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Full text of "Transactions"

3LGXANDGR PRIKROSG C.B. 



The Transactions 

of the 

Edinburgh Obstetrical Society 



PRINTKD BY 

OLIVER AND BOYD 

EDINBURGH, SCOTLAND 



The Transactions 

of the 

Edinburgh Obstetrical 
Society 



Session 1923-1924 



VOLUME XLIV 



Edinburgh 
Oliver and Boyd, Tweeddale Court 

Publishers to the Society 
1924 



PREFACE 

THE present volume of Transactions is the third issued under 
the new arrangements with the Edinburgh Medical Journal, 
rendered necessary by the increased cost of publication. 

The Treasurer will be grateful for notices of changes of 
address, deaths, or any other information necessary to keep 
the lists up to date. 

The views expressed in this volume are to be taken as 
the opinions of the Fellows concerned ; they do not necessarily 
reflect the opinion of the Society as a whole. 



THE EDITOR. 



57 Manor Place, 
Edinburgh, 27 th November 1924. 



Edinburgh Obstetrical Society 



Office- Bearers for Session 1 9 2 3 - 1 9 2 4 

President 
Prof. B. P. WATSON, M.D., F.R.C.S.Ed., F.A.C.S. 

Vice-Presidents 
Senior— JAMES LAMOND LACKIE, M.D., F.R.C.P.Ed. 
Junior— R. W. JOHNSTONE, C.B.E., M.D., F.R.C.S.Ed., M.R.C.P.Ed. 

Treasurer 
WILLIAM MACRAE TAYLOR, M.B., F.R.C.S.Ed., 8 Melville Street. 

Secretaries 
JAMES YOUNG, D.S.O., M.D., F.R.C.S.Ed., 29 Manor Place. 
FRANCIS J. BROWNE, M.D., F.R.C.S.Ed., 54 Northumberland Street. 

Librarian 

R. W. JOHNSTONE, C.B.E., M.D., F.R.C.S.Ed., M.R.C.P.Ed., 
26 Palmerston Place. 

Editor of Transactions 

DOUGLAS MILLER, M.D., F.R.C.S.Ed., 57 Manor Place 

Members of Council 

Dr J. HAIG FERGUSON. 

Dr C. W. SOMERVILLE. 

Dr H. OLIPHANT NICHOLSON. 

Dr E. F. FISHER. 

Dr GERTRUDE HERZFELD. 

Dr DAVID SHANNON. 

Dr H. S. DAVIDSON. 

Dr STARK CHRISTIE. 



VI 



List of Presidents, Vice-Presidents, Treasurers, 
Secretaries, Librarians, and Editors 



Dr William Beilby, 

Sir James Y. Simpson, Bart., 

Dr John Moir, 

Dr Alex. Keiller, 

Dr T. H. Pattison, 

Dr T. Graham Weir, 

Sir James Y. Simpson, 

Dr John Burn, . 

Dr Charles Bell, . 

Dr L. R. Thomson, 

Dr Matthews Duncan, 

Sir A. R. Simpson, 

Dr David Wilson, 

Dr Angus Macdonahl, 

Sir A. R. Simpson, 

Dr John Connel, 

Sir J. Halliday Croom, 





PRESIDENTS. 






Year. 




Year. 




1840-41 


Dr C. E. Underbill, . 


1888-89 


Bart. 


1842-57 


Dr D. Berry Hart, 


1890-91 




1858-59 


Sir A. R. Simpson, 


1892-93 




1860-61 


Dr A. H. Freeland Barbour, 


1894-95 




1862-63 


Dr Alexander Ballantyne, 


1896-97 




1864-65 


Sir J. Halliday Croom, 


1898-99 


Bart. 


, 1866-67 


Dr R. Milne Murray, . 


1900-01 




1868-69 


Dr James Ritchie, 


1902-03 




1870-71 


Dr N. T. Brewis, 


1904-05 




1872-73 


Dr J. W. Ballantyne, . 


1906-07 




1874-75 


Prof. W. Stephenson, . 


1908-09 




1876-77 


Dr F. W. N. Haultain, 


1910-11 




1878-79 


Dr Haig Ferguson, 


1912-13 




1880-81 


Sir J. Halliday Croom, 


1914-19 




1882-83 


Dr William Fordyce, . 


1920-21 




1884-85 


Dr James Lamond Lackie, 


1922-23 


, 


1886-87 


Prof. B. P. Watson, . 


1923 



VICE-PRESIDE NTS. 



Sir J. Y. Simpson, Bart., 

Dr Alex. Ziegler. 

Dr J. Cowan, R.N., 

Dr Fairhairn, 

Dr Charles Ransford, 

Dr R. B. Malcolm, 

Dr Charles Bell, . 

John Kennedy, Esq., 

Dr John Moir, . 

Dr T. H. Pattison, 

Dr Beilby, . 

Dr T. Graham Weir, 

Dr R. B. Malcolm, 

Dr John Moir, . 

Dr T. Graham Weir, 

Dr John Moir,, . 

Dr W. dimming, 

Dr A. Thomson, . 

Dr T. H. Pattison, 

Dr David Wilson, 

Dr T. Graham Weir, 

Dr George S. Keith, 

Dr T. Graham Weir, 

Dr Alex. Keiller, 

Dr T. H. Pattison, 

W. S. Carmichael, Es 

Dr John Burn. 

Dr Charles Bell, . 

Dr William Bryce, 





Year. 




Year. 


rt., 


1840-41 


Dr J. A. Sidey, . 


1868-69 




1840-41 


Dr William Menzies, . 


1870-71 




1842 


Dr L. R. Thomson, . 


1870-71 




1842 


Sir A. R. Simpson, 


1872-73 




1843 


Dr J. Matthews Duncan, 


1872-73 




1843 


Dr Angus Macdonahl, 


1874-75 




1844 


Dr R. Peel Ritchie, . 


1874-75 




1844 


Dr James Young, 


1876-77 




1845-47 


Dr Alex. Milne, . 


1876-77 




1845-47 


Dr R. Peel Ritchie, . 


1878-79 




1848 


Dr Angus Macdonahl, . 


1878-79 




1848 


Sir A. R. Simpson, 


1880-81 




1849-53 


Dr Robert Bruce, 


1880-81 




1849-53 


Dr James Carmichael, . 


1882-83 




1854-55 


Sir J. Halliday Croom, 


1S82-83 




1854-55 


Dr Angus Macdonahl, . 


1884 




1856-57 


Dr Charles E. Underbill, 


1884-85 




1856-57 


Dr William Ziegler, 


1885 




1858-59 


Sir A. R. Simpson, 


1886-87 




1858-59 


Dr Leith Napier, 


1886 




1860-61 


Dr D. Berry Hart, 


1887-88 




1860-61 


Dr James Foulis, 


1888-89 




1862-63 


Dr A. J. Sinclair, 


1889 




1862-63 


Sir A. R. Simpson, 


1890 




1864-65 


Dr Peter A. Young, . 


1890-91 


l-i 


1864-65 


Dr John PI ay fair, 


1891-92 




1866-67 


Dr Freeland Barbour, . 


1892-93 




1866-67 


Dr A. Ballantyne, 


1893-94 




1868-69 


Dr James Ritchie, 


1894-95 



«3 



List of Office-Bearers 



Sir J. Halliday Croom, 
Sir A. R. Simpson. 
Dr R. Milne Murray, . 
Dr X. T. Brewis, ' . 
Dr J. W. Ballantyne, . 
] >v Samuel Macvie, 
Dr F. W. N. Haultain, 
Dr J. Haig Ferguson, . 
Sir A. R. Simpson, 
Professor J. A. C. Kynoeh. 
Sir J. Halliday Croom, 
Dr D. Berry Hart, 
Dr William Fordyce, . 
Dr F. W. N. Haultain, 



Tear. 

1895-96 

1896-97 

1897-98 

1S98-99 

1899-1900 

1900-1901 

1901-1902 

1902-1903 

1903-1904 

1904-1905 

1905-1906 

1906-1907 

1907-1908 

1908-1909 



Dr Freeland Barbour, . 

Dr Lamond Lackie, 

Dr X. T. Brewis, 

Dr J. W. Ballantyne, 

I >r < r. F. Barbour Simpson, 

! )r < reorge Keppie Paterson, 

Dr Angus Macdonald, 

Dr Robert Jardine, 

Dr Haig Ferguson, 

Dr William Fordyce, . 

Prof. B. P. Watson, . 

Dr J. Lamond Lackie, 

Dr R. W. Johnstone, . 



Year. 
1909-1910 
1910-1911 
1911-1912 
1912-1913 
1913-1919 
1913-1919 
1919-1920 
1919-1921 
1920-1922 
1921-1923 
1922-1923 
1923 
1923 



TREASURERS.' 





Year. 




Year. 


Dr Ransford. 


1840 to 1842 


Dr James Young, 


1867 to 1875 


Dr G. Paterson, . 


1842 to 1847 


Dr William Craig, 


1875 to 1910 


Dr Camming, 


1847 to 1854 


Dr Barbour Simpson, . 


1910 to 1912 


Dr Keiller, . 


1854 to 1859 


Dr John McGibbon, 


1912 to 1921 


Dr J. A. Sidey, . 


1859 to 1867 


Dr W. Macrae Taylor, . 


1921 




SECRE1 


rARIES. 






Year. 




Year. 


Dr P>ansford, 


1840 to 1842 


Dr A. H. Freeland Barbour, 


1881 to 1886 


Dr G. Paterson, . 


1840 to 1847 


Dr R. Milne Murray, . 


1883 to 1889 


Dr Dunsmure, 


1842 to 1847 


Dr N. T. Brewis, . 


1886 to 1893 


Dr dimming, 


1847 to 1854 


Dr J. W. Ballantyne, . 


1889 to 1896 


Dr Keith, . 


1847 to 1849 


Dr F. W. X. Haultain, 


1893 to 1897 


Dr J. M. Duncan, 


1849 to 1852 


Dr J. Haig Ferguson, . 


1896 to 1901 


Dr Keiller, . 


1852 to 1859 


Dr William Fordyce, 


1897 to 1904 


Dr J. A. Side}', . 


1854 to 1861 


Dr Lamond Lackie, 


1901 to 1907 


Dr A. R. Simpson, 


1859 to 1865 


Dr Barbour Simpson, . 


1904 to 1909 


Dr Peter Young, . 


1861 to 1863 


Dr Angus Macdonuld, . 


1907 to 1913 


Dr W. Stephenson, 


1863 to 1867 


Dr B. P. Watson, 


1909 to 1912 


Dr R. Peel Ritchie, 


1865 to 1873 


Dr E. Scott Carmichael, 


1912 to 1915 


Dr G. Stevenson Smith 


1867 to 1871 


Dr R. W. Johnstone, . 


1913 to 1921 


Dr James Andrew, 


1871 to 1875 


Dr H. S. Davidson, 


1920 to 1923 


Dr Alexander Milne, 


1873 to 1875 


Dr James Young, 


1921 to 1924 


Dr C. E. Underhill, 


1875 to 1879 


Dr F. J. Browne, . 


1923 


Dr James Carmichael, 


1875 to 1881 


Dr Douglas Miller 


1924 


Dr D. Berry Hart, 


1879 to 1883 








LIBRA 


RIANS. 






Year. 




Year. 


Dr J. Jamieson, . 


1875 to 1879 


Dr F. W. N. Haultain, 


1899 to 1909 


Dr C. E. Underhill, 


1879 to 1883 


Dr Lamond Lackie, 


1909 to 1921 


Dr Peter Young, . 


1883 to 1889 


Dr R. W. Johnstone, . 


1921 to 1924 


Dr R. Milne Murray, 


1889 to 1899 


Dr H. S. Davidson, 


1924 



EDITORS OF TRANSACTIONS. 



Year. 
1896 to 1899 
1899 to 1901 
1901 to 1905 
1905 to 1907 
1907 to 1910 
Previous to 1861 the office of Treasurer \ 



Dr J. W. Ballantyne, 
Dr N. T. Brewis, 
Dr J. Lamond Lackie, 
Dr Angus Macdonald, 
Dr W. Macrae Taylor, 



Dr Oliphant Xicholson, 
Dr James Young, . 
Dr F. J. Browne, . 
Dr Douglas Miller, 
Dr W. F. T. Haultain, , 
as conjoined with that of Senior Secretary 



Year. 
1910 to 1912 
1912 to 1921 
1921 to 1923 
1923 to 1924 
1924 



List of Fellows of the Society 



HONORARY FELLOWS. 



1901 Bar, Prof. Paul, M.D., Hue la 
Boetie, 122, Paris. 

1906 Bossi, Professor L. M., The 

University, Genoa. 

1915 Briggs, Professor Henry, M.B., 
F.R.C.S., 3 Rodney Street, 
Liverpool. 

1921 Brindeau, Dr A., Paris. 

1911 Buinm, Professor, Berlin. 

1913 Champneys, Sir Francis II., Bart., 
London. 

1898 Coe, Prof. Henry C, M.D., 27 East 
Sixty-fourth St., New York. 

1915 Cullen, Thomas S., M.B., F.A.C.S., 
The Johns Hopkins University, 
Baltimore, U.S.A. 

1910 Doderlein, Professor Alhert Sig- 
mund Gustav, Munich. 

1913 Edgar, Prof. James C, New York. 

1913 Fabre, Professor Jean, Lyon. 

1900 Fehling, Professor Herman, M.D., 
Gungenbach Strasse, 4, Baden- 
Baden. 

1915 Jacobi, Professor, Brussels. 

1898 Kelly, Prof. Howard A., M.D., 
Johns Hopkins Hospital, Balti- 
more, U.S.A. 

1907 Kinoshita, Dr Seichu, Professor of 

Obstetrics and Gynaecology, Im- 
perial University, Tokio, Japan. 
1906 Makieyeff, Prof. Alexander Matve- 
jevic, Tlie University, Moscow. 



1895 Martin, Emeritus-Professor Dr A., 

Freiherr von Stein Strasse, 2, 

Berlin, W. 
1903 Morisani, Professor O., San Felice 

a Piazza Dante, 10, Naples. 
1913 Nagel, Professor Wilhelm, Pots- 

dainer Strasse, 96, Berlin, 

W. 57. 

1901 Ott, Professor D. von, M.D., Pro- 

fessor of Obstetrics, University 
of St Petersburg. 

1902 Pestalozza, Professor, Instituts 

Obstetrico Policlinico, Roma. 
1921 Phillips, Sir John, London. 
1895 Pinard, Professor A., Rue Cam- 

baceres, 10, Paris. 
1921 Reid, Dr W. L., Glasgow. 
1921 Routh, Dr Amand J., London. 
1921 Smyly, Sir Win. J., Dublin. 
1901 Sneguireff, Professor W., University 

of Moscow. 
1921 Spencer, Prof. Herbert, London. 
1897 Williams, Sir John, Bart., G.C.V.O., 

M.D., LL.D., Plas Llanstephan, 

Carmarthenshire. 
1912 Williams, Professor J. Whitridge, 

Johns Hopkins University, 

Baltimore. 
1905 Zweifel, Professor, Frauenklinik 

University, Leipzig. 



CORRESPONDING FELLOWS. 



1884 
1880 
1894 
1896 
1864 



1879 
1877 
1880 
1893 
1881 
1882 
1893 
1894 
1871 
1878 



Arnott, Brig. Surg. -Lieut. -Col. Jas. 
Bosch, Dr Van Den, Liege. 
Curatulo, Prof. G. E., Rome. 
Eyres, Hugh Middleton, Richmond. 
Finlay, Right Hon. Viscount, 

G.C.M.G., M.D., LL.D., K.C., 

London. 
Glaister, Prof., Glasgow. 
Grassett, Dr F., Toronto. 
Helme, Dr J. M., Camforth. 
Howard -Jones, Dr J., Newport. 
Hurst, Dr George, Australia. 
Husband, Dr H. Aubrey, Jamaica. 
Hutchison, Dr Robert, London. 
Jennings, Dr David D.. New York. 
Lambert, Dr, Paris. 
Macdougall, Dr John A., The Hill, 

Balerno, Midlothian. 



1879 Machattie,Dr Thomas A., Bathurst, 

N.S.W., Australia. 
1870 M'Kendrick, Professor, Stone- 
haven. 

1883 Mills, Dr B. Langley, India. 

1884 Neve, Dr E. F., Kashmir, India. 

1885 Puckle, Dr S. Hale, Church Stoke, 

Mont. 

1887 Shiels, Dr G. F., San Francisco. 

1888 Stevenson, Sir Edmond Sinclair, 

Cape Town, South Africa. 

1880 Turner, Dr William, O.B.E., 

M.V.O. 

1885 Underbill, Dr F. T., Vancouver. 

1886 Whitton, Dr A. B., Turin', Aber- 

deenshire. 



List of Fellows 

ORDINARY FELLOWS. 

(«.) LIFE MEMBERS. 



Date of 
Admission. 



Adam, Dr George Kothwell, 84 Collins Street, Melbourne, 

Australia, ....... 1879 

Anderson, Dr John, An Laimhrig, Pitlochry, . . . 1896 

Ballantyne, Dr Harold S., Ashton, Eskbank, . . . 1897 

Barbour, Dr A. H. Freeland, 4 Charlotte Square, . . 1879 

5 Barclay, Dr William John, Invercargill, New Zealand, . 1899 
Barrington, Dr Fourness, 213 Macquarrie Street, Sydney, 

Australia, . . . . . . . 1884 

Brock, Dr G. Sandison, M.B.E., 6 Corso d'italia, Rome, . 1894 

Burton, Dr Arthur, Stenson, Cromer, .... 1912 

Chipman, Dr W. W., 285 Mountain St., Montreal, Canada, . 1895 

10 Craig, Dr John, 71 Bruntsfield Place, . . . . 1900 

Croom, Dr David Halliday, 16 Rothesay Place, . . 1903 

Crow, Dr W. J., 13 Merchiston Place, . . . 1909 

Camming, Dr John, 1 Strathearn Place, . . . 1896 

Davidson, Dr Hugh, 52 Melville Street, . . . 1904 
15 Dumat, Dr Henry Aylmer, 7 Devonshire Place, Durban, 

Natal, South Africa, ..... 1898 

Ferguson, Dr J. Haig, 7 Coates Crescent, . . . 1885 
Fitzwilliams, Dr Gerald Lloyd, Alexandra Buildings, 

Hong Kong, China, ..... 1907 

Fleming, Dr Andrew M., C.M.G., Salisbury, Rhodesia, . 1904 
Fowler, Dr Simson, Waverley, Juniper Green, . . 1892 
20 Gibson, Dr R. Wilson, Town Head House, Orton, West- 
moreland, ....... 1903 

Grant, Dr Lewis, Neston, Cheshire, .... 1896 

Houghton, Dr C. Hobart, Malvern, Natal, South Africa, . 1907 

Hutchison, Dr Alex., Stonetield, Grantown-on-Spey, . . 1913 

Inch, Dr Robert, Gorebrklge, ..... 1887 

25 Johns, Dr W. Wilton, Ramleh, Nairn, . . . 1912 

Johnstone, Dr R. W., C.B.E., 26 Palmerston Place, . . 1903 

Kanga, Dr K. B., Dr Nazareth's Hospital, Karachi, India, 1912 

Kerr, Dr F. K., M.C., 168 Newhaven Road, Leith, . . 1912 

Livingston, Dr George R., 47 Castle Street, Dumfries, . 1898 
30 M* Arthur, Dr W. Taylor, 2025 Western Avenue, Los Angeles, 

California, . . . . . . . 1901 

M'Brearty, Dr J. Wilson, Greymouth, West Coast, New 

Zealand, . . . . . . 1899 

M'Culloch, Dr John, Lindsay, Ontario, Canada, . . 1909 
M'Gibbon, Professor John, 5 Fountain Street, Houghton, 

Johannesburg, South Africa, .... 1902 

M 'Master, Dr A. G, 7 Moultrie Road, Rugby, . . 1906 
35 Macnab, Dr James C. G., Johannesburg, Transvaal, South 

Africa, . . . . . . . 1904 

Maddox, Dr Ralph H., I.M.S., CLE., c/o Messrs Thomas 

Cook & Son, Ludgate Circus. London, E.C., . . 1887 
Martin, Dr Christopher, Cleveland House, George Road, 

Edgbaston, Birmingham, ..... 1888 

Melville, Dr George, The K\ lie, Penicuik, . . . 1912 

Melville, DrKenmure, 2 Churcbhill, .... 1900 
40 Morgan, Dr T. H., Wickham Terrace, Brisbane, Queensland, 

Australia, ....... 1895 

Mules, Dr P. Henry, Woodville, Wellington, New Zealand, . 1903 

Nicholson, Dr H. Oliphant, 20 Manor Place, . . . 1900 

Pitts, Dr Edith Cochrane-Brown, Waimate, New Zealand, . 1905 

Ritchie, Dr A. G., 5 Walker Street, .... 1912 

15 Ronaldson, Dr J. Bruce, Penn Road, Beaconsfield, Bucks, . 1911 

Ross, Dr James F. W., 481 Sherbourne Street, Toronto, Canada, 1 889 



List of Fellows 



Date of 
AdmiHHion. 

Russell, Dr J. Lawson, 20 Liverpool Road, Chester, . . 1906 

Sabawala, Dr Behram Pestonjee, Naupura, Surat, India, . 1912 

Simpson, Dr G. F. Barbour, 43 .Manor Place,. . . 1898 

50 Simpson, Dr W. Petrie, Viewbank, Bathgate, . . 1892 

Simson, Dr H. J. F., 36 Grosvenor Street, London, W., . 1897 

Sloss, Dr William, 706 Stmt Street, Ballarat, Victoria, 

Australia, ....... 1902 

Stewart, Dr J. D. Grahame, c/o Allan, 1 Dundas Street, . 1913 

Taylor, Dr James A., Dunkeld, .... 1912 

55 Taylor, Dr W. Macrae, 8 Melville Street, . . . 1895 

Vatve, Dr Gopal Govind, Shanwar Peth, Kolhapur City, 

Bombay Presidency, India, ... . . 1894 

Wells, Dr'A. Simpson, 26 Kloof Road, Cape Town, South 

Africa, . . . . . . . 1903 

Welsh, Dr David, Melton Constable, Norfolk, . . . 1919 



(b.) ANNUAL SUBSCRIBERS. 

d'Abreu, Dr A. J., 19 Lombard Street, Waterford. Ireland, . 1922 

60 Alexander, T. H. W., North view, Elgin, . . . 1922 

Allison, Dr J., Fuller House, Kettering, Northampton, . 1888 

Alston, Dr James, 57 Nile Grove, . . . . 1922 

Anderson, Dr William, Armadale, Linlithgowshire, . . 1912 
Anklesaria, Dr H. N., Fatch Munzel, New Queen's Road, 

Bombay 4, India, ...... 1906 

65 Armour, Dr E. F., 6 Bruntsfield Terrace, . . . 1889 
Averill, Dr L. C. L., c/o Miss Munro, 49 Arden Street, . 1923 
Barnetjon, Dr Elsie M„ 17 Abercorn Terrace, Portobello, . 1907 
Barnetson, Dr R. Balfour, 17 Abercorn Terrace, Portobello, . 1904 
Barton, Dr S. Saxon, The Beach, St Michael's Hamlet, Liver- 
pool, ...... . 1923 

70 Beesley, Dr R. W., 135 Deane Road, Pulton, . . . 1894 

Heesly, Dr Lewis, 42 Northumberland Street, . . . 1904 

Bell, Dr J. Lumsden, The White Hall, Driffield, E. Yorks., . 1884 
Beveridge, Dr Arthur James, Tayside House, Nethergate, 

Dundee ....... 1912 

Bevridge, Dr Gordon, 5 George Street, Kirkcaldv, . . 1919 

75 Bianchi, Dr L. F., 40 Brighton Place, Portobello, . . 1912 
Blacklee, Dr Herbert F., Dallington, Abbey Road, Barrow-in- 
Furness, . . . . . . . 1920 

Blaikie, Dr R. H., 5 Mayfield Gardens, . . . 1888 
Block, Dr Isidore Jack, O.B.E., 39 Louis Botha Avenue, 

Houghton Estate, Johannesburg, . . . . 1921 

Bowie, Dr J. M., 10 Walker Street .... 1912 

80 Brewis, Dr R. Adams, The West Gate, Dursley, Gloucester- 
shire, ....... 1888 

P.rock, Dr A. J., 8 Rothesay Place, . . . . 1912 

Hrodie, Dr T. Scott, 21 Belhaven Terrace, Wishaw, . . 1900 

Brown, Dr Henry Hilton, 10 Inverleith Row, . . 1921 

Brown, Dr William, O.B.E. , 5 Bon-Accord Srpuare, Aberdeen, 1904 

85 Brown, Dr W. S. Murdoch, 14 Grosvenor Street, . . 1912 

Browne, Dr Francis J., 54 Northumberland Street, . . 1919 

Brownlee, Dr James, 254 Linthorpe Road, Middlesborough, . 1905 
Buchanan, Dr Robert Wilson, 43 Magdalen Yard Road, 

Dundee ... .... 1913 

Buist, DrR. C, 166 Nethergate, Dundee, . . . 1895 

90 Buhner. Dr Ernest, Ashlyn, Fenham, Nrwcastle-on-Tyne, . 1923 

Butchart, Dr C. A., 52 Leith Walk, Leith, . . . 1894 



List of Fellows 



95 



100 



105 



110 



111 



120 



125 



130 



135 



140 



Callender, Dr D. M., Highden, Hatherley Road, Sidcup, 
Kent, ....... 

Callender, Dr T. M., Inverard, Sidcup, Kent, . 
Cameron, Dr S. J., 15 Lynedoch Street, Charing Cross, 
Glasgow, ....... 

Campbell, Dr Helen T., 49 Ann Street. 
Campbell, Dr Malcolm, Inverawe, Droitwieh, . 
Carlow, Dr W. W., 25 Walker Street, 
Carmichael, Dr A. N. S., 2 Merehiston Avenue, 
Carmichael, Dr Edward, Ardveieh Lodge, Liberton, . 
Carmichael, Dr George S., 25 Braid Road, 
Carmichael, Dr Norman Scott, 43 Moray Place, 
Carruthers, Dr G. J. R., 4a Melville Street, . 
Cattanach, Dr J. G., 3 Alvanley Terrace, 
Chisholm, Dr A. E., 9 Springfield, Dundee, . 
Christie, Dr Arthur W. Stark, 56 Northumberland Street, 
Clark, Dr Katherine S., 16 Drummond Place, 
Clark, Dr Patrick A. Bennet, 142 Upper Richmond Road, 
East Sheen, London, S.W. 14, .... 

Clarke, Dr Thomas William, 17 Elmwood Gardens, Acton 
Hill, London, W.3, ..... 

Craig, Dr J. G., 1 Clifton, York, .... 

Craig, DrR. W., Pathhead-Ford, Dalkeith, . 
Croll, Dr Andrew, Saskatoon, Saskatchewan, Canada, 
Carrie, Dr A. S., 20 Oxford Terrace, Hyde Park, 
London, AV., ...... 

Cuthbert, Dr A. Hume, 7 Blenheim Place, 
Darling, Dr William, M.C., 65 Bruntsfield Place, 
Davidson, Dr G. S., 10 Albyn Place, Aberdeen, 
Davidson, Dr Samuel, Mansefield, Kelso, 
Davidson, Dr S. G. , 41 Bridge Street, Hawick, 
Davie, Dr P. Cousin, 15 Archer Street, Timaru, New Zealand, 
Davison, Dr A. W., 959 Chester Road, Stretford, near 
Manchester, ...... 

Dewar, Dr J. M., 5 Chalmers Street, .... 

Dewar, Dr M., 5 Chalmers Street, .... 

Dick, Dr Bruce M., Paddington Green Children's Hospital, 
London, ....... 

Dickson, Dr D. Elliot, Hillcrest, Lochgelly, . 
Dickson, Dr George A., Invermae, South Queensferry, 
Dobie, Dr D. Robertson, Earncliffe, Coldwells Road, Crieff, . 
Donald, Dr George, 46 Ferry Road, Leith, 
Donald, Dr Pollock, Leith Mount, Ferry Road, Leith, 
Douglas, Dr C. E., Winthank House, Cupar, . 
Dunbar, Dr H. J., 47 Cathedral Road, Cardiff, 
Dyer, Dr Ethelbert W., 402 Moore Road, Durban, South 
Africa, ....... 

Easterbrook, Dr C. C, Crichton House, Dumfries, 
Eden, Dr T. Watts, 26 Queen Anne Street, Cavendish Square, 
London, W. , . . .... 

Edington, Dr D. C, Birbeck House, Penrith, . 
Elder, Dr Edward A., 4 Battery Road, Singapore, Straits 
Settlements, ...... 

Elder, Dr Eleanor, 6 John's Place, Leith, 
Evans, Dr O. F., 20 Princes Avenue, Liverpool, 
Fahmy, E. O., 18 St Milan's Terrace, . 
Fairfax, Dr Norman P., Caddon View, Innerleithen, . 
FairHe, Dr Margaret, 170 Nethergate, Dundee, 
Fairweather, Dr J. W. C, Netherton, Auchinblae, Fordoun, 
Kincardineshire, ..... 

Farie, Dr G. J., The Elms, Wimbledon Hill, London, 

S.W. 19 . 

Fergusson, Dr Samuel, Lylestone House, Alloa, 



Date of 
Admission. 

1902 
1896 

1921 

1923 
1904 
1910 
1912 
1887 
1909 
1908 
1901 
1893 
1911 
1912 
1903 

1914 

1913 
1908 
1905 
1912 

1882 
1923 
1900 
1921 
1906 
1924 
1919 

1920 
1910 
1891 



1908 
1912 
1894 
1912 
1922 
1924 
1905 

1906 
1S92 

1888 
1897 

1906 
1903 
1890 
1923 
1912 
1920 

1921 

1903 
1912 



List of Fellows 



\>*te of 
Admission. 



Finlay, Dr Thomas, 3 East Fettes Avenue, . . . 1912 
Finlay, Dr T. Y., 9 Hermitage Gardens, . . . 1908 
145 Fisher, Dr E. F., 7 Buckingham Terrace, . . . 1920 
Fitzgerald, Dr Gordon, O.B.E., Dunedin, Withington, Man- 
chester, ....... 1913 

Fleming, Dr Andrew, St John's Komi, Corstorphine, . . 1905 

Flett, Dr A. B., 15 Walker Street, .... 1903 

Fordyee, Dr William, 17 Walker Street, . . . 1888 

150 Forrest, Dr Stephen, Alexandria. Egypt, . . . 1910 

Fowler, Dr W. Hope, 21 Walker Street, . . 1900 

Fraser, Dr J. Hosack, Fernfield, Bridge of Allan, . . 1895 

Frost, DrW. E., 51 Melville Street, .... 1900 

Galloway, Dr T. M., Hawklymuir, Kirkcaldy, . . 1921 

155 Gardiner, Dr Frederick, 60 George Square, . . . 1900 

Gardner, Dr L. P. M., 74 Pilrig Street, . . . 1912 

Gemmell, Dr A. A., M.C., 28 Rodney Street, Liverpool, . 1924 

Gemmell, Dr J. E., 28 Rodney Street, Liverpool, . . 1885 

Gibbs, Dr J. H., 10 Manor Place, . . . . 1905 

160 Gibson, Dr Alexander, 661 Broadway, Winnipeg, Manitoba, 

Canada, . . . . . . 1908 

Giles, Dr A. B., 4 Palmerston Place, .... 1891 

Gilruth, Jas. D., Hyde Park House, Arbroath, . . 1923 
Gordon, Dr Alexander Stewart, Rosebery House, Inver- 

keithing, . . . . . . . 1920 

Gow, Major P. F., D.S.O., I.M.S., c/o Grindley & Co., 

Hastings Street, Calcutta ..... 1924 

165 Graham, Dr D. J., 2 Melville Crescent, . . . 1895 

Gray, Dr J. A., 4 Wolseley Terrace, .... 1907 

Green, Dr John Ligertwood, 23 Minto Street, . . 1902 

Gregory, Dr W. H., North Bar Without, Beverley, Yorks, . 1893 

Greig, David M., F.R.C.S.E., 12 Abbotsford Crescent, . 1922 

170 Gunn, Dr James T., Deanswood, Auchterarder, . . 1912 

Guthrie, Dr A. Cowan, 10 Harley Street, London, W. 1, . 1888 

Hamilton, Dr Martha L., 19 Pitt Street . . . 1919 

Hartley, Dr J. Jackson, O.B.E., 10 Ainslie Place, . . 1914 
Harvey, Dr Charles, Beckford Lodge, Sav-la-Mar, Jamaica, 

W.I., . . . . . . . 1889 

175 Harvey, Dr James, 12 Grosvenor Street, . . . 1891 

Haultain, Dr W. F. Theodore, 6 Walker Street, . . 1922 
Heard, Richard, Lt.-Col. I. M.S., l.G. Civil Hospitals, Lahore, 

Punjab, India, ...... 1912 

Hendrick, Dr A. C, 20 Bloor Street East, Toronto, . . 1912 

Hendry, Dr James, 4 Clifton Place, Glasgow, . . . 1919 

180 Hendry, Dr Wilhelmina, 11 Bellevue Crescent, . . 1921 

Herzfeld, Dr Gertrude, 16 Great Stuart Street, . . 1921 

Hewetson, Dr J., Holmfield, Reigate, . . . 1881 

Hewitt, Dr J., 16 Whitehall Street, Dennistoun, Glasgow, . 1924 
Hirschman, Dr Nathaniel, 20 Pearce Street, Doornfontein, 

Johannesburg, South Africa, .... 1922 

185 Holland, Dr Eardley L., 55 Queen Anne Street, London, 

V8.1, .... ... 1920 

Holmes, Capt. Frank, R.A.M.C., R.A.M.C. Mess, Grosvenor 

Road, London, S.W. 1., . . . . . 1922 

Hume, Dr Wm. Maitland, Bushey Lodge, Teddington, 

Middlesex, ...... 1911 

Hunter, Dr A. J. Gordon, 41 Castle Street, Dumfries, . 1910 
Hunter, J. W. A., St Mary's Hospital, Whitworth Park, 

Manchester, . . . . . . 1923 

190 Huskie, Dr David, Hamilton House, Moffat, . . . 1912 
Impey, Dr Lance, 8 Essotto Court, Breda Street, Cape Town, 

S. Africa, . 1920 

Inch, Dr T. Douglas, O.B.E., M.C., Stobsmills House, 

Gorebridge, 1914 



List of Fellows 



Date of 
Admission. 
Jacobs, Hubert S., 287 Little Collins Street, Melbourne, 

Australia, ....... 1923 

Jardine, Dr F. E., 65 Northumberland Street, . . 1910 

195 Jardine, Dr Robert, 20 Royal Crescent, Glasgow, W., . 1897 

Johnston, Dr G. Minto, 36 Essleniont Road, . . . 1912 

Johnston, Dr Robert B., 66 Christchurch Road, Streatham 

Hill, London, S.W. 2, .... 1903 

Kalyanvala, Dr D. N., Chief Med. OIF., Porbandar State, 

Bombay Presidency, India, .... 1922 

Keir, Dr Ivan C, Beauacre, Melksham, Wilts, . . 1903 

200 King, Dr Isabel Falconer, 43 Stirling Road, . . . 1924 

Kynoch, Professor Campbell, 8 Airlie Place, Dundee, . 1892 

Lange, Dr Gustav, 3/4 St Mary's Building Streets, c/o Eloif 

and Kerk Streets, Johannesburg, South Africa, . . 1922 

Langwill, Dr Arch., 15 Marloes Road, London, W. 8, . 1913 

Langwill, Dr H. G., 4 Hermitage Place, Leith, . . 1891 

205 Langwill, Dr James, Lisaghmore, Kirkcaldy, . . . 1911 

Lawrie, Dr Thomas Harcourt, St Clair, Polmont Station, 

Stirlingshire, . . . . . . 1912 

Ledger, Dr A. G. K., Chantry House, Shoreham, Sussex, . 1906 

Lee, Dr Alaister Fraser, 29 Great King Street, . . 1920 

Lee, Dr Herbert E., Coolabah, Belmore Street, Burwood, 

N.S.W., Australia, . . . . , 1892 

210 Lindsay, Dr D. M., 8 Park Quadrant, Glasgow, . . 1921 

Lindsay, Dr G. M. S., Alnwick Infirmary, Alnwick . . 1921 

Listen," DrR. Prosper, 16 Alma Street, Abertillery, Mons., . 1922 

Littlejohn, Professor Harvey, 11 Rutland Street, . . 1890 

Lochhead, Dr James, Castle Road, Gibraltar, . . . 1904 

215 Lochrane, C. D., 64 Friargate, Derby, . . . 1923 

Lorimer, Dr Duncan, O.B.E., 2 Forbes Road, . . 1906 

Lowry, Professor Chas. Gibson, 12 University Square, Belfast, 1920 
M'Cann, Dr F. J., 14 Wimpole Street, Cavendish Square, 

London, W. 1, . . . . . . 1896 

Macdonald, Dr Angus, 38 Colinton Road, . . . 1897 

220 Macdonald, Dr John, Marathon House, Cupar-Fife, . . 1902 

Macdonald, Dr W. Fraser. 42 Polwarth Terrace, . . 1910 

M'Ewan, Dr Peter, 7 Blenheim Mount, Manningham Lane, 

Bradford, . . . . . . . 1905 

MacGregor, Dr Alastair, 14 Welbeck St., London, W.l, . 1905 

M'Intosh, Dr A. Morison, C.M.G., 17 Bright's Crescent, . 1912 

225 Mackay, Malcolm E., 406 M'Leod Buildings, Edmonton, 

Canada, . . . . . . . 1912 

Mackay, Dr W. B., 23 Castlegate, Berwick-on-Tweed, . 1899 

M'Kendrick, Dr Archd., 12 Rothesay Place, . . . 1906 

Mackenzie, Dr T. C, Ruigh-Ard, Inverness, . . . 1900 

M'Kerron, Dr R. Gordon, 2 Queen's Terrace, Aberdeen, . 1896 

230 Mackin, Dr Patrick, 132 Vivian Street, Wellington, New 

Zealand, ....... 1895 

Mackness, Dr G. Owen C, Auchlean, Broughty-Ferry, . 1887 

M'Laren, Dr John, 39 Lauriston Place, . . . 1910 

M'Laren, Dr Robert, 10 Gilmore Place, . . . 1912 

M'Larty, Dr Malcolm, 23 Abercromby Place, . . . 1900 

235 Maclean, Sir Ewen J., M.D., 12 Park Place, Cardiff, . . 1902 

Maclean, Dr Jean, Infirmary and Dispensary, Bolton, . 1921 

Macnair, Robert, Ellendene, Gillsland, Carlisle, . . 1919 

MacPherson, Dr J. M., South view House, Yeadon, near 

Leeds, 1921 

Malcolmson. Dr Alexander M., 1 Belccrave Road, Corstorphine, 1901 

240 Mallace, Dr A. C, Elm House, Hawick, . . . 1908 

Marshall, Dr L. R. H. P., The Briars, Peebles, . . 1912 

Martin, Dr Angus, 25 Northumberland Square, North 

Shields, . . . . • • • 1906 

Martin, Dr Charles, Abernant Lake Hotel, Llanwrtyd Wells, 1892 



List of Fellows 



Martin, Dr Norman Alexander, c/o Dr Philip, Bon Accord 
House, Morpeth, Northumberland, 
245 Matheson, Dr Angus, Duntulm, North Berwick, 

Mayne, Dr C. A., 8 Ardmillan Terrace, 

Meikle, Dr J. Hally, 12 Midmar Gardens, 

Menzies, Dr W. Menzies, 25 Castle Terrace, 

Miller, Dr A. S., Rannoeh House, Tranent, 
250 Miller, Dr Douglas Alexander, 57 Manor Place, 

Milligan, Dr Harley P., Hessle, East Yorks, . 

Milne, Dr W. Morrison, o Minto Street, 

Mitchell, Dr C. R. P., Southlield House, Malvern, . 

Moir, Dr J. Chassar, The Mount, Montrose, . 
255 Molony, Capt. J. B. de Win ton, O.B.E., I. M.S., c/o Chartered 
Bank of India, Australia, and China, Bombay, . 

Moorhouse, Dr J. Ernest, 6 Melville Terrace, Stirling, 

More, Dr John, Rothwell, Kettering, . 

Morris, Dr George, 2 Morningside Park, 

Mowat, Dr R. S., 40 Raeburn Place, . 
260 Munro, Dr J. Ramsay, High Street, Spalding, 

Murray, Dr E. Farquhar, 52 Jesmond Road, Newcastle-on 
Tyne, 

Murray, Dr Janet, 18 Carrick Road, Ayr, 

Nasmyth, Dr Alexander, Hillwood House, Penicuik, . 

Newton. Dr R. H. H., 5 Murrayfield Avenue, 
265 Ogilvy, Dr Stewart Grant, Fairmont, Fauldhouse, 

Oliphant, Dr E. H. Lawrence, 23 Newton Place, Glasgow, 

Orbell, Dr Ronald S., 12 Reed Street, Oamaru, New 
Zealand, ...... 

Orr, Dr John, Heather Lea, Clarendon Road, Eccles, Lanes. 

Orr, Dr John, 6 Strathearn Road, 
270 Orr, Dr T. S. A., 33 Welbeck Street, London, W. 1, . 

Orr, Dr W. Basil, 13 Braid Road, 

Patch, Capt. C. Lodge, M.C., I. M.S., Asylum House, Lahore 
India, ...... 

Paterson, Dr G. Keppie, 19 Albany Street, 

Pearson, Dr C. Mowbray, 14 Manor Place, 
275 Pearson, Dr J. H. H., 34 Dundas Street, 

Pell, Dr J. W., Hodge Memorial Hospital, Hankow, China, 

Peterson, Dr George R., Saskatoon, Saskatchewan, Canada, 

Playfair, Dr John, 5 Melville Crescent, 

Poole, Dr T. D., North Side House, Linthwaite, Huddersfield 
280 Porter, Dr Frederick, 65 Morningside Road, 

Prentice, Dr W. H., Rosebank, Bolton Road, Pendleton 
Manchester, ..... 

Primrose, Dr Alex., 100 College Street, Toronto, Canada, 

Pringle, Dr J. Hogarth, 172 Bath Street, Glasgow, . 

Proudfoot, Dr Frank Gregoire, 43 St Giles, Oxford, . 
285 Rabagliati, Dr A. H., 640 Musgrave Road, Durban 
Natal, ...... 

Ritchie, Dr James, Craigowan, Colinton Road, 

Ritchie. Dr T. C, O.B.E., Prospect House, Malpas, Cheshire 

Robarts, Dr Henry H., Ennerdale, Haddington, 

Roberton, Dr Ernest, Remeura Road, Auckland, New Zealand 
290 Robertson, Dr Ian Monro, 19 Learmonth Terrace 

Robertson, Dr Robert, 44 Melville Street, 

Robertson, Dr R. Macdonald, 53 Bruntstield Place, 

Ronaldson, Dr R. Miller, 9 Melville Crescent, 

Rose, Dr Joan K., 2 Chester Street 
295 Ross, Dr T. W. E., 31 Morningside Road, 

Rutherford, Dr A., 24 Palmerston Place, 

Saunders, Dr F. A., Hill Street, Grahamstown, Cape Colony 
South Africa, ..... 

Scott, Dr Alexander, The Firs, Broxburn, 



Date of 
Admission. 

1920 
1912 
1924 
1906 
1910 
1912 
1920 
1908 
1898 
1903 
1924 

1922 
1892 
1908 
1922 
1910 
1901 

1920 
1921 
1912 
1922 
1895 
1885 

1907 
1887 
1912 
1912 
1889 

1913 

1S82 
1902 
1912 
1914 
1912 
1873 
1890 
1904 

1901 
1887 
1886 
1913 

1903 
1880 
1911 
1904 
1887 
1923 
1897 
1912 
1912 
1922 
1904 
1921 

1885 
1906 



List of Fellows 



Secord, Dr E. R., 112 Market Street, Brantford, Ontario, 
Canada, ...... 

300 Shannon, Dr David, 26 Woodside Place, Glasgow, 
Shaw, Dr C. J., Sunnyside Asylum, Montrose, 
Shearer, Dr Alfred, The Bank, Newtown, N. Wales, . 
Silberbauer, Dr Stanley F., 9 Hof Street, Cape Town, South 
Africa, ...... 

Simpson, Dr Archibald, Murivance, Shrewsbmy, 

305 Simpson, Dr F. D., 49 Melville Street, 

Slight, Dr J. D., 17 Victoria Road, Leicester, 
Sloan, Dr A. T., D.S.O., 22 Melville Street, . 
Smith, Dr John, Bryce Hall, Kirkcaldy, 
Smith, Dr J. N. Douglas, Ashwood, Broughty Ferry, . 

310 Smith, Dr W. Ramsay, Central Board of Health, Adelaide 
South Australia, ..... 
Sneddon, Dr William, Logan Bank, Cupar-Fife, 
Somerville, Dr C, Viewpark, Bonnyrigg, 
Somerville, Dr James W., The Grange, Galashiels, 
Spence, Dr John W. L., 40 Palmerston Place. 

315 Sprunt, Dr Thomas, Pathological Department, University 
Edinburgh, ..... 

Stark, Dr J. Nigel, 4 Newton Place, Charing Cross, Glasgow, 
Steen, Dr Horatio W. J., 88 Portsdown Road, Maida Vale 

London, W. 9 .... . 

Stephen, Dr W. A., Loftus-in- Cleveland, Yorkshire, . 
Steuart, Dr Murray B., Oakley, Kirkcudbright, 

320 Stevens, Dr John, 78 Polwarth Terrace, 

Stewart, Dr A. M., 196 Ferry Road, Leith, . 
Stewart, Dr Flora M. , 14 Carlton Street, 
Stewart, Dr R.. 25 George Square, 
Stewart, Dr T. M. J., 127 Princes Avenue, Hull, 

325 Stewart, Dr W. Ross, Major, I. M.S., St Mark's Road 
Bangalore, India, ..... 
Stewart-Sandeman, Dr Laura, 22 Waverley Place, Aberdeen, 
Stirling, Dr R., 4 Atholl Place, Perth, 
Straehan, C. G., 112 Gilmore Place, . 
Strachan, Dr G. I., Windsor Place, Cardiff, . 

330 Strain, Dr Arthur C. , 3 Clifton, Avenue, West Hartlepool, 
Stmtheis, J. W., F.R.C.S.E., 15 Ainslie Place 
Swift, Dr Brian H., 12 North Terrace, Adelaide, 
Temple, Dr G. H., Ailanthus, Weston-super-Mare, 
Tew, Dr W. P., 385 Waterloo Street, London, Canada, 

335 Thatcher, Dr C. H., 8 MelvilleCrescent, 

Thatcher, Dr L. H. F., 8 Melville Crescent, . 

Thin, Dr Robert, 25 Abercromby Place, 

Thomas, Dr R. C, 13 Clytha Park Road, Newport, Mom, 

Thompson, Dr James L., Castlemaine, Victoria, Australia, 

340 Thomson, Dr A. D. R., 19 Bridge Street, Musselburgh, 
Thomson, Dr John, 14 Coates Crescent, 
Thomson, Lr T. J., 3 Greenhill Park, 
Thvne, Dr T. J., c/o Peters, 16 Walker Street, 
Tod, Dr John, 67 Ferry Road, Leith, . 

345 Tolmie, Dr Peter Morrison, Hull Tuberculosis Sanatorium 
Cottingham, E. Yorks, .... 
Tuke, Dr A. L. S., 12 Comely Park, Dunfermline, 
Venters, Dr Isabel, 2 Greenhill Gardens, 
Walker, Dr Arthur S., Ashleigh, Middlesbrough 
Ward, Dr Gladys, 65 Wallwood Road, Leytonstone, London 
E. 11. . 

350 Watson, Professor B. P.. 8 Manor Place, 

Watson, Dr H. Ballingall, 1 Clifton Terrace, . 

Watson, Dr R. H., 1 Barton Road, Dover, 

Watt, Dr Robert Honey, Esk Villa, Langholm, Dumfries, 

xvi 



Date of 
Admission. 

1902 
1910 
1903 
1898 

1912 
1906 
1900 
1898 
1922 
1885 
1924 

1892 
1888 
1902 
1902 
1912 

1922 
1908 

1922 
1894 
1912 
1894 
1913 
1923 
1885 
1921 

1921 
1912 
1892 
1922 
1921 
1904 
1922 
1923 
1888 
1923 
1877 
1910 
1891 
1923 
1894 
1877 
1887 
1902 
1887 
1892 

1920 
1911 
1907 
1906 

1921 
1902 
1921 
1896 
1912 



List of Fellows 



White, Dr A. L., 145 Manchester Road, Rochdale, near 
Manchester, .... 

355 Wilson, Dr James, Dalhousie Grange, Bonnyrigg, 
Wood, Dr A. Murray, 180 Ferry Road, Leith, 
Young, Dr James, D.S.O., 29 Manor Place, . 
Young, Dr John, Oakmount, Lasswade, 



Hat.' of 
Admission. 

1903 
1889 
1912 
1907 
1924 



The foil oicing Fellows have dial during the Session 1923-24. 



ORDINARY FELLOWS. 



Lackie, Dr James Lamond, 



Life Member. 



1889 



Annual Subscribers. 



Ainslie, Dr A. C. , . , 




. 




1898 


Brewis, Dr N. T., 








1883 


Broad, Dr B. W., 








1895 


Honeyford, Dr John, 








1922 


Morison, Dr Albert E. , . 








1888 


Price, Dr A. W. Gordon, 








1890 


Scott, Dr T. R., . 








1880 


Sloan, Dr Allen T., 








1893 



xvn 



CONTENTS 



I.— COMMUNICATIONS RELATING TO OBSTETRICS 



J-AGK 



i. Valedictory Address on Recent Advances in Obstetrics and 

Gynaecology. J. Lamond Lackie i 

2. Induction of Labour by Quinine and Pituitrin. F. J. Browne . 25 

3. Note on a Case of Rupture of the Uterus following the Adminis- 

tration of Pituitrin for the Induction of Labour. William 
Fordyce ........ 33 

4. The Association of Placenta Praevia and the Albuminuric 

Toxaemias. Douglas Miller . . . . .65 

5. Veratrone — with Special Reference to a Case of Severe Reaction. 

A. E. Chisholm ....... 73 

6. Some Observations on Seventy Years of Country Midwifery 

Practice. C. E. Douglas. . . . . .81 

7. One Hundred Successive and Successful Caesarean Sections in 

Cases of Contracted Pelvis. S.J.Cameron . . .118 

8. Caesarean Section. E. Farquhar Murray . . . .122 

9. A Note on Pelvimetry. S. J. Cameron and J. Hewitt . .137 

10. Further Observations on Still-Birth and Neonatal Death : Their 

Causes, Pathology, and Prevention. F. J. Browne . .158 

11. A Case of Malignant Hydatidiform Mole with Pulmonary 

Metastases. Professor James Miller . . . .217 

12. Administration of Thyroid Gland during Pregnancy. J. Ramsay 

Munro ........ 225 



II.— COMMUNICATIONS RELATING TO GYNAECOLOGY 

1. Adenomyoma of the Uterus with Tuberculous Infection. R. \V. 

Johnstone ........ 54 

2. A Pendulous Tumour of the Labium Majus exhibiting Unusual 

Features. J. Haig Ferguson ..... 149 

3. Hydroureter and Hydronephrosis Secondary to Prolapse and 

Cystocele. James Young ..... 207 

4. Case of Early Chorion-Epithelioma. J. Haig Ferguson . . 212 
Index ........ . 227 



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The Transactions 

of the 

Edinburgh Obstetrical Society 

SESSION LXXXIIL— 1923-1924 



At the First Meeting of the Society held on 14th November 
1923, the following Office-Bearers were elected for the ensuing 
Session : — 

President 
Prof. B. P. WATSON. 

Vice-Presidents 
Senior— Dr J. LAMOND LACK IE. | Junior— Dr R. W. JOHNSTONE. 

Secretaries 

Senior— Dr JAMES YOUNG, | Junior— -Dr F. J. BROWNE, 

29 Manor Place. 54 Northumberland Street. 

Treasurer 

Dr W. MACRAE TAYLOR, 
8 Melville Street. 

Librarian 

Dr R. W. JOHNSTONE. 

Editor of Transactions 

Dr DOUGLAS MILLER, 

50 Northumberland Street. 

Members of Council 
*Dr J. HAIG FERGUSON. I Dr H. S. DAVIDSON. 

*Dr CHARLES W. SOMERVILLE. Dr A. W. STARK CHRISTIE. 

*Dr H. OLIPHANT NICHOLSON. Dr E. F. FISHER. 

Dr DAVID SHANNON. Dr GERTRUDE M. A. HERZFELD. 

Those marked with an asterisk were elected last year and hold office for 
two years. 



The Transactions 

of the 

Edinburgh Obstetrical Society 

VALEDICTORY ADDRESS. 

By J. LAMOND LACKIE, M.D., F.R.C.P.E., President. 

It now falls to me to restore the trust you placed in my hands 
two years ago, and in doing so I take the opportunity of again 
thanking you all most cordially for the great honour you did 
me in electing me to this Presidential Chair, and for the 
unfailing sympathy and courteous consideration you have shown 
me during my tenure of office. In view of its responsibilities 
and high traditions I accepted the position with great diffidence, 
and I am very conscious of many shortcomings in the discharge 
of my duties. Still, thanks to your great kindness, these two 
years will ever remain with me as a most pleasant and stimu- 
lating memory, for to have occupied the Chair of this ancient 
Society is to me the greatest of honours, of which I am 
genuinely and justly proud. 

In a valedictory address it is a customary but a painful 
task to take notice of the gaps which the hand of death has 
made in our ranks during one's term of office. Two years 
ago our three senior Fellows were Sir James Affleck, who 
joined the Society in 1869, Sir Halliday Croom, who joined in 
1870, and Dr William Craig, who joined in the same year. All 
have now passed beyond the veil. By the death of Sir James 
Affleck, Edinburgh lost one of her most skilful, distinguished, 
and beloved physicians, and many institutions mourned the 
loss of a genuine friend and helper. Sir James Affleck's 
interests and activities were unlimited, and we in this Society 
remember with gratitude his willing service to the Royal 
Maternity and Simpson Memorial Hospital, to which for so 
long he acted as consulting physician. The members of the 
staff recall with thankfulness his valued aid and guidance in the 
diagnosis and treatment of medical complications of pregnancy 
and the puerperium. Naturally he was not an active member 
of this Society, but I have no doubt that owing to his connection 

OBST. I A 



J. Lamond Lackie 



with the Maternity Hospital he continued a member to the 
end, and I know he was always interested in our proceedings. 

By the passing of Sir Halliday Croom, the city of Edinburgh 
has lost one of its most distinguished and well-known citizens, 
the University one of its most brilliant teachers, and our 
Obstetrical Society one of its most devoted members. 

John Halliday Croom, who was born in Sanquhar in 1847, 
was educated at the Royal High School of Edinburgh and 
subsequently at the University, where he graduated in 1868. 
It was not till 1882 that he took the degree of M.D., receiving 
at the same time a gold medal for his thesis. For some months 
in 1869 he studied in Paris and in London, and then he settled 
in Edinburgh as a general practitioner. Success came rapidly ; 
but in spite of crowded hours Croom found time for teaching, 
which in the future was to become his main life's work. 
He became assistant to the Professor of Medicine, and this 
post he held for one year. However, even then his chief 
interest was in Obstetrics, and when Professor A. R. Simpson 
was appointed to the Chair of Midwifery, Croom became his 
first University and private assistant. He commenced tutorial 
classes and conducted these with marked and increasing success. 
In 1877 he resigned his University appointment and commenced 
an annual three months' course of lectures on Midwifery and 
Gynaecology in Minto House. This class proved one of the 
most attractive in the whole Medical School, and many hundreds 
of graduates look back on it with the happiest memory. 
In 1905 he succeeded Sir Alexander Simpson as Professor 
of Midwifery in the University, and this appointment seemed 
to stimulate Sir Halliday Croom to still further effort in 
teaching. There could have been no more popular election, 
and for sixteen years more he taught the students with his 
accustomed vigour and vivacity. With ease he always com- 
manded the attention and the interest of his students. They 
became infected by their teacher's enthusiasm, while his 
impressive and dramatic style, combined with an unfailing sense 
of humour, made every lecture most effective and never to 
be forgotten. It has been truly said that "his illustrations 
and apt remarks were always striking, and culled as they 
were from a ripe experience, many of them have become 
aphorisms indelibly fixed in the minds of the thousands who 
in the course of fifty years of teaching have had the privilege 
of passing through his hands." 

2 



Valedictory Address 



Croom prepared his lectures with infinite care, and into 
their delivery he put his whole soul and energy. It is 
impossible to convey to those who never heard him a real 
impression of his quite extraordinary gifts as a teacher, for 
he was unrivalled and unique. I can recall a member of a 
post-graduate course many years ago saying to me, " Dr Croom 
lectures as if the salvation of one's immortal soul depended on 
the diagnosis of an ectopic gestation." He was forceful, com- 
pelling, and emphatic in all he said and did, and in nothing 
more than in his teaching. 

Early in his career Croom obtained hospital appointments. 
In 1883 he became Assistant Gynaecologist to the Royal 
Infirmary, and two years later he succeeded to the charge 
of wards, which he served for the full term of fifteen years. 
In 1 90 1 he was appointed Consulting Gynaecologist to the 
Royal Infirmary. In 1887 he was elected full physician to 
the Maternity Hospital, and there he served for twenty years, 
when he resigned active charge and became consulting physician. 
However, on his appointment to the Chair in 1905, he returned 
to the active staff and served on it for a further sixteen years, 
so that he was connected with the Maternity Hospital for forty- 
four years in all, a truly remarkable record. I should like to 
take this opportunity of recalling the great debt that our 
School of Medicine owes to our friend and master, who was 
the first to institute a course of clinical midwifery in the wards 
of the Royal Maternity Hospital. With characteristic energy 
Croom threw himself into the organisation and conduct of the 
course, and his teaching was followed with delight and eagerness 
by the large number who joined the clinique. 

But besides being a great teacher, Sir Halliday Croom was 
a great consultant and operator, and his services were requested 
in all parts of the kingdom, and also abroad on several occasions. 
He was an exceptionally busy man, and one knows the difficulty 
he constantly had in meeting all the demands on his time and 
strength. And yet, withal, we find he wrote about a hundred 
articles and addresses of great practical interest and importance. 
He was a most devoted Fellow of this Society, which held him 
in such esteem that on three occasions he was elected President, 
and when he retired an Honorary Fellowship was conferred 
upon him, a distinction which he much appreciated. To this 
Society he contributed much that he wrote, and he was a 
constant speaker in the discussions. He published two 



J. Lamond Lackie 



volumes — one on The Bladder during Parturition^ and one 
on Minor Gynecological Operations, which latter ran through 
several editions in this country and in America. 

Sir Halliday Croom, who was a Fellow of both the Royal 
College of Physicians and of the Royal College of Surgeons, 
had many honours conferred upon him. He was a Fellow 
of the Royal Society of Edinburgh, President of the British 
Gynaecological Society, an Honorary Fellow of the American 
and Belgian Gynaecological Societies, President of the 
Obstetrical Section of the British Medical Association in 1896, 
and Chairman of the Central Midwives Board for Scotland. 
Dublin conferred upon him its Honorary M.D., and on his 
retirement the University of Edinburgh acknowledged his 
services by making him an Honorary Doctor of Laws. Those 
who were present on the occasion will not readily forget the 
unsurpassed demonstration of affection on the part of students 
and friends with which he was greeted. In 1902 he received 
the well-deserved honour of Knighthood. 

Sir Halliday Croom, whose handsome and dignified figure 
was so well known in Edinburgh, was a man of charming 
personality, displaying at all times an almost old-fashioned 
courtesy and geniality to all, and he was one of the kindest 
and most hospitable of men. Those of us who enjoyed his 
more intimate friendship will always remember many an 
evening at 25 Charlotte Square, when he played the part of 
the ideal host. His conversation sparkled with humour, and 
his fund of stories seemed to be limitless. But he could be 
serious too, and in the quiet of his smoking-room he enjoyed 
nothing more than a friendly discussion or argument on the 
pressing questions of the day. 

He felt his retirement from the Chair of Midwifery and 
from active work most keenly and, as so often happens, his 
health rapidly seemed to fail. He had had few interests 
outside his work ; reading became his only resource and he 
read much on many subjects. He was urged to write some 
memoirs, but he always replied that he could no longer 
concentrate on anything. 

Sir Halliday Croom has gone to his rest : he has left behind 
him a noble example of good work well done, and his name 
will ever be revered in the affectionate regard of hosts of 
friends and pupils. We have a great inheritance in the 
memory of his life and work, which should ever prove an 

4 



Valedictory Address 



inspiration, stimulating us, as far as in us lies, to maintain 
the high traditions of this Society of which he was such a 
distinguished Fellow. 

It is difficult to express what this Society owes to the 
late Dr William Craig, who was its Treasurer for thirty-five 
years — from 1875 to 1910. Dr Craig, who passed away in 
his ninetieth year, joined this Society in 1870, and throughout 
his long life never ceased to take an active interest in all its 
doings. Many of us know that it was entirely due to his 
enthusiasm and business ability that the Society was raised 
from the verge of bankruptcy to the flourishing condition in 
which he left it when he presented his last financial statement 
and resigned the Treasurership in 1910. Some of us remember 
how thoroughly Dr Craig enjoyed the first meeting of every 
session. He clearly and definitely let us understand how our 
finances stood ; he pointed out that we could not go on sending 
Transactions to men who did not pay their subscription, and 
then with an almost vicious pleasure, though we knew he 
had no personal animosity to anyone and that his interest in 
the Society was his only motive, he moved that Drs So and So's 
names be deleted from the Roll of Fellowship as they were 
three years in arrears. Then different Fellows put in pleas 
for the various delinquents; in the end all were generally 
given another chance and no one was more pleased than the 
Treasurer. On more than one occasion Dr Craig was offered 
the Chair of this Society but his innate modesty prevented 
him accepting and he preferred to remain as Treasurer to the 
end of his active connection with the Society. All who knew 
him regarded Dr Craig with the very highest esteem, and this 
Society will ever hold his name in affectionate and most 
grateful memory. 

The death of Dr J. W. Ballantyne on 23rd January of this 
year came as a great shock to his colleagues and to his many 
friends, and it is true to say that by none is his loss more 
sincerely deplored than by the Fellows of the Edinburgh 
Obstetrical Society. 

Born sixty-two years ago, John William Ballantyne was 
educated first at Bonnington Park School, Peebles, and later 
at George Watson's College. From there he passed to the 
University and graduated M.B., CM. in 1883, winning at the 
same time the Buchanan Scholarship, which is annually awarded 
to the graduate most distinguished in Gynaecology. The 

obst. 5 a 2 



J. Lamond Lackie 



scholarship carried with it the appointment of House Surgeon 
in the University Ward for Diseases of Women, at that time 
under the care of Professor A. R. Simpson, and this post he 
filled, as well as later that of House Surgeon in the Maternity 
Hospital, with conspicuous success. Thus early in his career 
Ballantyne came under the influence of Simpson and became 
identified with the special department of which by and by 
he became such a distinguished ornament and to which he 
contributed so much. In 1888 he became a Fellow of the 
Royal College of Physicians, and a year later he graduated 
M.D. with a thesis on "Some Anatomical and Pathological 
Conditions of the New-born Infant," for which he was awarded 
a Gold Medal and the Gunning Simpson Prize in Midwifery. 
During five years Ballantyne acted as University and private 
assistant to Professor Simpson, and after this period of 
probation and training he took his diploma as a Lecturer on 
Midwifery and Gynaecology in the School of Medicine of the 
Royal Colleges. From then till the time of his death he was 
ever engaged in teaching his subject both to men and women 
students. In 1916 when women were admitted to the University 
classes in Medicine he was asked to undertake their teaching 
in his Alma Mater, and this appointment he held until the end. 

In 1900 Ballantyne was elected Assistant Physician to the 
Royal Maternity and Simpson Memorial Hospital, and four 
years later he became a full physician. It was in this Hospital 
that he gradually but surely developed his great scheme for 
the better pre-maternity care of expectant mothers, with which 
his name will be associated for all time. Most of you know 
with what enthusiasm and earnestness he took up this work. 
From the Annual Reports we know of the ever-increasing 
numbers who attended his clinic ; we know of the many hours 
per day he spent in his department without a murmur or 
complaint of the tax upon his time and energy. 

In 191 9 the City authorities instituted a department for the 
treatment of venereal disease occurring during pregnancy and 
labour, and to the charge of this Dr Ballantyne was also 
naturally appointed. This work gave him another and a 
fresh field for study, for observation and for research, and 
during these recent years he applied himself with his 
accustomed zeal to the problem of this complication which 
so endangered the health and the lives of the pregnant and 
the parturient. Dr Ballantyne's connection with the Maternity 

6 



Valedictory Address 



Hospital was a long and honourable one, and his services to the 
institution cannot possibly be overestimated. 

Elected a Fellow of this Society forty years ago, Ballantyne 
in course of time occupied the various offices in succession 
until in 1906 he was elected President, and it is safe to say 
that no one ever brought greater lustre to the reputation of 
this Society. It is pleasant to recall and to emphasise his 
long association with the " Edinburgh Obstetrical " and the 
outstanding part he played in all its proceedings. The first 
paper Ballantyne read was entitled " On Cases of Clinical and 
Pathological Interest in the Buchanan Ward " and was a record 
of his work as Resident under Professor Simpson. From 1884 
to 1886 Ballantyne seemed to have been especially interested 
in the sphygmograph, and he read two papers on tracings 
taken during labour and during puerperal eclampsia. It is 
remarkable to find that at that time he looked upon eclampsia as 
a complication arising in a patient who was the victim of Bright's 
disease. These papers on the pulse embodied an immense 
amount of work, and one wonders how even then he found 
time to undertake it. In 1886-7 he showed "Drawings of 
Frozen Sections of a Newly-born Child with General Dropsy," 
and in 1887-8 recorded a case of "Mitral Stenosis in Labour 
and the Puerperium." Year by year Ballantyne contributed 
to our Transactions, and from the very first showed an 
extraordinary knowledge of literature of any subject he took 
up. It was in 1891 that he first read a communication on 
what was to become a most important part of his life work — 
" Studies in Fcetal Pathology and Teratology." He urged that 
the pathology of the fcetus had an importance which was not 
fully recognised, and complained that the subject had not pro- 
gressed pari passu with the pathology of the adult organism. 
He pointed out the difficulties of the study and suggested 
how they rpight be removed. He urged fuller investigation 
of specimens illustrating fcetal disease, and suggested an 
inquiry into all the obstetrical circumstances of each case. 
Thereafter he brought before this Society endless papers on 
the subject, and all possible anomalies of fcetus were exhibited. 

