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AT  THE 


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-?  7  J^'9' 


OBSTETRICAL  TRANSACTIONS. 


VOL.  XXXIV. 


TRANSACTIONS 


OBSTETEICAL    SOCIETY 


LONDON. 

VOL.  XXXIV. 

FOR  THE   YEAR   1892. 
WITH  A  LIST  OF  OFFICERS,  FELLOWS,  ETC. 


LONDON: 

LONGMANS,  GEEEN,  AND  CO. 

1893. 


R6 
/ 

1/'.  39- 


PHINTED    I)V    ADLABD    AND    SON, 
UAKTHOLOMKW    CLOSE,    E.C.,    AND    20,    HANOVEK    SQUAEK,    W. 


OBSTETRICAL   SOCIETY   OF   LONDON. 


PEE8IDENT. 


VICE- 
PEESIUENTS. 


HOXORiKT 

MEMEEHS 

OF    COUNCIL. 


OTHER 

MEMBEUS 

OF    COUNCIL. 


OFFICEES   FOR   1893. 
Elected  February  1st,  1893. 


TEEASTJREE. 

CHAIRMAN   OF 

THE  BOARD  FOR 

THE  EXAMINATION 

OF  MIDLIVES. 

HONOEAET 

SECEETARTES. 

HONOEART 

LIEEAEIAN. 


HEEMAiS^,  G.  EENEST,  M.B. 

r  COEET,  THOS.  C.  STEUAET,  M.D.  (Belfast). 

DOEAN,  ALBAN. 

HOLLINGS,  EDWIN,  M.D. 

MEEEDITH,  WM.  APPLETON,  M.B.,  CM. 

THOENTON,  JOHN  KNOWSLET,M.B.,  CM. 
I  WEBB.  HAEET  SPEAKMAN  (Welwyn). 

POTTEE,  JOHN  BAPTISTS,  M.D. 
[  CHAMPNETS,FEANCIS  HENRY,  M. A.,  M.D. 


r  HOEEOCKS,  PETEE,  M.D. 
I  DUNCAN,  WILLIAM,  M.D. 

[  DAKIN,  W.  EADFOED,  M.D. 

r  OLDHAM,  HENEY,  M.D.  (Trustee). 

BARNES,  EOBERT,  M.D.  {T>-ustee). 

HEWITT.  GRAILY,  M.D. 

HICKS,  JOHN  BEAXTON,  M.D.,  F.E.S. 
^  TILT,  EDWAED  JOHN,  M.D. 

PEIESTLEY,  WILLIAM  O.,  M.D. 

WEST,  CHAELES,  M.D. 

BLACK,  JAMES  WATT,  M.A.,  M.D. 

WELLS,  Sir  THOS.  SPENCEE,Baet.  (Trustee). 
f  BEACH.  FLETCHEE,  M.B.  (Dartford). 

BEOWN,  ANDEEW,  M.D. 

CLAPHAM,  EDANTAED,  M.D. 

COATES,  feed.  WM.,  M.D.  (Salisbury). 

CULLINGWOETH,  CHAELES  JAMES,  M.D. 

DONALD,  AECHIBALD,  M.D.  (Manchester). 

FEEEMAN,  HENEY  W.  (Bath). 

FULLEE,  HENEY  EOXBUECH,  M.D. 

GEEYIS,  HENEY,  M.D. 

GOW,  WILLIAM  JOHN,  M.D. 

GEIFFITH,  WALTEE  S.  A.,  M.D. 

LEWEES,  AETHUE  H.  N.,  M.D. 

PEEIGAL,  AETHUE,  M.D.,  (Barnet). 

PHILLIPS,  JOHN,  M.A.,  M.D. 

EFTHEEFOOED,  HY.  TROTTER.  B.A.,  M.B. 

TAIT,  EDWARD  SABINE.  M.D. 

TURNER,  JOHN  SIDNEY. 
L  WADE,  GEORGE  HERBERT  (Chislehurst). 


LIST  OF  PAST  PRESIDENTS  OE  THE 
SOCIETY. 


1859  EDWARD  EIGBY,  M.D. 

1861  WILLIAM  TYLER  SMITH,  M.D. 

1863  HENRY  OLDHAM,  M.D. 

1865  ROBERT  BARNES,  M.D. 

1867  JOHN  HALL  DAVIS,  M.D. 

1869  GRAILY  HEWITT,  M.D. 

1871  JOHN  BRAXTON  HICKS,  M.D.,  E.R.S. 

1873  EDWARD   JOHN   TILT,   M.D. 

1875  WILLIAM  OVEREND  PRIESTLEY,  M.D. 

1877  CHARLES  WEST,  M.D. 

1879  WILLIAM  S.  PLAYEAIR,  M.D. 

1881  J.  MATTHEWS  DUNCAN,  M.D.,  F.R.S. 

1883  HENRY  GERVIS,  M.D. 

1885  JOHN  BAPTISTE  POTTER,  M.D. 

1887  JOHN  WILLIAMS,  M.D. 

1889  ALFRED  LEWIS  GALABIN,  M.D. 

1891  JAMES  WATT  BLACK,  M.D. 


REFEREES  OE  PAPERS  FOR  THE  YEAR  1893 

Appointed  by  the  Council. 


BLACK,  J.  WATT,  M.D. 

liOULTON,  PERCY,  M.D. 

CHAMPNEYS,  FRANCIS  HENRY,  M.A.,  M.D. 

CULLINGWORTH,  CHARLES  JAMES,  M.D. 

DORAN,  ALBAN. 

GALABIN,  ALFRED  LEWIS.  M.A.,  M.D. 

GERVIS,  HENRY,  M.D. 

HEWITT,  GRAILY,  M.D. 

HICKS,  JOHN  BRAXTON,  M.D.,  F.R.S. 

LAWRENCE,  A.  E.  AUST,  M.D.,  Bristol. 

MALINS,  EDWARD,  M.D.,  Birmingham. 

POTTER,  JOHN  BAPTISTE,  M.D. 

PRIESTLEY,  WILLIAM  0.,  M.D. 

STEPHENSON,  WILLIAM,  M.D.,  Aberdeen. 

SUTTON,  J.  BLAND. 

WELLS,  Sir  T.  SPENCER,  Bart. 

WILLIAMS,  JOHN,  M.D. 


STANDING    COMMITTEES. 


BOARD  FOR  THE  EXAMINATION  OF  MIDWIVES. 


CHAIRMAN.      CHAMPNEYS,FEANCIS  HENRY,  M.A.,  M.U. 
BOXALL,  ROBERT,  M.D. 
PHILLIPS,  JOHN,  M.A.,  M.D. 
ROUTH,  AMAND,  M.D. 
(HERMAN,  G.  ERNEST,  M.B.,  President. 
Ex-oFFicio.  \  HORROCKS,  PETER,  M.D.,  1  -r.       ^ 

(DUNCAN,  WILLIAM,  M.D.,  j  ^'"*-  '^^'^*- 


LIBRARY  COMMITTEE. 


CHAMPNEYS,  FRANCIS  HENRY,  M.A.,M.D. 

DORAN,  ALBAN, 

HEWITT,  GRAILY,  M.D. 

PHILLIPS.  JOHN,  M.A.,  M.D. 
fHERMAN,   G.   ERNEST,  M.B.,  President. 
I  POTTER,  JOHN  B.,  M.D.,  Treasurer. 
EX-OFFICIO.-^  HORROCKS,  PETER,  M.D.,  ■)  ^       <, 

I  DUNCAN,WILLIAM,M.D.,3  ^''^'  '^^''*- 
I  DAKIN,  W.  R.,  M.D.,  Hon.  Lib. 


PUBLICATION   COMMITTEE. 


BLACK,  J.  WATT,  M.D. 

GERVIS,  HENRY,  M.D. 

HEWITT,  GRAILY,  M.D. 

PLAYFAIR,  WILLIAM   S.,  M.D. 

POTTER,  JOHN  BAPTISTE,  M.D. 

WILLIAMS,  JOHN,  M.D. 
fHERMAN,  G.  ERNEST,  M.B.,  President. 
I  CHAMPNEYS,  FRANCIS  HENRY,M.A.,M.D., 
EX-OFFICIO.  -{       Editor. 

I  HORROCKS,  PETER,  M.D.,  )  ^^       o  ^ 
LDUNCAN,  WILLIAM,  M.D.,  j  ^'"'-  '^^^^- 


HONORARY  LOCAL  SECRETARIES. 


Jones,  Evan Aberdare. 

Goss,  T.  BiDDULPH  Bath. 

Sharpin,  Henry  W Bedford. 

CoRRY,  Thomas  C.  S.,  M.D Belfast. 

Malins,  Edward,  M.D Birmingham. 

FuRNER,  WiLLOUGHBY Brighton. 

RiGDEN,  George  Canterbury. 

Lawrence,  A.  E.  Aust,  M.D Clifton. 

Braithwaite,  James,  M.D Leeds. 

Thompson,  Joseph  Nottingham. 

Walker,  Thomas  James,  M.D Peterborough. 

Walters,  James  Hopkins  Reading. 

Wilson,  Robert  James  St.  Leonard's. 

Keeling,  James  Hurd,  M.D SheflSeld. 

BuRD,  Edward,  M.D.,  CM Shrewsbury. 

Childs,  Christopher,  M.D Weymouth. 

Branfoot,  Arthur  Mudge,  M.B Madras. 

Perrigo,  James,  M.D Montreal,  Canada. 

Anderson,  Izett  W.,  M.D Jamaica. 

Takaki,  Kanaheiro Japan. 


OBSTETRICAL   SOCIETY   OF  LONDON. 


teustees  op  the  society  s  property. 

Henry  Oldham,  M.D. 
Robert  Barnes,  M.D. 
Sir  Thomas  Spencer  Wells,  Bart. 


HONORARY  FELLOWS. 

BRITISH    SUBJECTS. 


Elected 

1871     KiDD,  George  H.,  M.D.,  F.R.C.S.I.,  Obstetrical  Surgeon 

to  the  Coombe  Lying-in  Hospital ;    30,  Merrion  square 

south,  Dublin, 

1 892  Lister,  Sir  Joseph,  Bart.,  F.R.S.,  LL.D.,  1 2,  Park  crescent, 
Portland  place,  N.W. 

1892  Turner,  Sir  William,  F.R.S,,  Professor  of  Anatomy, 
University  of  Edinburgh  ;  6,  Eton  terrace,  Edinburgh. 

1S70  West,  Charles,  M.D.,  F.R.C.P.,  Foreign  Associate  of 
the  Academy  of  Medicine  of  Paris  ;  Kenilworth,  Eaton 
road,  West  Brighton.     Pre^.  18/7-8. 


foreign  subjects. 

1866  Lazarewitch,  J.,  M.D.,  Professor  Emeritus  and  Physician 
to  the  Maximilian  Hospital ;  Spaskaja,  2,  St.  Peters- 
burg.    Trans.  3. 

1862  LusK,  William  Thompson,  M.D.,  Professor  of  Obstetrics, 
Bellevue  Hospital  Medical  College,  New  York. 


xii  FliLLOWS    OF    THE    SOCIETY. 

Elected 

1864  Fajot,  Ch.  M.D.,  late  Professor  of  Midwifery  to  the  Faculty 
of  Medicine,  Paris. 

1877     Stoltz,  Professor,  M.D.   Nancy. 

1891  Tarnier,  St£phane,  M.D.,  Professor  of  Obstetrics,  Faeultd 
de  Medecine  de  Paris  ;   15,  Rue  Duphot,  Paris. 

1872  Thomas,  T.  Gaillard,  M.D.,  Professor  of  Obstetrics  in  the 
College  of  Physicians  and  Surgeons  ;  296,  Fifth 
avenue,  New  York. 

1862  ViECHOW,  Rudolf,  M.D.,  Professor  of  Pathological  Ana- 
tomy in  the  University  of  Berlin. 


CORRESPONDING    FELLOWS. 

1873     Martin,  A.  E.,  M.D.,  Berlin.     Traiis.  1. 
1876     BuDiN,    P.,    M.D.,    129,    Boulevard    St.    Germain,    Paris. 
Trans.  \ . 

1876  Chadwick,  James  R.,  M.A.,  M.D.,  Physician  for  Diseases 

of  Women,  Boston  City  Hospital ;    Clarendon  street, 
Boston,  Massachusetts,  U.S. 

1877  GooDELL,  William,  A.M.,  M.D.,  Professor  of  Gynecology 

in    the    University    of   Pennsylvania  ;    1418,    Spruce 
street,  Philadelphia,  Pennsylvania. 

1877     Storeu,  Hokatto  R.,  M.D. .Newport,  Rhode  Island.  U.S.A. 


ORDINARY     FELLOWS. 

1893. 


Those  marked  thus  (*)  have  paid  the  Composition  Fee  in  lieu  of  further 

annual  subscriptions. 

Those  marked  thus  (f)  reside  beyond  the  London  Postal  District. 

The  letters  O.F.  are  prefixed  to  the  names  of  the  "  Original   Fellows  "  of  the 

Society. 


Elected 

189Ut  AcKERLEY,  Richard,  M.B..  B.S.Oxon.,  Alexandra  House, 
Ashburton,  Devon. 

1891  Adams,  Charles  Edmund,  227,  Gipsy  road,  West  Norwood, 
S.E. 

1884t  Adams,  Thomas  Rutherford,  M.D.,  Stamford  House,  78, 
St.  James's  road,  Croydon. 

1890  Addinsell,  Augustus  W.,  M.B.,  C.M.Edin,,  30,  Asliburn 
place,  South  Kensington,  S.W. 

1883*tALLAN,  Robert  John,  L.R.C.P.Ed.,  The  Glen,  Summer 
hill,  Sydney,  New  South  Wales.  [Per  Alexander 
Allan,  Esq.,  Glen  House,  The  Valley,  Scarborough.] 

1890t  Allan,  Thomas  E.,  L.R.C.P.  &  S.Ed.,  7,  Salford  terrace, 
Tonbridge. 

18731  Allen,    Henry    Marcus,     F.R.C.P.    Ed.,    20,    Regency 

square,  Brighton. 
1887     Ambrose,  Robert,  B.A.,  L.R.C.P.  &  S.Ed.,  1,  Mount  place, 

Whitechapel  road,  E. 

1878t  Anderson,  Izett  William,  M.D.,  9.5,  Duke  street.  Kings- 
ton,  Jamaica.     Trans.  1.     Hon.  Loc.  Sec. 

1875  Anderson,  John  Ford,  M.D.,C.M.,  41,  Belsize  park,  N.W. 
Council,  1882. 

1859  Andrews,  James,  M.D.,  Everleigh,  Green  hill,  Hampstead, 
N.W.     Council,  1881. 


XIV  FELLOWS    OK    THE    SOCIETY. 

Elected 

I888t  Annacker,  Ernest,  M.D.,  Berlin,  292,  Oxford  road, 
Manchester. 

ISQOf  Anson,  George  Edward,  M.A.,  M.D.Cantab.,  The  Terrace, 
Wellington,  New  Zealand. 

1870*tAppLETON,  Robert  Carlisle,  The  Bar  House,  Beverley. 

1884     Appleton,  Thomas  A.,  46,  Britannia  road,  Fulham,  S.W. 

1883t  Archibald,  John,  M.D.,  Woodhouse  Eaves,  Loughborough. 

18/1  Argles,  Frank,  L.R.C.P.  Ed.,  Hermon  Lodge,  Wanstead, 
Essex,  N.E.     Council,  1886-7. 

1888t  Armstrong,  James,  M.B.  Edin.,  84,  Kodney  street,  Liver- 
pool. 

1886  Ashe,     William    Percy,     L.R.C.P.  Lond.,     41,    Sloane 

gardens,  S.W. 

1892t  Ashworth,  James  Henry,  M.D.  Brux.,  Halstead,  Essex. 
1872     Ayling,  Arthur  H.  W.,  41,  Devonshire  street,  W. 

1887  Bailey,  Henry  Frederick,  The  Hollies,  Lee  terrace,  Lee, 

S.E. 

1887t  Baker,  Oswald,  L.R.C.P.  &  S.  Ed.,  Surgeon-Major,  Indian 
Army,  Rangoon,  India. 

1880t  Balls-Headley,  Walter,  M.D.,  F.R.C.P.,  4,  Collins  street 
east,  Melbourne,  Victoria. 

1869*  Bantock,  George  Granville,  M.D.,  Surgeon  to  the 
Samaritan  Free  Hospital ;  12,  Granville  place,  Portman 
square,  W.     Council,  1874-6.     Trans.  2. 

1893t  Barber,  Richard  Henry,  L.E.C.P.  &  S.Edin.,  505, 
Williams  avenue,  Albina,  Portland,  Oregon,  U.S.A. 

1886*tBARB0UR,  A.  H.  Freeland,  M.D. Edin.,  8,  Melville  crescent, 
Edinburgh. 

O.F.  Barnes,  Robert,  M.D.,  F.R.C.P.,  Consulting  Obstetric 
Physician  to  St.  George's  Hospital;  7,  Queen  Anne 
street.  Cavendish  square,  W.  Vice-Pres.  1859-60. 
Council,  1861-62,  1867.  Treas.  1863*64.  Pres. 
1865-66.     Trans.  32.     Trustee. 


FKLLOWS  OF  THE  SOCIETY.  XV 

Elected 

18/5  Baknes,  R.  S.  Fancourt,  M.D,,  Physician  to  the  Chelsea 
Hospital  for  Women  ;  7,  Queen  Anne  street,  Cavendish 
square,  W,  Council,  1879-81.  Board  Exam.  Mid- 
wives,  1880-2.     Trans.  2. 

1884  Barraclough,  Robert  W.  S.,  M.D.,  34,  Dulwich  road, 
Heme  hill,  S.W. 

ISSfif  Barrington,  Fourness,  M.B.Edin.  (c/o  The  Commercial 
Bank  of  Sydney,  18,  Birchin  Lane,  E.G.) 

1891  Barton,   Edwin  Alfred,  L.R.C.P.Lond.,  35,  Cheniston 

Gardens,  Kensington,  W. 

1892t  Barton,Francis Alexander, B.A.Cantah., L.R.C.P.Lond., 
Gonville  House,  Penge  road,  Beckenham. 

1887     Barton,  Henry  Thomas   61,  Harford  street,  E. 

1887t  Barton,  William  Edwin,  L.R.C.P.  Lond,,  Staunton-on- 
Wye,  near  Hereford. 

1861*tBARTRCM,  John  S.,  F.R.C.S.,  Surgeon  to  the  Bath  General 
Hospital;   13,  Gay  street,  Bath.     Council,  1877-9. 

1892t  Batchelor,  Ferdinand  Campion,  M.D.Durh.,  Dunedin, 
New  Zealand. 

1873  Bate,  George  Paddock,  M.D.,  412,  Bethnal  Green  road, 
N.E.  ;  and  2,  Northumberland  Houses,  King  Edward 
road.  Hackney.     Council,  1882-4. 

1887t  Baumgabtner,  Henry  Spelman,  M.B.  Durh.,  1,  North 
street,  Saville  place,  Newcastle-on-Tyne. 

1871t  Beach,  Fletcher,  M.B.,  F.R.C.P.,  Darenth  Asylum,  Dart- 
ford,  Kent.     Council,  1893. 

1871  Beadles,  Arthur,  Park  House,  Dartmouth  Park,  Forest 
hill,  S.E. 

1892  Beadchamp,  Sydney,   M.B.,  B.C.Cantab.,   146,  Cromwell 

road,  S.W. 

1866*tBELCHER,  Henry,  M.D.,  28,  Cromwellroad,  West  Brighton. 

187 If  Bell,  Robert,  M.D.  Glasg.,  29,  Lynedoch  street,  Glasgow. 

1880t  Beninqton,  Robert  Crewdson,  M.D.  Durh.,  59,  Osborne 
road,  Newcastle-on-Tyne. 


Xvi  FELLOWS    OF    THE    SOCIETY. 

Elected 

1889t  Benson,  Matthew,  M.D.Brux.,  35,  Dicconson  street, 
Wigan 

1893  Beenau,  Henry  Ferdinand,  L.E.C.P.  Lond.,  Park  House, 
East  Fincliley,  N. 

1883  Bertolacci,  J.  Hrwetson,  care  of  Dr.  March,  Woodlawn, 
Spencer  park,  New  Wandsworth,  S.W. 

1889t  Best,  William  James,  I,  Cambridge  terrace,  Dover. 

1893t  Bett8,  Frederick  Bernard,  L.R.C.P.  Lond.,  Autofagasta, 
Chili,  South  America. 

189 If  Beville,    Frederick    Wells,    L.R.C.P.Lond.,  The  Firs, 

Palace  road.  East  Molesey. 
1887t  Biden,  Charles  Walter,  L.R.C.P.Lond.,  Laxfield,  Frana- 

lingham. 
1879     Biggs,  J.  M.,  Hillside,  Child's  hill,  N.W. 
1892     Bird,  Matthew   Mitchell,  M.D.,  B.S.Durh.,  St.  Mary's 

Hospital,  W. 

I889t  Bisshopp,  Francis  Robert  Bryant,  M.A.,  M.B., 
B.C.  Cantab.,  Belvedere,  Mount  Pleasant,  Tunbridge 
Wells. 

1890  Black,  George,  M.B.,  B.S.Lond.,  50,  Cazenove  road, 
Stamford  hill,  N. 

1868*  Black,  James  Watt,  M.A.,  M.D.,  F.R.C.P.,  Obstetric  Physi- 
cian to  the  Charing  Cross  Hospital  ;  15,  Clarges  street, 
Piccadilly,  W.  Council,  1872-4.  Vice-Pres.  1885-6. 
Chairman,  Board  Exain.  Midwives,  1887-90.  Prus. 
1891-2. 

I861*tBLAKE,  Thomas  William,  Hurstbourne,  Bournemouth, 
Hants. 

1872*tBLAND,  George,  Surgeon  to  the  Macclesfield  Lifirmary  ; 
Park  Green,  Macclesfield. 

1887  Bluett,  Geokgk  Mallack,  L.R.C.P.  Lond.,  3,  Priory  road, 
Bedford  park,  Chiswick,  W. 

1892  Bond,  William  Arthur,  M.A.,  M.D.,  B.S.Cantab.,  21,  Old 
square,  Lincoln's  Inn,  W.C. 


FKLLOWS    Ol'    THE    SOCIETY.  XVll 

Elected 

1883     BoNNEY,  William  Augustus,  M.D,,  145,  Beaufort  street, 

Chelsea,  S.W. 
1893t  BoswELL,  Henry  St.  George,  M.B.  Edin.,  High  street, 

Saffron  Walden, 

1866*  BouLTON,  Percy,  M.D.,  Physician  to  the  Samaritan  Free 
Hospital  ;  6,  Seymour  street,  Portmau  square,  W. 
Council,  1878-80,  1885.  Hon.  Lib.  1886.  Hon.  Sec. 
1886-9.  Fice-Pres.  1890-92.  Board  Exam.  Midwives, 
1890-91.     Trans.  A. 

1886t  BousTEAD,  Robinson,  M.D.,  B.C.  Cantab.,  Surgeon-Major, 
Indian  Army;  10,  Palmeira  avenue,  Hove,  Brighton 
(c/o  Messrs.  H.  S.  King  and  Co.,  45,  Pall  Mall,  S.W.) 

1877  BowKETT,  Thomas  Edward,  145,  East  India  road,  Poplar, 
E.     Council,  1890. 

1884*  BoxALL,  Robert,  M.D.Cantab.,  Assistant  Obstetric  Physi- 
cian to,  and  Lecturer  on  Practical  Midwifery  at,  the 
Middlesex  Hospital ;  29,  Weymouth  street,  Portland 
place,  W.  Council,  1888-90.  Board  Exam.  Midwives, 
1891-3.     Trans.  10. 

1884t  Boys,  Arthur  Henry,  L.R.C.P.  Ed.,  Chequer  Lawn,  St. 
Albans. 

1886t  Bradbury,  Harvey  K.,  208,  Ashby  road,  Burton-on- 
Trent. 

1877t  Bradley,  Michael  McWilliams,  M.B.,  Jarrow-on-Tyne. 

1873  Braithavaite,  James,  M.D.,  Obstetric  Physician  to  the 
Leeds  General  Infirmary ;  Lecturer  on  Diseases  of 
Women  and  Children  at  the  Leeds  School  of  Medicine  ; 
16,  Clarendon  road.  Little  Woodhouse,  Leeds.  Vice- 
Pres.  1877-9.     Trans.  4.     Hon.  Loc.  Sec. 

1880f  Beanfoot,  Arthur  Mudge,  M.B.,  Superintendent  of  the 
Government  Lying-in  Hospital,  Madras,  and  Professor 
of  Midwifery  and  Diseases  of  Women  and  Children  in 
the  Madras  Medical  College,  Pantheon  road,  Madras. 
Hon.  Loc.  Sec. 

1887  Bridger,  Adolphus  Edward,  M.D.  Ed.,  16,  Orchard  street, 
Portman  square,  W. 


XVlll  FELLOWS    OF    THE    SOCIETY. 

Elected 

1888*tBKiGOs,  Heniiy,  M.B.,  F.R.C.S.,  Surgeon  to  the  Hospital 
for  Women,  and  Hon.  Med.  Officer  to  the  Lying-in- 
Hospital,  Liverpool ;  3,  Rodney  street,  Liverpool. 

1864  BuiGHT,  John  Meaburn,  M.D.,  Alvaston,  Park  hill,  Forest 
hill,  S.E.     Council,  1873-74. 

1869     Brisbane,  James,  M.D.,  16,  St.  John's  Wood  road,  N.W. 

ISBof  Briscoe,  John  Frederick,  The  Lammas,  Esber,  Surrey. 

I887t  Brodie,  Frederick  Garden,  M.B.,  Oak  street,  Fakenham, 
Norfolk. 

1866  Beodie,  George  B.,  M.D.,  Consulting  Physician-Accoucheur 
to  Queen  Charlotte's  Lying-in  Hospital ;  3,  Chesterfield 
street,  Mayfair,  W.  Council,  \S7 3-7 b.   Fice-Pre^.,  1889. 

1892  Brodie,  William  Haig,  M.D.,  C.M.Edin.,  88,  Oxford 
terrace,  Hyde  park,  W. 

1889t  Brook,  William  Henry  B.,  M.D.  Lond.,  F.R.C.S.,  James 
street,  Lincoln. 

1876  Brookhouse,  Charles  Turing,  M.D.,  43,  Manor  road, 
Brockley,  S.E. 

1889t  Brown,  Alfred,  M.A.,  M.B.,  CM.  Aber.,  Claremont,  Higher 
Broughton,  Manchester. 

1868  Brown,  Andrew,  M.D.  St,  And.,*  1,  Bartholomew  road, 
Kentish  town,  N.W.     Council,  1893.     Trans.  1. 

186.5*  Brown,  1).  Dyce,  M.D.,  29,  Seymour  street,  Portmau 
square,  W. 

1889*tBR0WN,  William  Carnegie,  M.D.  Aber.,  Penang,  China. 

1S76  Bhunjes,  Martin,  33a,  Gloucester  place,  Portman  square, 
W. 

1865  Brunton,  John,  M.D.,  M.A.,  Surgeon  to  the  Royal 
Maternity  Charity;  21,  Euston  road,  N.W.  Council 
1871-3.  Vice-Pres.  1882-4.  Board  Exam.  Midwives, 
1877-82.     Trans.  6. 

1883     Buksh,  Kaheem,  The  Hall,  Plaistow,  E. 

18S2*  Buller,  Audley  Cecil,  M.D.,  Oxford  and  Cambridge 
Club,  Pall  Mall,  S.W. 


FELLOWS    OF    THK    SOCIETY.  xix 

Elected 

1885*tBuNNY,  J.  Brice,  L.R.C.P.  Ed.,  Newbury. 

1877t  BuRD,  Edward,  M.D.,  M.C.,  Senior  Physician  to  the  Salop 

Infirmary ;    Newport    House,    Shrewsbury.     Coimcil, 

1.S8G-7.     Hon.  Loc.  Sec. 

1891  Burgess,  Edward  Arthur,  26,  Chichester  road,  Crickle- 
wood,  N.W. 

1888  Burton,  Herbert  Campbell,  L.R.C.P.  Lend.,  Lee  Park 
Lodge,  Blackheath,  S.E. 

1878  Butlee-Smythe,  Albert  Charles,  L.R.C.P.Ed.,  76,  Brook 
street,  Grosvenor  square,  W.     Council,  1889-91. 

1887*  Buxton,  Dudley  W.,  M.D.  Lond.,  82,  Mortimer  street, 
Cavendish  square,  W. 

18861  Byers,  John  W.,  M.D.,  Physician  for  Diseases  of  Women 
to  the  Royal  Hospital,  Belfast;  Lower  crescent,  Bel- 
fast. 

1883    Caldwell,  William  T.  D.,  M.D.,  209,  Brixton  road,  S.W. 

1891  Oalthrop,  Lionel  C.   Evbrard,  M.B.  Durh.,   II,  Beau- 

mont crescent,  West  Kensington,  "W. 

1887t  Cameron,  James  Chalmers,  M.D.,  Professor  of  Midwifery 
and  Diseases  of  Infancy,  McGill  University;  941,  Dor- 
chester street,  Montreal. 

I887t  Cameron,  Murdoch,  M.D.  Glas.,  7,  Newton  terrace. 
Charing  Cross,  Glasgow. 

1892  Campbell,  John  William,  B.A.,  M.B.,  B.Ch.    Cantab., 

Highclere,  Oakleigh  park.  Whetstone,  N. 
1888*fCAMPBELL,  William  Macfie,  M.D.  Edin.,  1,  Princes  gate 
East,  Liverpool. 

186 If  Candlish,  Henry,  M.D.,  6,  Barns  street,  Ayr,  N.B. 
1886f  Carpenter,  Arthur  Bkistoave,  M.A.,  M.B.Oxon.,  Wyke- 

ham  House,  Bedford  park,  Croydon. 
1872     Carter,  Charles  Henry,  M.D.,  Physician  to  the  Hospital 

for  Women,  Soho  square  ;  4.5,  Great  Cumberland  place, 

Hyde  park,  W.     Cou7icil,  \880-2.     Trans.  4. 
1890     Carter,  Robert  James,  M.B. Lond.,  4,  St.  John's  Wood 

terrace,  N.W. 


XX  FELLOWS    OF    THE    SOCIETY. 

Elected 

1877  Cakvek,  Eustace  John,  Glenthorpe,  Woodside  Lane, 
North  Finchley,  N, 

1887     Case,  William,  34,  Westbourne  road,  Arundel  square,  N. 

1863t  Cayzer,  Thomas,  Mayfield,  Aigburth,  Liverpool. 

1875t  Chaffers,  Edward,  F.R.C.S.,  54,  North  street,  Keighley, 
Yorkshire. 

1876*  Champneys,  Francis  Henry,  M.A.,  M.D.Oxon.,  F.R.C.P., 
Physician-Accoucheur  to,  and  Lecturer  on  Midwifery 
at,  St.  Bartholomew's  Hospital;  42,  Upper  Brook 
street,  W.  Council,  X^^^A.  Hon.  Lib.  \882-3.  Hon, 
Sec.  1884-7.  Vice-Pres.  1888-90.  Board  Exam.  Mid- 
wives,  1883,  1888-90;  Chairman,  1891-93.    Trans.  16. 

1859  Chance,  Edward  John,  F.R.C.S.,  Surgeon  to  the  Metro- 
politan Free  Hospital  and  City  Orthopaedic  Hospital ; 
14,  Russell  square,  W.C. 

lfiG7*tCHARLES,  T.  Edmondstoune,  M.D.,  Cannes,  France. 
Council,  1882-4. 

1874t  Charlesworth,  James,  M.D.,  Physician  to  the  North 
Staffordshire  Infirmary ;  25,  Birch  terrace,  Hanley, 
Staffordshire. 

188Gt  Charpentier,  Ambrose  E.  L.,  M.D.  Durh.,  60,  High  street, 
Uxbridge. 

1892t  Chei'mell,  Charles  William  James,  M.D.  Brux.,  87, 
Buckingham  road,  Brighton. 

1868*tCuiLD,  Edwin,  "Vernham,"  New  Maiden,  Kingstou-on- 
Thames,  Surrey. 

lS90t  Childe,  Charles  Plumley,  B.A.,  F.R.C.S,,  Cranleigh, 
Kent  road,  Southsea. 

1883t  Childs,  Christopher,  M.A.,  M.D.  Oxon.,  Lindisfarne, 
AVeymouth.     Hon.  Loc.  Sec. 

1863*tCHisiiOLM,  Edwin,  M.D.,  Abergeidie,  Ashfield,  near  Sydney, 
New  Soutli  Wales.  [Per  Messrs.  Turner  and  Hen- 
derson, care  of  Messrs.  W.  Dawson,  121,  Cannon 
street,  E.G.] 


FELLOWS    OF    THE    SOCIETY.  XXi 

Elected 

1883  Clapham,  Edward,  M.D.,  29,  Lingfield  road,  Wimbledon. 
Council,  1892-93. 

1859  Claremont,  Claude  Clarke,  Millbrook  House,  1,  Hamp- 
stead  road,  N.W. 

1879     Clarke,  Reginald,  South  Lodge,  Lee  park,  Lee,  S.E. 

1893     Clarke,  W.  Bruce,  F.R.C.S.,  46,  Harley  street,  W. 

O.F.f  Clay,  Charles,  M.D.,  Tower  Lodge,  Poulton-le-Fylde, 
Lancashire. 

18761  Clay,  George  Langsford,  West  View,  443,  Moseley 
road,  Highgate,  Birmingham, 

O.F.f  Clay,  John,  Professor  of  Midwifery,  Queen's  College,  Bir- 
mingham ;  Allan  House,  Steelhouse  lane,  Birmingham. 
Council,  1868-69.     Vice-Pres.  18/2-4. 

1889  Clemow,  Arthur  Henry  Weiss,  M.D.,  CM.  Edin.,  1, 
Comeragh  road.  West  Kensington,  W. 

O.F.  Cleveland,  William  Frederick,  M.D.,  Stuart  villa, 
199,  Maida  vale,  W.  Council,  1863-64.  Fice-Pres. 
1875-77,  1887-89.     Trans.  1. 

1881t  Close,  James  Alex.,  M.B.,  2031,  Olive  street,  St.  Louis, 
Missouri,  U.S.A. 

1865*tCoATEs,  Charles,  M.D.,  Physician  to  the  Bath  General 
and  Royal  United  Hospitals;  10,  Circus,  Bath. 

1882t  CoATEs,  Frederick  William,  M.D.  (travelling).  Council, 
1891-93. 

1875  Coffin,  PticHARD  Jas.  Maitland,  F.R.C.P.  Ed.,  98,  Earl's 
Court  road,  W. 

1878  Coffin,  Thomas  Walker,  22,  Upper  Park  road,  Haver- 
stock  hill,  N.W. 

1875*fCoLB,  Richard  Beverly,  M.D.  Jefferson  Coll.  Philad., 
218,  Post  street,  San  Francisco,  California,  U.S. 

1888t  Collins,  Edward  Tenison,  Campden  House,  Oakfidd 
road,  Selly  park,  Birmingham. 

1877     CoLMAN,  Walter  Tawell  (travelling). 


XXii  FELLOWS    OP   THE    SOCIETY. 

Elected 

1866t  Coombs,  James,  M.D.,  Bedford, 

1874  Cooper,  Hekbert,  L.R.C.P.  Ed.,  Tburlow  House,  Hamp- 

stead,  N.W. 

1888  Cooper,  Peter,  L.R.C.P.Lond.,  Stainton  Lodge,  35, 
Shooter's  Hill  road,  Blackheath,  S.E. 

1890  CoPELANU,  William  Henry  Laurence,  M.B.Cantab.,  59, 
Warwick  road,  Earl's  Court,  S.W. 

1888t  Corby,  Henry,  B.A.,  M.D.,  62,  South  Mall,  Cork. 

1875*tCoRDES,  Aug.,  M.D.,  M.R.C.P.,  Consulting  Accoucheur  to 
the  "  Misericorde  ;"  Privat  Docent  for  Midwifery  at  the 
University  of  Geneva ;  1 2,  Rue  Bellot,  Geneva.  Trans.  1. 

1883     Corner,  Cuesham,  113,  Mile  End  road,  E. 

1888t  Cornish,  Charles  Newton,  L.R.C.P.  Ed.,  Busbey  Heath, 
Herts. 

1860*tCoRRY,  Thomas  Charles  Steuart,  M.D.,  Senior  Surgeon 
to  the  Belfast  General  Dispensary  ;  Ormeau  terrace, 
Belfast.  Council,  1867.  Vice-Pres.  1891-93.  Son. 
Loc.  Sec. 

1888t  Cory,  Isaac  Rising,  L.R.C.P.  Lond.,  Sbere,  Guildford. 

1875  Cory,  Robert,  M.D.,  Assistant  Obstetric  Physician  to  St. 

Thomas's  Hospital ;  73,   Lambeth   Palace   road,    S.E. 
Co?iHc«7, 1879-81,1884-5.  Fice-Pre*.  1887-88.  TransA. 

1886t  Cox,  Joshua  John,  M.D.  Ed.,  St.  Eonan's,  Clarendon  road, 
Eccles,  Manchester. 

1869t  Cox,  Richard,  M.D.  St.  And.,  Theale,  near  Reading. 
Trans.  1. 

1893t  Craig,  James,  M.D.  Edin.,  Brisgow  House,  Beckenham. 

1877  Crawford,  James,  M.D.  Durb.,  Grosvenor  Mansions,  80, 
Victoria  street,  S.W. 

ISSlf  Creasy,  James  Gideon,  West  House,  Wrotham,  Kent. 

18761  Crew,  John,  Manor  House,  Higham  Ferrers,  Northampton- 
shire. 


FELLOWS    OF    THE    SOCIETY.  Xxiii 

Elected 

1893  Cripps,  William  Harrison,  F.E.C.S.,  2,  Stratford 
place,  W. 

1889t  Croft,  Edward  Octavius,  L.R.C.P.  Lond.,  8,  Clarendon 
road,  Leeds. 

188 If  Ceonk,  Herbert  Geoege,  M.B.  Cantab.,  Eepton,  near  Bur- 
ton-on-Trent. 

1886*tCR0ss,  "William  Joseph,  M.B.,  Horsham,  Victoria,  Aus- 
tralia. 

1889t  Crouch,  Edward  Thomas,  Lee  House,  Stoke  road,  Gosport. 

187;")*  CuLLiNGWORTH,  Charles  James,  M.D.,  F.R.C. P.,  Obstetric 
Physician  to,  and  Lecturer  on  Obstetric  Medicine  at, 
St.  Thomas's  Hospital;  46,  Brook  street,  Grosvener 
square,  W.  Council,  1883-5,  1891-93.  Fice-Pres. 
1886-8.     Board  Exam.  Midwives,  IS89 -9 1.    Trans.  9. 

18.59t  Cuegenven,  J.  Brendon,  Teddington  Hall,  Teddington. 
Council,  1870-72.     Trans.  3. 

1889*tCuESETJi,  Jehangir  J.,  M.D.  Brux.,  94,  Chundunwadi, 
Bombay. 

188.5  Dakix,  W.  Eadford,  M.D.,  Obstetric  Physician  to,  and 
Lecturer  on  Midwifery  at,  St.  George's  Hospital;  57, 
Welbeck  street.  Cavendish  square,  W.  Council,  1889- 
91.     Hon.  Lib.  \892-93.     Trans.  3. 

1868  Daly,  Frederick  Heney,  M.D.,  185,  Amhurst  road. 
Hackney  Downs,  N.E.  Council,  1877-9.  Vice-Fres. 
1883-5.     Trans.  2. 

1882f  Dambrill-Davies,  William  R.,  Alderley  Edge,  Cheshire. 

1888t  Dane,  Robert,  General  Hospital,  Singapore,  Straits  Settle- 
ments. 

1893  Dauber,  John  Henry,  M.A.  Oxon.,  L.R.C.P.  Lond.,  20, 
Davies  street,  Berkeley  square,  W. 

1889     Davies,    Fredeeick   Henry,  M.B.,  C.M.Edin.,  40,   St. 

Stephen's  avenue.  Shepherd's  Bush,  W. 
1876    Davies,  Gomer.  L.R.C.P.  Ed.,  9,  Pembridge  villas,  Bays- 

water,  W. 


Xxiv  FELLOWS    OF    THE    SOCIETY. 

Elected 

1884  Davies,  John,  91,  New  North  road,  N. 

1885  Davies,  William   Morriston,  M.D.,  55,  Gordon  square, 

W.C. 
1892t  Davis,  Robert,  Oakleigh,  Epsom, 

1877    Davson,  Smith  Houston,  M.D.,  Campden  villa,  203,  Maida 

vale,  W.     CoMwc«7,  1889-91. 
1891     Dawson,   Ernest,  L.R.C.P.Lond.,   The   Mount,   Hamp- 

stead,  N.W. 
1889     Dawson,  William  Edwaed,  L.K.Q.C.P.  &  L.M.,  83,  Chis. 

well  street,  E.G. 
1880t  Day,  William   Hankes,  Surgeon   to   the   City   Prisons, 

Norwich;  3,  Surrey  street,  Norwich.     Titans.  1. 

1859     Day,  William  Henry,  M.D.,  Physician  to  the  Samaritan 
.     .  Free   Hospital  for  Women    and    Children;    10,  Man- 

chester square,  W.  Co?<n«7, 1873-75.  Vice-PresA885-G. 

1889     Des  Vceux,  Harold  A.,    M.D.Brux.,  4,  Ashley  gardens, 

Victoria  street,  S.W. 
1879t  DoLAN,  Thomas  Michael,  M.D.,  Horton  house,  Halifax. 

1886t  Donald,  Archibald,  M.A.,  M.D.  Edin.,  274,  Oxford  road, 
Manchester.     Council,  1893.     Trans.  1. 

1879*  DoEAN,  Alb  AN  H.  G.,  F.R.C.S.,  Surgeon  to  the  Samaritan 
Free  Hospital ;  9,  Granville  place,  Portman  square,  W. 
Council,  1883-5.  Hon.  Lib.  1886-7.  Hon.  Sec.  1888-91. 
Vice-Pres.  1892-93.     Trans.  11. 

1890t  Douty,  Edward  Henry,  M.A.,  M.B.,  B.C.  Cantab.,  69, 
Bridge  street,  Cambridge. 

1887  DovASTON,  MiLWARD  Edmund,  81,  Queen's  crescent, 
Haverstock  hill,  N.W. 

1880  Downes,  Denis  Sidney,  L.K.Q.C.P.  I.,  55,  Kentish  town 
road,  N.W. 

1884t  Doyle,  E.  A.  Gaynes,  L.R.C.P.,  Colonial  Hospital. 
Port  of  Spain,  Trinidad. 

O.F.t  Drage,  Charles,  M.D.,  Hatfield,  Herts.  Council,  1861-4, 
Trans,  1. 


FELLOWS    OF    THE    SOCIETY.  XXV 

Elected 

1885t  Drage,  Lovell,  M.A.,  M.B.,  B.S.  (Oxon),  Burleigh  Mead, 
Hatfield. 

187 If  Drake-Brockman,  Edward  Forster,  F.R.C  S.,  L.R.C.P. 
Lond.,  Brigade-Surgeon ;  Superintendent  Eye  Infirmary, 
Madras ;  Professor  of  Physiology  and  Ophthalmology, 
Madras  Medical  College.  [Per  Messrs.  Richardson 
and  Co.,  East  India  Army  Agency,  25,  Suffolk  street, 
Pall  Mall,  S.W.] 

1884    Drake,  Charles  Henry,  204,  Brixton  hill,  S.W. 

1883  Duncan,  Alexander  George,  M.B.,  25,  Amhurst  park, 
Stamford  hill,  N. 

O.F.  Duncan,  James,  M.B.,  8,  Henrietta  street,  Covent  garden, 
W.C.     Council,  1873-74. 

1882  Duncan,  William,  M.D.,  Obstetric  Physician  to,  and  Lec- 
turer on  Obstetric  Medicine  at,  the  Middlesex  Hospital ; 
G,  Harley  street,  W.  ComwcjY,  188.5-6,  1888-89.  Ron. 
Lib.  1890-91.     Hon.  See.  1892-93.     Trans.  2. 

18i)3f  Dunn,  Philip  Heney,  L.E.C.P.  Lond.,  Stevenage,  Herts. 

1891  Eady,  George  John,  M.D.Brux.,  Glengarry,  West   End 

lane,  AYest  Hampstead,  N.W. 

1871  Eastes,  George,  M.B.,  F.R.C. S.,  35,  Gloucester  place, 
Hyde  park,  W.     Council,  1878-80. 

1883t  EccLES,  F.  Richard,  M.D.,  Professor  of  Physiology, 
Western  University  ;  1,  EUwood  place.  Queen's  avenue, 
London,  Ontario,  Canada. 

1892  EccLES,  William  McAdam,  M.B.,  B.S.  Lond.,  St.  Bartho- 

mew's  Hospital,  E.C. 

1893  Eden,  Thomas  Watts,  M.D.,  CM.  Edin,,  Queen  Charlotte's 

Hospital,  Marylebone  road,  N.W. 

1890t  Ehrmann,  Albert,  L.R.C.P.Lond.,  Bitterne,  near  South- 
ampton. 

I879t  Elder,  George,  M.D.,  CM.,  Surgeon  to  the  Samaritan 
Hospital  for  Women,  Nottingham;  17,  Regent  street, 
Nottingham, 


XXvi  FELLOWS    OF    THE    SOCIETY. 

Elected 

18781  Ellery,  Richard,  L.R.C.P.Ed.,  Plympton,  Devon. 

1873t  Engelmann,  George  Julius,  A.M.,  M.D,,  3003,  Locust 
street,  St.  Louis,  Missouri,  U.S. 

1884     English,  Thomas   Johnston,   M.D.,    128,   Fulham   road, 

S.W. 
1892t  Evans,  John  Morgan,  L.R.C.P.Lond.,  Llandrindod  Wells, 

Radnorshire. 

1875t  Ewakt,  John    Henry,  Eastney,  Devonshire  place,   East- 
bourne. 

1876t  Farxcombe,  Richard,  40,  Belgrave  street,  Balsall  heath, 
Birmingham. 

1869     Farquhae,    William,    M.D.,    Deputy    Surgeon-General, 
17,  St.  Stephen's  road,  Bayswater,  W. 

1861     Faer,    Geo.    F.,    L.R.C.P.  Ed.,  Slade   House,    175,    Ken- 
nington  road,  S.E.     Council,  1885. 

1882t  Farrar,  Joseph,  M.D.,  Gainsborough. 

1868*  Fegan,  Richard,  M.D.,  Westcombe  park,  Blackheath,  S.E. 

1888t  Fegen,  Charles    Milton,   Devonshire   House,  Brandon, 
Suffolk. 

1886     Fennell,  David,  L.K.Q.C.P.I.,  35,  The  Grove,  Highbury, 

N. 

1883     Fenton,  Hugh,  M.D.,  27,  George  street,  Hanover  square, 
W. 

1886t  Fisher,  Frederick  Bazley,  L.E.C.P.  Lond.,  West  Walk 
House,  Dorchester. 

1882t  Fitzgerald,    Charles   Egerton,   M.D.,    West  Terrace, 
Folkestone. 

1892t  Finny,  W.  Evelyn  St.  Lawrence,  M.B.  Dubl,  Kenlis, 

Queen's  road,  Kingston  hill. 
1877*tfoNMARTiN,   Henry    de,  M.D.,   1,  Anchor  Gate  terrace, 

Portsea. 

1884t  Ford,  Alexander,  L.R.C.P.Ed.,  9,  Beresford  street, Water- 
ford. 

1877*tFoRD,  James,  M.D.,  Eltham,  Kent. 


FELLOWS    OF    THE    SOCIETY.  XXVH 

Elected 

1884     FouRACRE,  Robert  Perriman,  20,  Tollington  park,  N. 

ISSGf  Fowler,  Charles  Owen,  M.D.,  Trevor  Lodge,  Thornton 
heath. 

1875*fFRASER,  Angus,  M.D.,  Physician  and  Lecturer  on  Clinical 
Medicine  to  the  Aberdeen  Royal  Infirmary  ;  232,  Union 
street,  Aberdeen. 

1888t  Feaser,  James  Alexander,  L.R.C.P.  Lond.,  Western 
Lodge,  Romford. 

I867t  Freeman,  Henby  W.,  24,  Circus,  Bath.    Council,  1891-93. 

1880t  Fry,  John  Blount,  Ashley  Lodge,  Esher,  Surrey. 

1883  Fuller,  Henry  Roxburgh,  M.D.  Cantab.,  45,  Curzon 
street,  Mayfair,  W.     Council,  1893.     Trans.  1. 

I886f  Furner,  Willoughby,  F.R.C.S.,  2,  Brunswick  place, 
West  Brighton.     Hon.  Loc.  Sec. 

1874*  Galabin,  Alfred  Lewis,  M.A.,  M.D.,  F.R.C.P.,  Obstetric 
Physician  to,  and  Lecturer  on  Midwifery  at,  Guy's 
Hospital ;  49,  Wimpole  street,  Cavendish  square,  W. 
Council,  1876-78.  Hon.  Lib.  1879.  Hon.  Sec.  1880-3. 
Vice-Pres.  1884.  Treas.  1885-8.  Pres.  1889-90. 
Trans.  12.  ' 

1888  Galloway,  Arthur  Wilton,  L.R.C.P.  Lond.,  79,  New 
North  road,  N. 

1863  Galton,  John  H.,  M.D.,  Chunam,  Sylvan  road.  Upper 
Norwood,  S.E.     Council,  1874-6,  1891-92. 

1881     Gandy,  William,  Hill  Top,  Central  hill,  Norwood,  S.E. 
1886t  GrARDE,  Henry  Croker,  F.R.C.S.  Edin.,  Maryborough, 
Queensland. 

1887  Gardiner,  Brtjce  H.  J.,  L.R.C.P.  Ed.,  Gloucester  House, 
Barry  road,  East  Dulwich,  S.E. 

1879t  Gardner,  John  Twiname,  Northfield  House,  Hfracombe. 

1872t  Gardner,  William,  M.A,,  M.D.,  Professor  of  Gynaecology, 
McGill  University ;  Gynaecologist  to  the  Montreal 
General  Hospital;  109,  Union  avenue,  Montreal, 
Canada. 


XXviii  FELLOWS    OF    THE    SOCIETY 

Elected 

1892t  Gardner,    William,   M.B,,   C.M.Glas.,   Melbourne   (c/o 

The    Manager,    Commercial     Bank   of    Australia,    1, 

Bishopsgate  street  Within,  E.G.). 

I870t  Garner,  John,  52,  New  Hall  street,  Birmingham. 

189 It  Garrett,  Arthur  Edward,  L.R.C.S.,  &  L.M.Ed.,  The 
Limes,  Rickmansworth. 

1873t  Garton,  William,  M.D.,  F.R.C.S.,  Inglewood,  Aughton, 
near  Ormskirk. 

1889*  Gell,  Henry  Willingham,  M.A.,  M.B.  Oxon.,  43,  Albion 
street,  Hyde  park,  W. 

18J9*  Gervis,  Henry,  M.D.,  F.R.C.P.,  Consulting  Obstetric 
Physician  to  St.  Thomas's  Hospital ;  40,  Harley  street. 
Cavendish  square.  Council,  1864-66,  1889-91,  1893. 
Hon.  Sec.  1867-70.  Fice-Pres.  1871-3.  Treas. 
1878-81.     Pres.  1883-4.     Trans.  8. 

1866*  Gervis,  Frederick  Heudebourck,  1,  Fellows  road, 
Haverstock  hill,  N.W.  Council,  1877-9.  Fice-Pres. 
1892.     Trans.  1. 

1884t  GiBB,  Charles  John,  M.D.,  Westgate  House,  Newcastle- 
on-Tyne. 

1875  GiBBiNGS,  Alfred  Thomas,  M.D.,  93,  Richmond  road, 
Dalston,  N.E.     Council,  1885-6,  1888. 

1883  Gibbons,  Robert  Alexander,  M.D.,  Physician  to  the 
Grosvenor  Hospital  for  Women  and  Children ;  29, 
Cadogan  place,  S.W.     Council,  1889-90.     Trans.  1. 

1874t  Gibson,  James  Edward,  Hillside,  West  Cowes,  Isle  of 
Wight. 

1892  Giles,  Arthur  Edward,  M.D.  Lond.,  M.R.C.P.,  2,  Hare- 
wood-square,  N.W. 

1869     Gill,  William,  L.R.C.P.  Lond.,  11,  Russell  square,  "W.C. 

1 89 1  Gimblett,  William  Henry,  L.R.C.P.L,  34,  Perabury  road, 
Clapton,  N.E. 

189 If  Gledden,  Alfred  Maitland,  M.D.,  c/o  L.  Bruck,  13, 
Castlereagh  street,  Sydney,  N.S.W. 


FELLOWS    OF    THE    SOCIETY.  XXIX 

Elected 

1871  GoDDARD,  Eugene,  M.D.  Durh.,  North  Lynne,  Highbury 
New  Park,  N.     Trayis.  1. 

1871  *GoDsoN,  Clement,  M.D.,  CM.;  9,  Grosvenor  street,  W. 
Council,  1876-77.  Ho7i.  Sec.  1878-81.  Vice-Pres. 
1882-4.  Board  Exam.  Midwives,  1877,  1882-86. 
Trans.  5. 

1868f  Godwin,  Ashton,  M.D.,  9,  Prospect  terrace,  Ramsgate. 
1883     Gordon,  John,  M.D.,  20,  Wickham  road,  Brockley,  S.E. 
1869t  Goss,  Tregenna  Biddulph,   1,  The  Circus,  Bath.      Hon. 
Loc.  Sec. 

1891t  Gostling,  William  Ayton,  M.D. ,  B.S.Lond.,  Barninghain, 
West  Worthing. 

1889  Goullet,  Charles  Arthur,  L.R.C.P.Lond.,  2,  Finchley 

road,  N.W. 

1890  Gow,   William   John,   M.D. Loud.,  Physician-Accoucheur 

in  charge  of  Out-patieuts,  St.   Mary's   Hospital ;   13, 
Upper  Wimpole  street,  W.     Council,  1893. 

lS93t  GowAN,  Bowie  Campbell,  L.R.C.P.Lond.,  Raven  Dene, 
Great  Stanmore. 

1885t  Grakt,  Ogilvie,  M.D.,  Queen  Mary's  House,  Inverness. 

1890t  Gray,  Harry  St.  Clair,  M.D.  Glas.,  15,  Newton  terrace, 

Glasgow. 
187.5t  Gray,  James,  M.D.,  15,  Newton  terrace,  Glasgow. 

1890     Green,    Charles    David,    M.D.Lond.,   Addison    House, 

Upper  Edmonton. 
I884t  Greene,  Walter,  L.K.C.P.  Loud.,  Wallingford. 

1887     Greenwood,   Edwin    Climson,  L.R.C.P.,    19,  St.  John's 

wood  park,  N.W. 
1863  *Griffith,   G.    de    Gorreuuer,  34,  St.    George's  square, 

S.W.  Trans.  2. 
1879*  Griffith,  Walter    Spencer    Anderson,    M.D.  Cantab., 

F.R.C.S.,   M.R.C.P.,  Assistant  Physician-Accoucheur 

to  St.  Bartholomew's  Hospital ;   114,  Harley  street,  W. 

Council,     1886-8,     1893.       Board   Exam.    Midwives, 

1887-89.     Trans.  6. 


XXX  FELLOWS    OF    THE    SOCIETY. 

Elected 

1870  *Gi{iGG,  William  Chapman,  M.D.,  Physician  to  the  In- 
patients, Queen  Charlotte's  Lying-in  Hospital;  Assistant 
Obstetric  Physician  to  the  Westminster  Hospital ; 
27,  Curzon  street,  Mayfair.  Council,  \S7 5-77.  Board 
Exam.  Midwives,  1878-79. 

1888*tGKiMSDALE,  Thomas  Babington,  B.A.,  M.B.  Cantab.,  50, 
Eodney  street,  Liverpool. 

O.F.f  GrimsdalEjThos.  F.,  L.E.C.P.  Ed.,  Consulting  Surgeon  to 
the  Lying-in  Hospital  ;  29,  Rodney  street,  Liverpool. 
Council,  1861-62.      Vice-Pres.  1875-76. 

1882t  Gripper,  Walter,  M.B.  Cantab.,  The  Poplars,  Wallington, 
Surrey. 

1880  Grogono,  Walter  Atkins,  Berwick  House,  Broadway, 
Stratford,  E. 

1879t  Grove,  William  Richard,  M.D.,  St.  Ives,  Huntingdonshire. 

1892     GuBB,  Alfred  Samuel,  M.D.  Paris,  29,  Gower  street,  W.C. 

1887t  Hackney,  John,  M.D.  St.  And,,  Oaklands,  Hythe. 

1881t  Hair,  James,  M.D.,  Brinklow,  Coventry. 

1889  Hale,  Charles  D.  B.,  M.D.,  8,  Sussex  gardens,  Hyde 
park,  W. 

1889t  Hall,  Frederick,  M.D.St.  And.,  St.  Mark's  House,  Leeds. 

1871t  Hallowes,  Frederick  B.,  Redhill,  Eeigate,  Surrey.  Coun- 
cil, 1885-6,  1888-90. 

1880  Hames,  George  Henry,  F.R.C.S.,  29,  Hertford  street. 
Park  lane,  W. 

1887t  Hamilton,  John,  F.R.C.S.Ed.,  Beechhurst  House,  Swad- 
lincote, Burton-on-Trent. 

1883  Handfield-Jones,  Montagu,  M.D.  Lond.,  M.R.C.P.,  Phy- 
sician-Accoucheur  to,  and  Lecturer  on  Midwifery  and 
Diseases  of  Women  at,  St.  Mary's  Hospital  ;  35, 
Cavendish  square,  AV.     Council,  1887-89.      Trans.  1. 

18G0  Hahdky,  Key,  Surgeon  to  the  West  City  Dispensary;  4, 
Wardrobe  phice.  Doctors'  Coramous,  E.G. 


FELLOWS    OF    THE    SOCIETY.  XXxi 

Elected 

1889t  Hakdwick,  Arthur,  M,D.  Durh.,  Newquay,  Cornwall. 

1886t  Hardy,  Henry  L.  P.,  Holly  Lodge,  Richmond  road, 
Kingston-on-Thames. 

1892     Harold,  John,  L.R.C.P.Loud.,  72,  Wimpole  street,  W. 

1889  Harper,  Charles  John,  L.R.C.P.  Lond.,  Church  end, 
Finchley,  N. 

1877  Harper,  Gerald  S.,  M.B.Aber.,  40,  Curzon  street.  May- 
fair,  W. 

1878t  Harries,  Thomas  Davies,  F.R.C.S,,  Grosvenor  House, 
Aberystwith,  Cardiganshire. 

1867*  Harris,  William  H.,  M.D.,  32,  Cambridge  gardens,  W. 

1880*  Harrison,  Richard  Charlton,  13,  Saudringham  gardens, 
Ealing,  W. 

1893t  Harrison,  Sydney  Nevill,  M.B.,  B.C.Cantab.,  Aveley 
Court,  Stourport. 

1890t  Hart,  David  Berry,  M.D.Edin.,  29,  Charlotte  square, 
Edinburgh. 

1886t  Hartley,  Horace,  L.R.C.P.  Ed.,  Stone,  Staffordshire. 

1886t  Hartley,  Reginald,  L.R.C.P.  Ed.,  Kirkgate  House,  Thirsk. 

1880  Harvey,  John  Stephenson  SELWYN,M.D.Durh.,M.R.C.P.. 
1,  Astwood  road,  Cromwell  road,  S.W, 

iy65t  Harvey,  Robert,  M.D.,  Abbottabad,  Punjab.  [Per 
Messrs.  Cochran  and  Macpherson,  152,  Union  street, 
Aberdeen.]     Trans.  1. 

1886  Harvey,  Sidney  Fred.,  L.R.C.P.Lond.,  117a,  Queen's 
Gate,  S.W. 

lS92t  Hawkins-Ambler,  George  Authur,  F.R.C.S. Ed.,  162, 
Upper  Parliament  street,  Liverpool. 

1888t  Haycock,  Henry  Edward,  L.R.C.P.Ed,,  Ironville  House, 
Alfreton,  Derbyshire. 

I893t  Haydon,  Thomas  Horatio,  M.B.,  B.C.  Cantab.,  50,  Mount 
Ararat  road,  Richmond,  Surrey. 


XXXll  FELLOWS    OF    THE    SOCIETY. 

Elected 

1873     Hayes,  Thomas   Chawford,  M.A.,  M.D.,  F.R.C.P.,  Ob- 

stetric    Physician    to    King's    College    Hospital,   and 

Lecturer  on  Practical    Midwifery  at  King's    College  ; 

17,  Clarges  street,  Piccadilly,  W.     Council,    1876-78. 

VicePres.   1890-91. 
1880     Heath,    William    Lenton,    M.D.,  88a,    Cromwell    road, 

Queen's  gate,  S.W.     Council,  1891.     Trans.  1. 

1893  Heelas,  Walter  Wheeler,  L.R.C.P.Lond.,  General 
Lying-in  Hospital,  York  road,  S.E. 

1892t  Hellier,  John  Benjamin,  M.D.Lond.,  Lecturer  on  Dis- 
eases  of  Women  and  Children,  Yorkshire  College; 
Surgeon  to  the  Hospital  for  Women  and  Children, 
Leeds;   1,  De  Grey  terrace,  Leeds. 

1890t  Helme,    T.    Arthur,    M.D.  Edin.,    St.    Mary's    Hospital, 

Manchester, 
1867t  Hembeough,  John  William,  M.D.,  Earsdon,  Newcastle- 

on-Tyne. 

1876*  Herman,  George  Ernest,  M.B.,  F.R.C.P.,  Obstetric  Phy- 
sician to,  and  Lecturer  on  Midwifery  at,  the  London 
Hospital ;  20,  Harley  street,  Cavendish  square,  W. 
Council,  \878-79.  Hon.  Lib.  1880-1.  Hon.  Sec.  1882-5. 
Vice.Pres.  1886-7.  Board  Exam.  Midwives,  1886-88. 
Treas.  1889-92.     Pres.  1893.     Trans.  26. 

O.F.  Hewitt,  Graily,  M.D.,  F.R.C.P.,  F.R.S.  Ed.,  Consulting 
Obstetric  Physician  to  University  College  Hospital ; 
'6^,  Berkeley  square,  W.  Hon.  Sec.  18.59-64.  Treas. 
186.5-66.  Fjce-Prea.  1867-68.  Pres.1869-70.  Trans. 2\. 

1860*  Hicks,  John  Braxton,  M.D.,  F.R.C.P.,  F.R.S. ,  Consulting 
Obstetric  Physician  to  Guy's  and  St.  Mary's  Hospitals  ; 
34,  George  street,  Hanover  square.  Council,  1861-2, 
1869.  Hon.  Sec.  1863-65.  Vice-Pres.  1866-68. 
Treas.  18/0.     Pres.  1871-2.      Trans.  38. 

1892t  Hills,  Thomas  Hyuk,  L.R.C.P.Lond.,  60,  St.  Andrew's 
street,  Cambridge. 

1886t  Hodges,  Herbkkt  Chamney,  L.R.C.P.Lond.,  Watton, 
Herts.      Trans.  1. 


FELLOWS    OF    THE    SOCIETY.  XXXlil 

Elected 

O.F.  Hodges,  Richard,  M.D.,  F.R.C.S.,  358,  Camden  road,  N. 
Trans.  3. 

1887t  HoDsoN,  Henry  Algernon,  L.R.C.P.  Ed.  &  L.M.,  23, 
Brunswick  square,  Brighton. 

1886t  HoLBERTON,  Henry  Nelson,  L.R.C.P.  Lond.,  East 
Molesey. 

1875  Rollings,   Edwin,   M.D.,    25,   Endsleigh   gardens,  N.W. 

Council,  1888-90.     Fice-Pres.  1893. 
1886     HoLLOWAY,  William  George,  B.A.,  M.D.  Cantab.,  5,  Ben- 
tinck  street,  Cavendish  square,  W. 

1859  Holman,  Constantine,  M.D.,  26,  Gloucester  place,  Port- 
man  square,  W,  Council,  1867-69.  Vice-Pres. 
1870-71. 

189 If  Holman,  Robert  Colgate,  Whithorne  House,  Midhurst, 
Sussex. 

1864*  Hood,  Wharton  Peter,  M.D.,  11,  Seymour  street,  Port- 
man  square,  "VV. 

1S72  Hope,  William,  M.D.,  Physician  to  Queen  Charlotte's 
Lying-in  Hospital  ;  54,  Curzon  street,  Mayfair,  W. 
Council,  1877-9.     Soard  Exam.  Midwives,  1873-4. 

1884     Hopkins,  John,  L.R.C.P.  Ed.,  93,  Camberwell  road,  S.E. 

1883*  Horrocks,  Peter,  M.D.,  F.R.C.P.  Lond.,  Assistant  Ob- 
stetric  Physician  to,  and  Demonstrator  of  Practical 
Obstetrics  at,  Guy's  Hospital ;  26,  St.  Thomas's  street, 
S.E.  CoMrtciY,  1886-7.  Hon.Lib.\%^S-9.  Hon.  Sec. 
1890-93.     Trans.  1. 

1876  Horsman,  Godfrey  Charles,  22,  King   street,  Portman 

square,  W. 

1883     HosKiN,  Theophilus,  L.R.C.P.  Lond.,  186,  Amhurst  road, 

N.E. 
1883     HoucHiN,  Edmund  King,  L.R.C.P.  Ed.,  23,  High  street, 

Stepney,  E. 
I884t  Hough,  Charles  Henry,  Full  street,  Derby. 

1877  Howell,  Horace  Sydney,  M.D.,  East  Grove   House,  18, 

Boundary  road,  St.  John's  Wood,  N.W. 

c 


XXXIV  FELLOWS    OF    THE    SOCIETY. 

Elected 

1879t  Hubbard,  Thomas  Wells,  Rock  House,  Boughton  Mon- 
chelsea,  Maidstone. 

1885  Hughes,  Edgak  A.,  L.R.C.P.Lond,,  91,  Onslow  gardens, 

S.W. 

1889t  Humphrys,  Charles  Beyer,  L.R.C.P.  &  S.  Edin.,  Hurst 
Lea,  Sevenoaks. 

1884*tIIuRRY,  Jamieson  Boyd,  M.D.  Cantab.,  43,  Castle  street, 
Reading.     Council,  1887-9.     Trans.  2. 

1878t  Husband,  Walter  Edward,  56,  Bury  New  road,  Man- 
chester. 

1882  HuTTON,  Robert  James,  L.R. C.P.Ed.,  Carshalton,  Staple- 
ton  Hall  road,  Finsbury  park,  N. 

1883t  Inmax,  Robert  Edward,  Gadsbill  Cottage,  Higbara,  Kent. 

1884t  Irwin,  John  Arthur,  M.A.,  M.D.,  14,  West  Twenty-ninth 
street,  New  York. 

1887  Jackson,  G.  E.  Corrie,  F.R.C.S.  Ed.,  5,  Gt.  Marlborough 
street,  W. 

1883t  Jackson,  George  Henry,  6,  Cliff  Bridge  terrace,  Scar- 
borough. 

1884     Jackson,  James,  15,  Huntingdon  street,  Barnsbury,  N. 

18731  Jakins,  William  Vosper,  L.R.C.P.  Ed.,  165,  Collins  street 
East,  Melbourne. 

I872t  Jalland,  Robert,  Horncastle,  Lincolnshire.     Trans.  1. 

1890t  James,  Charles  Henry,  L.R.C.P.Lond.,  Surg.  Indian 
Army  (care  of  Messrs.  Grindlay  and  Co.,  55,  Parlia- 
ment street,  S.W.). 

1877t  Jamieson,  Patrick,  M.A.,  3,  St.  Peter's  street,  Peterhead, 
Aberdeenshire. 

1885t  Jamieson,  Robert  Alexander,  M.D.,  Shanghai.  [Per 
Messrs.  Henry  S.  King  and  Co.,  65,  Cornhill,  E.G.] 

1886  Jamison,   Arthur    Andrew,    M.D.    Glas.,    18,  Lowndes 

street,  S.W. 
1883*tJENKiN3,    Edward    Johnstone,    M.B.  Oxon.,    Australian 
Club,  Sydney.     [Per  H.  K.  Lewis,  136,  Gower  street, 
W.  C] 


FELLOWS    OF    THE    SOCIETY.  XXXV 

Elected 

1877t  Jenks,  Edward  W.,  M.D.,  84,  Lafayette  avenue,  Detroit. 

Michigan,  U.S. 
1882     Jennings,  Charles  Egerton,  M.D.  Durh.,  F.R.C.S.  Eng., 

Assistant  Surgeon  to  the  North-West  London  Hospital ; 

48,  Seymour  street,  Portman  square,  W. 

1889t  Johns,  Henry  Douglas,  M.B.,  B.S,  Durh.,  Ivy  Lodge, 
Hornsea,  HuU. 

1883t  Johnson,  Arthur  Jukes,  M.B.,  52,  Bloor  street  West, 
Toronto,  Ontario,  Canada. 

1877t  Johnson,  Samuel,  M.D.,  5,  Hill  street,  Stoke-upon-Trent. 

1881  Johnston,  Joseph,  M.D.,  24,  St.  John's  Wood  park,  N.W. 
Council,  1891-92. 

1879     Johnston,  Wm.  Beech,   M.D.,   157,  Jamaica   road,   Ber- 

mondsey,  S.E. 
18681  Jones,  Evan,  Ty-Mawr,  Aberdare,  Glamorganshire,    Council, 

1886-8.     Fece.-P?m  1890-91.     Hon.  hoc.  Sec. 

1878  Jones,  H.  Macnaughton,  M.D.,  F.R.C.S.L  and  Edin., 
141,  Harley  street,  Cavendish  square,  W. 

1881f  Jones,  James  Robert,  M.B.,  171,  Donald  street,  Winnipeg, 
Manitoba,  Canada. 

1868     Jones,  John,  60,  King  street.  Regent  street,  W. 

1887t  Jones,  J.  Talfourd,  M.B.  Lond.,  Rose  Bank,  South  terrace, 

Eastbourne. 
1886     Jones,  Lewis,  M.D.,  Oakmead,  Balham,  S.W. 

1885t  Jones,  P.  Sydney,  M.D.,  16,  College  street,  Hyde  park, 
Sydney.  [Per  Messrs.  D.  Jones  and  Co.,  1,  Gresham 
buildings,  Basinghall  street,  E.C.] 

1873t  Jones,  Philip  W.,  River  House,  Enfield. 

18S6t  Jones,  William  Owen,  The  Downs,  Bowden,  Manchester. 

1879t  JouBERT,  Charles  Henry,  M.B,  Lond.,  F.R.C.S.  Eng., 
Surgeon-Major,  Bengal  Medical  Department ;  Obstetric 
Physician  to  Eden  Hospital,  and  Professor  of  Mid- 
wifery and  Diseases  of  Women  and  Children,  Calcutta 
Medical  College ;   6,  Harington  street,  Calcutta. 


XXXVl  FELLOWS    OF    THE    SOCIETY. 

Elected 

1878t  JuDsoN,  Thomas  Robert,  L.R.C.P.  Lond.,  Hayraan's 
Green,  West  Derby,  Liverpool. 

IS/of  Jukes,  Augustus,  M.B.,  N.  W,  Mounted  Police,  Regina, 
N.-W,  Territory,  Canada. 

1878t  Kane,  Nathaniel  H.  K.,  M.D.,  Lanherne,  Kingston  hill, 
Surrey. 

1890t  Kanthack,  Alfredo  Antunes,  M.D.  Lend.,  31,  Rodney 
street,  Liverpool. 

1884  Keates,  William  Cooper,  L.R.C.P.,  2,  Tredegar  villas, 
East  Dulwich  road,  S.E. 

]880t  Kebbell,  Alfred,  Flaxton,  York. 

O.F,  Keele,  George  Thomas,  81,  St.  Paul's  road,  High- 
bury, N.     Council,  1885. 

1883t  Keeling,  James  Hurd,  M.D.,  267,  Grlossop  road,  Sheffield. 
Hon.  Loc.  Sec. 

1890  Keith,  Skene,  M.B.,  C.M.Edin.,  42,  Charles  street, 
Berkeley  Square,  W. 

1 874  Kempster,  William  Henry,  M.D.,  Oak  House,  Bridge  road, 
Battersea,  S.W. 

1886  Kennedy,  Alfred  Edmund,  L.R.C.P,  Ed.,  Chesterton 
House,  Plaistow,  E. 

1879  Ker,  Hugh  RicHAKD,  L.R.C.P.  Ed.,  14,  Devonshire  Eoad, 
Balham,  S.W. 

1872  Kerr,  Norman  S.,  M.D.,  F.L.S.,  42,  Grove  road.  Regent's 
park,  N.W. 

1877*tKERSwiLL,  John  Bedford,  M.R.C.P.  Ed.,  Fairfield,  St. 
German's,  Cornwall. 

1878t  Khor^,  Rustonjee  Naserwanjee,  M.D.  Brussels,  L.Med. 
Bombay,  Physician  to  the  Parell  Dispensary,  Bombay ; 
Girgaum  road,  Bombay. 

O.F.  Kiallmark,  Henry  Walter,  5,  Pembridge  gardens,  Bays- 
water.     Council,  1879-80. 

I892t  KiNGscoTE,  Ernest,  M.B.,  C.M.Edin.,  Crane  Cottage, 
Salisburv. 


FELLOWS    OF   THE    SOCIETY.  XXXVll 

Elected 

1860t  KiNGSFORD,  Edward,  F.R.C.S.,  Surgeon  to  the  Sunbury 
Dispensary  ;  Sunbury-on-Thames. 

1892t  KiNSEY-MoRGAN,  AUGUSTUS,  1,  Stanhope  gardens,  Bourne- 
mouth. 

1872*  KiscH,  Albert,  186,  Sutherland  avenue,  W. 

I876t  Knott,  Charles,  M.R.C.P.  Ed.,  Liz  Ville,  Elm  grove, 
Southsea. 

1889     Lake,    George    Robert,    72,  Gloucester   crescent,    Hy 
park,  W. 

1867*  Laxgford,  Charles  P.,  Sunnyside,  Hornsey  lane,  N. 

1883     Laxgley,  Aaron,  L.R.C.P.  Ed.,  149,  AValworth  road,  S.E. 

1886  Lankester,   Herbert  Henry,  M.D.  Lond.,   1,  Elm  park 

gardens,  South  Kensington,  S.W. 

1886t  Lauder,  William,  i\I.D.  Edin.,  260,  Oxford  road,  Man- 
chester. 

1893t  Layer,  Henry,  Head  street,  Colchester. 

1887  Law,  William  Thomas,  ]\LD.  Edin.,  9,  Norfolk  crescent,  W. 

1875t  Lawrence,  Alfred  Edward  Aust,  M.D.,  Physician- 
Accoucheur  to  the  Bristol  General  Hospital;  19, 
Richmond  hill,  Clifton,  Bristol.  Council,  1885-86, 
1888.     Vice-Pres.,  1889-90.    Hon.  Loc.  Sec.    Trans.  1. 

1878t  Leachman,  Albert  Warren,  M.D.,  Fairley,  Petersfield, 
Hants. 

1884*tLEDiARD,  Henry  Ambeose,  M.D.,  43,  Lowther  street, 
Carlisle.     Council,  1890-92.     Trans.  1. 

1887t  Lees,  Edwin  Leonard,  M.D.,  CM.  Ed.,  2,  The  Avenue, 
Redland  road,  Bristol. 

1860t  Leishman,  William,  ]M.D.,  Physician  to  the  University 
Lying-in  Hospital,  Eegius  Professor  of  Midwifery  in 
the  University  of  Glasgow;  11,  Woodside  crescent, 
Glasgow.  Council,  1866-68.  Vice-Pres.  1869-70. 
Trans.  1. 

18S5  Lewers,  Arthur  H.  N.,  M.D.  Lond.,  M.R.C.P.,  Obstetric 
Physician  to  the  London  Hospital ;  60,  Wimpole  street, 
W.     Council,  1887-89,  1893.     Trans.  7. 


XXXVlll  .FELLOWS    OF    THE    SOCIETY. 

Elected 

1877t  Lewis,  John  Riggs  Miller,  M.D.,  Deputy-Surgeon  General 
Markham  Lodge,  Liverpool  road,  Kingston  hill,  Surrey. 

1885t  LiDiARD,  Sydney  Robert,  L.R.C.P.  Ed.,  Berkeley  House, 
Anlaby  road,  Hull. 

IS/of  LiEBMAN,  Carlo,  M.D.  Vienna,  Principal  Surgeon,  Trieste 
Civil  Hospital,  Trieste,  Austria.    Trans.  1. 

1868  Llewellyn,  Evan,  L.R.C.P.  Ed.,  114,  Bethune  road,  Stam- 
ford hill,  N, 

1872*tLocK,  John  Griffith,  M.A.,  2,  Rock  terrace,  Tenby. 

1893f  Logan,  Roderic  Robert  "Walter,  Leighton  Buzzard. 

1859t  Lombe,  Thomas  Robert,  M.D.,  Bemerton,  Torquay. 

1890  Low,  Harold,  M.B.Cantab.,  Round  Hill  Villa,  Syden- 
ham, S.E. 

18931  Lowe,  Walter  George,  M.D.  Lond.,  F.R.C.S.,  Burton- 
on-Trent. 

1890  Lubbock,  Edgar  Ashley,  L.R.C.P.Lond.,  4,  Westfield 
terrace,  Fulham  road,  S.W. 

1873t  Lush,  William  John  Henry,  M.D.Brux.,  Fyfield,  near 
Andover. 

1878*tLYCETT,  John  Allan,  M.D.,  Gatecombe,  Wolverhampton. 

1871t  McCallum,  Duncan  Campbell,  M.D.,  Emeritus  Professor, 
McGill  University;  45,  Union  avenue,  Montreal,  Canada, 
Trans.  4. 

1890  McC ANN,  Frederick  John,  M.B.,  C.M.Edin.,  34,  Bernard 
street,  W.C.     Trans.  2, 

1890  McCaw,  John  Dysart,  F.R.C.S.,  Ivy  House,  Lincoln  road, 
East  Finchley,  N. 

1892t  Mackay,  William  John,  M.B.,  M.Ch.  Sydney,  Rooty  hill, 
Sydney,  N.S.W. 

I879t  Mackeough,  George  J.,  M.D.,  Chatham,  Ontario,  Canada, 
O.F.t   Mackinder,  Draper,  M.D.,  Consulting    Surgeon    to   the 

Gainsborough  Dispensary;  Gainsborough,  Lincolnshire. 

Council,  1871-3.     Trans.  2. 


FELLOWS    OF    THE    SOCIETY.  XXXIX 

Elected 

1893  McLean,  Ewan  John,  M.D,,  CM.  Edin.,  Hospital  for 
Women,  Chelsea,  S.W. 

1886  McMuLLEN,  William,  L.K.Q.C.P.I.,  319a,  Brixton  road, 

S.W. 

1893  Macpiiail,  Archibald  Lamont,  L.F.P.S.  &  L.M.  Glas., 
138,  Stoke  Newington  road,  N, 

1884  Malcolm,  John  D.,  M.B.,  CM.,  Surgeon  to  the  Samaritan 
Free  Hospital  ;    13,  Portman  street,  AV. 

1871t  Malins,  Edward,  M.D.,  Obstetric  Physician  to  the 
General  Hospital,  Birmingham  ;  8,  Old  square,  Bir- 
mingham. Co?<nc?7,  1881-3,  Vice-PresA^M-d.  Hon. 
Loc.  Sec. 

1868*tMARCH,  Henry  Colley,  M.U.,  2,  AVest  street,  Roch- 
dale.     Council,  1890-92. 

1887  Mark,  Leonard  P.,  L.R.CP.  Lond.,  61,  Cambridge  street, 

Hyde-park  square,  W. 

18G0t  Marley,  Henry  Frederick-,  The  Nook,  Padstow,  Cornwall. 
1862*tMARRiOTT,  Eobert  Buchanan,  SwafFliam,  Norfolk. 

1887t  Marsh,  0.  E.  Bulwer,  L.R.CP.  Ed.,  Parkdale,  CJytha 
park,  Newport,  Monmouthshire. 

1890t  Martin,  Christopher,  M.B.,  CM. Edin.,  3,  TJie  Crescent, 
Birmingham.      Trans.  1. 

1887t  Mason,  Arthur  Henry,  L.R.CP.Lond.,  Oakwood,  Walton- 
on-Thames. 

1884  Massey,  Hugh  Holland,  2,  North  terrace,  Camberwell, 
S.E. 

1884  Masters,  John  Alfred,  M.D.Durh.,  Westall  House, 
Brook  green,  W. 

1877  Maunsell,  H.  Widenham,  A.M.,  M.D.,  37,  Stanhope 
gardens,  Queen's  gate,  S.W. 

1883  Maurice,  Oliver  Calley,  75,  London  street,  Reading. 
Council,  1888-90. 

1890  May,  Chichester  Gould,  M.A.,  M.B.  Cantab.,  26,  Walton 
street,  Pont  street,  S.AV. 


Xl  FELLOWS    OF    THE    SOCIETY. 

Elected 

.877     May,  Lewis  James,  Bouutis  Thorne,  Seven  Sisters  road, 

Finsbury  park,  N. 
1884t  Maynakd,  Edward  Charles,  L.R.C.P.  Ed.,  2.  Cambridge 

gnrdens,  Richmond  hill. 

189 If  Mayner,  Alfred  Edgar,  M.D.Montreal,  27,  Sutton  street, 

Kingston,  Jamaica. 
1885t  Meller,  Charles  Booth,  L.R.C.P.  Ed.,  Cowbridge,  Gla- 

morganshire. 

1886     Mennell,  Zebulon,  1,  Royal  crescent,  Notting  hill,  W. 
1882     Meredith,  William  Appleton,  M.B.,  CM.,   Surgeon  to 

the  Samaritan  Free  Hospital  for  Women  and  Children  ; 

21,  Manchester  Square,  W.     Council,   1886-8.     Fice- 

Pres.  1891-93.     Trans.  3. 

1893t  MiCHiE,  Harry,  M.B.  Aber.,  27,  Regent  street,  Nottingham. 
1875*tMiLES,  Abijah  J.,  M.D.,  Professor  of  Diseases  of  Women 

and  Children  in  the  Cincinnati  College  of  Medicine, 

Cincinnati,  Ohio,  U.S. 
1876t  MiLLMAN,   Thomas,    M.D.,   490,    Huron   street,  Toronto, 

Ontario,  Canada. 

1880t  Mills,    Robert  James,  M.B.,  M.C.,   35,    Surrey  street, 
Norwich. 

1876  Milson,  EicHARD  Henry,  M.D.,  88,  Finchley  road,  South 

Hampstead,  N.W.     Council,  1690. 
1892t  Milton,   Herbert    M.    Nelson,    Kasr-el-Aini    Hospital, 
Cairo,  Egypt. 

t869*tMiNNs,  Pembroke  R.  J.  B.,  M.D.,  Thetford,  Norfolk. 
1867*  Mitchell,  Robert  Nathal,  M.D.,  Chester  House,  Wick- 
ham  road,  Brockley,  S.E. 

1893t  MoNTBRUN,  D.  Antonio  de,  L.R.C.P.  Lond.,  Port  of  Spain, 
Trinidad,  AV.L 

1892t  MoNTBRUN,   Domingo  de,    M.D.Caracas,    Port   of  Spain, 
Trinidad,  W.L 

1877  Moon,  Frederick,  M.B.,  Bexley  house,  Greenwich,  S.E. 
18.')9t  Moorhead,  John,  M.D.,  Surgeon  to  the  Weymouth   Lifir- 

mary  and  Dispensary  ;  Weymouth,  Dorset. 


FELLOWS    OF   THE    SOCIETY.  xli 

Elected 

1888t  Morgan,  George   John,  L.K.Q.C.P.  &  L.M.,  Dovaston 

House,  Kinnerley,  near  Oswestry. 
1888     MoRisoN,  Alexander,  M.D.Ed.,  Dunnottar,   11.5,  Green 

lanes,  Stoke  Newington,  N. 

1890  Morris,    Charles    Arthur,    M.A.,   M.B.,    B.C.Cantab., 

F.R.C.S.,  30,  Ebury  street,  S.W. 

1883     Morris,  Clarke  Kelly,  Gordon  Lodge,  Charlton  road, 

Blackheath,  S.E. 
1893     Morrison,    James,    L.E.C.P.  Lond.,    St.    Bartholomew's 

Hospital,  E.G. 

1891  MoRTLocK,   Charles,  L.R.C.P.Lond.,  83,  Oxford  terrace, 

W. 
1886t  Morton,     Shadforth,  M.D.  Durham,  24,  Wellesley  road, 

Croydon. 
1879     Moullin,  James    A.    Mansell,    M.A.,   M.B.,    Assistant 

Physician  to  the  Hospital  for  Women  and   Children, 

69,  Wimpole  street,  Cavendish  square,  W.     Trans.  1. 
1885     Murray,    Charles    Stormont,    L.R.C.S.  and  L.M.   Ed., 

85,  Gloucester  place,  Portman  square,  W. 
1893t  Murray,  Robert  Milne,   M.B.  Edin.,   10,  Hope  street, 

Edinburgh. 
O.F.      Musgrave,  Johnson  Thomas,  L.E-.C.P.  Ed.,  Irlam  Villa, 

39,Finchleyroad,  N.W.     CohwciY,  1859-60.     Trans.  \. 
1888     Myddelton-Gavey,    Edward    Herbert,    94,    Wimpole 

street,  W. 
1893t  Nairne,  John  Stuart,  F.R.C.S.  Ed.,  12,  Royal  crescent. 

Crossbill,  Glasgow. 
1887     Napier,    A.    D.    Leith,    M.D.  Aber.,    M.E.C.P.  Lond., 

F.R.S.  Edin.,  Physician  to  the  Royal  Maternity  Charity ; 

67,  Grosvenor  street,  W.     Trans.  2. 
1892t  Nash,  W.  Gifford,  F.R.C.S.,  2,  Harpur  place,  Bedford. 
1859t  Neal,  James,  M.D.,  Parterre,  Sandown,  Isle  of  Wight. 
1882t  Nesham,  Thomas  Cargill,  M.D.,  Lecturer  on  Midwifery 

in  the  University  of  Durham   College  of  Medicine  at 

Newcastle-on-Tyne  ;  12,   Ellison  place,   Newcastle-on- 

Tyne.     Council,  1889-91. 


Ixii  FELLOWS    OF    THE    SOCIETY. 

Elected 

1859*tNEWMAN,  William,  M.D.,  Surgeon  to  the  Stamford  and 

Rutland    Infirmary ;     Barn    Hill    House,    Stamford, 

Lincolnshire.    Council,  18/3-75.     Vice-Pres.  18/6-77. 

Trans.  5. 
I889t  Netvniiam,     William      Hakry     Chbistopher,      M.A., 

M.B.Cantab.,  1,  Leicester  place,  Clifton,  Bristol. 

18931  NicHOL,  Frank     Edward,    M.A.,   M.B.,    B.C.Cantab., 

1 1,  Ethelbert  Terrace,  Margate. 
1873t  Nicholson,  Arthur,  M.B.  Lend.,  98,   Montpellier  road, 

Brighton. 
1879t  Nicholson,  Emilius  Rowley,  M.D.,  11,  19,  Cornwallis 

gardens,  Hastings. 

1876     Nix,  Edward  James,    M.D.,    11,   Weymouth  street,   W. 

Council,  1889-90. 
1882t  Norman,  John  Edward,  Lismore  House,  Hebburn-on-Tyne. 

]883t  NuNN,  Philip  W.  G.,  L.R.C.P.  Lond.,  Maplestead,  Christ- 
church  road,  Bournemouth. 

1884t  Oakes,  Arthur,  M.D.,  Lachsmeade,  Staveley  road,  East- 
bourne. 

1880t  Oakley,  John,  Holly  House,  Wood's  end,  Halifa.v,  York- 
shire. 

1886  Ogle,  Arthur  Wesley,  L.R.C.P.  Lond.,  90,  Cannon 
street,  E.C. 

O.F.  Oldham,  Henry,  M.D.,  F.R.C.P.,  Consulting  Obstetric 
Physician  to  Guy's  Hospital ;  4,  Cavendish  place,  Caven- 
dish square,  W.  Vice-Fres.  1859.  Council,  1860, 
1865-60.  r/-e««.  1861-62.  P/<e*.  1863-64.  TransA. 
Trustee. 

1888  Oliver,  Franklin  Hewitt,  L.R.C.P.  Lond.,  2,  Kingsland 

road,  N.E. 

1889  Oliver,   James,  M.D.,  F.R.S.  Edin.,  F.L.S.,  Physician  to 

the   Hospital  for  Women,  Soho  square;    18,  Gordon 
square,  W.C. 

1884  Openshaw,  Thomas  Horrocks,  M.B.,  M.S.,  16,  Wimpole 
street,  \V. 


FELLOWS   OF    THE    SOCIETY.  xliii 

Elected 

1890  Ore,  A.  Aylmer,  M.A.,  M.B.Oxon.,  204,  Earl'a  Court 
road,  W. 

1890t  OsBURN,  Harold  Burgess,  L.R.C.P.,  Bagshot,  Surrey. 

1877t  OsTERLOH,  Paul  Rudolph,  M.D.  Leipzic,  Physician  for 
Diseases  of  Women,  Diaconissen  Hospital;  16,  Sido- 
nienstr.,  Dresden. 

1892  Owen,  Samuel  Walshe,  L.R.C.P.Lond.,  10,  Shepherd's 
Bush  road,  "W. 

1889*  Page,  Harry  Marmaduke,  F.R.C.S.,  10",  London  wall, 
E.G. 

1891t  Page,  Herbert  Markant,  M.D.Brux.,  16,  Prospect  hill, 
Redditch. 

1883  Palmer,  John  Irwin,  47,  Queen  Anne  street,  Cavendish 
square,  W. 

1877*  Paramore,  Richard,  M,D.,  2,  Gordon  square,  "W.C. 

1867*tP-^i^K3,  JoHX,  Bank  House,  Manchester  road.  Bury,  Lanca- 
shire. 

1887  Parsons,  John  Inglis,  M.D.Durh.,  M.R.C.P.,  Physician 
to  Out  Patients,  Chelsea  Hospital  for  M^omen,  3,  Queen 
street,  Mayfair,  W.     Trails.  1. 

1880     Parsons,  Sidney,  78.  Kensington  Park  road,  W. 

1889  Parsons,  Thomas  Edward,  Paddock  House,  Ridgeway, 
Wimbledon. 

1865*tPA.TERS0N,  James,  M.D.,  Hayburn  Bank,  Partick,  Glasgow. 

1882*  Peacey,  William,  M.D.,  11,  Breakspears  road,  Brockley, 
S.E. 

1864  Pearson,  David  Ritchie,  M.D.,  23,  Upper  Phillimore 
place,  Kensington,  W. 

1871  Pedler,  George  Henry,  6,  Trevor  terrace,  Rutland  gate, 
S.W. 

ISSOf  Pedley,  Thomas  Franklin, M.D. , Rangoon, India.  Trans.  1. 

ISSlf  Perigal,  Arthur,  M.D.,  New  Barnet,  Herts.  Council, 
1892-93. 


xliv  FELLOWS    OF    THE    SOCIETY. 

Fleeted 

1871t  Perkigo,    James,    M.D.,    53,    Union    avenue,    Montreal, 

Canada.     Hon.  Loc.  Sec. 
1879*  Pesikaka,  Hormasji  Dosabhai,  23,  Hornby  row,  Bombay. 
1883     Pettifer,  Edmund  Henuy,  32,  Stoke  Newington  green,  N. 

1879  Phillips,  George  Richard   Turner,   24,    Palace   court, 

Bayswater  hill,  W.     Council,  1891. 

1882  Phillips,  John,  M.A.,  M.D.  Cantab.,  F.R.C.P.,  Assistant 

Obstetric  Physician   to   King's   College   Hospital;   71, 
Grosvenor  street,  W.     Council,  1887-9,  1893.     Board 
Exam.  Midwives,  1892-3.     Trans.  7. 
1891     Phillips,  W.  E.  Picton,  38,  Walsingham  House,  Piccadilly. 

1878     Philpot,  Joseph  Henry,  M.D.,  61,  Chester  square,  S.W. 

Council,  1891. 
1871*  Philps,  Philip  George,  21,  Russell  road,  Kensington,  W. 
1876     PiCAED,  P.  KiRKPATRicK,  M.D.,  59,  Abbey  road,  St.  John's 

Wood,  N.W. 

1889t  PiNiioRN,  Richard,  L.R.C.P.  Lend.,  5,  Cambridge  terrace, 
Dover. 

1889t  Playfair,  David  Thomson,  M.D.,  CM.  Edin.,  Redwood 
House,  Bromley,  Kent. 

1893  Playfair,  Hugh  James  Moon,  M.D.  Lond.,  44,  Cambridge 
terrace,  W. 

1864*  Playfair,  W.  S.,  M.D.,  LL.D.,  F.R.C.P.,  Physician- 
Accoucheur  to  H.I.  &  R.H.  the  Duchess  of  Edinburgh  ; 
Professor  of  Obstetric  Medicine  in  King's  College, 
and  Obstetric  Physician  to  King's  College  Hospital; 
31,  George  street,  Hanover  square,  W.  Council,  1867. 
1883-5.  Hon.  Librarian,  1868-9.  Hon.  Sec.  1870- 
72.     Fice-Pres.  1873-5.     Pres.  1879-80.     Trans.  15. 

1880  PococK,  Frederick  Ernest,  M.D.,  The  Limes.  St.  Mark's 

road,  Notting  hill,  AY. 

1883  PococK,  Walter,  374,  Brixton  road,  S.W. 

1891  Pollock,  William  Rivers,  M.B.,  B.C.Cantab.,  56,  Park 
street,  Grosvenor  square,  W. 

1883     PooK,  William  John,  L.R.C.P.,  2,  Hemingford  road,  N. 


FELLOWS    OF    THE    SOCIETY.  xlv 

Elected 

1876  Pope,  H.  Campbell,  M.D.,  F.R.C.S.,  Broomsgrove  Villa, 
280,  Goldhawk  road.  Shepherd's  Bush,  W. 

1891  Pope,  Henry  Sharland,  M.B.,  B.C.Cantab.,  Royal  Chest 
Hospital,  City  road,  E.C. 

1888  PoPHAM,  Robert  Brooks,  L.R.C.P.Lond.,  (>7,  Bartho- 
lomew road,  Camden  road,  N."W. 

1882t  Porter,  Joseph  Francis,  M.D.,  Helmsley,  Yorkshire. 

1864  Potter,  John  Baptiste,  M.D.,  F.R.C.P.,  Obstetric  Physi- 
cian to,  and  Lecturer  on  Midwifery  and  Diseases  of 
Women  at,  the  Westminster  Hospital ;  20,  George 
street,  Hanover  square,  W.  Council,  18/2-6,  1890-92. 
Hon.  Lib.  1877-8.  Vice-Pres.  1879-81.  Treas.  \  882-4, 
1893.  Board  Exam.  Midwives,  \883-4.  Pre*.  1885-6. 
Trans.  1. 

I884t  Powell,  John  James,  L.R.C.P.  Lond.,  Norwood  Lodge, 
Weybridge. 

I885t  Praeger,  Emil  Arnold,  Nanaimo,  British  Columbia. 

1886  Prangley,  Henry  John,  L.R.C.P.  Lond.,  Tudor  House, 
197,  Anerley  road,  Anerley,  S.E. 

1880*  Prickett,  Marmaduke,  M.A.Cantab.,  M.D.,  Physician  to 
the  Samaritan  Hospital;  12,  Devonport  street,  Glou- 
cester square,  W.     Council,  1892. 

O.F.*  Priestley,  William  0.,  M.D.,  LL.D.,  F.R.C.P.,  Consulting 
Obstetric  Physician  to  King's  College  Hospital;  17, 
Hertford  street,  Mayfair,  W.  Council,  1859-61,  1865- 
66.      Vice-Pres.  1867-69.     Pres.  1875-76.     Trans.  6. 

1876*tQuiRKE,  Joseph,  L.R.C.P.  Ed.,  The  Oaklands,  Hunter's 
road,  Handsworth,  Birmingham. 

1861  Rasch,  Adolphus  A.  F.,  M.D.,  Physician  for  Diseases  of 
Women  to  the  German  Hospital;  7,  South  street.  Fins- 
bury  square,  E.C.     Council,  1871-3.     Trans.  6. 

1878t  Eawlings,  John  Adams,  M.R.C.P.Ed.,  Preswylfa, 
Swansea. 

1870*  Ray,  Edward  Reynolds,  Dulwich,  S.E. 

1860*  Eayner,  John,  M.D.,  Swaledale  House,  Highbury  quad- 
rant, N. 


Xlvi  FELLOWS    OF    THE    SOCIETY. 

Elected 

1879  Read,  Thomas  Laurence,  U,  Petersham  terrace,  Queen's 
gate,  S.W.     Council,  1892. 

1 874  Rees,  William,  Priory  House,  1 29,  Queen's  crescent.  Haver- 
stock  hill,  N.W. 

1879t  Reid,  William  Loudon,  M.D.,  Professor  of  Midwifery  and 
Diseases  of  Women  and  Children,  Anderson's  College  ; 
Physician  to  the  Glasgow  Maternity  Hospital ;  7,  Royal 
crescent,  Glasgow, 

1889  Remfry,  Leonard,  M.A.,  M.D.,  B.C.  Cantab.,  Obstetric 

Physician   to  the   Great  Northern   Central   Hospital, 
60,  Great  Cumberland  place,  Hyde  park,  W. 
1875*tREY,  Eugenio,  M.D.,  39,  Via  Cavour,  Turin. 

1890  Reynolds,  John,  M.D.Brux.,  11,  Brixton  hill,  S.W. 

I872t  Richardson,  William  L.,  M.D.,  A.M.,  Professor  of  Obs- 
tetrics in  Harvard  University  ;  Physician  to  the  Boston 
Lying  in  Hospital;  225,  Commonwealth  avenue, 
Boston,  Massachusetts,  U.S. 

1889t  Richmond,  Thomas,  L.R.C.P.  Ed.,  2,  "West  garden  street, 

Glasgow. 
1888t  Riding,  William   Steer,    M.D.Edin.,   Buckerell   Lodge, 

Honiton. 

I872t  Rigden,  George,  Surgeon  to  the  Canterbury  Dispensary; 
60,  Burgate  street,  Canterbury.  Trans.  1.  Hon.  Loc. 
Sec. 

1871*  Rigden,  Walter,  M.D.  St.  And.,  16,  Thurloe  place,  S.W. 
Council,  1882-3.     Trans.  1. 

1892  Roberts,  Charles  Hubert,  F.R.C.S.  Eng.,  25,  Welbeck 
street.  Cavendish  square,  W. 

O.F.*tRoBERTs,  David  Lloyd,  M.D.,  F.R.C.P.,  F.R.S.  Edin., 
Obstetric  Physician  to  the  Manchester  Eoyal  Infirmary  ; 
and  Lecturer  on  Clinical  Midwifery  and  the  Diseases  of 
Women  in  Owens  College  ;  1 1,  St.  John  street,  Deans- 
gate,  Manchester.  Council,  1868-70,  1880-2.  Vice- 
Pres.  1871-2.     2'rans.  5. 

1867*tRo»KRTs,  David  W.,  M.D.,  56,  Manchester  street,  Man- 
Chester  square,  W. 


FELLOWS    OF    THE    SOCIETY.  xlvii    * 

Elected 

1890t  Roberts,  Hugh  Jones,  Sea  View,  Penygroes,  R.S.O.,  N. 
Wales. 

1883  Egberts,  John  Coryton,  L.R.C.P.  Ed.,  71,  Peckham 
rye,  S.E. 

1874  Robertson,  William  Borwick,  M.D.,  St.  Anne's,  Tlmrlow 
park  road,  West  Dulwich,  S.E. 

1890  EoBiNSON,  Arthur  Henry,  M.D.Durh,,  The  Infirmary, 
Bancroft  road,  N.E. 

1892  Robinson,  George  H.  Drummond,  M.D.,  B.S.  Lond., 
143,  Wilberforce  road,  Finsbury  park,  N. 

1887  Robinson,  Hugh  Shapter,  L.R.C.P.  Ed.,  Talfourd  House, 
Camberwell,  S.E. 

1884t  Eobinson,  Luke,  M.R.C.P.  Lond.,  533,  Sutter  street,  San 
Francisco,  California. 

1892  Robinson,  Mark,  L.R.C.P.  Lond.,  Geraldine  Lodge, 
75,  East  hill,  Wandsworth,  S.W. 

lS90t  Robson,  a.  W.  Mato,  F.R.G.S.,  Hillary  place,  Leeds. 

1876t  Roe,  John  Withington,  M.D.,  Ellesmere,  Salop. 

1874t  Roots,  William  Henry,  Canbury  House,  Kingston-on- 
Thames. 

1874     Roper,  Arthur,  Lewisham  hill,  Blackheath,  S.E.    Council, 

1886-8. 
1865*tRoPEE,  George,  M.D.,  Consulting  Physician  to  the  Royal 

Maternity  Charity  ;  Oulton  Lodge,  Aylsham,  Norfolk. 

Council,  1875-77,  1883-5.      Vice-Pres.   1879-81,  1889, 

Board  Exam.  Midivives,  1880-1,  1883-5.     Trans.  10. 

1859  Rose,  Henry  Cooper,  M.D.,  Penrose  House,  Hampstead, 
N.W.     Council,  187^-77.     Trans.  4. 

1883t  RossER,  Walter,  M.D.,  1,  Wellesley  villas,  Croydon. 

1884t  Rossiter,  George  Frederick,  M.B.,  Surgeon  to  the 
Weston-super-Mare  Hospital;  Cairo  Lodge,  Weston- 
super-Mare. 

lS84t  Roughton,  Walter,  L.E.C.P.Lond.,  Cranborne  House, 
New  Barnet. 


Xlviii  FELLOWS    OF    THE    SOCIETY. 

Elected 

1882  RouTH,  Amand,  M.D.,  B.S.,  Assistant  Obstetric  Physician 
to,  and  Teacher  of  Practical  Obstetrics  and  Gynaecology 
at,  Charing  Cross  Hospital;  14a,  Manchester  square, 
W.  Council,  1886-8  Board  Exam.  Midwives,  1893. 
Trans.  2. 

O.F.*  RouTii,  Charles  Henkt  Felix,  M.D.,  Consulting  Physician 
to  the  Samaritan  Free  Hospital  for  Women  and  Ciiildren  ; 
52,  Montagu  square,  W.  Council,  1859-61.  Fice-Pres. 
1874-6.     Trans.  13. 

l887*tRowE,  AiiTHUii  Walton,  M.D.  Dur.,  1,  Cecil  street,  Margate. 

188  If  RowoRTH,  Alfred  Thomas,  Grays,  Essex. 

1886  RusHWORTH,  Frank,  M.B.  Lond.,  1a,  Goldhurst  terrace. 
South  Hampstead,  N.W. 

1888t  EusHWORTH,  Norman,  L.R.C.P.  Lond.,  Beechfield,  Walton- 
on-Tbame8. 

1886t  RuTHEEFOORD,  Henry  Trotter,  B.A.,  M.B.  Cantab., 
Taunton.     Council,  1892-93.     Trans.  1. 

1866t  Saboia,  Baron  V.  de,  M.D.,  Director  of  the  School  of  Medi- 
cine, Rio  de  Janeiro  ;  39,  Rua  dos  Andrados,  Rio  de 
Janeiro      Trans.  2. 

1864t  Salter,  John  H.,  D'Arcy  House,  ToUeshunt  D'Arcy,  Kel- 
vedon,  Essex. 

1868*  Sams,  John  Sutton,  St,  Peter's  Lodge,  Eltham  road,  Lee, 
S.E.     Council,  1892. 

1886t  Sanderson,  Robert,  M.B.  Oxon.,  33,  Montpellier  road, 
Brighton. 

1872     Sangstee,  Charles,  148,  Lambeth  road,  S.E. 

1870t  Saul, William,  M.D.,  Lyndthorpe,Bo8combe,  Bournemouth. 

1891  Saunders,  Frederick  William,  M.B.,  B.C.Cantab.,  17, 
Barkston  gardens.  South  Kensington,  S.W. 

1872t  Savage,  Thomas,  M.D.,  Surgeon  to  the  Birmingham  and 
Midland  Hospital  for  Women ;  33,  Newhall  street, 
Birmingham.     Council,  1878-80. 


FELLOWS    OF    THE     SOCIETY.  xHx 

Elected 

1877  Savory,  Charles  Tozer,  M.D.,  6,  Douglas  road,  Canon- 
bury,  N.     Trans.  1, 

1890  ScHACHT,    Frank    Frederick.    B.A.,    M.D.Cantab.,    168, 

Earl's  Court  road,  S.W. 

1870t  Scott,  John,  M.D.,  Cramond  House,  Sandwich. 

1888  Scott,  Patrick  Cumin,  B.A.,  M.B.  Cantab.,  38,  Shooter's 
Hill  road,  Blackheath,  S.E. 

1866  Sequeiea,  James  Scott,  68,  Leman  street,  Goodman's 
fields,  E.,  and  Crescent  House,  Cassland  crescent, 
Cassland  road,  South  Hackney,  E. 

1882  Serjeant,  David  Maurice,  M.D.,  1,  The  Terrace,  Cani- 
berweU,  S.E. 

1875  Seton,  David  Elphinstone,  M.D.,  1,  Emperor's  gate, 
S.W.     Council,  1884. 

1860  Sewell,  Charles  Beodie,  M.D.,  21,  Cavendish  square, 
W..  and  13,  Fenchurch  street,  E.C.    Council,  1880-2. 

O.F.f  Sharpix,  Henry  Wilson,  F.R.C.S.,  Surgeon  to  the  Bed- 
ford General  Infirmary,  Bedford.  Council,  1871-3. 
Trans.  1 .    Son.  Lac.  Sec. 

1887  Shaw,  John,  M.D.  Lond.,  Obstetric  Physician  to  the  North 
West  London  Hospital ;  3J,  Queen  Anne  street,  Caven- 
dish square,  W.     Trans.  2. 

1891  Shaw-Mackenzie,    John    Alexander,    M.B. Lond.,    24, 

Savile  row,  W. 

1890  Shillingford,  Henry  Baetlett,  Park  House,  Rye  lane> 
Peckham,  S.E. 

1890  Silk,  John  Frederick  William,  M.D.  Lond,,  29,  Wey- 
mouth street,  Portland  place,  W. 

1874t  Sinclair,  Alexander  Doull,  M.D.,  Consulting  Physician 
to  the  Boston  Lying-in  Hospital ;  35,  Newbury  street, 
Boston,  Massachusetts,  U.S. 

1888t  Sinclair,  William  Japp,  M.D.  Aber.,  Honorary  Physician 
to  the  Southern  Hospital  for  Women  and  Children  and 
Maternity  Hospital,  Manchester ;  and  Professor  of 
Obstetrics  and  Gynaecology,  Owens  College,  Man- 
chester; 250,  Oxford  road,  Manchester. 
vol.  xxxiv.  d 


1  FELLOWS    OF    THE    SOCIETY. 

Elected 

1879t  Slight,  George,  M.U.,  37,  Western  street.  King's  road, 

Brighton. 
1881t  Sloan,  Archibald,  M.B.,  272,  Bath  street,  Glasgow. 
18-6t  Sloan,  Samuel,  M.D.,  CM.,  5,  Somerset  place,  Sauchiehall 

street  West,  Glasgow. 
1890t  Sloman,  Frederick,  IS,  Montpellier  road,  Brighton. 
1861     Sltman,  William  Daniel,  26,  Caversham  road,  Kentish 

Town,  N.W.     Council,  1881. 
1867*  Smith,    Hetwood,    M.D.,    18,   Harley   street,   Cavendish 

square,  W.     Co?<wci7,  1872-5.    Board  Exam.  Midwives, 

1874-76.     Trans.  6. 
18881  Smith,  Howard  Lyon,  L.R.C.P.Lond.,  Buckland  House, 

Buckland  Newton,  near  Dorchester. 
1890     Smith,  Hugh,  M.D.Lond.,  Englefield  House,  High  street, 

Highgate,  N. 
1875     Smith,  Richard  Thomas,  M.D.,  Physician  to  the  Hospital 

for  Women,  Soho  square ;  53,  Haverstock  hill,  N.W. 
1886t  Smith,    Samuel    Parsons,    L.K.Q.CP.L,    Park    Hyrst, 

Addiscombe  road,  Croydon. 
1882t  Smith,   Stephen    Maberly,  L.R.C.P.  Ed.,    Yarra   street, 

Geelong,  Melbourne.     [Per  Henry  M.  Smith,  c/o  The 

London  and   County  Bank,  Henrietta  street,  Covent 

garden,  W.C.] 
1879t  Smith,  Wm.  Hugh  Montgomery,  L.R.C.P. Ed.,  24,  London 

road.  West  Croydon,  Surrey. 

1 868*  Spaull,  Barnard  E.,  1,  Stanwick  road,  West  Kensington,  W. 

1888  Spencer,  Herbert  R.,  M.D.,  B.S.  Lond.,  Assistant  Obstetric 
Physician  to  University  College  Hospital;  10,  Mans- 
field street.  Cavendish  square,  W.  Council,  1890-92. 
Trans.  2. 

1876t  Spencer,  Lionel  Dixon,  M.D.,  Brigade-Surgeon,  I. M.S., 
Bengal  Establishment  [care  of  Messrs.  Grindlay  and  Co., 
55,  Parliament  street,  S.W.]. 

1882  Spooner,  Frederick  Henry,  M.D.,  Maitland  Lodge, 
Clapton,  N.E. 


FELLOWS    OF    THE    SOCIETY.  H 

Elected 

1876t  Spurgin,  Herbert  Branwhite,  82,  Abington  street, 
Northampton. 

1893  Stack,  E.  H.  Edwards,  M.B.,  B.C.  Cantab.,  St.  Bar- 
tholomew's Hospital,  E.G. 

1884t  Stevenson,  Edmond  Sinclair,  F.R.C.S.  Ed.,  Strathallau 
House,  Rondebosch,  Cape  of  Good  Hope.     Trans.  1. 

1877t  Stephenson,  William,  M.D.,  Professor  of  Midwifery, 
University  of  Aberdeen  ;  3,  Rubislaw  terrace,  Aberdeen. 
Council,  1881-3.     Vice-Pres.,  1887-89.     Trans.  2. 

1873t  Stewart,  James,  M.D.,  1,  Crescent  place,  Whitby,  York- 
shire. 

1875*tSTEWART,  William,  F.E.C.P.Ed.,  Dyrock  Cottage,  Prest- 
wick,  near  Ayr,  N.B. 

1884t  Stiven,   Edward  W.  F.,  M.D.,  The  Manor  Lodge,  Harrow. 

1884  Stivens,  Bertram  H.  Lyne,  11,  Kensington  gardens 
square,  W. 

1883  Stocks,  Frederick,  421,  Wandsworth  road,  S.W. 

1866*  Strange,  William  Heath,  M.D.,  2,  Belsize  avenue, 
Belsize  park,  N.W.     Council,  1882-4. 

1884  Sunderland,  Septimus,  M.D.,  36,  Bruton  street,  Berkeley 

square,  W. 

I886t  Sutcliffe,  Arthur  Edwin,  Chorlton  Lodge,  Stretford 
road,  Manchester. 

1883*  Sutherland,  Henry,  M.A.,  M.D.  Oxon.,  M.R.C.P.,  r., 
Richmond  terrace,  Whitehall,  S.W. 

1888     Sutton,  John  Bland,  F.R.C.S.,  48,  Queen   Anne  street, 

Cavendish  square,  W.     Trans.  1. 
1893     Swan,    Richard   Jocelyn,  Park  House,  32,  Caraberwell 

new  road,  S.E. 
1859*tSwATNE,  Joseph  Griffiths,  M.D.,  Physician-Accoucheur 

to  the   Bristol   General  Hospital ;    Harewood    House, 

74,  Pembroke  road,  Clifton,  Bristol.     Council,  \8G0-Gl, 

Vice.Pres.  1862-64.     Trans.  9. 
1892t  S WAYNE,  Walter  Carless,  M.B.  Lond.,  3,  Leicester  villas, 

St.  Paul's  road,  Clifton. 


lii  FELLOWS    OF    THE    SOCIETY. 

Elected 

1888*  Sworn,  Heniiy  George,   L.K.Q.C.P.  &  L.M.,    16,  Albion 
road,  HoUoway  road,  N. 

1883  Tait,    Edward    Sabine,    M.D.,    48,    Highbury   park,   N. 

Council,  1892-93.      Trans.  1. 
1879     Tait,  Edward  W.,  48,  Highbury  park,  N.     Council,  1886-7. 
1871t  Tait,  Lawson,  F.R.C.S.,  Surgeon  to  the  Birmingham  and 

Midland  Hospital  for  Women  ;  7,  The  Crescent,  Bir- 
mingham.    Trans.  15. 
1880t  Takaki,  Kanaheiro,  F.R.C.S.,  10,  Nishi-Konyacho,  Kio- 

bashika,  Tokio,  Japan.     Hon.  Loc.  Sec. 
1859     Tapsou,  Alfred  Joseph,  M.B.  Lond.,  36,  Gloucester  gar- 

dens,    Westbourne    terrace,    \V.       Council,     1862-64. 

Fice.Pres.   1891. 
1863     Tapson,  Joseph  Alfred,  L.R.C.P.  Lond.,  Holmwood,  The 

Grove,  Clapham  common,  S.W.      Trans.  1. 

1891  Targett,  James   Henry,  M.B.,  B.S.Lond.,  F.R.C.S.,  6, 

St.  Thomas's  street,  S.E. 

1892  Tate,  Walter  William  Hunt,  M.B.  Lond.,  57,  Lambeth 

palace  road,  S.E. 

1871     Tayler,   Francis  T.,  B.A.  Lond.,  M.B.,  Claremont  villa, 
224,  Lewisham  high  road,  S.E. 

1869t  Taylor,  John,  Earl's  Colne,  Halstead,  Essex. 

1890*tTAYLOR,  John  William,  F.R.C.S.,   59,  Bath  street,  Bir- 
mingham.    Trans.  1. 

1892     Taylor,  William  Bramley,  145,  Denmark  hill,  S.E. 

1885t  T.yylor,  William  Charles  Everley,  M.R.C.P.  Edin.,  34, 
Queen  street,  Scarborough. 

1890t  Thomas,  Benjamin  Wilfred,  L.R.C.P.  Lond.,  Welwyn. 

1884  Thomas,  George  H.  W.,  23,  Oxford  gardens,  W. 

1887t  Thomas,    William    Edmund,    L.R.C.P.    Ed.,    Bridgend, 
Glamorganshire. 

I882t  Thomas,  Hugh,  The  Grange,  Coventry  road,  Birmingham. 

1867*tTH0MPS0N,    Joseph,    L.R.C.P.   Lond.,    1,    Oxford   street, 
Nottingham.     Trans.  1.     Hon.  Loc.  Sec. 


fELLOWS    OF    THE    SOCIETY.  HH 

Elected 

1878t  Thomson,  David,  M.D.,  Park  square,  Luton,  Bedford- 
shire. 

1879  Thornton,  J.  Knowsley,  M.B.,  CM.,  Surgeon  to  the 
Samaritan  Free  Hospital  for  Women  and  Children,  22, 
Portman  street,  Portman  square.  Council,  1882-3. 
Hon.  Lib.  1884-5.  Hon.  Sec.  1886.  Fice-Pres.  1888, 
1893.     Trans.  6. 

1873t  Ticehurst,  Charles  Sage,  Petersfield,  Hants. 

1866     Tillet,  Samuel,  32,  West  Kensington  gardens,  W. 

O.F.  Tilt, Edward  John,  M.D.,  Consulting  Physician-Accoucheur 
to  the  Farringdon  General  Dispensary  ;  27,  Seymour 
street,  Portman  square,  W.  Council,  1867-68.  Vice- 
Pres.  1869-70.  Treas.  1871-2.  Pres.  1873-4. 
Trans.  7. 

18831  Tinker,  Frederick  Howard,  F.R.C. P.  Ed.,  Talbot  House, 
Hyde,  Cheshire. 

1887t  Tinley,  Thomas,  M.D.  Durh.,  Hildegard  House,  Whitby. 

1879t  TivY,  William  James,  F.R.C.S.  Ed.,  8,  Lansdown  place, 
Clifton,  Bristol. 

lS72t  Tolotschinoff,  N.,  M.D,,  CharkoflF,  Russia. 

1884     Travers,  William,  M.D.,  2,  Phillimore  gardens,  W. 

18731  Trestrail,  Henry  Ernest,  F.R.C.S.  Ed.,  M.R.C.P.  Ed., 
36,  Westbourne  gardens,  Glasgow,  W.     Trans.  1. 

1893  Trethowan,  William,  M.B.,  CM,  Aber.,  5,  Callow  street, 
South  Kensington,  S,W, 

1 886     Tuckett,  Walter  Reginald,  Hazeldene,  Woodford,  Essex. 

1865*  Turner,  John  Sidney,  Stanton  House,  81,  Anerley  road, 
Upper  Norwood,  S.E.     Council,  1893. 

1891  Turner,  Philip  Dymock,  M.D.Lond.,  95,  Cromwell 
road,  S.W, 

1 88 If  TuTHiLL,    Phineas    Barrett,    M,D.,    Station     Hospital, 

Gibraltar. 
1861     Tweed,   John  James,  Junr,,  F.R.C.S.,    14,  Upper  Brook 

street,  W. 
1890     Tyrrell,    Walter,  L.R.CP.Lond.,    104,  Cromwell  road, 

S.W. 


liv  FELLOWS    OF    THE    SOCIETY. 

Elected 

1893     Umney,  William  Francis,  M.D.  Lond.,  Eardley  House, 

Lawrie  park  road,  Sydenham,  S.E. 
1874     Venn,  Albert  John,  M.D.,  Physician    for  the  Diseases 

of  Women,    West    London    Hospital;    122,    Harley 

street,  W. 
1873     Verley,  Reginald  Louis,  F.R.C.P.  Ed.,  28b,  Devonshire 

street,  Portland  place,  W. 
1892t  Verrall,    Thomas   Jennee,    L.RoC.P.Lond.,   97,   Mont- 

pellier  road,  Brighton, 
1879t  Wade,  George  Herbert,  Ivy  Lodge,  Chislehurst,  Kent. 

Council,  1892-93. 
1860t  Wales,  Thomas  Garneys,  Downham  Market,  Norfolk. 
1866t  Walker,  Thomas  James,  M.D.,  Surgeon  to  the  General 

Infirmary,  Peterborough  ;  33,  Westgate,  Peterborough. 

Council,  18/8-80.     Hon.  Loc.  Sec. 
1889     Wallace,  Abraham,  M.D.  Edin.,  64,  Harley  street,  W. 
1870    Wallace,  Frederick,   Foulden   Lodge,    Upper   Clapton, 

N.E.     Council,  1880-2. 

1872*tWALLACE,  John,  M.D.,  Assistant- Physician  to  the  Liverpool 
Lying-in  Hospital;  1,  Gambier  terrace,  Liverpool. 
Council,  1883-5. 

1883  Wallace,  Richard  TJnthank,  M.B.,  Cravenhurst,  Craven 
park,  Stamford  hill,  N. 

1893t  Walls,  Willlam  Kay,  M.B.  Lond.,  St.  Mary's  Hospital, 
Manchester. 

1879*  Walter,  William,  M.A.,  M.D.,  Surgeon  to  St.  Mary's 
Hospital,  Manchester ;  20,  St.  John  street,  Man- 
chester. 

1867*  Walters,  James  Hopkins,  Surgeon  to  the  Royal  Berkshire 
Hospital ;  1.5,  Friar  street,  Reading,  Berks.  Council, 
1884-6.     Trans.  1.     Ho7i.  Loc.  Sec. 

1873t  Walters,  John,  M.B.,  Church  street,  Reigate,  Surrey. 

1884t  Watson,  Pekcival  Humble,  L.E.C.P.  Lond.,  72,  Jesmond 
road,  Nevrcastle-on-Tyne. 

I884t  Waugh,  Alexander,  L.Pi.C.P.  Lond.,  Midsomer-Norton, 
^ath. 


FELLOWS    OF    THE    SOCIETY.  Iv 

Elected 

O.F,  t  Webb,   Hauet    Speakman,    New   place,   Welwyn,   Herts. 

Council,  1889-91.     Vice.-Pres.  1892-93. 
1886t  Webber,  William  W.,  L.R.C.P.  Ed.,  Crewkerne. 

1893t  Webster,  Thomas  James,  Brynglas,  Merthyr  Tydvil. 

1884t  Wedmorb,  Ernest,  M.B.  Cantab.,  Obstetric  Physician  to 
the  Bristol  Royal  Infirmary;  11,  Richmond  Hill, 
Clifton. 

1876t  Weir,  Archibald,  M.D.,  St,  Mungho's,  Great  Malvern. 
1887t  Wells,  Albert   Primrose,  M.A.,  L.R.C.P.  &  S.,  L  M., 
7,  St.  George's  road,  Beckenham. 

1876t  Wells,  Frank,  M.D.,  Hawes  street,  Brookline,  Massachu- 
setts. 

O.F.  Wells,  Sir  T.  Spencer,  Bart.,  F.R.C.S.,  Surgeon  in  Ordi- 
nary to  H.M.'s  Household ;  Consulting  Surgeon  to  the 
Samaritan  Free  Hospital  for  Women  and  Children  ;  3, 
Upper  Grosvenor  street,  W.  Council,  1859.  Vice- 
Pres.  1868-70.     Trans,  5.     Trustee. 

1886t  West,  Charles  J.,  L.R.C.P.  Lond.,  The  Grove,  Fulbeck, 
Grantham. 

1888t  Weston,  Joseph  Theophilus,  L.K.Q.C.P,  &  L.M.,Lashio, 
Upper  Burmah,  India  [care  of  Thos.  Cook  and  Son, 
Ludgate  Circus,  E.C.]. 

1886     Wharry,  Robert,  M.D.  Aber.,  6,  Gordon  square,  W.C. 

1890  Wheaton,  Samuel  W.,  M.D. Lond.,  Physician  to  the  Royal 
Hospital  for  Children  and  Women  ;  52,  The  Chase, 
Clapham  common,  S.W. 

I860t  Wheeler,  Daniel,  Chelmsford. 

1889t  Whitcombe,  Charles  Henry,  F.R.C.S.  Edin.,  Westerham, 
Kent. 

1890  White,  Charles  Percival,  M.A.,  M.B.,  B.C.Cantab., 
144,  Sloane  street,  S.W. 

1890     White,  Edwin  Francis,  F.R.C.S.,  Westlands,  280,  Upper 

Richmond  road.  Putney,  S.W. 
1882     Wholly,  Thomas,  M.B.  Durh.,  Winchester  House,  50,  Old 

Broad  street,  E.C. 


Ivi  FELLOWS    OF    THE    SOCIETY. 

Elected 

lS87t  Wigan.Charles  Arthur,  M-B.Durh.,Portishead, Somerset. 

1877     WiGMORE,  William,  131,  Inverness  terrace,  Hyde  park,  W. 

1883t  Wilkinson,  Thomas  Marshall,  L.R.C.P.Ed.,  33,  Avenue 

road,  Grantham. 
1879t  Willans,  William  Blundell,  F.R.C.P.  Ed.,  Much  Had- 

ham,  Herts. 

1889t  Williams,  Arthur  Henry,  M.A.,  M.B.,  B.C.  Cantab.,  54, 
London  road,  St.  Leonard's-on-Sea. 

1887t  Williams,  Charles  Robert,  M.B.,  CM.  Ed.,  15,  Ivanhoe 
terrace,  Ashby-de-la-Zouch. 

1872  Williams,  John,  M.D.,  F.R.C.P.,  Physician-Accoucheur  to 
H.R.H.  Princess  Beatrice,  Princess  Henry  of  Batten- 
berg  ;  Professor  of  Midwifery  in  University  College, 
London,  and  Obstetric  Physician  to  University  College 
Hospital ;  63,  Brook  street,  Grosvenor  square,  W. 
CoMwaV,  1875-76,  1892.  Hon.  Sec.\Q77-9.  Vice-Pres. 
1880-2.  Board  Exam.  Midwives,  188  \ -2  ;  Chairman, 
1884-6.     Pres.  1887-8.     Trans.  12. 

1890  Williams,  Reginald  Muzio,  M.D.Lond.,  95,  St.  Mark's 
road,  N.  Kensington,  W. 

1881  Willis,  Julian,  M.R.C.P.  Ed.,  64,  Sutherland  avenue, 
Maida  vale,  W. 

1860t  Wilson,  Robert  James,  F.R.C.P.  Ed.,  7,  Warrior  square, 
St.  Leonard's-on-Sea,  Sussex.  Hon.  Loc.  See.  Vice- 
Pres.  1878-80. 

1892t  Wilson,  Thomas,  M.D.,  B.S. Loud.,  4,  Waterloo  road  S., 
Wolverhampton. 

1891t  WiNULE,  Bertram  C.  A.,  M.A.,  M.D.,  B.Ch.Dub., 
Queen's  College,  Birmingham. 

1886t  Winterbottom,  Arthur  Thomas,  L.R.C.P.  Ed.,  Lark  hill, 
Swinton,  Manchester. 

1877  WiNTLE,  Henrt,  M.B.,  Kingsdown,  Church  road,  Forest 
hill,  S.E. 

1887t  Withers,  Robert,  Lawrence,  Otago,  New  Zealand. 


FELLOWS    OF    THE    SOCIETY.  Ivil 

i:iected 

1880t  Woodward,  G.  P.  M.,  M.D.,  157,  Liverpool  street,  Sydney, 

New  South  "Wales. 
1890     WoRNUM,  George  Porter,  6,  College  terrace,  Belsize  park, 

N.W. 

188 It  WoRTHiNGTON,  Geoege  Finch  Jennings,  M.K.Q.C.P., 
Tliorncliffe,  Poole  road,  Bournemouth. 

1876t  Worts,  Edwin,  6,  Trinity  street,  Colchester. 

1887t  Wright,  Charles  James,  Surgeon  to  the  Hospital  for 
Women  and  Children,  Leeds ;  Professor  of  Midwifery 
to  the  Yorkshire  College  ;  Lynton  Villa,  Virginia  road, 
Leeds. 

1888*tWYATT-SMiTH,  Fraxk,  M.B.,  B.C.Cantab.,  British  Hospital, 

Buenos  Ayres. 
1889     Wynteb,    Andrew    Ellis,    L.R.C.P.  Lond.,    30,    Upper 

Berkeley  street,  Portman  square,  W. 
1871     Yarrow,  Geoege  Eugene,  M.D.,  Oakley  House,  317,  City 

road,  E.C.     Council,  1881-3. 
1882*tYoTJNG,  Charles  Grove,  M.D.,  New  Amsterdam,  Berbice 

British  Guiana. 


CONTENTS. 


List  ofOfficers  for  1893  . 

List  of  Presidents 

List  of  Referees  of  Papers  for  1893 

Standing  Committees 

List  of  Honorary  Local  Secretaires 

Trustees  of  the  Society's  Property 

List  of  Honorary  and  Corresponding  Fellows 

List  of  Ordinary  Fellows 

Contents  .... 

List  of  Plates  and  Woodcuts 

Advertisement .... 

Hours  of  attendance  at  Library    . 


PAGii: 

V 

vii 

viii 

ix 

X 

xi 
xi-xii 
xiii 
lis 
Ixv 
Ixvi 
Ixvi 


January  6th,  1892— 

Primary  Sarcoma  of  both  Ovaries,  shown  by  Dr.  J.  A. 

Shaw-Mackenzie  .... 

Abscess  of  Ovary,  shown  by  Dr.  Heywood  Smith 
An  Ovai'ian  Dermoid,  shown  by  Mr.  J.  Bland  Sutton  . 
Ovarian  Dermoid  ;  Infiltration  of  Broad  Ligament  with 

Fat,  shown  by  Mr.  J.  Bland  Sutton 
Hydrosalpinx  undergoing  Spontaneous  Cure,  shown  by 

Mr.  J.  Bland  Sutton     .... 
Ruptured  Uterus,  shown  by  Dr.  Boxall 
Report  of  Committee  on   Dr.    Herman's   Specimen   of 

Amorphous  Acardiac  Twin  (^'Transactions,'  vol.  xxxiii, 

p.  493)  ..... 

I.  On  the  Relation  between  Backward  Displacements  of 

the  Uterus  and  Prolonged  Haemorrhage  after  Delivery 

and  Abortion.  By  G.  Ernest  Herman.  M.B.,F.R.C.P. 


9 
11 


11 


14 


Ix  CONTENTS. 

PAGE 

II.  Twenty  Cases  of  Fibroma  and  other  Morbid  Conditions 
of  the  Uterus  Treated  by  Apostoli's  Method.  By 
J.  Inglis  Parsons,  M.D.  .  .  .22 

February  3rd,  1892— 

Annual  Meeting    .  .  .  .  .23 

Fatal  Rupture  of  an  Ovarian  Cyst  in  an  Infant,  shown 

by  Mr.  Alban  Doran  for  Dr.  George  B.  Beetle  .       24 

Double Pyosalpinx,  shown  by  Mr.  A.  C.  Btjtler-Smythe      24 
Retroflexion  of  the  Uterus  in  a  New-born  Child,  shown 

by  Dr.  Herbert  R.  Spencer        .  .  .25 

Supposed  Unruptured  Tubal  Gestation  Sac,  shown  by 

Dr.  W.  S.  Playpair        .  .  .  .28 

in.  Protracted  Gestation.     By  C.  Paget   Blake.   M.D., 

F.R.C.P.  .  .  .  .  .28 

Annual  Meeting — The  Audited  Report  of  the  Treasurer 

(Dr.  Herman)  .  .  .  .  29,  30 

Report  of  the  Honorary  Librarian  for  1891  (Dr. 

William  Duncan)         .  .  .  .29 

Report  of  the  Chairman  of  the  Board  for  the  Exa- 
mination of  Midwives  (Dr.  Champneys)       .  29,  31 

Election  of  Honorary  Fellows    .  .  .31 

Election  of  Officers  and  Council  for  the  year  1892  .      31 

Annual  Address  of  the  President  (Dr.  J.  Watt 

Black)  .  .  .  .  .33 

March  2nd,  1892— 

Report  of  Committee  on  Dr.  Hey  wood  Smith's  Specimen 

of  Abscess  of  the  Ovary  (p.  3)  .  .  .83 

Acephalous  Acardiac  Foetus,  shown  by  Dr.  Handpield- 

JONES  .  .  ,  .  .84 

Tubo-ovarian  Cyst,  shown  by  Dr.  Handpield- Jones    .      85 
Cancerous  Uterus  removed  by  Yaginal  Hysterectomy, 

shown  by  Dr.  Horrocks  .  .  .85 

Cancerous  Uterus  removed  by  Vaginal  Hysterectomy, 

shown  by  Dr.  Am  and  Routh        .  .  .87 

Sections    of   Fibroma   of   the    Ovary,    shown   by   Dr. 
Rutherfoord  .  .  .  .88 

IV.  Case  of  Csesarean  Section  for  Contracted  Pelvis.     By 

C.  J.  Cullingworth,  M.D.,  F.R.C.P.  .  .      89 

V.  Case  of  Cesarean  Section.     By  John  Shaw,  M.D.        .      98 
VI.  A   Successful  Case   of   Ca^sarean  Section.     By  A.    D. 

Leith  Napier,  M.D.      ....     105 


CONTENTS.  Ixi 

PAGE 

April  6th,  1892— 

Specimen  of  Axial  Rotation  of  a  right-sided  Parovarian 
Cyst  with  attached  Right  Ovary  and  Fallopian  Tube 
distended  by  Haemorrhage,  shown  by  Dr.  Leith 
Napier  .  '  .  .  .    124 

Specimen  of  Cystic  Ovary  and  Enlarged  Tube,  shown  by 
Dr.  Leith  Napier  ....     126 

Utei-us  with  Kidneys  and  Ureters,  from  a  Case  of  Ca;sa- 
rean  Section,  shown  by  Dr.  William  Duncan  .     127 

Malformation  of  Rectum  and  Bladder,  Congenital 
Absence  of  both  Kidneys  and  Ureters,  Imperforate 
Anus,  Absence  of  Right  Hypogastric  Artery,  and 
Deformed  Feet,  shown  by  Dr.  Giles  .  .     129 

Case  of  Congenital  Diaphragmatic  Hernia,  shown  by  Dr. 
Giles.  .  .  .  .  .132 

Ruptured   Tubal   Gestation,   shown   by  Dr.  Culling- 

WORTH  .....      134 

Case  of  Squamous-celled  Carcinoma  of  the  Cervix  Uteri, 
in  which  the  disease  had  extended  in  an  upward  and 
not  in  a  downward  direction,  shown  by  Dr.  Culling- 
WORTH  .  .  .  .  .     136 

Adjourned  Debate  on  CsBsarean  Section  .  ,     138 

May  4th,  1892— 

Papillomatous  Cyst  of  both  Ovaries,  causing  profuse 
Ascitic  Effusion,  shown  by  Mr.  Alban  Doran  .     149 

Unruptured  Tubal  Gestation,  with  Apoplexy  of  the 
Ovum,  shown  by  Dr.  Cullingworth  .  .     155 

Report  on  Dr  Cullingworth's  Specimen  of  Tubal  Gesta- 
tion     ......     157 

Foetus  of  four  months'  development  contained  within  an 
unniptured  Amnial  Sac  with  Placenta  Pree via  attached, 
shown  by  Dr.  Leith  Napier         .  .  .    158 

Large  Multiple  Fibro-myoma,  removed  by  Hysterectomy, 
shown  by  Dr.  Leith  Napier         .  .  .    159 

VII.  Six  Cases  of  Craniotomy,  with  remarks  on  the  relative 
position  of  Craniotomy  and  Ca^sarean  Section.  By 
Arthur  H.  N.  Lewers,  M.D.       .  .  .    161 

June  1st,  1892— 

Case  of  Extra-uterine  Gestation,  shown  by  Dr.  Malins     181 
Tubal  Gestation  with  Apoplectic  Ovum  ;  Sac  unruptured, 
shown  by  Dr.  Cullingworth      .  .  .    182 


Ixii  CONTENTS. 

PAGE 

Prolapse  of  Meckel's  Diverticulum  in  an  Infant,  forming 
an  Umbilical  Tumour,  shown  by  Dr  Wheaton  .     184 

Micrococci  in  the  Substance  of  a  decomposing  Fibroid 
Tumour  removed  by  Hysterectomy,  shown  by  Dr. 
Wheaton          .....    187 

Microscopic  Section  of  the  Uterine  Mucous  Membrane 
in  an  Infant  suffering  from  Uterine  Haemorrhage, 
shown  by  Dr.  Wheaton  ....  190 
VIII.  Case  of  Ectopic  Pregnancy  in  which  the  Foetus  seems  to 
have  been  developed  to  the  full  time  in  the  Peritoneal 
Cavity,  still  retaining  its  Amniotic  Covering.  By 
Lawson  Tait,  F.R.C.S.  .  .  .  .192 

IX.  Two  Cases  of  Hysterectomy.  By  Lawson  Tait,  F.R.C.S.     199 
X.  Note  on  the  Growth  of  the  Placenta  after  Death  of  the 
Foetus    in    Ectopic    Gestation.     By   Lawson   Tait, 
F.R.C.S.,  and  Christopher  Martin,  M.B.  .    206 

July  6th,  1892— 

Cancer  of  the  Body  of  the  Uterus,  shown  by  Dr. 
Lewers  .....     213 

Specimen  of  Double  Ovai'ian  Apoplexy  from  a  case  of 
Acute  Peritonitis,  shown  by  Dr.  Des  Yceux  .     214 

Ovarian  Hydrocele  containing  Papillomata,  shown  by 
Mr.  J.  Bland  Sutton     ....    215 

Tubal  Pregnancy;  Ruptui'e  into  Bi-oad  Ligament; 
Operation ;  Recovery ;  shown  by  Mr.  J.  Bland 
Sutton  .....    217 

Two  Cases  of  Pyosalpinx,  shown  by  Dr.  Cullingworth     219 

Myoma  of  the  Cervix  Uteri,  shown  by  Dr.  Culling- 
worth .....    223 

Knitting-needle  used  to  procure  Abortion,  shown   by 
Di-.  William  Duncan    ....    223 
XL  On  Menstruation  in  Cases  of  Backward  Displacement 

of  Uterus.    By  G.  Ernest  Herman,  M.B.,  F.R.C.P.    225 
XII.  Two  cases  of  Double  Ovariotomy  during  Pregnancy. 

By  W.  A.  Meredith,  M.B.,  CM.  .  .    239 

October  5th,  1892— 

Distension  of  Vagina  and  Uterus  with  Muco-puriform 
Fluid,  accompanied  by  Dilatation  of  Bladder  and 
Ureters  from  Pressure,  in  a  Child  seven  weeks  old, 
shown  by  Dr.  W.  McAdam  Eccles  .  .  .    250 


CONTENTS.  Ixiii    " 

PAGE 

Pelvis  of  a  Cat,  with  Bladder,  Uterus,  and  Rectum  in 
situ,  shown  by  Dr.  Rutherfoord  .  .     251 

Ruptured  Uterus  and  Yagina,  shown  by  Dr.  Amand 
RouTH  .  .  .  .  .252 

XIII.  The  Yahie  of  Abdominal  Section  in  certain  Cases  of 
Pelvic  Peritonitis,  based  on  a  Personal  Experience  of 
Fifty  Cases.  By  C.  J.  Cullingworxh,  M.D.,  F.R.C.P.     254 


November  2nd,  1892— 

Large   Pyosalpinx   simulating   Tubo-ovarian   Abscess, 

shown  by  Dr.  Cullingworxh       .  .  .    437 

Ruptured    Tubal    Pregnancy,    shown    by    Dr.    Aust 

Lawrence        .....    439 
Haematosalpinx,    Haemorrhagic    and    Cystic    Ovaries, 

shown  by  Dr.  Leith  Napier         .  .  .    439 

Dermoid  Cyst,  shown  by  Dr.  Galabin  .  .     441 

Adjourned  Debate  on  Dr.  Cullingworth's  paper  on  the 

Value  of  Abdominal  Section  in  Certain  Cases  of  Pelvic 

Peritonitis  .....    442 


December  7th,  1892— 

Aseptic  Instruments,  shown  by  Dr.  Horrocks  .    460 

Transfusion  Apparatus,  shown  by  Dr.  Horrocks  .    460 

Ovaries  removed  from  a  Case  of  Osteomalacia,  shown  by 

Dr.  Rasch  .  .  .  .  .462 

Papillomatous  Ovarian  Cyst,  shown  by  Dr.  Lewers      .     462 
Malformed  Fcetus,  shown  by  Dr.  Amand  Routh  .     463 

Placenta  Prsevia  associated  with  Unusual  Size  and  Shape 

of  the  Placenta,  shown  by  Dr.  Boxall         .  .     464 

Supposed  Unruptured  Tubal  Gestation  Sac,  shown   by 

Dr.  W.  S.  Playfair        .  .  .  .465 

Haematosalpinx,  shown  by  Dr.  Malins  .  .    466 

Report  on  Dr.  Malins'  Specimen  of  Haematosalpinx        ,     466 

of   Committee   on    Dr.    Playfair's    Specimen    of 

Haematosalpinx  ....    467 

on  Dr.  Giles's  Specimen  of  Malformation  of 

Rectum  and  Bladder,  Congenital  Absence  of  both 
Kidneys  and  Ureters,  &c.  ...     468 

on   Dr.   Cullingworth's   specimen  of  Tubal 

Gestation  with  Apoplectic  Ovum  .  .  .     468 


Ixiv  CONTENTS. 

PAGE 
Pregnant  Uterus  Bicornis,  shown  by  Dr.  J.  R.  Rat- 

CLIFFE  .....     469 

Report  of  Committee   on   Dr.  Ratcliffe's  Specimen  of 
Uterus  Bicornis  ....     470 

XIV.  On  the  Occurrence  of  Sugar  in  the  Urine  during  the 
Puerperal  State.  By  Frederick  J.  McCann,  M.B., 
and  William  Aldren  Turner,  M.D.         .  .    473 

XV.  Case  of  Galactorrhoea  during  a  First  Pregnancy.     By 

W.  S.  A.  Griffith,  M.D.  .  .  .491 


Index  ......    495 

Additions  to  the  Library      .  .  .  .    515 


PLA.TE. 

PAGE 

Ruptured  Tubal  Gestation  (Dr.  Cullingworth)  .     134 

WOODCUTS. 

An  Ovarian  Dermoid  (Mr.  J.  Bland  Sutton)  .  .        5 

An   Ovai-ian  Dermoid ;    Infiltration   of  the  Broad  Ligament 

with  Fat  (Mr.  J.  Bland  Sutton)        .  .  .7 

A  Hydrosalpinx  undergoing  Spontaneous  cure  (Mr.  J.  Bland 

Sutton)    ,  .  .  .  .  .9 

Amorphous  Acardiac  Twin  (Dr.  Herman) 

Fig.  1. — Specimen  as  seen  from  outside,  showing  Hairy 

Scalp  and  Tongue  .  .  .12 

Fig.  2. — Si^ecimen  seen  in  Section  .  .  .12 

Retroflexion  of  the  Uterus  in  a  New-born  child  (Dr.  Herbert 

R.  Spencer)  .  .  .  .  .26 

Debate  on  Caisarean  Section  (Dr.  Murdoch  Cameron) 

Fig  1. — Form  of  Abdomen  and  Line  of  Incision  .     118 

Fig.  2.—  Ditto  ditto       .  .118 

Fig.  3. — Sti'aightened    Graily    Hewitt    Pesaary,   and 

Line  of  Incision  .  .  .     119 

Fig.  4. — Showing  position  of  Hands,  and  points  where 

Sutures  are  introduced  .  .  .     120 

Fig.  5.  —Showing  Sutures  in  position  .  .     120 

Dissection  illustrating  Specimen  of  Malformation  of  Rectum 

and  Bladder,  A:c.  (Dr.  Giles)      ...  .     131 

Dissection  illustrating  specimen  of  Congenital  Diaphragmatic 

Hernia  (Dr.  Giles)  .....     133 

Portion  of  Transverse  Section  of  Tumour  of  Umbilicus  formed 

by  prolapse  of  Meckers  Diverticulum  (Dr.  Wheaton)     .     185 
An  Ovarian  Hydrocele  containing  Papillomata  (Mr.  J.  Bland 

Sutton)     ......    216 

The  Value  of  Abdominal  Section  in  Certain  Cases  of   Pelvic 
Peritonitis  (Dr.  Cullingworth). 

Figs.  1  and  2. — Double  Pyosalpinx,  showing  the  irre- 
gular Dilatations  of  the  Tubes  (Case  30)    .     330 
Figs.  3  and  4. — Pyosalpinx  due  to  Gonorrhoea,  show- 
ing irregular  Dilatations  of  the  Tubes,  and 
the  Walls  thickened  by  Chronic  Inflamma- 
tion (Case  43)      .  .  .    373 
Fig.  5. — Pyosalpinx  of  left  side  (Case  45)     .  .     379 
Fig.  6. — Hydrosalpinx  of  right  side  (Case  45)  .    379 

VOL.  XXXIV.  e 


ADVERTISEMENT. 

The  Society  is  not  as  a  body  responsible  for  the  facts  and 
opinions  wliich  are  advanced  in  tbe  following  papers  and  com- 
munications read,  nor  for  tliose  contained  in  tbe  abstracts  of  tbe 
discussions  wbicb  bave  occurred  at  tbe  meetings  during  tbe 
Session. 

20,  Hanover  Square,  W. 


LIBRARY  AND  MUSEUM, 
20,  Hanover  Square,  W. 


Hours  of  Attendance:  Monday  to  Friday,  1.30  p.m.  to  6  p.m.; 
Saturday,  9  a.m.  to  11  a.m.,  and  in  tbe  Evenings  on  wbicb  tbe  Society 
meets,  from  7.15  p.m.  to  7.45  p.m. 


R.  W.  SAVAGE, 

Librarian. 


OBSTETRICAL  SOCIETY 


LONDON. 


SESSION   1892. 


JANUAEY  6th,  1892. 
J.  Watt  Black,  M.D.,  President,  in  the  Chair. 
Present — 40  Fellows  and  7  Visitors. 

Books  were  presented  by  Dr.  Auvard,  Dr.  J.  A.  Irwin, 
Dr.  B.  S.  Schultze,  and  the  Medical  Society  of  London. 

Robert  Colgate  Holman,  M.R.C.S.  (Midhurst),  was 
declared  admitted  as  a  Fellow  of  the  Society. 

The  following  gentlemen  were  elected  Fellows  of  the 
Society: — SydneyBeauchamp,M.B.,  B.C.Cantab.;  Matthew 
Mitchell  Bird,  M.D.,  B.S  Durh.  ;  William  Arthur  Bond, 
M.A.,  M.D.,  B.S.Cantab.  ;  William  Haig  Brodie,  M.D., 
C.M.Edin.  ;  John  Morgan  Evans,  L.R.C.P.Lond.  (Llan- 
drindod  Wells)  ;  William  Gardner,  M.B.,  CM.Glas.  (Mel- 
bourne) ;   George   Arthur   Hawkins-Ambler,   F.R. C.S.Ed. 

VOL.  XXXIV.  1 


2  PRIMARY    SARCOMA    OF    BOTH    OVARIES. 

(Clifton)  ;  Thomas  Hyde  Hills,  L.R.C.P.Lond.  (Cam- 
bridge) ;  Ernest  Kingscote,  M.B.,  C.M.Edin.  (Salis- 
bury) ;  Domingo  Montbrun,  M.D.Caracas,  M.R.C.S.Eng. 
(Trinidad)  ;  Charles  Hubert  Roberts,  L.R.C.P.Lond.  ; 
Thomas  .Tenner  Verrall,  L.R.C.P.Lond.  (Brighton)  ;  and 
Thomas  Wilson,  M.D.,  B.S.Lond.  (Wolverhampton). 

The  following  gentlemen  were  proposed  for  election  : — 
Arthur  Edward  Giles,  M.B.Lond.  (St.  John's,  S.E  )  ;  and 
Mark  Robinson,  L.R.C.P.Lond.  (Wandsworth). 

The  President  nominated  the  following  gentlemen  as 
Auditors  of  the  accounts  for  1891  : — Dr.  Boulton,  Dr.  M. 
Handfield-Jones,  Dr.  W.  S.  A.  Griffith,  Dr.  Amand 
Routh,  and  Mr.  Alban  Doran. 


PRIMARY  SARCOMA  OF  BOTH  OVARIES. 
By  .J.  A.   Shavst-Mackenzie,  M.  B. 

Dr.  J.  A.  Shaw-Mackenzie  exhibited  a  specimen  of 
primary  sarcoma  of  both  ovaries.  The  pathological  points 
of  interest  were  a  large  cyst  of  clear  fluid  in  connection 
with  the  left  ovarian  mass,  the  uterus  and  tubes  free  from 
malignant  deposit,  and  no  such  deposits  elsewhere.  Ascites 
and  double  pleuritic  effusion  were  present. 

The  specimens,  weighing  5^  lbs.,  were  taken  post  mortem 
from  a  married  woman  aged  .28,  admitted  in  a  dying 
condition  to  the  Chelsea  Hospital  for  Women,  under  Dr. 
Gerald  Harper.  There  had  been  amenorrhoea  for  ten 
months,  and,  as  the  abdomen  enlarged  and  vomiting 
occurred,  pregnancy  was  suspected  by  the  woman  and 
diagnosed  by  the  practitioner. 


•      ABSCKSS    OF    OVARY.  3 

Both  masses  were  free^  and  could  have  been  removed  in 
an  earlv  staa-e. 


ABSCESS  OF  OVARY. 
By  Heywood  Sjuth,  M.D. 

Dii.  Heywood  Smith  exhibited  a  specimen  that  he 
thought  would  prove  of  considerable  interest.  It  was  ap- 
parently an  abscess  of  the  left  ovar}*,  which  he  had  removed 
from  a  lady  in  Warrington  Lodge  on  November  18th. 
The  case  was  as  follows  : — The  patient  was  confined  in 
India,  March  27th,  after  a  natural  labour.  On  the  third  day 
she  was  taken  Avith  fever.  Ten  days  afterwards  a  lump 
formed  on  the  left  of  the  abdomen,  which  subsided  in  a 
week.  Two  weeks  later  another  swelling  formed  just 
above  the  left  inguinal  region.  She  arrived  in  England 
about  the  beginning  of  September,  and  was  admitted 
into  one  of  the  hospitals  for  women.  She  was  there 
lor  nine  weeks,  but  nothing  seems  to  have  been  made  out 
there,  except  that  she  was  suffering  from  some  pelvic 
inflammation  Avith  pyrexia.  At  the  end  of  nine  weeks  she 
was  brought  to  Warrington  Lodge,  with  the  characteristic 
temperature  of  suppuration.  A  tumour  the  size  of  a  large 
orange  existed  on  the  left  of  the  uterus  and  intimately  con- 
nected with  it,  not  very  hard,  and  somewhat  moveable.  Dr. 
H.  Smith  called  in  Dr.  CullingAvorth,  w^ho  agreed  with  him 
as  to  the  necessity  of  an  operation,  deeming  the  tumour  to 
be  a  pyosalpinx.  At  the  operation  there  were  adhesions 
to  the  omentum,  and  several  in  the  pelvis.  The  pedicle 
was  thick  and  rather  friable.  The  uterus  lay  deep  down 
on  the  right ;  the  right  oviduct  was  thick  and  tortuous. 
A  glass  drainage-tube  was  inserted.  The  tumour  was  the 
size  of  a  small  fist.  On  section  it  seemed  to  consist  of  an 
abscess,  many-celled,  with  thickened  walls,  which,  how- 


4  ABSCESS    OP    OVARY. 

evei%  were  very  thin  in  places,  and  gave  way  after  the 
tumour  was  lifted  out  of  the  pelvis  ;  there  was  also  a  cyst 
at  one  end,  tlie  size  of  a  Tangerine  orange,  which  con- 
tained bloody  fluid. 

Dr.  Cullingworth  examined  the  tumour,  and  at  his  sug- 
gestion Dr.  Heywood  Smith  asked  that  a  committee  might 
be  appointed  to  examine  and  report  on  the  specimen. 

The  day  after  the  operation  the  fluid  coming  from  the 
drainage-tube  began  to  be  offensive.  The  day  after,  the 
patient  on  awaking  felt  something  give  way,  after  which 
discharge  distinctly  fascal ;  iiatus  also  passed  by  the  tube. 
Three  days  after  the  operation  an  enema  was  given^  and 
the  water  came  up  through  the  drainage-tube.  The 
patient,  however,  gradually  gained  strength,  though  a 
faecal  fistula  remained,  which,  however,  was  closing  slowly. 

Dr.  Heeman  asked  if  the  faecal  fistula  could  have  been  due  to 
the  pressure  of  the  end  of  the  draiuage-tube  on  the  bowel.  He 
had  seen  several  cases  apparently  so  caused,  both  after  operations 
and  after  the  opeuing  of  a  puerperal  abscess,  pointing  in  the  middle 
line  of  the  abdomen  just  below  the  umbilicus.  They  all  healed 
when  the  tube  was  removed. 

Dr.  CuLLiNGWORTU  Said  he  had  shown  the  specimen  to  Mr. 
Shattoek,  the  Curator  of  St.  Thomas's  Hospital  Museum,  and  that 
neither  Mr.  Shattoek  nor  he  remembered  to  have  seen  anything 
quite  like  it  before.  Mr.  Shattoek  said  it  was  more  suggestive 
of  actinomycosis  than  any  other  condition  with  win'ch  he  was 
acquainted,  and  was  of  opinion  that  the  responsibility  of  exa- 
mining and  reporting  upon  it  would  be  more  fitly  undertaken  by  a 
committee  than  by  an  individual.  He  (Dr.  Cullingworth)  hoped 
the  President  would  be  good  enough  to  refer  the  specimen  to  a 
committee  of  pathological  experts. 

In  answer  to  Dr.  Herman,  Dr.  Heywood  Smith  said  he  did 
not  think  the  glass  drainage-tube  had  anything  to  do  with  the 
causation  of  a  faecal  fistula,  as  it  took  place  too  soon  after  the 
operation  ;  lie  considered  it  was  caused  by  the  tearing  down  of 
some  adhesion  which  existed  between  the  abscess  and  the  bowel. 

A  committee,  consisting  of  Mr.  Doran,  Mr.  Sutton,  and 
Dr.  Heywood  Smith,  was  appointed  to  report  on  this 
specimen. 


AN    OVAEIAN   DERMOID. 

By  J,  Bland  Sutton. 

The   dermoid  wliicli  forms  the  subject  of  this  commu- 
nication   was  removed  by  Mr.  Henry  Morris  from  a  single 


Twisted  pedicle. 


Corpus  luteum. 


Sebaceous 
adenoma. 


An  ovarian  dermoid.  Tlie  cyst  contained  hair,  but  it  had  become 
bald.  A  large  sebaceous  adenoma  projected  into  the  cavity,  and 
a  large  corpus  luteum  was  present  in  the  wall. 

lady,  between  thirty  and  forty  years  of  age.      The  uterus 
contained  a  large   myoma    which   blocked   up   the    pelvic 


6  OVARIAN    DERMOID. 

cavity  ;  tlie  dermoid  lay  in  the  left  iliac  fossa,  adherent  to 
a  coil  of  ileum.  The  pedicle  was  tightly  twisted,  and  the 
tumour  was  engorged  with  blood. 

The  dermoid,  which  is  represented  two  thirds  the 
natural  size  in  the  accompanying  drawing,  has  thick 
walls  containing  secondary  cysts,  several  of  which 
are  occupied  by  fat  of  the  consistence  of  cacao  butter. 
There  is  also  a  large  corpus  luteum.  The  main  cavity  of 
the  dermoid  contained  sebaceous  material,  intermixed 
with  a  quantity  of  short  hairs,  light  brown  in  colour. 
When  the  loose  material  was  washed  away  no  hairs  could 
be  seen  growing  from  the  cyst  wall ;  it  is  an  example 
of  an  ovarian  dermoid  becoming  bald  with  age.  Hang- 
ing' in  the  cyst  by  a  thick  pedicle,  after  the  fashion  of  a 
polypus,  is  a  soft,  skin-covered  tumour,  which  appears 
minutely  dotted  when  viewed  Avith  the  naked  eye. 
Sections  from  this  part,  when  examined  under  the  micro- 
scope, exhibit  little  else  than  clusters  of  the  largest 
sebaceous  glands  I  have  ever  seen  in  the  human  subject ; 
indeed,  this  polypoid  mass  may  be  appropriatel}^  described 
as  a  sebaceous  adenoma. 

Not  the  least  interesting  point  in  the  tumour  is  the 
presence  of  a  large  corpus  luteum,  which,  to  the  naked 
eye  and  the  microscope,  Avas  absolutely  indistinguish- 
able from  the  so-called  corpus  luteum  of  pregnancy.  I 
have  on  several  occasions  seen  similar  large  corpora  lutea 
in  ovaries  removed  from  women  between  thirty  and  forty- 
five  years  of  age  for  the  purpose  of  anticipating  the  meno- 
pause in  cases  of  uterine  myomata.  The  patients  had 
never  been  i^regnant. 


OVARIAN  DERMOID  ;   INFILTRATION  OF  BROAD 
LIGAMENT    WITH   FAT. 

By  J.  Bland   Sutton. 

As  is  well  known,  the  mesosalpinx  is  normally  free  of 
fat.  Recently  Mr.  Malcolm  was  good  enough  to  place 
in  ray  hands  an  ovarian  dermoid  the  size  of  a  melon, 
which  was  removed  by  Mr.  K.  Thornton.  The  peculiarity 
of  the  tumour  cousisted  in  the  circumstance  that  the 
mesosalpinx  and  adjacent  parts  of  the  broad  ligament 
were  infiltrated  with  rich  granular  fat. 

Ovarian  dermoids  frequently  abound  in  fat,  even  when 
growing  in  \erj  lean  subjects.  On  dividing  this  tumour 
I  found,  in  those  parts  adjacent  to  the  mesosalpinx,  a 
quantity  of  soft  fat  collected  in  cells,  which,  on  section, 
resembled  honey  in  the  honeycomb,  except  that  the  cells 
were  elliptical  instead  of  being  hexagonal. 

On  tracing  this  fatty  region  of  the  tumour  in  its 
relation  with  the  broad  ligament  it  was  clear  that  the 
capsule  of  the  dermoid  had  ruptured,  and  the  tissues  of  the 
tumour,  especially  the  fat,  had  burrowed  along  the  lines 
of  least  resistance,  and  made  their  way  between  the  layers 
of  the  mesosalpinx  and  surrounded  the  tube.  Embedded 
in  the  fat  were  some  fat-containing  cysts,  and  a  solid 
spherical  body  which,  on  microscopical  examination, 
exhibited  glandular  structure. 

The  dermoid  is  interesting  as  it  throws  light  on  a  spe- 
men  exhibited  to  the  Pathological  Society  by  Mr.  Doran,* 
in  which  the  broad  ligament  was  infiltrated  with  fat. 
In  that  case  the  ovaries  were  occupied  by  dermoids  con- 
taining much  greasy  material.  In  the  brief  description 
of  the  specimens    no  explanation  is  offered  as  to  the  pro- 

*  'Trans.  Path.  Soc.,'  vol.  xli,  p.  202. 


OVARIAN    DERMOID. 


ba"ble  source  of  the  fat.  As  far  as  my  observations 
extend  tlie  presence  of  fat  in  the  mesosalpinx  is  very 
exceptional. 


Fallopian  tube 


Infiltration  of  tlie  mesosalpinx  with  fat,  secondarj'  to  rupture  of  the 
capsule  of  an  ovarian  dermoid. 

Parono*  described  a  caso  di  Uj)oma  all'  ovaia  ed  ovidotto 
di'destra,  but  I  have  not  been  able  to  consult  the  original 
memoir. 

*  'Ann.  di  Ostet./  Milano,  1891,  xiii,  103—105,  pi.  i. 


A  HYDROSALPINX  UNDERGOING  SPONTANEOUS 

CURE. 

By  J.  Bland  Sutton. 

The  parts  represented  in  the  figure  are  the  uterus  and 
remnants  of  tlie  appendages  removed  post  mortem  from 
a  lady^  forty-five  years  of  age,  Avho  died  suddenly  in  a 
nursinsf  home. 


Hydrosalpinx  in  a  late  stage. 

She  had  been  under  the  care  of  an  eminent  obstetiic 
physician  for  pelvic  trouble,  and  intense  pain  in  the  right 
side    of  the   head.       No   active   treatment   was    adopted. 


10  HYDHOSALPINX    UNDERGOING    SPONTANEOUS    CURE. 

Death  was  due  to  a  gumma  in  the  right  temporo-sphe- 
uoidal  lobe  ol:  the  brain. 

The  body  of  the  uterus  was  natural,  but  the  left 
Fallopian  tube  was  dilated  into  a  tortuous  cyst  with  ex- 
tremely thin  transparent  walls.  The  dilated  tube  con- 
tained fluid  of  a  pale  straw  colour.  The  right  tube  is 
simply  an  impervious  cord,  and  the  corresponding  ovary 
was  not  detected  even  after  a  most  careful  search. 

I  have  elsewhere  expressed  the  opinion  that  under 
favourable  conditions  an  obstructed  and  dilated  tube 
may  undergo  spontaneous  cure.  The  walls  of  the  tubes 
become  excessively  thin,  until  at  last  they  rupture  ;  and  as 
the  fluid  from  an  old  hydrosalpinx  is  not  infective,  it  is 
absorbed  by  the  peritoneum,  and  the  shrunk  sac  atrophies. 
The  atrophied  tube  is  seen  on  the  left  side  ;  whilst  with 
the  hydrosalpinx  on  the  right  side  rupture  appeared  to  be 
imminent. 

Such  a  mode  of  spontaneous  cure  appears  to  be  rare ; 
thus  the  specimen  is  the  more  instructive,  and  is  valuable 
as  additional  evidence  in  support  of   my  contention. 

Dr.  Herman  said  that  Mr.  Bland  Sutton's  statement,  that 
with  uterine  fibroids  a  corpus  luteum  as  big  as  that  of  pregnancy 
was  sometimes  seeu,  was  just  now  opportune,  for  Dr.  R.  J.  Lee, 
in  a  letter  recently  published  in  the  '  Lancet,'  had  said  that  the 
tact  of  pregnancy  could  be  stated  with  certainty  from  the  cha- 
racter of  tlie  corpus  luteum.  He  (Dr.  Herman)  had  seen,  in  an 
ovary  removed  from  a  case  of  uterine  tibroid,  a  corpus  luteum, 
an  uich  in  diameter.  Dr.  Popow,  in  a  paper  published  in  vol. 
.\xiv  of  the  '  Transactions,'  had  described  a  corpus  luteuu)  like 
that  of  pregnancy,  but  not  associated  with  it.  These  observa- 
tions showed  that  size  at  least  was  not  a  criterion  ;  and  if  Dr. 
Lee  knew  of  any  other  criteria,  he  had  not  mentioned  what  they 
were. 


11 

EUPTURED    UTERUS. 
By  R.  Box  ALL,  M.D. 

De.  Boxall  exhibited  a  uterus  whicli  had  been  ruptured 
during  labour.  There  were  two  superficial  tears  through 
the  peritoneal  surface  of  the  anterior  wall  near  the  fundus, 
and  several  incomplete  lacerations  through  the  mucous 
membrane  in  the  lower  segment  of  the  uterus,  all  mainly 
lonsritudinal  in  direction. 


Report  of  Committee,  nominated  December  2nd,  1891,  on 
Br.  Herman's  Specimen  of  Amorphous  Acardiac  Twin 
{'Transactions,'  vol.  xxxiii.,  p.  493). 

Your  committee  have  met  this  day,  and,  after  examining 
the  specimen  named  above,  have  drawn  up  and  signed 
the  following  report  : — This  specimen  consists  of  an  oval 
elastic  body,  6  centimetres  long,  4"25  by  2"5  cm.  broad, 
after  immersion  for  some  time  in  alcohol. 

Its  surface  consists  entirely  of  skin.  A  circumscribed 
area,  about  2  cm.  in  diameter,  is  covered  with  dark 
brown  hair,  some  of  the  hairs  being  3  cm.  long.  Below 
this  area,  which  appears  to  represent  the  scalp,  is  a  small 
fleshy  wattle,  under  1  cm.  long,  closely  resembling  a 
tongue.  The  scalp  and  tongue-like  body  are  separated 
by  a  deep  depression.  Under  the  tongue-like  body  is  a 
tuberous  projection,  bearing  short,  dark  brown  hair.  The 
smoother  general  surface  of  the  body  for  1*5  cm.  below 
it  bears  yet  shorter  hair.  Elsewhere  no  hair  is  to  be 
found. 

Close  below  the  scalp  the  membranes  are  attached  to 
the  body  of  the  monster.      There  is  no  distinct  umbilical 


12 


AMORPHOUS    ACARDIAC    TWIN. 


Fig.  1. — Specimen  as  seen  from  outside,  showing  hairy  scalp  and 
tongue.  The  small  cutaneous  tubercle  lies  low  down  near  the 
risht  border. 


Neural  arch 


Body  of       ^"^x  V^f  '' 
vertebra        _     |      M    ^ 
Spinal  cord 


Fig.  2. — Specimen  seen  in  section. 


AMORPHOUS    ACARDIAC    TWIN.  13 

cord,  but  two  large  vessels  joined  together  enter  the 
mass.  2'5  cm.  below  the  attacliment  of  the  membranes  is 
a  minute  tubercle  sunk  in  a  recess. 

The  interior  consists  chiefly  of  oedematous  connective 
tissue  with  fat,  but  no  cystic  cavities.  Tw^o  centimetres 
below  tlie  level  of  the  area  of  attacliment  of  the  mem- 
branes lies  a  mass  of  bone  and  cartilage,  divided  by 
section,  and  bearing  the  characters  of  a  cervical  vertebra. 
A  thick  cord,  apparently  the  spinal  cord,  runs  through  the 
vertebra,  and  terminates,  after  a  course  of  over  2  cm. 
through  the  oedematous  connective  tissue  of  the  monster, 
in  the  tubercle  on  the  surface. 

There  is  no  trace  of  intestine,  nor  of  any  solid  organ, 
nor  any  blood-vessel  visible  to  the  naked  eye. 

The  monster  is  an  Acardiacus  Amorphus,  distinctly 
approaching  to  the  Acormus  type. 

G.  E.  Herman. 
W.   S.   A.   Griffith. 
Alban  Doran. 
J.  Bland  Sutton. 


14 


ON  THE  RELATION  BETWEEN  BACKWARD 
DISPLACEMENTS  OF  THE  UTERUS  AND 
PROLONGED  HAEMORRHAGE  AFTER  DELI- 
VERY   AND    ABORTION. 

By   G.   Ernest  Herman,   M.B.,  F.R.C.P., 

OBSTETRIC    PHYSICIAN    TO    THE    LONDON    HOSPITAL. 

(Received  March  20tli,  IS'.H.) 
{Abstract.) 

This  paper  is  based  on  an  analysis  of  3641  consecutive  out- 
patients at  the  London  Hospital. 

The  authoi"  shows  by  figures — 

That  backward  displacements  of  the  uterus  are  more  common 
in  parous  women  than  in  those  who  have  not  had  children. 

That  they  are  more  common  in  those  seeking  advice  soon 
after  delivery  or  abortion  than  in  those  not  applying  for  treat- 
ment until  long  after  childbirth  or  abortion. 

That  they  are  more  frequent  among  those  in  whom  delivery 
or  abortion  has  been  followed  by  prolonged  hsemorrhage  than  in 
those  in  whom  it  has  not. 

That  prolonged  haemorrhage  after  delivery  or  abortion  is  more 
frequent  in  cases  of  backward  displacement  of  the  uterus  than 
in  cases  without  such  displacements. 

Therefore  that  there  is  a  relation  between  backward  displace- 
ment of  the  uterus  and  prolonged  haemorrhage  after  delivery  and 
abortion. 

It  is  shown  that  these  statements  apply  both  to  haemorrhage 
after  delivery  and  to  haemorrhage  after  abortion. 


BACKWARD    DISPLACEMENTS    OF    THE    UTERUS,    ETC.  15 

It  has  been  noticed  that  in  cases  in  which  haemorrhaare 
persists  unusually  long  after  delivery  or  abortion,  back- 
ward displacement  of  the  uterus  is  often  found.  It  has 
been  said  that  this  is  because  the  displacement  causes  the 
h£emorrhao;e.  It  has  also  been  said  that  the  hEemorrhaofe, 
by  weakening  the  patient,  causes  the  displacement. 
R.  Barnes  ('  Diseases  of  Women,'  1st  edition,  p.  095) 
adopts  and  unites  both  views.  He  says  the  "  secondary 
or  acquired  form  of  retroflexion  most  commonly  arises  after 
childbirth  or  abortion.  Labours  attended  by  exhausting 
conditions,  as  hasmorrhage,  dispose  especially  to  this  dis- 
placement. .  .  .  Retroflexion,  in  its  turn,  keeps  up 
secondary  puerperal  haemorrhage,  and  thus  each  evil  aggra- 
vates the  other."  It  is  scarcely  necessary  to  quote  from 
text-books  to  show  that  this  teaching-  has  found  followers. 
But,  so  far  as  I  am  aware,  no  one  has  yet  demonstrated 
that  retroflexion  of  the  uterus  is  found  more  frequently 
in  women  whose  delivery  or  abortion  has  been  followed 
by  much  haemorrhage,  than  in  those  whose  haemorrhage 
has  been  of  brief  duration.  In  this  communication  I 
propose  to  test  by  facts  the  opinion  referred  to  above. 

It  is  impossible,  from  questioning  patients  as  to  their 
histories,  to  get  at  any  accurate  idea  of  the  amount  of  blood 
lost  during  and  after  labour  or  abortion.  The  only  thing 
that  can  be  correctly  ascertained  is  the  length  of  time 
that  the  haemorrhage  lasted ;  and  as,  by  the  theory,  it  is 
secondary  haemorrhage  which  the  displacement  causes, 
the  duration  of  the  haemorrhage  is  the  important  point. 

In  the  following  investigation  by  "  i^rolonged  hsemor- 
rhage  "  is  meant  hgemorrhage  lasting  longer  than  a  fort- 
night after  delivery,  or  longer  than  a  week  after  abortion. 
The  tables  which  follow  are  compiled  from  notes  taken  by 
myself  of  3641  consecutive  London  Hospital  out-patients. 
The  out-patient  department  appears  to  me  the  most 
suitable  field  for  investigating  this  subject.  To  reach  a 
correct  conclusion  as  to  the  relation  between  haemorrhage 
and  displacement  we  ought  to  take  all  cases.  Now  the 
cases    admitted  into  the  hospital  are  mostly  selected  on 


16  BACKWARD    DISPLACEMENTS    OF    THE    OTERUS    AND 

account  of  their  gravity.  The  cases  on  wliich  my  conclu- 
sions ai'C  based  are  taken  without  any  selection  whatever. 

How  may  we  ascertain  the  true  relationship  between 
backward  displacement  of  the  uterus  and  hteraorrhage  ? 

It  might  be  proposed  to  eliminate  from  the  cases  of 
hasmorrhage  all  those  in  which  the  cause  could  be  ascer- 
tained with  something  like  certainty — such  cases,  for  in- 
stance, as  those  due  to  retained  secundiues  ;  and  then  to 
inquire  whether  in  the  residuum  of  cases  of  unexplained 
causation  there  was  a  small  or  large  number  of  cases  of 
backward  displacement.  But  it  appears  to  me  that 
this  mode  of  investigation  would  show  results  too  much 
influenced  by  the  preconceived  opinions  of  the  investi- 
gator to  be  quite  trustworthy.  If  he  found  very  few 
cases  in  which  he  could  find  no  cause  but  displacement, 
it  might  be  objected  that  in  cases  in  which  the  haemor- 
rhage was  really  due  to  the  displacement  he  had  wrongly 
assigned  it  to  other  causes.  If  there  were  many  cases  in 
which  nothing  but  displacement  was  discovered  to  account 
for  it,  it  might  be  said  that  more  exhaustive  investiga- 
tion would  have  revealed  other  causes.  Besides  which, 
to  assume  that,  in  a  case  of  hasmorrhage  with  displace- 
ment, the  bleeding  is  either  due  or  not  due  to  the  dis- 
placement is  to  beg  the  question  at  issue.  In  the  most 
simple  and  evident  of  all  causes,  namely,  retention  of 
secundines,  it  might  be  asserted  that  the  retention  is  the 
effect  of  displacement.  Therefore  it  seems  to  me  that  no 
convincing  result  could  follow  an  investigation  conducted 
on  these  lines. 

The  best  of  all  tests  of  the  dependence  of  haemorrhage 
on  displacement  of  the  uterus  would  be  the  effect  of  treat- 
ment. If  it  were  found  that,  as  a  general  rule,  in  cases 
of  backward  displacement  of  the  uterus  with  haemorrhage, 
other  remedies,  without  replacement  of  the  uterus,  did 
not  stop  the  ha^niurrhage,  but  when  the  uterus  was 
supported  did  stop  it ;  or  that  support  of  the  uterus, 
without  other  roniedies,  was  usually  followed  by  speedy 
cessation   of  hajmorrhage;   these   facts  would   go   far  to- 


PEOLONGED   H.EMORRHAGE   AFTER  DELIVERY   AND  ABORTION.    17 

wards  demoustratiiig  the  dependence  of  the  htemorrhao-e 
on  the  displacement.  But  htemorrhage  is  so  serious  a 
symptom,  that  humanity  forbids  us  to  withhold  any  treat- 
ment that  we  know  to  be  influential  in  stopping  it,  in 
order  that  we  may  observe  the  uncomplicated  action  of 
something  the  effect  of  which  is  doubtful ;  not  to  mention 
the  possibility  that  such  an  investigation  would  often 
be  rendered  incomplete  because  unsuccessful  experimental 
treatment  might  lead  the  patient  not  to  wait  for  the  com- 
pletion of  the  experiment,  but  to  go  somewhere  else  for 
better  treatment.  Hence  I  cannot  refer  to  cases  under 
my  own  care  as  tests  of  the  effect  of  treatment,  for  in 
nearly  all  of  them  both  ergot  was  given,  and  the  uterus, 
if  displaced,  was  supported. 

There  remains  the  method  of  comparing  the  relative  fre- 
quency of  prolonged  hsemorrhage  after  labourer  abortion 
in  cases  with  displacement  and  without  displacement ;  and, 
putting  the  question  in  another  form,  the  relative  frequency 
of  backward  displacements  of  tlie  uterus  in  cases  of  pro- 
longed haemorrhage  and  in  cases  without  prolonged  haemor- 
rhage. If  it  be  the  fact  that  backward  displacement  of  the 
uterus  has  any  effect  in  prolonginghfemorrhageafter  labour 
or  abortion,  then  we  ought  to  find  such  haemorrhage  more 
frequent  in  cases  with  backward  displacement  than  in  those 
without  it  ;  and  we  also  ought  to  find  backward  displace- 
ment more  often  in  cases  in  which  heemorrhage  after  labour 
or  abortion  has  been  prolonged  than  in  those  in  which  it 
has  not  lasted  longer  than  usual. 

