable to give any account of her illness.
Dr. Bedford Fenwick read notes of
An Unusual Case of Degenerating Fibroid,
and showed the specimen.
The patient was 31 years of age, she had been married
thirteen months, and was confined on August 4, 1904, at full
time. The periods began at 14, had always been regular,
lasting six to seven days, always profuse, and with slight
pain. Since the labour, she had had increasing losses, and
for some time past an increasing amount of most offensive
discharge. She has been rapidly losing flesh, colour and
strength, and in fact presented the appearance and ordinary
symptoms of malignant disease of the uterus. The cervix
however, was perfectly healthy, the uterus was enlarged.
specimens and Cases 355
the anterior wall being hard and nodular, and the right
ovary was large and tense. The sound passed easily
3^ inches forwards, and the uterine canal was quite smooth.
Dr. Fenwick therefore diagnosed the case as one of
degenerating fibroid, and performed hysterectomy by
abdominal section in the ordinary manner. The patient
made an uneventful recovery, and rapidly gained flesh and
strength, and her colour became normal.
The specimen shows that the anterior wall of the uterus
contains two fibroids of about equal size, measuring 3^ inches
across, and 2 inches from above downwards. Each fibroid
is enclosed in a separate capsule, the upper one being
uniformly thick all round. At the lower part of the lower
fibroid necrotic degeneration has commenced, and the pus
and debris were escaping from the small cavity through a
narrow opening into the uterine canal, just above the
internal os. The case is interesting not only because the
specimen is so unusual, but because the symptoms so closely
simulated those of malignant disease of the uterine body.
It is also noticeable that the right ovarian artery which is
obstructed by the fibroid outgrowths at the fundus was
greatly thickened, its muscular coat being hypertrophied,
and the right ovary was converted into a large blood cyst,
containing 8 ounces of black blood, the tube also being
swollen and thickened. The left ovarian artery was quite
normal in calibre, and the left ovary and tube were perfectly
healthy, and Dr. Fenwick emphasied the fact that where the
ovarian artery entered the fundus on the left side the area
was free from any fibroid outgrowth.
After some remarks from Dr. Macnaughton-Jones, the
specimen was referred for a pathological report, on the
motion of Dr. Purcell, seconded by Dr. R. T. Smith.
The President said that their Editor had left on the
table a copy of Dr. Macnaughton-Jones' " Diseases of
Women," and particularly wished to draw attention to the
beautiful illustrations of glandular endometritis bearing on
Dr. Alexander's communication.
356 The British GyncBCological Society
BRITISH GYNECOLOGICAL SOCIETY.
Thursday, January 12, 1905.
Professor JOHN W. TAYLOR in the Chair.
Annual General Meeting.
Dr. Macan drew attention to the Ballot List and to the
omission of the office of Assistant-Editor. He had great
pleasure in proposing for that office, Dr. J. Hutchinson
Swanton. This was formally seconded by Mr. Charles
Ryall. Drs. Hodgson and Savage were appointed
Scrutineers.
The election of Officers for the current year resulted as
follows : —
Hon. President.— R. Barnes, M.D., F.R.C.P., F.R.C.S.
President.— W\\\\2im Alexander, M.D., M.Ch., F.R.C.S.
(Liverpool).
Vice-Presidents. — E. Stanmore Bishop, F.R.C.S. (Man-
chester) ; Bedford Fenwick, M.D., ALR.C.P. (London) ;
F. Bowreman Jessett, F.R.C.S. (London) ; R. P. Ranken
Lyle, B.A., M.D., B.Ch. (Newcastle-on-Tyne) ; Sir A. V.
Macan, M.A., M.B., M.Ch., M.A.O., F.R.C.P. (Dublin);
J. J. Macan, M.A., M.D. (London) ; H. Macnaughton-Jones,
M.D., F.R.C.S. I. (London) ; Christopher Martin, M.B.,
CM., F.R.C.S. (Birmingham) ; J. A. Mansell Moullin, M.A.,
M.B., M.R.C.P. (London) ; Professor Thomas Oliver, M.A.,
LL.D., M.D., F.R.C.P. (Newcastle-on-Tyne) ; Heywood
Smith, M.A., M.D., M.R.C.P. (London) ; W. Dunnett
Spanton, F.R.C.S. (Hanley).
Hon. Treasnren--W. H. Slimon, M.D., CM., F.F.P.S.
(London).
Annual Genej'al Meeting 357
Council.— T. Gelston Atkins, B.A., M.D., M.Ch. (Cork) ;
N. T. Brewis, M.B., CM., F.R.C.P., F.R.C.S. (Edinburgh) ;
G. Roe Carter, M.R.C.P.I. (London) ; Sir J. Halliday Croom,
M.D., F.R.S.E. (Edinburgh) ; WilHam Duncan, M.D.,
M.R.C.P., F.R.C.S. (London) ; F. Edge, M.D., M.R.C.P.,
F.R.C.S. (Wolverhampton) ; George Elder, M.D., CM.
(Nottingham); T. J. English, M.D. (London); J. H. Fer-
guson, M.D., F.R.C.P., F.R.C.S. (Edinburgh); Clement
Godson, M.D., M.R.C.P. (London); Arthur Helme, M.D.,
M.R.C.P. (Manchester) ; Professor R. J. Kinkead, A.B.,
M.D. (Galway) ; J. Macpherson Lawrie, M.D. (Weymouth) ;
Samuel Lloyd, M.D. (London) ; John Padman, M.R.C.S.
(London) ; Professor Ernesto Pestalozza, M.D. (Florence) ;
J. J. Redfern, M.A., M.D., M.Ch., M A.O. (Croydon) ;
Charles Ryall, F.R.C.S. (London) ; R. T. Smith, M.D.,
M.R.C.P. (London) ; J. H. Swanton, M.A., M.D., M.Ch.,
M.R.C.P. (London) ; Professor J. W. Taylor, M.Sc, M.D.,
F.R.C.S. (Birmingham) ; W. Travers, M.D., F.R.C.S.
(London) ; H. F. Vaughan-Jackson, M.R.C.S., L.R.C.P.
(Potter's Bar) ; Hugh Woods, B.A., M.D., B.Ch., M.A.O.
(London).
Editor of the Joiimal—]. J. Macan, M.A., M.D.
Assistant Editor. — J. Hutchinson Swanton, M.D.
Hon. Secretaries. — S. Jervois Aarons, M.D., CM.,
M.R.C.P. ; E. Small wood Savage, M.A., M.B., B.Ch.,
F.R.C.S.
Auditors.— C. H. Bennett, M.D. ; F. A. Purcell, M.D.
Trustees of the Property of the Society. — G. Granville Ban-
tock, M.D., F.R.C.S.; R. S. Fancourt Barnes, M.D.,
F.R.S.E. ; Clement Godson, M.D., M.R.C.P.
Treasurer's Report and Balance Sheet.
Dr. Slimon said he had much pleasure in presenting to
the notice of the Fellows the Balance Sheet for the year
ending December 31, 1904. As each Fellow had a copy in
his hand, it was unnecessary to say very much about it.
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Annual General Meeting 359
During the year he had received ^305 los. gd. in annual
subscriptions, and in the same period, ;^io5 5s. in payment
of arrears. He might draw attention to the fact that on the
credit side it had been necessary in some of the accounts to
pay for five quarters, which reduced the balance in his
hands on the year's working. Still, on the whole it was
satisfactory, for there was a balance at the bank of
^45 1 8s. lod. It was also seen that there was certified to
be standing to the credit of the Society in Grand Trunk
Railway 4 per cent. Debenture Stock, ;^"270, and a small
amount in Caledonian Railway Stock. During the year,
they had lost nine F'ellows by death, eighteen by resigna-
tion, whereas twenty new Fellows had been elected. He
moved the adoption of the Report.
Dr. Heywood Smith seconded the motion, which was
carried unanimously.
Dr. Bedford Fenvvick proposed that a cordial vote of
thanks should be accorded to the Treasurer for the extreme
efficiency he had shown in the arduous and, he feared, very
disagreeable task of getting in arrears, and in connection
with his management of the finances of the Society
generally.
Dr. C. H. Bennett said it gave him much pleasure as
one of the Auditors, in seconding the vote of thanks to the
Treasurer, he felt peculiarly qualified to do so, as his own
inspection of the accounts enabled him to judge of the
admirable way in which they had been kept and of the
labour and thought which Dr. Slimon must have devoted to
them.
The adoption of the Report and Balance Sheet and
the vote of thanks to the Treasurer were then carried
unanimously.
A vote of thanks to the Auditors, Dr. C. H. Bennett and
Dr. F. A. Purcell, was then proposed by Dr. Macnaughton-
JONES, seconded by Dr. J. Jardine, carried and acknow-
ledged by Dr. C. H. Bennett, on behalf of himself and
co-auditor.
360 The Bj'itisk Gynaecological Society
Dr. J. J. Macax then submitted the following Report : —
Report of the Editor of the British Gyx.-ecological
Journal for the Year 1904.
The numbers of the British GvN.^icoLOGiCAL Journal
issued during the year 1904 appear, on the average, to be
thinner than formerly, but this is entirely owing to the
change in the paper upon which they are printed. They
contain forty sheets or 640 pages, apart from the List of
Officers and Fellows in the February number. This list
now appears in small pica type, and occupies one-fifth
more space than formerly, but the extra cost in paper is
more than balanced by the saving in that of composition.
The Proceedings of the Society, lists of New Fellows,
and Nursing Examinations, furnish about seven-sixteenths of
the contents of the four numbers, that is to say, 279 pages ;
Original Communications other than those read before the
Society, 76 pages ; Reviews and Publications Received, 53
pages ; and the Summary of Gynaecology and Obstetrics,
extends to 200 pages.
The labour entailed in abstracting the short triplicate
report for the Lancet, The Journal of Obstetrics and Gyna-
cology of the British Empire^ and British Medical Journal, has,
owing to the great length of the shorthand notes, proved very
arduous, and I venture to point out that it would be a great
help and would also save unnecessary expense, if exhibitors
would not only prepare written descriptions of their speci-
mens, as they generally do, but, in reading their notes, would
indicate to the reporter when their extempore supplementary
remarks are to be taken down. I have several times been
handed careful, concise descriptions of specimens, fit for the
press, and afterwards found the shorthand reporter's notes
encumbered with prolix paraphrases of the same, full of
repetitions, and even inaccurate as regards details.
To remove misapprehension from the minds of any
Fellows who may not appreciate the difficulty of reducing
Annual General Meeting 361
to the limited amount likely to be inserted in the journals
referred to, the written communications, including very often
an important paper, and the shorthand reporter's notes,
which in themselves have extended on several occasions in
the past year to and over fifty foolscap typewritten folios, I
may explain that the amount asked for was "not to exceed
500 words," and that I cannot remember that the space
granted by the Lancet, which has been more liberal than the
British Medical Journal, has ever exceeded a column. At
our meetings there are often a score of speakers, indepen-
dent of the author of the paper of the evening, and it has
been intimated to me that mention of the names without the
gist of the remarks of those taking part in a discussion, is
useless, and that no specimen will be reported without details
of special interest. Reports exceeding the assigned limit,
entail trouble on the Sub-Editors of the Journals, and are
cut down or omitted altogether. As a rule, indeed with
only one exception in the past year, receiving the shorthand
report on Saturday morning, I have been able to deliver
my reports at the offices of the papers on the following
Monday morning, but this has only been by studying the
MSS. already in my hands on the Friday, and by working
the greater part, or the whole, of Saturday and Sunday. In
addition to these short reports, there is the more complete
account to be posted to the Medical Press and Circular on or
before Tuesday, and finally the preparation of our Pro-
ceedings for our own Journal, the comparison of the
speakers' returned slips with the first proof, the correction of
that proof and the revise, and the preparation of the con-
tents of the Proceedings. This work, formerly undertaken
by an Assistant Editor, for the last three years has been
done by me, but I am relieved to find that the Council
of the Society have, in accordance with the suggestion in
my last report, decided on recommending the re-appoint-
ment of an assistant editor, for which there are weightier
reasons, in the interest of the Society, than the mere amount
of the work to be done. At present, in the event of my being
562 The British Gynceco logical Society
unable from illness, or otherwise, to bring out the Journal,
its publication would probably have to be interrupted for
a time.
I shall the more heartily welcome the co-operation of
Dr. j. Hutchinson Swanton as he has not consented to
undertake the work without investigating its difficulties and
amount. The efficiency with which he has discharged the
duties of Secretary, his experience in that office, his intimate
acquaintance with, and keen interest in, the affairs of the
Society, assure me that his help in the conduct of the
Journal will be most valuable, and personally there is no
one I should prefer as a colleague.
Apart from the many valuable papers read before the
Society and published in the Proceedings, among which 1
may perhaps mention our President's Address " On the
Diminishing Birth-rate," Dr. Macnaughton-Jones " On
Pessaries and their Dangers," Mr. Stanmore Bishop " On
Ventral Hernia," Mr. Christopher Martin "On Intractable
Prolapse," and Dr. Dudley Buxton " On the Vernon-
Harcourt Chloroform Inhaler," the Original Communica-
tions occupy 76 pages, and include a remarkable case of
hermaphrodism, by Sir Hector Clare Cameron, a very
practical paper by Dr. Ludwig Pincus, of Danzig, " On
the Treatment of Pelvic Affections by Compression and
Position on an Inclined Plane," and other papers of interest.
Reviews of about thirty books by British, American,
French, German, Russian and Spanish authors occupy more
than 50 pages. I am deeply indebted to those Fellows of
the Society who have helped me in this department of the
Journal, and note with satisfaction that the more important
works published on gynaecology and obstetrics continue to
be sent to our Journal for review.
Owing to the variations in the length of the Proceedings
in the different numbers of the Journal the Summary of
Gynaecology and Obstetrics has necessarily been unevenly
distributed, but its total length is the same as in 1903. It
covers a very wide field, and I venture to hope draws
Annual General Meeting 363
attention to almost every current topic of interest to
gynaecologists. I gladly take the opportunity of acknowledg-
ing the valuable assistance I have had in this part of the
Journal, especially from my collaborators, Dr. Frederick
Edge, Dr. P. Z. Hebert and Mr. Furneaux Jordan, to
whom I desire to express my cordial thanks. I shall be
glad to receive, and if possible make use of any condensed
abstracts that other Fellows may be kind enough to send
me, but, except in connection with more recent observa-
tions, such work should not have been more than six
months before the profession.
It is gratifying to see that the Summary is being widely
studied, quoted, and otherwise utilised both at home and
abroad. Seven out of the eight abstracts of gynaecological
work contained in the November number of a North British
Journal had been noticed in the Summary in our August
number ; a remarkable coincidence if merely accidental. 1
not only meet with many quotations from our Journal in
American and continental exchanges, but have received
several appreciative letters, one referring especially to the
notices of American work w^hich generally are from the
pen of Mr. Furneaux Jordan.
It has been proposed that the functions of the Finance
Committee and those of the Journal Committee of the
Council should be entrusted to one body to be called
the Journal and Finance Committee. I believe that this
course will facilitate the business of the Society, and trust
that a closer association with our experienced and esteemed
Treasurer will aid me in conducting the Journal with
suitable economy.
J. J. Macax.
In moving the adoption of this Report, Dr. Macax
incidentally added that the reports of the Society's meetings
had been regularly inserted in the Lancet and the Journal of
the British Empire, and latterly, also in the British Medical
Journal.
364 The British Gyncecological Society
Dr. Heywood Smith having seconded the motion, the
Report was adopted.
Thanks to the Editor.
Dr. Bedford Fenwick said he had been entrusted with
the responsible, and yet most easy task, of proposing a
cordial vote of thanks to the Editor for his Report and for
his work for the Society during the past year. It was very
responsible, because the Journal presented the Society's
proceedings to the world at large. And yet it was an easy
task, because the manner in which it did so merited the
cordial appreciation of every Fellow of the Society. All
felt grateful to Dr. Macan for his exertions, and as a former
Editor of the Journal he (Dr. Fenwick) knew how difficult
the work was, and was aware how much time, trouble and
labour it must have cost the Editor to produce the Journal
in the excellent way in which it came before them each
quarter. He had a further criterion of its value because he
was in touch with journals published in many parts of the
world, and was frequently struck with the number of
extracts from the British Gynecological Journal in
their pages, showing that the matter so quoted was up-
to-date, and so thought worthy of quotation. He might
allude to a point to which Dr. Macan had himself made
only slight reference, namely, the work of making the
abstracts for the Summary outside the Society's proceedings,
fell almost entirely upon Dr. Macan.
Mr. Ryall said it gave him much pleasure to second the
vote of thanks to Dr. Macan, their esteemed Editor. He
could not add much to what had been so well expressed by
Dr. Bedford Fenwick, but he cordially endorsed what he
had said.
The motion was carried and briefly acknowledged by
Dr. Macan.
Specimens.
In the unavoidable absence of the exhibitor. Dr. George
Elder, the notes on his specimen were read by the Secretary,
Dr. Aarons.
specimens and Cases 365
Ruptured Ovarian Cyst.
Mrs. B., aged 50, was seen in consultation on Thursday,
November 3, 1904. Patient had a well-marked ovarian
cystoma of the right side, reaching up to the umbilicus, and
was advised to have an early operation performed. On the
following Monday (November 7), she came by train some
twenty miles to a nursing home, where, in the evening, I
saw, but did not examine her, as from her general appear-
ance and absence of complaint, there was no reason to
believe that the conditions had changed. Temperature
same evening, 97*8°, and pulse 88.
Next morning, on being placed on the operating table,
the prominence of the tumour was found to be replaced by
a general flattening of the abdomen, and the fluid was
diffused. On section, typically viscid, straw-coloured
ovarian fluid poured out of the abdominal cavity, and on
this being mopped out, the flaccid cyst was felt resting on
the right posterior wall, and was removed. As will be seen
in the specimen, there were two small ruptures, and in other
places the wall has been much thinner.
Subsequently, on questioning patient, she stated that on
the Saturday evening she had some severe abdominal pain
and sickness, which kept her in bed all Sunday, but did not
seriously upset her general condition nor prevent her taking
the railway journey on the Monday. The smallness of the
openings would account for the fact that the rupture was
not followed by shock and the slight disturbance to her
health was due to the benign character of the fluid. Some
sudden distension of the cyst on Saturday evening, due
probably to a slight twisting of the pedicle, may have caused
the rupture.
My reason for bringing this specimen before the Society
is that it not only illustrated one of the rarest and gravest
accidents to which ovarian cystomata are liable, but also
emphasised the principle so often insisted upon before the
Society, that is, the importance of counselling immediate
operation whenever a tumour of this nature is diagnosed.
366 The British Gyncecological Society
As Dr. Elder was not present, the case was not dis-
cussed.
Dr. J. IXGLis Parsons showed a specimen of —
Double Pyosalpinx.
Mrs. B., aged 35, a patient of Dr. Frye, was admitted on
November 18, 1904, complaining of severe pain in the
abdomen, which had confined her to bed for six weeks.
She had been married twelve years, but had had no children
or miscarriages. Her menstruation had been regular, but
profuse, and accompanied by severe pain for a few days
preceding the flow.
Six years ago she had a severe attack of pelvic inflamma-
tion with much pain. On examination, a hard, irregular
tumour was found on both sides of the uterus. Temperature
normal.
November 22. — On opening the abdomen the intestines
were found adherent to, and almost covered by, two masses,
one on each side of the uterus. After separating the intes-
tines further inspection revealed enlarged tubes bound down
by extensive adhesions matted to the uterus. These were
removed with some difficulty, but without rupture.
The patient made an uninterrupted recovery and left
hospital three weeks after operation.
He added that the points of interest were the symme-
trical enlargement on each side, and the fact that the tubes
had been got away without opening them. Those who had
operated in such cases would know how difficult it some-
times was to do this when the intestines had been forming
a sort of roof to the uterus and tubes, and one had to deal
with dense adhesions. He began by separating the adhe-
sions from underneath the back of the uterus, and in
time both tubes came up successively, and could then be
removed.
Dr. jERVOis Aarons asked whether a diagnosis of double
pyosalpinx had been made before operating on the case, or
Discussion on Specimens 367
the blood examined for leucocytosis in view of the possi-
bility of pus being present in the pelvic cavity.
Dr. Robert Bell said he had come across many
cases of pyosalpinx, and all were bilateral and very easily
removed. The specimens of one case he showed to the
late Professor Joseph Coats, who placed them in the Patho-
logical Museum in the Western Infirmary, Glasgow. He
had seldom met with adhesions in connection with pyosal-
pinx, and found little difficulty in their removal.
Dr. Macxaughtox-Jones said that his experience did
not correspond with that of Dr. Bell. He had, again and
again, found pyosalpinx with extensive adhesions, nor was
their removal always easy. Indeed, some of the most
difficult cases in gynaecology were those of pyosalpinx, in
which the tube was absolutely embedded in adhesions, with
a plastic wall completely surrounding it. It was only when
one broke through this wall that the pus in the tube was
reached. Neither was pyosalpinx necessarily bilateral.
Tuberculous pyosalpinx, for instance, frequently affected
the tube on one side only. He had exhibited two such
specimens before the Society ; one was a large pus sac, and
the patient from whom he removed it had since borne three
children.
Dr. HODGSOX asked if Dr. Parsons had noticed whether
the adhesions in pyosalpinx were much more extensive than
in hydrosalpinx.
Dr. Parsoxs, in reply, said the temperature in this case
was normal while the patient was in hospital, and that was
frequently the case. It was a very old case, and he believed
the absence of fever was due to the fact that the system had
become accustomed to the presence of the toxin. Probably
the condition had existed before marriage, and was the cause
why the patient had remained sterile for twelve years. He
was willing to admit that he did not diagnose pyosalpinx
before operation, as it was impossible to form an accurate
opinion owing to tenderness on examination. He could not
agree with his friend, Dr. Bell, about the absence of
368 The British Gyncecological Society
adhesions in pyosalpinx, but must concur with Dr. Mac-
naughton-Jones that such cases were sometimes the worst
which gynajcologists had to deal with. He would rather
do a hysterectomy than operate upon some cases of pyo-
salpinx. The worst case of the kind he had seen was one
in which he assisted one of his juniors at the operation.
Both his colleagues were present, and they advised him not
to proceed, but sew up the abdomen, which was accordingly
done. In another case, a very bad one indeed, it was impos-
sible to remove the sacs without leaving a large raw surface,
and the patient died of intestinal obstruction some fourteen
days after the operation. His experience was that one met
with much worse adhesions in pyosalpinx than in hydro-
salpinx ; and it was sometimes most difficult to separate the
bowel without tearing it, particularly if the case was recent.
The President then delivered his
Valedictory Address.
Each Annual Meeting of the Society reminds us that
we have reached another stage in its progress, another land-
mark on the journey of life, the summit of another hill from
which, as our bent inclines us, we can look backwards or
forwards. It is a camping ground or resting-place, where,
as previously arranged, one section of the journey done, the
titular head of the Company falls back into the ranks, and
another takes his place to lead his fellows on the journey
of the morrow. But before the change is made, it is only
fitting that we should glance for a few moments at all that
has taken place since last we gathered at our Annual Meet-
ing. We have to regret the loss of nine Fellows of the
Society by death, and among them two of the most distin-
guished. Dr. Engelmann, of Boston, who died at the close
of 1903, and Dr. Milne Murray, of Edinburgh, in February
last. The profession generally, and gynaecology in particu-
lar, has also suffered severely by the death of Mr. Knowsley
Valedictory Address 369
Thornton, of the Samaritan Free Hospital, and that of
Dr. Wiham R. Pryor, of New York, and we cannot but feel
distinctly the poorer and weaker for their absence. " They
rest from their labours," and it is for us, and especially for
the rising generation among us, to enter into those labours.
Passing on to a brief consideration of the year's work,
we may well enquire what lessons are to be learned from
the treasures, new and old, of which we have become the
depositories. The year through which we have just passed,
though in some respects quiet and uneventful, has been one
with which we have very good reason to be satisfied, for the
work which has been done has been perhaps as good, and
quite as productive, as that of any preceding year. Several
of the Papers read before the Society have not only been of
high value in themselves, but have opened up more or less
fresh ground for future work. For example, the communi-
cations of our President-elect, Dr. Alexander, and of Dr.
Macnaughton-Jones, on the severer forms of haemorrhagic
endometritis, dealt with a subject still imperfectly under-
stood, and one upon which the clinician, the pathologist
and the surgeon may all still work with advantage. And
after listening to the valuable paper of Mr. Christopher
Martin on the extirpation of the vagina and uterus for
incurable prolapse, and to the discussion arising from it,
who can doubt that the definite recognition and isolation
of the pelvic fascia involved in the course of this operation
will not encourage many other workers to better knowledge
and better workmanship in the repair of hernial protrusions
from the vagina ?
New ground, too, was broken, if in a different way, by
the joint communication of Dr. Dudley Buxton and Mr.
Vernon Harcourt on Chloroform Inhalation, and something
of the same tendency may be noticed in many of the shorter
papers and reports of cases ; in Dr. Spanton's paper on
Bladder Irritation, Dr. Helme's on Spinal Puncture for
Eclampsia, Mr. Jessett's case of Gangrene following Hyste-
rectomy, Dr. Fenwick's cases of Myomata, Dr. Edge's
VOL. XX. — NO. 80. 25
370 The British Gyncecological Society
Splenectomy, Mr. Jordan's Vaginal Ovariotomy, Dr. Tred-
gold's case of Violent Menorrhagia treated by adrenalin,
and others. I should like to say more on this subject, if I
had time, for we cannot too warmly welcome, or too highly
appreciate, any communication which brings individual
thought and experience to bear on the greater problems of
gynaecology, and which shows a wise originality, either in
conception or in practice. And such communications are
not only ever welcome at the meetings of the Society, but
find a permanent and honourable setting in its archives, in
the Journal of the Society, where through the laborious
researches of the Editor and his collaborators this material
is being continually supplemented by records of all that is
best in Continental and American thought and practice.
Another duty, and a more personal one, demands my
next consideration. Every provincial President, as you are
doubtless aware, has to lean very much on the kindness and
consideration of those who are more permanently engaged
in ministering to the success of the Society. Apart, then,
from, or in addition to, the Votes of Thanks which have
already been given by the Fellows to our chief Office-bearers,
I desire to tender my most hearty personal thanks to my
colleagues on the Council who have so generously over-
looked my shortcomings and so often supplied my place,
and especially to our Secretaries, Dr. Swanton and Dr.
Aarons, for numberless acts of kindness, to our esteemed
Editor for his uniform readiness to help, and his patience
over my illegible hand-writing, and, finally, to my indefatig-
able representative at the Council Meetings, Dr. Mac-
naughton-Jones. This done, however, I am free to say
something about the work we have undertaken, and which
binds us together. Looking back on the journey over
which we, as a Society, have travelled, 1 find the history
of this Fellowship somewhat strangely coterminous with
the history of my own chief life-work.
Twenty years ago I joined you as a Foundation Fellow,
and for twenty years I have been engaged in the practice of
Valedictory Address 371
operative gynaecology. The accompanying table gives a
yearly record of all the abdominal sections I have per-
formed on women during this period. The cases are
strictly consecutive, and the total number of sections is
1,291. The total mortality is 85, or 6'5 per cent.
On examining this mortality more closely, I notice that
a large proportion of the deaths were unavoidable, or were
only indirectly due to the operation. One patient was
attacked by apoplexy during anaesthesia, and eventually died
from this, the operation (a resection of bowel) being per-
fectly satisfactory, as proved by post-moHem examination.
Five of the patients suffering from acute perforative peri-
tonitis, and four with intestinal obstruction, were almost
moribund at the time of operation, and many others (no
less than twenty-two) suffering from malignant disease, died
rather from the original affection than from the operation,
exploratory or otherwise, which was undertaken for their
possible relief.
There are, however, certain other cases of failure which
are and must remain a trouble to me. Specially some early
cases of sepsis after operation, one case of secondary
hemorrhage, and finally, some cases of difficult myoma
operated upon during a time of transition, when the old
operation of the clamp (perfected so far as it could be, I
think, by a method of my own), was slowly giving way to
the more modern and better methods of supra-vaginal
amputation and pan-hysterectomy.
I did the (then) more difficult operation under very bad
conditions, and my work suffered accordingly. If I and
some of my patients had been able to wait for riper expe-
rience, I think the result in all of these cases might have
been different. In one instance of a neglected myoma, I
met with a greater amount of peritoneal displacement than
1 have ever seen or read of elsewhere, and it may perhaps
be of service to record it here. The descending and trans-
verse colon had been raised by the growth of an enormous
tumour of the left side so that the transverse colon passed
372 The British Gyncecologi
'cal Society
Year.
1883
1884
1885
1886
1887
1888
4
3
2
3
I
I
I
I
3
I
I
1889
6
7
2
5
7
I
2
I
I
I
1890
4
12
3
3
7
I
3
I
2
I
2
2
1891
3
15
3
9
7
3
I
2
I
4
I
I
I
Exploration
Ovariotomy
Double Ovariotomy
Abdominal Hysterectomy
Myomectomy
Conservative Operations —
Hysteropexy, Salpingostomy,
Igni-punciure of Ovaries, &c.
Removal of one or both Append-
ages for —
Tubal Disease
Myoma ...
Acute Septic Ovaritis
Chronic Ovaritis
Infantile Uterus
Bleeding
Peripheral Neuritis and Mental
Weakness
Varix of Broad Ligament
Abdominal Enucleation of Cysts
of Broad Ligament ...
Ectopic Gestation, Removal of
Csesarean Section...
Hysterotomy for Inversion of
Uterus
Incision and Drainage for —
Peritonitis (Septic, Tubercular)
Ascites
Papilloma
Cancer
Abscess ...
Radical Cure of Hernia
Operation for Intestinal Obstruc-
tion ...
Colotomy ..
Gastrotomy, Pyloroplasty, &c. ...
Gastro-enterostomy
Excision of Intestine
Removal of Appendix
Removal of Mesenteric Tumours
Cholecystotomy and ChoIedo-|
chotomy
Excision of Gall Bladder ...
Excision of Hydatids
Nephrectomy
Vaginal Conservative Operations.
Vaginal Coeliotomy with Ab-
scess-drainage, Igni-puncture,
Vaginal Fixation, &c.
Vaginal Hysterectomy
Vaginal Ovariotomy
Vaginal Enucleation of Broad
Ligament Cyst
I
I
I
2
I
I
I
I
3
2
I
I
I
I
3
7
3
I
I
4
2
I
Totals
Mortality
I
2
5
10
22
5
21
2
33
2
41
5
51
0
Valedictory Address
373
1892
1893
1894
1895
1896
1897
1898
1899
1900
1901
1902
1903
1904
Totals.
Mor-
tality
2
3
2
0
I
I
3
4
I
2
I
I
2
43
8
12
16
10
II
13
15
17
15
12
14
8
9
8
207
II
4
2
5
7
3
I
7
3
4
2
4
50
4
4
3
2
4
7
I
6
4
2
I
4
4
I
7
9
I
14
6
2
72
10
'5
2
7
13
4
I
3
->
3
4
7
5
8
60
I
9
20
'7
II
12
8
5
3
3
3
7
4
7
•35
5
i6
I
19
'4
II
6
2
I
10
14
2
6
8
2
4
I
4
I
4
I
4
I
I
I
148
3
16
2
I
I
4
7
2
4
2
I
3
I
2
I
I
2
I
23
I
5
4
5
7
6
3
5
6
I
4
I
I
4
I
I
3
I
57
5
I
2
I
3
2
8
3
I
5
4
4
3
4
2
6
2
I
54
4
3
5
2
2
5
2
2
3
I
I
20
2
7
5
I
I
3
I
6
I
I
I
I
36
4
2
I
7
I
6
I
I
4
I
10
5
I
3
I
4
4
8
55
5
2
4
2
2
I
I
2
3
1
I
4
I
19
3
2
I
I
I
I
4
2
I
I
3
2
2
4
2
3
5
7
4
34
I
I
I
I
3
—
1
5
2
1
3
4
I
6
2
I
4
...
4
38
2
2
2
2
I
4
I
I
2
14
—
12
12
3
3
8
9
13
5
4
7
76
2
2
4
10
10
II
8
6
4
5
3
8
72
2
I
I
I
I
2
2
I
I
9
I
71
90
102
96
95
66
98
89
78
77
77
76
90
1,291
—
I
6
7
8
9
10
7
6
3
6
2
5
I
85
374 The British Gyncscological Society
from right to left across the middle of the back of the
tumour, and the omentum formed a cap covering the
summit of the growth and falling to some extent over its
anterior surface. The almost irresistible inference at first
was that the transverse colon was adherent to the back of
the tumour. It was indeed closely attached everywhere to
the tumour, but by peritoneal displacement, and not by
adhesion.
In concluding here my references to the record of
deaths, I think I am justified in noting that I have, I hope,
learnt something from my failures, and that in spite of, or
rather perhaps, by virtue of, advancing years, and by virtue
of some teachableness, my last five or six years of work have
been my best years, and the last year is, on the whole, the
best of all, giving, with a fair proportion of grave and
important work, a death-rate of only about i per cent.
This, I think, may deservedly give more weight to the
remarks I wish to make on the progress of my practice. I
have lived in frankly septic days, when from ignorance, little
or nothing was left undone that could encourage sepsis ;
in days of more or less empirical asepsis, when men were
stumbling, as if blindfold, towards a path of safety ; and in
later years, when the darkness had lifted and one could see
the plain outlines of the road which led towards the goal.
All this time, during which I have myself been working, has
been a time of searching for better methods of asepsis, and
a time of experiment in this direction.
The first dawning for me (I speak for myself) came with
the definite recognition of the mathematical value of heat
in sterilisation. The full grasp of this all-illuminating fact
made the continued use of the old sponge impossible, and
this was cast aside for the artificial sponge of gauze, which,
like the instruments, the towels and the dressing, could be
subjected to a really sterilising bath or atmosphere.
Next to this, there is nothing which has given me so
much satisfaction and confidence in all my later work as
Valedictory Address 375
the adoption of the permanganate of potash and oxalic acid
method of Kelly, for the sterilisation of the hands of myself,
assistant, and chief nurse or nurses. This method, first
introduced at Sparkhill by my colleague, Mr. Martin, and
supplemented in my own practice by the additional use both
of methylated spirit and solution of the red iodide of mer-
cury— a method employed, not only at the time of operating,
but immediately after touching any case or dressing that
may leave serious contagion behind it — has proved much
more reliable than anything I had previously tried. It is
not difficult to obtain, the drugs are common and inex-
pensive ; it requires no measurement, the solutions are
saturated ; it is not hurtful to the hands, as are all the
carbolic acid compounds and derivatives, and I do not
think that since I have regularly employed it I have had
any case of sepsis that can be reasonably referred to hand
infection. 1 believe if this method were generally used by
practitioners and nurses, not only before the operative work
of a confinement, but immediately after any dangerous con-
tact in ordinary practice, it would be possible to eliminate
the danger that undoubtedly still remains in private mid-
wifery practice.
Perhaps you will pardon a palpable digression if I briefly
relate an instance which seems to throw some side-light on
the value of the method.
The children of a practitioner who was well known to
me, had suffered for several years from tinea tonsurans.
They had received the best dermatological advice and treat-
ment, but the disease persisted, and threatened to injure or
stop their education. The skin was unbroken, and I sug-
gested that the method I used for my hands should be
applied to the children's heads. This was done thoroughly,
and within a few months no trace could be found of the
complaint.
This is, of course, only a single instance, but others, who
have more opportunity than I have of testing its value, may
be inclined to employ it further.
37^ The British Gynceco logical Society
Next to the use of prolonged boiling and steaming for
the sterilisation of everything necessary to the operation
that can be so treated, and to the employment of the
fortified Kelly's method for the hands, I know of no change
which has been of greater service in my work than the dis-
carding of the comprehensive single stout ligature — like the
Staffordshire knot — for the control of the pedicle or broad
ligament, and the use, instead of this, of a series of finer
interlocking chain-ligatures.
These, if of silk, can be readily made aseptic by boiling in
biniodide of mercury solution (one per mille), so that every
vessel can be controlled by its own sterilised ligature with
but little or no tissue intervening, and this without causing
any tension or dragging. In this way I am convinced the
operator can best ensure himself against any danger of
subsequent haemorrhage.
1 generally use a sharp, widely-curved needle of sufficient
size to carry the No. 3 or No. 4 ligature silk easily. I
thread it with a long length of silk and pass the needle
through the broad ligament close to the ovarian vessels.
One strand of the double silk is then cut, forming the
ovarian ligature. The remaining strand is pulled further
through the eye of the needle, and the needle passed back
through the broad ligament near to, but not including, the
uterine vessels. The needle is cut off, leaving two further
ligature loops, one for the uterine vessels, and one for the
middle of the broad ligament. The ligatures are inter-
locked, and the pedicle tied in a chain of three ligatures.
More may of course be used if this is considered advisable.
Closely connected with the use of this method of ligature
is the employment of finer silk. Obviously, if but little
beyond the vessel is enclosed in the ligature, finer silk may
be used with perfect safety, and 1 employ this extensively
both for the ligation of vessels and for the suture of peri-
toneum and fascia in the closure of the abdominal wound.
In fact, for many years now, I use nothing but silk and
silkworm gut, finding that the finer sizes of the silk can be
Valedictory Address 377
adequately sterilised by half an hour's boiling in biniodide
solution, and that in time they are as perfectly absorbed as
catgut.
Bearing, I believe, on the same point of aseptic ligatures,
is the interesting question of what has become of the lost
disease, " pelvic haematocele," or, as some prefer to call it,
" broad ligament h^ematoma," Years ago it was one of
the commonest complications of the convalescence after
operation. In our own hospital I remember the time when
four or five patients were lying side by side, and all suffering
from this same affection. Now it has so universally dis-
appeared that I can easily imagine a student and observer
of the present day hesitating to accept the experience of
the older ovariotomists on this subject. What is the cause
of its disappearance ? Many appear to have thought that
the haematocele was secondary to some puncture of a vessel
in the broad ligament, due to the use of a sharp-pointed
needle (though the favourite time of its onset was not until
nine or ten days after operation), and that the accident was
to be prevented by using a blunt pedicle needle. In the
practice of several, the change in the use of the needle has
been coincident with the disappearance of the tumour, but
I believe it has been simply a coincidence.
As I have already said, I have largely gone back to the
use of a sharp-pointed needle, but without finding any
recurrence of the haematocele. In the older days I think
the silk used for tying the pedicle was often septic, and a
slow process of ulceration occurred, opening the vessels
about a week or so after the date of operation.
In turning now to the consideration of special opera-
tions, I notice first, that the removal of the uterine appen-
dages for myoma has slowly given way in my practice to
the operation of hysterectomy, both abdominal and vaginal,
but I have not entirely given up the older operation. As 1
have, however, quite recently published my opinions on
^jS The British Gyncecological Society
the choice of operation in myoma,^ there is no necessity for
me to refer to it again, and I pass on to notice the marked
change which has taken place in my practice regarding the
removal of the appendages for tubal disease, and especially
for disease due to gonorrhoeal salpingitis.
The cases of this, numbering 20 in 1893, and 17 in 1894,
have come down to an average of 4 or 5 in the last five
years, and that this is not due simply to the adoption of
vaginal rather than abdominal methods of operating is seen
at once on looking at the statistics of both operations. The
change is, of course, due to the systematic carrying out of
the mercury and iodine treatment in all cases of gonor-
rhoeal salpingitis, as advised by myself in the paper 1 read
before the Society in 1899.
Not only is the operation of removal needed much less
often than formerly, if this be done, but when acute pyo-
salpinx makes an immediate operation imperative, a vaginal
coeliotomy with thorough emptying of pus sacs and drain-
age, followed up afterwards by treatment with the biniodide
of mercury is, in many cases, a better method of treatment
than that formerly adopted. I shall, however, have to refer
to this again later. The after history of these cases, so far
as I have been able to follow it, compares very favourably
with that of the older cases of extirpation.
It may be well to note here that the gist and point of my
previous communication on this subject has been very
insufficiently grasped by many who have spoken and
written regarding it.
The value of the treatment has nothing whatever to do
with syphilis or its possible complications. Experience
appears to show that the biniodide of mercury has a direct
curative power in gonorrhoea, being probably slowly de-
structive to the gonococcus in the tissues.
Perhaps another digression may tend to enforce this.
A gentleman contracted a gonorrhoea after an impure
^Journal of Obstetrics and Gyficecology, August, 1904.
Valedictory Address 379
connection, and thereafter was troubled with a slight gleet
which he could not cure. He became engaged to be
married, and for eighteen months resided abroad, where he
somewhat naturally either forgot his slight ailment, or at all
events, let it alone. He came back to England three or
four months before his proposed marriage, and sought the
very best advice for the cure of his gleet. Instruments were
passed, he was assured that he might marry with safety, but
the discharge was slightly increased rather than diminished
by treatment. He married, and within six weeks his young
wife was suffering from double pyosalpinx with dangerous
symptoms of peritonitis and high pyrexia. Pus had already
formed, and the disease was much too acute for medicinal
treatment alone to stay its progress.
I opened the pouch of Douglas, separated the adhesions,
evacuated pus on both sides of the uterus and carried out
prolonged pelvic drainage with iodoform gauze, keeping the
patient all the time under treatment. She made a slow but
very perfect recovery, and during this time I saw a good
deal of her husband. He was still suffering — almost imper-
ceptibly— but still suffering slightly from his chronic gleet,
and I thought I had sufficient grounds for suggesting that
he might very reasonably adopt the same medical treatment
as that given to his wife. Both patients recovered com-
pletely. This is nearly five years ago. Shortly after his
wife's recovery they went abroad to live, and have, I under-
stand, enjoyed the best of health ever since. Only a few
weeks ago, a doctor who was associated with me in the
treatment of the case, stopped me very kindly to tell me of
the very good health that both had enjoyed since they w^ere
under our care.
Turning now to the question of inguinal colotomy, there
is a small detail in its performance which has proved of
very great comfort to myself, and as I have never seen it
mentioned by others, I think it may be of service to
describe it. I generally use the method introduced, I
380 The British Gynceco logical Society
believe, by the French surgeon, Reclus, in which a spigot of
glass is passed tlnough the mesentery under the bowel, and
the loop of colon rides over this protruding from the in-
cision. I guard against any danger of further protrusion of
bowel by sewing the peritoneum to the loop of bowel all
the way round by a continuous suture of fine silk. This,
however, is not the innovation to which I want to draw
your attention.
The bowel, as I daresay you know, is usually divided by
the cautery straight down to the spigot on the third or
fourth morning. Now this, though practically painless, I
found out to be a very awkward proceeding on account of
haemorrhage. As many as five or six large arterial vessels
spouted at the deepest part of the division. The loss of
blood was considerable. The clumsiness of the proceeding
was manifest to the patient, who was quite conscious, and
there was decided pain and discomfort in seizing the bleed-
ing points and applying ligatures. This may be entirely
avoided, I find, by passing a ligature on each side of the
spigot at the original operation and tying off a small amount
of mesentery. The tying of the mesentery cuts off the full
blood supply from the line of opening, and makes the sub-
sequent division of the bowel right down to the spigot,
practically bloodless.
Speaking generally and ver)^ broadly, conservative opera-
tions on the uterine appendages by abdominal section have
rather disappointed me, the benefit derived being rarely
worth the mark of the abdominal incision. In order to
understand me rightly, however, it may be necessary to
define more exactly what I mean by conservative operations
on the appendages. I include in this the undoing of adhe-
sions involving the appendages, but not those specially
involving intestine. Some of the most perfect successes I
have had after operation have been due to the undoing of
intestinal adhesions, which caused incomplete obstruction,
and were a daily source of pain and misery, but were
Valedictory Address 381
accompanied by no tangible lesion on examination. These
obviously are essentially intestinal operations, whatever may
have been the cause of the original inflammation.
Again, though a few cases of hvsteropexy and ventro-
suspension have been included for the sake of convenience
in my tabular statement (and rightly included) as "con-
servative operations," they are not really conservative opera-
tions on the uterine appendages.
By this term I chiefly mean salpingostomies, partial
excision of the ovaries, ignipuncture of the ovaries, and
shortening of the ovarian ligaments, with or without
separation of adhesions from above ; and it is these
operations which appear to me to have been rather dis-
appointing.
Some patients have been relieved, but few or none have
reported themselves as quite well afterwards. In some
cases the operation has appeared to do harm, and I have
had to remove the appendages afterwards. In one case
(and one only) has the operation been followed by a preg-
nancy. None of these operations have been undertaken
rashly. On the contrary, I do not know any class of case
in which I have expended more thought, caution and
ingenuity — if I may term it so — in treatment.
In some of these cases — and this is a point which needs
consideration before operation is proposed — I think there
has been throughout some fatal want of correspondence
between the sexual organs or functions of husband and wife
which vitiated every attempt to give the patient perfect
comfort. The utero-vaginal prolapse, painful retroflexion
and prolapse of ovaries, met with in some of these cases
seem to be due directly to this, and to be consequently
almost incurable.
It may be a hard thing to acknowledge and accept, but
some women are undoubtedly unfit for the married life
which has fallen to their lot, and no mere operative change
can make them otherwise. For simple prolapse of ovaries
due to backward displacement, the operation which has
382 The British Gyncecolo^ical Society
given me the best final results is that of simple shortening
of the round ligaments without needless opening of the
peritoneum.
My vaginal operations call for some passing com-
mentary. I was considerably attracted at first by anterior
vaginal coeliotomy, but have now practically abandoned it,
as I dislike all methods of uterine fixation. But posterior
vaginal coeliotomy has, in many ways, become more and
more attractive to me, 1 recognise that it has a very special
field of its own, and this field of usefulness needs a better
recognition by the general, as well as by the gynaecological
surgeon. There are, for example, certain conditions requir-
ing operative treatment in which the vagina is so infinitely
better as a route for approach and treatment that I have no
hesitation in saying the neglect of this and the use of the
abdominal route instead may amount to bad practice.
Acute pelvic peritonitis due to gonorrhoea, when the
mischief is mainly behind the uterus, and abdominal dis-
tension, peritonitic vomiting and sleeplessness from pain
form a triad demanding immediate interference, is, as I
have already said, pre-eminently such a case — a case for
vaginal, rather than abdominal, operation.
Again, in some cases of abscess due to appendicitis, the
pus tends to collect in the pouch of Douglas, while
adhesions roof in the abscess from above. In such cases
the proper method of exploration is by the pouch of
Douglas, and a life may easily be unnecessarily sacrificed
by choosing the more usual incision. Even in virgins and
young children the possible advantage of this route should
never be forgotten or overlooked.
Again, a perirectal abscess in the pelvis — sometimes a
long-neglected pyosalpinx — not infrequently opens at the
upper limit of the abscess sac into the rectum and dis-
charges into this by overflow rather than by emptying.
The patient falls into a condition of hectic, and, as some
instructive post-mortem preparations show, has often died of
Valedictoiy Address 383
her disease. Such a pus sac may, of course, be occasionally
removed successfully from above, but in the condition of
which I am speaking, the better practice is immediately to
freely open up the pus sac from the pouch of Douglas or
directly from the vagina, and establish rational drainage
from the most dependent portion of the abscess. This
is generally sufficient to ensure a quick and permanent
recovery.
Again, there are cases of thrombotic pyaemia after
parturition in which suppuration occurs in the immediate
neighbourhood of the thrombus. The disease may some-
times be stopped and the patient cured by evacuation of the
pus and gauze drainage well carried out either through the
pouch of Douglas or between the layers of the broad liga-
ment. Some cases of this kind (included in my list) I hope
to report more fully at a later period. All of these cases
can only be treated satisfactorily by vaginal surgery.
With less certainty, but still with marked advantage in
special instances, vaginal ovariotomy and vaginal enucleation
demand increasing consideration. I find I have used these
operations, in ten or (really) eleven cases and under certain
conditions, as when a single cyst is blocking the pelvis
during labour and preventing a delivery, I hold vaginal
ovariotomy as more than a fair alternative, but distinctly
superior to abdominal removal. The great point of the
technique of posterior vaginal section, apart from the dis-
infection of the vagina, is the use of the iodoform-gauze
drain behind the uterus instead of any suture of the incision.
This applies to vaginal hysterectomy also, unless the sutures
and raw surfaces are turned well outside the peritoneum, as
in the German method. The gauze drain prevents any
danger of intestinal adhesions at the site of operation and
effectually guards the patient from an adherent retroflexion
as a late result of the vaginal interference. I often leave the
drain in situ for twelve or fourteen days before removal.
The only time when I have chosen closure instead of
drainage has been when doing a vaginal ovariotomy during
labour.
384 The British Gyncscological Society
In this retrospect of work, I have endeavoured to touch
lightly but lirmly on the main points which strike me as
definitely calling for reference. With the exception of the
two digressions, I have written as tersely as I could, and
much in the same way as one talks to a friendly colleague
in the operating-room, when the operation is over and the
surgeon for a brief period opens his heart and strives to
give, as best he can, a simple statement of his work and the
reasons of his practice.
The comradeship of the Society may, I hope, be trusted
to condone any want of circumstance or ceremony in this
presentation of my address. We are all travellers in a
common journey, travellers who, in the graphic words of
Mr. Cunninghame Graham- — " kicking at our horses sides,
straining our eyes, keep pushing forward, stumbling and
objurgating on the trail." But we are more than this — we
are explorers in an unknown country where, over and over
again, no man has trod before us, where no certain trail can
be found for us to follow, and where the talk round the
camp fire at night, Y»^hen occasion calls for it, cannot well be
less or more than plain and straight and truthful.
Before I vacate the Chair, Gentlemen, I want to say for
you all and for myself, some words of welcome to our new
President, Dr. Alexander. He is well-known all over the
world and nowhere, perhaps could we have found one
whose reputation, ability, and kindness of heart so naturally
entitled him to the honour and confidence of his fellows.
We welcome him most heartily as our President, we assure
him of our loyalty and support, and wish him every happi-
ness and success in this his year of office.
Dr. Macnaughton-Jones said that on several occasions
he had had to propose a vote of thanks to a retirmg Presi-
dent, but had never done so with more diffidence than
- Preface to Mogreb-el-Acksa, 1898.
Valedictory Address 385
on the present occasion. After the comprehensive summary
of interesting and valuable work the President had given,
he felt it a responsible task adequately to express the feelings
of the Society, or convey a due appreciation of that work.
Professor Taylor had not been surpassed by any of his
predecessors in the assiduity with which he had attended
the meetings of the Society and directed its proceedings.
The address just delivered was most suggestive, and would
form one of the most valuable statistical records which had
ever appeared in the Journal. One fact struck him particu-
larly. During the last four years of his work Professor
Taylor had performed 36 abdominal and 20 vaginal hyste-
rectomies, 56 in all ; and during the same period 320
operations of all kinds. As of that number 56 were
hysterectomies, and among the whole 320 there had been
but 14 deaths, the low rate of mortality was a convincing
proof of the merit of Professor Taylor's work. He was
also struck by the fact that 57 operations for extrauterine
pregnancy, and various complications associated with it,
had been done, with only two deaths. Furthermore, 38
cholecystotomies, including excisions of the gall-bladder,
had been done, with only two deaths, and of the 72 vaginal
hysterectomies in the table only two were fatal. The Society
might congratulate itself on having had as a President one
who could bring before it such a perfect record of surgical
work. The President had recommended a valuable detail
in practice which was too often neglected. Operating
surgeons had necessarily to come into contact with septic
influences and make examinations involving septic infec-
tion, and he urged that, immediately after contact with such
septic conditions, they should always use a powerful anti-
septic. This advice should be borne in mind by every
operating gynaecologist. Professor Taylor was the third
President of the Society who had come from the Birming-
ham School, a school which must always hold a high place
in the annals of gynaecology. The most original obstet-
rician which the United Kingdom had produced was
VOL. XX. — NO. 80. " 26
;^S6 The British GyncBco logical Society
Simpson, of Edinburgh, but he would say unhesitatingly
that Lawson Tait was the most original gynaecologist that
England had ever produced. Another familiar name,
which one was proud to see on the list of Honorary
Fellows, had been associated with Birmingham in their minds
since their student days, was that of Savage. With these
illustrious men Professor Taylor was fitly associated. No
past President of the Society had more completely gained
the esteem of its Fellows than had Professor Taylor ; they
wished him every success in his practice, long life, and every
prosperity, and hoped that he, who had hardly reached the
zenith of his fame, would on many future occasions grace
their proceedings by his learning and vast experience.
Dr. Heywood Smith seconded the vote of thanks to
Professor Taylor for his able address and for his conduct
of the business of the Society during the past year. He
cordially endorsed all the proposer of the resolution had
said in appreciation of what the President had done during
his term of office. His conduct, both on entering the
Presidential Chair and on leaving it, had been characterised
by great courage. The Society would never forget the
outspoken address with which he inaugurated his term of
office, which had been referred to and quoted extensively
by lay journals, and had started a discussion which ought
to result in an improvement in the social morality and birth-
rate in this and other countries. They were also extremely
grateful for the address just delivered, and it was a great
encouragement to the younger specialists in that branch of
syugery that by similar earnestness and attention to details
they might hope to emulate the President's success.
The motion having been carried by acclamation.
The President thanked the Fellows very warmly for
the kindness which he had received since he was elected
President. His year of office had been a very happy one,
and he wished the Fellows a very successful and pleasant
session under the Presidency of his esteemed successor, Dr.
Alexander.
A Visit to Some Foreign Clinics 387
ORIGIN A L COMMUNICA TIOXS.
A Visit to Clinics at Ghent, Bonn and Brussels,
WITH SOME Remarks — Pathological and Practical.
By H. i\lACNAUGHTON-JONES, M.D., M.Ch., M.A.O. (Hon.-
Causa), &c.
Ghent.
At the end of last year I had the opportunity of visiting
Ghent. Dr. Eugene Boddaert, one of our Fellows, and
Assistant to the Surgical Clinic of the University, was most
courteous in showing me all the latest improvements
effected there. He is the son of the Professor of Clinical
Medicine in the University who has a warm appreciation
of the teaching he received in London at the hands of
Lionel Beale, Fergusson, Erichsen, Luther Holden, Savory
and West,
The new University clinics are practically completed
and include a series of lecture and clinical theatres, as
perfectly furnished with every modern accessory, as can be
seen anywhere. They are well worth visiting. The civil
hospital is a short distance from the University, and con-
tains several operating theatres. There are in all 710 beds,
311 for men, 244 for women and 155 for children. I saw
an interesting operation performed by Dr. Bersacques, one
of the surgeons. This was the removal by the circular
incision, of a large sacculated tuberculous kidney, com-
pletely fixed by numerous surrounding adhesions. The
age of the girl was 13. It was one of those cases in which
ureteral catheterisation for the purpose of early diagnosis
would have been of use, and would have indicated operation
388 Original Communication
soon enough to have prevented the extreme degree of
degeneration that had occurred. Though there were sup-
purating sinuses leading down to the kidney, the case has
made an excellent recovery. I had also the pleasure of
seeing Dr. Frederic operate in the gynaecological theatre.
The Director of the Obstetrical Clinic at Ghent is
Professor van Cauwenberghe, and his assistant is Dr.
Schoenfeld ; there are some 300 deliveries per annum.
Adjoining the clinic is the School for Midwives. Professor
van Cauwenberghe is also Director of the Frauenklinik, in
which Dr. van Wilder is the principal assistant. There is
an excellent aseptic operating theatre reserved for coelio-
tomies, on the same floor as the wards.
Catgut, prepared by Bergmann's (oil of juniper and
sublimate) method, is the material used for sutures. Only
in some malignant cases is the transverse incision in
coeliotomy resorted to.
I was much interested in a case of hour-glass con-
traction of the stomach, the particulars of which were
detailed to me by Dr. Beyer, the pathologist of the clinic.
He has just written an interesting and comprehensive essay
on this abnormality, in which he reviews its literature from
the time of Morgagni, who first described it in 1767, up
to the present. {Essai sur I'Estoniac Biloculairc, par Beyer,
Dec, 1904). To the gynaecologist the interest in these cases
centres itself particularly in their etiology and the part
played by the corset, either directly or indirectly, in their
causation. The following is a summary of Dr. Beyer's
views. Of the three specimens in the museum, two were
taken from patients at the clinic, and a third was sent to
him by Professors Firket and Beco, of Liege.
In the first of Dr. Beyer's cases, the patient, aged 37,
died in the hospital, of pulmonary tuberculosis, in
November, 1902, and the abnormality appears to have
been due to an old ulcer which had been cured. At the
time of the post mortem the interesting observation was
made that the stomach showed a constriction near its
A Visii to Some Foreign Climes 389
pyloric end which, when the two hands compressed the
sides, corresponded exactly to where the left costal border
came in contact with the anterior margin of the left hepatic
lobe. The stenosis admitted the passage of the little finger.
The second case was that of a married woman, aged 38,
who entered the clinic at the end of 1903, and who died of
malignant anaemia and purpura. Here the pathological
conditions do not throw much light on the causation of the
contraction, which permitted the passage of the thumb.
In the third case, there was no clinical history, neither
ulcers nor cicatrisation were present, and there was nothing
abnormal in the arterial supply. Here the little finger could
be passed through the contraction.
The view that this anatomical anomaly may be con-
genital has been advanced by different authorities, and an
analogy has been drawn between it and the stomach of the
ruminants. On the other hand, it has never been met with
in the anthropoid apes, and as Dr. Beyer points out, there
is a distinct difference between the contraction of the hour-
glass stomach and the multiple stomach of the ruminants.
However, whether it be due to an arrest of development
(Castallani), to the presence of abnormal muscular fasciculi
in the stomach wall, or is the consequence of some
abnormal disposition of the arteries associated with the
congenital anomalies of development, it would seem that
the bilocular state is far more frequently acquired than
congenital, and that in its etiology gastric ulcer plays the
most important part. Such ulceration is sometimes asso-
ciated with local changes in the peritoneum and the forma-
tion of bands and adhesions, after operative procedures
(Kummell), traumatisms, or the injection of caustic fluids
(Carle, Potain, Schnitzler, Korter). Mayo Robson and
Moynihan in England, and v. Eiselsberg, Mickulicz and
Kocher, in Germany, have recorded cases in which scirrhous
carcinoma has been the causal factor. Guillemot and
Langenbeck have recorded other causes, the former syphilis
and the latter tubercle. Rassmussen, however, has attri-
39© Original Communication
buted a great part in the production of the stenosis to the
wearing of the corset, the pressure this exerts on the border
of the left costal cartilage constricting the stomach against
the anterior border of the left lobe of the liver. He con-
siders that the compression produces a circumscribed
necrosis, followed by ulceration, and that the consequent
cicatrisation contracts the stomach. In Dr. Beyer's first
case the situation of the stenosis corresponded to that
indicated by Rassmussen, who likewise draws attention to
the atrophic groove produced on the liver by the corset.
That in many cases the corset cannot be the cause, is
shown by the presence of the bilocular stomach in men.
While it may by pressure bring about conditions predis-
posing to the formation of ulcers, it can hardly be capable
of producing extreme degrees of stenosis while the stomach
is movable in the abdominal cavity. Stenosis has also been
found under the left lobe of the liver (v. Hacker). There
can be little doubt, from all the observations that have been
made, that ulceration is the most frequent primary source
of the acquired form of this abnormality.
Dr. Beyer points out that we often find in females a sort
of biloculation which does not result from any tetanic con-
traction of the circular muscular fibres in a limited line, and
which is maintained after death, for neither insufflation nor
hydraulic pressure causes it to disappear. But it corres-
ponds always to the point of intersection of two lines
represented by the free edge of the left hepatic lobe and the
costal border. This can be easily demonstrated when the
abdominal cavity is opened, if an assistant compresses the
two costal borders from without inwards, when the left
hepatic lobe is pushed to the left, and the corresponding
costal border approaches the middle line, compressing the
great curvature and the anterior face of the stomach against
the left lobe of the liver. If we now slip the index finger
under the liver we feel there a narrow space limited behind
by the colon. Here compression is exerted above by the
liver, behind by the vertebral column, in front by the costal
A Visit to Some Foreign Clinics 391
border, and below by the gastrophrenic hgament. In this
manner biloculation of the stomach is produced. When we
find neither ulceration nor cicatrices in such a stomach it
must be admitted, Dr. Beyer says, that the corset by itself
may bring about the abnormality. Such compression,
should there be free peristalsis, has usually no effect, but if
there be gastritis and ulceration, peristalsis is impeded and
the influence of the compression is then exerted.
In the great majority of cases the bilocular stomach is
found in women, and more frequently in advanced life, Dr.
Beyer's cases, 37 and 38 years of age, being exceptional. In
his opinion, contrary to that of Hirsch, the final result of
the stenosis is an atrophic state of the stomach wall and
a dilatation of the organ. In this view he is confirmed by
the observations of Saake. The dilatation, however, is rarely
excessive, and the capacity of the two cavities does not
exceed that of the normal stomach. In Dr. Beyer's cases
the stomach appeared absolutely healthy, as in those
reported by other observers.
Roger Williams, who has more fully studied the
pathology of this condition than any other recent writer in
this country, has shown that in the majority of cases there
are pathological changes, either ulceration, cicatrisation,
induration, calcification, or perigastric adhesions (Saundby).
Dr. Beyer considers that, as otherwise it is folded longi-
tudinally, the smoothness of the mucous surface is patho-
logical, and due to a disappearance of the epithelium and
atrophic changes in the muscular, mucous and submucous
tissues, while at the same time there is a fibrous invasion
and a hyaline degeneration in the muscular fasciculi.
The differentiation of the congenital from the acquired
abnormahtyis difficult. Roger Williams and others attempt
to distinguish the two states by such anatomical considera-
tions as the length and narrowness of the constriction, and
its distance from the pyloric extremity. The absence of
pathological modifications, especially of any thickening at
the site of the stenosis, they consider is characteristic of
392 Original Communication
the congenital form. Dr. Beyer regards the pathological
changes which are above noticed, as characteristic of the
acquired state.
With regard to symptomatology : the symptoms which
follow from various degrees and stages of ulceration of the
stomach or from acquired biloculation are so closely allied,
that it is hardly possible to rely on any such as will enable
us to distinguish clinically between the two. The congenital
hour-glass stomach is discovered on the post-tnortcm table,
and must be most difficult to diagnose during life. Insuffla-
tion of the stomach, with a gaseous mixture, the common
method of distending it, may help, as we may find the usual
evidence of dilatation, and the outline of a dilated stomach
may be present with the clinical symptoms. If, on the
contrary, the cardiac pouch is comparatively small, this fact
would be in favour of the presence of biloculation ; still,
as Mathieu has shown, the pyloric pouch may be hidden
under the right lobe of the liver, or, owing to compression
or torsion, the constriction may be so great that only the
cardiac pouch is dilated. Wolfler suggests two diagnostic
signs given by lavage of the stomach ; that the first part of
the water that returns is clear and the second is discoloured
or dirty, while when the lavage has been finished, the
patient vomits the alimentary contents unmixed with bile.
Again, when the stomach is washed out with a given
quantity of fluid, only a portion returns, proving that some
of the liquid has been retained by the stenosis in the
pyloric pouch, though, as Ewald notices, this phenomena
may be due to a weakness of the pylorus. In a case of
Hochenegg's the patient vomited twice ; the first ejection
contained food hardly altered, the second, which was often
an hour after the first, was composed of altered matters,
which were bitter and acid. A peculiar bruit heard with the
stethoscope, and indicating the passage of air or liquid from
one cavity into the other, is said by some authors to afford
a means of diagnosis, while others profess to feel this
passage by placing the hand at the level of the stenosis.
A Visit to Some Foreign Clinics 393
Ewald introduces an empty balloon, the size of an orange,
into the stomach. Should the latter be an hour-glass
one, the balloon after inflation cannot be detected at the
pyloric side. On inflating the balloon it is found that as a
rule it is on a level with the left costal border. Also upon
the application of the gastrodiaphanoscope, should a
bilocular stomach exist, the transparent portion is at the left
of the umbilicus, or if the stomach be inflated with air, the
pyloric portion is found projecting to the right. Such
methods of examination, however, are not without danger,
and tend to provoke haemorrhages.
Once the constriction is present, the only proper treat-
ment is operative, and Beyer divides the different procedures
that have been practised into two classes : —
A. (i) Resection of the cicatrix ; the results of which
have not been favourable. (2) Digital dilatation of the
stenosis as performed by Loreta, which he says should be
completely abandoned. (According to Mayo Robson, in
78 cases there has been a mortality of 39*7 per cent.)
(3) Gastroplasty, in which the stenosis is incised parallel to
its axis, and sutured so as to bring back to back the two
ends of the incision. The results have not been favourable.
B. Under the second category he includes gastro-
anastomosis and-gastro-enterostomy, which he says is the
operation of selection.
I have here given only the outlines of Dr. Beyer's com-
munication, which is worthy of perusal in its entirety.
According to the recent statistics of Mayo Robson, of
twenty-three cases operated upon, four were malignant.
The results were more favourable than any which have
hitherto been published, as of the eleven cases operated
upon by gastroplasty alone, all recovered, as did the six
patients on whom posterior gastro-enterostomy was per-
formed. Of the four malignant cases, three are reported
as having recovered, a partial gastrectomy having been
performed in two.
394
Original Communication
Bonn.
All who have passed down the Rhine know the line
building which stands alone, overlooking the river on its
right bank at Bonn. It is the State building of the Uni-
versity Frauenklinik, and is a detached portion of the
Krankenhaus, with its various departments. It was founded
in 1872, and there have been but two directors since. The
first was Professor G. v. Veit, the distinguished obstetrician
and gynaecologist, who died in 1903. He was succeeded by
its present head, Professor Fritsch, who has been connected
Fig. I.
Fig. 2.
with the clinic for ten years. It contains eighty beds, forty
of which are obstetrical and forty are gynaecological. The
stall consists of the Oberarzt, Dr. Reifferscheid ; Dr.
Eversmann, Dr. Michel, and Dr. Zurhelle, assistants ; Dr.
Welsch, a voluntary assistant, and Professor Schroeder,
pathologist. I cannot too warmly acknowledge the extreme
courtesy, kindness and attention which I received during
my visit, and I am especially indebted to Professor Schroeder
and Dr. Zurhelle, the former for the time he spent in going
over the pathological specimens in the museum with me
and the latter for affording me every opportunity of seeing
A Visit to Some Foreign Clinics
;95
the working of the clinic, and giving me all the information
that I required with regard to its methods.
Professor Fritsch operates at 8 a.m. The aseptic details
are very perfect. Sublimate and alcohol are the principal
antiseptics used. About a quarter of an hour is consumed
rubber
Fig. 3. — Automatic Suprapubic Retractor (with weight, 7 lb.).
(Prof. Fritsch's.)
in the preparation of the hands, all the washing being done
under running water. Muslin masks are used, which cover
the entire head, leaving only an aperture for the eyes.
These masks (figs, i and 2) I now use altogether and have
found them quite comfortable, causing no inconvenience.
39^ Original Communication
They completely prevent any danger of infection from saliva.
They are taken straight from the steriliser and adjusted after
the sterilisation of the hands. The gut which is almost
altogether used in the clinic is iodised catgut, but ammonium
sulphuric gut is occasionally employed. Chloroform is the
anaesthetic used, and it is given with the large mask. The
sterilisation of the vagina is completed in the theatre. The
operating table is one devised by Professor Fritsch himself.
It is readily raised or lowered into the Trendelenburg
position by the anaesthetist, w^ho works the reversible screw
in front of him, which also serves to adjust its height. In
certain operations, such as ventro-fixation or suspension in
oophorectomy and small myomata, the transverse incision
is the one adopted, but this is not the Kustner-Rapin
incision carried through the aponeurosis of the abdominal
muscle inside the limit of the pubic hair, but the higher
one, on a level with the iliac spine, as performed by
Pfannenstiel. An ample view of the pelvic cavity is
obtained, the subsequent bond of union is strong, the
cosmetic effect is good, and the possibility of hernia
diminished.
In the abdominal toilet gut is used for the peritoneum
and also for the muscle ; the fascia is carefully united by
interrupted sutures of celloidin-zwirn and catgut alternately,
the skin being closed with silkworm gut. When the w^ound
is closed vioforni is dusted over it, and it is covered wuth
some vioform and ordinary sterilised gauze. Then, with a
brush, a plaster of lead and zinc is laid pretty thickly over
the edges of the gauze. This is covered with another layer
of gauze and plaster, and the entire dressing is held in place
by an excellent form of adhesive plaster made up in rolls,
and perforated so as to avoid the retention of any moisture.
I now dress coeliotomy wounds myself as follows : Vioform
is dusted on the incision ; over this two layers of iodoform
or vioform gauze are placed, then some plain sterilised
gauze, the edges of which are secured all round by broad
strips of colaetin (zinc and lead plaster) the whole being
A Visit to Some Foreign Clinics 397
secured and covered by the perforated plaster I have
mentioned. No other covering is required. Vioform
(obtained from Perzel u, Shultz, Hamburg) is iodichloroxy-
chinosol. It is more easily distributed on wounds than
iodoform, is sterilisable, and is odourless.
A few points that I noticed in the operations at the
clinic are worth noting. Professor Fritsch operates fre-
quently by morcellation, and I saw him remove some intra-
uterine mvomata of considerable size by this method. In
some cases the cervix is divided bilaterally. In hysterec-
tomy the suprapubic retractor (p. 395), of a shape similar to
that used by Doyen, is fixed by a weight, which is readily
adapted and out of the way. The supravaginal operation is
that most frequently resorted to. Catgut is used for liga-
ture, and to cover the pedicle. For carcinoma the operation
performed is almost always vaginal panhysterectomy, and
only rarely the operations of Wertheim and Schuchardt.
In performing perineorrhaphy. Professor Fritsch makes
a deep transverse incision in front of the anus, parallel to
the posterior commissure, carrying the incision as high as
possible, from 7 to 8 centimetres behind the vagina. The
result is a funnel-shaped wound as deep as the finger. The
sides of the wound are then joined by deep catgut sutures,
which pass from side to side, in sagittal form, reaching the
tuberosities.
The Alexander-Adams operation is a favourite one with
Professor Fritsch, and is the procedure adopted in the
majority of cases to rectify backward displacement, and
also, as an accessory step, in the operations for prolapse and
procidentia. The method pursued is almost identical with
Alexander's original method. The canal is rarely opened
up to the internal ring ; the ligament is drawn well forwards
and anchored to the sides of the canal and the aponeurosis.
Dr. Reifferscheid has invented an automatic retractor for
use in the Alexander-Adams operation, so as to enable the
operator to dispense with an assistant. Fritsch has availed
himself of Pincus' treatment (atmocausis) in menorrhagia,
398
Original Communication
and in haemonhagic endometritis, and has pronounced this
method to be "safe, painless, and effective." In operating,
whether in passing Hgatures or suturing, he avails himself
less of the use of a needle holder than any operator I have
ever seen ; and there is a peculiar deftness in the facility
with which his fingers work. His aphorism with regard
to early sepsis after cceliotomy is widely quoted, and the
conditions which sometimes arise on the second day have
been faithfully described by him, the principal of these
being tympanites, dry tongue, and rapid pulse, due fre-
quently to a too great interference with the physiological
Fig. 4. — REiFFERCHEins's Retractor.
functions of the peritoneum, so that the woman " does not
die because she is septic, but is septic because she is dying."
In the obstetric department I found that, speaking
generally, the treatment of eclampsia consisted in the early
emptying of the uterus when possible, keeping the patient
in a dark room, packing, the repeated use of the hot bath,
the administration of morphia and clysters of chloral
hydrate (50 grains), the diet being principally milk. In
septic peritonitis hydrotherapeutic measures, such as ice
and sublimate packing, are resorted to, and port wine is
given freely. Professor Fritsch is emphatic about the
necessity of examination of the uterus one week after
labour, so as to ascertain its position and guard against
displacement.
Enquiring as to the experience in the clinic of the use
of Bossi's dilator, the results were not favourable. Dr.
PLATE I.
+ Feet II f .
Subchorionic tuberous hLT?matoma.
(Page 399)
(Preparation in the Frauenklinik at Bonn. — Professor Schroeder.)
A Visit to Some Foreign Chnics 399
Bischoff, the Assistant at the chnic in 1902, pubHshed the
results of live cases (Centralb. f. Gyii., 1902, No. 47), in all of
which there were lacerations from its use. Dr. Zurhelle, in
a recent case, had a successful result, but there were also
slight lacerations treated by immediate suture.
«
Description of Specimen, Plate I.
By the kind permission of Professor Fritsch, I brought
one most interesting specimen from the museum to show
at the British Gynaecological Society.^ It was one of tuberous
sub-chorionic hceniatouia of the deciduu, and the specimen
was reported on by Professor Schroeder.- The patient's age
was 31 years ; she was a tripara and the catamenia had been
completely absent. She aborted in the seventh month.
Haemorrhage occurred and the mole was spontaneously
expelled. The specimen is not complete, as portions of the
membranes on the reflexa side are lost. The very small
ovisac measured 6 by 7 cm. The amniotic fluid was not
diminished in quantity. On the outer surface of the sac
abundant decidual tissue was still adherent. The upper
pole of the "chorion laeve " was free, the villi there being
scanty, whereas underneath they were more abundant, like
portions of decidua. The blood effusions are seen in
patches on the greyish-white maternal surface. The special
feature of the ovum were the numerous protuberances
that arched forward on the foetal side of the membranes,
especially on its basal surface ; they were less numerous on
the inside of the " reflexa wall," and altogether absent on
the upper portion of the " chorion laeve." The pro-
tuberances were of a brown and bluish -red colour. They
varied in size from a millet seed to a cherry ; many had a
broad base, some appeared pedunculated and were rather
flaccid. On the side of the serotina they were so numerous
' It was shown at the meeting of the Society on November lo, 1904.