Many of us remember his inaugural address of 1906, in which 
he cleverly and humorously recorded an imaginary telephonic 
conversation with the President of 1940. Ballantyne pictured 
the obstetrical methods of teaching and practice which might 
then pertain, and already in several directions his prophecy is 

7 



J. Lamond Lackie 



proving true. In debate or in discussion of others' papers he 
was ever ready and always interesting. His criticism was 
kindly and helpful, and he never failed to introduce just a 
touch of humour which added much to the attraction of his 
speaking. Everyone listened to Ballantyne, his remarks were 
never commonplace : they were always of the unexpected. 
We all remember the merry twinkle of his eye and his 
cheery smile as he evolved an argument which at first 
seemed somewhat fantastic, but which before he had finished 
shed new light on the subject under discussion and suggested 
a new line of thought. Throughout all the ages his name will 
be associated with antenatal pathology and antenatal care, and 
his pioneer work in these departments will never die. We are 
proud to think that it was first of all to this Society that he 
made most of his communications on these subjects, and that 
through our Transactions they became known throughout the 
civilised globe. It is true to say that "Preventive Midwifery" 
to a large extent is the direct outcome of his labours, and we 
rejoice that he lived to see his work appreciated and recognised 
throughout the obstetrical world. 

In 1902 the Royal College of Physicians awarded him the 
Cullen prize " for the greatest benefit to practical medicine in 
the previous four years." The work of Ballantyne, though at 
first received with scepticism and sometimes even with derision, 
became rapidly known throughout the obstetrical world, and 
no name in this great school of medicine was more familiar to 
obstetricians in every part of the globe than that of Ballantyne. 
Honours came to him in recognition of his work. At different 
times he was Examiner in Midwifery and Gynaecology to the 
Universities of Aberdeen, Edinburgh, Glasgow, and Edinburgh ; 
he was elected an Honorary Fellow of the Glasgow Obstetrical 
and Gynaecological Society and of the American Association 
of Obstetricians and Gynaecologists, while at the annual meeting 
of the British Medical Association in London, 1910, he was 
Vice-President of the Obstetrical Section. 

Writing was extremely easy to Ballantyne, and its literary 
excellence always reached an exceptionally high level. He was 
a voracious reader, not only of all literature relating to his own 
department, but of all scientific work and of general literature 
as well. He had a wonderful memory and his mind was a 
veritable store of information, which was always at the disposal 
of his friends when a reference or literary help was required. 

8 



Valedictory Address 



He had an extensive and comprehensive private library which 
was one of his chiefest joys, and nothing gave him greater 
pleasure than his work as Honorary Librarian of the Royal 
College of Physicians. 

Dr Ballantyne was a seeker after truth for its own sake, 
for he had no ambition towards success in practice. Scotland 
has lost its most devoted worker in the field of antenatal 
pathology and pre-maternity care, and the world has lost 
a gifted pioneer whose whole life was dominated by an 
unselfish desire to do something for the science and art of 
Obstetrics, and something to alleviate the suffering of humanity. 
In time to come no eloquence will be required to extol him : 
his published works and his wonderful influence on Obstetrics 
of to-day and of the future will ever be a monument of the 
rarity of his genius and of his exceptionally brilliant intellect. 

This year there also passed away in London Dr Sol Jervois 
Aarons, who was a member of this Society, and who was a most 
loyal alumnus of Edinburgh University. He was a prominent 
student in the early nineties, and so won the affection and 
respect of his fellows that he was elected President of the 
Union in 1894. After graduation he was House Surgeon in 
Sir Halliday Croom's ward in the Royal Infirmary, and later 
Resident under the same chief in the Royal Maternity Hospital. 
Thereafter he settled in London as an obstetrician and 
gynaecologist and rapidly achieved a large and successful 
practice. Many of us here remember Sol Aarons of fascinating 
manner and imbued with the great gift of doing kindness to 
others. We recall his last visit to Edinburgh, when he paid 
a special visit to do honour to the late Sir Halliday Croom 
at a Complimentary Dinner in 1922, and we remember w r ith 
pleasure his buoyant spirits on that evening and the gaiety 
he added to the gathering by his reminiscences of his former 
chief. We ^deplore his loss, which is a truly personal and 
sincere one to all who knew him. 

We also much regret the death of Dr Thomas Wood of 
Ferry Road, who was a well-known figure at our meetings and 
who frequently took part in the discussions. In 1890 he read 
an important paper on " Experiments on the Fcetus and Their 
Bearing on its Attitude and Position in utero" which gave 
rise to a lively debate. 

We also deplore the loss of Dr George Dickson of 
Merchiston Park, who died during last session. He was 

9 



J. Lamond Lackie 



especially interested in infants, and wrote several papers on 
their ailments. 

Dr Joshua Cox, who joined this Society in 1876, and who 
became a leading practitioner in Manchester, and Dr Jas. 
Murray of this city, who enjoyed the confidence and the 
esteem of a large clientele, have also passed away. 

The work of the Society during the past two years has 
been varied, interesting and progressive. To enumerate the 
papers is superfluous, to individualise would be invidious. 
Both from a scientific and practical aspect we have ample 
evidence of energetic and enthusiastic workers whose efforts 
have attained a high level and give promise of maintaining 
the Society in the prominent position it has so long occupied. 
It says much for the activity of the Society and for the industry 
of the Fellows that so much material has been provided. 
I would, as so many past Presidents have done, appeal especially 
to general practitioners to bring before us clinical notes, 
however short, of the interesting and uncommon cases met 
with in practice. Such papers would enhance the value of our 
Transactions and widen the interest and enlarge the outlook 
of the Society on all things obstetrical and gynaecological. 

I am glad to say I am not yet old enough to justify my 
writing a " Looking Back," but it is interesting to me to reflect 
on the changes that have taken place since I became a 
Fellow of this Society. I do not refer to the necessarily ever- 
changing personnel and the gradual dropping out of many 
whose names will always be honoured in the realm of Obstetrics 
and Gynaecology, but rather I would point to the recent progress 
that has been made in our science and art. In many directions 
this has been very striking, but in others it has been disappoint- 
ing, and we are groping for more light and clearer elucidation. 

Among the unsolved problems of Obstetrics none is of 
greater interest or calls more urgently for solution than the 
subject of the toxaemias of pregnancy. Within recent years 
the majority of investigations have pointed to the placenta as 
the most probable source of the "poison." In this connection 
no one has done better work that Dr Jas. Young, a Fellow 
of this Society, who has advanced the view that the phenomena 
of eclampsia result from a flooding of the mother's system 
with the early autolytic products of placental necrosis. Recent 
biochemical research on renal and hepatic function suggests 



Valedictory Address 



that in eclampsia the metabolic factor does not possess the 

significance which Watson and Harding have shown must be 

assigned to it in the earlier months. While this is so, the 

lowered incidence of eclampsia during the War years, especially 

in continental clinics, probably as the result of a diet poor in 

proteid, suggests that this, the dietetic factor, is of the first 

importance, if not in the etiology of the pre-eclamptic state, 

certainly in its aggravation and in the development of 

eclampsia. The Dublin method of treatment, which, compared 

with statistics from other hospitals yields such good results, is 

based on this hypothesis. It is quite certain that the condition 

of the alimentary canal is all important in determining the 

effect of the toxin on the system generally, and nowadays 

treatment is largely directed to it and not to the obstetrical 

condition at all. 

As regards the symptomatic treatment of eclampsia, it is 

interesting to note that when I was Resident in the Maternity 

Hospital our instructions were that on no account were we to 

give morphia to an eclamptic. To-day the routine treatment 

at the hospital is the administration of morphia from time 

to time as required to control the seizures. Another important 

therapeutic measure in combating eclampsia has been introduced 

within the last few years, and there can be no denying its 

wonderful effect. Many .believe that in veratrone we have 

a far better remedy than in morphia, and the remarkable action 

it has in lowering the blood pressure, and as a depressant of 

the central nervous system is very certain. The greatest care 

must be exercised in its use, for in the larger doses its 

depressing effect on the heart may be alarming and even fatal. 

Veratrone, I believe, is one of the most valuable therapeutic 

remedies at our command, and we have seen the most surprising 

and satisfactory results from its use. 
> 

With regard to the obstetrical treatment of eclampsia, I 
would refer only to one or two important points that emerged 
from the discussion at the British Congress of Obstetrics and 
Gynaecology held in Liverpool last year. It was concluded 
from the reports sent in from various hospitals that the mean 
mortality from eclampsia in mild cases was 6-4 per cent, and 
in severe cases 32-4 per cent., a ratio exactly of 1 to 5. If the 
mild cases delivered by the simple methods of natural delivery^ 
assisted delivery and induction are compared with the severe 
cases delivered by the same methods, the mortality rates are 

11 



J. Lamond Lackie 



5-2 per cent, and 26-5 per cent, respectively — i.e., the ratio 
of 1 to 5 is almost exactly maintained. If we compare in the 
same manner the cases delivered by Cesarean section, we 
find that the mild cases showed a mortality of 9-8 per cent., 
the severe cases a mortality of 43-2 per cent., which also 
corresponds closely to the mean ratio of I to 5. Hence it 
is shown that cases which can be classified as severe may be 
expected to show a mortality rate five times greater than 
those classified as mild, no matter what method of delivery 
is adopted. It is also clear that the cases in which there was 
no obstetric interference, or in which simple methods only were 
adopted, show a much lower mortality than those delivered 
by Caesarean section and accouchement force. It appears 
further that in mild cases Caesarean section increases the 
maternal risk to the extent of nearly 2 to 1, and that cases 
delivered by the three simpler methods have a much better 
chance. In short, the cases in which there was the minimum 
of obstetric interference show much the best results. 

With regard to the haemorrhages that occur in the later 
months of pregnancy, the most striking advance is the treat- 
ment of some cases by Caesarean section. It is now realised 
that in a severe typical case of concealed accidental haemorrhage 
the damage to the uterine muscle may be so severe as to 
render it quite inert, with disastrous consequences. For that 
reason many hold that the safest treatment is Caesarean section 
followed by hysterectomy. All are unanimous about the 
Caesarean section ; but of late there has been a tendency to 
try to save the uterus, even when the damage to the uterine 
wall has been considerable, and two such cases were reported 
to this Society last session. Attempts to discover the cause 
of accidental haemorrhage have been made ; the most recent 
theory is that it is due to mechanical causes of the nature of 
an obstruction of the venous return from the uterus. 

It is also an innovation of the last twenty years to treat 
placenta praevia by Caesarean section, and there can be no 
doubt that in some cases it is the best line of treatment. For 
the majority of cases, especially in multiparae, bipolar podalic 
version is still the most favoured operation ; but in primiparae, 
in whom the os is rigid and undilatable by packing, Caesarean 
section is now recognised as the most satisfactory means of 
saving both mother and child. As another alternative to 
bipolar podalic version it has recently been advocated that 

12 



Valedictory Address 



pressure on the placental site after rupture of the membranes 
by a distended hydrostatic bag should be adopted. The reason 
for this is that the fcetal mortality is so serious from bipolar 
version, and it is suggested, and with good reason, that many 
infants might be saved if the haemorrhage were controlled by 
a bag instead of by pressure of the breech on the bleeding site. 
By this method there would be no interference with the child 
till the moment for actual delivery arrived, and not necessarily 
even then. 

There is no more difficult task set the obstetrician than to 
determine the best management of a case of slightly contracted 
pelvis. At all events one great advance in the treatment of 
these cases is the recognition that the high forceps operation 
is one to be almost rigidly avoided, except on very rare 
occasions. Indeed of late there has been a growing con- 
viction that forceps for all indications are used much too 
frequently, and there can be no doubt that such is the case. 
Patient waiting is often much better practice than even 
the most skilful forceps delivery. The maternal and fcetal 
mortality from the high forceps operation is greater than 
that from properly chosen and properly timed Caesarean 
section. 

Within recent years, Caesarean section has become so 
safe that there is a risk of the indications for it becoming 
too numerous, and so extended that one is quite convinced 
that the operation is undertaken too often without any real 
justification. However, one of the most interesting develop- 
ments is the employment of Caesarean section in cases of 
heart disease complicating pregnancy and labour. It is now 
known that though a patient, with serious uncompensated 
cardiac disease, may survive the actual strain of labour, the 
effect is shown later in great aggravation of the lesion and 
its symptoms, and often in the death of the patient some 
months after delivery. Caesarean section is proving a means 
of obviating this, and the results so far published are good. 
There is the further advantage in that the patient can be 
sterilised at the time of operation. 

Pubiotomy is a very old operation, and has been revived 
not so much in this country as in others. Menge's recent 
statistics of 104 cases with no maternal deaths, and only 
six fcetal deaths, make one wonder if this operation is 
receiving in this country the attention it deserves. It is 

13 



J. Lamond Lackie 



recognised that it is not an operation of election but one to 
be adopted only in multiparae and only when forceps have 
failed and the conditions present contra-indicate Caesarean 
section. It is an operation which ought to compete very 
strongly with craniotomy which should become rarer and 
rarer and be reserved entirely for cases of hydrocephalus 
and cases in which the child is already dead. 

There has been no change of note in the actual mechanical 
operation of Induction of Premature Labour, but the induction 
of labour at or about full time is a commoner operation than it 
used to be. Every case that goes beyond the expected date 
of parturition demands careful investigation. Some deny the 
possibility of the post-mature foetus, but for my part I am 
convinced that I have seen many. Further, I am certain that 
in such the growth is rapid and disproportion between pelvis 
and head speedily takes place. Once this seems likely to occur 
induction of labour is more than justified. 

Without exception, the most striking therapeutic agent that 
has been introduced into obstetric practice within recent years 
is the extract of the posterior lobe of the pituitary gland. So 
powerful is it as an oxytocic that it is now constantly used to 
bring on labour, which in the majority of cases it does effectively 
if used at or about full time. If used to induce premature labour 
its success is not nearly so certain, but it always forms a useful 
adjunct to the mechanical means employed. As regards its 
use during labour this has been much abused, and it is now 
recognised that the employment of the drug during the 
second stage may be fraught with greatest danger. The 
cases must be carefully chosen. Only when there is no 
disproportion, when the head is in the cavity of the pelvis, 
when the patient is a multipara, and when the uterus is 
sluggish may pituitrin be injected. If these conditions are 
not present there is great danger of laceration of parts and 
even of rupture of the uterus, of which several cases have 
now been recorded. As a stimulant of uterine contraction 
after the third stage, pituitrin has supplanted ergot to a large 
extent and nearly always proves most efficient. The duration 
of effect is shorter than after the use of ergotin, but when 
necessary there is no reason why both should not be used. 

As regards the management of labour, a most striking 
advance has been the employment of morphia-scopolamine 
narcosis, which has proved highly efficient in lessening or 

14 



Valedictory Address 



even abolishing the pains of labour in quite the majority of 
cases. The only deterrent to its universal use is the alleged 
dangerous effect upon the infant, and one is now convinced 
that sometimes the effect may be somewhat disturbing. Cases 
are recorded in which nothing but the use of twilight sleep 
could be adduced as the cause of the death of the infant, but 
throughout all the ages such cases have occurred when 
treatment by narcosis during labour was quite unknown. 

The more scientific and reasoned management of malposition 
of the vertex is one of the most valuable improvements in 
obstetric practice that have been introduced within recent 
years. Early diagnosis of the complication and, in the event 
of undue delay, artificial rotation have entirely superseded the 
former treatment of extraction by brute force applied by 
forceps, so often attended by great and irreparable damage to 
both mother and child. The recognition of these malpositions 
of the head is an important part of the work of the antenatal 
department, and in view of what has been said with regard 
to the late Dr J. W. Ballantyne one need not do more than 
simply point out that the institution of pre-maternity care 
is perhaps the greatest achievement of the obstetric art 
within the past twenty years. 

Obstetricians have no good ground for congratulating 
themselves on any improvement in the incidence of puerperal 
septic fever. In hospital practice it certainly is much less, 
but in private the morbidity and mortality are greater than 
they were seventy years ago. This is almost unexplainable, 
since the general principles of asepsis and antisepsis are so 
thoroughly understood. The difficulties of carrying out every 
detail in private are recognised : the accoucheur knows what 
is required, but suitable conditions in the patient or her 
surroundings are not always present. One need not enter 
upon a discussion as to the relative value of local antiseptic 
treatment and of general treatment along with drainage in 
puerperal fever, a subject which was well considered by this 
Society last summer. There are still those who believe in 
active treatment of the genital canal, while others see in that 
nought but an increase of bacteraemia and of danger. The use 
of sera in sepsis is comparatively old : vaccines are a recent 
introduction. Both too often are found wanting and ineffectual 
in puerperal fever. Some hope for better results from a 
prophylactic vaccine, and one would like to see a record of a 

IS 



}. Lamond Lackie 



large series of cases in which every case, normal and abnormal, 
was treated in this way. It is only by such clinical evidence 
that the true value of vaccines can be estimated. 

One must refer to the induction of pneumoperitoneum 
and the use of Rontgen rays, on which last year we had a 
most interesting paper by Dr Impey, and which in America is 
regarded by some as a most valuable aid in the diagnosis of 
pregnancy. Dr Lee, however, remarks that he knows of deaths 
from the manipulation and very properly asks if this should 
not deter us from using it, especially when a little time and the 
obstetrician's fingers would be sufficient to make an accurate 
diagnosis. On similar lines radiography in the diagnosis of 
tubal patency is a recent suggestion, and has been carried out 
by Rubin's method of gaseous insufflation of the uterus and 
tubes. More recently Kennedy has located the site of occlusion 
by radiographic examination after filling the organs with a 
20 per cent, solution of sodium bromide under pressure. It 
might also be pointed out that, with improved technique, X-rays 
are becoming more and more useful in helping to determine 
any disproportion between the head and the pelvis. 

In gynaecology, as in obstetrics, great advances have been 
made. Our knowledge of the pathology of pelvic tumours 
and other lesions has become more complete. Of late, much 
interest has been taken in the nature and origin of the so-called 
adeno-myoma, and light is being gradually shed on the problem 
of its origin. To Sampson belongs the credit of having first 
drawn attention to the frequency of adeno-myoma, and of 
having suggested that the haematomata in the ovary are 
endometrial in origin. 

No subject has given rise to more discussion and more 
diversity of opinion than the treatment of suppurative 
salpingitis. There is one school that believes in immediate 
operation the moment the condition is diagnosed, no matter 
whether the infection be gonococcal or streptococcal. In some 
cases extensive incision of the tubes and drainage are carried 
out, in others, when the inflammatory condition has reached 
the ulcerative or gangrenous stage, the tube is removed entirely. 
Another school believes in the expectant treatment of sup- 
purative salpingitis in the early stages, and only operate later 
when the acute symptoms have subsided, and when chronic 
tubal disease and ill - health demand interference. One of 
the objects of both schools is the restoration of the function 

16 



Valedictory Address 

of the tubes, but so far the results from both methods of 
procedure have been disappointing in that direction. 

The treatment of that most common of all gynaecological 
symptoms — intrinsic dysmenorrhcea — is still a vexed question. 
The British Obstetrical and Gynaecological Congress, which 
met in April last in this city made an attempt to define the 
aetiology and the treatment, but it was extraordinary how 
diverse were the opinions of those who took part in the 
discussion. Professor Blair Bell, who introduced the subject 
in an exhaustive and most valuable paper, pointed out that 
dysmenorrhcea was a relative term, and that the severity of 
the pain depended on the patient herself and on her environ- 
ment to a large extent. He put in a plea for a more accurate 
study of the pathology of the condition and for a clearer 
definition of the various causes of the pain. Along with some 
fault in the endocrine balance, under-development of the uterus 
was an important factor in causation, and he classified the 
various directions in which this non-development might show 
itself. Blair Bell also regarded intrauterine clotting alone 
or in conjunction with other causes as a common factor in 
the production of painful menstruation. He pointed out that 
dysmenorrhcea otcurred in at least 50 per cent, of all women, and 
that child-bearing had not so great an influence in the natural 
cure as was generally supposed. Excluding dysmenorrhcea 
due to excessive exfoliation of the endometrium, he claimed 
that by a scientific attempt to remove the causal factor 80 per 
cent, of cases were much relieved or cured. He ur°"ed 
that effort should be directed towards stimulating the ovaries 
and uterus to fuller development, and with this in view he 
advocated the use of five grains of whole-ovary substance three 
times a day, and from three to five grains of thyroid substance 
every night. While admitting that in special circumstances, 
which he indicated, dilatation and curettage might be the 
correct line of treatment, Blair Bell condemned the empirical 
performance of this operation as at present so commonly 
undertaken, for, if generally applied, it led to disappointment, 
the percentage of cure being about half of that obtained by 
the scientific treatment of the cause. For the relief of pain 
while the cure of stimulating development was in, progress, 
nothing new was suggested, belladonna and the coal-tar 
analgesics being found the most useful. For one of the worst 
forms of undeveloped uterus, viz., the cochleate uterus, Blair 

obst. 17 b 



J. Lamond Lackie 



Bell recommended a vaginal hysterotomy, but this operation 
did not seem to find much favour among the Members of 
Congress. 

A method of treating gynaecological disease which has 
within the last fifteen years come rapidly to the front is that 
of radiotherapy which may be carried out by X-rays, by radium, 
or by both. There is great difference of opinion with regard 
to its use, and although remarkable results have been published 
all observers are not equally enthusiastic. Thus it is interesting 
to find the President of the Section at the British Medical 
Association meeting at Portsmouth in July last declaring that 
he regarded X-ray treatment as a return to the methods of 
barbarism, while a reader of a paper on the subject had just 
recorded a series of surprisingly good results. Radiotherapy 
should not be regarded as an opponent of surgery but as an 
alternative when operation seems contra-indicated. Hence it 
is that radium is playing an important part especially in the 
treatment of cancer of the cervix. There are but few who 
would rely entirely upon radium in the treatment of operable 
cancer, but all are agreed that in many inoperable cases there 
is nothing so effective as radium for alleviating symptoms and 
so prolonging life. It has also been used with apparent benefit 
before operation, after operation, and for metastases in or near 
the vagina. For cancer of the body nearly all authorities 
prefer operation to the use of radium. 

There has been a good deal of controversy over the use 
of radiotherapy in uterine fibroids. Many contra-indications 
have been cited, and there is no doubt that treatment either 
by X-rays or by radium is not without risk. It has indeed 
been estimated even by the most enthusiastic that only about 
17 per cent, of fibroids are suitable for radiation. Large 
tumours, those complicated by inflammation of the adnexa, 
submucous tumours, those complicated by degenerations or 
malignant disease, and those that cause pain are all regarded 
as unsuitable. It must occur to one at once that it is absolutely 
impossible in many cases to say whether degeneration or 
malignant disease is a complication or not. Still the fact 
remains that in small fibroids in women over forty, and in 
cases where operation is contra-indicated on account of inter- 
current disease or other disability, such as excessive loss of 
blood, good results have been obtained. According to some 
there seems to be a distinct field for radium and X-ray 

18 



Valedictory Address 



treatment in the management of chronic metritis, fibrosis uteri 
and climacteric haemorrhage ; but here again there are so many 
contra-indications that some condemn the procedure entirely. 
However, there is no denying the excellent results obtained 
in some of these cases from the introduction into the uterus 
of ioo milligrammes of radium for twelve hours. For the 
uncontrollable haemorrhage of young women it seems only 
fair to try the effect of radiotherapy before resorting to 
hysterectomy. In such cases it has been shown that the radium 
or the X-rays can be administered in such doses that the 
ovarian function is not permanently damaged. It seems also 
to have been proved that a course of repeated applications of 
X-rays is more destructive to the ovaries than a single 
application of radium. 

While endocrinology is not strictly a new science, there 
is no branch of medicine which has in recent years attracted 
so much attention. Mention may be made of the close cor- 
relation which modern research has shown exists between the 
internal secretory organs and the functions of menstruation and 
reproduction. It has become recognised that many morbid 
gynaecological conditions have as their basis some aberration 
in endocrine function ; as instances of such may be mentioned 
precocious or delayed puberty, certain of the menorrhagias 
of puberty and the menopause, and possibly certain cases of 
dysmenorrhcea and sterility. It is further probable that while 
hypo- or hyper-activity of any member of the endocrine group 
may be responsible for disordered menstrual or reproductive 
function, the different ductless glands are so finely balanced in 
their action that any want of harmony is incompatible with 
perfect health. In spite of the great amount of work done it 
must be admitted that our knowledge of the physiology of the 
glands of internal secretion is far from complete. It follows 
that we have as yet no rational basis for the treatment of such 
conditions, and while the exhibition of appropriate glandular 
extracts is on occasion brilliantly successful, it must be 
confessed that in the present state of our knowledge organo- 
therapy is largely empirical and often disappointing. Treatment 
by an individual gland is frequently unsatisfactory and most 
confusing, for the same gland is used in the treatment of very 
different conditions and the results are slow, especially in the 
treatment of menstrual disorders. Undoubted benefit has 
attended the use of the whole ovarian extract in the artificial 

19 



J. Lamond Lackie 



menopause, and that of corpus luteura in the nausea of 
pregnancy. However, the present tendency and future develop- 
ment will be along the lines of pluriglandular therapy, due 
to the probable correlation between the pituitary, thyroid, 
mammary gland, suprarenal and ovary, rather than in the use 
of single extracts. This seems to render glandular therapy 
more empirical than ever, but it certainly reduces the difficulty 
of the choice of gland and makes the prescription easier. 

Blair Bell points out that the artificial menopause is 
induced only when there has been pre-existing ovarian activity. 
He asks why it is that ovarian substance or extract does not 
produce specific results at the physiological menopause, whereas 
whole gland ovarian substance, especially when combined with 
thyroid gland, gives marked relief when the menopause has 
been induced by operative procedure. He suggests that there 
may be at the climacteric some substance circulating in the 
blood, or something withdrawn from it which leads to atrophy 
of the ovaries, and also to other physiological and structural 
alterations at the " change of life." 

With a fuller understanding of the physiology of the pelvic 
organs there has come a more determined attempt to practise 
conservative gynaecological surgery in suitable cases, and Giles's 
recent paper on this subject is most instructive. The all- 
important function of child-bearing and the ovarian function 
are preserved when possible : menstruation and the marital 
function though of lesser importance should not be interfered 
with if their retention is feasible. If, on operating on the 
adnexa, an ovary or even a portion of one can be preserved, 
menstruation will continue and the patient will not have the 
sense of mutilation, from which those who lose both ovaries 
entirely nearly always suffer. Further, the internal secretion 
of the ovary will be preserved to some extent. Hence in 
removing the uterus for simple tumours or fibrosis, an 
attempt should be made to retain as much ovarian tissue as 
possible. 

Similarly, in removing the Fallopian tubes, the ovaries may 
also be affected and must be sacrificed, but in many cases it is 
possible to save some ovarian tissue. Conservative surgery of 
the Fallopian tubes is now more commonly practised, chiefly 
with a view to preserving the channel between ovary and uterus 
and so retaining the possibility of pregnancy. So far the 
results are not very encouraging, but salpingostomy, drainage 

20 



Valedictory Address 



of pus tubes, and opening up of an occluded uterine ostium 
are three conservative operations that are frequently performed 
to-day. 

As regards the uterus, it is now more universally recognised 
that many uterine fibroids can be treated by myomectomy 
instead of hysterectomy. When the fibroid can be removed 
and a useful uterus left behind, and when other conditions 
are favourable for child-bearing, myomectomy is the preferable 
operation, but of course, after the age of forty to forty-five, it is 
of no practical value. However, when all is said and done, 
there is no denying that the results of conservative surgery 
in gynaecology are often disappointing, and that too often a 
second operation is required which might have been avoided 
had the original one been more complete. 

And now, I should like to thank the various officials of the 
Society, not only on my own account, but on yours, for their 
untiring work during these past two years. It is due to their 
interest and energy in its welfare that the Society has been able 
to maintain its traditional vigour and vitality. We are especially 
indebted to our Secretaries, who have never spared themselves, 
not only in their routine duties but in securing for each meeting 
a Billet of valuable papers and interesting specimens. A great 
deal of the success of the Society depends on the whole-hearted 
enthusiasm of the Secretaries, and I am sure you will agree 
that by Dr Davidson and Dr Young we have been most 
admirably served. 

Two years ago Dr F. J. Browne kindly undertook the 
duties of Editor of Transactions, and I fear there are none 
who covet his post. We all agree that Dr Browne has dis- 
charged his duties, under present conditions, with exceptional 
efficiency, and he has earned our warmest thanks. 

The duties of our Librarian have never been arduous, and 
now it is proposed to make them lighter still. With your 
sanction it was agreed to disperse our Library, such as it was, 
and now the books are housed some in the Royal College oi 
Physicians, some in the library of the Royal Medical Society, 
while others are, by request, being sent to the University 
of Iowa. With such excellent medical libraries as those which 
exist in Edinburgh, it was felt that to attempt to maintain one 
for this Society was unnecessary and unsatisfactory from its 
very incompleteness. However, we are indebted to Dr 
Johnstone for his past duties of storage, and for the trouble 

2 I 



J. Lamond Lackie 



he has taken in arranging for the final resting-place of the few 
books we possessed. 

Words almost fail me when I come to speak of the work 
of our Treasurer, Dr Macrae Taylor. The best testimonial 
to his devotion to the Society is his annual statement, and 
I venture to say that it is largely due to his faithfulness and 
his financial genius that the Society is, at all events, in a 
solvent condition. At one time after the Great War it seemed 
as if we were once more on the verge of bankruptcy ; but thanks, 
in large measure, to the skill and initiative of Macrae Taylor 
we have pulled through, and there is every prospect of a speedy 
return to our former sound financial position. The value of 
his work in the arrangement with the sister Society, the Medico- 
Chirurgical, and the publishers of the Edinburgh Medical 
Journal cannot be overestimated. The Obstetrical Society 
must for all time feel indebted to our present Treasurer for 
most valuable services, just as it can never forget the work 
of his distinguished predecessor, Dr William Craig. 

It seems right that I should refer to the important 
Obstetrical and Gynaecological Congress which was held here 
in April of this year. We were very proud to welcome 
the Congress to Edinburgh, and the Society did all in its 
power to make the meeting the success it proved. We were 
indebted to many Fellows for contributions towards the expenses 
of entertainment and printing, and the officials whom I have 
already mentioned as well as the Vice-Presidents and the 
Council did a great deal of solid work in connection with the 
Congress. From conversation and from many letters it was 
evident that the members of the other Societies found real 
pleasure in their visit, and their gratitude and evident enjoy- 
ment amply repaid us for any trouble taken. 

In conclusion, it is now my privilege to welcome my 
successor to the Presidential Chair of this Society. I have 
said that two years ago I accepted the honour of the Chair 
with diffidence : to-night I resign it with the greatest confidence. 
Professor B. P. Watson, after a valuable experience in Toronto, 
has been recalled to his Alma Mater to succeed the late Sir 
Halliday Croom and to carry on the work of a long line 
of distinguished Professors. Already his influence for good 
in the department has been recognised, and we wish him 
all happiness and success in his new sphere of work. It is 
only fitting that this Society should, as soon as possible, confer 

22 



Valedictory Address 



on him the highest honour it has in its power to bestow, and 
in doing so we feel assured that Professor Watson, as President, 
will most worthily uphold and continue the honourable traditions 
of the Edinburgh Obstetrical Society. 



Professor Watson said, — My first duty, Fellows of the Obstetrical 
Society, before I assume the Presidential Chair, must be to thank you 
for the very signal honour you have done me. I recognise and know 
that this honour comes to me because of the position I hold and not 
because of any intrinsic merits of my own, and I can only say that I 
shall exert myself to the utmost to further the interests of the Society 
and of all that the Society stands for. I know that I shall have the able 
support of all its office-bearers, and upon that I rely. I can say no 
more but to thank you most heartily for this very great honour. 

Dr Haig Ferguson said, — Mr President, you will allow me to 
intervene for a moment. While welcoming you most heartily to 
the Chair, we cannot allow our recent President to depart without 
expressing our very high appreciation of his services. We all know 
how well Dr Lackie has fulfilled his Presidential duties. He has 
come up to all our expectations, and we have been delighted with 
his Chairmanship. We have been equally delighted to-night by his 
charming address. We realise most fully that during the last two 
years he has not only had the routine duties of the Chair to perform, 
but he has also had a great many extra duties to overtake. The 
Gynaecological Congress which was held last April was fully 
appreciated, not only by us but by all our visitors, and it was 
greatly due to our President's initiative and to his courteous 
method of conducting business that the meeting was such a great 
success. There have been letters from all parts of the country 
saying how much our visitors enjoyed their visit here, and how 
much they appreciated the kindness which was vouchsafed to them 
by the Society and by other friends in Edinburgh. I have no 
hesitation in saying that much of this was due to our retiring 
President, who graced the Chair and who did so much to make 
the meeting a success. I therefore have the greatest pleasure in 
asking you to accord a most hearty vote of thanks to Dr Lackie, 
and we hope that before very long we may see him again in the 
Chair. 

Dr Fordyce said, — Will you allow me in a single word to second very 
cordially this vote of thanks to our retiring President. I think that 
apart from my seniority I have a special right to do this, because 
Dr Lackie and I commenced our obstetrical careers together, and 

23 



J. Lamond Lackie 



we have been fast friends ever since. We have a great heritage as 
members of this Society in the traditions that have been handed 
down to us from previous generations, and these traditions 
Dr Lackie as our President has most worthily and honourably 
upheld in his occupancy of the Chair, both in the routine duties 
pertaining to that office and in his unfailing efforts in the interests 
of our Society ; and also in the two most excellent and eloquent 
addresses that we have been privileged to hear from him. He 
has been an excellent and worthy President, and as he was 
talking to-night he recalled to my mind very vividly his former 
master and friend, Sir Halliday Croom, and in saying that I think 
I can pay him no higher compliment. Dr Ferguson has referred 
to the part that he played in the British Gynaecological Congress 
which was held last spring under the auspices of our Society. 
Dr Lackie has himself modestly referred to that, but I am sure we 
will all admit that whatever success attended that meeting — and it 
was a very great and unqualified success, as one heard from 
members afterwards both by letter and by word of mouth — that 
success was very largely due to the genial personality and the 
untiring efforts of Dr Lamond Lackie. 



PRIVATE BUSINESS. 

Meeting — 14th November 1923. 

The following were elected Ordinary Fellows of the Society : — 
L. C. L. Averill, M.C., M.B., Ch.B., Bishopscourt, Pannell, Auckland, 
New Zealand; Ernest Bulmer, M.B., Ch.B., Ashlyn, Fenham, 
Newcastle-on-Tyne ; James Rennie, M.B., Ch.B. (Aberd.), 7 Bath 
Street, Stonehaven; Ian Monro Robertson, M.B., Ch.B. (Edin.), 
19 Learmonth Terrace, Edinburgh; William P. Tew, M.B. (Toronto), 
385 Waterloo Street, London, Canada ; Rufus Clifford Thomas, 
M.R.C.S. (Eng.), L.R.C.P. (Lond.). 



24 



THE INDUCTION OF LABOUR BY QUININE 
AND PITUITRIN.* 

By F. J. BROWNE, M.D., F.R.C.S. (Edin.). 

That a physiologically active substance could be obtained 
from the pituitary body was first discovered by Oliver and 
Schafer 1 in 1895. Some time afterwards (in 1906) Dale found 
that an extract of the posterior lobe could produce uterine 
contractions. This discovery was confirmed by Blair Bell a in 
1909; by experimental observations on rabbits he found that 
it caused powerful uterine contractions and that the contractions 
so produced were more prolonged than normal. He introduced 
it to obstetric practice in the same year for the treatment of 
uterine inertia and post-partum haemorrhage. 

It was natural that obstetricians, more or less dissatisfied 
with the existing methods of inducing labour, and because the 
scope of induction was being extended in various directions, 
should see in the new drug a possible physiological method 
of inducing labour pains in the human subject. Accordingly 
we find creeping into the literature, especially the German 
literature, references to the use of pituitrin for this purpose. 
The earliest paper I have been able to find is that of Fries 4 
who, in November 191 1, records that he had found it successful 
in bringing about labour pains whether at term or prematurely, 
in every case in which he had tried it, namely, four altogether. 
He however had found it unsuccessful in the induction of 
abortion, but thinks that it might have been successful if it 
had been continued long enough and in large enough doses. 
In 2 cases of nephritis with pre-eclamptic signs it succeeded 
at the 36th and 38th week of pregnancy respectively, in starting 
labour pains, although the labour had to be subsequently ended 
by forceps, while in 2 other cases at term it was also 
successful, no ill effects occurring to mother or child. He used 
the pituitrin in 1 c.c. doses without any preliminary preparation 
by quinine and at long intervals, varying from two to twenty- 
four hours. Studeney 5 in December of the same year records 
his experiences in 2 cases. One was a premature case in 
which repeated doses entirely failed to induce labour pains; 
the other was fourteen days post-mature and the administration 
of 3 to 6 c.c. in graduated doses ended the pregnancy with 

* Read 12th December 1923. 
OBST. 25 C 



F. J. Browne 



a good result to mother and child. Haugh and Meyer in 
191 2 had found, however, that pituitrin was useless to excite 
uterine contractions that had not yet begun, though they found 
it useful to increase them in uterine inertia. Stein and Dover 
in 1917 recorded an experience of 34 cases of induction 
at term by means of pituitrin. They began the induction 
with a dose of castor oil, followed in two hours by two 3-minim 
intra-muscular injections of pituitrin with an interval of three 
hours between each. If labour pains started the pituitrin was 
resumed at half-hour intervals. If no pains resulted the 
treatment was stopped and another attempt was made on 
the third day following, giving the same small doses. They 
found that true labour usually started after the second injection. 
Stein considered it useless to attempt to induce abortion or 
premature labour by this method. 

Cron"'in 1922 reported his results in 45 cases, ranging from 
the eighth month of pregnancy to three weeks' post-maturity. 
In 65 per cent, induction was successfully accomplished by 
a combination of castor oil, quinine and pituitrin, not more 
than three injections of 5-minim doses of pituitrin being given 
during a single attempt at induction, but as many as six 
courses at intervals of three to six days were given to a 
single case. He noted that the method was more effective 
in cases at term or post-mature than in those which were 
premature ; and concluded with Stein that for bringing on 
therapeutic abortion or premature labour, pituitary extract 
alone, or in combination with other drugs, is practically useless. 

The chief exponent and advocate of the method, however, 
was Professor B. P. Watson who, in 191 3, published the records 
of 3 cases in which he had induced labour by pituitrin ; one 
was at eight months, one at term, and one was three weeks 
post-mature. In 1920 he read a paper s before the American 
Gynecological Society in which were recorded the results of 
its use in a series of 62 cases, 53 of which were successful 
and 9 unsuccessful, and in 1922 9 he published the results 
obtained in a further series of 195 cases. Labour was 
successfully induced in 176 or 90 per cent, with no maternal 
mortality and a foetal death rate of 6 per cent., which was 
somewhat lower than the general foetal mortality rate for 
all cases in the hospital in the previous six months. None 
of the foetal deaths could fairly be ascribed to the use of 
pituitrin. 

26 



Labour by Quinine and Pituitrin 

After reading Professor Watson's second paper, I thought 
that, if successful, the method would be one peculiarly adapted 
to our venereal department. There a large proportion of the 
cases going into labour suffer from purulent vaginal discharges. 
Induction of labour by any of the ordinary mechanical methods 
such as bags or bougies was attended by more than usual risk 
of carrying organisms from the vagina into the uterine cavity. 
Besides, about that time we were beginning to extend the 
indications for induction by inducing all primigravidse at term, 
or a week before, in order that a more easy and less prolonged 
labour might result with, in consequence, less risk to the child. 
Accordingly with Dr Ballantyne's permission and approval 
pituitrin induction was introduced into the department in 
October 1921, and has been our routine method since then. 

Owing to the comparatively few deliveries in our department 
I am only able to present to you the results of 44 cases, a small 
number, but perhaps sufficient with the case of Dr Fordyce to 
form the basis of a discussion. Of the 44 cases, 26 suffered from 
purulent vaginal discharges. 

Method Used. — At present we use the exact technique 
advised by Professor Watson in his second paper, which is as 
follows : (1) Castor oil, gi. at 6 p.m. ; (2) quinine hydrochloride, 
grs. x. at 7 p.m. ; (3) enema at 8 p.m. ; (4) quinine hydro- 
chloride, grs. x. at 9 p.m. ; (5) quinine hydrochloride, grs. x. at 
12 midnight. If effective labour pains have not started twelve 
hours after the first dose of quinine, namely by 7 a.m., we start 
the intra-muscular injection of pituitrin, injecting i c.c, and 
repeating this every half-hour until labour starts, or 3 c.c, that 
is, six injections are given. That is one full course. If labour 
pains do not start, the treatment is repeated again after twenty- 
four hours. The quinine hydrochloride is given dissolved in 
10 minims of dilute hydrochloric acid. 

In most of our cases, however, the method used was some- 
what different from this. We first gave castor oil (§i.) and after 
that had acted we started quinine gr. x. every two hours till 
3 doses or gr. xxx. were given. Two hours after the last dose 
of quinine the first injection of pituitrin was given, and this was 
repeated every half-hour until labour started, or 4 c.c. (8 doses) 
were administered. If this first course failed we repeated it 
again next day. I do not think that these slight variations in 
technique made much difference to our results. 

Indications for Induction. — These were as follows : dis- 

OBST. 27 C 2 



F. J. Browne 



proportion, 18 cases; primiparity at term, 16 cases; post- 
maturity, 4 cases ; toxaemia, 4 cases ; discomfort and weariness 
at term, 2 cases ; hydramnios, 1 case. 

Parity. — Twenty-seven of the patients were primigravidas ; 
all the others were multigravidae. 

Stages of Pregnancy. — Twenty-three were at term, 3 were 
post-mature according to the estimated dates, and 18 were 
premature ; the most premature of the latter group was born at 
thirty-two weeks. 

Amount of Pituitrin Used. — The average amount used in 
the 40 successful cases was 4 c.c, that is, one full course. In 
2 cases labour started with castor oil alone, in 3 with castor oil 
and quinine. All these were at term and one was post-mature. 

In 4 cases only one injection of pituitrin (0.5 c.c.) was required. 
Three of these were at term and 1 was post-mature. In 1 case 
two injections only were required. She was pre-eclamptic and at 
term. In 4 cases only three injections (1.5 c.c.) were required. 
One of these was at term ; 1 was one week, 1 two weeks, and 
another three weeks premature. In 12 cases one full course 
was required ; in 7 cases, two courses ; in 4 cases, three courses ; 
in 2 cases, four courses ; while in 1 case labour only began after 
the third injection of the fifth course. This was a primigravida 
at term and the duration of labour after pains started was 
only nine hours. She was suffering from a purulent vaginal 
discharge, yet the puerperium ran a normal course. Pains 
were strong and regular but in no way abnormal ; delivery 
was spontaneous, the perineum intact and mother and child 
did well. 

Results of Induction attempts. — Out of the 44 cases, 40 
were successful, i.e. a little over 90 per cent. 

Analysis of the Cases in which the Method failed. — All 
the failures occurred in cases where premature induction was 
attempted. In one case — a primigravida with a contracted pelvis, 
estimated to be at the thirty-sixth week of her pregnancy — 
one and a half courses were given. She became flushed and 
sick after each injection, and the treatment was therefore 
discontinued. Another case was suffering from hydramnios, 
which caused her considerable distress on walking about, 
and on lying upon her back. She had four courses without 
result. Strangely enough after the first injection of the first 
course she got slight pains and in consequence the injections 
were stopped, and we have never been able to produce them 

28 



Labour by Quinine and Pituitrin 

since. This leads me to emphasise one important point which 
has been pointed out by Professor Watson, viz., that the onset 
of pains is not sufficient indication for stopping the injections. 
They should be continued until the cervix begins to open and 
the membranes to bulge. It is therefore of practical importance 
to start the pituitrin injections in the morning, so that a doctor 
may be easily available throughout the course in order to 
determine when conditions are such that the treatment may 
be stopped. If this precaution had been observed in all our 
cases, I believe that a smaller average amount of pituitrin 
would have been required. The other two cases of failure 
were two and four weeks premature respectively. To one 
four courses and to the other five courses were given, and in 
each labour had ultimately to be started by other methods. 
The one in which five courses were given had the largest 
amount of pituitrin given to any one case, and two days' 
interval were allowed between each course. 

Time taken to Start and Complete Labour. — Counting 
from the first dose of quinine the average time taken till the 
onset of labour averaged twenty-nine hours, which I think 
would compare very favourably with the time taken for any 
of the mechanical methods. The average time taken to com- 
plete labour, reckoning again from the first dose of quinine, 
was forty-five hours. The average duration of labour was 
therefore sixteen hours. In the 14 successful premature cases 
the average time taken till the onset of labour was thirty- 
nine hours, and to complete labour forty-eight hours. The 
average duration of labour therefore was nine hours. The 
time taken to start labour was therefore considerably longer 
in premature cases, while the average duration was, as might 
be expected, somewhat shorter. As we shall see afterwards, all 
the failures occurred in premature cases. 

Results. — The chief objection that has been urged against 
the use of pituitrin is that it is dangerous to the mother and 
child. Thus it is said to have caused rupture of the uterus, 
post-partum haemorrhage, premature separation of the placenta, 
tetanus uteri, laceration of the cervix and perineum, and death 
of the child. 

The only two unpleasant incidents I have met with are two 
cases of tetanic contraction of the uterus. 

The first case of this that occurred was in a primigravida 
with a minor degree of pelvic contraction, estimated to be 

29 



F. J. Browne 



two weeks premature. Three courses of pituitrin were given, 
two days elapsing between the first and second, and twenty- 
four hours between the second and third. No pains were 
excited, and the treatment was stopped. Two days after the 
last course, the lower uterine segment was packed with gauze 
by means of Nicholson's packer and labour induced in that 
way. Very strong and continuous pains started three days 
after the last dose of pituitrin. Chloroform was administered, 
but the child was born dead from asphyxia. I think the 
chloroform had not been administered quickly enough or 
sufficiently pushed. This case tends to show that pituitrin 
may have a cumulative action. It is the only case in which 
we lost the child through pituitrin. 

The second case of tetanic uterine contraction occurred 
in a woman pregnant for the third time. The pelvis was 
contracted and labour induced at thirty-five weeks. One 
course of pituitrin only was given, labour started nine and a 
half hours after the first dose of quinine, and the total 
duration of labour was only one hour. I was in the hospital 
late one night when severe and continuous contractions set in. 
I at once administered chloroform, the spasms were controlled 
and the child was born alive and well, and there was no post- 
partum haemorrhage or other maternal complication. These 
are the only two mishaps we have met with, and they certainly 
suggest that the drug should be used with great caution, and 
only in circumstances in which chloroform can be immediately 
administered if necessary. 

This tendency to tetanic contraction has been noted by 
other observers, although Watson has not found it occur in 
his large series of cases. Thus Royston, 10 writing in 1923, has 
found, after a 2-minim dose given during the second stage, a 
tetanic contraction set in which lasted thirteen minutes, during 
which time the fcetal heart rate dropped from 120 to 80. In 
4 other cases anaesthetics were necessary to stop tetanic con- 
traction following 2-minim doses. He records 2 cases in 
which still-birth was attributed to pituitrin in doses of less 
than 5 minims, and advises starting with 2-minim doses in 
order that the response of the patient may be observed, 
M'Neile n thinks that tetanic contraction is more likely to occur 
in primigravidae, and that post-partum atony of the uterus 
with resulting haemorrhage is likely to follow it. As noted 
above, there was no post-partum haemorrhage in my two cases. 

3° 



Labour by Quinine and Pituitrin 

With regard to rupture of the uterus, several cases have been 
recorded in which rupture occurred after administration of 
pituitrin during the first and second stages of labour. M'Neile 
was able to find 16 such cases up to 1916, including one of his 
own, and resulting in thirteen maternal deaths. In most, if 
not all, of the cases, however, there was disproportion or mal- 
position, and pituitrin should not have been used. I have 
been able to find no case in the literature in which rupture 
occurred as a result of pituitrin induction. 

There was only one case of post-partum haemorrhage in 
the series. The patient was an elderly primigravida at term. 
Only one injection (0-5 c.c.) of pituitrin had been given, and 
the entire labour lasted twenty-one hours, being terminated 
by forceps. The haemorrhage was not excessive and was 
easily controlled. In view of the small amount of pituitrin 
used, it does not seem fair to attribute it to that cause. 

Considering that 26 cases of the series suffered from 
purulent vaginal discharges, the puerperal charts are of some 
interest. In no case was there any serious disturbance in 
the puerperium, though 3 cases showed a temporary rise of 
temperature which in each passed away in a few hours ; and 
in none of the three was the febrile disturbance prolonged 
into a second day. These charts will, I think, compare 
favourably with a similar number of clean cases taken at 
random from any hospital, and not even of cases of induction 
but of spontaneous labour. This absence of puerperal sepsis 
in such unfavourable circumstances forms, in my opinion, one 
of the strongest arguments in favour of the induction of labour 
without mechanical interference. 

There is one point of interest regarding the use of pituitrin 
in pre-eclamptic cases with high blood pressure. One of the 
first cases in which we used the method (in October 1921), was 
such a patient. The blood pressure before the first injection 
was 165 mm. and after it 145 mm.; after the second course 
of pituitrin the blood pressure had fallen to 122. Both 
mother and child did well. A similar experience has been 
recorded by Watson, who has used it even in eclamptic cases 
with impunity. Druskin 12 also states that high blood pressure 
is not a contra-indication, because it is characteristic of 
pituitrin that its action on the circulation is most marked 
when the blood pressure is low, but has very little effect when 
it is high. 

obst. 31 c 3 



F. J. Browne 



Results to the Child. — In the series I have unfortunately to 
record 4 still-births. These all occurred in the early days of 
its use ; in the last 30 cases there was no still-birth. One 
still-birth occurred in a difficult breech case where there was 
delay in the birth of the after-coming head. Another was a 
very large child in a primipara, persistent occipito-posterior 
requiring manual rotation and forceps delivery ; in a third the 
mother had a contracted pelvic outlet. Though she was induced 
two weeks before term the child was large, weighing 3570 grams., 
and required a difficult forceps delivery. The fourth was the 
case of tetanic uterine contraction previously mentioned. This 
last was the only still-birth that could be attributed to the 
pituitrin. 

This still-birth rate is high, but it compares favourably with 
that obtained from other methods of induction. Brodhead 13 in 
191 2 recorded the results of 139 cases of induction by De Ribes 
bag in which the number of still-births was 32, or more than 
double the percentage recorded by us. I would emphasise 
again the fact that only one of the four fcetal deaths can be 
attributed to pituitrin. 

Conclusion. — I have tried to put the case for and against 
pituitrin as fairly as possible. I believe that we possess in it 
a useful method of inducing labour, free from many of the 
disadvantages of the mechanical methods. It does away with 
the need for anaesthetics — a great advantage. There is no risk 
of introducing septic organisms into the uterine cavity or of 
prematurely rupturing the membranes. It is, however, uncertain 
in its action. There are a few cases (all premature in this 
series) which apparently fail altogether to respond to the 
treatment ; but the percentage is small and instrumental 
induction is not prejudiced in any way if it has to be resorted 
to after pituitrin has failed. The method must of course only 
be used in suitable circumstances. It is needless to say that 
it should never be employed in cases of marked disproportion 
or in a transverse presentation, or in presence of any obstruction. 

There is a risk of setting up tetanic uterine contractions, and 
there is some evidence that pituitrin can have a cumulative 
action although this is a point upon which I would not care 
to be dogmatic. 

Those of you who were at the meeting of the British 
Medical Association in Glasgow, in the summer of 1922, may 
recall that Russell Andrews made a statement regarding the 

32 



Labour by Quinine and Pituitrin 

variation in activity of different ampoules of pituitrin. If you 
take two ampoules of pituitrin, apparently similar in every way, 
obtained from the same maker, at the same time, one ampoule 
may be eighty times as strong as the other. I understand that 
the Medical Research Council are now making attempts to 
standardise the drug. When this has been done, I believe that 
we shall be in possession of an almost ideal method for induction 
of labour, but even then care will be necessary, because though 
the drug may be standardised, it is impossible to standardise 
patients. There will always remain the patient who is peculiarly 
susceptible to its action and probably also the patient who is 
entirely uninfluenced. 

References. — x Oliver, G., and Schafer, E. A., Journ. of Physiol., 1894 
and 1895, vols, xvi., xvii., and xviii. 3 Blair Bell, W., Brit. Med. Journ., 
1909, vol. ii., p. 1609. 4 Fries, Muenchener Medizinische IVochenschrift, 
14th November 191 1, p. 2438. 5 Studeney, Wie?ier Klinische [Voche?ischrift, 
21st December 191 1, p. 1766. 6 Stein and Dover, Med. Rec, 1917, No. 90, 
vol. ii., p. 23S. ' Cron, Amer. Journ. Obst. and Gynec, 1922, vol. 3. 8 Watson, 
B. P., Amer. Journ. Obst. and Gynec, 1920-21, No. 1, vol. i. ° Watson, 
B. P., Amer. Journ. Obst. and Gynec, 1922, No. 6, vol. iv. 10 Royston, Amer. 
Journ. Obst. and Gynec, 1923, vol. v., p. 296. u M'Neile, A?uer. Journ. 
Obstet., 1916, vol. Ixxiv., p. 432. 12 Druskin, Amer. Journ. Obstet., 1914, 
vol. lxx., p. 592. 1:! Brodhead, Amer. Journ. Obstet, 1912, p. 753. 



NOTE ON A CASE OF RUPTURE OF THE UTERUS 
FOLLOWING THE ADMINISTRATION OF 
PITUITRIN FOR THE INDUCTION OF LABOUR.* 

By WILLIAM FORDYCE, M.D., F.R.C.P. (Edin.). 

The following note of a case of rupture of the uterus is, I think, 
worthy of placing on record, as it seems to indicate a possible 
danger in the use of pituitrin and quinine for the induction of 
labour, which so far as I know has not been pointed out. 

Case I. — Mrs S., aged 40, xi.-para, was admitted to the Edinburgh 
Maternity Hospital from the Antenatal Department on 13th June 1923. 
She had menstruated last on 5th September and was therefore at full- 
time. The cervix was completely taken up and the os was slightly open. 
The head was presenting but had not entered the brim. The previous 
obstetric history was as follows : She had given birth to ten children, 
* Read 12th December 1923. 
33 



William Fordyce 



all of whom she stated were large. The ist and 2nd labours, and the 
5th, 6th, 7th, and 8th had all been difficult, calling for the use of 
forceps, and on one occasion craniotomy had also been performed. 
Her last child had been born two and a half years previously. The 
patient herself was a big, heavy, strong woman of over average size and 
rather stout. 

In the Antenatal Department Dr Browne thought there was a 
slight disproportion between the head and the pelvis, but I could 
not satisfy myself that this was the case. The pelvis at any rate 
seemed to me to be large and roomy. As, however, her previous 
obstetric history seemed to support Dr Browne's opinion, it was 
decided to induce labour at once and, as we were at the time giving 
atrial in the hospital to the method by quinine and pituitrin, this was 
commenced shortly after her admission. 

The usual dose of castor oil was given at 9 p.m. At 10 p.m. the 
patient had 10 grs. of quinine, and about n p.m. had an enema of 
soap and water, as a result of which the bowels were freely moved. 
At 12 midnight and at 3 a.m. she had further doses of quinine, 10 grs. 

At 1 p.m., on the 14th, 0.5 c.c. of pituitrin was administered intra- 
muscularly into the buttock, followed at 1.30 and 2 p.m. by other 
similar doses. 

At 2.30 p.m. the patient had a pain, not unduly severe, the nurse 
in charge said, and she was removed to the delivery room. With this 
pain the membranes ruptured. Within the next quarter of an hour 
the patient had other two pains, the second being long and severe. 
Thereafter, though she complained of general abdominal pain and 
distress, there were no evident uterine contractions. 

At 3 p.m., that is half an hour after labour had started, the patient 
complained of difficulty in breathing and of severe pain in the region 
of left costal margin. Dr Alexander, the Senior House Surgeon, who 
saw the patient at this time, found her propped up in bed and rather 
breathless, with a feeble, somewhat irregular, and rapid pulse. Her 
symptoms were attributed to some temporary cardiac weakness, and 
she was treated accordingly with a small dose of amyl nitrite and 
brandy and strychnine. For a time her condition seemed markedly to 
improve, but the dyspnoea, which all through had been the most 
pronounced symptom, got worse, and by 4.30 was giving rise to serious 
anxiety. I saw her for the first time shortly after this, and my first 
impression was that her symptoms were cardiac in origin. But on 
examination of the abdomen my suspicions were aroused by the diffuse 
tenderness which was present. Nothing much more could be made 
out; as I have already stated, the patient was abnormally stout. I 
thought, however, that I could make out that the head was fixed in 
the brim. 

34 



A Case of Rupture of the Uterus 

The recollection of a former case suggested to my mind the 
possibility of a concealed haemorrhage. 

On vaginal examination I found the os almost fully dilated ; the 
presenting head, though still high up, had entered the brim. During 
this examination a considerable quantity of dark-coloured blood 
escaped along with a few clots, and on pushing the head back, which 
one did with care, a large gush of the same dark-coloured blood took 
place. 

This rather confirmed my suspicions that I had to do with a case 
of concealed haemorrhage which was finding its way externally, but on 
passing my fingers through the os to exclude any low implantation 
of the placenta as a cause of the bleeding, I found a large tear in the 
postero-lateral wall of the uterus. Dr Young, my colleague, who was 
fortunately in the hospital at the time, saw the patient also, and on 
examination confirmed my diagnosis of uterine rupture. 

Immediate abdominal operation seemed to offer the only, though 
very slight chance of saving the patient's life, as by this time she 
seemed to be in extremis, and was now bleeding very freely from 
the vagina. Preparations were hurriedly made for this and the 
operation was proceeded with, without removing the patient from 
her bed and with a certain departure from aseptic principles which 
the urgency of the patient's condition seemed to warrant. There 
was a considerable quantity of blood in the peritoneal cavity but 
not to any alarming extent. The placenta and membranes were 
entirely extruded from the uterus and were found high up under the 
diaphragm. The foetus which was large, and when weighed later 
was found to be 9 lb. n oz., was free also in the abdominal cavity, 
with the exception of the head, which still occupied the lower part 
of the uterus. The uterus itself lay over to the left side and was 
contracted to an almost stony consistence. The rent in the uterus 
extended obliquely upwards from the region of the right utero-sacral 
ligament towards the fundus on the left side. 

From the edges of the tear free bleeding was still taking place. 
To stitch the tear seemed impossible, so we rapidly amputated the 
uterus as far as possible below the tear, the bleeding vessels being 
secured as we did this. The large stump which was left as a result 
of this procedure was then covered by a flap of peritoneum and the 
abdomen hurriedly closed. 

The patient stood the operation better than we expected, and at 
its conclusion she was certainly no worse than when it was commenced. 
Still, her chances of recovery seemed very slight, but to our great 
surprise and satisfaction, and largely owing to the unremitting care 
and attention of Dr Alexander in the after-treatment, she made an 
excellent recovery. At the end of the second week she developed 

35 



William Fordyce 



a slight cellulitis but her temperature only once rose above ioo° F., 
and she left the hospital one month and three days later and now 
enjoys good health. 

The cause of the rupture in this case cannot with certainty 
be attributed to the use of the pituitrin. It is in a different 
category altogether, I think, from those cases of rupture which 
have followed the use of pituitrin in the second stage where 
there is some obstruction. It must be remembered also that 
several cases of rupture have been recorded in the first stage 
where no pituitrin has been given and where the rupture has 
been attributed to some diseased condition of the uterine 
muscle. Such cases have generally been in elderly multiparae. 

Bandl, too, was of the opinion that rupture was predisposed 
to where the lower uterine segment had been unduly stretched 
in previous labours. 

The subject of the foregoing notes was an elderly multipara 
and her previous obstetric history would indicate that, certainly 
the lower uterine segment had in former labours been unduly 
stretched. Still the rapid occurrence of the rupture after the 
pituitrin and the violence of the contraction which speedily 
followed its administration make me believe that in multiparas 
at any rate the use of pituitrin for the induction of labour is 
attended with some risk. For this reason I have ventured to 
bring this case before the Society to get the opinion of the 
members on this point. 

In conclusion I wish to acknowledge my great indebtedness 
to Dr Young for his valued assistance at the operation and to 
Dr Alexander for his after-treatment of the case. To them 
more than myself I feel is due the credit for the recovery of 
the patient. 

Discussion. 

Dr Haig Ferguson said — Dr Browne has given us a very logical 
paper, discussing the whole question of pituitary introduction in a 
masterly way, and there is no doubt that from his point of view in 
connection with venereal cases the induction of labour by means 
of drugs such as pituitrin is the ideal thing, because in such cases 
the passage of bougies for the induction of labour is attended with 
very serious risks. I personally have been rather disappointed with 
the results of pituitrin, and that for two reasons. In one set of cases 
the pituitrin acted too severely and produced most alarming symptoms 
owing to tetanic spasm of the uterus. In one case the spasm lasted 

36 



A Case of Rupture of the Uterus 

for about half an hour in spite of chloroform and I feared the uterus 
was going to rupture. In spite, however, of the anxiety which these 
cases gave one the children were born alive and there were no 
complications. At first I used to give i c.c. of pituitrin in a single 
dose. Later on I gave 0.5 c.c. and now I seldom give it in larger 
doses than 10 minims, and since doing this I have never had any 
cases of severe spasm. In other cases pituitrin seems to have no 
effect whatever upon the uterus, and my impression is that its effect 
is best when labour is induced at or near full-time. There is further 
to be considered the uncertainty in the strength of the pituitrin which 
one uses. I believe some preparations are very much stronger than 
others, and it is greatly to be desired that there should be some 
standardisation of the drug which I hope may soon be accomplished. 
One also has to bear in mind the personal idiosyncrasy of the patient 
to the action of the drug. The method which I adopt of inducing 
labour is first to give castor oil, as Professor Watson suggests, and 
to keep the patient for two or three days on a course of quinine 
hydrochloride or bi-sulphate, which undoubtedly sensitises the uterus 
and makes it easier to provoke uterine contractions. As a matter 
of fact this preliminary course of quinine and castor oil in some 
cases sets up labour without any further treatment. Where, however, 
no symptoms of labour show themselves, I generally give 10 minims 
of pituitrin every two or three hours. Even with this method, 
however, I have often been unsuccessful and have had ultimately 
to adopt mechanical methods. There is no doubt, however, that 
if mechanical means are used after this preliminary treatment the 
uterus generally reacts very quickly to the mechanical stimulus. I 
have never seen any instance such as Dr Fordyce records, but I 
do not think that one can wholly blame pituitrin in this case. 
Dr Fordyce did not mention whether the uterine wall was diseased. 
{Dr Fordyce: I don't think so.) I have seen some cases where 
so-called idiopathic rupture of the uterus took place where no pituitrin 
was given. Such cases are probably the result of some degenerative 
change in the uterine wall. Of course the pituitrin might have been 
a contributing factor to the rupture in Dr Fordyce's case. In my 
opinion pituitrin is an extremely dangerous drug and must be given 
with the greatest caution, the patient being watched during the 
whole period of its administration. From my own experience I 
should plead for the giving of smaller doses of pituitrin than those 
generally recommended, and if the patient stands them well to increase 
the dose gradually later on. I do not think that pituitrin is cumulative 
in its action. It would indeed be a great advance if one had certain 
means of inducing labour safely by medicinal means so as to obviate 
mechanical interference. 

37 



William Fordyce 



Dr Lackie said that be would at once like to say that his results 
in inducing premature labour by pituitrin were not nearly so 
satisfactory as those obtained by Dr Browne. He was quite sure that 
not more than 70 per cent, of the cases were complete successes, and 
there was no doubt that when pituitrin was used to induce labour at 
or about full-time it was much more successful than when used to 
induce premature labour. As regards the technique, the numerous 
variations in this were not of very much importance. He had tried 
the different ways of administrating the quinine and pituitrin, but 
could not make up his mind that one method was any better than the 
other. His usual method was to give quinine in 10-gr. doses three 
times a day for three days and then to give pituitrin in A c.c. doses 
every hour until six had been given. One was in the habit of 
concluding that so long as the membranes were unruptured there 
was no danger to the patient from the use of pituitrin, but we had 
to remember that the drug might cause a very rapid first stage and 
the membranes might rupture very soon after the administration, so 
that risk might be incurred in that way. There was no mistaking the 
wonderful effect of pituitary extract in causing contraction. The pain 
that came on was much more striking and more severe than when 
pain started naturally as in a normal labour. When first of all 
Dr Lackie used pituitrin a good many years ago he had a series of 
very successful cases and was immensely pleased with the drug, but 
since then he had had many disappointments. 

As regards Dr Fordyce's paper he had the feeling that pituitrin 
was, to a certain extent, responsible for the rupture of the uterus ; it 
was a most instructive case, and drew our attention to the fact that 
the use of pituitrin was not by any means without danger. Personally, 
Dr Lackie had never seen any serious complication from its use, and 
he had never seen a severe case of tetanic contraction. 

Dr Orr said Dr Browne's arguments have been very explicitly 
stated, and I think that we have all of us learned a good deal from the 
special cases. With regard to the matter of pituitrin and quinine it is 
a little difficult, I think, just to estimate how much of the effect is due 
to either. Personally, I have only experienced the use of quinine, 
which I have used very frequently in post-mature cases with entirely 
satisfactory results. The only preparation beforehand was castor oil — 
nothing else was required. Then the quinine was given, and the 
preparation which I found most useful is acid hydrochloride which is 
extremely soluble in water, and my dosage is 5 grs. given four 
hourly. I find it has a stronger effect than quinine sulphate or 
bi-sulphate. The amount of quinine to be given is of some considerable 
importance, because I think in the matter of dosage we can find a 
possible explanation for Dr Fordyce's case. I think most of us have 

38 



A Case of Rupture of the Uterus 

been struck by the fact that the rupture took place comparatively 
early in labour — very soon after the contractions took place — and also 
that the position of the tear was somewhat unusual, occurring, as I 
gather, in the contrasting part of the uterus. Explanation can be 
found in this — that quinine in some people produces haemorrhages in 
muscle tissue and from mucous membranes, and it is just a possibility 
that in this case the quinine was to blame, a haemorrhage occurring 
into the uterine muscle, and that the blood from that weakened the 
uterine muscle, predisposing it to rupture, and escaped by the tear. 
The blood from the haemorrhage may have escaped observation at the 
operation, and its existence would not have been apparent. I can 
conceive of no other possible explanation in this case. Quinine may 
have been the culprit in causing the haemorrhage and predisposition 
to rupture. 