1.  Is  prolonged  htemorrhage  after  labour  or  abortion 
more  frequent  in  cases  with  backward  displacement  of  the 
uterus  than  in  cases  without  it  ? 

As  material  for  answering  this  inquiry  I  have  only 
taken  cases  in  which  delivery  or  abortion  had  taken  place 
within  three  months.  Had  more  remote  events  been 
taken  into  account,  the  fallacy  would  have  been  inti-oduced 
that  the  displacement  might  not  have  been  acquired  till 
some  time  after  the  labour  or  abortion,  and  was  not  pre- 
sent  during   the   period   of    haemorrhage  ;    or  that  a  dis- 

VOL.  XXXIV.  2 


18 


BACKWARD    DISPLACEMENTS    OF    THE    UTERUS    AND 


placement  might  have  been  present  during  recovery  from 
the  labour  or  abortion,  and  the  uterus  have  afterwards  re- 
gained its  right  position. 

I  find  that  out  of  3641  out-patients,  411  had  been 
delivered  or  aborted  within  three  months.  In  78  of  these 
the  uterus  was  displaced  backwards,  leaving  333  in  which 
displacement  was  not  present.  Table  I  shows  the  number 
and  the  percentage  of  cases  in  which  prolonged  hemor- 
rhage was  present  in  the  two  sets  of  cases.  It  shows  an 
excess  of  13*6  per  cent,  of  cases  of  haemorrhage  among  the 
patients  with  displacements. 

Table  I. 


No.  of  cases 

delivered  or 

aborted  within 

3  months. 

No.  of  cases 

with 

prolonged 

haemorrhage. 

Percentage  of 
CHses  with 
prolonged 

hseraorrliage. 

Cases  with  backward  displacement         .          78 
Cases  without  backward  displacement .        333 

57 

198 

73 

59-4 

Difference 

.      13-6 

I  conclude,  therefore,  that  prolonged  lisemorrhage  after 
lahour  or  abortion  is  more  frequent  in  cases  of  backirard 
displacement  of  the  uterus  than  in  those  loithout  this  dis- 
placement. 

2.  Is  backward  displacement  of  the  uterus  more  fre- 
quent in  cases  of  prolonged  hasmorrhage  after  labour  or 
abortion  than  in  cases  in  which  such  haemorrhage  has  not 
been  prolonged  ? 

Table  II  gives  the  figures  that  I  am  able  to  supply  in 
answer  to  this  question.  It  shows  that  backward  dis- 
placements of  the  uterus  are  more  frequent  among  women 
who  have  had  children  than  in  the  general  average  of 
patients  ;  that  they  are  more  frequent  in  those  patients 
seeking  advice  during  the  three  mouths  following  delivery 
or  abortion  than  in  those  not  applying  for  treatment  until 


PROLONGED  HEMORRHAGE  AFTER  DELIVERY  AND  ABORTION,    19 

after  the  lapse  of  a  longer  period  (a  fact  from  which  it 
may  be  inferred  that  a  uterus  which  soon  after  a  labour 
or  abortion  was  displaced  backwards  may  afterwards  re- 
gain its  normal  position  Avithout  special  treatment),  and 
that  backward  displacements  are  more  frequent  among  those 
in  tcJiom  labour  or  abortion  is  folloioed  by  prolonged  hsemor- 
rhage  than  in  those  in  which  it  is  not. 

Table  II. — SJtowing  proportion  of  backivard  displacements 
among  patients  generally,  among  parous  women, 
among  those  who  had  recently  had  a  child  or  abor- 
tion, and  among  those  icith  prolonged  haemorrhage 
after  delivery  or  abortion. 


No.  of  cases. 

No.  with 

backward 

displacements. 

Perceritape  of 

backward 
displacemeDts. 

Patients  generallj'         .         .         .         . 

3641 

394 

10-8 

Parous  women      ,         .         .         .         . 

2352 

308 

131 

Patients  who  had   been   delivered    or 

had  aborted  within  3  months    . 

411 

78 

19 

Patients  with   prolonged   hsemorrhagt 
after  delivery  or  abortion  . 

255 

57 

22-3 

Taking  these  two  tables  together,  they  seem  to  me  to 
show  that  there  is  a  relation  between  bacJcicard  displace- 
ment of  the  uterus  and  prolonged  haemorrhage  after  delivery 
or  abortion. 

If  we  assume  that  the  displacement  is  the  cause  of  the 
haemorrhage,  and  endeavour  to  measure  its  influence  by 
taking  the  frequency  of  hasmorrhage  among  those  without 
displacement  as  representing  the  frequency  of  hasmor- 
rhage  from  causes  independent  of  the  displacement,  we 
have,  among  the  patients  with  displacements,  82  per  cent, 
of  haemorrhage  from  other  causes,  18  per  cent,  due  to  the 
displacement.  But  in  many  cases  probably  several  causes 
of  haemorrhage  exist  together. 

Is  prolonged  haemorrhage    more   common  after  labour 


20 


BACKWARD    DISPLACEME^^TS    OF    THE    UTERUS    AND 


or  abortion  ?  Table  III  shows  that,  according  to  the 
definition  I  have  adopted,  it  is  more  common  after  abor- 
tion. It  may  be  thought,  perhaps,  that  to  take  a  week 
after  abortion  as  the  time  after  which  continuous  hfemor- 
rhage  is  pathological  is  to  fix  too  early  a  date.  But, 
according  to  my  experience  of  cases  in  which  the  uterus 
has  been  thoroughly  cleared  out,  it  ceases  within  this  time. 
Still,  the  difference  in  the  duration  of  haemorrhage  after 
labour  and  abortion  respectively  taken  in  this  paper  as 
pathological  may  account  for  the  excess  of  hsetnorrhage 
after  abortion  here  shown.  But  it  does  not  account  for 
the  difference  between  the  cases  witb  and  without  back- 
ward displacement. 

Table  III. — SJtowing   the  frequency   of  prolonged  haemor- 
rhage after  labour  and  abortion  respectively. 


Childbiitli 

Abortion 


Total. 


244 
167 


Cases  of 
bEemorrhage. 


120 
135 


Percentage  of 
hemorrhage. 


49 

80-8 


Is  the  association  of  backward  displacement  of  uterus 
witli  prolonged  heemorrhage  especially  marked  after 
labour  or  after  abortion  ?  Tables  lY  and  V  show  such 
information  as  ray  case-books  give  on  this  question. 
They  show  that  the  association  is  both  with  hsemorrhage 
after  labour  and  with  haemorrhage  after  abortion. 

Table  IV. — Shoicing  the  frequency  of  ptrolonged  lisemor' 
rhage  after  labour  and  abortion  respectively  in  cases 
without  backward  displacement  of  uterus. 


Total. 


Childbirth 
Abortion 


198 
135 


Cases  of 
haemorrhage. 


90 
108 


Percentage  of 
haemorrhage. 


45-4 
80 


PROLONGED   HAEMORRHAGE  AFTER  DELIVERY   AND  ABORTION.  21 

Table  V. — Slunuing  the  frequency  of  prolonged  haemor- 
rhage after  labour  and  abortion  respectively  in  cases 
with  backward  displacement  of  uterus. 


Total. 

Cases  of 
lieemorrliage. 

PercentHge  of 
liiemorihage. 

651 

84-4 

\ 

Childbirtli I         46 

i 
Abortion 32 

1 

30 
27 

Taking  it  as  demonstrated  that  there  is  a  close  relation- 
ship between  the  displacement  and  the  haemorrhage,  the 
question  arises,  which  is  the  cause  and  which  the  effect  ? 
I  have  no  data  from  which  to  give  a  satisfactory  answer 
to  this  question  ;  therefore  I  will  not  discuss  the  question 
further  than  by  making  one  remark.  It  appears  to  me 
that  the  association  of  the  displacement  with  hgemorrhage 
both  after  labour  and  after  abortion — indeed,  in  the  cases 
with  displacement  the  excess  of  cases  of  haemorrhage  after 
labour  is  greater  than  the  excess  of  cases  of  hgemorrhage 
after  abortion — is  against  the  view  that  the  hgemorrhage 
is  simply  and  solely  of  mechanical  production.  The  uterus 
is  larger  after  delivery  than  after  abortion,  and  the  larger 
it  is  the  less  likely  is  it  to  get  into  a  small  Douglas's 
pouch  with  tight  margins.  My  opinion  is  that  a  view 
somewhat  like  Barnes's  is  probably  correct — that  exhaus- 
tion from  hasmorrhage  favours  the  occurrence  of  displace- 
ment ;  which  then,  in  a  few  cases,  leads  to  interference 
with  the  return  of  blood  from  the  uterus,  and  so  to  con- 
tinuance of  the  hgemorrhage. 


22 


TWENTY  CASES  OF  FIBROMA  AND  OTHER 
MORBID  CONDITIONS  OF  THE  UTERUS 
TREATED  BY  APOSTOLI'S  METHOD. 

By  J.  Inglis  PaesonS;,  M.D. 

(Received  April  25th,  1891.) 

This  contribution^  having  already  appeared  in  the 
'  Lancet/  vol.  i,  1892,  p.  467,  is  not  published  here  {"  Laws 
and  Regulations/'  Chapter  xvi.  Section  10).  The  dis- 
cussion which  followed  the  reading  of  the  paper  is  pub- 
lished in  the  report  of  the  January  meeting  of  the 
Society  in  the  '  Lancet/  vol.  i,  1892,  pp.  196-7. 


ANNUAL    MEETING. 

Febedaey  3rd,   1892. 

J.  Watt  Black,  M.D.,  President,  in  the  Chair. 

Present — 52  Fellows  and  3  Visitors. 

The  President  declared  the  ballot  open  for  one  hour, 
and  appointed  Dr.  John  Phillips  and  Mr.  J.  H.  Targett  as 
Scrutineei's. 

The  following  gentlemen  were  admitted  Fellows  of 
the  Society  : — Thomas  Jenner  Yerrall,  L.R.C.P.Lond. 
(Brighton)  ;  Matthew  Mitchell  Bird,  M.D.,B.S.  (Durham)  ; 
J.  H.  Targett,  M.B.,  B.S.Lond.,F.R.C.S.  ;  William  Haig 
Brodie,  M.D.,  C.M.Edin. ;  A.  Maitland  Gledden,  L.R.C.P. 
Lond.  ;  C.  Hubert  Roberts,  L.R.C.P.Lond. ;  William 
Arthur  Bond,  M.A.,M.D.,  B.S.Cantab. ;  Henry  Sharland 
Pope,  M.B.,  B.C.Cantab. 

The  following  gentlemen  Avere  elected  Fellows : — 
Arthur  Edward  Gile.'^,  M.B.Lond.  (St.  John's,  S.E.)  ; 
Mark  Robinson,  M.R.C.S.,  L.R.C.P.Lond.  (Wandsworth). 

The  following  were  proposed  for  election  : — William 
Evelyn  St.  Lawrence  Finny  (Kingston  Hill,  Surrey),  M.B., 
M.C.DubL  ;  Walter  Carle.ss  Swayne,  M.B.Lond.,  M.R.C.S. 
(Clifton)  ;  Augustus  Kmsey-Morgan,  M.R.C.S.,  L.S.A. 
(Bournemouth)  ;  George  D.  Robinson,  M.D.Lond.,  B.S.  ; 
and    John    William    Campbell,   M.B.Cantab.   B.Ch.,   B.A. 


24 


FATAL    EUPTURE    OF    AN    OVARIAN    CYST    IN 
AN    INFANT. 

By  Alban  Doran,  for  George   B.  Beale,  M.D. 

The  specimen  consisted  of  the  uterus  and  appendages 
from  an  infant  aged  six  weeks.  The  clinical  history  of 
the  case,  with  a  drawing,  is  given  iu  the  '  British  Medical 
Journal  '  vol.  ii,  1891,  p.  1255.  The  specimen  now 
belongs  to  the  museum  of  the  Royal  College  of  Surgeons. 


DOUBLE    PYOSALPINX. 

By  A.  C.  Bdtler-Smythe. 

Mr.  Butler-Smythe  showed  a  rare  specimen  of  double 
pyosalpinx  which  he  had  successfully  removed  from  a 
young  married  lady  in  December,  1891.  He  pointed  out 
the  fact  that  though  the  tubes  had  been  enormously  dis- 
tended and  universally  adlierent,  no  discomfort  had  been 
complained  of  till  October  last,  when  the  patient  dis- 
covered a  swelling  iu  her  abdomen.  At  the  same  time 
it  was  highly  probable,  judging  from  the  history  of  the 
case,  that  the  tubes  had  been  in  a  diseased  condition  for 
years. 

Mr.  Blaxj)  Sutton  stated  that  he  had  examined  the  tubes 
exhibited  by  Mr.  Butler-Smythe,  and  found  them  lined  inter- 
nally with  granulation-tissue.  All  traces  of  epithelium  and 
mucous  membrane  had  disappeared.  Large  dilated  tubes  of  this 
character  differed  in  many  points  from  the  common  form  of 
pyosalpinx  secondary  to  septic  endometritis  and  gonorrhoea.  He 
had    ouly    seen    two  other  examples   similar  to  the   specimens 


RETEOFLEXION  OF  THE  UTERUS   IN  A  NEW-BORN  CHILD.      25 

exhibited,  and  until  we  knew  more  about  their  pathology  they 
should  stand  in  a  separate  class.  A  feature  worth  mentioning 
in  regard  to  sui-h  tubes  is  that  in  removing  them  it  is  necessary 
to  enucleate  each  tube  from  the  broad  ligament. 

Mr.  DoEAK  asked  if  the  uterus  was  distinctly  seen  in  Mr. 
Butler-Smythe's  specimen.  The  large  tube  resembled  two  speci- 
mens in  the  museum  of  the  Royal  College  of  Surgeons  (Pathol. 
Series,  Nos.  4571-2)  once  exhibited  by  Mr.  Doran  himself  at  the 
Pathological  Society  (vol.  xxxi,  18S0,  p.  192),  supposed  to  consist 
of  two  greatly  enlarged  Fallopian  tubes.  Mr.  Bland  Sutton,  in 
Bis  'Surgical  Diseases  of  the  Ovaries'  gave  reasons  for  believing 
that  these  tubes,  and  similar  specimens  described  elsewhere,  were 
really  instances  of  hydrometra  or  pyometra  in  bicornute  uteri. 
The  precise  explanation  of  so  interesting  a  condition  is  impos- 
sible, unless  the  operator  can  satisfy  us  that  he  could  find  no 
true  uterus  either  during  operation,  or  in  case  of  death  at  the 
necropsy. 

In  reply  to  Mr.  Doran's  observation  Mr.  Suttok  remarked 
that  in  Sir  Spencer  AVells'  remarkable  specimens  the  legume- 
shaped  cysts  were  not  only  distended,  but  the  muscular  walls 
were  greatly  hypertrophied.  lu  distended  tubes  the  muscle 
tissue  yields  and  atrophies. 


RETROFLEXION    OF   THE    UTERUS   IN   A  NEW- 
BORN    CHILD. 

By  Herbert  R.  Spencer,  M.D.,  B.S. 

The  specimen  and  drawing  show  a  sagittal  section 
(slightly  to  the  left  of  the  middle  line)  of  the  frozen  body 
of  a  stillborn  child,  weighing  about  6^^  lbs.  On  open- 
ing the  abdomen  I  found  an  unusually  long  large  intes- 
tine, and  on  examining  the  uterus  I  found  it  retroflexed  ; 
accordingly,  the  abdomen  was  stitched  up  without  dis- 
turbance of  any  of  the  viscera,  the  body  frozen,  and  a 
section  made  by  Mr.  Lawrence,  the  curator  of  University 
College  Museum.  The  drawing  I  completed  from  a  trac- 
ing taken  immediately  after  the  section  was  made.  Mucus 
was  removed  from  the  vagina  and  uterus,  and  a  thin  layer 


26       RETROFLEXION  OF  THE   UTERUS  IN  A   NEW-BORN   CHILD. 

of  tissue  dissected  off  the  wall  of  the  rectum,  and  the 
small  intestine  was  cut  away  after  the  specimen  had  been 
some  days  in  spirit. 


One-half  natural  size. 

The  uterus  is  seen  to  be  retroflexed,  this  position  being 
evidently  due  to  the  large  descending  colon  which  lies 
between  the  uterus  and  the  bladder,  as  it  comes  over  from 
the  left  side  of  the  abdomen  to  pass  down  on  the  right 
side  of  the  pelvis  into  the  rectum.  Moored  as  it  is  to  the 
back  of  the  abdomen  by  its  mesentery  (7  mm.  long),  this 
piece  of  colon  would  inci-ease  the  amount  of  flexion  if  the 
gut  became  more  distended  or  during  contraction  assumed 
a  rounder  form. 

The  colon  is  very  long  and  convoluted,  having  altogether 


RETROFLEXION  OP  THE   UTERUS  IN  A  NEW-BORN   CHILD.       27 

eigtt  acute  flexures ;  tlie  portion  contained  in  the  left 
half  of  tlie  body  measured  15  inches  in  length. 

The  anterior  lip  of  the  cervix  is  1  mm.  below  the  level 
of  the  top  of  the  symphysis  pubis  ;  the  fundus  is  40  mm. 
above  that  level.  The  posterior  wall  of  the  body  of  the 
uterus  is  4  mm.  from  the  sacral  promontory. 

The  external  os  is  in  the  middle  of  the  pelvis ;  the 
cervical  canal  is  retroverted  at  an  angle  of  25  to  the  axis 
of  the  pelvic  brim  ;  the  canal  of  the  body  is  retroflexed 
at  an  angle  of  40°  to  the  cervical  canal. 

The  cervical  canal  is  25  mm.  long. 
,,     corporeal      ,,        10  ,, 

,,     thickness  of  the  fundus  of  the  uterus  is  5'5  mm. 
„  „  ,,        anterior  wall   of  body  at   internal 

OS  is  3  mm. 
,,  ,,  ,,        posterior  wall  of  body  at  internal 

OS  is  9  mm. 
„  ,,  ,,       anterior    wall    of    cervix    at     the 

middle  is  4  mm. 
„  ,,  ,,       posterior    wall    of    cervix    at    the 

middle  is  7'5  mm. 

It  will  be  noticed  that  the  posterior  wall  at  the  seat  of 
the  flexion  is  three  times  as  thick  as  the  anterior. 

This  is  the  only  example  of  retroflexed  uterus  I  have 
met  with  in  over  one  hundred  necropsies  in  female  still- 
born children.  Langerhans  {'  Archiv  fiir  Gynakologie/ 
Bd.  xiiij  S.  305),  in  about  forty  frozen  sections  of  new- 
born females,  never  met  with  this  condition ;  neither 
did  Crede,  after  observations  extending  over  a  long  period 
('Archiv  fur  Gynakologie,'  1870).  Carl  Ruge  (' Zeit- 
schrift  fiir  Geburtshiilfe/  Bd.  ii,  S.  24)  has  published  two 
cases  with  a  dra■\^'ing.  He  calls  attention  to  the  thinness 
of  the  anterior  wall  at  the  seat  of  flexion,  but  does  not 
consider  the  effect  of  the  intestine  in  causing  the  displace- 
ment ;  it  is  noteworthy,  however,  that  in  one  of  his  cases 
it  is  mentioned  that  the  colon  and  the  rectum  (which 
passed  down  on  the  right  side  of  the  pelvis)  were  distended 


28  PROTRACTED   GESTATION. 

{stark  gefiillt)  with  meconium  ;  in  the  other  case  the  large 
intestine  had  been  emptied  of  meconium  (in  a  breech  pre- 
sentation), and  in  front  of  the  uterus  lay  an  empty  coil  of 
small  intestine.  Tschaussow  {'  Anatomischer  Anzeiger/ 
1887,  s.  546)  also  figures  a  case. 

Dr.  HouROCKs  pointed  out  that  the  uterus  was  not  only  retro- 
flexed,  but  also  pushed  bodily  backwards  towards  the  sacrum, 
retroponirt,  or  retroposed  ;  also  that  it  was  elevated,  the  top  of  the 
uterus  lying  near  to  and  in  front  of  the  lumbar  vertebrae. 

Dr.  Champneys  tliought  that  Dr.  Spencer's  explanation  was 
probably  correct.  The  arrangement  of  the  bowels,  and  especiall}' 
of  the  colon,  in  infants  was  subject  to  considerable  variation. 
Granted  the  displacement  of  the  colon  and  its  distension,  as  seen 
in  the  specimen,  the  displacement  of  the  uterus  was  accounted 
for.     The  uterus  was  retroposed,  retroliexed,  and  retroverted. 


SUPPOSED   UNRUPTURED    TUBAL   GESTATION 

SAC. 

By  W.  S.  Playfatk,  M.D. 

A  COMMITTEB,  Consisting'  of  Drs.  Herman,  Griffith,  and 
Playfair,  was  appointed  to  report  on  this  specimen. 

T^he  original  account  of  the  case  will  be  published  with 
the  report. 


PROTRACTED    GESTATION. 

By  C.  Paget  Blake,  M.D.,  F.R.C.P.  (communicated  by 
AV.  S.  Playfair,  M.D.). 

(Received  June  lUtli,  1801.) 


29 


Annual  Meeting. 

The  audited  balance-sheet  of  the  Treasurer  (Dr.  Herman) 
was  read.  It  was  moved  by  Dr.  W.  S.  A.  Griffith,  seconded 
by  Dr.  Cullingworth,  and  carried  unanimously — "  That 
the  audited  report  of  the  balance-sheet  just  read  be 
received,  adopted,  and  printed  in  the  next  volume  of  the 
'  Transactions.'  " 

The  report  of  the  Honorary  Librarian  (Dr.  William 
Duncan)  was  read.  Mr.  Bland  Sutton  proposed  and 
Dr.  Lewers  seconded — "  That  the  report  of  the  Honorary 
Librarian  be  received,  adopted,  and  printed  in  the  '  Trans- 
actions.' '■"      This  was  carried  unanimously. 

Report  of  the  Honorary  Librarian. 

"  During  the  past  year  123  volumes  have  been  added 
to  the  Library.  These  are  made  up  of  52  books  and 
13  tracts  (1  volume)  presented  to  the  Library,  and  13 
books  and  20  tracts  (2  volumes)  purchased.  The  periodicals 
make  55  volumes. 

"  The  total  number  of  volumes  in  the  Library  at  the 
end  of  1891  amounts  to  4361. 

''  William  Duncan." 

The  report  of  the  Chairman  of  the  Board  for  the  Exa- 
mination of  Midwives  (Dr.  Chauipneys)  was  then  read. 
It  was  proposed  by  Dr.  Davson,  seconded  by  Dr.  Euther- 
foord,  and  agreed  to  unanimously — "  That  the  report  of 
the    Chairman    of   the    Board    for    the    Examination    of 


30 


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25 

OFFJCERS    AND    CODNCIL.  31 

Midwives   be   received,    adopted,    and    published   in  the 
*  Transactions.'  " 

Beport  of  the  Chairman  of  the  Board  for  the  Examination 
of  Midwive.H. 

"  The  numbers  of  candidates  for  the  certificate  of  the 
Society  continue  to  increase,  and  have  latterly  increased 
largely. 

"  In  1891,  258  presented  themselves,  of  whom  204 
passed,  54  failed  (including  two  absentees),  giving  nearly 
20  per  cent,  of  rejections.  The  grand  total  since  1872  (the 
first  examination)  stands  thus  :  candidates  1388,  passed 
1124,  failed  249,  absent  15,  giving  19  per  cent,  of  rejec- 
tions (including  absentees). 

"  F.  H.   Champneys." 

The  Scrutineers  having  presented  their  report,  the 
result  of  the  Ballot  was  declared  by  the  President  as 
follows  : 

Honorary  Fellows  (British  subjects). — Sir  Joseph  Lister, 
Bart.  ;  Sir  William  Turner  (Edinburgh).  [Foreign  sub- 
jects.)— Professor  Carl  S.  F.  Crede  (Leipzig)  ;  Professor 
William  Thompson  Lusk  (New  York). 

Officers  and   Council. 

President.— J.  Watt  Black,  M.A.,  M.D. 

Vice-presidents. — Percy  Boulton,  M.D.;  Thomas  Charles 
Steuart  Corry,  M.D.  (Belfast)  ;  Alban  Doran  ;  Frederick 
H.  Gervis  ;  William  Appleton  Meredith,  M.B.,  CM.  ; 
Harry  Speakman  Webb  (Welwyn). 

Treasurer. — G.  Ernest  Herman,  M.B. 

Chairman  of  the  Board  for  the  Examination  of  Mid- 
wives. — Francis  Henry  Champneys,  M.A.,  M.D. 

Honorary  Secretaries. — Peter  Horrocks,  M.D. ;  William 
Duncan,  M.D. 

Honorary   Librarian. — W.  Radford  Dakin,  M.D. 


OZ  OKFICERS    AND    COUNCIL, 

Other  ifcmhers  of  Council. —  Edward  Clapham,  M.D. ; 
Frederick  William  Coates,  M.D.  (Salisbury)  ;  Charles 
James  CullingwortJh,  M.D. ;  Henry  W.  Freeman  (Batli)  ; 
John  H.  Galtou,  M.D.  ;  Josepli  Johnston,  M.D.  ;  Henry 
Ambrose  Lediard,  M.D.  (Carlisle)  ;  Henry  Colley  March., 
M.D.  (Rochdale)  ;  Arthur  Perigal,  M.D.  (Barnet)  ;  John 
Baptiste  Potter,  M.D.  ;  Marmaduke  Prickett,  M.A.,  M.D.  ; 
Thomas  Laurence  Read  ;  Heniy  Trotter  Rutherfoord,  B.A., 
M.B. ;  John  Sutton  Sams  ;  Herbert  R.  Spencer,  M.D. ; 
Edward  Sabine  Tait,  M.D.  ;  George  Herbert  Wade 
(Chislehurst)  ;   John  Williams,  M.D. 

The  President  then  delivered  the  Annual  Address. 


33 


ANNUAL    ADDRESS. 

Gentlemen, — In  common  with  the  whole  of  Her 
Majesty's  subjects,  the  Council  of  the  Obstetrical  Society 
of  London  has  noticed  with  the  greatest  sorrow  the  la- 
mented death  of  His  Royal  Highness  the  Duke  of  Clarence 
and  Avondale. 

I  regret  to  state  that  our  worthy  Librarian,  Mr.  R.  W. 
♦Savage,  is  lying  seriously  ill  of  double  pneumonia,  super- 
vening on  an  attack  of  bronchitis  with  which  he  was 
seized  three  weeks  ago.  I  inquired  after  him  at  his 
residence  in  Brondesbury  Villas,  Kilburn,  this  afternoon, 
and  was  informed  that  his  condition  improves  but  slowly. 
In  the  meantime  the  Council  has  found  it  necessary  to 
arrange  for  the  temporary  performance  of  his  duties  by 
an  efficient  substitute. 

Your  Council  considered  this  evening  a  letter  of  January 
16th,  1892,  received  by  our  Senior  Secretary  from  Dr. 
Jacobs,  the  General  Secretary  of  the  Periodical  Interna- 
tional Congress  on  Gyntecology  and  Obstetrics,  which  has 
been  founded  on  the  suggestion  of  the  Belgian  Society  of 
Gynaecology  and  Obstetrics,  and  which  will  hold  its  first 
meeting  in  Brussels  from  the  14th  to  the  19th  of  Septem- 
ber next.  The  letter  indicates,  as  subjects  which  will 
come  under  discussion,  pelvic  suppurations,  extra-uterine 
pregnancy,  and  placenta  pnevia,  and  invites  the  Fellows 
of  this  Society  to  take  part  in  the  work  of  the  Congress. 
The  following  is  the  text  of  the  letter  : 


VOL.  xxxiv. 


34  ANNUAL    ADDRESS. 

"CoxGRES    Pkkiodiqxje    International    de    Gynkcologie    et 
d'Obstktrique. 

"  Premiere  Session — Bruxelles,  1892. 

"  Bruxelles;  16  Janvier,  1892. 

"  Secretariat  jreiieral :  Dr.  Jacobs, 

12,  Rue  des  Petits-Carines,  Bruxelles. 

"Monsieur  et  tres  honore  Confrere, 

"  J'ai  riionneur  cVinforraer  MM.  les  President  et 
Membres  de  la  '  Societe  d'Obstetrique  de  Londres  ^  de 
rinitiative  prise  par  la  '  Societe  beige  de  Gynecologie  et 
d'Obstetrique '  de  fonder  van  Congres  International 
periodique  d'Obstetrique  et  de  Gynecologie,  dont  la  1"'* 
Session  aura  lieu  a  Bruxelles  du  14  au  10  Septembre 
1892. 

"  Trois  questions  ont  ete  portees  a  I'ordre  du  jour  : 

"  1°.  Des  suppurations  pelviennes  ;  rapporteur,  M.  le 
Dr.  Segond,    de  Paris. 

"  2°.  Des  Grossesses  extra-uterines ;  rapporteur,  M. 
le  Dr.  A.  Martin,  de  Berlin. 

"  3°.  Du  placenta  pra3via  ;  rapporteur,  M.  le  Dr.  Berry 
Hart,  d'Edimbourg. 

''  La  Societe  beige  de  Gynecologie  et  d'Obstetrique  es- 
pere  rencontrer  de  la  Societe  Obstetricale  de  Londres  et 
convie  les  Membres  a  prendre  part  aux  travaux  du 
Congres. 

"  Croyez,  Monsieur  et  tres  lionore  confrere,  a  toute  ma 
consideration, 

"  Dk.  Jacobs. 

"  A  M.  Alban  Doean, 

Secretaire  de  la  Societe  Obstetricale  de  Londres, 
Londres." 

The  Couucil  lias  resolved — ■'  That  the  President  be  re- 
quested to  do  all  in  his  power,  by  communication  to  the 
Society  and  otherwise,  to  promote  the  objects  of  the 
proposed  Congress." 

A  letter  addressed  to  myself  by  Mr.  Fell  Pease,  M.P., 
and   Mr.    Rathbone,  M.P.,    in   December    last,   inquiring 


ANNUAL  ADDRESS.  So- 

whether  this  Society  was  of  opinion  that  a  petition  should 
be  presented  to  the  Government,  asking  them  to  appoint 
a  Select  Committee  to  inquire  into  the  question  of  the 
Legal  Registration  of  Midwives,  was  laid  before  the 
Council  of  the  Society  at  its  meeting  in  January.  The 
Council  being  of  opinion  that  the  appointment  of  a  Select 
Committee  was  eminently  desirable,  and  believing  that  it> 
would  meet  your  wishes  by  giving  an  affirmative  reply  to 
the  query,  resolved — "  That  the  Council  approve  of  the 
proposal  to  petition  Government  to  appoint  a  Select 
Committee  to  inquire  into  the  question  of  the  Legal 
Registration  of  Midwives,  and  that  they  are  willing  to 
sign  a  petition  to  that  effect. '' 

The  Board  for  the  examination  of  midwives  is  increas- 
ingly successful.  In  1881  the  number  of  candidates  was. 
258,  and  the  number  passed  204,  as  against  202  examined 
and  159  passed  in  1890. 

It  is  satisfactory  to  find  that  our  financial  position  is 
fully  as  good  as  it  was  a  year  ago.  On  December  31st, 
1891,  our  cash  balance  was  £275  14s.  Id.,  while  it  was 
£266  3^.   lOtL  on  the  same  date  in  1890. 

During  the  year  1891  the  membership  of  the  Society 
has  somewhat  declined.  The  number  of  new  ordinary 
Fellows  elected  was  23.  By  death,  resignation,  and 
erasure  we  have  lost  43  ordinary  Fellows.  Three,  how- 
ever, of  the  deaths  included  in  this  number  have  to  be 
debited  to  previous  years,  although  not  known  to  us  until 
now.  The  deaths  in  question  are  those  of  Dr.  John  Boyd 
Caskie,  of  Islington,  who  died  in  1889  ;  and  of  Dr.  John- 
Moore  Fisher,  of  Hull,  and  Mr.  Herbert  C.  Rowbotham, 
of  Derby,  who  both  died  in  1890.  We  must  hope  that 
during  the  current  year  the  balance  will  be  redressed. 
This  result  will  be  rendered  all  the  more  likely  if  we  our- 
selves will  manifest  greater  eagerness  to  make  known  to 
our  medical  friends  the  advantages  of  membership. 

So  far  as  is  ascertained  as  yet,  the  ordinary  Fellows 
parted  from  us  by  death  during  1891  number  five.  I  pro- 
pose to  notice  them  in  the  order  of  their  decease. 


ANNUAL  ADDRESS. 


Charles  Vereall  Willett. 


Charles  Verrall  Willett  was  educated  at  St.  Bartholo- 
mew's Hospital.  He  became  M.R.C.S.Eng.  and  L.S.A. 
in  1861.  He  was  appointed  House  Surgeon  to  the  Great 
Northern  Hospital  in  1864,  after  having  served  as  Surgeon 
on  the  Peninsular  and  Oriental  Company's  steamships 
'^  Tagus,"  "  Alhambra/'  and  "  Sultan."  He  became  House 
Surgeon  to  the  Brighton  and  Hove  Dispensary  in  1865. 
He  settled  in  practice  in  Brighton  in  1866,  at  Shoreham, 
Sussex,  in  1867,  again  in  Brighton  in  1869,  at  Brandon, 
Suffolk,  in  1878,  at  Bristol  in  1884,  in  West  Kensington, 
London,  in  1887,  and  again  at  Shoreham,  Sussex, 
in  1891. 

He  was  the  author  of  a  paper  on  "  Traumatic  Hernia 
of  Abdomen  from  Injury  from  Buffer  of  Railway  Engine." 

He  joined  this  Society  in  1879.  His  death  took  place 
in  Manchester  Street,  London,  on  March  6th,  1891. 

Francis  Joseph  Salter. 

Francis  Joseph  Salter,  of  18,  College  Road,  Leeds, 
studied  medicine  at  the  Yorkshire  College,  Leeds,  and  at 
the  Leeds  Infirmary.  He  became  L.R.C.P.Edin.  and 
L.M.  in  1882,  and  L.R.C.S.Edin.  and  L.M.  in  the  same 
year.  He  was  appointed  Visiting  Surgeon  to  the  Chester 
General  Infirmary,  and  afterwards  House  Surgeon  to  the 
Devonshire  Hospital,  Buxton,  Derbyshire.  He  joined 
this  Society  in  1883,  and  in  the  same  year  he  sent  two 
brief  communications  to  the  '  British  Medical  Journal ;' 
one  on  the  "  Nephritis  of  Pregnancy  affecting  Vision," 
and  the  other  on  "  True  Knots  of  the  Umbilical  Cord." 
He  died  on  March  25th,  1891,  at  the  early  age  of 
thirty-four. 

Dr.  William  Edward  Steavenson. 

William  Edward  Steavenson,  of  Welbeck  Street, 
Cavendish    Square,  was  born  at  Hartest  Rectory,   Bury 


ANNUAL    ADDRESS.  37 

St.  Edmunds,  on  March  22nd,  1850.  He  died  from 
influenza  and  bronchitis  on  June  1st,  1891,  at  the  age  of 
forty-one.  His  father  was  the  late  Rev.  Joseph  Steaven- 
son.  Vicar  of  All  Saints,  Newmarket,  and  a  descendant 
of  the  Steavensons  of  Stanton  and  Elton  in  the  Peak,  in  the 
county  of  Derby,  of  the  time  of  King  James  the  Second. 

After  receiving  his  general  education  at  the  Ipswich 
School  he  commenced  the  study  of  medicine  at  St.  Bartho- 
lomew's Hospital  in  1869.  He  became  M.R.C.S.Eng. 
in  1873  and  L.S.A.  in  1874.  In  1873-4  he  was  House 
Surgeon  at  St.  Bartholomew's  Hospital.  In  1874  he 
entered  at  Downing  College,  Cambridge,  as  an  under- 
graduate, and  he  was  Natural  Science  Prizeman  there  in 
1877.  He  became  M.B.Cantab,  in  1879,  and  M.D.Cantab, 
in  1884.  He  became  a  Member  of  the  Royal  College  of 
Physicians  of  London  in  1883.  In  1878  he  returned  to 
St.  Bartholomew's  Hospital  as  House  Physician. 

He  was  successively  House  Surgeon  and  House  Phy- 
sician at  the  Hospital  for  Sick  Children,  Great  Ormond 
Street,  from  1879  to  1882. 

He  was  Casualty  Physician  at  St.  Bartholomew's  Hos- 
pital from  1883  to  1885. 

In  1882  he  was  appointed  to  organise  and  superin- 
tend the  Electrical  Department  which  had  just  been 
created  at  St.  Bartholomew's  Hospital.  This  appointment 
he  held  iip  to  the  time  of  his  death. 

He  was  also  Physician  to  the  Alexandra  Hospital  for 
Children  with  Hip  Disease,  and  to  the  Grosvenor  Hos- 
pital for  Women  and  Children  in  Vincent  Square.  He 
was  likewise  Physician  for  Diseases  of  Women  and  Chil- 
dren to  the  St.  George's  and  St.  James's  Dispensary. 

He  was  one  of  the  original  secretaries  of  the  Cam- 
bridge Medical  Graduates'  Club. 

Although  he  held  so  many  public  appointments  entail- 
ing arduous  Avork,  he  was  not  a  man  of  strong  constitu- 
tion and  iron  frame,  but  the  reverse,  having  been  a 
sufferer  from  spasmodic  asthma  from  childhood,  with 
consequent   emphysema.       The   fortitude  with  which  he 


38  ANNUAL   ADDRESS. 

laore  up  against  physical  disability  was  tlie  admiration 
of  a  wide  circle  of  attached  friends. 

He  displayed  great  energy  in  teaching  as  well  as  in 
practice,  and  he  was  a  frequent  contributor  to  medical 
literature. 

As  the  subject  of  his  thesis  for  the  M.B.  degree  of 
the  University  of  Cambridge  he  chose  Spasmodic  Asthma, 
the  disease  from  Avhich  he  himself  suffered  so  much.  It 
was  published  in  1879,  and  it  had  the  fortune,  unusual 
with  inaugural  dissertations,  to  run  into  a  second  edition. 
Assuming  that  in  all  cases  of  spasmodic  asthma  the 
predisposing  cause  is  an  abnormal  excitability  of  the 
vagus  or  of  the  respiratory  centre,  he  maintains  that  a 
common  exciting  cause  is  to  be  found  in  the  electrical 
condition  of  the  atmosphere  or  of  the  locality,  taken  in 
relation  with  the  electrical  condition  of  the  patient  at  the 
time.  From  observations  on  his  own  case  he  was  led  to 
consider  that  negative  electricity  has  a  deleterious  influ- 
ence. He  explains  the  frequent  onset  of  asthma  in  the 
small  hours  of  the  morning  by  the  fact  that  the  free 
positive  electricity  of  the  atmosphere  then  approaches  its 
minimum.  By  eleven  o'clock  in  the  morning,  when  the 
positive  electricity  of  the  atmosphere  attains  its  first 
maximum,  the  attack  passes  off. 

Interested  thus  early  in  electricity  in  its  medical  bear- 
ings, he  selected  it,  on  taking  the  M.D.  deg'ree  of  his 
university  in  1884,  as  the  subject  of  his  thesis,  which  he 
entitled  "  Electricity,  and  its  Manner  of  Working  in  the 
Treatment  of  Disease,^'  This  rather  quaint  name  is  a 
literal  translation  of  the  title  of  a  Latin  inaugural 
thesis  written  by  his  grandfather's  brother,  Dr.  Robert 
Steavenson,  of  Newcastle-on-Tyne,  on  graduating  in 
Medicine  in  the  University  of  Edinburgh  in  1778.  He 
here  explains  the  malaise  and  oppression  which  many 
persons  experience  before  a  thunderstorm  by  the  fact  that 
the  atmosphere  in  the  neighbourhood  of  the  earth  is  at 
the  time  negatively  electrified.  He  expresses  his  belief 
that  he  had  produced  a  fit  of  asthma  in  himself  by  acci- 


ANNUAL   address".  39 

dentally  becoming  charged  with  negative  electricity.  The 
immunity  from  pure  nervous  asthma  experienced  by  many 
asthmatics  in  foggy  weather  he  considers  due  to  the  pre- 
dominance of  positive  electricity  in  such  weather.  He  even 
thinks  that  it  may  be  possible  in  the  future  to  prevent 
gout  by  the  application  of  electricity. 

Having  thus  a  strong  predilection  for  the  subject  of 
medical  electricity,  he  gradually  became  an  electrical 
specialist.  As  such  he  exhibited  the  fervid  enthusiasm 
which  seems  to  be  inseparable  from  electrical  specialism, 
and  which  necessitates  a  specially  searching  examination 
and  analysis  of  the  therapeutical  results  claimed  for  elec- 
tricity. As  an  expert  in  the  medical  uses  of  electricity 
he  was  largely  consulted  by  both  patients  and  practitioners. 
In  the  practice  of  that  perilous  specialty  he  held  fast  his 
integrity  to  the  end. 

In  1890  he  published  a  work  on  "  The  Uses  of  Elec- 
trolysis in  Surgery. '^  After  defining  and  explaining  elec- 
trolysis, he  gives  an  account  of  its  use  in  aneurysm, 
neevi,  strictures,  diseases  of  the  urinary  organs,  diseases 
of  women,  fistulge,  wounds,  ulcers,  and  hydatids.  He  also 
describes  and  figures  various  instruments  devised  by  him- 
self for  electrical  treatment. 

He  wrote  papers  on  "The  Medical  Act  (1858)  Amend- 
ment Bill  and  Medical  Reform  ;  '^  "  Troublesome  Fre- 
quency of  Micturition  ;  "  "  Four  Cases  of  Neuralgia  of 
the  Sciatic  Nerve  successfully  treated  by  Galvanism ; " 
"  The  Therapeutical  Applications  of  Electricity;"  ''  Treat- 
ment of  Fibroid  Tumours  by  Electricity  ;  "  "  Removal  of 
Superfluous  Hairs  ;  "  "  Thirty  Cases  of  Fibro-myomata  of 
the  Uterus  treated  by  Electrolysis,'^  of  whom  twenty-three 
were  said  to  be  benefited  by  the  treatment  ;  besides  other 
papers  in  the  medical  journals  and  in  the  '  St.  Bartholo- 
mew's Hospital  Reports.' 

At  the  Annual  Meeting  of  the  British  Medical  Associa- 
tion at  Brighton,  in  1886,  he  read  a  paper  on  "  The 
Employment  of  Electricity  in  the  Treatment  of  Diseases 
of  the  Urinary  Organs." 


40  ANNUAL    ADDEESS. 

In  1888  be  read  a  paper  at  this  Society  on  "  The  Use 
of  Electrolysis  in  Gynaecological  Practice.''  He  gave  a 
concise  account  of  the  theory  and  action  of  electrolysis, 
and  he  advocated  its  employment  in  stricture  of  the 
female  urethra,  stenosis  of  the  os  uteri  and  cervical  canal, 
atresia  of  the  uterine  canal  following  amputation  of  the 
cervix,  abrasions  of  the  cervix  uteri,  chronic|  cervical 
catarrh,  uterine  fibroids,  and  cancer.  j'TnnmT 

He  married  a  granddaughter  of  Benjamin  Travers. 
He  is  survived  by  her  and  by  an  only  child. 

Dr.  James  Henry  Bennet. 

James  Henry  Bennet  was  born  in  Manchester  on 
March  16th,  1816.  His  father  was  a  cloth  manufacturer, 
who,  in  addition  to  other  inventions,  devised  and  gave  irs 
name  to  the  thick  corded  cotton  stuff  which  is  known  as 
corduroy.  Early  left  a  widow  with  a  young  family, 
Bennet's  mother  took  up  her  residence  in  Paris  after  her 
husband's  death,  and  sent  her  son  James  Henry,  who  was 
then  seven  years  of  age,  to  the  St.  Louis  College,  where  he 
obtained  an  excellent  classical  education.  Having-  detei'- 
mined  to  stud}^  medicine,  James  Henry  entered  at  Guy's 
Hospital,  but  very  soon  left  it  to  become  apprentice  to  his 
uncle,  Mr.  Osmond  Taberer,  in  Derbyshire.  In  the  early 
part  of  1836,  when  he  was  twenty  years  of  age,  he  returned 
to  Paris  and  joined  the  medical  schools.  He  was  a  diligent 
student  there,  and  in  1840,  coming  out  fifth  in  a  list  of 
175  candidates  for  the  interned,  he  was  appointed  an 
Interne  for  four  years.  As  clinical  clerk,  dresser  or 
Interne  he  was  associated  with  several  of  the  physicians 
and  surgeons  who  paid  special  attention  to  gynascology. 
From  the  time  when  he  went  tothe  Paris  medical  schools 
he  was  thrown  into  contact  with  Yelpeau,  and  during  the 
year  1838  he  was  clinical  clerk  and  dresser  to  that  great 
surgeon  at  the  Charite  Hospital.  He  was  Interne  at  the 
St.  Louis  Hospital  in  1840,  and  again  in  1843  under 
Jobert     (de    Laniballe)     and   Emery.       In    1841    he    was 


ANNUAL    ADDRESS.  41 

Interne  at  the  Salpetriere.  In  1842  he  was  Interne  at 
La  Pitie  under  Lisfranc  and  Gendrin. 

He  took  the  degree  of  M.D.Paris  in  1843,  when  he  was 
twenty-seven  years  of  age,  and  in  the  same  year  he  settled 
in  practice  in  Cambridge  Square,  Hyde  Park,  London.  He 
afterwards  removed  to  Grosvenor  Street.  In  1844  he 
became  a  Member  of  the  Royal  College  of  Physicians  of 
London.  In  1845  he  was  appointed  Physician-Accou- 
cheur to  the  Western  General  Dispensary,  but  he  resigned 
the  appointment  in  1850,  owing  to  his  positive  inability  to 
attend  to  the  duties,  so  numerous  had  the  patients  become, 
to  quote  his  own  words.  He  became  Physician-Accoucheur 
to  the  Eoyal  Free  Hospital  in  1853,  and  remained  con- 
nected with  it  until  1859. 

For  some  years  he  was  sub-editor  of  the  'Lancet,'  pre- 
ceding Dr.  Tyler  Smith  in  that  office. 

In  1859  the  harassing  cares  and  labours  of  a  London 
professional  life  having  broken  down  his  vital  powers,  as 
he  says,  he  was  obliged  to  seek  abroad  rest  and  a  genial 
winter  climate.  The  reminiscences  of  former  travel  led 
him  to  the  Riviera,  and  the  ties  of  friendship,  to  again  quote 
his  own  words,  to  Mentone,  then  an  Italian  city.  He  had 
become  consumptive,  and  departed  southwards  in  the 
autumn  of  1859,  "  to  die  in  a  corner,"  as  he  and  his  friends 
thought.  At  Mentone  he  gradually  regained  a  measure 
of  strength,  and  returned  to  professional  work.  In  future 
he  spent  his  winters  at  Mentone  and  his  summers  in 
England,  partly  in  Grosvenor  Street,  London,  and  partly 
at  The  Ferns,  Weybridge,  Surrey.  In  1875  he  retired 
altogether  from  practice  in  England. 

Shortly  after  settling  in  London  he  married  a  daughter 
of  Mr.  Joseph  Langstaff,  F.R.C.S.  formerly  President  of 
the  Medical  Board  of  Calcutta.  He  is  survived  by  her. 
He  had  no  children.  He  died  at  the  age  of  seventy-five  at 
La  Bolleue,  Alpes  Maritimes,  France,  on  July  28th,  1891. 
Under  the  patronage  of  the  Mayor,  the  inhabitants  of 
Mentone,  which  may  be  said  to  have  been  discovered  as  a 
health-resort  by  him,  and  which  largely  owes  its  growth 


42  ANNUAL   ADDRESS. 

aud  prosperity  to  his  writings  and  personal  influence,  are 
about  to  erect  a  public  driuking-fountain  as  a  memorial  of 
liim.  Dr.  Siordet  is  Chairman  of  the  Committee,  and 
H.B.M.  Vice-Consul  is  Treasurer. 

Bennet  was  a  man  of  great  mental  energy,  and  of 
ardent  temperament,  with  strong  opinions,  strong  feelings, 
an  enthusiastic  love  of  nature,  and  an  intense  egoism. 

He  began  a  career  of  incessant  literary  activity  in  1840 
by  writing  a  paper,  never  published,  on  the  curability  of 
consumption. 

In  1841  he  published  an  address  delivered  to  the 
members  of  the  Parisian  Medical  Society,  of  which  he 
was  then  Vice-President. 

His  graduation  thesis,  presented  to  the  Faculty  of 
Medicine  of  Paris  in  1843,  was  on  "  Inflammation  and 
Ulceration  of  the  Neck  of  the  Uterus." 

In  1844  he  wrote  in  the  'Lancet '  on  the  "  Treatment 
of  Rheumatism  by  Large  Doses  of  Nitrate  of  Potass  and 
Sulphate  of  Quinine, '^  and  on  "  The  lufluence  of  Large 
Blisters  on  the  Urinary  Organs,  and  their  Use  during  the 
Acute  Period  of  Inflammatory  Diseases. '' 

In  1845  he  wrote  a  series  of  articles  in  the  '  Lancet' 
on  "  Inflammation,  Ulceration,  and  Induration  of  the 
Neck  of  the  Uterus."  These  he  expanded  and  published 
in  the  same  year  as  a  separate  work,  with  the  title  "  A 
Practical  Treatise  on  Inflammation,  Ulceration,  and  In- 
dui'ation  of  the  Neck  of  the  Uterus."  The  work  reached 
a  fourth  edition  in  1861,  under  the  title  "  A  Practical 
Treatise  on  Inflammation  of  the  Uterus,  its  Cervix  and 
Appendages,  and  on  its  Connection  with  other  Uterine 
Diseases."  The  first  edition  was  translated  into  German, 
and  the  second  into  French.  An  Ameincan  edition  was 
published  five  times. 

Among  his  other  works  may  be  mentioned  "  A  Review 
of  the  Present  State  of  Uterine  Pathology,"  1856  ;  "  Nutri- 
tion in  Health  and  Disease,"  1858,  a  work  which  attained 
a  third  edition  in  1877  ;  "  On  the  Treatment  of  Pulmonary 
Consumption  by  Hygiene,  Climate,  and  Medicine,"  1866, 


ANNUAL    ADDRESS.  43 

and  a  tliird  edition  of  the  same  greatly  enlarged  in  1878. 
The  first  and  the  last  of  these  three  works  appeared  pre- 
viously in  the  pages  of  the  '  Lancet.' 

He  also  Avrote  several  works  on  climate  and  scenery, 
the  most  important  of  which  is  "  Winter  and  Spring  on 
the  Shores  of  the  Mediterranean/'  fifth  edition,  1875. 
The  first  edition  was  published  in  18G1  under  the  name 
"  Mentone  and  the  Riviera  as  a  Winter  Climate."  His 
works  of  scenery  and  travel  are  written  in  a  picturesque 
style,  and  abound  in  interesting  descriptions. 

Besides  those  already  mentioned  he  wrote  innumerable 
papers  in  the  '  Lancet.'  The  following  list,  taken  in 
chronological  order,  will  sufficiently  indicate  the  subjects 
discussed  in  these  papers  : — "  Inflammatory  Ulceration  of 
the  Cervix  Uteri  during  Pregnancy,"  1846  ;  "  On  Sul- 
phuric Acid  as  a  Remedy  for  Poisoning  by  Lead,"  184(5  ; 
"  On  Ulceration  of  the  Cervix  Uteri  accompanying  Uterine 
Polypi,'''  1847  ;  "  Ulceration  of  the  Cervix  following  the 
Removal  of  Uterine  Polypus,"  1847  ;  "  On  Inflammation 
and  Ulceration  of  the  Neck  of  the  Uterus  in  the  Virgin 
Female,"  1847  ;  "  On  Inflammation  and  Abscess  of  the 
Uterine  Appendages  in  the  Non-puerperal  Condition," 
1848  ;  "  On  Healthy  and  Morbid  Menstruation,"  1852  ; 
"Haemorrhage  in  Early  Pregnancy  practically  considered," 
18o8j'^On  the  Connection  between  Phthisis  and  Uterine 
Disease,"  1865;  "  On  the  Sui-gical  Treatment  of  Painful 
Menstruation,"  1865;  "The  Fossil  Man  at  Mentone," 
1872  ;  and  "  On  the  Cause  and  Prevention  of  Sea-sickness 
in  Short  Passages,"  1874.  His  letters  to  the  '  Lancet,' 
chiefly  controversial,  were  also  numerous. 

Besides  this  he  frequently  wrote  in  the  '  British  Medi- 
cal Journal,'  and  he  read  various  papers  at  the  annual 
meetings  of  the  British  Medical  Association.  He  sent 
numerous  contributions  to  the  '  Gardener's  Chronicle'  also. 

As  a  gynaecologist  he  was  dominated  by  the  idea  of 
inflammation  and  ulceration.  While  in  Paris  he  had 
closely  followed  the  practice  of  Lisfranc  and  of  Gendrin 
at   La    Pitie,  and    he   had    come    to    range   himself   with 


44  ANNUAL    ADDRESS. 

Recamier  and  them  iu  regarding-  inflammation  as  the  root 
of  uterine  disease,  rejecting  altogether  the  mechanical 
doctrines  of  the  school  of  Amussat  and  Velpeau.  In 
Paris  he  had  become  familiar  with  the  nse  of  the  vaginal 
speculum.  For  years  he  had  witnessed  the  constant  em- 
ployment of  it  by  Lisfranc  and  by  Gendrin  at  La  Pitie, 
by  Jobert  (de  Lamballe)  at  the  St.  Louis,  and  by  Boys 
de  Loury  at  the  St.  Lazare.  He  came  to  London  full  o£ 
enthusiasm  for  the  French  gynaecological  teaching,  which 
he  soon  found  opportunity  to  put  into  practice,  and  which 
he  promulgated  with  all  the  zeal  of  a  devotee. 

Although  the  vaginal  speculum  had  been  familiarly 
employed  iu  this  country  by  Sir  James  Simpson,  Dr. 
T^'ler  Smith,  Sir  Charles  Locock,  Dr.  Murphy,  and  others 
before  Bonnet's  time,  yet  it  is  to  him,  and  in  a  less 
measure  to  Mr.  Whitehead,  of  Manchester,  who,  like 
Bennet,  had  studied  in  Paris,  that  is  chiefly  due  in  this 
country  the  credit  of  having  shown  the  great  frequency 
of  visible  morbid  conditions  of  the  cervix  uteri.  This,  as 
is  well  known,  was  not  done  without  arousing  a  fierce 
controversy,  in  which  many  of  the  advocates  and  of  the 
opponents  of  the  use,  or  of  the  frequent  use,  of  the  speculum 
took  up  an  extreme  position,  and  in  which  some  of  the 
combatants  battled  for  victory  rather  than  for  truth. 

The  not  unnatui'al  disinclination  of  gynascologists  and 
others  to  believe  in  ulceration  of  the  cervix  uteri  and  in 
the  necessity  for  using  the  speculum  was  greatly  aggra- 
vated by  the  overdrawn  and  alarmist  account  of  the 
disease  given  by  Dr.  Bennet,  and  by  the  employment  of 
what  was  regarded  as  an  indelicate  means  of  investiga- 
tion and  of  treatment. 

Bennet  had  painted  a  dismal  picture  of  the  conse- 
quences of  ulceration  of  the  neck  of  the  uterus  associated 
with  inflammation  and  hypertrophy.  Among  these  con- 
sequences he  included  prolapsus  uteri ;  extension  of  in- 
flammation to  the  vagina,  vulva,  rectum,  and  bladder  ; 
hajmorrhoids;  prolapsus  ani;  neuralgia  in  the  uterus,  face, 
head,  neck,  back,  chest,  and  elsewhere  ;   disorders  of  men- 


ANNUAL    ADDRESS.  45 

struation;  mammary  troubles ;  dyspepsia;  lithiasis;  biliary 
derangement ;  palpitation  ;  irregular  cardiac  action  ;  dys- 
pnoea ;  phthisis ;  impairment  of  sight  and  of  hearing ; 
spinal  irritation ;  convulsive  hysteria  ;  aphonia  ;  insomnia  ; 
and  insanity.  He  says  further  that  chronic  inflammation 
of  the  uterine  neck,  if  neglected,  not  unfrequently  causes 
the  death  of  the  patient. 

The  heroic  and  prolonged  treatment  which  he  considered 
necessary  also  stirred  up  strong  opposition.  For  inflam- 
mation of  the  neck  of  the  uterus  accompanied  by  ulcera- 
tion he  followed  the  French  school,  and  recommended  the 
application  of  nitrate  of  silver,  mineral  acids,  the  acid 
nitrate  of  mercury,  potassa  fusa,  jiotassa  cum  calce,  and 
the  actual  cautery,  the  habitual  use  of  which  last  in  such 
cases  he  had  become  familiar  with  in  Paris  in  the  hospital- 
practice  of  Jobert  (de  Lamballe).  For  some  years,  he 
says,  he  frequently  resorted  to  the  actual  cautery  in  cases 
in  which  he  wished  to  modify  the  vitality  of  very  intract- 
able ulcerations  persisting  within  the  os  uteri,  using 
freely  olive-shaped  cauteries  sufiiciently  small  to  pass 
within  the  morbidly  dilated  os.  On  account  of  the  dread 
with  which  it  inspired  patients,  however,  he  in  course  of 
time  all  but  ceased  to  employ  this  mode  of  treatment,  and 
contented  himself  with  potassa  cum  calce  instead. 

It  was  in  the  second  edition  of  his  work  on  "  Inflam- 
mation of  the  Uterus,"  greatly  enlarged  and  published  in 
1849,  that  Dr.  Bennet  dogmatically  advanced  the  views 
above  indicated.  The  controversy  about  the  use  of  the 
speculum  culminated  in  1850,  when  the  question  was 
brought  under  discussion  at  the  "Westminster  Medical 
Society,  at  the  Royal  Medical  and  Chirurgical  Society, 
and  at  the  Medical  Society  of  London. 

The  opponents  of  the  frequent  employment  of  the 
speculum  were  vehement  in  their  denunciations.  Thus  a 
most  distinguished  London  obstetrician,  who  himself  was 
in  the  habit  of  using  the  speculum  in  obstinate  cases  of 
leucorrhoea,  went  so  far  as  to  state,  in  an  unguarded 
•expression    in   a  letter   to    the    'Lancet'    in   1850,  that 


46  ANNUAL    ADDRESS. 

Mr.  Whitehead,  of  Manchester,  who  had  examined  with 
the  speculum  2000  women,  had  been  guilty  of  "2000  immo- 
ralities altogether  unjustifiable.''  Dr.  Marshall  Hall  wrote 
to  the  '  Lancet'  in  1850  denouncing  the  instrument,  and  de- 
claring that  a  new  and  and  lamentable  form  of  hysteria  had 
been  induced  by  the  use  of  it,  and  that  patients  examined 
by  it  "become  reserved  and  moody  and  perverse,  and  speak 
unintelligibly  in  broken  sentences."  "  Whole  families," 
he  says,  "  have  been  subjected  to  the  use  of  the  speculum." 
"  There  is  a  fashion,"  he  adds,  "  even  in  regard  to  the 
prevalence  of  ailments.  When  Louis  XIV  was  suffering 
from  fistula  ani  all  the  gentlemen  and  ladies  of  the  court 
thought  it  proper  to  walk  lame."  Dr.  Marshall  Hall's 
allegation  as  to  the  abuse  of  the  speculum  is  borne  out  by 
Dr.  Tyler  Smith's  statement  at  the  Westminster  Medical 
Society  in  1850  that  "  at  the  present  time  a  veritable 
uterine  panic  affects  the  upper  and  middle  classes  of 
society,  and  every  woman  with  the  slightest  ache  or  dis- 
charge is  not  satisfied  until  the  peccant  organ  has  been, 
ocularly  inspected."  A  good  illustration  of  the  extrava- 
gance of  some  of  the  advocates  of  the  speculum  is  to  be 
found  in  the  letter  of  a  London  practitioner  in  the 
'  Lancet '  in  1850,  recommending  the  use  of  it  for  the 
diagnosis  of  doubtful  presentations  in  parturition.  It  is, 
however,  scarcely  necessary  to  adduce  published  evidence 
of  the  abuse  of  the  speculum,  for  it  is  notorious  that  it 
was  sometimes  used  twice  a  day  in  the  same  patient  for 
the  treatment  of  ulceration  of  the  cervix. 

Part  of  the  criticism  to  which  Dr.  Bennet  was  subjected 
he  brought  upon  himself  by  his  inaccurate  use  of  the  term 
"ulceration."  "From  his  own  descriptions,"  says  Dr. 
Tyler  Smith,  addressing  the  Westminster  Medical  Society 
in  1850,  "  it  is  evident  that  Dr.  Bennet  classes  abrasions, 
excoriations,  and  granulations  together  as  forms  of  ulcera- 
tion— a  proceeding  which,  it  appears  to  me,  is  utterly 
opposed  to  all  sound  pathology."  Dr.  Robert  Lee  spoke 
on  the  subject  still  more  emphatically.  "  Dr.  Bonnet's 
ulcer,"   he   said    at   the  Royal    Medical   and    Chirurgical 


ANNUAL    ADDKESS.  47 

Society  iu  1850,  "  could  not  bo  recognised  by  the  sense 
of  touch,  for  it  had  no  margin,  inverted  or  everted  ;  it 
could  not  be  seen  through  the  speculum  till  the  part  had 
been  rubbed  with  the  nitrate  of  silver.  It  had  neither 
centre  nor   circumference,  beginning  nor  end." 

That  controversy  may  be  said  to  be  ended.  Can  we 
say  that  prejudice  and  personal  and  party  feeling-  are 
entirely  banished  from  scientific  discussions  now  ? 

Bennet's  services  to  gynaecology  were  not  limited,  as 
is  sometimes  supposed,  to  showing  the  great  frequency  of 
so-called  ulceration  of  the  os  uteri,  and  the  use  of  the 
speculum. 

He  was  one  of  the  first  to  discover  that  pelvic  inflam- 
mation exists,  and  not  only  so,  but  that  it  frequently 
exists,  in  the  non-puerperal  state.  This  may  be  seen  in 
the  second  edition,  1849,  of  his  work  on  Inflammation  of 
the  Uterus,  and  in  his  subsequent  writings. 

In  the  same  edition  of  that  work  he  draws  attention  to 
the  presence  of  cervical  catarrh  in  erosions  of  the  os  uteri, 
and  to  the  necessity  for  exposing  the  cervical  canal  by 
separating  the  lips  of  the  os,  and  for  treating  that  catarrh 
as  well  as  the  more  obvious  erosion. 

In  the  same  edition  of  that  book  he  attributes  the  ex- 
cessive vomiting  of  pregnancy  to  inflammatory  ulceration 
of  the  cervix.  He  had  become  acquainted  with  the  fact 
in  the  Paris  hospitals  ten  or  twelve  years  previously,  he 
says.  In  1875  he  published  a  paper  in  the  '  British 
Medical  Journal,^  in  Avhich  he  points  out  that  when  such 
is  the  cause  of  the  hyperemesis,  the  difiiculty  and  danger 
usually  cease  when  suitable  applications  are  made  to  the 
cervix.  His  teaching  on  this  subject  was  too  long  dis- 
regarded. 

In  1846  he  discovered,  as  he  relates  in  his  "  Review  of 
the  Present  State  of  Uterine  Pathology,'^  1856,  that  the 
uterine  canal  in  nulliparous  women  is  not  straight,  but 
curved  with  an  anterior  curvature.  In  other  words,  he 
discovered  in  the  living  subject  the  normal  ante-flexion 
of  the  uterus. 


48  ANNUAL   ADDRESS. 

In  tlie  second  edition  of  his  work  on  "  Inflammation  of 
the  Uterus,"  1849,  he  notes  the  presence  of  a  natural  stric- 
ture or  coarctation  at  the  internal  os  uteri.  "  From  its  uni- 
versality and  occasional  persistence  after  death  it  must," 
he  says,  "  be  the  result  of  the  anatomical  structure  of 
parts,  and  probably  of  the  presence  of  a  kind  of 
sphincter." 

In  the  1861  edition  of  the  same  work  he  describes  a 
method  which  he  had  for  many  years  substituted  for 
plugging  the  vagina  in  cases  of  uterine  haemorrhage. 
This  is  plugging  the  cervical  canal  instead,  not  with  tents, 
but  with  two  or  three  small  pieces  of  cotton  tied  to  a 
piece  of  thread,  Avhich  he  wedges  in  firmly  afterwards, 
•covering  the  cervix  with  two  or  three  larger  pieces  left  in 
■close  contact  with  it  on  the  withdrawal  of  the  speculum. 

In  the  same  edition  he  shows  how  erroneous  it  is  to 
regard  pain  in  the  ovarian  region  as  being  necessarily 
ovai'ian  in  origin,  pain  in  that  region  having  nothing  to 
do  with  the  ovaries  as  a  rule. 

He  became  a  Fellow  of  this  Society  in  1873,  and  he 
was  a  member  of  Council  from  1881  to  1883.  In  the 
latter  year  he  read  a  paper  at  the  Society  on  the  "  Os 
Uteri  Internum  ;  its  Anatomy,  Physiology,  and  Patho- 
logy," recalling  his  past  work  on  the  subject,  and  dealing 
with  the  question  of  incision  and  dilatation  of  the  internal 
OS  uteri. 

Edward  Overman  Day. 

Edward  Overman  Day,  of  78,  Waterloo  Road,  S.E., 
joined  the  Society  in  1878.  He  died  suddenly  on  August4th, 
1891,  at  the  age  of  thirty-nine.  He  was  found  by  his 
servant  at  his  surgery  in  a  fainting  condition  shortly  after 
his  arrival  there  in  the  morning  of  that  day.  He  never 
rallied,  his  death  being  attributed  to  simple  failure  of  the 
heart's  action. 

He  had  been  a  student  at  Guy's  Hospital,  and  he 
became  M.R.C.S.Eng.   and  L.S.A.  in  1873.      In  addition 


ANNUAL    ADDRESS.  49r. 

to  holding  Benefit-Society  appointments  he  was  Assistant 
Surgeon  and  Administrator  of  Anaesthetics  to  the  Royal 
Hospital  for  Children  and  Women,  Waterloo  Bridge  Road. 
He  was  the  author  of  "  How  to  prevent  the  Diseases  of 
Babyhood  ;"  of  an  account  of  a  successful  case  of  tracheo- 
tomy in  a  child  ten  months  old,  in  the  '  St.  Thomas's 
Hospital  Reports'  for  1878,  and  of  an  account  of  a  new 
hip- joint  splint  in  the  '  Medical  Press  '  for  1880  ;  and  he 
was  the  inventor  of  the  Ne  Plus  Ultra  Feeding  Bottle,  as 
described  in  the  *  British  Medical  Journal'  for  1881. 

Although  so  young-  he  had  acquired  an  enormous 
practice  amongst  the  residents  in  his  neighbourhood.  He 
had  an  especially  high  reputation  for  skill  in  the  diseases 
of  children.  He  enjoyed  great  personal  popularity,  and 
he  had  great  kindness  of  disposition  and  frank  and  genial 
manners.      He  was  withal  a  shrewd  man  of  business. 

During  the  past  year  death  has  removed  no  fewer  than 
four  of  our  ten  foreign  Honorary  Fellows.  These  were 
Professor  Fordyce  Barker  of  New  York,  Professor  Carl 
Braun  von  Fernwald  of  Vienna,  Professor  Scanzoni 
von  Lichtenfels  of  Wiirzburg,  and  Professor  Theodor 
Hugenberger  of  Moscow,  i  knew  all  of  them,  having 
become  acquainted  with  Hugenberger  in  Edinburgh  in 
1863,  and  Fordyce  Barker  in  London  in  1875,  and  having 
frequented  the  clinic  of  Braun  in  Vienna  for  three  months 
in  1868,  and  that  of  Scanzoni  in  Wiirzburg  for  a  short 
time  in  the  same  year. 


Professor  Benjamin  Fordyce  Barker. 

Benjamin  Fordyce  Barker,  the  son  of  Dr.  John  Barker, 
a  country  practitioner  in  Maine,  was  born  in  Wilton  in  that 
State  on  May  2nd,  1818.  He  died  at  his  home  in  New- 
York  on  May  30th,  1891,  aged  seventy-three.  He  had 
been  in  failing  health  since  an  attack  of  illness,  said  to  be 
typhoid  fever,  contracted  in  London  in  1885.     The  imme- 

VOL.  XXXIV.  4 


50  ANNUAL    ADDRESS. 

diate  cause  of  his  death  was  ingravescent  apoplexy,  asso- 
ciated with  interstitial  nephritis  and  valvular  disease  of 
the  heart.  He  was  related  to  Dr.  George  Fordyce,  F.R.S., 
the  well-known  Avriter  on  fevers.  In  1843  he  married 
Miss  Dwight,  of  Springfield,  Massachusetts,  a  descendant 
of  the  elder  Pitt,  Lord  Chatham.  She,  with  an  only  son, 
survives  him. 

He  began  his  academical  education  at  Bowdoin  College, 
in  liis  native  State,  in  1833,  when  he  was  fifteen  years 
of  age.  He  took  his  academical  degree  in  1837  at 
the  age  of  nineteen,  and  the  degree  of  Doctor  of  Medicine 
in  1841,  when  he  was  twenty-three  yeai's  of  age.  After 
that  he  studied  medicine  for  a  short  time  in  Boston, 
Massachusetts,  and  subsequently  in  Edinburgh  and  in 
Paris. 

He  commenced  practice  in  Norwich,  Connecticut,  in  1845, 
but  he  was  appointed  Professor  of  Midwifery  in  Bowdoin 
Medical  College  in  1846,  and  he  then  took  up  his  residence 
there.  In  1850  he  came  to  New  York  to  practise  at  the 
suggestion  of  various  friends,  and  in  the  same  year  he  was 
appointed  Professor  of  Midwifery  in  the  New  York  Medical 
College,  of  which  he  was  one  of  the  founders.  In  1852  he 
was  appointed  Obstetric  Physician  to  Bellevue  Hospital 
and  Professor  of  Obstetrics  in  its  Medical  College,  and  in 
1860  Professor  of  Clinical  Midwifery  and  of  Diseases  of 
Women  in  the  same  college.  He  became  consulting 
physician  to  several  hospitals,  and  amongst  others  to  the 
Woman's  Hospital  of  New  York.  He  w^as  for  many  years 
President  of  its  Medical  Board,  remaining  so  up  to  the 
time  of  his  death.  He  was  one  of  the  founders  and  he 
was  the  first  President  of  the  American  Gyneecological 
Society  in  1876—7.  He  wasPresidentof  New  York  Academy 
of  Medicine  from  1879  to  1884,  and  of  the  Medical 
Society  of  the  State  of  New  York  in  1860.  He  was  an 
honorary  Fellow  of  the  Obstetrical  Societies  of  London, 
Edinburgh,  New  York,  Philadelphia,  and  Louisville,  of  the 
Philadelpliia  College  of  Physicians,  and  of  the  Royal 
Medical  Society  of  Athens. 


ANNUAL    ADDRESS.  51 

lu  1886  he  received,  at  the  tercentenary  celebration 
of  the  University  of  Edinburgh,  the  honorary  degree  of 
LL.D.,  an  honour  which  he  especially  valued,  as  it  had 
been  conferred  upon  very  few  Americans  previously. 
The  same  degree  was  conferred  upon  him  by  Bowdoin 
College,  by  Columbia  College,  and  by  the  University  of 
Glasgow. 

While  he  showed  great  energy  and  vigour  in  all  that 
he  undertook,  he  was  a  man  of  remarkable  amiability,  and 
of  singular,  not  to  say  feminine,  sweetness  of  disposition, 
of  a  sunny  and  genial  temperament,  and  of  unbounded 
generosity  and  hospitality.  He  was  held  in  general 
affection  and  esteem  in  the  United  States,  by  the  medical 
profession  and  by  the  general  public  alike. 

It  was  his  habit  from  1858  onwards  to  spend  part  of 
the  summer  in  Europe,  and  he  often  came  to  England. 
He  was  well  known  in  London,  and  was  everywhere  a 
welcome  guest.  He  was  frequently  present  at  the 
annual  meetings  of  the  British"  Medical  Association. 

He  counted  among  his  intimate  personal  friends  in 
Europe,  not  only  many  members  of  the  medical  profes- 
sion, but  also  many  celebrated  persons  outside  the  pi'o- 
fession.  He  has  been  spoken  of  as  the  Sir  Heni-y  Holland 
of  America. 

He  had  no  taste  for  operative  surgery,  and  he  seldom 
took  the  knife  into  his  hand,  although  on  one  occasion  he 
performed  the  Cifisarean  section.  He  was  widely  celebrated 
as  a  physician,  and  especially  as  a  therapeutist.  He  was 
no  mere  specialist,  but  was  deeply  interested  in  general 
medicine.  His  enormous  jDractice  was  accordingly  by  no 
means  limited  to  obstetrics  and  gynaecology.  He  attended 
General  Grant  during  his  last  illness,  and  he  was  one 
of  the  physicians  summoned  to  the  death-bed  of  President 
Garfield. 

He  was  extremely  popular  as  a  teacher.  He  spoke 
with  great  fluency,  although  for  the  last  twenty  years  of 
his  life  his  voice  was  rendered  husky  by  partial  paralysis 
of  one  of  his  vocal  cords. 


52  ANNUAL    ADDRESS. 

He  was  often  cliosen  to  give  addresses  at  Medical 
Societies,  and  he  wrote  many  papers  which  appeared  in 
medical  periodicals,  or  were  published  independently. 
The  following  selected  list  will  give  an  adequate  idea  of 
his  work  in  this  direction  : — An  address  "  On  some  Forms 
of  Disease  of  the  Cervix  Uteri '^  in  1848,  published  in  the 
*  Proceedings  of  the  Connecticut  Medical  Society' ;  a  lec- 
ture on''  Uterine  Displacements  "  in  the 'New  York  Medical 
Gazette/  1858  ;  "  Malposition  of  the  Foetus  detected  by 
External  Manipulations  during  Labour  ;  Cephalic  Version 
by  the  same  Means  Successful/'  in  the  '  American  Medical 
Times  '  for  1860 ;  "  On  the  Ca9sarean  Section/'  in  the 
'  American  Medical  Times'  for  1860  and  1861  ;  "  On  the 
Use  of  Anaesthetics  in  Midwifery/'  in  the  '  Transactions 
of  the  New  York  Academy  of  Medicine '  in  1863  (read  in 
1861)  j  "The  Rise  in  Harlem — a  Comedy/' in  1864  ;  a  pam- 
phlet on  "Sea-sickness;  a  Popular  Treatise  for  Travellers 
and  the  General  Reader/'  published  in  1870  ;  "  Some 
Clinical  Observations  on  the  Malignant  Diseases  of  the 
Uterus/'  read  before  the  New  York  Academy  of  Medicine 
in  1870  ;  and  a  paper  on  "Uterine  Disease  as  an  Exciting 
Cause  of  Insanity/'  in  the  '  Journal  of  the  Gynaecological 
Society  of  Boston '  for  1873. 

His  collected  papers  have  been  translated  into  French 
and  into  German. 

His  well-known  work,  "  The  Puerperal  Diseases,"  con- 
sisting of  clinical  lectures  delivered  at  the  Bellevue  Hos- 
pital, was  published  in  1874,  and  it  reached  a  fourth  edi- 
tion in  1884.  It  was  translated  into  French,  German, 
Italian,  Spanish,  and  Russian.  In  selecting  some  of  the 
special  features  of  this  celebrated  work,  note  may  be  first 
taken  of  his  lecture  on  "  Thrombus  of  the  Vulva  and 
Vagina  in  connection  with  Parturition."  Of  this  rather 
rare  affection  Barker  had  seen  no  fewer  than  twenty-two 
cases,  thirteen  in  hospital  and  nine  in  private  practice. 
Of  the  total  number  two  only  were  fatal,  both  from 
puerperal  fever.  Having  such  an  experience  to  guide 
him,  he  formulates  the  following  three  principles  of  treat- 


ANNUAL    ADDRESS.  63 

ment : — First,  that  if  the  thrombus  is  not  so  large  as  to 
cause  great  pain  by  its  pressure  on  the  adjacent  tissues, 
or  to  interfere  matei-ially  with  the  delivery,  or  if  rupture 
and  the  escape  of  blood  almost  immediately  follow  the 
development  of  the  tumour,  the  forceps  should  be  applied 
and  delivery  effected  at  once.  In  the  latter  case  hasmor- 
rliage  must  be  immediately  afterwards  arrested  by  com- 
presses of  cotton  batting,  soaked  in  a  solution  of  persul- 
phate of  iron,  and  applied  directly  to  the  bleeding  vessels. 
The  tampon  usually  recommended  in  such  cases  is  to  be 
avoided.  Second,  that  when  the  tumour  has  attained 
such  a  size  as  to  offer  a  mechanical  obstacle  to  delivery, 
it  should  be  at  once  incised  and  emptied  of  all  clots,  and 
delivery  should  then  be  effected  with  forceps.  Third, 
that  when  the  thrombus  does  not  appear  until  after 
delivery  it  should  be  incised  as  soon  as  coagulation  has 
taken  place,  if  it  is  of  any  considerable  size.  When  the 
tumour  is  high  up  in  the  pelvic  cavity,  however,  incision 
may  not  be  advisable. 

In  his  lecture  on  puerperal  mania  he  estimates  the  pro- 
portion of  cases  of  that  disease  to  the  whole  number  of 
cases  of  labour  as  one  in  eighty.  This  high  rate  he  attri- 
butes chiefly  to  moral  causes.  He  is  convinced  also  that 
the  climate  has  a  marked  influence  in  developing  the 
nervous  susceptibilities  of  Europeans  who  settle  in  America. 
He  mentions  the  curious  fact  that  since  1855  he  had  seen 
thii'teen  cases  of  puerperal  mania  in  the  wives  of  physi- 
cians. He  states  as  the  probable  explanation  of  the  fact 
that  they  were  all  ladies  of  more  than  usual  quickness  of 
intellect,  and  that,  having  access  to  their  husbands^  books, 
they  had  read  just  enough  midwifery  to  fill  their  minds 
with  apprehensions  as  to  the  horrors  which  might  be  in 
store  for  them. 

He  never  could  bring  himself  to  accept  the  new  learning 
about  puerperal  fever.  He  here  maintains  that  septicemia, 
pjsemia,  and  puerperal  fever  are  three  distinct  diseases. 
In  the  summer  of  1875,  the  year  after  the  first  issue  of  his 
work,  "  The  Puerperal  Diseases,^'  he  came  from  America 


54  ANKUAL    ADDKESS. 

for  the  express  purpose  of  taking-  part  in  the  discussion 
on  puerperal  fever  in  our  Society.  He  contended  that 
puerperal  fever  is  a  distinct  disease,  and  quite  diiferent 
from  septic  poisoning.  He  maintained  that  it  occurs 
epidemically,  and  declared  that  persons  who  deny  that  it 
ever  occurs  as  an  epidemic  must  attach  a  subtlety  of 
meaning  to  the  word  epidemic  which  is  not  consonant  with 
(the)  common  sense.  He  appeared  to  deprecate  dogma- 
tism, however,  for  he  ended  his  speech  by  saying-, 
'^  Allow  me  to  close  with  the  suggestion  that  it  may  be 
well  for  all  of  us  who  discuss  puerperal  fever  to  remember 
the  exhortation  of  Oliver  Cromwell  when  he  lost  patience 
with  a  Scotch  Assembly  :  *  I  beseech  you,  brethren,  by 
the  mercies  of  God,  conceive  it  possible  that  you  may  be 
mistaken.'  "  If  this  quotation,  taken  apparently  from 
Cromwell's  letter  addressed  from  Musselburgh,  in  1650, 
to  the  General  Assembly  of  the  Kirk  of  Scotland,  is  to  be 
taken  as  implying  that  Barker  was  staggered  by  the 
arguments  advanced  in  the  debate,  he  soon  recovered 
from  the  passing  doubt,  and  in  the  fourth  edition  of  "  The 
Puerperal  Diseases,"  published  in  1884,  he  stoutly  main- 
tains his  oiiginal  position. 

One  of  the  last  papers  written  by  Dr.  Barker  was  on 
"  The  Influence  of  Maternal  Impressions  on  the  Foetus," 
and  was  published  in  the  '  Transactions  of  the  American 
Gynaecological  Society  '  for  1886.  He  thinks  that  the 
effect  of  maternal  impressions  is  as  well  proved  and  as 
certain  as  any  other  facts  which  cannot  be  explained  by 
science.  Without  assenting  to  the  enthusiastic  opinion, 
published  by  an  American  Fellow  of  this  S9ciety,  that  the 
correctness  of  the  theory  of  maternal  impressions  has  been 
demonstrated  and  proven  as  a  positive  fact  by  Dr. 
Barker,  one  may  readily  concede  that  some  of  the  cases 
narrated  by  him  are  remarkable  as  coincidences  at  any 
rate.  Tliis  applies  especially  to  a  case  in  which  perfora- 
tions were  found  in  the  ear-lobes  of  a  new-born  child 
whose  mother,  while  in  the  first  month  of  her  pregnancy 
— her  fifth — had  been  violently  agitated  by  the  piercing 


ANNDAL    ADDRESS.  55 

of  her  daughter's  ears  for  rings.  Anyone  interested  in 
the  question  will  find  in  Dr.  Barker's  paper,  and  in  the 
discussion  on  it,  numerous  cases  related  and  a  copious 
reference  to  the  literature  of  the  subject. 


Professor  Carl  Kudolf  Eitter  Bradn  von  Fernwald. 

Carl  Rudolf  Ritter  Braun  von  Fernwald  was  born  on 
March  22nd,  1823,  at  Zistersdorf,  a  little  town  of  1600 
inhabitants,  thirty-two  miles  north-east  of  Vienna,  where 
his  father,  Dr.  C.  A.  Braun,  was  a  medical  practitioner.  In 
1841  he  entered  the  University  of  Vienna,  and  in  1847  he 
took  his  doctor's  degree.  In  1849  he  succeeded 
Semmelweis  as  Assistant  in  the  Obstetric  Clinic  under 
Professor  Klein.  In  1853  he  became  a  privat-docent, 
and  in  the  same  year  he  was  appointed  Professor  of 
Obstetrics  and  Vice-Director  of  the  School  for  Midwives 
at  Trent,  in  the  Austrian  Tyrol.  In  1856,  on  the  death 
of  Klein,  he  was  called  back  to  Vienna  as  Professor  of 
Midwifery  in  the  University  and  Director  of  the  Obstetric 
Clinic.  In  1858  a  Clinic  for  the  diseases  of  women  was 
established,  and  placed  under  his  direction.  He  continued 
in  these  posts  until  his  death,  which  took  place  on  March 
28th,  1891,  when  he  had  just  entered  on  his  sixty-ninth 
year.      He  left  a  widow,  three  sons,  and  three  daughters. 

He  was  made  Dean  of  the  Medical  Faculty  of  the 
University  of  Vienna  in  1867,  and  again  in  1871,  Rector 
Magnificus  of  the  University  in  1869,  Knight  of  the  Order 
of  the  Iron  Crown,  3rd  class,  in  1872,  and  Aulic  Coun- 
cillor in  1877.  He  received  decorations  from  the 
sovereigns  of  several  foreign  countries,  the  honorary 
Doctorate  of  Laws  of  the  University  of  Edinburgh,  and 
the  honorary  Fellowship  of  many  scientific  societies  in 
Great  Britain,  America,  Italy,  and  Russia,  as  well  as  in 
Austria  and  Germany.  He  was  President  of  the 
Gynaecological  Society  of  Vienna  from  its  foundation  in 
lb87  to  the  time  of   his    death.      He    continued   actively 


56  ANNUAL    ADDRESS. 

engaged  in  scientific  work  to  within  less  than  six  weeks  of 
his  death,  for  he  presided  at  the  meeting  of  the  Gynaeco- 
logical Society  on  February  17th,  1891,  and  showed  a 
woman  in  whom  he  had  removed  per  vaginam  a  myo- 
matous uterus.  He  also  showed  a  woman  on  whom  he 
had  performed  Ceesarean  section.  He  was  taken  ill  of 
bronchial  catarrh  on  the  following  day,  and  never  rallied. 

With  his  great  medical  learning,  his  vast  personal  expe- 
rience in  midwifery  and  diseases  of  women,  his  clinical 
skill  and  his  scientific  method,  he  had  a  great  reputation 
as  a  teacher,  and  he  gathered  round  him  students  and 
practitioners  from  almost  all  civilised  countries. 

He  was  equally  famed  as  a  writer.  The  first  important 
literary  work  in  which  he  engaged  was  the  '  Klinik  der 
Geburtshilfe  und  Gynaekologie,'  published  in  parts  in 
1852,  1853,  and  1855.  Besides  writing  a  number  of 
articles  in  the  '  Klinik '  in  conjunction  with  Chiari  and 
Spaeth,  he  contributed  to  it  from  his  own  pen  a  paper  on 
A  New  Method  (Colpeurysis)  of  dilating  the  Os  Uteri  in 
Metrorrhagia,  Eclampsia,  Cross-births,  and  Contracted 
Pelvis,  which  had  appeared  in  1851  in  the  ^Zeitschrift  der 
kaiserlichen  koniglichen  Gesellschaft  der  Arzte  zu  Wien,' 
a  long  and  important  paper  on  Convulsions  from  Hys- 
teria, Epilepsy,  Cerebral  Diseases,  Mineral  and  Vegetable 
Poisoning,  and  Uraemic  Intoxication,  and  a  still  longer 
paper  on  the  Nature  and  Treatment  of  Puerperal  Diseases, 
and  on  their  Relation  to  certain  Zymotic  Diseases. 

His  well-known  and  highly  popular  '  Lehrhuch  der 
Geburtshiilfe  '  was  published  in  1857.  Taking  a  wide  view 
of  the  subject,  and  desiring  to  present  to  students  and 
practitioners  a  complete  picture  of  the  field  of  obstetrics, 
he  included  in  this  work  not  only  the  anatomy,  physio- 
logy, and  regulation  of  the  female  reproductive  organs, 
but  also  those  affections  of  them  which  may  cause  sterility, 
complicate  pregnancy,  or  interfere  with  parturition.  He 
found,  however,  that  this  arrangement  was  not  entirely 
satisfactory,  and  that  ns  a  lecturer  on  diseases  of  women 
as  well  as  on  midwifery  he  was  involved  by  it  in  frequent 


ANNUAL    ADDRESS.  57 

repetition.  Accordingly,  when  he  published  a  second 
edition  in  1881,  he  took  the  terra  gynascology  in  its  ety- 
mological sense,  and  entitling  his  work,  '  Lehrbuch  der 
gesammten  Gynaekologie/  he  included  in  it  midwifery  as 
well  as  diseases  of  women.  In  fact,  he  did  much  more 
than  this,  for  he  fused  midwifery  and  diseases  of  women 
into  a  single  and  homogeneous  theme.  In  the  first 
division  of  the  work,  headed  "  Physiologic  und  Diatetik 
der  weiblichen  Fortpflanzungsfunctionen,''  he  included  the 
anatomy  and  physiology  of  the  female  reproductive  oi'gans, 
the  physiology  and  management  of  menstruation,  the 
physiology  of  impi'egnation,  the  physiology  and  management 
of  pregnancy,  the  physiology  and  management  of  labour, 
and  the  physiology  and  management  of  lying-in  women 
and  of  new-born  children.  In  the  second  division  of  his 
work,  headed  "  Pathologie  und  Therapie  der  weiblichen 
Generationsorgane,"  he  treats  of  diseases  of  the  uterus, 
of  the  vagina,  and  of  the  vestibule,  diseases  and  anomalies 
of  the  contents  of  the  gravid  uterus,  disproportion  and  its 
consequences  in  labour  (contracted  pelvis,  and  ruptures  of 
the  genital  organs  and  of  the  symphysis  pubis),  obstetric 
operations,  diseases  of  pregnant  women,  puerperal  fever, 
diseases  of  the  annexes  of  the  uterus,  diseases  of  the 
ovaries,  disease  of  the  bladder  and  urethra,  and  diseases 
of  the  mamma.  As  became  the  successor  of  Semmelweis, 
he  shows  himself  in  this  work  to  be  a  strong  as  he  was 
an  early  advocate  of  thorough  antiseptic  precautions. 
The  best  means  of  estimating  the  period  of  pregnancy  is 
the  Aveight  and  length  of  the  foetus  as  ascertained  by 
bimanual  examination.  In  the  Vienna  clinic,  where  this 
method  had  been  employed  for  years,  errors  of  fourteen 
days  were  rare.  As  evidence  of  his  delicacy  of  touch,  it 
may  be  mentioned  that  he  says  that  the  foetal  head  may 
sometimes  be  felt  through  the  anterior  vaginal  wall  at 
the  end  of  the  fourth  month  of  pregnancy.  In  both 
editions  he  describes  the  use  of  the  external  hand,  both 
for  fixing  the  uterus  and  for  aiding  in  the  evolution  of 
the  foetus  in  the  operation  of  version.      He  had  never  seen 


58  ANNUAL    ADDRESS. 

a  death  from  the  vomiting  of  preguancy.  He  believes 
that  under  the  use  of  the  newer  medication  the  induction 
of  abortion  for  hyperemesis  may  be  entirely  avoided. 
He  himself  had  not  had  to  resort  to  it  for  twenty  yeai-s. 
He  places  great  reliance  on  drugs,  and  especially  on  large 
doses  of  potassium-bromide.  When  they  fail  he  pencils 
the  vaginal  portion  with  a  solution  of  nitrate  of  silver,  as 
recommended  by  Bennet,  and  he  has  invariably  found  the 
application  successful.  He  uses  a  10  per  cent,  solution. 
He  is  convinced  that  the  absence  of  albuminuria  is  no 
proof  of  the  absence  of  Bright's  disease,  for  albumen  may 
be  entirely  absent  from  the  ui-ine  in  the  severest  forms  of 
that  disease,  atrophy  and  amyloid  degeneration.  The 
work  is  a  great  storehouse  of  medical  erudition.  A  single 
chapter  of  the  first  edition,  that  on  Uraemic  Eclampsia,, 
was  translated  by  Dr.  Matthews  Duncan,  and  after 
appearing  in  the  '  Edinburgh  Medical  Journal '  was 
separately  published  in  1857. 

Much  of  his  original  work  he  contributed  to  medical 
periodicals.  His  favourite  method  of  dealing  with  pro- 
lapsus uteri  accompanied  by  hyperplasia  of  the  cervix 
was  for  many  years  amputation  of  the  vaginal  portion  by 
the  galvano-caustic  wire.  He  describes  the  operation  in 
three  articles  in  the  '  Wiener  medizinische  Wochenschrift  ' 
for  1859.  Tracing  the  after  effects  of  the  operation,  he 
found  that  it  is  followed  as  a  rule  by  atrophy  of  the 
uterus.  This  is  shown  by  a  remarkable  shortening  of 
the  organ,  and  by  a  thinning  of  its  walls.  Sometimes  the 
length  of  the  uterus  was  diminished  by  nearly  a  half. 
Sufficient  notice  has  not  been  taken  of  this  important 
observation.  His  paper  describing  the  above  results  is 
to  be  found  in  the  *  Zeitschrift  der  k.  k.  Gesellschaft  der 
Arzte  in  Wien  '  for  1864,  and  is  entitled  "  Ueber  die 
fettige  Involution  des  Uterus  bei  Bindegewebs-Wucher- 
ungen  (bei  chronischem  Infarcte)  desselben  ausserhalb 
des  Puerperiums."  He  describes  six  cases.  In  five  the 
galvano-caustic  was  used,  and  in  one  the  ecraseur. 

He   was    the    first   to   describe   the  placental    polypus, 


ANNUAL    ADDRESS.  59 

aud  to  distinguish  it  from  the  mere  fibrinous  or  decidual 
polypus  of  Kiwisch.  In  a  paper  ''  Ueber  die  Nosogenie 
der  Intra-uterinen  Placental-Polypen/'  in  the  '  Allgemeine 
Wiener  medizinisehe  Zeitung  '  for  18G0,  he  describes  five 
cases  of  it  with  placental  structures  in  all,  and  two 
museum-specimens  of  polypoid  tumours  in  the  puerperal 
uterus. 

In  a  paper  ''  Ueber  die  Wenduug  der  Querlage  durcli 
Palpation  wahrend  der  Schwangerschaft/'  published  in 
the  '  Allgem.  Wien.  med.  Zeit.'  for  1862,  he  states  that 
in  the  Vienna  clinic  cross-births  had  been  for  many  years 
habitually  rectified  during  pregnancy  by  external  manipu- 
lations, so  that  they  were  rare  in  labour. 

In  the  '  Wien.  med.  Wocb.'  for  1872  he  described  two 
cases  of  conception  without  immissio  1)61118.  In  the  first 
there  was  no  trace  of  a  vaginal  orifice  to  be  found  in  the 
vulva,  but  it  was  discovered  on  careful  examination  within 
the  urethra.  It  was  a  small  opening  two  lines  in  length. 
In  the  second  case  there  was  a  minute  opening  in  the 
hymen  two  lines  in  width.  It  was  not  possible  to  pass 
the  tip  of  the  finger  through  the  opening. 

The  following-  are  some  of  his  other  important  papers, 
for  which  a  bare  mention  must  suffice  : — An  article  on 
the  Pathogenesis  of  Hydrorrhoea  Gravidarum,  in  the 
'  Zeitschrift  der  k.  k.  Gesellsch.  der  Arzte  zu  Wien  '  for 
1858 ;  an  article  on  the  Induction  of  Labour  by  the 
use  of  a  Catgut  Bougie,  in  the  '  Wiener  medizinisehe 
Wochenschrift '  for  1858  ;  three  articles  on  Incarcera- 
tion of  Ovario-vagiual  Hernia  and  its  Treatment,  with 
five  cases  related,  in  the  last-named  periodical  for  1859  ; 
the  case  of  a  Mummified  Twin  Foetus,  bearing  on  the 
question  of  supei'foetation,  m  the  '  Zeit.  der  k.  k.  Ges. 
der  A.  zu  Wien  ^  for  1860;  two  articles  on  Periuterine 
Hematocele  and  its  Treatment,  in  the  same  periodical 
and  year  ;  five  articles  on  the  Pathogenesis  of  Retro- 
uterine Hsematocele,  in  the  *  Wien.  med.  Woch.'  for 
1861  ;  four  articles  on  the  Connection  between  Colloid 
(Amyloid)     Metamorphosis    of    the    Epitheliuui    of    the 


60  ANNUAL    ADDRESS. 

Kidneys  and  Eclampsia  Gravidarum,  in  the  '  Beilage  '  or 
Supplement  of  tlie  '  Zeitscli.  der  k.  k.  Gesellsch.  der  Arzte 
in  Wien '  for  1864;  an  article  on  Arrested  Develop- 
ment of  the  Uterus,  Vagina,  and  Vestibule,  in  the 
'  Wien.  med.  Woch/  for  1874 ;  three  articles  on 
Flexions  of  the  Uterus,  in  that  periodical  for  1875  ; 
and  five  articles  on  the  'Treatment  of  Metritis,  Endo- 
metritis, Vaginitis,  and  Vulvitis,  in  the  same  periodical 
for  1878. 

He  was  a  pioneer  in  hygiene  and  sanitation  as  well  as 
in  asepsis.  In  1864  he  published  in  the  '  Zeitsch.  der  k. 
k.  Gesellsch.  der  Arzte  in  Wien  '  an  elaborate  paper  on 
the  Ventilation  of  the  University  Clinic.  He  describes 
the  simple,  efficient,  and  inexpensive  system  of  ventilation 
devised  by  Dr.  Bohm,  a  military  surgeon,  which  had  been 
in  use  in  the  University  Clinic  for  Obstetrics  and  Gynee- 
cology  for  four  months  previously.  Calorifers  were  used 
to  induce  currents  of  fresh  air,  and  advantage  was  also 
taken  of  the  natural  differences  of  temperature  in  the 
outer  and  inner  air  to  effect  ventilation.  His  great 
administrative  energy  is  shown  in  this  paper  by  his 
enumeration  of  no  fewer  than  thirty- one  reforms  which 
had  been  introduced  into  the  obstetrical  and  gynaecological 
teaching  and  the  hygienic  arrangements  of  the  clinic 
since  he  entered  on  his  office  in  the  end  of  1856,  These 
reforms  included  isolation  of  all  cases  of  puerperal  illness 
in  a  separate  building ;  the  exclusion  of  all  pregnant 
women  from  the  sick-room,  and  the  appointment  of  a 
special  attendant  to  enforce  the  prohibition  ;  the  setting 
aside  of  a  special  room,  capable  of  being  heated,  for  the 
performance  of  operations  ;  the  abolition  of  sponges ;  the 
substitution  of  glycerine  for  lard  in  making  vaginal 
examinations  ;  the  allotment  of  thermometers  to  the  lying- 
in  wards  ;  ventilation  of  the  soil-pipes  ;  the  sealing  of  the 
closet-pans  by  flap  apparatus  ;  and  the  establishment  of  a 
clinic  for  diseases  of  women. 

One  of  the  last  articles  from  his  pen  was  a  detailed 
account  of  the  salubrity  of  the  clinic  under  his   charge, 


ANNUAL    ADDRESS.  (Jl 

and  of  the  effects  of  antiseptics  during  the  twenty- 
nine  years  of  his  administration.  It  appeared  in  the 
'  Wien.  med.  Woch/  for  1886.  The  result  of  the  various 
measures  adopted  had  been  that  in  the  years  1881,  1882, 
1883,  1884,  and  1885  the  mortality  from  puerperal  fever 
had  sunk  to  0'4,  0-6,  0*2,  0*3,  and  O'S  per  cent,  respec- 
tively. The  deliveries  in  those  years  had  been  3481, 
2834,  3011,  2993,  and  2751  respectively,  and  the  total 
mortality  1,  1*4,  0*7,  1"2,  and  0*9  respectively. 

He  was  a  peculiarly  neat  and  dexterous  operator,  and 
he  wrote  from  time  to  time  on  gynaecological  surgery. 
He  wrote  four  articles  on  the  cure  of  urinary  fistulge  in 
the  'Wien.  med.  Woch.'  for  1872.  He  w^rote  two  articles 
in  the  same  periodical  for  1883  on  Twelve  Cases  of 
Csesarean  Section  with  Hysterectomy,  and  in  the  volume 
for  1884  five  articles  on  One  Hundred  Cases  of  Laparo- 
tomy for  Tumours  of  the  Genital  Organs. 

He  displayed  much  mechanical  ingenuity  in  devising 
and  in  modifying  obstetrical  and  gynaecological  instru- 
ments. It  is  perhaps  through  some  of  those  instruments 
that  his  name  is  most  widely  known  to  practitioners  in 
this  country. 

In  the  first  part  of  the  '  Klinik  der  Geburtshilfe  und 
Gynaekologie'  of  Chiari,  Braun,  and  Spaeth,  1852,  several 
of  his  instruments  are  described  and  figured.  First,  there 
is  his  Schlingentrager,  or  sling-carrier,  or  Strophebrochos, 
or  Brochopheron,  a  gutta-percha  rod  with  a  running  noose 
of  tape  for  snaring  a  foot,  to  facilitate  turning  in  difficult 
cases  of  podalic  version.  Second,  there  is  his  Nabelschnur- 
repositorium,  or  funis-repositor,  or  Apotheter,  first  de- 
scribed and  figured  in  Scanzoni's  '  Lehrbuch  der  Geburts- 
hilfe '  in  1849,  and  consisting  of  a  rod  of  gutta-percha 
and  a  loop  of  ribbon  2  lines  in  breadth  for  returning  the 
prolapsed  funis.  Third,  there  is  his  Schliisselhaken, 
or  key-hook,  or  Decollator,  a  blunt  hook  for  decapitation. 
It  is  a  powerful  instrument,  which  has  been  employed  by 
most  obstetricians  in  Germany  and  in  Italy  in  preference 
to  a  cutting  instrument.   Fourth,  there  is  his  Pump-douche 


62  ANNUAL    ADDRESS. 

apparatus,  or  Colpantlon,  throwing  a  continuous  stream  of 
water  three  or  four  lines  in  diameter,  for  inducing  prema- 
ture labour  by  distending  the  vagina  after  the  method  of 
Kiwisch.  Fifth,  there  is  his  Colpeurynter,  in  which  the 
animal  bladder  of  Hiiter  is  replaced  by  a  bag  of  caoutchouc, 
and  by  which  it  was  intended  to  tampon  the  vagina,  and 
to  dilate  the  cervical  canal  for  many  purposes.  He  had 
described  his  Colpeurynter  in  1851  in  the  '  Zeitsch.  der 
k.  k.  Gesellsch.  der  Aerzte  zu  Wien.' 

His  modification  of  the  cephalotribe  is  described  and 
figured  in  the  '  Kliuik  der  Geburtshilfe  und  Gynaekologie  ' 
in  1855.  The  right  handle  is  shorter  than  the  left,  and 
has  a  joint  in  the  middle. 

His  curved  trephine,  or  Pereterion,  for  perforating  the 
fa?tal  skull,  was  described  in  the  '  Klinik  '  in  1855  also. 
In  Germany,  where  a  trephine  is  preferred  as  a  perforator, 
this  instrument  is  frequently  emploj^ed.  In  1864  the  late 
Dr.  Charles  G.  Ritchie  gave,  at  this  Society,  an  account 
of  the  operation  of  cephalotripsy  as  performed  in  Vienna 
by  Professor  Braun,  and  exhibited  his  perforator  and 
cephalotribe. 

In  1858  Braun  described,  in  the  '  Wiener  med.  Woch.,' 
his  catgut  bougie,  a  foot  long  and  two  to  three  lines 
thick,  which,  in  the  previous  year,  he  had  employed 
several  times  to  induce  premature  labour  instead  of  using 
a  catheter  or  gum-elastic  bougie.  In  1870,  however,  he 
gave  up  the  use  of  bougies  for  the  purpose,  partly 
because  of  the  length  of  time  required — in  one  case  of 
his  eight  days — before  labour  set  in,  and  partly  because 
he  often  found  endometritis  set  up  from  detachment  of 
decidua  and  placenta,  entrance  of  air  and  septic  infection, 
as  he  explains  in  his  '  Lehrbuch  der  gesammten  Gynae- 
kologie.' His  latest  method  was  to  puncture  the  mem- 
branes with  a  pointed  quill  5  centimetres  above  the  internal 
OS,  so  that  in  general  the  licjuor  amnii  escaped  slowly.  In 
thirty-four  cases  of  premature  labour  induced  in  this  way 
for  contracted  pelvis  from  1868  to  1878,  twenty-nine 
children,  or  85  per  cent.,  were  born  alive. 


ANNUAL    ADDRESS.  63 

In  the  'Wien.  med.  Wocli.'  for  1863  he  describes  a 
uterine  sound  which  he  had  contrived  for  the  purpose  of 
serving  as  a  hysterophor,  dilator,  and  cervical  tampon  as 
well  as  a  probe  for  investigation.  It  has  a  metal  stem, 
with  a  terminal  portion  3  inches  long,  consisting  of 
laniinaria  digitata  (or  of  hardened  caoutchouc). 

x\t  the  Obstetrical  Society  of  Berlin  in  April,  1865,  as 
reported  in  the  '  Monatsschrift  fiir  Geburtskunde  '  for  that 
year,  Dr.  Fiirst,  of  Franzensbad,  exhibited  and  described 
a  syringe  which  had  been  invented  by  Braun  for  injecting 
the  cavity  of  the  uterus,  chiefly  for  the  treatment  of 
endometritis.  The  syringe  has  a  glass  cylinder  which 
cannot  contain  more  than  about  twelve  drops  of  liquid. 
The  liquid  is  discharged  into  the  uterine  cavity  very 
slowly,  drop  by  drop,  for  safety.  The  syringe  is  figured 
by  Schroeder  and  others. 

He  modified  Simpson's  cranioclast,  making  it  longer 
and  somewhat  thicker,  and  adding  a  screw  at  the  lower 
end  of  the  handles  to  strengthen  the  grip.  It  is  an 
admirable  instrument  for  traction  after  perforation,  but  it 
is  less  efficient  for  breaking  down  the  arch  of  the  skull.  It 
is  first  described  and  figured  in  the  'Wiener  medizinische 
Presse  '  for  1871  by  Dr.  Karl  Rokitansky,  jun.,  Assistant 
in  Braun' s  Clinic  for  Midwifery  and  Gynaecology. 

He  also  slightly  modified  Simpson's  forceps,  as  he 
describes  in  his  '  Lehrbuch  der  gesammten  Gynaekologie,' 
and  produced  an  instrument  which  is  frequently  used  in 
Germany.  He  approximated  the  points  of  the  blades 
from  one  and  a  quarter  inches  to  slightly  less  than  one 
inch,  and  he  increased  the  greatest  distance  between  the 
blades  by  about  one-seventh  of  an  inch.  He  increased 
the  pelvic  curve.  He  retained  the  Smellie  or  English 
lock. 

In  the  '  Wien.  med.  Woch.'  for  1886  he  described  and 
figured,  under  the  name  ''  Forceps  Trimorpha,"  an  axis- 
traction  forceps  contrived  by  him.  It  is  constructed 
for  easy  introduction. 


64  annual  address. 

Professor  Friedrich   Wilhelm    Scanzoni   von 

LiCHTENFELS. 

Friedrich  Wilhelm  Scanzoni  von  Lichtenfels  was  born 
on  December  21st,  1821.  His  father,  who  came  from  the 
neighbourhood  of  Lake  Garda  iu  the  Italian  Tyrol,  was  a 
railway  official  in  Prague.  His  mother  was  the  daughter 
of  Dr.  Beutner  von  Lichtenfels,  a  medical  practitioner 
in  the  Bohemian  capital.  He  joined,  the  ancient  and 
once  famous  University  of  Prague  in  1838,  and  he  took  his 
medical  degree  there  in  1844.  He  then  travelled  abroad 
for  a  time,  and  on  his  return  to  Prague  he  was 
appointed  Assistant  Obstetric  Physician  to  the  Depart- 
ment for  Paying  Patients  in  the  Imperial  Royal  Lying-in 
Hospital.  He  soon  became  Assistant  to  the  Chair  of 
Midwifery,  and  afterwards  Physician  and  Lecturer  on 
Gynaecology  to  the  Imperial  Royal  Genei'al  Hospital. 
From  that  appointment  he  was  called,  in  1850,  to  succeed 
Kiwisch  as  Professor  of  Obstetrics  and  of  Gynecology  in 
the  University  of  Wiirzburg  and  Director  of  the  Lying-in 
Institution. 

He  held  these  appointments  until  1888,  when  he 
resigned  them  in  consequence  of  the  impairment  of  his 
mental  vigour  from  excessive  strain  prolonged  through 
many  years.  He  then  retired  to  his  estates  in  Upper 
Bavaria.  He  died  at  his  Castle  of  Zinneberg,  at  the  foot 
of  the  Bavarian  Alps,  on  June  12th,  1891,  in  his  seventieth 
year.  He  married  Fraulein  von  Honiger,  who,  with  four 
sons  and  two  daughters,  survives  him. 

He  was  made  a  Privy  Councillor,  and  was  decorated 
with  many  foreign  as  well  as  Bavarian  orders.  In  1863 
King  Max  conferred  upon  him  the  surname  of  von 
Lichtenfels,  carrying  an  hereditary  title  of  nobility.  He 
was  made  corresponding  or  honorary  Fellow  of  innumer- 
able scientific  societies, 

A  man  of  first-rate  intellect,  of  remarkable  diagnostic 
skill,  of  brilliant  conversational  powers,  of  striking  personal 
appearance,  and  of  peculiarly  affable  and  kindly  manners, 


ANNUAL    ADDRESS.  65 

he  early  acquired  a  great  reputation  as  a  practitioner,  as 
a  writer,  and  as  a  teacher. 

As  soon  as  he  had  settled  at  Wiirzburg  he  found 
himself  fully  engaged  in  private  practice.  This  practice 
rapidly  increased,  and  it  soon  became  something  pheno- 
menal. At  the  time  when  patients  were  flocking  to 
Simpson  in  Edinburgh  from  almost  all  parts  of  the  world, 
ladies  flocked  from  France,  Germany,  and  Russia  to 
Scanzoni  at  Wiirzburg,  where  they  filled  the  hotels  of  the 
town  so  that  new-comers  had  difficulty  in  obtaining 
accommodation.  In  the  summer  of  1^58  he  attended  the 
Empress  of  Russia  in  her  confinement  at  St.  Petersburg, 
and  was  reported  to  have  received  a  fee  of  100,000  roubles, 
Avorth  at  that  time  about  £16,000  sterling,  and  also  a 
mansion  at  Wiii'zburg.  It  is  necessary  to  add,  as  an 
explanation  of  this,  that  he  was  detained  in  Russia  four 
months.  In  1863  he  again  attended  the  Czarina  in  her 
confinement  at  St.  Petersburg. 

In  1863  Scanzoni  was  about  to  resign  his  chair,  when  a 
numerously  signed  petition  was  sent  to  the  King  of 
Bavaria  begging  that  measures  might  be  taken  to  induce 
him  to  remain  at  Wiirzburg.  An  autograph  letter  from 
the  King  requesting  him  to  remain,  and  allowing  him  to 
depute  to  his  assistant  Dr.  Franque  the  theoretical  part  of 
his  teaching,  had  the  desired  effect,  and  Scanzoni  con- 
sented to  stay. 

His  literary  energy  was  remarkable,  and  was  con- 
spicuous even  through  the  busiest  part  of  his  professional 
life.  Not  to  dwell  on  his  earlier  efforts — as,  for  example, 
his  rather  theoretical  paper  on  the  genesis  of  puerperal 
fever  in  1846,  his  paper  on  obstetric  auscultation  in  1847, 
his  paper  on  spastic  stricture  of  the  os  uteri  in  labour, 
also  in  1847,  his  article  on  the  pathology  of  the  human 
ovum  in  1849,  all  published  in  the  '  Vierteljahreschrift  fiir 
die  praktische  Heilkunde  herausgegeben  von  der  medicin- 
ischen  Facultat  in  Prag,'  or  his  article  on  the  fetiology  of 
abortion  in  the  '  Zeitschrift  der  Wiener  Aerzte'  for  1847, — 
he  published  in  1849,  while  still  in  Prague,  the  first  part  of 

VOL.  XXXIV.  5 


66  ANNUAL    ADDRESS. 

his  '  Lelirbuch  der  Geburtsliilfe/  an  exhaustive  treatise, 
and  not,  as  might  be  inferred  from  its  title,  a  mere  handbook. 
It  was  completed  in  1852.  It  reached  four  editions,  the  last 
in  1867.  This  great  work,  characterised  by  lucid  descrip- 
tion, and  by  the  application  to  obstetrics  of  the  most 
recent  researches  in  physiology,  pathology,  and  chemistry, 
at  once  placed  Scanzoni  in  the  foremost  rank  of  obstet- 
ricians. It  was  one  of  the  most  popular  treatises  on  the 
subject  in  Germany,  and  it  long  maintained  its  place  as  a 
standard  work.  Many  interesting  features  of  this  treatise 
might  be  mentioned.  To  select  two  or  three  points  onl}^ 
he  shows  that,  contrary  to  the  opinion  generally  held,  the 
foetus  not  unfrequently  undergoes  a  complete  change  of 
position  in  the  last  months  of  pregnancy,  and  even  during 
the  first  part  of  labour.  He  attributes  shoulder  presen- 
tations chiefly  to  abnormal  relaxation  of  the  uterine  wall, 
a  condition  which  he  always  found  present  in  such  cases. 
Even  in  his  first  edition  he  advocates  cephalic  instead  of 
podalic  version  in  cross-births  when  circumstances  are 
favourable.  He  also  shows  the  use  of  an  external  hand 
to  aid  in  performing  version. 

A  smaller  work  on  the  same  subject,  his  '  Compendium 
der  Geburtshilfe,'  was  published  in  1854,  and  reached  a 
second  edition  in  1861. 

In  1852,  on  completing  his  '  Lehrbuch,^  he  published  a 
portion  of  it  as  a  separate  volume,  under  the  title  '  Die 
Geburtshilflichen  Operationen.' 

In  1853  he  commenced  the  issue  of  his  serial  the 
'  Beitrage  zur  Geburtskunde  und  Gynakologie,'  which  was 
continued  until  1873,  and  extended  to  seven  volumes.  In 
addition  to  editing  the  '  Beitrage '  he  contributed  to  it  many 
articles  from  his  own  pen.  Some  of  these  were — The 
Pathology  of  Uterine  Flexions,  On  Van  Huevel's  Saw- 
Forceps,  Malformation  of  the  Female  Genital  Organs, 
On  the  Employment  of  Anaesthetics  in  Obstetric  Practice, 
On  the  Pathology  of  Uterine  Polypi,  The  Secretion 
of  the  Mucous  Membranes  of  the  Vagina  and  of  the 
Cervix  Uteri — an  article   written  conjointly   by    Kolliker 


ANNUAL    ADDRESS.  67 

and  Scanzoni — On  the  Continuance  of  Ovulation  during* 
Pregnancy,  On  the  Removal  of  the  Vaginal  Portion  for 
the  Cure  of  Prolapsus  Uteri,  and  On  Marion  Sims's 
Doctrine  of  the  Cause  and  of  the  Treatment  of  Sterility. 
He  is  strongly  opposed  to  the  mechanical  views  of  Sims. 

In  the  first  volume  of  the  '  Beitrage,'  published  in 
1853,  he  proposed  the  induction  of  premature  labour  of 
irritating  the  nipples  by  suction  with  a  breast-pump, 
having  succeeded  in  two  cases  by  this  method. 

In  the  third  volume  (1858)  he  relates  a  case  of  death 
from  the  injection  of  carbonic  acid  into  the  cervical 
cavity  in  a  woman  pregnant  four  months.  Death  took 
place  in  one  hour  and  three-quarters.  He  subsequently 
published  another  fatal  case,  and  thus  banished  from 
practice  the  method  of  provoking  labour  wliich  he  had 
himself  originally  proposed  in  1856  in  the  'Wiener 
medizinische  Wochenschrift,^  where  he  describes  a  case 
of  the  successful  induction  of  premature  labour  by 
the  passing  of  carbonic  acid  into  the  vagina.  He  had 
been  induced  to  try  this  method  by  the  statement  of 
Brown- Sequard  that  carbonic  acid  excites  contraction  in 
non-striated  muscular  fibre. 

In  the  fifth  volume  (1869)  he  has  an  important  paper 
on  a  case  of  chronic  inversion  of  the  uterus  with  critical 
remarks,  in  which  he  shows  that,  contrary  to  the  received 
opinion,  uterine  polypi  do  not  cause  inversion  of  the 
uterus,  all  the  supposed  cases — twenty-two  in  number — 
being  found  on  examination  to  be  merely  submucous 
fibroids,  with  a  broad,  non-pediculated  base. 

He  describes  in  his  various  writings  some  rare 
obstetric  cases,  of  which  the  following  are  the  most  re- 
markable. In  the  first  volume  of  his  *  Beitrage '  he 
describes  and  illustrates  by  two  figures  a  curious  case  of 
pregnancy  in  a  rudimentary  uterine  horn,  with  probable 
migration  of  the  ovum  from  the  right  ovary  to  the  left 
uterine  horn.  The  patient  was  a  woman  of  thirty-five  years 
of  age,  who  had  previously  aborted  of  twins,  and  had  after- 
wards had  three  children.      In  the  seventh  volume  of  the 


68  ANNUAL    ADDRESS. 

'  Beitrage '  (1878)  he  describes  one  of  the  few  recorded 
cases  of  hernia  of  the  gravid  uterus.  The  uterus,  as 
shown  by  the  passing  of  a  bougie  on  one  occasion  through 
the  vagina  into  the  deepest  part  of  the  hernial  tumour, 
and  the  ovaries  also,  were  contained  in  a  left  inguinal 
hernia.  At  the  menstrual  periods  he  had  found  swelling 
and  tenderness  of  the  contents  of  the  sac.  Conception 
took  place  twice,  and  was  followed  by  spontaneous  abor- 
tion in  the  third  month  the  first  time,  and  by  induced 
abortion  at  twenty-one  weeks  the  second  time.  In  the 
*  Allgemeine  Wiener  medizinische  Zeitung  '  for  1859  he 
relates  a  remarkable  case  in  which  the  right  sacro-iliac 
synchondrosis  was  ruptured  during  labour.  An  abscess 
of  the  ai'ticulation  followed  and  appeared  at  Poupart's 
ligament.  In  the  same  periodical  for  1864  he  described 
a  case  of  pregnancy  without  immissio  i^enis.  The  patient, 
twenty-nine  years  of  age,  was  four  months  pregnant  when 
Scanzoni  saw  her.  The  orifice  in  the  hymen  was  barely 
large  enough  to  admit  a  surgical  probe.  The  hymen 
itself  was  firm,  tense,  and  unyielding. 

In  this  country  Scanzoni  was  best  known  as  a  writer 
on  diseases  of  women. 

In  1854-7  he  edited  and  enlarged  Kiwisch's  '  Klinische 
Vortrage  iiber  specielle  Pathologie  und  Therapie  der 
Krankheiten  des  weiblichen  Geschlechtes.^  The  work 
having  been  left  incomplete  at  the  death  of  Kiwisch, 
Scanzoni  added  a  third  volume,  which  he  published  in 
1855,  on  diseases  of  the  mamma,  diseases  of  the  bladder 
and  urethra,  and  special  diseases  of  the  nei'vous  system, 
among  which  he  included  puerperal  eclampsia  and  puer- 
peral mania. 

In  1857  he  published  his  classical  work,  the  '  Lehrbuch 
der  Krankheiten  der  weiblichen  Sexualorgane.'  This 
work  reached  a  fifth  edition  in  1875.  It  was  translated 
into  French,  and  from  French  into  American.  It  is  im- 
possible to  reproduce  here  his  excellent  descriptions  of 
disease  which  were  drawn  from  his  own  experience  and 
not  compiled  from  other  writers,  but  the  following  points 


ANNUAL    ADDRESS.  69 

may  be  noted.  Like  Brauu,  he  condemns  a  restricted 
specialism,  and  he  argues  that  obstetrics  and  gynaecology 
must  reciprocally  complete  each  other.  He  treats  in  a 
masterly  way  the  subject  of  the  fibrinous  polypus  described 
by  Kiwisch  in  1851.  He  shows  that  Kiwisch  was  in  error 
in  supposing  that  such  polypi  arise  from  the  coagulation 
of  menstrual  blood.  He  further  shows  that  for  their  pro- 
duction there  must  previously  be  a  cavity  in  the  uterus 
and  an  incomplete  abortion — or  delivery,  as  he  might  have 
added.  He  describes  the  changes  produced  by  flexious 
in  the  uterine  tissues.  He  remarks  that  he  has  never 
cured  a  flexion.  He  rejects  intra-uterine  pessaries,  after 
sufiicient  experience  of  them,  as  being  both  useless  and 
dangerous.  In  his  last  edition  he  expresses  his  belief  in 
the  usefulness  of  vaginal  pessaries  in  some  cases.  He 
employs  mostly  a  pelvic  girdle  or  bandage,  with  a  hypo- 
gastric cushion  or  pad  for  anteflexion  and  even  for  retro- 
flexion. He  describes  that  rare  affection,  varicose  ulcer 
of  the  cervix  uteri,  in  the  first  as  well  as  in  the  later  edi- 
tions, and  he  Avas  the  first  to  do  so.  He  describes  a 
simple  means  devised  by  himself  for  determining  the 
thickness  or  thinness  of  the  pedicle  of  an  intra-uterine 
polypus.  He  seized  the  polypus  witii  forceps  and  twisted 
it  round,  judging  of  the  thickness  of  the  pedicle  by  the 
degree  of  resistance  to  torsion.  He  rightly  maintains, 
contrary  to  Kiwisch  and  others,  the  occasional  presence 
of  a  souffle  in  ovarian  tumours  when  solid  and  vascular. 
As  one  means  of  discovering  the  presence  of  fluid  in 
ovarian  tumours,  he  auscultates,  f»nd  at  the  same  time  taps 
on  the  abdomen  with  the  hand,  thus  shaking  the  liquid 
and  producing  a  characteristic  sound.  It  is  shown  by 
Scanzoni  in  this  work  that  in  hasmatometra  from  atresia 
of  the  cervix  the  walls  of  the  uterus  vary  greatly  in 
thickness  in  different  cases.  It  seemed  to  him  that  the 
uterine  wall  was  thick  or  thin  according  as  the  blood  had 
accumulated  slowly  or  rapidly.  In  one  case  in  which  the 
uterus  contained  9  lbs.  of  blood  the  walls  were  as  thin 
as  paper,  having  been  mechanically  distended,  as  he  sup- 


70  ANNUAL    ADDRESS. 

poses,  before  muscular  fibres  had  time  to  develop.  In 
another  case,  in  which  the  symptoms  of  occlusion  had  ex- 
isted for  five  years,  the  uterine  wall  was  a  third  of  an 
inch  thick  at  the  upper  part.  In  all  his  editions  he  makes 
the  curious  and  interesting  observation  that  paraplegia 
may  lead  to  atrophy  of  the  uterus.  He  had  seen  several 
young  women  who,  previously  perfectly  healthy  with  regu- 
lar menstruation,  had  ceased  to  menstruate  after  an 
attack  of  paraplegia,  and  in  whom  he  had  found  the 
uterus  extremely  small.  In  several  he  had  been  able  to 
verify  his  diagnosis  of  uterine  atrophy  by  'post-morteni 
examination.  It  is  somewhat  remarkable — and  it  speaks 
well  for  the  obstetric  practice  of  Wiirzburg  and  the 
country  round — that  in  all  his  editions  he  says  that  in  his 
experience  the  most  common  cause  of  vesico-vaginal  fistula 
is  cancer  of  the  uterus  extending  to  the  vaginal  wall. 
The  most  frequent  cause  of  urethral  caruncles  or  angio- 
mata  he  considers  to  be  chronic  catarrh  of  the  urethral 
mucous  membrane. 

From  his  enormous  experience  in  gynaecology,  and  his 
thorough  investigation  of  cases,  he  met  with  numerous 
examples  of  rare  diseases  and  of  rare  conditions. 

Thus,  in  his  'Lehrbnch  der  Krankheiten  der  weiblichen 
Sexualorgane,'  he  states  that  in  1849  he  was  present  at 
the  necroscopy  of  a  woman  of  about  sixty  years  of  age, 
in  Avhom  the  right  Fallopian  tube  was  the  seat  of  a  hydro- 
salpinx the  size  of  a  goose's  egg,  and  the  left  tube  was  a 
flaccid  sac  the  size  of  a  hen's  egg,  with  its  abdominal  end 
completely  closed,  but  its  uterine  end  patent  and  about 
tliree-fifths  of  an  inch  in  width.  The  flaccid  sac,  which 
contained  a  few  drachms  of  sanguineous  fluid,  was  an 
example,  therefore,  of  the  "  hydrops  tubte  profluens"  of 
Rokitansky. 

He  describes  in  his  'Lehrbuch'  an  example  of  that  ex- 
tremely rare  affection,  abscess  of  the  uterus  unconnected 
with  pregnancy  or  Avith  parturition.  The  case  was  that  of  a 
young  woman  who  was  seized  with  severe  metritis  after 
sudden  suppression  of  menstruation.   On  the  twenty-second 


ANNUAL    ADDRESS.  71 

day  of  Tier  illness  symptoms  of  peritonitis  supervened.  The 
patient  died  on  the  thirty-first  day.  The  cause  of  death 
■was  found  to  be  the  rupture  of  an  abscess  as  large  as  a 
goose's  egg  in  the  upper  part  of  the  body  of  the  uterus. 

He  relates  also  in  this  work  a  case  of  menstrual  reten- 
tion from  imperforate  hymen  in  a  girl  of  nineteen,  in  which 
after  two  years  of  severe  dysmenorrhoeal  suffering  the 
hymen  suddenly  ruptured  spontaneously  during  an  attack 
of  uterine  colic,  and  two  pounds  of  foetid  decomposed  blood 
escaped. 

In  a  woman  who  died  in  her  sixty-first  year,  and  in 
whom  up  to  the  time  of  her  death  there  had  been  fairly 
regular  menstrual-like  heemorrhages,  he  found  in  the 
upper  part  of  the  cervical  canal  two  mucous  polypi  the 
size  of  a  bean.  The  ovaries  were  quite  atrophic  and 
without  any  trace  of  corjnis  liiteunn  or  of  fresh  blood  ex- 
travasation. Without  a  i^ost-mortem  examination  a  quite 
misleading  inference  might  have  been  drawn  as  to  the 
persistence  of  menstruation  in  such  a  case. 

In  this  treatise  he  also  describes  a  case  as  primary 
cancer  of  the  left  tube,  but  as  there  was  also  a  cancerous 
tumour  of  the  right  ovary  the  case  is  not  a  conclusive  one. 

In  1860  in  the  'Wiirzburger  medicinische  Zeitschrift'  he 
describes  a  curious  case  of  periodical  hydruria  in  a  Russian 
lady,  aged  thirty,  who  came  under  his  care  in  1858.  She 
had  six  living  children.  The  watery  discharge,  estimated  by 
the  patient  at  from  six  to  eight  quarts,  appeared  every 
four  weeks.  Menstruation  was  very  irregular  and  very 
scanty.  The  case  had  been  mistaken  for  hydrometra,  and 
]iad  been  treated  by  Jobert  (de  Lamballe)  by  the  applica- 
tion of  the  actual  cautery  to  the  cervix  uteri  three  times. 
Under  the  use  of  the  chalybeate  waters  of  Wildungen  the 
hydruria  disappeared,  and  the  menstruation  became  regular. 

In  the  same  year  and  in  the  same  periodical  he  pub- 
lished a  paper  on  urticaria  as  a  symptom  of  irritation  of 
the  female  sexual  organs.  He  described  three  cases  in 
which  urticaria  with  severe  febrile  disturbance  speedily 
followed  the  application  of  leeches  to  the  cervix  uteri.      In 


72  ANNUAL    ADDRESS, 

one  of  the  cases  tlie  patient  had  suffered  on  many  occa" 
sions  from  urticaria  at  the  menstrual  period. 

His  work  '  Die  chronische  Metritis/  a  volume  of  over 
300  pages,  published  in  18G3,  is  dedicated  to  the  Obstet- 
rical Society  of  London,  of  which  he  had  recently  been 
elected  an  honorary  Fellow,  and  is  also  addressed  to  the 
Society  in  an  introduction  or  preface.  The  book  was 
written  to  set  the  subject  of  uterine  inflammation  on  a 
scientific  and  pathological  basis,  and  to  combat  the  views 
advanced  by  Bennet  in  this  country  and  by  Becquerel  in 
France.  This  work  of  Scauzoni's  is  a  great  improvement 
on  previous  Avritiugs  on  the  subject,  and  has  been  the 
foundation  on  which  subsequent  writers  have  built.  A 
novel  characteristic  of  the  work  is  that  he  treats  fully  of 
the  histological  changes  found  in  chronic  metritis.  He 
asserts  that  the  so-called  inflammatory  affections  of  the 
cervix  uteri  had  been  made  too  much  of  in  the  preceding" 
twenty  years,  and  that  many  maladies  and  many  sym- 
ptoms with  which  they  had  no  connection  had  been  attri- 
buted to  them.  The  pathological  changes  in  the  body  of 
the  uterus  are  of  far  greater  significance,  he  maintains, 
than  the  swellings,  hypertrophies,  granulations,  and  ulcers 
of  the  cervix.  He  attaches  extreme  importance  to  exces- 
sive sexual  indulgence  as  a  cause  of  metritis.  He  con- 
siders that  one  of  the  chief  causes  of  acute  metritis,  fol- 
lowed by  chronic  metritis  and  lifelong  sterility,  is  sexual 
excess  immediately  following  marriage,  and  he  especially 
reprobates  the  custom  of  wedding  tours,  which  afford  un- 
limited opportunity  for  such  excess.  He  has  traced  many 
cases  to  this  cause.  Henry  Bennet  had  previously  ex- 
pressed similar  views  in  his  work  on  Inflammation  of  the 
Uterus.  In  discussing  membranous  dysmenorrhoea  he 
states  that  he  had  lately  noticed  the  great  frequency  with 
which  membranous  shreds  are  passed  in  dysmenorrhoea, 
although  they  are  not  generally  discovered  until  they  are 
specially  hooked  for.  He  gives  an  ingenious  theoretical 
explanation  of  the  pathological  process.  There  are  two 
stages,  he  considers.      The   first   is  excessive  hyperaemia, 


ANNUAL   ADDRESS.  7§t 

and  consequent  swelling  and  loosening  of  the  mucosa. 
The  second  stage  is  a  very  abundant  production  of  new- 
cells  in  the  deeper  strata  of  the  mucosa,  by  which  the 
more  superficial  layers  are  raised  and  possibly  separated 
in  shreds  or  portions.  Further,  the  swelling  of  the  mucosa 
in  the  neighbourhood  of  the  internal  os  may  so  impede 
the  escape  of  the  menstrual  blood  that  continuoiis  uterine 
contraction  is  induced,  and  the  loosely  attached  mucous 
membrane  is  thus  thrown  off  either  entire  or  piecemeal. 

In  1 882  he  published,  in  the  '  Festschrift  zur  dritten 
Saecularfeier  der  Alma  Julia  Maximiliana  gewidmet  von 
der  medicinischeu  Facultat  der  Universitat  Wiirzburg,' 
an  account  of  198  cases  of  labour  with  contracted  pelvis 
in  the  Wurzburg-  clinic  since  he  took  charo-e  of  it  in 
November,  1850.  There  had  been  10,557  deliveries  from 
that  time  to  November  1st,  1881.  The  number  of  con- 
tracted pelves  was  159,  thirty-niue  of  the  patients  having 
been  delivered  twice.  This  was  Scanzoni's  last  publica- 
tion. 

In  addition  to  the  above  he  wrote  in  various  periodicals 
numerous  articles  on  obstetrics  and  gyntecology. 

In  gynaecological  surgery  he  was  strongly  conservative. 
Thus  even  in  the  second  edition  of  his  '  Lehrbuch  der 
Krankheiten  der  weiblichen  Sexualorgane/  published  in 
1859,  he  refused  his  sanction  to  the  operation  of  ovario- 
tomy, and  called  it  a  rash  surgical  venture.  As  late  as 
1865  he  showed  his  bias  by  insisting,  in  the  '  Wiirzburger 
medicinische  Zeitschrift/  on  the  inferiority  of  ovariotomy 
to  other  surgical  operations  as  a  means  of  radically  curing 
disease.  If  one  ovary  is  left,  disease  may,  he  argued,  be 
left  in  it,  or  may  afterwards  attack  it ;  while  if  both  ova- 
ries are  removed  at  one  operation  the  danger  to  life  is 
immense. 

Like  most  obstetricians,  he  sought  to  improve  the  tools 
with  which  he  worked.  His  cephalotribe,  which  is 
described  and  figured  in  the  first  edition  of  his  '  Lehrbuch 
der  Geburtshilfe,'  with  its  peculiar  aud  iugenious  com- 
pressing mechanism   after  Hiiter,  is  allowed  to  be  one  of 


74  ANNUAL    ADDRESS. 

the  best  of  the  Continental  forms  of  the  instrument.  So 
far  as  I  know,  it  introduced  the  operation  of  cephalo- 
tripsy  into  this  country,  for  it  was  the  instrument  employed 
by  Sir  James  Simpson  in  1861  when  he  crushed  the 
head  and  effected  delivery  by  it  in  two  cases.  Simpson's 
and  other  English  cephalotribes  were  devised  after  this 
successful  use  of  Scanzoni's  instrument. 

Scanzoni's  decapitator,  or  Auchenister,  described  by  him 
in  the  '  Wiirzburger  medicinische  Zeitschrift '  in  1860,  was 
intended  by  him  to  obviate  the  difficulties  and  risks  attending 
the  use  of  sharp  hooks,  such  as  Levret's  or  Ramsbotham's, 
and  the  danger  of  damaging  the  uterus  by  instruments 
like  Braun's  key-hook.  The  Auchenister  consists  of  a 
blunt  hook  which  is  to  be  passed  over  the  neck  of  the 
foetus,  and  of  a  knife-blade  which  is  protected  by  a 
sheath,  and  is  worked  by  a  screw  so  as  to  cut  through  the 
neck. 

He  somewhat  modified  Braun's  funis-repositor,  and  he 
describes  and  figures  the  modification  in  the  second 
edition  of  his  '  Lehrbuch  der  Geburtshilfe  '  (1853). 

In  his  ^Lehrbuch  der  Geburtshilfe'  (1853)  he  describes 
and  figures  a  douche-apparatus  invented  by  him.  It  is 
worked  by  a  pump,  and  is  intended  for  the  induction  of 
labour  by  injecting  water  into  the  vagina  after  Kiwisch's 
method. 

His  modification  of  Cusco's  speculum,  with  handles 
which  can  be  doubled  up  for  portability,  was  shown  at  our 
exhibition  of  instruments  in  1866,  as  was  also  his  cephalo- 
tribe. 

In  the  fourth  edition  of  his  'Lehrbuch  der  Krankheiten 
der  weiblichen  Sexualorgane  '  (1867)  he  describes  and 
figures  a  pessary  for  prolapsus  invented  by  him.  It  con- 
sists of  a  horn  or  wooden  bulb  fixed  to  a  short  stem,  which 
is  connected  by  a  ball-and-socket  ]oint  with  a  cup  which 
protrudes  through  the  vulva,  and  is  supported  by  a  perinasal 
bandage.  He  had  previously  employed  for  prolapsus  a 
modification  by  himself  of  Roser's  apparatus,  which  he 
figures  and  describes  in  his  first  edition  (1857). 


ANNUAL    ADDRESS.  75 

In  conclusion  it  may  be  remai'ked  tliat  onr  late  liono- 
raiy  Fellow,  a  professor  and  practitioner  in  a  provincial 
Bavarian  town  of  40,000  inhabitants,  left  his  mark  upon 
almost  every  obstetrical  and  gynaecological  subject,  and 
Avas  renowned  wherever  scientific  medicine  is  valued.  It 
is  to  Scanzoni  as  mucli  as  to  any  man  that  gynaecology 
owes  a  place  among  the  medical  sciences. 

Peofessor  Theodor  Hugenberger. 

Theodor  Hugenberger  was  the  son  of  a  pastor  in  Kur- 
land,  one  of  the  three  Baltic  provinces  of  Russia,  and  was 
born  on  June  1st,  1821.  In  1842  he  entered  at  the 
University  of  Dorpat  in  the  adjoining  province  of  Livonia, 
a  university  founded  by  Gustavus  Adolphus  in  1632,  the 
same  year  in  which  he  was  assassinated  at  the  battle  of 
Liitzen.  Hugenberger  took  his  degree  in  medicine  in 
1847,  and  was  immediately  thereafter  sent  to  Kronstadtas 
a  naval  surgeon.  In  the  next  year  he  was  ti*ansferred  to 
an  appointment  in  the  Kalinkin  Naval  Hospital  at  St. 
Petersburg,  and  was  at  the  same  time  appointed  medical 
attendant  of  the  office  for  preparing  State  documents,  an 
establishment  in  which  nearly  1000  persons  were  employed. 
While  holding  these  appointments  he  managed  to  become 
an  obstetrician,  and  in  1857  he  was  ordained  Professor  of 
Midwifery  and  Physician-Accoucheur  to  the  Lying-in  and 
Midwives'  Institute  of  the  Grand  Duchess  Helene  Paw- 
lowna  in  St.  Petersburg.  In  1872  he  was  appointed 
Director  of  the  Imperial  Lying-in  Establishment  of  the 
Moscow  Foundling  Institution.  He  remained  in  the  occu- 
pation of  that  post  until  1887,  when  he  retired  and  went 
to  his  native  place.  He  died  on  June  29th,  1891,  at  the 
age  of  seventy,  at  Majorenhof,  a  seaside  place  near  Riga, 
to  which  he  had  gone  for  his  health. 

He  received  the  title  of  Privy  Councillor,  and  he  was 
decorated  with  the  Order  of  the  Empress  Anna,  first  class, 
and  with  the  Order  of  the  Grand  Prince  Wladimir,  second 
class. 


7t)  ANNUAL   ADDRESS. 

He  was  an  honorary  Fellow  of  many  medical  societies. 

He  was  a  man  of  the  highest  character,  and  was  noted 
as  a  teacher  and  as  a  writer  on  obstetrical  subjects. 

He  paid  several  visits  to  this  country.  In  1866  he  came 
expressly  from  Russia  to  see  the  Exhibition  of  Instruments 
of  this  Society  at  the  Eoyal  College  of  Physicians.  He 
showed  his  own  long  forceps,  which  had  the  peculiarity  of 
being  shorter  in  the  curved  portion  of  the  blade  than 
any  other  European  forceps  exhibited.  The  blade-bow 
measured,  in  the  straight,  five  and  a  half  inches  only, 
while  Van  Huevel's,  which  Avas  the  longest  in  the  Exhibi- 
tion, measured  ten  inches.  There  was  a  Japanese  forceps 
shown  which  measured  in  the  bow  of  the  blade  four  and 
three-eighths  inches  only.  In  addition  to  his  own  forceps, 
Hugenberger  exhibited  also  a  specimen  of  Levret^s,  one 
of  Professor  Krassowski's,  and  one  of  Siebold's,  and  like- 
wise Etlinger  and  Hugeuberger's  cephalotribe. 

He  frequently  took  part  in  the  proceedings  of  the 
Obstetric  Section  of  the  Society  of  Physicians  of  St. 
Petersburg.  Ho  wrote  numerous  monographs,  chiefly  in 
the  '  St.  Petersburger  medicinische  Zeitschrift/  and  he  also 
published  many  reports  of  the  institutions  with  which  he 
was  connected. 

At  a  meeting  of  the  Obstetric  Section  of  the  St.  Peters- 
burg Society  of  Physicians  in  1860,  as  reported  in  the 
'St.  Petersburger  medicinische  Zeitschrift^  for  1861,  he 
exhibited  the  uterus  from  a  remarkable  case  of  spontaneous 
rupture  of  that  organ  in  lateral  placenta  praevia  with 
occipital  presentation  of  the  vertex.  The  accident  was 
followed  by  death  in  less  than  five  minutes.  The  main 
laceration  was  eight  inches  in  length,  and  went  through 
the  middle  of  the  placental  site.  It  began  below  the  left 
Falloj)ian  tube,  and  extended  to  the  vagina.  The  uterine 
tissue  was  much  softened,  and  some  of  its  muscle-bundles 
were  fatty.  The  placenta  was  partly  hepatised  and  partly 
hypenemic  and  decomposed. 

In  1861  he  gave  some  interesting  particulars  at  a  dis- 
cussion on   placenta    prtuvia   in   the   same    Society.      The 


ANNUAL  ADDRESS.  77 

discussion  is  reported  in  the  '  St.  Petersburger  raed.  Zeit- 
sclirift '  for  1862.  In  about  8000  labours  at  the  St. 
Petersburg  Mid  wives'  Institution,  from  1845  to  1859  in- 
clusive, there  were  forty-two  cases  of  placenta  praevia. 
The  actual  number  of  labours,  as  appears  afterwards, 
was  8036.  This  gives  the  unusual  proportion  of  1  in 
191.  There  were  sixteen  maternal  deaths,  or  38  per 
cent.  There  were  only  eight  primiparai,  while  many 
had  had  ten  or  more  children.  He  distinguished  a 
lateral,  a  marginal  or  partial,  and  a  central  or  total 
attachment  of  the  placenta.  There  were  eleven  of  the 
first,  eighteen  of  the  second,  and  thirteen  of  the  third 
variety.  The  first  bleeding  occurred  from  one  to  five 
weeks  before  labour  in  some,  but  in  most  it  did  not 
take  place  until  labour  had  set  in,  and  especially  so  when 
the  attachment  of  the  placenta  was  lateral.  There 
were  three  cross-births,  and  five  breech  or  footling  pre- 
sentations. The  insertion  of  the  funis  was  velamentous 
in  as  many  as  four. 

At  the  same  meeting  he  related  a  case  of  central  attach- 
ment of  the  placenta  in  which  the  use  of  the  tampon  was 
followed  by  detachment  of  the  smaller  or  overlapping 
portion  of  the  placenta,  internal  htemorrhage,  and  a  con- 
tinuous and  ominous  discharge  of  serum.  Delivery  was 
effected  by  turning,  but  the  patient  died.  As  some  writers 
deny  that  detachment  of  the  placenta  ever  follows  the  use 
of  the  tampon,  this  case  is  a  noteworthy  one. 

Hugenberger's  most  important  monograph  was  "  Das 
Puerperalfieber  im  St.  Petersburger  Hebammeninstitute 
von  1845  bis  1859,"  published  separately  in  1862  from  the 
'  St.  Petersburger  med.  Zeitschrift '  of  that  year.  He 
gives  the  frequency  and  mortality,  the  prevalence  accord- 
ing to  season,  the  history  of  seven  outbreaks,  the  local 
and  general  phenomena,  prophylaxis,  and  treatment.  The 
total  number  of  women  delivered  was  8036,  and  the  total 
deaths  306,  a  mortality  of  3*81  'per  cent.  The  number  of 
deaths  from  puerperal  fever  was  238,  or  2*96  per  cent. 
of  deliveries.      The  months  of  December,  January,  Feb- 


78  ANNUAL    ADDRESS. 

ruary,  and  April  showed  nearly  twice  as  high  a  puerperal 
fever-death-rate  as  those  of  July,  August,  September, 
and  October.  The  frequency  of  puerperal  fever  and  the 
mortality  from  it  rose  in  proportion  to  the  duration  of 
labour  beyond  twenty  hours.  Obstetric  operations  in- 
creased the  frequency  of  puerperal  fever  and  the  mor- 
tality. Traumatic  injuries  of  the  passages  had  a  like 
efPect,  as  had  also  hgemorrhag'e  during  or  after  parturition, 
and  macerated  or  putrid  foetuses. 

In  the  '  Zeitschrift '  for  1863  Hugenberger  published  an 
elaborate  Report  of  the  Midwives'  Institution  from  1845- 
to  1859  inclusive,  giving  much  statistical  information, 
detailed  cases,  and  general  remarks. 

In  the  '  Zeitschrift  '  for  1864  he  has  a  paper  on  Five 
Cases  of  Acute  Atrophy  of  the  Liver.  He  thinks  that 
this  disease  is  much  less  rare  than  was  supposed  by 
C.  Braun,  who  had  met  with  it  once  only  in  28,000  preg- 
nancies, and  by  Spaeth,  who  had  seen  it  twice  only  in 
33,000  pregnancies.  The  fifth  case  occurred  in  the  prac- 
tice of  Sir  James  Simpson  in  1863,  and  was  not  seen  by 
Hugenberger  during  life.  He  witnessed  the  necroscopy 
performed  by  Dr.  Alexander  Simpson  and  myself,  and  he 
remarks  that  my  mici-oscopic  examination  of  the  liver, 
afterwards,  showed  complete  destruction  of  the  liver- cells. 
He  gives  numerous  particulars  of  the  case  and  of  the 
necroscopic  appearances.  His  narrating  a  case  such  as 
this,  seen  during  a  holiday  tour,  is  a  good  illustration  of 
his  medical  zeal  and  industry. 

In  the  '  Zeitschrift '  for  1865  he  published  an  article 
on  Puerperal  Blood-Effusions  into  the  Connective  Tissue, 
and  described  eleven  cases  of  haematoma  which  had  oc- 
curred in  14,000  deliveries  in  the  St.  Petersburg  Mid- 
wives'  Institution  in  the  course  of  the  previous  twenty 
years.  Seven  were  labial,  two  perivaginal,  and  two  peri- 
uterine. Four  of  them  burst  spontaneously.  Absorption 
of  the  blood,  either  complete  or  partial,  he  had  never  seen. 
There  were  four  deaths. 

With  the  date  1868  he  published  separately,  from  the 


ANNUAL    ADDRESS.  79 

*  Zeitsclirift '  for  1869,  an  article  on  a  Kyphotic  trans- 
versely Contracted  Pelvis.  The  spinal  curvature  was  in 
the  lumbar  region.  He  gives  the  clinical  history  of  his 
case,  a  full  description  of  the  pelvis,  and  an  excellent 
statement  of  the  diagnosis  of  that  rather  rare  variety. 
He  notes  the  acute  angular  curvature  of  the  lower  part 
of  the  spine,  the  projection  forwards  and  upwards  of  the 
symphysis  pubis,  the  increased  relative  length  of  the  ex- 
ternal conjugate,  the  narrowing  of  the  transverse  diaroetep 
as  shown  through  the  insertion  of  two  or  more  fingers 
side  by  side  into  the  pelvis,  and  numerous  other  charac- 
teristics, which  should  be  mentioned  if  time  permitted. 

He  published  separately  in  1873,  from  the  '  Zeitschrift  * 
of  1872—3,  a  paper  on  Premature  Rupture  of  the  Mem- 
branes C  Zur  Lehre  von  vorzeitigen  Blasensprunge  "). 
He  traverses  the  prevailing  opinion  that  premature  rupture 
of  the  membranes  usually  delays  the  labour,  and  he  sup- 
ports his  contention  by  statistical  evidence.  He  advocates 
artificial  rupture  in  various  circumstances,  even  in  primi- 
paras,  as  a  valuable  means  of  strengthening  the  pains  and 
of  promoting  labour.  He  himself  would  rupture  the  mem- 
branes when  the  os  is  the  breadth  of  a  finger  and  a  half 
only.      He  states  several  contra-iudications,  however. 

In  a  paper  on  Rupture  of  the  Yagina  during  Labour 
("  Ueber  Kolpaporrhexis  in  der  Geburt'^),  in  the  'Zeit- 
schrift' for  1875,  he  describes  an  intei*esting  case  of 
kolpaporrhexis  antica  dextra  in  a  contracted  rickety 
pelvis.  In  twenty-nine  cases  of  rupture  of  the  vagina 
collected  by  him  there  were  ten  deaths. 

In  a  Report  of  the  Moscow  Lying-in  Institution  for 
1875,  separately  published  in  1876,  he  is  able  to  announce 
a  total  mortality  of  1*4  per  cent,  only,  and  a  puerperal 
fever-mortality  of  082  per  cent.  only.  In  that  year  there 
were  3420  deliveries  and  twenty-eight  deaths  from  puer- 
peral fever. 

Other  papers  written  by  Hugenberger  were  a  case  of 
Osteomalacia  (•' Ein  Fall  flexiler  Halisterese  ")  with  full 
details  in  the   'Zeitschrift'   for   1872-3;   on  the  Indica- 


80  "  ANNUAL   ADDRESS. 

lions  for  Caesarean  Section  {''  Zur  Frage  der  Indicationen 
zum  Kaiserschnitt '')  in  the  '  Zeitschrift '  for  1873-4;  on 
Stone  in  the  Female  Bladder  {"  Zur  Casnistik  der  Harn- 
blasensteine  in  der  weiblichen  Fortpflanzungsperiode ") 
in  the  'Zeitschrift^  for  1875;  on  Erysipelas  in  Childbed 
("  Ueber  Erysipelas  in  Wochenbette  "),  with  fifteen  cases 
described,  in  the  '  Arcliiv  fiir  Gynaekologie'  for  1878  ;  and 
a  Case  of  Obliquely  Ovate  Rachitic  Hydrorrachitic  Pel- 
vis ("  Ein  Schrag-ovales.  rachitisch-hydrorrachitisches 
Becken  ")  in  the  '  Archiv  fiir  Gynakologie  '  for  1879. 

Any  attempt  at  a  review  of  the  scientific  work  of  the 
Society  during  the  past  j^ear  is  rendered  impossible  by  the 
heavy  demand  made  on  the  time  of  this  meeting  through 
the  death  of  so  many  distinguished  Fellow^s.  The  annual 
volume  recording  that  work  will  presently  be  in  your  hands 
to  speak  for  itself.  It  will  be  a  more  portly  volume  than 
usual,  and  I  venture  to  express  a  confident  opinion  that  it 
will  also  be  found  to  possess  exceptional  scientific  value. 
In  fact,  Dr.  Herbert  Spencer's  admirable  aiid  beautifully 
illustrated  paper  on  "  Visceral  Hasraorrhages  in  Stillborn 
Children ''  is  alone  sufficient  to  justify  such  an  opinion. 

In  conclusion  I  have  to  thank  the  Honoraiy  Secretaries, 
and  especially  Mr.  Alban  Doran,  the  Senior  Secretary,  for 
the  great  assistance  which  they  have  rendered  to  me  in 
the  discharge  of  my  duties  as  President.  Mr.  Doran  now 
retires  from  the  Secretaryship  after  four  years  of  arduous 
exertion  in  the  service  of  the  Society,  and  of  rare  devotion 
to  its  interests.  You  will  not  lose  his  aid,  however,  as  an 
official  of  the  Society,  for  you  have  by  your  vote  to-night 
elected  him  one  of  your  Vice-Presidents. 

It  was  moved  by  Dr.  Braxton  Hicks,  seconded  by 
Dr.  Amand  Routh,  and  agreed  to  unanimously — "  That  the 
thaiiks  of  the  meeting  be  given  to  Dr.  J.  Watt  Black  for 
his  most  interesting  address,  and  that  it  be  printed  in  the 
next  volume  of  the  '  Transactions.'  " 

It  was  moved  by  Dr.  Playfair,  seconded  by  Dr.  Herman, 


VOTES    OF    THANKS.  81 

and  carried  unanimously — "  That  the  thanks  of  the  meet- 
ing be  given  to  the  retiring  Vice-Presidents,  Drs.  Hayes 
and  Tapson,  and  Mr.  Evan  Jones  (Aberdare),  and  to  the 
other  retiring  members  of  Council,  Mr.  Butler- Sm^^the,  Dr. 
Dakin,  Dr.  Davson,  Dr.  Gervis,  Dr.  W.  Leuton  Heath, 
Dr.  Nesham  (Newcastle-on-Tyne),  Mr.  G.  R.  T.  Phillips, 
Dr.  J.  H.  Philpot,  and  Mr.  H.  S.  Webb  (Welvvyn).'^ 

A  vote  of  thanks  to  the  retiring  Honorary  Secretary, 
Mr.  Alban  Doran,  was  proposed  by  Dr.  Champneys,  who 
thought  that  a  few  additional  words  were  needed  on  the 
occasion  of  the  retirement  of  Mr.  Doran.  The  duties  of 
senior  secretaiy  were  most  onerous,  and  he  doubted  if  any 
society  whatever  had  had  the  good  fortune  to  possess 
a  more  unselfish  and  devoted  ofiicer  than  Mr.  Doran. 
Those  who  had  worked  with  him  appreciated  this,  espe- 
cially since  the  illness  of  Mr.  Savage,  which  had  thrown  a 
quantity  of  extra  and  alien  work  on  him  ;  this  work  he  had 
discharged  with  the  greatest  alaci-ity  and  cheerfulness. 
Dr.  Champneys'  motion  was  seconded  by  Dr.  M.  Hand- 
field-Jones,  and  carried  unanimously. 


VOL.  xxxiv. 


MARCH   2nd,   1892. 

J.  Watt  Black,  M.D.,  President,  in  the  Chair. 

Present — 45  Fellows  and  6  Visitors. 

Murdoch  Cameron,  M.D.  (Glasgow)  ;  Arthur  Edward 
Giles,  M.B.Lond.  (St.  John's,  S.E.)  ;  and  Charles  James 
Wright,  M.R.C.S.  (Leeds),  were  admitted  Fellows  of  the 
Society. 

Thomas  Hyde  Hills,  L.R.C.P.Lond.  (Cambridge)  ;  and 
Ernest  Kingscote,  M.B.,  C.M.Edin.  (Salisbury),  were  de- 
clared admitted. 

The  following  gentlemen  were  elected  Fellows  of 
the  Society  : — John  William  Campbell,  B.A.,  M.B., 
B.Ch. Cantab.  ;  W.  Evelyn  St.  Lawrence  Finny,  M.B., 
M.Ch.Dubl.  (Kingston  Hill)  ;  Augustus  Kinsey-Morgan, 
M.R.C.S.  (Bournemouth)  ;  George  Drummond  Robinson, 
M.B.,  B.S.Lond.  ;  and  Walter  Carless  Swayne,  M.B.Lond. 
(Clifton). 

The  following  gentlemen  were  proposed  for  election  : — 
Alfred  Samuel  Gubb,  M.D.Paris,  L.R.C.P.Lond.;  and 
John  Harold,  L.R.C.P.Lond. 


Beport  of  Committee  on  Br.  Heyivood  Smith's  Specimen  of 
Abscess  of  the  Ovary  {p.  3). 

The  specimen  consists  of  an  ovary  without  tube  or  any 
portion  of  the  broad  ligament.     It  measures  10  centimetres 
VOL.  XXXIV.  7 


84  ACEPHALOUS    ACARDIAC    FGtTUS. 

in  lengtli,  4  centimetres  in  breath.  The  stroma  is  dense, 
pale,  and  includes  a  few  small  cysts,  probably  degenerate 
Graafian  follicles.  The  greater  part,  however,  is  occupied 
by  two  almost  spherical  cavities.  One  3  centimetres  in 
diameter,  which  when  fresh  contained  blood,  is  lined 
with  a  rough  corrugated  membrane.  The  other  cavity  is 
completely  filled  by  a  pale  yellow  substance  ;  it  measures 
3'5  centimetres  in  diameter.  The  substance  filling  the 
cavity  leaves  a  convex  surface  when  cut,  and  particles  of 
semi-fluid  pus  ooze  from  it.  It  bears  the  appearance  of 
solidified  pus. 

Microscopic  sections  of  the  yellow  substance  have  been 
made  and  examined.  In  sections  stained  in  Nielsen's 
solution  no  evidence  of  actinomycosis  could  be  detected. 
In  sections  staiued  in  fuchsiue  methyl-blue,  no  tubercle 
bacilli  could  be  found.  Each  section  showed  a  collection 
of  cells  with  large  nuclei,  and  mostly  spherical  in  form, 
bearing  all  the  characters  of  inflammatory  cells.  The 
stroma  is  scanty,  and  consists  of  strands  of  plain  muscle- 
fibres,  such  as  are  seen  in  the   stroma  of  a  healthy  ovary. 

J.  Bland  Sdtton. 

Alban  Doran. 

Heywood  Smith. 


ACEPHALOUS    ACARDIAC    FCETUS. 

By  M.  Handfjeld-Jones,  M.D. 

Dr.  Handfield-Jones  showed  a  specimen  of  an  acepha- 
lous, acardiac  foetus  from  a  twin  pregnancy.  Labour 
had  come  on  at  the  end  of  the  fifth  month.  The  other 
foetus  was  perfectly  formed. 


85 

TUBO-OYARIAN    CYST. 
By  M.   Handfield-JoneSj  M.D, 

Dr.  Hanbfield-Jones  also  showed  a  specimen  of  tnbo- 
ovarian  cyst  removed  three  weeks  previously.  There 
was  no  opening  between  the  distended  tube  and  the  ova- 
rian cyst,  but  the  latter  was  filled  with  pus,  and  would 
probably  liave  opened  later  into  the  hydrosalpinx  which 
was  situated  above  it.  The  specimen  demonstrated  an 
early  stage  in  the  formation  of  tubo-ovarian  cystoma. 

Dr.  Handfield- Jones  referred  to  a  specimen  of  fibro- 
sarcoma of  the  ovary  which  he  had  shown  at  a  previous 
meeting.  The  amount  of  cell-growth  varied  very  greatly 
in  different  parts  of  the  tumour.  Viewing  some  sections 
the  tumour  might  have  been  considered  a  pure  fibroma, 
but  other  sections  showed  the  sarcomatous  nature 
markedly. 

Mr.  Alban  Doean  always  maintained  that  many  tubo-ovarian 
cysts  developed  from  tubes  and  ovaries  matted  together  by  old 
inflammation,  and  subject  to  cvstic  degeneration.  He  had  dis- 
cussed this  question  in  the  '  Transactions  of  the  Pathological 
Society,'  vol.  xxxviii,  1887,  p.  241,  and  vol.  xxxix,  1888,  p.  200 ; 
also  in  his  remarks  on  Dr.  W.  S.  A.  Grriffith's  monograph  on 
tubo-ovarian  cysts  ('  Trans.  Obstet.  Soc.,'  vol.  xxix,  1887,  p.  306). 


CANCEROUS    UTERUS    REMOVED    BY   VAGINAL 
HYSTERECTOMY. 

By  P.  HoRROCKS,  M.D. 

Dr.   Horrocks   showed   a   uterus   removed   by   vaginal 
hysterectomy   on    account    of    malignant    disease    of    the 


86    CANCEROUS  UTEEUS  REMOVED  BY  VAGINAL  HYSTERECTOMY. 

cervix.  He  said  that  tte  patient  was  progressing  favour- 
ably a  fortnight  after  the  operation,  and  that  he  pre- 
ferred to  tie  the  broad  ligaments  with  ligatures  rather 
than  to  use  pressure  forceps.  He  exhibited  a  micro- 
scopical section  of  the  growth. 

Dr.  Champneys  asked  Dr.  Horrocks  in  what  respect  he  found 
pressure-clamps  unsatisfactory.  He  had  found  ligatures  untrust- 
worthy, and  had  seen  them  slip  in  the  hands  of  others.  After 
they  had  slipped,  it  was  very  difficult  to  secure  the  bleeding 
points. 

Dr.  CuLLiNGWOETH  Said  that  unfortunately  the  ligature  had 
its  victims  as  well  as  the  pressure  forceps.  He  mentioned  a 
recent  case  in  which  the  patient  died  apparently  from  haemor- 
rhage caused  by  the  slipping  of  one  of  the  ligatures.  This  was, 
however,  no  proof  that  the  ligature  method  ought  to  be  aban- 
doned, as  the  accident  might  be  due  not  to  any  inherent  fault  in 
the  method,  but  to  carelessness  or  inexperience  on  the  part  of 
the  operator.  The  case  he  had  alluded  to  would  be  published  in 
due  course. 

Dr.  HoEBOCKS,  in  reply,  said  he  had  not  done  any  prelimi- 
nary operation  beyond  thorough  irrigation.  As  a  fact,  the  cancer 
was  very  vascular,  and  not  of  the  sloughing  type.  He  was  un- 
able to  tell  how  far  the  disease  extended  before  operation,  but 
from  the  height  to  which  the  finger  could  reach,  he  bad  believed 
it  to  extend  into  the  cavity  of  the  body  of  the  uterus.  This, 
however,  did  not  seem  to  be  the  case.  He  preferred  the  liga- 
ture because  it  was  more  pliable,  and  lay  out  of  the  way  during 
operation,  and  he  preferred  to  take  up  a  bit  at  a  time  ;  there  was 
thus  less  risk  of  slipping.  He  considered  the  lower  half  of  the 
broad  ligament  more  difficult  to  secure  than  the  upper,  because 
there  were  more  vessels,  and  at  the  latter  part  of  the  operation 
the  top  of  the  broad  ligament  could  be  reached.  Pressure 
forceps  in  order  to  hold  firmly  must  be  strong,  and  have  good 
leverage  ;  for  this  it  was  necessary  they  should  be  long,  and  hence 
they  were  in  the  way  during  operation,  and  slight  movements 
caused  great  effects,  and  sometimes  tore  the  broad  ligaments  or 
came  off  partially. 


87 


CANCEKOUS    UTERUS    REMOVED    BY  VAGINAL 
HYSTERECTOMY. 

By  Am  AND  Routh^  M.D. 

Dr.  Amand  Routh  showed  a  uterus  with  cancer  of  the 
fundus  which  he  had  removed  fourteen  days  previously. 

The  patient,  a  widowed  multipara,  had  had  a  watery  dis- 
charge for  nine  months  and  metrorrhagia  for  three  months, 
and  consulted  Dr.  Rutherfoord  at  the  Samaritan  Free 
Hospital  for  Women,  and  he  kindly  transferred  her  to 
Dr.  Routh.  The  patient's  uterus  was  retroverted  and 
enlarged,  and  there  was  a  small  mucous  polypus  hanging 
from  the  cervix.  As  the  polypus  seemed  insufficient  to 
account  for  the  symptoms,  the  uterus  was  rapidly  dilated 
under  chloroform.  On  exploration  a  cancerous  growth 
was  felt,  and  the  uterus  was  therefore  removed  entire  by 
vaginal  hysterectomy.  Both  ligatures  and  clamps  were 
used,  and  much  difficulty  was  experienced  in  drawing 
down  the  uterus,  as  the  fundus  and  right  broad  ligament 
were  extensively  adherent  to  the  omentum.  The  vaginal 
wound  was  quite  healed  on  the  sixth  day,  but  unfortu- 
nately acute  mania  developed  on  the  ninth  day,  and  was 
still  present  when  the  specimen  was  shown. 

Later. — The  mania  disappeared  on  the  thirteenth  day, 
but  the  patient  died  suddenly  (?  embolism)  when  appa- 
rently quite  convalescent  on  the  sixteenth  day. 

Dr.  Amand  Routh,  in  reply  to  remarks  on  Dr.  Horrocks's 

specimens  and  his  own,  pointed  out  that  it  was  not  always  easy  to 
feel  the  upper  limit  of  the  broad  ligament  ligatured  by  silk,  though 
quite  easy  when  clamps  were  used,  so  that  one  could  then  readily 
feel  how  far  one  might  extend  the  division  of  the  ligaments 
upwards  by  the  scissors. 

It  was  also  an  advantage  when  clamps  were  used, and  removed 
on  second  day,  that  no  ligatures  had  to  come  away  by  a  slow 
process  of  ulceration,  which  tended  to  delay  complete  union. 


SECTIONS  OF  FIBROMA  OF  THE  OYAKY. 

By  H.  T.   RUTHERFOORD,  M.D. 

Dr.  Bdtherfoord  exhibited  microscopical  sections  from 
a  solid  fibroma  of  tlie  ovary.  The  tumour  was  a  hard, 
slightly  lobulated  mass,  weighing  nearly  three  pounds. 
Under  the  microscope  bundles  of  fibrous  tissue  were 
visible,  in  many  places  crossing  and  recrossing  each  other. 
Near  the  pedicle  of  the  tumour  the  sections  showed  a 
somewhat  similar  structure,  but  in  addition  there  were 
present  a  few  rounded  or  oval  nests  surrounded  by  a 
wavy,  shining  band.  Within  this  constricting  ring  was 
a  mass  of  granular  material  with  no  definite  structure. 
These  bodies  in  all  probability  represented  Graafian  follicles 
which  had  been  compressed  and  desti'oyed  by  the  new 
growth  of  fibrous  tissue. 

Mr.  Alban  Doran  observed  that  he  had  entered  fully  into 
the  pathology  of  specimens  of  the  class  here  exhibited  in  his 
memoir  "  On  Myoma  and  Fibro-myoma  of  the  Uterus  and  Allied 
Tumours  of  the  Ovary  "  ('  Transactions,'  vol.  xxx,  1888).  Their 
malignancy  was  very  slight,  indeed  they  seemed  clinically  inno- 
cent. The  patient  from  whom  he  had  removed  in  March,  1889, 
a  solid  ovarian  tumour  very  similar  to  the  present  specimen  (see 
discussion  on  Dr.  Haudfield-Jones's  "  Fibro-sarcoma  of  the 
Eight  Ovary,"  '  Transactions,'  vol.  xxxi,  1889,  p.  126),  was  alive 
and  well  in  November,  1891,  as  was  the  woman  from  whom  he 
removed  in  May,  1889,  a  fibromn  of  the  ovarian  ligament  weigh- 
ing over  sixteen  pounds  ('  British  Medical  Journal,'  vol.  i,  1287, 
and  'Transactions,'  vol.  xxxi,  p.  200). 


89 


CASE  OF  CESAREAN  SECTION  FOR  CONTRACTED 

PELVIS. 

By  Charles  J.  Cullingworth,  M.D.,  F.R.C.P. 

(Received  November  28th,  1891.) 

B.  M.  J — ,  aged  21  ^  married,  was  admitted  into  St. 
Thomas's  Hospital  for  her  first  confiuemeut  ou  September 
25th,  1891. 

Family  history. — As  regards  other  members  of  the 
family,  no  definite  history'  of  rickets  could  be  obtained ; 
but,  of  seven  brothers  and  sisters,  five  died  in  early 
childhood. 

Previous  history. — The  patient  herself  never  had  any 
serious  illness.  At  four  years  of  age  signs  of  rickets 
were  noticed ;  at  eleven  an  operation  was  performed  on 
the  left  leg,  and  iron  splints  were  worn  for  some  time. 
At  seventeen  both  femora  were  divided  and  straightened 
at  the  West  London  Hospital,  with  satisfactory  results. 

Sexual  history. — The  catamenia,  which  commenced  at 
the  age  of  fourteen,  have  been  regular  and  of  the  twenty- 
eight  days  type,  the  flow  lasting  four  days.  Patient  was 
married  January  1st,  1890.  The  date  of  the  last  men- 
struation was  Januai-y  4th  to  8th,  1891.  On  July  17th, 
1891,  she  called  to  engage  the  services  of  her  doctor  in 
her  approaching  confinement.  From  her  dwarfed  ap- 
pearance he  suspected  a  contracted  pelvis.  Having  con- 
firmed his  suspicions  the  next  day  by  a  vaginal  exami- 
nation, he  recommended  the  induction  of  premature 
labour  at  the  end  of  the  seventh  month.  Accordingly 
on  August  12th  and  on  several  succeeding  days  attempts 
were  made  to  induce  labour.  These  proving  unsuccess- 
ful, a  consultation   was  held  with  a  neighbouring  practi- 


90  C^SAEEAN  SECTION  FOR  CONTRACTED  PELVIS, 

tioner,  at  wliich  it  was  decided  that  the  case  was  not  a 
suitable  one  for  the  induction  of  premature  labour,  and 
that  the  patient  should  be  advised  to  go  to  full  term  and 
submit  to  Cfesarean  section  or  one  of  its  modifications. 
I  saw  her  at  the  end  of  August,  and  confirmed  this  view. 
The  patient  and  her  friends  acquiesced.  Accordingly, 
she  was  admitted  on  September  25th  with  a  view  to 
operation  at  the  end  of  the  first  week  in  Octobei',  that  is 
to  say,  a  few  days  before  the  date  when  labour  might  be 
expected  to  take  place — unless,  of  course,  labour  should 
commence  earlier. 

The  patient  is  a  fairly  well-nourished  woman,  of  plea- 
sant but  timid  expression.  She  walks  with  a  waddling 
gait.  Her  height  is  four  feet  five  inches.  There  is 
marked  lordosis ;  no  angular  curvature  of  spine.  There 
is  barely  one  inch  of  space  between  the  lower  ribs  and 
the  iliac  crests,  the  space  being  less  on  the  left  side  than 
on  the  right,  owing  to  the  left  side  of  the  pelvis  being 
on  a  higher  level  than  the  right.  Both  femora  present  a 
marked  forward  and  outward  curve  in  their  lower  halves, 
the  deformity  being  more  marked  on  the  left.  The  hip- 
joints  are  freely  moveable.  Both  tibia3  present  a  double 
curve,  the  convexity  of  the  curve  being  to  the  right  in 
their  upper  and  to  the  left  in  their  lower  portions.  When 
the  legs  are  extended,  and  the  malleoli  in  contact,  the 
knees  are  separated  by  an  interval  of  over  two  inches. 
The  bones  of  the  arms  and  skull  are  normal.  There  is 
slight  beading  of  the  lower  ribs. 

The  measurements  of  the  pelvis  are  as  follows  : 


Dist.  sp.  il. 

.     8^  in. 

„     cr.  il. 

.     9  in. 

Conj.  ext. 

, 

,     6i  in. 

„      <liiig- 

,     .3  in. 

Estimated  conj. 

vera 

,     2^—21  in 

The  sacral  promontory  is  directed  towards  the  left 
side  to  such  a  marked  extent  that  one  finger  only  can  be 
inserted  between  the  projecting  sacrum  and  the  left 
lateral  wall  of  the  pelvis.      The  pelvis  is,  therefore,  both 


CESAREAN  SECTION  FOE  CONTRACTED  PELVIS.  91 

generally  and  obliquely  contracted,  and  flattened,  tlie 
deformity  being  due  to  rickets  and  scoliosis. 

The  head  of  the  foetus  lies  in  the  right  iliac  region, 
the  back  forwards  and  to  the  left ;  the  long  axis  of  the 
enlarged  uterus  is  oblique,  extending  from  the  left  hypo- 
choudrium  to  the  right  iliac  region.  The  foetal  heart- 
sounds  and  movements  are  distinct.  The  position  of  the 
placenta  is  made  out  by  palpation  to  be  on  the  right 
side  near  the  fundus,  not  extending  as  far  as  the  median 
line.'^  The  right  ovary  can  be  distinctly  felt  three  inches 
above  and  internal  to  the  anterior  superior  spine  of  right 
ilium.      Heart  and  lungs  normal.      Urine  normal. 

On  October  8th,  the  bowels  having  been  relieved  by 
enema,  and  the  vagina  freely  douched  with  mercuric 
chloride  solution  1  in  5000,  the  operation  of  Caesarean 
section  was  performed  at  two  in  the  afternoon.  Labour 
had  not  commenced.  The  patient  having  been  antes- 
thetised,  a  mesial  incision,  five  inches  in  length,  was 
made,  commenciug  one  inch  above  the  umbilicus,  and  ex- 
tending to  within  three  inches  of  the  pubes.  The  whole 
thickness  of  the  abdominal  wall  was  divided  to  the  extent 
of  an  inch  by  the  first  incision,  and  the  uterus  exposed. 
The  deeper  structures  were  then  divided  to  the  same 
extent  as  the  superficial,  without  any  bleeding  that  called 
for  arrest.  The  uterus  was  found  rotated  on  its  long 
axis,  its  anterior  surface  being  directed  to  the  left, 
and  the  right  broad  ligament  and  appendages  being 
directed  forwards,  and  lying  a  little  to  the  right  of 
the  abdominal  wound.  The  hand  was  then  introduced, 
and  the  position  of  the  uterus  rectified  with  some  dif- 
ficulty on  account  of  its  tendency  to  resume  its  abnormal 
position ;  this  was,  however,  eventually  prevented  by 
pressure  in  the  left  flank.  (In  making  the  incision 
through  the  abdominal  wall  and  in  rectifying  the  rotation 
of  the  uterus  two  small  wounds  were  made,  in  the  one 
case  with    the   point   of  the   knife,  in  the  other  with  the 

*  This  means  that  the  placenta  was  situated  on  the  posterior  wall,  the 
uterus  being  shown  later  to  be  rotated  on  its  long  axis. 


92  CESAREAN  SECTION   FOR  CONTRACTED  PELVIS. 

finger-nail,  in  the  serous  covering  of  the  uterus  ;  these 
were  closed  at  once  with  fine  silk  sutures.)  The  edges 
of  the  abdominal  wound  were  then  held  in  close  apposi- 
tion to  the  anterior  surface  of  the  uterus  Toy  the  hand  of 
an  assistant  placed  on  each  side,  and  a  straight  incision 
was  made  down  the  anterior  surface  for  a  distance  of  four 
inches.  Haemorrhage  from  the  divided  vessels  and  sinuses 
was  restrained  by  digital  pressure  on  the  divided  surfaces. 
This  incision  was  carried  for  a  short  distance  through 
the  thickness  of  the  uterine  wall  till  the  membranes 
bulged  into  the  wound.  The  membranes  were  at  this 
moment  accidentally  ruptured.  The  deep  part  of  the 
wound  was  thereupon  rapidly  enlai'ged  upwards  and 
downwards,  until  it,  too,  measured  four  inches,  the  hand 
quickly  introduced,  and  the  child  extracted,  the  left  leg 
being  the  first  part  to  be  seized. 