' So7iderabdruck aus den Sitzuiigsber-ichten der Niedert'hein. Ges. f.
Natur. Heilktwde. Bonn, March 14, 1904.
400 Original Communicatio7i
that their sides were facetted from pressure. On section their
haematomatous character was apparent. Over some the
torn amnion floated ; the membranes were plaited about
several, while others were enveloped by the amnion, and
the chorion adhered closely to their contour. The foetus
(plate i) was 5I mm. long and the buds of the extremities
were barely visible. Microscopically in such haematomata
the amniotic epithelium is generally well preserved. The
cilia are necrotic. No small vessels or remains of such
are visible. There is no proliferation of the epithelium.
The intervillous spaces are thrombosed. The decidua is
also necrotic from pressure caused by effusion.
In this group of molar cases the periods cease, while the
subjective and objective signs of pregnancy go on until the
uterus reaches the size of the fist, when the symptoms of
pregnancy are arrested. If there be any haemorrhage it is
but slight ; after some months, possibly at the full term of
pregnancy or later, the contents of the uterus are expelled
spontaneously. The foetus remains small, varying in size
from some millimetres to that of two or three months'
development. Hajmatomata push the chorion and amnion
inwards in the region of the basal layer and protrude into
the amniotic cavity. They are sometimes polypoid or villous
in shape. Breus held that though the chorionic circulation
ceased at the death of the foetus, the membranes continued
to gr*-Av, and that at the same tnue they became convoluted
from their disproportionate size to the uterus, the enlarge-
ment of which ceased with the death of the foetus. Where
the membranes are not fixed to the decidua by the chorionic
villi they bulge into the amniotic cavity, either as folds or
diverticula, and secondary bleeding converts them into
haematomata.
Contrary to this opinion of Breus, or that of Neumann,
who regards the tuberous processes as the rcsiilf of sub-
chorionic haemorrhage, Professor Schroeder inclines to the
view advocated by Davidsohn, that this form of mole is
due to hydramnios, and (taking the ground that there is a
PLATE II.
Cystic degeneration in ovaries of stillborn child (Schroeder).
(Page 401)
A Visit to Some Foreign Clinics 401
disproportion between the size of the embryo and that of the
ovisac in hydramnios, and that the carneous mole is an
early hydramniotic ovum in which the liquor amnii is
slowly absorbed, while concurrent hccmorrhage takes place
into the ovum), regards such disproportion as the cause of
the projection of the foetal membranes into the amniotic
cavity. The hydramnios, which results from the blocking
from the outflow from the placental sinuses, leads to
increased blood pressure, and the latter to increased secre-
tion of liquor amnii. Later, there is stasis in the placenta)
Finuses, and as a consequence subchorionic hcemorrhage,
while, later still, the liquor amnii is absorbed through
thrombosis of the placental sinuses.
I also brought back some sections of ovaries made by
Professor Schroeder, showing cystic degeneration in a still-
born foetus. The degeneration occurred in the Graafian
follicles ; the stroma was studded with inflammatory cor-
puscles (plate 2).^
Dr. Cuthbert Lockyer, who has examined these sec-
tions microscopically, writes to me that the features which
strike him as most characteristic are : (i) The extensive
cystic change ; (2) the extreme vascularity of the organ.
The cystic change has resulted from distension of Graafian
follicles. Many of the cystic spaces are lined by epithelium
derived from the stratum granulosum. Other cysts show
no such differential lining ; it (the latter) has either dis-
appeared or has never been formed. Degenerative ova can
be seen in a few of the cystic spaces, whilst in the cortical
stroma there are numbers of large discrete uninuclear cells,
presumably primordial ova, lying free and not enclosed in
follicles. The swollen connective tissue cells around the
cysts also form a very notable feature.
Brussels. ,
At Brussels I visited the hospital of St. Anne, which is as
complete and perfect an institution of its kind as 1 have ever
' Shown at the Gynaecological Society on November lo, 1904.
VOL. XX. — iNO. 80. 27
402
Original Covuiuin ication
been in. There I had the pleasure of watching Professor
Jacobs operate in his beautifully fitted theatre, which one
must see in order to be able to appreciate it. The most
novel feature of his technique consisted of the closure of the
skin in the abdominal toilet, by means of Dr. Michel's suture
instrument. Professor Jacobs uses the automatic form (fig. 5)
of the appliance, though the smaller and cheaper variety is
the one now more generally used abroad (fig. 6) (Colin —
Fig. 5.
Fir,. 6.
Paris). This holds the small clamps, which are automatically
released over the line of incision, and by pressure of the for-
ceps secures the adaptation of the edges. The wound is thus
rapidly closed, the clamps are removed at the end of five
days. 1 saw this done, and also the completely healed
wounds which had been treated by this method. They
were most satisfactory. I am now using it myself.
I discussed \vith Professor Jacobs the important question
of the results from operative interference in cancer of the
uterus, including those cases in which ablation of all the
peri-uterine structures was carried out, as well as excision of
A Visit to Some Foreign Clinics 403
a portion of the vagina. In June, 1904, he published in the
Progres Medicale Beige, his results up to that date. These
results are not encouraging. The total number of such
operations amounted to 95, and the immediate mortahty
was 6'3 per cent. Of si.\ patients, it was not possible sub-
sequently to obtain the history ; among the remaining 89
recurrence took place nnmediately in 5 ; during the first
year, in 43 ; in 20 during the second year ; in 4 during the
third ; in 2 during the fourth ; and in 2, in the fifth. There
were only six cases e.xempt from recurrence at the end of
six years. On the other hand, of 82 cases operated on by
vaginal hysterectomy, 81 survived the operation. Of these,
the history of 11 could not be traced, and of the 70
remaining cases there were 49 recurrences in the first year,
9 in the second, 11 in the third, and i in the fourth. No
case lived more than four and a half years.
With regard to glandular involvement, the principal
consideration is infection of the parametrium. The ganglia
were infected in 51 per cent., free from infection in 20 per
cent., and the seat of secondary infection in 28 per cent.
To 1904, in 7 cases in which there had been no recurrence,
there was infection of the ganglia in 4 cases. Of 76
recurrences, 5 took place immediately after operation,
though the whole pelvic ganglionic chain had been removed
with the subjacent peritoneum, and the pelvic cellular tissue,
as far as the intestine, the bladder, and the ureters. These
five operations could not, however, be said to be complete.
He implanted a ureter in one case nito the sigmoid, in
another, into the bladder, and in 3 cases, he ligatured the
left iliac veins. In 43 cases which recurred m the course
of the first year, he had removed the lymphatics with
the large ganglia twenty-one times, and on four occasions
one or two large ganglia at the side of the uterus, below
the portio vaginalis. Among these 76 cases he found
lymphatic ganglia in 45. The recurrence in 47 cases began
in the vaginal cicatrix ; twenty-nine times it was in the
pelvis, leaving the vaginal cicatrix absolutely intact. In
404 Original Communication
4 or 5 cases he performed a secondary laparotomy. There
were generally intestinal adhesions at the level of the en-
larged ganglia or the bladder. The base of the vagina
was free from adhesions. In one case he resected 17 cm.
of the small intestine, at the same time ablating large
masses of underlying glands. When the recurrence was in
the pelvis it was generally in the parametrium, with rapid
involvement of the intestine. Intestinal and mesenteric
metastases were rare. Professor Jacobs thinks that the
recurrences should not be in any way attributed to cancer-
ous grafting in the course of an operation, but rather to
numerous deposits of cancer at the outset of the disease,
multiple localisations of the same cancerous infection, to
retrograde metastases through the lymphatics, caused by
obstruction, or, a more simple explanation, to the continued
evolution of growths not completely removed. He does
not believe that the contact of the tissues with the cancerous
elements causes any grafting of the latter on the former
during an operation, whether such contact be short or long,
and in support of this view, instances the exceptional
involvement of the vaginal surface in cancer of the neck of
the uterus, and also the rarity of transmission from individual
to individual, even from coitus, in cases of uterine cancer.
He attaches great importance to thorough disinfection
of the vagina and the portio before operation, which he
says should be carried out by the surgeon himself a few
days previously. In operating he adopts the median in-
cision and the Trendelenburg position. Having freed
the uterus and adnexa from all their attachments as far
as the vaginal ad dc sac, he proceeds with a wide dis-
section of the pelvic structures freeing the ureters and
bladder as far as the sacro-iliac articulation at either side.
The hand is used in manipulating the uterus so as to avoid
lacerating the uterine tissues. After the ablation of the
infected parts he closes the pelvic floor thus : He unites
the vaginal walls at either side with a few interrupted
sutures, leaving the middle of the wound open for subse-
A Visit to Some Foreign Clinics 405
quent subperitoneal drainage. Thus he drains separately
each broad ligament if necessary. The peritoneum is
completely closed by a suture. He does not drain trom
the abdominal cavity. He does not consider that operation
is advisable in cases in which the ureters have to be cut and
implanted in the bladder and bowel, or in which the
infection extends to the utero-sacral folds, the rectum and
the pelvic floor.
4o6 Reviews
REVIEWS.
The Principles and Practice of Gynecology for
Students and Practitioners. By E. C. Dudley,
A.M., M.D., Professor of Gynaecology, North-western
University Medical School ; Gynaecologist to St. Luke's
and Wesley Hospitals, Chicago, &c., &c. Fourth
Edition, revised and enlarged ; with 419 illustrations
in colours and monochrome, of which 18 are full-page
plates. Royal 8vo, pp. xiii. and 770. London : Henry
Kimpton, 1905. Cloth. Price 25s.
The third edition of Professor Dudley's book on gynae-
cology was published in 1903, and reviewed in the May
number of this Journal (vol. xix. p. 86.) In the present
edition an attempt has been made to include the recent
advances in our knowledge, and in doing this many chapters
have been rearranged and altered. The sections relating
to General Diagnosis, Local Treatment, Major Operations,
Drainage, Urethritis, Cystitis, Ovarian Tumours, Embryo-
logy, Malformations and the Treatment of Salpingitis,
Ovaritis and Pelvic Peritonitis have been subjected to
special revision and to a great extent rewritten, with
practical additions.
A special feature of this edition over the previous edition
is that over three hundred new illustrations have been in-
troduced to the exclusion of all borrowed reproductions,
and that all major and minor manipulations and operations
have been pictured so as to show the several steps of each
procedure as they take place. A series of drawings is
devoted to each operation ; for example, twelve drawings
have been inserted to explain the steps in hystero-myomec-
Reviews 407
tomy, and thirty-two to illustrate perineal lacerations and
the steps in perineorrhaphy. Nearly all the illustrations are
good, though some are redundant and seem to overlap each
other in what they are intended to show. The drawings
showing the embryology of the generative organs are good,
and, with the accompanying tables setting forth the homo-
logues in the two sexes, make that chapter intelligible.
In discussing the surgical treatment of salpingitis. Pro-
fessor Dudley rightly lays down that the uterus does not
necessarily become a pernicious, continuous, disabling and
dangerous source of infection after-removal of the append-
ages : he thus disposes of the fiction that immediate total
ablation is necessary, or desirable, in all cases. He advises,
in some cases, vaginal incision with drainage: in others,
removal of the tubes, including those parts which penetrate
the cornua of the uterus, and again in others, where the
pelvic organs are matted together in one infected mass,
vaginal hysterectomy.
In cancer of the uterus, he holds that abdominal hyster-
ectomy and removal of the infected peri-uterine and lumbar
glands, is not advisable because the complete radical opera-
tion entails an increased and dangerous traumatism, in
what must be a long and tedious operation, without giving
a reasonable guarrantee against further recurrence.
The text is clear and lucid and, although many things
have been left unsaid, the work is concise, and the surgical
technique, aided by so many admirable and explanatory
pictures, is readily understood. The work, may be recom-
mended to students and practitioners alike, especially as a
treatise in operative procedure, and as such reflects great
credit on a surgeon who can be little short of brilliant in
his art.
The Surgical Treatment of Bright's Disease. By
George M. Edebohls, A.M., M.D., LL.D., Professor
of the Diseases of Women in New York Post-Graduate
Medical School and Hospital ; Consulting Surgeon
4o8 Reviews
St. Francis' Hospital, Consulting Gynaecologist to
St. Johns' Riverside Hospital, Yonkers, and to Nyack
Hospital, New York, &c., &c. Large 8vo, 2 plates,
pp. vi. and 339. New York : P'rank F. Lisiecki, 1904.
In this book the author has not attempted to give a
complete and systematic treatise on the surgical treatment
of Bright's disease, but only to demonstrate such facts,
especially as regards results, as have been obtained from his
own experience. Until quite recently, chronic nephritis
has been considered an incurable disease, and any new
form of treatment which held out the hope of cure for
this common and fatal malady would be readily welcomed
by the medical profession ; nevertheless. Dr. Edebohls'
suggestion that chronic Bright's disease should be treated
by surgical methods, came rather as a shock to medical
practitioners, as, heretofore, it had been universally taught
that no surgical operation of any kind should be undertaken
in any part of the body of a patient suffering from chronic
nephritis, unless it was of vital necessity. Dr. Edebohls
shows that this opinion is wrong, that surgery is of the
greatest benefit to the patient, and may, in certain cases,
be the only means of preventing the disease or its compli-
cations proving fatal.
The first part of the work consists of a reproduction,
in chronological order, of various papers, on the surgical
treatment of chronic nephritis and allied conditions, written
between the years 1899 and 1904. The remainder of the
volume contains the histories of the seventy-two patients
upon whom he has operated, and an analysis of these cases
and their results.
It follows, therefore, that much of the subject-matter in
the early part of the book is repeated in the various papers,
with such additions and alterations as have been suggested
by increased knowledge and experience. Practically speak-
ing all the opinions and theories of the author, and the
details of the treatment are to be found in the article entitled
"The Surgery of Nephritis," published in May, 1904.
Reviews 409
After describing how he came to adopt operative treat-
ment in 1898, Dr. Edebohls advocates one method of
operation only, namely, decapsulation of the kidney. Both
kidneys should be dealt with at the same sitting, as the chief
danger in the operation lies in the narcosis, and the patient
should not be unnecessarily exposed to the risk of a second
anaesthesia. The operation should not be prolonged for
more than an hour, but in the hands of anyone expert
in renal surgery, it is unlikely that more time than this
would be required. The anesthetic used should be that
which the surgeon generally employs, and no special form
of administration is essential. After the kidney has been
exposed by the usual lumbar incision and separated from its
fatty capsule, it is, if possible, delivered, and the true capsule
is stripped off and removed as far as the renal pelvis. Care
must be taken not to tear away portions of kidney substance,
as the capsule is likely to be adherent in places. The kidney
is then dropped back into its pouch and the wound sutured.
The rationale of this procedure is that by removal of the
impervious capsule proper, new vascular connections are
created between the kidney and the surrounding tissues, the
circulation in the organ is thereby greatly improved and the
patient benefited in a manner similar to that by which
the symptoms due to cirrhosis of the liver are relieved by
modern methods of operative treatment. It must clearly
be understood that renal decapsulation is not undertaken
with any idea of relieving tension, as operation shows that
in chronic nephritis the capsule does not even fit the kidney
tightly ; in fact, in some cases appears to be looser than
normal.
Although the formation of new vessels leading to the
kidney accounts for the ultimate good effects after operation,
the immediate benefit cannot be attributed to this cause,
and Dr. Edebohls considers that this is brought about by
the necessary manipulations of the kidney during the decap-
sulation. This can readily be believed in view of the good
results which are so often seen after exploring an apparently
normal kidney for renal symptoms.
4 1 o Revieivs
After the operation of renal decapsulation, a new capsule
is invariably formed, but this is always softer than before,
and the danger of subsequent contraction need not be
considered. At the present time, the author advises his
operation in all forms of chronic nephritis, and the only
contra-indications are tlie presence of some condition
which absolutely prohibits any operation, advanced vas-
cular and cardiac affections {i.e., dilatation) and retinitis
albuminurica.
Before any new operation for such a disease as chronic
nephritis can be accepted, it must be shown, in the tirst
place, that cure or improvement follows the operation with
practical uniformity ; secondly, that a cure, once obtained,
is, as a rule, lasting; and thirdly, that improvement obtained
by operation in character, in the great majority of cases is
steadily progressive. These conditions the analysis of the
cases and their results show to have been fulfilled, and it
is with much pleasure that we offer our congratulations to
Dr. Edebohls on the success which he has achieved.
Anyone who has attempted a similar feat will appreciate
the difficulties of producing such an eminently interesting
and instructive work as the one under consideration. The
histories of the seventy-two cases are most thoroughly and
carefully given and all the results brought up to date ; two
cases of puerperal eclampsia of renal origin are included in
which decapsulation of the kidneys, without any doubt,
absolutely saved the patients' lives. The chapters devoted
to discussing the question of priority in regard to decapsu-
lation might have been omitted with advantage.
The book contains two plates illustrating the vasculari-
sation of the new capsule, and concludes with an excellent
bibliography and an index.
The surgical treatment of Bright's disease is too recent to
offer any definite criterion as to its advisability as a routine
practice, but the results certainly show that it is a matter
requiring the most careful attention. In the first place,
considering ,the fatal nature of the disease and the fact that
Reviews 4 1 1
many of the patients operated upon were practically
moribund at the time of operation, the mortality is small ;
again, although many of the patients wiio survived are not
classed as cures, yet so much improvement in their general
health has occurred that they are quite satisried with the
result of the operation ; and, lastly — and this by itself would
be sufficient to justify the operation — a fair proportion have
been absolutely cured. Dr. Edebohls has only given us the
results of his cases up to the end of the year 1903, and
he does not consider that sufficient time has elapsed to
publish those of his operations in 1904. We shall look
forward, therefore, with much interest and some impatience
to the publication of the later series of cases.
The Surgery of the Diseases of the Appendix
Vermiformis and their Complications. By
William Henry Battle, F.R.C.S.Eng., Surgeon to
St. Thomas's Hospital, formerly Surgeon to the Royal
Free Hospital, Hunterian Professor of Surgery at the
Royal College of Surgeons of England, &c. ; and Edred
M. Corner, M.B., B.C.Cantab., F.R.C.S.Eng., Surgeon-
in-Charge of Out-patients to St. Thomas's Hospital and
Assistant Surgeon to the Hospital for Sick Children,
Great Ormond Street, Erasmus Wilson Lecturer at the
Royal College of Surgeons of England, &c. London :
Archibald Constable and Co., 1904. Demy 8vo, pp.
208. Price 7s. 6d. net.
A new book on appendicitis, considering the wealth of
literature on the subject which exists and ever increases,
may at first seem superfluous, but it is the very amount of
such literature that gives the present volume its value. So
extensive and so scattered are the writings on appendicitis,
that it is impossible for anyone to study the whole subject
unless he has much leisure and access to a large library.
This volume is the outcome of much work, both
practical and literary, on the part of the authors. The
4 1 - Reviews
accepted ideas, views on the pathology, diagnosis and treat-
ment of the diseases of the appendix are presented to the
reader, not only in a concise form, but from the point of
view of practical surgeons before whom a constant stream
of illustrative cases is ever passing. The first chapter, on
the history of the disease, the anatomy, physiology, and
development of the appendix supports the view that the
appendix is a physiologically functional, and not merely a
useless vestigial, structure. When to operate ? is a question
often asked, and one on which there is considerable diversity
of opinion. While not advocating immediate operation in
all acute cases, the authors urge that the decision whether
to operate or not, should be made within the first forty-
eight hours. If this cannot be done they consider that
the doubt should be settled by operation, as cases operated
upon early nearly always do well, whereas if the operation be
done after the third day the surgeon will generally regret
that he did not interfere earlier.
Discussing the methods of incision, the authors recom-
mend an incision through the anterior sheath of the right
rectus muscle ; the muscle is then retracted towards the
middle line and the posterior layer of the sheath divided.
They consider that this method gives the best exposure of
the parts, the wound can be enlarged vertically as far as
required, and at the end of the operation the rectus muscle
covers up the whole of the incision in the posterior layer
of the sheath and peritoneum. The risk of hernia by this
method seems to be reduced to a minimum, as they have
had only one case, which occurred after extensive suppura-
tion in the wound. They describe a new method of dealing
with the stump ; by means of a special clamp the inner coats
are divided, the peritoneal covering remains intact and is
ligatured, and the tissue left to be sewn into the caecum is
scarcely larger than that left after tying an artery. They
consider this to be the quickest, neatest, and most aseptic
method of removing the appendix.
The difficulty of making a diagnosis in acute abdominal
Reviews 4 1 3
conditions is one with which every surgeon is frequently
confronted. An excellent chapter on the differential
diagnosis of such conditions will be found in this work.
From the examination of a large number of consecutive
cases of acute abdominal diseases, the authors found that in
37 per cent, the cause of the inflammation was appendicitis
and its complications. The rarer forms of appendicular
disease and morbid growths and the various complications
receive notice. The bearing of appendicitis on life assurance
is fully considered.
We have read the book with great pleasure, and can
recommend it as an excellent and practical treatise, present-
ing the subject to the reader in all its bearings in a most
concise and interesting manner.
We have not before met with, nor can we find any satis-
factory authority for the word " exviscerate " used in this
work, instead of the usual and more euphonious eviscerate.
Cleft-Palate and Hare-Lip : the Earlier Operation
ON THE Palate. By Edmund Owen, M.B., F.R.C.S.,
Consulting Surgeon, St. Mary's Hospital ; Hospital for
Children, Great Ormond Street, &c. London : Bailliere,
Tindall and Cox, 1904. Cr. 8vo, pp. iii, with 39
illustrations. Medical Monograph Series. 2s. 6d. net.
This little book will be received with much interest, as
it embodies the experience of a surgeon well qualified to
speak with authority on the subject.
The method of dealing with cleft palate which he advo-
cates, differs considerably from that generally taught and
described in the text-books, and is a distinct advance in the
treatment of this deformity. He strongly recommends early
operation, the most favourable time being, m his opinion,
between the ages of two weeks and three months, as he
finds that infants even at this early age can bear the shock,
while if cases are left until later ages, the palatal muscles
having no fixed attachment fail to develop, and the cha-
4 1 4 Reviews
racteristic defect in speech can never then be remedied. In
the method he advocates, that of Dr. Bropliy, of Chicago,
the essential feature is that tlie maxillary processes are
brought together and sutured. This can usually be done
at an early age, but later on when the maxillai have become
more ossified is impracticable. A chapter is devoted to the
development of the palate and lips. Very full and detailed
descriptions of the operation, the material, the instruments,
and the assistants, add considerably to the practical value
of this very complete monograph.
Clinical and Pathological Observations on Acute
Abdominal Diseases due to Conditions of the
Alimentary Tract and the Uniformity of their
Origin. Being the Erasmic Wilson Lectures, 1904.
By Edred M. Corner, M.A., xM. B.Cantab., F.R.C.S.,
Surgeon to outpatients St. Thomas' Hospital, Assistant
Surgeon to the Hospital for Sick Children, Great
Ormond Street, &c., &c. Demy 8vo, pp. 98. London :
A. Constable and Co., 1904. 3s. 6d. net.
The aim of these lectures is to point out the identity of
the pathological changes in all acute ulcerative, perforative,
and gangrenous processes of the alimentary tract, and to
show that such processes are due to the same pathological
causes as in other parts of the body, modified only by the
special vascular and bacteriological relations of the parts
concerned.
The book is divided into short sections, each dealing with
instances of these processes as they have been observed in
different regions. Clinical cases are cited and their patho-
logy discussed in the light of subsequent operative or post
mortem investigation.
The author points out that gangrenous and perforative
conditions depend upon bacterial infection rather than on
mechanical causes ; numerous illustrative cases are quoted,
and many others will occur to all who have to deal with
acute abdominal conditions. In some cases bowel, which
Reviews 4 1 5
after perhaps two or three days strangulation has appeared
ahnost beyond hope, has been returned into the abdomen
and the patient has made a good recovery. In others,
though the strangulation has been of short duration, and
the condition of the bowel has not given much anxiety, the
patient has died and extensive gangrene has been discovered
post mortem. The same diverse results have followed
thrombosis of mesenteric vessels : one case with extensive
thrombosis recovers, another, with much less, proves fatal.
Some perforated ulcers are stitched up and heal without a
bad symptom, others break down and at the autopsy the
stitches are found torn out and the surrounding bowel
gangrenous. These varying results are due, the author
maintains, to the fact that, in one class of case, the organisms
are of less virulent type and do not tend to spread beyond
the damaged area, in the other, virulent cocci prevail and
the process is an acute infective necrosis. There is, he
shows, a free anastomosis between the visceral vessels, and
he cites cases and experiments to show how recovery may
take place after extensive areas of bowel have been cut off
from their blood supply provided that the parts remain
aseptic, while thrombosis of a comparatively small vessel may,
in the presence of an acute infection, give rise to extensive
necrosis of the bowel. His observations on appendix
abscess bring out a point which does not appear to be
generally known, that is, the frequency of abscess in acute
cases which recover, the abscess discharging itself into the
bowel. He shows that all acute cases in which the pain
and pyrexia continue for a few days are probably accom-
panied by suppuration. Such cases are generally classed
among the non-suppurative. The frequency of faecal fistula
after operation, as in several cases quoted, bears out the
truth of this. This able monograph may be heartily re-
commended, and will be read by all surgeons with both
pro tit and interest.
4 1 6 Reviews
Practical Manual of Diseases ok Women and Uterine
Therapeutics, for Students and Practitioners.
By H. I^lACNAUGHTON-JONES, M.D., M.Ch., &C., &C.
Ninth edition. With 637 illustrations and 125 coloured
and plain plates ; pp. xxxviii., 1044. Demy 8vo. Price
21S. net. London, 1904 : Bailliere, Tindall and Cox.
The ninth edition of this well-known book appears for
the first time in the " University Series" of its publishers. It
has been largely re-written and, as the author justly says, has
been brought into line with the most recent clinical opera-
tive and pathological advances. A hundred additional pages
and nearly a hundred more plates make it somewhat bulky,
but this inconvenience can be avoided, as it is also published
in two smaller volumes. We do not know of any other
book by a British gynaecologist so rich in examples and
illustrations, and the latter are particularly well executed,
and are most elucidative of the text. In the part of the
book devoted to the consideration of uterine myomata
alone, there are 133 illustrations and 15 plates. The whole
book gives evidence of untiring enthusiasm, a comprehensive
knowledge of every detail of gynjecological work, not only
in this country but the world over, and of sound and mature
judgment founded on large personal experience. That it
should be looked upon as a text-book for "students," in the
ordinary meaning of the word, we are hardly prepared to
agree. The ordinary student, for instance, cannot be
expected to take a great interest in all the different methods
of performing hysterectomy for myoma, in all the details by
which one differs from another, and in all the reasons why
one method is and should be preferred to another. While
such matters are of supreme importance to the gynaecologist,
to the student the matters of most importance are that he
should be able to diagnose the myoma, and should know
when to advise operation and when not to do so.
In the first chapter, " Anatomical and Clinical," a new and
important section is devoted to the vermiform appendix,
Reviews 4 1 7
and this is well ; for it should be known that infection of
the adnexa is not infrequently due to a diseased appendix,
and also that post-operative adhesions may involve the
appendix and cause pain and disappointment to the patient.
To avoid this, the pedicle should be covered with peri-
toneum, and the bowels should be mov-ed early after the
operation. Early symptoms of appendicitis should not be
mistaken for inflammation of the adnexa. Cases bearing on
these points are described and illustrated, notably one of a
large cystic ovary which had formed for its entire length a
Hrm union with an appendix containing two hard smooth
concretions the size of beans.
Dr. Macnaughton-Jones has given up the use of silk
ligatures, and for suturing the skin employs a strong white
thread of cotton impregnated with celloidin and called
celloidinzwirn, which is cheaper than silk, and has the
advantage of being capable of sterilisation by heat, after
which it is kept in perchloride solution. It may also be used
for deep sutures and ligatures. For other sutures and liga-
tures he uses catgut or Kroenig's cumol gut, which he linds
very reliable, and the preparation of which he describes.
He sterilises his hands and arms by thorough scrubbing
(with nail-brushes that are always kept in an antiseptic solu-
tion) and washing under a running tap of lysoform and
with Izal soap. They are then scrubbed with i in 1,000
sublimate solution and finally held for a few minutes in
equal parts of sublimate solution (i in 1,000) and absolute
alcohol. There are two basins for rinsing the hands in
during the operation : one of sterilised water, the other of
lysoform. Full directions are given for the cleansing of the
abdomen and vagina, and rendering the whole operative area
and surroundings aseptic. We are glad to see how strongly
anyone is condemned who, after the most elaborate anti-
septic preparations to secure asepsis, spoils it all by using his
pocket handkerchief or twirling his moustache. We have
seen such things done, and they must be stopped. We agree
with the author that if a patient loses her life from sepsis
VOL. XX. — NO. 80. 28
4 1 8 Reviews
that might have been prevented, the surgeon must hear the
responsibihty.
For uterine displacements requiring operative treatment,
a very small proportion, in cases absolutely uncomplicated
Dr. Macnaughton-Jones prefers the modified Alexander-
Adams operation. In cases complicated by adhesions or
adnexal disease, he thinks it is better to perform a coeliotomy
and, after dealing conservatively, if possible, with the adhe-
sions and adnexa, utero-suspension, or, if the patient is past
the child-bearing age, a ventrofixation.
For prolapse of the uterus and vagina there are many
operative procedures, from the late Lawson Tait's simple
repair of the perineum, to Christopher Martin's complete
extirpation of the uterus and vagina. They all have their
due description and due appreciation. We believe that the
ideal operation has yet to be devised. At present relief is
best afforded by some combination of operations, as for
example, in two instructive cases treated by hysterectomy
and colporrhaphy, the method of Leopold and Wolff. The
author says, *' that in chronic inversion of the uterus the
older methods of pressure and taxis will be abandoned in
favour of reposition by an operative procedure." The ex-
cessively low mortality of such operations, the rapidity and
completeness of the relief, as compared with that afforded
by repositors, certainly lends support to this statement.
The difficulty, first noted by Shaw-Mackenzie, of differ-
entiating between a haemorrhagic or glandular endometritis
and malignant disease is emphasised. The severe haemor-
rhage, even if arrested by curetting, returns in a short time
with increasing severity and demands, as in the case described,
hysterectomy for its cure. Many of these cases are micro-
scopically indistinguishable from cancer.
The portion in this edition devoted to myoma has been
very much enlarged and is a complete monograph in itself.
It is the outcome of a large personal experience and of a
wise judgment of the work of many of the most famous
gynaecologists which the author has had the advantage of
Revieivs 4 1 9
seeing. We would draw especial attention to what he says
about the complications and degenerations of myoma.
These are far more frequent than has generally been thought.
The latest investigations show that the mortality arising from
these tumours is at least 33"3 per cent. The mortality from
hysterectomy may be put at from 2 to 10 per cent. ; we think
it is much nearer 2 than 10. It must always be remembered
that the operating surgeon meets with complications of a
most serious nature, such as tubal and ovarian disease,
omental and intestinal adhesions, peritonitis and ascites,
degeneration and necrosis of tiie tumour and many others,
which help to swell the mortality after hysterectomy. They
are due entirely to the erroneous idea still laid down in most
text-books, that myomata are generally harmless and should
be left alone until they directly and immediately threaten
life. In the face of facts, this old teaching should be given
up, and it is gratifying to see this put so strongly by the
author. We would point out, too, that the men who put
forward and exaggerate the mortality rate of hysterectomy
as an argument against its performance are the very ones
who are responsible for a higher death-rate than is necessary.
The delay that they advise is the cause of the lethal com-
plications. We speak plainly, it is high time we did so.
After reviewing the entire subject of treatment in cancer
of the uterus, it would seem that from the extreme radical
measures with removal of glands, the results are hardly
more hopeful than those obtained by a free pan-hyste-
rectomy, with removal of such glands as may be felt, and
of as much of the vagina as may be called for.
We wish we could refer more fully to the important
chapters on chorion-epithelioma, illustrated by three beauti-
ful coloured plates of Sir Halliday Croom, on tuberculosis
of the female genitalia, on diseases of the appendages, and
on tubal pregnancy. In the last of these reference is made
to the view of Bischoff, His, and Strassmann, that the union
of the ovum and spermatozoa takes place in the Fallopian
tube. According to this theory each pregnancy begins as
420 Reviews
an extra-uterine one, and remains such only from some
obstruction or want of propulsion. Professor Taylor has
noticed the frequency of an atrophic condition of the tube
in tubal pregnancy, and pointed out that any want of
development, any contraction, any swelling of the mucous
membrane or any failure of muscular power in the tube,
increased the tendency towards a tubal instead of a uterine
pregnancy. Clarence Webster's case of imdoubted ovarian
pregnancy is mentioned. There is a very tine plate of an
instantaneous photograph of a reti'O-uterine h?ematocele
from rupture of the foetal sac (from Bimim). Several cases
are reported, illustrative of the value of conservative
operations.
All these chapters, together with those on affections of
the vulva, vagina, bladder and urethra, including a fine
description of the surgery of the ureter, reach a very high
standard. They, like the whole book, are most interesting.
We would say that it is a book that every gynaecologist
should read, that it is a veritable storehouse of valuable
information, anatomical, pathological and clinical, and is
most easy to read, since all the valuable points are illustrated
by cases in the actual experience of the author. It should
have a large circulation.
TABUL.4C GYX.^iCOLOGic^, 26 Mehrfarbige auf Pauslein-
wand Gedruckte Lithographische Tafeln, mit Kurzem
Erlaeuterndem Text, Herausgegeben von Professor
Dr. Friedr. Schauta, o. o. Professor der Geburtshilfe
und Gynaekologie an der Wiener Universitaet, und Dr.
F. HiTSCHMAN, Assistent der I. Universitaets-Frauen-
klinik (Hofrat Schauta) in Wien. Leipzig und Wien :
Franz Deuticke, 1905. Preis in Mappe 120 marks.
(Text : Folio 60 pp.)
Six large diagrams, coloured lithographs printed on
tracing linen, and in size 24 inches by 20 inches, illustrating
gyncccological and obstetrical histology and pathology, have
been sent to us as a sample of the complete set, which, as
Reviews 421
catalogued, numbers twenty-eight, although on several of
the plates two or more pictures are represented. The
colours are yellow, black, and different shades of red. The
magnification varies in the different plates from the low to
the higher powers of the microscope, and a remarkably good
effect is produced by holding the plates up to the light, for,
by reason of the transparency of the linen, the transmitted
light shows up in great clearness every detail ; the plates are
intended to be used only in this way, either by day or lamp-
light. The specimens sent to us, while they are to a certain
extent diagrammatic, are faithful to Nature. They com-
prise : (i) Intervillous circulation of the normal placenta ;
(2) the transverse sections of the Fallopian tube across the
isthmus and ampullary end (both on one plate) ; (3) the
early ovum embedded in the decidua of the uterus ; (4) an
incomplete tubal abortion (transverse section) ; (5) a ruptured
tubal gestation, showing erosion into the peritoneal cavity,
and (6) chorion epithelioma of the vagina. The first five
of these are good. The intervillous circulation of the
placenta and the sections of the Fallopian tube are especially
so. The catalogue shows that the other plates exemplify
the normal and the pathological histology of the pregnant
and non-pregnant uterus, including follicular and papillary
erosion, carcinoma and epithelioma of the cervix, hyper-
plastic and hypertrophic glandular endometritis, adeno-
carcinoma and sarcoma of the corpus uteri, as well as
inflammation and new growths of the Fallopian tubes and
ovaries.
We feel sure that the present publication will have a
future, and we can recommend these tables and plates to all
professors and lecturers on the subjects with which they
deal. They supply a distinct want in the available means
of teaching gynaecology, for experience shows that, as an
introduction and aid to personal observation, exactness in
detail in the pathology of disease can best be imparted to
others by pictorial illustrations.
42 2 Revieivs
The Preparation and After-treatmext of Section'
Cases. By W. J. Stewart McKay, M.B., M.Ch.,
B.Sc, Senior Surgeon to the Lewisham Hospital for
Women and Children, &c., Sydney, N.SAV. Royal
8vo, pp. XX. and 651, with 113 illustrations. London :
Bailliere, Tindall and Cox, 1904. Price 15s.
The instructions in regard to the preparation and after-
treatment of section cases to be found in text-books are not
full enough for the man who has had little experience in
abdominal surgery and, remembering his own initial diffi-
culties, Mr. McKay in this book has tried to make things
easier for others beginning such work. In so doing he
displays not only the results of a large and successful per-
sonal experience, but a most comprehensive acquaintance
with the recorded work of other surgeons — British, Ameri-
can and Continental. While freely quoting apposite cases
he does not omit those of his own failures, from which a
lesson is to be learned. He is a sound instructor on asepsis
antisepsis and sterilisation, and moreover essentially practi-
cal, as appears particularly in his description of the sterilisa-
tion and preparation of instruments, ligatures and dressings
at the surgeon's home, their packing and transportation,
and the other preliminaries for an operation in a private
house. For disinfection of the hands, he uses Lockwood's
biniodide of mercury method ; he considers the introduc-
tion of rubber gloves as one of the greatest advances made
towards minimising the danger of infection, especially when
the surgeon's hands have been exposed to that danger or
are cut or abraded, or for military service in the field, and
especially for the assistants at an operation. For superficial
ligatures he recommends silkworm gut ; for buried ones,
cumol catgut or silver wire. He has not used a marine
sponge for several years. While Olshausen, Zweifel,
Howard Kellv and others have led to the abolition of
drainage tubes and this abolition may not have affected the
results of operation in aseptic clinics, he thinks it would
deprive the less skilful of prophylactic measures against
Reviews 423
peritonitis they cannot afford to dispense with at present.
He insists that the vagina should always be made ready for
surgical interference, even when the proposed operation is
expected to be entirely abdominal.
The details of treatment in ordinary cases for the first
week are fully discussed. Sips of hot water may be given
after the first six hours ; to relieve pain and secure sleep the
author has found morphia, even in very small doses {-^^ — ^
gr.), and trional, most satisfactory. Gastric lavage as a
means of relieving obstinate vomiting, though mentioned, is
we think hardly given the credit it deserves. It is after-
wards recommended as an almost indispensable preliminary
to anaesthesia if the vomiting has been stercoraceous, and
also in connection with post-operative ha.niiatemesis. An
efiort is made in all cases to obtain an evacuation of the
bowels on the third day.
We would draw particular attention to the admirable
chapters on Pulse, Temperature and Respiration, and on
the Tongue. To that on Shock, which Mr. McKay charac-
terises as the most important matter in the treatment after
abdominal section ; and to those on Septic Intoxication,
&c.. Peritonitis and Obstruction, all very full, and enriched
by numerous cases and quotations. Watson Cheyne is
cited as saying that many deaths set down to shock are
really due to saprasmia, and Mr. McKay says that many
cases reported by the earlier ovariotomists as "collapse,"
were no doubt acute septicaemia. After the consideration
of the other complications the last chapter is devoted to the
repair of ventral hernia.
We have read the book with the keenest interest, and are
sure it will be welcomed by all abdominal surgeons, few if
any of whom would fail to learn from it. In this we agree
with Mr. Christopher Martin, who has seen it through the
press, a particularly difficult task, when the manuscript is
another's.
PUBLICATIONS RECEIVED.
From F. BAUEKMiiisTEU, Glasgow ; J. F. Bkrgmann, Wiesbaden :
Belastungslagerung. Grundzuege einer nicboperativen Behandlung chronisch-
entzuendlicher Frauenkranheiten. von Dr. LUDWIG Pincls, Frauenar/.t
in Danzig, mit 25 Abbildungen. Large 8vo, pp. viii. and 152, 1905.
Price 3s. gd.
Ilandbuch der Geburlshuelfe. . . In drci Baenden herausgegeben von
F. V. WiNCKEL in Muenchen. Mil zahlreichen Abbildungen im Text
und auf Tafeln, Zweiter Band. I. Teil, pp. x. and 654, price 14s. gd. ;
II. Teil, pp. X. and 798 (655—1452), price 18s. gd.
Transactions of the North of England Obstetrical and Gyn.eco-
LOGICAL Society, 1904, Fasciculi vi. and vii.
Also the following Pamphlets and Reprints : —
By J. Henry Barbai, Instructor in Surgery, University of California :
Fractures into and about the Elbow-joint.
Strangulated Femoral Hernia containing Appendix.
Surgical Treatment of Chronic Dysentery and Uretero-cystostomy.
By Dr. S. Flatau, Nuernberg :
Merkblatt verfasst im Auftrage der Fraenkischen Gesellschaft fuer Geburts-
hilfe und Frauenheilkunde : Ueber die Gefahren des Unterleibskrebses,
ein Mahnwort an die Frauenwelt ; also a flyleaf to all the Midwives, and a
circular to all the Medical Practitioners in Franconia : Zur Bekaempfung
des Uteruskrebses.
By Edgar Garceau, M.D., Surgeon to St. Elizabeth's Hospital, Boston:
La Cystite chronique rebelle, traduit de I'anglais par le Dr. Leon Imbert,
de ^lontpelier, 1904.
Removal of Calculus in the Ureter by a New Method ; and. Vesical Appear-
ances in Renal Suppuration.
By Dr. Ernest Hoennicke, Physician to the Royal Insane Asylum,
Sonnenstein, Saxony :
Zur Theorie der Osteomalacic. Zugleich ein Beitrag zur Lehre vcn den
Krankheiten der Schilddruese.
By Sir Arthur Vernon Macan, M.B., &c., Ex-President Royal College of
Phybicians, Ireland : Accidental Haemorrhage.
By E. S. McKee, M.D., Cincinnati: The Ethics of Gonorrhcea in the Female.
By W. P. Manton, M.D., Detroit, Michigan:
The Value of Non-Operative Local Treatment on Pelvic Disorders.
By Dr. Franz v. Neugebauer, Director of the Gynpecological Section 01
the Evangelical Hospital at Warsaw :
Hydromeningocele sacralis anterior (Sonderabdruck aus Hegar' s Beiiraege,
Band ix. , Heft 2), with 15 illustrations in the text.
By Dr. Ludwig Pincus, Frauenarzt in Danzig:
Die Bedeutung dei Atmokausis und Zestokausis fur die allgemeine Praxis
{Berliner Klinik, Heft 198, December, 1904).
By Francis J. Quinlan, M.D., LL.D. :
Inaugural Address of the President of the New York County Medical
Association, October 17, 1904.
By Clarence Edward Skinner, M.D., LL.D., Newhaven, Connecticut:
A Large Fibrosarcoma Treated by Roentgen Radiation.
By J. Bland Sutton, F.R.C.S., Surgeon to the Chelsea Hospital for
Women, &c., &c. : Essays on Hysterectomy.
i
SUMMARY OF GYW^COLOGY, IXCLUDING OBSTETRICS.
MAY, 1904.
Adrenalin, and Similar Preparations of the
Suprarenal Glands, in Gyn.ecology.
Peters, Dresden {Der Frauenarzt, 1904, Nos. i and 2),
reports most brilliant success from the use of adrenalin in
pruritus vulvae and acute vulvitis. In two most obstinate
cases previously treated in vain with all possible drugs,
a rapid cure was obtained by the following method : a
pad of cotton-wool soaked in a i : 2,000 solution of supra-
renin was applied for four minutes, all existing ulcers
were touched with caustic, and a dressing of byrolin was
applied. At night cotton-wool soaked in a i : 3,000 solu-
tion was introduced ; moreover, the suprarenin was again
applied for a short time twice each day. The improve-
ment was immediate and continued. Peters has tried
not only the English adrenalin but renoform (Freund
and Redlich) and suprarenin hydrochloricum (Hoechst),
As there does not appear to be any difference in their
action, he recommends the cheapest preparation, supra-
renin (10 cm. of I per cent, solution, is. 6d.).
Psychoses .\nd Operative Gynaecology.
Fredericq {Bull. Soc. Beige Gyn. ObsL, t. xiv., No. 4),
in a recent communication to the Belgian Gynaecological
and Obstetrical Society, said that while all authors ad-
mitted the extreme frequency of affections of the genital
organs in women with psychoses, they were by no means
likeminded as to the existence of any causal relation
between sexual and mental diseases. Baldy denies any
such relation, never having met with a case in which the
gynaecological trouble could be considered as the direct and
sole cause of dementia, and this view is taken by many
2 Stuninary of Gyno'cology, including Obstelrics
others. On the other hand, Schultze, Savage, Hall, &c.,
have insisted upon the great importance of sexual diseases
in the etiology of mental disorders. Others, again, admit
the possibility of a causal relation, but consider its
presence to be quite exceptional. Loewenfeld classifies
the gynaecological disorders of the insane as : (i) Those
directly or indirectly causing the psychoses ; (2) those
associated with other factors in doing so ; (3) those inde-
pendent of the mental state, but due to the same cause ;
and (4) those resulting from primary nervous disease.
Even those who admit a causal relationship between
sexual and mental diseases, hold opposite opinions as
to the propriety of operative treatment. Gilliam, for
instance, considers that every woman the subject of a
psychosis or epilepsy should be castrated. Others have
declared that no gynaecological operation should be per-
formed on the insane. Neither of these extreme views
should be accepted — no doubt the divergence of opinion
is to be sought in the difference in the results obtained
by different operators.
In 1887 Willers published an important report on the
results of castration in the treatment of psychoses. He
divided the cases into four groups : (i) Genital organs
healthy, 15 cases — 4 cured, 4 temporarily cured, 7 un-
affected or aggravated ; (2) ovaries healthy, genital canal
not so, 8 cases — 6 cured, i temporarily improved, i aggra-
vated ; (3) ovaries diseased, canal healthy, 20 cases —
13 cured, 3 improved, 4 unaffected ; (4) ovaries diseased,
canal more or less so, 14 cases — 13 cured, i aggravated.
Schramm has published 2 cases of epileps}^ Butler Smythe
I of ovarian neuralgia, Merkel 3 of neuroses, cured by
castration ; Reamy 6 cases of epilepsy, of which 5 were
cured ; Imlach i success, Ceccherelli 3 cases of hystero-
epilepsy, Munde 5 successes, all cured by castration. Rohe
in 20 such operations had 2 deaths, 4 complete cures, 3 so
far improved that the}-^ could be discharged, and 7 slightly
improved. Kroemer, in 1895, reported 3 cases of hystero-
epilepsy and i of mania, all cured by castration, though
not immediately after the operation.
On the other hand, Sharp, Goodell, Lusk, Lee, Fischkin,
de la Tourelle, not to mention others, have reported failures,
and are entirely opposed to castration as a method of
treating nervous affections in general.
Psychoses and Operative GyncEcology j
It seems possible that the difference in the results
of operation depends on the time at which it is under-
taken, that the failures have been when the genital disease
has had time to establish its bad effect upon the nervous
centres, and that the successes have been owing to timely-
operations. In any case the frequency of gynaecological
diseases in women the subjects of psychoses, for which
no other possible cause can be found, together with the
fact that by an operation it is often possible to cure the
sexual lesion, and at the same time cure or, at all events,
relieve the mental disorder, compels one to admit that there
must be some close connection between the psychoses and
the genital organs, though the nature of that connection
is still undefined, and also that it is justifiable to operate
on the insane, not merely in order to cure their genital
diseases, but with the hope of improving their mental
condition.
If this be admitted, it follows that, as recommended
by Hall, every woman mentally afflicted should be sub-
mitted to gynaecological examination, whether she com-
plains of any genital disorder or not, and this should take
place before her admission into an asylum ; secondly, that
as Schultze and Savage have suggested, a gynaecological
expert should be attached to every asylum, whose duty
it would be to diagnose the cases likely to be improved by-
surgical interference ; and, thirdly, that in every asylum
arrangements should be made for gynaecological opera-
tions, in order to avoid transferring the patients to another
hospital.
All this applies to insane women who have genital
disorders ; but is it right to operate upon genital organs
not manifestly diseased, as many have done ? Gordon,,
for instance, advises castration whenever the nervous
troubles are dependent upon the menstrual periods, even
when the adnexa are healthy. Kelly and others concur
in this view. And one could not blame anyone for trying
to cure by castration a hystero-epilepsy which had not
appeared till puberty, and then only at the menstrual
periods, even though the ovaries seemed normal on
palpation.
A different question is whether gynaecological opera-
tions are, as many authors affirm, more frequently than
^ Summary of Gynecology, including Obstetrics
others, followed by psychoses. Women, in any case, are
more liable to post-operative ps^^choses than men.
Fredericq has met with three cases of post-operative
mania : Two after vaginal hysterectomy — one patient
had the fixed idea that she must have the operation begun
again by the abdominal route, the other developed ideas
of persecution ; the third case was one of melancholia,
after a simple curettage for fungous endometritis. There
are very few cases recorded at all like the last, of mental
derangement after such a simple operation as curettage.
In the great majority of post-operative psychoses, the
nervous troubles have followed the removal of the
ovaries. Tait admitted their occurrence, but asserted
that they did not persist, and that it was not right to
judge of the effect of an operation till some time after
it. Champoniere states that there is a wide difference
between abdominal surgery in general, and operations
on the female genitalia, and that there is a difference
equally wide between different ovariotomies ; that the
less disease affects the ovaries, the greater the impression
produced on the nervous centres by their removal. Simple
castration is much more dangerous as regards the nervous
system than ablation of an ovarian tumour, that is to say,
obligatory castration.
The Value of Leucocytosis in Gynecology.
DuTZMANN, Berlin {Monats. f. Geb. u. Gyn., Bd. xviii.,
S. 243), gives the conclusions drawn from 2,000 exami-
nations of the blood of 223 patients.
(i) The enumeration of the leucocytes is a valuable
help in diagnosis in cases of exudation when purulent
softening is taking place, and strengthens the indications
for incision.
(2) The reaction of the white corpuscles to iodine
when pus is present tends to confirm the diagnosis in
doubtful cases.
(3) In gynaecological affections of the adnexa, with or
without suppuration, the enumeration of the leucocytes
is a useful means of differential diagnosis, and may be of
importance in deciding upon the method of operation,
vaginal or abdominal.
Cancer of Bartholin s Gland 5
(4) In cases of myoma, carcinoma, or tubal gestation,
it often constitutes the only evidence of a collection of
pus in some part of the system (in the adnexa, in a haemo-
tocele, or in the uterine cavity).
(5) Tuberculous pus causes no increase, and gonor-
rhoeal very little, in the number of leucocytes ; facts that
must be referred to greater tolerance and less absorptive
power of the peritoneum for these bacteria.
(6) In cases of large ovarian tumours, especially those
with twisted pedicles, and with great irritation of the peri-
toneum, there may be greatly increased leucocytosis in
the absence of any suppuration ; the iodine reaction will
then give a negative result,
(7) In sepsis the count of white blood cells is very
valuable for prognosis, inasmuch as persistent hyper-
leucocytosis is favourable, and a diminution in the number
of white cells the reverse. From this singular fact one
may perhaps learn the exact time for operative inter-
ference in puerperal fever.
(8) In eclampsia, the white blood cells behave as in
sepsis. In hyper-leucocytosis, the convulsions decrease
in frequency ; when the number of cells is normal or sub-
normal, the fits become more frequent and the case becomes
worse. This supports the idea that eclampsia is due to
infection.
Cancer of Bartholin's Gland,
Fritsch, Bonn {Monats. f. Geb. u. Gyn., Bd. xix., S. 60),
reports the following case : A woman, aged yy, otherwise
healthy, complained of a tumour of the external genitals,
which had been growing for some three years, and at first
small, now the size of a walnut, interfered with her walk-
ing. It gave rise to a profuse mucous discharge, which
was sometimes very foetid. The tumour was of a cauli-
flower form, composed of several lobes of tolerably firm
consistence, of a red colour, like fresh granulations, covered
with vitreous mucus, which when wiped off quickly re-
appeared, welling in drops out of the tissue. The growth
was fairly movable. The inguinal glands on both sides,
especially on the right, were swollen. It was easily
removed with the right nympha, and the vaginal mucous
membrane stitched to the skin ; the wound healed well.
6 Summary of Gynecology, including Obstetrics
The form of the growth was that of a mushroom, and
projected over healthy tissue on all sides. A section,
hardened in alcohol, showed the stalk as a hard whitish
strip of connective tissue reaching inwards for about i cm.
The mass to the naked eye resembled a papilloma, it was
apparently solid throughout, with no spots of extravasation
or softening. Microscopically the stroma of firm connec-
tive tissue exhibited signs of inflammation, and a small
abscess was in process of formation at one spot. At
the base of the tumour there was a cyst the size of a
hemp-seed, no doubt the remains of Bartholin's gland.
Most of the growth presented the structure of a simple
papilloma, but in some places there were evident signs of
carcinomatous change. It was, in fact, a papilloma which
had evidently originated from the polynuclear cyclindrical
epithelium of the duct of Bartholin's gland, and in various
ways resembled villous vesical cancer.
Benign Cystadenoma of the Vulva.
Pick, Berlin {Archiv f. Gyn., Bd., Ixxi., S. 347), reports :
In two cases, women of 40 and 45 years respectively, a
number of new growths, some rather larger than a pea,
were present in the labia majora, and were found to con-
sist of well-developed glandular canals. Their structure
exactly resembled that of normal sweat glands. The
growths were tubular (cyst) adenoma of the type of the
sweat glands, and not malignant.
The Origin of Vaginal Cysts.
Fredet {Ann. Gyn. Obst., 1904, March) sums up our
present knowledge on the origin of vaginal cysts in the
following conclusions : (i) No other origin for these cysts
has been established with certainty except in aberrant
tissue of the Wolffian canals, and pseudo-glandular canali-
culi and the vulvo- vaginal glands. (2) A cyst on the
upper part of the lateral wall of the vagina is possibly
Wolffian ; if very low, it is probably derived from vulvo-
vaginal gland tissue. (3) Cysts in the anterior wall of
the vagina point to aberrant tissue derived from glands
of the cervix or urethra as their origin. (4) Cysts on the
posterior vaginal wall are the most difficult to explain ;
Double Congenital Cysts of the Vagina y
high up, they may originate from the pseudo-glandular
diverticuli of Gartner's duct, or the canaliculi of the
Wolffian body ; lower down, in the median line, we may
be dealing with an embryonic Douglas's cul-de-sac ; near
the vulva, vulvo-vaginal gland tissue may be the starting
point. P. Z. H.
Double Congenital Cysts of the Vagina.
Con {Revista de Chirurgic, 1903, p. 416) reports : In
a patient, aged 41, who came to the hospital on account
ol uterine haemorrhage, there was a cyst as large as a nut
in the left labium minus, and a similar one in the left side
of the posterior vaginal vault about the level of the os
tincae. In shape each cyst was round and elongated ; there
was fluctuation, but no pain in either, and they were easily
enucleated. In removing the upper cyst the peritoneum
in Douglas's pouch gave way, and drainage was necessary,
but the recovery was fever free and uninterrupted. The
contents of each cyst was thick, opaque, yeUo wish- white,
thread-forming matter.
[ Multiple vaginal cysts (two to six) are not common.
In many cases those met with seem to be connected with
each other ; in others they are separated more or less ex-
tensively. They are invariably in one line, which is almost
always directed from without inwards and from above
downwards, a circumstance that makes it probable that the
origin of the majority is in Gartner's ducts, the remains
of the Wolffian canals, and that very few are extra vaginal
remains of Miiller's ducts.
Anatomical and Clinical Notes on Vaporisation of
THE Uterus.
FuCHS {Archiv f. Gynaek., Bd. Ixix., Heft. 3), in
this work, limits the indications for vaporisation to con-
ditions in which a new therapeutical influence is actually
required, and records the beneficial effects obtained by
this method in such conditions at the Kiel Klinik. The
method, however, as there practised, is the systematic
combination of curettage and the application of steam.
In 68 cases of uterine haemorrhage so treated, Fuchs
had 60 permanent cures (88-2 per cent.) ; immediate and
8 SiDumary of Gyiicecology, including Obstetrics
final menopause resulted in i8 ; arrest of haemorrhage for
some weeks or months, followed by normal menstruation,
in 23 ; and, without any prolonged amenorrhoea, the
catamenia became of normal or subnormal intensity in
19 cases.
In 3 of the 8 cases, which were but partially or not at
all improved, curettage had been omitted ; a fact which
supports the importance of the preliminary use of the
curette.
To avoid the danger of stenosis of the cervix, and espe-
cially of atresia of the internal os, Fuchs advises that no
metallic terminals should be employed.
The successes obtained at the Kiel Klinik by the
combination of curettage and steam are the more re-
markable as it was only exceptional cases that were char-
acterised as permanently cured on written reports ; the
patients were almost invariably subjected to personal
control on many subsequent occasions.
Hantke, Berlin {Monats. f. Geb. u. Gyn., Bd. xvii.),
reports that in Czempin's Klinik the use of hot steam is
adopted for the purpose of bringing on the menopause.
In climacteric hcemorrhages it has most brilliant success,
and renders total extirpation quite unnecessary. It is
also indicated by subserous and some forms of interstitial
myomata, in which a radical operation is no longer possible,
and by uncontrollable haemorrhage after castration, and
haemophilia. Finally, it should be employed for inducing
sterility instead of the methods employed hitherto.
Precocious Menopause.
SiREDEY (C. R. Soc. Obst. Gyn. Pcsd., December, 1903),
after mentioning tuberculosis, cancer, arterio-sclerosis,
Bright's disease, cardiac affections, and chronic paludism
as occasional causes of early menopause, refers to
other cases in which women have unexpectedly ceased
to menstruate ten, fifteen, or even twenty years before
the average climacteric age. Some of these cases may
be explained by excessive involution of the uterus after
very frequent labours or prolonged lactation ; but a large
proportion of them occur in nulliparous or sterile women
in whom a comparatively late appearance of the cata-
Retroflexion of the Uterus and its Treatment g
menia, and a scanty menstrual flow, justify the supposition
that the genital functions were not normally developed.
In other respects their health has been generally good,
and, as a rule, the menopause causes them very little
inconvenience, except, possibly, transient flushings of
the face and giddiness, which the patients hardly ever
consider of sufficient importance to lead them to consult
a physician. This is in striking contrast with the effects
of an artificial menopause, brought on by a surgical opera-
tion, which is often followed by intense nervous symptoms,
constant flushes of heat, giddiness, vertigo, headache
and tachycardia, to an extent which may preclude the
patient from undertaking any kind of work, and often
require prolonged treatment. One particular condition
observable in cases of precocious menopause is the gradual
effacement or atrophy of the cervix, and may furnish a
guide to the diagnosis. As early as two or three months
after the last appearance of the menses some atrophy of
the cervix may be detected, although the body of the
uterus still retains its normal size, and does not begin
to atrophy until the cervix has dwindled to a mere promi-
nence in the vaginal vault. This character distinguishes
the atrophied from the infantile uterus, in which the cervix
continues disproportionately larger than the body, and
the portio vaginalis is considerable.
P. Z. H.
Retroflexion of the Uterus and its Treatment.
Graefe {Graefe's Samml. zw. Abhandl., Bd. v., Hft. 2)
insists that retroflexion of the normal uterus requires
no treatment, as the troubles of which the patients com-
plain do not arise from the displacement. A painstaking
anamnesis and general, not merely gynaecological, exami-
nation will, as a rule, reveal chlorosis and hystero-neuras-
thenia, and these are the conditions which are to be cured,
and it is better not to tell the patients that any displace-
ment is present. It is, indeed, only when the invahd is
possessed with the fixed idea that it is only by the correction
of the kink in her womb that her sufferings can be relieved,
that any steps should be taken in regard to it, and then
it is better to abstain from pessary treatment, and to fix
the uterus by the Alexander-Adams's operation. In cases
10 Summary of Gyncecology, inc hiding Obstetrics
of sterility it is allowable to attempt a cure by remedying
the retroflexion of an otherwise normal uterus, and this
is so even when the uterus and appendages are fixed by
adhesions. Retroflexion of the gravid uterus does not
in every case require treatment, though reposition and
the support of a pessary is advisable when the patient
cannot be kept under close observation, especially if the
fundus is very low down. Should symptoms of incar-
ceration appear, even very slight ones, the above treatment
is indicated, and the indication is also present when one
or more abortions have occurred from a retroflected womb.
If the gravid uterus be fixed by adhesions which have
not yielded to repeated attempts at reposition, or several
applications of the colpeurynter, and the organ be delayed
in rising out of the small pelvis into the abdomen, lapar-
otomy is justifiable in order to separate the adhesions
and correct the displacement ; an enlarged hj^peraemic,
tender, retroflected uterus should not be left alone, but
should be replaced and fixed in anteflexion by a pessary
or by operation. The same indications are present if
one or both ovaries have descended with the fundus uteri.
Such complications as metritis and endometritis must, of
course, be treated at the same time.
Alexander- Adams's Operation.
Steidl, Strassburg {Monats. f. Geb. u. Gyn., Bd. xix.,
S. 234), reports that in sixty cases which were all, except
as regards the incision, performed in the way originally
described by Alexander, there were only 4-4 per cent,
of recurrences, and that in four women who conceived
after the operation, apart from some dragging pain, gesta-
tion and labour were normal. The cases are given in
tabular form.
Prolapse and the Alexander-Adams's Operation.
Jacoby {Archiv f. Gyn., Bd. Ixx., S. 506) reports upon
257 operations for prolapse performed in Asch's Khnik
at Breslau in the seven years 1894 to igoi. The results
were controlled in 202, of which 94-5 per cent, were per-
manentl}^ cured. The proceeding chosen depended upon
the particular conditions of each case, but the correction
Results of Operations fo7' Prolapse ii
of the position of the uterus was invariably undertaken
when that organ in retroversion or retroflexion shared
in the prolapse of the vaginal wall. For this purpose
he recommends the Alexander-Adams's operation in every
respect as giving better permanent results than any other
method.
The Permanent Results of Operations for Prolapse
AND Retroflexion.
Baatz {Monafs. f. Geb. u. Gyn., Bd. xix., S. 410) reports
on the results of 217 operations for prolapse performed
in the Koenigsberg Klinik by various methods ; the results
were ascertained in every instance by personal control,
and generally by Professor Winter himself, and in none
depended upon a written report. He compares the
results of plastic operations in the vagina performed before
and after Professor Winter took charge, and concludes :
Vaginal prolapse without retroversion of the uterus
may be treated by plastic vaginal operations as extensive
as possible. When combined with mobile retroversion of
the uterus in women still possibly fertile, all primary pro-
lapse of the uterus, and all prolapse with rigid retroflexion
as well as all large and total prolapse, is best treated by
ventrifixation and extensive plastic operations on the
vagina. Prolapse of the vagina with mobile retroversion,
in the climacterium, when the prolapse is neither total nor
very large, is most successfully treated by vaginal fixa-
tion with extensive plastic operation. In uncomplicated
retroflexion, whether mobile or rigid, ventral fixation
gives the best result. When the portio is greatly hyper-
trophied, or the cervix much elongated, supravaginal
amputation of the portio is desirable. The results at
Koenigsberg, as those of Kroenig and Feuchtwanger,
show that the Alexander- Adams's operation is not a reliable
one for prolapse. As regards Hegar's statistics of 92 per
cent, of permanent cures by plastic operations alone
Baatz points out that results at all approaching them
in success have not been obtained by any other operator.
Baumm, who recently claimed to have cured 69*8 per
cent, without rectifying the position of the uterus, depended,
in three-fourths of his cases, on written reports of the cures.
12 Sjuiwiary of Gymcscology, including Obstetrics
The Effect of Pregnancy on the Cicatrices of
Previous Operations upon the Uterus.
V. Fellenberg, Berne {Archiv f. Gyn., Bd. Ixxi., S. 306),
reports two cases which show that after excisions or enu-
cleations from the uterine wall the wounds must be most
carefully sutured, if necessary in layers, and that the
patients should be kept under observation during any
subsequent pregnancy. In each case an abdominal sec-
tion had been performed, and the uterine end of one tube
excised by a wedge-shaped incision. Both the women
conceived, and in one the uterus ruptured with a fatal
result at the seat of the scar, presumably, owing to the
implantation of the ovum near by ; in the other, the wall
of the uterus at the cicatrix seemed during the pregnancy
and labour extraordinarily thin ; the labour came on
prematurely, and the child was dead ; the puerperium,
however, was normal.
V. Caumonberghe {Semaine mcd., 1904, No. 9),
referring to the Academy of Medicine of Belgium upon
a communication of Herman, said : The patient was a
dwarf, only 1-05 metres in height, upon whom Herman
in April, 1903, performed Cfesarean section for the second
time, two years after the former operation. On examina-
tion of the abdomen at full term, the head of the foetus
could be felt immediately below the skin, and Herman
diagnosed a rupture of the uterus, with extrusion of the
child into the abdominal cavity, and the child was extracted
after laparotomy. There was no blood in the sac, the
amniotic fluid was tinged with meconium ; the placenta was
broadly based on the posterior wall of the fundus of the
uterus, while the anterior wall of the sac was formed by the
omentum above, the abdominal wall in front, and the
utero-vesical cul-de-sac below. It seemed that the cicatrix
of the incision in the uterus made to deliver the former
child had given way, and that the present gestation sac
was partly within, and partly without, the uterus. The
edges of the opening in the uterus were thick and rounded,
and did not bleed ; the amniotic sac followed the placenta,
detaching itself from within outwards as far as the edges
of the abdominal wound.
Extirpation of the Spleen ij
Bisection of the Uterus in Abdominal Hysterectomy.
Faure {Semaine med., 1904, No. 9), at the Societe
de Chirurgie, recently insisted on the advantages of
bisection of the uterus in abdominal liysterectomy when
the adnexa were adherent on both sides. When the adhe-
sions affected one side only he recommended the American
method of attacking the uterus, first on the free side,
and turning it over upwards from below towards the other.
But when both the left and the right adnexa were adherent
to the pelvic parieties, as well as to the uterus, bisection,
in his opinion, was the method of choice, as by it the
adnexa on each side could be easily detached and removed
with the corresponding half of the uterus. Schwartz, on
an experience of thirty or thirty-five cases, also approved
of bisection. Ricard thought that no one now systemati-
cally adopted the same procedure in every hysterectomy,
but varied the method employed according to the exigen-
cies of each case.
Extirpation of the Spleen : Its Indications and
Results.
Jordan, Heidelberg {Zentralb. j. Gyn., 1904, No. 15),
says that extirpation of the spleen may now be considered
not merely a justifiable, but an extraordinarily successful
operation, the field for which is constantly being extended.
While the function of the spleen is still obscure, no case
free from objection has so far been brought forward to
show that death has been directly due to deprivation of
that organ, and it must be admitted that the function of
the spleen can very quickly be supplied by other organs.
Indications for the extirpation of the spleen are given
by injury or traumatic prolapse, and absolutely by sub-
cutaneous rupture, as Jordan exemplifies by reporting
a case. He also describes six successful splenectomies
performed by himself for various reasons, and quotes
several others. Even a wandering spleen he considers
is more safely treated by extirpation than by splenopexy.
The prognosis of extirpation is favourable when the lesion
is purely a local one, but, if it depend on constitutional
disease, the operation is not merely useless, but directly
dangerous to life. The manner in which the abdominal
i^ Stiminary of Gyncscology, including Obstetrics
incision should be made depends entirely upon the con-
ditions of the particular case. Women are far more subject
to lesions of the spleen than men.
The Causes of H.5:morrhage in Myomatous Uteri.
Theilhaber and Hollinger, Munich {Archiv f. Gyn.,
Bd. Ixxi., S. 289), have ascertained from the examination
of eighteen myomatous uteri that the endometrium in
cases attended with haemorrhage does not differ in any
characteristic way from that of cases which do not bleed ;
on the other hand, in the muscular tissue of the former
the muscular areas are smaller, the connective tissue
surrounding them thicker, and the blood vessels more
numerous and of larger calibre, than in the latter. There
is, in fact, the condition known as myofibrosis uteri.
The Degeneration of Uterine Myomata.
Worrall, Sydney {Australian Med. Gaz., 1904, No, i),
reports the following cases : (i) M. C, aged 51, consulted
a surgeon thirteen years ago for a tumour associated with
profuse menstruation, and was told that it would dis-
appear at the change of life. Four years later, as it had
continued to grow, she consulted another surgeon, who
gave the same opinion. The menopause occurred when
she was 48, and the tumour did not increase in size till
six months ago, since when it has done so rapidly, and
she had become very weak, emaciated and dropsical.
Abdominal hysterectomy relieved her greatly for a fort-
night ; but a mass formed in the liver, and she died
exhausted, but without suffering, in a few weeks. The
tumour was a mixed cell sarcoma. (2) J. H., aged 47,
had suffered for three years from almost constant uterine
haemorrhage, and a gradually enlarging abdominal tumour.
A smooth, elastic mass, extending three inches above the
umbilicus, was removed by abdominal hysterectomy with
some difficulty, owing to its soft, pultaceous character
from myomatous degeneration and to deep peritoneal bur-
rowing. The patient made a good recovery. (3) A multi-
para, aged 44, last child aged 13, had had menstruation
lasting for several months, at intervals for the past two
years. A prominent irregular tumour reaching nearly
The Degeneration of Uterine Myomata i ^
to the umbilicus was removed by abdominal hysterectomy,
and she had an easy recovery. The tumour was a beautiful
specimen of myxomatous degeneration of a myoma in the
posterior uterine wall. (4) E., aged 27, who had a fibroid
polypus removed five years ago, and a year later was oper-
ated on for ectopic gestation, had had almost constant
haemorrhage for the past two years, and was quite blanched.
Her uterus was enlarged as if three months gravid, and
contained a submucous myoma undergoing myxoid de-
generation. She made an easy recovery after abdominal
hysterectomy. (5) R. H., single, aged 43, had a severe
attack of peritonitis eighteen months ago, when the doctor
in attendance discovered an abdominal tumour. A year
ago she was advised by a surgeon that the tumour would
probably disappear at the change of life. It had, how-
ever, rapidly increased in size during the past few months,
and her menstruation was very profuse, lasting a fortnight.
Abdominal hysterectomy. The tumour was a multinodular
myoma, the pedicle of which had undergone axial rotation
from left to right three times. It was extensively adherent
to the parietes, and to the omentum from the dilated
vessels in which it had been nourished. On section it
presented a large softened area, resembling brain tissue
and suggestive of malignant change, but proving to be
a necrobiosis from impeded vascular supply. A good
example of the origin of peritonitis from torsion of the
pedicle of a myoma, and of compensating blood supply
through omental adhesions. (6) E. M., hysteromyomec-
tomy and removal of the appendages for a right multi-
locular ovarian cyst, the size of a pear, and a sessile
outgrowth from the posterior uterine wall in the centre
of which there was a large focus of calcareous degenera-
tion. She had suffered from severe hypogastric pain for
four months, and the tumour was increasing in size.
Worrall insists that though the various degenerations
of myomata are recognised in the text-books, sufficient
importance is not given to the evil effects of these tumours
on the general health, owing to anaemia, cardiac change
and renal destruction, and also to degenerations and
infections of the tumours themselves. Of the myomata
he had removed in the past three years, 15 per cent, were
undergoing degeneration of one kind or another. The
1 6 Sujumary of Gynecology, mcluding Obstetrics
first case reported is an absolute proof that sarcomatous
degeneration does occur, but even if histologically benign,
a degenerating tumour of the uterus is clinically malignant,
and surely, even if slowly, fatal.
Sarcomatous Degeneration of Myomata.
Haueer (I. D., Muenchen, Zeniralb. f. Gyn., 1904,
No. 11) describes three instances of sarcomatous degenera-
tion of myomata from the private practice of Professor
Klein ; they occurred among 138 cases of myomata.
He comes to the following conclusions : About 3 per cent,
of the myomata removed by operation exhibit sarcomatous
degeneration. Even after the menopause, therefore, myo-
mata may not be considered free from danger, but should
be examined at least every other month. If they are
evidently increasing in size, especially after the climacteric,
the safest course is extirpation. The results of well-timed
operations for myoma, when there is little or no degenera-
tion of the heart, are so favourable that it is better to
operate on myoma which are still certainly innocent,
than on such as have become malignant. It is only such
myomata as remain constant in size or are diminishing
that may be considered to be free from danger, and even
these should be kept under observation. Nevertheless,
the enlargement of myomata during gestation must not
be in itself considered an absolute indication for operation.
Myoma and Heart Disease in their Causal Relation.
Fleck, Goettingen {Archiv f. Gyn., Bd. Ixxi., S. 258),
states that in 325 cases of myoma coming under obser-
vation during twelve years, 133, that is, a percentage
of 40-9, were suffering from pathological cardiac lesions.
This statement, however, includes every variation from
the normal conditions of the heart. He believes that in
reality the percentage of heart disease in uterine myoma
is considerably higher, or that possibly both the uterine
and cardiac affections are due to a common cause, some
anomaly in the processes of metabolism. This is suggested
by the comparative frequency of obesity, and the constant
occurrence of gross anatomical changes in the ovaries,
in association with uterine myomata.
Consei'^oative Operations for Myomata ly
The Treatment of Uterine Myomata.