Dr Johnstone said — I well remember the late Dr Ballantyne, in one 
of his gifted forecasts, saying in this hall that the time would come 
when we would give a tablet which would bring on labour in an 
automatic way, and there is no doubt that in this method of using 
pituitrin we are moving in that direction. In the brief account which 
Dr Browne gave of the introduction of this drug he did not mention 
work which has been done in Edinburgh by Mr Quarry Wood. A year 
ago, at the Edinburgh Pathological Club, Mr Wood read an account of 
his research on the pituitary gland, and one of the things which struck 
me most as an obstetrician was that he had found in a series of 
pregnant rabbits that towards the end of the pregnancy there formed 
in the pituitary gland a reservoir of considerable size where secretion 
was accumulated. After labour this reservoir or lake and its contents 
were very much diminished, and he not unnaturally suggested that 
this indicated that the rabbit accumulated pituitary extract against the 
occurrence of labour. Personally, I am inclined to think that if those 
observations are confirmed they will go a very long way to indicate 
that the cause of the onset of labour in the human female is to be 
found in some similar change in the pituitary gland. 

I would briefly mention my own experiences with regard to this 
method of using pituitary extract which I have employed in quite 
a number of cases. I have not had time to look up my cases so that 
I am unable to give any figures as to the proportion of successes, but 
my general impression is that on the whole they were fairly satisfactory. 
I had one case of tetanic spasm in 1914 in a primiparous patient. I 
had given her twilight sleep, and in these early days I think I had 
rather overdosed the patient. The pains stopped, and in order to 
stimulate them again I gave her 0.5 c.c. of pituitary extract with the 
most astounding result within a few seconds. The patient's uterus 
passed into a spasm which continued for five or six minutes, the patient 

39 



William Fordyce 



being all the time in extreme agony, until great anxiety for fear of 
rupture I administered chloroform with the result that the spasm 
passed off. The child was born perfectly well and the patient made 
a good recovery. That is my only experience of the sort, and in that 
case the pituitary extract was given during labour and not for the 
purpose of inducing labour. 

I should like to describe two other minor complications which 
I have experienced. Firstly, the premature rupture of the membranes 
before the pains have begun. In a considerable number of cases 
induced with pituitrin this occurred. Secondly, in quite a number 
of cases I have noticed that when one commences the administration 
of the pituitrin the head is probably high up at the brim and by the 
time labour has got well under weigh the head has been driven right 
down into the lower part of the cavity of the pelvis, the external os 
being still quite small — about the size of a sixpence — and the cervix 
stretched out over the head. If that, as in a number of cases of mine, 
was associated with the premature rupture of the membranes, one had 
all the conditions which made for a very slow and prolonged first 
stage. These are my only difficulties and they are both, comparatively 
speaking, trifling. 

With regard to Dr Fordyce's case I must say I do not think that 
Dr Orr's explanation is sufficient. It seems to me even a little 
far-fetched, and my view of it would be rather that the pituitrin 
possibly sensitised the uterus, which was already through " wear and 
tear" predisposed to rupture; and certainly that would explain the 
extraordinary tetanic contraction of the ruptured uterus after the 
rupture had occurred. 

Dr Young said with regard to the topic of discussion I have no 
figures to advance, and I think this whole problem can only be 
decided by a large number of figures. I think we must all feel 
strongly that the evidence which Dr Browne has given us, supported as 
it is by the large amount of material by Professor Watson, is extremely 
convincing, and at any rate shows that in pituitary extract, employed 
in conjunction with quinine, we have undoubtedly a valuable means of 
bringing on labour. I think there is little doubt about that. With 
regard to the dangers, I recall cases in which I used pituitary extract 
in the early days when the results were anything but satisfactory. 
One case particularly I recall is that of a young primipara, in the year 
1912, who had been hanging fire for about a week with sleepless nights, 
full of worry and nervousness. For three or four days the os was 
about the size of a sixpence. I remember going in one Sunday 
morning and deciding to give pituitary extract which had been 
recommended in some of the journals, I injected about half a c.c, 
and went back with my needle to put it away and had not 

40 



A Case of Rupture of the Uterus 

shut the case up before the girl screamed in acute agony — within 
certainly a minute. The pain went on, the patient shouting in agony. 
Two, three, four, five minutes passed and I whisked out my chloroform 
mask and had it on her face within about six or seven minutes. After 
I had washed up I examined the patient and found the os fully dilated 
— dilated from the size of a sixpence to full dilatation with one pain ! I 
rubbed the forceps over with pure lysol and applied them, quite 
expecting the child to be dead, but it lived. In view of recent 
knowledge it is evident that almost certainly we had been dealing with 
one of those extremely erratic doses. With regard to Dr Fordyce's 
case it is very difficult to escape the conclusion that the rupture 
was due somehow or other to the pituitrin. The explanation which 
Dr Johnstone has given is probably the right one — the patient had had 
ten or eleven children, and the contraction induced by the pituitrin 
was sufficient to tear the enfeebled lower uterine segment through. 

Dr Somerville said — In my own experience in general practice in 
the country the first case was most successful. The next case was a 
failure, and in the third case I spent three days sitting writing letters 
in a neighbouring room, four miles away from home, waiting for 
something to happen. However, it turned out successful, and 
everything ended up happily. I should like to give a word of warning 
in the use of quinine. I don't think the papers have yet been 
published, but both in West Africa and in Glasgow cases of 
pneumonia that had had quinine previously, died exactly in proportion 
to the amount of quinine they had had. Reports on the use of 
quinidine in heart disease show what a very powerful drug it is. 
We must be careful in our use of quinine. 

There is one solvent of quinine which I am surprised is not more 
used and that is tartaric acid. Five grs. of tartaric acid will 
dissolve 10 grs. of quinine in 30 minims of water. This is cheap and 
easily procured, and both for intramuscular use and for oral 
administration is very handy. 

Dr Haultain said — In some twenty-five cases, about two years ago, 
in which I used it I had not the good results that Ur Browne has given 
to-night. Perhaps I did not use enough pituitrin, as I only used the old 
method of giving castor oil followed in two hours by 10 grs. of quinine, 
and then \ c.c. of pituitrin an hour after the quinine. At the first attempt 
just over 50 per cent, came off with the injection. At the second 
attempt about another 50 per cent, came off. I found that the first 
stage was delayed considerably in most of these cases. 

Has anybody ever used intramuscular quinine for induction of 
labour? Out East we found during the war that intramuscular quinine 
was much more beneficial in the treatment of malaria than oral quinine. 
This would act on the uterus more rapidly than the oral administration, 

4i 



Exhibition of Specimens 

and I put forward that a small intramuscular injection of quinine 
might be very suitable for the induction of labour. 

Dr Macrae Taylor thought it would be useful if the discussion 
could be extended to include the application of pituitary extract in 
ordinary obstetric practice, not confining it to its use in the induction 
of labour. Fellows who are engaged in general practice would be glad 
to know more about the actions of this potent auxiliary. It cannot be 
used in all patients alike nor at all stages of labour. It has its dangers 
as well as its beneficial effects. Experiences of different preparations 
and information as to standardisation would be of great value. 

Dr Keppie Paterson said that of course "Pituitrin" was a pro- 
prietary name for Parke, Davis's special preparation, and no one could 
use the name pituitrin for any other preparation. 

Dr Goiv said — I have had some experience in India where we are 
continually using quinine, and I must disagree with previous speakers 
who have urged caution in its employment. I have used it in bringing 
on labour at term and in post-mature cases, and my practice has been 
to give as much as 10 grs. at hour intervals. The only preliminary 
preparation the patient had was castor oil and enemata. The time of 
onset of labour varied enormously. We have been very chary about 
using pituitrin in India because of the uncertainty in its strength and 
the deleterious effect of high temperature. 



Meeting — 12th December 1923. 

EXHIBITION OF SPECIMENS. 

Professor Watson showed — (1) A uterine fibroid -with 
sarcomatous degeneration. The patient, aged 49, had been 
married for twenty-six years and had never been pregnant. For the 
past five years menstruation had gradually become more profuse, but 
had always been perfectly regular until a month before admission. On 
the 25th August a severe haemorrhage commenced and continued up 
to the time of admission — 30th August. Large clots were passed. 
During these five days she had pain in the abdomen and frequently 
felt nauseated. There had been no inter-menstrual discharge except 
a slight leucorrhcea. Gradually increasing abdominal distension had 
been noticed for two years. On abdominal examination a swelling 
could be felt rising from the brim of the pelvis, soft and elastic in 
consistence and reaching to above the umbilicus. It was difficult to 
say whether the tumour was solid or cystic. At operation the tumour 
was found to be a uterine fibroid and supravaginal hysterectomy was 
performed. The tumour was an interstitial fibroid as large as a Rugby 

42 



Exhibition of Specimens 

football. It was very soft in consistence and on section was nearly 
diffluent in places ; these areas were pale in colour but had no yellow 
tinge. There were no haemorrhages. Microscopic examination of 
these areas in the centre of the tumour showed a very cellular structure, 
with little or no fibrous stroma and blood-vessels with only endothelial 
walls. Many of the cells showed active mitosis. The whole picture 
was most suggestive of sarcoma, and this diagnosis was confirmed by 
Dr Dawson of the Royal College of Physicians Laboratory. 

(2) A uterine fibroid with carcinomatous invasion in a 

patient with carcinoma of the vulva and of the caecum. The patient, 
aged 52, i-para, had noticed, nine months previous to admission, a 
small swelling in the vulva ; this gradually increased in size and 
occasionally gave her pain. Recently the pain had greatly increased 
and her general health had deteriorated. A yellow foul-smelling 
discharge, streaked with blood, had been present for the last six 
months and had gradually become more profuse. Her menstrual 
periods stopped a year ago. Since then there had been occasional 
small bleedings about which the patient was very indefinite. Eight 
months ago there had been a profuse flooding lasting a few hours. 
Since then there had been no discharge apart from that already 
mentioned. On examination it was found that there was an extensive 
carcinoma in the region of the vestibule below the urethra. It 
involved the inner aspect of the left labium minus, and to a lesser 
extent, the right. The growth extended up into the vagina for a 
distance of about three-quarters of an inch. The urethra itself and 
the clitoris were not involved. The surface of the growth was broken 
down and sloughing. The condition was obviously one of carcinoma. 
In addition, it was noted that there was a large firm swelling in the 
lower abdomen, extending to above the umbilicus. The swelling was 
continuous with the cervix and was obviously a uterine fibroid. As 
the carcinoma of the vulva was considered inoperable owing to its 
extension up the vaginal walls and its fixation to the pubic bone, it 
was treated with radium with marked improvement. There was, 
however, severe pain in the abdomen and pain and swelling of the 
left leg. To relieve these conditions, which were obviously due to 
the pressure of the fibroid, it was decided to perform hysterectomy. 
On opening the abdomen a large fibroid tumour was exposed. On 
the right side the appendages were very adherent to the pelvic 
wall and to the caecum, so the broad ligament was clamped between 
them and the uterus and tumour removed by supravaginal hysterectomy, 
together with the left tube and ovary. It was then found that there 
was apparently a malignant growth involving the lower end of the 
caecum and the right appendages. The lower part of the caecum was 
resected and removed along with the tube and ovary on the right side. 
The patient's pain was completely removed as the result of the 

43 



Exhibition of Specimens 

operation. She made a good recovery and returned home three weeks 
later. The vulval growth was a basal-cell carcinoma showing no cell 
nests but numerous mitotic figures. On cutting into the fibroid 
tumour, which was an interstitial one, large areas of broken-down 
yellowish tissue were found scattered throughout, in the centre as 
well as at the periphery; examination of these showed them to be 
masses of columnar cell carcinoma. The growth involving the right 
tube and caecum was likewise a columnar cell carcinoma. This 
latter growth may have been an extension from the carcinoma in 
the uterus, the initial site of which was in the endometrium and 
which had invaded the fibroid tumour. This growth, however, was 
independent of that in the vulva, so that one must conclude that this 
patient had at least two independent carcinomatous tumours. 

(3) A dermoid tumour of the ovary with twisted pedicle 
simulating a pelvic abscess, and removed per vaginam. The patient, 
aged 28, ii-para, had been delivered by forceps of a full-term child in 
April 1923. After the confinement she had a persistent greenish 
vaginal discharge and did not recover her strength. On 27th October 
this discharge became brownish in colour. At the end of June and 
again on 24th October she had severe pain in the left iliac fossa which 
gradually got worse, and on the 24th she began having pain on 
micturition. She vomited twice on this day. On admission her 
temperature was 100.5 an d her pulse 102. The abdomen showed 
marked tenderness in the left iliac fossa and above the pubis; the 
abdomen was not distended and moved freely on respiration. On 
pelvic examination a large rounded swelling was found occupying the 
pouch of Douglas and bulging down to near the vaginal orifice. It 
was extremely tense and tender rendering examination difficult. The 
cervix was pushed up against the back of the pubis. A diagnosis was 
made of an abscess in the pouch of Douglas. Under anaesthesia the 
posterior fornix was opened by an incision behind the cervix. As soon 
as the peritoneum was opened a quantity of pus escaped. On intro- 
ducing the finger through the opening a tense swelling could still be 
felt and, on puncturing this, a sebaceous material escaped suggestive of 
the content of a dermoid tumour. Some adhesions were separated with 
the finger and the collapsed cyst gradually pulled down through the 
opening in the posterior fornix. It was then found that the tumour 
was a dermoid of the right ovary with several twists on the pedicle. 
The pedicle was clamped and cut through. A drainage tube was 
inserted into the pouch of Douglas. There was free discharge from 
this for ten days ; the tube was then removed. The opening in the 
posterior fornix closed, and the patient was discharged nineteen days 
after operation. The tumour presented the ordinary characters of a 
cystic dermoid tumour. It was almost black in colour and the pedicle 
twisted several times. 

44 



Exhibition of Specimens 

(4) A necrobiotic fibroid removed by myomectomy from a five 
months' pregnant uterus. The tumour was the size of a small cocoa-nut. 
It was situated low down on the posterior wall of the uterus and was 
removed by enucleation through a vertical incision in the posterior 
uterine wall. On section it showed the early stages of necrobiosis. 
The patient had had severe and persistent pelvic and abdominal pain 
for a week. Examination revealed a tense tender swelling felt through 
and bulging into the posterior fornix. It was elastic in consistence 
and suggested a cystic tumour possibly with a twisted pedicle. This 
was the more likely as the patient was only twenty-five years of age, and 
she had been curetted by her doctor fifteen months previously when 
the uterus did not appear to be enlarged. She miscarried twenty-four 
hours after operation, but otherwise made a good recovery. 

Dr Fordyce showed a large cervical fibroid weighing i6i- lb. 
which he had removed from a multiparous patient, aged 43. The 
patient had complained of menorrhagia for eighteen months and of 
frequency of micturition for twelve months ; she had also noticed 
that her abdomen had increased in size during the last twelve months. 
On examination there was a large rounded swelling reaching well above 
the umbilicus. The surface was smooth and the tumour felt soft but 
not fluctuant. The diagnosis rested between an ovarian tumour and 
a cervical fibroid, but owing to its fixation in the pelvis and to its 
resemblance to a cervical fibroid removed a fortnight previously a 
diagnosis of the latter was made. At operation the tumour was 
shelled out more easily than was at first anticipated and hysterectomy 
performed. The patient made a good recovery. 

Dr Lackie showed — (1) A uterus with a group of fibroids removed 
by hysterectomy at the fourth month of pregnancy. The patient 
had one or two haemorrhages, and on examination quite a number 
of fibroids were found. On the day on which she was removed to 
a nursing home a four months' foetus was expelled, but the placenta 
remained behind. No attempt was made to extract this, but two 
days later the uterus was removed with the placenta in situ. From 
its position behind a fibroid it would have been impossible to remove 
it per vaginam. The patient made an uninterrupted recovery. 

(2) A uterus with a group of fibroids removed by hysterectomy 
following Cesarean section. The patient was sent to hospital on 
1st July this year (1923) on account of a certain amount of bleeding and 
of pain in the region of one of the fibroids which could be felt through 
the abdominal wall. One suspected necrobiotic changes, but as the 
pain yielded to heroin, and as there was no temperature, it was 
determined to attempt to carry the patient on to nearly full time. 
Between 9th July and 1st November she paid frequent visits to the 
obst. 45 d 



Exhibition of Specimens 

hospital, sometimes remaining in for a day or two on account of 
pain, but on every occasion she was relieved by hypodermics. On 
nth November Caesarean section was performed and a living child 
extracted. This operation was followed immediately by a supravaginal 
hysterectomy. The patient made a perfectly good recovery. 

Dr Haiiltaiii showed a specimen of interest as the true nature 
of the condition was not found out until the specimen was hardened 
and cut. The patient, an unmarried woman of 34 years of age, 
complained chiefly of pain and difficulty of micturition. There was 
also pain on the right side, sickness, and scanty periods which were 
also irregular. On vaginal examination a small mass was to be felt 
in front of the lower part of the body of the uterus, which was lying 
to the left, a mass being present on the right side, which could either 
be a fibroid or a horn of a bi-cornuate uterus. The mass was attached 
to the uterus and moved with it. I did a supravaginal hysterectomy, 
and when I got the specimen and examined it I found that the 
mass was attached to the uterus, and that the right tube and round 
ligament were both attached to the mass and had no connection with 
the uterus whatsoever. I put the case down as a bi-cornuate uterus, 
and five or six days later when the specimen was hardened and cut 
I found that the mass was really a fibroid which had apparently 
grown from the cornu of the uterus and had taken the tube and 
round ligament out with it, being both attached to this fibroid and 
separated from the uterus. 



Meeting — 12th December 1923. 

PRIVATE BUSINESS. 

The following were elected Ordinary Fellows : Helen Turner 
Campbell, M.B., Ch.B., and Flora Margaret Stewart, M.B., Ch.B. 



46 



THE INDUCTION OF LABOUR BY QUININE 
AND PITUITRIN. 

Discussion {continued from p. 42). 

The President, Professor B. P. Watson, said — In continuing the 
discussion of Dr Browne's paper read at the December Meeting of the 
Society, we must bear in mind that a considerable amount of discussion 
has already taken place, and it will be necessary for speakers to be 
brief and to the point in their remarks. At the close of last meeting 
I was asked to initiate this discussion to-night. It seemed to be the 
feeling of several members that something ought to be said regarding 
the use of pituitary extracts in labour generally, but we must remember 
that Dr Browne's communication was on the induction of labour with 
pituitary, and our attention must be chiefly focussed on that. 

All that I shall permit myself to say on other uses of pituitary in 
labour is what I have said elsewhere before. Pituitary extract should 
be used in the course of labour for one purpose and one purpose only, 
viz., to stimulate uterine contraction when this is markedly inadequate, 
and where we are absolutely satisfied that given adequate contraction 
there is no possible obstruction to the dilatation of the cervix or to 
the passage of the child. To give pituitary to a patient with a rigid 
cervix or in a case of delay due to a small pelvis, large head, mal- 
position of the head or rigid pelvic floor is to court disaster. Cases 
of rupture of the uterus and foetal death are bound to occur if it is 
used in such cases, but this is no argument against its use in the 
properly selected cases. 

If the conditions mentioned are observed it may be safely given 
either in the first, second, or third stages of labour. 

The next thing I would say is that if there is an idiosyncrasy 
on the part of the patient to the drug it will be revealed at once. 
Occasionally it sets up vomiting, and sometimes induces faintness. 
For that reason the initial dose should never be a large one, certainly 
not more than \ c.c, and latterly I have often used only \ c.c. with 
results apparently as good as with the larger dose. The initial uterine 
pain after injection is sometimes prolonged and tetanic. The first 
dose should therefore always be given in the presence of the medical 
attendant so that an angesthetic may be administered if necessary. In 
my experience this has been required very seldom. 

As regards the repetition of the dose for the purpose of inducing 
labour, my experience is that, if the first dose produces no bad effects, 
subsequent doses will be equally well borne as the drug has no 
cumulative effect. This is well shown by the effect in the blood 
pressure. At my instigation a member of my former staff carried 
obst. 47 d 2 



F. J. Browne and William Fordyce 

out a series of observations on this point. He found that the first 
dose of pituitary never raised the blood pressure more than five points, 
and that subsequent doses had no effect whatever. I therefore do not 
hesitate to use it for the induction of labour in pre-eclamptic toxaemia, 
or to administer it to such a patient in labour. I have used it 
frequently in cases of placenta praevia, both for the purpose of induc- 
ing labour and for accelerating labour when it has begun. Used in 
this way, in combination with the vaginal pack, it has given better 
results both as regards mother and child than routine version. 

There is another use for pituitary extract of which I should like to 
mention, namely, in the operation of Caesarean section. For some 
years I have always injected directly into the uterine muscle, as soon 
as the uterus was exposed in the abdominal incision, i to i c.c. of 
pituitary extract. Its effect in causing very strong contraction of the 
uterus is almost instantaneous, the result being that there is much 
less bleeding from the uterine incision than otherwise would be the 
case. Even in cases where the incision is over the placental site 
there is a negligible amount of haemorrhage. 

Dr Browne has described so well the technique of the administra- 
tion of the drug for the induction of labour that I need not go into 
that further. The details of that technique were very gradually 
worked out by me and my colleagues in Toronto, and doubtless, as 
experience grows, they will be considerably modified. Dr Browne 
mentioned one of the advantages of the method, viz., that it enabled 
one to start labour with safety in a patient into whose uterus one 
would hesitate to introduce a bougie, bag, or packing, on account of 
gonococcal or other infection in the vagina or cervix. It has also this 
great advantage in cases of contracted pelvis that, if it is found in the 
course of labour that natural delivery is not likely to take place, the 
Cesarean operation is not prejudiced as it would be had bougies or 
bags been used. 

I am glad to find that Dr Browne's experience coincides with my 
own as regards the proportion of successes. 

My own figures are: Total cases, 195; successful, 179; per- 
centage of successes, 91. 

In 146 cases or 75 per cent., labour began as the result of one 
routine induction, the average number of doses of pituitary extract 
each patient received being 3.2. There remained 49 patients in whom 
labour did not begin. In 8 of those no further attempt at induction 
was made, leaving 41 who underwent a second routine induction with 
pituitary extract. In 23 of these or 56 per cent., the second attempt 
was successful, the average number of doses of pituitary extract being 
2.8. In 5 of the 18 unsuccessful cases no further attempt at induction 
was made, leaving 13 who underwent a third routine induction with 



Labour by Quinine and Pituitrin 

pituitary extract. In 10 of these or 77 per cent., this third attempt 
was successful, the average number of doses of pituitary extract being 
3. In 49 of the cases the induction was carried out at from four 
weeks to one week before term. In these premature cases the number 
of successes was 37 or 75.5 per cent., showing, as we would expect, 
that induction is more difficult before than at or after term. 

The maternal mortality was nil. There were no cases of laceration 
of the cervix and no greater proportion of pelvic floor lacerations than 
in ordinary labour. There were two cases of retained placenta and two 
cases of rather severe haemorrhage accompanied by shock following 
the birth of the placenta. Both of the latter were primiparoe over 
39 years of age. I submit that the number and nature of these com- 
plications is no greater than would be met with in a like number of 
deliveries where no pituitary had been used. 

There were 12 foetal deaths, giving a fcetal death rate of just over 
6 per cent. Our fcetal death rate for all cases in the hospital was 
6.5 per cent. Three of these children were monsters. Two died in 
utero apparently from placental infarction due to pregnancy toxaemia. 
Three died of cerebral haemorrhage, two died of atelectasis within three 
days of birth, and in two no autopsy could be obtained to ascertain the 
cause of death. Taking into consideration the nature of the cases in 
which induction was carried out, I think that the results so far as foetal 
death rate is concerned compare favourably with those obtained by 
any other procedure. 

Dr Fordyce said — Might I just make a few remarks with regard 
to my own personal experience in the induction of labour. Of course 
one welcomes the idea of a method of inducing labour short of 
mechanical means such as introducing bougies or packing the uterus, 
but frankly I must confess that my own experience in the inducing of 
labour before full time has been remarkably disappointing. It is 
extraordinary the difference between your own results, Mr President, 
and the cases in which I have employed it in the Maternity Hospital. 
In a number of cases it has absolutely failed. In one that I can 
remember we gave pituitrin three times, in another five times. The 
case which had it five times was in the Ante-natal Department and 
Dr Browne, who actually took over charge afterwards, said that we 
could not have been doing it properly. I think that by the time he 
saw her she had had two of the full courses of treatment and afterwards 
she had three courses (five in all), and she finally went to full time and 
then went into labour. Dr Browne's explanation was that this was one 
of the cases where labour would not have come on before full time 
whatever had been done. In our experience in the Maternity Hospital 
as a method of inducing labour before full time it really almost fell 
into disuse, and I can assure you, sir, that we did carry out the method 

49 



F. J. Browne and William Fordyce 

as you have laid down. As regards the use of pituitrin in stimulating 
uterine pains, one of course has had frequent experience of that. I 
have never actually used it in Cesarean section before making the 
incision. Generally, before making the incision, I have the nurse give 
it hypodermically in the buttock, but I can quite understand how the 
injecting of it into the uterine muscle would be much more efficacious. 
Dr Haig Ferguson said — My experience with regard to the induc- 
tion of premature labour by pituitrin is much the same as Dr Fordyce's. 
You mentioned the effect of pituitrin when a woman becomes some- 
what inert towards the end of the second stage when I think a dose of 
pituitrin might be safer than the use of forceps in some surroundings. 
You also spoke about giving pituitrin in Cesarean section. I have 
never injected it into the uterus, as you suggest, but I have found 
that in giving pituitrin in Cesarean section if one gives it too soon 
there may be some difficulty in sewing the uterus up. The uterus 
gets so hard that the superficial Lembert sutures tend to cut and there 
is difficulty in getting the peritoneal edges to approximate. I have, 
therefore, been in the habit of delaying the giving of pituitrin until one 
is well on in one's stitching, so as to avoid this difficulty. I have 
observed it on several occasions. 

Dr Macrae Taylor said that every individual case should be 
treated on its merits. In all cases, a small dose should be used at 
first in order to test the patient's susceptibility to pituitary extract. 
There are some patients who tolerate it very badly and in whom it 
produces collapse or other alarming symptoms. The real value of 
pituitary extract in labour is in cases that are sluggish ; long labours 
where the patient is getting tired out and the uterus is becoming 
feeble — cases of elderly primipara;, and cases of premature rupture of 
membranes with dribbling away of the liquor amnii. There is no 
reason why it should not be used in the first stage of labour, provided 
the patient has tolerance, and that it is used in small doses. If used 
rashly it is apt to produce laceration of soft parts. 

Dr Johnstone said — With regard to what you have said, sir, 
to-night, I was very much interested to hear that you got in many 
cases as good results from a very small dose — about \ c.c. — as 
you did from the larger doses. I have always myself been under 
the impression that pituitrin was overdosed by the manufacturers. 
I have had the same experience as you have had, and have often got, 
I think, quite as good results from the injection of 2 or 3 minims. 
One of the conditions in which I have found small doses exceedingly 
useful is in cases of "twilight sleep" where the pains are beginning 
to get rather weak, possibly as a result of overdosage, and the 
combination with hyoscine of, let us say, 2 or 3 minims of pituitrin 
sometimes works extremely well. 

5° 



Labour by Quinine and Pituitrin 

With regard to the use of pituitrin in Caesarean section, I have 
tried it at the Maternity Hospital on your recommendation and I think 
in the classical operation it is extraordinarily effective in diminishing 
the haemorrhage, but it does make the muscles so rigid that there is 
a greater risk of tearing. I have also tried it in a lower segment 
Caesarean section where it considerably increased the difficulty of 
delivering the child. That is, in any case, a difficulty in the lower 
segment operation. The uterus had so contracted round the body of 
the child that I had really serious difficulty in extracting it, and in 
future I would be inclined to restrict its use to the classical operation. 

Dr Gordon said — Pituitary extract has been used by me in 
general practice since 1916. At first I gave it both to primiparae and 
multiparas Its use in primiparae as a routine was given up after two 
fcetal deaths — both were born with pale asphyxia. The heart was 
beating in both cases but all usual methods to induce breathing failed. 
In all multiparas I give it where there is no disproportion, where the 
presentation is normal, and when the os is fully dilated or nearly so. 
I have usually found that in from two to five minutes after intra- 
muscular injection (into the extensor carpi radialis of right arm) a 
fairly intense pain ensues and continues almost without relaxation till 
delivery is complete. I have known cases being delivered within five 
minutes of the injection. Invariably light chloroform anaesthesia is 
given. If delivery does not take place within twenty minutes of the 
injection forceps are applied. Separation of the placenta when 
pituitary is given would appear to occur earlier, and often the cord is 
not ligatured till the placenta is delivered — usually in five to fifteen 
minutes. Some labours are almost bloodless and I consider there is 
less chance of retained or adherent placenta or retention of bits of 
membrane. After pains are less frequent and there is also less risk of 
post-partum haemorrhage. Forceps are now rarely used and I find 
that the proportion of cases which show morbidity is very much less 
than formerly. Only in one case did I note tetanic pains. 0.25 c.c. 
to 0.5 c.c. in my experience is quite sufficient in most cases. I have 
never given more than 1 c.c. In general practice in my opinion it 
saves much anxiety, many hours of waiting, and the patient is often 
spared many hours unnecessary suffering. 

Dr Young (Lasswade) said — I have had a great experience of 
hurrying up labours. In a country practice, where one has to go 
miles in a night, and where one may have two cases going on at 
the same time within six miles of each other, one must get one of 
them over as soon as possible, and then pituitrin is looked on as 
a godsend. In a multipara case I never go out at any time without 
carrying my pituitrin. In one case the patient had been in labour 
for thirty-six hours when I arrived. The os was about the size of 
obst. 51 d 3 



F. J. Browne and William Fordyce 

a five-shilling piece. I gave her a dose of pituitrin and administered 
her chloroform immediately afterwards. The second pain shot the 
child right into the bed. Since I have used pituitrin for more than 
six years I have never had a retained placenta. In one or two cases 
when I put my hand on the uterus I felt something almost like a 
tearing feeling, as if something was giving way, and away comes the 
placenta absolutely complete, membranes included. It is possible 
that there may be some adhesion of the placenta to the uterus, and 
the muscular contraction of the uterus pulls itself off the placenta 
and so saves one introducing the hand to pull it off. I have from ioo 
to 150 confinements per year. One usually finds that with pituitrin 
there is equal contraction all over, and that after the child is born 
the uterus is always as hard as a ball. Of course I would never dream 
of using pituitrin in a case of contracted pelvis, and have never tried 
it in eclampsia, because I am not sure what would happen in an 
eclamptic patient. I usually just wait in these cases, but certainly 
in an ordinary case for hurrying labour, especially in multipara;, I 
find that about h c.c. is as much as I have had to use, and have 
never used more than ih c.c. 

I might relate a case of a woman whom one could depend on to 
have a good haemorrhage afterwards. The child was usually born before 
I got there, and I had to wait for a time afterwards to attend to the 
haemorrhage. She usually had a very rapid labour and very severe 
haemorrhage. In her last confinement, from the fifth month onwards, 
I gave her calcium lactate with the idea of making the blood a little 
more coagulable. I gave 1 c.c. of pituitrin, and the child was born 
twenty minutes afterwards with practically no haemorrhage. 

In reply Dr Browne said — I think there is no doubt at all that 
the explanation of the great difference that one finds in the response 
to pituitrin in these cases is that the drug is sometimes relatively inert. 
Of course we know that patients differ very much in susceptibility 
to all methods of induction. We all know the patient in whom there 
is great difficulty in inducing labour by means of bougies. 

Dr Johnstone referred particularly at the last meeting to the 
work of Mr Quarry Wood. That was most interesting work and 
I heard Mr Wood's paper and should have mentioned his work in 
mine. I have talked to Mr Wood since about his results, and he 
confirmed what Dr Johnstone said, that there is, in the posterior lobe 
of the pituitary towards full time in the pregnant rabbit, a lake of 
pituitary extract, and that after the rabbit is delivered, this pituitary 
lake collapses, and he lent me two lantern slides illustrating the 
difference in the pituitary lake before and after the birth of the 
young rabbits. The first slide, which I show, illustrates the pituitary 
lake distended, and the second one the lake collapsed. I think it 

5 2 



Labour by Quinine and Pituitrin 

is possible that eventually we shall find the explanation of the onset 
of labour in some such physiological cause as this. We also know 
that the corpus luteum atrophies towards the end of pregnancy, and 
it may be that as the pituitary extract increases in the posterior lobe 
of the gland and the corpus luteum atrophies, it is the disturbance 
of balance between the two that gives rise to the onset of labour. 
It is said that abortion occurs if the corpus luteum is removed in 
the first six weeks of pregnancy. If that is so and the corpus luteum 
is so important in causing adhesion of the ovum, it would explain 
why we have difficulty in inducing labour in premature cases. There 
is, I believe, no recorded case in which abortion has been produced 
by pituitary extract. 

Dr Haig Ferguson raised the question as to whether the uterus was 
examined in Dr Fordyce's case. I have examined a section for the 
edge of the tear stained by Van Gieson's method to show up the 
fibrous and muscular tissue. So far as I can see there is no 
degeneration whatever. 

Touching the point that Dr Orr raised with regard to the hae- 
morrhage, there is no haemorrhage amongst the muscle fibres. 

Dr Fordyce referred to the case of failure of induction in the Ante- 
natal Department — that was one of the cases that I recorded as a 
failure in my paper. It was a case of hydramnios, and that probably 
accounted for the difficulty in inducing labour. 

I should like in conclusion to emphasise that the method has a 
great advantage in the particular kind of case with which I deal in the 
Maternity Hospital — that is the venereal case with discharge, where 
there is particular danger in inducing labour by means of mechanical 
methods. 

In reply Dr Fordyce said — With regard to my case, of course I did 
not press the point at all in my statement as to the definite cause of 
the rupture. I merely stated that it had occurred very shortly after the 
initial dose of pituitrin. Dr Browne's criticism was quite a fair one, 
that it was a case where there was possibly some disproportion, but as 
the patient had already given birth to six or seven children before I 
thought that I was perfectly justified at any rate in seeing if the head 
would come through. I think that if it was due to the pituitrin it was 
very probably, as Dr Browne has said, due perhaps to some excessively 
strong pituitrin, or possibly to some idiosyncrasy on the part of the 
patient, similar possibly to the case which Dr Johnstone recorded 
where the effects of the pituitrin were exceedingly sudden and very 
powerful. I think the case was worth recording as an indication of a 
possible danger in the use of pituitrin. At any rate until we have a 
really standardised preparation on which we can depend we cannot 
tell what the effects are to be in its use. 

53 



ADENOMYOMA OF THE UTERUS WITH 
TUBERCULOUS INFECTION.* 

By R. W. JOHNSTONE, C.B.E., M.D., F.R.C.S.E. 

The liability of fibroids to various forms of degeneration is 
one of the commonplaces of gynaecological pathology and is 
generally recognised as being due to the somewhat exiguous 
nature of their vascular supply, which is usually confined, or 
almost confined, to the capsule. The December meeting of 
our Society provided examples of two of the more rare forms 
of degeneration and infection in the specimens shown by the 
President of a sarcomatous degeneration in the centre of a 
fibroid polypus, and of a carcinomatous invasion of a fibroid. 
Microbic infections are much less frequent than degenerative 
changes except in polypoidal submucous fibroids which become 
exposed to the vaginal secretions. Infection of these may go 
on to sloughing and gangrene. Sub-serous fibroids may also be 
infected by adhesions to the bowel and to inflamed tubes, while 
a third possible route of infection is by the blood stream. 
Actual suppuration in fibroid tumours is, however, rare, for 
Lockyer, in his monograph, records experience of only three 
cases, whilst Kelly and Cullen found but four in 1428 myoma 
cases. Tuberculous infection is one of the rarest varieties. 
Cullen records one case of an interstitial fibroid three inches in 
diameter which on section was of a putty-like consistence, and 
smears showed the presence of tubercle bacilli. Bole records 
a case of what he calls a diffuse myoma of the anterior wall, 
which was partly necrotic and proved on microscopic examina- 
tion to be tuberculous. The "diffuse" nature of the tumour 
makes one dubious if this were not really an adenomyoma. 

It would therefore appear that the capsule of a fibroid, 
which renders it prone to degeneration, protects it in some 
measure from microbic infection, except in the special anatomical 
conditions mentioned. If we keep these facts in mind, it is not 
surprising to find that, conversely, adenomyomata of the uterus, 
which are in the majority of cases diffuse and unencapsulated, 
and in which the glandular (endometrial) areas are usually more 
or less directly derived from the vascular uterine mucosa, should 
be comparatively immune from degenerations. On the same 
line of reasoning infection and malignant invasion might be 

* Read 13th Feb. 1924. 

54 



Adenomyoma of the Uterus 

expected to be more common in these tumours owing to the 
absence of a resistant capsule, more especially if we regard the 
development of the neoplasm as in itself a reaction to an 
infection. Experience, however, negatives such an expectation 
for we find that while cystic degeneration of adenomyomata is 
rare, malignant or infective changes are still rarer. 

It is for these reasons that I wish to present to the Society 
to-night a case of adenomyoma of the uterus with widespread 
tuberculous infection, a condition of which, so far as I can find, 
only six instances have been recorded in medical literature. 

The first two cases are recorded in von Recklinghausen's 
well-known monograph, which appeared in 1896, and which 
did so much to establish the recognition of adenomyoma as 
a pathological entity. The first case was that of a woman 
forty-four years old, childless ; menstruation had always been very 
profuse and painful, and for the four years prior to operation 
so abundant as to cause severe anaemia. The tumour was 
a little smaller than a fcetal head and was incarcerated in the 
pelvis, causing obstructive symptoms in the bladder and rectum. 
Examination of the tumour after removal showed it to be an 
adenomyoma with dilated gland spaces, and with " epithelioid 
tubercles " widely spread throughout the entire uterine wall, but 
especially favouring the adenomatous areas. In one portion of 
the tumour there were carcinomatous changes in the epithelium 
of the glandular elements, and the case thus presented a 
specially interesting combination of adeno-carcinoma and 
tuberculous infection in an adenomyoma. 

It is only fair to state that von Recklinghausen appears 
to have had some dubiety about this case, but his opinion 
has been generally accepted as the correct interpretation of 
the appearances found. 

Von Recklinghausen's second case was that of a woman 
of fifty-five, also sterile. She had come to her menopause in 
her thirtieth year and at the age of forty-five there had been a 
malodorous hemorrhagic discharge which returned at irregular 
intervals. The tumour was the size of the closed fist and a 
diagnostic curettage revealed carcinoma of the body of the 
uterus. Total extirpation of the uterus was performed, and 
examination of the uterus showed that it not only contained 
carcinoma of the endometrium but was also the seat of 
adenomyoma, with " epithelioid tubercles " scattered throughout, 
and in many cases situated in the cellular mantle of the 
glandular areas. 

55 



R. W. Johnstone 



The third specimen was recorded by Lichtenstern in 1901. 
The patient was a single woman of twenty-two who complained 
of dysmenorrhcea at irregular intervals. Her uterus contained 
a tumour the size of an orange, and after its removal this was 
found to be an adenomyoma of endometrial origin with countless 
tubercles scattered throughout it. Lichtenstern was of opinion 
that the tuberculous infection was probably secondary to the 
adenomyoma. 

The fourth specimen was described by Hosli in 1904. The 
patient was aged forty-four, and the tumour was found to be 
intraligamentous in situation. On examination it proved to 
be an adenomyoma with tuberculous giant-cell systems scattered 
throughout. 

The fifth specimen was described by Archambauld and 
Pearce in 1907. The patient was aged twenty and was 
unmarried. There was only one case of tuberculosis in the 
family — a paternal uncle. Menstruation began at the age of 
sixteen, was always scanty and irregular, the intervals being 
always longer than usual and sometimes as much as five or six 
months. Menstruation was not accompanied by pain. In 
December 1904 she was examined on account of an unusually 
prolonged period of amenorrhcea and the uterus was found to 
be infantile in type, moderately retroverted, painless and 
movable, but accompanied by slight inflammation of the 
appendages. Six months later the patient suddenly developed 
haemoptysis and for more than a year was treated in sanatoria 
for pulmonary tuberculosis. In November 1905, eleven months 
after the previous examination, an attack of pelvic pain deter- 
mined a second examination, when the body of the retroverted 
uterus was found to be enlarged to the size of a mandarin 
orange, and on the left side and apparently continuous with 
the uterus was another mass with a soft-solid consistence. 
A diagnosis of pelvic tuberculosis was made and operation 
undertaken in January 1906. After separation of many 
adhesions the uterus, as large as an orange, together with the 
appendages on both sides, was removed, the patient making 
a good recovery. On examination the posterior wall of the 
uterus was found to contain a rounded tumour which proved 
to be an adenomyoma riddled with tuberculous nodules, many 
of which were caseating. Tubercles were also present in the 
right Fallopian tube, but not in the left. No tuberculosis was 
found in the endometrium, even that portion of it bordering 
the tumour. Pearce, who was responsible for the pathological 

56 



Adenomyoma of the Uterus 

examination, states that there was nothing to indicate that the 
glandular elements and prolongations had been the route of 
entry of the tuberculous disease, which was disseminated apart 
from the adenomatous elements. 

The sixth case occurred in Landau's clinique in Berlin and 
was very fully studied by Grimbaum, to whose paper in the 
Archives fur Gynaecologie in 1907 I am indebted for several 
of the references to previous literature. The patient was 
forty-five years of age, married, and had never been pregnant. 
Fifteen years before the operation she had been treated for 
a pulmonary catarrh with cough and haemoptysis. After one 
and a half years of treatment the patient recovered completely 
and felt absolutely well. Five years before operation she 
experienced a feeling of weight in the pelvis and a tumour of 
the uterus was diagnosed, but the patient refused operation. 
The monthly periods were regular and profuse but without 
any special pain. However, a year before operation the patient 
experienced increasing pain on micturition and ultimately 
difficulty in the evacuation of the bladder amounting to actual 
retention and necessitating catheterisation. This led her to 
submit to operation, and a uterine tumour the size of a child's 
head was removed by hysterectomy. On examination the 
tumour proved to be a diffuse adenomyoma, the glandular 
portions of which were here and there dilated into small cysts. 
Close to the normal gland tissue in the lymph-adenoid stroma 
were " epithelioid tubercles " with multi-nucleated giant-cell 
systems. Some of these tubercles were caseating in the centre. 
The tuberculous infection was present also in the endometrium 
and in the superficial portion of the muscular wall of the uterus, 
and Griinbaum remarks that in some places there existed, in 
close proximity to intact and healthy endometrium, areas 
riddled with tubercles degenerating to the extent of complete 
necrosis and caseation. The cornua and the interstitial portions 
of the tubes showed changes suggestive of adenomyoma (or of 
salpingitis isthmica nodosa), but no clear evidence of tuberculosis 
was to be found in any part of the tubes. Griinbaum draws 
attention to the fact that the tuberculosis was most advanced in 
the portion of the tumour furthest removed from the cavity 
of the uterus, and had produced widespread caseation in the 
peripheral layers which were evidently part of the adenomatous 
tumour. The muscular tissue had suffered least from the 
tuberculosis. The absence of any tubal infection is remarkable, 
as the Fallopian tubes are universally recognised as being the 

57 



R. W. Johnstone 



parts of the generative organs in the female most susceptible 
to tuberculous infection. Griinbaum regarded his adenomyoma 
as almost certainly of true endometrial origin and the tuberculous 
infection as secondary to the tumour growth, believing that the 
adenomatous processes favoured the progress of the tuberculosis 
from the endometrium into the tumour. In favour of this view 
he adduces the arguments that (i) large areas of the tumour 
were free from tuberculosis, in particular the tubal angles and 
the tubes themselves ; (2) tuberculosis of the endometrium has 
not been known to produce deeply sunk tube-like glandular 
swellings. He regards the case as one of a blood-borne infection 
from an old latent focus in the lung. 

Besides these six cases I have not been able to find any 
other record. Cullen in his immense experience of adeno- 
myoma does not appear to have met with this complication, 
and Lockyer in his book on Fibroids and Allied Tumours 
records only a case of adenomyoma of the uterus associated 
with tuberculous salpingitis, in which, however, the uterus and 
tumour were uninfected. 

My own case is that of Mrs R., aged 45, who was sent 
to Ward 36, Royal Infirmary, as an out-patient in September 
1923 by Dr Margaret Cameron of Portobello. The patient had 
been married for twenty-one years but had never been pregnant. 
Her menstruation began when she was twelve and had been 
regular, -? T . In her youth the periods had been profuse, but 
for the last twenty years the amount of loss had been very 
average. Nineteen years ago she had some pain low down on 
the left side associated with a yellow discharge. This was 
treated by douching and with a ring pessary (sic), and her 
symptoms disappeared. In July 1923 she began to suffer from 
pain low down on the right side, radiating round to the back 
and so severe as to interfere with her sleep at nights. Her 
general health has been satisfactory although she has had an 
occasional winter cough. Her father died at the age of thirty- 
nine from haemoptysis, but apart from this there is no history of 
tuberculosis in the family — two brothers and five sisters being 
alive and well. Two sisters died in infancy. On examination 
the uterus was found to be enlarged to the size of an orange, 
lying in marked anteversion. A diagnosis of fibroid tumour 
was made and the abdomen opened on 27th September. The 
uterus contained what appeared to be two interstitial fibroids 
side by side on the posterior wall. The left tube was slightly 
thickened and nodular towards its uterine end. Otherwise the 

58 



" ■■■ n 




SOT 






\^ : v'i : U 




1 \Y. V- 



J7< 



FlG. i.— Photograph of a drawing of portion of tumour (H.P.)> showing structure 
of adenomyoma, and presence of tuberculous giant-cells in the cellular 
stroma. 



Adenomyoma of the Uterus 

appendages appeared normal. Supravaginal hysterectomy was 
performed with double salpingo-oophorectomy. The patient 
made an excellent recovery, complicated only by a few days of 
slight cough with sticky sputum, harsh vesicular breathing at 
both apices, and some few crepitations at the bases. The 
sputum did not show the presence of any tubercle bacilli. The 
temperature, which never exceeded ioo° F., fell to normal on 
the seventh day and did not again rise. She left hospital on 
the twentieth day after operation in good health, and has since 
reported twice as feeling very well and free from pain or other 
symptoms. 

At the close of the operation I examined the specimen to 
see if there was any degeneration which would account for her 
pain. On incision the larger of the two tumours showed 
numerous small yellow areas, soft in consistence, studded 
throughout a very coarse-looking fibroid. The condition was 
obviously abnormal and I asked the University Gynaecological 
Laboratory for an early report upon it. I am obliged to 
Dr Douglas Miller for giving me this report which was to the 
effect that the tumour was adenomyomatous in nature, and 
that the cellular stroma surrounding the gland elements was 
infiltrated with tuberculous giant-cell systems. This report 
together with the slight pulmonary symptoms which occurred 
during her convalescence, determined a further examination of 
her lungs, and Dr Fergus Hewat, who kindly saw her with me, 
was able to detect some dullness and shrinkage of the lung at 
the right apex. He was of opinion that this was probably due 
to old-standing tuberculosis, but at the time of his examination 
he could detect no traces of any active disease. 

The uterus contains two swellings in its posterior wall, the 
larger on the left being about the size of a plum. Both tubes 
are thickened throughout and present nodular thickenings in 
addition, which are most marked at the cornu on each side. 
Other minor thickenings in the isthmus and ampulla in each 
tube can be felt between the fingers better than they can be 
seen. The tumours on the posterior wall have the structure 
of diffuse adenomyoma and are infiltrated with tuberculous 
nodules and giant-cell systems. The distribution of these appears 
to be mainly, but not exclusively, in the cellular mantle of the 
glandular elements (Fig. i). Both the glandular areas and the 
tubercles are most numerous in the left and larger tumour, and 
the tuberculous infection is most noticeable in the part of the 
tumour nearest to the endometrium and the cavity of the uterus. 

59 



R. W. Johnstone 



The section, which includes part of the endometrium, shows 
clearly the inflowing of the endometrium into the myomatous 
tissue, and proves the endometrial origin of this adenomyoma. 
It also demonstrates very beautifully how the mucosal elements 
seem to flow like streams along the paths of least resistance, 
opening out into lakes or pools with cystic spaces where 
opportunity permits. This low power section has thus an 
appearance which is somewhat reminiscent of a contour map 
of a well-watered countryside (Fig. 2). 

The anterior wall is one inch thick but shows no clear 
evidence of adenomyoma and the demarcation between mucosa 
and muscularis is normally defined. A few tubercles are present 
in the endometrium, and in the inner portion of the muscular 
wall there are several lymphoid nodules of round cells containing 
tuberculous multinucleated giant cells. I have not found any 
trace of gland invasion in the sections taken from the anterior wall. 

Tubercles are present in the cornual swelling of the left 
tube which presents many cystic spaces lined with glandular 
epithelium, but with little or no cellular stroma around them. 
This is characteristic of salpingitis isthmica nodosa, and also, 
according to Sampson, of adenomyoma growing from the tubal 
epithelium. The two conditions are probably often confused. 
Sections of one of the thickenings in the outer isthmic region 
of the right tube show one or two similar cystic spaces in 
addition to the tube lumen. There is no clear evidence of 
tubercle in the right tube, but there are a few nodular collections 
of round cells which are strongly suggestive of it. 

Here then is a uterus presenting simultaneously (1) two 
diffuse adenomyomatous tumours in its posterior wall, which 
are clearly of endometrial origin, and (2) . disseminated 
tuberculous infection, alike of the endometrium, the muscular 
wall, the tumour growths, and certainly the left tube — possibly 
also the right. The question naturally arises whether the 
two conditions have more than a fortuitous association. The 
presence of glandular invasion in the cornua is of special 
interest in this connection, whether we interpret it as 
adenomyoma arising from the tubal epithelium, or as 
"salpingitis isthmica nodosa." The two conditions have a 
great deal in common, and, as is well known, the view was 
enunciated that adenomyoma, like so-called salpingitis isthmica 
nodosa, was of the nature of a reaction to a chronic infection 
of which tuberculosis was the type. 

In regard to the present specimen, the first point to be 

60 




FlG. 2. — Low power view of section from posterior wall of uterus, including normal 
endometrium at upper right-hand corner (E), and portion of tumour. The lines 
drawn from £' show ingrowths of endometrium running up into the tumour, 
which prove the mucosal origin of the glandular areas in the tumour. 



Adenomyoma of the Uterus 

considered is the origin of the tuberculous infection — was it a 
descending infection through the tubes, or a blood-borne infection ? 
— for the possibility of an ascending infection from the cervix 
may be almost discarded. Archambauld and Pearce, and also 
Gri'mbaum regarded the glandular elements of the adenomyoma 
in their cases as presenting areas of diminished resistance which 
determined the settlement in them of tubercle bacilli circulating 
in the blood. The two former writers quote Schakoff' s article 
on "Tuberculosis of the Female Genital Organs" to the 
effect that firstly, " genital tuberculosis in women is usually 
secondary, most commonly to pulmonary tuberculosis"; and 
secondly, " in tuberculosis of the uterus and ovaries, when the 
tuberculous lesions exist as isolated foci without neighbouring 
lesions, the inoculation has occurred by the blood stream." 

I am not disposed to challenge these axioms, which indeed 
seem thoroughly rational ; and this case of mine would appear 
to support them for the following reasons. Firstly, there is no 
trace of any peritoneal tuberculosis in the specimen removed, 
nor, secondly, was there any sign of peritoneal involvement seen 
at the time of operation ; and thirdly, the tuberculous infection 
is much more marked in the uterus than in the tubes, a point 
which would seem to exclude invasion of the uterus by the 
route of the mucous surface. I would regard this, therefore, as 
in all likelihood a blood-borne tuberculous infection, secondary 
to some old-standing tuberculous focus in the lungs, which has 
settled more in the endometrium of the body of the uterus than 
in the tubes. From the endometrium it seems to have passed 
into the wall of the uterus, and judging from the much greater 
prevalence of the tubercles in the cellular mantle around the 
glad elements of the tumour, as compared either with the 
endometrium or with those portions of the wali of the uterus 
not affected by the tumour, it seems legitimate to argue that 
the glandular prolongations into the adenomyoma have provided 
the tuberculous disease with a ready access to the tumour, and 
have indeed proved to be areas of a diminished resistance which 
has determined the settlement of tubercle bacilli in them. 

References. 

Archambauld and Pearce, "Tuberculose d'un Adenomyome de l'Uterus," 
Revue de Gynecologie et de Chirurgie Abdominale, 1907, tome xi., p. 3. 

Bole, " Uber primare Uterustuberkulose," Gynaekologia Helvetica, 1903, 
p. 99. 

Cullen, T. S., "Adenomyoma of the Uterus," Philadelphia and London, 
W. B. Saunders Coy., 1908. 

61 



R. W. Johnstone 



Griinbaum, D., "Adenomyoma corporis uteri mit Tuberkulose," Archiv. 
fur Gynaekologie, 1907, Bd. lxxxi., p. 383 ; also "Das klinische Verhalten 
des Adenomyoma uteri," Archiv. fiir Gynaekologie, 1908, Bd. lxxxvi., 

p. 387- 
Hosli, " Uber einen Fall von Fibromyoma intraligamentare adenomatosum 

mit Tuberkulose," Dissert. Zurich, 1904 (Ref. from Griinbaum). 
Lichtenstern, " Beitrag zur Lehre des Adenomyoma uteri," Monatschr. f. 

Geb. unci Gyn., 1901, Bd. xiv., p. 308. 
Lockyer, Cuthbert, Fibroids and Allied Tumours, London, Macmillan & Co., 

1918. 
v. Recklinghausen, Die Adenomyome und Cystadenome der Uterus und 

Tubenwandung, Berlin, 1896. 
Schakoff, " Contributions a la Connaissance de la Tuberculose des Organes 

Genitaux de la Femme," Gy?icecologia Helvetica, 1904, p. 139. (Ref. 

from Archambauld and Pearce.) 

Discussion. 

Dr James Young said — We are particularly fortunate in having a 
record in our Society Transactions of such a rare pathological con- 
dition. It opens up some interesting topics in regard to the etiology 
of adenomyoma, although Dr Johnstone has only touched on that very 
shortly. One has always been impressed by the fact that an infective 
condition, more particularly in the Fallopian tubes, where the patho- 
logical changes can be more clearly recognised, is capable of stimulat- 
ing a most intense overgrowth of fibrous tissue and of the epithelial 
elements, and sometimes also of muscle, and one has seen a pathologist 
suspect carcinoma of the tube, when as a matter of fact one found that 
it resolved into a tubercular infection. More particularly in the 
condition of chronic salpingitis isthmica nodosa which Dr Johnstone 
has cited you get this change in its more extreme forms. I mention 
that because I think it would be unwise to exclude the possibility of 
the tuberculosis having some possible bearing on the whole histological 
picture which Dr Johnstone showed on the screen to-night. It is rare, 
undoubtedly, as a factor in the uterus. It is not by any means rare in 
the tube. 

Dr Haig Ferguson said — I am not going to criticise the pathology 
of the question, whether the tubercle was a primary condition, or 
whether it is simply invading a pre-existing adenomyoma. I think 
Dr Johnstone has most clearly described the case and has brought 
out the points in an ideal way which we all greatly admire. 

The President, Professor Watson, said — What I was thinking as 
Dr Johnstone read his paper was very much along the lines in which 
Dr Young has expressed himself. It has always been a remarkable 
thing to me in examining tuberculous tubes to note the difference in 
the invasion of the tubercle according to the part of the tube which 

62 



Adenomyoma of the Uterus 

one examines. One finds usually that towards the fimbrial extremity 
the tubercle is entirely confined to the mucous membrane. As you 
trace the tube along towards the isthmus you find the tubercle 
invading the muscular wall, and as is well known, you may fail, in 
the chronic stages, to find definite evidence of tubercle in the 
distended outer part of the tube, but you will always find evidence 
of tubercle in the form of giant-cell systems in the muscle at the 
isthmic end, and it is there that this condition of salpingitis isthmica 
nodosa is typically seen. There has always been a question in my 
mind whether that appearance is due to a tuberculosis which has 
confined itself primarily to the mucous membrane, followed by an 
intense proliferation of the epithelium, or whether there has been an 
invasion of the tubercle into the wall, carrying along with it some of 
these epithelial elements; whether the cystic spaces which we see are 
real gland spaces, or whether they result from the process going on in 
the lumen of the tube. It is not often that one can trace an actual 
connection between the mucous membrane of the uterus and the 
adenomyomatous mass in the uterus. It is a moot point in a case 
like this which is the primary condition. Was there an adenomyoma, 
or was there a primary tuberculous invasion of the endometrium and 
as a result of the extension of the invasion into the muscle wall this 
epithelial overgrowth extending into the uterus ? I don't know 
whether Dr Johnstone has formed any definite idea in the examination 
of the specimen as to which he thinks is the primary, or whether the 
adenomyoma may possibly be secondary to the tubercle. 

We are much indebted to Dr Johnstone for bringing this rare 
condition before us. 

In reply Dr Johnstone said — The main burden of my reply must 
be to thank the Fellows for the extraordinary patience with which they 
have listened to a paper of purely pathological interest. Dr Young 
and yourself, sir, have fastened upon the main question raised by the 
specimen — namely, the causal relationship, if any, between the two 
conditions. I don't think that one can dogmatise about it at all. 
It is easy enough to argue, but I did rather come down on this side 
of the fence — that I thought the tumour was an adenomyomatous 
condition primarily and the tuberculosis secondary. The main reason 
for my doing so was simply that the adenomyomatous invasion seemed 
to be far in advance of the tuberculosis. That is not a thing that I can 
demonstrate without many more sections than can be shown at a 
meeting like this. The tuberculosis was predominantly in the parts of 
the tumours adjacent to the endometrium, whereas the adenomyoma 
invaded much more deeply. I shall take an opportunity of showing 
the slides to Professor Watson and Dr Young. 

^3 



Meeting — 13th February 1924. 

EXHIBITION OF SPECIMENS. 

Professor Watson showed a cervical fibroid — a typical example of 
a fibroid growing from the posterior lip of the cervix and bulging down 
into the cellular tissue of the pelvis, giving rise to some trouble in its 
removal, which of course had to be done by a complete hysterectomy. 

Dr Chisholm showed a specimen of a monster. The mother 
was a young primipara. Labour lasted rather over twenty-four hours. 
A provisional diagnosis of R.O.P. had been made and hydrocephalus 
suggested as the result of vaginal examination. Fcetal heart sounds 
were not heard. The head was born spontaneously. There was 
some little delay in extracting the body. The perineum was very 
slightly torn. The child was born dead. 

The placenta shows a short cord and there is a remarkably small 
opening in the membranes. The husband is said to have masturbated 
for many years, and the patient is said to have made attempts by 
douching, etc., to get rid of the embryo in early pregnancy. The 
monster shows many abnormalities. There is a mild degree of 
hydrocephalus. The thorax and upper limbs appear to be normal. 
The lower part of the body is greatly distorted. The liver shows 
irregularity, and the left kidney is large and of unusual shape and 
the presence of a right kidney is doubtful. The right testicle 
appears to have completely failed to descend and demonstration 
of the left testicle is uncertain. The penis is present, as also the 
scrotum, which is empty. There are gross intestinal abnormalities, 
including a condition suggesting volvulus in the caecal region. The 
colon, especially the descending part, is greatly distended. The 
greater part of the abdominal viscera were contained in a large 
ventral hernia (exomphalos). The lower limbs are in a condition 
known as sympus monopus. This implies that the limbs are rotated 
completely outwards and backwards and are fused by their outer 
aspects, the united knees being bent backwards in relation to the 
body instead of forwards. The single foot is really a union of the 
two feet by their outer aspects. There is webbing between thighs and 
legs keeping up a permanent flexion of the knees. There is a band 
between the side of the foot and the anal region. The condition 
dates from probably about the fourth week of intrauterine life. 

Dr Johnstone showed a uterus with adenomyoma infected 
with tubercle about which he spoke in his paper. 

PRIVATE BUSINESS. 
The following were elected Ordinary Fellows of the Society : Chris- 
tina O. Mayne, M.B., Ch.B. ; A. A. Gemmell, M.C., M.B., Ch.B. ; 
Peter Fleming Good, D.S.O, M.A., M.B, Ch.B., D.P.H.(St And.). 

64 



THE ASSOCIATION OF PLACENTA PPwEVIA 
AND THE ALBUMINURIC TOXEMIAS. 

By DOUGLAS MILLER, M.D., F.R.C.S.Ed. 

The purpose of this communication is to submit evidence in 
favour of acceptance of the hypothesis advanced by Dr James 
Young in 19 14 as to the importance of placental infarction in 
the etiology of the toxaemias of the later months of pregnancy. 
Young's earlier work in this connection is so well known to the 
Society that it is unnecessary to refer to it in great detail. It 
will be recalled that as the result of a scientific investigation he 
professed to show that eclampsia and pre-eclamptic toxaemia 
resulted from the absorption of products of early degeneration 
of a piece of placenta, the blood supply of which had been cut 
off. His observations were based on a study of the morbid 
changes found in the placenta in cases of toxaemia, and he 
claimed to have reproduced in animals by the injection of early 
autolytic products of the placenta a disease closely simulating 
the classical picture of eclampsia. In his 19 14 paper the 
association of toxaemia with accidental haemorrhage was 
referred to ; the usual conception that toxaemia is the cause of 
premature placental detachment was challenged and arguments 
were advanced to show that the separation precedes, and 
through the consequent necrosis of placental tissue originates 
the toxaemia. In particular, it was shown that where delivery 
of the placenta follows quickly on interference with the 
maternal blood supply, toxaemia is absent or inconspicuous ; on 
the other hand, where a sufficient time elapses to allow of the 
development of infarction, toxaemia is invariably present. 

These investigations were largely anatomical and experi- 
mental in nature. In a second communication, published in 
192 1 in conjunction with the writer, the results of a clinical 
study of forty cases of toxaemia and allied conditions were 
submitted and evidence brought forward in support of the 
earlier observations. 

In placenta praevia, where time allows of it, there develop 
in the separated portion of the placenta naked-eye and micro- 
scopic changes identical with those found in the separated 
placenta of accidental haemorrhage. If Young's theory is well 
founded, evidence of toxaemia should accordingly be forth- 
obst. 65 E 



Douglas Miller 



coming in those cases of placenta previa in which, subsequent 
to its detachment, the delivery of the placenta is sufficiently 
long delayed to allow of the development of infarction. That 
this requirement is satisfied the present communication 
professes to show. Moreover, as compared with accidental 
haemorrhage, the evidence provided by a study of placenta 
praevia is less confusing and equivocal in that toxaemia can 
possess no etiological relationship to the latter condition, and 
when it is present must be regarded as a chance phenomenon 
or as a consequence of the placental necrosis which has occurred. 
That it is not coincidental is suggested by the frequency with 
which the two conditions are associated. 

The observations here submitted are based on a study of 
49 cases of placenta praevia, observed for the main part in 
the Edinburgh Royal Maternity Hospital, to the physicians 
of which my thanks are due for facilities afforded. The cases 
under review represent, with three exceptions, a consecutive 
series. 

While a rise in blood-pressure is probably the earliest sign 
of toxaemia we possess, in cases of severe haemorrhage this 
indication may obviously be wanting, and in this investigation 
the presence of albumen in the urine was taken as a test, a 
catheter specimen of urine being obtained for purposes of 
analysis shortly after admission of the patient to hospital and 
in the majority of cases at subsequent intervals thereafter. 

Of the 49 cases, 7 occurred in primigravidae, 42 in multipara?, 
the average parity being 4.5. 

The cases have been classified as follows : — 

Group I. — Cases of placenta praevia with albuminuria on 
admission to hospital (exclusive of three cases of eclampsia) : 
there were # twelve cases of this nature. In three only a trace of 
albumen was present and quickly disappeared ; in three the albumen 
increased from a trace at the first analysis to a considerable deposit 
on subsequent examinations. In one case on admission to hospital 
forty-eight hours after the initial haemorrhage albumen in consider- 
able quantity was present. Labour had not commenced, and the 
haemorrhage having ceased, the patient was kept under observation. 
The urine gradually cleared, and forty-eight hours after the patient's 
arrival in hospital only a trace of albumen was found. On the third 
day after admission, with the onset of labour, fresh placental detach- 
ment and renewed haemorrhage occurred, and were followed in the 
course of twenty-four hours by the reappearance of albumen in con- 

66 



Placenta Praevia and Albuminuric Toxaemias 

siderable amount. In the remaining five cases albumen in greater 
or less amount was found. 

Group II. — Cases of placenta preevia in which the urine on 
admission to hospital was albumen-free, but in which albuminuria 
subsequently developed. There were seven cases of this type. In 
three only a trace of albumen developed and quickly disappeared. 
In one case in which the patient had been under treatment in the 
antenatal department for gonorrhoea, the urine had been repeatedly 
tested with negative results, the last analysis being made four days 
prior to the onset of haemorrhage ; subsequent to the haemorrhage 
albuminuria in considerable amount developed. In a further case, 
the patient, an xi-para, had enjoyed perfect health until the seventh 
month of her pregnancy, when she was admitted to hospital with a 
history of vaginal haemorrhage having occurred. A diagnosis of 
placenta praevia was made and labour induced. Shortly after delivery 
severe headache, dimness of vision and widespread oedema developed, 
and the urine was found to be heavily loaded with albumen. The 
albuminuria never completely subsided and the patient was trans- 
ferred to the Royal Infirmary, where she died some months later, 
her kidneys having apparently sustained irreparable damage. In the 
remaining two cases of this group a considerable degree of albuminuria 
developed subsequent to admission to hospital. 

Group III. — Cases of placenta proevia combined with eclampsia. 
There were three instances of this association. In one of these the 
combination was probably coincidental; the patient was a primi- 
gravida, toxaemic symptoms had been present for some months and 
the placenta was extensively diseased. In the case of a second 
patient, a vi-para, bleeding had been occurring intermittently for a 
month, and more or less continuously for a week prior to admission. 
On admission to hospital the os was almost fully dilated and com- 
pletely covered by placenta. The urine contained a trace of albumen. 
After delivery toxaemic symptoms developed and culminated in an 
eclamptic seizure thirty-six hours after the completion of labour. The 
patient died, and the diagnosis of eclampsia was confirmed at the 
autopsy. In the third case, the patient, a ii-para, had enjoyed perfect 
health until the onset of haemorrhage in the thirty-sixth week of 
pregnancy. This was followed by the development of a fulminating 
toxaemia, and before delivery was completed an eclamptic convulsion 
had occurred. After delivery the toxaemia rapidly subsided, and by 
the twelfth day of the puerperium the albumen had completely 
disappeared. 

Group IV. — In 25 cases the urine remained albumen-free 
throughout. 