The  head  emerged  slowly,  owing  to  the  small  size  of 
the  uterine  wound,  which  the  head  filled  tightly,  but  by 
gentle  traction  combined  with  depression  of  the  edges  of 
the  incision  the  extraction  was  easily  accomplished. 
The  cord  was  clamped  and  divided,  and  the  child  handed 
over  to  an  assistant.  The  placenta  was  then  grasped 
and  removed  Avith  the  membranes,  and  two  fingers  were 
passed  through  the  cervix  into  the  vagina  to  ensure 
patency  of  the  canal.  The  uterus  was  now  brought  out 
of  the  abdomen  and  protected  by  hot  sponges.  It  con- 
tracted well,  the  haemorrhage  being  slight  and  readily 
restrained  by  firmly  grasping  the  uterus  and  pressing  the 
edges  of  the  wound  together.  There  was  no  protrusion 
of  the  intestine,  and  little  or  no  blood  entered  the  peri- 
toneal cavity.  Five  minims  of  solution  of  ergotine  were 
given  hypodermically  at  this  stage.  No  elastic  ligature 
was  used.  The  deep  sutures,  ten  in  number,  were  then 
introduced,  beginning  at  the  lower  angle  of  the  incision, 
and  avoiding  the  decidua.  The  material  used  was  silk. 
After  all  clots  had  been  removed  from  the  cavity  of  the 
uterus  these  deep  sutures  were  tied  in  such  a  manner  as 
slightly    to    blanch    the    tissues   between   them.      Eleven 


CESAREAN  SECTION  FOR  CONTRACTED  PELVIS.  93 

half-deep  silk  sutures  were  passed,  one  midway  between 
each  two  of  the  deep  sutures,  and  tied.  In  passing-  the 
lowermost  sutures  a  sinus  was  punctured  ;  the  oozing  fi*om 
the  puncture  was  arrested  by  a  fine  silk  suture.  The 
Fallopian  tubes  were  ligatured  in  their  continuity.  The 
peritoneal  cavity  was  cleansed  by  sponging,  but  appa- 
rently the  entrance  of  blood  and  liquor  amnii  had  been 
effectually  prevented.  The  uterus,  which  had  remained 
well  contracted  throughout,  was  now  gently  kneaded  and 
returned  into  the  abdomen,  and  the  great  omentum 
drawn  down  over  its  anterior  surface.  The  edges  of  the 
abdominal  incision  were  then  a.pproximated  by  thirteen 
deep  and  six  superficial  silkworm  gut  sutures,  and 
covered  by  absorbent  pads  and  wool  held  in  position  by 
a  many-tailed  flannel  bandage.  The  patient  was  put 
back  to  bed  in  one  hour  from  the  commencement  of  the 
operation.  Some  blood  escaped  from  the  vagina  in  the 
course  of  the  operation,  but  the  total  amount  lost  was 
inconsiderable.  The  infant,  a  well-formed  male,  was 
quite  free  from  lividity,  and  cried  immediately  afterbirth. 
It  measured  20^  inches,  and  weighed  7  lbs.  7  oz.  The 
placenta  measured  8^  inches  by  6^  inches,  and  weighed 
1  lb.  6  oz.      The  cord  was  18  inches  in  length. 

The  patient  rallied  well  and  made  a  good  recovery. 
During  the  first  few  days  the  temperature  and  pulse 
were  considerably  above  normal  (as  will  be  seen  from  the 
table  at  the  end  of  the  paper),  and  on  two  occasions  the 
condition  of  the  lungs  and  pleui-a  caused  some  anxiety. 
After  the  first  week,  however,  convalescence  was  uninter- 
rupted. The  lochia  were  from  the  beginning  so  scanty 
that  I  began  to  fear  I  had  stitched  up  the  cervical  canal. 
On  the  morning  after  the  operation,  therefore,  I  passed 
my  fingers  into  the  uterus,  which  I  found  empty  and  well 
contracted.  An  intra-uterine  douche,  administered  at  the 
same  time,  returned  only  slightly  blood-stained. 

After  this  the  discharge  consisted  of  little  else  than 
clear  ropy  mucus,  of  which  there  was  a  fair  quantity. 
Flatus  passed  naturally  'per  rectum  thirty-six  hours  after 


94 


CESAREAN   SECTION   FOR  CONTRACTED  PELVIS. 


the  operation.  On  the  third  day,  the  abdomen  being  a 
good  deal  distended,  an  enema  was  administered  with  the 
result  of  bringing  away  a  large  quantity  of  flatus,  and 
giving  great  relief.  The  bowels  acted  several  times  on 
the  morning  of  the  fifth  day,  and  more  freely  in  the 
afternoon  after  an  enema  of  olive  oil.  On  the  seventh 
day  the  vaginal  douche  was  discontinued,  as  there  was 
practically  no  discharge. 

On  the  ninth  day  the  stitches  were  removed,  and  the 
patient  was  moved  into  the  general  ward,  and  propped 
up  whilst  taking  her  meals. 

On  the  fifteenth  day  she  was  carried  to  the  couch,  and 
three  days  later  she  walked. 

On  October  22nd  (fifteenth  day)  a  vaginal  examination 
was  made  :  the  uterus  was  freely  moveable,  and  the 
degree  of  involution  normal. 

The  patient  left  the  hospital  well  on  October  31st, 
twenty-four  days  after  the  operation.  The  wound  had 
united  so  well  that  the  cicatrix  was  scarcely  perceptible. 


Record  of  temperature,  pulse,  and  respiration. 


Date.           Hour. 

Temp. 

Pulse. 

Resp 

Oct.  8th,  3.45  p.m. 

96-8°        .. 

148 

26 

8  p.m. 

99-6 

136 

26 

Midnight 

101-2 

130 

24 

„    9tb,  4  .i.ni. 

101-2 

132 

24 

8  a.m. 

101 

132 

24 

Noon 

100-4 

140 

24 

4  p.m. 

101-8 

136 

26 

8  p.m. 

102 

126 

26 

Midnight 

101-8 

142 

23 

„  10th,  4  a.m. 

.       101-8 

140 

26 

8  a.m. 

101-2 

136 

26 

Noon 

101-4 

132 

26 

4  p.m. 

101-4 

134 

28 

8  p.m. 

102-2 

136 

32 

Midnight 

101-2 

140 

32 

„  lltb,  4  a.m. 

99-8 

130 

26 

8  a.m. 

99-2 

120 

26 

CESAREAN  SECTION  FOR  CONTRACTED  PELVIS. 


95 


Date.          Hour. 

Temp. 

Pulse. 

Rasp 

3t.  11th,  noon 

..       100-6° 

132 

24 

4  p.m. 

..       100-4 

126 

22 

8  p.m. 

99-6 

124 

24 

Midnight 

98-8 

128 

20 

„  12th,  4  a.m. 

98-8 

126 

20 

8  a.m. 

..       100-4 

128 

22 

Noon 

102 

130 

24 

4  p.m. 

...       103 

134 

23 

8  p.m. 

..       101-6 

130 

26 

Midnight 

103 

132 

30 

„  13th,  4  a.m. 

..       101-8 

132 

30 

8  a.m. 

99-8 

136 

28 

Noon 

99-4 

130 

20 

4  p.m. 

98 

120 

22 

8  p.m. 

99-6 

124 

26 

Midnight 

98 

108 

24 

„  14th,  4  a.m. 

98-2 

112 

24 

8  a.m. 

98-6 

110 

24 

Noon 

..       100-6 

104 

24 

4  p.m. 

..       101 

111 

24 

8  p.m. 

99-8 

112 

26 

Midnight 

..       100-2 

120 

26 

„  loth,  4  a.m. 

98-2 

112 

26 

8  a.m. 

98-6 

111 

24 

Noon 

99-4 

110 

24 

4  p.m. 

..       100 

115 

24 

8  p.m. 

..       100-4 

116 

26 

Midnight 

99-6 

110 

24 

„  16th,  a.m. 

98-4 

110 

22 

p.m. 

90-4 

108 

22 

„  17th,  a.m. 

98-4 

96 

20 

p.m. 

90 

108 

22 

„  18th,  a.m. 

98  8 

98 

20 

p.m. 

99-4 

108 

20 

„  19th,  a.m. 

98-4 

100 

20 

p.m. 

99-2 

108 

20 

For  tlie  next  four  days  tlie  highest  record  of  tempera- 
ture was  99°j  after  which  it  was  uniformly  normal  up  to 
the  day  the  patient  left  the  hospital. 

In  this  case  all  the  conditions  were  favourable  to 
success.  The  patient  was  in  good  health  and  was  under 
observation  for  some  time  before  the  operation,  whilst  the 


96  C-2ESAREAN   SECTION   FOR  CONTRACTED  PELVIS. 

operation  itself  took  place  amidst  all  tlie  advantages  of 
a  hospital  and  at  au  hour  arranged  beforehand  so  that 
everything  was  in  readiness.  The  points  of  chief  interest 
may  be  very  briefly  summarised. 

The  uterus  was  found  rotated  on  its  long  axis,  so  that 
its  right  lateral  border  was  directed  forwards,  almost 
immediately  beneath  the  abdominal  incision.  The  dis- 
placement having  been  rectified,  the  uterus  was  opened 
in  situ,  obviating  the  neqessity  of  a  long  incision  and 
protracted  exposure.  The  elastic  ligature  was  dispensed 
with,  haemorrhage  from  the  cut  surface  being  held  in 
check,  first  by  digital  pressure,  and  subsequently  by  keeping 
the  edges  of  the  wound  pressed  together.  The  object  of 
this  omission  was  to  avoid  a  possible  factor  in  producing 
asphyxia  of  the  child,  and  imperfect  uterine  contraction. 
Whether  as  a  result  of  this  precaution  or  not,  the  child 
was  not  asphyxiated  in  the  slightest  degree,  and  the  contrac- 
tion and  retraction  of  the  uterus  were  most  satisfactory. 
The  method  of  suturing  adopted  was  by  deep  and  half- 
deep  silk  sutures.  The  deep  sutures  were  carried  through 
the  entire  thickness  of  the  uterine  wall,  merely  avoiding 
the  decidua.  They  were  ten  in  number.  Between  each 
two  deep  sutures  ii  half-deep  suture  was  inserted.  This 
method  closed  the  wound  much  more  securely  than  when 
the  deep  sutures  are  only  passed  through  two-thirds  of 
the  tliickness  of  the  uterine  wall,  and  the  superficial 
sutures  are  limited  to  the  peritoneum.  The  interior 
of  the  uterus  was  thoroughly  emptied  of  clot,  &c.,  and 
no  antiseptic  douching  or  swabbing  was  employed.  Steri- 
lisation was  effected  by  ligature  of  each  Fallopian  tube. 
The  lochial  discharge  scarcely  amounted  to  more  than  a 
stain.  A  similar  scantiness  of  lochia  is  not  infrequent 
after  ordinary  labour  where  there  has  been  severe  post- 
partum hferaorrhage,  but  why  it  occurred  in  this  instance 
I  am  at  a  loss  to  explain.  It  has  already  been  stated 
that  it  caused  me  some  temporary  alarm. 

I  intended  to  i-ecord,  along  with  this  case,  another  one 
in    which    the   operation    was   performed    on    account   of 


CESAREAN   SECTION  FOR  CONTRACTED  PELVIS.  97 

advanced  cancer,  but  the  notes  have  unfortunately  been 
mislaid.  With  this  exception,  all  my  previous  cases  have 
been  already  published  (see  '  Trans.  Obstet.  Soc.,'  1887, 
p.  252;  'Lancet,'  January  4th,  1890;  and  'Lancet,' 
May  17th,  1890).  I  hope  shortly  to  find  the  missing 
notes  and  make  good  the  omission. 


98 


CASE  OF  CESAREAN  SECTION. 
By  John  Shaw,  M.D., 

OBSTETRIC   PHYSICIAN    TO   THE    NORTH-WEST   LONDON    HOSPITAL. 

(Received  October  7th,  1891.) 

The  patient  was  a  primipara,  unmai'riedj  and  the  sub- 
ject of  rickets.  Her  height  was  4  feet  5  inches.  The 
pelvis  was  strongly  rickety,  the  true  conjugate  being 
24  inches.  Sanger's  modification  of  the  Ctesarean  section 
was  undertaken  before  the  actual  commencement  of 
labour  ;  as  judged  by  the  slow  and  irregular  action  of  the 
heart,  it  appeared  that  the  life  of  the  foetus  was  in  peril. 

There  was  not  as  much  loss  of  blood  as  after  an  aver- 
age confinement.  The  sutures  of  the  uterus  were  of 
chromic  catgut,  stout  deep  interrupted  ones  and  a  fine 
continuous  peritoneal  one.  The  ovaries  were  not  removed, 
but  both  the  Fallopian  tubes  were  crushed  through  by 
tying  with  silkworm  gut. 

The  child  was  delivered  alive,  and  left  the  hospital  in 
five  weeks  strong  and  healthy. 

The  mother  suffered  from  septicaemia  apparently  due  to 
the  retention  of  some  shreds  of  membrane,  but  recovered 
after  repeatedly  washing  out  the  uterine  cavity.  A  slight 
subsequent  attack  of  parametritis  quickly  subsided,  and 
the  patient  left  the  hospital  perfectly  well. 

C.  W — ,  aged  21,  single,  came  to  the  out-patient  depart- 
ment of  the  North  West  London  Hospital  on  December  r)th, 
1888,  complaining  that  her  period  had  stopped  for  four 
months,  that  she  had  a  very  bad  cough  and  felt  very  weak. 
The  patient  was  exceedingly  rickety^  presenting  the  cha- 


CESAREAN    SECTION.  99 

racteristic  physiognomy,  witli  curvature  of  the  long-boues 
and  enlargement  of  their  epiphyses.  Her  intelligence  Avas 
decidedly  below  the  normal  standard.  She  was  pale  and 
emaciated.  Subsequently  it  was  ascertained  that  she  was  in 
a  state  of  extreme  poverty,  being  one  of  six  living  and  sleep- 
ing in  a  single  room.  The  periods  began  at  seventeen  years 
of  age,  and  continued  regular  till  the  time  mentioned. 
On  December  12th  she  was  examined,  and  the  womb  was 
found  to  extend  to  just  above  the  un)bilicus  ;  the  foetal 
heart-sounds  (144  per  minute)  occasionally  intermitted, 
and  were  best  heai'd  to  the  right  of  the  umbilicus.  The 
uterine  souffle  was  very  distinct  in  the  middle  line.  The 
distance  between  the  crests  was  8|  inches,  and  the  ante- 
rior superior  spines  were  7f  inches  apart  ;  the  measure- 
ment from  the  upper  border  of  the  symphysis  pubis  to 
the  last  lumbar  spine  was  6  inches,  and  from  its  lower 
border  to  the  tip  of  the  coccyx  3j  inches. 

Professor  John  Williams  kindly  saw  the  patient  for  me 
and  advised  the  immediate  induction  of  labour,  or,  if  she 
should  go  on  to  term,  Porro's  operation  in  preference  to 
craniotomy.  The  patient's  father  resolutely  refused  to 
allow  of  the  artificial  induction  of  labour,  and  as  her  cir- 
cumstances were  so  distressful  she  was  taken  into  the 
Hampstead  Home  Hospital  for  the  month  or  so  preceding 
her  expected  confinement.  There  was  considerable  diffi- 
culty in  fixing  the  probability  of  this  date  ;  the  patient's 
account  was  that  it  was  four  months  since  she  had  seen 
anything,  but  on  carefully  questioning  her  mother  it 
appeared  probable  that  she  conceived  in  the  early  part  of 
August,  a  date  which  would  correspond  with  the  measure- 
ments of  the  Avomb  .Doubtless,  on  the  other  hand,  the  pro- 
minence of  the  sacral  angle  would  so  far  project  the  en- 
larged uterus  as  to  give  it  the  appearance  of  a  pregnancy 
more  advanced  than  really  was  the  case. 

For  a  week  before  the  operation  the  os  uteri  was  en- 
larged to  about  the  size  of  a  shilling,  and  the  cervix  was 
thinned  out  just  as  if  labour  was  commencing.  As  the 
foetal  heart-sounds  became  more   slow   and  irregular,  and 

VOL.  XXXIV.  8 


100  C-SSAREAN    SECTION. 

the  pregnancy  had  probably  arrived  at  the  full  time,  Dr. 
Richard  Smith,  who  kindly  saw  her  for  me,  advised  that 
the  operation  should  not  be  delayed,  and  kindly  gave  me 
the  support  of  his  presence  during  its  performance  on  the 
following  day  (May  9th,  1S89).  The  operation  was  per- 
formed with  all  antiseptic  precautions  except  that  the 
spray  was  not  used. 

An  incision  was  made  through  the  abdominal  walls 
corresponding  to  the  height  of  the  uterus,  and  the  part 
of  the  incision  above  the  navel  was  at  once  sutured.  The 
womb  was  slowly  turned  out  of  the  abdomen,  but  in  spite 
of  care  to  avoid  this  accident  some  omentum  became  en- 
tangled in  the  upper  sutures,  and  these  in  consequence 
required  to  be  re-introduced.  The  incision  into  the 
uterus  was  made  in  the  middle  line  after  an  india-rubber 
ligature  had  been  loosely  applied  around  its  lower  seg- 
ment. A  piece  of  mackintosh  from  which  a  parabolic 
section  had  been  removed  was  held  tightly  around  the 
womb,  so  as  to  prevent,  as  far  as  possible,  any  escape  of 
fluids  into  the  peritoneum,  a  precaution  which  was  dis- 
tinctly of  service,  as  the  meconium  was  discharged  at  the 
moment  that  the  child  was  being  delivered.  The  uterine 
wall  was  incised  layer  after  layer  in  the  manner  described 
by  Dr.  Champneys,  to  whose  admirable  description  of  a 
Caesarean  section  {'  Obst.  Soc.  Trans.,'  vol.  xxxi,  p.  136) 
any  success  which  attended  this  case  is  largely  due.  On 
reaching  the  sac  the  membranes  were  ruptured  and  the 
child  delivered  by  the  feet. 

It  was  very  pale  and  waxy-looking,  perhaps  owing  to 
the  elastic  ligature  having  been  rather  too  tight  for  the 
comfort  of  its  circulation;  but  under  the  judicious  care  of 
Mr.  Clayton  it  speedily  gained  consciousness,  and  by  the 
time  that  the  operation  was  completed  was  in  a  vigorous 
condition. 

The  placenta,  which  was  attached  to  the  posterior  wall 
at  the  upper  part,  was  then  removed,  and  as  the  mem- 
branes also  came  away  very  readily,  it  was  believed  that 
the  subsequent  scouring  out  of  the  uterine  cavity  was  un- 


CESAREAN    SECTION.  JQl 

necessary— a  mistake  which  endangered  the  success  of 
the  operation.  Whilst  the  sutures  were  being  introduced 
the  uterus  was  packed  with  sponges,  but  these  were  all 
removed,  and  the  uterine  cavity  first  douched  with  a 
solution  of  perchloride,  and  subsequently  dried  and 
dusted  with  iodoform,  before  any  of  the  knots  were 
tied. 

Immediately  on  removing  the  placenta  the  elastic  lio-a- 
ture  had  been  tightened,  and  the  amount  of  blood  lost 
was  quite  insignificant.  The  sutures,  which  were  of  chromic 
catgut,  were  introduced  at  intervals  of  half  an  inch  or  so, 
avoidmg  the  uterine  mucous  membrane  by  about  an 
eighth  of  an  inch,  and  emerging  about  a  quarter  of  an 
inch  or  a  little  more  from  the  line  of  incision.  The 
sutures  were  tied  from  below  upwards  by  the  ordinary 
surgical  knoc,  strengthened  with  a  third  turn  ;  by  the 
time  that  the  last  one  was  tied  the  first,  or  lowest,  had 
become  quite  loose,  and  had  to  be  re-introduced. 

The  peritoneum  beyond  the  area  on  each  side   of  the 
deep  sutures  was  brought  into  apposition  by  a  continuous 
suture  of  fine  chromic  catgut,  starting  about  three  quarters 
of  an  inch  below  the  incision   and   finishing  at   the  same 
distance  above  it.      The   line   of  suture   was  then   dusted 
with  iodoform,  and   the   womb   replaced  in  the  abdomen, 
where,  owing  to   the  obliquity  of  the  uterus,   the  line  of 
incision  became  quite  hidden  by  the  right  abdominal  wall. 
Till  this  moment  the  treatment  of  the  Fallopian  tubes 
had  been  overlooked  ;   a  strong  suture  of  silkworm  gut, 
therefore,  was  now    passed  through   the   left  broad  liga' 
ment  near  to  the  uterus,  and  through  the  right  ligament 
hallway  along  the   course  of  the   corresponding  oviduct, 
m  both   cases  immediately   below   the    tubes  ;   their  con- 
tinuity was  then  crushed   through   by  tightly   ligaturing. 
The  abdominal  wound   was   closed   with  silkworm  gut;  a 
wood-wool   pad,   strapping,   and   a   many-tailed   bandage 
completed  the  dressing. 

The  after  progress  of  the   case  was  very  anxious,   and 
may  be  summarised  somewhat  as  follows  : 


102  CESAREAN    SECTION. 

The  patient  suffered  very  slightly  from  shock  after  the 
operation,  and  complained  but  little  at  an}^  time  of  pain. 
For  the  first  twenty -four  hours  she  was  not  at  all  sick, 
but  in  the  afternoon  of  the  day  following  the  operation 
she  vomited  once,  also  twice  on  the  second  day,  and  once 
on  the  third,  fifth,  and  sixth  days.  The  lochia  ceased  on 
the  second  day,  but  on  the  third,  whilst  passing  a  long* 
rectal  tube  in  order  to  I'elieve  the  abdominal  distension 
from  which  the  patient  was  suffering,  some  clots  were 
expelled  from  the  vagina.  There  was  never  any  foetor 
of  the  discharge  to  be  detected. 

On  the  second  djiy  after  the  operation  the  bowels  acted 
twice,  and  on  the  third  day  six  times  ;  for  the  next 
twelve  days  the  patient  suffered  from  diarrhoea  more  or 
less  urgent,  on  one  day  (the  ninth)  having  as  many  as 
ten  motions.  The  urine  was  passed  naturally  from  the 
time  of  the  operation,  and  was  frequently  loaded  with 
lithates.  There  was  never  any  albumen,  but  with  the 
onset  of  septic  symptoms  indican  was  detected  in  the 
urine. 

The  pulse  rose  with  great  persistency  from  the  time  of 
the  operation  till  the  fifth  day,  when  it  was  150  per  minute, 
but  from  the  time  that  the  uterus  was  washed  out  the 
pulse  steadily  diminished  in  frequency.  The  temperature 
on  the  third  day  rose  beyond  108,  but  fell  again  on 
passing  the  long  rectal  tube  just  mentioned,  which 
seemed  to  have  had  the  effect  of  pressing  out  some  clot 
from  the  uterus  or  vagina.  On  the  fifth  day  again  the 
temperature  reached  103°,  but  fell  after  the  irrigation  of 
the  uterine  cavity.  The  respiration  was  usually  not 
above  28  per  minute,  and  the  chronic  cough  from  which 
the  patient  suffered  gave  no  further  trouble,  though  it 
has  persisted  till  the  present  time. 

With  respect  to  the  treatment  adopted,  for  the  first 
twenty-four  hours  the  patient  was  fed  only  by  nutrient 
suppositories,  and  it  is  to  be  observed  that  during  that 
time  she  had  no  sickness.  On  the  second  day  milk  and 
soda  water,  one  ounce  of  each,  was  given  every  two  hours^ 


C-DSAREAN    SECTION.  103 

and  later  in  tlie  day  a  little  beef-tea  and  arrowroot.  She 
was  not  sick  till  she  had  taken  the  beef-tea,  about  forty 
hours  after  the  operation.  The  diarrhoea  was  regarded 
as  being  septic  in  origin,  and  appeared  to  be  greatly 
helped  by  small  enemata  of  olive  oil  and  turpentine. 
There  was  no  corroborative  evidence,  such  as  sponginess 
of  the  gums,  to  indicate  that  the  absorption  of  mercury 
might  have  played  a  part  in  it,  though  it  is  to  be  observed 
that  the  dressing  was  a  mercuric  wood-wool  pad. 

On  the  fifth  day  it  was  felt  that  the  patient^s  condition 
was  so  extreme,  with  a  temperature  of  103°,  a  pulse  of 
150,  and  the  dull,  listless  aspect  of  sepsis,  that  it  was 
decided  to  wash  out  the  uterine  cavity  in  the  hope  of 
relieving  her  condition.  A  solution  of  perchloride  was 
used  for  the  purpose,  and  shreds  of  membrane  to  a  con- 
siderable extent  came  away.  This  irrigation  was  twice 
subsequently  repeated,  each  time  with  some  removal  of 
debris. 

During  convalescence  the  patient  had  a  very  slight 
attack  of  parametritis,  but,  as  far  as  is  known,  never  had 
the  least  peritonitis  at  any  period  of  her  illness. 

The  case  is  of  interest  for  several  reasons,  especially 
on  account  of  the  success  which  attended  the  irrigation 
of  the  uterus  five  days  after  its  free  incision  ;  further,  on 
the  score  of  certain  mistakes  which,  in  the  author's  present 
judgment,  were  made  in  the  conduct  of  the  case. 

Firstly,  in  the  absence  of  the  actual  onset  of  labour  it 
would  have  been  much  wiser  to  have  done  Porro's  opera- 
tion, seeing  that  the  os,  diluted  only  to  the  size  of  a 
shilling,  did  not  allow  of  sufficient  drainage  of  the  uterine 
cavity  during  the  natural  involution  of  the  womb. 
Secondly,  in  the  anxiety  to  prevent  hemorrhage  too  much 
ergot  was  administered  ;  a  dose  was  given  a  few  hours 
before  the  operation,  a  hypodermic  injection  of  the  same 
immediately  after  the  emptying  of  the  uterus,  and  twice 
after  the  operation  suppositories  of  ergotine  were  adminis- 
tered. The  ergot  doubtless  accentuated  the  difficulty  in 
obtaining  adequate  drainage.      In  the  actual  operation  the 


104  CESAREAN    SECTION. 

omission  to    scour  out  tlie  uterine  cavity  was   probably  a 
serious  error. 

That  the  child  was  delivered  alive  appeared  largely 
owing  to  the  instrumentality  of  Mr.  Clayton.  Four  hours 
after  birth  he  weighed  5  lbs.  5  oz.,  and  measured 
19  inches ;  on  leaving  the  Hampstead  Home  Hospital 
with  his  mother  five  weeks  later  he  weighed  6  lbs. 
11  oz.,  and  measui^ed  22  inches.  If  it  had  not  been 
for  the  attack  of  septic  fever  the  mother  would  most 
probably  have  been  able  to  nurse  him  well.  Dr.  A.  H. 
Cook  gave  the  anaesthetic,  Dr.  Wilbe  assisted  me,  and  in 
the  after-treatment  of  the  case  my  friend  Dr.  Strange 
gave  me  valued  advice  and  encouragement. 

On  July  10th  the  patient  reported  herself  as  feeling 
quite  well ;  the  uterus  was  situated  rather  high  up,  and 
was  quite  moveable.  In  April  of  this  year  (1891)  she 
came  to  the  hospital  and  reported  that  the  catamenia  had 
returned  about  a  year,  that  they  were  quite  regular,  but 
that  she  had  some  pain  in  the  back  which  continued 
whilst  the  period  lasted,  i.  e.  about  three  days.  Her 
cough  still  troubled  her,  and  there  was  some  hernia 
through  the  scar  below  the  umbilicus  ;  otherwise  she 
seemed  quite  well. 


]05 


A  SUCCESSFUL    CASE    OF    CESAREAN 
SECTION. 

By  A.  D.  Leith  Napier,  M.D.,  M.R.C.P., 

PHTSICIAN-ACCOrCHEUK,    ST.    PANCEAS    AXU    NOETHEEN    DISPEXSAEY  ; 
PHYSICIAN  TO   OrT-PATIENTS,  CHELSEA  HOSPITAL  POE  WOMEN. 

(Received  September  25tli,  1891.) 

{Abstract.) 

The  patient  was  a  secuudipara,  having  been  delivered  of  a 
dead  child  at  term  on  March  15th,  1890.  Delivery  was  very 
difficult,  being  effected  by  craniotomy  and  embryulcia.  She 
was  advised  to  have  premature  labour  induced  at  the  seventh 
month  if  she  again  became  pregnant.  She  did  not  come  under 
observation  on  this  occasion  until  the  end  of  the  eighth  month. 
She  was  a  short,  squat-built  woman,  barely  four  feet  ten  inches 
in  height,  with  well-marked  rictety  curvature  of  the  left  tibia 
and  limited  movement  of  the  left  hip-joint.  She  had  suffered 
from  convulsions  in  early  childhood,  and  was  very  delicate  as  a 
child,  not  having  been  able  to  walk  till  she  was  five  years  of  age. 
Her  pelvis  was  of  the  contracted  flat  variety,  with  a  conjugata 
vera  of  2|  inches. 

Csesarean  section  (Sanger-Miiller,  with  deep  and  "  half-deep  " 
sero-muscular  sutures  afiei-  Howard  Kelly's  method)  was  per- 
formed on  June  14th,  1891,  280  days  from  date  of  last  period. 
Labour  had  not  commenced,  nor  had  any  means  been  adopted 
to  excite  pains.  The  placenta  was  anteriorly  placed.  The 
operation  lasted  about  forty-six  minutes,  six  minutes  being 
occupied  from  the  first  incision  in  emptying  the  uterus  of 
fcetus,  placenta,  and  membranes,  and  nearly  forty  minutes 
more  being  required  to  the  end  of  the  operation.  Some  delay 
arose  on  account  of  the  flabby  state  of  the  uterus.  The  sutures 
were    sterilised  silk,  Nos.  3  and   4,  prepared    after   Barker's 


106  CJKSAKEAN    SECTION. 

method,  I.  e.  boiled  ia  carbolised  water.  The  Fallopian  tubes 
were  tied  with  two  silk  ligatures,  aud  divided  between  these  by 
scissors ;  the  ovaries  were  not  removed.  There  was  some  post- 
partum haemorrhage. 

The  patient  developed  a  very  severe  attack  of  jjleuro-pneu- 
monia.  She  had  shortly  before  coming  into  the  ward  suffered 
from  influenza.  There  was  no  peritonitis  or  appearance  of 
general  sepsis  at  any  time.  Eecovery  was  very  good,  the 
patient  going  home  well  on  the  thirty-fourth  day  after  opera- 
tion.    The  child,  a  boy,  is  alive  and  well. 

Remarks  are  made. 

Clara  S — ,  aged  29,  married,  living  with  her  husband, 
a  German,  who  is  a  journeyman  baker  but  in  poor  cir- 
cumstances, at  Clarendon  Square,  N.W.,  attended  at  St. 
Pancras  Dispen.^ary  on  May  25th,  1891. 

She  was  a  short,  squarely  built  woman,  barely  four 
feet  ten  inches  in  height,  and  walked  lame.  Her  teeth 
were  very  irregular  and  much  decayed.  Both  tibiae  were 
curved,  the  left  markedly  so.  There  was  limited  move- 
ment  of  the  left  hip-joint.  The  patient  had  recently 
suffered  from  a  severe  attack  of  influenza  ;  her  complexion 
was  pale  and  pasty,  and  she  was  generally  weak  and  flabby. 

Family  history, — Nothing  important.  Both  parents 
living ;  the  mother  is  a  healthy  well-formed  woman  of 
fifty-eight,  with  a  favourable  obstetric  history. 

Previous  history  of  patient. — The  mother  states  that, 
"  as  a  child,  Clara  was  small  and  weakly.  She  suffered 
severely  from  convulsions  as  an  infant,  and  up  to  eighteen 
months  ;  was  an  out-patient  at  University  College  Hospital 
for  a  long  time  ;  had  weakness  and  deformity  of  the 
limbs,  was  unable  to  walk  till  over  five  years  of  age." 

Menstrual  history.  —  Catamenia  at  sixteen,  quantity 
scanty,  somewhat  irregular,  and  always  painful.  Married 
when  twenty-six. 

Previous  labour. — On  March  15th,  1890,  attended  at 
term  by  Dr.  Stanley,  R.  M.  0.,  St.  Pancras  Dispensary, 
who,  after  ineffectual  attempts  with  forceps,  sent  for  me. 


CESAREAN    SECTION.  107 

The  child  was  ascertained  to  be  dead  ;  the  head  presented 
high  above  the  brim.  The  paitis  were  feeble  and  value- 
less, the  OS  was  undilatable,  and  the  patient  extremely- 
exhausted.  The  cervix  was  divided  by  scissors.  Crani- 
otomy was  performed,  but  delivery  was  found  impossible 
until  after  very  thorough  embryuicia  had  been  effected. 
The  headless  trunk  Avas  eventually  delivered,  one  arm, 
the  luugs,  and  liver  having  been  previously  removed. 
The  delivery  was  the  most  difficult  I  ever  accomplished, 
and  occupied  three  and  a  half  hours.  The  patient,  con- 
sidering the  extreme  severity  of  the  case,  convalesced 
well.      Dr.  Stanley  ceased  attendance  on  April  16th. 

With  a  view  to  being  prepared  for  future  possible  diffi- 
culties I  asked  Dr.  John  Williams,  the  consulting  physi- 
cian-accoucheur of  the  dispensary,  to  see  the  woman  after 
her  thorough  recovery.  This  Dr.  Williams  most  kindly 
did,  and  after  making  pelvic  measurements,  advised  that, 
in  event  of  another  pregnancy,  labour  should  be  induced 
at  latest  at  the  seventh  month.    ■ 

Present  i:iregnancy . — Last  catamenia  ended  September 
7th,  1890,  having  lasted  four  days.  She  felt  foetal  move- 
ments about  Februaiy,  1891,  but  was  uncertain  of  the 
exact  date.  June  14th,  1891,  280  days  from  last  day  of 
last  period,  the  patient,  in  consequence  of  her  having  had 
influenza,  and  partly  because  both  she  and  her  husband 
were  anxious  to  have  a  living  child,  failed  to  report  her- 
self when  at  the  seventh  month  of  gestation.  Both  thought 
it  unlikely  that  a  seven  months  child  would  live.  She 
attended  when  eight  months  pregnant,  and  readily  agreed 
to  undergo  the  risks  of  the  major  operation.  She  was 
admitted  to  the  dispensary  on  June  8th,  1891. 

The  pelvic  measurements  were — 

Dist.  cr.  il.  (bi-iliac)  .  .  .10  in. 

,,     sp.  il.  (bi-spinous  .  .     10^  in. 

Conj.  extern.         .  .  .  .     6^  in. 

„       vera  .  .  .  .     2|  in. 

Ope7-atio7i. — On  June  14th  an  enema  was  given  in  the 
morning,  and  the  vagina  douched  with    1    in   2000  per- 


108  C^SAEEAN    SECTION. 

chloride  of  mercury  solution.  The  abdomen  was  thoroughly 
■washed  with  soap  and  water,  and  afterwards  with  the 
perchloride  solution.  I  was  assisted  by  Dr.  Cullingworth 
of  St.  Thomas's  Hospital  (of  whose  kindness  in  lending 
me  his  valuable  aid  I  am  deeply  sensible),  and  by  my 
colleague  Mr.  Holthouse.  Dr.  Schacht  administered  ether. 
After  being-  placed  on  the  table,  two  towels  moistened 
with  carbolic  solution  (1  in  20)  were  placed  over  the  chest 
and  pelvis ;  the  abdomen  was  covered  with  alembroth 
gauze  in  which  a  free  slit  was  made.  The  external  in- 
cision was  commenced  about  an  inch  above  the  umbilicus, 
and  continued  downwards  for  other  four  inches.  Only 
one  vessel  in  the  abdominal  wall  required  forcipressure. 
The  uterus  was  rapidly  reached,  and  found  to  be  lying 
markedly  anteverted,  the  fundus  being  tilted  well  forward. 
The  external  incision  was  enlarged  one  and  a  half  inches, 
i.  e.  to  six  and  a  half  inches.  The  left  hand  was  then 
inserted  behind  the  uterus,  and  very  easily  displaced  it 
outside  the  abdomen.  The  placental  attachment  had  been 
previously  determined  as  being  on  the  anterior  wall;  the 
position  of  the  fcetal  head  lying  over  the  left  iliac  fossa 
was  also  confirmed.  An  elastic  ligature  was  placed 
round  the  cervix.  An  incision  of  two  inches  was  made 
into  the  uterus  down  through  the  lower  placental  area, 
and  simultaneously  the  uterus  was  turned  over  to  the 
right  side  ;  a  very  moderate  gush  of  blood  and  liquor  amnii 
escaped.  The  elastic  ligature  was  tightened,  and  effec- 
tually controlled  further  haemorrhage.  The  uterine  in- 
cision was  enlarged  to  about  three  and  a  half  inches  in  all ; 
it  was  free  of  the  fundal  and  lower  uterine  zones.  The 
left  hand  was  inserted  past  the  placenta ;  the  head  of  the 
foetus  was  instantly  grasped,  and  the  child  extracted  as 
rapidly  as  possible.  The  cord  was  clamped  by  two  small 
pressure  forceps,  then  divided,  and  the  child,  a  well- 
developed  male,  handed  to  Mr.  Harper,  who  almost  im- 
mediately had  it  breathing  vigorously.  After  removal  of 
the  foetus  the  placenta  was  found  practically  detached, 
and  was  extracted  ;   the  membranes  were  somewhat  closely 


CiESAEEAN    SECTION.  109 

adherent  anteriorly,  but  were  separated  readily  by  the 
fingers,  and  with  the  exception  of  one  small  piece  attached 
in  the  cervical  zone  were  wholly  removed.  Two  fingers 
of  the  left  hand  were  passed  through  the  cervix  from  the 
uterus.  From  the  beginning  of  the  abdominal  incision 
to  this  stage  occupied  six  minutes.  The  uterus  was  large, 
soft,  and  flabby  ;  the  walls  seemed  oedematous  ;  there  was 
hardly  any  sign  of  contraction.  Very  hot  sponges  were 
placed  all  over  the  uterus  immediately  after  the  extrac- 
tion of  the  foetus,  and  renewed  as  they  cooled.  The 
uterine  cavity  was  swabbed  out  with  two  dry  cotton-wool 
sponges,  prepared  in  1  in  1000  perchloride  solution. 
There  was  no  intra-uterine  liEemoi'rhage.  Barker's  steri- 
lised No.  4  silk  was  used  for  the  deep  sutures,  No.  3  for 
the  sero-muscular.  Bantock's  modification  of  Hagedorn's 
needles  was  used  for  all  the  uterine  stitches,  Hagedorn's 
long  needle-holder  being  employed  to  introduce  the 
needles.  Fourteen  deep  sutures,  as  deep  as  possible,  but 
avoiding  the  whole  thickness  of  the  walls,  with  ten  sero- 
muscular "  half-deep,^'  i.  e.  including  one-fourth  of  the 
whole  thickness,  were  inserted.  When  tightened  the 
sutures  perfectly  coapted  the  edges  of  the  uterine  in- 
cision. The  elastic  tubing  was  now  removed  ;  no  ex- 
ternal oozing  occurred.  The  uterus  was  returned  to  the 
abdominal  cavity.  Contractions  were  excited  by  gentle 
friction,  and  there  were  some  feeble  responsive  efforts. 
Both  Fallopian  tubes  were  tied,  each  by  two  pieces  of 
stout  silk,  and  then  divided  between  the  ligatures  by 
scissors ;  there  was  no  bleeding.  The  division  of  the 
tubes  seemed  to  cause  very  great  depression  of  the  pulse 
for  the  moment. 

Two  small  sponges  on  holders  were  passed  deeply  into 
the  pelvis  ;  there  was  neither  blood  nor  fluid  of  any  kind, 
so  that  no  further  sponging  or  washing  out  was  deemed 
necessary.  A  large  flat  sponge  maintained  the  intestines 
within  the  abdomen,  another  was  placed  over  the  uterus  ; 
the  former  was  removed,  the  omentum  drawn  down  over 
the  uterus,  the   uterine  sponge  at   the   same   time   with- 


110  CJ5SAREAN    SECTION. 

drawn  and  placed  below  the  parietes.  Fifteen  silkworm 
gut  sutures  were  introduced  through  the  whole  thickness 
of  the  walls,  including  the  peritoneum  ;  four  superficial 
silk  sutures  were  afterwards  inserted.  No  strapping  was 
used.  Pressure  was  maintained  over  the  uterus,  which 
now  contracted  once  or  twice  satisfactorily.  The  sponge 
was  removed  and  the  abdomen  closed.  The  uterine  and 
abdominal  suturing,  with  the  ligation  and  division  of  the 
Fallopian  tubes,  and  the  other  steps  above  described, 
occupied  nearly  forty  minutes,  but  time  was  lost  through 
our  anxiety  not  to  close  the  abdomen  until  we  had  clear 
assurance  of  good  uterine  contractions.  The  dressings 
were  only  partially  applied,  as  the  uterus  did  not  seem  to 
maintain  good  contraction.  A  full  dose  of  ergotine 
(ii\xij)  was  injected  hypodermically.  A  free  gush  of 
haemorrhage  now  escaped  j>er  vaginam.  A  hot  intra- 
uterine douche  of  boric  acid  solution  was  given.  A  second 
gush  of  blood  escaped  ;  the  vagina  and  lower  uterine  zone 
were  cleared  of  some  clots,  and  the  missing  piece  of 
membrane  extracted  from  the  uterus  digitally.  Another 
very  hot  douche  was  then  given,  and  the  threatened 
htemorrhage  ceased.  As  the  patient^s  pulse  was  unsatis- 
factory half  a  drachm  of  pure  ether  and  subsequently 
brandy  were  injected  hypodermically.  She  was  removed 
to  bed,  the  bandage  readjusted,  and  a  further  dose  of 
ergotine  given.  The  whole  quantity  of  blood  lost  was 
certainly  not  more,  rather  less,  than  with  a  normal  labour. 
The  dressings  employed  were  alembroth  gauze  and  sali- 
cylic wool  pads.  No  iodoform  was  introduced  within  the 
uterus,  nor  was  any  dusted  over  the  incision. 

It  was  originally  intended  to  douche  the  uterus  from 
the  abdomen  with  a  hot  sublimate  solution,  but  as  there 
appeared  to  be  no  particular  reason  for  this  procedure  it 
was  omitted.  I  question  if  the  subsequent  hasraorrhage 
would  have  been  averted  by  this.  I  think  the  semi- 
detached small  piece  of  membrane  and  the  somewhat 
tight  elastic  ligature,  which  for  the  time  must  have  caused 
partial  paralysis  of   the   uterine  muscles,  had   more  influ- 


CESAREAN  sp:ction.  111 

ence.  There  were  no  difficulties  or  hitches  during'  the 
operation,  for  which  I  have  in  great  measure  to  thank 
the  tact  and  foresight  of  my  able  assistants.  The  cliild, 
a  male,  Avas  21  inches  long,  weighed  7  lbs.  8i  oz.,  and 
was  strong  aud  vigorous. 

Subsequent  Narration  of  the  Case. 

Immediately  after  operation  the  temperature  was  sub- 
normal, and  continued  so  for  some  hours.  Patient  looked 
very  weak  in  the  evening ;  the  breathing  became  fast 
and  difficult ;  the  pulse  became  very  fast  during  the 
early  morning  of  June  15th.  At  8.15  a.m.  the  pulse  im- 
proved, but  the  respiration  was  40  per  minute  and  very 
laboui'ed  ;  the  patient  appeared  cyanosed  about  the  lips, 
finger-nails,  &c.  On  auscultation  fine  rales  were  heard 
all  over  the  right  lung,  and  to  a  less  degree  over  the  left. 

On  the  16th  I  had  the  advantage  of  a  consultation 
with  my  colleague  Dr.  Younger,  who  ag'reed  in  the  dia- 
gnosis of  non-septic  pleuro-pneumonia. 

17th. — There  was  a  sudden  development  of  very  severe 
pain  in  the  interscapular  region  ;  this  pain  extended  into 
the  lower  axillary  and  lumbar  regions. 

On  examination  bronchial  breathing,  with  fine  crepita- 
tion towards  the  end  of  inspiration  and  some  broncho- 
phony, was  heard  ;  this  was  most  marked  at  the  loAver 
right  base.      Cooing  rhonchi  heard  over  left  chest. 

18tli. — The  chest  dulness  somewhat  diminished  ;  sego- 
phony  noted  on  previous  day  almost  gone.  Mucous  rales 
over  front  of  chest. 

21st. — The  right  base  is  clearing  up  ;  the  sounds  in  the 
infra-scapular  region  are  defined,  but  quite  at  the  base 
nothing  can  be  heard.  The  improvement  after  this  was 
continuous,  and  after  June  22nd  the  temperature,  with  the 
exception  of  a  few  irregular  unimportant  jumps,  became 
normal. 

As  the  lung  condition  was  the  only  real  source  of  anxiety 
after  the   first  few  days,  the   main   responsibility   of  the 


112  CiESAREAN    SECTION. 

after-treatment  fell  on  Dr.  Younger,  who  was  most  kind 
and  assiduous  in  liis  care  of  the  patient. 

Temperature  was  102'2°  eveniug  after  operation  ;  it  then 
dropped  to  99'5°,  rose  at  5.30  a.m.  on  15tli  to  102*2°. 
On  the  IGth  and  17tli  June  it  remained  about  101  to 
102°  ;  but  on  the  evening  of  the  17th  104*2°  was  reached  ; 
this  was  tbe  highest  record.  On  the  18 th  103°  was  re- 
corded, but  after  this  there  were  no  high  records j  for 
the  next  day  or  so  102°  and  slightly  upwards  was  some- 
times noted.  From  June  23rd  there  was  very  marked 
improvement.  On  the  28th  the  temperature  was  abso- 
lutely normal,  and  steadily  remained  so. 

Pulse  was  not  very  rapid  at  first,  being  120  immediately 
after  the  patient's  return  to  bed,  then  falling  to  about  104. 
In  the  evening  with  a  rising  temperature  the  pulse  in- 
creased to  130,  and  then  to  160,  lu  the  early  morning 
of  the  15th  it  could  not  be  counted.  On  the  16th  and 
for  the  next  few  days  it  varied  between  120  and  136. 
On  the  17th,  at  the  time  of  the  high  temperature,  there 
was  a  rise  to  160,  but  this  only  lasted  a  short  time.  The 
pulse  was  fast  throughout  ;  in  fact,  after  the  patient  was 
practically  quite  well  it  continued  fast.  This  may  be 
accounted  for  partly  from  her  being  very  neurotic,  and 
partly  fi'oui  the  post-influenzal  condition  in  which,  as  has 
been  shown  by  Dr.  James  Anderson  and  others,  rapidity 
of  pulse  is  usual. 

Resjnration  was  very  rapid  and  difficult  during  the  time 
of  chest  complications. 

Lochia. — Slight  during  first  few  hours,  a  small  clot 
passed  on  15th.  On  17th  slight  flow,  no  smell.  19th, 
rather  freer  in  quantity,  character  sanguineo-purulent. 
23rd,  slight  show.  27th  (the  thirteenth  day),  none. 
29th,  a  slight  return,  bright-coloured,  after  action  of 
bowels  ;  patient  was  worried  about  the  baby  being  taken 
away.      July  7th,  a  slight  return — possibly  periodic. 

Vomiting  none.  Mild  dry  retching  once  afternoon  of 
operation  none  afterwards. 

Pain. — Patient  was  very  neurotic,  and  inclined  to  com- 


CESAREAN    SECTION.  113 

plain  of  pain  on  recovering  from  the  anesthetic.  Had 
a  few  after-pains  on  day  after  operation.  There  Avas 
never  any  marked  abdominal  tenderness,  nor  at  any  time 
notable  distension. 

Micturition. — Catheter  only  twice  necessary.  Passed 
nrine  naturally  the  day  after  operation.  There  was  some 
incontinence  with  coughing  for  two  days.  A  week  after 
she  had  some  vesical  tenesmus,  and  asked  to  have  the 
catheter  passed  ;  this  was  done,  but  the  bladder  found 
empty. 

Boivels. — Flatus  passed  afternoon  of  16th  and  very  freely 
on  17th  (the  third  day).  On  the  third  day  the  patient 
had  a  drachm  of  Sodae  Potass.  Tart.  In  consequence  of  a 
misunderstanding  four  other  doses  were  given  during  the 
day.  In  the  afternoon  and  evening  there  were  six  free 
actions ;  further  action  was  checked  by  an  enema  of 
starch  and  laudanum.  On  the  fourth  day  there  were 
three  loose  actions  ;  another  astringent  enema  was  given. 
From  this  time  there  was  natural  action  without  medicine. 

Diet. — A  tea  spoonful  of  hot  water  was  given  a  few 
hours  after  operation,  and  repeated  now  and  again.  On 
the  evening  after  operation  an  enema  of  Brand's  essence 
and  brandy  and  water  given.  l(Hh,  two  teaspoonfuls  of 
Brand's  essence  by  the  mouth,  milk,  soda  water,  champagne, 
cup  of  corn-flour.  17th,  chicken  tea,  brandy  and  soda,  iced 
milk,  arrowroot,  beef  tea  and  toast.  Fifth  day,  fish 
diet.  Seventh  day,  chicken.  On  account  of  the  rapid 
pulse  stimulants  were  given  early — champagne  and  brandy 
on  day  after  operation.      There  was  no  vomiting. 

Medicines. — Carbonate  of  ammonia,  digitalis,  and  small 
doses  of  belladonna  for  chest  troubles.  Quinine  in  gr.  v 
and  gr.  x  doses,  sometimes  plain,  sometimes  with  hydro- 
bromic  acid,  was  given  to  control  temperature.  When  the 
severe  pain  occurred  in  the  chest  morphia  and  hyoscyamus 
were  given  by  the  mouth.  Poultices  to  the  chest  and 
side,  with  extract  of  belladonna,  were  applied  when  pain 
was  severe.  On  the  eighth  day  a  tonic  of  cinchona,  uux 
vomica,  and  sal  volatile  was  prescribed. 


114  C-«:SAREAN    SECTION. 

Surgical  history. — The  wound  was  dressed  with  alem- 
broth  gauze  ;  the  dressing  was  changed  on  the  third  day. 
The  bandage  had  slipped  up  and  caused  some  superficial 
irritation  and  blistering  on  the  back,  which  occasioned 
some  subsequent  trouble  and  inconvenience. 

On  the  fourth  day  the  abdominal  wound  looked  abso- 
lutel}'-  healed  and  healthy. 

On  the  fifth  day  one,  and  on  the  sixth  day  the  other  three 
superficial  silk  sutures  were  removed.  On  June  21st 
(seventh  day)  eight  deep  stitches  removed.  A  strip  of 
Seabury  and  Johnston's  plaister  was  placed  over  the 
abdomen  for  support. 

On  the  twelfth  day  the  remaining  stitches  were  removed. 

A  troublesome  vesicular  eruption,  evidently  caused  by 
the  alembroth  gauze  and  the  free  perspiration,  appeared 
over  the  abdomen  on  the  eighth  day.  By  the  tenth  day 
many  of  the  vesicles  coalesced.  The  irritability  had  quite 
gone  by  the  twelfth  day.  When  the  vesicles  appeared 
the  alembroth  gauze  was  suspended,  and  plain  gauze  with 
powder  of  boric  acid  substituted. 

General  and  obstetric  covrse. — Patient  was  able  to  read 
by  the  end  of  the  first  week.  She  took  her  food  well 
and  slept  well  throughout. 

On  July  2nd  (eighteenth  day)  she  was  sitting  up  in 
bed,  and  about  a  week  later  was  allowed  to  get  up.  She 
went  home  well  on  July  18th,  the  thirty-fourth  day,  and 
was  able  to  walk  from  her  house  to  the  dispensary  on 
July  20th,  bringing  her  baby  with  her. 

A  pelvic  examination  was  made  on  July  13th,  when  the 
uterus  felt  perfectly  normal,  was  freely  moveable  ;  the 
patient  had  no  pain  or  tenderness. 

Periods. — There  was  an  appearance  of  bright  red 
blood  on  July  7th,  which  lasted  seven  hours  ;  on  August 
20th  she  had  a  slight  flow  for  thirty-six  hours,  and  on 
August  31st  and  September  1st  there  was  a  somewhat 
free  discharge.* 

•  She  now  menstruates  regularly  every  iimnth  without  pain,  and  in    very 
moderate  quantity  (March,  1892). 


CESAREAN    SECTION.  115 

The  baby  was  rather  fretful,  and  was  sent  to  friends  on 
June  29th.  Since  the  mother  took  charge  of  him  he  has 
greatly  improved.  The  husband  has  been  in  poor  cir- 
cumstances, and  therefore  the  patient  has  been  worried 
a  good  deal. 

Ee^narks. — As  I  do  not  believe  that  one  successful 
Caesarean  section  entitles  an  operator  to  speak  authorita- 
tively, any  more  than  one  swallow  constitutes  a  summer, 
I  shall  make  my  observations  as  brief  and  a  propos  as 
possible. 

This  operation  was  one  of  those  which  might  have  been 
avoided  by  the  induction  of  premature  labour  at  the 
seventh  month  ;  but,  considering  the  patient's  personal 
elements,  viz.  her  having  had  severe  influenza  about  the 
time  of  the  possible  conservative  operation,  the  extremely 
severe  nature  of  the  first  labour,  not  to  add  the  relatively 
large  size  of  the  foetus  on  this  occasion,  I  think  it  highly 
improbable  that  both  child  and  mother  would  have  sur- 
vived. 

A  brief  reference  to  my  choice  of  operation.  In  this 
instance  I  preferred  Ceesarean  section  to  Porro-Caesarean 
because  (1)  the  woman  might  possibly  have  borne  living 
children  afterwards  at  the  seventh  month,*  (2)  the  shock 
of  Porro  seems  to  be  greater,  (3)  there  was  no  antecedent 
injury  to  the  genital  tract  and  no  septic  infection ;  and  in 
this  case,  with  the  severe  pulmonic  complication,  I  think 
it  was  fortunate  that  an  exposed  raw  surface,  with  the 
irritation  and  strain  of  the  necessary  clamp,  incident  to 
Porro,  were  avoided.  As  it  was,  the  patient  had  heavy 
odds  against  her  recovery ;  with  these  added  I  feel  con- 
vinced she  would  have  succumbed.  Further,  I  venture 
to  hold  that  as  the  improved  Ctesarean  is  not  only  the 
more  conservative  but  the  more  scientific  operation,  it 
should  always  be  preferred  in  suitable  cases. 

As  to  the  technique  of  the  operation.  If  the  uterus 
can  be  turned  outside  the  abdomen   easily,  it  certainly 

*  The  division  of  the  Fallopian  tubes,  which  of  necessity  would  preclude 
this,  was  determined  shortly  before  operation. 

VOL.  XXXIV.  9 


116  C^SAEEAN    SECTION. 

expedites  tlie  most  difficult  part  of  tlie  operation — accu- 
rate suturing.  I  adopted  Dr.  Howard  Kelly's  procedure, 
except  that  I  used  my  deep  sutures  rather  more  liberally 
than  he  recommends.  His  "  half-deep  ^'  sutures  were 
preferred  to  superficial  sero-serous  sutures.  ''  They  are 
introduced  after  the  deep  sutures  are  tied^  and  sweep 
through  both  lips  of  the  closed  incision,  including  not 
more  than  one-fourth  of  the  uterine  wall.^^  An  import- 
ant practical  suggestion  made  by  Dr.  M.  Cameron  at  the 
British  Medical  Association  meeting  at  Bournemouth  in 
August,  1891,  was  that  the  central  deep  suture  should  be 
first  tied.  Nothing  could  have  answered  better  than 
Barker's  sterilised  silk ;  and  the  rapidity  with  which  the 
clean-piercing  Hagedorn's  needles  can  be  passed  was  also 
a  decided  satisfaction.  Some  operators  advise  that  the 
placenta  should  be  avoided  in  placenta  prasvia  Caesarea. 
In  my  case  it  would  have  been  difficult  to  do  so  without 
wounding  the  fundal  or  cervical  regions,  which  seems  to 
me  a  far  more  serious  evil. 

That  an  elastic  ligature  is  an  unmixed  blessing  I  doubt. 
With  a  thoroughly  capable  assistant,  I  think,  if  I  have 
another  case,  I  would  be  disposed  either  to  dispense  with 
it,  or  only  tighten  it  in  event  of  bleeding.  I  cannot  but 
think  that  the  risk  of  post-partum  bleeding  must  be 
increased  by  the  application  of  a  tight  ligature  round  the 
cervix  for  half  an  hour  or  more. 

Ligation  and  division  of  the  Fallopian  tubes,  originally 
suggested  by  Blundell,  of  Guy's,  about  1820,  has  been 
practised  by  various  operators.  I  conclude  that  tying  the 
tubes  with  double  ligatures  and  then  cutting  cleanly 
across  with  scissors  is  more  likely  to  be  satisfactory  than 
trusting  to  their  division  by  ligature  only.  The  time 
occupied  is  practically  the  same. 

As  to  the  time  of  operating.  The  modern  feeling, 
with  which  I  sympathise,  seems  to  be  to  operate  at  the 
end  of  pregnancy,  independent  of  the  commencement  of 
labour.  It  is  true  that  the  absence  of  contractions  may 
be  a  source  of  theoretical  unquiet ;  but  if  emptying  the 


C^SAEEAN    SECTION.  117 

uterus  by  abdominal  section^  stitcliing  up  the  incision, 
and  the  subsequent  administration  of  ergot  and  applica- 
tion of  friction  fail  to  produce  contractions,  it  is  some- 
thing as  yet  unlearned.  After  labour  pains  have  begun 
there  may  be  prematui*e  rupture  of  the  amnion,  which  will 
unquestionably  be  a  disadvantage.  Besides,  it  is  surely 
better  to  select  a  convenient  time  of  day  for  careful 
operation,  rather  than  be  obliged  to  operate,  perchance 
with  great  inconvenience,  at  any  odd  time. 

Much  is  now  made  of  rapidity  in  operating.  A  recent 
American  writer  claims  to  have  performed  Porro's  sec- 
tion at  a  very  rapid  "  record "  rate.  It  is  urged  that 
Ccesarean  section  must  always  occupy  more  time.  This  I 
doubt.  Surely  the  most  important  part  of  the  operation 
to  do  quickly  is  to  eiupty  the  uterus  so  as  to  obtain  rapid 
contraction  and  avoid  haemorrhage.  In  my  case  this 
stage  was  reached  in  about  six  minutes ;  had  it  not  been 
on  account  of  the  atonic,  flabby  state  of  the  uterus,  I 
think  we  might  have  ended  the  operation  in  other  twenty 
minutes. 

I  trust  that  as  experience  ripens  we  may  all  follow  in 
the  footsteps  of  Leopold  of  Dresden  and  Cameron  of 
Glasgow,  whose  brilliant  records  are  so  highly  creditable 
to  nineteenth  century  obstetrics. 

Dr.  MuEBOCH  Cameeox  said  that  the  Csesarean  operation 
having  been  established  as  the  operation  alike  of  choice  and 
necessity,  a  few  simple  directions  on  the  procedure  might  be 
useful  to  those  who  may  at  any  future  time  require  to  perform  it. 

To  begin  with,  the  earlier  the  operation  is  carried  out  the 
better  result  will  follow.  When  the  patient  is  seen  early  enough, 
she  should  he  prepared  by  attention  to  diet  aud  bowels.  In  any 
case  an  enema  should  be  giveu,  and  the  bladder  emptied  imme- 
diately before  operation. 

Labour  should  have  set  in  and  the  os  allowed  to  dilate  slightly. 
The  arrangements  are  the  same  as  in  other  abdominal  operations, 
viz.  cleansing  of  the  walls,  shaving  the  pubes,  and  the  applica- 
tion of  warm  water  india-rubber  bottles  round  the  patient.  The 
instruments  required  are  scalpels,  a  blunt-pointed  bistour}',  di- 
rector, compression  forceps,  fifteen  pairs  of  Hagedorn's  21- 
inch  straight    needles   threaded  with   antiseptic  Chinese  twist 


118 


C-ESAREAN    SECTION. 


(kept  in  1 — 20  carbolic  and  Spt.  Vin.  Eect.),  catgut  sutures, 
scissors,  large,  flat,  and  small  round  sponges,  and  ligatures  for 
the  umbilical  cord.  A  serrenoeud  should  be  at  hand  where 
rupture  is  suspected,  as  hysterectomy  may  be  necessary. 

The  abdominal  incision  is  in  the  median  line  as  in  ovariotomy. 
As  regards  its  extent  it  may  be  from  five  to  six  inches,  and  will 
vary  in  position  according  to  the  distension  of  the  abdomen. 
Thus  if  the  abdomen  takes  this  form  (Fig.  1),  the  incision  may 
be  got  without  extending  beyond  the  umbilicus ;  but  when  it  is 
pendulous,  thus  (Fig.  2)  : 


Fig.  1. 


Fig.  2. 


the  incision  must  of  necessity  extend  more  or  less  above  the 
umbilicus. 

Before  opening  the  uterus  the  operator  should  satisfy  himself 
that  the  uterus  is  not  only  in  the  median  line,  but  that  it  is  not 
twisted  upon  its  axis,  as  in  such  a  case  you  are  more  likely  to  cut 
down  upon  the  placenta. 

The  uterus  having  been  placed  in  the  median  line,  the  opera- 
tor should  pass  in  his  fingers,  and  feel  if  he  can  detect  the 
Fallopian  tube  on  either  side  (usually  the  left),  as  at  times  the 
organ  is  so  much  rotated  as  to  present  its  lateral  surface  ante- 
riorly. The  next  point  is  to  open  the  uterus  with  as  little  loss 
of  blood  as  possible,  and  this  can  easily  be  done  by  placing  an 
almost  straightened  Graily  Hewitt's  pessary  flab  upon  the  wall 
around  the  point  of  incision  (Fig.  3). 

The  assistant  whilst  steadying  the  uterus  can  easily  place  two 
fingers  upon  the  pessary,  and  slight  pressure  will  readily  prevent 
bleeding.  The  incision  (always  in  the  median  line)  should  be 
made  without  puncturing  the  membranes. 

If  the  placenta  lies  in  the  line  of  incision  it  will  soon  be  dis- 
covered, but  need  cause  no  alarm,  as  the  finger  can  readily  stop 
any  gush  of  blood  from  that  source. 

Whenever  the  membranes  are  reached  a  director  is  placed 
within  the  opening,  which  is  then  enlarged  with  a  blunt-pointed 
bistoury  so  as  to  admit  the  finger.     At  this  point  the  compress- 


CESAREAN    SECTION.  119 

ing  pessary  is  removed,  and  the  incision  extended  upwards  and 
downwards  sufficiently  to  permit  the  passage  of  the  foetus.  The 
extension  of  the  incision  downwards  should  be  limited,  as  it  is 
likely  to  interfere  with  proper  contraction  of  the  uterus.  Should 
the  placenta  intervene,  the  incision  is  quickly  made  through  its 
thickness  and  then  extended,  upwards  and  downwards,  cutting 
at  the  same  time  the  uterine  wall  and  placenta.  Under  such 
circumstances  the  operator  must  be  expert,  so  as  to  prevent  loss 
of  blood.     Flat  sponges  prevent  the  discharge  passing  into  the 

Fig.  3. 


peritoneal  cavity.  The  uterus  should  not  be  everted  until  it  is 
emptied.  In  every  case  the  incision  should  be  made  with  the 
bistoury,  and  tearing  avoided.  No  ligature  round  the  cervix  is 
required  to  control  bleeding ;  and  besides,  the  constriction  might 
induce  inertia. 

There  should  be  no  hesitation  in  making  the  incision,  which  is 
extended  upwards  and  downwards  by  a  single  cut  from  within 
outwards  in  each  direction.  The  left  hand  is  then  inserted  with- 
out rupturing  the  membranes,  and  the  head  turned  out  with  the 
fingers.  Should  the  feet  present,  they  may  be  seized,  and  the 
child  extracted  without  delay. 

If  the  shoulder  presents,  a  hand  should  be  placed  upon  it  to 
prevent  its  expulsion,  as  it  adds  very  much  to  the  difficulty,  see- 
ing the  uterus  immediately  contracts  whenever  any  portion  of 
the  child's  body  is  allowed  to  protrude. 


120 


CESAREAN    SECTION. 


The  child  having  been  extracted,  the  assistant  places  a  flat 
sponge  over  the  upper  angle  of  the  incision  to  prevent  the 
bowels  from  escaping.  The  cord  having  been  tied  and  divided, 
the  placenta  is  immediately  removed  with  the  left  hand,  great 
care  being  taken  to  secure  the  removal  of  all  membranes  and 
prevent  the  entrance  of  blood  into  the  abdominal  cavity.  The 
assistant  now  everts  the  uterus  from  the  cavity  and  pushes  a 
flat  sponge  behind  it.  The  lips  of  the  wound  are  next  everted,  the 
assistant  grasping  the  upper  angle  and  wall  with  his  right  hand, 
and  the  lower  angle  and  wall  with  his  left,  in  the  following 
manner : 


a.  Eight  hand.     b.  Left  hand.     c.  Cut  surfaces  everted. 
d  e.  Points  where  sutures  are  introduced. 

The  operator  immediately  inserts  the  silk  ligatures,  beginning 
at  the  middle,  each  suture  grasping  the  outer  two-thirds  of  the 
uterine  wall.     Seven  or  eight  sutures  should  suffice. 


Fig.  5. 


Sutures  in  position. 

The  lips  of  the  wound  are  carefully  sponged  as  each  ligature 
is  tied ;  this  done,  the  whole  organ  is  enveloped  in  a  large  flat 


.CiESAREAN    SECTION.  121 

warm  sponge  and  firm  compression  made,  which  immediately 
causes  contraction.  Should  any  oozing  appear  at  the  needle 
punctures  a  second  warm  sponge  should  be  applied,  and  very 
slight  pressure  will  suffice  to  overcome  any  tendency  to  relaxa- 
tion. Should  the  peritoneal  edges  gape  at  any  points,  a  few 
superficial  catgut  sutures  should  be  inserted  to  bring  the 
surfaces  together.  The  performance  of  hysterectomy  for  oozin<T 
is  bad  treatment,  as  pressure  with  a  warm  sponge  with  both 
hands  never  fails  to  secure  contraction. 

Greig  Smith  and  others  advise  the  introduction  of  a  drainage- 
tube  through  the  cervix  and  vagina,  and  the  leaving  it  there  to 
act  as  a  drain.  Nothing  could  be  worse.  Of  course  it  is  the 
procedure  of  a  surgeon,  but  everyone  who  has  practised  midwifery 
knows  that  the  presence  even  of  a  clot  in  the  uterus  may  lead  to 
serious  haemorrhage. 

Such  a  body  as  a  tube,  if  not  expelled,  would  induce  haemorrhage, 
distension  of  the  uterus,  and  bursting  of  the  incision,  with  speedy 
death  of  the  patient.  This  is  no  mere  theory,  but  is  what  has 
actually  taken  place  where  drainage  had  been  resorted  to.  On 
no  condition  should  the  uterine  cavity  be  washed  out  or  medi- 
cated in  any  way.  The  less  the  parts  are  interfered  with  the 
better.  Before  replacing  the  uterus  in  the  abdomen  it  might 
be  desirable  to  ligature  the  Fallopian  tubes  with  antiseptic  silk, 
in  order  to  prevent  future  pregnancy. 

This  procedure  is  efi'ective,  and  leads  to  no  complications  nor 
bad  results,  nor  is  menstruation  interfered  with. 

The  uterus  having  been  replaced,  the  cavity  is  cleansed,  and  the 
external  wound  in  the  parietes  completely  closed  in  the  ordinary 
manner  with  antiseptic  silk.  Intermediate  silkworm  gut  sutures 
give  more  intimate  union,  and  may  be  left  for  some  days  after 
the  ordinary  silk  sutures  have  been  removed,  say  about  the 
tenth  day.  The  wound  is  dusted  with  iodoform,  a  small  strip  of 
boracic  cotton  placed  along  the  wound,  two  or  three  strips  of 
plaster  applied  from  side  to  side  to  prevent  strain  on  the  sutures 
in  case  of  distension  or  cough.  A  pad  of  wood-wool  tissue  or 
sublimated  gamgee  is  applied,  and  the  bandage  firmly  secured 
after  treatment.  The  diet  for  the  first  three  days  consists  of 
sips  of  warm  water  and  milk  in  increasing  quantities.  For  a 
few  nights  half  a  grain  morphine  suppository  is  given.  The 
urine  is  drawn  ofi"  for  two  days  every  six  hours,  and  on  the  fourth 
day  a  teaspoonful  of  glycerine  in  two  ounces  of  soapy  water  is 
administered  as  an  enema.  The  bowels  having  been  moved,  the 
patient  is  allowed  chicken  soup,  beef  tea,  &c.  The  child  is  put 
to  the  breast  on  the  third  day. 

A  list  of  fifteen  cases,  with  only  two  deaths,  was  then  shown  by 
Dr.  Cameron,  and  these  in  no  way  due  to  the  operation ;  the 
first  having  resulted  from  injuries  from  a  fall  of  ten  feet  before 


122  C-ESAREAN    SECTION. 

admission,   with   haemorrhage,   and   the   second   from   Bright's 
disease. 

On  the  motion  of  Dr.  Leith  Napier,  seconded  by  Dr. 
Handfield-Jones,  the  discussion  was  adjourned  until  the 
next  meeting. 


APRIL  6th,  1892. 

J.  Watt  Black,  M.D.,  President,  in  the  Chair. 

Present — 50  Fellows  and  3  Visitors. 

Books  were  presented  by  Dr.  Herman,  Dr.  Braxton 
Hicks,  Mr.  Daniel  Syme,  the  Royal  Medical  and  Chirur- 
gical  Society,  the  American  Gynaecological  Society,  the 
Medical  and  Chirurgical  Faculty  of  the  State  of  Mary- 
land, the  St.  Bartholomew's  Hospital  Staff,  and  the 
Westminster  Hospital  Staff. 

Sydney  Beauchamp,  M.B.,  B.C.Cantab. ;  George 
Drummond  Robinson,  M.B.,  B.S.Lond.  ;  and  John 
William  Campbell,  B.A.,  M.B.,  B.Ch. Cantab.,  were  ad- 
mitted Fellows  of  the  Society. 

W.  E.  St.  Lawrence  Finny,  M.B.,  M.Ch.Diibl.  (King- 
eton  Hill);  William  Gardner,  M.D.,  C.M.Glas.  (Mel- 
bourne) ;  George  Arthur  Hawkins  Ambler,  F.R.C.S.Ed. 
(Clifton)  ;  and  Domingo  Montbrun,  M.D.  (Port  of  Spain), 
were  declared  admitted. 

Alfred  Samuel  Gubb,  M.D.Paris,  L.R.C.P.Lond.  ;  and 
John  Harold,  L.R.C.P.Lond.,  were  elected  Fellows  of  the 
Society. 

The  following  gentlemen  were  proposed  for  election  :^ 
Francis  Alexander  Barton,  L.R.C.P.Lond.  (Beckenham)  ; 
and  W.  Gifford  Nash,  F.R.C.S.  (Bedford). 


124 


SPECIMEN  OF  AXIAL  ROTATION  OF  A 
RIGHT-SIDED  PAROVARIAN  CYST  WITH 
ATTACHED  RIGHT  OVARY  AND  FALLO- 
PIAN TUBE  DISTENDED  BY  H^MOR- 
RHAGE. 

Shown  by  A.  D.  Leith  Napier,  M.D. 

M.  B — ,  single,  27,  seen  in  consultation  on  December 
14tli,  1891. 

Family  history. — Paternal  sypbilis. 

Personal  history. — Health  fairly  good,  but  never  strong; 
has  interstitial  keratitis.  Three  years  ago  fell  down  a 
stair,  suffered  subsequently  from  abdominal  pain  ;  three 
months  ago  had  acute  pain  in  abdomen  with  sickness  and 
great  prostration  ;  was  then  in  bed  over  a  fortnight. 
Periods  at  fifteen,  always  regular  ;  dysmenorrhoea  ;  last 
menstruation  three  weeks  before  present  illness. 

Present  illness. — On  December  11th  seized  with  sudden 
acute  abdominal  pain,  accompanied  by  violent  and  un- 
controllable sickness  ;  micturition  very  painful ;  obstinate 
constipation.  Diagnosis  of  ovarian  tumour  of  right  side' 
complicated  by  peritonitis,  probably  due  to  twisting  of 
the  pedicle.      Immediate  operation  advised. 

Operation  in  Chelsea  Hospital  for  Women  on  December 
15th.  On  opening  the  abdomen  a  highly  coloured  cysfc 
was  disclosed.  Adhesions  in  front  and  especially  on  right 
side  of  pelvis.  On  tapping  about  two  pints  of  thin  light' 
red  fluid  was  obtained.  When  emptied  the  cyst  was  par- 
tially withdrawn  from  the  abdomen,  a  hard  lobulated  mass 
was  felt,  which  dipped  deeply  on  the  pelvis  and  pushed' 
down  the  retroverted  uterus.  Posterior  adhesions  werO' 
separated,  and  the  tumour  removed  ;  its  size  was  fully  that 
of  a  large  cocoa-nut.  The  right  Fallopian  tube  and  ovary 
were  firmly  attached  to  the  cyst.  On  the  lower  part  of 
the  cyst-wall  was  a  mass  of  organised  blood  which  had' 


AXIAL    ROTATION    OF    EIGHT-SIDED  PAROVARIAN    CYST.    125 

undergone  some  degeneration.  The  pedicle,  which  was 
composed  partly  of  right  Fallopian  tube  and  partly  of  a 
portion  of  right  broad  ligament,  was  rotated  from  right  to 
left,  and  very  short.  A  piece  of  congested  inflamed 
omentum  was  ligatured  and  removed.  Such  portions  of 
intestine  as  were  visible  were  reddened  in  colour,  and  had 
the  superficial  vessels  injected.  Shreds  of  inflammatory 
lymph  and  several  small  ante-operation  clots  of  blood 
were  removed  on  sponging.  The  patient  made  an 
excellent  recovery.  She  reported  herself  on  February 
22nd,  1892,  when  she  was  menstruating;  this  was  the 
second  period  since  the  operation.  She  has  had  no  dys- 
menorrhoea  as  formerly.  Description  of  specimen  (which 
is  now  shrunken  from  spirit  and  of  very  dark  colour)  : — 
A  large  cyst  distinct  from  and  below  right  ovary.  The 
whole  of  the  specimen  was  deeply  congested,  free  haemor- 
rhages had  occurred  within  the  wall ;  in  the  lower  portion 
the  blood  had  passed  beyond  the  wall.  Dr.  Shaw- 
Mackenzie  regarded  the  condition  of  some  parts  of  the  cyst 
as  analogous  to  commencing  moist  gangrene.  The 
ovary  and  Fallopian  tube  were  also  sites  of  hasmorrhage. 
In  vol.  xxii,  p.  86,  of  our  '  Transactions,'  there  is  an 
interesting  paper  by  Mr.  Law  son  Tait  "  On  axial  rotation 
of  ovarian  tumours  leading  to  their  strangulation  and 
gangrene."  In  this  paper  and  the  subsequent  discussion, 
in  which  Sir  Spencer  Wells,  Dr.  Bantock,  Dr.  Heywood 
Smith,  and  Mr.  Doran  took  part,  may  be  found  several 
pertinent  facts  and  suggestions.  Mr.  Bland  Sutton  has 
also  devoted  a  chapter  of  his  recent  work  on  *  Surgical 
Diseases  of  the  Ovaries  and  Fallopian  Tubes'  to  "  Axial 
Rotation."  I  can  add  nothing  to  Mr.  Sutton's  excellent 
description,  except  that  I  venture  to  suggest  that  this 
specimen,  evidently  one  of  acute  torsion,  seems  to  illus- 
trate what  Mr.  Sutton  disputes,  viz.  that  axial  rotation  of 
the  pedicle  may  cause  gangrene.  No  patient  could  have 
been  in  more  imminent  peril  before  operation,  no  con- 
valescence could  have  been  more  rapid  or  satisfactory. 


126 


SPECIMEN  OF  CYSTIC  OVARY  AND  ENLARGED 
TUBE.  ABDOMINAL  SECTION.  HISTORY 
OF  PREGNANCY  WITHIN  TWO  MONTHS. 

Shown  by  Dr.  A.  D.  Leith  Napier. 

S.  D — ,  vet.  36j  married  fifteen  years.  Five  children. 
Three  abortions.      Last  pregnancy  two  years  ago. 

Complaining  of  right-sided  pelvic  pain  for  about  four 
years  prior  to  admission  to  hospital.  Admitted  September 
22nd,  1891.  Period  appeared  a  month  before  this,  and 
continued  four  weeks  ;  ceased  three  days  prior  to  ad- 
mission. 

Examination  pe?-  hyiJogastrium. — Nothing  definite,  slight 
tenderness  in  the  right  iliac  region.  Per  vaginam  cervix 
enlarged,  deep  erosion  of  anterior  lip.  Bimanually  a  freely 
moveable  cystic  swelling  about  size  of  a  hen's  egg  to  left 
of  uterus. 

Operation  (October  1st). — The  right  tube  and  ovary 
■were  matted  together  and  adherent  to  surrounding  tissues. 
On  adhesions  being  separated  the  ovary  and  tube  were 
found  to  be  normal,  and  were  left  in  situ.  On  the  left 
side  a  small  cystic  swelling  was  discovered ;  this  was 
brought  up,  and  proved  to  be  a  cyst  of  the  left  ovary, 
which  with  the  tube  was  removed.  Absolutely  non-febrile 
convalescence.      Left  hospital  well  26th  October. 

The  specimen  is  a  small  multilocular  ovarian  cyst. 

March  19th,  1892. — The  patient  attended,  stating  she 
has  had  amenorrhoea  for  over  three  months,  but  is  feeling 
very  well,  and  has  had  no  pain  since  the  operation.  Exa- 
mined, pregnancy  of  three  months  established. 

This  case  shows  (1)  the  advantage  of  early  operation 
in  cystic  ovarian  disease  ;  (2)  the  tolerance  of  the  re- 
productive organs ;  (3)  the  wisdom  of  leaving  a  healthy 
ovary  alone. 


.       9f 

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3 

127 


UTERUS,  WITH  KIDNEYS  AND  URETERS,  FROM 
A  CASE  OF  CESAREAN  SECTION. 

Shown  by  Dr.  W.  Duncan. 

The  patient  was  a  secundipara, -with  well-marked  rickets. 
First  child  was  delivered  with  much  difficulty  by  embry- 
otomy fifteen  months  previously. 

Pelvic  measurements  were  as  follows 

Between  anterior  superior  spines 
Between  iliac  crests 
External  conjugate 
Diagonal  conjugate 

Ccesarean  section  was  performed  on  March  12th,  1892, 
a  few  days  before  the  expected  onset  of  labour.  The 
abdomen  was  opened ;  the  gravid  uterus  brought  out  of 
the  abdominal  cavity,  and  enveloped  in  a  towel  wrung 
out  of  hot  mercuric  chloride  solution.  The  uterus  was 
next  incised  in  the  middle  line  until  the  membranes  were 
reached  ;  the  incision  was  then  enlarged  to  admit  the 
hand,  and  the  child  (a  healthy  male)  was  delivered  by 
seizing  the  head,  and  without  rupturing  the  membranes. 
The  placenta  and  membranes  were  next  carefully  removed. 
The  uterus  was  with  a  good  deal  of  difficulty  made  to 
contract  by  the  insertion  of  a  lump  of  ice  into  its  cavity 
(after  hot  water  had  failed) .  It  was  then  sewn  up  by 
about  eight  deep,  and  the  same  number  of  half-deep 
sutures.  The  Fallopian  tubes  were  tied  in  two  places,  and 
divided  between  the  ligatures.  Then  the  abdominal  wound 
was  sewn  up  in  the  usual  way.  The  operation  lasted  fifty 
minutes. 

The  patient  on  the  eighth  day  Avas  so  satisfactory,  and 
the  abdominal  wound  looked  so  well,  that  all  the  stitches 
were  removed,  and  broad  pieces  of  strapping  applied  over 


128  UTERUS  PROM  A  CASE  OP  CESAREAN  SECTION. 

the  abdomen.  Six  liours  later,  during  a  sudden  fit  of 
coughing,  the  whole  length  of  the  abdominal  wound  was 
torn  open,  and  the  intestines  protruded  ;  these  were  with 
a.  good  deal  of  difficulty  cleansed  and  returned,  and  then 
the  wound  re-sewn  up.  The  patient  died  of  collapse  and 
commencing  peritonitis  thirty-four  hours  later. 

Report  hy  the  Pathologist,  Dr.  Voelcker. — The  uterus  is 
enlarged  and  flabby.  There  is  a  median  incision  3*25 
inches  long  in  the  anterior  wall ;  the  incision  has  been 
closed  by  seventeen  silk  sutures.  These  are  largely  covered 
by  inflammatory  lymph.  The  sutures  have  cut  into  the 
uterine  tissue  in  some  cases  to  a  depth  of  a  quarter  of  an 
inch,  but  nowhere  is  any  communication  with  the  interior 
of  the  uterus  to  be  made  out.  Some  of  the  stitches  have 
yielded.  The  uterus,  measured  within  its  cavity,  is  5'5 
inches  long,  and  at  the  fundus  4*75  inches  broad.  It  is 
flabby  ;  os  patulous  ;  admits  finger  readily.  The  placental 
gite  is  near  the  fundus  on  the  posterior  wall. 

Kidneys. — Bight  :  Pelvis  much  dilated.  Kidney  not 
much  enlarged ;  pale ;  capsule  rather  adherent. 

Left  kidney  rather  larger  ;  pale ;  capsule  strips  with  a 
little  difficulty ;  cortex  fair  thickness,  pale,  consistence 
rather  decreased.      Pelvis  very  little  if  at  all  dilated. 

Ureters. — Right  convoluted  and  dilated  in  its  whole 
extent ;  a  small  irregular  calculus  is  found  impacted  at 
its  lower  extremity.  Urine  can  be  forced  into  the  bladder, 
the  vesical  orifice  being  patent,  though  a  small  tag  of 
mucous  membrane  projects  from  the  orifice.  The  stone 
is  partly  encapsuled  by  the  ureter. 

Left  ureter  presents  nothing  abnormal. 


129 


MALFORMATION  OF  RECTUM  AND  BLADDER, 
CONGENITAL  ABSENCE  OF  BOTH  KIDNEYS 
AND  URETERS,  IMPERFORATE  ANUS,  AB- 
SENCE OF  RIGHT  HYPOGASTRIC  ARTERY, 
AND  DEFORMED  FEET. 

By  Aethuk  E.  Giles,  M.B.,   B.Sc.Lond. 

This  child  was  sent  to  me  by  a  midwife  in  the  out- 
door department  of  the  General  Lying-in  Hospital.  It 
had  breathed  only  once  or  twice. 

External  appearance. — The  upper  part  of  the  body  was 
well  formed.  The  feet  were  deformed,  there  being  only 
two  toes  on  one  foot,  and  one  on  the  other.  There  was 
no  trace  of  an  anus.  The  scrotum  consisted  of  two  sepa- 
rate halves ;  they  and  the  penis  were  small. 

On  dissection  the  brain  was  well  developed  and  the 
thoracic  organs  normal.  The  stomach,  liver,  small  intes- 
tine, and  the  greater  part  of  the  large  intestine  were  also 
well  formed.  The  rectum  was  found  to  pass,  inferiorly, 
directly  into  the  bladder,  into  which  opened  the  vasa 
deferentia.  The  ''  apex  "  of  the  bladder  was  not  well 
differentiated,  passing  insensibly  into  the  urachus.  The 
urethra  was  about  the  size  of  the  urachus. 

The  aorta  divided  high  up  into  two  unequal  parts — the 
left,  which  was  considerably  the  larger,  divided  very  soon 
into  the  left  hypogastric  and  a  common  iliac,  which  again 
divided  into  internal  and  external  iliac.  The  right  com- 
mon iliac  was  small,  and  divided  at  the  level  of  the  pelvic 
brim  into  external  and  internal  iliac,  the  right  hypogastric 
being  completely  absent. 

No  trace  of  ureters  could  be  found.  Two  oi'gans  occu- 
pied the  position  and  had  the  shape  of  kidneys,  whilst 
the  supra-renal  bodies  appeared  to  be  absent.  But  on 
dissecting  off  the  "  renal  "  connective  tissue  the  organs 
had  rather  the  appearance,  superficially,  of  supra-renals 


130         MALFOEMATION    OF    RECTUM    AND    BLADDER^    ETC. 

than  of  kidneys.  Mr.  S.  G.  Shattock,  Pathologist  to  St. 
Thomas's  Hospital,  kindly  examined  them  histologically 
for  me.  He  writes,  ''  The  organs  sent  consist  of  the  two 
supra-renal  capsules  ;  I  have  examined  only  one  of  them, 
and  it  has  the  ordinary  histological  structure.  I  presume 
the  other  is  its  fellow.      There  are,  therefore,  no  kidneys." 

The  bladder  certainly  has  the  appearance  of  not  having 
been  functionally  employed. 

The  testicles  were  high  in  the  abdomen,  connected  with 
the  epididymis  of  each  side  ;  they  had  rather  the  appear- 
ance of  ovaries  than  of  testicles,  as  far  as  size  and  shape 
are  concerned.  Mr.  Shattock  was  good  enough  to  exa- 
mine pai't  of  one  of  them  microscopically,  and  reports 
that  it  has  the  testicular  structure. 

The  nature  of  the  deformity  in  this  case  is  unusual. 
Complete  absence  of  kidneys  and  ureters  is  rare.  Mayer, 
of  Bonn,  reports  a  case  in  the  '  Zeitschrift  flir  Physiologic,' 
but  in  his  case  there  was  also  absence  of  the  bladder,  and 
the  spinal  cord  was  found  to  be  arrested  in  development 
at  its  lower  end. 

The  deformity  of  the  rectum  and  bladder  is  not  the 
usual  one.  In  atresia  ani  vesicalis,  when  the  rectum  opens 
into  the  bladder,  the  opening  is  commonly  into  the  base 
of  an  otherwise  well-formed  bladder.  I  believe  that  the 
present  case  is  explained  by  the  developmental  "  fault " 
having  occurred  very  early,  probably  soon  after  the  fortieth 
day,  at  which  period  the  rectum  and  incipient  bladder 
communicate.  I  think  further,  from  the  appearance  of 
the  parts,  that  the  allantois  arose  quite  from  the  terminal 
part  of  the  proctodasum,  instead  of  a  little  way  from  the 
end,  as  is  customary  ;  and  this,  if  so,  may  in  a  measure 
account  for  the  condition  found. 

There  is  here  no  communication  between  rectum  and 
bladder;  the  latter  is  empty,  and,  indeed,  there  is  hardly 
any  real  ''  cavity." 

The  absence  of  the  right  hypogastric  artery  is  note- 
worthy, but  I  cannot  find  that  it  has  any  relation  to  the 
other  deformities. 


MALFORMATION    OF    BLADDER    AND    RECTUM,   ETC. 


131 


.  Aorta.  B.  Vena  cava.  c.  Right  supra-reual  capsule.  D.  Left 
supra-renal  capsule,  e.  Left  common  iliac  artery.  F.  Right 
common  iliac  artery.  G.  Rectum,  u.  Epididymis.  I.  Testis. 
J.  Bladder  (base).  K.  Vas  deferens.  l.  Left  hypogastric 
artery.  Ji.  Bladder  (apex).  >'.  Urachus.  o.  Urethra,  r.  Left 
external  iliac  artery.  Q.  Anterior  crural  nerve  (left).  E.  Pubes 
(left  side,  divided). 


VOL.  XXXIV. 


10 


132  .  CONGENITAL    DIAPHRAGMATIC    HERNIA. 

I  have  not  been  able  to  find  in  the  compendious  works 
of  Forster  and  of  Ahlfeld  any  account  of  a  similar  defor- 
mity, nor  do  I  know  of  any  drawing  of  this  condition. 

I  propose  to  leave  the  consideration  of  the  malforma- 
tion of  the  feet  for  a  future  occasion. 

Dr.  Leith  Napier  asked  if  there  was  any  history  of  hydram- 
nion.  With  the  absence  of  renal  organs,  &c.,  and  the  other 
deformities  shown,  this  was  of  some  clinico-pathological  im- 
portance. 

A  Committee  consisting  of  Mr.  Alban  Doran,  Drs.  Dakin 
and  Giles,  was  appointed  to  report  on  this  specimen. 


A  CASE  OF  CONGENITAL  DIAPHRAGMATIC 
HERNIA. 

By  Arthur  E.  Giles,  M.B.,  B.Sc.Lond.,  &c. 

I  WAS  called  out  to  this  case  by  a  midwife  in  the 
Maternity  District  of  the  General  Lying-in  Hospital. 
On  my  arrival  the  baby  had  been  born  about  an  hour  and 
a  half,  and  had  not  breathed  properly.  There  was  then 
just  a  faint  fluttering  of  the  heart.  After  carrying  on 
artificial  respiration  for  some  time  I  found  the  heart  had 
stopped.  The  abdomen  was  very  prominent;  the  liver 
could  be  felt  to  be  enlarged,  and  there  was  evidently 
some  ascitic  fluid  in  the  peritoneal  cavity.  I  was  specially 
struck  with  the  difficulty  of  compressing  the  chest  while 
performing  artificial  respiration. 

Post-mortem  examinatioiu—The  liver  was  unusually 
large,  and  the  abdomen  contained  about  1|  oz.  of  clear 
fluid.      The  stomach  and  duodenum  were  very  much  dis- 


CONGENITAL    DIAPHRAGMATIC    HERXIA. 


133 


■mVZ  r  ^'^^  ^","«-  ^-  ^'='^'  ^""?'  atrophied,  d.  Heart 
m  pencardium.  e.  Intestines,  f.  Diapliragm.  o.  Stomach 
H.  Duodenum,  i.- Spleen.  J.  Large  intestine^  K.  Left  eSe 
1.  Bladder,     m.  Lelt  hypogastric  artery. 


:134  RDPTURED    TUBAL    GESTATION. 

tended,  as  was  also  the  large  intestine.  An  aperture  was 
found  in  the  diaphragm,  posteriorly  on  the  right,  admit- 
ting two  fingers.  Through  this  the  whole  of  the  small 
intestine,  the  ascending  colon,  and  the  vermiform  ap- 
pendix had  passed  into  the  thorax.  There  was  no  peri- 
toneal sac.  The  right  supra-renal  capsule  also  lay  in  the 
thoracic  cavity. 

The  intestine  just  below  the  duodenum  was  narrow,  as 
if  it  had  been  pressed  upon  by  the  margin  of  the  dia- 
phragmatic aperture,  thus  accounting  for  the  great  dis- 
tension of  the  stomach  and  duodenum. 

The  right  lung  was  atrophied,  especially  the  lower  lobe. 
The  left  was  normal  size,  and  contained  some  air. 

Both  testicles  were  in  the  abdomen.  Other  organs 
normal. 

The  child  was  well  developed,  weighing  8  lbs.,  and 
measuring  22  inches. 

Dr.  Hetayood  Smith  wished  to  draw  attention  to  a  similar 
case  that  he  had  exhibited  before  the  Society,  July  2nd,  1873 
('  Obstet.  Traus.,'  vol.  xv,  p.  162).  The  mother  was  twenty- 
nine  years  of  age,  and  that  was  her  fifth  child.  In  that  case  the 
hernia  was  on  the  left  side,  and  there  was  no  peritoneal  sac. 


RUPTURED  TUBAL  GESTATION. 

By    C.    J.    CULLINGWORTH,    M.D. 

Dr.  C.  J.  CuLLiNGWORTH  exhibited  the  foetus,  placenta, 
and  membranes,  together  with  a  decidual  cast  of  the 
uterine  cavity,  from  a  case  of  ruptured  tubal  gestation. 
The  patient,  a  married  woman  of  37,  was  admitted  to  St. 
Thomas's  Hospital,  February  23rd,  1892,  looking  very 
weak  and  ill,  and  presenting  the  ordinary  physical  signs  of 
pelvic    hajmatocele,    the    uterus    being  pushed  forwards 


DESCRIPTION   OF   PLATE   I, 

Illustratiug  Dr.  Cullingwortli's  Specimen  of  Ruptured 
Tubal  Gestation. 

The  fcEtus  is  represented  a  little  under  the  natural  size.  Beneath 
it,  and  connected  with  it  by  the  umbilical  cord,  is  the  torn  and 
irregular  placenta  with  the  foital  membranes,  the  latter  being  turned 

inside  out. 

On  the  left  the  lower  figure,  also  somewhat  reduced  in  size,  repre- 
sents the  ruptured  and  now  empty  Fallopian  tube,  whilst  the  figure 
above  shows  the  decidual  membrane,  oj  natural  size,  forming  a  cast 
of  the  uterine  cavity,  in  the  wall  of  which  a  window  has  been  cut  to 
display  the  inner  surface  of  the  membrane. 


PLATE  I 


OBSTETRICAL  TRANSACTIONS  VOL  XXXTV. 


m^ 


Xjr 


■Vcst,Jfewm.an  chrLth. 


RUPTURED   TUBAL    GESTATION.      -  135' 

against  the  abdominal  wall  by  an  ill-defined  soft  swelling' 
that  filled  the  pelvis  and  extended  two  inches  higher 
than  the  fundus  uteri.  The  history  was  as  follows: — 
The  patient  was  confined  of  her  fourth  and  last  child 
five  years  ago.  Her  last  menstrual  period  ceased 
November  24th,  1891.  From  that  time  she  had  suffered 
more  or  less  continuous  pain  in  the  lower  part  of  the 
abdomen,  especially  on  the  right  side.  On  the  20th 
January,  1892,  she  was  suddenly  seized,  whilst  sitting 
quietly  in  the  house,  with  a  very  violent  pain  in  the 
right  iliac  region,  which  compelled  her  to  go  to  bed. 
Two  hours  later  she  had  a  somewhat  profuse  haemor- 
rhage per  vaginam.  She  had  two  subsequent  attacks  of 
htemorrhage,  slighter  in  character,  during  the  following 
month,  and  she  was  in  constant  though  less  severe  pain. 

On  admission  (February  23rd)  the  case  was  diagnosed. 
as  a  pelvic  haematocele,  due  either  to  ruptured  tubal 
gestation  or  a  tubal  abortion.  On  March  8th  painful 
uterine  contractions  came  on,  and  the  decidual  cast  now 
exhibited  was  expelled  per  vaginam.  The  diagnosis  was, 
of  course,  placed  thereby  beyond  doubt.  It  was  decided, 
however,  for  the  present  to  watch  the  case,  being  prepared 
to  interfere  at  any  moment  if  the  necessity  arose.  When 
the  patient  had  been  in  the  hospital  for  a  month,  and 
the  tumour  was  found  not  to  have  diminished,  but,  if 
anything,  increased  in  size,  it  was  determined  to  open 
the  abdomen.  This  was  done  on  the  21st  of  March.  A 
mass  of  dark  firm  clot,  11^  oz.  by  weight,  was  found 
filling  the  pelvis,  and  in  the  midst  of  this  mass  there 
was  found  a  foetus  4  inches  long,  with  cord  6i  inches 
long,  placenta,  and  foetal  membranes.  The  hgematocele 
was  roofed  in  by  adherent  omentum  and  intestine.  After 
the  pelvis  had  been  cleared,  the  dilated  and  ruptured 
right  tube  was  brought  into  view  and  removed.  The 
patient  had  so  far  made  an  uninterrupted  recovery. 

The  size  of  the  foetus  made  it  evident  that  either  the 
patient  was  mistaken  as  to  her  dates,  and  was  really 
eleven  or  twelve  weeks  pregnant  when  the  first  symptoms 


156     SQUAMOUS-CELLED  CARCINOMA  OF  THE  CERVIX  UTERI. 

of  internal  haemorrhage  occurred,  or  the  foetus  had  con- 
tinued to  live  and  grow  for  three  or  four  weeks  notwith- 
standing the  haemorrhage. 

A    pencil    drawing    of    the    decidual    membrane    was 
exhibited  along  with  the  specimen. 


A  CASE  OF  SQUAMOUS-CELLED  CARCINOMA 
OF  THE  CERVIX  UTERI,  IN  WHICH  THE 
DISEASE  HAD  EXTENDED  IN  AN  UPWARD 
AND  NOT  IN  A  DOWNWARD   DIRECTION. 

By    C.    J.    CULLINGWORTH,    M.D. 

Dr.  CuLLiNGWORTH  showod  a  uterus  recently  removed 
by  vaginal  hysterectomy  for  cancer  of  the  cervix,  and 
placed  a  section  of  the  growth  under  the  microscope. 

The  case  appeared  a  typical  one  for  a  radical  opera- 
tion. The  uterus  was  freely  moveable  in  all  directions, 
no  thickening  of  the  lateral  connective  tissue  could  be 
felt ;  there  had  been  no  offensive  discharge  until  the  last 
fortnight ;  the  disease  had  not  spread  on  to  the  vaginal 
wall  or  even  the  j'ortio  vaginalis  cervicis,  and  the  patient 
had  not  suffered  in  her  general  health.  The  only  physical 
signs  of  disease  were  hardness  and  thickening  of  the 
cervix,  and  a  ragged  and  somewhat  ulcerated  condition 
of  the  lower  part  of  the  cervical  canal.  He  had  certainly 
regarded  the  case  as  a  well-marked  example  of  columnar- 
celled  carcinoma  commencing  in  the  cervical  glands, 
infiltrating  the  whole  thickness  of  the  cervix,  and  showing 
no  tendency  to  invade  the  vagina.  He  was  surprised  to 
find,  during  the  operation,  that  the  anterior  wall  of  the 
cervix  crumbled  under  the  merest  touch  along  its  whole 
length,  rendering  it  impossible  to  obtain  the  usual  plane 
of  cleavage  between  it  and   the  bladder.      At  one    spot 


SQUAMOUS-CELLED   CARCINOMA  OF  THE  CERVIX  UTERI.    137 

contiguous  to  tlie  reflection  of  the  peritoneum,  a  small 
rent  was  made  in  tlie  bladder  during  the  separation  of 
that  viscus.  This  was  of  course  sutured  at  once.  The 
object,  however,  that  Dr.  Cullingworth  had  in  view  in 
bringing  this  specimen  forward  was  to  point  out  that 
although  the  whole  of  the  cervix  was  diseased,  and  the 
lowest  quarter  of  an  inch  of  the  body  without  any  involve- 
ment of  the  mucous  membrane  on  the  vaginal  side  of  the 
OS,  the  disease  histologically  proved  to  be  a  more  than 
usually  typical  example  of  squamous-celled  carcinoma. 
It  was  evident  that  our  views  and  teaching  as  to  the 
respective  directions  of  extension  of  the  two  varieties  of 
carcinoma  met  with  in  the  cervix  uteri  required  modifica- 
tion, or,  at  any  rate,  that  the  rule  as  to  the  tendency  to 
downward  extension  of  squamous-celled  carcinoma  was 
not  without  exception. 

Dr.  CHAiipifETs  said  that  the  question  whether  cancer  of  the 
cervix  ever  extended  to  the  body  was  hardly  crucial.  It  was 
generally  known  that  it  did  so  extend  sometimes.  The  point 
was,  at  what  period  did  it  so  extend?  The  disease  extended  in 
all  directions,  though  not  with  equal  rapidity.  The  most  impor- 
tant extension  was  outwards  into  the  cellular  tissue  surrounding 
the  cervix.  Did  it  ever  extend  into  the  body  without  extending 
into  this  cellular  tissue  ?  He  was  inclined  to  say  no.  If  this 
were  so  it  was  useless  to  operate  on  any  case  in  w^hich  cancer 
of  the  cervix  had  extended  into  the  body.  In  Dr.  Cullingworth's 
case  this  appeared  to  be  so,  for  the  cervix  was  all  but  eaten 
tlirough.  He  should  be  glad  to  know  how  long  a  time  elapsed 
before  recurrence  took  place. 

Dr.  CiTLLiNGWOETn,  in  reply  to  Dr.  Champneys,  said  he  had 
not  brought  this  case  forward  with  a  view  to  discussing  the 
advisability  of  the  operation  or  its  technique,  but  because  of  its 
singular  pathological  importance.  He  might,  however,  say  that 
he  did  not  believe  it  possible  to  have  ascertained  the  extent  of 
the  disease  before  operation.  Had  he  suspected  its  extent  he 
would  certainly  not  have  operated.  The  patient  unfortunately 
died  from  the  effects  of  the  operation,  so  that  he  could  give  no 
information  as  to  recurrence.  In  reply  to  Dr.  Lewers  he  pointed 
out  that  the  disease  had  extended  into  the  body,  and  that 
the  operation  of  supra-vaginal  amputation  of  the  cervix  would 
have  been  useless.  The  microscopic  specimen  on  the  table  had 
been  taken  from  the  affected  portion  of  the  body. 


138 


ADJOURNED   DISCUSSION  ON  CvESAREAN  SEC- 
TION. 

Dk.  Heywood  Smith  said  in  tliis  discussion  one  of  the 
most  important  points  was  the  time  of  operation,  and  he 
had  no  doubt  but  that  if  other  matters  could  be  arranged, 
it  was  far  better  to  wait  until  labour  had  set  in  before 
operating,  as  then  there  would  be  a  far  better  chance  of 
the  uterus  properly  contracting.  Through  the  courtesy 
of  Dr.  Duncan  he  had  the  opportunity  of  witnessing  his 
operation,  and  the  great  difficulty  in  obtaining  contraction 
of  the  uterus  ;  that  gave  rise  to  a  considerable  loss  of 
blood,  and  the  question  arose,  having  regard  to  the 
absence  of  proper  healing  both  of  the  abdominal  wound 
and  also  of  that  of  the  uterus,  whether  the  hemorrhage 
might  not  have  been  due  to  this  cause. 

Mr.  Bland  Sutton  related  the  following  details  of  a 
case  in  which  he  performed  Caesarean  section.  The 
patient,  twenty-six  years  of  age,  was  taken  in  labour  with 
her  second  child  at  seven  o'clock  on  the  morning  of  March 
24th.  At  the  end  of  ten  or  twelve  hours,  as  there  was 
little  advnnce,  the  practitioner  in  charge  of  the  case  made 
a  careful  examination  of  the  pelvis,  and  found,  to  his 
surprise,  that  the  promontory  of  the  sacrum  approached 
the  symphysis  so  closely  as  to  reduce  the  conjugate 
diameter  of  the  pelvis  to  less  than  an  inch  and  a  half. 
It  then  became  clear  that  interference  was  necessary. 
As  the  woman  was  anxious  to  save  the  child  if  possible, 
it  was  decided  to  perform  Csesarean  section  or  Porro's 
operation  instead  of  craniotomy,  and  Mr.  Sutton  was 
asked  to  sec  the  patient  with  the  view  of  performing  one 
or  other  of  these  operations. 


CESAREAN    SECTION.  139 

Assisted  by  Mr.  John  Murray  and  Mr.  Daniel  Thurston, 
who  was  in  charge  of  the  case,  Mr.  Sutton  performed 
Cassarean  section.  The  uterus  was  not  withdrawn  at  any 
time  from  the  abdomen.  The  sutures  used  were  sterilised 
silk,  and  inserted  after  the  manner  directed  by  Sanger. 
Very  little  blood  was  lost,  and  the  operation,  which  was 
extremely  simple,  only  occupied  thirty  minutes,  even 
though  it  was  done  in  a  small  private  room  and  under 
adverse  circumstances.  The  child  was  dead,  and  its 
head  had  assumed  a  conical  form  from  the  extreme  pres- 
sure to  which  it  had  been  subjected  during  the  fourteen 
hours  the  woman  had  been  in  labour. 

Mr.  Sutton  took  the  opportunity  of  sterilising  the  patient 
by  tying  each  Fallopian  tube  near  the  uterus  by  a  single 
piece  of  silk.  Tying  in  two  places  and  dividing  between 
the  ligatures  is  unnecessary,  as  one  ligature  will  obliterate 
the  lumen  of  this  soft  duct. 

The  after  treatment  was  most  skilfully  carried  out  by 
Mr.  Thurston,  assisted  by  Bloomsbury  nurses,  and  she 
has  made  a  rapid  and  easy  recovery.  Mr.  Sutton  stated 
that  he  had  always  regarded  Caesarean  section  with  horror, 
as  all  the  cases  in  which  he  had  seen  it  performed  quickly 
died.  The  interesting  cases  described  at  the  last  meet- 
ing of  the  Society  had  caused  him  to  look  more  favourably 
on  the  operation,  and  induced  him  to  carry  it  out  in  this 
case  instead  of  a  Porro,  and  the  result  fully  justifies  the 
choice. 

Before  carrying  out  the  operation  the  husband's 
opinion  was  specifically  asked  in  regard  to  the  sterilisa- 
tion of  the  patient.  He  deliberately  assented  to  the 
carrying  out  of  this  manoeuvre.  The  patient  not  being 
a  dwarf  it  became  interesting  to  ascertain  the  cause  of 
the  pelvic  narrowing.  A  subsequent  examination  of  the 
pelvis  seems  to  indicate  that  the  patient  has  spondylo- 
listhesis. 

Dr.  Cbampn'eys  said  that  in  a  subject  so  large  he  would 
only  allude  to  two  or  three  points  of  practical  importance. 


140  c^aesAREAN  section. 

The  first  was  tlie  danger  of  uterine  atony.  In  addition 
to  the  choice  of  time  (after  the  onset  of  labour),  it  was 
important  to  prevent  the  uterus  from  being  chilled.  The 
spray  was  objectionable  from  this  point  of  view,  so  Avas 
the  elastic  ligature  round  the  neck  of  the  uterus. 

The  second  point  was  a  difficulty  which  arose  in  some 
cases  where  labour  advanced  too  far,  namely,  a  sort  of 
hour-glass  contraction  round  the  child's  neck  and  above 
its  head,  making  its  extraction  difficult.  In  a  recent  case 
this  cost  the  child  its  life,  although  it  was  recognised 
early,  and  although  the  head  was  promptly  and  power- 
fully pushed  up  by  an  assistant. 

The  third  point  was  the  best  way  of  securing  the  broad 
ligaments  if  it  was  desired  to  excise  a  piece  of  the  Fallo- 
pian tube  by  way  of  sterilising  the  patient.  If  the  tube 
was  tied  in  two  places  and  the  piece  cut  out,  it  left  a  raw 
and  bleeding  edge  of  mesosalpinx.  The  best  way  was  to 
tie  the  tube  simply,  then  to  pinch  up  a  loop  of  tube,  to 
tie  this  with  the  ends  of  the  first  ligature,  and  then  to 
cut  off  the  loop  of  tube.  There  was  no  raw  or  bleeding 
edge  left  by  this  plan. 

Dr.  William  Duncan  thought  that  the  Ceesarean  sec- 
tion was  to  be  preferred  to  Porro's  operation  except  in 
cases  where  there  were  uterine  tumours  which  could  be 
removed  at  the  same  time,  and  also  when  the  uterus  was 
affected  with  cancer.  Hitherto  he  had  preferred  and 
practised  bringing  the  uterus  outside  the  abdomen  before 
opening  it,  considering  that  by  doing  so  the  complete 
prevention  of  the  passage  of  blood,  amniotic  fluid,  or 
meconium  into  the  abdominal  cavity  more  than  counter- 
balanced the  risk  attending  the  longer  external  incision. 
He  narrated  a  case,  however,  on  which  he  had  performed 
Caesarean  section  since  the  last  meeting  of  the  Society, 
and  which  was  doing  well  on  the  eighth  day,  but  several 
hours  after  the  stitches  were  removed,  and  in  spite  of 
plaister  having  been  applied  over  the  abdomen  the  whole 
length  of  the  abdominal  incision  was  torn  open  during  a 


q^SAEEAN    SECTION.  141" 

fit  of  cougliing,  tlie  intestines  protruded^  and  death  from 
collapse  ensued  tliirty  hours  after  the  accident. 

He  considered  that  placing  an  elastic  ligature  round 
the  cervix  was  bad  practice,  as  it  tended  to  cause 
asphyxia  of  the  child  and  paralysis  of  the  uterine  muscle. 
He  also  thought  that  hour-glass  contraction  of  the  uterus 
could  be  absolutely  prevented  by  taking  care  to  effect 
delivery  of  the  child  before  rupturing  the  membranes. 

Dr.  Peter  Horrocks  thought  that  if  Caesarean  section 
and  Porro's  operation  had  equal  mortalities,  then  the 
former  would  be  preferable  on  the  ground  of  its  being 
less  of  a  mutilation.  But  he  thought  both  operations 
were  good,  and  that  they  should  be  done  respectively  in 
suitable  cases.  Thus  he  considered  that  after  rupture  of 
the  uterus,  and  certain  cases  of  tumour  complicating 
pregnancy,  Porro's  should  be  selected  in  preference  to  the 
other.  In  regard  to  Cassarean  section  itself,  it  could  not 
be  compared  at  the  present  time  with  cases  operated  on 
in  the  past.  For  in  most  cases  formerly  it  was  done  as  a 
dernier  ressort,  and  in  all  cases  without  the  antiseptic 
precautions.  He  had  performed  the  operation  by  Sanger's 
method  three  times,  and  assisted  at  a  fourth.  Two  of  the 
former  died,  the  other  two  recovered  ;  all  the  children 
survived.  Of  those  that  died,  one  insisted  on  getting  out 
of  bed  on  the  fifth  day,  and  so  injured  herself  ;  the  other 
developed  parotitis  on  the  left  side,  which  spread  to  such 
an  extent  that  tracheotomy  had  to  be  performed  :  she  died 
daring  the  operation,  choked.  He  considered  that  re- 
moving the  uterus  out  of  the  abdomen  before  delivery 
was  fraught  with  danger,  and  if  it  could  be  avoided  it 
was  better.  The  elastic  ligature  did  not  prevent  uterine 
contraction,  as  might  be  a  ]^)riori  supposed.  Sanger  and 
Leopold  had  done  it  with  impunity.  In  all  his  own  cases 
the  operation  had  been  done  before  labour  had  begun. 
One  of  the  chief  points  in  Sanger's  method  was  bringing 
the  peritoneal  surfaces  together  with  numerous  fine  silk 
sutures.    This  occupied  much  valuable  time,  and  speed  was 


142  CJSSAEEAN    SECTION. 

an  antiseptic.  In  the  first  case  he  put  a  glass  drainage- 
tube  through  the  cervix  into  the  vagina,  but  it  caused' 
haemorrhage  and  was  soon  removed. 

He  begged  to  state  emphatically  that  it  was  not 
necessary  for  the  uterus  to  be  in  a  state  of  active  con-' 
traction  in  order  that  hgemorrhage  should  be  stopped. 
It  was  enough  if  the  uterus  was  retracted,  that  is,  con- ' 
traction  having  taking  place  the  fibres  then  relax,  but' 
are  not  stretched  out  again.  After  an  ordinary  labour 
the  uterus  was  alternately  hard  (active  contraction)  and 
soft  (passive  relaxation  =  retraction),  and  yet  no  hsemor- 
rhage  took  place.  Hence  it  was  useless  stimulating  the 
uterus  further  unless  haemorrhage  was  actually  taking 
place.  He  showed  sections  of  the  Fallopian  tubes  tied  by 
kangaroo  tendon.  The  patient  lived  seven  days.  In- 
jection of  the  tubes  under  great  pressure  seemed  to  prove 
complete  obliteration  of  the  lumen  of  the  tube.  In 
his  next  case  he  intended  to  operate  by  Cameron's 
plan. 

Dr.  RouTH  said  he  wished  to  speak  upon  three  points 
which  he  thought  had  not  been  sufficiently  insisted  upon 
in  the  discussion. 

1st.  To  operate  upon  a  woman  on  whom  the  Cassarean 
section  had  been  once  performed  successfully  was  a 
proceeding  almost  free  from  danger,  at  any  rate  in^ 
finitely  less  dangerous  than  the  first  operation  itself. 
Obstetric  records  gave  many  examples  of  such  persons 
being  operated  upon  three,  four,  and  even  seven  times, 
and  safely  delivered  by  Cassarean  section.  The  adhe- 
sions contracted  between  womb  and  abdominal  wall  con- 
verted the  operation  into  an  extra-peritoneal  one.  It 
might  be  an  unusual  mode  of  child-bearing,  but  a  safe 
one,  if  patients  were  willing  to  take  the  risk.  From 
the  tenor  of  this  discussion  he  believed  Csesarean  section 
would  be  much  more  frequently  perforrfied  than  heretofore, 
and  the  improvements  in  abdominal  surgery  justified  one 
in  believing  they  would  be  much  more  successful.      If  so, 


CESAREAN    SECTION.  143 

many  women  would  be  placed  iu  this  comparatively  safe 
condition  for  Cesarean  section  being  repeated. 

2nd.  In  the  case  of  a  first  operation  it  was  very  impor- 
tant  by  every  possible  means  to  ascertain  if  the  child 
was  alive  or  dead,  especially  if  from  the  history  of  the 
case  there  were  grounds  to  suspect  that  the  child  had 
been  long  dead,  for  probably  the  child  might  be  putrid, 
and  in  such  cases  it  was  very  difficult  to  prevent  poison- 
ing, even  with  all  aseptic  measui'es.  Dr.  Duncan  had 
instanced  such  a  fatal  case.  He  (Dr.  Routh)  had  also 
operated  on  a  case  iu  w^hich  child  and  even  membranes 
were  putrid,  and,  in  spite  of  all  precautions  taken,  death 
followed.  Abdominal  surgery  in  cases  of  putrid  abscesses 
with  thin  parietes  proved  amply  how  often  fatal  escape  of 
the  contents  into  the  peritoneum  occurred.  In  these 
cases  Porro's  operation  was  clearly  preferable  to  Cfesarean 
section. 

3rd.  The  incision  in  the  uterus  should  be  made  in  the 
upper  two  thirds  of  the  uterus^ — that  part,  in  fact,  which 
would  contract  on  removal  of  the  contents  of  the  uterus  ; 
and  care  should  be  especially  taken  not  to  cut  down  to 
the  cervix,  for  the  very  contraction  of  the  uterus  would 
tend  to  open  the  cut  cervical  portions  and  make  a  strain 
on  the  ligatures,  giving  rise  to  hfemorrhage.  In  one  case 
in  which  the  operation  was  performed  by  himself,  in  which 
catgut  sutures  were  applied,  and  in  which,  he  feared,  he 
cut  too  low  down,  the  catgut  ligatures  applied  gave  way, 
and  death  followed  from  hsemorrhage.  This  case  was 
recorded  in  the  '  Transactions.' 

Dr.  Braxton  Hicks  thought  it  a  point  Avorthy  of  re- 
membrance that  formerly  it  was  a  question  w^hether  any 
stitches  should  be  put  into  the  uterine  wound  or  not,  and 
many  cases  that  recovered  were  not  sewn  up.  He  con- 
sidered the  recent  improvement  in  the  death-rate  of 
Caisarean  section  w  as  lai-gely  owing  to  the  increase  in  the 
number  of  stitches  used.  When  only  six  were  put  in,  as 
was  generally  the  number  formerly,  if  one  gave  way  an 


l^^  .CiESAREAN    SECTION. 

extra  strain  fell  on  the  remainder,  and  tliese  generally 
cut  their  way  through  to  the  edges  of  the  wound  ;  then, 
if  vomiting  occurred,  the  contents  of  the  uterus  were 
extruded  into  the  peritoneum.  He  expressed  his  consent 
to  the  advantages  of  Porro's  operation  in  cases  of  uterine 
fibroids.  In  a  case  he  operated  on,  a  large  sinus  was 
divided,  which  passed  transversely  across  the  line  of  in- 
cision, the  bleeding  from  which  could  not  be  restrained 
except  by  under-running,  the  elastic  bandage  not  having 
then  come  into  use. 

Dr   Leith  Napier,  in  reply,  mentioned  that  befoi-e  con- 
sidering   the  points  which  had  been  touched  on  by  the 
speakers  he  would  like  to  submit  the  most  recent  mfor- 
mation  procurable  on  the   subject  from   the   two    distm- 
guished  operators  he  had  referred  to  at   the  end   of    his 
Lner       He  had  been  favoured  with  a  letter  from  Professor 
Leopold,  of  Dresden,  dated  23rd  March,  1892,  in  which 
letter  it  was   stated  in  reply   to   categorical   inquiries     1 ) 
the  total  of  Leopold's  Csesarean  sections  up  to  date  ot  his 
letter  was  fifty,  forty-six  being  true   Caesarean  and  four 
Porro-Cgesarean.      (2)    Of  this  number  forty-six  mothers 
and  all  the  children  were  saved.      (3)   Leopold   considers 
Ca^sarean  section  justified  by  a  conjugate  vera  of    7   cm. 
and  less,  that  is   2-75   inches  and  less.      (4)    He  advises 
^N^aitino-  for  the  commencement  of  labour  before  operation 
Leopofd  will  shortly  publish  an  account  of  his  cases,  which 
will   be    anxiously    looked    for   by   all   operating  obstet- 

ricians.  ,   ,^      r         7-»„ 

Under  date  April  4th,  1892,  he  had  a  letter  from  Di. 
Murdoch  Cameron,  of  Glasgow,  relating  the  accomplish- 
mentof  his  eighteenth  Cesarean  section.  Ihis  patient 
had  twice  previously  had  craniotomy  performed  Dr. 
Cameron's  first  fifteen  cases  were  published  m  tabular 
form  in  the  '  1^-ovincial  Medical  Journal '  for  January  of 

^^'Sinr'the  last  meeting  of  the  Society  Dr.  ^^J-^^^nh^^ 
three  other  cases,  namely,  on  March  16th,  March  2.th, 


CiESAREAN    SECTION.  145 

and,  as  above  stated,  April  4th.  In  none  of  his  cases  did 
the  conjugate  exceed  2f .  Of  the  eighteen  cases,  two,  the 
ninth  and  eleventh,  died.  The  mortality,  therefore,  of 
these  two  operators,  was  under  9  per  cent.  Some  cases 
had  been  forty-eight  hours  in  labour. 

Dr.  Napier  submitted  copies  of  the  temperature  and 
pulse  charts  of  Dr.  Cameron^s  sixteenth  and  seventeenth 
cases,  from  which  it  would  be  seen  how  favourable  the 
recoveries  had  been. 

Speaking  next  of  Dr.  Cullingworth's  case,  he  referred 
to  the  difficulty  and  delay  experienced  in  such  cases  by 
the  uterine  obliquity. 

There  had  been  very  little  divergence  of  opinion  among 
the  speakers  in  the  debate.  Therefore  he  might,  to  ab- 
breviate his  remarks,  deal  with  some  important  points 
raised  generally  rather  than  individually. 

As  to  turning  the  uterus  outside  the  abdomen  before 
extraction  of  the  child,  in  some  cases  this  was  unneces- 
sary ;  in  others  it  greatly  simplified  and  expedited  the 
operation.  In  the  case  he  had  recorded  the  total  length 
of  the  incision  necessary  to  permit  extrusion  of  the  uterus 
was  6|  inches,  and  the  size  of  the  child — length  21  inches, 
weight  7;^  lbs. — was  certainly  over  the  average.  The 
intestines  gave  no  trouble  ;  no  upper  abdominal  stitches 
were  inserted  into  the  abdominal  wound.  On  the  whole, 
he  thought  it  better  in  future  to  adopt  the  plan  of 
removing  the  child  before  extruding  the  uterus,  when  its 
removal  could  be  effected  easily,  but  the  suggestion  of 
Miiller  was  never  likely  to  be  wholly  abandoned. 

As  to  the  elastic  ligature,  Cameron's  experience  and 
Dr.  Cullingworth's  case  showed  it  to  be  unnecessary. 
Still,  the  theoretical  dangers  of  asphyxia  of  the  child  and 
post-partum  uterine  atony  leading  to  non-contractility 
were  probably  exaggerated.  Dr.  Horrocks's  remarks 
were  exceedingly  valuable  on  the  use  of  the  ligatui-e.  As 
an  insurance  it  would  be  advisable,  unless  reliable  assist- 
ance was  obtainable,  to  continue  using  it.  If  skilled 
assistants  were  procurable  it  would  be  superfluous. 


146  CiESAREAN    SECTION. 

Then  the  question  as  to  the  period  of  operation  was 
important.  Dr.  Culliiigworth  and  the  author  had  operated 
before  the  advent  of  labour.  Leopold  and  Cameron  always 
waited  for  contractions  to  commence  naturally.  There 
were  j'^'^'os  and  cons,  either  way,  and  on  this  point  he  would 
reserve  his  judgment.  Harris's  cases  of  uteriue  tolerance 
after  injury ,  which  Dr.  Handfield-Jones  had  referred  to, 
showed  that  it  was  not  essential  to  wait  for  labour  pains. 

Dr.  Leith  Napier  then  referred  to  the  remarks  of  some 
of  the  individual  speakers.  He  congratulated  Mr.  Bland 
Sutton  on  the  happy  result  of  his  case.  It  was  the  greater 
ti'iumph  for  the  operation  and  operator  that,  so  far  as 
could  be  judged  from  an  obstetric  standpoint,  it  was 
hardly  a  suitable  or  promising  case  to  treat  in  this  way. 
Had  Mr.  Sutton  regarded  the  facts  of  the  foetal  death 
and  prolonged  parturition  less  from  the  surgical  stand- 
point, it  was  probable  he  would  have  adopted  either  crani- 
otomy or  Porro  instead  of  Caesareau  section. 

He  was  glad  to  find  that  Dr.  Champneys  had  adopted 
the  suggestion  of  cutting  the  tubes  across  rather  than 
simply  ligating  them.  Dr.  Duncan  had  anticipated  his 
reply  to  the  hypothesis  advanced  by  Dr.  Champneys  that 
the  severed  ends  might  bleed  ;  as  a  matter  of  observation 
there  was  no  oozing,  and  the  divided  mucous  membrane 
became  retracted  within  its  peritoneal  covering — the 
doubling  up  was  unnecessary.  Dr.  William  Duncan's 
recent  case  was  a  most  interesting  one,  but  as  it  had  been 
discussed  by  others  he  need  only  say  that  possibly  the 
personal  condition  of  the  patient  had  far  more  to  do  with 
the  conditions  which  occurred  than  some  of  the  speakers 
seemed  to  think. 

In  conclusion  he  thanked  the  Fellows  for  a  very  in- 
teresting discussion. 

Dr.  CuLLiNGWORTH,  in  reply,  said  that,  with  regard  to 
waiting  in  all  cases  until  labour  had  commenced,  he  did 
not  agree  with  Dr.  Cameron  that  this  was  necessary.  The 
advantages  of  operating  in  the  daytime,  at  an  hour  fixed 


C-HSAREAN    SECTION.  147 

beforehand,  were  obvious,  and  experience  showed  that 
the  operation  itself  was  sufficient  to  excite  uterine  action, 
and  ensure  full  contraction  and  retraction.  He  had  tried 
both  the  method  of  turning  out  the  uterus  before  delivery, 
and  that  of  opening  the  uterus  and  removing  its  contents 
in  situ,  and  much  preferred  the  latter,  as  obviating  the 
necessity  of  a  long  abdominal  incision  and  possible  expo- 
sure and  chilling  of  intestines.  The  uterus  could  be 
brought  outside  aftei-  being  emptied,  if  thought  desirable, 
in  order  to  facilitate  the  suturing  of  the  uterine  wound, 
without  any  elongation  of  the  parietal  incision.  He  had 
learnt  much  from  the  recorded  experience  of  Dr.  Cameron, 
and  felt  grateful  to  him  for  having  done  so  much  towards 
simplifying  and  shortening  the  operation.  He  regarded 
as  distinct  improvement  the  abandonment  of  the  elastic 
ligature,  and  the  arrest  of  hasmorrhage  from  divided 
sinuses  by  direct  pressure  on  the  cut  surfaces.  Another 
decided  advance  was  the  method  of  suturing  by  a  mode- 
rate number  of  deep  and  half-deep  sutures,  doing  away  with 
the  wearisome  peritoneal  suturing  until  recently  thought 
to  be  so  essential. 

He  would  recommend  any  of  the  Fellows  who  were 
interested  in  the  subject,  or  who  were  expecting  to  be 
called  upon  to  operate,  to  refer  to  a  very  useful  little 
paper  by  Dr.  Howard  Kelly,  of  the  Johns  Hopkins  Hos- 
pital, Baltimore,  in  the  '  Amer.  Journ.  of  Obstetrics  '  for 
May,  1891,  entitled  "The  Steps  of  the  Ceesarean  Section 
—  the  do^s  and  the  don't's."  It  contained  many  valuable 
hints,  and  might  with  advantage  be  consulted  side  by  side 
with  Dr.  Cameron's  and  other  papers  on  the  subject. 

He  regarded  Porro's  operation  as  a  most  valuable 
resource  in  exceptional  cases,  and  thought  that  in- 
creased experience  would  enable  us  to  formulate  the  con- 
ditions in  which  the  one  or  the  other  operation  was  to  be 
preferred. 


VOL.  XXJIY.  11 


MAY  4th,  1892. 

J.  Watt  Black,  M.D.,  President,  in  tlie  Chair. 

Present — 36  Fellows  and  8  Visitors. 

A  book  was  presented  by  the  American  Association  of 
Obstetricians  and  Gynsecologists  ;  and  a  Vaginal  Speculum 
was  presented  to  the  Museum  by  Dr.  Coromilas. 

Alfred  Samuel  Gubb,  M.D.Paris ;  and  John  Harold, 
L.R.C.P.Lond.,  were  admitted  Fellows  of  the  Society. 

John  Morgan  Evans,  L.R.C.P.Lond.  (Llandrindod 
Wells)  ;  and  Thomas  Wilson,  M.D.Lond.  (Wolverhamp- 
ton), were  declared  admitted. 

Francis  Alexander  Barton,  B.A.Cantab.,  L.R.C.P.Lond. 
(Beckenham)  ;  and  W.  Gifford  Nash,  F.R.C.S.  (Bedford), 
were  elected  Fellows  of  the  Society. 


PAPILLOMATOUS  CYST  OF  BOTH  OVARIES 
CAUSING  PROFUSE  ASCITIC  EFFUSION; 
REMOVAL;  RECOVERY. 

By  Alban  Doean,  F.R.C.S. 

Mks.  E.   W — ,  aged  22,  married  four  years,  was  ad- 
mitted into  my  ward  at  the   Samaritan  Hospital  on  April 


150  PAPILLOMATOUS    CYST    OP    BOTH    OVARIES. 

16tli,  1892.  Dr.  P.  M.  O'Brien  of  Eeading,  who  had 
attended  the  case,  informed  me  that  abdominal  swelling 
was  first  noticed  in  September,  1891.  Pregnancy  was 
suspected,  but  the  catamenia  continued.  A  cystic,  cir- 
cumsci'ibed  tumour  was  detected  after  a  time,  the  abdo- 
men afterwards  became  greatly  swollen,  and  dropsy  of  the 
labia  set  in  and  was  relieved  by  acupuncture. 

On  admission  the  patient  appeared  very  sickly ;  she 
had  been  unable  to  lie  down  on  her  back  or  on  either  side 
for  nearly  three  months.  The  abdominal  distension  was 
extreme,  the  girth  at  the  umbilicus  exceeding  47  inches. 
The  distance  from  the  ensiform  cai'tilage  to  the  umbilicus 
was  11  inches  ;  from  the  umbilicus  to  the  symphysis  pubis 
10  inches.  The  skin  was  glossy,  and  very  oedematous 
below  the  umbilicus.  Fluctuation  was  universal.  All 
parts  of  the  abdomen  were  dull  ou  percussion  except  the 
right  flank.  The  posterior  vaginal  wall  was  prolapsed, 
being  full  of  fluid.  The  small  uterus  (the  patient  had 
never  been  pregnant)  was  almost  fixed.  The  secretion  of 
urine  was  scanty  ;  during  the  week  before  operation  the 
greatest  amount  passed  in  twenty-four  hours  was  14  oz. 
It  was  phosphatic  and  not  albuminous.  The  legs  were 
very  oedematous.  The  temperature  was  normal ;  the  pulse 
108,  very  small  volume. 

There  was  no  evidence  nor  any  family  history  of  disease 
of  the  heart,  livei',  or  kidneys. 

On  April  23rd  I  operated,  with  the  assistance  of  my 
colleague  Mr.  Butler-Smythe.  I  made  a  short  incision 
ending  several  inches  above  the  symphysis,  nevertheless 
the  cellular  tissue  between  the  peritoneum  and  bladder 
was  exposed.  Forty-five  pints  of  dark  reddish-brown 
fluid  escaped.  As  it  rushed  out  of  the  abdomen  it  pushed 
out  of  the  edges  of  the  abdominal  wound  a  thick  white 
membrane  which  looked  like  cyst-wall.  I  detached  some 
of  it  from  its  connections,  but  then  saw,  deep  in  the 
abdomen,  what  looked  like  a  secondary  cyst.  I  explored 
it  and  found  that  it  was  surrounded  by  intestine.  The 
membrane  at  the  abdominal  wound  was  greatly  thickened 


PAPILLOMATOUS    CYST    OF    BOTH    OVARIES.  151 

peritoneuTn.  The  true  cyst  projected  a  few  inches  above 
the  pelvic  brim  ;  masses  of  papillomata  sprang  from  its 
outer  surface.  I  passed  my  hand  down  the  back  of  the 
cyst,  and  found  that  it  extended  deeply  into  the  pelvis. 
I  feared  that  it  was  irremovable,  but  tapped  it  anteriorly, 
meaning  to  fix  it  to  the  parietes  if  it  would  not  allow  of 
complete  excision.  Two  pints  of  fluid  escaped,  and  the 
cyst  came  out  easily  ;  it  proved  to  be  the  right  ovary.  I 
then  found  another  cyst  covered  with  papillge  ;  it  was  the 
left  ovary.  The  two  tumours  touched  each  other  behind 
the  small  uterus.  There  were  no  adhesions  and  no 
papillomatous  growths  on  the  intestines.  The  pedicles 
required  very  careful  ligature.  The  peritoneum  was 
thoroughly  flushed  with  hot  water.  Then  the  detached 
piece  of  peritoneum  ai'ound  the  abdominal  wound  was 
trimmed  away  and  the  sutures  applied,  the  flushing 
repeated,  a  drainage-tube  inserted,  and  the  patient  put 
to  bed.  The  drainage-tube  was  removed  nineteen  hours 
after  the  operation  ;  during  the  first  few  hours  several 
ounces  of  clear  serum  came  away. 

All  the  bad  symptoms  due  to  the  ascites  rapidly  dis- 
appeared. In  the  fourth  twenty-four  hours  after  opera-r 
tion  95  oz.  of  urine  were  passed.  Twelve  days  later  the 
patient  appeared  in  excellent  health. 

She  remained  in  good  health  in  June,  1892. 

The  right  tumour  weighed  seven  ounces  when  empty ; 
two  pints  of  clear,  glairy  ovarian  fluid  were  emptied 
out  of  it  in  the  course  of  the  operation.  It  formed 
a  single  large  cyst,  which  burrowed  into  the  broad 
ligament  and  came  in  contact  with  the  Fallopian  tube. 
The  ostium  and  canal  of  the  tube  were  quite  open  ;  its 
walls  were  much  thickened,  and  it  was  elongated  to  the 
extent  of  three  or  four  inches.  On  the  inner  wall  of  the 
cysts  were  several  papillomatous  growths.  Larger  growths 
of  the  same  kind  sprang  from  the  outer  wall.  Thei'e  was 
no  evidence  that  these  outer  growths  had  originated  from 
the  inner  wall,  subsequently  perforating  the  cyst.  There 
were  several  minute  papillomatous  growths  clearly   deve- 


152  PAPILLOMATOUS    CYST    OP    BOTH    OVARIES. 

loping  ou  tlie  surface  of  tlie  cyst.  Other  papillomatous 
bodies  were  developing  interstitially,  apparently  in  secon- 
dary cysts. 

The  left  tumour  weighed  ten  ounces  when  complete, 
and  was  made  up  of  three  lobes.  It  had  partly  burrowed 
into  the  mesosalpinx,  but  was  separated  from  the  tube 
by  a  spherical,  thin-walled  broad  ligament  cyst  one  inch 
in  diameter.  The  tube  was  not  elongated  as  on  the  right 
side,  and  its  ostium  and  canal  were  patulous.  The  ovarian 
cyst  was  covered  with  large  papillomata,  one  of  which 
had  clearly  perforated  the  cyst-wall  from  within  outwards. 
A  semilunar  space  surrounded  about  half  of  its  root  ;  the 
free  edge  of  the  cyst-wall  bounding  the  space  was  quite 
smooth.  The  space  allowed  of  free  communication 
between  the  cavity  of  the  cyst  and  that  of  the  peri- 
toneum. 

The  extreme  ascitic  effusion  was  an  interesting  feature 
in  this  case.  It  was  the  natural  result  of  the  irritation 
of  papillomatous  growths.  The  resonance  in  the  right 
flank,  even  when  the  patient  lay  on  that  side,  was  remark- 
able. The  manner  in  which  the  bladder  was  drawn  up 
high  out  of  the  pelvis  by  mere  distension  of  the  abdominal 
walls  will  serve  as  a  warning  to  operators  in  similar  cases. 
I  have  known  the  bladder  to  be  opened  by  a  careful 
operator.  The  tumours  had  nothing  to  do  with  the  dis- 
placement of  the  bladder. 

The  alteration  in  the  peritoneum  and  the  manner  in 
which  the  stream  of  fluid  pushed  it  out,  so  that  it  looked 
like  a  cyst-wall,  was  interesting.  1  have  frequently 
seen  the  peritoneum  stripped  off  in  this  manner.  As 
long  as  only  a  little  is  detached  no  harm  is  done,  but  the 
separated  part  must  be  trimmed  away,  else  it  may  slough. 
A  space  bare  of  peritoneum  is  no  disadvantage,  as  Kelter- 
born  has  shown.  In  this  case  no  bare  space  was  left,  as 
the  peritoneum,  stretched  by  the  ascitic  fluid,  could  easily 
be  made  to  meet  along  the  line  of  the  abdominal  wound. 

Lastly,  a  case  of  this  kind  always  demands  operation. 


PAPILLOMATOUS    CYST    OP    BOTH    OVARIES.  153 

Great  ascitic  effusion  and  oedema  of  the  extremities  musfc 
not  allow  the  surgeon  to  deny  the  patient  the  advantages 
of  an  exploration  at  least.  The  papillomata  must  never 
be  torn  off,  else  haemorrhage  which  cannot  be  controlled 
will  certainly  follow.  The  operator  must  calmly  ascertain 
if  the  structure  from  which  the  papillomata  grow  be  remov- 
able. The  peritoneum  should  always  be  flushed  out  after 
removal  of  cysts  of  this  kind  to  ensure  the  thorough  clear- 
ing away  of  broken-off  fragments  of  the  papillomatous 
growths.    Sponges  are,  I  find,  insufficient  for  the  purpose. 

Dr.  W.  Duncan  asked  Mr.  Doran  if  be  could  explain  why 
papillomatous  growths  were  supposed  to  disappear  after  the  great 
bulk  of  the  tumour  bad  been  removed.  He  bad  recently  operated 
on  a  case  in  which  there  was  a  papillomatous  growth  the  size  of 
an  orange  in  one  ovary  ;  this  was  adherent  to  intestine,  which 
latter  was  studded  with  secondary  growths,  so  that  under  the 
circumstances  he  decided  not  to  proceed  with  the  operation. 

Dr.  CuLLiNGWOETH  said  Mr.  Doran  had  not  overrated  the 
importance  of  his  case  from  a  practical  point  of  view.  It  showed 
tbat  no  case  of  rapidly  forming  ascites,  with  unknown  or  sus- 
pected malignant  origin,  should  be  allowed  to  terminate  without 
an  exploratory  operation.  For  though  papillomatous  growths 
from  the  ovary  are  very  irritating  to  the  peritoneum,  they  are 
only  locally  infective,  so  that  when  they  are  removed  the  patients 
are  cured.  He  bad  bad  two  cases  very  similar  to  tbat  of  Mr. 
Doran  within  the  last  two  years.  The  first  was  the  wife  of  a 
medical  man,  from  wbom  he  removed  fifteen  pints  of  ascitic 
fluid  through  an  incision  made  in  the  abdominal  wall  for  the 
double  purpose  of  removal  of  the  fluid  and  exploration.  The 
proliferating  and  adherent  masses  of  disease  on  both  sides  of  the 
pelvis  alarmed  bim,  and  be  closed  the  abdomen.  The  patient  was 
remarkably  benefited  by  the  evacuation  of  the  fluid,  and  remained 
free  from  any  re-accuraulation.  She  went  through  much  anxiety 
and  fatigue  during  the  next  six  months,  and  at  the  end  of  that 
time  found  the  pelvic  pain  was  becoming  so  severe  tbat  she 
appealed  for  something  more  to  be  done.  He  reopened  the 
abdomen,  attacked  the  pelvic  growths  more  boldly,  and  cured 
the  patient,  who  is  now,  eighteen  months  after  the  operation, 
strong  and  well.  Three  weeks  after  the  first  exploratory  opera- 
tion in  this  case  another  case  presented  itself,  this  time  in  the 
hospital.  Seventeen  pints  of  ascitic  fluid  were  removed  through 
an  abdominal  incision,  and  the  pelvis  explored.  So  confusing 
and  adherent  a  mass  of  cystic  and  papillomatous  growth  existed 
in  the  pelvis  that  nothing  was  attempted  in  the  way  of  removal. 


154  PAPILLOMATOUS    CYST    OF    BOTH    OVARIES. 

The  patient  remained  well  for  six  months,  then  the  fluid  began 
to  re-accumulate,  and  three  months  later  she  came  to  see  if  any- 
thing more  could  be  done.  Encouraged  by  the  result  in  the 
other  case,  he  here  also  reopened  the  abdomeu,  removed  the 
disease,  and  cured  the  patient.  He  saw  her  only  a  day  or  two 
ago.  She  was  in  blooming  health,  and  it  was  now  sixteen 
months  since  the  operation.  Dr.  W.  Duncan  had  stated  that  he 
knew  of  no  good  evidence  as  to  the  disappearance  of  diff'use 
papilloma  of  the  peritoneum  after  removal  of  the  original 
disease,  the  focus  of  infection.  He  (Dr.  CuUingworth)  thought 
be  could  supply  him  with  at  least  one  authenticated  example. 
He  had  already  published  the  case,  and  would  now  only  allude  to 
it  in  the  briefest  manner.  Six  years  ago  he  operated  upon  a 
Salford  factory  girl  of  twenty-two  years  of  age,  who  had  a  large 
abdominal  tumour  which  had  formed  with  suspicious  rapidity. 
Symptoms  had  become  urgent  a  fortnight  before  the  operation, 
and  the  medical  man  in  attendance  luvd  tap|)ed  the  tumour.  On 
opening  the  abdomen  papillomatous  growth  and  the  gelatinous 
contents  of  the  cyst  were  seen  protruding  through  the  aperture 
made  by  the  trocar,  and  already  the  peritoneum  in  the  neigh- 
bourhood was  abundantly  studded  with  papillomatous  growth. 
The  omentum  was  enormously  thickened,  and  was  thicldy  covered 
with  new  growth.  The  case  looked  desperate.  The  tumour  was 
removed  with  difiiculty ;  no  attempt  was  made  to  deal  with  the 
omentum  or  other  infected  parts.  It  was  explained  to  the  friends 
how  it  was  scarcely  possible  to  hope  for  ultimate  recovery.  To  his 
(Dr  .Cullingworth's)  utter  surprise  the  patient  got  well  without 
a  bad  symptom,  and  twelve  months  afterwards  was  at  her  work 
in  perfect  health. 

Mr.  Alban  Doean  replied  that  pathology  could  not  explain 
why  papillomata  diffused  over  the  serous  coat  of  the  intestines 
sometimes  disappeared  after  the  original  ovarian  tumour  was 
removed,  and  sometimes,  on  the  other  hand,  grew  all  the  quicker. 
He  had  seen  both  results  follow  ovariotomy.  In  exploring  the 
surgeon  must  make  up  his  mind,  and  he  careful  not  to  bi'eak 
down  papillomata  that  he  cannot  remove.  After  extirpating  a 
papillomatous  ovary  it  is  safer  to  flush  the  peritoneum  with  hot 
water,  as  that  is  the  surest  way  to  dislodge  broken  fragments  of 
papilloma.  Simple  opening  of  the  abdomen,  the  ascitic  fluid 
being  allowed  to  escape,  seems  to  benefit  the  patient  when  the 
papillomata  are  irremovable. 


155 


UNRUPTURED    TUBAL    GESTATION,   WITH 
APOPLEXY    OF    THE    OVUM. 

By  0.  J.   Culling  WORTH,  M.D. 

Dr.  CuLLiNGWORTH  exhibited  a  Fallopian  tube,  removed 
by  abdominal  section  on  the  8tli  of  April  from  a  patient 
whose  case  was  diagnosed  as  one  of  unruptured  tubal  ges- 
tation. The  patient,  a  healthy  woman  aged  32,  had  only 
once  previously  been  pregnant,  namely,  eight  years  ago, 
when  she  aborted  at  the  fourth  month.  She  menstruated 
regularly  up  to  the  l2th  November,  1891,  when  her 
last  period  occurred.  She  subsequently  believed  herself 
to  be  pregnant.  At  the  beginning  of  February  she  was 
standing  upon  a  table  cleaning  windows,  when  she  slipped, 
and  saved  herself  by  jumping  from  the  table.  Two  days 
afterwards  a  slight  hasmorrhage  commenced.  This  in- 
creased in  quantity  and  continued  for  two  months,  when 
the  patient  was  admitted  into  St.  Thomas's,  having  ap- 
plied entirely  on  account  of  the  continuous  hasmorrhage. 
She  had  never  had  any  pain,  and  there  was  no  interfer- 
ence with  the  general  health.  On  examination  a  large, 
soft,  elastic,  well-defined  swelling  was  felt  to  occupy  the 
right  posterior  quarter  of  the  pelvis,  pushing  the  uterus 
a  little  to  the  left  of  the  middle  line,  and  moving  to  a 
certain  extent  independently  of  it.  The  vaginal  roof  was 
not  depressed,  but  a  strongly  pulsating  blood-vessel  could 
be  felt  running  along  it  on  the  right  side.  After  a  little 
hesitation  the  sound  was  passed,  and  the  uterine  canal 
found  to  be  2|  inches  long  and  empty.  The  diagnosis 
was  tubal  gestation  with  apoplectic  ovum,  or,  much  more 
improbably,  an  ovarian  cyst  with  recent  or  incomplete 
abortion. 

At  the  operation  the  right  tube  was  found  to  be  enor- 


156  TUBAL    GESTATION. 

mously  distended  with  blood-clot  and  adherent  to  the 
surrounding-  parts.  The  uterus  was  small  and  pushed 
over  to  the  left.  When  the  tube  had  been  separated  and 
brought  to  the  surface  it  was  observed  to  have  attached 
to  it,  at  its  distal  extremity,  a  foetus  2|  inches  long-, 
tightly  enclosed  in  a  sac,  through  which  the  denuded 
bones  of  one  leg  and  part  of  one  arm  were  protruding. 
There  were  only  one  or  two  insignificant  clots  in  the 
peritoneal  cavity.  Although  the  preparation  had  not 
yet  been  disturbed,  it  seemed  certain  that  the  placenta 
and  a  portion  of  the  membranes,  continuous  with  that 
covering  the  pelvis,  were  still  within  the  tube  amongst 
the  blood-clot.  The  foetal  sac  was  of  a  yellowish  colour 
and  was  lying  beneath  the  tube,  adherent  to  the 
rectum  and  floor  of  Douglas's  pouch.  The  covering  of 
both  it  and  the  distended  tube  was  extremely  thin,  and 
much  care  was  needed  during  the  separation  to  preserve 
it  intact.  In  lifting  the  tube  to  the  surface  its  wall  gave 
way  on  the  anterior  surface,  causing"  a  rent  which  dis- 
closed the  clot  within. 

The  right  ovary  was  cut  across  in  removing  the  tube. 
The  left  appendages  were  adherent  but  otherwise  normal, 
and  were  not  disturbed. 

The  patient  made  an  uninterrupted  recovery,  and  was 
now  well  and  awaiting  her  discharge  from  the  hospital. 

As  the  specimen  had  not  yet  been  dissected,  he  could 
only  express  a  provisional  opinion  as  to  its  nature.  It 
seemed,  however,  probable  that  at  the  time  of  the  acci- 
dent an  incomplete  tubal  abortion  had  occurred,  the  foetus 
escaping  enveloped  in  its  membrane  or  membranes,  leav- 
ing behind  it  within  the  tube  the  rest  of  the  membranes, 
the  placenta,  and  the  greater  part  of  the  effused  blood. 

The  entire  absence  of  pain  both  before  and  after  the 
accident  was  a  remarkable  feature  in  the  case. 

A  water-colour  drawing  of  the  fresh  specimen  by  Mr. 
R.  E.  Holding  was  exhibited. 


TUBAL    GESTATION.  157 

Mr.  Alban  Doean  laid  stress  upon  the  careful  exploration  of 
all  cases  of  extra-uterine  gestation  and  of  haematosalpinx  where 
the  ostium  of  the  tube  was  dilated.  Haematosalpinx  seemed 
to  imply  gestation  in  the  tube  rather  than  any  inflammatory 
change. 

Dr.  AV.  Duncan  thought  the  specimen  one  of  extreme  interest, 
and  suggested  that  a  sub-committee  be  appointed  to  report 
upon  it. 

Dr.  RuTHEEFoOED  wished  to  know  if  the  specimen  might  not 
be  one  of  tubal  gestation  in  which  rupture  of  the  tube,  but  not 
of  the  overlying  peritoneum,  had  taken  place,  so  that  the  fcetus 
had  escaped  and  was  lying  outside  the  tube  but  beneath  the 
peritoneum. 

Dr.  CULLINGWOETH,  in  reply,  said  that  although  it  would,  of 
course,  spoil  his  specimen  for  museum  purposes,  he  would  not 
raise  any  objection  to  the  appointment  of  a  committee  to  examine 
and  report  upon  it,  especially  as  doubts  had  recently  been  ex- 
pressed by  a  distinguished  authority  as  to  the  occurrence  of 
tubal  abortions,  and  it  was  possible  that  this  specimen  might 
furnish  important  evidence  on  the  question. 


Beport  on  Dr.  Gullingworth's  Specimen  of  Tubal  Gestation. 

The  specimen  consists  of  an  oval  body,  9  centimetres 
long  by  6i  in  vertical  measurement.  From  one  extremity 
hangs  a  piece  of  tissue  3  centimetres  long,  evidently  the 
uterine  end  of  the  Fallopian  tube.  The  greater  part  of 
the  swelling  as  seen  on  section  consists  of  a  mass  of  pale 
red  clot,  which  shows  distinct  lamination.  This  clot 
is  invested  by  the  wall  of  the  Fallopian  tube.  From 
the  other  or  outer  extremity  projects  a  cyst,  4^  centi- 
metres in  vertical  measurement  and  broader  below  than 
above.  To  the  upper  and  outer  part  of  the  cyst-wall 
adheres  a  foetus,  of  which  the  parts  are  very  distinct. 
The  ribs  and  vertebral  column  are  plainly  visible,  and  the 
exti'emities  of  one  side  project  through  the  cyst-wall ;  the 
lower  part  of  cyst  was  occupied  by  blood-clot.  Between 
the  cyst  and  the  clot  in  the  Fallopian  tube  is  a  more  or 
less   circular   smooth-edged  aperture,    1|  centimetres  in 


158  FCETUS    WITH    PLACENTA    PREVIA    ATTACHED. 

diameter,  wliicli,  from  the  appearance  of  the  surrounding 
parts,  appears  to  be  a  constriction  of  the  tube.  Imme- 
diately below  and  internal  to  tlie  foetal  cyst  is  the 
ovary.  The  foetal  cyst  is,  therefore,  part  of  the  tube. 
Our  opinion  is  that  the  specimen  consists  of  a  gravid  tube 
of  which  the  larger  and  inuer  compartment  contains  the 
placenta  infiltrated  with  blood-clot,  and  the  smaller  or 
outer  cavity  is  occupied  by  the  foetus,  which  is  compressed 
against  its  periphery  by  blood-clot.  There  is  no  proof 
that  the  tube  has  undergone  rupture. 

J.  Bland   Sutton. 

Chas.  J.  Cullinqworth. 

Alban  Doran. 

William  Duncan,  Convener. 


A  FCETUS  OF  FOUR  MONTHS'  DEVELOPMENT 
CONTAINED  WITHIN  AN  UNRUPTURED 
AMNIAL  SAC  WITH  PLACENTA  PREVIA 
ATTACHED. 

By  A.  D.  Leith  Napier,  M.D. 

The  patient  from  whom  this  was  obtained  was  a  3'oung 
married  woman,  aged  24  ;  she  was  married  the  beginning 
of  August,  1890,  and  delivered  of  her  first  child  March 
22nd,  1891.  Convalescence  was  tedious.  She  had  never 
felt  very  well  since.  She  had  seen  no  period  since  con- 
finement. 

On  February  29th,  1892,  she  had  a  discharge  of  blood 
Avhich  lasted  twelve  hours.  About  this  time  occasional 
irregular  sickness  occurred. 

On  March  29th  she  had  a  profuse  flow  of  blood,  which 
was  thought  by  the  patient  to  be  menstrual.  This  con- 
tinued without  ceasing  until  the  date  of  her  admission  to 
St.  Pancras  Dispensary  on  April  25th.      She  was  then  very 


MULTIPLE    PIBRO-MYOMA.  159 

anaemic,  felt  and  looked  ill.  There  was  a  centrally  situated 
abdominal  swelling  reaching  fully  halfway  to  umbilicus. 

On  April  27th  she  was  examined  and  found  to  be 
pregnant.  The  cervix  admitted  the  points  of  two  fingers. 
The  placenta  presented,  this  was  detached  and  the  mem- 
branes left  intact ;  pains  supervened,  and  in  little  over 
three  hours  the  specimen  shown  was  expelled. 

The  condition  was  a  somewhat  unusual  one,  illustrating 
the  precise  relations  of  the  placenta  in  such  cases,  and 
also  other  evident  features  of   interest. 


A    LARGE   MULTIPLE   FIBRO-MYOMA,  REMOVED 
ON   APRIL    29th   BY    HYSTERECTOMY. 

By  A.  D.  Leith  Napier,  M.D. 

This  was  one  of  the  first,  if  not  the  first  large  tumour 
exhibited  at  the  Society  in  which  the  intra-peritoneal 
method  of  securing  the  pedicle  had  been  employed.  The 
patient  Avas  45  years  of  age,  married  twenty-one  years  ; 
had  one  child  stillborn  at  term  a  year  after  marriage  ;  two 
abortions,  one  eighteen  years  ago,  the  other  nine  years  ago. 

She  had  noticed  the  tumour  for  over  five  years  ;  within 
the  last  eighteen  months,  it  had  become  much  larger. 
Operation  was  imperative  on  account  of  exceedingly  profuse 
and  frequently  recurrent  hEemorrhages.  As  many  as  100 
to  120  napkins  had  been  required  on  several  occasions. 
Medicinal  treatment  and  rest  had  been  tried  patiently 
without  improvement.  The  patient's  general  condition 
was  not  favourable ;  she  had  chronic  bronchitis  with 
emphysema  and  a  dilated  heart. 

The  operation  was  done  in  the  usual  manner,  the  vessels 
being  secured,  the  tumour  then  cut  off,  and  the  peritoneum 
stitched  over  the  pedicle  formed  by  the  cervix.    The  tumour 


160  I  MULTIPLE    PIBRO-MYOMA. 

weiglied  about  three  pounds.  One  ovary  was  cystic,  and 
botli  tubes,  especially  the  right,  distended  with  serum. 
The  patient  did  well  until  May  2nd,  when  symptoms  of 
rapid  pulse  and  abdominal  distension  without  pain  super- 
vened. There  was  no  high  temperature.  She  died  on 
May  3rd.  A  post-mortem  examination  made  twelve 
hours  after  death  showed  that  the  cause  was  acute 
intestinal  obstruction.  A  loop  of  ileum  had  become 
doubled  on  itself,  and  was  adherent  to  the  peritoneum 
covering  the  right  side  of  the  stump.  There  was  no  trace 
of  peritonitis  or  sign  of  hgemorrhage. 

The  result  was  most  regrettable,  as  the  condition  of 
parts  found  warranted  the  belief  that  the  operation 
but  for  this  unfortunate  obstruction  would  have  been  suc- 
cessful. All  the  alleged  evils  of  intra-peritoneal  treat- 
ment of  the  stump  had  been  avoided.  The  case  was  a 
most  testing  one,  and  the  intra-peritoneal  method  had 
stood  the  test  well.  We  at  times  learned  more  from 
actual  failures  than  unexplained  successes,  and  he  there- 
fore thought  the  specimen  worthy  of   being  shown. 

Dr.  Hetwood  Smith  thought  that  perhaps,  since  the  uterine 
stump  was  not  sutured  with  Lambert's  sutures,  the  line  of 
suture  not  being  so  smooth  as  when  the  serous  membrane  was 
turned  in,  might  have  led  to  the  adhesion  taking  place  in  the 
bowel.  In  the  method  of  peritoneal  suture  that  he  had  lately 
advocated  the  resulting  line  of  suture  presented  quite  a  smooth 
surface,  and  he  considered  where  this  was  done,  and  the  wound 
healed  at  once,  there  would  be  little  chance  of  such  an  accident, 
happening. 


161 


SIX  CASES  OF  CRANIOTOMY,  WITH  EEMARKS 
ON  THE  RELATIA^E  POSITION  OF  CRANIO- 
TOMY AND  CESAREAN  SECTION. 

By  Arthur  H.  N.  Lewers,  M.D.Lond.,  M.R.C.P., 

ASSISTANT   OBSTETEIC   PHTSICIAN    TO   THE   LONDOK    HOSPITAL. 

(Received  Miiy  11th,  1891.) 

{Abst7'act.) 

The  author  records  six  cases  of  craniotomy  for  pelvic  con- 
traction. 

Four  of  the  cases  (Nos.  1,  2,  3,  and  4)  may  be  described  as 
neglected  cases,  having  been  many  hours  in  labour  before  the 
operation  was  undertaken,  and  in  two  (Nos.  1  and  4)  delivery 
was  only  effected  with  great  difficulty.     All  the  cases  recovered. 

Reference  is  made  to  Dr.  Donald's  paper,  "  Methods  of 
Craniotomy,"  in  which  eighteen  cases  of  craniotomy,  all  of 
which  also  recovered,  are  recorded.  Taking  these  cases  in 
conjunction  with  his  own,  the  author  argues  that  the  mortality 
of  craniotomy  is  extremely  small,  and  therefore  concludes  that 
while  Caesarean  section,  in  spite  of  all  modem  improvements, 
still  remains  a  very  dangerous  operation,  it  should  not  be 
undertaken  as  a  matter  of  election,  but  restricted  entirely  or 
almost  entirely  to  cases  where  no  other  method  of  delivery  is 
possible. 

A  table  of  the  author's  cases  is  appended. 

There  is  much  difference  of  opinion  at  the  present  time 
as  to  the  indications  for  performing  craniotomy  or  cephalo- 
tripsy  rather  than  Caesarean  section  or  Porro's  operation 
in  certain  cases  of  pelvic  contraction. 

Although,  as  all  know,  the  Caesarean  section  has  within 
the  last  few  years  been  greatly  improved,  and  its  mortality 


162  CRANIOTOMY. 

iu  consequence  diminislied,  it  cannot  be  denied  that  it 
still  remains  a  very  dangerous  operation. 

Notwithstanding  this  there  is  a  perceptible  tendency 
to  enlarge  the  field  of  the  operation,  and  to  advance  it 
from  the  position  of  an  operation  of  necessity  to  that  of 
one  of  election. 

While  the  operation  remains  a  very  dangerous  one  this 
seems  to  be  a  change  of  very  doubtful  expediency,  for 
obviously  the  advantage  gained  as  a  result  of  modern  im- 
provements, by  those  who  now  submit  to  the  operation  as 
a  matter  of  necessity,  may  be  easily  counterbalanced  or 
even  altogether  outweighed  by  the  mortality  occurring 
among  those  operated  on  as  a  matter  of  election,  who  ten 
or  fifteen  years  ago  would  never  have  been  subjected  to 
Csesarean  section  at  all. 

Let  us  consider  the  case  of  a  patient  with  a  simple  flat 
pelvis,  having  a  conjugata  vera  of  two  and  a  half  inches 
at  full  term  in  London.  What  she  ought  to  know  is,  not 
what  the  lowest  mortality  of  Cfesarean  section  may  be  in 
Germany,  but  what  the  mortality  of  the  operation  has 
been  recently  at  the  hands  of  competent  operators  here 
in  London.  She  ought  also  to  know  the  mortality  of 
craniotomy  under  similar  circumstances  in  a  pelvis  with 
the  same  measurements  as  her  own.  The  right  course  to 
be  adopted  in  such  a  case  can  only  be  ascertained  by  com- 
paring the  statistics  of  the  two  operations — Csesarean 
section  and  craniotomy — respectively. 

So  far  as  I  know,  there  are  no  statistics  of  Caesarean 
sections  performed  in  this  country  which  enable  us  to 
state  the  percentage  mortality  of  the  operation  so  as  to 
give  the  patient  a  fair  idea  of  its  risk.  It  is  true  that 
Dr.  Murdoch  Cameron  has  published  a  series  of  ten  cases 
in  which  the  death-rate  was  only  10  percent. — an  exceed- 
ingly good  result ;  but,  unfortunately,  there  is  reason  to 
believe  this  rate  to  be  far  below  that  of  other  operators 
in  the  United  Kingdom,  so  that  it  cannot  for  a  moment 
be  accepted  as  representing  the  average  risk  of  the 
operation. 


CRANIOTOMY.  1  gg 

Neither  are  obstetricians  agreed  as  to  the  present  mor- 
tahty  of  craniotomy,  some  beh'eving  it  to  be  little  more 
than  that  of  natural  labour,  others  placing  it  as  high  as 
20  per  cent.,  and  even  higher.  For  instance.  Dr.  G^Eus- 
tache,  of  Lille,  at  the  International  Medical  Congress  of 
1881,  in  comparing  embryotomy  and  Csesarean  section, 
said,  '' Je  croisnepas  depasser  les  limites  des  probabilites 
en  faisant  la  mortalite  de  Tembryotomie  a  50  pour  100  " 
On  the  other  hand,  in  Dr.  Donald's  valuable  paper 
''  Methods  of  Craniotomy,''  read  before  this  Society  in 
January,  1889,  eighteen  cases  of  craniotomy  are  recorded 
in  which  the  mortality  was  nil. 

In  the  following  six  cases  of  craniotomy  which  have 
come  under  my  care  at  the  London  Hospital  the  mor- 
tality Avas  also  nil. 

Taking  my  own  cases  in  conjunction  with  Dr.  Donald's 
I  cannot  but  conclude  that  the  danger  of  craniotomy  has 
been  exaggerated,  and  that  the  risk  of  this  operation, 
even  in  cases  of  great  difficulty,  is  really  small. 
Coming  to  the  details  of  my  cases— 
As  to  difficulty.— In  Cases  1  and  4  delivery  was  only 
effected  with  great  difficulty.  In  these  the  conjugata 
vera  measured  21  inches.  In  Case  1  turning  had  been 
performed  before  I  saw  the  case,  and  the  legs  and  part 
of  the  body  were  outside  the  vulva,  but  it  had  then  been 
found  impossible  to  complete  delivery. 

It  may  be  remembered  that  Dr.  Donald,  in  the  paper 
already  referred  to,  recommends  version  as  a  matter  of 
choice  in  such  cases,  followed  by  perforation.  Certainly 
m  this  case  of  mine  (Case  1)  the  difficulty  of  getting 
down  the  arms  was  very  great,  and  the  subsequent  cephalo- 
tnpsy  far  from  easy.  In  fact,  delivery  was  quite  as 
difficult  in  this  case  as  in  Case  4,  in  which  the  contraction 
was  as  nearly  as  possible  the  same,  but  in  that  case  ver- 
sion was  not  performed. 

In  the  remaining  four  cases  delivery  was  relatively 
easy;  the  true  conjugate  in  each  of  these  was  as  fol- 
lows : 

VOL.  XXXIV.  22 


164  CRANIOTOMY. 

Id  Case  2,  2| — 2|  inches.  (In  this  case  there  was 
slight  general  contraction  of  the  pelvis  also.) 

In  Case  3,  8|  inches. 

In  Cases  5  and  6,  2|  inches.  (Operations  5  and  6 
were  in  the  same  patient.) 

As  to  the  instruments  used. — The  cephalotribe  was  em- 
ployed in  all  the  cases.  In  Case  4  the  cranioclast  and 
the  craniotomy  forceps  were  also  tried^  but  the  former 
was  not  found  of  any  service  in  that  case,  partly,  as  it 
seemed,  on  account  of  the  moveable  hinge,  and  partly 
owing  to  the  head  lying  so  far  foi'wards  relatively  to  the 
pelvic  axes.  The  craniotomy  forceps  were  used  to  remove 
most  of  the  cranium,  and  delivery  was  completed  with  the 
cephalotribe. 

As  to  antiseptics. — All  the  cases  were  treated  with  the 
most  careful  attention  to  antiseptic  principles  after  they 
came  under  my  observation.  But  in  Cases  2  and  4  pro- 
longed attempts  had  been  made  to  effect  delivery  before 
the  patients  were  brought  to  the  hospital,  and  most  pro- 
bably antiseptics  were  not  employed. 

As  to  convalescence. — In  Cases  1,  5,  and  6  convalescence 
was  rapid  and  uneventful.  In  Case  8  it  was  delayed  by- 
persistent  fever  and  sub-involution,  apparently  due  to 
sloughing  of  the  endometrium.  In  Case  4  only  was  the 
outlook  at  any  time  really  alarming.  This  patient  almost 
certainly  had  an  attack  of  pneumonia,  but  owing  to  her 
weak  state  the  chest  was  not  thoroughly  examined. 
Ultimately  she  recovered  completely.  In  Case  2  the 
patient's  condition  was  never  such  as  to  occasion  anxiety, 
but  convalescence  was  considerably  retarded. 

Measurements  of  the  pelves. — In  each  case  the  following 
measurements  were  taken  before  delivery  : 

1.  Between  the  anterior  superior  iliac  spines. 

2.  Maximum  distance  between  the  iliac  crests. 

3.  The  external  conjugate,  and 

4.  The  diagonal  conjugate.  (In  Case  1  this  was 
taken  after  delivery.) 

After   delivery  the  conjugata  vera   was  in  each  case 


CRANIOTOMY.  165 

determined  by  the  introduction  of  the  hand.  Another 
plan  of  determining  the  true  conjugate  was  employed 
besides  the  introduction  of  the  hand  in  Case  5,  and  1  have 
used  it  in  some  other  cases  not  recorded  in  this  paper. 
The  method  I  refer  to  is  the  introduction  of  a  rinsr 
pessary  into  the  true  conjugate.  It  is  not  difficult  to 
adjust  a  thick  pessary  so  that  it  shall  lie  exactly  in  the 
conjugate  of  the  brim  without  being  pressed  out  of  shape. 
When  a  pessary  has  been  found  that  exactly  fits,  its  dia- 
meter gives  the  true  conjugate. 

Three  of  the  patients  were  primipar^,  and  two  were 
niultiparae.      In  Case  3  there  is  no  note  on  this  point. 

Case  1. — A.  T — ,  aged  22,  a  primipara,  was  admitted 
into  the  London  Hospital,  in  labour,  on  January  27th, 
1886.  She  had  been  in  labour  forty-eight  hours  before 
admission,  and  was  sent  up  to  the  hospital  because  the 
pelvis  was  thought  to  be  contracted.  The  vertex  had 
presented,  but  before  I  first  saw  the  case  turning  had 
been  done,  and  the  legs  and  part  of  the  body  were  out- 
side the  vulva.  The  operator  had  then  found  himself 
unable  to  complete  delivery. 

Careful  external  measurements  of  the  pelvis  were  then 
taken,  and  found  to  be  as  follows  : 

Between  the  anterior  superior  iliac  spines  =  10|  inches. 

Maximum  distance  between  the  iliac  crests  =  10^  inches. 

External  conjugate  =  5|  inches. 

Between  the  posterior  superior  iliac  spines  =  2|  inches. 

Height  of  the  symphysis  pubis  =  2  inches. 

There  was  great  difficulty  in  getting  the  arms  down, 
and  the  left  humerus  was  fractured  in  doing  so.  The 
occiput  was  then  perforated,  and  the  cephalotribe  applied. 
The  skull  had  to  be  crushed  twice  before  it  could  be 
made  to  descend,  and  it  was  only  even  then  delivered 
with  difficulty. 

The  diagonal  conjugate  was  'd^  inches,  and  the  true 
conjugate  (measured  by  the  introduction  of  the  hand)  was 
2f  inches.      The  contraction  was  found  to  be  not  limited 


166  CRANIOTOMY. 

to  the  brim,  but  to  extend  about  as  low  as  tlie  second 
sacral  vertebra. 

The  foetus,  which  was  a  female,  weighed  (without  the 
brain)  6  lbs.  13^  oz.  On  dissection  it  was  found  that  the 
base  of  the  skull  had  been  thoroughly  crushed.  The 
cervical  vertebral  column  had  been  fractured,  the  head 
only  being  attached  to  the  body  by  the  integument  and 
soft  parts.  The  centre  in  the  lower  end  of  the  femur 
was  well  ossified. 

For  six  days  after  the  operation  the  patient  had 
moderate  fever,  on  the  third  day  after  delivery  the 
temperature  reaching  102  ,  on  the  fourth  day  varying  from 
100-2''  to  102°,  on  the  fifth  day  from  100-2°  to  102-6°,  on 
the  sixth  day  from  99-8°  to  103",  on  the  seventh  day  from 
98-6°  to  100-4°,  on  the  eighth  day  from  99°  to  100-4°,  on 
the  ninth  day  from  99-6°  to  101"2°.  From  the  tenth  day 
the  temperature  was  normal.  The  patient's  general 
condition  was  never  such  as  to  occasion  anxiety,  and  she 
left  the  hospital  quite  well. 

Case  2. — A.  L.  C — ,  aged  21,  was  admitted  into  the 
London  Hospital,  in  labour,  on  January  9th,  1886.  She 
had  had  one  child  two  years  previously.  The  labour  on 
that  occasion  was  said  to  have  taken  place  at  full  term, 
and  to  have  lasted  only  six  hours.  The  child  lived  six 
months. 

On  the  present  occasion  she  had  been  attended  in  the 
first  instance  by  a  midwife ;  after  thirty-six  hours,  as  no 
progress  was  being  made,  a  doctor  was  called  in.  He 
applied  the  forceps  ;  while  he  was  making  traction  the 
forceps  slipped  off,  and  the  patient  screamed,  saying, 
*^  You  have  cut  me.''  Another  doctor  was  then  called  in, 
and  during  about  five  hours  efforts  were  made  to  effect 
delivery  without  success.  The  patient  was,  therefore, 
sent  up  to  the  hospital.  The  resident  accoucheur  made 
another  attempt  with  the  forceps,  and  then  sent  for  me. 

The  measn/rements  of  the  pelvis  were  as  folloivs  : 

Between  the  anterior  superior  iliac  spines  =  8j  inches. 


CRANIOTOMY.  167 

Maximum  distance  between  the  iliac  crests  =  9|  inches. 

External  conjugate  =  6^  inches. 

Diagonal  conjugate  =  3f — 3^  inches. 

The  presentation  was  right  occipito-posterior,  and  the 
fcetal  heart  was  heard.  There  was  a  laceration  of  the 
soft  parts  in  the  neighbourhood  of  the  sacral  promontory 
into  which  the  tip  of  the  finger  could  be  passed.  After 
the  forceps  had  been  again  tried  unsuccessfully  cephalo- 
trips}'  was  performed.  The  true  conjugate  was  carefully 
measured  after  delivery,  and  estimated  at  2|  to  2|-  inches. 
It  will  be  seen  that  there  was  slight  general  contraction 
of  the  pelvis. 

For  twenty-nine  days  after  delivery  this  patient 
suffered  from  more  or  less  fever,  though  her  condition 
was  never  such  as  to  make  one  really  anxious  as  to  the 
ultimate  result. 

During  the  Jirst  weeh  the  temperature  was  rarely  below 
101°,  and  reached  102*6°  on  several  occasions.  The 
pulse  varied  from  132  on  the  day  after  delivery  to  80  at 
the  end  of  the  first  week. 

During  the  second  iceek  the  temperature  varied  from 
99-2°  (lowest)  to  103°,  and  on  one  occasion  104°.  The 
pulse  on  the  only  occasion  on  which  it  was  recorded  in 
the  notes  during  this  week  was  80. 

During  the  third  weeh  the  temperature  varied  between 
98-2°  and  101-8°. 

During  the  fourth  weeh  the  temperature  varied  from 
99°  to  101  "2°,  and  from  the  twenty-ninth  day  onwards  the 
temperature  was  normal. 

Convalescence  was  therefore  retarded  considerably, 
but  the  long  time  the  patient  had  been  in  labour,  and  the 
number  of  operative  procedures  she  had  undergone  before 
coming  to  the  hospital,  1  think  sufiiciently  account  for 
it.      Ultimately  recovery  was  complete. 

Case  3. — Sarah  J — ,  aged  25,  was  admitted  into  the 
London  Hospital,  in  labour,  on  May  13th,  1886.  Labour 
had    begun    on   the    previous   day   about   2.25   p.m.,  and 


168  CEANIOTOMY. 

•about  8.30  on  tliat  day  the  os  was  said  to  Lave  been 
about  the  size  of  a  five-shilling  piece.  At  two  minutes 
past  midnight  the  os  was  found  to  be  fully  dilated. 
The  vertex  presented,  and  there  was  a  large  caput 
succedaneum. 

About  3.7  p.m.  on  the  afternoon  of  the  13th  the  resi- 
dent accoucheur  was  sent  for  to  see  the  case.  He 
attempted  to  deliver  with  the  forceps  (the  patient  being 
under  chloroform),  but  failing  to  do  so  had  the  case  sent 
up  to  the  hospital.      I  saw  her  about  6  p.m. 

The  measurement.'i  of  the  pelvis  tcere  as  follows  : 

Between  the  anterior  superior  iliac  spines  =  8|  inches. 

Maximum  distance  between  the  crests  =  lOf  inches. 

External  conjugate  =  7  inches. 

Diagonal  conjugate  =  4  inches. 

The  true  conjugate  (after  delivery)  was  found  to  be 
3-|  inches. 

On  examining  the  abdomen  the  ring  of  Bandl  was  felt 
about  four  fingers'  breadths  above  the  pubes.  The  foetal 
heart  was  not  heard.  The  labia  were  much  swollen,  and 
meconium  was  being  discharged.  The  sagittal  suture 
was  felt  running  across  the  pelvis,  parallel  to  the  trans- 
verse diameter  ;  the  anterior  fontanelle  lay  to  the  right, 
much  obscured  by  the  caput  succedaneum. 

Chloroform  was  given,  and  the  forceps  again  tried,  but 
without  success.  Cephalotripsy  was  then  performed,  the 
head  being  crushed  twice.  There  was  a  good  deal  of 
bleeding  after  the  placenta  came  away  ;  it  was  checked 
by  hot  water  injections  and  the  hypodermic  administra- 
tion of  ergotin  (4^  grains  in  all  being  given). 

On  the  evening  of  May  15th  the  temperature  was  103°. 

May  31st. — Ever  since  delivery  there  has  been  a  lump 
to  be  felt  reaching  up  to  the  umbilicus,  at  first  of  course 
taken  to  be  the  uterus,  but  latterly,  as  the  patient  has  had 
more  or  less  fever  since  the  confinement,  thought  to  be 
due,  in  part  at  least,  to  inflammatory  exudation.  To-day 
the  patient  was  examined  on  the  couch,  and  it  was  then 
found  that  a  large    sound    could   be    passed    up    to    the 


CEANIOTOMY.  169 

highest  point  of  the  tumour  in  the  abdomeu,  thus  proving 
it  to  be  the  body  of  the  uterus.  The  sound  passed 
about  5j  inches.  The  uterus  was  washed  out  with 
carbolic  lotion;  the  fluid  that  came  back  first  was  extremely 
offensive. 

June  13th. — A  yellow,  leathery  mass  about  2  inches 
long  by  1  inch  broad  was  found  hanging  from  the  os. 
It  was  twisted  off  with  cervix  forceps  ;  it  had  an  intensely 
foetid  odour. 

24th. — The  uterus  still  being  about  the  same  size  as 
on  May  31st,  and  the  patient's  general  condition  unsatis- 
factory, fever  still  persisting,  an  angesthetic  was  given, 
and  the  interior  of  the  uterus  thoroughly  scraped  with  a 
Recamier's  curette.  Several  yellow  flakes,  extremely 
offensive,  about  -^  of  an  inch  thick,  Avere  removed, 
perhaps  enough  to  fill  two  or  three  table-spoons. 

From  this  time  the  patient  rapidly  improved,  her 
highest  temperature  being  100°  (on  June  27th),  and  from 
that  time  normal. 

By  July  14th,  just  three  weeks  after  the  curetting,  the 
uterus  had  involuted  to  its  ordinary  size,  and  the  sound 
only  passed  the  normal  distance.  The  uterus  was  freely 
moveable. 

The  persistent  subinvolution  during  six  weeks  after  the 
confinement  was  a  very  remarkable  feature  in  this  case  ; 
and  the  rapidity  with  which  involution  proceeded,  after 
the  endometrium  had  been  curetted,  was  equally  striking. 
It  seemed  to  me  that  probably  the  length  of  time  for 
which  labour  was  allowed  to  continue  without  progress 
had  led  to  some  sloughing  of  the  endometrium,  and  that 
the  yellow  flakes  removed  by  the  curette  had  originated 
in  that  way.  The  os  was  known  to  have  been  fully 
dilated  at  least  eighteen  hours  before  delivery  was  com- 
pleted. 

Case  4. — Emma  H — ,  a  primipara  aged  27,  was  admitted 
into  the  London  Hospital,  in  labour,  on  Sunday,  January 
8th,  1888. 