Pfannenstiel, Giessen {Deutsche m. Wchns., 1904,
No. 14), disapproves of injections of ergotin and intra-
uterine measures in general, considering the curette should
not be used unless the whole of the intrauterine mucosa
•can be brought within the reach of the finger and curette,
nor unless the cavity is empty, that is to say, is not made
uneven by projecting tumours, or except after the removal
of submucous myomata. He defines the indications for
operation as: (i) A certain size of tumour; (2) acute
suffering ; (3) submucous myomata (haemorrhage) ; (4)
eccentric and deeply-seated tumours that are getting
larger, especially such as are subvesical and may press
on the urethra, or lateral, and lead to injur}^ of the veins
or thrombosis ; (5) pediculate subserous tumours apt for
torsion or incarceration ; (6) quickly-growing myomata,
suggesting sarcoma ; (7) all cases which are complicated
b)y the myoma. The best time for operating, in his opinion,
is after the menstrual period.
Conservative myotomy should not be made a matter
of principle, and in large interstitial or multiple myomata,
and in diffusely extended adenomvoma, the corpus uteri
should be removed with the tumour. Enucleation is
best adapted for submucous polypi. Too much care
may be bestowed on preserving the power of conception,
but hardly upon preserving the function of the ovaries.
Pfannenstiel is in favour of abdominal rather than vaginal
operations, but lays great stress upon an aseptic condition
of the uterine cavity and cervical canal. He has aban-
doned abdominal total extirpation.
The Scientific Basis for Conservative Operations
FOR Myomata.
Winter [Zeitschr. f. Geb. u. Gyn., Bd. li., Hft. 2), on
the basis of his own cases in the Koenigsberg Frauen-
klinic and those of his predecessor Dohrn, and a series
of statistics recently published, discusses from every point
of view the differential indications which have to be con-
sidered in deciding in individual cases whether radical
or conservative operation is the more suitable. The
hypotheses relied on are briefly as follows : Conservative
1 8 Summary of GyncBCology, including Obstetrics
operation preserves the menstrual function ; it enables
some women under 40 years of age to conceive ; it is not
followed by omission symptoms. On the other hand,
even when every nodule that can be seen or felt is removed,
conservative operation is not a sure preventative against
recurrence ; it does not certainly remove the patient's
sufferings, and its immediate results, when it is vaginal,
and still more when it is abdominal, are less favourable
than radical operation. Winter therefore concludes : —
Conservative measures are indicated absolutel}^ : by
all subserous tumours with slender pedicles if the uterus
itself is free from any myomatous nodules ; by all sub-
mucous tumours in process of expulsion, even though
they be so large as to make the uterus reach above the
navel, it being presupposed that the lower pole of the tumour
can be forced into the pelvis, and that the corpus uteri
is freely movable.
Radical operation is absolutely indicated by myomata
in sarcomatous degeneration, and b}' such as are com-
bined with carcinoma.
The following tumours call for the exercise of judg-
ment : Broadly inserted subserous myomata ; myomata
entirely interstitial, provided that the enlargement of
the uterus is but moderate ; large submucous myomata
with broad insertions when the cervix is closed, and the
various forms of multiple myomata.
Winter defines his own point of view^ : Uterine myo-
mata in general demand radical operation. Conservative
operation is justified in suitable cases if the patient ear-
nestly desires children, and if she sets much value on
retaining her menstrual function. During pregnancy,
conservative measures are generally to be preferred, and
radical operation to be limited to well-defined cases.
Total or Subtotal Hysterectomy for Fibromata.
Jacobs, Brussels {Bull. Soc. Beige Gyn. Obst., t. xiv..
No. 4), in connection with the recent discussion at the
French Society of Surgery (aw^e vol. xix., Summary, p. 186),
opened the same question in the Belgian Gynaecological
and Obstetrical Society. He confessed that he had formerly
been a partisan of total abdominal hysterectomy for
fibroids, on the grounds of one personal and several reported
CJwrio-ectodermal Epithelioma i^
observations of malignant degeneration of the stump.
He had, however, changed his opinion and was opposed
to the view of Richelot. If the cervix was a bad one,
enlarged, lacerated and torn, with large ectropions, &c.,
he admitted that total extirpation was the proper course ;
but if, as he took it to be in most cases of fibroma, the
cervix was normal, he was entirely in favour of subtotal
hysterectomy. Fibrous tumours undoubtedly tend to
degenerate, but the degeneration is rarely malignant.
Fibroma and cancer being the two diseases most commonly
affecting the uterus, it is natural that we should all see
the combination of the two occasionally. But it does not
follow that the fibrosis has any influence in causing malig-
nant degeneration of the stump, and as yet no statistical
evidence has been brought forward to support that idea.
He was now decidedly in favour of subtotal hysterectomy
for fibroids. He had performed several hundred total
hysterectomies, many hundred subtotal, and his mortality
was practically the same for the two operations ; but
he held that if both methods offered the patients the same
prospect of cure, it was desirable to avoid opening the
vagina. Total hysterectomy was the longer of the two,
it was always more laborious, and, in spite of all that had
been said at the French Surgical Society, was liable to
be attended by serious haemorrhage.
Chorio-ectodermal Epithelioma.
L. Landau, Berlin {Zentralb. /. Gyn., 1904, No. 7),
has seen five cases of chorio-ectodermal epithelioma, and
gives the histories of three. All patients were young
people, all were operated upon, and with one exception
all died from recurrence or metastases, which proves the
malignity of these tumours. Landau thinks them to
be not very uncommon, and does not suppose that any
parasite is a factor in tlieir development.
Chorionepithelioma.
Reeb, Strassburg {Archiv f. Gyn., Bd. Ixxi., S. 379),
reports the following cases from Fehling's Klinik : (i) A
quintipara, aged 26, had haemorrhage four weeks after
child-birth, and a fibrinous polypus and some remains
of decidua were removed with the finger ; three weeks
20 Snniinary of Gyncccology, including Obstetrics
later the haemorrhage recurred, the curette was then used
and a diagnosis of chorionepitheHoma made, upon which
the uterus, adnexa, and a tumour in the vaginal vault
the size of a pea, were extirpated by the vagina. Fatal
haemorrhage occurred on the thirty-fourth day after the
operation. Metastases were found in the omentum, lungs
and paravaginal tissue. (2) A decipara had haemorrhage
four weeks after an abortion in the third month. On
palpation and the use of the curette a diagnosis of syncytial
new growth was made, and the uterus was extirpated
by the vagina. No recurrence had taken place ten months
later.
Primary Genital Tuberculosis.
GoTTSCHALK {AvcMv f. Gyji., Bd. Ixx., S. 74) reports
a case of extreme tuberculous disease of the ovaries and
tubes which had been under observation, and remained
cured, for three years after vaginal total extirpation. In
the ovaries there were sacs of caseous matter, the contents
of which (as also that of the tubes) proved quite virulent.
Arising from the posterior lip of the os uteri there was a
peculiar cauliflower villous growth, of which the epithe-
lium under the microscope proved polymorphous and
exhibited stratiiication, vacuolisation, and was beset with
tubercle. As the patient, an intact virgin, was not affected
with any other tuberculous deposits, and her father was
a tuberculous person, Gottschalk supposes that there
liad been transmission by the semen, and that the tuber-
culosis was primary and hereditary. According to Boveri,
we may suppose that such tubercle bacilli as are trans-
mitted by the semen infect those portions of the fertilised
ovum only from which the germinal cells of the new
organism are produced. This would explain how the
disease primarily affected the ovary and from thence
descended to the tube.
Tuberculosis of the Female Genitalia.
ScHAKHOFF (L D., Geneva, 1903, Zentralh. f. Gyn.,
1904, No. 14), from the examination of forty-three speci-
mens in the Pathological Institute at Geneva (Prof. Zahn),
draws the following conclusions : Tuberculosis of the
female genital organs is comparatively uncommon, but
Cai'cinovia and Tnbercitlosis of the Uterus 21
may affect any part of the genital tract, most frequently
the tubes, rarely the cervix, and most rarely the vagina.
It affects women of every age, but is most common between
20 and 40. It is generally secondary to tuberculosis of
the lungs or bronchial glands, more rarely to intestinal
disease, and with the exception of the vagina, which may
be infected from without, the affected parts are contami-
nated through the blood-vessels. The peritoneum is
often involved, especially when the tubes are diseased.
Tuberculosis is conveyed from a primary focus, directly,
by the blood-stream, to the tubes, and from thence, by
continuity, to the uterus or peritoneum. The uterus
may be affected, directl}^, from a primary focus ; but is
so more commonly by continuity from the tubes. In
the former case a predisposing factor may be found in
the puerperal state, or some affection which, by mechanical
irritation, induces an active hypersemia. Vaginal tuber-
culosis occurs, secondarily, owing to descent from the tubes
or uterus ; when primary the infection is from the urine
or faeces. The ovaries may be affected from the tubes,
peritoneum, or rectum, by continuity through adhesions ;
but ovarian tuberculosis may also occur quite independ-
ently of any disease in its neighbourhood, owing to
infection through the circulation, from a primary focus in
some other part of the S3"5tem. , ,
On the Combination of Carcinoma with Tuberculosis
OF the Uterus.
Wallart, St. Louis {Zeitschrift f. Geb. u. Gyn., Bd. 1.,
Hft. 2), draws the attention of gynaecologists to the reports
of two cases of uterine tuberculosis associated with car-
cinoma, observed by himself and published by Kaufman
in the second edition of his text-book. In the first, the
patient was a woman of 55, who was curetted, and in the
abraded portions of the uterine mucosa numbers of caseated
tubercles with giant cells were found, together with adeno-
carcinoma. In the second, the patient, a woman of 50,
had secondary genital tuberculosis by descent from the
peritoneum to the tubes and uterus, probably due in the
first place to primary pulmonary disease. Contrary to
the usual condition of things in such cases, the cervix had
undergone serious alteration, as it showed the extremely
22 Summary of GyncBcology, including Obstetrics
rare combination of tuberculosis with carcinoma ; more-
over, it was evident that the carcinomatous changes in
the cervical tissue were of later origin than the tubercu-
losis which had already affected the paracervical glands,
while the cancer was limited to the inmost layers of the
cervix. In a third case he has found caseous tuberculosis
of the mucosa of the corpus in a woman of 37, associated
with extensive cervical carcinoma. As the two diseases
were at some distance apart, the author considers the asso-
ciation merely a coincidence.
With regard to his second case and similar ones else-
where published, Wallart believes that in some instances
tuberculosis of the uterus, especially of the cervix, may
constitute the predisposing factor for carcinoma. He
believes, further, that the combination of carcinoma and
tuberculosis in the uterus is not so uncommon as has been
supposed.
Co-existence of Carcinoma of the Ovaries and of
THE Corpus Uteri.
Boeckelmann {Thesis, Leipzig, Zentralb. f. Gyn., 1904,
No. 4) reports a case of bilateral carcinoma of the ovaries,
with co-existing carcinoma of the corpus uteri. While
the latter exhibited the structure of adenoma malignum,
the ovarian tumours were distinctl}^ papillomatous in
character. The cancer of the corpus he considers to be
primary, and the ovarian tumours not to be metastasis,
but independent new growths. [Cf. Dr. Gelston Atkins's
Case, ante p. 46.]
Adenomyoma of the Uterus.
Cullen, Baltimore {Orth-Festschrifi, 1903), describes
a series of cases of adenomyoma of the uterus that came
under observation and operation at the Johns Hopkins
Hospital, and illustrates the histological details of the
several cases by a number of excellent drawings. In the
adenomata of the corpus uteri the first change is a diffuse
myomatous thickening of the inner muscular wall with
which is associated a penetrating ingrowth of the normal
mucosa into the diffuse myomatous growth. Portions of
this myoma may become subperitoneal or intraligamen-
tary, and often form large cystic adenomyomata, while
Uterine Metastases in the Iliac Glands 2j
other portions of the diffuse new growth may project
into the cavity of the uterus in the form of submucous
adenomyomata. Cullen also describes a unique instance
of adenomyoma of the cervix, with cervical glands. The
theory of a causal nexus between the adnexa and uterine
adenoma was not supported in any way by the results
of examination of the tubes and ovaries in fifteen cases.
The differential diagnosis of adenomyoma from myoma
of the uterus is not a matter of certainty. The growth
is innocent, as is proved by two cases in which the cure
was effected though the growth was but partially removed.
Adenocarcinoma of the corpus uteri may develop from
an adenomyoma, as in a case described by Cullen. He
also describes a diffuse adenomyoma of the corpus uteri
in a case of squamous epithelioma of the cervix, and another
case in which adenocarcinoma and adenomyoma, quite
independent of one another, were found in the same uterus.
On the origin of adenomyoma of the uterus, Cullen
expresses himself as follows : " All adenomyomata of
the uterus, in which the glandular elements resemble
those of the uterine mucosa, and which are surrounded
by a stroma of the same character as that surrounding
normal uterine glands, owe the origin of their glandular
elements to the uterine mucosa or to Miiller's ducts,
just the same whether they are interstitial, subperitoneal
or intraligamentary, and whether they are solid or cystic.
In regard to adenomyomata arising from the uterine
portion of the uterine cornu, Cullen thinks that in the
greater number of cases their glandular elements are
derived from the uterine mucosa, while the glandlike
spaces in the adenomyomata from the tubal portion of
the cornu generally depend on external prolongations of
the tubal mucosa. In adenomyomata of the round liga-
ment Cullen supports the view that they owe their origin
to aberrant portions of Miiller's ducts.
Metastases of Uterine Carcinoma in the Iliac Glands
Manteuffel, Halle (Hegar's Beitrage, Bd. viii., Hft. 2),
from a comparison of the results of chnical investigation
of the condition of the iliac glands with those of micro-
scopical examination, concludes that the limits of a radical
operation cannot be settled on the basis of the former.
2/f. Summary of Gyncecology, including Obstetrics
Metastases in the glands are of such extreme importance
in the general aspect of recurrence of uterine carcinoma,
that the extirpation of the glands is almost essential for
radical operations, and should, on principle, always be
attempted.
Further Experienxe in the Abdominal Extirpation of
THE Carcinomatous Uterus.
Kroenig, Jena {Monats. f. Geb. Gyn., Bd. xix., S. 205),
reports further upon 53 cases of uterine carcinoma, on
38 of which he performed a radical operation, which in
23 was his own modification of Wertheim's abdominal
total extirpation (i death from haemorrhage) ; in 11,
the transversal incision keeping the field of operation
extraperitoneal (2 deaths) ; in 2 other cases, transverse
incision with temporary extraperitoneal field, both fatal ;
and two vaginal total extirpations. After discussing the
technique, advantages and disadvantages of the various
methods, Kroenig considers that the hopes he expressed
as to the results of his modification of Wertheim's method
in regard to mortality and reconvalescence have been
fulfilled.
In advanced cancer, which is immovable even under
narcosis, and in which it may be expected that the bladder
and ureters are involved, Kroenig now makes the trans-
verse incision, and keeps the operation field extraperitoneal
in Mackenrodt's way, in spite of the drawbacks of the
increased danger of infection, owing to the cavity left,
and the extensive wound in the connective tissue, and of
the increased anxiety in regard to the functions of the
bladder, consequent upon the loss of abdominal pressure
in the early days after the operation. The extension of
the indications afforded by the transverse incision rendered
partial resection of the bladder and ureter necessary in six
cases, but the dangers of shock and escape of urine after
resection of the bladder or ureters is less than by other
methods.
Four cases of recurrence were operated on, and their
subsequent course was encouraging.
When, on abdominal section, radical measures were
found to be out of the question, Kroenig in every case
ligatured the arterial vessels, and removed the ovaries
Laparotomia Hypogastrica Extraperitonealis 2^
if they were not past their activity. In this v/ay, with
simultaneous vaginal treatment, he hopes in future to
obtain, at all events, good palliative results.
Laparotomia Hypogastrica Extraperitonealis.
Mackenrodt's method, as described by him to the
German Gynaecological Society in 1901, is as follows :
A curved incision is carried through the skin from one
anterior iliac spine to the symphysis, and then to the
other spine ; both recti are then detached from the sym-
physis, the peritoneum is detached from behind them
almost up to the umbilicus, and the abdominal walls at
each side are cut through in the same line as the wound
in the skin. The peritoneum is then opened where its
anterior fold passes on to the wall of the bladder ; adnexa
and corpus uteri are drawn out, the spermatic vessels
are tied and divided, and the peritoneum is immediately
closed. The whole of the rest of the operation, including
the removal of the uterus and clearing out the hollow
of the pelvis, is entirely extraperitoneal. Free drainage of
the cavity left.
In 1902 he reported to the Berlin Gynaecological and
Obstetrical Society on 11 cases of laparotomia hypogastrica
extraperitonealis, as he calls his operation. Of these
10 were for uterine, i for rectal carcinoma — all cases of
advanced disease ; one woman died from the operation.
In nearly every case in which he has seen recurrence take
place after operation for cancer he is satisiied that the
lymphatic glands played an important part in the recur-
rence, and this especially in cases in which, at the time
of the operation, the glands were not even swollen ; he
is, therefore, convinced that it is not enough to remove,
as Wertheim does, the glands which are enlarged, but
that the whole of the glands and lymphatic vessels must
be extirpated. He claims that his method is really radical,
and that he has improved the prognosis of the operation
as by exact and thorough treatment of the extensive con-
nective tissue wound he is able with almost perfect cer-
tainty to avoid exudative inflammation of the connective
tissue, even when there is putrid pyometra. He knows
no way to prevent peritonitis after the older operations.
As his results have improved he has extended the indications.
26 Summary of Gyncscology, including Obstetrics
[Continental surgeons are not by any means likeminded
about the surgical treatment of uterine cancer. Many
agree with Fritsch that, after a few years, the old vaginal
methods will, when not applied to cancer in which recur-
rence is certain, but confined to " good cases," be properly
appreciated. Early diagnosis and prompt operation will do
more to secure better results than extended indications.]
Uterine Carcinoma, Abdominal or Vaginal Total
Extirpation.
V. Herff {Korrespondenshlatt. /. Schw. Aerzte, 1904,
No. 3), after a careful review of the cognate literature,
and a detailed appreciation of his personal experience,
concludes that as yet there is no obligation to operate
upon all cases of cancer of the uterus by the abdominal
way. He prefers in favourable cases of cancer of the portio
the vaginal operation (a modification of Schuchardt),
supplemented by a limited investigation of the glands
when the disease is moderately advanced ; but in cancer
of the corpus the abdominal operation. In any case the
future of the surgical treatment of uterine cancer, in his
opinion, does not depend so much upon performing as
extensive extirpation as possible, but rather upon opera-
tions being carried out in the earliest possible commencing
stage of the new growth.
Uterine Carcinoma and Pregnancy, with Some
Remarks on Vaginal Cesarean Section.
Orthmann, Berlin {Monats. f. Geb. u. Gyn., Bd. xviii.),
reports upon 116 cases of uterine carcinoma which came
under observation within three years and a quarter. Six
of the cases were complicated by pregnancy, one being
past operation. In another case, at the end of pregnancy,
there was advanced carcinoma of the portio and cervix.
An incision was made round the portio, the bladder pushed
out of the way and the anterior wall of the cervix was
divided without opening the plica vesico-uterina, and
a child, 8 lbs. in weight, was then extracted, but not with-
out further tearing of the incised wound and some lacera-
tion of the anterior vaginal and posterior vesical walls.
The uterus was then extirpated. The bad condition of
Cancer of both Ovaries in a Girl 27
the patient necessitated the vaginal method. Orthmann
concludes from this case that vaginal C^esarean section
enables us to effect immediate delivery by the vagina,
and to follow it by vaginal extirpation of the uterus at
any time, even at the end of pregnancy, in any case in
which vaginal extirpation can be considered.
Generally the division of the anterior wall alone is
required. Version and extraction is the quickest way
of delivering the woman, and the least trying for her.
The most favourable prognosis for mother and child in
circumscribed carcinoma of the portio, or commencing
cancer of the cervix, is afforded by extirpation after
delivery. In advanced disease, an abdominal operation
is indispensable.
Ca\xer of both Ovaries in a Girl, aged 14.
KouzxETZKY {Ann. Gyn. Obst., March, 1904) reports
a case of a girl, aged 14, who came to him for treatment,
complaining of pain, sometimes violent, and of a tumour
in her abdomen, which had been noticed for the first
time about six months before. He found, on palpation,
a mobile tumour as large as two fists, and somewhat irreg-
ular on the surface, which he diagnosed to be a malignant
neoplasm of the ovary or omentum. On December 19,
1900, he opened the abdomen and removed the tumour,
which was found to be the right ovary. The left ovary
was about the size of a walnut and lobulated on its surface,
and it was also removed. Both were submitted to micro-
scopical examination, and were pronounced by Dr. Martzi-
novsky and Prof. Nikiforov, of the Pathological Institute,
of [Moscow, to be affected with medullar}^ cancer. On
November 24, 1902, nearly two years after the operation.
Dr. Kouznetzky had occasion to see the patient, who had
grown considerably. She felt very well, and was in
domestic service. No indication of any return of the
disease could be detected.
P. Z. H.
Endothelioma Ovarii (H.^mangiosarcoma), with Meta-
stases IN the Lymphatic Glands and Uterus.
Federlin, Strassburg {Hegar's Beitraege, Bd. viii.,
Hft. 2), found in an ovarian tumour a structure formation
28 Szwiinary of Gyncscology, including Obsteti'ics
that seemed connected with the blood-vessels, inasmuch as
numerous superimposed layers of cells surrounded a blood-
vessel like a cloak. Moreover, even in the connective
tissue there were cords of the new growth that, by their
arrangement, gave the impression that they had developed
in pre-existing spaces ; the inner surface of the smaller
cysts was lined by a coating of many layers of cells, in
many places projecting inwards in the form of papillae.
The same structure was found in a nodule in the uterus ;
moreover, in the lymphatic glands there were indications
of alveolar structure.
PSEUDOEXDOTHELIOMA OF THE OvARY.
PoLANO, Wuerzburg {Zeitschr. f. Geh. u. Gyn., Bd. li.,
Hft. i), reports five cases of malignant degeneration of
the ovary, which were pronounced to be endothelioma
ovarii by eminent authority, and which he has selected
from a very large number for publication in detail, as
being characteristic of certain types of erroneous diag-
nosis. None of these five cases were endothelioma ;
two were genuine adenomatous carcinoma of the ovary,
two were ovarian metastases of carcinoma of the stomach,
and one was a malignant ovarian struma (goitre).
These being the chief sources of error, the tumours
even to the naked eye are so different from each other
that in the majority of cases it will seem possible, even
without any microscopical examination, to make a correct
diagnosis promptly. In true adenomatous cancer, the
tumours are generally large, soft and friable, and owing
to extravasation of blood, suggest torsion of the pedicle,
while, internally, they exhibit well-marked medullary
and necrotic areas. Malignant ovarian struma is charac-
terised by a typical reticulated network of hollow cavities,
which, in their structure and contents, closely resemble
honeycomb. In ovarian metastases of cancer in other
organs we find hard, nodulated tumours, generally of
moderate size, which almost invariably show considerable
oedema in their central parts.
Whenever there is reason to fear that an ovarian tumour
may be malignant, an exact chemical examination of the
contents of the stomach and intestine should be made.
Should this afford no positive evidence of cancer, an ex-
Total Separation of the Ovary 2g
ploratory laparotomy should be undertaken and all the
viscera of the abdominal ca\-ity, and the peritoneum, the
stomach and the lumbar lymphatics, should be explored
by palpation. Should the result point to a primary car-
cinoma of a single ovary of no excessive size, the indica-
tion is to perform bilateral salpingo-oophorectomy and
supravaginal amputation of the uterus. But this pro-
ceeding is contraindicated in all ovarian cancer that is
not primary, or that is really bilateral, or even if unilateral,
complicated by serious adhesions, or by metastases in
the peritoneal cavity or lymphatic glands.
Ax IXSTANCE OF TOTAL SePARATIOX OF AX OvARY AXD
ITS Displacement into the Anterior Douglas.
Strobel (I. D., Munich, Ze;i/m/6. /. Gyn., 1904, No. 11),
relates the following case : In a woman of 57, who died
from intestinal cancer, the uterus was found to be 8 cm.
long, the left ovary and tube were normal ; but on the
right side, at the seat of the insertion of the tube, there
was merely an appendage, i cm. long and 0-4 cm. thick,
which terminated in a rounded blind end, into which
no probe could be passed, the peritoneum covering it
smoothly all over. In the utero-vesical pouch, hanging
back from the bladder on a pair of bands, 3 cm. wide,
there was an oval body, 4 cm. long, 2-8 cm. thick, and
3 cm. broad, planted on which and wound spirally about
its longer axis there was a cord 7 cm. long. No other
inflammatory processes in the form of fibrous bands were
to be found in the genital organs. The microscopical
examination showed that the body in the utero-vesical
pouch was the ovary and tube detached from the right
side of the uterus. It is of some etiological import, per-
haps, that when 21 the patient had peritonitis, and for
two days fsecal vomiting.
jc? Notes
NOTES.
We have with regret to record the following deaths : —
Dr. Peter G. de Saussure, on March 8, 1904, aged
46, at Charleston, Professor of Obstetrics, Gynaecology,
and the Diseases of Children, in the Medical College of
the State of South Carolina, where he had graduated.
Dr. M. T. Brennan, on March 12, 1904, aged 42, Gynae-
cologist of Notre Dame Hospital, and for fourteen years
a Professor of Laval University. He was a native of
Montreal.
Dr. Stephen P. Truex, aged 48, suddenly, on March 31,
1904, while performing an operation in the Bashwick
Central Hospital. He was Gynaecologist to the Long
Island College Hospital, and Lecturer on Obstetrics and
Gynaecology in the Manhattan Post-Graduate Hospital.
Dr. Max von Strauch, Privat-dozent of Obstetrics
and Gynaecology at Moscow.
Professor Geheim Medicinalrat Dr. Adolf Gusserow,
Director of the Charite Frauenklinik of the Midwives
Training School at Berlin, retired at the end of the Winter
Session.
Professor Ernst Bumm, of Halle, has succeeded Pro-
fessor Gusserow in the Chair of Obstetrics and Gyneecology
at Berlin.
Professor Kuestner, of Breslau, and Professor Hof-
MEIER, of Wuerzburg, declined the position at Halle vacated
by Professor Bumm, which has now been filled by the
appointment of Professor J. Veit, of Erlangen, as Pro-
fessor of Obstetrics and Gynaecology and Director of the
University Frauenklinik at Halle.
Notes 31
Professor Johannes Pfannenstiel, of Giessen, has
succeeded Professor Veit at Erlangen, and Professor B.
Kroenig, Director of the University FrauenkHnik at
Jena, has succeeded Professor Veit at Erlangen.
Professor Bumm has been made a Privy Councillor,
and Professor Kuestner has been decorated with the
Third Class Order of the Royal Crown of Prussia ; he was
already a Privy Councillor.
The following appointments as Privatdozenten are
announced, the " venia legendi " in Midwifery and Gynae-
cology having been granted to : Dr. Paul Stroemer,
at Giessen; his test Lecture was "On the Prophylaxis
during Pregnane}^ of Morbidity in Childbed " ; Dr. Richard
Freund, at Munich, who qualified with an essay on " The
Blood-vessels of the Normal and Diseased Uterus " ; and to
Dr. R. Albenzio, at Naples.
The Royal Imperial Societ}'- of Physicians at \"ienna
announces that the Goldberger Prize will be adjudged in
October, 1906, for the best essay upon " The Influence
of Pregnancy upon Tuberculosis of the Respiratory Organs."
Professor Fehling, of Strassburg, has been made an
Honorary Fellow of the Italian Gynaecological Society.
Professor Hegar has been presented with the Freedom
of the City of Freiburg.
Our distinguished Honorary Fellow, Dr. Thomas Addis
Emmet, recently celebrated his golden wedding at his
home in Madison x\venue, Manhattan.
Dr. Henry Macnaughton-Jones was recently elected
a Corresponding Fellow of the Munich G3'naecological
Society.
Dr. C. T. Cullingworth, who this month delivers the
Ingleby Lectures in the University of Birmingham, taking
as his test, " A Plea for Exploration in Suspected Malignant
Disease of the Ovary," is to be given the honorary degree
of LL.D. by the University of Aberdeen.
At the weekly meeting of the Managers of the Edin-
burgh Royal Infirmary on March 21, Dr. F. W. Haultain,
F.R.C.P.E., was appointed an Assistant Gynaecologist to
32 Notes
that institution. There were eight candidates for the
vacancy, due to the lamented death of Dr. R. !Mihie ^Murray.
The appointment of Dr. Haultain meets with the almost
unanimous approval of the medical profession in Edin-
burgh. He is a most successful lecturer on midwifery and
gynaecology in the Extra-mural School. He had, last
winter session, the largest class (159 students) on record
in the school.— B. M. J.
At a meeting in Belfast last May, it was decided to
present to Professor J. W. Byers a portrait in oils of
himself to be hung in the Examination Hall of Queen's
College, Belfast, and to Mrs. Byers a replica of the por-
trait, in recognition of the courage and frankness with
which he had so victoriously defended himself from a
very disagreeable action. The esteem and regard in which
the Professor is held was demonstrated when on March 18,
1904, in the Great Hall of the Queen's College, the portrait
painted by Henrietta Rae was unveiled by the Right Hon.
Thomas Sinclair, in the presence of a large number of the
most distinguished people in Belfast and the North cf
Ireland, and accepted on behalf of the College by the Rev.
Dr. Hamilton, the President, who occupied the Chair.
The Right Hon. Thomas Andrewes made the presentation
of the replica to Mrs. Byers, and a large number of speeches
was made eulogising the Professor and expressing the
kindest wishes for him and his wife, and for their son.
The Birmingham and Midland Hospital for Women,
the demands upon which have greatly increased since
it was first opened in 187 1, is to be accommodated in a
new building, the foundation stone of which was laid
on April 20 by Mr. Arthur Chamberlain.
The January number of American GyncBcology was
destroyed in the Baltimore fire, and the issue of that
excellent journal has been delayed for the present.
SUMMARY OF GYNECOLOGY, I XCLUDING OBSTETRICS.
AUGUST, 1904.
Chlokixe Asepsis.
Stewart (Amer. your Obst., January, 1904) advocates,
as the best solution for rendering the skin aseptic, an acid
chlorine one, composed of acetic acid two teaspoonfuls, calx
chlorinata four teaspoonfuls, and cool sterile water one
quart. Five minutes' scrubbing with this, after live minutes'
proper mechanical cleansing, has always prevented the
growth of streptococcus, staphylococcus, and bacillus com-
iiiunis coli, after the hands were intentionally contaminated
with those germs. The solution does not make the skin
sore. To destroy the germs on the vulva, the solution
should be diluted with two additional parts of water. The
odour of chlorine can be removed by washing the hands in
two tablespoonfuls of acetic acid mixed with a quart of
water.
J. F. J.
Adrenalin in Gynecology and Obstetrics.
Fenomenoff, Kasan (Thcrapia, 1904, No. i), has used
adrenalin to arrest haemorrhage in a series of operations
upon the uterus and vagina. He soon found that the effect
of the drug upon the uterine mucosa was not the same as on
that of the vagina. In the excision of portions of the mucosa
from the vaginal wall in colporrhaphy, he did not when
using adrenalin notice any loss of colour in the mucosa,
nor any decrease in the usual amount of bleeding. The
vaginal mucous membrane, in fact, does not react to the
direct application of adrenalin. On the other hand, when
the portio vaginalis or cervical mucosa were treated with
the preparation, the blood lost (for instance, in curetting)
was much less ; the red portio assumed a blue colour, the
curetted material was pale, and the haemorrhage, compared
with what it had formerly been, was reduced to a minimum.
j^ Summary of Gyncecology, including Obstetrics
While incision of the vaginal portion otherwise led to
rather free bleeding, if the part had been previoush^ painted
with adrenalin there was hardly any at all. Under the use
of adrenalin, mucous polypi of the uterus could be removed
without any loss of blood, and they lost their colour and
shrivelled up. These observations suggested that adrenalin
might be beneficially employed in hccmorrhagic endome-
tritis, by the direct application of a solution in the cavity of
the womb.
To determine the effect of adrenalin solutions upon the
peritoneum, Fenomenoff made a number of experiments
upon rabbits, in which, after an aseptic laparotomy, a
gauze plug saturated with a one per mille solution of
adrenalin was kept for half a minute in contact with the
abdominal serosa. The part so pressed upon changed its
colour and appeared as a pale blue spot. When adrenalin
was applied to one horn of the utei-us but not to the other,
the former on incision hardly bled at all, while the latter
did so freely. Adrenalin may therefore be a most beneficial
styptic in the separation of adhesions and attachments of
various kinds, a proceeding which has frequently been
attended with haemorrhage, serious in amount and ditttcult
to arrest. It seems indeed probable that adrenalin will prove
very important in gyna3cological and obstetric practice.
Hot Air in the Tkeatmext of some Akekctioxs of
THE Gexit.al Organs.
Salom, Vienna {\Vic]icy hi. Wchns., 1904, No. 23), reports
upon some trials made in Chrobak's Klinikwith an apparatus
upon Reitler's system. In some instances the application
of hot air had to be abandoned on account of palpitations
of the heart, or feelings of extreme anxiety. As the physio-
logical effect of the very high temperature of the air
employed, the local temperature after application rose above
40°, while the general temperature of the body was increased
by several tenths, or even more. The blood pressure was
considerably diminished, but the chief effect of the treat-
ment was the hyperidrosis and hypera^mia it induced, and
the way in which it relieved pain. Among the fifty-seven
cases treated there were many of parametritis, and as the
case histories given show, the results even in large and verv
painful exudations were sometimes very good ; in the acute
stages of adnexal swellings they were unfavourable, but in
Action of Caustics on tJie Living Endometriujn J^
the subacute and chronic cases of this kind were sometimes
good. Inflammatory processes in the peritoneum were for
the most part improved. On the whole the method has
much to recommend it.
Ischuria in Retroflexed Gravid Uterus.
Reed (Anwr. Jour. Obst., February, 1904) says that reten-
tion of urine in retroflexion of the gravid uterus is not due
to direct compression of the urethra, or neck of the bladder,
whereby the lumen is mechanically closed, but that it must
be regarded as a form of " pressure paralysis," due to inter-
ference with the nerves supplying the bladder in some part
of their course. Compression of the principal motor nerve
(pelvic nerve) is the most common source of retention.
The part most subject to pressure is the pelvic ganglion
lying near the great cervical ganglion of the uterus, although
the nerve may be affected in any part of its course, either
near its distribution to the bladder, or close to the sacral
exit of the component fibres. Compression of the sensory
nerves, either in the course of the nerve or peripherally (in
the bladder), may also rarely produce retention. Both
afferent and efferent filaments may be affected simul-
taneously in a given case of retention, but the order is
usually consecutive. Pathological conditions of the pelvis
and abdomen which irritate the sensory fibres of the bladder
produce the so-called "irritable bladder." Retention of
urine post-paiiiiiii and after laparotomy for tumours, is due
to diminished intra-abdominal pressure, weakness of the
abdominal muscles from over-distension, and the dorsal
decubitus. J. F. j.
Ox the Action of Caustics on the Living Endome-
trium, A Contribution to the Treatment of
Endometritis.
Rielander, Marburg {ZeitscJii: f. Geb. u. Gyii., Bd. li.,
Heft. 3), concludes, from experimental researches, that in
the use of intrauterine caustics an alcoholic preparation of
the drug is to be preferred to a watery one, because it
more easily finds its way over the surface, probably also
into the substance of the tissues. By employing Playfair's
sound, armed with drugs dissolved in alcohol, one can
secure a uniform and sufficiently deep cauterisation over the
whole of the uterine mucosa ; the same is true of soluble
J<5 Snnwiary of GyncBCology, including Obstetrics
medicated pessaries, so that Braun's syringe is superfluous.
The reticular texture of the uterine mucosa makes it easy of
penetration by the caustic material, while the compact
muscular fibres resist the entrance of the drug. The pene-
tration of a watery solution into the mucosa is a gradual
process, that of an alcoholic one very quick (the tissues, in
the former case, being much changed, in the latter, promptly
fixed). When a 30 per cent, formalin solution is used, the
burnt cicatrix begins to be cast off within twenty-four hours
and the regeneration of the mucosa can commence. If
Playfair's sound be employed the caustic does not affect
even the uterine end of the tube.
Intraperitoxeal Shortening of the Round Liga-
ments, Using Catgut only for Fixation Sutures.
Menge, Leipzig {Zcntralb. f. Gyii., 1904, No. 21), con-
siders every backward displacement of the uterus to be
pathological, and that therefore in certain cases operative
treatment is the right one. His method of ventrofixation,
which in 130 cases has invariably been successful, consists
in stitching tlie sling made by intraperitoneal shortening of
the round ligaments to the abdominal wall at the level of
the insertion of the ligaments into the uterus, using catgut
only for the stitches.
Ventral and Vaginal Fixation in Child-Bearing Age.
V. Gu^rard, Duesseldorf {Monats. f. Geh. u. Gyn., Bd.
xix., S. 229), is convinced that no interference with labour
need be expected from either ventral or vaginal fixation
properly carried out.
In 57 labours after ventral fixation, there was no diffi-
culty in 51, forceps were applied in 5. The fixation had
been made supplementary to other operations in 49 instances,
and retroflexion had recurred in 2.
In 41 labours after vaginal fixation, there was no diffi-
culty in delivery in 39 ; the low forceps was used in
4 ; nor was there any disturbance during pregnancy.
Retroflexion recurred in one instance. The fixation was
made with two silk threads inserted somewhat below
the mid-point between the insertions of the tubes and
that of the peritoneum, and the stitches were removed
after fourteen days. There were seven abortions after
vaginal fixation.
Abdominal Surgery jy
Abdominal Surgery.
Clark {Auicr. four. Obsf., May, 1904), in referring to
the diagnosis of abdominal conditions, says that to give
the patients every possible benefit from the abdominal
incision, all parts of the abdomen should be manually ex-
plored in almost all cases in which the symptoms are not
fully explained by the pathological condition for which the
operation is done. The exploration must be thorough,
with special attention to the appendix, kidneys, gall-bladder,
pancreas and gastro-intestinal tract. However, when the
operation in the pelvis has been attended with the evacua-
tion of pus, which if generally distributed in the peritoneal
cavity might give rise to a peritonitis, this exploration
should be omitted ; as also in cases which are in a critical
condition at the termination of the operation. Again, when
the clinical symptoms are clear cut and point definitely tt)
a single condition, for which alone the operation is per-
formed, the exploration should be omitted, Clark gives
his opinions on the following debatable points.
(i) Should the normal appendix be removed as a coin-
cident part of all pelvic operations ? With intelligent
patients the question of its removal must be left to their
decision.
(2) Should gall-stones, if discovered in the course of
another operation, be removed ? In every case, unless the
patient's condition is a contraindication to any further
operation, gall-stones, even though they have not produced
symptoms, should be removed.
(3) If the right kidney has a range of mobility from 2
to 6 centimetres, under which circumstances most of
them may easily be palpated, what set of symptoms are
sufficiently pathognomonic of a pathological mobility to
indicate nephrorrhaphy ? The kidney should only be sus-
pended when the symptoms point directly to the kidney as
the cause of trouble. In my experience the percentage
of these cases is not more than one in 150 cases.
(4) What degree of descensus of the stomach and trans-
verse colon require operative measures for their restoration ?
If the transverse colon is situated at the brim of the pelvis,
and the lower curvature of the stomach is below the um-
bilicus, this organ should be replaced and held in position
by stitching the gastrocolonic omentum in a transverse line
across the upper portion of the abdomen.
S8 Stunmary of Gynaecology, including Obstetrics
(5) Is any group of symptoms signiBcant of sigmoid-
ptosis ? As to this he is in doubt, but he believes that the
cases of fixed aching pain at the brim of the pelvis, asso-
ciated with obstinate constipation, in the absence of pelvic
lesion, are strongly significant of this condition.
(6) Should sigmoidpexy be performed for these ? In
the more exaggerated cases it oft'ers a hope of correcting
the dislocation and relieving the svmptoms.
J. F. J.
Supravaginal Amputatiox for P'ibroid Tumours.
Hayd {A'incr.Jonr. Obst., January, 1904) reports fourteen
cases of this operation, with one death. The death was due
to peritonitis from leaking of urine through a small hole
which had been torn in the bladder wall and which had
been sutured. He only advocates complete removal of the
uterus, i.e., including the cervix, in cases where the cervix
is the seat of marked cystic degeneration, or has a bad tear,
or is associated with considerable vaginal prolapse, or
where, for any reason, drainage would be desirable. He
points out the danger of over-conservatism in the treatment
of uterine fibroids. He condemns electricity, ligation of
the uterine arteries, and removal of the appendages.
J. F. J.
Dystocia Due to a Myoma : Spontaneous Delivery.
Calderini {Archivis Ost. Gin., 1904, No. 2) reports :
In a primipara in labour at term, progress was delayed
by a large myoma situated in the pelvis. The foetus
had been dead for four days, but was not putrefied.
Immediate intervention was impossible owing to the
circumstances of the case, and delivery ultimately took
place spontaneously. Various factors contributed to the
completion of the birth ; the pressure made upon the
tumour by the explorer, good and forcible uterine con-
tractions, the death of the foetus, and consequent softening
of its head, which was, therefore, able to engage in the
narrow^ space of the os uteri. Observations made during
the labour and puerperium proved the tumour to be a
subserous myoma. The woman left the klinik in good
health thirteen days after delivery ; the only sequela was
hivasiou of a Fibroniyoma by an Adenocarcinoma jg
a thrombosis of the left leg after she returned home, and
from which she recovered.
IXVASIOX OF A FiBKOMYOMA BY AN ADEXOCARCIXOMA.
C. P. Noble (Amcr. your. Obsf., March, 1904), reports
a unique case of the invasion of a fibroid tumour of the
uterus by an adenocarcinoma, which by metaplasia had
assumed the appearance of a squamous-celled carcinoma.
The patient, aged 63, had passed the nienopause at the age
of 45, and for nine months had had some vesical trouble
and a leucorrhoeal discharge, which for a few weeks had
been blood-stained. The cervix felt normal, the body of
the uterus was enlarged and irregular in shape. Supra-
vaginal hysterectomy was performed. Nothing abnormal
was apparent to the eye except a degenerating fibroid which
was connected with the inner wall of the uterus by a pedicle.
On section, the tumour was of a uniform greyish-white
colour, smooth, glistening and of a dense consistence, with
here and there a few opaque greyish-yellow patches sug-
gesting fatty degeneration. Under the microscope it was
found that the smooth muscle had been replaced largely
by connective tissue. Throughout were numerous masses
of epithelium of the epidermoid type, in the centre of which
there was a tendency to form epithelial pearls. The surface
of the tumour was covered with thin squamous epithelium,
which in places extended as a papillary growth into the
interior of the tumour. The epithelial masses in the tumour
must have arisen either from : (a) metastases from tumour
in other parts of the body — there was no evidence of such
tumour ; (6) extension to myoma of cancer of the uterus
— there was no evidence to show that they could have arisen
from glandular elements contained within the tumour ;
(c) the development of the cancerous tumour from the
epithelium covering it — in favour of this it was noted that
where the tumour was in contact with the uterine wall, its
outer surface was covered by a growth of cylindrical cells
in distinctly tubular or adenomatous arrangement. From
this point papillary-like processes, lined by the same
type of cell, extended into the loose texture of the tumour
and formed for themselves lymphatic-like spaces ; as they
extended more deeply into the tumour they lost their
cylindrical form, and became of the pavement-cell type.
All stages could be traced, from typical cylindrical cells to
40 Sttnimary of Gyncecology, inctuding Obstetrics
masses of flat pavement cells, with a tendency to form
epithelial pearls. It is probable that tiie character of the
epithelial cells was due to an ingrowth of glands from the
surface, and that these had undergone a metaplasia due
to the limitation of the growth offered by the surrounding
tissues. The cervix, perfectly normal as far as could be
ascertained, was not subsequently removed, and tiie patient
made a good recovery.
J. F. J.
Abdomixal venous Vagixal Hysterectomy.
Ueaver {Amcr. 'Jour. Obsf., January, 190^) opposes
vaginal hysterectomy for carcinoma of the cervix uteri,
except in the presence of obstacles necessitating such a
course, such as a stout abdomen, nephritis, or old age. He
does a complete hysterectomy by the abdominal route in
fundal as well as in cervical carcinoma, and holds that the
abdominal operation offers an increased space for necessary
manipulation, greater security against haemorrhage and less
risk of injuring the ureters. It is easier to keep beyond
the area of diseased tissue ; a larger portion of the broad
ligaments together with their lymph channels can be excised
and glandular enlargements removed. In his operations
for cancer of the cervix, the cancer area is curetted and
cauterised with pure carbolic acid, and if necessary the
cervix is sewn tightly to prevent oozing. Gauze drainage
is introduced into the vagina from above downwards and
projects slightly into the pelvis, where the anterior peri-
toneal flap is brought over it and stitched to the posterior
wall of the vagina. The area of drainage is thus extra-
peritoneal. J. F. J.
Uterine Caxcer Statistics.
Besson (yl. Sci. Med., Lille, June 11 and 18, 1904)
records 173 cases of uterine cancer treated in La Charite
Hospital, by Professor Duret from 1890 to 1903 inclusive,
and forming 6 per cent, of the total number of vi^omen
admitted into that hospital. Their ages varied between 25
and 76, with a maximum frequency between 40 and 50.
Of the 173 cases 104 were inoperable at the time of their
admission ; 69 were operated on, 46 by vaginal hysterec-
tomy, with a mortality of 15 per cent., and 23 by abdominal
hysterectomy, with a mortality of 434 per cent. In 123
Tuberculosis of the Female Genitalia 41
of the cases the disease was precisely localised ; 94 were
cervical and 29 corporeal cancers. Of the 53 who survived
operation 9 were lost sight of ; of the remaining 44, 22, or
50 per cent., died within a year, and 15, or about 38 per
cent., survived more than two years. Of these 15, 3 died
from relapse after between two and three years, 3 between
three and four years, i after seven years, i after eight years.
The other 7 had remained without recurrence of the disease
for twenty-seven, thirty-one, thirty-seven months, and five,
six and a quarter, seven and five years respectively, since
the operation.
From the study of these cases and of the work of other
operators, Besson formulates the following conclusions :
(i) Uterine cancer may occur at a very early period of a
woman's life ; it is therefore of the utmost importance to
examine any woman suffering from leucorrhoea, in order to
ensure timely intervention in cases of developing cancer ;
(2) the mortality at present in cases operated upon is two
or three times greater after total abdominal hysterectomy
than after vaginal hysterectomy ; (3) the proportion of 38
per cent, of survivals in operated cases after two years appears
encouraging ; (4) the greater proportion of survivals in
cases operated on by vaginal hysterectomy, indicates the
corresponding superiority of this operation in cancers
sufficiently localised ; (5) total abdominal hysterectomy
has, therefore, a more restricted, but yet a positive, indica-
tion in cases of extensive propagation of the disease, pro-
vided the general health of the patient is in a satisfactory
condition ; (6) in advanced cases, with break-down of the
general health, all intervention should be avoided, and
palliative means only resorted to
P. Z. H.
Tuberculosis of the Female Genitalia.
Murphy (Amer. Jour. Obst., January and February,
1904) says that after tuberculosis of the tubes, tuberculosis
of the fundus uteri is most frequent. The uterine lesion is
usually secondary to the tubal, and therefore that part of
the fundus about the orifices of the tubes is most often
invaded. The tubercular process may be of three varieties :
miliary, ulcerative, and pyometra (mixed infection). The
ulcerative form may occlude the cervix and lead to hydro-
metra and pyometra. Owing to the uterine changes in-
cident to menstruation, infection of the uterus is less likely
42 Summary of Gyncpcology, including Obstetrics
than of the tubes, as shown by the fact that uterine tuber-
culosis is most frequent before puberty and after the
menopause. The tubercular processes may extend deeply
into the muscular wall of the uterus, leaving only a thin
sac filled with thick pus and caseous material. There may
be very slight enlargement of the uterus or none at all. If
pregnancy occurs in a tuberculous uterus, it may go on to
lull term, but from the softening of the walls there is always
danger of rupture occurring. The symptoms are usually
those of ordinary endometritis. Menstruation may be
regular, suppressed or profuse. Leucorrhoea is the rule.
The diagnosis can only be cleared up by an examination
of the uterine scrapings. The profuse and intractable
leucorrhoea of both extremities of life is very frequently due
to tuberculosis of the uterine fundus. Removal of the
uterus, and of the appendages at the same time, is neces-
sary except in children, for whom curetting should be done
and hysterectomy be only a last resource.
The Fallopian tubes are predisposed to tuberculosis by
their spiral form and pleated mucosa, which favour stagna-
tion of secretions. A preliminary catarrh enhances the
dangers of infection. The sources of infection are, from
the peritoneum, through the blood or lymph vessels, and
from outside the body. The tubes may be infected with-
out the peritoneum or the latter without the former, though
in the author's experience in cases of tubercular peritonitis
in which the fimbriated end of the tube was free, tubercu-
losis of the tube was very rarely absent. Experiments upon
monkeys, detailed in full, showed that the disease is trans-
ferred from the peritoneum to the tubes, and also that
tubercular infection occurring in any portion of the ab-
dominal cavity, tends to a more exaggerated expression in
the pelvic peritoneum ; that the retroperitoneal glands of
the pelvis and the post-peritoneal glands in the lumbar
region were the only ones involved ; that the tubercular
infection does not, in the monkey, invade the tubal mucosa,
since the fimbriated ends become closed and shut off the
passage, but that it invades the walls from the peritoneum.
The symptoms of tubal tuberculosis are those of sal-
pingitis with repeated pelvic peritonitis. Pain is frequent^
periodical and localised. There is a slight evening rise of
temperature. The periodic pelvic peritonitis is due to the
expulsion of tubercular debris from the tubes into the peri-
toneum. Menstruation is, as a rule, regular and not painful.
Tuberculosis of the Female Genitalia ^j
Sterility is the rule. The tubes must be completely extir-
pated. The ovary is not usually deeply involved, and if
possible one or part of one ovary should be saved.
Tuberculosis of the ovary is extremely seldom primary,
but generally secondary and likely to occur in acute miliary
tuberculosis of the lungs. The most frequent source of
infection is the peritoneum and tubes. The disease begins
as a perioophoritis and the deeper portions become infected
through the lymphatics. In one case Murphy operated
upon, the communication to the ovary was by direct per-
foration of the tubal wall. Ovarian tuberculosis may be
miliary, caseous or tubercular abscess. The symptoms are
those of the tubal or peritoneal disease from which it
originates, and the diseased ovary will be removed with
the diseased tube, or during the treatment of tubercular
peritonitis. Tuberculous Graafian follicles can be shelled
out from the ovaries in young individuals and the rent
sutured up.
Tuberculosis of the peritoneum is more frequent in
females than in males. It is frequently difficult or impos-
sible to determine the route by which the bacilli reach the
peritoneum. The most frequent source is the intestine.
The bacilli may attack the intestine first and the peritoneum
next, or, absorbed by the superficial lymphatics of the in-
testinal mucosa, may attack the peritoneum primarily.
From the pathological standpoint there are four varieties :
(i) disseminated, miliary, serous (ascitic) ; (2) nodular,
ulcerative, or perforative (the least frequent) ; (3) adhesive,
tibro-plastic or obliterative ; (4) suppurative (or general
mixed infection). The symptoms vary greatly in the
different types of the disease. In the disseminated ascitic
variety the attacks resemble recurrent peritonitis of ap-
pendiceal origin, except that the field of activity is the
pelvis instead of the right iliac fossa. The attacks are not
necessarily associated with menstruation, being due to the
periodic discharge of tubercular material from the tubes.
There is pronounced leucocytosis. Between the attacks
the remission is not complete ; there is continued hyper-
sensitiveness of the pelvic peritoneum. In the nodular,
perforative variety, the whole force of the process is con-
centrated into small areas. The symptoms take no definite
form, there is no periodicity to the attacks and the diagnosis
cannot be definitely made except by exploratory incision.
In the adhesive obliterative variety there is destruction of
44 Summary of Gyncecology, including Obstetrics
the endothelial lining of the peritoneum and production of
connective tissue of varying degrees of density. Circum-
scribed cysts are formed. These may become infected from
the bowel and suppurate. The ends of the tube, open or
sealed, communicate with one of these cyst or pus cavities.
The peritoneum is usually thickened and resembles wet
leather. The symptoms are those of continued inflamma-
tion with little septic intoxication. There is little elevation
of temperature except when a circumscribed mixed infec-
tion occurs. Leucocytosis is not pronounced. Emaciation
is progressive but not rapid. The clinical course resembles
that of combined tubal infection and ovarian cyst with
pericystic inflammation. To any of these tubercular con-
ditions an infective process may be added in which the
virulence of infection plays a very important role, both in
the pathological changes and in the symptomatic mani-
festations. The tendency is to circumscription of the
process. The fimbriated ends of the tube become closed
or fixed to a neighbouring structure or terminate in a
circumscribed abscess. Whenever the fimbriated end of
the tube is sealed it may be taken that there has been a
mixed infection, and that there will be exacerbations of
the inflammation mimicking the exacerbations of specific
pyosalpinx. Encysted collections of fluid will suppurate
and form abscesses. If the infection be virulent there will
be chills, elevation of temperature, hectic diarrhoea and
rapid emaciation. The wall of the abscess may necrose
and the contents escape into the bowel, bladder, vagina or
through the skin. The prognosis in these cases is bad,
recovery being rare. The chief things in treatment are to
suppress the tubal lesion, which is the starting point, to
cut off the supply of new tubercular debris and to avoid
mixed infection. Abdominal section, followed by removal
of the tubes if possible, evacuation of the ascitic fluid and
tubular drainage are indicated. If the infection be tuber-
cular only and not mixed, there is a good prospect of a
cure. All operative treatment should be followed by
systemic treatment of an antitubercular nature.
J. F. J.
Actinomycosis of Both Ovaries.
Geldner, Breslau {Monats. f. Geb. u. Gyn., Bd. xviii.,
S. 693), reports a case of actinomycosis affecting both
ovaries, and confined to them. The ovarian tissue was
Ovarian Hcenioi'Thage 4S
throughout beset with actinomycosis. The infection of
one ovary apparenth* took place through a fistula from
a tuberculous hip joint, extending to the neighbourhood
of Douglas' pouch ; but the disease of the other ovary
must be considered a metastasis.
Ovarian Haemorrhage.
Buerger [Zeitschr. f. Geh. u. Gyn., Bd. li., Heft 2)
reports a case of a very hard-working woman, aged 31,
who was admitted into hospital with symptoms of internal
haemorrhage. On abdominal section the source of the
bleeding was found to be in the ovary, w^hich was removed,
and the w^oman recovered. The substance of the ovary
was crowded with luteum cysts, and the walls of some
of these were extremely thin. Under the influence of
menstrual hyperaemia these cysts had become distended
with blood and then ruptured.
A Primary Ovarian Tumour of Krukenberg's Type.
ScHENK, Prague {Zeitschr. f. Geh. u. Gyn., Bd. h., Hft. 2),
reports the second instance in which a tumour of the
Krukenberg type has been a primary ovarian growth ;
the first was described by Krukenberg himself, and all
other published cases of this form of new growth ha\-e
been secondar}^ The chief characteristic of these solid
and generally bilateral tumours of the ovary consists
in settlement of large, round, distended cells in the fine
spaces between the fibres of the connective tissue (v. ante,
vol. xviii., p. 82. The primary tumour is generally a
gastric scirrhus).
On Thyroid Tissue in Ovarian Embryomata.
PoLANO [Muenchener med. Wchns., 1904, No. i) reported
to the Wuerzburg Physico-Medical Society, on December 3 ,
1903, the case of a woman of 56, who in the beginning
of 1903 was operated on for ascites and a tumour of the
right ovary. The tumour removed was the size of a small
fist, smooth though somewhat lumpy, and consisted
of small cysts. At the pole opposite the hilum of the
46 Sutnmajy of GyncEcology, including Obstetrics
ovary there was a fungoid growth, and microscopical
examination disclosed three different tissue formations :
(i) Normal thyroid gland, (2) a colloid goitre, and (3) a
malignant tumour of the thyroid gland. He showed the
tumour and microscopical sections.
p After reviewing the prevailing theories, and shortly
alluding to the mystical views formerly held about em-
bryomata, he mentioned as theories which were open to
scientific discussion : (i) Detachment by tying (the axle-
string of Hiss, Fraenkel, Handler, &c.) ; (2) pathogenesis
(Waldeyer, Pfannenstiel, Kockel, &c.) ; and (3) foetal inclu-
sion (Marchand, Bonnet). The results of the classical
work of Wilms were now accepted as histologically correct.
As Bonnet had declared, in attempting any theoretical
explanation of the origin of these tumours, the principle to
be adhered to was : to reject speculative views unsupported
by facts, and everything opposed to phenomena which are
proved to be in accordance with the biological laws of
the animal world. This criticism, in the opinion of most
pathologists and anatomists — Wilms especially included
— applies to all the theories hitherto propounded except
that of Marchand and Bonnet.
Polano then traced the two-fold development of this
tlieory, which had resulted from the publication of com-
plicated and more simple formations.
Among the former are two cases of chorion-epithelio-
matous formations in embryomata of the testicle, published
by Schlagenhaufer and Steinert, to which Marchand and
Schmorl have lent their authority. These cases fulfilled
Bonnet's theoretical postulate for the presence of embryonal
membranes, and furnished a proof, in Polano's opinion
absolutely unanswerable, of the foetal origin of the syn-
cytium. It seems possible that in typical embryomata
of the testicle and ovary the amnion also may be concerned.
The Bidermone and this Wuerzburg case may be cited
as instances of the simpler forms ; for though one cannot,
as in the cases of Robert Meyer, Kretschmer and Glockner,
point to small bones or nodes of cartilage (though, as in
Saxerschen's case, in which a tooth was found in an ovary,
such may have existed), we must suppose either that a
very highly differentiated blastomere went astray, or that
the other derivatives or the fold have been suppressed
Dermoid Cysts of both Ovaries 4"/
{e.g., dissolution of bone in Meyer's case). In accordance
with the hypothesis lirst laid down by Pick, there is no
room for doubt as to the embryonal character of tumours
of this kind.
In regard to the malignant degeneration affecting part
of this tumour, clinically it is remarkable that, according
to recent examination, this patient was found to be quite
well and had no ascites.
Ovarian Dermoid, with a Papillomatous Outgrowth
Perforating the Bladder.
MuENCH {Thesis, Tuebingen, Zentralb. f. Gyn., 1904,
No. 7) relates the following case. A woman of 51 was
sent into the medical klinik moribund. She had suffered
from urinary troubles and persistent pain in the bladder
for twelve months, and, moreover, complained of cardiac
palpation and dropsy. The post-mortem examination re-
vealed : Mitral stenosis, general cardiac hypertrophy,
thrombosis of the left auricle, thrombosis of both femoral
veins, pulmonary embolism, &c. There was also a dermoid
of the left ovary about the size of a hen's egg, and a papil-
lomatous excrescence from the cyst had perforated the
waU of the bladder. The outgrowth had the form and
size of a raspberry, and had broken through the posterior
vesical wall a little to the left of the middle line.
Dermoid Cysts of both Ovaries and Pregn.-\ncy.
Condamin {Ann. Gyn. Obst, March, 1904), in connection
with a case in which he removed bilateral dermoid ovarian
cysts from a woman aged 36, who had had five normal
pregnancies, reviews 97 cases of bilateral dermoids, col-
lected by Loewy and Gueniot. Menstruation, when referred
to, in these is said to have been normal or nearly so, except
in some instances in which excessive size of the cysts or
torsion of the pedicle had modified the ovarian vitality.
Pregnancy has been recorded in 30 of the 98 cases ; many
of these patients were multiparae, 9 were from one to five
months' gravid at the time of the operation, and 4 in whom
part of an ovary was preserved at the operation afterwards
conceived. In conclusion, he recommends that in extir-
pating bilateral ovarian dermoids in women under 40, an
^8 Summary of Gyn(2cology\ including Obstetrics
operator should, if possible, aim at preserving a portion of
an ovary and the corresponding tube, even if they have
been altered by compression, with the double object of
retaining the menstrual activity and the possibility of
conception. In view of the possible danger of recurrent
disease, many gynaecologists would, for the sake of ensuring
greater safety to the patient, prefer to make the sacrifice.
P. Z. H.
Suppuration of an Ovarian Cyst after Enteric Fever.
Zantschenko, Kasan {Monats. f. Geb. u. Gyn.. Bd. xix.,
S. 67), reports a case of extirpation, eight months after
recovery from typhoid fever, of an ovarian cyst, which
during that interval had enlarged and suppurated. Exami-
nation of the contents for micro-organisms, and the cul-
tures obtained thereb}^, proved that the infection of the
cyst was entirely due to the typhoid bacillus, and had
occurred through the blood-vessels at the time of the fever.
The tumour originally was a pseudo-mucous ovarian cyst,
and suppuration of such has not been previously recorded.
The Function of the Corpus Luteum.
Fraenkel {Archiv f. Gyn., Bd. Ixviii., Heft 2), in an
important article based upon a series of researches on
rabbits, and upon what is known of human physiology,
comes to the follomng conclusions :
The differentiation of the corpus luteum '" verum "
from the corpus luteum " spurium " cannot be justified
either by their histology- or function, and must be aban-
doned. The corpus luteum, which in the human being
is formed every four weeks, in animals at relatively regular
intervals, is a gland whose primary function is always
the same, to furnish periodically an impulse to the nourish-
ment of the uterus, whereby it is prevented from sinking
back into its infantile, or prematurely acquiring its senile,
condition, and also whereby it is enabled to make its mucous
membrane ready for the reception of a fertilised ovum.
Should an ovum be fertilised, the function of the corpus
luteum for a time still remains the same in principle,
namely, to preside over the increased nourishment required
The Function of the Corpus Lnteum /f.g
by the uterus for the implantation and development of
the ovum. Should conception not occur, the corpus luteum
induces a hyper?smia leading to menstruation, and there-
upon to its own involution. The theoretic ideas of Pflueger
and Loewenhardt, upon the connection of ovulation with
menstruation, yield to the new law now demonstrated, which
is to the following effect : " The cause of menstruation is
the secretory activity of the corpus luteum."
It is then the activity of the corpus luteum, and not
the pressure of the enlarging follicle on the ovarian nerves,
that induces menstruation ; for periodically ever}^ four
weeks this activity leads to uterine hyperaemia, followed
either by pregnancy or by menstruation.
The ovary may be considered generally to be one of
the most sensitive reagents in the human body. One
evidence of this is that if an increase in nourishing fluids
is wanted owing to increased excretion, either morbid
{e.g., diabetes), or physiological {e.g., suckling), or to its
being perverted, and accumulating in improper form (fat)
in the wrong place, then until compensation is established,
the maturation of the ovum and the formation of the
corpus luteum is omitted, and thereby atrophy of the uterus
and amenorrhcea are induced.
It is evident that the therapeutic influence of the
modern remedy oophorin, or o\ariin, entirely depends
upon the presence and amount of corpus luteum substance
it contains. In the cow the corpus luteum attains the
size of a walnut, occupying two-thirds of the volume of
the ovary. From it the corpus luteum substance, called
by Fraenkel " lutein," is easily obtained. By the adminis-
tration, three times daily, of 03 grammes of this substance,
all omission symptoms can be relieved with absolute cer-
tainty, but this new and improved preparation is not an}-
more than oophorin a specific, but from the nature of
the thing the cure is merely symptomatic.
The importance of the corpora lutea being now at
last fully recognised, Fraenkel urges that the corpus luteum
should be preserved intact as long as possible during the
corresponding pregnane}'. On the ground of the greatly
improved technique it has become the custom to perform
ovariotomy during pregnancy. It has, however, been
noticed, and this previously unknown circumstance has
50 Sutmnary of Gynaecology, including Obstetrics
seemed inexplicable, that even in cases unattended by
the slightest trouble, from some unknown cause abortion
took place. For this reason, indeed, Tsirne suggested that
no pregnant woman should be submitted to ovariotomy
before the fourth month, because from that time the
danger of abortion is not so great. Fraenkel now gives
us the explanation so long lacking, and advises his operat-
ing colleagues to more cautious proceedings. If the
tumour be small and give little trouble, is enlarging slowly
or not at all, and does not seriously threaten the pregnancy
or labour, it is better to defer operation till after delivery ;
if. however, the tumour constitutes a danger, one should,
if possible, postpone the operation till after the fourth
month, and in any case endeavour to operate in such a
way as to leave the corpus luteum intact, and with the
technique in resection of the ovaries now acquired, there
is generally no difficulty in doing so.
RiES {Amcr. J our. Obst., February, 1904) reports a case
bearing on the question raised Fraenkel. by The patient
menstruated on September 26, and was operated upon on
October 25 following. A corpus luteum, from which pro-
fuse haemorrhage had taken place, was completely enucleated
and the edges of the ovarian tissue sutured together. Forty-
eight hours after the operation menstruation occurred,
lasted the usual time and was of the usual amount. It is
possible that the extirpation was performed too near the
term of the expected menstruation to affect it, enough of
the hypothetical internal secretion having already been
produced.
J. F. J.
Hydatid Mole and Ovary, a Contribution to the
Pathology of the Corpus Luteum.
Jaffk, Berlin {Archiv f. Gyn., Bd. Ixx., S. 462), reports
a case from Landau's klinik, in which a radical vaginal
operation was performed for hydatid molar pregnancy.
Clinically, it appeared to be chorion-epithelioma malignum.
The woman was cured. Both ovaries contained a number
of corpus luteum cysts. Jaffe then proceeds to discuss in
detail and defend the theory according to which, in cases
The Origin of Tubal Occlusion ^i
oi hydatid mole, primary over-production of lutein tissue
sets up in the ovum, in the uterus or tube, an excessive
activity of the chorionic epithelium which is the cause of
the formation of the hydatid mole.
Hydatid Mole and Twin Normal Ovum. Displace-
ment OF Lutein Cells in one Ovary.
Birnbaum, Goettingen {Monats /. Geb. m. Gyn., Bd. xix.,
S. 175), reports a case of a twin pregnancy in which, at
the end of the sixth month, while one ovum was normally
developed the other had degenerated into forming an
hydatid mole. There was neither endometritis nor any
systemic disease originally. Nephritis came on after
conception, and the woman died six weeks after delivery
from myocarditis.
In one of her ovaries there was a displacement of lutein
cells, due to an offset of lutein lamellae from a corpus
luteum. To this condition an important rule in the etiology
of hydatid moles has been ascribed by Pick.
Conservative Treatment of the Uterine Adnexa.
Clarke {A mer. "Jour. Obsf., January, 1904) reports several
cases. In one case the outer half of the right Fallopian
tube was involved in tubercular disease ; he removed that
part alone and left the inner half of the tube patent by a
salpingostomy. In another the appendix was adherent
to a small ovarian cyst, only the cyst and appendix were
removed, part of the ovary being retained. The patient
subsequently married and had a child. Other cases of
resection of the ovaries are reported, also seven cases of the
conservative treatment of inflammatory conditions of the
appendages. In cases of small pyosalpinx the tube was
disinfected by sterilised water and then by mild sublimate
solution. Pregnancy occurred subsequently in the first
case. The results, on the whole, have been excellent.
J. F. J.
The Origin of Tubal Occlusion.
Chiarabba {Archivio Osi. Gin., 1904, No. 2) takes
a rapid survey of the more usual results of chronic sal-
pingitis (retraction of the tubes, stenosis, atresia), and
of the complications more easily recognised, and proceeds
^2 Smmnary of Gynaecology, including Obstetrics
to a more detailed study of the histopathology and of the
mechanism of the formation of stenosis, which he illustrates
by the conditions in a case cured by Lawson Tait's opera-
tion. After describing the clinical course and curative
process of the case, he concludes that an inflammatory
process originating in the mucosa and extending along
the other tissues towards the abdominal os, must have
caused the shedding of epithelium which remained en-
veloped in an inflammatory membrane. After various
phases this membrane ultimately formed ahhesions and,
so to say, cemented together the muscular fibres, which
in themselves were not factors in the stenosis.
In regard to the epithelial tissue met with in the midst
of the connective tissue, Chiarabba believes that it was
derived from remains of the mucous investment of the
edge of one of the fimbriae, which became enclosed in the
new tissue, and continued to develop its vital action without
taking part in the formation of the cicatrix.
Fleck, Goettingen {Archiv f. Gyn., Bd. Ixxi., S. 411),
attributes the occlusion of the tube in gynatretic hydro-
salpinx to the formation of adhesions around its distal
extremity, and the formation of these adhesions to the
escape of menstrual blood irritating the peritoneum. The
influence of bacteria is not necessary.
An Early Operation for HiEMAxoMEXRA, with Ac-
companying HEMATOSALPINX, IN THE RUDIMENTARY
Horn of a Uterus Bicornis.
Prochownick [M iienchener med. Wchns., 1904, Feb-
ruary 2) exhibited to the Hamburg Medical Societ}' in
December a specimen removed earlier than any other
of the kind yet published. The patient, scarcely 15 years
old, had begun to menstruate four months before the
operation, and for that time had been constantly losing
some blood, but had not suffered any pain until the last
three days. The child was poorly developed, absolutely
intact, never having been even examined. She had always
been healthy. On examination per rectum the diagnosis
lay between a tumour of the right ovary, incarcerated or
twisted on its axis, on the one hand, and an anomaly of
development on the other. When the abdomen had been.
Adnexal Disease and Appendicitis jj
opened by Pfannenstiel's incision, it was at once found that
there was neither any accumulation of blood or other fluid
in the peritoneal cavity, nor any appearance of inflamma-
tion on the parietal or visceral serosa. The genital organs
were in no way adherent, and were easily lifted up into
the abdominal wound, and on the left side were normal.
The left horn of the uterus was continued into a normal
cervix and normal vagina ; the tube was slightly serpen-
tine, but otherwise regularly formed, open, unthickened,
and free from any irritation ; the ovary, plumper than
the right one and like that of a mature \irgin, contained
a recently ruptured follicle. The right rudimentary horn,
clearly indicated by the round ligament, was the size of
a large walnut, firmly elastic (filled with blood), and appa-
rently quite unconnected with the left horn ; the tube
passing from it at first slender, then slightly distended
with blood, finally made a series of four twists, to nearly
i8o° about its axis, each loop of which from the uterus
outwards was longer and more distended by blood
than the preceding one ; these twists were not folded
one on the other, but were nevertheless, together with
their ligamentary attachment, sharply bent away from
one another ; their entire length when stretched out
amounted to from 28 to 30 cm. The contained bloody
fluid was bright red. The end of the tube was not of
the common post-horn shape, but swollen into a knob,
and from the knob a fine cord extended for 3 cm. to finish
in a completely open ostium, with a typical pavilion. Just
before the fimbriated extremity a fine process passed
off to the right, typically childish, smooth, cylindrical
ovary, and must be supposed to be the fimbria ovarica.
Whether the apparently open extremity of the tube was
not an accessory oviduct is a question to be decided by
the histological examination.
Even as it was, the specimen certainly proved that
in this case the formation of the hasmatosalpinx was entirely
the result of mechanical causes, without any inflammatory
or infectious processes.
Adnexal Disease and Appendicitis.
SuNKLE [Cleveland Med. Journ., 1904, No. 2) declares
that in many cases operated upon for appendicitis the
5^ Summary of Gyncrcology, including Obstetrics
appendix is found to be perfectly normal, the symptoms
having been due to disease of the ovary and tube. Thus
Legueu reports two cases of extrauterine pregnancy,
one in a patient aged 48, diagnosed by him as appendi-
citis. In neither case had there been any menstrual
irregularity, uterine haemorrhage, or the usual signs of
pregnancy, and both cases were feverish. Downes tells
of the removal of the appendix from two women by a
general surgeon, without any relief ; in each case the
removal of an ovary containing pus effected a cure. Lusk
relates a case diagnosed by an eminent surgeon as appen-
dicitis, and in which all who examined the case thought
they felt the thickened appendix ; there was no history
of missing a period, but a tubal pregnancy was found
at the operation. Richelot mentions six cases in which
it was impossible to make a positive diagnosis before
opening the abdomen. In fact, the differential diagnosis
between appendicitis and tubo-ovarian disease, while
generally simple, is not infrequently almost impossible,
especially when the signs are misleading, or when a vaginal
examination without anaesthesia does not reveal any
trouble. Morris lays much stress on rigidity of the abdo-
men as a differential sign. The situation of the pain is
undoubtedly of value ; in chronic inflammation of the
appendix it is most felt on pressure over McBurney's
point ; in tubo-ovarian disease the most tender spot is
lower down in the ovarian region or in the vagina. Nausea,
gastric and intestinal troubles, or an intact hymen, point
towards appendicitis ; disordered genital functions or
fixity of the uterus suggest tubo-ovarian disease.
In about one case in ten the ligament of Clado is present,
extending from the meso-appendix to the right ovary ; it
contains a small branch from the ovarian artery and a
chain of lymphatics, and may thus form a road for infec-
tion between the adnexa and appendix. But even when
this is not present, close proximity may cause extension
of an inflammation from one to the other. If is often
impossible to teU which was the seat of the primary dis-
order ; but the colon bacillus or gonococcus might, if
present, decide the point.
Providing that time and the safety of the patient
permit it, the appendix, if it exhibits any deviation from
Interstitial Pregnancy ^^
the normal, should be removed at any gynaecological
coeliotomy. Indeed, the time seems not far distant when
it wiU be the rule to do this in every laparotomy.