67 



Douglas Miller 



In the complete series of 49 cases albuminuria was found 
in 22, a percentage of 44.9. In the consecutive series of 46 
cases, 19 patients — 41 per cent. — showed albumen. If one ex- 
cludes three cases in which toxaemic symptoms were present prior 
to the onset of haemorrhage, the incidence falls to 37 per cent. 
If one further excludes the five cases in which not more than a 
trace of albumen was at any time present, the percentage falls 
to 25.5 Even at its lowest estimate a 25.5 per cent, relative 
incidence of albuminuria in 49 cases of placenta praevia is 
suggestive, and must constitute a powerful argument in support 
of the thesis which Young has sought to establish. (No 
statistics similar to the above have, so far as I know, been 
published, so that it is impossible to say whether or not these 
ratios exceed the average findings.) 

The association of albuminuria with placenta praevia is 
admittedly less frequent, and the degree of toxaemia less 
conspicuous, than with accidental haemorrhage. In explanation 
of the relative infre.quency of toxaemia in placenta praevia the 
following considerations may be offered: (1) For the pro- 
duction of a moderate degree of toxaemia it is probably 
necessary that a considerable extent of the placenta should 
undergo degeneration. Young has suggested that for an 
eclamptic seizure it is necessary that one-half or one-third of 
the placenta be infarcted. In the majority of cases of placenta 
praevia, however, the area of separated placenta is comparatively 
small and the resulting toxaemia correspondingly inconspicuous. 
For the same reason toxaemia in abortion or in extra-uterine 
pregnancy is seldom met with. (2) As compared with placental 
separation in accidental haemorrhage, the possible channels for 
the exit and absorption of toxic products in placenta praevia 
are comparatively limited. In the former, best exemplified 
for the present purpose in the retro-placental haematoma, the 
area of degeneration is completely surrounded with living 
placental tissue and a ready access into the systemic circulation 
of any toxic material is thus allowed. In placenta praevia, 
however, if one excepts the completely central variety, the 
separated portion is in more limited contact with healthy 
placenta, and the diffusion of poisonous material elaborated in 
the infarcted area is inevitably less free. In support of this 
explanation it is of interest to note that out of the 1 1 cases 
of central placenta praevia observed albuminuria was present 
in 5 (45 per cent), whereas out of the 32 lateral and marginal 

68 



Placenta Praevia and Albuminuric Toxaemias 

cases albumen was noted as present only in 11 (34 per cent.). 
(3) In the majority of cases of placenta praevia delivery is 
completed in a relatively short time after the first onset of 
bleeding. Only when a sufficient interval of time elapses to 
allow of the evolvement of degenerative processes in the 
placenta can evidence of toxaemia be expected. In this 
connection it may be noted that in those cases in which the 
urine remained albumen-free the average time elapsing between 
the first haemorrhage and the completion of delivery was 
approximately eighteen hours, whereas in the albumen-positive 
cases the average interval was approximately thirty-two hours. 

Young has shown, one believes conclusively, that placental 
infarction is dependent on some interference with the maternal 
blood supply to the organ. While not strictly germane to the 
association of placenta praevia and toxaemia with which this 
paper is primarily concerned, it is of interest, in conclusion, to 
refer briefly to a group of recent observations which appear 
to shed light on the pathogenesis of infarction where its pro- 
duction is, as in the majority of cases of albuminuric toxaemia, 
less obvious than such a mechanical interference with maternal 
blood supply as occurs in accidental haemorrhage and placenta 
praevia. Young has suggested that in the absence of placental 
detachment a thrombosis in the decidual vessels may constitute 
the impairment of maternal blood supply responsible for the 
development of infarction. In this connection the recent 
writings of Stroganoff, La Vake, Mosher, and Talbot assume 
a special interest. These observers have directed attention to 
the frequent association of chronic sepsis with albuminuric and 
eclamptic toxaemia, and, impressed with its genus epidemicus, 
its prevalence in populous centres, the accompanying fever and 
leucocytosis, and the relative immunity conferred by one attack, 
have sought to establish a bacterial hypothesis. In a con- 
secutive series of 97 cases Talbot found that a septic focus 
in teeth, gums, or elsewhere was present in all cases without 
exception. La Vake has reported similar findings in a series 
of 13 cases. While the interpretation of this association of 
chronic sepsis with albuminuria and eclampsia is not obvious, 
the occurrence of an infective thrombosis in the peripheral 
blood vessels in such conditions as rheumatic fever, measles, 
influenza, and pneumonia is not uncommon, and the inference 
suggests itself that in the decidual vessels, peculiarly prone to 
thrombosis as Goodall has shown them, clotting may occur as 
obst. 69 e 2 



Douglas Miller 



the result of a hematogenous infection and that infarction may- 
follow. Talbot mentions this as a possible mode of pro- 
duction of infarction, and while he attributes to the infarct no 
etiological relationship towards eclampsia, the temptation is 
strong to correlate his work with Young's, and to suggest 
that in albuminuric toxaemia, unaccompanied by antepartum 
haemorrhage, the sequence of events may be : a septic focus, 
an infective thrombosis in the maternal blood vessels of the 
placental site, infarction in those portions of the placenta thus 
deprived of their blood supply, and finally toxaemia from the 
absorption of autolytic products of disintegrating placenta. 



Discussion. 

The President {Professor B. P. Watson) said this communication 
of Dr Miller's is an abridged form of a much larger piece of work 
which he has recently done, and which the University has recognised 
by awarding him a Gold Medal for his thesis. Dr Miller is to be 
congratulated on putting so many of his facts into so small space. 
Many of us have previously discussed Dr Young's theory of eclampsia, 
and it is interesting to have an independent observer confirming its 
results in certain respects. It is good that we are having work done 
in Edinburgh which is directed towards confirming or refuting the 
theory which has been put forward by one of ourselves. I do not want 
to be hypercritical, but I do not think that we can accept albuminuria 
as the only indication, or as really a very important indication, of 
pregnancy toxaemia. There are other just as important physical signs, 
and I wonder if Dr Miller has any information in these cases with 
regard to blood pressure. He said that in cases of haemorrhage the 
blood pressure was naturally lower than normal. In the subsequent 
history of these patients was there any indication of blood pressure? 
In post-mortem examinations what were the characteristic changes 
in the liver in those cases ? Albuminuria may be due to many causes, 
and mere albuminuria does not mean necessarily a pregnancy toxaemia 
in the sense in which we ordinarily use the term. Whether that 
albuminuria is indicative of a true eclamptic toxaemia is quite another 
matter, and there is a great deal more work to be done along these 
lines before we can say that the albuminuria which we get in these 
cases of placenta praevia and accidental haemorrhage is due to the 
same cause as in true pre-eclamptic or eclamptic toxaemia. Albu- 
minuria is a mere side issue in eclamptic toxaemia. For these reasons 
I hope that both Dr Miller and Dr Young, either working in con- 
junction or separately, will continue this investigation. 

70 



Placenta Praevia and Albuminuric Toxaemias 

Dr Fordyce said — I congratulate Dr Miller on an exceedingly 
interesting paper. It certainly does seem strong confirmation of 
the theory of eclampsia that Dr Young has so ingeniously brought 
forward, although I have always had misgiving in accepting Dr 
Young's theory. Dr Miller has explained why in necrosis of a placenta 
in abortion, even up to the sixth month, one seldom meets with 
eclampsia. He says it is probably from the small amount of necrosis, 
although you do have necrotic placental tissue. Dr Miller's paper 
does make one believe that Dr Young's theory must be correct, though 
I always think that the thrombosis and the infarcts are probably 
secondary to the toxaemia which has already developed. 

Dr Johnstone said — I think Dr Miller's paper is of considerable 
importance, mainly because it brings forward a great deal of evidence. 
That evidence certainly can be regarded as confirmatory of Dr Young's 
theory in regard to eclampsia, although I daresay opponents of Dr 
Young's theory might plausibly interpret it in other ways. It is 
evidence, and yet more evidence that we must have before we can 
come to any conclusion as to the Tightness or wrongness of this theory. 
It is of importance also in that it is an endeavour to link up eclampsia 
with accidental haemorrhage and placenta praevia, because the more 
one looks into these things the more one is impressed with the 
probability that underlying them all there is some common factor. I 
would congratulate Dr Miller and ask one question — How do the 
changes found in the separated portion of the placenta in placenta 
praevia compare with the changes found in the placenta in eclampsia? 

Dr Steven said — I should like to ask one question, if Dr Miller 
can tell us what number of cases of albuminuric toxaemia there was 
in the hospital during the same period in which the condition of 
placenta praevia was not present? Is this paper based on the whole 
of the cases of albuminuric toxaemia, or only on those cases of 
albuminuric toxaemia in which placenta praevia was present? 

Dr Young said — I have listened with great interest to Dr Miller's 
paper, and of course I have been kept an courant with the investigation 
which he has been carrying out. I welcome the evidence he has 
brought forward to-night in support of the views I urged before this 
Society about ten years ago. At that time I showed that when a 
piece of placenta is separated from the uterine wall or from its 
maternal blood supply it undergoes rapid necrosis, and if the rest of 
the placenta remains attached to the uterus we have a mass of dead 
meat lying directly in the maternal circulation. It is evident that the 
only part of the body where this unique pathological process is possible 
is in the pregnant uterus. For a long time I have conceived the 
idea that in an ordinary case the factors responsible for this change 

7i 



Douglas Miller 



are very largely mechanical, and are very similar to the factors that 
are responsible during pregnancy for the swelling of the feet and legs 
and of the vulva, and for the distension of the veins often present in 
these regions. If, in addition to causing a stasis of the external iliac 
and vulvar veins, this factor can cause a stasis of the ovarian or 
uterine veins, we would at once have a back pressure operating on the 
uterine sinuses. One would have a process which might detach the 
placenta shutting off the blood supply, and a view of this sort 
accounts for all the changes which are associated with the phenomenon. 
This pressure acting on the relatively slack multiparous uterus would 
tend to cause a haemorrhage with placental separation, which, when 
extensive, would end rapidly in labour, and under these circumstances 
we would expect either no toxaemia or only a transient albuminuria. 
On the other hand, where the placenta is partially separated and is 
retained in the uterus after its separation, one should expect intense 
toxaemia. This accords with the clinical fact that in concealed 
accidental haemorrhage one invariably finds intense toxaemia. It has 
always been a surprise to me that this striking clinical fact has not 
before impressed itself more forcibly on the obstetrical mind. In it, 
I believe, lies the secret of the whole eclamptic phenomenon. The 
same back pressure operating in the uterus of a primigravida would 
tend less to massive separation by haemorrhage and more to stasis 
and thrombosis. Dr Johnstone has indicated the fact that Dr Miller's 
views link up placenta praevia, accidental haemorrhage, and eclampsia. 
I think that the last two are simply manifestations of the same 
sequence of events operating in differing degrees. The fact that we 
do get the tendency to toxaemia in placenta praevia is a very strong 
confirmation that we are dealing with a process which is throughout 
largely mechanical in its origin. 

In reply, Dr Miller said — The rarity of toxaemia in abortion and in 
extra-uterine pregnancy is probably to be explained by the limited 
extent of placental necrosis met with in these conditions as compared 
with the average full-time eclamptic placenta. On the other hand, 
instances of the combination of extra-uterine pregnancy and eclampsia 
have been recorded; Ebehr, in a review of the literature of fifty cases 
of eclampsia in early pregnancy, mentions three cases in which the 
gestation was extra-uterine. 

With regard to Dr Johnstone's question — Where in placenta 
praevia delivery is sufficiently long delayed to allow of the occurrence 
of infarction in the separated portion, the appearances, naked-eye and 
microscopic, correspond in every particular with those found in the 
recent red infarct commonly encountered in the eclamptic placenta. 

In reply to Dr Steven, I am sorry I cannot give the total number of 
albuminuric patients treated in the hospital during the course of the 

72 



Veratrone 

investigation ; this was concerned solely with cases of placenta prsevia, 
its object being to determine the incidence of albuminuria in this 
condition. 

With regard to Prof. Watson's criticism, the degree of anaemia 
present in the majority of cases greatly diminished the value of the 
blood pressure record as an index of toxaemia. In a considerable 
proportion, however, in which albumen was present in more than a 
trace the diastase reaction suggested strongly that one was dealing with 
a true toxaemia. 



VERATRONE— WITH SPECIAL REFERENCE TO 
A CASE OF SEVERE REACTION. 

By A. E. CHISHOLM, F.R.C.S. Ed., Assistant to Obstetrical and 
Gynecological Department, Royal Infirmary, Dundee. 

VERATRONE is prepared from veratrum viride. It is described 
as being an aseptic, non-alcoholic, physiologically standardised 
preparation. Each cubic centimetre represents 0-25 gram, of 
the drug. It is standardised to a definite degree of activity by 
physiological tests. It contains a small proportion of chloretone, 
which acts as a preservative. The patient should always be 
kept in the recumbent position when this drug is employed. 
It is suitable both for hypodermic and for oral administration, 
the former method leading to more prompt physiological action 
than the latter. The dose is stated to be 0-5 to i-o c.c. hypo- 
dermically, followed at short intervals by doses of 0-25 c.c, 
until the pulse rate is reduced to nearly normal. It is further 
stated by the makers, Messrs Parke, Davis & Co., that it 
brings down temperature and causes diaphoresis and diuresis, 
also that it tends to control convulsions and to eliminate the 
toxic materials to which they are due. It is also stated that 
the fall in pulse rate may be so rapid that it may cause some 
alarm, in which case a hypodermic injection of strychnine may 
be given. 

Jardine, 1 in referring to cases of eclampsia treated by 
veratrone, mentions a case of such severe depression that 
gr. 1/30 of strychnine had to be given. The patient quickly 
rallied, but she was insane for two days. This latter condition 
may have been quite independent of the veratrone. Another 
patient of his looked like dying after the administration of 
veratrone, but she revived on receiving gr. 1/30 of strychnine. 

73 



A. E. Chisholm 

That an alarming state of affairs may follow rapidly on 
the administration of an official dose is well illustrated by the 
following case : — 

Mrs C, aged 36. Sexual History. — Miscarriage in 1920 at 3 to 3J 
months; miscarriage in 192 1 at 3 to 3^ months; miscarriage in May 
1922 at 5^ months. There was a history of the patient having been 
treated for syphilis in the past. 

She was admitted to a Nursing Home on 24th September 1923 
when I first saw her. Up to a fortnight before this she had felt well, 
but then she began to be troubled with pain in the region of the 
umbilicus, headache, and dimness of vision. Mentally she was quite 
bright, with no evidence of drowsiness. The urine was plentiful and 
the bowels moved well. She had had some tendency to diarrhoea, but 
this was probably due to the saline treatment she had been receiving. 
There was no oedema of the legs, but there was slight oedema of the 
abdominal wall. The face was pale and rather puffy-looking. A few 
days before admission to the Home there had been a sort of twitching 
attack, but the nature of this is not clear and there had been no 
true fit. 

The pulse at midday was 130. Blood pressure at 4 p.m. 200. 
Urine loaded with albumen. Foetal heart sounds not heard. The 
blood pressure being so high, and vision being so markedly affected, 
along with the improbability of a living child being carried to full 
term, it was decided that labour should be induced. An arrangement 
was made with the private doctor (Dr Anton) to meet me at a given 
hour in the evening in order that this procedure might be carried 
out. I advised that 1 c.c. of veratrone should be given. I gave the 
injection myself and can vouch for the fact that the dose was correct. 
This was at 4.30 p.m. on 24th September 1923. 

In about half an hour there was some vomiting and the bowels 
moved. Shortly after that the patient became comatose and extremely 
restless. The pulse fell markedly and the blood pressure fell to 50 
or less. 

At 5.15 p.m. gr. 1/100 of digitalin was injected. 

At 6.15 p.m. the bowels moved and there was some vomiting, and 
the patient spoke intelligibly. 

By 6.45 p.m. she was unconscious again, the pulse was 72, but 
of better, although still of poor, quality. 

At 8 p.m. 1 c.c. of camphor in oil was injected. 

The patient was still unconscious and very restless. The restless- 
ness took almost a violent form, all four limbs being employed, and a 
nurse was busily engaged all the time in keeping her covered. There 
was no evidence of air hunger. The association of low blood pressure 
and weak pulse with violent muscular exertion is difficult to explain. 

74 



Veratrone 

At 9.5 p.m. and again at 9.25 p.m. \ c.c. of pituitrin was given. 

The pulse improved in character but the unconsciousness persisted, 
and there was occasional dark vomit. The patient was hypersensitive 
to needle prick, and the corneal reflex was active. The pupils were 
moderately dilated. 

At 9.30 p.m. gr. 1/12 of heroin was injected. Prior to this 
urine had been passed involuntarily. The patient was still restless 
and unconscious, although perhaps less deeply so than before. On 
the whole she seemed a little better, and anxiety was slightly relieved. 
She was not in a condition for active manipulations such as induction 
would necessitate. Such a procedure would have been difficult and 
perhaps dangerous on account of the still somewhat violent restless- 
ness, nor did we feel tempted to give her a general anaesthetic at 
that time. 

The restlessness continued till about 1 a.m. (25th September), 
when the patient spoke rather incoherently. After that she slept well. 

By 10 a.m. the blood pressure was 200. Shortly before that 12 oz. 
of urine had been drawn off. The patient spoke intelligibly and the 
vision seemed rather better, but was still much blurred. Faces could 
not be recognised. 

At 10.20 a.m. a little chloroform was given, and labour was 
induced by drawing off a moderate amount of liquor amnii through 
a silver male catheter. By evening there was a marked improvement 
in sight and in the severity of the headache, as well as in the general 
condition. 

Urine was passed frequently and apparently involuntarily. This 
may have been due to descent of the fcetus. 

By 10 p.m. labour pains had commenced and continued all night. 

By morning (26th September) much urine had collected in the 
bladder, there having been some retention, no less than 60 ozs. being 
drawn off. The general condition had much improved. 

At 1 p.m. a dead, premature male baby was born. The head 
was rather soft, but there was no maceration. There was no trouble 
with the placenta. Chloroform was given during delivery. During 
the afternoon there was fairly free loss of blood, but the uterus was 
not flabby. 

There was still retention of urine by next day (27th September), 
but there was no lack of it. The pulse was rapid. The patient felt 
better, sight had improved, and she was quite intelligent. Blood 
pressure in the evening was 160. 

Retention of urine persisted on 28th and 29th September. 
Albumen was moderate in amount and granular casts were seen. 
No quantitative albumen test was carried out. Urine was plentiful, 
over 100 ozs. being excreted in twenty-four hours. 

75 



A. E. Chisholm 

Blood pressure 160. Amaurosis still present although less marked 
than formerly. 

Records show that blood pressure varied for several days from 
135 to 160. The albuminuria varied from moderate to much 
albumen, the latter record applying to a catheter specimen taken on 
4th October. 

The general condition as well as the vision markedly improved, 
and the patient returned home on 8th October. 

By 19th November there was still a little albumen in the urine, 
the general condition was good, and the eyesight only slightly 
affected. The last report I had of the blood pressure was received 
by telephone on 21st December 1923. It was then 170. 

On the evening of 24th September, after the veratrone had been 
given, the pulse is recorded as being 68. This is not what could be 
called a very slow pulse, but it denoted a considerable drop when one 
considers that it had been 130 at mid-day. 

Soon, however, the pulse rose, and the record shows that it 
remained rather rapid for a good many days, ranging from 88 to 
112. From 10th October onwards it became more nearly normal in 
frequency. 

A report on the condition of the urine sent to me by Dr Hynd 
of the Clinical Institute, St Andrews, reads as follows : — 

Specimen of Urine, 21/2/24. 

"The only abnormality detected was a slight trace of protein. 
The specific gravity was not low and I could detect nothing unusual 
in the deposit, but this was difficult to examine as the toluene in 
this particular case could not be easily got rid of and remained 
emulsified. 

"I rather think this has been a proper 'eclampsia,' and the 
albuminuria — now slight — will in time clear up." 

It is impossible to say if the patient was in a pre-eclamptic state 
or not. The persistence of albumen in the urine rather suggests 
that she may have had kidney trouble for some time before, and 
the fact of her having had syphilis may account for some of her 
reactions. 

The dose of veratrone given was that advised for a blood 
pressure of over 190. I do not think there should be any more 
risk in giving this drug when no eclampsia is present than when it is 
definitely established. The indication, it would seem, is the high 
blood pressure. 

I look on this as a case of special susceptibility to the drug. 
It has been given frequently of late in the Maternity Hospital 
at Dundee with no untoward results as in the case here recorded. 

76 



Veratrone 

The temperature on the morning and evening chart only 
once reached 99 ° F., and, on the whole, it tended to be rather 
subnormal. The phenomenon of violence duringunconsciousness 
combined with a very low blood pressure and acute cutaneous 
and corneal sensibility might be commented on. The move- 
ments were not convulsive and there was no appearance of 
air hunger. 

The drug is contra-indicated in all cases characterised by 
depression, valvular cardiac lesions, dilated or fatty heart, or 
when vomiting, were it to occur, might be dangerous. A 
contra-indication mentioned in the manufacturers' leaflet is 
the presence of kidney disease. But this is difficult to be sure 
of if one does not know the past history of the patient from that 
point of view, and when the urine is loaded with albumen in cases 
of threatened or actual eclampsia. Also, it is an emergency drug 
and much investigation is not usually possible. 

Fothergill, 2 quoting Macpherson, indicates that veratrone 
given in considerable doses ante-partum, and followed by a 
good deal of bleeding during or after delivery, may endanger 
the patient's life from too great a drop in blood pressure. In 
my case recovery of blood pressure had taken place long before 
labour had even commenced. 

I wrote to the manufacturers to ask for any further informa- 
tion they might be able to let me have, and I received a very 
courteous and interesting reply, some of the points being noted 
below. 

Veratrone is prepared from veratrum viride, a North- 
American plant. The chief alkaloids in veratrum viride are 
jervine, veratrine, and veratroidine. There are also others. 
Veratrone is quarter the strength of the fluid extract which is 
standardised to contain 1 per cent, of the alkaloids. Veratrum 
album (white hellebore) is a similar plant to veratrum viride, 
but has certain differences in the proportions, as in the kinds, 
of the contained alkaloids. It tends to be more irritant than 
veratrum viride, leading in overdoses to more severe abdominal 
pain and diarrhoea, with a greater tendency to a fatal issue. 3 

In their letter they state that experimental work with 
veratrone on the circulatory and respiratory systems shows that 
the conclusions to be drawn are : 1. That small therapeutic doses 
slow down and deepen the respiration, decrease the pulse rate, 
and produce a fall in blood pressure. 2. That toxic doses first 
of all produce momentary stimulation of the respiratory centre, 

77 



A. E. Chisholm 

resulting in a few quick gasps, followed by respiratory paralysis 
and death from asphyxia. 

R.J. Collins 4 recounts some experimental work which he 
did with veratrum. He states that slowing of the heart is 
chiefly due to stimulation of the vagus centre. Toxic doses 
act by an exaggerated action on the vagus leading to marked 
slowing and irregularity of the heart's action. This slowing 
may be followed by sudden extreme acceleration and rise of 
blood pressure (partly asphyxial and partly spasmodic). This 
rise may last for several minutes, succeeded by a rapid and 
progressive fall ending in death. 

Other signs of toxicity are profuse sweating, nausea, followed 
quickly by vomiting, diarrhoea, dysphagia, paralysis, light con- 
vulsions — these results being noticed in experimental animals. 

He found that in dealing with human beings fullness and 
throbbing in the head were noticed when the pulse rate reached 
its minimum. This effect was noticed after the administration 
of veratrum album. 

Veratrone only differs essentially from other preparations 
of veratrum viride in that, its strength being uniform, its action 
is fairly certain, as well as in the fact that it causes less incon- 
venience to the patient because of the elimination from it of 
irritating and inert substances. Also it is a sterile preparation. 
Its use is chiefly for the reduction of blood pressure, and as a 
rule it is employed for that condition in eclampsia. Of its 
usefulness, as of its powerfulness, there can be no doubt. Its 
action is rapid and must be closely watched. 

Fothergill 5 writes, apparently quoting from another worker, 
that the administration of veratrum viride is usually accom- 
panied by nausea, retching, and leaking of the skin — an acute 
diaphoresis — in itself a desirable result. He states that a diffuse 
diuresis follows in from two to four hours after administration 
of the drug, and that in presence of complete suspension of 
urine, for from twenty-four to thirty-six hours veratrum viride, 
if given in doses of from 5 to 1 5 minims of the pharmacopceial 
fluid extract, will always induce a very copious diuresis, as much 
as 2 quarts or more of urine being voided in from two to four 
hours. In my case there was diuresis following. This would 
appear to be a common sequence in cases of eclampsia quite 
apart from any special treatment. The control of convulsions 
as well as the elimination of toxines is claimed for the drug. 
Glendinning, 6 referring to Haultain's further experiences in 

78 



Veratrone 

the use of veratrone, states that the fits were inhibited in every 
instance, that is in \"J cases of eclampsia or pre-eclampsia. In 
this series i c.c. of veratrone was given and the blood pressure 
noted. If the blood pressure rose again to 160 or more, \ c.c. 
was at once given. In this series, too, the actions chiefly noted 
were marked and rapid fall of blood pressure, lasting usually but 
a few hours, associated with slowing of the pulse, increase of 
urinary secretion, diaphoresis, and, in a few instances, vomiting, 
especially when the pulse rate fell below 50 per minute. It is 
possible, too, that the veratrone may have a further action in the 
nature of an antidote to the eclampsia poison — this at least is 
suggested — for in subsequent rises of blood pressure fits are said 
seldom to occur. This last statement, however, seems to be 
rather at variance with Haultain's earlier experience as 
recounted before in the Transactions of this Society. 7 

In this earlier series of seven cases all the patients were 
eclamptics and treatment by veratrone for high blood pressure 
was very successful. But there was a tendency for fits to recur 
as the blood pressure rose again to about or above 150, after 
an initial dose had been given. Haultain held that the high 
vascular tension had much to do with the convulsive seizures 
and that the lowering of it was in itself an important part 
of the treatment. (See cases 3, 6, and 7 of the series.) He 
thought that a pulse of 60 or below indicated a blood pressure 
consistent with safety, and that a pulse of 50 was well within 
the safety limit. I think that this is perhaps putting it too 
definitely, for it would seem likely that a rapid fall from a very 
high speed to a very low speed may be dangerous, while a more 
gradual or a slow fall between the same limits of frequency may 
be without prejudice. 

Lackie quoted a case, at the same meeting, which he had 
seen in consultation. After taking veratrum viride for a week 
this patient began to take fainting turns every few hours. 
She recovered under strychnine, and went into labour without 
eclampsia. 

Pouchet 8 describes certain experiments with veratrine in 
serial doses on dogs. At first the cardiac contractions were 
increased in number with diminished amplitude, later the)' 
were reduced in number but with augmented amplitude, later 
still there were some intermittences. Blood pressure fell lower 
and lower till it reached almost to zero, whilst respiration 
became accelerated and later was reduced in frequency, taking 

79 



A. E. Chisholm 

on a convulsive or precipitate type, dyspnoea being marked 
and the range of respiration being superficial, until it was 
ultimately suspended altogether. 

H. C. Wood 3 thus summarises the action of veratrum 
viride : — 

" Veratrum viride has no distinct local action, yields readily 
its active principles to absorption and probably to elimination, 
though concerning its fate in the system we have no definite 
information. The free sweating which accompanies its marked 
action may be simply the result of a profound arterial depression, 
there being no proof that the drug exerts a specific influence 
upon the glands of the skin. Similarly the excessive secretion 
of bile which it sometimes induces may be a secondary result 
due to the severe vomiting. 

" By the depressing action of jervine upon the heart muscle 
and upon the vaso-motor centres, veratrum viride lowers the 
arterial pressure, in the beginning slowing the pulse by a direct 
influence of jervine upon the heart muscle and by the stimu- 
lating influence of veratroidine upon the pneumogastric nerve, 
but later increasing the rapidity of the pulse by paralysing the 
pneumogastric nerve (veratroidine), and probably also by some 
action upon the heart muscle (jervine). 

" Chiefly, if not solely, through a centric influence, it 
causes violent vomiting, and, in rare cases, when there is in it 
an excess of veratroidine, purging. On the motor side of 
the spinal cord it acts as a powerful depressant, but is 
without influence upon the cerebrum, the motor nerves, and 
the muscles. Probably, on account of the vaso-motor paralysis 
which it produces, favouring an increase of heat dissipation, it 
decidedly lowers animal temperature, a fall of as much as four 
or even more degrees sometimes occurring in the poisoned 
lower animals before death." 

References. — l Jardine, Brit. Med. Journ., 17th January, vol. xiv., 
p. 141. 2 Fothergill, Med. Annual, 1919, p. 136. 3 H. C. Wood, 
Therapeutics : Its Principles and Practice, 1905. 4 R. J. Collins, Archives 
of International Medicine^ July 191 5, vol. xvi., pp. 54-58. 5 Fothergill, 
Med. Annual, 1918, p. 454. (i Glendinning, Med. Annual, 1916, p. 468. 
7 Haultain, Trans. Edin. Obst. Soc, 19 12-13, vol. xxxviii., p. 306. 8 Pouchet, 
Lecons de Pharmocodynamie et de Maticre Medicate, pp. 725-728. 



80 



SOME OBSERVATIONS ON SEVENTY YEARS 
OF COUNTRY MIDWIFERY PRACTICE. 

By C. E. DOUGLAS, M.D., F.R.C.S.E., Cupar-Fife. 

The communication which I venture to bring before you this 
evening has three objectives in view. First, to examine the 
statement frequently made and supported by statistics, that 
puerperal mortality is as high to-day as it was seventy years 
ago ; second, to question the opinion, also widely held, that 
the bulk of this mortality is the result of instrumental and 
other interference with the course of labour ; and third, to 
suggest that this matter of puerperal mortality might profitably 
be examined from a somewhat new standpoint to which I will 
finally direct your attention. 

The material from which any conclusions arrived at are 
drawn is the experience gained in a mixed small town and 
country practice from the end of " the forties " till the present 
day, of cases in all classes of society, from those in the county 
houses around to the tramps in the lodging-houses. Needless 
to say they are not the experience of one man. But they 
cover a period of obstetric history of more importance than 
any (if we except that of the epoch-making invention of the 
Chamberlen forceps), a period which began before chloroform 
was generally used in obstetrics, before Oliver Wendell Holmes' 
pronouncement had taken the ear of Europe, and when anti- 
septics were undreamed of. They fall naturally into three 
series, one embracing the " fifties " and a little more ; another 
beginning with my early days from 1880 into the "nineties"; 
and the rest up to a recent period. I shall give you the figures 
upon which the positions I wish to take up are based ; I shall 
then describe the development of our science in one or two 
directions ; and, finally, shall lead up to my main endeavour, 
namely, to establish the rule that the parous woman, ipso facto, 
is apt to die. 

I. 

Now, as regards the statement that the mortality of to-day 
is no better than that of old times, hear the two following pro- 
nouncements. Dr Ewan J. Maclean x says : " Taking a quin- 
quennial period of seventy years ago, the puerperal death-rate 
from all causes was 4.9 per 1000 as compared with 4.2 
obst. 81 F 



C. E. Douglas 



sixteen years ago, and deaths from puerperal fever account 
for 50 per cent, of them." 

Your former President, Dr F. W. N. Haultain, 2 says : " The 
mortality from puerperal causes in Scotland is as high as it 
was fifty years ago, viz., about 5 per 1000, or I in 200 cases." 
But, before we take statements such as these at their face value, 
we might usefully consider the authority on which they are 
based — that is the parish registers of the time. Registration 
in its present form was hardly known. In England, indeed, 
while there had been church registers since the middle of the 
sixteenth century, the State only took over the business of 
registration of births and deaths in 1836, and it was not until 
1874 tnat either became compulsory. In Scotland, the corre- 
sponding date was 1854, and we may be sure that anything 
like accuracy would be the growth of some years at the 
very least. 

Be that as it may, I have some figures in my possession 
which tend to show that the belief that the maternal mortality 
was as low then as now is erroneous, and that on the contrary 
it was considerably higher. I have the midwifery case-book of 
my predecessor in this practice, a practice taking in all kinds 
of patients, principally the wives of agricultural workers, a strong, 
healthy body of women, with practically never a rickety pelvis. 
He and his brother were in practice together from the end of 
1847 to 1864, when the book ends. There are in it the names 
of 936 cases. Of these only 6 or 7 per cent, required interfer- 
ence, so that 93 per cent, were normal cases. The abnormal 
cases are shown in the Table. They correspond in frequency 
very much as at present, but have some points of difference 
which bear on the subject-matter of this paper. Thus, we note 
that they are very " modern " in three respects, the low pro- 
portion of forceps cases, only 21 in the whole series, or 1 in 
44, or 2.2 per cent., the small number of versions, only two, 
both in placenta prasvia, and the practice of craniotomy. There 
is a very large proportion, 93 per cent, in which no operative 
interference is reported ; and lastly, and most importantly, 
there is a very high maternal mortality of which four-fifths 
are in non-operative cases. Twenty maternal deaths in 936 
cases means a mortality of 21 per 1000. In only four of 
these is any operative action noted — one a forceps case, one 
a breech, one a case of twins, and one a retained placenta, 
which died on the twenty-fourth day, probably then a septic 

82 



Seventy Years Country Midwifery Practice 

case. In the other 16 cases no operation was reported, and 
we may infer that they died either from sepsis, or what was 
much more common in those days, from exhaustion in a day 
or two. We are accustomed to read of such cases even in 
the general literature of the period. It is needless to say how 
accurate an observer was Charles Dickens, and the death of 
Mrs Dombey is probably typical of many cases of the time. 
But from whatever cause, twenty mothers died in this practice 
in sixteen years. This is so much at variance with modern 
experience that I approached the Registrar-General for Scotland, 
giving him the names and addresses and dates. He very kindly 
had a search made for me, and though unable to trace my cases 
he gave me names of eleven other women who had died in 
child-bed in Cupar in the years from 1847 to 1854. These 
may be taken as having occurred in the practices of the other 
doctors and midwives in Cupar at the time, and they go to 
confirm the impression that at that time there was a consider- 
ably higher mortality amongst women than at the present day. 
To form a correct appreciation of the situation in those 
years we should have a clear idea of the state of knowledge 
and the rules of practice laid down by teachers at that time. 
Take, for example, the Practical Observations of James Hamilton, 
Professor of Midwifery in Edinburgh, published in 1836. It is 
true that my predecessors qualified in 1845 and 1848; but 
James Y. Simpson had only recently succeeded Hamilton in 
the Chair ; they were students of the College, not of the 
University ; and I know of no work published after Hamilton 
that would be likely to have been an authority to them. 
Hamilton's teaching was then dominant. Let us see what 
it consisted of. 

A tedious first stage was treated by venesection in the 
first instance, followed by "an opiate enema"; if this did not 
suffice, the os was dilated manually. The second stage was 
mainly concerned with support of the perineum, for hours 
if need be — he mentions having done this for twelve hours 
without leaving the patient — and " fine lard," to the extent of 
a pound for a case, was used to lubricate the passage. The 
third stage was a still more extraordinary performance. You 
felt along the cord till you could reach the centre of the 
placenta, and if this could be done it was ready for extraction. 
Twisting the cord round the fingers of the right hand you 
pulled on it till it came away, again supporting the perineum 

83 



C. E. Douglas 



with the left hand. If the placenta were retained for more 
than an hour it should be removed. (This appears to be an 
innovation on the practice of leaving it for a long time.) If 
adherent, the placenta is to be grasped by the examining hand, 
and " pressure is now to be made upon its substance, bringing 
its circumference towards its centre and detaching leisurely 
and carefully all that can be separated by this manipulation. 
The separated mass is to be extracted by pulling with the 
navel string." 3 

Simpson's teaching, it may be observed, is very similar. 4 

When we come to discuss the " forceps question," I shall 
have to quote again from this interesting writer ; but we may 
reasonably say that a system which deals with its tedious 
cases, not by operation but by venesection, opiate enemata, 
and manual dilatation without antiseptic precautions ; that 
lubricates the passages with " fine lard " ; and that pulls out 
all its placentae by the " navel string " and removes adherent 
placentas by pulling at the centre in a " leisurely " manner, is 
not a system from which we could expect results comparable 
with those of modern methods. 

I now put beside this series another of cases occurring in 
the same area, which series I shall presently divide into two. 
These fell during the year 1880, when I began practice in 
Cupar, till 1923, and comprise 2200 cases in approximately 
1600 women. Of these cases 557 were abnormal in some way, 
being 26 per cent., leaving 74 per cent, of " normal " cases. 
The abnormalities were as follows : Forceps cases 393, being 
18 per cent., or 1 in 5-5 ; twins 28, or 1 in 78 ; pelvic and cross- 
births 35, or 1 in 62; placenta praevia 15, or 1 in 146; post- 
partum haemorrhage 11, or 1 in 200; retained placenta 40, or 
1 in 55 ; eclampsia 10, or 1 in 220; prolapse of cord 4, or 1 in 
550; accidental haemorrhage 8, or 1 in 275; monstrosities 11, 
or 1 in 200 ; brow 2, or 1 in 1 100, and one each of face presenta- 
tion and haematoma vulva. This shows a total of 557 cases, or 
26 per cent, in which interference of some kind was required as 
against 60, or 7 per cent, in the first series. 

The maternal deaths were 11 in number, being 5 per 1000. 
Of these, two were eclampsias ; one forceps case had mitral 
valvular disease with bronchitis and died suddenly on the 
fourth day ; one forceps case was sent to Dundee by my locum 
tenens, and was delivered there, but died two days afterwards 
from exhaustion ; one normal labour was a case of advanced 

84 



Seventy Years Country Midwifery Practice 

phthisis, who died ten days after confinement ; one forceps case 
died of sepsis ; and five normal labours died of sepsis. There 
were then six deaths from sepsis, or 2-7 per 1000 of the 
whole. This is so important a part of my argument that I 
must put in a short note of each case. 

No. 72. — Mrs M., iii-para. Quite normal labour. Had a 
rigor on the seventh day and died on the sixteenth day. 

No. 306. — Mrs W., iii-para. Easy labour. Placenta delayed 
in passage and needed help with two fingers in the vagina. Six 
days afterwards had a slight temperature, never going very high 
till the end, but persistent. Was seen by an Edinburgh specialist, 
who ordered sublimate douching, intra-uterine ; died on the 
sixteenth day. 

No. 454. — Mrs T., iii-para. Was a forceps case on account 
of weak pains. Did well, but developed the usual symptoms 
and died. In this case we found afterwards that the "handy 
wife," a very good woman, but ignorant, had been helping to 
nurse some scarlet fever cases in the same block of buildings. 
This of course was many years ago, in 1891. 

No. 549 was under charge of my locum tenens while I 
was on holiday, and I got no particulars, except that it was 
an easy labour. 

It will be observed that these cases were all in the first 
550 cases of the series, the latest being in 1891, only one being 
an operation case. This group, being exactly one-quarter of 
my experience, I put in one series, as against the rest, being 
three-quarters. In this latest three-quarters there are only two 
septic deaths, neither being an operation case, as follows : — 

No. 1 541. — Mrs B., iii-para. Had quite an easy labour, 
being only once examined, with the usual precautions. The 
cottage was unusually insanitary, having stood empty for a long 
time and being very damp. On the fourth day she had a rigor 
and eventually died. I found that the infant was suffering 
from erysipelas of the cord which had been going on for some 
days, the old woman in charge not thinking fit to report it to 
me. They both died. 

No. 2065. — Mrs M., i-para. This case is of special interest 
as it seemed so entirely normal. She was examined once under 
the most strict precautions to ascertain the condition of the os, 
which dilated quickly. The membranes were unusually tough 
and were ruptured on the perineum, after which birth took 
place without the slightest perineal tear, the most intact perineum 
obst. 85 f 2 



C. E. Douglas 



I have seen. She made an uneventful recovery, and on the 
ninth day was out in the garden when she had a chilly feeling 
and I was sent for. The temperature was 104 F. No pain nor 
interference with milk or lochia. Beyond slight pain in the left 
flank no local symptoms whatever. No examination was made. 
Quinine was given, and the temperature went down on the 
eleventh day for twenty-four hours when it rose again. Still 
no local symptoms. She was now seen by a Dundee specialist 
who examined her, thought the right tube was tender and 
diagnosed a pyosalpinx. Blood culture showed a few micrococci. 
There being no indication for local treatment, she had vaccines, 
both stock, and then autogenous, phylaccogen, stimulants, and 
everything. She died on the thirtieth day after confinement. 

Grouping now the three periods, the series of the " fifties," 
when no idea of infection was dreamed of, the second, in the 
" eighties," when it was perceived to have a bearing on obstetrics, 
and the modern period, when antisepsis is carefully carried out. 
we have as results on the maternal mortality : — 

First period 936 cases, gross mortality 21 per 1000, non- 
operative 17 per 1000; second period 550 cases, gross mortality 
10 per 1000, septic 7-2 per 1000; third period 1670 cases, gross 
mortality $-6 per 1000, septic \-J per 1000. These figures, 
I submit, favour my contention that the mortality, seventy or 
fifty years ago, was much more than is commonly believed. 
A priori it was to be expected that improvement should 
take place. The state of knowledge in the first period was 
so different that it would be very extraordinary if we could 
do no better than those so handicapped by ignorance. The 
second period, again, w r as one in which antiseptics, as applied 
to obstetrics, were only in their infancy. This may be illus- 
trated by reference to the literature of the time. Take Robert 
Barnes, 5 for instance. His work is one which even now may be 
read with profit, e.g. his chapters on podalic version. But his 
list of " instruments and accessories in order to be prepared for 
all emergencies" includes nothing antiseptic but permanganate 
of potash — " 5i of the permanganate in §x of water makes 
the ' antiseptic injection ' to be injected through the uterus 
after labour to counteract septicaemia." His directions for 
transport are really worth reproducing, giving the light they 
do upon the current ideas in 1871 : — 

" The most convenient mode of packing these things is to 
adapt a travelling leather bag. There is always spare room 

86 



Seventy Years Country Midwifery Practice 

for anything likely to be wanted besides its ordinary furniture 
or for bringing away a pathological specimen ; and by turning 
out the obstetric furniture you have a travelling bag again." 

My own recollection is to the same effect. In the seventies, 
even in Edinburgh, we were not taught to apply the antiseptic 
method in obstetrics. I well remember our friend, the Emeritus 
Professor of Clinical Surgery, then clerking with Lister, dis- 
cussing the future of the antiseptic system, and predicting that 
one day we should have to apply it in midwifery ; whereupon 
much hilarity prevailed at the idea of spraying the perineum. 
Remember that in those days the air was believed to be the 
principal source of danger, hence the spray. 

The early cases of the series then were treated on the 
most elementary lines of antisepsis. A pair of wooden-handled 
Simpson forceps, a bottle of ergot, another of carbolic acid, and 
some carbolic oil as a lubricant, were the usual accompaniments 
to a case. The instrument makers used to sell a handy case 
containing two bottles, one for ergot, one for oil, a g.e. catheter, 
a pair of scissors, and some needles with a bobbin of silver wire : 
and there you were. Let us here contrast the modern ritual, 
for it is nothing else, to be performed (a) at an ordinary case, 
(b) before operation. 

At every case the external examination is made of the 
abdomen, to know the lie of the child and position of the foetal 
heart. Gloves are being boiled, while the hands are scrubbed 
as for a surgical operation. Nurse having given an enema to 
wash out the bowel, the perineum and vulva are well scrubbed 
by the doctor himself, the soap used being that liquid soap sold 
as " Sterilla," applied on a pledget of wool and rubbed to a 
good lather ; wiped off with pledgets of wool wrung out of 
lysol solution, always clearing away from the ostium towards 
the anus, not otherwise. The hands are again sterilised with 
Sterilla. The gloves are now emptied from the saucepan into 
a basin which has been scalded with boiling water. They are 
taken out thus. The left is chosen, emptied, and put on. It 
lifts out the right which is then put on, and both washed in the 
boiled water to which lysol or periodide has been added. The 
left hand then lifts the patient's right labium clear so that the 
ostium is well shown. Having decided how many fingers are 
to be inserted, these are passed into the vagina, taking care 
not to touch the labia on the way. The next finger must not 
be passed ; it has necessarily been pressed up against the anus, 

87 



C. E. Douglas 



and is not safe. The examination having been made, the 
gloves are washed in the solution and boiled again. 

If operation has been decided upon, in addition to the 
foregoing procedure, the bowel and bladder are emptied. The 
patient is placed in the required position, and chloroform is 
given till she is nearly " over," when nurse takes the towel. 
The perineal toilette is repeated. A clean tunic is put on, the 
hands are sterilised, the gloves, sterilised with the instruments 
in a steriliser, are put on, and the operation proceeded with. 

If, then, we consider the difference of treatment in these 
three periods, we must come to the a priori judgment that there 
should be some difference in the mortality results; and when 
we consider the figures I have given we may perhaps feel that 
a priori judgment is justified in point of fact and of experience, 
and that my first contention has some logical grounds of 
support, namely, that the puerperal mortality shows a pro- 
gressive improvement as the years go on. 

II. 

The second question which I wish to consider is the belief 
widely spread amongst gynaecologists, that much of the mortality, 
or morbidity, is due to operative interference. I shall deal with 
the morbidity question later on, but as to mortality, my series 
of cases points towards the view that mortality is relatively low 
in operation cases, and correspondingly high in "normal" cases, 
not subject to operation. In the first series, four fatal cases in 60 
operations is not surprising, considering the state of knowledge 
at the time, especially when there are in that series 16 cases 
of death where presumably no operation had taken place. In 
the second series, only one forceps case died of sepsis, and one 
from exhaustion in Dundee. True, the eclampsias and the 
heart case each had had forceps applied, but the deaths cannot 
be charged to the operation which in each case was performed 
to combat the greater peril. One septic death in 393 forceps 
cases is not an inordinate mortality, and there were no deaths 
in the other 164 operative procedures undertaken. 

There being thus one septic death in 557 operations, what 
is the figure for the "normal" cases? Taking 557 from the 
total of 2200, we have 1663 "normal" cases with five septic 
deaths, or one in 333 cases. Both series of cases, then, seem 
to bear out the belief held by most men in general practice that 

88 



Seventy Years Country Midwifery Practice 

sepsis occurs at least as often in cases where little or nothing 
has been done as in operation cases. Many would say that 
even fatal cases occur where the patient has not been touched 
by either nurse or doctor. I have had no fatalities, but one 
frequently has cases of " morbidity." 

Let me quote three : — 

(i) A tramp wife, in a common lodging-house, had a 
premature infant. She had it very rapidly, and all was over 
before I came on the scene. There was no nurse, so no one 
else could have touched her. She went through the usual 
course of a puerperal sepsis, but, having the constitution, tough 
as leather, of the tribe, she won through. (Oddly enough last 
year I had another of the same class in the same lodging- 
house. It was a cross-birth, and required version. She made 
an uneventful recovery). 

(2) Twenty-five years ago a young woman came home to 
her mother's house to have an illegitimate child. She had no 
difficulty, and I attended her, a quite normal case, not touched 
by either her mother or me. Yet that young woman came 
through the longest period of puerperal peritonitis I have ever 
seen. 

(3) Two years ago a woman in labour sent for the district 
nurse, who, seeing that she was progressing rapidly, sent for 
me. I arrived after the birth of the child. It was a simple 
case, and was touched by no one. On the fourth day she had 
a temperature of 102, with pain, tenderness, slight diarrhcea, etc. 
Seeing the temperature remained high, I explored the uterus 
under an anaesthetic. Finding nothing but a few shreds on the 
placental site, I washed out, touched up with carbolic, put in a 
drain, and she was normal in twenty-four hours. Such cases 
are constantly met with in practice, and suggest that not all 
cases of sepsis are caused from outside the body and that some 
other factor than conveyance of sepsis is present. 

Foetal Mortality. — The effect of forceps delivery upon foetal 
mortality is an important point which may be dealt with here. 

Of the 393 forceps cases, 192 were in primiparae with a 
fcetal mortality of 10 = 5-2 per cent. ; 201 were multiparas with 
6 deaths, or 2-9 per cent. ; being in all 16 deaths = 4-07 per cent. 
In all the operations, 557, there were 49 deaths = 8-6 per cent. ; 
these included all the deaths, such as the monstrosities, 
craniotomy, etc., details of which are in the Table. The total 

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C. E. Douglas 



deaths in non-operation cases were 32, or 1-9 per cent., these 
being chiefly premature births. The mortality over all was 81, 
being 3-8 per cent, of the whole. 

Morbidity. — Leaving now the question of mortality, let us 
consider the charge that is made with regard to morbidity. No 
need here to take up your time by quoting expressions of 
opinion in support of this. We must accept the statements 
made to the effect that cases of injury from forceps delivery 
are frequently met with in gynaecology. Dr Comyns Berkeley, 
in particular, may be taken as giving voice to this view. 13 
Evidence such as his cannot be denied its full weight. There 
is certainly a considerable amount of perhaps avoidable mischief 
done by interference in unsuitable cases, or by a less degree of 
skill than might be applied. Various explanations are given, 
the most common being that the teaching of midwifery does 
not include sufficient practical work. Most probably errors of 
judgment in selection of suitable cases and of the proper time 
for interference are at the bottom of the mischief. 

The use of forceps is believed to cause a large amount of 
morbidity. I have tried to follow up my forceps cases with the 
view of noting any adverse results. Of localised injur)' to the 
foetal head, cases were fairly frequent, but were temporary, 
leaving no after effects. I have had one cephalhematoma 
which did no permanent damage. Some have alleged that 
epilepsy, idiocy, or mental deficiency can be charged to the 
abuse of forceps. I have examined this from both sides, going 
over my forceps cases to find any that developed any of these 
nerve tendencies, and conversely getting the history of epileptics 
and idiots in my practice to see if forceps had been used at 
birth. Of the 393 forceps cases I can trace 119. I find in 
these 119 forceps cases two imbeciles. Both were rather 
microcephalic than otherwise, and needed forceps delivery on 
account of the mother's weakness. There are many women, 
of the Mrs Dombey type, who simply do not know how to 
bear children. What to others comes naturally, almost refiexly, 
they can make nothing of, and have to be helped both in the 
second and the third stages. One of the two was an elderly 
primipara with feeble pains and no idea of helping herself. The 
other had an interesting obstetric history. The wife of a wealthy 
banker in one of the European capitals, she was the daughter 
of a well-known Edinburgh family residing in a country house 
near us. She had had a very bad time with her first child, 

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Seventy Years Country Midwifery Practice 

abroad, and determined to come home for her next to her 
mother's house, and incidentally I had the care of her. Her 
labour was tedious, not from disproportion but from want of 
physical energy to deliver herself. Forceps were required and 
she made a good recovery. The child, a girl, did well, and is 
long since happily married. The next was the case in question, 
another forceps case, and a Mongolian imbecile, who died 
lately, aged 30 years. Two years afterwards she had a breech 
presentation, and finally two years after that a boy, also a 
forceps case, a healthy boy, who did his part and was grievously 
wounded in the Great War. This case illustrates the type 
which is so frequently the subject of forceps delivery, the weak 
woman of no physique, who just goes on making futile attempts 
to deliver herself, until one steps in and puts her through it. 
With all these five instrumental or operative interferences she 
was none the worse ; I had the care of her for years afterwards, 
and she never had any uterine trouble. 

Two women gave birth to children who developed epilepsy. 
Neither of these required forceps. On the other hand, of the 
119 cases, I find a very large number who in after life have 
done exceptionally well, probably on account of the large 
heads which necessitated the use of instruments. 

Then, again, there are the women well built and muscular 
who have some slight degree of the justo minor pelvis. Let 
me give you the history of one. She was a ploughman's wife 
and came to me at her third confinement. The two previous 
to this had been attended by one of whom you will approve. 
He told me once, with pardonable pride, that he had gone for 
ten years without applying the forceps. He had kept this 
woman without any help in two confinements, and she 
approached her third with fear and trembling. There was 
nothing wrong with her but a small pelvis, and I delivered 
her quite easily, much to her comfort and joy. Her next was 
also under my care, and I remember the gladness in her voice 
when I appeared. " Eh, doctor, that's richt. Come awa wi' 
yer gibbles ! " Her next was a normal case, all were delivered 
alive, and she never had any sign of uterine trouble of any sort. 
It must, of course, be remembered that the class of person met 
with in the country is very different from those in the poorer 
parts of Edinburgh, and particularly in Glasgow. We do not 
have rickety pelves, perhaps a " flat " pelvis very rarely, and this 
accounts for the comparatively good results that we can show. 

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Then with regard to maternal morbidity. This may be 
divided into that from sepsis, uterine displacement, and 
perineal injury. 

For a case of sepsis after forceps extraction I have searched 
my records. I can give only three cases, one a bad one. It 
was one of those very trying cases occurring in a primipara, 
with occipito-posterior presentation, a tough undilatable os, and 
powerful pains. This was about twenty years ago before the 
modern way of dealing with occipito-posterior presentations was 
generally known. Neither chloral hydrate nor chloroform having 
any effect on the os, it was dilated by hand until there was room 
to get at the head and apply the forceps. Delivery was then 
effected without much force being applied, and the child was 
born alive. But sepsis of a mild form set in. Before it was 
lessened she had to remove from their house, and she passed 
from my care to that of a colleague who told me that pelvic 
cellulitis had developed, and after about eighteen months she 
died. This case is my one regret in all my experience, and 
I learned much from it — this, namely, never to apply the 
forceps until the first stage is well over and the head engaged 
in the pelvis. 

Another was a rather old primipara in whom I had applied 
forceps for weak pains, and in whom I had to give help in 
removing the placenta, which was not retained, but rather lay 
in the vagina till someone would help it out. She had a mild 
septicaemia which stopped at once on being douched with weak 
lysol. The third was my first "failed forceps case," in 1887. 
As far as I can follow my cases, these are all the forceps cases 
which have gone septic. 

Post-operative sepsis in my experience is most commonly 
met with where we should naturally expect to find it, namely, 
in cases of retained or adherent placenta. 

Retained Placenta. — By this I mean a placenta which has 
remained within the uterus for an hour after delivery and has 
resisted attempts to remove it by pressure. I have had 40 
cases ; in these there was sepsis in seven, the others had no 
rise of temperature. There are a few points of interest in the 
experiences of these cases. Only 16 were retained placenta 
pure and simple. Of the rest, 12 were after forceps delivery, 
one was a placenta prsevia, one had a really bad post-partum 
haemorrhage, there were seven sepsis cases, and three were after 
anencephalous foetuses. Now there were seven anencephali in 

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Seventy Years Country Midwifery Practice 

my series, so that for three out of seven to be connected with 
retention of the placenta may indicate some connection between 
these morbid conditions. Two women had the condition twice 
each and both in consecutive pregnancies. The degree of 
severity varied much. Some occurred in that class of whom 
I have spoken before, the woman who cannot help herself, 
and cannot even get up strength to push the placenta out 
of the uterus, and there it lies until one withdraws it. Two 
of the worst sepsis cases occurred when only the membranes 
were adherent. One was a strong, healthy woman, living the 
active life of a farmer's wife. Her sixth confinement was the 
only one at all abnormal, as a brow presentation threatened. 
I managed to push it up and got down the occiput and she 
delivered herself all right, but the membranes did not come 
fully away. She was pretty worn out so I left her to nature. 
Sepsis developed. I washed out, but this did not stop it, and 
an Edinburgh specialist saw her. He repeated the clearing- 
out process and dosed her with phylaccogens, after which she 
began to improve and eventually got quite well, but has had 
no more babies. The other delivered herself of the placenta 
normally, but a large surface of membrane was very firmly 
adherent. She developed a septicaemia from a staphylococcal 
infection. This was in January 1897 when vaccine treatment 
of sepsis was just being discussed, and I published the case 
in the Edinburgh Medical Journal of that year. She has had 
no more children but is in good health. I think that, as a 
rule, few people have any more pregnancies after adherent 
placenta. 

For uterine displacements there is much the same report 
to make. I have one case under my care of a woman whom 
I delivered twenty-five years ago of her second child. The 
first had been a forceps case, as was the second, and ever since 
there had been a tendency to displacement, which within the 
last few years required a support. But again, on the other 
hand, I get cases of displacement in which no forceps had been 
used. Thus I have a case where the child turned out to be 
an epileptic and the mother has a prolapse. Here, surely, is 
a case for the prosecution. But on looking up my records I 
find that it was a perfectly normal case. Again, I had a very 
bad procidentia in an old woman who told me that thirty-three 
years before I had attended her in child-birth. Here, again, I 
went to my records. Another " normal " case. The procidentia 

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C. E. Douglas 



was caused by some calcareous fibroids, which were removed 
and she is now well. 

Similarly with perineal injury. The forceps cannot properly 
be blamed here. The worst cases of perineal tears are from 
midwives' cases of the old type. I have seen two complete 
tears into the rectum in such cases, one an aged woman who 
had many years ago been attended by a midwife. The ostium 
vaginas and the anus were in one with a slight partition, the 
anterior wall of the rectum coming down to about an inch from 
the orifice. The other was a woman whom I attended in 
labour and on examination could find no anus. The condition 
was the same as in the other case. She had complete control 
except for the passage of flatus. Two observations fall to be 
made. One, that far from the forceps being a cause of tears, 
if properly used, they often help to avoid them. To pull with 
forceps when the perineum is on the stretch during the height 
of the uterine systole is to court trouble, but if during the 
a-systolic period, when the soft parts are relaxed, we gently 
coax the head down, using our leverage to bring the occiput 
well forward, we can usually save the perineum completely. 
Another is, that if a tear is made, it behoves the accoucheur to 
see that it is mended. I had a case illustrating this the other 
day. My patient, under treatment for an acute diarrhoea, said 
that it was very difficult for her, as, since her last baby thirty- 
one years ago, she had never had proper control on account of 
a tear she had got then. Now I myself had attended her in her 
first confinement thirty-five years ago. She was then a fairly 
elderly primipara, needed forceps, and had a tear which was 
repaired at once. In her next two confinements the same 
thing occurred. The doctor stitched the perineum once, but on 
the last occasion he did not do so, and for thirty-one years 
she has had to suffer the consequence. 

The real test as to alleged injury done by using the forceps 
is to find out how far it has interfered with functional fitness. 
Has the woman been able to have children afterwards? I find 
on looking at it from this, I submit, reasonable criterion, that 
the prospect of future parity is distinctly good. I have gone 
over my family histories of as many women as I can trace, and 
the general trend of their histories is to bear this out. Thus 
of 60 women who had forceps applied, 38 had one or more 
normal labours afterwards ; 13 had to have forceps in subsequent 
labours ; 3 had first normal and then forceps labours ; and 

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Seventy Years Country Midwifery Practice 

only 6 did not have another infant. Of these one died some 
years after the event ; one was an aged primipara ; one 
an illegitimate birth ; leaving only three healthy young 
working-class wives in whom further labours might have 
been expected. 

On the whole question of the use of forceps, I submit that 
the risk is being exaggerated at the present time. Any 
damage that is done is apparently done because some very 
simple rules are broken. If we all waited till the os was fully 
dilated and the second stage well advanced over two or three 
hours ; and if we applied the sound surgical rule that when 
operation is indicated the sooner it is done the better for 
the patient ; and if the most complete care were taken in 
antisepsis, there need be no such dreadful exhibitions as are 
described in Dr Comyns Berkeley's address. 

After all, this controversy is a perennial one — it is not being 
raised by any means for the first time. In the end of the 
seventeenth century it was the great de la Motte who permitted 
himself to say that " he who keeps secret " (and a fortiori, he 
who objects to the use of) "so beneficent an instrument as the 
harmless obstetric forceps deserves to have a worm devour his 
vitals for all eternity!" 7 But the opposition was strong enough 
to succeed in lessening the frequency with which forceps were 
used, so that we find in Hamilton 8 an abstract of Madame la 
Chapelle's practice in 1816 in the Hospice de la Maternite in 
Paris. Of 15,380 patients, only 93 were delivered by forceps, 
or 1 in 165 cases, which has quite a modern look about it. 
She gives some account of 49 of these cases. " Seven women 
were thirty hours, two were thirty-three hours, one forty-eight 
hours, two three days, two several days, and one had been 
three days under the first stage. Thirteen women of the 
49 died. Twenty-six infants were born alive." 

Clearly then Madame la Chapelle was not a defender of the 
usage. Hamilton himself, though he deprecates keeping a 
woman in labour for more than twenty-four hours in the 
first stage, yet says that in forty-eight years' practice he only 
applied the forceps in 33 cases. 9 The advocates of the forceps 
appear to have rallied again, for Haeser, writing in 1875, alludes 
to it as the one of the most beneficial instruments ever invented. 10 
And Barnes n says of it : " Take, for example, the noblest 
(instrument) of all, the forceps. The more perfect we make it, 
the more lives we shall save, and the more we throw back into 

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C. E. Douglas 



reserve those terrible weapons which only rescue the mother at 
the sacrifice of her offspring." 

What are the alternatives to forceps delivery? Caesarian 
section or craniotomy seems most in favour. This being a 
paper which is concerned with country midwifery, the Caesarian 
operation is practically out of court. Probably in days to come 
it will be simplified. It is not a difficult operation even now, 
and the younger generation may take the cases into the nearest 
Cottage Hospital and do them or have them done ; but the 
time is not yet. As for craniotomy, a revolting procedure, I 
have only done it once on a dead baby in a tramp lodging- 
house. I had applied forceps (this was long before the axis 
traction forceps came in), and after perforation I finished off 
with forceps. The mother did well, and the operation itself 
is not difficult, but it is revolting in all its aspects, and I venture 
to think there is yet a better way. Version is my next resort, 
and I do not understand the modern prejudice against it. I 
have used it in all the cases, nine in number, in which I have 
failed to deliver by means of the forceps, and I have had no bad 
results such as are so graphically described in Dr Shannon's 
valuable paper, " The Failed Forceps Case and its Treatment." 12 
I note that though he, like most others, inclines to Caesarian 
section or perforation, yet on occasion he resorts to version. I 
should say that all of these occurred before 1895, with the °ld 
Simpson forceps. Since using the Milne Murray instrument I 
have had none. What used to happen was that in an occipito- 
posterior presentation, if much pressure were put on, the forceps 
began to slip, and the danger arose of them suddenly giving 
way and causing extensive laceration. In such cases I used to 
take them off, pass in my left hand, turn, and deliver if necessary 
with the forceps to the aftercoming head. I agree with Barnes, 13 
who says : " The head will come through the pelvis more easily 
if drawn through base first than if by the crown first." 

All the mothers recovered without morbidity except the 
first, away back in 1887, who had a mild sepsis. Four children 
were alive. They were mostly working women of the agricultural 
labour class, a very migrant tribe, so I cannot trace all of them ; 
but one I delivered quite normally two years afterwards, and 
another eighteen months afterwards of twins, version being 
again performed with good results both for mother and children. 

Another condition in which we are warned against version is 
hydrocephalus, where craniotomy again is prescribed. In both 

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Seventy Years Country Midwifery Practice 

my cases of hydrocephalus I performed version. In the second 
I had to apply forceps to the aftercoming head, and Barnes' 
dictum above quoted was justified. In point of fact the 
hydrocephalic head comes away with surprising ease when 
so treated. I had a case showing this not long ago. A young 
locum tenens sent for me to help him with what he described 
in his message as "locked twins." On my arrival I found a 
footling presentation, and what had misled the young doctor, 
a large swelling above the pubes, soft, fluid, and with some bony 
points in evidence. I washed up and examined. There was no 
sign of another head, and the swelling seemed continuous with 
the rest of the child's body. So with a very little traction the 
whole head came down with a " cloop " like the cork out of a 
bottle. All three women became pregnant in due course of 
time and all had normal labours. 

Version is at the present time rather underrated. Besides 
these nine " failed forceps " versions, I have done it thirty-one 
times in this series for many conditions, losing fifteen children, 
including the nine monstrosities. All the mothers recovered. 
One woman, a tradesman's wife, had it performed four times. 
Her first child was still-born, delivery by forceps. Sixteen 
months afterwards she had a footling for which version was 
performed, a difficult case where the arms were over the head, 
one requiring fracture to get it down. That was in February 
1897. In October 1899, she had another footling which was 
also turned, more easily this time; in April 1902 yet another 
footling, also turned. She rested until July 1908 when she 
had a breech presentation, where version was also done. This 
concluded her obstetric history, and of gynaecological history 
she has none. 

Let me put in evidence my last version case, which I fear 
transgresses some of the rules of present-day teaching. 

No. 2179. — Mrs T., aged 31, i-para. Premature rupture of 
membranes, 5 A.M. Sent for district nurse during the day. No 
pains till evening, when nurse sent for me. Os fully dilated, 
pains strong. Anterior lip swollen, being pressed on by vertex. 
There had been bleeding going on since morning from a partial 
placenta praevia lying over the posterior lip. It was a head 
presentation, but felt curiously soft like a dead head, but fcetal 
heart was going. Under chloroform, I tried to put on forceps, 
but could not get them on, so decided to turn. It was very 
difficult. Waters had gone fifteen hours ago and there seemed 
obst. 97 g 



C. E. Douglas 



no resiliency in the body. It took about two hours, and when 
I had got a foot down I had to fix a tape to it ; then, with 
two fingers on the head, with traction on the foot, I got the 
version completed. As the body came down a spina bifida 
showed itself, and I then saw where I was. Forceps to the 
aftercoming head brought down a large hydrocephalus. One 
hoped to be at the end of one's troubles, but after waiting forty- 
five minutes for the placenta to clear, it came, but with a sense 
of something giving way. Her condition was wonderfully good, 
so I gave her some pituitrin, 0-5 c.c, and left her. She ran 
a slight temperature for two days, and as it was 101-4 on the 
third day I gave her chloroform and drew down the uterus. 
I found a very small amount of placental tissue adherent which 
I gently removed with my fingers and washed out the uterus. 
Temperature 98, pulse 100, on completion of the operation. 
On the sixth day pulse and temperature were normal and 
remained so. This patient has already become pregnant, and 
has had a quite normal delivery. It is not often that one meets 
with a combination of five abnormalities in one case. 

I need hardly remind you that in pleading for the more 
frequent practice of version as against the lethal instruments, 
I am sinning in good company. Sir James Simpson, addressing 
this Society on 20th January 1847, put forth a similar plea, 
and quoted a case which takes rank as one of great historical 
interest. It was a case " very lame, with the lumbar vertebrae 
much distorted," where at the last pregnancy craniotomy had 
been used after forceps had been tried and failed. On this 
occasion ether was given, being the first case in which it was 
used in labour, and Simpson turned and extracted the infant 
in " not above two or three minutes," preferring, " above all, 
the transient and not necessarily fatal depression of the flexible 
skull of the foetus for the destructive and necessarily deadly 
perforation of it." As the patient " left her bed, dressed, and 
walked into the next room on the fourth day after delivery," 
one feels that altogether she might have met with similar 
treatment seventy years later, and thus might be regarded as 
seventy years in advance of her time. 14 

These reminiscences of country practice have carried me 
away from my main line of argument. But there is yet 
another subject of interest on which I should like to say 
something before resuming it, namely, the development of our 
knowledge of eclampsia during these forty odd years. 

