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OBSTETRICAL TRANSACTIONS.
VOL. XXV.
TRANSACTIONS
OF THB
OBSTETRICAL SOCIETY
ov
LONDON.
VOL. XXV.
FOB THE TEAR 1883.
WITH A LIST OF OFFICERS, FELLOWS, ETC.
LONDON:
LONGMANS, GBEEN, AND CO.
1884.
TKnmU BY J. B. ADULBD, BABTHOLOXXW CL08B.
OBSTETRICAL SOCIETY OF LONDON.
OFFICEES FOB 1881.
EUCTUD rCHKUAaT &TII, ISgl.
UOKORUtX
PBZSISEHT.
PHZaiDEITT.
TBKABDBEB.
HOXoaiBT
BCCRKTASIEB.
HONOSXSI
or oon CH-
OP cocKcn,.
I FABBE, AKTHUK, M.D., F,R.S.
GEBVIS, HENET, M.D.
BEUNTON, JOHN, M.D.
DALT, FKEDEBILK HEXET, M.D.
OALABIN. ALFRED LEWIS, StLA., MD.
GODSON, CLEMENT, M.D.
MALINS, EDWAKD, M.D. (Birmingham),
WOKSHIl', J. LUCAS (Sevenoaks)
POTTEE, JOHN BAFTISTE, M D.
HERMAN. GEORGE ERNEST. M.B.
CHAMPNET8, FRANCIS HENRr.M.A.M.B.
■ THORNTON, JOHN KNOWSLEY. M.B., CM.
WILLIAMS, JOHN, MD.
OLDHAM, HENRY. M.D, (f-rf iv«. »«rf IVwto.),
BARNES, ROBERT, M.D. (P«* iVe». <-d ZV«(«>.
DAVIS, JOHN HALL, M.D.
HEWirr, GRAILY, M.D.
HICKS, JOHN BRAXTON. MD.. F.B.S.
1 TILT. EDWARD JOHN, M.D.
PRIESTLEY, WILLIAM O., M.D.
I WELLS. Sib THOS. SPENCER, Bibt , F.E.C 8.
(Tru^Uf).
^DPNCAN, J. M.\TTHEWS, M.D., FR.S.
''AVELING. JAMES H-. M.D.
BATE. GEORGE PADDOCK, MD
BUBCHELL, PETER LODWICK. M.B.
CHARLES. T. EDMONDSTOUNE. M.D.
(Cannes).
CORY. ROBERT, M.D.
CULLINGWORTH, C. J., M.D. {M«nch«ler).
DOR.AK. ALB.AN.
GBIFFITH, JOHN T., M.D.
HICKINBOTHAM, JA3 , M.D. (BirmiDghajn).
LANCHESTER. HENRY T., M.D. (Croydon).
M.\DOE. HENKY M., M.D.
MURRAY. OCSTAVUS CHABLE8 P., M.D.
PL.4Y1-AIR, WILLIAM 8., MD.
BOPEH, GEORGE, M.D.
SETON, DAVID ELPHINSTONE. MD
STRANGE. WILLIAM HEATH, M.D.
WALL.ACE. JOHN. M.D. (Liverpool).
WALTERS, JAMES HOPKINS, (Beading).
LIST OF PAST PRESIDENTS OF TIIK
SOCIETY.
1859 EDWARD RIG BY, M.D.
1861 WILLIAM TYLER SMITH, M.D.
1863 HENRY OLDHAM, M.D.
1865 ROBERT BARNES, M.D.
1867 JOHN HALL DAVIS, M.D.
1869 GRAILY HEWITT, M.D.
1871 JOHN BRAXTON HICKS, M.D., F.R.S.
1873 EDWARD JOHN TILT, M.D.
1875 WILLIAM OVEREND PRIESTLEY, M.D.
1877 CHARLES WEST, M.D.
1879 WILLIAM S. PLAYFAIR, M.D.
1881 J. MATTHEWS DUNCAN, M.D., P.R S
REFEREES OF PAPERS FOR THE YEAR 1884
Appointed bt the Councii^
BARNES, ROBERT, M.D.
DUNCAN, JAMES MATTHEWS. M.D., F.R.S.
EDIS, ARTHUR W., M.D.
GALABIN, ALFRED LEWIS, M.A., M.D.
GERVIS, HENRY, M.D.
GODSON, CLEMENT, M.D.
HEWITT, GRAILY, M.D.
HICKS, JOHN BRAXTON, M.D., F.R.S.
LEISHMAN, WILLIAM, M.D., Glasgow.
MALINS, EDWARD, M.D., Birmingham.
PLAYFAIR, WILLIAM S., M.D.
POTTER, JOHN BAPTISTE, M.D.
ROBERTS, D. LLOYD, M.D., Manchester.
ROPER, GEORGE, M.D.
STEPHENSON, WILLIAM, M.D., Aherdeen.
THORNTON, J. KNOWSLEY, M.B., CM.
WELLS, SiE T. SPENCER, Baet., F.R.C.S.
WILLIAMS, JOHN, M.D.
^
STANDING COMMITTEES.
BOARD FOR THE EXAMINATION OF MIDWIVES.
CHAiRMAis. WILLIAMS, JOHN, M.D.
BURCHELL, PETER LCD WICK, M.B.
GODSON, CLEMENT, M.D.
POTTER, JOHN BAPTISTE, M.D.
ROPER. GEORGE, M.D.
SGERVI8, HENRY, M.D., President,
HERMAN, G. ERNEST, M.B., JHon. Sec.
CHAMPNBYS, FRANCIS HENRY, M.B.,^on.
Sec.
KX-OFFIOIO.
LIBRARY COMMITTEE.
AVELING, JAMES H., M.D.
BARNES, ROBERT, M.D.
EDIS, ARTHUR W., M.D.
GALABIN, ALFRKD LEWIS, M.D.,
WILLIAMS, .lOJlN, M.D.
^GERVIS, HKNRY, M.D., President
POTTER, JOHN BA1»T1STE. M.D., Treasurer.
BX-OFFICIO. -
HERMAN, G. KHNKST. M.H., -)
CHAMPNEYS, FRANCES H KNRY, \ Hon,Secs.
M.A.,M.B. 3
THORNTON, J. KNOWNLKY. M.B.. Hon. Lib,
COMMITTEE FOR THE COLLECTION OF
SPECIMENS OF PELVES, ETC.
F,X-OrFICIO.
BARNES, EGBERT, M.D.
BALLS.IIEADLEY. WALTER Melbourne.
BASSETT. JOHN, M-I)., Birmingham.
BLACK, JAMES WATT, M.D.
BRANEOOT, ARTHUR MUDGE, MB.,
Madras.
GRIMSDALE. THOMAS F,, L.R.C.P. KU.,
Liverpool.
HATES, THOMAS C, M.D.
LEISHMAN, WILLIAM, M.D., Gloagow.
McCALLUM, DUNCAN CHARLES, M.D.,
Mo ut real.
PERRIGO, JAMES, M.D., Montreal.
POTTER. JOHN BAPTISTE, M.D.
PRICE, WILLIAM NICHOLSON, Leeds.
ROBERTS, DAVID LLOYD, M.D., Man-
SWAYNE, JOSEPH GRIFFITHS, M.D.,
BriHtol.
HENKY GEBVLS. M.D,. Preudent.
HERMAN G. ERNE^iT, M.B., Hon. Sec.
CHASIPNBYS, FRANCIS HENRY, M.A.,
M.I
, Jlon. Sec.
} SMITH. HETWOOD, M.D.
HONORARY LOCAL SECRETARIES.
Jones, Evan Aberdare.
BiKTEtM, John S., F.R.C.S Bath.
CoBRY, TuoMAS C. S., M.D Belfast.
Savage, Tuomas, M.D Birmingham
Saikmans, Fbedehick William Brighton.
SvfAyNB, Joseph Gbiffiths, M.D BriBtol.
Cahlyle, David, M.D CarliBle.
Jbffcoat, James Henev Chatham,
Battev, RavnekW., M.D Gloucester.
Clark, James Fess Leamington.
BnAiruwAiTE, James, M.D Leeds.
Wallace, John, M.D Liverpool.
RoBEnTS, David Lloyd, M.D MnncLester,
Jackson, Edwakd, M.B NewcaslIe-on-Tyne.
Elder, Geohqe, M.B., CM Nottingham.
Walker, Tiio.mas James, M.D Peterborcngh,
Eyelev, Joslpu FitEDEHicK, L.R.C.P Plvmouth.
IIakrinson, Isaac, Esq., F.R.C.S Rendiug,
WrLsox, RoBEHT James, F.R.C.P. Ed St. Leonard's.
Keelixg, James Hubd, M.D Sheffield.
BuKD, EniVABD, M.D, CM Shrewshury.
MuBPHY, Jaues, M.D Sunderland.
Fowler, James ... Wakefield.
Habbis, WiLLi&u John Worthing.
Haiivey, Bobeet, M.D .. Calcutla.
Brabfoot, Arthur Modoe, M.B Madras.
FEttBioo, James, M.D Moiitreal, Canada.
Temple, James Alobknon, M.D Toronto, Canada West.
Anderson, Izett W., M.D Janinicn.
TaKaKI, Kakaheibo, F.R.C.S Jnpnn.
OBSTETRICAL SOCIETY OP LONDON.
trustees of the society's pbopebty.
Henry Oldham, M.D.
Robert Barnes, M.D.
Sir Thomas Spencer Wells, Bart.
HONORARY FELLOWS.
BRITISH SUBJECTS.
Elected
1862 Duncan, James Matthews, M.D., A.M., LL.D., F.R.S.
Physician-Accoucheur to, and Lecturer on Midwifery
and Diseases of Women and Children at, St. Bartholo-
mew's Hospital ; 71, Brook street, Grosvenor square,
W. Council, 1878-80. Pra. 1881-82. Trans. 12.
1870 Fabbe, Arthub, M.D., F.R.S. (Hon. Pees.), Physician-
Accoucheur to H.R.H. the Princess of Wales; 18,
Albert Mansions, Victoria street, Westminster. Trane, 1 .
1871 Keilleb, Alexandeb, M.D., F.R.S. Ed., Physician to the
Royal Maternity Hospital, Lecturer on Midwifery and
Diseases of Women and Children at Surgeons' Hall,
Edinburgh ; 21, Queen Street, Edinburgh.
1871 KiDD, Geobge H., M.D., F.R.C.S.L, Obstetrical Surgeon
to the Coombe Lying-in Hospital, and Examiner in
Midwifery at the Queen's University and Royal College
of Surgeons of Ireland; 30, Merrion square south,
Dublin.
Elected
18/0 West, Chakles, M.D., t'.R.C.P., Corregpo tiding Member ^
of ihe Acudemy of Medicine of Pnris ; 29, Promenade I
de> AngUii, Nice, Alpes Maritimes, France. Pret. J
1877-8.
FOULIGN' SVDjeCTB.
Barker, Foruvce, M.D., Professor of Clinienl Midwifery
nnd DiseRsea of Women at (lie Bellevue IIoBpital
Medical College, and Ohatetric Ftiy«ician to the Beilevue
Hospital ; Consulting Physician to the New York State ]
Woman'* Hospital, &c, ; 8o, Madison avenue, New York.
Bbiun, Cabl, M.D., Professor of Midwifery, Vienna.
CouEiT, Amguee, M.D , Clinical Professor at tlie Faculty I
of Medicine of Monlpellier,
Faye, F. C, M.D., Professor of Midwifery in the Uniyeraity
of Chriscianin.
HuQENBERGRK, Theodob, M.D., a la Matrruitc et aiix
Enfants Trouv^a Hfipitsl dea Accouchements, Mogcdw.
Lakarewitcu, J., U.J}., KlinrkofT, Russia. Tran». 3.
Pajot, Ch. M.D., Professor of Midwifery to the Faculty of
Medicine, Paris.
'ON, M.D., Professor of Midwiferv,
SCANZONI, F. W
Wursburg.
SrOLTZ, Professor, M.D. Nancy.
Thomas, Abrahau Evebard Simon, M.D., I^eyden.
Thomas, T. GAiLLAao, M.D., Professor of Obstetrics in the
College of Physicians and Surgeons ; 296, Fifth
avenue, New York.
ViRCHOW, RuDOLr, M.D., Professor of Pathological Ana-
tomy in the Univeraity of Berlin.
FELLOWS OF THE SOCIETY. XIU
CORRESPONDING FELLOWS.
Elected
1873 Mastin, a. E., M.D., Berlin. Trans. 1.
1876 BuDiN, P., M.D., 22, Rue de I'Od^on, Paris. Trans. 1.
1876 Chadwick, James R., M.A., M.D.> Physician for Diseases
of Women, Boston City Hospital; Clarendon street,
Boston, Massachusetts, U.S.
1877 OooDELL, William, A.M., M.D., Professor of Clinical
Gynaecology in the University of Pennsylvania ;
Philadelphia, Pennsylvania.
1876 LusK, William J., M.D., Professor of Obstetrics, Bellevue
Hospital Medical College ; New York.
1876 PRETdT, OsCAE, M.D., Moscow.
1877 Stoker, Horatio, M.D., Boston, Massachusetts, U.S.A.
ORDINARY FELLOWS.
January, 1884.
Those marked thus (*) have paid the Composition Fee in lieu of further
annual subscriptions.
The letters O.F. are prefixed to the names of the *< Original Fellowt" of the
Society.
Elected
1879 Addis, Philip, L.R.C.P. Ed., Iver, Bucks.
1859 Aldbrsey, William Hugh, M.B. Lond., F.R.C.S., 7, St.
James' Road, Surbiton.
1878 Aldbed, Henby Allen, M.D., 4, Westbouroe park, W.
1878 Alfobd, Frederick Stephen, 61, Haverstock hill, N.W.
1883 Allan, Robert John, L.R.C.P. Ed., 1, Oxford mansion, W.
1873 Allen, Henry Marcus, F.R.C.P. Ed., 20, Regency
square, Brighton.
1859 Amsden, George John, M.D., 28, North Villas, Camden
Square, N.W.
1878 Anderson, Izett William, M.D., 95, Duke street. Kings-
toni Jamaica. Trans, 1. Hon, Loe, Sec,
1 875 Anderson, John Ford, M.D., CM., 28, Buckland crescenti
Belsiie park, N.W. Council, 1882.
1866 Andrews, Henry Charles, M.D., 1, Oakley square, N.W.
Council, 1882-3.
1859 Andrews, jAMsSi M.D., Everleigh, Green hill, Hampsteadi
N.W. Council, 1881.
ISi^O Appleton, Robert Carlislb, The Bar House^ BeTerlejr;
KEl.LOWS OP THE SOCIETY. XV
Elecied
ttJaS Abcher, John, F.R.C.S., 9, Carpenter road, Edgbaaton,
Birmingfaani.
1883 Akchibald, John, M.B., Lynton House, Brixton Rise, S.W.
1S71 Ahgles, Frank, L.B.C.P.Ed,, Hermon Lodge, Wanstead,
Ebbci, N.E.
lH(j 1 Aksistkono, JoiiN, M.D., Oreeu etreet green, Dartford, Kent.
18S3 AvELiNG, Charles Taylor, M.D., Tlie Oaklands, Upper
Clapton, R.
O.F. Atblino, Jaubs H,, M.D., Fhyaician to the Chelsea Hospital
for Women; I, Upper Wimpole Street, W. Councii,
1865-6G, 18;2, 1884. Son. Sec. 1873. Hon. Lib.
1874-6. Viee-Pre*. 18/7-8. Trans. 9.
1872 Ayling, Arthur H. W., 94a, Great Pottl.ind street, \V.
1859 Ayliso, William Henry, L.R.C.P.Ed., 34a, Great ForUand
street, W.
1tl>S0 Bailey, Fraxcis James, 51, Grove Street, Liverpool.
1873 Bailey, James Johnson, M.D., L.R.C.P.Ed., Woodville
CottRge, Marple, CheRbire.
1877 Baker, Albert de Winter, 2, Lawn terrace, Dawlish,
Devon.
18/6 Baker, John Penning, 6, York place, Poitmnn square, W.
1880 BALLa-HEADLEi, Walter, M.D., 190, CoUina alreei enat,
Melbourne, Victoria.
181)9 Baniock, George Gbantille, M.D., Surgeon lo tlie
SaniaritRD Free Hospital i 12, Granville place, Portnian
square, W. Council, 1874-6. Tran». 2.
O.F. Barnes, Robert, M.D., F.R.C.P., Obstetric Physician to.
and Lecturer on Jilidwifery at, St. George's Hospilat;
15, Harley street, Cavendish square, W. Fiee-Pres.
1859-60. CowneiV, 1861-62, 1867. Treat. 18G3-G4.
Pres. 18C:).C6. Trana. y^. Trualee.
1875 Barnes, R. S. Fakcjoukt, M.D., Physirian to the British
Lying-in Hospital; Assistant Obstetric Fhysicinn to
tlie Great Northern Hospilal ; Fhysicinn to ih; Chelsea
Hospital for Women ; I'liysicinn lo the Royal Maternity
Charity; 7, Queen Anne street, Cnvendish square, W,
Couar^i, 1879-81. Tram. 2.
FELLOWS OF 1
; SOCIE
I8"3
1867
1871
1871
Elected
1877 BiRSES, TnoM\B HENitv, M.D,. .11. London rond, Croydon,
186l» BiRTttliM, John S., F.R.C.S., Surgeon to the Bath General
HoBpital; 13, Gay street, Bath. Hon. Loe. Sec.
Council, 1877-9.
1866 Babsett, John, M.D., Professor of Midwifery nt the Queen'*
College, Birmingham; 144, Hockley Hill, Birmingham.
Council, 1874-6. Viee.-Prei. 1880-2. Trana.Z.
Bate, George Paddock, M.D., L.B.C.P. Ed., 412, Bethnal
Green road, B ; and 2, Northumberland Housei, King
Edward road. Hackney, Council, 1882-4.
Batten, Rayneb W., M.D., PhyBidau to the Gloucester
General InHrmary; I, Brunswick iquare, Gloucester.
Hon. Loc. Sec.
Beach, Fletcheb, M.B., Darenth Asylum, Dortford, Kent.
Beadles, Artbub, Park House, Dartmouth Park, Forest
bill, S.E.
Belcher, Henby, M.D., L.R.C.P. Ed.; 12, ParilioB
parade, Brighton.
Bell, Robebt, M.D. Glnsg., 29, Lynedoch street, Glasgow.
Benington, Robeut Creivdson, 108, Denmark hill, S.E.
1873* Bennet, James Hesbt, JI.D., The Ferns, Weybridge, and
Meutone. Council, 1881-3. Trant. 1.
Berry, Samuel, F.R.C.S., CouBuliiug Surgeon -Accoucheur
to the Queen's Hospital, and Professor of Midwifery
and the DiseascH of Women and Children in the
Queen's College, Birmingham; Hatfield, CaveudiKh
road, Clnpham park, S.W. I'icc-Pref. ISb'J. Trane. I.
UTOLACci, J, Hkwetson, Vardcu House, St. John's hill,
New Wandsworth. S.W.
1879 BiGQS, J. M., 6, Sunnyside villas, Child's hill, Hendon,
N.W.
1878 BiNDos, W». John Vkreker, M.D., D.Sc, F.R.C.S.Ed.
(Travelling).
18C8 Blacs, Jameb Watt, M.D., Obstetric Physician to the
Charing Cross Uospilnl ; lii, Clarges street, riccmlilly,
W. Council, 1872^.
FELLOWS OF THE SOCIETY. XVII
Elected
1880 Black, Robebt Fea^vcis, L.R.C.P. Ed., Emrainer in Mid-
wifery, Trinidad Medicdl Board ; 4, Chacon street. Port
of SpniD, Trinidnd.
1861* Blikg, Tuouas Williau, Haretboame, Bourn etnoutli,
Hants.
1872 Bland, Oeoboe, Surgeon to tUe Macclesfield Iitfirmary;
Park Green, MAccIe!i6eld.
1882 Blott, Herbert, 38, Oinaburgii street, N.W.
1883 Bonnet, William Augustus, M.D., l-)5, Beaufort street,
Chelsea, S.W.
1882 BoNSALL, Qeobge It. Edleston, L.R.C.P. Ed., Alexandra
Villa, Elthorne road, Hornsey rise, N.
1872 BoswoRTH, Joas Rodtledge, Sutton, Surrey.
1866 BouLTOV, Pebcy, M.D., PUysiciflu to the Samaritan Free
Hospiul ; Obstetric Physician to Out-Patients, Queen
Charlotte's Lying-in Hospital ; 6, Seymour street, Port-
man square, W. Council, 1878-80, Tram. 3.
1877 BowKETT, Thomas Edward, \Ao, East India Road, Poplsr,
E.
1869 Boyd, Hbrbeht, Surgeon-Major, 14th Sikhs [agents,
Henry S. King and Co., Aa, Pall MhU].
1877 Bbablet, Michael McWilliams, M.B., Jarrow-on-Tyne.
1873 BRAiTHWArrE, James, M.D., Lecturer on Midwifery and
Diseases of Women and Children nt the Leeds School of
Medicine; Assistant Sui^eon to the Leeds Hospital for
Women and Children ; ) 6, Clarendon road, Little Wood-
house. Leeds. Vtce-Prei. 1877-9. Tram. 3. Hon.
Loc. Sec.
IS(i2 BiiAiTiiivAiTE, William, M.D., hite Lecturer on Midwifery,
Leeds School of Medicine; Clarendon House, 20, Cla-
rendon road, Leeds. Council, 1^69-70.
1880 BitANFOOT, Arthcb Mcdge, M.B., Superintendent of the
Government Lying-in Hospital, Madrss, and Professor
of Midwifery and Diseases of Women and Children in
the Madras Medical College, Pantheon rond, Madras.
Hon. Loc. See.
vol. Sxv. b
XTUl FELLOW-i OF THE SOtlETY.
Ulecled
1875 Breweh, Aleiasdek Hampton, JUl, Queen's rofld,
DaUtoD, E. Tram. 1 .
1S62 Brickwell, John, Sawbridgewortli, Herts,
\6T2 Bm DO WATER, Thomas, M.B., Harrow -on- the- Hill, N.W.
1S64 Bbioht, John Meabuhn, iM.D., The Glen, Forest bill,
Sydenham, S.E. Council, 1873-74.
IS69 Bbisbase, Jaues, M.D., 21, Park road. Regent's iiarfc,
N.W,
18(i6 Bbodie, Geohqe B., M.D.,CoQSultiug Physician-Accoucbeiir
to Queen Charlotte's Lylng-io Hospital ; 3, Cliesterfield
street, Mayfair, W. Council, 1373-?5.
1876 BsooKHorsE, CHARLsa Tdrini}, M.D., 43, Manor road.
New CroBB, S.E.
1868 Brown, Andrew, M.D. St. And., 1, Bartholomew road,
Kentish town, N.W. Tram. 1.
I860 Bbown, D. Dvce, M.D., 29, Seymour Street, PortmBii
square, "W.
1878 Beowm, George, 3, Gibson square, Islington.
1866 Brown, George Diiansfield, Henley tUIs, Uibridge road,
Ealing, Middlesex.
1578 Browning, Benjauin, 70, Union road, Rotherhithe.
1S76 Brunjks, Martis, 27, Edgware road, W.
1865 Bhukton, John, JI.D., M.A., Surgeon to the Royal
Maternity Clmrity; 21, Euston road, N.W. Council,
1871-3. Fice.Pres. ISSi-J. Trana. G.
1863 BatANT, Thomas. F.R.C.S,, Surgeon to Guy's Hospital j
53, Upper Brook street, W. Council, 1866-67.
O.F. Bryant, Walter John, F.R.C.S., M.R.C.P, Ed., 23a,
Sussex square, Hyde park gardens, Vf, Council, 1859.
1870 Bock, Joseph Handle, L.R.C.P. Ed., 26, Sidbury, Wor-
cester.
1880 BuKStr, Kaheeh, London Hospital, S.
!682* Bulleu, Al'dlet Cecil.
1878 Buncombe, J. Dobbee, Victoria West, Ca[)e Colony.
1861 BcsNr, Joseph, M.D., Hon. Surgeon to the Newbury Dig.
pensary ; NortUbrook street, Newbury, Berks.
1877 BuRCHEii., Peter Lodwick, M.B., Surgeon- Accoucheur
to tbe City of Loodon Lying-in Hospital ; 2, KingaUnd
road, E. Coaneil, 1882.-1. Trant. 1.
1877 BuRD, Edward, M.D., M.C., Senior Physician to the Salop
iDBrmary ; Newport House, Shrewsbury, Hon, Loc.
See.
1878
BuftN, Stacey Soctherdon, Richmond, Surrey.
1862 Bdhto.s, Johx Mol-lden, F.B.C.S., Lee park lodge, Lee,
Kent, S.E. Council, 1868-6S.
1878 Butler-Suythe, Albert Ch.^eles, M.R.C.P. EJiu., 35,
Brook street, Grosvenor square, W.
1868 Butt, William Fhederick, L.R.C.P. Loud., 23 Park
street. Park lane, W. Council, 1876.7B.
1883 Caldwell, William T, D-, M.D„ 284, Kennlngton park
road, S.B.
1883 Camebok, Charles Hamilton Hone, L.R.C.P. Lond.,
Lochie), Harlesden, Willcsden, N.W.
1861 Candlish, Henry, M.D., Physician to the Alnwick In-
firmary ; 26, Fenkle street, Alnwick, Northumberland,
1861 Ca.«JDY, John, M.D., Surgeon-Major, Army Medical Depart-
ment, Statiou Hospitsl, Portland. [Messrs. Wm.
Watson & Co., Anglo-Indian Agency, 27, Leadenhall
street, E.C.] 3, Prospect place, Portland.
1872 Carlrss, Edwabd Nicholls, M.B., CM., Lansdowne
grove, DcTizes, Wills.
1863 Carlyle, David, M.D., 2, The Crescent, Carlisle. Trant. 1,
Hon. Loe. See.
1872 Cartee, Charles Henry, M.D., Pbysician to the Hospiul
for Women ; 45, Great Cumberland place, Hyde Parki
W. Cmmeil, 1680-2. Tran: 4.
FELI.O
* OF THE t
;iETV.
Elected
1877 Carvkb, Eustace John, Fnirlawn, Fullinm.
16G9 CAasiE, John Boyd, M.D., 19, Tyndnle place, IsliDg-
ton, N.