Extrauterine Migration of the Ovum in
Ectopic Gestation.
Worrall, Sydney {Australian Med. Gaz., 1904, No. 3),
reports upon the situation of the corpus luteum in four
cases of ectopic pregnancy. In none of the four was there
any corpus luteum in the ovary of the same side as the
pregnancy ; in two instances the corpus luteum was found
in the ovary on the opposite side, and in the other two
it must be supposed to have been there ; so that in all
four instances the ovum must have reached the tube by
migration either through or external to the uterus. As
in the last case the fimbriated end of the tube correspond-
ing to the corpus luteum was occluded, WorraU considers
that the migration of the ovum must have been extra-
uterine.
Cripps and Williamson {B. M. /., 1904, i., p. 711)
report a case of tubal gestation after complete removal
of the ovary on the same side. Also {ibid., p. 712) cases
quoted from Kuestner and Howard Kelly.
Interstitial Pregnancy.
Weinbrenner, Magdeburg {Zeitschr. f. Geb. u. Gyn.,
Bd. li., Hft. i), has collected thirty-five cases of inter-
stitial pregnancy, which are not, as others published,
open to objection, and supplements them with two further
cases from Thorn's practice, in both of which, after
abdominal section, the gestation sac was excised from
the fundus, and the wound in the uterus stitched up with
catgut. In the first case the ovum had developed for
from one to two months in the uterine end and the whole
of the interstitial part of the tube, and had thrust apart
the surrounding muscular fibres. A portion of the pars
isthmica tubse had been dragged into the seat of the ovum.
The tumour formed by the implantation of the ovum
pas.sed almost imperceptibly into the normal fundus of
the very slightly enlarged uterus, the fundus being directed
from the left anteriorly backwards to the right. The
J 6 SiLmmary of Gyu(Tcology\ including Obstetrics
tube and ovary projected from the apex of the tumour,
the fundus was almost vertical. The patient recovered.
Thorn's second case was a true interstitial gestation
developed in uterine muscular tissue, neither of the tubes
showing any alteration. On the upper and posterior wall
of the left uterine horn there was a fluctuating tumour,
shaped like a mushroom and invested by loops of intes-
tine and omentum, in the purulent and putrid contents
of which lay a macerated four months' fcetus. Peritonitis,
which led to a fatal result, was present. The first case,
according to Kleb's nomenclature, was one of tubo-inter-
stitial gestation ; the second one of interstitial gestation
proper.
Ectopic Gestation, with Retention of the Dead Fcetus
Beyond Term.
Schmidt (I. D., Munich, Zentralh. f. Gyn., 1904, No. 11)
reports tw^o cases successfully operated upon in v. Winckel's
klinik. In the anamnesis of the first, a woman of 40.
there was nothing to suggest extrauterine pregnancy, and
the diagnosis made was " multiple myomata," a mistake
only discovered at the operation, when the entire sac
was removed. In the second, a woman of 37, the dia-
gnosis of ectopic gestation was made before the operation.
The foetal sac was so adherent to the intestines that it
had to be left and drained through the abdominal wound,
and also through the vagina. Both children were beyond
term, and were much compressed, almost spherical, with
deformed lower extremities (varus). The sac waU con-
tained much hypertrophied muscular tissue, in several
places to the thickness of a centimetre, so that the preg-
nancies must have been tubal.
Concurrent Tubal and Uterine Pregnancy.
WoRRALL, Sydney {Australian Med. Gaz., 1904, No. 3),
reports the following case : T. E., aged 33, the mother
of two children, of whom the youngest was 6 years old,
was admitted into the Sydney Hospital on July 20, 1903,
complaining of pain in the right inguinal region, which
began four weeks ago, was attended with vomiting, and
followed in a week by hemorrhage, which had continued
off and on up to her admission. There had been repeated
Ectopic and Intranterine Pregnancy 57
exacerbations of the pain. She had had two abortions
since the birth of her last child, the more recent eighteen
months ago. Her menses had been absent for two months
previous to the haemorrhage, and she thought herself
pregnant. The uterus was found to be enlarged, and
thrust over to the left by a mass felt in the right fornix
the size of an orange. A diagnosis of ectopic gestation
was made ; but the uterus, being curetted under ether,
was found to have contained an unruptured ovum of
about the fourth or fifth week, and the diagnosis was altered
to early uterine pregnancy, complicated by small ovarian
cyst. The patient was weakly, and had lost a consider-
able amount of blood ; abdominal section was therefore
postponed for a few days, when the tumour was found
to be the right Fallopian unruptured, with greatly thickened
walls containing an unruptured ovum, in which the foetus,
three-quarters of an inch long, was surrounded by a lami-
nated blood-clot.
Worrall attributes the pain to haemorrhage into the
ovum, and consequent distension of the tube, and also
to the escape of some blood from the ostium abdominale
into the peritoneal cavity. The patient made a good
recovery.
CoMBiXED Ectopic and Lxtraiterixe Pregxancy.
F. F. Simpson {Amer. your. Obsf., March, 1904) tabulates
113 reported cases, from a consideration of which he con-
ckides that there is a greater reason for appropriate and
timely surgical intervention in compound than in simple
ectopic pregnancy. The ectopic pregnancy is a source of
grave danger, the ectopic foetus has rarely been deliv'ered
alive and still more rarely has reached maturity. The
greatest safety to the mother lies in removing the ectopic
products before any complications have occurred. By
preference, however, the author defers operation until the
patient has recovered from acute anaemia. One case
reported was as follows : Patient nulliparous, menstruated
December 20, 1902 ; missed in January ; on February 19
had sudden severe pain in the region of the right tube ;
anaemia ; pulse 120 and temperature 103°. There was a
tender mass the size of a small cocoanut m lier right pelvis
and her uterus was slightly enlarged. She was kept at rest
and in four weeks her temperature and pulse had become
jc? Summary of Gynecology, inciuding Obstetrics
nearly normal. The uterus was then foimd more enlarged,
with a purple cervix and a globular elastic fundus, and was
evidently pregnant. The diagnosis made was combined
ectopic and intrauterine pregnancy, and on April 9 a right
ectopic pregnancy with a large peritubal ha3matocele was
removed by abdominal section. The patient went on well
and had a normal confinement on September 12.
J- I^^ J-
On Impregnation.
Toff, Braila {Zentralb. f. Gyn., 1903, No. 14), discusses
two points which are of interest in connection with the
President's address {ante, p. 18). He asks whether for
a woman sexual congress is merely a more or less intense
nervous excitement, without further and deeper influence
on the constitution of her system, and whether during
pregnancy the woman's body is just a receptacle to retain,
and nourish, and ultimately usher the ovum into the
world, without in itself undergoing any other changes m
the process than those affecting the sexual organs and
mammary glands.
In the course of her married life a woman ordinarily
receives into her vagina a relatively large quantity of
semen, which, in accordance with physical laws, enters
into endosmotic and exosmotic exchange wdth the tissue
juices of her own body. A portion of the semen is no
doubt absorbed, in the course of time a not inconsider-
able amount, and in this way the wife's system is im-
pregnated by that of the husband. To this cause Toff
attributes the strengthening effect of habitual sexual
intercourse upon ansemic and feeble young women, and
on the other hand, the debilitating results of malthusian
preventive measures.
In regard to the second point also Toff insists on the
importance of paternal influence conveyed by the semen,
not only upon the child conceived, but also on the maternal
organism. He lays stress on two important phenomena :
(i) Latent syphilisation, without absolute syphilis, of
the mother of a child begotten b}^ a luetic man, and (2) the
immunisation of a pregnant rabbit against anthrax by
the inoculation of the foetus in her womb. From all
this Toff argues that by sexual intercourse, and also by
gestation, the female organism becomes actually impreg-
On Hceniatonioles . 59
nated with the tissue-juices or chemical combinations of
the male body, and that to this may be attributed the
manifold changes induced in the female system by co-
habitation and pregnancy. It is difficult to assign a limit
to the duration of such impregnation ; it is, however,
a well known fact that children engendered by a second
husband often resemble the first. In breeding animals
this fact is still more prominent.
Toff considers in principle the deduction logical that
impregnation of this kind is desirable for, and is of
material advantage to, the female system. On the other
hand, if the male is unhealthy, his semen exercises a bad
influence, to which Toff suggests that certain symptoms of
pregnancy, such as salivation, hyperemesis, cephalalgia,
eclampsia, &c., may be attributed. Even hereditary
influence may come into play in this way, though the
man himself may apparently be quite sound.
On H^matomoles.
Bauereisen {Zeitschr. f. Geh. u. Gyn., Bd. h., Hft. 2),
in endeavouring to trace the etiology, on the basis of exact
histological examination of a series of sections of the
fruit sac, from a molar pregnancy, in which the prema-
ture embryonal structures proved of peculiar interest,
concludes that there is a typical form of molar pregnancy
to which the term aneurysmal mole applies better than
haematomole. The original cause of this condition lies
in disease of the uterine mucosa, its direct cause is the
obstruction of the veins of the intervillous spaces by the
deportation of chorionic villi. Secondary causes may
be found in the early occurrence of hydramnion, and in
the independent growth of the membranes after the death
of the embryo.
The Blood in Pregxanxy.
Payer, Graz {Archiv f. Gyn., Bd. Ixxi., S. 421), supple-
ments a comprehensive review of the literature of this
subject with a report of his own researches, which show
that the blood of pregnant women is normal as regards
the number of red corpuscles, the amount of haemoglobin,
and molecular concentration ; but is slightly deficient
in alkalinity and exhibits a moderate leucocytosis, cor-
6o Suvimary of Gymccology, including Obstetrics
responding to the maximum physiologically normal. He
saggests that this leucocytosis may be connected with
the deficient alkalescence.
Carstairs, Douglas (5. M. /., 1904, i., p. 709), prac-
tically confirms the above. In considering the coagulation
time in connection with the alleged tendency of the blood
in eclamptics to form thrombi readily, he concludes that
there is nothing to support the contention that the thrombi
found in certain organs in fatal cases of eclampsia are
due to an increased coagulability of the blood in that
condition.
The Freezing Point of the Blood in Pregnancy,
Labour and Childbed.
FuETH, Leipzig {Zeitschr. f. Geb. u. Gyn., Bd. li., Hft. 2).
concludes from thirty exact experiments that the freezing
point of the blood of women during gestation and labour
at term is distinctly (from 0'035° to 0-04° C.) higher than
than that of the blood of women who are neither preg-
nant nor parturient. This fact cannot, as has been sup-
posed, depend upon hydraemia, which recent researches
has proved to be absent. Various causes might account
for the elevation of the freezing point, difference in the
renal activity, or in the nutrition or altered respiration,
and consequent difference in the gaseation of the blood ;
but exact researches prove that none of these can be
accepted, so that Fueth has to content himself with pub-
lishing the fact of this remarkable condition without
being able to offer any explanation of it.
Hyperemesis Gravidarum.
Jung, Greifswald {Monats. f. Gch. u. Gyn., Bd. xviii.,
S. 570), characterises hyperemesis as the transition of
a condition which, during pregnancy, is to some extent
physiological into a pathological state, owing to changes
regularly occurring in the system of a gravid woman.
It is seldom met with, and must in no way be confused
with the ordinary vomiting of pregnancy. True hypere-
mesis gravidarum, with all its consequences, may be simu-
lated by a condition intermediate between autosuggestion
and simulation. Therapeutically all so-caUed specific medi-
Osteomalacia 6i
cines are to be avoided. If an absolute diagnosis has been
made, perfect rest in bed must be prescribed ; fluid nourish-
ment (ice milk) may be given by the mouth, but if the
vomiting continue, nutrient clysters only for some days,
after which oral nourishment may be tried again. Great
care must be taken lest the patient should secretly procure
and consume other food than that ordered ; failures in
private practice may often be attributed to this cause.
Interruption of the pregnancy for hyperemesis must be
avoided if possible, and in most cases may be so, and before
such interruption is decided upon, the patient should
submit to treatment in a hospital.
Osteomalacia, with Multiple Pigmented Sarcomata
AND Bone Cysts.
ScHMORL, Dresden {Muenchener m. Wchns., 1904,
No. 12, S. 537), exhibited to the Dresden Medical and
Scientific Society the skeleton of a woman who died at
the age of 75. She had a very old spontaneous fracture
of the left thigh, which had never united. Death was
apparently due to purulent bronchitis. At the autopsy
a typical osteomalacia was found, curvature of the spine,
with the formation of fishy vertebrse, osteomalacic pelvis,
deformation of the thorax, a spongy condition of the
cortical parts of the long bones, twisted clavicles, &c.
All the bones were affected, including even the calvarium,
which was converted into finely porous, reddish-white
bony tissue, very soft, and cutting like soft wood.
In many of the bones, skull-cap, sternum, ribs, verte-
brae, pelvis and long bones, there were brownish-black
tumours, in size from that of a pea to a cherry, mostly
in the cortical, but here and there in the central parts
of the bones, and consisting of spindle and giant cells.
The brown pigment contained iron. In the brown tumours
in the ribs there were cysts, some as large as peas ; at
the seat of the fracture in the thigh there was a large
brown tumour. The bone marrow was for the most part
changed into fibrous tissue ; there was marrow fat in
the long cyclindrical bones.
Schmorl, comparing the case with similar ones reported
by V. Recklingshausen, Schoenenberger and Hirschberg,
pointed out that it differed from them inasmuch as the
62 Siumnary of Gyiuccology, incliidivg Obstetrics
pigmented sarcomata were found not merely in the cortical
but also in the marrow cavities, and embedded not merely
in fibrous but also in fatty marrow.
In regard to the obscure aetiology and pathogenesis,
Schmorl was inclined to agree with v. Reckhngshausen
in attributing the genesis of the tumours to physical causes.
Eclampsia.
Meyer-Wirz {Archiv f. Gyn., Bd. Ixxi., S. 15) reports
upon 117 cases of eclampsia treated in the University
Frauenklinik at Zurich during the last eighteen years.
Apart from 3 fatal cases of sepsis the mortality was 32,
or 27-3 per cent., amongst mothers, and of the mature
or viable children 38 per cent. The f requeue}^ of the
disease was once in ii7"3 labours. In 38 instances the
fits commenced after admission into the klinik, and in
8 of these cases it had been ascertained before the first
convulsion that the urine was free from albumen. On
the other hand, in 35 cases submitted to autopsy, there
were only 8 in which previous renal affections could be
excluded with certaint}^ Prophylactic treatment is most
beneficial. After the onset Prof. Wyder is entirely in
favour of active measures, with cautious limitation as
regards cervical incisions and vaginal section, more unre-
servedly as regards metreurysis and dilatation of the
cervix by Bossi's method, not omitting the usual drugs, &c.
Eclampsia Treated by Thyroid Extract.
Baldonsky, Tomsk {Wratsch. Gas., 1804, No. i), con-
firms the favourable eftects of the administration of thyroid
extract in eclampsia reported by Nicholson of Edinburgh,
on the ground of two cases so treated by him in Professor
Grammataki's Klinik. The first was one of rather severe
eclampsia in a multipara, the fits ceased after the adminis-
tration of two o'3 gramme tablets, and after a third was
given the patient completely regained her consciousness.
The treatment was continued for the two following days
and the woman got well. More than a fortnight later she
had a severe recurrence (sixteen fits), which was subdued bv
I '8 grammes of the extract. The second case was that of
a woman in her first labour; the fits ceased after two tablets,
although the waters had not broken, and she had a normal
labour and childbed. Narcotics as well as thyroid extract
were freely administered in the first case.
Boss is Method in Abortion 6j
Dilatation of the Cervix by Bossi's Instrument.
Hammerschlag, Koenigsberg {Monats. /. Geh. u. Gyn.,
Bd. xvii., Hft. 6), reports upon 17 cases in which Bossi's
dilator was employed : In 8 for eclampsia, 5 for infection,
once for premature detachment of the normally situated
placenta, and 3 times for prolapse of the cord. Dilatation
and delivery never took at the most more than forty-five
minutes. The danger of laceration of the cervix is con-
stant, and tears of this kind occurred in three cases, in
extent varying from incomplete rupture of the uterus
down to slight tears in the portio ; none of these accidents
led to a fatal result. The details of the cases are given,
and a resume of the German literature on the method of
dilatation. The conclusions Hammerschlag arrives at are
as follows : Bossi's method affords the means of deliver-
ing a woman considerably more quickly than any other,
but is always liable to cause laceration of the cervix. It
should only be employed by a skilled obstetrician, and
under stringent indications in regard to the mother
(eclampsia, severe infection, premature detachment of
the placenta from its normal seat, or serious internal
indications) ; under other circumstances metreurysis is a
less serious proceeding. Bossi's method is contraindicated
by placenta praevia, or intense rigidity of the cervix. It
is never indicated in the interest of the child, unless any
danger to the mother from its employment can be excluded.
Bossi's Method in Abortion and after Taking up of
the Cervix.
Schuermann, Berlin {Monats. /. Geb. u. Gyn., B. xviii.,
S. 513), on the basis of ten cases of abortion in the fourth
to the sixth month and of labour at term, considers that
dilatation of the os uteri with Preiss's modification of
Bossi's instrument, after the portio vaginalis has been
taken up, is a less severe and less dangerous proceeding
than making incisions, but that the use of the instrument
while the cervix still persists to a greater or less extent
should be extremely limited. He prefers Preiss's modifi-
cation to any other, but thinks it could be improved by
increasing the pelvic curve, and by longer slightly curved
cervical parts.
6^ Surnmary of Gyncccology, including Obstetrics
Hahl, Helsingfors. also reports favourably on its' use
in eleven cases : Eclampsia, ablatio placentae, abortus
four to six months, imminent rupture, fever, asphyxia
foetus, partus praematvn-us art.
Twins Born at an Interval of Seventeen Days from
A Uterus Septus.
Paulin {Hospitalstidende, 1904, No. 6) reports : A
secundipara, aged 25, whose catamenia were established
regularly at 16, who had never aborted, and whose first
child, a boy, had been born at term two and a half years
previously, was under treatment in hospital for scarlatina
from February 22 to April 15, 1903. She believed herself
to have conceived directly after her discharge, as she
had no return of menstruation. She had good health
during her pregnancy until on December 15, 1903, she
was surprised by the waters breaking ; no labour pains
occurred till the same evening, but at 8 p.m. a living girl
was born, head presenting, and shortly afterwards a normal
placenta (with polar perforation) and normal membranes.
The midwife noticed that there was a second child in the
womb, and, as no contractions occurred, Paulin was sum-
moned to the case. He easily made out the foetal parts,
and heard the heart sounds distinctly ; on examination
he felt in the vagina, and to the left side of some soft tissue,
a comparatively hard and rigid cervix, with a partially
patent orifice ; the finger could not be introduced far enough
to feel the child. The woman soon fell asleep, felt well
the next day, and there were no uterine contractions.
Haemorrhage soon stopped, and she had no lochia ; the
breasts were lax and no milk was secreted ; no fever.
She got up on the ninth day, and looked after her house
till December 31, when the waters broke, the pains did
not come on till that night ; but at 6 a.m. on January i,
1904, a living female child was born, breech presenting ;
normal placenta and membranes, again with polar per-
foration, soon followed. After delivery the contracted
womb could be felt in the right side of the hypogastrium.
Haemorrhage and lochia were rather copious, but she had
a normal and fever-free childbed. The breasts soon en-
larged, and the supply of milk was so plentiful that she
was able to suckle both children.
Puerperal Sepsis and Serotherapy 6^
The weight of the first child, born four or five weeks
too soon, was 1,900 grammes ; that of the second, fourteen
days before term, 2,500 grammes. On January 18, 1904.
Professor Kaarsberg examined the woman, and found
the uterus as large as if in the second month of pregnancy ;
but there was no marked elongation of the anteroposterior
diameter. About i cm. above the orifice he found a
septum dividing the interior of the uterus into two cavities,
a left and a right, into each of which the sound passed
forwards and outwards. No division of the uterus into
two could be detected by external palpation. Paulin,
reviewing other cases of the kind already published, does
not think that in any of them, or in the present case, there
can be any question of superfoetation.
Central Rupture of the Perineum.
AzwANGER {Wiener med. Presse, 1904, No. 3) reports :
In a breech presentation one of the elbows of the foetus
took the wrong way, and was forced through the peri-
neum. In the extraction of the head the bridge left
behmd the posterior commissure was torn through.
Puerperal Sepsis and Serotherapy.
GuizzETTi (Rif. med., 1903, Nos. 44, 45) reports upon
six severe cases of puerperal fever treated with antistrep-
tococcic serum. One case, which before treatment was
ascertained to be due to a mixed infection, was fatal,
the others were all supposed to be infected by strepto-
cocci only. The serum used was obtained from the In-
stitut Pasteur, and was one of the so-called polyvalent
serums, that is to say, was obtained by van de Velde's
process from a horse which had been immunised against
various kinds of streptococci and their toxines. The
amount used was from 50 to 100 cm. in divided doses of
10 cm. Guizzetti was most favourably impressed with the
action of the serum ; the fever rapidly diminished, and
with it all symptoms of infection, especially the confusion
of the sensorium. The onset of septicaemia was either
warded off, or when it had already appeared ran a milder
course. Metastases disappeared, on the whole, with sur-
prising quickness, and complete recovery was much accele-
66 Siiiuuuwy of Gyncccology, including Obstetrics
rated. On the other hand, the effect on the uterine mucosa
was on the whole less, and was tardy, so that he does not
hesitate to recommend local measures in addition to
serotherapy. He offers the explanation that other infec-
tious germs than the streptococcus may be at work in
the uterus. The serum treatment, however, prevented
the de\elopment of purulent lymphangitis and thrombo-
phlebitis in the uterus and adnexa.
Caie [Brit. Med. Journ., November 7, 1903) reports :
A primipara of 25 was attacked by very severe puerperal
infection. Local treatment proving of no avail, the injec-
tion of 25 cm. antistreptococcic serum caused rapid im-
provement, and as a precautionary measure the injections
were repeated (daily ?) for a week. At the seat of the
injections on the abdomen, and one week after the last
one, two small abscesses appeared, and a third on her
elbow, and Caie refers these to the serum and not to any
fault in the antisepsis.
Jones (ibid.) gives a detailed account of another case
which did not improve till 90 cm. of serum (Pasteur) had
been injected.
Grochtmanx {Deutsche m. Wchns.. 1904, No. 10) cured
a very severe sepsis after abortion with 100 cm. of Aron-
sohn's serum.
Puerperal Gangrene of the Extremities.
WoRMSER, Basle (Wiener kl. Rundschau, 1904, Nos.
5 and 6), has collected 80 cases of gangrene in childbed,
which he divides into three groups, according as they
commenced : (i) During pregnancy, 7 cases ; (2) during
childbed, 66 cases ; (3) 7 were instances of Ra^-naud's
disease. The first and third group, as not being strictly
puerperal, fall out of consideration. Of the puerperal
cases, in 58 the lower extremities only were affected, in
the other 8 various other parts of the body, sometimes —
and as a rule in cases of very severe pyaemia — several parts
in the same patient. The cause of such gangrene is invari-
ably infection followed by processes obliterating arteries
or veins, or vessels of both systems, in which processes
endocarditis is an important factor. As the statistical
details given by Wormser show, the prognosis is very
Mortality in Hysterectoviy 6y
unfavourable, from one half to two-thirds of the patients
die, including all cases not operated on.
Pyelo-Nephritis and the Puerperal Condition.
Wallich (C. R. Soc. Obst. Gyn. Peed., February, 1904)
endeavours to answer the following question : What is
the effect of a pyelo-nephritis upon a woman in the puer-
peral condition, when the \-ulva is exposed several times
a day to the infective influence of a purulent urine ; and
whether, in case of an elevation of temperature, it is possible
to distinguish between a fever due to pyelo-nephritis and
one due to puerperal infection ?
From a number of collected observations he formulates
the following conclusions : The recovery may be perfectly
normal and apyretic, particularly if no fever has been
present for some time before labour ; but there may be
pyrexia if the pyelo-nephritis had provoked any fever
shortly before labour. This pyrexia, however, might
be distinguished from the fever of puerperal infection
by its presenting wider oscillations of daily temperature,
sometimes reaching, or even exceeding, 2°, and by a morning
remission to 37° C, or lower. Moreover, the pulse would
not exhibit an acceleration corresponding to the elevations
of temperature ; and the general condition of the patient,
outside the daily period of fever, would be more satisfac-
tory^ than in puerperal infection. P. Z. H.
Mortality in Hysterectomy for Puerperal Infection
POST Abortum.
Mouchotte {Ann. Gyn. Obst., March, 1904) has collected
30 of these cases, which he classifies as follows : (a) Fifteen
hysterectomies for infection limited to the uterus or com-
plicated with utero-ovarian thrombosis ; 13 vaginal, with
7 recoveries and 6 deaths ; 2 abdominal, with i recovery
and I death ; (b) 15 hysterectomies for uterine infection,
complicated with peritonitis at the beginning or during
the course of the disease, with or without pyosalpinx ;
5 vaginal, with 3 recoveries and 2 deaths, and 10 abdominal,
with 5 recoveries and 5 deaths. These figures should not be
considered as indicating one method of operation in pref-
erence to the other, as the details of the various cases show
that a greater number of those operated on by the abdo-
68 Suvuiiary of Gyiuecology, iucbidi'.ig Obstetrics
minal method were in a very serious condition, than was
the case in those operated on per vaginam. Of 3 other
cases of total abdominal hysterectomy performed for
puerperal infection post ahortum, complicated with fibro-
myoma, i recovered and 2 died.
P. Z. H.
Puerperal Metrophlebitis and Trendelenburg's
Operation.
Grossmann {Archiv /. Gyn., Bd. Ixx., S. 538) reports :
In a period of four years 105 women were treated for
puerperal sepsis in the Friedrichstadt Hospital at Dresden ;
54 died and 51 were submitted to post-mortem examination.
In 14 instances there was only thrombophlebitis, in 24 only
lymphangitis, in 13 both forms of lesion were found. In
all the cases of thrombophlebitis, with one exception,
in addition to the hypogastric or spermatic veins other
vessels were affected, in 3 instances the vena cava. In
the I remaining case, in which Trendelenburg's operation
(extraperitoneal ligature and resection of the thrombosed
veins) might have come in question, the woman was too
far gone for any operative interference.
Subchorionic Cysts.
Albeck, Copenhagen (Zeiischrift f. Geb. u. Gyn., Bd.
li., Hft. i), found in the literature available to him 164
cases among 2,265 iii which the placenta contained cysts.
This number must be regarded as below the true one,
as cysts of the placenta when small are easily over-
looked in any examination not directed specially to their
detection. Albeck, by systematic research of a series of
266 placenta, found cysts in 118 instances, or 44*3 per
cent., and in 6 cases the cysts were entirely within the
placental tissue ; one must therefore accept his state-
ment that subchorionic cysts are extremely common,
while intraplacental cysts, to say the least, are not rare.
Subchorionic cysts may be classed in two groups :
(i) The flat loose cysts formed in the subchorionic decidua,
and (2) the small, full, elastic cysts which arise in connec-
tion with decidual prominences. The histological struc-
ture, the direct, or indirect, connection with the decidua
serotina and other evidence, supports the view that the
The .'Etiology of Placental Polypi 6()
origin of both forms of placental cyst is from the decidua ;
the question whether the villi invariably found in the
walls of the cysts are necessary for their formation the
author leaves unanswered. The so-called layer of Nitabuch
is formed from the reticular connective tissue within the
decidua serotina, and therefore must not be accepted as
the boundary between maternal and foetal tissue.
The i^TiOLOGY of Placental Polypl
MiCHAELis, Leyden (Monats. f. Geb. u. Gyn., Bd. xvii.,
E. Hft.), gives the detailed description of the microscopical
examination of a placental polypus, and on the ground
of his researches concludes that the view, hitherto accepted,
that the origin of such growths is to be attributed to the
persistence of fragments of the placenta upon the surface
of the mucosa, does not hold good in all cases. He con-
siders that the foundation of placental polypi is formed
by chorionic villi situated within maternal vessels which
have undergone decidual changes. The villi within these
vessels exhibit in their epithelium and stroma Kerntheilung's
figuren, and are therefore alive and evidently actively
growing. The vessels containing the villi originally seated
deeply in the mucosa, become extruded out of that mem-
brane. This is one, perhaps the only, cause of the origin
of placental polypi. It is, of course, an example of the
exportation of chorionic villi.
The Frequency of Mammary Carcinoma in Relation
TO the Suckling of Children.
Lehmann (I. D., Munich, Zentralh. /. Gyn., 1904, No.
11), after collecting the statistics and discussing the various
conditions and the customs of the women of Bavaria,
Germany, and other European and eastern lands as regards
lactation, points out that a comparison of the frequency
with which mothers suckle their children and that of
the occurrence of mammary cancer, shows that in dis-
tricts and countries in which women carry out their maternal
duties, mammary carcinoma is much more uncommon
than in those in which women do not suckle their chil-
dren. It appears, therefore, that the habit of not nursing,
persisted in throughout generations, and the consequent
hyperplasia of the mammae, is a definite factor in the occur-
rence of mammary cancer.
JO Notes
NOTES.
We have with regret to record the deaths of the following
well-known American Obstetricians and Gynaecologists : —
Dr. John M. Duff, Professor of Obstetrics and Gynae-
cology in the Western Pennsylvania Medical College at
Pittsburg. He presided over the Obstetric and G^aiaeco-
logical Section when the American Medical Association met
in that city.
Dr. Henry D. Ingraham, Gynaecologist to three
hospitals in Buffalo, New York, a member of the American
Association of Obstetricians and Gynaecologists.
Dr. Thomas Murray Drysdale, one of the founders of
the American Gynaecological Society, twice President of
the Philadelphia Obstetrical Society, and Consulting Gynae-
cologist to the Medico-Chirurgical Hospital of that city,
aged 72.
Sir Arthur Vernon Macan has been appointed Ex-
aminer in Midwifery and Obstetrics in the University of
Oxford.
Dr. F. W. N. Haultain has been appointed Examiner in
Obstetrics and Gynaecology for the Indian Medical Service.
Mr. Alban Doran has been elected an Honorary
Fellow of the Obstetrical and Gynaecological Society at
Berlin.
The same distinction has been conferred on Dr. Leopold
Meyer of Copenhagen.
At the celebration of the Fiftieth Anniversary of the
foundation of the Leipzig Obstetrical Society, the Honorary
Fellowship of the Society was bestowed upon Professor
Mangiagalli of Pavia, and Professor Pestalozza and
Notes yi
Professor Truzzi were made corresponding P'ellows of the
Society.
Dr. C. J. CULLIXGWOKTH, whose term of office as
Obstetric Physician to St. Thomas's Hospital was extended
three years ago, has recently, on his retirement from the
active staff — after sixteen years' service — been appointed
Consulting Obstetrical Physician and a Governor of the
hospital.
Dr. H. McM. Paixter has been appointed Professor of
Midwifery at the College of Physicians and Surgeons of
New York.
Dr. Wm. Nieberdixg, Professor at the School for
Midwives, and Privat-dozent of Obstetrics and Gynaecology
at the University of Wiezburg, has at his own wish been
allowed to retire.
Dr. A. Hegar, Professor of Obstetrics and Gynaecology
and Director of the Frauenklinik at the University of
Freiburg i. Br,, has at his own wish been allowed to resign
his duties (from October i, 1904), and in recognition of his
long and distinguished services has been promoted to the
first rank of Privy Councillor, with the title of " Excellency."
Professor Pfaxxexstiel of Giessen, having declined the
Chair to be vacated by Professor Hegar at P'reiburg, it has
been accepted by Professor Kroexig of Jena, who will enter
on his duties on October i, 1904.
We learn that the Chair of Alidwifery at Erlangen was
declined by Professor Pfannenstiel of Giessen, and by Pro-
fessor Kroenig of Jena ; Dr. Stoeckel was placed temporarily
in charge of the Frauenklinik. Extraordinary Professor
Karl Menge of Leipzig has now accepted the appointment.
Professor Hofmeier having declined to leave Wuerz-
burg for Halle, the Wuerzburg students honoured him with
a torchlight procession.
Professor GUSSEROW of Berlin, who recently retired,
i been gi
Oak leaves.
has been given the 2nd Class Order of the Red Eagle with
The title of Geheimer Medizinal Rat has been granted
to Professor JOHAXXES Pfaxxexstiel of Giessen, and to
Dr. von Guerard of Elberfeld.
y2 Notes
The title of Professor has been accorded to Privat-dozent
Dr. Haxs Schroedek, Assistant to Professor Fritsch of
the University at Bonn ; and also to Privat-dozent Dr.
Karl Franz, Assistant to Professor Bumm at Berlin.
The following are the names of those recently made
Agreges d'accouchements, of the Faculties of Medicine
of Paris, Dr. Brindeau ; of Lille, Dr. Bue ; of Montpelier,
Dr. Ch. Giierin ; of Nancy, Dr. Fruhensholz ; and of
Toulouse, Dr. Thoyer.
Privat-DOZENTEX. The venia legendi in Obstetrics
and Gynaecology has been given to : — Dr. Paul Mathes,
at the University of Graz ; Dr. Julius Voigt, at the Uni-
versity of Goettingen ; Dr. Karl Fraxz, at the University
of Berlin, on an inaugural lecture on "The Importance of
the Ureters to Gynaecologists " ; Dr. Siegfried Hammer-
SCHLAG, Senior Physician in Professor Winter's Klinik
at the University of Koenigsberg, on an Inaugural Lecture
on "Rupture of the Uterus"; Dr. Maximilian Henkel.
at the University of Berlin, on an Inaugural Lecture on
" The Treatment of Retroflexion " ; Dr. Baisch, Assistant
at the University Frauenklinik, at Tuebingen, on an
Inaugural Address on "The Infections of the Female
Genital Organs " ; Dr. Ferdixaxd Schenk, at the German
University at Prague, and to Dr. Emilio Alfieri, of the
University at Parma.
Dr. Paul Kroe:\ier, Professor Pfannenstiel's Assistant
at Giessen, has qualitied with an essay on " The Lymphatics
of the Female Genitalia, and the changes they undergo in
Malignant Disease of the Uterus."
Dr. Wilhelm Zangemeister has assumed his duties as
First Assistant at the University Frauenklinik (Professor
Winter), and gave an Inaugural Address " On Determining
the General Indications in Obstetrics."
The Italian Obstetrical and Gynaecological Societv will
meet at Palermo in October next.
The American Gynaecological Society has amended its
Constitution, and declares that its objects shall be " the
promotion of knowledge in all that relates to diseases of
women, to Obstetrics and io Abdominal Surgery."
The American As'^ociation of Obstetricians and Gynae-
cologists will meet this year in September under the
Presidency of Dr. Walker B. Dorset, of that city.
SUMMARY OF GYNECOLOGY, INCLUDING OBSTETRICS.
NOVEMBER, 1904.
ANESTHESIA SeXUALIS.
Xexadovics, Franzensbad (Monats. f. Gcb. it. Gyii., Bd.
xix., S. 823), after reviewing the fundamental anatomy and
psycho-physiology of sexual life, discusses the cjuestion of
sexual insensibility in women, the different varieties and
numerous etiological factors of which demand both causal
and symptomatic treatment. In this general fortification of
the organism and nervous system, sexual hygiene, instruction
and mental influence play an important part. For such
treatment he suggests that Franzensbad is a favourable spot.
Spinal Analgesia, especially in Regard to its Em-
ployment IX Gyx.ecology axd Obstetrics.
Stolz, Graz {Archiv. f. Gyn., Bd. Ixxiii., S. 558-652),
traces the development of spinal analgesia from its flrst
suggestion by Corning in 1885, and Bier's practical ex-
periments thirteen years later, to the present day. He has
himself employed it in 155 gynaecological and 25 obstetric
operations, usmg from 0*04 to 0*08 grammes of tropacocaine
dissolved in cerebro-spinal fluid obtained by the puncture,
as many cubic cm. of the fluid being used as centigrammes
of tropacocaine are to be injected. The puncture was
generally made between the fourth and fifth lumbar ver-
tebrae. The itiethod proved quite successful for plastic
operations in the perineum and the rectum for fistula and
the paravaginal incision. Moreover, vaginal extirpation of
the cancerous tissues in Schuchardt's way, and abdominal
extirpation with exeresis of the pelvic glands and connec-
tive tissue, was also undertaken under spinal anaesthesia, but
in the laparotomies the result was always uncertain, and nar-
cosis by inhalation had to be induced to prolong the anal-
gesia m many cases. The troublesome complications and
the sequelae commonly reported Stolz met with but seldom.
y/f. Summary of GyncBcology, including Obstetrics
and only to a slight degree. In the 25 obstetric operations
(forceps, version, manual detachment of the placenta, &c.),
the dose injected was 0*05 gm. In 21 instances the anal-
gesia was complete, and it was always sufficient.
Martin, Greifswald (Miieiichener ni. IVchiis., 1904, No.
41), reported to the meeting of German Naturalists and
Physicians at Breslau that he had used Bier's method of
lumbar ancxsthesia in 30 cases of labour, in primiparce and
multiparae. In 25 instances the course of labour, including
the third stage, and that of the puerperium also, was quite
normal. The injections, which were not always easy to
administer, were made under Schleich's local anaesthesia.
One cubic centimetre of a solution of adrenalin (1 : 2,000)
was first injected, and the solution of cocaine hve minutes
afterwards. The anaesthesia was immediate and lasted a
long time, the analgesia not so long. There were no com-
plications such as collapse or paraesthesia. As the labour
pains were not felt, the action of abdominal pressure was
deficient — indeed, entirely absent except where demanded
from the patient by the observer. Martin thinks for the
present this method should not displace the use of chloro-
form in private practice, where not contra-indicated, but
that it is worthy of further experimental trial.
Leucocytosis in Gynecological DisiiASK.
Pankow, Jena (Archiv f. Gyii., Bd. Ixxiii., S. 227), dis-
cusses the sources of error which affect the question of
counting leucocytes. The cases he reports concern the
behaviour of the leucocytes in purulent and non-purulent
affections of the generative organs and peritoneum, in car-
cinoma, myoma, after operation, and during pregnancy,
labour and childbed. In gynaecological affections the
enumeration of the leucocytes does appear to be of practical
importance in deciding whether pus is present or not. On
this point the behaviour of the leucocytes is a surer guide
than the temperature curve, and repeated counts above
10,000, when other causes can be excluded, are always sug-
gestive of suppurating adnexal disease. [C/. Diitzmann,
ante p. 4.]
Kraurosis Vulve.
Jung, Greifswald [Zciis. f. Geb. 11. Gyii., Bd. lii., Hft. i),
characterises kraurosis vulvce as a chronic inflammation with
Cauliflower Groivths of the Vulva 75
a tendency to shrinking of the corium, and with the dis-
appearance of the elastic fibres of the affected tissue. This
chronic atrophic vulvitis with loss of the elastic elements he
has demonstrated in four cases here described in detail and
most artistically illustrated ; yet 'Clinically or macroscopically
there was no suggestion of kraurosis about them. The
changes in the skin consisted in thickening and pigmenta-
tion, or in another case in extreme thinning, a white and
tendinous appearance, or, again, in hardly any macroscopic
change. Signs of chronic inflammation : small-celled infil-
tration, hyperaemia, oedema, loss of elastic elements, and
sclerosis of the connective tissue of the corium, were present
m each case. Histologically, therefore, he finds that there
is no qualitative, but merely a quantitative, difference
between pronounced kraurosis and chronic vulvitis, and,
for the future, that no distinction should be drawn between
these affections in principle, but merely in degree. Krau-
rosis is to be looked upon as a final stage of chronic
vulvitis, and can be no longer considered an independent
and peculiar form of disease. Its etiology is identical with
tliat of vulvitis, which in each case is the fundamental
process in which it originates.
On Cauliflower Growths of the Vulva.
Hellendal, Tuebingen (Hegar's Beitraegc, Bd. viii.,
Hft. 2), on the basis of a case of elephantiasis tuberosa,
one of elephantiasis condylomatosa, one of papilloma car-
cinomatosum, and ten of carcinoma vulvae, operated upon
m the Tuebingen Klinik, discusses the clinical and ana-
tomical peculiarities of cauliflower growths of the vulva.
He holds that considering their rarity the records of these
tumours should be supplemented by drawings. Elephan-
tiasis is, of course, recognisable by the great hypertrophy of
tlie cutaneous and subcutaneous connective tissue. In con-
glomerate growths of condylomata acuminata, the scanti-
ness of such connective tissue, together with the hypertrophy
of the papillary bodies, is striking. In papillary carcinoma
evidence may be found in the atypical proliferation in the
growths in the deeper tissue supported by the presence of
cancroid cells. Every case must be submitted to micro-
scopical examination, without which the diagnosis of these
tumours is hardly possible.
^6 Su7nmary of Gyncrcology, inchidi7ig Obstetrics
The Relation between the Cervix and the Bladder
AND ITS Significance in Radical Operations f'OR
Cancer.
Sampson {Johns Hopkins Hosp. Bull., 1904, May) points
out that the area to which the cervix of the uterus is in
contact with the bladder behind the trigone varies m different
individuals, and also according to the position of the uterus
in the pelvis and the degree of distension of the bladder.
Under normal circumstances the two organs are but loosely
attached to one another and their separation is easily accom-
plished. In carcinoma of the cervi.x the vesico-vaginal
fistulae resulting from necrosis of the growth, and the acci-
dental injury of the bladder in hysterectomy for that disease,
bear witness to the rapidity with which the cancer, when
extending forwards, involves the bladder wall. When the
uterus, parametrium and upper portion of the vagina are
detached from the bladder a large area of the vesical wall
is exposed, extending from the utero-vesical peritoneal fold
above, to a point below varying with the detachment of the
vagina, but generally involving part, or the whole, of the
trigone ; laterally this area, if the ureters are dissected out,
may extend outside the openings of these canals into the
bladder. There is no advantage in removing much of the
lower portion of the vagina ; if it is not involved in the
disease, the more removed the greater the injury to the
bladder, but the wide excision of the tissue is most impor-
tant. The amount of injury to the bladder varies with
the difficulty in freeing it, which in turn depends on the
degree to which it is adherent. The blood supply of the
bladder may be impaired by the ligation of the large vessels
from which the vesical arteries arise ; moreover, all vessels
passing to the area of the bladder wall detached are
destroyed, and possibly some in the wall itself injured.
Nerves and ganglia, perhaps important in maintaining the
physiological activity of the bladder, may also be destroyed
in operations for cervical carcinoma. Retention of urine,
or inability to empty the bladder, completely bear witness
to the injury to the function of the organ apt to follow these
operations. In consequence of this injury the bladder is
less capable of resisting infectious organisms which may
gain access to it ; an additional avenue for such is afforded
by the injured area of the bladder wall. Cystitis is very
apt to result, and occurred in 12 out of 16 cases, in which
Sampson traced the effects of the operation upon the
Cystitis after Gyncsco logical Opei'-atioits //
bladder, and in 2 of the 12 cases resulted in renal infection
and death. In 3 of the other 4 cases an accidental vesico-
vaginal fistula was present and, as in 2 of these cases large
numbers of B. coli were present, by allowing full drainage,
apparently prevented cystitis.
It seems best after these operations that every three or
four hours the bladder should be emptied by a catheter, and
afterwards irrigated, as a prophylactic means of preventing
retention of urine and avoiding or mitigating cystitis, and
that if severe cystitis occurs, a vesico-vaginal fistula should
be made, which may be done without even a local anaes-
thetic. The excision of such portions of the bladder wall
as may be adherent to the cancerous growth improves the
chance of cure, and a vesico-vaginal fistula diminishes the
danger of post-operative cystitis and of possibly fatal ascend-
ing infection of the urinary tract.
Cystitis after Gynecological Operations.
Baisch, Tuebingen {Hegar's Beitrdge, Bd. viii., Heft 2),
has made bacteriological examination of the urine in 40
cases in which cystitis was detected on the very first day
of its appearance. Streptococci were present in 6, staphy-
lococci in 34, and in 10 instances the B. coli was associated
with streptococci or staphylococci. The B. coli was never
found alone if there had been no cystitis existing before
the operation, and many leucocytes were present in the
sediment ; but when the urine was examined from day
to day this was changed, and about the second week
counted from the beginning of the cystitis, the B. coli
appeared in association with the staphylococci and strepto-
cocci, and, on the average, from the third or fourth week
the still thick and mucopurulent urine almost always
afforded a pure culture of the B. coli. Post-operative
cystitis is, in fact, a staphylococcic or streptococcic infec-
tion, in which the B. coli takes a secondary part. As regards
the source whence these infective germs come and how they
reach the bladder, the idea of direct infection from the
bowel is unsupported by any evidence whatever. To
determine whether the germs came from the urethra, Baisch
and Piltz investigated the bacteriology of the urethra and
ascertained that that canal had no fiora of its own, that
such germs as it contained were derived from the vulva,
vestibulum, or vagina, and varied according to their origin.
The germs, moreover, are not the same during pregnancy
yS Summary of Gyncscology, including Obstetrics
as during childbed, nor in the healthy as in the bedridden,
nor in patients operated on as in those not yet so. Staphy-
lococci are constantly present in the secretions of the vulva
and urethra in patients who have not undergone operation,
but the B. coli only in two-thirds of the cases ; in all women
confined to bed after operation, both staphylococci and B.
coli are present in the urethral secretions. The immigration
of the B. coli is due to the lying in bed ; infrequent mic-
turition, however, undoubtedly helps. The omission of
such mechanical cleansing no doubt favours the upward
course of the germs.
Post-operative cystitis is, as a rule, due to catheter infec-
tion, though it is true that cystitis occurs in from 2 to 3
per cent, of the cases in which no catheter is used. Post-
operative retention of urine (ischuria) and the lesions
the bladder is exposed to in many gynaecological operations,
favour its occurrence. Experiments upon animals proved
that the introduction of infective germs into the bladder,
with or without the assistance of retention of urine, was
not itself enough to cause cystitis, but that such inflam-
mation did occur after an injury sustained by the external
surface of the organ.
It is of great importance for the prevention of post-
operative cystitis to induce the patient to make water of her
own accord. To this end, when there is ischuria in the
evening after the operation, Baisch advises the injection
of 20 cm. of 2 per cent, sterilised glycerine of borax into
the gall bladder by means of a Nelaton catheter and a
piston syringe. Spontaneous micturition generally occurs
within five minutes, but should the injection not have this
result the bladder should be washed out with 500 ccm. of a
3 per cent, solution of boric acid each time the catheter
has been used. If this be done post-operative cystitis will
hardly ever occur.
ROSENSTEIN, Berlin {Zcntralb. f. Gyii., 1904, No. 28),
says that even after slight operations he has not found the
retention of urine prevented by the injection of glycerine
of borax. The method of irrigation recommended by
Baisch demands much time and patience, and even then
is not uniformly successful ; in the 25 cases of Wertheim's
total extirpation, there were 3 instances of cystitis in spite
of preventive irrigation. He draws attention to the double
catheter he described in 1902, consisting of an outer safety
tube which is introduced into the urethra only as far as the
Bathing during the Menstrual Period yg
sphincter, and an inner tube, which without coming into
contact with the external genitaha is passed directly into the
bladder through the safety tube ; moreover, in order that the
inner tube should not carry on into the bladder any infec-
tive germs which the outer one may have taken as far as
the sphincter, the two tubes are made of different diameters ;
the inner tube is provided with a rigid guide, and nowhere
touches the safety tube, and so avoids any infective germs
collected upon it. The new model of the instrument made
bv Loewenstein is hardly thicker than an ordinary glass
catheter and may be used without causing any injury, even
when the urethra is a narrow one. Rosenstein gives statis-
tics from Professor Israel's Klinik. In 34 operative cases
during the last year and a half the catheter was employed
repeatedly, sometimes as often as twenty times, but there
was only one case of cystitis among them.
Congenital and Acquired Atresia of the Female
Genitals and its Treatment.
HOFMEIER, Wuerzburg (Zeits. f. Gcb. n. Gyn., Bd. hi.,
Hft. 2), publishes a number of cases of the above categoiy
and describes the various treatments he has adopted. The
first case shows that even in apparently congenital atresia
with partial duplication of the genitalia, intense inflamma-
tory processes in the adnexa of the affected side must have
taken place, and in this instance before the formation of a
true haematometra. The second, an acquired and extensive
atresia of the upper part of the cervix, was treated by an
artificial fistula between the cavum uteri and the vagina.
The next, a uterus bilocularis with haematometra of the
occluded side, was operated on in the same way. Hofmeier
also describes an operation, by Pfannenstiel's plan, on a
complete atresia of the vagina with haematometra in a
fully-developed uterus, and cases of true congenital atresia,
some with considerable collections of blood, but without
the formation of haematosalpinx.
Bathing During the Menstrual Period.
Edgar (Amer. Jour. Obst., September, 1904), says that
all forms of bathing during the menstrual period are largely
a matter of habit, and can usually be acquired by careful
and general precaution. But this does not hold good for
every woman, and surf bathing, in which the skin remains
chilled for some time, should always be excepted. The
8o Summary of Gynaecology, inciiidiiig Obstetrics
daily tepid sponge bath (85° to 92° F.) during the menstrual
period is not only harmless but is demanded by the rules of
hygiene. In most women, if not in all, tepid sponge bathing
on the second or third day after the estabHshment of the
flow, is a perfectly safe practice, and in most women the
habit of using a tepid shower or tub bath after the first day
or two of the flow can be acquired with safety.
J. F. J.
Precocious Menstruation.
Stein, Heubende {Deutsche vi, U^chns., 1904, No. 35),
reports a case in which a girl of 6 months had catamenia
coincident with her mother, and in which the secondary
characteristics of sex were also developed.
WisCHMANN (Zentralb., 1904, No. 30), discussing the
cases quoted by Veit and Prochownic, in connection with
one in which the catamenia were established at 10 years of
age (twelve periods in sixteen months), speaks of the pro-
gnosis as dubious, and insists on the importance of informing
the parents that sexual feeling may be developed very early.
Pregnancy has occurred at the age of 9 years.
Precocious Menstruation and Sarcoma of the Ovary.
RiEDL, Linz (Wiener kl. Wchns., 1904, No. 35), reports a
case of a child of 6 years old in whom, from the beginning
of her fourth year, bleeding from the genitals occurred
regularly. A tumour, which was as large as a man's head,
and proved to be a round-celled sarcoma with numerous
softened cysts, was extirpated from the left ovary. The
haemorrhage ceased after the operation, but the tumour
soon recurred.
Tubal Menstruation.
Thorn, Magdeburg (Zentralb. f. Gyii., 1904, No. 32),
denies that there is any menstruation in the healthy tube
on the evidence of laparotomies purposely performed on
menstruating women, and of specimens removed by vaginal
hysterectomy on account of carcinoma, myoma, or endo-
metritis. On the other hand, the process undoubtedly
affects tubes which have undergone morbid changes, as
has been proved by observations of genital atresia and
tubo-abdominal or tubo-vaginal fistula. He reports two
such cases, in one the haemorrhage accompanied normal
menstruation, in the other was substituted for it.
Hceniorrhagic Glandular Endometritis 8i
Early Menopause.
SCHALIT (Austral. Med. Jour., 1904, Aug.), reports the
case of a woman of 33 years of age, who menstruated irreg-
ularly from 14 years of age, was married at 17, and con-
ceived live months later ; she had two days' haemorrhage
at first, second and third months, and an occasional show
up to term. A healthy female child was born after a
difficult labour followed by haemorrhage. After six months'
nursing her milk failed, and she had several severe haemor-
rhages at irregular intervals. She conceived again one year
after her first labour, but aborted at two months with severe
floodings, and afterwards irregular haemorrhages. She had
no regular menstruation for twelve months, but then again
conceived, and after the birth of a weakly male child by a
difficult labour with great haemorrhage, she was ill for a
long time, had no milk, and menstruation never reappeared.
That is to say, the menopause was established at the age of
21. Her grandmother, who enjoyed good health till the
age of 74, menstruated at 13, married at 17, and had three
healthy children, but her menses finally ceased at 35. Her
mother, a healthy pluripara, did not reach her climacteric
till the age of 48.
Leucorrhcea and Yeast Treatment.
GOENNER, Basle {Korrbl.f. Sch. Acrzte, 1904, p. 181), has
found that fluor, whether gonorrhoeal or not, is best treated
with fresh yeast, which, rubbed up with sugar to form a
thickish fluid, he smears with a proper spoon on the walls
of the vagina, and also upon the vulva when that is inflamed.
The yeast is kept in the vagina by a plug of wadding.
HEMORRHAGIC GLANDULAR ENDOMETRITIS.
Pforte (I. D. Berlin, 1903 ; Zentralb f. Gyn., 1904, No.
42), relates : An intellectually deficient woman, 44 years of
age, who had had five children, complained of profuse
bleeding. Save an enlarged uterus, nothing pathological
was found in her genitals. As she did not get better as an
out-patient, her uterus was curetted, and the debris showed
a glandular endometritis. Her condition did not improve ;
she admitted onanism and coitus interruptus, and under
treatment and advice improved, but soon relapsed, and the
haemorrhage became so profuse as to threaten a fatal
anaemia. Panhysterectomy was therefore performed. The
82 Summary of Gyncecology, including Obstetrics
uterus was the size of one four months' pregnant. The
musculosa was much thickened, even to 6 cm. The mucosa
was swollen and thrown up into ridges ; the musculosa
consisted of two independent layers, an outer thinner and
an inner thicker layer, the latter distinguished by being
beset with cavities, some larger, some smaller. The micro-
scopical examination, which was carried out with the
greatest possible care, proved that these cavities were
formed by prolongation of the glands into the musculosa
and ectasis therein. Two forms could be recognised ; in
the one, the glandular prolongations joined together to
make large fissures ; in the other, they passed parallel into
the deep tissue and slung round to form tight balls, as if
they had come to harder tissue. The cellular coat was
single-layered, and showed no malignant change. The
stroma was plentiful and stained very deeply.
Failure of the Pessary Treatment of Mobile
Retroflexion.
Klein [Muenchener iii. Wclins., 1904, S. 141 2) reported
to the Munich Gynaecological Society on July 13, 1904,
that to gain a clear idea of the advantages of pessary treat-
ment he had analysed the results obtained in his private
practice during the last ten years. Among 4,750 patients,
526 had backward displacement of the uterus, mobile in
362 cases, fixed in 164 ; but to be of any value at all in
the estimate, the patients must have been at least a fortnight
under observation. Of the mobile retroflexions, 112 (31 per
cent.) were so. The others probably found the treatment
in no way beneficial, and therefore may be omitted. Of
the 112 the uterus kept its forward position in 17 cases
(15 per cent.) A doubtful result, replacement as long as
the pessary was left, and falling backwards when it was
removed, was obtained in 37 (33 per cent.) Failure, the
uterus falling back in spite of the pessary, in 58 cases (52
per cent). Fixation of the uterus on account of retroflexion
was done in only 20 cases, four times unsuccessfully.
Very often, in spite of the fixation, the displacement recurs
later on. He had at the Poliklinik seen dozens of women
with retroflexion after being" operated upon elsewhere. One
cannot estimate the result of the operation for at least five
years. Moreover, antefixation often gives rise to pain. The
treatment of retroflexion, in his opinion, has completely
failed, and the standpoint he has now adopted on the
The Alexander- A dams Operation 83
ground of his own accurately tested material is almost that
of Theilhaber. He replaces the uterus in retroflexions of
the third degree in which the organ is incapable of helping
itself ; in retroflexions of the first and second degrees that
is by no means the case. He replaces the uterus also, even
when the displacement is not of the third degree, in sterile
women in whom no other cause for the sterility can be
detected, and, of course, also every incarcerated retroflexion
of the gravid womb.
Croquet Ball Thirty Years in the Vagixa.
Orloff (Roiissky Wnilsch, 1904, No. 11), reports: A
woman of 66 was admitted into hospital suffering from
pains in the hypogastrium and vagina, and a fetid discharge.
Married at 26, she had her first child at 34, and afterwards
suffered from severe pains in her lower abdomen, due to
prolapse of the womb. These pains became much worse
after her second confinement, and the patient then herself
introduced a croquet ball into her vagina. From that time
the weight and pains ceased ; the functions of the bladder
and rectum were not disturbed. On examination the vagina
was found in a condition of senile atrophy, the finger im-
pinged upon a round and hard body. The urethra admitted
an ordinary sound, the urine was clear, and there was
nothing abnormal about the rectum. On account of the
senile atresia of the lower part of the vagina, it was necessary
to remove the round ball piecemeal, though it was quite
movable in its place. A pronounced colpitis with some
superficial ulceration was cured in five days. The ball had
been more than thirty years in the vagina without causmg
any serious lesion. The wood of which it was made seemed
in no way changed.
The Alexaxder-Adams Operatiox axd its Permaxent
Results.
Reifferscheid, Bonn (Arcliiv. f. Gyii., Bd. Ixxiii., S.
159), says that in six and a half years this operation has been
performed at the Bonn Frauenklinik in 241 cases, of which
102 were followed up. In this reduced number the per-
centage of recurrence was only 4 ; 39 women conceived,
and in no instance was there any serious trouble owing
to the operation. Reifferscheid holds that the Alexander-
Adams operation is less dangerous than any of the other
8^ Sztmmary of Gyncecology, incliidmg Obstetrics
surgical methods of dealing with retroflexion, and that when
the uterus is mobile it is almost as efficacious as ventro-
fixation.
McKay, Sydney (Aiisiml. Med. Gaz., July, 1904), has
performed Alexander's operation in more than 150 cases,
and considers it one of the best operations a gynaecologist
can perform, it is most suitable for retroflexion without
prolapse in virgins and married women. Moreover, if after
performing a curettage he finds the uterus is retroverted,
he always shortens the round ligaments, for, if the position
of the uterus be not corrected, abdominal pressure may in
time cause retroflexion or prolapse. Shortening the round
ligaments, combined with amputation of the cervix and
colporrhaphy acts well, even if there is slight prolapse as
well as backward displacement, as it allows the utero-sacral
ligaments (the chief support of the uterus) to regam their
tone. And even for severe prolapse, if the woman is in the
child-bearing period the operation may be done, but if
the menopause is near, or already past, ventrofixation or
vaginal hysterectomy is the proper operation. In one of
his operations, finding that there was a small hernial sac,
and that through it he could easily explore the uterus and
ovaries, he extended the plan of his operation. He found
out later that Goldspohn had anticipated him. It is so
easy to explore the ovaries and tubes through the internal
ring that he now adopts this method instead of the median
mcision when he has to remove a small ovarian cyst or a
hydrosalpinx. It is often possible to break down adhesions
on both sides of the uterus by one insertion of the finger,
but sometunes it has been necessary to open the internal
ring on both sides.
GoLDSPOHN's Operation.
KOSSMANN {Miienchener Med. Wchns., 1904, S. 1033), in
a communication to the Berlin Medical Society, June i,
1904, expressed the opinion that women suffering from
retroflexion, even when the uterus is mobile, are subject to
many pathological symptoms not due to the malposition of
the uterus, but to the adhesions this organ has contracted
with the surrounding viscera, especially with the great
omentum. To this fact he attributed the partial success
attending the methods of fixation generally employed, and
the Alexander- Adams operation, for even when the uterus
is restored to a good position these methods do not affect
Correction of Uterine Deviations 85
the adhesions. In this respect he held that the operation
described by Goldspohn some four years ago had indubit-
able advantages. In it, after the round ligament has been
drawn outwards in the usual way, the operator passes his
index finger into the abdominal cavity through the inguinal
canal, and in this way is able to expose the whole surface
of the uterus, to break down adhesions, and to ascertain the
condition of the adnexa, and, if need be, draw them out-
wards for cauterisation, or even for removal. The only
disadvantage attending this proceeding is that if the inguinal
wound should become infected, the cicatrix may lack resist-
ing power and hernia may supervene. On the other hand,
in women who already have hernia as well as retroflexion,
the radical cure may be undertaken at the same time as
the correction of the displacement.
Correction.
The Blunt Hook Operation for Shortening the
Round Ligaments.
Dr. H. W. Longyear has written in reference to our
abstract from the Anier. Jour. Ohst., November, 1903 {ante
vol. XIX., p. i6s), that he in no way claims to be the author
of the blunt hook operation for shortening the round liga-
ments, which was originated by Dr. J. H. Kellogg, of Battle
Creek, Michigan.
The Correction of Uterine Deviations by Plastic
Shortening of the Round and Sacro-uterine
Ligaments after Laparotomy (Fibro - Fibrous,
Indirect Fixation).
Sperling, Ko&mgshevg {Zentralb. f. Gyii., 1904, Xo. 35),
is against all vaginal and inguinal methods of fixation, and
ventrofixation also. His method, which as yet he has onlv
tried in a few cases, consists in opening the abdomen in the
middle line, dividing the peritoneal investment of the sacro-
uterine ligaments in the direction of their length, and, on the
usual principle of plastic operations, uniting the slit trans-
versely. The free ends of the folded and so shortened
ligaments are united, and the transverse ligament so formed
is stitched to the cervical wall. In pathological anteflexion
he operates on similar principles.
86 Summary of Gyncrcology, including Obstetrics
The Results of Suspensio Uteri.
Stone {Amer. four. Obst., August, 1904) has investi-
gated the results in 767 operations. The advantage of
Kelly's operation is due to the frequent necessity for open-
ing the abdomen in order to treat some condition associated
with displacements. The abdomen once opened in the
middle line, suspension is preferred to making additional
incisions for the Alexander-Adams operation. Suspension,
too, succeeds in holding the uterus in a position which does
not interfere with the progress of labour. Amongst the
cases investigated, there have been 49 full term deliveries
with uniformly successful results. When retroversion is
associated with downward displacement, fixation rather
than suspension should be done, in addition to plastic
operations. Fixation should, however, never be done in a
patient who is not past the child-bearing age.
J.F.J.
Stitch Abscesses after Uterine Fixation.
Mackenrodt {Zeutralb. f. Gym., 1904, No. 33, S. 1002)
recently exhibited at the Berlin Obstetric and Gyn?ecological
Society a uterus in the walls of which were many abscesses.
One communicating with the cavum had for a long time
caused a haemato-purulent discharge. The uterine tissue
felt nodular, as if from myomata. The phlegmonous in-
flammation and abscesses had their origin in the stitches of
an antefixation performed by another surgeon for retro-
flexion. The kind of suture used could not be ascertained.
The condition could not have been due to a perforation
during curettage preliminary to the antefixation, the rupture
of the large abscess with the cavum uteri had occurred
at a later period. Mackenrodt had met with such stitch
abscesses causing most serious trouble in many cases, after
various methods of antefixation and ventrofixation, and after
the enucleation of myomata.
Spontaneous Ventrofixation Leading to Retention
OF THE Placenta.
FuCHS, Breslau {Zcuinilb. f. Gyn., 1904, No. 29), reports
a case of a secundipara on whom, owing to a mistaken
diagnosis, laparotomy had been performed a year previously ;
instead of the suspected ovarian tumour there was pre
nancy, which terminated prematurely two months later
o_
Transverse Supra-Pubic Division of the Skin 8 J
Labour was easy, except that the placenta had to be detached
manually, owing to the absence of contraction of the anterior
wall of the uterus on which it was situated. This complica-
tion is attributed by Fuchs to adhesions between the uterine
and abdominal walls consequent on the untimely laparotomy.
Coating the Hands with a Solution of Rubber in
Benzine, a Substitute for Indiarubber Gloves.
Murphy {Jour. Amcv. Med. Ass., 1904, Sept. 17), has
found by experiment that a coatin^^ of a 4 per cent, solution
of rubber in benzine, poured on the hands and allow^ed to
diy without friction, while it does not afford so perfect a
protection as intact gloves, is, considering the chances ot
puncture, equal or even superior to wearing gloves, and
infinitely safer than operating with the bare hand. The
coating is slightly permeable by perspiration, but this, he
asserts, is not septic, while epithelium and the secretion of
the hair follicles are so. One application on the hands and
forearms is sufficient for the whole day, but the fingers must
be cleansed and redipped after each operation. The skin
suffers less than from wearing gloves.
A Self-retaining Retractor.
Reifferscheid, Bonn {Zcntralb. f. Gyii., 1904, No. 35),
describes an instrument consisting of two retractors open-
ing like a pair of scissors, the blades to be fixed at any
desired angle by a rack. It enables one to dispense with an
assistant to hold the edges of the wound apart, and has
proved especially useful in the Alexander-Adams operation,
it is made by Eschbaum in Bonn.
The Control of the Gauze Pads in Laparotomy.
ROSSEL {Zeniralb. f. Gy;/., 1904, No. 25), describes a
method employed for the last ten years by his chief. Dr.
Bircher, Director of the Cantonal Hospital, Aaran. Every
compress introduced into the abdomen is weighted ; a
weight of about two scruples is fastened to the corner of
each pad by a linen cord some seven inches long, and when
the pads are introduced the weights hang down on either
side of the abdomen.
Transverse Supra-Pubic Division of the Skin.
Kreutzmann {Auier. Jour. Obst., July, 1904) points out
the advantages of this method of making the mcision ; since
88 Summary of GyncBcology, including Obstetrics
the abdomen can be opened in the middle hne, intra-
abdominal or pelvic work can be done, and then at each
outer end of the same incision the round ligaments on the
outside of the inguinal canal can be found and the
Alexander operation performed. He reports three cases
treated by this method. Tiie cases must be carefully
selected so that the pelvic work may be carried out through
a small vertical incision in the linea alba. The Alexander
operation he considers is the best surgical method of treat-
ing displacement of the uterus. Fixation of the uterus he
condemns entirely. Shortening of the round ligaments
inside the abdomen he disapproves of because the weakest
part of the ligament in the inguinal canal is not strengthened.
It is this weak part of the ligament which is done away with
in the Alexander operation.
J. F. J.
The Treatment of Pus in the Pelvis.
Stoner {Aiiici'. your. Obst,, September, 1904) says where
pus exists outside the peritoneal cavity it should be attacked
when possible through an extra-peritoneal incision, and such
abscesses readily heal after incision and drainage. Abscesses
of the tube, or tube and ovary combined, are intractable in
healing after simple incision and drainage. The immediate
mortality may be lessened, but the morbidity is certainly
increased. Total removal is therefore the better surgery.
Whether the pus is sterile or not, drainage should follow
operations in which the peritoneum has been soiled with
pus. When vaginal incision is practised, it must be
thorough. Mere puncturing or aspirating the abscess is
the historic relic of surgical impropriety.
J. F. J.
The Treatment of Post-Operative Peritonitis.
Grandin {Amer. your. ObsL, July, 1904) divides post-
operative peritonitis into three types ; the paretic, the inflam-
matory, and septic. If in any case he has reason to think
that the operation will be performed in the presence of pus,
or that, from the nature of the case, pus will form, he
administers three hours before the operation 10 grains of
calomel with 20 grains of bicarbonate of soda. In the
paretic type, in which the abdomen becomes gradually
tympanitic, the stomach rejects both food and drugs, and
the temperature is but slightly elevated, the chief thing to
Relation of the Appendix to Pelvic Disease 8g
do is to relax the spasm of the bowel. There should be no
administration of calomel and salts and other drugs. If
calomel has been given already, he now gives either
atropin or hydrobromate of hyoscin in full dose by hypo-
dermic injection. The spasm relaxes and the patient is
relieved. In the inflammatory type, when three or four
days after the operation the temperature, the pulse, and the
respiration rise concomitantly and the stomach is hostile to
food and medicine, the bowels may or may not respond, but
the peritoneum is inflamed and wants rest. Calomel for
the bowels is already there, he therefore puts an ice bag on
the abdomen, washes out the stomach, feeds by the rectum,
and gives free doses of codein, which neither paralyses the
bowel nor upsets the stomach. In the septic type the
toxaemia is not local but general, and the treatment must be
to maintain the action of the heart by alcohol and strych-
nine, and if the kidneys are inefficient to use digitalis and
to inject saline solution into the veins, rectum or sub-
cutaneous tissue. Any foci of pus must be opened according
to surgical rule.
J. F. J.
The Relation of the Appendix to Pelvic Disease.
Peterson {Amcr. Jour. Obst., July, 1904), from careful
clinical and microscopic examination of 200 cases of pelvic
disease with a view to ascertaining the prevalence of appen-
dicular disease, concludes : Only a little over 50 per cent,
of appendices removed during the course of operations for
pelvic lesions will be found microscopically normal. The
remainder show forms of acute and chronic inflammation,
or the result of former inflammation. The average length
of the appendix is between 8 and 9 cm. The maximum
length of the appendix is found between the ages of 20
and 30 years. After this period the average length of the
appendix is less ; the diminution is probably due in many
cases to inflammatory changes. Menstrual pain may be
due to, or be increased by, the presence of an inflamed
appendix. The congestion accompanying menstruation
increases the inflammation and gives rise to attacks of
appendicular colic. The dift'erentiation between pain due
to pelvic lesions and pain due to chronic appendicitis is not
easy. The appendix is adherent twice as" frequently in those
cases where microscopic examination shows past or present
disease. A certain proportion of adherent appendices are,
G
go Summary of Gyncecoiogy, incliidi-ng Obstetrics
however, perfectly normal microscopically. The shape of
the appendix does not serve as an index of its normality
or disease. Appendices may be club-shaped, constricted,
or bent upon themselves, and yet perfectly normal micro-
scopicallv. The appendix is the seat of faecal concretions
in at least 8 per cent, of all cases. Their presence does not
denote that the appendix is diseased. Nearly 50 per cent, of
patients with chronic adnexal disease show accompanying
disease of the appendix. This may be the result of the direct
contact of the appendix with diseased appendages, or infec-
tion may travel from the latter to the appendix through the
lymphatics connecting the two. In chronic disease of the
appendix, adnexal adhesions are present in nearly 50 per
cent, of the cases. In some of these, however, microscopic
examination shows the appendix to be normal. In 50 per
cent, of patients with myomata of the uterus there is disease
of the appendix. In 70 per cent, of patients with cystoma
of the ovary there is disease of the appendix. The ordinary
median abdominal incision amply sufhces for the removal
of the appendix. Such a removal should neither increase
the mortality nor prolong the convalescence. Since it
is impossible for the surgeon to determine by the gross
appearance alone whether an appendix is diseased, and
since when the abdomen is opened for other purposes
nearly 50 per cent, of appendices are found diseased, it
is the duty of the surgeon, in the absence of contra-
indications, to remove the appendix in every such case.
This is especially so since primary carcinoma has occa-
sionally been found in such an early stage that it could
not have been detected by inspection at the time of the
operation. J. F. J.
Present Indications for Vaginal Hysterectomy.
Faure (C. R. Soc. Obsi. Gyn. Peed., July 1904) resumes
these indications as follows : Vaginal hysterectomy may be
resorted to in cases of small fibroma, of painful or incurable
metritis, and, exceptionally, in inceptive epithelioma of the
cervix in corpulent and aged women. On the other hand,
it should be resorted to in cases of inversion and of pro-
lapse, when it is found desirable to remove the uterus, and it
IS absolutely indicated in cases of extensive, virulently septic,
peri-uterine lesions which persistently get worse and which
colpotomy appears insufticient to cure, in cases of puerperal
Abdominal Operations for Uterine Myoniata gi
infection which do not improve under ordinary means of
treatment, and in subacute pelvic peritonitis propagating
itself towards the abdominal cavity.
P. Z. H.
Intractable Vomiting Associated with a Uterine
Fibrosis and Chronic Adnexal Disease.
Gaillard {Soc. Med. des Hop., 1904, May 13) reported a
case of intractable vomiting in a nervous woman, aged 42,
the subject of numerous small uterine fibromata, one with
a pedicle projecting like a polypus into the vagina, and
also suffering from chronic adnexal inflammation. When
panhysterectomy was performed the vomiting ceased and
did not return ; the woman, who was almost in extremis
at the time of operation, is now perfectly well.
Abdominal Operations for Uterine Myomata.
PiTHA, Prague {Wiener m. IVcIins., 1904, No.34-37), gives
a critical review of 211 cases operated upon in Pawlik's
Klinik in the years 1888-1901, where myomata are con-
sidered to be benign growths not to be interfered with,
unless they cause insupportable trouble, or threaten the
function of vital organs. The only abdommal operations
considered were enucleation and panhysterectomy after
Doyen's method. The mortality of the former was 28, of
the latter 10 per cent.
Coexisting Uterine and Ovarian Fibromyomata.
F. E. Taylor {Edin. Med. Joiirn., June, 1904), points out
that ovarian fibromyomata coexisting with uterine of the
same kind are generally small. Occasionally one may in
such cases meet with a large tumour, and there is then a
great tendency to torsion of the pedicle.
On Cysts of the Broad Ligament.
GiBELLi, Genoa {ArcJirc /. Gyn., Bd. Ixxiii., S. 306),
reports upon two egg-shaped tumours situated between the
folds of the broad ligament. The inner surface of each
tumour was lined with cylindrical epithelium. Gibelli
attributes one of these cysts to a remnant of Wolff's duct,
the other to an accessory tube. In one case drainage was
secured from the lower angle of the abdominal wound, and
the woman was discharged cured. The other woman, from
whom a malignant tumour of the rectum had been removed
g2 SuDuiiary of Gynaecology, including Obstetrics
at the same time as the broad ligament cyst, died on the
fourth day after the operation.
Radiotherapy of Uterine Tumours.