170  CRANIOTOMY. 

Labour  had  begun  on  the  morning  of  Saturday,  the  7th, 
at  10  a.m.  At  12  on  Saturday  night,  as  no  progress 
"was  being  made,  a  doctor  was  called  in.  He  perforated 
the  head,  assisted  by  a  friend,  but,  as  they  could  not 
deliver,  the  patient  was  sent  up  to  the  hospital. 

I  saw  the  case  about  4  a.m.  on  Sunday  morning. 

The  following  were  the  measurements  of  the  pelvis  ; 

Between  the  anterior  superior  iliac  spines  =  11  inches. 

Maximum  distance  between  the  crests  =11  inches. 

External  conjugate  =  5^  inches. 

Diagonal  conjugate  =  2|  inches. 

The  true  conjugate  was  found  (after  delivery)  to  be 
2f  inches. 

An  arm  was  down  in  the  vagina,  and  the  perforated 
head  lay  above  and  somewhat  anterior  to  the  pubes. 
The  prolapsed  arm  was  amputated  at  the  shoulder-joint. 
I  then  tried  to  seize  the  head  with  the  cranioclast,  but 
was  unable  to  get  a  good  hold,  the  head  lying  so  far 
forwards,  as  well  as  being  above  the  pubes.  The  cephalo- 
tribe  was  then  used,  and  with  great  difficulty  I  succeeded 
in  applying  it  to  the  head.  Much  time  was  occupied  in 
getting  it  to  grasp  the  head  ;  and  the  head  was  crushed 
several  times  before  it  could  be  made  to  descend.  Some 
portions  of  the  cranium  were  also  removed  with  craniotomy 
forceps.  The  body  did  not  enter  the  pelvis  till  it  was 
seized  with  the  cephalotribe  and  its  bulk  reduced. 

The  weight  of  the  child  without  the  amputated  arm, 
brain,  and  some  parts  of  the  cranium  was  6j  lbs. 

On  the  whole  I  consider  this  case  to  have  been  the 
most  difficult  of  the  series. 

Subsequent  progress. — This  patient  was  very  ill  for 
three  weeks  after  her  confinement. 

During  the  first  week  the  temperature  varied  from  sub- 
normal (97*2°)  on  the  second  day  to  104°  on  the  fifth  and 
sixth  days,  and  on  the  seventh  day  she  had  a  rigor.  The 
pulse  ranged  from  102  to  164.  On  the  seventh  day  she 
was  breathing  36  to  the  minute. 

During  the  second  week  she  was  still   for  the  most  part 


CRANIOTOMY.  171 

feverisli,  but  the  temperature  was  not  quite  so  liigh,  103 
being  the  maximum.  Tlie  pulse  ranged  from  110  to  140, 
and  the  respiration  from  24  to  34. 

During  the  third  tceek  the  temperature  was  lower,  only 
reaching  101  on  three  occasions,  and  usually  being  from 
98-2°  to  100°.  The  pulse  varied  from  100  to  13G,  and 
the  respiration  from  16  to  25. 

About  the  end  of  the  first  week  the  patient  had  almost 
certainly  an  attack  of  pneumonia,  as  she  had  cough  with 
rusty  sputa  and  rapid  breathing.  The  chest  was,  how- 
ever, not  examined,  as  the  patient  was  very  weak. 

On  February  20th  the  cough  had  almost  left  her.  The 
uterus  was  found  to  be  freely  moveable,  and  there  was 
no  evidence  of  the  damage  sustained  by  the  soft  parts  at 
the  time  of  delivery.  She  could  then  hold  her  water  two 
hours,  but  for  several  days  after  the  confinement  the  urine 
escaped  involuntarily. 

The  patient's  height  was  4  feet  5f  inches. 

Case  5. — Alice  C — ,  aged  24,  primipara,  was  admitted 
into  the  London  Hospital,  in  labour,  on  November  16th, 
1888. 

The  patient  was  seen  in  the  first  instance  at  her  own 
home  by  a  maternity  pupil,  who  found  the  cord  prolapsed. 
He  tried  to  replace  it  by  putting  her  in  the  knee-elbow 
position,  but  was  not  able  to  get  it  back.  The  resident 
accoucheur  then  saw  the  case,  and  found  that  the  pelvis 
was  contracted.  The  os  uteri  w^as  about  the  size  of  a 
shilling.  This  was  at  1  a.m.  The  patient  was  admitted 
into  the  hosjjital  about  11  a.m.,  and  I  saw  her  about  11.30. 

The  measurements  of  the  pelvis  were  as  follows  : 

Between  the  anterior  superior  iliac  spines  =  10 j  inches. 

Maximum  distance  between  the  crests  =  10|  inches. 

External  conjugate  =  5|  inches. 

Between  the  posterior  superior  iliac  spines  =  2|  inches. 

The  diagonal  conjugate  was  taken,  but  not  recorded. 

Chloroform  was  given,  and  cephalotripsy  performed. 
The  true  conjugate  was  found  to  be  2^  inches.      In  addi- 


1  72  CRANIOTOMY. 

tion  to  measuring  it  by  the  introduction  of  the  hand,  the 
plan  of  inserting  a  thick  watcli-spring  ring  pessary  into 
the  conjugate  was  emploj'ed.  It  Avas  found  that  a  pessary 
with  a  diameter  of  2^  inches  just  fitted  into  the  conjugate. 
Subsequent  "progress. — During  six  days  after  delivery 
the  patient  was  febrile  at  some  period  of  the  twenty-four 
hours,  the  maximum  being  1 02°  on  the  night  of  November 
16th  ;  but  her  general  condition  was  satisfactory  othenvise, 
and  she  made  a  rapid,  recovery.  Her  height  was  4  feet 
1\  inches. 

Case  6. — This  was  a  second  confinement  in  the  same 
patient  (Case  5).  She  was  admitted  into  the  London 
Hospital,  in  labour,  on  March  3rd,  1890.  The  vertex  pre- 
sented, and  the  membrane  had  ruptured  spontaneously. 
As  I  was  out  when  a  message  came  about  the  case,  the 
resident  accoucheur  proceeded  to  perform  craniotomy, 
knowing  that  it  had  been  necessary  at  her  previous  con- 
finement. He  used  the  cranioclast,  the  craniotomy  forceps, 
and  the  cephalotribe. 

The  patient  made  a  rapid  recovery,  the  highest  tem- 
perature being  only  100'4°,  and  she  left  the  hospital  on 
March  18th. 

In  conclusion,  I  would  call  attention  to  the  fact  that 
Cases  1,  2,  3,  and  4  had  been  many  hours  in  labour  before 
admission,  and  that  prolonged  attempts  had  been  made 
to  effect  delivery  before  craniotomy  was  performed,  so 
that,  though  these  patients  recovered,  they  must  have  in- 
curred a  greater  risk  than  they  would  have  done  if  the 
necessity  for  the  operation  had  been  recognised  early. 

As  regards  risk,  it  would  not  be  fair  to  compare  cases 
of  Ca3sarean  section  at  an  early  stage  of  labour  with  cases 
of  craniotomy  after  labour  had  been  in  progress  many 
hours,  or  even  days.  Early  cases  should  be  compared 
with  early  cases,  for  in  either  Csesarean  section  or  cranio- 
tomy the  prognosis  must  be  better  when  the  operation  is 
undertaken  early,  at  a  time  when  the  tissues  are  in  a 
healthy  condition,  and  the  patient's  strength  unimpaired. 


CRANIOTOMY. 


173 




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174  CRANIOTOMY. 

Dr.  John  Phillips  had  contributed  a  paper  on  the  same 
subject  as  Dr.  Lewers  three  years  ago  ('  British  Medical  Journal,' 
June  1st,  1889),  but  although  on  similar  lines  his  conclusions 
were  different.  His  own  cases  of  craniotomy  were  sixteen  in 
number,  and  all  recovered  ;  twelve  of  these  were  for  contracted 
pelvis,  of  which  four  could  be  included  under  the  same  category 
as  those  related  by  the  author.  He  could  not  but  conclude  from 
his  own  experience  that  cephalotripsy  was  a  very  difficult  opera- 
tion, especially  after  repeated  attempts  by  others  to  deliver  by 
means  of  the  forceps.  The  author  had  not  alluded  to  statistics 
of  large  numbers  of  craniotomies — for  example,  Determann  at 
Berlin  (1876—1887)  performed  the  operation  239  times  in  22,051 
cases,  with  a  mortality  of  128  per  cent,  up  to  1882,  and  94  per 
cent,  from  1882  to  1887  ('  Zeitschrift  f  Geburt.  u.  Gyn.,'  1888, 
Bd.  XV,  s.  323).  Other  statistics  from  Leipzig  gave  the  mortality 
as  80  per  cent.  Dr.  Phillips  thought  these  figures  were  of  great 
value.  He  would  like  to  ask  Dr.  Lewers  how  he  proposed  to 
deal  with  the  cases  he  had  related  in  event  of  a  second  pregnancy  : 
for  his  own  part,  he  considered  that  having  once  performed 
craniotomy  on  any  patient,  and  warned  her  of  the  risk  she 
incurred  by  again  becoming  pregnant,  he  would  only  repeat  the 
operation  under  protest  or  decline  altogether. 

Dr.  Petee  Hoeeocks  said  that  the  important  point  in  the 
paper  was  the  comparison  between  craniotomy  and  Caesarean 
section.  He  quite  agreed  with  the  author  that  general  statistics 
of  the  two  operations  were  valueless.  In  the  Guy's  Lying-in 
Charity  the  number  of  cases  of  craniotomy  collated  by  Dr. 
Galabinfrom  1865  to  1875  was  1  in  1310,  or  '07  per  cent. ;  from 
1875  to  1885  collated  by  himself  the  number  was  1  in  1074,  or 
"07  per  cent.  In  all,  during  the  last-mentioned  decennial  period, 
24  cases  required  perforation ;  of  these  4  mothers  died,  2  from 
rupture  of  the  uterus,  1  from  rupture  of  vagina  into  rectum 
owing  to  atresia,  and  1  from  suppurative  peritonitis  which  fol- 
lowed after  prolonged  efforts  at  delivery  had  been  otherwise 
made.  He  thought,  therefore,  that  excluding  such  cases  as  these, 
where  death  would  probably  ensue  whether  craniotomy  was  per- 
formed or  Caesarean  section,  it  must  be  admitted  that  craniotomy 
as  at  present  performed,  with  all  modern  methods  and  precautions 
and  antiseptics,  had  a  much  lower  maternal  mortality  than  had 
Caesarean  section  performed  under  similar  conditions  even  in  the 
most  successful  hands.  But  he  did  not  think  this  fact  should 
prevent  us  from  offering  to  a  patient  the  alternatives.  As  a 
matter  of  fact  the  mortality  after  Caesarean  section  was  a  dimin- 
ishing one,  and  no  doubt,  like  all  other  operations,  would  improve 
more  and  more  with  increasing  experience.  He  must  confess  to 
an  increasing  aversion  to  perforation  of  a  living  child's  head. 
The  certain  death  of  the  child  on  the  one  hand,  and  the  almost 


CRANIOTOMY.  175 

certain  safety  of  it  on  the  other,  must  be  takeu  into  considera- 
tion ;  and  if  the  mother  and  father  and  friends  were  willing  to 
take  the  extra  risk  involved,  he  considered  Csesarean  section 
quite  justifiable.  He  mentioned  a  case  of  great  pelvic  contrac- 
tion wiiich  recently  occurred  in  the  Guy's  Lying-in  Charity, 
where  the  alternatives  were  placed  before  the  parents.  They 
would  not  consent  to  any  extra  risk,  and,  moreover,  were  glad 
not  to  have  a  living  child  ;  hence  craniotomy  was  performed, 
and  the  mother  made  a  good  recovery. 

Dr.  Champnets  said  that,  in  a  subject  so  large  as  that  before 
the  meeting,  only  a  few  points  could  be  discussed.  There  was, 
for  instance,  no  time  to  speak  of  the  very  important  relation  of 
the  induction  of  premature  labour  to  Caesarean  section.  In  a 
pelvis  susceptible  of  the  former  treatment  in  a  subsequent  labour 
it  was  plainly  our  duty  to  perforate  even  a  living  child  on  the 
first  occasion.  It  must,  however,  be  borne  in  mind  that  the 
statistics  of  Professor  Belluzzi  showed  that  few  children  grew 
up  who  were  delivered  through  a  pelvis  of  less  than  3  inches. 

A  point  in  favour  of  Cesarean  section  which  had  not  yet 
been  referred  to  was  the  opportunity  of  sterilising  the  patient 
which  it  aftbrded. 

The  mortality  of  simple  craniotomy  was  probably  nil.  The 
plunging  of  a  perforator  into  the  head  of  a  child  should  not  be 
a  risk  to  the  mother.  The  dangers  of  craniotomy  were  principally 
two.  The  first  consisted  not  in  the  operation,  but  in  the  futile 
attempts  at  delivery  by  forceps  which  so  often  preceded  it.  This 
explained  the  paradox  that  the  maternal  mortality  was  greater 
in  slight  than  in  great  contractions  of  the  pelvis,  for  in  the  latter 
no  such  attempts  were  made.  The  second  consisted  not  in 
perforation,  but  in  extraction.  Intra-uterine  craniotomy  was 
one  of  the  most  dangerous  operations  in  midwifery.  It  was 
easy  to  perforate,  and  at  the  time  of  perforation  the  os  was 
often  pretty  large,  but  as  soon  as  the  head  collapsed  a  little  it 
shrank  up  again.  It  was  then  too  small  to  apply  the  cephalo- 
tribe,  especially  high  up  in  the  pelvis,  and  delivery  had  to  be 
effected  by  removing  the  vault  of  the  skull  piecemeal,  followed 
by  cephalotripsy  as  a  rule,  the  cervix  being  almost  always 
severely  lacerated  in  the  process.  This  subject  was  seldom 
mentioned,  but  such  cases  were  not  rare  in  practice. 

With  regard  to  the  ethical  question,  he  did  not  think  that 
Caesarean  section  was  done  often  enough  in  England,  but  he 
could  not  agree  with  Dr.  Phillips  that  a  woman  should  be  left  to 
die  because  she  refused  Caesarean  section.  Such  a  refusal  would 
not,  he  felt  sure,  be  upheld  by  a  court  of  law,  nor  by  professional 
opinion.  If  called  to  a  case  in  which  Cesarean  section  would 
be  the  proper  treatment,  lie  believed  that  it  was  the  duty  of  the 
medical  man  to  set  forth  plainly  the  right  course  to  pursue  ;  but 


170  CRANIOTOMY. 

if  that  was  declined,  it  was  then  his  duty  to  save  the  patient's 
life  by  perforation,  liis  pi'ovince  being  that  of  a  guardian  of  life 
and  health,  and  not  that  of  a  judge. 

Dr.  AViLLiAM  Duncan  thought  that,  notwithstanding  the 
great  advance  made  in  surgery  recently,  we  are  not  in  a  pusition 
to  dogmatise  on  the  comparative  merits  and  risks  of  Csesarean 
section  and  craniotomy.  Until  recently  Caesarean  section  had 
not  had  a  fair  chance  in  this  country,  being  only  performed  a 
few  times  and  as  a  dei'tiier  ressort  but  Leopold's  statistics 
(which  cannot  be  disputed)  showed  that  the  mortality  of  the 
operation  was  only  8  or  9  per  cent.  It  was  very  doubtful 
whether  craniotomy  had  a  less  mortality  ;  the  cases  quoted  by 
the  author  were  too  few  on  which  to  base  an  opinion.  It  was 
exceedingly  important  to  bear  in  mind  two  facts  not  mentioned 
in  the  paper  :  the  first  was  that  whereas  in  one  operation  all  the 
children  were  saved,  in  the  other  they  were  necessarily  destroyed  ; 
and  although  the  lite  of  the  mother  should  be  our  first  considera- 
tion, still  that  of  the  child  must  not  be  ignored.  At  any  rate, 
the  mother  should  have  the  position  fully  explained,  so  that  she 
may  choose  whether  she  would  run  a  little  more  risk  in  order  to 
have  her  child  saved.  The  second  fact  to  which  he  wished  to 
allude  was  that  many  women  after  craniotomy  were  left  more  or 
less  crippled  from  lacerations  and  pelvic  inflammations,  whereas 
nothing  of  the  kind  was  seen  after  CiBsarean  section.  An 
important  advantage  of  the  latter  operation  was,  as  had  been 
already  mentioned,  the  opportunity  it  gave  of  placing  the  woman 
in  a  condition  that  she  could  not  again  conceive.  He  feared 
that  in  spite  of  the  lessened  mortality  after  Caesarean  section 
the  general  practitioners  would  still  have  resort  to  craniotomy 
in  preference  to  the  other,  but  he  thought  the  time  had  arrived 
when  we  ought  to  completely  revise  the  teaching  and  practice  of 
delivering  a  woman  by  craniotomy  in  all  (except  the  most  severe) 
degrees  of  contracted  pelves. 

Dr.  Heebeet  Spencee  thought  that  such  small  pelves  (four 
of  which  had  a  conjugate  diameter  of  2^  inches  or  less)  as  those 
given  in  Dr.  Lewers's  paper  were  very  rare.  At  IJniversity 
College  Hospital  there  had  not  been  one  pelvis  with  such  a  small 
conjugate  diameter  as  2^  inches  in  over  10,000  labours.  In  such 
a  case  he  would  prefer  Caesarean  section  as  equally  or  less 
dangerous  to  the  mother  than  craniotomy.  He  asked  whether 
Dr.  Lewers  had  included  in  his  paper  all  the  cases  of  craniotomy 
which  had  occurred  at  the  London  Hospital  in  over  five  years,  or 
onlv  those  performed  by  himiself.  Judging  from  the  experience 
at  other  hospitals,  Dr.  Spencer  thought  it  could  not  be  that 
craniotomy  had  only  twice  been  necessary  in  pelves  measuring 
over  2i  inches  in  the  conjugate.  At  University  College  Hospital 
craniotomy  had  been  performed  for  contracted  pelvis  eleven  times 


CRANIOTOMY.  177 

in  10,000  labours,  always  with  success  to  the  mother.  The 
pelves  had  mostly  varied  between  3^  inches  and  2f  inches  in  the 
conjugate,  and  in  such  cases  he  considered  craniotomy  had  a 
very  slight,  if  any,  maternal  mortality,  and  was  in  this  respect 
greatly  superior  to  Ccesarean  section.  Much  luid.  been  said  of 
Dr.  Leopold's  results  in  Cae^arean  section,  but  that  operator's 
results  in  craniotomy  were  mncli  better  (71  cases  without  a  death 
from  the  operation).  Admitting  the  principle  that  the  cliild 
might  be  sacrificed  in  the  interest  of  the  mother,  he  would,  in 
any  individual  case  of  labour  with  a  mature  living  child,  adopt 
that  method  of  delivery  which  gave  the  best  chance  to  the  mother, 
and  would  prefer  craniotomy  in  all  the  ordinary  cases  of  con- 
tracted pelvis  and  Caesarean  section  in  those  extreme  cases  which 
were  very  rare. 

Dr.  Hai^dfield-Jones  thought  that  if  Caesarean  section  was 
to  be  employed  more  frequently,  and  practitioners  of  medicine 
were  to  be  taught  that  tiiey  ought  to  do  that  operation  in  many 
cases  in  which  they  had  hitherto  performed  craniotomy,  then  it 
would  be  necessary  to  consider  whether  the  Porro  operation 
would  not  be  safer  in  the  hands  of  men  unaccustomed  to  abdo- 
minal surgery  rather  than  the  Sanger- Caesarean  section.  Cer- 
tainly the  ris-ks  of  haemorrhage,  the  complication  oi'  uterine 
atony,  and  the  difficulties  of  suture  of  the  womb-incision  were 
avoided  in  the  Porro  operation.-  Dr.  Hand  field- Jones  asked 
whether  the  case  of  delayed  involution  quoted  in  the  paper  was 
not  one  of  "  metritis  desiccans,"  and  asked  if  the  author  had 
examined  the  sloughs  microscopically  for  muscular  tissue. 

Dr.  CuLLi>rGWOETn  thought  the  series  of  cases  reported  by 
Dr.  Lewers  an  unsuitable  basis  upon  which  to  raise  a  discussion 
on  the  relative  merits  of  craniotomy  and  Caesarean  section. 
With  the  exception  perhaps  of  Xo.  6,  which  was  not  a  case  of 
Dr.  Lewers's  at  all,  all  the  cases  had  been  subjected,  before 
Dr.  Lewers  saw  them,  to  long  and  repeated  attempts  at  delivery  ; 
in  all  of  them,  presumably  (though  the  point  was  not  alluded  to 
in  the  paper),  the  child  was  dead.  In  such  cases  as  these  no  one 
would  for  a  moment  entertain  even  the  thought  of  Caesarean 
section.  Obviously  craniotomy  was  not  only  the  right  thing  to 
do,  but  the  only  thing  to  do.  It  was  when  one  was  consulted 
by  a  patient  before  labour  set  in,  the  child  being  alive  and  the 
pelvic  deformity  considerable,  that  the  real  difficulty  occurred 
of  deciding  what  advice  to  give.  The  question  was  entirely  one 
of  degree.  Probably,  if  a  vote  were  taken,  all  obstetricians 
would  agree  that  the  patient  should  be  advised  to  undergo 
Caesarean  section  if  the  conjugate  diameter  were  2|-  inches  or 
under  ;  the  majority  would  most  likely  be  in  favour  of  giving 
that  advice  where  the  conjugate  did  not  exceed  2^  inches,  whilst 
a  large  minority  would  he  thought  be  disposed  to  recommend 


178  CRANIOTOMY. 

Caesarean  section,  under  such  circumstances,  if  tlie  contraction 
were  even  as  considerable  as  2|  inches.  He  himself  would  be 
found  in  the  last-named  category. 

With  regard  to  the  hesitation  shown  by  British  practitioners 
in  advising  their  patient?  to  submit  to  Caesarean  section,  it  was 
a  state  of  things  that  would  continue  until  a  larger  number  of 
successful  cases  had  been  recorded.  The  late  Dr.  Matthews 
Duncan,  in  a  discussion  in  that  Society  in  the  year  1887  on  a 
paper  of  his  (Dr.  Cullingworth's),  had  put  this  very  forcibly. 
"  It  was  to  Germany,"  said  Dr.  Duncan,  "that  we  must  look  for 
the  guidance  of  experience  to  such  wonderful  successes  as  those 
of  Sanger  and  Leopold,  and  Crede  and  Grusserow.  It  was  such 
successes  alone    that  should  and   would   lead   us   in   this  great 

practical  question No  amount  of  eloquence  about 

the  abolition  of  craniotomy — and  there  had  been  much  of  such 
talk — would  help  forward  that  much-to-be-desired  result.  Nothing 
but  success  in  some  alternative  operation,  such  as  Caesarean 
section,  success  like  that  of  Sanger  or  Leopold,  would  be  con- 
vincing eloquence  or  do  the  least  good."  He  (Dr.  CuUingworth) 
could  not  help  thinking  it  matter  for  regret  that  any  words 
should  be  used  in  reference  to  this  subject  which  would  have  a 
tendency  to  discourage  in  this  country  the  performance  of 
Caesarean  section  in  suitable  cases. 

Dr.  RuTHEEFOORD  remarked  that  the  author  in  his  paper 
arrived  at  the  conclusion  that  the  Caesarean  section  should  be 
an  operation  undertaken  as  a  necessity,  and  not  as  one  of  election. 
Dr.  Rutherfoord  thought  this  conclusion  was  hardly  justified  by 
the  cases  brought  forward  by  the  author.  In  five  out  of  the  six 
tabulated  cases  the  surroundings  and  accompanying  circum- 
stances were  most  unfavourable  before  craniotomy  was  performed ; 
there  had  been  a  want  of  antiseptics,  prolonged  and  persistent 
interference  with  the  uterus  had  been  carried  out,  and  in  all 
there  had  been  repeated  attempts  to  deliver  with  forceps.  In 
8|)ite  of  these  unfavourable  circumstances  very  successful  results 
had  been  obtained.  Dr.  Eutherfoord  believed  similarly  successful 
results  might  be  obtained  were  Caesarean  section  made  an  opera- 
tion of  election,  with  this  advantage,  that  a  living  child  would 
be  brought  into  the  world. 

Dr.  Leith  Napier  thought  that  the  question  raised  by  the 
author  regarding  the  relative  dangers  of  craniotomy  and  Caesarean 
section,  and  which,  by  arrangernent,  had  not  been  discussed 
at  the  last  meeting,  deserved  notice.  Dr.  Lewers  erred  in 
suggesting  that  the  mortality  of  craniotomy  was  nil,  and  that  of 
Caesarean  section  "  very  much  higher  than  reported."  Takinglarge 
numbers  of  cases,  the  maternal  mortality  in  antiseptic  craniotomy 
was  6"G  per  cent.,  a  very  excellent  figure  compared  with  the  general 
result ;  in  the  hands  of  the  best  operators  the  maternal  mortality 


CRANIOTOMY.  "179 

was  about  8*8  per  cent,  in  Cesarean  section,  and  the  infantile 
mortality  practically  nil.  It  might  be  averred  that  these  splendid 
results  of  Leopold  and  Cameron,  in  their  50  and  18  cases  respec- 
tively, were  not  likely  to  be  reached  by  the  majority  of  operators. 
But  if  we  referred  to  an  article  in  the  'JSew  iTork  Medical 
Journal '  for  August  29th,  1885,  three  years  before  Cameron's 
first  case,  and  when  Leopold  had  only  operated  by  Sanger's 
method  three  or  four  times,  we  would  find  that  Dufeilhay  as 
cited  by  Lusk  gave  statistics  showing  81  per  cent,  of  women 
saved.  In  another  series  of  61  operations  in  rural  districts  there 
were  more  than  78  per  cent,  of  recoveries.  There  could  be  no 
doubt  that  craniotomy  must,  except  under  special  circumstances, 
such  as  infantile  death,  &c.,  be  regarded  as  a  most  undesirable 
procedure  ;  and  little  less  doubt  that  Caesarean  section  would  be 
generally  preferred  in  the  near  future.  He  would  not  now 
enter  on  his  personal  experience  of  craniotomy,  which,  however, 
had  been  sufficient  to  enable  him  to  speak  with  some  conhdence 
in  stating  that  he  had  performed  this  ghastly  operation  much 
oftener  in  the  past  than  he  hoped  to  do  in  the  future  with  his 
more  recent  knowledge  of  Csesarean  section. 

Dr.  Lewees,  in  reply,  said  it  was  important  to  keep  in  view 
the  fact,  however  we  explain  it,  that  the  mortality  of  Caesarean 
section  in  London,  performed  by  operators  of  acknowledged 
competence  in  other  serious  operations,  was  still  very  high,  from 
20  to  50  per  cent.,  and  even  in  some  cases  higher.  This  was  a 
matter  ot  common  knowledge,  and  it  appeared  clearly  also  in  the 
course  of  the  discussion  on  Caesarean  section  at  the  last  meeting 
of  the  Society.  This  being  so,  it  would  obviously  be  wrong  to 
advise  patients  to  undergo  the  operation  on  the  ground  that 
some  operators  in  Grermauy,  and  Cameron  in  Glasgow,  have  a 
mortality  of  about  9  or  10  per  cent.  It  was  said  that  in  order 
to  get  such  results  the  operation  must  be  done  more  frequently 
than  hitherto.  Granting  this  for  the  sake  of  argument,  con- 
tracted pelves  were  not  sufficiently  common  in  London  to  give 
all  the  London  obstetricians  many  cases  each.  The  cases  of 
craniotomy  in  his  paper,  and  others  to  which  he  had  referred, 
showed  that  the  mortality  of  that  operation  here  v\as  very  low  ; 
and  Leopold's  statistics  brought  out  the  same  thing,  as  ne  had 
had  71  cases  of  craniotomy  with  2  deaths,  both  cases  of  eclampsia, 
against  a  mortality  of  about  9  per  cent,  for  Caesarean  section. 
l>r.  Lewers  entirely  agreed  with  Dr.  Champneys  that,  in  each 
case,  the  risk  of  Caisarean  section  and  craniotomy  respectively 
should  be  put  plainly  before  the  patient  and  her  friends,  and 
that,  if  they  decided  for  craniotomy,  it  was  our  duty  to  perform 
it,  even  time  after  time.  We  had  no  right  to  compel  a  patient, 
or  even  to  urge  her,  to  take  a  very  dangerous  path  of  retreat 
from  her  painful  position  when  an  almost  certainly  safe  one  lay 
open  to  her. 

VOL.  XXXIV.  13 


JUNE   1st,   1892. 

J.  Watt  Black,  M.D.,  President,  in  the  Chair. 

Present — 49  Fellows  and  10  Visitors. 

Books  were  presented  by  Professor  W.  T.  Lusk,  M.D., 
and  Sir  William  Turner,  F.R.S. 

Augustus  Kinsey-Morgan,  M.R.C.S.  (Bournemouth)  ; 
W.  Gifford  Nash,  F.R.C.S.  (Bedford)  ;  and  Walter  Car- 
less  Swayne,  M.B.Lond.  (Clifton),  were  declared  admitted 
as  Fellows  of  the  Society. 

The  following  gentlemen  were  proposed  for  election  : — 
William  McAdam  Eccles,  M.B.,  B.S.Lond. ;  William 
John  Mackay,  M.B.,  M.Ch. Sydney  (Sydney)  ;  Samuel 
Walshe  Owen,  L.R.C.P.Lond.  ;  and  William  Bramley 
Taylor,  M.R.C.S  (Denmark  Hill,  S.E.). 


A  CASE  OF  EXTRA-UTERINE  GESTATION. 
By  E.   Malins,  M.D. 

Dr.  Malins  showed  a  specimen  of  extra-uterine  gesta- 
tion from  a  patient  operated  upon  by  him  the  previous 
day.  The  patient,  aet.  39,  was  married  a  second  time  six 
months  ago.  By  her  first  husband  she  had  one  miscarriage 
and  three  children,  the  last  pregnancy  15^  years  ago,  the 
labours  all  easy.  She  menstruated  regularly  until  about 
five  months  ago,  then  became  unwell  for  six  weeks,  but 
has  seen  nothing  for  the  past  three  months.      She  was 

VOL.  XXXIV.  14 


|g2  TUBAL    GESTATION. 

admitted  into  the  General  Hospital,  Birmingham,   com- 
plaining  of  abdominal  pain.      There  xvas  felt  a  large  mass 
extendino-  from  the  pelvis  to  the  right  iliac  fossa,  and  a 
smaller  one  on  the  left  of  the  median  line.      Per  vaginam 
there  was  a  large  mass  behind  and  to  the  right  of  the 
cervix  felt  bimanually  ;   the  uterns  was   drawn  up  to  the 
left,  the  OS  being  felt  jnst  behind  the  pubes-this  was  the 
left  mass  felt  externally.      Extra-uterine   pregnaiicy  was 
diagnosed.      The  abdomen  was  opened  m  the  median  line 
on  May  31st,  1892.      A  large  extra-uterine  gestation  cyst 
was  found  in  the  pelvis,  ruptured   at  the   posterior   and 
lower  part,  a   quantity  of  blood  being  in  the  ^^dommal 
cavity       The  foetus  was   extracted  ;   it  weighed  lib.  5oz. 
There  was  considerable  hemorrhage.      The   placenta  was 
left  the  edges  of  the  cyst  sewed  to  the  abdommal  wound  as 
well  as  possible,  and  the  cyst  packed  with  sponges  soaked 
in   perchloride  of  iron  solution.      The  patient  lived  a  few 
hours   only,    her    condition    before   the    operation    being 
almost  hopeless. 


TUBAL    GESTATION    WITH   APOPLECTIC    OVUM, 
SAC    UNRUPTURED. 

By  C.  J.    CuLLINCxWORTH,  M.D. 

Dr  CuLLiNGWORTH  exhibited  a  Fallopian  tube  distended 
near  its  fimbriated  end  to  about  the  size  of  a  pigeon's 
eo-g  by  what  he  believed  to  be  an  apoplectic  ovum. 
°  The  patient  was  a  married  woman,  aged  34,  the  mother  of 
three  children.  Her  last  menstrual  period  ceased  November 
15th,  1891  ;  after  this  she  had  no  discharge  until  February 
3rd,'l892,  when,  after  three  or  four  days'  malaise,  there 
occurred  a  sudden  and  sharp  haemorrhage.  She  went  to 
bed  and  had  been  confined  to  bed  ever  since,  except  that 
after  the  first  few  weeks   she  tried  sitting  up  m  a  chair 


TUBAL    GESTATION.  183 

for  part  of  the  day.  She  could  not  sit  longer  than  three 
or  four  hours  at  a  time,  and,  at  the  end  of  a  fortnight, 
again  found  it  necessary  to  keep  her  bed  altogether, 
on  account  of  the  haemorrhage,  so  that  for  upwards  of 
three  months  she  had  not  been  able  to  take  any  part  in 
the  work  of  the  house.  From  time  to  time,  during  this 
period,  she  was  seized  with  pains  like  those  of  labour. 
These  attacks  were  followed  by  an  increase  in  the  amount 
of  haemorrhage,  which  seemed  to  bring  relief.  On  May  1 1  th, 
after  having  been  free  from  pain  for  a  fortnight,  she  had 
a  more  than  usually  severe  attack.  Her  doctor  said  she 
was  pregnant,  and  that  there  was  something  wrong,  and 
advised  her  to  come  into  the  hospital.  Instead  of  doing 
so,  she  applied  to  the  Surrey  Dispensary,  and  was  visited 
by  the  medical  officer,  who,  finding  a  swelling  behind  the 
cervix,  in  Douglas's  pouch,  diagnosed  retroversion  of  the 
gravid  uterus.  Ineffectual  attempts  were  made  to  reduce 
the  supposed  displacement.  Dr.  Wheaton  then  saw  the 
patient,  and,  feeling  considerable  doubt  as  to  the  diagnosis, 
sent  her,  on  May  14th,  to  St.  Thomas's  Hospital. 

She  was  then  in  considerable  pain,  and  there  was  some 
haemorrhage  going  on.  In  three  days  the  pain  ceased, 
and  did  not  recur ;  the  hgemorrhage  continued.  On 
bimanual  examination,  a  smooth,  soft,  even,  oblong  swell- 
ing two  fingers'  breadths  in  thickness  was  felt  passing 
obliquely  downwards  from  the  situation  of  the  right  uterine 
appendages  to  the  floor  of  Douglas's  pouch,  to  which,  as 
well  as  to  the  back  of  the  cervix  uteri,  it  was  fixed  by 
adhesions. 

The  right  appendages  could  not  be  felt  in  their  normal 
situation  ;  the  left  could.  The  uterus  was  slightly  retro- 
verted,  but  not  otherwise  displaced ;  its  canal  was  of 
normal  length.  It  was  thought  most  probable  that  the 
swelling  was  the  right  tube,  distended  with  blood, 
and  adherent  in  Douglas's  pouch,  and  the  diagnosis  was 
early  tubal  gestation,  unruptured,  with  apoplectic  ovum. 
The  abdomen  was  opened  May  26th,  and  the  specimen 
(now   exhibited)   removed.      There  were  recent  adhesions 


184  PROLAPSE  OP  Meckel's  diverticulum. 

in  the  pelvis.  A  soft  elastic  swelling  was  found  in 
Douglas's  poucli,  connected  with  tlie  right  broad  ligament 
aud  somewhat  firmly  adherent  to  the  peritoneum  over  the 
rectum.  On  bringing  this  to  the  surface,  it  was  seen  to 
be  a  sacculated  portion  of  the  right  Fallopian  tube  one 
and  a  quarter  inches  long  by  three  quarters  of  an  inch 
wide^  of  a  dark  yellowish-brown  colour,  and  apparently 
distended  by  blood-clot.  The  fimbriated  end  of  the  tube 
was  patent,  and  a  bristle  could  be  passed  into  it  and  made 
to  emerge  at  the  divided  uterine  end.  There  was  a  little 
altered  blood-clot  in  the  undilated  portion  of  the  tube. 

The  preparation  was  being  hardened  in  spirit,  previous 
to  its  being  laid  open.  He  had  little  doubt  that  the  con- 
tents of  the  dilated  tube  would  be  found  to  consist  of 
an  apoplectic  ovum,  but  he  should  be  very  j^leased  if  the 
same  committee  that  was  appointed  to  report  on  the 
specimen  he  showed  at  the  last  meeting  were  asked  to 
examine  and  report  upon  this  one. 

The  other  tube  and  both  the  ovaries  were  normal,  and 
were,  therefore,  not  interfered  with  beyond  the  separation 
of  adhesions. 

The  patient  had  not  had  a  single  bad  symptom  since 
the  operation  and  the  temperature  had  on  no  occasion 
exceeded  99*8°. 

A  Committee,  consisting  of  Dr.  Cullingworth,  Mr. 
Doran,  Dr.  William  Duncan,  and  Mr.  J.  Bland  Sutton, 
was  appointed  to  report  on  this  specimen. 


PROLAPSE  OF  MECKEL'S  DIVERTICULUM  IN  AN 
INFANT,  FORMING  AN  UMBILICAL  TUMOUR. 

By  S.  W.  Wheaton,  M.D. 

The  specimen  was  removed  from  a  male  infant,  aged 
10  weeks,  admitted  into  the  Royal  Hospital  for  Children 
and  Women  under  the  care  of  the  author.      A  small  pink 


PEOLAPSE  OP  MECKEL  S  DIVERTICULUM. 


185 


tumour  was  noticed  at  the  umbilicus  two  weeks  after  the 
separation  of  the  cord ;  it  had  steadily  increased  in  size, 
and  on  admission   Avas  as  large  as  a  filbert.      The  tumour 


Portion  of  transverse  section  of  tumour  of  umbilicus  formed  by  prolapse  of 
Meckel's  diverticulum. 

a.  Placed  in  the  central  canal  of  the  tumour,  h.  Mucous  membrane 
resembling  that  of  small  intestine,  c.  Peripheral  surface  of  tumour  showing 
mucous  membrane  resembling  that  of  small  intestine,  d.  Point  of  transition 
from  structure  of  mucous  membrane  to  that  of  skin.  e.  Muscular  fibre 
transverse  and  longitudinal. 

was  irregular  in  shape,  measuring  one  inch  in  length  and 
half  an  inch  in  breadth  ;  it  was  attached  by  a  narrow 
pedicle  to  the  umbilicus.  At  the  upper  end  of  the  tumour 
was  a  small  orifice  situated  in  the  middle  of  a  depression. 


186  PROLAPSE  OF  Meckel's  diverticulum. 

A  mucoid  fluid  constantly  came  away  from  the  orifice,  and 
a  probe  passed  down  it  travelled  downwards  and  back- 
wards into  the  abdomen  easily  for  2|  inches,  at  which 
point  it  was  stopped  by  resistance.  The  surface  of  the 
tumour  was  pink  and  velvety  in  appearance.  The  growth 
was  removed  by  ligature,  and  the  stump  treated  with 
solid  nitrate  of  silver.  The  child  had  no  bad  symptoms,  and 
was  seen  four  months  later,  when  it  was  quite  well ;  the 
umbilicus  looked  healthy,  and  no  cyst  was  to  be  felt  in 
the  abdomen. 

A  transverse  microscopical  section  of  the  tumour  shows 
that  the  central  canal  through  which  the  probe  was  passed 
is  lined  by  mucous  membrane,  which  resembles  that  of  the 
small  intestine,  except  that  villi  and  solitary  glands  are 
absent ;  the  intestinal  glands  are  well  developed.  The  ex- 
ternal surface  of  the  tumour  is  covered  also  with  mucous 
membrane,  exactly  similar  to  that  of  the  central  canal, 
except  that  the  glands  are  larger,  and  that  in  places  the 
mucous  membrane  is  seen  to  be  in  the  process  of  trans- 
formation into  skin.  The  transformation  of  the  cylindrical 
epithelium  of  mucous  membrane  into  the  squamous  epithe- 
lium of  skin  is  extremely  interesting,  and  is  no  doubt  due 
to  the  effect  of  exposure  and  irritation  of  the  mucous  sur- 
face. Mr.  Solly  has  described  similar  changes  in  the  case 
of  a  uterine  polypus,  which  had  projected  through  the  os 
uteri,  and  the  cylindrical  epithelium  covering  which  in  the 
portion  exposed  to  friction  had  become  transformed  into 
the  squamous  variety. 

Between  the  two  layers  of  mucous  membrane  are  two 
layers  of  transverse  and  longitudinal  muscular  fibres,  which 
together  with  connective  tissue  and  vessels  compose  the 
bulk  of  the  tumour.  There  is  no  doubt,  from  the  micro- 
scopical and  other  characters,  that  the  tumour  is  formed 
by  a  prolapse  of  the  mucous  membrane  of  Meckel's  diver- 
ticulum. The  literature  relating  to  umbilical  tumours  is 
very  scanty,  especially  of  those  occurring  in  infants.  No 
description  of  any  similar  case  could  be  found  by  Dr. 
Wheaton.      The    tumours   which   had   been    described  as 


MICROCOCCI    IN    A    FIBROID    TDMODT?.  187 

occurring  in  this  situation  in  infants  were — (1)  Adenomata, 
in  which  the  growth  was  formed  of  masses  of  glandular 
tissue  resembling  that  of  the  small  intestine,  but  not 
ari'anged  in  any  definite  order.  (2)  Cases  in  which  the 
tumour  consisted  of  a  projection  caused  by  mucous  mem- 
brane, which  might  resemble  that  of  the  small  intestine, 
including  the  presence  of  solitary  glands ;  or  might,  on 
the  other  hand,  resemble  that  of  the  pyloric  end  of  the 
stomach.  (3)  Capillary  angiomata  and  naevi.  (4)  Granu- 
lomata  composed  simply  of  masses  of  small  round  cells. 
(5)  Dermoid.  The  presence  of  the  central  canal  lined  by 
mucous  membrane  distinguishes  the  specimen  from  all 
the  before  mentioned  conditions.  It  remains  to  be  seen 
whether  a  cyst  will  develop  in  the  remaining  portion  of 
the  diverticulum  ;  if  the  communication  between  it  and 
the  small  intestine  is  closed,  the  formation  of  a  cyst  seems 
an  extremely  probable  occurrence. 


MICROCOCCI  IN  THE  SUBSTANCE  OF  A  DE- 
COMPOSING FIBROID  TUMOUR  REMOVED 
BY    HYSTERECTOMY. 

By  S.  W.  Wheaton,  M.D. 

The  patient  from  whom  the  tumour  was  removed  was 
admitted  into  St.  Thomas's  Hospital  under  the  care  of 
Dr.  Cullingworth.  She  presented  a  cachectic  appearance, 
and  a  tumour  was  present  in  the  lower  part  of  the  abdo- 
men extending  up  to  the  level  of  the  umbilicus.  The 
tumour  had  increased  rapidly  in  size  during  the  three 
months  before  admission.  Soon  after  admission  the 
tumour  increased  still  more  rapidly  in  size,  and  became 
acutely  tender  and  painful ;  the  temperature  became  con- 
tinuously   high,    and    the    patient  lost    strength    rapidly. 


188  MICROCOCCI    IN    A    FIBROID    TUMOUR. 

The  symptoms  pointed  to  rapid  sarcomatous  degeneration 
occurring  in  a  uterine  fibroid,  except  tlie  continuous  high 
temperature,  which  indicated  rather  that  suppuration  was 
present.  Abdominal  hysterectomy  was  performed,  and 
the  patient  made  an  excellent  recover}^  the  temperature 
becoming  normal  at  once  after  the  operation.  Tlie  tumour 
was  found  to  be  a  large  interstitial  fibroid  ;  when  it  was 
incised  during  the  operation  bubbles  of  foul-smelling  gas 
escaped  from  the  incision. 

The  tumour  on  section  presented  a  uniformly  yellowish- 
pink  colour,  with  spongy,  elastic  texture  ;  there  was  no 
suppuration  nor  sloughing  to  be  seen  anywhere  ;  it  had  a 
most  offensive  odour,  like  that  of  decomposing  fish. 

A  portion  was  removed  immediately  after  the  operation 
and  preserved  in  spirit ;  sections  of  this  were  made,  and 
stained  by  Gram's  method.  The  sections  showed  that  the 
tumour  was  a  fibromyoma,  containing  a  great  many  dilated 
lymphatic  spaces.  The  cells  of  the  tumour  were  swollen, 
opaque,  and  granular,  and  their  nuclei  indistinct.  Con- 
tained within  the  lymphatic  spaces  were  lai'ge  masses  of 
micrococci  in  the  zoogloea  stage,  embedded  in  a  sti'ucture- 
less  material ;  similar  micrococci  were  also  seen  lying 
among  the  cells  of  the  tumour,  both  in  masses  and  also 
scattered  about  singly.  There  Avas  no  haemorrhage  into 
the  tumour,  nor  sign  of  sarcomatous  changes,  and  a 
remarkable  absence  of  any  proliferating  small  round  cells 
in  the  neighbourhood  of  the  micrococci,  such  as  would  be 
present  in  inflammation. 

The  specimen  is  a  remarkable  example  of  a  peculiar 
decomposition  occurring  in  a  tumour  whilst  within  the 
living  body.  In  all  probability  the  tumour  first  became 
oedematous,  and  then  organisms  obtained  entrance.  Owing 
to  the  deficient  blood  supply,  no  inflammatoi-y  changes 
took  place,  and  therefore  no  formation  of  pus  occurred. 
At  the  same  time  the  blood  supply  was  sufiicient  to  pre- 
vent gangrene  from  setting  in.  The  presence  of  a  large 
amount  of  moisture,  absence  of  air,  and  maintenance  of 
a  uniform  temperature,  are  the  conditions  which  lead  to 


MICROCOCCI    IN    A    FIBROID    TUMOUR.  189 

the  formation  of  adipocere  in  decomposing  animal  matter. 
In  all  probability,  if  the  patient  survived,  the  tumour, 
under  these  conditions,  would  have  become  converted 
into  a  fatty  mass  resembling  adipocere,  with,  perhaps, 
the  additional  presence  of  calcareous  material.  Interstitial 
fibroids  are  sometimes  found  in  this  condition  on  making^ 
post-mortem  examinations  in  cases  of  death  from  inde- 
pendent causes  in  elderly  females.  In  the  case  in  point, 
however,  the  products  of  decomposition  were  sufficiently 
injurious  and  abundant  to  cause  persistent  high  tempera- 
ture and  progressive  emaciation,  which  would  have  resulted 
in  the  death  of  the  patient  unless  she  had  been  relieved 
by  operation. 

Dr.  "Wheaton,  in  reply  to  Dr.  Horroeks,  said  that  although 
the  symptoms  suggested  sarcomatous  degeneration  of  the  tumour, 
there  were  no  signs  of  any  such  change  on  microscopical  exami- 
nation. Mr.  Doran  had  published  a  case  of  sarcomatous  de- 
generation of  a  uterine  fibroid,  and  he  had  also  examined  a 
specimen  in  which  this  change  had  occurred. 

Dr.  CuLLiNGWOKTii,  in  reference  to  the  second  case  to  which 
Dr.  AVheaton  had  alluded,  said  that  the  only  explanation  he 
could  suggest  of  the  very  peculiar  and  unusual  condition  of  the 
fibroid  was  that  the  tumour  might  have  been  penetrated  and 
infected  by  the  uterine  sound.  The  tumour  extended  to  within 
an  inch  of  the  ensiform  cartilage,  and  filled  the  whole  width  of 
the  abdomen.  A  sound  was  passed  soon  after  the  patient's 
admission.  She  was  then  in  considerable  pain,  but  was  otherwise 
well.  Two  days  afterwards  a  rigor  occurred,  and  the  temperature, 
which  had  not  hitherto  exceeded  100°,  rose  to  103°.  This  looked 
very  much  as  though  the  examination  were  in  some  way  to 
blame.  He  had  disinfected  the  sound  in  the  usual  manner  by 
immersing  it  in  a  solution  of  corrosive  sublimate,  but  the 
patient  had  a  yellow,  intermenstrual  discharge,  and  it  is  of 
course  possible  that  the  sound  after  disinfection  had  become 
re-infected  in  the  vaginal  or  uterine  canal,  and,  penetrating 
(unconsciously  to  the  manipulator)  a  softened  portion  of  the 
fibroid,  had  conveyed  the  infection  to  its  interior.  However 
caused,  the  change  set  up  was  of  the  most  serious  nature,  and  it 
became  evident  that  unless  surgical  treatment  were  adopted,  the 
patient  must  soon  succumb.  The  operation  of  abdominal  hysterec- 
tomy was  accordingly  performed.  There  was  nothing  unusual  in 
the  appearance  of  the  uterus.  But  when  it  was  cut  through  in 
the  pathological  laboratory,  the  livid  discoloration  and  stale  tlsh 


190  INFANTILE    UTERINE    HAEMORRHAGE. 

odour  led  Mr.  Shattock  to  at  ouce  pronounce  the  tumour  to  be 
in  a  state  of  incipient  gangrene.  There  were  no  signs  of 
softening  or  suppuration,  and  the  change  was  strictly  limited  to 
the  tumour  itself,  the  uterine  wall  which  entirely  surrounded  it 
being  absolutely  healthy.  The  patient's  recovery  was  uninter- 
rupted. He  (Dr.  CuUingworth)  would  be  very  grateful  to  any 
Fellow  of  the  Society  who  could  refer  him  to  the  record  of  any 
case  at  all  similar,  as  he  had  not  so  far  been  successful  in  dis- 
covering such  a  case. 

Mr.  Alban  Doran  said  that  his  paper,  to  which  Dr.  Wheaton 
referred,  was  entitled  "  Myoma  of  the  Uterus  becoming  Sarco- 
matous," and  was  published  in  the  '  Transactions  of  the  Patho- 
logical Society  of  London,'  vol.  xli,  p.  206,  plate  xii. 


MICROSCOPIC  SECTION  OF  THE  UTERINE 
MUCOUS  MEMBRANE  IN  THE  CASE  OF 
AN  INFANT  SUFFERING  FROM  UTERINE 
HAEMORRHAGE. 

By  S.  W.  Wheaton,  M.D. 

The  preparations  were  made  from  a  specimen  shown 
by  Mr.  C.  H.  James  and  reported  in  the  '  Transactions ' 
for  1890. 

The  sections  showed  that  the  haemorrhage  had  occurred 
into  the  superficial  layers  of  the  uterine  mucous  membrane, 
and  therefore  was  capillary  in  its  origin.  Very  few  red 
blood  corpuscles  remained  entire,  but  they  had  become 
broken  up,  and  their  debris,  together  with  blood  pigment, 
formed  the  yellow  patches  seen  in  the  uterine  mucous 
membrane.  A  few  small  uterine  glands  were  to  be  seen 
in  the  mucous  membrane  ;  they  were  very  short,  and  did 
not  extend  for  any  distance  into  the  muscular  layer.  The 
yellow  coloration  of  the  liver  of  the  child,  which  was  the 
only  other  sign  of  disease  in  the  body,  was  found  to  be 
also  due  to  capillary  haemorrhage,  and  the  deposition  of 
blood-pigment  between  the   liver  cells.      The  presence  of 


INFANTILE    UTERINE    HEMORRHAGE.  191 

uterine  glands  at  the  time  of  birtli  has  been  denied  ;  but 
the  author  has  found  them  to  be  always  present  at  the 
fundus,  although  very  short  and  barely  extending  to  the 
muscular  layer.  In  this  case  they  were  present  at  eight 
months,  and  it  might  be  thought  that  their  premature 
development  had  some  connection  with  the  hfemorrhage  ; 
but  the  author  knew  of  no  observations  to  show  how  early 
in  foetal  life  the  glands  began  to  develop.  The  presence 
of  capillary  haemorrhages  in  the  liver  rather  tended  to 
show  that  the  uterine  hgemorrhage  was  merely  part  of  a 
general  tendency  to  capillary  hsemorrhage,  Avhich  was  so 
common  in  new-born  children,  and  of  which  a  complete 
account  had  been  given  by  Dr.  Spencer  in  the  last  volume 
of  the  *  Transactions.' 


Dr.  CuLLiNGWOETH  Said  no  doubt  some  of  the  Fellows  pre- 
sent were  aware  that  about  fifteen  years  ago  he  had  published  a 
short  monograph  on  "  Haemorrhage  from  the  Genital  Organs  of  the 
recently-boru  Female  Child,"  in  the  preparation  of  which  he  had 
ransacked  medical  literature  for  250  years  back,  and  had  collected 
all  the  cases  he  could  find  reported  during  that  period.  The 
cases  so  seldom  ended  fatally,  however,  that  scarcely  any  oppor- 
tunities had  been  afforded  of  examining,  post  mortem,  the  condi- 
tion of  the  uterine  mucous  membrane.  Hence  this  case  of  Mr. 
James's  was  of  extreme  interest  and  importance,  and  he  hoped 
that  Dr.  Wheaton,  in  his  account  of  the  appearances  of  the 
mucous  membrane  under  the  microscope,  would  refer  to  the 
volume  and  page  of  the  '  Transactions  '  in  which  Mr.  James's 
communication  appeared,  so  as  to  facilitate  future  reference. 


192 


A  CASE  OF  ECTOPIC  PREGNANCY  IN  WHICH 
THE  FCETUS  SEEMS  TO  HAVE  BEEN  DEVE- 
LOPED TO  THE  FULL  TIME  IN  THE  PERI- 
TONEAL CAVITY,  STILL  RETAINING  ITS 
AMNIOTIC    COVERING. 

By   Lawson  Tait, 

PROFESSOK   OF    GYNECOLOGY    IN   QUEEN'S   COLLEGE,   BIRMINGHAM. 

(Received  November  4th,  1891.) 

Case  of  ectopic  gestation  in  a  patient,  aged  36,  sent  hy 
Dr.  Taplin,  of  Dor  ring  ton,  admitted  on  October  Sth,  1891. 

The  patient  had  expected  to  be  confined  in  April,  but 
labour  did  not  come  on,  and  slie  was  quite  positive  that  she 
had  last  felt  foetal  movements  upon  May  8th,  1891.  Her 
first  menstruation  occurred  at  the  age  of  fourteen  ;  she  was 
regular  every  four  weeks,  the  period  lasting  about  a  week, 
moderate  amount  of  loss,  with  no  pain,  till  she  married  at 
the  age  of  thirty-one. 

She  had  two  children,  the  last  three  years  ago  ;  but 
never  had  any  miscarriages.  Since  the  birth  of  her  last 
child  she  felt  perfectly  well,  and  continued  to  suckle  it  till 
August,  1890  ;  during  that  period  was  unwell  about  every 
three  weeks,  the  flow  lasting  a  week,  no  pain,  and  the 
amount  of  loss  not  quite  so  much  as  before  her  marriage. 

Her  last  period  was  in  the  middle  of  July,  1890  ;  after 
this  she  saw  nothing  till  May  20th,  1891.  During 
that  period  the  abdomen  increased  in  size  regularly,  but 
it  was  larger  than  it  had  been  in  previous  pregnancies. 
She  had  morning  sickness  at  times,  but  not  so  much  as 
in  her  previous  pregnancies.  The  breasts  increased, 
and  she  believes  that  they  contained  milk  in  February, 
1891.      In  the  last  week  of  Septembei-,  1890,  she  had  an 


ECTOPIC    PREGNANCY.  193 

attack  of  what  lier  medical  man  told  her  was  "  inflam- 
mation of  tiie  covering  of  the  bowels/'  She  had  severe 
pain,  intense  sickness,  great  thirst  and  distension,  and 
was  in  bed  for  a  whole  month,  and  then  continued  to 
improve  till  January,  1891. 

Her  first  feeling  of  foetal  movements  was  about 
Christmas,  in  the  lower  part  of  the  abdomen,  and  these 
continued  till  May  8th.  One  day,  in  the  middle  of 
January,  she  fainted  whilst  dressing,  and  had  to  be 
carried  back  to  bed.  On  attempting  to  rise  at  intervals 
during  the  day,  she  fainted  each  time,  so  the  doctor  was 
sent  for  in  the  evening.  She  had  no  pain  during  the 
day,  but  at  night  severe  pain  came  on,  which  she  likened 
to  the  pain  of  labour.  Next  day  she  had  less  pain, 
and  gradually  recovered,  so  that  she  was  able  to  get 
up  at  the  end  of  a  week.  The  movements  of  the  child 
then  became  very  painful,  and  were  more  violent  than  in 
her  previous  pregnancies.  She  continued  well  till  May 
8th,  when  all  movement  ceased  suddenly.  Towards 
the  end  of  May  she  had  a  slight  menstrual  show,  and 
has  seen  slight  shows  every  few  days  since  then.  The 
breasts,  which  then  contained  a  good  deal  of  milk,  gra- 
dually became  smaller,  and  the  milk  disappeared.  From 
May  till  October  she  noted  a  considerable  diminution  in 
her  size  round  the  waist. 

On  pelvic  examination,  the  uterus  was  found  not  much, 
if  at  all,  enlarged,  but  a  large  and  very  tender  mass, 
globular  and  boggy,  was  to  be  felt  to  the  right  and  behind 
the  uterus,  filling  up  the  pelvis. 

In  the  abdomen,  moving  very  freely,  but  evidently 
tethered  to  the  front  abdominal  wall,  was  a  large  mass, 
any  movement  of  which  gave  rise  to  pain  and  discomfort, 
in  which  the  parts  of  a  child  were  distinctly  made  out 
and  diagnosed  by  Mr.  Charles  Martin,  who  registered  a 
complete  diagnosis  to  the  effect  that  it  was  a  case  of 
"  ectopic  gestation  which  had  gone  to  the  full  time,  and 
died  on  May  8th,  the  present  condition  of  the  child  being 
one  of  maceration." 


194  ECTOPIC    PREGNANCl. 

I  performed  abdominal  section  on  October  12th^  and  at 
once  came  upon  the  umbilical  cord,  wbicli  ran  down  from 
the  body  of  the  child  into  the  pelvis,  and  was  inserted 
into  a  large  globular  mass  which  occupied  the  pelvis. 
The  child  was  lying  loose  in  the  abdominal  cavity,  except 
that  all  its  upper  surface  had  become  adherent  to  the 
omentum  and  to  the  anterior  parietal  peritoneum.  The 
child  lay,  as  described  by  Mr.  Charles  Martin,  with  the 
head  in  the  left  lumbar  region  and  the  feet  falling  down 
into  the  pelvis,  and  the  face  looking  downwards.  The  only 
difficulty  in  removing  the  child  was  to  separate  it  from 
the  adhesions  to  the  omentum,  and  to  the  abdominal 
wall,  which  were  really  very  dense.  The  child  was  still 
enclosed  in  its  membranes,  but  the  liquor  amnii  had 
entirely  disappeared.  The  umbilical  cord  went  straight 
down  to  a  round,  smooth,  globular  mass  about  the  size  of 
a  cocoa-nut,  which,  as  I  have  said,  occupied  the  pelvic 
cavity  and  was  adherent  to  surrounding  tissues.  The 
question  of  the  removal  of  the  placenta,  which  this  sub- 
stance really  was,  occupied  my  mind  for  a  few  seconds. 
On  making  tentative  efforts  to  separate  the  globular  mass, 
I  found  that  it  peeled  out  with  considerable  ease,  very 
much  as  a  broad  ligament  cyst  would,  and  after  it  was 
separated  down  to  a  pedicle  which  was  the  cornu  of  the 
uterus,  it  became  perfectly  evident  that  the  globular 
mass  was  the  right  Fallopian  tube. 

When  the  pedicle  was  divided  it  presented  its  charac- 
teristic mamillae.  Some  very  large  vessels  permeated  this 
pedicle,  and  it  was  extremely  friable,  so  I  did  not  venture 
to  deal  with  it  by  ligature,  but  put  a  temporary  clamp  on, 
which  clamp  was  removed  after  forty-eight  hours,  the 
patient  making  an  uninterrupted  recovery. 

Looking  at  the  preparation  and  looking  at  the  history, 
it  seems  to  me  that  the  explanation  of  the  case  is  very 
simple.  In  July  the  patient  had  become  pregnant,  and 
in  September,  in  about  the  tenth  week  of  tubal  gestation, 
the  tube  ruptured,  and  she  had  the  characteristic  illness 
described   by    her    medical    attendant    as    "  peritonitis." 


ECTOPIC    TREGNANCY.  195 

Lookincr  at  the  Fallopian  tube  removed,  tlie  scar  of  the 
rupture  of  tlie  foetus  was  perfectly  visible  wlien  tlie  pre- 
paration was  fresh  at  the  point  where  the  umbilical  cord 
was  inserted  into  it.  The  foetus  alone,  enveloped  in  the 
amnion,  would  appear  to  have  been  extruded  at  the  time 
of  the  rupture,  and  the  entirety  of  the  placenta  retained 
in  the  tube.  After  the  removal  of  the  placental  cyst,  the 
uterus,  which  had  previously  been  retroverted,  was  found 
to  rise  into  its  normal  position,  and  behind  it,  occupying  the 
whole  of  Doiiglas's  pouch,  a  mass  of  old  clot  and  debris 
was  discovered  and  was  carefully  cleaned  out.  This  haemor- 
rhage into  Douglas's  pouch  had  apparently  occurred  but 
once.  It  must  have  been  pretty  extensive  to  leave  about 
half  a  pound  of  tough,  boggy  old  debris  and  clot  at 
the  bottom  of  the  pelvic  cavity  lying  practically  free 
in  the  peritoneum.  To  the  fact  that  it  did  not  recur  the 
patient  probably  owes  her  life.  The  life  of  the  foetus 
was  preserved  by  reason  of  the  complete  retention  of 
the  placenta  within  the  tube,  and  that  seems  to  be 
explained  by  the  point  of  rupture  not  coinciding  with  the 
placental  margin,  which  is  not  likely  to  have  been  the  case 
in  this  instance,  seeing  the  relation  of  the  umbilical  cord 
to  the  scar.  The  retention  of  the  life  of  the  foetus  is  also 
very  likely  due  in  great  measure  to  the  integrity  of  the 
amnion.  This  point  of  rupture  is  certainly  exceptional, 
for  in  the  great  majority  of  instances  that  I  have  exa- 
mined, now  nearly  a  hundred  in  number,  the  rupture  has 
generally  been  by  the  placental  margin  or  involving  the 
margin,  and  to  this  fact  I  have  attributed  the  extremely 
fatal  character  of  rupture  of  a  tubal  gestation. 

It  is  very  interesting  to  see  proved  in  these  cases,  what 
would  be  assumed  as  perfectly  possible  from  our  know- 
ledge of  the  distension  of  the  tubes  by  serum  and  pus,  that 
they  are  capable  practically  of  indefinite  distension,  pro- 
vided that  the  process  is  a  slow  one  and  that  its  risk  of 
rupture  is  not  induced  by  the  enlargement  of  the  vessels 
and  the  thinness  of  the  wall  necessary  in  pregnancy. 
After    the    tear    in    the    tube    had    healed,   the   rate    of 


196  ECTOPIC    PREGNANCY. 

development  of  the  placenta  would  induce  a  slighter  and 
far  less  rapid  distension  of  the  tube,  as  the  great  bulk  of 
the  rapidly  increasing  gestation  must  be  in  the  growth  of 
the  child  and  in  the  effusion  of  amniotic  fluid  ;  besides, 
the  destruction  of  the  ovular  cavity  would  practically 
remove  existence  of  edges  from  the  placenta,  and  it 
would  come  to  occupy  evenly  the  whole  of  the  tubular 
cavity.  In  this  way  we  can  understand  why  there  is  no 
appeai'ance  of  a  secondary  rupture. 

Further  interest  is  given  to  the  case  inasmuch  as  it 
shows  that  a  living  foetus,  practically  not  more  than  ten 
weeks  of  age,  is  capable  of  resisting  the  digestive  powers 
of  the  peritoneal  cavity  if  the  amnion  is  unbroken,  whereas 
it  is  perfectly  certain  that  this  is  not  the  case  when  the 
foetus  dies  at  that  age,  and  even  to  a  considerably  later 
period  of  its  existence  if  exposed  bare  to  the  action  of  the 
peritoneum. 

A  very  singular  cause  of  speculation  arises  from  the 
creation  of  dense  adhesions  between  the  living  tissues  of 
the  parietal  peritoneum  and  what  we  must  regard  as  the 
practically  dead  tissues  of  the  foetus.  It  is  difficult  to 
imagine  that  such  an  essentially  vital  process  could  occur 
between  living  tissues  and  tissues  absolutely  dead.  Some- 
thing like  an  illustration  of  this  occurs  in  Hamilton's 
sponge-grafting  experiments,  but  there  it  becomes  per- 
fectly certain  that  it  is  not  a  real  adhesion,  but  simply  a 
bracing  together  of  the  really  living  and  really  dead 
tissues  by  the  penetration  of  the  sponge  cavities  by  long 
fingers  of  living  cell-tissue,  so  that  the  sponge  becomes  a 
sort  of  trellis-work.  There  is  not  any  real  union,  but  in 
this  case  the  union  must  have  been  absolutely  continuous 
and  cellular.  This  intra-peritoneal  child  was,  of  course, 
dead  as  an  individual,  and  dead  so  far  as  its  physical 
functions  were  concerned,  although  it  could  not  be  regarded 
as  absolutely  dead  tissue.  Some  kind  of  low  form  of  vital 
action  must  have  been  going  on  in  it — a  conclusion  which 
I  think  is  established  by  the  fact  of  its  resisting  decom- 
position, and  the  formation  of  the  adhesions. 


ECTOPIC    PEEGNANCY.  197 

If  this  case  had  been  left  uninterfered  with,  there  is 
very  little  doubt  that  the  outcome  would  have  been  a  very- 
unsatisfactory  and  very  protracted  illness  for  the  mother. 
Any  injury  or  illness  on  the  part  of  the  mother  would 
have  completely  destroyed  what  little  power  there  seemed 
to  be  retained  in  the  fcetus  of  carrying  on  functions  of  a 
kind  resembling-  those  of  life^  and  would  at  ouce  have  led 
to  its  decomposition  and  resulting  peritonitis. 

Even  without  the  intervention  of  such  an  accident,  it 
is  difficult  to  see  how  the  woman  could  have  avoided  a 
fatal  issue  when  the  digestion  advanced  towards  the 
looseuiug  of  the  foetal  bones  ;  for  even  when  this  takes 
place,  as  we  know  it  often  does,  in  the  closed  cavity  of 
the  broad  ligament,  the  result  almost  invariably  is  pro- 
tracted suppuration  and  discharge  of  the  foetal  bones 
through  the  rectum  when  the  left  broad  ligament  is 
occupied,  and  through  the  bladder  if  the  gestation  be  on 
the  right  side. 

The  loosened  bones  would  inevitably  have  dropped 
into  the  peritoneal  cavity  and  given  rise  to  much  pain 
of  a  mechanical  kind,  even  if  the  patient  escaped  the  great 
risks  of  inflammatory  trouble. 

So  far  as  I  know  the  history  of  ectopic  gestation,  this 
case  is  unique,  in  the  escape  of  the  foetus  into  the  peri- 
toneal cavity  with  absolute  retention  of  the  placenta  in  the 
cavity  of  the  Fallopian  tube.  It  gives  a  clear  and  indis- 
putable explanation  of  at  least  one  variety  of  the  so- 
called  "  abdominal  pregnancies,"  and  probably  indicates 
the  true  solution  of  all  the  cases  of  this  variety,  very  few 
of  which  are  known.  Further,  in  every  particular  it 
points  to  that  great  conclusion  concerning  ectopic  gesta- 
tion which  is  the  fundamental  principle  of  the  pathology 
of  these  cases  which  I  have  advanced — that,  initially,  all 
the  cases  are  tubal.  Not  a  particle  of  evidence  has  yet 
been  adduced  which  points  to  any  other  conclusion  than 
this,  with  one  apparent  exception  which  has  been  brought 
under  my  notice — a  case  exhibited  at  the  Berlin  Inter- 
national   Congress    last    year,    in    which    the    exhibitor 

VOL.  XXXIV.  35 


198  ECTOPIC    PREGNANCY. 

asserted  he  had  at  last  discovered  the  proof  of  an  ovarian 
pregnancy,  because  he  found  clear  evidence  of  ovarian 
structure  over  a  considerable  part  of  the  wall  of  a  cavity 
containing-  the  ectopic  gestation.  The  real  explanation 
of  the  fact  was  that  the  cavity  was  the  broad  ligament, 
which,  distended  by  the  gradual  growth  of  the  child,  had 
carried  with  it  the  ovary  as  a  thinned  layer,  precisely  as 
is  seen  not  uncommonly  in  the  growth  of  broad  ligament 
cysts. 


199 


TWO    CASES    OF    HYSTERECTOMY. 
By  Lawson  Tait, 

PEOFESSOE  OF   GTX^COLOGY   IN   QUEEN'S   COLLEGE,   BIRMINGHAM, 
(Received  November  4tb,  1891.) 

P.  B — ,  aged  52,  was  sent  to  me  from  the  neighbour- 
hood of  Swansea  by  Dr.  Rice  Morgan  (never  had  any 
children),  complaining  of  intense  pain  in  the  abdomen, 
which  was  very  greatly  enlarged  by  a  marginal  swelling 
in  which  the  pseudo-fluctuation  was  distinctly  present, 
but  no  definite  opinion  could  be  given  as  to  whether  it 
was  a  soft  oedematous  myoma ,  of  the  uterus  or  a  cystic 
tumour  enclosed  in  a  very  thick  capsule.  It  reached  up 
to  the  sternum,  and  the  pseudo-fluctuation  could  be  felt 
equally  in  every  diameter.  The  tumour  was  set  upon  the 
cervix  uteri  in  a  way  which  made  its  uterine  uature  per- 
fectly distinct. 

She  began  to  menstruate  at  thirteen,  menstruation  being 
regular  every  four  weeks,  always  profuse,  the  period  lasting 
from  eight  to  ten  days.  Four  years  ago  she  first  felt 
discomfort  in  the  lower  abdomen,  and  noticed  that  she 
began  to  lose  less  than  she  was  in  the  habit  of  doing  ;  she 
had  a  great  deal  of  pain  on  the  first  day  of  menstruation ; 
the  period  gradually  diminished  for  two  years,  and  then 
ceased  altogether.  She  has  seen  nothing  for  two  years. 
During  the  last  two  months  the  tumour  has  grown  with 
more  rapidity.  Two  months  ago  she  began  to  have  severe 
pain  all  over  the  abdomen  ;  and  as  the  tumour  was  inter- 
fering with  her  breathing,  she  was  sent  to  me  for  opera- 
tion. The  diagnosis  offered  was  a  soft  oedematous  myoma 
of  the   uterus.      The  abdomen   was   opened  in  the  middle 


200  HYSTERECTOMY. 

line  by  an  incision  of  nearl}"  four  inches.  The  nature  of 
the  tumour  was  at  once  seen  to  be  uterine.  The  sense  of 
fluctuation  increased  so  that  I  had  no  hesitation  in  plung- 
ing a  trocar  into  the  body  of  it,  and  evacuating  from  it  about 
six  pints  of  fluid.  During  the  emptying  of  the  tumour  the 
cyst  wall  contracted  exactly  like  a  pregnant  uterusasits  con- 
tents became  expelled.  When  empty  it  became  perfectly 
evident  that  the  tumour  was  the  uterus,  and  I  therefore 
clamped  it  and  removed  the  organ  completely.  On  re- 
moval it  weighed  nearly  five  pounds.  On  being  laid  open 
it  presented  the  appearance  now  visible.  There  was  a 
capsule  of  pure  unaltered  uterine  tissue  nearly  three 
quarters  of  an  inch  thick,  and  from  the  endometrium 
there  grew  large  irregular  masses  varying  from  one  eighth 
of  an  inch  to  an  inch  in  thickness.  The  cavity  contained 
a  large  quantity  of  sloughy  material,  smelling  very  badl}'-, 
as  did  the  contents  of  the  cyst  which  had  been  evacuated. 

The  patient  made  an  easy,  rapid  recovery.  The  clamp 
came  off  on  the  twentieth  day,  and  the  wound  is  now 
quite  healed, 

S.  L — ,  42  years  of  age,  began  to  menstruate  at  thir- 
teen ;  was  regular  without  any  special  characteristics  till 
she  was  married  at  sixteen.  She  had  three  children,  all 
labours  being  quite  normal.  When  thirty-seven  years  of 
age  she  began  to  lose  v«ry  profusely  every  month,  the 
period  lasting  from  a  week  to  ten  days,  without  pain  ;  then 
she  discovered  that  she  had  some  substauce  in  the  lower 
part  of  the  abdomen.  She  was  admitted  as  an  out-patient 
to  the  Women's  Hospital,  and  I  found  a  large  multi- 
nodular myoma  reaching  above  the  umbilicus.  I  removed 
the  appendages  on  May  13th,  1888.  She  reported  herself 
on  July  26th,  1890  as  never  having  menstruated  since  the 
operation,  and  was  perfectly  well.  On  examination  the 
tumour  was  found  to  have  nearly  disappeared.  Subse- 
quently to  this  a  metrorrhagia  had  re-established  itself,  and 
she  was  admitted  to  the  hospital,  and  the  uterine  cavity  ex- 
plored in  the  hope  of  finding  a  polypus  ;  but  nothing  of  the 
kind  was  discovered,  and   the  intra-uterine  surface    was 


HYSTERECTOMY,  201 

curetted  with  temporary  relief.  But  the  discharge  came  on 
as  profusely  as  before  in  the  beginning  of  the  present  year, 
and  it  became  evident  that  the  tumour  had  again  iuoi*eased 
in  size  and  had  altered  very  materially  in  character,  hav- 
ing lost  its  multinodular  chai*acter,  which  it  had  presented 
very  distinctly,  and  became,  as  it  grew,  more  and  more 
globular  and  even.  The  hemorrhage  became  again  so 
profuse  that  she  was  admitted  to  hospital,  and  on  Octo- 
ber 12th,  1891  hystei'ectomy  was  performed.  No  trace 
of  ovaries  or  Fallopian  tubes  could  be  found,  the  traces 
of  the  multinodular  myoma  were  very  indistinct,  and  it 
was  perfectly  certain  that  the  disease  had  been  practically 
cured.  A  large  and  apparently  independent  growth  had 
taken  place,  of  solitary  ovoid  or  soft  oedematous  character, 
and  that  had  grown  up  to  a  height  quite  as  great  as  the 
original  tumour  had  reached.  The  progress  of  recovery 
was  uninterrupted ;  the  clamp  came  off  on  the  twentieth 
day,  and  the  wound  rapidly  healed. 

This  case  presents  in  my  experience  the  unique  ex- 
ample of  the  combined  presence  of  the  two  varieties  of 
myoma.  I  have  never  seen  a  characteristic  soft  oedema- 
tous myoma  in  the  presence  of  multinodular  masses,  and  I 
am  perfectly  certain  that  the  soft  oedematous  mass  which  I 
removed  in  the  process  of  hysterectomy  was  not  in  exist- 
ence at  the  time  of  the  first  operation.  I  am  also  abso- 
lutely certain  that  the  multinodular  myoma  disappeared 
to  at  least  four  fifths  of  its  bulk — a  conclusion  which  is 
perfectly  sustained  by  the  relatively  small  pieces  of  multi- 
nodular myoma  that  are  presented  in  the  specimen.  The 
growth  of  the  oedematous  myoma  was  watched  at  inter- 
vals, and  I  have  little  doubt  that  it  was  a  perfectly  new 
growth  and  dates  in  origin  subsequently  to  the  operation 
performed  for  the  first  disease.  The  case  therefore  affords 
another  of  the  numerous  pieces  of  evidence  which  are 
accruing  in  my  experience  that  make  me  believe  that 
while  multinodular  myoma  is  a  disease  of  menstrual  life, 
the  soft  oedematous  myoma  is  not  so,  and  that,  while  it 
may  be  influenced  by  the  removal  of  the  ajipendages  during 


202  HYSTERECTOMY. 

the  active  part  of  menstrual  life^  it  is  liable  to  resist  tliat 
operation,  and  it  will  do  so  particularly  when  the  men- 
strual activity  is  diminishing,  towards  the  ages  of  forty- 
five  and  forty-eight.  I  have  abundant  evidence  to  show 
that  these  soft  oedematous  myomata  frequently  come  into 
existence  and  complete  their  growth  after  menstruation 
has  completely  ceased,  so  that  I  conclude  that  the  soft 
oedematous  myoma  is  not  a  disease  of  menstrual  life,  and 
that  the  removal  of  the  appendages  will  in  the  majority 
of  instances  fail  to  effect  a  cure,  whilst  in  the  case  of 
multinodular  myoma  this  operation  effects  a  cure  with 
perfect  certainty  in  95  per  cent,  of  all  the  cases. 

Dr.  Arthur  Johnstone  has  started  a  theory  that  the 
soft  oedematous  myoma  grows  from  the  endometrium,  but 
I  have  never  seen  any  specimens  at  all  that  supported 
this  conclusion.  In  every  instance  that  I  have  seen  the 
capsule  of  muscular  tissue  has  been  continued  by  a  dis- 
tinct and  decidedly  thick  layer  between  the  endometrium 
and  the  inner  relations  of  the  tumour,  this  shutting  oft' 
all  associations  of  the  tumour  with  the  endometrium,  and 
emphatically  contradicting  all  possibility  of  the  endo- 
metrium being  the  source  of  its  origin. 

The  ease  with  which  these  tumours  can  be  dealt  with 
by  enucleation  from  their  beds  in  the  muscular  tissue  is 
very  characteristic  of  them,  and  in  this  they  differ  very 
materially  from  the  hard  nodules  of  the  multinodular 
tiimour,  which,  although  capable  of  separation  and  enu- 
cleation, are  not  so  easily  thus  removed  as  the  others. 
The  enucleation  process  also  demonstrates  completely  that 
there  is  no  relation  between  these  tumours  and  the  endo- 
metrium. 

The  second  specimen  which  I  show  probably  repre- 
sents a  distinct  disease  and  an  example  of  what  Dr. 
Johnstone  has  seen.  It  is  the  first  of  the  kind  I  have 
ever  come  across,  and  is  clearly  a  different  disease 
altogether  from  the  soft  oedematous  myoma,  and  grows 
from  the  endometrium.  It  may  form  one  of  the  excep- 
tional  kinds   of   endometric   cancer,    but,    whether  it   be 


HYSTERECTOMY.  203 

malignant  or  not,  it  certainly  is  growing-  from  tlie  endo- 
metrium, and  therefore  presents  perfectly  different  cha- 
racteristics from  the  soft  oedematous  myoma,  which  does 
not  so  oi'igiuate,  but  originates  in  muscular  tissue. 

Mr.  Alban  Doran  believed  that  the  "oedematous  fibroid"  of 
women  who  had  reached  the  menopause  or  passed  that  epoch 
was  a  special  form  of  tumour.  Edematous  fibroid,  in  the  sense 
of  oedema  of  an  ordinary  fibroid  from  definite  faut^es,  was  quite 
anotlier  kind  of  disease.  Thus  a  partly  impacted  tumour  was 
sometimes  removed  by  operation  ;  a  few  hours  after  its  removal 
it  would  be  found  shrunken  to  half  its  original  size.  The 
impaction  had  caused  true  oedema,  which  ot"  necessity  disap- 
peared, for  mechanical  reasons,  after  the  knife  passed  through 
the  tissues  of  the  tumour.  The  *'  oedematous  fibroid  "  of  the 
menopause  was  often  unaccompanied  by  any  visible  cause  of 
oedema.  Its  vessels  might  be  seen,  passing  between  its  surface 
and  its  capsule,  free  from  any  sign  of  pressure  without  or 
plugging  within,  whilst  its  entire  mass  lay,  free  from  any  severe 
pressure,  in  the  abdominal  cavity  above  the  pelvic  brim.  These 
tumours  did  not  lose  much  by  draining  of  their  fiuid  after 
removal,  though,  like  all  soft  tumours,  they  shrank  when  im- 
mersed in  spirit. 

Dr.  William  Duncan  asked  if  the  fluid  removed  from  the 
large  cyst  in  the  first  case  of  myoma  had  been  examined  chemi- 
cally, also  if  the  cyst  wall  had  been  subjected  to  microscopical 
examination,  as  these  cystic  myomata  have  been  shown  in  some 
cases  to  consist  of  greatly  dilated  lymphatics. 

Dr.  Peter  Horrocks  said  that  in  all  probability  the  word 
"fibroid"  included  a  group  of  difterent  tumours.  We  already 
knew  of  difterences  in  the  clinical  histories  of  these  tumours^ 
and  no  doubt  there  was  a  difference  in  their  pathology.  In  his 
own  experience  he  found  the  ordinary  hard  fibroid  a  non- 
malignant  tumour,  which  but  rarely  caused  death,  and  then  only 
by  an  accident,  as  it  were.  These  tumours  might  become  oedema- 
tous, as  Mr.  Doran  had  observed,  but  the  oedema  was  different 
from  that  of  the  so-called  soft  oedematous  myoma. 

Dr.  Hayes  said  that  abdominal  tumours  had  an  odd  habit, 
sometimes,  of  disappearing  and  reappearing  under  the  ken  even  of 
competent  and  careful  observers.  -Mr.  Tait's  teaching  for  a  long 
time  back  was  clear,  viz.,  that  removal  of  the  uterine  appendages 
in  the  case  of  the  hard  fibroid  or  myoma  was  frequently  followed 
by  its  shrinking  or  practical  disappearance,  but  that  in  the  case 
of  the  soft  fibroid  the  operation  was  valueless.  Mr.  Tait  would 
now  have  us  believe  by  this  case  that  not  only  will  the  hard 
fibroid  shrink,  but  the 'soft  myoma  will  originate  and  grow  after 
the  removal  of  the  uterine  appendages.     Dr.  Hayes  had  never 


204  HYSTERECTOMY. 

known  tbe  soft  fibroid  to  originate,  though  it  might  continue 
growth,  subsequent  to  the  menopause.  He  thought  Mr.  Tait 
was  mistaken,  and  that  the  softer  fibroid  was  present  when  the 
first  operation  was  performed. 

Dr.  Leith  jS^apier  remarked  on  the  diff'erent  degrees  of  hard- 
ness found  in  multiple  myofibromata.  Doubtless  imbibition  of 
fluid  leading  to  oedema  of  the  tissues,  and  inflammatory  changes 
in  the  capsule,  accounted  for  conditions  dift'ering  widely  from  the 
degree  of  hardness  generally  met  with.  But  if  wo  regarded 
certain  of  these  soft  (edematous  fibroids  as  examples  of  myxo- 
fibromata,  and  recognised  that  degenerative  cystic  changes  in 
these  might  originate  general  softening  in  some  instances,  and 
in  others  cause  larger  cysts  to  form  in  the  substance  of  the 
growth,  it  would  be  a  nearer  approach  to  what  seemed  the  true 
pathology.  It  was  extremely  difiicult  to  draw  clear  distinc- 
tions between  a  soft  oedematous  fibroma  and  a  true  myxo- 
fibroma. 

He  mentioned  an  illustrative  case  showing  that  very  hard 
tumours  may  quickly  become  soft  in  consequence  of  cystic 
change.  The  case  was  one  operated  on  some  months  ago ; 
originally  it  was  intended  to  perform  oophorectomy,  hoping  by 
this  to  influence  the  rapidly  increasing  growth  of  a  hard  multiple 
myofibroma.  On  opening  the  abdomen  the  central  portion  of 
one  of  the  large  nodules  was  found  to  be  soft  and  fluctuating — 
it  had  undergone  mucoid  degeneration.  Hysterectomy  was 
therefore  considered  better  than  oophorectomy  ;  on  removal  the 
tumour  consisted  of  hard  fibrous-like  lobules,  with  the  exception 
of  the  one  portion  which  contained  a  distinct  cyst  in  its  centre, 
and  was  evidently  undergoing  general  softening. 

Dr.  W.  S.  A.  GRirrixn  said  there  were  three  well  recognised 
conditions  which  might  cause  enlargement  of  fibroids  after  the 
climacteric — first,  simple  oedema  ;  secondly,  liquefaction  of  the 
constituent  muscle-cells  and  connective  tissue  in  difl'erent  parts 
of  the  tumours  leading  to  the  formation  of  large  and  small  irre- 
gular, cyst-like  cavities  with  ragged  walls,  and  generally  associated 
with  calcification  of  other  parts  of  the  tumour  ;  thirdly,  tbe 
development  of  true  cysts  with  a  smooth  glistening  wall,  but 
usually  without  an  epithelium. 

There  was  a  comparatively  rare  form  of  soft  fibroid,  which  grew 
much  more  rapidly  tlian  the  usual  kind,  and  which  contained, 
amongst  the  bundles  of  muscle  and  connective-tissue  fibres,  a  large 
amount  of  what  appeared  to  be  lymphoid  tissue.  All  these  forms 
he  iiad  exhibited  at  the  meetings  of  this  Society,  with  micro- 
scopical sections. 

Dr.  Leavers  thought  that  probably  some  tumours  were  in- 
cluded under  the  name  "  fibroid  "  that  had  an  entirely  diff'erent 
clinical  history  and  pathology  from  the  common  variety.     He  had 


'hysteeectomy.  205 

seen  two  cases  in  point,  where  there  were  large  uterine  tumours, 
composed  of  a  large  number  of  small  cysts  separated  by  fibrous 
tissue.  In  neither  of  them  was  there  menorrhagia,  nor  was  the 
length  of  the  uterine  cavity  increased,  though  in  one  of  the  cases 
the  tumour  reached  up  to  the  epigastrium  :  in  this  case  the  meno- 
pause had  occurred  a  year  previously  ;  in  the  other  the  patient 
was  a  young  woman  about  twenty. 


206 


NOTE  ON  THE  GROWTH  OF  THE  PLACENTA 
AFTER  DEATH  OF  THE  FCETUS  IN  ECTOPIC 
GESTATION. 

By  Lawson  Tait  and  Christopher  Martin,  M.B. 

(Received  February  10th,  1892.) 

On  June  18th,  1891,  Dr.  Hartill,  of  Willenhall,  sent  to 
Mr.  Tait  a  patient  with  the  following  history,  and  on 
reading  his  letter  and  before  seeing  the  patient,  he  had 
no  difficulty  in  diagnosing  a  ruptured  tubal  pregnancy. 
The  history  was  as  follows  : — She  was  28,  and  had 
had  one  child  two  years  before.  Two  months  before 
Mr.  Tait  saw  her,  after  having  seen  nothing  for  seven 
weeks,  she  was  suddenly  seized  with  acute  pain  in  the 
left  lower  abdomen.  Protracted  syncope  set  in,  and  then 
the  temperature  went  up,  and  for  some  days  the  abdomen 
became  extremely  tender.  Fourteen  days  later  she  was 
again  seized  with  acute  pain,  followed  by  syncope  and  by 
a  rising  temperature  and  pretty  general  abdominal  ten- 
derness, which,  however,  was  most  severe  in  the  left  iliac 
region.  Her  previous  general  health  had  been  far  from 
robust,  and  menstruation  had  always  been  irregular. 

On  examination,  Mr.  Tait  found  the  uterus  large,  irre- 
gular, and  somewhat  fixed,  and  a  firm,  indurated,  tender 
mass  was  to  be  felt  to  the  left  of  it.  There  was  no  history 
of  the  passing  of  decidua,  and  the  patient  had  no  idea  that 
she  was  pregnant.  The  previous  treatment  had  been 
rest  and  opium.  The  abdomen  was  opened  the  following 
day  and  the  specimen  shown  removed.  The  abdomen 
contained  a  quantity  of  old   and  recent  blood-clot.      The 


GROWTH     OF    THE     PLACENTA    IN    ECTOl'IC    GESTATION.     207 

riglit  appendages  were  adlierent,  but  otlierwise  apparently 
uormal.  The  left  Fallopian  tube  was  the  seat  of  an 
ectopic  gestation,  and  when  removed  was  the  size  of  a  very 
large  orange.  There  was  a  considerable  rent  on  one  side 
of  the  tube,  which  was  the  evident  source  of  the  luemor- 
rhage.  On  splitting  open  the  gestation  sac,  there  was 
seen  to  be  a  small  cavity  lined  with  amnion,  and  contain- 
ing a  very  small  quantity  of  liquor  amnii ;  sessile  on  the 
wall  of  this  amniotic  cavity,  there  being  no  umbilical  cord, 
was  a  small  foetus,  less  than  an  inch  in  length,  much 
flattened,  shrunken,  and  macerated,  which  had  evidently 
been  dead  some  time.  The  greater  part  of  the  gesta- 
tion mass  was  composed  of  placental  tissue  infiltrated 
to  a  slight  extent  with  blood-clot.  At  the  time  of 
removal  it  was  only  slightly  detached  from  the  tubal 
wall,  but  in  consequence  of  its  having  been  frequently 
examined,  it  has  now  become  detached  to  a  considerable 
extent.  It  had  the  appearance  when  fresh  of  actual 
placenta  and  not  of  blood-clot.  In  consequence  of  its 
prolonged  immersion  in  hardening  fluids  it  has  now 
greatly  lost  its  distinctive  placental  appearance. 

Mr.  Martin  has  made  a  series  of  microscopic  sections 
which  demonstrate  conclusively  that  the  mass  in  question 
is  truly  placental  tissue  and  not  blood-clot.  There  does 
not  seem  to  be  any  development  of  maternal  blood  sinuses. 
The  chorionic  villi,  instead  of  dipping  free  into  large 
blood-spaces  and  being  washed  by  the  maternal  blood- 
stream (as  in  the  case  in  the  intra-uterine  placenta),  are 
embedded  in  a  highly  vascular,  delicate  connective  tissue 
in  the  tube  wall  which  is  evidently  of  recent  formation. 

We  think  in  this  case  that  there  can  be  no  doubt  that 
the  patient  had  an  ordinary  tubal  pregnancy  which 
ruptured  about  the  seventh  or  eighth  week.  This  rup- 
ture did  not  extend  into  the  amniotic  cavity,  but  was 
limited  to  the  tube  wall.  At  the  point  of  rupture  a 
limited  separation  of  the  placenta  had  occurred.  After 
this  first  rupture  she  seems  to  have  recovered  fairly  well. 
A  fortnight  later   she  had  a  second  rupture.      The  child 


208  GROWTH    OF    THE    PLACENTA    AFTER    DEATH 

seems  to  Lave  died  at  the  first  ruj^ture  aud  subsequently 
become  flattened  and  shrivelled.  The  liquor  amnii  be- 
came absorbed,  this  being  indicated  by  the  peculiarly- 
wrinkled  condition  of  the  foetal  surface  of  the  placenta, 
and  the  small  size  and  irregularity  of  the  amniotic  cavity. 

The  most  interesting  point  of  this  specimen  is  that  the 
placenta  has  apparently  gone  on  growing,  for  it  far 
exceeds  in  amount  that  which  is  normally  present  with  a 
foetus  in  so  early  a  stage  of  development.  It  is,  in  fact, 
a  placenta  in  the  stage  of  development  of  the  fourth 
month  of  pregnancy,  while  the  foetus  is  only  a  seven 
weeks^  foetus.  Spiegelberg  gives,  as  the  result  of  ob- 
servations on  200  foetuses,  the  following  measurements  by 
which,  from  the  length  of  the  foetus,  its  age  may  be 
calculated.  At  the  commencement  of  the  fifth  week  its 
length  is  1*5  cm.  ('6  inch),  and  increases  during  each  of  the 
following  weeks  by  about  '5  cm.  ('2  inch),  so  that  at 
the  end  of  the  eighth  week  it  reaches  3"5  cm.  (1"3  inch), 
and  at  the  end  of  the  third  month  the  body  length  is 
7  cm.  (2"75  inches).  The  foetus  in  the  specimen  measures 
1  inch,  so  that,  taking  the  above  measurements  as  oar 
guide,  its  death  must  have  taken  place  during  the  seventh 
week,  or,  in  other  words,  at  the  time  of  the  first  rupture 
of  the  tube.  All  authorities  are  agreed  that  there  is  no 
distinct  placental  cake  before  the  third  month,  the  chori- 
onic villi  being  developed  uniformly  all  round  the  ovum 
as  a  shaggy  coat.  But  we  have  only  to  look  at  the  mass 
of  placenta  in  this  case  to  see  that  it  is  a  well-defined  and 
well-developed  structure,  and  as  large  as  that  found  at  the 
fourth  month  of  pregnancy. 

In  consequence  of  the  small  size  of  the  foetus  and  the 
absorption  of  the  liquor  amnii,  the  amniotic  cavity  is  diminu- 
tive. This  has  led  to  the  whole  gestation  mass  appear- 
ing somewhat  smaller  than  it  otherwise  would  have  done. 

This  specimen,  we  think,  demonstrates  conclusively 
what  Mr.  Tait  has  so  frequently  urged,  namely,  that  the 
placenta,  after  the  death  of  the  foetus,  may,  in  some 
cases,  go   on   growing   and  be  a  source  of  disaster  to  the 


OF    THE    FCETUS    IN    ECTOPIC    GESTATION.  209 

patient.  Had  the  gestation-inass  not  been  removed  by 
operation,  the  patient  would  no  doubt  have  been  the  sub- 
ject of  a  third  attack  of  rupture  and  syncope,  and  possibly 
would  have  succumbed  from  internal  haemorrhage — this 
in  consequence,  not  of  the  continued  development  of  the 
foetus,  but  of  tlie  continued  growth  of  the  placenta. 

If  we  consider  for  a  moment,  it  is  not  after  all  such  an 
extraordinary  thing  that  the  placenta  should  sometimes 
continue  to  grow  after  the  death  of  the  child.  In  cases 
of  intra-uterine  pregnancy  where  the  fastus  dies  prema- 
turely, and  is  retained  in  uteru,  a  huge  placenta  is  fre- 
quently found. 

Spiegelberg  says,  "  Simple  hypertrophy,  i.  e.  great 
bulkiness  of  the  placenta  in  comparison  to  the  foetus,  is 
especially  seen  in  conjunction  with  dead  and  above  all 
with  macerated  foetuses  ;  it  depends  upon  hypertrophy  of 
the  decidua  and  its  prolongations.  It  appears  that  the 
maternal  portion  of  the  placenta  continues  to  grow  for 
some  time  after  the  death  of  the  foetus.'^ 

This  growth  of  the  placenta  after  foetal  death  is  no  new 
discovery.  It  was  pointed  out  in  the  early  part  of  the 
eighteenth  century  by  Morgagni,  who,  in  his  classical 
work  (' De  Sedibus  et  Causis  Morborum'),  in  discussing 
cases  where  a  large  placenta  is  found  with  either  a  small 
foetus  or  no  foetus,  says,  "  The  placenta  may  grow  to  an 
unnatural  bulk  after  the  little  foetus  is  dead  (and  on  that 
account  more  likely  to  elude  observation)."  (Morgagni, 
Epistle  xlviii,  article  xxvi.) 

In  the  interesting  condition  known  as  ''  fleshy  mole  " 
we  find  additional  evidence  in  support  of  our  case.  Here 
blood  is  effused  into  the  structure  of  the  ovum.  The 
fa3tus  perishes,  but  the  ovum  is  retained  for  many  weeks 
or  months  in  utero.  It  is  then  expelled  as  a  thick  fleshy 
mass.  "  Part  of  the  membranes  or  of  the  placenta  retains 
its  organic  connection  with  the  uterus.  The  attached 
portion  of  the  placenta  continues  to  be  nourished,  although 
abnormally.  The  foetus  may  entirely  disappear,  or  it 
may  remain  macerated,  shrivelled,  and  greatly  altered  in 


210  GROWTH    OP    THE    PLACENTA    AFTER    DEATH 

appearance.  The  effused  blood  becomes  decolourised  from 
tlie  absorption  of  tlie  corpuscles  ;  and  fresh  vessels  are 
developed  in  the  fibrin,  which  increase  the  vascular 
attachment  of  the  mole  to  the  uterine  Avails.  The  pla- 
centa and  membranes  may  go  on  increasing  in  thickness 
until  they  form  a  mass  of  considerable  size  "  (Playfair, 
vol.  i,  282). 

The  fact  which  is  most  suggestive  of  all  is  that  in  the 
condition  known  as  hydatidiform  degeneration  of  the 
chorionic  villi,  in  the  majority  of  cases  no  foetus  can  be 
found  ;  whilst  the  chorionic  villi  grow  with  extraordinary 
vigour.  This  clearly  proves  that  the  embryonic  portion 
of  the  placenta  possesses  inherent  powers  of  growth 
independent  of  the  continued  development  of  the  foetus. 
We  quite  admit  that  in  this  case  we  have  to  deal  with  a 
diseased  condition  of  the  placenta  and  not  a  normal  state  ; 
but  the  whole  process  of  ectopic  gestation  is  itself  a 
morbid  process  quite  as  much  as  is  the  hydatid  chorion. 

Hart  and  Barbour,  in  their  '■  Manual  of  Gynfecology/ 
give  the  following  case  :  ''  Extra-uterine  Gestation  with 
Death  of  the  Foetus,  attended  by  further  Growth  of  the 
Placenta  which  led  to  fatal  Haemorrhage. — The  patient 
had  two  months'  amenorrhoea,  followed  by  three  months  of 
irregular  haemorrhages.  A  tumour  as  large  as  a  four 
and  a  half  months'  pregnancy  was  found  behind  the  uterus. 
It  was  aspirated,  and  the  patient  died  of  haamorrhage. 
After  death  the  uterus  was  found  to  be  5|  inches  in 
length  ;  the  gestation  sac  lay  in  the  pouch  of  Douglas, 
and  was  chiefly  occupied  by  placenta,  which  was  as  large 
as  the  placenta  of  the  fifth  month  of  pregnancy.  The 
cavity  of  the  amnion  contained  but  little  fluid,  and  the 
foetus  was  only  a  three  months'  foetus.  The  continued 
growth  of  the  placenta  after  the  death  of  the  foetus  had 
led  to  fatal  hemorrhage." 

Dr.  Champneys  and  Mr.  Thornton  have  also  brought 
forward  evidence  which  supports  our  views.  Mr.  Strahan 
points  out  that  if  the  placenta  grows  for  a  time,  even 
after  the  child  has  been  killed  in  the  pre-rupture  stage, 


OP    THE    P(ETnS    IN     ECTOPIC    GESTATION.  211 

this  would  be  enough  to  cause  rupture  of  the  tube  ;  and 
thus  it  is  another  argument  against  the  use  of  electricity 
for  the  purpose  of  killing  the  foetus,  because  it  does  not 
save  the  patient  even  then  from  the  danger  of  rupture, 

Mr.  Bland  Sutton,  in  his  book  on  the  '  Surgical  Diseases 
of  the  Ovaries  and  Fallopian  Tubes/  writes,  "  In  the 
majority  of  cases  the  foetus  dies.  When  this  event  occurs 
at  the  fourth  or  fifth  month  there  is  reason  to  believe  that 
the  placenta  may,  in  some  instances,  continue  to  grow 
instead  of  undergoing  atrophy.  At  any  rate  it  is  quite 
certain  that  now  and  then,  in  cases  of  tubal  gestation,  a 
blighted  foetus  is  found  attached  to  a  placenta  which  is 
not  only  out  of  relative  proportion  to  the  foetus,  but  is 
absolutel}'^  larger  than  the  placenta  of  a  uterine  foetus  at 
the  full  term." 

Dr.  W.  S.  A.  Geiffith  first  inquired  if  Mr.  Tait,  in  describing 
growth  of  the  placenta,  referred  to  the  foetal  or  maternal  or  both 
portions. 

Mr.  Tait  replied  foetal  only. 

Dr.  W.  S.  A.  GrEiFFiTH  then  stated  what  a  difficult  task  was 
attempted  by  those  who  held  similar  views,  namely,  to  satisfy 
themselves  at  least  that  the  foetal  placenta,  a  part  of  the  foetus, 
continued  to  grow  after  the  foetus  itself  was  dead.  In  the  first 
place,  it  must  be  remembered  that  there  was  greater  variety  in 
size  in  extra-uterine  even  than  in  intra-uterine  placentae,  and  very 
large  ones  were  well  known  in  cases  in  which  post-mortem  growth 
was  impossible.  Indeed,  there  was  a  reasonable  explanation  for 
such  large  placental  development  in  the  absence  of  the  decidua 
reflexa,  and  in  the  probable  greater  difficulty  of  fulfilling  its 
functions,  owing  to  the  imperfect  formation  of  the  maternal 
portion.  Again,  we  ought  to  have  undoubted  proof  of  intra- 
uterine post-mortem  growth  in  cases  where  the  chorion  remained 
attached  to  the  uterus  for  some  weeks,  but  all  the  evidence  on 
this  point  was  certainly  against  the  occurrence  of  any  such 
growth.  The  cystic  degeneration  referred  to  as  evidence  could  not 
be  accepted  in  the  face  of  this  fact ;  besides,  enlargement  of  villi 
due  to  such  degeneration  was  not  growth.  Mr.  L.  Tait  did  not 
refer  to  the  rare  myxoma  fibrosum  of  the  chorion,  which,  so  far 
as  Dr.  Griffith  knew,  was  the  only  strong  point  in  favour  of  the 
theory,  and  even  that  could  not  be  said  to  have  been  proved  to 
occur  after  foetal  death. 

Dr.  Petee  Hoeeocks  believed  it  possible  for  the  chorionic 


212       GROWTH    OF    THE    PLACENTA    IN    ECTOPIC    GESTATION. 

villi  or  placenta  to  grow  after  the  death  of  the  foetus.  He 
thought  it  would  be  difficult  to  account  for  the  relative  small- 
ness  of  the  fcetus,  in  certain  cases  of  both  extra-  and  intra- 
uterine gestation,  on  any  other  hypothesis.  When  the  foetus 
was  dead  it  could  get  no  nutrition  for  itself  owing  to  the  cessa- 
tion of  circulation  ;  but  the  chorionic  villi  were  in  a  different 
position.  They  were  embedded  in  maternal  structures  either  in 
the  uterus  or  outside  it.  It  was  very  conceivable  that  they 
might  derive  nutrition  from  the  vessels  of  those  structures,  and 
it  was  quite  certain  that  they  did  so  in  the  case  of  hydatidi- 
form  degeneration  where  there  was  great  increase  in  growth, 
the  nutrition  for  which  must  come  from  the  maternal  vessels, 
inasmuch  as  the  foetus  in  most  cases  was  dead  from  quite  an 
early  period  of  gestation.  He  mentioned  a  case  on  which  he 
had  operated,  where  the  foetus  had  died  so  early  as  to  be  undis- 
coverable,  and  yet  where  the  tumour  had  continued  to  increase 
in  size,  apparently  by  growth  of  the  chorionic  villi. 


JULY  6th,  1892. 

J.  Watt  Black,  M.D.,  President,  in  the  Chair. 

Present — 25  Fellows  and  4  Visitors. 

A  book  was  presented  by  Dr.  de  Havilland  Hall. 

The  following  gentlemen  were  elected  Fellows  of  the 
Society  : — William  McAdam  Eccles,  M.B.,  B.S.Lond.  ; 
William  John  Mackay,  M.B,,  M.Ch.Sydney  (Sydney)  ; 
Samuel  Walshe  Owen,  L.R.C.P.Lond.  ;  and  William 
Bramley  Taylor,  M.R.C.S.  (Denmark  Hill). 

The  following  gentlemen  were  proposed  for  election  : — 
Charles  William  James  Chepmell,  M.D.Brux.  (Brighton)  ; 
and  John  Benjamin  Hellier,  M.D.Lond.  (Leeds). 


CANCER  OF  THE  BODY  OF  THE  UTERUS. 
By  Aethue  H.  N.  Lewees,  M.D. 

Dr.  Lewers  showed  a  uterus  removed  by  vaginal 
hysterectomy  for  primary  cancer  of  the  body.  The  im- 
mediate result  was  quite  successful,  and  at  the  present 
time,  over  three  months  since  the  operation,  the  scar  was 
quite  sound,  and  the  patient  in  good  health.  As  he  pro- 
posed to  record  the  full  details  of  the  case  when  two 
years  had  elapsed  without  recurrence,  or  earlier  if  recur- 
rence  should  have  taken  place,  he  only  brought  forward 

VOL.  XXXIV.  16 


214  DOUBLE  OVARIAN  APOPLEXY. 

the  specimen  at  present  as  one  of  considerable  interest 
as  a  specimen.  A  section  was  exhibited  under  the 
microscope,  showing  the  growth  to  be  a  typical  columnar 
epithelioma. 

Dr.  HoEEOCKs  asked  if  ligatures  were  used  during  the  opera- 
tion to  any  portion  of  either  broad  ligament. 

Dr.  Lewees  in  reply  said  no  ligatures  were  used  in  the  case, 
only  pressure-forceps,  which  had  been  left  on  for  forty-eight 
hours. 


SPECIMEN    OF    DOUBLE     OVARIAN    APOPLEXY 
FROM  A  CASE   OF  ACUTE  PERITONITIS. 

By  H.  A.  Des  Vceux,  M.D. 

Dr.  Des  Voenx  in  his  remarks  said  that  the  specimen 
was  taken  from  a  girl  aged  2S,  single,  who  had  a  long 
history  of  unrelieved  dyspepsia.  Her  menstrual  history, 
as  far  as  could  be  ascertained  from  her  mother  and  a 
friend,  had  always  been  normal,  and  her  last  menstrua- 
tion had  ceased  a  week  before  death.  The  patient  was 
found  in  an  extreme  state  of  collapse  on  May  18th,  with 
a  history  of  sudden  acute  pain  commencing  twelve  hours 
previously.  The  pain  was  referred  to  the  epigastrium; 
there  was  none  in  the  pelvis. 

The  patient  died  twenty-four  hours  after  the  onset  of 
acute  symptoms.  A  ruptured  gastric  ulcer  had  caused 
acute  peritonitis,  of  which  there  was  little  sign  in  the 
pelvis.  The  ovaries  were  normally  situated ;  their  sur- 
face was  smooth  and  irregular,  and  presented  numerous 
purple  prominences.  The  general  colour  was  of  a  deep 
pink.  On  section  the  ovaries  appeared  to  be  deeply 
injected  and  showed  numerous  hajmorrhages  (the  lai'gest 
about  the  size  of  a  small  cherry)  which  seemed  to  be 
follicular.  The  tubes  were  injected,  swollen,  and  soft; 
the  ostia  were  patulous.      A  small  amount  of  thin   muco- 


OVARIAN    HYDROCELE    CONTAINING    PAPILLOMATA.         215 

pus  was  in  the  tubes.  There  was  a  muco-sanguiiieous 
discharge  in  the  cavity  of  the  uterus,  whose  mucous 
membrane  hooked  normal.  On  microscopical  examina- 
tion of  the  ovaries,  the  hjemorrhage  was  found  to  extend 
throughout  the  whole  of  their  stroma. 


AN  OVARIAN  HYDEOCELE  CONTAINING 
PAPILLOMATA. 

By  J.  Bland  Sutton. 

The  specimen  is  an  example  of  that  variety  of  cyst 
to  which  I  have  ventured  to  apply  the  term  ovarian 
hydrocele.  In  this  instance  the  cyst  is  as  large  as  a 
cocoa-nut,  Avhich  it  also  resembles  in  shape.  Lying  upon 
the  crown  of  the  cyst  is  the  Fallopian  tube.  The  uterine 
section  of  the  tube  is  of  natural  size,  but  on  approaching 
the  crown  of  the  cyst  it  becomes  gradually  dilated,  and 
finally  opens  into  the  cyst  by  a  large  circular  aperture, 
from  which  the  folds  of  the  mucous  lining  of  the  tube 
radiate  and  are  imperceptibly  lost  on  the  walls  of  a 
tubular  chamber,  which  seems  to  form  a  sort  of  vestibule 
to  the  large  cyst.  In  these  points  the  specimen  does  not 
differ  from  other  described  examples  of  ovarian  hydro- 
cele. The  most  remarkable  feature  of  the  cyst  is  the 
presence  upon  the  inner  walls  of  large  masses  of  papillo- 
mata  identical  with  those  met  with  in  typical  paroopho- 
ritic cysts.      I  failed  to  find  any  trace  of  the  ovary. 

The  tumour  was  removed  by  Mr.  Henry  Morris  from 
the  right  broad  ligament  of  a  woman  fifty-seven  years 
of  age.  The  left  broad  ligament  contained  a  typical 
paroophoritic  cyst.  The  most  noticeable  point  in  the 
clinical  history  was  a  sudden  and  rapid  increase  in  the 
size  of  the  cysts. 

On    several   occasions   I    have    watched    patients   with 


216 


OVARIAN    HYDROCELE    CONTAINING    PAPILLOMATA. 


abdominal  tumours  awaiting  their  turn  to  come  into  hos- 
pital, when  they  have  been  seized  with  great  abdominal 
pain,  and  the   tumour  has   undergone   such   sudden  and 


VESTIBULE 


An  ovarian  hydrocele  containing  papillouiata. 

rapid  enlargement  as  to  induce  the  surgeon  to  believe 
that  the  tumour  has  undergone  axial  rotation.  At  the 
operation  a  papillomatous  cyst  has  been  found,  but  nothing 
to  account  for  its  sudden  increase  in  size. 


217 


TUBAL  PREGNANCY;  RUPTURE  INTO  BROAD 
LIGAMENT;  OPERATION;  RECOVERY. 

By  J.  Bland  Sutton. 

Early  in  May  I  saw,  in  consultation  with  Dr.  Clegg, 
of  Stratford,  Mrs.  L — ,  who  was  suffering  great  pain  in 
consequence  of  a  swelling  which  occupied  the  left  iliac 
fossa. 

The  patient  was  thirty-five  years  of  age,  and  had  been 
married  thirteen  years.  She  had  never  been  pregnant. 
Throughout  the  whole  of  her  married  life  she  had  never 
missed  a  period  till  January,  1892  ;  since  that  month 
she  had  not  seen  anything.  In  March  she  was  seized 
with  sudden  acute  pain  in  the  pelvis.  A  doctor  was 
summoned,  and  pronounced  the  trouble  to  be  hysteria. 
She  then  began  to  have  difficulty  in  passing  urine,  and 
pain  during  defgecation.  Towards  the  end  of  March 
she  perceived  a  swelling  in  the  lower  abdomen,  more 
on  the  left  than  the  right  side.  This  slowly  increased  in 
size,  and  as  the  swelling  became  larger  the  pains  became 
so  severe  as  to  cause  her  to  keep  her  bed. 

On  examining  the  patient  I  found  a  large  tender 
swelling  on  the  left  side  of  the  abdomen,  and  extending 
into  the  iliac  fossa.  Vaginal  examination  revealed  a 
large  swelling  to  the  left  of  the  uterus,  and  presumably  in 
the  broad  ligament.  The  uterus,  somewhat  enlarged, 
was  pushed  to  the  right,  and  seemed  tethered  to  the 
swelling.      There  were  no  breast  signs. 

From  these  signs  I  came  to  the  same  conclusion  as 
Dr.  Clegg,  namely,  that  the  patient  was  the  victim  of  tubal 
pregnancy.  In  the  course  of  the  next  ten  days  the  swell- 
ing had  obviously  increased  in  size,  and  there  was  more 
suffering,  so  she  was  sent  into  hospital. 

On  May  25th   I  opened   the  abdomen,  and  found   the 


218  TUBAL    PREGNANCY. 

swelling  to  occupy  the  left  broad  ligament.  I  incised  its 
summit,  a  proceeding  which  was  followed  by  a  rush  of 
arterial  blood.  The  clot,  foetus,  and  placenta  (fourth 
month)  were  quickly  removed  and  the  cavity  stuffed  with 
sponges.  The  edges  of  the  sac  were  carefully  stitched 
to  the  lower  angle  of  the  abdominal  wound,  the  fragments 
of  placenta  removed,  and  a  glass  drainage-tube  inserted. 
There  was  free  oozing  for  about  twenty  hours.  I  gave 
explicit  instructions  that  if  the  patient  passed  any  clots 
from  the  vagina  they  were  to  be  kept.  About  thirty-six 
hours  after  the  operation  the  patient  complained  of  fre- 
quent pains  and  became  restless,  and  in  a  few  hours  passed 
a  large  clot.  This  I  carefully  teased  out ;  it  proved  to 
be  a  complete  uterine  decidua.  There  is  a  large  orifice 
corresponding  to  the  mouth  of  the  uterus,  and  a  small 
circular  opening  at  each  angle  of  the  sac  where  it  com- 
municated with  the  Fallopian  tubes.  The  patient  made 
an  admirable  convalescence,  and  left  the  hospital  thirty- 
three  days  after  the  operation. 


Mr.  Alban  Doean  admitted  that  certain  tubo-ovarian  cyats 
might  be  termed  "  ovarian  hydrocele  "  in  the  sense  understood 
by  Mr.  Sutton,  who  had  introduced  the  term.  Diagnosis  of 
"ovarian  hydrocele  "  was  hardly  possible.  Some  of  the  speci- 
mens from  St.  Thomas's  Hospital  which  Mr.  Doran  exhibited 
before  the  Society  in  1887  ('  Transactions,'  vol.  xxix,  p.  302) 
were  probably  ovarian  hydroceles.  These  cysts  were  subject  to 
attacks  of  recurrent  inflammation.  In  a  case  related  by  Mr. 
Doran  before  the  Pathological  Society  in  1888  ('  Trans.  Path. 
Soc.,'  vol.  xxxix,  1888,  p.  200)  the  patieut  sufi'ered  from  pelvic 
pains  for  many  years  before  the  tumours,  cystic  degeneration  of 
both  appendages,  were  removed.  Indeed,  seven  years  before 
operation  she  had  been  under  the  care  of  Dr.  Hayes,  who 
detected  a  tumour.  These  cysts  were  possibly  "  ovarian  hydro- 
celes," though  there  was  no  communication  between  the  cystic 
ovaries  and  the  cystic  tubes.  Mr.  Doran  maintained,  however, 
that  the  great  majority  of  tubo-ovarian  cysts  arose  from  the 
fusion  of  tubes  and  ovaries  which  had  undergone  cystic  degene- 
ration after  long-standing  inflammation. 

Dr.  Leith  Napiee  remarked  on  the  importance  of  the  papil- 
lary growths  inside  the  cyst.  He  asked  if  any  microscopic 
examinations    had   been   made.      Were   the   growths   benign  ? 


PYOSALPINX.  219 

Macroscopically  the  appearaace  was  colloid-like.  Had  any 
papillae  been  seen  elsewhere  than  in  the  interior  of  the  cyst  ? 
Referring  to  Mr.  Doran's  remarks,  he  recognised  how  valuable 
Mr.  Doran's  opinion  was  on  all  pathological  questions  ;  still  it 
would  be  difficult  to  accept  the  suggestions  now  made  without 
further  elaboration ;  doubtless  on  some  future  occasion  Mr. 
Doran  would  recur  to  the  subject  at  greater  length. 

Mr.  Alban  Doran  stated,  in  reply  to  Dr.  Leith  Napier,  that 
a  series  of  preparations  in  the  museum  of  the  College  of 
Surgeons  clearly  demonstrated  the  fusion  of  tubes  and  ovaries 
which  had  become  cystic  after  long-standing  inflammation.  He 
had  described  this  change,  at  some  length,  in  a  memoir  read 
before  the  Pathological  Society  in  18S7  ('  Trans.  Path,  Soc.,' 
vol.  xxxviii,  p.  241).  In  a  paper  published  four  years  later,  Drs. 
Schramm  and  jN^eelsen  showed  that,  in  the  course  of  indepen- 
dent observations,  they  had  marked  the  same  changes  ('  Zur 
Kentniss  der  Tubo-ovarialcvsten,"  '  Archivf.  G-ynak.,'  vol.  xxxix, 
1891). 


TWO    CASES    OF    PYOSALPINX. 
By  Charles  J.   Cullingworth,  M.D. 

Dr.  Cdllingworth  exhibited  two  specimens  of  pyo- 
salpinx  removed  by  abdominal  section. 

Case  1. — The  first  was  a  good  example  of  gonorrhoeal 
pyosalpinx  from  a  woman,  aged  23,  who  was  married  in 
February,  1890,  and  a  fortnight  later  noticed  a  yellow 
vaginal  discharge,  with  pain  on  micturition,  for  which  she 
attended  St.  Bartholomew's  Hospital  as  an  out-patient  for 
four  months.  In  October,  1890,  she  gave  birth  to  a  dead 
foetus  at  the  seventh  month.  Her  second  child  was  born 
February  Utb,  1892,  five  weeks  before  the  expected  time  ; 
it  only  lived  twenty-four  hours.  A  fortnight  afterwards 
the  patient,  who  had  been  up  for  two  days,  had  to  return 
to  bed  on  account  of  severe  shooting  pain  in  the  lower 
part  of  the  abdomen  and  in  the  left  leg.  She  was  in  bed 
for  twelve  weeks,  and  was  then  admitted  to  St.  Thomas's 
Hospital,    where    she    remained    for   about   twelve    days, 


220  PYOSALPINX. 

improving  so  much  that  at  the  end  of  that  time  she  declared 
herself  quite  well.  On  reaching  home,  however,  the  pain 
returned,  and,  as  it  continued  to  get  worse,  she  was  re- 
admitted to  the  hospital  June  13th,  1892.  On  examina- 
tion under  ether  a  not  very  hard,  irregular  mass  was  felt 
in  Douglas's  pouch,  closely  adherent  to  the  upper  part  of 
the  cervix  uteri.  The  mass  apparently  consisted  of  the 
right  uterine  appendages,  displaced,  inflamed,  and  ad- 
herent. Nothing  abnormal  was  discovered  on  the  left 
side. 

Abdominal  section  was  performed  on  June  23rd.  The 
pelvis  was  roofed  over  by  adherent  intestine  and  omentum, 
and  the  pelvic  contents  were  densely  matted  together. 
The  right  tube  was  traced  out  for  a  short  distance  from 
the  uterus.  It  then  turned  backwards  and  ran  down- 
wards and  inwards  to  the  floor  of  Douglas's  pouch,  where 
it  was  inseparably  connected  with  another  harder  swelling. 
The  whole  was  separated  and  brought  within  view.  The 
whole  tube  was  irregularly  thickened,  elongated,  and 
adherent.  Up  to  the  point  where  it  joined  the  flatter 
and  harder  swelling,  its  colour  was  deep  red.  The 
harder  portion  of  the  mass  had  entirely  lost  its  colour,  and 
looked  as  if  it  had  been  long  immersed  in  spii'it.  Its 
appeai'ance  was  very  misleading.  The  impression  at  the 
time  was  that  it  consisted  of  the  left  tube,  with  its  meso- 
salpinx, much  altered  by  chronic  inflammation,  and  so 
firmly  adherent  to  the  distal  end  of  the  right  tube  that  it 
had  been  torn  away  from  its  uterine  connections.  It  was 
found  subsequently,  on  opening  up  the  specimen,  that 
what  had  been  thought  to  be  the  tube  and  mesosalpinx 
of  the  opposite  side  was  an  old,  thick-walled,  abscess- 
cavity  formed  by  a  sudden  dilatation  of  the  right  tube 
itself,  close  to  its  distal  end.  The  pouch  was  shut  off 
from  the  remainder  of  the  tube,  and  was  lined  by  blood- 
stained granulation  tissue.  The  straighter  part  of  the 
tube  was  lined  by  acutely  inflamed  and  oedematous 
mucous  membrane,  not  ulcerated.  Both  the  tube  and  its 
pouch    contained    purulent    fluid.      The    tube    embraced 


PYOSALPINX.  221 

within  its  fold  a  cystic  ovary  the  size  of  a  pig-eon's  egg-. 
A  coil  of  small  intestine  had  become  firmly  united  to  the 
tube  by  a  parchment  adhesion  f  inch  in  diameter.  This 
was  carefully  separated,  and  the  denuded  surface  of  intes- 
tine folded  in  upon  itself  and  secured  in  that  position 
by  four  fine  silk  sutures  drawing  together  its  opposite 
margins. 

The  tube  and  pouch,  with  the  adjacent  ovary,  were  then 
ligatured  and  removed. 

The  left  ovary  was  felt  of  normal  size  and  consistence, 
wrapped  up  in  a  mass  of  adherent  intestine  and  broad 
ligament.  It  was  not  disturbed.  The  left  tube  was  not 
made  out. 

There  being  a  good  deal  of  oozing  from  the  adhesions, 
the  peritoneum  was  well  irrigated  with  hot  boric  acid 
solution,  and  a  glass  drainage-tube  was  inserted  and  kept  in 
for  twenty  hours. 

Recovery  had  so  far  been  uninterrupted  ;  the  tempera- 
ture had  never  reached  100°,  and  after  the  first  three 
days  had  been  uniformly  normal.  The  portion  of  tube 
removed  measured,  with  the  pouch,  6f  inches  long. 
The  pouch  itself  measured  2x2^  inches. 

Case  2. — The  second  specimen  was  from  a  woman 
aged  31,  who  had  had  four  severe  attacks  of  pelvic 
inflammation  since  her  marriage,  nine  years  ago  ;  the  last 
attack  commencing  suddenly  on  May  30th,  1892.  There 
was  no  evidence  as  to  the  cause  of  the  inflammation. 
The  patient  had  an  abortion  at  the  age  of  eighteen,  but 
since  her  marriage  had  not  been  pregnant.  There  was  no 
distinct  history  of  gonorrhoea. 

On  admission  to  St.  Thomas's  Hospital,  June  16th, 
1892,  the  uterus  was  found  displaced  to  the  left  side  by 
a  soft  irregular  swelling,  filling  up  the  right  posterior 
quarter  of  the  pelvis,  and  passing  inwards  behind  the 
cervix.  The  mass  was  divided  by  a  sulcus  running  trans- 
versely   along    the   whole    length   of    its   under    surface. 


222  PYOSALPINX. 

Nothing  abnormal  was  detected  on  the  left  side.  The 
diagnosis  was  I'ight  pyosalpinx. 

On  June  24th  the  abdomen  was  opened.  The  contents 
of  the  right  side  of  the  pelvis  were  matted  by  recent 
adhesions  in  fronts  and  by  old  and  very  dense  adhesions 
behind  and  below.  For  some  time  it  was  impossible  to 
differentiate  the  diseased  parts.  Eventually  a  greatly 
enlarged,  elongated,  tortuous,  and  distended  right  tube 
was  shelled  out  without  rupture  and  brought  to  the 
surface  sufficiently  to  be  tied  off  and  removed,  along  with 
the  adjacent  ovary,  which  was  adherent  but  otherwise 
normal.  No  definite  enlargement  of  the  left  appendages 
could  be  detected,  and,  as  they  were  involved  in  a  mass 
of  adherent  intestine,  they  were  not  disturbed. 

The  whole  mass  removed  measured  3x  1|  inches.  The 
length  of  tube  involved  was  6^  inches.  The  tube  was 
occluded  at  its  abdominal  extremity.  The  diameter  of 
its  dilated  outer  portion  was  1^  inch;  of  its  inner  por- 
tion ^  inch.  It  was  filled  with  pus.  As  it  was  being 
hardened  for  preservation  in  the  museum,  it  had  not  yet 
been  laid  open. 

The  patient  was  going  on  exceedingly  well,  the  tem- 
perature since  the  operation  never  having  exceeded  100  . 
The  drainage-tube  was  removed  in  forty-five  hours.  The 
bowels  were  relieved  by  enema  on  the  third  day,  and 
again  on  the  sixth  and  seventh  days.  The  stitches  were 
removed  as  usual  at  the  end  of  a  week. 


Dr.  Hayes  did  not  think  that  the  facts  were  at  all  sufficient 
to  support  Dr.  Cullingworth's  conclusion  that  the  pyosalpinx 
was  due  to  gonorrhoea.  Allowing  that  the  patient  had  had  gonor- 
rhoea, we  should  have  to  believe,  if  the  conclusion  were  true,  that 
the  infective  matter  was  transmitted  by  the  endometrium  to  the 
mucous  membrane  of  the  Fallopian  tube,  and  that  either  the  endo- 
metrium escaped  infective  inflammation  or  was  quickly  freed  from 
its  effects,  and  immediately  permitted  conception  and  gestation, 
whilst  the  lining  membrane  of  the  tube  was  infected  and  perma- 
nently disabled. 

Dr.  CuLLiNGWOKTii,  in  re]»ly,  said  he  was  quite  prepared  to 
admit  that  the  evidence  of  gonorrhoea  in  the  specimen  shown 


KNITTING-NEEDLE    USED    TO    PROCURE    ABORTION.  223 

to-night  was  not  absolutely  conclusive,  and  he  could  quite  under- 
stand that  it  was  insufficient  to  convince  sceptical  minds.  He 
should  shortly  publish  several  cases,  however,  in  which  he  had 
removed  purulent  tubes  from  patients  who  were  actually  suffering 
from  gonorrhoea  at  the  time  of  the  operation,  and  in  which,  there- 
fore, the  evidence  was  more  nearly  complete.  He  had  himself 
no  doubt  that  gonorrhoea  was,  next  to  sepsis,  the  most  fruitful 
source  of  suppurative  salpingitis.  With  regard  to  the  possibility 
of  pregnancy  occurring  in  the  subject  of  a  pyosalpinx,  it  must  be 
remembered  that  the  uterine  mucous  membrane  was  in  a  much 
better  position  for  recovery  than  the  lining  of  the  Fallopian  tube, 
because,  in  the  case  of  the  uterus,  there  was  a  means  of  free  exit 
for  the  discharges,  while  in  the  Fallopian  tube  there  was  not. 
It  was  the  absence  of  natural  means  of  drainage  that  made 
suppurative  inflammations  of  the  Fallopian  tube  more  serious 
than  similar  affections  of  any  of  the  other  mucous  membranes  in 
the  body.  In  reply  to  Mr.  Bland  Sutton  he  was  afraid  that  the 
pus  in  these  specimens  had  not  been  microscopically  examined. 


MYOMA  OF  THE   CERVIX  UTERI. 

By  Charles  J.  Cullingworth,  M.D. 

Dr.  Cullingworth  exhibited  a  specimen  of  myoma  of 
the  posterior  wall  of  the  cervix,  two  inches  and  a  half  in 
diameter,  removed  by  enucleation  per  vaginam. 


KNITTING-NEEDLE    USED    TO    PROCURE 
ABORTION. 

By  AViLLiAM  Duncan,  ^I.D. 

Dr.  William  Duncan  showed  a  knitting-needle,  nine 
inches  long,  which  an  unmarried  girl,  six  months  preg- 
nant, thrust  through  her  umbilicus  into  the  uterus,  in 
order  to   procure  abortion,  having   previously  attempted 


224  KNITTING-NEEDLE    USED    TO    PROCDEE   ABORTION. 

unsuccessfully  to  bring  about  this  result  by  thrusting  the 
needle  up  i^er  vaginam.  Two  days  after  the  needle  had 
been  passed  in.  Dr.  Duncan  was  telegraphed  for,  and  in 
his  absence  his  colleague,  Mr.  Pearce  Gould,  went  and 
performed  abdominal  section.  After  the  abdomen  was 
opened  just  the  tip  of  the  needle  was  found  projecting 
from  the  fundus  uteri ;  it  was  seized  with  forceps  and 
removed,  a  stitch  being  inserted  into  the  uterine  puncture, 
as  there  was  some  haemorrhage.  Two  days  later,  notwith- 
standing the  use  of  opium,  the  patient  miscarried,  and  a 
black  speck  was  seen  on  the  child's  buttock,  where  appa- 
rently the  needle  had  penetrated.  The  woman  made  an 
uninterrupted  recovery. 

Dr,  Leith  Napiee  asked  how  far  the  pregnancy  had  advanced, 
and  if  viable,  was  the  child  born  alive  ? 

Dr.  Hetwood  Smith  said  that  with  regard  to  knitting-needles 
being  used  to  procure  abortions,  he  once  knew  a  lady,  now  dead, 
who  brought  on  abortion  thirty-five  times  with  a  knitting-needle, 
and  he  was  sent  for  several  times  to  her  for  severe  flooding. 


225 


ON  MENSTRUATION    IN   CASES   OF  BACKWAED 
DISPLACEMENT   OF  UTERUS. 

By  G.  Ernest  Herman,  M.B.Lond.,  F.R.C.P., 

OBSTETEIC   PHYSICIAN    TO   THE    LONDON    HOSPITAL. 

(Received  June  lltli,  1891.) 

No  one  will  dispute  that  alterations  in  menstruation 
sometimes  occur  with  backward  displacements  of  the 
uterus.  But  very  different  opinions  have  been  held  as 
to  the  relation  between  the  displacement  and  the  men- 
strual changes.  Some  have  doubted  whether  the  rela- 
tion was  more  than  coincidence.  Some  have  held  that 
the  relation  was  that  of  cause  and  effect ;  but  even  among 
those  united  in  this  opinion  there  is  not  agreement  as 
to  the  frequency  with  which  the  displacement  produces 
these  changes. 

I  have  in  a  former  paper  {'  Trans./  vol.  xxxiii)  given 
reasons  for  speaking  of  retroversion  and  retroflexion  of 
the  uterus  as  "  displacements.^^  In  another  paper 
('  Trans./  vol.  xxiv)  I  have  discussed  their  relation  to 
menstrual  pain.  In  the  present  communication  I  bring 
forward  some  further  facts,  the  consideration  of  which  I 
hope  may  help  to  give  precision  to  our  knowledge. 

I  propose  to  consider  two  questions — 

1.  What  are  the  alterations  in  menstruation  that  occur 
with  backward  displacements  of  the  uterus  ? 

2.  What  reason  is  there  for  thinking  them  effects  of 
the  displacement  ? 

This  communication  is  based  upon  notes,  more  or  less 
detailed,  of  the  condition  of  menstruation  in  388  cases 
of  backward   displacements  of  the  uterus,  taken  without 


226  MENSTRUATION    IN    CASES    OF    BACKWARD 

any  selection,  from  the  out-patient  department  of  tlie 
London  Hospital.  I  might  have  made  this  number  larger 
by  adding  to  them  notes  of  in-patients,  or  of  out-patients 
selected  for  note-taking  for  special  reasons ;  but  to  get  a 
correct  idea  of  the  frequency  of  different  changes  I 
restrict  myself  to  a  period  during  which  I  have  notes  of 
evei'y  case  without  selection.  I  have  omitted  only  a  few 
cases  in  which  from  haste  the  notes  are  too  imperfect  to 
be  of  any  use. 

1.   As  to  Quantity. 

I.  I  find  78  cases  in  which  the  patients  were  not  men- 
struating, or  20*1  per  cent.,  about  one  fifth  of  the  whole 
number. 

These  cases  may  be  divided  into  four  groups  : 

1.  Thirteen  cases  in  which  the  patient  described  the 
symptoms,  and  the  uterus  presented  the  signs,  of  early 
pregnancy. 

2.  Forty  cases  in  which  the  patient  had  recently  given 
birth  to  a  child,  or  aborted,  or  was  suckling,  and  had  not 
menstruated  since  the  delivery  or  abortion. 

The  length  of  time  between  the  abortion  or  delivery 
and  the  patient's  application  for  treatment  was  as 
follows  : 

A.  Six  cases  following  abortion  : — 1  nine  days,  2  three 
weeks,  1  a  month,  2  three  months. 

B.  Thirty-four  cases  following  delivery.  Twenty-three 
within  three  months  : — 1  five  weeks,  4  six  weeks,  1  seven 
weeks,  10  two  months,  7  three  months.  Eleven  after 
more  than  three  months  : — 2  five  months,  1  six  months, 
2  seven  months,  1  nine  months,  2  eleven  months,  2 
twelve  months,  1  fifteen  months; 

It  will  be  seen  that  of  these  patients  two  thirds  ap- 
plied for  treatment  within  the  first  three  months  after 
delivery. 

3.  Twenty  cases  in  which  the  patient  had  passed  the 
menopause.      The   age  at  which   menstruation  ceased  in 


DISPLACEMENT    OF    THK     UTERUS.  227 

these  patients  was  as  follows  : — 1  at  thirty-seven,  1  at 
forty-two,  1  at  forty-three,  2  at  forty-four,  1  at  forty- 
five,  5  at  forty-seven,  3  at  forty-eight,  5  at  forty-nine,  1 
at  fifty.      Average  46'4  years. 

4.  Five  cases  in  which  the  amenorrhcca  was  due  to 
pathological  causes.  These  were  : — 1  imperfect  develop- 
ment of  uterus,  1  superinvolution,  1  bad  hygienic 
conditions  (prostitute,  aged  17),  1  mental  shock,  1 
undiscovered — probably  premature  menopause  (patient 
aged  28). 

It  will  be  clear  that  in  none  of  these  cases  could  the 
absence  of  menstruation  be  attributed  to  the  displace- 
ment, and  therefore  that  in  them  the  displacement 
exerted  no  effect  whatever  upon  the  menstrual  function. 

II.  I  find  seventeen  cases  in  which  not  only  was  no 
alteration  in  menstruation  complained  of  by  the  patient, 
but  in  answer  to  special  inquiry  she  stated  that  there 
had  been  no  change  in  the  quantity  of  the  flow. 

We  have  therefore  ninety-five  cases,  or  24*4  per  cent., 
in  which  it  is  quite  certain  that  the  displacement  did  not 
modify  the  amount  of  the  menstrual  flow. 

III.  In  152  cases  out  of  1310  I  have  merely  a  note  as 
to  the  quantity  of  the  menstrual  flow,  but  no  statement 
as  to  any  recent  alteration.  Some  of  these  patients  may 
have  been  asked  whether  the  quantity  had  or  had  not 
been  altered,  but  I  have  not  a  distinct  record  that  the 
inquiry  was  put  in  this  form.  All  I  can  say  is,  that 
none  of  them  mentioned  any  alteration,  but  that  it  is 
possible  that  closer  inquiry  might  have  elicited  that 
there  had  been  increase  or  diminution  in  some  of  these 
patients.  But  women  do  not  usually  underestimate  the 
importance  of  changes  in  the  menstrual  function  ;  and 
therefore  I  think  it  probable  that  if  in  many  of  these 
patients  a  marked  alteration  in  the  quantity  of  the  cata- 
menial  flow  had  been  present,  most  of  them  would  have 
mentioned  it. 

There  is  no  way  that  can  be  applied  in  practice  of 
accurately    measuring    the    amount    of    blood    lost,    and 


228  MENSTRUATION    IN    CASES    OF    BACKWARD 

tlierefore  we  are  obliged  to  take  tlie  statements  of 
patients,  as  to  whether  they  lose  much  or  little,  as  cor- 
rect (except,  of  course,  in  cases  in  which  the  hfemorrhage 
is  suflScient  to  produce  anaemia  and  be  called  flooding). 
If  we  assume  that  women  are  acquainted  with  what  the 
average  amount  is,  take  this  as  a  standard,  and  state  cor- 
rectly in  what  way  their  own  loss  differs  from  it,  we 
should  expect  to  find  (the  standard  being  the  average  of 
the  whole)  as  many  departures  from  the  normal  in  one 
direction  as  in  the  other.  The  following  figures  nearly 
accord  with  this  expectation. 

Of  the  152,  in  63  menstruation  was  said  to  be  scanty, 
in  6Q  profuse,  in  16  moderate,  in  7  variable. 

There  is  a  little  preponderance  of  the  patients  whose 
flow  was  profuse.  I  shall  presently  show  that  the  most 
common  variation  is  that  the  flow  is  increased ;  and  this 
preponderance  may  indicate  that  in  some  of  these  women 
the  flow  had  been  increased,  although  they  did  not 
mention  it.      But  the  number  of  such  must  have  been  small. 

Putting  all  these  figui-es  together,  we  have  95  in  which 
there  certainly  was  no  change,  and  152  in  which  none 
was  complained  of  ;  m  all,  247  cases,  or  63*6  per  cent.,  in 
which  probably  the  displacement  produced  no  effect  upon 
the  amount  of  the  flow. 

lY.  In  141  cases  the  patient  stated  that  the  quantity 
of  the  flow  had  lately  changed ;  in  18  the  amount 
was  diminished,  in 46  increased;  in  77  there  was  haemor- 
rhage not  conforming  to  the  monthly  type.  In  one  of 
these  there  was  probably  cancer  of  the  body  of  the  uterus, 
and  in  two  others  small  fibroids ;  these  I  leave  out  of 
account  in  what  follows. 

Of  the  74  which  remain,  in  20  cases  haemorrhage  had 
been  continuous,  or  nearly  so,  since  delivery ;  in  19  the 
haemorrhage  had  been  continuous,  or  nearly  so,  since 
abortion  ;  in  32  the  haemorrhage  had  been  separated  by 
an  interval  of  apparent  health  from  the  termination  of 
the  last  pregnancy  ;  in  3  the  patient  had  never  been 
pregnant. 


DISPLACEMENT    OF    THE    UTEEDS.  229 

So  that  in  the  141  cases  in  which  the  quantity  of  the 
menstrual  flow  was  altered,  in  123,  or  87*2  per  cent.,  the 
alteration  was  in  the  direction  of  increase,  either  in 
quantity,  frequency,  duration,  or  in  more  than  one  of 
these  respects. 

Taking  all  the  patients  who  were  menstruating,  and 
assuming  that  when  no  menstrual  chano'e  was  mentioned 
it  was  because  none  had  been  observed,  we  have  123  cases 
out  of  310,  or  40  per  cent.,  as  the  lowest  possible  estimate 
of  the  frequency  of  increased  haemorrhage. 

^\Tiat  reason  is  there  for  thinking  that  this  hasmorrhage 
is  the  result  of  the  displacement  ?  Most  diseases  of  the 
uterus  have  some  effect  upon  menstruation,  and  so  do  many 
alterations  in  health  in  which  the  uterus  is  not  the  part 
chiefly  involved.  In  the  class  of  patients  in  whom  back- 
ward displacements  of  the  uterus  are  chiefly  found,  in- 
crease of  the  flow  is  a  commoner  symptom  than  its  dimi- 
nution. Is  the  frequent  increase  in  the  flow  in  patients 
with  retroversion  and  retroflexion  of  the  uterus  entirely 
due  to  conditions  which  occur  also  in  women  without 
displacement,  or  is  it  an  effect  of  the  displacement  ? 

How  might  it  be  proved  to  be  an  effect  of  the  displace- 
ment ?  The  most  satisfactory  mode  of  proof  would  be  by 
a  demonstration  of  changes  in  the  endometrium  disposing 
it  to  bleed,  and  not  occurring,  or  not  occurring  with  the 
same  frequency,  in  patients  without  displacement.  Till 
such  a  demonstration  has  been  supplied,  our  knowledge  of 
the  effects  of  displacement  must  be  admitted  to  be  in- 
complete. Such  a  demonstration  must  be  long  in  appear- 
ing, for  two  reasons  : — (1)  that  displacements  are  not  fatal, 
and  are  not  diseases  of  such  gravity  as  to  require  removal 
of  the  uterus,  and  therefore  specimens  available  for  the 
purpose  are  only  seldom  to  be  had  ;  and  (2)  our  knowledge 
of  the  changes  which  take  place  in  the  healthy  uterus 
during  the  menstrual  cycle  is  as  yet  too  incomplete  to 
enable  us  to  assert  of  many  slight  changes  that  might  be 
found,  that  they  are  pathological.  Practical  proof  might 
be  given  by  the  effect  of  treatment.      If  it  were  found  (1) 

VOL.  XXXIV.  17 


230  MEXSTRUATION    IN    CASKS    OF    BACKWARD 

that  haemorrhage  from  uteri  displaced  backwards  was  in- 
variably or  iu  a  large  proportion  of  cases  stopped  by  ele- 
vating the  uterus  without  other  treatment^  and  (2)  that 
all  treatment  which  did  not  include  elevation  of  the  uterus 
was  unsuccessful,  then  the  effect  of  displacement  in  pro- 
ducing haemorrhage  would  be  scarcely  controvertible. 
But  I  know  of  no  one  who  has  brought  forward  evidence 
of  this  kind,  nor  am  I  able  to  do  so  ;  because  (1)  in  the 
treatment  of  haemorrhage  most  practitioners  think  it  their 
duty  not  to  omit  anything  which  may  help  to  stop  bleed- 
ing, and  therefore  this  experiment  cannot  be  systemati- 
cally carried  out  ;  and  (2)  in  many  cases — indeed,  in 
almost  all — the  hasmorrhage  sooner  or  later  stops,  whether 
treated  or  not  ;  and  the  question  is  Avhether  it  lasts  longer 
and  recurs  sooner,  more  often,  and  more  copiously,  in 
patients  treated  without  lifting  the  uterus  than  in  those 
in  whom  the  uterus  is  supported.  To  determine  this, 
observation  over  a  long  period  of  time  is  required,  and 
long  continuance  of  unsuccessful  treatment  would  so  often 
lead  to  the  withdrawal  of  its  subject  from  the  experiment 
that  the  observations  might  be  fragmentary. 

The  general  impression  which  experience  has  left  on 
my  mind  is  that  haemorrhage  iu  cases  of  backwai'd  dis- 
placement of  the  uterus  stops  sooner  in  cases  in  which  the 
uterus  is  kept  supported  than  in  those  in  which  it  is  not. 
But  I  am  not  able  to  adduce  evidence  of  scientific  value 
to  show  that  this  is  the  fact.  If  the  haemorrhage  be  not 
the  result  of  the  displacement  it  must  be  due  to  the  coin- 
cidence with  the  displacement  of  causes  which  would  pro- 
duce similar  haemorrhage  if  the  uterus  were  in  normal 
position.  We  have  seen  that  40  per  cent,  of  the  patients 
with  retroversion  or  flexion  of  the  uterus  complained  of 
haemorrhage.  If  this  be  due  to  coincidence,  we  ought  to 
find  that  among  patients  ot  the  same  class,  not  the  subjects 
of  uterine  displacement,  haemorrhage  was  also  present  in 
40  per  cent. 

To  make  this  comparison  the  difficulty  is  to  get  a  group 
of  patients   of  the  same   class  to  put   beside   that  of  the 


DISPLACEMENT    OF    THE    UTEKDS.  231 

patients  with  retroversion  and  retroflexion.  We  cannot 
fairly  compare  tlie  cases  of  displacements  with  the  general 
average  of  patients,  because  it  includes  cases  of  caucer, 
polypi,  fibroids,  haemorrhage  connected  with  pregnancy — 
conditions  not  present  in  the  cases  with  displacement  from 
which  my  figures  are  compiled.  On  the  other  hand,  it 
also  includes  women  not  menstruating  from  physiologi- 
cal causes,  or  seeking  advice  on  account  of  amenorrhoea. 
What  we  Avant  to  know  is  the  frequency  of  uterine 
haemorrhage  in  menstruating  women,  not  pregnant  and 
not  the  subjects  of  evident  organic  disease  ;  in  patients 
with  retroversion  and  retroflexion,  and  in  patients  Avithout 
these  displacements,  respectively.  It  must  be  perfectly 
obvious  that  (unless  retroversion  and  retroflexion  of  the 
uterus  inhibit  every  other  cause  of  uterine  haemorrhage, 
and  this  no  one  has  yet  asserted)  in  a  considerable  propor- 
tion of  cases  of  retroversion  and  retroflexion  there  must 
be  haemorrhage,  not  due  to  the  displacement,  but  to  other 
accidentally  concomitant  conditions.  But  if  backward 
displacements  of  the  uterus  have  any  effect  at  all  in 
producing  haemorrhage,  this  symptom  ought  to  be  more 
common  in  cases  of  backward  displacement  of  the  uterus 
than  in  patients  generally. 

I  have  gone  through  my  out-patient  case-books  and 
noted  the  cases  complaining  of  abnormal  or  increased 
haemorrhage.  I  have  excluded  cases  of  cancer  and  of 
fibroids,  for  they  are  equally  excluded  from  my  tables  of 
cases  of  displacement.  I  have  excluded  also  women  who 
were  pregnant  or  suckling,  or  had  passed  the  climacteric, 
for  they  are  also  excluded  from  the  lists  of  displacements 
on  which  my  estimate  of  the  frequency  of  hsemorrhage  is 
founded,  I  have  also  excluded  cases  of  single  women 
under  twenty-five,  for  they  are  but  little  liable  to  dis- 
placements, while  chlorosis  and  other  conditions  leading 
to  amenorrhoea  are  frequent  among  them,  and  hence  their 
inclusion  would  unduly  diminish  the  apparent  frequency 
of  conditions  which  cause  haemorrhage. 

These  cases  being  excluded,  I  have  taken  500  consecu- 


"I'Yl  WENSTRUATION    IN    CASES    OF    BACKWARD 

tive  patients  without  any  other  selection.  I  find  that 
146  of  these  complained  of  haemorrhage,  or  29'6  per  cent. 

Emmett"^  gives  a  table  showing  what  he  considers  to 
have  been  the  '^  effect  "  of  cellulitis  upon  menstruation. 
As  inflammation  of  cellular  tissue  ^^^r  se  has  not  been 
shown  to  have  any  special  effect  upon  the  uterine  mucous 
membrane,  Dr.  Emmett^s  figures  to  my  mind  indicate  the 
number  of  times  that  morbid  conditions  causing  haemor- 
rhage were  coincident  with  pelvic  cellulitis,  and  that  they 
therefore,  like  my  500  out-patients,  may  g-ive  us  some 
help  towards  estimating  the  frequency  of  such  conditions 
among  patients  generally.  (I  am  unable  to  understand  from 
the  tables  how  Dr.  Emmett^s  percentages  are  got  at,  but 
I  take  them  on  his  authority  as  correct.)  He  found  out 
of  303  cases  the  quantity  of  menstruation  increased  in 
17*36  per  cent.,  its  duration  in  11  "45  per  cent.  These 
taken  together  give  us  abnormal  hemorrhage  in  28*81 
per  cent.,  very  nearly  the  same  proportion  as  in  my  500 
out-patients. 

I  conclude,  therefore,  that  abnormal  hremorrhage  from 
the  uterus  is  more  frequent  in  patients  .with  backward 
displacement  of  the  uterus  than  in  patients  generally. 
Taking,  on  the  basis  of  my  cases  and  those  of  Emmett, 
30  per  cent,  as  about  the  proportion  of  the  avei-age  of 
patients  in  whom  the  minor  causes  of  abnormal  haemor- 
rhage are  present,  and  assuming  that  these  causes  will  be 
present  as  frequently  in  patients  with  displacements,  we 
have  left  about  10  per  cent,  as  the  proportion  of  cases  in 
which  the  haemorrhage  is  probably  caused  by  the  dis- 
placement. 

Winckelt  has  given  figures  in  the  form  of  percentages 
to  show  the  condition  of  menstruation  in  retroversion  and 
retroflexion  of  the  uterus.  (He  does  not  explain  how  the 
percentages  are  obtained,  but  I  take  them  on  his 
authorit}^  as  correct.)  He  does  not  state  whether  men- 
struation was  increased  or  diminished,  but  merely  whether 

*  '  Gynecology,'  1st  ed.,  p.  265. 

t  •  Die  Pathologic  der  Weiblichen  Sexual  Organe/  Leipsig,  1881,  s.  128. 


DISPLACEMENT    OF    THE    UTERUS.  233 

it  was  scanty  or  profuse.  He  found  55  per  cent,  in  whom 
it  was  profuse,  25  per  cent,  in  whom  it  was  scanty.  I 
find  out  of  152  patients  who  mentioned  no  alteration  it 
was  profuse  in  Q6,  and  in  141  who  complained  of  altera- 
tion that  it  was  increased  in  123.  In  all,  profuse  in  189 
out  of  293,  or  64  per  cent.  I  find  that  out  of  those  who 
did  not  mention  an  alteration  it  was  scanty  in  63,  and  of 
tliose  who  did,  diminished  in  18.  Total  81,  or  27  per 
cent.  These  figures  do  not  differ  to  a  great  extent  from 
those  of  Winckel. 

It  has  been  stated  that  displacements  of  the  uterus  are 
among  the  causes  of  the  condition  known  as  "  chronic 
metritis."  In  this  disease,  it  is  said,  menstruation  is  at 
first  profuse,  and  then,  as  the  lymph  supposed  to  be 
exuded  develops  into  fibrous  tissue,  and  this  tissue  shrinks 
and  compresses  the  vessels,  menstruation  becomes  scanty. 
I  do  not  find  among  my  cases  any  whose  clinical  history 
bears  out  this  statement,  and  therefore  I  conclude  that 
such  a  sequence  of  changes,  at  least  in  a  marked  degree, 
is  not  common  among  patients  with  retroversion  and 
retroflexion.  Of  course  it  is  possible  that  it  may  have 
occurred,  and  patients  may  not  have  mentioned  it.  If 
this  were  so,  and  if  it  were  a  usual  and  regular  course  of 
events,  the  average  age  of  patients  whose  menstruation 
had  diminished  in  quantity  ought  to  be  higher  than  that 
of  those  in  whom  the  flow  had  become  profuse.  I  find 
the  average  age  of  the  18  patients  in  whom  the  flow  had 
diminished  was  31*6,  that  of  the  46  patients  in  whom  it 
■was  increased  30*8.  This  difference  is  in  accordance 
with  the  theory  I  have  adverted  to,  but  is  hardly  enough 
to  be  demonstrative. 

The  conclusions  to  which  my  analysis  of  these  cases 
leads  me  are  briefly  these  : — 

1.  As  to  Quantity. 

1 .  In  one  fourth  of  the  cases  there  was  amenorrhoea, 
accounted  for  by  causes  irrespective  of  the  displacement. 


234  MENSTRUATION    IN    CASES    OF    BACKWARD 

and  this   amenoi'rlioea  was   not  altered   by  the    displace- 
ment. 

2.  In  about  three  fifths  of  the  whole,  there  was  no 
alteration  in  the  quantity  of  the  menstrual  flow. 

3.  In  half  of  those  who  were  menstruating-,  there  was 
no  alteration  in  the  quantity  of  the  menstrual  flow. 

4.  In  about  40  per  cent,  of  those  who  were  menstruat- 
ing, haemorrhage  was  increased. 

5.  That  in  patients  generally,  the  frequency  of  inci- 
dence of  causes  of  haemorrhage,  other  than  gross  organic 
disease  and  pregnancy,  is  probably  about  30  per  cent. 

6.  That  therefore  the  proportion  of  women  with  back- 
ward displacements  who  suffer  from  abnormal  haemor- 
rhage is  larger  than  that  among  women  whose  uteri  are 
in  normal  position  ;  and  this  justifies  the  belief  that  in  a 
small  proportion  of  cases,  probably  about  10  per  cent.,  the 
displacement  is  the  cause  of  the  haemorrhage. 

2.  As  to  Pain. 

In  a  former  paper  {'  Trans. ,^  vol.  xxiv)  I  have  criti- 
cised the  theories  as  to  the  mode  in  which  retroversion 
and  retroflexion  of  the  uterus  produce  menstrual  pain. 
In  that  paper  I  adduced  some  clinical  evidence,  based  on 
the  effect  of  treatment,  to  show  that  menstrual  pain  may 
be  produced  by  these  displacements  ;  and  I  assumed  that 
this  clinical  fact  was  sufficiently  proved.  I  do  not  pro- 
pose here  to  go  over  that  ground  again.  I  shall  here 
only  adduce  some  facts  to  show  the  frequency  of  the  as- 
sociation of  menstrual  pain  with  backward  displacement 
of  the  uterus. 

In  estimating  the  frequency  of  menstrual  pain  with 
backward  displacements  of  the  uterus,  I  eliminate  first  of 
all  those  who  were  not  menstruating,  and  those  whose 
hasraorrhage  did  not  conform  to  the  monthly  type. 
These  removed,  226  cases  are  left.  In  ten  of  these  I 
have  no  record  as  to  whether  there  was  or  was  not  men- 
strual pain.      These  deducted,  there  remain  216  women 


DISPLACEMEXT    OF    THE    UTERUS.  235 

who  were  menstruating  regularly,  and  as  to  whom  I  have 
notes  whether  menstruation  was  or  was  not  painful. 

Of  the  216  patients,  44  had  no  pain,  or  20'3  per  cent,, 
172  had  more  or  less  pain  ;  of  these  62  said  their  pain 
was  severe  ;  24  said  their  pain  was  slight ;  in  86  I  have 
only  a  note  that  there  was  pain,  but  no  account  of  its 
severity.  In  82  the  menstrual  pain  had  either  been 
recently  acquired,  or  the  customary  menstrual  pain  re- 
cently increased,  or  o6'3  per  cent. 

Broadly  speaking,  in  only  one  fifth  of  the  cases  was 
menstrual  pain  absent,  and  in  more  than  one  third  of  the 
cases  menstrual  pain  had  been  recently  acquired. 

In  a  paper  published  in  our  '  Transactions,'  vol.  xxi,  I 
related  an  inquiry  into  the  frequency  of  dysmenorrhoea 
with  anteflexion.  For  the  purpose  of  that  paper,  I  in- 
quired into  the  amount  of  menstrual  pain  in  110  women, 
nearly  all  of  them  nulliparae,  and  most  of  them  prosti- 
tutes, and  about  one  fourth  of  them  the  subjects  of  ante- 
flexion, which  many  persons  at  that  time  regarded  as  a 
potent  cause  of  dysmenorrhoea.  It  is  well  known  that 
dysmenorrhoea  is  often  cured  by  childbearing.  In  these 
cases,  therefore,  it  is  probable  that  the  amount  of  dys- 
menorrhoea was  greater  than  in  the  general  average  of 
women.  Of  the  110,  42,  or  38  per  cent.,  menstruated 
without  pain,  or  nearly  twice  as  many  in  proportion  as 
among  the  patients  with  backward  displacements  of  the 
uterus,  although  the  majority  of  the  latter  were  parous 
women. 

These  figures  are  sufficient  to  show  that  pain  at  the 
menstrual  period  is  more  frequent  in  patients  with  retro- 
version or  retroflexion  of  the  uterus  than  in  the  general 
average  of  healthy  women,  and  the  natural  inference  is 
that  the  displacement  is  the  cause  of  the  pain. 

The  question  arises,  what  is  the  pain  ?  The  term 
"  dysmenorrhoea  "  is  widely  used  in  the  sense  of  pain  at 
the  menstrual  period.  Some  more  accurate  writers,  the 
most  conspicuous  of  them  being  the  late  Dr.  Matthews 
Duncan,    confine    it    to    pain    actually    produced    by   the 


230  MENSTRUATION    IN    CASES    OF    BACKWARD 

uterine  contractions  which  expel  the  flow.  In  some  of 
the  cases  from  which  my  figures  were  taken  I  have  no 
doubt  that  the  menstrual  pain  did  consist  in  abnormally- 
painful  uterine  contractions.  In  others  it  was  simply  an 
aggravation  of  the  bearing  down,  &c.,  which  the  patients 
felt  at  all  times ;  and  in  yet  other  cases,  pain  of  other 
kinds.  The  data  at  my  disposal  are  not  complete  enough 
to  enable  me  to  say  in  what  proportion  each  different 
kind  of  pain  contributed  to  the  total  number  of  cases  of 
pain  at  the  menstrual  period. 

Assuming  that  we  are  correct  in  believing  that  displace- 
ment of  the  uterus  backwards  produces  or  increases  men- 
strual pain,  the  question  suggests  itself  whether  the  pain 
is  modified  by  the  amount  of  blood  lost  ? 

On  a  'priori  theoretical  grounds  an  explanation  might 
be  found  whether  the  patients  with  increased,  or  those 
with  diminished,  flow  sufl^ered  the  more.  If  those  with 
copious  menstruation  had  more  pain,  it  might  be  argued 
that  those  with  increased  haemorrhage,  who  form  the 
majority,  represent  the  alteration  due  to  the  displace- 
ment, while  in  the  few  with  diminished  menstruation  the 
diminution  is  due  to  some  accidentally  concomitant  con- 
dition ;  that  the  increased  menstruation  represents  dis- 
turbance of  circulation,  and  that  this  disturbance  would 
be  expected  to  cause  pain  as  well  as  hfemorrhage.  On 
the  other  hand,  if  those  who  lost  copiously  were  compara- 
tively free  from  pain,  it  might  be  said  that  the  hasmor- 
rhage  lessened  congestion,  and  thus  relieved  pain.* 

Bringing  the  question  to  the  test  of  fact,  I  find  that  of 
those  whose  menstruation  was  described  as  scanty  or 
diminished,  the  condition  as  to  pain  was  as  follows  : — Pain- 
less^ 17,  or  21  per  cent.;  painful,  64,  or  79  per  cent.;  with 
recently  acquired  or  increased  pain,  25,  or  30*7  per  cent. 
Of  those  whose  menstruation  was  'profuse  or  'increased,  the 
statements  as  to  pain  give  the  following  result: — Painless, 
15,  or  13"8  per  cent.;  painful,  94,  or  86"2  per  cent.;   with 

*  As  it  lias  Ijcen  shown  to  do  in  ciiucer.   (Sue  Clmuipnejs,  'Trans.,'  vol.  xxii, 
p.  19. 


DISPLACEMENT    OF    THE    UTEKUS.  237 

recently    acquired    or    increased  pain^,    41,    or    o7"G    per 
cent. 

The  general  conclusion  to  which  I  come  is  that  menstrual 
pain  is  more  frequent  in  women  with  backward  displace- 
ment of  uterus  than  in  the  general  avei'age  of  women.  Of 
women  with  retroversion  or  retroflexion  of  the  uterus 
who  are  menstruating,  pain  appears  to  be  absent  in  only 
about  one  fifth,  while  of  women  in  general  two  fifths  or 
more  menstruate  without  pain.  Menstrual  pain  associated 
with  backward  displacement  of  uterus  appears  to  be  rather 
more  frequent  in  those  who  menstruate  profusely  than  in 
those  who  menstruate  scantily.  The  percentages  of 
patients  with  backward  displacements  of  the  uterus  who 
suffer  from  increased  pain  and  from  increased  hsemorrhage 
are  very  nearly  alike  (38  per  cent,  of  pain  and  40  per 
cent,  of  hemorrhage),  and  this  fact  suggests  a  close 
alliance  as  to  cause. 

De.  Hates  thought  that  the  value  of  the  paper  was  impaired 
by  the  fact  that  the  amount  of  hjemorrhage  in  the  cases  w  as  not 
specified.  Bleeding  varied  so  much,  even  in  healthy  women,  in 
its  amount  and  frequency,  and  in  the  same  woman  under  trifling 
disturbances,  keeping  of  course  always  within  moderate  bounds, 
that  comparisons  were  difficult  and  misleading.  Further,  in 
backward  displacements  of  the  uterus  the  ovaries  were  often 
prolapsed  and  tender.  Such  a  condition  of  the  ovary  ^jer  se  not 
infrequently  gave  rise  to  troublesome  and  even  considerable 
haemorrhage.  This  was  proved  by  the  fact  of  haemorrhages  in 
cases  of  prolapsed  ovaries  without  any  retroflexion  of  uterus, 
and  the  arrest  of  haemorrhage  by  the  removal  of  the  prolapsed 
organ.  In  the  paper  no  mention  was  made  of  the  position  of  the 
ovaries  when  the  uterus  was  backwardly  displaced.  Again,  re- 
specting the  dysmenorrhoea,  he  would  have  liked  some  specifica- 
tion of  the  amount  of  pain  in  the  individual  cases. 

De.  Eutheefooed  asked  how  many  of  the  40  per  cent,  of 
women  with  increased  menstrual  flow  were  multiparae,  and  what 
was  the  average  number  of  children  per  woman  ?  He  could  not 
accept  retroflexion  alone  as  a  cause  of  increased  menstruation, 
and  thought  it  probable  subinvolution  might  account  for  the 
menorrhagia. 

De.  Hetwood  Smith  asked  Dr.  Herman  whether  in  his  in- 
vestigations into  so  large  a  number  of  backward  displacements 
of  the  uterus  he  had  made  any  observations  as  to  the  number  of 
cases  of  retroflexion  of  the  gravid  uterus  ? 


238  BACKWARD    DISPLACEMENT    OP    THE    UTEEUS. 

De.  Addijtsell  asked  whether  in  those  cases  in  which  pain 
was  the  prominent  symptom  there  had  been  increased  difficulty 
in  passing  the  sound — as  the  retroflexion  would  tend  to  increase 
the  stenosis  of  the  internal  os — and  thus  account  for  the  pain  in 
Dr.  Herman's  cases. 

Dr.  Herman  had  no  doubt  that  among  his  cases  of  backward 
displacement  were  many  cases  of  subinvolution.  Subinvolution 
was  present  also  among  the  cases  with  which  he  had  compared 
the  cases  of  displacement.  He  did  not  think  subinvolution  was 
especially  common  in  multiparae.  Prolapse  of  the  ovary  was 
present  in  many  of  his  cases,  but  he  did  not  known  the  exact 
number.  He  had  often  observed  pregnancy  occur  in  cases  of 
backward  displacement,  though  he  could  not  without  reference 
to  his  case-books  say  how  often.  In  a  paper  read  in  December, 
1891,  he  had  discussed  this  point.  He  found  the  sound  generally 
caused  pain  in  patients  of  all  classes  when  it  passed  the  internal 
OS.  He  had  not  perceived  anything  to  make  him  think  there  was 
stricture  at  the  internal  os. 


289 


TWO    CASES    OF    DOUBLE    OVAEIOTOMY 
DUEING   PREGNANCY. 

By  W.  A.  Meredith, 

SFEGEOy   TO  THE   SAMAEITAN  PEEE  HOSPITAL. 
(Received  January  29th,  1892.) 

[Abstract.) 

Case  1. — A  primipara,  25  years  of  age,  from  whom  two 
papillomatous  ovarian  cysts,  together  weighing  6  lbs.,  were 
removed  by  abdominal  section  in  the  third  month  of  pregnancy. 
The  operation  was  complicated  by  very  extensive  adhesions,  and 
a  drainage-tube  was  subsequently  used  for  a  space  of  thirty-six 
hours.  Convalescence  was  speedy,  and  uninterrupted  by  any 
evidence  whatever  of  uterine  disturbance.  The  patient  re- 
turned home  on  the  twenty -sixth  day,  and  was  safely  delivered 
of  a  well-developed  boy  at  the  full  term  of  gestation. 

Case  2. — A  multipara,  aged  31,  operated  on  in  the  third 
month  of  pregnancy.  The  tumours  in  this  instance  weighed 
5  lbs.  The  left  ovary  was  a  multilocular  cystoma  with  a 
recently  twisted  pedicle  ;  the  right  ovary  was  a  dermoid  cyst. 
No  drainage  was  employed.  Convalescence  was  perfectly 
uneventful ;  and  the  patient  was  subsequently  confined  at  term 
of  a  daughter. 

In  both  cases  delivery  was  followed  by  normal  contraction  of 
the  uterus,  and  by  subsequent  complete  involution  of  the  organ. 

Previously  recorded  cases  of  double  ovariotomy  during  the 
course  of  pregnancy  were  noted  as  amounting  to  but  four  in 
number.  All  the  mothers  recovered;  but  two  only  out  of  the 
four  operations  referred  to  were  followed  by  the  birth  of  a 
living  child — in  one  instance  prematurely  at  the  eighth  month, 
and  in  the  other  at  the  full  lerfii  of  gestation. 


240  DOUBLE    OVARIOTOMY    DDRING    PliEGNANCY. 

The  successful  removal  of  an  ovarian  cyst  during  the 
course  of  pregnancy  is  so  comparatively  common  an 
occurrence  at  the  present  day  that  special  record  of  such 
an  event,  even  though  followed  by  the  birth  of  a  living 
child,  Avould  hardly  seem  called  for  ;  and,  personally,  I 
should  not  deem  it  necessary. 

A  like  criticism  may  possibly  be  considered  applicable 
to  a  record  of  the  two  cases  which  I  bring  before  the 
Society  this  evening ;  but  I  think  that  the  fact  of  the 
infrequency  with  which  such  instances  have  up  till  now 
been  reported  may  well  be  deemed  sufficient  to  justify 
the  present  communication. 

Case  1. — M.  Y — ,  aged  25,  married  fifteen  months,  and 
never  previously  pregnant — was  referred  to  my  chai'ge  in 
the  Samaritan  Free  Hospital  in  November,  1890,  by  my 
colleague,  Dr.  Amand  E-outh,  under  whose  care  she  had 
occasionally  attended  in  the  out-patient  department  of  the 
hospital  for  some  months  before  her  admission. 

History. — She  had  always  enjoyed  good  health  pre- 
viously to  her  marriage  in  September,  1889.  Shortly 
after  this  event,  she  discovered  a  small  tender  swelling 
in  the  left  inguinal  region,  and  was  laid  up  with  an  attack 
of  pelvic  inflammation  for  some  eight  or  nine  weeks 
under  the  care  of  Dr.  Staines,  of  Bloom sbury  Square, 
In  the  following  March  (1890)  she  first  consulted  Dr. 
Routh,  who  then  noted  the  existence  of  a  firm  bilobed 
tumour  closely  connected  with  the  uterus.  On  June 
4th  the  anterior  portion  of  the  tumour  w^as  found  to  be 
increasing  in  an  upward  direction ;  and  a  secondary  mass 
was  felt  deep  in  the  pelvis  behind  the  uterus,  which  was 
slightly  enlarged,  with  somewhat  impaired  mobility. 
Menstruation  continued  regular  without  excessive  loss, 
the  flow  lasting  four  days. 

The  patient  was  subsequently  lost  sight  of  until  the 
following  October,  when  she  returned  to  the  hospital 
looking  very  ill,  with  a  history  of  seven  weeks'  amenor- 
rhoea,  accompanied   by  abdominal  pains  and  rapid  loss  of 


DOUBLE  OVARIOTOMY  DURING  PREGNANCY.       241 

flesh.  I  first  saAv  her  with  Dr.  Routh  on  NovernLcr  lOth, 
and  she  entered  the  hospital  on  November  12th. 

The  following-  notes  were  then  made  of  her  condi- 
tion : — "  A  delicate-looking,  but  fairly  well  nourished  little 
woman,  without  any  pelvic  deformity.  No  evidence  of 
heart,  lung,  or  kidney  mischief.  Abdomen  occupied  by  a 
firm,  elastic,  soiuewhat  irregular  tumour,  extending  highest 
in  the  left  side,  where  its  upper  border  reaches  nearly  to 
the  costal  arch.  Epigastrium  and  both  flanks  resonant. 
Anterior  to  the  larger  tumour,  a  secondary  mass  of  firmer 
consistence  rises  from  the  pelvis  to  midway  between 
pubes  and  umbilicus.  This  latter  growth  overlies  the 
uterus,  which  on  bimanual  examination  is  found  to  be 
considerably  enlarged,  lying  retroverted  with  its  fundus 
in  the  right  iliac  fossa,  and  a  characteristically  softened 
cervix  pointing  towards  the  left  side  of  the  pelvis.  An 
ill-defined  soufile  is  audible  in  the  right  inguinal  region.^' 

No  menstrual  loss  had  occurred  since  August  loth. 
Morning  sickness  had  been  noted  for  some  five  or  six 
weeks. 

Diagnosis. — Pregnancy  with  advanced  disease  of  one, 
or  possibly  of  both,  ovaries. 

Operation,  on  November  18th,  1890. — The  ordinary 
median  incision,  made  somewhat  higher  up  than  usual, 
revealed  a  multilocular  ovarian  cyst  partially  covered  by 
adherent  omentum,  and  firmly  connected  with  the  parietal 
peritoneum  over  the  left  side  of  the  abdomen.  After 
evacuation  of  the  more  prominent  cyst  cavities,  the  in- 
cision was  extended  upwards  above  the  umbilicus  in 
order  to  effect  separation  of  the  very  extensive  parietal, 
omental,  and  intestinal  adhesions  covering  the  upper  sur- 
face of  the  tumour,  which  was  then  turned  out  of  the 
abdominal  cavity.  A  pedicle  of  moderate  length,  con- 
nected with  the  left  side  of  the  enlarged  uterus,  was 
clamped  previously  to  division,  and  subsequently  ligatured 
with  silk. 

The  right  ovary,  consisting  of  the  mass  already  referred 
to  as  situated  anterior  to  the  main   tumour   before  opera- 


212       DOUBLE  OVARIOTOMY  DDKING  PREGKANCY. 

tiou,  had  been  displaced  during  the  removal  of  this  latter, 
and  was  so  completely  enveloped  in  adherent  omentum 
that  I  had  some  difficulty  in  discovering  it,  and  still  more 
when  I  had  done  so  in  freeing  it  from  its  adhesions. 
After  securing  its  pedicle  and  removing  the  growth,  at 
least  a  dozen  fine  ligatures  were  required  to  arrest  bleed- 
ing from  the  damaged  omentum,  and  several  more  were 
applied  to  bowel  adhesions. 

No  difficulty  was  now  experienced  in  raising  and 
replacing  the  pregnant  uterus  in  good  position. 

A  quantity  of  sanguineous  fluid  remained  in  the  pelvic 
cavity  ;  and  I  therefore  inserted  a  glass  drainage-tube, 
which  was  removed  thirty-six  hours  later,  when  both 
pulse  and  temperature  were  at  normal — a  point  not  sub- 
sequently exceeded  during  the  patient's  stay  in  hospital. 

Convalescence  was  speedy,  and  uninterrupted  by  any 
evidence  whatever  of  uterine  disturbance.  Foetal  move- 
ments were  felt  by  the  patient  for  the  first  time  on 
December  2nd.  She  was  allowed  to  leave  her  bed  on 
December  9th,  and  returned  home  on  December  14th, 
the  twenty-sixth  day  after  operation. 

Both  tumours  were  good  examples  of  papillomatous 
cysts.  Together  they  weighed  six  pounds.  The  larger 
of  the  two  was  extremely  multilocular,  showing  extensive 
papillary  growths  of  the  firm  non-vascular  variety,  not 
only  within  its  various  loculi,  but  also  in  scattered  groups 
upon  its  outer  surface,  these  latter  proliferations  being 
apparently  independent  of  any  directly  subjacent  internal 
growths.  The  smaller  tumour,  of  the  size  of  a  foetal 
head,  contained  one  main  cavity  densely  packed  with 
sprouting  papilloma.  No  infection  of  the  general  perito- 
neum was  noted. 

Subsequently  to  the  patient's  return  home  the  preg- 
nancy pursued  a  perfectly  normal  course,  and  terminated 
in  the  birth  of  a  well-developed  boy  on  June  11th,  1891. 
Dr.  H.  Taylor,  of  Kennington  Park  Road,  who  kindly  took 
charge  of  the  patient  at  my  request,  reported  to  me  that 
delivery  was  readily  effected  after  an  eight  hours'  labour, 


DOUBLE  OVARIOTOMY  DURING  PREGNANCY.       243 

and  that  the  uterus  subsequently  contracted  normally. 
The  lochia  ceased  at  the  end  of  the  fortnight,  and  both 
mother  and  child  came  to  see  me  at  the  hospital  five 
•weeks  after  the  confinement.  The  uterus  then  measured 
three  and  a  half  inches  by  the  sound,  and  was  quite 
moveable. 

Case  2. — E.  J — ,  31  years  of  age,  married  twelve  years, 
and  mother  of  six  children,  of  whom  the  youngest  was 
one  year  and  ten  mouths  old,  entered  the  Samaritan 
Hospital  under  my  care  on  February  16th,  1891. 

Previous  history. — Although  never  strong,  she  had 
enjoyed  fairly  good  health  until  about  twelve  months 
before,  when  she  noticed  some  loss  of  flesh,  accompanied 
by  abdominal  swelling.  In  June,  1890,  she  was  admitted 
into  St.  Bartholomew's  Hospital,  whence  she  was  dis- 
charged after  some  weeks'  stay,  owing  to  her  refusal 
to  submit  to  an  operation.  In  the  folloAving  October  she 
consulted  Sir  Spencer  Wells,  who  advised  her  to  apply  at 
the  Samaritan  Hospital ;  but  she  did  not  do  so  until  Feb- 
ruary, 1891,  when  she  attended  as  an  out-patient,  and 
was  referred  to  my  care  on  February  14th,  in  consequence 
of  a  sharp  attack  of  abdominal  pain. 

On  her  admission,  two  days  later,  the  following  notes 
were  taken  of  her  condition  : — ''  Emaciation  considerable. 
Abdomen  contains  a  mobile  tender  cyst,  extending  up- 
wards above  the  umbilicus  and  downwards  into  the  left 
side  of  the  pelvis  in  front  of  the  uterus,  which  lies  retro- 
verted  towards  the  right,  beneath  the  tumour.  The  cervix 
offers  no  very  characteristic  signs  of  pregnancy,  but  the 
indistinctly  traceable  body  of  the  uterus  is  decidedly  en- 
larged and  softened.      No  souffle  is  audible," 

The  catamenia  were  stated  to  have  rarely  been  regular 
as  to  time  of  onset  or  duration.  They  were  last  seen  in 
the  previous  November  (1890),  when  the  flow  lasted  for 
forty-eight  hours. 

The  diagnosis  made  was  : — Ovarian  cyst  with  pregnancy, 
presumably  in  the  third  month. 


244       DOUBLE  OVARIOTOMY  DURING  PREGNANCY. 

At  the  opei^ation,  on  February  18th,  a  thick-walled 
multilocular  cyst  of  the  left  ovary,  with  a  recently-twisted 
pedicle,  was  removed  without  difficulty.  On  raising  the 
large  retroverted  uterus,  which  evidently  contained  a 
foetus,  I  discovered  the  right  ovary,  enlarged  to  the  size 
of  a  turkey's  egg,  lying  unadherent  at  the  bottom  of 
Douglas's  pouch.  It  was  removed  entire,  and  on  section 
was  found  to  be  a  dermoid  cyst  filled  with  fat  and  hair. 
The  total  weight  of  the  two  tumours  was  five  pounds. 
The  abdomen  was  closed  without  drainage. 