1S78 Caskie, William Alex., M.A., M.B., Manse Court, 17, |
Main street, Lnrgs, Ayrshire, N. B.
1863 Cayzeb, TilosiAS, Mayfield, Aigbarlb, Liverpool.
1875 Chaffehs, Edwakd, F.R.C.S., 5-1, North atreet, KeigUleyJ
Yorkshire.
1873 Chalmers, John, ?ll.D, 43, Caledonian rond, N.
1876 Champneys, Fbakcis Heney', M.A., M.B.Oion., F.K.C.P.»!
AsaiBtitnt Obsletric Physician to St. George's Hospitnl,)
60, GreRt Cumberland place, W. Council, IE
Hon. Lib. 1883.3. Hon. See. 1881. Trans. 5.
1859 Chance. Euwahd Joun, F.R.CS., Surgeon to tbe Metro- 1
politan Free Hospital and City Orthopedic Hospital ;
5y, Old Broad street, City, E.G.
1807* Chables, T, Edmondstoune, M.D., Cannes, France.
Council, 1882-4.
1874 C11ABLF.SW0&T11, Jaiieb, 25, BircU terrace, Hanley, Stafford-
•hii-<
Cnii.u, Edwin, "Vernham," New Maiden, Kingston-on-
Tbames, Surrey.
Cbilds, CiiRiMOPHEE, M.A„ M.B. Oxon.,2, Royal terrace,
Weymouth.
ISeS" Chisholm, EiiwiN, M.D., Ahergeldie, Asli6eld, near Sydney,
New South Wales. [Per Messrs. Turner and Hen-
derson, care of Messrs. W, Davson, 12I, Cannon
street, E.G.].
CllURciiil.T., Alex, Fehbier, M.B., Surgeon-Major.
ClathaM, Edwabd, M.D., 2!l, Lingfield road, Wimbledon.
1839 Claremont, Olal'de Clarke, Millbrook House, 1, Hamp-
atead road, N.W.
1859 Clabk, James Fens. Clent House, Deauchamp
Leamington, lion. Loe. Soc.
1S70 ClABKB, BeoiNaid, South Lodge, Lee park, Lre, S.E.
1868
1883
1879
1883
J
FELLOWS OF THE SOCIBTY. XXI
Elected
1872 Clakkb, Willuu Michell, late Surgeon to the British
Geoeral Hospitnl ; 2, York buildtDgs, Clirton, Briatol,
O.F. Clay, Chaeles, M.D., late Lecturer oa Midwifery nnd
Clioical Medicine in St. SInry's HospitHl, Mancliester ;
Audensbaw Lodge, Audenslmw ; Bad 101, PiccRdilly,
Manctiesier. Council, IS(i3-63. Trans. 3.
1876 Clat, Georob Langsfouw, West View, 1-13, Moseiey
road, Higbgnte, Birmiiigbnm.
O.F. Clay, John, Profesgor of Midwifery, Queen's College, Bir-
mingham ; Allan House, Steelhouse lane, BirmiDgbam.
Council, 1868-09. Vice-Frea. 1872-4.
O.F. Clxvblami, Williaii Fbedebick, M.D., Stuart villa,
199, Maida vale, W. Council, X'^^'iM. rice-Fret.
1875-77. Traas. 1.
1881 CtOBE, JiJiEs Alex, M,B., L.R.C.P. Ed., Suramerfield, St.
ClairCo., Illinois, U.S.A.
1865* CoATKM, Chauleb, M.D., Physician to the Bath General
and Royal United Huspitais; 10, Circus, Bath,
1862 CoATEs, Fredebick William, M.D., St, John street, SaliS'
burj.
1883 CuATBli, Wii.LiA>f, London Hospital, E.
1878 CocKELL, Fbeuekick Euoab, Jun., 17(i, Richmond road,
DalstDu, E.
1875 Corns, Rich-iud Jas. MAixLAiin, F.R.C.P, Ed., Alwingion
houae, Baron'a court, West Kensington, W.
1878 CoP«N, Thouas Walkeb, 81, Queen's crescent. Haver-
stock hill. N.W.
1875 Cole, Richakd Beverlv, M.D. Jefferson Coll. PLilad.,
218, Post street, San Francisco, Californin, U.S.
1876 CoLEMAS, Matthew Owen, M.D., 5, Victoria terrace,
Surbiton, Surrey.
1877 Colman, WALTEii Tawell, Hon. Surgeon to the Brighton
Hospital for Women ; 87, Buckingham road, Brighton,
186ti Coombs, Ja«es, M.D., Bedford,
XSn FELLOWS OF THE SOCIETY.
Mected
1883 CooNEY. John Edwin, L.R.C.P. Ed., 3, ArnoH terrace,
Greyhound road, Fjlham, S.W,
18/3 Cooper, Feank W., Leytonatone, Eases.
187'1 CooPEB, HEitBBBT, L.R.C.P. Ed., Rosalyn hill, Uampateail,
N.W.
1861 Cooper, John, M.B.C.P. Ed., Clapbam rise, S.W.
18f5 Corses, Auo., M.D., ProfesKor of Obstelrics at the Univer-
sity of Genera; 12, Rue Bellot, Geiicvn. Train. \.
1883 COENBH, CCBSHAM, 128, Mile Eull road, E.
1866 CoBNWALL, James, F.R.C.S., Fairford, Gloucestershire.
I860 CoRRY, Thouas Charles Steoart, M.D., Senior Surgeon
to tbe Belfast Genernl Dispensary ; Ormeau terrace,
Belfast. Council, 18G7, Hon. Loc. Sec.
1659 Cory, Freuebic^k Charles, M.D., Portlaod villa. Buck-
hurst liill, Essex. Council, 1867-69. Tiana. 1.
1H75 Cory, Robert, M.D., Assistant Obaletric Physician to St.
Thomas's Hospital; 73, Lambelh Palace roail, S.E,
Council, IS79-8I, 1884. Trans. 1,
1879 Cowan, George Hoyle, M.B., Napanee, Ontario, Canada.
1869 Cox, Richard, L.R.C.P. Ed., Tbeale, near Reading.
1S77 Crawford, James, L.K.Q.C.P.I., Igbtham, Sevenoaks.
18S2 Cheabe, Jasies Robertson, F.R.C.S. Ed., L.R.C.P. Ed., 2, |
Ogle Terrace, South Shields.
1881 Cbeasi, James Gideon, Brasted, Sevenoaks, Kent.
1874 Crejien, Patrick John, M.D., 4, Camden place, Cork.
IS76 Cbew, John, Higham Ferrers, Nortbamptonahire,
1859 Cboit, J. McGRieoR A. T., M.D., M.R.C.P., 15, Abbey J
road, St. John's Wood, N.W.
1881 Cbonk, Herbert Geoboe, M.B. Cnmb., Bepton, neu But*
ton-on. Trent.
1869 Cboss, Robert Shacklefoiid, Fetersfield, Hanti.
187.i" Culli-sg WORTH, Cmables James, M.D., M.R.C.P., Physi- '
eiaa to St. Marv'e Hospital, Manchester ; Lecturer on
Medical Jurisprudeuee at tbe Ovens College School of
Medicine; 260, Oxford rond, Manchester. Cotmeil,
1S83.4. Trant. 2.
FELLOWS OF THE SOCtETV. XXIH
Elected
1862 CuMBERBATCB, Laitbenck Trent, M.D., 25, Cado^D
place, Belgrnve sqanre, S.W. Coitneil, 1S68-70. Vice-
Pres. 1878.
186" CoOLAa&X, Hdgh, M,D., 9, Grange road, Uermondsey, S.E.
CuBQEKVZK, J. Bhexdos', 1 1, CrsTen hill gardens, Bays-
water, W. Coiindl, 1870-72. Trans. 3.
Dalv, Fbederick Hekbv, M.D.. I8.i, Amhurat road,
Hackney Downs, N.E. Council, 1877-9. Fiee-Pret,
1883-4. Trans. 2.
Dam BRILL- Da VIES, Willi&u It., S&adbacli, Cheshire.
Davidson, Chaeles, F.R.C.S. Ed., 29, CBsilaud road,
Uackney, E.
Davies, Gouek. L.R.C.P. Ed., 9, Pembridge Tillfls, Dn;a.
water,_W.
1678 Davies, Hexby Nacnton, Glyn Rhondda House, Cjmer,
Pontypridd, Glamorganshire.
Davis, John Hall, M.D., F.E.C.P., Ohsfetrlc Physician
to, and Lecturer on Midwifery and Diseases of Womeu
and Oiildren at, the Middlesex Hospital; Physician
to the Royal Maternity Charity ; CodbuI ting Physician-
Accoucheur to the St. Pancras InRmiary; 37, Glouces-
ter place, Portman square, W., and 41, Boundary road,
N.W. Council, 1859, 1864-65. Tice-Pree. 1861-63.
Pret. 1867-63. Trant. 14.
Davson, Smith HocsTOK,M.D.,Canipden villa, 203, Maidn
vale, W.
Day, Edmcnd Ovehuan', Assistant Surgeon to the Royal
Infirmary for Children and Women, "Waterloo Bridge
road ; 78, Waterloo road, S.E.
Day, William Hakkks, Surgeon lo the City Prisons,
Norwich; All Saints' Green, Norwich.
Day, William Hekby, M.D., Physician to the Samaritan
Free Hospital for Women and Children; 10, Man-
chester square, W. Council, 1873-75.
1877 Deivab, Jous, L.R.C.P. Ed., 132, Sloane street, S.W.
1860 Dickenson, Johk, F.R.C.S., Hon. Surgeon lo the Wreiham
Infirmary; Wrexham, Denbighshire.
1859
1868
1882
1883
1876
O.F.
1877
isrs
1880
1S59
Eltcle
1879
1880
O.F.
1371
PELLOWB OP THE SOCIETY.
d
DoLiN, Thouas Michael, L.R.C.P. Ed., 32, Korth pand^
Halifax.
DoEAS, Aldas II. G., F.R.C.S., Surgeon to Out-Patients,
Samariinn Free Hospital i 51, Seymour street. Fort-
man square, W. Council, 1883-J. Trans. 4.
DowKES, Denis Sidney, L.K.Q.CP. f., 55, Kentish town
rond, N.W.
DaiQE, Chakles, M.D„ Hatfield, Herts. CotmcH, I86I.4.
Trans. I.
DitAKE-BuocKMAN, Edward Fosster, F.R.CS., L.R.C.P.
LoiiJ,, Surgcon-Mnjor; Superinteudent Eye Inlirmary,
Jladrns; Profeasor of Ph3-siology and OphtbBlmology,
Madras Medical College. [Per Mesar*. Ricliardson
and Co,, Kaal India Array Agency, 13, PaU Mall, S.W.]
DiiiNO, William Ernest, L.R.C.P. Ed., BougUlon-under-
Illeau, Faversham, Kent.
Dl'kcan, ALEXANSEn Geohge, M.B., Calton Louse, Am-
Imrst park, Stamford liill, N.B.
Duncan, Jaues, M.B., 6, Henrietta aireet, Covent garden,
W.C. Council, IH73-74.
Di'NCAN, William Arcudeckne, M.D., St. Tljomas's
Hospital. S.E.
DuTT, Upendka Krishna, L.U.C.P, Ed., 20, Beadon street,
t'nlcutta.
Eauv, George John, M.B.C.P. Ed., RosHu, Calerham
Vniley.
Ea3TES, George, M.B., F.R.C.S., Snrgeon-AccoucUeur to
tlie Westeni Geuernl Dispeasary ; 69, Connaiiglit street,
Hyde park square, W. Council, 1S78-8D.
Eaton, John Cuauberlin, Ancaster, Graullmm, Lincoln-
shire,
EcCLES, F. Richard, M.D., London, Ontario, Canada.
Ems, Arthcb W., M.D., AEsistant-Pliysician-Accoucbeur
to the Middlesex Hospital; Physician to tlie Chelsea
Hoapital for Women ; 22, Wimpole street, W. Council,
18/3.74. Hon. See. I*l7'l-7r. VieePrei. 1878.80.
Tram. S.
FELLOWS OF THE EOCIETV. SXV
Elected
1^79 Eldeb. Geobgk, M.B., CM., Surgeaa to the Hospital for
Women, Noltiiigiinm ; 17, Itegeiit street, Nottioghnm,
Hon. Lqc. See.
1879 ELKiKGTON.AttTHOEGDY.Surgeon-Mfljor.GrenBdiei- Guards,
52, GilliDgham street, Eccleston square, S.W.
1878 Elleev, Richakd, L.R.C.P.Ed., Plymptoii, Devon.
1S73 £NGELMA!iN, Geouge JuLiLS, A.M., M.D., 3003, Loeust
street, St. Louis, Missouri, U.S.
1875 EwABT, John Henhv, Enatiiey, Devonshire place, East-
bourne.
1875 Eveley, Joseph Fbedeeick, L.B.C.P. Lend., 3, Hill-park
cresceut, PlymouCb. Hon. Loe. See.
1876 Fabncoube, Kicbard, 40, Belgrave street, Balsnli heatlt,
Birauugham.
Itl69 Farqcuab, William, M.D., Surgeon-Major, Madras Anay,
Ootacamuud, Madras Presidency. [Per W. Farqubar,
3, Powia square, W.]
1801 Fabb, Geo. F., L.R.C.P.Ed., Slade House, 175, Ken-
uinglou road, S.E.
1882 Fabhau, Joseph, L.R.C.P. Ed.. 8, Queen's terrace. More-
cam be.
1881 Fabbeb, Gkoboe Albext, Spring villa, Brighouse, Halifai.
1879 Faybee, Sib Jobeph, M.D., K.C.S.L, Hon. Physician to
H.M. tbe Queen and to H.B.H. the Prince of Wales ;
Physician to H.R.H.the Duke of Edinburgh ; President,
Medical Board, India Office, &c. ; 53. Wirapole street,
Cavendish square. Council, 1883.
1868 FcoAN, Richard, M.D., WcBtcombe park, Blaekheatb, S.E.
1873
1878
1877*
1877'
FlHEOAN, JAiiEs IIebbi^kt, M.D., Obstetric Surgeon to, and
Lecturer on Midwifery at, the Liverpool Lying-in
Hospital ; 48, Rodney street, Liverpool.
FisuER, JoHK MooBE, M.D., 6, Pryme street, Hull.
Fitzgerald, Charles Egebtos. M.D., West Terrace,
Folkestone.
Fllst, Aetiicr, L.tt.C.P., Weatg»te-on-Sea, Isle of Tbanet.
FoNMAETis, Hesbv BE, M.D., KnapbiJl, Woking, Surrey.
Fohd, James, M.D„ Eklinni, Kent.
SXVl FELLOWS OP THE aOCIE"
EUcied
18()5 Fowler, Jasies, F.S.A., Hon. Surgeou to the Clayti
pitfll and Wakefield General Dispenfiary
Parade, Wakefield. Council, 18;2-l. Hon. Loe. See.
1862 Fbaik, Joseph, U.D., Hon. Surgeon to tke South Shields
Diepensary ; Frederick street, South SUielde.
1875 Frasee, Akqus, M.D., Phyaician and Lecturer on Clinical
Medicine to the Aberdeen Royal Infirmary ; 232, Union
street, Aberdeen.
1867 Freeman, Henby W., 24, Circus, Bath.
1881 Fbodsiiau, John Mill, M.D., Denham House, Upper
Streatham.
1880 Fev, John Bloukt, Svindon, Wiltshire.
1867 Fuller, Chahleb C.,33, Albany street, Regent'i park, N.W.
1880 Fuller, Henry Roxburoh, M.A.Cantab,, 45, Curzon
street, Mayfair, W.
1874* Galabin, Alfred Lewis, M.A., M.D„ Obstetric Physician
to, and Lecturer on Midwifery at, Guy's Hospital ; 49,
"Wimpole street, CaTendish square, W. Council, 1876-
78. Bon. lib. mo. Hon. See. 1880-3. Vice-Pret.
1884. Trtnia. 11.
1863 Galtos, John H , M.D„ Woodside road, Upper Norwood,
S,E. Coun.-il, 1874-6,
1881 Gandy, William, Hill Top, Gipsy hill, S.E.
1879 Gardner, John TwiNAME, 6, Hillsboro' terrace, Hfracombe.
1872 Gabdneb, William, M.A., M.D., Professor of Gyneecology,
MeGill Uuiversity; Physician to the University Dis-
pensary for Women ; Physician to the Montreal General
Hospital ; 914, Dorchester street, Montreal, Canada.
1863 Garman, Henry Vincent, Kent Ilouae, 6, Bow road, E.
1876 Garner, John, 52, New Hall street, Birmingham.
1879 Garstano, Tiiohas W. HaRHopp, Dohcross, near Oldlam,
1873 G.\HTox, William, M.D., F.R.C.S., Hardehaw street, St.
Helen's, Lancashire.
1875 GAivirn, J. Jackson, 23, Westbounie park terrace, W.
18/7 Oell, Thomas Silvester, M.D.
m
■ton Hos-
3, South I
TELLOWS OF THE SOCIETY. XXVll
Sleeted
1859 Gervis, Henry, M,D., F.R.C.P., Obstetric Phyflicinn to,
aud Lecturer upon Obstetric Medicine at, St. Tliomaa's
Hospital ; Eiamioer in Obstetric Medicioe at the UdU
Tersity of London ; JO, Harley street, CaTendish square.
Council, 1864-66. Son. Sec. 1867-70. Fice-Prn.
1871-3. Treat. 1873-81. Pre*. 1883-4. Trans. 7.
1866 Gehvis, FaEDKBiCK Heudebourck, 1, Fellows rond,
HaTcrstock hill, N.W. Council, 187 7-0. Tram. I.
1S75 GiBBiNos, Alfred Thomas, M.D., 93, Riclimond rond,
Dalstoii, N,E.
1883 GmDoNS, Robert Alexander, M.D., 32, Cadogan place,
S.W.
IS74 Gibson, Jaubs Edwaud, Hillside, West Cowei, Isle of
Wight.
1866 GiDDiSQS, William Kirro, L.R.C.P. Ed., Shaftesbury
House, CaWerley, near Leeds, Yorkshire.
1877 OlFFARD, DocGLAs WiLLiAV, 5, PavUiou Parade, Old
Steyne, Brightoa.
1875 Giles, Peter Bboome, L.R.C.P. Ed., The Quinla.Brobury,
Hereford.
1869 Gill, William, L.R.C.P. Loud., II, Russell square, W-C.
1807 GiTTiKS, John, L.R.C.P. Ed., St.'oUve's Union, Parisli
street, Soulhwark, 134, Tooley street, S.E.
1871 GoDDAEP, EuoEKK, L.R.CP. Lond., North Lynne, High<
bury New Park, N. Tram. 1.
1876 GoDFBAY, Alfred Chakleb, M.B., 43, La Molte street,
Jersey.
1877 GoDBOX, Chables, F.R.C.S., 1, Astwood road, Cromwell
road. South Kensington, S.W.
187 1 Godson, Clement, M.D., CM., Consuliiug Pliysician to tlie
City or LundoD Lying-in Hospital ; AuUtant Physiciau-
Accoucheur to St. Bartholomew's Hospital; 9, Gros-
venor street, W. Council, 1876-77. Hon. See. 1378-
81. VicePreg. 1882-4. Trans. 5.
1868 GoBwiK, AsHTON, H.D., 28, Bromplon crescent, Brompton,
XXVlll
FELUnVS
OF THE
E/eele
/
1873
GOLDaillTH
John.
M.D., F
Highvorth Houie, Worthing,
Sub Bex.
1S73 OooDCHiLD, Natu^miel, L.R.C.P. Ed., 9, Higbgate road,
N.W.
1883 Gordon, John, M.D., 10, Amersham road, New Cross, S.E.
1869 Gosa, Treoenka Biddulph, 36, Tbe Paragon, Bnth.
1S75 GiiAY, James, M.D., 15, Newton terrace, Glasgow.
1874 Greene, Willuu Thomas, M.D., Moira Houbp, Peckbam
rye, S.E. Council, 1880. Trans. 1.
1863 Obiffith, G. de GoKBEauER, Lecturer on Diseaaea of
Womeu and Cbildren at the Zenana and Medical
Mission Training Scliool for Ladies ; 34, St. George'a
square, S.W. Trans. 3.
1869 Gkiffiih, John T., M.D., Talfourd Houae, Camherwell,
S.E. Council, 18S4.
1979 GBiFriTH Walter Spencer Anderson, F.R.C.S., M.R.C.P.,
Tulor in Obstetrics and Gyntecology at St. Bartbo-
loniev'R Hospital ; 35, Great Ormoud Street, W.C.
Trant. 1.
1880 GaiFFirus, Griffith, Bryncelyn, Pontardawe, Swansea,
place. Valley.
1870 Gbiqo, William Chapman, M.D., Pliysician to the In-
patients. Queen Charlotte's Lying-in Hospital; Assistant
Obstetric Physician to the Westminster Hospital;
AsBistant-Physician lo the Victoria Hospital for Cliil-
dren ; ti, Curzon street, Mayfair. Council, I87J-77.
O.F. Grimsd*lf.,Thos. F., L.B.C.P. Ed., Cunsulting Surgeon lo
the Lyiug-in Hospital, and late Lecturer on UiEeases
of Children, &c., at the lloyal liifirmnry Scbool ot
Medicine ; 29, Rodney street, Liverpool. Council,
1861-62. rice-Fret. 1875-7e.
1882 Geipper. Walter, M.B.Caulab., M.R.C.S,, C, Sumner
Place, South Kensington, S.W.
1880 Gkooono, Walter Atkins, lil6. High Street, Stratford, E.
1877 GB03HOLE, Freiiebick Hermann VARLEif, L.K.Q.C.P.I.,
Pier House, Aberdovcy. Meriouotbahire, North Wales.
Elected
1876 Groth, Ebnst It. G., M.D., 5, Wevraouth street, Portland
place, W.
18"9 Grove, William Hichard, M.D., St. Ues, Huntingdoaahire.
1867 Hadawav, James, L.R.C.P. Ed., 47b, Welbeck atreet,
Caveudieti sqiure, W.
1876 Hadden, Johh, M.D., 31,Weat street, Horncastle, Lincoln-
shire.
1S81 Hair, Jaues, M.D., Westgate, Peterborough.
1859 Hall, Fredebick, 1, Jermyn street, St. James's, S.W,
1871 Hallowes, FREnEiiicK B., Redhill, Eeigate, Surrey.
1880 Hames, George Henry, F.R.C.S., 2, Queensborough ter-
1831) Hamilton, Thomas, M.D., Melrose House, Green Inncs,
Stoke Newingtoii, N.
1860 IIardev, Key, Surgeon to the West City Dispensary ; 4,
Wardmbe place. Doctors' Commons, E.C.
1S"7 Harper, Gerald S., 5, Hertford street, May Fair, W.
1S78 Harries. Thomas Davies, F.B.C.S., 36, North Parade,
Aberystwith, Cardigan alii re.
O.F. Harrinson, Isaac, F.K.C.S., Castle street, Rending, Berks.
Council, 1862-65. Hon. Loe. See.
t862 Harris, Charles, M,D„ Northi&m, Ashford, Kent.
1872 Harms, Henry, M.D., F.R.C.S., Trengweath place. Redruth
CoruwnU.
1867 Harris, William H., M.D., late Profesfior of Midwifery in
the Madrae Medical College, and Superintendent of the
Lying-in Hospital, Mndraa ; 78, Ojford gardens, W.
[ageni : Mr. H. K. Lewia, Gower street].
1861 Harris, William John, 26, Marine Parade, Worthing.
Hon. Loe. See.
1880 Harrison-, Richard Charlton, 4, The Terrace, St. Mary's
vale, Chatham,
1879 H.MtvEY, Geoboe, L.R.C.P. Ed., "Wirlts worth, Derhyshire.
1880 Harvky, John Stephenson, 26, Hue Wisaocq, Boulogne-
aur-Mer, France.
XXX FELLOWS OP THE SOCIETY.
Elected
1865 HiEVEV, Robert, M.D,, 52, Chowriiighee, Calcutta.
[Per MeaarB, Cochran and Anderson, 152, Union
street, Aberdeen. 1 Tram. 1. lion. Loc. See.
1865 Hates, Hawkesley Roche, Basingstoke, Hanta.
1873 Hayes, Thomab Ckaivford, M.D., ABWstont Obstetric Phy-
sician to King's College Hospitnl; 17, Clarges street.
Piccadilly, W. Council, 1876.78.
1880 Heath, William Lentok, 51. B., 85, Gloucester Road,
South Kensington, S.W. Trant. I.
1867 Hembrocgh, John William, Ivy cottage, Waltham,
Grimsby.
ISSI Hepeubn, William Alex., Ros^lyu House, Coxhoe, Co,
Burham.
1876 Herman, George Eenest, M.B., Obstetric Physician to,
and Lecturer on Midwifery at, the London Hospital,
7, West street, Finsbury circus, E.G. Coimeil, 1878-
79. Hon.m. 188U-I. Hon. S«. 1882-4. Trans. 5.
O.F. Hewitt. Graily, M.D., F.R.C.P., Professor of Midwifery
in University College, London, and Obstetric Physician
to University College Hospital i 36, Berkeley square,
W. Hon. Sec. 18.i9-64. Treat. 1865-66. Fice-Pret.
1867-68. Prea. 1869-70. Trans. 20.
1867 HicKiNBOTHAU, James, M.D., Physician to the Birming-
ham and Midland Hospital for Women ; 26, Broad
street, Birmingham. Council, 1834. Trant. 2.
1870 Hicks, Eijward Johk W., M.D., CM., Regent's road,
Great Yarmouth.
1S60 Kicks, John Braxton, M.D., F.R.C.P., F.R.S., Consulting
Obstetric Physician to Guy's Hospital ; 24, George
street, Hanover square. Council, 1861-2, 1869. Hon.
Sfc. 1863-65. rice-i'Ms. 1866-68. TVm*. 1870. Pret.
1871-2. Tram. 36.
1860 Hioos, TttoMAB Frederic, L.R.C.P. Ed„ Beaconsdeld
House, Dudley, Worcestershire.
1879 lIiLT., T. A\'uon, L.R.C.P. Ed,, 96, Earl's court road, W.
FELLOWS OP THE SOCIETY. SXXl
ElKted
\S7'2 HiLLiAKD, RoBEUT Harvey, M.D., Aylesbury.
1876 HoAE, WiLUiM. [Care of E. Ground, M.B., Gabriel's
bill, Maidstone.]