Deutsch {Mtienchener m. Wcliiis., 1904, No. 37) reports
the successful treatment of four cases of uterine myomata
by the Rontgen rays ; in all instances the tumour was
materially reduced in size ; in two, vesical troubles that had
existed for a long time were relieved by a very few sittings ;
in both these cases, however, after a long series of appli-
cations, symptoms occurred resembling those supervening
in the treatment of goitre with thyroid gland ; the ex-
treme emaciation, the nervous disorders (palpitation, irrita-
bility, lassitude, &c.), disappeared directly the treatment
was interrupted. Severe haemorrhages in one case were
materially diminished by a series of radiations without any
medical treatment. In two instances a sero-sanguineous
vaginal discharge occurred directly after the radiation of the
hypogastrium.
In one instance in which a uterine myoma coexisted with
a larger ovarian cystonia, a rapid diminution occurred in
the former after thirty applications : the ovarian tumour was
comparatively little smaller. From the effect of the Rontgen
rays in checking the haemorrhage and putrid discharge in
an inoperable carcinoma, they appear to palliate the effects
of malignant disease, and they would certainly seem to be
suitable treatment for cases of uterine myoma in which
operation, not always free from danger, is contramdicated.
The Lymphatics of the Female Genitals and their
Alterations in Malignant Disease of the Uterus.
Kroemer, Giessen {ArcJiiv. /. Gyn., Bd. Ixxiii., S. 57),
has investigated the course of the lymphatics in the cadaver
in thirty cases, nine of which were carcinomatous. Experi-
mental injection gave results agreeing to a surprising extent
with those of Briihns and others. After discussing separately
the inguinal glands, and the lymphatic vessels of the anterior
abdominal wall, bladder and urethra, female genitals, anus
and rectum, he proceeds to the microscopic examination of
the histology of the lymphatic vessels of the uterus and its
adnexa.
The study of the normal anatomy. is followed by the
investigation of the alteration of the lymphatic system of
the uterus on the occurrence and development of a malig-
Total Extii^pation of Uterine Carcinoma gj
nant tumour in that organ. The results necessarily point
to the necessity of strictly separating the malignant tumours
of the uterus according to their seat and histological struc-
ture, and of not looking upon them all as carcmoma, for
clinical observation has proved that they exhibit great varia-
tions in regard to the rapidity in which the glands become
infected. The article is richly illustrated by thirty-seven
figures on six plates.
The Question of the Lymphatic Glands and Recur-
rence AFTER Total Extirpation.
Mackenrodt, Berlin {Monats.f. Geb. u. Gyii., Bd. xix.,
Hft, 4), argues that considering the applicability of the
mode of operation recommended by him, the proportion
of the sixty cases of cancer reported by Schauta (Z.,
Bd. xix., H. 4) in which a radical exeresis of the disease
might have been possible, would be much more favour-
able. Even in the early stages at least one half of all cases
are affected with evident or latent infection of the glands,
and all such cases are lost unless the operation extends to
the removal of the local glands.
In 95 per cent, of all cases in which the glands are in-
fected, only those of the first line are so. The rare infections
of the glands in the second line are far less dangerous in
regard to local recurrence than the glands of the first line
close to the cicatrix. [This is absolutely contradictory to
Schauta's views.]
Justification of Vaginal Total Extirpation of
Uterine Carcinoma.
Schauta, Vienna {Mounts, f. Geb. u. Gyii., Bd. xix.,
S. 475), records the results of much laborious anatomical
research into the conditions of the glands in uterine cancer.
In a very large number, of available subjects, examining not
only those local glands which are within the range of opera-
tion, but also the lymphatics of the second line which are
not within the reach of surgical interference (the lumbar,
coeliac and superficial and deep inguinal glands), it
appeared that in 35 per cent, of the cases in which the
disease had attacked the glands of the first line, those of
the second line were also carcinomatous ; in 8"3 per cent,
the glands of the second line were affected, though those
of the first were free. In 43"3 per cent, none of the glands
suffered, while it was only in 13 "3 per cent, of the cases in
g/f Summary of Gynecology, including Obstetrics
which the first line were diseased that the second were
entirely unaffected. Hard, enlarged infiltrated glands often
proved not to be cancerous, while foci of the disease were
found in quite small ones ; and such foci were found not
only in the glands, but in the connective tissue, lymph
spaces, and even in the veins between them.
These results show that the complete radical removal of
carcinoma of the uterus, with all carcinomatous glands in
relation with it, is possible only in the most exceptional cases
in which the glands are affected at all.
In the latter part of the article Schauta gives clinical
evidence in favour of the vaginal method as extended by
Schuchardt's supplementary incision, and deprecates the
general adoption of the abdominal radical operation, or any
excessive search for cancerous glands.
The most recent Developments of Abdominal Total
Extirpation of the Carcinomatous Uterus,
together with the Exhibition of a Woman
Operated upon in the Year 1878.
W. A. Freund, Berlin (Mneuchciicr mcd. Wchnschr.,
October 4, 1904), presented at the Meeting of German
Naturalists and Physicians at Breslau last September, a
woman, aged 53, as the earliest irrefutable instance of cure
of a uterine cancer. It was ascertained by the micro-
scopical examination of a portion of the growth removed
before the operation and of the uterus itself after removal,
that the case was really one of carcinoma, and not only was
there a cervical cancer, but also, quite isolated from that,
a cancer of the fundus uteri. The woman is up to her
work, attends to her household duties, and feels well ; there
is a small hernia in the lower angle of the abdominal wound
but no recurrence of the disease. This is by no means the
only happy result Freund has had ; for instance, he cited
a case in which he operated twenty years ago for recurrent
cancer, yet the woman has remained cured. The former of
these two women he operated upon in the raised pelvis
position, which is by no means new, but is depicted in a
work of Scultet ; healing was by first intention, and she had
recovered from the operation in ten days. Although the
majority of operators are now, and rightly so, preferring the
abdominal route, Freund holds that too radical procedure is
to be avoided. Pollaczek has already insisted that ligature
Total Extirpation of the Carcinomatous Uterus 95
en masse should not be attempted, as it interferes with the
nutrition of the parts involved and does not prevent
secondary haemorrhage.
The results of operations for mammary carcinoma, in
which the disease may extend to and even penetrate the
periosteum, led Freund to resort to the abdominal route,
and in every case examine the glands and remove any that
were enlarged. But Mackenrodt, Riess, Rumpf, Kroenig
and Wertheim, go further and lay open the connective
tissue and remove all the glands, enlarged or not. Poirier
and others have made this operation possible by their
anatomical researches, but it is still questionable whether
it is possible to remove all the glands ; many have
aimed at removing the whole of the connective tissue, but
that is quite impossible. In this direction one must not
attempt too much, for cases have been known in which
tumours, apparently carcinomatous, have retrograded after
operation. Nor can one forget in forming a judgment
upon the method of operation, that even in the hands of the
most expert surgeons some other operations have a large
mortality, those on the stomach, for instance, one of twenty
per cent.
DoEDERLEix, Tuebingen {IbhL), said it was now possible
to give a positive opinion about the abdominal operation,
since according to the demand of v. Winckel, five years'
observation was enough to decide on the utility of any
surgical procedure. In the Klinik at Tuebingen, between
October i, 1897, and December 31, 1899, there were 151
cases of cancer of the uterus, of which 48 per cent, were
operated upon by the vaginal route, and the absolute cures
under five years' observation amounted to i9"6 per cent. In
the year 1902-4, 172 cases were operated upon by the abdomi-
nal way, and the proportion of cures was 30 per cent. It is
noteworthy that the number of cures increases with that of
the cases operated upon. If the operability of all cases seen
increases, the percentage of absolute cures does so also, and
Schuchardt has in this respect the best results. 61 per cent,
of operable cases and 24*5 per cent, of absolute cures.
Doederlein himself has now, in regard to cervical carcinoma,
which is admittedly much more unfavourable than cancer
of the body of the womb, an operability of 44 per cent.,
and it may be asserted that the abdominal method has
effected not only an increase in the operability, but a con-
g6 Summary of Gyncecology including Obstetrics
siderable decrease in the primary mortality. By this route
one is enabled to examine all the glands carefully, which is
the more important because cancer often advances by great
leaps along the lymphatic channels ; one may, for example,
find a healthy gland close to the uterus and one infiltrated
with the disease much higher up. In one operation of his,
two years and a half ago, the ureter was cancerous up to the
kidney, and the affected parts were extirpated, and up to the
present there has been no recurrence of the disease. He
has also operated in a case of recurrent cancer, which has
not again returned. He therefore prefers the abdominal
operation.
Mackenrodt {Ibid.) held that five years' observation
was insufficient, as recurrence might come much later.
He disapproved of vaginal operation, although the recur-
rences were often not to be attributed to the operation, but
were glandular, indeed, might affect not merely the intra-
abdominal, he had seen even the inguinal glands infil-
trated with the disease from a cancer of the body of the
womb. The removal of the glands was therefore necessary
in all cases ; recurrences were met with at the root of the
ligaments, deep down at their ramifications ; free exposure
and dissection was therefore, he thought, indispensable.
The aim of the operation was to clear out the whole of the
parts in the neighbourhood of the pelvic wall and the broad
ligaments, including the obturator fossae ; the plexus venosus
hypogastricus should be taken away, and also the fascia and
lymphatic system of the levator ani, which are often the seat
of recurrence. Mackenrodt said he had abandoned the
median incision, which did not give a view of the important
parts at all satisfactorily, and had adopted the transverse
incision of the old anatomists, above and convex towards
the pubes, dividing both recti and extending to the anterior
spines of the ilia. The peritoneum of this flap he used to
close the peritoneal cavity temporarily during the operation.
He gave us his results : In the year 1900 he operated on
12 cases, 2 cases (i6'6 per cent.) died from the results of
the operation, another case sank after four months, from
pyelonephritis. The rest remain well. In 1902, of 22 cases,
4 (18 per cent.) died from the operation, 50 per cent, under
observation for between two and three years remain well,
and recurrence took place ni the rest. In 1900, 6 cases out
of 22 died, one from pneumonia ; recurrence has taken place
Total Extirpation of the Cai'cinouiatoiLs Uterus <)J
in 3 ; but not in the other 13 under observation for from
one to two years. The number of cases operated on in 1904
was 15 ; one only died, from pneumonia ; one recurrence
took place, but the other patients are all healthy up to the
present. Leaving this year out of the question, but includ-
mg the fatalities, the proportion of cases surviving under
observation for from owo. to four years is 70*8 per cent.
In the Discussion.
KUESTNER, Bres'.au, said that it was unnecessary to wait
for statistics, as in all cases of cancer that method of attack
must be best which best enabled one to operate in sound
tissue. Resection of a ureter was sometimes necessary and
could only be done from the abdomen.
Veit, Halle, said that the mortality still attending opera-
tions for cancer depended not entirely on the disease itself,
but upon the liability to an infection set up by strepto-
cocci present in both the cancer and the glands. Some way
must be found to get rid of these micro-organisms.
Pankow, speaking for Kroenig, of jena, unavoidably
absent, pointed out that while Wertheim's method was
employed exclusively the operability had been 617 per cent.,
with a primary mortality of 3*8. But since the disease had
been attacked also by the Mackenrodt-Amann plan, while
the operability had increased to 87 per cent., the primary
mortality had risen to 267. This high mortality depended
on the technical difficulty of the cases so undertaken, or the
amount of foul discharge. Death was generally due to
sepsis, occasionally to the permanent exposure of the peri-
toneal cavity through the field of operation in the small
pelvis. After forming peritoneal flaps it was in two cases
found that the stitches had not held, in one the septum was
perforated, and once, though the covering was intact, septic
peritonitis supervened. The gravity of the case in which
the transverse incision was used appears from the fact that
in 47 operations after Wertheim's method the ureter was
only resected twice, but had to be so ten times in 24 opera-
tions by the other method. No death was due to resection
and implantation of the ureter, and in only one instance
had the tension been so great as to interfere with the union,
and the subsequent removal of the kidney necessary ; this
was, however, successful.
Glands were removed in 40 per cent, of all the cases, and
in 50 per cent, of these proved to be cancerous. Examina-
g8 Summary of Gynaecology, includmg Obstetrics
tion of the parametria proved that some, which chnically
appeared to be free, were involved in the disease, while
others, diagnosed as w'idely infiltrated, were entirely free
from it.
The clinical course of the cases alter Wertheim's opera-
tion differed from that after the transverse incision (Macken-
rodt-Amann). After Wertheim's the healing of the wounds
was generally good, any suppuration was for the most part
limited in amount. When any cystitis occurred, it w'as
generally slight and soon passed off. But in only three
instances did the curved incision heal by first intention — in
all the others there was troublesome discharge, in spite of
drainage upwards and downwards. Moreover, owing to
lack of abdommal pressure, and to the extensive detach-
ment of the bladder generally required in advanced cases,
obstinate and rather severe cystitis was almost the rule.
Wektheim, Vienna, said that as he begun his abdominal
operations in 1898, he had now a certain number of cases
available of more than five years' standing ; he w^ould, how-
ever, only bring forward his four-year-old statistics for
comparison wdth those of other operators. His percentage
of absolute cures, four years under observation, was i8"8,
while Chrobak's was 7*4 and Schauta's 5"i per cent. His
cases three years under observation gave a percentage of
absolute cures of 27"5, Chrobak's 7*4, Schauta's 6'6, and
Zweifel's io'2 per cent. The superiority of the abdominal
method was amply demonstrated by these figures.
Martin, Greifswald, expressed himself in favour of the
median incision, for twenty years ago he had tried the
horseshoe incision, on other indications, and been dis-
satisfied with it. He thought that for the present the
statistics of operations for uterine carcinoma were not to be
relied upon, as the various methods of operating were not
brought to sufficient perfection.
Freund, Strassburg, approved of Mackenrodt's horse-
shoe incision, as affording easier access to the deeper parts,
and a better view^
HOFMEIER spoke of the five years' limit as purely arbi-
tary, recurrences took place even after ten years. He
mentioned that twenty years ago he had operated on a
woman for recurrent cancer and she was now quite well.
DOEDERLEIN, in closing the discussion, said that one
should in the first instance try to find the glands and
remove them ; should they prove to be too extensively
Characters of Benignant CJiorionepithelioma gg
diseased throughout, the case was not one for radical opera-
tion. This is the best course from a practical point of
view, for sometimes one makes a radical operation only to
be afterwards convinced by inspection of the glands that
the case was not one for operation at all. He advocated
the closure of the field of operation rather than drainage.
Clamping of the vagina and the antecedent cauterisation of
the cancer are important factors in the result of the opera-
tion, and are therefore to be recommended.
Ox THE CO-EXISTEXCE OF SARCOMA AXD CAKCIXOMA IX
THE Uterus.
Nebesky, Innsbruck (ArcJuv f. Gvii., Bd. l.xxiii., S, 653),
reports the following case : A woman of 57 was ascertained
by the curette to have a sarcoma of the womb, and her
uterus and adnexa were therefore removed by laparotomy.
The left mamma was also amputated on account of hard
nodules which were getting larger. She recovered, and
examination of the mamma disclosed carcinoma. In her
uterus there was a large spindle-celled sarcoma containing
giant cells, and also a papillary adeno-carcinoma. Xebesky
detected the co-existence of sarcoma and commencing
carcinomatous degeneration in another uterus also, and is
therefore inclined to think such co-existence not altogether
exceptional.
The Histological Characters of Bexignaxt
Chorioxepithelioma.
V. Velits, Pressburg {Zciis. f. Geb. u. Gyii., Bd. lii.,
S. 301), concludes : Clinical evidence proves that chorion-
epithelioma with its metastases may be cured spontaneously.
This peculiarity may perhaps be explained by its foetal
origin, in consequence of which it is only under favourable
circumstances possible for it to flourish in the maternal
system. Spontaneous cure depends upon necrobiosis,
which in advanced stages is perceptible to the naked
eye. Microscopically spontaneous cure is evidenced by
depressed vitality of Langhans' cells (little or no mitosis),
and the appearance of wandering cells, which occur in
exact proportion to the disappearance of Langhans' cells,
and are degeneration products of the perishing chorion-
epithelioma and of the vesicular mole. The common
characteristic of the vesicular mole and chorionepithelioma
is that in both the essential factor is proliferation of the
100 Sttniinary of Gynaecology , including Obstetrics
epithelium of the chorionic villi. Since benignant vesicular
moles are capable of causing vaginal metastases, but only
benignant ones, in estimating the importance of these
metastases and of a possibly pathological process in the
uterus, we must have a clear idea constantly before us
of the exact histological structure of chorionepithelioma
proper.
Chorionepithelioma : Prognosis and Treatment.
Hammerschlag, Koenigsberg {Zeits. f. Geb. u. Gyii.,
Bd. Hi., S. 209), gives a detailed report of five cases with
a critical consideration of their histology in relation to the
points at present in question. On the whole he accepts
Marchand's views. He draws the following novel and
interesting conclusions : Growths of chorionic epithelium
in the uterus may, perhaps under the help of curettage,
undergo involution. Nevertheless, a malignant tendency
may have existed in. the cells of the chorionic epithelium
and be manifested by the formation of malignant chorion-
epithelioma outside the sphere of its settlement. Renewed
curettage may accidentally give evidence of the unsuspicious
nature of the latter, and is therefore not a sufficient basis
upon which to found the clinical treatment and prognosis.
A considerable time (two to five years) may elapse between
the pregnancy and the fatal termination of the chorion-
epithelioma dependent thereon.
Chorionepithelioma after Tubal Pregnancy.
HiNZ, Berlin {Zeits. /. Gcb. 11. Gyn., Bd. lii., S. 97),
reports a case of the above, in a quartipara, aged 33, which
in its histological details did not differ from Marchand's
classical case, and which developed in direct relation to
the extirpation of a tubal pregnancy.
Adenomyomata of the Genitalia.
Kleinhans, Prague (Zeits. f. Geb. u. Gyn., Bd. lii.,
S. 266), reports two additional instances of genital adeno-
myoma. The new growth was situated, in one, in the upper
third of the posterior vaginal wall extending nearly up to
the portio ; in the other, at the attachment of a myomatous
uterus to the rectum. These cases are interesting, clinically,
because too little is known about their malignity, and conse-
quently of the prognosis of their extirpation, and, anatomi-
Adcnomyoma of the Uterus loi
cally, because it is impossible to assign them a definite
position in the classification of tumours.
Semmelink {Zciiiralb. f. Gyn., 1904, No. 32, S. 980)
exhibited a specimen in which the entire genital tract, with
the exception of the tubes, was permeated with adenomyo-
matous elements. He agreed in the opinion enunciated
by Pfannenstiel, that adenomyomata of the ovary with
secondary formation of cysts might develop in the same
wav. Discussing the various theories of the origin of
adenomyoma, especially those of v. Recklingshausen, Lock-
staedt and Cullen, he inclined to the view that adenomyo-
mata are not all equivalent, but may be derived from Wolff's
ducts as well as from Mueller's, and that too much impor-
tance is not to be attached to their localisation. No remains
of Gaertner's ducts could be detected in the cervix.
Adenomyoma of the Uterus.
Murdoch Cameron and Leitch (Lancet, July 9, 1904)
give an excellent monograph upon this rare new growth,
which they attribute to an ingrowth of the endometrium into
the muscular tissue (inclusio glandularis). These inclusions
not only grow themselves but lead to proliferation of the mus-
cular tissue (adenomyoma benignum), from which not infre-
quently malignant adenoma or adenocarcinoma is developed.
Primary Genital Tuberculosis in Childhood.
Allaria (La Pediatria, vol. xi., p. 383) has collected
nineteen cases of primary tuberculosis of the female genitalia,
and reports another in a girl aged 11 years, who died from
pneumonia. At the autopsy the lungs were found studded
with recent tubercle, and there were a few caseous nodules
about the trachea. There was evidence of old tubercular
peritonitis. The uterus was enlarged and its cavity dis-
tended with caseous matter, and the mucosa contained
numerous tubercles. Both tubes were affected, but the
ovaries were free from the disease ; the vagina, external
genitals and urinary tract were also free.
Hypertrophic and Non-Ulcerative form of Vulvar
Tuberculosis.
Petit and Bender, Paris {Revue de Gyn., Tom. vii., 6),
report the occurrence, and recurrence after excision, of an
elephantoid growth principally affecting the labia majora
102 SiDuviary of Gyncecology, including Obstetrics
and minora of a woman, aged 31. The microscopic appear-
ance was characterised by the absence of any ulceration, by
the disappearance of the sebaceous glands, by extreme
oedema of the corium, and by more or less numerous, and
generally deeply seated, tubercles with foci of small-celled
mfiltration containing plasma cells and mast-cells. A few
tubercle bacilli were present. The case is analogous to one
reported by Poeverlein (I.D., Muenchen., 1902), which, from
there being no ulceration, was clinically pronounced to be
sarcoma.
Ovular Forms ix Ovarian Cancer.
LlEPMAN, Berlin {Zeds. f. Geh. u. Gyii., Bd. Hi., S. 248),
explains the structures resembling ova in ovarian tumours
as products of retrogressive metamorphosis. They cannot
be ovular, as supposed by some, for apart from the fact that
they would then represent biological monstrosities, minute
study of their histological structure, comparative micro-
scopical measurements, and the existence of similar "ova" in
a series of tumours in no way related to the ovaries, prove
that the description of the egg-like formations in ovarian
tumours as true ova is altogether incorrect.
The Pathological Histology of Chronic
Oophoritis.
Pinto, Dresden {Zcnimlh. f. Gyn., 1904, No. 23), has
made careful histological examination of twelve cases of
chronic inflammation of the adnexa from Leopold's Klinik,
and makes a preliminary report of the results to the follow-
ing effect.
There is no basis for the division of chronic oophoritis
into interstitial and parenchymatous forms ; the changes
affect stroma and follicles alike. In some instances the
inflammatory process invades the ovarian tissue by con-
tiguity {c.g.f after precedent tubal disease) and extends
gradually from the surface to the deeper layers of tissue ;
in others the pathogenic germs reach the ovary by the
blood-vessels and lymphatics of the hilum.
In the former case, the lesions are confined to the
cortical substance ; in the latter, they are more dissemi-
nated ; the stroma, the vessels and the medullary substance
are more involved in the disease, and consequently the
follicles are also modified. The lesions are parenchymatous
Pathological Histology of Chronic Oophoritis loj
as well as interstitial in both. In the former the oophoritis
may be called " cortical," in the latter " ditYuse."
In Coiiical Oophoritis, the ovary is of normal size with
superficial adhesions. The tunica aibuginea is more or less
thickened. In the stroma of recent cases there is small-
celled infiltration, especially round the vessels ; in older
cases part of the spindle-celled connective tissue is trans-
formed into a fibrous tissue poor in cells, and it is only here
and there that one finds patches of sound tissue containing
primary follicles. These are always diminished in number ;
those which still persist may be normal or may show the
effects of chromatolysis, atrophy of the nucleus and lique-
faction of the protoplasm. The more superficial Graafian
follicles in process of development undergo more or less
alteration of the epithelium and ovum. Some of those most
deeply situated appear normal. Many follicles are in
process of occlusion, others appear as cysts visible to the
naked eye. But the number of these follicles does not
exceed that in a normal ovary ; the epithelium and ova may
be normal or more or less changed. In this form of
oophoritis the medullary substance is but little, if at all,
altered.
In Diffuse OopJioritis the ovary is prone to be small
and furrowed on the surface. In cases not too old, the
cortical substance shows a hyperplasia of the stroma with
more or less diminution in the number of primary follicles.
In old cases the cortical matter is atrophied. The number
of Graafian follicles is always diminished ; they may be
normal, or show atresic or cystic degeneration ; but the
follicular changes, generally, are less pronounced than in
the other form of oophoritis. In the medullary substance,
in recent cases, processes of hyperplasia have been found
in the stroma ; in the older cases, on the other hand, the
connective tissue of the stroma is dense and poor in cells.
The vessels are commonly very numerous ; some exhibit
hyaline degeneration of the media and intima, others the
effects of endarteritis obliterans, or perivascular sclerosis.
Marked dilatation of the lymphatic vessels is sometimes
seen also, more frequently haemorrhagic foci in the stroma
as well as in the follicles ; more rarely foci of small-celled
infiltration. Usually this ditifuse form of oophoritis corre-
sponds with the so-called interstitial oophoritis and ultimately
leads to sclerosis of the ovary (premature senility of the
ovary, according to Bulius). In some cases one must
10^ Siiuiuiary of Gyncecology, including Obstetrics
suppose that both forms of oophoritis are associated. It is
worth noticing that one finds a certain number of normal
follicles even m very advanced instances of both forms of
inflammation.
Pinto cannot accept the views of Martin and Orthmann,
w^ho describe one form of oophoritis with lesions limited to
the organ itself, and another including the surface and
surrounding parts in the inflammation and consecutive to
a perioophoritis adhesiva. He does not believe that micro-
cystic degeneration is associated w-ith a chronic inflamma-
tory process in the ovary. Whether, as Martin holds,
universal oophoritis {i.e., microcystic degeneration) shall be
considered a chronic inflammation, in which, in conse-
quence of a perioophoritis adhesiva, the surface and sur-
rounding parts are involved, is an open question.
In view of its origin and microscopical anatomy, Pinto
accepts two forms of oophoritis (i) a cortical, (2) a diffuse.
Infection, either gonorrhceal or puerperal, takes the first
place in their etiology. Menstrual troubles, abnormal
w^ays of gratifying sexual instinct, chlorosis, pelvic tumours,
wiiich have been advanced as causing the disease by inter-
fering with the circulation, Pinto considers rather as pre-
disposing conditions favourable to infection.
Hernia of the Ovary with Torsion of the Pedicle.
Gaugele {Deutsche Zeits. f. Chir., Bd. Ixxiii., S. 216)
reports a case of the above which is of interest, as, although
he has found only eight others recorded, the accident is
probably less uncommon than has been supposed ; that is
to say, an intrasaccular torsion without strangulation, the
twisted part of the pedicle not corresponding with the neck
of the sac, but being generally at some distance below it.
A female infant, 8 months old, was brought to the
Herzog's Pasdiatric Klinik at Munich on December 3, 1903.
From birth she had had a small inguinal tumour on the
left side, easily reducible by the mother, but the previous
evening this tumour had become much larger, and could
no longer be returned into the abdomen. It was twice the
size of a pigeon's egg, very hard and tender on pressure.
There w^as no abdominal trouble, and the child's general
condition was so nearly normal that strangulation of the
bowel was most improbable, and they therefore concluded
that some other viscus, the ovary or uterus, must be in-
Endothelioma Ovarii lo^
carcerated. An operation was performed immediately, a
hard, smooth, bluish tumour was exposed, covered by a
fold of peritoneum, to which it was adherent. It was con-
tinued into a pedicle at the neck of the sac, quite normal
in appearance and quite free, but blackish a little lower
down. This discoloured portion was found to be a zone
of torsion, and the tumour to consist of an ovary six times
as large as usual at the child's age, together with the corre-
sponding tube. As the lesions were too far advanced for
conservative treatment, the pedicle was ligatured in the
sound portion and the tumour removed. Recovery was un-
eventful. Comparing this case with the other eight collected
ones, Gaugele concludes that though as 3^et the diagnosis
has never been made before the operation, clinical analysis
gives data enough for it. In the hrst place the subjects
were all very young, less than a year old in six cases out of
the eight, the others being respectively 3 and 5 years old.
They were all cases of congenital inguinal hernia, most of
them of the right side. The size, ovoid shape, and the
hardness of the hernial tumour, in the first place suggest
the nature of the contents, but what above all should attract
attention is the absence of any intestinal symptoms, charac-
teristic vomiting, arrest of faeces, or tympanitis, and also the
fact that the general system is hardly affected, which would
contrast strangely with the supposition of an incarceration
of the bowel. It is to be noticed that such torsion, within
the sac provokes far less reaction than torsion within the
abdomen. Immediate operation is, of course, indicated,
and is the only chance of saving the ovary.
Endothelioma Lymphaticum Ovarii.
Heinricius, Helsingfors (Archiv f. Gyii., Bd., Ixxiii.,
S. 323), reports a case in which a solid ovarian tumour was
removed from a woman aged 32, the other ovary, healthy in
appearance, being left. The woman died eight months
after leaving hospital, as it was said, from abdominal cancer.
On the ground of microscopical evidence Heinricius sup-
poses that the tumour removed originated from the endo-
thelium of the lymph spaces or smaller lymphatic vessels.
Endothelioma Ovarii, with Uterine and Glandular
Metastases.
F'ederlin, Strassburg (Hcgar's Beitraegc, Bd. viii., Hft. 2),
describes two cystic ovarian tumours, clinically resembling
H
io6 Sunmiary of Gymecology, inc hiding Obstetrics
cystosarcoma or carcinoma, removed by laparotomy, together
with a uterus containing similar nodules and the greatly
enlarged inguinal glands of the right side. Microscopical
examination proved that the case was one of haemangio-
sarcoma of both ovaries, with metastases in the uterus and
inguinal glands. No instance of the kind has been previously
recorded.
Two Solid Ovarian Embryomata.
ROTHE, Breslau {Monals.f. Geb. u.Gyii., Bd. xix., S. 799),
reports two cases, from which he concludes that it is im-
possible to draw a definite distinction between teratomata
and dermoid cysts. There is no fundamental difference
between embryomata and dermoid cysts ; nor do we know
the causes which lead, in the one case, to a solid proliferating,
and in the other, to an enlarging cystic tumour.
On the Fate of Peritoneal Implantations from
Papillary Ovarian Cystomata.
Hollinger(1. D. Muenchen, 1903 ; Zcntralb.f. Gyn., 1904,
No. 42) reports : a patient in Theilhaber's Klinik, aged 40,
had been conscious for three months of a rapidly enlarging
tumour in her abdomen, which was diagnosed as an ovarian
tumour of the right side. The diagnosis was confirmed by
operation, the left ovary was left behind. On the intestinal
serosa there were dispersed small white nodules ; there was
ascites ; the outer surface of the tumour was smooth, its
inner surface covered with numerous papillary excrescences.
The patient did very well after the operation, but ten years
later returned with a cystic abdominal tumour which, like
the other, was removed by operation, and proved to be a
papillary growth of the left ovary, of the same microscopical
structure as the former one. The intestinal serosa, however,
was perfectly free from the numerous nodules it had formerly
contained.
Carcinomatous Papillary Ovarian Cystomata Rup-
tured INTO THE Peritoneal Cavity.
Levi {Archivio di Obst. c Gin., May, 1904) gives a full
account of a case of the above, which came under his own
notice, with a detailed description of the microscopical
characters of the tumour removed by operation, and from
the study of this case and the literature of the subject, he
Pai'ovarian Cyst loy
draws the following conclusions : (i) Carcinomatous cysts
of the ovary may develop at any period of life ; (2) they
originate in the cells of the tubes of Pfliiger, as do also the
papillomata of the germinal epithelium of the ovary ; (3)
histologically, cancerous cysts are difficult to distinguish
from papillomata, but can be recognised when masses of
atypical epithelial elements are found ; (4) a papilloma which
at first has a benign course may degenerate into a carcino-
matous form ; (5) the rupture of a cystic tumour into the
peritoneal cavity may pass unobserved owing to the absence
of definite symptoms ; (6) the liquid of carcinomatous cysts,
apart from suppuration, is not of a septic nature ; at all
events the germs it contains are not pathogenic ; (7) the
prognosis of every ovarian tumour ought to be guarded,
because it is not possible to exclude, with any certainty, the
possibility of malignancy ; (8) the treatment should be the
operative removal of all that is suspected ; (9) in recurrent
and in very advanced cases complicated with numerous
metastases, it is better not to interfere, as the operation may
have a fatal result. F. E.
Parovarian Cyst.
Xagel (Zeiitmlb.f. Gyn., 1904, No. 33, S. 1,000) recently
exhibited at the Berlin Obstetric and Gynaecological Society,
a single chambered parovarian cyst of the right side, of the
capacity of 33 litres, successfully removed by laparotomv
from a woman aged 52. The largest cyst of the kind
hitherto recorded (Jeanbran and ]\Ioitessier) contained 23
litres. This large cyst was completely invested with peri-
toneum, which could be stripped off the wall of the sac
as a separate membrane. The ovary was intact, standing
prominently out from the sac wall, and under the micro-
scope showed characteristic structure (stroma. Graafian
follicles and corpora albicantia) ; the ovarian ligament proper
passed from it to the uterus. The tube, greatly stretched
longitudinally, was in an atrophied condition, exhibiting the
microscopic changes of senile atrophy as described by
Ballantyne ; the closed fimbriated end was gradually lost in
the wall of the cyst.
The Permeability of the Tubes by Fluids Injected
INTO THE Uterus, especially in regard to Experi-
mental Trials upon the Living.
Thorn {Zentralb. f. Gyn., 1904, Xo. 38) has been using
Braun's syringe for 22 years without any serious accidents.
loS Sunniiary of Gyncccology, including Obstetrics
such as have led Doederlein and Zweifel to consider the
intra-uterine injection of caustics to be dangerous. He says
that if the cervix be sutiliciently dilated the injected fluid
will not find its way into the tubes, and that under any
circumstances it is most exceptional for it to do so. In six
cases of extirpation of the uterus he injected tincture of
iodine and a solution of methyl violet without any precau-
tions immediately before performing vaginal panhysterec-
tomy. In the first five he found nothing in the tubes, and in
the sixth merely a slight discolouration in the interior of
the left tube, which he attributed to diffusion of the colour-
ing matter. He considers it fallacious to apply to the living
deductions made from experiments on the cadaver, in
which contractions of the cornua do not happen. The
contradiction of Doederlein and Zweifel's experience by
Thorn's, needs elucidation by further experiments.
Sounding the Tube and Uterine Perforations.
Thorn, Magdeburg {Zcntnilb. f. Gyii., 1904, No. 36),
finds it impossible in the cadaver to introduce an ordinary
uterine sound into the lumen of the isthmus of the normal
tube when the parts are in situ, or removed from the body,
and sets down all alleged instances of sounding the tube in
the living body as cases of perforation of the uterus, esteem-
ing this to be absolutely certain in normal or puerperal uteri.
Even when the uterus was inverted (four cases) he could
not sound the tube ; he was, however, able to do so in a
large myomatous uterus, as was proved when total extirpa-
tion was afterwards performed. He gives as indispensable
conditions for the sounding of the tube, an abnormal width
of the lumen of the tube, especially of the ostium uterinum,
and of the interstitial portion, resisting power of the walls,
and dilatation and an erect position of the uterine horn.
These conditions are fulfilled, as four unobjectionable
published cases prove, by myomata or by malformations
of the uterus.
Suppurative Adnexal Disease consequExNT on Enteric
Fever.
DiRMOSER, Vienna {Zcntralb. f. Gyn., 1904, No. 40),
quotes a case of Joseph Koch's to show that pyosalpinx need
not necessarily be due to the streptococcus, gonococcus, or
tubercle bacillus, but may be caused by the B. typhosus, and
Tubal Pi'egnancy log
describes a second case, a maiden, aged 20, who six months
after a severe attack of enteric fever was found, on laparo-
tomy, to have a suppurating ovary on the right side and
a pyosalpinx on the left. The pus contained typhus bacilli,
which must have found their way from the large intestine to
the tube and ovary along the lymphatics.
A very interesting case is noticed in the Lancet of
August 6. D.ARXALL {JouY. Amcv. Med. Ass., July 2, 1904)
reports: A., aged 30, fell ill on May 21, took to her bed on
June 9, and was attacked with severe diarrhoea, when her
temperature was 103°. At 8 p.m. that evening her tempera-
ture was 105°, and metrorrhagia began. Menstruation had
occurred two weeks previously and had always been regular.
The enteric developed and the Widal reaction was obtained.
Ergot was given and the vagina packed with gauze, which
checked the haemorrhage. Exitus on June 16. At the
autopsy no cause for the haemorrhage could be found in the
uterus, the appendages appeared to be normal.
TUB.AL PREGN.ANCY.
ZuNTZ, Berlin (Archil' /. Gyn., Bd. Ixxiii., S. 22), reports
upon 100 cases of extrauterine pregnancy, in two-thirds of
which precedent inflammatory conditions in the genitalia
had existed, and possibly were the cause of the anomaly ;
in such conditions, however, gonorrhoea was by no means so
common as puerperal infection. To determine the diagnosis
he recommends exploratory puncture from the vagina. All
cases except ten were operated upon, four by vaginal in-
cision, all the others by laparotomy, and thirteen out of the
eighty-six ended fatally.
Two UxusuAL Cases of Tubal Pregnancy.
VoiGT, Goettingen {Moiiats. f. Geb. u. Gyiiaek., Bd. xix.,
S. 791), reports a case of tubo-abdominal pregnancy in
which, after the rupture of the wall of the tube, the develop-
ment of the unbroken ovum had continued, and formations
were found at the placental seat which in structure were inter-
mediate between the normal growths of the foetal elements
and that of chorion epithelioma. It might be supposed that
they represented a transition towards malignant new growth.
In another case tubal pregnancy coexisted with complete
occlusion of the fimbrial end of the tube. When abortion
occurred the blood, after tilling up the tube, forced its way
1 10 Sum7nary of Gynaecology, including Obstetrics
into the ovary and discharged itself through a corpus kiteum
cyst into the abdominal cavity.
Ampullary Tubal Pkegxaxcy with Torsion of the
Pedicle : Laparotomy : Recovery.
BiDONE (Bull. Soc. Med. Bologna, 1904, Fasc. 6), reported
a case which, as he could only find five similar ones recorded,
he thought important from its rarity. There was a tumour
at the left side of the pelvis, evidently formed from the
dilated ampulla of the tube at the part corresponding to
the isthmus, the pedicle was twisted rather more than one
revolution to the left. The pavilion was obhterated and
the external surface of the foetal sac was roughened, but
entire. There was no blood nor any residue of precedent
effusion in the peritoneal cavity. The sac when opened
showed marked turgidity of the veins, and in two places
extravasation of blood within its wall corresponding to the
tubal decidua. The foetus, from 3*5 to 4 months' develop-
ment, had not been long dead, and was well-preserved and
fresh.
According to Bidone, the symptoms of torsion of the
pedicle of a gravid tube are similar to, but more serious
and explosive than, those associated with the torsion of an
ovarian cyst.
In short, owing to the arrest of circulation in the gravid
tube alterations take place in its peritoneal investment,
which soon lead to the formation of adhesions with the
other viscerae, or with the parietal peritoneum where it is
in contact with the foetal sac, and the new vessels formed
in these adhesions may, in some measure, contribute to the
nourishment of the sac. [C/. Bedford Fen wick's case,
ante, p. 256].
Secondary Abdominal Pregnancy.
Pruesmann, Berlin (Zeits. f. Geb. n. Gyn., Bd. lii., S. 288),
reports two cases: In the frrst a pregnancy in the left tube
developed within the ligament, the sac ruptured and the con-
tents escaped into the peritoneal cavity. Development con-
tinued fourteen days beyond term before pains came on,
and a live child was extracted from the coelom by lapar-
otomy; the placenta was firmly adherent to the peritoneum
and intestines, and could not be removed. The patient died
from collapse shortly after the operation. In the second
Ovarian Pregnancy iii
case, an interstitial pregnancy on the right side afterwards
becoming abominal, a mummified seven months' foetus
was retained for a whole year ; the woman recovered after
laparotomy.
Pestalozza {La Gitiecologia, 1904, No. 2 ; B.M.J., E. ii.
170) operated on a case in which the foetus lay in Douglas'
pouch, the placenta in the ampulla of the tube, the cord
passing out of the ostium. He compares it with a case
described by Leopold in which a foetus expelled from a
ruptiu'ed uterus continued to develop in Douglas' pouch.
Ovarian Pregnaxcy.
Merkkl {Mnenchener in. Wcluis. 1903, No. 34) recently
reported the following case : A woman, aged 39, who had
born one child on January 2, was submitted to laparotomy
on June 24, on account of internal haemorrhage attributed to
a ruptured ectopic gestation. The tumour was found in the
right adnexa ; transversely and adherent upon it lay the long
and very crooked, but otherwise normal, vermiform appendix,
which was detached without cutting, and the right adnexa
were then removed. The tube and ovary on the left side
were quite normal. The patient made a rapid recovery. On
investigating the specimen it appeared that the right tube
was somewhat twisted but otherwise quite normal, especially
so at its fimbriated extremity ; the infundibulo-ovarian liga-
ment was intact. Of the right ovary a certain portion was
preserved, seated like a skull cap on the soft tumour, which
was of the size of a hen's egg. The only evident opening
in the tumour corresponded to the detached appendix, but
on the side which {in sitn) had been turned to Douglas'
pouch there was a small aperture with' tattered edges, out
of which fresh blood was oozing, and this no doubt was
the rupture. The case fulfils all Leopold's conditions. The
ovary of the same side was deficient and continuous with
the sac ; the sac was connected with the uterus by the
ovarian ligament, and neither the tube nor the infundibulo-
ovarian ligament was involved.
In " Martin's Diseases of the Ovary," 1899, Orthmann
enumerated thirty-one cases of ovarian pregnancy, but
Fueth, writing in 1902, admitted only twenty-one. Merkel's
case, and those published by Wathen, Machenhauer, Thomp-
son, Mayo-Robson, Simon and Condamin, bring the number
up to twenty-eight. The only possible seat for the ovum to
112 Summary of Gynecology, including Obstetrics
develop within tlie ovary, is the mature or recently ruptured
follicle; penetration of a still unruptured though greatly
thinned wall of a follicle Klob declares to be impossible.
Placentation in Woman.
Friolet, Basle {Hegar's Beitraege, Bd. ix., Hft. i), after
verification of the work of others and some original
researches, comes to the following conclusions : The ovum
buries itself in the mucosa and is not, as was believed,
walled in by the cells of the mucous membrane. The inter-
villous space probably arises after the manner of the forma-
tion of a massive trophoblastic calyx, and afterwards becomes
altered into a blood space with an interspersed scaffolding,
and from the members of this scaffold the chorionic villi
are formed by the ingrowth of the foetal mesoblast of the
wall of the germinal vesicle. The intervillous space has
nothing to do with the cavum uteri, and undoubtedly from
the beginning has the function of a blood sinus. The villous
epithelium in its early stages consists of a double layer of
cells, Langhans' layer and the syncytium, the latter prob-
ably derived from the foetal ectoderm, with fine ciliae
externally. The question of the origin of the syncytium
is unsettled, but Friolet's own researches all suggest that it
IS derived from the trophoblast. When fully formed the
syncytium appears to be independent of Langhans' layer.
BicoRNuous Uterus ; Left Horn containing a Seven
Months' Macerated Fcetus, removed without
Interruption of a Four Months' Pregnancy.
KOUWER {Zentralb. f. Gyii., 1904, No. 32, S. 978) recently
exhibited at the Netherlands Gynaecological Society the
above-mentioned. The patient had had five normal labours;
she had suckled her last child for eighteen months, had then
had two normal menstruations followed by seven months'
amenorrhcea. Haemorrhage for five months led her to the
klinik. The diagnosis of the pregnancy in the right horn
was not difficult, but the nature of the tumour o-n the left
side could only be determined on laparotomy.
The Heart and Circulation in Pregnancy.
Stengel and Stanton {Univ. Pmna. Med. Bull, 1904,
Sept.), after reviewing the evidence that has been advanced
bearing on the alleged hypertrophy of the heart during
The Heart and Circiilatioii in Pregnancy iij
pregnancy, conclude from the clinical study of upwards of
seventy cases under the care of Barton Cooke Hirst, in the
maternity department of the University Hospital, Penn-
sylvania, that there is not, during pregnancy, any hyper-
trophy of the left ventricle, nor any special increase in its
work. The increase in dulness to the left is due to the
upward displacement of the diaphragm and consequent dis-
placement of the heart upwards and outwards. Comparison
of the outlines before and after labour show a rapid return
to the normal position. An extenston of the area of dulness
to the left, and distinct pulsation, was frequently noted in the
second and third interspaces, probably due to distension of
the conus arteriosus and root of the pulmonary artery. This
is the more probable, as a systolic murmur was often clearly
audible over the same area. Moreover, the right border of
the heart was, on the average, too far to the right ; there
is probably, therefore, some continuous dilatation of the
right ventricle to an apparently moderate extent during
the later months of pregnancy.
In multiparae, the separation of the recti during preg-
nancy dimmishes the tendency of the diaphragm, and
consequently of the heart, to displacement, but after delivery
may lead to a downward displacement of the apex, and
though the tirst position of the heart may not have been far
from normal, the contrast between the positions before and
after labour may be as pronounced as in primipar^e. It
the diastasis be not considerable and the muscles regain
their tone, the heart and its apex may be restored to their
normal position.
Durmg labour, the blood pressure is sometimes notably
increased, but there is no material increase in pressure either
before or after labour.
Mackenzie, Burnley {Brit. Med. Jouni., 1904, Feb., 921),
concludes, m regard to pregnancy occurring in women
with valvular disease, that : (i) When there is distinct
evidence of failure of compensation, or when the patient
is liable to frequent attacks of failure of compensation,
pregnancy should be forbidden. (2) With fair compensa-
tion, if there should be paralysis of the auricle, as evidenced
by the presence of a diastolic murmur and the absence of
a presystolic murmur, or of a continued irregularity of the
pulse, or of a jugular pulse of the ventricular type, preg-
nancy should be forbidden. (3) With fair compensation,
114 Summary of Gyncecology, including Obstetrics
with a mitral murmur systolic or presystolic in time, with
the apex beat within the nipple line, and due to the left
ventricle, the patient may undertake the burden of preg-
nancy. In all cases of valvular disease, when conception
has taken place, the patient should be kept under close
observation. One feature of great prognostic significance
is the presence or absence of symptoms of oedema of the
lungs.
Psychosis ix Pregxaxcy : Ixduced Abortiox :
Recovery.
Treub, Amsterdam {Zeiitralb. f. Gyn., 1904, No. 23),
reports : A quartipara of 31, influenced by reading " Notre
Dame de Paris," had, from the beginning of her pregnancy,
the fixed idea that the child would be a monster ; she
refused food so as not to feed it, and could not sleep
because she could hear it cry "like someone being choked."
She attempted suicide by throwing herself under a train.
After some days' observation in hospital, the induction of
abortion was decided upon. A laminaria tent was intro-
duced, and she immediately appeared to be better, slept
pretty well that night, though she dreamed that the monster
had cried out because a pin had been stuck in its head.
Two days afterwards the uterus was emptied under anaes-
thesia. She slept v.-ell, took her food, and was soon
absolutely normal, and in a fortnight was discharged cured.
Alienists do not, as a rule, expect much benefit from
induced abortion in the psychoses of pregnancy.
The Albumixuria of Pregxaxcy.
Little {Amen youni. Obst., September, 1904), has made
a statistical study of the albuminuria of pregnancy, labour,
and the puerperium, and he concludes from his tables
thus : —
Albumin is noted in the catheterised specimens of urine
from one half of all pregnant women, and is equally frequent
in primiparae and multiparae. Casts apparently occur with
greater frequency in multiparae. At the time of labour
there is a marked increase in the albumin alone, and in the
albumin associated with casts, the increase being specially
marked in primiparae ; this may be due to the muscular
work and to the increase of blood pressure dunng labour.
It is unusual to find casts present without albumin ; but it
Eclampsia and its Treatfiient ii S
must be borne in mind that tiie quantity of albumin may
be too small for easy recognition. Albumin and casts are
found in the puerperium less often than in pregnancy ; in
no case was albumin present during pregnancy and absent
at the time of labour, while there were only three cases
sliowing casts in pregnancy and not in labour. On the
other hand, two-thirds of the cases showing casts at time
of labour had had albuminuria during pregnancy. In nine
cases of threatened eclampsia, and in twenly-tive others with
detinite eclampsia, albumin was invariably present. The
case of hyperesis gravidarum showed much albumin and
many casts. Nausea and vomiting w^ere noted in 20 per
cent, of the primiparae, and 33"3 per cent, of the multiparas,
who, later on, showed albuminuria. In 71 per cent, of the
cases the first note of the condition was made within the
last eight weeks of pregnancy.
J. T. J.
ECLAMPSI.A .4ND ITS TREATMENT.
Kermauner, Heidelberg {Zentralh.f. Gyn., 1904, No. 36),
reports on the conservative treatment of eclampsia in the
Heidelberg Klinik by hot baths, packing, injections, hifu-
sions of salt solution in the usual way, and, in cyanosis, by
venesection, and, on the occurrence of more serious symp-
toms, by the induction of labour. He refers to nine cases,
six during pregnancy, three in childbed. Two of the former
and one of the latter were fatal. The cases occurring in
childbed are an absolute proof that emptying the uterus is
not in itself a cure for the disease.
Eclampsia and Cesarean Section.
Halliday Croom [Brit. Med. Jour., 1904, June 18)
recently reported to the Edinburgh Obstetrical Society two
cases in which he had performed Caesarean section on
account of eclampsia, and reviewed a series of fifty-four
collected cases. The maternal mortality of 50 per cent, he
attributed to the desperate condition of the patients at the
time of the operation. He held that the uterus in eclampsia
should be emptied as quickly as possible, and that Cccsarean
section was the best method of doing it.
Hammerschlag, Koenigsberg {Zciitralb. f. Gyn., 1904,
No. 36), reports four cases, two fatal and two successful, of
anterior vaginal hysterotomy (Bumm) combined with version
ii6 Summary of Gyncscology, including Obstetrics
and extraction. The subsequent tamponade recommended
by Duehrssen he would adopt only when necessary. He
has found twenty-one cases recorded with nine deaths, a
mortality of 43 per cent., compared with 55 per cent., in-
cluding 12 per cent, from sepsis, after the abdominal opera-
tion. He admits the operation to be indicated in the most
severe cases of eclampsia with a rigid cervix ; in others he
would employ Bossi's dilator.
Maly, Reschenberg {Zciifnilb. f. Gyii., 1904, No. 34),
reports a successful Duehrssen operation on a quintipara
eclamptic, aged 27.
Eclampsia in the P'ifth Month of Pregxax'CY without
Foetus : Hydatid Mole.
Hitschmaxn, Vienna {Zciitnilb. f. Gyii., 1904, No. 37),
relates as unique, and as proving that eclampsia may occur
independently of any foetal metabolism, the following case :
A secundipara, aged 18, was attacked by eclampsia when
four and a half months pregnant, and was delivered of an
hydatid mole. Fehling's theory, according to which the
intoxicating material in this di.sease is the product of meta-
bolic changes m the foetus, is not valid for all cases. Hitsch-
mann holds that it is to be sought for in the foetal portions
of the ovum, and Veit also has latterly inclined to this view.
Diagnosis of Contracted Pelvis in the Living
Woman.
Sellheim (Zeits. f. Gch. 11. Gyii. Bd. li., Hft. 3, p. 395),
in discussing the limit of pelvic space upon which an
obstetrician is justified in relying for the safe natural spon-
taneous delivery of a full-term living child, asks himself this
question : Is the application of forceps necessary when the
useful diameter of the pelvis (the conjugata vera) is 8 or
even only 7 centimetres ? He also criticises the methods
of measurement generally used, and suggests modifications.
(i) Examination of the inferior strait of the pelvis. — The
most important region of the inferior strait is that which is
limited by the ischio-pubic rami. Upon its conformation,
more or less in accord with the projection of the sub-occiput
in its process of expulsion, depends the greater or less
utilisation of the space offered to the foetal head during
labour. The examination of a great number of pelves show
Contracted Pelvis in the Living Woman i ij
a complete series of intermediary forms, from the right angle
with rectilinear sides to a well-curved arc, the most
favourable being those which conform to the shape of the
sub-occiput, a small untilled space under the angle of the
pubic arch having the advantage of protecting the urethra.
By introducing the two thumbs into the vagina, the patient
being in the obstetrical (dorsal) position, it is possible to
map out the pubic arch and to form a good idea of the
shape and direction of the pubic curve, of the possibility
of a spontaneous delivery, and also of the risk of rupture to
which the soft parts are exposed.
(2) Superior strait. — All deductions drawn from external
measurement must be regarded as unreliable for the apprecia-
tion of the internal diameters of the superior strait. This
conclusion has been arrived at by Sellheim, after the
examination of eighty pelves in the dry state. The routine
method of deducting i'5 to 2 centimetres from the diagonal
conjugate to obtain the true conjugate diameter, often
leads to erroneous results. Internal exploration is, there-
fore, the only method of appreciating correctly the form
and dimension of the superior strait.
(3) Transverse diameter of the superior strait. — The
author, like Kehrer, considers that the most im^portant
transverse diameter is that in which the foetal head in its
progression presents its long diameter, viz., the pelvic trans-
verse diameter nearer the symphysis, and he has utilised
for his observations a foetal head deformed by its passage
through a flat pelvis, and compared its shape with that of
the arch formed by the symphysis pubis, and the space
allowable in its descent under the ischio-pubic arch,
taking account of any compensating room transverselv for
any lateral compression of the head. Here, again, digital
examination affords to the experienced obstetrician a rapid
guide as to whether a case under examination is one with
a pelvis normal, rachitic, or justo-minor.
The applicability of this method of diagnosis has been
tested by submitting to it all the women admitted into the
gynaecological and obstetrical sections of the hospital. At
first all the explorations were made by Hegar, but later on
the first explorations were made by the author, and the
control explorations by Hegar.
Results. — During the last ten years, 8,400 cases were
minutely examined, and 211, or 2-5 per cent., were found to
have contracted pelves. Of these 118, or 55'92 per cent.,
1 18 Summary of Gyncecology, including Obstetrics
were flat with a maximum true conjugate diameter of 9*5
centimetres, and 93, or 44*08 per cent., generally contracted
with a maximum true conjugate diameter of 10 centi-
metres. Of the flat pelves, 95 per cent, were rachitic, the
others were infantile, a few with traces of rachitism. Of
the generally contracted pelves, 57 per cent, were rachitic,
18 per cent, of infantile type with traces of rachitism, and
about 6 or 7 per cent, show^ed no traces of rachitism or of
infantile type. In the flat pelves, the limit for spontaneous
delivery was 7"95 centimetres ; a living child was extracted
in a case of a diameter of 7*25 cm., and there was a case
of forceps delivery with a diameter of 7*5 cm.
The limits for spontaneous delivery in the generally
contracted pelves was 8 cm. or even less for rachitic cases ;
and 8'5 cm. for the infantile type and the generally and
regularly contracted.
In rachitic pelves, living children were extracted when
the true conjugate diameter did not exceed 8 cm., and in
forceps cases 77 cm., whereas in infantile pelves these
limits were 8"5 cm., and 8*i cm. respectively,
P. Z. H.
Prophylactic Version in Cases of Pelvic
Contraction.
Bruno Wolff {Berliner Klinik, October, 1904, Heft.
196) defines version to be strictly speaking prophylactic
only when, the head presenting and the pelvis being con-
tracted, the operation is performed before any trouble has
arisen in the condition of the mother or child, to avoid
dangers which may possibly occur if the labour is allowed
to proceed with the child's head first. The proceeding was
based by its founder, Simpson, on the idea that the smaller
end of the cone going first, an after-coming head would pass
through a flat pelvis more easily than a head first ; more-
over, in the former case the child's body is of material
assistance in extracting the head. When performed before
the membranes have ruptured, and when the os is quite
dilated, version is a comparatively simple and easy pro-
ceeding ; injury to the soft parts is most exceptional, and
delivery is rapidly completed. On the other hand, labour,
if allowed to proceed head first, may be prolonged for hours
or days, and finally either a deferred version, high forceps,
symphyseotomy, or craniotomy, all much more serious
proceedings for mother and child than early version, may
Prophylactic 'Version in Pelvic Contraction iig
have to be faced. It is peculiarly in private practice that
this is of moment ; indeed, as regards symphyseotomy,
Hofmeier has declared, and all German obstetricians agree,
that it has no place in private practice. Against turning it
has been urged that the moulding of the aftercoming head
is far from favourable to the child, and that the latter, when
extraction is difBcult, is very liable to serious injury. Even
those obstetricians who do not condemn prophylactic
version altogether, are not by any means like-minded as to
the indications for it. Some do it in the interest of both
mother and child, or more especially in that of child
(Gusserow, Nagel, Leopold, Runge), others perform it chiefiy
or exclusively for the sake of the mother (Schroeder, Ols-
hausen, Fritsch, Bumm). Some confine it to moderately
contracted pelvis (C.\'\ not less than 8 cm.) others reserve it,
by preference or exclusively, for more pronounced contrac-
tion. Opinions differ also as to whether the proceeding is
adapted more especially to the flat pelvis, or to the pelvis
justo minor. It is generally deemed unsuitable for primi-
parse, but Runge and Duehrssen perform it even in such
— Duehrssen supplementing it with lateral incisions in the
introitus and, if need be, in the cervix. Most unfavourable
opinions have recently been expressed on prophylactic
version by Kroenig and Menge (Leipsic), Ludwig and Savor
(Vienna), and Henkel (Berlin), but it has been warmly
defended by Albert, Krull and v. Magnus, and by Wolff
himself, who points out that in the extern maternity of the
Charite Hospital during the years 1 892-1902, labour was
conducted in 581 women with contracted pelves ; version
w^as performed in 243 ; prophylactically in 54 instances.
Wolff compares the results of these prophylactic versions
with each other and with those of expectant treatment, and
finds that there was a very marked difference according as the
pelvic contraction was of the first grade only (C.V. =8 cm.)
or not, and also according to whether the operation was
done under favourable circumstances, intact membranes
and fully dilated cervix, or otherwise. The mortality of
the children, when the membranes were unbroken, the
cervix fully dilated and the contraction only of the first
degree, was absolutely nil (30 cases) while the labours with
the same degree of pelvic contraction which were allowed
to proceed head first (85 cases), showed a mortality for the
children of 9-4 per cent. When the version was not done
till after the rupture of the membranes, the results were not
120 Summary of Gyncecologyy incitiding Obstetrics
so good as those of the expectant treatment. When the
contraction of the pelvis was greater than of the tirst degree
(C. V. ^-= 8 cm.), prophyhictic version, whether it was
performed before or after the rupture of the membranes,
gave no better results than expectant treatment. The
number of such cases was, however, too small to justify any
definite deductions. Wolff concludes : In the conduct of
labour in contracted pelves, whether prophylactic version is
to be undertaken or not, it is of chiefest importance to
prevent the rupture of the membranes before the mouth of
the womb has become fully dilated, perhaps by the intro-
duction of a colpeurynter into the vagina. When this
can be done the conditions are most favourable for expec-
tant treatment, as well as for version and extraction.
Prophylactic version should not be undertaken after —
certainly not long after — the rupture of the membranes, nor
unless the os uteri is sufficiently dilated to admit of the
extraction of the child immediately after turning. But it is
by no means in every case of contracted pelvis, even when
the membranes are intact and the cervix almost or quite
fully dilated, that prophylactic version is in place. Version
is always more dil^cult in primiparae, in whom, moreover,
the chances of satisfactory delivery of the child head first
are more favourable ; it is better therefore to abstain in
primiparae from this interference. And even in multiparae
sometimes before the waters come away the os has fully
dilated and the head has engaged so favourably that a
happy, and, after the rupture of the membranes, an expe-
ditious course of the labour may be relied on. In such
cases one would of course not interfere with the position.
Yet in a considerable number of cases of contracted pelves
of the first degree (C. V. not below 8 cm.), with intact mem-
branes and a fullv dilated os, from the history of former
labours it appears more or less improbable, though perhaps
not impossible, that without serious difficulty the child can
be born head first without suffering any injury ; in such
cases prophylactic version, undertaken before the waters
have escaped, offers an almost certainly favourable result for
both mother and child ; while expectant treatment must
always leave the issue doubtful, especially as regards the
child.
The hiductioii of Laboui- i2i
Induction of Premature Labour by Puncture
OF THE Membranes.
DE Regnier, Basle {Hcgar's Reitraegc, Bd. ix,, Hft. i),
comes to the conclusion that in cases in which prompt
delivery is not indicated, or in which, with a corresponding
size of the foetal head, the conjugate diameter amounts to
from 7'25 to 9*5 cm., and the obstacle to delivery is the
space available, puncturing the membranes offers the best
prognosis both for mother and child.
The Immediate and Later Results of the Induction
OF Premature Labour for Contracted Pelvis.
HUNZIKER, Basle {Hcgar's Beitracge, Bd. ix., Hft. i),
reports that in the Basle Klinik about one-fifth more
children are born alive by the mduction of labour, and
twice as many are alive on the tenth daj^, as would be by
spontaneous delivery.
Induction of Labour, especially as Regards the Fate
OF THE Children.
Lorey, Halle {Archiv f. Gyii., Bd. Ixxi., S. 316), alluding
to the disfavour in which the induction of labour has been
held, quotes the authority of Kroenig, who, in his work on
the "Contracted Pelvis," published in 1900, declared that
this proceeding did not offer a better prognosis for the
children than expectant treatment, even with the possibility
that at term symphyseotomy or Caesarean section might be
declined and perforation be obligatory ; moreover, that this
was especially so in the degrees of contraction in which
induction had principally to be considered.
In view of this condemnation, Lorey has analysed 137
cases from the Klinik at Halle, till lately under the direction
of Professor Bumm, and finds that in 100 labours, in 82
women with pelves exhibiting a contraction varying from
6*5 cm. to 10*25 cm., the induction of labour resulted in the
delivery of 74 children alive and 26 still-born ; during the
ten days after birth 13 other children died, giving a total
mortality of 39 per cent. Now these 82 women had had
in previous labours 207 children, of which 196 had been
born spontaneously, or at all events without either the in-
duction of labour or Caesarean section, and the immediate
mortality of these 196 children exceeded 78 per cent. In
contractions of the pelvis, therefore, the results of the pre-
122 Summary of Gynaecology, includtng Obstetrics
mature induction of labour as regards the children are twice
as good as spontaneous delivery or extraction by forceps, or
after version.
Nevertheless, induced labour does not begin to give satis-
factory results unless the contraction of the pelvis is as low
as 8 cm., and the pregnancy has reached the thirty-sixth
week at the least.
As regards the further fate of the children : 40 of the
56 of whom Lorey was able to get a report lived more than
a year, a proportion of 7i*4 per cent., or 73'2 per cent, if
one abstracts i case of infanticide. Indeed, deducting 5
illegitimate children, including the i killed by its mother,
we find that of 51 children delivered prematurely and dis-
charged alive from hospital only 11 died in their first year,
a mortality of 21*5 per cent. Now the general mortality of
children in their first year in Halle is 24 per cent.
The length of gestation is most important : Of the
infants born before the thirty-fourth week not one lived for
a year. The induction of labour before the thirty-fifth
week may be deemed equivalent to perforation, and is only
to be performed in the interests of the mother. The pro-
gnosis for the children whenever labour is induced on
account of the mother's ill health, is very bad indeed.
The Later Effects of Instrumental Dilatation of
THE Cervix of the Parturient Uterus.
V. Bardeleben {Archiv f. Gyn., Bd. Ixiii., S. 187)
reports that in six cases in which mechanical dilatation
had been employed, examination about five months after-
wards detected lacerations of the cervix in four, in one
instance extensive laceration of the portio, and in one a
singular injury affecting merely the pars supravaginalis.
Clinical observation had convinced him that inflammatory
genital affections were extremely common after extensive
tears of the portio or cervix, occurring in 75 per cent, of
the cases. The secondary infections and retracted cicatrices
following the cervical lacerations, which are certainly not
unusual, must also be considered a serious disadvantage of
mechanical dilatation.
Bossi's Dilator.
Muus {HospUalstidciide, 1904, Nos. 17-18) gives the
results of the use of Bossi's metal dilator in the Roval
Bossi's Dilator i2j
Lying-in Institution under the direction of Professor
Meyer. The instrument was employed to dilate the os
and accelerate delivery in thirty -five cases, and half an
hour was sytematically expended in completing the dilata-
tion in the cases of twenty-one primiparae and nine multi-
paras. In thirteen of these cases the portio vaginalis was
not injured at all ; in seventeen there were inconsiderable
single or double lacerations which did not extend to the
vagmal vault ; in one instance the tear extended above the
internal os, but there was no haemorrhage. The patient
died from eclampsia after delivery. In two instances the
dilatation was effected very rapidly in the course of from
three to seven minutes, in one during the agony, and in the
other on account of grave eclampsia, and in both cases
serious cervical lacerations were found at the autopsy.
Finally, in two instances of abortion unsuccessful attempts
were made to dilate an extremely rigid os internum. The
technique is not difficult, nor, if care be taken, is the method
severe on the patient. The indications for its use in the
above cases were : (i) Eclampsia in fifteen cases with three
deaths, a better result than given by vaginal Caesarean
section ; (2) premature detachment of a normally placed
placenta in five cases, normal childbed in all ; (3) placenta
pr?evia in three instances, normal recovery in two, fatal
puerperal fever in the third ; (4) rigid cervix, tardy labour
and infection in one case, with normal childbed ; (5) severe
pyelonephritis in five cases, which did well ; (6) serious
heart disease in three cases, early in labour in two with
good result, during the agony in the third in order to
save the child ; (7) abortion in three cases, once with,
and twice without, success.
Hahl, Helsingfors {Archiv f. Gyn., Bd. Ixxi., S. 509),
reports on the use of Bossi's instrument in the klinik directed
by Heinricius, where it has been employed, with favourable
results, in eleven instances. It must, however, be noted
that very great care was exercised and the time taken in
dilatation was long, even upwards of an hour. He gives as
indications : eclampsia, prematurely detached but normally
placed placenta, some cases of abortion in the fourth to the
sixth month, cases of uterine inertia when mother or child
is in danger, and those in which other methods of inducing
labour have been tried in vain. To complete delivery after
the dilatation, Hahl very properly recommends forceps in
1 2^f. Summary of GyncBcology, including Obstetrics
preference to version, for he also has found that the cervix
contracts again and that lacerations may be caused, or
extended to a dangerous extent, by the forcible extraction
of the aftercoming head. Placenta praevia he considers a
contraindication. He differs from Leopold as to uterine
contractions being set up by the dilatation ; the third stage,
however, is generally favourable.
F^ROMMEK {Zcntralb. f. Gyn., 1904, No. 34) points out
that the modification of Bossi's instrument, described by
Walcher as " new," is almost identical with his own. He
gives two cases of dilatation without laceration or bleeding,
and will by no means admit Duehrssen's claim to the
superior advantages of vaginal Cajsarean section.
SCHALLEK, Stuttgart {Ibid., 1904, No. 35), reports a
serious rupture of the uterus, extending into the right
parametrium during a careful dilatation with Walcher's
instrument, with the object of palpating the cavity of
the non-gravid womb of a 36-year-old woman who had
had two children. Plugging with iodoform gauze : ergot
internally : recovery.
v, Erdberg, Riga {Ibid., 1904, No. 35), reporting a case,
without laceration or bleeding, but ending fatally from
eclampsia after the extraction of a live child, draws attention
to the effect of the dilator in eliciting uterine contractions,
which in his opinion has not been sufficiently noticed, and
also to the important fact that the cervix is merely dilated —
is not taken up into the uterus, but lies like the mouth of a
sack in the vagina. The genital canal is open for delivery,
but not in a physiological way. This condition explains
the lacerations of the cervix which often occur during
delivery. It was for this reason that, in the case reported,
to avoid laceration and ensure sufficient room, he allowed
the dilator, expanded to its extreme extent, to remain in situ
for two minutes, and then delivered with the forceps. He
supposes that for the same reason Bossi recommends forceps
rather than version.
Ehrlich, Dresden {Arclnv f. Gyn., Bd. Ixxiii., S. 439-
543), assistant at Professor Leopold's Klinik, in a very
eulogistic article gives a summary of the extensive literature
of Bossi's method of dilating the cervix, the anamnesis of
30 additional cases in which it has been employed for
other causes than the induction of labour, and, on the basis
Hebotoiny 12^
of the series (47 cases in all), discusses the indications,
technique, and results of the operation. The indication was
eclampsia in 31 cases. The method is applicable at any
period of pregnancy and in any condition of the cervix,
the most important point in it is the management of the
mstrument. In 75 per cent, of the cases there was no lacera-
tion of the cervix at all, or any laceration was slight and
insignificant. Two serious tears occurred, one extending
through the cervix to the vagina, another deep cervical one
requiring 6 stitches ; no other lacerations of importance
were due to the dilatation alone, but occurred in cases in
which the forceps was used, or some other obstetric opera-
tion performed. Nor did Bossi's method in any instance
lead to serious puerperal trouble. Ehrlich insists much
upon the contraction which the cervix undergoes after the
instrument is withdrawn, and upon the effect this may have
on the child after version. Indeed, Leopold's experience
of version and extraction after dilatation was almost pro-
hibitive.
The Induction of Premature Labour by means of
Bossi's Method of Dilating the Cervix, supplp:-
mented by metreurysis.
Heller {Ibid., S. 544-559), also one of Professor
Leopold's assistants, reports on 30 cases of induction of
labour for contracted pelvis. The cervix was dilated in
about fifteen minutes to 4 or 5 cm. diameter with Bossi's
instrument or one of its modificatious (Frommer, Krull), or
in seven cases by de Seigneux's instrument, and a metreu-
rynter then introduced. The bag was ejected, on the
average, after 7 hours, and the labour lasted from 4 to 25*5
hours, ir5 hours on the average. Of the 30 children 25
were born alive. In 8 cases there were lacerations of the
cervix from i to 5 cm. in length.
In France Bossi'b instrument is not approved of.
Maury, for instance, in a recent Paris Thesis {Zentralb. j.
Gyii., 1904, No. 43), while recommending that in all cases
of eclampsia the uterus should be emptied as soon as pos-
sible, says that manual dilatation of the cervix (Bonnaire) is
to be preferred to the instrumental method.
Hebotomy.
VAN DE Velde, Haarlem {Zentralb. f. Gyii., 1904, No. 30),
to whom the revival of Stoltz's " Hebotomy," that is, the
1 26 Summary of Gy7icecology, including Obstetrics
division of the os pubis with a saw to obtain a permanent
expansion of a narrow pelvis, is due, has found a supporter
in Doederlein. To two cases previously reported he now
adds three others, all successful as regards both mother and
child. Moreover, the second was a twin birth ; serious
atonic haemorrhage was controlled by plugging. A com-
parison of the pelvic measurements before and after the
operation, which he considers in every way superior to
svmphyseotomy, showed an enlargement of as much as
I'S cm.
Doederlein, Tuebingen {Zentralh. f. Gyn., 1904, No. 42),
reports four more cases with successful results for both
mother and child, and recommends a novel proceeding,
the application of a sterile rubber tube round the pelvis in
every case, to prevent excessive spreading of the bones
during the extraction of the head ; moreover, he advises
that the bone should not be sawn through until the course
of the labour shows that the passage of the head is not pos-
sible without the section of the pelvis.
Ferroni, Milan {Zentralb. f. Gyn., 1904, No. 35), reports
a successful case of hebotomy in a young woman with
contracted pelvis, aged 27, attended by severe haemorrhage
during the section of the os pubis, and the formation of a
large puerperal hasmatoma in the labium majus. A living
child was extracted with forceps. He has found twenty-six
cases already published, of which twenty-five recovered and
one died from chloroform.
Berry Hart, at the Edinburgh Obstetric Society last
January, estimated the mortality of the operation at 6 per
cent., but compared with symphyseotomy, considered it
had the advantages that asepsis was easier, accidental injury
of neighbouring parts was not so easy, and non-union of
the divided parts was not so common.
Repeated Rupture of the Uterus.
Patz, Hohenelbe (Wiener ni. Wclins., 1904, No. 35),
reports a case in which a woman's life was on two occa-
sions saved by laparotomy after rupture of the uterus during
labour, considerable haemorrhage, and escape of the foetus
into the peritoneal cavity. On the first occasion the
laceration was sutured ; on the second, supracervical ampu-
tation of the uterus was performed.
I
Meaning of Fever in Parturition izy
Stovaine in Obstetrics.
DOLERIS and Chartier (C. R. Soc. Obst. Gyn. Pad., July,
1904) report two cases of rachidian injection of stovaine
in painful and prolonged labour. A few minutes after
injecting 2-5 centigrammes, the uterine contractions began to
increase, they became more frequent and longer, and some-
times ran one into the other. They were, however, quite
painless. The action was prolonged for about an hour, the
labour and dilatations proceeded wnthout any pain. In
another case reported, labour was induced prematurely at
seven months by the rachidian injection of 3 centigrammes
of stovaine, the result being obtained in six and a half hours.
It foUow's, therefore, that anajsthetisation by the action of
stovaine for surgical operations in pregnant women is
contra-indicated.
P. Z. H.
The Meaning of P^ever During Parturition.
Ihm, Koenigsberg {Zeits. f. Geb. ti. Gyn., Bd. lii., Hft. i),
from a careful statistical study of 200 cases, concludes the
most important etiological factor in fever during labour is
the rupture of the membranes too soon or in an early stage.
The prognosis of such fever is little or no worse for primi-
para3 than for multiparae. If delivery takes place spontane-
ously the prognosis is far better than if operative interference
is required ; under the former conditions multiparous
women are more likely to have a feverish childbed. The
protraction of labour after the waters have come away does
not appear of dangerous import for the puerperium, unless
it extends beyond three days and the fever has come on
very soon after the rupture of the membranes. The total
length of the infection (from the observation of the fever,
&c., to the end of the labour) is no sufficient basis for a
definite prognosis ; a very protracted infection is as likely
as not to be followed by a fever-free puerperium. Neverthe-
less, cases in which the fever has come on only a short time
(one or two hours) before delivery without any, or w^ith
only slight, assistance, offer as a rule a more favourable
prognosis {e.g., fever due to feeble contractions though the
head is at the pelvic exit). The intensity of the infection is
a better criterion. Tympany of the uterus is alarming, as
also the complication of placenta praevia. Elevation of the
temperature and rigors during labour do not in themselves
1 28 Summary of GyiKrcology including Obstetrics
imperil the case. The condition of the pulse is important,
and if it is persistently rapid tlie look-out is not favourable,
especially if the temperature sinks or remains the same.