The  patient's  convalescence  was  uneventful.  The  tem- 
perature never  exceeded  99*6°  F.  Throughout  her  stay_ 
in  hospital  no  evidence  whatever  of  uterine  disturbance 
was  noted,  and  she  returned  home  on  March  16th,  the 
twenty-sixth  day  after  operation,  having  quickened  about 
a  week  previously  to  that  date. 

The  pregnancy  followed  a  perfectly  normal  course,  and 
Mr.  Cursham  Corner,  of  Mile  End  Eoad,  who  took  charge 
of  the  patient,  wrote  me  that  she  was  safely  delivered  on 
September  11th,  1891,  of  a  well-developed  daughter 
eight  pounds  in  weight.  The  confinement  was  natural, 
and  in  noways  different  from  her  previous  ones. 

Both  of  these  patients  came  to  see  me  on  December 
14th,  1891,  bringing  their  infants  with  them.  In  each 
instance  I  found  on  pelvic  examination  that  the  uterus 
was  well  involuted,  and  normal  as  to  position  and  mo- 
bility. The  abdominal  incisions  were  perfectly  sound,  and 
well  united  throughout.  Both  children  were  fine  healthy 
babies,  and  were  being  nursed  by  their  respective 
mothers. 

Previously  recorded  cases  of  removal  of  both  ovaries 
for  advanced  cystic  disease  during  the  course  of  px'eg- 
nancy,  so  far  as  I  have  been  able  to  ascertain,  amount  to 
but  four  in  number. 

The  first  one  of  this  series  in  point  of  date  is  con- 
tained in  our  'Transactions,'  vol.  xxviii,  p.  41.  The 
patient,  a  primipara,  was  operated  on  in  1885  by  Mr.  J. 
K.   Thornton,  who    removed    two   dermoid   ovarian    cysts 


DOUBLE    OVARIOTOMY    DURING    PREGNANCY.  245 

during  the  fourth  month  of  pregnancy.  The  operation 
was  followed  by  recovery,  and  subsequently  by  the  birth 
of  a  living  child  at  the  end  of  the  eighth  month. 

The  next  case  in  the  series  is  reported  in  the  twentieth 
volume  of  the  *  American  Journal  of  Obstetrics '  (for 
1887,  p.  730),  by  Dr.  Munde,  of  New  York,  who  oper- 
ated in  the  fifth  month  of  pregnancy.  The  tumours  in 
this  instance  also  were  dermoid  cysts.  Their  removal 
was  followed  by  miscarriage  at  the  end  of  seventy-two 
hours,  but  the  patient  recovered. 

In  1888,  Dr.  Potter,  of  Buffalo,  U.S.A.,  published  in 
the  twenty-first  volume  of  the  '  American  Journal  of  Ob- 
stetrics'  (p.  1028)  a  very  full  and  interesting  report  of  a 
case  of  removal  of  two  ovarian  cysts  during  the  fifth 
month  of  pregnancy.  A  threatened  miscarriage  a  week 
after  operation  was  averted  by  full  doses  of  opium,  and 
the  patient  subsequently  gave  birth  to  a  living  child  at 
term. 

The  fourth  case  referred  to  was  briefly  noted  in  the 
*  Journal  of  the  British  Gynaecological  Society  '  for  1890 
as  one  of  double  dermoid  ovarian  cysts  removed  during 
the  third  month  of  pregnancy  by  Dr.  Bantock.  No 
further  details  of  this  case  have  been  published,  but  I 
understand  from  Dr.  Bantock  that  the  pregnancy  termi- 
nated prematurely  at  the  seventh  month  in  the  birth  of  a 
child,  who  survived  but  a  few  hours. 

In  the  discussion  following  the  report  of  Dr.  Potter's 
case  above  alluded  to  (loc.  cit.),  mention  appears  of  a  case 
of  double  oophorectomy  performed  during  the  third  month 
of  pregnancy  by  a  Dr.  Montgomery  ;  but  no  details  are 
given  as  to  the  nature  of  the  disease  for  which  the 
uterine  appendages  were  removed,  although  it  is  stated 
that  the  patient  recovered,  and  afterwards  bore  a  living 
child. 

Setting  aside  this  case  as  not  being  one  of  ovarian 
tumour,  and  consequently  not  bearing  directly  upon  the 
subject  of  this  communication,  we   have  a  group  of  six 

VOL.  XXXIV.  18 


246  DOUBLE    OVARIOTOMY    DURING    PREGNANCY. 

cases  of  double  ovariotomy  performed  during  the  course 
of  pregnancy  without  a  maternal  death,  and  followed  in 
four  out  of  the  six  by  the  subsequent  birth  of  a  living 
cliild — in  one  instance  prematurely  at  the  end  of  the 
eio-hth  month,  and  in  the  three  remaining  instances  at  the 
completion  of  the  full  term  of  gestation. 

In  conclusion,  I  will  very  briefly  indicate  what  seem 
to  me  the  chief  noteworthy  points  in  connection  with  the 
two  cases  which  I  have  brought  forward  this  evening 
from  my  own  practice.  They  may,  I  think,  be  summa- 
rised as  follows  : 

1.  The  persistence  of  ovulation,  and  the  occurrence  of 
normal  pregnancy  with  coexisting  extremely  advanced 
cystic  disease  of  both  ovaries. 

2.  The  entire  absence  after  operation  of  any  evidence 
of  uterine  disturbance  as  the  result  of  prolonged  and 
troublesome  intra-peritoneal  manipulations,  entailing  in 
both  instances  considerable  handling  of  the  pregnant 
uterus,  and  followed  in  one  instance  by  the  use  of  a 
glass  drainage-tube  in  the  pelvic  cavity  for  the  space  of 
thirty- six  hours. 

3.  The  subsequent  occurrence  in  both  cases  of  easy 
and  natural  delivery,  at  term,  of  a  healthy  well-developed 
child,  followed  by  normal  contraction  of  the  uterus, 
normal  duration  of  lochial  discharge,  natural  performance 
of  the  function  of  lactation,  and  finally  by  perfectly 
normal  and  complete  involution  of  the  uterus. 

From  a  sti'ictly  clinical  standpoint  there  is  not  much 
to  add  to  the  details  already  given. 

In  both  my  cases  resort  to  active  surgical  interference 
in  face  of  the  presumed  existence  of  pregnancy  was 
deliberately  adopted  as  offering  the  best  possible  chance 
of  safety  both  for  mother  and  child — a  conclusion  fully 
confirmed  by  the  results. 

In  each  instance  the  operation  was  performed  with 
strict  antiseptic  precautions,  but  without  the  use  of  the 
carbolised   spray,  which  I  have  now  entirely  discarded  in 


DOUBLE  OVARIOTOMY  DURING  PREGNANCY.       247 

my  abdomiual  work  for  over  tliree  years  past,  with  con- 
sequent great  improvement  in  my  results. 

Finally,  to  neither  of  my  patients  was  any  opium 
administered  throughout  their  stay  in  hospital — a  note- 
worthy fact,  as  indicating  the  smoothness  of  their  con- 
valescence. 

Mb.  Alban  Doean  observed  that  it  was  certainly  justifiable 
to  remove  an  ovarian  cyst  during  pregnancy.  The  diagnosis  of 
two  cysts  in  a  pregnant  woman  was  difficult,  but  when,  on  the 
removal  of  one  ovary,  the  opposite  organ  was  also  found  to  be 
cystic,  i^.  ought  to  be  removed.  Indeed,  its  removal  hardly  in- 
creased the  chances  of  abortion.  If  left  behind,  after  irritation 
by  handling,  it  might  set  up  uterine  contractions.  The  Fallopian 
tube,  in  these  cases,  was  specially  sensitive.  The  evidence  that 
ovulation  continued  when  both  ovaries  were  in  an  advanced  stage 
of  cystic  disease  implied  that  when  thus  diseased  they  influenced 
the  uterus,  and  no  doubt  prejudicially.  Hence  their  thorough 
removal,  in  cases  of  pregnancy,  was  highly  advisable. 

Db.  Leweks  was  much  interested  in  the  first  case,  where  a 
glass  drainage-tube  had  been  used,  and  where  there  were 
papillary  growths  on  the  outer  or  peritoneal  aspect  of  the  cysts 
without  infection  of  the  peritoneum.  He  had  recently  had  a 
case  of  ovariotomy  in  a  patient  who  was  five  months  pregnant. 
In  this  case,  as  there  were  no  adhesions,  there  was  no  reason  to 
insert  a  drainage-tube,  but  had  it  been  desirable  to  do  so  it 
would  have  been  a  difficult  matter  to  pass  the  tube  in  the  usual 
way  to  the  bottom  of  Douglas's  pouch,  as  this  was  practically 
obliterated  by  the  pressure  of  the  pregnant  uterus.  He  had  had 
a  case  of  double  ovariotomy  recently  where  there  were  numerous 
papillary  growths  from  the  outer  or  peritoneal  aspect  of  the 
cysts  without  any  infection  of  the  peritoneum,  and  not  due  to 
intra-cystic  papillary  growths  bursting  through  the  cyst-wall. 
In  this  case  there  was  good  reason  to  believe  these  papillary 
growths  on  the  peritoneal  aspect  of  the  cysts  had  been  present 
for  a  considerable  time,  as  three  years  before  he  operated  an 
operation  had  been  advised  against  elsewhere  on  the  supposition 
that  the  patient  had  pelvic  cancer. 


OCTOBER  5th,  1892. 

J.  Watt  Black,  M.D.,  President,  in  the  Chair. 

Present— 48  Fellows  and  13  visitors. 

Books  were  presented  by  Dr.  Robert  Barnes,  Dr. 
Coromilas,  the  Clinical  Society  of  London,  the  Guy's 
Hospital  Staff,  and  the  St.  Thomas's  Hospital  Staff. 

William  McAdam  Eccles,  M.B.,  B.S.Lond.,  and  Samuel 
Walshe  Owen,  L.R.C.P.Lond.,  were  admitted  Fellows  of 
the  Society. 

The  following  gentlemen  were  elected  Fellows  : — 
Charles  William  James  Chepmell,  M.D.Brux.  (Brighton)  ; 
and  John  Benjamin  Hellier,  M.D.Lond.  (Leeds). 

The  following  gentlemen  were  proposed  for  election  : 
— James  Henry  Ashworth,  M.D.St. And.  (Halstead) ; 
Robert  Davis,  M.R.C.S.  (Epsom)  ;  Herbert  M.  Nelson 
Milton,  M.R.C.S.  (Cairo)  ;  and  Walter  William  Hunt 
Tate,  M.B.Lond. 


VOL.   XXXIV.  19 


250  DISTENSION    OP    VAGINA   AND    UTERUS. 


DISTENSION  OF  VAGINA  AND  UTERUS  WITH 
MUCO-PUEIFORM  FLUID,  ACCOMPANIED  BY 
DILATATION  OF  BLADDER  AND  URETERS 
FROM  PRESSURE,  IN  A  CHILD  SEVEN 
WEEKS    OLD. 

By  W.  McAdam  Eccles,  M.B.,  B.S.,  F.R.C.S. 

N.  D — ,  born  on  January  17tli,  1892,  the  second  child 
of  a  healthy  mother,  the  first  child  being  perfectly  normal. 
A  few  days  after  birth  a  swelling  presenting  at  the  vulva 
was  noticed.  The  child  was  apparently  in  perfect  health 
until  March  10th,  1892,  when  the  abdomen  became  much 
distended,  and  there  was  continued  vomiting. 

March  12th. — Worse.  Was  first  seen  on  this  date. 
Abdomen  everywhere  much  distended  and  tympanitic, 
except  just  above  the  pubes.  Presenting  at  the  vulva 
was  a  rounded,  tense,  elastic  swelling,  with  impulse  on 
crying,  resonance  on  percussion  with  finger  pressed  firmly 
upon  it.  What  seemed  to  be  the  hymen  was  seen 
anterior  to  the  swelling.  The  child  had  retention  of 
urine,  a  catheter  was  passed,  and  a  pint  of  clear  urine 
was  withdrawn.  The  rectal  examination  revealed  a  tense 
mass  lying  in  front  of  the  anterior  wall  of  rectum.  No 
further  treatment  was  adopted,  as  there  was  a  mistaken 
diagnosis  of  vaginal  hernia,  and  the  child  gradually  sank, 
and  died  on  March  21st,  1892. 

The  post-mortem  examination  revealed  a  distended 
urinary  bladder,  much  hypertrophied,  and  lying  behind 
it,  and  reaching  to  above  the  umbilicus,  a  dilated  vagina 
containing  some  ounces  of  muco-purulent  fluid.  At  the 
summit  was  perched  a  dilated  uterus,  but  neither  of  the 
Fallopian  tubes  was  distended.  The  vagina  was  occluded 
at  its  lower  end,  and  its  cavity  measured  four  inches  long 
by  three  broad,  and  four  inches  from  before  backwards. 
The  cervix  uteri  would  admit  the  little  finger  easily  ;  the 
uterus  was  in  the  position  of  extreme  anteversion.      Both 


THE    PELVIS    OP    A    CAT.  251 

ureters  were  gi'eatly  dilated,  being  pressed  upon  by  the 
distended  vagina.  Both  kidneys  were  hydronephrotic  to 
a  marked  degree,  the  left  having  a  little  pus  in  it.  There 
was  no  communication  between  the  ureters  and  vagina. 
The  rectum  passed  down  behind  the  tumour  somewhat  to 
the  right  side,  and  had  evidently  been  subject  to  much 
pressure. 

The  specimen  is  preserved  in  the  museum  of  St. 
Bartholomew's  Hospital,  No.  3016A,  with  two  drawings, 
Nos.  51 7B  and  517C. 

A  reference  to  a  somewhat  similar  case  will  be  found 
in  the  '  Obstet.  Soc.  Trans.,'  vol.  xix,  p.  5. 

Dr.  W.  S.  A.  GrEiFFiTH  referred  to  a  remarkable  specimen 
recorded  by  Dr.  Gervis  in  '  Obstet.  Trans.,'  vol.  v,  in  which  the 
foetal  uterus  and  oviducts  were  distended  with  flaky  serum  (three 
quarters  of  a  pint),  and  pointed  out  that  Mr.  Eccles'  specimen 
illustrated  one  of  the  rarer  causes  of  retention  of  urine  in  young 
women,  namely,  that  due  to  distension  of  the  vagina  by  fluid, 
usually  retained  menses. 


THE    PELVIS    OF    A    CAT,    WITH    BLADDER, 
UTERUS,  AND  RECTUM  In  sihi. 

By  H.  T.  RuTHERPOORD,  M.B.,  M.R.C.P. 

The  cat  had  died  during  parturition  two  hours  after 
giving  birth  to  five  large  kittens.  At  the  post-mortem 
examination  it  was  found  that  the  uterine  cornua  were 
extremely  dilated,  very  thin,  and  contained  a  kitten  in 
each  horn. 

The  kitten  lowest  down  occupied  pai't  of  the  right 
cornu  and  the  body  of  the  uterus,  and  had  its  head  rest- 
ing on  the  brim  of  the  pelvis.  The  intestines  were  empty, 
pushed  up  against  the  diaphragm  and  exceedingly  ansemic, 
as  were  all  the  other  ororans  in  the  abdomen  and  thorax. 


252  RUPTURED  UTERUS  AND  VAGINA. 

There  was  no  obstruction  at  the  brim  or  in  the  pelvis 
to  prevent  the  birth  of  the  sixth  kitten. 

Death  was  due  to  exhaustion  consequent  upon  the 
anaemic  condition  o£  the  cat ;  and  the  number  of  large 
kittens,  which  had  stretched  out  the  uterus  and  cornua,had 
set  up  a  condition  of  primary  uterine  inertia,  a  condition 
rarely  found  in  animals. 


RUPTURED  UTERUS  AND  VAGINA. 
By  Amand  Routh,  M.D. 

The  specimen  is  from  a  patient  in  the  Charing  Cross 
Hospital  Maternity  Department. 

The  Obstetric  House  Physician  had  turned  for  arm 
presentation,  and  had  delivered  the  child  without  much 
difficulty.  The  woman  then  became  greatly  collapsed, 
and  as  the  placenta  was  not  forthcoming  he  was  sent  for. 

The  woman  was  losing  some  blood  'per  vaginam,  but 
was  evidently  suffering  from  internal  haemorrhage  and 
shock.  The  cord  was  hanging  from  the  vulva,  but  the 
placenta  could  not  be  felt  by  the  examining  finger.  On 
passing  the  hand  into  the  vagina,  which  was  full  of  clot, 
he  found  his  fingers  to  impinge  directly  upon  the  sacrum 
and  the  iliac  vessels  pulsating  feebly.  It  was  evident 
then  that  the  vagina  was  torn  badly  on  its  posterior 
aspect.  The  cord  passed  through  the  rent,  and  it  appeared 
that  the  tear  involved  also  the  lower  relaxed  segment  of 
the  uterus,  for  though  it  was  impossible  to  distinguish 
vagina  from  this  lower  zone  of  the  uterus,  the  tear  appeared 
to  start  from  the  contracted  portion  of  the  uterus.  By 
external  palpation  the  placenta  appeared  to  be  in  Douglas's 
pouch,  and  it  was  pressed  down  externally  till  it  could  be 
felt  in  the  vagina,  and  was  then  withdrawn. 

The  patient  was  by  this  time  extremely  collapsed,  very 


RUPTURED  UTERUS  AND  VAGINA.  253 

feeble,  pulse  140,  very  restless,  and  vomiting,  and  evi- 
dently would  not  live  long,  so  tliat  even  supposing  the 
rupture  was  such  as  to  have  indicated  abdominal  section 
it  would  have  been  impossible.  He  determined,  therefore, 
to  use  an  intra-venous  injection  of  salt  and  water.  Coal 
was  borrowed  to  boil  some  water  (2  a.m.  in  September), 
which  unfortunately  became  sooty,  there  being  no  lid  to 
the  saucepan,  and  a  lump  of  salt  was  at  last  found.  He 
injected  into  the  median  cephalic  vein  about  two  pints  of 
this  warmed  solution  with  Richardson's  admirable  appa- 
ratus, which  was,  he  thought,  the  best  for  the  purpose.  In 
ten  minutes  the  patient  felt  quite  comfortable,  pulse  96, 
and  after  a  hypodermic  injection  of  morphine  and  bella- 
donna had  a  quiet  night.  Next  morning  she  was  removed 
to  Middlesex  Hospital,  Charing  Cross  Hospital  being 
closed  for  repairs,  and  Dr.  Boxall  did  all  that  could  be 
done  to  save  her  life,  but  she  developed  septic  pleurisy 
and  a  parotid  bubo,  and  died  on  the  eighth  day. 


254 


THE  VALUE  OF  ABDOMINAL  SECTION  IN 
CERTAIN  CASES  OF  PELVIC  PERITONITIS, 
BASED  ON  A  PERSONAL  EXPERIENCE  OF 
FIFTY    CASES. 

By  Charles  J.   Cullingworth,  M.D.,  F.R.C.P. 

(Received  Sept.  19th,  1891,  and  Feb.  20th,  1892.) 
(Abstract.) 

The  question  considered  in  this  paper  is  whether  surgical 
interference  is  or  is  not  frequently  called  for  in  cases  of  pelvic 
peritonitis.  The  author  answers  this  question  in  the  affirmative, 
and  supports  his  opinion  by  a  detailed  record  of  fifty  cases  in 
which  he  has  himself  operated.  The  paper  is  accompanied  with 
a  table,  showing  for  each  case  the  symptoms,  the  physical  signs, 
the  diagnosis,  the  actual  condition  disclosed  at  the  operation,  the 
nature  of  the  operation  performed,  and  the  results,  immediate 
and  (where  possible)  remote.  The  cases  are  arranged  in  the 
order  of  their  occun*ence,  their  classification  being  reserved  for 
the  concluding  part  of  the  j^aper.  This  method  seems  to  be 
the  best  suited  for  showing  the  gradual  development  of  the 
author's  present  views  and  practice,  and  at  the  same  time  serves 
to  emphasise  the  fact  that  a  correct  classification  can  only  be 
made  after  the  diagnosis  has  been  tested  by  actual  inspection  of 
the  diseased  parts. 

The  cases  include  the  whole  of  the  author's  experience  of  the 
operation  up  to  the  end  of  February,  1891,  and  are  classified  as 
follows : 

Suppurating  salpingitis  .  .  .  .  .  .20 

Non-snj)purating  salpingitis,  including  six  cases  complicated  with 
suppurating  ovarian  cyst     .  .  .  .  .  .12 

Tuberculai"  disease  of  Fallopian  tubes  .  .  .  .2 


ABDOMINAL    SECTION    IN    PELVIC    TERITONITIS. 


255 


Pelvic  abscess,  seat  undetermined  .... 
PeduncuLited  retro-peritoneal  cyst,  with  abscesses  in  walls  . 
Tubercular  abscess  in  abdominal  wall,  with  masses  in  pelvis  (tuber 

cular  glands)  and  miliary  tubercle  of  peritoneum  . 
Hematocele    ....... 

Hcematosalpinx  with  bsematocele        .... 

Haematoma  of  broad  ligament  .... 

Broad  ligament  cysts : 

(a)  With  ovaritis  2  "1 

(J)  With  hydrosalpinx  1  J 
Encysted  peritonitic  effusion  ..... 
Retroflexed  uterus  with  fibroids  .... 


1 
1 

50 


Pelvic  peritonitis  was  common  to  all  the  cases  except  the 
last-named  (Case  32),  in  which  an  erroneous  diagnosis  was 
made. 

The  cases  of  suppurating  salpingitis  are  subdivided  as 
follows : 


(o)  With  occlusion  (pyosalpinx)  (Cases  7,  15,  30,  40,  43) 

(b)  With  distal  end  open  (Cases  16  and  36)  .  . 

(c)  With  suppurative  disease  of  the  ovary  (Case  37) 

(d)  With  a  direct  communication  between  the  tube  and  a  suppurat 

ing  cyst  of  tlie  adjacent  ovary  (suppurating  tubo-ovarian  cyst) 
(Cases  17,  18,  20,  25,  33,  50)    . 

(e)  With  non-suppurating  cystic  ovary  (Case  27) 
(_/")  With  suppurating  haematocele  (Case  14) 
(ff)  With  hydrosalpinx  (Cases  9  and  45) 
(A)  With  intra-peritoneal  abscess  (Cases  28  and  49) 


6 
1 
1 

2 

2 

20 


The  cases  of  non-suppurating  salpingitis  are  subdivided  as 
follows : 


(a)  Uncomplicated  cases  (Cases  19  and  24)   . 

(b)  With  suppurating  ovarian  cyst  (Cases  4,  12,  26,  89,  41,  48) 

(c)  With  non-suppurating  ovarian  cyst  (Cases  35  and  46)  • 

(rf)  With  hsematosalpinx  and  hemorrhagic  ovarian  cyst  (Case  2) 
(c)  With  double  haematocele  (Case  11) 


2 

6 
2 

1 
1 

12 


Pelvic  suppuration  was  present  in  thirty  cases,  or  60  per  cent. 
It  occurred  in  the  Fallopian  tube  alone  in  thirteen  cases,  in  the 
ovary  alone  in  six  oases,  in  both  tube  and  ovary  in  seven  cases 


256  VALUE    OF   ABDOMINAL    SECTION    IN 

(in  six  of  wliich  tube  and  ovary  were  in  direct  communication), 
while  in  the  remaining  four  cases  the  seat  of  suppuration  was 
either  not  precisely  determined  or  did  not  involve  either  the 
tube  or  the  ovary. 

There  was  strong  piresumptive  evidence  of  gonorrhoja  in  a 
large  proportion  of  the  cases,  and  in  at  least  five  cases  the  proof 
seemed  complete. 

Nine  of  the  cases  died,  a  mortality  of  18  per  cent.  Seven  of 
the  deaths  were  due  to  peritonitis,  probably  septic,  one  to  acute 
nephritis,  and  one  to  collapse  on  the  eleventh  day. 

Of  the  fatal  cases  one  was  tubercular  disease  of  the  tubes,  two 
were  purulent  salpingitis,  one  was  double  salpingitis  with  old 
hsemorrhage,  two  were  suppurating  tubo-ovarian  cysts,  one  was 
retro-peritoneal  suppurating  cyst,  two  were  old  peritonitis  with 
serous  cysts  of  broad  ligament. 

As  experience  increased,  the  mortality  became  sensibly  dimin- 
ished. 

Hsemorrhage,  to  a  greater  or  less  extent,  existed  in  tvs^elve  of 
the  thirty-two  cases  of  salpingitis.  In  five  cases  there  was 
amenorrhcea,  in  three  dysmenorrhcea,  whilst  in  twelve  the 
menstrual  function  was  undisturbed. 

In  sixteen  cases  the  removal  of  the  appendages  was  complete, 
in  twenty-three  partial.*  Of  the  former,  fifteen  recovered ;  of 
the  latter,  seventeen. 

The  peritoneum  was  flushed  in  twenty-two  cases,  of  which 
eighteen  recovered. 

Drainage  was  employed  in  forty-seven  out  of  the  fifty  cases. 

In  two  cases  a  faecal  fistula  formed,  which  in  each  instance 
healed  spontaneously. 

In  five  cases  the  patients  complained  some  time  after  the 
operation  of  more  or  less  persistent  pain. 

A  sinus  .existed  in  two  of  the  cases  when  the  patients  were 
last  seen. 

In  four  cases  a  hernia  has  occurred  in  the  line  of  incision. 

Attention  is  called  to  the  unreliability  of  the  temperature  as  a 
sign  of  the  existence  of  pelvic  suppuration,  the  temperature 
before  operation  having  been  absolutely  normal  in  twelve  of  the 
thirty  cases  in  which  suppuration  was  piesent. 

*  By  "complete  "  is  here  meant  bilateral,  and  by  "partial  "  unilateral. 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  257 

In  the  course  of  the  remarks  appended  to  each  case  the  fol- 
lowing incidental  propositions  are  laid  down,  either  directly  or 
by  inference  : 

1.  Recurrent  attacks  of  pelvic  peritonitis  in  the  female  ought 
always  to  lead  to  a  strong  suspicion  of  the  existence  of  chronic 
disease  of  the  uterine  appendages,  and  to  careful  bimanual 
examination. 

2.  Purulent  collections  in  the  pelvis  are  particularly  apt  to 
set  up  recurrent  peritonitis,  and  ai-e  more  common  than  is 
usually  supposed. 

,  3.  Where  distinct  swellings  are  found  in  the  posterior 
quarteis  of  the  pelvis,  in  connection  with  recurrent  attacks  of 
pelvic  peritonitis,  surgical  relief  is  usually  indicated,  and,  gene- 
rally speaking,  the  sooner  such  relief  is  afforded  the  better. 

4.  Purulent  inflammation  of  the  mucous  membrane  of  the 
Fallopian  tube  differs  from  purulent  inflammation  of  other 
mucous  membranes  in  the  absence,  owing  to  the  anatomical 
situation  of  the  Fallopian  tubes,  of  a  natural  outlet  for  the  pus. 
A  very  slight  amount  of  swelling  of  the  mucous  membrane 
suffices  to  block  the  tube  at  its  uterine  end,  and  if  pus  be  pre- 
sent in  the  tube,  it  must  then  either  remain  pent  up  in  the  tube, 
•or  be  poured  out  through  the  fimbriated  end  into  the  peritoneum, 
in  either  case  becoming  a  source  of  danger. 

5.  Salpingitis  being  a  painless  affection,  the  wall  of  a  pyo- 
salpinx  may  be  on  the  point  of  perforation  before  an  acute 
attack  of  peritonitis  gives  warning  of  the  presence  of  serious 
disease. 

6.  It  is  safer  to  attack  cases  of  pelvic  suppuration  from  above 
than  from  below. 

7.  Suppurating  tubo-ovarian  cysts  are  usually  the  result  of 
ulceration  on  the  tubal  side  of  the  adhesion  between  tube  and 
ovary,  but  in  exceptional  cases  result  from  ulceration  on  the 
ovarian  side. 

8.  The  immediate  results  are  more  satisfactory  after  complete 
(bilateral)  than  after  partial  (unilateral)  operations. 

9.  One  of  the  chief  risks  in  the  operation  for  the  separation 
and  removal  of  inflamed  tubes  is  the  liability  to  mistake 
thickened  and  adherent  intestine  for  diseased  tube.  The  way 
to  avoid  error  is  to  trace  the  tube  from  its  uterine  end  outwards. 


258  VALUE    OF    ABDOMINAL    SECTION    IN 

10.  The  exce2:»tional  instances  in  which  pain  persists  after 
operation  for  gross  lesions  of  the  uterine  appendages  are  gene- 
rally to  be  explained  either  by  omental  or  intestinal  adhesions, 
or  by  the  co-existence  with  the  actual  disease  of  a  neurotic  con- 
dition, of  which  the  pelvic  pain  is  a  mere  local  expression. 

11.  Tubal  disease  in  the  virgin  is  generally,  if  not  always, 
tubercular. 

12.  Hydrosalpinx,  in  the  great  majority  of  cases,  is  merely  a 
form  of  retention-cyst,  due  to  occlusion  of  the  distal  end  of  the 
tube  from  without. 

13.  Simple  collections  of  serum,  both  large  and  small,  are  apt 
to  form  beneath  the  peritoneum  covering  the  tiibe  and  broad 
ligament  in  chronic  cases  of  pelvic  inflammation,  especially  in 
those  of  very  long  standing.  Probably  the  best  treatment  of 
these  cysts,  after  exposing  them  and  making  certain  of  the 
diagnosis  by  abdominal  section,  is  simj^le  puncture  and  evacua- 
tion, the  risk  of  removal  being,  in  the  author's  experience,  out 
of  proportion  to  their  importance. 

14.  Haematosalpinx,  though  no  doubt  due,  in  the  majority  of 
cases,  to  tubal  gestation  with  apoplexy  of  the  ovum,  is  some- 
times an  incident  in  the  course  of  a  chronic  salpingitis.  In 
these  exceptional  cases  the  walls  of  the  distended  tube,  instead 
of  being  attenuated  by  the  distension,  as  Bland  Sutton  has 
shown  them  to  be  in  tubal  gestation,  are  thickened  by  inflam- 
matory deposits. 


Part  I. — Cases  1  to  25. 

This  paper  is  offered  as  a  contribution  towards  the 
settlement  of  a  question  that  has  been  for  several  years 
hotly  debated,  both  in  this  country  and  in  America^ 
namely,  whether  surgical  interference  is  or  is  not  fre- 
quently called  for  in  cases  of  pelvic  inflammation. 

The  discussion  has,  in  this  country,  recently  assumed 
a  phase  that  makes  it  incumbent  on  those  of  us  who  have 
any  evidence  to  bring  forward  to  do  so  with  as  little 
delay  as  possible.  I  propose,  in  this  communication,  to 
approach  the  subject  solely  from  the  point  of  view  of  my 


CERTAIN    CASES    OP    TELVIC    PERITONITIS.  259 

own  experience,  an  experience  that,  I  venture  to  think, 
is  now  sufficiently  extensive  to  justify  me  in  laying  my 
results  before  the  Society. 

It  has  been  a  matter  of  much  difficulty  to  decide  in 
what  order  the  cases  should  be  arranged.  All  things 
considered,  it  has  appeared  to  me  best  to  present  them 
in  the  order  of  their  occurrence.  By  this  plan  the 
Society  will  be  enabled  to  follow  the  steps  by  which  I 
have  been  gradually  led  to  the  adoption  of  my  present 
views,  and  to  judge  how  far  those  views  are  warranted 
by  the  teachings  of  my  own  experience.  Moreover  any 
attempt  at  classification  must  necessarily  be  based  upon 
knowledge  obtained  during  the  operation,  and  would 
therefore  fail  to  convey  a  correct  impression  of  the  diffi- 
culty of  the  problem  that  confronts  us  at  the  bedside  and 
in  the  consulting-room.  If  these  cases  could  all  be 
accurately  diagnosed  and  classified  before  operation,  our 
task  would  be  much  easier. 

But  although  great  advances  have  recently  been  made 
in  the  diagnosis  of  intra-pelvic  disease,  the  most  experi- 
enced amongst  us  will  acknowledge  that  it  is  not  yet 
possible  to  make  out  the  precise  condition  of  the  parts  in 
every  case  of  pelvic  inflammation.  We  cannot  even 
always  distinguish  with  certainty  between  purulent  and 
non-purulent  cases.  If  we  could,  the  scope  of  the  dis- 
cussion would  be  much  narrower.  Indeed,  I  am  inclined 
to  think  that  we  should  then  all  agree.  In  the  mean- 
time we  must  take  things  as  they  are,  and,  recognising 
onr  deficiences  both  in  knowledge  and  in  power  of 
observation,  make  allowance,  in  any  rules  we  may  lay 
down,  for  occasional  errors  of  diagnosis. 

I  am  sorry  to  have  to  burden  my  paper  with  the  details 
of  so  many  cases.  But  without  details  the  communica- 
tion, regarded  as  a  piece  of  evidence,  would  be  worthless. 
In  the  accompanying  table  are  presented  the  main 
points  in  each  case,  viz.  the  circumstances  that  induced 
me  to  operate,  the  nature  of  the  operation,  the  actual 
condition  found,  and  the  result. 


260  VALUE    OF    ABDOMINAL    SECTION    IN 

Several  of  the  earlier  cases  have  already  appeared  in 
print.  The  inclusion  of  these  in  the  tables  requires  no 
apology,  but  the  fact  that  some  of  them  are  again  related 
with  full  details  in  the  paper  itself  seems  to  call  for  a  few 
words  of  explanation.  I  should  have  been  glad,  both  for 
the  sake  of  shortening  my  paper  and  avoiding  repetition, 
to  omit  them ;  but  the  object  of  this  communication 
being  to  present  a  complete  and  faithful  history  of  my 
personal  experience,  it  seemed  to  me  better  to  tell  the  story 
of  some  of  my  cases  over  again,  than,  by  omitting  them,  to 
mar  the  completeness  and  so  lessen  the  value  of  the  record. 

With  the  exception,  therefore,  of  five  cases  (of  which 
the  particulars  have  been  published  quite  recently,  and 
the  references  to  which  are  given  in  the  table),  this  paper 
includes,  in  more  or  less  detail  (sufficient,  I  hope,  for 
purposes  of  criticism  and  discussion),  an  account  of  every 
case  in  which  I  performed  abdominal  section  for  the  relief 
of  pelvic  inflammation  up  to  the  end  of  February,  1891. 

I  had  been  operating  for  nearly  twelve  years,  in  cases 
of  ovarian  and  other  abdominal  tumours,  before  I  ven- 
tured to  open  the  abdomen  in  a  case  of  intra-pelvic 
disease  where  there  was  no  abdominal  tumour.  There 
had  been  for  some  time  a  growing  conviction  in  my  mind 
that  such  operations  ought  to  be  undertaken  ;  but,  being 
somewhat  slow  to  take  up  new  methods  of  treatment,  it 
was  several  years  before  conviction  ripened  into  action. 
At  length  a  typical  case  presented  itself. 

Case  1.*  Symptoms  of  pelvic  peritonitis  for  six  years ; 
swelling  on  both  sides  of  the  uterus,  more  marked  on  right ; 
abdominal  section  ;  chronic  ovaritis  on  right  with  polycystic 
tumour  of  each  broad  ligament ;  removal  of  tumours  and 
of  right  tube  and  ovary  ;  recovery  ;  pain  entirely  relieved. 
— Annie   McC — ,    aged    25,    applied    at    the    out-patient 

*  An  account  of  this  and  the  followint^  case  was  published  in  a  paper 
entitled  "  Abdominal  .Section  for  the  Kemoval  of  Small  Intra-pelvic  Tumours 
of  the  Ovaries  and  Adjacent  Parts,  with  Notes  of  Two  Cases,"  '  Brit.  Med. 
Journ.,'  January  30th,  1886. 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  261 

department  of  St.  Mary's  Hospital,  Manchester,  on 
account  of  constant  pain  and  sensation  of  weight  in  the 
lower  part  of  the  abdomen,  rendering  her  quite  unable  to 
continue  her  calling  as  a  dressmaker.  She  was  married 
at  the  age  of  seventeen,  had  never  been  pregnant,  and 
had  now  been  a  widow  for  three  years.  The  pain  com- 
menced six  years  ago,  and  had  continued  ever  since  with 
one  or  two  short  intervals ;  it  was  most  severe  on  the  left 
side.  She  had  consulted  several  eminent  gynfecologists 
in  London,  and  had  at  one  time  been  a  patient  at  the 
Chelsea  Hospital,  where  she  obtained  considerable  tem- 
porary relief.  But  the  symptoms  returned  when  she 
resumed  her  ordinary  life,  and  increased  in  severity  from 
year  to  year  until,  twelve  months  ago,  she  found  she  was 
unable  to  maintain  the  sitting  posture  sufficiently  long 
to  continue  her  occupation.  During  the  last  six  months 
she  had  earned  what  she  could  as  an  artist's  model.  She 
had  an  anaemic  and  careworn  appearance,  and  her  general 
health  was  evidently  becoming  impaired. 

On  bimanual  examination  of  the  pelvis,  a  firm,  rounded, 
tender  swelling  was  felt  to  the  right  of  and  slightly 
behind  the  uterus  ;  the  uterus  itself  was  normal  in  size 
and  position.  The  patient  attended  the  outdoor  depart- 
ment for  about  seven  weeks,  and,  as  she  did  not  in 
any  way  improve,  I  suggested  an  exploratory  incision, 
with  a  view  to  removing  the  disease,  if  it  were  found 
practicable.  As  her  life  was  a  burden  to  her,  and  she 
was  unfit  for  any  kind  of  work,  she  readily  consented  to 
run  the  risk  of  the  operation  ;  and  accordingly  I  admitted 
her  as  an  in-patient  on  May  11th,  1885,  and  explored  the 
abdomen  with  antiseptic  precautions  on  the  13th. 

I  expected  to  find  a  chronically  inflamed  and  enlarged 
ovary  on  the  right  side,  and  an  inflamed  and  adherent 
ovary  without  marked  enlargement  on  the  left.  What  I 
did  find  was  as  follows  :  on  the  right  side  a  chronically 
inflamed  and  adherent  ovary  of  the  size  of  a  walnut,  and 
in  addition  to  this  a  firm  tumour  of  the  broad  ligament, 
of  the  size  of  a  closed  fist,  consisting  of  a  compact   mass 


262  VALOE    OP    ABDOMINAL    SECTION    IN 

of  exceedingly  small  cysts  ;  on  the  left  side  another  broad 
ligament  tumour,  of  similar  character  to  that  on  the  right 
side,  but  smaller.  The  left  ovary  was  apparently  healthy. 
I  enucleated  both  the  broad  ligament  tumours,  and  re- 
moved the  right  ovary  with  part  of  the  Fallopian  tube, 
leaving  the  left  ovary  and  tube  undisturbed.  The  opera- 
tion was  rendered  somewhat  difficult  by  numerous  very 
firm  adhesions.  A  glass  drainage-tube  was  inserted  and 
left  in  for  forty-eight  hours.  The  temperature  rose  to 
102°  F.  in  the  evening  of  the  day  of  operation,  but  soon 
fell  to  100°  F.  ;  and  although  it  rose  on  the  morning  of 
the  fifth  day,  and  again  on  the  morning  of  the  sixth  day, 
to  101°  F.,  it  did  not  again  occasion  the  least  anxiety, 
and  the  patient  made  an  excellent  recovery. 

I  saw  her  seven  months  later.  Her  only  complaint 
then  was  that  she  menstruated  too  frequently.  She  had 
lost  her  anaemic  appearance,  and  had  become  stout  and 
well,  and  being  entirely  relieved  of  her  pain,  she  was  now 
able  to  follow  in  comfort  her  occupation  as  a  dressmaker. 

It  will  be  observed  that,  in  this  case,  two  small  tumours 
were  found,  one  in  each  broad  ligament.  But  as  these 
were  not  diagnosed,  and  the  operation  was  performed 
under  the  impression  that  the  whole  of  the  mischief  was 
of  inflammatory  origin,  the  case  is  evidently  entitled  to  a 
place  in  this  series.  No  mention  is  made  of  the  condition 
of  the  tubes.  I  was  not  at  that  time  alive  to  the  impor- 
tance of  tubal  inflammation  as  a  precursor  of  pelvic 
peritonitis.  As  often  happens,  the  pain  was  on  the 
opposite  side  to  that  on  which  the  disease  was  most 
marked.  This  is  a  clinical  fact  that  I  am  unable  to  ex- 
plain. I  am  content  to  know  that  the  pain  disappeared 
when  the  disease  was  removed. 

Case  2.  Severe  dysmenorrhoea  for  seven  years;  con- 
tinuous pain  with  hsemorrhage  for  two  months  ;  tender,  firm, 
ohlong  swelling  on  right  side  displacing  uterus  to  left ;  ab- 
dominal section  ;  hlood-cyst  of  right  ovary,  smaller  cyst  of 
left ;    chronic   inflammation  of  right   tube,   tvith  hxmato- 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  263 

salpinx,  left  tube  healthy ;  both  ovaries  and  right  tube 
removed ;  recovery. — Mary  M — ,  aged  26,  married  to  a 
winder  in  a  cotton  mill,  was  admitted  into  St.  Mary's 
Hospital,  Manchester,  on  September  25th,  1885,  com- 
plaining of  continuous  pain  in  the  lower  part  of  the 
abdomen,  especially  on  the  right  side  and  down  the  right 
thigh.  The  pain  had  existed  for  seven  years,  commenc- 
ing soon  after  the  birth  of  her  only  child.  At  first  it 
only  came  on  immediately  before  each  menstrual  period, 
but  even  then  it  was  so  severe  while  it  lasted  that  she 
was  rendered  unfit  for  work.  During  the  last  two  months 
the  pain  had  been  severe  and  continuous,  and  there  had 
been  persistent  hsemorrhage  from  the  uterus. 

The  patient  on  admission  was  thin  and  anaemic,  with 
a  haggard  and  pinched  countenance,  betokening  much 
suffering.  On  bimanual  examination  of  the  pelvis  the 
right  side  was  found  to  be  occupied  by  an  oblong,  firm 
swelling,  very  tender  to  the  touch,  pushing  over  the 
uterus  to  the  left  of  the  middle  line.  The  diagnosis  was 
uncertain,  but  I  thought  it  most  probable  that  there  was 
distension  of  the  right  Fallopian  tube.  The  hot  douche 
and  absolute  rest  were  found,  at  the  end  of  a  fortnight, 
not  to  have  resulted  in  the  least  relief  ;  and  accordingly, 
the  risk  having  been  explained  to  the  patient,  an  explora- 
tory incision  was  made  in  the  middle  line  of  the  abdomen 
on  October  7th.  The  right  ovary  was  found  to  be 
enlarged  to  the  size  of  a  hen^s  egg,  and  to  be  cystic  ;  the 
contents  of  the  cyst,  which  escaped  during  removal,  con- 
sisted of  dark  fluid  blood  altered  by  long  retention. 
Closely  connected  with  the  diseased  ovary  was  a  thick 
fusiform  swelling,  consisting  of  the  Fallopian  tube  dis- 
tended with  blood,  partly  fluid  and  partly  clotted,  the 
walls  of  the  tube  being  much  thickened  by  chronic 
inflammation,  and  firmly  adherent  externally  to  a  coil  of 
small  intestine.  After  carefully  separating  the  adhesions 
the  tube  and  ovary  were  both  removed,  the  ligature  being 
placed  close  to  the  uterus.  The  left  ovary  was  also  found 
to   be    enlarged   from    incipient    cystic   disease,   and  was 


264  VALUE  OP  ABDOMINAL  SECTION  IN 

accordingly  removed.  The  tube  on  the  left  side  was 
healthy.  A  glass  drainage-tube  was  inserted  at  the  lower 
angle  of  the  wound,  and  was  allowed  to  remain  until  the 
fourth  day.  The  patient  made  an  excellent  recovery,  the 
temperature  only  once  rising  to  100°  F.  She  had  some 
pain  about  a  fortnight  after  the  operation,  but  it  soon 
passed  off,  and  in  the  month  of  December  she  had  become 
entirely  free  from  pelvic  discomfort,  and  was  able  to  go 
about  as  usual. 

This  was  a  case  of  chronic  unilateral  salpingitis,  in  the 
course  of  which  haemorrhage  had  occurred,  distending  the 
tube  with  blood.  Such  cases  are  distinguished  from 
hsematosalpinx  due  to  apoplexy  of  the  ovum  in  a  tubal 
gestation,  not  only  by  the  discoveiy  of  chorionic  villi 
in  the  latter,  but  also  by  the  condition  of  the  walls  of 
the  tube,  which  in  cases  of  haemorrhage  due  to  tubal 
gestation,  are,  as  Bland  Sutton  has  pointed  out,^  abnor- 
mally thin  instead  of  being  abnormally  thick.  In  the 
one  there  is  simple  distension  with,  at  the  most,  some 
turgescence ;  in  the  other  there  is  inflammation  as  well 
as  distension.  The  co-existence,  in  cases  of  inflammatory 
haematosalpinx,  of  blood-cysts  in  the  adjacent  ovary  is  by 
no  means  infrequent.  Several  additional  examples  will 
be  given  in  the  course  of  this  paper. 

Case  3.  Recurrent  pelvic  peritonitis  for  ten  years ; 
constant  pain  in  left  iliac  region  and  bach,  with  discharge 
of  hlood  from  rectum  and  pain  on  defsecation,  for  Jive 
years  J  thiclcening  in  situation  of  both  broad  ligaments ; 
prolapsed  and  adherent  left  ovary ;  abdominal  section ; 
chronic  pelvic  peritonitis,  ovaries  normal,  adherent;  left 
broad  ligament  thickened,  right  tube  distended  with  sermn, 
three  cysts  in  right  broad  ligament ;  cysts  and  right  tube 
*  "  It  is  a  fact  important  to  be  remembered  that  when  a  Fallopian  tube 
becomes  distended  by  fluid  Mccumulations,  or  even  by  an  impregnated  ovum 
developing  within  it,  the  walls  of  the  tube  gradually  thin.  In  this  respect 
the  tubes  are  in  striking  contrast  with  the  uterus." — "  Lecture  on  the  Value 
of  Comparative  Pathology  to  Philosophical  Surgery,"  '  Brit.  Med.  Journ.,' 
February  21st,  1891,  p.  398. 


CERTAIN  CASES  OP  PELVIC  PERITONITIS.       265 

removed ;  death  ;  autopsy. — J.  R — ,  aged  35,  married, 
housekeeper,  was  admitted  into  St.  Mary's  Hospital, 
Manchester,  January  12th,  1886,  on  account  of  severe 
pain  in  left  iliac  region.  She  had  been  married  eighteen 
years,  and  had  borne  two  children,  the  last  one  fifteen 
years  ago.  Her  health  had  been  exceedingly  good  up 
to  ten  years  ago,  when  she  had  an  attack  of  peritonitis, 
and  was  confined  to  bed  altogether  for  about  five  months. 
She  had  a  considerable  quantity  of  vaginal  discharge  and 
also  a  good  deal  of  bleeding  and  purulent  discharge,  from 
the  bowel.  A  year  or  two  later  she  began  to  suffer 
severe  pain  in  the  left  iliac  region.  At  first  this  only 
came  on  immediately  before  each  menstrual  period  ;  after 
a  short  time  it  became  constant,  though  it  was  always 
worse  at  the  periods.  Five  years  ago  she  was  again  laid 
up  for  a  considerable  time.  On  leaving  the  hospital  she 
became  an  out-patient,  and  she  has  attended  more  or  less 
regularly  ever  since.  The  pain  has  gradually  become  more 
severe  and  constant,  and  is  felt  in  the  back  as  well  as  the 
iliac  region.  The  patient  has  been  entirely  unable  to 
undertake  ordinary  housework  for  several  years,  and  her 
suffering  is  often  exceedingly  severe.  Lately  she  has 
lost  flesh.  Menstruation  is,  for  the  most  part,  regular ; 
during  the  last  month  there  has  been  some  irregular 
hsemorrhage. 

On  admission  there  is  nothing  abnormal  to  be  detected 
on  examination  of  the  abdomen. 

Per  vaginam,  os  uteri  patulous,  old  laceration  of  cervix 
on  left  side.  Uterus  retroverted  and  slightly  displaced 
to  right  ;  swelling  in  Douglas's  pouch  consists  of  corpus 
uteri.  The  left  broad  ligament  gives  the  sensation  of 
being  thickened,  and  a  small  body,  tender  to  the  touch, 
is  felt  behind  it,  close  to  the  uterus.  There  is  very 
slight  thickening  in  the  region  of  the  right  broad  liga- 
ment ;  a  soft  cord  can  be  felt,  like  the  Fallopian  tube. 
The  diagnosis  was  chronic  ovaritis  of  left  side,  with 
extensive  adhesions.  The  abdomen  was  opened  on  the 
13th  of  January.      The  contents  of  the  pelvis  were  much 

VOL.  XXXIV.  20 


266  VALUE    OP    ABDOMINAL    SECTION    IN 

matted.  The  uterus  was  retroverted  and  fixed  hj  adhe- 
sions. There  was  no  cyst  or  tumour  detected  on  the  left 
side.  Both  ovaries  appeared  to  be  normal.  In  the 
right  broad  ligament  three  cysts  were  found  of  varying 
size,  the  largest  being  about  equal  in  size  to  a  goose's 
egg.  The  smallest  cyst  appeared  to  be  in  direct  com- 
munication with  the  interior  of  the  Fallopian  tube,  which 
was  distended  with  serum.  The  parts  removed  consisted 
of  the  tube  and  broad  ligament  cysts  from  the  right  side. 
A  drainage-tube  was  inserted,  and  the  wound  closed. 
There  was  a  good  deal  of  pain  and  a  little  sickness 
during  the  first  forty-eight  hours,  but  it  was  not  until 
the  morning  of  the  fourth  day  that  the  patient's  condition 
gave  rise  to  serious  anxiety.  The  temperature,  hitherto 
under  100°,  gradually  rose,  the  pulse  became  rapid,  and 
there  was  constant  retching.  She  died  a  little  after  midday. 
On  post-mortem  examination  the  following  day  the 
omentum  was  found  thickened  and  hyperaimic.  A  band 
passed  down  from  it  into  the  left  side  of  the  pelvis,  where 
it  was  firmly  adherent.  There  were  two  or  three  fluid 
ounces  of  blood-stained  serum  in  the  peritoneal  cavity, 
but  there  was  no  evidence  of  suppuration  there  or  else- 
where. The  pouch  of  Douglas  was  obliterated  by  the 
retroverted  and  adherent  uterus.  On  the  right  side 
there  was  a  large  adherent  blood-clot  just  above  the 
ligatui-e  ;  no  ovary  could  be  found  on  that  side.  On  the 
left  side  there  was  considerable  thickening  of  the  broad 
ligament ;  the  left  ovary  was  slightly  enlarged.  The 
intestines  were  considerably  distended,  their  sei'ous  coat 
showing  signs  of  commencing  inflammation.  There  was 
an  abrasion  of  the  outer  coat  of  the  ileum,  about  a  quarter 
of  an  inch  in  diameter,  situated  about  five  or  six  inches 
from  the  caecum.  Old  adhesions  existed  between  the 
coils  of  intestine  in  the  upper  part  of  the  abdomen  and 
between  intestine  and  omentum.  The  intestinal  canal 
was  opened  from  pylorus  to  rectum,  no  stricture  or  ulcer 
being  discovered.  The  liver,  kidneys,  spleen,  pancreas, 
and  stomach  showed  no  morbid  change. 


CERTAIN    CASKS    OF    PELVIC    PERITONITIS.  267 

In  this  case  I  was  surprised  not  to  find  evidence  of 
ovarian  inflammation.  As  a  matter  of  fact^  no  lesion  was 
found  sufticient  to  account  for  the  extensive  peritonitis. 
It  is  quite  possible  that  with  greater  experience  I  might 
have  been  able  to  recognise  and  remove  something  of 
greater  pathological  importance  than  a  few  subperitoneal 
cysts  and  a  tube  distended  with  serum.  For  I  know  of 
no  operation  in  which  experience  is  more  helpful  than  in 
this.  For  sevei*al  years  this  patient  had  been  my  faithful 
attendant  at  my  consulting  rooms,  and  the  disastrous  result 
of  the  operation,  which  I  was  most  unwilling  to  undertake, 
distressed  me  exceedingly. 

The  three  following  cases,  which  also  occurred  before 
I  left  Manchester,  were  fortunately  more  successful. 

Case  4.  Recurrent  pelvic  peritonitis  commencing  shortly 
after  marriage  three  years  ago  ;  constant  pain  for  two  years  ; 
inahility  to  vjork  ;  small,  fixed  sivelling  on  right  side  of 
uterus ;  abdominal  section ;  chronic  salpingitis  of  both 
sides;  small  siipjntrating  ovarian  cyst  on  right  j  left  ovary 
adherent,  otherwise  normal;  both  tubes  and  both  ovaries 
removed;  recovery;  complete  disappearance  of  pain. — Mary 
B — ,  aged  25,  married,  was  admitted  into  St.  Mary's 
Hospital,  Manchester,  April  20th,  1886,  complaining  of 
severe  pain  on  the  right  side  of  the  pelvis  and  less  severe 
pain  on  the  left,  also  of  a  bearing-down  sensation,  worse 
after  walking  and  at  the  menstrual  periods.  The  sym- 
ptoms commenced  a  few  weeks  after  her  marriage  three 
years  ago.  Two  years  ago  she  was  in  the  hospital  under 
my  care  for  some  weeks,  and  left  greatly  improved.  On 
resuming  her  household  duties,  however,  she  broke  down 
again  at  once,  and  for  two  years  the  pain  has  now  been 
constant,  entirely  unfitting  her  for  work.  She  has  never 
been  pregnant. 

The  uterus  is  normal  in  size,  mobility,  and  position.  In 
the  right  posterior  quarter  of  the  pelvis  is  a  mass  about  the 
si/iC  of  a  small  orange,  separated  from  the  uterus  by  a 
distinct  sulcus. 


268  VALUE    OF    ABDOMINAL    SECTION    IN 

The  general  liealtli  is  fairly  good  ;  the  temperature 
normal.      There  lias  recently  been  some  loss  of  flesh. 

The  diagnosis  was  dilated  right  tube.  Abdominal 
section  was  performed  April  30th. 

The  pelvic  viscera  were  densely  matted  ;  a  coil  of  intes- 
tine had  become  firmly  adherent  to  the  bladder.  Both 
Fallopian  tubes  were  thickened,  each  being  half  an  inch 
in  diameter.  The  right  ovary  was  enlarged,  its  length 
being  three  inches.  On  section  it  was  seen  to  contain 
two  main  cysts,  one  an  inch  in  diameter,  the  other 
two  inches.  The  larger  cyst  was  full  of  pus.  The 
left  ovary  was  normal,  but  universally  adherent.  Both 
tubes  and  both  ovaries  were  removed.  A  drainage- 
tube  was  inserted  and  retained  for  forty-eight  hours. 
Menstruation  commenced  on  the  third  day,  and  lasted 
until  the  seventh.  Pain  on  movement  of  the  right  leg 
was  complained  of  on  the  third  day.  Next  day  it  was 
worse,  but  from  that  time  it  gradually  diminished  and 
eventually  disappeared.  On  the  sixth  and  seventh  days 
there  were  hallucinations  of  sight  on  closing  the  eyes ; 
these  did  not  continue.  The  sutures  were  removed  and 
an  enema  of  olive  oil  was  given  on  the  sixth  day ;  the 
bowels  acted  freely  on  the  seventh.  The  temperature 
during  convalescence  never  exceeded  100°  F.,  and  the 
patient  was  in  due  course  discharged  well.  Six  months 
afterwards  she  presented  herself  looking  stout  and  well. 
The  pain  had  entirely  disappeared. 

On  October  26th,  1892,  in  reply  to  some  inquiries,  I 
received  from  the  patient's  medical  attendant  a  letter,  from 
which  the  following  is  an  extract : — "  The  pain  she  had  in 
the  right  iliac  region  has  not  troubled  her  since  the  opera- 
tion. The  pain  in  the  left  hip  continued  very  constant  until 
about  two  years  ago,  but  since  then  she  feels  it  only  after 
a  day's  washing.  She  had  rather  a  severe  flooding  about 
six  months  after  the  operation,  and  menstruated  three  or 
four  times  after  that  at  irregular  intervals.  She  has  not 
menstruated  now  for  two  years.  She  has  a  continuous 
yellow  discharge.      She  says  she  never  was  very  strong. 


CERTAIN  CASES  OF  PELVIC  PERITONITIS.        269 

and  at  present  considers  herself  as  well  as  ever  she  was. 
The  operation  has  certainly  converted  her  from  a  chronic 
invalid  into  a  woman  capable  of  performing  her  household 
duties." 

Case  5.  Fain  and  tympanitic  swelling  in  the  loiver 
part  of  the  abdomen,  commencing  with  an  acute  attach  ten 
weeks  before  admission ;  after  two  months'  rest  and  treat- 
ment  pain  diminished,  hut  swelling  increased ;  abdominal 
section  ;  large  abscess  in  peritoneal  cavity,  extending  deeply 
into  the  right  side  of  the  pelvis,  and  shut  off  by  adhesions  ; 
cavity  emptied,  washed  out,  and  drained ;  purulent  dis- 
charge for  several  months;  rapid  improvement  of  general 
health,  and  ultimately  complete  recovery. — M.  E.  B — ,  single, 
aged  21,  a  weaver,  was  admitted  into  St.  Mary's  Hospital, 
Manchester,  on  April  12th,  1887,  with  swelling  of  the 
lower  part  of  the  abdomen,  and  complaining  of  pain, 
especially  at  the  bottom  of  the  back.  The  pain  and 
swelliug  commenced  ten  weeks  previously,  at  the  end  of 
a  menstrual  period.      She  had  not  menstruated  since. 

The  lower  half  of  the  abdomen  was  uniformly  distended  ; 
there  was  no  fluctuation,  and  the  percussion  note  was  tym- 
panitic throughout.  No  distinct  tumour  could  be  felt. 
The  uterus  was  of  normal  size,  its  mobility  impaired. 
Nothing  could  be  made  out  as  to  the  condition  of  the 
uterine  appendages.  After  two  months'  rest  in  bed  the 
size  of  the  abdomen  had  rather  increased  than  diminished. 
A  distinct  ridge  could  be  felt  running  transversely  across 
the  abdomen  a  little  below  the  umbilicus. 

Abdominal  section  was  performed  June  8th,  1887.  On 
opening  the  peritoneal  cavity  the  omentum  was  found 
adherent  to  the  anterior  abdominal  wall,  and  tacked  down 
to  the  pelvis  along  its  entire  breadth.  With  much  diffi- 
culty the  right  border  of  the  omentum  was  separated  and 
raised  ;  it  was  then  found  that  all  the  pelvic  viscera  were 
matted  together  by  adhesions.  In  separating  these  the 
finger  passed  through  a  very  friable  membrane  into  a 
cavity,    from    which    there    escaped    a    quantity   of   thin 


270  VALUE    OF    ABDOMINAL    SECTION    IN 

sanious  pus,  mixed  with  flakes  of  lymph.  The  opening" 
was  enlarged,  and  the  fluid  soaked  up,  as  it  escaped,  by- 
means  of  sponges.  The  finger  was  then  introduced 
within  the  abscess  cavity,  which  dipped  in  the  most 
irregula^r  manner  here  and  there  amongst  the  viscera,  and 
was  evidently  a  portion  of  the  peritoneal  cavity  shut  off 
by  adhesions.  It  extended  a  considerable  distance  up- 
wards into  the  abdomen  and  downwards  into  the  rigrht 
side  of  the  pelvis.  The  bladder  formed  part  of  its  anterior 
wall.  The  cavity  was  washed  out  with  warm  water  ;  the 
edges  of  the  abscess  sac  were  secured  on  each  side,  as 
well  as  their  friable  character  permitted,  to  the  edges  of 
the  lower  part  of  the  abdominal  incision,  and  the  upper 
part  of  this  incision  was  closed.  A  drainage-tube  was 
left  in  the  sac.  The  uterus  and  appendages  were  not 
made  out.  There  was  some  rise  of  temperature  during 
the  first  week,  the  highest  record  being  101 '8°  F.  at  2 
a.m.  on  the  11th  June  (fourth  day).  On  the  third  day  the 
patient  passed  flatus  through  the  rectal  tube  and  was  able 
to  dispense  with  the  catheter.  Menstruation  commenced 
the  same  day  and  continued  until  the  sixth  day.  On  the 
fourth  day  a  discharge  of  offensive  pus  took  place.  The 
discharge  soon  lost  its  offensive  character,  but  its  quantity 
was  for  some  time  considerable.  In  the  meantime  the 
patient's  health  rapidly  improved.  In  a  fortnight  she  was 
sitting  up,  and  on  July  23rd  she  Avas  allowed  to  go  home 
for  a  few  days.  She  was  readmitted  on  August  17th, 
and  as  she  became  very  useful  as  a  ward  help  she  was 
kept  under  observation  for  three  months.  There  was 
still  some  purulent  discharge  from  a  small  sinus  when  she 
left  the  hospital  ;  this  continued  for  some  time,  and  finally 
cea.sed.  I  saw  her  in  August,  1892,  five  years  after  the 
operation.  She  was  then  in  excellent  health,  and  was 
menstruating  regularly.    She  had  been  married  two  years. 

Cask  6.  Metrorrhagia  and  pain  in  the  ahdoiiien  with 
hearing  down,  co'inmencing  tivo  months  after  marriage ; 
obscure  retro-uterine  swelling  reaching  to  umbilicus,  with 


CERTAIN    CASKS    OF    I'ELVIC    rElUTONlTlS,  271 

increasing  j)CLi'>^  ttiid  tenderness  and  occasional  rise  of  tem- 
perature ;  rest  and  hospital  treatment  for  nine  montJis 
without  relief;  abdominal  section;  large  intra-peritoneal 
abscess  ;  drainage ;  prolonged  suppiLration  ;  recover]]. — 
Eva  J — ,  aged  23,  married,  was  admitted  into  St.  Mary's 
Hospital,  Manchester,  on  January  19tli,  1887,  complaining 
of  irregular  hsemorrhage  and  a  sensation  of  bearing  down. 
The  symptoms  dated  from  a  few  weeks  after  her  marriage, 
which  took  place  six  months  ago.  She  attributed  them 
to  having  bathed  in  the  open  sea  during  menstruation. 
Three  months  ago  some  swelling  of  the  lower  part  of  the 
abdomen  was  observed,  and  she  was  thought  to  be  preg- 
nant. She  had  been  kept  in  bed  for  some  weeks  previous 
to  her  admission. 

On  admission  the  abdominal  walls  were  tense,  but  no 
definite  tumour  could  be  made  out.  There  was  dulness 
on  percussiun  from  pubes  upwards  to  within  an  inch  of 
the  umbilicus.  The  uterus  was  normal  in  length,  position, 
and  mobility.  She  had  an  attack  of  pain  in  the  hypo- 
gastrium  on  the  23rd  of  January,  and  was  treated  with 
poultices  and  the  hot  douche.  She  left  the  hospital  re- 
lieved on  March  5th,  and  was  readmitted  July  12th. 
Her  genei-al  health  had  greatly  improved,  and  the  bearing- 
down  sensation  had  almost  disappeared.  The  menstrual 
flow  had  taken  place  regularly.  She  was  examined 
under  an  anaesthetic  on  July  18th.  Behind  the  uterus, 
which  was  normal,  there  was  an  obscure  swelling  rising 
into  the  abdomen  nearly  as  high  as  the  umbilicus.  She 
went  home  again  on  the  23rd  July,  and  was  once  more 
admitted  on  September  22nd,  having  become  worse  ever 
since  leaving  the  hospital.  She  had  suffered  much  more 
abdominal  pain,  the  size  of  the  abdomen  had  increased, 
and  menstruation  had  been  irregular,  the  intervals 
varying  from  three  to  five  weeks.  The  temperature  was 
raised,  the  appetite  poor,  and  the  patient  was  incapable 
of  the  least  exertion. 

The  abdomen  was  swollen  and  tender,  the  muscles  of 
the  abdominal  wall  ri^id.      On   bimanual  examination  a 


272  VALUE    OP   ABDOMINAL    SECTION    IN 

large  fluctuating  swelling  could  be  felt  behind  the  uterus, 
filling  up  the  retro-uterine  pouch  and  rising  into  the  ab- 
domen nearly  to  the  umbilicus.  The  right  lateral  fornix 
was  depressed  by  a  firm  swelling.  No  decided  dulness  on 
percussion,  but  the  hypogastrium  and  part  of  each  iliac 
region  were  duller  than  the  rest  of  the  abdomen  ;  the 
flanks  were  resonant. 

Abdominal  section,  October  12th. — Immediately  beneath 
the  abdominal  wall,  and  adherent  to  it,  was  a  swelling 
with  a  covering  of  what  appeared  to  be  peritoneum. 
During  the  separation  of  the  adhesions  the  wall  of  the 
swelling  was  slightly  torn,  and  some  pus  oozed  out.  The 
opening  was  enlarged,  and  about  20  fl.  oz.  of  slightly 
fetid  yellowish-green  pus  escaped,  along  with  some  lymph- 
flakes.  The  fingers  were  now  passed  into  the  abscess- 
cavity,  which  was  found  to  be  very  extensive.  It  passed 
upwards  above  the  level  of  the  umbilicus,  and  dipped 
down  into  the  pelvis.  On  the  right  side  a  prolongation 
extended  to  the  pelvic  floor.  The  uterus  and  appendages 
were  not  made  out.  The  inner  surface  of  the  abscess 
wall  was  rough  in  places,  but  for  the  most  part  smooth 
and  uniform.  The  edges  of  the  opening  were  secured  to 
the  edges  of  the  middle  portion  of  the  abdominal  incision, 
and  the  incision,  above  and  below,  was  brought  together 
by  silkworm  gut  sutures.  A  glass  drainage-tube  was 
inserted  into  the  cavity  and  retained  there  for  seventy- 
two  hours,  an  india-rubber  tube  being  then  substituted. 

Convalescence  was  very  slow.  The  discharge  was  pro- 
fuse, and  as  it  became  offensive  the  cavity  was  washed 
out  daily  with  a  solution  of  potassium  permanganate. 
By  the  5th  of  November  the  general  health  had  begun  to 
improve,  and  the  amount  of  discharge  from  the  wound  to 
diminish.  When  she  went  home  on  the  10th  of  March, 
1888,  there  was  still  a  copious  discharge  from  the  sinus, 
which  continued  for  some  time.  When  I  last  heard  of 
her,  in  July,  1892,  four  years  and  three  quarters  after 
the  operation,  she  was  perfectly  well. 

It  is,  to  my  mind,  certain  that  in  each  of  these  three  cases 


CERTAIN    CASES    OP    PELVIC    PEKITONITIS.  273 

(4,  5,  and  G)  it  would  liave  been  better  to  operate  earlier. 
In  none  of  tbem  did  tbe  patient  derive  the  least  benefit 
from  the  delay.  On  the  contrary,  I  believe  that,  had  the 
abdomen  been  opened  when  the  patients  first  came  under 
observation,  there  would  have  been  much  less  suppuration 
subsequently,  and  convalescence  would  have  been  far  less 
prolonged.  It  is  the  experience  derived  from  such  cases 
as  these,  and  from  some  others  that  will  be  related  pre- 
sently, that  has  convinced  me  of  the  general  inexpediency 
of  delay.  If  sui'gical  relief  is  to  be  given,  the  more 
prompt  that  relief  the  better.  In  Case  4  two  years  were 
wasted,  in  Case  5  two  months,  and  in  Case  6  nine  months, 
not  to  speak  of  the  additional  waste  of  time  involved  in 
the  prolonged  convalescence. 

I  now  pass  on  to  the  cases  that  have  occurred  to  me 
since  I  removed  to  London.  The  first  of  these.  Case  7,  is 
one  that  had  been  in  the  ward  for  some  weeks  under  the 
care  of  my  predecessor. 

Case  7.  Pain  in  left  iliac  region  sixteen  months ; 
swelling  twelve  months  ;  amenorrhoea  six  montJts ;  ob- 
scurely fluctuating  tumour  pushing  uterus  to  right  ;  severe 
illness  icith  wasting  and  pyrexia ;  abdominal  section ; 
i^aseating  abscess  em^ptied  and  drained,  edges  secured  to 
<ibdominal  incision ;  rapid  improvement  in  health,  but 
sinus  persistent,  discharging  muco-pus  ;  sinus  dissected  out 
twenty-one  months  after  operation  ;  found  to  consist  of  left 
Fallopian  tube ;  recovery ;  small  sinus  remaining . — 
E.  F — ,  aged  25,  single,  a  servant,  was  admitted  into 
Adelaide  Ward,  St.  Thomas's  Hospital,  under  the  care 
of  Dr.  Gervis,  on  February  13th,  1888,  complaining 
of  a  swelling  in  the  left  iliac  region,  accompanied  with 
constant  pain  and  fever.  The  pain  commenced  in 
November,  188G,  and  the  swelling  was  noticed  in  February, 
1887,  being  then  equal  in  size  to  a  hen's  egg.  Men- 
struation, after  gradually  becoming  scanty,  ceased  in 
July,  1887. 

On   admission   she    was    very    ill.       Her   temperature, 


274  VALUE     OF    ABDOMINAL    SECTION    IN 

usually  ranging  between  99°  F.  and  101°  F.,  occasionally 
readied  102°  F.  and  103°  F.  She  was  losing  flesh,  and 
was  in  constant  pain.  There  was  a  tense,  hard,  ob- 
scurely fluctuating  tumour,  causing  a  slight  prominence 
in  the  left  lower  fourth  of  the  abdomen.  There  was 
dulness  on  percussion  ov^cr  it.  It  was  closely  connected 
with  the  uterus  ;  it  reached  in  height  from  the  pubic 
ramus  to  within  half  an  inch  of  the  umbilicus,  and  in 
width  from  the  left  lateral  wall  of  the  pelvis  to  an  inch 
and  a  half  beyond  the  middle  line  of  the  abdomen  on  the 
right. 

When  I  came  on  duty  at  the  end  of  March,  the  account 
given  to  me  was  that  the  patient  had  not  improved  during 
the  six  weeks  she  had  been  in  the  hospital ;  the  swelling 
and  pain  had  not  diminished,  and  the  loss  of  flesh  and 
pyrexia  had  been  continuous.  I  accordingly  determined 
to  make  an  exploratory  incision. 

Abdominal  section  was  performed  on  the  5th  of  Api'il, 
1888.  On  opening  the  peritoneal  sac  some  ascitic  fluid 
and  transparent  jelly-like  material  escaped.  The  tumour 
was  attached  to  the  uterus  (which  was  pushed  over  to 
the  right),  and  was  covered  Avith  peritoneum.  There 
were  no  adhesions  in  front  or  behind.  A  trocar  was 
inserted  and  3  fl.  oz.  of  pus  withdrawn.  The  open- 
ing was  then  enlarged  to  the  length  of  an  inch  and 
a  half,  and  the  finger  inserted.  The  wall  of  the  abscess 
cavity  was  5  in.  thick,  and  lined,  on  its  roughened  inner 
surface,  with  caseous  material,  of  which  as  much  as 
possible  was  pressed  and  scooped  out.  After  washing 
out  the  cavity  with  hot  boracic  solution,  and  the  peri- 
toneum with  simple  hot  water,  the  wall  of  the  abscess 
was  stitched  to  the  edges  of  the  abdominal  incision,  the 
rest  of  which  was  closed  by  sutures  of  silkworm  gut. 
An  india-rubber  drainage-tube  was  inserted  into  the 
cavity. 

Next  day  the  temperature  rose  to  102°,  and  the  pulse 
to  150.  On  the  third  day  the  temperature  ranged  from 
98-6°  to    101-2°;   on  the  fourth,   from  99°  to   100-4°;   on 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  275 

the  fiftb,  from  98-0°  to  101-6°;  and  on  the  sixth,  from 
98*4°  to  99°.      After  that  it  was  uniformly  normal. 

There  was  a  copious  discharge  of  pus,  and  three  weeks 
after  the  operation  a  quantity  of  cheesy  material  was  cast 
off  with  the  discharge.  After  the  first  five  days  the 
patient's  general  condition  quickly  and  permanently  im- 
proved. She  gained  flesh,  and  was  able  to  sit  up  in  bed 
at  the  end  of  a  fortnight.  In  a  month  the  tumour  had 
contracted,  its  upper  limit  being  2  in.  below  the  level 
of  the  umbilicus. 

She  left  the  hospital,  on  the  12th  of  July,  stout  and 
well,  but  still  wearing  the  drainage-tube.  The  sinus 
was  2i  in.  long,  and  about  3  fl.  oz.  of  muco-pus  escaped 
during  each  twenty-four  hours.  She  had  menstruated 
once. 

On  September  18th,  1888,  she  presented  herself  at  the 
hospital.  Her  condition  had  still  further  improved. 
She  still  wore  the  tube  ;  the  discharge  was  now  slight. 
She  had  menstruated  twice  since  leaving  the  hospital. 

At  the  beginning  of  1890  the  patient  was  still  wearing 
a  drainage-tube,  all  attempts  to  discard  it,  even  with 
curetting  of  the  sinus,  having  failed.  This  fact,  together 
with  the  continued  presence  of  mucus  in  the  discharge, 
convinced  me  that  the  abscess  was  not  in  the  connective 
tissue  of  the  broad  ligament,  as  was  thought  at  the  time 
of  operation,  but  in  a  cavity  lined  by  mucous  membrane. 
By  stitching  the  edges  of  the  abscess  wall  to  the  edges  of 
the  abdominal  incision,  a  fistulous  communication  had 
evidently  been  established  between  this  cavity  lined  by 
mucous  membraue  and  the  exterior.  It  seemed  to  me 
highly  probable  that  the  case  was  one  of  pyosalpinx, 
and  that  I  had  unintentionally  performed  the  operation 
of  salpingostomy. 

I  therefore  readmitted  the  patient,  and  on  the  14th 
January,  1890  (a  year  and  nine  months  after  the  opera- 
tion), the  sinus  was  carefully  dissected  out.  It  was 
found  to  consist  of  the  left  Fallopian  tube,  thickened,  but 
no  longer  dilated,  running  directly  forwards  from  the  left 


276  VALUE    OP   ABDOMINAL    SECTION    IN 

cornu  of  tlie  uterus,  which  had  become  twisted  half  round 
on  its  vertical  axis,  so  that  its  anterior  surface  looked  to 
the  right,  and  its  posterior  to  the  left.  The  tube  was 
removed  close  to  the  uterus,  the  exposed  mucous  mem- 
brane in  the  stump  being  cauterised  by  a  heated  iron 
skewer.  The  normal  right  tube  and  ovary  were  felt 
behind  the  uterus. 

The  last  time  I  saw  this  patient,  viz.  on  July  25th, 
1891,  she  was  strong  and  well,  although  there  was  still  a 
very  slight  muco-purulent  discharge  from  the  old  sinus. 

In  a  letter  I  received  from  her  December  14th,  1892, 
she  told  me  she  was  about  to  be  married.  Menstruation 
was  regular,  generally  painful  and  somewhat  profuse. 
There  was  still  a  slight  discharge  from  the  sinus. 

The  lesson  to  be  learned  from  this  most  interesting  case 
is  not  to  be  satisfied  with  half-measures.  Regarding  the 
case  as  one  of  abscess  in  the  broad  ligament,  I  did  not 
attempt  to  do  more  than  empty  and  drain  it.  The  sequel 
showed  that  the  whole  cyst  should,  if  possible,  have  been 
removed.  As  to  the  nature  of  the  abscess,  the  presence- 
of  a  quantity  of  caseous  material  points  strongly  to 
tubercle.  No  microscopic  examination,  however,  having 
been  made,  the  tubercular  character  of  the  mischief  is 
necessarily  conjectural.  There  is  strong  reason  for 
believing  that  all  cases  of  pyosalpinx  in  the  virgin  (and 
this  patient  had  the  physical  signs  of  virginity)  are  tuber- 
cular in  their  character. 

Case  8.  Illness  of  twelve  months'  duration;  tense 
fluctuating  swelling  above  puhes ;  pain  in  left  iliac  region  ; 
'pyrexia  and  wasting  ;  abdominal  section  ;  pelvic  peritonitis, 
with  encysted  collection  of  serum;  fluid  removed;  imme- 
diate relief  of  symptoms  ;  recovery. — Alice  L — ,  aged  20, 
a  widow,  was  admitted  to  St.  Thomas's  Hospital  May 
12th,  1888,  with  symptoms  of  pelvic  peritonitis,  and  a 
supra-pubic  swelling  which  had  not  hitherto  been  noticed. 

She  had  given  birth,  a  year  previously,  to  a  stillborn 
child  at  about  the  seventh  month  of   pregnancy,  and  had 


CEKTAIN    CASES    OF    PELVIC    PERITONITIS.  277 

suffered  from  pain  in  the  left  iliac  region  ever  since.  She 
had  been  unable  to  work,  but  had  not  been  confined  to 
bed  until  quite  recently.  She  was  now  thin,  pale,  and  ill ; 
her  temperature  was  102"6°,  her  pulse  114.  Above  the 
pubes  was  a  distinctly  fluctuating  swelling,  three  inches 
in  its  vertical  measurement,  and  extending  three  inches 
to  the  right  of  the  middle  line,  and  a  little  less  to  the 
left.  It  was  tender  to  the  touch,  dull  on  percussion,  and 
immoveable.  The  uterus  was  fixed,  displaced  somewhat  to 
the  right,  and  of  normal  length.  Above  the  vaginal  roof 
on  the  left  side,  a  tense  brawny  swelling  could  be  felt. 
The  fundus  of  the  bladder  was  situated  an  inch  above  the 
pubes.      The  swelling  was  thought  to  be  an  abscess. 

Abdominal  section,  May  21st. — The  contents  of  the 
pelvis  were  completely  roofed  over  by  adherent  omentum. 
On  separating  the  omentum  the  swelling  was  exposed  to 
view.  A  bladder  sound  was  introduced,  and  showed  the 
fundus  of  the  bladder  to  reach  only  to  the  lower  angle 
of  the  abdominal  incision.  "A  small  trocar  was  passed 
into  the  swelling,  and  a  little  straw-coloured  serum 
escaped.  The  opening  was  enlarged  by  means  of  the 
finger  and  the  cavity  explored.  It  was  found  to  be 
lined  by  peritoneum  and  to  be  very  irregular,  dipping 
here  and  there  amongst  the  pelvic  viscera.  It  was 
bounded  by  the  uterus  on  the  right,  and  by  the  left 
broad  ligament  in  front  and  to  the  left.  A  glass  drainage- 
tube  was  inserted  and  the  abdominal  wound  closed. 

The  temperature,  which  during  the  w^eek  preceding  the 
operation  had  ranged  from  99°  to  100*4°,  fell  at  once  to 
normal,  and  only  once  reached  99°  during  convalescence. 
A  little  suppuration  took  place  from  the  tube-track  at  the 
beginning  of  June,  but  only  lasted  a  few  days.  On  the 
6th  June  the  patient  was  able  to  sit  up.  On  the  12th 
the  uterus  was  found  still  slightly  displaced  to  the  right, 
and  a  small  fluctuating  swelling  was  detected  above  the 
vaginal  roof  on  the  left  side.  On  the  19th  this  swelling 
had  disappeared,  and  the  uterus  was  nearly  in  the  middle 
line.      The  patient  was  sent  to  a  convalescent  home  on  the 


278  VALUE    OP    ABDOMINAL    SECTION    IN 

20tli,  and  on  the  18th  of  July  she  returned,  looking  and 
feeling  perfectly  well.  She  had  gained  flesh,  had  a 
healthy  colour  in  her  cheeks,  and  was  in  the  highest 
spirits. 

In  September,  1892,  she  was  readmitted.  Having 
remained  well  and  at  work  for  four  years  and  a  quarter, 
she  had  a  sudden  attack  of  pelvic  pain  a  week  before  ad- 
mission. A  hard  irregular  mass  was  found  in  the  right 
posterior  quarter  of  the  pelvis.  Abdominal  section  was 
again  performed,  and  the  uterine  appendages  on  the  right 
side  were  removed  for  chronic  inflammatory  disease. 

This  case  was  a  good  illustration  of  the  effects  of  tension. 
Encysted  collections  of  serum  in  the  pelvis  produce  no 
symptoms  unless  there  is  tension,  when  they  give  rise  to 
severe  constitutional  disturbance,  and  may  easily  be 
mistaken  for  pelvic  abscess.  Indeed,  I  do  not  know  how 
the  two  conditions  can  be  distinguished.  The  diagnosis 
is  of  the  less  importance,  however,  as  the  indications 
for  treatment  are  the  same  in  both.  The  reason  for 
the  swelling  making  its  appearance  above  the  pubes 
was  that  Douglases  pouch  was  nearly  obliterated  by  adhe- 
sions. 

An  outline  of  the  next  case  was  published  in  the  '  British 
Medical  Journal  '  for  July  20th,  1889.  The  parts  removed 
at  the  operation  and  at  the  autopsy  had  already  been 
exhibited  at  a  meeting  of  this  Society,  along  with  a 
coloured  drawing  which  the  Council  did  me  the  honour  to 
publish. 

Case  9.  Gonorrhoea;  r ig lit  hydrosalpinx ;  abdominal 
section  ;  removal  of  distended  tube  and  adjacent  ovary  ; 
death  from  acute  peritonitis  in  fifty-six  hours  ;  autopsy  ; 
pus  in  the  pelvis,  in  the  left  tube,  and  in  remains  of  right 
tube  ;  perforating  ulcer  of  intra-uterine  portion  of  both 
tubes,  cicatrising  on  left,  more  recent  on  right. — Mary 
C — ,  aged  19,  single,  until  recently  a  prostitute,  was  ad- 
mitted into  Magdalen  Ward  in  May,  1888,  suffering  from 
gonorrhoea,  and   transferred  to   Adelaide   Ward,   August 


CERTAIN    CASES    OP    I'ELVIC    PERITONITIS.  279 

20tli,  1888,  on  account  o£  pain  in  the  left  iliac  region, 
supposed  to  be  due  to  ovaritis. 

At  the  latter  part  of  1887  she  had  a  yellow  vaginal 
discharge,  with  pain  in  both  iliac  regions,  lasting  for 
eleven  weeks.  After  being  better  for  a  moutli  these 
symptoms  recurred  in  March,  1888,  when  a  swelling 
developed  in  the  left  side,  which  varied  in  size  from  time 
to  time.  On  being  admitted  to  Magdalen  she  com- 
plained of  pain  only  on  the  left  side  ;  she  had  a  thick 
purulent  vaginal  discharge,  which  was  most  profuse  when 
the  swelling  was  less  marked,  and  less  so  when  it  became 
hard  and  well  defined.  Sometimes  the  discharge  was 
blood-stained.  There  was  no  pain  on  micturition. 
During  her  stay  in  Magdalen  she  had  an  attack  of  very 
severe  pain  in  the  left  side,  with  a  high  temperature  and 
extreme  prostration,  thought  at  the  time  to  be  due  to 
acute  ovaritis. 

On  admission  to  Adelaide  Ward  there  was  discovered 
a  slight  lateral  displacement  of  the  uterus  to  the  left. 
Lying  behind  and  to  the  right  of  the  uterus  was  a  not 
very  tense,  smooth,  oblong  swelling,  equal  in  size  to  an 
egg,  and  giving  a  sense  of  fluctuation.  This  was  dia- 
gnosed as  a  hydrosalpinx  of  the  right  tube,  the  tube 
having  become  occluded  at  its  fimbriated  extremity  and 
bent  upon  itself,  so  that  the  outer  distended  portion  lay 
behind  the  inner  portion  and  the  uterus.  There  was  still 
a  purulent  discharge  from  the  vagina.  On  the  evening 
of  September  12th,  after  having  been  examined  bimanu- 
ally,  the  patient  was  sick  and  complained  of  acute  pain 
in  the  right  iliac  region.  The  temperature  rose  to  103*4°, 
and  the  pulse  to  134.  The  patient  looked  ill  and  some- 
what collapsed.  The  right  iliac  region  was  swollen  and 
tender.  It  was  thought  that  the  swollen  tube  must  have 
been  a  pyosalpinx  that  had  ruptured,  and  it  was  decided, 
if  the  symptoms  did  not  improve,  that  the  abdomen  should 
be  opened.  Next  day,  however,  the  patient  was  much 
better,  and  the  temperature  fell  to  what  it  was  before  the 
attack.       The    swelling    and    tenderness    gradually    dis- 


280  VALUE    OP    ABDOMINAL    SECTION    IN 

appeared.  On  September  22nd  I  ventured,  for  the  first 
time  since  the  attack,  to  make  a  vaginal  examination. 
The  result  was  that  I  found  the  retro-uterine  swelling 
unaltered,  or,  if  anything,  a  little  fuller  and  more  tense. 

On  October  18th  abdominal  section  was  performed  for 
the  removal  of  the  dilated  tube,  which  the  illness  of  the 
previous  month  led  me  to  regard  as  a  source  of  danger. 
The  dilated  tube  was  pyriform  in  shape,  measuring  thi'ee 
and  three  quarter  inches  in  length,  two  inches  and  a 
quarter  in  breadth  at  its  widest,  and  an  inch  and  a  quarter 
at  its  narrowest  part.  The  broadest  part  was  at  the 
fimbriated  extremity,  which  was  closed.  The  dilated 
portion  was  confined  to  the  outer  part  of  the  tube,  and 
was  lying  behind  the  uterus,  the  undilated  part  of  the 
tube  being  bent  upon  itself.  There  were  no  adhesions 
about  the  swollen  tube,  and  it  was  removed,  along  with 
the  adjacent  ovary,  without  difficulty.  The  contents  of 
the  dilated  tube  were  serous.  The  left  tube  felt  as 
though  it  contained  hard  nodules  in  the  substance  of  its 
walls  ;  the  left  ovary  was  adherent.  The  left  appendages 
were  not  removed. 

The  patient  died  of  septic  peritonitis  fifty-six  hours 
after  the  operation. 

At  the  necropsy  (made  by  Dr.  W.  B.  Hadden)  there 
were  found  some  recent  peritoneal  adhesions  in  the  lower 
part  of  the  abdomen  ;  a  small  quantity  of  thick  pus  was 
found  in  the  pelvis.  There  were  two  black  spots  on  the 
peritoneal  aspect  of  the  fundus  uteri,  one  at  each  cornu.* 
The  tissues  beneath  were  disorganised.  A  band-like 
process  of  great  omentum  passed  to  the  gangrenous  spot 
on  the  left  side,  and  was  firmly  adherent  there.  The 
cavity  of  the  uterus  was  of  average  size  ;  the  mucous 
membrane  was  coated  with  fluid  blood  (menstrual  ?).  On 
opening  the  remains  of  the  right  Fallopian  tube  from 
within,  the  first  half  of  the  intra-uterine  portion  was 
normal,  the  second  or  outer  half  was  ulcerated,  and  a 
perforation,  seven  millimetres  in  length,  existed  on  its 
*  See  coloured  plate  in  the  '  Trans.  Obstet.  Soc.,'  vol.  xxx,  p.  406. 


CERTAIN    CASES    OP   PELVIC    PERITONITIS.  281 

upper  surface  corresponding  to  the  gangrenous  spot 
already  described  as  existing  on  the  right  cornu  of  the 
uterus.  From  the  outer  border  of  the  uterus  to  the  point 
where  the  tube  had  been  divided  the  lining  membrane 
appeared  healthy.  There  was  a  little  pus  lying  in  the 
tube.  The  left  tube  was  a  little  dilated,  especially  at  its 
distal  part,  which  contained  some  pus.  On  opening  the 
intra-uterine  portion  of  the  tube,  the  inner  half  of  that 
portion  Avas  healthy  in  appearance  ;  the  outer  half  was 
either  occluded,  or  at  any  rate  so  constricted  that  the 
finest  wire  could  not  be  made  to  pass.  Between  the  con- 
striction and  the  black  spot  on  the  peritoneal  surface  the 
tissues  were  softened  and  of  a  deep  red  colour.  No 
communication  could  now  be  detected  between  the  interior 
of  the  tube  and  the  peritoneal  cavity.  Beyond  this  were 
two  hard  nodules  (gummata  ?)  which,  on  section,  were 
seen  to  be  pale  circumscribed  masses  of  exudation,  com- 
pletely surrounding  the  mucous  membrane.  The  left 
ovary  was  of  normal  size  and  much  softened. 

This  case,  so  far  as  I  know,  is  unique.  It  shows  to 
what  unsuspected  risks  patients  suffering  from  gonorrhoeal 
salpingitis  are  exposed.  If  ulceration  can  take  place  in 
the  intra-uterine  portion  of  the  tube  to  such  an  extent 
as  to  destroy  the  whole  thickness  of  the  uterine  wall, 
and,  perforating  the  peritoneal  coat,  allow  the  purulent 
contents  of  the  tube  to  discharge  themselves  into 
the  peritoneal  cavity,  it  is  obvious  that  even  removal 
of  the  tubes  would  not  suffice  to  avert  the  risk.  For- 
tunately this  portion  of  the  tube  appears  to  be  ulcer- 
ated so  rarely  that,  for  practical  purposes,  we  may 
leave  this  danger  out  of  account.  Besides,  the  case 
before  us  shows  that  perforation  is  not  necessarily  fatal. 
There  can  be  little  doubt  that  the  alarming  symptoms  that 
supervened  whilst  the  patient  was  in  Magdalen  Ward, 
when  it  will  be  remembered  all  the  suffering  was  on  the 
left  side,  mark  the  time  when  the  perforation  of  the  left 
tube  occurred  ;  and  that  the  equally  alarming  symptoms 
that    occurred   after    an    examination    in  the   month  of 

VOL.  XXXIV.  21 


282  VALUE    OP   ABDOMINAL    SECTION    IN 

September  marked  the  pi'ecise  moment  when  the  perfora- 
tion took  place  on  the  right  side.  On  both  these  occa- 
sions the  patient  became  collapsed,  and  was  for  some  hours 
in  extreme  danger,  but  the  peritoneum  of  this  young  and 
robust  subject  proved  equal  to  the  emei'gency,  the  ex- 
travasated  matters  became  absorbed,  and  a  friendly  band 
of  omentum  sealed  up  the  aperture.  The  hydrosalpinx, 
which  was  the  only  lesion  discovered  or  discoverable  on 
vaginal  examination,  was,  of  course,  a  mere  retention- cyst 
produced  by  the  closing,  during  one  of  the  attacks  of  pelvic 
peritonitis,  of  the  fimbriated  end  of  the  tube.  In  itself 
the  lesion  did  not  justify  an  operation,  but  it  was  evident 
from  the  recurrent  attacks  of  acute  pelvic  inflammation 
that  there  was  something  more  than  hydrosalpinx.  Hence 
I  decided  to  open  the  abdomen.  I  did  not,  however, 
even  during  the  operation  discover  anything  beyond  the 
hydrosalpinx.  The  black  spots  at  the  uterine  cornua 
were  concealed  from  view  by  bands  of  omentum,  and  the 
left  tube,  in  external  appearance,  was  as  nearly  as  pos- 
sible normal.  With  regard  to  the  fatal  result  of  the 
operation,  I  am  quite  unable  to  offer  an  explanation.  I 
instituted  a  most  minute  inquiry  as  to  the  possibility  of 
any  antiseptic  precaution  having  been  overlooked,  but 
without  result. 

Two  other  points  I  wish  to  call  attention  to  before  I 
pass  on,  namely,  (1)  the  fact  that  in  the  same  tube  a 
collection  of  serum  may  exist  at  one  end,  and  a  collection 
of  pus  at  the  other  ;  and  (2)  the  fact  that  rupture  of  the 
Fallopian  tube  may  take  place  at  a  part  where  there  is  no 
appreciable  dilatation.  To  this  latter  point  Dr.  Lewers 
has  already  directed  attention  (see  *  Trans.  Obst.  Soc.,' 
vol.  xxvii,  p.  298). 

Case  10.  Recurrent  pelvic  peritonitis;  constant  pain 
nnore  or  less  severe,  and  general  feeling  of  illness  for  last 
fifteen  months  ;  fluctuating  tumour  above  pubes  ;  abdominal 
section;  removal  of  pedunculated  retro-peritoneal  cyst  with 
two  daughter-cysts,  the  tatter  suppurating  ;  death  on  eighth 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  283 

day ;  autopsy  :  small  quantity  of  pus  in  pelvis  ;  partial 
ohstrnction  of  small  intestine  at  site  of  old  adhesion. — 
Sarah  T — ,  aged  32,  single,  a  dressmaker,  was  admitted 
into  Adelaide  Ward  December  13th,  1888.  Five  years 
ago,  when  over-worked  as  a  teacher,  she  cauglit  cold  (not 
during  a  menstrual  period),  and  had  a  severe  illness  with 
much  abdominal  pain,  incapacitating  her  for  six  months. 
After  she  came  to  reside  in  London  she  felt  well  until  the 
autumn  of  1887,  when  she  had  a  similar  attack;  a  third  took 
place  three  months  before  admission.  Since  that  time 
the  abdominal  pain  has  been  constant,  sometimes  severe, 
sometimes  slight.  Menstruation  has  been  regular  and 
painless  throughout. 

On  admission,  patient  looked  thin,  sallow,  ill,  and  tired. 
She  was  of  a  highly  nervous  temperament  and  unusually 
intelligent.  She  complained  of  some  fulness  at  the  lower 
part  of  the  abdomen,  but  was  not  aware  of  the  existence  of 
any  tumour. 

The  abdomen  was  rendered  very  slightly  prominent  by 
a  rounded  fluctuating  tumour,  situated  almost  centrally 
and  reaching  from  pubes  to  umbilicus,  a  distance  of  6^ 
inches.  It  extended  3  inches  to  the  right  and  2^  inches 
to  the  left  of  the  middle  line  ;  it  was  dull  on  percussion. 
The  uterus  was  normal  in  size  and  consistence,  and  was 
pushed  to  the  left  side,  the  sound  passing  with  difficulty 
after  being  slightly  bent.  The  urine  was  loaded  with 
lithates.      Temperature  ranged  from  98*6°  to  101°. 

Abdominal  section  December  20th,  1888.  The  omen- 
tum was  adherent  to  the  cyst,  and  there  were  some  recent 
adhesions  to  the  anterior  abdominal  wall,  especially  on  the 
right.  After  these  had  been  separated,  the  cyst,  which 
was  covered  by  peintoneum,  was  tapped.  Thirty  fluid 
ounces  of  dark  brown  fluid  (proving  on  microscopical 
examination  to  be  altered  blood)  were  removed,  with  some 
thick,  grumous,  flaky  material,  and,  towards  the  end,  some 
pus.  The  cyst-wall  was  very  pliable,  and  gave  way  in  all 
directions  on  the  slightest  manipulation.  The  remaining 
adhesions  were  then  separated  ;  they  were  very  numerous. 


284  VALUE    OF    ABDOMINAL    SECTION    IN 

firm  and  vascular^  and  involved  intestine,  mesentery,  and 
parietal  peritoneum.  The  pedicle,  which  could  not  be 
brought  into  view,  was  secured  with  a  single  ligature  and 
divided.  The  cyst  consisted  of  one  main  and  two 
daughter  cysts  ;  the  latter  had  both  been  in  a  state  of 
suppuration,  and  had  burst  into  the  main  cyst  during  the 
operation.  The  right  Fallopian  tube  was  not  seen.  The 
uterus  and  the  left  ovary  and  tube  were  matted  densely 
together  by  old  adhesions  ;  Douglas's  pouch  was  obli- 
terated by  adhesions.  The  peritoneum  was  flushed,  a 
glass  drainage-tube  was  inserted  into  the  right  side  of  the 
pelvis,  and  the  wound  was  sutured. 

At  9.30  a.m.  the  following  day  there  had  been  no  sick- 
ness ;  the  tube  was  removed. 

On  the  third  day  (December  22nd)  patient  became  very 
restless,  and  the  pulse  rapid,  flickering,  and  uncountable. 
There  was  no  pain. 

On  December  23rd  the  condition  was  very  alarming  : 
extremities  cold,  bowels  acting  involuntarily,  respiration 
embarrassed,  slight  distension  of  abdomen  ;  no  pain  and 
no  sickness.  Towards  evening  patient  appeared  to  be 
moribund.  At  4  a.m.  on  the  24th  she  was  apparently 
.dying,  when  suddenly  she  sat  up  and  asked  to  have  the 
pillow  changed.  During  that  day  she  remained  a  trifle 
better,  but  continued  very  nervous  and  irritable.  The 
bowels  were  relaxed,  the  motions  passing  unconsciously. 
She  continued  in  much  the  same  state  and  quite  conscious 
up  to  4  a.m.  on  the  27th,  when  she  lost  consciousness, 
and  she  died  at  8  a.m. 

The  highest  temperature  on  the  day  after  the  operation 
(viz.  on  December  21st)  was  100-6°;  on  the  22nd,  99-8°; 
on  the  23rd,  100-4°;  on  the  24th,  99°;  on  the  25th, 
97'6°  ;  after  which  it  rose  once  to  99-2°,  but  was  generally 
sub-normal. 

Autojysy  (by  Dr.  H.  P.  Hawkins). — Omentum  firmly 
adherent  to  wound  ;  a  small  collection  of  pus  under  its 
lower  end.  Lower  end  of  omentum,  passing  through  coils 
of  small  intestine,  was  firmly  attached  by  an  old  adhesion 


CERTAIN    CASES    OP   PELVIC    PERITONITIS.  285 

to  tlie  back  of  tlie  pelvis,  by  tlie  side  of  the  rectum  and 
ti'ansverse  colon,  which  latter,  collapsed  and  empty,  had 
been  drawn  out  of  position  by  the  omentum.  Superficial 
coils  of  small  intestine  much  distended  with  gas  ;  some 
injection  of  vessels  along  lines  of  contact,  but  only  a  few 
shreds  of  lymph.  There  was  a  little  blood-stained  fluid 
free  in  the  lateral  parts  of  the  peritoneal  cavity.  The 
coils  of  intestine  that  lay  in  the  pelvis  were  acutely  in- 
flamed, and  adherent  to  each  other  by  soft,  recent  blood- 
stained lymph.  Between  the  coils  on  the  left  side  was  a 
collection  of  about  half  a  fluid  drachm  of  green  viscid  pus. 
On  removing  the  intestines  the  floor  of  the  pelvis  seemed 
levelled  by  adhesions  and  deposit  of  inflammatory  material, 
there  being  no  sign  of  bladder,  uterus,  ovaries,  or  broad 
ligaments.  On  this  floor  lay  two  or  three  fluid  ounces  of 
viscid  greenish  pus,  without  odour.  The  uterus  and 
adnexa  were  scooped  out.  The  left  ovary  and  tube  were 
adherent  on  all  sides,  and  lay  behind  the  uterus  and  left 
broad  ligament.  The  right  ovary  and  tube  were  also 
found  amidst  a  mass  of  adhesions.  The  remains  of  the 
pedicle,  with  ligature  attached,  were  found  projecting 
from  the  peritoneum,  covering  the  lower  part  of  the  back 
of  the  corpus  uteri.  The  uterus  itself  was  normal.  The 
tumour  removed  was  evidently  a  cyst  underlying  the 
peritoneum.  There  had  been  no  secondary  hasmorrhage. 
Where  a  coil  of  small  intestine  crossed  the  right  side  of 
the  pelvic  brim,  it  was  firmly  attached  to  the  psoas  by 
old  adhesions,  causing  partial  obstruction.  Meckel's 
<liverticulum  and  the  appendix  vermiformis  were  normal. 
Left  pleura  completely  and  firmly  adherent,  the  lung  being 
torn  during  removal.  Right  pleura  adherent  over  apex. 
No  fluid  in  pleurae.  A  few  caseous  or  partially  calcified 
nodules  at  apex  of  left  lung.  Some  hypostatic  basal 
congestion.  Anterior  surface  and  edge  of  right  lung 
extremely  emphysematous  ;  caseous  nodules  at  apex,  rest 
healthy.      Heart  and  other  organs  normal. 

Of  the  two  possible  causes   of  death  in    this   case,  viz. 
the   partial    obstruction    of    the   small   intestine   and  the 


286  VALOE    OF    ABDOMINAL    SECTION    IN 

septic  peritonitis,  the  latter  seems  the  more  probable. 
There  is  little  doubt  that  the  source  of  iufection  was  the 
purulent  matter  that  escaped  from  the  cyst  dui'iug  the 
operation,  a  portion  of  which  must  have  remained  in  spite 
of  the  flushing.  Any  way,  I  determined  not  again  to  rely 
upon  flushing  alone  in  the  event  of  a  similar  accident, 
but  to  sponge  carefully  whether  I  flushed  or  not. 

With  regard  to  the  precise  nature  of  the  cyst  I  do  not 
feel  able  to  offer  an  opinion.  It  was  not  connected  with 
either  of  the  tubes,  the  ovaries,  or  the  broad  ligaments. 
It  was  covered  by  peritoneum,  and  was  attached  by  a 
distinct  pedicle  to  the  back  of  the  uterus,  an  unusual 
position  for  a  cyst  of  this  character. 

The  case,  though  an  exceptional  one,  is  included  in  this 
series  because  the  patient  sought  relief,  and  the  opera- 
tion was  undertaken,  on  account  of  the  recurrent  attacks 
of  pelvic  peritonitis. 

Case  11.  Chronic  salpingitis  mid  chronic  pelvic  perito- 
nitis ;  hsemorrhage  from  both  Fallopian  tubes,  forming 
intra-peritoneal  hsematocele  on  each  side  of  the  pelvis,  en- 
cysted amongst  old  pelvic  adhesions  and  embraced  by  the 
en^panded  fimbriae  of  the  tubes  ;  abdominal  section  ;  removal 
of  blood- clots  and  both  tubes  ;  death  on  ninth  day  from  acute 
nephritis. — The  patient,  a  married  woman  aged  32,  had 
recovered  well  after  each  of  her  four  confinements,  the 
last  of  which  took  place  two  years  and  seven  months  ago. 
Eighteen  months  ago  she  had  a  miscarriage,  followed  by 
an  illness  of  eight  weeks'  duration.  There  had  been  two 
early  miscarriages  since,  the  last  one  twelve  weeks  before 
admission.  The  patient  dated  her  illness  from  that  time. 
She  had  suffered  during  the  past  month  from  pain  in  the 
back  and  in  the  right  iliac  region,  and  latterly  there  had 
been  pain  during  micturition  and  defecation. 

Nothing  abnormal  could  be  detected  in  the  abdomen. 
Behind  and  to  the  right  of  the  uterus,  which  was  of 
.normal  size,  fairly  moveable,  and  situated  slightly  to  the 
left,  was  a  smooth,  firm,  elastic,  immoveable  swelling,  which 


CERTAIN    CASES    OF    PELVIC    rEKITONITIS.  287 

occupied  the  right  posterior  quarter  of  the  pelvis^  and 
extended  an  inch  to  the  left  of  the  middle  line.  The 
left  fornix  was  narrowed.  High  above  it  could  be  felt 
an  obscure  swelling,  tender  on  pressure.  I  have  unfor- 
tunately no  note  of  the  diagnosis.  All  I  can  say  on  this 
point  is  that  I  was  not  prepared  to  find  that  the  main 
swelling  was  a  blood-clot. 

On  opening  the  abdomen,  a  rounded  solid  tumour, 
apparently  continuous  with  the  right  Fallopian  tube,  was 
found  occupying  the  retro-uterine  pouch,  and  extending 
outwards  to  the  right  pelvic  w'all.  From  the  outer  side 
of  the  swelling  the  tube  curved  forwards  and  inwards  to 
the  right  cornu  of  the  uterus.  The  mass  was  fixed  by 
extremely  firm  adhesions  to  the  pelvic  walls  and  to  the 
rectum.  On  the  left  side  a  similar  but  much  smaller 
mass  was  situated  behind  the  left  broad  ligament.  The 
body  of  the  uterus  was  free  and  fairly  moveable.  With 
the  exception  of  the  rectum,  the  intestines  were  not  in- 
volved. It  was  evident  there  had  been  old  pelvic  pei'i- 
tonitis,  and  that  amongst  the  matted  tissues  were  two 
solid  tumours,  one  on  each  side,  that  on  the  right  being 
the  larger.  The  masses  were  with  extreme  difficulty 
separated  by  the  fingers.  The  larger  tumour  was  first 
brought  into  view.  It  consisted  of  a  firm  blood-clot, 
equal  in  size  to  a  hen's  egg,  and  of  a  more  or  less 
globular  shape,  and  was  embraced  by  the  expanded 
fimbriae  of  the  right  tube.  The  tube  itself  was  thickened, 
empty,  and  undilated,  and  was  bent  backwards  upon  itself. 
The  broad  ligament  was  also  much  thickened.  The  ovary 
was  not  seen.  The  tube  was  removed  with  the  tumour. 
The  smaller  mass,  on  the  left  side,  also  consisted  of  firm 
blood-clot,  laminated  and  partly  decolourised.  Like  its 
fellow,  it  was  embraced  by  the  fimbriae  of  the  corre- 
sponding tube.  The  tube  and  blood-clot  were  removed. 
The  ovary,  white  and  shrivelled,  was  firmly  adherent  to 
the  pelvic  wall,  and  was  not  removed. 

The  patient  was  much  collapsed  after  the  operation. 
Next  day  the  urine  was  found  to  contain  a  trace  of  albu- 


288  VALUE    OP   ABDOMINAL    SECTION    IN 

men.  The  quantity  of  albumen  increased,  and  the  urine 
became  scanty  and  smoky.  Death  took  place  on  the  ninth 
day,  the  temperature,  except  on  the  day  following  the 
operation,  having  been  uniformly  under  100°. 

At  the  autopsy  the  kidneys  were  intensely  hypersemic, 
and  generally  showed  evidence  of  acute  nephritis.  The 
retro-uterine  pouch  was  occupied  by  two  feet  of  small 
intestine,  which  had  contracted  slight  adhesions.  On 
removing  them  the  pouch  was  seen  to  be  lined  with  a 
thin  layer  of  firm  stratified  blood-coagulum,  one  sixth  to 
one  eighth  of  an  inch  in  thickness.  No  fluid  blood  was 
present ;  no  pus  ;  no  general  peritonitis :  no  serous 
effusion  ;  no  obstruction  or  strangulation  of  bowel  ;  no 
visceral  injury.  The  ureters  also  were  normal  and  un- 
injured. The  post-mortem  examination  was  made  by  the 
late  Dr.  Gulliver.  He  concludes  his  report  by  stating 
that,  in  his  opinion,  the  cause  of  death  was  acute  nephritis, 
the  parts  concerned  in  the  operation  appearing  to  be  as 
healthy  as  could  be  desired. 

I  believe  a  complete  diagnosis  before  operation  was  in 
this  instance  impossible.  The  haemorrhage  appeared  to 
have  been  secondary  to  inflammatory  clianges  in  the  tubes, 
and  the  clots  assumed  their  misleading  shape  and  position 
from  being  imprisoned  amongst  old  pelvic  adhesions. 
The  cause  of  death  was,  so  far  as  my  experience  is  con- 
cerned, an  unusual  one  after  these  operations. 

Case  12. — Recurrent  pelvic  peritonitis  extending  over 
•five  years ;  abdominal  section ;  chronic  inflammation  of 
both  Fallopian  tubes ;  small  suppurating  cyst  of  left 
ovary ;  removal  of  both  ovaries  and  both  tubes ;  uninter- 
rupted recovery. — The  patient  (S.  A.  W — ),  an  unmarried 
girl  aged  22,  had  been  delivered  of  a  full-term  child  at 
the  age  of  fourteen.  Two  years  afterwards  she  began  to 
suffer  from  pain  and  swelling  in  the  lower  part  of  the 
abdomen,  and  a  yellow  vaginal  discharge,  for  which  she 
underwent  a  course  of  treatment  in  the  Bridgnorth  Infir- 
mary.     Two  years  later  she  had  a  recurrence  of  the  sym- 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  280 

ptoms,  and  again  became  an  inmate  of  that  institution. 
Five  mouths  before  admission  she  is  said  to  have  caught 
cold  during  menstruation  ;  an  attack  of  shivering  occurred, 
and  the  flow  ceased  for  a  few  days.  In  two  months 
from  that  date  she  sought  admission  into  the  Bridgnorth 
Infirmary  for  the  third  time  ;  she  remained  there,  in  bed, 
for  six  weeks,  and  was  then  transferred  to  St.  Thomas's 
Hospital. 

She  was  pale  but  not  emaciated.  She  complained  of 
pain  in  the  back  and  in  the  right  iliac  region.  The  uterus 
was  normal  in  length,  fixed,  and  strongly  flexed  to  the  right. 
Extending  from  the  uterus  to  the  left  pelvic  wall  was 
a  thick,  smooth,  hard,  elastic,  slightly  moveable  mass,  the 
outer  extremity  of  which  was  on  a  level  with  the  anterior 
superior  spine  of  the  left  ilium,  and  three  quarters  of  an 
inch  internal  to  it.  She  had  come  up  to  London  with  the 
view  of  undergoing  an  operation,  but  as  the  pyrexia, 
which  had  been  a  very  marked  symptom  up  to  the  time 
of  leaving  Bridgnorth,  disappeared  from  the  moment  of 
her  arrival  at  St.  Thomas's  Hospital,  I  thought  the 
swelling  might  be  merely  a  hydrosalpinx  surrounded  by 
firm  adhesions,  and  determined  to  watch  the  case  a  little 
before  proceeding  to  operate.  She  was  accordingly  kept 
in  bed  for  six  weeks.  At  the  end  of  that  time,  the  swell- 
ing being  no  less,  and  the  patient,  though  less  anaemic, 
being  still  unable  to  move  about,  it  was  decided  to  make 
an  exploratory  incision.  Only  on  two  occasions  (February 
11th  and  March  1st)  had  the  temperature  exceeded  the 
normal  during  the  whole  six  weeks. 

On  March  21st  the  abdomen  was  opened.  On  the  left 
side  was  found  a  small  ovarian  cyst,  3|  inches  long  by 
2j  inches  wide,  filled  with  thin  flocculent  pus.  The  left 
tube,  thickened  and  dilated,  was  adherent  to  its  surface. 
Cyst  and  tube  were  separated  from  their  adhesions  and  re- 
moved. On  the  right  side  the  Fallopian  tube  was  found 
dilated,  its  walls  (Edematous,  and  its  fimbriated  extremity 
adherent  to  the  floor  of  Douglas's  pouch.  The  ovary  was 
double  its  normal  size   and   almost  universally  adherent. 


290  VALUE    OF   ABDOMINAL    SECTION    IN 

The  tube  and  ovaty  were  separated  from  their  adhesions 
and  removed. 

Convalescence  was  uninterrupted,  the  temperature  never 
exceeding  100°. 

I  had  a  letter  about  her  in  January,  1891.  She  was 
quite  well,  free  from  pain,  and  following  her  employment 
as  a  domestic  servant. 

This  case  tells  its  own  story.  I  need  not,  therefore, 
detain  you  by  comments  upon  it. 

Case  13.  Recurrent  pelvic  peritonitis  and  cellulitis; 
hard  mass  behind  and  to  left  of  uterus,  thought  to  he  sub- 
peritoneal fibroids ;  great  improvement  under  rest ;  re- 
admission  a  year  after luards ;  exploratory  incision  ;  dia- 
gnosis confirmed;  discharge  of  pus  per  rectum;  abdomen 
reopened;  deep-seated  abscess  opened,  emptied,  and  drained  ; 
recovery. — The  patient,  a  married  woman  aged  39,  had 
borne  seven  children  and  had  had  two  miscarriages. 
After  her  last  confinement,  which  took  place  twelve  years 
ago,  she  was  ill  and  feverish  for  two  weeks. 

On  admission,  May  23rd,  1888,  she  had  been  losing 
flesh  and  in  poor  health  for  twelve  months,  for  the  last 
four  of  which  she  had  been  suffering  from  abdominal 
pain  and  tenderness,  worse  after  walking.  A  fortnight 
before  admission  she  had  had  a  sudden  attack  of  acute 
pain,  and  the  bowels  had  not  acted  for  six  days.  The 
pain  continued  more  or  less  up  to  her  admission,  and  was 
accompanied  with  vomiting.  She  was  a  tall,  strongly 
built  woman,  but  pale,  emaciated,  and  very  ill.  Above 
the  vaginal  roof,  posteriorly  and  to  the  left,  was  a  hard, 
tender,  irregular  mass.  The  cervix  was  fixed,  and  par- 
tially surrounded  by  induration. 

The  patient  was  kept  in  bed  for  a  month  and  poulticed, 
her  temperature  being  normal  throughout.  At  the  end 
of  that  time  she  had  improved  immensely,  having  re- 
gained flesh  and  lost  her  look  of  illness.  The  resistance 
and  tenderness  in  Douglas^s  pouch  had  diminished,  and 
the  hard  lump   on  the  left  side  was  more  clearly  defined. 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  291 

The  case  was  thought  to  be  one  of  subperitoneal  fibroids 
of  the  uterus,  with  pelvic  peritonitis  and  cellulitis. 
She  remained  in  the  hospital  another  monthj  still  continu- 
ing to  improve  in  her  general  condition,  and  was  dis- 
charged on  the  2nd  August,  1888. 

She  remained  well  uuiil  October,  1888,  when  she 
again  began  to  fail.  Shortly  after  that  she  attended  as 
an  out-patient  occasionally,  and  on  Jul}^  17th,  1889,  she 
was  readmitted  into  the  ward.  Her  general  condition 
was  much  the  same  as  when  she  was  first  admitted, 
fourteen  mouths  previously.  There  was  no  increase  of 
temperature.  A  large,  irregular  swelling  could  be  felt  on 
bimanual  examination  extending  from  the  uterus  pos- 
teriorly, and  to  the  left  lateral  wall  of  the  pelvis.  I  was 
still  inclined  to  the  belief  that  the  main  swelling  was  a 
mass  of  subperitoneal  fibroids,  but  there  being  an  element 
of  uncertainty  about  it,  I  suggested  an  exploratory  inci- 
sion, to  which  she  eagerly  consented 

On  August  2nd,  1889,  I  accordingly  opened  the  abdo- 
men. Behind  and  to  the  left  of  the  uterus,  was  a  smooth 
hard  mass,  quite  immoveable,  and  covered  by  the  perito- 
neum, to  which  coils  of  intestine  were  adherent.  No 
fiuctuation  could  be  detected  in  it.  The  mass  appeared 
to  spring  from  or  to  be  very  closely  attached  to  the  left 
side  of  the  uterus.  The  impression  conveyed  was  that  of 
a  fibroid  burrowing  beneath  the  peritoneum.  Under  these 
circumstances  the  abdomen  was  closed  without  any  attempt 
at  further  interference. 

After  the  operation  the  bowels  acted  five  times,  and  one 
of  the  motions  was  observed  to  contain  a  quantity  of  pus. 
It  then  transpired  for  the  first  time  that  yellow  matter 
had  from  time  to  time  been  evacuated  with  the  stools  since 
the  month  of  May.  This  threw  a  new  light  upon  the 
case.  It  was  now  fairly  certain  that  the  mass,  which  had 
been  thought  to  be  a  fibroid,  was  a  thick-walled  pelvic 
abscess,  which  communicated  with  the  rectum,  the  size  of 
the  aperture  being  insuflficient  for  complete  evacuation. 
The  temperature  still  remained  normal.      I  proposed,  how- 


292  VALUE    OP    ABDOMINAL    SECTION    IN 

ever,  in  the  light  of  the  fresh  facts  which  had  come  to  my 
knowledge,  to  reopen  the  abdomen.  I  did  so,  four  weeks 
after  the  former  operation.  The  internal  appearances  were 
the  same  as  on  the  last  occasion.  I  now  proceeded  to 
pass  a  medium-sized  trocar  into  the  swelling  (after  having 
cleared  it  of  adherent  intestine,  &c.),  and  withdrew  an 
ounce  or  two  of  very  offensive  pus.  I  then  removed  the 
trocar  and  cannula,  and  enlarged  the  opening,  by  means 
of  a  scalpel,  to  a  size  sufficient  to  admit  my  finger,  which 
passed  deeply  down  into  a  smooth-walled  cavity.  The 
edges  of  the  opening  were  then  secured  to  the  edges  of 
the  incision  in  the  abdominal  wall  by  two  silk  sutures  on 
each  side,  and  a  4-inch  glass  drainage-tube  inserted. 
A  second  drainage-tube  was  passed  down  to  the  pelvic 
floor  on  the  right  side  of  the  uterus,  to  drain  the  peri- 
toneal cavity.  The  upper  part  of  the  abdominal  wound  was 
then  closed  by  silkworm  gut  sutures  in  the  ordinary  way. 

The  patient  made  an  excellent  recovery.  She  had  no 
vomiting  and  no  rise  of  temperature  from  beginning  to 
end.  The  drainage-tube  in  the  peritoneal  cavity  was 
removed  the  morning  after  the  operation.  Within  forty- 
eight  hours  of  the  operation  all  the  sutures  connecting 
the  abscess-cavity  with  the  abdominal  incision  were 
removed,  and  the  glass  drainage-tube  used  to  drain  the 
abscess-cavity  was  replaced  by  one  of  india-rubber.  This 
was  finally  removed,  on  the  fourteenth  day,  and  on  the 
twenty-eighth  day  all  discharge  had  ceased. 

The  patient  left  the  hospital  on  the  28th  September  stout 
and  well,  and  has  remained  well  ever  since,  except  that 
she  has  a  hernial  protrusion  at  the  lower  part  of  the  abdo- 
minal wound.  There  has  never  been  seen  the  slightest 
stain  of  matter  from  the  rectum  since  the  day  of  operation. 

I  have  described  this  case  in  some  detail  because  our 
most  useful  lessons  are  learnt  from  our  mistakes.  I  ought 
to  have  known  there  was  pus  in  that  pelvis  from  the  re- 
current peritonitis,  which  I  now  know  to  be  a  far  truer 
test  than  the  temperature.  Even  when  the  operation 
was  concluded  I  felt  unable  to  give  an  opinion   as  to  the 


CERTAIN    CASES    OF    PELVIC    PEEITONITIS.  293 

precise  character  and  situation  of  the  abscess.  I  have 
no  doubt  now,  after  larger  experience,  that  it  was  either  a 
pyosalpinx  or  a  small  suppurating  cyst  of  the  ovary, 
adherent  to  and  covered  in  by  an  enormously  thickened 
broad  ligament.  I  have  also  no  doubt  that  if  I  had  to 
operate  on  the  case  to-day  I  should  not  be  satisfied  with 
emptying  and  draining,  but  should  remove  the  diseased 
part,  after  separating  it  from  its  adhesions  to  the  broad 
ligament  and  other  surrounding  structures.  Had  this  been 
done,  the  hernia  would  in  all  probability  have  been  avoided. 
Not  less  interesting  or  less  successful  is  the  case  that 
comes  next  in  order. 

Case  14.  Recurrent  attacks  of  jpelvic  peritonitis  follow- 
ing gonorrhoea  ;  great  emaciation  and  inability  to  earn  a 
livelihood ;  abdominal  section  ;  purulent  salpingitis  tvith 
intra-peritoneal  abscesses ;  left  tube  removed ;  abscesses 
emptied  and  drained;  acute  pneumonia ;  recovery. — A  brief 
account  of  this  case  appeared,  in  a  paper  published  in  the 
'  British  Medical  Journal  '  for  December  27th,  1890,  on 
the  "Differential  Diagnosis  of  Pelvic  Inflammations," 
from  which  I  take  the  liberty  of  quoting  a  paragraph  or 
two.  The  patient  was  "  a  young  woman,  aged  28,  with  a 
w'orn,  pale  face,  and  wretchedly  thin.  She  was  admitted 
September  10th,  1889,  complaining  of  severe  pain  in  the 
lower  part  of  the  abdomen,  and  with  a  temperature  of 
101|°.  She  had  been  married  five  years,  but  had  been 
separated  from  her  husband  for  three  years  on  account 
of  his  intemperance  and  cruelty,  and  during  this  time 
had  had  to  maintain  herself  and  her  two  children  by 
dressmaking.  Only  on  one  occasion  since  their  separation 
had  she  and  her  husband  cohabited.  This  act  of  inter- 
course took  place  twelve  months  before  her  admission. 
Very  soon  afterwards  she  began  to  have  a  profuse  yellow 
vaginal  discharge.  .  .  .  In  a  few  weeks  she  became 
too  ill  to  continue  at  her  work,  and  had  to  give  up  her 
home  and  go  into  the  parish  infirmary  with  her  children. 
She  came  out  in  three  or  four  months,  but  soon  had  to 


294  VALUR    OP    ABDOMINAL    SECTION    IN 

return.  She  ag-ain  took  her  discharge  and  resumed  her 
occupation.  Her  health,  however,  soon  gave  way  again. 
She  suffered  great  pain  in  the  lower  part  of  the  abdomen, 
in  the  groins,  and  in  the  back,  and  eventually  sitting 
became  so  difficult  and  painful  that  she  had  to  relinquish 
her  employment,  and  for  some  weeks  before  admission 
she  had  subsisted  on  the  generosity  of  friends." 

The  uterus  was  pushed  over  to  the  left  side  and  to  the 
front  by  a  tender,  irregular  mass  filling  the  right  side  of 
the  pelvis  and  Douglas's  pouch.  The  diagnosis  was  gonor- 
rhoea! salpingitis  with  suppuration,  and  pelvic  peritonitis. 

"  Abdominal  section  was  suggested  and  readily  agreed 
to.  The  operation  was  performed  on  September  14th, 
1889.  There  was  no  genei'al  peritonitis,  but  the  pelvis 
was  occupied  by  a  mass  of  adherent  viscera,  difficult  to 
recognise  and  separate.  The  uterus,  of  normal  size,  lay 
in  front  and  to  the  left."  The  left  tube,  much  thickened, 
first  ascended  and  then  curved  abruptly  downwards  and 
backwards,  so  that  it  lay  mainly  behind  the  uterus,  where 
it  was  firmly  adherent.  At  the  angle  of  flexion  it  pre- 
sented a  distinct  knuckle  of  enlargement.  Its  upper  sur- 
face was  free.  Its  lower  surface  was  coated  with  old 
blood-clot,  and  formed  part  of  the  wall  of  a  small  abscess- 
cavity,  from  which,  when  opened,  there  welled  up  blood- 
stained serum,  lymph  flocculi,  and  pus.  The  cavity  was 
intra-peritoneal.  The  broad  ligament  was  much  thick- 
ened, and  both  it  and  the  swollen  tube  were  so  friable  that 
when  the  tube  had  been  separated  from  its  adhesions,  and 
was  about  to  be  removed,  the  ligatures  placed  around  the 
broad  ligament  tore  through.  Some  bleeding  took  place 
from  the  torn  surface,  and  was  arrested  by  four  fine  silk 
ligatures  passed  through  the  broad  ligament,  and  tied 
over  the  cut  surface.  On  being  removed  the  tube  was 
seen  to  be  pervious  throughout.  A  thin,  purulent  fluid 
exuded  from  it  on  pressure.  Its  walls  were  greatly 
thickened,  as  also  was  the  mesosalpinx.  Drawings  of 
the  tube  were  published  in  the  paper  already  alluded  to. 

The  right  tube  was  less  thickened  but  much  distorted. 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  295 

and  very  intimately  adherent  to  surrounding  parts.  Its 
direction  was  first  forwards,  then  backwards  and  down- 
wards, terminating  behind  the  uterus.  The  cfecum  and 
its  appendix  being  apparently  involved  in  the  adhesions, 
the  tube  was  not  removed.  It  was  separated,  however, 
sufficiently  from  its  adhesions  to  open  up  a  second  small 
abscess-cavity,  distinct  from  that  on  the  left  side,  and 
separated  from  it  by  a  vertical  septum.  The  contents  of 
the  two  cavities  were  similar.  A  glass  drainage-tube 
was  inserted  into  each  cavity  after  it  had  been  well 
douched  with  hot  boracic  solution.  The  ovaries  were  not 
distinguished.      The  operation  lasted  an  hour  and  a  half. 

"  The  patient  had  a  severe  attack  of  pneumonia  after 
the  operation,  and  there  was  a  good  deal  of  suppuration 
through  the  drainage-tube  before  the  abdominal  wound 
entirely  closed,  but  she  eventually  made  an  excellent  re- 
covery, gaining  flesh,  and  looking  quite  bright  and  cheer- 
ful. Before  going  out  she  complained  of  a  vaginal 
discharge,  which,  on  examination,  proved  to  be  due  to  a 
purulent  inflammation  of  the  urethra  and  nympha?,  and  to 
a  purulent  cervical  catarrh,  for  which  she  underwent  the 
usual  treatment  before  she  left  the  hospital.  The  gonor- 
rhoea! origin  of  the  pelvic  inflammation  was  thus  abun- 
dantly confirmed.  The  patient  was  able  to  be  sent  to  a 
convalescent  home  on  October  29th,"  after  being  seven 
weeks  in  the  hospital. 

I  have  recently  been  at  some  pains  to  trace  her  where- 
abouts, but  without  success,  so  that  I  am  unfortunately 
not  able  to  report  her  present  condition,  or  to  say  whether 
the  remarkable  improvement  effected  by  the  operation 
has  been  maintained. 

The  case,  as  I  have  already  remarked  elsewhere,  was  a 
typical  example  of  the  class  of  cases  that  until  recently 
were  regarded  as  pelvic  cellulitis,  and  treated  accordingly. 

Case  15.  Becurrent  pelvic  peritonitis  following  gonor- 
rhoea;  fixed,  tense,  ohlong  swelling  in  right  side  of  pelvis, 
with  purulent  endometritis;  abdominal  section  ;  pyosalpinx 


296  VALUE    OF    ABDOMINAL    SECTION    IN 

on  right  side ;  'prolapsed  and  adherent  hut  otherivise  normal 
ovary ;  right  tube  and  ovary  removed;  recovery  without  rise 
of  temperature  ;  readmission  for  curettage  of  uterus  ;  cure. — 
The  patient  was  a  prostitute,  aged  22.  Two  yeai's  ago  she 
had  a  yellow  vaginal  discharge  and  a  sore,  followed  by 
enlarged  glands  in  the  groin,  and,  later,  by  sore  throat 
and  blotches  on  the  face.  Four  months  ago  she  was 
seized  with  sudden  and  severe  pain  in  the  lower  part  of 
the  abdomen,  chiefly  in  the  right  iliac  region,  shooting 
down  the  right  thigh  and  causing  her  to  draw  up  the 
knee.  She  was  feverish  and  kept  her  bed  for  two  days. 
She  vomited  several  times  and  had  diarrhoea.  There  was 
a  somewhat  copious  vaginal  hfemorrhage,  and  irregular 
haemorrhages  have  occurred  from  that  time,  especially 
after  exertion  and  always  after  intercourse.  A  similar 
attack  of  pain  with  fever  took  place  a  fortnight  after  the 
first  attack,  and  a  third  one  two  weeks  ago.  On  each 
occasion  she  was  in  bed  for  about  three  days. 

Patient  is  a  healthy  blonde,  in  good  muscular  condi- 
tion. She  has  had  more  or  less  vaginal  discharge,  some- 
times white,  sometimes  yellow,  ever  since  the  acute  attack 
of  gonorrhoea  two  years  ago. 

There  is  no  abdominal  swelling,  but  a  feeling  of  resist- 
ance in  the  right  iliac  region.  The  vulva  is  normal,  save 
for  a  stain,  such  as  would  be  produced  by  silver  nitrate, 
on  the  fourchette.  Uterus  is  of  normal  size,  displaced  to 
the  left  and  fixed.  In  the  right  posterior  quarter  of  the 
pelvis  there  is  a  fixed,  ill-defined,  tense,  oblong  mass, 
which  can  be  felt  to  bulge  into  the  rectum  anteriorly  and 
to  the  right  side.  Nothing  abnormal  can  be  detected  to 
the  left  of  the  uterus.  At  the  bottom  of  Douglases  pouch 
can  be  felt  a  small  cystic  swelling,  like  an  ovary.  Tem- 
perature normal. 

The  diagnosis  was  right  pyosalpinx,  with  prolapsed 
and  adherent  ovary. 

The  patient  being  willing  to  have  an  operation,  the 
abdomen  was  opened  on  October  ]  7th,  1889.  The  right 
tube  and  ovary  were   displaced  behind   the    uterus   and 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  297 

firmly  matted  to  surrounding  parts.  The  tube  was 
enlarged,  tortuous,  and  distended ;  its  closed  fimbriated 
end,  measuring  an  inch  in  diameter,  was  adherent  to  the 
bottom  of  Douglas's  pouch.  The  tube  was  studded  with 
a  number  of  subperitoneal  cysts  ;  one  at  the  outer  end  had 
been  felt  on  vaginal  examination,  and  had  been  mistaken 
for  a  small  prolapsed  cystic  ovary.  At  the  angle  of 
flexion,  near  the  uterine  end  of  the  tube,  the  adhesions 
were  very  firm  to  the  vermiform  appendix  and  other 
parts.  The  ovary  was  slightly  enlarged,  and  contained 
a  number  of  cystic  dilatations,  some  of  them  being  filled 
with  serum,  others  with  altered  blood. 

The  right  tube  and  ovary  were  removed.  The  tube 
was  found  to  be  distended  with  pus.  The  left  appendages 
appeared  to  be  normal. 

The  patient  made  an  uninterrupted  recovery,  her 
highest  temperature  being  99'4°.  She  left  the  hospital 
on  the  seventeenth  day.  A  month  later  she  returned,  by 
arrangement,  to  be  treated  for  purulent  endometritis.  The 
cervix  was  dilated,  the  interior  of  the  uterus  curetted,  and 
Churchill's  iodine  solution  applied  on  cotton  wool.  She 
was  discharged  in  three  days,  feeling  quite  well.  She 
presented  herself  fifteen  months  afterwards,  and  was 
quite  well.  She  had  remained  free  from  pain  and  dis- 
charge, and  menstruated  regularly.  A  vaginal  examina- 
tion revealed  nothing  abnormal  in  the  pelvis. 

This  case  is  a  typical  example  of  pyosalpinx,  from  the 
spread  of  gonorrhoeal  infection  along  the  endometrium  to 
the  tube.  When  once  pus  has  collected  within  the  tube, 
there  is  no  way  of  escape  for  it  but  in  a  vicious  direction, 
and  hence  the  only  satisfactory  method  of  treatment  is  to 
remove  it  by  operation.  The  case  again  illustraets  the 
uselessness  of  the  thermometer  as  a  test  of  the  presence 
of  pus  in  the  pelvis,  a  much  safer  criterion  of  which  is  the 
occurrence  of  repeated  attacks  of  pelvic  peritonitis. 

Case    16.  Menorrhagia  and  dysmenorrhoea  for  fourteen 
years ;  occasional   treatment  hy  pessaries,  dilatation,    and 
VOL.  XXXIV.  22 


298  .         VALUE    OF    ABDOMINAL    SECTION    IN 

hot  injections,  with  only  temporary  relief ;  right  side  of 
pelvis  and  retro-uterine  pouch  occupied  by  an  irregular 
swelling,  thought  to  he  due  to  disease  of  right  tube  and 
"peritoneum  ;  abdominal  section  ;  inflammation  of  right 
tube,  right  broad  ligament,  and  pelvic  peritoneum ;  cystic 
disease  of  right  ovary  ;  left  app)endages  apparently  normal ; 
removal  of  right  tube  and  ovary ;  death  from  shoch  {?) ; 
autopsy  ;  uterus  and  left  tube  full  of  purulent  mucus.— 
Lydia  B — ,  a  single  woman  aged  34,  head  nursemaid  in  a 
private  family,  was  sent  to  me  for  my  opinion  under  the 
following  circumstances.  Menstruation  commenced  at 
the  age  of  fourteen,  and  was  regular  and  painless  until 
the  age  of  nineteen,  when  she  began  to  have  pain  before 
the  flow,  and  the  periods  became  more  frequent  and  the 
loss  greater.  This  went  on  for  four  years  before  she 
sought  advice.  She  was  then  examined,  and  was  told  that 
she  had  inflammation  of  the  womb.  She  was  laid  up  at 
home  for  seven  weeks,  and  injections  of  hot  water  were 
ordered.  After  that  she  attended  as  an  out-patient  at 
the  Soho  Hospital,  and  wore  a  pessary  for  three  months. 
Three  years  later,  being  no  better,  she  saw  Dr.  Braxton 
Hicks  at  Guy's  Hospital,  who  said  the  passage  was  too 
small,  and  would  have  to  be  stretched.  She  was  an 
in-patient  for  a  fortnight,  when  she  underwent  an  opera- 
tion the  nature  of  which  she  did  not  know.  She 
afterwards  attended  at  Gruy's  as  an  out-patient,  and 
wore  a  pessary  for  nine  months.  For  the  next  four 
years  her  condition  was  improved,  though  she  never 
felt  well.  In  June,  1888,  she  became  worse,  and 
in  December  the  pain  was  so  severe  and  she  was  so  faint 
and  sick  at  each  period  that  she  again  took  medical 
advice.  The  passage  was  again  declared  to  be  too  small, 
and  was  dilated  on  two  occasions  just  before  her  periods. 
She  was  ordered  four  or  five  hours'  rest  every  day,  and 
hot  vaginal  injections.  She  was  said  to  have  descent  of 
the  womb,  and  a  ring  pessary  was  inserted,  which  she 
wore  for  three  months.  She  then  came  under  the  care  of 
Mr.  Hosking,  of  Turner's  Hill,  complaining-  of  severe  pain 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  209 

in  the  lower  part  of  the  abdomen  on  the  left  side,  and  in 
the  right  leg.  Examination  j)er  v(((/inai)i  occasioned  great 
pain,  especially  on  the  left  side.  Nothing  gave  relief  but 
morphia  and  rest  in  bed.  These  did  much  good,  except 
to  the  pain  in  the  left  side,  but  at  the  next  period  all  the 
suffering  returned,  and  the  pain  became  so  constant  that 
Dr.  Hosking  advised  that  another  opinion  should  be  taken. 

The  abdomen  was  normal  in  appearance  and  on  palpa- 
tion. On  bimanual  examination  per  vaginam,  the  uterus 
was  found  fixed,  normal  in  size  and  position.  There  was 
no  depression  of  the  lateral  fornices.  An  irregular 
nodular  swelling  filled  up  and  depressed  the  retro-uterine 
pouch.  In  connection  with  it  a  sausage-shaped  mass 
could  be  traced  from  the  right  side  of  the  uterus,  twisted 
upon  itself,  and  descending  backwards  and  inwards 
towards  the  swelling  in  Douglas's  pouch.  An  examina- 
tion of  the  left  side  of  the  pelvis  caused  more  pain  than 
the  right,  but  nothing  abnormal  was  detected  to  account 
for  the  tenderness. 

The  diagnosis  was  suppurative  salpingitis  with  pelvic 
peritonitis.      Operation  was  advised  and  agreed  to. 

On  opening  the  abdomen  the  right  Fallopian  tube  was 
found  thickened,  and  bent  backwards  and  inwards  in  the 
direction  of  a  mass  filling  up  the  pelvis  behind  the  uterus, 
and  intimately  adherent  to  the  surrounding  peritoneum, 
which  was  enormously  thickened.  The  separation  of  this 
mass  was  difficult,  and  took  up  much  time.  During  the 
manipulations  a  quantity  of  thin  fluid,  of  a  reddish- 
brown  colour,  escaped.  On  bringing  the  mass  into  view  it 
was  seen  to  consist  of  the  cystic  right  ovary  (the  largest 
cyst  in  which  had  burst),  embraced  by  the  right  Fallopian 
tube  and  broad  ligament,  both  of  them  many  times  their 
normal  thickness.  The  tube  was  empty,  and  its  lumen  not 
appreciably  widened.  The  broad  ligament  was  soft  and 
friable,  and  the  ligature  cut  through  it,  necessitating  a 
second  ligature  around  the  pedicle.  The  left  adnexa  were 
to  all  appearances  normal,  and  were  not  disturbed.  The 
operation  lasted  1  hr.  10  min. 


300  VALUE    OF    ABDOMINAL    SECTION    IN 

Seven  hours  after  the  operation  the  patient  had  not 
rallied  from  the  shock,  and  on  removing-  the  dressings  the 
pads  were  found  so  saturated  with  blood  that  it  was 
decided  to  reopen  the  wound  and  search  for  the  bleeding" 
point.  This  was  done,  but  no  bleeding  point  was  dis- 
covered. The  pedicle  was  further  secured  by  another 
ligature.  The  infundibulo-pelvic  ligament  was  also  trans- 
fixed and  ligatured  to  make  sure  of  the  ovarian  artery. 

The  patient  never  rallied.  The  legs  were  bandaged  in 
flannel,  ether  was  given  subcutaneously,  brandy  and  water 
and  champagne  were  given  by  the  mouth,  and,  lastly,  the 
patient  Avas  placed  in  a  blanket-bath,  but  all  to  no 
purpose,  death  occurring  forty-seven  hours  after  the 
operation.  There  was  no  vomiting  throughout,  but  there 
was  more  or  less  suppression  of  urine  from  the  time  of  the 
operation.  The  quantity  drawn  off  on  the  25th  was  as 
follows  : — at  2  a.m.,  4  fl.  oz. ;  at  9  a.m.,  6  fl.  dr. ;  at  4  p.m., 
none  ;  at  midnight,  1  fl.  dr.  ;  and  at  4  a.m.  on  the  26th, 
none.  The  temperature  an  hour  after  the  operation  was 
96°  ;  for  the  next  twelve  hours  it  was  from  98°  to  98*6°  ; 
then  it  rose  100'4°,  and  from  that  time  forward  varied  from 
100-8  to  101-6. 

Dr.  Hadden  made  a  post-mortem  examination  forty- 
eight  hours  after  death.  The  wound  had  united.  The 
intestines  were  distended.  The  stomach  contained  much 
dark  green  fluid.  There  was  no  peritonitis  and  no  blood 
in  the  peritoneal  cavity.  The  bladder  was  empty.  The 
right  ureter  was  carefully  dissected  out  and  found  intact. 
Kidneys  healthy  and  pale.  Lungs  gorged  with  blood. 
Heart  nearly  empty  ;  firm  clot  in  right  auriculo-ventricular 
valve.  Uterus  large,  some  muco-pus  in  its  cavity  ;  lining 
membrane  hypertemic.  Left  Fallopian  tube  normal  in 
length,  consistence,  and  general  appeai'ance.  On  section 
it  was,  however,  found  to  contain  thick  muco-pus  along  its 
entire  length. 

I  have  described  this  disappointing  case  so  fully  that 
my  comments  upon  it  must  be  brief,  although  many  points 
suggest  themselves  for  remark.      What  was  the  origin  of 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  301 

the  pelvic  inflammatiou  ?  Was  it  septic  ?  If  so,  was  the 
infection  conveyed  on  one  of  the  occasions  when  the  cervix 
was  dilated  ?  Was  the  cystic  condition  of  the  ovary 
secondary  to  the  peritonitis  ?  What  is  the  lesson  to  be 
learnt  from  the  fact  that  the  apparently  healthy  left  tube 
was  found  after  death  to  be  full  of  pus  ?  Is  it  that 
where  one  tube  is  found  manifestly  diseased  both  tubes 
should  be  removed  ?  What  was  the  cause  of  death  ?  If 
it  was  shock,  why  was  the  shock  so  profound  ?  Was  the 
reopening  of  the  abdomen  in  any  way  accountable  for  the 
fatal  result,  and  was  it  justified  ?  These  are  some  of  the 
questions  that  suggest  themselves — questions,  it  seems  to 
me,  more  easily  asked  than  answered. 

Cases  17  to  21  have  been  published  very  fully  else- 
where :  Cases  17,  18,  and  20  in  the  'St.  Thomas's  Hos- 
pital Reports,'  vol.  xix ;  Cases  19  and  21  in  the  '  Brit. 
Med.  Journ.,'  December  27th,  1S90. 

Case  22.  Sudden  -pain  in  left  iliac  region  six  months 
after  an  attach  of  pJilegmasia  dolens  in  the  left  leg  ;  soft 
non-fuctuating  swelling  on  left  side  of  pelvis  displacing 
uterus  to  right ;  patient  very  ill,  with  high  temperature ; 
abdominal  section;  mass  situated  between  layers  of  left 
broad  ligament,  with  surrounding  adhesions ;  appendages 
healthy ;  adhesions  partially  separated  ;  tumour  not  dis- 
turbed ;  abdomen  closed ;  recovery. — A  married  woman, 
aged  27,  was  admitted  January  10th,  1890,  looking  pale 
and  ill,  and  complaining  of  great  weakness  and  of  severe 
pain  in  the  left  iliac  region.  She  had  borne  seven  chil- 
dren, all  her  labours  having  been  easy  and  natural  until 
the  last  one,  which  took  place  in  April,  1889.  On  that 
occasion  the  arm  presented,  and  delivery  took  place  under 
an  anaesthetic  in  the  Maternity  Home  at  Battersea.  About 
three  days  after  delivery  patient  was  hot  and  restless,  and 
had  pains  all  over.  She  rose  on  the  tenth  day,  but  was 
at  once  seized  with  pain  in  the  left  leg,  and  returned  to 
bed.      "  White  leg  "  supervened,  and  patient  was  laid  up 


302  VALUE    OF    ABDOMINAL    SECTION    IN 

seven  weeks  in  tlie  liospital  and  three  weeks  at  home. 
After  this  she  felt  well,  though  the  leg  ached  in  wet 
weather.  Menstruation  became  re-established,  and  con- 
tinned  regular  up  to  her  present  illness. 

On  January  4th,  in  an  interval  following  a  menstrual 
period,  patient  was  suddenly  seized  with  acute  pain  in  the 
left  side  of  the  lower  part  of  the  abdomen,  obliging  her 
at  once  to  discontinue  her  work  and  go  to  bed.  Four 
days  later,  the  pain  being  still  present,  she  commenced  to 
vomit,  rejecting  everything  she  took. 

On  admission  the  abdomen  presented  a  normal  appear- 
ance. No  tumour  could  be  seen  or  felt.  There  was 
some  tenderness  with  a  sense  of  resistance  over  the  left 
iliac  region.  Bimanually  the  uterus  was  found  anteflexed, 
the  fundus  being  pushed  somewhat  to  the  right.  The 
left  fornix  was  depressed,  the  bulging  having  an  even 
and  regular  contour.  The  tenderness  was  too  great  to 
permit  of  a  very  thorough  examination,  but  a  swelling  of 
considerable  size  could  be  made  out  on  the  left  side  of 
the  uterus,  elastic  but  not  fluctuating.  The  tissues 
around  the  upper  portion  of  the  cervix  were  swollen  both 
in  front  and  behind. 

On  the  13th  January  the  pain  had  increased,  especially 
towards  the  back.  There  was  a  sensation  of  pressure  on 
the  bowel.  The  patient  was  very  ill,  and  the  tempera- 
ture varied  between  100*2°  and  104°. 

The  diagnosis  being  pelvic  abscess,  it  was  determined 
to  open  the  abdomen  the  following  day — if  the  symptoms 
were  not  relieved  in  the  meantime.  Next  day  there  had 
been  a  slight  purulent  discharge  from  the  rectum,  mixed 
with  much  mucus,  and  the  patient  appeared  much  relieved. 
The  operation  was  therefore  postponed  until  the  l7th. 
The  temperature  on  the  14th  varied  between  101°  and 
104-2°,  on  the  15th  between  99°  and  101°,  and  on  the  16th 
between  98°  and  99-4°. 

A  further  vaginal  examination  was  made  on  the  15th. 
The  oedematous  swelling  about  the  vaginal  reflection  had 
disappeared.       Through   the    left    fornix   could  be  felt  a 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  303 

large  tense  mass,  teudcr  to  the  toucli,  continuous  with  a 
swelling-  behind  the  uterus,  pushing  it  forwards  and  to  the 
right.  The  vagina  was  shortened  on  the  left  side,  but 
there  was  no  brawny  condition  of  the  roof,  such  as  to 
indicate  the  presence  of  cellulitis. 

On  opening  the  abdomen  the  swelling  was  found  to  be 
situated  between  the  layers  of  the  left  broad  ligament. 
Its  surface  was  even,  and  its  consistence  soft  but  solid. 
It  distended  the  broad  ligament  along  its  whole  length, 
displacing  the  uterus  forwards  and  to  the  right.  There 
was  no  sulcus  between  the  uterus  and  the  swelling,  the 
uterus  being  differentiated  only  after  inserting  a  sound. 
Posteriorly  the  mass  was  adherent  to  the  tube,  ovary, 
and  pelvic  wall,  and  there  was  some  adhesive  peritonitis 
to  the  right  of  the  uterus.  After  separating  some  of  the 
adhesions  it  was  decided  not  to  interfere  further,  it 
appearing  probable  that  the  swelling  was  a  hgematoma. 
The  right  tube  and  ovary  were  normal,  and  lay  behind  the 
displaced  uterus.  A  drainage-tube  was  passed  into  the 
retro-uterine  pouch  and  the  abdomen  closed.  The  tube 
was  removed  in  six  hours.  The  temperature  for  the  first 
two  days  ranged  from  99*4°  to  102'6°;  after  that  it  seldom 
exceeded  100°. 

Three  weeks  after  the  operation  the  mass  had  dimin- 
ished considerably,  especially  at  its  outer  part,  both  in 
height  and  thickness.  The  uterus  was  in  the  middle  line. 
A  week  later  the  patient  went  home  nearly  well.  I  met 
her  some  weeks  afterwards.  She  was  veiy  well,  though 
still  conscious  of  discomfort  on  the  affected  side  after  pro- 
longed exertion. 

It  seems  probable  that  the  pus  discharged  from  the 
rectum  with  such  signal  relief  to  the  symptoms,  four 
days  after  admission,  was  due  to  the  bursting  of  a  small 
abscess.  There  was  no  evidence  of  fluctuation  in  the 
tumour  when  exposed  at  the  operation,  and  it  was,  there- 
fore, not  meddled  with.  The  suddenness  of  onset  led  me 
to  regard  the  effusion  as  a  haematoma  of  the  broad  liga- 
ment.     The  peritonitis  was  evidently  secondary. 


304  VALUE    OP    ABDOMINAL    SECTION    IN 

Case  23.  Sudden  attach  of  pain  nine  weeks  after  last 
menstruation,  followed  by  a  hasmorrhagic  discharge  froTn 
the  vagina  continuing  for  three  months,  with  an  inter- 
current attach  of  inflammation;  elastic  non fluctuating 
mass  behind  uterus  and  left  broad  ligament ;  no  change 
aj  ter  a  fortnight' s  rest;  abdominal  section;  mass  of  old 
blood-clot  enucleated  ;  uterine  appendages  not  disturbed ; 
recovery. — A  married  "woman,  aged  28,  the  mother  of  two 
children,  was  admitted  January  6th,  1890.  She  stated 
that  on  September  20th,  1889,  nine  weeks  after  the  last 
menstrual  period,  she  was  seized  somewhat  suddenly  with 
pain  in  the  lower  part  of  the  abdomen,  of  an  intermittent 
character,  with  nausea  and  faintness.  She  did  not  think 
she  was  pregnant  at  the  time,  nor  does  she  think  so  now. 
Two  days  after  this  attack  a  hsemorrhage  from  the  vagina 
commenced,  and  this  has  continued  almost  without  inter- 
mission up  to  three  days  before  her  admission,  that  is, 
for  over  three  months.  On  the  ninth  day  she  had  to  lie 
up  for  what  was  said  to  be  inflammation  of  the  womb> 
and  remained  in  bed  for  three  weeks.  Defecation  was 
preceded  by  severe  pain. 

On  admission  she  was  somewhat  anaemic.  She  had  no 
abdominal  swelling ;  the  abdominal  muscles  were  flaccid  j 
there  was  some  tenderness  in  the  left  iliac  region.  An 
oval  swelling  of  the  size  of  an  orange  was  discovered,  on 
bimanual  examination,  behind  the  uterus  and  the  left 
broad  ligament.  The  swelling  was  smooth  and  elastic, 
but  non-fluctuating  ;  its  long  axis  was  directed  forwards 
and  to  the  left ;  it  was  moveable  within  certain  narrow 
limits,  and  could  be  traced  as  being  closely  connected 
with  the  left  uterine  appendages. 

There  was  at  this  time  no  hgemorrhage  or  pain.  The 
temperature  was  normal. 

No  change  having  taken  place  in  tiie  swelling  after 
a  fortnight's  rest  in  bed,  abdominal  section  was  pro- 
posed and  agreed  to. 

The  operation  took  place  on  January  21st,  1890.  The 
uterus  was  pushed  forwards  by  a  mass  behind,  which  was 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  305 

closed  in  by  adhesions.  The  adhesions  having  been 
partially  separated,  the  mass  was  enucleated,  two  or  three 
fluid  ounces  of  serum  escaping  during  the  process.  When 
removed,  the  mass  was  found  to  be  composed  of  an  outer 
wall  of  firm  blood-clot,  containing  within  it  a  quantity  of 
soft,  disintegrating  blood-clot  of  a  brown  colour.  No 
trace  of  organised  structure  could  be  detected.  The  mass 
measured  3  inches  by  2  inches.  The  cavity  left  had  a 
smooth  internal  surface,  and  was  encircled  by  the  broad 
ligaments,  tubes,  and  ovaries,  and  posteriorly  was  bounded 
by  the  pelvic  wall.  The  uterine  appendages  presented 
no  marked  lesion,  and  were  not  disturbed.  The  cavity 
was  douched  with  hot  boracic  solution  ;  a  drainage-tube 
was  inserted,  and  kept  in  for  forty-eight  hours. 

The  patient  made  a  rapid  recovery,  the  temperature 
never  exceeding  100°. 

Three  weeks  after  the  operation  a  vaginal  examination 
was  made.  No  swelling  or  other  abnormal  condition  was 
detected.      She  went  out  next  day,  feeling  quite  well. 

It  seems  to  me  very  probable  that  this  was  a  case  of 
so-called  tubal  abortion.  As  no  foetal  remains,  however, 
were  discovered,  the  origin  of  the  haematocele  must  re- 
main mei'e  matter  of  conjecture. 

This  patient  would  no  doubt  have  made  a  satisfactory 
recovery  without  operation.  Had  I  diagnosed  the  case 
as  one  of  haematocele,  I  should  have  certainly  postponed 
operative  interference,  and  tried  the  effect  of  prolonged 
rest.  Having,  however,  opened  the  abdomen,  it  was  ob- 
viously one's  duty  to  remove  the  effused  blood.  This 
was  all  that  was  done,  and  the  only  result  of  the  opera- 
tion to  the  patient  was  that  her  recovery  was  hastened. 

Case  24.  Pelvic  peritonitis  with  constant  vomiting, 
following  a  chronic  purulent  vaginal  discharge ;  abdo- 
minal section;  chronic  interstitial  inflammation  of  both 
tubes  with  adhesions  matting  together  tubes  and  ovaries  ; 
both  tubes  and  both  ovaries  removed  ;  persistent  vomiting 
during  convalescence  with  alarming  prostration  ;  recovery  ; 


306  VALUE    OF    ABDOMINAL    SECTION    IN 

re-establishment  of  menstruation. — A  muscular,  healthy- 
looking  girl  aged  18,  a  lady  cricketer  by  profession, 
applied  for  admission  on  March  24thj  1890,  on  account  of 
severe  pain  in  the  left  iliac  region,  which  had  commenced 
four  weeks  previously  during  a  menstrual  period.  She 
was  unmarried,  but  had  been  leading  an  irregular  life 
since  the  age  of  sixteen.  She  stated  that  she  had  had  a 
yellowish-white  discharge  from  the  vagina  for  two  years, 
and  that  lately  the  discharge  had  become  thicker  and 
yellower.  A  week  before  admission  she  had  a  lump  in 
the  left  groin. 

On  admission  her  temperature  was  100'2  .  The 
abdomen  was  somewhat  distended,  and  its  walls  rigid. 
A  bimanual  examination  revealed  a  tense,  somewhat 
elongated  swelling,  the  size  of  a  small  apple,  in  the  left 
posterior  quarter  of  the  pelvis.  High  up  behind  the  uterus 
was  a  small  hard  body,  thought  to  be  a  displaced  and  ad- 
herent ovary.     The  uterus  was  normal  in  size  and  position. 

A  fortnight  after  admission  vomiting  set  in,  and  for 
several  days  every  meal  was  rejected.  There  was  paiu 
in  the  back  and  at  the  epigastrium.  The  swelling  in  the 
side  of  the  pelvis  had  become  more  defined,  and  it  could 
now  be  made  out  that  the  left  tube  was  thickened  and 
adherent,  and  embraced  an  ovary  of  the  normal  size. 
No  swelling  was  detected  on  the  right. 

Abdominal  section  was  performed  on  April  10th.  The 
tube  on  each  side  was  found  thickened  and  adherent. 
The  ovaries  were  healthy,  but  so  completely  involved  in 
the  adhesions  that  it  was  necessary  to  remove  them 
along  with  the  tubes.  The  right  tube  was  the  thicker  of 
the  two,  being  \  inch  in  diameter.  The  diameter  of  the 
left  tube  was  equal  to  that  of  a  large  goose-quill. 
Neither  tube  contained  pus.  The  mucous  membrane  was 
normal  in  appearance.  The  fimbriated  extremity  in  both, 
tubes  was  bent  sharply  on  itself,  the  orifice  in  each  case 
barely  admitting  an  ordinary  internal  sound.  There  was 
some  vomiting  for  the  first  two  days.  It  then  ceased  for 
two   days,   but    on    April    14th    it  recommenced   without 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  307 

obvious  cause,  and  continued  day  by  day  until  the  patient's 
condition  became  alarming.  She  lost  llesh,  aud  became 
dark  and  sunken  about  the  eyes.  On  April  25th  the 
climax  was  reached.  The  resident  was  summoned  at 
seven  in  the  morning-.  He  found  the  patient  very  ill, 
with  a  dry  coated  tongue  and  a  pulse  of  130,  and  com- 
plaining of  severe  abdominal  pain.  A  few  hours  later 
the  pulse  was  140,  the  voice  had  changed  and  become 
hollow,  and  the  dark  rings  around  the  eyes  were  very 
marked.  She  complained  of  a  sensation  in  the  head  as 
of  "  a  raging  storm.''  She  had  all  the  appearance  o£ 
impending  death.  From  that  time,  however,  she  gradu- 
ally improved.  The  voice  resumed  its  natural  tone,  and 
on  the  29th  April  the  vomiting  finally  ceased.  On  the 
1st  May  her  appetite  returned,  and  on  the  14tli  she  was 
able  to  be  sent  to  a  convalescent  home. 

I  did  not  see  her  again  until  the  25th  July,  1891,  when 
she  presented  herself  at  the  out-patient  room,  having  had 
continuous  hagmorrhage  for  seven  weeks.  She  was  look- 
ing well  and  in  good  condition.  She  had  had  no  pelvic 
pain  since  leaving  the  hospital.  Two  months  after  the 
operation  she  menstruated,  and  had  menstruated  regularly 
up  to  the  commencement  of  the  hasmorrhage  for  which 
she  now  sought  advice.  She  had  been  employed  as  a 
waitress,  and  had  been  on  her  feet  all  da}-.  She  had  had 
no  flushings  of  the  face,  but  had  recently  been  subject  to 
fainting.  On  examination  the  uterus  was  normal,  and  no 
swelling  could  be  felt  on  either  side  of  the  pelvis.  On 
March  5th,  1892,  she  was  in  excellent  health,  and  was 
still  menstruating  regularly. 

I  was  loth  to  operate  on  so  young  a  patient,  and  did  so 
only  because  I  believed  that  there  was  suppuration  in  the 
pelvis,  and  that  the  vomiting  and  rise  of  temperature 
were  due  to  septic  absorption.  I  was  surprised  not  to 
find  pus.  On  another  point  the  diagnosis  was  defective. 
I  had  only  discovered  the  mischief  on  the  left  side, 
whereas  that  on  the  ricfht  was  even  more  marked. 

The  vomiting,   which  assumed  such  a  dangerous  form 


308  VALUE    OP    ABDOMINAL    SECTION    IN 

during  convalescence,  I  am  quite  unable  to  account  for, 
unless  there  was  some  independent  affection  of  the  stomach. 
The  bowels  acted  well,  and  there  was  no  albuminuria. 

It  is  interesting  to  note  the  re-establishment  of  men- 
struation, notwithstanding  the  removal  of  the  ovaries  and 
tubes.  The  important  point  is  that  the  pelvic  pain  has 
entirely  disappeared,  and  that  the  health  is  completely 
restored. 

Case  25.  Severe  attach  of  pelvic  peritojiitis,  lasting  four 
months;  temporary  improvement,  followed  by  a  recurrence 
of  the  infammation,  ivith  general  abdominal  swelling  and 
symptoms  of  septic  absorption ;  occasional  discharges  of 
ojfensive  pus  from  the  bowel;  ill-defined  dulness  and  resist- 
ance on  left  side  ;  abdominal  section ;  two  suppurating 
tubo-ovarian  cysts,  one  on  each  side,  that  on  the  left  situated 
in  the  abdomen,  that  on  the  right  in  the  pelvis  ;  rapid  pulse 
for  four  days  ;  pain  and  rise  of  temperature  during  second, 
third,  and  fourth  weeJcs  ;  recovery. — The  wife  of  a  shop- 
keeper at  Slough  was  admitted  to  St.  Thomas's  Home  on 
May  17th,  1890,  under  my  care.  She  was  thirty-eight 
years  of  age,  and  had  no  children.  She  had  a  miscarriage 
six  years  ago,  and  has  had  more  or  less  pain  on  the  left 
side  ever  since. 

In  August,  1889,  while  on  a  visit  to  Margate,  she  got 
wet.  The  next  day  she  became  overheated  whilst  danc- 
ing, and  the  day  following  was  out  for  some  time  on  the 
water.  Next  morning  she  was  taken  very  ill  with  severe 
pain  in  the  lower  part  of  the  abdomen.  Being  no  better 
after  four  or  five  days,  a  doctor  was  called  in,  and  she  was 
in  bed  and  very  ill  for  three  or  four  months.  Twice  dur- 
ing this  illness  she  had  a  discharge  from  the  bowel  of 
horribly  offensive  pus.  At  the  end  of  the  period  named 
she  was  sufficiently  better  to  get  up  and  walk  about.  She 
returned  home  to  Slough,  but  in  a  week  or  two  became 
ill  again.  There  had  been  harduess  and  resistance  in  the 
left  iliac  region  whilst  at  Margate.  Now  there  occurred 
general  abdominal  swelling,  and  patient  became  even  more 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  309 

sick  than  during  her  previous  illness.  She  also  had  diffi- 
culty in  micturition.  In  March,  1890,  when  her  present 
medical  attendant  was  first  called  in,  her  temperature 
averaged  100°  in  the  morning  aud  103°  in  the  evening. 
There  was  obstinate  constipation  and  an  irregular  swell- 
ing in  the  abdomen,  extending  on  the  left  side  to  the  lower 
costal  cartilages,  fairly  smooth  and  soft  on  the  left  side, 
lumpy  about  the  umbilicus  and  dull  all  over  on  percussion. 
On  bimanual  examination  the  lumps  could  be  moved  en 
masse  between  the  hands.  High  up  behind  the  cervix 
was  a  uniform  elastic  swelling.  On  March  5th  there 
occurred  for  the  third  time  an  offensive  purulent  discharge 
from  the  bowel.  This  gave  great  relief,  and  was  followed 
by  a  fall  of  temperature.  On  March  10th  the  tempera- 
ture became  normal,  and  has  remained  so.  A  menstrual 
flow  occurred  in  March,  but  not  since. 

On  admission  there  was  considerable  swelling  of  the 
abdomen,  with  hardness  and  resistance  on  the  left  side, 
and  a  rounded  prominence  in  the  middle  line.  The  cervix 
uteri  was  pushed  upwards  and  forwards,  the  os  uteri  being 
above  the  upper  margin  of  the  symphysis  pubis.  The 
sound  passed  three  inches  ;  its  point  entered  the  rounded 
swelling  in  the  middle  line  of  the  abdomen,  and  could  be 
distinctly  felt  an  inch  below  the  umbilicus  and  a  little  to 
the  right.  A  large,  smooth,  uniform,  fluctuating  swelling 
occupied  and  depressed  the  retro-uterine  pouch.  There 
was  a  distinct  sulcus  between  the  swelling  and  the  poste- 
rior vaginal  wall. 

The  patient  was  not  in  pain,  but  was  extremely  ill  and 
helpless.  The  motions  were  still  offensive,  and  the  bowels 
did  not  act  without  assistance. 

An  enema  was  administered,  and  brought  away  large 
masses  of  hard  lumpy  fgeces. 

Abdominal  section  was  performed  on  May  19th.  The 
uterus  was  situated  high  up  in  the  middle  line  immedi- 
ately beneath  the  abdominal  wall.  It  was  enlarged,  and 
presented  on  its  peritoneal  surface  several  sessile  fibroids. 
Both  Fallopian  tubes  were  thickened  and  elongated,  and 


310  VALUE    OF    ABDOMINAL    SECTION    IN 

lay  stretched  over  the  surface  of  large  thick-walled  cystic 
swelliugs.  That  on  the  left  side  extended  from  below  the 
posterior  part  of  the  brim  of  the  pelvis  upwards  to  the 
lower  costal  margins  ;  it  was  adherent  to  the  omentum, 
to  the  peritoneum  lining  the  iliac  fossa,  to  the  posterior 
surface  of  the  broad  ligament,  to  the  tumour  on  the 
opposite  side,  and  to  the  back  of  the  cervix  uteri.  Its 
wall  gave  way  during  removal,  and  about  a  pint  of  blood- 
stained pus  escaped.  The  other  cyst  connected  with  the 
right  tube,  dipped  deeply  behind  the  uterus,  filling  the 
sacral  cavity  and  right  side  of  the  pelvis.  It  was  of  a 
similar  character  to  the  one  on  the  left  side.  During  the 
separation  of  the  extremely  firm  adhesions  to  the  cervix 
uteri  and  right  broad  ligament  the  wall  of  the  cyst  gave 
way.  The  tumours  were  removed  by  transfixion,  ligature, 
and  division  of  their  pedicles,  consisting  of  the  uterine 
end  of  the  tube  and  the  thickened  broad  ligament.  A 
large  thick  mass  of  inflamed  and  adherent  omentum  was 
ligatured  and  removed.  The  operation  lasted  two  hours  ; 
at  the  end  of  the  first  hour  the  patient  became  very  livid, 
and  remained  so  to  the  end. 

The  tumours  proved  to  be  suppurating  ovarian  cysts, 
with  the  Fallopian  tubes  opening  into  them.  The  open- 
ing on  the  left  side  was  large  enough  to  admit  the  little 
finger,  that  on  the  right  was  smaller.  The  left  cyst  in 
its  empty  and  collapsed  state  measured  four  inches  in 
diameter  ;  the  right  measured  six  inches  in  its  long  dia- 
meter, five  inches  in  its  shorter.  On  the  wall  of  the  left 
cyst  were  several  daughter-cysts. 

The  patient  eventually  made  a  good  recovery.  The 
pulse  was  rapid  (over  130)  for  the  first  four  days,  though 
the  temperature  was  normal.  There  was  no  sickness  or 
abdominal  distension.  The  bowels  acted  spontaneously 
on  the  fifth  day,  and  more  freely  after  an  enema.  Dur- 
ing the  second,  third,  and  fourth  weeks  the  temperature 
and  pulse  rose,  and  there  were  some  dulness,  pain,  and 
resistance  in  both  iliac  fossae,  Avith  slight  purulent  dis- 
charge from  the  lower  angle  of  the  wound.      In  the  fifth 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  311 

week  tlie  pain  became  mucli  less  and  the  temperature  and 
pulse  normal.  There  was  still  some  purulent  discharge 
when  she  left  the  home. 

Six  months  after  she  went  home  her  medical  attendant 
wrote  to  me  that  the  patient  was  walking  about  and 
attending  in  her  husband's  shop.  There  was  still  some 
purulent  discharge  from  the  sinus,  generally  very  little, 
but  sometimes  a  good  deal.  She  had  menstruated  four 
times. 

In  Februai'y,  1891,  she  was  stout  and  well.  There  was 
no  swelling  discoverable  on  pelvic  examination.  The 
sinus  was  still  discharging,  but  very  slightly.  Menstru- 
ation still  continued,  sometimes  every  month,  and  some- 
times at  intervals  of  two  months.  Her  only  complaint 
was  of  backache  after  exertion.  I  saw  her  again  in 
October,  1891  ;  she  was  still  looking  well.  The  sinus  was 
discharging  very  slightly  indeed.  She  serves  in  her 
husband's  shop  twelve  hours  a  day.  Menstruation  has 
only  occurred  once  during  the  past  eight  months. 

August  16th,  1892. — Sinus  closed  eight  months  ago. 
Slight  tendency  to  hernia  at  lower  end  of  scar.  Men- 
struation irregular,  sometimes  every  month,  sometimes 
every  three  months.  Complains  of  indigestion,  otherwise 
quite  well. 

It  may  be  objected  that  this  case  would  have  appeared 
more  appropriately  under  the  head  of  ovariotomy  than  in 
the  present  series.  To  this  I  would  reply  that  when  the 
patient  first  came  under  my  observation  there  was  no 
definite  abdominal  tumour  to  be  made  out,  and  that  the 
data  necessary  for  arriving  at  a  detailed  diagnosis  were 
not  available.  The  operation  was  undertaken,  as  a  matter 
of  fact,  for  the  relief  of  recurrent  peritonitis,  believed  to  be 
due  to  pelvic  suppuration. 

Nothing  short  of  bold  surgical  treatment  could,  in  my 
opinion,  have  saved  this  patient's  life.  The  operation,  as 
may  be  imagined,  was  difficult  and  prolonged,  and  indeed 
dangerous  ;  but  what  was  the  alternative  ?  Either  things 
must  have  been  left  to  take   their  course,  or  one   might 


312  VALUE    OF    ABDOMINAL    SECTION    IN 

liave  been  conteut  with  emptying  and  draining  the  sup- 
purating cysts  instead  of  removing  them.  In  the  former 
case  death  would  almost  have  been  inevitable  ;  in  the 
latter,  even  supposing  recovery  to  have  taken  place,  it 
would  have  been  much  more  prolonged,  and  would  almost 
certainly  have  been  followed  by  a  serious  hernial  protru- 
sion at  the  abdominal  wound. 


Part  II. — Cases  26  to  50. 

Case  26.  Pelvic  peritonitis  with  signs  of  tubal  inflam- 
mation on  hath  sides,  and  a  small  tense  swelling  on  left 
side  of  pelvis  pushing  uterus  to  right  of  middle  line ; 
further  development  whilst  under  observation  j  abdominal 
section  ;  both  tubes  thickened,  adherent,  and  occluded  ;  left 
ovary  enlarged  and  cystic,  one  cyst  suppurating  ;  removal 
of  right  tube,  and  of  left  tube  and  left  ovary  ;  abscess  at 
lower  angle  of  ivound  on  the  eleventh  day  ;  recovery. — The 
patient,  a  laundress,  aged  25,  married,  was  admitted 
May  5th,  1890,  on  account  of  pain  in  the  left  iliac  region, 
haemorrhage,  loss  of  appetite,  and  general  weakness.  She 
had  borne  one  child  at  full  term  in  January,  1888,  her 
recovery  being  on  that  occasion  rapid  and  satisfactory. 
In  April,  1889,  she  miscarried,  at  two  months,  of  twins. 
Since  then  she  has  never  felt  well,  but  there  were  no 
definite  symptoms  until  twelve  months  after,  namely, 
three  weeks  before  her  admission.  Menstruation  had 
been  regular.  Her  last  period  commenced  on  April  23rd, 
1890  ;  it  lasted  a  week.  A  day  or  two  later  the  flow 
recommenced  and  has  continued  up  to  her  admission,  the 
discharge  latterly  having  been  dark  and  clotted.  There 
has  been  a  good  deal  of  pain  in  the  left  iliac  region,  and 
during  the  past  few  days  there  have  been  pain  and  diffi- 
culty in  micturition,  pain  in  the  lower  bowel,  and  consti- 
pation. There  is  no  history  of  sickness  or  sudden  pain. 
Patient  has  lost  flesh  ;  her  appetite  has  failed,  and  she 
feels  weak. 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  313 

She  is  a  liglit-complexioned  woman,  pale  and  anaemic. 

Nothing  abnormal  is  noticed  in  the  appearance  of  the 
abdomen.  On  palpation  a  swelling  is  felt  in  the  left 
iliac  region,  with  a  well-defined  upper  margin  an  inch 
above  the  level  of  the  anterior  superior  spine.  It 
extends  a  little  beyond  the  middle  line  towards  the  right 
side.  It  is  comparatively  dull  on  percussion,  and  some- 
what tender. 

The  uterus  is  fixed,  slightly  retroflexed  and  deflected 
to  the  right  side,  and  of  normal  length.  The  left  fornix 
is  somewhat  depressed  by  a  tense,  tender  swelling  in  the 
left  posterior  quarter  of  the  pelvis,  extending  from  the 
uterus  outwards  to  the  lateral  wall  of  the  pelvis,  and 
moveable  to  a  very  limited  extent  antero-posteriorly. 

The  temperature  and  pulse  normal. 

Urine  free  from  albumen. 

During  the  fortnight  following  admission  the  physical 
signs  underwent  several  important  changes.  On  May 
10th  there  was  observed  a  tongue-shaped,  smooth,  elastic 
swelling  between  the  rectum  and  the  upper  part  of  the 
posterior  vaginal  wall,  evidently  due  to  effusion  in 
Douglas's  pouch.  For  several  days  patient  suffered  from 
vesical  and  rectal  tenesmus,  and  frequently  passed  mucus 
like  white  of  ego:  from  the  bowel.  Otherwise  she  was 
feeling  well  and  free  from  pain.  The  temperature 
ranged  from  normal  to  101*2°.  On  May  15th  the  poste- 
rior swelling  had  become  smaller  and  less  tense  ;  that  on 
the  left  side  remained  as  before.  On  the  18th  both 
Fallopian  tubes  were  felt  thickened,  their  outer  portions 
flexed  and  adherent  behind  their  respective  broad  liga- 
ments. The  left  tube  lay  in  a  plane  somewhat  anterior 
to  that  in  which  the  right  one  was  lying.  The  uterus  was 
still  a  little  to  the  right  of  the  middle  line,  and  the  swell- 
ing on  the  left  remained  unaltered. 

Abdominal  section  was  proposed  to  the  patient,  but  as 
her  pain  had  greatly  diminished  she  did  not  at  first  give 
consent.  In  a  day  or  two,  however,  she  expressed  her 
willingness  to  undergo  the  operation. 

VOL.  XXXIV.  23 


314  VALUE    OP    ABDOMINAL    SECTION    IN 

On  May  22nd  an  incision  of  three  inches  in  length 
was  made  in  the  middle  line  of  the  abdomen.  The 
uterus  was  found  fixed  to  the  right  of  the  middle  line, 
the  upper  part  of  the  cervix  being  adherent  posteriorly, 
obliterating  Douglas's  pouch.  The  right  tube  was  flexed 
upon  itself,  and  adherent  behind  the  right  border  of  the 
uterus.  The  ovary,  normal,  but  universally  adherent, 
was  embraced  by  the  tube.  The  left  tube  was  found 
with  difficulty.  It  was  coiled  upon  itself  and  lay  em- 
bedded in  a  cavity  shut  off  by  adhesions.  The  left  ovary 
was  enlarged  to  the  size  of  a  hen's  egg,  cystic  and 
adherent  throughout.  It  lay  behind  the  left  broad  liga- 
ment. The  left  ovary  and  tube  were  separated  first,  the 
manipulations  being  difficult  and  prolonged.  In  bring- 
ing the  parts  to  the  surface  two  cysts  gave  way  in  the 
ovary,  one  containing  blood-stained  mucus,  the  other  puru- 
lent fluid.  The  fimbriated  end  of  the  tube  was  occluded, 
the  fimbriae  being  indistinguishable.  About  1|  inches 
of  the  outer  end  of  the  tube  Avas  removed  with  the  di- 
seased ovary.  The  inner  portion  of  the  tube — measuring 
about  3  inches  in  length — was  left,  the  adhesions  being 
so  firm  and  deeply  seated  as  to  render  removal  nearer  the 
uterus  almost  impracticable.  The  right  tube  was  noAV 
with  much  difficulty  separated  from  its  adhesions.  The 
whole  tube,  thickened  to  the  size  of  the  forefinger,  was 
removed.  Its  fimbriated  end  was  occluded,  and  around 
the  closed  end  was  a  mass  of  hard  yellow  material  like 
altered  lymph.  The  ovary  being  of  normal  size,  and 
being  bound  down  by  a  firm  peritoneal  band,  was  left 
undisturbed.  The  abdominal  cavity  was  douched  and  a 
drainage-tube  inserted.  The  operation  lasted  an  hour 
and  a  half. 

The  patient  had  no  untoward  symptom  until  the  seventh 
day,  when  she  did  not  feel  well,  and  there  was  some  cir- 
cumscribed hardness  and  tenderness  on  the  left  side. 
On  the  eleventh  day  a  large  quantity  of  thick  blood- 
stained pus  escaped  from  the  lower  angle  of  the  wound. 
After  this  the  patient  was   much  more   comfortable,   and 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  315 

the  hardness  disappeared.  A  fortnight  later  she  went 
home,  the  discharge  having  almost  ceased.  A  stitch 
came  away  at  the  end  of  August,  and  the  sinus  then 
closed. 