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Seventy Years Country Midwifery Practice 

Eclampsia and Albuminuria. — This toxic condition appears 
to be on the increase. In the first series of 936 cases, there 
were three eclampsias, practically three per 1000 cases. 
As any albuminuria at that time, being untreated, would most 
probably develop into eclampsia, we may take this as an 
indication of the prevalence of the condition. In 1 165 cases 
under my care I had 10, 5 of albuminuria and 5 eclampsias, 
or rather under 10 cases per 1000. From case 1165 till my 
last case, No. 2120, were 955 cases, in which I had 5 eclampsias 
and 9 albuminurias, making 14 in all, being as near as may be 
to 15 per 1000. In the three series, therefore, the ratio runs 
up from 3 to 10 and 15 per 1000, a very definite increase. 
I may now detail some of the cases. 

My first case, in 1887, was tragic. I was sent for to the 
country to see a girl said to be having fits. I found her, an 
unmarried girl, who had just come back to her mother, in labour, 
and having one convulsion after another. The second stage 
was well advanced, head nearly reaching the perineum, so I 
delivered with forceps at once, and then treated the convulsions 
as best I could but with no result, and death took place very 
soon. The case contrasted with a case of albuminuria and 
dropsy which I had had early in the year. A primipara, aged 22, 
seven months' pregnant in December 1886, had oedema of legs, 
thighs, and vulva, labia much swollen. Urine heavily loaded 
with albumen, with granular casts. Put to bed with appropriate 
milk diet, alkalies, and diuretics, the oedema largely subsided, 
but was not away by the date of her confinement, which came 
off on 15th January and was uneventful. Symptoms subsided, 
and by March the urine was practically normal. She had 
another child in December of that year, when there was no 
return of the albuminuria. She then, in December 1890, had 
albuminuria in a third pregnancy, without eclampsia, and since 
has had a large family without any trouble. From that time 
I always inquired as to symptoms suggestive of kidney mischief, 
and whenever there was albuminuria I treated with alkalies and 
milk diet with uniform success. But, in 1899, I had a case 
without any warning. She was a farmer's wife, a primipara, 
over 30 years of age. The first stage was rather long and 
I left her for a time. On returning I found her just going into 
an eclamptic fit. Fortunately, the second stage had begun 
and I was able to turn and deliver her of a living child. Under 
chloroform she came round. She had had no preliminary 

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C. E. Douglas 



symptoms of any kind, and two years later had a normal labour. 
From that date I have examined every woman's urine before 
labour if I could get it, and that is now not at all difficult. No 
case of albuminuria that had been under treatment became 
an eclampsia. Two eclampsias died. Treatment in all was 
chloroform in the first instance, and chloral hydrate to follow. 
One resisted treatment with chloroform, but the fits ceased at 
once on bleeding. One albuminuria case was of interest, in 
that she had had one kidney removed. She did quite well. 
I have also had to attend two women who were epileptics. 
Neither gave any trouble during the confinement, but each had 
fits shortly after. One eclampsia, coming on three days after 
labour, ended in mania, from which she recovered in a few 
months. 

Three of the 10 cases were in unmarried girls, and all 
were very severe. One was an interesting medico legal-case. 
She was a domestic servant with an old lady who sent for 
me one Sunday afternoon to say the girl had had a fit. I 
found that she had been in her usual health except that she 
had spoken of having missed some periods to her mistress. 
That morning she had a slight fit which passed off. In the 
afternoon she had a bad seizure and they sent for me. She 
was then deeply unconscious. There was some haemorrhage 
going on, and the uterus could be felt above the pubes. Under 
these circumstances I diagnosed eclampsia in a probable four 
months' pregnancy. I got a colleague to give chloroform, and 
explored. I found the uterus empty and with a relaxed cervix. 
It was evident that she had had a child not far off full- 
time. The urine was of course loaded with albumen. Under 
chloroform, with chloral hydrate to follow, she soon came round. 
The police took charge, and found a full-time foetus in a brown- 
paper parcel in her trunk. It had been born dead. She was 
tried for concealment, and a sympathetic jury let her off. 
The Salvation Army have given her work. One of the other 
unmarried girls died, my first and last fatal case of eclampsia, 
now thirty-five years ago. The other fatal case was under 
the care of an assistant during my absence on Service. 

The general inference from these experiences seems to 
be that this, the most dreadful complication of maternity, 
while certainly more common, is very amenable to preventive 
measures, and that with good prenatal care it should become 
very infrequent. 

ioo 



Seventy Years Country Midwifery Practice 

in. 

Coming back now to the main line of thought. Is it still 
to be believed and taught that for seventy years no advance 
has been made, no serious encroachment upon the mortality 
of those days? Is this paralysing doctrine still to be preached 
that all our efforts have been of none avail, that women are 
dying as they used to do in the old days, that in obstetric 
practice alone the teaching of Lister had no result for good ? 
We are then on the horns of a dilemma. Either there has 
been some improvement, roughly comparable to the statistics 
given, or there has been none, in which case the question 
arises, why? The proposition I am now to pose is this, that 
while there are grounds for believing that improvement has 
taken place, it is still unaccountably small, that there remains 
what has been called " an irreducible minimum," and that we 
should seek some explanation of our failure to achieve better 
results with all the effort that has been made, and is being 
still more strenuously made. Is there not a tertium quid which 
has not been explored ? 

In every other department of medicine attention is being 
paid to the factor of immunity. We postulate the existence 
of such a factor, and we have means whereby it may be utilised 
in prophylaxis or in treatment. This point need not be 
enlarged upon. Tuberculosis and diphtheria, to name only 
two diseases, have been largely influenced by dealing with 
the immunity factor. And its " opposite number," decreased 
immunity, or increased susceptibility, is also not unknown. The 
hypothesis which I wish to submit for your consideration is this, 
that in the parous woman we may have for the time being an 
increased susceptibility to death, and that this is the tertium 
quid which has never been considered as a whole, and allowed 
for as a prime factor in the problem. Consider the known 
facts. A woman is the subject of organic heart disease. If 
she does not become pregnant, she may go on for many years 
and quite possibly die of something else. If she becomes 
pregnant she will die, if uncared for. And she will die, not at 
her confinement, which conceivably might be expected to strain 
her weakened heart {vide Jellett infra), but she will suddenly die a 
few days afterwards when doing nothing in particular. Similarly 
with tuberculosis. This, again, in the nullipara may go on for 
years. Let her become pregnant, and what happens ? She 

OBST. IOI g 2 



C. E. Douglas 



has taken on her principal duty to the race ; and nature supports 
and sustains her till that duty be fulfilled. But when it is over 
she dies. Three per cent, of women 15 are the subject of an 
autogenous toxaemia. If not watched and controlled they may 
die in eclampsia. In labour, apart from operation, they are far 
more susceptible to sepsis than at any other time. Take a case. 
A woman has a baby, untouched by nurse or doctor. Her only 
lesion is a small perineal tear. She develops sepsis and dies. 
If she got that tear in the non-pregnant condition, say by injury, 
would there have been the slightest reason to expect death ? 
Finally, it is a very old experience in the dead house, that a 
cut received in dissecting the body of a woman dead of puerperal 
fever is almost certain death. Why? Is it not that in a subject 
where the immunity factor is decreased the strain of organism 
present is correspondingly virulent ? Are there not reasons, 
then, for postulating in the parous woman, at this point alone 
in her sex life, a decrease in the power of the forces that resist 
death which in their entirety we describe by the term immunity ? 
The text-books are silent on this point. Labour is taken to be 
a physiological process in a healthy woman. The only author I 
can find who even discusses the matter is Dr Henry Jellett of 
Dublin. 10 He says : " Labour is a physiological process, and as 
such has no more an inherent rate of mortality than has any 
other physiological process. ... In all cases in which the 
mother suffers from any disease of sufficient intensity to be 
influenced by constitutional changes, labour will be attended by 
a rate of mortality. There is nothing strange in this. The act 
of emptying the rectum or bladder is a physiological process, 
and is unattended with mortality under normal circumstances, 
but if an individual suffers from cardiac disease, aneurysm or 
such-like pathological conditions, the mere natural straining 
necessary to perform the act of defalcation or micturition may 
be the causa causans which completes the breakdown of the 
heart or the rupture of the aneurysm. . . . The process of 
labour renders a woman especially liable to infection." But 
no one has asked the question, Why ? Why is she so liable ? 
Why does intercurrent disease kill her then and at no other 
time? And why does it wait till labour is over and kill 
her then ? 

I submit the proposition that it is something deeper than 
we have yet surmised. Life and death are inextricably mixed 
in nature. That " genesis " has a profound effect upon the 

102 



Seventy Years Country Midwifery Practice 

living organism, while sometimes the theme of the seer and the 
poet has only been dealt with in our times by one deep thinker, 
Herbert Spencer. He shows, by instances from botany, that 
the effort towards the preservation of the species causes such 
an effect upon the organism that when the sex function is 
fully developed the growth of the individual stops. He does 
not go on to deal with it in its power of affecting the life of the 
individual, but as we shall see there are cases when life becomes 
extinct soon after the race effort is consummated. He points 
out from a study of the coco-nut palm, that as fertility begins 
growth gradually stops, and pari passu the one declines as the 
other advances ; so that by the time that full, reproductive 
power is established growth entirely ceases. " Here," he says, 
"we see the antagonism between growth and sexual genesis 
under both its aspects — see a struggle between self-evolution 
and race-evolution, in which for a time the first overcomes the 
last, and the last ultimately overcomes the first." 17 And in 
a footnote he quotes Carpenter's Physiology ; " there is a 
certain degree of antagonism between nutritive and repro- 
ductive functions, the one being executed at the expense of the 
other. ... It may be universally observed that, when the 
nutritive functions are particularly active in supporting the 
individual, the reproductive system is in a corresponding degree 
undeveloped, and vice versa." 1S 

Now, this " struggle between self-evolution and race- 
evolution" does not end with the cessation of growth. Many 
forms of plant life die down at once on fulfilment of the sex 
instinct, the grasses for example. In the insect world, notably 
with the spiders, the males die off, or are killed off by the 
females immediately after having fulfilled the sexual function, 
while the females themselves die soon after constructing the 
cocoons. 19 J. H. Fabre, after describing the courtship of that 
curious insect the praying mantis, says : " During the day or 
at least next morning, the male is seized by his companion who 
first gnaws through the back of his neck and then methodically 
devours him, leaving only the wings." " The mantis is never 
satisfied with embraces and conjugal feasts. After a rest of 
variable duration, a second male is welcomed and devoured 
like the first. A third succeeds him, does his duty and affords 
yet another meal. ... In the course of two weeks I have seen 
the same mantis treat seven husbands in this fashion.' 20 
Similarly, with another insect, the golden gardener beetle, 

103 



C. E. Douglas 



"the foolish creature allows himself to be devoured without 
retaliating. This tolerance reminds one of the scorpion of 
Languedoc who, on termination of the hymeneal rites, allows 
the female to devour him without attempting to use his weapon, 
the venomous dagger which would form a formidable defence." 
..." It reminds us also of the male of the praying mantis 
which still embraces the female though reduced to a headless 
trunk, while the latter devours him by small mouthfuls with no 
rebellion nor defence on his part." 21 

These apparently are instances where the individual having 
fulfilled his duty for the race is regarded as of no account, and 
finished off accordingly. On the part of the female, also, there 
are instances in Nature where she dies immediately after con- 
cluding her sexual function. To give one instance, it has 
recently been shown 2 - that in the long and complex life- 
history of the common eel, born in the far-distant Sargasso 
Sea, 3000 miles away, they cross the Atlantic to migrate to 
our rivers and ponds. Years afterwards both sexes betake 
themselves back to the depths of the Sargasso Sea and there 
the females deposit their ova and immediately die, the sexual 
function having been completed. 

Here, then, we have evidence that not only does growth 
stop with the fulfilment of the sexual function, but that with 
certain plants and animals life itself ceases when the preserva- 
tion of the species has been provided for. And I suggest that 
in woman there is a tendency to reversion here and that 
parous women show a tendency to death after the perform- 
ance of their great function, a tendency not shown by their 
nulliparous sisters. 

The position then is that the statistics usually accepted 
give the distressing pronouncement that maternal deaths, and 
presumably maternal morbidity, are as they were fifty years 
ago. Figures have been laid before you which disagree with 
this pronouncement ; and unless we accept these we are left 
on the other horn of the dilemma, namely, we must accept the 
pronouncement and say that fifty years of improvement in 
all other branches of surgery have no counterpart in obstetrics. 
I have raised the question in the attempt to solve the anomaly. 
Can there be a hitherto undetected factor ? Has the immunity 
resistance of the parous woman ever been considered ? Is she 
really in a physiological condition similar in all respects to 
her nulliparous sister? And I suggest that this is not so, and 

104 



Seventy Years Country Midwifery Practice 

that in a lowered resistance we may find the tertium quid 
which seems to be waiting recognition. 

I have ventured to call up the seer and to quote the poet 
in support of different proofs of my theory. Who does not 
remember that marvellous prose poem in which Ecclesiastes 
describes the approach of old age : "In the day when the 
keepers of the house shall tremble, and the strong men shall 
bow themselves, and the grinders cease, because they are few, 
and those that look out of the windows be darkened . . . and 
desire shall fail ; because man goeth to his long home ; and 
the mourners go about the streets" (Ch. xii., verses 3-5). 

Then the supposition that woman may exhibit traits 
indicating reversion to lower types is very curiously supported 
by the researches of J. H. Fabre which I have quoted as to 
the way in which the praying mantis devours her lover. 
Readers of Keats may have been puzzled by a phrase in his 
" Endymion " : — 

" Within his car, aloft, young Bacchus stood 
Trifling his ivy dart in dancing mood, 

With sidelong laughing, 
And little rills of crimson wine imbued 
His plump white arms, and shoulders, enough white 

For Venus' pearly bite." 

We may take it that the Greek knowledge of sex matters was 
varied and profound ; and they would not give to Venus an 
attribute quite unknown in their experience of woman. This 
discovery of Fabre's throws light upon this allusion in modern 
poetry and so far goes in support by its analogy of the foregoing 
supposition, namely, that some women exhibit a trait only 
paralleled in types very far beneath the level of the human 
race. 

To recapitulate : I have tried to show — 

1. That some improvement has been made from the heavy 

mortality seventy years ago. 

2. That maternal mortality takes place quite as frequently 

in non-operative cases as after operation. 

3. That forceps deliveries are not necessarily so dangerous 

as is at present being taught. 
i°5 



C. E. Douglas 



4. That if forceps be only applied after full dilation of the 

os, and then as soon as their use is clearly indicated, 
without undue delay, the safest period has been 
selected. 

5. That in cases where forceps are not indicated there is 

a wider scope for the practice of version than is at 
present believed. 

6. That eclampsia, with good antenatal care, should be 

eliminated from our experience ; but that its treat- 
ment by chloroform is a sound procedure. 

7. That while there has been improvement in maternal 

mortality, it is still unduly high. 

8. That this may be due to the presence of a hitherto 

unrecognised factor. 

9. That this factor may be described as a reversion in the 

parturient woman to certain types of organism in 
which there is a tendency to death after fulfilment 
of the sexual function. 

A doctor in general practice is more concerned with 
practical bearings than with scientific explanations of a theory. 
What, then, would be the influence of this as a working 
hypothesis ? This, that the pregnant woman must be regarded 
as one who should be studied from a different angle. Rather 
than look on her as simply a normal person who has become 
pregnant, she should be regarded as a woman in danger of 
her life from toxaemias either endogenous or exogenous. 
Whether the bacteriologists can give us one or more vaccines 
to use as prophylactics we cannot say. There may be some 
hope that way. In any case, two thoughts should be in the 
mind of anyone who means to assume the responsibility of 
conducting a maternity case : — 

First — That this woman stands in danger of death, if not 
protected from it by every means that antenatal care can 
give her ; and — 

Second — That her confinement, whether normal or not, 
must be conducted on the lines of a major surgical operation. 

It is worth it. 

106 



Seventy Years Country Midwifery Practice 

Statistical Tables. 
Mortality, Maternal and Foetal, per iooo. 





1st Series (936) 
1848-1864. 


2nd Series (550) 
1880-1891. 


3rd Series (1G70) 
1891-1923. 


Maternal — 
Operation . 

Non-operation 

Fcetal — 
Operation . 

Non-operation 
Septic Mortality . 


4 l 

y = 20 = 2 1 
16 J 

4 Ui7 = iS 
I3J 


\ = 6=IO 

^ = 25 = 40 
I4j 


sP S " 3 

38 1 

^=56=33 
I8J 


17 


7-2 


i-7 



Forceps Operation Mortality. 





Cases. 


Deaths. 


Foetal Deaths. 


Forceps — 
Primipara . 

Multipara . 
Totals 


192 
201 


I 
I 


10= 5-2 per cent. 
6 = 2.9 P er cent. 


393 


= o-S per cent. 


16 = 4-07 per cent. 



General Operation 


Mortality. 






Operation. 


1st Series (936) 
1S48-1864. 


2nd Series (22 
1SS0-1923. 


00) 
















Number. 


Maternal 
Death. 


Foetal 
Death. 


Number. 


Maternal 
Death. 


Fcetal 
Death. 


Forceps .... 
Pelvic presentation . 
Placenta prcevia 


21 

9 

5 


I 

I 
O 


O 
O 
O 


393 

35 
15 


O 
O 


16 
8 
3 


Retained placenta . 


3 


I 





40 


O 





Post-partum haemorrhage 4 
Accidental haemorrhage . 
Twin births . . . 10 


O 
O 
I 


O 
O 



11 

8 

28 


O 
O 
O 




4 



Eclampsia . . . 3 
Prolapse of cord . . 1 


O 
O 






10 
4 


O 


4 
2 


Craniotomy 
Monstrosities * 


2 


O 
O 


2 
2 


I 
11 


O 
O 


1 
11 


60 


4 


4 


557 


4 


49 



Hydrocephalus 
Anencephalous 
Exomphalos 



107 



C. E. Douglas 

References. — ! Brit. Med. Journ., vol. ii., p. 976, 1923. - Edin. Med. 
Journ., vol. i., p. 23, 191 1. 3 Hamilton, Practical Observations in Midwifery, 
vol. i., p. 229, Edinburgh, 1836. 4 Sir J. Y. Simpson, Works, vol. i., p. 10 
et seq. 5 Barnes, Obstetric Operations, London, 2nd ed., 1871. ° Brit. 
Med. Journ., vol. i., p. 89, 1923. 7 J. H. Baas, History of Medicine, p. 522. 
8 Loc. cit., p. 199. 9 Loc. cit, vol. ii., p. 95. 10 Loc. cit., p. 522, note. 
11 Barnes, loc. cit., p. 15. 12 Shannon, Edin. Med. Journ., vol. ii., p. 121, 
1923. 13 Barnes, loc. cit., p. 232. 14 Simpson's Works, vol. i., p. 394, 1871. 
15 Fairbairn, Encyclop., p. 131. 1C Jellett, Manual of Midwifery, p. 295, 
1905. T ~ Spenser, Principles of Biology, vol. ii., p. 437. 18 Carpenter, 
Principles of Physiology, 3rd ed., p. 592. 19 End. Brit., 12th ed., vol. xxv., 
p. 665. 20 Fabre, J. H., Social Life in the Insect World, p. 83. 21 Fabre, 
loc. cit., p. 116. 22 Proc. Brit. Assoc, 1923. 

Discussion. 

Dr Haig Ferguson said — We have just heard a strikingly interesting 
address. I have never heard in this Society such a beautifully written 
paper, or one with such a variety of classical and literary illustrations. 
On the whole the paper strikes an optimistic note as regards present- 
day obstetric treatment. Dr Douglas said that 3 per cent, of all 
puerperal women are liable to autogenous infection and I am inclined 
to think that he is not far wrong. This shows that ordinary precautions 
are powerless to prevent infection in a certain number of cases, and it 
calls therefore for a more careful investigation of women before labour 
to find out which of them are in this dangerous condition. Certain 
investigations are on foot at present which rather bear out Dr Douglas's 
statement, and the question comes to be whether it will not be 
necessary systematically to examine the vaginal secretion in all women 
before confinement and to ascertain whether any pyogenic organisms 
are present. Dr Browne is at present doing some good work in 
this direction in the Maternity Hospital. Dr Douglas seemed to 
indicate that forceps are not so frequently used now as they were. 
I am inclined to think that they are used more frequently than in 
former days. One cannot, of course, compare the indications of 
forceps application in the old days with those of the present. In 
former days the application of forceps was almost invariably delayed 
too long until the patient was exhausted and almost in extremis. 
Nowadays the tendency is perhaps in the other direction and they are 
sometimes applied too frequently and certainly sometimes too soon. 
I agree with Dr Douglas that forceps judiciously applied is a most 
important factor in saving rupture of the perineum. The worst cases 
of torn perineum that I have seen have been in cases of so-called 
natural labours. Forceps judiciously applied in suitable cases and at a 
suitable time do nothing but good, but it takes considerable experience 
before a practitioner finds out their full advantages and limitations. 

108 



Seventy Years Country Midwifery Practice 

The young practitioner goes out into practice very frequently without 
having had any experience in the use of forceps, and his earlier patients 
I fear are apt to suffer from this. One hopes that in the future more 
practical teaching may avert this difficulty, which will be a great 
advantage to the community. Dr Douglas seems to regard version 
as being an operation seldom used nowadays. I hardly agree with 
this view, as version is still regarded as extremely useful and must not 
be relegated to the past. We all join in hoping that Dr Douglas 
will ere long give us other papers, which he is so well qualified by 
his wide experience to do. 

Dr Fordyce said — This is one of the most interesting papers I have 
heard, and it is the sort of paper we have pled for from our general 
practitioners for a number of years. I would like to think with 
Dr Douglas that it is a mistake that the mortality from childbirth 
has not decreased in seventy years, and I do think that Dr Douglas 
has brought forth adequate reasons why that should be so. He proved 
it in his own practice. Of course the personal element must be taken 
largely into account. Anyone who knows Dr Douglas knows that 
he would treat these cases with exceptional skill and care, and this 
would account for a decreased mortality as his experience extended. 
The other factor, of course, is that Dr Douglas is dealing with a 
class of patient which is different from, one might say, the average 
patient. The crowded life of towns nowadays must, of course, 
diminish the vitality of people and that should be taken into account. 
I hope that the mortality really is diminishing in spite of what 
Berkeley and Bonney say. Dr Douglas spoke about the fcetal 
mortality in his cases of forceps and gave us his percentage. I would 
like to ask him if he has any record of the foetal mortality in the cases 
where he did not apply forceps. I agree that version has not passed 
out. Years ago in this Society there were fierce discussions as regards 
the relative merits of forceps and version in minor degrees of con- 
traction of the pelvis. Professor Simpson was a strong advocate of the 
value of version and frequently employed it himself in cases in the 
Maternity Hospital where now we would put on forceps. Regarding 
one historical point — the Mrs Dombey type of case. I have often 
wondered exactly what Mrs Dombey died of. Dr Douglas seemed 
to indicate that it was because she did not make an effort ! It is 
true that Mrs Chick was constantly urging her to make an effort, 
but Dr Douglas must remember the anxiety of these efforts after the 
child was born. I think that probably Mrs Dombey may have been 
a very energetic woman and that it is quite possible she died from 
haemorrhage afterwards and not from the results of inefficiency on her 
own part. 

Dr Johnstone said — I was glad that Dr Douglas went into the 

109 



C. E. Douglas 

question not only of mortality but also of morbidity. Particularly in 
regard to sepsis there is a tendency to take mortality as the standard 
to the exclusion of morbidity. This, after all, is an exceedingly 
important matter, because, apart from the number of women who die, 
the question comes really to what Dr Douglas practically described 
as his "efficiency test." How is the efficiency of women affected then, 
if they recover from puerperal infection? So far as my experience 
goes, I think that in many cases where recoveries take place the 
general efficiency is materially diminished. I don't think that any 
woman ever suffers from acute general septicaemia without its leaving 
a considerable scar on her life history. I entirely agree that, if forceps 
were never applied until the cervix is fully dilated, the controversy 
with regard to the use and abuse of forceps would practically cease. 
With regard to Dr Douglas's closing points there is no doubt that it is 
ludicrous to compare parturition as a physiological process with other 
physiological processes such as the evacuation of the rectum or 
bladder. All these processes are performed in the interest of the 
individual ; parturition is performed in the interests of the race and 
is on an entirely different physiological plane from the others. What 
Dr Douglas said with regard to the possibility of there being a lowered 
resistance in women during pregnancy and parturition is certainly very 
suggestive. There are probably many elements to consider. He 
asked the question why should a woman die of a septic perineal tear 
when she would probably not suffer much from the tear if she were 
not pregnant? One reason is probably the enormously increased 
lymph vascular supply which is developed during pregnancy and which 
is laid down by Nature in order to permit rapid absorption of tissue 
in the course of the puerperium. While in a healthy puerperium this 
arrangement is of the utmost value. It becomes of the most sinister 
significance possible when organisms are introduced. 

Dr Young said — One of the most important matters dealt with in 
Dr Douglas's address is the role played by endogenous or autogenous 
infection. Dr Douglas's paper will attract attention to this extremely 
important point in regard to obstetric practice in so far as it affects the 
question of morbidity and mortality. I have always had a feeling that 
this subject of autogenous infection has been neglected in the past. 
The figures that Dr Douglas has put forth to-night have a suggestive 
bearing in this connection and imply that in a certain proportion of 
cases the raw pelvic surfaces are infected by microbes that may up to 
that time have been latent in the woman's body. If this mode of 
infection can be established it means that we have got to settle down 
to an entirely new method of attack on this problem, and one would 
like to see a wholesale series of investigations carried out along these 
lines. The latter part of Dr Douglas's paper interested me very much, 

no 



Seventy Years Country Midwifery Practice 

where he touched on questions of more philosophical interest — 
questions which relate more to the factors of comparative biology 
and pathology. I remember some years ago to my shame being 
entangled in a correspondence in one of the medical journals on 
the ultimate nature of pregnancy and how far pregnancy was to be 
looked upon as a pathological process and how far a physiological 
process. I took up the attitude that pregnancy was very closely 
related to a pathological condition and I remember instancing the 
examples which Dr Douglas has given us to-night of the praying 
mantis and the spiders. One would like to see Dr Douglas elaborate 
these points. 

Dr Browne said — To my mind the incidence of puerperal sepsis 
will never be diminished materially until it is recognised that the 
autogenous sources of infection are of importance in its causation. 
One of the chief sources of this is the vagina which, I believe, 
frequently contains organisms during pregnancy which are potentially 
pathogenic and which even though kept in abeyance by the acid 
contents of the vagina before the onset of labour may during labour 
and the puerperium, when the degree of acidity is diminished, become 
sufficiently virulent to cause puerperal sepsis. Investigations along 
these lines are being carried out in the Maternity Hospital. 

Dr H. G. Lang-will expressed the appreciation of the general 
practitioners and referred to what he called the "Osier touches" in 
Dr Douglas's paper. 

The President, Professor Watson, said — Dr Douglas has done a 
great service in two ways : he has given us authentic figures with 
regard to puerperal mortality and morbidity, and he has shown 
that we cannot rely on the official statistics with regard to these 
conditions in the Registrar-General's returns. Whilst the figures 
may be comparable, say for the last twenty years they are certainly 
not comparable now and fifty or seventy years ago. It is question- 
able if the present day figures and those of the last twenty years are 
comparable with each other, because there is no question that 
registration of these deaths is much more conscientiously done now 
than it was say twenty years ago. These are things we must take 
into consideration seriously in estimating whether we are getting 
any better results to-day than were obtained twenty or thirty years 
ago. Dr Douglas has done a great service in bringing up his last 
point as to whether there is not in a pregnant woman a greater 
tendency to disease and to death than in the non-pregnant patient. 
I think we undoubtedly see that for example in tuberculosis, and it 
was forcibly brought home to us in the influenza epidemic when 
women went into labour with pneumonia. The mortality was as 

in 



C. E. Douglas 



much as 30 per cent, in these cases, showing that these women had 
a lower resistance and that any endemic disease is a more serious 
thing in the pregnant than in the non-pregnant woman. That, of 
course, means that in our treatment of women in labour aseptic 
treatment must be more perfect if possible, than our technique in 
ordinary surgical operations; that point requires emphasis. In 
ordinary midwifery practice the antiseptic or aseptic principle has 
not been followed as it has been in our surgical operating theatres. 
It is doubly necessary to carry out that technique perfectly in labour. 

I thank you, Dr Douglas, in the name of the Society for giving 
us a very enjoyable evening. 

In reply, Dr Douglas said — I thank you heartily for the patient 
way in which you sat through that very long paper. With regard to 
Mrs Dombey ! should like to say that in those days they did not 
die of sepsis, they died of exhaustion. That scene in which the 
doctor and the specialist who was brought in is one of the cruellest 
descriptions that Dickens has ever given. He was, of course, largely 
a democrat, and was not at all fond of the professional classes, and 
that description of the doctor and of the man in general practice 
at the bedside of Mrs Dombey is something that we all ought to read. 
Those who know John Gait's writing, I hope have read the latest 
series of short stories called The Howdie and Other Tahs. In that 
you will notice that every case died that day or the next day. If 
Mrs Dombey had died of sepsis, Dickens would have made her die 
a fortnight hence, but she died that same day. That brings out 
exactly that in those days they did not die of sepsis. They had not 
time to die of sepsis ! They died of exhaustion because they were 
left in labour for such a terrible time. 



Meeting— 1 2th March 1924. 

PRIVATE BUSINESS. 

The following were elected Ordinary Fellows of the Society : 
Samuel George Davidson, M.A., M.D., Hawick; Charles Edward 
Douglas, M.D., F.R.C.S. Ed., Cupar-Fife; I. U. Douglas Smith, 
M.B., Ch.B., Broughty Ferry. 



Meeting — 14th May 1924. 

EXHIBITION OF SPECIMENS. 

Dr Theodore Haultain showed — a specimen from an unmarried 
woman, aged 26, who had very few symptoms. Her menstrual periods 
were regular every twenty-eight days, and only lasted five days, and 
the only symptom was that three weeks ago she had had pain on the 
right side which lasted about twelve hours ; the pain was not so severe 
as to put her off work. At the finish of the period following she had 
very severe pain in the right iliac fossa, and this was accompanied by 
excessive vomiting. I was told that she had vomited the whole night ; 
she was sent into hospital as an acute appendicitis. When I saw her 
I found she had great distension in the abdomen, the right rectus 
was rigid and there was a swelling in the right iliac fossa reaching 
nearly to the umbilicus. I thought the probability was that there 
was an ovarian tumour with a twisted pedicle, so I opened the 
abdomen and found a tumour about the size of a melon, full of blood. 
I untwisted the pedicle, which had two and a half turns in it, and 
removed the tumour, and found on examining it that the ovary was 
at the side of the cyst, and that it was not an ordinary ovarian cyst, 
but probably a fimbria! cyst arising from the homologues of the 
rete testes in the fimbria ovarica. 

Dr Farquhar Murray showed — (1) a specimen of double uterus 
removed from a single woman, aged 35, who had suffered from severe 
dysmenorrhcea. She dreaded the approach of each period and had 
to lie up during it. There was only one cervix and vagina, and the 
broad ligaments were very short on both sides. 

(2) A ruptured uterus was from a case originally diagnosed as 
concealed accidental haemorrhage at the eighth month. At operation 
the abdomen was full of blood and on opening the uterus the child 
was found to be dead, but there was no evidence of intra-uterine 
haemorrhage. The bleeding was traced to a vein at the back of the 
uterus on a level with the pelvic brim ; this was ligatured and the 
uterus was closed. Two years later identical symptoms occurred at the 
seventh month of pregnancy, and it was considered that the old scar 
was rupturing. At operation the foetus was found lying in its amniotic 
sac in the abdomen, and the placenta was protruding through the 
back of the lower uterine segment, the old Cesarean scar being firmly 
healed. The pathological report on sections taken from the edge of 
the rupture states: "There is simple inflammatory reaction and a 
considerable amount of fibrosis, but there is no evidence of true 
tumour growth." The urine was negative. 

obst. 113 h 



Exhibition of Specimens 

Dr S. J. Cameron showed — two specimens of chorion epithelioma 
of the uterus, (i) The specimen was a small neoplasm occupying 
the fundus. Scattered throughout the uterine wall are small black 
currant-like patches which show the characteristic structure of a 
chorion epithelioma. The interesting point is that they were both 
recognised as chorion epithelioma without microscopic examination. 
I think there is no gynecological condition which necessitates the 
co-operation of the physician and the pathologist more than in the 
recognition of this lesion, but I was so sure of the nature of the illness 
in this case that I did not hesitate to excise the uterus. The patient 
had been delivered a few weeks previously of a full-term child, and 
I was asked to see her on account of " flooding." At this consultation 
I removed a small piece of tissue which was adherent to the fundus. 
Within a week the bleeding reappeared, and on examination I found 
that the neoplasm had reformed and so having diagnosed chorion 
epithelioma I excised the uterus and the patient made an uninterrupted 
recovery. 

(2) On the other hand, the next specimen that I show you, in 
which you see a tumour in the cervix, has a different history altogether. 
This I excised a few months ago from a young woman, aged 22, who 
came to the Western Infirmary complaining of profuse bleeding. On 
examining the patient I thought she had a rapidly growing carcinoma 
of the cervix. I opened her abdomen, ligatured the internal iliac 
arteries, and did a radical operation. When I split open the cervix 
I recognised from the vicious blue-coloured look of the tumour and 
the presence of hemorrhagic areas throughout its substance that it 
was probably a chorion epithelioma, and an interesting point is that 
this girl at her last pregnancy (two years ago) had a hydatidiform 
mole removed. 

(3) This fibromyomatous tumour associated with pregnancy 
is only part of the original specimen. I was called out 'to see the 
patient owing to the fact that during the night she had been seized 
by acute abdominal pain. The temperature was elevated and the 
pulse rate was accelerated. On examination I discovered she had a 
huge abdominal tumour which extended up to the diaphragm. There 
was a history of two months' amenorrhoea, so a diagnosis of pregnancy 
associated with "red degeneration" of the fibroids was made. I 
performed supra-vaginal hysterectomy, and here you will see a little 
fcetus of about two months lying between fibroid tumours which show 
red degeneration ; thrombosis is present in the veins immediately 
above the tumours. 

(4) The history of the next specimen, which is a gravid uterus, 
is curious. The patient had the most pronounced scoliosis I have 
ever seen. She came complaining of abdominal pressure, and also 

114 



Exhibition of Specimens 

stated that she had amenorrhoea. It was evident that she was 
pregnant and that a large fibroid tumour was present and so, in order 
to try and relieve her, I enucleated the fibromyoma. She carried 
on for two months more, when on account of the spinal deformity 
the intra-abdominal pressure began to get unbearable. She came to 
the Maternity Hospital where my colleague Dr M'Lellan excised the 
uterus, and you will see very distinctly the triangle existing between 
the upper and lower limbs. 

(5) My final specimens are bilateral ovarian tumours which 
I excised from a patient who appeared with abdominal swellings, and 
the interesting point is that out of the large number of cysts which 
I have removed I think this is only the second occasion on which 
I have seen papillomata arising from the outer surfaces. Most 
of the so-called examples are cases where the interior of the cyst is 
directed outwards owing to perforation and eversion. My experience 
has been that in most cases of outer surface papillomata the ovary is 
usually normal. In the specimens I show you luxuriant growths cover 
the outer surfaces of the cysts, while the interior are practically free 
from papillomata. 

Dr Haig Ferguson showed — (1) a twisted ovarian tumour 
with hsemato-salpinx. Mrs B., aged 58, xiii-para, menopause 
nine years ago. The patient was seized with violent pain at 3 a.m. on 
the nth March while still in bed. She was sent in to the Infirmary 
in the morning and the diagnosis was made of a twisted ovarian 
tumour. She was operated upon on admission. The tumour was 
on the right side with a complete twist from right to left. There was 
well-marked haemato-salpinx. 

(2) Twisted ovarian cyst with hsemato-salpinx. Mrs J., 
aged 57, ii-para, menopause ten years ago. The patient had noticed 
her abdomen swelling for about a year, and two days before admission 
she had slight twinges of pain in the lower abdomen. The following 
day the pain became severe and continuous. She was operated upon 
on admission and a right ovariotomy was performed. There were 
two complete twists of the pedicle from left to right, away from the 
middle line. In this case also was a large hcemato-salpinx. It is 
interesting to note that in both these cases such well-marked effusion 
of blood into the fallopian tubes had taken place. Dr Ferguson had 
seen this in several previous cases of axial rotation of ovarian cysts. 
In both these cases the patient did well. 

(3) A case of cystic fibroid. Mrs P., aged 46, ii-para. Patient 
complained of increasing breathlessness and stoutness for two years 
and enlargement of the abdomen altogether very much more marked 
during the four months previous to admission. Periods very profuse for 
the last two years. The whole abdomen was filled by a smooth rounded 

"5 



Exhibition of Specimens 

swelling extending upwards almost to the ensiform cartilage. The 
veins were very prominent and there was no free fluid in the abdomen. 
The patient had been tapped abdominally before admission when 
about twelve pints of fluid had been removed. The uterus could not 
be made out separate from the tumour, but it was thought that it 
probably was pushed aside, and that the tumour was a cystic ovarian. 
At the operation on the 5th of November last the tumour was found 
to completely fill the abdomen, and instead of being as was thought 
of ovarian origin, it turned out to be a large cystic fibroid. It was 
easily removed by supra-vaginal hysterectomy. The patient made 
an uninterrupted recovery. 

(4) Double pyo-salpinx with left ovarian abscess. E. D., 
nullipara, aged 20. The patient was admitted to Ward 36 on 24th 
April 1924. Severe pain in the lower abdomen for three days before 
admission and sickness, but no obstruction. Temperature 103, pulse 
130. Periods had always been regular. Last one a fortnight before 
admission. There was no general peritonitis, but great tenderness 
and rigidity over the lower abdomen on the left side, and a bulging 
tender fluctuating tumour was felt per vaginam in the left later fornix. 
On opening the abdomen both tubes were found distended with pus 
and apparently tubercular from their size. There were also tubercular 
glands in the mesentery. There was a large abscess of the left ovary 
filling the left half of the pelvis. The adhesions were so dense that 
in order to deal with the tubes and abscess it was necessary to remove 
the uterus by supra-vaginal hysterectomy, and while removing the 
abscess on the left side, some fetid pus escaped. The abscess in all 
probability was primarily a tubercular abscess which had become 
infected by Bacillus coli. After removing the uterus and appendages 
a very large raw surface was left which it was impossible to cover. 
Dr Ferguson, instead of packing tried the introduction of ether into 
the peritoneal cavity, which had been strongly recommended by 
Tarnowsky in similar cases, as a substitute for drainage. It is said 
to act as an anti-aggression, producing or increasing leucocytosis and 
aiding nature's defences against infection. Fully one ounce of ether 
was poured into the peritoneal cavity just before the cavity was closed 
and the abdomen was sewn up in the usual way. The records of 
cases that have been published have all been satisfactory, but Dr 
Ferguson would like to record a difficulty that occurred in this case, 
as the patient's respiration was entirely arrested for about one and a 
half hour's thereafter, and artificial respiration had to be kept up during 
that time. The patient, however, made a rapid recovery eventually, 
the wound healing up by first intention. It was discovered afterwards 
that she had a + + Wassermann reaction as well as a + + gonococcal. 
None of the cases recorded in which ether has thus been used have 

116 



Exhibition of Specimens 

shown any difficulty as regards stoppage of respiration. Most of them 
slept soundly for some hours after the operation. In future Dr Ferguson 
would be inclined to use less ether locally. 

Dr G. Herzfeld showed — (i) a microphotograph, showing an 
adenomyoma. The patient, a married woman of 29, was operated on 
by me for a retroversion of the uterus. During the operation I noticed, 
on the posterior surface of the fundus of the uterus, an area smaller 
than a threepenny bit, where the peritoneum showed slight puckering. 
I remembered seeing a similar appearance when watching Professor 
Donald operate in Manchester : he was operating for bilateral tarry 
cysts of the ovaries, and pointed out this puckering as indicative of 
adenomyoma. I therefore removed the affected area, which was 
about one-third of an inch thick, and had it sectioned by Dr Dawson. 
His report is as follows: "A small portion of the tissue submitted 
shows the structure of the endometrium. The remainder shows 
unstriped muscle fibres and connective tissue." 

(2) A large mass of fibroids, interesting because of the bulk. 
The largest tumour, about the size of a fcetal head, lay in the left 
hypochondrium, almost touching the spleen, and in order to deliver 
the tumour, I had to incise the abdominal wall to within two inches 
of the xiphisternum. The second largest mass was firmly impacted 
in the pelvis. The patient had absolutely no symptoms, and only 
submitted to operation because her friends were remarking on her 
figure. 



PRIVATE BUSINESS. 

Dr John Young, M.B., Ch.B., Oakmount, Lasswade, was elected an 
Ordinary Fellow of the Society. 



Obst. 117 H 2 



ONE HUNDRED SUCCESSIVE AND SUCCESSFUL 
C/ESAREAN SECTIONS IN CASES OF CON- 
TRACTED PELVIS.* 

By SAMUEL J. CAMERON, F.R.F.P.S. 

DETAILS of the technique employed in performing these opera- 
tions have been so fully described by me in the Obstetrical 
Transactions of the Royal Society of Medicine that the following 
summary will sufficiently explain my procedure and record my 
observations. 

In the first place I attribute my success to a great extent in 
substituting craniotomy for Csesarean section in cases where, 
in addition to rupture of the membranes of many hours' duration, 
there is also a probability of the existence of septic infection 
through repeated vaginal examinations having been made before 
the patient came under personal observation. In the early years 
of my operative practice I lost several patients from septicaemia 
through not observing these precautions, although I must admit 
that many cases which were undoubtedly infected, made un- 
interrupted or, in some instances, tardy recoveries. 

Next let me urge the advisability of entering the abdomen 
through the rectus sheath as by so doing a firm scar is obtained, 
whereas a middle line incision exposes the patient to the risk of 
ventral hernia as the tissues in this region are attenuated by 
the distended uterus. Owing to the tendency to dextrorotation 
of the gravid organ, the incision should usually be made on the 
right side. 

It seems to me important that two knives should be used 
during the operation — one to sever the abdominal wall and the 
other to incise the uterus. In this way there is no chance of 
inoculating the uterine tissues if the skin has been imperfectly 
prepared. 

Four large swabs are placed between the margins of the 
abdominal wound and the uterus before the latter is opened. 

After delivery of the child the uterus is inverted as it ensures 
complete evacuation of the uterine contents. 

Catgut should be employed in closing the uterine wound as 
it soon becomes absorbed. On the other hand silk persists and 
often creates intraperitoneal adhesions. Frequently I have seen 
persistent sinuses develop from infected silk sutures and on two 

* Read 14th May 1924. 
118 



Caesarean Sections in Contracted Pelvis 

occasions I have observed uterine fistula; form from the same 
cause. Every month the miserable patients menstruated on to 
the abdominal wall. Again I have removed vesical calculi 
owing to the silk sutures having worked through the bladder wal 1 

When intraperitoneal adhesions have formed between the 
uterine scar and the parietal peritoneum (a circumstance which 
should be suspected if there is indragging of the abdominal wall 
when the uterus is moved), a transverse incision should be 
made above the upper limit of the cutaneous scar. A similar 
incision should be made in the fundal region, and through this 
wound the uterine contents should be extracted. By so doing 
the uterus is permitted to remain in a state of ventrofixation. 
To break down the adhesions would be a mistake as fresh bands 
are almost certain to form, and in some instances union to 
intestinal loops instead of to the parietal peritoneum would 
take place. 

In several instances I have met with profuse post-partum 
haemorrhage in " repeat sections " when the uterus is adherent 
to the abdominal wall. Apparently retraction is hindered, and 
in such instances it is a wise precaution to inject pituitary 
solution into the uterine musculature before closing the 
abdominal wound. 

Rupture is liable to occur in about 5 per cent, of cases 
during a subsequent pregnancy or labour. I always teach that 
a diagnosis of rupture through a Caesarean scar is justifiable, if 
the patient in a subsequent pregnancy presents an ex-sanguine 
appearance, and if at the same time she complains of abdominal 
pain. My experience of these cases leads me to believe that 
the course of events after rupture depends largely on whether 
the uterine contents are expelled completely or not. Should 
the products be only partly extracted through the rent, 
haemorrhage is usually profuse and death may rapidly ensue. 
On the other hand, if the entire contents are quickly ejected 
into the peritoneal cavity, then very little blood is lost, and the 
uterus will be found to be firmly retracted. Indeed, I have 
known a patient with this complication walk into hospital, and 
I believe that some cases may be successfully operated on after 
the uterus has been ruptured for several days. 

All the cases are nursed in Fowler's position, and if there 
be any indication that bronchitis is impending I would urge 
that the patient be placed without delay in a steam tent, as 
great comfort and benefit invariably attend its use. I would 

119 



Samuel J. Cameron 



point out that bronchitis is prevalent in rachitic cases, and for 
this reason I always give the patients chloroform, although I 
use ether extensively in my gynaecological practice. 

Discussion. 

Dr Ranken Lyle said — There is one point in this paper to which, 
I think, Dr Cameron attaches too much importance. It is the 
question of rupture of the uterus in a confinement subsequent to a 
Caesarean section. I have never seen this accident myself, although 
I have personally performed about 300 Cesareans, and have seen a 
great many more. I have always wondered why some persons lay 
so much stress upon the possibility of this accident, and think that 
it must possibly be due to some imperfection in the method of suturing 
the uterine incision. The sterilisation of the patient in anticipation of 
such an accident is, I think, an entirely wrong proceeding, because 
if the accident did happen to occur, it could quite easily be dealt 
with at the time. In regard to septic cases, or cases suspected to be 
septic, I do not think that it is proper to refuse to do a Caesarean, 
if the case is otherwise suitable for this operation, because I have 
found from experience that certain cases believed to be infected 
recover without an untoward symptom. One case in particular, in 
which a practitioner, with a suppurating sore on the back of his hand, 
had tried to deliver by version but failed. Caesarean section was 
performed in the usual manner, the patient developed an abscess, 
which burst in the lower angle of the wound, but otherwise she made 
a good recovery, and the child was saved. 

To-night I have come here to congratulate my colleague, 
Dr Farquhar Murray, on the excellence of his work, and in his 
paper you will hear his suggestions with regard to dealing with these 
septic cases, and I cordially agree with him. I do not think it is 
right either to remove the uterus in such cases, or to do anything 
which would prevent conception at a future date. 

I would like to emphasise the question of craniotomy. The word 
" craniotomy " should be abolished from all text-books. I do not 
think it should be done under any condition whatever. Not only is 
it an objectionable operation, but the results obtained from it are 
much worse than those obtained from alternative operations. I 
recently read of craniotomy being recommended in some cases of 
occipito-posterior presentations, and in a text-book recently published, 
craniotomy was mentioned as an alternative to high forceps operation. 
I consider this absolutely wrong teaching. There is one exception 
to what I say, and to which Dr Farquhar Murray refers in his excellent 
paper, but I have not met with such a case, and if such a case did occur, 
I really think that Caesarean section would be a preferable operation. 



Caesarean Sections in Contracted Pelvis 

There is one other point in regard to Cesarean section to which 
I do not agree, and that is the sterlisation of the patient for any 
reason whatsoever. I have a record of having performed the greatest 
number of Caesarean sections on one patient. I performed it no less 
than seven times successfully, and she is almost due for her eighth 
Caesarean. To have sterilised her on her second Caesarean would 
have been a positive shame. 

I should like to record my high appreciation of Dr Farquhar 
Murray's work. It is really a valuable addition to Obstetrics. 

Dr Fordyce said that Dr Cameron was to be congratulated on the 
results of these ioo consecutive Cesarean sections. Even granting, as 
he has done, that they were more or less selected cases, to have done 
this major operation, with its many risks and possibilities of failure, 
one hundred times consecutively with success as regards a living 
mother and a living child in each case is a great surgical feat. He 
would confine himself to asking if Dr Cameron had given up the 
fundal transverse incision he had seen him employ, and secondly, he 
would like to know what technique he employs in stitching the 
uterine wall. 

Dr Cameron, in reply, said — I have no doubt catgut is the right 
material to use in those cases. I have abandoned silk for the reasons 
stated and, in addition, silk does not lash the tissues together as it is 
generally supposed to do. The disadvantages of the formation of 
adhesions, sinuses, and fistulae are sufficient to condemn it. Dr Lyle 
is fortunate in never having seen rupture through a Caesarean scar. 
The first one I saw was sufficient to impress me with the gravity of 
this complication as the unfortunate woman was lying a corpse on the 
slab with her belly full of blood. That faults in technique are not 
the sole causes is evidenced by the fact that I have dealt with this 
complication in four cases which had been previously delivered by 
different operators. 

As regards sepsis, I really do not like to operate in these septic 
cases. In my earlier cases I operated on cases whether they were infected 
or not. Although there were many successes yet a few patients died, 
and if you can light on a method which will save the woman every 
time, why not do so; and unlike Dr Lyle, I think that craniotomy 
still has a place in obstetric surgery. As regards the fundal incision, 
I limit its use to those repeat cases in which the uterus is adherent to 
the parietes. I have lost several children in Caesarean section, as most 
people have. The hundredth baby died about a week after : a positive 
Wasserman was obtained. 

As to my method of suturing the uterus — that I do by inserting 
about six or eight interrupted sutures of catgut and then one continuous 
suture. 

121 



C/ESAREAN SECTION.* 

Observations based on an Operative Experience of over ioo cases, with 
special reference to Clinical and Pathological findings in cases of 
Obstructed Labour, and describing an Operative Technique in 
Infected Cases. 

By E. FARQUHAR MURRAY, M.D., F.R.C.S., Obstetric Physician, 
Princess Mary Maternity Hospital ; Lecturer in Midwifery and 
Gynaecology, College of Medicine, Newcastle-upon-Tyne. 

This paper records an experience of 116 sections, the majority 
of which were performed to anticipate or relieve obstructed 
labour due to pelvic contraction, the others for less common 
indications. 

Operation. — The abdominal incision is median and sub- 
umbilical unless Bandl's ring is present when it is placed 
higher. The uterus is opened in the upper segment, and the 
hand passed between the placenta and the uterine wall ruptures 
the membranes and extracts the child. After removal of the 
placenta I c.c. of pituitary extract is injected, and the uterus is 
closed with four to six interrupted catgut sutures taking up the 
whole thickness of the wall. A continuous suture or further 
interrupted sutures adjust the superficial layers and peritoneum, 
and the abdomen is closed. The operation takes from twelve 
to twenty minutes. The gaping mouths of sinuses seen while 
incising the uterus suggested that a safer method of approach 
must be adopted in septic or suspect cases. 

Situation of Placenta (75 cases). — The placenta is posterior 
or anterior in position in a proportion of 4 to 3, but in cases 
who have had previous sections the proportion is 3 to 1, 
suggesting that the residual scar tissue contributed to this 
result. It is noteworthy that the placenta was anterior in 
the only case of rupture of an old scar. 

Rupture of Old Scar. — This risk is negligible. In many the 
uterus showed no trace of a previous incision, but in some there 
was definite scar tissue, and the wall felt dense when incised. 
In no case was thinning evident, although in many instances 
the patient had been in labour a number of hours, and one 
at least has since been delivered without resort to section. The 
case which ruptured had had four previous sections and came in 
for her fifth. After several hours in labour the pain became 
* Read 14th May 1924. 
122 



Caesarean Section 

very severe and she was operated on shortly after admission. 
The complete ovum was lying in the abdominal cavity, which 
contained much blood, and the placenta presented. The uterus 
firmly contracted appeared ready for a resuture which was done. 
The mother made a perfect recovery. 

Contracted Pelvis. — A large number of the patients were 
definitely undersized and rachitic. Three had old hip trouble 
with, in two cases, the limb ankylosed in such marked adduction 
as to render delivery difficult if not impossible, but each in 
addition had marked flattening on the affected side of the pelvis. 

The previous obstetric histories were instructive. A x-para 
with a c.v. of 3 inches reported the survival of one child — 
the others died at birth following instrumental delivery, while 
a vi-para and a iv-para recorded a series of still-births preceding 
the successful Caesarean section. In a number of cases when 
the child survived delivery it died some weeks or months later 
from " fits." One vii-para reported that her four children 
delivered alive with forceps died between six weeks and three 
months from this cause. 

Primiparae, having no antecedent obstetric history, are 
entirely dependent for their safety on a pre-maternity examina- 
tion. The outstanding impression gained in dealing with these 
cases was the extremely obvious indication that something was 
wrong, gained in practically every instance by abdominal 
examination without resort to either pelvimetry or an internal 
examination. The problem viewed purely as one of elementary 
mechanics was obvious. The head was above the brim and 
actually overriding it ; or sitting in the brim and no pressure 
from above could push it in ; or the head was definitely engaged 
but a large amount was still above the brim. Since in a normal 
case merely the forehead can be felt above the brim some 
weeks before term, surely something must be wrong if more 
of the head is felt. Where there is the least doubt the patient 
should be anaesthetised, and with fingers — or even the whole 
hand — in the vagina, the exact relationship of the head (the 
ball) to the pelvis (the socket) should be decided on a purely 
mechanical basis. When the patient is in labour and it is 
believed that the head may come through, a careful watch 
should be kept on the mother for exhaustion, the child for 
distress, and the course of labour for the non-descent of the 
presenting part or the formation of Bandl's ring with a view 
to performing an immediate section, should occasion arise. 

123 



E. Farquhar Murray 



Contraction of the pelvic outlet is less common but more 
treacherous. In the majority the pelvis was small and the delay 
was at the brim or high up, but in some cases the abdominal 
examination suggested that all was well, and the head appeared 
to be well engaged. In such cases no difficulty was experienced 
at the operation in extracting the head from the pelvis. A 
certain number of cases invited the application of forceps, 
especially when the head was impacted in the mid-cavity in 
cases of funnel-shaped pelves, and in two cases where it was 
actually at the outlet. A thorough examination, however, 
showed that the lower strait could not possibly allow the passage 
of a head in a condition consistent with the survival of the child, 
and without inflicting serious trauma on the mother. 

Caesarean section as an operation is often regarded as of 
sole interest to the specialist, and for use in cases of marked 
pelvic contraction. It has not yet come into its own in minor 
degrees of this condition. 

Obstructed Labour — Peritoneum. — The peritoneal fluid was 
markedly increased in a number, and in one was blood-stained. 
Uterus. — The presence of Bandl's ring as a shallow, trans- 
verse groove was noted in a number, and frequently corresponded 
to the child's neck. In several cases the incision had to be 
prolonged into the lower uterine segment to divide the ring 
before the head could be extracted. 

The level of the ring varied, and in one or two late cases 
was almost up to the umbilicus. The lower uterine segment 
was thin in cases of over-distension — sometimes not thicker than 
wet blotting-paper — and in two cases blood was extravasated 
under the peritoneal coat indicating that it was on the point 
of rupture. 

The upper uterine segment in several very late cases was 
in a state of tonic contraction, the surface veins and uterine 
sinuses being flattened and empty, and merely a little dark 
blood trickled away on section. The trauma to which the 
lower uterine segment, cervix, and vagina are subjected is 
recorded, but the damage which results in obstructed labour 
from natural forces is not sufficiently recognised. 

Intact membranes suggest that the child is fairly safe from 
undue pressure, but this was disproved by finding meconium 
in the liquor, and marked moulding of the head before 
rupture of the membranes. The lower uterine segment and 
cervix was nipped between the head and pelvic brim in most 

124 



Caesarean Section 

cases, and in one this was so marked that the still-born child 
had an area the size of a two shilling piece on the post-parietal 
showing bare bone. The mother died later from general 
peritonitis following sloughing of the bruised lower uterine 
segment, which actually had a hole in it. In another fatal 
case the child's head was bruised and ecchymosed over an 
area corresponding to the promontory. One other case 
presented a laceration of the cervix extending to the vault 
although forceps had not been used. 

Placenta and Membranes. — It was very noticeable that in 
late cases obviously infected, the chorion appeared yellow and 
pultaceous in the lower areas and could not be stripped off 
suggesting that infection was tracking up in this layer outside 
the amnion. In one this change in the chorion was almost 
universal and the placental site itself appeared septic. 

Liquor Amnii. — In late cases this was scant and usually 
contained meconium. In a number it was definitely offensive. 

Diagnosis of Infection. — Many hours in labour, much inter- 
ference or the presence of Bandl's ring is strong presumptive 
evidence : a discharge developing during labour, after rupture 
of the membranes, with soreness and redness of the vulva, is 
almost certain proof, and a temperature is more likely due to 
sepsis than to exhaustion. Offensive liquor found on opening 
the uterine cavity, or a positive culture from liquor obtained 
per abdomen, is proof positive. Cultures were taken in a few 
cases, and the results are instructive in showing how soon after 
rupture the liquor may become infected. 



Bacteriology \ — 







Result. 




Membranes. 


Liquor. 




Pyrexia. 










Mother. 


Child. 




Unruptured . 


No growth 


A 


A 
A 


O 
I 


Ruptured 6A hours 


B. Diphtheroid 


A 


A 


O 


8 „ 


No growth 


A 


A 


5 


» II 


, 


B.C.C. and Streps. 


A 


A 


n 


16 


, 


Offensive 


D 


A 




,, 20 


, 


Streps. 


D 


A 




25 


, 


B.C.C. and Streps. 


A 


A 


5 


26 


, 


B. Tetanoides 


A 


D 


4 


3D 


, 


Offensive 


D 


I) 




48 


, 


,, 


D 


D 




„ 48 


' 


" 


A 


D 


11 



125 



E. Farquhar Murray 



Offensive lochia or the discharge of pus from the wound 
during convalescence is suspicious of antecedent infection. 

During convalescence each day on which the temperature 
was above ioo° F. was noted, unless it could be attributed to 
some definite cause, e.g. breasts. The following average duration 
of pyrexia was met with : — 

Membranes Unruptured. 

(17 cases) Labour under 12 hours .... 2 days 
(13 cases) Labour over 12 hours. . . . . 3 „ 

Membranes Ruptured. 

(18 cases) Labour under 12 hours .... 5 days 
(5 cases) Labour over 12 hours 7 „ 

Results. — Forty-three cases operated on early in labour with 
unruptured or recently ruptured membranes showed 100 per 
cent, maternal and fcetal survival. With the exception of two 
anaesthetic deaths the cases which died were all very exhausted 
and definitely infected. 

Maternal Deaths — CASE I. — A ii-para with a c.v. 3 inches 
had been forty-eight hours in labour and the membranes 
ruptured for sixteen hours. She was very exhausted, the pulse 
being 132 and the temperature 97-2° F. Attempts at forceps 
delivery had been made for two and a half hours on a head 
above the brim. One c.c. of pituitary extract had been injected, 
and this necessitated almost continuous anaesthesia for several 
hours until she was brought to the hospital. 

On opening the uterus the liquor was found to be offensive 
and the placental site appeared septic. The child survived, 
but the patient died on the third day. 

Post-mortem. — Septic endometritis, suppurative peritonitis, 
and toxaemic changes in the organs were found. 

CASE II. — A i-para with a c.v. 2\ inches had been in labour 
forty-eight hours and the membranes ruptured for thirty-six 
hours. She was very exhausted and the pulse was 144. 
Numerous attempts had been made at delivery with forceps of 
the head which was above the brim. Finally the head was 
perforated. 

The uterus was in tonic contraction, and, at operation, the 
lower uterine segment was found to be extravasated with blood. 
The upper uterine segment was bloodless, and appeared on 

126 



Caesarean Section 

section like wet leather, and a rapid subtotal hysterectomy was 
performed. The patient died shortly after the operation was 
completed. 

Cultures of the liquor grew streps and B. coli. 

Post-mortem. — There. was no peritonitis but the vagina was 
extensively lacerated. Section of the uterine wall showed acute 
inflammatory cedema and necrosis with streptococci present in 
the musculature. 

Case III. — A i-para with a c.v. 3I inches and a funnel- 
shaped pelvis, had been in labour with ruptured membranes 
for forty-eight hours, and the child was dead. Bandl's ring 
was present, the head was above the brim, and there was 
an offensive vaginal discharge. At operation the peritoneal 
cavity contained blood-stained serum and the lower uterine 
segment was extravasated with blood. The upper uterine 
segment was in tonic contraction, and the veins were flattened 
and empty. On opening the uterus the liquor was offensive 
and the placental site appeared septic. She died on the third 
day. 

Cultures of the liquor grew streptococci. 

Post-mortem. — Peritonitis was present and the lower uterine 
segment was gangrenous and pulpy. The anterior vaginal wall 
was bruised, lacerated, and surrounded by gangrenous inflamma- 
tion, and there was a sloughing erosion on the posterior wall 
of the bladder. An acute haemorrhagic inflammation extended 
through the left broad ligament up to the lower pole of the 
kidney. Broncho-pneumonia was present in both lungs and 
the other organs showed toxic changes. 

Case IV. — A iv-para with a c.v. 3 inches had been in 
labour twenty-four hours and the membranes ruptured for 
twenty hours. She was very exhausted, the pulse was 120 
and the temperature 99 F. She had had a discharge for some 
days and the vulva was sore and excoriated. The chorion 
appeared sloughy and cultures from the liquor grew strepto- 
cocci. She died, but the child survived. 

Post-mortem. — There was no peritonitis, but there was a 
slight purulent exudate over the uterine incision. Septic 
endometritis was present, especially about the site of the 
uterine incision. Both lungs showed commencing broncho- 
pneumonia and pleurisy. 

127 



E. Farquhar Murray 



Case V. — A i-para suffering from eclampsia and with a 
badly contracted pelvis had been in labour several days. The 
child was dead and its scalp had sloughed due to pressure on 
the promontory of the sacrum. 

Post-mortem. — General peritonitis and a hole in the 
posterior wall of the lower uterine segment were found. 

Case VI. — A ii-para with albuminuria had been in labour 
three days and the membranes had been ruptured twenty-one 
hours. The head was above the brim and markedly moulded. 
The child survived but the patient died of septicaemia and 
peritonitis. Neither cultures nor a post-mortem examination 
were obtained. 

Case VII. — Anaesthetic death. 

CASE VIII. — Anaesthetic death. This patient was very 
exhausted and had had several previous anaesthetics and one 
attempt at forceps delivery. 

Case IX. — See placenta praevia. 

Case X. — See occipito-posterior. 

Fcetal Deaths. — Mother Survived: — 
i. Infected case; 84 hours in labour; membranes ruptured 
48 ; much moulding. 

2. Labour 1 1 hours ; membranes ruptured 6 ; head above 

brim ; vessels in cord thrombosed. 

3. Infected case ; membranes ruptured 26 hours ; Bandl's 

ring ; frequent forceps. 

4. Labour 24 hours ; forceps before admission ; cord 

prolapsed. 

5. Labour 17 hours; head above brim ; cord prolapsed. 

6. Labour 20 hours ; head above brim ; macerated. 

7. Labour 29 hours ; membranes ruptured 23; child had a 

spina bifida. 

8. Infected case; labour 31 hours; membranes ruptured 

6 hours ; prolapse of cord. 

Mother Died : — 

1. Child's head perforated before admission. 

2. Membranes ruptured 36 hours; Bandl's ring; frequent 

forceps. 

3. Obstructed labour and eclampsia. Child's scalp necrosed 

due to pressure. 

4. Central placenta praevia ; patient blanched and collapsed. 

128 



Caesarean Section 

The deaths of babies could not be attributed to the operation, 
as, with the sole exception of one or two in the last stages of 
foetal distress, the others were known to be dead. 

The only point for discussion is whether, presuming the 
death of the child, the mother could have been delivered safely 
by any other method. 

Delivery by forceps was out of the question apart from the 
fact that it had already been tried in a number. 

Version was also contra-indicated, either by the pelvic 
measurements, or by the condition of the uterus, which in some 
cases was on the point of bursting or tightly gripped the child 
in a Bandl's ring. 

Craniotomy is certainly not justifiable if the child is alive, 
but where the child is dead it might be considered on a head 
well down in the cavity. 

Cesarean Section or Craniotomy. — The case for Cesarean 
section is as follows : Let it be granted that the twelve babies 
were known to be dead when the patient was seen. Eight of 
the mothers left the hospital alive and well. Four died ; each 
of the four was profoundly exhausted, and could not have stood 
an anaesthetic lasting many minutes. Three were definitely 
infected, one of whom had a c.v. of 2| inches, and one had 
eclampsia (see Maternal Deaths 2, 3, 5); the fourth was a case 
of central placenta prsevia — a multipara who was blanched and 
had chronic nephritis. 

Craniotomy on a head above the brim of a contracted pelvis, 
with an os 1/3 to 1/2 dilated, would in itself tax the skill of an 
expert obstetrician. Add to this a Bandl's ring gripping the 
child's neck, the lower uterine segment on the point of bursting, 
the tissues bruised and highly infected, the mother profoundly 
exhausted, and the procedure becomes sheer folly. Craniotomy 
on live children has been recommended in septic cases with a 
view to avoiding Caesarean section. The criticism of this is the 
difficulty of proving infection, and its wisdom as a procedure 
even in the presence of proved infection. The bacteriological 
table contains nine proved cases of infection ; of these five 
mothers recovered— the four who died would almost certainly 
have died in any case — five children have survived who might 
therefore have been craniotomised had the operation been 
practicable (see Maternal Deaths 1, 2, 3, 4). 

Hysterectomy in infected cases : a subtotal hysterectomy, 
presumably to remove the placental site after the risk of infection, 
obst. 129 1 



E. Farquhar Murray 



is not indicated in suspect cases, and as a procedure in late 
cases is merely playing with the fringe of the trouble which by 
that time is deeply spread in the surrounding tissues. The 
post-mortem reports are amply confirmatory. This applies also 
to a total hysterectomy. 

Technique in Infected Cases. — The patient is put in the 
lithotomy position, and the vagina is douched out with eusol. 
The uterus is eventrated and held well forwards, and after being 
packed round with swabs, the edges of the abdominal incision 
are clipped together over the swabs. Towels are wrapped round 
the uterus outside the abdomen, and are further protected by 
a layer of rubber sheeting. The fundus is incised transversely 
and the child extracted. An assistant holds the anterior and 
posterior walls apart, and thus prevents separation of the placenta 
until the muscular funnel lined by the placenta and membranes 
has been well douched out with eusol, the fluid escaping readily 
at the vagina. The placenta and membranes are then pressed 
down into the vagina with swab pressure, and extracted from 
below. The cavity is flushed again with eusol, and the uterus 
and abdomen closed as before. 

The peritoneal cavity is well protected, and the uterine 
incision avoids the very vascular placental site, which is 
protected from infection until the membranes have been well 
flushed. Extraction of the placenta from below prevents the 
more highly infected membranes in the lower pole from being 
dragged over the placental site and wound edges. This is only 
possible if the os is half or more dilated. 

This technique has been adopted in five cases, but in one 
the placenta had to be extracted through the abdominal incision 
owing to insufficient dilatation of the os. 