Fever while the sac is unruptured seems to be less unfavour-
able. Therapeutically, prophylaxis is most important ; the
more rapid, simple and natural the delivery in feverish
labour, the more reason is there to hope for a fever-free
childbed.
The Prevention of Childbed Fever.
ZWEIFEL, L.e\pz\g (Zentralb. f. Gyn., 1904, No. 21), says
that on vaginal examination shortly after the discharge of
the placenta, one or two clots of the size of a hazel nut are
nearly always to be found in the vaginal culs-de-sac. As
such fibrinous depots might well be the origin of rises of
temperature, he has them carefully removed by dry pads in
all labour cases under his care, and since he has done so
the puerperal morbidity has fallen to 57 per cent., or,
excluding pulmonary and other complications, to 3'3 per
cent.
Mueller (Ibid., No. 26) likewise attaches much import-
ance to the retention of small blood clots and pieces of
placental tissue as a cause of childbed fever. He holds
they should always be removed by douching, and himself
employs an instrument with which he can exercise some
friction.
BOKELMAN (Ibid., yio. 26) says that such cleansing of
the vagina, if at all necessary soon after delivery, ought to
be repeated at regular intervals during convalescence, for
clots continue to be formed. Such interference, when the
patient is just entering on her much needed rest, would not
only be annoying to her, but would separate tears just
beginning to heal and offer opportunities for infection. He
deems strict asepsis of all objects coming in contact with
the genital tra.ct during labour and absolute rest of the
parts after delivery as the two essential factors in preventing
fever during childbed.,
Can Fatal iNFECtio^^s Ibe Avoided in Lying-in Insti-
tutions WHICH are Used for Instruction ?
Ah,lfeld {Zentralb. f. Gyn., 1904, No. 33) asserts that
they can. In 8,000 labours conducted in the Marburg
Klinik under his direction, there was only one death from
Seropathy of Puerperal Fever I2<^
sepsis after normal spontaneous delivery, and in that case
the woman had made a vaginal examination herself " to see
if the child was coming." In the whole number there were
only twenty deaths from sepsis, a percentage of o"286, a
happy result which he attributes to his method of disinfec-
tion with hot water and alcohol. The prophylactic removal
of blood clots from the vagina recommended by Zweifel he
condemns as strongly as Bokelmann.
On the Recognition' of True Septic-emia.
KxEiSE, Halle [Archivf. Gyii., Bd. Ixxiii., S. 330), reports :
A woman, aged 32, was delivered spontaneously, but had
been examined during labour fourteen times by the midwife.
She got up on the fourth day, but the same evening was
feverish and after three days more was brought to the
hospital. Her lochia were not increased, nor stinking, but
the contents of the uterus showed a pure culture of strepto-
cocci. The blood from a vein in the lower arm also gave
a pure culture of streptococci. She died on the fourteenth
day of childbed without ever having a rigor. Macroscopi-
cally, the autopsy was negative ; microscopically, the uterine
wall, heart, liver and kidneys, were pervaded by streptococci,
yet there was no local reaction in any tissue. This sort of
streptococcic infection has been variously called sepsis,
septicaemia, streptococcaemia, and Kneise would prefer,
following Bumm's example, to apply to this form of wound
mfection (general infection distributed by the circulation)
the name " true septicaemia."
On THE Seropathy of Puerperal Fever.
BUMM {Miiciichcner m. ]Vchns., 1904, No. 25), in an
address to the Berlin Medical Society on June 15, 1904,
said : " The influence of antiseptic treatment upon puer-
peral fever has been less than upon any other form of
traumatic infection. It is true that in hospitals, formerly
its breeding places, puerperal fever is now reduced to a
minimum, but in general practice, in which far more
labours occur than in hospital, the influence of antiseptics
cannot be seen. As many women, from 4,000 to 5,000
yearly in Prussia alone, die now from puerperal infection as
in the days before antiseptics. Even in Berlin, six weeks'
experience had shown him that matters were not much
better^ although in general the mortality in large cities
was less than in country districts. Midwives had been
1^0 Summary of Gynecology, including Obstetrics
accused of insufficient disinfection, but unfairly so. The
difficulty lay in the impossibility of carrying out disinfec-
tion in a private house (insufficient help, prolonged attend-
ance), and in the necessity of midwives undertaking the
more menial details of nursing, whereby they were con-
stantly contaminated afresh, &c. Women themselves are
often to blame, for going about too long with bleeding or
even already putrescent abortions without calling in a
doctor. It cannot be expected that we shall have any
improvement in the prophylaxis of puerperal fever with the
present system of antisepsis. Such improvement can only
be obtained by parturients being taken into institutions
for childbirth, instead of being confined at home. For
the present, therefore, the task of successfully contend-
ing with puerperal fever is our daily duty, and since all
means of doing so hitherto at oui- disposal have proved
insufficient, since local antisepsis is not efficient in sepsis,
but only in decomposing processes, since surgical measures
such as extirpation of the uterus, curetting, or according
to the last French fashion, brushing out the uterus, have
proved harmful, one must welcome the attempt to strike
at the root of the evil by the help of seropathy.
Still it was not received exactly with enthusiasm, for in
the particular instance of streptococcic infection one could
not expect any great success from it, especially after the
early disappointments experienced with Marmorek's serum.
One would have thought that the past ten years might
have brought some unanimity as to the value of seropathy :
that this has not been the case depends on the enormous
variability of puerperal fever, the prognosis of which it is so
hard to estimate in individual cases. In the worst kind of
general sepsis the prognosis is not doubtful ; nor, on the
other hand, is it so in those of local infection. Between
these two forms lie the vast majority of the cases, those in
which the temperature once or twice exhibits an elevation
accompanied by rigors, and which, like the localised pro-
cesses, generally (in 70 per cent.) recover of themselves ;
and if in such cases seropathy were employed, that recovery
would too often be attributed to the serum. One can hardly
be sceptical enough in giving credit of this kind ; a point to
be taken to heart in regard to the serotherapy of angina
(diphtheria), scarlet fever, rheumatism, &c., also.
The true appreciation of the action of serum is
further obscured by the differences in the quality of
Seropathy of Puerperal Fever ijT
the sera supplied. He (Bumm) had tried them all
(Marmorek, Tavel, Merck, Menzer, Aronsohn), and thanks
to the liberality of the discoverer and the manufacturers
(Scheering), he had had especially extensive opportunities
of using Aronsohn's, so that the majority of his experiments
were based upon this preparation.
In appreciating the results no comparison of statistics
would be employed, for statistics were misleading. For
instance, if all the cases of one-day fever were injected they
would yield loo per cent, of cure. It is better to divide the
cases of puerperal fever into sub-classes and consider each
of these independently.
(i) Peritonitis puerperalis septica : five cases all treated
with large doses of serum : all fatal, and none betraying any
influence upon the temperature or upon the presence or
abundance of streptococci in the blood.
(2) Operative peritonitis following serious obstetric
operations : mixed infections, four cases, likewise without
effect,
(3) True septicaemia : three cases ; in two, in which the
blood of the cadaver was overloaded with streptococci,
no effect ; in the third the temperature was three times
promptly reduced by injection of serum and the case
recovered under the formation of a thrombophlebitis of
the right leg.
(4) Septic endocarditis : three cases, without effect. In
one instance the serum was injected intravenously and
appeared to be detrimental.
(5) True pyaemia (thrombophlebitis purulenta) : three
cases without effect. Intravenous injection seemed to be
detrimental.
(6) Parametritis and perimetritis as localised processes
which the natural forces can cure, were expressly excluded
from the experiments.
(7) Endometritis streptococcica (the chief group) : fifty-
three cases, of which a number were slight ones, but
thirty-two severe, with dense investment of the wounds
and of the endometrium. The blood was examined in
seventeen and streptococci were found in twelve ; five
were fatal (pyaemia, lymphangitis) ; the serum injection
had no certain effect in seven, but in twenty-one the
clinical aspect and temperature curve showed indubitably
that it had.
Bumm was therefore convinced of the favourable action
IJ2 Summary of Gyncecology, including Obstetrics
of serum injections in such localised affections. He had,
moreover, found additional objective evidence in the con-
dition of the lochial secretion. In the lochia from an
infected uterus the streptococci are found in lonj^ chains
between the pus corpuscles, but under the favourable action
of the serum a change, often a critical one, takes place,
and the chains become shorter and are found inside the
leucocytes. This pha<4ocytosis signifies that under the
influence of the serum the organism has been again fitted
for the task which, in cases of spontaneous recovery, it
is capable of and performs. In eight cases examined
upon this point, phagocytosis was established within twelve
hours after the injection. This investigation is to be carried
further.
The serum, as presented to us to-day, is therefore
inefficient in serious cases : yet as — exxept when injection
is intravenous — it does no harm it should be given further
trial. Bumm had seen two abscesses occur, in each case in
connection with serum obtained, not from the Berlin factory,
but from another source, and not clear and transparent.
In localised processes seropathy is to be recommended
unconditionally, since in a large number of cases it was
beneficial ; wdien the uterus contained streptococci and
membranous exudation, serum w^as especially desirable, but
it was of no use except in large doses.
Bumm considered that an important step in advance
lay in the fact that by Tavel's process the serum had no
longer to be obtained from streptococci that had passed
through the bodies of animals. He also recommended
the prophylactic use of serum in cases of serious obstet-
rical operations. As yet the serum had no bactericidal
action ; he had endeavovired to procure an active serum, but
the experiments made in Basel by his assistant, Burckard,
he could not for the present continue in Berlin.
In the discussion Olshausen joined issue with Bumm
as to puerperal fever not having decreased in private
practice. No direct conclusion could be drawn on that
point from statistics, for now% under the strong pressure of
those in office, many more cases of puerperal fever were
notified. Personally he was convinced there had been a
decrease. It was a very difficult matter to appreciate the
action of the serum, because of the uncertain prognosis in
cases of streptococcic infection. He had seen favourable
Pseudokermaphfodism . ijj
terminations without the use of serum, not merely in cases
of one-day fever, but in such as had had thirty or forty
ris^ors, once even seventy rigors in seventy days. Such
curves were typical of thrombophlebitis, which was a con-
dition quite open to spontaneous cure. Personally he had
only tried serum in most desperate cases and without any
success, but he would now make further trials on Bumm's
recommendations.
\V. A. Fkeuxd appreciated Bumm's division of the
puerperal fevers from the anatomical point of view ; still
there were other forms of this variable disease, and he asked
how one could recognise that a case was one of endometritis
septica, and that the infection had not extended beyond
the mucosa ? He had made several trials of Marmorek's
serum, invariably without success, but nevertheless thought
that on the ground of recent improvements further trial of
seropathy was absolutely advisable.
BuMM, in reply, said that he recognised endometritis
by its appearance, that is to say, by the inspection of the
genital organs, and that the infection had not yet extended
beyond the uterus, by the negative result of examination of
the blood, or by the absence of other septic symptoms.
Retention of a Fully Developed Fcetus fok Three
Months after Term.
GOLDENSTEIN, Jassy {Zentralh. f. Gyii., 1904, No. 26),
reports a case in which he delivered a woman of 40, who
had had eight normal labours, of a macerated foetus 51 cm.
long. The patient had severe pains, passing off in a few
hours, three months previously and since then had missed
the movements of the child. During the three months she
had had no vaginal discharge, she had been able to do her
work, not suffering in an}' way, and only sought his advice
to be quit of uncertainty as to her condition.
PSEUDOHERMAPHRODISM.
Rydygier {La Gynecologic, 1904, August) reports : A
patient of 44 was admitted into hospital with a hernia of the
right labium major which had existed for six years, and
during that time had merely grown larger. The patient had
never menstruated, aborted, or had a child. The mammary
glands were well developed. Examination disclosed a
tumour the size of a fist situated in the inguinal region and
right labium majus, giving a dull tympanitic sound on per-
1^4 Siimmary of Gynaecology, including Obstetrics
cussion, and easily reducible into the peritoneal cavity.
Two fingers could be passed through the inguinal rings.
Neither collum or corpus of the uterus could be felt.
Kocher's operation for the radical cure of the hernia was
performed.
The hernia contained a body resembling a uterus with
its adnexa. The uterus appeared to be rudimentary ; on
the right, there was a body which on section seemed like a
testicle, and there was a hard cord on the same side. To
the left of the uterus there was a large cyst with thick walls.
^Microscopic examination proved that the body on the right
had the typical structure of a testicle, but there were no
spermatozoa in the canaliculi. In the cyst on the left
nothing was found except bundles of smooth muscular
fibre ; the hard cord was merely the vas deferens, wi!h
highly developed smooth fibres. In view of the presence
of a uterus and a testicle the author considers the case one
of complete masculine pseudohermaphrodism ; he has only
found five similar ones recorded.
Westerman, Haarlem {Zcntralh. f. Gyn., 1904, No. 39,
S. 1,174), saw a person, aged 30, brought up as a girl, who
had a beard but no mammae. The imperforate penis was
6 cm. long ; the posterior commissure of the labia majora
was well formed. Behind the opening of the luxthra a
sound could be passed through a second opening sur-
rounded by a delicate membrane, into a long canal lying
in the posterior wall of the bladder. The genitals and anus
bore masculine hair.
Of internal genitals the following were present : A rudi-
mentary uterus with, on the left, a well-formed tube and
fimbria, a rudimentary ovary and round ligament ; on the
right in place of the ovary a body that, according to micro-
scopic examination, might be a testicle with epididymis; no
vesiculae seminales. The vagina was present also.
Notes ij^
NOTES.
We note with regret the deaths of several distinguished
Gynaecologists and Obstetricians : —
Dr. William Rice Pkyor, Professor of Gynaecology in
the New York Polyclinic Hospital, and one of the foremost
gynaecologists in the United States, died on August 26, 1904,
at the early age of 46. He was a member of the Inter-
national Congress of Gynaecology and Obstetrics, of the
American Gynaecological Society, the New York Obstetrical
Society, &c., &c. We reviewed his Text-book of Gynae-
cology in our February number. He edited the American
Text-book of Gynaecology in 1896, and his work on Pelvic
Inflammation (1900), was well known.
Mr. John Lilly Lane, Gynaecologist to the City of
Dublin Hospital, and formerly Assistant Master of the
Rotunda Hospital. He had also been Maternity Physician
to Steevens' Hospital, and was Lecturer on Midwifery in
the former Carmichael School, where he had himself been
a student.
Dr. John Joseph Cranny, who died on July 27, 1904,
Surgeon to the Jervis Street Hospital, Dublin, was Examiner
in Midwifery at the Royal College of Surgeons of Ireland,
and had been Assistant Master of the Rotunda Hospital.
He was a man of wide culture and as popular as well-
known.
Dr. W. Massan, Extraordinary Professor of Obstetrics
and Gynaecology at Moscow.
Sir W. Japp Sinclair is to be complimented not only
on his knighthood, but on his action as a Member of the
Midwives Board.
Dr. William J. Smyly, formerly Master of the Rotunda
Hospital, and ex-President of the British Gynaecological
Society, succeeds Sir Arthur Macan as President of the
Royal College of Physicians of Ireland.
Dr. Harry Oliphant Nicholson, F.R.C.P.Edin., has
been appointed Assistant Physician to the Royal Maternity
and Simpson Memorial Hospital, Edinburgh.
Dr. Ewen J. Maclean, M.R.C.P.Lond., F.R.C.S.Edin.,
has been appointed Lecturer on Midwifery (under the
ij6 Notes
iMiclwives Act) to the University College of South Wales
and Monmouthshire, Cardill.
Dr. Harold F. jkwktt lias been appointed Visiting
Gynsecologist, and Dr. W. L. Chapman Obstetrician to the
Bushwick Hospital.
Dr. Fabke has been ap[X)intecl Professor of Clinical
Obstetrics at Lyons in place of the late Dr. Fochier.
Dr. Franz, Oberarzt at the Charite Frauenkiinik at
Berhn (Professor Bumm) has been made Professor of
Obstetrics and Gynaecology at the University of Jena, in
place of Professor Bernard Kroenig, removed to Frei-
burg i. Br. Privat-Dozent Dr. Stoeckel, of Erlangen,
succeeds Professor Franz as Oberarzt at the Charite.
Privat-dozenten. — The " venia legendi " in Obstetrics
and Gynaecology has been accorded to : — Dr. Emilio
Alfieri, at Pavia ; Dr. O. Pankow, at Jena ; Dr. Ottomar
Hoehne, at Kiel ; Dr. Carl Barsch, at Tuebingen ; Dr.
Heinrich Peham, at Vienna ; Dr. Maximilian Henkel, at
Berlin ; and to Dr. BUKOJEMSKY, at Odessa.
At the P'ifteenth International Congress of Medicine to
be held at Lisbon in 1896, the Agenda of the Section for
Obstetrics and Gynaecology, as at present arranged are : —
(i) Obstetrical nomenclature. (2) Autointoxications in
pregnancy. Report by Professor Pinard (Paris). (3) Indi-
cations and technique of the Cassarean operation. Report
by Professor Alfredo da Costa (Lisbon). (4) Treatment of
uterine retrodeviations. Reports by Dr. Richelot (Paris),
and Professor Sousa Refoios (Coimbra). (5) Treatment of
uterine myomata. Report by Professor A. E. Martin
(Greifswald). (6) Diagnosis and treatment of ovaritis.
The following subjects are suggested for communi-
cations to this Section : —
(i) Conservative surgery of the ovaries. (2) Tuber-
culosis of the adnexa. (3) Forms of metritis. (4) Utero-
vaginal prolapse. (5) Early diagnosis of pregnancy. (6)
Insertion of the placenta in the inferior segment of the
uterus. (7) Symphyseotomy. (8) Relations between ap-
pendicitis and pregnancy. (9) Treatment of lacerated
perineum. (10) Pyelonephritis and pregnancy. (11) Treat-
ment of uterine cancer. (12) Pregnancy and cancer of the
uterus. (13) Treatment of puerperal infections.
SUMMARY OF GYN.-ECOLOGY, IXCLUDIXG OBSTETRICS.
FEBRUARY, 1905.
Ox THE Typical Localisatiox op^ P'eelixgs of Paix and
Texderxess Origixatixg from the Different
Parts of the Female Gexitalia.
SCHAEFFER, Heidelberg {Mitcnchciicr in. Wchiis., 1904,
No. 44), with most careful precautions against subjective
and hysterical statements, has examined more than 3,000
patients, most of them repeatedly, and finds that the localisa-
tion of pain and tenderness due to affections of the genitalia
in women is essentially typical ; corresponding to some
extent with the areas of Head, but for the most part capable
of more extended differentiation as regards the fields of
display, and in its grouping much more legitimate and in
accordance with ascertained facts. There is, for example,
no ovarian area of Head, but there are two different areas
of sensibility in relation to the ovary according as the region
affected is rather the one corresponding to the suspensory
ovarian ligament (regio supra iliaca bis lumbalis posterior)
or that to the mesosalpinx (regio infra- umbilicalis supra-
iliaca). From the cornua of the uterus reflex phenomena
appear in the iliac regions of the same side with radiations
into the superior hypogastric on one side and the hypo-
chondriac on the other. 'J'he middle hypogastric infra-
inguinal corresponds to the internal os uteri ; the lower
uterine segment, like the lower half of the cervix, is almost
anaesthetic, but the middle of the mons veneris inguinal
region corresponds to the upper half of the cervix ; to the
firm subserous attachments, the infra-umbilical region
round to the superior sacral, or sacrococcygeal w-ith radia-
tions into the upper parametria ; to the inferior parametria,
the inferior hypogastric region radiating to the sacral ; to
Douglas' folds, the superior sacral region ; to the vaginal
vaults, the anococcygeal region and the hypogastric region
radiating to the sacral ; to the portio vaginalis, the mons
K
1^8 Summary of Gyncecology, including Obstetrics
veneris lower median hypogastric region ; and to the lower
third of the vagina, the mons veneris itself.
The localisation and radiation depend, not on any certain
recognised nerve routes, but upon the course of the vessels,
and are easily to be explained by the history of development.
Gersuny's Paraffin Injections in Gynecology.
Stolz, Graz (Mounts, f. Gcb. n. Gyn., Bd. xx., Hft. 5), dis-
cussing the use of paraftin injections in gynaecology, points
out that they have been employed more particularly in in-
continence of urine and in prolapse of the uterus and vagina.
When the urethra is completely lost submucous injection of
the projecting swelling of the mucosa and reposition of the
injected mass may be considered, or when the urethra is still
preserved, injection of a single large depot of vaseline in the
neighbourhood of the neck of the bladder. Plastic operation
is, however, to be preferred for the relief of incontinence, on
account of the danger of embolism which attends injections,
and the latter should only be employed in cases otherwise
intractable. Even in prolapse, the results are so uncertain
and the danger of embolism from the injection of large
amounts of vaseline so real, that such injections are not in-
dicated, except when pessaries fail and no operation can be
undertaken. Stolz concludes, from cases of his own, that
the proceeding is more difficult, and the prognosis less
favourable, when the urethra is wanting, but that, when the
urethra is still present, this method seems to be effective and,
moreover, that vaseline is to be preferred to hard paraffin.
Int.act Hymen in a Parturient.
Klingmueller, Strehlen {Zcits. f. Med. Bcamtc, 1904,
No. 9), reports that in a parturient woman, aged 22, who
before conception had always had great dysmenorrhoea and
to whom coitus was very painful, the hymen consisted of
a perfectly uninjured, very thick, and strong membrane,
with a central opening at the most not larger than a knitting
needle. The forefinger passed easily into the bladder
through the enlarged urethra, the orifice of which was sur-
rounded with a thick roll of mucous membrane ; no doubt
congress had been by this way.
RiCHTER, Dessau {ibid., No. 11), reports a case in which
at labour the hymen formed a white tendinous membnme
stretched over the foetal head ; it had to be split from its
central opening, which was not larger than a pea.
Dysmenorrhcea in Unniam'ied Women ijg
Imperforate Hymen.
RiCHTER also reports a case of haematocolpos in a
maiden, aged t6, wlio for a year had suffered from severe
sacral and abdominal pain ; the tumour reached up to the
umbilicus and the hymen protruded convexly. About two
litres of dark clotted blood was set free by a trocar, and the
opening in the hymen was afterwards enlarged.
Paralysis of the Non-pregnant Uterus.
KOSSMANN, Berlin {Zciitnilh. f. Gyii., 1904, No. 44), again
records a case in which he introduced 14 cm. of a curette
into the uterus without encountering any opposition. A
sound passed directly afterwards only penetrated for 7 cm.,
nor could the curette be then passed any deeper. An
anterior colpotomy performed immediately afterwards
proved that thei^e was no injury to the uterine wall. He
is convinced that in this as in his previous case {ante, vol.
xiv., p. I jo) there must have been a temporary paralysis of
the uterine musculosa.
On Accumulations of Blood in Duplicate Genitalia,
WITH Unilateral Atresia.
Katz, Berlin {Arcliiv f. Gvii., Bd. Ixxiv., S. 349), reports:
in the case of a girl aged 26 in Abel's Frauenklinik, who had
always had severe abdominal pain at her periods, the dia-
gnosis made was, haematometra in the right atretic horn of
a duplex uterus and ovarian haematoma. After anterior
colpotomy, the right rudimentary horn, with the corres-
ponding ovary and tube (ha^matosalpinx) were removed,
the uterus and healthy left adnexa were not, and the girl
got perfectly well. Katz gives a very complete list of the
literature of these accumulations.
Operation for Dysmenorrhcea in Unmarried Women.
Sellman {Amcr. Joiirii. Obst., Nov. 1904) believes that
in many cases of dysmenorrhcea relief can be given by
minor surgical procedures, but that few cases of stenosis
can be relieved by ordinary dilatation, and he has intro-
duced, for cases in which its effect is only temporary, a
form of dilator called the reamer. These instruments are
made of three sizes, and are cone or olive shape, with
moderately sharp knives on their lateral surfaces and a
blunt end to avoid perforation.
i/fo Summary of Gyncscology, including Obstetrics
The small sized reamer is slowly introduced until it is
felt in contact with the point of contraction, the instrument
should then be given several twists towards the right, exert-
ing a slight pressure upwards ; this is essential in order to
engage the dense tissue against the sharp edges of the
knife. This movement is persisted in until the instrument
slips into the cavity of the uterus. It may be necessary to
use the second or even the larger size. The canal is then
packed with iodoform gauze, which is again renewed in
three days, and a wire stem pessary is worn for a short
time afterwards. In inflammatory conditions of the uterine
mucosa or parenchyma, he believes curetting to be the best
method of relieving congestion. Yox dysmenorrhoea due to
sensitive, congested or cystic ovaries, he advocates opera-
tion and resection of the ovary.
Disciissioji. — LONGYEAR did not agree with so much
operative intervention in the dysmenorrhoea of young
unmarried women. He protested against operating upon
cases that were of short duration. Hayd referred to those
most perplexing cases in which examination disclosed no
definite pathology. If there were retroversion, a tender
ovary or an inflamed tube, then there would be a rational
basis on which to work. A contracted os did not neces-
sarily cause dysmenorrhoea ; many cases were due to an
impoverished condition of the whole system. He did not
care for the reamers. Humistox did not think dysmen-
orrhoea occurred unaccompanied by inflammation of the
uterine mucosa, he therefore dilated and curetted. The
author's reaming-out process would not restore or keep in
place a retroflexed uterus. YouxG Browx said that unless
there was a distinct pathological condition present it \va.i>
better to leave these cases alone. DuNXiXG thought that
in the majority of cases there were errors in development,
either of the uterus or of the nervous system. For dysmen-
orrhoea due to anteflexion he believed in the operation
of Dudley, which must, however, be done upon a well-
developed and not upon an under-sized uterus.
J. F. J.
A Resum]^ of the Surgery of Retrodeviatiox of
THE Uterus.
DORSETT {Amcr. your. Obsf., November, 1904), in his
Presidential Address to the American Association of Obstet-
I
Amputation of the Inverted Uterus i^i
ricians and Gynaecologists, has surveyed the whole of the
operative field, describing amongst others the Alexander-
Adams operation, those of Mackenrodt, Gottschalk, and
Duehrssen, and finally Olshausen's, Kelly's, and his own.
Kelly's he considers as dangerous on account of the risk of
entanglement of the bowels in resulting adhesion bands.
In the majority of cases retrodeviations of the uterus are
complicated by inflammatory diseases of the appendages,
and the field for operative work outside the peritoneal cavity
is necessarily small. He does not contemplate the possi-
bility of a thorough inspection of the appendages from
above. He w'ould discard the entire class of operations
that contemplate the vaginal incision, either anteriorly or
posteriorly, on account of the greater liability to sepsis, as
well as from the impossibility of anchorage to firm
structures.
J. F. J.
The Technique of Amputation of the Inverted
Uterus.
Falk, Berlin (MiiciicJwitcr in. Wchns., 1904, No. 44),
admits that Kuestner's method makes the conservative
treatment of inversion of the uterus possible in most cases,
but holds that amputation of the inverted womb is justifi-
able, not only when the displacement is due to tumours,
but also when infection is present. The more usual methods
of amputation after the application of an elastic tube, or by
ligatures en masse, passed through the funnel of the inversion
may result in injury to the intestines, or endanger the life
of the patient from haemorrhage when the tightly stretched
broad ligaments retract. In removing the inverted uterus,
therefore, Falk urges abstension from putting a ligature
round the uterus and from ligatures en masse, in order
that we may ascertain, by a transverse incision about the level
of the inner os, that the funnel of the inversion is empty.
Ligature of the spermatic vessels and of the broad ligaments
should precede the removal of the uterus after it has been
dislocated forwards through a transverse incision in its
anterior wall. The author has used this method in a case
of total inversion of a prolapsed and infected uterus in a
machine sempstress aged 26, from whom during pregnancy
he had removed an ovarian cyst larger than two clenched
fists, the pressure of which on the uterus threatened
abortion. The further course of pregnancy and childbirth
1^2 Summary of Gynecology, including Obstetrics
under the care of another physician had been normal,
but on account of hccmorrhage the placenta was expressed
by Credo's method, and prolapse of the inverted uterus took
place. Four weeks later he saw the woman in a most
miserable condition, bloodless and feverish, but after
operation as described she made a good recovery. When
amputation of the uterus is necessary Falk thinks it should
always be done in the above way, as the transverse incision
can be made as large as desirable, and if necessary extended
by a longitudinal incision in the anterior wall.
Anterior Vaginal Cgeliotomy.
Grube {Muenchencr Jii. ]\^cJiiis. 1905, S. 141) gave a
demonstration at the Hamburg Medical Society on January
10, 1905, of the technique and advantages of anterior vaginal
coeliotomy, illustrated by 1 1 diascopic pictures taken during
the operation. He reported 70 cases, of which he had only
lost one (less than 1*5 per cent.) ; in one only he had been
compelled to do an abdominal operation, and once the
bladder had received an injury, which, however, was at once
sutured, and healed promptly. He stands fast to the
principle of operating by the vagina whenever possible, as
such operations give the surgeon ampler indications, and
apart from other advantages are much safer to life. Whether
the vaginal way will suffice, or an abdominal operation will
be required, can nearly always be determined by bimanual
palpation, with perhaps the use of the sound, in deep
narcosis.
FiBRINORRHCEA PLASTICA, MYOMA CaVERNOSUM AND
Endometritis Chronica CvsncA.
Wallart, St. Louis {Zeits. f. Geb. u. Gyii., Bd. liii. Heft
2), describes a unique case : a woman of 59 years of age,
from whose uterus, several times a day, white or yellow
caudate egg-shaped bodies, as large as a half-sovereign, were
discharged. Minute examination showed that these bodies,
which resembled the eggs of a dog-fish, were formed of
fibrin. As the uterus was much enlarged, and the suspicion
of malignant disease could not be excluded, the organ was
extirpated, and was found on histological examination to
exhibit the pathological changes named in the title.
A Rare Form of Cervical Myoma.
Zacharias, Leipzig {Zciis. f. Gch. 11. Gyii., Bd. liii.,
S. 182), descrilDCS a peculiar fibromyomatous transformation
The Treat7nent of Myoma /^j
of the entire cervix and portio, the cervical canal being
symmetrically surrounded by the new growth, which was
not delimited towards the body of the uterus by anything
like a capsule, and had caused a notable enlargement of the
cervix and portio. The diagnosis made had been one of
carcinoma, as a putrid, stinking discharge, and haemorrhage
persisting for six weeks, had driven the patient to seek
medical advice.
Conservative Tkkatmext of Uterine Myomata.
Henkel, Berlin {Zcits. f. Gch. u. Gyii., Bd. liii.. Heft 3),
reports that Olshausen's Klinik is remarkable for the small
number of operations that are there undertaken for myoma,
only 16 per cent, of the women who apply for advice on
account of such growths being submitted to operation.
This rigid selection necessarily implies a systematic develop-
ment of conservative treatment, the details of which Henkel
describes in this article, from which one learns, in addition
to very many practical hints, that under suitable treatment,
sev^ere menorrhagia and metrorrhagia, even of long standing,
may by suitable treatment be cured without operation.
The Treatment of Myoma.
Martin, Greifswald {Mounts, f. Gcb. 11. Gyii., Bd. xx.,
S. 1130J, in discussing the treatment of myoma, addresses
himself chiefly to the question posed by Winter {ante, p. //),
as to whether there is a scientific basis for the conservative
method of operating on these growths. Martin's own
brilliant results encourage him to adhere to the vaginal and
whenever possible to conserv^ative methods of operating.
The continuance of menstruation is one very definite
advantage of conservative practice, while after radical
operation it is seldom that omission symptoms do not
occur. Though recurrences of tumours after enucleation
do take place and give local trouble they do not constitute
complete failures. In enucleation it is essential to preserve
plenty of muscular tissue. The conservative methods offer
real advantages as regards the patient's future condition.
It is, however, impossible to leave it to the patients to say
whether the operation shall be conservative or radical ; the
question can only be decided at the time of operation. At
the beginning of the operation Martin makes an inquisi-
tional curetting and frequently makes an extensive resection
i^^ Summary of GyncBCology, including Obstetrics
of the superfluous mucosa in order to diminish the dis-
charging surface. He does not admit that the vaginal route
impUes imperfect control of the bed of the tumour, and
that one must therefore operate in a radical fashion ; to him
the limits of the vaginal operation depend entirely on the
size of the tumour. When there is any dit^culty in moving
the tumour in the pelvis, Schuchardt's incision may be a
great assistance. Martin prefers the abdominal route only
in suppurating affections of the adnexa, and then even
for small myomata. He considers that the amplifica-
tion of the vaginal operation in Mackenrodt's way is by no
means free from danger, on account of the neurotrophic
changes m the ovaries which are to be feared. Martin was
in the habit of resecting the capsule of the myoma before
this proceeding was proposed by Henkel. He closes the
bed of the tumour by a continuous catgut suture.
The Indications for Operation for Fibroids
OF THE Uterus.
Noble (American Medicine, September, 1904) is con-
vinced that the teaching concerning the complications and
degenerations of fibroids is faulty. He refers to his paper
read in 1901 before the British Gynaecological Society, and
to series of cases reported by Cullingworth, Frederick,
ScharHeb, and Hunner and McDonald. There are thus
available 983 cases of fibroid tumours from which an
analysis can be made as to the nature of the degeneration
and complications of these growths. The analysis is very
long and onlv the chief points in it can be here referred to.
In 78 cases there was cystic degeneration of ovaries, in 69
hyaline degeneration and in 67 necrosis of the tumour, in
47 ovarian cysts, in 46 salpingitis, in 58 hydrosalpinx, in 33
pyosalpinx, in 44 myxomatous degeneration, in 40 cystic
degeneration, in 34 intraligamentous development of fibroids,
in 29 cancer of the body of the uterus, in 22 sarcoma, in 12
cancer of tlie cerv^ix of the uterus. Cancer of the body is
here relatively more frequent than of the neck. This is the
opposite of what occurs in women without fibroid tumours,
in whom cancer of the neck is four times as frequent as
that of the body. The fibroid tumour must exert such an
influence upon the nutrition of the uterus as to predispose
to the development of cancer of the body.
A consideration of this analysis should dispel the idea
that fibroid tumours are benign growths, and that their
Removal of Fibroids of the Uterzis 145
chief danger consists in the fact that they sometimes cause
haemorrhage. The analysis shows that 16 per cent, would
have died because of the degenerations in the tumours, that
18 per cent, would have died from the complications present,
and a certain percentage would undoubtedly have died from
intercurrent diseases brought about by the chronic anaemia
and by injurious pressure from the tumours upon the pelvic
and abdominal organs. The statement that fibroid tumours
disappear after the menopause is quite erroneous. Many
grow more rapidly after than before the climacteric, and
they are at least as liable to degenerations and complications.
Women with fibroids are sick women, suffering either from
the fibroids or from various complications. The risk they
run of losing their lives by not having the fibroids operated
upon is greater than that of submitting themselves to opera-
tion, at least a third of these 983 women would have died
had they not been operated upon. A fibroid tumour should
l^e removed just as an ovarian one, irrespective of the
symptoms produced, loecause we know the life history of
these growths, and that if left alone they will, in at least a
third of the cases, produce a fatal result.
j. F. J.
Removal of Fibroids of the Uterus ox Diagnosis.
Eastman {Amer. Jour. Obstd., November, 1904) thinks
that medical treatment and those operations which are
planned to avoid hysterectomy only serve to palliate, while
the day for successful surgical treatment passes by, and he
has abandoned electrical treatment as well as the ligation
of the uterine arteries. He condemns procrastination, or
waiting for the menopause, for a consideration of the
secondary changes in the tumour compels him to early
operation. Seeing that at least 5 per cent, undergo sarco-
matous degeneration, seeing that other parts of the uterus
may be infected with cancer, and that necrotic and infec-
tious changes may arise in the tumours and gangrene occur,
and moreover, that if the tumour is allowed to grow to a
large size, there is the additional danger of cardiac disease
supervening, he does not hesitate to advise operation on
diagnosis. Complications which would have eventually
resulted in death were encountered in 43 of 117 cases he
has operated upon himself.
In the discussion, Carsteks said that a hbroid of the
uterus should be removed just as a diseased appendix. It
7^6 SzLminary of GyucBcology, including Obstetrics
would have to be removed sooner or later, and the sooner
the patient ceased being an invalid the better.
LOXGYKAK did not admit that every fibroid should be
removed when diagnosed, unless there were certain reasons,
such as pain or hccmorrhage, for operating. He had a
number of women under observation with fibroids, but
without any serious symptoms.
Gilliam admitted that his mind had become less con-
servative in the last few years, but he had not changed
to anything like the extent that Dr. Eastman had. The
mortality in uncomplicated cases was 2 or 3 per cent., but
taking the cases as they came, the mortality would be 5 to
10 per cent.
ZiXKK would not insist upon immediate operation. The
certain risk in all these cases must be considered. He had
patients under observation with fibroid tumours which
caused them no niconvenience whatever.
J. F. J.
Operation for Fibroid Tumours of the Uterus.
RUFUS Hall (Amcr. Jour. Ohstet., November, 1904)
discusses the question of advising early operation. The
present low mortality (not more than 2 or 3 per cent.)
should encourage the physician to advise early operation
before complications arise in the pelvis or abdomen, which,,
when the operation becomes imperative, causes a high
mortalitv. In a patient between 35 and 40, when the
tumour is small, and there are no serious symptoms, and
if she is free from pain, except at her periods, it is wiser not
to operate, but to keep her under observation. If there be
pain at times other than the periods, the cause should be
sought for. If the period is prolonged to ten or twelve
days and the haemorrhage be severe, and cannot be con-
trolled by the usual medication and rest, an operation should
be considered. If the tumour is larger than a cocoanut, and
the haemorrhage severe, the period lasting eight to ten days,
an operation will be necessary sooner or later. One of the
dangers of delay is h^ematoma of the ovary, which usually
forms in an ovary bound down by adhesions. Hall regards
haematoma as a very grave complication of fibroid tumours.
The fluid contents are very virulent, and after the operation
lead to septic peritonitis. And haematoma of the ovary
is more dangerous than a suppurating tube, since the tube
is above the tumour and can be reached and removed with-
AdenomyoiJia Uteri 147
out rupture. One patient in seven with pus tubes developed
post-operative peritonitis ; five in every six in which there
was haematoma developed peritonitis. Another reason for
advising early operation is that secondary changes may
occur in the tumour itself. These changes are usually of a
serious nature, and especially so when coming on after a
menopause, for then they are nearly alwavs malignant.
^J. F. J.
Two Hundred Supravaginal Hysterectomies
FOR Fibromata.
Lauwers, Bruxelles {Zcutralb. f. Gyii., 1904, No, 48),
reports 194 recoveries and 6 deaths in 200 cases of supra-
vaginal hysterectomy for fibromata, a mortality of 3 per
cent. There was cystic degeneration of the tumours in 5
cases ; calcification in 4 ; cavernous change in i ; necrosis
in 5, infection in one instance. One case was complicated
by carcinoma of the uterine body, and sarcomatous degener-
ation was present in 3. The myomata were intra-ligamen-
tary in 11 cases; adherent in 12. Other complications met
with were : pregnancy in 4 cases ; ascites in 2 ; peritonitis
in 2 ; ovarian carcinoma in i ; ovarian cysts in 3 ; and
dermoids in 2 ; haematoma in 17 ; hydrosalpinx in 12 and
pyosalpinx in i. There was extreme anaemia in 41 patients,
with phthisis in 2 ; and albuminuria in 3 cases.
Adenomyoma Uteri.
Meyer, Leipzig (Zeits f. Geb. n. Gyii., Bd. liii., S. 167),
in a case diagnosed as fixed retrodeviation of the uterus
with inflammatory adnexal tumours, on opening the abdo-
men found that the condition was as follows : somewhat
below the level of the insertion of the tubes, on the posterior
surface of the uterus, there were two nodules the size of
cherry stones, symmetrically placed right and left. As the
infiltrating growth characteristic of adenomyoma and
rendering enucleation impossible was present, total extir-
pation was performed. From subsequent histological
examination it seemed probable that the origin of the
tumours lay in foetal dislodgments of epithelial germs of
Mueller's ducts.
Multiple Primary Tumours.
Grawitz, Greifswald {Deutsche m. WcJins., 1904, No. 49),
reports that the autopsy upon a woman, aged 67 years,
148 Summary of Gyncecology, including Obstetrics
revealed three forms of new growth, entirely independent
of each other: multiple small uterine myomata ; a large
sarcoma (with metastases) extending far into the broad
ligament, and possibly originating in a rudimentary acces-
sory ovary ; and a carcinoma of the small intestine, also
with metastases.
Carcinoma of the Clitoris.
SCHMIDLECHXER, Ofen Fest (/i i-c/i/r. /. Gy//., Bd. Ixxiv.),
reports one case of the above ma woman, aged 67, recurring
one year after operation, and another m a patient aged 59,
operated on recently.
Abdominal and Vaginal Extirpation of the
Carcinomatous Uterus.
Doederlein, Tuebingen [Hegar's Beitracge, Bd. ix.,
Heft. 2), endeavours to show from the results of vaginal
and abdominal operations in his Klinik that, as he recently
stated, the radical abdominal extirpation of the uterus and
lymphatic glands is impossible, or, at all events, not yet
imperative. Of all the cases of uterine cancer seen at the
Klinik 48*3 per cent, were operated on by the vagina, with
a mortality of i6"4 per cent, and permanent cure in 40'6
per cent, of those operated upon, of i5'8 per cent, of all
cases seen, percentages of operations and of cures bearing
comparison with other statistics. He very justly desires
that, in future, cancer of the body should be kept distinct
from cancer of the cervix, on account of the far better
prognosis. Ten cases of cancer of the body of the uterus
were all alive and well five years after the operation, and for
this form of the disease vaginal hysterectomy offers the
best prospect, as extirpation of the lymphatics is super-
fluous. An abdominal operation should be done in the
same way as for myoma, that is to say, one should keep
close to the cervix.
Doederlein removed enlarged glands from the pelvis in
65 instances, and these glands were cancerous in 22*8 per
cent, of the cases, but in only 9 per cent, of cancers of the
corpus uteri, and in those the disease had broken through
the uterine wall. The value of extirpation of the glands
in cervical cancer is illustrated by two very instructive cases.
Doederlein makes out the glands by palpation through the
peritoneum before cutting down upon them ; he strongly
Sarcoma of the Pelvic Connective Tissue i^g
recommends Wertheim's angular clamp forceps for isolating
the carcinoma.
The Ultimate Cause of Death in Uterixe Caxcek.
Cealac (Revista dc Chinirflic, 1904, No, 7) describes the
final stages before death, and the autopsies of two patients
who succumbed to uterine epithelioma. The ultimate
cause of death was renal disease with consequent uraemia,
originating in compression of the ureters. In one case the
ureters above the spot where they were constricted by the
cancerous growth were dilated to the size of an intestinal
convolution ; the pelvis of the kidney was as large as a
closed fist ; the renal tissue proper was much diminished
and beset with numerous cysts. The patient had been
making less and less water, and finally only 100 gms. daily ;
her urine contained albumen, and well-defined symptoms of
uraemia set in, under which the woman ultimately died.
The other case had a similar course, and at the autopsy
disclosed a greatly dilated ureter and one large white and
one small white kidney.
Primary Sarcoma of the Pelvic Coxxective Tissue.
PULVERMACHER {Zeiifi'alb. f. Gxii., 1905, No. 2) reports
a woman, aged 2)^ years, who died from recurrence, five
months after the removal by laparotomy of a primary sar-
coma of the pelvic connective tissue. The tumour, a large
spindle-celled sarcoma, had originated and developed in
the right broad ligament and had given rise to small nodu-
lar metastases in several organs.
Large Fibrosarcoma successfully Treated by
Roxtgen Radiation.
Skixxer, New Haven, Conn. {Archives Electrologv and
Radiology, 1904, October), reports the following very re-
markable case : A woman, aged 34, came under the care
of Dr. W. B. Coley on April 19, 1901. She had a well-
marked family history of malignant disease, and three years
previously her uterus and appendages had been removed
for w'hat was taken to be a uterine fibroid (macroscopically).
In February, 190 1, she noticed, near the lower part of
the cicatrix in the abdominal wall, a hard tumour which
rapidly increased in size. The tumour on examiiiation was
found to be as large as a cocoanut, firmly fixed, entirely
J ^0 Summary of Gynaecology, including Obstetrics
felling the right iliac fossa, and extending nearly up to the
umbilicus and two inches to the left of the median line.
An incision made under cocaine sliowed that it infiltrated
the abdominal muscles, and microscopical examination
proved it to be a fibrosarcoma. The erysipelas toxines were
used for ten months, during the first two of which the
growth decreased to less than half the size, after which there
was no change for some time. Later on the influence of
the toxines seemed to have vanished, the tumour begun to
enlarge, and in January, 1902, was growing rapidly; the
abdomen was then as large as if seven months gravid.
When, at this time, the case came under Dr. Skinner's
treatment, the diameters of the tumour were : transverse, at
the level of the iliac spines, 10 inches; vertical median,
8 inches ; antero-posterior, about 5 inches. Anteriorly the
tumour was evenly convex, rather more prominent on the
right side, of a stony hardness and firmly adherent to the
overlying skin and to the os pubis. The patient weighed
128 lbs. was rapidly losing flesh, markedly cachectic, and
could hardly mount half a dozen stairs. She complained of
abdominal pressure, and disturbance of the functions of
bowel and bladder. Her condition was rapidly growing
worse. Pain had never been present.
Treatment with the X-rays of high penetration was
begun on January 28, 1902, by means of a Truax improved
tube excited by a static machine. The anode was placed
9 inches from the skin, the applications were for fifteen
minutes and made to different areas on successive sittings,
one layer of thin towelling being interposed, and the rest
of the surface protected by tinfoil. A fortnight later, after
six applications, an area of about 5 inches in diameter had
been noticeably softened to a depth of about an inch, and
the skin had become freely moveable over this area ; the
patient's general condition had markedly improved, and the
functions of the bladder and bowel were decidedly more
efftcient. The distressing sensations of pressure in the
abdomen had nearly disappeared, and the patient had gained
3 lbs. in weight.
The applications were continued at the rate of one every
27 days (forty-six in all) up to June 5, 1902, when it was
found that the dnnensions of the tumour had increased on
the right side, but decreased on the left ; the growth was
irregular in outline, its longest axis running from about the
level of the gall bladder to the left pubis. She had had
Fibrosai'coma Treated by Rontgen Radiation i^i
three or four attacks of pyrexia during the treatment ; they
lasted from tlu-ee to seven days, and were probably toxaemic
in character. The last, in ]\Iay, had been the longest and
most severe. Her general condition was very good, she
ate and slept well, and could walk moderate distances with-
out difficulty. Otherwise the treatment would probably
have been discontinued. On June 7 she went home for
ten days, and when she returned she was greatly improved ;
the tumour was some 20 per cent, smaller, so that she had
had to take in her dress and shorten the fronts of her skirts.
From that time to September 3, 1902, she received
thirty-one radiations, and the tumour slowly but steadily
lessened in size. She resumed her occupation as a teacher,
tentatively, returning for treatment every week or two till
April 25, 1903, receiving forty-six radiations, or about one
every five days. On several occasions w^hen she could only
remain one day, she received two radiations in twenty-four
hours. She suffered from some erythema and her skin had
assumed a brawny, leather}- consistence. She had toxasmic
attacks, not severe enough to interfere with her daily duties,
and the decrease in the size of the tumour continued, being
particularly noticeable after each such attack. Following
the treatment on April 25, she had a sharp attack of toxaemia
with slight soreness in the growth for six days ; this was
followed by a very marked lessening in size. Up to August
29, 1903, she had only eight further radiations, and on that
date she weighed 139 lbs., and the tumour was no longer
noticeable when she was clothed.
In September she suffered from an ulcer above the
upper border of the right pubis, the size of a florin and a
quarter of an inch deep, with pain, severe for a fortnight,
and gradually subsiding for six weeks afterwards. Her next
radiation was on November 25, 1903, before the ulcer had
healed. The tumour had diminished rapidly though the
radiations had been omitted, and now resembled a disc-like
mass, 3 inches in diameter and i in thickness, to the right of
the median line just above but now detached from the pubis.
It was insensitive to manipulation. From this time till May
20, 1904, she received five radiations only ; on this date she
weighed 147 lbs. and ihc iximour had entirely disappeared.
She was examined by Dr. Coley and others who had had
the case under their observation long before it came under
Dr. Skinner's care. A spindle-celled sarcoma, large, inoper-
able, and which, after lesisting every measiwc applied for
I ^2 Swmiiary of Gynaecology, including Obstetrics
its relief, had been developing:* with lethal symptoms, had
been entirely removed, and the patient restored to a condi-
tion of unimpaired usefulness and apparently perfect health
by 136 applications of the X-rays extending over a period
of 849 days.
Skinner concludes : (i) Rontgen radiation may dis-
sipate large, deeply-seated malignant neoplasms hopelessly
lethal under other management ; {2) its failures depend on
factors, at present undetermined, which it seems justifiable
to hope may in the future be identified and eliminated ;
(3) a direct connection between systemic toxaemia and the
disappearance of malignant growths under Rontgen radia-
tion is probable ; (4) the radiation should be persisted in
as long as the patient's condition will permit, even if no
benefit is observable ; (5) it has not been proved that the
therapeutical effect of rays derived from a coil is identical
with that of such as are derived from a static machine ;
there may be differences to account for success and failure.
Even should recurrence take place, this woman, three
years ago doomed to an early death, has for two years been
restored to unimpaired usefulness in an arduous walk in
life, and to good health as perfect and a body weight greater
than she ever had before, and this has been done by the
instrumentality of the Rontgen ray.
Changes in the Ovaries associated with Hydatid
Moles and Normal Gestation.
Wallart, St. Ludwig i. E. {Zcits. f. Geb. 11. Gyii., Bd.
liii., S. 36), after a review of previous researches into the
above question, gives the results of his personal investiga-
tions in a case of malignant uterine tumour supervening
upon an hydatid mole. In both ovaries he found the theca
interna of most of the follicles changed into an epithelioid
tissue, that proved to be lutein-tissue, and many of the
follicles themselves dilated into cysts of various size. In
normal gestation also, one meets with extensive production
of lutein tissue frequently very irregularly arranged, and
the formation of cysts of different sizes. Changes in the
ovary of this kind are evidently physiological, for they can
be shown to occur in animals. The case which is the basis
of the paper was one of a tumour which appeared after the
birth of an hydatid mole, and which eigh't months later led
to metastases in the lungs and vagina. The histological
structure of the tumour resembled a large-celled ensanguined
Decidiioiiia Malignii))i ijj
sarcoma. The author classes the case as one of atypical
malignant chorion epithelioma.
Chorion Epithelioma after Hydatid Mole
AND ITS Diagnosis.
Krukenberg, Brunswick {ibidem, S. 76), gives a good
exposition of the great difficulties in diagnosis presented by
atypical cases. When the clinical symptoms are suspicious,
it is advisable to allow oneself to be guided by them to
obtain by a radical operation the rescue of the patient, which
may still be possible, instead of waiting for the unsafe and
uncertain results of histological examination.
Deciduoma Malignum.
WORRALL, Sydney {Austral. Med. Gaz., Oct. 20, 1904),
reports as the first case of the kind recorded in Australia :
Mrs. G., aged 35, the mother of three children, the youngest
five years old, miscarried at the sixth week two years ago,
but made a perfect recovery. She conceived about April,
1903, and a month later a slight flow set in and continued
until December 12, when, after a smart haemorrhage, a
vesicular mole weighing 1*75 lb. was brought away with
the curette by Dr. P'orster, of Narradine. The haemorrhage
recurred intermittently, and the curette was again resorted to
with temporary benefit, but bleeding returned, and, as the
uterus was increasing in size, Dr. Forster suspected malig-
nancy, and on consultation Worrall recommended curettage
and examination of ihe scrapings, and a large quantity of
apparently decidual tissue was removed with much htemor-
rhage, the uterine wall being left quite smooth and firm. She
made a good recovery, and expressed herself as feeling very
well. She was asked to report herself in two weeks, or
sooner if the haemorrhage returned, but she did not do so
for nearly two months after the curettage, when it appeared
that she had remained well and gained flesh for a month,
but that the bleeding had then returned and continued ;
she had lost more than all the flesh gained ; the uterus had
again increased in size, was soft and elastic and still fairly
mobile. Consent to radical treatment was obtained with
some trouble, and the uterus, with the appendages, and much
of the broad ligaments, was removed by the vagina. There
were no metastatic growths in the vagina, and to the naked
eye the disease seemed to be confined to the endometruun,
which was the seat of a soft, vascular, friable growth, the
L
1 1^^ Siimmary of Gyiuccology, inc hiding Obstetrics
size of an orange, so loosely connected with the endo-
metrium that it could be cleanly removed by the finger
lip. The patient made a good recovery, and began to
gain flesh, but very shortly pain set in over the liver, with
fever and a quickened pulse, and, towards the end of the
month, Worrall made out a mass in the right hypo-
chondrium, with dulness and impaired respiration at the
base of the right lung. Vaginal examination disclosed
nothing. On August 4 she had a very severe attack of
hepatic pain, and died after being comatose for an hour ;
she had been slightly delirious for some nights previously ;
the urine continued normal. No post mortem could be
obtained. Dr. Forster's clinical diagnosis was confirmed by
Dr. Windeyer's examination of the curetted scrapings — and
it was his report, which is given in detail, with several illus-
trations, that led Worrall to try and rediscover the patient.
The Deportation of Chorionic Villi and its
Significance.
HiTSCHMANN {Zeits. f. Gel). 21. Gyii., Bd. liii., S. 14), on
the basis of histological investigation of specimens of tubal
pregnancy, tries to show that under the term "deportation"
Veit has included two different conditions : (i) Villi from
tubal pregnancy arrested in the veins adjoining the seat
of the ovum but still connected with their original stem,
and (2) villi detached from the ovum and deported in the
veins more or less away from it. The former is a con-
dition which, in tubal pregnancy, is physiological ; it is
merely that displaced parts of the placenta serve to enlarge
the intervillous spaces and extend the actively resorbent
surfaces ; the villi grow inside the eroded vessels and are
in no sense " deported." The latter condition constitutes
deportation proper, and is of importance in the genesis of
primary chorionepitheliomatous tumours outside the uterus.
The importance Veit attaches to deportation Hitschmann
cannot recognise in either condition.
Placental Tumour.
Labhardt, Basle (Hegar's Beitraege, Bd. viii., Hft. 2), re-
ports a case of chorioma placentae et haematoma deciduae
serotinae. On the maternal side of the placenta, about three
fingers' breadth from its edge, there was a small dark red
growth embedded in the placenta, to the other tissue of
Tubercular Peritonitis /J5
which it was attached only by a small pedicle near the edge.
The tumour extended almost through the entire thickness of
the placenta and proved to be an angioma of the vessels of
the villi. The patient showed a remarkable tendency to
haemorrhage. Earlier in her pregnancy a polypoid haema-
toma had developed in the decidua ; following the shaking
of a railway journey she had repeated hajmorrhage, followed
by premature detachment of the placenta, induction of
labour and death of the foetus.
Genital Tuberculosis.
ROSENSTEIN, Berlin {Monats.f. Geb. it. Gyii., Bd. xx., Heft
4), is led from the examination of seven cases to conclude
that no case of tuberculosis affecting the ovary only, and
not involving the peritoneum or tube, has been recorded
that is not open to objection. Tiie infection of the tubes is
seldom an ascending one, the inflammation being generally
continuous from above, or conveyed by the blood. Tubal
tuberculosis is bilateral and at first attacks the mucosa, and
just as in the ovaries, is subject to rapid retrogressive changes.
Characteristic alterations can furnish a diagnosis without
any staining of bacilli.
Tubercular Peritoxitis.
LONGYEAR (Ainer. Jour. Obstct., Nov., 1904) records a
variety of tubercular peritonitis which he calls pseudo-
membranous monocystic. It is characterised by the forma-
tion of a thick, white, fibrinous pseudo- membrane covering
the parietal peritoneum all over the tubercular surface, and
cementing the coils of intestine together in such a way as
to form a sac, of greater or less capacity according to the
progress of the disease, and containing straw-coloured fluid,
with jelly-like masses and shreds floating therein. The
treatment is abdominal section, evacuation of the fluid,
and thorough washing out of all shreds and gelatinous
masses with normal salt solution, thorough drainage by
glass or rubber tube, and both abdominal and vaginal when
necessary. The sac requires frequent washing out until the
pseudo-membrane has disintegrated, and the purulent dis-
charge has ceased. Creosote, cod-liver-oil, supporting diet
and suitable hygienic surroundings are essential. The
prognosis is unfavourable.
J. F. J.
jc6 Siinuuarv of Gyiuecology, including Obstetrics
Localised Peritonitis from a Foreign Body, Simulat-
ing A Metastasis oy ax Ovarian Tumour to the
Bladder.
Opitz, Marburg {Momiis. J. Gcb. u. Gyii., Bd. xx., Heft 4),
ill removing a cystic ovarian tumour, the contents of which
inckided much cholcsterin, a yellowish-white thickening,
the size of half-a-crown, was found on the bladder, and
was removed on the supposition that it was a metastasis.
The histological structure of this specimen showed that
between nodules consisting chiefly of giant cells, there were
numerous gaps which represented the former seats of crystals
of cholesterin dissolved out during the fixation of the speci-
men in alcohol. These crystals probably were the remains,
after absorption, of the contents of a ruptured cyst emptied
and encapsuled on the bladder.
Benignant Ovarian Xew Growths, especially Myoma.
Basso, Dresden {ArcJiiv. f. Gyn., Bd. Ixxiv., S. 70), has
met with 45 published cases of fibromyoma of the ovary,
and reports upon two of the kind and one of myoma. His
examinations support the idea that the muscular tissue of
these growths is derived from the walls of the vessels, as he
could not detect any trace of transference of muscular
fascicles from neighbouring organs to the tumour.
Clinical Remarks on Ovarian Tumours.
LiPPERT, Leipsic {Archiv /. Gyn., Bd. Ixxiv., S. 389),
reports upon 638 ovarian tumours and parovarian cysts
treated by operation in the Leipsic University Frauenklinik,
and in the private practice of Professor Zweifel, during the
years 1887- 1903, with a mortality for malignant growths of
13 per cent., for benign 37 per cent., or for the whole 5-17
per cent. Ascites complicated 83 of the 129 malignant
tumours, a percentage of 64-34, t)ut only 18-47 P^^ cent, of
the benignant growths. The tumours are classified as
(i) Glandular cystoma, 389; (pseudo-mucinous, 342 ; pseudo-
papillary, 13; serous, 34). (2) Papillary cystoma, 30.
(3) Dermoid cystoma, 66. (4) Fibroma, fibromyoma, 11.
<5) Sarcoma, 16. (6) Carcinoma, 68. (7) Other tumours,
malignant or in malignant degeneration, 15. (8) Parovarian
cysts, 43. The clinical aspect of ihe cases is discussed from
the most varied standpoints.
Oil Enibryoiua of the Tube /J/
Hernia of the Ovary.
Heegaard {Bibliotek f. Laeger, 1904, Nos. 5-8) in this
monograph shows that the idea that the so-called congenital
inguinal hernia of the ovary depends on an anomaly cor-
responding to the descent of the testicle, is quite untenable.
He points out that in such hernia the sac only is congenital,
the hernia is developed afterwards and, for anatomical
reasons, is more commonly met with in children. He
describes two cases hitherto unpublished. The first is one
of special interest : In a girl four weeks old, an inguinal
hernia of the ovary on the left side became incarcerated in
consequence of torsion of the pedicle ; the left ovary and
tube were removed, and one month after the operation there
was a swelling in the scar which could not be reduced.
This swelling proved to be the right ovary, and its reduction
w^as effected by an incision into the canal of Nuck, which
was patent.
Ox Embryoma of the Tube.
Orthmann, Berlin {Zciis.f. Gcb. n. Gyn., Bd. liii., S. 119),
describes an atheromatous tubal cyst extirpated by himself,
and then narrates the few cases of embryoma of the tube
that have been recorded, only five others in all, and some
very imperfectly described. In his own case, lying almost
quite free within a greatly dilated tube, which w'as patent
at each end, there was a rudimentary embryonal design.
The capsule of the tumour consisted of the tubal wall, greatly
stretched, and exhibiting almost the same changes which
are found in a sactosalpinx due to inflammatory processes.
One peculiarity, however, was the fatty infiltration of the
folds of the mucosa and the ingrowth of hair into its
substance. The contents of the tube consisted of the typical
compound which is accepted as the product of the embryo.
The embryonal body, which was attached to the tube
wall by a very thin pedicle, contained elements of all three
embryonal layers.
Tubal Pregnancy with Coexisting Acute Pyosalpinx.
Hitschmann, Vienna {Zc'its. /. Gch. u. Gyn., Bd. liii,,
S. i), says that a causal influence in the tubal implantation
of the ovum upon catarrhal and, more especially, upon
gonorrhoeal processes, is hardly disputed, but most authors
accuse chronic changes and suppose that acute gonorrhoea
in the tube would prevent implantation. The case he
i§8 Suninmry of Gyncrcology, including Obstetrics
reports controverts this supposition. The mucous mem-
brane of the tube exliibited signs of recent gonorrhoeal
inflammation, and perimucous abscesses. This inflamma-
tory process, which arrested the normal progress of the
fertilised ovum, was necessarily the primary one. In regard
to implantation in the wall of the tube the histological
details of the case are of interest, as the author made sure
that the veins opened did not serve for the enlargement of
the intervillous spaces, but that almost the whole of the
ovum stuck fast in the dilated vein. Weigert's method of
staining showed that nearly the whole surface of the ovum
was invested with elastic tissue in dense bundles or broken
up by foetal cells. The placenta, therefore, seems to develop
only in the capillaries, while in the tube the ovum spreads
out in tJiL* veins.
Ectopic Gestation to Term.
V. LiNGEN, St. Petersburg {Zentralh. f. Gyii., 1904, No.
50), reports a successful operation on a tertipara, aged 37,
which revealed a full term ectopic gestation with a dead
foetus in an unruptured tubal sac. The sac was hour glass
in shape and simulated two tumours ; one contained the
placenta, the other the foetus and the umbilical cord, which,
however, was not inserted into the placenta but into the
wall of the sac.
Twin Tubal Pregnancy.
Schauta {Zentralh. f. Gyu., 1905, No 2) divides twin
pregnancies involving the tube into 3 categories (i) Simul-
taneous intrauterine and extrauterine pregnancies. These
are the most numerous; Patellani in 1896 collected 37 already
published. (2) Two ova developed in one tube ; of this kind
Schauta has found 19 recorded. (3) An ovum is very rarely
situated in each tube, as recorded by Kristinus, Psaltoff, and
Frederick. Schauta reported a recent case of the second
kind.
Weinlechner reported a fourth case in which there was
an ovum in each tube; both tubes burst at the end of the
first month. He also mentioned that he had operated for
tubal pregnancy on a woman from whom Schauta had
previously removed one tube for the same cause, and
suggested that it was a question whether it was not desirable
to remove both tubes in such cases as a matter of prophy-
laxis. This was negatived by Schauta and v. Erlach,
Primary Abdoimnal Pregnancy i^^
and Wertheim said the proportion of recurrences was only
about 6 per cent, and too low to justify such mutilation ;
simultaneous extrauterine and intrauterine pregnancy was
not unusual, at least loo cases had been collected since
Patellani's article.
Ovarian Pregnancy.
Calaianx {Muciichcner in. Wdins., 1905, No. 5) exhibited
to the Hamburg Medical Society, on January 24, 1905, a
specimen of ovarian pregnancy not open to any objection
whatever, neither tube, fimbrias nor infundibulo-pelvic liga-
ment taking any part in the formation about the fertilised
ovum in the ovary. Remarking on the rarity of such cases
he said 34 had been recorded.
Primary Abdominal Pregnancy.
LiNCK, Danzig {Monats.f. Geh. 11. Gyii., Bd. xx., Heft. 6),
reports that at the operation upon a woman with the
symptoms of severe internal haemorrhage, not only fresh
blood was found in the peritoneal cavity, but a chorionic
placenta, the epithelium of which, as demonstrated by the
microscopical examination, had grown into the serosa of the
pouch of Douglas to such an extent as to form an intimate
organic connection with the peritoneum. The histological
examination excluded the idea of any secondary process.
The genital organs, uterus, tubes, and ovaries appeared at
the operation absolutely normal, their peritoneal mvestment
also normal, and there was no trace of residua or coloura-
tion from past haemorrhage anywhere in the neighbour-
hood of the small pelvis. Linck holds that the implantation
of the ovum in the posterior peritoneal fold in the pouch of
Douglas was in this case primary.
The Condition of the Vessels in Tubal Pregnancy.
Fellner, Vienna {Archiv. f. Gyn., Bd. Ixxiv., S. 481), in
the examination of series of sections of three tubal pregnancies
of from two to three weeks' gestation, found that the arterial
vessels, as they approached the intervillous spaces, appeared
to be filled with spindle cells and round cells. This pro-
liferation in the lumen of the vessel arose from thickenings
of the intima, and the cells were decidual ones. This casts
some doubt upon the widely received opinion that cells of
the periphery of the ovum (Langhans' cells) become dis-
placed into the veins (deportation), the truth apparently
i6o Siiniinary of Gymecology, including Obstet7ncs
being that decidual cells are formed in the arterial vessels,
and the process is therefore rather an autothrombosis than
deportation.
Decidual Cell Formation ix the Appendix ix Tubal
Pregnaxcy — Pekiappexdicitis Decidualis.
Hirschberg, Berlin {Archiv.f. Gyii., Bd. Ixxiv., S. 620),
reports upon two cases of right tubal pregnancy with
adherent appendices successfully treated by laparotomy.
In one of these two cases there was proliferation in the
appendix of decidual cells derived from the connective
tissue cells of the serosa. Such metamorphosed connective
tissue cells are absolutely distinct from the hypertrophic
peritoneal endothelium met with in plastic peritonitis of all
kinds, or after haemorrhage into the peritoneal cavity.
Foetal Heart Souxds.
Sarwey {Zentvalb. f. Gvii., 1904, October i) asserts that
a skilled auscultator can detect the foetal heart sounds
much earlier than four and a half months. He has always
been able to do so between the thirteenth and eighteenth
weeks, and once even in the twelfth, generally just above
and rather behind the symphysis.
Phlebectasis ix the Gravid Uterus axd its Clixical
i.mportaxce.
Halban, Vienna (Mounts, f. Gcb. 11. Gyii., Bd. xx., S. 313),
reports a case of this rare condition. In a primipara,
aged 26, the interruption of pregnancy was indicated by
repeated haemorrhages in the early months. Some tissue
removed by Schultze's forceps along with the placenta led
to further examination, which revealed a deep laceration of
the cervix and perforation of the uterus, and the uterus was
thereupon extirpated. Upon section, an extreme degree of
phlebectasis was visible, which must have been due to some
specific gestation change in the veins. The great clinical
importance of this case lies in the primary insufBciency of
the pains, the extreme atony after delivery, and the extreme
friability of the uterine wall.
Appexdicitis durixg Pregxaxcy.
ScHLEYER (Riisskie Vraisdi, 1904, Xos. 27-28) describes
four cases of appendicitis during pregnancy ; three were
operated upon, one of which died, and the fourth left the
The Re-Action of Pregnancy i6i
hospital without operation. In all the cases the pregnancy
terminated prematurely. The one which was fatal became
very much worse after the course of the spontaneous abor-
tion, while in the one which was not operated upon, and in
which the abortion set m only at the beginning of the
treatment, and was rapidly completed artificially, the general
condition materially improved. Schleyer concludes that,
owing to its peculiar course and the special indications for
operative interference, appendicitis in pregnant women is to
be differentiated from the same affection in others. The
only rational and certain means of dealing with it is by
well-timed operation ; the medical attendant must employ
every possible means to prevent the premature onset of
labour, but if travail has once set in and cannot be arrested,
prompt but careful evacuation of the uterus is indicated.
The Reaction of Pregnaxcy ox the P\etal Organs
and their puerperal involution.
Halban, Vienna {Zciiz. f. Geb. a. Gyii., Bd. liii., Heft 2),
in an article based on exact histological examination of the
mammae and genitalia of 21 new born foetuses, arrives,
practically, at the following conclusions : — The reaction of
pregnancy on the maternal system is to be attributed to the
effects of chemical material. In the child, changes take
place quite similar to those in the mother. The female
foetus exhibits an hypertrophy and hyperaemia of the womb ;
and the decidual reaction in the mother appears to have an
analogy in a menstrual reaction in the foetus. The well-
known genital haemorrhage in new-born girls is the next
stage in this reaction. The mammae of the foetus hyper-
trophies during gestation, just in the same way as the
mother, and exhibits characteristic histological changes.
Moreover in the male foetus the mammae and the prostate
react like the mammae of the female, exhibiting hypertrophy
and the same histological changes. In the same way the
poison of pregnancy has analogous effects in the foetus as
in the mother^ as regards leucocytosis, increase of fibrin,
renal affection, and oedema.
The active products of pregnancy are derived from the
placenta, to the chorionic epithelium of which an internal
secretion must be attributed. After delivery, these products
of the placenta act no more, and both in mother and child
processes of involution take place in all the organs which
1 62 Stuninary of Gyncccology, ijicluding Obstetrics
during pregnancy were hyperticjphied, and regeneration of
those injured by intoxication.
Eclampsia is the effect of a deeper intoxication by the
poison normally in action during pregnancy. The poisons
of that disease come from the placenta, circulate in both
maternal and foetal systems, and, in each, cause analogous
changes; when the injurious effects have not gone too far,
the affected organs may, after the placenta is separated, be
again completely restored.
Spixal Puxctuke in Eclampsia.
Kroexig, Jena {Zciitralblatt. f. Cryn., 1904, No, 39), in
two cases of eclampsia ascertained that the pressure of the
liquor cerebralis in the subarachnoid space was enormously
increased, amounting, during the convulsions, to between
500 and 600 mm. of water or even more. He used Quincke's
apparatus, which is well adapted for estimating the pressure
and at the same time allows any desirable quantity of fluid
to be abstracted without renewed puncture. Relatively
large quantities of the fluid could be withdrawn before the
pressure was reduced to the normal average (120 mm.) in
one case 37'5, and in the other 47 cc.m. He also punctured
the arachnoid in another case and all three recovered, but
tJie number is too small to draw any definite conclusions,
especially as in two of the cases vaginal Cassarean section
was another factor in the treatment.
Henkel, Berlin (/6/(i., No. 45), practised spinal puncture
in eclampsia, in Olshausen's Klinik, as long ago as 1901,
and gives a short report on sixteen cases, of which four
ended fatally (25 per cent., about the ordinary mortality).
The spinal fluid was in some cases more or less increased, in
others normal in amount. He abstained from publishing
the cases as he concluded that the course of the disease was
in no way affected by the puncture.
Kleinwaechter, Prague {ibid.), points out that T. A.
Helme, of Manchester, reported a case of lumbar puncture
in eclampsia {ante, p. S4), to our Society in April, 1904, an
account of which was published in the Lancet in the same
month.
Kroenig {ibid., No. 49) protests that his object in spinal
puncture was not therapeutical, but merely to determine
whether, in eclampsia, the pressure in the subarachnoid
space w^as increased.
CcEsarean Section in Puerperal Eclampsia i6j
Eclampsia and Decapsulation of the Kidney.
SiPPEL, Frankfort [Zcntralb. f. Gyii., 1904, No. 45), on
theoretical grounds and the basis of an autopsy, referring
to a previous article of his own {ibid., 1904, No 15), in
which he suggested that the relief afforded by section of
the renal capsule, or of the kidney itself, upon anuria and
albuminuria, accidentally discovered by Reginald Harrison,
was a surgical point that should be borne in mind in con-
nection with eclampsia, draws attention to a decapsulation
of the kidney performed, by Edebohls, on a primipara aged
23, on account of severe eclampsia with gestatory nephritis,
the convulsions having recurred two days after forced
delivery during coma. The woman recovered. Sippel
insists on the need of exact observations upon which a
positive opinion may be founded, as a preliminary to the
general acceptance of Edebohls' operation.
Eclampsia and Cesarean Section.
Wanner, Duesseldorf {Zcntralb. f. Gyn., 1904, No. 45),
reports two instances of the most severe form of eclampsia,
eight to fourteen days before term. Both children were
delivered alive, but the mother in the first case died forty-
eight hours after abdominal Csesarean section, the other
woman, delivered by vagmal hysterotomy, recovered.
Vaginal Cesarean Section in Puerperal Eclampsia.