She  presented  herself,  at  my  request,  on  September  26th, 
1891,  looking  stout  and  well.  She  had  had  no  pain,  had 
menstruated  regularly,  and  had  been  in  perfect  health 
ever  since  her  discharge  from  the  hospital. 

October  22nd,  1892. — Continues  well  and  strong,  and 
free  from  pain.  Menstruates  regularly.  Has  a  slight 
hernial  protrusion  in  two  or  three  places  along  the  wound. 

The  portion  of  the  left  tube  removed  was  much  thick- 
ened. Its  mucous  membrane  presented  a  number  of 
minute  transparent  elevations  (?  tubercles),  and  in  the 
tube  wall  there  were  several  patches  of  softened  and  dis- 
coloured tissue  of  the  size  of  a  pea.  Some  flakes  of  lymph 
were  found  in  the  tube,  but  no  pus.  The  right  tube  only 
contained  some  mucus. 

This  case  is  a  typical  example  of  a  very  numerous 
group,  in  which  inflammation  of  both  Fallopian  tubes  is 
associated  with  cystic  degeneration  of  one  or  both  ovaries, 
and  in  which  the  seat  of  the  suppuration  underlying  the 
pelvic  peritonitis  is  not  tubal  but  ovarian.  Very  often,  as 
in  this  case,  only  one  comparatively  small  cyst  is  found  in  a 
state  of  suppuration,  the  remaining  cysts  containing  fluid 
of  the  character  usual  in  cystic  adenoma  of  the  ovary. 
Sometimes  the  contents  of  several  of  the  cysts  have 
become  purulent.  This  suppuration  is  probably  owing  to 
the  invasion  of  the  ovary  by  infective  micro-organisms 
from  the  neio-hbourinsc  tube. 

These  cases  seem  to  me  to  have  an  important  bearing 
on  the  etiology  of  suppurating  tubo-ovarian  cysts,  as 
showing  that  ulceration  of  the  walls  of  an  ovarian  cyst 
leading  to  a  communication  between  tube  and  ovary  may 
commence  from  within  as  well  as  from  without, — that  is  to 
say,  may  originate  from  suppuration  within  the  ovary  as 
well  as  from  suppuration  in  the  tube.  I  shall  have  some- 
thing more  to  say  on  this  subject  later  on. 


816  VALUE    OF    ABDOMINAL    SECTION    IN 

Case  27.  Acute  pelvic  inflammation  foUoiving  exposure 
to  rain  and  cold  six  iveeks  after  confinement  ;  recovery,  fol- 
lowed by  fourteen  months  of  apparently  good  health  ;  re- 
admission  for  persistent  haemorrhage  ;  signs  of  chronic  pelvic 
peritonitis,  ivith  thicl'ening,  displacement,  and  fixation  of 
both  tubes  j  removal  of  both  tubes  and  both  ovaries  by  ab- 
dominal section  ;  loose  pus-cells  discovered  by  the  microscope 
in  the  lumen  of  the  tube,  but  no  j^ii-i' silent  collection  visible 
to  the  unaided  eye  ;  abdominal  ostia  of  tubes  much  con- 
tracted and  adherent;  recovery. — A  young  widow,  aged 
23;  was  first  admitted  into  Adelaide  Ward  in  December, 
1888,  nine  weeks  after  her  first  confinement.  She  had 
been  an  inmate  of  the  surgical  wards  on  account  of  breast 
abscess,  and,  happening  to  be  discharged  on  a  wet  day, 
got  her  clothing  wet  through  on  her  way  home.  During 
the  night  she  was  attacked  with  severe  pain  in  the  lower 
part  of  the  abdomen,  shooting  down  the  thighs.  The 
pain  continued  up  to  the  time  of  her  admission,  three 
weeks  later.  On  admission  a  hard  ridge  of  inflammatory 
exudation  was  felt  between  bladder  and  cervix  (anterior 
parametritis).  A  few  days  afterwards  the  hardness,  dimin- 
isbing  in  front,  had  extended  to  the  left  broad  ligament, 
which  could  be  felt  as  a  hard  flattened  mass,  moveable 
within  certain  narrow  limits  independently  of  the  uterus. 
On  January  4th  the  cellulitic  exudation  had  subsided  sufii- 
ciently  to  permit  the  mapping  out  of  the  Fallopian  tubes, 
which  could  be  felt  as  firm  cords  running  outwards,  one 
on  each  side,  from  the  body  of  the  acutely  anteflexed 
uterus  along  the  free  border  of  the  broad  ligament.  The 
patient  rapidly  improved,  and  left  the  hospital  free  from 
pain  and  with  a  normal  temperature  on  January  19th, 
1889. 

After  leaving  the  hospital  she  remained  well  and  able 
to  do  her  work  for  fourteen  months.  At  the  beginning 
of  April,  1890,  after  having  had  a  yellow  vaginal  discharge 
for  a  fortnight,  she  had  to  leave  her  work  on  account  of 
persistent  haemorrhage. 

On  May   17th,  1890,  she  was  readmitted  to  Adelaide 


CERTAIN    CASES    OF    PELVIC    PERITONITIS,  317 

Ward,  the  liaemorrliage  having  then  lasted  for  five  weeks. 
On  the  23rd  she  was  examined  under  an  anaesthetic.  The 
uterus  was  in  normal  position.  There  was  a  hard  irregular 
swelling  in  both  posterior  quarters  of  the  pelvis,  more 
marked  on  the  right,  where  the  tube  could  be  made  out 
distinctly  as  a  thick  cord  bent  backwards  upon  itself, 
and  dipping  down  behind  the  uterus.  On  the  same  side 
there  was  also  a  softer  and  more  circumscribed  swelling, 
thought  to  be  the  prolapsed  ovary.  There  was  much  ten- 
derness in  the  situation  of  Douglas's  pouch.  Four  days 
later  there  was  a  tense  fluctuating  swelling  in  Douglas's 
pouch.  This  gradually  subsided,  leaving  an  irregular 
hardness,  distinctly  nodulated,  and  the  thickened  and  ad- 
herent right  tube  could  again  be  clearly  defined. 

On  June  6th  an  incision  three  and  a  half  inches  long 
was  made  in  the  middle  line.  On  passing  the  fingers  into 
the  pelvis  a  quantity  of  serum  escaped.  Tracing  the  right 
tube  from  the  cornu  of  the  uterus  it  was  found  thickened, 
bent  on  itself,  and  adherent  behind  the  broad  ligament 
and  the  uterus,  enclosing  within  its  fold  the  ovary,  which 
was  enlarged  to  the  size  of  a  pigeon's  egg,  and  contained 
several  cysts,  one  of  w-hich  was  filled  with  pus.  The  tube 
and  ovary  were  separated  and  removed.  The  left  tube 
and  ovary  were  universally  adherent,  though  apparently 
themselves  unaltered.  These  were  also  separated  and  re- 
moved. There  were  still  some  thickened  irregular  masses 
at  the  bottom  of  the  retro-uterine  pouch,  but  as  it  seemed 
certain  these  were  only  portions  of  thickened  omentum 
they  were  not  disturbed.  The  abdomen  was  irrigated 
with  hot  solution  of  boracic  acid,  and  then  cleansed  by 
sponging.  A  drainage-tube  was  inserted  and  the  wound 
closed.  The  opei^tion  lasted  an  hour  and  twenty-five 
minutes. 

On  examination  of  the  parts  removed,  the  right  tube 
was  found  thickened  to  a  diameter  of  half  an  inch,  the 
wall,  on  section,  measuring  from  three  sixteenths  to  a 
quarter  of  an  inch  in  thickness.  The  external  surface 
was  covered  with  vascular  shreds  of  adherent  peritoneum. 


318  VALUE    OF    ABDOMINAL    SECTION    IN 

The  mucous  membrane  was  swollen  and  oedematous.  The 
opening  at  the  fimbriated  end  was  contracted  to  the  size 
of  a  mere  pin-hole  ;  the  fimbriae  were  thrown  back  and 
adherent.  Ko  fluid  was  visible  in  the  canal.  A  section 
of  the  tube  was  examined  under  the  microscope  by  Mr. 
Shattock,  who  reported  small- celled  infiltration^  with  a 
few  loose  pus-cells  in  the  lumen  of  the  tube.  The  left 
tube  was  thickened  to  the  size  of  a  goose-quill,  denser 
and  firmer  than  normal.  The  mucous  membrane  of  the 
outermost  inch  was  livid,  swollen,  and  soft  ;  the  rest  was 
normal.  The  fimbriated  end  was  narrowed,  but  still  per- 
vious. Portions  of  both  ovaries  had  been  left  in  the 
pedicle  on  the  distal  side  of  the  ligature. 

The  patient  had  a  slight  rise  of  temperature  on  the 
evening  of  the  fifteenth  day,  with  some  abdominal  pain, 
followed  by  swelling  and  tenderness  behind  and  to  the 
right  of  the  uterus.  These  symptoms  subsided  in  a  few 
days,  and  on  July  10th  she  was  sent  to  a  convalescent 
home  feeling  very  well. 

On  April  2nd,  1891,  I  met  the  patient  looking  stout 
and  well.  Her  complexion,  which  had  been  pale  and 
sallow,  had  assumed  a  healthy  colour.  She  was  free  from 
pain.  There  had  been  ameiiorrhoea  for  four  or  five 
months  after  the  operation,  since  which  time  she  had 
menstruated  regularly. 

January  7th,  1893. — Well  and  strong,  and  free  from 
pain  except  at  the  menstrual  periods,  which  are  quite 
regular,  but  for  the  last  six  months  have  been  painful. 
Married  a  second  time  two  years  ago.  Vaginal  examina- 
tion reveals  nothing  to  account  for  the  dysmenorrhoea. 

This  was  a  case  in  which  prolonged  rest  would  in  all 
probability  have  resulted  in  cure.  The  patient,  however, 
being  a  widow,  and  dependent  on  her  own  exertions  for 
a  livelihood,  naturally  preferred  a  shorter  and  more  certain 
method  of  treatment,  fully  appreciating  and  accepting  the 
physiological  consequences.  I  was  sui-prised  not  to  find 
a  larger  collection  of  pus  in  the  tubes.  The  microscope, 
however,  proved  that  it  was  there,  though  in  small  quan- 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  319 

tity.  The  re-establisliment  of  menstruation  was  probably 
due  to  a  portion  of  the  ovary  having  been  unavoidably 
left  in  the  pedicle,  the  ligature  below  the  portion  so  left 
not  having  completely  destroyed  its  functions. 

Case  28.  Recurrent  pelvic  peritonitis  ;  constant  pain  in 
hacJo  and  lower  part  of  abdomen;  uterus  elevated  and 
displaced  forwards ;  large  tense  swelling  on  left,  hard 
irregular  mass  on  right;  abdominal  section;  purulent 
salpingitis  on  right  side  icith  suppurating  intra-peritoneal 
hasmatocele  ;  inflamed  and  adherent  intestine  in  left  pos- 
terior quarter  of  p)elvis  ;  left  tube  and  ovary  not  found ; 
recovery. — A  married  woman,  aged  34,  residing  at 
Streatham,  was  admitted  June  23rd,  1890,  complaining  of 
constant  pain  in  the  lower  part  of  the  abdomen  and  in 
the  back. 

She  was  married  at  twenty-one,  and  had  had  four 
children,  the  last  one  five  years  ago.  Two  days  after 
the  birth  of  her  first  child  she. had  an  attack  of  inflamma- 
tion, but  she  was  able  to  be  up  on  the  tenth  day,  and 
had  no  further  trouble.  About  two  years  ago  she  had 
another  attack  of  internal  inflammation,  supposed  to  be 
due  to  a  chill  during  menstruation.  She  was  poulticed 
and  syringed,  and  recovered  in  a  few  days.  She  was 
well  up  to  three  weeks  ago,  when  she  was  seized,  a  fort- 
night after  a  period,  with  aching  pains  in  her  limbs ; 
these  disappeared,  leaving,  however,  a  constant  pain  in 
the  lower  part  of  the  abdomen,  especially  on  the  right 
side,  and  in  the  back.      No  swelling  had  been  noticed. 

On  admission  she  had  the  appearance  of  a  pale  but 
otherwise  healthy  woman.  The  thoracic  viscera  were 
normal,  the  urine  healthy.  The  abdomen  was  some- 
what distended.  Resonance  was  somewhat  impaired  over 
the  lower  half  of  the  hypogastric  region. 

On  examination  under  ether,  June  24th,  the  fundus 
uteri  was  found  elevated  to  three  quarters  of  an  inch 
below  the  umbilicus.  The  mobility  of  the  uterus  was 
impaired,    its    cavity    not    enlarged.       In    the   left   iliac 


320  VALUE    OF    ABDOMINAL    SECTION    IN 

region  was  a  tense  cystic  swelling  tlie  size  of  a  large 
orange,  moving  with  the  uterus  and  evidently  connected 
with  it  by  adhesions  or  otherwise.  It  extended  to  within 
three  quarters  of  an  inch  of  the  umbilicus.  Fluctuation 
was  distinctly  made  out  bimanually.  On  the  right  side, 
high  up  by  the  side  of  the  uterus  and  adherent  to  it,  was 
a  hard,  irregular  swelling  of  the  size  of  a  Tangerine 
orange,  giving  the  impression  of  tube  and  ovary  involved 
in  a  mass  of  adhesions. 

A  few  days  later  the  mass  on  the  right  side  had 
become  less  distinct ;   that  on  the  left  remained  the  same. 

The  temperature  on  admission  was  100  "4°;  afterwards 
it  varied  from  normal  to  99*6°. 

Abdominal  section  was  performed  July  3rd.  The 
omentum  roofed  in  the  contents  of  the  pelvis,  which  were 
densely  matted  together  and  difficult  to  distinguish. 
The  omentum  having  been  separated  and  pushed  aside, 
the  enlarged  and  thickened  right  Fallopian  tube  was 
found  deeply  situated  at  the  back  of  the  pelvis  and 
adherent  on  all  sides.  The  adjoining  ovary  was  likewise 
embedded  in  adhesions,  but  in  other  respects  it  was 
normal.  Both  were  separated  and  removed.  During  the 
separation  there  escaped  from  amongst  the  adhesions  a 
quantity  of  grumous  fluid,  consisting  of  altered  blood 
mixed  with  pus.  The  left  side  was  now  explored.  At 
length  a  thick-walled  tube  was  discovered  dipping  down 
into  the  left  posterior  quarter  of  the  pelvis  and  firmly 
adherent.  This  was  sepai'ated  and  brought  into  view, 
when  it  was  recognised  by  the  appendices  epiploicae  to  be 
a  coil  of  large  intestine,  inflamed,  thickened,  prolapsed, 
and  adherent.  The  search  for  the  left  Fallopian  tube 
was  thereupon  resumed,  but  neither  it  nor  the  left  ovary 
were  discovered.  The  pelvis  was  irrigated  with  hot 
boracic  acid  solution,  a  glass  drainage-tube  inserted,  and 
the  abdomen  closed. 

The  portion  of  the  right  tube  removed  was  three  inches 
in  length.  The  fimbriated  end  was  open,  and  had  a 
diameter  of  one  third  of  an  inch.      The  tube  was  thickened 


CERTAIN    CASES    OF    PELVIC     PERITOXITIS.  321 

and  iullamed.  On  section  it  was  found  to  contain  a  few 
drops  of  pus.  Its  external  surface  presented  a  thickened, 
indurated,  ragged  patch,  of  dark  colour,  three  quarters 
of  an  inch  in  length,  which  gave  the  impression  of  having 
formed  part  of  the  wall  of  an  intra-peritoneal  abscess. 
About  two  thirds  of  the  normal  ovary  had  been  removed 
with  the  tube. 

The  patient  had  more  pain  than  is  usual  during  the 
first  few  days,  but  made  a  good  recovery.  The  bowels 
were  opened  by  enema  on  the  fifth  day.  The  tempera- 
ture on  the  second  day  rose  to  100*4° ;  after  that  it  never 
reached  100°. 

On  vaginal  examination,  July  18th,  a  mass  was  felt  on 
the  left  side  depressing  the  vaginal  roof  ;  nothing 
abnormal  on  right  side  or  behind  the  uterus.  The 
patient  was  up  the  following  day,  and  left  the  hospital 
well  a  month  after  the  operation. 

Two  or  three  points  in  this  case  call  for  remark.  In 
the  first  place,  the  association  of  salpingitis  with  an  intra- 
peritoneal ha^matocele,  an  association  observed  in  several 
other  cases  in  this  series,  seems  to  point  to  a  causal  con- 
nection between  the  two  conditions.  Where,  as  in  this 
instance,  the  salpingitis  is  purulent,  the  fimbriated  end 
remaining  patent,  the  haematocele  almost  inevitably  under- 
goes suppuration,  forming  one  variety  of  pelvic  abscess. 
Another  feature  in  the  case  worth  noting  is  the  difiiculty 
that  arose  from  an  inflamed,  prolapsed,  and  adherent  coil 
of  intestine  simulating  an  inflamed  Fallopian  tube.  It  is 
next  to  impossible  sometimes  to  distinguish,  by  touch 
alone,  the  one  from  the  other,  and  even  when  sufficiently 
separated  to  be  brought  into  view  it  is  not  always  easy 
at  first  sight  to  say  with  certainty  Avhether  it  is  inflamed 
bowel  or  inflamed  tube  that  lies  before  one.  It  is  only 
by  carefully  tracing  the  tube  to  its  uterine  end,  or,  in 
the  case  of  intestine,  by  noting  appendices  epiploicge 
upon  it,  or  by  tracing  it  beyond  the  inflamed  portion  and 
finding  it  continuous  with  healthy  bowel,  that  the  dia- 
gnosis can  be  established.      One  of  the  chief  risks  of  the 


322  VALUE    OP    ABDOMINAL    SECTION    IN 

opei'atiou  for  the  removal  of  diseased  tubes  consists  in 
this  liability  to  mistake  intestine  for  Fallopian  tube. 
There  can  be  no  doubt  that  the  smooth,  tense  swelling" 
which  was  felt  before  the  operation  on  the  left  side  of  the 
pelvis,  and  which  was  still  perceptible  a  fortnight  after 
the  operation,  was  inflamed  intestine,  prolapsed  and 
adherent.  Now  that  all  the  pus  has  been  removed  the 
inflammation  of  the  prolapsed  bowel  will  gi'adually  subside. 
If  an  opportunity  should  occur  of  examining  the  patient 
again  I  shall  expect,  therefore,  to  find  the  swelling  much 
smaller  in  size  and  softer  in  consistence. 

Case  29.  Recurrent  iielvic  j^eritonitis  following  an  attack 
of  general  peritonitis  seven  years  ago  at  the  age  of  twenty  ; 
attacks  more  frequent  during  last  two  years;  dragging 
2)ain  in  right  iliac  region  after  the  least  exertion,  necessi- 
tating the  life  of  a  chronic  invalid  ;  uterus  fixed ;  hard 
irregular  mass  in  each  posterior  quarter  of  pelvis,  more 
marked  on  right  ;  abdominal  section ;  contents  of  pelvis 
densely  matted ;  right  tube  distended  by  a  mass  of  soft 
tuberculous  material,  its  ivalls  softened  and  marked  by 
scars  of  old  ulcers ;  left  tube  enlarged,  thickened,  and 
empty  ;  mucous  membrane  granular;  mass  of  soft  tuber- 
culous matter  in  left  side  of  pelvis ;  lengthy  operation, 
severe  shock ;  slow  convalescence ;  copious  escape  of  pus 
from  rectum  seven  weeks  after  operation ;  recovery. — 
A  single  lady,  aged  27,  had  for  seven  years  been  subject 
to  attacks  of  localised  peritonitis  in  the  pelvis,  chiefly  on 
the  right  side,  following  an  attack  of  general  peritonitis 
at  the  age  of  twenty,  when  she  was  confined  to  bed  for 
six  weeks.  The  localised  attacks  had  been  more  frequent 
during  the  past  two  years.  They  usually  occurred  in 
connection  with  a  menstrual  period,  and  were  always 
ushered  in  with  acute  pain  and  were  attended  with  fever. 
During  the  whole  time  there  had  been  dragging  pain  in 
the  right  iliac  region  after  the  least  exertion.  About  two 
years  ago  there  was  a  swelling  in  the  right  iliac  region, 
which   afterwards   disappeared.      For   the  last  five  or  six 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  323 

weeks  she  had  been  much  in  bed  ;  before  that  she  had  been 
in  the  habit  of  rising  at  ten  and  retiring  to  bed  at  nine. 
She  had  lost  a  stone  in  weight  during  the  last  two  years, 
but  retained  a  good  colour,  and  ate  and  slept  well. 

Her  mother  and  a  maternal  uncle  had  died  of  phthisis. 

The  patient  herself  had  always  been  delicate.  At  the 
age  of  fourteen  she  had  an  illness,  said  to  be  due  to  some 
disease  of  the  liver ;  this  illness  was  followed  by  hysteria. 
She  had  had  two  attacks  of  pleurisy.  The  first  men- 
struation occurred  at  the  age  of  twenty  (after  the  attack 
of  general  peritonitis  above  alluded  to) ;  since  then  she  had 
menstruated  regularly. 

There  was  no  unusual  appearance  about  the  abdomen. 
Vaginal  examination,  rendered  difficult  by  the  virginal 
condition  of  the  orifice,  showed  fixation  of  the  uterus  Avith 
a  hard  irregular  mass  in  the  right  posterior  quarter  of  the 
pelvis,  and  a  similar  but  less  defined  mass  in  the  left 
posterior  quarter.      The  vaginal  roof  was  not  depressed. 

It  being  evident  that  there  was  chronic  disease  of  the 
uterine  appendages  of  both  sides,  with  much  matting  of 
the  parts,  and  probably  with  suppuration,  abdominal 
section  was  suggested  and  agreed  to. 

The  operation  was  performed  July  10th,  1890.  There 
were  such  extensive  adhesions  of  intestine  and  omentum 
to  the  abdominal  wall  and  to  the  anterior  surface  of  the 
pelvic  viscera  that  a  long  time  was  occupied  in  obtaining 
access  to  the  pelvis.  The  contents  of  the  pelvis  were 
densely  matted  together.  The  right  side  was  first  dealt 
with.  During  the  separation  of  the  densely  adherent 
tube  and  ovary  on  that  side,  the  finger  passed  into  a  mass 
of  caseous  material,  which  proved  to  be  in  the  interior  of 
the  Fallopian  tube.  The  wall  of  the  tube  at  this  part 
was  so  soft  that  it  gave  way  in  its  entire  circumference, 
separating  the  tube  into  two  distinct  portions,  an  outer 
dilated  portion  and  an  inner  portion.  The  outer  portion 
was  carefully  separated  from  its  deeply  seated  adhesions 
and  removed.  The  torn  end  presented  the  appearance  of 
an  old  abscess-cavity,  filled  with  caseous  material.      The 


324  VALUE    OF    ABDOMINAL    SECTION    IN 

fimbriated  eud  was  closed.  The  ovaiy,  normal  in  size 
and  entirely  embedded  in  adhesions,  was  then  shelled  out 
and  brought  into  view.  The  broad  ligament  was  then 
transfixed  beneath  the  ovary,  and  the  ovary  and  uterine 
end  of  the  torn  tube  were  ligatured  and  removed.  On 
the  left  side  the  condition  of  the  parts  was  extremely 
puzzling,  so  much  so  that  I  was  sorely  tempted  to  abandon 
the  attempt  to  deal  with  it.  Eventually,  however,  the 
ovary  was  discovered  embedded  in  adhesions,  and  then 
the  greatly  elongated  and  thickened  Fallopian  tube.  In 
separating  the  latter  another  collection  of  caseous  material 
was  entered  by  the  finger.  This  mass  was  outside  the 
tube,  in  a  cavity  formed  by  peritoneal  adhesions.  On 
separating  the  densely  adherent  fimbriated  end  of  the 
tube  there  was  a  smart  hsemorrhage.  After  a  careful 
examination  of  the  tube,  to  make  sure  it  was  not  an  in- 
flamed coil  of  intestine,  which  it  much  resembled,  the 
greatly  thickened  broad  ligament  was  transfixed  in  the 
usual  manner,  and  the  tube  and  ovary  were  removed. 
The  pelvic  cavity  was  then  douched  with  hot  water,  and 
afterwai'ds  well  sponged.  A  glass  drainage-tube  was 
inserted  and  the  abdominal  wound  closed.  The  operation 
lasted  nearly  three  hours.  At  its  close  the  patient  was 
very  cold,  and  was  suffering  severely  from  shock.  Half 
an  hour  afterwards  a  subcutaneous  injection  of  j  gr.  of 
morphia  was  administered.  The  patient  slept  a  little,  and 
the  surface  gradually  became  warmer.  At  10.30  p.m.  the 
dressings  were  changed  and  the  urine  drawn  off  by 
catheter.  The  slight  movement  involved  in  the  re- 
adjustment of  the  binder  induced  vomiting.  The  pulse 
was  very  rapid  and  feeble.  During  the  night  and  up  to 
6.30  on  the  following  day  there  was  occasional  vomiting. 
At  G  p.m.  morphia  was  given  subcutaneously,  after  which 
she  slept  for  two  hours.  At  10.30  p.m.  the  condition  had 
decidedly  improved ;  the  pulse  was  stronger  and  less 
frequent  (128)  ;  the  patient  was  in  good  spirits  and 
begged  for  nourishment.  On  the  morning  of  the  third 
day  she  was  bright  and  talkative,   and   interested  in   her 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  325 

future.  An  india-rubber  tube  was  substituted  for  the 
glass  one.  At  noon,  urine  was  passed  naturally,  and 
at  3  p.m.  flatus  escaped  j^er  anum. 

The  india-rubber  tube  was  only  kept  in  for  twenty- 
four  hours.  The  bowels  acted  slightly  on  the  fifth  day 
and  copiously  on  the  seventh.  The  stitches  were  removed 
on  the  eighth  day.  On  August  6th,  a  month  after  the 
operation,  the  patient  left  for  Eastbourne.  Her  tempera- 
ture had  never  reached  100°  up  to  that  time,  nor  had  she 
complained  of  any  pain  or  discomfort.  Ten  days  after 
her  arrival  at  Eastbourne  she  had  a  rigor  with  slight  rise 
of  temperature,  and  some  local  tenderness  in  the  left 
iliac  region.  A  fortnight  later  (September  2nd)  a  little 
pus  was  observed  in  the  stools,  and  next  day  10  or  12 
fl.  oz.  of  pus  passed  'per  rectum.  On  September  19th 
the  temperature  still  remained  high,  and  more  or  less  pus 
continued  to  be  passed  from  the  bowel  every  day.  On 
October  15th  the  patient  was  eating  well  and  Avas  very 
comfortable,  but  the  temperature,  normal  in  the  morning, 
rose  every  evening  to  101°,  and  night-sweats  were  re- 
ported to  be  constant.  On  October  19th  Mr.  Ewart,  of 
Eastbourne,  made  a  vaginal  examination.  The  uterus 
was  retroverted  and  fixed.  There  Avas  hardness  low 
down  in  the  recto-vaginal  septum  and  all  round  the 
rectum. 

After  this  she  slowly  improved,  and  in  January,  1891, 
she  was  able  to  drive  about  in  a  sledge,  and  had  lost 
almost  all  the  aching  pain  in  the  pelvis  which  she  used  to 
suffer  after  walking. 

I  saw  her  at  my  rooms  on  September  28th,  1891 — 
fourteen  months  after  the  operation.  She  was  then 
looking  well  and  cheerful,  but  she  had  not  yet  reached 
her  normal  weight.  She  could  walk  a  mile  without  dis- 
comfort. There  was  a  little  purulent  discharge  from  the 
rectum  almost  every  day.  Occasionally  there  was  a 
darker  discharge  with  pain  and  rise  of  temperature  ;  for 
example,  a  fortnight  before  the  interview  the  tempera- 
ture, for  four  or  five  days,  was  100°  to  102°,  being  usually 


326  VALUE    OF    ABDOMINAL    SECTION    IN 

normal  or  subuormal.  The  catamenia  have  not  been  re- 
establislied,  and  the  frequent  flusliings  of  the  face  seem 
to  indicate  that  menstruation  lias  ceased.  She  is  free 
from  pain  except  under  the  occasional  circumstances 
above  noted. 

In  July,  1892,  two  years  after  the  operation,  she  wrote 
to  tell  me  that  the  discharge  only  appeared  about  once  or 
twice  in  six  weeks,  and  was  then  very  slight.  On  November 
17th,  1892,  I  saw  her.  She  was  looking  and  feeling  very 
well,  and  had  had  no  pain  since  the  spring.  She  was 
leading  a  busy  and  active  life,  and  thoroughly  enjoying 
it.  The  discharge  from  the  bowel  ceased  from  June  to 
September.  Since  then  there  had  been  a  very  little  dis- 
charge on  three  occasions. 

Further  note  on  the  condition  of  the  ijcirts  removed. — 
Both  ovaries  normal.  Right  tube  dilated,  two  inches  in 
length ;  internal  surface  ii'regularly  puckered,  showing 
evidence  of  old  cicatrices ;  rugae  obliterated  ;  contents  a 
yellow,  putty-like  substance ;  a  portion  of  fimbriated  end 
torn  off  and  found  adherent  to  the  ovary  ;  proximal  end 
ragged,  irregular,  and  softened,  this  condition  extending 
to  all  the  coats.  Left  tube  enlarged,  thickened,  elon- 
gated, and  occluded  at  its  outer  end.  Lumen  empty. 
Mucous  membrane  thickened  and  congested ;  surface 
granular,  not  ulcerated.  A  section  submitted  to  micro- 
scopical examination  showed  no  evidence  of  tubercle. 

Although  this  patient  was  in  a  rank  of  life  that  en- 
abled her  to  have  every  comfort  and  to  take  an  unlimited 
amount  of  rest,  the  increasing  frequency  and  severity  of 
the  recurrent  attacks  of  local  peritonitis  seemed  to  point 
to  the  desirability  of  operative  interference,  an  interfer- 
ence justified  by  the  result.  The  tubercular  disease,  though 
local  and  inactive,  was  a  continual  source  of  in-itation, 
and,  even  if  it  had  not  eventually  produced  general  in- 
fection, would  almost  certainly  have  condemned  the 
patient  to  a  life  of  chronic  invalidism  for  a  long  time  to 
come.  The  formation  of  a  pelvic  abscess  nearly  six 
weeks  after  the  operation  was  wholly  unexpected,    and 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  327 

proved  a  serious  liiudrance  to  recovery.  It  was  well  that 
the  abscess  discharged  itself  quickly  by  the  bowel,  or  the 
consequences  might  have  been  still  more  serious.  Con- 
sidering the  serious  nature  of  the  operation  I  do  not 
think  the  patient's  present  condition  can  be  regarded  as 
otherwise  than  highly  satisfactory.  Her  discomforts  are 
slight,  and  she  is  able  to  move  about  and  enjoy  life  to 
an  extent  that  she  had  not  been  able  to  do  for  several 
years. 

Case  30.  Severe  pain  in  left  iliac  region,  hack,  and  left 
thigh  of  four  days'  duration,  tvith  history  of  a  similar 
attach  three  months  previously  after  a  fall ;  disapj^earance 
of  pain  twenty-four  hours  after  admission;  dense,  irregular 
mass  in  each  posterior  quarter  of  pelvis  ;  swollen  and.  tor- 
tuous tube  traceable  from  uterus  on  each  side  into  the 
sivelling  ;  abdominal  section  ;  both  tubes  irregularly  dilated, 
occluded,  and  full  of  pus  ;  walls  thickened  and  deeply  ulce- 
rated ;  110  microscopic  or  other  evidence  of  tubercle  ;  im- 
interrupted  recovery  ;  patient  well  and  strong  lohen  seen 
fifteen  months  afterwards. — A  young  married  woman^  aged 
24,  the  mother  of  three  children,  was  admitted  July  12th, 
1890,  on  account  of  severe  pain  in  the  back  and  in  the 
left  iliac  region,  extending  down  the  thighs  and  causing 
difficulty  in  walking.  The  symptoms  had  come  on  suddenly 
four  days  previously.  She  had  once  before  had  similar 
pain,  viz.  after  a  fall  on  the  left  side  during  a  menstrual 
period  three  months  ago. 

There  was  no  history  of  phthisis  in  the  family.  Her 
labours  had  all  been  easy,  and  recoveries  rapid  and  satis- 
factory. Her  youngest  child  was  born  fourteen  months 
ago.  She  had  had  a  yellow  vaginal  discharge  for  some 
years  ;  it  commenced,  in  fact,  before  she  was  married,  and 
has  never  caused  her  inconvenience. 

She  was  thin  and  antemic,  but  very  cheerful.  The 
urine  was  clear  and  contained  no  albumen.  Her  tempe- 
rature varied  from  98'8°  to  102'2  . 

On  vaginal  examination  the  posterior  fornix  was  found 


328  VALDE    OP    ABDOMINAL    SECTION    IN 

depressed^  and  there  was  increased  resistance  in  both 
lateral  fornices.  From  the  sides  of  the  uterus  a  dense 
mass  could  be  felt  passing  out  towards  the  latei*al  walls 
of  the  pelvisj  more  marked  on  the  right  side.  A  portion 
of  the  swelling  on  each  side  can  be  felt  as  a  tortuous  and 
thickened  tube  traceable  into  the  posterior  fornix. 

The  patient  had  no  pain  after  being  in  the  hospital 
twenty-four  hours,  but  as  it  appeared  certain  the  case 
was  one  of  chronic  purulent  salpingitis,  abdominal  section 
was  proposed.  The  patient  assented,  and  the  operation 
took  place  July  21st,  1890. 

The  right  uterine  appendages  were  densely  adherent 
in  the  right  posterior  quarter  of  the  pelvis.  During  their 
separation  some  thick  yellow  pus  escaped  from  a  very 
small  opening  in  the  tube-wall  at  a  point  near  the  distal 
end,  where  the  tube  was  distended  and  its  wall  thin.  The 
broad  ligament,  thickened  by  cellulitis,  having  been 
transfixed  and  ligatured  below  the  ovary,  and  a  second 
ligature  having  been  placed  around  the  tube  to  prevent 
escape  of  its  purulent  contents  after  its  division,  the  tube 
and  ovary  were  removed.  The  left  tube  was  now  exa- 
mined and  found  in  a  similar  condition  ;  it  was  accord- 
ingly separated,  and,  with  its  adjacent  ovary,  ligatured 
and  removed.  The  abdominal  cavity  was  well  flushed 
with  hot  boracic  solution,  and  a  glass  drainage-tube 
inserted  before  closing  the  abdomen.  The  pouch  of 
Douglas  being  partially  obliterated  by  adhesions,  an 
unusually  short  tube  (3f  inches  long)  was  used. 

The  patient's  temperature  rose  on  the  evening  of  the 
second  day  to  101'4°,  and  on  the  evening  of  the  third 
day  to  100*6''.  After  that  it  never  reached  100°,  and 
from  the  eighteenth  day  was  normal.  She  left  the 
hospital  on  August  12th,  free  from  pain  and  well.  In 
response  to  my  request  she  came  to  see  me  at  the  hos- 
pital on  the  6tli  November,  1891,  nearly  sixteen  months 
after  the  operation  ;  she  looked  so  stout  and  well  as  to  be 
scarcely  recognisable.  She  assured  me  she  had  been 
entirely  free  from  pain  from  the  time  she   left  the  hos- 


CERTAIN    CASES    0¥    PELVIC    PERITONITIS.  329 

pital,  and,  in  fact,  had  become  quite  stout,  and  was 
enjoying  better  health  than  she  had  done  for  several 
years.  She  has  a  menstrual  period  of  normal  character 
about  every  two  months.  There  had  been  no  symptoms 
of  an  appi'oaching  menopause. 

Description  of  the  parts  removed. — Right  tube,  3|  inches 
long,  enlarged  and  thickened,  fimbriated  end  closed, 
dilated  in  two  places,  viz.  at  the  free  end,  where  the  dia- 
meter is  1^  inches,  and  at  a  distance  of  half  an  inch  from 
the  uterine  end,  where  the  diameter  is  rather  less.  The 
larger  of  these  dilatations  is  dusky  red  in  colour  and 
congested  ;  the  smaller  has  so  thin  a  wall  that  the 
yellow  colour  of  the  pus  within  shows  through  it  dis- 
tinctly. The  peritoneal  covering  of  the  tube  is  much 
thickened  and  covered  with  shreds  of  tissue,  the  remains 
of  adhesions.  In  one  or  two  places  the  adherent  sur- 
faces shows  a  parchment  induration.  At  the  upper  and 
posterior  border  there  is  a  portion  of  adherent  omentum, 
ligatured  and  divided  during  the  operation.  On  the 
anterior  surface  of  the  dilated  end  there  are  two  small 
perforations,  the  peritoneum  surrounding  these  being 
black.  The  walls  of  the  tube  are  j  inch  thick.  No 
tubercles  are  visible.  The  mucous  membrane  is  much 
swollen  and  ulcerated  in  irregular  patches,  especially 
in  the  dilated  portions,  which  contains  creamy  pus 
mixed  with  mucus,  and  without  odour.  The  floors  of 
the  ulcers  are  pitted  and  shaggy,  with  flakes  of  breaking- 
down  tissue  hanging  from  them.  The  perforation  at  the 
distal  end  communicates  with  the  abscess-cavity. 

The  left  tube  is  more  convoluted  than  the  right.  It 
is  irregularly  dilated,  the  main  dilatations  being  three 
in  number,  the  largest  of  which  is  at  the  distal  end, 
the  smallest  near  the  uterine.  The  peritoneal  covei'ing 
is  thick,  and  shreddy  from  torn  adhesions  ;  beneath  it 
is  a  small  serous  cyst.  The  wall  of  the  tube  is  so 
thin  at  the  dilated  portions  that  the  yellow  colour  of  the 
pus  inside  is  clearly  shown  in  striking  contrast  to  the 
dusky  red  colour  of  the  rest  of  the   tube.      The  mucous 

VOL.  xxxiv.  24 


330 


VALUE    OF    ABDOMINAL    SECTION    IN 


Fig.  1. 


Fig.  2. 


Double  pyosalpinx ;  natural  size.     The  drawing  shows  the  irregular 
dilatations  of  the  tubes.     The  ovaries  are  normal.     (Case  30.) 


N^^N 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  331 

membrane  is  generally  tliickened  ;  each  dilated  portion 
is  separate  from  the  rest,  and  contains  creamy  pus  with- 
out odour.  The  wall  of  the  tube  has,  in  the  case  of  the 
smallest  of  the  three  abscesses,  been  destroyed  by  ulcera- 
tion to  such  an  extent  that  only  the  peritoneal  coat 
remains.  The  characters  of  the  ulcers  are  the  same  as 
in  the  right  tube. 

The  ovaries  are  normal  in  size  and  appearance  ;  they 
are  full  and  pulpy,  and  contain  a  few  small  cysts.  In  the 
left  is  a  recent  corpus  luteum. 

A  noticeable  feature  in  this  case  was  the  short  duration 
of  acute  symptoms,  there  having  been  but  two  attacks  of 
pain,  each  lasting  only  a  few  days,  and  separated  from 
each  other  by  an  interval  of  three  months.  Yet  the 
condition  of  the  tubes  showed  that  the  disease  was  of 
long  standing,  and  that  their  removal  was  only  effected 
just  in  time  to  avoid  rupture,  with  escape  of  the  purulent 
contents  into  the  peritoneal  cavity.  The  ulceration  had 
extended  down  to  the  peritoneal  coat,  which  itself  was  on 
the  point  of  rupture  in  at  least  two  places.  This  case  is 
a  sufficient  answer  to  those  who  advocate  a  preliminary 
trial  of  palliative  measures  in  all  cases  indiscriminately. 
A  delay  of  even  a  few  days  would  have  exposed  this 
patient  to  a  very  serious  risk. 

The  nature  of  the  infection  seems  doubtful.  There  is 
nothing  in  the  history  that  points  definitely  either  to 
septic  or  gonorrhoeal  infection.  I  suspected  from  the 
nature  of  the  ulceration,  that  the  disease  would  prove 
to  be  tubercular,  but  my  friend  Dr.  W.  S.  A.  Griffith, 
who  very  kindly  removed  a  portion  from  the  middle  of 
one  tube  for  examination  under  the  microscope,  assured  me 
that  he  could  discover  no  evidence  of  tubercle,  although  he 
examined  several  sections.  The  case  must,  then,  for  the 
present  remain  unclassified. 

The  result  of  the  operation  was,  and  continues  to  be, 
all  that  one  could  desire. 

Case  31.  Pelvic  hsematocele  simulating  cystic  tumour ; 


332  VALUE    OP   ABDOMINAL    SECTION    IN 

operation  averted  hy  the  unexpected  dimimition  in  the  size 
of  the  fiivelling ;  rapid,  disappearance  of  the  tumour;  ex- 
ploratory abdominal  section  four  months  later,  on  account 
of  persistent  disablement  and  j^elvic  pain  ;  remains  of  hsema- 
tocele  found,  and  matting  of  contents  of  pelvis  ;  no  ap- 
preciable lesion  of  the  uterine  appendages ;  right  ovary 
separated  and  re^noved  ;  right  tube  separated,  but  not  re- 
moved ;  left  appendages  undisturbed  ;  recovery  ;  tivo  years 
afterwards  in  excellent  health  and  free  from  pain. — 
A  married  woman,  aged  23,  was  sent  from  Scarborougli 
on  the  1st  February,  1890,  to  be  operated  upon  for  an 
ovarian  tumour.  There  was  a  fluctuating  swelling  in  the 
abdomen,  centrally  situated,  reaching  upwards  to  the 
level  of  the  umbilicus,  and  dipping  down  into  the  pelvis, 
causing  in  the  latter  situation  a  large  bulging  tumour 
behind  the  upper  part  of  the  vagina.  The  uterus  was 
pushed  upwards,  forwards,  and  to  the  left.  Menstruation 
had  been  regular.  The  swelling  had  been  first  noticed  four 
months  previously,  being  then,  according  to  the  patient's 
account,  the  size  of  a  walnut.  Three  weeks  before 
admission,  at  the  commencement  of  a  menstrual  period, 
patient  was  seized  with  severe  pain,  which  continued  for 
the  three  days  of  the  period ;  since  that  time  the  abdomen 
had  been  much  larger  than  it  was  before.  The  patient 
had  been  married  three  years,  but  had  not  become  preg- 
nant. 

I  saw  no  reason  to  doubt  the  diagnosis  of  the  medical 
attendant,  except  that  I  regarded  the  tumour  as  being  a 
broad  ligament  cyst  rather  than  an  ovarian.  It  hap- 
pened that  there  were  several  more  urgent  cases  needing 
operation  just  at  that  time,  and  that  some  delay  occurred 
in  consequence.  On  the  17th  of  February,  a  little  more 
than  a  fortnight  after  admission,  the  abdomen  was  observed 
to  be  decidedly  less  prominent  and  the  tumour  less  tense. 
Fresh  measurements  were  thereupon  taken,  and  it  was 
found  that  they  had  diminished  in  all  dii'ections.  The 
upper  limit  of  dulness,  which  had  been  6|  inches  above  the 
pubes,  was  now  only  4.      The  distance  between  the  pubes 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  333 

and  the  umbilicus  had  become  reduced  from  8  inches  to  C^ 
inclies,  and  that  between  the  umbilicus  and  the  anterior 
superior  spine  of  each  ilium  from  G  inches  to  a  little  over 
5  inches.  The  swelling,  felt  per  vaginam,  was  also  smaller 
and  less  tense,  and  the  cervix  uteri  was  no  longer  squeezed 
agaiust  the  left  pubic  ramus.  In  short,  it  was  evident 
that  the  swelling  was  a  hfematocele,  and  that  it  was  dis- 
appearing. The  process  of  absorption  went  on,  as  it 
usually  does  when  it  once  begins,  with  amazing  i-apidity. 
On  February  25th  no  tumour  could  be  felt  on  abdominal 
examination.  High  up  behind  the  cervix  uteri,  which 
was  now  in  its  normal  position,  could  be  felt  bimanually  a 
flaccid,  circumscribed  collection  of  fluid,  causing  little  or 
no  depression  of  the  vaginal  roof.  On  the  8th  March 
the  swelling  was  still  diminishing.  On  the  18th  it  con- 
veyedan  impression  very  much  like  that  given  by  a  distended 
tube,  and  on  the  25th  this  character  was  still  more 
marked.  The  patient  returned  to  Scarborough  on  the 
28th,  and  w^as  desired  to  present  herself  for  examination 
in  three  months. 

She  came  up  to  London  again  at  the  end  of  July,  and 
was  readmitted  to  the  hospital  on  the  2nd  of  August, 
1890.  She  had  not  been  able  to  do  much  work  during 
the  four  months  she  had  been  at  home,  on  account  of 
weakness  and  backache.  Occasionally  she  had  had  pain 
in  the  left  iliac  region,  and  most  of  her  time  had  been 
spent  on  the  couch.  She  was  anxious  that  something 
should  be  done  for  her  if  possible.  There  was  a  hard 
irregular  swelling  in  the  left  posterior  quarter  of  the 
pelvis.  An  exploratory  incision  having  been  determined 
upon,  the  operation  was  performed  on  August  4th.  Both 
tubes  and  both  ovaries  were  universally  adherent  in  the 
posterior  part  of  the  pelvis.  The  tubes  were  not  dilated 
or  appreciably  thickened.  The  right  tube  was  sepa- 
rated as  far  as  possible  ;  as  it  appeared  healthy,  it  was 
not  removed.  The  right  ovary  was  also  shelled  out  from 
its  adhesions.  Its  external  surface  was  so  thickened  and 
ragged   that    it    was    thought   wise   to   remove    it.      The 


334  VALUE    OF    ABDOMINAL    SECTION    IN 

adliesions  on  tlie  left  side  were  extremely  dense,  and  as 
there  did  not  appear  to  be  any  disease  of  the  appendages 
on  that  side,  they  were  not  disturbed.  There  was  a  large 
cavity  behind  the  uterus,  with  ragged  walls.  In  this 
cavity  were  several  fragments  of  old  blood-clot.  A  glass 
drainage-tube  was  inserted  and  the  abdomen  closed. 

The  patient  recovered  satisfactorily,  and  left  the  hos- 
pital on  August  23rd.  Her  general  condition  was 
improved,  and  she  was  free  from  pain.  The  uterus  was 
fairly  moveable.  Some  hard,  irregular  thickening  could 
be  felt  above  the  left  vaginal  fornix,  none  above  the 
right.  There  was  slight  tenderness  in  the  situation  of 
Douglas's  pouch. 

I  wrote  to  her  medical  attendant  at  Scarborough  for 
news  of  her  in  October,  1891.  His  reply,  dated  October 
12th,  stated  that  he  had  called  on  the  patient  that  day. 
She  looked  very  well,  and  expressed  herself  as  being 
better  than  for  years  past.  She  was  able  to  do  her  work, 
had  no  pain  or  bearing  down  or  backache.  Menstrua- 
tion was  regular,  and,  though  rather  scanty,  was  painless. 
July  15th,  1892. — Presented  herself  at  the  hospital  in 
excellent  health.  Has  no  pain,  menstruates  regularly, 
and  is  able  to  do  all  her  housework  and  attend  to  a  small 
business  as  well.  On  examination  no  swelling  on  right 
side  of  pelvis  ;  left  appendages  adherent,  otherwise  normal. 
This  patient  had  lost  a  brother  from  consumption  at 
the  age  of  twelve.  She  herself  had  had  her  knee  excised 
by  Mr.  Croft  when  she  was  ten  years  old,  and,  shortly 
after  leaving  the  hospital  on  that  occasion,  had  an  attack 
of  inflammation  of  the  bowels.  It  seems  not  unlikely  that 
her  sterility  was  due  to  damage  done  to  the  uterine 
appendages  by  that  attack.  As  to  the  cause  of  the 
haematocele,  which  I  so  nearly  operated  upon  under  the 
impression  that  it  was  a  cystic  tumour,  the  subsequent 
abdominal  section  shed  no  light.  I  think  it  not  impro- 
bable, however,  that  it  originated  in  rupture  of  an  early 
extra-uteriue  gestation  sac,  or  perhaps  in  a  so-called  tubal 
abortion.      The  operation  was  simply   exploratory   in   its 


CERTAIN    CASES    OP    PELVIC     PERITONITIS.  335 

intention.  I  thought  the  persistent  pain  and  disablement 
might  be  due  to  a  hgematosalpiux  or  some  other  disease 
of  the  appendages.  Nothing  of  the  kind  was  detected, 
and  the  patient  would  no  doubt  have  recovered  just  as 
well  without  any  operation. 

The  next  case  is  one  of  erroneous  diagnosis.  I  opened 
the  abdomen  expecting  to  find  an  inflamed  and  adherent 
tube  and  an  adherent  ovary  lying  beneath  the  body  of  a 
retroflexed  and  adherent  uterus,  instead  of  which  I  found 
no  adhesions  at  all — nothing,  in  fact,  but  a  normal  ovary 
prolapsed  beneath  a  retroflexed  uterus. 

Case  32.  Continuous  pelvic  pain  and  dysmenorrlicea ; 
irreducible  retroflexion  of  uterus,  ivith  prolapsed  ovary 
beneath  it  in  Douglas's  piouch  ;  hard  swelling,  thought  to 
be  the  infl,amed  and  adherent  tube,  immediately  above  the 
ovary;  abdominal  section;  retroflexed  uterus;  body  in- 
carcerated in  hollow  of  sacrum  from  flbroidj  enlargement  ; 
tube  and  ovary  normal,  the  latter  prolapsed  ;  no  adhesions  ; 
reduction  of  the  displacement ;  recovery,  with  coviplete 
relief  of  symptoms. — A  woman,  aged  40,  applied  at  the 
out-patient  room  on  account  of  constant  pain  in  the  pelvis 
and  dysraenorrhoea  of  six  months'  standing.  She  had  been 
married  since  the  age  of  eighteen,  had  borne  one  child  a 
year  after  marriage,  and  had  not  been  pregnant  since. 
On  vaginal  examination  the  uterus  was  found  retroflexed 
and  fixed.  Beneath  the  retroflexed  body,  at  the  bottom 
of  Douglas's  pouch,  was  a  small  soft  body,  thought  to  be 
the  prolapsed  and  adherent  ovary,  and  between  the  two  a 
hard,  fixed,  irregular  swelling,  thought  to  be  the  inflamed 
and  adherent  tube.  The  patient  was  advised  to  come  up 
for  operation  if  the  pain  and  disablement  continued. 

A  few  weeks  later  she  begged  to  be  admitted.  She 
was  taken  into  the  hospital  on  August  4th,  1890,  and  the 
abdomen  was  opened  the  following  day  by  an  incision 
2\  inches  long.  The  retroflexed  body  of  the  uterus  was 
found  tightly  incarcerated  beneath  the  sacral  promontory. 
On  lifting  it  up  it  was  seen  to  be  enlarged  and  distorted 


336  VALUE    OF   ABDOMINAL    SECTION    IN 

by  fibroids.  Deep  down  in  Douglases  pouch  lay  the 
prolapsed  right  ovary.  Both  it  and  the  tube  were  per- 
fectly normal.  There  were  no  adhesions  of  any  kind. 
The  ovary  having  also  been  lifted  up  into  its  proper  posi- 
tion, a  Hodge's  pessary  was  introduced pe?-  vaginani.,  to  pre- 
vent a  recurrence  of  the  uterine  displacement.  Until  this 
was  done  the  uterus  showed  a  tendency  to  fall  back  the 
moment  it  was  left  unsupported.  After  the  introduction 
of  the  Hodge  it  remained  in  its  normal  position.  The 
abdominal  wound  was  then  closed.  No  ill  effects  followed 
the  operation,  and  the  patient  went  home  on  August  29th 
with  the  uterus  in  its  normal  position,  and  still  wearing 
the  pessary.  She  lost  all  her  uncomfortable  symptoms 
from  that  time.  The  pessary  continued  to  be  worn  until 
April  18th,  1891,  when  it  was  finally  removed.  The 
uterus  had  remained  in  its  normal  position  the  whole  time 
(nearly  nine  months),  and  the  patient's  health  had  been 
excellent. 

I  have  included  this  case  because,  although  the  uterine 
appendages  proved  to  be  healthy  and  non-adherent,  they 
were  thought  to  be  diseased,  and  the  object  of  the  opera- 
tion was  to  remove  them.  The  hard,  fixed  swelling  above 
the  prolapsed  ovarj'-,  thought  to  be  the  inflamed  tube,  was 
one  of  several  fibroids  projecting  from  the  body  of  the 
uterus.  The  operation  furnished  the  only  opportunity 
that  has  ever  occurred  to  me  of  observing  the  effect  of  a 
Hodge's  pessary  from  inside  the  pelvis.  It  raised  the 
vaginal  roof  with  its  peritoneal  covering  into  a  distinct 
fold,  and  so  far  confirmed  the  theory  that  it  acts  by 
elongating  the  posterior  cul-de-sac,  thereby  drawing  the 
cervix  upwards  and  backwards  into  its  normal  position. 

Case  33.  Small  cystic  ovary  knotvn  for  several  years  to 
he  prolapsed  in  Doitglas's  pouch;  gradual  development  in 
size  with  slight  pain  ;  sudden  attack  of  intense  pelvic 
peritonitis  with  formation  of  an  abdominal  swelling  con- 
tinuous with  that  in  pelvis  ;  subsidence  and  subsequent  re- 
currence  of  acute  symjdoms  ;   abdominal  section;   matting 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  337 

of  'pelvic  viscera;  snpinirating  cyst  of  left  ovary  with  foetid 
contents,  communicating  by  a  direct  opening  vith  hijiamed 
left  tube  ;  right  tube  inflamed  and  adherent  ;  diseased  parts 
removed  ;  death  on  fifth  day. — A  married  lady  aged  31, 
who  had  formerly  been  under  my  care  at  Manchester,  was 
sent  up  to  me  for  operation  on  August  30th,  1890,  under 
the  following  circumstances. 

She  had  been  married  eleven  years,  and  had  never 
been  pregnant.  She  first  consulted  me  in  February,  1887, 
having  then  been  under  medical  treatment  for  twelve 
months  on  account  of  dyspareunia.  At  that  time  the 
only  thing  discovered  on  examination  was  a  small,  tender, 
cystic  tumour  in  Douglas's  pouch,  which  I  thought  was 
the  left  ovary  enlarged  and  adherent.  The  uterus,  normal 
in  size,  was  displaced  a  little  to  the  right  and  freely  move- 
able. There  were  frequent  attacks  of  neuralgia  of  the 
head  and  face  ;  otherwise  the  general  health  was  good. 
A  year  later  the  left  (prolapsed)  ovary  wa,s  still  very 
tender  ;  the  right  ovary,  now  folt  for  the  first  time,  was  also 
tender  and  slightly  enlarged.  On  December  29th,  1889, 
the  patient  came  up  to  London  to  consult  me.  The  con- 
dition then  was  as  follows  : — Left  side  of  pelvis  occupied 
by  a  tender  irregular  mass,  partly  cystic,  pushing  uterus 
over  to  right.  Uterus  normal  in  length  and  moveable. 
The  question  of  operation  was  discussed,  and  it  was 
arranged  that  she  should  see  me  a  little  later,  when  she 
had  quite  recovered  from  a  recent  attack  of  bronchitis. 
On  August  1st,  1890,  I  heard  that  she  was  very  ill.  She 
had  menstruated  normally  from  July  7th  to  15th,  and  a 
week  afterwards  had  been  sitting  reading  out  of  doors, 
and  feeling  perfectly  well,  when,  on  rising  to  go  home, 
she  found  that  every  time  she  put  her  foot  to  the  gi'ound 
an  extremely  severe  pain  struck  up  into  the  lower  part 
of  the  abdomen.  She  reached  home  with  difficulty. 
Soon  after  arriving  at  her  house  she  had  a  severe  rigor 
with  chattering  of  the  teeth.  Dr.  Donald  saw  her  the 
same  evening,  and  diagnosed  pelvic  peritonitis.  He  found 
the  left  ovary  enlarged  and  the  left  appendages  generally 


338  VALUE    OP    ABDOMINAL    SECTION    IN 

matted.  She  improved  rapidly,  and  in  three  or  four  days 
lier  pulse  and  temperature  were  normal,  and  she  had  no 
pain.  On  July  31st  she  tad  permission  to  get  up,  but 
was  unable  to  do  so  on  account  of  a  return  of  the  pain. 
The  following  day  Dr.  Donald  discovered  a  large  soft 
swelling  in  tbe  left  broad  ligament  pushing  tlie  uterus  to 
the  right.  The  only  symptoms  were  backache  and  flatu- 
lence. The  swelling  was  thought  to  be  a  haematocele. 
During  the  month  of  August  the  patient  made  little  pro- 
gress. The  pulse  was  uniformly  rapid,  the  temperature 
normal  in  the  morning  and  between  100  and  101°  in  the 
evening.  On  the  30th  August  she  came  to  London  with 
a  view  to  operation.  Although  she  had  been  five  weeks 
in  bed  she  was  able  to  walk  with  an  ease  that  surprised 
her.  She  had  no  pain.  There  was  a  fluctuating  swell- 
ing causing  some  prominence  above  the  pubes,  centrally 
situated,  dull  on  percussion,  measuring  4^  inches  trans- 
versely and  reaching  to  within  2^  inches  of  the  umbilicus. 
Bimanually  the  swelling  was  felt  to  occupy  the  left  side 
of  the  pelvis  ;  the  uterus  Avas  fixed,  and  lay  in  front  and 
to  the  right. 

Abdominal  section  was  performed  on  September  1st. 
The  omentum  covered  the  pelvic  viscera  completely. 
After  separating  it  and  turning  it  aside,  the  pelvis  was 
found  to  be  occupied  by  a  large  mass  of  matted  viscera, 
consisting  of  uterus,  both  Fallopian  tubes  gi-eatly  thick- 
ened and  enlarged,  and  on  the  left  a  large  thick-walled 
cyst.  The  right  tube  and  ovary  were  traced  out  first  and 
separated  from  their  adhesions.  The  ovary  was  slightly 
larger  than  normal,  of  firm  consistence,  and  universally 
adherent.  The  tube  was  thickened,  dilated,  and  com- 
pletely occluded  at  its  distal  extremity.  It  measured 
4  inches  in  length,  and  was  coiled  round  and  adherent  poste- 
riorly. During  the  separation  a  quantity  of  foul-smelling 
pus  welled  up,  which  was  afterwards  found  to  have  escaped 
from  a  rent  in  the  cyst  of  the  left  ovary,  to  which  the  right 
tube  had  been  adherent.  The  right  tube  and  ovary  were 
ligatured  and  removed.      The   broad  ligament  was   much 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  339 

thickened  from  chronic  inflammation,  but  was  not  friable. 
The  parts  on  the  left  side  were  then  dealt  with.  The 
tube  was  much  thickened  and  elongated,  and  stretched 
out  over  the  cystic  tumour.  The  fimbriated  end  was  dug" 
out  from  the  deepest  part  of  Douglas's  pouch  with  some 
diflBculty.  The  thick-walled  cyst,  now  empty,  was  then 
shelled  out,  and  found  to  be  an  inflamed  suppurating  cyst 
of  the  left  ovary,  4  inches  in  diameter.  There  were  two 
small  rents  in  its  wall,  and  one  large  one.  It  was  found 
that  this  last  had  been  caused  by  tearing  away  the  fim- 
briated end  of  the  tube,  which  closely  fitted  the  apei'ture, 
having  formed  part  of  the  cyst-wall,  and  opened  directly 
into  the  cyst.  The  left  broad  ligament  was  greatly 
thickened,  but  formed  a  satisfactory  pedicle.  The  tube 
and  cyst  were  removed.  A  coil  of  intestine  had  partici- 
pated in  the  inflammatoi-y  process,  its  walls  being  as 
thick  and  firm  as  those  of  the  inflamed  tubes.  The  opera- 
tion lasted  one  hour  and  forty  minutes.  The  shock  was 
alarmingly  severe,  and  in  fear  lest  the  patient  should  die 
on  the  table,  I  did  not  stay  to  irrigate  the  peritoneum, 
but  having  inserted  a  drainage-tube  and  cleansed  the  peri- 
toneum as  well  as  T  could,  closed  the  wound  and  put  her 
back  to  bed. 

After  an  hour  or  two  she  rallied,  and  for  the  first  day 
or  two  I  thought  the  was  going  to  recover.  On  the  third 
day,  however,  she  became  very  ill  and  restless,  and  on  the 
fifth  day  she  died.  There  was  no  post-mortem  examina- 
tion. 

This  case  made  a  strong  impression  on  my  mind.  It 
shows  very  strikingly  the  futility  of  expectant  and  pallia- 
tive treatment  where  there  is  obvious  disease  of  the  appen- 
dages, even  though  the  symptoms  may  at  first  be  com- 
paratively insignificant.  The  probability  is  that  there 
Avas  incipient  aud  unsuspected  tubal  disease,  in  addition  to 
the  small  cystic  ovary,  when  the  patient  was  first  under 
treatment.  I  was  not  competent  at  that  time  to  diagnose 
tubal  disease  in  its  early  stages,  and  it  is  quite  possible, 
if  there  were  physical  signs,   that   they  were  overlooked. 


340  VALUE  OF  ABDOMINAL  SECTION  IN 

The  course  of  pathological  events  seems  to  have  been  the 
following  :  Concurrent  suppurative  salpingitis  and  cystic 
disease  of  the  ovary  ;  pelvic  peritonitis,  with  adhesion  of 
both  tubes  to  the  gradually  enlarging  cyst;  ulceration  of 
the  cyst-Avall,  ending  in  perforation  and  direct  communi- 
cation between  the  cyst  and  one  of  the  suppurating  tubes  ; 
infection  of  the  contents  of  the  cyst,  causing  suppura- 
tion of  contents  and  inflammation  of  the  cyst-wall  ;  acute 
peritonitis  and  septiceemia.  The  operation,  unfortunately, 
was  too  late  to  save  the  patient's  life.  No  one,  however, 
will,  I  think,  hesitate  to  agree  that  it  was  the  right 
treatment,  and  gave  the  patient  her  only  chance. 

Case  34.  History  of  two  attacks  of  severe  abdominal 
pain,  one  eighteen  months  ago  after  tnissing  one  menstrual 
period,  the  other  a  month  ago  after  m,issing  two  periods ; 
soft  irregular  swelling  behind  and  to  the  left  of  the  uterus, 
extending  upwards  and  forming  a  distinct  abdominal  tumour  ; 
ill-defined  thiclcening  of  right  broad  ligament  ;  abdominal 
section ;  ruptured  blood-cyst  of  right  broad  ligament ; 
left  hsematosalpinx  with  intra-peritoneal  hsematocele  ;  re- 
moval of  diseased  parts  and  of  right  ovary  ;  recovery. — A 
married  woman,  aged  29,  was  admitted  into  St.  Thomas's 
Hospital  August  19th,  1890,  complaining  of  pain  in  the 
lower  part  of  the  abdomen  and  the  back,  and  of  a  swelling 
in  the  left  iliac  region. 

She  was  married  at  the  age  of  eighteen,  has  had  four 
children  and  no  miscarriages.  Her  last  child  was  born 
five  years  ago.  After  that  she  menstruated  regularly 
until  eighteen  months  ago,  when,  being  a  fortnight  beyond 
her  usual  monthly  period,  she  was  seized  very  suddenly 
with  an  attack  of  pain  in  the  lower  part  of  the  abdomen. 
This  was  followed  a  few  hours  later  by  a  discharge  like  that 
of  menstruation.  She  was  seen  at  once  by  a  doctor,  who 
said  she  had  an  internal  inflammation.  She  was  on  that 
occasion  confined  to  bed  for  three  weeks.  She  afterwards 
again  menstruated  normally  until  three  months  ago,  when 
she    missed   two    periods.      On  the    morning  of    Sunday, 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  341 

July  20th,  that  is  a  month  ago,  when  the  third  period  was 
about  due,  patient  was  again  suddenly  seized  whilst  at 
her  housework  with  a  very  severe  pain  in  the  lower  part 
of  the  abdomen,  chiefly  on  the  left  side  and  in  the  back, 
compelling  her  to  go  to  bed  at  once.  Her  face  is  said  to 
have  been  pale  and  her  features  drawn.  Hot  flannels 
were  applied  all  day.  The  pain  passed  off,  but  next  day, 
whilst  riding  in  a  tramcar,  it  returned  very  violently,  and 
she  was  seized  with  vomiting.  Her  husband  met  the  car, 
and  had  to  carry  her  most  of  the  way  home — about  half  a 
mile.  She  went  to  bed  on  reaching  home,  and  the  next 
day  she  sent  for  a  doctor.  On  that  day  a  very  slight 
hfemorrhagic  discharge  from  the  vagina  took  place,  which 
has  continued  up  to  her  admission,  the  discharge  never 
amounting  to  more  than  a  stain.  Soon  after  the  com- 
mencement of  the  attack  she  noticed  a  swelling  in  the 
left  iliac  region.  She  had  not  considered  herself  preg- 
nant, as  she  had  not  had  her  usual  morning  sickness. 

On  admission  the  patient  wa,s  of  a  rather  sallow  com- 
plexion, but  was  well  nourished. 

The  abdominal  walls  were  flaccid  ;  a  firm  and  some- 
what tender  swelling  could  be  felt  in  the  lower  part  of 
the  left  side  of  the  abdomen.  The  limit  of  this  swelling 
in  an  upward  direction  was  2  inches  below  the  level  of  the 
umbilicus  ;  that  on  the  left  side  reached  as  far  as  the 
middle  of  Poupart's  ligament,  while  that  on  the  right  just 
transgressed  the  middle  line.  The  swelling  was  dull  on 
percussion. 

The  breasts  were  not  swollen,  but  some  secretion  could 
be  squeezed  from  the  nipples. 

A  vaginal  examination  was  made,  under  ether,  on 
August  27th.  There  was  much  creamy  mucus  in  the 
vagina;  the  mucous  membrane  was  not  discoloured.  The 
cervix  uteri  was  in  its  normal  position.  The  body  of  the 
uterus  was  felt  immediately  beneath  the  abdominal  wall, 
a  little  to  the  left  of  the  middle  line.  The  sound  passed 
three  inches.  Behind  the  uterus  was  a  soft  irregular 
swelling,    about   the   size  of    two  fists,  rising  above  the 


342  VALUE    OF    ABDOMINAL    SECTION    IN 

level  of  the  fundus  and  on  a  plane  posterior  to  it.  The 
uterus  could  be  moved  to  a  slight  extent  upwards  and 
downwards  independently  of  the  swelling  behind  it. 
There  was  a  small,  hard,  moveable  body  felt  above  the 
fundus  uteri,  in  front  of  the  deeper  swelling,  and  immO' 
diately  beneath  the  abdominal  wall.  Between  the  uterus 
and  the  right  lateral  wall  of  the  pelvis  some  thickening 
existed  in  the  neighbourhood  of  the  broad  ligament. 

Abdominal  section  was  performed  September  4th, 
1890.  The  first  thing  seen  was  a  thin-walled,  dark- 
coloured  tumour  situated  to  the  right  of  the  middle  line, 
with  omentum  closely  adherent  to  it.  The  tumour  was 
separated  first  from  the  omentum,  and  then  from  its 
deeper  adhesions.  On  bringing  it  to  the  surface  there 
was  observed  a  rent  on  its  posterior  aspect,  through  which 
dark  clot  was  protruding.  There  were  many  small  clots 
of  the  same  kind  lying  free  in  the  peritoneal  cavity.  The 
rupture  had  evidently  occurred  before  the  operation.  On 
the  surface  of  the  tumour  the  right  Fallopian  tube  was 
stretched  out.  The  tumour  itself  appeared  to  be  a  cyst 
of  the  broad  ligament  filled  with  blood-clot.  The  ovary 
was  normal.  The  cyst,  with  the  adjacent  tube  and  ovary 
having  been  removed,  the  left  side  was  dealt  with. 
There  was  here  a  larger  tumour  situated  deeply  behind 
the  uterus,  and  closely  adherent  to  a  coil  of  large  intes- 
tine which  had  become  prolapsed  into  the  cavity  of  the 
pelvis,  and  was  intimately  adherent  behind  to  the  posterior 
pelvic  wall.  The  abdominal  incision  was  now  enlarged 
upwai'ds  and  downwards  until  it  measured  3J  inches. 
Beneath  the  tumour  was  a  quantity  of  old  and  recent 
blood-clot  encysted  in  the  pei'itoneal  cavity.  The  hard 
moveable  nodule  felt  above  the  fundus  uteri  before  opera- 
tion was  the  smaller,  uterine,  end  of  a  pear-shaped  swell- 
ing, 24  inches  long  by  1^  inches  wide,  consisting  of  the 
left  Fallopian  tube,  containing  a  firm  dark  blood-clot. 
The  tube  was  removed,  the  haematocele  cleared  out,  and 
the  peritoneal  cavity  douched  with  hot  boracic  solution. 
A  drainaofe-tube  was  inserted  and   the  abdominal  wound 


CKRTAIN    CASES    OF    PELVIC    PERITONITIS.  343 

closed.  The  operation  lasted  one  hour  and  twenty- 
minutes. 

No  trace  of  an  ovum  was  discovered.  The  patient 
made  a  good  recovery,  and  left  the  hospital,  looking  and 
feeling  well,  on  the  4th  of  October,  thirty  days  after 
the  operation.  There  was  a  veiy  small  discharging  sinus 
at  the  lower  angle  of  the  wound. 

I  saw  her  on  January  5th,  1892,  when  she  attended 
the  hospital  at  iny  request.  She  has  been  well  and  at 
work  Avithout  interruption  since  leaving  the  hospital. 
She  is  in  robust  health,  with  a  good  colour,  and  is  still 
gaining  flesh.  She  has  menstruated  regulai'ly,  com- 
mencing seven  weeks  after  the  operation.  The  wound  is 
soundly  healed, 

October,  1892. — Stout  and  well  ;  no  pain  ;  menstruates 
regularly. 

The  history  of  this  case  strongly  suggests  tubal  gesta- 
tion, but  no  positive  evidence  of  it  was  obtained ;  and 
presuming  the  hgematosalpinx  and  htematocele  on  the  left 
side  to  have  had  such  an  origin,  it  is  difficult  to  see  what 
connection  the  ruptured  blood-cyst  in  the  right  broad 
ligament  can  have  had  Avith  ectopic  gestation,  unless, 
indeed,  one  supposes  that  the  veins  of  the  right  broad 
ligament  sharing  the  genei'al  enlargement  of  the  pelvic 
veins  due  to  pregnancy,  one  of  them  ruptured  into  an 
already  existing  broad  ligament  cyst.  There  may  be  a 
difference  of  opinion  as  to  the  propriety  of  including  the 
case  in  the  present  series,  but,  as  its  nature  was  doubtful, 
it  seemed  to  me,  on  the  whole,  the  wiser  course  not  to 
omit  it. 

Case  35.  History  of  j^ civic  j)ain  extending  over  a  jperiod 
of  more  than  fifteen  years  ;  recurrent  pelvic  peritonitis 
during  last  seven  years,  with  long  intervals  of  apparently 
good  health;  small  cystic  swelling  behind  left  broad  liga- 
ment ;  irregular  swelling  on  right  side  of  pelvis,  thought 
to  be  an  inflamed  and  adherent  Fallojnan  tube  ;  abdominal 
section;    old  pjelvic  peritonitis;   small,  tense,  thick-walled 


344  VALUE    OF    ABDOMINAL    SECTION    IN 

cyst  of  left  ovary  ;  left  tube  slightly  thickened;  right  tube 
thicJcened  to  a  diameter  of  half  an  inch,  densely  adherent, 
fimbriated  end  bound  down  and  occluded  ;  no  evidence  of 
suppuration;  both  tubes  and  both  ovaries  removed  ;  quick 
recovery  and  subsequent  freedom  from  pain,  and  improve- 
rtient  in  general  health. — A  married  woman  aged  51^ 
a  mangier,  was  admitted  September  5th,  1890. 

It  was  discovered  when  she  was  one  year  and  nine 
months  of  age  that  she  had  so-called  congenital  dis- 
location of  the  hips.  She  married  at  thirty,  and  bore 
two  children  during  the  next  three  years,  her  laboui'S, 
contrary  to  expectation,  being  easy  and  natural.  Two 
years  after  the  birth  of  her  second  child  she  began  to 
suffer  from  aching  in  the  lower  part  of  the  abdomen  and 
down  the  thighs.  Shortly  after  this  she  miscarried  at 
two  months.  She  recovered  well,  but  a  month  later 
she  had  so  much  pain  that  she  became  an  out-patient  at 
St.  Thomas's  Hospital  under  Dr.  Cory,  and  eventually  an 
in-patient  under  Dr.  Gervis.  This  was  in  1875.  In  1882 
she  again  became  an  out-patient  for  bearing-doAvn  pain 
and  yellow  discharge,  and  a  pessary  was  inserted, 
which,  however,  gave  no  relief.  A  year  later.  Dr.  W. 
Duncan,  acting  for  Dr.  Cory,  told  her  she  had  a  small 
tumour  that  needed  puncturing.  Patient  was  admitted, 
but  left  the  hospital  in  two  months,  nothing  in  the  way 
of  operation  having  been  done.  Belladonna  was  applied 
externally.  Two  days  after  leaving  the  hospital  patient 
was  seized  with  severe  labour-like  pains,  rigors,  and 
vomiting.  She  was  readmitted  for  parametritis  and 
enlarged  Fallopian  tube.  Poultices  were  applied,  and 
in  three  weeks  she  was  pronounced  by  Dr.  Gervis  to  be 
so  much  better  as  not  to  need  operation.  For  five  years 
she  remained  fairly  well.  Then  she  had  another  attack 
of  pain  with  rigors  and  vomiting,  and  was  sent  to  the 
Dulwich  Infirmary,  where  she  remained  nine  weeks,  a 
recurrence  of  the  severe  symptoms  occurring  when  she 
had  been  there  three  weeks.  Nine  months  ago  (Christ- 
mas, 1889)    she  missed  two  periods,  and  then  had  a  rather 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  345 

profuse  discharge,  with  pain  in  the  left  side.  Three 
weeks  later  she  had  an  ordinary  period,  and  since  then 
(six  months  ago)  she  has  not  menstruated  at  all.  Four 
months  ago  she  consulted  a  doctor  for  pain  in  the  left 
side  and  a  yellow  discharge.  Caustic  was  applied  to  the 
womb  once  a  week  for  a  month  without  benefit,  and 
seven  weeks  ago  she  became  an  out-patient  at  St.  Thomas's, 
when  she  was  advised  to  submit  to  operation. 

On  admission  she  appeared  in  fairly  good  health.  On 
vaginal  examination  the  body  of  the  uterus  was  found 
large,  the  cervix  in  normal  position  and  fairly  moveable. 
Bimanually,  to  the  left  of  the  uterus,  a  smooth,  tense, 
elastic  swelling,  the  size  of  a  small  orange,  was  discovered. 
It  was  quite  separate  from  the  uterus  and  fixed.  Above 
the  right  fornix,  on  a  plane  posterior  to  the  cervix,  was 
an  irregular,  ill-defined  swelling,  thought  to  be  an 
enlarged  and  adherent  Fallopian  tube.  Abdominal  section 
was  performed  on  September  9th,  1890.  Behind  the  left 
broad  ligament  was  a  tense  round  cyst,  firmly  wedged  in 
the  pelvis,  but  not  adherent.  It  was  with  some  little  dif- 
ficulty brought  into  view,  and  was  found  to  be  a  single 
thick- walled  cyst  of  2^  inches  diameter,  containing  transpa- 
rent fluid,  of  specific  gravity  1005.  The  cyst  and  adja- 
cent tube  were  removed.  On  the  right  side  the  tube, 
somewhat  thickened,  was  prolapsed  and  adherent,  the 
fimbriated  end  being  very  firmly  bound  down  in  Douglas's 
pouch.  Surrounding  the  tube  were  several  subperitoneal 
serous  cysts.  The  separation  was  difiicult  OAving  to  the 
firmness  of  the  adhesions,  but  eventually  the  tube  and 
normal  ovary  adjacent  were  tied  off  and  removed.  The 
body  of  the  uterus  was  studded  with  a  number  of  small 
subperitoneal  fibroids.  There  was  a  good  deal  of  oozing 
from  torn  adhesions,  but  no  ligatures  were  required.  The 
abdominal  wound  was  closed  in  the  usual  way. 

The  portion  of  the  right  tube  removed  measured  2f 
inches  in  length  and  4  inch  in  breadth.  The  portion  of  the 
left  tube  removed  was  2  inches  long  and  only  slightly  thick- 
ened.     There  was  no  fluid  in  either  tube. 

VOL.  xxxiv.  25 


346  VALUE    OF    ABDOMINAL    SECTION    IN 

Recovery  was  satisfactory  and  rapid  ;  the  liigliest 
recorded  temperature  being  99*2  .  The  patient  left  the 
hospital  well  on  the  8th  October.  On  February  28th,  1891, 
she  presented  herself  looking  remarkably  well.  She  had 
gained  flesh  and  had  had  no  pelvic  pain  of  any  conse- 
quence since  the  operation.  She  had  not  menstruated. 
She  subsequently  developed  a  small  hernia  at  the  lower 
angle  of  the  wound.  Otherwise  she  remained  well  and 
free  from  pain. 

There  can  be  little  doubt  that  an  eax-lier  operation 
would  have  saved  this  patient  from  years  of  suffering 
and  ill-health.  With  regard  to  the  nature  of  the  salpin- 
gitis, the  evidence  is  insufficient  to  show  whether  it  was 
septic  or  gonorrhoeal.  The  case  shows  how  insufficient 
palliative  treatment  is  to  effect  a  permanent  cure  under 
such  circumstances,  and  offers  a  strong  argument  in  favour 
of  early  surgical  interference. 

The  next  case  affords  still  stronger  evidence  on  this 
point. 

Case  36.  Chronic  ill-health  for  several  years  ivith  inter- 
mittent attachs  of  purulent  vaginal  discharge  and  increasing 
dysmenorrhoea  ;  acute  syinjytoms  of  pelvic  peritonitis  after 
exposure  to  wet;  sivelling  in  left  piosterior  quarter  of  p)elvis 
diagnosed  as  thichened,  tortuous,  and  adherent  tube  ;  uterus 
fixed  ;  abdominal  section  ;  whole  contents  of  pelvis  matted 
by  old  adhesions ;  botli  tubes  thichened,  tortuous,  and 
adherent,  containing  muco-purulent  fluid ;  ovaries  adhe- 
rent, their  outer  coat  thickened  ;  ajjpendages  on  both  sides 
removed  ;  recovery,  followed  by  continuous  improvement  in 
health. — A  single  woman,  aged  34,  employed  as  a  bar- 
maid, was  admitted,  October  9th,  1890,  complaining  of 
pain  in  the  left  side  of  the  lower  part  of  the  abdomen  and 
of  slight  haemorrhage  from  the  uterus.  She  was  pale, 
thin,  and  careworn,  and  had  the  aspect  of  a  person  suf- 
fering from  chronic  illness.  She  stated  that  she  had 
suffered  from  a  thick,  yellow,  vaginal  discharge  many 
times  during  the  past  twelve  years.      For  eight  years  she 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  347 

had  lived  as  a  married  woman,  but  bad  never  been  preg- 
nant. She  bas  suffered  severely  from  dysmeuorrboea 
from  tbe  commencement  of  menstruation,  tbe  pain  begin- 
ning a  week  before  tbe  flow,  becoming  acute  during  tbe 
first  few  bours  and  tben  gradually  abating.  Tbese  sym- 
ptoms have  been  increasing  in  severity  during  the  last 
five  years.  For  some  months  sexual  intercourse  bas  been 
impossible  on  account  of  the  pain  it  caused.  There  has 
been  no  definite  pain  in  the  pelvis,  however,  at  other  than 
the  menstrual  periods  until  three  weeks  ago,  when  her 
present  illness  began,  though  the  general  health  has  been 
seriously  failing  for  several  years. 

On  September  23rd,  the  day  after  the  last  period 
ceased,  she  got  wet  whilst  going  to  her  work  and  again 
on  returning  home.  On  tbe  afternoon  of  the  24th  she 
began  to  suffer  from  severe  pain  in  the  lower  part  of  the 
abdomen  and  had  poultices  applied.  In  spite  of  the  pain 
she  got  up  and  went  to  her  usual  evening  employment. 
Next  day  the  pain  was  less  severe,  but  a  slight  haemor- 
rhage commenced.  She  again  went  out  in  the  evening. 
The  following  day  she  was  obliged  to  remain  in  bed,  and 
on  the  27th  the  hsemorrbage  became  so  profuse  that  a 
doctor  was  sent  for  and  deemed  it  necessary  to  plug  the 
vagina.  During  the  following  week,  the  haemorrhage 
continued  slightly  and  the  doctor  told  her  she  was  suffer- 
ing from  inflammation. 

On  admission,  the  temperature  was  99°,  the  pulse  100, 
the  tongue  coated,  the  bowels  confined.  On  examination 
per  vaginam,  the  uterus  was  found  fixed.  In  the  left 
posterior  quarter  of  the  pelvis  was  a  moderately  hard 
mass,  passing  outwards  from  the  uterus,  tben  curving 
backwards  and  terminating  in  the  retro-uterine  pouch. 
This  swelling  was  believed  to  be  the  distended  and  adhe- 
rent Fallopian  tube. 

Abdominal  section  was  proposed  and  agreed  to.  The 
operation  was  performed  on  October  16tb,  1890.  Some 
serous  fluid  escaped  on  opening  the  abdomen.  The  pos- 
terior part  of  the  pelvis  contained  a  mass  of  adherent 


348  VALUE    OP    ABDOMINAL    SECTION    IN 

viscera,  consisting  of  the  uterus,  both  Fallopian  tubes 
tortuous  and  enlarged,  the  ovaries,  some  omentum  and 
several  coils  of  intestine.  The  omentum  having  been 
separated  and  a  ragged  portion  ligatured  and  removed, 
the  right  tube  and  ovary  were  with  difficulty  separated 
and  removed,  the  difficulty  being  greatly  increased  by 
the  adhesion  of  the  uterus  posteriorly  preventing  its 
being  lifted  up  so  as  to  bring  the  parts  well  into  view. 
The  left  appendages  were  then  separated,  with  still 
greater  difficulty,  and  removed.  A  small  quantity  of 
old  blood-clot  was  found  beneath  the  fimbriated  end  of 
the  tube,  surrounded  by  adhesions.  Some  coils  of  intes- 
tine, adherent  to  the  posterior  wall  of  the  pelvis,  were 
left  undisturbed.  The  peritoneal  coat  of  one  of  the  coils 
of  intestine  was  accidentally  pinched  beneath  the  ligature 
round  the  right  tube.  It  was  quickly  set  free  without 
dividing  the  ligature,  and  the  little  wound  closed  by 
three  fine  silk  sutures.  There  being  a  good  deal  of 
oozing  a  drainage-tube  was  left  in  and  the  abdominal 
wound  was  closed.      The  operation  lasted  two  hours. 

The  walls  of  both  tubes  were  found  on  section  to  be 
considerably  thickened.  There  was  some  muco-purulent 
fluid  in  both,  the  quantity  being  greater  in  the  left  than 
in  the  right.  There  was  no  ulceration  of  the  mucous 
membrane.  The  ovaries  were  large  and  succulent,  their 
outer  coat  thickened  and  shaggy  from  peritoneal  adhe- 
sions. 

The  patient  made  a  good  recovery.  She  passed  flatus 
at  8  p.m.  on  the  second  day.  She  passed  urine  natur- 
ally on  the  second  and  third  days,  required  the  catheter 
on  the  fourth  and  fifth,  and  after  that  again  passed  urine 
voluntarily.  The  drainage-tube  was  removed  in  forty- 
eight  hours.  The  bowels  acted  after  an  enema  on  the 
fourth,  eighth,  and  eleventh  days.  The  temperature  on 
the  day  following  the  operation  varied  between  99*8°  and 
100"8° ;  for  the  next  three  weeks  it  was  under  100°. 
There  was  a  little  ill-smelling  pus  found  daily  on  the 
vaginal  pad  up   to  the  25th  of  October,   i.  e.  during  the 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  349 

first  ten  days.  The  stitches  were  removed  on  the  ninth 
day.  There  was  no  abdominal  distension  throughout. 
There  was  some  rise  of  temperature  with  abdominal  pain 
and  vomiting  on  November  12th,  but  these  symptoms 
quickly  disappeared.  The  patient  was  sent  to  a  conva- 
lescent home  on  November  22nd  ;  whilst  there  she  gained 
44  lbs.  in  Aveight.  On  January  6th,  1891,  she  was  still 
gaining  weight  and  improving  in  colour  and  remained 
free  from  pain.  There  was  nothing  abnormal  to  be  felt 
in  the  pelvis,  save  a  little  hardness  high  up  behind  the 
cervix. 

On  October  27th,  1891,  having  had  a  severe  cold 
attended  with  some  pelvic  pain,  she  presented  herself  to 
ascertain  whether  there  was  anything  wrong.  On  vaginal 
examination  no  abnormal  swelling  or  tenderness  was 
found  ;  the  uterus  was  moveable,  and  the  posterior 
quarters  of  the  pelvis  were  free.  On  March  10th,  1893, 
she  attended  at  the  hospital.  There  had  been  no  men- 
struation since  the  operation.  She  had  been  at  work 
uninterruptedly  since  February,  1891,  and  declared  herself 
to  be  now  in  better  health  than  she  had  been  for  several 
years  before  the  operation. 

Though  there  is  no  absolute  proof  that  this  was  a  case 
of  gonorrhoeal  salpingitis,  all  the  evidence  is  in  favour  of 
that  opinion.  The  beneficial  effect  upon  the  health,  of 
the  removal  of  the  diseased  tubes,  has  seldom  been  more 
striking.  One  can  scarcely  recognise  the  patient  as  being 
the  same  person. 

Case  37.  Pelvic  pain  for  six  years  ;  jperitonitis  twelve 
months  ago  ;  contimially  increasing  pain  since  ;  admission 
chiejiy  on  account  of  haemorrhage  due  to  a  mucous  polypus  ; 
removal  of  polypus ;  pelvic  pain  complained  of,  thought  to  he 
functional;  development  of  septicsemic  symptoms ;  mass  dis- 
covered on  one  side  of  pelvis  ;  abdominal  exploration  ;  both 
tubes  tortuous,  inflamed  and  adherent  tuith  muco-purulent 
contents;  small  cyst  of  rigid  ovary  full  of  foetid  pus  ;  small 
intra-peritoneal  abscess  in  Douglas' s  j^ouch  ;   removal  of  both 


350  VALUE    OF    ABDOMINAL    SECTION    IN 

tubes  and  suppurating  ovarian  cyst;  recovery  followed  by 
improved  health  ;  death  a  few  months  later  from  cancer  of 
stomach. — A  single  woman,  aged  46,  a  housekeeper,  was 
admitted  into  the  hospital  September  23rd,  1890,  com- 
plaining of  pain  in  the  pelvis,  especially  on  the  right  side, 
and  of  slight  but  continuous  uterine  haemorrhage.  The 
hgemorrhage  dated  from  March,  1889,  and  the  pain  from  an 
attack  of  peritonitis,  in  August,  1889,  which  was  caused  by 
getting  wet,  and  which  obliged  her  to  keep  her  bed  for 
several  weeks.  For  at  least  five  years  before  this,  however, 
she  appeared  to  have  suffered  more  or  less  from  pain  in  the 
right  side  of  the  pelvis  and  in  the  back,  especially  on 
walking  or  making  any  exertion.  This  pain  has  been 
much  worse  during  the  last  three  months. 

The  patient  was  a  dispirited-looking  woman,  of  dark 
complexion,  of  fairly  healthy  colour  and  in  moderately 
good  condition. 

On  September  23rd,  a  small  mucous  polypus  of  the 
cervix  was  removed  by  torsion. 

On  September  30th,  an  examination  was  made  under 
ether.  An  irregular,  hard,  adherent  mass  was  found  high 
up  behind  and  to  the  left  side  of  the  uterus.  This  was 
thought  to  be  the  prolapsed  and  adherent  left  tube  and 
ovary. 

On  October  6th,  the  hasmorrhage  had  ceased,  but  the 
pain  continued.  I  was  disposed  to  think  the  patient 
magnified  her  sufferings,  which  at  this  time  I  regarded 
as  largely  of  a  functional  character.  A  week  later, 
however,  it  was  observed  that  the  patient  was  becoming 
thinner  and  weaker ;  the  pain  complained  of  was  more 
severe,  especially  on  the  right  side  ;  the  temperature  rose 
a  little  in  the  evening ;  and  the  tongue  had  become 
dry,  red,  and  glazed.  It  wa-s  evident,  therefore,  that 
there  was  some  septic  absorption  going  on,  and  I  sug- 
gested an  exploratory  operation,  which  the  patient  readily 
agreed  to. 

The  operation  took  place  on  October  23rd.  The 
omentum,  thickened  by  inflammation,  roofed  over,  and  was 


CERTAIN    CASES    OP    PELVJC    PERITONITIS.  351 

adherent  to,  the  contents  of  the  pelvis,  which  were  them- 
selves all  densely  matted  together  from  old  peritonitis. 
The  right  tube,  much  enlarged  and  universally  adherent, 
was  first  separated.  During  the  process,  a  quantity  of 
dirty,  brown,  foetid,  purulent  fluid  welled  up.  When  the 
appendages  were  brought  fully  into  view,  it  was  seen  that 
this  fluid  had  escaped  from  a  small  inflamed  cyst  of  the 
right  ovary  owing  to  accidental  rupture  during  separation. 
The  remainder  of  the  right  ovary  was  dense  and  thickened 
from  chronic  inflammation. 

The  bladder  was  much  thickened  and  the  proximal 
portion  of  the  right  tube  was  intimately  adherent  to  it. 
The  connection  was  highly  vascular  but  was  separated 
without  injury  to  the  bladder.  The  left  tube  was  much 
enlarged  and  thickened  and  universally  adherent,  its  fim- 
briated end  being  very  firmly  adherent  to  the  lower  part 
of  the  posterior  surface  of  the  uterus.  Both  tubes  were 
removed.  There  were  still  remaining  some  hard  irregular 
masses  in  the  left  posterior  quarter  of  the  pelvis  ;  but, 
although  the  left  ovary  was  contained  amongst  these, 
they  were  so  densely  and  deeply  adherent  that  it  was 
deemed  unwise  to  attempt  their  removal.  Below  the  ad- 
herent left  tube,  in  Douglas's  pouch,  there  was  a  small 
collection  of  purulent  fluid,  containing  masses  of  coagu- 
lated lymph.  There  was  a  good  deal  of  oozing  from 
separated  adhesions,  but  no  wounded  vessel  was  of  suffi- 
cient importance  to  need  ligature.  A  large  piece  of 
inflamed  omentum  that  had  been  much  soiled  by  the 
foetid  pus  was  ligatured  and  cut  off.  A  drainage-tube 
was  passed  as  deeply  as  possible,  and  the  abdominal 
wound  closed  in  the  ordinary  way.  The  operation  lasted 
two  hours. 

Description  of  parts  removed. — Both  tubes  were  enlarged, 
their  coats  thickened  and  succulent,  a  quantity  of  thick 
purulent  mucus  in  their  canal.  The  mucous  membrane 
was  swollen  and  discoloured,  but  the  rugae  were  very 
distinct,  and  there  was  no  ulceration.  The  fimbriated 
ends  of  the  tubes  were  constricted   as   by  a  ligature,   but 


352  VALUE    OP    ABDOMINAL    SECTION    IN 

were  not  occluded.  The  portion  of  the  right  tube  re- 
moved measui-ed  4^  inches  in  length  ;  it  was  much  con- 
torted, and  was  larger  both  in  breadth  and  length  than 
the  left  tube.  The  portion  of  left  tube  removed  was  3 
inches  in  length. 

The  left  ovary  was  absent. 

The  right  ovary,  an  inch  and  a  half  in  diameter  was  dense 
from  chronic  inflammation.  At  one  end  of  it  was  a  thick- 
walled  cyst,  the  size  of  a  Tangerine  orange,  from  which 
the  contents  had  escaped. 

The  temperature,  which  immediately  before  the  opera- 
tion had  averaged  99°  in  the  morning,  and  100°  to  101° 
in  the  evening,  fell  after  the  operation  nearly  to  normal, 
the  highest  record  during  the  first  week  being  99*4°.  The 
patient  required  morphia  the  first  two  nights.  The 
drainage-tube  was  removed  in  forty-four  hours.  The 
patient  had  an  action  of  the  bowels  (after  an  enema)  and 
passed  urine  naturally  on  the  fourth  day.  The  stitches 
were  removed  on  the  ninth  day. 

On  the  twelfth  day,  the  patient  having  complained  of 
a  good  deal  of  pain  for  a  day  or  two,  there  was  observed 
some  abdominal  distension,  with  tenderness  and  fluctua- 
tion near  the  lower  angle  of  the  wound.  The  lower  part 
of  the  wound  was  accordingly  reopened  for  a  short  dis- 
tance (^  inch)  and  exit  given  to  a  large  quantity  of  thick, 
dirty,  ill-smelling  pus.  An  india-rubber  drainage-tube 
was  inserted,  and  left  in  until  November  29th,  when  the 
discharge  had  ceased.  After  that  there  was  no  further  dis- 
charge, except  once,  viz.  on  December  4th,  when,  in 
consequence  of  some  pain  about  the  lower  end  of  the 
wound,  a  probe  was'  passed  and  a  little  pus  welled  out. 
The  temperature  between  November  4th  and  December 
9tli  ranged  between  97°  and  99-2°. 

The  patient  left  the  hospital  on  December  lOtli,  looking 
stout  and  well. 

On  February  27th,  1891,  she  had  gained  flesh,  and  was 
feeling  well.  She  complained  of  a  little  pain  on  the  right 
side  of  the  pelvis,  where  there  was  some  thickening  to  be 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  353 

felt  in  the  situation  of  the  pedicle.  There  was  no  swell- 
ing on  the  left  side  or  posteriorly. 

On  June  24th  she  wrote, — "  Since  seeing  you  I  have 
greatly  imjiroved  in  health,  and  can  walk  better  than  I 
have  done  for  years." 

Shortly  after  this,  she  consulted  me  on  account  of  a 
tumour  in  the  breast.  The  tumour  was  removed  by  one 
of  my  surgical  colleagues  and  proved  to  be  a  carcinoma. 
She  recovered  from  the  operation,  but  I  heard  that  she 
died  in  Novembei",  1891,  from  cancer  of  the  stomach. 

There  is  no  evidence  to  show  what  was  the  origin  of  the 
purulent  salpingitis  in  this  case.  I  am  not  in  possession 
of  the  private  history  of  the  patient  and  cannot  say 
whether  the  mischief  was  gonorrhoeal  or  septic.  Not- 
withstanding the  eminent  respectability  of  the  patient,  I 
strongly  suspect  it  was  gonorrhceal.  Finding  a  mucous 
polypus  to  account  for  the  haemorrhage,  and  regarding 
the  pain  the  patient  complained  of  as  mostly,  if  not  wholly 
neurotic,  I  very  nearly  let  her  leave  the  hospital  without 
having  treated,  or  even  discovered,  the  active  disease 
going  on  in  the  uterine  appendages.  Even  when  I  found 
an  inflammatory  mass  behind  and  to  the  left  of  the  uterus, 
I  thought  it  was  merely  the  remains  of  an  old  pelvic  peri- 
tonitis, and  might  safely  be  disregarded.  It  was  only 
when  unmistakable  symptoms  of  septic  absorption  showed 
themselves  that  I  realised  the  serious  nature  of  the  case. 
The  result  fully  justified  the  exploratory  operation.  There 
was  pus  in  an  ovarian  cyst,  in  both  tubes,  and  amongst 
the  adhesions  in  Douglas's  pouch.  The  effect  of  removing 
all  this  was  highly  satisfactory.  Unfortunately  the 
patient  succumbed  to  cancerous  disease,  first  of  the  breast 
and  afterwards  of  the  stomach,  before  she  had  enjoyed  her 
renewed  health  for  more  than  a  few  months. 

Case  38.  Puerperal  peritonitis  thirty  years-  ago  ;  no  sub- 
sequent pregnancy  ;  great  pain  and  discomfort  in  2)elvis 
Muce,  especially  at  menstrual  periods ;  symptoiiis  wor.seduring 
last  few  months  ;    soft  swelling  in  front  of  retroverted  and 


854  VALUE    OF   ABDOMINAL    SECTION    IN 

adherent  uterus-^  filling  up  right  side  of  j^elvis  ;  abdominal 
section  ;  several  serous  cysts  of  right  hroad  ligament  ;  uterus 
and  appendages  hound  downhy  old  adhesions ;  cysts  removed; 
uterus  set  free  ;  death  on  twelfth  day  from  septic  pierito- 
nitis. — A  married  woman,  aged  51,  Avas  admitted  l^ovem- 
ber  3rd,  1890,  on  account  of  very  severe  pain  in  the  lower 
part  of  the  back,  increased  by  movement  or  stooping,  also 
of  great  pain  before  and  during  defecation. 

She  had  borne  but  one  child  a  year  after  her  marriage, 
thirty  years  ago.  She  states  that  she  was  in  labour  a 
week  and  that  she  was  in  bed  for  six  weeks  after  her 
confinement,  with  what  the  doctor  said  was  inflammation. 
Since  then,  there  has  been  constant  pelvic  pain  with 
dysmenorrhoea  and  a  tendency  to  slight  heemorrhage  on 
the  slightest  provocation.  Menstruation  ceased  from 
August  1889  to  January  1890.  Then  there  was  a  profuse 
flow  which  lasted  a  month  and  from  that  time  to  April 
there  was  a  continuous  slight  loss  accompanied  with  in- 
cessant pain  in  the  back  and  lower  part  of  the  abdomen. 

On  admission  there  could  be  felt  a  soft  swelling  equal 
in  size  to  a  man^s  closed  fist  in  front  and  to  the  right  of 
the  uterus.  The  cervix  was  directed  downwards  and 
forwards  ;   the  sound  passed  backwards  three  inches. 

Per  rectum  the  posterior  surface  of  the  body  of  the 
uterus  could  be  traced  to  the  fundus,  round  which  the 
finger  could  be  hooked  ;  from  the  cornua  a  tense  band 
passed  upwards  and  outwards  on  each  side,  presumably 
the  upper  border  of  each  broad  ligament  rendered  tense. 

Abdominal  section  was  performed  on  November  10th. 
Occupying  the  whole  of  the  right  side  of  the  pelvis  were 
a  number  of  thin-walled  subperitoneal  cysts  of  the  right 
broad  ligament,  one  of  which  was  the  size  of  a  large 
orange.  Some  of  the  cysts  contained  clear  serum,  others 
contained  serum  stained  by  altered  blood.  All  the  cysts 
were  densely  adherent  to  surrounding  parts,  except  ante- 
riorly. With  considerable  difiiculty  they  were  separated, 
brought  into  view,  and  removed  by  transfixion  of  the 
broad  ligament  beneath    them.      The   body  of  the   retro- 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  355 

verted  uterus  was  adherent  to  the  posterior  pelvic  wall  by 
a  number  of  firm  bands  which  were  torn  through  by  the 
fingers.  The  uterus  was  then  straightened  and  a  Hodge's 
pessary  introduced  into  the  vagina.  The  tubes  and  ovaries 
were  bound  down  by  old  adhesious  and  prevented  the  body 
of  the  uterus  from  being  fully  anteverted.  They  were 
not  disturbed.  A  good  deal  of  bleeding  took  place  from 
the  separated  adhesions.  The  peritoneal  cavity  was 
douched  with  hot  boracic  solution,  a  glass  drainage-tube 
inserted  and  the  abdominal  wound  closed. 

Next  day  there  was  slight  hiccough,  retching,  nausea, 
pain,  thirst,  and  a  good  deal  of  abdominal  distension.  On 
the  third  day  there  was  continual  sickness.  Much  flatus 
and  a  little  fa3cal  matter  passed  after  enemata,  but  the 
distension  continued.  Drachm  doses  of  magnesium  sul- 
phate were  tried,  and  at  long  intervals  injections  of  mor- 
phia. On  the  fifth  day  the  distended  abdomen  was  punc- 
tured in  two  places  with  insignificant  result.  This  treat- 
ment was  repeated  next  day  with  no  effect.  On  the 
seventh  day  a  copious  enema  mixed  with  glycerine  was 
given.  This  was  followed  by  the  passage  of  several  liquid 
motions  and  much  flatus,  the  distension  remaining  unre- 
lieved. After  this  there  was  no  more  sickness,  and  the 
bowels  continued  to  act.  It  was  now  thought  that  the 
danger  had  passed,  and  the  patient's  bed  was  moved  into 
the  general  ward,  but  at  4  a.m.  on  the  twelfth  day  she 
complained  of  very  severe  pain,  and  at  8.20  a.m.  she  died 
in  a  state  of  collapse. 

The  temperature  was  for  the  most  part  normal  or  sub- 
normal throughout ;  the  highest  record  until  a  few  hours 
before  death  was  99*4°.  The  pulse  varied  from  80 
to  120. 

Autopsy  made  thirty  hours  after  death  by  the  late  Dr. 
Gulliver.  General  peritonitis.  The  coils  of  intestine 
were  glued  together  by  exudation,  and  there  was  a  con- 
siderable quantity  of  ill-smelling  semi-purulent  fluid  in 
the  cavity.  The  inflammation  was  most  intense  in  the 
pelvis.      The   uterus   was    adherent   to    the   back   of    the 


356  VALUE    OF    ABDOMINAL    SECTION    IN 

pelvis  by  some  old  fibrous  bands.  The  left  Fallopian 
tube  was  occluded  at  its  fimbriated  end  and  formed 
a  cyst  containing  about  an  egg-cup  full  of  clear  fluid. 
Ovary  normal.  On  the  right  side  of  the  pelvis  was  the 
stump  of  the  uterine  appendages  with  its  ligature. 

Had  I  known  that  the  swelling  on  the  right  side  of  the 
pelvis  consisted  merely  of  a  number  of  sub-serous  cysts, 
I  should  not  have  advised  an  operation.  Looking  back 
upon  the  case,  I  think  probably  the  best  treatment  after 
opening  the  abdomen  would  have  been  to  puncture  and 
evacuate  the  cysts  instead  of  removing  them.  The  after- 
treatment  was  based  on  the  supposition  that  the  sym- 
ptoms were  due  to  simple  intestinal  paralysis.  The 
autopsy  showed  that  they  were  really  due  to  septic  peri- 
tonitis. 

Case  39.  Attack  of  i^elvic  i^eritonitis  in  March,  1889  j- 
hard  smooth  swelling  in  right  'posterior  quarter  of  pelvis 
pushing  uterus  forivards  and  to  the  left  ;  bursting  of  abscess 
into  rectum  on  nineteenth  day  ;  recovery  with  disappearance 
of  tumour  and,  fixation  of  uterus  ;  readmission  November, 
1890,  on  account  of  pelvic  pain  and  slight  purulent  discharge 
from  rectum  ;  reappearance  of  sicelling  on  right  side  of 
pelvis;  abdominal  section;  small  thick-walled  suppu- 
rating cyst  of  right  ovary  removed ;  no  intra-peritoneal 
abscess  discovered,  bid  subsequent  escape  of  pus  from  wound  ; 
recovery  with  complete  7'e- establishment  of  health. — An  un- 
married woman,  aged  33,  an  ironer,  was  admitted  Novem- 
ber 4th,  1890,  on  account  of  pain  in  the  pelvic  region  and 
a  purulent  discharge  from  the  rectum. 

Nineteen  months  ago,  viz.  on  March  19th,  1889,  eight 
days  after  a  normal  menstrual  period  she  was  suddenly  taken 
ill  whilst  at  her  work,  with  pain  in  the  back  and  lower  part 
of  the  abdomen,  shivering,  nausea,  and  a  profuse  discharge 
of  blood  from  the  vagina.  She  went  home  at  once  and 
to  bed,  and  lay  awake  with  the  pain  all  night.  Next 
day  she  attempted  to  resume  her  work,  but  had  to  leave 
it  and  go   home.      She   was  afterwards  seen   by  a  doctor 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  357 

who  told  lier  she  had  inflammation  of  the  bowels  with  a 
displacement  of  the  womb,  and  advised  her  to  seek  admis- 
sion to  a  hospital. 

She  was  admitted  at  St.  Thomas's  under  my  care 
April  1st,  1889.  The  haemorrhage  had  by  this  time  ceased, 
having  lasted  four  days.  She  still  complained,  however, 
of  severe  pain  in  the  lower  part  of  the  abdomen,  and  she 
had  retention  of  urine,  requiring  the  use  of  the  catheter. 
There  was  a  discharge  of  mucus  from  the  bowel  whenever 
she  moved. 

The  condition  found  on  vaginal  examination  was  as 
follows  : — Uterus  displaced  anteriorly  and  fixed  ;  fundus 
If  inches  above  top  of  symphysis  pubis  a  little  to  left  of 
median  line.  On  right  side  extending  from  uterus  to 
lateral  wall  of  pelvis,  a  hard,  uniform,  smooth  swelling, 
inseparable  from  the  uterus  and  rather  tender  to  the 
touch.  No  swelling  on  left  side.  Immediately  behind  the 
supra-vaginal  portion  of  the  cervix,  a  small,  hard,  irregu- 
lar swelling.  The  upper  margin  of  the  swelling  on  the 
right  side  2:^  inches  above  Poupart's  ligament. 

On  April  6th  a  discharge  of  pus  took  place  from  the 
bowel ;  this  continued  for  forty-eight  hours.  The  pus 
was  thick,  yellow,  and  without  odour.  The  total  quantity 
passed  was  estimated  at  6  to  8  fl,  oz.  On  April  9th  there 
was  a  discharge  from  the  bowel  of  clear  transparent 
mucus.  On  the  18th  the  patient  felt  quite  well,  she  had 
no  pain  and  there  was  no  discharge.  On  the  30th  the 
physical  signs  were  as  follows  : — Uterus  absolutely  fixed  ; 
no  swelling  behind  it,  but  the  parts  in  Douglas's  pouch 
so  adherent  that  the  vaginal  roof  cannot  be  pushed  up. 
No  depression  of  either  lateral  fornix,  but  the  whole  of 
the  right  side  of  the  pelvis  occupied  by  an  irregular,  fixed, 
hard  mass.  Bimanually,  no  tumour  can  be  felt.  Nothing 
abnormal  on  left  side. 

The  patient  was  free  from  pain ;  her  temperature  was 
normal  and  had  been  so  since  the  8tli. 

On  May  21st  the  resistance  above  right  fornix  and  in 
Douglas's  pouch  was  less  marked,  though  still  quite  evi- 


358  VALUE    OP    ABDOMINAL    SECTION    IN 

dent.  Fixation  o£  uterus  less  absolute.  Patient  left  the 
hospital  on  June  8th. 

For  the  next  two  months  after  this  she  remained  quite 
free  from  pain  or  inconvenience  of  any  kind.  But  about  the 
end  of  that  time  she  noticed  that  she  had  to  go  to  stool  more 
frequently  than  usual,  and  she  often  passed  nothing  but  a 
small  quantity  of  yellow  matter.  This  continued  up  to  three 
weeks  before  her  readmission,  when  the  desire  to  defe- 
cate became  much  more  frequent,  the  matter  passed  being 
generally  purulent.  For  the  last  week  she  had  suffered 
a  good  deal  of  pain  whilst  at  work. 

Patient  is  a  thin,  sallow,  dark-complexioned  Avoman 
with  a  badly  formed  chest.  On  readmission  (Novem- 
ber 4th,  1890)  there  was  a  hard,  smooth  swelling  felt  to 
right  of  and  behind  the  uterus,  and  the  evacuations  con- 
tained pus.      The  pulse  was  72,  the  temperature  normal. 

Abdominal  section  was  performed  November  12th,  1890. 
A  small,  inflamed,  tense,  and  thick-walled  cyst  of  the 
right  ovary  containing  3|  fl.  oz.  of  dark,  thick,  fcetid 
pus,  was  with  much  difficulty  separated  from  the  very 
dense  and  vascular  adhesions  which  surrounded  it  on  all 
sides.  The  cyst  was  brought  into  view,  punctured  with 
a  trocar,  partially  emptied  and  removed,  together  with 
the  inflamed  right  tube  which  was  closely  incorporated  in 
the  cyst-wall,  but  was  pervious  throughout  and  did  not 
communicate  with  the  interior.  The  cyst  was  single;  it 
measured  2|  inches  x  H  inches;  its  wall  was  of  the  uni- 
form thickness  of  ^  inch  ;  its  cavity  was  lined  by  inflam- 
matory lymph.  No  intra-peritoneal  abscess  was  found  or 
any  communication  with  the  rectum  discovered  ;  the  left 
-ovary  was  healthy  but  surrounded  with  adhesions,  which 
were  separated  without  removing  either  tube  or  ovary. 
The  peritoneal  cavity  was  douched  and  a  glass  drainage- 
tube  inserted  before  the  abdomen  was  closed.  The  opera- 
tion lasted  an  hour  and  a  half. 

The  patient  was  sick  from  time  to  time  up  to  2  p.m.  on 
the  14th.  As  there  was  pus  in  the  discharge,  the  glass 
drainage-tube  was  replaced   that  day  by  an  india-rubber 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  359 

one.  Flatus  passed  naturall}-  on  the  15tli.  The  discharge 
was  slight^  the  microscope  showed  it  to  contain  pus.  On 
the  17th  the  bowels  were  opened  four  times  after  a  dose 
of  castor  oil ;  no  pus  was  visible  in  the  evacuations.  The 
stitches  were  with  one  exception  removed  on  the  20th  ;  a 
little  ill-smelling  pus  was  then  coming  from  the  wound. 
On  December  8th  there  being  little  or  no  discharge,  the 
drainage-tube  was  finally  removed.  On  December  13th 
patient  was  very  comfortable ;  there  had  been  no  pain  or 
rise  of  temperature  since  the  removal  of  the  tube.  She 
sat  up  in  bed  on  the  1 0th,  got  up  for  the  first  time  on  the 
15th,  and  left  the  hospital  well  on  the  31st.  There  was 
no  swelling  in  the  pelvis,  the  uterus  was  fixed.  The 
highest  temperature  after  the  operation  was  99*4°,  except 
once  (on  November  21st)  when,  after  an  enema,  it  reached 
100°.  From  and  after  December  1st  it  was  uniformly 
normal  or  subnormal. 

April  18th,  1891. — Patient  presented  herself  on  account 
of  a  pharyngeal  catarrh.  In  other  respects  she  was  quite 
well.  She  had  gained  flesh  and  her  skin  had  assumed  a 
healthy  colour.  She  had  had  no  pain  in  the  pelvis  or 
discharge  from  the  bowel  since  leaving  the  hospital. 
She  had  menstruated  regularly  and  been  able  to  do  her 
work  easily. 

October  17th,  1891. — Applied  for  help  towards  the 
purchase  of  a  belt,  the  abdominal  wall  being  weak.  She 
has  no  pain,  but  when  tired  has  cramp-like  sensations  in 
the  lower  part  of  the  abdomen.  She  has  not  menstruated 
for  three  months.  She  is  working  hard  as  an  ironer  two 
or  three  days  every  week  from  8  in  the  morning  to  9  at 
night. 

Although  no  intra-peritoneal  abscess  was  discovered 
during  the  operation,  the  subsequent  discharge  of  pus 
through  the  abdominal  wound  makes  it  probable  that  such 
an  abscess  existed,  the  remains  of  the  large  abscess 
which  had  burst  into  the  rectum  eighteen  months  pre- 
viously. The  inflamed  condition  of  the  right  Fallopian 
tube  renders  it  more  than  likely  that  the   abscess  had  its 


360  VALUE    OF    ABDOMINAL    SECTION    IN 

origin  in  suppurative  salpingitis,  the  pus  escaping  from 
the  tube  into  the  peritoneum.  The  incomplete  evacuation 
of  tlie  abscess  when  it  burst  into  the  bowel  would 
account  for  the  subsequent  symptoms  and  for  the  infec- 
tion of  the  neighbouring  ovary.  The  result  of  the  opera- 
tion was  all  that  could  be  desired. 

Case  40.  Pain  in  left  iliac  region  and  tem-j^orary  rise  of 
temperature  on  the  ninth  day  ajter  delivery,  without  dis- 
coverable lesion;  recurrence  of  the  pain  at  intervals ;  pain 
icorse  on  returning  to  worh  ;  six  months  after  confinement 
development  of  a  fixed  swelling  in  left  posterior  quarter  of 
pelvis,  with  2nirulent  discharge  fror)i  uterus;  diagnosis  of 
salpingitis  with  pelvic  peritonitis  ;  abdominal  section  ;  left 
pyosalpinx  with  adhesion  of  tube  and  ovary  ;  left  append- 
ages removed  ;  recovery  interrupted  by  acute  bronchitis  but 
otheriuise  satisfactory  ;  piersistence  of  pelvic  pain ;  no 
lesion  discoverable. — An  unmarried  girl,  aged  22,  a  servant, 
was  delivered  of  a  full-term  child  at  the  General  Lying-in 
Hospital  in  April,  1890.  The  labour  was  tedious,  and 
delivery  was  effected  by  forceps.  The  perineum  was 
slightly  torn.  On  the  ninth  day  the  temperature,  which 
up  to  that  time  had  not  exceeded  100°,  rose  to  102*6°, 
and  the  patient  complained  of  pain  in  the  left  iliac  region. 
Dr.  Herman  made  a  vaginal  examination  and  found 
nothing  abnormal.  Next  day  the  pain  had  disappeared 
and  the  temperature  was  normal.  On  the  14th  day  the 
patient  was  sent  to  a  convalescent  home,  where  she  re- 
mained four  weeks.  During  her  stay  there  she  had  a 
recurrence  of  the  pain  which  was  quickly  relieved  by  the 
application  of  a  blister.  After  leaving  the  home,  she  had 
a  good  deal  of  pain  in  the  back  and  in  the  left  iliac 
region,  with  frequent  discharge  of  blood  from  the  vagina. 
She  was  able  to  do  her  work,  however,  until  the  begin- 
ning of  September,  when  the  pain  became  severe,  and  the 
discharge  continuous  and  profuse. 

She  was  admitted  to  St.  Thomas's  Hospital  October 
2oth,  1890.      A  purulent  discharge  was  seen  issuing  from 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  361 

the  OS  uteri,  both  lips  of  which  were  the  seat  of  a  catar- 
rhal erosion.  The  cervix  was  dilated  and  the  interior  of 
the  uterus  curetted,  with  the  result  of  bringing  aAvay  some 
clots  and  some  fragments  of  membrane.  The  pain  and 
yellow  discharge  continued,  and  on  November  14th  an 
examination  was  made  under  anaBsthesia.  On  the  left 
side,  anterior  to  and  below  the  retroverted  body  of  the 
uterus,  was  felt  a  well-defined  oblong  mass,  depressing 
the  left  vaginal  fornix.  The  mass  was  divided  by  a 
sulcus  into  two  portions,  one  a  smooth,  rounded  body, 
suggestive  of  an  ovary,  the  other  a  hard,  elongated  swell- 
ing passing  some  distance  outwards,  and  situated  behind 
and  below  the  smaller  swelling.  Nothing  abnormal  was 
felt  on  the  right  side. 

The  diagnosis  was  diseased  left  Fallopian  tube,  with 
pelvic  peritonitis  and  adhesion  of  tube  and  ovary  to  each 
other  and  to  surrounding  parts. 

Abdominal  section  was  proposed  and  agreed  to. 

The  operation  was  performed  on  November  19th.  The 
uterus  was  slightly  thicker  and  larger  than  normal,  somewhat 
retroverted  and  inclined  to  the  right  side,  and  connected 
with  the  posterior  wall  of  the  pelvis  by  numerous  bands 
of  adhesion,  recent  and  easily  separated.  The  left  tube 
and  ovary  were  adherent  to  each  other,  to  the  back  of  the 
broad  ligament  and  to  other  surrounding  parts.  The 
tube  was  thickened  by  inflammation,  and  unequally  dilated, 
owing  to  a  sharp  bend.  The  main  dilatations  were  two 
in  number,  and  were  felt  to  contain  fluid.  The  distal  end 
was  occluded.  The  ovary  was  normal  in  size  and  appear- 
ance, but  completely  enveloped  by  adhesions.  The  ovary 
and  tube  were  removed  tosrether.  The  rig-ht  tube  was 
normal.  The  right  ovary  was  normal  in  size  and  appear- 
ance, but  was  prolapsed  and  adherent  over  its  entire  sur- 
face. These  adhesions  having  been  easily  separated,  the 
right  tube  and  ovary  were  left  without  further  interfer- 
ence. There  was  a  considerable  amount  of  oozing  from 
the  separated  adhesions.  The  pelvis  was  well  sponged 
and   a   glass   drainage-tube   inserted   before    closing   the 

VOL.  XXXIV.  26 


362  VALUE    OF   ABDOMINAL    SECTION    IN 

abdominal  wound.  The  operation  lasted  an  hour  and  a 
quarter. 

On  opening  the  diseased  left  tube  it  was  found  to  con- 
tain thin  purulent  fluid.  The  mucous  membrane  was 
pale  and  swollen,  but  showed  no  sign  of  ulceration,  new  or 
old.  The  muscular  wall  was  thickened  ;  it  measured  a 
J  inch.      The  ovary  was  normal. 

Convalescence  was  retarded  by  an  attack  of  bronchitis, 
but  otherwise  she  made  a  good  recovery,  and  was  able 
to  be  sent  to  a  convalescent  home  on  December  10th. 

On  January  18th,  1891,  she  was  readmitted  and  she 
then  made  the  following  statement.  Two  or  three  days 
after  leaving  the  hospital  she  began  to  reject  her  food 
from  half  an  hour  to  an  hour  after  each  meal.  Pain  in 
the  back,  which  was  present  to  a  slight  extent  when  she 
was  discharged,  became  worse,  shooting  into  the  right 
side.  She  had  had  attacks  of  shivering  followed  by  per- 
spirations. Three  days  after  leaving  the  hospital,  the 
yellow  vaginal  discharge  had  reappeared. 

Her  temperature  on  readmission  was  normal.  She  was 
examined  on  the  16th  of  January,  and  again  under  ether 
on  the  28th,  with  an  entirely  negative  result.  No  swell- 
ing could  be  found  in  either  posterior  quarter  of  the  pelvis. 
She  was  accordingly  discharged. 

A  few  months  later  she  applied  at  the  Westminster 
Hospital  complaining  of  pelvic  pain.  She  was  examined 
by  Dr.  Potter  and  nothing  abnormal  Avas  found. 

On  November  17th,  1891,  she  presented  herself  again 
at  St.  Thomas's,  still  complaining  of  pelvic  pain  and  some 
metrostaxis.  I  examined  her  carefully  but  could  not  detect 
any  swelling.  The  uterus  was  movable  and  the  posterior 
quarters  of  the  pelvis  free. 

This  is  one  of  the  very  few  cases  in  which  pain  has 
persisted  after  removal  of  diseased  appendages.  It  may, 
of  course,  be  due  to  mischief  in  the  remaining  and  appa- 
rently healthy  tube,  but  in  the  absence  of  any  evidence  of 
peritonitis  or  alteration  in  the  size  and  position  of  the 
right    appendages,   I   am   much    more   disposed   to  think 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  363 

that  the  pain  has  no  pathological  significance.  I  hope  I 
am  not  doing  the  girl  an  injustice  if  I  suggest  that  her 
persistent  complaints  are  due  to  her  having  discovered  that 
hospital  life  is  easier  than  the  Avork  of  a  domestic  servant. 

Case  41.  Acute  j)elvic  peritonitis  seven  -weeks  after  fourth 
confinement ;  a  iceeh  later  large  mass  on  left  side  of  pelvis 
and  smaller  one  on  right,  depressing  vaginal  roof  laterally  ; 
after  another  iceek,  sivellings  smaller  aiul  better  defined, 
thicliened  and  adherent  tubes  being  traceable;  develojmient 
of  cellulitis  around  cervix ;  gradual  recovery ;  return  to 
household  duties  for  nine  months,  though  in  more  or  less 
constant  pain  ;  recurrence  of  acute  peritonitis  ;  soft  mass 
in  right  posterior  quarter  of  pelvis  with  thickened  Fallopian 
tube  ;  diagnosis  of  diseased  right  ovary  icith  inflamed  tubes 
and  peritonitis  ;  abdominal  section  :  right  ovary  enlarged 
and  honeycombed  icith  abscesses  ;  right  tube  occluded  and  in- 
flamed ;  pelvic  contents  matted  together  ;  right  appendages 
removed  ;  left  fairly  healthy,  not  removed  ;  accidental  wound 
of  intestine  sutured ;  escape  of  foetid  pnis  from  lower  angle 
of  wound  on  tenth  day  ;  fascal  stain  on  one  occasion  only  ; 
recovery  xcith  re-establishment  of  health  ;  small  sinns  with 
slight  discharge  two  months  after. — A  married  woman, 
aged  25,  was  first  admitted  to  St.  Thomases  Hospital 
December  2nd,  1889.  She  had  been  confined  of  her 
fourth  child  seven  weeks  previously.  After  the  confine- 
ment she  suffered  severely  from  after-pains  and  headache, 
and  was  kept  in  bed  for  fourteen  days.  The  headache 
persisted,  and  although  she  went  about  the  house  she  did 
not  go  out-of-doors.  Some  hours  before  her  admission, 
she  was  seized  with  sudden  abdominal  pain  and  faintness. 
This  attack  she  attributed  to  having  got  her  feet  wet  two 
days  previously,  whilst  washing  clothes  in  the  yard. 

She  was  a  stout,  pale,  anaemic,  despondent  woman  of 
feeble  intelligence.  Her  urine  contained  one  sixth  to  one 
tenth  albumen. 

The  fundus  uteri  was  '!•  inches  above  the  pubes  and  2 
inches  below  the  umbilicus.      There  was  a  sense  of  resist- 


364 


VALUE    OF    ABDOMINAL    SECTION    IN 


ance  in  left  iliac  regioB,  bounded  above  by  a  well-defined 
margin  on  a  level  with  the  anterior  superior  iliac  spine. 
There  was  tenderness  in  the  right  iliac  fossa,  without 
definite  swelling  or  sense  of  resistance.  The  percussion- 
note  was  absolutely  dull  from  the  top  of  the  pubes  to  a 
line  3  inches  above  that. 

On  vaginal  examination  the  uterus  was  found  fixed,  the 
cervix  shortened,  the  os  patulous.  The  left  fornix  was 
depressed  by  a  firm  slightly  elastic  mass,  continuous  with 
the  mass  felt  in  the  abdomen.  The  right  fornix  was 
slightly  depressed,  by  a  similar  though  less  easily  defin- 
able mass.  There  was  no  fulness  or  depression  of  the 
pouch  of  Douglas,  but  high  up  a  firm  band  could  be  felt 
stretching  across  behind  the  upper  part  of  the  cervix. 
This  band  was  still  more  distinct  on  examination  per 
rectum. 

The  temperature,  which  on  admission  was  101°,  varied 
on  the  3rd  December  between  100-6°  and  102-6°. 

4th 

5th  „  „ 

6th  „  „ 

7th  „  „ 

8th 

9th 
10th 
After  which   it  was  usually  normal,  and 
100-6°  up   to  the  time  of  the   patient's   discharge   on  the 
26th  January. 

On  December  17th  (a  fortnight  after  admission)  the 
firm  mass  in  the  left  iliac  fossa  had  disappeared.  The 
left  vaginal  fornix  was  slightly  depressed  by  a  firm  mass 
which,  bimanually,  could  be  differentiated  into,  anteriorly, 
a  thickened  and  contorted  Fallopian  tube,  traceable  from 
the  cornu  of  the  uterus  outwards  and  curving  round  to 
the  back  of  the  broad  ligament,  and  posteriorly,  a  larger 
softer  mass,  thought  to  be  the  ovary.  High  up,  behind 
the  cervix,  could  be  felt  a  fixed,  firm,  swelling  continuous 
with  the  adherent  mass  already  described  as  occupying 


100-4° 

J  J 

103-2° 

99° 

}} 

101-2° 

100° 

}> 

101-8° 

99-6° 

>} 

102-4° 

98-4° 

)) 

102-8° 

97° 

)} 

]  03-4° 

98° 

}) 

100° 

1,  and 

did 

not  exceed 

CERTAIN    CASES    OF    PELVIC    PERITONITIS.  365 

the  left  posterior  quarter  of  the  pelvis.  The  right  appen- 
dages were  not  felt  through  the  vagina,  but,  -per  rectum, 
the  right  tube,  thickened,  could  be  felt  bent  upon  itself 
and  turning  down  behind  the  uterus. 

The  urine  still  contained  one  tenth  albumen.  On 
January  10th,  1890,  the  uterus  was  in  normal  position,  its 
mobility  impaired.  Masses  felt  on  both  sides  of  the 
pelvis,  apparently  consisting  of  broad  ligament  and  appen- 
dages intimately  matted  together.  The  mass  on  the  right, 
higher  up  than  that  on  the  left,  extended  outwards  and 
backwards  to  the  pelvic  wall.  On  the  left  the  tube  ran 
out  and  back  and  then  cui'ved  downwards  behind  the 
uterus,  closely  adherent  to  the  mass  round  which  it  curved. 
The  lateral  fornices  were  depressed ;  the  supra- vaginal 
portion  of  the  cervix  was  completely  surrounded  by  a 
hard  collar.  Per  rectum  a  depression  could  be  felt  in 
the  middle  line  above  the  cervix,  and,  higher  up,  a  firm 
transverse  band,  causing  a  projection  in  the  rectum. 
From  this  band  tense  bands  could  be  felt,  diverging 
like  the  arms  of  the  letter  V,  and  passing  upwards  and 
backwards.  The  right  arm  of  the  V  was  more  distinct 
than  the  left,  which  was  interrupted  by  a  rounded  pro- 
minence. 

On  January  22nd,  1890,  the  swellings  in  the  pelvis 
were  all  found  smaller,  and  on  the  26tli  the  patient  went 
home. 

The  patient  was  readmitted  on  November  12tli,  1890. 
She  then  stated  that  she  had  been  able  to  do  her 
housework  and  look  after  her  children  ever  since  she  left 
the  hospital,  though  she  had  never  felt  really  well,  and 
had  suffered  from  time  to  time  from  pain  in  the  pelvis 
and  thighs,  especially  on  the  right  side.  On  November 
8th  she  was  taken  ill  with  vomiting  and  very  severe  pain 
in  the  abdomen  and  right  groin  shooting  down  the 
thigh.      Since  then  she  has  perspired  profusely  at  night. 

On  vaginal  examination  there  was  found  an  ill-defined 
soft  mass  behind   and  to   the  right  of  the  uterus  ;   and  a 


366  VALUE    OF    ABDOMINAL    SECTION    IN 

smaller,  harder,  and  more  irregular  mass  on  the  left. 
The  uterus  was  normal  in  position.  There  was  a  trace  of 
albumen  in  the  urine. 

The  diagnosis  was  a  diseased  and  enlarged  right  ovary 
with  inflamed  and  adherent  Fallopian  tubes. 

On  November  28th,  1890,  abdominal  section  was  per- 
formed. The  pelvic  viscera  were  found  matted  together, 
omentum  and  large  intestine  being  also  involved.  A 
band  of  omentum  was  adhei'ent  to  the  bladder,  and  a 
broader  one  to  the  parts  behind  the  uterus.  These  were 
tied  and  divided.  To  the  right  of  and  behind  the  uterus 
was  a  soft  rounded  mass,  which,  after  careful  separation 
of  adhesions,  w^as  brought  into  view  and  seen  to  be  the 
right  ovary  diseased  and  enlarged.  With  the  ovary  was 
removed  the  inflamed  and  thickened  right  tube.  The 
left  appendages  being  fairly  healthy,  it  was  decided  not 
to  remove  them.  A  thickened  coil  of  large  intestine 
dipped  down  to  the  floor  of  the  retro-uterine  space  to  which 
it  was  intimately  adherent.  This  having  been  separated 
and  brought  into  view,  it  was  found  that,  during  the  process 
of  separation,  the  coats  of  the  intestine  had  been  torn, 
leaving  an  aperture  large  enough  to  admit  the  tip  of  the 
finger,  through  which  the  mucous  membrane  protruded. 
This  rent  was  closed  by  four  Lembert^s  sutures  of  fine  silk. 
The  tip  of  the  appendix  vermiformis  was  also  adherent  to 
the  floor  of  the  retro-uterine  space;  this  was  left  undis- 
turbed. The  pelvis  was  now  cleansed  with  sponges,  a 
glass  drainage-tube  inserted,  and  the  abdominal  wound 
closed. 

Description  of  2)arts  removed. — The  right  ovary  mea- 
sured 2\  inches  by  If  inches.  On  section  it  was  found 
to  be  honeycombed  with  spaces,  containing  thick  yellow 
pus.  The  portion  of  right  tube  removed  was  2i  inches 
in  length.  Its  wall  was  ^  inch  thick;  the  fimbriated  end 
was  occluded.  The  mucous  membrane  was  swollen  and 
oedematous.  There  was  no  ulceration  and  no  pus  was 
found  in  the  tube.  The  mesosalpinx  was  thickened. 
Mr.  Shattock  reported  that  the  ovary  had  very  much  the 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  367 

appearance  of  tuberculous  disease.  A  portion  was  put 
aside  for  microscopical  examination,  but  appears  to  have 
got  misplaced,  as  it  could  not  afterwards  be  found. 

The  convalescence  was  somewhat  prolonged.  The 
drainage-tube  was  removed  in  twenty-four  hours.  On 
the  third  day  some  blood  escaped  from  the  rectum.  On 
the  fourth,  the  urine  contained  a  good  deal  of  blood. 
On  the  fifth  day  two  fluid  ounces  of  blood  passed  from 
the  rectum.  The  stitches  were  removed  in  a  week.  On 
the  following  day,  there  was  a  fsecal  stain  on  the  dressing  ; 
nothing  of  the  kind  was  seen  again.  On  the  tenth  day 
a  little  foetid  pus  escaped  on  probing  the  lower  angle  of 
the  wound,  and  on  the  twelfth  day  there  was  a  more  free 
discharge  of  pus  of  the  same  character,  but  again  without 
any  admixture  of  feeces.  After  this,  the  temperature  was 
normal,  the  discharge  was  very  slight  and  less  offensive, 
and  the  patient  improved  in  every  way.  She  was  dis- 
charged on  the  24th  January,  1891.  She  had  gained 
flesh  and  had  a  good  appetite.  The  sinus  had  not  quite 
healed  ;  the  discharge  was  very  slight,  and  not  offensive. 
On  February  17th  the  sinus  was  still  discharging;  the 
general  health  was  very  good.  The  first  menstruation 
occurred    February  18th  to  IGtli. 

Whatever  the  nature  of  the  ovarian  abscesses  in  this 
case,  it  seems  quite  certain  that  the  earlier  attack  of 
pelvic  inflammation,  in  which  the  tubes,  the  peritoneum, 
and  the  pelvic  connective  tissue  were  all  involved,  was  of 
a  septic  character.  My  own  belief  is  that  the  ovary 
became  the  seat  of  suppuration  at  that  time,  as  part  of 
the  septicaemic  process,  and  that  the  disorganization  of 
the  ovary  had  been  going  on  ever  since,  without  produc- 
ing very  definite  symptoms,  until,  on  some  slight  provoca- 
tion, a  fresh  attack  of  acute  peritonitis  occurred  and  the 
patient  became  very  seriously  ill.  This  is  a  very  common 
experience.  A  patient  often  goes  about  for  months  with 
pelvic  suppuration,  provided  the  pus  be  well  shut  off 
from  the  peritoneum.  But  she  is  always  on  the  brink 
of  a  precipice,   liable    at   any  moment  to  have    her  life 


368  VALUE    OF    ABDOMINAL    SECTION    IN 

imperilled  from  fresh  inflammation  or  from  tlie  advance 
of  the  destructive  process. 

Case  42.  Uterine  hemorrhage  folloiced  hy  occasional 
pain  in  the  pelvic  region  in  a  girl  of  twenty  ;  continuance 
of  symptoms  for  two  months  ;  sicelling  in  abdominal  wall, 
and  soft  elastic  mass  in  right  posterior  quarter  of  pelvis, 
thought  to  he  a  hsematoma  ;  no  diminution  after  a  month's 
rest ;  abdominal  section;  abscess  [tubercular]  in  sheath  of 
right  rectus  abdominis ;  miliary  tubercle  of  entire  peri- 
toneum, without  p)eritonitis  ;  soft  mass  beneath  j^eritoneum 
covering  posterior  j^art  of  floor  of  p>elvis  on  each  side ; 
abscess  in  abdominal  wall  evacuated;  abdomen  closed; 
recovery;  no  further  sympitoms  beyond  icasting ;  twelve 
months  later  health  compAetely  restored. — A  girl  aged  20, 
engaged  as  a  mother's  help,  applied  for  treatment  in  the 
out-patient  department  of  St.  Thomas's  Hospital  on 
account  of  haemorrhage  which  had  been  going  on  for  two 
months.  There  was  no  obvious  cause  for  the  hemor- 
rhage, menstruation  having  been  previously  quite  regular. 
It  commenced  with  a  profuse  discharge  in  August,  1890, 
two  weeks  after  a  period,  as  she  was  carrying  coals  in  the 
usual  way.  She  had  no  pain  at  the  time,  but  has  since 
occasionally  had  pain  in  the  lower  part  of  the  abdomen. 

She  was  admitted  on  the  25th  October,  1890.  She  had 
a  healthy  appearance  ;  her  colour  was  good,  and  she 
walked  as  though  nothing  were  amiss.  The  heart  and 
lungs  were  normal.  There  was  a  small  smooth  swelling, 
about  the  size  of  a  pigeon's  Q^g,  apparently  in  the  abdo- 
minal wall,  just  above  the  right  pubic  spine. 

A  vaginal  examination  was  made  on  October  29tli 
under  ether.  The  uterus  was  of  normal  size  ;  the  body 
directed  somewhat  towards  the  left,  cervix  towards  the 
right.  To  the  right  of  the  uterus  and  on  a  plane  posterior 
to  it,  was  a  soft  ill-defined  swelling.  This  was  thought 
to  be  a  haematoraa  of  the  broad  ligament,  and  it  was  de- 
cided to  watch  it. 

On  November  15th  the  mass  had  rather  increased  than 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  369 

diminished,  and  it  was  decided  to  make  an  exploratory 
incision.  There  has  been  no  ha3morrhage  since  Octo- 
ber 28th. 

On  November  22nd  abdominal  section  was  performed. 
The  lump  above  the  right  pubic  spine  was  cut  into  in 
making  the  incision,  and  was  found  to  be  an  abscess  in 
the  sheath  of  the  right  rectus  ahdominis.  About  1^  fl. 
oz.  of  thick  curdy  pus  was  evacuated.  On  opening  the 
abdominal  cavity,  the  parietal  and  visceral  layers  of  peri- 
toneum were  seen  to  be  everywhere  studded  thickly  Avith 
miliary  tubercles.  A  large,  soft,  elastic  mass  was  felt 
deeply  down  in  the  posterior  part  of  each  side  of  the  pelvis. 
The  structures  implicated  could  not  be  differentiated.  It 
Avas  considered  inadvisable  to  interfere  Avith  these  SAvell- 
ing,  and  a  drainage-tube  having  been  inserted,  the  abscess- 
cavity  in  the  abdominal  wall  Avas  thoroughly  scraped  and 
the  abdomen  closed. 

The  patient  recovered  from  the  opei'ation  without  a  bad 
symptom,  and  left  the  hospital  on  the  20th  December. 
After  this,  she  became  veiy  thin  and  Aveak. 

Exactly  twelve  months  after  the  operation  the  patient 
Avas  examined  by  Dr.  Herbert  HaAvkins,  Assistant  Phy- 
sician to  St.  Thomas's  Hospital.  She  Avas  looking  very 
Avell  and  had  completely  regained  her  strength.  She 
presented  no  physical  signs  of  disease  either  in  the  chest 
or  abdomen.  Shortly  before  this  I  had  made  a  vaginal 
examination  and  found  little  or  no  sAvelling  ;  the  uterus 
Avas  in  its  normal  position. 

October  22nd,  1892. — Is  again  losing  flesh  and  feeling 
weak.      No  definite  signs  of  disease. 

There  can  be  little  doubt  that  the  masses  in  the  pelvis 
were  of  tubercular  origin ;  their  probable  seat  being 
beneath  the  peritoneum  lining  the  floor  and  posterior  wall 
of  the  pelvis.  I  did  not  open  them  because  I  did  not  see 
how,  at  such  a  depth,  they  could  be  efficiently  drained,  and, 
in  the  presence  of  disseminated  tubercle  of  the  general 
peritoneum,  it  did  not  seem  justifiable  to  attempt  any 
radical  operation  for   their  removal.      For   some   months 


370  VALUE    OF    ABDOMINAL    SECTION    IN 

the  pale  and  wasted  appearance  of  the  patient  suggested 
general  tuberculosis,  and  her  present  healthy  look  and 
improved  condition  have  certainly  filled  me  with  surprise. 
The  case  is  one  of  much  interest  and  importance  in  con- 
nection with  the  curability  of  peritoneal  tubercle.  Its 
bearing  on  this  question  has  been  dealt  with  by  my 
colleague,  Dr.  Hawkins,  in  a  paper  published  in  the 
*  St.  Thomas's  Hospital  Reports/  New  Series,  vol.  xx,  p.  25. 

Case  43.  Pelvic  j^'^^'^^)  commencing  tivo  months  after 
marriage,  gradually  increasing  for  two  years  ;  loss  of  flesh 
and  of  strength  ;  entire  inahility  to  work  for  eight  months, 
and  for  one  month  entire  confinement  to  hed  ;  -pelvis  filled 
with  a  lohulated  swelling  pushing  uterus  foricards  and,  to 
left,  diagnosed  as  double  pyosalpinx ;  history  of  gonorrhea 
in  the  husband  a  few  months  before  marriage ;  abdominal 
section  :  both  tubes  greatly  distended  icith  pus  ;  ulceration 
of  their  mucous  membrane  ;  tubes  removed  ;  shock  of  opera- 
tion severe  ;  uninterrupted  convalescence  ;  complete  restora- 
tion to  health  v:ith  regular  and  normal  menstruation.— 
A  thin,  ana?mic,  highly  nervous  woman,  25  years  of  age, 
was  admitted  December  9th,  1890,  complaining  of  pain  in 
the  lower  part  of  the  abdomen,  with  loss  of  flesh  and 
appetite  dating  from  two  months  after  her  marriage  in 
August,  1888.  There  had  been  no  pregnancy.  Menstrua- 
tion which,  before  marriage,  had  been  regular  and  almost 
painless,  had  since  been  irregular  and  preceded  by  con- 
siderable pain.  The  pain  in  the  intermenstrual  periods 
came  on  gradually^  and  was  worse  after  standing  and  after 
exertion.  It  was  felt  not  only  in  the  abdomen  but  in  the 
back  and  thighs,  and  was  accompanied  by  increasing 
weakness  and  inability  to  do  her  work.  She  first  noticed 
a  vaginal  discharge  about  nine  months  after  her  marriage  ; 
sometimes  it  was  white,  but  more  often  yellow  and  offen- 
sive. She  consulted  a  doctor  who  diagnosed  displacement, 
whereupon  she  was  treated  for  many  months  by  different 
kinds  of  pessaries  without  benefit.  In  August,  1890,  she 
consulted  Dr.  Gervis,  who  told  her  that  her  womb  was  not 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  371 

displaced,  but  that  she  was  suffering  from  iuflammation. 
Dr.  Gervis  again  saw  her  two  days  before  her  admission, 
and  as  she  was  in  a  less  satisfactory  condition  than  on  the 
previous  occasion,  he  advised  her  to  come  into  St.  Thomas's 
Hospital. 

Patient  had  been  unable  to  do  any  work  for  eight 
months,  and  for  the  last  four  months  had  been  obliged  to 
lie  down  almost  entirely.  For  the  past  month  she  had 
been  in  bed. 

No  abdominal  swelling  was  present ;  and  no  tumour  or 
undue  sense  of  resistance. 

The  uterus  was  moveable  and  inclined  slightly  to  the 
left.  There  was  a  lobulated  mass  situated  behind  and  to 
the  right  of  it,  with  a  well-marked  sulcus  between  the 
lobes  where  they  met  behind  the  uterus.  The  vaginal 
roof  on  both  sides  was  somewhat  depressed  by  the  pelvic 
mass. 

The  temperature  was  normal  during  the  week  following 
admission,  except  on  December  15th  and  16th,  w4ien  it 
rose  to  100°. 

The  diagnosis  was  enlarged  and  suppvirating  Fallopian 
tubes — double  pyosalpinx,  probably  gonorrhoeal. 

The  husband  had  suffered  from  gonorrhoea  eight  mouths 
before  marriage,  and  believed  himself,  at  the  time  of  his 
marriage,  to  be  cured. 

Abdominal  section  having  been  proposed  and  agreed 
to,  the  operation  was  performed  on  December  17th,  1890. 

The  pelvis  w^as  filled  by  a  large  mass,  consisting  of  the 
two  Fallopian  tubes,  greatly  enlarged,  curved  upon  them- 
selves, and  universally  adherent  to  the  parts  around,  viz. 
to  the  uterus,  to  the  broad  ligaments,  to  each  other,  to 
omentum,  to  intestine,  and  to  pelvic  wall.  The  two 
tubes  were  separated  and  removed.  The  process  of 
separation  was  prolonged  and  difficult.  The  tube  in  each 
case  underwent  a  slight  tear,  permitting  the  escape  of  a 
little  thick  pus.  The  rents  were  quickly  clamped.  A 
good  deal  of  oozing  took  place  from  the  raw  surfaces. 
The  ovaries  were  not  seen.      Two  processes  of  thickened 


372  VALUE  or  abdominal  section  in 

peritoneum  were  ligatured  and  removed,  and  an  enlarged 
mesenteric  gland  the  size  of  a  pea  was  also  removed  for 
examination.  No  miliary  tubercles  were  seen,  but  there 
were  one  or  two  suspicious  subperitoneal  thickenings  on 
the  intestine.  One  of  these  was  suppurating  and  burst. 
The  peritoneal  cavity  was  abundantly  douched  with  hot 
boracic  solution  and  then  sponged,  and,  after  a  glass 
drainage-tube  had  been  inserted,  the  abdominal  wound 
was  closed.      The  operation  lasted  two  hours. 

Description  of  parts  removed. — The  right  tube  had  a 
circumference  of  4^  inches,  its  length  was  A\  inches  ;  its 
breadth  H  inches  ;  its  width  when  laid  open  3  inches. 
The  left  tube  had  a  circumference  of  Q\  inches ;  its 
length  was  6  inches ;  its  breadth  3  inches ;  its  width 
when  laid  open  4  inches. 

The  surfaces  were  red  and  vascular  and  covered  in 
places  with  shreds  of  adhesion.  The  contents  of  both 
consisted  of  very  thick  pus  with  some  mucus.  The 
mucous  membrane  was  ulcerated  throughout. 

The  mesenteric  gland,  on  section,  proved  to  contain 
either  cheesy  tubercle  or  inspissated  pus.  It  was  examined 
microscopically  by  Mr.  Shattock,  who  reported  that  there 
was  no  trace  of  tubercular  disease. 

The  collapse  after  the  operation  was  very  severe  and 
prolonged,  but  after  reaction  had  set  in  convalescence 
progressed  without  interruption.  No  suppuration  occurred 
from  the  wound,  and  the  temperature  on  no  occasion 
exceeded  100-2". 

On  January  9th,  1891,  a  vaginal  examination  showed 
the  uterus  central  in  position,  the  fundus  adherent  to  the 
anterior  abdominal  wall.  There  was  no  swelling  behind 
or  to  the  right  of  the  uterus  ;  the  base  of  the  left  broad 
ligament  was  thickened,  slightly  depressing  the  vaginal 
roof.  For  three  or  four  days  before  the  patient  went 
home,  there  was  a  purulent  vaginal  discharge. 

On  March  6th  the  patient  attended,  looking  and 
feeling  well ;  she  had  gained  flesh  ond  had  no  pelvic  pain 
or  discomfort.      Both  posterior  quarters  of  the  pelvis  were 


CERTAIN    CASES    OF    PELVIC    PERITONITIS. 


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374  VALUE    OF    ABDOMINAL    SECTION    IN 

free.  The  vaginal  mucous  membrane  was  bright  red  and 
was  covered  with  purulent  discharge.  The  discharge 
issuing  from  the  os  uteri  was  clear  and  transparent.  She 
had  menstruated  twice. 

I  last  saw  her  January  5th,  1892,  more  than  a  year 
after  the  operation.  She  was  free  from  pain,  quite  well, 
and  in  full  work.  She  was  still  gaining  flesh.  Men- 
struation was  quite  regular. 

This  case  was  one  of  the  most  satisfactory  in  the  series. 
The  tubes  were  the  largest  I  have  ever  yet  met  with ; 
they  simply  consisted  of  large,  tense  bags  of  pus.  All 
the  evidence  goes  to  show  that  the  mischief  was  of  gonor- 
rhoeal  origin.  I  am  glad  to  be  able  to  report  as  to  the 
patient's  condition  a  year  after  the  operation.  The  re- 
storation to  health  is  complete. 

The  rapidity  of  convalescence  after  so  prolonged  an 
operation,  and  notwithstanding  the  unavoidable  escape  of 
some  of  the  purulent  contents  of  the  tubes  into  the 
pelvis,  was  singularly  satisfactory. 

It  will  be  noted  that  on  four  out  of  the  seven  days 
that  elapsed  between  the  patient's  admission  and  the 
operation  the  temperature  was  normal  or  subnormal. 
The  bearing  of  this  fact  on  the  diagnosis  of  pelvic  suppu- 
ration is  obvious. 

Case  44.  Pelvic  pain  for  eighteen  months  luith  progres- 
sive iveaTcness  and  loss  of  flesh  folloiving  an  abortion  ;  tender 
swellings  in  both  posterior  quarters  of  pielvis  ;  disappearance 
of  signs  after  a  feiv  weeks  of  hospital  treatment  ;  recurrence 
of  pain  immediately  after  discharge  ;  readmission  three 
m,onths  later  after  missing  three  menstrual  periods  ;  large 
sausage-shaped  swelling  in  situation  of  right  tube,  with  soft 
mass  in  Douglases  pouch ;  abdominal  section  :  right  tube 
distended  toith  firm  clot,  soft  clot  protruding  from,  open  end 
of  tube,  continuous  loith  mass  of  clot  in  pelvic  cavity  ;  left 
tube  occluded ;  appendages  removed  ;  recovery  interrupted 
by  a  pelvic  abscess. — A  married  woman,  aged  25,  was 
admitted    into   St.    Thomas's  Hospital   on  August    lltb. 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  375 

1890,  on  account  of  sickness,  loss  of  flesh,  and  pain  in  the 
lower  part  of  the  abdomen,  especially  after  standing-  or 
walking.  Her  symptoms  dated  from  an  abortion  at  the 
fifth  month,  a  year  and  a  half  previously.  She  had  been 
married  seven  years.  A  year  after  marriage  she  had  a 
still-born  child  at  seven  months,  and  fourteen  months 
later  she  had  another  child  born  at  seven  months.  After 
this  she  had  two  abortions,  each  at  five  months.  She 
remained  in  bed  a  fortnight  after  the  latter  of  these 
abortions,  and  had  to  go  back  again  to  bed  almost  imme- 
diately, on  account  of  the  symptoms  above  enumerated. 
She  had  also  suffered,  ever  since  that  time,  from  a  thick 
yellow  vaginal  discharge,  and  from  pain  on  micturition. 

The  patient's  husband,  a  sailor,  was  in  the  surgical 
wards  with  a  severe  stricture  of  the  urethra  at  the  same 
time  that  she  herself  was  in  Adelaide  Ward. 

The  abdomen  was  resonant  throughout  ;  no  tumour  was 
perceptible. 

On  August  19th,  the  patient  was  examined  per  vaginam 
under  ether.  The  uterus  was  normal  in  size  and  position 
and  was  fairly  moveable.  A  firm,  elastic  swelling  was 
felt  on  the  left  side  in  the  situation  of  the  left  Fallopian 
tube  ;  the  diameter  of  the  swelling  was  estimated  at  f  inch. 
There  was  also  a  swelling  on  the  right  side  of  the  pelvis, 
less  clearly  defined,  thought  to  be  the  tube  bent  upon 
itself.  In  the  posterior  cul-de-sac  there  was  a  small,  hard, 
moveable  body  to  the  left,  and  an  ill-defined,  irregular 
swelling  high  up  to  the  right,  probably  the  distal  end  of 
the  right  tube.  The  patient,  who  on  admission  looked 
worn  and  ill,  had  now  greatly  improved  in  appearance  and 
suffered  less  pain. 

On  August  27th,  the  physical  signs  in  the  pelvis  had 
altered  remarkably  for  the  better.  The  uterine  append- 
ages could  be  made  out  distinctly  on  each  side,  nearly  of 
normal  dimensions,  those  on  the  left  being  perhaps  a  little 
larger  than  on  the  right.  There  was  no  tenderness  on 
either  side.  High  up  in  Douglas's  pouch  there  was  a 
tender  spot,  but  bimanually,  with  a  finger  in  the  rectum. 


376  VALUE    OF    ABDOMINAL    SECTION    IN 

the  fingers  can  be  made  nearly  to  meet  behind  the 
uterus. 

The  patient  was  discharged  on  August  30th. 

On  December  15th,  she  was  readmitted,  having  been 
laid  up  ever  since  leaving  the  hospital.  She  had  not 
menstruated  since  the  first  week  in  September. 

There  was  a  mass  in  the  hypogastric  region  rising  two 
inches  above  the  symphysis,  and  having  a  breadth  of  two 
inches.  There  was  no  corresponding  prominence  of  the 
abdomen.  The  cervix  uteri  was  depressed,  the  body 
displaced  forwards  and  anteflexed.  Behind  and  to  the 
right  of  the  uterus  was  a  swelling,  even,  soft  and  tender, 
extending  outwards  from  the  right  cornu  of  the  uterus  and 
terminating  posteriorly  behind  the  supra-vaginal  portion 
of  the  cervix  on  the  left  side.  In  the  position  of  the  left 
broad  ligament,  a  thickened  tube  could  be  felt  along  its 
border.  The  mass  in  the  retro-uterine  pouch  caused  a 
depression  of  the  posterior  part  of  the  vaginal  roof. 

Abdominal  section  was  performed  on  December  18th. 
The  right  tube  formed  a  sausage-shaped  mass  and  was 
adherent  to  the  surrounding  parts.  From  its  fimbriated 
end,  which  was  open,  protruded  a  large  quantity  of  dark 
firm  clot.  The  left  tube  was  occluded  at  its  distal 
end,  but  was  otherwise  normal.  Both  tubes  were  removed 
with  the  adjacent  ovaries.  The  clots  lying  in  the  pelvis 
were  cleared  away,  and  the  cavity  was  well  douched. 

Description  of  the  parts  rer)ioved. — The  portion  of  the 
rio'ht  tube  removed  was  4  inches  long,  and  5J  inches  in 
circumference.  It  was  filled  with  old,  firm,  partly  decolour- 
ised clot,  closely  adherent  to  its  walls.  From  its  open 
mouth  a  quantity  of  firm  black  clot  projected.  Enlarged 
veins,  filled  with  clot,  were  seen  beneath  the  mucous  mem- 
brane. 

The  portion  of  the  left  tube  removed  was  2  inches  in 
length  and  2^  inches  in  circumference.  Its  distal  end 
was  occluded.  Otherwise  it  was  normal,  except  for  a 
subperitoneal  cyst. 

A  week  after  the  operation,  the  patient  began  to  com- 


CERTAIN    CASES    OP    PELVIC     PERITONITIS.  377 

plain  of  paiu  in  the  pelvis  and  the  temperature  rose  to 
101°.  On  the  eleventh  day,  there  was  some  abdominal 
distension  and  a  swelling  could  be  felt  per  vaginam,  to  the 
left  of  the  uterus.  Two  days  latei",  the  lower  end  of  the 
wound  was  bulging.  On  passing  a  probe  and  exercising 
a  little  force,  an  abscess  was  reached,  and  about  4  fl.  oz. 
of  dark-brown  highly  offensive  fluid,  of  putrid  odour  was 
evacuated.  Next  day  the  temperature  had  come  down 
from  a  maximum  of  102 '4°  to  one  of  98*2°  and  the  pain 
had  disappeared. 

On  the  18th  January,  1891,  the  patient  left  the  hospital 
with  a  normal  temperature  and  a  very  slight   discharge. 

The  sinus  finally  closed  on  February  7th. 

On  March  21st,  three  months  after  the  operation,  the 
patient  attended,  complaining  of  flushings  of  the  face  and 
of  some  pelvic  pain  during  the  last  few  days.  There 
was  a  hard,  tender  spot  at  the  site  of  the  pedicle  on  the 
right  side,  and  a  small  nodule  of  hardness  on  the  left  side 
of  Douglas's  pouch.      The  uterus  was  freely  moveable. 

The  probable  explanation  of  this  case  is  that  the  attack 
of  salpingitis  and  pelvic  peritonitis  from  which  the  patient 
suffered  in  August  left  her  with  damaged  appendages  ; 
that  she  became  pregnant  soon  after  leaving  the  hospital  ; 
that  the  gestation  was  tubal ;  and  that  it  ended  in  tubal 
abortion.  As  no  remains  of  an  ovum  were  found,  this 
view  is,  of  course,  hypothetical.  Had  it  been  placed 
beyond  doubt  that  haematosalpinx  was  the  result  of  con- 
ception, I  should  have  classed  the  case  under  the  head 
of  extra-uterine  gestation,  and  not  included  it  in  the 
present  series. 

Case  45.  Pain  in  the  left  iliac  region  with  irregular  and 
painful  menstruation,  and  jotirulent  intermenstrual  dis- 
charge for  two  years  ;  fixed  swelling  in  left  posterior  quarter 
of  pelvis  size  of  small  orange  ;  less  defined  and  morefiaccid 
swelling  on  right  side;  abdominal  section ;  pyosalpinx  on 
left  side  ;  hydrosalpinx  on  right  ;  removal  of  both  tubes  and 
both  ovaries,  the  latter  being  normal  but  intimately  involved 

VOL.  xxxiv.  27 


378  VALUE    OP    ABDOMINAL    SECTION     IN 

in  tJie  adhesions  ;  rapid  recovery  from  the  operation  ;  per- 
sistence of  pelvic  pain  ;  development  of  tense  cyst  in  left 
hroad  ligament  ;  removal  hy  enucleation  at  King's  College 
Hosjntal ;  pain  still  tinrelieved. — A  thin,  delicate-looking-, 
anaemic  married  woman,  aged  32,  was  admitted  into  St. 
Thomas's  Hospital,  December  15th,  1890. 

Her  marriage  took  place  in  1877.  She  has  had  one 
child,  stillborn,  a  year  after  her  marriage.  The  labour 
was  normal,  and  she  was  able  to  get  up  in  a  fortnight,  but 
she  has  never  felt  strong  since. 

Her  present  illness  commenced  two  years  ago  with  a 
•yellow  vaginal  discharge,  bearing-down,  painful  micturition, 
and  pain  in  the  left  iliac  region,  felt  most  after  standing 
and  walking.  From  that  time  she  has  been  continuously 
under  medical  treatment,  using  vaginal  injections.  There 
had  been  during  the  whole  of  the  past  two  years  irregular 
and  painful  menstruation,  A  week  ago,  she  began  to- 
suffer  from  diarrhoea  and  a  very  severe  shooting  pain  in  the 
lower  pai't  of  the  abdomen,  shooting  down  the  left  thigh. 
She  was  so  weak  and  ill  that  she  was  attended  by  a  doctor 
at  her  own  home  ;  and  being  no  better  after  a  few  days, 
came  up  to  the  hospital. 

On  admission,  the  treatment  was  directed  to  the  dys- 
menorrhcea,  which  at  that  time  was  what  she  chiefly  com- 
plained of.  The  cervical  canal  was  dilated  with  graduated 
metallic  bougies.  This  occasioned  a  good  deal  of  pain, 
and  the  patient  became  faint  and  covered  with  perspira- 
tion. She  complained  of  much  pain  in  the  left  iliac 
region  during  the  next  few  days,  and  on  December  26th 
the  resident  in  charge  made  a  vaginal  examination.  He 
noted  that  the  uterus  was  moveable  and  slightly  retro- 
verted  ;  behind  and  to  the  left  side  of  the  uterus  was  a 
rounded  elastic  swelling  equal  in  size  to  a  small  apple, 
slightly  depressing  the  vaginal  roof  on  the  left  side. 
Nothing  abnormal  was  detected  on  the  right  side. 

The  temperature  was  usually  normal ;  one  day  it  was 
99°  and  another  99"4°  ;  these  were  the  highest  records 
since  her  admission. 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  379 


Fig.  5. 


Pyosalpinx  (left). 


Hydrosalpinx  (right). 

Pyosalpinx  of  left  side  and  Hydrosalpinx  of  right  in  the  same 
patient.  The  hydrosalpinx  is  secondary,  being  the  result  of  occlusion 
of  the  distal  end  of  the  tube  by  peritonitis  set  up  by  the  pyo- 
salpinx on  the  opposite  side.     Natural  size.     (Case  45.) 


380  VALUE    OP    ABDOMINAL    SECTION    IN 

On  discoveriiig  the  morbid  condition  of  the  left  uterine 
appendages,  tlie  resident  advised  the  patient  to  remain  in 
the  hospital  until  my  return.  She  insisted,  however,  on 
going  out  and  left  the  hospital  the  same  day  (December 
26th). 

On  reaching  home  she  was  in  great  pain  and  was 
obliged  to  keep  her  bed. 

She  was  readmitted  on  January  1st,  1891. 

On  January  3rd  she  was  examined  under  an  anesthetic. 
The  uterus  was  retroverted,  directed  to  the  right,  and 
freely  moveable.  To  the  left  and  postei'iorly  was  felt  a 
distinct  mass  of  the  size  of  a  tangerine  orange  ;  it  was 
separated  from  the  uterus  by  a  sulcus.  On  the  right  side 
was  a  thickening  of  soft  consistence  like  that  of  a  coil  of 
intestine,  in  the  situation  of  the  broad  ligament. 

Abdominal  section  was  performed  on  January  8th.  On 
the  right  side,  covered  by  adherent  omentum,  was  found 
a  tense  dark-coloured  swelling,  with  thin  walls,  consisting 
of  the  right  tube,  doubled  and  coiled  upon  itself,  occluded 
at  its  fimbriated  end,  and  distended  with  clear  fluid.  The 
swelling  lay  partly  in  front  of  the  uterus.  Behind  and 
adherent  to  it  was  the  normal  ovary.  After  separating 
the  right  tube  and  ovary  from  their  adhesions,  and  re- 
moving them,  the  separation  of  the  left  appendages  was 
preceded  with.  They  formed  an  adherent  mass  which 
occupied  the  left  posterior  quarter  of  the  pelvis  and  ex- 
tended into  the  retro-uterine  pouch.  On  bringing  the  mass 
into  view  it  was  found  to  consist  of  the  normal  ovary 
surrounded  by  the  much  elongated  and  twisted  Fallopian 
tube  which  was  of  an  opaque,  yellowish-white  colour,  and 
distended  with  fluid,  afterwards  proved  to  be  pus.  Both 
tube  and  ovary  were  removed.  No  pus  escaped  into  the 
pelvis  during  the  operation.  The  pelvis  was  cleansed  by 
sponging,  a  glass  drainage-tube  inserted  nnd  the  abdo- 
minal wound  closed. 

The  removed  portion  of  the  right  tube  was,  when  un- 
coiled, 4^   inches  long   and   an  inch   in    diameter.      The 


CERTAIN     CASKS    OF    PKLVIC    PERITONITIS.  381 

mass,  before  beiug  iiucoiled,  measured  2^  iuclies  iu  leng-tli 
and  2  inches  in  breadth. 

The  removed  portion  of  the  left  tube  was,  when  uncoiled, 
54  inches  long,  and  |  inch  iu  diameter.  The  mass  before 
being  uncoiled  measured  2|  inches  x  If  inches. 

The  fluid  in  the  right  tube  was  thin  serum  ;  that  in  the 
left  was  thick,  yellow  pus.  The  walls  of  the  former  were 
attenuated  ;   those  of  the  latter  much  thickened. 

The  patient  made  a  rapid  and  uninterrupted  recovery 
and  left  the  hospital  well  on  January  31st. 

Her  subsequent  history  is  somewhat  interesting. 

On  February  24th,  she  had  improved  considerably  in 
health,  but  complained  of  some  pain  in  the  left  iliac 
region.  On  vaginal  examination  a  swelling  equal  in  size 
to  and  closely  simulating  a  tense  and  full-sized  ovary  was 
felt  lying  against  the  left  lateral  wall  of  the  pelvis. 
Nothing  abnormal  was  detected  on  the  right  side. 

Had  I  not  known  that  both  ovaries  had  been  removed, 
I  should  have  regarded  this  little  swelling  as  the  left 
ovary,  rendered  tense  by  a  small  cyst.  Anyway,  I 
regarded  it  as  of  little  or  no  importance,  and  did  not 
propose  to  take  any  steps  for  its  removal. 

The  patient,  after  a  little  time,  applied  at  King's 
College  Hospital  still  complaining  of  pain  in  the  left  side. 
She  was  admitted  under  the  care  of  Dr.  Hayes,  who  very 
courteously  communicated  with  me.  I  gave  him  the 
history  of  the  patient  so  far  as  I  knew  it.  On  July  15th, 
1891,  I  received  a  letter  from  him  informing  me  that  he 
had  that  morning  operated  upon  her,  and  removed  a  cyst, 
the  size  of  a  large  hen's  egg,  from  the  left  broad  ligament. 
It  was  enucleated  and  removed  without  rupture. 

On  November  13th,  Dr.  Horrocks  wrote  to  tell  me  that 
the  patient  had  come  under  his  care  at  Guy's  Hospital,  and 
to  ask  me  if  it  was  correct  that  I  had  removed  one  of  her 
ovaries  some  months  ago,  and  if  so,  what  was  the  condi- 
tion of  the  one  left  behind.  I  gave  him  the  particulars  of 
the  previous  operations.  He  has  since  informed  me  that 
my  report  prevented  him  from  reopening  the  abdomen  in 


382  VALUE    OP    ABDOMINAL    SECTION    IN 

search  for  an  ovary  that  had  ah-eady  been  removed.  He 
tells  rae  that  the  patient  declares  that  she  has  just  as  much 
pain  as  she  had  before  any  operation  was  performed. 

Had  I  removed  the  appendages  in  this  case  merely  on 
account  of  pain,  the  after-histoi*y  just  recorded  would 
have  obliged  me  to  confess  that  the  operation  had  failed 
in  its  object.  Fortunately  for  my  peace  of  mind,  it  was 
not  so,  and  all  that  the  after-history  really  shows  is  that  a 
neurotic  condition  co-existed  with  a  definite  serious  lesion, 
and  that  the  removal  of  the  part  actually  diseased  has  not 
cured  the  neurosis. 

With  reference  to  the  fact  of  there  being  a  pyosalpinx 
on  one  side  and  a  hydrosalpinx  on  the  other,  I  believe  the 
explanation  to  be  that  the  latter  was  a  mere  incident  in 
the  course  of  the  pelvic  peritonitis  set  up  by  the  pyo- 
salpinx, being  as  it  were  a  retention-cyst  due  to  the 
occlusion,  by  peritoneal  adhesions,  of  the  fimbriated  end 
of  the  tube. 

Case  46.  Purulent  vaginal  discharge  for  four  years  ;  acute 
pelvic  peritonitis  after  a  debauch  and  exposure  to  ivet ; 
tender  sivelling  in  left  side  of  pelvis  displacing  uterus  to 
right  j  thickened  tube  in  front  of  sivelling  j  abdominal 
section:  interstitial  salpingitis  on  left  side;  blood-cyst 
of  left  ovary  ;  left  tube  and  ovary  removed  ;  right  appen- 
dages normal;  recovery. — An  unmarried  girl,  aged  23,  a 
machinist,  was  admitted  into  St.  Thomas's  Hospital, 
January  3rd,  1891,  on  account  of  abdominal  pain  of  three 
weeks'  duration,  and  a  yellow  vaginal  discharge  that  she 
had  had  for  four  years. 

She  stated  that  on  the  12th  December,  1890,  and  again 
on  the  following  day,  she  had  got  her  feet  wet,  and  that 
in  the  afternoon  of  the  second  day  she  was  attacked  with 
"  crampy "  pains  in  the  lower  part  of  the  abdomen. 
Two  days  later  she  took  to  her  bed,  and  had  remained 
there  up  to  the  time  of  her  admission.  A  few  days 
before  this  attack  she  went  out  for  the  evening  with  a 
discarded    suitor,    and    had    something    to    drink.        On 


CERTAIN    CASES    OF    PEI.VIC    PERITONITIS.  883 

awaking  next  morning  she  found  liei'self  very  sore,  and 
noticed  some  blood  on  lier  linen.  She  remembered  that 
her  companion  had  taken  liberties  with  her,  but  was  not 
aware  that  actual  intercoui'se  had  taken  place. 

She  was  a  pale,  poorly-nourished  girl,  deeply  mai'ked 
by  smallpox.  Her  skin  Avas  hot  and  dry  ;  her  tempera- 
ture at  8  p.m.  on  the  da}^  of  admission  was  ]0^'6°  and  at 
midnight  104-2°.  She  had  no  rash.  The  tongue  was 
thickly  coated  with  white  fur.  The  abdomen  was  rigid  but 
not  distended  ;   tliere  was  no  tumour  perceptible. 

Next  day  she  was  much  better.  The  temperature  was 
102-4°  at  4  a.m.  ;  101°  at  8  a.m.  ;  100-6°  at  noon  ;  99°  at 
4  p.m.  and  101°  at  8  p.m.  After  that,  the  temperature  be- 
came gradually  lower,  and  on  January  10th  it.  was  normal. 

A  vaginal  examination  was  made  on  January  9th, 
having  been  deferred  on  account  of  menstruation.  The 
uterus  lay  a  little  to  the  right.  A  tender  swelling  the 
size  of  a  small  apple  could  be  felt  on  the  left  side  of  the 
pelvis,  causing  some  depression  of  the  vaginal  roof.  In 
front  of  the  swelling,  immediately  beneath  the  abdominal 
wall,  Avas  a  tense  band  running  horizontally  outwards, 
thought  to  be  the  thickened  Fallopian  tube.  Nothing 
abnormal  was  detected  on  the  right  side. 

Abdominal  section  was  performed  on  January  15th.  The 
left  tube  was  found  thickened  and  adherent,  embracing  the 
ovary,  enlarged  to  the  size  of  a  pigeon's  egg.  During  the 
process  of  separation  a  cyst  in  the  ovary  was  accidentally 
ruptured,  giving  exit  to  a  small  quantity  of  dark  fluid 
blood.  The  left  broad  ligament  was  somewhat  thickened 
by  cellulitis.  The  left  tube  and  ovary  were  removed. 
The  right  appendages  were  healthy.  The  pelvic  cavity 
was  sponged  and  the  abdomen  closed  without  drainage. 

The  portion  of  left  tube  removed,  when  uncoiled, 
measured  3|  inches  in  length  and  |  inch  in  its  greatest 
diameter.  It  walls  were  three  times  the  normal  thickness. 
The  mucous  membrane  was  healthy.  The  fimbriated  end 
of  the  tube  was  open  and  there  was  no  fluid  of  any  kind 
in  the  canal. 


384  VALUE    OP    ABDOMINAL    SECTION    IN 

The  patient  made  an  uninterrupted  recovery  and  was 
discharg-ed  well  on  February  7tli,  both  sides  of  the  pelvis 
being  free  from  abdominal  swelling. 

This  was  an  example  of  interstitial  salpingitis,  pro- 
bably of  old  date  and  due  in  the  first  instance  to  an  endo- 
salpingitis,  which  had  now  disappeared.  It  seems  most 
likely,  from  the  history,  that  the  inflammation  was  of  gonor- 
rlioeal  origin,  the  acute  attack  of  pelvic  peritonitis,  imme- 
diately preceding  admission,  being  probably  excited  by  the 
debauch  she  described,  and  aggravated  by  subsequent 
exposure  to  wet. 

The  main  part  of  the  swelling  consisted  of  the  cystic 
ovary,  which  had  been  the  seat  of  a  more  or  less  recent 
hcemorrhage. 

The  strictly  unilateral  character  of  the  inflammation  was 
somewhat  unusual. 

Case  47.  Sudden  attach  of  jyaiii  hi  pelvis  two  months 
after  confinement  five  years  ago  ;  recurrent  attacks  of  a 
similar  character  ever  since  ;  continuous  jjain  in  left  iliac 
region  for  a  month,  obliging  patient  for  the  most  part  to 
keep  her  bed;  no  menorrhagia  or  vaginal  discharge  ;  tem- 
pter ature  normal  ;  large  mass  occupying  left  posterior 
quarter  of  pelvis  ;  indistinct  thickening  on  right  side  ;  no 
depression  of  vaginal  roof ;  abdominal  section  :  pelvic  con- 
tents matted  by  adliesiovs  ;  outer  half  of  left  tube  distended, 
and  filled  with  clot  continuous  with  a  small  intraperitoneal 
hsematocele  ;  hydrosalpinx  on  right  side  ;  ovaries  cystic  ; 
ovaries  and  tubes  removed  ;  recovery. — A  married  woman, 
aged  31,  employed  as  a  charwoman,  was  admitted  into  St. 
Thomas's  Hospital  January  8th,  1891. 

The  catamenia  had  not  commenced  until  the  age  of 
seventeen  and  were  habitually  scanty.  The  patient 
married  at  twenty-four,  and  had  one  child  at  full  term  a 
year  afterwards.  8he  recovered  well  from  the  confine- 
ment, but  two  months  afterwai-ds  she  was  suddenly  seized 
whilst  walking  with  pain  in  the  lower  part  of  the  abdomen, 
especially  on  tiie  left  side.      The  pain  was  very  severe  and 


CERTAIN     CASES    OF    PELVIC    PERITONITIS.  385 

extended  iiito  the  thighs.  It  soon  disappeared,  but,  ever 
since,  patient  has  been  subject,  especially  after  over-exer- 
tion, to  attacks  of  pain  of  a  similar  character,  accompanied 
with  headache,  nausea  and  faintness.  The  attacks  do  not 
appear  to  have  had  any  special  connection  with  the  cata- 
menia.  During  the  last  month  they  have  become  more 
frequent,  occurring  every  two  or  three  days,  and  patient 
has  also  suffered  from  continuous  aching  pain  in  the  left 
iliac  region  and  in  the  back.  She  went  to  bed  of  her  own 
accord,  and  then  sent  for  her  doctor,  under  whose  care  she 
has  been  for  three  weeks.  She  could  not  remain  altogether 
in  bed,  as  she  had  to  attend  to  her  sick  husband,  but  she 
was  quite  unable  to  follow  her  usual  avocation.  She 
has  been  losing  flesh  for  the  past  six  months.  There  has 
never  been  any  meuorrhagia  or  vaginal  discharge. 

Her  appearance  is  that  of  a  woman  of  healthy  constitu- 
tion ;  she  has  a  fair  complexion  ;  a  good  colour  in  her 
cheeks  and  a  cheerful  disposition.  Her  temperature  is 
normal.  On  vaginal  examination,  there  is  felt  a  large  mass 
directly  continuous  with  the  left  coriiu  of  the  uterus  and 
filling  the  left  posterior  quarter  of  the  pelvis.  The  mass 
is  hard  and  nodulated  posteriorly  and  terminates  behind 
the  uterus  in  Douglas's  pouch.  There  is  no  depression 
of  the  left  vaginal  fornix.  There  is  some  ill-defined 
thickening  on  the  right  side  of  the  uterus.  The  right 
vaginal  foi'nix  is  not  encroached  upon.  The  uterus  is 
normal  in  length,  anteflexed,  and  displaced  to  the  right  of 
the  median  line.  On  withdrawing  the  examining  fingers, 
they  are  seen  to  be  stained  with  fluid  of  a  brownish-red 
colour,  evidently  altered  blood. 

Abdominal  section  was  performed  on  January  22nd, 
1891.  Both  tubes  were  dilated  and  universally  adherent, 
their  distal  ends  lying  firmly  matted  in  the  retro-uterine 
pouch.  In  separating  the  left  tube,  the  inner  half  of 
which  was  of  normal  size,  the  outer  half  expanded  in  a 
funnel-shaped  form,  a  small  intraperitoneal  hsematocele 
was  opened,  containing  firm,  dark  clot.  Precisely  similar 
clot  filled  the  expanded  outer  half  of  the  tube,  and  pro- 


386  VALUE    OF    ABDOMINAL    SECTION    IN 

truded  from  its  dilated  extremity  into  the  haematocele, 
which  was  hemmed  in  on  all  sides  by  adhesions  and  was 
about  equal  in  size  to  a  Tangerine  orange. 