O.F. HoDOES, RicHABD, M.D., F.R.C.S., 25, York place, Baker
street, W. Tram. 3.
1864 HoFFMEisTER, William Cabtee, M.D., Surgeon to tbe
Queen in tbe Isle of Wight ; Clifton Houbc, Cowea,
lale of Wight. Coaiieil, 1877-9.
1875 HoLLisos, Edwix, L.R.C.P. Ed., 4, Gordon street, Gordon
square, W.C.
lSa9 HoLMAN, CossTASTiNE, M.D„ The Barone,It€igate, Surrey.
Council, 1367-69. Vke-Prei. 1870-71.
1880 HoNiBALL, OscAE DuHscousE, M.D., New Amaterdam,
British Guiana.
1864 Hood, Whakton Petee, M.D., 65, Upper Berkeley atreet,
Portman square, W.
18/2 Hope, William, M.D., Physician to Queen Charlotte's
Lying-in Hospital i 56, Curzon atreet, Mayfair, W.
CovnHl, 1877-9.
1883* HoRSOCKs. Peteb, M.D,, M.R.C.P. Lond., Aasislant Ob-
stetric Physician to, and Demonstrator of Practical
Obstetrica at, Guy's Hospital ; !l, St. Thomas's street,
S.E.
1876 HoKSiiAN, Godfbey CoARLEa, 22, King street, Portman
aquare, W.
1983 HosKi.v, TtiEorHiLDS, L.R.C.P. Lond., 186, Amhurst rond,
N.E.
1883 HoccuiN, Eduond Kixo, L,R.C.P. Ed., 29, High street.
Stepney, E.
1877 Howell, Hobace Sidney, M.D, 11, Bonndary road,
St. John's Wood, N.W.
1879 HtJBBABD, TuoMAa Wells, Lenham, Bromley, Kent.
18M Hunt, Joseph William, 11. D,, B,9,. 101, Queen's rond,
Dalston, E.
1883 HcRPORD, CiiAKLEs, L.B.C.S.I., 258, Caledonian road, N.
xxsii
^!5PIH
^^^^^H
1878
Husband, Walter Edivard, 56, Bury New Eosd, Uui- ^^H
^^M
185S
Hutchinson, Jonathan, F.R.C.S., F.R.S., Siii^eon to the ^H
LoiidoD Hospital ; 15, Cavendish aqunre, W. Covneil, ^^|
1869-71. Fi«-PrM. 1881-3. Trant. \. ^H
1682
HcTTON, Robert James, L.R.C.P. Ed., Sttipkton Hoase, ^^M
Stepkton Hall road. Crouch hill, N. ^^M
1877
ILOTT. James John, L.R.C.P. Ed., Resident Medical Officer, ^H
Whitechapel Union Infirmary, Baker's row, E. ^H
1879
Inkson, James, M.D., Surgeon -Major, Army Medical De- ^^M
^M
1883
Inman, Robert Edward, 243, Hackney road, E. ^^M
1864
Jackson, Edwahd. M.B., 81, Osborne Road, Jesmond, New- ^^M
castlc-on-Tyne. ^H
1883
Jackson, George Henkv, Lnnsdovne House, Totlenliam. ^^M
1864
Jackson, Robbiit, M.D., 53, Hotting hill square, W. ^^M
1883
Jakins, Pekcy S., 9, Osnaburgh street, Regent's park, N, ^^H
1873
Jaxins, William Vosfer, L.R.C.P. Ed., Sturt street ^^|
Bnllarnt, Victoria. [Per Isaac N. Jnkins, Esq., 32, ^^|
Oannburgli street, Regeni'e park.] ^^^|
1872
JaLLAND, Robert, tlorncastle, Lincolnsbire. Trans. 1. ^^H
1878
James. Waltek Culver, M D., M.C, 11, Marines road, ^H
Kenaiiiglon, W. ^^H
1877
Jamieson. Patrick, M.A., 3, St, Peter'a sireel, Peterhead, ^^M
Aberdernibire. ^^M
1881
Jeifcoat, James Henhv, Surgeon Major, Array Medical ^H
Dt|iarlmeiil, 6, Upper Nile terrace, Rochester. Hon. ^^M
^^M
1883'
'Jenkins, Edward Johnstone. M.B. Oion., Australian ^^M
Club, Sydney (per H. K. Lsiris, 136, Gower street. ^H
W. ^H
1877
Jenks, Edward W., M.D., 170, Stale alreet, Chicago, ^^M
Illinois, U.S. ^H
^^ 1882
Jenmnos, Charles Egerton, L.R.C.P. Lond., fi, FercT- ^^M
^^^
gardens, Tynemouih. ^^^|
^B
FKLLOWa OF THE SOCIKTV. SXXlll
Elected
1883 JoHHSON, Abthdb JiiKE3, M.B., 1, Yorkville avenue,
Toronto, Ontario, Canada.
1877 JoHKSON, Sauuel, M.D., 5, Hill street, Sloke-upon-Trent.
1881 JoHNSTOK, JosHPn, M.D., Brigade Surgeon, Army Medical
Department! St. Jolin'a Wood Barracks, N.W.
1879 Johnston, Wm. Beech, M.D., 157, Jamaica rond, Ber-
BiondBey, S.E.
1868 Jones, Evan, Ty-Mawr, Aberdare, Glamorgansbire. Hon.
1878 JoNBs, H. M*cN*UQnTO-f, M.D., F.B.C.S.I. and Edin.,
Examioer in Obatelrica, Royal Uaiversity of Ireland ;
Professor of Obstetrics, Queen's College, Cork; 141,
Harley street, Cavendish square, W.
1881 Jones, James Robert, M.B., Box, 320, Winnipeg, Mani-
toba, Canada,
1868 Jones, John, 60, King street. Regent street, W.
1874 Jones, John Thomas, L.K.Q.C.P. I., 179, Brixlou road,
S.W.
1S"6 Jo^ES, Leslie, M,D., CM., 3, Brighton pai-ade, Blackpool.
1883 Jones, Mostaoo Handvield, M.R.CP. Lond., 1i, Mon-
tagu square, W.
1S73 JosEs, Philip W., Silver street, Enfield.
1873 Jones, Thomas Derhv, L.R.C.P. Ed., 328, Upper street,
Islington, N.
j 883 Jokes, W. H. Fenton, 28, Duke street, Manchester square
W.
167!) JoUBEBT, Charles Henry, M.D., Darjeeling, Bengal^
[care of Messrs. Gray and Co., 21, Canning street,
Cftlcutta].
1878 JuDsoN, Thomas Robert, L.R.C.P. Lend., Haymaa'a
Green, West Derby, Liverpool.
1875 Jokes, Auoustvs, M.B., N. W. Mounted Police, Regina,
N. W, Territory, Caaads.
1878 Kane, Nathaniel H. K., M.D., Lanherne, Kingston hill,
Suney.
1880 Kebdell, Alf]Ii;u, I'lnxtou, York.
vol. ixv. C
WBV^^^H
xsslv
PI!LLOW3 OF TUE ^^^^^|
^^^^1
O.F.
Keele. George Thomas, 81, St. Paul's rosd, High-
bury, N.
1880
Kbeliss, James Hckd, M.D., 267,Glo8aop road, Sheffield.
//on. Loc. Sec.
1874
Kemfsteb, William Henry, L.R.C.P. Ed., Onk House,
Bridge rond, Bntteraett.
18-9
E'er, IIdgii Richard, L.R.C.P. EJ., Comberton HouM,
Hnles-Owen, BirmingljHm,
13f)5*
Kernot, George Cmarle3, M.D., 5, ElpbinBtone road.
lUiiiiiigH, Sussex.
1883
Kekr, J. King, M.D., Leytonstone, E.
1872
Kerr, Nohman S., M.D., F.L.S., ■12, Grove road, Regeni'a
park, N.W.
187?'
Kerswiu., Joiis Bfdford, M.R.C.P. Ed., Fairfield, St.
German's, Corn w nil.
1878
Khory, Rl'stonjee Nasebwasjee, M.D. BruBseh, L.Med.
Bombay, Physician to the Parell Dispensary, Bombay,
Lecturer to Native Midwives, Grant Medical CoUegp, _
Bnmbay ; Girgaura road, Bombay.
O.F.
KiALLUARK, Henry Walter, 5, Pembridge gardena, Bay».
wBier. Council, lB79-8(>,
18G0
Kinosford, Edward, F.R.C.S., Surgeon to the Sunbury
1862
KiKKPATHicK, John Ultherfobd, M.D. Dubl., King's Pro.
feasor of Midwifery, Dublin University; 4, Uppef
MerrioD street, Dublin. ChuncH, 1872-4.
1872
KiscH, Albert, 3, Sutherland gardens, Maida vale, "W.
1867
Knagos, Henrt Guard, M.D., 189, Camden road, N.W.
1876
Knott, Charles, M.R.C.P, Hd., Liz Ville, Elm grovf.
Hoiitbaea.
1881
Lacy, CHABLBa Setuward de Lacy, M.B, 31, Groaveiior
street, W.
187S
Lanchebteh, Henry Thomas, M.D., Park House, Park
lane, Croydon, Surrey. CownciY, ISSJ,
1867
Langfowd, Charles P., 29, Duncan terrace, Islington, N.
1883
Langley, Aaron, L.R.C.P. Ed., 149, W'alwortb road, S.B.
.^H
FELLOWS OP 1
Sleeted
O.F. Laxgmore, John
terrace, Hyde
JiiAELEB, M.B., F.R.C.S., 20, Osford
park, W. Council, 1861-64. Viee-
Fflirlpy, Petersfieli],
The Elmi., Heck-
Pret. 18(
1872 LATTEr,JAME3,23, St. Mnry Abbott's terrace, Kensington, W.
1875 Lawrence, Alp»ed Edwabd ArsT, M.D., Physician-
Accoucheur to the Bristol Oeuer&l Hospital ; 1 5,
Richmond hill, Clirion, Bristol.
1878 Leachmas, Albert Wabeen, Jr.D,
Hnnts.
1882 Lee, Francis Botkton, F.R.C.P, Ed,
ttiondwike.
1860 Leishuan, William, M.D., Physician to the University
Lying-in Hospilsl, Hegius Professor of Midwifery in
the UniTersily of Glasgow; II, Woodside creecent,
Glasgow. Coitndl, 1866-68. Vice-Prei. 1869-70.
Trans. I.
1382 Leokabd, Henby James, M.B., 279, Camden road, N.'W.
1881 Le Page, Jons Fisher, L.R.C.P, Ed,, 17, The Crescent,
Salford, MnTichesler.
1877 Lewis, JoHX Rioos Millrh, M.D., Deputy- Surgeon General,
Woodlands, Queen's road, Norbiton, S.W.
IS75 Lisbmax, Carlo, M.D. Vienna, Principal Surgeon, Triesle
CiTil Hospital, Triesle, Austria. Tram. I.
1876 LiLLEY, Geobge Herdeet, M.D., M.R.C.P., Medical Officer
H.M.'i Convict Prison, Portland, Dorset.
1873 Lindsay, W, B., M.D., Strathroy, Ontario, Canada.
1874 LiTHGOw, Robert Alexander Douglas, M.R.C.P. Ed.,
I, IjVnlton place, Hans place, S.W.
ISGS Llewellyn, Evan, L.R.C.P. Ed., 9, Mount place, London
Hospital, E.
1872* Lock, John Griffith, M.A., Lansdowne House, Tenby.
1859 Lombe, Thomas Robert, M.D., Bemerton, Torquny.
1870 Lo50, Mark, M.D., Ludlow, Salop.
1878 LoRiMEB, John Archibald, 33, Castle street, Fariiham.
XXXVl FELLOWS OF THE SOCIETY.
Wected
1876 LoTETT, Henhv Albert, Swanaen, Tastnaoia. [Per 8. W.
Lovett, St. Stephen's street, Norwich.]
1S62 Lowe, Georoe, F.It.C.S., 5, Horninglow atreet, Burton-on-
Trent, Stafforilsliire. Trans. 1 .
1866 LucEV, William CufliTT, M.D., The Elms, Busbhill Park
Enfield.
1873 Lc3H, William John Henry, F. B.C. P. Ed., Aaaociate of
Sing'a College, London ; FyHelil House, Andover.
1878* LroETT, John Allan, M.D., The "Hollies," Graieeley, ■Wol-
verhampton.
1869 Lydall, Wykbham H., L.H.C.P.Ed,, 19, Mecklenburgh
Bqnare, W.C.
1S7I McCallum, Duncan Campbell, M.D., Profesaor of Mid-
wifery end DiseRiiea of Women and Children, McGJll
Uuiveraily ; PhysiciRn to the University Lying-in
HoapitHi; and Fbyaieiaa to the Moutreal General
Hospital; 45, Union avenue, Monlrenl, Canada.
Tram. 4.
1879 Mackeouoh, Oeoeoe J., M.D., Chatham, Ontario, Canada.
O.F. Mackindeb, Drapek, M.D., Consulting-SDrgeon to the
Gainsborough Diapensnry; Gainahorough, Lincolnihire.
Giiincif, 1871-3. Tram. 2.
1879 Maclaciiin, IIenby Nobuand, M.D,, 155, Mncquarie
street, Sydciey, New South Wales.
1879 JIacseilaoe, Datid, L.R.C.P. Ed.
1879 MacSwinney, Geokgb Henry, M.D,, Westall Honae,
Brook greet), HnmmcrsmitU.
1859 Madge, IIenby M., M.1>., 4, Upper Wimpole street, W.
Council, 1863-65, 1884. Fice-Pies. 1872-4. Tran».
15.
1871 Malins, Edward, M.D., Obstetric Plijaician to the
General Hospital, BirmiDgham ; 8, Old square, Bir-
mingham, Covttcil, 1881-3. Vice-Prtt. 188-1.
1876 JIanby, Fbederick Edwarp, 10, King alreet, Wolver-
litRipton.
fELLOWS OF THE SOCIETY. XXSVU
Elected
1876 Mandess, HohacE; Agincourt House, York town, Farn-
borough Station.
1SG3 MA.RCH, Henbt Colley, M.D., 2, West street, Roch-
dale.
I860 MAB1.EY, Hekbt Pbederick, Fadstov, Cornwall.
1862 Mabbjott, Bobebt Biioiianav, SwaSham, Norfolk.
18/6 MABaHALL, Feakcis JniiN, Resident Medical Officer to St.
George' • Hospilnl.
18/3 Mabtin, Henry Chabhinoton, M.B,, CM., II, Somers
place, Hyde park, W,
1875 JIasox, John Wallis, 1, Osaaburgh terrace, Rfgeiii's
pnrk, W.
lt'77 Mason, Samcel Bctleb, L.E.C.P. Ed., Denhm lloiiio
Pontypool, Monmouth ill ire.
1S77 Mauksell, H. Widenham, AM., M.D., Pitt ami London
street, Dunedin, New Zealand.
1883 Macbice, Oliver Callev, 75, London street, Reading.
1877 May, LEivia James, Boantis Tborne, Seven Siatera road,
Finshury Park, N.
O.F. Meadows, ALfsED, M.D., Fliyaician-Accoucbenr to, and
Lecturer on Midwifery at, St. Mary's Hospital ;
27>George street, Hanover square, W, Council, l8G2-ti-l.
Hon. Sec. 18t>5-6G. Hon. Lib. 1865. Treai. 1867-6!),
rice.Prei. I87-I-6. Trans. IS.
1882 Meredith, William Ae-pletos, M.B., CM., 6, Queen
Anne street, CaveudUh square, W.
1883 MiBDLBMisT, RoBEET pEECV, L.R.C.P. Lond., 10, Bedford
place, Russell square, W.C.
1875 *MiLE3, Abijau J., M.D., Professor of Diaeatea of Women
and Children in the Cincinnati College of Medicine,
CiDcinnati, Ohio, U.S.
1871 MiLLEB, Hcou, M,D., Physician -Accoucheur Co the Glasgow
Maternity Hospital ; 298, Bath crescent, Batb street,
Glasgow.
1876 Miu-MAH, Thomas, M.D., A»yliim for tlie Insane, London,
Ontario, CanaJa.
PELLOWS OV THE SOCIETY.
16/6
1867
18G8
1877
1878
1678
187?
O.F.
O.F.
.C, All SainU' Green,
^6, Fiucliley road, South
Elected
188U Mills, Robekt Jaxies, M.B.,
Norwich,
MiLSON, ElCHABD HeNRT, M.D
Hampatead, N.W.
MlLWARD, Jajies, 27, Charles Street, Cardiff. Trana. I.
Minns, PEMBaoKE U, J. B.,.M.D., Thctford, Norfolk.
Mitchell, Rouert Natual, M.D., Cbester House, Wick-
Lam road, Lewisliam High road, S.E.
MooTHoosAWMif MooDELLY, P. X., M.D., F.L.S,, Native
Stirgeon, Uncovenanled Service, and Teacher of Mid*
wifery, L. F. Midwifery, Manargoodi, Tanjore District,
Madras Presidency. Tram. 1 .
Moos, Fkbdebick, M.B., Beiley house, Greenwich.
1673 Moon, Robeet Heney, F.E.C.S., Fern Lodge, Lower
Norwood,
1859 Moorkead, JoQN, M.D„ Surgeon to the Weymoulh Infir-
mary and Diapensai-y ; Wejuiouth, Dorset.
1883 MoBiiis, Clarke Kelly, Upper Wellaiid terrace, Spalding.
1879 Mocllin, James A. Mansell, M.A., M.B., 69, Wimpole
afreet, Carendish square, W. Trans. 1.
MoWAT, Geoeoe, St. AlbauB. Trans. 1.
Muitt. Jaues C, p., L.R.C,P. Ed., 44, Cornwall road. West-
bourne park.
Murphy, JASiEa, M.D., Surgeon to the Hospital for
Women and Cliildren, Sunderland, and Lecturer ou
Botany in ihe University of Durham College of Medi-
cine at Newcaaile-upon-Tyne ; Holly House, Sunder*
land. Hon. Loc, See.
Murray, Glstatus Charles P., M.D., Obstetric Physician
10 the Great Northern Hospital; 66, Great Cumber-
land place, Hyde park, W. Council, ltjG4-65. 1683-4.
Hon. See. 18CC-69. Fice-Pret. 1870-72. Treaa.
1873-77. Trans. 3.
MusoRAVE, Johnson Tuouas, L.B.C.P. K\\., Irlam villa,
39, Fiuchley road, N.W. Cquncil, l8.=i9-60. Trans. I,
FELLOWS OF THE SOCIETY,
Elected
1863
, II, Bridge street, SlraU
Ka30n, John James, M.B. Loud.
ford-on- A von.
IS59 Neal, Jaues, M.D., Ute Hon. Surgeon lo the Lyiug-in
Hospilal, Birmingham ; Barcelona House, Sandovn,
Isle of Wight.
1876 Nesbitt, Dawson, M.D., 3-1, Cambridge place, Hyde Park, W,
18fl2 NesiiAM, TiioM.ts Cargili., M.D., Lecturer in Midwifery
in ibe Uuiversity of Durham College of Medicine at
newcaslle-ou-Tyiie ; 43, Northumberland street, Nev-
caatle-on.Tyue.
1881 Netheeclift, William Henrv, Resident MeJical Super-
intendent, Cheleea Infirmary, Cnle street, S.W.
1876 Newham, James, 16, Princes sireet, Caveudisb square, AV.
1859 Newman, William, M.D., Surgeon lo the Stamford anil
Rutland Infirmary; Barn Hill House, Stamford,
Lincolnshire. Council. 1873.7.i. Vice-Fret. 1876-77
Trant. 4.
1883 Newsuolhe, Abthub, M.D., 39, High street, Clapham, S.W.
1673 Nicholson, Arthiib, M.B. Lond., 98, Monlpellier road,
Brighton.
1879 Nicholson. Emilius Rowley, M.D,, 89, Camden road, N,W,
1876 Nix, Edward Jaubb, M.D., N:*, Great Portland street, W.
1882 NoBMAN, John Euwabo, Lismore House, Hebburn-oii-Tyiie.
1883 Nunn, Philip W. G., L.R.C.P.Lond., ChriUchurch road,
Bournemouth.
1880 Oakley, John, Holly House, Wood's End, Halifai, York-
18C8 Oates, Paukinson, M.D., IG-J, Cambridge street, Ecclesion
square, S.W.
1876 Oqstok, Fhancis, Junr., M.D., 1J6, Union struei, Aberdeen.
O.F. Oldham, Henuv, M.D., F.R.C.P., Consulting Ohstetrio
Physician to Guy'i Hospital ; A, Cavendish place. Caven-
dish square, W. Fiee-Fret. 1859. Council, I860,
1865-66. TVeM. 1861-62. Pre*. 1863-64. Trana.U
Trutlee.
1869 Ord, George Bice, Sireaibam hill, Surrey. Council 1881.
PELLOVB or THE BOCIBTT.
£hcted
ISPO Orton, Chahles, M.R.C.P. EJ., Netson place, Newcflsile-
mider-Lyme, Staffordsiiire.
18/7 OsTEBLOH, Paul Rudolph, M.D. Leipzic ; Dresden.
IS77 OsTLBKE, Robert, M.B., CM., 47, Sioke Kewington
rond, N.
1S63 Oswald, James Waddell Jeffhies, M.D,, 245, Ken-
niDgtoo road, S.E. Trans. 4.
1880 OcTiiwAiTE, 'WiLLUM, Hebert House, Denninrk Hill, S.E.
1SS3 Paluer, Joh>' Ibwik, Caubiiry House, KiD<;$tou-on-Thames.
1H77 Falmeh, Montagu H. C, London rond, Newbury, Berks.
1677 Pa&auobe, Richabd, 18, Hunter street, Brunaviok square,
W.C.
1882 Pabkes, Louis, M.D., 51, Cadogau square, S.W.
1867 Parks, John, The Wylde, Bury, Lancashire.
IS73 Pauks, Luther, A.m., M.D., I.Place Duplaa, Pau,Pninee.
[Agents: Messrs. Baring Brotliera & Co., 8, Biahopagate
street witbiu, E.G.]
1872 Pabb, Georoe, M.D., 18, Upper Phillimore place, KeuBing-
tOD, W.
1880 Parsons, Sidseh, 78, Kensington park rond, W.
1865* Paterson, James, M.D., Hsyburn Bank. Partick, Glaagoir.
1879 Pauli, Theopkilus William, L.R.C.P. Ed., Luton, Beda.
1874 Payne, William S. Hele, 54, Queen*s Rond, Peckliam,
S.E.
1882 Peacev, William, M.B., 214, Lewisham bigh road, S.E.
1864 Pearson, David Ritchie, M.D., 23, Upper Phillimore
place, Kensington, W.
1871 Pbdler, Georoe Henbv, 6, Trevor terrace, Rutland gale,
S.W.
1880 PsDisv, TuoMAS Franklin, Rangoon, India.
1880 Peel, Robert, 1 14, Collins street east, Melbourne, Victoria,
1881 Penny, Georgb Town, B.A., Stanley Houae, Oakfield road.
Upper Tollington Park, N.
1881 Perigal, Abtihib, M.D., New Bsrnet, Herts.
FELLOWS OF THE SOCIETY, xli
Elected
IS71 Perriqo, Jamer, M.D., 163, Bleury atreet, Montreal,
Canada. Hon. Loc. Sec.
1S79* Pesikaka, Hoemasji Dosabhai, 23, Hornby row, Bombny.
1S73 Pettifeb, Edmuxd Henry, 29, Stoke Newington green, H.
1879 Phibbs, Rodert Featbehstoke, L.B.C.P. Ed., Pellinm
House, 30, Sutherlanil gardens, Maidn vale, W.
1879 Phillips, George Richahu Turxeb, 21, Leinster square,
Bayavater, W.
1882 Phillips, John, B.A., M.B., Physician to Out-paiients,
British Lying-in Hospitnl; Aasistant PUyaician, Chelsea
Hospital for Women; 14, Orelinrd street, PorCman
fquare, W,
1 S78 Philpot, Joseph Henry, M.D,. 26, South Ealon place, S.W,
1871 Philps, Philip George, 4, Queen's road, Peckham,S.E,
1870 PiCABD, P. Kihkpatrick, M.D., 59, AbWv road, St. Jotin's
Wood, N.W.
1874 Pioo, Thomas, M.D., Physician to the Manchester
Southern Hospital for Women and Children; 98,
Mosley street, Manchester.
186C PiWHEH, William John, 43, High street, Boston, Lincoln-
1864 Plavfaib, W. S., M.D., F.R.C.P., Physician Accoucheur
to H.I. & R.H. the Duchess of Edinburgh; Pro-
fessor of Obstetric Medicine in King's College, and
Obstetric Physician to King's College HospiUl; 31,
George street, Hanover Square, W, Council, 1867.
1883-4. Hon. Librarian, 1868-9. Hon. See. 1870-
72. Fict-Pie^., 1873-5. Prei. 1879-80. Trans. 13.
1880 PococK, Frederick Ebkest, M.D., The Limes, St. Mark's
road, Notiing hill, W.
1S83 PococK, Walteb, Broadlands, Effra road, Briiton, 8.W.
O.F.* Pollabd, Williaw, Surgeon to the Torbay Hospital ;
Southlands, Torquay, Devon.
1883 PooK, William John, L.B.C.P., 44, Canonbury square, N.
1877 PoDLB, S. WoBsswoRTH, M.D., Dunedin, Sidcup, Kent.
Trant. I.
xHv FELLOWS OF THE SOCIETY.
Elected
0,F. RoGEES, William Richahd, M.D., PhyBician to the Sama-
ritan Free Hospital for Women and Cliildren ; Con-
sulting Physician to the Hoapital for Women, Vincent
square, S.AV. ; 56, Bernera street, Oxford street, W.
Council, 1870-72. Trans. 4.
1874 Roots, William Henry, Canbnry House, King*ton-on-
Tbames.
1874 RoFEK, Akthuk, 17, Granville park, Blackheatb.
1865 BOPEB, George, M.D., Physician to the Royal Maternity I
Charity ; Phjaiciaii to the Royal Hospital for Dist
of Children and Women, Waterloo Bridge road ;
Ovington gardens. S.W. Council, 1875-77. 1S83.4. |
Fiee-Prea. 1879-81. Trans. 10.
1859 Rose, Henry Cooper, M.D., RoaaJyn hill, Hampstend,
N.W. Council, 1875-77. Trans, i.