One very late case died (see Maternal Deaths 4). All the 
cases were believed to be infected although only proved by 
cultures in two, both of whom survived. Four live children 
resulted, the fifth being dead at the time of operation. 

After Results. — One of the mothers has since had a 
Cesarean section at the time of election with no evidence of 
thinning of the old scar. 

Placenta Prcevia. — Section was performed on four occasions. 
Three primiparae with placentae over the os were successfully 
delivered of live children (7J-, jh, 6| lb.). Two of them had 
been plugged before operation. 

One a vi-para, with chronic nephritis and general oedema, 

130 



Caesarean Section 

and blanched from loss of blood due to central placenta praevia, 
died shortly after the operation. The child was still-born. 

The placenta in the former cases was definitely elongated, 
and suggested that it had undergone stretching in the long 
axis of the uterus during the development of the lower 
uterine segment. 

The course of the operation gave rise to no anxiety from 
bleeding. The operation should always be considered in the 
child's interests if it is near term, especially in primiparaj and 
where the placenta is partially or wholly over the os. 

Prolapse of Cord. — If this is associated with pelvic contraction, 
and there is the least doubt about the safety of version, in the 
mother's interests, lest her uterus rupture, or the child's interests 
as its head comes through the brim, the wisest course is to leave 
the condition alone and make immediate arrangements for a 
section. In the majority of cases the child is dead, and the whole 
concern is to arrange for the safe delivery of the mother. 

Occipito Posterior. — Obstructed labour resulted from this on 
three occasions, the head in each case being above the brim. 
All were multiparas, and two gave a history of normal deliveries. 
Bandl's ring was present in both and rendered a version 
impossible. Live children resulted in each case, but one mother 
with a badly bruised lower uterine segment, died of septicaemia 
and peritonitis. The liquor was offensive but no culture was 
taken or post-mortem performed. 

Pendulous Abdomen. — A woman with marked Pott's 
curvature was delivered through a fundal incision. Her 
chest rested on her pelvis and compelled the uterus to grow 
horizontally forwards. In labour the direction of force would 
have driven the child's head against the spine. 

Undue importance is attached to pendulous abdomen as a 
sign of contracted pelvis. 

Tumours. — Five cases of obstruction were due to tumours, 
some being seen late in labour after many examinations and 
attempts at forceps delivery. In two cases the pelvic fibroid 
simulated the fcetal head, and this caused delay in diagnosis. 
The diagnosis in labour between an impacted ovarian and 
posterior fibroid is difficult. 

Fibroids (3). — 1. Elderly primipara with large multiple 
fibroids ; Caesarean section followed by a subtotal hysterectomy. 
2. Large cervical fibroid. Caesarean section ; fibroid to be 
removed later. 

131 



E. Farquhar Murray 



3. Large cervical fibroid ; liquor offensive ; uterus and 
abdomen closed. Developed a large abscess which burst 
through the wound, and later required a secondary suture. 
Six months later the abdomen was opened, and merely 
a few peritoneal adhesions indicated the previous infection. 
The fibroid was enucleated ; the patient is now seven months 
pregnant. 

In dealing with fibroids where it is hoped to conserve the 
uterus, the question of accessibility and vascularity will decide 
whether to attempt removal at the time of section or postpone 
till involution is complete. In infected cases the latter course 
is certainly the wiser one to adopt. 

Ovarians (2). — Both cases required section before the 
ovarian cyst could be disimpacted and removed. Tapping 
such a tumour p. v. does not commend itself owing to doubt as 
to its exact nature. It was quite out of the question to push 
the tumour past the presenting part. 

Cervical and Vaginal Stenosis. — A patient with cervical 
stenosis showed signs of obstructed labour, the os was closed, 
rigid, and difficult to reach. She had been twice curetted. A 
number of these cases met with have responded to incision of 
the fibrous ring, but this was not possible here. 

The vaginal stenosis could not be explained. An elderly 
multipara with a ring of contraction below the cervix was 
watched carefully in the later months of pregnancy, and 
early in labour, but as the ring showed no relaxation a 
Csesarean section was performed. 

Eclampsia (2). — Both cases had in addition marked pelvic 
contraction and obstructed labour. One died later from 
sloughing of the lower uterine segment ; the baby was dead. 
The other had a fit on the table and was operated on while 
unconscious ; an anaesthetic was given when stitching up. 
Both she and the baby survived. 

Discussion. 

The President, Professor B. P. Watson, said — We have all listened 
with interest to this paper. It is well that we have those two papers 
together — the one by Dr Cameron giving an account of his series of 
cases, all of which did well, as the result, as he said, of careful selection, 
and one by Dr Murray giving the record of a number of cases which 
he tackled irrespective of the presence or absence of infection. To 
me the chief interest is in his method of dealing with those cases 

132 



Cesarean Section 

which arc presumably or certainly infected. I am sure that some of 
us will take, an opportunity of trying his method, which he has given 
us in such detail. 

Dr Haig Ferguson said — I congratulate Dr Farquhar Murray on 
his boldness and on his skill, and thoroughly agree that he has done 
the right thing in interfering as he has in these septic cases and thus 
giving the patients some chance of recovery. I entirely disagree with 
Dr Ranken Lyle's statement that craniotomy should never be per- 
formed. In the case of a dead child with the head in the pelvis it 
was clearly indicated, and even in a living child it might be indicated 
if on account of sepsis and previous manipulations a Cesarean section 
was deemed to be too dangerous for the mother. Dr Farquhar 
Murray's technique in regard to the cleansing of the uterus in septic 
cases seems to me very useful and important. In such desperate 
cases as Dr Farquhar Murray had brought forward the interests of the 
mother would be better served by doing a hysterectomy rather than 
by attempting to cleanse the badly infected uterus. I should like to 
ask what were the indications of Cesarean section in the two cases 
of ovarian tumour which Dr Murray spoke of? 

Dr Fordyce said — I have for long been interested in this question 
of doing Cesarean section in so-called infected cases. I have been 
struck with the success attending Cesarean sections on several 
occasions in undoubtedly septic cases when no other method of 
delivery was available. In cases, on the other hand, where the patient 
has died following the operation it was impossible to say if death 
would not also have followed craniotomy. In a bad case of infection 
Dr Murray's pathological findings seemed to show that the chances 
of recovery after craniotomy were almost less than where Cesarean 
section was done. 

Dr Johnstone said — The first thing that struck me in what Dr 
Farquhar Murray said was that in Edinburgh we are fortunate in 
having a very different level of practice outside hospital. We rarely 
if ever see quite such appalling cases as Dr Murray has described. 
In the second place, I was struck by the characteristically dogmatic 
statement of Professor Lyle that craniotomy should have no place in 
midwifery. If I may be allowed to be equally dogmatic, I would 
say that, frankly, I think that is nonsense. I think craniotomy has 
a very real place, but this is not the occasion on which to state what 
the place is. I was prepared, when Dr Murray began to detail his 
cases, to meet some cases which I would regard as indications for 
craniotomy. I thought to myself this is going to show us some of 
the cases where craniotomy would have been the preferable operation, 
but after hearing him I concluded that probably the patients that died 

*33 



E. Farquhar Murray 



would have died in any case In such very doubtful 'cases, it must 
remain really a matter of opinion whether it is better to sacrifice the 
child in some hope of saving the mother, or to do a Cesarean section 
in the hope of saving the child, even in the face of the almost certain 
death of the mother. One of the most interesting parts of the paper 
was the account of the method which Dr Murray has devised for 
dealing with suspect cases. It struck me as very original. I would 
like him to elucidate one particular point, and that is how he gets 
adequate access to the abdomen when the patient is in the lithotomy 
position with the thighs flexed on the abdomen. I was a little 
disappointed that he made no mention of the lower segment incision, 
because in my comparatively small experience I have done this 
operation five or six times, and I have been inclined to regard it as 
a distinct advance, especially late in labour, on the classical operation. 

Dr Davidson said — I am much more interested in Dr Murray's 
paper as he has not specially selected his cases. I was struck by his 
remark that he had noticed definitely some sub-peritoneal haemorrhage 
beneath the loose peritoneal covering of the lower uterine segment. 
Does he consider that a preliminary stage toward rupture? Another 
point of interest was the question of Caesarean section versus craniotomy 
when the child was dead. The same point occurred with me a 
few days ago, the cord having ceased to pulsate in a case where the 
head was very freely movable above the brim, though the cervix had 
been fully dilated an hour or two. In such cases is the best course 
to perform Cesarean section or craniotomy? In such cases I am 
inclined to think that Cesarean section is a safer operation than 
craniotomy for the mother, the child being a negligible factor. 
I was most interested in the case Dr Murray quoted of pregnancy 
with a cervical fibroid. I had a similar case a few years ago and 
consulted the late Dr Haultain about it. He told me he had had two 
such cases and in both he had performed Cesarean section and left 
the tumour to be dealt with afterwards. In the first case the result 
was fatal to the mother from an apparently septic infection of the 
tumour; in the second, a very protracted convalescence followed from 
the same cause. I therefore removed the tumour at the same time 
as I performed the Cesarean section, with the happiest result. I 
found the tumour extremely easy to enucleate as the capsule was so 
loose, and I have no doubt that removal of such a tumour at the same 
time is the preferable line of treatment. 

Dr Young said — These two papers have raised some interesting 
points in connection with the whole question of treatment of con 
tracted pelvis by Cesarean section, and I think, whilst we are all 
prepared to congratulate Dr Cameron on his unique results, we have 
a feeling that in all probability there were certain cases which, 

134 



Caesarean Section 

under ordinary fair conditions quite suitable for Caesarean section, he 
declined in order to maintain his record unsullied. At the same 
time we will probably admit that the technique which he has evolved 
has contributed largely to his excellent results, and for that reason we 
are very willing to profit by his teaching and experience. At the 
same time the paper we have had from Dr Farquhar Murray is one 
which appeals to the unprejudiced mind as a more serious effort to 
tackle a difficult problem, and I am quite sure that Dr Murray's paper 
will be recognised as a valuable contribution to this whole discussion. 
At the same time if we take Dr Ranken Lyle as expressing ex cathedra 
the teaching in Newcastle with regard to craniotomy, I think it is right 
that we should voice a word of protest. I agree with Dr Johnstone 
that it would be a very unwise thing if we made such an uncom- 
promising pronouncement on an operation which has established itself 
as a valuable operation, especially in possibly septic cases. I do not 
think that Dr Farquhar Murray has proved that these cases, which 
he lost by Caesarean section, might not have been saved by craniotomy. 
Then with regard to the question of craniotomy in a living child. 
I remember in a discussion in America some years ago, when this 
whole problem was raised, Professor Munro Kerr made a statement 
that in a large number of cases the interest of the mother and her 
subsequent reproductive history might be to sacrifice a living child. 
I am inclined to agree with this statement. 

In reply, Dr Farquhar Murray said — With reference to Dr 
Johnstone's remarks about craniotomy, I know that Professor Lyle 
considers craniotomy of live children unjustifiable, and that with 
the possible exception quoted in my paper, considers that Caesarean 
section provides a safer method of delivery than craniotomy in the 
case of dead children. My experience of craniotomy is limited to 
some half dozen cases where the child was known to be dead. On 
each occasion I regarded it as a long, difficult, and dangerous 
operation. I have been very impressed by the exhausted condition 
of many of the patients when first seen, and where the question of 
Caesarean section versus craniotomy might arise. They cannot stand 
a long anaesthetic nor much interference, and a section provides the 
quickest method of delivery. In the one case in which I wavered 
between advising a Caesarean or a craniotomy, owing to the badly 
lacerated condition of the lower vaginal tract, I found on a detailed 
examination under anaesthesia that the uterus was already ruptured 
into the broad ligament. The experience gained by operating on 
late cases of obstructed labour has fully convinced me of the peril 
of attempting to pass craniotomy forceps between the foetal head 
and the extremely thinned-out lower uterine segment. I have no 
experience of the lower uterine segment incision, but I believe there 

135 



E. Farquhar Murray 



are statistics to show that the morbidity is slightly less than is the 
case with the upper uterine incision in septic cases. I attribute this 
entirely to the fact that the placental site and sinuses are protected from 
infection until the liquor has drained away and afterwards during the 
process of stripping off. The lithotomy position does not interfere 
with access to the abdomen if the legs are kept well out. 

Dr Fordyce asked if I considered there was great advantage to 
be gained by my special technique in very late cases. I do not think 
that any form of douching will be of great help where the whole 
chorion is infected, but the technique I adopt cuts down the risk of 
further infection to the minimum. The fundal incision certainly 
avoids the main part of the placental site and is usually within an 
inch of the edge of the placenta. 

Dr Young suggested that cases in which the os was 1/3 to 1/2 dilated 
might have been given a longer time in which to complete dilatation. 
I differ from him on this point as I am convinced that these cases of 
obstructed labour in which there is definite thinning of the lower 
uterine segment, owing to the formation of a retraction ring, are really 
having second stage pains, although the size of the os would suggest 
that they were still in the first stage. I have repeatedly seen such 
cases in which with persistent strong and frequently recurring pains 
the os remains practically the same size over prolonged periods. 

Dr Davidson referred to the question of the removal of fibroids at 
the time of the section. I would certainly remove the fibroid if it 
was readily accessible and there was no danger of meeting uncontroll- 
able bleeding. 

Dr Haig Ferguson asked for details about the two cases of ovarian 
cyst complicating labour. I found that I could not disimpact the 
cysts which were firmly wedged in the pelvis below the presenting 
part until I had emptied the uterus. 

I am indebted to my chief Professor Lyle for much valuable advice 
on many of the practical points dealt with in this paper. 



i3< 



A NOTE ON PELVIMETRY.* 

By S. J. CAMERON, M.B., F.R.C.P. and S. (Glasgow), and 
J. HEWITT, M.B. (Glasgow). 

For many years vvc have been dissatisfied with the results of 
the usual bimanual method of estimating the relative size of 
the foetal head and maternal pelvis. Similar dissatisfaction 
has been expressed to us by several of our colleagues, and 
accordingly we have carefully investigated this method of 
pelvimetry to determine the sources of error. 

As a result of our observations, we are satisfied that one of 
the main fallacies of the method is the attempt to depress the 
head into the brim with one hand. Time and again we have 
effected an easy forceps delivery in cases in which we had 
failed to obtain even partial engagement by the use of the 
bimanual method, and we are convinced that if he rely on this 
form of examination the practitioner will perform many an 
unnecessary Caesarean section. It is pure theory to argue 
that by using his own hand the examiner can maintain the 
head in the most favourable attitude and position, and can 
exert pressure in the proper axis more accurately than can an 
assistant. Evidently the value of an assistant to push the head 
down with both hands was appreciated by that great authority on 
antenatal work, the late Dr J. W. Ballantyne, for, in a discussion 
on pelvimetry in Edinburgh on I2th January 1 921, he remarked 
on the advantage of having " two examiners for some of the 
difficult cases, one to push the fcetal head down into the brim 
and the other to estimate by vaginal touch how far it entered." 
This is precisely our opinion. 

We would also point out that cases of pronounced pelvic 
contraction, where most force is likely to be required, are the 
very ones where pressure is most difficult to apply, inasmuch 
as the abdomen is usually pendulous and the hand and forearm 
are obliged to adopt a cramped attitude. 

Secondly, we are of opinion that in Munro Kerr's method, as 
universally illustrated, taught, understood, and practised, the 
position of the examining hand precludes accurate estimation 
of the degree of cranial descent. 

The position of the forearm and hand during this method 
of examination is shown in Munro Kerr's Operative Midwifery. 

* Read 14th May 1924. 
op.st. 137 K 



S. J. Cameron and J. Hewitt 

In the illustration it will be observed that the flexed thumb 
lies well above the pelvic brim, and from the position of the 
forearm (which is midway between pronation and supination) it 
is evident that the index and middle fingers must be extended 
as in estimating the diagonal conjugate. That this is the 
position commonly practised is proved by the testimony of 
several obstetric teachers whom we have questioned on the 
subject, and also by the following illustration from Herman's 
"Difficult Labour" (Fig. i). 




\ 




Fig. i. — Munro Kerr's method of estimating the relative size of the fetal head 
and maternal pelvis. By kind permission, from Herman's Difficult Labour, 
Carlton Oidfield (Cassell & Co., Ltd.). 



In making our investigations on the contracted pelvis shown 
(C. V. 3") we found that external and internal contact was 
only established if the extended fingers were passed right 
back to the sacrum, and that if the thumb was to be kept in 
contact with the head the base of the index finger had to be 
pressed very firmly against the pubes (Fig. 2). 

We purposely placed the head as a posterior-parietal 
presentation to give the method the benefit of the maximum 
overlap. 

It will be observed that it is the lateral margin of the index 
finger which comes into contact with the foetal head, and 
anyone who cares to investigate our work will find that such 

138 




Fig. 




Fig. 3. 




Fig. 4. 




Fig. 5. 



A Note on Pelvimetry 

contact does not give the examiner any indication of the 
amount of descent. 

We maintain that the tips of the fingers are essential for 
this purpose, but we will show in the accompanying photographs 
that if the forearm is maintained in a position of semipronation 
while the tips of the fingers rest against the lowest part of the 
fcetal skull, the thumb is far removed from the pubes and 
estimation of the overlap is impossible (Figs. 3 and 4). 

We would suggest that if a bimanual examination must be 
made, the forearm should be fully supinated so that the palmar 
surface of the index and middle fingers is directed towards the 
anterior vaginal wall. In this position it is possible to touch 
the side of the head with the thumb and the lowermost part of 
the head with the tips of the fingers (Fig. 5). 

Munro Kerr expressly states that the estimation of the 
overlap by means of the thumb is the most important detail 
in the manipulation. In our experience the degree of overlap 
is more accurately determined by external palpation with the 
free hand, and on this point we have received unreserved 
corroboration from all with whom we have discussed the 
matter. 

In summary, therefore, we regard the bimanual method 
as unsatisfactory for the following reasons : — 

(a) The examiner's single hand is incapable of exercising 
sufficient downward pressure in difficult cases. 

(/>) The position of semipronation of the examining hand 
renders accurate estimation of the cranial descent 
impossible. 

(c) With the forearm in this position and the finger tips 

in contact with the lowest point of the head, the thumb 
will be found remote from the pubes and therefore 
cannot estimate the overlap. 

(d) Even when the examining hand is fully supinated and 

the thumb placed on the side of the head, the estima- 
tion of the overlap cannot be made so accurately as 
is possible by external palpation with the free hand. 

Consequently, it seems to us that in our teaching and practice 
we will have to revert to the discarded methods of Muller and 
Pinard, of which Kerr's is a modification. We suggest that the 
head be forced downwards by an assistant, while the examiner, 
keeping his forearm fully supinated and the tips of his index 

obst. 139 K 2 



S. }. Cameron and }. Hewitt 

and middle fingers on the lowermost part of the head, estimates 
the degree of descent. Thereafter the amount of overlap 
should be estimated by unrestricted external palpation with 
the free hand. 

Discussion. 

The President said : I have experienced the same difficulty as has 
been mentioned in this paper — the difficulty of pressing down the head 
with one hand and estimating the overlap with the other. If I am single- 
handed I prefer to estimate overlap by external palpation alone, simply 
placing the fingers of the right hand over the front of the pubes and 
pressing the head down with the other. In carrying out the so-called 
Munro Kerr procedure I always have an assistant to press down the 
head, feel the amount of engagement with the fingers of the right hand 
in the vagina, and estimate the overlap with the fingers of the left hand 
placed over the pubes. There is another thing to be taken into 
consideration — the degree of pendulousness of the abdomen and also 
the inclination of the plane of the pelvic brim. These are both 
important things in coming to a conclusion as to the relative size of 
the head and the pelvis. If the inclination of the pelvis is altered in 
one way or in another, or if the abdomen is pendulous, the head may 
not be engaged in a primipara even at the beginning of labour, and 
yet, as labour goes on, the head moulds in quite readily. 

Dr Haig Ferguson said : The authors of this paper have done a 
useful thing in bringing forward the inaccuracy of the diagram 
illustrating Munro Kerr's method of estimating the relationship of the 
fcetal head to the pelvic brim. As a matter of practice we are all in 
the habit of examining with the internal fingers in supination. I agree 
that in many cases the abdominal pressure by both the hands of an 
assistant is of great help, at the same time the internal fingers are 
essential to estimate whether the head is being pushed down in the 
proper axis of the pelvis. One instinctively supinates the fingers of 
the internal hand while carrying out Munro Kerr's method in spite 
of the incorrect diagram which Drs Cameron and Hewitt have done 
well to call attention to. 

Professor Ranken Lyle said : In examining these cases to find out 
how far the head will descend, I always press the head into the brim 
with my left hand, or get an assistant to help me. In addition I place 
my hand flat on the head and on the front of the pubes to estimate 
the overlap, and if I find that the surface of the head is exactly on the 
same level as the front of the pubes, I assume that the head will most 
probably descend into the pelvis during labour. If the front of the 
head, however, is more prominent than the front of the pubes, I feel 
convinced that the head will not automatically enter the brim. 

140 



A Note on Pelvimetry 

Dr Fordyce said : Dr Hewitt has demonstrated very clearly that 
it is impossible to estimate the amount of descent of the head with 
the hand in the position as generally figured in Munro Kerr's method, 
and doubtless in future this will be altered. Every method of 
estimating the relative size of the head to the brim of the pelvis by 
making the head engage by external pressure is open to the fallacy 
that one can never be certain, first, if one is making the head engage 
in perfect flexion as nature would do when labour sets in, and second, 
one can never be sure how much moulding of the head will take 
place. In minor degrees of pelvic deformity I always allow the patient 
to go into labour and am guided as to further treatment by noting the 
effect of labour on the descent of the head. It is surprising how often 
labour terminates naturally in cases where there has been a consider- 
able degree of overlapping at the end of pregnancy, and which 
seemed to indicate a disproportion warranting induction or Cesarean 
section. 

Dr Fraser Lee said : As one of Dr Munro Kerr's old residents, I 
have watched him examine cases with his method many times, and 
that diagram shows that it is a physical impossibility with the two 
fingers in that position. I have never seen Dr Munro Kerr have any 
difficulty, therefore it is obvious that his fingers are in the position of 
supination. With the thumb you can have a very fair idea of the 
amount of overlapping of the pelvic brim, and whether the head will 
ultimately mould in or not. 

Dr Johnstone said : As Mr Cameron and Dr Hewitt have shown 
the manoeuvre illustrated in Dr Munro Kerr's illustration to be a 
physical impossibility, it is reasonable to believe that the diagram is 
really at fault. In my experience one hand is rarely strong enough 
even to push down the head sufficiently, and even if one could, by any 
acrobatic ability, force the fingers into the required position, the left 
arm has not enough power to push the head sufficiently far down. 
Therefore I have always been in the habit of using an assistant. 

In reply, Dr Cameron said : We brought up that point about the 
difficulty experienced in controlling the head with the hand in cases 
of pendulous abdomen. We consider that is absolutely impossible in 
pronounced pendulous abdomen that one hand can do it : two hands 
must be used. This is well exemplified in the difficulty experienced 
in steadying the head during craniotomy in many cases of contracted 
pelvis. We would direct the attention of Drs Haig Ferguson, Lee 
and Johnstone to the fact that the illustration figured in Munro Kerr's 
Operative Midwifery is not a diagram as they believe, but an actual 
photograph of the author's arms and hands demonstrating his own 
method, and as it has repeatedly appeared, the natural conclusion is 

T41 



S. j. Cameron and J. Hewitt 

that it illustrates the author's method to his satisfaction. Not only so, 
but this fallacious procedure has been and is being taught in the 
various schools throughout the Kingdom as is evidenced by fig. i, 
which demonstrates the procedure as understood by Carlton Oldfield 
among other teachers of obstetrics. Moreover, every teacher of 
obstetrics and practitioner whom we have asked to place his arms 
and hands in the position occupied during this method of examination 
has placed them in the position shown in the photograph. Indeed, 
the universal acceptance of this impossible manoeuvre was one of the 
factors which prompted us to make this communication. 



142 



Meeting — 12th June 1924. 

PRIVATE BUSINESS. 

The following were elected members of the Society : — John Hewitt, 
M.B., Ch.B. (Glasgow); Isabel Falconer King, M.B., Ch.B., D.P.M. 
(Lond.); J. C. Moir, M.B., Ch.B. 

EXHIBITION OF SPECIMENS. 

Dr Fordyce showed — (1) Large submucous fibromyoma, 
showing well-niarked red degeneration. The patient, a 
nulliparous woman, was aged 46, and had been bleeding excessively 
for the past three years. During the last six months the haemorrhage 
had been more or less continuous so that she was profoundly anaemic. 
She had no temperature and no foetid discharge. The tumour was 
easily removed, and the interesting point about it was that on 
making a section immediately after the operation there seemed to be 
a considerable part of the tumour actually bursting through the 
capsule. There was a large mass of necrotic tissue, which seemed 
to be a part of the tumour, which had burst through the capsule and 
was lying in the uterine cavity. 

(2) Puerperal uterus with large fibroid tumour. The 
patient was seen on account of severe haemorrhage occurring during 
the fourth month of pregnancy, and a large fibroid mass in the lower 
part of the uterus was found which seemed then to render abortion 
almost impossible; it was decided therefore to delay interference. 
There was another haemorrhage at the seventh month, and another 
again after admission to a nursing home for Cassarean section. The 
foetus was removed with difficulty, and then, after the placenta was 
removed, the whole uterus was extirpated. To remove the fibroid 
alone was quite impossible. 

(3) Unusual pelvic tumour simulating ovarian cyst. This 
was removed from a patient, aged 53, who was sent to the Royal 
Infirmary from the north of England, with a history of a swelling in 
the right side which had lasted for eighteen months. The patient had 
no other symptoms. There was a large abdominal swelling about 
the size of an eight months' pregnancy. It seemed at first to be a 
simple ovarian tumour but exhibited some unusual features. On 

143 



Exhibition of Specimens 

opening the abdomen it presented the bluish-white appearance of 
an ordinary ovarian cyst, but in passing one's hand down into the 
pelvis one found that there was a fleshy, thick attachment to the fundus 
of the bladder which was not an adhesion. On passing one's hand 
round behind this, one found the uterus lying behind the tumour to 
which the surrounding structures were adherent, especially the 
appendix, which was very much stretched and which one had to 
remove. While removing the mass from its pedicle and stitching 
over the peritoneal raw surfaces, the uterus was found lying behind 
and freely movable with both broad ligaments and both ovaries ; 
the tumour, therefore, was not ovarian in origin. The pathological 
report, beyond stating that the cyst wall was composed of well- 
formed fibrous tissue, threw no light on the nature or origin of the 
growth. I can only suggest as a possibility that the tumour was 
growing from the urachus. 



(4) Tubal pregnancy. The patient, a young married woman 
of 25, complained of pain in the left side four weeks before admission 
to hospital, and a week later had a sudden, sharp, agonising pain and 
complete collapse. A week later she had another attack of pain 
followed by collapse, sickness and vomiting, and a day before 
admission, a third attack. In ordinary circumstances one would have 
expected to find that the ovum was so disintegrated that it would 
be dead, and that possibly there would be much intraperitoneal 
hemorrhage. There was no free haemorrhage. After removing the 
cyst, the embryo proved to be still alive and showed active movements. 
I have never seen a foetus of this size kicking so vigorously. The 
patient travelled from Fife to the Infirmary just before the fourth 
attack, and was fortunate to have escaped a more serious haemorrhage. 

Professor B. P. Watson showed — (1) a uterus showing great 
hypertrophy of supravaginal cervix from case of prolapse. 
This specimen illustrates very well the great elongation of the 
supravaginal portion of the cervix which occurs as the result of 
prolapse. The uterus was removed by vaginal hysterectomy, a 
procedure which I sometimes carry out in cases of complete procidentia. 
After removal of the uterus, the broad ligaments are stitched together 
to form a new pelvic floor, according to the method first fully described 
by Mayo. When cystocele is marked the bladder is placed on the 
upper surface of the united ligaments, the vaginal roof is stitched to 
the under surface of the ligaments, and an extensive pelvic floor repair 
done. In my experience this is the operation which has given me the 
best results in those cases of complete prolapse. 

144 



Exhibition of Specimens 

(2) Large chocolate cyst of ovary. Miss G. W., aged 27, 
nullipara, has never been very, strong and has always lost rather 
excessively at her menstrual periods, especially when menstruation 
first began. She never had any pain until five or six months before 
operation, when she began to have severe pain lasting for twenty-four 
or thirty-six hours before the period. She has also in the last two 
months had fairly severe pain, lasting for about twenty-four hours 
midway between the periods. Examination showed a distinct swelling 
on the left side of the pelvis, which was rather firm in consistence, 
fixed and tender. Operation. — On opening the abdomen a cyst about 
the size of an orange was found on the left side. It was densely 
adherent to the intestine, to the back of broad ligament and surround- 
ing structures. In freeing it, it ruptured, and a quantity of chocolate- 
coloured fluid escaped. It was dissected out with considerable 
difficulty and removed together with the tube. The right ovary and 
tube were quite healthy. There was no evidence of adenomas else- 
where in the peritoneal cavity. Examination of the wall of the cyst 
shows in one area a gland exactly like a uterine gland; there is no 
stroma surrounding it. Throughout the wall there are numerous areas 
of fresh haemorrhage, but in none of these can any tissue resembling 
endometrium be detected. 



(3) Large ovarian tumour complicating pregnancy. Mrs 
M'S., aged 40, para iii. Patient had three previous pregnancies and 
labours, all of which have been normal, the last being fourteen and a 
half years ago. Two and a half years ago she noticed that the 
abdomen was enlarging. The enlargement has progressed very slowly; 
in fact she did not notice herself getting much bigger until five months 
before operation. During the past five months the abdomen has 
enlarged very markedly and quickly. Six months prior to operation 
her menstruation stopped, the date of the last period being at the 
beginning of November 1923. She did not pay much attention to this, 
as she had had a period of amenorrhcea lasting for five or six months 
twelve years before. On admission the abdomen was found enlarged 
up to the ensiform cartilage — the veins prominent and skin tense. 
There was dullness over the whole abdomen, except for a very small 
area in the left flank. On palpation the swelling felt tense and uniform, 
except that a distinct sulcus could be detected about the level of the 
umbilicus running obliquely across the abdomen outwards and down- 
wards towards the left side. Below the sulcus the consistence of the 
swelling was slightly different from that above. 

On vaginal examination the cervix felt distinctly soft, was lacerated, 
directed downwards and backwards. The uterus could not be distinctly 
outlined bimanually, but, on the softening of the cervix, the feeling 

145 



Exhibition of Specimens 

of expansion in the vaginal fornices, and the distinct sulcus above 
mentioned, the diagnosis of six months' pregnancy plus ovarian tumour 
was made. It was evident that operation was immediately required 
owing to the amount of distention of the abdomen. The abdomen 
was opened by a long incision just to the right of the middle line 
extending from half way between umbilicus and ensiform down to 
pubis. On opening the abdomen the diagnosis was confirmed. The 
tumour was a very large one pressed up beneath both costal margins. 
It was delivered entire and removed in the ordinary way. From the 
time of operation the patient was greatly distressed by abdominal 
distention. This was partially relieved by the administration of 
enemas, as the result of which she got rid of a fair amount of flatus. 
The stomach was washed out on several occasions. On the fifth day- 
she was still distended, and was given ^ grain of physostigmine and 
\ c.c. of pituitrin, followed by an enema. She passed a large quantity 
of flatus and some faecal matter. That night she miscarried without 
very much difficulty, and there was very little loss of blood. The 
abdominal distention, however, continued, although she was still 
passing flatus. She slowly became weaker, and died on the tenth day 
after operation. On post-mortem examination there was free turbid 
fluid, of a yellowish colour, in the abdominal cavity, of a faecal nature, 
and a plastic exudate over both visceral and parietal peritoneum. The 
intestine was distended and very friable. The coils were adherent. 
The caecum showed several perforations, some of them probably post- 
mortem. The uterus appeared healthy for a woman who had been 
recently pregnant. 

Dr Haig Ferguson showed (with lantern demonstration) — Uterus 
showing squamoid metaplasia of gland epithelium of body 
with early malignancy, and from the same patient, ovary showing 
early sarcoma. The uterus and right ovary were removed from 
Mrs C, aged 45, nullipara, who had been suffering from continuous 
uterine haemorrhage for about two years before the operation, which 
took place on 1st February 1924. The patient had been twice 
curetted with no benefit, and the microscopical reports on the scrapings 
were negative. I thought that the condition was one of so-called 
fibrosis, and advised removal of the uterus. I accordingly removed 
the uterus by supravaginal hysterectomy, along with the right ovary 
which was cystic and had a curious papillary appearance. The left 
ovary was not removed as it was quite healthy in appearance, and the 
patient had begged that one ovary should be left if possible. I am 
much indebted to Dr Dawson for the beautiful sections which he has 
so skilfully prepared. 

Fig. 1 is a portion of the endometrium of the body showing 

146 







Mj * 



Fig. i. — Portion of endometrium showing metaplasia of gland epithelium, 
with early malignanc)'. 

a. Glands with normal columnar epithelium becoming slightly irregular. 

b. " Squamoid " metaplasia of {a). 



aoi»a» 






w? 



... f 



i| <S ot T 



,Vl» 







1 t< £ \ 



I ** 



3 



#/■ 






FlG. 2. — Ovary with areas of early sarcomatous change in stroma. 

a. Sarcoma cells. 

b. Very numerous mitoses. 



Exhibition of Specimens 

metaplasia of gland epithelium with early malignancy. (a) Glands 
with normal columnar epithelium becoming slightly irregular ; (/;) 
"Squamoid" metaplasia of (a). 

Fig. 2 shows a portion of the ovary from the same patient with 
areas of early sarcomatous change in stroma, (a) Sarcoma cells ; 
(b) very numerous mitoses. 

The specimen is particularly interesting in showing clearly the 
gradual transition from columnar to squamoid epithelium in the body 
of the uterus, and the early beginning of malignancy ; and in addition 
the clear demonstration of sarcomatous changes in the ovary of the 
same patient, a most unusual combination so far as I am aware. 

The patient, though still suffering from a certain amount of anaemia, 
is well, and her pelvis and abdomen seem to be quite free from 
disease. 



148 



A PENDULOUS TUMOUR OF THE LABIUM MAJUS 
EXHIBITING UNUSUAL FEATURES.* 

By JAMES HAIG FERGUSON, M.D., F.R.C.S. Ed. 

The case which I bring before your notice presents several 
points of clinical and pathological importance which I venture 
to hope may be of interest to the Society. It certainly provided 
those of us who saw it with many difficulties and anxieties 
both in diagnosis and management, the record of which may 
prove helpful to others who should happen to meet with a 
similar condition. 

The case is shortly as follows : — 

C. J., an otherwise healthy and well-nourished virgin, aged 40, 
was admitted to Ward 36, Royal Infirmary, in 1918, with a large 
interstitial fibroid of the uterus about the size of a seven months' 
pregnancy. The tumour was apparently growing fairly rapidly, and 
the chief symptoms she had were those of pressure mainly on the 
pelvic viscera, and producing inter alia obstruction to the venous 
circulation of the left lower extremity. She had in fact a condition 
of subacute phlegmasia with considerable pain and some pyrexia. A 
certain amount of improvement occurred with rest in bed, but only to 
a limited extent, and I therefore decided to operate in spite of the 
presence of phlebitis. I removed the tumour by a supravaginal 
hysterectomy, leaving both the ovaries, which were normal. The 
patient made an uneventful and rapid recovery, her leg gradually 
diminished in size and she was able to return to her duties as a 
monthly nurse within six months. I had some difficulty in persuading 
her not to begin work earlier, but I was naturally anxious that her leg 
should be thoroughly well first, and she has had no trouble with it 
since. I mention this preliminary illness as it has some bearing, as we 
shall see, on subsequent developments. 

In 192 1, the patient had a fall on her coccyx which shook her 
considerably, and shortly thereafter she noticed a swelling in the left 
labium majus. For two years this swelling gradually increased in size. 
She had practically no pain, only occasional twinges which seemed to 
radiate into the vagina. She, however, had very considerable dis- 
comfort on sitting down, especially after she had been standing or 
walking for any length of time. The swelling was tender and 
troublesome mainly because of its bulk. 

Early in 1922, she told me about the condition when she was 

* Read 12th June 1924. 
Obst. 149 L 



James Haig Ferguson 

nursing a case for me, and she asked me to look at it. This I 
remember doing rather hurriedly, and I told her I thought it was a 
fatty tumour and advised her to have it removed when she was free. 
She told me at that time that another doctor had seen it some months 
before and said it was a hernia. I may add that she never at any time 
suffered from any obstructive or other bowel symptoms, and though 
she thought the tumour varied a little in size from time to time it 
never had been reduced by taxis, and it was undoubtedly slowly 






Fig. i. 



increasing in size. I myself found it was irreducible and somewhat 
adherent to the skin, and I could find no impulse on coughing. 

Bearing in mind, however, that it had been diagnosed earlier 
as a possible hernia, I asked her to see Mr Struthers, and he kindly 
examined her and took her into his ward in Leith Hospital for 
thorough investigation. Mr Struthers at first satisfied himself after 
a chloroform examination that the swelling was really limited to 
the perineal region and had no relation to the abdomen. He 
accordingly decided to operate, expecting to find a comparatively 
simple condition. 

He operated on gth May 1922, and found an exceedingly 

15° 



Tumour of the Labium Majus 

puzzling and difficult state of matters which he well describes as 
follows : — 

" I came down on what looked like a bladder wall, but it seemed 
to have no relation to the bladder for there was no sign of a 
diverticulum. I cut into it, and eventually found my way into a 
long protrusion which seemed as if it might be related to the 
peritoneal cavity, and coming down alongside the bladder and 
vagina underneath the symphysis pubis. The upper end was so 



,H r - - tO* 



$ 



..** 






./,/>^. 






Fig. 2. 



inaccessible that it seemed impracticable to deal with it from below. 
The perineal wound was accordingly closed on the supposition that 
the condition would require to be dealt with through the abdomen. 
My present impression is that it is some extraordinary kind of hernial 
protrusion possibly following the hysterectomy of four years ago." 

The patient soon recovered from this exploratory operation, but 
the swelling of course remained, and continued steadily though slowly 
to increase in size. 

Mr Struthers came to the conclusion that the condition might 
be a variety of levator hernia (pudendal hernia), of which thirteen 
cases in all have been reported (two by Sir Astley Cooper and one 
as far back as 1769) in an interesting article by Chase in Surgery, 

151 



James Haig Ferguson 

Gynecology, and Obstetrics, vol. xxxv., 1922. All these recorded 
cases, reported in detail, seem to have been in parous women, one 
after forceps delivery associated with vesico-vaginal fistula and 
fracture of the pubes. 

The circumstances in the present case were entirely different ; there 
were no evidences of congenital deficiency of the floor or walls of the 
pelvis, and I could not agree with my friend Mr Struthers that the 
previous hysterectomy could possibly be a factor in the production of 
the condition which now faced us. 

Meantime our patient had resumed her work in spite of her 
increasing discomfort. She had the misfortune to meet with a motor 
accident which resulted in a Pott's fracture, and she was taken into the 
Royal Infirmary, where by a curious coincidence she found herself again 
happily under Mr Struthers' care. On recovery from her accident she 
made up her mind that something must be done for her labial swelling 
as the condition was becoming intolerable. Mr Struthers and I there- 
fore decided again to interfere, and she herself gladly consented to 
have anything done which we thought advisable. 

As Mr Struthers, from the experience he had of the exploratory 
operation in Leith Hospital, was of opinion that there was possibly some 
connection between the peritoneal cavity and the labial swelling, we 
decided to open the abdomen first to clear up the matter: bearing in 
mind that Chase had convincingly brought out in the description of 
his case of pudendal hernia that operation by the combined route gave 
the best results, and that the first step should be the exploration of the 
abdomen. We therefore opened the abdomen together and found that 
there was no protrusion of bowel, omentum, or peritoneum through the 
floor of the pelvis. Everything was absolutely normal in the pelvic 
diaphragm as seen from above. The two small atrophic ovaries were 
recognised, and there were no adhesions or other abnormalities to be 
discovered. Vaginal and rectal bimanual examination with one hand 
in the abdomen failed to establish any connection between the labial 
swelling and any of the abdominal contents. 

The patient made a rapid recovery from the operation, and in a 
fortnight's time was transferred to Ward 36 to have the perineal 
swelling attended to. 

On admission to Ward 36 in August 1923 (her age being now 45), 
the condition was as follows : — 

There was a pendulous swelling coming down from and involving 
the left labium majus. It was the size of a large Jaffa orange, and it 
tended to extend backwards towards the anus. The skin over it was 
smooth and unchanged in colour, and a cicatrix was visible towards its 
base, where the skin was adherent. The swelling was soft and not 
reducible, and there was no impulse to be recognised on coughing. 

152 




Telangiectatic Fibromyoma, with hyaline degeneration removed from labium 
majus, measuring 2 feet 2 inches in length. 



Tumour of the Labium Majus 

I operated on the 13th August 1923, making a free incision over 
the swelling and separating it from its skin covering. The tumour was 
densely adherent to the surrounding parts, especially posteriorly. In 
its lower part the growth was in close relationship to the anterior wall 
of the rectum, and it extended upwards and forwards until the upper 
limit lay well up behind the symphysis pubis. During the process of 
dissecting it out it gave one distinctly the impression that one was 
pulling out, hand over hand so to speak, a piece of intestine both from 
its appearance and from its consistence. 

I certainly would not have had the assurance to have continued 
pulling it down as I did, unless one had had the absolute knowledge 
and complete proof, acquired from the previous exploration of the 
abdomen, that we were not dealing with any of the abdominal contents. 
I am sure Mr Struthers will bear me out in this. 

After removal, the mass was found to consist of solid cedematous- 
looking tissue, measuring 2 ft. 2 in. (66 centimetres) in length 
without any attempt at stretching it ; at its lower part it measured 
3 in. in diameter, tapering off till it was about the thickness of a finger 
where it lay behind the pubes (Coloured Plate). There was no 
evidence of any lumen. The upper part was ligatured somewhere in 
the region of the bladder and severed as far up as possible. A smaller 
portion of tumour substance was found lying near the rectal wall, 
apparently separate from the main mass, and this was also removed. 

The cavity left after removal of the tumour was obliterated so 
far as possible with catgut sutures, the redundant skin was removed 
and the wound closed without drainage. 

The patient made an uninterrupted recovery and was discharged 
well, with a firmly healed scar, on the 3rd September 1923. She has 
since returned to her nursing duties and feels quite fit for her work. 

The tumour has been examined by several pathologists, who 
vary a little in their reports, chiefly, I think, owing to the fact 
that some of the early slides were not very well stained, possibly 
through their being taken from a portion of the tumour which 
did not stain well. Dr Dawson has taken infinite trouble in 
the matter, and has succeeded in getting some excellent sections, 
which I show. His report is : — 

" A Telangiectatic Fibroviyoma (with Hyaline Degeneration). 
— The fundamental structure underlying the different portions 
of the tumour, is that of a fibromyoma, with advanced 
hyaline degeneration and marked oedema (Figs. 1 and 2). 

" Sections taken from different parts all show this fibro- 
myomatous structure, but in some areas the unstriped muscle 
fibres have undergone almost complete atrophy. 

OBST. 153 L2 



James Haig Ferguson 

" The pressure to which the tumour growth has been subjected 
has possibly accounted for the elongated form which it has 
assumed : growth having taken place along the line of least 
resistance. 

" In addition to the underlying basic structure, secondary 
angiomatous formations (Fig. 3) — both capillary and cavernous 
— have occurred. These have been determined in part by the 
obstruction to the capillary supply of the growing tumour — and 



















I 



Fig. 3. 

in less part by a capillary new-formation secondary to small 
haemorrhages. Numerous phagocytic cells containing blood 
pigment are present in these areas. 

" There are, further, focal areas consisting of foreign-body 
giant-cells around the remaining strands of the dissociated 
ligatures (Fig. 4). A few nerve-twigs are present in the loose 
outer parts of the growth. 

" No evidence of gland elements could be found in the 
portions sectioned." 

Clinically Mr Greig was inclined to think, from the slides 

J 54 



Tumour of the Labium Majus 

that he examined, that the tumour is an exaggerated overgrowth 
of a neurofibromatosis which will show its generalised tendencies 
later on. The more recent sections, however, which Dr Dawson 
has made hardly bear out this contention. 

The only other cases at all resembling the one I have 
described which I have been able to find recorded in literature 
are : — 

(i) A myxoma of the vulva described by Simpson {Journal 
of Obstetrics and Gynecology of the British Empire, vol. viii., 













Fig. 4. 

P- 393)- I n this case the tumour became ulcerated, and haemor- 
rhage took place. Histologically it was composed of myxo- 
matous tissue with strands of fibrous tissue. 

(2) A teratoma of the labium majus (intestinal occlusion) 
reported by Duclaux and Herrenschmidt in the Bull, de la Soc. 
d anatomique de Paris, 1905, vol. Ixxx., p 406. In this case the 
tumour was the size of a goose egg in a woman of 24. The 
tumour was congenital, and, according to the patient, had not 
increased in size to any appreciable extent. It was not painful, 
but only embarrassing from its size. It had a small violet- 

J55 



James Haig Ferguson 

coloured opening on the free border of the labium majus, with 
numerous circular creases or folds exactly like that of an iliac 
anus, and opening into a cul-de-sac 5 or 6 centimetres long, 
from which a little muco-purulent fluid oozed. This patient 
had a double vagina and a double uterus. The naked-eye 
appearance of the tumour after removal resembled a lipoma. 
The tumour was removed by Segond, the operation presenting 
no difficulties as it shelled out very easily. 

The microscopic examination showed mucosa of large 
intestine, and more especially rectal mucosa. The authors came 
to the conclusion that it was a case of fcetal inclusion of one or 
more pieces of hind-gut in the surrounding tissue, isolated, 
perhaps, from the cloaca by an irregular partition. The anus 
was normal. 

I fear I may have wearied you by this detailed description 
of what must be a very rare condition, but the unusual features 
of the case, I think, justify one in recording it fully. 

Discussion. 

Professor Donald said — I have never had any experience of a 
tumour of this description, but I have seen one case of hernia in the 
perineum. That was a case in which there could be no doubt, because 
on percussion the mass was tympanitic, and when one pressed the 
swelling there was gurgling and it was partially reducible. Under 
these conditions, of course, there was no difficulty in diagnosing a 
hernia. I opened the abdomen and found a distinct gap in the levator 
muscle, and my operation simply consisted in withdrawing the 
herniated structures and stitching up the gap, making the pelvic floor 
intact. I think that if there is a hernia there, there will not be much 
difficulty in diagnosing it. 

Dr Fordyce said — I should like to know whether the base of the 
attachment was along the whole length of the labium majus and how 
far it extended down freely. 

Professor Watson — We are greatly obliged to Dr Haig Ferguson 
for bringing this rarity before us, and I am sure it will occupy an 
important place in the literature of the future. 

Mr J. IV. Struthers also spoke. 

Dr Haig Ferguson said in reply — I am sorry I have not a 
photograph of the swelling. There was nothing special to see except 
the large swelling, which involved the labium majus and extended back 
towards the anus. Mr Struthers has spoken in a modest way of what 

156 



Tumour of the Labium Majus 

he did, but I think it was greatly due to his advice to explore the 
abdomen, that I was enabled to carry on with the final operation, which 
was successful. 

Note. — Since writing the above Mr Greig has kindly 
furnished me with the following references to similar cases: — 
In the Medico - Chir. Transactions, London, 1832, xvii., u, 
W. Lawrence records a large cellular tumour occupying the 
labium pudendi which was 32 inches in its largest circumfer- 
ence. It was growing inwards along the side of the vagina. 
It recurred during pregnancy and was again operated upon. 
Lawrence refers to a similar tumour removed by Mr Earle of 
St Bartholomew's Hospital. 

Fleming reports in the Royal Dublin Pathological Society's 
Transactions, 1853-54, a labial tumour which was separated 
chiefly by traction from the neighbourhood of the sacro-sciatic 
ligament. 

Paget, in his Lectures in Surgical Pathology, 4th ed., London, 
1876, p. 454, records the removal of a tumour from the labium 
of a woman of 60 and another from a woman of 34. He refers 
to a specimen, weighing 10 lbs., removed by Liston and now in 
the R.C.S. Museum, London. These are referred to as fibro- 
cellular tumours. 

Stelwagon in Diseases of the Skin, p. 737, describes Dartoic 
Myomata which grow from the scrotum or labia and are often 
pedunculated and usually telangiectatic {Myoma telangiectodes). 
They may have developed as myoma around the walls of blood- 
vessels in the corium. 



i57 



FURTHER OBSERVATIONS ON STILL-BIRTH 
AND NEONATAL DEATH: THEIR CAUSES, 
PATHOLOGY, AND PREVENTION.* 

By FRANCIS J. BROWNE, M.D. (Aberd.), F.R.C.S. (Edin.). 

In May 1921 I presented to the Society a communication on 
this subject summarising the results of my investigations into 
a consecutive series of 200 still-births. The present paper is 
based on an investigation of a further series of 200 cases, which 
have been fully examined, and embodies the important points 
of a second report to the Medical Research Council in November 
1922. As in my first paper, I have dealt only with fcetuses of 
viable age, viz., 28 weeks or over, those of earlier age presenting 
so many points of difference in their pathology that they are 
better dealt with in a separate report. 

The method of investigation was the same throughout. A 
complete post-mortem examination of the fcetus or infant and 
placenta was made, including a microscopical investigation of 
the organs, and the history of the labour and subsequent events, 
if any, was obtained from the resident, theatre sister, and chart. 
The mother was then examined and questioned regarding her 
family and personal history and the history of her pregnancy. 
A similar examination of the father was aimed at, but he 
generally proved to be a very elusive person. 

The information thus collected was recorded and studied in 
relation to the post-mortem findings ; and from the results so 
obtained an attempt was made to arrive at a decision regarding 
the cause of death, and to draw certain conclusions of practical 
importance regarding the management of pregnane}- and 
labour. 

Some of you may remember that in my first paper I classified 
the causes of death under ten headings: (1) Craniotomy; 
(2) Asphyxia; (3) Maceration; (4) Cerebral Haemorrhage; 
(5) Syphilis; (6) Pneumonia; (7) Suprarenal Haemorrhage; 
(8) Scopolo - Morphine Narcosis; (9) Premature Birth; (10) 
Miscellaneous. 

In my second report I have classified the causes of 
death under three headings, viz. : Antenatal Death, Intranatal 
Death, and Neonatal Death, subdividing the causes of each 

* Read 12th June 1924. 
•5S 



Further Observations on Still-Birth 

in a way that will later become apparent. This classification 
is a great improvement on the one previously adopted, 
although it also possesses many defects. 

Antenatal Death. 

The causes of this have been classified as follows : — 



24 
10 

4 
1 
1 
6 



I. Toxemic — 

(a) Syphilis ...... 

(b) Placental infarction .... 

(c) Uteroplacental apoplexy. (Ablatio placentae) 

(d) Premature senility of the placenta 

(e) Maternal glycosuria .... 
(/) Eclamptic convulsions .... 
(£■) Drugs ...... 

II. Mechanical — 

(a) Placental separation in praevia ... 2 

(b) Placental separation from trauma 

(c) Knots or torsion of umbilical cord . . . 1 

III. Developmental — 

(a) One artery in cord (?) . . . . .1 

(b) Small placental area ..... 1 

(c) General oedema of foetus . . . . 1 

(d) Other congenital abnormalities . . . ... 



IV. Undetermined 



60 



From this table it is apparent that the most frequent cause 
of antenatal death was syphilis, of which there are 24 cases. 
In only 15 of these, however, was the spirochete found in the 
foetal organs, and therefore only 15, or 25 per cent, of all the 
cases of antenatal death were certainly syphilitic, the other 9 
being diagnosed by the so-called secondary signs of syphilis. 
How far we are justified in diagnosing syphilis from these 
secondary signs and in the absence of the spirochete is a 
disputed point which I shall not enter into. 

Diagnosis of the Cause of Death in a Macerated Fcetus. 

It may be of interest and helpful if, at this stage, I outline 
the chief points to which attention should be directed in the 
examination of a macerated fcetus in order to determine as far 
as possible the cause of death. 

i59 



Francis J. Browne 



In the first place we start our examination with the know- 
ledge that the most frequent single cause of intra-uterine death 
of the foetus is syphilis, therefore when one finds a macerated 
foetus there is a strong presumption that syphilis has been the 
cause of its death. 

In the examination of a macerated foetus it is not always 
necessary to examine the entire body. 

There is usually nothing in the external appearance of the 
macerated foetus by which the cause of death can be diagnosed. 
Sometimes, however, in the syphilitic foetus the abdomen is 
rather prominent on account of the large liver beneath the 
abdominal wall, while in the non-syphilitic foetus it is flattened 
or carinated because the liver is small and shrunken. I know 
of nothing else in the external appearance that will help in 
the least. 

Internally the organs to be chiefly examined are the liver 
and spleen. 

Liver. — In the syphilitic macerated foetus the liver is firm in 
consistence, of a greyish-brown colour, is frequently abnormally 
enlarged, and sometimes its surface is studded with minute 
greyish spots. This firm consistence is due to the fact that 
the syphilitic liver is frequently the seat of cirrhosis, so that it 
has a dense fibrous framework which resists the changes of 
maceration. In the non-syphilitic, on the other hand, the liver 
is extremely cellular, its glycogen content is large, there is little 
fibrous tissue, and maceration results in a rapid diminution of 
its size. The liver, therefore, in a foetus that has died from, say, 
albuminuria, and has been retained in utero for even a few days 
after death, rapidly loses weight, becomes shrunken, and dark 
red in colour from haemoglobin staining. It lies tucked up 
behind, and almost hidden by, the diaphragm, and presents 
an altogether different appearance from the large, firm, 
prominent, and rather pale-yellow liver of syphilis. 

Weight of the Liver in relation to Festal Body Weight. — A 
normal fresh liver may weigh as much as T Vth of the body 
weight. Anything over this is probably syphilitic. Usually, 
however, the liver in syphilis is considerably under this ratio 
and falls within normal limits, and so the weight of the liver 
is often of very little value as an aid to diagnosis. 

Investigating this point in the macerated foetus, I examined 
the liver weight ratios in 17 macerated foetuses in whom 
syphilis could with certainty be excluded, and found it to 

160 



Further Observations on Still-Birth 

average 29, the heaviest ratio being 17-3 and the lightest 434 
Any weight ratio which falls within these limits must therefore 
be looked upon as normal. The weight ratios of nineteen 
syphilitic livers of foetuses which were spirochete positive 
varied between 13-4 and 44, while the average was 23-2 and 
therefore somewhat higher than in the non-syphilitic. It 
follows from this that the liver of a macerated foetus showing 
a weight ratio higher than 17 is probably syphilitic. That this, 
however, is not very helpful in diagnosis is shown by the fact 
that of the nineteen syphilitic livers referred to above only 
three had weight ratios of over 17 ; these three were respectively 
13-4, 15, and 15-2. 

Spleen. — The spleen of the macerated foetus has usually 
undergone very little diminution in size. This is probably 
because of its slight glycogen content as compared with the 
liver. In my experience the spleen of a normal fresh foetus 
may weigh as much as T io-th of the body weight, and in a fresh 
foetus any weight ratio over 150 is probably an evidence of 
syphilis. In the rare condition known as general foetal dropsy 
the spleen may exceed this weight ratio, but this condition may 
be, sometimes at least, syphilitic. 

Placenta. — The placenta should next be examined. The 
important points are its weight ratio and general appearance. 

The Weight Ratio of the Placenta. 

In order to settle as far as possible the debated question 
as to whether the placental weight ratio is increased in syphilis 
or not, all the syphilitic placentas available in the course of the 
entire investigation have been considered together, and their 
weight ratios compared with those of placentas that were 
known to be non-syphilitic. In the first place, therefore, it was 
necessary to find the mean ratio of the normal non-syphilitic 
placenta, and its normal limits of variation at different age 
periods. In order to estimate this, all cases in which there was 
any possibility whatever that syphilis might be present were 
excluded, as was also necessary in the case of twins, craniotomies, 
and placentas in which there was an abnormal amount of white 
or red infarction, as in such cases the placental weight ratio 
could not be regarded as normal. Excluding such cases there 
remained 58 placentas which were all certainly non-syphilitic, 
divided up as follows: 24 full-time fresh, 14 fresh from 34 to 

161 



Francis J. Browne 



38 weeks, 13 from 24 to 33 weeks, and 7 at various periods 
from 23 weeks downwards. 

The frequency distribution of the weight ratios in these cases 
is shown in the following table : — 



Normal Placentas in Non- Macerated Foetuses: Weight Ratios. 



Period of Development. 



39 weeks and over 
34 to 38 weeks 
24 to 33 weeks 
23 weeks and under 






1-1 


2-1 


3-1 


4-1 


5-1 


6-1 


7-1 


8-1 


to 


to 


to 


to 


to 


to 


to 


to 


to 


1. 


2. 


3. 


4. 


5. 


6. 


7. 


8. 


9. 










6 


$ 


3 


7 


I 










25% 


20% 


12% 


29% 


4% 










2 


3 


S 


I 


2 










14% 


21% 


36% 


7% 


14% 






4 


4 


4 


1 












3o% 


30% 


30% 


8% 








I 


I 


3 


I 













9-1 
to 
10. 



2 

9% 



Period of Development. 



39 weeks and over 
34 to 38 weeks 
24 to 33 weeks 
23 weeks and under 



10-1 
to 
11. 



ll-l 
to 
12. 



12-1 
to 
13. 



13-1 
to 
14. 



14-1 15-1 

to to 
15. 16. 



16-1 
to 
17. 



Number 

of 
Cases. 



24 

14 

13 

6 



The mean ratio of the placenta in the case of the full-time 
foetuses was 6-4, the heaviest being 4-1 and the lightest 9-5. In 
the 34 to 38 weeks group the mean ratio was 6-9, the heaviest 
being again 4-1, and the lightest 15-2. The mean ratio in the 
24 to 33 weeks group was only 3-8, the heaviest being 2-5 and 
the lightest 5-9. Other exceptionally heavy weight ratios 
were 2-6 (2 cases) and 2-7. The history of the case with the 
heaviest weight ratio (No. 512) was as follows: v-para, all 
other children alive and well, youngest 1 year; present preg- 
nancy normal except for hyperemesis in early months ; 
admitted to hospital at sixth month with influenzal pneumonia 
and threatened abortion. Complete abortion occurred. W.R. 
negative ; placental ratio 2-5. No evidence of syphilis in mother 
or foetus. 

Of the group of cases of 23 weeks and under, details are 
given in the following table : — 

162 



Further Observations on Still-Birth 



Normal Placentas : 



Weight Ratios , 
and under. 



Twenty-three Weeks 





Weight 


Length 


Weight 


Placental 


Estimated 


No. 


of 


of 


of 


Weight 


Period of 




Foetus. 


Foetus. 


Placenta. 


Ratio. 


Development. 


590 


230 grms. 


23 cm. 


100 grms. 


2-3 


21 weeks 


609 


255 .. 


25 „ 


115 .. 


2-2 


19 n 


608 


255 ., 


27 „ 


140 „ 


1-8 


19 >, 


591 


666 „ 


31-5 » 


170 ,, 


3-9 


23 i) 


622 


175 „ 


22 „ 


170 1! 


I-O 


IS „ 


604 


315 „ 


25 ,, 


I30 „ 


2-4 


21 „ 


5S5 


300 „ 


25-5 ,, 


ISO „ 


2-0 


19 ., 



The two heaviest ratios, viz., i-o and i-8, were both found 
in cases of probably criminally - induced abortion in healthy 
primigravidae with negative Wassermann reactions. 

From the above figures it may be deduced that in the case 
of a fresh foetus at the eighth month or over the weight ratio of 
the placenta may vary normally between 4 and 16, but that a 
ratio above 4 is abnormal provided there is no abnormal intra- 
placental clotting (red or white infarcts). Below the eighth 
month, however, this rule does not hold and a ratio of 2 or 
even I or less may be looked upon as normal. 

There is no doubt that in earlier abortions than any of these 
recorded here the placental weight may normally much exceed 
that of the foetus. 

Placentas of Macerated Fcetuses. 

The placentas of 19 macerated fcetuses in which syphilis could 
with certainty be excluded were available for examination. 
The requisite details concerning these are expressed in the 
table on next page. 

Further, the placentas were available in 24 macerated 
syphilitic fcetuses, not all of which, however, were spirochaete 
positive. Details of these are shown in the table on next page. 

From these tables we see that the mean ratio of the placenta 
in the case of the non-syphilitics was 7-3, the heaviest being 
4-2 and the lightest io-i. Of the 24 syphilitic macerated 
fcetuses the placental mean ratio was 4-4, the heaviest being 
0-5, and the lightest 9-8. We can only reckon as showing 
abnormal placental enlargement any case in which the placenta 
shows a weight ratio higher than the heaviest normal, viz., 
4-2. It will be seen that 14 of the macerated syphilitics, or 
58 per cent., fulfil this requirement. 

163 



Francis J. Browne 



MACERATED NON-SYPHILITICS. ALL AGES. 





Weight 


Weight 




Foetal 

Length. 


No. 


of 
Foetus. 


of 
Placenta. 


Batio. 


222 


1040 grms. 


140 grms. 


7-4 


38-5 cm. 


235 


750 „ 


130 „ 


5-7 


34'0 , 




263 


850 „ 


200 „ 


4-2 


36-0 , 




265 


950 „ 


120 „ 


7-9 


34-o , 




295 


669 „ 


139 1, 


4.8 


32-o , 




329 


1585 ,. 


270 „ 


5-9 


40-0 , 




369 


1634 )i 


169 „ 


9.6 


44-0 , 




375 


1000 „ 


135 ,. 


7-4 


43-o , 




379 


1620 „ 


220 „ 


7-3 


42-0 , 




389 


1215 ,, 


152 „ 


7-9 


42-0 . 




236 


2350 ., 


320 „ 


7-0 


49-5 . 




366 


4470 „ 


630 


7-0 


56-o , 




359 


396o „ 


390 „ 


IO-I 


56-o , 




214 


1300 „ 


220 ,, 


5-9 


41-0 , 




221 


1050 „ 


in „ 


9-4 


38-0 , 




278 


2800 „ 


320 


8-7 


52-0 , 




280 


2275 ,. 


290 „ 


7-8 


48-0 , 




282 


2545 >, 


262 „ 


9-7 


49'd , 




315 


2440 „ 


417 „ 


5-8 


52-0 , 





MACERATED SYPHILITICS. ALL AGES. 
Place n tas — Macerated Syphilitics. 



\ 


Weight 


Weight 




Length 




No. 


of 


of 


Ratio. 


of 






Foetus. 


Placenta. 




Foetus. 




15 


2360 grms. 


770 grms. 


3-o 


46 cm. 


Sp. + 


29 


2000 ,, 


480 „ 


4.1 


48 „ 


Sp. + 


440 


2700 „ 


500 ,., 


5-4 


52 „ 


Sp. + 


41 


2COO „ 


5oo „ 


4.0 


49 ,, 


Sp. + 


44 


40 „ 


7o „ 


o-5 


? >! 


Sp. - 


45 


490 „ 


32o „ 


i-5 


_ ? 


Sp. - 


48 - 


I790 >, 


400 ., 


4-4 


4° „ 


Sp. - 


54 


2000 „ 


270 „ 


7-4 


35 >i 


Sp. + 


135 


2300 „ 


850 „ 


2-7 


43 >i 


Sp. - 


145 


620 ,, 


140 „ 


4-4 


33 „ 


Sp. + 


157 


1225 „ 


325 „ 


3-8 


46 „ 


Sp. + 


201 


1890 „ 


400 ,, 


4-7 


42 „ 


Sp. - 


208 


2290 „ 


800 „ 


2-8 


4S „ 


Sp. - 


216 


1400 ,, 


I 7° i) 


8-2 


43 „ 


Sp. - 


226 


1300 „ 


320 „ 


4.0 


38 „ 


Sp. 4- 


231 


2870 „ 


890 „ 


3-3 


48 „ 


Sp. - 


239 


1125 „ 


313 ., 


3-5 


4i ,. 


Sp. + 


252 


2240 „ 


37o „ 


6-o 


45 ., 


Sp. + 


255 


2200 „ 


520 „ 


4-2 


46 „ 


Sp. + 


260 


2060 „ 


210 ,, 


9-8 


45 .. 


Sp. 4- 


268 


47o „ 


120 „ 


3-9 


29 11 


Sp. + 


271 


i57o „ 


320 „ 


4.9 


45 ,. 


Sp. + 


279 


2520 „ 


677 ,, 


3-7 


46 „ 


Sp. + 


292 


2269 „ 


614 „ 


37 


48 „ 


Sp. + 



164 



Further Observations on Still-Birth 

The placenta of every syphilitic macerated foetus is enlarged. 
That it does not always show an abnormally high weight ratio 
is accounted for by the fact that the variations of weight ratio 
amongst normal placentas are so wide. A normal placenta may 
be as light as ^th of the body weight. Obviously, if this is 
enlarged by syphilis it would be probably still within the 
normal limits. 

The syphilitic placenta, too, presents certain well-known 
characteristics. It is pale from avascularity and thickened 
from the foetal to the maternal surface. The enlargement of 
the placenta is due to enlargement of the individual villi 
from infiltration of fibroblasts and fibrous tissue which in turn 
press upon and destroy the capillaries in the villi. This 
enlargement of the villi reduces the intervillous space in which 
it is commonly supposed that the maternal blood circulates. It 
is this diminution of the intervillous space as well as the 
avascularity of the villi that is the direct cause of fcetal death 
in these cases. 

It is of interest to observe that in the case of the syphilitic 
foetus formation of red infarcts is rarely found. I have never 
seen red infarcts in a syphilitic placenta, which shows that 
whatever be the explanation of infarct formation in the 
placenta, it is not due to obliteration of the fcetal vessels, 
because the syphilitic placenta is the placenta par excellence 
in which obliterating endarteritis of the fcetal vessels is found. 
On the other hand, when albuminuria of pregnancy or chronic 
nephritis has been the cause of death, red and white infarcts 
with large blood-clots are almost invariably found and this is 
a most helpful method of deciding as to the cause of foetal 
death. The albuminuric placenta, too, is neither enlarged nor 
thickened, although its weight ratio is sometimes increased 
beyond the normal on account of the presence of numerous 
blood-clots and solid areas of infarction. 

Examination of the Ftvtal Organs for Spirochcetes. 

This is best carried out by making an emulsion of the tissues 
and examining by the dark-ground microscope. 