The  right  tube  and  ovary  being  involved  in  the  mass 
behind  the  uterus,  were  now  freed  from  their  adhesions 
to  allow  of  the  more  complete  separation  of  the  left  tube. 
Both  ovaries  were  enlarged  and  cystic,  being  equal  in 
size  to  a  pigeon's  egg.  The  left  tube  and  ovary  were 
now  removed.  The  left  tube  on  being  laid  open  measured 
^  inch  across  at  its  narrower  portion,  and  an  inch  at  its 
dilated  extremity. 

The  right  tube  was  dilated  and  occluded,  forming  a 
hydrosalpinx.  After  removal  it  measured  while  still  un- 
opened 24  inches  in  length,  1^  inches  in  its  greatest 
breadth.      Its  closed  end  measured  1  inch   x    H  inches. 

On  a  coil  of  small  intestine  which  was  adherent  in 
Douglas's  pouch,  there  was  a  patch  of  adherent  blood- 
clot  about  the  size  of  a  sixpence. 

The  peritoneal  cavity  was  Hushed,  a  drainage-tube  in- 
serted and  the  abdominal  wound  closed. 

The  patient  made  a  good  recovery.  On  the  thirteenth  day 
a  little  pus  was  noticed  on  the  dressing,  and  on  making 
gentle  pressure  a  quantity  of  inoffensive  pus  escaped  from 
the  lower  angle  of  the  wound.  There  was  a  slight  dis- 
charge for  three  or  four  days,  and  the  wound  then  healed. 
The  patient  left  the  hospital  well  on  the  25th  of  Febru- 
ary. There  were  some  irregular  hard  lumps  to  be  felt 
behind  and  to  the  left  of  the  cervix,  evidently  connected 
with  the  pedicle  on  that  side.  They  gave  no  pain  and 
were  not  tender. 

The  order  of  pathological  events  in  this  case  is  not  easy 
to  trace.  From  the  history  and  physical  signs  I  expected 
to  find  a  pyosalpinx  on  the  left  side.  The  swelling  con- 
sisted instead  of  a  hsematosalpinx  communicating  with  a 
small  haematocele.  Whether  this  was  an  early  tubal  abor- 
tion is  matter  of  conjecture.  No  evidence  of  the  remains 
of  an  ovum  was  detected.  The  hydrosalpinx  was  evi- 
dently secondary  to  the  peritonitis,  due  to  the  sealing  up 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  387 

of  the  fimbriated  end  of  the   right  tube  by  inflammation, 
and  the  formation  of  a  quasi-retention  cyst. 

Case  48.  Pain  in  right  iliac  region  and  recurrent  pelvic 
peritonitis  dating  from  confinement  three  years  ago  ;  hurxt- 
ing  of  an  abscess  per  vaginam  eight  months  ago  ;  persistent 
discharge  of  pus  siihsequently  ;  acute  symptoms  during 
week  preceding  admission  j  onciss  behind  and  to  right  of 
uterus  with  physical  signs  of  cellulitis  and  sinus  in  upper 
•part  of  posterior  vaginal  wall  ;  diagnosis  of  abscess  con- 
nected with  supjnirative  inflammation  of  right  nterine  ap- 
pendages ;  abdominal  section:  pelvic  contents  matted; 
right  ovary  enlarged  and  containing  numerous  cysts,  many 
of  them  filed  with  pus  ;  fstulous  communication  between 
one  of  these  and  vagina  ;  removal ;  recovery. — A  young 
married  woman,  aged  22,  employed  as  a  still-room  maid, 
was  admitted  into  St.  Thomas's  Hospital  January  loth, 
1891,  on  account  of  severe  pain  in  the  right  iliac  region 
and  other  symptoms. 

Her  marriage  took  place  when  she  was  eighteen.  She 
was  confined  of  her  first  and  only  child  a  year  subse- 
quently, and  has  never  been  quite  well  since.  vShe  had  a 
greenish  discharge  for  about  two  months  after  the  labour, 
and  suffered  from  time  to  time  from  pain  in  the  right 
iliac  region.  This  pain  varied  in  intensity  but  never 
entirely  disappeared,  and  twelve  months  ago  she  went 
into  the  Canterbury  Hospital.  She  was  there  for  a  month 
and  states  that  she  underwent  an  operation  of  some  kind. 
She  remained  well  after  this  for  three  months,  when  the 
pain  having  returned,  she  one  day  whilst  seated  quietly 
in  a  chair,  felt  a  sudden  flow  of  discharge  from  the  vagina. 
The  discharge  Avas  thick,  foetid,  yellow  in  colour,  and 
very  profuse.  For  two  or  three  weeks  the  pain  was 
easier,  but  it  has  never  wholly  disappeared.  The  dis- 
charge has  continued  with  intervals  to  the  present  time, 
but  since  the  first  day  has  had  no  ill  odour.  A  week  ago 
she  was  suddenly  seized  in  the  night  with  acute  pain  in 
the  right  iliac  region.      The  pain  was  relieved  by  poultic- 


388  VALUE    OF    ABDOMINAL    SKCTION    IN 

ing,  but  the  patient  has  since  been  quite  unable  to  get 
about  or  resume  her  work. 

The  patient  is  in  fairly  good  condition  but  anasmic. 
The  temperature  is  normal. 

On  vaginal  examination  the  uterus  was  found  in  normal 
position,  the  cervix  was  fixed  by  adhesions  posteriorly. 
The  pouch  of  Douglas  was  filled  with  a  hard,  rounded 
mass,  extending  further  to  the  right  side  than  to  the  left. 
The  vaginal  roof  on  the  right  side  was  slightly  depressed. 
There  was  dense  hardness  in  the  tissues  at  the  posterior 
vaginal  reflection  and  immediately  in  front  of  the  cervix  ; 
in  the  latter  position  simulating  acute  anteflexion  of  the 
uterus.  At  the  upper  part  of  the  posterior  vaginal  wall 
was  a  small  opening,  the  size  of  a  pea  with  indurated 
margins. 

The  diagnosis  was  chronic  abscess  in  Douglas's  pouch, 
communicating  with  the  vagina,  and  connected  with  sup- 
purative inflammation  of  the  right  uterine  appendages. 

Abdominal  section  was  performed  January  29th,  1891. 
The  omentum  was  adherent  to  the  pelvis.  The  pelvic 
viscera  were  densely  matted  by  old  adhesions  ;  the  broad 
ligaments  were  hard,  rigid,  and  thickened.  A  loop  of 
intestine  and  a  band  of  omentum  were  adherent  to  the 
anterior  abdominal  wall  just  above  Poupart's  ligament  on 
the  right  side.  A  soft,  oblong  mass  was  separated  from  its 
adhesions  to  the  posterior  aspect  of  the  corpus  uteri.  This 
mass  dipped  down  into  Douglas's  pouch,  where  its  dense 
adhesions  were  separated  with  difficulty.  The  long  axis 
of  the  mass  was  directed  downwards.  When  fully  sepa- 
rated and  brought  into  view,  it  was  found  to  be  connected 
with  the  right  broad  ligament,  and  to  consist  of  the  much 
enlarged  right  ovary  with  the  Fallopian  tube  stretched  over 
and  adherent  to  it.  Both  were  removed.  The  appen- 
dages of  the  opposite  side  were  then  separated  ;  during 
the  process  rupture  of  the  ovary  took  place,  a  dark  blood- 
clot  escaping.  The  tube  and  ovary  were  removed,  the 
gi'eater  part  of  the  ovary  remaining  as  part  of  the  pedicle. 
The   peritoneum  was  douched,  and  a  glass   drainage-tube 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  389 

introduced  before  closing  the  wound.  A  quantity  of  pus 
having  tlowed  from  the  vagina  during  the  operation,  a 
vaginal  douche  of  solution  of  corrosive  sublimate,  1  in 
5000  was  administered.  The  operation  lasted  an  hour 
and  a  half. 

Description  of  parts  removed. — The  right  ovary  measured 
2j  inches  by  If  inches  by  1  inch.  It  consisted,  on  section, 
of  a  number  of  inflamed  cysts,  many  of  them  full  of  pus, 
and  all  with  hyper^emic  walls.  An  opening,  large  enough 
to  admit  a  goose-quill,  and  surrounded  by  granulation- 
tissue,  Avas  found  on  that  part  of  the  surface  of  the  ovary 
which  had  lain  most  deeply  in  the  pelvis.  This  opening 
communicated  directly  with  one  of  the  abscess-cavities  in 
the  substance  of  the  ovary,  and  pus  was  seen  exuding 
from  it. 

The  right  tube  was  attached  to  the  ovary  and  was 
elongated.  On  section  its  lining  membrane  was  found 
healthy  and  its  canal  empty. 

The  left  Fallopian  tube  was  beaded  from  kinking,  but 
was  otherwise  healthy.  No  ovarian  tissue  was  found  in 
the  pai-ts  removed  on  the  left  side. 

The  highest  temperature  recorded  during  the  patient's 
convalescence  was  90'8  .  She  was  restless  durinsr  the 
night  of  the  30th,  and  vomited  several  times.  After  this 
there  "was  no  vomiting.  The  drainage-tube  was  removed 
in  forty-eight  hours.  Menstruation  commenced  Feb- 
ruary 1st  and  lasted  five  days.  Some  cystitis  appeared 
on  February  3rd  but  soon  subsided  under  treatment.  An 
abscess  formed  in  the  abdominal  wall  near  the  upper 
part  of  the  wound,  and  burst  on  February  8th. 

On  February  27th  a  vaginal  examination  was  made. 
There  was  a  smooth,  firm,  tender  swelling  to  the  left  of 
the  uterus;  none  in  Douglas's  pouch  or  in  the  right  side 
of  the  pelvis.  There  was  a  dimple  in  the  post-vaginal 
wall  at  the  site  of  the  fistula. 

At  the  beginning  of  March  the  patient  again  menstru- 
ated, and  ou  March  7th  she  left  the  hospital  well. 

On  November  15th,  1891,  the  patient  was  readmitted, 


390  VALUE    OF    ABDOMINAL    SECTION    IN 

coniplaiuing*  of  attacks  of  pain  commencing  in  the  right 
iliac  region,  lasting-  severely  for  a  few  hours  and  then 
gradually  diminishing  until  they  pass  off  in  the  course  of 
about  a  week.  She  has  had  four  such  attacks  ;  the  first 
in  June,  the  second  in  July^  the  third  in  September,  and 
the  last  just  before  her  readmissiou.  There  is  vomiting 
during  the  first  two  days  of  each  attack.  The  attacks 
have  no  connection  with  menstruation,  which  has  been 
regular.  Between  the  attacks  the  patient  has  felfc  well 
and  strong.  Temperature  is  normal.  On  vaginal 
examination  no  swelling  could  be  detected  on  either  side 
of  the  pelvis  ;  the  uterus  was  fairly  moveable.  There 
was  a  little  tenderness  on  the  right  side. 

This  case  exemplifies  very  strikingly  the  advantage  of 
dealing  with  chronic  abscess  in  the  deeper  part  of  the 
pelvis  from  above  rather  than  from  below.  Had  the 
treatment  here  consisted  of  enlarging  the  sinus  in  the 
posterior  wall  of  the  vagina  and  draining  the  abscess- 
cavity  thus  laid  open,  there  would  still  have  been 
numerous  other  abscesses  to  be  reckoned  with,  that  such 
an  incision  could  not  have  reached.  The  opening  found 
on  the  surface  of  the  ovary  was  no  doubt  the  aperture  of 
communication  with  the  vagina,  due  to  ulceration  of  the 
wall  of  the  cyst  and  of  the  parts  to  which  it  was  adherent. 
The  opening  had  been  insufficient  to  allow  of  the  complete 
emptying  of  the  abscess ;  hence  the  persistent  vaginal 
discharge.  The  absence  of  pyrexia  before  operation,  not- 
withstanding the  condition  of  the  right  ovary,  is  note- 
worthy, as  also  is  the  freedom  from  pelvic  suppuration 
and  sepsis  during  the  recovery,  considering  that  some 
soiling  of  the  pelvis  during  the  removal  of  the  ovary 
must  almost  certainly  have  occurred. 

The  attacks  of  pain  described  by  the  patient  as  having 
occurred  at  intervals  since  the  operation  are  probably  to 
be  explained  by  intestinal  or  omental  adhesions  at  the 
site  of  operation. 

Case  49.   Pain  in  joints  and  high  tem'perature  for  six 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  391 

weeJcs,  regarded  as  due  to  acute  rheumatism  ;  discovery  of 
•purulent  vaginal  discharge ;  development  of  abdominal 
pain  ;  patient  found  to  be  silvering  from  acute  gonorrhoea  ; 
both  sides  of  pelvis  occupied  by  irregular  swellings,  right 
tube  traced  distinctly ,  enlarged  and  tortuous,  left  less  dis- 
tinct;  abdominal  section:  pelvic  contents  matted;  intra- 
peritoneal abscess  in  Douglas's  pouch  fed  by  the  open- 
mouthed  suppurating  Fallopian  tubes;  removal  of  tubes 
and  ovaries ;  recovery  ivithout  suiypuration ;  immediate 
disappearance  of  pyrexia  and  other  pyxmic  symptoms. — 
An  unmai*ried  girl,  aged  24,  a  chambermaid  at  an  hotel, 
■Nvas  admitted  into  St.  Thomas's  Hos]3ital,  December  15th, 
1890,  under  the  care  of  Dr.  Payne,  for  what  appeared  at 
first  to  be  an  attack  of  acute  rheumatism.  There  had 
been  pains  in  the  right  wrist  for  three  days,  and  in  the 
back  of  the  neck,  the  left  shoulder,  left  elbow,  left  leg 
and  left  knee  for  two  days. 

On  admission  the  tongue  was  coated  Avith  a  white  fur ; 
the  temperature  102-2°  to  102;8°;  the  pulse  120.  There 
were  coarse  rhonchi  heard  over  the  upper  part  of  the  left 
lung  and  moist  sounds  near  the  apex  of  the  right  lung 
behind.  The  heart  sounds  were  normal.  The  rig^ht 
wrist,  left  shoulder,  left  knee,  and  left  tarso- metatarsal 
joints  were  tender  and  painful,  without  obvious  effusion 
or  any  oedema  or  redness  of  the  superjacent  skin. 

On  December  22nd  there  was  no  pain  or  stiffness 
except  in  the  left  knee,  which  was  stiff,  swollen,  and 
tender.  The  temperature  has  varied  between  98*2°  and 
102°,  the  maximum  record  on  the  16th  having  been  101  "4°, 
on  the  17th,  101-6°;  on  the  18th,  100-8°;  on  the  19th, 
99-6°;  on  the  20th,  99-4°;  on  the  21st,  102°  ;  and  on  the 
22nd,  101-2°. 

On  January  15th,  1891,  the  temperature  was  102-8  . 
The  lungs  were  resonant  everywhere,  the  breath-sounds 
normal ;  no  unhealthy  signs  at  apices  ;  slight  cough  ;  no 
expectoration.  Bowels  regular.  Tongue  fairly  clean. 
No    tenderness    about    any    joint.       Left   knee    slightly 


392  VALUE    OF    ABDOMINAL    SECTION    IN 

swollen  and  kept  in  a  position  of  flexion,  extension  caus- 
ing pain. 

On  January  IStli  a  vaginal  discharge  was  noticed  ;  no 
abdominal  pain  ;   temperature  99'4°  to  104*4°. 

On  January  27th  the  patient  having  complained  during 
the  past  three  days  of  pain  in  the  lower  part  of  the  abdo- 
men with  headache,  sickness,  and  shivering,  a  suspicion, 
already  existing,  that  the  case  was  not  one  of  ordinary 
rheumatism,  was  strengthened,  and  I  was  asked  to  see 
her  and  make  a  pelvic  examination. 

I  reported  that  she  was  suffei'ing  from  gonorrhcea  and 
pelvic  inflammation,  and  she  was  accordingly  transferred, 
the  same  day,  to  Adelaide  Ward,  under  my  care. 

The  temperature  since  the  last  note  had  been  as 
follows— (January  19th)  102°  to  102-8°;  (20th)  99°  to 
102-8°;  (21st)  97°  to  99°;  (22nd)  97-6°  to  102-2°;  (23rd) 
100-6°  to  103-4°;  (24th)  99-8°  to  102°;  (25th)  97°  to 
99-8°;  (26th)  98-4°  to  100-4°;    (27th)  98°  to  102-6°. 

On  being  questioned  with  a  view  to  determine  if  pos- 
sible the  date  of  infection,  the  patient  stated  that  the 
only  time  she  had  been  exposed  to  such  a  risk  was  on 
November  4th,  1890,  when  a  stranger  staying  in  the 
hotel  took  forcible  advantage  of  her,  and  was,  in  conse- 
quence, dismissed  from  the  hotel  by  the  manager,  to 
whom  she  reported  the  occurrence  the  same  evening. 
During  the  five  weeks  she  afterwards  remained  in  her 
situation  she  had  some  pain  on  micturition  and  a  vaginal 
discharge.  She  left  her  situation  on  December  11th. 
On  awaking  the  following  morning  she  for  the  first  time 
felt  pain  in  the  right  wrist.  The  remaining  particulars 
of  her  illness  have  already  been  given. 

On  examination  (after  her  removal  to  Adelaide  Ward) 
there  was  found  some  pus  on  the  vulva,  and  there  was  a 
copious  flow  of  pus  and  mucus  from  the  vagina  on  intro- 
ducing the  finger.  There  was  slight  redness  at  the  pos- 
terior margin  of  the  vaginal  orifice ;  no  marked  redness 
or  swelling  of  the  meatus  nrinarivs,  but  pus  issued  from 
the  meatus  on  making  pressure  along  the  urethra.      There 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  393 

was  no  abnormal  redness  or  swelling  of  the  vaginal  mucous 
membrane,  or  of  the  orifices  of  the  ducts  of  Bartholin's 
glands.  No  pus  exuded  from  the  latter  on  pressure. 
Through  the  speculum  some  blood  and  mucus  were  seen 
issuing  from  the  os  uteri,  on  which  was  a  broad  ring  of 
catarrhal  erosion.  Bimanually,  there  was  felt  in  the  right 
posterior  quarter  of  the  pelvis  a  firm  resisting  mass ;  and 
an  elongated  tube-like  swelling  could  be  felt  passing 
outwards  from  the  right  cornu  of  the  uterus,  then  turning 
downwards  and  backwards  behind  the  uterus,  forming  a 
distinct  cystic  swelling  in  Douglas's  pouch.  Some  thick- 
ening could  also  be  felt  in  the  left  side  of  the  pelvis,  but 
of  a  less  defined  character.  The  uterus  was  inclined  to 
the  right. 

The  diagnosis  was  acute  gonorrhoea,  with  pyosalpinx, 
pelvic  peritonitis,  and  pyaemia. 

Abdominal  section  having  been  proposed  and  agreed 
to,  the  operation  was  performed  February  5th,  1891. 
The  pelvic  viscera  were  matted  together  by  very  firm 
adhesions  behind  and  on  each  side  of  the  uterus.  On 
separating  the  tangled  mass  from  the  back  of  the  corpus 
uteri  some  thick,  inodorous  pus  made  its  'escape,  the 
finger  passing  into  a  cavity  the  size  of  a  Tangerine 
orange.  This  cavity  was  the  pouch  of  Douglas,  walled 
in  by  the  uterus,  coils  of  intestine,  and  the  uterine 
appendages. 

The  right  appendages  were  now  separated  from  their 
adhesions  and  brought  into  view.  Closely  adherent  to 
them  was  the  thickened  vermiform  appendix.  On 
separating  it  the  tip  was  ragged  and  bleeding ;  the  distal 
end,  to  the  extent  of  an  inch,  was  therefore  ligatured  and 
removed.  The  tube  and  ovary  were  then  removed.  As 
there  was  some  pus  in  the  divided  end  of  the  tube  in  the 
stump,  the  stump  was  cauterised.  The  removed  portion 
of  the  tube  was  thickened  and  full  of  pus,  but  showed  no 
ulceration  ;  its  fimbriated  end  was  widely  open,  allowing 
the  contents  to  exude  into  the  pelvic  cavity.  For  some 
time  the  left  appendages  could  not   be  found  ;   they  were 

VOL.  xxxiv.  28 


394  VALUE    OF    ABDOMINAL    SECTION    IN 

at  length  discovered,  behind,  adherent  to,  and  wrapped 
round  by  the  broad  ligament.  On  removal  the  tube  was 
found  to  be  in  a  similar  condition  to  its  fellow  on  the 
opposite  side,  namely,  thickened  and  full  of  pus,  with  the 
fimbriated  end  open,  allowing  the  escape  of  its  contents 
into  the  peritoneal  cavity.  Loops  of  thickened  intestine 
were  also  adherent  in  the  pelvis  ;  for  the  most  part  they 
were  left  undisturbed. 

The  pelvis  and  abdominal  cavity  were  well  douched,  a 
glass  drainage-tube  inserted,  and  the  abdomen  closed. 
The  length  of  the  incision  was  2f  inches.  The  duration 
of  the  operation,  one  hour  and  three  quarters. 

The  patient  made  an  excellent  recovery.  She  was  only 
once  sick.  The  drainage-tube  was  removed  in  forty- 
eight  hours.  The  temperature  on  the  evening  after  the 
operation  was  t01"8°,  after  that  it  was  generally  normal 
and  never  reached  100°.  There  was  no  suppuration  from 
the  wound.  Twelve  days  after  the  operation  the  patient 
was  able  to  lie  on  the  couch.  She  left  the  hospital  well 
on  the  28th  March,  the  last  three  or  four  weeks  having 
been  devoted  to  treating  the  gonorrhoeal  inflammation  of 
the  cervix,  vagina,  &c. 

The  portion  of  right  tube  removed  measured  3|  inches 
in  length  and  was  bent  at  a  right  angle  ;  its  widest 
diameter  (at  the  bend)  was  f  inch.  The  portion  of  left 
tube  removed  was  2|  inclies  in  length,  and  was  also  bent 
at  a  right  angle,  with  a  diameter  of  f  inch  at  the  bend. 
Otherwise  the  left  tube  was  smaller  than  the  right. 

This  case  may  be  commended  to  the  consideration  of 
those  who  disbelieve  in  the  gonorrhoeal  origin  of  purulent 
salpingitis  and  general  pelvic  inflammation.  The  clinical 
evidence  here  is  almost  as  complete  as  could  be  wished. 
The  case  is  also  an  answer  tx)  those  who  recommend  a 
long  trial  of  rest  and  palliative  treatment  before  operating. 
Nothing  could  have  been  gained  here  by  waiting. 

The  manner  in  which  the  parts  healed  without  a  trace 
of  suppuration,  notwithstanding  the  extent  of  suppuration 
at  the  time  of  the  operation  and  the  prolonged  manipula- 


CERTAIN    CASES    OF    PELVIC    rERITONITIS.  395 

tions  that  were  required,  is  very  noteworthy,  as  also  is  the 
rapid  disappearance  of  the  pytemic  symptoms. 

Case  50.  Pelvic  pain  with  diarrhoea  and  hsemorrhage 
from  hoivels,  alternating  ivith  constipation  for  six  ^veeJcs, 
attributed  to  getting  ivet  ;  admission  to  medical  wards  as  a 
case  of  typhoid  ;  on  vaginal  examination  an  irregular,  long, 
smooth  sicelling  found  in  left  side  of  pelvis  with  some 
indistinct  thiclcening  on  right ;  history  of  impure  connec- 
tion and  vaginal  discharge  ;  diagnosis  of  left  pyosalpinx  ; 
abdominal  section  :  left  pyosalpinx  communicating  by  an 
^dcerated  opening  with  a  suppurating  ovarian  cyst ;  right 
tube  thickened  and  occluded ;  both  tubes  and  ovaries 
removed  ;  rapid  recovery. — A  servant  girl,  aged  19,  single, 
was  admitted  into  the  medical  wards  of  St.  Thomas's 
Hospital  February  lOth,  1881,  supposed  to  be  suffering 
from  enteric  fever. 

She  had  been  wet  through  on  the  3rd  of  January,  and 
during  the  night  had  been  seized  with  severe  pain  in  the 
right  iliac  region.  For  a  week  she  tried  to  get  through 
part  of  her  work,  but  from  that  time  had  been  obliged  to 
be  in  bed.  Three  weeks  before  admission  there  was 
noticed  a  considerable  quantity  of  blood  in  the  motions  on 
two  successive  days.  She  was  at  that  time  suffering  from 
diarrhoea.  For  the  fortnight  before  admission  the  bowels 
Avere  constipated.  On  the  Friday  and  Monday  before 
admission  there  had  again  been  blood  in  the  motions,  but 
less  in  quantity.  During  the  whole  of  the  past  six 
weeks  there  have  been  headache,  loss  of  flesh,  and  pains 
in  the  limbs.  The  patient  has  also  had  a  yellow  discharge 
from  the  vagina. 

On  February  18th  she  complained  of  a  good  deal  of 
pain  in  the  lower  part  of  the  abdomen,  thighs,  and  back, 
and  lay  on  her  back  with  the  knees  drawn  up.  The 
temperature  had  varied  since  admission  from  normal 
to  100-8°. 

I  was  asked  to  see  and  examine  her  the  following  day. 
The   uterus  was    retroverted    and    its   mobility  impaired. 


396  VALUE    OP    ABDOMINAL    SECTION    IN 

There  was  an  irregular  but  somewhat  elongated  and 
smooth  swelling  in  the  left  posterior  quarter  of  the  pelvis, 
and  some  less  distinct  thickening  in  the  right.  I  found  on 
enquiry  that  the  girl  had  frequently  had  sexual  intercourse 
between  June,  1889,  and  the  middle  of  1890,  but  that 
nothing  of  the  kind  had  taken  place  after  the  latter  date 
until  a  week  before  the  commencement  of  her  present 
illness.  I  gave  it  as  my  opinion  that  the  patient  was 
suffering  from  pyosalpinx  on  the  left  side  and  some 
thickening  of  the  right  tube,  with  secondary  peritonitis, 
the  disease  being  either  gonorrhceal  or  tubercular.  She 
was  thereupon  transferred  to  Adelaide  Ward  on  February 
21st.  On  the  24th  an  examination  was  made  under  ether, 
with  the  result  of  confirming  the  opinion  already  given. 

Abdominal  section  was  performed  on  February  26th. 

In  the  left  posterior  quarter  of  pelvis  was  found  a  thin- 
walled,  not  very  tense,  soft,  cystic  swelling,  with  tube 
attached  to,  if  not  forming  part  of  it.  The  tumour  was 
easily  separated,  the  adhesions,  though  universal,  being 
slight  in  character  and  recent.  Notwithstanding  the 
gentlest  handling,  the  cyst-wall  gave  way  and  a  purulent 
discharge  welled  up.  On  bringing  the  mass  into  view  it 
was  found  to  be  a  suppurating  cyst  of  the  left  ovary, 
communicating  by  an  ulcerated  opening  the  size  of  a  pea 
with  the  Fallopian  tube,  which  was  thickened  and  con- 
tained pus  amongst  its  inflamed  rugse.  The  right  tube 
was  enlarged,  occluded,  and  adherent  ;  the  right  ovary 
was  normal.  Both  tubes  and  both  ovaries  were  removed. 
The  peritoneal  cavity  was  douched,  a  drainage-tube  in- 
serted, and  the  abdominal  wound  closed.  There  was  a 
good  deal  of  oozing  from  separated  adhesions,  the  arrest- 
ing of  which  occupied  a  good  deal  of  time,  and  the  opera- 
tion lasted  an  hour  and  a  half. 

The  patient  made  a  rapid  recovery  and  left  the  hospital 
well  on  April  1st.  The  suture-tracks  in  the  abdominal 
wound  suppurated,  which  is  an  unusual  occurrence,  but 
there  was  no  purulent  discharge  from  the  pelvis.  A 
metrostaxis  commenced  on  the  day  of  operation  and  lasted 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  307 

until  March  5th,  after  Avhich  there  was  an  offensive 
vaginal  discharge  for  several  days. 

The  patient  was  sent  to  a  convalescent  home  ;  but  she 
was  dismissed  from  there  for  bad  conduct,  and  I  have 
heard  nothing  of  her  since. 

The  case  is  of  special  interest  as  showing  the  commu- 
nication between  tube  and  ovary  in  actual  process  of 
formation.  There  w^s  probably  ulcerative  salpingitis  in 
the  first  instance  with  adhesion  to  a  cystic  ovary,  fol- 
lowed by  perforation  of  tube  and  cyst-wall  and  infection 
of  contents  of  the  cyst. 


Part  III. 

No  classification  of  such  a  series  of  cases  as  that  here 
recorded  can  be  altogether  free  from  objection  ;  but  the 
following  table  will,  I  trust,  be  found  fairly  satisfactory. 
In  order  to  prevent  unnecessary  repetition  I  may  premise 
that  in  all  the  cases  but  one  there  was  marked  pelvic 
peritonitis.  The  exception  was  Case  32,  in  which  I  made 
a  wrong  diagnosis,  mistaking  for  inflamed  and  adherent 
appendages  a  retroflexed  uterus,  enlarged  and  distorted 
from  fibroids,  and  incarcerated  beneath  the  sacro-verte- 
bral  promontory.  I  have  included  the  case  here  because 
admission  to  this  series  has  been  determined  by  the 
object  for  which  the  operation  was  undertaken,  and  nob 
by  what  was  found.  Setting  this  case  aside  then  for  the 
present,  the  conditions  causing  or  associated  with  the 
peritonitis  in  the  remaining  49  cases  were  as  follows  : 

Tubercular  disease  of  Fallopian  tube  (Case  21  and  29)  .       2 

Suppurating  salpingitis  (Cases  7,  9,  14,  15,  16,  17,  18,  20,  25, 

27,  28,  30,  33,  36,  37,  40,  43,  45,  49,  50)  .  .     20 

Non-suppurating  salpingitis,  including   six  cases  complicated 

with  suppurating  ovarian    cyst  (Cases  1,  2,  4,  12,  19,  24, 

26, 35,  39,  41,  46,  48)  .  .  .  •     12 

Pelvic  abscess,  seat  undetermined  (Cases  5,  6,  13)       .  .       3 

Suppurating,  pedunculated,  retro-peritoneal  cyst  (Case  10)         .       1 


398  VALUE    OF   ABDOMINAL    SECTION    IN 

Abscess  in  abdominal  wall  (?  tubercular)  with  masses  of  enlarged 

pelvic  glands  and  miliary  tubercle  of  peritoneum  (Case  42)       1 
Hjematocele  (Cases  23  and  31)     . 


Haematosalpinx  witb  haematocele  (Cases  34 
Hajmatoma  of  broad  ligament  (Case  22) 
Broad  ligament  cysts — 

(a)  Witb  ovaritis  (Cases  1  and  38) 
(6)  Witb  hydrosalpinx  (Case  3) 

Encysted  serous  effusion  (Case  8) 


.  2 

44,  and  47)              .  3 

.  1 

.      2 
.       1 

—  3 

.  1 

49 


The  cases  of  suppurating  salpingitis  may  be  sub- 
divided as  follows  : 

(a)  With  occlusion  (pyosalpinx)  (Cases  7,  15,  30,  40,  43)  .     5 

(b)  With  distal  end  open  (Cases  16  and  36)  .  .2 

(c)  With  suppurative  disease  of  the  ovary  (Case  37)    .  .     1 

(d)  With  a  direct  communication  between  the  tube  and  a  suppu- 
rating cyst  of  the  adjacent  ovary  (suppurating  tubo-ovarian 
cyst)  (Cases  17,  18,  20,  25,  33,  50)  .  .  .6 

(e)  Witb  non-suppurating  cystic  ovary  (Case  27)  .  .  1 
{/)  With  suppurating  baematocele  (Case  14)  .  .  1 
(g)  With  hydrosalpinx  (Cases  9  and  45)  .  .  2 
(A)  With  intra-peritoneal  abscess  (Cases  28  and  49  .  .2 

20 

The  cases  of  non-suppurating  salpingitis  may  be  clas- 
sified into — 

(a)  Uncomplicated  cases  (Cases  19  and  24)  .  .  .2 

(b)  Witb  suppurating  ovarian  cyst  (Cases  4,  12,  26,  39,  41,  48)  .     6 

(c)  With  non-suppurating  ovarian  cj'st  (Cases  35  and  46)  .     2 

(d)  With  hajmatosalpinx  and  hajmorrhagic  ovarian  cyst 
(Case  2)     .  .  .  .  .  .1 

(e)  With  double  baematocele  (Case  11)  .  .  .1 

12 

Numher  of  cases  in  which  there  ivas  pelvic  suppuration. 
— Perhaps  the  most  interesting  point  brought  out,  on 
analysing  these  cases,  is  the  large  proportion  in  which  there 
was  some  form  of  pelvic  suppuration.  Thus,  out  of  the 
total  number  of  fifty,  this  condition   existed   in  no  fewer 


CERTAIN    CASES    OF  PELVIC    PERITONITIS.  399 

than  thirty,  i.  e.,  in  60  per  cent.  With  regard  to  the 
seat  of  the  suppuration,  in  thirteen  cases  it  was  the 
Fallopian  tube  alone  ;  in  six  cases  it  was  the  ovary  alone  j 
while  in  seven  cases  it  was  both  tube  and  ovary,  the 
two  being,  in  six  of  these,  in  direct  communication.  In 
the  remaining  four  cases  the  seat  of  suppuration  was 
either  not  accurately  determined,  or,  as  in  Case  10,  did 
not  involve  either  tube  or  ovary.  In  no  instance  was 
there  evidence  of  the  suppuration  being  in  the  pelvic 
connective  tissue. 

Origin  of  the  suppuration. — I  hope  at  some  future  time 
to  discuss  more  fully  than  is  here  possible,  the  etiology  of 
suppurative  inflammation  of  the  uterine  appendages.  In 
the  meantime  I  may  say  that,  the  larger  my  experience, 
the  less  disposed  I  am  to  attribute  to  catarrh  anything 
like  the  share  it  is  popularly  supposed  to  have,  in  causing 
pelvic  inflammation.  Even  cases  like  Nos.  27  and  36, 
where  the  evidence  in  favour  of  a  catarrhal  origin  seems 
at  first  sight  indisputable,  prove  on  further  investigation 
to  be  chronic  cases,  in  which  exposure  has  merely  had 
the  effect  of  producing  an  acute  exacerbation.  The  real 
causes  of  pelvic  inflammation  in  the  great  majority  of 
cases  will,  I  believe,  eventually  prove  to  be  sepsis,  gonor- 
rhoea, and  perhaps  tubercle.  Amongst  the  cases  here 
recorded,  the  evidence  of  gonorrhoeal  origin  is  very  strong 
in  a  good  many  cases,  and  in  at  least  five  cases  (Nos.  9, 
14,  15,  43  and  49)  seems  irresistible. 

Mortality. — The  total  number  of  fatal  cases  was  nine, 
a  mortality  of  18  per  cent.  The  cause  of  death  in  four 
cases  (3,  9,  10,  16)  was  peritonitis,  no  doubt  septic  ;  in 
one  case  (11)  the  only  lesion  discovered  at  the  autopsy 
was  acute  nephritis  ;  in  another  case  the  patient  had  intes- 
tinal obstruction  ;  an  artificial  anus  was  made,  and  death 
occurred  next  day  from  peritonitis.  I  have  little  doubt 
that  the  obstruction  was  really  due  to  septic  peritonitis. 
In  the  remaining  three  cases  no  post-mortem  examination 
was  made.  One  of  the  patients  (38)  died  suddenly  from 
collapse  on  the  eleventh  day;  the  other  died  with  symptoms 


400  VALUE    OF    ABDOMINAL    SECTION    IN 

of  septic  peritonitis.  Of  the  patients  who  died,  one  was  a 
case  of  tubercular  disease  of  the  Fallopian  tubes  ;  two  were 
cases  of  purulent  salpingitis;  two  were  cases  of  suppurating 
tubo-ovarian  cyst  ;  two  were  cases  of  very  chronic  pelvic 
peritonitis,  in  whichvery  little  was  removed  at  the  operation  ; 
one  was  a  case  of  double  salpingitis,  non-purulent,  with 
a  small  htematocele  at  the  open  mouth  of  each  tube ;  and 
one  Avas  a  case  of  heemorrhagic  retro -peritoneal  cyst,  with 
abscesses  in  its  walls. 

Nature  of  operation. — The  operation  involved  the  com- 
plete removal  of  the  appendages  in  16  cases,  and  their 
partial  removal  in  23.  In  the  remaining  11  cases  none 
of  the  appendages  was  removed.  Of  the  16  complete  re- 
movals, 15  recovered  ;  of  the  23  partial  removals,  17  re- 
covered ;  of  the  11  patients  in  whom  neither  tube  nor 
ovary  was  removed,  9  recovered. 

Flushing  of  peritoneum. — The  peritoneal  cavity  was 
flushed  with  hot  solution  of  boric  acid  in  22  cases,  18  of 
which  recovered. 

Drainage. — The  drainage-tube  was  used  in  47  out  of 
the  50  cases.  In  88  cases,  the  glass  drainage-tube  alone 
was  employed  ;  the  length  of  time  it  was  kept  in  was  as 
follows  : — Twenty-four  hours  in  14  cases  ;  thirty-six  hours 
in  4  cases  ;  forty-eight  hours  in  14  cases  ;  sixty  hours  in 
4  cases ;   seventy-two  hours  in  2  cases. 

In  7  cases  an  india-rubber  tube  was  substituted  for  the 
glass  tube ;  at  the  end  of  twenty-four  hours  in  1  case, 
forty-eight  hours  in  4  cases,  and  seventy-two  hours  in 
2  cases. 

In  2  cases  india-rubber  tubes  were  employed  throughout. 
Fsecal  fistula. — In  2  cases,  a  faecal  fistula  formed  after 
the   operation  ;    spontaneous  closure   took    place    in   each 
instance. 

Pain. — In  the  large  majority  of  the  cases  pain  was  per- 
manently relieved.  Almost  all  the  patients  who  recovered 
have  returned  to  the  hospital  to  report  themselves  at  more 
or  less  prolonged  intervals  after  their  discharge.  Only 
five  of  these  have  complained  of  pelvic  pain. 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  401 

Simis  at  loiver  angle  of  wound. — In  6  cases  it  is  noted 
that  a  sinus  existed  wlien  the  patient  went  home  ;  in  only 
2  of  these  has  healing  failed  to  take  place  since  (Nos.  7 
and  41). 

Hernia  at  site  of  abdominal  wound. — Four  patients  have 
developed  a  hernia  at  the  line  of  incision.  One  of  them 
had  had  the  abdomen  opened  twice. 

On  the  whole,  the  rapidity  of  convalescence  and  freedom 
from  unpleasant  sequelae  have  been  remarkable.  Of  the 
forty-one  patients  who  recovered,  twenty-four  escaped 
without  the  slightest  suppuration  (except  in  one  or  two 
instances  in  the  suture-tracks),  including  no  fewer  than 
nine  cases  of  suppurative  disease  of  the  tubes,  two  cases 
of  suppurating  ovarian  cyst  with  salpingitis,  and  two  cases 
of  suppurating  tubo-ovarian  cyst. 

Hasmorrhage  as  a  symptom  of  tubal  inflammation. — The 
efPect  of  tubal  inflammation  upon  the  menstrual  function 
is  illustrated  by  the  following  figures.  Out  of  the  thirty- 
two  cases  of  salpingitis  included  in  the  present  series, 
twelve  had  more  or  less  continuous  haemorrhage,  five  had 
amenorrhoea,  three  had  dysmenorrhoea,  and  twelve  men- 
struated normally.  Dividing  the  cases  into  purulent  and 
non-purulent  salpingitis,  we  find  that  amongst  twenty 
cases  of  purulent  salpingitis,  eight  had  metrorrhagia,  three 
had  amenorrhoea,  three  had  dysmenorrhoea,  and  six  had 
no  disturbance  of  menstruation.  Of  the  twelve  cases  of 
non-purulent  salpingitis,  complicated  and  uncomplicated, 
four  had  metrorrhagia,  two  had  amenorrhoea,  whilst  in  six 
there  was  no  interference  with  the  menstrual  function. 
So  far,  therefore,  as  the  small  number  of  cases  here  re- 
corded enables  us  to  judge,  irregular  uterine  haemorrhage 
is  a  symptom  of  salpingitis  in  rather  more  than  a  third  of 
the  cases,  or  to  speak  more  precisely,  in  two-fifths  of  the 
purulent  cases,  and  in  one-third  of  the  non-purulent. 
The  haemorrhage  is  seldom  profuse,  and  appears  never  to 
be  in  itself  a  source  of  danger. 

The  temperature  as  a  guide  to  the  diagnosis  of  pelvic 
suppuration. — It  is  generally  held  that  if  the  temperature 


402  VALUE    OF    ABDOMINAL    SECTION    IN 

is  not  raised,  it  is  a  fairly  certain  indication  tliat  there  is 
no  suppuration.  The  following  figures  show  that  this 
test  is  unreliable.  In  twelve  of  the  thirty  cases  in  which 
suppuration  was  present  the  temperature  before  operation 
was  absolutely  normal.  In  one  case  there  was  a  single 
rise  of  temperature  (after  examination)  to  103°  ;  in  another 
case  the  temperature  only  twice  exceeded  the  normal 
during  a  period  of  six  weeks  ;  in  a  third  case  there  was 
but  a  single  rise  of  temperature  in  ten  days,  and  that 
only  to  100°  ;  in  a  fourth  case,  during  a  period  of  eight 
days,  the  temperature  only  on  one  occasion  exceeded  100  , 
and  in  a  fifth  case  the  highest  record  was  100" 4°.  In 
twelve  cases  the  temperature  was  distinctly  febrile.  Of 
one  case  I  have  no  note  of  the  temperature  before  opera- 
tion. A  much  more  valuable  guide  to  the  diagnosis  of 
the  presence  of  pus  in  the  pelvis  is  the  recurrence,  on 
comparatively  slight  provocation  or  without  ostensible 
provocation  of  any  kind,  of  more  or  less  severe  attacks  of 
pelvic  peritonitis,  after  apparent  recovery  from  the  first 
attack.  What  happens  in  such  cases  is  that  the  pus  be- 
comes  enclosed,  and  for  a  time  gives  no  sign  of  its  pre- 
sence. Then  comes  some  slight  exciting  cause,  and  the 
purulent  collection  becomes  the  centre  of  an  acute  and 
wide-spread  inflammation.  Or,  in  the  absence  of  such 
exciting  cause,  the  tissues  enclosing  the  pus  undei-go 
ulceration,  until  at  last  perforation  occurs,  and  the  pus, 
after  having  been  imprisoned,  it  may  be  for  months  or 
years,  is  set  free  in  the  pelvis  or  escapes  into  some  neigh- 
bouring viscus  or  canal.  I  do  not  propose  in  this  paper 
to  enter  into  an  elaborate  defence  of  the  operation  of 
which  it  treats.  My  object  is  to  present  a  statement  of 
facts,  and  to  let  them  speak  for  themselves.  The  opera- 
tions here  described  were  not  '^  done  in  a  corner. ''  With 
few  exceptions  they  were  performed  at  St.  Thomas's  Hos- 
pital before  the  resident  officers  and  students,  and  any 
colleagues  or  other  visitors  who  cared  to  witness  them. 
Being  a  new  departure,  they  were  watched  with  keen  inte- 
rest.   The  parts  removed  were  submitted,  while  still  fresh, 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  403 

to  tlie  curator  of  the  hospital  museum,  Mr.  Shattock,  who 
examined  them  then  and  there,  and  is  responsible  for  the 
■description  recorded  in  the  notes.  It  is  scarcely  pos- 
sible to  have  more  complete  guarantees  against  reckless 
surgery  or  inaccuracy  of  statement.  It  would  be  absurd  to 
maintain  that  every  case  in  such  a  long  series  was  a  suit- 
able one  for  operation  ;  but  the  instances  in  which  I  had 
reason  to  regret  having  operated  were  exceedingly  few, 
and  were  much  less  numerous  than  those  in  which  I 
regretted  not  having  operated  sooner.  In  the  remarks 
appended  to  the  individual  cases,  I  have  endeavoured 
honestly  to  confess  my  mistakes.  The  operations  here 
recorded  have  nothing  in  common  with  those  which  are 
undertaken  merely  for  the  relief  of  pelvic  pain  without 
obvious  lesion.  Of  these  latter  I  have  no  experience. 
The  only  instances  in  which  I  have  removed  the  normal 
tubes  and  ovaries  are  those  in  which  the  operation  has 
been  performed  for  uterine  fibroids.  I  make  this  state- 
ment in  order  to  limit  any  discussion  that  may  follow  the 
reading  of  this  paper,  to  the  operation  with  which  it  deals, 
an  operation  which  I  believe  to  be  founded  on  sound 
surgical  principles,  and  destined  to  take  its  place  amongst 
the  est^-blished  operations  of  modern  surgery. 

I  shall  be  disappointed,  however,  if  this  communication 
is  regarded  merely  as  a  plea  for  more  frequent  recourse 
to  surgical  treatment.  I  trust  it  may  also  have  some 
value  as  a  contribution  to  our  knowledge  of  the  diagnosis 
and  pathology  of  some  of  the  most  common  diseases  of  the 
female  pelvic  organs,  especially  tubal  disease  and  its 
numerous  and  very  serious  complications. 

Posiscript  (August  15th,  1892). — During  the  eighteen 
months  that,  have  elapsed  since  Febi'uary,  1891,  Avhen  the 
above  paper  was  commenced,  I  have  completed  a  second 
series  of  fifty  operations  of  a  similar  kind.  In  this  series 
the  mortality  has  been  less  than  half  that  of  the  first  fifty, 
nine  deaths  having  occurred  in  the  first  fifty,  and  four  in 
the  second.     Amongst  the  last  twenty-five  cases  operated 


404 


VALUE    OF    ABDOMINAL    SECTION    IN 


upon,  not  one  lias  proved  fatal.  It  is  therefore,  I  think, 
fair  to  say  that  the  mortality  in  this,  as  in  most  serious 
operations,  tends  to  diminish  with  increased  experience. 
Of  the  four  patients  in  whom  the  operation  proved  fatal, 
at  least  three  would  have  died  within  a  very  short  time  if 
they  had  not  been  operated  upon  ;  the  operation  was  too 
late  to  save  them. 

The  fatal  cases  included — 

1  suppurating  ovai'ian  cyst. 

1  suppurating  tubo-ovarian  cyst. 

1  tubercle  of  ovary. 

1  pelvic  abscess  of  nuccrtain  origin. 

The  details  of  the  second  fifty  cases  cannot  of  course  be 
given  without  unduly  prolonging  an  already  too  long 
paper.  It  may  be  interesting,  however,  to  append  a 
classified  list  of  them. 


Tubercular  disease  of  Fallopian  tube 

Suppurating  salpingitis  (including  two  cases  of  suppurating 

ovarian  cyst,  and  two  of  suppurating  tubo-ovarian  cyst) 
Non-suppurating  salpingitis  (complicated  in  four  cases  by  sup 

purating  ovarian  cyst) 
Suppurating  subperitoneal  cyst  . 
Pelvic  abscess,  seat  uncertain 
Tubercular  disease  of  ovary,  with  suppuration 
Suppurating    ovarian    cyst    (complicated   in    one    instance 

inflammation  of  the  vermiform  ajipendix) 
Hydrosalpinx        .... 
Serous  cyst  of  ovarian  ligament 
Inflamed  ovarian  cyst 
Dermoid  cyst  of  ovary    . 
Perityphlitis,  after  delivery,  with  suppuration 
Tubercular  peritonitis      .  .  . 

Malignant  disease  of  pelvis 
Haematosalpinx    .... 
Unruptured  tubal  gestation,  with  apoplectic  ovum 


20 

6 
1 
3 
3 


by 


4 
1 
1 
1 
1 
1 
1 
1 
4 
1 

50 


The  specimens  from  eleven  of  these  cases  have  been  ex- 
hibited to  this  Society,  and  descriptions,  accompanied  with 
a  brief  clinical  history,  have  been  printed  in  its   '  Transac- 


CERTAIN    CASES    OF    FELVIC    PERITONITIS.  405 

tions/^      Six  other  of  the  cases  have  been  published  in 
detail  in  the  '  Lancet. 'f 

*  A  series  of  seven  cases  of  Pyosalpiiix,  shown  November  4tli,  1891.  Two 
cases  of  Tubal  Gestation  with  Apoplectic  Ovum,  shown  May  and  June,  1892. 
Two  cases  of  Pyosalpinx,  shown  July,  1892. 

t  See  "  Mirror  of  Hospital  Practice  "  in  'Lancet '  for  July  2ncl  and  9th, 
1892.     "  Six  cases  of  Abdominal  Section  for  Recurrent  Pelvic  Peritonitis." 


406 


VALUE    OP   ABDOMINAL   SECTION    IN 


No. 


Name. 


A. 
McC. 


M.M. 


J.  R. 


M.  B. 


M.  E. 
B. 


Occupation  and 
residence. 

< 

Date  of 
operation. 

1885 

Dressmaker, 

25 

May  13 

MaDchester 

W. 

Winder  in 

26 

Oct.  7 

cotton  mill 

M. 

1886 

Housekeeper, 

35 

Jan.  13 

Manchester 

M. 

House  work. 

25 

April  30 

Royton 

M. 

1887 

Weaver, 

21 

June  7 

Rawteustall 

S. 

Place  of 
operation. 


St.  Mary's 

Hospital, 

Manchester 


Symptoms. 


Anaemia ;  emaciation ; 
constant  pain  in  left 
iliac  region ;  inability 
to  sit,  and  hence  to 
follow  occupation 


Anaemia;  emaciation; 
continuous  pain  in 
lower  part  of  abdo- 
men, especially  on 
right  side ;  metror- 
rhagia (two  months) 


Continuous  pain  in  pel- 
vis; repeated  attacks 
of  pelvic  peritonitis 


Recurrent  pelvic  peri- 
tonitis ;  constant  pel- 
vic pain,  incapacitat- 
ing her  for  work 


Amenorrhoea  19  weeks, 
severe  pain  in  lower 
part  of  abdomen,  com 
mencing  with  acute 
attack  10  weeks  before 
admission.  After  2 
months'  rest  in  hospital 
pain  and  tenderness 
subsided,  but  swelling 
increased 


CERTAIN    CASES    OF    PELVIC     PERITONITIS. 


407 


Physical  signs  and 
diagnosis. 


Condition  found  and  nature 
of  operation. 


Glass 
drainage- 
tube. 


vie  peritonitis 


mg,  firm,  tender 
tiling  on  right  side 
pelvis,  pushing 
;rus  to  left.  Pro- 
oly  the  right  Fallo- 
m  tube  distended 


rus  fixed ;  tender 
elling  in  right  side 
pelvis.  Diagnosis. — 
ironic  ovaritis  with 
hesions 


1,  rounded,  tender  Right  ovary  size  of  wal- 
lUing   to    right    of    nut,  intianied  and  in- 
l    behind    uterus ;    durated.  Firm  tumotir 
rine    mobility   im-    of    each    broad    liga- 
red.     Diagnosis. —    ment,  consisting  of  a 
ronic  ovaritis  with    compact  mass  of  small 
cysts ;       left      ovary 
healthy ;  all  parts  ad- 
herent. Tumours  enu- 
cleated ;    right    ovary 
and  tube  removed 
Fallopian  tube  on  right 
distended  with  blood ; 
its    walls    thickened ; 
right   ovai'y  enlarged 
to  size  of  hen's  egg, 
containing    a     blood- 
cyst;  left  ovary  cystic. 
Both  ovaries  and  right 
tube   removed ;    adhe 
rent  viscera  separated 
Contents  of  pelvis  mat- 
ted;   right   tube   dis- 
tended   with    serum 
three  serous  cysts  in 
broad  ligament.  Cysts 
and      diseased      tube 
removed ;      adhesions 
separated 
all  fixed  tumour  on  Eight  ovary  cystic  and 
ht   side   of    pelvis,    enlarged,  3  in.  long; 
;e  of  orange.     Dia-.  one   large   cyst   tilled 
lom. — Dilated  right    with  pus;  universally 
be  adherent;  both  tubes 

much  thickened,  with 
cysts  in  walls.  Both 
tubes  and  both  ovaries 
removed 

domen  swollen,  ten-  All  contents  of  pelvis 
;r,  resonant;  no  tu-  matted  together  by  ad 
our ;  no  fluctuation ;  hesions ;  tense  abscess 
;erus  normal  in  size,  on  right  side  of  pelvis, 
ced.       Diagnosis. —    with  thin  walls.     Ab 


48 
hours 


ncertain 


scess  emptied,  irri- 
gated, and  drained ; 
walls  secured  to  abdo- 
minal incision.  Uterus 
and  appendages  not 
distinguished 


No     R. 


hours 


Until 
death 


No 


No!  D. 


48 
hours 


No 


24 
hours. 
India- 
rubber 
tube 
5  months 


No 


Remarks. 


Seven  months  later 
stout  and  well,  free 
from  pain,  and  able  to 
earn  her  living.  See 
'Brit.  Med.  Journ.,' 
Jan.  30,  1SS6. 


Temp,  during  conva 
lescence  only  once 
reached  100^  F.  Two 
months  after  operation 
free  from  pain,  able  to 
go  about  as  usual.  See 
'  Brit.  Med.  Journ.,' 
Jan.  30,  188(J. 


Died  on  third  day  from 
peritonitis. 


Convalescence  rapid 
Six  mouths  after  ope 
ration  stout,  well,  and 
free  from  pain.  Oct. 
25,  1892.— Feels  as 
well  as  ever  she  was ; 
no  pelvic  pain ;  has 
not  menstruated  for 
two  years. 

Convalescence  rapid,ex- 
cept  that  a  discharg- 
ing sinus  existed  for 
many  months.  In  Au 
gust,  1892,  she  was 
perfectly  well,  and  had 
been  married  2  years 
Menstruated  regu- 
larly. 


408 


VALUE    OP   ABDOMINAL    SECTION    IN 


10 


11 


K.  .1. 


E.  F. 


A.  L. 


M.  C. 


S.  T, 


G.  C. 


_^ 

■r^    ^ 

Occupation  and 

"  o 

Date  of 

Place  of 

residence. 

operation. 

operation. 

Symptoms. 

1887 

None, 

23 

Oct.  12 

St.  Mary's 

Menorrhagia;  abdomi- 

Winton,  near 

M. 

Hospital, 

nal  pain  dating  from 

Patricroft 

1888 

Manchester 

two  months  after  mar- 
riage, and  becoming 
worse ;  incapable  of 
least  exertion 

Servant, 

25 

April  5 

St.  Thomas's 

Amenorrhcea ;    emacia- 

Ashford 

S. 

Hospital, 
London 

tion;  pyrexia;  con- 
stant pain;  bedridden 

None, 

20 

May  21 

Pain  in  left  iliac  region 

Southwark 

W. 

and  in  micturition. 
Pallor,  emaciation, 
general  feeling  of  ill- 
ness.    Temp.  102-G° 

Tailoress, 

19 

Oct.  18 

99 

Gonorrhoea ;    recurrent 

Dalston 

S. 

pelvic  peritonitis;  con- 
stant pelvic  pain 

Dressmaker, 

32 

Dec.  20 

>» 

Recurrent  pelvic  perito- 

Marylebone 

S. 

1889 

nitis  ;  almost  constant 
pelvic  pain,  especially 
on  left  side.  Looks 
thin,  sallow,  ill,  and 
tired 

House  work, 

32 

Feb.  21 

J, 

Haemorrhage;   pain  in 

Barking 

M. 

1 

back,  vulva,  right 
thigh,  and  knee 

CERTAIN  CASES  OP  PELVIC  PERITONITIS. 


409 


Physical  signs  and 
diagnosis. 


Condition  found  and  nature 
of  operation. 


ii^e fluctuating  swell-' 
ig  to  right  of  and| 
ehind  uterus,  which 
;  normal  in  size  and 
ushed  forwards.  Dia- 
nas is.— lietTO'\i.tQT'me 
bscess 

nse,  hard,  obscurelv 
actuating  tumour  in 
;ft  iliac  region  ;  ute- 
as  fixed.  Diagnosis. 
-Pelvic  abscess 


nse,  fluctuating, 

ightly  prominent 
.veiling  above  pubes  ,• 
terus  fixed  and  dis- 
laced  to  right ; 
rawny  swelling  above 
iginal  roof  on  leftl 
de.  Diagnosis. — 
elvic  abscess  I 

nse,  fixed,  cystic 
veiling  behind  and  toj 
ght  of  uterus  J  uterus! 
xed;  thickening  on 
ft.  Diagnosis, — 

ight  hydrosalpinx 


Intra-peritoneal  abscess 
in  right  side  of  pelvis  ; 
20  fl.  oz.  pus  removed ; 
cavity  irrigated  and 
drained;  edges  secured 
to  abdominal  incision 
nothing  removed 

Abscess  to  left  of  ute- 
rus; 3  fl.  oz.  pus  re- 
moved ;  wall  i  in. 
thick,  lined  with  case- 
ous material.  Cavity 
emptied  and  drained ; 
opening  secured  to 
abdominal  incision 

Intra-peritoneal  effu- 
sion of  serum  (20  fl. 
oz.)  walled  in  by  pelvic 
viscera  and  by  adhe- 
sions. Cavity  emptied 
and  drained 


Right  hydrosalpinx. 
Tube  and  adjacent 
ovarv  removed 


Glass 

draiuHge- 

tube. 


stinct,  globular,  fluc- 
lating  tumour  above 
abes,  causing  little  or 
J  prominence  of  ab- 
>minal  wall.  Uterus 
ashed  to  left 


ooth,  firm,  elastic, 
imoveable  mass  be- 
nd and  to  right  of 
;erus;  obscure  thick- 
ling  high  up  in  left, 
)sterior    quarter    of 


Pelvic  viscera  densely 
matted;  retro-uterine, 
pedunculated,  subperi- 
toneal cyst,  containing 
30  fl.  oz.  dark  brown 
fluid  (altered  blood) 
and  two  small  suppu- 
rating cysts  in  its  wall 

Old  pelvic  adhesions ; 
amongst  them  on  each 
side  a  firm  blood-clot 
embraced  by  tlie  fim- 
briae of  the  Fallopian 
tube;  righttubethick- 
ened,  empty,  sind  un- 
dilated.  Both  tubes 
and  left  ovary  removed 
with  the  clots 


72 

hours. 
India- 
rubber 
tube 
5  months 

India- 
rubber 
tube 
many 
months 


India- 
rubber 

tube 
11  days 


No 


20 

hours 


No 


Yes 


No 


Remarks. 


R. 


Rapid  improvement  in 
'  general  health,  but 
discharging  sinus  ex- 
isted for  several 
j  months.  In  July, 
',  1892,  was  quite  well. 


R 


R 


No 


50 
hours 


Yes 


No 


Immediate  improve- 
ment in  health,  but 
sinus  left,  discharging 
muco-pus.  On  Jan.l4,j 
1890,  sinus  dissected 
out ;  found  to  consist, 
of  left  Falloi^ian  tube,' 
thickened,  but  no 
longer  distended.  I 

Highest  temp,  after  | 
operation,  99°  F.    Re- 

mained   well    and    at 

work  for  4?  years.  In  Sept.,! 
1892,  attack  of  pelvic  pain  ;j 
mass  on  right  sideof  uterus;! 
right  appendages  removed 
for  chronic  inflammatory 
disease. 

D.  P.M. — General  perito- 
nitis ;  pus  in  left  tube 
and  in  remains  of  right 
tube.  See  '  Obst.  Soc. 
Trans.,'  vol.  xxx,  p. 406 
and  plate;  also  'Brit. 
Med.  Journ.,'  July  20, 
1889,  pp.  123,  124. 
P.M. — Suppurative  pe- 
ritonitis. Both  ova- 
ries and  both  tubes 
involved  amongst  the[ 
pelvic  adhesions.  See 
'  St.  Thomas's  Hosp. 
Rep.,'  vol.  xviii,  p.  76. 


D.  Died  on  ninth  day., 
P.M. — Acute    nephri- 

:  tis.   No  cause  of  death 

i  discovered     in     parts. 

;  concerned  in  the  ope-j 
ration.     See  '  St.  Tho-I 

j  mas's      Hosp.     Rep.,' 

I  vol.  xix,  p.  179. 


VOL.    SXXIV. 


29 


410 

VALUE    OF    ABDOMINAL    SECTION 

IN 

Occupation  and 

"   O 

Date  of 

Place  of 

DuratioB 

Ko. 

Name. 

residence. 

-< 

operation.  1 

1 

operation. 

Symptoms. 

iilu'esg. 

1889 

12 

S.  A. 

Servant, 

22 

March  21 

St.  Thomas's 

Recurrent  pelvic  peri- 

5 yeai 

W. 

Worfield, 

S. 

Hospital, 

tonitis  ;  constant  pain 

Bridgnorth 

1- 

para 

Loudon 

right  iliac  region;  in- 
ability to  work  or  even 
move  about;  pyrexia 

1 

13 

A.  M. 

None, 

39 

Aug.  2 

Constant   pelvic   pain ; 

2  yeai 

Newington 

M. 

and 
Aug.  30 

purulent        discharge 
from  rectum ;    emaci- 
ation; anaemia 

14 

A.  0. 

Dressmaker, 

Waterloo 

Koad 

28 
M. 

Sept.  14 

" 

Pain,  loss  of  appetite, 
great  emaciation ;  py- 
rexia ;  inability  to  sit, 
and  therefore  to  earn 
living 

12  mon;j 

15 

S.  B. 

Prostitute, 

22 

Oct.  17 

„ 

Recurrent  pelvic   peri- 

4 

London 

M. 

(?) 

tonitis  ;  irregular 
hjBmorrhage.      Puru- 
lent   discharge    from 
uterus 

montli 

16 

L.  B. 

Nursemaid, 

34 

Oct.  24 

Dysmenorrhcea  ;    pain 

1 
111 

Turner's   Hill 

S. 

in   right  hip  and  left 
iliac  region,  the  pain 
latterly          constant ; 
always  ailing 

years! 

1 

17 

A.  C. 

None, 
Edmonton 

40 
M. 

Nov.  18 

» 

Seized  5   weeks  before 
1  admission   with   stab- 

5 weei 

bing    pain    in    lower 

part  of  abdomen.    Subsequently  had 

general   bronchitis,  pains   of  rheu- 

matic character,  abdominal  pain  and 

vomiting,  with  temp.  102°.     On  ad- 

mission    extremely     ill  ;     broncho- 

pneumonia,     occasional      vomiting. 

much  pain  in  right  iliac  region  and 

. 

down  right  leg.    Temp.,  Nov.  8th  to 

18th,  varied 

1 

from  99-8°  to  104-8° 

CERTAIN    CASES    OF    PELVIC    PERITONITIS. 


411 


Physical  signs  and 
diagnosis. 


'terus  pushed  to  right 
by  a  smooth,  firm, 
elastic,  slighty  move 
ible  mass,  filling  up 
left  posterior  quarter 
of  pelvis 


[ard  mass  behind  and 
to  left  of  uterus.  Dia- 
gnosis.—  Pelvic  ab 
scess 


ender,  irregular  swell 
ing  behind  and  to  right 
)f  uterus,  displacing 
uterus  to  left.  Dia- 
jnosis. — Pyosalpinx 

ixed,  ill-defined,  irre- 
gular mass  in  right 
josterior  quarter  of 
jelvis.  Diagnosis. — 
Pyosalpinx 


terus  fixed ;  hard, 
rregular  mass  behind 
iterus,  connected  with 
ausage-shaped  swell- 
ng  traceable  to  rightj 
ornu  of  uterus  ;  ten 


Condition  found  and  nature 
of  operation. 


Glass 

drainage 

tube. 


Remarks. 


R.  Temp,  at  no  time  ex- 
ceeded 100°  during 
convalescence.  Apr.25. 


Small  suppurating  cyst        20         No 
of    left    ovary ;    both     hours 
tubes   thickened    and 

dilated;    right   ovary    — Sent   to   Convalescent   Hospital,    East- 
twice  normal  size  and   bourne.     Jan.,  1891. — Quite  well  and  at 
adherent.     Both  ova-    work   as   a   domestic  servant.      See    'St, 
ries    and    both   tubes   Thomas's  Hosp.  Rep.,'  vol.  xix,  p.  155. 
removed  | 

20 
hours 


Thick  -  walled  abscess 
deep  in  left  side  of 
pelvis;  1^  fl.  oz.  pus 
withdrawn ;  edges  se- 
cured to  margins  of 
abdominal  incision 

Purulent        salpingitis 
with  suppurating  hffi-j    India- 
matocele.      Left  tube    rubber 


48  hours. 


removed  tube 

2  weeks 

Right    tube    occluded,        24 
filled  with    pus;    left!    hours 
to  external  appearance 
normal.      Right  tube 
removed 


No 

R. 

Yes 

R. 

No 

R. 

No  pus  from  rectum 
after  operation.  Jan., 
1891.-^  Ventral  her 
nia,  otherwise  quite 
well. 


Acute  pneumonia  dur 
ing  convalescence. 
Health  restored  by 
operation.  See  '  Brit 
Med.  Journ.,'  Dec.  27, 
1890. 
Rapid  recover}'.  Temp, 
uniformly  normal.  A 
month  later,  uterus 
curetted,  &c.  March 
7th,  1891. — Quite  well,  menstruation 
regular,  no  discharge,  condition  of  pelvis 
normal. 


Right  tube  enlarged' 
and  adherent.  Left: 
tube  apparently  nor- 
mal. Right  tube  and 
ovary  removed  | 


48 
hours 


Yes 


D. 


lerness  in  left  posterior  quarter  of  pelvis ;  no  swelling. 
'nosis. — Disease  of  right  Fallopian  tube 


Dia- 


l-defined,  soft,  elastic 
welling  in  lower  part 
if  abdomen,  extending 
Tom  right  lateral  wall 
>f  pelvis  nearly  to 
eft,  appreciable  per 
■aginam,  where  it  is 
mooth,uniform,  tense, 
ind  elastic.  Uterus 
ixed,  pushed  forwards 
ind  to  left.  Diagnosis 
—Pelvic  suppuration ; 
lepticEemia 


44 
hours 


Yes  I  R. 


Tumour  aspirated,  18 
fl.  oz.  fetid  pus  with- 
drawn. Operation  twol 

days  later.  Right  tube  much  elongated 
and  enlarged,  with  thickened  walls,  com- 
municating with  ovarian  cyst  by  opening 
large  enough  to  admit  finger,  contents 
suppurating.  Left  ovary  cystic,  size 
of  orange,  inner  surface  papillomatous. 
General  adhesions.  Both  ovaries  and  both 
tubes  removed 


P.M.— Pus    found 
uterus    and     in 
tube. 


left 


Broncho  -  pneumonia 
(septic  ?)  at  time  of 
operation.  Tempera- 
ture, evening  of  ope 
ration,  101-6°;  after 
wards  never  exceeded 
99-6°.  July  17, 1891. 
— Remains  well.  See 
*  St.  Thomas's  Hosp. 
Rep.,'  vol.  xix,  p.  165 


412 

VALUE    OP   ABDOMINAL   SECTION 

IN 

1 

Occupation  aud 

Date  of 

Place  of 

Dnration 

Xo. 

Name. 

residence. 

5-3 
~  c 

<! 

operation. 

operation. 

Symptoms. 

illness. 

1889 

18 

C.  D. 

Norwood 

29 
M. 

Nov.  25 

St.  Thomas's 

Hospital, 

London 

Recurrent  pelvic  peri- 
tonitis.     Acute    pain 
in  right  side  of  abdo- 
men ;      hajmorrhage. 
On    admission,     pale, 
thin,    and    extremely 
ill  ;     temp.      102-6°; 
resp.   40;    sordes    on 
teeth  and  lips 

7  year 

19 

A.H. 

None, 

27 

Nov.  28 

5J 

Pain    in   left   iliac   re- 

2i 

Clapham 

M. 

gion  ;  pyrexia 

years 

20 

R.  H. 

None, 

54 

Dec.  5 

}) 

Weakness  ;       pallor  ; 

6  or  8 

Wandsworth 

M. 

haemorrhage ;      temp, 
normal    in     morning, 
99-8°     to     100-4°    in 
evening  ;  dull  pain  in 
lower  part  of  abdomen; 
swelling  of  legs  and 
feet 

weeks  1 

i 

i 

21 

Mr8.C. 

None, 

30 

Dec.  24 

St.  Thomas's 

Severe  paroxysmal  pain 

5  moatt 

Luton 

M. 

.  Home 

lower  part   of    abdo- 
men and  back;  menor- 
rhagia;  night-sweats; 
emaciation 

1 

CERTAIN  CASES  OP  PELVIC  PERITONITIS. 


413 


Physical  signs  and 
(liHgiiosis. 


rregular  swelling  felt 
deeply  in  lower  part 
Df  abdomen  ;  per  vagi- 
nam  tense,  smooth, 
ilastic,  swelling  fillin 
up  right  side  of  pel- 
vis ;  uterus  to  right 
ind  fixed.  Diagnosis. 
— Pelvic  suppuration ; 
septiccemia 


terus  fixed ;  irregu- 
ar,  hai'd  mass  passing 
)utwards  from  eacli 
;ornu,  that  on  left 
massing  forwards,  that 
)n  right  backwards. 
Diagnosis.  —  Double 
ialpingitis 

ounded,  firm,  smooth, 
obulated  tumour 

ibove  pubes  on  left; 
I  swelling  on  right 
ess  firm,  with  tense 
Daud  of  tissue  running 
;ransversely  across  it. 
rumour  on  left  is 
iterus  enlarged  j  that 
)u  right  separate  from 
t.  Diagnosis.  —  Fi- 
jroid  enlargements  of 
iterus;  ovarian  cyst 
)ehind  right  broad 
iganient 

terine  mobility  im- 
jaired ;  high  up  on 
•ight  side  elongated 
iwelling,  tender  and 
ortuous.  Diagnosis 
—Chronic  inflamma- 
tion of  right  tube  and 
jelvic  peritoneum, 
rJrobably  tubercular 


Condition  found  and  nature 
of  operation. 


Glass 
drainage- 
tube. 


Right  tube  much  thick- 
ened and  lengthened, 
communicating  with 
cyst  of  ovary  by  open- 
ing ^  in.  in  diameter, 
contents  suppuratin 
Left  tube  also  in  a 
state  of  suppurative 
inflammation.  Left 
ovary  not  seen.  Gene 
ral  adhesions.  Both 
tubes  and  ovarian  cyst 
removed 

Both  tubes  thickened, 
occluded,  and  densely 
adherent ;  ovaries  adhe 
rent.  Ovaries  and  tubes 
removed 


Right  tube  irregularly 
distended,  communi- 
cating with  cyst  ot 
ovary  by  aperture 
large  enough  to  admit 
a  goose-quill.  Portion 
of  tube  removed  62  in. 
long;  contents  sup- 
purating, fetid.  Left 
ovary  cystic,  1^  in. 
X  I  in.,  removed  to 
check  growth  of  bleed- 
ing fibroid 


Chronic  inflammation 
of  both  tubes  ;  cystic 
disease  of  right  ovary ; 
dense  peritoneal  adhe- 
sions; miliary  tuber- 
cles on  peritoneum  of 
tubes,  intestine,  and 
uterus.  Tubercular 
ulcers  in  both  Fallo- 
pian tubes,  filled  with 
caseous  matter 


50 

hours 


24 
hours 


26 

hours 


24 

hours 


Yes 


No 


Yes 


Yes 


D. 


R. 


Remarks. 


Died  from  peritonitis, 
5.30  a.m.,  Nov.  29, 
having  had  artificial 
anus  made  previous 
day  for  intestinal 
obstruction.  See '  St. 
Thomas's  Hosp.  Rep.,' 
vol.  xix,  p.  168. 


See  '  Brit.  Med.  Journ.,' 
Dec.  27,  1890.  Jan., 
1891.  —  Quite  well, 
except  for  a  small 
ventral  hernia. 


Acute  endocarditis  dur 
ing  convalescence.  See 
'St.  Thomas's  Hosp 
Rep.,'  vol.  xix,  p.  172 


See  'Brit. Med. Journ.,* 
Dec.  27,  1890. 


414 


VALUE    OP   ABDOMINAL    SECTION    IN 


No. 


Name. 


22 


L.  T. 


23 


24 


K.  A. 


E.  B. 


Occupation  and 
residence. 


None, 
Battersea 


None, 
Kentish  Town 


Cricketer, 
King's  Cross 


25 


Mrs.L, 


26 


Stationer, 
Slough 


M.  J. 
H. 


Date  of 
operation. 


1890 
Jan.  17 


Jan.  21 


April  10 


Place  of 
operation. 


Symptoms. 


St.  Thomas's 
Hospital 


38 
M. 


May  19 


St, 


Thomas's 
Home 


Duration 
illness. 


Laundress, 
Tooting 


25 
M. 


May  22 


St.  Thomas's 
Hospital 


Pallor  ;  anxiety  of 
countenance ;  severe 
pain  in  left  iliac  re- 
gion ;  high  tempera- 
ture 


Attack  ushered  in  by 
pain  and  vomiting;  9 
weeks  after  last  men- 
struation ;  since  that 
continuous  haemor- 
rhage 

Recurrent  pain  in  left 
iliac  region ;  vomit 
ing;  pyrexia.  His 
tory  of  yellow  vaginal 
discharge  for  two 
years 


Pain  in  left  side  since 
miscarriage  6  years 
ago.  Was  taken 
acutely  ill,  August, 
1889,  at  Margate, 
after  getting  wet,  and 
has  been  in  bed  almost 
ever  since  with  abdo- 
minal pain.  Occa- 
sional offensive  dis- 
charges of  matter 
from  rectum.  Temp 
100°  to  103°  until 
March ;  since  March 
normal 

Not  well  since  miscar 
riage  12  months  ago ; 
lost  flesh  and  had  pain 
in  left  iliac  region 
pain  worse  during  and 
since  last  period,  with 
difficulty  of  micturi- 
tion and  pain  before 
defecation 


2  week 


3^ 

monthf 


Acute' 

sympton 

6  week 


6  years 

acute 

sympton 

9  montl 


Acute 

syinptoi 

6  week 


CEETAIN    CASES    OP    PELVIC    PERITONITIS. 


415 


riivsical  sigBS  and 
'  diagnosis. 


arge,  tense,  tender 
I  nass  in  left  posterioi 
Quarter  of  pelvis  and 
.oehiud  uterus,  push- 
.ng  uterus  to  right. 
Diagnosis.  —  Pelvic 
;ibscess 

t  val  swelling  size  ot 
prange  behind  uterus 
'md  left  broad  liga- 
ment. Diagnosis. — 
Uncertain 

ense,  elongated,  non- 
fluctuating,fi.x:ed  swell- 
ing in  left  posterior 
quarter  of  pelvis,  with 
small,  firm  body  en- 
closed iu  its  fold. 
Diagnosis. — Inflamed 
left  tube,  enclosing 
normal  ovary ;  botb 
adherent 

'onsiderable  abdominal 
swelling  with  hard-j 
ness  and  resistance 
over  left  side  and 
rounded  prominence 
in  middle  line.  Cer- 
vix uteri  pushed  up- 
wards and  forwards ; 
large  fluctuating 

swelling  behind,  de- 
pressing retro-uterine 
pouch.  Diagnosis. — 
Pelvic  suppuration, 
probably  of  ovarian 
cyst,  fistulous  opening 
into  rectum 
"umour  in  left  iliac 
region,  felt  but  not! 
seen ;  uterus  pushed 
to  right,  fixed ;  tense, 
tender,  slightly  move- 
able mass  on  left; 
similar  mass  on  right. 
Diagnosis.  —  Chronic 
intiammation  of  both 
tubes,  with  small  ova- 
rian cjst 


Condition  found  and  nature 
of  operation. 


Glass 
drainage- 
tube. 


7 
hours 


No 


Exudation  in  left  broad 
ligament    with    even 
surface,  and  soft  but' 
firm    consistence ;    adhesive    peritonitis ; 
appendages  normal.      Probably  a  haema- 
toma.     Nothing  removed 


48 
hours 


i  Yes  !  R. 


Old       intra-peritoneal 
blood    effusion.       No 
organised       structure 
discovered.  Tubes  andovaries  adherent, but 
presenting  no  marked  lesion ;  not  removed 


Both  tubes  thickened 
from  old  inflamma- 
tion ;  mucous  mem- 
brane healthy  ;  no 
fluid  in  canal;  right 
tube  thicker  than  left; 
both  firmly  adherent. 
Ovaries  healthy,  adhe- 
rent. Tubes  and 
ovaries  removed 

Both  Fallopian  tubes 
thickened  and  elon- 
gated, stretched  over 
large  suppurating 
ovarian  cysts,  with 
which  the  tubes  were 
in  direct  communica- 
tion by  openings,  that 
on  the  left  large 
enough  to  admit  little 
finger,  that  on  right 
smaller.  Both  cysts 
removed  with  the 
tubes 


Both  tubes  enlarged, oc- 
cluded, and  very  firmly 
adherent.  Right  ovary 
normal,  adherent ;  left 
ovary  cystic,  size  of 
hen's  egg,  one  cyst 
suppurating.  Both 
tubes  and  left  ovary 
removed 


20 
hours 


72 
hours 


No 


Yes 


24 
hours 


Yes 


R 


R 


On  Feb.  7  mass  much 
less  in  all  dimensions; 
temp,  normal. 


Probably     a     so-called 
tubal  abortion. 


R.  Much  vomiting  and 
pain  up  to  April  27, 
with  alarming  emacia- 
tion ;  after  which  re- 
covery rapid.  March 
5,  1892. —  Has  had 
no  pain  since  leaving 
hospital.  Has  men- 
struated regularly.  Is 
well  and  strong. 
Convalescence  pro- 

tracted. In  February, 
1891,  presented  her- 
self, looking  stout  and 
well.  Sinus  still  dis- 
charging slightly;  no 
swelling  in  either  pos 
terior  quarter  of  pel 
vis ;  menstruated  four 
times  in  5  months; 
dui'ation  normal,  quan- 
tity variable.  No  pain, 
but  back  aches  after 
exertion.  Aug.,  1892. 
— Quite  well ;  sinus 
healed  8  months  ago. 
Some  suppuration  after 
removal  of  stitches  at 
lower  angle  of  wound. 
After  12th  day  reco- 
very rapid.  Sept.  2. — 
Stout  and  well.  Oct. 
22,  1892.— Well  and 
strong;  no  pain ;  men- 
struates regularly  ;  ten- 
dency to  hernia  in  2  or  3 
places  along  wound. 


416 

VALUE 

OP    ABDOMINAL    SECTION 

IN 

No. 

Name. 

Occupation  and 
residence. 

■T-,  S 

<1 

Date  of 
operation. 

Place  of 
operation. 

Symptoms. 

i 

Duration  j 

illnesa.  | 

1890 

27 

E.  G. 

Bookfolder, 

23 

June  6 

St.  Thomas's 

Severe  pain  lower  part 

18  moat  \ 

Lambeth 

W. 

Hospital 

of  abdomen,  shooting 
down      thighs,     com- 
mencing 6  weeks  after 
confinement.        Sym- 
ptoms subsided  under 
hospital  treatment  in 
Dec,  1888.     Well  up 
to  April,  1890,  when 
she    had    to    give   up 
work    owing   to   pain 
and  haemorrhage 

• 

28 

E.  L. 

None, 
Streatham 

34 
M. 

July  3 

Recurrent  pelvic  peri- 
tonitis ;       continuous 
pain  for  past  3  weeks 
iu    right    iliac   region 
and  back 

2  yearsj 

j 

29 

S.  P 

None, 

27 

July  10 

Private 

Recurrent  pelvic  peri- 

7 years 

Stowmarket 

S. 

Nursing 
Home 

tonitis,  more  frequent 
last   2   years.     Drag- 
ging   pain    in     right 
iliac  region  after  leas-t 
exertion.        Loss      of 
weight.        Has     been 
chiefly  confined  to  bed 
past  5  or  6  weeks 

30 

A.  T. 

None, 

24 

July  21 

St.  Thomas's 

On     July    5th    severe 

13  days 

Peckham 

M. 

Hosjjitul 

attack  of  pain  in  left 
side,  extending  down 
leg;    temp.    98-8^   to 
102-2' 

CERTAIN    CASES    OF    PELVIC    PERITONITIS. 


417 


Physical  signs  and 
diagnosis. 


Condition  found  and  nature 
of  operation. 


regular,  hard  swell- 
ng  in  each  posterioi- 
[uarter  of  pelvis,  more 
narked  on  right,\vhere 
he  tube  can  be  felt 
bickened  and  the 
ivary  prolapsed ;  swell- 
ng  and  tenderness  in 
Douglas's  pouch 


3nse,fluctuating  swell- 
ng  to  left  of  uterus ; 
m  right,  high  up,  a 
lard  irregular  swell- 
ng,  giving  the  im- 
jression  of  tube  and 
)vary  embedded  in  a 
nass  of  adhesions 


Right  tube  thickened 
and  adherent ;  right 
ovary  enlarged,  cystic, 
and  adherent;  left  tube 
and  ovary  adherent ; 
tube  size  of  goose- 
quill.  Under  micro- 
scope, pus  in  contents 
of  tubes.  Both  tubes 
and  both  ovaries  sepa 
rated  and  removed 


Glass 
drainage- 
tube. 


46 
hours 


44 
hours 


terus  fi.xed;  irregular 
and  hard  mass  on  right 
side ;  less  defined  mass 
on  left.  Diagnosis. — 
Tubal  disease  with 
pelvic  peritonitis 


Pelvic  contents  matted 
together;  on  right  side 
thickened  tube  and 
normal  ovary  densely 
adherent.  During  se- 
paration blood-stained 
pus  escaped  from 
amongst  the  adhesions. 
A  thickened  and  pro- 
lapsed loop  of  large 
intestine  adherent  on 
left  of  uterus.  Left 
tube  and  ovary  not 
found.  Right  append 
ages  removed;  pus  in 
right  tube 

Pelvic  contents  densely 
matted.  On  right  side 
mass  of  caseous  mate- 
rial, partly  inside  and' 
partly  outside  the  tube,  the  tube  havinc 
entirely  lost  its  rugae,  and  become  sepa 
rated  by  a  ring  of  ulceration  into  two 
parts.  Left  side  of  pelvis  also  contained 
caseous  material.  Tube  extremely  adhe- 
rent, occluded,  thickened,  and  elongated. 
Both  ovaries  and  both  tubes  removed 


Dense  mass  in  each  pos- 
terior quarter  of  pel  vis 
passing  out  from  ute- 
rine cornu,  nnd  ter- 
minating as  a  thick- 
ened tube  behind 
uterus.  Diagnosis 
Double  tubal  disease, 
probably  purulent, 
[with  peritonitis 


44 
hours 


Yes 


R. 


Yes 


R. 


No 


R. 


Remarks. 


Left  hospital  well  in  a 
month.  April  2, 1891. 
— Quite  well  and  free 
from  pain.  Has  men- 
struated regularly  last 
6  months.  Jan.  7, 
1893.  —  Well  and 
strong ;  married  again 
2  years  ago ;  men- 
struates regularly ;  no 
pain  except  at  men- 
strual period. 

Highest  temp,  after 
operation  100'4°.  Left 
hospital  well  in  a 
month. 


Both  tubes  full  of  pus 
and  deeply  ulcerated 
and  perforated ;  walls 
very  thick,  distal  ends 
closed ;  ovaries  normal, 
adherent.  Both  tubes 
and  ovaries  removed 


20 
hours 


Yes    R 


Did  well  first  month, 
then  had  rise  of  temp., 
and  eventvially  an  ab- 
scess burst  into  rectum. 
Jan.,  1891.  —  Very 
well;  has  lost  almost 
all  the  aching  pain 
after  exertion.  Nov. 
17,  1892.— Feels  very 
well  ;  no  pain  since 
Spring. 


No  pain  on 
hospital.  Hs 
flesh,  and  is 
spirits. 


leaving 
3  gained 
in  good 


418 

VALUE 

OP    ABDOMINAL    SECTION 

IN 

Name. 

Occupation  and 

Date  of 

Place  of 

Duration  ( 

No. 

residence. 

§3 

Si 

operation. 

operation. 

Symptoms. 

illness. 

1890 

31 

M.M. 

None, 

23 

Aug.  4 

St.  Thomas's 

Admitted  Feb.  1,  1890, 

11  montl 

Scarborough 

M. 

Hospital 

with  large  pelvic  ha3- 
matocele,   which    dis- 
appeared.      Returned 
to  Scarborough  March 
25th.     On  Aug.  2  re- 
admitted, not  having 
been  able  to  do  much 
work   on   account    of 
backache  and  pain  in 
left  iliac  region 

\ 

1 

32 

E.  B. 

None, 
Kent  Road 

40 
M. 

Aug.  5 

Continuous  pelvic  pain 
and  dysmenorrhcea 

6  month 

33 

Mrs.F. 

None, 

31 

Sept.  1 

Private 

Dyspareunia  for  several 

4  years; 

Manchester 

M. 

Nursing 
Home 

years.     Attacked  sud- 
denly in   July,   1890, 
whilst  sitting  reading 
out  of  doors,  with  ex- 
tremely  acute    pelvic 
pain.      In  bed    for    a 
week,     when      severe 
symptoms      recurred, 
followed    by   prostra- 
tion,  backache,  flatu- 
lence,   high   tempera- 
ture, and  rapid  pulse 

acute 

symptom 

5  weeks 

34 

E.  B. 

None, 

29 

Sept.  4 

St.  Thomas's 

Missed   two  menstrual 

6  weeks 

Lambeth 

M. 

Hospital 

periods;  at  third  seized 
with    aching   pain    in 
lower  part  of  abdomen 
and   back ;  face  pale, 
features   drawn ;    has 
been  in  bed  since,  and 
has     had     continuous 
slight      haemorrhage ; 
pain     has      gradually 
diminished 

CERTAIN    CASES    OP    PELVIC    PERITONITIS. 


419 


Physical  signs  aud 
diasuosis. 


•egular,  hard  mass  in 
■ft  posterior  quarter 
I  pelvis.  Diagnosis. 
-Tubal  disease 


Condition  found  and  nature 
of  operation. 


Glass 
drainage- 
tube. 


xed,  irregular  swell- 
,ig  behind  and  be- 
eath  body  of  retro- 
exed  uterus.  Diagno- 
is.  —  Adherent  tube 
nd  ovary  behind 
etroflexed  and  adhe- 
ent  uterus 


eft  side  of  pelvis  occu- 
)ied  by  a  fluctuating 
swelling  rising  into 
ibdomen,  and  reach- 
ng  to  within  2J  in.  of 
imbilicus.  Some  pro- 
ninence  of  abdominal 
(vall  above  pubes. 
Uterus  in  front  and 
to  right  fixed.  Dia- 
gnosis. —  Suppurating 
cyst  of  ovary  and  pel- 
vic peritonitis 


None 


Both   tubes   and    both        24 
ovaries  matted  by  ad-     hours 
hesions;  tubes  not  en- 
larged, and  but  little 
thickened ;  remains  of 
blood-clot  behind  ute 
rus.     Cavity  cleansed, 
right  ovary  removed; 
right  tube  separated. 
Left  tube  and   ovary 
not  interfered  with 
Prolapsed  right  ovary 
behind  body  of  retro- 
flexed  uterus,  enlarged 
from  fibroids  and  in- 
carcerated.      No    ad- 
hesions.     Tubes    and 
ovaries  healthy.     Dis- 
placement   of    uterus 
and    ovary    rectified. 
Pessary  introduced  ^er 
vaginam.  Nothing  re-; 
moved 

Pelvis  occupied  by 
matted  viscei'a,  with 
covering  of  omentum. 
Both  Fallopian  tubes 
enlarged  and  thickened  ;  left 
tube  stretched  out  over  thick 
walled  suppurating  cyst  of  left 
ovary,  with  which  the  tube  was 
in  direct  communication  at  its 
fimbriated  extremity.  Contents 
of  tube  and  ovary  fetid.  Right 
tube  occluded.  Right  ovary  in- 
durated and  slightly  enlarged. 
Both  tubes  and  both  ovaries 
removed 


No 


No 


36 

hours 


R. 


No 


'irm  tumour  in  left 
iliac  region ;  uterus 
pushed  upwards  aud 
forwards;  length  of 
uterine  canal  3  in. ; 
soft,  irregular  swelling 
behind  uterus ;  thick- 
ening of  right  broad 
ligament 


Ruptured  blood-cyst  of 
right  broad  ligament ; 
intra-peritoneal  hae- 
matocele ;  left  tube 
distended  with  blood- 
clot;  no  trace  of  fcetus 
discovered.  Cyst  of 
broad  ligament  re 
moved  with  right 
tube  and  ovary.  Left 
tube  removed 


48  hours; 

then 
india- 
rubber 

tube 
3  days 


Remarks. 


D. 


Discharged  Aug.  23rd ; 
no  pain ;  general  con- 
dition improved.  July, 
1892.  —  Is  in  better 
health  than  for  years. 
No  pain  or  backache. 
Menses  regular.  Is 
quite  fit  for  work. 


August  29th. —  Went 
home  well;  uterus  in 
good  position.  April 
18th,  1891.  —  Stout, 
well,  and  free  from 
discomfort. 


Alarming     amount    of 
shock  at  close  of  ope 
ration.    Died  at  11.40 
a.m.,    Sept.   5th.     No 
P.M. 


Yes 


R. 


Oct.  4th.— Discharged, 
looking  and  feeling 
well.  Very  slight  dis 
charge  from  sinus  at 
lower  angle  of  wound 
Jan.  5th,  1892,— 
Well  and  at  work 
ever  since  leaving  hos- 
pital. Oct.,  1892.— Stout 
and  well ;  no  pain  ;  men 
struates  regularly. 


420 

VALUE 

OP 

ABDOMINAL    SECTION 

IN 

t 

No. 

Name. 

Occupation  and 
residence. 

"  o 

bis 

Date  of 
operation. 

Place  of 
operation. 

Symptoms. 

Duratioi 
illness. 

1890 

35 

L.  B. 

Mangier, 

Walworth 

Road 

51 
M. 

Sept.  9 

St.  Thoma.s's 
Hospital 

Recurrent     pelvic     in- 
flammation ;    pain    in 
left   side   and   yellow 
discharge 

17  yea 

1 

36 

E.  B. 

Barmaid, 

34 

Oct.  16 

Chronic   ill-health    for 

Some 

1 

Chelsea 

S. 

years ;  severe  pain  and 
hajmorrhage  3  weeks 
ago  after  getting  wet. 
Now  complains  of  pain 
in  left  side  of  pelvis, 
shooting  down  thigh, 
and  of  slight  haemor- 
rhage.        Emaciated, 
very     pale,    and     ex- 
tremely ill 

years. 

Acute 

sympton 

3  week.' 

37 

J.  H. 

None, 
Streatham 

46 

S. 

Oct.  23 

Peritonitis    after    get- 
ting  wet  in  Aug.,  1889. 
Since    then    pain    in 
pelvis,     especially     in 
right  side,  and   after 
walking,  standing,  &c. 
Metrorrhagia.      Sym- 
ptoms   worse    last    3 
months 

14  montl 

1 

38 

M.N. 

None, 

51 

Nov.  10 

Profuse  and   irregular 

1 
Many 

Battersea 

M. 

menstruation    accom- 
panied     with      pain, 
dating  from  puerperal 
illness  30  years   ago. 
Great  and  continuous 
pain  in   back,  especi- 
ally on  stooping  and 
before  defecation 

years 

m 

CERTAIN    CASES    OP    PELVIC    PEEITONITIS. 


421 


Physical  signs  and 
diagnosis. 


Condition  found  and  nature 
of  operation. 


Glass 
drainage- 
tube. 


erus  enlarged ;  on 
ft  side  of  pelvis  a 
uooth,  tense,  fixed, 
astic  swelling,  size 
c  small  orange.  In 
ght  posterior  quarter 
E  pelvis  an  irregular, 
1-defiued  swelling. 
Hagnosis.  —  Ovarian 
rst  on  left ;  inflamed 
ibe  on  right 

erus  fixed ;  fixed,  ir- 
?gular,  hard  mass 
Uing  up  left  poste 
.or  quarter  of  pelvis, 
jrminating  behind 
terus.  Diagnosis. — 
)isteuded  and  adhe- 
ant  left  tube  and  ad- 
erent  ovary 


Small  ovarian  cyst  on 
left  removed,  witli 
adherent  but  other- 
wise normal  tube. 
Enlarged,  prolapsed, 
and  adherent  tube  re- 
moved, with  normal 
ovary,  on  the  right 


Uterus  and  appendages 
of  both  sides  involved 
in  a  mass  of  old  ad- 
hesions. Both  tubes 
thickened,  containing 
muco-purulent  fluid  ; 
outer  coat  of  both 
ovaries  thickened. 
Adhesions  separated, 
both  tubes  and  both 
ovaries  removed 


regular,  hard  swelling 
igh  up  in  left  poste- 
ior  quarter  of  pelvis, 
dherent  to  uterus 
Diagnosis. —  Inflamed 
ube  and  ovary,  adhe- 
eat 


48 
hours 


Both  tubes  thickened 
and  enlarged,  with 
thick,  purulent  mucus 
in  their  canal.  Right 
ovary  cystic,  and  dense 
from  chronic  inflam 
mation ;  contents  of 
cyst  purulent,  and 
fetid.  Both  tubes  and 
right  ovary  removed 


)ft  swelling  in  pelvis 
n  front  of  and  to 
•iglit  of  uterus;  uterus 
ixed  and  retroverted. 
Diagnosis.  —  Cyst  in 
Delvis,  with  chronic 
jelvic  peritonitis 


A  number  ofthin-walled 
cysts  of  right  broad 
ligament.  Uterus  re- 
troverted and  adhe- 
rent. Tubes  and  ova- 
ries bound  down  by 
old  adhesions.  Cysts 
of  broad  ligament 
removed.  Adherent 
appendages  not  dis 
turbed 


44 
hours 


s 


~      ^ 


No     R. 


No 


44 
hours 


No 


48 
hours 


Remarks. 


Yes     D, 


Oct.Sth.— Left  hospital 
well.  1891,  Feb.  28th. 
— Presented  herself  at 
the  hospital,  looking 
well  and  in  good  con- 
dition. Has  had  little 
or  no  pelvic  pain  since 
operation.  Has  not 
menstruated.  March 
17th. — Small  ventral 
hernia. 

Improved  rapidly. 

Went  to  convalescent 
home  Nov.  22nd, 
where  she  gained  4^ 
lbs.  in  weight.  Mar. 
10th,  1893.  — Is  ii] 
better  health  than  she 
has  been  for  years; 
complains  of  flushes 
and  occasional  head- 
ache. Has  not  men- 
struated. 

Dec.  10th.— Left  hos- 
pital stout,  well,  and 
free  from  pain.  Feb 
27th,  1891.  — Looks 
stout  and  well ;  com- 
plains of  a  little  pain 
on  right  side.  Some 
swelling  and  tender 
ness  to  right  of  ute- 
rus. In  June,  1891, 
quite  well.  Died  in 
November  from  cancer 
of  stomach. 

Continued  vomiting 
and  abdominal  disten- 
sion.  Died  in  a  state 
of  collaj)se  on  the  21st 
Nov.,  having  com- 
plained of  intense  pain 
for  four  hours  pre- 
viously ,     No  P.  M. 


422 


VALUE    OF   ABDOMINAL    SECTION    IN 


No. 


Name. 


Occupation  and 
residence. 


39 


S.  K. 


Ironer, 

Battersea 


Date  of 
operation. 


1890 
Nov.  12 


Place  of 
operation. 


40 


A.  B. 


Servant, 
Brixton 


22 

S., 

1- 

para 


Nov.  19 


41 


E.  C. 


None, 
Lambeth 


25 
M. 


Nov.  28 


Symptoms. 


St.  Thomas's 
Hospital 


Pelvic  peritonitis  in  19  mon) 
Adelaide  Ward,  April, 
1889,  when  she  had  a 
discharge  of  pus  from 
rectum.  Left  hospital 
June  8th,  and  re-, 
mained  well  for  two 
months.  Since  theni 
had  constant  desire  to 
defecate,  and  passed 
pus 


Pain  in  left  iliac  region,  6  montl 
dating  from  9th   day 
after         confinement. 
Frequent  haemor- 

rhages. For  past  6 
weeks  pain  severe,  dis- 
charge of  blood  con- 
tinuous and  profuse 


First  admitted  Dec.  2, 
1889,  7  weeks  after 
confinement,  with  his- 
tory that  a  few  hours 
previously  had  been 
seized  with  severe  ab- 
dominal pain,  faint- 
ness,  and  vomitin?. 
Temp.l00-6°  to  102-6\ 
Urine  ^  to  -jo  albumen. 
Discharged  much  bet- 
ter Jan.  22, 1890.  Re- 
admitted Nov.  12  with 
recurrence 


CERTAIN    CASES    OP    PELVIC    PERITONITIS. 


423 


Physical  signs  and 
dia'cuosis. 


Condition  found  and  nature 
of  operation. 


ird  and  smooth  swell- 
ig  behind  and  to  right 
f  uterus.  Evacuations 
ontain  pus.  Dia- 
nosis.  —  Suppurating 
varian  cyst  commu- 
icating  with  rectum 


Glass 
drainage- 
tube. 


Small,  inflamed,  thick-  48  hours;  Yes 
walled,      tense,      and    replaced  j 
firmly   adherent   sup-  by  india- 
purating  cyst  of  right    rubber 

'  ovary.  Right  tube  in-|  tube 
flamed.  Left  tube  and 
ovary  adherent,  other- 
wise healthy.  Right 
tube  and  suppurating 
cyst  removed 


arulent  discharge 
rom  cervix ;  cervical 
Tosion ;  uterus  retro- 
•erted ;  anterior  to 
md  below  body  of 
aterus,  on  left  side,  a 
veil-defined  oblong 
nass  depressing  left 
'ornix,  and  divided 
nto  two  portions  by  a 
;ulcus.  Right  side 
:ree.  Diagnosis. — 
Diseased  left  tube 
vith  normal  ovary 
idherent 

i-defined  soft  mass 
aehind  and  to  right 
)f  uterus  ;  smaller. 
Harder,  and  irregular 
mass  to  left.  Dia- 
gnosis.— Inflamed  and 
idherent  Fallopian 
bubes  with  diseased 
and  enlarged  right 
Dvary 


Thickened  and  un- 
equally dilated  left 
tube,  containing  thin 
pus,  adherent ;  with 
the  normal  ovary  to 
broad  ligament  and 
other  parts.  Uterus 
retroverted  and  adhe- 
rent. Right  tube  nor- 
mal; right  ovary  nor- 
mal, but  prolapsed  and 
adherent.  Left  ap- 
pendages removed 
Uterus  and  right 
ovary  set  free 
Pelvic  viscera  matted ;' 
right  tube  thickenedj 
and  occluded ;  walls! 
\  in.  thick  ;  no  ulcera- 
tion ;  no  contents ; 
mesosalpinx  thick- 
ened ;  right  ovary 
enlarged  (2^  in.  x 
If  in.),  on  section 
found  to  be  riddled 
with  small  abscesses, 
left  appendages  nor- 
mal ;  right  only  re- 
moved; coil  of  intes- 
tine thickened  and  ad- 
herent in  Douglas's 
pouch,  during  separa 
tion  of  which  a  small 
rent  was  made  in  the 
bowel ;  this  was  closed 
by  sutures 


30 

hours 


24 
hours 


Remarks. 


No 


No 


R. 


Suppuration  fron 

wound  for  7  weeks 
Temperature  after 
operation  only  once 
exceeded  99-4° ;  it  was 
100°  on  Nov.  21st  from 
bowel  disturbance. 
Discharged  well  Dec. 
31st.  April  18th,  1891. 
■ — No  pain  in  pelvis  or 
discharge  from  the 
bowel  since  leaving 
hospital ;  menstruates 
regularly. 

Discharged   well    Dec 
10, 1890.  Readmitted 
in  January,  1891,  on 
account  of  some  pelvic 
pain.     Examined  per 
vaginam,  Jan.  16  and 
28,  with  negative  re 
suit.      The    tempera 
ture  was  normal.  Evi- 
dently an  instance  of 
malingering. 


Discharged  Jan.  24 
1891,  having  gained 
flesh  and  with  a  good 
appetite ;  a  slight 
purulent  discharge 
from  lower  angle  of 
wound.  Only  once 
(Dec.  5)  was  there  a 
faecal  stain  on  dress- 
ing. Feb.  17. — Sinus 
not  quite  healed ; 
menstruated  for  first 
time  Feb.  13  to  16, 


424 


VALUE    OP    ABDOMINAL    SECTION    IN 


No. 


Name. 


42 


A.  H. 


Occupation  and 
residence. 


Mother's  help 
Brixton 


43 


E.  S. 


None, 
Richmond 


■=r  I     Date  of 
« "3  I  operation. 


1890 
20     Nov.  22 

S. 


44 


E.J.S 


None, 
Battersea 


Dec.  17 


Place  of 
operation. 


Symptoms. 


25 
M. 


Dec.  18 


St.  Thomas's  Continuous  haemor 
Hospital  rhage  for  2  months, 
commenced  suddenly 
with  a  profuse  flow, 
2  weeks  after  a  period, 
as  she  was  carrying 
coals.  Occasionally  a 
little  pain  at  lower 
part  of  abdomen.  No 
loss  of  flesh  ;  no  pal- 
lor ;  no  interference 
with  general  health 


Fain  in  lower  part  of 
abdomen,    back,    and 

i  thighs,  especially  af- 
ter standing.  Gradual 

j  loss  of    strength  and 

I  flesh.  For  8  months 
unable  to  do  house- 
work; for  last4months 
has  been  obliged  to  lie 

i  down  almost  entirely 

;  Temp,  normal 


Abdominal  pain  and 
weakness  ;  loss  of 
flesh ;  thick  yellow 
vaginal  discharge; 
pain  on  micturition. 
Has  had  to  lie  up  fre- 
quently. (Husband 
in  Clayton  Ward  in 
August,  1890,  for 
urethral  stricture) 


CERTAIN    CASES    OP    PELVIC    PERITONITIS. 


425 


Fbysical  signs  mid  Condition  found  and  nature 

diagnosis.  i  of  operation. 


ru8  normal ;     body 

left,  neck  to  right. 
j  right  of  uterus,  on 
,plaue  slightly  pos- 
jior  to  it,  a  soft, 
[defined  swelling. 
\agnosis.  —  Haeina- 
ina  of  broad  liga- 
j-nt.     (The  swelling 

s  observed  gradu- 
ly  to  increase  in 
je ;  operation  a 
'■nth    after    adinis- 

n) 


rus  displaced  to 
t ;  large,  tender, 
mlated  swelling  he- 
ld and  to  right ; both 
•nices  (lateral)  de- 
3ssed.  Sulcus  be- 
een  right  lateral 
d  posterior  portions 
swelling.  Dla- 
osis. — Double  pyo 
pinx 


flitted  August  11, 
90.  Both  tubes  felt 
ckened  and  adhe- 
it.  Improved  great- 
in  hospital.  Went 
t  August  30.  Re- 
mitted Dec.  15, 
ving  been  laid  up 
ice  discharge.  Even, 
t,  tender  swelling 
hind  andtoriglit  of 
arus.  Thickened 
be  along  free  border 
left  broad  ligament 


Abscess  in  sheath  of 
right  rectus,  1^  fl.  oz. 
thick  curdy  pus  evacu- 
ated. Parietal  and 
visceral  peritoneum 
everywhere  studded 
with  miliary  tuber- 
cles. Large,  soft, 
fluctuating  sessile 

mass  lying  deeply  in 
each  posterior  quarter 
of  pelvis.  Structures 
implicated  not  differ- 
entiated. Abdominal 
incision  closed 


Both  tubes  enormously 
enlarged,  occluded, 
and  distended  with 
thick  pus ;  circum- 
ference of  right  4|  in., 
of  left  6i  ill. ;  mu- 
cous membrane  ulcer- 
ated. Both  tubes  se- 
parated and  removed. 
Ovaries  not  seen 


Right  tube  enlarged 
and  adherent,  circum- 
ference oj  in.,  filled 
with  old  adherent 
clot,  which  protruded 
from  open  fimbriated 
end ;  outside  tube  a 
quantity  of  dark  firm 
clot.  Enlarged  veins, 
filled  with  clot,  seen 
beneath  raucous  lining 
of  tube.  Left  tube 
occluded,  otherwise 
normal.  Both  tubes 
and  both  pvaries  re- 
moved 


Glass 
drainage- 
tube. 


25 

hours 


52  hours, 
replaced 
by  india- 
rubber 

tube 
20  hours 


60 
hours 


I  •  '      - 


No 


Yes 


Yes 


Remarks. 


Readmitted  March  9 
with  emaciation  and 
hectic  ;  no  change  in 
physical  signs.  A 
year  after  operation 
in  good  liealth ;  no 
physical  signs  of  dis- 
ease now  detected 
anywhere.  Oct.  22, 
1892.  Is  again  losing 
flesh  and  feeling  weak. 
No  definite  signs  of 
disease  either  in  abdo- 
men or  pelvis. 


Prolonged  and  severe 
shock  after  operation. 
Highest  temp,  during 
convalescence  100*2°. 
Discharged  Jan.  24, 
1891.  March  6,1891. 
— Lookiugand  feeling 
well;  has  menstruated 
twice ;  no  pelvic  pain, 
Gonorrhceal  vaginitis. 
Sept.  15.— Had  influ- 
enza in  May,  not  well 
since  ;  nothing  abnor- 
mal in  pelvis ;  men- 
struation regular. 

Suppuration  in  pelvis 
during  convales- 

cence, pus  discharged 
through  lower  angle 
of  wound.  Left  hos- 
pital Jan.  18,  1891; 
very  little  discharge. 
Feb.  17.— States  that 
sinus  closed  on  Feb.  7; 
quite  well ;  nothing 
abnormal  per  vagi- 
nam. 


VOL.  XXXIV. 


30 


426 


VALUE    OP   ABDOMINAL    SECTION    IN 


No. 


Name. 


45     I.  E. 


46 


K.W. 


47 


C.  P. 


Occupation  and 
residence. 


None, 
Bermondsev 


32 
M. 


Machinist,    i  23 
Peckham        S. 


Charwoman, 
Peckham 


31 
M, 


Date  of 
operation. 


1891 
Jan.  8 


Jan.  15 


Jan. 22 


Place  of 
operation. 


St.  Thomas's 
Hospital 


Symptoms. 


Yellow  discharge ; 

bearing-down  pain ; 
pain  in  left  iliac  re- 
gion, chiefly  on  stand- 
ing  or  walking.  Dys- 
meuorrhoea ;  irregular 
menstruation ;  pain 
on  micturition.  Se 
riously  ill  for  one 
week ;  acute  pain  on 
left  side  and  diarrhoea 


Attacked  suddenly  with 
"  forcing  pains  " 
abdomen.  Two  months 
later  got  her  feet  wet, 
and  was  seized  with 
crampy  pains  in  lower 
part  of  abdomen.  Has 
been  in  bed  a  fort- 
night. Temp.,  day  of 
admission,  100'6°  to 
104-2'' 


Two  months  after  con- 
finement seized  sud- 
denly with  severe  pain 
in  left  iliac  region  and 
down  thigh.  More  or 
less  subject  to  similar 
attacks  ever  since. 
Last  mouth  much 
worse,  with  loss  of 
flesh ;  pain  on  defeca- 
tion. No  disturbance 
of  menstruation 


CERTAIN    CASES    OP    PELVIC    PERITONITIS. 


427 


Physical  signs  aud 
diagnosis. 


Couditioii  found  aud  nature 
of  operation. 


Glass 
drainage- 
tube. 


rus  retroverted  and  Pelvic  viscera  matted, 
splaced  to  right.  To  Left  tube  elongated, 
t  and  posteriorly  a  thickened,  twisted, 
and  full  of  pus.  Right 
tube  thin-wailed  and 
tense,  being  distended 
with  serum.  Ovaries 
adherent  but  normal, 
both  tubes  and  both 
ovaries  removed 


24 
hours 


iss  separated  by  a 
Icus  from  body  of 
erus.  On  right 
ne  thickening  5  in. 
breadth,  feeling 
:e  a  coil  of  iutes- 
le.  Diagnosis.  — 
)uble  tubal  disease, 
obably  purulent 


rus  slightly  dis- 
iced  to  right  by  a 
nder  mass  in  left 
sterior  quarter  of 
Ivis  size  of  small 
pie,  depressing  va: 
1  fornix 


Left  tube  thickened 
and  adherent,  embrac 
ing  enlarged  ovary, 
size  of  pigeon's  eg^, 
containing  a  cyst  full 
of  blood.  On  section, 
wall  of  tube  found 
three  times  its  normal 
thickness  ;  mucous 
membrane  normal. 
Right  tube  and  ovary 
normal.  Left  tube 
and  ovary  removed 


•ge  mass  high  up  in 
Ft  posterior  quarter 

pelvis,  traced  from 
erine  cornu  to  back 

cervix.  Indistinct 
ickening  in  right 
isterior  quarter  of 
:lvis.  Diagnosis. — 
ouble  tubal  disease 


No 


No 


No 


R. 


Both  tubes  dilated  and  4.8  hours.  Yes 
adherent.  Conical  replaced  1 

blood-clot    expanding  by  rubber 
outer    inch    of    right      tube 
tube,  and   continuous 
with    small    hamato-: 
cele  amongst  the  peri-i 
toneal  adhesions. 

Hydrosalpinx   of   left 
tube 


R. 


Recovery  rapid.  Dis- 
charged well  Jan.  31. 
A  month  later  had 
some  pain  on  left  side. 
Feb.  24.— A  small 
swelling,  size  of  nor- 
mal ovary,  on  left  side 
of  pelvis ;  complains 
of  pain  on  that  side. 
On  July  15  patient 
went  into  King's  Col- 
lege Hospital,  where, 
a  few  days  later.  Dr. 
Hayes  removed  a  cyst 
of  the  left  broad  liga- 
ment. Nov.  13. — In 
Guy's  Hospital,  com- 
plaining of  pain  and 
desiring  another  ope- 
ration ;  no  discover- 
able lesion. 

Rapid  recovery.  Dis- 
charged well  Feb.  7. 
Mar.  26,  1892.— At- 
tended on  account  of 
having  lost  flesh.  No 
pain  ;  menstruation 
regular.  Uterus  move 
able ;  no  abnormal 
swelling  in  pelvis. 


Discharged    well    Feb 
25. 


428 

.       VALUE    OP    ABDOMINAL    SECTION 

IN 

1 

Occupation  and  •a.s 

Date  of 

Place  of 

Duratio  f 

Name. 

residence.        j  c;-5 

1  "^ 

operation. 

1 

operation. 

Symptoms. 

illnes 

i 

1891 

48 

K.W. 

still-room 

22 

Jan.  29 

St.  Thomas's 

Pain  in  right  iliac  re- 

4 yea 

maid, 

M. 

Hospital 

gion   since     birth     of 

Streatham 

child     4     years    ago. 
Eight  months  ago  had 
a  sudden  escape  of  pus 
from     vagina,    which 
has  continued  to  flow 
ever  since 

,' 

49 

F.C.B. 

Chamber- 
maid, 
City 

24 

S. 

Feb.   5 

" 

Violated    by   stranger, 
4th  Nov.,  1890.     Five 
weeks   later    was  ad- 
mitted     under       Dr. 
Payne    for    pains    in 
joints  and  fever.      At 
end  of  January  puru- 
lent vaginal  discharge 
noticed,    and    patient 
complained   of  pelvic 
pain.     Temp.    99"    to 
104-4° 

7  wee 

50 

M.  W. 

Servant, 

Wand  i3  worth 

Road 

19 

S. 

Feb.  26 

» 

On    Jan.    3     got    wet 
through,  and    during 
night  seized  with  se- 
vere pain  in  right  iliac 
region.     Was  thought 
to  have  typhoid,  and 
admitted    to    medical 
wards     on     Feb.    10. 
Constant       headache, 
diarrhoea,          haemor- 
rliage  from  bowel,  no 
sickness 

7  wee 

CERTAIN    CASES    OP    PELVIC    PERITONITIS. 


429 


Physical  signs  and 
diasDosis. 


Condition  found  and  nature 
of  operation. 


Glass 
drainage- 
tube. 


iglas's  pouch  occu- 
ed  by  large,  hard 
ass,  extending  more 
right  than  left, 
ing  of  dense  hard- 
•S3  around  cervix, 
nail  aperture  high 
)  ou  posterior  vagi- 
d  wall.  Diagnosis. 
-Pelvic  abscess  with 
itulous  opening  into 
igina 


mlent  urethritis  and 
aralent  discharge 
cm  vagina ;  elon- 
ited  tube-like  swell- 
ig  in  right  posterior 
ttarter  of  pelvis ; 
veiling  less  marked 
left.  Douglas's 
ouch  occupied  by 
fstic  swelling.  Dia- 
nosis.  —  Gonorrhceal 
ilpingitis 


Right  ovary  2i  in.  x 
Ij  in.  X  1.  in.,  con- 
sisting on  section  of  a 
number  of  inflamed 
cysts,  many  of  them 
full  of  pus.  An  open- 
ing, surrounded  by 
granulation  tissue,  on 
surface,  communicat- 
ing with  one  of 
the  abscess  cavities. 
Whole  mass  adherent 
behind  and  below 
uterus.  Right  tube 
thickened.  Left  tube 
beaded  from  kinking, 
otherwise  liealtby. 

Right  tube  and  ovai\v 
and  left  tube  removed 

Pelvic  viscera  matted 
Collection  of  pus  in 
Douglas's  pouch.  Both 
tubes  thickened,  with 
pus  in  their  canal, 
trickling  from  open 
fimbriated  end  into 
the  retro-uterine  ab- 
scess. Uterine  appen- 
dages both  sides  re- 
moved. Appendix 
vermiformis  removed 


Feb.  19  irregular 
ut  somewhat  don- 
ated and  smooth 
welling  in  left  pos- 
erior  quarter  of  pel- 
less  marked 
welling  on  right. 
diagnosis. —  Purulent 
alpingitis  on  left  with 
cclusion ;  on  right, 
dthout.  Gonorrhceal 
r  tubercular 


20 

hours 


Thickened  tube  on  left 
contaiuiKg  pus,  and 
communicating  by  a 
recently  ulcerated 
opening  with  the  in- 
terior of  a  small  sup- 
purating cyst  of  ad- 
jacent ovary.  Right 
tube  enlarged  and 
adherent.  Right 

ovary  normal.  Both 
tubes  and  both  ovaries 
removed 


Yes     R. 


48 
hours 


Yes 


44 
hours 


Yes    R. 


Remarks. 


Discharged  well  March 
7.  Nov.  15,  1891.— 
Readmitted  on  ac- 
count of  paroxysmal 
attacks  of  pain  in 
right  groin  with 
vomiting.  Between 
the  attacks  patient 
well  and  strong 
Menstruates  regularly. 
No  abnormal  swellinf 
in  pelvis  ;  a  little  ten 
derness  ou  right  side. 
Temp,  normal. 


Temp,  after  operation 
96°,  3  hours  later 
101-8°,  at  midnight 
98'4°,  after  which 
never  reached  100° 
Joint  pains  disap- 
peared, and  patient 
quickly  recovered  her 
usual  health. 


Recovery  rapid. 


430  VALUE    OF    ABDOMINAL    SECTION    IN 

Dr.  John  Williams  said  tliat  he  felt  personally  indebted  to 
Dr.  Cullingworth  for  bringing  this  paper  before  the  Society,  for, 
althongh  he  differed  widely  from  Dr.  Cullingworth,  both  in  con- 
clusions and  in  practice,  he  believed  that  the  discussion  of  the 
paper  would  help  to  place  the  practice  of  opening  the  abdomen 
for  pelvic  disease  on  a  sounder  and  more  reasonable  basis  than 
that  on  which  it  rested  at  present.  The  first  difference  he  had 
with  Dr.  Cullingworth  was  as  to  the  title  of  the  paper.  He 
thought  the  title  "  The  Value  of  Abdominal  Section  in  certain 
Cases  of  Pelvic  Peritonitis"  was  misleading  ;  for  on  examining 
the  cases  he  found  that  twenty-four  of  the  fifty  were  cases  of 
ovarian  or  other  cysts,  which  were  simple,  inflamed,  or  suppu- 
rating ;  and  with  regard  to  the  propriety  of  the  removal  of  them 
there  were  no  two  opinions.  In  these  cases  the  pelvic  inflam- 
mation present  may  have  been  independent  of  the  new  growths, 
although  it  was  well  known  that  inflammation  was  a  very 
frequent  consequence  of  the  presence  of  cystic  disease  in  tlie 
pelvis.  Then  there  were,  again,  six  cases  of  pelvic  abscess  in 
which  the  only  reasonable  plan  of  treatment  was  to  open  them, 
let  out  the  pus,  and  drain  them.  It  might  be  a  matter  of  opinion 
whether  the  opening  should  be  made  from  the  vagina  or  through 
the  abdominal  wall.  In  some  cases  the  way  through  the  vagina 
would  probably  have  been  better,  while  in  others  the  abdominal 
method  would  be  preferable.  There  were,  moreover,  ten  cases 
of  hsematocele,  one  with  ruptured  cyst  of  the  broad  ligament 
and  one  suppurating,  and  one  case  of  haematoma  of  the  broad 
ligament.  The  case  in  which  suppuration  had  occurred,  all 
would  agree,  should  have  been  treated  like  an  abscess,  but  it  is 
probable  that  the  other  nine  would  have  got  well  without  opera- 
tive interference,  for  death  from  hsematocele  is  extremely  rare. 
Dr.  Williams  had  only  seen  two  such.  There  were  five  cases  of 
apparently  uncomplicated  cases  of  hydrosalpinx,  and  seven  of 
salpingitis  or  hydrosalpinx,  for  he  could  not  admit  that  Cases  9, 
IG,  and  36  were  cases  of  suppurating  salpingitis.  With  regard 
to  Case  9,  Dr.  Cullingworth  found  during  the  operation  that 
the  right  tube  contained  serous  fluid,  and  the  left  was  healthy. 
This  in  itself  would  be  enough,  perhaps,  to  establish  Dr. 
Williams'  view  of  this  case,  but  what  was  seen  on  post-mortem 
examination  appeared  to  demonstrate  the  correctness  of  it,  for 
the  woman  died  from  septic  peritonitis,  and  pus  was  found  not 
only  in  the  left  tube,  but  also  in  the  stump  of  the  tube,  which 
was  the  seat  of  a  serous  eff"usion  at  the  time  of  operation.  Two 
cases  operated  upon  were  cases  of  tubercular  disease  of  the  tubes. 
He  did  not  think  that  operation  was  justifiable  in  cases  of  this 
disease,  and  especially  when  tubercle  was  found  in  other  organs. 
He  had  an  observation  to  make  with  regard  to  the  result.  The 
mortality  was  very  high,  but  he  did  not  think  that  it  was  higher 
than  the  mortality  from  these  operations  was  throughout  the 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  431 

country  generally,  although  in  a  few  hands  it  was  less.  The 
cases — or  many  of  them — presented  great  difficulties  to  the 
operator,  and  it  was  in  such  cases  that  the  mortality  was  high 
in  skilled  hands.  He  had  pointed  out  that  skill  in  operating 
favoured  a  low  mortality,  and  that  one  great  secret  of  a  very  low 
mortality  was  operating  upon  cases  in  a  condition  as  near  that 
of  health  as  possible.  There  was  a  mortality  which  necessarily 
arose  from  the  difficulties  of  the  operation,  and  this  mortality 
was  eliminated  when  operations  of  this  kind  were  undertaken  for 
trivial  deviations  from  health.  When  considering  the  mortality 
of  the  operation  the  mortality  from  the  disease  should  be  borne 
in  mind.  He  had  seen  two  cases  of  death  only  from  ruptured 
tubes  or  abscesses,  and  he  calculated  that  with  a  mortality  of 
IS  per  cent,  the  mortality  of  the  operation  was  several  hundred 
times  greater  than  that  of  the  disease.  Then  as  to  the  perma- 
nent result :  nine  died  after  the  operation  ;  one  within  twelve 
months  of  cancer  of  the  stomach  ;  fourteen  were  seen  a  year  or 
more  after  the  operation,  eight  appeared  not  to  have  been. 
Were  the  cases  operated  upon  cured  ?  Nine  died  after  the 
operation,  and  one  of  cancer  of  the  stomach  twelve  months  after 
operation.  This  left  forty  to  be  accounted  for.  Of  fourteen 
only  of  these  was  anything  known  after  the  lapse  of  twelve 
months  after  the  operation.  Of  eight  there  was  no  account  at 
all  after  they  left  hospital.  This  left  thirty-two.  It  was  impos- 
sible to  trace  all  patients  operated  upon  in  a  place  like  London 
and  under  a  Government  such  as  ours.  This  could  only  be  done 
when  every  one  was  under  police  supervision,  as  in  Germany  ; 
and  Dr.  Williams  knew  of  no  statistics  of  any  value  on  the 
permanent  result  of  removal  of  the  appendages  except  those  of 
Schmallfuss.  Those  of  English  operators  were  absolutely  worth- 
less because  of  the  impossibility  of  following  the  cases.  Of 
the  thirty-two  operated  upon  by  Dr.  Cullingworth  and  subse- 
quently traced  at  all,  five  suffered  pain  of  a  more  or  less  per- 
manent character,  six  had  sinuses  for  a  longer  or  shorter  interval, 
four  had  hernia,  and  two  required  a  second  operation ;  that 
meant  that  in  about  half  the  cases  more  or  less  suflering  was 
present  after  the  operation.  So  far  as  he  could  gather  from 
the  most  reliable  statistics  about  30  per  cent,  of  patients  from 
whom  diseased  appendages  were  removed  were  cured  by  the 
operation.  Many  more  were  benefited  and  cured  by  time  and 
other  treatment,  while  the  rest  continued  to  suff'er. 

Mr.  Albax  Doran  considered  that  it  was  good  surgery  to 
ensure  the  escape  of  pus  and  of  other  products  of  inflammation, 
and  that  in  so  far  as  that  object  was  gained  Dr.  Cuilingworth's 
practice  was  sound.  He  noted  that  Cases  5,  6,  S,  and  13  were 
typical  instances  of  good  surgery ;  abscesses  were  opened  or 
serous  effusions  liberated,  and  the  patients  recovered  without 
mutilation.      Parametric  abscesses  required  similar  treatment. 


432  VALUE    OF    ABDOMINAL    SECTION    IN 

It  was  not  suflBcient  to  make  a  mere  puncture  ;   a  free  incision 
should  be  made  through  an  abscess  which  pointed  anteriorly,  the 
cavity  should  be  washed  out,  and  then  explored  as  carefully  as 
the  peritoneal  cavity  is  explored  in  an  ordinary  abdominal  section. 
Then  there  would  be  no  fear  of  leaving  deeper  collections  of  pus 
unopened.     He  himself  treated  suppurative  parametritis  as  a 
matter  for  the  operating  table,  and  not  for  mere  puncturing  and 
poulticing.     In  a  recent  case  where  the  appendages  as  well  as 
the  parametrium  were  inflamed,  he  left  the  tubes  aud   ovaries 
alone  after  free  opening  of  abscesses.     Recovery  was  perfect,  all 
local  signs  of  tubo-ovarian  disease  steadily  disappearing.     Case 
13  showed  that  when  pus  was  discharging  from  the  rectum,  the 
fistulous  tract  closed  of  itself  when  the  abscess  was  well  opened 
from  the  abdominal  aspect.     In  cases  like    19,   where  a  cyst 
opening  into  the  rectum  was  removed,  it  would  be  interesting  to 
know  how  the  operator  avoided  damage  to  the  rectum  and  faecal 
fistula.     Dr.  Cullingworth  overlooked  one  cause  of  persistence 
of  pain  after  removal  of  the  appendages.     The  stump  was  usually 
more  or  less  unhealthj",  like  the  parts  cut  away,  and  the  ligature 
might  cause    much  irritation.      The   stump  of   a   true   ovarian 
tumour,  it  must  be  remembered,  was  usually  made  up  of  tissues 
free    from  inflammatory   changes,  hence  it   bore  ligature  well. 
When  an  abscess  was  opened  without  removal   of  appendages, 
then,  if  other  parts  were  healthy  at  the  time,  recovery  was  very 
complete,    no   stump  and  no  ligature  remained    behind.       Mr, 
Dorau    then    referred    to    MM.  Pean  and   Segond's  practice  of 
vaginal  liysterectomy  for  the  cure  of  pelvic  suppuration.     British 
surgeons  would  hardly  adopt  this  operation.     The  patients  often 
recovered  because  the  wholesale  cutting  allowed  the  free  escape 
of  pus.     Amputation  of  the  thigh  for  hip-joint  disease  might 
also  cure  the  patient  by  allowing  of  the  free  escape  of  pus.     In 
both  cases  good  surgery   demanded  the  same  object  by  other 
means  which  did  not  include  perilous  mutilation.     The  French 
operators  asserted  that  it  was  dangerous  to  remove  the  ovaries 
and  leave  tlie  uterus  ;  whilst,  when  the  uterus  was  removed,  even 
inflamed  appendages  underwent  atrophy.     Grammatikati,  how- 
ever, had  found,  from  after-histories  ('  British  Med.  Journal,' 
Oct.  1st,    1892,  Epitome,  p.  55),    that  the  appendages  did   not 
atrophy  under  these  circumstances.     Mr.  Doran  urged  that  when 
the  operator  found  that  the  tube  and  ovary  were  merely  bound 
down  by  adhesions,  they  should  be  set  free,  but  never  removed. 
In  five  cases  where  Mr.  Doran  had  only  separated  adhesions, 
complete  cure  from  pain  had  followed  ;  in  one  other  case  where 
he  removed   the  a])pendages  on  one  side,  and  liberated  their 
fellows  from  adhesions,  the    patient  afterwards  bore  children. 
Drainage  was  good  in  these  conservative  cases,  as  it  ensured  the 
escape  of  the  products  of  inflammation.     He  noted  how  often 
Dr.    Cullingworth  used   the    drainage-tube,    according   to    the 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  433 

tables.  This  practice  was  probably  more  justifiable  aud  impor- 
tant than  might  at  first  appear.  As  far  as  Dr.  Culliiigworth's 
practice  harmonised  with  the  simplest  principles  of  general 
surgery  as  above  explained,  so  far  would  it  abide  and  become 
established. 

Dr.  Platfaib  said  that  none  of  the  previous  speakers  seemed 
to  him  to  have  sufficiently  recognised  the  great  value  of  Dr. 
Cullingworth's  paper.  He  could  hardly  recollect  any  previous 
paper  he  had  heard  in  the  Society  in  which  more  trouble  had 
been  taken,  and  in  which  cases  had  been  more  accurately  and 
carefully  recorded.  The  subject  was  one  of  immense  importance, 
and  it  merited  the  most  careful  consideration  and  discussion. 
While  he  thus  fully  recognised  the  merit  of  Dr.  Cullingworth's 
work,  he  felt  that  his  conclusions  were  in  many  respects  open  to 
criticism.  Xor  could  he  at  all  endorse  many  of  them.  As  to 
the  general  principle  that  when  marked  structural  disease  of  the 
uterine  appendages  existed,  connected  with  suppuration,  a  free 
exit  should  be  given  to  the  pus,  and  that  such  exit  was  often 
best  obtained  by  laparotomy,  every  one  now-a-days  would 
probably  agree.  That  was  consistent  with  sound  general  surgical 
principles.  But  it  seemed  to  him  that  Dr.  Cullingworth's 
surgical  zeal  carried  him  far  beyond  this,  and  that  iiis  axioms,  if 
generally  adopted,  would  lead  to  much  rash,  hazardous,  and 
frequently  unnecessary  interference.  He  would  object  al- 
together, for  example,  to  the  acceptance  of  Dr.  Cullingworth's 
third  proposition  :  "  Where  distinct  swellings  are  found  in  the 
posterior  quarters  of  the  pelvis,  in  connection  with  recurrent 
attacks  of  pelvic  peritonitis,  surgical  relief  is  usually  indicated, 
and,  generally  speaking,  the  sooner  such  relief  is  afforded  the 
better."  Who  was  there  that  had  had  sufficiently  long  experi- 
ence of  mere  conservative  practice  who  could  not  call  to  mind 
case  after  case  of  severe  and  recurrent  pelvic  peritonitis  accom- 
panied by  complete  fixation  of  the  uterus  with  "distinct  swellings 
in  the  posterior  quarters  of  the  pelvis  "  which  nevertheless  even- 
tually completely  recovered  without  surgical  interference  of 
any  kind  ?  Would  it  not  be  easy  to  conceive  what  disastrous 
results  would  follow  if  every  youthful  and  ardent  gynaecologist 
said,  "  Here  is  a  swelling  in  the  posterior  quarter  of  the  pelvis  ; 
Dr.  Cullingworth  says  it  must  be  at  once  dealt  with,  therefore 
I  must  open  the  abdomen  "?  This  may  possibly  be  all  very  well 
with  Dr.  Cullingworth's  surgical  aptitude  and  experience,  but 
even  in  his  hands  nearly  one  out  of  every  five  of  his  patients 
died.  AVhat  would  be  the  results  in  hands  less  skilled  ?  80 
far  from  admitting  that  such  cases  should  be  interfered  with 
soon  rather  than  late,  he  believed  that  removal  of  diseased 
appendages  should  be  considered  a  dernier  instead  of  a 
premier  ressort,  and  should  be  looked  upon  as  a  confession  of 
failure  to  cure.     These  cases  rarely  proved  fatal  ^^er  se.     Doubt- 


434  VALUE    OF    ABDOMINAL    SECTION    IN 

less  they  led  to  a  vast  amount  of  pain,  suffering,  and  broken 
health,  which  very  often  fully  justified  operation,  but  they  could 
generally  wait  until  we  were  quite  sure  that  nature  could  not 
effect  a  cure.  Once  the  operation  was  done  it  could  not  be 
undone.  If,  however,  the  history  were  sufficiently  long,  and  the 
evidence  of  structural  disease  by  examination  were  clear  and 
distinct,  then  he  fully  admitted  that  laparotomy  was  a  per- 
fectly justi  liable  procedure,  and  one  which  he  himself  constantly 
resorted  to.  Take,  as  illustrations,  Cases  22,  28,  and  24,  in  Dr. 
Cullingworth's  tables.  No.  22  had  been  ill  two  weeks  only  ;  her 
symptoms  were  "  pallor,  anxious  countenance,  severe  pain,  and 
high  temperature."  Surely  these  were  very  insufficient  grounds 
for  laparotomy,  yet  this  was  done  after  an  illness  of  only  a 
fortnight's  duration.  Nothing  abnormal  was  found  beyond 
exudation,  and  even  Dr.  Cullingworth's  zeal  stopped  short  of 
removing  her  appendages.  In  less  than  a  month  the  patient  was 
discharged  well — a  result  which  would  certainly  have  followed 
had  she  been  left  alone.  So  in  22,  the  same  thing  happened  in 
an  illness  lasting  only  three  and  a  half  months,  and  in  23  the  tubes 
and  ovaries  were  removed  in  a  girl  of  eighteen  after  an  illness 
of  six  weeks,  they  are  reported  as  being  thickened  and  firmly 
adherent  ;  but  are  such  pathological  changes  certainly  incurable  ? 
All  this  indicated  very  decided  practice  no  doubt,  but  was  it 
conservative,  and  was  it  judicious  ?  Again,  no  less  than  seven  out 
of  the  fifty  laparotomies  were  in  cases  of  hajraatocele,  but  was  it 
not  the  fact  that  the  vast  majority  of  haematic  effusions  about 
the  pelvis  get  well  without  any  interference  at  all  ?  Six  more 
were  in  cases  of  "non-suppurating  salpingitis,"  a  condition 
surely  not  beyond  the  hope  of  spontaneous  cure.  He  trusted 
that  in  making  these  criticisms  on  his  friend  Dr.  Cullingworth's 
cases  he  was  not  going  beyond  the  limits  of  legitimate  discus- 
sion, but  he  felt  it  his  duty  to  point  out  that,  in  his  judgment, 
the  conclusions  arrived  at  were  such  as  could  not  be  safely 
admitted  as  correct.  The  only  other  point  he  had  to  mention 
was  Dr.  Cullingworth's  extreme  partiality  for  the  drainage-tube, 
which  was  used  in  forty-seven  out  of  the  fifty  cases.  In  his  own 
operations  he  hardly  ever  used  it,  and  yet  he  certainly  should 
have  no  fear  of  contrasting  his  own  results  with  those  which 
Dr.  Cullingworth  had  given.  He  felt  quite  confident  that  Dr. 
Cullingworth  resorted  to  drainage  with  an  altogether  needless 
frequency. 

Dr.  Champxets  sliared  in  the  feelings  of  other  speakers  who 
had  objected  to  the  title  of  the  paper.  Pelvic  peritonitis  was  a 
complication  of  a  very  large  number  of  known  diseases,  and  he 
thought  that  it  was  evident  that  a  good  many  of  these  were 
capable  of  diagnosis,  and  had  indeed  been  diagnosed  before 
operation.  Among  these  were  ovarian  tumours,  tubo-ovarian 
cysts,  and  hematoceles.     He  thought  it  was  of  some  import- 


CERTAIN    CASES    OP    TBLVIC    PERITONITIS.  435 

ance  to  point  this  out,  because  one  of  the  chief  objects  of  the 
paper  was  to  show  that  abdominal  section  was  often  called  for 
in  pelvic  peritonitis.  In  the  ordinary  sense  of  the  term  this 
was  not  the  case,  nor  did  the  cases  in  the  paper  bear  out  that 
view.  But  if  the  heading  of  the  paper  were  retained,  he  would 
ask  who  in  that  room  had  ever  seen  nine  deaths  from  pelvic 
peritonitis,  or  even  four  deaths  (the  number  of  fatal  cases  after 
operation  in  the  paper  and  appendix  respectively)  ?  Pelvic 
peritonitis  was  one  of  the  commonest  of  all  affections  of  the 
pelvis,  and  the  cases  were  rarely  dangerous  to  life.  As  regarded 
the  duration  of  the  disease  before  operation,  he  did  not  think 
that  mere  lapse  of  time  proved  the  necessity  for  operation. 
Nothing  was  commoner  than  for  patients  to  go  about  for  months 
with  this  affection,  or  to  lie  up  after  a  fashion  at  home.  When 
they  came  under  observation  the  temperature  was  raised,  and  there 
was  pain,  both  of  which  conditions  ceased  on  strict  confinement  to 
bed,  and  might  never  return  after  proper  medical  treatment. 
As  regarded  the  imminence  of  the  escape  of  pus  noted  in  some 
cases  m  the  paper,  he  did  not  think  there  was  often  any  cause 
for  alarm  even  if  this  took  place.  The  pus  escaped,  an  ordinary 
perimetric  abscess  formed  (often  with  great  rapidity),  and  its 
evacuation  was  followed  by  cure.  Haematocele  very  rarely 
justified  an  operation.  He  did  not  agree  with  the  opening  of  pelvic 
abscesses  by  abdominal  section  except  in  rare  cases.  The 
advantage  of  abdominal  section  was  the  opportunity  which  it 
gave  of  exploring ;  but  the  risk  to  life  was  considerable, 
drainage  was  in  opposition  to  gravitation,  and  the  risk  of 
ventral  hernia  was  great,  for  these  cases  necessarily  required 
drainage,  sometimes  for  a  long  while.  The  advantage  of 
superior  antiseptics  in  abdominal  opening  was  more  theoretical 
than  practical,  for  it  was  quite  easy  to  get  excellent  surgical 
results  in  vaginal  operations  if  we  knew  how  to  manage  them. 
On  the  whole,  then,  he  was  still  unconvinced  that  pelvic  peri- 
tonitis required  abdominal  section  except  in  rare  and  excep- 
tional cases. 

Dr.  Peter  Hoerocks  said  that  probably  there  had  been  a 
difficulty  in  choosing  a  title  for  the  paper  which  should  group 
these  various  cases  together,  and  no  doubt  the  title  selected  was 
open  to  criticism ;  but  at  the  same  time  there  was  this  common 
feature  about  the  cases,  that  they  all  had  more  or  less  pelvic 
peritonitis.  Whilst  agreeing  with  Dr.  John  Williams  that  the 
tendency  of  cases  of  this  kind  was  not  towards  a  fatal  issue,  still 
he  thought  it  was  justifiable  to  operate  when  there  was  constant 
complaining  of  pain.  He  did  not  think  that  these  fifty  cases 
were  such  as  could  be  cured  by  rest.  No  doubt  if  given  hospital 
rest  and  treatment  they  would  be  better  for  a  time,  but  on 
leaving  the  hospital  they  soon  relapsed,  and  so  went  from 
hospital  to  hospital  and  from  physician  to  physician.     He  con- 


436  ABDOMINAL    SECTION    IN    PELVIC    PERITONITIS. 

sidered  there  was  iuternal  evidence  to  prove  that  it  was  this 
class  of  case  that  Dr.  Cullingworth  was  treating  by  abdominal 
seetiou.  It  was  a  very  easy  matter  to  obtain  a  low  mortality  in 
abdominal  operations  by  operating  on  cases  with  little  or  nothing 
the  matter  with  them.  He  mentioned  a  case  where  the  patient 
suffered  from  leucorrhoea.  Her  ovaries  and  tubes  were  removed, 
and  of  course  the  leucorrlioea,  owing  to  the  atrophy  set  up,  dis- 
appeared. This  lie  considered  unjustifiable.  Dr.  Cullingworth's 
first  series  of  fifty  cases  had  a  mortality  of  18  per  cent.  They 
were  not  healthy  organs  with  which  he  had  to  deal,  or  he  might 
have  shown  a  much  smaller  mortality.  Some  of  the  patients 
might  prefer  to  bear  the  pain  rather  than  run  so  great  a  risk, 
but  he  considered  it  was  quite  justifiable,  after  ordinary  means 
for  relief  had  failed,  or  had  only  been  of  temporary  effect,  to 
place  the  option  of  abdominal  section  before  the  patient  with 
the  object  of  affording  permanent  relief.  In  those  cases  where 
the  Fallopian  tubes  were  distended  he  called  attention  to  the 
prominence  of  pain  as  a  symptom.  It  was  always  present ;  it 
was  that  which  drove  the  patient  to  the  doctor  ;  it  occurred 
during  the  periods  (dysmenorrhoea)  and  between  the  periods ; 
it  was  a  constant  symptom.  Menorrhagia  or  metrorrhagia  or 
both  wei'e  common,  but  not  so  constant  as  pain.  He  was  sur- 
prised to  hear  Dr.  Playfair  say  that  no  one  would  think  of 
removing  tubercular  ovaries  and  tubes.  He  mentioned  the  case 
of  a  girl  on  whom  he  operated  about  four  years  ago.  Bacilli 
were  found,  and  she  had  general  miliary  tuberculosis  of  the  peri- 
toneum in  addition  to  tubercular  disease  of  the  ovary.  She  was 
living  and  well  at  the  present  time. 


NOVEMBER    2nd,    1892. 

J.  Watt  Black,  M.D.,  President,  in  the  Chair. 

Present — 47  Fellows  and  12  visitors. 

Chai'les  William  James  Cliepmell^M.D.Brux,  (Brighton), 
was  declared  admitted  as  a  Fellow  of  the  Society. 

The  following  gentlemen  were  elected  Fellows  of  the 
Society  : — James  Henry  Ashworth,  M.D.St.  And.  (Hal- 
stead)  ;  Eobert  Davis,  M.R.C.S.  (Epsom)  ;  Herbert  M. 
Nelson  Milton,  M.R.C.S.  (Cairo)  ;  and  Walter  William 
Hunt  Tate,  M.B.Lond. 


LARGE    PYOSALPINX    SIMULATING    TUBO- 
OVARIAN    ABSCESS. 

By  Charles  J.   Cullingworth,  M.D. 

The  specimen  was  removed  by  operation  August  15th, 
1892,  from  an  unmarried  girl,  aged  21,  who  first  presented 
symptoms  of  illness  three  weeks  previously.  It  consisted 
of  an  enlarged  and  inflamed  Fallopian  tube  which  had 
become  dilated  at  its  distal  extremity  to  an  unusual 
degree,  and  contained  more  than  a  pint  of  foetid  pus. 
The  dilatation  began  so  abruptly  and  was  so  extensive 
that  the  case  was  at  first  regarded  as  a  suppurating  tubo- 
ovarian  cyst.  The  reasons  for  regarding  the  suppurating 
cavity  as  a  portion  of  the  tube  were  as  follows  : 

1.  The  lining  of  the  cavity  was  continuous  with  that  of 
the  tube. 


438    LARGE    PYOSALriNX    SIMULATING    TUBO-OVARIAN    ABSCESS. 

2.  The  microscope  showed  the  presence  of  unstriped 
muscular  tissue  in  the  cyst-wall. 

3.  The  ovary  was  quite  distinct  and  perfectly  normal. 
(It  could  not  be  shown,  as  it  remained  in  the  patient's 
abdomen.) 

The  same  reasons  went  to  show  that  it  was  not  what 
Mr.  Sutton  had  described  as  ovarian  hydrocele,  in  which 
case  the  ovary  would  have  been  found  either  in  the  cyst- 
wall  or  projecting  from  it  on  the  inner  side. 

The  specimen  was  of  considerable  importance  as  show- 
ing how  closely  a  pyosalpinx  might  simulate  a  suppurating 
tubo-ovarian  cyst.  Dr.  Cullingworth  felt  sure  that  some 
museum  specimens,  described  as  tubo-ovarian  cysts  or 
abscesses,  would  turn  out,  on  careful  examination,  to  be 
of  the  same  character  as  the  preparation  now  exhibited. 

The  tube  on  the  opposite  side  (the  left)  was  somewhat 
of  the  shape  of  a  horse-shoe,  but  more  angular.  Its  walls 
were  thickened  and  its  cavity  was  dilated  along  its  whole 
length,  occluded  at  its  distal  extremity,  and  filled  with 
pus.  The  left  ovary,  like  its  fellow  of  the  opposite  side, 
was  normal  and  was  not  removed. 

Dr.  W.  S.  A.  GrBiFFiTH  wished  to  draw  attention  to  the  fre- 
quency with  wliich  some  speakers  referred  to  "  gonorrhoeal "  sal- 
pingitis, as  if  this  were  a  cause  easily  ascertained  ;  his  experience 
being  that  it  was  neither  easy  nor  common  to  obtain  satisfactory 
evidence  of  the  gonorrhooal  origin  of  pelvic  inflammations,  and 
that  these  most  frequently  occurred  after  abortion,  labour,  and 
various  methods  of  intra-uterine  treatment,  especially  by  the  use 
of  intra-uterine  pessaries  and  tents,  in  all  of  which  the  probable 
cause  was  a  septic  one. 


439 

RUPTURED    TUBAL    PREGNANCY. 
By  AusT  Laweence,  M.D. 

Dk.  Aust  Lawrence  showed  a  specimen  of  ruptured 
tubal  pregnancy  which  he  had  removed  successfully  three 
weeks  ago. 

The  history  was  typical,  showing  the  absence  of  men- 
struation for  seven  weeks  ;  then  several  severe  attacks  of 
abdominal  pain  at  intervals  of  a  few  days,  the  passing 
of  a  membrane,  and  symptoms  of  early  pregnancy.  The 
local  condition  showed  a  fulness  in  the  right  groin  and 
to  the  side  and  front  of  the  uterus. 

Dr.  Aust  Lawrence  remarked  that,  in  all  of  the  six; 
cases  which  he  had  operated  on,  pain  was  the  earliest  and 
most  prominent  sj'mptom,  and  existed  for  some  days  (in  this 
case  seventeen  days)  before  uterine  ha3morrhage  set  in. 

He  advocated  thorough  drainage,  and,  if  necessary, 
washing  out  of   the  pelvis  in  all  these  cases. 

The  specimen  showed  the  patent  ostium  abdominale  of 
the  Fallopian  tube.  The  gestation  sac  was  partly  in  the 
tube  and  pai'tly  in  the  broad  ligament. 

The  abdomen  was  full  of  blood,  partly  liquid  and  partly 
clotted. 


HEMATOSALPINX,    HEMORRHAGIC    AND 
CYSTIC    OVARIES. 

By  Leith  Napiek,  M.D. 

Mrs,  C — ,  aged  33,  married  thirteen  years,  five  chil- 
dren ;  last  pregnancy  three  years  ago,  ended  in  abortion. 
She  had  been  regular  until  four  months  before  the  present 
illness.     Eight  weeks  before  admission,  when  at  the  time  of 


440  n.EMATOSALPlNX,     ETC. 

lier  period,  she  suffered  sudden  acute  pelvic  pain,  followed 
by  a  flow  of  bright  blood  ^>er  vaginam  ;  this  hgemorrhage, 
with  very  short  interruptions,  had  been  continuous  since. 

On  examination  the  uterus  was  found  of  normal  size  ; 
a  retro-uterine  cystic  tumour  occupied  the  left  posterior 
quarter  of  the  pelvis.  The  patient  rested  in  bed  from  the 
IStli  to  the  24th  September,  1892,  when,  declining  opera- 
tion, she  went  home.  She  returned  on  the  30th  Septem- 
ber, suffering  from  greatly  increased  left  iliac,  sacral,  and 
hypogastric  paiu.  The  haemorrhage  was  almost  arrested. 
Vaginal  examination  showed  impaired  uterine  mobility  on 
the  left  side.  There  was  tenderness  on  bimanual  examina- 
tion. A  small  cyst  of  the  left  broad  ligament  was  noted, 
also  a  tortuous  tubular  body  occupying  Douglas's  pouch, 
and  running  in  the  direction  of  the  left  and  upper  part 
of  the  true  pelvis. 

On  November  3rd  the  abdomen  was  opened,  and  a 
blood-cyst  of  the  left  broad  ligament  about  the  size  of  an 
apple,  and  both  tubes  and  ovaries,  were  removed. 

The  right  appendages  lay  behind  and  above  the  uterus, 
and  were  adherent  to  the  inflamed  structures  on  the  left 
of  the  uterus.  There  were  a  good  many  adhesions  ;  some 
of  them  were  very  firm.  The  left  appendages  with  the 
thin-walled  blood-cyst  were  then  removed. 

The  left  appendages  consisted  of  an  enlarged  ovary,  a 
dilated  Fallopian  tube,  curved  round  the  end  of  the  ovary 
and  firmly  adherent  to  it,  and  a  piece  of  broad  ligament. 
The  ovary  measured  2  inches  by  If  inches.  On  divid- 
ing it,  a  blood-clot  measuring  1\  inches  in  its  long 
diameter  was  found  ;  the  chief  part  of  the  clot  was  within 
a  cyst  of  considerable  size,  but  the  blood  had  also  entered 
the  ovarian  tissue.  There  were  three  small  blood-cysts 
in  the  cortex.  A  small  area  of  apparently  normal 
ovarian  tissue  lay  between  the  large  blood-clot  and  this 
capsule.  The  Fallopian  tube  was  tortuous  and  dilated  ; 
its  walls  were  thickened,  its  outermost  inch  was  con- 
verted into  a  nearly  globular  cyst  of  the  size  of  a 
large   cherry  ;  this   was    ruptured  on  its  upper  aspect,  it 


DERMOID    CYST,  441 

contained  a  quantity  of  firm  blood-clot.  The  cyst-walls 
showed  appreciable  thinning'  as  compared  with  the  thick- 
ened wall  of  the  tube  proper.  In  two  places  near  its 
uterine  end  the  lumen  of  the  tube  was  partially  obliterated 
by  old  adhesions.  The  abdominal  ostium  was  entirely 
occluded^  the  fimbria3  being  represented  by  a  small  tuft  on 
the  wall  of  the  tube  cyst. 

The  right  appendages  were  similarly  altered^  but  to  a 
less  marked  extent.  The  ovary  was  enlarged  and  cystic. 
The  Fallopian  tube  was  tortuous  and  dilated  with  thick- 
ened walls,  and  its  abdominal  ostium  closed  ;  it  was  curved 
back  on  itself  so  as  to  approximate  its  uterine  and 
abdominal  ends,  and  was  very  firmly  adherent  to  the 
ovary. 

The  patient  made  an  excellent  non-febrile  recovery. 

The  ovarian  tissue  was  fairly  normal ;  it  contained 
numerous  Graafian  follicles,  many  of  which  showed  thick- 
ened walls  and  considerable  dilatation.  The  sections 
made  of  the  cyst  and  its  contents,  of  which  there  were 
a  large  number,  revealed  no  trace  of  foetal  or  placental 
structures.  The  blood-clot  was  organising  in  parts,  and 
showed  a  tendency  to  break  down  in  others. 


DERMOID   CYST. 

By  A.  L.   GrALABIN,  M.D. 


VOL.    XXXIV. 


31 


442 


ADJOUENED  DISCUSSION  ON  Dk.  CULLING- 
WOETH'S  PAPEE  ON  THE  VALUE  OF  ABDO- 
MINAL SECTION  IN  CEETAIN  CASES  OF 
PELVIC  PEEITONITIS. 

De.  Geeyis,  after  paying  a  tribute  to  the  value  of  Dr.  Culling- 
wortb's  gynaecological  work  and  the  importance  of  his  present 
paper,  expressed  the  opinion  that  if  the  title  adopted  by  Dr. 
Cullingworth  for  bis  paper  were  carefully  considered  the  objec- 
tions to  it  stated  by  some  of  the  speakers  at  the  last  meeting 
would  be  much  lessened.  Dr.  Cullingwoi'th  did  not  appear  to 
propose  operative  measures  in  all  cases  of  pelvic  peritonitis,  as 
might  be  supposed  from  some  o£  the  remarks  which  had  been 
made,  but  only  in  certain  cases,  and  these  cases  would  appear 
from  the  third  of  the  series  of  propositions  Dr.  Cullingworth 
had  drafted  to  be  cases  of  "  recurrent  peritonitis,"  associated 
with  "distinct  swellings"  in  "the  posterior  quarters  of  the 
pelvis."  And  with  this  proposition  he  (Dr.  Gervis)  could  not 
hesitate  to  agree.  It  was  true  that  many  of  these  cases  were  not 
fatal ;  but  in  many  there  was  more  than  one  element  of  risk, 
and  in  all  there  was  much  positive  suffering,  and  more  or  less 
permanent  invalidism  and  disablement,  for  the  relief  of  which 
ordinary  medical  measures  were  of  little  avail.  Proposition  6, 
Dr.  Gervis  thought,  held  true  of  the  majority  of  cases  of  suppura- 
tion in  the  pelvis,  but  not  infrequently  cases  occurred  which 
might  be  opened  through  the  vagina.  On  Proposition  10  Dr. 
Gervis  would  remark  that  in  addition  to  the  causes  of  persistent 
pain  after  operation  there  noted,  actual  neuritis  from  pressure 
of  inflammatory  deposits  or  spread  of  inflammation  held  a  place, 
but  that  with  regard  to  it  the  prognosis  was  favourable.  He 
(Dr.  Gervis)  could  not  find  in  Dr.  Cullingworth's  paper  the  ten 
cases  of  hajmatocele  to  which  Dr.  J.  Williams  alluded  at  the  pre- 
ceding meeting  ;  indeed,  he  could  scarcely  make  out  Dr.  Culling- 
worth's own  number  of  five,  and  in  these  the  hsematocele  did  not 
always  appear  to  be  the  determining  cause  for  operation.  But  on 
the  general  question  of  abdominal  section  in  cases  of  hsematocele 
Dr.  Gervis  agreed  with  Dr.  Williams  that  it  was  rarely  called 
for  apart  from  the  occurrence  of  suppuration.  Dr.  Gervis  was 
also  disposed  to  agree  with  Dr.  Williams's  remarks  with  refer- 
ence to  operation  in  cases  of  salpingitis  associated  with  tubercle. 
Unfortunately,  however,  the  diagnosis  of  tubercular  salpingitis 
was  not  always  easy.  As  to  some  of  the  occasional  sequelae  of  the 
operation,  to  which  Dr.  Williams  referred  as  seriously  diminish- 


VALDE    OF   ABDOMINAL    SECTION,    ETC.  443 

ing  its  remedial  value,  such  aa  the  persistence  for  a  time  of  a 
sinus,  or  the  occurrence  of  a  hernia  in  the  line  of  incision,  Dr. 
Gervis  thought  that  although  undoubtedly  vexatious,  they  were 
hardly  of  sufficient  importance  to  outweigh  the  great  gain  attained 
by  the  procedure  in  question. 

Mr.  Mayo  Eobsox  said  that  although  he  had  not  the  advan- 
tage of  hearing  Dr.  Cullingwortb's  paper,  he  had  had  the  privi- 
lege of  reading  the  abstract  and  tables,  and  of  seeing  an  account 
of  the  discussion  on  it  at  the  last  meeting  of  the  Obstetrical 
Society.  As  he  had  had  some  experience  in  treating  the  class  of 
diseases  described,  he  thought  that  it  might  be  of  iutei'est  to  the 
Society  if  he  took  part  in  tbe  discussion  and  gave  his  own  con- 
clusions. He  found  it  somewhat  difficult  to  discuss  under  the 
one  heading  of  pelvic  peritonitis  so  many  different  diseases  as  were 
included  in  the  paper,  and  as  there  could  be  really  no  difference 
of  opinion  as  to  the  advisability  of  removing  ovarian  and  other 
cysts  associated  with  pelvic  inflammation,  which  included  half  of 
the  cases  in  Dr.  Cullingworth's  paper,  his  remarks  did  not  apply 
to  such  ;  but  he  would  state  in  passing  that  it  was  often  impossible 
to  diagnose  between  such  cysts  and  inflammatory  aftections  of  the 
appendages.  He  preferred, although  the  discussion  was  in  a  special 
Society,  to  discuss  the  matter  as  a  general  surgeon  and  on  general 
principles,  as  he  felt  sure  tliat  it  was  seldom  necessary  to  depart 
widely  from  these  in  treating  such  cases  of  localised  peritonitia. 
If  they  had  an  abscess  in  the  neighbourhood  of  the  caecum,  they 
did  not  hesitate  to  open  and  drain  it,  lest  it  burst  into  the  peri- 
toneal cavity  and  produced  death  from  general  peritonitis;  and 
why  should  there  be  any  argument  as  to  the  propriety  of  dealing 
with  a  pelvic  abscess  on  similar  principles  ?  If  a  patient  suffered 
from  recurrent  attacks  of  perityphlitis  so  called,  and  tbe  disease 
depended  on  recurring  inflammation  of  the  appendix  vermi- 
formis,  they  did  not  hesitate  to  remove  the  appendix;  this 
he  had  done  within  the  last  year  on  four  occasions,  not  only  con- 
verting chronic  invalids  into  perfectly  healthy  persons,  but  re- 
moving from  them  tlie  constant  menace  of  an  attack  more  severe 
than  usual,  which  might  end  fatally.  Why  should  anyone  argue 
that  a  similar,  though  larger,  collection  of  pus  in  the  Fallopian 
tube  should  not  be  treated  on  the  same  principles  ?  Some 
months  ago  he  saw  a  young  patient  suffering  from  frequently 
recurring  attacks  of  pain  over  the  pylorus,  associated  with 
emaciation,  and  not  yielding  to  treatment  skilfully  applied  by  the 
physician  in  charge  of  the  case.  From  the  history  he  diagnosed 
adhesions  over  the  pylorus  following  on  gastric  ulcer.  He  opened 
the  abdomen  and  separated  the  adhesions,  effecting  a  complete 
cure,  the  patient  being  now  robust  and  well.  AVhy  should  it  be 
thought  unwise  in  recurrent  pelvic  peritonitis  to  separate  adhe- 
sions, as  a  rule  far  more  extensive  than  these,  and  which  not 
only  produced  pain  lasting  for  a  week  before  and  a  week  aftei* 


444  VALUE    OP    ABDOMINAL    SECTION    IN 

each  menstrual  period,  but  which  produced  distress  on  walking 
with  pain  on  def'aecation  and  micturition  and  as  a  rule  dys- 
pareuniaand  sterility  ?  And  in  such  cases,  if  absolute  rest  and 
general  treatment  had  failed  to  relieve,  and  if  the  cause  be  dis- 
covered to  be  a  removeable  one,  why  should  one  hesitate  to  re- 
move it,  and  relieve  the  patient  from  the  life  of  a  chronic  invalid  ? 
Where  life  was  endangered,  surely  no  one  could  dispute  that  an 
operation  which  gave  a  good  chance  of  cure,  and  which  need  have 
a  mortality  of  not  more  than  5  to  7  per  cent.,  was  wise.  But  even 
where,  as  in  the  greater  number  of  cases  of  recurrent  pelvic  peri- 
tonitis, chronic  invalidism  and  suffering  were  perfectly  certain, 
and  danger  might  at  any  time  arise,  it  seemed  to  him  that  the 
patient  and  her  friends  should  join  in  the  consultation  and  help 
in  the  decision  as  to  operation  or  not ;  reproach  was  then  out  of 
the  question.  It  was  well  known  that  pelvic  haematocele  would 
nearly  always  clear  up  without  operation,  and  unless  the  tempe- 
rature and  pulse  indicated  suppuration  he  should  certainly  prefer 
to  leave  such  cases  to  nature ;  and  out  of  a  large  number  of  cases 
he  found  he  had  only  operated  on  two  such,  one  of  which  had  sup- 
purated and  burst  into  the  rectum,  threatening  death  from  hectic 
fever  and  exhaustion,  and  in  the  other  the  sac  had  become  con- 
verted into  a  horribly  foetid  collection  of  blood  and  pus.  In  the 
list  of  cases,  sixty-five  in  number,  of  which  he  had  handed  round 
a  printed  record,  it  would  be  found  that  he  had  given  details,  as 
far  as  possible  on  Dr.  Cullingworth's  lines,  of  all  his  hospital  and 
private  cases.  It  would  be  seen  that  out  of  sixty-five  cases  there 
had  been  two  deaths  referable  to  operation,  thus  giving  a  mortality 
of  3  per  cent.,  which  he  should  think  disposed  of  one  of  the 
arguments  used  by  opponents  of  the  radical  treatment  in  these 
cases.  On  several  occasions  he  had  simply  opened  and  drained 
abscesses  through  the  peritoneum  after  thoroughly  cleansing  the 
pus-containing  cavity,  and  although  in  several  such  cases  he  had 
had  brilliant  results,  he  quite  agreed  with  Dr.  CuUingworth  that 
such  a  procedure  was  not  so  satisfactory  as  removing  the  abscess 
sac,  which  was  frequently  a  distended  tube  ;  at  times,  however, 
it  must  be  the  wiser  course.  He  did  not  agree  with  those 
speakers  who  argued  that  such  abscesses  could  usually  be  safely 
attacked  from  the  vagina.  He  had  looked  through  and  carefully 
considered  Dr.  Cullingworth's  conclusions,  and  found  no  difficulty 
in  agreeing  with  them  all  in  the  main,  although  there  might  be, 
and  probably  was,  some  difference  in  the  detail  of  the  procedures 
which  they  would  each  follow  ;  for  instance,  he  seldom  flushed  out 
the  peritoneal  cavity,  and  thought  he  drained  less  frequently.  He 
did  not  agree  with  those  who  argued  that  this  class  of  cases  very 
seldom  ended  fatally  if  left  to  nature,  as  he  had  known  a  number 
so  to  do.  In  no  single  case  had  operation  been  done  without 
consultation  with  colleagues  or  other  medical  men,  and  without 
the  fullest  explanation  to  patient  and  friends  ;  and  in  no  case 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  445 

had  operative  measures  been  adopted  before  milder  means  had 
had  a  fair  trial.  Healthy  organs  bad  never  been  removed  ; 
and  if  the  disease  had  been  on  one  side  alone,  the  disease  had 
been  removed  and  the  healthy  appendage  left.  In  none  of  the 
operations  here  given  had  normal  ovaries  been  removed  for  the 
cure  of  nervous  symptoms,  as  in  the  very  few  cases  operated  on 
by  him  some  years  ago  on  this  account ;  he  found  so  little  relief 
given  that  he  had  not  been  tempted  of  late  to  try  to  eifect  a  cure 
of  these  cases  by  surgical  means.  In  all  his  cases  gross  organic 
disease,  as  shown  by  the  presence  of  a  tumour,  had  been  the 
reason  for  employing  surgical  measures,  and  he  could  not  see  why 
sentiment  should  lead  him  to  leave  diseases  which  incapacitated 
and  endangered  life  whether  he  was  dealing  with  a  Fallopian  tube 
or  a  knee-joint.  Their  role  as  surgeons  was  to  effect  a  cure,  and 
if  after  trying  medical  means  failure  was  proclaimed,  then  they 
could  with  all  justice  and  with  eveiy  show  of  reason  adopt  some 
radical  and  more  certain  method. 

Mr.  Knowsley  Thornton  said  that  he  had  taken  Dr. 
CuUingworth's  paper  and  tables  and  studied  them  carefully, 
endeavouring  to  put  himself  in  the  position  of  a  student  who 
had  to  form  an  opinion  on  these  data  alone,  and  the  result  was 
that  he  would  be  entirely  deterred  from  sanctioning  or  perform- 
ing these  operations.  First  there  was  the  terrible  mortality, 
18  per  cent.,  carrying  one  back  to  the  early  and  unsuccessful 
days  of  abdominal  surgery — a  mortality  which  could  not  in  any 
way  be  justified  by  the  mortality  of  the  diseases  themselves 
when  left  alone.  There  was  the  extraordinary  fact  that  nearly 
half  the  cases  were  incomplete ;  six  had  sinuses  and  four 
hernia,  both,  in  spite  of  what  Dr.  Grervis  had  said  to  the 
contrary,  very  real  miseries,  often  far  greater  sources  of  weak- 
ness and  pain  than  the  diseases  which  the  operations  were 
undertaken  to  cure.  He  would  not  dwell  here  upon  the 
remarkably  frequent  use  of  the  drainage-tube  and  flushing,  both 
in  his  opinion  calculated,  when  used  in  this  indiscriminate 
manner,  to  be  sources  of  danger  rather  than  of  safety.  So  much 
for  the  opinion  which  he  should  have  been  bound  to  form  if  he 
had  nothing  but  Dr.  Cullingworth's  paper  and  tables  to  guide 
him.  He  had,  however,  taken  the  trouble  to  go  over  his  own 
case-books,  and  found  that  he  had  in  the  whole  of  his  practice, 
extending  over  twenty  years,  operated  eighty-seven  times  in  this 
class  of  case  with  six  deaths,  or  a  mortality  of  about  7  per  cent. ; 
and  it  must  be  remembered  that  all  his  early  work  was  done  in 
times  far  difl'erent  from  the  present,  when  the  experience  of  many 
brilliant  surgeons  has  taught,  or  ought  to  have  taught,  those  who 
now  begin  this  work  how  to  operate  in  much  greater  safety  for 
the  patient.  In  the  whole  series  he  had  only  three  incomplete 
cases,  and  his  mortality  would  have  been  only  half  what  it 
was   if  he   had   not    resolutely   completed    three    other    cases, 


446  VALUE    OP   ABDOMINAL    SECTION    IN 

recognising  the  fact  that  these  operations,  if  only  partial, 
would  be  far  better  let  alone  altogether  for  tlie  patient's  sake. 
He  liad  begun  these  operations  with  the  enthusiasm  of  the 
young  surgeon,  he  now  performed  them  less  and  less  often, 
finding  with  increased  experience  that  natural  cures  were  far 
more  common  than  he  had  supposed,  and  that  the  results  of 
operation  were  not  always  so  brilliant  as  was  anticipated.  Care 
in  making  the  operations  aseptic,  and  especially  in  protecting 
the  transfixing  ligatures  from  any  septic  contamination,  and 
using  very  fine  pure  Chinese  twist,  lie  considered  the  chief 
elements  of  success.  Sinuses  and  pain  after  operation,  he 
believed,  both  arose  chiefly  if  not  entirely  from  septic  ligatures. 
He  had  only  had  one  persistent  sinus,  and  that  was  in  an  early 
tubercular  case  in  which  he  used  much  thicker  silk  than  he  ever 
did  now.  He  had  had  one  or  two  fsecal  fistulae,  and  one  of  his 
deaths  was  due  to  this  misfortune  ;  the  others  had  healed  spon- 
taneously. In  this  connection  he  would  point  out  that  two  of 
Mr.  Mayo  Robson's  cases  died  of  faecal  fistula,  clearly  the  result 
of  the  operation,  and  should  be  included  in  his  fatal  cases — at 
once  doubling  the  percentage  mortality,  and  bringing  it  up  very 
much  to  his  own.  He  believed  that  if  only  urgent  and  proper 
cases  were  operated  upon  it  would  never  fall  much  below  a  6  per 
cent,  level.  Were  the  diseases  for  which  the  operations  were 
undertaken  as  fatal  even  as  this  ?  He  doubted  it,  he  had  never 
seen  a  fatal  case  himself.  Dr.  John  Williams  had  seen  two, — 
surely  this  was  not  much  for  their  united  experience.  Then, 
again,  how  few  fatal  cases  were  ever  published  !  He  also  would 
greatly  discount  recurrent  peritonitis;  much  was  called  local 
peritonitis  which  had  no  claim  to  be  so  named.  He  was  frequently 
seeing  cases  said  to  be  suffering  from  recurrent  attacks  of  local 
(pelvic)  peritonitis,  but  failed  to  recognise  the  symptoms,  so  that 
when  he  was  told  cases  suffered  from  recurrent  attacks  of  this 
disease  he  was  very  sceptical,  and  he  did  not  find  many  real 
cases  of  peritonitis  in  Dr.  Cullingworth's  list.  He  doubted  the 
wisdom  or  justifiability  of  surgical  interference  in  haematocele 
unless  it  had  suppurated,  and  he  thought  many  collections  of 
pus  in  the  pelvis  were  much  better  opened  per  vaginam,  where 
drainage  was  not  against  gravity.  He  criticised  in  some  detail 
Dr.  Cullingworth's  concluding  propositions,  and  asked  on  what 
grounds  he  said  that  salpingitis  was  a  painless  affection.  The 
double  or  complete  operation  he  was  inclined  to  think  more 
satisfactory  in  the  long  run  in  most  cases,  but  some  were  quite 
successful  with  the  appendages  only  removed  on  one  side.  He 
did  not  wish  to  pose  as  the  opponent  of  all  operative  interference 
in  these  cases  ;  some  undoubtedly  demanded  operation  ;  some 
operations  were,  however,  failures  in  point  of  cure.  Others  and 
the  majority  were,  however,  brilliantly  successful.  He  would 
not,  however,  like  it  to  go  forth   from  the  Obstetrical  Society 


CERTAIN    CASES    OP    PELVIC    TERITONITIS.  447 

and  from  the  consideration  of  the  paper  that  Dr.  Culling- 
worth's  propositions  were  commended  by  all,  or  an  encourage- 
ment would  be  given  to  young  surgeons  all  over  the  country 
to  try  their  prentice  hands  at  these  admittedly  extremely  difficult 
and  dangerous  operations,  which  were,  in  his  opinion,  already 
too  common,  and  the  general  results  in  which  did  not  justify 
the  heavy  mortality  attending  them  any  more  than  the  natural 
mortality  of  the  diseases  tor  which  they  were  performed. 

Mr.  John  W.  Taylor  said  that  he  heartily  agreed  with 
the  general  tenour  of  every  one  of  the  propositions  laid  down 
by  Dr.  Cullingworth.  Whether  the  classification  of  the  cases 
on  which  they  were  founded  was  a  wise  one  or  not,  he  was 
glad  to  recognise  that  all  of  the  cases  under  discussion  were 
unmistakably  inflammatory,  and  all  resulted  in  decided  peritonitis. 
There  was  no  question  in  this  controversy  of  the  removal  of 
cirrhotic  or  cystic  ovaries.  The  discussion  was  at  least  narrowed 
down  to  the  question  of  removal  when  distinct  peritonitic 
symptoms  were,  or  had  been  present,  and  on  this  question  he 
was  largely  in  agreement  with  the  author.  The  only  fault  he 
liad  to  find  (if  he  might  presume  to  say  so)  was  that  even  now 
the  propositions  dealt  with  too  wide  a  subject — that  the  cases 
which  Dr.  Cullingworth  had  brought  forward  for  discussion  had 
only  the  clinical  feature  of  peritonitis  as  their  bond  of  union, 
and  that  one  or  two  of  the  propositions  as  applied  to  the  whole 
number  of  cases  might  be  described  as  somewhat  crude  or  rough. 
In  his  own  experience  he  found  that  gonorrhoeal  inflammatory 
disease  of  the  appendages  was  a  special  disease,  due  to  a  specific 
contagion,  possessing  many  features  in  common  with  other 
inflammatory  aflections  of  the  appendages,  but  quite  distinct 
from  them  in  its  course  and  in  its  results.  And  here  he  would 
suggest  to  Dr.  Cullingworth  that  virginity  by  no  means  pre- 
cluded the  possibility  of  this  disease.  Not  a  few  of  the  cases  of 
purulent  vulvitis  and  vaginitis  met  with  in  early  childhood  were 
found  to  be  due  to  accidental  infection,  and  such  cases  might 
result  in  typical  gonorrhoeal  pyosalpinx  years  afterwards,  when 
the  primary  disease  had  been  lost  sight  of.  If  the  disease,  then, 
be  a  distinct  and  special  one,  equally  distinct  and  definite  should 
be  the  rules  governing  its  treatment.  It  was  to  this  disease 
(because  it  was  a  contagious  one,  and  the  uterus  as  a  centre  of 
contagion  was  always  left  behind)  that  the  advice  of  complete 
removal  of  the  appendages  on  both  sides  peculiarly  applied.  If 
operation  be  -required  at  all  in  this  disease  it  needed  to  be 
thorough.  Though  only  one  tube  and  ovary  appeared  to  be 
involved,  if  the  cause  be  gonorrhoeal  the  appendages  on  both 
sides  should  in  his  opinion  be  removed.  He  had  never  known  a 
tube  and  ovary  left  in  the  operative  treatment  of  this  disease 
without  a  more  or  less  disappointing  sequel.  On  the  other  hand, 
not  all  inflammatory  affections  of  the  appendages  were  gonor- 


448  ,      VALUE    OF    ABDOMINAL    SECTION    IN 

rhoeal.  The  naked-eye  characters  might  be  almost  identical :  there 
might  be  extensive  adhesions,  abscess  of  the  ovary,  or  a  limited 
purulent  peritonitis  around  the  appendages  (such  cases  were  not 
uncommon  after  parturition,  or  might  occur  in  the  course  of  the 
exanthemata,  or  might  result  from  an  inflamed  ovarian  cyst  or  a 
suppurating  hsematocele).  Then  he  believed  that  the  nature  of  the 
case  was,  and  its  treatment  should  be,  radically  different.  Here, 
if  the  inflammatory  aft'ection  were  confined  to  one  side  of  the 
pelvis,  there  would  be  no  need  to  remove  the  appendages  of  the 
opposite  side.  He  found  that  such  cases  made  good  and  per- 
manent recoveries  when  the  operation  was  strictly  limited  to  the 
visible  site  of  disease,  many  of  the  patients  continuing  fertile 
and  becoming  repeatedly  pregnant  after  the  operation  for  the 
original  inflammatory  attack  and  consequent  peritonitis.  This 
was  a  distinction  which  he  believed  to  be  insufficiently  recognised, 
and  which  had  a  most  important  bearing  on  their  practice.  He 
could  not  agree  with  those  speakers  who  urged  that  operative 
treatment  sbould  be  withheld,  and  only  used  as  a  last  resort. 
This  would  foster  a  practice  which  was  always  attended  by  bad 
results  and  surgical  discredit.  Those  who  had  frequently  to 
operate  for  the  conditions  under  discussion  were  taught  by  ex- 
perience when  operation  was  required  and  when  it  was  best 
undertaken;  and  although  "  practice  makes  perfect,"  and  cases 
which  at  first  it  seemed  impossible  to  do  anything  with  became 
comparatively  easy  as  time  went  on,  they  could  not  allow,  iu 
justice  to  their  patients  or  themselves,  that  only  cases  of  last 
resort  should  have  the  benefit  of  their  skill.  His  own  practice 
on  diagnosing  a  case  of  acute  or  subacute  tubal  disease,  unless 
there  be  special  urgency  was  to  send  the  patient  to  bed  for  a 
fortnight  or  a  month,  administering  bromides.  If  at  the  end  of 
that  time  there  be  no  improvement  an  operation  was  usually 
necessary.  The  circumstances  of  the  patient  were  sometimes  of 
first  importance.  The  case  of  a  wife,  for  example,  who  had 
contracted  gonorrhceal  salpingitis  through  no  fault  of  her  own, 
and  was  subsequently  deserted  by  her  husband  ;  who  struggled  to 
maintain  herself  and  her  children,  but  lost  situation  after  situa- 
tion on  account  of  recurrent  attacks  of  peritonitis,  called  for 
radical  treatment  and  cure  with  no  uncertain  voice.  On  such  a 
case  he  had  operated  yesterday,  and  he  had  great  reason  to 
hope  that  the  operation  would  enable  the  patient  to  earn  her 
own  living,  and  keep  herself  and  children  out  of  the  work- 
house. If  Dr.  Cullingworth  would  allow  him  to  say  so, 
he  thought  his  operation  mortality  would  be  considerably 
reduced  as  time  went  on.  Acute  pyosalpinx  must  always  be 
dangerous,  but  the  operative  removal  of  the  more  chronic 
collections  of  pus  should  be  almost  uniformly  successful.  In  his 
own  hospital,  where  operations  for  these  diseases  were  not  in- 
frequent, one  of  the  operating  staff"  had  worked  for  upwards  of 


CERTAIN    CASES    OF    PELVIC    PERITONITIS.  449 

two  years  without  a  death,  and  another  had  a  simihir  record  for 
upwards  of  a  year.  He  had  but  little  doubt  that  from  the 
practice  of  these  two  surtreons  a  list  of  fifty  consecutive  cases 
might  be  compiled,  all  of  which  had  been  successful.  With 
Dr.  Culliugworth's  remarks  regarding  operative  dangers  and 
detail  he  entirely  agreed.  The  rectum  on  the  leftside  was  a  fre- 
quent source  of  danger  and  difficulty.  It  was  usually  involved  in 
the  adhesions,  and  its  separation,  as  a  structure  not  to  be  re- 
moved, from  an  hypertrophied  tube  and  bag-like  ovary  was  often 
very  difficult.  The  fact  that  the  permanent  attachments  of  the 
rectum  were  posterior,  while  those  of  the  ovary  and  tube  were 
anterior,  was  of  considerable  help  when  the  main  adhesions  to  the 
back  of  the  uterus  had  been  broken  down  and  separated.  All 
of  these  cases  where  extensive  adhesions  were  undone  needed 
drainage.  Dr.  Culliugworth's  practice  in  this  respect  was,  in  his 
opinion,  entirely  to  be  commended. 