1880 Ross, David Palmes, M.D., Kingston, Jamaica.
1883 RossER, Walter, M.D., 1, Wellesley villas, Croydon.
1882 ROUTH, Amand J. McC, M.D., B.S., Assistant Obstetrio I
Physician, Charing Cross Hospital ; Physician to the 1
Samaritan Free Hospital ; G, Upper Montagu s
O.F. RouTU, Charles Henri Eelix, M.D., Physician to tUt |
Samaritan Free Hospital for Women and Cliildren ; 52,4
Montagu square, W, Council, 1859-61. Fice-Prei.M
1874-6. Trajis. 13.
1881 ROWORTH, Alfeed Tuomas, Gray's, Essex.
1882 RuasELL, Fbancis J. R., L.K.Q.C.P., 48, Lupus street,
S.W.
1870 Russell, Logan D. H., M.D., e, Alfred street, Gt. George
street, Liverpool.
IBtiC Saboia, v., M.D., Rio de Janeiro, South America. Tram, S
I8S3 Salteb, Francis Joseph, L.R.C.P, Ed., 9, Lyddon terrace
Leeds.
1864 Salteb, John H., D'Arcy House, Tolleshunt D'Arcy, 1
vedon, Essex.
1875 Salzmann, Frbdeiiick William; Senior Surgeon to th
Hospital for Women ; 18, Montpellier road, Brightoi
Coimril, 1880-2, Hon. Loe. Sec.
THE SOCIETY. xlv
£ltcted
1868* Sams, Jobn Sjittos, St. Peter's Lodge, Eltham road, Lee,
Kent.
1883 Sandel, Anundo Lall, M.B., 89, South Coliugn street,
Calcutta.
18/2 Sanosteb, Charles, US. Lambeth road, S.E,
18/0 Saul, William, M.D., -J, Charlotte street, Fitzroy square,
W.
1872 Savage, Thomas, M.D., Surgeon to the Birmingham and
Midland HoBpilnl for Women; 12, Old square, Bir-
mingham. Council, 1878-80. Huti. Loc. See.
Satohy, Cuables Tozgb, M.D., I, Douglas road, Canon-
bury, N. Tram. 1.
Scott, Jons, F.R.C.S., 10, Tayistock square, W.C. Council,
1868-70. Fice-Prta. 1871-3. Trans, 1.
Scott, John, M.D,, New street, Saudwich.
Se<SUeiba, James Scott, 68, Leman street, Goodman's
fields, E., and Crescent House, Cassland Crescent,
Cassland road. South Hackuey.
Serjeant, David Maurice, M.D., I, The Terrace, Cam-
berwell, S.E.
Setos, David ELPHisaiouE, M.D., 12, Thurloe place.
South Kensington. Council, 1884.
Sewell, Chables Bbodie, M.D., 21, CaTCudish equare,
W., and 13, Fenchureh street, E.G. Council, 1880-2.
1^162 Shaaman, Maum, Surgeon to the Birmingham Free Uoa-
pitnl for Sick Children ; 1 8, New ilnll street, and
llollington, Bristol road, Birmiugbara.
Sharpin, IlESar Wilson, F.R.C.S., Surgeon to the Bed-
ford General Infirmarv, Bedford. Council, 1871-3.
1677
O.F.
1870
1866
lb75
1860
O.F.
1882 Sheari), William FBANt;i3, L.R.C.P. Ed., Clyde House,
Putney. S.W.
1S67 SiiEPHEED, Frederick, L.R.C.P. £U., 33, King Henry's
road, Primrose liill. N.W.
18.i9 Shifton, William Pakkbii, Cousuliiug Surgeon to the
Devonshire Hospital ; Buxton, Derbyshire.
^r ^i
FELLOWS OF TBE BOCIETT. ^^^^^^^H
^M Sleeted ^^^^H
^M
SiscLAiB, Alexaitdzh Docll, M.D., Viriting Phyridan to
the Boatou Lving-in Hotpita] ; Member of the Botrd
of CoDiiilting Phyiiciaos and Snrgeons, Boston City
Ilospiul ; 35, Newbury itreet, Boston, Massachusetts,
U.S.
^M
SiKiGXiSO, GioscE, M.D., 24, Strada Banchi Nuovi, Napoli.
^M 674
Skinnbk, Stbpubk, M.S., Perndale. Cleiedon, SoiDer-^^|
^1 1879
SUOHT, Geobce, M.V., 3, CliSbrd street, Bond street, W. ^^M
^M 1S8I
Sloan, Abcuibild, M.B., 5(i, Buccleugb street, Olasgow. ^^M
^M
SlOaK, Samuel, M.D., CM., 1. Newton terrace, Glaagow. ^^M
^M 1661
Sltuan, William Damel, 26, Caversham road, Kentitlti^^H
TowD, N.W. CofnciV, 1881. ^^M
^^^^ 1867
Smith, IIkvwood, M.D., Physician to the Hospital fo''^^|
Women, Soho sqnare, and Physician to the Britiib^^^f
Lying-in Hospital; 18, Ilarley street, Cavenditk^^f
square, ^V. Council, IS72-5. Tran». 6. ^H
^ O.F.
Smith, Pbothkkoe, M.D., Physician to the Hospital for
Women, Soho square ; 42, Park street, Groavenor
square, W, Trana. 2. ^^
H
Smith, Richard Thomas, M.D., Assistaut-Physicinn to iha -^^M
Hospilnl for Women, Soho iqnare; ^3, Haverstock hill^ ^^H
^H
^M
Smith, Stepiibn Mabeglv, L.R.C.P. Ed., Geelong, M»1n^^|
bourne. [Per Henry M. SmilL, 34, Southamptodi^^H
Itreet, Cogent Garden, W.C] ^^M
^M
Smith, Wm. Hitgh Moktgomeky, L.R.C.P.Ed, 24, London ^H
road, Weil Croydou, Surrey. ^^M
^M
Smith, William Johnbon, M.D., Consulting Physician to ^^M
tlic Weymouth Infirmary and Dispensary; Greenhil), ^^H
Weymouth, Dorset. Council, 1969-71. ^^H
^M
Snell, Gi>MrivD GEonoE CAUituTiiEBa, 102, Bonner rond,^^H
Victoria park, E. ^^^H
^^^^ 1882
Snkll, Oeobof., L.R.C.P.Ed., The Asylum, Berbice, B^^|
Elected
1868 Sfacll, Bar\abd E., Lynvood House, 47. Hammersmith
romd.
1875 Spbscek, Lionel Disos, M.D., Bengal Army [care of
Messrs. Grindlny and Co., 55, PsrUament street].
188-2 Sfooner, Frederick HEsar. M,D., L.R.C.P. Lond.,
Howard Honse, Lover Clapton, E.
1862 SpBr, G. Frederick Hlme, M.D., Surgeon-Major 2iid
Life Goards, Army and Navy Clob. S.W.
1876 SpintGiN, Herbert Branwhite, 49, Aliiagton road
Northampton.
1876 SpcsBSLL, Fia.xxAX, L.R.C.P. Ed., Belvedere, Kent.
O.F. SqciBE, WrLLiAM, M.D.,M.R.C.P., 6, Orchard Blreet, Port.
man aquare, W. Cmmeil, IS66-6S. Fice-Prei. 18/6-
77. Ti-ani. 3.
1877 Stkphesbos, Wiluam, M.D., Professor of Midwifery,
UniTQTBily of Aberdeen ; 261, Union Street, Aberdeen.
CoURcil, 1881-3. Trans. I.
1873 STEWiET, James, M.D., 2, Skinner street, Wliitby, Yorkshire.
187S* Stewart, William, L.R.C.P. Ed., Higli6eld House,
Barnsky, Yorkshire.
1876 Stewart, William Edward, F.R.C.S. Ed., 16, Harley
Str»el, AV,
J879 Stilwell, Robert R., M.D., Beckenlinm, Kent.
1863 Stocks, Frederick, 421, Wandsworth road, S.W,
1859 Stone, Joseph, M.D., 1 75, Upper Brook street, Manchester.
O.F. Stowebs, Nowbll, 125, Kennington park road, Kenninston,
S.E,
1866 STRAiiOB, William llE.iTH, M.D., 2, Belsize arentie,
Belaize park, N.W. Comeil. 1882-4.
1871 STtBOES, Moktagub J., M.D., The LimeB, Beckenliam,
Kent.
1880 ScTHEKLAND, Chables James, L.R.C.P. Ed., 16, Frederick
atreet. South Shieldf, Durham.
1883* Sutherlakd, Heubv, M.A.. M.D. Oion., M.R.C.P., G,
Eitlimond terrace, Wliitehnll, S.W,
xiviii
FELLOWS OF THE ^^^^^^^|
mected ^^1
1862
ScTTON, Field Flowers, M.D., BtJham liill, Clapham,
S.W.
1859
SvfATNE, Joseph GBirriTUS, M.D., Phyaiciau- Accoucheur
to the Bristol Geuersl Hospital; Harewood House,
74, Pembroke road, Clifton, Brislol. Council, 1860-61,
Yice.Pret. 1862-64. Trans. 7. Hon. Loe. See.
1883
Tait, Edward Sabink, M.B,, 1, The Bank, Crouch hill, N.
1879
Tajt, Edward W., 5-1, Highbury park, N.
1871
Tait, Lawson, F.K.C.S., Surgeon to the Birmingham and
Midland Hospital for Women ; Consulting Surgeon
to the West Bromwich Hospital; 7, Great Charles
street, Birmingham. Trans. 12.
1880
Takaki, Kanaueiko, F.R.C.S., 10, NisLi-Konyacho, Kio-
bnshika, Tokio, Japan. Hon. Loc. Sec.
1871
Tajikbr, Joun, M.D., F.L.S., Physician for Diseases of
Womeu, to the Farriiigdon General Dispensary, and
Obstetric Physician to tiie Lying-in Charity, Holbom j
102, Harley street, CaTeiidisb square. W. '
1859
Tapsos, Alfred Joseph, M.B. Lond., 36, Gloucester gar- 1
dens, Weatbourne terrace, \V. Council, 1862-64. 1
1863
Tapsos, Joseph Alfred, Surgeon to the Clapliam General ^J
Dispensary; 83, High street, Clnphani,S.W. Traia.l, ^H
1871
Tayler, Francis T., B.A. Lond., and M.B., Clarcmout lilla, ^H
22-1, Lewisham high rond, S.E. ^H
O.F.
Tayloe, Edward, South lodge, Clapham comnion, S.W, ^^|
Council, 1682. ^^|
O.F.
Taylor, Charles, M.D.,Pine house, 216, Camberwell New ^H
road, S.E. CounciV, 1869-71. ^H
1881
Taylor, F. Peeley, F.R.C.8. Ed,, Charlolle Town, Prince ^^|
Edward Island, Canada. ^H
IStil)
Taylor, Jons, Earl's Colue, Halstead, Essex. ^H
1871
Taylor, John W., M.D., Rothiay House, Piiucc of Wales 1
terrace, Scarlio rough. J
FEi.Liins OK THK aociETV. xlix
SIteled
18~2 Temple, Jaues Algernon, M.D., ProfesBor of Obitetrict,
Trinitj' College ; Pliysician to Toronto General Hoapilal ;
Pbysicinn Accouclieur to tbe Burnside Ljing-in-
Hospitnl ; 191, Simcoe street, Toronto. Hon. Loo. Sec.
1862 Thane, Geobge Dancer, M.D., 15, MonWgue street,
Russell square, W.C. Council, 1881.
1882 Thomas, Hugh, Cambridge House, Small-liestli, Birroing*
bom.
18&0 Thompson, Henry, L.R.C.P. Loud., AsBistant Surgeon,
Hull General Infirmary, 16, Albion street, Hull.
1S67 Thompson, Joseph, L.R.C.P. Lond., 1, Oxford street,
Notlingbsm. Trans. 1.
1878 Thomson. David, M.D., 17, Market bill, Luton, Bedford-
sbire.
1874 Thomson, William 8inclaie, M.D., 40 LBd:}roVe grove,
Kensington park gardens, W.
1878 Thomson, William Aknold, F.R.C.S.L, Tbe Limes,
Amptbill, Beds.
1867 Thobblrn, John, M.D., M.R.C.P., Professor of Obstetric
Medicine, Owens College, Manchester; 62, King street,
Maucliester. Council, 1876-78. Fice. Pret. 1881-3.
18r>0 Thobnb, Geoboe Lewobthy, M.B., Lenham, near Maid-
stone, Kent.
1879 Thobnton, J. Knowsley, M.B., CM., Surgeon to the
Samaritan Free Hospital for Women and Children, 22,
Porlman street, Portman square. Council, I8S2-3.
Eon. Lib. I88J. Trant. 5.
1867 Thornton, William HEKKV.Surgeonlo the Royal National
Hospital for Scrofula ; Berkeley Lodge, Margate.
1874 Ticehurst, Ai^gl'sti^b Kowland, Silcbester House, Peven-
sey road, St. Leonard's-on-Sea.
1873 TtcEHUUST, Charles Sage, Peter^field, Hants.
1860 TlFFEN, Robert, M.D., Wigton, Cumberland.
1866 TiLLBT, Samtel, The Cedars, Cranford, Middlesex.
VOL. JXV. d
1 rr.Li.ows OF the society.
Elected
O.F. Tilt.Edwabo John, M.D., Consulting Physician-AccoucheB
to the FarriogdoD General DiBpensarj ; 27. Seym
itreet, Portman square, W. Council, 1867-68, Pi
Pres. 1869-70. Treat. 1871-2. Prei. lS73-«<
Tram. 7.
1883 Tinker, Fbederick Howard, F.R.C.F. Ed., Brooklanj]
House, Hyde, Cheahire.
1679 TiVY, William Ja.me9, F.R.C.S. Ed., 8, Lansdown plaee,!
Cliftou, Bristol.
1872 T010T3CHIN0FF, N., M.D., Kieff, Russia [per M. N. OrlofiiJ
3, Bleieho road. Lavender hill, S.W.].
1869 ToMKiKs, Charles P., L.K.Q.C.P.I., Beddington pir^l
Croydon.
1870 TowNE, Alkxamueb, 364, Kingaland road, N.E.
1873 Tbestbail, HENEtEKNEsT,F.R.C.S.,M.R.CP.Ed.,W«Imer \
House, Victoria road, Aldershot. Trant. I,
1672 TucuMANN, Mauo, M.D., Asaistant Surgeon to the German ]
Hospital ; US, Adelaide road, Ilaverstock hill, N.W.
1865 TUBKEB, JotiN Sidney, Surgeon to the Anerley Dispensary ; ]
Stanton House, Thicket road. Upper Norwood, Surrey, j
IB81 TuTuiLL, Fhineas Barrett, M.D., Station Hospital, Gib- 1
1661 Tweed, John James, Juur., F.R.C.S., H, Upper Broolcl
street, W.
1874 Undekuill, Tuouas, M.D., Summerfield, West Bromwich^j
Staffordshire.
1874 Venn, Aldkbt John, M.D., Obstetric Pliysidau, Metro- I
politan Free Hospital; Assistant Physician, Victoria I
Hospital for Sick Children; 8, Upper Brook atreetiJ
Grosvenor square, W.
1880 Vebdon, Walter, F.R.C.S., 410, Briiton road, S.W.
1673 Verley, Reginalu Louis, F.R.C.P. Ed., 28b, Devooahinl
street, Portland place, W.
1879 Waue, Geohoe IIebbeht, Ivy Lodge, Cbislehursl, Kent.
1864 Wahltucb, Adolphe, M.D., 8, Acomb street, Greenheya, J
Mane beater.
FELLOWS or THE 80CIETV.
li
EUcUJ
1860 Walxs, Thomas Gabnbys, Dowabnin Market, Norfolk.
1883 Walker, Alexandeb, M.D., Hotham House, Putney, S.W.
1877 Waikek, George, L.R.C.P., M.R.C.S., 12, Lingfield road,
Wimbledon.
1866 Wai-keb, Thohas Jahes, M.D., Sargeon to the General
Infirmary, Peterborough ; 18, Westgate, Peterborough.
Eon. Loe. See. Council, 1878-80.
1873 Walkkb, Thomas Osuorne, Crick, near Rugby, North-
ampton shire.
1883 Wallace, Richard Unthank, M.B., 186, Amhurst road,
N.E.
1870 Wallace, Fbedkrick, 96, Cazeaove road, Upper Clapton,
N. Couneit, 1880-2.
1872 Wallace, John, M.D,, AwU tan I- Physician to the Li*erpool
Lying-in Hoapital ; I, Gambler terrace, Liverpool.
Bon. Loe. Sre. Council, 1883-4.
1879* Walter, William, M.A., M.D., Surgeon to St, Mary'.
Hospital, and the Mancbeiiter and SalFord Lying-in
Uonpital ; 20, St. John street, Manchester.
1667 Waltbbs, Jame9 Hopkins, Ataistant Surgeon to the Royal
Berkshire Hospital; 4B, Castle a tree I, Reading, Berks.
Council, 1884.
1873 Walters, John, M.B., Church street, Reignte, Surrey.
1859 Warden, Charles, M.D., Hon. Surgeon to the Birming-
ham Lying-in Hospital; 31, Newhall street, Birmiug-
1862 Watkiks, CfiABLES Stewart, 16, King William atreet,
Strand, W.C.
Weatrerlv, Lionel Alex., M.D., CM. Aberd., Portiahead,
Somersetshire.
Webb, Fred. E., 113, Maida Tale, W.
Wkbb, HBNitT SfeaKMan, Welwyn, Herts.
1872 Wesster, Thomas, MsWern House, Redland, near Bristol.
1876 Weir, Archibald, M.D., St. Mungho's. Great Malwrn.
1867 Wblleb, Geoboe, The Mall, Wanstead, Essex.
1879
1867
O.F.
tii
FELLOWS or THE BOCIBI
Elected
1876 Wells, Frank, M.D., late Profeinor of Obsletrica snd the
Disensea of Womeu and Cbildreo in tbe Cleielnnd
Medical School; Chapel Statioo, Brookliae, Massachu-
O.F. WELLa, Sm T. Spbnceb, Bart., F.R.C.S., SurgeoD in Orc^>J
HBrjr to H.M.'b Household ; Cnnsulting Surgeon to Warn
Samsritan Free Hospital for Women and Children ; 3,1
Upper Grosvenor street, W. Council, 1859. Vie9~\
Pre: 1868-70. Tram. 5. TruHic
1859 Westmacott, John Guibe, M.D., Medical Officer to tbel
PaddingtOQ Provident Dispensary; Howlcy House,
Howley place, Pnddington, W. Trant. 1.
18/6 Wharton, Henhy Thornton, M.A. Oiford, 39, St. George'a |
road, Kilburn, N.W.
1870 Wheatcroft, Samuel Hanson, L.R.C.P. Ed., I.itcham
Swnffham, Norfolk.
1860 Wiieeleb, Daniel, Chelmsford, Essex.
1873 Wbitb, Fredekick Beoad, 15, Maida vale, W.
1882 Wholey, Thomah, L.R.C.P. Lond., London Hospital, E.
1883 WicKs, WiLLtAM Caibns, M.B., 1, Park parade, NewcaaUe- I
OB-Tyne.
1877 WioMORE, William, 130, InTeroeis terrace, Hyde park,
W.
1867 Wilbe, Richard Hatdock, M.D., York Lodge, 21, Finchic/ 1
road, St. John'B Wood, N.W.
1879 Wilkin, John Frederick, M.U., Beckenham, Kent.
1883 Wilkinson, Thomas Marshall, F.R.C.S. Ed., Lincoln.
1879 WiLLAKS, WiLUAM Bldndell, F.R.C.P. Ed., Much Had- |
ham, Herts.
1879 WiLtETT, Charles Vebrall, 8a, Oxford and Camhridga I
Mansions, W.
Williams, Abthuk Wvnn, M.D., Physician to the Samari-
tan Free Hospital; 1, Montagu square, W. CotmeU,
1871. Trant. 7.
1861
FELLOWS or THE SOCIETY.
1876
1871
Williams. John, M.D., F.RC.F., A BaiBtnnt- Obstetric Phy-
sicisn lo UiiiTerBity College Hoapital ; 11, Queen Anne
■treet, Cuvendiih square, W. Courteil, 1875-76. Hon.
Sec. 1877-9. Fice-Prei. 1880-2. Chairman Mid-
wi/ery BoarJ 16S-I. TranM. 6.
Willis, Julian, M.R.C.P. £d., 82, Sutherland gardeni,
Mnida vale, W.
Wilson, Joes Hbnbt, L.K.Q.C.P. Ireland, Obstetric Physi-
cian to the Ladies' Charity end Lying-in Hospital;
Kensington Lodge, Kensington, Liverpool.
Wilson, Robert James, F.R.C.P. Ed., 7, Warrior square,
St. Leonard's-on-Sea, Sussex. Bon. hoe. See. Fiee-
Pret. 1878-80.
WiLTsHiBE, Alpbeu, M.D., F.R.C.P., Joint Lecturer on
Midwifery at, and Assistant -Obstetric Physician to,
St. Mary's Hospital, and Physician for the Diseases of
Women to the West London Hospital; 57, Wimpole
Btreet, Cavendish stjuare, W., and Torridon, Somera
road, ReigBte. Council, IBJO. Hon. lib. 1871-3.
Hon. See. 1B74-6. Vice-Pres. 1877-9. Tran*. 5.
WiNTLE, Henrt, M.B., Kiogsdown, Church road, Forest
bitl,S.£.
Woodward, G. P. M., M.D.
Worship, J. Lucas, Manor Home, Rirerhead, SeTenoaki,
Kent. OiiiiiciV, 1875-77. rice-Pre*. 1883-4. Traru.S.
WoBTHiNOTON. Georgk Finch Jenninqs, M.K.Q.C.P.,
Sidcup, Chislehurst.
WoBia, Edwin, 6, Trinity atreet, Colchester.
Yairow, Geokoe Edqenb, M.D., 67, Old street, E.C.
Council. 1881 -3.
TOCKD, Charles Grote, M.D., New Amsterdam, Berbice,
British GuianB.
Yocfi), David, M D., 20, Piazu dt Spagns, Rome [care of
Mr. Lewis, Oower Street].
ToONO, WiLUAM Butler, 10, Culle atreet, Reading, Berls.
CONTENTS.
LiBt of Officers for 1884 .
List of PreaidentB
List of RiifereeB of Papers for 1884
StuidiDg Committees . .
List of Honorary Local Secretai'ies
TruBtees of the Society's Property
List of Honorary and Oorresponding Fellows
List of Ordinary Fellows
Contents ....
Lial of Plates ....
Advertiaement ....
January lOtfa, 18S3—
F<BtuB with Outgrowth finm end of Coccyx, shown by
Dr. HxywooD SniTH ....
Uterus removed by Porro'a Operation, shown by Dr.
UsTwooD Smith ....
L Not«a of a Specimen of Anteflexion of the Uterns. By
W. 8. A. GniyFiTH, F.R.C.S., M.B.C.P. .
H. Case of Extirpation of Dt«rus and Appendages for
Epithelioma of the Cavity. By J. Enowblst
Tbobrtok, M.B„ C.U.
February 7th. 1883—
Annual Ueeting ....
Specimen of Retro-uterine Ferimetrio Abscsas, shown
by Mr. W. S. A. GEiFriTH
VAan ^
III. Epithelioma of Cervii, remoyed bj fieraaenr Wire
during Pregnancy without causing Abortion. Bj
Clbmebt Godson, M.D. . . .18
Annual Meeting; The Audited Report of the Treasurar
(Dr. J. B. Potter) . . . 25-26
Report of the Honorary Librarian for 1882 (Dr.
F. H. Champneyh) . . . .26
Kcpoi-t of the Board for the Examination of Mid-
wivea. By Br. J. H. Aveiing, Chairman . 27
- — Election of Council and Officers for the year 1883 28
Annual Addrewi of the PrCBident (J. Matthbw8
Duncan. M.D.,F.R.S. Ed.) . .29
March 7th. 1883—
Cast of Female Bladder, shown by Dr. J. H. Atelino 33
Fibroid Tumour of the Ovary removed by Abdominal
Section. Bhown by Dr. John Williams . . 36
Dermoid Cyst of the Right Ovary, shown by Dr.
Granville Bantock , . . .38
Hydrosalpinx of the Fallopian Tube, shown by Dr.
Geanvillb Bantock , . . .38
Specimens of Fibroid Tumour of the Uterus, shown
by Dr. Granville Bantock . .38
Specimens of Fibroid Tumour of the tTterus, shown by
Dr. W*BN Williams . , .46
Inaugural Address of the President {Henbt Gertis,
M.D.) . . .47
IV, Tui-ning in Cases of Contracted Brim. By P. L,
BCRCHELL. M.B. . . .61
April 4th, 1883—
F(ttus, with Placenta attached, ^bowing a knot in the
Umbilical Cord, shown by Dr. GoDSON
Dermoid Cyst, shown by Dr. Euis .
Uterine Fibro-myoma, shown by Mr. Khowslet
Thobnton ....
Fibro.myoma and a new Axis-traction YuleeUi
Forceps, shown by Dr. BoBEET Barnes .
Placenta with Cyst on the Foetal Surface, shown by
Dr. John Williams .
Eeport of Committee on Tumour shown by
Winn Williams at the March Meeting .
CONTENTS.
T. On the " Pressure of the Femoi'a " and ita Influence
on the Sbiipo of the FelviB. By Fbanois H.
Chakpmeys, M.A., M.B. Oxon., P.B.C.P. .
TI. Ouae of Labour with Atresia Vaginie. By Fawcourt
Baknm, M.D., M.R,C.P.
Hay 2nd, 1883—
Tn. Case of Eitra-uterine FffltatioD. By J. A. Marsell
MouiJJN. M.B.. M.BC.P.
Specimens of Myo-fibromata of the tTterns, shown by
Dr. Gkevib , . ■ . .
Cystic Degeneration of Subperitoneal Fibroid of the
UternH, shown by Dr. Cartek .
Cystic Disease of both Oraries, shown by Dr. Carter
PmtaJ Monstrosity, shown by Mr. F. E. Coceeli., jun.
Twin Female Monster, shown by Dr. Ghalmekb for
Dr. HURFOBD ....
Specimen of Hydrosalpini, shown by Mr. Lawson
Tait . . ' .