Carstens (Atner. Jour. Obstet., November, 1904) refers
only to those very serious attacks, whether the first, second,
or third, where the convulsions do not cease, but, unless
there is intervention, follow one another in rapid succession
until death ends the scene. In such cases, the only chance
for the patient is prompt delivery, but he has abandoned
rapid dilatation, multiple incisions in the cervix, and similar
devices, in favour of Duehrssen's suggestion of vaginal
Cassarean section, mainly on the principle that cutting is
better than tearing. He reports three cases. In the first,
two deep lateral incisions were made so as to cut the fibres
of the internal os. In the two later cases, the bladder was
separated bluntly from the uterus up to the peritoneum,
and then with the knife a clean cut was made in the middle
line of the uterus up to the internal os. The child was
delivered in about seven minutes, and in another seven
minutes the placenta was removed and the incision in the
uterus sewn up with dry sterilised catgut. The median
1 6^ Sumniai'y oj Gyiuccology, including Obstetrics
incision is to be preferred to the lateral, since it avoids the
risk of wounding or tearing the large vessels at the side of
the uterus. In each case the prompt delivery saved the
patient. He thinks that any general practitioner ought to
be able to do this operation.
Disciissiou. — ZiNKE said that a general practitioner ought
not to interfere in these cases, if he had the opportunity of
secuiing the help of a well-equipped specialist. Loxgyear
tiiought that this operation would replace the old methods
of dilating by rubber bags, &c., which had been very un-
satisfactory. Stamm thought that it was better to make an
anterior and posterior incision, since then they would not
have to be made so long or so deep. SCHWARZ objected
to the name of the operation, for it was not, practically
speaking, a Csesarean section at all.
J. F. J.
Vaginal C.'1^:sarea\ Section.
H. v. Bardeleben, Berlin {Zciitnilb. /. Gyii., 1904,.
No. 46), has examined the condition of the uterus in eight
women in whom hysterotomia vaginalis anterior had been
performed, in most cases for eclampsia, and found the
results most favourable. In five instances the form of the
portio was perfectly restored, two had indentations within
physiological limits, and only one a cleft of any conse-
quence. There were no serious displacements of the uterus,,
though there was anteposition in one case, and retroversion
with anteflexion in two others. In none of the cases was
there any uterine discharge or haemorrhage due to the
operation. In his opinion, as a method of emptying the
uterus, the operation has many advantages over dilatation.
Accouchement Forcil.
Zinke (Ajiier. Jour. Obst.f November, 1904) discusses
the possible methods of accouchement force, and draws the
following conclusions : (i) The graduated metal or vulcanite
dilators and the ordinary bladed dilators are mainly
employed preparatory to digital, manual, and bag dilatation
of the cervical canal or os uteri. (2) The bag or hydrostatic
dilators, preferably Champetier-de-Ribes bag and its modifi-
cations, should be employed only when time is not an
important element in the case, and when the cervix is so
soft that the bag can be easily introduced. This method is
contra-indicated in central placenta prievia, and in eclampsia,.
Repeated Ccesarean Section i6j
mild or severe. If in this condition it is necessary to empty
the uterus, deep incisions of the cervix, or vaginal or
abdominal hysterotomy, give the best results for mother
and child. (3) For the manual dilatation of Harris and the
bi-manual dilatation of Bonnaire and Edgar, a soft and
dilatable cervix is absolutely essential. When time is an
important element, they are to be preferred to the bag.
But the life of the foetus is often lost, and, unless great care
is observed, sepsis, tears, hcEmorrhage, shock, and sometimes
even death of the mother, may occur. (4) Deep incision of
the cervix and Duehrssen's vaginal Caesarean section are
destined to play an important wlc in the management of
forced labours in the future. It is the method of choice in
the presence of sepsis of the vagina, when the cervix is
intact, whether hard, elongated, or not, or is the site of
extensive cicatrization. (5) Ca^sarean section should only
be done when the child is viable, and manifests signs of
life and vigour, and in the presence of placenta praevia,
detached placenta, or eclampsia associated with a closed
cervix. If quickly done under these circumstances, it
entails less risk to both mother and child than any other
mode of delivery. If there is the slightest disproportion
between the parturient tract and the child, it is to be pre-
ferred to Duehrssen's operation. (6) The Bossi and similar
dilators are dangerous instruments, and sooner or later will
reach their final destination in the lumber room of obstetric
instruments.
Discussion. — ScHWARZ pointed out that central placenta
praevia could only be diagnosed when the cervix was dilated,
and that then the child should be delivered without a
Caesarean section. From his experience he was prepared
to give the Bossi dilator a further trial. Ross would leave
eclamptic cases out of consideration. In others, he would
give the preference to Caesarean section. He condemned
the Bossi dilator.
Carstens in placenta praevia advised turning, but in
exceptional cases Caesarean section might be necessary.
J. F. J.
Repeated Cesarean Section.
V. Leuwen, ITtrecht (Ann. Gyn. Obsf., 1904, October),
has collected 117 cases of repeated Caesarean section, from
the study of which he concludes that : (i) Post-operative
troubles are infrequent, and the woman's capability for
1 66 Summary of GyncECology, including Obstetrics
work is seldom permanently impaired. This point, how-
ever, has been comparatively little studied. Abel, reporting
on 34 cases from Zweifel's Klinik, notes that in 5 there was
pain during the catamenia, but in only one instance was
the ability to work impaired, though the abdominal wound
suppurated in 13, and silk ligatures were expelled in 9
cases through the abdominal wall and once through the
bladder. In 20 cases in Kouwer's Klinik 18 were traced, of
whom 5 were pregnant and in good health, 3 others had
been happily delivered prematurely, 2 had aborted. Two
ventral herniae had caused but little trouble. There were
adhesions between the uterus and abdominal wound in 9
cases, in only one of which was there complaint of pain.
Silk ligatures were discharged by suppuration in 2 cases.
There were only 2 of the 18 women who suffered from
incapacity for their work, and that only temporarily. (2) The
repeated operation did not compromise the patient's fertility.
After one C^esarean section, 137 women have conceived
194 times. Of these pregnancies, 117 were terminated by
repetition of the operation (Porro in 13) ; of the other 77,
21 by natural labour at term ; 22 by the induction of pre-
mature labour , 8 by spontaneous and 3 by induced abor-
tion ; 3 by symphyseotomy ; 3 by embryotomy ; 3 by
the forceps ; 2 by version and extraction, and there was
rupture of the uterus in the cicatrix or elsewhere in 6 cases.
(3) As regards the uterine wound, while many operators
have been unable to find any trace of the cicatrix of a
previous Caesarean section, in 24 of the 194 pregnancies in
which the operation was repeated the uterine wound had
not healed perfectly, and the cicatrix ruptured in 4, while
it was extensile throughout in 14 and in parts in 6 cases.
V, Leuwen attributes this to faults in technique or infection
rather than to any particular suture material, and suggests
care in excluding the decidua from the suture to avoid the
introduction of germs from it into the musculosa, and also
that the ligatures should be cut off as short as possible to
avoid irritation of the peritoneum, or, better, that their ends
should be buried beneath the serosa. (4) There were peri-
toneal adhesions present in 76 of the 117 repeated sections ;
on the significance of such adhesions there is much dif-
ference of opinion ; v. Leuwen considers them troublesome
and dangerous, though not especially so in causing abortion,
which is less frequent in pregnancy after Caesarean section
than in ordinary gravid women. (5) Infection is no doubt
Ruptures of the Uterus idy
the cause of imperfect healing of the uterine wound in
many cases, and also that of many peritoneal adhesions.
Olshausen has noted the frequency of pyrexia after
Caesarean section, and in 59 cases in various kliniks
V. Leuwen found it occurred in 90 per cent. Considering
the difficulties attending the preparation of these patients
for operation this is not surprising. (6) The mortality of
the repeated operation is less than that of primary Cassarean
section. Of 104 of the repeated operations only 3 were
fatal. This is no doubt due to the fact that, taught by
experience, the women seek advice before labour has
commenced, and thus not only avoid delay and misapplied
attempts to hasten or effect delivery, but are admitted into
hospital under more favourable conditions.
P. Z. H.
Spontaxeous Ruptukk of Cicatrix op^ C^sareax
Sectiox.
Eksteix, Teplitz {Zciitralb. f. Gyn., 1904, No. 44). A
woman delivered twice by perforation, and once by
Cesarean section, at the end of her fourth pregnancy,
suffered from spontaneous rupture of the uterus while she
was washing the room. On laparotomy, three days after-
wards, it was found that the cicatrix of Fritsch's transverse
mcision had given way throughout its extent. Porro's
operation was performed, but the woman died an hour and
a half afterwards. Examination of the uterus showed that
the whole of the scar was permeated by placental tissue.
Ekstein suggests that in future the uterus should be sutured
with a narrow leaden ribbon, which would give the cicatrix
a natural resistance.
MuxRO Kerr (J. Obs. Gyn, Brit. Eiiip., 1904, November),
relates a similar case at term without any warning. He
blames the fundal incision, and refers also to Meyer's case
(Zciitralb. f. Gyn., 1903, p. 1416).
Ruptures of the Uterus ix the Scars of Former
Labours.
Labhardt, Basle (Zcits.f. Gcb. u. Gyn., Bd. liii, Heft 3),
reports three cases which show the importance of cicatrices
in the uterus, especially in its lower segment, in subsequent
labours. The cases in which the scars affected the supra-
vaginal part of the cervix seem particularly dangerous ; the
thinning of the tissue there is most extreme, and the giving
1 68 Suiuiuary of Gyiuecology, includuig Obstetrics
way of the scar is most to be feared, on account of the
proximity of the peritoneum. This is to be remembered in
connection with Duehrssen's deep incisions and vaginal
Caesarean section.
Rupture of the Uterus during Labour.
IVANOF, Moscow {A]ui. Gvit. Obst., 1904, August, Septem-
ber and October), contributes an elaborate article on the
etiology, prophylaxis and treatment of lupture of the uterus,
based on the study of material accumulated during the last
twenty-five years in the Maternity of Moscow and on the
recent literature on the subject ; he formulates the following
conclusions : —
(i) The majority of ruptures in cases of placenta previa
are produced by some act of violence.
(2) The same may be said of cases of transverse
presentation.
(3) When a case of transverse presentation has been
submitted to clumsy attempts to hasten delivery before the
arrival of the accoucheur, there is a predisposition to rupture
during the operation.
(4) The decapitating hook of Braun, a very imperfect
instrument, may cause a rupture.
(5) The majority of ruptures produced by violence are
found on one side or other of the os, and are prone to be
longitudinal and to involve the cellular tissue of the broad
ligaments.
(6) In cases of hydrocephalus of the child, rupture of
the uterus is often due to this condition being recognised
too late.
(7) In cases of contracted pelvis, rupture may take place
under the influence of distension and compression of the
inferior part of the uterine wall between the child's head
and the prominences or depressions in pelvic surfaces.
(8) In contracted pelves, previous labours may predispose
to rupture owing to pressure upon lesions of the uterine
wall and subsequent resulting cicatrices.
(9) In flat pelves, spontaneous ruptures are almost always
produced transversely in the supravaginal portion of the
uterine cervix, and the rupture generally occurs very soon
after the beginning of labour.
(10) The great majority of cases of so-called " colpo-
porrhexis" are transverse ruptures of the supravaginal
portion of the uterine cervix.
Hebotomy i6g
(ii) The conservative treatment of rupture in cases of
contracted pelvis after several protracted labours accom-
panied with difficult operations, is decidedly dangerous,
especially when any cicatrices can be detected by palpa-
tion in the supravaginal portion of the cervix.
(12) Beside the modifications of the uterine wall above-
mentioned, or due to malignant tumours or defective
development of the organ, inflammatory cellular infiltration
is another important predisposing factor in causing rupture.
(13) Some pathological modification of the elastic tissue
of the organ has generally been invoked to account for
rupture, but no such change has ever been demonstrated
in ruptured uteri. The only changes observed consist in
phvsiological modifications supervening during pregnancy
or labour, or during the puerperal period.
(14) The results of conservative treatment of rupture of
the uterus during labour are only half as favourable as those
of surgical intervention.
(15) Every rupture of the uterus during labour should
be dealt with by a surgical operation, which alone can offer
the means of arresting haemorrhage and attending to the
wound. P. Z. H.
Hebotomy.
Leopold, Dresden iZcntvalh. f. Gyn., 1904, No. 46),
reports on 5 cases of hebotomy performed on the principles
of Doederlein and Gigli. The mothers all did well, and had
a normal childbed ; three of the children were still alive.
Gigli, Florence {ibid.), in a short but vigorous article
defends his rights in the operation he calls " lateral section
of the pelvis," especially against van de Velde {ante. p. 126),
who calls it "hebotomy." The latter term has found more
acceptance in Germany, but Gigli's claim to priority is
generally admitted. There is little new in Gigli's article ; he
lays down two fundamental conditions, however, (i) The
incision must be made outside the symphysis pubis ; (2)
and it should be also outside the insertion of the ligamenta
pubovesicalia.
HOFMEIER, Wuerzburg {Mueiicliciicr in. Wchns., 1905,
No. I, p. 51), has performed this operation as an alternative
to perforation with most satisfactory result. The child
extracted by forceps did well. The woman had a normal
childbed and was able to walk well four weeks after delivery.
V. Franqu^, Prague {ibid., p. 52), also reports favourably
(two cases).
lyo Summary of Gyncecology, including Obstetrics
ZWEIFEL {ihid., 1905, No. 1) defends symphyseotomy
and says that Gigli has no claim to priority in regard to
lateral section, as he calls it, save and except as regards his
wire saw.
Daxgers of the Glass Catheter during Parturition.
HuNNER, Baltimore {Aiiicr. Med., 1904, November 5
p. 805), was consulted in a case in which a glass catheter
used by the medical attendant was broken between the
descending head and the symphysis pubis, and half its
length left in the bladder. Labour proceeded normally
except for a slight perineal tear, for which four catgut
sutures were inserted. No bladder symptoms appeared till
the tenth day, when frequency of micturition was noticed.
The only one of the four sutures unabsorbed was then
removed, and, with due precautions and the use of cocaine,
a No. 10 Kelly's speculum was passed into the bladder, in
the Sim's position, and nearly the whole of the broken
catheter was extracted with the alligator forceps, but owing
to its curved shape, the speculum had to come with it. To
detect and remove the remainder, in four small pieces, the
patient was supported in the knee-breast position. There
had been turbidity of the urine, and the cystoscope disclosed
decided hyperasmia, but the patient was given cystogen
thrice daily and copious draughts of water, and there was
no further appearance of cystitis. There are theoretical
objections, at all events, against the use of even a metal
catheter during labour, and Hunner recommends a soft
rubber one as the only secure method of avoiding traumatic
injury in the first and second stages of labour ; though its
aseptic manipulation is a more difficult matter than that of
either glass or metal instruments.
Formalin in Puerperal Sepsis.
HOERSCHELMANN {St. Petersburg m. WcJiiis., 1904,
Anier. Med., 1904, ii., 82) reports : A primipara, aged 24,
began to complam of malaise in the seventh month. She
had been well till then and thought she had overworked
herself making hay. The day before her admission she
had severe pain, and discharged discoloured amniotic fluid.
She was examined with every antiseptic precaution and the
next day gave birth spontaneously to a macerated foetus,
the amniotic fluid being very foetid. A putrid placenta was
expressed two hours later. Temperature normal, but next
Seropathy in Puerperal Fever lyi
day rigor, temperature 104°, pulse 1150. Intrauterine douche
of boric acid, icebag locally and ergot internally. Repeated
chills, high fever and foetid discharge ; next day, lysol
douches. Three days later an enema was given consisting
of a pint of a I per cent, solution of salt containing eight
drops of formalin and, at the same time, opium by the
mouth. The patient had a stool within ten minutes, her
temperature fell somewhat and she felt much better. During
the night she had profuse sweats and the symptoms of
sepsis practically vanished ; she made a rapid recovery.
Seropathy in Puerperal Fever.
Hamilton {Amcr. Jour. Obst., November, 1904) realises
clearly that the majority of cases are caused by the strepto-
coccus, but that a mixed infection may produce symptoms
so similar that, without a bacteriological examination, a dia-
gnosis cannot be made. We must, however, admit as a
possibility the lessening of the mortality by the serum treat-
ment. He reports in full three serious cases in which
examination had proved the infection to be due to the
streptococcus ; in all three cases, following the serum injec-
tion there was a fall of temperature and pulse. Auxiliary
treatment was also adopted, such as strychnine, alcohol
sponging, antiseptic douching and stimulating diet, and
recovery followed, the temperature becoming practically
normal by the sixth or eighth day of treatment.
J. F. J.
Hoffmann, Salzwedel [DenfscJic m. Wchns., 1904, No.
46), records a case successfully treated by Aronson's serum.
Peham, Vienna (Arcliiv. f. Gyn., Bd. Ixxiv., S. 47), reports
upon 44 cases treated in Chrobak's Klinik with Paltauf's
antistreptococcus serum obtained from horses injected with
cocci from cases of sepsis, peritonitis, puerperal processes
and erysipelas. The action of the serum was more definite
in the cases in which the uterine secretion contained
streptococci only. Early administration and a compara-
tively large dose, 100 ccm. at one time, appeared most
important. No deleterious effect was noticed, even when
the infection was not from streptococci. The necessary
local treatment was carried out in all the cases, 31 of which
recovered.
Pilcer and Eberson, Tarnow (Themp. Monatsch.,
October, 1904), report upon 28 cases, of which only 4
were fatal, a happy result that must be attributed to the
IJ2 Stuiunary of Gyncecology, including Obstetrics
action of the serum. The serum is no specific, but, in
conjunction with other measures, is a powerful means of
overcoming puerperal infection. Its action is declared by
promoting the formation of leucocytes. It should be given
once or several times in doses of from 40 to 60 grammes.
V, jAWORSKi, Warsaw (Zciifralb. f. Gyn., 1904, No. 45),
considers that in puerperal infection no artificial serum is
as good as the so-called surgical one, that is to say, a 0*84
per cent, solution of chloride of sodium injected with a
sterile syringe subcutaneously or deeply into the subcu-
taneous connective tissue. Frequent small injections (10
to 100 ccm.), once or twice a day, act better than large
infusions. Healthy glands and sound kidneys are essential.
Py.^MiA ; Successful Ligature of the Uterine Veins.
BUMM, Berlin {Miicucheuer m. Wchns., 1904, p. 2115),
reported to the Charite Medical Society that in two instances
of chronic pyaemia he had obtained an uninterrupted re-
covery by ligaturing the hypogastric veins as suggested by
Freund. The operation is more quickly done from the
peritoneal cavity, but cai^e was necessary to avoid the uterus.
Pseudo-Hermaphrodism.
Moiser, Winchester {Lancet, 1904, October 15), reports
the following case: a patient admitted to the Royal Hants
County Infirmary on June 18, 1904 ; she had severe pain
in the left ovarian region lasting eight days, with slight
epistaxis on one or two days. She was aged 19, rather
masculine in appearance, with a voice lower in tone than
most women ; no hair on her face. Pubic hair normal
in amount. Breasts and mons veneris poorly developed ;
labia majora normal, labia minora very small. Clitoris
1*5 inches long ; glans, prepuce and fr?enum well developed,
imperforate, the meatus urinarius being in a position normal
in the female. No hymen, vagina narrowed at upper end
and blind. Neither uterus, ovaries, tubes or testicles could
be made out even under anaesthesia.
The patient had never menstruated, but every month
since Christmas, 1893, she had had epistaxis at regular
intervals, accompanied with aching pain in the left ovarian
region, and lasting five days.
A laparotomy was performed, and a vermiform appendix
three inches in length containing seven hard faecal con-
Hermaphrodismus Femininus Externus //j
cretions was removed. No internal genital organs were
found. Her temperature was normal throughout, and to
the time of writing she had no return of the pain.
The case hardly justifies its title. The date of the
operation is not given. Possibly the molimina may return.
Hermaphrodismus Femininus Externus.
Friedrich {Muciichcner in. [fV////5., 1905, No. 5, p. 240)
showed to the Greifswald Medical Society a virginal
individual aged 19, with an imperforate penis, or clitoris
4 cm. long, who had never menstruated, had a bass voice,
a male larynx, and masculine hair on the abdomen.
The external genitals and vagina were well developed, the
uterus small and like a mere ribbon. There were several
abdominal tumours, solid and cystic, one very near the
right kidney, but none connected with the uterus. Lapa-
rotomy disclosed bilateral ovarian tumours, which were
easily extirpated. In the four weeks since the operation the
clitoris had atrophied to a remarkable extent. Friedrich
referred to the way in which men, even fifty years old,
assumed the female type after castration and amputation of
the penis for carcinoma.
Grawitz reported on the tumours ; the right was an
ordinary ovarian cystoma, the left a dermoid, a teratoma,
the chief portion of which was a rhabdomyosarcoma.
//^ Notes
NOTES.
We have with regret to record the following deaths : —
Mr. Thomas Henderson Pounds, F.R.C.S., a Fellow
of the British Gynaecological Society, died at Derby on
December 24, 1904. He was a skilled surgeon of good
repute, and had no small share in establishing the Derby-
shire Hospital for Women. He was only 48 years old.
Dr. James Armstrong, Consulting Physician to the
Liverpool Lying-in Hospital, on December 26, 1904.
Dr. C. MacCallum, Emeritus Professor of Obstetrics
and the Diseases of Women and Children in the McGill
University, Montreal, on November 13, 1904, in his 8ist
year.
Dr. Edwin Hellyer, on January 16, 1905, at Kensing-
ton, Philadelphia, a specialist in Obstetrics and the Diseases
of Women.
Dr. J. M. Lwow, Privat-Dozent of Obstetrics and
Gynaecology in the Faculty of Medicine at Kasan.
Dr. Clement Godson has been made a Corresponding
Fellow of the Italian Obstetrical and Gyna3Cological Society.
One of the first three endowments of ^1,000 under the
Jessie Alice Palmer Fund, has been accorded to Queen
Charlotte's Lying-in Hospital, in recognition of the services
to science of Dr. W. S. A. Griffiths: Westminster Hospital
and the British Home for Incurables obtaining the others.
Dr. Henry Jellett, F.R.C.P.I., has been appointed to
the post of Obstetric Physician and Gynjecologist to Steevens'
Hospital, Dublin, and Dr. R. H. Fleming to that of
Gynecologist to the City of Dublin Hospital, in each
instance in succession to the late Dr. J. L. Lane.
Geheimrat Franz Ritter von Winckel, Professor of
Obstetrics and Gynaecology in the Ludwig-Maximilian's
Notes 7/5
University, at Munich, has been decorated with the Order of
Merit of St. Michael, of the second class.
Geheimrat Dr. Kuestner, of Breslau, has just celebrated
his twenty-five years' jubilee as Professor. He was made
Extraordinary Professor at Jena in 1879, and was called to
succeed Professor Fkitsch when Fkitsch was transferred
to Bonn.
Professor P. Grawitz, Director of the Institute of
Pathological Anatomy at Greifswald, has been made a
Medical Privy Councillor.
Dr. Karl Menge, Professor of Obstetrics and Gynae-
cology and Director of the Frauenklinik in the Universtiy
of Erlangen, has, for the time being, been appointed Director
of the School for Midwives at that place.
Professor Opitz is to be the Director of an institute for
the treatment of persons suffering from cancer, which is
about to be established by the Municipality of Marburg.
The title of Professor has been accorded to : Dr. Karl
HOLZAPFEL, Privat-dozent of the Diseases of Women in the
University of Kiel, and to Dr. Mackexrodt, of Berlin.
The following appointments as Privat-dozenten are
announced, the venia legcndi in Midwifery and Gynaecology
having been granted to : Dr. AXTOXIXO Bextivegxa at
Palermo ; Dr. Oskar Paxkow, Second Assistant to Professor
Kroexig, at Freiburg ; Dr. F. Pl\i at Modena ; Dr. A.
Rielaxder, Senior Assistant to Professor Ahlfeld at Mar-
burg, his inaugural lecture being " On the Perforation of the
Living Child, and its Scientific and Legal Justification " ;
and to Dr. K. Skrobansky at the Military Medical Academy
at St. Petersburg.
Dr. Adam Bauereisex has been appointed Chief
Physician to the University Frauenklinik at Erlangen, to
succeed Privat-dozent Dr. Stoeckel, who has been trans-
ferred to the Charite Hospital at Berlin.
The Medical Council of the University of Halle-
Wittenberg has conferred the degree of M.D. Jionoris causa
upon Dr. Phil. Willy Merck, one of the partners in the
well-known firm of E. Merck, of Darmstadt, in recognition
of his merits in connection with Materia Medica.
iy6 Notes
The eleventh congress of the Italian Obstetrical and
Gynaecological Society will be held this year at Rome, under
the presidency of Professor Ercole Pasquali, of Rome.
The Vice-presidents are Professor LuiGi Mangiagalli, of
Milan, and Professor Ottavio AIorisani, of Naples ; the
Secretaries, Dr. Cesare Micheli and Dr. F. S. ROCCHI,
of Rome. Professor Raixeri, of Vercelli, will report on
" Dystocia of the Neck of the Womb " ; Professor Miranda,
of Catania, " On the Indications for the Extirpation of the
Adnexa in Hysterectomy."
The Fifth Ixterxatioxal Coxgress of Obstetrics
AXD Gyx.-ECOLOGY is announced to take place at St.
Petersburg on September ii to i8, 1905, under the patronage
of His Majesty the Emperor of Russia. The Organisation
Committee, of which the President is Professor Dmitri von
Ott, and which includes the professors and representatives of
all the most renowned schools of obstetrics and gynaecology
of the Russian Empire, invites every one interested in these
branches of medicine to take part in the proceedings of the
meeting, which it ventures to hope will be as numerously
attended as the previous ones, and it will do everything in
its power to render the long journey and the visit to Russia
as agreeable and comfortable to the foreign guests as pos-
sible. In regard to the international character of the
Congress, and to facilitate all those joining it sharing in
its work, the Committee have decided to allow the members
themselves to choose any European language for their
communications and discussions. The questions placed
on the order of the day are as follows : —
(i) Vaginal Methods in Gynaecology and Obstetrics.
(2) Accouchement Force.
(3) The Surgical Treatment of Uterine Fibromyomata.
(4) The Critical Appreciation of the Different Methods
of Operative Treatment of Retrodeviations of the
Uterus.
(5) Chorionepithelioma.
The General Secretary of the Committee is Dr. P.
Sadovski, St. Petersburg (Nevski pr. 90) ; the Treasurer,
Professor A. Zamschin, St. Petersburg (Wassiliewski Ostrow,
University Line 3).
Abstracts i7i the Summary ijy
INDEX TO VOLUME XX.
ABSTRACTS IN THE SUMMARY OF GYN.^COLOGY AND OB-
STETRICS.—
Abdominal surgery (Clarke), J7.
Accouchement force (Zinke), 164.
Actinomycosis, ovarian (Geldner), 44.
Adenocarcinoma invading a fibroma (Noble), jg.
Adenomyoma of the genitals (Kleinhans), 100 ; (Semmelink), loi : of the uterus
(Cullen), 22 : (Cameron and Leitch), loi ; (Meyer), 14^.
Adnexal disease and appendicitis (Sunkle), jj ; conservative treatment
(Clarke), ji ; suppurative, consequent upon enteric fever (Dirmoser), loS.
Adrenalin in gynaecology and obstetrics (Peters), /; (Fenomenow), jj.
Alexander's operation, 10, Sj, 84.
Amputation of the inverted uterus (Falk), 141.
Anaesthesia sexualis (Nenadovics), /j.
Analgesia (spinal) in gynaecology and obstetrics (Stolz), 7j ; (Martin), 7^.
Anterior vaginal coeliotomy (Grube), 142.
Appendix, the, in relation to pelvic disease (Peterson), 8g ; appendicitis during
pregnancy, 160 ; peri-appendicitis decidualis, ibo.
Asepsis, chlorine (Stewart), jj.
Atresia, genital (Hofmeier), 79; in bilateral genitalia, i^g.
Autothrombosis rather than deportation (Fellner), i^g.
Bossi's Method of Dilating the Cervix : — in labour and abortion
(Schuermann), 6j ; after-effects (v. Bardeleben), 122: (Muns), 122;
(Hahl), I2J ; (Frommer, Schaller, v. Erdberg), 124; in Leopold's klinik
(Ehrlich), 124; (Heller), 12^ ; in France (Maury), 12^.
CESAREAN Section: — in eclampsia (Halliday Croom), //j ; (Wanner),
163 ; repeated (v. Leuwen), 163 ; spontaneous rupture of the fundal
incision (Ekstein), 767 ; vaginal, and cancer of the gravid womb
(Orthmann), 26; in eclampsia (Hammerschlag), 115', (Maly), 116:
(Carstens), /6j ; (v. Bardeleben), J64.
Cancer : — of Bartholin's glands (Fritsch), 5 ; of the clitoris (Schmidlechner),
148 ; mammary, and suckling (Lehmann), 6g; ovarian, bilateral, at 14,
(Kouznetzky), 2j ; ovular forms in (Liepmann), 102 ; uterine, abdominal
extirpation (Kroenig), 24; abdominal or vaginal extirpation (V. Herff),
26; (Deaver), 40 ; (Schauta), gj ; (Freund, and others), 9^; (Doederlein),
148; Laparotomia hypogastrica extraperitonealis (Mackenrodt), ^5 ; lym-
phatics and recurrence (Kroemer), 9^ ; (Mackenrodt), ^j; metastases in
N
178
Index to the Twentieth Volume
Abstracts — continued.
the iliac glands (Manteufel), ^j; statistics (Besson), 40; and papilloma
(Boeckelmann), 22; ultimate cause of death in (Cealac), i4g ; with
tuberculosis (Wallart), 2r ; of the gravid womb and vaginal Cesarean
section (Orthmann), 2O.
Catheter during parturition, danger of the glass (Hunner), lyo.
Cauliflower growths of the vulva (Hellendal), 75.
Cervix Uteri: — a rare form of cervical myoma (Zacharias), /^^ ; and the
bladder in radical operations for cancer (Sampson), 76.
Childbed, see Puerperium.
Chorioectodermal epithelium (Landau), ig.
Chorioma placentas (Labhardt), 1^4.
Chorionepithelioma: — (Reed), ig ; (Worrall), ijj ; after hydatid mole
and its diagnosis (Krukenberg) ijj ; after tubal pregnancy (Hinz), /oo ;
histology of binignant (Velits), jy ; prognosis and treatment (Hammer-
schlag), 100.
Chorionic villi, the deportation of (Hitschmann), 1^4.
Contracted pelvis, the diagnosis of (Sellheim), f/6 ; prophylactic version in
(Wolff), 118.
Control of gauze pads in laparotomy (Rossel), Sj.
Corpus Luteum : — The functions of the (Fraenkel), 48; (Ries), jo ; and
hydatid moles (Jaffe), jo.
Croquet ball thirty years in the vagina (Orloft), 8j.
Cystadenoma of the vulva (Pick), 6.
Cystitis after gynaecological operations (Baisch), jj ; (Rosenstein), y8.
Cysts: — Broad ligament (Gibelli), gi ; vaginal; double (Con), 7; origin of
(Fredet), 6 ; subchorionic, 68.
Decapsulation of the kidneys in eclampsia (Sippel), 16^.
Displacement and detachment of an ovary, 2g ; displacement of lutein cells in
case of hydatid mole (Birnbaum), j"/.
Displacements of the Uterus : —
Inversion : — Amputation of the inverted uterus, 141.
Retroflexion .■-—Treatment (Graefe), g ; pessaries and their failures (Klein), 82 ;
the Alexander operation (Steidl), 10; (Reifferscheid), <?j ; (^IcKay), 84 ;
Goldspohn's operation (Kossmann), 84; the blunt hook operation (Long-
year), cS^; intraperitoneal shortening of the round ligaments (Menge), j<5,
and of the sacro-uterine (Sperling), Sj ; the surgery of retrodeviations
(Dorsett), 140; uterine fixation in child-bearing age (v. Guerard) j6;
stitch abscess after (Mackenrodt), 86; retention of the placenta (Fuchs),
86 ; the results of suspension (Stone), 86.
Retroflexion of the gravid uterus and ischuria (Reed), jj".
Prolapse : — The Alexander operation (Jacoby), 10 ; results of operation for
(Baatz), //.
Dysmenorrhoea in unmarried women, operation for (Sellman), ijg.
Eclampsia : — (Meyer, \Virtz),6j"; Cesarean section in (Halliday Croom), i/j;
(Wanner) i6j ; vaginal (Hammerschlag), 11 j ; (Maly), 7/6; (Carstens),
76j ; conservative treatment (Kermauner), //j; decapsulation of the
Abstracts in the Suniviary lyg
Abstracts — continued.
kidneys in, i6j ; spinal puncture in (Kroenig, Ilenkel, Kleinwaechter),
162; thyroid extract in (Baldonsky), 6^ ; in the fifth month without a
foetus (Hitschmann), ij6.
Ectopic Gestation : — Abdominal, primary (Linck), i^g; secondary (Prues-
mann), uo ; (Pestalozza), ///; extrauterine migration of the ovum
(Worrall), 55; interstitial (Weinbrenner), jj ; ovarian (Merkel), m ;
(Calmann), isg ', tubal (Zuntz, Voigt), log ; retention of dead foetus
(Schmidt), j6; to term (v. Lingen), 138; with acute pyosalpinx (Hitsch-
mann), r^7 ; with torsion (Bidone), no; and uterine (Worrai), j6 :
(Simpson), JT? >' twin tubal (Schauta), 1^8.
Embryoma of the tube (Orthmann), 757.
Endometritis, caustics in (Rielander), jj ; hsemorrhagic glandular (Pforte), 81.
Endothelioma lymphaticum (Heinricius), 705 ; with metastases (Federlin), 705.
Enteric fever and metrorrhagia (Darnall), 709; and suppurative adnexal
disease, 108.
Extirpation of the spleen (Jordan), t^ ; extrauterine migration of the ovum, jj.
Fever during parturition (Ihm), 127.
Fibrinorrhcea plastica, &c., endometritis and myoma (Wallart), 14.2.
Fibroids, Fibromyoma, Myoma: — A rare form of cervical (Zacharias), 142;
co-existing uterine and ovarian fibroids (Taylor), gi ; degenerations of
uterine (Worrall), 14; sarcomatous (Hauber), /6 ; dystocia due to
(Calderini), jc?; haemorrhage and its causes (Theilhaber and Hollinger),
14; heart disease (Fleck), /6 ; hyperemesis (Gaillard), g/: invasion of
fibromyoma by an adenocarcinoma (Noble), jt?.
Treatment : — Conservative (Henkel), 14^ ; conservative operations (Winter),
77; (Martin), 7^j ; abdominal operations for (Pitha), 97; hysterectomy,
supravaginal (Hayd), j8 ; total or subtotal (Jacobs), 18; two hundred
hysterectomies for (Lauwers), 7^7; the indications for operation for
fibroids (Pfannenstiel), 77; (Noble), 144 ; (Eastman), 14J ; (Rufus Hall),
746.
Fibrosarcoma successfully treated by Roentgen radiation (Skinner), 7^9.
Formalin in puerperal sepsis (Hoerschelmann), 770.
Hsematometra in a uterus bicornis, with haematosalpinx ; (Prochownic), J2 ;
(Katz), ijg.
Haematomoles (Bauereisen), jg.
Haemorrhage, ovarian, 4J ; in uterine fibrosis and its cause, 14.
Hebotoniy (van de Velde), 12^ ; (Doederlein, Ferroni and Berry Plart), 126;
(Leopold), (Gigli), (Hofmeier), (v. Franque), 769.
Hermaphrodismus femininus externus (Friedrich), 77^.
Hernia of the ovary (Heegaard), 7,-7; with torsion (Gaugele), 104.
Hot air in gynaecology (Salom), J4.
Hydatid moles and the corpus luteum (Jaffe), jo ; changes in the ovaries
associated with (Wallart), ij2 ; chorionepithelioma after, and its diagnosis,
displacement of lutein cells associated with (Birnbaum), 57.
Hymen intact in a parturient (Klingmueller), i^S ; (Richter), 7^15"; imperforate,
hasmatocolpos (Richter), jjg.
i8o Index to the Twentieth Volume
A^STViACTS— continued.
Hyperemesis due to a myoma, gi ; gravidarum, do.
Hysterectomy, bisection of the uterus in abdominal (Faure), / j ; for sepsis
after abortion (Mouciiotte), 6y ; myoma, supravaginal, for, j8 ; the
indications for vaginal (Faure), go ; two hundred ditto (Lauwers), j8 ;
total or subtotal ditto, /<?.
Impregnation (Toff), jS.
Induction of abortion for psychosis, //^.
Induction of labour, puncturing the membranes (de Regmier), /^/ ; immediate
and later results (Hunziger), /-?/ ; infant mortality (Lorey), /21.
Infection in institutions for teaching midwifery (Ahlfeld), /^(?.
Instrumental dilatation, see Bossi.
Inversion, see Displacements.
Ischuria in retroflexion of the gravid uterus, jj.
Kraurosis vuIvk (Jung), 74.
Leucocytosis in gyncecology (Duetzmann), 4 ; (Pankow), 7^.
Leucorrhoea and yeast treatment (Goenner), Sf.
Ligature of the veins in pysemia (Bumm), /ys.
Mammary carcinoma and suckling (Lehmann), 6g.
Menopause, early (Siredey), S : (Schalit), S/.
Menstruation, bathing during (Edgar), yg ; precocious (Stein, Wischmann),
So ; and ovarian sarcoma (Riedl), So ; tubal (Thorn), 80.
Metrorrhagia in enteric fever, log.
Mortality: — After hysterectomy for sepsis after abortion, 67; infant ditto
after induced labour, 121.
Osteomalacia, with pigmented sarcomata (Schmorl), 61.
Ovaries, Ovarian: — Actinomycosis, 44; benignant ovarian new growths,
especially myoma (Basso), 1^6; bilateral dermoid cysts (Conuamin), ^7;
carcinomatous papillary ovarian cystomata (Levi), 106 ; peritoneal implan-
tations from ditto (Holiinger), 106 ; corpus luteiun, its functions, 48 ; and
hydatid mole, 50 ; changes associated with hydatid moles and normal
gestation (Wallart), 132; chronic oophoritis (Pinto), 102 ; cyst suppur-
ating after typhoid (Zantschenko), 48 ; dermoid, papillomatous outgrowth
perforating the bladder (Muenck), ^7; detachment and displacement of an
(Strobel), 2g ; solid embryomata (Rothe), 106; thyroid tissue in (Polano),
4J ; endothelioma ovarii (Federlin), 2j ; lymphaticum (Heinricius), /oj' ;
with metastases (Federlin), 705 ; hoemorrhage (Buerger), 4^ ; hernia, 1^7 ',
with torsion, 104; pseudo-endothelioma (Polano), 28 ; tumours, clinical
remarks on (Lippert), /j 6 ; primary Krukenberg (Schenk), 4^ ; simulated
vesical metastasis of an (Opitz), 1^6.
Pain, the localisation of genital (Schaeffer), 7J7.
Papilloma, 47, 106.
Parafifin injections in gynaecology (Stolz), /ji?.
Paralysis of the non-pregnant uterus (Kossmann), ijg.
Abstracts in the Suniinafy i8i
Abstracts — continued.
Parovarian cyst (Nagel), loj.
Pelvis, the treatment of pus in the (Stoner), 88.
Peri-appendicitis decidualis (Hirschberg), ibo.
Perineum, central rupture of the (Azwanger), 6j.
Peritoneal implantations from papillary ovarian cystomata (Ilollinger), lob.
Peritonitis, post-operative (Grandin), 88; tubercular (Longyear), /jj.
Placental polypi (Michaelis), 6g : tumours (Labhardt), 134 ; sub-chorionic cysts
(Albeck), 68.
Placentation in woman (Friolet), 1/2.
Pregnancy: — albuminuria in (Little), 1/4; Appendicitis during (Schleyer),
/60 ; the condition of the blood in (Payer), 59; (Carstairs, Fueth), 60;
foetal heart sounds (Sarwey), /60 ; heart and circulation in (Stengel and
Stanton), 1/3; (Mackenzie), //j; hyperemesis gravidarum (Jung), 60;
phlebectasis in the gravid uterus (Halban), /60 ; psychosis and induction
of abortion (Treub), 114 ; reaction upon foetal organs (Halban), i6f ; twins
in a uterus septus (Paulin), 64 ; in both horns of a bicornuous uterus
(Kouwer), 112.
Prolapse, see Displacements.
Pseudo-hermaphrodism (Rydygier), /jj ; (Westerman), 1J4 ; (Moiser), 172;
(Friedrich), ijj.
Psychosis and operative gynaecology (Fredericq), / ; induction of abortion
for, 114.
Puerperal metrophlebitis and Trendelenburg's operation (Grossmann), 68.
Puerperal sepsis, formalin in (Hoerschelmann), 170; gangrene (Wormser), 66 ;
prophylaxis (Zweifel, Mueller, Bokelmann, Ahlfeld), 12S ; serotherapy
(Giuzzetti, Caie, &c.), 65 ; (Bumm, &c.), 1^9: (Hamilton, Hoffmann,
Peham, Jaworski), 171.
Pycemia, ligature of the veins in (Bumm), 172.
Pyelo-nephritis in childbed (Wallich), 67.
Retention of blood in duplicate genitalia (Katz), ijq ; of a dead fcetus beyond
term (Schmidt), j6 ; of a fully - developed foetus for three months
(Goldenstein), ijj ; of the placenta after uterine fixation, 86.
Retractor, a self-retaining (Reiffersheid), 87.
Retroflexion, see Displacements.
Rupture, central, of perineum (Azwanger), 6j ; of the uterus in labour (Ivanof)
168; repeated (Patz), 126; in old cicatrix (Eckstein), 167 ; (Labhardt),
167 ; (v. Fellenberg and Caumonberghe), 12.
Sarco.MA : — Coexisting with uterine carcinoma (Nebesky), 99; ovarian and
precocious menstruation, osteomalacia with pigmented, 6/ ; primary, of
the pelvic connective tissue (Fulvermacher), 149 ; Roentgen radiation in
(Skinner), 149.
Septicemia, the recognition of true (Kneise), ug.
Solution of rubber in benzine for covering the hands (Murphy), 87.
Spinal analgesia, 73", 74.
Stovaine in obstetrics (Doleris and Chartier), 127.
Sub-chorionic cysts (Albeck), 68 ; suspension of the uterus, its results, 86.
1 82 Index to the Twentieth Vohmie
Abstracts — continued.
Thyroid extract in eclampsia, 62.
Thyroid tissue in ovarian embryomala (Polano), 4^.
Transverse suprapubic division of the skin (Kreutzmann), Sj.
Tuberculosis: — Genital (Gottschalk, Schakoff), 20 ; (Murphy),^/; (Rosen-
stein), JS5 ', co-existing in the uterus with cancer (Wallart), 21 ; hyper-
trophic non-ulcerative, of the vulva, loi ; peritoneal (Longyear), IS5 1
primary, in childhood (Allaria), 101.
Tubes, Tubal, 5^^ Ectopic gestation ; embryoma, /J7 ; occlusion and its origin,
57 y permeability to intra-uterine injections (Thorn), joj ; sounding and
perforation (Thorn), 108.
Tumours, see Cancer, Fibroid, Ovary, Sarcoma ; multiple primary (Grawitz),
7^7; radiotheraphy of uterine (Deutsch), ^j".
Twin, see Ectopic Gestation.
Twins from a uterus septus (Paulin), 64; in a bicornuous uterus, 112.
Uterus, Uterine, see also Cancer, Displacements, Rupture; adeno-
myoma, 22, loi, 14^.
Vagina : — Anterior vaginal creliotomy, 142 ; cysts, 6, 7 ; vaporisation (Fuchs),
7; (Hantke), 8.
Version, prophylactic, uS.
Vulva: — Benign cystadenoma of the, 6; cauliflower growths, 75 ; kraurosis
vulvae, 7^; hypertrophic non-ulcerative tuberculosis, joi.
Aarons, Dr. S. Tervois.
Exhibits : A new uterine mop, 255 ; ruptured ovarian cyst (for Dr. Elder), 365.
Remarks : On the Vernon Harcourt inhaler, 69 ; extirpation of the uterus and
vagina for prolapse, 331 ; on double pyosalpinx, 366.
Accessory Fallopian tubes, 253.
Adenoma hasmorrhagica, 345.
Adnexal tumours, embedded, 321.
Alexander, Dr. William, President, 1905.
Paper: Adenoma ha;morrhagica of the endometrium, 345 ; in reply, 353.
Angiotribe, Downes' electro-thermic, 154.
Aseptic mouth and nose cap, 10.
Atkins, Dr. T. Gelston.
Specimens and Cases : Hystero-salpingo-o<"'phorectomy for pelvic suppuration,
44 ; for ovarian papilloma and cervical carcinoma, 46.
Eakewell, Dr. R. T. Remarks : On the Vernon Harcourt inhaler, 69.
Bell, Dr. Robert.
Remarks : On embolism after abdominal operation, 252, 253 ; pyosalpinx, 367.
Bishop, Mr. E. Slanmore.
On the prevention of ventral hernia as a sequel to abdominal section, 159 ;
in reply, 186.
Remarks: On pessaries, 147.
Bladder : Calculus formed on silk sutures, 77.
Woollen fibres as a cause of irritation of the, 14.
BONNEY, Dr. Victor. Report on Dr. Duncan's specimen of tubal pregnancy, 7.
Index to the Twentieth Volume i8j
Broad ligament : Cyst, enucleated by the vagina, 139.
Fibroma of the, 47, 48, 50, 76.
Buxton, Dr. W. Dudley.
Chloroform in surgical anaesthesia ; the Vernon Harcourt inhaler and exact
percentage vapours, 56 ; in reply, 70.
Cancer : Glandular ovarian, with fatal recurrence, 25S ; of the Fallopian tube,
336 ; combined operation for uterine, 266 ; of the corpus uteri, 342.
Clip for the peritoneum in laparotomy, 254.
Collins, Dr. E. Tenison. Remarks : On vaginal ovariotomy, 264.
Crochet hook from the abdominal cavity, 241.
Cysts : Broad ligament cyst, 139 ; dermoid ovarian, with torsion, 79 ; ovarian, in
pregnancy, 260 ; ruptured ovarian, 365 ; ovarian blood cysts, 324, 326 ;
cyst simulating femoral hernia, 13 ; tubal, 7 ; with torsion, 256 ; tubo-
ovarian, removed by posterior vaginal creliotomy, 140.
Dauber, Dr. J. H. Remarks : On pregnancy after oophorectomy, 343.
Discussions : On the Vernon Harcourt inhaler, 68 ; on pessaries and their
dangers, 142 ; on the prevention of ventral hernia, 182 ; on hemorrhagic
endometritis, 326 ; on extirpation of the uterus and vagina for prolapse, 328 ;
on adenoma hoemorrhagica of the endometrium, 350.
Duncan, Dr. William.
Cases and Specimens : Tubal pregnancy ruptured on the nineteenth day and
ten days after curettage, I; in reply, 10; fibroid uterus removed by the
vagina, 47 ; fibroid of the vaginal wall, 47 ; large myoma of the broad
ligament, 48 ; in reply, 53 ; cancerous uterus removed by the combined
operation, 266 ; in reply, 269.
Reviarks : On papilloma, 47 ; tuberculous pyosalpinx, 261.
Eclampsia, spinal subarachnoid puncture in, 84.
Ectopic gestation : Early rupture of tubal, I ; diagnosis from signs, 354.
Edge, Dr. Frederick.
Specimens and Cases : Myoma enucleated from right broad ligament, 76 ;
vesical calculus formed on silk sutures, 77 ; displaced spleen ; splenectomy,
77 ; in reply, 79 ; glandular ovarian carcinoma with early fatal recurrence,
258 ; roany-lobed myomatous uterus, 258 ; in reply, 259.
Remarks : On spinal puncture, 96 ; genital and systemic tuberculosis, 264 ;
hysterectomy for cancer, 269.
Elder, Dr. George. Specimen : Ruptured ovarian cyst, 365.
Election of officers for 1905, 356.
Examination papers for nurses, 281.
Fenwick, Dr. Bedford.
Specimens and Cases : Fibroid uterus removed for menorrhagia, 54 ; tubal cyst
with torsion of the pedicle and commencing necrosis, 256 ; ovarian disease
associated with uterine fibroids, 322 ; in reply, 325, 326 ; an unusual case
of degenerating fibroid, 354.
Remarks: On myomata of the broad ligament, 78; .sjilenectomy, 79; the
treatment- of eclampsia, 95; tuberculous pyosalpinx, 263; extirpation of
the uterus and vagina for prolapse, 329 ; on the Editor's report, 364.
184
Index to the Twentieth Volume
Fibro-cystic tumour of the uterus, 49.
Fibroma, P^ibromyoma, Myoma : Broad ligament, 47, 48, 50, 76 ; cervical, dis-
placing the bladder, 82; degenerating, 354; giant, 163; multiple, 54,
249, 258 ; submucous, 51 ; unsuccessful enucleation, 47 ; and ovarian
disease, 322, 324, 326 ; of vaginal wall, 47 ; thrombosis complicating
fibroid tumour, 252.
Gangrene of the leg after hysterectomy, 246.
Gangrenous bowel removed from a ventral hernia, 137.
Haematoma, tuberous subchorial decidual, 335.
Hemorrhagic endometritis, 270.
Harcourt, Mr. A. Vernon. Remarks : On his chloroform inhaler, 70.
Helme, Dr. T. Arthur.
Spinal subarachnoid puncture in eclampsia, 84 ; ?'« rej>ljy, 96.
Hodgson, Dr. R. H.
Remarks : On the treatment of eclampsia, 96 ; pessaries, 145 ; pain in
salpingo-oophoritis, 321 ; extirpation of the uterus and vagina for prolapse,
328 ; pyosalpinx, 367.
Hydrometra, 72.
Hydrosalpinx: Bilateral, 75; and accessory Fallopian tubes, 253.
Hystero-salpingo-oophorectomy, 44, 46.
Iodoform toxsemia, 11.
Jessett, Mr. F. Bowreman.
Specimens and Cases : Bilateral dermoid ovarian cysts with torsion of the left
pedicle, 79 ; cervical fibroid displacing the bladder, 82 ; giant myoma,
153 ; gangrene of the leg after abdominal hysterectomy, 246 ; tn rep/y,
252 ; submucous, interstial and subperitoneal myomata in a uterus re-
moved by abdominal hysterectomy, 249.
Remarks : On vaginal hysterectomy, 52 ; on Mr. Martin's specimen of
bicornuous uterus, 244 ; vaginal hysterectomy for cancer, 267 ; carcinoma
of the Fallopian tube, 338 ; precancerous conditions of the endometrium,
351-
Jordan, Mr. J. Furneaux.
Specimens and Cases : Hydrometra, 72 ; double hydrosalpinx, 75 ; double
tuberculous pyosalpinx, 260 ; cystoma of the left ovary removed without
interrupting pregnancy, 260 ; in reply, 265.
Remarks : On spinal puncture in eclampsia, 95 ; malignant ovarian growths,
259 ; Cesarean section, 343 ; hsemorrhagic endometritis, 352.
Macan, Dr. J. J., Editor. Report on the Journal of the Society, 360.
Remarks : On malignant degeneration of the stump after supravaginal hysterec-
tomy, 52 ; on abdominal suture, 185 ; on gangrene after abdominal opera-
tion, 251 ; on hysterectomy for cancer, 268 ; hemorrhagic endometritis,
.127.
Macnaughton-Jones, Dr. H.
A visit to Clinics at Ghent, Bonn and Brussels, with some remarks,
pathological and practical, 387.
On the application of pessaries and their dangers, 97.
Index to the Twentieth Volume 18$
Macnaughtox-Jones, Dr. H. — contimied.
The Downes electro-thermic angiotribe, 154 ; discussion thereon, 142 ; in
reply, 150.
Specimens and Cases : Tubal cyst, 9 ; aseptic mouth and nose cap, 10 ; strange
result of iodoform dressing, II ; accessory Fallopian tubes and their
relation to broad ligament cysts and hydrosalpinx, 253 ; weighted clip for
the cut edge of the peritoneum in abdominal section, 254 ; hsemorrhagic
endometritis, 270, 326 ; in reply, 327 ; embedded adnexal tumours, 321 ;
desquamative salpingitis, 321 ; in reply, 322 ; tuberous subchorial decidual
hsematoma, 335 ; carcinoma of the Fallopian tube, 336 ; in reply, 338.
Remarks: On the President's inaugural address, 43; papilloma of the ovary,
47 ; the pathogenesis of cystic tumours, 53 ; the Vernon Harcourt inhaler,
69 ; myomata of the broad ligament, 79 ; hydrosalpinx, 79 ; the treatment
of eclampsia, 94 ; cysts of the broad ligament, 141; giant myoma, 153;
ventral hernia, 182 ; perforation of the uterus, 244 ; artificial vagina, 245 ;
embolism after abdominal operation, 252 ; tuberculous pyosalpinx, 262 ;
ovariotomy during pregnancy, 262 ; on abdominal hysterectomy for cancer,
268 ; extirpation of the uterus and vagina for prolapse, 330 ; sterilisation
by atmocausis, 344 ; adenomatous changes in the endometrium, 350 ;
pyosalpinx, 367 ; on valedictory presidential address, 384.
Macnaughton-Jones, Dr. H., junior.
Remarks : On abdominal suture, 185 ; pain afier abdominal hysterectomy, 251.
Martin, Mr. Christopher.
On the treatment of intractable prolapse by extirpation of the uterus and
vagina, 272 ; discussion, 328 ; in reply, 334.
Specimens and Cases : Bone crochet hook removed from the abdominal cavity,
241 ; arrested development of the uterus, 242 ; of a bicornuous uterus,
243 ; in reply, 245.
Remarks: On tubal pregnancy, 10; pelvic pressure as indicating operation on
fibroids, 325.
Meetings of the Britisii Gynaecological Society: — February 11, 1904,
i; March 10, 1904, 44; April 14, 1904, 72; May 12, 1904, 137;
June 9, 1904, 153 ; July 14, 1904, 241 ; October 13, 1904, 256 ;
November 10, 1904, 321 ; December 8, 1904, 336 ; Annual General
^Meeting, January 12, 1905, 356
MoULLiN, Dr. J. A. Mansell.
Remarks: On pessaries, 147; on extirpation of the uterus and vagina for
prolapse, 328 ; ligature of the tubes, 343 ; the curette in malignant
disease, 351.
New Fellows, 188.
Nursing Examinations, 281.
Original Communications : —
A case of violent menorrhagia of puberty successfully treated with suprarenal
extract; by A. F. Tredgold, M.K.C.S., &c., 287
A visit to Clinics at Ghent, Bonn and Brussels, with some remarks, pathological
^and practical ; by 11. Macnaughton-Jones, M.D., 387.
Amenorrhoea of four years' duration following a bicycle accident ; recovery ;
by S. L. Craigie Mondy, M.R.C.S., &c., 284.
i86 Index to the Twentieth Volume
Original Communications — continued.
Belastungslagerung ; by Dr. Ludwig Pincus, 189, 290.
Deductions from the study of pelvic diseases in the female insane ; by Ernest
A. Hall, M.D., &c., 120.
Ovary : — Abscess of large size, 340 ; cyst, in pregnancy, 260 ; ruptured cyst,
365 ; disease in uterine fibrosis, 322, 326 ; glandular cancer of the, 258.
Pain after abdominal hysterectomy, 251,
Parsons, Dr. J. Inglis.
Specimens and Cases : Fibrocystic uterine tumour, 49 ; in reply, 54 ; fibroma
of the broad ligament, 50; submucous myoma, 51 ; double pyosalpinx,
366 ; tn reply, 367.
Remarks : On papilloma, 47 ; chloroform anaesthesia, 68.
Pessaries and their dangers, 97.
Pope, Dr. H. C. Remarks : On Dr. Duncan's specimen, 10.
Probe cleaner (Dr. Duke's), 326.
Publications Received, 135, 240, 318, 424.
PuRCELL, Dr. F. A.
Remarks : On vaginal hysterectomy fur cancer, 267 ; carcinoma of the
Fallopian tube, 338 ; conseivation of the ovaries, 350.
PyosalpinK : Bilateral, 366 ; bilateral tuberculosis, 260.
Reviews : —
Battle and Corner : Diseases of the Appendix Vermiformis, 411.
Cohen, Dr. S. S. : Physiologic Therapeutics, vol. vii. Mechanotherapy and
Physical Education ; by Dr. J. K. Mitchell and Dr. L. H. Gulick, 317.
Corner, Edred M., F.R.C.S., &c. : Acute Abdominal Diseases, 414.
Douglas, Dr. Richard : The Surgical Diseases of the Abdomen, 132.
Dudley, Professor E. C. : The Principles and Practice of Gynaecology (4th ed.),
406.
Edebohls, Professor George M. : The Surgical Treatment of Bright's Disease,
407.
Edgar, Professor J. Clifton: The Practice of Obstetrics, 130.
Farabreuf and Varnier : Le pratique des Accouchements, 310.
Fargas, Professor Miguel A. : Tratado de Ginecologia, 227.
Freund, Dr. Leopold : Radiotherapy for Practitioners, 315.
Hare, Dr. Hobart Amory : Progressive Medicine, vol. iv., 1903, 229.
Jellett, Dr. Henry : A Short Practice of Gynaecology (2nd ed.), 124.
Kermauner, Dr. Fritz : Anatomie der Tuben-Schwangerschaft, 311.
Macnaughton-Jones, Dr. H. : Diseases of Women (9th ed.), 416.
McKay, Mr. J. W. Stewart : The Preparation and After-treatment of Section
Cases, 422
Mandl, Dr. Ludwig : Die Biologische Bedeutung der Eierstoecke, &c., 313.
Merck, E. : Annual Report of Pharmaceutical Chemistry and Therapeutics,
1903. 239-
Montgomery, Professor G. G. : Practical Gynaecology (2nd ed.), 237.
Montprofit, Professor A. : La Gastro-Enterostomie, 235.
Owen, Edmund, F.R.C.S., &c. : Cleft Palate and Harelip, 411.
Reed, Dr. Charles A.L. : A Text-book of Gynaecology (2nd ed.), 123.
v. Rein, Professor : Twenty-five Years' Teaching Activity, 308.
hidex to the Twentieth Volume i8y
Reviews — continued.
Roberts, Dr. C. Hubert, and Dr. Max L. Trechmann : Translation of
Orthman's Gyncecological Pathology, 129.
Schaefter, Dr. Oscar : Atlas of Operative Gynaecology (Translated by Dr. C.
Webster), 231.
Schauta and Hitschmann : Tabuloe Gyniscologica;, 420.
Sellheim, Dr. Hugo : Der Normale Situs der Organe im Werblichen Becken,
233-
Stacpoole, Miss Florence : Ailments of Women and Girls, 239.
Stoeckel, Dr. Walter: Die Cystoscopie des Gynaekologen, 314.
Stoeltzner, Dr. Wilhelm ; Pathologic und Therapie der Rachitis, 134.
Williams, Mr. W. Roger : V^aginal Tumours, 125.
V. Winckel, Professor Franz Ritter : Handbuch der Geburtshuelfe, 225.
Winter, Dr. Georg : Die Bekaempfung des Uteruskrebses, &c., 126.
ROBSON, Mr. Mayo. Remarks : On the Vernon Harcourt inhaler, 68.
RouTH, Dr. C. H. F.
Remarks: On pessaries, 144; giant myoma, 153; hsemorrhagic endometritis,
352.
Ryall, Mr. Charles.
Specimens and Cases : (For Mr. Jessett) giant myoma, 153 ; in reply, 154.
Re/narks : On drainage by the vagina, 53 ; on ventral hernia, 184 ; on
gangrene after hysterectomy, 250 ; on hysterectomy for cancer, 268, 269 ;
hsemorrhagic endometritis, 327 ; on the Editor's report, 364.
Salpingitis, desquamative, 321.
ScHARLiEB, Mrs. M. A. D., M.D.
Remarks : On thrombosis complicating fibroid of uterus, 252 ; malignant
ovarian growths, 259.
Slimon, Dr. V/. H., Treasurer. Report and balance sheet, 1904, 358, 359.
Smith, Dr. Heywood.
Specimens : Sloughing tumour in a fibroid uterus with an ovarian blood cyst,
326 ; (for Dr. Alexander Duke) a device for removing wool from Playfair's
probe, 326.
Remarks: On the President's inaugural address, 43; displaced spleen, 78;
Dr. Macnaughton-Jones's paper on pessaries, 119, 142 ; abdominal hernia,
140 ; perforation of the uterus, 243 ; embolism after abdominal operations,
251 ; accessory Fallopian tubes, 254 ; new uterine mop, 255 ; the sound
in diagnosis, 267 ; hysterectomy for ovarian disease, 321 ; ligature of the
tubes, 343 ; hemorrhagic endometritis, 352 ; on the Editor's report, 364.
Smith, Dr. Richard T.
Case: Ectopic gestation, 354.
Remarks : On gangrene after abdominal operation, 251.
Snow, Dr. Herbert.
Specimens and Cases : Cyst simulating femoral hernia, 13.
Remarks : On tubal pregnancy, 9 ; on pessaries, 144 ; on the sound in uterine
cancer, 268.
Spanton, Mr. W. D.
One of the causes of bladder irritation in girls, 14.
Remarks : On closing the abdominal wound, 10.
i88 Index to the Twentieth Volume
Spinal puncture in eclampsia, 84.
Splenectomy of the displaced organ, 77.
Taylor, Professor John W. , President.
Inaugural address : The diminishing bitth-rate and what is involved by it,
18.
Valedictory address : Twenty years' operative gynaecology, 368.
Specimens and Cases : A loop of gangrenous bowel successfully removed from
a strangulated hernia of an abdominal cicatrix, 137 ; broad ligament cyst
enucleated by the vagina, 139 ; tubo-ovarian cyst removed by posterior
vaginal coeliotomy, 140 ; in reply, 141 ; Fallopian tubes ligatured twice
at previous operations, and removed at a third Caesarean section, 338 ;
large abscess of the ovary, 340 ; cancers of the body of the uterus, 342.
Remarks : On tubal pregnancy, 9 ; vote of thanks for his inaugural address,
43 ; Dr. Atkins's operations, 47 : enucleation, 52 ; vaginal myomata, 52 ;
welcome to %asitors, 68 ; Dr. Helme's paper, 94 ; pessaries, 148 ; giant
myoma, 153; on ventral hernia, 1S5; genital and systemic tuberculosis,
265 ; vaginal ovariotomy, 265 ; on the lateral incision in vaginal hysterec-
tomy, 268 ; the uterus in adnexal disease, 322 ; ovarian blood cysts
associated with uterine myoma, 324 ; extirpation of the uterus and vagina
for prolapse, 331 ; adenoma of the endometrium, 352.
Tuberculosis, genital and general, 263.
Tubes : Accessory Fallopian, 253 ; cancer of Fallopian, 336 ; tubal cyst, 7 ;
with torsion, 256 ; unoccluded by ligature, 338.
Tubo-ovarian cyst removed by posterior colpotomy, 140.
Uterine mop (Dr. Aarons), 255.
Uterus : Arrested development of the, 242 ; bicornuous, 243 ; and vagina
extirpated for prolapse, 272.
Vaginal ovariotomy, 260.
Ventral hernia after abdominal section, 159.
Vesical calculus formed on silk sutures, 77.
LIST OF
OFFICERS, COUNCIL & FELLOWS
OF THE
BRITISH GYNECOLOGICAL SOCIETY,
1905.
t
1905.
LIST OF OFFICERS AND COUNCIL
OF THE BRITISH GYNECOLOGICAL SOCIETY.
Honorary President.
R. Barnes, M.D., F.R.C.P., Eastbourne.
President.
William Alexander, M.D., M.Ch., F.R.C.S., Liverpool.
Vice-Presidents .
E Stanmore Bishop, F.R.C.S., Manchester.
Bedford Fenwick, M.D., M.R.C.P., London.
F. BowREMAN Jessett, F.R.C.S., London.
R. P. Ranken Lyle, B.A., M.D., B.Ch., Newcastle-on-Tyno.
Sir A. V. Macan, M.A., M.B., M.Ch., M.A.O., F.R.C.P.,
Dubhn.
J. J. Macan, M.A., M.D., London.
H. Macnaughton-Jones, M.D., F.R.C.S.L, London.
Christopher Martin, M.B., CM., F.R.C.S., Birmingham.
J. A. Mansell Moullin, M.A., M.B., M.R.C.P., London.
Thomas Oliver, M.A., LL.D.. M.D., F.R.C.P., Newcastle-
on-Tyne.
Heywood Smith, M.A., M.D., M.R.C.P., London.
W. Dunnett Spanton, F.R.C.S., Hanley.
Hon. Treasurer.
W. H. Slimon, M.D., CM.. F.F.P.S., London.
Council.
T. Gelston Atkins, B.A., M.D., M.Ch., Cork.
N. T. Brewis, M.B., CM., F.R.C.P., F.R.C.S., Edinburgh.
G. Roe Carter, M.R.CP.L, London.
Sir J. Halliday Croom, M.D., F.R.S.E., Edinburgh.
William Duncan, M.D., M.R.CP., F.R.C.S., London.
F. Edge, M.D., M.R.CP.. F.R.C.S., Wolverhampton.
George Elder, M.D., CM., Nottingham.
T. J. English, M.D., London.
J. H. Ferguson, M.D., F.R.C.P., F.R.C.S., Edinburgh.
Clement Godson, M.D., M.R.CP., London.
Arthur Helme, M.D., M.R.CP., Manchester.
Professor R. J. Kixkead, A.B., M.D., Galway.
J. Macpherson Lawrie, M.D., Weymouth.
Samuel Lloyd, M.D., London.
John Padman, M.R.C.S., London.
Professor Ernesto Pestalozza, M.D., Florence.
J. J. Redfern, M.A., M.D., M.Ch., M.A.O., Croydon.
Charles Ryall, F.R.C.S., London.
R. T. Smith, M.D., M.R.C.P., London.
J. H. SwANTON, M.A., M.D.. M.Ch., M.R.C.P.. London.
Professor J. W. T.\ylor, M.Sc, M.D., F.R.C.S., Bir-
mingham.
W. Travers, M.D., F.R.C.S., London.
H. F. Vaughan-Jackson, M.R.C.S.. L.R.C.P., Potter's Bar.
Hugh Woods, B.A.. M.D.. B.Ch., M.A.O., London.
Editor of the Journal. fl
J. J. Macan, M.A., M.D.
Assistant Editor.
J. H. SwANTOx, M.A., M.D., M.R.C.P.Lond.
Hon. Secretaries.
S. Jervois Aarons, M.D., CM., M.R.C.P.
Smallwood Savage, M.A., M.B., B.Ch., F.R.C.S.
Trustees of the Property of the Societx.
G. Granville Bantock, M.D., F.R.C.S.
R. S. Fancourt Barnes, M.D., F.R.S.E.
Clement Godson, M.D., M.R.C.P.
Auditors.
C. H. Bennett, M.D.
F. A. PURCELL, M.D.
PAST PRESIDENTS OF THE SOCIETY.
1885 Alfred Meadows, M.D., F.R.C.P.
1886 Lawson Tait, F.R.C.S.
1887 G. Granville Bantock, M.D., F.R.C.S.Edin.
1888 Arthur W. Edis, M.D., F.R.C.P.
1889 Sir Arthur V. Macan, M.B., F.R.C.P.I.
1890 C. H. F. RouTH, M.D., M.R.C.P.Lond.
1891 W. Chapman Grigg. M.D., M.R.C.P.Lond. .
1892 Alexander Russell Simpson, M.D., F.R.C.P.
1893 Frederick Bowreman Jessett. F.R.C.S.Eng.
1894 Thomas Savage, M.D., F.R.C.S.Eng.
1895 Clement Godson, M.D., M.R.C.P.
1896 Clement Godson, M.D., M.R.C.P.
1897 A. W. Mayo-Robson, F.R.C.S.
1898 H. Macnaughton-Jones, M.D., F.R.C.S. I.
1899 H. Macnaughton-Jones, M.D., F.R.C.S. I.
1900 W. J. Smyly, M.D., F.R.C.S. I.
1901 J. A. Mansell Moullin, M.A., M.B., M.R.C.P.
1902 Sir J. Halliday Croom, M.D., F.R.S.E.
1903 Heywood Smith, M.A., M.D., M.R.C.P.
1904 John William Taylor, M.Sc, M.D., F.R.C.S.Eng.
STANDING COMMITTEES.
Executive Committee.
The President )
The Treasurer i- ex-officio.
The Secretaries J
William Duncan, M.D.
F. Bowreman Jessett, F.R.C.S.
H. Macnaughton-Jones, M.D.
J. A. Mansell Moullin, M.A., .M.B.
Heywood Smith, M.A., M.D.
Hugh Woods, B.A., M.D., M.A.O.
Journal and Finance Committee.
The President 1
The Treasurer i
The Editor - ex-officio.
The Assistant Editor ,
The Secretaries I
Bedford Fenwick, M.D.
Charles Ryall, F.R.C.S.
The Treasurer, Convener.
Pathological Committee.
S. Jervois Aarons, M.D.
H. OvERY, M.B., F.R.C.S.
Alexander Paine, M.D.
Referees of Papers for the Year 1905.
William Duncan, M.D.
G. Elder, M.D., Nottingham.
F. BowREMAN Jessett, F.R.C.S.; London.
J. Inglis Parsons, M.D., London.
R. D. Purefoy, M.D., Dublin.
Charles Ryall, F.R.C.S.
A. R. Simpson, M.D., Edinburgh.
Heywood Smith, M.D., London.
R. T. Smith, M.D., London.
Honorary Local Secretaries.
John W. Byers, M.D., Belfast.
Murdoch Cameron, M.D., Glasgow.
F. J. Clendinnen, M.D., Melbourne.
E. Tenison Collins, M.R.C.S., Cardiff. f
George Elder, ]\I.D., Nottingham.
B. McE. Emmet, New York, U.S.A.
F. W. N. Haultain, M.D., Edinburgh.
Henry Jellett, M.D., Dublin.
J. A. Lycett, M.D., Wolverhampton.
R. P. Ranken Lyle, M.D., Newcastle-on-Tyne.
Christopher Martin, M.B., F.R.C.S., Birmingham.
James Metcalfe, M.D., Bradford.
W. H. C. Newnham, M.B., M.R.C.S., Bristol.
C. Yelverton Pearson, M.D., Cork.
James F. W. Ross, M.D., Toronto.
A. Lapthorn Smith, M.D., Montreal.
E. S. Stevenson, M.D., Cape Town.
William Walter, M.D., Manchester.
Ralph Worrall, M.D., Sydney.
British GyntTCological Society vii
THE BRITISH GYNECOLOGICAL SOCIETY.
Founded 1884. Ixcorporated 1885.
List of Abbreviations.
H.P., Honorary President. Hon. Sec, Honorary Secretary.
Pres., President. Hon. Loc. Sec, Honorary Local
V.-P., Vice-President. | Secretary.
C, Council. ' F.F., Foundation Fellow.
Libr., Librarian. L., Life Fellow.
Treas., Treasurer.
Those marked with an asterisk (*) have not communicated their
address.
Those marked with a dagger (t) are on the list of Resident
Fellows, or are non-Resident Fellows who have intimated their wish
to receive Agenda Notices of the Ordinary Meetings.
HONORARY FELLOWS.
1885 Emmett, Thomas Addis, M.D., New York.
1885 Hegar, a., M.D., Freiburg i. B.
1885 KoEBERLE, F., M.D., Strasbourg.
1885 Martin, A., M.D.. Berlin.
1885 V. WiNCKEL, F., M.D., Municli.
1887 Barnes, Robert, M.D., London.
1891 Pozzi, S., M.D., Paris.
1893 Kufferath, E., M.D., Brussels.
1898 Leopold,. Georges, M.D., Dresden.
1895 Atthill, Lombe, M.D., Dublin.
1899 Kelly, Howard A., M.D., Baltimore.
1899 Schauta, Frederic, M.D.. Vienna.
1900 Savage, Thomas, M.D., Birmingham.
1900 Doyen, Edward, M.D., Paris.
1901 RouTH, Charles Henry Felix, M.D., London.
1901 Schultze, Bernhard Sigmund, M.D., Jena.
1902 Zweifel, Paul, M.D., Leipsic.
1903 V. Rein, G., M.D., St. Petersburg.
1903 Snegirev, Vladimir Fedorovic, M.D., Moscow.
1903 Mangiagalli, Luigi, M.D., Pa via.
1903 Morisani, Ottavio, M.D., Naples.
1903 Jacobs, C, M.D.. Brussels.
viii List of Fellows of the
HONORARY FELLOWS DECEASED.
1885-1895 Keith, Thomas, M.D., London.
1885-1902 Lazarewitch, J., M.D., St. Petersburg.
1885-1902 PoRRO, S., M.D., Milan.
1887-1899 Tait, Lawson, F.R.C.S., Birmingham.
1885-1901 Harvey, Robert, M.D., Calcutta.
1885-1897 Tarnier, S., M.D., Paris.
1885-1903 Thomas, T. Gaillard, M.D., New York,
ORDINARY FELLOWS, 1905.
Elected
1899 fAARONS, S. Jervois, M.D., C.M.Edin., M.R.C.P.
Lond., Pathologist and Curator of Museum.
Hospital for Women, Soho, 14, Stratford
Place, w. Hon. Sec. 1903-5.
1888 L. Adam, G. Rothwell, M.B., CM., Carlton House,
Hotham East Street, Melbourne, Victoria.
F.F. fADAMS, Joseph, M.B., C.M.Edin., 93, Bewsey
Street, Warrington, Lancashire.