An examination such as I have outlined is usually sufficient, 
but if no satisfactory cause of death has been found it is well to 
examine the other organs in order to see if there is no gross 
abnormality. A striking instance of the usefulness of such an 
extended examination occurred a few weeks ago. A patient, 

obst. 165 M 



Francis J. Browne 



aet « 39> married two years and pregnant for the first time and in 
her ninth month, came to the Antenatal Clinic complaining that 
for a week she had not felt foetal movements although up to 
that time they had been normal. On examination I failed to 
find foetal heart sounds or detect foetal movements. There was 
no albumen in the urine, the Wassermann reaction was negative, 
and the patient appeared perfectly healthy and always to have 
been so. Dr Cheng measured the abdomen at the umbilicus 
and she was asked to return in one week. At her second visit, 
foetal movements and foetal heart sounds were still absent and 
the girth of the abdomen appeared to be the same as before. 
In addition to this there had been for a day or two a slight 
brownish discharge. The same night labour started and a 
macerated foetus was expelled. I examined the foetus and 
placenta and failed to find any evident cause of death. I was 
about to put the case aside as one of these unsatisfactory cases 
that are sometimes met with in which the cause of death is put 
down as undetermined, when it occurred to me to examine the 
other organs. On doing so I found that the kidneys appeared 
to be absent, but on more careful examination they were found 
with great difficulty amongst the fat in the loin. Both were 
rudimentary, only weighed I gram each, and microscopic 
examination showed that they consisted chiefly of fibrous stroma 
with very little kidney tissue. This then was probably the 
cause of foetal death, although I have twice found an infant born 
alive with both kidneys completely absent, yet they only lived for 
a few minutes. Miss Hewer 1 has recently shown that the foetal 
kidney starts secreting urine as early as the twelfth week, and if 
it does so, it is reasonable to suppose that such secretion plays 
an important part in the foetal economy, and that if suppressed 
it may lead to intra-uterine death. The importance of the 
finding in this case was that I was able to give to the mother 
a good prognosis with regard to future pregnancies, which was 
important to her, especially at her rather advanced age. 

Other Points that are helpful in deciding as to the 
Cause of Antenatal Death. 

History of the Mother. — There may be a history of old 
nephritis, which if found with placental infarction shows the 
cause of death to be albuminuria. There may be a history of 
syphilis, but, as has been frequently pointed out before, a history 

166 



Further Observations on Still-Birth 

of syphilis is very infrequently obtained in multiparas who have 
borne a succession of undoubtedly syphilitic children. I have 
discussed the reason for this elsewhere, 2 and, briefly put, my 
conclusions are as follows. In syphilitic primigravidas, signs of 
syphilis, such as rash, or sore throat, were present in 70 per cent, 
of my own series. Of multiparas, on the other hand, only 2 per 
cent, of latent syphilitics gave a history of infection, although all 
revealed it by their products of conception, Wassermann reaction, 
or evidence of tertiary syphilis, or by all combined. Now, as all 
multiparas have at one time been primigravidae, they must have 
come at one time, namely, during their first pregnancy, under 
the 70 per cent, rule ; that is, at least 70 per cent, of multiparas 
have really at one time suffered from secondary syphilis, and 
not from a mild form of it, but from the rather severe symptoms 
with which one commonly meets in primigravid syphilitic 
women. This proves to my mind that multiparas suffering 
from latent syphilis have really at one time shown the usual 
evidences of syphilis but that they have forgotten it in the 
strain and stress of child-bearing and of household duties, or 
that they purposely deny it. There seems to be no escape 
from this conclusion. 

The Wassermann Reaction in Pregnancy. 

In my experience the presence of a strongly positive 
Wassermann reaction is very decisive evidence of the presence 
of syphilis in a pregnant woman. It does not necessarily mean 
that she will bear a syphilitic child, for I have examined the 
organs of a child of such a mother, whose death had occurred 
from asphyxia, and failed to find any naked-eye or histological 
evidence of syphilis. I think there is no doubt also that a 
woman may have a persistently negative Wassermann reaction 
and yet may produce a succession of syphilitic foetuses. But 
1 have never met with a case in which a mother with a negative 
Wassermann produced a spirochaste positive foetus. I have 
without exception found that a mother who gave birth to a 
spirochaste positive fcetus had herself a strongly positive 
Wassermann reaction. This, of course, raises the question : 
How far are we justified in diagnosing syphilis of the fcetus 
in the absence of the spirochaste and from the so-called 
secondary signs, viz., enlarged liver, spleen, and placenta, and 
fibrosis of foetal organs ? My present position on that matter 

obst. 167 m 2 



Francis J. Browne 



is much less dogmatic than it was three years ago, and I now 
think he would be a bold man who would say, with our 
present scanty knowledge of antenatal pathology, that no other 
toxin than that of syphilis can produce these changes. It 
seems to be impossible at present to speak authoritatively 
upon this subject, but I think there is another test that may 
be usefully employed in doubtful cases, viz., the therapeutic 
test. When there is a bad obstetrical history of repeated still- 
births, abortions, or neonatal deaths and yet the Wassermann 
reaction is negative and spirochetes are absent from the fcetal 
organs, and there is no other apparent cause for fcetal death, 
a full treatment with N.A.B. may be given and the result 
watched. I have employed that method with good results in 
a few cases regarding which I have not time to give all the 
details. The last case in which I used it was a multipara who 
had had a succession of births of macerated foetuses. I had 
examined three of these altogether, and on each occasion the 
so-called secondary signs of fcetal syphilis were present, viz., 
enlarged liver, spleen, and placenta, but the mother's Wassermann 
reaction was repeatedly negative, both during pregnancy and 
in the intervals between, and the fcetal organs were always 
spirochete negative. During her last pregnancy she received 
2-04 grams sulfarsenol and 3-44 grams of N.A.B. intravenously, 
with the result that she was delivered at term of a living and 
apparently healthy child. I saw this child a few days ago ; it 
is now ten months old and seems to be in good health. There 
are obvious objections to be urged against the conclusion that 
this proves the case to be one of syphilis, and I only put the 
suggestion forward tentatively. 

Again, it is commonly stated in literature that the pregnancy 
tends to modify the Wassermann reaction and make it negative. 
With this point in mind I examined 100 cases, and con- 
cluded that there was no evidence whatever that the reaction 
was ever modified by pregnancy. I have never known a case 
in which a Wassermann reaction, positive before pregnancy 
became negative during pregnancy, apart from treatment, nor 
have I ever known a case in which a Wassermann reaction 
negative during pregnancy became positive after delivery. 
This is one of those statements which are repeated from book 
to book without apparently any foundation in fact. 

Maternal Glycosuria as a Cause of Foetal Death. — Pregnancy 
in a diabetic woman is rare and frequently ends in abortion or 

168 



Further Observations on Still-Birth 

in the production of a macerated foetus. What the direct cause 
of fcetal death in these cases is, is difficult to say, and does not 
seem to be referred to in the literature. I have seen one case 
in which the placenta, though there was no albuminuria, was 
a mass of red and white infarcts. It is possible that the 
irritation of the sugar-laden blood so changes the syncytial 
covering of the villi that clotting of the blood occurs in the 
intervillous spaces. It is a comparatively rare cause of fcetal 
death and opportunities for investigation of the mechanism 
of causation are few. 

Knots or Twisting of the Umbilical Cord. — A good deal of 
controversy has gathered around the question as to whether 
knots on the cord can ever obstruct the circulation sufficiently 
to cause fcetal death. In some experimental observations on 
this subject which I carried out recently I found that when 
there was no knot on the cord fluid passed through the 
umbilical vein at a pressure of 10 mm. mercury. When one 
slack knot was put on the cord and no weight attached and the 
knot not in any way tightened the fluid passed through at a 
pressure of 20 mm. Even a slack knot therefore caused some 
obstruction and this was made evident also by the visible 
swelling and engorgement of the cord on the proximal side 
of the knot. When two true knots were formed, one super- 
imposed on the other, the fluid passed at a pressure of 60 mm. 
A single knot was next placed on the cord and a weight of 
20 grams tied to the distal end, no attempt being made to 
tighten the knot except by the weight attached to the end. 
The fluid now passed at a pressure of 40 mm. 

With a weight of 50 grams a pressure of 70 mm. was required. 
,, „ 100 „ „ 100-iiomm. ,, 

„ 140 „ „ 140-150 mm. „ 

„ „ 160 grams fluid failed to pass at a pressure of 165-170 mm. 

The arterial pressure in the umbilical cord varies from 39-3 
to 83-7 mm., while the venous pressure is about 16 mm. 
(Feldman). These experiments show that even a slack knot 
may be sufficient to interfere with, if not to completely obstruct, 
the circulation in the cord, but that any pull upon the knot 
such as might be exerted if the cord were shortened by being 
wound around the child's neck or body might easily cause 
sufficient tightening to impede completely the circulation. 
Amongst developmental causes of fcetal death I shall only 
refer to one, namely, small placental area. This also is a 

169 



Francis J. Browne 



rare cause of foetal death and was assigned as the cause in 
only one or two of my cases. It is difficult to say how much 
placenta is necessary to carry on fcetal life, and one can only 
diagnose the condition tentatively and by exclusion of other 
known causes. Nothing is known regarding the causes of the 
condition and it cannot be foreseen nor prevented. 

Undetermined. — In 8 of my last series of 60 cases of 
antenatal death the cause of fcetal death could not be deter- 
mined with certainty. I think it is possible that some of these 
cases may be explained by the hypothesis put forward by 
Professor Arthur Robinson 3 in his Struthers lecture (1922), that 
there are certain ova or zygotes that do not possess the power 
of development beyond a certain stage of embryonic or fcetal 
life, and that this want of the power of development is not due 
to environment, such as an abnormal endometrium, but to an 
inherent defect in the germ-cell, of unknown origin, but possibly 
of the same nature as the causes which lead to the production 
of monstrosities. 

Prevention of Antenatal Death. — At present our power to 
prevent antenatal death is practically limited to cases of 
albuminuria and syphilis. With regard to the latter there 
are only four special points that require mention : (1) Treat- 
ment of the pregnant syphilitic by intravenous administration 
of the arsenical compounds should be begun as early as 
possible in pregnancy, or better still before pregnancy has 
commenced. (2) It may be continued with impunity until 
the end of pregnancy. (3) It should be repeated in every 
succeeding pregnancy whether the patient appears to be cured 
or not. (4) The arsenical preparations and mercury should 
not be given at the same time, but mercury should only be 
given in the intervals between the courses of Novarsenobillon 
or other arsenical preparation. 

Summary. — (1) The most frequent cause of antenatal death 
in this series of 60 cases was syphilis, which accounted for 
24 cases, or 40 per cent. In only 15, or 25 per cent., of the 
60 cases of antenatal death, however, was the spirochete found, 
the others being diagnosed from the secondary signs of syphilis. 
How far one is justified in doing this is a matter for discussion. 

(2) In the diagnosis of the cause of antenatal death careful 
consideration must be given to the results of clinical and 
pathological examination, and even when all these data are 
available there will still remain a small percentage of cases 

170 



Further Observations on Still-Birth 



in which it is impossible to state definitely what the cause of 
death has been — 8 in the present series of 60. 

(3) In such case the patient should be followed if possible 
through two or three successive pregnancies and the product 
of conception, if available, examined. 

(4) About 60 per cent, of the cases might have been 
prevented by adequate antenatal supervision. 

Intranatal Death. 

The causes of this may be conveniently classified as 
follows : — 

I. Traumatic — 

(a) Craniotomy . . . . . .II 

(b) Cerebral haemorrhage . . . . .14 

(c) Asphyxia . . . . . . . 36 

(d) Suprarenal haemorrhage . . . . .1 

(e) Other Injuries . . . . . .... 

II. Infective — 

Pneumonia (present also in four others included 

under Craniotomy) . . . . .1 

III. Toxaemic — 

Scopolo-morphine Narcosis . . . .... 

IV. Developmental ... .... 4 

V. Undetermined . . . . . . .... 

_67 

I. Traumatic. 
From this table it will be seen that by far the most frequent 
cause of intranatal 'death was asphyxia, which accounted for 
more than half the total. 

(a) Craniotomy. 

This was performed altogether in 14 cases of the 200, but 

as in 3 of these the child breathed after delivery they are 
classified under neonatal death. The reasons for craniotomy 
were as follows : — 

Hydrocephalus . . . . . .4 

Contracted pelvic inlet . . . .7 

Contracted outlet with large child . . . .1 

Eclampsia . . . . . . .1 

Large size of child, pelvis normal . . . .1 

In 4 of the 10 non-monstrous children craniotomy was 
performed upon the living child, and 3 of these breathed after 
birth. In 5 of these cases there was catarrhal pneumonia 

171 



Francis J. Browne 



present, and in all the membranes had been ruptured for a long 
time prior to birth, the child in each case being born dead. The 
matter will be referred to again in connection with pneumonia 
neonatorum. 

(b) Cerebral Hemorrhage. 

No useful purpose would be served by considering separately 
the cases of cerebral haemorrhage giving rise to intranatal 
death and those causing post-natal death, as it is entirely a 
matter of the site and degree of haemorrhage whether death 
takes place during or shortly after birth. Taking together, 
therefore, the cases of intra- and neonatal death, it is seen that 
cerebral haemorrhage was present in 32 cases, or 16 per cent., 
14 of these being still-births and 18 neonatal deaths. In my 
first series of 200 there were 59 cases, giving a total of 91 for 
the complete series of 400, 38 of which were still-births and 53 
neonatal deaths. 

Method of Delivery. — Of the 32 cases in the present series 
19 were delivered by the vertex, 11 by the breech, 1 as a face, 
and in I the method of delivery was unknown, the child, the 
second of twins, having been born outside the hospital before 
arrival of the nurses. It lived sixteen days with its left lateral 
ventricle distended with blood-clot. 

Of the 19 cases delivered by the vertex 8 were forceps and 
1 1 natural deliveries. Of the 8 forceps deliveries 6 were 
classified as decidedly difficult while in 2 no special difficulty 
had been encountered. 

In all cases the cause of difficulty was disproportion between 
the head and the pelvic inlet, due in 3 cases to pelvic con- 
traction, and in 2 there was an occipito-posterior position 
requiring manual rotation. 

Among my first series of 200 still-births and neonatal deaths 
there were 9 difficult forceps deliveries resulting in cerebral 
haemorrhage. If we classify the two series together we find that 
the causes of difficulty may be tabulated as follows : — 

Contracted pelvis (in 2 cases persistent O.P.) . . 9 

Large size of child (3 cases persistent O.P.) . . 6 

Hcevwrrhagic Diathesis as a Cause of Cerebral Hemorrhage. — 
Attention has been drawn to this condition by Warwick, 4 who 
concluded after 36 autopsies, in 18 of which cerebral haemorrhage 
was present, that " haemorrhagic disease of the newly born " was 

1 72 



Further Observations on Still-Birth 

an important etiological factor in this condition. In my first 
series I had seen no case in which it was necessary to assume 
the presence of this diathesis in order to explain the occurrence 
of haemorrhage. Since then, however, I found at least 2 cases. 
One was a case of easy low forceps delivery in a primigravida 
after a second stage lasting four hours, in which there was one 
of the most extensive cerebral haemorrhages I have ever seen, 
involving the 3rd, 4th, and left lateral ventricles all of which were 
distended with clot. The right middle fossa of the skull contained 
dark fluid blood and there was a large quantity of clot under- 
neath both tentoriacerebelli. The child lived twenty-four hours. 
The other was a case which I examined for Dr Fraser Lee, and 
which he will perhaps report to the Society at a future meeting. 

Breech Delivery as a Cause of Cerebral Hemorrhage. — Those 
who heard my first paper on this subject will recall that I 
accused breech delivery of playing an important part in the 
causation of cerebral haemorrhage. My later findings have 
fully confirmed this. Of the 11 cases of cerebral haemorrhage 
delivered as breech 8 were primary breech, while 3 were 
converted into breech after forceps had failed. If we reject 
these 3 cases, and assume the normal frequency of breech 
delivery to be 3 per cent., we arrive at the conclusion that 
breech delivery is ten times as likely to give rise to cerebral 
haemorrhage as is delivery by the vertex, a result exactly 
corresponding to that arrived at in my first series. 

Cerebral Hemorrhage in Premature Infants. — Taking all 
presentations together, 18 cases were at term and 14 premature. 
In the Edinburgh Maternity Hospital the proportion of 
premature to full-time labour is about 1 in 13. We can 
therefore conclude that cerebral haemorrhage is seven times as 
likely to occur in premature infants as in infants at term. This 
is a remarkable result when we consider the frequent difficulty 
of labour at term, and the ease and rapidity with which it takes 
place when the child is premature. This frequency of cerebral 
haemorrhage in premature infants even when the labour 
has been easy and natural formed one of the most outstanding 
features of the present investigation, and the reasons for it 
have been discussed in my previous report. The liability to 
haemorrhage in premature infants is greatest at from seven to 
seven and a half months, less at eight months, while at thirty-six 
weeks the liability appears to be no greater than at term. 

Intra-ventricular Hemorrhage. — This was present in 14 cases 

173 



Francis J. Browne 



of the present series, but in 3 the haemorrhage was only 
underneath the ependymal lining of the ventricle and in 1 
subependymal haemorrhage was associated with intraventricular. 
These subependymal haemorrhages are usually small, seldom 
exceeding the size of a split pea, and probably have little or 
no injurious effect, but in one the haemorrhage was large, 
extensively infiltrating the adjacent brain substance ; the clot 
projected into the cavity of the lateral ventricle but its 
ependymal covering remained unruptured. 

Of purely intraventricular haemorrhage there were thus 
1 1 cases. In 6 of these the haemorrhage was into both lateral 
ventricles, 1 of these being associated with haemorrhage in the 
4th ventricle, and in 1 the clot in the left lateral ventricle 
extended into the 3rd. In 2 cases the clot occupied the right 
ventricle alone, and in 2 the left alone, but in 1 of these it 
extended into the 3rd and 4th ventricles. 

Maturity. — All, except one case in which the haemorrhage 
was ascribed to haemorrhagic diathesis, were premature. In my 
first report, which dealt with 22 cases, I therefore made the 
statement that " as a matter of practical experience one 
does not expect to find intraventricular haemorrhage in a full- 
time child," and my later experience amply confirms this. The 
condition appears to be entirely confined to premature infants. 

Method of Delivery. — Of the 13 cases in which the method 
of delivery was known, 10 were delivered by the vertex and 
3 by the breech. Assuming 3 per cent, to be the normal 
frequency of breech presentation, we arrive at the conclusion 
that intraventricular haemorrhage is seven times as likely to 
occur in breech as in vertex delivery — a result exactly corre- 
sponding to the finding in my first series. 

Injuries to the Septa of the Dura Mater within the Cranium. — 
There were 36 cases in which the septa of the dura mater 
were more or less injured, i.e., 18 per cent. The extent of the 
tearing is shown in the following table : — 



Complete tears in both tentoria cerebelli (1 with 

a tear in the falx cerebri) 
Incomplete tears in both 
Incomplete tear in right tentorium only 
Complete in left tentorium alone (1 with tear in falx 

cerebri) ..... 
Incomplete in left only 
Right complete, left incomplete 
Left complete, right incomplete 
174 



18 

5 
3 

2 

4 



Further Observations on Still-Birth 

In 24 cases, therefore, the tearing was complete, in 12 
incomplete. 

The very slightest cases of incomplete tears are here in- 
cluded, and in some of these the tearing of the upper layer only 
amounted to an abrasion. In three cases the tearing of the 
tentorium was so deep as to extend into the straight sinus, 
with extensive cerebral haemorrhage as a direct result. 

In order to analyse the ^etiological relationship possibly 
existing between tears of the dural septa and cerebral haemor- 
rhage it is necessary to consider — 

(1) Cases in which tears of the septa occurred without 
cerebral haemorrhage. 

This occurred in 20 cases, the amount and situation of the 
injury to the septa being as follows : — 



Complete tears of both tentoria cerebelli 
Complete tear in left tentorium alone 
Incomplete tears in both tentoria 
Incomplete tear in right alone 
Incomplete tear in left alone . 
Complete tear in right, incomplete in left 
Complete in left, incomplete in right . 



Thus, out of a total of $6 cases in which tentorial tearing 
occurred, there were 20, or 56 per cent., in which there was no 
cerebral haemorrhage. In 12 of these the tears of the tentorium 
were complete, and in 8 incomplete. 

(2) Cases in which cerebral haemorrhage occurred inde- 
pendent of tears in the dural septa. 

Out of the total of 32 cases of cerebral haemorrhage there 
were 18, or 56 per cent, in which the dural septa were entirely 
uninjured. (For details of sites of haemorrhage see full report.) 
In 1 1 of the cases the haemorrhage was intraventricular, and 
in all except three it was in the area drained by the great vein 
of Galen. Fourteen of the cases occurred in premature infants 
and 4 at term. It is also apparent that the frequency with 
which cerebral haemorrhage occurred apart from tearing of the 
dural septa was exactly the same as the frequency of tearing 
of the septa without cerebral haemorrhage, viz., 56 per cent. 

(3) Cases in which tearing of the septa and cerebral 
haemorrhage co-existed. 

i75 



Francis J. Browne 



In the present series of 200 cases of still-birth and early 
post-natal death, there are 54 cases in which either tears of the 
dural septa or cerebral haemorrhage or both together occurred. 
Out of these 54 there were 16 in which cerebral haemorrhage 
occurred in association with tentorial tears. Of these 16 the 
tearing was incomplete in 5. 

Details of site and amount of the cerebral haemorrhage in 
these cases are as follows : — 

Case No. 367. — Tentorial tear incomplete on both sides ; 
falx cerebri intact. Clot 2jxiix-|- in. over left cerebral 
hemisphere and under left parietal bone. Clots in right middle 
fossa, over right tentorium and beneath it. 

No. 325. — Tentorial tears incomplete on both sides; falx 
cerebri intact ; much blood-stained serum over all surfaces of 
brain including base ; no actual haemorrhage. 

No. 203. — Tear incomplete on right side only. Clot overlies 
right tentorium ; sub-dural haemorrhage under right parietal 
bone ; clot over posterior end of corpus callosum. 

No. 246. — Tear incomplete in left side only ; falx intact ; 
one or two small haemorrhages, 1 cm. diameter, surrounding 
veins on upper surface of cerebrum. 

No. 285. — Incomplete tear in left tentorium (slight abrasion 
only) ; right intact ; falx cerebri intact ; haemorrhage in 3rd, 
4th, and left lateral ventricles, in middle fossa of skull and 
under both tentoria cerebelli. 

In these 5, therefore, the tentorial tearing was so slight 
that there could not possibly be any etiological relationship 
between it and the occurrence of the haemorrhage. We may 
therefore reject these cases, and there remain 1 1 cases in which 
cerebral haemorrhage was associated with complete tears. Of 
these there were 3 cases of complete tearing on both sides in 
which the tear had extended into the straight sinus, resulting 
in great effusion of blood into the middle and posterior fossae 
of the skull. Of the remaining 8 cases the tear was complete 
in both tentoria in 6, in one of which the falx cerebri was also 
torn in its anterior half. In 1 case the tear was complete 
in the right tentorium and incomplete in the left, and in 1 
complete in the left, the right being intact but the falx cerebri 
torn. The site and amount of haemorrhage in these cases was 
as follows : — 

176 



Further Observations on Still-Birth 

No. 281. — Both tentoria deeply torn; haemorrhage over pons, 
and both cerebral peduncles, and temporo-sphenoidal lobes. 

No. 231. — Complete tears both tentoria; vein of Galen intact 
but distended with blood. Subdural clot over left frontal lobe, 
both middle fossae of skull full of fluid blood ; clots under both 
lobes of cerebellum, medulla and pons, and adherent to them. 

No. 348. — Complete tears both tentoria. Some haemorrhage 
over base of brain generally. 

No. 353. — Falx completely torn in anterior half. Complete 
tears in both tentoria. Fair amount of haemorrhage in substance 
of both tentoria and between them and cerebellar lobes. Large 
clot in right lateral ventricle. Left ventricle also filled with 
clot which extends into third ventricle. 

No. 381. — Both tentoria deeply torn; large quantity fluid 
blood in posterior and middle fossae. 

No. 397. — Complete tears in both tentoria; haemorrhage 
into substance of both tentoria and into falx cerebri. 

No. 322. — Complete tear in right tentorium, incomplete in 
left. Clot underneath both lobes of cerebellum. 

No. 305. — Complete tear in left tentorium, right intact, falx 
torn. Blood-clot lies in contact with left side of falx cerebri in 
its entire length ; clot overlies left tentorium. Head much 
moulded in the occipitofrontal diameter. 

Four of these cases, viz., 305, 348, 381 and 397, may for 
various reasons be neglected as far as any connection between 
the septal injuries and cerebral haemorrhage is concerned. There 
remain 4 cases out of 32, viz., 281, 321, 322 and 353, in which 
a causal relationship may possibly exist. Also, while there 
were 12 cases of complete tearing in which no cerebral 
haemorrhage was found, there are only 8 cases of complete 
tearing, apart from the three cases in which the tears entered 
the straight sinus, which were associated with cerebral haemor- 
rhage. It follows that complete tears of the tentorium are 
more frequently found apart from cerebral haemorrhage than 
with it ; and again, while cerebral haemorrhage occurred in 
18 cases without tears of the dural septa of any degree, and 
in 23 if we include the five cases of haemorrhage in which 
only incomplete tears 'were found, it occurred in association 
with septal tears in only 8 cases excluding again the three 
cases in which the tear extended into the straight sinus. There- 
fore cerebral haemorrhage was about three times as frequent 
apart from injuries to the dural septa as with them. 

obst. 177 n 



Francis J. Browne 

Method of Delivery as a Predisposing Cause of Tentorial 
Tears. — A study of the method of delivery showed that 
tentorial tearing was about eighteen times as likely to occur 
in breech as in vertex deliver)-, and that in vertex cases tears 
of the septa were almost entirely confined to cases of difficult 
forceps delivery, but that they do occur, though rarely, in 
forceps cases in which there has been no special difficulty, 
and occasionally even in cases in which no instruments have 
been used. It is probable that improper application of the 
blades, for example, in an oblique or anteroposterior diameter 
may account for some of the injuries in easy forceps cases. 

In my previous report the statement occurs, " In every case 
of breech delivery at term some degree of tentorial tearing was 
observed." The findings in the present series do not quite 
confirm this observation, as there were four cases of breech 
delivery at term in which the dural septa were entirely intact, 
all these being cases in which internal podalic version was 
performed, twice on account of lateral placenta praevia and 
twice on account of transverse presentation. 

It is possible that undue haste in delivering the aftercoming 
head is responsible for man)' of these septal injuries. Within 
the last year or two the opinion has been freely expressed by 
many experienced observers that the injuries are less due to the 
breech delivery in itself than to ill-advised and hasty attempts 
to deliver the child after birth of the breech. The orthodox 
teaching has hitherto been that after birth of the breech, the 
cord is subjected to pressure between the child's body and the 
maternal passages, and that in consequence delivery must be 
accomplished in eight to ten minutes in order to save the child 
from asphyxia. It seems, however, that the unborn child can 
bear the cutting-off of its oxygen supply for a much longer 
period than an adult, and that it may be left undelivered after 
birth of the breech for as long as twenty minutes without injury 
resulting. Potter, 5 whose experience of breech deliveries must 
be unequalled, writes as follows : " / never Jiasten delivery after 
the umbilicus comes into view because experience has taught me 
that haste is unnecessary, that severe complications such as 
extension of arms and head are very apt to take place when we 
interfere with the natural forces at this particular stage of 
delivery." On one occasion he took twelve minutes with no 
injury to the child, a loop of cord being exposed the entire time 
and not pulsating. Holland 6 also emphasises the danger and 

178 



Further Observations on Still-Birth 

needlessncss of haste and the need for slow, careful, and 
deliberate delivery with the minimum of supra-pubic pressure. 
" Instead of using forceful haste, he says, we must be deliberate 
and deliver gently and gradually the after-coming head." 

In this connection the revival of an old method which seems 
to have fallen into undeserved disuse might not be without 
advantage. This is the introduction of the hand of the 
accoucheur, palm upwards, along the child's face, and hence 
between its face and the posterior vaginal wall ; by flexing 
the wrist the posterior vaginal wall is pushed away from the 
child's mouth and nostrils and air is thus allowed to enter 
freely. In this way the child is enabled to breathe, and the 
necessity, if such there be, for hastening delivery is obviated. 

Antenatal Supervision. — In 26 out of the 32 cases of 
haemorrhage there had been no antenatal supervision whatever ; 
in 2 supervision had been inadequate, while in the remaining 
4 the supervision might be termed adequate. One was 
a primigravida, breech presentation ; external version failed on 
account of oligo-hydramnios. The second was a primipara 
aged 39. Labour induced at term for large size of child, by 
packing lower uterine segment two days before delivery, vertex 
R.O.P., difficult forceps, child lived twenty-four hours. In 
addition to the cerebral haemorrhage the lungs showed advanced 
catarrhal pneumonia. Earlier induction in this case, or 
induction by a different method, would probably have produced 
a better result. The third was also a primigravida who was 
being swabbed for vaginal discharge. The swabbing seemed 
to have brought on premature labour at the eighth month, and 
this, though easy, led to cerebral haemorrhage. The fourth case 
was again a primigravida with persistent O.P. and child two 
weeks post-mature. Difficult forceps delivery. Earlier induction 
would probably have prevented disaster to the child in this case. 

Prevention of Cerebral Hemorrhage. — The points to be kept 
in mind in the prevention of cerebral haemorrhage are as follows: — 

(a) Avoidance of breech deliveries by the performance of 
external cephalic version in every case in which the breech 
presents, about the commencement of the ninth month of 
pregnancy. 

(b) Avoidance of difficult forceps deliveries by the timely 
induction of labour, especially in primigravidae, and the 
avoidance of hasty delivery when such is not necessary in 
the interests of the mother. 

179 



Francis J. Browne 



(c) Limitation of induction of labour to cases which have 
completed the thirty-fifth, or better still, the thirty-sixth week 
of pregnancy. 

In conclusion it may be said in the words used in my first 
report, " The problem of the prevention of cranial injuries is 
intimately bound up with that of the prevention of breech and 
of difficult vertex deliveries." 

(V) Asphyxia. 

In 36 cases the cause of intranatal death was asphyxia. 
It was therefore by far the most frequent cause and accounted 
for more than half the total number of intranatal deaths. The 
points by which asphyxia may be recognised have been referred 
to in my former report. 

Parity. — Nineteen of the cases, or 53 per cent., occurred in 
primigravidae, 5 in ii-paras, 5 in iii-paras, and 7 in all others com- 
bined. Primiparity thus clearly predisposes to this condition, and 
does so, no doubt, by causing prolongation of the second stage of 
labour on account of an undue amount of rigidity of the tissues. 

Presentation. — Of the 36 cases 20 were delivered as vertex 
and 16 as breech; of the latter 11 were primary breech and 5 
were converted into .breech by internal podalic version, chiefly 
for such maternal complications as placenta praevia. 

Nature of Delivery in the Vertex Cases. — Of the 20 vertex 
cases only 9 were delivered by forceps, the remaining 1 1 being 
delivered naturally ; of the 9 forceps cases the delivery was 
classed as difficult in 4, the cause being in each case dis- 
proportion between the child and pelvis. In all the forceps 
cases labour was prolonged and in one the mother was 
eclamptic. In another in which the pelvis was justo minor 
and labour had been induced eight days before term there was 
prolapse of the cord. In all the other forceps cases the cause of 
asphyxia was probably prolongation of the second stage. Of 
the 1 1 cases in which delivery had been natural there was 
prolapse of the cord in 2, and prolongation of the second 
stage in 3 ; in 1 there was eclampsia, and it is probable that 
the convulsions were the direct cause of the asphyxia; in 1 case 
in which pituitrin had been used to induce labour tetanic uterine 
contractions ensued and caused the child's death ; in another the 
cause was probably separation of a marginal placenta praevia ; 
while in 3 no cause for the asphyxia was evident, labour being 
normal in every respect and not unduly prolonged. 

180 



Further Observations on Still-Birth 

Nature of Delivery in the BreeeJi Cases. — As stated above, 
1 6 of the 36 cases were delivered by the breech, and of these 
1 1 were primary breech or transverse, while 5 were converted 
from vertex on account of certain complications which were as 
follows : — 

Central placenta praevia . . . . 2 

Lateral „ . . . .1 

Failure of forceps . . . . .2 

In these 5 cases it would be obviously incorrect to attribute 
the asphyxia to the breech delivery, as in 3 of the cases it may 
have been due to placental separation and in 2 may have 
occurred prior to the performance of podalic version. 

In the 11 cases of primary breech the labour was 
uncomplicated in 7, and there was no reason, apart from the 
breech delivery, for the occurrence of asphyxia. Of the 4 
remaining cases, in 1 there was contracted pelvis, in 1 a lateral 
placenta praevia, in another accidental haemorrhage, and in the 
fourth eclampsia. Rejecting the 5 cases of breech which were 
converted from vertex on account of maternal complications 
and also the 6 cases referred to above, amongst both the 
vertex and the breech deliveries which were complicated by 
ante-partum haemorrhage or eclampsia, and assuming 3 per 
cent, to be the normal frequency of breech delivery, we arrive 
at the conclusion that asphyxia is about ten times as likely to 
occur in breech as in vertex delivery. The causes of intra- 
partum asphyxia may therefore be classified as follows : — 

Vertex cases : — 

Prolonged labour — pelvis normal . . 9 

Prolonged labour — pelvis contracted 

Prolapsed cord . 

Eclampsia 

Placental separation in lateral previa . 1 

Tetanic uterine contractions 1 

No cause evident . . . . .3 

Total 
Breech cases : — ■ 

Difficult delivery in contracted pelvis . . 2 

Difficult delivery because of large child, pelvis normal 1 

Placental separation in praevia (2 central, 2 lateral) . 4 

Placental separation in accidental haemorrhage . 1 

Eclamptic convulsions . . . . 1 

No special cause evident (except breech delivery) . 7 

Total . . .16 

OBST. l8l N 2 



Francis J. Browne 



Prevention of Asphyxia Neonatorum. — A study of the cases 
of intra-partum asphyxia will reveal the fact that about 27, or 
75 per cent., of the 36 cases may reasonably be classed as 
preventable. Such are the cases of prolonged labour in vertex 
cases, the case of eclampsia, that of tetanic uterine contractions, 
and most of the breech cases. 

The greater danger of asphyxia occurring in the course of 
breech delivery points to the advisability of the performance 
of prophylactic cephalic version in all cases of breech pre- 
sentation. It is to be noted that 5 out of the further 7 
cases in which asphyxia occurred during breech delivery were 
primiparae. The exceptions were a ii-para and an xi-para ; in the 
latter the child was of excessive size, and weighed 3950 grams. 
The patient was admitted to hospital with the body born and 
the head still undelivered. This shows that while prophylactic 
external cephalic version is advisable in all cases in which it 
can be carried out, in primiparae it should never be omitted. 

There is no doubt that many cases of asphyxia which occur 
during prolonged labour, natural or otherwise, could be pre- 
vented by the induction of labour about ten days before term, 
unless the child is below the average size or the pelvis unusually 
roomy. Finally the large number of cases in which asphyxia 
occurs unexpectedly and without any evident cause to account 
for it, indicate the necessity for constant attention to the con- 
dition of the fcetus during the second stage of labour in order 
that interference may be undertaken at once should the necessity 
for it be indicated by the condition of the fcetal heart sounds. 

I should like to direct attention once .more to the method 
of prevention of asphyxia in breech deliveries to which I 
referred under cerebral haemorrhage, viz., the introduction of 
the hand along the child's face, flexing the wrist, and thus 
allowing air to enter freely and the child to breathe. 

The Hydrostatic Test of Live Birth. 

When I began this investigation into the causes of still-birth 
and neonatal death, I had, in common with most, an idea that the 
hydrostatic test was an almost infallible proof of live birth, and 
that if the thoracic organs, including the heart and thymus gland, 
floated buoyantly in water the child from which they had been 
taken must have been born alive, provided putrefaction could be 
excluded. The investigation had not proceeded very far until 
not a few cases were met with where the test was found to 

182 



Further Observations on Still-Birth 

fail and in which, though the child was certainly born dead, 
the lungs floated buoyantly in water with the heart and thymus 
attached, and at the same time presented the usual evidences 
of natural respiration having occurred, such as increase of weight 
and bulk, crepitation, light red colour, and surface marbling. 
It soon became evident that there were certain fallacies in this 
finding which had to be carefully excluded. By far the most 
important of these was that artificial respiration and frequently 
direct insufflation of the lungs had been carried out by the 
medical attendant in the hope of starting pulmonary respiration. 
The lungs might then be so inflated as to fill the chest more 
or less completely, but the condition could be recognised by 
the weight of the lungs, by the absence of marbling and 
by the small amount of blood which could be squeezed out 
of the cut surface. When a child first breathes through 
its lungs the amount of blood circulating through them is 
at once enormously increased and in consequence the 
weight, of the lung is thereby almost doubled, and at the same 
time the blood in the capillaries of the now widely separated 
alveolar walls gives to the lung surface the characteristic marbled 
appearance. This inrush of blood to the pulmonary capillaries 
is due to the negative pressure set up in the lungs when the 
child attempts to breathe. In direct insufflation no such 
negative pressure is set up, hence the lung, though expanded, 
is not increased in weight, and there will be no marbling 
upon the surfaces, which present a greyish-pink homogeneous 
appearance. 

If artificial respiration has been carried out by any of the 
methods entailing pressure upon the thorax, e.g. Sylvester's 
or Schultze's, the movements more nearly imitate natural 
respiration and blood will to some extent be attracted to the 
lungs provided that the heart is still beating. In such cases, 
therefore, the lungs will have increased in weight to some 
extent, and there will be some indefinite marbling upon the 
surface. It is probable, however, that no large amount of lung 
expansion can occur by any method of artificial respiration 
other than direct insufflation. In this investigation it was 
possible to keep closely in touch with the accoucheur and 
hence the fallacy could be clinically excluded, and this was 
the method of control invariably adopted. Besides, it is evident 
that in criminal cases in which questions of live birth were 
involved, such a fallacy would not enter. 

183 



Francis J. Browne 



After excluding this fallacy it was evident that the lungs 
were not infrequently more or less inflated in infants that had 
unquestionably been born dead, and in whom no method of 
artificial respiration had been carried out. Such were almost 
invariably cases of prolonged labour in which there had been 
manual interference on the part of the attendant, and in which 
the child had been asphyxiated in the course of birth. The 
introduction of the hand had allowed air to enter the birth 
canal, and the child's respiratory centre being stimulated by 
accumulation of carbon dioxide in the blood in the course of 
the process of asphyxiation, it inspired and drew the available 
air into its lungs. The amount of resulting inflation of the 
lung would depend upon the volume of air available for 
inspiration. The latter is the main factor limiting the degree 
of inflation that may occur in the lungs, the other factor being 
the compression to which the thorax is subjected by the uterus 
or pelvic canal. The following are three examples of cases in 
which the delivery was effected by craniotomy upon a dead 
child and in which there could therefore be no suspicion of 
any method of artificial respiration having been attempted. 

(i) iii-para, set. 30, contracted pelvis, admitted in labour, 
after unsuccessful application of forceps, craniotomy 
performed, child born dead. Full-time female — 3620 
grms. without brain. Lungs float buoyantly with 
heart attached. 

(2) Primipara, set. 34, admitted in labour, breech, after- 

coming head required perforation, dead born. Full- 
time male — 3070 grms. without brain. Lungs partly 
aerated and float buoyantly in water with heart 
attached. 

(3) ii-para, set. 24, thought to be one month post-mature, 

admitted in labour, pelvis normal, forceps tried 
unsuccessfully before admission, head above brim, 
child dead, craniotomy. Full-time or post-mature 
male, ioi lb. in weight. Right lung floats buoyantly, 
also apex of left. 

In all these cases the lungs were only partially inflated, but 
sufficiently well to float buoyantly in water with the heart 
attached. I have not met with a case in which both lungs 
were wholly inflated, and it is claimed that if they were so it 

184 



Further Observations on Still-Birth 

would be absolute proof that the child had lived and breathed 
after birth. Taylor, 7 however, quotes a case within his own 
experience in which a destructive operation had been necessary 
to effect delivery. Nevertheless, after the head was born and 
while the body was still undelivered the child cried loudly for 
an instant. On opening the chest he found the lungs projecting 
forward over the sides of the pericardium, and when each was 
cut into 1 6 pieces each piece floated buoyantly in water even 
after sufficient pressure had been applied to rupture the cloth 
in which the pieces were wrapped. He, however, noted that 
there was no sense of crepitation under the knife and looked 
upon this as evidence that the air-cells were incompletely filled. 

In this connection the question must be asked : Are the 
lungs ever fully inflated within the first twenty-four hours after 
birth? It is not sufficient to say that they completely fill the 
chest for they may do so without full inflation. In the ordinary 
method of carrying out the hydrostatic test the lung is cut into 
small pieces, each weighing about I gram, and if all float the 
lung is said to be fully aerated. But this does not really prove 
full aeration, because one or two alveoli fully aerated in the 
centre of each piece of lung would be sufficient to keep the 
whole afloat though all the remaining area of the portion were 
airless ; and the test is only positive because the pieces of lung 
were not sufficiently small. If we examine microscopically the 
lungs of any infant that has lived for twenty-four hours after 
birth and breathed normally during that time, we shall find 
that there are many areas of atelectasis scattered throughout 
even an ordinary microscopic section. It is doubtful whether 
if this test were applied even to the lungs of infants that had 
lived and breathed normally for a week and cried with average 
frequency they would ever be found to be fully inflated. In 
the course of this investigation I have examined very many 
sections of lungs, healthy and otherwise, from infants dying 
within the first two weeks after birth, and I do not think I have 
met with one where full aeration had occurred in this sense of 
the word. 

It is thus apparent that when it has been stated that full 
aeration of the lungs is a proof of live birth this description of 
the condition of the lungs has only been used loosely, and that 
if it were strictly interpreted such proof of live birth would of 
necessity never be obtained, except in cases in which such 
proof was unnecessary, because of the presence of other proofs 

185 



Francis J. Browne 



of live birth, such as food in the stomach. If then the lungs 
are never fully inflated even when a child has lived for twenty- 
four hours, and they may be partly inflated when a child is 
born dead, what degree of aeration is incompatible with dead 
birth ? In other words, when can it be said that we have 
crossed the border-line between a degree of pulmonary aeration 
that is compatible with dead birth and a degree that is 
incompatible with it ? Or to put it in percentages, which are 
of course necessarily arbitrary : If the lungs are never more than 
90 per cent, aerated (a liberal estimate) within twenty-four hours 
after birth, and they may be 50 per cent, inflated when the child 
has been born dead (which they not infrequently are), at exactly 
what number are we going to draw the line and say, on this 
side of the line the child must have been born alive, and on 
that it must have been born dead? It is surely evident that 
no such definite line can be drawn at all, and upon this point 
alone if on no other the hydrostatic test must fail. 

Vagitus uterinus is a well-authenticated phenomenon, and 
before it can occur the child's chest must, have been more or 
less expanded by the entry of air into the air passages. I am 
not aware that a post-mortem examination has ever been 
carried out upon a dead-born child from which the vagitus 
uterinus wa? heard, but if such were done the lungs would 
probably be found to be very well inflated. Besides breathing 
in the uterus, a child may breathe in the vagina, or after the 
head is born and the body still unborn, or in the case of breech 
delivery it may breathe after the body is born and while the 
head is still retained in the uterus or vagina. In the third 
case the amount of air entry is only limited by the compression 
of the thorax by the pelvic canal, in the others by this and the 
amount of air available in the birth passages. There is no 
reason whatever why if there has been manual interference 
sufficient air should not be allowed to enter to aerate the lungs 
almost completely. In criminal cases such manual interference 
on the part of a medical attendant would be lacking, but it 
may be carried out by the patient herself during the pangs of 
prolonged labour. Indeed it is probable that the mere act 
of separating the labia would allow air to rush in and balloon 
the vagina, especially if the patient were lying in the semi- 
prone position — a very usual one to assume. 

On the other hand it is not infrequent to find cases in 
which an infant had lived for some time, without there being 

186 



Further Observations on Still-Birth 

any visible aeration of the lungs. I referred to three such 
cases in my first report. One had lived half an hour, the second 
two days, and the third four hours, the period of development 
being seven and a half months, eight months, and eight months 
respectively. The lungs in these cases sank in water, and when 
cut into 20 or 25 small pieces each weighing about 1 gram, 
each piece sank. They showed all the usual appearances of 
complete atelectasis. 

From these considerations it is evident that as a test of 
live birth the hydrostatic test fails, and I must express my 
entire agreement with the statement in Taylor's Medical 
Jurisprudence* that " for respiration however complete or 
incomplete to be considered proof of live birth, an eye-witness 
to those respirations is essential." 

Conclusions. 

(1) Asphyxia was the most frequent cause of intranatal 
death and was met with in 36 cases, or 56 per cent., of the 
total intranatal deaths. 

(2) Primiparity and breech delivery were the two chief pre- 
disposing causes, the latter being twelve times as frequently 
associated with it as vertex delivery. 

(3) Its incidence may be diminished by the practice of 
premature induction of labour ten days before term, especially 
in primiparae, by external cephalic version in the case of breech 
presentations, and by careful watching of the foetal heart during 
the second stage of labour, even when this does not seem to be 
unduly prolonged. 

{d) Suprarenal Htemorrhage. 

Considering together the cases of still-birth and neonatal 
death as was done in the case of cerebral haemorrhage, there 
are 9 cases, or 4-5 per cent., in which post-mortem examina- 
tion revealed haemorrhage into the suprarenal body. This is 
to be compared with 18 cases, or 9 per cent., dealt with in my 
first report. Of these 9, 5 were still-born and 4 lived for 
varying periods, the longest being four days, in which case 
there was a massive haemorrhage into the medulla and cortex 
of the right suprarenal. 

Parity. — Two of the mothers were primiparae, three were 

187 



Francis J. Browne 



ii-para, one a iii-para, one xi-para, one xii-para, and one 
xiv-para. 

Site of Hemorrhage— The sites of the haemorrhage in the 
9 cases were as follows : — 

Into medulla of both capsules 
Into medulla of right capsule . 
Into medulla and cortex of both 
Into medulla and cortex of right 
Under capsule of right (ruptured into peritonea 
cavity) . 



Nature of Delivery. — Two of the cases were delivered as 
vertex and 7 as breech. Of the 2 vertex cases one was 
eclamptic and had five fits before admission. Delivery was 
by easy forceps but it is probable that the death had taken 
place before forceps were applied, from asphyxia caused by the 
convulsions. Signs of asphyxia in the thoracic organs were 
especially well marked, and we have seen that this is likely 
to be so when asphyxia has taken place before labour has 
begun. The haemorrhage was underneath the capsule of 
the right and had ruptured into the peritoneal cavity. Its 
occurrence was probably not due to birth injury but to 
asphyxia. In the other vertex case labour had been easy 
and natural, the child being born with white asphyxia two 
hours after rupture of the membranes. The medulla of the 
right suprarenal contained about half a dram of fluid blood. 
Artificial respiration had been performed after birth by the 
method of Schultze and it is possible that this and not birth 
injury was the cause of the suprarenal injury. The fluidity 
of the blood rather pointed to this and to the haemorrhage 
having taken place after asphyxia had occurred. 

All the remaining 7 cases were delivered by the breech, 
3 of these being primary breech and 4 breech by internal 
podalic version. Even if we admit that in the 2 vertex cases 
the haemorrhage was the direct result of birth trauma, we thus 
see that breech delivery is much more culpable than vertex 
delivery. In fact, if we assume that 3 per cent, is the normal 
frequency of breech delivery we arrive at the conclusion that 
suprarenal haemorrhage is twenty-five times as likely to be 
associated with breech delivery as with delivery by the vertex. 
It is a somewhat striking coincidence that in my first series in 



Further Observations on Still-Birth 

which quite different figures were dealt with, the culpability of 
breech delivery in the causation of suprarenal haemorrhage was 
found to be very similar, viz., it was found to be twenty-two 
times as likely to give rise to suprarenal haemorrhage as was 
delivery by the vertex. Its culpability in this respect as 
compared with that of vertex delivery is thus much greater 
than in the case of asphyxia or of cerebral injuries, including 
tentorial tearing, and is a fact that requires to be taken into 
account in considering the method by which suprarenal 
haemorrhages are caused. 

Associated Conditions. — In 5 cases signs of asphyxia were 
well marked. In 3 cases there was also severe cerebral 
haemorrhage which probably would of itself have proved fatal, 
and in 1 case there was no other abnormality found, and the 
haemorrhage, which consisted of clotted blood in the medulla 
of both suprarenals, was the probable cause of dead birth. 
The pelvis in this case was slightly contracted and the cord 
prolapsed, and internal podalic version had been carried out. 
There was no evidence of asphyxia and the clotting of the 
blood seemed to put this out of count. In one case the mother 
and child were syphilitic, but the mother had been partially 
treated during her pregnancy and in the child the examination 
failed to reveal any very definite evidence of syphilis except 
some doubtful increase of interstitial tissue in certain organs. 
In my experience syphilis does not play any striking part in 
the causation of suprarenal haemorrhages. 

Causation of Suprarenal Hemorrhages, — Various theories 
have from time to time been put forward as having an im- 
portant bearing on the causation of suprarenal haemorrhages 
during birth. Such, for example, are too early ligation of the 
cord which would not account for its greater frequency in 
breech cases, compression of the inferior vena cava between 
the liver and the vertebral column, asphyxia, syphilis, etc. In 
considering causation in my two series comprising 27 cases, 
three facts stand out, viz., its frequent association with asphyxia, 
its greater liability to occur in the right gland, and its 
greater frequency during breech delivery. Though suprarenal 
haemorrhage is frequently associated with asphyxia yet the 
former is comparatively rare in asphyxia (compare the 
numbers of cases of each in these two series). In other 
words suprarenal haemorrhage is not very frequently met 
with when death has been due to asphyxia, though signs of 

189 



Francis J. Browne 



asphyxia are common enough when there has been supra- 
renal haemorrhage. In all the still-born children in the 
present series of cases of suprarenal haemorrhage, only one 
was unassociated with asphyxia. But even this one shows that 
the latter is not the sole factor in the production of supra- 
renal haemorrhage. The overfilling of the right heart in 
asphyxia will cause damming back of blood in the inferior 
vena cava. Now, as the right suprarenal vein opens directly 
into the inferior vena cava, it follows that in such a case the 
main force of the blood column will fall upon the right 
suprarenal, while the left gland is protected by the opening 
of the suprarenal vein into the left renal vein. This at once 
explains the greater frequency with which haemorrhage occurs 
on the right side. We know too that multiple small haemor- 
rhages, and especially haemorrhages within the lateral ventricles, 
very probably occur as a result of asphyxia, but nowhere 
would we expect them to be more likely to occur than in the 
cortex and especially in the medulla of the suprarenal body, 
the cellular structure of which is almost entirely unsupported 
by any fibrous stroma. A similar damming back of blood 
would occur as the result of compression of the inferior vena 
cava between the liver and the vertebral column, and here 
again, and for a similar reason, the strain would fall almost 
entirely on the right gland. Such liver compression would 
be far more likely to occur during breech delivery in which 
the cervix and vagina have been dilated less completely than 
they would have been by the forecoming head in vertex 
delivery. 

As syphilis is sometimes associated with massive haemor- 
rhages in other organs, one would expect it to be a predisposing 
cause of suprarenal haemorrhage, but in my experience it 
does not play any important part, and none of my definitely 
syphilitic cases were associated with it. 

Summary. 

(i) Nine cases of suprarenal haemorrhage are dealt with 
in the present series, viz., 4-5 per cent. 

(2) It was far more frequently met with in the right 
capsule than in the left, a fact which may be explained 
on anatomical grounds, viz., by the right suprarenal vein 
opening into the inferior vena cava and the left into the left 
renal vein. 

190 






Further Observations on Still-Birth 

(3) It is twenty-five times as likely to occur in breech 
delivery as in delivery by the vertex. 

(4) It is probably caused by 'the backward pressure of 
blood in the inferior vena cava found in asphyxia and by 
the compression of the latter between the liver and vertebral 
column in breech delivery. 

II. Infective. 

Pneumonia. — The whole subject of pneumonia is best taken 
up under neo-natal death, but it is necessary to explain here that 
there were five infants which were dead born from intranatal 
causes, in whom examination of the lungs revealed catarrhal 
pneumonia. Four of these were delivered by craniotomy, after 
prolonged labour, but in at least one, born without craniotomy, 
the cause of intranatal death was possibly catarrhal pneumonia, 
no other satisfactory explanation of death being found at 
post-mortem examination. If infants are sometimes born 
with advanced catarrhal pneumonia, as is conclusively proved 
in the section on neonatal death, then it is obvious that it 
is also a possible cause of intranatal death (see neonatal 
death). 

III. TOX.EMIC. 

In my last report 3 cases were referred to in which the 
cause of death seemed to have been scopolo-morphine narcosis. 
In all cases more than one dose of morphine had been given 
in association with hyoscine, and the opinion was advanced 
that the morphine was the lethal agent. Since those cases 
occurred only an initial dose of morphine with hyoscine has 
been given, followed by hyoscine alone, and no further cases 
have since been met with in the Maternity Hospital in which 
there was any suspicion that death was due to scopolo-morphine 
narcosis.* 

IV. Developmental. 

Amongst developmental causes of fcetal death are classed 
a few deformities which are incompatible with post-natal life 
for any but a very short period. 

* Since this was written I have examined a still-born child in which no 
cause for death could be found. Suspicion attached to scopolo-morphine 
narcosis, although the initial dose of morphine had not been repeated. 

191 



Francis J. Browne 



These were as follows : — 

General dropsy of the fcetus . 4 

Anencephaly ...... 2 

Absence of both kidneys . ... 2 

Hydrocephalus, previously classed under craniotomy 4 
Both kidneys rudimentary, both ureters absent, 
bladder rudimentary, hydrocephalus, spiria 
bifida and latipes equino varus . . .1 

The cases of absence of the kidneys and of general fcetal 
dropsy presented many features of pathological and embryo- 
logical interest, and will be fully dealt with in separate 
communications. 






Neonatal Death. 

Of this there were in the present series 73 cases. 
As I have elsewhere 9 fairly recently dealt with this part of 
the subject I shall here refer only to a few of the outstanding 
points. The causes may be classified as follows ; — 
(A) Traumatic : — 
Intranatal — 

Cerebral haemorrhage . . .18 

Suprarenal haemorrhage . . .5 

Craniotomy (child breathing after birth) . 3 
Other injuries .... 4 

Post-natal — 

Overlaying . • . . .0 

Injury during artificial respiration . . o 

Other injuries . . . . 1 



(B) Infective :— 

Antenatal- 
Syphilis 

Intranatal — 

Pneumonia (5 dead born) 
Other infections 

Post-natal — 
Pneumonia 
Other infections 

(C) Toxaemic : — 

Necrosis of liver 

(D) Prematurity {per se) 

(E) Developmental 

(F) Other conditions not peculiar to the newly born 

e.g., volvulus, gastro-enteritis, etc. 

(G) Undetermined 



192 



1 

18 
4 

1 
o 

93 



Further Observations on Still-Birth 



Syphilis. 

By far the most frequent cause of neonatal death was 
an antenatal infection, syphilis. In the present series there 
were n cases, or 5-5 per cent. Only 2 of these n, how- 
ever, contained demonstrable spirochetes in the fcetal organs, 
the other 9 being diagnosed from the so-called secondary signs 
of syphilis. Including the 24 cases of syphilis in which the 
foetus was born macerated the total number of cases in this 
series diagnosed as syphilitic was 35, or 17-5 per cent. As only 
15 of the macerated foetuses were spirochete positive, it is 
evident that the total number of spirochaete positive foetuses 
in the series was only 17, or 8-5 per cent. As previously 
explained it is extremely difficult to decide how far we are 
justified in diagnosing syphilis in the face of failure to find 
the spirochaete. 

In addition to the points previously mentioned under ante- 
natal death as being of use in the diagnosis of syphilis, we have 
in the fresh foetus the assistance to be derived from histological 
examination of the foetal organs. The changes are, generally 
speaking, of the nature of a fibrosis. Now as there is no 
standard for the amount of connective tissue normally present 
in a foetal organ it is difficult sometimes to say when we have 
passed over the border - line dividing the normal from the 
abnormal. In such cases of doubt it is safest to suspend 
judgment and watch the course of a future pregnancy. 

The distribution of the syphilitic changes in the various 
parts of the foetus was as follows : — 

Prematurity ...... 7 

Marasmus ...... 3 

Skin eruptions ...... 3 

Jaundice ...... 1 

Enlargement of the liver ... .2 

,, „ spleen .... 4 

Chondro-epiphysitis . . . . .2 

Spirochetes in fcetal organs . . . . 2 

Massive haemorrhage in the lungs . . .1 

Interstitial pneumonia . . . . .8 

Periportal cirrhosis . . . . .6 

Fine cirrhosis in liver . . . . .2 

Hemopoietic liver . . . . .5 

Miliary gummata in liver 1 

Fibrosis of pancreas ..... 5 

„ „ pituitary ..... 1 

„ „ thyroid . . . .4 

Thymus changes . . . . .3 

OBST. 193 O 



Francis }. Browne 



It is noteworthy that while an abnormal degree of placental 
enlargement was present in 58 per cent, of macerated syphilitics 
it was only present in 33 per cent, of the fresh syphilitics. The 
reason for this is evident. Enlargement is caused by fibrosis 
and cellular infiltration of the placental villi, and this will be 
more marked in macerated syphilitics because it has been 
sufficient to cause intra-uterine death. 

In my second report I have given details of the weight ratios 
of a large series of normal livers studied in order to determine 
the heaviest weight ratio of a normal fcetal liver. This I found 
in my series to be 12-5. A fresh fcetal liver, therefore, showing 
a weight ratio higher than this is probably syphilitic. Counting 
in this way, only 17 per cent, of the fresh syphilitics showed 
abnormal liver enlargement. In only one of the two spirochete 
positive foetuses was the liver abnormally enlarged, their 
weight ratios being respectively 18-6 and 12- 1. The question 
as to what constituted abnormal enlargement of the spleen 
was also studied in a similar series of cases, and the conclusion 
was reached that a weight ratio of 150 or under was normal. 
Taking 150 as the upper limit of normal enlargement 33 per 
cent, of the fresh syphilitics, including the two spirochaete 
positive foetuses, showed an abnormal degree of splenic enlarge- 
ment. This sign then appears to be more useful in diagnosis 
than enlargement of the liver because it is more frequently 
present. 

Pneumonia. 

This was by far the most frequent cause of neonatal death 
and was found in 24 out of the 74 cases, or 33 per cent. In 
most of these the pneumonia was the actual cause of death, but 
in a few it was associated with other conditions, such as syphilis 
or cerebral haemorrhage, which in themselves would probably 
have proved fatal. In addition to these 24 cases of neonatal 
death there were 24 cases in which pneumonia was found in 
dead-born children. 

Maturity. — Of the 28 cases, 13 were at term and 15 
premature, 4 of the latter being at 8i months, 6 at 8 months, 
and 5 at 7 to jh months. Prematurity therefore appears to 
predispose to the disease. 

Duration of life varied from a few minutes to six weeks. 
With the exception of two cases all the deaths occurred within 
the first two weeks after birth. 

i94 



Further Observations on Still-Birth 

Condition of the Lungs. — This varied from a slight patchy 
catarrhal pneumonia to advanced grey hepatisation with serous 
or purulent pleural effusion. In one child which had lived for 
thirty-four hours only both pleural cavities contained blood- 
stained and slightly purulent fluid with a lymph exudate over 
the surfaces of both lungs. The lower lobes of both lungs were 
in a state of red hepatisation. In this case the membranes 
had been ruptured eighteen and a half hours before delivery. 
Cultures on blood agar from the lungs gave a pure growth of 
a short chained streptococcus. It is probable that in this case 
infection had occurred and the disease commenced before birth. 
In the case of another infant which lived for two days there was 
pleural effusion accompanying the pneumonia. In three cases 
there was syphilitic interstitial change in the lung revealed only 
on microscopic examination. The pneumonia is generally 
evident on naked-eye examination. Frequently the lungs are 
partly aerated especially in premature infants, and this renders 
the diagnosis more difficult. The affected lobes have a rubbery 
feel, are more solid in consistence than the merely atalectic 
lung, and on squeezing the cut section, blood and frothy sero- 
purulent fluid are exuded. Not infrequently, however, both in 
the aerated and non-aerated lung, the pneumonia is only 
revealed on histological examination and so is liable to be 
overlooked unless this is carried out. Microscopically all 
decrees are met with, from a mere catarrh of endothelial cells 
with a few polymorphonuclear leucocytes, to a condition of 
grey hepatisation. In most cases the alveoli contain numerous 
polymorphonuclear leucocytes, lymphocytes, catarrhal endo- 
thelial cells, red blood cells, and debris. Not infrequently the 
alveoli are filled with extravasated blood to the apparent 
exclusion of everything else, the bleeding taking place from 
rupture of small capillaries in the alveolar walls during the 
stage of congestion. In such cases, if the haemorrhage is 
extensive enough and a sufficient area of lung involved, the 
child, previously apparently healthy, may die suddenly or be 
found dead in its cot — a condition described in a previous 
communication 10 under the name of "acute hemorrhagic 
pneumonia of infants." 

It is remarkable that in none of the cases of pneumonia, 

even those in which the disease was found to be advanced at 

autopsy, had the true condition been suspected during life. No 

characteristic symptoms had been noted which might have led 

obst. 195 02 



Francis J. Browne 



to a physical examination. When a young infant is cyanosed, 
with cold skin and extremities, feeds badly, and is fretful, 
pneumonia should be suspected. These were the only 
symptoms noticed in my cases, with the exception of one or 
two in which breathing was rapid, shallow, and somewhat 
wheezy. 

Intranatal Pneumonia. 

In my previous paper I cited some cases of very early 
infantile death from pneumonia. In one case the infant lived 
only eight hours after birth, and post-mortem examination 
revealed pleural effusion with advanced catarrhal pneumonia 
in the stage of grey hepatisation affecting both lungs. The 
mother had been admitted to hospital after a long-delayed first 
stage due to primary inertia, the membranes having been 
ruptured for some time prior to admission. Forceps were 
applied in hospital and a " blue " baby breathing badly was 
born which died eight hours later. It seemed impossible 
that such an advanced degree of grey hepatisation could have 
been reached in the eight hours during which the child lived, 
and its blueness and difficulty in breathing at birth and 
continuing till death were strong evidence of the presence 
of pneumonia before birth. Positive proof was, however, 
lacking, and this has now been supplied by examination of 
six cases in the present series, five of which were dead-born 
and the other practically so, having only lived long enough 
to gasp once or twice after its delivery by means of craniotomy. 
In all six pneumonia of catarrhal type was found on histological 
examination. I shall only give details of one of the cases in 
which the pneumonia was the most advanced of all, and an 
illustration of which I shall show on the screen. 

Case No. 380. — xiv-para, set. 37. First four labours natural, 
others more difficult and instrumental, but children born alive 
and healthy except the last, which died of injury to the skull 
received at birth. No antenatal supervision. Admitted to 
hospital after being in labour ten hours and the membranes 
ruptured for thirty-six hours. Forceps applied unsuccessfully 
in hospital, craniotomy twenty hours after admission ; child 
breathed after delivery. W.R. negative. Full-time female child, 
2935 grms. after craniotomy, length 54 cm. Lungs partly aerated 
but otherwise appeared normal to naked eye. Microscopically 
they showed catarrhal pneumonia in a fairly advanced stage. 

196 



Further Observations on Still-Birth 

Alveoli filled with polymorphonuclear leucocytes, endothelial 
cells, and granular debris. The pneumonia was very wide- 
spread, occupied the entire section examined, and was passing 
over into the stage of grey hepatisation. The liver showed 
marked cloudy swelling. 

In all the cases there was a prolonged interval between 
rupture of the membranes and delivery, and in two forceps had 
been applied without success before admission to hospital. 
Information as to the exact interval elapsing between rupture 
of membranes and birth was available in only three cases, in 
which it was two weeks, twenty-three hours, and fifty-six hours 
respectively. In the last the disease was the most advanced of 
all and infection must have taken place very soon after rupture 
of the membranes had occurred. 

In all cases the mother was perfectly well and passed 
through a normal puerperium. 

Path of Infection. — The view that the infection in these cases 
is from the amniotic cavity by the naso-pharynx and bronchial 
tubes and not by the blood-stream seems to be supported by the 
following considerations : — 

(i) The distribution of the pneumonic patches in early 
cases. The pneumonia is of the catarrhal type, and in early 
cases, e.g. No. 261, is still confined to the area around the 
bronchioles. 

(2) The mothers were all in good health throughout 
pregnancy and showed no evidence of blood infection. The 
puerperium was in all cases completely afebrile. 

(3) In infants born after the membranes had been ruptured 
for a long time it is often possible to find organisms in swabs 
taken from the naso-pharynx. These may be shown to 
correspond with those in the mother's vagina at the time of 
labour, e.g. yeast organisms. The infection then probably takes 
place by way of the air passages, the ruptured membranes 
permitting the entrance of organisms to the infant's nose and 
mouth cavities, whence they are carried either by aspiration or 
continuous surface growth to the lungs. It is probable that 
organisms are in the first place carried from the vagina to the 
vicinity of the infant's mouth and nostrils on the hands of the 
accoucheur or on obstetric instruments, though this is not 
necessary. It is certain that a fcetus when being asphyxiated 
has its respiratory centre stimulated by the acidosis consequent 
upon the accumulation of C0 2 in the blood, with the result that 

197 



Francis J. Browne 

it inspires. This, as we have previously seen, accounts for the 
partially expanded lungs one meets with so frequently in 
dead-born children. Infected mucus or liquor amnii lying in 
proximity to the mouth or nose may easily be drawn into the 
trachea or bronchi. This gasping may be easily observed in 
fcetal rabbits. If the pregnant sac is exposed and opened so 
as to leave the amnion intact, and if the placenta is now 
separated the foetus can be seen to gasp repeatedly before 
death. In the sections of lungs of foetuses dying from intra- 
natal pneumonia the alveoli of the unaffected portions contained 
a little debris with epithelial cells that might have been derived 
from the liquor amnii. 

Toxcemic Causes. 

Under this heading is classed one infant (No. 306). The 
mother was pre-eclamptic when admitted in labour, though 
she never developed actual convulsions. The delivery was 
natural, and the child, though at term, was feeble, blue, 
and somewhat rigid at birth, and was only restored with 
difficulty. No convulsions were noted but the nurse said it 
"was having turns of cyanosis." It died fifteen hours later, 
and at post-mortem examination catarrhal pneumonia was 
found and very marked liver necrosis. Except for a zone 
around the margin it was a uniform bright-yellow colour which 
at the edges shaded off into more or less normal liver tissue. 
In these yellow areas there was no indication of lobules. 
Microscopically the necrosis was found to be well marked, some- 
times destroying almost the entire lobule. It was irregular 
in distribution, but, generally speaking, was most frequent 
around the central hepatic vein. The liver cells in the necrotic 
areas were pale with indefinite outline, and their nuclei stained 
badly, or in areas where the necrosis was more advanced the 
cells and nuclei had entirely disappeared and some debris 
alone remained. The kidneys showed oedema and congestion. 
The capillary tufts were congested, and in consequence swollen 
so as to completely fill the capsule. The tubular epithelium 
except for some swelling appeared fairly normal. 