Specimen of Pjosolpini, shown by Mr. Lawbon Tait
Parovarian Cyst, shown by Mr. Lawson Tait
Vm. Case of Eitra-uterine Gestation Bimiilating sO'Oalled
Missed Labour. By Adolph Kasch, M.D.
IX. On the Behaviour of the Uterus in Puerperal
Eclampsia, aa obserted in two cases. By J.
Braxton Hicks. M.D.. F.R.S., *c.
June 6th, 1863—
Case of Spurious Hermapbroditism, shown by Dr.
GUALUEKS ....
Specimen of Sarcoma of the Ovary, Hbown by Dr.
Eldbb, .....
General and considerable Congestive Hypertrophy of
the Uterns, with Acute AnteUexion and presence of
an Ovarien Oyat, shown by Dr. Gkailt Hewitt
and Dr. SiLcocK ....
Polypus adherent to Vagina, shown by Dr. Pottbr .
Specimens of Pyosalpini, shown by Mr. Lawson Tait
Fallopian Tubes distended with Pus (Pyoaalpinj),
shown by Mr. J. Kkowblei Thobnton .
Myxomatous Degeneration of Uterine Fibroids, shown
by Dr. Godson ....
VOL. xxr. <■
jasB of Aoutu Oangniiie of the Vulva i
with remarks. By G. EaNBaT Hei
Loud., M.R.O.P.
1 Adult,
N, MB.
Jnly ith, 1883—
Specimen of Bemorrbagic EffusioD, bIiOwd bj Di-.
BoBEET Barnes . . . I
DemoDHtrationa illuBtrating the Separation and Ea-
palBion from the Uterus of the Placenta, hy Pi-.
Cbampnbys . . . . 1
Ovarian Tumour, shown by Dr. UEADOwa . . 1
Specimen of Submucous Fibroid of the tTterue, shown
byDr. Gebtis . . . 1
Spunous Hermaphroditism, GenitO'Urinai^ Orgnna,
shown by Dr. Chalmers . . . 1
Hydatidiform Mole, shown hjr Dr. W. A. DUWCAN 1
Hysterectomy, the parts removed by, ahown by Mr. J.
KnowbleyThoemion . . . 1
Ovarian Cyst, Bhown by Mr. J. Knowslet Thoknton 1
Fibrinous Polypus, ahown by Mr. W. S. A. GairFlTH 1
Hypertrophied Left Nympha, shown by Dr. Fancourt
Barnes . . . . . ]
XI, The ObBtetricB of the Kyphotic Pelvis. By Fkancis
H. Champneyb, M.A., M.B. Oxon.. F.R.C.P. . 1
XII, Note on Uterine Myoma, ite Pathology and Treatment.
By Lawbon Tait, F.B.C.S. . . . ]
October Srd. 1883—
Case of Hypertrophy of the Brea,als, shown by Dr. J.
A. Mansell Mocllin . !
Large Fibre -cellular Tumour, shown by Dr. W. A.
Ddncah . . . ;
Arrested Development of one Twin. Double Placenta,
shown by Dr. Eoia . . . , |
Placenta Snocenturiata, shown by Dr. Chamfnexb , :
SIII. Gangrene of the Thigh daring the seventh month of
Pregnancy. By JoBEFH GuiririTHB Swatne, M.D. 1
XIV. On the Ob tJtei-i Internum, its Anatomy, Physiology,
and Pathology. By J. Henby Beknet, M.D.
November 7th. 1883—
Siibporiloncal Uterine Fib ru ids, shown by Dr.
Meadows . ,
I CONTENTS. hx
PAGB
Oblique Bachitio Pelvis, shown by Mr. W. S. A.
Gbivvith ..... 232
Dysmenorrhoeal Membrane, shown by Dr. Wtnn
Williams ..... 233
Bepari on Hydatidiform Mole shown by Dr. W. A.
Duncan at July Meeting 233
Report on Buptured Oyarian Cyst shown at October
Meeting by Dr. W. A. Duncan . . . . 234
XV. Three Cases of Pyosalpinx. By Lawson Tait,
F.B.C.S. ..... 234)
XYI. Case of Idiopathic Ghingrene of the Uterus. By
Lawson Tait, F.B C.S. . . .248
XVII. An undescribed Disease of the Fallopian Tubes. By
Lawson Tait, F.B.C.S. .249
December 5ib, 1883—
The causation of Lateral Obliquity of the FoBtal Head,
diagrams shown by Dr. Galabin . . 252
XVIII. On the Mechanism of Labour, more especially with
reference to Naegele*s Obliquity and the Influence
of the Lumbo-sacral Curve. By Bobb&t Babnbs,
M.D. . . .258
Index .... .291
Additions to the Libra kt .... 307
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TOL. XXV.
r
ADVERTISEMENT.
Tub Society is not as a body responsible for the facts and
opinions whioh are advanced in the following papers and com-
munications read, or for those contained in the abstracts of the
discussions which have occurred, at the meetings duiing the
Session.
53, Bebnbbs Stkest.
LiBBiBT AM> Museum,
54, B£U>£B3 Street, \V.
OBSTETEICAL SOCIETY
LONDON.
SESSION 1883.
JANUARY 10th, 1883.
[atthews Duncan, M.D,, F.R.S. Ed., President, iu
Chair.
Present— 33 Fellowa and 2 visitors.
Boobs woro presented by Dr. James Barr, Dr. L. D.
Bulkley, Dr. Henri Martin, Dr. L. A, Neugebaaer, Dr.
Plajfair, and the Council of University College.
George R. E. Bonsall, L.H.C.P. Ed. (Homsey Rise), was
was declared admitted a Fellow of the Society.
The following gentlemen wero elected Fellows -of the
Society: — William Augustus Bonney, M.D. ; Christopher
Childs, M.A., M.B. Oxon. (Weymouth) ; Edward Clapham,
M.D. (Wimbledon); William Coatca, M.R.C.S. ; W. H.
Fenton Jones, M.R.C.S. ; William John Pook, L.R.C.P.;
James J. Reynolds, L.R.C.P. Load. (Portland); John
Corytou Roberts, L.R.C.P. Ed. ; Edward Sabine Tait,
M.B. } and William Cairns Wicks, M.B. Ed. (Newcastle-
on-Tyne) .
TOL, XXV. 1
3 FOBRO 8 OPERATION.
Dr. Hetwood Sjcth exhibited a fcetus witli an
growth from the end of the coccyx, similar to one fignred
iu Martin's ' Atlas/ PI. LXXIT, fig. 4, bnt whereas that
was found to he a f(Btu8 in fcetu, this tumonr, 3i inches
long, and 7 inches in circumference, was fonnd to consist
of a mass of undeveloped embryonic tissue and some email
round cells, with a very faint fibrillar arrangement. The
moat remarkable feature in the specimen was, however, that
which seemed to constitute it the " missing link." From the
coccyx there are traceable four prolonged vertebrw, as of a
tail, consisting each of a cartilaginous body with apinoaa
processes. The specimen came from a woman, eat. 34, who
had had seven previous pregnancies. She ceased men-
struating May lat, 1882. Dr. Heywood Smith saw her
October 25th, and diagnosed something ivrong with the
foetus, which was expelled November 16th, The mother
had about the third month been annoyed on several occa-
sions by a man obtruding himself on her notice who was
BuSering from a large tumour of his neck.
Dr. Hevwood Smith also exhibited the uterus of a patient
which he had removed two days previously by Porro's
operation. The patient, set. 20, a strumous subject, was
taken in labour at term on Saturday, January 6th ; on the
7th there was a show, but the midwife, though she felt the
funis presenting, failed to recogniso the great deformity
of the pelvis. She was seen by the medical officer of the
St. Giles's Workhouse on the morning of the 8th, when the
cord was prolapsed and dead ; he then perforated the head,
and Dr. Heywood Smith was called to the patient at 1.45.
He found the conjugate diameter to be only 1 J or If inches,
bnt, thinking there was a little more room on the left side
of the pelvis, he attempted delivery with the cephalotribe
and with craniotomy forceps. After three quarters of an
hour of ineffectnal attempts, in which only a few fragments
of bono were removed, and considering any further attempt
at the removal of the child j^ifr vias nalurales would expose
the patient to very grave risk, he determined to perform
JINTKFLESION 0? THE Ol'BHUS. 3
Porro's operation. Tliia was done about 4.15 p.m. uiidei-
eucalyptus air, the uterus being drawn out of the abdominal
wound before it was opened. The stump was secured at the
lower angle of the wound. The operation lasted nearly an
hoar. The specimen exhibited showed very clearly the
mgffl on the external surface of the uterus.
Dr. FAHcorBT Babnes remarked that the proceeding of
Attempting to draw the uterus out of the abdomen before
incising it, as recommended by Miiller, was a vicious one, and
required a large abdominal incision, as veil as further compli-
cating the operation by adding to the difficulty of one of the
most important steps in the operation, the application round the
cervii of Cintrat's ligature. The ori^nal phin of Porro, in-
cising the uterus, and before drawing it out of the abdomen,
was the best in all respects.
NOTES OF A SPECIMEN OF ANTEFLEXION OF
THE UTERUS.
By W. S. A. Griffith, F.R.C.S., M.R.C.P.,
lUTOH Vf UlDWiriBT AKS TBI DIBUSIS Ot WOUIH, ST. BABTHOLOKBW'S
This epecimenj which I found in the museum attached to
the Sussex County Bospital at Brighton, I am enabled to
bring forward by the kindness of it-. Nathaniel Bhiker the
curator. The following is the description in the Museum
Catalogue :
"J. 31. Preparation ahowing complete anteflexion of
uterus, the organ is bent sharply on itself bo that the
fundus is in juxtaposition to the fundus of the bladder.
The adjacent parts, Fallopian tubes, ovaries, &c., were all
agglutinated into one mass by firm old adhesions.
" The cavity of the womb is much contracted at the bend,
while towards the fundus it is dilated into a sac of the size
and shape of an almond, and contains the remains of a clot
I of blood.
"The preparation was taken from an unmarried womau>
4 ANTEFLBIIOS OF THB UTBEHS.
set, 28, who while in apparently perfect health was (
while dancing with pain in the left iliac region which steadily
increased. This was succeeded by obstinate constipation
and trne ileus, of which she died in about three days.
"At the post-mortem examination she was found to have
acute peritonitis with great effusion of lymph, the result of
the baratirg of a cyst in the broad ligament, which took
place probably at the time of seizure.
" She always suffered pain towards the termination of the
catamenial periods which were otherwise regular.
" The fixed condition of the uterua was detected during
life by vaginal examination.
"Presented to the museum by Dr. Hall."
I am indebted to Mr. Brenchley, of Camberwell, whose
patient she was nearly twenty-five years ago at Brighton ;
and to Dr. Hall, of Brighton, who was called in consultation
during the fatal illness, for some further details which they
have been kind enough to send mo in answer to a request
for further information especially as regards the existence
of dysmenorrhoea.
IIG, The OrovQ, Camberirell, S.B.,
Oct. 2gth.
Deab Sik, — The patient was a remarkably fine, tall, well-
grown, and handsome young woman. She had remarkable
good health, and never complained of anything, bat there
was a history, three years previously, of acute pain and
inflammation in the left iliac region. When seen, she
referred her pain to this part, and it was, in no sense, an
ordinary case of peritonitis, it was diagnosed to be infiam-
mation of left ovary. She had pain there, sickness, and
constipation, she lived bnt three or four days. On post-
mortem, a moat extraordinary state of the gut was found,
and herein was my chief interest. There appeared to have
been old inflammation of the left ovary, it was destroyed,
and was a mere bag of creamy deposit. It had adhered to
the gut, and this inflammation had burst the gut, and a
large pouch had thus been formed, the gut having
adhesions all round to the pelvis. It was quite green and
ASIBfLEXION OP TBE DTBEUB, 5
semi-gftngrenoaa. The marvel was how she could have got
about with such a state of the gut, for it was evidently of
long standing. It took place probably in the firat attack
three years previouBly, the second attack proving fatal.
The parts around were dragged down by the adhesions of
the gut and ovary, and I take it that the anteflexion of the
uterus was entirely brought about by the dragging of the
adhesions. — Toura very truly, Hoeatio Bbenchlbt.
Deab Sib, — In reply to your letter, respecting the
specimen of "Anteflexion of the Uterus" which I pre-
sented, many years since, to the museum of the Brighton
Hospital, I have little to add to the description of it con-
tained in the catalogue. The subject of it was a patient of
Mr. H. Brenchley, then residing here. I was called in con-
snltation upon the case about twenty-four or thirty-six
hours before death, which waa due to acute peritonitis with
obstruction of the bowels, taking the form of ileus with
stercoraceous vomiting. Injections with O'Beomo's tube,
&c., were tried and found unavailable. On examination
after death the whole intestines were matted together by
effusion of lymph, and incapable of being separated or
distinguished one portion from another, and drawn down
and firmly adherent to the outline of the pelvic cavity, so
much so, that it was a difficult matter to find and separate
the uterus from the agglomerated mass, and it was to this con-
dition principally, if not entirely, that the intestinal obstruc-
tion was owing, and all injections proved ineffective. The
young woman was a lady's maid, and enjoyed good general
health, only, as a rule, complaining of pain at the menstrual
epochs towards, I understood, their subsidence. The
evening she was seized the period was just passing away,
and she was in high spirits and dancing about in fun with
the other servants, when she was suddenly seized with
violent pain in the left inguinal region followed by acute
peritonitia and death on the third day. I recollect being so
AKTEFLEXION OF THT; UTElirS.
Btruck with the complete character of the anteflexion that 3
coniteraplated sending the specimen for the inspection i
the late Dr. Churchill, of Dublin, who expressed in '
work his disbelief of such a pathological condition of th
womb,— Yours truly, Alpeed Hall.
The history seem8 clear that she waa to all intents e
purposes- a perfectly healthy woman until eight days befoM
death, though she had suffered three years previously from
a pelvic ioflammation which affected chiefiy the left iliiM
region.
The cause of death was probably strangulation anffi
gangrene of the bowel caused by the gradual contraction
of the old perimetric adhesions, complicated probably bjS
some effect of her romping and dancing. This occurred jui
at the termination of a menstrual period, evidence of whid
is manifest in the condition of the mucous membrane of t!
uterus.
As to dyamenorrhcea Mr. Brenchley tells me that no comj
plaint was made to him on this point until the fatal illness^
when the question ^vas asked, she then stated that shot I
always bad some pain towards the subsidence of the period. §
but not of such a character as to give rise to any complaint; I
or to interfere with her duties.
The uterus is completely anteflexed and its fundua' I
is bound down by adhesions, in all probability the result o£ I
inflammation three years before her death; the ovaries.
Fallopian tubes, and broad ligaments are in the same way. I
matted together and scarcely recognisable ; the membraae; I
binding down the flexion is quite distinct and is seen, I
to pass across, not down, to the apex of the bend.
The walls of the uterus show what a firm healthy o
it was, and exhibit the condition described by Dr. BantockJ
viz. a thickening of the concave side of the bend prob-
ably from a crowding together of the shortened but thick-:1
ened muscular fibres at this point, there is no marked thining: f
of the convex wall of the uterus and it is probably corre<
to say there is none at all.
ANTEFLEXION 07 THE UT1RI78. 7
In the description which I have copied from the ' Museum
Catalogue,' it is stated that " the cavity of the womb is much
contracted at the bend ;" this statement ia not correct, it is
here even after twenty-five years in alcohol somewhat larger
than normal. The bend is situated just at the junction of
the cervix and body and above it the cavity is considerably
dilated and was found to contain the remains of a clot of
blood, the specimen is probably nniqiie in this point and is
of special interest in giving the positive anatomical proof of
the possibility of such a condition which Dr. Herman said
in his paper last summer was wanting.
What was the cause of this dilatation ? If we reject, as
I think we may do in this case, mechanical obstruction, we
may fall back upon chronic congestion which ia very likely
to have occurred in an organ doubled on itself, and whose
blood must escape by irregular and tortuons channels.
The results of the dilatation were probably retention of
menstrual blood and debris, as was seen at the post-mortem
examination, and this would he expelled, not as from the
normal linear cavity of the uterus by overflow, but after the
overflow had ceased by contraction of the uterus, which, if
painful, would explain the " after pains " which she experi-
enced.
This specimen helps to establish the important patholog-
ical fact that the acutest form of flexion of the uterus may
be produced without interfering with the nutrition of its
walls or diminishing its cavity, and that it may exist during
the most sensitive period of the menstrual life without pro-
ducing any symptoms or interfering in any way with perfect
health.
Had she been married, the chance of becoming pregnant
would have been probably more remote from the condition
of the ovaries and Fallopian tubes than from the state of the
QterUB.
Dr. BocTH thought the case quoted did not prove that the
canal of a flexed uterus was necesiarily not couBtricted at the
internal oe, because, first this woman wu meustruating at the
time, and if Waa a ^bwD fact tbat in Buch casee the uterine
ANTEFLEXION OS THE DTERUS.
mate -pne- ^^|
lat even a ^^^
8
cavity became in time dilated. Thus it was the legitimate
tice incaaes wbere the canal was eo constricted that
amail probe could not be paased, to wait for a period when the
opcDing became visible, and then meaaurea of dilatation could
be carried out. The lining membrane here was ulcerated or
diseased, or bo injured here by the apirit, that the patency at the
inner oa might be result of disease, and not the normal conditioa
existing in other cases.
Dr. Ghailt Hewitt thought Mr. GrifSth'a case interesting
in view of the rarity with which the condition of anteflesion vr aa
observable post-mortem. He would direct attention to a most
valuable case recorded by Dr. Walslie, many years ago, in Ash-
well's work, a case he had recently quoted in the new edition of
bia own work on ' Diseases of Women.' Tbere waa also a most
complete specimen in TTniversity College Museum, which had
been, be believed, there placed by Sir William Jenner some
years ago. As regards tlie condition of the uterine canal ia
iheae caaea, it seemed to be supposed by some tbat if the canal
was pervioua there could be no obatruction to the exit of men-
strual or other fluid, but in. point of fact the canal waa often
quite pervious, and yet there waa a virtual obstruction in conse-
quence of the coaptation of the opposite walls of the canal and
tbe clinical facts observed, the passage of clota, the paiua attend-
iug tbis, and tbe accumulation of leiicorrbosal fluid in the uteroB
obaervsble in such cases, amply showed the eiiatenoe of obstruc-
tion. This virtual obstruction was often produced by the
swollen, congested condition of the uterine tiasuee resulting
from the flexion.
Dr. Heematt said tbat Mr. Crriffith's specimen did not in bia
(Dr. Herman's) mind furnish proof of the mechanical theory of
the production of dysmenorrboia by flexion of the uterus. There
was no angle in tbe canal ; it was bent in a curve, and there
was no obstruction, tbe canal being, as Mr. Griffitb had said,
rather larger than usual. Dilatntion of tbe uterua was met with
without flexion of the uterus, and therefore, unleaa it were main,
taiued that flexion prevented dilatation of the uterus, there was
no reason why it should not occur with flexiou. Besidea, thia
uterus was adherent, and there were coses, which be bad quoted
in a paper read before the Society last year, which gave aome
reason for thinking tbat when tbe uterus was adherent and
flexed, its canal might become blocked. But, as he had said in
that paper, because a uterus fixed as well as bent became dilated,
it did not follow that beojling of a uterua which waa free to
would produce tbe same effect.
Dr. Bantocs desired to expresa his satiafactton at finding bis
views BO remarkably confirmed by tbe specimen exhibited. He
had loD^ contended that flexion alone of the uterus did not
neceaaanly produce pain at the coaunencement of menstrnation
4
4
4
EXTIRPAnOM OP CTEElT8j ETC. 9
— the most severe pain of dysmeaorrhcea ; that this pain was
absent when the caual was of large calibre ; that conatriction of
the internal oa waa the chief factor in the production of this
' form of djsmenorrhcea ; that the flexion was so frequently the
cause oE this constriction that it might be regarded as at least
the indirect cause of the dysmenorrbcea ; that enlargement of
the uterine cavity vaa an invariable result of the (ante) flexion,
and that in this we found the eiplanation of the pain occurring
towards the termination of the period. All these points were
illustrated in the apecimen. He thought the viewa of those who
adopted the " mechanical theory " were not sufficiently repre-
sented when the flexion alone waa kept in view. It waa certainly
so in bia case.
Mr. Geiffitu observed, in answer to Dr. Routh, that a micro-
scopical examination of the mucous membrane of the uterua had
been made by Mr. Bowlby, and that it presented only the
characters commonly met with at the termination of menstrua-
tion. This was in accordance with the history of the case.
CASE OF EXTIRPATION OF UTERUS AND APPEN-
DAGES FOR EPITHELIOMA OF THE CAVITY.
By J. Knowsley Thobnton, M.B., CM.
eDBQBOK TO TEB BAMABITAH HOSPITAI. tOB WOKBH.
I
i
The operations for extirpation of the cancerous uterua
are still on their trial, and it is therefore a. duty to report
every case in detail. I fear this is not as yet sufficiently
recognised by those members of the profession who have
performed these operations. Many cases have been reported
at the time of operation, and then no more has been heard
of them, at least in the medical journals, or at the societies ;
one has been referred to as a success by a well-known
surgeon in a published paper, without the operator thinking
it necessary to contradict the misstatement, though the
patient died within a day or two of the opei-ation ; others
have been reported when immediately successful, but have
died within a few months of recurrence of the disease,
without any public statement of the fact. This reticence
JO
EXTIRPATION OP UTERUS AND AFPBHDAOSS
on the part of the operators in this countrjj points, I thiafe; j
too sorely to the fact that the operation is rarely an imme-< '
diatcly successful one, and when it is, gives bat a Bhorf ^
interval before fatal recurrence of the disease.
I think anyone who carefully studies the past history of
uterine cancer, in all its forms, must come to the conclusion
that speedy recurrence is likely to be the rale, rather than
the exception, because from the uatm-e of the organ and
ita relations to neighbouring parts it is impossible, in the
vast majority of cases, to cut sufficiently wide of the disease
to avoid infiltrated tissue. I do not refer to tissue infil-
trated palpably, to such rough guides as touch and sight,
but to that which the microscope would show to be affected.
So strongly have I felt the truth of these theoretical
objections to the operation, especially in the commoner
forms of disease which attack the vaginal portion of the
uterus, that I have refused over and over again to operate
in cases sent to me aa suitable for operation. When it
was first revived by Freund, I did in one case consent to
operate for epithelial cancer of the cervix, but after further
consultation the patient decided against operation, and I feel
sure that I was wrong and that she was well advised.
The cases which have always seemed to mo to be the
only cases in which the operation is justifiable, are those in
which tho disease is confined to the mucous membrane in
the cavity of the uterus or to the uterine wall. These cases
are, however, i-arely to be diagnosed with sufficient cer-
tainty before the glands are affected or the surrounding
tissues, so as to cause some fixing of the organ. The case
I am about to relate was one of the rare exceptions to the.
general rule.
In October of this year, I saw with Dr. Matthews Duncan,
a widow lady, aged sixty-four, with the following history : —
Married at twenty-seven and confined prematurely within,
one year, while travelling abroad. Never again pregnant.
Husband paralysed within two years of marriage, and the
patient nursing and tending him for twenty years, then,
seventeen years a widow.
POH EPITHELIOUA OF THE CAVITY.
U
The menscH appeared first when she was fifteen. Tlia
menopause occurred without special trouble about fifty, and
nearly ten years later while travelling on the continent aha
again became unwell, and metrostaxis recurred at irregular
interrals. In the autumn of 1880, she consulted Dr.
Christian Budd, of North Pawton, and he found a little
warty growth on the os, and twice cauterised it with nitrio
acid, this gave temporary relief, but the coloured discharge
recurring he advised her to go to London, and in July, 1881,
she passed under the care of Dr. Matthews Duncan, who
fonnd a small pea-sized, shrivelled polypus and removed it.
Again she was better for a time, but in July, 1882, she
returned to Dr. Duncan, and he dilated the cervical canal
and found the cavity of the uterus full of soft epithelioma.
He then suggested complete extirpation, and Sir James
Paget having seen the patient in consultation and sanctioned
the operation, I was asked to examine her and if I thought
the case a suitablo one to undertake the operation. I made
a careful examination and fonnd the uterus fairly mobile,
and the general condition o£ the patient such as to warrant
hi hopeful a prognosis as one could give in so serioos a case.
Both Dr. Duncan and myself thoroughly explained to the
patient the great risk, and I do not think that we either of
ns minimised the danger. With generally favorable con-
ditions, two somewhat unfavorable symptoms were present.
The temperature was persistently subnormal, this I have
often noted in cases of malignant disease, and believe to
indicate that the powers of the patient are already lowered
by the local mischief.
The free mobility of the uterus was somewhat interfered
with at its left upper angle. The patient had, however,
some years back, had an attack of peritonitis, and this might
bo a sequel of that illness.
The operation was performed on October 25th, 1882, at
8.30 a.m., in tho presence of Dr. Duncan and Professor
dementi, of Catania, Dr. Champneys kindly giving the
Bneesthetic and Mr. Meredith assisting.
The patient wae first placed in the lithotomy position.
12 IJTIBPATION 0? UTBBU9 AND APPEMDAGEa
and the vagina thoroughly cleansed with carboUaed water,
and the cervical canal packed with pieces of sponge dipped
into tincture of iodine, in the hope that any fluid which was
fittorwards during manipulation squeezed out of the uterus
would be rendered aseptic. I was prepared either to
remove the organ by the vagina or by abdominal section,
but decided in favour of the latter procedure, being chiefly
guided by the consideration that Schroeder in his remark-
ably auccessful serioa of vaginal extirpations has found it
advisable to leave the ovaries and tubes. If they are
removed the broad ligament stumps are too short and the
ligatures apt to slip. In the last report I have seen of hia
practice he had had eight cases with only one death, and
this occurred from haimorrhage due to slipping ot one of
the broad ligament ligatures. But to leave the tubes in a
case of cancer of the lining membrane of the uterus seema
to me a partial operation of a kind which is not justified by
the pathology of the disease. As it turned out in the case
under discussion, it would have been quite impossible to
remove tho left tube and ovary by the vaginal operation, as
the tube was closed at its fimbriated extremity by adhesions
to the aide of the pelvis, and was cystic and much shortened.
It was this condition which caused the impaired mobility
ot the uterus on the left side noted before the operation by
Dr. Duncan.