1888 Aiken, George Henry, M.D., Fresno, California.
F.F. fALEXANDER, WiLLiAM, M.D., F.R.C.S.Eng., 31,
Rodney Street, Liverpool.
C. 1887-9 & 1900-2. V.P. 1890-2. Pres. 1905.
F.F. Allan, James, M.D.Aberd., D.P.H.Camb., Medical
Superintendent, Union Infirmary, Leeds.
1896 *Allen, Henry Marcus, F.R.C.P.Edin., M.R.C.S.
1902 Anderson, Daniel Elie, M.D.Paris, M.B., B.A.,
B.Sc.Lond., &c., 121, Avenue des Champs
Elysees, Paris.
1898 tAPPLEBE, E. A., L.R.C.P.Edin., L.F.P.S.G., i,
Southgate Road, Winchester.
1885 tARMSTRONG, WiLLiAM, M.R.C.S.Eng., Thornchffe,
Hartingdon Road, Buxton.
C. 1897-9. V.-P. 1900-2.
1903 *Arnold, Samuel Carnelly, M.B., C.M.Edin.
1898 Atkins, Thomas Gelston, M.A., M.D., R.U.I.,
Surgeon Cork County Hospital, and Co. and
City of Cork W^omen's and Children's Hospital.
20, St. Patrick's Place, Cork. C. 1905.
1905 Atkins, T. Webster. L.R.C.P., L.R.C.S.Edin.,
L.F.P.S.Glasg., 31, Shepherd's Bush Road, w.
British Gyncecological Society ix
Elected
1898 Bagnell, William Harry, L.R.C.S.I., L.R.C.P.
Edin., Officier de Sante Bordeaux, 4, Rue de
Perpigna, Pau, France.
1889 Bagot, William S., M.D.Dub., L.R.C.S.I., Gynae-
cologist to St. Luke's Hospital, Denver,
402-404, Opera House Block, Denver,
Colorado, U.S.A.
1888 L. Baker, Clarence Attwood, M.D., 312, Congress
Street, Portland, Maine, U.S.A.
1885 L. Baker, William Henry, M.D., Professor of
Gynaecology Harvard University, Surgeon to
the Free Hospital for Women, Boston, 22,
Mount Vernon Street, Boston, Mass., U.S.A.
1898 fBAKEWELL, Robert Turle, M.B.Lond., 27, Wel-
beck Street, Cavendish Square, w.
1903 *Baldwin, W. W., M.D., New York, U.S.A.
1904 Bale, Rosa Elizabeth, L.R.C.P. & S.Edin., 24,
Portland Square, Plymouth.
1887 Balleray, G. H., M.D., 240, West 72nd Street,
New York, U.S.A.
F.F. L. fBANTOCK, G. Granville, M.D., F.R.C. S.Edin.,
Consulting Surgeon to the Samaritan Free
Hospital, 14, Upper Hamilton Terrace, n.w.
Trustee. Pres. 1887. V.-P. 1884-6 &
1887-9. Treas. 1888-90. C. 1891-3.
Libr. 1894-6.
F.F. L. tBARBOUR, x\. H. Freeland, M.A., B.Sc, M.D.,
Assistant Obstetric Physician Royal Infirmary,
Edinburgh, 4, Charlotte Square, Edinburgh.
C. 1884-8 & 1901-3. V.-P. 1893-5.
F.F. L. fBARNES, Robert, M.D., F.R.C. P., Consulting
Obstetric Physician to St. George's Hospital,
Consulting Physician to the Royal Maternity
Charity, &c., &c., Bernersmede, Eastbourne.
Hon. Pres. 1884-1905.
F.F. fBARNES, R. S. Fancourt, M.D., M.R.C.P.,
F.R.S.E., Physician to the British Ljdng-in
Hospital, and the Royal Maternity Charity,
15, Chester Terrace, Regent's Park, n.w.
Trustee. Editor 1884-1891. Hon.- Sec.
1884-6. V.-P. 1887-9 & 1892-4.
List of Felloivs of the
Elected
1899 fBARRETT, James Franxis, M.B., B.Ch., R.U.I.,
Edburga House, The Bank, Highgate.
1886 L. Barrington, Fourness, M.B., F.R.C.S.Eng., 213,
Macquarie Street, S^^dney, Australia.
1885 L. Batchelor, Ferdinand Campion, M.D.Durh.,
M.R.C.S.Eng., L.R.C.P.Edin., Lecturer on
Midwifery and Gynaecology University of
' Otago, George Street. Dunedin, New Zealand.
V.-P. 1893-5.
F.F. L. fBAYFiELD, Horace Osborne, L.R.C.P.Edin.,
L.F.P.S.Glasg., Tracadie, Merton Road, Wim-
bledon, s.w.
1903 Beatton, Gilbert Taylor, M.D.Edin., The Cliff,
Bradford, Yorks.
1892 Beckwith, Frank E., M.D., 139, Church Street,
New Haven, Conn., U.S.A.
F.F. fBELL, Robert, M.D., F.F.P.S.Glasg., Physician to
the Glasgow Institute for Diseases of Women
and Children, 15, Half ]Moon Street, Picca-
dillv, w. C. 1885-7. V.-P. 1891-3.
1898 tBELLis, Edward, L.R.C.P., L.R.C.S.L, 81, HoUand
Park Avenue, Notting Hill, w.
F.F. fBENNETT, Charles Henry M.D., M.R.C.S., L.S.A..
College House, Hammersmith, w.
V.-P. 1895-7. Auditor 1895-1905.
C. 1892-4.
190/f Bernard, Claude Abel, ]\I. D.Bordeaux, Roc
Maria. Dinard, Brittanv, France.
F.F. IBertolacci, John Hewetson, L.S.A., Elstead,
Godalming.
1903 Bielby, Miss Elizabeth. M.D.Berne, L.M. and
L.R.C.P.L, Lahore, India.
1886 fBiGGS, Moses G., M.R.C.S., loi, Northcote Road,
New Wandsworth, s.w.
1903 BiRTWELL, Daniel, L.R.C.P., L.R.C.S.Edin., Dur-
ban, Natal.
1898 fBiSHOP, Edward Stanmore, F.R.C.S.Eng.,
L.R.C.P.Edin., Surgeon to the Ancoats Hos-
pital, 189, High Street, Manchester.
V.-P. 1903-5. C. 1901-2.
F.F. L. fBLAKE, Edward, !M.D.. Berkeley Mansions, 64,
Seymour Street. Hyde Park, w.
British Gyncsco logical Society xi
1898 fBLAKisTON, Aubrey, L.R.C.P., L.R.C.S.Edin.. 5,
Grosvenor Street, Grosvenor Square, w.
1901 BoDDEART, Eugene, M.D., Rue Guilliaume Tell 36,
Ghent, Belgium.
1890 L. BoLDT, H. J., M.D., 39, East 6ist Street, New
York.
1903 Bossi, Professor L. M., Director oi the Obstetrical
and Gynaecological Clinic, Via Assaroti 20,
Int. ii., Genoa.
1891 fBouRKE, W. H., M.D., 8, Moreton Gardens, s.w.
C. 1900-2.
1887 fBouRNS, N. Whitelaw, M.D.Brux., M.R.C.S.Eng.,
L.R.C.P.Edin., 78, Redcliffe Gardens, South
Kensington, s.w. C. 1899.
1887 tBowiE, Alex., M.D., CM., 4, Hertford Street,
Park Lane, w.
1885 L, Boyd, Jam^s P., M.D., Professor of Obstetrics and
Gynaecology Albany Medical College, 152,
Washington Avenue, Albany, New York,
U.S.A.
1887 Boyd, J. St. Clair. M.D.. M.Ch.. B.A.O., R.U.I..
27 Victoria Place, Belfast.
1903 Brandt, John Egerton, B.A.Camb., M.D.Edin.
and Paris, Royat, Pu}' de Dome (summer),
and Nice, France (winter).
1891 tBREWis, N. T., M.B., CM., F.R.CP.Edin., Assist-
ant Gynaecologist to the Royal Infirmary,
23, Rutland Street, Edinburgh. C 1905.
1893 t^RiDGER, Adolphus E., M.D., F.R.CP.Edin.,
Physician St. Pancras and Northern Dis-
pensary, 18, Portland Place, w.
1899 fBROWN, John Henry, M.D.Edin., M.R.C.S., 14,
Burngrave Road, Sheffield.
1896 *Browne, Ralph Henry, M.D., M.R.C.S., L.R.C.P.
Lond.
1889 L. Brownlee, Milne, M.D., Woodstock, Ontario,
Canada.
1903 tBucKLEY, Samuel, M.D.Lond., M.R.C.P., F.R.C.S.,
72, Bridge Street, Manchester.
1885 L. Budin, Pierre, M.D., Professeur agrege a la
faculte de Medecine de Paris. x\ccoucheur de
la Charite, 4, Avenue Hoche, Paris.
xii List of Fellows of tJie
Elected
1903 *BuLL, Ralph Antony, L.R.C.P., L.R.C.S.Edin.
1892 BuMM, Ernest, M.D., Professor of Obstetrics and
Gyngecology in the Universit}^ of Berlin, Her-
warthstrasse, 5, Berlin, N.w., Germany.
1887 fBuRFORD, George Henry, M.B., C.M.Aberd., 35,
Queen Anne Street, w.
1898 tBuRKE, Patrick Joseph, M.D., M.Ch., M.A.O.,
R.U.I., 23. Long Lane, Borough, s.e.
F.F. L. fBuxTON, Dudley Wilmot, M.D., B.S., M.R.C.P.
Lond., Anaesthetist to University College Hos-
pital, 82, Mortimer Street, Cavendish Square,
w. C. 1895-7.
1885 tBvKRS, John William, M.A., M.D., M.Ch., R.U.L,
M.R.C.S.E., L.M., R.C.P.L, Professor of Mid-
wifery and Diseases of Women and Children,
Queen's College, Belfast, and Physician for
Diseases of Women to the Royal Hospital,
Belfast, Lower Crescent, Belfast.
Hon. Loc. Sec. C. 1893-5. V.-P. 1896-8.
1894 Byford, Henry T., M.D., 100, State Street,
Chicago, 111., U.S.A.
1904 C.A.LDERINI, Giovanni, M.D.Bologna, Professor of
Midwifery, Bologna, Italy.
F.F. fCAMBRiDGE, Thomas Arthur, M.R.C.S.Eug.,
L.S.A., Stanley Lodge, Waltersville Road,
Upper Hornsey Rise, n.
C. 1887-9. V.-P. 1890-2.
1887 Cameron, J. C, M.D., Professor of Midwifery
McGill University, 941, Dorchester Street,
Montreal.
1895 -fCAMERON, Murdoch, M.D., Regius Professor of
Midwifery and Diseases of Women in the
University of Glasgow. 7, Newton Terrace,
Glasgow.
Hon. Loc. Sec. C. 1899-1901. V.-P. 1902-4.
1898 fCAMERON, William John, M.B.Lond., EUerslie,
Balham Park Road, s.w.
1904 fCAMPBELL, Ernest Alexander, L.R.C.P. «& S.
Edin., L.F.P.S.Glas., 25, Bow Road, e.
British Gyucecological Society xiii
Elected
1894 fCAMPBELL. John, M.A., M.D., M.Ch., M.A.O.,
R.U.I., F.R.C.S.Eng., Senior Physician Samari-
tan Hospital for Women, Belfast, Crescent
House, University Road, Belfast.
C. 1899-1901. V.-P. 1902-3.
1902 Campbell, Malcolm, M.A., M.D., CM., F.R.C.S.
Edin., 17, Walker Street, Edinburgh.
F.F. fCAMPBELL, William Frederick, L.R.C.P.Edin.,
L.F.P.S.Glasg., 67, Bentham Road, South
Hackney.
1892 Cannaday, C. G., M.D., Roanake, Virginia, U.S.A.
1886 L. Carstens, J. Henry. M.D., Detroit, Michigan,
U.S.A.
1891 fCARTER, Arthur Joseph, M.R.C.S., 75, Shepherd's
Bush Road, w.
F.F. tCARTER, George Roe, M.R.C.P.I., L.R.C.S.L,
Oakhurst, 2, Anerley Park, s.e.
C. 1899-1901 & 1903-5.
1 901 tCARTON, Paul, M.D., B.Ch., B.A.O.Dub., 35, Rut-
land Square, Dublin.
1898 fCARWARDiNE, Thomas, M.S.Lond., F.R.C.S.Eng.,
16, Victoria Square, Clifton, Bristol.
F.F. fCASE, William, M.R.C.S., U.S.A., Denmark House,
Caister-on-Sea, Norfolk.
1895 IChambers, Eber, M.D.Aberd., M.R.C.S., District
Medical Ofhcer City of Uondon Uying-in Hos-
pital, I, Wilmington Square, w.c.
C. 1902. V.-P. 1903.
1885 U. Chambers, P. Flewellen, M.D., 26, West Forty-
seventh Street, New York, U.S.A.
1898 fCHEETHAM, SYDNEY WiLLIAMS, M.R.C.S., L.R.C.P.
Lond., 233, Romford Road, e.
1892 Cheney, Benjamin Austin, M.D., 40. Elm Street,
New Haven, Connecticut, U.S.A.
1898 Chestnut, Henry,L.R.C. P., L.R.C.S. Edin., Iralee,
Co. Kerry, Ireland.
1898 Chestnutt, John, B.A., R.U.L, L.R.C.S., L.R.C.P.,
Derwent House, Howden, East Yorkshire.
1904 Chipman, Walter William, M.D., F.R.C.S. Edin.,
Assistant Gynaecologist Ro3^al Victoria Hos-
pital, Montreal. Lecturer in Gynaecology,
McGill University, Montreal, Canada.
xiv List of Felloivs of the
Elected
1904 Clark, Ann Elizabeth, M.D.Berne, M.R.C.P.I.,
L. & L.M., 4, Calthorpe Road, Edgbaston,
Birmingham.
1895 fCLARK, Tom, L.R.C.P. & L.R.C.S.Edin., i, West-
burn Street, Eaton Square, s.w.
1887 L. fCLARK, Thomas Kilner, M.A., M.D.Camb.,
F.R.C.S.Eng., Surgeon Huddersfield Infirmary,
66, John WilHam Street, Huddersfield,
C. 1895-7.
1898 *Clarke, Joseph John, L.R.C.P. I.
1898 fCLARKE, Richard Ashmore, L.R.C.P., L.R.C.S.L,
Surgeon to Teddington Cottage Hospital,
Goudhurst, Teddington.
1896 fCLAYTON, Charles Hollingsworth, M.R.C.S.,
L.R.C.P., 10, College Terrace, Belsize Park,
N.W.
F.F. L. Clendinnex, Frederick John, L.R.C.P.Lond.,
L.R.C.P., L.R.C.S.Edin., 465, Malvern Road,
Hawksburn, Melbourne, Australia.
Hon. Log. Sec.
1899 CoATES-CoLE, J. M., M.R.C.S., L.R.C.P., Mara-
caibo, Venezuela, S. America.
1904 fCoHEN, Rachel, M.B., Calcutta. F.R.C.S.L, 9
Powis Square, Bayswater, w.
1903 Cole-Baker, Lyster, M.D., B.Ch., B.A.O.Dub.,
Bayfield, Kent Road, Southsea.
1893 tCoLENSO, Robert J., M.A., M.D.Oxon., M.R.C.S.,
7A, Emperor's Gate, s.w. C. 1902-4.
1890 fCoLLiNS, E. Tenison, M.R.C.S., L.S.A., Gynae-
cologist to Cardiff Infirmary, 12, Windsor
Place, Cardiff. Hon. Loc. Sec. C. 1896-8.
1903 Cook, James William, M.B., C.M.Aberd., 26,
Manchester Road, Bury, Lancashire.
1903 Cook, John R., M.D., Fairmont, W. Virginia,
U.S.A.
F.F. L. CoRDES, AuGUSTE E., M.D.Paris, M.R.C.P.Lond.,
Privat-Docent of Midwifery, ex-chirurgien
adjoint a la Maternite, 12, Rue Bellot, Geneva.
V.-P. 1897-9.
1900 fCoRRiGAN, William Jenkinson, F.R.C.S.L,
L.R.C.P. I., L.M., Cloughmore, Splott Avenue,
Cardiff.
British Gyncrcological Society xv
Elected
1900 fCowEN, Richard John, L.R.C.P.I., L.M.,
L.R.C.S.I., L.M., 15, Half Moon Street.
Piccadilly, w.
1898 fCRABBE, John Sandison, L.R.C.P., L.R.C.S.Edin.,
Dundallen, Gravelly Hill, near Birmingham.
1895 Craig, William Bedford, M.D., Visiting Gynae-
cologist to St. Luke's and St. Joseph's Hos-
pital, Denver, and Professor of Gynaecology
in the University of Denver Medical Depart-
ment, 122, East Sixteenth Avemie, Denver,
Colorado, U.S.A.
1900 ICrampton, Thomas Hobbes,L.R.C.P.I.,L.R.C.S.I.,
L.M., 30, Myddleton Square, e.g.
1886 fCRESSWELL, Pearson Robert, F.R.C.S.Edin.,
C.B., Surgeon Merthyr General Hospital, &c.,
Dowlais, Merthyr Tydvil.
1888 fCRisP, Ernest Henry, B.A.Camb., L.R.C.P.,
M.R.C.S., 43, Fenchurch Street, e.g.
1891 *Cromie, John, L.R.C.P., L.R.C.S.Edin.
1891 fCROOM, Sir John Halliday, M.D., F.R.C.P.Edin.,
F.R.C.S.Edin., F.R.S.E., Consulting GyucC-
cologist to the Royal Infirmary, Consulting
Physician to the Ro^^al Maternity Hospital,
and Lecturer on Midwifery and the Diseases
of Women at the School of the Royal Colleges,
Edinburgh, 25, Charlotte Square, Edinburgh.
C. 1884-6 & 1903-5. V.-P. 1887-9.
President 1902.
iQOi Cullen, Thomas. M.D., Gynaecologist to the
Johns Hopkins Hospital, 3, West Preston
Street, Baltimore, U.S.A.
1898 Gumming, George William Hamilton, M.D.
Durh., M.R.C.S., L.R.C.P., Annandale, Tor-
quay, S. Devon.
1895 fDAUBER, John H., M.A., M.B., B.Ch.Oxon.,
Assistant Physician Hospital for Women,
Soho, 29, Charles Street, Berkeley Square, w.
C. 1900-1.
F.F. fDAviES, Ellis Thomas, M.D., Hon. Surgeon
Samaritan Free Hospital for Women, Liver-
pool, I, St Domingo Grove, Liverpool.
C. 1901-3.
xvi List of Fellows of the
Elected
1900 fDAviES, John Stanley, M.B., C.M.Glasg., 262,
Queen's Road, New Cross.
i8q7 *Delamotte, Peter William, M.R.C.P.Edin.,
M.R.C.S.E.
1904 Dempsey, Alexander, M.D.. R.U.L., L.R.C.S.I.,
36, Clifton Street, Belfast.
1887 L. Dewes, Frederick Joseph, L.R.C.P.Lond.,
M.R.C.S.E., .Surgeon-Captain Madras Army,
c/o Messrs. A. Scott & Co., Rangoon, India.
F.F. L. tDiNGLE, William Alfred, M.D.St. And., L.R.C.P.
Lond., M.R.C.S.Eng., L.S.A., Surgeon Royal
Maternity Charity, 46, Finsbury Square,
E.G. " C. 1889-91. V.-P. 1892-4.
1888 L. Dirner, Gustav, M.D., 9, Kossuth Utoxa, Buda
Pesth, Hungary.
F.F. fl^ixoN, William Edward, L.R.C.P., F.R.C.S.
Edin., M.R.C.S., Oulton Lodge, Oulton Broad,
Lowestoft.
1891 Dodd, Tho]^l\s Antony, M.R.C.S.Eng., L.R.C.P.
Edin., 4, Eldon Square, Newcastle-on-Tyne.
1898 fDoDswoRTH, Frederick Charles, L.R.C.P.,
M.R.C.S., Ingleden House, Gunnersbury.
F.F. fDoLAN, Thomas M., M.D.Durh., F.R.C.S.Edin.,
Horton House, Halifax, Yorkshire.
C. 1886-8, 1892-4 & 1902-4. V.-P. 1889-91.
1898 fl^ON, William Walton, M.D.Glasg., 466, Edg-
ware Road, w.
1895 fDoNALD, Archibald, M.A., M.D.Edin., M.R.C.P.
Lond., Obstetric Physician Royal Infirmary,
Manchester, Piatt Abbey, Rusholme, Man-
chester. C. 1897-9.
1897 fDoNALD, Hugh Colligan, M.B., C.M.Glasg., 5,
Gauze Street, Paisley.
1898 fDoNovAN, William, M.D.Durh., L.R.C.P. & S.
Edin., " Glandore," Erdington, Birmingham.
1889 L. Douglas, Richard. M.D., no, S. Spruce Street,
Nashville, Tennessee, U.S.A.
1896 fDowNES, Joseph Lockhart, M.B., C.M.Glasg.,
269, Romford Road, e.
1898 t^RAKE, A. Thomson, M.B., R.U.I., 160, Lewisham
High Road, s.e.
British GyncECO logical Society x\'ii
Elected
F.F. L. fDRAPER, James William, L.R.C.P.Lond., M.R.C.S.
Eng., L.S.A., Almondbury, Hiidderslield.
1885 L. Dudley, Emilius Clark, A.B., M.D., Professor
of Gynaecology Chicago Medical College, 1617,
Indiana Avenue, Chicago, U.S.A.
1905 fDuKE, Alexander, F.R.C.P.I., L.R.C.S.I., L.M.,
162, Gloucester Terrace, Hyde Park, w.
1902 Duncan, William, M.D., M.R.C.P., F.R.C.S.,
Obstetric Physician and Lecturer on Obstetric
Medicine Middlesex Hospital, Senior Physi-
cian Chelsea Hospital for Womea, 6, Harley
Street, w. C. 1904-5.
F.F. *DuNDAS, MoRDAUNT George, M.R.C.S., L.S.A.
1896 fDuTCH, Henry, M.D.Brux., L.R.C.P.Lond., 8,
Berkeley Square, w.
1891 fEASTES, Thomas, M.D., F.R.C.S., 18, Manor
Road, Folkestone. C. 1897-1900.
1890 EccLES, F. R., M.D., Professor of Gynaecology at
the Western University, Ellwood Place,
London, Ontario, Canada.
1894 Edge, Frederick, M.D., B.S., B.Sc.Lond.,
M.R.C.P.Lond., F.R.C.S.Eng., Surgeon to the
Wolverhampton Hospital for Women, and
to the Birmingham and Midland Hospital for
Women, 54, Darlington Street, Wolver-
hampton. C. 1897-9 & 1903-5.
F.F. fELDER, George, M.D., Surgeon to the Samaritan
Hospital for Women, Nottingham, 17, Regent
Street, Nottingham.
C. 1890-2 •& 1904-5. V.-P. 1897-9.
1898 fELLiOTT, Frank Percy, M.B., C.M.Aberd., 113,
Grove Road, Walthamstovv, n.e.
1898 tEMERSON, Thos. G., M.D., M.Ch., R.U.L, Wan-
tage, Berks.
1894 Emmet, Bache McE., M.D., 18, East Thirtieth
Street, New York, U.S.A. Hon. Loc. Sec.
1892 Englemann, Fredk., M.D., Kreuznach, Germany.
1890 -fENGLiSH, T. Johnston, M.D.Brux., 13, Gilston
Road, s.w. C. 1904-5.
1892 L. Engstroem, Professor Otto, M.D., Helsingfors,
Finland.
xviii List of Fellows of the
Elected
1903 Evans, Frederick Wm., M.D., C.M.Aberd.,
M.R.C.S., 21, Charles Street, Cardiff.
1903 fFEGAN, Richard Ardra, M.R.C.vS., L.R.C.P.,
Templecrone, Westcombe Park, s.e.
1891 Fehling, Professor, M.D., Ruprechtsauer, Allee,
Strasbiirg.
1886 L, Fenger, Christian, M.D., 269, La Salle Avenue,
Chicago, Illinois, U.S.A.
1894 *Fenton, Frederick Enos, F.R.C.S., M.R.C.P.
Edin.
1896 fFENWiCK, Bedford, M.D.Diirh., M.R.C.P.Lond.,
Physician to the Hospital for Women, Soho,
20, Upper Wimpole Street, w.
V.-P. 1890-92, 1905. C. 1886-7 & 1902-4.
Libr. 1887-92. Hon. Sec. 1888-9. Editor
1892-4.
1893 *Ferguson, Geo. Gunnis, M.B., C.M.Glasg.
1895 fFERGUSON, James Haig, M.D., F.R.C.P.Edin., &c.,
Lecturer on Midwifery and Diseases of Women
School of Medicine of the Royal Colleges,
Gynaecologist Leith Hospital, Assistant Physi-
cian Royal Maternit}^ Hospital, Edinburgh,
25, Rutland Street, Edinburgh. C. 1904-5.
1899 fFiTZGERALD, Edward Desmond, M.R.C.S.,
L.R.C.P., 5, Castle Hill Avenue, Folkestone.
1903 FiTZGiBBON, Gibbon, M.D., B.Ch., B.A.O.Dub.,
Assistant Master Rotunda Hospital, Dublin.
1900 fFLEMiNG, Alexander John, M.D., M.Ch., R.U.L,
3, Arkwright Road, Hampstead, N.w.
1898 fFLOYD, Thomas 'Sargent, M.A., M.D.Dub., 16,
Devonshire Road, Claughton, Birkenhead.
1898 Fogerty, William A., M.D., M.Ch., M.A.O., Sur-
geon Limerick Hospital, 67, George Street,
Limerick.
1903 Foley, Thomas McCraith, L.R.C.P., L.R.C.S.L,
5, Queen Street, Scarborough, Yorks.
1891 fFoRDE, Ernest S., L.R.C.P. & S.Edin. Dairy,
Galloway.
1902 Franz, K., M.D., Professor of Obstetrics and
Gynaecology in the University of Jena, Ger-
many, Schaefferstrasse la.
British Gynaecological Society xix
Elected
1898 Fraxz, R. Grant, M.D.Marburg and Berlin,
Schwalbach, Germany.
1903 Frend, John Alfred, M.D., M.R.C.P., L.R.C.S.I.,
375, Calle Urquizae, Rosario, Argentina.
1885 fFuLLER, Leedham, M.R.C.S.Eng., L.S.A.Lond.,
Oatlands, Streatham Hill, s.w.
F.F. fGAGE-BROWN, Charles Herbert, M.D.,C.M.Edin.,
85, Cadogan Place, s.w. C. 1898-9.
1895 fGALLOWAY, Arthur W., L.R.C.P., M.R.C.S.,
" Malverns," Epping.
1903 Galloway, David James, M.D., Ch.M., F.R.C.P.
Edin., The Manor House, Singapore.
F.F. fGARDiNER, Bruce Herbert John, M.D., L.R.C.P.
Edin., M.R.C.S., 48, Barry Road, East Dulwich,
S.E.
F.F. Gardner, Willl\m, M.D., Professor of Gynae-
cology in McGill University, 109, Union
Avenue, Montreal, Canada. V.-P. 1887-9.
1904 George, Jessie Eleanor, L.R.C.P. & S.Edin.,
L.M.Dub., Ishwari Memorial Hospital,
Benares, India.
1895 fGiFFARD, H. E., M.R.C.S., Denham House, Egham,
Surrey.
1885 L. fGiLES, Peter Broome, M.R.C.S., L.R.C.P., Holne
Chase, BletcMey, Bucks.
1900 IGlenn, John Hugh Robert,M.D. Dub., F.R.C.P. I.,
Gynaecologist to Mercer's Hospital, 24, Lower
Bagot Street, Dublin.
1897 fGoDFREY, Frank W. A., M.B., & CM. Edin., Hon.
Surgeon Scarborough Hospital and Dispen-
sary, 5, Montpellier Terrace, Scarborough.
1891 -fGoDSON, Clement, M.D., M.R.C.P., Consulting
_^ Physician to the City of London Lying-in
Hospital, late Assistant Physician Accoucheur
St. Bartholomew's Hospital, 82, Brook Street,
Grosvenor Square, w.
Trustee. C. 1892-4, 1897-9, & 1904-5.
V.-P. 1902-3. Pres. 1895-6.
1886 L. Gordon, Seth Chase, M.D., 157, High Street,
Portland, Maine, U.S.A.
XX List of Fellows of the
Elected
1891 GowANS, William, M.D.Durh., F.R.C.S.Edin.,
Westoe House, Westoe, South Shields.
1896 Gray, William, M.D., C.M.Edin., Victoria Road,
West Hartlepool.
1891 Green, W. O., M.D., 709, 2nd Street, near Chest-
nut, Louisville, Kentucky, U.S.A.
1900 Greer, William Jones, F.R.C.S.I., L.R.C.P.I.,
L.M., D.P.H., 2, Cheptsow Road, Newport,
Monmouthshire.
F.F. tGRiFFiTH, G. de Gorreouer, L.R.C.P., M.R.C.S.,
late Senior Physician to Hospital for Women
and Children, Pimlico, 34, St. George's Square,
S.W., and New Indian Club, Whitehall Gardens,
s.w.
1885 L. f Grimsdale, Thomas Babixgtox, B.A., M.B.Camb.,
M.R.C.S., Gynaecological Surgeon Liverpool
Royal Infirmary, 29, Rodney Street, Liverpool.
Hon. Loc. Sec. C. 1894-6.
1898 fGuNTON, George Andrew, L.R.C.P.L, L.S.A., 3,
Sloane Court, s.w.
1895 Hall, Ernest Amos, M.D., C.M.Ont., L.R.C.P.
Edin., Burrard's Sanatorium, Vancouver,
British Columbia.
1885 L. Hall, Rufus B., M.D., 37, Crown Street, Walnut
Hills, Cincinnati, U.S.A.
1897 fHARLEY, Henry, M.D., R.U.I., 27, Victoria Road,
Battersea Park, s.w.
F.F. fHARRiES, Thomas Davies,M.R.C. P. Lond.,F.R.C. S.
Eng., Surgeon Aberystwith Infirmary and Car-
diganshire General Hospital, Grosvenor House,
Aberystwith,
1S98 fHARTT, Charles Henry, L.R.C.P.L, L.R.C.S.I.,
L.M., 14, Groom's Hill, Greenwich, s.e.
F.F. fHAULTAiN, Francis Wm. Nicol, M.D., F.R.C.P.
Edin., Physician for Diseases of Women,
Royal Dispensary, Lecturer on Midwifery and
Diseases of Women, Edinburgh School of
Medicine, 17, Rutland Street, Edinburgh.
Hon. Loc. Sec. C. 1896-8. V.-P. 1902-3.
1889 fHAWKES, A. E., M.D.Brux., L.R.C.P., L.R.C.S
Edin., 22, Abercromby Square, Liverpool.
British GyncBCological Society xxi
Elected
1904 Hawkes, Claude Somerville, F.R.C.S.Edin.,
Glencairn, Wickham Terrace, Brisbane,
Queensland.
1902 Hayes, George Sullivan Clifford, M.R.C.S.,
L.R.C.P., Parncah, Purecal Lines, Bengal.
1901 Haynes, Captain E. J. A., F.R.C.S., 390, Hay
Street, Perth, Western Australia.
1886 L. Headley, W. Balls, M.A., M.D., F.R.C.P.. 4,
Collins Street, Melbourne, Australia.
C. 1896-8.
1887 *Heald, Benjamin Grey, L.R.C.P.Edin., L.F.P.S.
Glasg.
F.F. fHEBERT, Paul Zotique, M.D., C.M.McGill,
L.R.C.P.Lond., i6a. Old Cavendish Street,
Cavendish Square, w. C. 1896-8.
1885 L. Heiberg, Wilhelm, M.D., Surgeon to the County
Hospital of Copenhagen, Frederiksberg, Copen-
hagen.
1898 fHELME, Thomas Arthur, M.D.Edin., M.R.C.P.
Lond., M.R.C.S.Eng., Hon. Senior Assistant
Surgeon Clinical Hospital for Women and
Children, Manchester, Mayfield, Victoria Road,
Manchester. C. 1903-5.
1887 L. Hetherington, Geo. Albert, M.D., St. John,
N.B., Canada.
1903 HiGHMOOR, Richard Nicholson, M.B., CM.
Edin., Litcham, Swaffham, Norfolk.
1871 fHiLL, J. Stoneley, M.B. & CM. Edin., 33, Great
Charlotte Street, Blackfriars Road, S.E.
F.F. fHiLLS, Augustus Phillips, M.R.C.S.Eng., Carlton
House, I, Prince of Wales Road, Battersea
Park, s.w.
F.F. fHiNE, Alfred Leonard, L.R.C.P.Lond., M.R.C.S.,
L.S.A., Northwold, Moss Hall Grove, N.
Finchley. C 189 1.
1887 L. HoAG, Junius C, M.D., 4669, Lake Avenue,
Chicago.
F.F. tHoDGSON, Robert Hugh, M.D.Durh., M.R.C.S.
Eng., 166, Peckham Rye, East Dulwich.
C 1894-7 & 1901-3. V.-P. 1898-1900.
1895 fHoLLAND, C E., M.B., CM. Edin., Airdrie, The
^ Avenue, Kew Gardens, Surrey.
xxii List of Fellows of the
Elected
F.F. fHoLLAND, Edmund, M.D., M.R.C.P., F.R.C.S.,
Physician to the Hospital for Women, Soho,
I, Titchfield Terrace, North Gate, Regent's
Park, N.w. C. 1893-5.
1S85 L. Hooper, John William Dunbar, L.R.C.P.,
L.R.C.S.Edin., Surgeon to the Women's Hos-
pital, Melbourne, 70, Collins Street, East
Melbourne.
1899 HoRNE, Andrew John, F.R.C.P.I., 94, Merrion
Square, Dublin.
1903 fHosFORD, Benjamin, M.A., M.D., M.Ch., M.A.O.,
R.U.I., 89, St, John's Road, Upper HoUoway,
n.
1898 fHowARD, Arthur Walters, M.R.C.S., L.R.C.P.,
83, Queen Street, Maidenhead.
1901 *Hughes, George Osborne, M.D., &c.
1887 fHuTCHisoN, George Wright, M.D.Aberd.,
M.R.C.P.Edin., Chipping Norton, Oxon.
F.F. tjAMES, W. Culver, M.D., 15, Marloes Road,
Kensington, w. C. 1884-6.
1903 tJAMESON, James Elliott, M.B., B.Ch., B.A.O.
Dub., 16, Church Road, Richmond, Surrey.
1894 tjARDiNE, James, M.B., C.M.Edin., 3, Lichfield
Gardens, Richmond, Surrey. C. 1902-4.
1888 tjELLETT, Henry, M.D.Dub., F.R.C.P.I., 61, Lower
Mount Street, Dublin.
Hon. Loc. Sec. C. 1902-4.
1887 tjESSETT, Frederick Bowreman, F.R.C.S.Eng.,
Surgeon to the Cancer Hospital, Brompton,
23, Brook Street, w.
C. 1891-2, 1894-7 & 1901-3.
V.-P., 1898-1900, 1904-5. Pres, 1893.
1883 L. Jewett, Charles, M.D., 330, Clinton Avenue,
Brooklyn, U.S.A.
1897 *JoHNSTON, G. J. Waldron, M.D., R.U.L
1886 tJoHNSTON, John, M.R.C.S.Eng., 2, Rocky Hill
Terrace, Maidstone.
1886 L. Johnstone, Arthur, W., M.D., Madisonville
Road, Cincinnati, Ohio.
British GyiK^co logical Society xxiii
Elected
1891 Johnstone, George, W., L.R.C.P., Government
Medical Officer, 3, Battery Road, Singapore.
1887 Jones, C. N. Dixon, M.D., 249, East 86th Street,
New York, U.S.A.
1899 Jones, Evan James Trevor, M.R.C.S., L.R.C.P.,
Ty-mawr, Aberdare, S. Wales.
1895 tJoNES, John, L.R.C.P., M.R.C.S., Claremont,
Newlands Park, Sydenham, s.e.
1904 Jones, Mary Dixon, M.D., New York, U.S.A.
1893 tJoRDAN, John Furneaux, M.B., R.U.I., F.R.C.S.
Eng., Surgeon Women's Hospital, Birming-
ham, 9, Newhall Street, Birmingham.
C. 1899-1901.
1895 fKEiTH, George Elphinstone, M.B., C.M.Edin.,
7, Manchester Square, w.
Hon. Sec. 1897-9. C. 1900-1.
1889 L. Kellogg, J. H., M.D., Battle Creek, Michigan,
U.S.A.
1898 Kelly, Howard A., M.D., Univ. of Pennsylvania,
Professor of Gynaecology and Obstetrics in
Johns Hopkins University, 1406, Eutaw Place,
Baltimore, Pa., U.S.A.
F.F. fKENNEDY, John Blydestyn, M.R.C.S.Eng.,
U.S.A., Stratford Hall, Stratford, e.
1903 Kerr, John Martin Munro, M.B., CM., F.F.P.S.
Glasg., Obstetric Physician Glasgow Maternity
Hospital, 28, Berkeley Terrace, Glasgow.
1900 fKiDD, Frederick William, M.D.Dub., Master of
Coombe Hospital, Professor of Midwifery and
Gyn.iecology, R.C.S.I., 17, Lower Fitzwilliam
Street, Dublin, C. 1902-3.
1886 L. King, Albert F. A., M.D., 1315, Mass. Avenue,
N.W., Washington, D.C., U.S.A.
1901 King, J. E., M.D., Univ. Buffalo, 93, Niagara
Street. Buffalo, U.S.A.
1898 fKiNKEAD, Richard John, M.D., L.R.C.S.L, Pro-
fessor of Obstetrics, Queen's College, Galway,
Forster House, Galway. C. 1905.
1839 Kirkley, C. a., M.D., 1 105, Jefferson Street,
Toledo, Ohio, U.S.A.
1904 Klein, Professor Gustav, M.D.Munich.
xxiv List of Fellows of the
Elected
F.F. fKNOTT, Charles, M.R.C.P.Edin., Liz ViUe, Elm
Grove, Southsea.
1903 tKNUTHSEN, Louis F. B., M.D.Edin., 33, Chesham
Street, s.w.
1902 Lackie, James Lamond, M.D., F.R.C.P.Edin.,
2, Randolph Crescent, Edinburgh.
1898 Landau, L., M.D., Professor of Gynaecology of the
University of Berlin, Berlin.
V.-P. 1900-3.
1902 Last, Cecil Edward, M.R.C.S., L.R.C.P., Bles-
soe House, Littlehampton.
1886 L. fLAWRiE, James McPherson, M.D., Physician to
the Weymouth Sanatorium, Greenhill, Wey-
mouth. C. 1894-6, 1905. V.-P. 1899-1901.
1899 fLEA, Arnold William Warrington, M.D., B.S.
Lond., F.R.C.S.Eng., Assistant to the Pro-
fessor of Obstetrics, Owens College, Assistant
Surgeon to the Clinical Hospital for Women
and Children, Manchester, 274, Oxford Road,
Manchester.
F.F. L. Leblond, Albert, M.D., Medecin de Saint-
Lazare, 53, Rue d'Hauteville, Paris.
1889 fLEiGH, W. W., L.R.C.P.Edin., M.R.C.S.Eng.,
L.S.A., Glyn Bargoed Treharris, R.S.O., South
Wales.
F.F. L. fLE Page, John Fisher, M.D., L.R.C.P.Edin.,
The Poplars, Cheadle, Cheshire.
F.F. *Leslie, William Murray, M.D.Edin., CM.,
F.R.C.S.E.
F.F, fLLOYD, Samuel, M.D., 60, Bloomsbury Street,
Bloomsbury, w.c. C. 1904-5.
1902 Lloyd, Thomas Edward, M.D.Brux., M.R.C.S.,
L.R.C.P., Woodstock House, Abergavenny,
Monmouthshire.
1893 fLLOYDE, John Hy., L.R.C.P., L.R.C.S.Edin.,
6, Harpur Place, Bedford.
F.F. fLow, Richard Marsden Pilkington, M.B., CM.,
L.R.C.P., L.R.C.S.Edin., L.M., 70, Philbeach
Gardens, s.w. C 1896-8.
1901 LowENTHAL, Louis L., M.R.C.S., &c., 3135,
South Park Avenue, Chicago, U.S.A.
British Gyncecological Society xxv
Elected
1894 LuTAUD, AuGUSTE, M.D. Paris, Redacteur en Chef
du Journal de Medecine de Paris ; Medecin
Adjoint de I'Hopital St. Lazare, 47, Boule-
vard Haussmann, Paris.
F.F. fLYCETT, John Allan, M.D.St. And., M.R.C.P.
Edin., Consulting Gynaecologist Wolverhamp-
ton and District Hospital for Women, Gat-
combe, Wolverhampton.
Hon. Loc. Sec. C. 1889-91.
1899 fLYLE, Robert Patton Ranken, B.A., M.D.,
B.Ch.Dub., Lecturer on Midwifer}^ and Dis-
eases of Women and Children, Durham
University College of Medicine, 11, Ellison
Place, Newcastle-on-Tyne
Hon. Loc. Sec. C. 1904. V.-P. 1905.
F.F. fMACAN, Sir Arthur Vernon, M.B., M.Ch., M.A.O.
Dub., F.R.C.P.L, King's Professor of Mid-
wifery Trinity College, Obstetric Physician
Sir P. Dun's Hospital, Ex-Master of the
Rotunda Hospital, Dublin, 53, Merrion
Square, Dublin. C. 1890-2.
V.-P. 1887-8 & 1904-5. Pres. 1889.
1885 L. fMACAN, Jameson John, M.A., M.D.Camb., Cheam,
Surrey. C. 1895-7. V.-P. 1898-1900, 1905.
Editor, 1899-1905.
1899 fMcARDLE, John Stephen, F.R.C.S.L, Surgeon to
St. Vincent's Hospital, 7, Upper Merrion
Street, Dublin.
1890 fMAcCoRMAC, John Sides Davies, L.R.C.P. &
L.R.C.S.Edin., L.F.P.S.Glasg,, 327, Chiswick
High Road, w.
1895 fMcDoNALD, James, M.D.Edin., Bloxwich, Walsall,
Staffs.
1898 fMAcDoNNELL, ALEXANDER, L.R.C.S.Edin. &
L.S.A., Manor Lodge, Stamford Hill, N.
1902 *McDowELL, William, jun., M.D., British
Columbia.
1897 Macgregor, Peter, F.R.C.S.Edin., Rashcliffe,
Huddersfield.
1889 L. Mackay, William Alexander, M.D., F.R.C.S.
Edin., Huelva, Spain.
XXV i List of Fellows of the
Klccled
1888 L. fMACKiNTOSH, G. D., L.R.C.P.I., L.M.Edin., 74A,
The Chase, Clapham Common, S.W.
1898 fMcMANUs, Leonard Strong, M.D., Mayo House,
Spencer Park, Wandsworth Common, s.w.
1892 MacMurtry, L. S., M.D., 1912, Sixth Street,
Louisville, Kentucky, U.S.A.
F.F. fMACNAUGHTON-JONES, H., M.D., M.Ch., M.A.O.,
R.U.I., F.R. C.S.I, and Edin., late Examiner
in Midwifery Royal University, Ireland, and
Professor of Midwifery Queen's College, Cork,
131, Harley Street, w.
C. 1890-2 & 1900-2. V.-P. 1895-7 &
1903-5. Pres. 1898-9.
1897 tMACNAUoHTON-JoNES, H. M.,^M.B., B.Ch., R.U.L,
L.R.C.P., M.R.C.S., 12, Sandwell Mansions,
West End Lane, n.w. Editor 1900-2.
1894 *Maddin, John Walsey, jun., M.D.
1903 fMAiLER, William, M.B., CM. Edin., Holmwood,
Palace Gates Road, Wood Green, n.
1888 Manton, Walter Porter, M.D., 32, Adams
Avenue, w., Detroit, Mich., U.S.A.
1895 *Martin, Charles, M.B., C.M.Edin.
1891 fMARTiN, Christopher, M.B.Edin., CM., F.R.C.S.
Eng., Surgeon Birmingham and Midland Hos-
pital for Women, Cleveland House, George
Road, Edgbaston, Birmingham.
Hon. Loc. Sec. C 1897-9. V.-P. 1903-5.
1896 Mattice, Richard Isa, M.D.McGill, L.R.C.P.
Lond., Winnipeg, Canada.
1896 t^AYBURY, Lysander, M.D., M.Ch., R.U.L,
M.R.CS.Eng., 9, Hampshire Terrace, Southsea.
1891 fMEARNS, William, M.A., M.D., Physician Chil-
dren's Hospital, Gateshead-on-Tyne, 22, Be-
wick Road, Gateshead-on-Tyne.
1891 Meek, H., M.D., 331, Queen's Avenue, London,
Ontario, Canada.
1887 Mendes de Leon, M.A., M.D., Sarphati Straat, iH,
Amsterdam. C 1892.
L. Merriman, Henry P., M.D., 2239, Michigan.
Avenue, Chicago, U.S.A.
British GyncFcological Society xxvii
Elected
1896 fMETCALFE, James, M.D.Brux., L.R.C.P., L.R.C.S.
Edin., Surgeon to St. Catherine's Home for
Cancer, Bradford, 8, Heaton Grove, Bradford,
Yorks.
1891 t^iCHiE, H., M.B.Aberd., CM., Surgeon to the
Samaritan Hospital, 27, Regent Street, Not-
tingham. C. 1894-6.
1895 fMiLLER, Fredk. R., M.D.Brux., L.R.C.P.Lond., 70,
Holland Park Road, West Kensington.
1905 MiLLiGAN, William Anstruther, M.A., M.B.,
CM., F.R.CS.Edin.. 104, Bethune Road, n.
1896 tMiNCHiN, P. DuNDAS, L.R.C.P., L.R.CS.Edin.,
Oldcroft, Godalming, Surrey.
1888 L. MOLESWORTH, Major William, I.M.S., M.B., B.S.
Durh., M.R.C.S., L.R.CP., c/o Messrs. Grind-
lay and Co., 54, Parliament Street, s.w.
1892 fMoLSON, John Cavendish, M.D., 10, Walsingham
Terrace, West Brighton.
1902 fMoNDY, Samuel Lee Craigie, M.R.C.S., L.R.CP.,
Grove Hall Asylum, Fairfield Road, Bow, E.
1896 Morgan, Thomas Howard, M.D., F.R.CS.Edin.,
Gympie, Queensland, Australia.
1887 fMoRisoN, Albert Edward, M.B., CM. Edin.,
F.R.CS.Edin., Wellington Road, West Hartle-
pool.
i8gi fMoRisoN, J. Rutherford, M.B., F.R.C.S., Surgeon
Newcastle-on-Tyne Infirmary, 14, Saville Row,
Newcastle-on-Tyne. C 1894-6.
1894 MoRLAND, Charles Henry Duncan, M.B., B.S.
Durh., F.R.C.S., Swatow, China.
1898 fMoRRis, Richard John, M.D.Durh., M.R.C.S.,
L.R.CP., L.S.A., Southfield, York Place,
Harrogate.
F.F. tMoRTON, Thomas, M.D.Lond., M.R.C.S., L.S.A.,
Ex-President of the Harveian Society of
London, 15, Greville Road, Kilburn, N.w.
C 1889-90 & 1899-1901.
1898 fMossE, Herbert Ryding, M.D., M.R.CS.Eng.,
37, North Side, Clapham Common, s.w.
xxviii List of Fellows of the
Elected
F.F. fMouLLiN, J. A. Mansell, M.A,, M.B.Oxon.,
M.R.C.P., Physician to the Hospital for
Women, Soho, Physician for Diseases of
Women to the West London Hospital, 80,
Porchester Terrace, Hyde Park, w.
C. 1884-6. Hon. Sec. 1887-8. V.-P.
1889-91 & 1903-5. Libr. 1892. Treas.
1893-1900. Pres. 1901.
1902 t^owLL, Richard Rothwell, M.B., B.S.Lond.,
Beresford, Hook Road, Surbiton.
1896 Murray, Chas. F. K., M.D., M.Ch., M.A.O., R.U.L,
Kenilworth House, Cape Town, S. Africa.
F.F. tMuTCH, F. Robertson, M.D., C.M.Aberd., Surgeon
to the Samaritan Hospital for Women,
Nottingham, " Strathgairn," Goldsmith
Street, Nottingham.
£889 fNAUMANN, J. C. Francis, M.D.Brux., L.R.C.P.
Lond., M.R.C.S.Eng., Physician Italian Hos-
pital, 12, Bedford Square, w.c.
1894 tNEATBY, Edwin A., M.D.Brux., L.R.C.P.Lond.,
82, Wimpole Street, w.
1891 Nedwill, Courtenay, M.D., R.U.L, M.R.C.S.,
Christchurch, Canterbury, New Zealand.
1886 L. Nelson, Daniel Thurber, M.D., 2400, Indian
Avenue, Chicago, U.S.A.
F.F. L. fNETHERCLiFT, WiLLiAM Henry, F.R.C.S.Edin.,
8, St. George's Place, Canterbury.
F.F. L. Neugebauer, Franz von, M.D., Directeur de
I'Hopital Evangelique, Leszno, 33, Warsaw,
Russia (Poland). V.-P. 1887-9.
1898 fNEViLLE, Thos., M.D., R.U.L, 123, Sloane Street,
s.w.
1896 INewnham, William Harry Christopher, M.A.,
M.B.Camb. M.R.C.S., Physician Accoucheur
Bristol General Hospital, Chandos Villa,
Queen's Road, Clifton. C. 1898-1900.
1898 Noble, Charles P., M.D.Maryland, 159, Locust
Street, Philadelphia, Pa., U.S.A.
Bjntish Gyncscological Society xxix
Elected
1896 fO'BRYEN, James Wheeler, M.D.Vermont,
L.R.C.P., L.R.C.S.Edin., Burgill, Sydenham,
S.E.
1898 fO'CoNNOR, William Moyle, M.A., M.D.Dub.,
Lyndhurst, Cargate, Aldershot.
1885 O'DoNNELL, Thomas Joseph, L.R.C.P.I., L.M..
L.R.C.S.I., Major R.A.M.C, Rath Conaill,
Dorgamn, Mysore, India.
1898 fO'HAGAN, Patrick Francis, L.R.C.P., L.R.C.S.
Edin., Tower House, London Road, Croydon.
1894 tOLivER, James, M.D., M.R.C.P.Lond., F.R.S.
Edin., Physician to the Hospital for Women,
Soho Square, W., 18, Gordon Square, w.c.
C. 1896-98. V.-P. 1900-2.
1891 IOliver, Thos, M.A., M.D., F.R.C.P., Professor of
Physiology University of Durham, Physician
Newcastle-on-Tyne Infirmary, 7, Ellison Place,
Newcastle-on-Tyne. C. 1892-4. V.-P. 1905.
1898 fOPPENHEiMER. Heinrich, M.D.Heidelberg,
M.R.C.P.Lond., 63, Finsbury Pavement, e.c.
1889 L. OsTROM, H. J., M.D., 42, West 48th Street, New-
York, U.S.A.
1905 OvERY. Henry, M.B.Edin., F.R.C.S., 8. Devon-
shire Street, Portland Place, W.
F.F. fPADMAN, John, M.R.C.S.Eng., 22, Bloomsbury
Square, w.c. C. 1904-5.
1905 Paine, Alexander, M.D., B.S.Lond., D.P.H ,
R.C.S.Lond., 113, Drayton Road, Harlesden,
N.w.
1888 L. Parkinson, J. Taylor, M.D., Brook View, Crystal
Brook, South Australia.
1898 fPARSONS, John Inglis, M.D., M.R.C.P., Physician
to the Chelsea Hospital for Women, 3, Queen
Street, Mayfair, w. C. 1900-2.
1903 Paterson, Charles Edward, M.D., C.M.Edin.,
Stirling Lodge, Farnborough, Hants.
1899 Peck, Francis Samuel, M.R.C.S., L.R.C.P.,
Lieut. -Col. Indian Medical Service, Professor
of Midwifery and Obstetric Physician at
Calcutta Medical College, 6, Harrington Street,
Calcutta.
XXX List of Fellows of the
Elected
1903 Pestalozza, Ernesto, Professor of (finical Ob-
stetrics and Gynaecology, Florence, Via Alfani,
60. C. 1905.
1903 Peterson, F. C, M.D.Buffalo, 606, East Genessee
Street, Syracuse, N.Y., U.S.A.
1891 fPHiLiPSON, Professor Sir George Hare, M.A.,
M.D.Camb., D.C.L., F.R.C.P., Professor of
Medicine University of Durham, Senior Phy-
cian Newcastle-on-Tyne Infirmary, 7, Eldon
Square, Newcastle-on-Tyne.
1903 L. Phillipson, Cecil E. Jones, M.D., Brux., &c.,
Port Alfred via Grahamstown, Cape Colony.
1902 Phillips, James, F.R.C.S.Edin., M.R.C.S.,
L.R.C.P., 2, Duckworth Grove, Bradford,
Yorks.
1904 Phillips, Mary Elizabeth, M.B.Lond., Presbeh,
Merthyr Cynog, Brecon.
1904 Phillips, Miles Harris, M.B., B.S., F.R.C.S.,
Jessop Hospital for Women, Sheffield.
F.F. L. PiNARD, Adolphe, M.D., Professeur a la Faculte,
Accoucheur de Lariboisiere, 11, Rocquepine,
Paris. V.-P. 1900-1.
1885 L. Polk, William M., M.D., Ex-President New
York Obstetrical Society, &c., &c., 7, East
Thirty-Sixth Street, New York, U.S.A.
1886 fPoPE, Harry Campbell, M.D.Lond., F.R.C.S.,
6, Ashchurch Grove, Goldhawk Road, Shep-
herd's Bush, w. C. 1890-2.
1891 fPouLTER, Arthur Reginald, M.R.C.S., L.R.C.P.,
4, Gordon Mansions, Gower Street, w.c.
F.F. fPuRCELL, Ferdinand Albert, M.D., M.Ch., R.U.I.,
M.R.C.S.Eng., L.M., Surgeon to the Cancer
Hospital, Brompton, 7, Manchester Square, w.
Auditor 1895-1905. C. 1888-9, 1893-5.
F.F. L. tPuREFOY, Richard Dancer, M.D.Dub., F.R.C.S.I.,
Obstetric Surgeon Adelaide Hospital, late
Master of the Rotunda Hospital, 20, Merrion
Square, Dublin.
C. 1884-6. V.-P. 1899-1901.
1895 tPuTSEY, William H., M.D.Durh., M.R.C.S., Fleet-
Surgeon (retired) R.N., 28, Ladbroke Gardens,
w.
British GyncEcoiogical Society xxxi
Elected
1887 fRAE, George A., L.R.C.P., L.R.C.S.Edin., i,
Outram Terrace, Stoke, Devonport.
1894 fRAMSAY, Frank Winson, M.D., B.S.Durh.,
F.R.C.S.Edin., Jesmond Dene, Bournemouth.
C. 1900-2.
F.F. fRAWLiNGS, John Adams, M.R.C.P.Edin., M.R.C.S.
Eng., Physician to the Swansea Hospital,
Preswylfa, Swansea. C. 1889-90.
1903 Rayner, David Charles, F.R.C.S.Eng., Assist-
ant Physician Accoucheur Bristol General
Hospital, 9, Lansdown Place, Victoria Square,
Clifton, Bristol.
1898 fREDFERN, John J., M.D., M.A.O., Surgeon to the
Croydon General Hospital, Croindene, Welles-
ley Road, Croydon. C. 1905.
1887 L. Reed, Charles A. L., M.D., Professor of Gyuce-
cology and Abdominal Surgery at the Cin-
cinnati College of Medicine and Surgery,
and Surgeon to the Cincinnati Free Surgical
Hospital for Women, Cincinnati, Ohio, U.S.A.
1905 fREES, Rhys Basil, L.S.A.Lond., Priory House,
Queen's Crescent, Haverstock Hill, n.w.
1901 Reid, Duncan James, M.D., Shanghai, China.
F.F. fREiD, W. Loudon, M.D.Glasg., F.F.P.S.Glasg.,
Professor of Midwifery and Diseases of Women
and Children, Anderson's College, Glasgow,
Physician to Dispensary for Diseases of
Women, Western Infirmary, 7, Royal Crescent,
Glasgow. C. 1888-9. V.-P. 1896-8.
1898 fRiCE, George, M.D.Durh., 46, Friargate, Derby.
1888 L. RiCKETTS, E. S., M.D., 93, East Fourth Street,
Cincinnati, Ohio, U.S.A.
F.F. L. tRoBERTS, D. Lloyd, M.D., F.R.C.P., F.R.S.
Edin., Physician to St. Mary's Hospital,
Manchester, and Lecturer on Clinical Mid-
wifery and the Diseases of Women in Owens
College, ir, St. John's Street, Manchester.
C. 1884. V.-P. 1896-8.
F.F. fRoBERTS, Thomas, L.S.A.Lond., 152, Westbourne
Grove, Bayswater, w.
F.F. L. *RoBERTSON, A. Milne, M.D.Edin.
xxxii List of Fclloivs of the
Elected
1898 fRoBiNSON, Malachi J., M.D.Ch., R.U.I., 257,
Essex Road, Canonbury, x.
1888 fRoBsoN, x\rthur W. Mayo, F.R.C.S.Eng., L.R.C.P.
Lond., Emeritus Professor of Surgery York-
shire College, Senior Surgeon Leeds General
Infirmary, 8, Park Crescent, Portland Place, w.
Hon. Loc. Sec. C. 1893-5, 1898-1900 &
1903-4. V.-P. 1896. Pres. 1897.
1885 L. RosEBRUGH, John Wellington, M.D., Hamilton,
Ont., Canada.
1888 L. Ross, James F. W., M.D., CM., L.R.C.P.Lond.,
Professor of Gyucecology and Abdominal Sur-
gery Ontario Medical College for Women,
Gynaecologist to Toronto General Hospital, St.
Michael's Hospital and St. John's Hospital for
Women, 184, Sherbourne Street, Toronto,
Canada. Hon. Loc. Sec.
F.F. fRouTH, Charles Henry Felix, M.D., M.R.C.P.,
Consulting Physician to the Samaritan Free
Hospital, 52, Montague Square, w.
V.-P. 1884-6 & 1896-8. C. 1888-9, 1891-4
& 1899-1901. Pres. 1890. Hon. Fellow.
1901.
F.F. L. Russell, Logan D. H., M.D., M.R.C.S., Glenfern,
Halfway Tree, Jamaica.
1897 fRYALL, Charles, F.R.C.S., Surgeon to the Cancer
Hospital, Surgeon to the Gordon Hospital,
Surgeon to Out-patients London Lock Hos-
pital, 51, Queen Anne Street, w.
Hon. Sec. 1900-2. C. 1903-5.
1901 fSx. Aubyn-Farrer, Claude, L.R.C.P., L.R.C.S.
Edin., 7, Westbourne Park Road, Porchester
Square, w.
1902 Savage, Smallwood, M.A., M.B., B.Ch.Oxon,
F.R.C.S., Surgeon Birmingham Lying-in
Charity and Wolverhampton Hospital for
Women, 133, Edmund Street, Birmingham.
Hon. Sec. 1905.
British GyncECological Society xxxiii
Elected
F.F. tSAVAGE, Thomas, M.D., M.R.C.P., F.R.C.S.Eng.,
late Professor of Gynaecology, ^lason's College,
Consulting Surgeon Birmingham and Midland
Hospital, The Ards, Knovvle, Warwickshire.
C. 1884-6 cS: 1895-7. V.-P. 1889-91.
Pres. 1894. Hon. Fellow 1900.
1892 tScHACHT, F. F., M.D., B.A.Camb., late Physician
to Out-Patients Chelsea Hospital for Women,
153, Cromwell Road, s.w.
Hon. Sec. 1893-6. Editor 1896-g. V.-P.
1897-9 & 1903-4. C. 1900-2.
1887 tSHAW, John, M.D.Lond., M.R.C.P.Lond., Obstetric
Physician and Gynaecologist North-West
London Hospital, 32, New Cavendish Street,
Cavendish Square, w.
C. 1888-90. V.-P. 1901-3. Hon. Sec.
1895-7.
1901 Shearer, Alfred, M.B., Ch.B., c/o Dr. Purchas,
Newtown, N. Wales.
1901 Shepherd, Thomas William, L.R.C.S.Edin.,
Castle Hill House, Launceston, Cornwall.
1895 tSiMEOX, E. Archibald, L.R.C.P., L.R.C.S.Edin.,
550, Hoe Street, Walthamstow, n.e.
1889 fSiMPSON, Alexander Russell, M.D., F.R.C.P.
Edin., F.F.P.S.Glasg., F.R.S.E., Professor of
Midwifery and Diseases of Women Edinburgh
University, Physician for Diseases of Women
Royal Inlirmary and ^Maternit}^ Hospital, 52,
Queen Street, Edinburgh.
'^V.-P. 1890-1. Pres. 1892. C. 1893-5.
1903 fSiMSOx, Henry J. Forbes, 1\I.B., C.]M.Edin..
F.R.C.S.Edin., M.R.C.P.Lond., Assistant
Physician, Hospital for Women, Soho Square,
\v., 80, Brook Street, w.
1899 jSiNXLAiR, Sir William Japp, M.D.Aberd.,
M.R.C.P., Professor of Obstetrics and Gynae-
cology Victoria University, and Physician to
the Southern Hospital, Manchester, 4, Stanley
Grove, Oxford Road, Manchester.
C. 1900. V.-P. 1901.
xxxlv List of Fellows of tlu
Elected
F.F. fSLiMON, William Hy., M.D., M.Ch., F.F.P.S.Glasg.,
26, New Cavendish Street, w.
C. 1899-1900 & 1902-3. Treas. 1904-5.
1886 tSLOAX, Samuel, M.D., F.F.P.S.Glasg., Consulting
Physician to the Glasgow ^Maternity Hospital.
5, Somerset Place, Sauchiehall Street, West
Glasgow. C. 1889-91.
1887 L. fSMART, David, M.B., B.Sc.Edin., 74, Hartington
Road, Liverpool.
1889 tSMiTH, Alfred J., M.B., M.Ch., M.A.O., R.U.I.,
Professor of ^lidwifery and Diseases of \^■omen
Catholic University, Dublin, Gynaecologist
St. Vincent's Hospital, 30, Merrion Square,
Dubhn. C. 1896-8. V.-P. 1902-4.
1898 Smith, Arthur Lapthorn, B.A., M.D., M.R.C.S.,
Professor of Clinical Gynaecology Bishops
University, Montreal, Surgeon-in-Chief vSa-
maritan Free Hospital for Women, Gynae-
cologist to the Montreal Dispensary, Surgeon
to the Western General Hospital, 7248,
Bishop Street, ^lontreal, Canada.
Hon. Loc. Sec.
F.F. L. fSMiTH, E. T. Aydon, U.S.A., Devon Uodge, 2,
Alexandra Road, St. John's Wood, x.w.
C. 1898-9.
F.F. L. tSMiTH, Heywood, M.A., M.D., M.R.C.P., 25,
Welbeck Street, w.
Hon. Sec. 1884-5. C. 1889-91 & 1898-
1900. V.-P. 1892-4, 1901-2 & 1904-5.
Pres. 1903.
1891 fS^HTH, James Wilkie, M.D., Balgonie House,
Ryton-on-Tyne, Durham.
F.F. tSMiTH, Richard T., M.D., M.R.C.P., Physician to
the Hospital for Women, Soho. 33, Wimpole
Street, w.
C. 1884-6, 1898-1900 & 1903-5. Hon.
Sec. 1889-90. V.-P. 1891-93.
1904 Smith, William Robert, M.D., B.S., F.R.C.S.
Eng., Beeston, Notts.
British Gyncscological Society xxx\'
Elected
F.F. fSMYLY, William Josiah, M.D., T.C.D., F.R.C.P.I.,
F.R.C.S.I., late Master of the Rotunda Hos-
pital, President of the Royal College of
Physicians, Ireland. 58, Merrion Square,
Dublin. C. 1888-90 & 1901-3. V.-P. 1892-4.
Pres. 1900.
1895 -f^MVTH, Alexander Carson, M.B., C.M.Edin.,
Lochiel, 16, Craven Park, Willesden, n.w.
F.F. tSMYTH, Brice, B.A., M.D., M.Ch., T.C.D., Con-
sulting Physician Hospital for Sick Children,
Physician Belfast L^nng-in Hospital, 20, Uni-
versity Square, Belfast.
C. 1887-9. ^^--P- 1889-91.
^^905 fS-MVTH, James, M.B^ C.M.Edin., ']■], Falcon Road,
Clapham Junction, s.w.
1893 -j-Smyth, John Walker, L.R.C.P., L.R.C.S.Edin.,
13, Colebrook Row, City Road, n.
F.F. fSpANTON, William Dunnett, F.R.C.S.Eng.. Sur-
geon to the North Staffordshire Infirmary,
Chatterley House, Hanley, Staffordshire.
C. 1887-9 & 1901-4. V.-P. 1890-92, 1905.
1898 SpearinCx, Andrew, L.F.P.S.Glasg., Victoria
House, Albert Road, Eccles, Lanes.
1898 Sprott, Wm. J., M.D., M.Ch., R.U.I. , Heath-
iield, Eccles Old Road, Manchester.
1903 Stealy, Jeremiah H., M.D., Ph.D., Freeport,
Illinois, U.S.A.
1898 Stekoulis, Constantin, M.D., Pera, Rue Soute-
razi 7, Constantinople.
1885 Stevenson, Edmund Sinclair, M.D.Brux.,
F.R.C.S.Edin., Strathallan, Rondebosch.
Cape Town, S. Africa.
1899 Stevenson, William John, M.D., CM., M.C.P. &
S. Toronto, 391, Dundas Street, London,
Canada.
1892 Stewart-McKay, W. J., M.B., M.Ch., B.Sc, Aus-
tralian Club, 26, Darlinghurst Road, Sydney,
N. South Wales.
1888 L. Stone, Isaac S., M.D., 1618, Rhode Island Avenue
N.W., Washington, D.C., U.S.A.
1893 Stoney, Ralph, L.R.C.S.L, L.R.C.P.L, Medical
Officer, Uganda Protectorate Service, Africa.
xxxvi List of Fellozvs of the
Elected
1886 fSTRANGE, W. Heath, M.D., 2, Belsize Avenue,
Hampstead, n.w.
1904 Sturge, ]\Iary Darby. ]\I.D.Lond., 45, Hagley
Road, Edgbaston, Birmingham.
1892 L. Sullivan, W. H., M.D., 80, Collins Street, Mel-
bourne, Victoria.
1885 fSuxDERLAND, Septoius, M.D., M.R.C.S., M.R.C.P.
Lond., Physician to the Royal Hospital for
Women and Children, 11, Cavendish Place,
Cavendish Square, w. C. 1894-6 & 1902-3.
1892 L. Sutton, R. Stanbury, ]M.D.. 419, Penn Avenue,
Pittsburg, U.S.A.
1900 fSwANTON, J. Hutchinson, M.D., M.A.O., R.U.I.,
M.R.C.P. Lond., 40, Harlej^ Street, Cavendish
Square, w. Hon. Sec. 1901-4.
C. 1905. Assistant Editor 1905.
F.F. L. fTAYLER, William Henry. M.D.St.And., M.R.C.S.
Eng., Hardicot, Kingsdown Road, Walmer,
Dover, Kent.
F.F. L. tTAYLOR, John William, F.R.C.S., Professor of
Gynaecology Birmingham University, Surgeon
to the Birmingham and [Midland Hospital for
Women, 22, Newhall Street, Birmingham.
C. 1891-3, 1900-2, 1905. V.-P. 1894-6.
Pres. 1904.
F.F. fTEMPLE, Thomas Cameron, M.R.C.S., U.S.A.,
Shefford, Beds.
1898 fTnoMAS, John Lynn, F.R.C.S.Eng., 21, Windsor
Place, Cardiff.
1885 tTnoMSON, David, M.D., Stourfield Park Sana-
torium. Bournemouth (travelling).
C. 1897-9.
1893 fTnoMSON, George, M.B., C.M.Glasg., 72, The
Avenue, Ealing, w.
1898 fTivY, William James, F.R.C.P., F.R.C.S.Edin.,
5, Victoria Square, Clifton, Bristol.
1895 fTRAVERS, F. T., M.B., B.S.Uond., F.R.C.S.Edin.,
Surgeon to the West Kent Hospital, 6, Claren-
don Place, Maidstone.
British Gynecological Society xxxvii
Elected
1892 fTRAVERS, W., M.D., F.R.C.S., late Physician to the
Chelsea Hospital for Women, 2, Pliillimore
Gardens, w.
C. 1894-6, 1900 & 1905. V.-P. 1897-9 &
1904. Treas. 1901-3.
1895 Treub, Hector, M.D., Professor of Obstetrics and
Gynsecology University of Amsterdam, Von-
delstraat, 83, Amsterdam. V.-P. 1897-g.
1898 Trower, Arthur, M.R.C.S., 104, Marina, St.
Leonards-on-Sea.
1889 L. fTuoHY, John Franxis, M.D., M.Ch., Lieut. -Col.
I. M.S., Hova House, i, Hova Terrace, Brighton.
1903 fTwEEDY, Ernest Hastings, F.R.C.P.I., &c..
Master of the Rotunda Hospital, Dublin,
Rotunda Hospital .
1887 L. Underwood, Edward F., M.D., Port Bombay,
India,
1885 L. Van der Veer, Albert, M.D., 28, Eagle Street,
Albany, New York, U.S.A.
1895 tVAUGHAN-jACKSON, HERBERT FrANCIS, L.R.C.P.,
M.R.C.S., Potter's Bar, Middlesex.
C. 1904.-5
,. Walker, Holford, M.D., 56, Isabella Street,
Toronto, Ontario, Canada.
1903 Walker, James Frederick, L. & L.M., R.C.P.I.,
L.R.C.S.I., Elm Lodge, Swallowfield, Reading.
1889 tWALLACE, Abraham, M.D.Edin., CM., F.F.P.S.
Glasg., formerl}^ Professor of Midwifery and
Diseases of Women Anderson's College, Glas-
gow, 39, Harley Street, w. C. 1894-6.
F.F. L. tWALTER, William, M.A., M.D.Dub., F.R.C.S.I.,
Physician to St. Mary's Hospital, Manchester,
20, St. John's Street. ^lanchester.
Hon. Loc. Sec. C. 1884-6 & 1891-3. V.-P.
1888-90.
xxxviii List of Fclloivs of the
Elected
1895 Walton, Paul, M.D., Chirurgien-adjoint des
Hopitaux de Gand, 33, Quai des Tonneliers,
Ghent, Belgium.
1897 L. Ward, Charles, F.R.C.S.I., 116, Long Market
Street, Pietermaritzburg, South Africa.
1891 Ward, J. L. W., J. P., L.R.C.P., Clasdir, Merthyr
Tydvil, Glamorganshire.
1895 fWHEATLY, A. W., M.B.Durh., M.R.C.S., i, Ken-
sington Square Mansions, Young Street,
Kensington.
1903 tWHiTCOMBE-BROWN, W. H., M.B., B.S., &c., High-
field, Westcliffe-on-Sea.
1897 fWHiTEHEAD, Henry Edward, M.R.C.S., L.R.C.P.,
475, Caledonian Road, Hollowa}^, N.
1890 fWiLLiAMS, Cyril John, L.R.C.P., Brookside,
Woodhall vSpa, Lincolnshire.
1897 tWiLLL\MS, Joseph Willl^m, M.R.C.S., L.R.C.P.,
128, Mansfield Road, Gospel Oak, n.w.
1895 fWiLLLA.MSON, JoHN, M.B., C.M.Edin., Surgeon to
Richmond Hospital, Rothsay House, Rich-
mond, Surrey.
1888 L. fWiLLis, Lieut.-Col. C. Fancourt, LM.S., M.D.,
M.R.C.P., Satara, Bombav Presidency.
1898 *WiLSON, George Dunn, L.R.C.P., L.R.C.S.Edin.,
481, Wandsworth Road, s.w.
1902 tWiLSON, Ralph Willl^m, M.D., C.M.Edin., The
Moorings, Kew Gardens, s.w.
F.F. L. Wilson, Robert T., M.D., Assistant Surgeon
Women's Hospital of Maryland, 20, Park
Avenue, Baltimore, Maryland, U.S.A.
1898 tWiLSON, Thomas, M.D., B.SXond., F.R.C.S.Eng.,
87, Cornwall Street, Newhall Street, Bir-
mingham.
1890 Wood, James C, M.D., 818, Rose Building,
Cleveland, Ohio, U.S.A.
1891 L. tWooDS, Hugh, M.D., B.S., M.A.O., 26, Welbeck
Street, w. C. 1905.
1889 I-. Worrall, Ralph, M.D., 20, College Street, Sydney,
N.S.W. Hon. Loc. Sec.
1903 Wybauw, R., M.D.Brux., Spa, Belgium.
1883 L. Wylie, Walker Gill, M.D., 28, West Fortieth
Street, New York, U.S.A. V.-P. 1894-6.
British Gyncecological Society xxxix
Elected
1898 Young, H. C. Taylor, M.D., CM., 221, Macquarie
Street, Sydney, New South Wales.
1891 fYouNG, Moffat, L.R.C.P., Victoria Road, West
Hartlepool.
1897 fYouNG, W. McGregor, M.B., C.M.Glasg., 171,
Woodhouse Lane, Leeds.
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