Dr.  Hetwood  Smith  said  that  some  months  ago  Dr.  John 
Williams  and  Dr.  Champneys  had  issued  a  quasi-authoritative 
manifesto,  wherein  they  feebly  attempted  to  apply  the  brake  to 
the  advanced  gynaecology  of  the  present  day,  and  after  the  speech 
they  had  just  heard  from  Mr.  Thornton  they  must  reckon  him 
as  a  third  who  upheld  a  retrogressive  policy  with  regard  to  the 
subject  that  was  under  discussion.  Mr.  Thornton  had  referred 
to  ventral  hernia  as  of  frequent  occurrence  and  of  grave  import, 
but  such  a  sequence  did  not  often  happen,  and  was  in  no  way  to 
be  weighed  against  the  chronic  invalidism  and  pain  that  the 
operation  was  intended  to  obviate ;  and  as  to  calling  it  an 
operation  of  "  expediency,"  it  was  in  most  cases  an  operation  of 
necessity.  He  entirely  agreed  with  Dr.  Culliugworth's  sixth  pro- 
position, that  "it  is  safer  to  attack  cases  of  pelvic  suppuration  from 
above  than  from  below^"  Some  of  those  who  had  attended  the 
Congress  at  Brussels  had  seen  M.  Segond  do  Pean's  operation  on 
a  case  of  ovarian  abscess.  He  first  of  all  removed  a  uterus 
morcellement,  and  then  proceeded  to  puncture  the  abscess — a 
method  they  had  considered  wholly  unjustifiable.  M.  Segond 
contended  that  the  removal  of  the  uterus  caused  the  uterine 
appendages  to  dwindle  ;  but  they  would  require  a  large  number 
of  necropsies,  after  a  long  interval  of  time,  before  they  would 
be  in  a  position  to  prove  such  a  statement.  Then,  again,  with 
regard  to  what  Dr.  Champneys  had  said  as  to  drainage  per 
vaginam  being  more  favourable  owing  to  gravity,  they  must 
remember  that  when  a  woman  was  lying  supine  the  drainage- 
tube  was  not  wholly  in  a  position  downwards.  Mr.  Thornton 
had  said  that  few  patients  died  in  these  cases  if  left  alone.  He 
would  like  to  know  on  what  grounds  Mr.  Thornton  made  that 
most  extraordinary  statement. 

Mr.  Skexe  Keith  drew  special  attention  to  the  length  of  time 
which  often  elapsed  before  recovery  was  complete  after  these 


450  VALUE    OF    ABDOMINAL    SECTION    IN 

operations.  Patients  were  frequently  under  tlie  impression  that 
after  operation  they  would  be  well  in  a  few  weeks.  If,  however, 
they  understood  that  instead  of  weeks  it  might  be  many  months 
before  tlie  return  to  health  would  be  perfect,  they  would  be  more 
willing  to  try,  in  the  first  place,  what  rest  would  do.  He 
strongly  advised  complete  rest  combined  with  general  treatment 
in  all  cases  where  there  seemed  to  be  any  chance  of  recovery 
without  undergoing  a  mutilating  operation ;  for  unless  the 
ovaries  were  hojjelessly  diseased  their  removal  was  a  grave 
injury.  At  the  t-nd  of  six  months  comparatively  few  of  these 
operation  cases  were  quite  well,  while  at  the  end  of  two  years 
the  results  would  be  found  to  be  very  satisfactory. 

Dr.  CuLLiNOW'ORTH,  in  reply,  thanked  the  Society  for  the  con- 
sideration that  had  been  given  to  his  paper,  and  the  length  of 
time  that  had  been  devoted  to  its  discussion.  Before  answering 
the  various  speakers  he  wished  to  remind  the  Fellows  that  the  dis- 
cussion had  necessarily  taken  place  under  disadvantageous  cir- 
cumstances. The  chief  value  of  the  paper  consisted  in  the  full 
clinical  and  pathological  details  it  contained  of  each  of  the  fifty 
cases  in  the  printed  table.  Those  details  were  not  yet  before 
them.  The  paper  was  much  too  long  to  be  read  in  extenso,  and 
had  only  been  presented  to  the  meeting  in  a  greatly  abbre- 
viated form.  It  was  next  to  impossible  to  give  a  satisfactory 
clinical  picture  of  a  case  either  in  the  form  of  a  table  or  a  sum- 
mary. When  his  critics  were  put  in  possession  o£  all  the  facts, 
which  they  would  be  shortly,  for  the  Council  had  generously 
undertaken  to  publish  the  full  text  of  the  paper  in  the  '  Trans- 
actions,' they  would  find  that  many  of  their  criticisms  were 
founded  on  a  misapprehension. 

The  objection  raised  by  Dr.  John  Williams  and  others  to  the 
title  of  the  paper  had  already  been  met  to  a  certain  extent  by 
Dr.  Gervis.  He  (Dr.  (JuUiugworth)  did  not  know  any  other 
title  that  would  have  been  sufficiently  distinctive  on  the  one 
baud,  or  sufficiently  comprehensive  on  the  other.  Pelvic  peri- 
tonitis was  the  oue  condition  that  was  common  to  all  the  cases. 
The  object  of  the  paper  was  to  show  that,  underlying  many  cases 
of  pelvic  peritonitis,  especially  where  the  inflammation  was  re- 
current, there  was  definite  disease  which  could  only  be  properly 
dealt  with  by  surgical  means.  The  fact  of  recurrence  showed 
persistent  irritation,  and  the  cases  here  presented  went  to  prove 
that  the  source  of  irritation  was  often  a  deep-seated  suppuration, 
either  in  the  tube,  or  in  the  ovary,  or  in  both.  The  words 
"  certain  cases  "  in  the  title  were  intended  to  limit  the  discussion 
to  those  cases  in  which  there  was  a  definite  swelling  in  one  or 
both  sides  of  the  pelvis.  It  was  in  those  onjy  that  he  advocated 
and  practised  abdominal  section. 

With  regard  to  many  of  the  operations  having  been  performed 
for  new  growths,  this    was  perfectly  true,  but  it  was  not  true 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  451 

that  these  were  cases  which  every  one  would  have  recognised  and 
operated  upon.  Of  new  growths  in  tlie  sense  of  tliere  being  a 
clearly  defined  abdominal  or  pelvic  tumour,  there  were  none ; 
and  in  not  a  single  instance  had  the  presence  of  a  new  growth 
been  previously  suspected,  either  by  the  patient  lierself  or  any- 
one else.  It  was  one  of  the  surprises  that  a  series  of  cases  like 
this  brought  out,  that  the  source  of  the  inflammation  in  many 
cases  of  recurrent  pelvic  peritonitis  was  suppuration  of  an  unsus- 
pected ovarian  cyst.  Such  cases  had  hitherto  been  diagnosed 
and  classified  uuder  the  vague  heading  of  pelvic  abscess.  When 
they  came  under  observation  the  signs  of  tumour  were  masked 
by  the  matting  and  exudation  due  to  the  secondary  peritonitis, 
and  by  the  co-existence  of  inflammatory  disease  of  neighbouring 
parts.  The  number  of  cases,  in  his  own  necessarily  limited 
experience,  in  which  new  growths  had  been  found  at  the  time  of 
operation  was  a  revelation  to  him.  In  many  cases  of  pelvic  peri- 
tonitis, the  swellings,  instead  of  disappearing  as  the  acute  attack 
subsided,  often  continued  to  grow  and  give  trouble.  The  ex- 
planation was  that,  in  these  cases,  the  lumps  were  not  masses  of 
inflammatory  exudation,  as  they  were  popularly  supposed  to  be, 
but  new  growths  in  a  state  of  inflammation.  Amongst  the  fifty 
cases  tabulated  there  were  no  fewer  than  nineteen  in  which  new 
growths  were  present.  Of  tliese  fourteen  were  suppurating  ovarian 
cysts,  and  five  were  ovarian  cysts  that  had  become  inflamed,  one 
of  them  in  consequence  of  intra-cystic  haemorrhage,  and  the  re- 
maining four  owing  to  inflammatory  disease  of  neighbouring  parts. 
Of  course,  as  experience  was  gained,  one  could  often  predict  with 
an  approximation  to  certainty  that,  in  the  midsbof  a  given  pelvic 
swelling,  such  and  sucli  a  definite  mass  of  disease  would  be  found. 
In  other  words,  these  operations  had  added  to  our  knowledge 
and  improved  our  diagnosis  of  pelvic  disease. 

He  would  refer  any  of  the  Fellows  who  were  interested  in  this 
question  to  a  series  of  six  cases  of  abdominal  section  for  peri- 
tonitis due  to  suppuration  of  previously  unsuspected  cysts  of  the 
ovary,  which  happened  to  be  all  under  treatment  at  the  same 
time',  and  which  he  had  reported  in  the  '  Lancet '  ("  Mirror  of 
Hospital  Practice")  for  the  first  two  weeks  of  July  of  the 
current  year.  There  would  be  found  in  that  series  two  remark- 
able cases  in  which  the  patient  was  suddenly  seized  with  sym- 
ptoms of  acute  pelvic  peritonitis.  It  was  determined  to  open 
the  abdomen  in  order  to  avert,  if  possible,  a  fatal  termination 
which  otherwise  seemed  inevitable.  Neither  of  the  patients 
knew  anything  of  any  tumour ;  yet,  on  opening  the  abdomen, 
€ach  was  found  to  have  not  one,  but  two  large  suppurating  ovarian 
cysts,  one  on  each  side  of  the  body.  The  signs  of  their  presence 
were  indeed  obscured  by  the  inflammation  and  matting  to  which 
they  had  given  rise,  and  the  operation  for  their  removal  pre- 
aented  unusual  difficulty. 


452  VALUE    OF    ABDOMINAL    SECTION    IN 

But  once  the  removal  accomplislied,  and  the  immediate  risks  of 
the  operation  survived,  these  two  women  were  quickly  restored 
from  a  condition  of  extreme  danger  to  one  of  almost  perfect 
health  and  comfort. 

Dr.  AVilliams  had  spoken  of  ten  cases  of  hsematocele.  This 
was  evidently  an  error,  as  there  were  not  more  than  eight,  even 
if  a  case  of  hsematoma  of  the  broad  ligament  were  included. 
The  eight  cases  included  Nos.  11,  14,  22,  23,  31,  34,  44,  and  47. 
In  No.  11  a  small  haematocele  had  formed  at  the  mouth  of  each 
Fallopian  tube,  the  haemorrhage  having  obviously  been  a  mere 
incident  in  tbe  course  of  a  chronic  salpingitis.  In  No.  14  there 
was  a  small  suppurating  hajmatocele  on  one  side,  connected  with 
purulent  salpingitis  of  the  same  side.  No.  22  was  a  case  in 
wliich  an  exploratory  operation  was  performed  for  what  was 
thought  to  be  pelvic  suppuration.  Tlie  left  broad  ligament 
proved  to  be  the  seat  of  the  swelling,  the  cliaracters  of  which  led 
to  the  diagnosis  of  a  hematoma.  The  abdomen  was  thereupon 
closed.  The  diagnosis  was  afterwards  confirmed  by  the  spon- 
taneous disappearance  of  tlie  swelling.  The  patient  did 
perfectly  well.  No.  23  was  also  a  case  of  doubtful  diagnosis  ; 
after  missing  two  menstrual  periods  the  patient  had  had  con- 
tinuous uterine  haemorrhage  for  three  and  a  half  months,  and 
there  was  an  oval  swelling  the  size  of  an  orange  behind  the 
uterus  and  left  broad  ligament.  The  swelling  proved  to  be  an 
old  hsematocele,  probably  the  result  of  a  so-called  tubal  abortion. 
No.  31  was  a  case  in  which  an  exploratory  incision  was  made  on 
account  of  a  pelvic  swelling  and  almost  complete  disablement, 
persisting  six  months  after  the  disappearance  of  an  unusually 
extensive  haematocele.  Nothing  was  found  except  pelvic 
adhesions  and  the  remains  of  the  old  hsematocele.  One  of  the 
ovaries  was  damaged  during  the  separation  of  the  adhesions,  and 
had  to  be  removed.  In  the  remarks  appended  to  the  report  of 
this  case,  he  had  acknowledged  that  the  patient,  who  had  made 
an  excellent  recovery,  would  have  done  just  as  well  without  any 
operation.  In  No.  34  there  was  a  haematosal[)inx  on  one  side,  and 
a  hajmatocele  on  the  other,  the  latter  being  due  to  haemorrhage 
into,  and  subsequent  rupture  of,  a  cyst  of  the  broad  ligament.  The 
blood  was  cleared  out,  the  diseased  parts  removed,  and  the 
patient,  who  was  e.xceedingly  ill  before  operation,  made  an 
excellent  recoveiy.  No.  44  was  the  case  of  a  patient  who  had 
been  ill  for  two  years,  and  who,  after  improving  greatly  under  a 
course  of  hospital  treatment,  was  readmitted  three  months  later, 
having  been  laid  up  ever  since  her  discharge.  There  was  a 
pelvic  swelling  on  the  right  side,  and  operation  was  advised. 
The  right  tube  was  distended  with  blood-clot,  and  measured 
5f  inches  in  circumference.  Outside  the  tube  there  was  a 
quantity  of  firm  clot.  There  was  some  suppuration  during 
convalescence,  but  the  patient  was  able  to  leave  the  hospital  in 


CERTAIN    CASES    OP    PELVIC    PERITONITIS,  453 

a  month,  and  three  weeks  later  the  sinus  closed  and  recovery 
was  complete.  The  last  case,  No.  47,  was  also  a  hajmatosalpinx 
communicating  with  a  small  haematocele  amongst  old  pelvic 
adhesions,  in  a  patient  the  subject  of  tubal  disease  of  six  years' 
duration.  She  made  an  excellent  recovery  after  the  operation, 
and  went  home  well.  It  would  thus  be  seen  that  not  one  of  the 
eight  cases  was  a  typical  haematocele,  or  was  operated  upon 
under  the  supposition  that  a  haematocele  was  present.  The  few 
operations  that  he  had  performed  for  hsematocele  had  been  in- 
tentionally omitted  from  the  paper,  as  not  coming  within  its 
scope.  The  subject  might  perhaps  be  profitably  discussed  on 
another  occasion. 

Much  had  been  said  by  Dr.  "Williams  and  others  about  the 
mortality.  The  mortality  in  the  first  series  of  fifty  cases  was  9 ; 
in  the  second  (mentioned  in  the  postscript),  4.  Dividing  these 
into  groups  of  twenty-five,  the  mortality  was  as  follows  : — In  the 
first  twenty-five  7,  in  the  second  2,  in  the  third  4,  in  the  last  none. 
The  mortality  of  the  first  twenty-five  might  be  reasonably 
regarded  as  the  result  of  inexperience,  and  that  of  the  last 
seventy-five,  viz.  8  per  cent.,  as  representing  his  present  mortality. 

In  connection  with  this  question  of  mortality  it  should  be 
stated  that,  of  the  fifty  patients,  fifteen  were  so  ill  at  the  time 
of  operation  that  it  was  evident  to  all  who  saw  them  that  a  fatal 
issue  was  rapidly  approaching.  Gf  these  fifteen,  four  died.  In 
other  words,  the  attempt  to  save  life  was  successful  in  eleven 
of  the  fifteen  cases,  and  unsuccessful  in  four.  Of  the  other  five 
patients  who  died,  four  were  totally  incapacitated  for  work  of 
any  kind  ;  and  the  fifth,  though  able  to  do  light  work  occasionally, 
was  laid  aside  by  an  attack  of  pelvic  inflammation  every  few  days. 

Dr.  AVilliams  had  said  that  the  mortality  diminished  as  the 
operation  came  to  be  performed  for  conditions  more  nearly 
approaching  those  of  health.  He  (Dr.  Cullingworth)  thought 
that  the  insinuation  conveyed  in  this  statement  was  unfair.  It 
was  not  the  case  that  his  later  and  more  successful  operations 
were  undertaken  for  less  serious  conditions,  or  w^ere  in  any 
degree  less  complicated  or  less  difficult  than  his  earlier  ones.* 

Dr.  Williams  had  referred  to  a  paper  by  Schmalf  uss  as  con- 
taining the  only  reliable  account  with  which  he  was  acquainted 
of  the  proportion  of  cases  in  which  pain  persisted  after  these 
operations.  He  held  in  his  hand  a  copy  of  Schmalfuss's  paper. 
The  title  of  it  was  "  Castration  for  Neuroses."  The  object  of 
Hegar's  operations  there  recorded  had  nothing  in  common  with 
the  object  he  (Dr.  Cullingworth)  had  in  view  m  the  operations 

*  Dr.  "Williams,  who  was  unable  to  be  present  at  the  adjourned  discussion, 
has  since  assured  me  that  he  did  not  intend  this  remark  to  apply  to  my  cases. 
I  accept  this  disclaimer  with  much  pleasure,  but  as  the  remark  lias  been  made 
public,  I  think  it  right  that  my  reply  should  have  equal  publicity. — C.  J.  C, 


454  VALUE    OF   ABDOMINAL    SECTION    IN 

described  iu  liis  paper.  When  an  operation  was  undertaken  for 
the  relief  of  pain,  irrespective  of  any  obvious  lesion,  the  operator 
must  be  prepared  for  disappointment.  On  the  other  hand,  where 
there  was  obvious  disease,  extirpation  of  the  source  of  inflamma- 
tion invariably  cured  the  patient,  provided  she  survived  the 
operation.  The  occurrence  of  a  little  subsequent  pain  no  more 
constituted  a  failure  than  did  the  occurrence  of  a  siiooting  pain  in 
the  mamma  after  the  removal  of  a  cystic  tumour  of  that  organ.  As 
a  matter  of  fact,  persistent  pain  had  been  met  with  in  singularly 
few  of  his  cases.  In  one  it  was  clearly  feigned,  and  in  the  rest 
the  patients  were  of  a  distinctly  neurotic  type,  and  their  improved 
general  condition  showed  the  pain  to  have  no  serious  significance. 
The  few  instances  of  hernia  and  unhealed  sinuses  occurred  in 
cases  where,  from  special  circumstances,  collections  of  matter 
were  drained  instead  of  being  extirpated.  In  such  cases  hernia 
was  almost  inevitable. 

Dr.  Williams  had  noted  that  two  cases  required  a  second 
operation.  In  both  cases  the  fault  lay  not  with  the  operation, 
but  with  the  operator.  The  cases  were  early  ones,  and  he  had 
not  acquired  the  requisite  boldness.  Hence  the  need  for  a  second 
operation,  which  iu  both  instances  cured  the  patient. 

He  could  not  agree  with  Dr.  Williams  that  an  after  history  of 
twelve  months  was  insufficient  to  decide  whether  or  not  an 
operation  of  this  kind  had  been  successful.  In  19  of  his  cases, 
however,  he  had  tidings  of  them  after  a  longer  period.  Thus 
11  patients  had  reported  themselves  between  one  and  two  years 
afterwards,  3  between  two  and  four,  2  between  four  and  five, 
and  3  upwards  of  five  years.  Of  the  rest,  the  majority 
had  reported  themselves  at  varying  periods  within  the  year,  and 
the  remainder,  about  eight  in  number,  might  fairly  be  considered 
cured,  for  his  experience  of  these  patients  was  that  they  came 
up  if  they  found  the  least  cause  for  anxiety.  Some  had  been 
traced  since  the  paper  was  handed  in,  and  a  note  of  their  condi- 
tion would  be  added  in  correcting  the  proof. 

The  cases  selected  by  Dr.  Williams  for  special  comment  pre- 
sented difiiculties  only  because  the  Eellows  were  not  as  yet  in 
possession  of  the  full  record.  He  would  not,  therefore,  occupy 
the  time  of  the  meeting  by  going  into  them. 

The  cases  which  Mr.  Doran  had  held  up  as  the  few  examples 
in  the  list  of  really  good  surgery  were  just  those  of  which  he 
(Dr.  Cullingworth)  was  not  particularly  proud.  They  were 
cases  of  simple  evacuation  and  drainage  of  suppurating  cavities, 
where  the  source  of  suppuration  was  not  removed.  Such  treat- 
ment involved  prolonged  suppuration,  weeks  or  months  of  bed, 
an  incomplete  cure,  and,  owing  to  the  impossiblity  under  such 
circumstances  of  satisfactory  healing  of  the  abdominal  wound, 
sooner  or  later  a  hernial  protrusion.  He  knew  better  now  than 
to  leave  suppurating  cysts  stitched  to  the  abdominal  parietes  if 


CERTAIN    CASES    OP    rELV'lC    PERITONITIS.  455 

they  could  possibly  be  removed  ia  their  eutirety.     rormidable 
adhesions  did  not  frighten  him  as  they  once  did. 

Mr.  Doran  expressed  surprise  that  iu  Case  39,  where  there 
was  a  communication  between  the  suppurating  cyst  and  the 
rectum,  separation  and  removal  of  the  cyst  were  accomplished 
without  the  occurrence  of  a  fjecal  fistula.  If  Mr.  Doran  would 
refer  to  Case  25,  he  would  find  the  same  good  result  followed  a 
similarly  bold  procedure  there,  and  he  would  also  note,  on  refer- 
ring to  Case  48,  that  a  communication  with  the  vagina  gave  no 
further  trouble  after  the  removal  of  the  adherent  cyst.  The 
fact  was  that  such  openings  closed  of  their  own  accord,  so  to 
speak,  as  soon  as  the  source  of  suppuration  was  removed. 

"With  regard  to  Pean's  method  of  treating  these  cases  by 
vaginal  hysterectomy,  which  had  been  advocated  by  Segond  at 
the  Brussels  Congress,  he  entirely  agreed  with  the  objections 
Mr.  Doran  had  indicated.  There  was,  however,  another  even 
stronger  objection.  In  the  cervical  canal  the  uterus  possessed 
an  outlet  for  its  discharges,  and  therefore  suppurative  inflamma- 
tion of  its  lining  membrane  would  not  go  on  indefinitely  as  in 
the  case  of  the  Fallopian  tube,  which  had  practically  no  outlet 
at  all,  or  only  in  a  vicious  direction.  The  argument,  therefore, 
that  the  uterus,  being  the  starting-point  of  the  pelvic  suppura- 
tion, should  be  the  first  object  of  attack,  fell  to  the  ground.  It 
was  well  known  that  one  portion  of  a  mucous  tract  might  be 
recovering  while  another  was  acutely  inflamed,  and  this  was 
what  was  constantly  happening  in  the  case  of  the  genital  tract. 

Notwithstanding  IMr.  Doran's  cautious  attitude  in  this  dis- 
cussion, he  had  not  always  spoken  so  uncertainly.  In  a  paper 
published  in  the 'Transactions  ot"  the  Medical  Society  of  London' 
(vol.  xiv,  1S91,  p.  245)  Mr.  Doran  wrote  as  follows  : — "  Oopho- 
rectomy [by  which  name  Mr.  Doran  persisted  in  speaking  ot" 
this  operation,  although  the  removal  of  the  ovaries,  so  far  from 
constituting  the  operation,  was  not  always  an  essential  part  of 
it]  is  the  best  operation  in  a  large  class  of  chronic  cases  where 
subacute  seizures  occur  frequently  and  at  gradually  shortening 
intervals,  and  where  careful  bimanual  palpation  proves  the  exist- 
ence o£  a  mass,  usually  tender,  on  one  or  both  sides  of  the 
uterus.  The  tube  and  ovary  are  degenerate  and  useless.  The 
more  cystic  they  become,  the  more  discomfort  they  cause,  and 
the  more  probably  will  they  form  adhesions  to  intestine,  omen- 
tum, &c.  Pyosalpinx,  a  not  unfrequent  complication,  is  in  itself 
a  source  of  danger  to  the  patient.  The  healtli  suffers,  the 
patient  is  crippled,  and,  if  poor,  incapacitated  from  earning  her 
bread."  He  thought,  after  that,  be  might  venture  to  claim 
Mr.  Doran  as  a  supporter. 

The  necessity  of  invoking  the  aid  of  gravitation  in  order  to 
obtain  efficient  drainage  was  a  notion  that  had  long  since  been 
exploded,  and  he  was  surprised  to  hear  Dr.  Champneys  advo- 


456  VALUE    OF    ABDOMINAL    SECTION    IN 

eating  the  treatment  of  pelvic  suppuration  per  vaginam  on  that 
ground.  Experience  had  abundantly  proved  that  the  force  of 
intra-abdominal  pressure  (a  force  which  was  often  greatly  under- 
estimated) was  amply  sufficient  to  drive  all  the  fluid  out  of  the 
abdominal  cavity  as  fast  as  it  accumulated,  if  only  a  means  of 
exit  were  provided.  The  fluids  effused  would  pass  upwards 
through  the  lower  angle  of  the  abdominal  wound  quite  as  readily 
as  through  the  vaginal  roof  It  was  unnecessary  even  to  use  a 
syringe. 

As  to  the  opening  of  pelvic  abscesses  from  below,  the  proceed- 
ing was  both  dangerous  and  inefficient.  It  was  far  easier  to  keep 
the  abdominal  wound  aseptic  than  to  ensure  the  asepticity  of  a 
wound  in  the  vaginal  roof  or  in  the  rectum.  The  inefficiency  of 
the  method  could  be  shown  by  reference  to  one  of  the  cases  in 
the  table  (No.  48).  In  that  case  there  was  a  sinus  in  the 
vaginal  roof  communicating  with  an  abscess  cavity  in  Douglas's 
pouch.  The  temptation  was  great  to  treat  the  case  by  enlarg- 
ing the  opening  and  washing  out  and  draining  the  cavity.  He 
decided,  however,  to  approach  the  disease  from  above,  and  found, 
as  he  anticipated,  a  large  suppurating  ovary,  which  he  succeeded 
in  separating  and  removing.  On  examining  the  specimen  the 
vaginal  sinus  was  found  to  communicate  w^ith  only  one  of  a 
number  of  abscesses,  with  which  the  whole  ovary  was  beset. 

Had  he  been  content  with  enlarging  the  vaginal  sinus,  little  or 
no  relief  would  have  been  given,  for  only  one  of  many  abscess 
cavities  would  have  been  laid  open.  Evidently  the  true  surgical 
method  was  to  eradicate  the  whole  of  the  disease.  In  Case  41 
a  similar  condition  of  the  ovary  was  found,  and  it  would  have 
been  equally  impossible  to  deal  efficiently  with  it  by  opening  it 
from  below.  To  Dr.  Champneys'  statement  that  pelvic  peri- 
tonitis was  rarely  dangerous  to  life  he  listened  with  still  greater 
amazement.  Either  Dr.  Champneys  was  not  talking  about  the 
same  thing  as  he  was,  or  had  shut  his  eyes  to  facts.  Then 
Dr.  Champneys  said  that  a  number  of  these  cases  were  ordinary 
cases  of  pelvic  abscess.  If,  by  that,  he  meant  abscesses  in  the 
connective  tissue,  he  was  mistaken  ;  there  was  no  such  case  in 
the  list.  If  he  meant  pelvic  suppuration,  of  whatever  kind,  of 
course  it  was  open  to  Dr.  Champneys  to  adopt  the  vague  name 
of  pelvic  abscess  if  he  preferred  it.  He  (Dr.  Cullingworth) 
thought  the  phrase  should  be  restricted  to  cases  in  which  the 
source  and  seat  of  suppuration  remained  undiscovered. 

Most  of  Dr.  Playfair's  criticisms  were  based  on  a  classified 
list  of  the  various  conditions  found  when  the  abdomen  was 
opened.  8uch  criticisms  were  easy  enough.  When  Dr.  Play- 
fair  came  to  read  the  full  details  he  would  be  the  first  to 
acknowledge  that,  in  almost  every  case,  there  were  good  grounds 
for  operating.  As  to  the  too  great  readiness  to  operate,  with 
which  Dr.  Playfair  seemed  disposed  to  charge  him,  he  could  not 


CERTAIN    CASES    OP    PELVIC    PERITONITIS.  457 

belp  thinking  that,  if  he  had  been  destined  ever  to  succumb  to 
the  operating  mania,  he  would  have  fallen  a  victim  to  it  some- 
what earlier  in  life.  He  was  exceedingly  glad  to  hear  the  remarks 
of  Mr.  Mayo  Kobson,  for  he  liad  looked  at  the  question  from  the 
point  of  view  of  a  general  eurgeon,  and  had  supported  the  conten- 
tion of  the  paper  as  being  in  accord  with  ordinary  surgical  prin- 
ciples. Mr.  Knowsley  Thornton  had  expressed  his  disbelief  in  the 
painlessness  of  salpingitis.  He  had  only  to  read  the  clinical 
records  in  the  paper,  and  he  would  see  how  invariably  it  hap- 
pened that  patients,  who  were  proved  by  operation  to  have  old- 
standing  tubal  inflammation,  had  been  unconscious  of  any  pelvic 
pain  up  to  the  time  that  secondary  peritonitis  occurred.  The 
moment  the  inflammation  spread  from  a  mucous  to  a  serous  mem- 
brane, pain  became  the  most  marked  symptom.  Turning  to  the 
excellent  speech  of  Mr.  J.  W.  Taylor,  he  was  under  the  impres- 
sion, as  he  listened,  that  he  was  telling  the  story  of  Case  14, 
so  similar  was  it  to  the  one  Mr.  Taylor  related.  Mr.  Skene 
Keith  seemed  to  doubt  the  frequency  of  such  conditions  as  were 
described  in  the  paper.  All  he  could  say  was  that  he  did  not  go 
out  into  the  highways  and  hedges,  and  compel  them  to  come  into 
St.  Thomas's,  and  yet  they  were  found  there,  as  was  proved  by 
his  paper,  in  great  abundance.  Such  cases  were  believed  to  be 
rare  simply  because  they  were  not  diagnosed.  He  was  sorry  to 
have  detained  them  so  long  ;  the  importance  of  the  subject  must 
be  his  excuse.  He  desired,  in  conclusion,  to  challenge  those  who 
decried  these  operations  to  bring  forward  a  series  of  fifty  similar 
cases  treated  by  other  than  operative  measures,  giving  the  full 
clinical  history  from  beginning  to  end,  and  where  death  occurred, 
an  account  of  the  conditions  disclosed  at  the  autopsy. 


YOL.  XXXIV.  32 


DECEMBER    7th,    1892. 

J.  Watt  Black,  M.D.,  President,  in  the  Chair. 

Present — 48  Fellows  and  8  visitors. 

Books  were  presented  by  Dr.  Frommel,  Dr.  Lazare- 
witch,  Dr.  Philip  D.  Turner,  Messrs.  Adlard  and  Son, 
the  Medical  Society  of  London,  the  Council  of  University 
College,  and  the  Edinburgh  Obstetrical  Society. 

William  Bramley  Taylor,  M.R.C.S.,  was  admitted  a> 
Fellow  of  the  Society. 

James  Henry  Ash  worth,  M.D.St.  And.  (Halstead)  ; 
Francis  Alexander  Barton,  L.R.C.P.Lond.  (Beckenham)  ; 
Robert  Davis,  M.R.C.S.  (Epsom)  ;  and  William  John 
Mackay,  M.B.,  M.Ch. Sydney  (Rooty  Hill,  N.S.W.),  were 
declared  admitted. 

The  following  gentlemen  were  proposed  for  election  : — ■ 
Richard  Henry  Barber,  L.R.C.P.&S.Edin.  (Portland, 
Oregon,  U.S.A.)  ;  Ferdinand  Campion  Batchelor,  M.D. 
Durh.  (Dunedin,  N.Z.) ;  Henry  Ferdinand  Bernau, 
L.R.C.P.Lond.  (East  Finchley,  N.)  ;  Frederick  Bernard 
Betts,  L.R.C.P.Lond.  ;  Henry  St.  George  Boswell,  M.B. 
Edin.  (Saffron  Walden) ;  James  Craig,  M.D.Edin.  (Beck- 
enham) ;  William  Harrison  Cripps,  F.R.C.S.  ;  W.  Bruce 
Clarke,  F.R.C.S.;  Philip  Henry  Dunn,  L.R.C.P.Lond. 
(Stevenage)  ;  Bowie  Campbell  Gowan,  L.R.C.P.Lond. 
(Great  Stanmore)  ;  Thomas  Horatio  Haydon,  M.B.,  B.C. 
Cantab.  (Richmond)  ;  Walter  Wheeler  Heelas,  L.R.C.P. 
Lond.  ;    Henry    Laver,   M.R.C.S.    (Colchester)  ;    Roderic 


460  TRANSFUSION    APPARATUS. 

Robert  Walter  Logan,  M.R.C.S.  (Leighton  Buzzard) ; 
Archibald  Lament  Macpliail,  L.F.P.S.  and  L.M.Glasg. ; 
Harry  Michie,  M.B.Aber.  (Nottingham)  ;  James  Morrison, 
L.R.C.P.Lond.  ;  John  Stuart  Nairne,  F.R.C.S.Edin. 
(Glasgow)  ;  Frank  Edward  Nichol,  M.A.,  M.B.,  B.C. 
Cantab.  (Margate)  ;  E.  H.  Edwards  Stack,  M.B.Cantab. ; 
Richard  Jocelyn  Swan,  M.R.C.S ;  William  Francis 
Umney,  M.D.Lond.  (Sydenham)  ;  William  Kay  Walls, 
M.B.Lond.  (Manchester)  ;  and  Thomas  James  Webster, 
M.R.C.S.  (Merthyr  Tydvil). 


ASEPTIC  INSTRUMENTS. 
By  Peter  Horrocks,  M.D. 

A  pair  of  midwifery  forceps  and  a  uterine  sound  were 
shown  as  examples  of  aseptic  instruments.  They  were 
made  of  metal  throughout,  and  free  from  all  indentations. 
A  special  point  was  the  absence  of  the  maker's  name,  the 
stamping  of  which  on  all  instruments  rendered  them 
difficult  to  clean. 


TRANSFUSION    APPARATUS. 

By  Peter  Horrocks,  M.D. 

A  SIMPLE  apparatus  for  the  transfusion  of  saline  fluids 
into  the  venous  system  in  cases  of  severe  haemorrhage 
was  shown.  It  consisted  of  a  cannula  in  silver  or  glass, 
-a  piece  of  tubing,  and  a  funnel.  A  plunger  went  with 
•the  funnel  so  that  it  could  be  used  as  a  syringe  if 
requisite.      It  was  quite  easy  to  obtain  a  bit  of  tubing 


TRANSFUSION    APrAKATUS.  461 

and  a  funnel  in  most  houses,  and  therefore  he  always 
carried  a  silver  cannula  in  his  pocket,  and  was  thus  pro- 
vided potentially  with  a  transfusion  apparatus.  In  cases 
of  extreme  h£emorrhage  with  collapse,  pulselessness,  &c., 
he  injected  five  to  six  pints  of  water  previously  boiled, 
but  cooled  down  to  about  101° — 102°  F.  by  means  of 
ice,  or  standing  the  containing  vessel  in  cold  water. 
Common  salt  was  added  to  the  water  in  the  proportion  of 
about  a  teaspoonful  to  the  pint. 

Dr.  Heebeet  Spexcer  was  glad  that  Dr.  Horrocks  had 
adopted  the  method  of  injecting  the  fluid  by  gravitation  instead 
of  by  a  syringe.  He  (Dr.  Spencer)  had  employed  the  gravita- 
tion method  for  the  last  five  years,  and  the  injection  bottle  he 
had  employed  was  figured  in  the  '  Lancet,'  of  June  18th,  1892. 
Dr.  Horrocks'  syringe,  if  used  to  inject  by  gravitation,  was  an 
improvement  on  the  ordinary  funnel ;  but  the  use  of  the  piston 
was  dangerous  from  the  liability  to  sudden  alterations  in  pres- 
sure, the  risk  of  introducing  air  and  dust,  the  need  of  a  reliable 
person  to  attend  to  the  refilling,  and  from  the  difficulty  in  keep- 
ing the  piston  aseptic.  The  apparatus  shown  by  Dr.  Horrocks 
would  also  allow  the  fluid  to  cool,  whereas  with  the  irrigation 
bottle  it  could  be  kept  at  a  constant  temperature.  Saline  trans- 
fusion was  still  in  an  experimental  stage,  and  it  would  help  in 
forming  a  correct  judgment  if  observers  employed  apparatus  of 
which  the  factors  had  a  definite  value,  and  if  they  gave  the  exact 
nature,  quantity,  temperature,  and  the  rate  of  injection  of  the 
fluid,  and  published  all  their  cases  as  he  (Dr.  Spencer)  had  done. 

Dr.  HoEROCKS,  in  reply,  said  that  he  had  been  working  at  the 
subject  with  the  late  Dr.  Wooldridge  some  years  before  his  death 
(1889)  ;  it  was  not  true  in  practice  that  danger  resulted  from 
using  a  syringe,  and  this  indeed  was  largely  practised  at  Guy's 
from  instructions  given  by  himself.  But  he  had  found  the 
apparatus  exhibited  to-night  to  be  clean,  simple,  cheap,  and 
efficient.  Moreover,  the  theoretical  objections  mentioned  by 
Dr.  Spencer  were  not  met  with  in  practice,  and  he  hoped  no 
medical  practitioner  would  allow  a  patient  to  die  from  hajmor- 
rhage  without  trying  a  copious  injection  of  salt  and  water  into 
the  veins.  He  had  tried  injection  into  the  cellular  tissue,  but 
it  was  not  quick  enough  in  these  severe  cases. 


462 


OVARIES  REMOVED  FROM  A   CASE   OF  OSTEO- 
MALACIA. 

By  A.  Rasch,  M.D. 

A  COMMITTEE,  Consisting  of  Drs.  Rasch,  W.  S.  A.  Griffitli, 
Boxall,  and  Horrocks,  was  appointed  to  report  on  this  case. 


PAPILLOMATOUS   OVARIAN    CYST. 

By  Arthur  H.  N.   Lewers,  M.D. 

The  cyst  was  removed  in  June,  1892,  from  a  patient  aged 
6L  The  point  of  interest  in  the  specimen  was  that  there 
were  pedunculated  papillomatous  growths  from  the  peri- 
toneal aspect  of  the  cyst.  These  projected  freely  into  the 
ascitic  fluid,  a  large  quantity  of  which  was  present  in  the 
peritoneal  cavity.  Nevertheless  there  was  no  infection  of 
the  peritoneum,  as  no  papillomata  were  present  anywhere 
except  on  the  sui-face  of  the  cyst.  There  were  some 
points  of  clinical  interest  also  in  the  case.  About  three 
years  before  Dr.  Lewers  saw  the  patient  she  had  been  to 
another  hospital  complaining  of  symptoms  of  intestinal 
obstruction  ;  cancer  of  the  ovary  was  there  diagnosed, 
and  the  patient  was  advised  to  have  colotomy  performed. 
She  fortunately  for  some  reason  did  not  consent ;  the 
symptoms  of  obstruction  appeared  to  have  subsided,  but  the 
abdomen  continued  to  enlarge.  She  was  sent  to  Dr. 
Lewers  in  May,  1892,  with  the  object  of  having  the  pres- 
sure symptoms  relieved  by  tapping,  but  with  no  hope  of 
obtaining  complete  relief.  Dr.  Lewers  saw  no  reason 
why  the  case  should  not  be  one  of  ovarian  tumour  with 
ascites,  and  at  the  operation  this  proved  to  be  the  case  ; 


MALFORMED    FCETUS.  463 

both  ovaries  were  similarly  affected.  The  patient  did 
quite  well.  Before  the  operation  the  girth  at  the 
umbilicus  was  43  inches  ;  when  leaving  the  hospital  the 
measurement  had  fallen  to  27^  inches.  Dr.  Lowers  had 
seen  the  case  within  the  last  few  days ;  there  had  been  no 
return  of  the  ascites,  nor  was  there  anything  abnormal  to 
be  detected  on  examination.  The  patient  said  she  was 
in  perfect  health. 

Dr.  CuLLiNGWOETH  Said  there  was  no  doubt  as  to  the  ten- 
dency of  papillomatous  growths  in  and  around  the  ovary  to 
infect  parts  with  which  they  came  in  contact,  and  he  thought 
the  probable  explanation  of  the  non-occurrence  of  such  infection 
in  l)r,  Lewers'  case  was  that  a  rapid  eiFusion  of  ascitic  fluid, 
from  the  irritation  produced  by  the  growth,  lifted  the  peri- 
toneum, as  it  were,  out  of  the  reach  of  the  growth,  and  therefore 
out  of  the  reach  of  infection,  by  separating  the  peritoneal  surfaces. 


MALFORMED    FCETUS. 

By  Amand  Routh,  M.D. 

Me.  Alban  Doeak  referred  to  Drs.  Matthews  Duncan  and 
Hurry's  memoir  ('  Trans.  Obstet.  Soc.,'  vol.  xxvi,  1884,  p.  206), 
and  to  Dr.  Dakin's  important  contributions  (ibid.,  vol.  xxii, 
pp.  200,  368),  which  threw  light  on  the  relation  between  spinal 
retroflexion,  ectopia  viscerum,  and  short  cords.  He  hoped  that 
Dr.  Dakin  would  examine  the  specimen.  The  condition  of  the 
genito-urinary  tract  should  be  determined.  The  most  remark- 
able malformations  were  seen  in  these  cases,  and  they  threw 
light  on  the  development  of  Miiller's  and  Grartner's  ducts.  Mx. 
Doran  referred  to  his  own  case,  described  in  an  article  "  Dissec- 
tion of  the  Genito-urinary  Organs  in  a  Case  of  Fissure  of  the 
Abdominal  Walls,"  in  the  '  .Journal  of  Anatomy  and  Physiology,' 
vol.  XV,  1881,  p.  226.  Dr.  Amand  Kouth's  case  resembled  it  in 
several  respects. 

A  committee,  consisting  of  Drs.  Dakin,  A.  Routh,  and 
Messrs.  Doran  and  Targett,  was  appointed  to  report  on 
this  specimen. 


464 


PLACENTA    PE^VIA    ASSOCIATED    WITH  UN- 
USUAL   SIZE  AND    SHAPE   OF  THE   PLACENTA. 

By  EOBEKT    B0XALL_,  M.D. 

De.  Boxall  showed  two  specimens,  in  both  of  which 
the  foetus  had  been  extruded  together  with  the  placenta 
in  an  unruptured  sac,  one  at  the  eighth,  the  other  in  the 
sixth  month  of  gestation.  Both  women  had  had  one  child 
previously,  in  the  one  case  four  and  a  half,  and  in  the 
other  three  and  a  quarter  years  ago,  but  no  miscarriage. 
In  both  the  vertex  presented. 

In  the  first  specimen  the  placenta  was  larger  than  usual, 
and  covered  about  one  third  of  the  foetal  envelope,  and  in 
addition  was  elongated  in  a  downward  direction,  so  that 
though  as  a  whole  the  placenta  maintained  a  normal  posi- 
tion, the  lower  edge  of  it  projected  in  front  of  the  foetal 
head,  and  thus  by  encroaching  on  the  dangerous  zone 
gave  rise  to  haemorrhage  for  five  days  before  the  expul- 
sion of  the  mass.  The  whole  of  the  chorion  was  found 
to  be  missing,  having  separated  from  the  margin  of  the 
placenta,  and  was  probably  passed  with  clots  during  the 
first  twenty-four  hours  after  delivery. 

In  the  second  specimen  the  placenta  was  spread  over 
the  lower  half  of  the  foetal  envelope,  and  was  so  thin  that, 
though  it  filled  the  lower  segment,  the  head  could  be 
easily  felt  through  it.  The  case  was  further  complicated 
by  the  presence  of  a  fibroid  in  the  anterior  wall  of  the 
uterus.  Haemorrhage  had  taken  place  about  once  a 
month  throughout  the  pregnancy,  and  for  six  weeks  had 
been  continuous.  The  patient  herself  had  no  idea  of  her 
pregnancy. 


465 


SUPPOSED     UNRUPTURED    TUBAL    GESTATION 

SAC. 

By  W.   S.   Playfair,  M.D. 

De.  Playfaie  exhibited  what  he  supposed  to  be  an 
unruptured  tubal  foetation  removed  by  abdominal  sec- 
tion. The  patient  exhibited  the  characteristic  symptoms 
of  ectopic  gestation  in  a  marked  way.  She  had  missed 
one  monthly  period  when  admitted  into  the  hospital 
for  severe  abdominal  pain.  At  this  time  there  was 
no  enlargement  of  the  tube  to  be  made  out.  She  was 
kept  some  three  weeks  under  observation.  During  this 
time  she  had  repeated  attacks  of  most  severe  pain,  an 
irregular  metrorrhagia,  darkened  areolae,  and  lacteal 
secretion  in  the  breast.  A  steadily  increasing,  elongated, 
swelling  like  a  sausage  was  now  to  be  made  out  in  the 
region  of  the  right  Fallopian  tube.  Believing  this  to  be 
probably  a  tubal  gestation,  an  exploratory  operation 
was  made.  The  tube  was  found  to  be  largely  distended 
and  thinned,  and  apparently  on  the  point  of  rupture.  It 
contained  a  quantity  of  blood-clot,  but  no  obvious  ovum. 
It  seemed  probable,  however,  that  the  ovum  had  perished, 
and  was  lost  in  the  surrounding  clot.  Microscopical 
examination  of  this  with  the  view  of  detecting  chorionic 
tissue  was  not  yet  completed.  It  was  curious  that 
twenty-four  hours  after  the  operation  the  patient  went 
through  a  typical  attack  of  the  prevailing  influenza  with 
an  initial  temperature  of  105° ;  this  ran  the  usual  course, 
and  the  patient  made  a  good  recovery. 

Dr.  Handfield-Jones  asked  whether  Dr.  Playfair  had 
noticed  any  intimate  incorporation  of  the  blood-clot  with  the 
wall  of  the  Fallopian  tube,  as  this  had  been  given  by  Dr. 
Orthmann  as  characteristic  of  the  hsematosalpinx  of  early  tubal 
pregnancy  as  distinguished  from  other  forms  of  hsematosalpinx. 


466 


•    HEMATOSALPINX. 
By  Edward  Malins,  M.D. 

Mary  N — ,  aged  19,  domestic  servant,  admitted  to 
the  General  Hospital,  Birmingham,  April  29th,  1892, 
under  the  care  of  Dr.  Malins.  First  menstruated  three 
years  ago,  lasting  three  days  ;  not  again  until  eighteen 
months  afterwards,  when  it  lasted  several  days,  and  was 
accompanied  by  "  clots."  About  Christmas  time  she  was 
knocked  down,  after  which  she  noticed  a  lump  in  the  left 
side  of  the  abdomen,  which  gradually  grew  larger  and 
caused  pain,  for  which  she  came  to  the  hospital. 

On  admission  a  moveable  mass  was  felt  in  the  left  iliac 
region  midway  between  the  umbilicus  and  the  middle  of 
Poupart's  ligament. 

Abdominal  section  in  the  median  line  was  done  on 
May  5th.  The  mass  was  found  to  be  the  left  Fallo- 
pian tube  distended  with  blood  ;  the  ovary  at  the  base. 
It  was  transfixed,  tied  with  silk,  and  removed.  Patient 
discharged  cured.  May  31st.      The  tube  weighed  4^  oz. 

There  was  no  suspicion  of  pregnancy  from  the  history  ; 
the  vagina  was  narrow  ;  there  was  a  ti'ansverse  septum 
over  a  small  apei'ture  at  the  summit  representing  the  os ; 
a  sound  passed  through  it  into  the  uterus.  The  right 
ovary  and  tube  were  seen  to  be  normal  at  the  time  of  the 
operation. 

Report  on  Dr.  Malins'  specimen  of  Haematosalpinx. 

A  portion  of  the  wall  of  the  dilated  tube  was  embedded 
in  celloidin,  and  sections  were  prepared  for  the  microscope. 
The  muscular  coat  of  the  tube  was  found  to  be  very  thin 
from  distension,  and  in  places  strands  of  its  fibres  were 
separated  by  granular  dehris  of  old  blood-clot.      Attached 


HJOMATOSALPINX.  467 

to  tlie  mucous  surface  of  the  muscular  coat  was  a  thin 
layer  of  granular  material,  together  with  polypoid  masses 
of  nucleated  tissue.  The  latter  under  a  high  power  were 
seen  to  consist  of  the  submucous  connective  tissue  in 
which  heemorrhage  had  taken  place  ;  they  were  partly 
covered  with  a  single  layer  of  columnar  epithelium,  like 
that  lining  the  mucosa  of  the  normal  Fallopian  tube. 
The  specimen  is  preserved  in  the  Royal  College  of 
Surgeons  Museum. 

-J.  H.  Targett. 


Report  of   Committee  on  Dr.   Playfair's  specimen  of 
Hsematosalpinx  shown  Fehruary  ^rd,  1892  [p.  28). 

The  specimen  is  a  dilated  Fallopian  tube.  After  shrink- 
ing in  spirit  the  cavity  measures  2^  inches  long  by  about 
1  inch  in  diameter.  The  wall  of  the  tube  is  little,  if  at 
all,  thickened.  Within  the  tube  at  the  time  of  removal 
we  are  informed  there  was  a  large  black  clot,  distending 
the  tube  at  the  time  of  operation  to  about  the  size  of  a 
lemon.  Many  sections  from  different  parts  of  this  clot 
have  been  examined  by  Mr.  Lenthal  Cheatle,  who  has 
failed  to  find  chorionic  villi  in  any  part  of  it. 

The  clinical  history  clearly  pointed  to  extra-uterine 
gestation,  but  the  specimen  shows  no  evidence  of  it. 

Mr.  Lenthal  Cheatle  informs  us  that  he  has  made 
microscopical  sections  of  the  wall  of  the  tube,  and  that 
they  show  inflammatory  infiltration,  but  no  trace  of 
chorionic  villi.  He  has  also  examined  some  flake-like  pro- 
jections from  the  wall  of  the  tube,  but  they  show  nothing 
but  fibrin. 

W.  S.  Playfair. 

Walter  S.  A.  Griffith. 

G.  Ernest  Herman. 


468 


Report  of  Go)nmittee  on  Dr.  A.  E.  Gileses  Specimen  of 
Malformation  of  Rectum  and  Bladder,  Congenital 
Absence  of  both  Kidneys  and  Ureters,  Sfc,  shown  April 
6th,  1892  {p.  129). 

The  structures  appear  to  be  precisely  as  indicated  in 
the  drawing  (p.  131).  In  respect  to  the  unnamed  band 
running  from  the  epididymis  (H)  to  the  scrotum  (its  lower 
part,  in  the  drawing,  running  to  the  left  of  E,,  the  pubes), 
it  is,  in  our  opinion,  the  left  gubernaculum  testis.  The 
corresponding  structure  exists  on  the  right  side. 

We  call  attention  to  a  somewhat  similar  case  of 
absence  of  kidneys,  published  in  July,  1892,  by  Dr. 
E-issmann,  of  Hanover  {"  Ein  Beitrag  zur  Frage  der  fotalen 
Nierenfunktionen,'^  'Centralb.  f.  Gynak.,'  No.  26,  1892,  p. 
497).  Both  illustrate  the  fact  to  which  Dr.  Rissmann 
calls  attention  :  "  a  well-developed  foetus  may  be  born 
alive  at  the  beginning  of  the  eighth  month  without  kidneys 
or  ureters." 

Arthur  E.  Giles. 

W.  R.  Dakin. 

Alban  Dor  an. 


Report  of  Committee  on  Dr.  Gullingworth's  specimen  of 
Tubal  Gestation  with  Apoplectic  Oviim  shown  June  Ist, 
1892  [p.  182). 

The  specimen  consists  of  the  greater  part  of  the  right 
Fallopian  tube,  7  centimetres  in  length.  Immediately 
above  the  abdominal  end  is  an  oval  swelling  of  the  size 
of  a  pigeon's  Qgg,  which  projects  freely  outwards  as  in 
the  drawing.  The  ostium  is  patulous  and  surrounded  by 
fimbriae,  which  are  somewhat  oedematous.      The   canal  of 


PREGNANT    UTERUS    BICORNIS,  469 

the  tube  is  not  only  pei'vious  (in  the  portion  of  the  tube 
which  is  here  preserved),  but  dilated  so  as  to  measure 
0*5  centimetre  at  the  narrowest  part. 

On  section,  the  oval  swelling  is  found  to  be  a  cyst  filled 
with  apparently  homogeneous  clot.  On  clearing-  out  the 
clot,  which  is  partly  adherent,  the  wall  of  the  cyst  appears 
simple,  without  any  evidence  of  former  loculi.  No  com- 
munication with  the  canal  of  the  tube  can  be  detected. 
There  is  a  ragged  hole  immediately  above  the  fimbriae, 
apparently  artificial. 

On  microscopical  examination  of  the  clot  no  chorionic 
villi  could  be  detected.  The  clot  was  intimately  adherent 
to  the  wall  of  the  cyst,  and  the  epithelial  investment  of 
the  mucous  membrane  did  not  exist. 

ChAS.  J.  CULLINGWORTH. 

Alban  Doran. 
William  Duncan. 
J.  Bland  Sutton. 


PREGNANT    UTERUS    BICORNIS. 

By  J.  R.  Ratcliffe,  M.B. 

The  specimen  was  taken  from  a  woman,  aged  about  30, 
who  had  been  killed  by  a  crane  accident.  She  had  had 
one  child  previously,  and  the  labour  had  been  normal. 
On  post-mortem,  the  two  pear-shaped  horns  of  the  uterus 
were  found  lying  completely  in  the  true  pelvis.  The 
rectum  was  mesial,  and  separating  the  two  horns  was 
a  median  recto-vesical  fold  2  inches  high.  The  right 
horn  was  4^  inches  long  with  a  circumference  of  6  inches, 
and  its  cavity  showed  a  well-marked  decidua  but  no 
foetus.  The  left  horn  was  44-  inches  lonw  with  a  circum- 
ference  of  6^  inches,  and  it  contained  a  foetus  between  the 
second  and  third  month  of  gestation.  The  right  ovary 
(that  on  the   opposite  side  to  the  pregnant  horn)  showed 


470  PREGNANT    UTERUS    BICORNIS. 

a  true  corpus  luteum,  and  there  was  none  in  the  left 
ovary.  The  two  uterine  cavities  joined  by  narrow  necks 
into  a  shallow  cervical  cavity  about  ^  inch  deep,  and  freely 
patent  into  the  vagina,  which  was  partially  double, 
being  5  inches  long  with  a  diameter  of  2|  inches,  and  on 
the  upper  and  lower  walls  was  a  longitudinal  raphe,  not, 
however,  united. 

Mr.  Ratcliffe  said  that  the  interest  of  the  specimen 
lay  (1)  in  the  fact  of  the  woman  having  menstruated 
regularly  up  to  the  time  of  her  death  ;  (2)  in  the  fact 
that  the  true  corpus  luteum  was  on  the  opposite  side  to 
the  pregnancy.  This  last,  he  said,  seemed  to  throw 
doubt  on  the  accepted  theoi*y  of  the  origin  of  the  true 
corpus  luteum.  If  the  ovum  which  had  given  rise  to  the 
foetus  had  come  from  the  ruptured  Graafian  follicle 
represented  by  the  corpus,  it  would  either  have  had  to 
come  from  deep  down  in  the  true  pelvis  and  mount 
the  high  recto-vesical  fold,  which  he  thought  very 
improbable,  or  it  would  have  had  to  pass  down  one 
tube  and  cornu  to  the  very  shallow  cervix  and  up  into 
the  other  cornu,  which  seemed  an  anatomical  impossi- 
bility ;  therefore  he  thought  that  the  corpus  luteum  did 
not  represent  the  Graafian  follicle  of  the  fertilised  ovum, 
but  retrogressive  changes  in  the  next  or  a  subsequent 
one,  which,  when  ready  to  burst,  found  the  uterus  gravid, 
and  so  aborted,  as  it  were. 

(The  specimen  is  in  the  Royal  College  of  Surgeons 
Museum.) 


Report    of     Committee    on    Dr.    Ratcliffe' s     Specimen    of 
Uterus  Bicornis  shown  June  \st,  1892  [p.  469). 

The  uterus  is  divided  into  two  distinct  cornua  of  about 
the  same  size,  each  nearly  5  inches  in  length.  In  the 
right  cornu  the  muscular  coat  is  hypertrophied  to  the 
extent  of  a  quarter  of  an  inch.  The  Fallopian  tube  is 
normal,  and  begins  immediately  external  to  the  uterine 


PKEQNANT    UTEKUS    BICORNIS.  471 

origin  of  the  round  ligament  ;  its  uterine  end  is  pervious. 
Although  the  cavity  of  this  cornu  is  wide,  there  is  no 
trace  of  any  product  of  gestation  to  be  detected.  The 
left  cornu  is  distinctly  larger  than  the  right.  Its  mus- 
cular coat  is  thickest  antero-inferiorly.  Superiorly  it  is 
thin,  about  half  as  thick  as  in  the  right  horn.  The 
relations  of  the  horn  to  the  round  ligament  and  Fallopian 
tube  are  as  on  the  right  side.  The  peritoneum  passes 
from  the  bladder  to  the  rectum  between  the  uterine 
horns,  making  a  mesial  triangular  fold,  with  the  base  or 
free  border  looking  upwards,  the  apex  lying  in  Douglas's 
pouch,  which  is  thus  divided  into  two  complete  cavities. 
The  right  ovary  contains  a  recent  mature  corpus  luteum  ; 
the  left  ovary  bears  only  a  few  small  follicles.  The  vagina 
is  very  capacious  ;  the  anterior  and  posterior  columns  are 
much  exaggerated.  The  cervix  uteri  is  very  short  and 
broad,  the  os  externum  single,  the  cornua  opening  sepa- 
rately just  above  it. 

The  ovum  from  the  right  ovary  may  have  been  washed 
up  the  left  cornu  just  as  it  left  the  right  cornu  imme- 
diately above  the  os  externum,  but  from  the  shallowness 
of  the  OS  this  seems  hardly  probable. 

J.  H.  Takgett. 

J.  R.  Ratclifpe. 

Alban  Doran. 

Note  hy  Dr.  Ratclife. — A  possible  explanation  seems 
to  be  that  the  fertilised  ovum  did  not  come  from  the 
corpus  luteum  seen,  but  that  this  luteum  represented 
retrogressive  changes  in  the  next  Graafian  follicle  about 
to  burst  after  the  one  from  which  the  ovum  came — 
changes  of  an  abortive  nature  ;  and  this  may  explain  the 
nature  of  the  true  corpus  luteum. 

In  the  right  cornu  was  a  well-marked  tuberculated 
decidua,  easily  stripped  by  the  handle  of  the  scalpel. 
There  was  no  trace  of  any  embryo. 

In  the  left  cornu  there  was  an  embryo  at  about  the 
second  or  third  month  of  gestation. 


472  PREGNANT    UTERUS    BIC0RNI8. 

The  cervix  was  grooved  antero-posteriorly  (not  lace- 
rated), and  the  os  opened  into  a  shallow  cavity  which 
immediately  (about  5  inch  up)  bifurcated  and  led  into 
the  two  horns.  The  median  peritoneal  fold  was  2  inches 
high. 

It  might  be  added  that  the  woman  had  had  one  normal 
labour  previously.  She  had  also  menstruated  up  to  the 
of  time  her  death,  and  did  not  know  herself  to  be  pregnant. 


473 


ON    THE    OCCURRENCE    OF    SUGAR    IN    THE 
URINE    DURING    THE    PUERPERAL    STATE. 

By  Frederick  J.  McCann,  M.B.Edin.,  M.R.C.P.Lond.,  and 
William  Aldren  Turner,  M.D.Edin.,  M.R.C.P.Lond. 

(Received  December  10th,  1891.) 

{Abstract.) 

The  authors  of  this  paper  have  investigated  a  series  of  one 
hundred  cases,  and  from  the  results  thus  obtained  have  arrived 
at  the  following  conclusions  : 

1.  That  sugar  is  present  in  the  urine  of  women  during  lacta- 
tion. (The  authors  assume  Avith  Hofmeister  that  this  sugar  is 
milk-sugar.)     Glucose  may  also  be  found. 

2.  That  sugar  is  present  at  some  period  in  every  case. 

8.  That  in  the  majority  of  cases  the  largest  amount  occurs 
on  the  fourth  and  fifth  days  of  the  puei'perium. 

4.  That  the  quantity  depends  on  (1)  the  condition  of  the 
breasts  ;  (2)  the  quantity  and  quality  of  the  milk  ;  (3)  the 
sucking  of  the  child.  Out  of  one  hundred  cases  the  average 
quantity  found  was  -35  per  cent.,  i.  e.  1^  grains  per  ounce. 

5.  That  when  lactation  is  diminished  or  suppressed,  the 
amount  of  sugar  diminishes  or  disappears. 

6.  That  when  the  production  and  exhaustion  of  the  milk  are 
equal,  the  amount  of  sugar  is  very  small. 

That  a  variable  amount  of  sugar  occurs  in  the  urine  of 
puerperal  Avomen  has  been  an  established  physiological 
fact  since  Blot  (1856)  first  drew  attention  to  the  subject. 

Since  1856  various  observers  have  investigated  the  sub- 
ject  with  varying  results,   so  that  no  definite  conclusion 

VOL.  XXXIV.  33 


474  OCCURRENCE    OF    SUGAR    IN    THE    URINE 

has  been  arrived  at  as  to  whether  sugar  is  constantly 
present  in  the  urine  of  every  woman  during  the  puer- 
perium  ;  moreover,  as  the  results  referred  to  have  been 
obtained  after  examination  of  a  very  small  number  of 
cases,  and  as  a  systematic  daily  investigation  of  the  con- 
dition of  the  mammary  glands  was  not  carried  out,  much 
valuable  information  was  thereby  lost.  Keeping  in  view 
these  discrepancies,  the  authors  of  this  paper  have  drawn 
their  conclusions  from  a  series  of  100  cases,  and  have  in 
addition  noted  the  daily  variation  in  the  condition  of  the 
breasts,  the  quantity  and  quality  of  the  milk,  together 
with  the  sucking  and  general  nutrition  of  the  child. 

The  effects  of  prematurity  of  the  foetus,  of  stillbirths, 
of  arrested  lacteal  secretion,  including  the  effect  of  bella- 
donna applied  to  the  breasts,  have  been  added. "^  The 
importance  of  this  method  is  at  once  evident,  for  the  seat 
of  the  production  of  the  sugar  being  in  the  mammary 
glands,  the  varying  conditions  to  be  observed  in  these 
organs  regulate  the  amount  of  lactose  present  in  the 
urine. 

As  previously  mentioned,  the  presence  of  sugar  in  the 
urine  of  suckling  women  was  first  pointed  out  by  Blott 
in  1856,  who  showed  that  ^'  in  all  puerperal,  in  all  suckling 
women,  and  in  a  certain  number  of  pregnant  women  sugar 
is  found  in  the  urine,  and  that  the  quantity  of  sugar  is  in 
direct  relation  to  the  activity  of  the  mammary  glands." 
LeconteJ  (1857)  refutes  the  previous  statements. 
Kirsten§  (1857)  confirms  as  to  the  presence  of  sugar, 
but  affirms  that  if  lacteal  secretion  be  hindered  the  sugar 
increases  instead  of  diminishes  ;  whilst  in  those  women 
who  have  much  milk,  and  whose  babies  thrive,  only  traces 
of  sugar  are  found  in  the  urine. 

Briickell   (1858)  says   that  "it  is  physiological  in  nurs- 

*  The  age  and  condition  of  the  patient,  the  character  of  tlie  labour  and  of 
the  puerperiuni  are  stated. 

t  '  Coniptes  Rendus/  xliii,  p.  676,  1856. 

J  '  Archives  generales  de  Medecin,'  Aug.,  1857. 

§  '  Monatsschrift,'  1857,  Bd.  ix,  s.  437. 

jl  '  Wiener  medicin.  Wochenschrift,'  1858. 


DURING    THE    POERTERAL    STATE.  475 

ing  women  and  in  healtliy  individuals  ;  Iwanoff^  (1861), 
that  the  glycosuria  of  pi'egnant  and  puerperal  women  is 
not  so  constant  as  Blot  thought,  but  nevertheless  is  often 
met  with. 

In  1873  De  Sinety,t  investigating  the  subject  at  length, 
stated  that  at  the  third  or  fourth  day  after  delivery,  he 
always  found  sugar  in  the  urine.  He  found  increase  of 
sugar  in  the  blood  of  bitches  during  lactation,  still  greater 
Avhen  lactation  was  suppressed. 

SpiegelbergJ  mentions  that  the  urine  is  frequently  sac- 
charine ;  the  sugar  is  in  the  form  of  lactose,  and  as  a  rule 
contemporaneous  with  the  establishment  of  lactation,  the 
quantity  being  generally  in  proportion  to  the  abundance 
of  the  milk.  He  regards  the  condition  as  one  of  resorp- 
tion diabetes. 

Hempel§  (1874-5),  from  a  careful  analysis  of  twelve 
cases,  concluded  that  sugar  was  present  at  some  period 
during  the  puerperium,  the  greatest  quantity  noted  being 
1'6  per  cent,  (in  this  case  the  breasts  were  enormously 
distended). 

Kaltenbach  ||  (1877),  while  corroborating  the  work  of 
previous  observers,  at  the  same  time  noted  the  relation  of 
sugar  in  the  urine  to  changes  in  the  mammary  glands. 

Hofmeister^  (1878)  showed  that  the  sugar  found  in 
the  urine  of  suckling  women,  possessed  all  the  characters 
of  milk-sugar. 

These  results  show  the  difference  of  opinion  which  has 
existed  in  the  minds  of  those  who  have  investigated  this 
subject,  and  as  yet  sufficient  data  have  not  been  brought 
forward  to  decide  the  initial  question,  Is  sugar  always 
present  at  some  period  in  the  urine  of  suckling  women  ? 
The  object  of  the  present  paper  is  to  decide  this  question, 

*  These  Dorpat,  1861. 

t  '  Gaz.  med.  de  Paris,'  p.  573,  1873. 

X  '  Text-book  of  Midwifery '  (Xew  Syd.  Soc),  vol.  i,  p.  290. 

§  '  Archiv  f .  Gyn.,'  Bd.  viii,  p.  312. 

ll  '  Zeitschrift  f.  Geb.  u.  Gyn.,'  iv,  p.  161. 

^  '  Centralblatt  f.  Gyn.,'  1878,  p.  88. 


476        OCOURRKNCE  OF  SUGAR  IN  THE  URINE 

and  to  elucidate  many  intei'esting  points  connected  with 
this  subject. 

In  carrying  out  this  investigation  much  time  might  be 
spent  ovei*  details  in  the  testing  employed,  and  as  it 
seemed  that  for  our  purpose  this  was  unnecessary,  we 
have  employed  one  uniform  method  throughout. 

For  qualitative  examination  the  test  used  was  Fehling's 
solution,  as  recommended  by  Sir  Wm.  Roberts,*  which  is 
as  follows  : 

Add  the  suspected  urine  to  boiling  Fehling's  solution, 
raise  again  to  the  boiling-point,  alloAV  to  cool,  note  change 
which  occurs.  If  a  small  quantity  of  sugar  be  present, 
green  milkiness  occurs ;  if  more  sugar,  a  yellow-green 
opacity,  which  deposits  on  cooling  a  bright  yellow  preci- 
pitate ;  if  much  sugai",  as  in  diabetes,  the  suboxide  falls  as 
a  brick-red  deposit  at  once  ;  the  last  reaction  occurs  when 
only  a  drop  or  two  of  urine  is  added  to  the  boiling  test 
solution. 

For  small  quantities  of  sugar  (1)  an  excess  of  the 
test  solution  is  required  ;  (2)  earthy  phosphates,  if  in 
excess,  to  be  precipitated  by  an  alkali  ;  if  not  in  excess, 
they  do  not  affect  the  test  much.  Phosphates  fall  as 
dirty  white  flocculi,  which  can  be  readily  distinguished 
from  the  precipitate  of  suboxide.  (8)  Uric  acid  and 
urates,  according  to  Roberts,  do  not  affect  the  value  of  the 
test.  (4)  Prolonged  boiling  must  be  avoided,  as  a  muddy 
deposit  falls,  due  to  precipitation  of  earthy  phosphates 
tinged  red.  This  last  appears  to  have  been  a  source  of 
fallacy  with  some  of  the  earlier  workers  at  this  subject. 
The  quantitative  estimation  was  made  with  Pavy^s  am- 
monio-cupric  solution. 

Samples  of  the  morning  urine  were  tested  after  strain- 
ing through  fine  muslin.  In  cases  giving  doubtful  reac- 
tion the  catheter  was  used,  the  first  sample  being 
always  drawn  off.  Although  complicated  tests  have  been 
employed  for  the  detection  of  sugar  in  the  urine,  it  was 
found  that  the  solutions  suggested  by  Fehling  and 
*  '  Urinary  and  Kenal  Diseases,'  4th  ed.,  1885,  p.  213,  et  seq. 


DURING    THE    rUERPERAL    STATE.  477 

Pavy  gave  results  sufficiently  accurate  for  clinical  pur- 
poses. 

A  large  series  of  cases  was  examined  in  order  to 
decide  definitely  if  lactose  was  always  present  at  some 
period  during  lactation.  The  result  has  been  that  in 
every  case  lactosuria  was  observed,  and  thus  the  debat- 
able question  may  be  considered  to  be  settled.  Never- 
theless the  quantity  varies  at  different  periods  and  in  dif- 
ferent individuals,  depending  on  various  circumstances  to 
be  referred  to  later. 

As  a  rule,  lactose  is  present  every  day  after  lactation  ; 
in  some  cases  none  can  be  discovered  on  certain  days. 

The  quantity  found  varied  from  '18  per  cent,  to  '69 
per  cent.,  the  average  being  •85  per  cent.,  i.  e.l^  grains 
per  ounce.  In  this  relation  it  may  be  mentioned  that  the 
amount  of  sugar  present  in  normal  urine  is  so  small 
that  its  presence  is  not  shown  by  the  ordinai-y  clinical  tests, 
and  may  therefore  be  disregarded. 

Date  of  First  Appearance  of  Lactosuria. 


1st  (lay  (day  of  labour)     29  per  cent. 
2nd  „    .  .  .     27       „ 

3rd  „    .  .  .     26       „ 


4th  day  .     11  per  cent. 

5tli  „  .       2       „ 


From  this  table  it  will  be  seen  that  in  the  largest 
number  of  cases,  viz.  29  per  cent.,  sugar  was  present  on 
the  day  of  laboui',  but  in  several  a  diminution  or  even 
absence  of  sugar  was  noticed  on  the  second  day,  appear- 
ing again  on  the  third  or  fourth  days  in  considerable  quan- 
tity. Mental  anxiety  is  stated  as  a  cause  of  temporary 
glycosuria,  but  whether  or  not  labour  acts  in  this  way  is 
difficult  to  determine  ;  more  probably  the  activity  of  the 
mammary  glands  is  aroused  at  this  time,  and  lactosuria 
is  produced.  The  late  appearance  of  lactose  on  the  fourth 
and  fifth  days  can  be  explained  by  the  fact  that  the  super- 
vention of  lactation  is  delayed  in  these  cases. 

Quantity  of  lactose. — The  following  table  indicates  the 
days  when  the  largest  amount  of  sugar  is  present : 


478 


OCCDRRENCE    OF    SUGAR    IN    THE    TJRINE 


2nd  day  in    5  per  cent. 


3rd   „   10 

4th   , 

,   26 

5th   , 

,   2G 

6th   , 

8 

7th   , 

5 

8th   , 

3 

9th  day 

in  4  per  cent. 

10th   , 

5 

11th   „ 

3 

12th   „ 

2 

13th 

2 

14th   , 

1 

To  compare  with  the  above  a  table  has  been  con- 
structed to  show  the  day  when  milk  first  appears  in  the 
breasts: 


1st  day  in  1  per  cent. 
2nd   „    5 
3rd   „   46 


4th  day  in  39  per  cent. 
5th   „   6 
6th   „   1 


From  the  first  of  these  tables  it  is  seen  that  the  largest 
amount  of  sugar  was  present  on  the  fourth  and  fifth  days 
in  26  per  cent.,  and  from  the  second  table  that  the  first 
appearance  of  milk  was  noted  on  the  third  day  in  46  per 
cent.,  and  on  the  fourth  day  in  39  per  cent.  Now  the 
mammary  glands  being  in  a  state  of  great  activity  on  the 
third  and  fourth  days  of  the  puerperium,  milk  is  rapidly 
formed,  and  thus  distension  of  the  breasts  soon  occurs  ; 
at  the  same  time  milk-sugar  is  absorbed  into  the  blood 
owing  to  the  excessive  production  or  diminished  outflow  of 
milk,  and  this  excess  of  milk-sugar  is  excreted  by  the  urine, 
and  is  thus  found  in  largest  amount  on  the  fourth  and 
fifth  days.  In  most  cases  after  this  period  the  amount  of 
sugar  remains  constant  if  the  milk  be  excreted  uninter- 
ruptedly, and  if  the  daily  quantity  be  not  excessive,  i.  e. 
if  the  production  and  exhaustion  be  equal. 

Cause  of  variations  in  quavtity. — The  most  important 
factor  in  causing  increase  of  lactosuria  is  distension  of  the 
breasts,  for  here,  the  outflow  of  milk  being  hindered,  milk- 
sugar  is  absorbed  into  the  blood  and  excreted  by  the 
urine.  The  same  effect  is  produced  by  the  application  of 
belladonna  to  the  breasts. 

Next  in  importance  comes  the  excessive  production  of 
milk.      Here,  also,  a  certain  amount  of  lactose  must  be 


DURING    THE    PUERPERAL    STATE.  479 

absorbed  and  excreted  by  the  urine  ;  this  is  well  seen  in 
cases  where  milk  is  constantly  overflowing  from  the 
breasts.  We  have,  therefore,  in  the  state  of  the  mammary 
glands  an  explanation  of  the  increase  or  diminution  of 
lactosuria.  Although  excess  of  milk  is  associated  with 
increased  lactosuria,  yet,  as  far  as  we  have  been  able  to 
determine,  the  quality  of  the  milk  may  be  inferior.  So 
long  as  the  milk  secreted  is  rich  in  milk-sugar  lactosuria 
occurs.  This  has  an  important  bearing  on  the  question 
raised  by  Blot  as  to  whether  the  amount  of  sugar  present 
in  the  urine  was  an  indication  of  value  in  choosing  a  wet- 
nurse.  Now  in  Case  9,  where  milk  overflowed  con- 
tinuously from  the  breasts,  a  large  amount  of  sugar  was 
present  in  the  urine,  but  the  milk  was  poor  in  quality, 
and  the  child  did  not  thrive  well.  Here  we  must  con- 
clude that  the  milk,  although  abounding  in  lactose,  and 
thus  causing-  increased  lactosuria,  may  still  be  poor  in 
nutritive  value,  and  that  the  indication  as  to  the  value  of 
a  wet-nurse,  taken  from  the  amount  of  lactose  in  the  urine, 
is  not  to  be  relied  upon. 

The  influence  of  sucking  must  also  be  mentioned,  as 
the  gland  acini  are  stimulated  reflexly  through  the  sensory 
nerves  of  the  nipple.  Not  only  is  the  milk  in  the  gland 
extracted,  but  new  milk  is  formed  owing  to  accelerated 
secretion,  and  in  all  probability  this  explains  the  occur- 
rence of  the  overflow  of  milk  from  the  breast  which  is 
not  used.  It  follows,  then,  that  more  absorption  of  lactose 
occurs  where  the  child  sucks  vigorously. 

These  points  will  be  best  understood  by  a  study  of  the 
following  cases. 

1.  A  typical  case. — No.  45,  aged  24,  healthy  primipara, 
breasts   well   developed.       Male    child,    alive,    full    time. 


No  milk. 

„  Colostrum  in  breasts. 

Milky  fluid  in  breasts. 
Milk  fully  in.    No  overflow.  No  distension. 
Good  supply  of  milk.     No   overflow.     No 
distension. 


weight  6 

lbs.  15  OZ. 

1st  day 

.     No  sugar 

2nd  „ 

.     "18  per  cent.     . 

3rd  „ 

•     -18 

4th  „ 

.     -34 

5th  „ 

.     -40 

6th  day    . 

•2-4 

per 

cent.     . 

7th  „       . 

•24 

>y 

8th  „       . 

•24 

it           • 

9th  „       . 

•24 

}}           • 

10th  „       . 

•24 

)> 

11th  „      . 

•29 

»           • 

12th  „       . 

•24 

»           • 

13th  „       . 

•24 

>j 

480  OCCURRENCE    OF    SUGAR    IN    THE    URINE 

Good  supply  of  milk.    Child  sucking  well. 


Slight  overflow  in  the   morning.      Child 

sucking  well. 
No  overflow.     Child  sucking  well. 


The  above  case  illustrates  well  raany  points  previously 
mentioned.  Lactosuria  was  detected  every  day  after  the 
second.  The  amount  of  lactose  was  increased  on  the 
fourth  day  (day  of  lactation),  the  largest  amount  being 
reached  on  the  following  day,  viz.  '40  per  cent.  On  the 
sixth  day  it  fell  to  '24  per  cent.,  this  remaining  constant 
until  the  tenth  day,  when  slight  overflow  of  milk  occurred, 
followed  by  increased  lactosuria  on  the  eleventh  day,  "29 
per  cent.  On  the  remaining  days  the  amount  was  again 
•24  per  cent. 

From  this  it  is  evident  that  after  lactation  is  well 
established  the  amount  of  lactose  remains  fairly  constant 
if  the  quantity  of  milk  be  not  excessive  and  the  mammary 
glands  act  normally,  the  child  at  the  same  time  sucking 
well ;  in  other  words,  where  the  production  and  exhaus- 
tion of  milk  are  equal.  The  largest  amount  of  lactose  is 
found  the  day  following  lactation,  as  the  breasts  are  at 
this  time  in  a  state  of  great  activity,  and  lactose  is  being 
absorbed  into  the  blood. 

2.  Case  illustrating  the  effect  of  breast  distension  and 
the  amplication  of  belladonna. — No.  52,  aged  19,  primi- 
para  (anaemic),  breasts  well  developed.  Female  child, 
alive,  full  time,  7  lbs.  4  oz. 

No  milk.     Colostrum. 

Milky  fluid  present.     Uses  nipple  shield. 

Milk   fully  in.     Breasts  distended.     Uses 

nipple  shield. 
Breasts  much  distended.     Some  overflow. 
Much  distension.     Slight  overflow. 
Distension  Ipss.  „  „ 

Distension  lessening.     Slight  overflow. 


Ist  day 

No  sugar 

2nd,, 

J. 

3rd  „       . 

•25  per  cent. 

4th  „ 

•67 

5th  „ 

•50 

6th  „ 

•42 

7th  „ 

•34 

DURING    THE    TUERPEEAL    STATE. 


481 


8th  day 

•24 

per  cent 

9th  „       . 

•24 

„ 

10th  „ 

•24 

„ 

11th  „ 

•39 

" 

12th  „ 

•34 

" 

13th  „       , 

•40 

» 

Uth  „       . 

•50 

>> 

15th  „       . 

•25 

,, 

16th  „       . 

Xo 

sugar . 

17th  „       . 

, 

18th  „       . 

, 

10th  „       . 

J 

Distension  lessening.     Slight  overflow. 
Belladonna  for  a  few  hours  to  right  breast. 
Right  breast  not  used.     Left,  good  supply. 
Left  breast  inflamed ;  belladonna  applied. 

Good  supply  from  right. 
Belladonna    still   applied    to    left.       No 

overflow. 
Belladonna    still   applied.      No    overflow. 

Child  weaned. 
Belladonna. 

Child  reapplied  to  right  breast. 
Belladonna  stopped. 
Some  milk  in  right  breast. 
Still  some  milk  iu  right  breast. 
No  milk. 


The  effect  of  breast  distension  is  well  illustrated  here 
by  the  increased  amount  of  lactose  found  on  the  fourth  and 
fiftb  days,  diminution  in  the  amount  of  distension  being 
accompanied  by  diminution  in  the  amount  of  lactosuria. 
The  quantity  remains  constant  until,  owing  to  the  applica- 
tion of  belladonna,  an  increase  occurs,  followed  by  a  diminu- 
tion and  final  disappearance,  when,  as  a  result,  the  milk  is 
not  produced,  at  the  same  time  the  stimulating  effect  of 
the  sucking  of  the  child  is  absent. 

3.  Case  illustrating  the  effect  of  'prematurity  and  still' 
hirth. — No.  2G,  aged  27,  primipara,  fairly  Avell  nourished, 
breasts  well  developed.  Male  child,  still,  premature, 
3  lbs.  8  oz. 


1st  day 

.     No 

sugar 

No  milk.     Colostrum. 

2nd,, 

•17 

per  cent. 

„                   „           (Urine  by  catheter.) 

3rd  „ 

No 

sugar 

Milk  in  both  breasts. 

4th  „ 

•34 

per  cent. 

Breasts  overflowing.     Slight  distension. 

5th  „ 

•22 

„ 

„             „                 No  distension. 

6th  „       . 

•22 

„ 

„             „                 No  discomfort. 

7th  ,. 

•24 

„ 

No  overflow. 

9th  „       . 

•19 

,, 

Very  little  milk. 

10th  „       . 

•19 

„ 

j>         » 

12th  „ 

j>         » 

13th  „       . 

•22 

„ 

Pale  watery  fluid  in  right  breast. 

14th  „       . 

fT 

•22 

.  1           ff 

No  fluid  in  breasts. 
I       p  1 ^j.    j:_i : :_    :j~_x 

Here,  again,  the  effect  of  breast  distension  is  evident. 


482 


OCCURRENCE    OF    SUGAR    IN    THE    URINE 


The  lactose  occurred  in  comparatively  small  quantity 
throughout.  With  the  diminution  of  milk  came  a  corre- 
sponding change  in  the  amount  of  lactose. 

4.  Case  shoicing  a  small  amount  of  lactose  accomi')anied 
by  a  small  tnilk-supply . — No.  81,  aged  26,  3-para,  anaemic, 
breasts  fairly  well  developed.  Female  child,  alive,  full 
time,  8  lbs. 

No  milk.    Colostrum.    (Urine  by  catheter.) 

Colostrum. 

Milky  fluid  in  breasts. 

Milk  present.   No  overflow.    No  distension. 

Slight  overflow.     Breasts  flabby. 

Right  breast  full.     No  overflow. 

Good  supply  of  milk. 

Slight  overflow.     Less  milk. 

Slight  distension  of  left.     No  overflow. 
No  overflow.     Child  sucking  well. 


The  effect  of  increased  milk-supply  together  v/ith  breast 
distension  is  well  illustrated  here  also. 

In  this  case  the  milk,  which  was  small  in  amount,  was 
being  consumed  rapidly  by  the  child,  so  that  no  lactose 
was  absorbed  into  the  blood. 

5.  A  large  quantity  of  sugar  xvltli  a  large  supply  of  milk. 
— No.  9,  aged  24,  primipara,  healthy,  breasts  well  deve- 
loped. Male  child,  full  time,  weakly,  6  lb.  12  oz.  ;  ill- 
nourished  Avhen  discharged  from  hospital. 

Milk  in  breasts. 


1st  day 

No  sugar 

2nd,, 

•22  per  cent.     . 

3rd  „ 

No  sugar 

4th  „ 

» 

5th  „ 

„ 

6th  „ 

3> 

7th  „ 

•17  per  cent.     . 

8th  „ 

No  sugar 

9th  „ 

•19  per  cent.     , 

10th  „ 

•22 

nth  „ 

•22 

12th  „ 

.     No  sugar 

13th  „ 
14th  „ 

•17  per  cent.     . 

,  .    ,       J  During  labour  '18  per  cent. 
^^    L  After  labour      -18 


2nd 
3rd 

4th 


5th 
6th 


•20 
•69 


•25 


•37 
•65 


Milk  overflowing.  Left  nipple 
depressed. 

Milk  poor  in  quality,  over- 
flowing, especially  from  right 
breast. 

Overflow  from  both  breasts. 

Much  overflow,  more  on  right 
side.  Nipple  shield  used. 
Child  not  sucking  well. 


DURING    THE    PDERPEEAL    STATE.  483 

7th  day  .  .     •25  per  cent. .     Overflow.  Child  sucking  better. 

8th  „    .  ,  .     -30        „         .     Overflow.     Child  sucking  well. 

9tli  „    .  .  .     "25        „         .     Continuous  overflow  from  both 

breasts. 
10th  „    .  .  .  .     Breasts   very   full.      Constant 

overflow. 
11th  „    .  .  .     •40        „         .     Overflow.  Child  sucking betttr. 

12th  „    .  .  .     •3-t        „         .     Overflow. 

13th  ,,    .  .  .     '25        „         .     Increased  overflow. 

14th  „    .  .  .     ^34        „         .     Overflow  continues. 

N.B. — The  possibility  of  diabetes  or  of  gouty  glyco- 
suria was  entertained  in  this  case,  but  no  evidence  of  these 
was  forthcoming. 

In  this  case  the  largest  amount  of  lactosuria  was 
obtained,  namely,  '69  per  cent,  on  the  third  day,  and  in 
addition  a  large  amount  was  present  daily  throughout  the 
puerperium. 

As  a  distended  condition  of  the  breasts  was  not  present, 
this  case  clearly  shows  how  excessive  production  of  milk 
leads  to  increased  lactosuria.  In  addition,  owing  to 
depression  of  one  nipple,  the  child,  who  was  weakly  at 
birth,  did  not  suck  vigorously,  and  thus  what  would  have 
been  a  source  of  increased  stimulation  to  the  mammary 
glands  was  absent.  The  milk  was  poor  in  quality,  but 
evidently  contained  a  large  quantity  of  milk-sugar.  It 
will  be  seen  also  that  sugar  was  present  during  and  after 
labour,  and  that  milk  existed  in  the  breasts  at  this  period."^ 

Although  as  Hofmeister  has  proved,  the  sugar  found 
in  the  urine  of  women  during  lactation  is  milk-sugar,  still 
temporary  glycosuria  might  also  occur. f  This  condition 
is  found  after  eating  an  excessive  quantity  of  saccharine 
and  amylaceous  food,  after  asthma  and  epileptic  fits, 
after    mental    anxiety, J    and    in   gouty    persons.       After 

*  The  diet  of  the  patients  consisted  chiefly  of  milk  for  three  days,  when  a 
meat  diet  was  substituted. 

t  Glycosuria  is  also  observed  during  recovery  from  cholera;  also  as  a 
result  of  blows  on  the  head  and  spinal  concussion. 

t  (a)  Goodhart,  '  Brit.  Med.  Journ.,'  Dec,  1889;  {h)  Ord,  'Brit.  Med. 
Journ.,'  Xov.,  1889. 


484  OCCURRENCE    OF    SUGAR    IN    THE    URINE 

chloroform  administration  a  substance  has  been  shown  to 
exist  in  the  urine  which  has  the  power  of  reducing 
Fehling's  solution."^ 

Fi'om  the  observations  on  this  subject  the  following 
conclusions  may  be  drawn  : 

1.  As  proved  by  Hofmeister,  the  sugar  present  in  the 
urine  of  women  during  lactation  is  milk-sugar.  Glucose 
may  in  addition  be  found. 

2.  That  lactosuria  is  present  at  some  period  in  every 
case. 

3.  That  in  the  majority  of  cases  the  largest  amount 
occurs  on  the  fourth  and  fifth  days  of  the  puerperium. 

4.  That  the  quantity  depends  on  (1)  the  condition  of 
the  breasts  ;  (2)  the  quantity  and  quality  of  the  milk  ; 
(3)  the  sucking  of  the  child.  Out  of  the  100  cases  the 
average  quantity  found  was  "35  per  cent.,  i.  e.  1^  grains 
per  ounce. 

5.  That  when  lactation  is  diminished  or  suppressed  the 
amount  of  lactosuria  is  also  diminished  or  disappears. 

6.  That  when  the  production  and  exhaustion  of  the 
milk  are  equal  the  amount  of  lactosuria  is  very  small. 

The  thanks  of  the  authors  are  due  to  Drs.  Hope  and 
Grigg  for  permission  to  publish  the  cases. 

*  Aslidown,  '  Report  of  Royal  College  of  Physicians'  Laboratory,  Edin.' 


DURING    THE    PUERPERAL    STATE. 


485 


Lactosuria  during  the  Puerperium. 
(*  Indicates  the  cases  detailed  in  full.) 


Dav  of 

Breatest 

On 

first 

First 

Case 

Age. 

Para. 

quantity 

what 

appear- 

day of 
lacta- 
tion. 

Remarks. 

)er  cent. 

day. 

ance 
of  sugar. 

1 

36 

6 

•40 

6tli 

4th 

3rd 

2 

21 

\  ' 

•24 

8th 

2nd 

4tl» 

3 

21 

•26 

10th 

3rd 

3rd 

Twins.  Breasts  distended  on 
10th  day. 

4 

24 

•40 

4th 

4th 

3rd 

Breasts  distended  on  3rd  day. 
Child  sucked  feebly. 

5 

25 

•50 

5th 

4th 

3rd 

6 

20 

•19 

9th 

4th 

3rd 

Breasts  overflowed.  No  disten- 
sion. 

7 

33 

•40 

3rd 

3rd 

3rd 

8 

24 

•66 

4th 

3rd 

3rd 

Breasts  distended  on  4tli  day. 

9 

20 

•69 

3rd 

1st 

1st 

Much  sugar  was  present 
throughout  the  puerperium.* 

10 

20 

•24 

4th 

2nd 

3rd 

11 

20 

•18 

4th 

3rd 

3rd 

No  distension  of  breasts.  Very 
slight  lactosuria  throughout. 

12 

38 

•34 

5th 

2nd 

3rd 

13 

32 

•40 

8th 

3rd 

6th 

Very  little  milk.  Child  had 
mixed  feeding. 

14 

22 

•34 

3rd 

'~~ 

3rd 

Urine  not  examined  on  1st  and 
2nd  days.  Milk  plentiful; 
much  overflow. 

15 

20 

•65 

5th 



3rd 

16 

27 

•19 

10th 

3rd 

3rd 

Very  slight  lactosuria  through- 
out. No  distension;  no  over- 
flow. 

17 

19 

•19 

5th 

3rd 

3rd 

18 

36 

•25 

6th 

2nd 

4th 

Very  small  milk  supply.  Child 
fed  artificially. 

19 

17 

•24 

7th 

3rd 

3rd 

Breasts  distended  on  5th  and 
6th  days. 

20 

21 

•40 

5th 

2nd 

3rd 

Breasts  distended  on  4th  day. 

21 

20 

•24 

4th 

2nd 

4th 

Slight  lactosuria  throughout. 

22 

24 

•25 

6th 

2nd 

3rd 

Small  milk  supply. 

23 

19 

•19 

11th 

1st 

3rd 

Lactosuria  slight  until  breasts 
overflowed  on  11th  day. 

24 

30 

•40 

5th 

3rd 

4th 

25 

24 

•18 

9tli 

5th 

3rd 

Very  slight  lactosuria.  No' 
overflow ;  no  distension. 

26 

27 

•34 

4th 

2nd 

3rd 

Child  stillborn ;  premature.* 

27 

20 

•40 

4th 

1st 

3rd 

28 

26 

•19 

12th 

3rd 

3rd 

Breasts  overflowed  after  11th 
day. 

29 

20 

•40 

5th 

2nd 

3rd 

486 


OCCURRENCE    OF    SUGAR   IN    THE    URINE 


Greatest 

On 

Day  of 

first 

First 

Case. 

Age. 

Para. 

quantity 

wliat 

appear- 

day of 

Remarks. 

per  ceut. 

day. 

ance 
of  sua;ar. 

lacta- 
tion. 

30 

29 

1 

•34 

4th 

1st 

3rd 

Large  supply  of  milk. 

31 

29 

1 

•65 

4th 

1st 

4th 

32 

23 

1 

•19 

7th 



2nd 

33 

36 

1 

•25 

13th 

1st 

4th 

Little  milk;  little  sugar. 

34 

39 

12 

•24 

5th 

5th 

— 

Child  stillborn  and  premature ; 
no  milk  could  be  expressed. 

35 

21 

1 

•19 

1 

11th 

1st 

3rd 

Child  stillborn ;  probably  pre- 
mature. Constant  overflow  ; 
no  distension. 

36 

21 

1 

•40 

5th 

1st 

4th 

Distension  on  5th  day. 

37 

24 

1 

•34 

10th 

2nd 

3rd 

Child  premature ;  alive. 

38 

24 

4 

•22 

2nd 

1st 

4th 

39 

37 

10 

•40 

2nd 

2nd 

3rd 

40 

20 

2 

•19 

8th 

1st 

4th 

Anencephalous  foetus. 

41 

30 

3 

•24 

3rd 

1st 

3rd 

42 

26 

2 

•24 

4th 

3rd 

3rd 

Breasts  distended  on  4th  day. 

43 

23 

1 

•19 

9th 

1st 

4th 

44 

23 

1 

•22 

3rd 

1st 

3rd 

45 

24 

1 

'40 

5th 

2ud 

4th 

# 

46 

22 

2 

•19 

4th 

2nd 

3rd 

47 

26 

1 

•24 

9th 

2ud 

3rd 

48 

18 

1 

•24 

5th 

1st 

3rd 

49 

24 

1 

•50 

4th 

2nd 

4th 

Large  quantity  of  sugar. 

50 

24 

1 

•34 

7th 

1st 

3rd 

51 

25 

1 

•40 

5th 

3rd 

4th 

Slight  distension  on  4th  day. 

52 

19 

1 

•67 

4th 

3rd 

3rd 

Great  distension  on  4th  and  5th 
days.* 

53 

22 

1 

•34 

5th 

3rd 

4th 

Child  stillborn  and  premature. 

54 

22 

1 

•34 

4th 

2nd 

5th 

55 

20 

1 

•25 

11th 

3rd 

3rd 

Overflowed  after  10th  day. 

56 

24 

2 

•50 

5th 

2nd 

4th 

Slight  distension  on  4th  and 
5th  days. 

57 

27 

3 

•34 

13th 

1st 

4th 

58 

41 

12 

•25 

3rd 

3rd 

4th 

Small  milk  supply. 

59 

20 

1 

•24 

6th 

3rd 

5th 

60 

24 

1 

•40 

2nd 

2nd 

4th 

61 

22 

1 

•40 

2nd 

— 

3rd 

62 

34 

1 

•40 

5th 

3rd 

3rd 

63 

21 

1 

•50 

4th 

2nd 

4th 

64 

21 

2 

•34 

4th 

2nd 

4th 

Child  premature ;  alive. 

65 

20 

1 

•24 

4th 

3rd 

2nd 

66 

32 

5 

•40 

7th 

1st 

4th 

Breasts  distended  on  7th  day. 

67 

21 

1 

•36 

14th 

1st 

4th 

Overflow  towards  end  of  puer- 
perium. 

68 

19 

1 

•34 

5  th 

3rd 

4th 

69 

20 

1 

•40 

4tli 

1st 

3rd 

70 

29 

1 

•40 

5th 

1st 

4th 

Not  much  milk.  Child  prema- 
ture; alive. 

71 

22 

1 

•40 

5tli 

1st 

3rd 

72 

29 

1 

2 

•50 

3rd 

1st 

3rd 

DDRING    THE    PUERPERAL    STATE. 


487 


Day  of 

Greatest 

On 

first 

I'irst 

Case. 

Age. 

Para. 

quantity 

what 

appear- 

day of 
lacta- 

Remarks. 

per  cent. 

(lay. 

ance 

of  sugar. 

tion. 

— --' 

73 

22 

1 

•34 

4th 

4th 

5th 

74 

26 

1   1 

•40 

3rd 

2nd 

5th 

75 

18 

1    1 

■34 

5th 

4th 

4th 

Breasts  slightly  distended  on 
5th  day. 

76 

24 

1 

•24 

5th 

1st 

4th 

Small  amount  of  sugar  through- 
out. 

77 

20 

1 

•34 

4th 

4th 

4th 

Child  weakly ;  premature. 

78 

21 

1 

•24 

6th 

4th 

4th 

79 

26 

1 

•40 

5  th 

— 

4th 

80 

28 

1 

•50 

3rd 

2nd 

4th 

81 

26 

3 

1 

•22 

2nd 

2nd 

4th 

Very  small  quantity  of  sugar,* 
associated  with  small  supply 
of  milk. 

82 

25 

2 

•22 

5th 

4th 

5  th 

83 

29 

2  1 

•40 

12th 

1st 

3rd 

84 

29 

1 

•22 

10th 

2nd 

3rd 

Late  distension  (9th  day). 

85 

20 

1 

•22 

4th 

1st 

2nd 

86 

19 

•24 

4th 

3rd 

4th 

87 

30 

•24 

6th 

3rd 

5th 

88 

36 

•25 

5th 

1st 

3rd 

89 

32 

•40 

4th 

2nd 

2nd 

Child  stillborn  J  premature. 

90 

19 

.. 

•34 

5th 

3rd 

3rd 

91 

20 

•22 

10th 

3rd 

2nd 

92 

20 

•24 

6th 

2nd 

4th 

93 

24 

•45 

4th 

4th 

3rd 

Breasts  distended  on  4th  and 
5th  days. 

94 

23 

•14 

5th 

— 

— 

95 

22 

•40 

6th 

2nd 

4th 

Breasts  distended  on  6th  day. 

96 

25 

•24 

4th 

4th 

4th 

97 

25 

•65 

5th 

3rd 

4th 

,  98 

27 

1 

•22 

7th 

1st 

4th 

99 

28 

•34 

4th 

1st 

4th 

Inflammation  of  breast  on  9th 
day. 

100 

22 

4 

•34 

3rd 

1st 

4th 

N.B.~The  numbers  in  the  three  last  columns  refer  to  the   days  of  the 
puerperiura. 


488  OCCURRENCE    OF    SUGAR    IN    THE    URINE 

Dr.  Amand  IiOUTH,  after  referriug  to  the  value  of  the 
authors'  paper,  asked  it"  they  had  been  able  to  follow  any  of  the 
eases  so  as  to  ascertain  whether  the  glycosuria  persisted.  In 
a  paper  read  before  this  Society  ('Transactions,'  vol.  xxiv)  by 
Dr.  Matthews  Duncan,  on  "  Peripheral  Diabetes  in  Pregnancy 
and  Lactation,"  the  author  gave  notes  of  several  cases  of  the 
former  and  two  of  the  latter  where  the  condition  persisted.  It 
was  true  that  in  these  cases  there  was  a  larger  percentage  of 
sugar  than  in  the  cases  now  under  discussion,  but  information 
on  the  question  would  be  valuable  as  to  the  permanency  of  the  ten- 
dency in  these  minor,  and  primarily  perhaps  physiological  cases. 

Dr.  BoxALL  said  that  his  attention  liad  been  early  directed  to 
the  presence  of  sugar  in  the  urine  of  suckling  women  by  a  case 
which  was  admitted  into  University  College  Hospital  for  the 
purpose  of  repairing  her  perineum.  The  infant  had  been  taken 
from  the  breast  on  the  morning  of  the  preceding  day.  On  exa- 
mining the  urine  a  copious  brick-red  deposit  of  suboxide  was 
given  by  Fehling's  test.  The  operation  was  in  consequence 
postponed  for  a  week  or  two,  by  which  time  the  sugar  had  disap- 
peared. Dr.  Boxall  put  forward  the  practical  point  for  con- 
sideration, whether  postponement  of  the  operation  was  or 
was  not  advisable  in  such  a  case.  When  resident  in  the 
General  Lying-in  Hospital  he  had  made  innumerable  observa- 
tions with  regard  to  the  presence  of  sugar  in  the  urine  of  lying-in 
women.  His  observations  coincided  in  every  respect  with  the 
conclusions  reached  by  the  authors  of  the  paper. 

Dr.  HoREOCKS  pointed  out  that  the  paper  was  on  a  physio- 
logical and  not  a  pathological  subject.  The  cases  were  not 
diabetic,  and  in  none  of  them,  therefore,  was  there  any  reason 
for  hesitating  to  perform  any  operation  required.  In  true  diabetes 
the  fear  of  operation  might  induce  coma,  but  otherwise  he  knew 
of  no  reason  for  not  operating  upon  diabetic  patients. 

Dr.  WiiEATON  said  that  he  had  examined  the  urine  in  a  large 
number  of  women  during  lactation,  and  agreed  in  the  main  with 
the  authors'  results.  He  did  not,  however,  think  that  sugar  was 
so  frequently  present  as  stated  in  the  paper.  Normal  urine 
always  contained  a  small  amount  of  copper-reducing  substances. 
In  the  instances  where  such  a  small  amount  as  "17  per  cent,  of 
sugar  was  found  by  the  authors,  he  thought  that  the  reduction 
of  the  copper  solution  was  probably  due  to  uric  acid  and  urates, 
which  were  generally  present  in  excess  in  the  urine  during 
the  early  part  of  the  lactation  period.  The  authors  had  not 
shown  that  the  sugar  present  in  the  urine  was  really  lactose  or 
milk-sugar,  the  distinction  between  which  and  the  ordinary 
dextrose  or  diabetic  sugar  was  very  difficult.  He  inquired 
whether  the  authors  had  found  any  test  which  would  distinguish 
between  these  two  forms  of  sugar.  It  was  stated  that  if  lactose 
were  present  the  urine  gave  a  pink  precipitate  after  boiling  with 


DURING   THE    PUERPERAL    STATE.  489 

basic  lead  acetate  and  the  addition  of  ammonia,  but  he  had  found 
this  test  fail  even  in  artificial  solutions  of  lactose.  It  seemed  a 
most  unusual  thing  that  the  secretion  of  a  gland  should  be  re- 
absorbed, and  it  would  be  important  to  ascertain  whether  the 
sugar  existed  in  the  blood  during  lactation,  and  also  whether 
similar  phenomena  occurred  in  animals.  He  had  found  that  in 
cases  where  a  considerable  amount  of  sugar  was  present  in  the 
urine  ol'  the  mother,  it  was  also  present  in  that  of  the  suckling 
infant.  This  suggested  that  the  sugar  in  question  was  incapable 
of  assimilation,  and  of  a  more  or  less  poisonous  nature  ;  and  that 
its  presence  in  excess  in  the  milk  might  be  injurious  to  the  child. 
Until  the  real  origin  of  the  sugar  was  ascertained  it  was  quite 
possible  that  it  was  derived  from  the  liver  of  the  mother,  under 
the  influence  of  a  temporary  congestion,  to  which  there  was  a 
great  tendency  in  the  organs  during  pregnancy  and  the  puerperal 
period,  or  a  ferment  might  be  present  iu  the  mother's  blood  pro- 
ducing a  similar  effect  by  the  decomposition  of  glycogen  in  the 
liver.  In  this  case  the  affection  would  be  a  true  but  temporary 
diabetes.  They  had  no  evidence  that  permanent  diabetes  ever 
followed  this  condition.  The  question  was  of  great  importance 
from  the  point  of  view  of  life  insurance,  although  women  did  not 
often  insure  their  lives,  especially  during  the  lactation  period. 
He  thought  that  a  case,  in  which  sugar  was  present  during  lacta- 
tion only,  might  be  accepted  at  the  ordinary  rates  for  insurance. 
Dr.  CuLLi>'GWORTH,  after  a  few  words  in  commendation  of  the 
paper,  suggested  an  alteration  in  the  heading  of  the  last  column 
of  the  main  table,  which  would,  he  thought,  make  its  meaning 
more  clear.  (Dr.  McCann  at  once  accepted  Dr.  Cullit)gworth's 
suggestion.) 

Dr.  Lewees  asked  whether  reliance  had  been  placed  solely  on 
Fehling's  test,  or  whether  other  controlling  observations  had  been 
made — for  example,  by  the  test  with  potash,  and  by  taking  the 
specific  gravity. 

Dr.  W.  S.  A.  Griffith  remarked  that  the  valuable  paper  just 
read,  though  short,  was  the  outcome  of  a  great  deal  of  work  done 
by  Dr.  McCann  while  resident  at  Queen  Charlotte's  Hospital. 
The  chief  results  of  this  investigation  were  the  demonstration  of 
the  constancy  of  the  presence  of  some  form  of  sugar  in  the  urine 
of  nursing  women,  and  the  probable  explanation  of  this  as  a  re- 
absorption  process  from  the  mammary  glands  varying  in  quantity 
with  the  activity  of  secretion,  and  the  difficulty  with  which  the 
breasts  were  emptied,  and,  as  had  been  suggested,  possibly  with 
the  composition  of  the  milk.  He  asked  whether  the  effects  attri- 
buted to  belladonna  were  not  probably  to  be  explained  by  the  same 
causes,  the  emptying  of  the  breasts  being  suddenly  arrested? 

Dr.  McCann  on  behalf  of  Dr.  W.  A.  Turner  thanked  the 
Fellows  of  the  Society  for  the  reception  given  to  the  paper.     The 
object  of  the  investigation  was  to  determine  whether  or  not  sugar 
VOL.  XXXIV.  34 


490  OCCUERENCE    OP    SUGAR   IN    THE    URINE. 

be  present  in  the  urine  of  every  woman  at  some  period  during 
lactation.  For  this  purpose  one  hundred  cases  were  recorded, 
and  over  1400  samples  of  urine  tested.  Although  more  or  less 
definite  statements  on  this  subject  appeared  in  the  text-books, 
yet  the  largest  number  of  cases  systematically  investigated  was 
twelve.  In  tlie  present  series  of  observations  the  condition  of 
the  mammary  glands  and  the  presence  of  sugar  in  the  urine  were 
recorded  daily.  The  authors  followed  strictly  the  method  of 
testing  with  Fehling's  solution  advocated  by  Sir  William  E-oberts. 
(1)  Avoid  prolonged  boiling.  (2)  Allow  suspected  urine  to 
stand  twenty-four  hours  before  deciding  that  it  does  not  contain 
sugar.  (3)  Do  not  add  excess  of  urine.  In  answer  to  the  ques- 
tions asked,  Dr.  McCann  pointed  out  the  importance  of  distinguish- 
ing between  glycosuria  and  diabetes.  As  was  the  case  with  albu- 
minuria, glycosuria  with  absence  of  constitutional  symptoms  was 
of  little  importance.  He  agreed  with  Dr.  Amand  South  in  think- 
ing that  the  cases  should  be  traced,  but  this  was  impossible,  owing 
to  lactation  being  stopped  when  the  patients  left  the  hosj^ital. 
In  answer  to  Dr.  Wheaton,  he  stated  that  defective  methods  of 
testing  accounted  for  the  statement  that  sugar  was  seldom  found 
in  the  urine  during  lactation,  that  the  only  method  of  distin- 
guishing glucose  fi'ora  lactose  was  by  the  polariscope  ;  that  where 
much  sugar  was  present  in  the  urine,  and  probably  accompanied 
by  a  large  amount  of  lactose  in  the  milk,  the  nutritive  value 
of  which  was  diminished  (see  Case  9  in  paper),  and  that  he 
purposed  making  some  experiments  on  animals  as  to  the  pres- 
ence o£  sugar  in  the  blood.  Various  tests  had  been  employed; 
the  quantitative  estimation  was  made  with  Pavy's  solution. 
Sugar  disappeared  from  the  urine  quicker  when  belladonna  was 
applied  to  the  breasts.  In  conclusion  he  referred  to  the  many 
important  points  still  requiring  elucidation  as  to  the  composition 
of  the  milk,  its  nutritive  value,  and  the  condition  of  the  blood 
during  lactation. 


491 


A    CASE    OF   GALACTORRHCEA    DURING    A 
FIRST    PREGNANCY. 

By  W.   S.  A.   Griffith,  M.D.,  F.R.C.S.,  M.R.C.P., 

ASSISTANT   PHYSICIAN   ACCOUCHEUK,    ST.    BAETHOLOMEW'S    HOSPITAL; 
XJNIVEESITY   lECTUEEE    IN   OBSTETEICS,   CAMBEIDGE. 

(Received  February  lltli,  1892.) 

The  case  here  recorded  was  under  the  care  of  Dr. 
Fentem,  of  Catcliffe,  Bakewell,  who  has  sent  me  the  notes 
and  given  me  permission  to  publish  them. 

The  common  dei&nition  of  galactorrhoea  is  an  excessive 
flow  of  milk,  accompanied  with  marked  debility  and 
wasting  of  the  patient.  But  though  these  latter  were 
fortunately  absent  in  this  case,  it  may  fairly  be  called  a 
case  of  galactorrhoea,  and  we  must  modify  our  definition 
accordingly,  and  include  cases  of  copious  milk-flow  in 
pregnant  and  non-pregnant  women. 

The  close  relationship  between  the  uterus  and  the 
breasts  needs  no  demonstration,  and  it  would  seem  a  very 
short  step  for  the  active  mammary  gland  of  pregnancy  to 
complete  its  function  and  secrete  milk  as  after  delivery. 

Treatment  in  this  case  was  of  the  usual  kind,  and 
apparently  was  without  material  benefit,  and  probably 
nothing  short  of  the  termination  of  the  pregnancy  would 
have  arrested  the  milk-flow. 

Mrs.  R — ,  aged  28,  was  married  on  February  18th, 
1890.  She  had  enjoyed  good  health  all  her  life,  and  first 
menstruated  when  thirteen  and  a  half  years  old,  keeping 
regular  until  her  marriage.  A  fortnight  after  this  the 
bowels,  which  previously  had  been  regular,  became 
obstinately    constipated,   and  the    appetite   bad.       There 


492  GALACTORRH(EA   DURING    A    FIRST    PREGNANCY. 

was  at  first  mucli  sickness.  On  March  28tli  she  noticed 
that  the  left  breast  was  secreting  milk,  and  three 
weeks  after  the  right  one  began.  At  first  the  quantity- 
measured  from  2  to  4  oz.  from  each  daily,  but  in  three 
months  it  increased  to  from  three  quarters  of  a  pint  to  a 
pint,  and  some  days  even  more.  The  secretion  was  at 
first  like  watery  milk,  but  it  soon  became  thicker,  and  at 
times  was  like  cream.  As  a  rule  it  was  like  new  milk. 
The  breasts  were  very  small  before  marriage,  but  began 
to  enlarge  immediately  after.  In  July,  the  patient  felt 
very  weak  and  had  much  headache,  especially  frontal,  and 
had  pains  down  the  shin-bones  with  aching  of  the  feet, 
which  burned  much  at  night. 

The  treatment  consisted  in  the  administration  of  iron 
and  quinine  with  pilocarpine,  and  in  firmly  bandaging  the 
breasts,  and  applying  pads  made  of  absorbent  wool, 
which  gave  relief;  on  August  29th  the  breasts  had 
almost  ceased  to  run,  but  ten  days  later  they  suddenly 
began  again,  and  continued  until  the  day  of  her  confine- 
ment, November  22nd,  1890.  During  the  last  month 
the  quantity  of  milk  was  less  than  at  any  period  after 
March  12th. 

After  her  confinement  both  mother  and  child  did  well  ; 
there  was  more  milk  than  the  child  could  take,  and  at 
times  it  ran  quite  in  a  stream,  but  the  mother's  health 
was  not  impaired  by  it. 

In  September,  1891,  however,  Mrs.  R —  complained  of 
weakness  and  faintness  when  exerting  herself,  and  Dr. 
Fentem  advised  her  to  nurse  the  baby  only  at  night ; 
there  was  still  plenty  of  milk,  and  the  baby  was  thriving. 
At  the  end  of  this  month  she  cut  her  hand  badly,  losing 
a  large  quantity  of  blood.  From  this  time  the  milk  gradu- 
ally diminished,  and  ceased  on  October  28th,  1891. 
Menstruation  had  returned  in  June,  1891,  profusely  the 
first  time,  and  recurred  three  times  afterwards  up  to 
September,  1891,  when  she  was  quite  strong  and  well. 

There  was  no  history  of  phthisis  in  the  family :  her 
mother  suffered  from  cancer  of  the  breast,    and  died  at 


GALACTORRHCEA    DURINa    A    FIRST    PREGNANCY.  493 

the  age  of  forty-five  ;  her  father  died,  aged  fifty-one,  from 
apoplexy  ;  there  are  two  brothers  and  two  sisters  living 
and  in  good  health. 

February  9th,  1892. — Mrs.  R —  is  again  pregnant,  and 
thinks  she  must  take  the  time  from  September  or  early 
in  October  ;  she  is  very  well,  and  suffers  none  of  the  in- 
conveniences of  her  first  pregnancy ;  the  breasts  seem 
perfectly  quiescent. 

Very  few  writers  refer  to  the  occurrence  of  galactor- 
rhoea  during  pregnancy  ;  this  case  appears  to  be  excep- 
tional in  its  occurrence  in  a  first  pi'egnancy,  and,  indeed, 
almost  at  its  very  commencement. 

Most  authors  do  not  describe  this  form ;  those  who  do, 
merely  mention  it  without  remarks  and  without  reference  to 
cases.  The  same  two  cases  are  quoted  by  C.  Devilliers 
{'  Dictionnaire  de  Medecine  et  de  Chirurgie  pratique,' 
t.  XV,  p.  544,  1872),  and  by  Gueneau  de  Mussy  ('  Archives 
generales  de  Medecine,'  1856,  p.  649). 

(1)  A  married  woman,  aged,  26,  ceased  nursing  fifteen 
days  after  delivery,  both  breasts  being  inflamed ;  the 
right  continued  to  secrete  a  little  clear  fluid,  which 
increased  considerably  when  she  again  became  pregnant ; 
the  flow  continued  through  the  second  pregnancy.  After 
a  normal  delivery  profuse  galactorrhoea  ensued. 

(2)  A  woman  in  the  fifth  month  of  pregnancy  (it  is 
not  stated  which  pregnancy)  suffered  from  a  flow  of  milk 
measui'ing  about  one  and  a  half  pounds  a  day,  which  was 
diminished  by  treatment  to  one  half-pound  ;  both  mother 
and  baby  did  well. 

These  are  the  only  cases  I  have  been  able  to  find. 


INDEX. 


PAGE 

Abdominal  section,  the  value  of,   in  certain  cases  of  pelvic 

peritonitis  (C.  J.  CuUingworth)  .  .  .     254 

Abortion,  the  relation  between  backwai'd  displacements  of  the 
uterus  and  prolonged  hsemoiThage  after  delivery  and  (G. 
E,  Herman)  .  .  .  .  .14 

knitting-needle  used  to  pi'ocure  (William  Duncan)  .     223 

Abscess  of  ovary  (Heywood  Smith)  .  .  .3 

tubo-ovarian,  large  pyosalpinx  simulating  (C.  J.  CuUing- 
worth)        .  .  .  .  .  .437 

Acardiac  acephalous  fcetus  (M.  Handfield-Jones)         .  .       84 

Acephalous  acardiac  foetus  (M.  Handfield-Jones)         .  .       84 

Addinsell  (A.  W.),  Remarks  in  discussion  on  G.  E.  Herman's 

paper  on  menstruation  in  cases  of  backward  displacement 

of  the  uterus  .....    238 

Address  (Annual)  of  the  President,  J.  Watt  Black,  M.D.,  Feb- 

i-uary  3rd,  1892  .  .  .  .  .33 

Annual  General  Meeting,  February  3rd,  1892  •  .       23 

Anus,  imperforate  (A.  E.  Giles)  ....  129 
Apoplexy,  double  ovarian,  from  a  case  of  acute  peritonitis  (H. 

A.  Des  Vceux)  .  .  .  .  .214 

of  the  ovum  in  a  case  of  unruptured  tubal  gestation  (C. 

J.  CuUingworth)        .....  155 

(C.  J.  CuUingworth)       ....  182 

Apostoli's  method  in  the  treatment  of  fibroma  and  other  morbid 

conditions  of  the  uterus  (J.  Inglis  Parsons)          .                 .  22 

Artery,  right  hypogastric,  absence  of  (A.  E.  Giles)  .  .  129 
Ascites  caused  by  papillomatous  cyst  of  both  ovaries  (Alban 

Doran)        .  .  .  .  .  .149 

Aseptic  instruments  (P.  Horrocks)                .                 .                 .  460 


Barker,    Benjamin    Fordyce, 
notice  of 


M.D.,    of   New   York,    obituary 


49 


496  INDEX. 

PAGE 


Beale  (George  B.),  see  Doran. 

Bennet,  James  Henry,  M.D.,  of  Mentone,  obituary  notice  of 

Bladder,  malformation  of  (A.  E.  Giles) 

• and  ureters,  dilatation  of,  from  pressure,  in  an  infant  (W 

McAdam  Eccles)       .... 
Blake  (C.  Paget),  protracted  gestation 
BoxALL  (Robert),  placenta  praevia  associated  with  unusual  size 

and  shape  of  the  placenta  (shown) 

• ruptured  uterus  (shown) 

BemarTca   in   discussion   on    F.   J.    McCann  and  W.  A 

Turner's  paper  on  the  occurrence  of  sugar  in  the  urine 

during  the  puerperal  state       ... 
Braun  von  Fernwald,  Carl  Rudolf,  Ritter,  M.D.,  of  Vienna, 

obituary  notice  of    . 
Broad  ligament,  infiltration  of,  with  fat,  in  a  case  of  ovarian 

dermoid  (J.  Bland  Sutton) 

■ rupture  of  tubal  pregnancy  into  (J.  Bland  Sutton) 

Butler-Smythe  (A.  C),  double  pyosalpinx  (shown) 


Caesarean  section  for  contracted  pelvis  (C.  J.  CuUingworth)    .       89 

■ (John  Shaw)   .  .  .  .  .98 

(Leith  Napier)  .  .  .  .105 

■ and  craniotomy,  i-emarks   on    the    relative  position    of 

(A.  H.  N.  Lewers)    ,.,...     161 

uterus,  with  kidneys  and  ureters,  from  a  case  of  (William 

Duncan)      .  .  .  .  .  .127 

Cameron  (Murdoch),  Remarks  in  discussion  on  C.  J.  Culling 
worth's,  John  Shaw's,  and  Leith  Napier's  papers  on 
Ca3sarean  section       .  .  .  .  .117 

Cancer  of  the  body  of  the  uterus  (A.  H.  N.  Lewers)    .  .     213 

Cancerous    uterus    removed    by    vaginal    hysterectomy     (P 

Horrocks)  .  .  .  .  .  .85 

(Amand  llouth)   .....       87 

Carcinoma,  see  Cancer. 

squamous-celled,  of  the  cervix  uteri,  in  which  the  disease 

had  extended  in  an  upwai-d  and  not  in  a  downward  direc- 
tion (C.  J.  CuUingworth)         .  .  .  .     136 

Cat,  pelvis  of,  with  bladder,  uterus,  and  rectum  in  situ  (H.  T. 

Rutherfoord)  .  .  .  .  .251 

Cervix,  see  Uterus  (cervix  of). 
Champneys  (F.  H.),  Beport  as  Chairman  of  the  Board  for  the 

Examination  of  Midwives        .  .  .  29,  31 


40 
129 

250 

28 

464 
11 


488 

55 

7 

217 

24 


INDEX.  497 

PAGE 
Champnets    (F.    H.),  Remarks  in  discussion  on  Herbert  R. 
Spencer's  specimen  of  retroflexion  of  uterus  in  a  new-born 
child  .  .  .  .  .  .28 

— —  in  discussion  on  P.  Horrocks'  specimen  of  cancerous 

uterus  removed  by  vaginal  hysterectomy  .  .       86 

— —  in  discussion  on  C.  J.  Cullingworth's  specimen  of 

squamous-celled  carcinoma  of  the  cervnix  uteri,  in  which 
the  disease  had  extended  in  an  upward  and  not  in  a  down- 
ward direction  .....     137 

in  discussion  on  C.  J.  CullingAvorth's,  John  Shaw's, 

and  Leith  Napier's  papers  on  Cajsarean  section  .  .     139 
in  discussion  on  A.  H.  N.  Lewers'  paper  on  six  cases 

of    ci'aniotomy,  and  the  relative  position  of  craniotomy 

and  Ca3sarean  section  .  .  .  .175 

■ in  discussion  on  C.  J.  Cullingworth's  paper  on  the  value 

of  abdominal  section  in  certain  cases  of  pelvic  peritonitis     434 
Child,  see  Infant. 
Craniotomy,  six  cases  of,  with  remarks  on  the  relative  position 

of,  and  Cassarean  section  (A.  H.  N.  Lewers)         .  .     161 

CuLLiNGWORTH  (C.  J.)>  case  of  squamous-celled  carcinoma  of 

the  cervix  uteri,  in  which  the  disease  had  extended  in  an 

upward  and  not  in  a  dowTiw'ard  direction  (shown)  .     136 

Beniarks  in  reply     .  .  .  .  .137 

myoma  of  the  cervix  uteri  (shown)        .  .  .     223 

large     pyosalpinx      simulating     tubo-ovai-ian      abscess 

(shown)       .  .  ...  .  .    437 

two  cases  of  pyosalpinx  (shown)           .                 .                 •  219 

Remarks  in  reply     .....  222 

ruptured  tubal  gestation  (shown)         .                 .                 .  134 

unruptured  tubal  gestation,  with  apoplexy  of  the  ovum 

(shown)       ......  155 

Remarks  in  reply     .                 .                 .                 •                 •  157 

Report  of  Committee               ....  157 

tubal   gestation  with  apoplectic  ovum,  sac   unruptured 

(shown)       ......  182 

Report  of  Committee               ....  468 

the  value  of  abdominal  section  in  certain  cases  of  pelvic 

peritonitis,  based  on  a  personal  experience  of  fifty  cases    .  254 

adjourned  debate     .....  442 

Remarks  in  reply     .....  450 

case  of  Csesarean  section  for  contracted  pelvis    .                 .  89 

Remarks  in  reply     .....  146 


498  INDEX. 

PAGE 

CULLINGWORTH  (C.  J.),  Bemcirlcs  in  discussion  on  Heywood 

Smith's  specimen  of  abscess  of  ovary    .  .  .4 

in  discussion  on  P.  Horrocks'  specimen  of  cancerous 

uterus  removed  by  vaginal  hysterectomy  .  .       86 

in  discussion  on  Alban  Doran's  specimen  of  papillo- 
matous cyst  of  both  ovaries  causing  profuse  ascitic  effusion     153 

in  discussion  on  A.  H.  N.  Lewers'  paper  on  six  cases 

of  craniotomy,  and  the  relative  position  of  craniotomy  and 
Caisarean  section       .  .  .  .  .     177 

in  discussion  on  S.  W.  Wheaton's  specimen  of  micro- 
cocci in  the  substance  of  a  decomposing  fibroid  tumour     .     189 

in  discussion  on  S.  W.  Wheaton's  specimen  of  section 

of  mucous  membi-ane  of  the  uterus  of  an  infant  suffering 
from  uterine  haemorrhage        ....     191 

in    discussion   on   A.    H.   N.   Lewers'    specimen   of 

papillomatous  ovarian  cyst     ....     463 

in  discussion  on  F.  J.  McCann  and  W.  A.  Turner's 

paper  on  the  occurrence  of  sugar  in  the  urine  during  the 
puerperal  state  .....     489 

Cysts,  see  Ovarian. 

see  Tumours. 

Dakin  (W.  R.),  Report  on  specimen  of  malformation  of  rectum 

and  bladder,  &c.,  shown  by  A.  E.  Giles  .  .  .     468 

Day,  Edmund  Overman,  M.R.C.S.,  of  Waterloo  Road,  S.E., 

obituary  notice  of     .  .  .  .  .48 

Dermoid  cyst  (A.  L.  Galabin)  .  .  '.  .     441 

ovai'ian  cyst  (J.  Bland  Sutton)  .  .  .5 

with  infiltration  of  broad  ligament  with  fat  (J.  Bland 

Sutton)        .  .  .  .  .  .7 

Des  Vceux  (H.  a.),  double  ovarian  apoplexy  from  a  case  of 

acute  peritonitis  (shown)  ....  214 
Diaphragmatic  hemia,  congenital  (A.  E.  Giles)  .  .     132 

Dilatation  of  bladder  and  ureters  from  pressure,  in  an  infant 

(W.  McAdam  Eccles)  .  .  .  .250 

Displacements,  backward,  of  the  uterus,  the  relation  between, 

and  prolonged  haemorrhage  after  delivery  and  abortion  (G. 

E.  Herman)  .  .  .  .  .14 

on  menstniation  in  cases  of  (G.  E.  Herman)    .     225 

Distension    of  vagina   and  uterus  with  muco-purulent  fluid 

in  a  child  seven  weeks  old  (W.  McAdam  Eccles)  .     250 

Diverticulum,    Meckel's,    prolapse   of,   forming   an    umbilical 

tumour  (S.  W.  Wheaton)         .  .  .  .184 


INDEX.  499 

PAGE 
DORAN  (Alban),  Report  on  specimen  of  amorphous  acardiac 

twin,  shown  by  G.  E.  Herman  .  .  .11 
on  specimen  of  abscess  of  the  ovary  shown  by  Hey- 

wood  Smith  .  .  .  .  .83 
on  specimen  of  unruptured  tubal  gestation,  with 

apoplexy  of  the  ovum,  shown  by  C.  J.  Cullingworth  .  157 
on  specimen  of  malformation  of  rectum  and  bladder, 

&c.,  shown  by  A.  E.  Giles  ....  468 
on  specimen    of  tubal    gestation  with    apoplectic 

ovum,  shown  by  C.  J.  Cullingworth       .  .  .     468 

" on  specimen  of  pregnant  uterus  bicornis,  shown  by 

J.  R.  Ratcliffe  .  .  .  .  .470 

• for  George  B.  Beale,  fatal  rupture  of  an  ovarian  cyst 

in  an  infant  (shown)  .  .  .  .24 

papillomatous  cyst  of  both  ovaries  causing  profuse  ascitic 

eflFusion  (shown)        .....     149 

Remarks  in  reply     .....     154 

• in  discussion  on  A.  C.  Butler-Smythe's  specimen  of 

double  pyosalpinx     .  .  .  .  .25 

in  discussion  on  M.  Handfield-Jones'  specimen  of 

tubo-ovarian  cyst      .  .    '  .  .  .85 

in  discussion  on   H.  T.  Rutherfoord's  specimen  of 

sections  of  fibroma  of  the  ovai-y  .  .  .88 

in  discussion  on  C.  J.  Cullingworth's  specimen  of 

unruptured  tubal  gestation,  with  apoplexy  of  the  ovum     .     157 

in  discussion  on  S.  W.  Wheaton's  specimen  of  micro- 
cocci in  the  substance  of  a  decomposing  fibroid  tumour     .     190 

in  discussion  on  Lawson  Tait's  paper  on  two  cases 

of  hysterectomy         .  .  .  .  .     203 

• in   discussion  on   J.    Bland   Sutton's   specimen   of 

tubal  pregnancy  with  rupture  into  the  broad  ligament   218,  219 

in  discussion   on   W.  A.  Meredith's  paper  on  two 

cases  of  ovariotomy  during  pregnancy  .  .  .     247 

' in  discussion  onC.  J.  Cullingworth's  paper  on  the  value 

of  abdominal  section  in  certain  cases  of  pelvic  peritonitis      431 

— —  •: in  discussion  on  Amand  Routh's  specimen  of  mal- 
formed foetus  .....    463 

Duncan  (William),  Report  as  Hon.  Librarian  for  1891  .       29 

on  specimen   of  unruptured  tubal    gestation,  with 

apoplexy  of  the  ovum,  shown  by  C.  J.  Cullingworth  .     157 

on    specimen    of    tubal    gestation    with    apoplectic 

oyum,  shown  by  C.  J.  Cullingworth       .  .  ,     468 


500  INDEX. 

PAGE 
Duncan  (William),  knitting-needle  used  to  procure  abortion 

(shown)       ......     223 

uterus,  with  kidneys  and  ureters,  from  a  case  of  Caesarean 

section  (shown)         .  .  ..  •  •     127 

Remarks   in   discussion   on  C.  J.  Cullingworth's,   John 

Shaw's,  and  Leith  Napier's  papers  on  Cesarean  section     .     140 

in  discussion  on  Alban  Doran's  specimen  of  papillo- 
matous cyst  of  both  ovaries,  causing  profuse  ascitic 
effusion       ......     153 

in  discussion  on  C.  J.  Cullingworth's  specimen  of 

unruptured  tubal  gestation,  with  apoplexy  of  the  ovum     .     157 

in  discussion  on  A.  H.  N.  Lewers'  paper  on  six  cases 

of  craniotomy  and  the  relative  position  of  craniotomy  and 
Caesarean  section       .....     176 

in  discussion  on  Lawson  Tait's  paper  on  two  cases 

of  hystei'ectomy        .....     203 

EccLES  (W.  McAdam),  distension  of  vagina  and  uterus  with 
muco-purulent  fluid,  accompanied  by  dilatation  of  bladder 
and  ureters  from  pressure,  in  a  child  seven  weeks  old 
(shown)       .  .  .  .  .  .250 

Ectopic  gestation,  see  Pregnancy  (extra-uterine). 

Election  of  Neiv  Fellows  .  .     1,  23,  83,  123,  149,  213,  249,  437 

Extra-uterine  pregnancy,  see  Pregnancy  (exti-a-uterine). 

Fallopian  tubes,  see  Hematosalpinx,  Hydrosalpinx,  Pyosalpinx. 

• enlarged,  and  cystic  ovary  (Leith  Napier)  .  .     126 

Fat,  infiltration  of  broad  ligament  with,  in  a  case  of  ovarian 

dermoid  (J.  Bland  Sutton)       .  .  .  .7 

Feet,  deformity  of  (A.  E.  Giles)      .  .  .  .129 

Fellows,  see  Lists,  Elections. 

— —  Honorary,  election  of  .  .  .  .31 

Fibroids,  see  Tumours  (fibroid). 
Fibroma  of  the  ovary,  sections  of  (H.  T.  Rutherfoord)  .       88 

and  other  morbid  conditions  of  the  uterus,  treated  by 

Apostoli's  method  (J.  Inglis  Parsons)    .  .  .22 

Fibro-myoma,  large  multiple,  removed  by  hysterectomy  (Leith 

Napier)        .  .  .  .  .  .     159 

Foetation,  see  Pregnancy. 

Foetus,  development  of,  to  the  full  time  in  the  pei-itoneal  cavity, 
still  retaining  its  amniotic  covering,  in  a  case  of  ectopic 
pregnancy  (Lawson  Tait)         ....     192 


INDEX.  501 

PAGR 

Foetus  of  four  months'  development  contained  within  an  un- 
ruptured amnial  sac  with  placenta  praevia  attached  (Leith 
Napier)        .  .  .  ...  .158 

growth  of  the  placenta  after  death  of  the,  in  ectopic 

gestation  (Lawson  Tait  and  C.  Mai-tin)  .  .    206 

malformed  ( Amand  Routh)    ....     463 

Forceps,  aseptic  (P.  Horrocks)        ....     460 

Galabin  (A.  L.),  dei'moid  cyst  (shown)       .  .  .     441 

Galactorrhcea,    case  of,  during  a  first  pregnancy  (VV.  S.  A. 

Griffith)      .  .  .  .  .  .491 

Gervis  (Henry),  Remarks  in  discussion  on  C.  J.  Culling- 
worth's  paper  on  the  value  of  abdominal  section  in  certain 
cases  of  pelvic  pei'itonitis         ....    44^1 

Gestation,  see  Pregnancy. 

Giles  (Arthur  E.),  malformation  of  rectum  and  bladder,  con- 
genital  absence  of  both  kidneys  and  ureters,  imperforate 
anus,  absence  of  right  hypogastric  artery,  and  deformed 
feet  (shown)  .....     12i> 

Report  of  Committee  ....     468 

case  of  congenital  diaphragmatic  hei'nia  (shown)  .     132 

Griffith    (W.    S.    A.),   Report   on   specimen   of  amorphous 

acardiac  twin,  shown  by  G.  E.  Herman  .  .       11 

' on   specimen  of  haematosalpinx,  shown  by  W.    S. 

Playfair      .  .  .  .  .  .467 

case  of  galactorrhcea  during  a  first  pregnancy  .  .     491 

Remarks  in  discussion  on  Lawson  Tait's  paper  on  two 

cases  of  hysterectomy  ....    204 

in  discussion  on  Lawson  Tait  and  C.  Martin's  note 

on  the  growth  of  the  placenta  after  death  of  the  foetus  in 
ectopic  gestation       .  .  .  .  .211 

• in  discussion  on  W.  McAdam  Eccles'  specimen  of 

distension  of  vagina  and  uterus  with  muco-purulent  fluid, 

in  a  child   ......    2.51 

in  disciission  on  C.  J.  Cullingworth's  specimen  of 

large  pyosalpinx  simulating  tubo-ovarian  abscess  .     438 

in  discussion  on  F.  J.  McCann  and  W.  A.  Turner's 

paper  on  the    occurrence  of  sugar  in  the  urine    during 

the  puerperal  state  .....    489 

Hsematosalpinx  (E.  Malins)  " .  .  .  •     46(5 

with  hsemorrhagic  and  cystic  ovaries  (Leith  Napier)       .    439 


602  INDEX. 

PAGE 

HsemoiThage,  prolonged,  after  delivery  and  abortion,  the  rela- 
tion between,  and  backward  displacements  of  the  uterus 
(G.  E.  Herman)         .  .  .  .  .14 

uterine,  mucous  membrane  of  the  uterus  of  an  infant 

suffering  from  (S.  W.  Wheaton)  .  .  .190 

Handfield-Jones  (M.),  acephalous  acardiac  foetus  (shown)   .      84 

tubo-ovarian  cyst    .  .  ,  .  .85 

Bemarlcs  in  discussion  on  A.  H.  N.  Lewers'  paper  on  six 

cases  of  craniotomy,  and  the  relative  position  of  cranio- 
tomy and  Csesarean  section     .  .  .  .177 

in  discussion   on   W.   S.    Playfair's    specimen    of 

supposed  unruptured  tubal  gestation  sac  .  .     465 

Hayes  (T.  C),  Remarhs  in  discussion  on  Lawson  Tait's  paper 

on  two  cases  of  hysterectomy  ....     203 

in  discussion  on  C.  J.  Oullingworth's  specimens  of 

pyosalpinx  .....     222 

in  discussion  on  G.  E.  Herman's  paper  on  menstrua- 
tion in  cases  of  backward  displacement  of  the  uterus  .     237 

Herman  (G.  E.)>  Report  as  Treasurer  for  1891  .  29,  30 

• : on  specimen  of  amorphous  acardiac  twin,  shown  by 

him  on  December  2nd,  1891  ('  Transactions,'  vol.  xxxiii, 

p.  493)         .  .  .  .  .  .11 

: on  specimen  of  hsematosalpinx,  shown  by  W,  S. 

Playfair)     .  .  .  .  .  .467 

< on  the  relation  between  backward  displacements  of  the 

uterus  and  prolonged  haemorrhage  after  delivery  and 
abortion     .  .  .  .  .  .14 

on  menstruation  in  cases  of  backward  displacement  of 

the  uterus  ......     225 

RemarJcs  in  reply     .....     238 

■  ■ in    discussion   on   Heywood   Smith's   specimen   of 

abscess  of  ovaiy        .  .  .  .  .4 

in  discussion   on   J.  Bland   Sutton's   specimen   of 

hydi'osalpinx  undergoing  spontaneous  cure  .  ,       10 

Hernia,  congenital  diaphragmatic  (A.  E.  Giles)  .  .     132 

Hicks  (J.  Braxton),  Remarks  in  discussion  on  C  J.  Oulling- 
worth's, John  Shaw's,  and  Leith  Napier's  papers  on 
Csesarean  section       .  .  .  .  ,     143 

Horrocks  (P.),  aseptic  instruments  (showp)  .  .     460 

cancerous    uterus    removed    by    vaginal    hysterectomy 

(shown)       .  .  .  .  .  .85 

. Remarks  in  reply    .  .  .  .  .86 


INDEX. 


503 


HOREOCKS  (P.),  transfusion  apparatus  (shown) 

Remurlcs  in  reply     .  .  .  .  . 

■ in  discussion  on  Herbert  R.  Spencer's  specimen  of 

retroflexion  of  uterus  in  a  new-born  child 

in  discussion  on  C.  J.  Cullingworth's,  John  Shaw's, 

and  Leith  Napier's  papers  on  Caesarean  section  . 

in  discussion  on   A.  H.  N.  Lewers'  paper  on  six 

cases  of  craniotomy,  and  the  relative  position  of  cranio- 
tomy  and  Csesarean  section     .  .  .  . 

in  discussion  on  Lawson  Tait's  paper  on  two  cases 

of  hysterectomy         .  .  .  .  . 

• in  discussion  on  Lawson  Tait  and  C.  Martin's  note 

on  the  growth  of  the  placenta  after  death  of  the  fcetus  in 
ectopic  gestation       ..... 

in  discussion   on  A.  H.  N.   Lewers'    specimen   of 

cancer  of  the  body  of  the  uterus 

in  discussion  on  C.  J.  Cullingworth's  paper  on  the 

value  of  abdominal  section  in  certain  cases  of  pelvic  peri- 
tonitis         ...... 

in  discussion  on  F.  J.  McCann  and  W.  A.  Turnei''s 

paper  on  the  occurrence  of  sugar  in  the  ui'ine  during  the 
puerperal  state  ..... 

Hugenberger,  Theodor,  M  D.,  of  Moscow,  obituary  notice  of    . 

Hydrocele,  ovarian,  containing  papillomata  (J.  Bland  Sutton) 

Hydrosalpinx  undergoing  spontaneous  cure  (J.  Bland  Sutton) 

Hysterectomy,  two  cases  of  (Lawson  Tait)  . 

large      multiple      fibro-myoma     removed      by    (Leith 

Napier)       ...... 

vaginal,  cancerous  uterus  removed  by  (P.  Horrocks) 

(Amand  Routh)    .... 


PAGE 

460 
461 

28 

141 


174 


203 


211 


214 


435 


488 

75 

215 

9 

199 

159 

85 
87 


Infant,  distension  of  vagina  and  uterus  with  muco-purulent 
fluid  in  an  (W.  McAdam  Eccles) 

mucous  membrane  of  the  uterus  of  an,  suffering  from 

uterine  haemorrhage  (S.  W.  Wheaton)  . 

prolapse  of  Meckel's  diverticulum  in  an,  forming  an  um 

bilical  tumour  (S.  W.  Wheaton) 

retroflexion   of   the  uterus   in  a  new-born    (Herbert  R, 

Spencer)     ..... 

fatal  rupture  of  an  ovarian  cyst  in  an  (Alban  Doran) 

Instraments,  aseptic  (P.  Horrocks) 


250 

190 

184 

25 

24 

460 


504  INDEX. 

PAGE 
Keith  (Skene),  Remarks  in  discussion  on  C.  J.  Cullingwortli's 
paper  on  the  value  of  abdominal  section  in  certain  cases  of 
pelvic  peritonitis       .....     449 
Kidneys  aiid  ureters,  congenital  absence  of  (A  E.  Giles)  .     129 

with    uterus,    from   a   case    of    Csesai-ean    section 

(William  Duncan)     .  .  .  .  .187 

Knitting-needle  used  to  procure  aboi'tion  (William  Duncan)   .    223 

Labour,  see  Parturition. 

Lawrence  (Aust),  ruptured  tubal  pregnancy  (shown)              .  439 

Lewers  (A.  H.  N.),  cancer  of  the  body  of  the  uterus  (shown)  .  213 

RemarJcs  in  reply     .....  214 

papillomatous  ovarian  cyst  (shown)     .                 .                 .  462 

six  cases  of  craniotomy,  with  remarks  on  the  relative 

position  of  craniotomy  and  Csesarean  section       .                 .  161 

Bemarhs  in  reply      .....     179 

in  discussion  on  Lawson  Tait's  paper  on  two  cases 

of  hysterectomy         .....     204 
in  discussion  on  W.  A.  Meredith's  paper  on  two 

cases  of  ovariotomy  during  pregnancy  .  .  .     247 
in  discussion  on  F.  J.  McCann  and  W.  A.  Turner's 

paper  on  the  occurrence  of  sugar  in  the  urine  during  the 

puerperal  state 
List  of  Officers  elected  for  1892 

of  ditto  for  189S 

of  past  Presidents    . 

of  Referees  of  Paper's  for  1893 

of  Standing  Committees 

of  Honorary  Local  Secretaries 

of  Honorary  Fellows 

of  Corresponding  Fellows 

•  of  Ordinary  Fellows 

■  of  Deceased  Fellows  (with  obituary  not 


489 
31 

V 

vii 

viii 

ix 

X 

xi 

xii 
xiii 

ces,  which  see)     36 — 75 


McCann  (F.  J.)  and  W.  A.  Turner,   on   the  occurrence  of 

sugar  in  the  urine  dui-ing  the  puerperal  state      .  .     473 

Remarhs  in  reply     .  .  .  .  .     489 

Malformation,  see  Monster. 

•  congenital  diaphragmatic  hernia  (A.  E.  Giles)  .  .     132 

of  foetus  (Amand  Routh)        ....     463 

•  of  rectum  and  bladder,  congenital  absence  of  both  kidneys 

and  ureters,  imperforate  anus,  absence  of  right  hypogastric 
artery,  and  deformed  feet  (A.  E.  Giles) .  .  .     129 


INDEX.  505 

PAGE 
Malins  (Edward),  case  of  extra-uterine  gestation  (shown)  .  181 
•  hsematosalpinx  (shown)  ....     466 

Report  on  ditto        .....     466 

Mabtin  (Christopher),  see  Lcnvson  Tait. 

Meckel's  diverticulum,  prolapse  of,  in  an  infant,  forming  an 

umbilical  tumour  (S.  W.  Wheaton)        .  .  .     184 

Menstruation  in  cases  of  backward  displacement  of  the  uterus 

(G.  E.  Herman)         .  .  .  .  .225 

Meredith  (W.  A.),  two  cases  of  double  ovariotomy  during 

pregnancy .  .  .  .  .  .     239 

Micrococci  in  the  substance  of  a  decomposing  fibroid  tumour 

(S.  W.  Wheaton)       .  .  .  .  .187 

Midwives,  registration  of,  and  proposal  to  petition  for  a  select 

committee  on  .  .  .  .  .34 

Monster,  acephalous  acardiac  foetus  (M.  Handfield- Jones)  .  84 
Mucous  membrane  of  the  uterus  of  an  infant  suffering  from 

uterine  haemorrhage  (S.  W.  Wheaton)  .  .  .     190 

Myoma  of  the  cervix  uteri  (C.  J.  Cullingworth)         .  .     223 

Napier  (Leith),  specimen  of  axial  rotation  of  a  right-sided 
parovarian  cyst  with  attached  right  ovary  and  Fallopian 
tube  distended  by  haemorrhage  (shown)  ,  .     124 

specimen  of  cystic  ovary  and  enlarged  tube ;  abdominal 

section;     history    of     pregnancy     within     two     months 
(shown)      .  .  .  .  .  .126 

large   multiple   fibro-myoma   removed  by  hysterectomy 

(shown)       .  .  .  .  .  .159 

fcetus  of  four  months'  development  contained  within  an 

unruptured   amnial   sac   with   placenta   praevia   attached 
(shown)       ......     158 

haematosalpinx,  hsemorrhagic  and  cystic  ovaries  (shown)  439 

successful  case  of  Csesai'ean  section     .  .  .  105 

Remarhs  in  reply     .....  144 

in  discussion  on  A.  E.  Giles's  specimen  of  malforma- 
tion of  rectum  and  bladder,  &c.  .  .  •  132 

in   discussion  on  A.  H.  N.  Lewers'  paper  on  six 

cases  of  craniotomy,  and  the  I'elative  position  of  craniotomy 
and  Caesai-ean  section  .  .  •  .178 

in  discussion  on  Lavvson  Tait's  paper  on  two  cases 

of  hysterectomy        .  .  .  .  •     -04 

in  discussion  on  J.  Bland  Sutton's  specimen  of  tubal 

pregnancy  ^vith  rupture  into  the  broad  ligament  .     218 

VOL.  ZXXIV.  3^ 


506  INDEX. 

PAGE 
Napiek  (Leith),  Beviarks  in  discussion  on  William  Duncan's 

specimen  of  knitting-needle  used  to  procure  abortion        .    224 


Obituary  notices  of  deceased  Fellows: 

Willett,  Charles  Verrall,  M.R.C.S.,  Shoreliam,  Sussex 

Salter,  Francis  Joseph,  L.R.C.P.  &  S.Edin.,  Leeds 

Steavenson,  William  Edward,  M.D.,  Welbeck  Street,  W 

Bennet,  James  Henry,  M.D.,  Mentone  . 

Day,  Edmund  Overman,  M.R.C.S.,  Waterloo  Road,  S.E. 

Barker,  Benjamin  Fordyce,  M.D.,  New  York  (Hon.  Felloio)       41) 

Braun  von  Fernwald,  Carl  Rudolf,  Ritter,  M.D.,  Vienna 
{Hon.  Fellow)         .  .  .  .  .55 

Scanzoni    von    Lichtenfels,    Friedrich    Wilhelm,    M.D., 
Wiirzburg  {Hon.  Fellow) 

Hugenberger,  Theodor,  M.D.,  Moscow  {Hon.  Fellow) 
Osteomalacia,  ovaries  removed  from  a  case  of  (Ad,  Rasch) 
Ovai'ian  apoplexy,  double,  from  a  case  of  acute  peritonitis 

(H.  A.  Des  Yoeux)     .... 

cyst,  fatal  rupture  of,  in  an  infant  (Alban  Doran) 

■ papillomatous  (A.  H.  N.  Lewers) 

dermoid  (J.  Bland  Sutton)     . 

infiltration  of  broad  ligament  with  fat  (J.  Bland 

Sutton)        ,  .  .  .  . 

hydrocele  containing  papillomata  (J.  Bland  Sutton) 

Ovaries  removed  from  a  case  of  osteomalacia  (Ad.  Rasch) 

ha;moi*rhagic  and  cystic  (Leith  Napier) 

papillomatous  cyst  of  both,  causing  profuse  ascitic  effu 

sion  (Alban  Doran)  .... 

sarcoma  of  both  (J.  A.  Shaw-Mackenzie) 

Ovariotomy,  double,  two  cases  of,  during  pregnancy  (W.  A 

Meredith)    ..... 
Ovary,  abscess  of  (Hey wood  Smith) 

cystic,  and  enlarged  tube  (Leith  Napier) 

fibroma  of  (H.  T.  Rutherfoord) 

Ovum,  apoplexy  of,  in  a  case  of  unruptured  tubal  gestation 

(C.  J.  Cullingworth) 
(C.  J.  Cullingworth) 


36 
36 
36 

40 
48 


64 

75 
462 

214 

24 

462 


7 
215 
462 
43» 

I4& 

2 

239 

3 

126 


155 

182 


Papillomata,  ovarian  hydrocele  containing  (J.  Bland  Sutton)  215 
Papillomatous  cyst  of  both   ovaries  causing  profuse  ascitic 

effusion  (Alban  Doran)             ....  140 
ovarian  cyst  (A.  H.  N.  Lewers)              .                 .                 •  462 


INDEX.  507 

PAGE 
Parovarian  cyst,  axial  rotation  of  (Leith  Napier)        .  .     124 

Parsons  (J.  Inglis),  twenty  cases  of  fibroma  and  other  morbid 

conditions  of  the  uterus  treated  by  Apostoli's  method  .  22 
Parturition,  see  Placenta. 

the  relation    between   backward    displacements   of    the 

uterus  and  pi-olonged   hemorrhage   after,    and   abortion 

(G.  E.  Herman)         .  .  .  .  .14 

Pedicle,   axial  rotation  of,  of   a   right-sided  pai'ovarian   cyst 

(Leith  Napier)  .....     124 

Pelvic  peritonitis,  the  value  of  abdominal   section  in  certain 

cases  of  (C.  J.  Cullingworth)  ....  254 
Pelvis,  contracted,  Csesarean  section  for  (0.  J.  Cullingworth) .       89 

(John  Shaw)  .  .  .  .98 

(Leith  Napier)      .  .  .  .105 

of  a  cat,  with  bladder,  uterus,  and  rectum  in  situ  (H.  T. 

Rutherfoord)  .  ,  .  .  .251 

Peritonitis,  acute,  double  ovarian   apoplexy  from   a  case  of 

(H.  A.  Des  Vceux)     .  .  .  .  .214 

pelvic,  the  value  of  abdominal  section  in  certain  cases  of 

(C.  J.  Cullingworth)  .  .  .  .254 

Phillips  (John),  Remarhs  in  discussion  on  A.  H.  N.  Lowers' 

paper  on  six  cases  of  craniotomy,  and  the  relative  position 

of  craniotomy  and  Csesarean  section      .  .  .     174 

Placenta,  growth  of  the,  after  death  of  the  fcetus  in  ectopic 

gestation  (Lawson  Tait  and  C.  Martin)  .  .     206 

unusual  size  and  shape  of  (R.  Boxall) .  .  .     464 

prEBvia  associated  with  unusual  size  and  shape  of  the 

placenta  (R.  Boxall)  ....    464 

attached  to  an  unruptured  amnial  sac  containing  a 

foetus  of  four  months'  development  (Leith  Napier)  .     158 

Playfair  (W.  S.),  supposed  unruptured  tubal  gestation  sac 

(shown)       .....  28,  465 

Bep<yrt  of  Committee  ....     467 

Bemarlis  in  discussion  on  C.  J.  Cullingworth's  paper  on 

the  value  of  abdominal  section  in  certain  cases  of  pelvic 
peritonitis  .....     433 

Pregnancy,  protracted  (C.  Paget  Blake)       .  .  .28 

case  of  galactorrhcea  during  a  first  ( W.  S.  A.  Griffith)      .     491 

two  cases  of  double  ovariotomy  during  (W.  A.  Meredith)     239 

of  a  uterus  bicornis  (J.  R.  Ratcliff"e)    .  .  .     469 

extra-uterine,  case  of  (E.  Malins)         .  .  .181 


508  INDEX. 

PAGE 
Pregnancy,  extra-iiterine,  case  of,  in  wbicli  the  foetus  seems  to 
have  been  developed  to  the  full  time  in  the  peritoneal 
cavity,  still  I'etaining  its  amniotic  covering  (Lawson  Tait)     192 

growth  of  the  placenta  after  death  of  the  fcetus  in 

(Lawson  Tait  and  C.  Martin)  .  .  .  .206 

tubal,    rupture    into    broad    ligament    (J.    Bland 

Sutton)       .  .  .  .  .  .217 

ruptured  tubal  (C.  J.  Cullingworth)  .  .     134 

(Aust  Lawrence)  .  .  .     439 

•  unruptured  tubal,  with  apoplexy  of  the  ovum  (C,  J. 

Culling  woi'th)  .....     155 

(C.  J.  Cullingworth)  .  .  .182 

. supposed  ixnruptured  tubal  (W.  S.  Playfair)  28,  465 

Prolapse  of  Meckel's  diverticulum  in  an  infant,  forming  an 

umbilical  tumour  (S.  W.  Wheaton)        .  .  .     184 

Puerperium,  the  occurrence  of  sugar  in  the  urine  during  the 

(F.  J.  McCann  and  W.  A.  Turner)         .  .  .473 

Pyosalpinx,  two  cases  of  (C.  J.  Cullingworth)  .  .     219 

double  (A.  C.  Butler-Smythe)  .  .  .24 

simulating  tubo-ovarian  abscess  (C.  J.  Cullingworth)      .     437 

Rasch  (Ad.),  ovaries   removed  from  a  case  of  osteomalacia 

(shown)       .  .  .  .  .  ,462 

Ratcliffe  (J.  R.),  pregnant  uterus  bicornis  (shown)  .     469 

Report  of  Committee  ....     470 

Rectum,  malformation  of  (A.  E.  Giles)         .  .  .     129 

Report  {audited)  of  the  Treasurer  for  \SQ1     .  .  29,30 

of  the  Hon.  Librarian  for  Vddl  .  .  .29 

of  the  Chairman  of  the  Board  for  the  Examination  of  Mid- 
wives  .  .  .  .  .  .29 

of  Committee  on  specimen  of  amorphous  acardiac  twin, 

shown  by  G.  E.  Herman  on  December  2nd,  1891  ('  Transac- 
tions,' vol.  xxxiii,  p.  493)        .  .  .  .  .11 

on  specimen  of  abscess  of  the  ovarij,  shown  by  Hey  wood 

Smith  on  January  6th,  1892     .  .  .  .83 

on  ■  specimen    of   unruptured    tubal    gestation,   with 

apoplexy   of  the   ovum,  shown  by    C.  J.   Cullingworth   on 
May  4th,  1892  .  .  .  .  .157 

on    specimen    of   hematosalpinx,    shown   by    W.   S. 

Playfair  on  Februoi-y  3rd,  1892  .  .  .     467 

on  specimen  of  malformation  of  rectum  and  bladder. 


&c.,  shown  by  A.  E.  Giles  on  April  6th,  1892  .  .     468 


INDEX. 


509 


PAGE 

Report  of  Committee  on  specimen  of  tubal  gestation  with  apo2)lectic 

ovum,  shoivn  by  C.  J.  CnlUiigivorth  on  June  1st,  1892  .     468 

■ —  on  specimen  of  uterus  bicornis,  shown  by  J.  R.  Ratcliffe 

on  June  1st,  1892        .  .  .  .  .470 

Retroflexion  of  the  uterus  in  a  new-born  child  (Herbert  R. 

Spencer)     .  .  .  .  .  .25 

RoBSON  (A.  W.  Mayo),  Remarks  in  discussion  on  C.  J. 
Cullingworth's  paper  on  the  value  of  abdominal  section  in 
certain  cases  of  pelvic  peritonitis  .  .  ,     443 

Rotation,  axial,  of  a  right-sided  parovarian  cyst  (Leith  Napier)     124 

RouTH  (Amand),  cancerous  uterus  removed  by  vaginal  hys- 
terectomy (shown)    .  .  .  .  .87 

•  Remarks  in  reply     .  .  .  .  .87 

malformed  foetus  (shown)       ....     463 

ruptured  uterus  and  vagina  (shown)    .  .  .     252 

Remarks   in   discussion  on    F.  J.    McCann   and   W.   A. 

Turner's  paper  on  the  occui'rence  of  sugar  in  the  urine 
during  the  puerperal  state      ....     488 

RouTH  (C.  H.  F.),  Remarks  in  discussion  on  C.  J.  Culling- 
worth's, Jx)hn  Shaw's,  and  Leith  Napier's  papers  on 
Cassarean  section      .  .  .  .  .     142 

Rupture  of  an  ovarian  cyst  in  an  infant  (Alban  Doran)  .       24 

of  uterus  (R.  Boxall)  .  .  .  .11 

and  vagina  (Amand  Routh)  .  .  .     252 

RuTHERFOORD    (H.   T.),    sections   of    fibroma   of   the   ovary 

(shown)       .  .  .  .  .  .88 

pelvis  of  a  cat,  with  bladder,  uterus,  and  rectum  in  situ  .     251 

■ Remarks  in  discussion  on  C.  J.  Cullingworth's  specimen 

of  unruptured  tubal  gestation,  with  apoplexy  of  the  ovum     157 

in  discussion  on  A.  H.  N.  Lewers'  paper  on  six  cases 

of  craniotomy,  and  the  relative  position  of  craniotomy  and 
Qsesarean  pection      .  .  .  •  •     178 
in  discussion  on  G.  E.  Herman's  paper  on  menstrua- 
tion in  cases  of  backward  displacement  of  the  uterus        .     237 

Salte  ,  Francis  Joseph,  L.R.C.P.  and  S.Edin.,  of  Leeds,  obit- 

uai'y  notice  of  .  .  •  •  .36 

Sarcojna,  primary,  of  both  ovaries  (J.  A.  Shaw-Mackenzie)       .         2 

Scanzoni  von  Lichtenfels,  Friedrich  Wilhelm,  M.D.,  of  Wiirz- 

hurg,  obituary  notice  of  .  .  •  .64 

Shaw  (John),  case  of  Caisarean  section        .  •  .98 


510  IKDEX. 

PAGE 

Shaw-Mackenzie  (J.  A.),  primary  sarcoma  of  both  ovaries 

(shown)       .  .  ,  .  .  .2 

Smith  (Heywood),  abscess  of  ovary  (shown)  .  .        3 

-^—  Memarks  in  reply     .  .  .  .  .4 

Report  of  Committee  .  .  .  .83 

MeviarJcs  in  discussion  on  A..  E.  Giles's  specimen  of  con- 
genital diaphragmatic  hernia ....     134 

in  discussion  on  C.  J.  Cullingworth's,  John  Shaw's, 

and  Leith  Napier's  papers  on  Caesarean  section  .  .     138 

in  discussion  on  Leith  Napier's  specimen  of  large 

multiple  fibro- myoma  removed  by  hysterectomy  .     160 

in   discussion   on   William  Duncan's   specimen  of 

knitting-needle  used  to  procure  abortion  .  .     224 

in  discussion  on  G.  B.  Herman's  paper  on  menstrua- 
tion in  eases  of  backward  displacement  of  the  uterus         .     237 

in  discussion  on  C.J.  Cullingworth's  paper  on  the  value 

of  abdominal  section  in  cei'tain  cases  of  pelvic  peritonitis  .  449 
Sound,  uterine,  aseptic  (P.  Horrocks)  .  .  •     460 

Spencer  (Herbert  R.),  retroflexion  of  the  uterus  in  a  new-born 

child  (shown)  .  .  .  .  .25 

Bemarks  in  discussion  on  A.  H.  N.  Lewers'  paper  on  six 

cases  of  craniotomy,  and  the  relative  position  of  cranio- 
tomy and  Cesarean  section     .  .  .  .176 

in  discussion  on  P.  Horrocks'  transfusion  apparatus  .     461 

Steavenson,  William  Edward,  M.D.,  of  Welbeck  Street,  W., 

obituary  notice  of     .  .  .  .  .36 

Sugar  in  the  urine  during  the  puerperal  state,  the  occurrence 

of  (F.  J.  McCann  and  W.  A.  Turner)     .  .  .473 

Sutton  (J.  Bland),  Report  on  specimen  of  amorphous  aca-i'diac 

twin,  shown  by  G.  E.  Herman  .  .  .11 
on   specimen   of  abscess  of  the   ovary   shown   by 

Heywood  Smith  .  .  .  .  .83 
on   specimen  of  unruptured  tubal  gestation,  with 

apoplexy  of  the  ovum,  shown  by  C.  J.  Cullingworth  .     157 

on  specimen  of  tubal  gestation  with  apoplectic  ovum 

shown  by  C.  J.  Cullingworth    -.  .  .  .     468 

hydrosalpinx  undergoing  spontaneous  cure  (shown)  .         9 

• ovarian  dermoid  (shown)        .                 .                 ,  .5 

infiltration  of  broad  ligament  with  fat  (shown)  .         7 

• hydrocele  containing  papillomata  (shown)  .     215 

tubal  pregnancy,  rupture  into  broad  ligament  (shown)  .     217 


INDEX. 


Ill 


PAGE 

Sutton  (J.   Bland),  Be7nar]cs   in  discussion   on   A.  C.  Butler- 

Smytlie's  specimen  of  double  pyosalpinx  .  24,  25 

in  discussion  on  C.  J.  Cullingworth's,  Jcon  Shaw's, 

and  Leitli  Napier's  papers  on  Caisarean  section  .  .     138 


Tait  (Lawson),  case  of  ectopic  pregnancy  in  which  the  foetus 
seems  to  have  been  developed  to  the  full  time  in  the  peri 
toneal  cavity,  still  retaining  its  amniotic  covering 

two  cases  of  hysterectomy    , 

and  Cheistopher  Martin,  note  on  the  growth  of  the 

placenta  after  death  of  the  foetus  in  ectopic  gestation 

Beviarhs  in  reply    .... 

Targett   (J.    H.),   Report   on  specimen   of   hajmatosalpinx, 

shown  by  E.  Malins  ... 
on  specimen  of  pregnant  uterus  bicornis,  shown  by 

J.  R.  Ratcliffe  .... 

Taylor  (John  W.),  Remarhs  in  discussion  on  C.  J.  Culling 

worth's  paper  on  the  value  of  abdominal  section  in  certain 

cases  of  pelvic  peritonitis 
Thornton  (J.  Knowsley),  Beniarhs  in  discussion  on  C  J.  Cul 

lingworth's  papei",  on  the  value  of  abdominal  section  in 

certain  cases  of  pelvic  peritonitis 
Transfusion  apparatus  (P.  Horrocks) 
Tubal  gestation,  ruptured  (0.  J.  CuUingworth) 

(Aust  Lawrence) 

•  into  broad  ligament  (J.  Bland  Sutton) 

unruptui-ed,  with  apoplexy  of  the  ovum  (0.  J.  CuUingworth) 

• (C.  J.  CuUingworth) 

sac,  supposed  unruptured  (W.  S.  Playfair) 

Tubo-ovarian  abscess,  lai'ge  pyosalpinx  simulating  (C.  J.  Cul 

lingworth)  .... 

cyst  (M.  Handfield- Jones)     . 

Tumour,  dermoid  cyst  (A.  L.  Galabin) 

ovarian  dermoid  (J.  Bland  Sutton) 

infiltration    of    broad    ligament    with   fat 

(J.  Bland  Sutton)     .... 

fibroid,  micrococci  in  the  substance  of  a   decomposing 

(S.  W.  Wheaton)      .... 

fibroma  of  the  ovary  (H.  T.  Rutherfoord) 

fibro-myoma,  large  multiple,  removed  by  hysterectomy 

(Leith  Napier)  .  .  .  • 

jnyoma  of  the  cervix  uteri  (C.  J.  CuUingworth) 


192 
199 

206 
211 

466 

470 


447 


445 
460 
134 
439 
217 
155 
182 
28,  465 

437 

85 

441 


187 


159 
223 


512  INDEX. 

PAGE 
Tumour,  papillomatous  cyst  of  both  ovaries  causing  profuse 

ascitic  effusion  (Alban  Doran)  .  .  .     149 
ovarian  cyst  (A.  H.  N.  Lewers)                   .  ..   462 

parovarian  cyst,  axial  rotation  of  (Leith  Napier)  .     124 

sarcoma,     primary,    of      both     ovaries     (J.    A.    Shaw- 
Mackenzie)  .  .  .  .  .2 

tubo-ovarian  cyst  (M.  Handfield-Jones)  ,  .       85 

umbilical,  formed  by  prolapse  of  Meckel's  diverticulum 

(S.  W.  Wheaton)      .  .  .  .  .184 

Turner  (W.  A.),  see  F.  J.  McCann. 

Ui'etevs  and  bladder,  dilatation  of,  from  pressure,  in  an  infant 

(W.  McAdam  Eccles)  .  .  .  .250 

and  kidneys,  congenital  absence  of  (A.  E.  Giles)  .     129 

with    uterus,   from    a   case   of    Csesarean   section 

(William  Duncan)    .  .  .  .  .127 

Urine,  the  occurrence  of  sugar  in  the,  during  the  puerperal 

state  (F.  J.  McCann  and  W.  A.  Turner)  .  .     473 

Uterus,  backward  displacements  of,  and  prolonged  haemorrhage 

after  delivery  and  abortion,  the  relation  between  (G.  E. 

Herman)    .  .  .  .  .  .14 

menstruation  in  cases  of  (G.  E.  Herman)  .     225 

reti-oflexion  of,  in  a  new-born  child  (Herbert  R.  Spencer)       25 

rupture  of  (R.  Boxall)  .  .  .  .11 

mucous  membrane  of,  in  an  infant  suffering  from  uterine 

hemorrhage  (S.  W.  Wheaton)  .  .  .190 

cancer  of  the  body  of  the  (A.  H.  N.  Lewers)       .  .     213 

cancerous,  removed  by  vaginal  hysterectomy  (P.   Hor- 

rocks)  .  .  .  .  .  .85 

(Amand  Routh)  .  .  .  .87 

fibroma  and  other  morbid  conditions  of  the,  treated  by 

Apostoli's  method  (J.  Inglis  Parsons)   .  .  .22 

with  kidneys  and  iireters,  from  a  case  of  Csesarean  section 

(Willian  Duncan)      .  .  .  .  .127 

bicorais,  pregnant  (J.  R.  Ratcliffe)       .  .  .     469 

cervix  uteri,  squamous-celled  carcinoma  of,  in  which  the 

disease  had  extended  in  an  upward  and  not  in  a  downward 
direction  (C.  J.  CuUingworth)  .  .  .     136 

myoma  of  (C.  J.  CuUingworth)    .  .  .     223 

and  vagina,  distension  of,  Avith  muco-purulent  fluid,  in  a 

child  seven  weeks  old  ( W.  McAdam  Eccles)  .  .    250 

rupture  of  (Amand  Routh)  .  .  «    252 


INDEX.  613 

PAGE 

Vagina  and  uterus,  distension  of,  witli  muco-purulent  fluid,  in 

a  child  seven  weeks  old  (W.  McAdam  Eccles)      .  .    250 
rupture  of  (Amand  Routh)           .                .  .    252 

Wheaton  (S.  W.),  micrococci  in  the  substance  of  a  decompos- 
ing fibroid  tumour  removed  by  hysterectomy  (shown)         .     187 

Remarks  in  reply     .....    189 

' microscopic  section  of  the  uterine  mucous  membrane  of 

an  infant  suffering  from  uterine  hajmorrhage  (shown)        .     190 

prolapse  of  Meckel's  diverticulum  in  an  infant,  forming 

an  umbilical  tumour  (shown)  ....     184 

— —  Remarlcs  in  discussion  on  F.  J.  McCann  and  W.  A. 
TuiTier's  paper  on  the  occurrence  of  sugar  in  the  urine 
during  the  puerperal  state       ....    488 

Willett,  Charles  Verrall,  M.R.C.S.,  of  Shoreham,  Sussex,  obi- 
tuary notice  of  .  .  .  .  .36 

Williams  (John),  BemarTcs  in  discussion  on  C.  J.  Culling- 
worth's  paper  on  the  value  of  abdominal  section  in  certain 
cases  of  pelvic  peritonitis        ....    430 


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Barnes  (Robert).  Expose  de  la  Theorie  du  Placenta 
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BiNAUD  (J.  William).  De  I'Hematocele  pelvienne  iutra- 
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BoNVALOT  (L.).  De  la  Morte  subite,  phenomenes  d'inhi- 
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Lazarewitch  (J.).  A  System  of  Obstetric  Medicine 
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Mackenrodt  (A.).  Beitrag  zur  intrauterinen  Therapie. 
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MiJNLiEFF  (A.).  Einige  Betrachtungen  iiber  Albu- 
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Pozzi   (S.).     Treatise    on     Gynaecology,    Clinical    and 

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Simpson  (Sir  James  Y.).     Account  of  a  new  Anaesthetic 

agent,   as   a   substitute   for   Sulphuric    Ether  in    Dr.  Philip 
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Smith  (William  Tyler).  A  Course  of  Lectures  on  Ob- 
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Stkatz  (C.  H.).  Gynakologische  Anatomie.  Circula- 
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Syme  (David).     On  the  Modification  o£  Organisms. 

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Uterusuiyoiuc. 
45.  MacJcenrodt,  Heitrag  zur  intrautcrinen  Therapic. 

48.  Skutsch,  Die  Palpation   der  Bauch-  uiid  Ueckcn- 

organe. 

49.  Gottschalk,  Beitrag  zur  Lelne  von  der  Atrophia 

Uteri. 
52.  Chazan,  Physiologic   uud   Diiitetik  der   Nachgc- 

burtsperiode. 
54.  Fehling,  tJbcr  Uterusruptur. 
56.  MijnUeff,  Eiiiige  Betrachtuiigen  iibcr  Albuminuric 

U!)d  Nepliritis  Gravidarum  in  Zusamnienhaug 

niit  dor  iutrautcrineu  Absterben  der  Frucht. 
58.  Sonntag,     Das     Hegar'schc     Schwangerschafts- 

zeichen. 

Waldeyer  (W.).  Beitrage  zur  Keuntniss  der  Lage 
der  weiblichen  Beckenorgane  nebst  Beschreibung 
eines  froutalen  Gefrierschnittes  des  Uterus  gra- 
vidus  in  situ.  plates,  folio,  Bonn,  1892   Purchased. 

Webster  (J.  Clarence).     Researches  in  Female  Pelvic 

Anatomy.  plates,  4to.  Edin.  1892        Ditto. 

Tubo-peritoneal  Ectopic  Gestation. 

plates,  4to.  Edin.  1892        Ditto. 
Wells  (Brooks   H.).     See  Foszi,  Treatise  on  Gynae- 
cology (translated). 

WiLKs  (Samuel).  See  II.  G.  Sutton,  Lectures  on 
Pathology. 

ZwEiFEL  (Paul).     Vorlesungen  iiber  klinische  Gynako- 

logie.  plates  and  woodcuts,  8vo.  Berlin,  1892    Purchased. 


TRANSACTIONS. 


American  Association  op  Obstetricians  and  Gyne- 
cologists— 
Transactions,  vol.  iv,  for  1891.  The 

8vo.  Phila.  1892  Association. 
American  Gynecological  Society — 

Transactions,  vol.  xvi,for  1891.     8vo.  Phila.  1891      Society. 
Baltimore — Medical  and  Chirurgical  Paculty  of    the 
State  of  Maryland  at  its  Ninety-third  Annual 
Session — 
Transactions.  8vo.  Baltimore,  1891     Faculty. 

Clinical  Society  of  London — 

Transactions,  vol.  xxv.  8vo.  Loud.  1892      Society. 

vol.  xxxiv.  3G 


522 


ADDITIONS    TO    THE    LIBRARY. 


Presented  by 
Deutsche  Gesellschaft  fur  Gynakologie- 

Verhandlungen  ;  Vierter  Kongress,  Band  iv. 

8vo.  Leipzig,  1893  Purchased. 

Medical  (Royal)  and  Chirurgical  Society — 

Transactions,  vol.  Ixxiv.  8vo.  Lond.  1891      Society. 

Medical  Society  of  London — 

Transactions,  vols,  xiv,  XV.     8vo.  Lond.  1891, 1892      Society. 

Obstetrical  Society  (Edinburgh) — 

Transactions,  Session,  1891-92,  vol.  xvii. 

8vo.  Edin.  1892      Society. 

Sydenham  (New)  Society — 

Publications,  vol.  140.     Pozzi,  Treatise  on  Gynae- 
cology. 


REPORTS. 

Hospitals. — Guy's    Hospital    Reports ;    Third    Series,      Hospital 
vol.  xxxiii.  8vo.  Lond.  1892        Staff. 

St.  Bartholomew's  Hospital  Reports  ;  vol.  xxvii. 

8vo.  Lond.  1891        Ditto. 

St.    Thomas's    Hospital   Reports ;  New   Series, 

vol.  XX.  8vo.  Lond.  1892        Ditto. 

Westminster  Hospital  Reports  ;  vol.  vii. 

8vo.  Lond.  1891        Ditto. 

Jahresbericht  iiber  die  Fortschritte  auf  dem  Gebiete  der 
Geburtshilfe  und  Gynakologie,  herausgegeben  von 
Richard  Froramel,  v.  Jahrgang,  1891. 

8vo.  Wiesbaden,  1892  Dr.  Eromrael. 


JOURNALS. 


Year-book  (The)    of   Treatment   for   1892.     A  critical 
review  for  Practitioners  of  Medicine  audSurcjery. 

8vo.  Loud.  1892    Purchased. 


MUSEUM. 

Vaginal  Speculum,  presented  by  Dr.  G.  Coromilas, 

ruiNTED    BY   ADLAKD   AND    SON, 
BARTHOLOMEW    CLOSE,   B.C.,   AND    20,    HANOVEB   SQUABE,   W. 


'  ■  ■  «  ^m    ^^  jiM  «.»  1  •  I  tru  }    k  V  Ivl/W 


RG  Obstetrical  Society  of 

1  London 

03        Transactions 

V.  3A 

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&  MedicaJ 

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