The patient was placed in the ovariotomy position, and
the abdomen opened in the median line by a six-inch
iucision, the parietes were very fat and there was some
difiBculty in entering the peritoneum, owing to the adhesion
of B fat omentum to the parietes along the whole of the
right side of the abdomen. Doubtless this had been caused
W thv inflammatory attack which sealed and caused adhesion
tf ihf left tube. In order to avoid the passage of any of
^tt Hiiid from the Cavity of the uterus into the peritoneum,
I did uot transfix the organ with a string, or have it held
)t^ I'.v « vulsvtlum, and this added to the difBculty in traus-
ItAiug tuU tying the broad ligaments. I was much aided,
iMt'fMV*^ bjr K wiggestion of Dr. Duncan's, which he kindly
FOR EPITHELIOMA OF THE CAVITV.
13
put into practice, viz. the insertion and inflation of a large
robber ball in the rectum.
The left broad ligament was first transfixed with a double
No. S silk (as in oophorectomy), the upper ligature, locked
■with the lower, was tied so as to include the spermatic
artery ; the lower ligature was then threaded again with a
third and carried through the broad ligament, the middle
loop being tied so as to include the pampiniform plexus,
and the third being left Jooae for tying the uterine artery.
The right broad ligament was treated in the same way.
The upper margin of the bladder being defined by the
introduction of a sound, a transverse cut, about two inches
long, was made through the peritoneal covering of the
ateras, and the two organs were separated by enucleation
with the finger down to the vagina. More hsemorrhage
took place during this procedure than at any other part of
the operation, but it was chiefly venous oozing and soon
ceased. The opening into the vagina wa^ made by the
introduction of sciasora with my right hand, cutting against
my left in the abdomen ; this I found the most troublesome
part of the operation, chiefly, I think, from the uterus not
being held up and fixed. I enlarged this opening laterally,
partly with scissora and partly by tearing, till I was close
to the uterine arteries on each side, and then I incised the
peritoneal covering of the back of the uterus, and enu-
cleating down to the vagina in such a way as to push back
the ureters, I cut into the vagina in this situation. At this
etage of the operation the ovaries and tubes were removed
and the broad ligaments divided down on each side to the
situation of the uterine arteries. The middle loop on the
left side immediately slipped off, the space being so very
short for cutting between the uterus and side of pelvis, but
I managed to secure the broad ligament without any
troublesome htemorrhage. The uterus was now merely
held by the small portions of broad ligament and vagina,
left to avoid cutting the uterine arteries, and the loose
ligatures on each side having been tied, the organ was cut
away. By thia time all haemorrhage of any moment had
10 ESTIHPATION of TTTEIirs, ETC.
be rendered more thoroughly aeeptic than eilks passed
through the vagina, and while their weight would tend
to draw the wounded Burfaces together, they would serve
as efficient drains by keeping a clear passage from the
bottom of the pelvis to the vaginal outlet.
Since coming to this decision I have learned that Mr.
Wells, in the new edition o£ his work on the ovaries, has
suggested the same method. I had not read this chapter
before performing the operation, or I think I should very
likely have given the suggestion a trial. The avoidance of
ligatured stumps seems to me of the first importance in the
pTeseuce of the very putrid matters usually present in
uterine cancer.
Dr. EoiB thought there was one practical point worthy of
notice, and that vss in cases where the abdotnmal operation it
performed, after ligaturing and dividing the several structures,
to remove the uterus per vaginam, so sb to avoid the smallest
risli of any malienant secretion from the uterus gaining entrance
to the peritoneal cavity.
Br. Baktock had extirpated the uterus tivice, once by the
abdominal section and once by the vagina. Of the first the
details nere given at sufficient length before the Boyal Medical
and Chirurgical Society. Of the other nothing has been pub-
lished. Both were fatal, from the difliculty of securing eiEcient
drainage and preventing an accumulation in Douglas's pouch.
He desired to point out that when the operation was done by
abdominal section it was much facilitated by flrat dividing the
mucous membrane of the vagina around the cervix, aa practised
by Freund.
Dr. AvELiKO said he believed the first proposal of pelvic
drainage was made by Dr. K. W. JohnsoD, in hia 'System of
Midwifery,' published in 1769. He writes, " Could an aperture
be made with safety at the bottom of the pelvis when hysterotomy
is performed, in order to give vent to those humours, the proba-
bility of the mother's recovery would then I think be greater,"
The President had taken part in three excisions of the uterus
for cancer. All proved fatal. lie was struck with the greater
facility of the operation per vaginam than that by laparotomy.
ANNUAL MEETING.
Februabv 7th, 1883.
J. Matthews DnNCAN, M.D., F.R.S. Ed., President, in the
Chair.
Present — 68 Fellows and 5 Tisitors.
On taking the chair the Pkesident declared the ballot
open for one hour, and nominated Dr. A. T. Gibbinga and
Mr. Hopkins Walters as scrutineers.
Books were presented by Dr, Barnes, Dr. Fancourt
Barnes, Dr. Matthews Duncan, and by the Royal Medical
and Chirurgical Society.
Wm. Augustus Bonney, M.D.; Wm, Coates, M.R.C.S.;
Wtn. Archdeckne Duncan, M,D. ; Joseph William Hunt,
M.D.; William John Pook, L.R.C.P.; Francis J. R.
Russell, L.K.Q.C.P. ; and Edward Sabine Tait, M.B.,
were admitted Fellows of the Society ; and the following
gentlemen were declared admitted : — Christopher Childs,
M.A., M.B. Oion, (Weymouth) ; Edward Clapham, M.D.
(Wimbledon) ; James J. Reynolds, L.R.C.P. (Portland) ;
W, Cairns Wicks, M,B. (Newcastle-on-Tyne).
The following gentlemen were elected Fellows of thfl
Society ; — Charles Davidson, M.R.C.S. Eug., and Philip
William Gowlett Nonn, L.R.C.P. Lond. (Bouruemouthl
VOL. XXT. 2
18
EPITHELtOHA OV CHHVIX.
Tho following gontlemea were proposed for election : — |
Baberm Buksli, M.R.C.S. Eng. j Patrick John Cren
II.D. (Cork) ; Henry Eoxburgli Fuller, M.A. Cantab., I
M.R.C.S.Eng.; Theophilua Hoskin, L.E.C.P. ; Percy S.
Jakins, M.R.C.S. Eng. ; Robert Edward luman, M.R.C.S., ]
Eng. ; and Ricliard Unthank Wallacej M.B. Loud.
Mr, Geifpith showed a specimen of retro-uterine peri- ]
metric abscess due to tbe opening into Douglas's pouch
of one of a number of rectal fistulEe, and remarked that |
one would have expected that the result of sucli a per-
foration would have been the development of acute i
general peritonitis rather than the formation of a chronic |
abscess limited to parts of the pouch. Ho bronght I
forward tbo specimen because it illustrated a cause of I
these abscesses not previously described.
EPITHELIOMA OF CERVIX, REMOVED BY ECRA-
SEUR WIRE DURING PREGNANCY WITHOUT j
CAUSING ABORTION.
By Cleitekt Godson, M.D.
B. C — , ajt. 35j a monthly nurse, married eighteen J
years, no children, but two miscarriages, the last six-j
years ago, was admitted into St. Bartholomew's Hospital T
on July 17th, 1882, under the care of Dr. Matthews 1
Duncan.
Catamenia commenced at fifteen years of age, and J
always regular since, except during her two short preg- J
nancies, the last occurrence a month ago.
Complains of yellow discharge for the last twelve 1
months. During tho last few weeks it has altered its J
character, being more watery and foetid. There hBal
been lately an occasional slight loss of blood between the j
EPITHELIOMA OP CEHVIX,
19
^H periods ; three -weeks ago there was a good deal of
^H bleeding following coitus.
^H Has uo pain except occasional sharp twinges in the
^H lower abdomen and back lately. Has been a healthy
^M woman, and there is no family history of phthisis or
^V carcinoma.
^H Dr. Matthews Duncan's e.eavunntion, — "Per kypogas-
^H trinin. — Nothing abnormal. Vulva healthy.
^1 Per vaginam. — Cervix enlarged, tuberous, and ulcerated,
^B bleeds easily, fills the end of a pretty largo specnlum.
^H Vagina healthy. Uterus mobile."
^H As the monthly period was due within a day or two
^H the operation for removal of the diseased cervix was
^M postponed.
^H July 2oth. — Menstruation commenced last evening,
^H two days late.
^H 29th. — The period ceased yesterday, the loss has not
^H been great.
^H On August lat, in the absence of Dr. Matthews
^H Dnncan, the patient) being an^sthetised with gas and
^^B ether, I passed the wire of an ^crasenr around the cervix
^H ns high as possible, and removed the diseased portion.
^^M Very little bleeding took place. The vagina was syringed
^^M with cold water, and then packed with dry cotton wool.
^V 2nd. — The patient has passed a good night. No pain;
^H no rise of temperature. Plug removed from vagina ; no
^M bleeding.
^M 4th. — No pain, and no discharge of blood.
^H 10th. — Feels well. I examined per vaginam and
B7 noted: — The stump of the anterior lip of the cervix feels
somewhat rough, that uf the posterior lip is smooth ; tho
examination does not give rise to bleeding. Per njwculum.
^^ — The stump of the anterior Hp is of a deep red colour,
^^L and shows slight prominences.
^H One of my clinical clerks remarked that he fancied this
^^K was the posterior lip, as there was a furrow in front of it
^^M which he took to be the os uteri. I explained to him
20 Et'lTRBLIOMA OF CBBVIX.
mucous membrane o£ tbe anterior vaginal fundus from
the amputated cervix, and that tho os uteri was situated
behind, and to demonstrate this I passed the sonnd
through the os, and it entered at ouce the cavity of the
body of the womb.
13tb. — Some htumorrhage occurred yesterday, very
bright coloured ; has had slight pains, intermittent ; the
loss is verj' alight to-day.
14th. — The paiua have increased, and this morning a
fcotus, apparently of about eight weeks' development, waa
expelled ; the placenta followed. All the pains have dis-
appeared since, there is hardly any loss of blood, and she
feels very comfortable.
This case aEforda many points of interest. There waa
nothing to lead us to suspect that she was pregnant.
She had not been so for six years, and she believed herself
to be menstniating regularly. It is true that she went
while iu hospital two days beyond her time, and probably
the loss which then occurred, and continued during three
days, was not menstrual blood, but came from the
ulcerated growth. There is littlo or no doubt that the
abortion waa caused by my having passed the sound
within the womb, for it occurred almost directly after-
wards, and ten days had elapsed after the removal of the
cervix without any sign of aborting.
This is the second time it has happened to me to
amputate a cancerous cervix during pregnancy without
abortion ensuing, in both cases in ignorance that preg-
nancy existed.
The other case is reported in the ' Transactions ' of
this Society for 1875, vol. xvii, p. 32, in s paper by
Dr. Charles T. Savory, communicated by me. This
patient was about five months pregnant when the opera-
tion took place, and she ultimately gave birth to a living
child after a very rapid labour.
Dr. Herman, in his admirable and exhaustive paper
on " The Treatment of Pregnancy complicated with Can-
cerous Disease of the Genital Canal," in vol. xx of t
EPITHELIOMA OP CEBVII. 21
'TransactioESj' p. 223, quotes ten cases in whicli tlie dis-
eased part was removed duriug pregnancy, in only one out
of these was the operation immediately followed by abor-
tion, and five out of the ten were delivered at full term,
Tlie case I am now reporting is therefore one more in
support of the conclusions which Dr. Herman has arrived
at, and with which I fully concur, viz. "that the diseased
pUrt may be removed during pregnancy without any great
risk of inducing abortion, and thai the removal of it
during pregnancy ia not much, if at all, more dangerous
than in the non-pregnant condition,"
Therefore, if at any stage of pregnancy a canceroas
growth of the cervix which is capable of being removed
be detected, there seems no doubt that the operation
Bfaould be undertaken without delay, and the idea of
abortion or premature labour ensuing should not be taken
into consideration.
This case supports Cohn stein's theory that cancer
rather favours the occurrence of pregnancy, for this
patient had not been pregnant for six years, and she
would not believe that she had aborted until I told her I
had seen the foetus. This is a theory I have long enter-
tained and taught ; and until now, when reading Dr.
Herman's paper, I did not know that anyone had
advanced it.
The case is an example also of what I am pointing out
on almost every day that I see the out-patients at St.
Bartholomew's Hospital, that this disease appears to
attack those who have previously been the healthiest of
women, in whose family no history of cancer can be
found, and who have not been subject to leucorrhcea or
have ever before been under treatment for any uterine
complaint.
This case also supports the observation I made in the
discussion upon Dr. Champneya' excellent paper on "The
Pain in Pelvic Cancer," that this is, as a rule, in cases of
cancerous disease of the neck of the womb, a late sym-
ptom. Ever since this paper was read, now three years,
22 EPITHEUOUA 0? CBBriX.
I have not seen a ease of the kind without carefully inves-
tigating this point, and it is rare for thore not to bo one
or two cases at each of my visits to the hospital ; and I
have been more than ever astonished at the extent to
which the disease may affect the cervix without any pain
whatever being felt. I Iiope before very long to tabulate
these cases and bring them before the Society.
I notice in Dr. Herman's paper that in several of the
cases he has recorded the pouch oE Douglas was opened,
during the operation, by the wire of the ecraseur. I
know also of several instances in which this has occurred.
I could not say how many times I have performed tliis
amputation, but it is a very large number, and this
accident hae never happened to me ; I foel certain,
because I never pull down tho cervix, 1 always keep the
end of the Ecraseur pushed well up in front of the cervix.
It seems only natural that if the cervix be pulled down a
portion of Douglas' pouch descends with it, and very
readily is included in the loop of the wire. Whereas, I
believe it is impossible to catch it if the cervix is pushed
up while the wire is being tightened around it.
Dr. RoiTTn stated that a practical deduction might be drawn
from Dr. GodBon's paper. If it was the fact that a cervix uteri
could be taken off by the licraseur without inducing abortion, then
in some of those casea in which cancer coexisted with advanced
jiregnancy, this operation might bo performed before labour
commenced, and possibly brought on prematurely, and the life
of child and mother saved without the risk of a probable
Ciesarian section. He had before mentioned a case which he
saw in Vienna, when at the full term a woman was in labour,
and the whole cervix caine away as a ring before the child. The
Ecraseur would thus only.be imitating nature, but we could select
the most favorable time.
Dr. Platfaib said that there were several points of great
interest recorded in Dr. Godson's communication on which he
would venture to offer a few remarks. In the first place, he
would observe that he could not agree with him in his state-
ment that epithelioma was most apt to occur in a perfectly
healthy cervix. So far as his own eijterience went, and he believed
it was corroborated by the writings of others, epithelioma gene-
rally commenced in a cervix that was in an unhealthy Etat«. For
1^1^
I
EriTHEtlOMA OF CBBVIS. 23
example, mauy American writers bad pointed out that it was
special!; a.pt to engraft itself ou a cervix that had been laceratecl
in previous labours, and be bad bimself observed several inetances
of this. At the same time he stated this as bis impression only ;
and it would require many carof ul oLservations before this point
could Ije positively decided. With regard to epithelioma com-
plicating pregnancy, there was one point of clinical interest with
regard to it to which Dr. Godson bad not alluded, and that was
the extreme rapidity with which malignant disease was apt to
increase during pregnancy. This was probably the result of the
increased vital activity of the uterine organs durbg gestation.
The President would probably recollect the case of a lady whom
he had been kind enough to attend during his (Dr. Playfair's)
absence from London two years ago. He bad had an opportunity
o£ watching the extremely rapid progress of the disease, and this
was so rapid that Dr. Duncan and Sir Spencer Wells, who had
seen the case with him, bad given it as their opinion that six
weeks or so would probably terminate the patient's BufleriDgs.
As soon as pr^nancy was ended by spontaneous abortion, the
disease ceased to advance as before, and this patient was still
alive. The last point be would refer to was the use of the cera-
seur for removing epithelioma of the cervix ; although this was
the eatabUshed practice, he believed it to be the worst way o£
dealing with the disease, for while it shaved off the sprouting
mass of epithelioma it left its base infiltrated with cancer cells,
from which a fresh outbreak of disease was sure to recur before
long. Such a procedure could only be looked on as a temporary
palliation of tbe more prominent symptoms, Putting aside the
question, then gtihjudice, of the entire removal of the uterus, bo
believed the only satisfactory operation for epithelioma of the
cervix was that practised by Marion Sims, which consisted in the
excision of the mass by knife and scissors, and the subsequent
application of chloride of zinc to destroy the infiltrated tissues of
the cervix. He bad done this repeatedly, and had several jatients
now alive and well, a considemble time after operation. Only
the day before be had seen a lady on whom be haii operated two
and a half years ago. She then bad a large sprouting epitheli-
oma filling the vagina, and now she is perfectly strong and in
robust health.
Dr. Hebmam thought it required a great deal of evidence to
show that cancer of the cervix favoured conception. He thought
that if it were so, pregnancy with cancer of the cervix would
be much commoner than it was. He did not think he exag-
gerated when be said be bad seen hundreds of cases of cancer of
the cervix in married women during the child-bearing ages, but
he bad only seen five complicated with pregnancy. If cancer
favoured the occurrence of pregnancy he thought he would have
2i
EPITHELIOMA 0» CKEVIX,
seen more cases of that complication. He had amputated the
cervix with the galTanic cautery, and thought that this instru-
ment did mora than remove a thin slice. It not only cut through
the cervii, but burnt the tisaues on each side for some little dis-
tauee £rom the line of division, Thia could be inferred from the
fact that the atump left wa« usually slightly funnel shaped, and
the piece removed was smaller after removal than it looked when
the wire was adjiiated before cutting through the cervix. He
avoided pulling down the cervix. In cases of cancer the enlarge-
ment of the cervix commonly prevented the wire from slipping
down when it was once passed up over the enlarged part ; but
where the wire had any tendency to slip, it was his practice to
cut with scissors a shallow groove for the wire to lie in, and thus
to secure its remaining in the desired position,
Dr. HooEBS said he had many years back brought to the
Society the neck of a uterus which had separated during a long
protracted labour from a Oerman lady. The child lived, and the
uterus, on being examined some months after, what remained of
neck was found iu a hardened atate. He subsequently lost sight
o£ the case. That abortion may follow amputation of a. cancerous
cervix was proved about twoyears back in a case admitted under
his care in the Saniarilan Hospital for repeated faeemorrhage.
The cervix was found to be a mass of epithelioma, bleeding on the
least touch, and the uterus was loi^e. When questioned she
strongly denied being pregnant, or that it could possibly be the
case. The cervix was removed by the electric wire cautery with
greatest precaution, yet severe hiemorrbage followed the ampu-
tation, checked by plugging with cotton wool and styptics. Three
days after bearing-down pains set in, and she aborted of a fcstus
about the fourth month, but would not believe this till it was
shown her ; no sound had been passed into uterus. Dr. Sogers
felt certain that Douglas's space might be opened into, notwith-
standing every possible care and without any traction being used ;
one such case nad occui-red in his practice, but no difficulty
occurred in its management.
Dr. Edis thought there was one point of great practical impor-
tance in cases of epithelioma of the cervix uteri, and that was the
early diagnosis of the disease, If any suspicion existed as to the
nature of the case when first seen, a second opinion should at
once be procured, and not allow the patient to go on unrelieved
until the disease became so marked as to prevent any error in
diagnosis, at the same time to preclude any idea of radical
treatment.
I
Annual Meetinq.
The Report of the Treasurer, Dr. Potter, with the
audited baUnce sheet, was then read.
It wna moved by Dr. Routh, aud seconded by Dr.
Daly, " That the audited report of the Treasurer just
read be received, adopted, and printed in the next volume
of the ' Transactions.' "
The Heport of the Hon. Librarian, Dr. Champneys, was
then read, and ita adoption was moved by Dr, John
Williams, eecooded by Mr. Fbedbbiok AYallace, aud
carried unanimously.
Report of the Honorary Lihrariaii.
I have the honour to present to the Society the usual
annual report.
The Library has been as freely used by Fellows in the
paat as in former years, and with the increase of its size
it is believed that its usefulness has increased also.
The limited space available in the present rooms,
together with the near proximity of other medical libraries,
have, aa hitherto, guided the Library Committee in the
choice of books recommended for purchase by the Society ;
but they have, on the other hand, endeavoured to acquire
each work of importance bearing on Obstetrics or Gynaa-
cology as it has appeared, and thus to make the Library
as complete as possible.
A provisional alteration in the Library hours on
Saturdays has proved a great convenience to the Snb-
Librarian, and appears to have caused no trouble to the
Fellows.
At the end of the year 1881 the Library consisted of
3056 volumes. Daring 1882 this number has been
26 BAUnCE-SHeET. ^^^1
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~ifl
EXAMINATION OP MIDWIVEB,
27
increased by the gift of 33 books and 41 pamphlets, the
latter being bound into 4 volumes, or a total o£ 37
Tolnmes, The Society has bought 20 books and 10
pamphlets, the latter being bound into 1 volume, making
21 volumes. The periodicale taken in amount to 46, this
makes a grand total of 31<30 volumes as against 3056 last
year.
Fbancis Henby Csaupneys.
The Keport of tho Chairman of the Board for the
Examination of Midwives was then read, audits reception,
and a vote of thanks to Dr. Aveliug and the other
Members of the Board, was moved by Dr. Edib, and
seconded by Dr. Cabtee, and was carried with applause.
The Examination of Midwives.
Tho Board of Examiners appointed by the Council of
this Society again presents its Annual Report. During the
past year forty -two candidates offered tUem selves for
psaminatiou. Of this number thirty-seven received fho
Society's diploma and five failed to satisfy tho Examiners.
The Board has now entered upon tho twelfth year of its
existence. Since its establishment it has been called
together about ninety times. It has examined 162 candi-
dates and admitted 145. This number represents about
1 per cent, of the women practising as midwives in
England and Wales. It is painfully evident, therefore,
that the honorary labour and saciifice of time which the
members of the Board have so cheerfully bestowed in
endeavouring to ameliorate the present condition of mid-
wives have had practically very little effect in consummating
the laudable intentions of the Society, Thousands of
women are still acting as midwivos who have no competent
knowledge of their calling. The Urea of mothers and
their infants are in constant jeopardy. Deplorable acci-
dents and mutilations occurring to women in childbirth
OrnCBBB AND COUNCIL.
iritj, and ^^^^
is related I
are recorded by tbe press with sickening regularity,
but a few meetings since a shocking instance was
bofore this Society in which the whole womb and part of
its appendages had been torn away by a woman calling
herself a midwife.
The Board of Esaminere, therefore, once more venturea
to urge upon the Council the pressing necessity which
exists for legislation providing for the instruction, licena- ■
ingj and registration of midwivesj and rendering it penal
for ignorant women to call themselves midwivea unless
they are legally licensed and registered by Act of
Parliament.
J. H. AvELiNO, M.D,,
Chairman of the Board for Ihe Examination of Midwivea.
The Scrutineers retired, and on their return the result
of the ballot for officers and council for the ensuing year
was declared as follows :
Sonorairy President. — Arthur Farre, M.D., F.R.S.
President. — Henry Gervis, M.D.
Vice-Presidents. — John Brunton, M.D. ; Frederick H.
Daly, M.D. ; Clement Godson, M.D. ; Jonathan Hatchin'
son, F.R.C.S.; John Thorburn, M.D. (Manchester);
J. Lucas Worship (Sevenoaks).
Treasurer. — John Baptiste Potter, M.D,
Bonorary Secretaries. — Alfi-ed Lewis Galabin, M.A.,
M.D. ; George Ernest Herman, M.B.
Honorary Librarian. — Francis Henry Champneys, M.A.,
M.B.
Honorary Memhers of Council. — Henry Oldham, M.D,
{Past Prcs. and Trustee) ; Robert Barnes, M.D. (Past
Pres. and Trnatee) ; John Hall Davis, M.D, ; Graily
Hewitt, M.D. ; John Braxton Hicks, M.D,, F.R.S. ;
William 0. Priestley, M.D. ; Edward John Tilt, M.D. ;
Sir Thos. Spencer Wells, Bart., F.R.C.S. {Trustee) ; J.
Matthews Duncan, M.D., F.R.S. Ed.
Other Mevtbera of Council.— ^enry Charles Andrews,
ahkhal ASDBEsa. 29
M,D, ; George Paddock Bate, M.D. ; Henry Bennet,
M.D. (Weybridge) ; Peter Lodivick Bnrchell, M.B. ;
T. Edmoudstoune Charles, M.D. (Cannes) ; Chas. J.
Cullingworth (Manchester); Alban Doran; Sir Joseph
Fayrer, M.D., K.C.S.I. ; Edward Malins, M.D. (Birming-
ham) ; Gostavus Charles P. Murray, M.D. ; William S.
Playfair, M.D. ; Walter Rigden ; George Roper, M.D. ;
William Stephenson, M.D. (Aberdeen) ; William Heath
Strange, M.D. ; John Knowsley Thornton, M.B., CM. ;
John Wallace, M.D. (Liverpool) ; George Eagene Yarrow,
M.D.
The Peebidbnt then delivered his Annual Address.
ANNUAL ADDRESS.
Gentleueit, — At this annual meeting, as at the last, I
have to congratulate the Society on continued prosperity.
Our library has been increased by the addition of lO-l
volumes, making 3160 in all. 42 women have been
subjected to the midwifery examination, and of these
37 have passed. Our fluctuating membership stands at
present (January) at the large figure of C94. Of these 37
have joined the Society during the year; and in the
same period 15 have resigned their Fellowship, and the
names of 24 have been erased from our list. Wc have
lost 8 by death ; Mr. John Sutcliffe, of Denmark Hill ; Mr.
Robert Charles Croft, of Camden road ; Dr. George Yeatos,
ofWalthamstow; Dr. Frederick John Butler, of Winchester;
Dr. Marshall; M.P. Dean ofKeene, Ontario; Mr. Frederick
George Wliite, of Exeter ; Mr. Alfred Boyd Hopkins, of
Shoreditch ; and Dr. Richard Cross, of Scarborough.
Dr. Richard Cross was a highly respected citizen and
esteemed practitioner in Scarborough. In the ' Medical
Times and Gazette ' I find that after studying at Guy's
Hospital he became, in 1639, a Licentiate of the Society of
Apothecaries, subsequently in 1840 a member of the
30 ANNUAL ADDRESS.
Boyal College of Surgeons, and M.D. of St. Andrews in I
1852. In 18(39 lie contributed to the ' Lancet' a table o{%
obstetrical studies. He lield several medical appointmente,
and was Mayor of the borough iu 1860-1. Ho died on
Not. 19th, 1882, and was interred with military honoin's,
the magistrates, Mayor and Corporation, attending the
funeral.