Prematurity. 

At post-mortem examination of premature infants one is 

not infrequently unable to find any cause of death. Death 

has occurred because of the under-developed condition of the 

198 



Further Observations on Still-Birth 

vital centres rendering the infant unable to accommodate itself 
to post-natal environment. In such cases one must inves- 
tigate the reason for the premature birth. In the present series 
there were 18 such cases, the causes of prematurity being 
twin pregnancy (2), induced labour (3), central placenta praevia 
(1), prolapsus uteri (1), accidental haemorrhage (1), not 
evident (4). Of these four in which no cause of premature 
birth was evident, in three the obstetrical history was suspicious 
of syphilis, but the result of examination was otherwise incon- 
clusive. It is in such cases useful to study the history and 
results of subsequent pregnancies, a procedure which during 
the course of the present investigation has been followed in 
not a few cases with very satisfactory results in regard to 
diagnosis. In the remaining one no definite cause for 
prematurity could be discovered except the mental and physical 
strain consequent upon an unemployed husband and poor 
home conditions. 

Prevention of Still-Birth. 

It is unnecessary to emphasise the need for adequate 
antenatal supervision during pregnancy. Its importance is 
admitted by all. There are one or two points, however, 
upon which I should like, in conclusion, to lay some emphasis. 

(1) The large number of deaths from asphyxia occurring 
during first labours, and associated there with rigidity of the 
tissues and a prolonged second stage, shows the importance 
of carefully watching the foetal heart rate during this stage, 
and prompt action in the interest of the child when this is 
indicated. I think that a strong case can be made out for 
the routine induction of labour in primigravidae about ten 
days before the expected date of delivery unless' the child is 
unusually small. An easier and less prolonged labour is 
thereby ensured. 

(2) Throughout this paper emphasis has been laid again 
and again upon the danger of breech delivery, especially in 
primigravidae. This points to the necessity for prophylactic 
external version. There are two reasons for this : the first 
is the increased risk to the child during delivery ; the second 
reason is that unless the vertex is the presenting part one 
has no method of finding out the relative proportions between 
the head and the pelvis. In my experience the best time for 

199 



Francis J. Browne 



attempting prophylactic external version is at the beginning 
of the ninth month. If left to a later period it is usually 
too difficult on account of the large size of the fcetus and 
the relatively small quantity of liquor amnii. If carried out 
earlier it may not remain in its new position for reasons the 
opposite of these. 

(3) Much may be done to shorten labour by external 
rotation of posterior cases by means of pads, according to the 
method introduced by Buist. 11 Our experience of this method 
is that it seldom fails to accomplish its object. The greater 
difficulty lies in diagnosis of occipito-posterior positions by 
external palpation, and I know of nothing in antenatal 
diagnosis requiring longer experience. The position of the 
fcetal heart sounds is of little assistance and may even be 
deceptive. 

(4) The provision of couveuses for premature infants is an 
urgent need in our hospital, while a special ward set apart for 
infants would probably result in a much diminished death- 
rate from infectious diseases such as pneumonia. It seems 
irrational to expect the new-born infant to escape infection 
when, as at present, it is nursed in a cot by the side of its 
mother, in a ward where there are patients with infected 
lochia, and attended by a nurse part of whose duties is to 
look after such patients. 

In conclusion, I should like to express my indebtedness 
to the Physicians of the Maternity Hospital, as well as the 
residents and sisters, for, in numerous ways, facilitating this 
investigation. To Dr J. W. Dawson I owe special thanks 
for advice in the interpretation of many difficult histological 
appearances. 

References. 

1 Hewer, Evelyn E., Quarterly Joum. of Exper. P/iys., April 1924, vol. 

xiv., Nos. 1 and 2. 

2 Browne, F. J., Joum. of Obstet. and Gy7ice. Brit. Emp., Winter 1923, vol. 

xxx., No. 4, p. 519. 

3 Robinson, Arthur, Edin Med. Joum., March 1921. 

4 Warwick, Margaret, Amer. Joum. Med. Set., 1919, vol. clviii., p. 95. 

6 Potter, Irving W., "The Place of Version in Obstetrics," p. 98. 

Holland, Eardley, " Causation of Fcetal Death." Ministry of Health 
Report, No. 7. 

7 Taylor, " Principles and Practice of Medical Jurisprudence," 7th ed., vol. 

ii., p. 204. 

200 



Further Observations on Still-Birth 

8 Taylor, loc. cif., p. 210. 

9 Browne, F. J., Brit. Afed.Journ., 1922, vol. ii., p. 590. 

10 Ibid., 1922, vol. i , p. 469. 

11 Buist, R. C, Brit. Med. JL, 1921, vol. ii., p. 782. 

Discussion. 

Professor Watson — I think one has seldom listened to a paper 
which contains so much real scientific material, and at the same 
time so many practical applications of the results of these scientific 
findings. It is difficult to pick out points where Dr Browne has 
mentioned so many of the greatest importance. I should like to 
mention one point with regard to the prevention of asphyxia in the 
new-born child, and that is, Do we pay enough attention to getting 
the air passages thoroughly clear before beginning artificial respira- 
tion in these cases ? Do we teach students and nurses the importance 
of aspirating the air passages before beginning artificial respiration ? 
Should we not make it a rule that every midwife and doctor carry 
an aspirating tube in his or her midwifery bag? Further, when 
such an aspirating tube is used it should be provided with a rubber 
end. The ordinary instrument that is sold has simply a glass end 
which may do damage to the child's pharynx and which does not 
get down into the air passages in the same way as a rubber 
tube does. 

With regard to what Dr Browne said about making the induction 
of labour a routine in every primipara ten days before time, I do not 
think it is a wise counsel, because I think that the experience of a 
great many of us is that, as a rule, labour which comes on naturally is 
quicker and easier than that which is induced artificially. Personally, 
I do not think it would be good teaching to advise that in every 
primiparous woman labour should be induced ten days before term. 
In some, of course, it is necessary. 

Dr Fordyce — I cannot agree as to the advisability of inducing 
labour in every primiparous woman seven days before labour with 
a view to preventing asphyxia. I am surprised that Dr Browne 
should question the possibility that intra-uterine death may result 
from a knot on the cord. I have had two cases where the fcetus 
was born dead and the condition of the cord — the tightness of the 
knot and absolute atrophy of the cord — proved that there could be 
no question as to the cause of the child being born dead. 

Dr Haig Ferguson — I quite agree with Dr Fordyce in what he 
has said about the induction of labour as a matter of routine in 
primiparae. The importance of inducing labour, if a woman (whether 
a primipara or a multipara) seems to have gone beyond her full-time, 

201 



Francis }. Browne 



is now clearly established, especially if there is any evidence of the 
head becoming too much ossified. A good deal depends, of course, 
on the accuracy of the dates, which should always be supplemented 
by a careful pelvic examination. 

With regard to what Dr Browne has said about the danger of 
knotting of the cord, one has constantly seen living children born 
where there have been old knots in the cord, but where the extra 
accumulation of Wharton's jelly at the spot has no doubt prevented 
kinking of the blood-vessels. Dr Browne has done well to call 
attention to the floating of the lungs in water in cases where children 
have apparently never breathed, and his observations thereon are 
very interesting. I was greatly interested in what he told us of 
intra-uterine pneumonia, which I hope he will deal with more fully 
in subsequent papers. 

Dr Young — One of the many points that impressed me in 
Dr Browne's paper was the somewhat new attitude which he has 
adopted with regard to the treatment of the after-coming head in 
breech presentations. He has shown that in our efforts to save the 
child we may be really doing our very utmost to prejudice the child's 
life. In the discussion which took place in London at the Royal 
Society of Medicine a few weeks ago the same question was raised. 

Miss Thomson — Might I ask if Dr Browne has found perisplenitis 
in his sections, and also if he has found many cases of inspired 
meconium ? 

Dr F. J. Browne (said in reply) — Professor Watson raised the 
question of the use of a rubber tube in aspirating. I think this quite 
a cood suggestion. I do not know if the rubber tube has been 
introduced into the Maternity Hospital, but if not, it should be. 

With regard to the question of routine induction of labour, I 
advocated this in my last paper. There is nothing new in it and I had 
no criticism whatever on the last occasion — nothing but praise in fact! 
Dr Osborne Greenwood wrote to me to say he had practised it for 
some years with great success. It can be done by means of quinine 
and castor oil. The benefit lies in the fact that in these last seven or 
ten days the child's head increases enormously in hardness, and 
induction a week or ten days before term makes all the difference to 
the ease with which the head moulds. The important thing is to 
estimate the hardness of the fcetal head, and one can easily do that 
by abdominal and vaginal palpation. Once it has reached a period 
of thirty-six weeks, it can then pass through the maternal passages with 
as little risk of injury as at full-time, while the labour is much less 
prolonged. Dr Oliphant Nicholson, who I am sorry is not here 
to-night to bear me out, has carried out that treatment for years and 
has also arrived at the same conclusion. 

202 



Farther Observations on Still-Birth 

It has never been settled until a few years ago whether knotting 
of the cord can cause fcetal death. There was no unity of opinion on 
the subject at all, and many people even now deny that the cord can 
ever be so tightened during the child's life as to cause obstruction of 
the fcetal circulation and death. 

Dr Haig Ferguson raised the question about the hydrostatic test. 
It is nothing new, and I stand absolutely with Taylor on this subject. 

There was no evidence of perisplenitis in any of my cases. With 
regard to the presence of inspired meconium, one frequently finds that 
a child does gasp when it is being asphyxiated. One can notice that 
in the case of rabbits. When one separates the placenta of a rabbit 
one sees the rabbit gasping repeatedly inside the amniotic sac. The 
child does the same thing, and inspires meconium and infected liquor 
amnii into its lungs. 



203 



Meeting — 16th July 1924. 

EXHIBITION OF SPECIMENS. 

Dr R. W. Johnstone showed three cases of fibroids associated 
with pregnancy. (1) The first specimen was removed from a 
married woman of 43, who had had one child. In 1920, during a 
second pregnancy, she developed mental symptoms, and at the request 
of Professor G. M. Robertson I evacuated the uterus. Two years later 
she thought herself again pregnant, but her menstrual history scarcely 
supported this belief. A normal period in the last few days of April 
and beginning of May was followed by another period beginning on 
the 3rd of June, and when I saw her this period had gone on more 
or less continuously for three weeks. On examination the uterus 
was found to be enlarged to the size of a fist, hard and irregular, and 
the diagnosis of small multiple fibroids, with possibly a very early 
threatened abortion, was made. In view of the previous nervous 
history it was decided to operate, and supravaginal hysterectomy was 
performed, the uterus being found to contain two fibroids and an 
early pregnancy. 

(2) The second case is that of a woman aged 34, three years 
married, and without a family. The patient was intensely neurotic. 
Her periods had been regular until two months before I was asked 
to see her by Dr M'Adoo of Portobello, and since then amenorrhcea 
had been associated with excessive vomiting. I was asked to see 
her as a case of hyperemesis gravidarum. I found her not emaciated 
and able to retain milk and beef tea. She was in a condition of fear 
with regard to the pregnancy, and at the thought of having to go 
through a confinement, which I can only describe as bordering upon 
frenzy. Abdominal examination revealed a hard, irregular tumour, 
extending up to above the umbilicus on the left side. Bimanual 
examination without an anaesthetic was impossible, and during the 
administration of the anaesthetic the patient's behaviour was such that 
I quite expected the police or the neighbours would come in to ask 
what was happening. Ultimately bimanual examination confirmed 
the diagnosis of a fibroid tumour. The cervix was slightly softened and 
there was a well-marked uterine souffle. Supravaginal hysterectomy 
was performed and one ovary left behind. The patient made an 
uninterrupted recovery but still remains markedly neurotic. 

(3) The third case was that of a woman aged 41, eleven years married, 
no children. She was always regular until three and a half months 
before I was asked to see her. Since then she had had amenorrhcea 
but no other signs or symptoms of pregnancy. She complained of 
pain above the symphysis pubis. On abdominal examination I found 

204 



Exhibition of Specimens 

a tense elastic swelling on the right side, extending up to one finger's 
breadth below the umbilicus and exclusively situated in the right 
side of the abdomen. On bimanual examination the uterus, together 
with what I took to be a fibroid tumour, was situated rather low down 
and to the left. I made a diagnosis of an ovarian cyst pressing down 
upon the uterus, which was probably the site of a fibroid, and I was 
inclined to attribute the amenorrhcea to some involvement of the 
remaining ovary. On opening the abdomen I discovered that what 
I had taken to be a cyst was in reality a pregnancy in the right horn 
of the uterus. The fibroid tumour in the other half of the uterus 
was as large as an orange, and there were several smaller fibroids 
situated throughout. In view of the position of the larger of the 
fibroids, I think that this operation, although made upon a mistaken 
diagnosis, would have been necessary later, as the patient could 
certainly not have delivered herself. The fibroid shows commencing 
red degeneration, which was probably the cause of the pain. 

Dr Young showed — (i) a case of prolapse and cystocele 
with marked hydronephrotic change in the kidneys. 

(2) Brain showing extensive cerebral haemorrhage from case 
of eclampsia. The patient was a girl of 21, who was six and a 
half months pregnant, and she was seen two days before I saw her 
by Dr Buist of Dundee, who examined the urine and found it healthy. 
Two days afterwards, on Thursday of last week, she travelled across 
to Dundee by the morning train to buy some baby clothes in view 
of the approaching confinement. Up to this time she had been 
healthy and vigorous and exhibited no symptoms of illness. She was 
sitting talking at eleven o'clock to her sister-in-law when she suddenly 
put her hand up to the right side of her head and complained of pain, 
and at the same time the sister-in-law saw the left side of her face 
become twisted, and she fell unconscious to the floor in a convulsive 
fit. An hour afterwards I saw her lying in that unconscious condition, 
breathing stertorously. The conjunctival reflex was gone, the pulse 
was 60, slow and full, and there was no oedema. At 1.30 she was 
removed to a nursing home and in the interval there were no fits. 
In the nursing home the pulse was 60 and regular; blood pressure — ■ 
systolic 150, diastolic 90; 7 02s. of clear, limpid, healthy-looking urine 
were evacuated by catheter and there was no trace of albumen. She 
had still no cedema. On vaginal examination the os was not dilated. 
At two o'clock she took another fit and remained unconscious, and 
between half-past two and three she died. At the post-mortem the 
convolutions of both hemispheres were flattened, and there was a large 
blood clot in the right hemisphere of the brain. The liver was found 
to be pale and diffusely hemorrhagic — a typical liver of eclampsia. 
The kidneys showed no definite naked-eye changes — nothing of any 
obst. 205 p 



Exhibition of Specimens 

abnormal nature was found in the very limited examination of the 
uterus which was possible. Microscopically the liver was found to 
show very definite hemorrhagic changes throughout, and in an early 
stage the necrotic changes characteristic of eclampsia. Dr Davidson, 
who is carrying out the examination, has agreed to report to the Society 
later on. At the same time the kidneys were found to be in a state 
of oedema and of intense cloudy swelling of the tubules. I take it 
that this woman was an instance of extremely intense toxaemia occurring 
suddenly. The poison appeared suddenly in the blood-stream and 
was sufficient to cause the cerebral haemorrhage which ended in her 
death a few hours later. The kidney damage was so intense that she 
had complete suppression of urine, the urine which was drawn off 
having been probably (passed?) during the preceding hours. The 
kidney itself was a kidney through which healthy urine could 
obviously never have passed. 



206 



HYDROURETER AND HYDRONEPHROSIS 
SECONDARY TO PROLAPSE AND CYSTOCELE.* 

By JAMES YOUNG, D.S.O., M.D., F.R.C.S. 

DURING the past five years I have seen two cases of extensive 
prolapse of the pelvic organs in which bilateral hydronephrosis 
was found at the post-mortem examination. 

The first case was that of a cadaver in the dissecting-rooms 
of the University of Edinburgh during the summer of 1919; 
for permission to refer to it I am indebted to Professor Robinson. 
There was a large mass projecting from the vulvar opening 
consisting of vaginal walls, bladder, and cervix. The uterine 
body was at its normal level in the pelvis in an anteverted 
position and the supravaginal cervix was therefore greatly 
elongated. The ureters were markedly distended on both 
sides, towards their upper end being as broad as the wrist. 
The kidneys were greatly enlarged and the pelves were dis- 
tended to form large sacs. There was a considerable amount 
of urine in the bladder, and when this was suddenly squeezed 
a large wave of urine was transmitted easily along the ureter 
to the kidney pelvis of both sides. I was so much impressed 
by the importance to gynaecologists of the pathological changes 
present in this case that I was anxious to study the case more 
fully by dissection, but this was denied me. 

The second case came under my notice last year. It relates 
to a woman, aged 52, who was admitted to Ward 34 on 30th 
July 1923. The history was as follows : " Womb coming down " 
since the birth of the second child sixteen years before. She 
had had an operation for the condition fifteen years before but 
it recurred a short time thereafter. She had had three labours 
since. Frequency of micturition for two years. No incontinence. 
General weakness for two years. A pessary had not been worn. 

A striking fact noted on physical examination of the patient 
was the sallow colour of her skin which had a marked yellowish, 
unhealthy tinge. The skin, in addition, was dry and inelastic 
and the hair was very thin. 

There was complete procidentia with an ulcer about the size 
of half-a-crown at the apex. The hernial mass was irreducible. 

The specific gravity of the urine was 1008 ; there was a 
trace of albumen. No pus, blood, or sugar. 

* Read 16th July 1924. 
Obst. 207 p 2 



James Young 



On 13th August 1923 I operated, following the procedure 
usually adopted in such cases, namely, anterior colporrhaphy with 
bladder fixation, amputation of the cervix, and posterior colpo- 
perineorrhaphy. The anaesthesia was induced by a mixture 
of chloroform two parts and ether three parts and continued 
by ether. The progress notes are as follows : night of opera- 
tion — bladder catheterised and 10 ozs. of pale urine containing 
pus were evacuated. 14.8.23 — Only 5 ozs. urine obtained in 
twenty-four hours. Patient developed jerky movements, 
choreiform in character, of the whole body and became very 
dull mentally. Pulse forcible, 124. Respirations stertorous. 
15.8.23 — Now quite unconscious. Almost complete suppression 
of urine. Pulse forcible but pressure poor. 16.8.23 — Patient 
died at 2.40 A.M. 

Post-mortem examination. — The kidneys were small and 
markedly hydronephrotic. The ureters were slightly distended. 
The bladder was healthy (see Fig.). 

These two cases reveal a complication of pelvic prolapse 
which, so far as I know, had not before been brought within 
the clinical ken of the gynaecologist. None of my colleagues 
with whom I have discussed the cases have either seen or heard 
of similar cases. So much impressed, however, was I by the 
glaring changes present in the first of these two instances, that 
I suspected that the same involvement of the urinary tract was 
probably of commoner occurrence than was commonly suspected. 
My conviction was so complete that in my text-book in 1921 
I mentioned hydroureter and hydronephrosis as one of the 
secondary complications of prolapse. 

My attention has recently been directed to a paper by 
Brettauer and Rubin in the issue of the American Jom-nal of 
Obstetrics and Gynecology of December 1923 on " Hydroureter 
and Hydronephrosis : a Frequent Secondary Finding in Cases 
of Prolapse of the Uterus and Bladder." This paper is based 
on a study of ten cases of prolapse, in six of which there was 
complete procidentia with large cystoceles, whilst in the other 
four there was partial prolapse. The cases were examined as 
follows. A catheter was passed into the ureter and the amount 
of immediate urine passed was measured. Thereafter the 
capacity of the kidney pelvis was tested by injecting sterile 
water. In three cases opaque fluid was injected and a radio- 
gram of the distended ureter and pelvis then taken. 

In eight cases (80 per cent.) there was "hydroureter and 

208 




Bilateral Hydronephrosis associated with long-standing- cystocel 



cystocele. 



James Young 



hydronephrosis. In two the urologic examination failed to 
show any abnormality. It is interesting to note that these 
were partial prolapses, one of which was accompanied by a 
large cystocele and the other by a moderate-sized cystocele. 
There were four cases of bilateral hydronephrosis and the 
other four had only one-sided lesion. In general the complete 
prolapses were associated with large cystocele and showed the 
bilateral kidney-ureter dilatation. In one case (case 10), that 
of an elderly multipara with a slight cystocele, the dilatation 
of the renal pelvis was bilateral, but of a moderate degree. 
Pessaries were worn by only three of these patients. In general 
it may be said that the older the patient and the longer the 
duration of the prolapse the more likely will the dilatation of 
the kidney pelves and ureters be associated with it." 

Brettauer and Rubin refer to a post-mortem study of pro- 
lapse by Tandler and Halban published in 1907. These authors 
found dilated ureters in fifteen out of twenty-three autopsies ; 
there is no reference to the kidneys as these had previously been 
removed. Brettauer and Rubin also quote two cases of genital 
prolapse reported by Hirokawa,in 191 1, in which ureter dilatation 
was found at the autopsy. 

It would seem that in this array of cases we have evidence 
that urinary stasis is a by no means infrequent result of genital 
prolapse. On the other hand the scanty reference to it in 
gynaecological literature must be held to imply that it is rarely 
sufficiently pronounced to endanger life in the large number 
of women who are nowadays operated on for this condition. 
Whilst this is so, the case which I have recorded teaches that 
in long-standing cases of prolapse the involvement of the 
kidneys may, on occasion, be so great as to lead to a 
fatal result. 

The presence of this abnormality hitherto unsuspected by 
operating gynaecologists indicates the need for a careful 
examination of the kidney function before an operation is 
decided upon. This examination is important in long-standing 
cases of cystocele in which the risk of severe kidney damage 
is especially great. In the future a seriously embarrassed renal 
function must be added to the contra-indications to the operative 
treatment of prolapse and cystocele. 

The causes. — Brettauer and Rubin believe that the pull 
on the ureters exerted by the abnormally dependent cervix and 
uterus causes a kinking of their lumen by the uterine vessels, 

210 



Hydroureter and Hydronephrosis 

and this is rendered all the more likely as the veins are 
frequently distended and thickened by prolonged stasis. In 
support of this view they urge that both in Tandler and 
Halbans' studies and in their own the distal end of the ureter, 
i.e., the part beyond the uterine vessels, is not affected by this 
dilatation. An alternative explanation which I would suggest 
is that the pressure exerted on the large hernial mass by the 
unyielding pelvic outlet would tend to produce a stasis in the 
ureters at a point very much corresponding to that indicated 
in the observations of Tandler and Halban and Brettauer 
and Rubin. 

References. 

Young, J., Text-book of Gyn., 1921, p. 106. Brettaner, J., and Rubin, I. C, 
" Hydroureter and Hydronephrosis : A Frequent Secondary Finding in 
Cases of Prolapse of the Uterus and Bladder," Amer. Journ. Obst. and 
Gyn., 1923, vol. vi., No. 6, pp. 696-709. Tandler and Halban, "Genital 
Prolapse," Vienna, 1907. (Quoted from Brettauer and Rubin.) 

Discussion. 

The President {Professor Watson) said this matter is of great 
importance and Dr Young should follow it up. It should be quite 
easy to do as we have always plenty cases of cystocele and procidentia, 
and in the Infirmary we have a properly-equipped Department for 
detailed examination of such cases with X-rays. One cannot imagine 
that the condition is common or very serious, because we are all 
operating on these cases every week — every day almost — and it is 
very seldom that one finds the sort of occurrence met with in 
this case. 

Dr Haig Ferguson said the only criticism that I would offer is 
that with such an amount of kidney dilatation as Dr Young's specimen 
shows, one would have expected that there would have been more 
distension of the ureters. The question arises if this condition of 
the kidneys might not be the result of an ascending infection, more 
than mere passive dilatation. We are indebted to Dr Young for 
having brought this case before us, because it is a matter which has 
not engaged much attention hitherto. These conditions should be 
looked for and recognised early. 

In reply to Dr Haig Ferguson Dr Young said the pathologist 
found no evidence of sepsis. 



CASE OF EARLY CHORION-EPITHELIOMA.* 

By JAMES HAIG FERGUSON, M.D., F.R.C.S.Ed. 

Case — Mrs Ellen Howie, aged 39, married seventeen years, with 
four children, ages of first and last 14 and 7 years respectively. 
One miscarriage four years ago. The patient, who was recommended 
by the late Dr Young of Musselburgh, was admitted to Ward 36, Royal 
Infirmary, on the 6th November 1923. The day before admission 
she had expelled a hydatidiform mole, which she described as being 
"like small white grapes." At the time it was thought that the whole 
mole had been expelled but the hsemorrhage again occurred, requiring 
vaginal packing, and she was sent in to the Infirmary for curettage. 

I explored the uterus on the 8th of November, and with my finger 
and a blunt curette removed some adherent remains of decidua and 
membrane which were somewhat foetid, but no definite evidence of 
hydatid mole could be discovered by microscopical examination. The 
report was to the effect that the scrapings consisted of degenerating 
decidual tissue, especially the spongy layer. She was discharged on 
the 3rd of December and told to report at once if there should be 
any recurrence of hsemorrhage, and her doctor was at the same time 
communicated with. 

For a fortnight she remained quite well, but a return of hsemorrhage 
took place shortly after that, and as the haemorrhage got worse, 
persisting severely even through the night, she was readmitted to Ward 
36 on the 5th January 1924, with a history of almost continuous severe 
bleeding for the past two weeks. On the 9th January I dilated and 
curetted the uterus and found it to be 1^ in. enlarged. The scrapings 
were not very profuse except from over a softish area on the left side 
of the uterus. The bleeding was profuse during the curetting— so 
much so that the uterus had to be plugged with gauze. There was 
nothing definite to be made out in the curettings beyond the fact 
that there was "a considerable degree of blood extravasation into the 
stroma of the endometrium." From the clinical evidence, however, 
I felt so convinced that the condition was one of chorion-epithelioma, 
especially owing to the fact of the profuse bleeding which took place 
during the curettage, which I regard as almost pathognomonic of 
chorion-epithelioma, that I decided to operate. I therefore removed 
the uterus with both tubes and ovaries by pan-hysterectomy. The 
patient made a rapid recovery and her anaemic condition, which had 
been very marked, soon righted itself. 

Dr Dawson kindly reported on the specimen as follows on the 
1 8th January : — 

" The Uterus. — A small haemorrhage is present embedded in the 
superficial muscle, the centre of this showing the presence of a 

* Read 16th July 1924. 
212 



A-*- 



n 





p-- 







*& "' 



FlG. i. — Section of chorionic villus embedded in uterine muscle. 
A. Hyaline core of villus. B. Uterine muscle. 

C. Proliferating Langhans' cells and syncytial cells. 



t ** ' "V * 1 

V . - ♦ h ^ *■■ v - 



f 



J r **4 » v" '.-V ' -V 



-! B 



*," . \ 



Fig. 2. — Section of necrotic tissue with proliferated Langhans' cells 
and syncytial cells. 
A. Necrotic core of villus (?). B. Muscle. 

C. Fig. 3. Syncytial cells and Langhans' cells. 



James Haig Ferguson 



chorionic villus, surrounded by foetal elements. The adjoining 
blood channels show a decidual reaction. The above change is 
present in the muscle coat, and may represent a stray villus ; further 
sections are being examined to determine the extent of the change. 

"Appendages. — Two areas of haemorrhage are present, one in the 
tissues surrounding the tube and one in the broad ligament. These 
show numerous polymorph cells and necrotic tissue cells. Their 
appearance in association with the villus in the uterine wall is being 
further investigated." 

On the 23rd January he further reports : — 

" Ovaries. — Both show a small luteal cyst. 

" Tabes and Broad Ligaments. — In the peritubal tissue and in 
the loose tissue of the broad ligaments are small haemorrhages, with a 
polymorph cell reaction : in the small vessels are small thrombi, which 
are old enough to show early organisation. No epithelial-like cells 
could be found in the thrombi, nor in the haemorrhages. 

" Uterus. — Further sections show the presence of a definitely 
marked decidual reaction and of large wandering cells, in the vessels 
even of the deep muscle." 

Dr Dawson further adds : " It is difficult to add anything to the 
previous report. The condition may represent simply a deep villus 
embedded in the superficial uterine muscle, but (1) the presence of 
this villus in the muscle substance; (2) the presence of large 
wandering cells in the deep muscle; (3) the marked decidual reactions 
in the blood vessels ; and more especially (4) the multiple thrombi 
in the efferent blood channels, and the multiple areas of haemorrhage, 
are all suggestive of an early chorion-epithelioma." 

In a supplementary report on the 8th February Dr Dawson says: — 

"Further sections of the uterus show a more marked invasion of 
the deeper muscle layer, with trophoblast cells, and confirm the 
diagnosis of early chorion-epithelioma." 

Discussion. 

Prof. Watson said — The special interest of Dr Haig Ferguson's 
case to me was the demonstration of the actual villus lying in the 
uterine wall. Of course that villus was obviously an old villus which 
had been there for a very considerable time, because whilst its 
epithelial, trophoblastic covering was in a state of activity, the actual 
villus was obviously degenerated; just as happens in a case of 
incomplete abortion, where one finds ghost villi in the outlines of the 
myxomatous core and it may be with still active epithelial covering. 

Dr Young said — Dr Ferguson's paper assumes special interest 
if one can be quite sure of the fact that one is dealing with a chorion- 
epithelioma. If so, I should think it is probably one of the very 
earliest cases of malignant chorion-epithelioma described. The 

214 



: 












* 



■- / 












• * • 

, 4*. 






Fig. 3 — Enlargement of Fig. 2 (Q 

A. Syncytial cells. n r. n _v. , ' 

■ti- -Langhans cells. 



'*:<K 






.--, 



1 




■ > 



L T ^ 



Fig. 4 ._One of multiple thrombi (organising) found in the efferent 
vessels of the broad ligament. 



A. Vessel wall. 



B. Organising thrombus 



James Haig Ferguson 

evidence, however, seems to be more or less circumstantial. One 
knows that there occurs an invasion, or rather a transportation, of 
chorionic elements into the deep regions of the uterine muscle even 
under ordinary conditions in a normal pregnancy, and the question 
arises as to whether or not the histological changes, for that reason, 
are quite consistent with the view that one is necessarily dealing with 
a tumour of this nature. But it is impossible to decide on that matter 
from the microscopic views we have had brought before us to-night, 
although one knows that before Dr Dawson would pronounce a 
decision of that sort he must have gone into the matter very carefully. 




%* fV 



FlG. 5. — Section showing 1st position of chorion-epitheliomatous mass in 
uterine wall, bulging into uterine cavity and surrounded by muscular 
tissue. Surface devoid of epithelium, possibly result of curettage. Large 
vessel exposed on surface. 2nd — V illus imbedded in wall. 3rd — Mass 
of trophoblast cells almost down to peritoneal covering. 

In reply, Dr Haig Ferguson said — Both Professor Miller and Dr 
Young are a little critical about the question of the embedded villus 
in the uterine wall, and I think they may have been misled by the 
first semi-diagrammatic representation, which was meant to show its 
relative position in the uterine wall. The microscopic sections, 
however, are absolutely conclusive that it is a villus, and Dr Dawson 
has no doubt whatever on the matter, both under the high and the 
low power. Dr Dawson is quite convinced that this is an early case 
of chorion-epithelioma, and based his opinion very specially on the 
fact of the marked invasion of the deeper muscle layers with tropho- 
blastic cells. 

216 



A CASE OF MALIGNANT HYDATIDIFORM MOLE 
WITH PULMONARY METASTASES.* 

By Professor JAMES MILLER, M.U. 

Many problems of clinical as well as of pathological interest 
gather round the group of tumours of which the hydaticliform 
mole and the chorion epithelioma are the commonest examples. 

Amongst the chief points of clinical interest are: (i) The 
question of the frequency of such growths. Williamson states 
that moles occur in the proportion of one in 2400 pregnancies. 

On the other hand, Meyer 1 claims from a careful analysis of 
a large number of early abortions that the proportion is one in 
261 pregnancies. Here is a remarkable discrepancy requiring 
some explanation. (2) Secondly, there is the question of the 
nature of the hydatidiform mole. Is it a tumour or merely 
a degenerative process ? Both views have their supporters, 
Mall and Meyer 2 strongly supporting the idea that the process 
is a degenerative one, and that all degrees of the condition are 
to be seen on careful examination of any large series of abortions. 
On the other hand, there are cases of hydatidiform mole which 
prove fatal, such as the case reported by Ballantyne and Young 3 ; 
also the cases of Aschoff, Neumann, Marchand, and others, in 
which a growth with chorionic villi in it proves locally malignant ; 
or the still more rare instances of tumours with metastatic villi, 
such as the case described by Solowij and Krzyszkowski. 4 
Apparently all stages of malignancy exist, and there must 
therefore be a simple neoplastic homologue to the invasive 
and metastatic type. 

The chief points of pathological interest are : (1) First, this 
group of tumours is unique in this respect that it arises, not 
from the tissues of the individual who carries it, but from those 
of a temporary parasite — the foetus. (2) They arise not so much 
from the tissues of the foetus as from certain temporary and 
decidual membranes, bathed indeed by the mother's blood and 
permeated by prolongations of the embryo's own vessels, but 
eventually dispensed with as useless to both mother and foetus. 
(3) A third point, of interest both to the pathologist and the 
clinician, is that there exists a common if not invariable con- 
nection between such growths and cystic disease of the ovaries. 
Bland Sutton 5 thus describes the relationship: "It is constant 

* Read 16th July 1924. 
obst. 217 Q 



Professor James Miller 

enough to lead to the belief that the two conditions are corre- 
lated." Such a connection at once suggests the theory of 
Fraenkel and Born, that the corpus luteum plays an important 
role in the implantation of the ovum. In aberrations of the 
implanting mechanism such as the hydatidiform mole it is not 
surprising to find disease of the ovarian tissue. Lastly, there 
is another point of common interest to clinician and pathologist, 
namely, that of nomenclature and classification. One would 
have thought that a term such as hydatid mole would long 
since have been dispensed with. The term originated with a 
fancied resemblance between the cement-like masses of the mole 
to the clusters of cysts found in hydatid disease due to the taenia 
echinococcus. This is just one of the anomalies of pathological 
nomenclature which, although logically indefensible, are very 
difficult to eradicate. 

The case which I have the honour to bring before the notice 
of the Society, and which I showed at the meeting of the 
International Association of Medical Museums, April 1924, is 
as follows : — 

A girl, A. Le B., aged 18, unmarried, admitted to the Hotel Dieu, 
Kingston, nth October 1923. Previous to this date the patient 
had been in hospital on four different occasions in connection with 
plastic operations on her hand which had been severely burned. When 
admitted on this occasion she complained of vomiting which had 
commenced three weeks previously, the food returning immediately 
after it had been taken. There was no pain or discomfort in the 
region of the stomach. She had never been constipated and she was 
regular as regards her menstrual periods. Her previous health had 
been good and her family history presented no special point of 
importance. The urine analysis was negative and the blood examina- 
tion gave the following result: R.B.C., 3,400,000; W.B.C., 8000; 
hasmo. 80 per cent. A smear showed the red blood corpuscles to be 
normal in size and shape. Pregnancy was at this time suspected as 
there was some pigmentation about the nipples and the patient did not 
deny the possibility of it ; but the menstrual history was against such 
a notion, so no vaginal examination was made. The patient was 
discharged on 13th November somewhat improved as a result of rest 
and dieting. She was readmitted on 6th December with a history of 
almost continuous vaginal bleeding since leaving hospital. She had 
a severe haemorrhage on the date of readmission. 

At this time she appeared somewhat anaemic, the temperature was 
99, the pulse 148, and the respiration 18. Between the periods of 
flooding there was a serous discharge. On 8th December a large 

218 



A Case of Malignant Hydatidiform Mole 

clot was expelled during the day. The temperature on that date 
was 100.4, the pulse 152, and the respiration 34. About 8 p.m. the 
patient was examined and very suddenly the bleeding became alarming 
and uncontrollable, and she expired in a few minutes. On account of 
the appearances of injury to the vaginal wall found at the examination, 
a post-mortem was performed and an inquest held. 

The sectio resulted as follows : The body, fairly well nourished, 
was pale. The heart, weighing 6 ounces, was normal. There were no 
adhesions in the pleural sacs, but both lungs showed a number of 
nodules the largest the size of a pea. containing fluid and clotted 
blood. The smaller nodules were firmer in consistence. Some of 
these nodules were visible on the pleural surface, others were seen on 
section of the lungs. The intervening lung tissue showed nothing of 
note. Nothing abnormal was found in the upper part of the abdomen. 
Liver, spleen, and kidneys were pale but normal. The suprarenals, 
gall-bladder, and pancreas were also normal. Stomach, intestine, and 
mesenteric glands were normal. 

The urinary bladder contained about a teaspoonful of amber- 
coloured urine. The mucous membrane on the posterior wall showed 
a small haemorrhagic area with a soft mass of what appeared to be 
growth protruding from it. The uterus was enlarged, extending to 
the umbilicus and measuring 6 inches from cervix to fundus. Its walls 
were relatively thin, \ to h inch in diameter. The contents were 
typical hydatid clusters mixed with blood-clot. The white current- 
like masses were more opaque in appearance than is usual. There was 
a clear line of demarcation between the musculature and the contents, 
and there were no invading masses of growth visible. The ovaries were 
the size of small oranges and were cystic throughout, the cysts being 
thin walled and without solid content. The tubes were normal. 

The vagina showed on the left lateral aspect near the cervix an 
appearance like a ragged wound measuring an inch in length. The wall 
around was infilliated with haemorrhagic growth and a similar mass 
protruded through the wound. On section this mass was found to be 
about the size of a hen's egg. It communicated with the lesion in the 
bladder wall. On the removal of the pelvic organs a number of dilated 
and thrombosed veins were found ramifying in the surface of the 
vaginal mass. The head and brain was normal. The conclusion 
come to was that death was due to haemorrhage from a growth in the 
vagina which was infil hating the bladder and which had metastasised 
into the lungs. The mass in the uterus was regarded as a neurotic 
mole. No foetus was found. 

Microscopic examination confirmed the view that the mass in the 
uterus was a degenerated hydatidiform mole. The usual appearances 
were present, viz., distended villi with covering epithelium, the cells of 

219 



Professor James Miller 

which had lost their characteristic staining. Much of the stroma 
stained deeply with hasmatein in a granular fashion indicating 
calcareous deposit. On the other hand, the mass in the vaginal and 
bladder walls showed evidence of marked activity. The same cellular 
elements were present, chiefly the Langhans cells and syncytial 
masses. Here and there typical chorionic villi were found. Such villi 
could be seen invading the muscular tissue of bladder and vagina. 
No doubt therefore remained that the growth was a malignant 
hydatidiform mole, or in the classification of Ewing a chorio-adenoma 
malignum. Sections of the thrombosed veins showed, in addition to 
blood-clot and unrecognisable necrotic material, cell elements similar 
to those present in the vaginal wall. No villi could be found in the 
vessels, however. The nodules in the lung showed an extremely 
interesting condition. The smaller ones were composed of large 
syncytium-like cells with connective tissue reaction around. Some of 
these were found within or spreading from arterioles. In the larger 
blood cysts, in addition to syncytial masses and groups of Langhans 
cells, definite and characteristic chorionic villi with myxomatous, 
connective tissue core. These could be seen working their way 
out through the consolidated lung around the cavity. The case 
therefore belongs to the very rare group of malignant hydatidiform 
moles with metastases, containing villi, in the lungs. 

After careful investigation of the literature and after inquiries 
from well-known authorities, I have only been able to find one 
other similar case. This was published, as stated, by Solowij 
and Krzyszkowski {loc. at.) in 1900. A perusal of the case 
shows it to have been that of a married woman, aged 47, who had 
had ten pregnancies, the last five years previous to her death. 
The patient eventually died of haemorrhage, and at the post- 
mortem examination the peritoneal cavity was found full of 
blood-clot, the haemorrhage having taken place from a tumour 
mass infilliating uterus and appendages. There was thus no 
possibility of ascertaining whether cystic disease of the ovaries 
was present, both ovaries having been completely destroyed 
by growth. There were no metastases in any of the organs 
with the exception of the lungs, which showed small pea-like 
nodules. Most of the lower branches of the right pulmonary 
artery were occupied by thrombi. The uterus contained a 
mass of hydatid-like material, necrotic and septic. The uterine 
wall, the appendages, the blood-clot in the pulmonary artery 
as well as the secondary deposits in the lungs all showed typical 
chorionic villi with myxomatous cores and covering layers of 
epithelium. The case thus presented similar features to the 

220 



A Case of Malignant Hydatidiform Mole 

one above described. The growth, however, had spread into 
the uterine wall and appendages rather than into the vagina 
and bladder. Moreover, rupture of the growth took place into 
the peritoneal cavity. 

In the light of such cases certain statements can be made 
and certain deductions drawn. 

First, as regards the position of this group of growths in 
the general classification of tumours. Adami classifies tumours 
as follows : — 

i. Teratomas or tumours derived from totipotent cells and 
containing cells derived from all three primitive germinal layers 
of the embryo. 

2. Teratoblastomas or mixed tumours, originating from 
multipotent cells, cells that is which are capable of giving rise 
to more than one order of cell but containing representatives of 
at most two of the three primitive layers. Such are the mixed 
tumours of the parotid, kidney, testicle, etc. 

3. Blastomas, or ordinary tumours, originating from uni- 
potential cells. These are divided as follows : — 

(a) Teratogenous blastomas, tumours formed of one order 

of cell originating, not from the tissues of the host, 
but from those of another individual or potential 
individual within the host, including (i) placental or 
hydatidiform mole ; (ii) chorion epithelioma. 

(b) Ordinary, autochthonous blastomas, including all the 

other types of simple and malignant growths, con- 
nective tissue, and epithelial. 

It is clear that in view of cases such as the one detailed 
above the hydatidiform mole, chorion epithelioma group must 
come out of section three. The reason being that in its fully 
developed form, which is the form found in the case cited, two 
of the primitive layers of the embryo, viz., epiblast and meso- 
blast, are represented. The representation of only two layers 
of the embryo would not, however, place it in group one. It is 
clear, however, that that is where it belongs. The tumour unit, 
to coin a phrase, in the group is the chorionic villus. That 
structure in the embryo attains to the status of an organ — the 
only organ of the trophoblast portion of the foetus. We may 
legitimately, I think, regard it as the teratoma of the tropho- 
blast. It is true that we must alter the definition of teratoma 
in order to admit it, but that in any case I should be inclined 
obst. 221 q 2 



Professor James Miller 



to do. I should make it read, as follows: A teratoma is a 
tumour derived from multipotent cells and containing repre- 
sentatives of two or more of the primitive germinal layers of 
the embryo. 

Under the primary heading teratoma I would distinguish 
two groups : (i) The embryomas formed of the tissues or organs 
of the embryo, sometimes of the entire embryo ; (2) the 
chorionas arising from the trophoblast. 

Under this second heading come : (a) Chorio-villoma 
simplex or hydatidiform mole, the non-invading villus tumour ; 
(b) chorio-villoma malignum, the type to which Ewing has 
given the name of chorio-adenoma, which is always locally 
destructive and may in rare instances metastasise as in the 
case just recorded ; (V) lastly, there is the common type oi 
chorio-epithelioma which contains only the epithelial elements, 
usually both Langhans layer and syncytium, a tumour which 
also shows varying degrees of malignancy, which may and 
usually does metastasise. The term chorio-adenoma introduced 
by Ewing is not one which appeals to me. True there is 
epithelium and stroma in the growth, but the epithelium is 
not glandular in type and the stroma and epithelium do 
not show the relationship to one another found in all other 
adenomas. Moreover, the stroma is an integral part of the 
tumour and is not a reaction on the part of the host. 

The only other point of interest which I propose to 
emphasise is the relationship between disease of the ovaries 
and chorio-villoma simplex. Cases of the kind do not often 
come to post-mortem, and it is further support for the view that 
destructive disease of the ovaries bears some relationship to 
aberrations of the trophoblast. 

References. 

1 Contributions to Embryology, Carnegie Institution of Washington, 1920, 
vol. ix., p. 327. - Ibid,, 1921, vol. xii. 3 Trans. Edin. Obst. Soc., i9i8,*vol. 
xxxviii. 4 Monats. f Geburt. and Gynec., 1900, vol. xii., p. 15. 5 Tumours, 
Innocent and Malignant, 7th edition, 1922^.474. 6 Text-book of Pathology, 
1914. 

Discussion. 

The President {Professor Watson) said— I said before Professor 
Miller spoke that I had never satisfied myself that there was such 
a thing as a malignant hydatidiform mole, but I do not think one 
can say that any longer. Professor Miller's demonstration has amply 

222 



A Case of Malignant Hydatidiform Mole 

proved that there is such a condition, and that there can be an actual 
transportation of villi or parts of villi in the blood stream which may 
give rise to metastatic growth. His classification strikes one as being 
a very good one, and some such classification is necessary in view of 
the case he has described, and of the other case which he refers to as 
already in literature. 

Can Professor Miller give us any information as to whether there 
is anything in the microscopic examination of a hydatidiform mole 
which would lead us to say that it was a malignant hydatidiform mole 
or was likely to be followed by malignancy, in the form of chorion 
epithelioma malignum ? There are some pathologists and gynaecolo- 
gists who hold that by a microscopic examination of the mole or mass 
passed from the uterus you can tell whether the mole is likely to be 
followed by malignancy or not. I can not; and as far as I can gather 
from what Professor Miller has said he has found nothing in the actual 
appearance of the mole itself which in any way differs from the great 
bulk of hydatid moles, or from, as he said, an ordinary pregnancy. 
This is a most important matter and ought to be cleared up. I have 
never been able to satisfy myself with regard to it. 

With regard to the cystic ovaries — were they ordinary cysts, or 
were they lutein cysts, or was there an excess of lutein tissue present ? 
The condition described usually is that there is an excess of lutein 
tissue in the ovary and though cysts may be present they are very 
often lutein cysts. Of course that is consistent with what we regard 
as one of the functions of the lutein * tissue, namely, that it has some 
function in the embedding of the ovum, and in its absence the ovum 
will not probably embed itself, while if the lutein is in excess there 
will be an excessive embedding or penetration of the ovum. 

Dr Young said — I agree that the time has come when we have to 
settle down to a new classification, in view of the appearance of these 
two linking tumours, and the classification that Professor Miller has 
given seems to satisfy the needs of the case. 

Professor Miller said in reply — The cysts in the ovaries were 
not lutein cysts. The organ was occupied entirely by thin-walled 
cysts without solid contents. There was no ovarian tissue at all, and 
the only supposition one could make is that there was no corpus 
luteum, but why that should have this effect upon the implantation of 
the ovum, contrary to what one would expect, I do not know. I am 
afraid I cannot differentiate between a malignant hydatid mole and a 
simple one, or tell whether or not one might become malignant 
eventually. Some 40 per cent, of cases of these hydatid moles do 
become malignant. As regards the villus in the uterine wall in 
Dr Haig Ferguson's case, backed by Dr Dawson, one is quite prepared 



Professor James Miller 

to accept it as a villus, but merely from what one saw there was a little 
in doubt. However, Dr Dawson must have had good reason for his 
statement. 

Is the hydatid mole a tumour at all? I object to the use of the 
term hydatid. It suggests a resemblance of the mass or elements of 
the mole to the cystic stage of the echinococcus, a resemblance which 
is very superficial. The name should not be encouraged in any way 
as a means of classification. There is apparently a stage when the 
condition is a purely degenerative one, but it is a difficult matter to 
say where the degeneration ends and the tumour begins. There 
is a considerable difference of opinion as to what is hydatidiform 
degeneration. Moll and Meyer say it occurs once in 261 cases of 
pregnancy, and they have made a careful examination of abortions. I 
should perhaps have emphasised more definitely that a malignant 
hydatidiform mole is a slightly different tumour from the one that I 
showed. The rarity of my case does not lie in its malignancy. 
There are, I think, some dozen of such cases described, but of the 
cases with metastatic villi in the lung, I think I am right in saying that 
there is only one other recorded. 



224 



ADMINISTRATION OF THYROID GLAND 
DURING PREGNANCY.* 

By J. RAMSAY MUNRO, M.D. 

The very intimate association between the thyroid gland and 
sexual activity has been recognised for a long time. M'Garrison 
states that 50 per cent, of pregnant women show slight thyroid 
swelling during pregnancy — primiparae to a surprising extent. 
Healthy thyroidal activity is excited and maintained by marriage 
and child-bearing. He also states that conception is to a great 
extent dependent on an adequate supply of thyroid substance 
to the organism, and that pregnancy has frequently followed 
thyroid feeding in subthyroidic married women. 

I desire to communicate the two following cases because I 
suggest they take us a step further, and are some evidence that 
healthy thyroidal activity is necessary in development of the 
healthy fcetus. 

The records I am giving are of two cases of premature 
labour due to death of the fcetus. It is possible that the 
enlargement of the thyroid seen in so many pregnant women 
might be caused by a demand for a greater amount of thyroid 
secretion. If the thyroid in an individual case be unable to 
meet the demand something must suffer, and most probably 
it would be the delicate fcetus, and that, I think, must have 
happened in these cases. 

Case I. — Mrs W., aged 26, was married in 1919 at the age of 
22. Her first child was born dead at the end of the seventh month 
in November 1919. She became pregnant again and the second 
child was born dead in November 1921 at the end of the eighth month. 
Both the children had died in utero, probably about three or four days 
before expulsion. After the second pregnancy I noticed that there 
was considerable prolapse of the uterus. In August 1923 she again 
became pregnant and I determined to see what organo-therapy might 
do. For the first three months I gave her tablets of corpora lutea, 
at the end of that time I began thyroid medication and gave it in 
gradually increased doses until the end of pregnancy. She complained 
of a feeling of constriction at the level of the isthmus of the thyroid 
and also difficulty in swallowing. When this occurred I used it as 
an indication to increase the dose. A sufficient increase was followed 
by relief. A male child, weighing 8^ lbs., was born in June, between 

* Read 16th July 1924. 
225 



J. Ramsay Munro 



three and four weeks over the average period of gestation. Labour 
was normal. When six months old the child weighed 23 lbs. 

Case II. — Mrs S., aged 34, married in 1914 at the age of 25. Her 
first child was still-born in 1919 after six months' gestation, and her 
second in 1921 after seven months. 

Prior to marriage her menstrual periods were irregular — sometimes 
three months intervening — and were accompanied by severe occipital 
headaches. After marriage they were regular. In 1923 she again 
became pregnant. In this case I did not give corpora lutea, but 
began straight away with small doses — h grain three times a day — of 
thyroid gland tablets. I gradually increased the dose as pregnancy 
advanced, the indication in this case being the feeling of "a lump in 
the throat." This feeling was relieved by a sufficiently large dose. 
The duration of pregnancy was prolonged to ten months, and she gave 
birth to a healthy male child weighing 7 lbs. The weight of the child 
at the end of 5^- months was 21 lbs. 

The two cases have features in common. I did not get a 
Wassermann test done — but I feel certain from an intimate 
knowledge of the patients and their husbands that there is 
no suspicion of syphilis either inherited or acquired. Both 
women were extremely anxious for a child, and in their 
previous pregnancies had done nothing to account for the 
premature labour. 

Case I. had marked prolapse of the uterus; and in Case II. 
there is some prolapse but not so obvious, but not requiring 
a ring as did Case I. 

In both during pregnancy, on account of the weakness of 
abdominal muscles and a tendency for the belly to become 
pendulous, I advised a supporting belt. Both pregnancies 
were of longer duration than usual. The infants were well 
developed and after birth quickly grew " both in wisdom and 
stature." I look on the prolapse and the weakness of the 
abdominal muscles as pointing to a subthyroidic condition. 

I am communicating these records because I understand 
that definite clinical evidence of the value of internal secretions 
in pregnancy is not copious, and because of the difficulty of 
preventing premature labour in certain non-syphilitic mothers. 

My thesis is that thyroid deficiency is a factor in the causation 
of some premature labours, and I hope I am not taking up the 
time of the Society with matters of which they are already 
aware, but my excuse must be that in general practice the time 
for keeping in touch with modern teaching is strictly limited. 

226 



INDEX 



Abscess, Left Ovarian, Specimen of 
Double Pyosalpinx with (James 
Haig Ferguson), 116 

Adenomyoma, Specimen of (G. Herz- 
feld), 117 
Specimen of Uterus with (R. W. 

Johnstone), 64 
Of the Uterus with Tuberculous 
Infection (R. W. Johnstone), 54 

Albuminuric Toxaemias, the Associa- 
tion of Placenta Praevia and the 
(Douglas Miller), 65 

Bilateral Ovarian Tumours, Speci- 
mens of (S. J. Cameron), 115 

Browne, Francis J., Further Observa- 
tions on Still-Birth and Neonatal 
Death ; their Causes, Pathology, 
and Prevention, 158 
The Induction of Labour by Quinine 
and Pituitrin, 25, 47 

CESAREAN Section (E. Farquhar 

Murray), 122 
Caesarean Sections in Cases of Con- 
tracted Pelvis, One Hundred Suc- 
cessive and Successful (Samuel J. 
Cameron), 1 18 
Cameron, Samuel J., Bilateral Ovarian 
Tumours, Specimens of, 114 
Chorion Epithelioma, Two Speci- 
mens of, 1 14 
Fibromyomatous Tumour, Speci- 
men of, 114 
Gravid Uterus, Specimen of, 114 
One Hundred Successive and Suc- 
cessful Caesarean Sections in 
Cases of Contracted Pelvis, 118 
Cameron, S. J., and J. Hewitt, A 

Note on Pelvimetry, 137 
Cerebral Haemorrhage from Case of 
Eclampsia, Case of (J. Young), 
205 



Cervical Fibroid, Specimenof(William 

Fordyce), 45 
Specimen of (B. P. Watson), 

64 
Cervix, Supravaginal, Specimen of 

Hypertrophy of (B. P. Watson), 

144 
Chisholm, A. E., Veratrone — with 

Special Reference to a Case of 

Severe Reaction, 73 
Monster, Specimen of, 64 
Chorion Epithelioma, Case of Early 

(James Haig Ferguson), 212 
Two Specimens of (S. J. Cameron), 

114 
Contracted Pelvis, One Hundred Suc- 
cessive and Successful Caesarean. 

Sections in Cases of (Samuel J. 

Cameron), 1 18 
Cyst, Fimbrial, Specimen of (Theodore 

Haultain), 113 
Ovarian, Specimen of Unusual 

Pelvic Tumour simulating (Wm. 

Fordyce), 143 
Of Ovary, Specimen of (B. P. 

Watson), 145 
Twisted Ovarian, with Haemato- 

salpinx, Specimen of (James Haig 

Ferguson), 1 15 
Cystic Fibroid, Case of (James Haig 

Ferguson), 115 
Cystocele, Case of Prolapse and (J. 

Young), 205 
Hydroureter and Hydronephrosis 

secondary to Prolapse and (James 

Young), 207 

Dermoid Tumour of the Ovary, 
Specimen of (B. P. Watson), 

44 
Double Pyosalpinx with left Ovarian 
Abscess, Specimen of (James 
Haig Ferguson), 116 



!27 



Index 



Double Uterus, Specimen of (Farquhar 

Murray), 113 
Douglas, C. E., Some Observations 

on Seventy Years of Country 

Midwifery Practice, 81 

Eclampsia, Case of Cerebral Haemor- 
rhage from Case of (J. Young), 
205 

Election of Fellows, 24, 46, 64, 112, 

117, 143 
Epithelioma, Chorion, Case of Early 

(James Haig Ferguson), 212 
Chorion, Two Specimens of (S. J. 

Cameron), 114 
Epithelium, Squamoid Metaplasia of 

Gland, Specimen of Uterus 

showing (James Haig Ferguson), 

146 

Fellows, Election of, 24, 46, 64, 112, 

117, 143 
Ferguson, James Haig, A Pendulous 
Tumour of the Labium Majus 
exhibiting Unusual Features, 
149 
Case of Early Chorion Epithelioma, 

212 
Specimens of — ■ 
Cystic Fibroid, 1 15 
Double Pyosalpinx with Left 

Ovarian Abscess, ) 15 
Ovary showing Early Sarcoma, 

146 
Twisted Ovarian Cyst with 

Hsemato-salpinx, 115 
Twisted Ovarian Tumour with 

Haemato-salpinx, 115 
Uterus showing Squamoid Meta- 
plasia of Gland Epithelium, 146 
Fibroid, Specimen of (T. Haultain), 
40 
Cervical, Specimen of (William 

Fordyce), 45 
Cervical, Specimen of (B. P. 

Watson), 64 
Cystic, Case of (James Haig Fergu- 
son), 115 
Necrobiotic, Specimen of (B. P. 
Watson), 45 



Fibroid Tumour, Large, Specimen of 
Puerperal Uterus with (William 
Fordyce), 143 
Uterine, with Carcinomatous In- 
vasion, Specimen of (B. P. 
Watson), 43 
Uterine, with Sarcomatous De- 
generation, Specimen of (B. P. 
Watson), 42 

Fibroids, Group of (J.Lamond Lackie), 

45 
Mass of (G. Herzfeld), 117 
Associated with Pregnancy, Three 
Cases of (R. W. Johnstone), 204 
Fibromyoma, Large Submucous 
showing well-marked Red De- 
generation, Specimen of (William 
Fordyce), 143 
Fibromyomatous Tumour, Specimen 

of (S. J. Cameron), 114 
Fimbrial Cyst, Specimen of (Theodore 

Haultain), 1 13 
Fordyce, William, Note on a Case of 
Rupture of the Uterus following 
the Administration of Pituitrin for 
the Induction of Labour, 33 
Specimens of — 

Cervical Fibroid, 45 
Large Submucous Fibromyoma, 
showing Well-marked Red De- 
generation, 143 
Puerperal Uterus with Large 

Fibroid Tumour, 143 
Tubal Pregnancy, 144 
Unusual Pelvic Tumour simulat- 
ing Ovarian Cyst, 143 

Gravid Uterus, Specimen of (S. J. 
Cameron), 114 

Hematosalpinx, Specimen of 
Twisted Ovarian Cyst with 
(James Haig Ferguson), 115 
Specimen of Twisted Ovarian 
Tumour with (James Haig 
Ferguson), 115 

Haemorrhage, Cerebral, from Case of 
Eclampsia, Case of (J. Young), 
205 



228 



Ind 



ex 



Haultain, Theodore, Fibroid, Speci- 
men of, 46 
Fimbrial Cyst, Specimen of, 113 

Herzfeld, Gertrude, Adenomyoma, 
Specimen of, 117 
Fibroids, Mass of, 117 

Hewitt, J., see S. J. Cameron, 137 

Hydatidiform Mole, A Case of 
Malignant, with Pulmonary 
Metastases (James Miller), 217 

Hydronephrosis, Hydroureter and, 
secondary to Prolapse and Cysto- 
cele (James Young), 207 

Hydroureter and Hydronephrosis 
secondary to Prolapse and Cys- 
tocele (James Young), 207 

Hypertrophy of Supravaginal Cervix, 
Specimen of (B. P. Watson), 144 

Johnstone, R. W., Adenomyoma of 
the Uterus, with Tuberculous 
Infection, 54 
Fibroids associated with Pregnancy, 

Three Cases of, 204 
Uterus with Adenomyoma, Speci- 
men of, 64 

Labium Majus, Pendulous Tumour of 
the, exhibiting Unusual Features 
(James Haig Ferguson), 149 

Labour, The Induction of, by Quinine 
and Pituitrin (F. J. Browne), 25, 
47 

Lackie, J. Lamond, Fibroids, Two 
Groups of, 45 
Valedictory Address, 1 

Metaplasia, Squamoid, of Gland 
Epithelium, Specimen of Uterus 
showing (James Haig Ferguson), 
146 

Metastases, A Case of Malignant 
Hydatidiform Mole with Pul- 
monary (James Miller), 217 

Miller, Douglas, The Association of 
Placenta Praevia and the Albu- 
minuric Toxaemias, 65 

Miller, James, A Case of Malignant 
Hydatidiform Mole with Pul- 
monary Metastases, 217 



Mole, A Case of Malignant Hydatidi- 
form, with Pulmonary Metastases 
(James Miller), 217 

Monster, Specimen of (A. E. 
Chisholm), 64 

Munro, J. Ramsay, Administration of 
Thyroid Gland during Pregnancy, 
225 

Murray, E. Farquhar, Cesarean 
Section, 122 
Double Uterus, Specimen of, 113 
Ruptured Uterus, Specimen of, 113 

Necrobiotic Fibroid, Specimen of 
(B. P. Watson), 45 

Ovarian Abscess, Double Pyosalpinx 
with Left, Specimen of (James 
Haig Ferguson), 116 

Cyst, Specimen of Unusual Pelvic 
Tumour simulating (William 
Fordyce), 143 

Cyst, Twisted, with Hemato- 
salpinx, Specimen of (James 
Haig Ferguson), 115 

Tumour, Twisted, with Hemato- 
salpinx, Specimen of (James 
Haig Ferguson), 115 

Tumours, Bilateral, Specimens of 
(S. J. Cameron), 115 
Ovary, Cyst of, Specimen of (B. P. 
Watson), 145 

Dermoid Tumour of the, Specimen 
of (B. P. Watson), 44 

Ovary showing Early Sarcoma, 
Specimen of (James Haig Fer- 
guson), 146 

Pelvic Tumour, Unusual, simulating 
Ovarian Cyst, Specimen of (Wm. 
Fordyce), 143 

Pelvimetry, A Note on (S. J. Cameron 
and J. Hewitt), 137 

Pendulous Tumour of the Labium 
Majus exhibiting Unusual Feat- 
ures (James Haig Ferguson), 149 

Pituitrin, Note on a Case of Rupture 
of the Uterus following the admin- 
istration of, for the Induction of 
Labour (William Fordyce), ^3 



22q 



Index 



Pituitrin, The Induction of Labour by 
Quinine and (F. J. Browne), 

25, 47 
Placenta Praevia and the Albuminuric 

Toxaemias, The Association of, 

(Douglas Miller), 65 
Pregnancy, Administration of Thyroid 

Gland during (J. Ramsay Munro), 

225 
Three Cases of Fibroids associated 

with (R. W. Johnstone), 204 
Tubal, Specimen of (William 

Fordyce), 144 
Tumour complicating, Specimen of, 

(B. P. Watson), 145 
Prolapse and Cystocele, Case of (J. 

Young), 205 
Hydroureter and Hydronephrosis 

secondary to (James Young), 207 
Puerperal Uterus with Large Fibroid 

Tumour, Specimen of (William 

Fordyce), 143 
Pulmonary Metastases, A Case of 

Malignant Hydatidiform Mole 

with (James Miller), 217 
Pyosalpinx, Double, with Left Ovarian 

Abscess,Specimen of (James Haig 

Ferguson), 116 

Rupture of the Uterus following the 
Administration of Pituitrin for 
the Induction of Labour, Note 
on a Case of (William Fordyce), 

33 
Ruptured Uterus, Specimen of 
(Farquhar Murray), 113 

Sarcoma, Early, Specimen of Ovary 
showing (James Haig Ferguson), 
146 

Seventy Years of Country Midwifery 
Practice, Some Observations on 
(C. E. Douglas), 81 

Squamoid Metaplasia of Gland Epi- 
thelium, Specimen of Uterus 
showing (James Haig Ferguson), 
146 

Still-Birth and Neonatal Death, 
Further Observations on (Francis 
J. Browne), 158 



Submucous Fibromyoma, Large, 
showing Well-marked Red De- 
generation, Specimen of (William 
Fordyce), 143 

Supravaginal Cervix, Specimen of 
Hypertrophy of (B. P. Watson), 
144 

Thyroid Gland, Administration of, 
during Pregnancy (J. Ramsay 
Munro), 225 
Toxaemias, The Association of 
Placenta Praevia and the Albu- 
minuric (Douglas Miller), 65 
Tubal Pregnancy, Specimen of 

(William Fordyce), 144 
Tumour complicating Pregnancy, 
Specimen of (B. P. Watson), 145 

Dermoid, of the Ovary, Specimen 
of (B. P. Watson), 44 

Fibromyomatous, Specimen of 
(S. J. Cameron), 1 14 

Large Fibroid, Specimen of Puer- 
peral Uterus with (William 
Fordyce) 143 

Twisted Ovarian, with Hemato- 
salpinx, Specimen of (James 
Haig Ferguson), 115 

Unusual Pelvic, simulating Ovarian 
Cyst, Specimen of (William 
Fordyce), 143 
Tumours, Bilateral Ovarian, Speci- 
mens of (S. J. Cameron), 115 
Twisted Ovarian Cyst with Hemato- 
salpinx, Specimen of (James Haig 
Ferguson), 1 15 

Ovarian Tumour with Hasmato- 
salpinx, Specimen of (James Haig 
Ferguson), 1 1 5 

Uterine Fibroid with Carcinomatous 
Degeneration, Specimen of (B. P. 
Watson), 43 
Fibroid with Sarcomatous De- 
generation, Specimen of (B. P. 
Watson), 42 

Uterus, Adenomyoma of the, with 
Tuberculous Infection (R. W. 
Johnstone), 54 
With Adenomyoma, Specimen of 
(R. W. Johnstone), 64 



230 



Index 



Uterus, Double, Specimen of 

(Farquhar Murray), 113 
Gravid, Specimen of (S. J. Cameron), 

114 
Note on a Case of Rupture of the, 

following the Administration of 

Pituitrin for the Induction of 

Labour (William Fordyce), 33 
Puerperal, with Large Fibroid 

Tumour, Specimen of (William 

Fordyce), 143 
Ruptured, Specimen of (Farquhar 

Murray), 113 
Showing Squamoid Metaplasia of 

Gland Epithelium, Specimen of 

(James Haig Ferguson), 146 

Valedictory Address (J. Lamond 

Lackie), 1 
Veratone (A. E. Chisholm), 73 



Watson, B. P., Specimens of— 
Cervical Fibroid, 64 
Cyst of Ovary, 145 
Dermoid Tumour of the Ovary, 42 
Hypertrophy of Supravaginal 

Cervix, 144 
Necrobiotic Fibroid, 42 
Tumour complicating Pregnancy, 

M5 
Uterine Fibroid with Carcinomatous 

Invasion, 42 
Uterine Fibroid with Sarcomatous 

Degeneration, 42 

Young, James, Cerebral Haemorrhage 

from Case of Eclampsia, Case of, 

205 
Hydrometer and Hydronephrosis 

secondary to Prolapse and Cysto- 

cele, 207 
Prolapse and Cystocele, Case of, 205 



PRINTED BY 

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