Dr. Frederick Jolm Batler, son of the Vicar of Empshot
was born March 2lBt, 1819, and died March 16th, 1882.
He was a student of Guy's Hospital, a member of the
Royal College of Surgeons 1840, and Fellow by examina-
tion in 1849 ; he waa also a Licentiate of the Society of
Apothocanes and M.D. of St. Andrews. He was machd
respected, largely employed in practice, held numerous J
appointments ; and at his funeral there attended the adju* f
tant and permanent staff of the 3rd Hampshire Militia]
Regiment.
Besides a large number of very valuable oral communi- 1
cations with specimens, we have had read at our meetingal
twenty papers, most of which will appear in our 'Transac-l
fions.' Of these the half has been obstetrical and thgl
other half gynieco logical. The obstetrical papers include J
Thornton on " A case of Extra-uterine Foetation witlil
hypertrophy of Placentasuccessfully treated by Abdominal 1
Section," Popow on "Corpus Lnteum," Champneya on I
"Obliquely Contracted Peh-iswiih Unilateral Synostosis;'
and again Champneys on "A Kyphotic Pekis," Duncaul
on " Puerperal Diabetes," Cliahbazian on " The TrcatmenfrB
of Post-partnm Htemorrhage by Ergotinine," Wynn'B
Williams on " A Now Mode of Operating for Euptured.l
Perineum," Edis on " Cancer of the Cervix obstructing J
Labour ; Cfesarian Section, Recovery ;" Herraan onf
"Two Cases of Cancer of Cervix obstructing Labour,"!
and Jennings on "Transfusion." The gj^nrecologicall
papers are Galabin on " Unilateral HKmatometi-a,"^
Playfair on " Tracbeloi-aphy," Braithw'aite on " Two!
Cases of Unilateral Vaginal Oophorectomy," John WilHamg I
on " The Natural History of Djsmenorrhoaa," Herman J
OQ "Tfae Belaikn of BMknrl
Uterus to 1
tarn in tlie ''
Imperforate HymeB," Swmjne oa '
Pessary," Griffitli tm" A.i
ThorctoQ OD " A Chae of
Uterus."
During the Sesrian cAjrt baa bees made to cUhb lar
the Society new moBB, &r it kaa lieaa b^ Mt tkat oar
library accommodatioB ooata too bo^ aod tkafc it vooU
be an adrantage to bare oar iBii<iii|^ bill and fibnij n
doaa proximity to one aaotber. In tbia naUor we o«»
much to oar Scaiior Saaormrj Suiii.'laij, wbo baa tfa n d
no pains in the oondoet <rf tbe bamiega ; bat oar fint
efforts bave proved Tain. Sinee tbeae orig in al ttt-nwirtn
with St. Peter's Hospital as a whc^ qnite recently indeed,
we have taken new premiaea for tbe library, being the
first floor of what was St. Peter's Hospital. Here we hare,
next door to the hall in which our meetings are held,
ample library accommodation. The new apartments are
larger, more comniodioas, and in erery way better than oar
present rooms and will co^ as much less. We may con-
gratalate oarselres on this change, and in the name of the
Society I may thank Dr. Galabin and the other members
of the Committee appointed to look after this part of onr
affairs, for the seal they have exhibited, and for the success
which has attended their wisely directed efforts.
This great Society has maoy functions to fulfil, and of
these not the least important is a moral one, which gets
little place in onr Btatement of " objects," and which has,
for two years, occupied no part of oar time. On, happily,
very rare and extraordinary occasions the Society may be
called upon to censure and even expel a Fellow, thus ex-
ercising moral discipline in a decided manner; bnt it
wisely avoids discussion of such matter, and keeps within
very narrow limits the direct exercise of control over its
members, leaving this branch of medical police to the
CuUoges of Physiciaus and of Surgeons, who have long
32 A^KNnlT. ADDRBBB.
taken ctarge of it. But eilonee does not indicate forget-
fulneas or low ostimation ; and our active juridical inter-
ference, concerned as it has been only with minor disorders
in individuals, givea no iudication of the aupromo import-
ance of our moral iutoreata as a Society. In no way can
we, or do we, do more good than, by increasing and diffu-
sing a kindly spirit and mutual goodwill in our ranks.
Nothing contributes more to our dignity and our euccesB
than sense o£ honour and lovo of truth. By promoting
science we increase the weight and power of truth. With-
out high moral qualities in the practitioner — qualities of
heart and of head — the work he does will all be tainted
by his imperfections, and correspondingly fall short in its
utility to his patients, his profession, and to himself. The
intellect may be stored, the judgment may be sound,
the hands may be skilful ; yet the work does not reach
nn attainable degree of perfection if the heart is not
right.
The promotion of science is avowedly onr great ohject,
and accordingly it is our chief performance. The work
has been done in previously announced papers and in
casual contributions. Of these, some have been purely
scientific, or in the view of the mere practical man appa-
rently useless ; some have been more or less practical or
immediately useful, or intended to be so. We want still
a great increase of the at first sight useless kind, and we
shall hold it the best evidence of the progress of the
Society that they appear and are cordially received. A
great master of medical method, Helmholtz, has said that
he who pursues science with practical results in view will
pursue in vain. The papers combining practical ends
with scientific elaboration have been admirable, and must
be useful aud honorable to us. This Society will always
regard such papers as deserving of encouragement, but
they need no Epecial fostering care, for the fruits of their
application in practice are a sufficient stimulus, sometimes
more than sufficient. The more this kind of utility is
paramount, the less is scientific severity, and the greater
AHNDAL ADDRESS. 32a
tbe departure from the guidance of logic, and consequently
tLe less reliability, A great result, indeed, of our scien-
tific work has teen to show us what we should not expect
to bo able to do, and what we should avoid attempting or
doing.
Besides scientific and mixed scientific and practical
papers, we have bad before ns proposals purely therapeu-
tical, and several histories of splendid work in practice.
The surgical achievements which find place in our ' Trans-
actions ' are as brilliant and wonderful and successful aa
any to be found in the history of the art. They show
what skill guided by science can dare and do, and the
novel operations contribote in this and other ways to the
solution of important practical problems. That a thing
can be done successfully ia not enough, however, to show
that it should be done. It ia not judicious to excise the
uterus in elderly women in order to prevent cancer of it.
For myself, I have no doubt that the novel operations or
series of them which have, in last scasion, been laid before
OB, will not be, in any sense, without good fruit, helping
towards a sound judgment as to the extent or the limits of
their applicability.
It is natural that the ingenious and bold surgeons who
devise and execute now operations should press them
strongly upon the profession, demanding quick approval,
and it ia to be lamented that they should bomelimes mis-
construe the relative slowness or silence of their brethren,
Were new therapeutical proposals to be quitkly adopted,
our whole practice would, by their number and variety,
be bronght into utter confusion. The silence or slownee*
of the profession regarding them is a kind and useful
reception, for nothing more violent is required to aecure
for most of them speedy oblivion ; while the stronger and
better few, Burviving.demonstrate their merits and demerita,
and secnre or lose a place in Medicine. By slowness and
silence, even with some active depreciation, the profession
obtains the best results, and this without any unnecessary
delay. The use and acceptation of a new and good operation
S2b annfiai. addruss,
has never been a simple proposal and jubilant reception
and Bhould not be ; the whole matter must have time to
ripen, anJ the special operation must exhibit plainly ita
qualities — what it can do, measured against what the
corresponding disease does. Sometimes, aa when ths
isBue of disease, not cancerous, is in all cases, or nearly
all, certain early death, the problem to be solved is a com-
paratively ejisy one : death for all versus a certain amount
of cure. But when there is uncertainty as to the nature,
difference of opinion as to the importance, or doubts as to
the very existeQce of the disease to be remedied, the pro-
fession does well to be silent and slow. The problem to
be solved is a difficult one; and if the operation puts life
in the balance, there is a heavy responsibility which demands
increased slowness and care.
The history of the operation of ovariotomy is often, one
may say regularly, cited as a warning against silence and
slowness of recognition ; but it is quite otherwise, being
a good example of an operation gradually and in due time
gaining for itself a beneficent position of eminence. That
theoretical and other mistakes were made in opposing it
may be very true ; and theoretical mistakes made in sup-
porting it too. But these neither hastened nor delayed
the adoption of the operation in ordinary practice. Aa
soon as it made a clear and sufficient saving of life it was
accepted enthusiastically everywhere, and not till then;
and we cannot wish a better fate for any similar proposal.
Even now, where there are not skilled ovariotoniista,
ovariotomy is not an accepted operation : the poor
sufferers have life prolonged by avoiding it. !
The proposer of a new operation should not expect Lib
brethren to see it in the same light as he does. For him
it is gilded, and he jealously guards and promoloa it.
His judgment of it is that of an enthusiast. The wise
practitioner may discommend it, or he may abstain from
recommending it ; and the proposer is too ready to inter-
pret this conduct as indicating disapproval of him and his
bold and original method, while it is really quite consi
DRESS. S20
tent with admiratioD, and even encouragement short of
avowed approval. Aa evidence in favour of it gradually
gets Btrength, eo the practitioner at lengtli ia Justified in
making trial of it, and he may at last adopt it ; and his
slowness, differing as it does from the inventor's wishes,
is wise, and not hostile to him.
Proposers of new operations have generally expended
mnch labour, and ofttimes much money, in developing
them ; and the profession should, and does, admire the zeal
and recompense the sacrifice, even though it may reject
the operation. But there is often too much expected by
the zealous proposer, and too little care taken by the critics,
even by those who are essentially kindly, to avoid injury
to the natural sensitiveness of such proposers. Against
these evils we can only urge the force of moral obligations,
which, though possibily too often in the mouth, cannot
be too potent in the heart.
I am not quite sure that enthusiasm alone esplains the
whole peculiarity of attitude of our recent promoters of
novel operative proceedings, for it appears to me to be
fairly deducible from the tenor of their practice and
writings that they do not attach the same value to life as
the profession generally. The spirit of the times has great
influence on such estimates, as is exemplified in many
ohangea in the conduct of statesmen and jurists, in some-
what analogous circumstances ; and it is possible that the
profession generally may be induced to come nearer to the
views of the promoters of special operations. Meantime,
the weight of professional opinion seems to be in favour
of the old high regard of the value of life. There is now
a demand in connection with this matter, for the combined
work of the surgeon and the actuary. Data might surely
be obtained which would be sufficient to settle, approxi-
mately, the value of life in the diseases calling for tooth-
extraction, removing of piles, excision of the mamma,
lithotomy, oophorectomy, ovariotomy, hysterectomy, and
others ; and, on the other hand, the danger of the opera-
tions themselves ; and from the two roi>uHs, viewed in the
AHNtJAL ADDBXSSi
liglit of eatablisted professional practice, might be dednced
a scale of justifiable or of ordinarily incurred risk wbich
might facilitate and corroborate judgment as to the due
proportion of danger in new operations. Already somo
limited computations of this kind hare been made, but
they have been done by special pleaders and are insiiffi*
cient.
A well-conducted inquiry would lead to conclusion a
which might, on the one hand, diminish our estimate of
tho value of life, or increase our estimate of the importance
of mere chronic ailing ; or the inquiry might confirm tho
opinions on these subjects which are at present generally
held. We might thus be able, with great assurance, to
judge whether or not a mortality of one in five or one in
twenty is to be encountei-ed in an operation for tho relief
of mere chronic ailing ; and so on, according to the
gravity of the ailing or the danger to life arising from the
Before leaving the chair, which I have with much plea-
sure to myself occupied for two years, and to which you
have elected a gentleman who is both well known and
highly esteemed, an experienced practitioner, a respected
teacher in a great school, whoso name is familiar to all
who take an interest in our proceedings, I give heartfelt
thanks to the Society. It is a matter of course that I
appreciate fully the honour of presiding over the largest
association ever devoted to the objects which I have
during my life pursued. I also value very greatly your
kind consideration and the uniformly cordial support which
you have afforded me in the performance of mj varioaa
duties.
It was moved by Dr. Potter, seconded by Dr. Cibtb-
LAKD, and carried by acclamation, "That the best thanks
of the Society be given to the retiring President, Dr.
Matthews Duncan, for the eflScient manner in which he
has presided over the meetings of the Society during his
term of office, and that he be requested to allow his
ANNUAL ADDRESS. 82b
interesting address to be printed in the next volume of the
* Transactions/ '*
It was moved by Dr. Aveling, seconded by Dr. James^
and carried unanimously^ ^^ That this meeting desires to
express its best thanks to the retiring Vice-Presidents,
Dr. J. Bassett and Dr. John Williams, and to the other
retiring Members of Council, Dr. Ford Anderson, Dr. 0.
H. Carter, Dr. Lloyd Roberts, Mr. P. W. Salzmann, Dr.
Brodie Sewell, Mr. Edward Taylor, and Mr. Frederick
Wallace."
MARCH 7Te, 1883.
Henry Geevis, M.D., President, in tlie Chair.
Present — 56 Fellows and 9 visitors.
Books were presented by Mr, Alban Doran, Dr. G, B.
Ercolani, Prof. H. Fritscb, Dr. E. Jenks, Dr. E. Noble
Smith, Dr. Valenta, and St. Bartholomew's Hospital.
John Coryton Roberts, L.R.C.P. Edin. (Peckham Rye) ;
was declared admitted a Fellow of the Society.
The following gentlemen were elected Fellows of the
Society :— Raheem Buksh, M.R.CS. Eng. ; Patrick John
Creme'n, M.D. (Cork) ; Henry Roxburgh Fuller, M.R.CS.
Eng. ; Theopbilus Hoskin, L.R.C.P, Load. ; Robert
Edward Inman, M.R.CS. Eng. ; Percy S. Jakinsj
M.R.C.S. Eng. ; Richard Unthank Wallace, M.B.
The following gentlemen were proposed for election : —
Robert John Allen, M.R.CS. Eng. ; John Edwin Cooney,
L.R.C.P. Edin.; John Gordon, M.D. (Now Cross); and
Robert Percy Middlemist, L.R.C.P. Lond.
CAST OF FEMALE BLADDER.
By Dr. J. H. Avelino.
The patient from whom this specimen was obtained
was dehvered of her first child on Sunday, Dec. 4tb, at 2
VOL. nv. 3
34
lSt op pehale blasdxb^
a.tu. The labonr, which had continned for eighteen honra,
was tprminated by forcepa.
On Monday, Tuesday, Wednesday, and Thursday it
was noticed that the urine was not passed properly, that
it dribbled away, and that the abdomen was enlarged.
On Thursday evening a catheter was passed and a qnan-
tity of dai-k, thick, offensive urine drawn. After this the
catheter was used three times a day and warm water and
Condy's fluid injected.
Three weeks after the confinement, something in the
bladder causing obstruction to the flow of urine through
the catheter, the urethra was dilated, when a rush of water
took place and a white membrane appeared at the orifice
of tlie urethra. This was carefully extracted and is now
exhibited. Mr, Sutton, who has kindly examined it for
me, says the exfoliation involves only the mucous mem-
brane, and that ho finds no muscular tissue.
Fortunately these specimens are rare. I believe only
one has been previously shown to the Society by Sir
Spencer Wells in 1861, and with him I may trust that the
" lesson may not be lost."
It is fifteen months now since the patient was confined,
she is pregnant and in fairly good general health. She
has, however, continuous incontinence of urine and a
recto-vaginal fistula, for the cure of which she was sent to
me by Mr. Warren Tay.
Mr. Waltebs (Heading) had seen a somewhat aimilar case.
Ho was called in consultation to a woman four and a half months
advanced in pregnancy, whose uterus had boon retroverted for
four days, with retention of urine. He succeeded in replacing
the uterus, Laving previously with a catheter drawn off about
three pints of most offensive urine loaded with pus. He ordered
a catheter to be passed night and morning, and the bladder to
bo at the same time washed out with a weak solution of carbolio
acid. Five days after the replacement of the uterus she was
seized with violent pain in the bladder with constant ui^ent desire
to pass water, and one or two amall ahreda of membrane came
away. The neit day she passed, apparently, the whole of the
I TUMOUR OP THE I
vesical mucous membrftae. The woman did perfectly well, was
delivered at term of a. living child, and baa bad no Bubsequent
vesical treatment.
FIBROID TUMOUR OP THE OVARY REMOVED
BY ABDOMINAL SECTION.
De. John Williams showed a fibroid tumour of the
ovary removed hy abdominal section. The subject of it
was a young girl 18 years of age. She had enjoyed good
health but she was always larger than other girls. She
was of fair complexion and well nourished. She had suf-
fered no pain in the abdomen and the growth had been
rapid dnring the past year, especially during the last six
weeks. She had gained flesh during the last few months.
The patient began to menstruate a year ago and had
been regular since, except that she missed the last cata-
menia due. ^^ > , , t . < > ^
The abdomen was accompanied by a large solid tumour
extending up to near the ensiform cartilage, it was slightly
moveable. Her uterus was freely moveable, normal in size
and position ; sound entered two and a half inches.
The abdomen was opened in the middle lino extending
from a point an inch above the pubes to a point two inches
above umbilicUH. There was no adhering, and the pedi-
cle, which was wide, short and thin, was transfixed and tied
in the usual way. The operation was performed under
antiseptic precautions. The patient made an excellent
recovery.
The tumour consisted of a large pear-sliaped mass, the
stalk of which was represented by a thin pedicle about
four inches long, and consisting only of the broad ligament, ,
i.e. the anterior and posterior layers of peritoneum vnth
intervening fibrous tissue and blood-vessels.
The tumour measured about eight inches in diameter at
its thickest part and presented a smooth surface, which
36 FIBBOID TDMODE OP THE OVARY.
was slimy in places as it covered by epithelimn. It ^
everywhere firm to the touch, but aome placee appeared '
softer than others.
The colour of the exterior was variable, for the most '
part of a yellowish -white tint, but large areas were of a i
yellowisb pink colour, and in a few places was bright red
from dilated vessels.
On section the tumour appeared to be made Dp of
numerous interlacing bauds of fibrous tissue, this being
densest in the centre and forming a kind of capsule over
the whole surface of the growth. While the larger part
showed the ordinary appearances of fibrous tissue there
were many areas which were soft and occupied by a gela-
tinous tissue evidently mucoid. These patches consisted
of delicate fibrous trabeculse enclosing tho gelatiuoas
mucin in a semi-flnid state for, when the tissue was
scraped, a viscid clear fluid escaped which gave a white-
Btringy precipitate with water aud also with alcohol.
The trabeculro of fibrous tissue in the growing margin
of the growth had a deep red tint, and the same colour
was noticed as well in parts of the centre.
In addition to the appearances already described, the i
fibrous tissue presented extensive calcification in the ceutrd ^
of the growth. This condition presenteditself as irregular i
spicules, most frequently found in the neighbonrhood o£ |
the blood-vessels, but forming on the whole a central (
tnass with radiating trabeculEe.
Blood'Vesgels. — The blood-vessels commencing at the
hiluB ran throughout the tumour in loose eheaths of deli-
cate connective tissue, but their walla presented normal
appearances, even in the smallest branches, the aides of
which were not simply the sides of channels hollowed in
the tumour substance. The veins were large and patent.
Lymphatics. — An attempt was made to inject the lymph
vessels (?) of the tumour by the puncture method without
success, and as also staining with nitrate of silver failed to
show anything else than a plexus of fibres, it may be con-
cluded that it contained none.
BEUOTBD BY IBDOUINAL BECTIOH.
37
Microscopical oppeartMiceg. — A section taken at the
growing border showed simple white fibrous connec-
tive tissue and the same could be found running down
as trabecular sheaths around the blood-vessels. The
bundles of fibres when teased showed the fibres to be all
similar to normal white fibres of connective tissue but
with the exceptional characters of being scarcely wavy
at all, of being homogeneous bright with a high refractive
power and showing no transverse bauds or constriotioua.
The fibres had in many cases an irregular outline, but
in others the sides were parallel, and the edge sharply
defined. Although not wavy the fibres were bluet and
curled, as though closely resembling elastic fibres but
elastin could not be proved to be present by the ordinary
There were excessively few corpuscles to be seen any-
where. Where present they were flattened cells resting
between the planes of fibrous tissue.
He walls of the blood-vessels were composed to au
unusual degree of connective tissue, but were otherwise
normal.
The calcification was present as irregular clear crystal-
line plates just as though the ground substance between
the fibres had become calcified. The calcareous plates
became merged to form spicules, and here and there
showed small dark points (pits), and in a few places a
connective tissue corpuscle was involved ; but the space
was not a normal lacuna and there were no canaliculi.
The growth was therefore a calcifying fibroma of the
ovary, a tumour of not uncommon occurrence in the lower
jaw, but, so far as I know, of considerable rarity as occur-
ruig in the ovary.
The PsKstnEST said, fibroid of the ovary being undoubtedly
-are it would be iutereating to hear some of the patieut's clinical
history from Dr. Williams.
EXHIBITION OF SPECIMENS.
By Db. Gbakville Bantock.
The firsb specimen I have to exhibit is a small dermoid
cyst of the right ovary which I removed from a widow,
a3t. 32, the mother of two children. I have thought it
might interest such of our Fellows as may not have seen
an example of this form of tumour, containing teeth and
hair. The cyst was filled with the usual characteristic
sebaceous matter.
The second specimen consists of both the Fallopian
tubes with the right ovary, and afEords an example of the
condition which is known as hydro-salpinx or dropsy of
the Fallopian tube. The left tube formed a tumour as '
largo as a cocoauut, which occupied the left side of J
Douglas's pouch, where it was firmly bound down and gave I
rise to great suffering especially when the bowels were
moved. It was so tender that the patient could hardly
bear any examination. In removing it I had to empty it
of its contents by aspiration to enable me to apply the
ligatures. The ovary was so bound down that I could
not remove it. The right tube was as large as a hen's
egg and was readily removed with the ovary. The con-
tents were thin and watery, reeembtiug the washings of
tea leaves, and presented microscopic elements in the form
of epithelial cells derived from the lining membrane.
I have now to show you a series of five fibroid tumours
of the uterus, removed by abdominal section, constituting
the operation of hysterectomy — variety supra-vaginal.
1, This specimen was removed from a single woman,
set. 39, who had suffered more or less during the last two
years. It had grown very rapidly in the last six monlhs,
and had caused her so much suffering that she could no
longer earn her living as a pattern-card maker, Men-
struation was irregular and scanty and had never been
abundant. The operation was rendered very difficult by
FIBBOID i'UMOUB 09 THS DTBE08.
39
I
the adhesion of the omentum to the whole anterior and
snperioi' aspects of the tumour, as well as to the parietes.
I could not find any trace of either ovary. The tumour
weighed 7 lbs, 9 oz. ; on its superior aspect it presents a
cavity, of the capacity of about 2 oz., and is a good exam-
ple of commencing cystiform degeneration.
2. Obtained fi-om a married ivomauj set. 45, who had
enfEered for two years. Menstruation was regular, rather
excessive, lasting seven or eight days, usually with clots,
but without affecting her general health. Latterly the
pain had become so severe that life had become intoler-
able. This was explained by the extensive adhesion of
the omentum both to the tumour and parietea, as in the
preceding case. The operation was very difficult from the
extent to which the uterine body was involved, aud such
was the drag upon the stump that I could not prevent es-
tensive sloughing of the skin under the supporting trans-
verse pins. I could not find any trace of the right ovarj-.
The site of the loft was occupied by a cyst containing half
a pint of fluid, which was removed by aspiration. The
cyst itself was so bound down that I could not remove it.
In the cavity of the uterus were two soft mucous polypi^
one as large as a broad bean. Weight of tumour 2 Iba.
It consists of the fundus of the uterus with numerous
fibroids, and one constituting more than half the mass,
growing out from the right side.
5. Removed from a married woman, at. 44, the mother
of four children. The tumour presented the characters
of a multilocular ovarian tumour ^vith colloid contents, and
even now its elasticity might be mistaken for fluctuation.
This was due to ccdema which also affected the broad
ligaments. The right ovary was ligaturt-d eeparately.
The tumour wns of rapid growth, having existed only sis
months, as far as the patient was aware. It weighed 4 lbs.
6 oz. The menetruation was regular and rather scanty.
I have taken the specimens out of their chronological
order, because a peculiar interest attaches to Nos. 3 and 4.
3. The patient from whom this specimen was removed
40
FIBHOm TDMOrR OF THB TTTaBUe.
was a Buigle woman set. 41. In Aprilj 1881, she came
under my care sufiering from aucli excessive menorrhagia
tHab she was in a state of profound anEemia. At that time
the operation of removing the ovaries and appendages was
occupying a great deal of attention, and the relations of
the growth to the uterine body and cei-vix were such that
I dared not contemplate the radical operation, and I
therefore performed Battey's operation. Within forty-
eight hours metrostaxis set in and lasted four weeks, at
times very severe. At the end of this period such a change
had taken place that, whereas the uterus with its tumour
reached to the umbilicus and the sound passed for about
eight inches, it was now midway between the umbilicus
and pubes, and the cavity measured only four inches. Such
was the extent of the metrostaxis that nearly seven weeks
elapsed before she could leave the hospital. Within the
next month the hsemorrhage reappeared, and before she
returned home I had the mortification of finding that the
nteroB was as big as ever. For twelve months she held
her own fairly well, and although the hsBmorrhage recuiTed
with great regularity, it was not so free as formerly, but
gradually it became more abundant and more prolonged,
and she began to go back. It will give you some idea of
the extent of this haemorrhage when I tell yon that from
the beginning of November till the middle of January it
never ceased, and at times was very severe. Under these
circumstances I had no hesitation in recommending the
removal of the tumour, although I had staring me in tho face
a note appended to the former operation, viz. that " the
removal of the tumour was impossible;" for I had in the
meantime learned how to treat these cases. The opera-
tion was not difScult, though it was not facilitated by the
shortening of the broad ligaments by the previous one.
Mark the great size of the uterine cavity, the enormous
thickness of the uterine wall, and the condition of the
tumour, which furnishes a good example of what I
call cysHfurm degeneration in an early stage. Weight o£_
tumour S lbs.
PIBEOID TDMOCE OP THB UTBBD8.
41
4. This specimen was taken from a widow, set. 48, the
mother of one child. About a year ago she was under
the care of a distinguished surgeon of Birmingham, who
removed the ovaries and appendages. She came under
my notice in November laat complaining of a tumour in
the abdomen, which caused her so much suffering that she
could not follow her occupation o£ housekeeper. This
tumour was as large as the head of a new-born child, and
adhered to the greater parb of a cicatrix of about six
inches in length. The operator was good enough to tell
me what he had done. At the patient's urgent request I
removed tho tumour, which she was positive had not de-
creased since the former operation ; on the contrary, she
was inclined to think it had increased. There was also
this remarkable fact that, whereas meustruation had been
verymoderate beforethe operation, it had actually increased
Bince, both in duration and quantity. The tumour weighed
2 lbs. 3 oz.
It may be within your recollection that, when, three
months ago, I had the honour of showing a similar series
of tumours, I stated that whatever might be the future of
oophorectomy in the treatment of fibroid tumours, it coald
not come into competition with hysterectomy ia such cases
as I then showed ; for while in some of the cases the
ovaries conld not be removed at all, in others it woold
have been the height of folly to leave behind after re-
moval of the ovaries, a tumour which was bleeding from
a great part of its surface through the breaking down of
adhesions, in yet others the tumour had already begun to
undergo cystiforra degeneration — a condition which is as
surely fatal aa the ovarian cystoma.
In the discussion which followed one of the speakers
gave it as his opinion that hysterectomy ought not to be
done until oophorectomy had been tried and had failed.
That is a proposition which to my mind is both unscientific
and irrational. It is unscientific because it refuses to take
notice of facts already known and of failures that have
been already met with. It is irrational beoaaae it is
42 FIBEOID TUMODB OP THE DTEEBB.
always unwise to draw a hard and fast line in such a case
as this. Bat I mnst not dwell on this point.
Great stress has been laid on the importance of securing
the ovarian arteries in Batter's operation. Even if this
were possible in all cases — and I am far from saying that
it is — what do we gain? It seems to be forgotten that
the uterus is supplied by one uterine and one ovarian
artery on each aide, and that the uterine is the larger of
the two. It seems to be forgotten that there is such a
thing aa a compousating law of nature, by which, when
of two sources of blood supply one is cut off, the balance
is restored through the remaining channel. The experi-
ments of Hunter on the growing horn of the stag, and the
practice of surgeons in the case of aneurism, show that
this is true in the case of collateral cii-culation. And it it
be tme in the case of collateral circulation, how much
more likely is it to be true in the case of direct supply.
I have only to add that all these patients have either
recovered or are convalescent, that of twenty-two cases
of hysterectomy treated by the extra-peritoneal method ia
the manner I have on a former occasion explained, twenty
have recovered, and tl.at in not one of these has the opera-
tion been done with what has been called " full nntiseptio
precautions."
Mr. Knowsley Thornton said, the two cases in which removal
or partial removal of the uterine appendages has been performed
are meet beautiful evidences of the value of this operatiou. I
say partial operation advisedly with regard to the first of them,
because I was present at the original operation, and I was present
again at the hjsterectoiuy, and examined the tumour immediately
after its removal. The right ovary was imperfectly removed,
and I saw during the hvsterectomy that a portion of the left
ovary still remained, half Isedded in the aide of the tumour. It
was then a very imperfect oophorectomy, and yet we see that the
tumour is atrophying and going through those degenerative
cystic changes which we aim at in performing this operation of
removal of the uterine appendages. I have shown, by one of my
cases, that this operation will cure that usually troublesome dis-
ease, true fibro-cyBt of the uterus. But in this specimen
some dia- ^^H
2 we have ^^H
tlBBOlD TDUODB OF THi! OTKUUS. 43
not to consider this disease, the cysts are merely part o£ t^e
process of de generation and absorption, which the original opera*
tion was designed to produce. We are told that the patient
had recurrence of hamorrhage, aud prolonged weeping from the
Uterus, aad this is just what we should expect with the ovariea
partially removed, and their remains kept in constant irritation
by the presence of silk ligatures ia their substance. All we
know of metrostaxis tends to show us that its great iaclucer is
ovarian irritation (i.e. irritation of the ovarian nerves). We see
this with the nerve tension from growing follicles in menstrua-
tion. We see it in the htemorrbages follo\ving quickly upon the
removal of the appendages. We see it after removal of one ovarvj
as in ovariotomy ; and we see it still more strikingly in cases m
which an elderly woman, years after the menopause, grows an
ovai'ian tumour, almost the first symptom is metro stasis, coming
at more or less regular intervals, and continuing while the
tumour ia small, and ceasing when the ovai^ is destroyed and
turned into a large and easily recognisable ovarian cystoma.
Metrostaxis and weeping from the uterus are by no means things
to complain of after removal of the append^es for the cure of
fibroid. They are a part of the cure, and my experience has
shown me, that cases in which they occur cure most rapidly. I
cannot speak with the same certainty as to the nature of the first
operation in the second case, as I did not see it ; but I was
present at the hysterectomy, and seeing the tumour it appeared
to me that the reinoval of the appendages had been imperfect as
regards one tube and one ovary. This tumour is also evidently
atrophying though more slowly, because it was receiving a con-
siderable blood supply from adhesions to the cicatrix and omen-
tum. I claim these two cases, then, as giving an excellent
illustration, and one which I trust we are not likely to have
frequent opportunities of seeing, of the value of the operation of
removal of the uterioe appendages for fibroid. Thereby seeing
these two patients as I did upon the operating table, I am perhaps
not in a very good position to judge of their health, but certainly
patients do not usually look their best just before operation, and
these women appeared to me to be in excellent health ; they both
had fair colour, they were both rather stout than thin, and were
evidently well nourished; their abdomens were distinctly flaccid,
showing that they had been more distended at some previous time.
I would ask then, with all the evidences which we hare before us,
that the first operations were surely, if slowly, fulfilling their
purpose, what justification did the condition of either of these
women afford for again putting their lives in danger by so serious
an operation as that of hysterectomy ? I at any rate cannot find
evidence of such justification in what we have lieen told about
them. They are recovering, and so far it is well, but they can
hardly be said to be convalescent while they have large suppu*
u
PIBEOID TCTKOUB OP THE rTEEUB.
rating wounds at the aite of the pedicle. Will their couditioa
twelve months hence be one of greater comfort than it would
have been if they had been advjaed to have a little patience, and
await the full benefit to be derived from the first operations ? I
admit that the operation for removal of the uterine append-
ages is often a very diflScult one, and one requiring considerable
manipulative skill, but it is a safer aud more conservative one,
than the more easy one of hysterectomy, which simply consists in
dragging uterus aud ovaries out of the abdomen, and fixing the
stump with a wire and piua in the cicatrix; a return to the clamp
principle, which haa so deservedly and universally fallen into dis-
credit in ovariotomy. laawomanmoreunHesedbythemereremova
of the uterine appendages, with her uterus remaining of its normal
size and in normal pOBition, or by a clean sweep of ovaries, tubes
and body of uterus, with the cervix dragged up and filed iu the
abdominal cicatrix, and very likely in addition a permanent
fistula, or the life-long misery of a bad ventral hernia ? Reply-
ing later to some remarks by Dr. Savage, Mr. Thornton pointed
out that his remarks aa to the justifiability of these operations,
merely referred to the two special cases, and that he did not
positively say that they were not justifiable, but asked for further
grouuds of justification than had been given.
Dr. Sataoe said his notion of "justifiable" as applied to
surgical proceedings was, that when the disease rendered the
patient's life intolerable a surgical operation not essentially fatal
was justifiable. This was the condition in Dr. Baotock's coses.
The surgical proceedings he adopted resulted in curing 20 out of
22, mortality 1 in 11. Ovoriotomists rejoice in succtsa of one
in ten. What better proof could there be justifying Dr. Ban-
tock'a operations ? Dr. Savage regarded Battey'a operation — not
that for the removal of diseasedtubea and ovaries — as detestable.
Mr. DoRAN observed that the relative merits of oophorectomy
and hysterectomy for fibroid must henceforth be judged by
statistics of the operations which have been performed and which
will be performed ; for it is evident that the advocates of the
two different operations are determined to continue to act as they
have hitherto acted and feel fully justified in so doing. It only
remains for others to watch these operators and to judge from
results, as it is now quite useless to protest against either opera-
tion on abstract grounds, since no protest will check the zeal of
the operators. Before either operation becomes established, like
ovariotomy, we must bear much fuller details of the experiences
of experts. Oophorectomy, iu a case of fibroid disease of the
uterus, is not an easy operation, the ovaries are difficult to reach
and to draw up into the abdominal wound and the pedicle ia far
harder to secure than ia an average caae of ovariotomy, and very
complete antestheaia ia of paramount importance throughout the
opetstion. Yet, with practice, the total removal of each ovary and
FIBEOID TDMODE OF THE DTEROa.
45
tlie secure ligature of its vessels might be, in most cases, insured.
BetnoTa] of the diseased uterus is, on the other }iand, a more
thorough measure, and it must be remembered that the organ ie
useless in these cases, as well as troublesome. Companaona of
long series of after- hi stories are needed before the profession can
say authoritatively that either, both, or neither of these opera-
tions are justifiable.
Dr. EocTH said hewas sorry to see altercations in the discussion.
The objects of this Society were the progress of science and truth,
not recrimination. He took exception to Mr.Thornton's remarts.
He had said that oophorectomy was the operation which should
have been performeil in two of Dr. Bantock's cases, not hyster-
ectomy. Now he (Dr. Eouth) believed that oophorectomy was
(except as a pia aller) a shameful, often useless operation.
Objection had been taken in older times in this Society to clitori-
deotomy because it uuseied a woman. But clitoridectomy could
scarcely be said to have this effect, for women bare children after-
wards, but oopborectomy completely unaexed a woman. Then
in this very Society cases had been detailed where oophorec-
tomy had completely failed to cure the sufferer, and death also
had resulted. Mr. Thornton had said the cutting away of the
appendages and ovaries in Dr. Bantock's last cases was imper-
fecUy done. It seemed scarcely kind, and we should need some
further evidence before we could assume that Dr, Savage, of
Birmingbam, and Dr. Bantock, had not succeeded because they
did not do it as completely as he, Mr. Thornton, wished it done.
Then it was well known that during the climacteric period, and
after, fibrous tumours often disappeared, One of these women
was forty-one, the other over fifty. Even supposing there was
atrophy already begun in the tumours, which was questionable,
how much was due to change of life, and how much to the
oophorectomy ? The esperiment to be crucial should be per-
formed in women in full sexual power, and in such was it justifi-
able ? Iq any case, these women before the hysterectomy were
bleeding incessantly, great invalids, confined to their beds, unable
to work for their living, and a continual drag upon their poor
relatives. Now they were healthy, strong, able to go about, and
useful members of society. Who could dare to say then that
the Operation was not justifiable?
Dr. Wyhm Williams stated that two of the specimens were
removed from patients whom he had sent to Dr. Bantj^k for
operation. They had been under his care for many months and
bad become quite incapacitated through pain and suffering of
vhich they were now relieved. If that is not sufficient justifica-
tion for the performance of the operation be did not know
what was,
Dr. Bantock, in reply, said, Mr. Thornton contends that
in these two cases of double operation hysterectomy was
40
FIDROID TCTMOUE OP THE OTEBUS.
unjustifiable, that the Uvea of the patients were uQWarrantably
exposed to peril. I think I have already justified the opera-
tion sufficiently ; in my own case the hemorrhage had become
so serious that the patient was not only a hopeleas invalid,
going from bad to worse, but was also a source of great
anxiety to her friends. If that is not a justification of the
operation I should like to know what is. I protest gainst the
course pursued by Mr. Thomtou. Mr. Tnomton sayB that,
haviug been present at the operation, he could assert that I did
not perform the operation as it should have been done. Well,
sir, I am not here to defend or speak of my own skill. Perhaps
1 did not do the operation properly. But when Mr. Thornton
says that the tumour- — which he has never had an opportunity of
examining — is in a state of atrophy, he asserts that of which the
case presents do evidence. The specimen fails to show, on the
most careful examination, any trace of either ovary, and only a
small portion of the uterine end of one of the tubes. If we take
the evidence of the specimen, then, we must believe that the
operation was well done. It is not my province to defend Dr,
Savage — whose name I had not mentioned but Mr. Thornton lias
correctly given — but seeing the large experience be has had of
this operation, 1 think we may safely take it for granted that he
did it well. And, as in my own case, an appeal to the specimen
confiiTQS this. I maintain, then, that complete justification has
been shown.
Dr. Wynn Williams exhibited two specimena of tumours
removed from the uterus by the ecraseur. The first, an
ordinary fibroid tumour, removed Feb. 22nd from a woman,
set. 48 ; youngest child fifteen years of age ; six months
ago had a severe flooding and has had more or leas hsemor-
rhage ever since, her colour having become perfectly
yellow. The second was removed on the same day from
a woman, Eet. 35, her youngest child three years of age ;
she was a patient at the Samaritan Hospital three years
ago, under Dr. Gouth. This tumour is of a particularly
soft, flabby character and was found more so on removal
before it had been placed in spirit and would appear to be
a large mucous polypus intermixed with fibroid tissue,
indeed it was so soft that until an incision was made into
it, thei:e was some doubt as to whether it contained fluid
or not. It ia in two portions, and was removed on two
47
Separate occasions. The first portion protroded through the
OS uteri and had its attachment within the 03 to fully two
thirds oE its circumference. After the removal of the first
portion another portion protruded through the 03 which
was remoTod on the 6th of March. This portion was
also particularly 30ft, and has a fleshy, mucous -looking
covering. Several portions had to be removed by torsion
and cut away with the cautery knife. It should be men-
tioned that when the patient was under the care of Dr.
Ronth there were some doubts as to whether or not it was
an inverted uterus. It was not until after the application
of Dr. Aveling's instrument that it was diagnosed to be a
fleshy or mucona polypus.
" Dr. EoPTH. — In regard to Dr. Wyun Williams's case, this
point of interest should not be lost sight of. When he (Dr.
Eouth) first saw her, the polypus projecting was attached all
round the oh, and diagnosed by three colleagues as inversion of
the uterus. It was only after Dr. Aveling's instrument had been
used a day, that the adhesions gave way on one side, and that the
sound could be introduced and the case accurately diagnosed.
The PRESIDEKT then delivered his Inaugural Addre:
INAUGURAL ADDRESS.
Ghhtlguen, — When some fonr-and-twenty years ago,
within the first year of our Society's esisteuce, I was
admitted to its Fellowship, few things could have occurred
to me as less likely to happen than that at some fntnre
day I should be chosen to its Presidency, And in taking
the chair this evening, and returning you my best thanks,
I can but say that I am at once very sensible of the hononr
conferred, and very conscioos of my own inadei^ua<^.
Indeed, since a few weeks ago, when by your kindness I
was elected, the voice of an inward monitor has many
times whispered in my ear the qaeetioo, " Amice, quomodo
4S
ISADGTIRAL ADDREH8.
Luc intraati ? " I am reasstired, lioweverj by tlie remem-
brance that for more than eighteen years I have known
nothing but consideration from the Fellows of the Society
in the other offices I have had the honour to hold, and
that I can confidently rely on the cordial aasiatance of our
experienced Secretaries, of the distinguished men who
have preceded me in this chair, and indeed of every Fellow
of the Society. We are all feliow-workers for a common
object ; the success of our Society and the promotion of
obstetric science ia onr common aim. The establish-
ment of onr Society in 1858 began, without doubt, a new
era for obstetric medicine in this country. It was pre-
viously scarcely looked upon as a science, bnt regarded
rather as an art, and as &n art even in which but a rough
kind of skill was required. Its teachers were passed over
in the distribution of professional honours, and its prac-
titioners thought of aa of a somewhat inferior rank. Now,
thanks largely to the work and enterprise and success 'of
our Association, matterSj though still not all we could
wish, are distinctly brighter. Much of the work done by
Fellows of this Society is recognised on all hands as of
high scientific merit as well as of great practical value.
One testimony, which struck me at the time as gratifying,
recurs to me in connection with this room. On the occa-
sion of Mr. Wells giving to the Royal Medico-Chirurgical
Society the particulars of the 200 cases of ovariotomy
which completed his roll of 1000 cases, the then President,
Mr. Erichsen, after referring in terms of high eulogy to
the great success of Mr. Wells, went on to say, "And
surgeons are yet more indebted to ohstetriciana for other
great improvements in operative surgery, for it is to them
we owe the great precautions which, independently of
antiseptic or Listerian methods, have tended to lower the
mortality of ordinary surgical cases." And, as an outcome
of our work and its success, I think I may venture to say
onr professional etatna ia, moderately perhaps, but yet
distinctly, improved, A surgeon whose chief eminence is
in connection with gyntecological work is President of his
IHAUOnEAL ADDBIteS. 49
College. An obstetric physician was not long since Presi-
dent of the Eoyal Medical and Chirurgical Society ; and it
ia lare that the Council of the College of Physicians does
not now contain one or more representatives of obstetric
naedicine. It may not be uninteresting in this connection
to mention a recent decision of the Senate of the Univer-
sity of London. It has been customary for the gold medal
given at the M.D. examination to be awarded to the can-
didate who, in addition to possessing the highest marks in
hia other subjects, wrote the best commentary on the case
in medicine, to the exclusion of those candidates who,
however well they did in the rest of the examination,
selected for comment the case in obstetric medicine. At
a recent meeting of examiners this injustice was referred
to by your late President and myself ; and I am pleased
to say that, on the representations of the Registrar, who
himself coincided with our view, the Senate has decided
that in future the case in obstetric medicine and the case
in medicine shall rank as of equal value in the competition
for the medal. At the meeting inaugurating this Society,
Dr. Tyler Smitbj whose name can never be referred to by
us in this room without emotions of sincere and grateful
regard, thus expressed himself : " The chief business of
an obstetrical society would be to diminish the mortality
of childbirth, and the task was one of the highest import-
ance." And at tho first annual meeting, a few weeks
afterwards, our first President, Dr. Rigby, said : " The
great object, and that which will form the great strength
and importance of this Society, is the collection of valuable
facts on questions of obstetric practice." And I think I
may venture to assert that if this evening, at the begin-
ning of the twenty-fifth year of the Society's existence,
we take a retrospective glance aL its work, we shall find
that it has very distinctly fni-thered these two well-defined
aims — the advancement of knowledge and the abatement
of mortality. It would bo an onerons task, and perhaps
an invidions one, to refer specifically to the many comma-
sications which have conduced to these ends. Every
VOL. XZT. 4
^m an invid
^H sicationi
50
IKAUOCBAL atdrkbb.
eeesion has piled the heap higher, and it forma now a mass i
of work of which we may be legitimately proud. But it '
may be permitted to refer for a few minutes to the two
great debates of the Society on the subjects of puerperal
fever and the use of the forceps, in both of which, and '
particularly in the former, additions of the greatest moment
were made to our knowledge, and so to our power, I
think I may fairly assert that up to the period of the
debate on puerperal fever the moat diverse views as to its
etiology were taughtj and in its treatment the most varied
practice followed. One authority held that any fever
occurring in childhood became ipso facU> puerperal fever,
whether that fever were typhus or typhoid or scarlatina.
Another, equally distinguished, looked upon scarlatina as
of the essence of puerperal fever, or at least as its most
frequent and important factor, Another, that the fever-
was but the result of the local inflammatory changes going
on in the pelvis and abdomen. Another, regarding a local
incident in its pathology as the disease itself, believed that
puerperal fever was primarily and essentially a diphtheria
of the vagina and endometrium, spreading thenco to the
system through the lymphatics, or to the peritoneum along
the tubes. And yet another, that puerperal fever was a
specific fever developed by the crowding together of puer-
peral women, and producing a specific poison, which by
conveyance could communicate puerperal fever, and puer-
peral fever only, to other lying-in women. But so marked
a change followed the collation of facts and comparison
of views which occurred in this debate, that in nearly
every text-book which has been issued since tho subject of
puerperal fever is treated simply, and as if it were a matter
of course, under the title puerperal septiceemia. That
many problems in connection with it yet remain to be
unfolded is, however, certain; and while the general outline
of the picture and many of its details, are clearly depicted
for us, much in the filling up of tho canvas remains for
the skilled pencils of Fellows of this Society. One point
deserving at least a passing word is this. Just as under
INADOUIUL abDBESS,
51
the head puerperal fever nomerous diatinct febrile condi-
tions were formerly grouped together, ao probably baa
been the case also under the designation puerperal septi-
CEemia. This term should obviously be limited to the
infection of the system by septic fluids in which micro-
organisms capable of self -multi plication are found. This
has indeed been insisted upon, from one point of view, by
our late President, in the distinction he draws between
aepticsamia and the condition he terms " saprasmia," in
which he believes the poison to be chemical, and not a living
ferment. But probably over and beyond this the subject ia
in need of elucidation. Another point on which I would
venture a remark is the connection between scarlatina and
puerperal fever. A fonner President of our Society, and
one whose work is always of the ablest, has shown how
frequent that association is. But if, as we believe, puer-
peral fever proper is puerperal septicemia, the mere com-
munication of scarlatina cannot induce puerperal fever in
a lying-in woman without it in some way initiates septic
changes. If a puerperal woman has scarlatina after her
labour, and shows no evidences of septic poisoning, no
parametritis, no peritonitis, no distant trouble in her lungs
or brain, I think we may fairly say she has scarlatina and
nothing more. But if, in addition to a scarlatina rash
and a scarlatina sore-throat, she lias such septic manifes-
tations, we might with equal fairness say she has both—
the one complicating the other j and indirectly it may be
the one accounting for the other. Now, on the one band,
scarlatina in one patient may indirectly be the parent of
puerperal fever in another, through the medium of the
septic discharges which occar from sloughy surfaces in the
throat or nose or ear ; and, on the other, if the patient
herself develope scarlatina symptoms, the occurrence of
the exanthem may induce in her acute vaginitis or endo-
metritis, and so originate inflammatory discharges, which,
becoming septic, may graft by auto-infection septiceemic
symptoms upon those of the primary scarlatina. Were
the connection closer tha^ this, it appears to me it would
52 INADaUB&L ADDBEBS.
be scarcely possible for general practice to be carried on.
One otber point to which attention has not perhaps been
generally given, bat which seema to be of much interest
in connection both with the etiology and prophylaxis of
metria, is the virtual predisposition which exists in the
puerperal woman to septio invasions. Her blood being in
a watery state with lessened albumen and increased fibrin ;
her nervooa system worn by the anxieties and discomforts
of gestation ; her glandular system faulty, and its capacity to
eliminate diminished; her general physical strength lowered
by the efEort Involved in the maturing of her offspring,
and by the various pathological incidents which accom-
pany pregnancy — incidents, in their bearing on her general
health, described with characteristic brilliancy in his Lum-
leian Lectures by Dr. Barnes — it is matter for little sur-
prise that she resists toxic agents so inefficiently. One "
may almost say, indeed, that this condition of system
presents a special predisposition to the reception and
development of infective maladies ; and explains also the
recognised importance of a woman's health being at its
best when she enters upon the ordeal of labour. That
the establishment of the present view of puei-peral fever
has well fulfilled the chief object of this Society as defined
by Dr. Higby — " the lessening of mortality in connection
with childbirth "■ — is abundantly true. We now know
precisely what to do to avert or lessen the risk of commu-
nicating contagion ; and we also know what to aim after
in the treatment we adopt for the developed malady,
although we must add that as yet, unfortunately, our prophy-
laxis is much ahead of our powers in actual treatment. We
know with certainty how to lessen the risk of injection,
by antiseptic precautions, and the proper management of
the third stage of labour ; but when infection has occurred
we as yet lack that intimate knowledge of the poison which
would enable us at once to neutralise or destroy it, and
our efforts can only be directed, though often with
encouraging snccesB, to the maintenance of strength, the
promotion of healthy function, and the control of the
INAUaTTBAL ADDKESS.
63
I
several local lesiona which arise with the propagation o£
the poison and the progress of the case. The application
of the principles of antisepticism to midwifery, which is at
once the note and indication of our advance in propliylactio
care, is, without question, the greatest of all the recent
advances in our art. And it is equally iuHuential in the
domain of operative gyntecology. We undertake our
operations now as we enter upon our midwifery attendance,
with the assurance that by scrupulous attention to anti-
sepsis we can all but eliminate the most potent element of
danger. The importance, again, of the proper manage-
ment of the third stage of labour is also very largely in
virtue of its promotion of antisepsis. The efficient contrac-
tion of the uterus, by checking hsmorrbage and expelhng
clots and decidual fragments, lessens at once both the
channels and Bources of possible an to -infection. The
debate on the use of the forceps covered a less wide field,
but its influence was equally for good ; and it is now the
accepted view of the profession that where the need exists
— and it is part of our education and duty to learn and to
teach the indications of that need — delay in using the
forceps is not leas harmful than inefGciency in their
application.
But although so much has been done by debate and
communications and discussion much still remains to do.
Is it not a reproach to ns, for example, that after the fre-
quent consideration of such a subject as uterine flexion we
are bo little agreed as to its etiology, its pathologj-, its in-
fluence, or its treatment ? Can it be with satisfaction
that those of us who teach have to tell our classes that,
while some authors of distinction hold that flexions are at
once the most frequent and important of uterine maladies,
others equally able speak of them as though certainly
common, of minor significance, nay, as often but "the
condition of equilibrium of the woman's pelvic viscera, and
a constituent part of her comfort and health "? Surely
it should be possible to ascertain the truth in so everyday
a question as this I May not this difference of opinion
54
INAUODBAL ADDRESS.
arise from some such error as led to the fabled quarrel
about the colour of the shield, aud illustrate the truth that
both disputants may be right, each from his own point of
view ; that the shielcl, in fact, now as then, has both a
golden and a silver side ; that the one observer has noted
chiefly cases of flexion with symptoms, and the other
cases without, or in which the symptoms directly following
from the flexion were few and unimportant ? Or may
there not be some ground common to both, and explana-
tory of the divergence, and this be possibly what I once
ventured to suggest in a discussion on the subject in this
room, that flexion per ite, flexion as flexion, was of minor
consequence unless associated with obstruction ; that it
was the virtual obstruction produced by the flexion which
led to a certain chain of events — menstrual retention, en-
dometritis, uterine hyperoamia, and its various epipheno-
mena ? Or again, when one observer speaks of obstructive
djsmenorrhoaa as a definite malady, depending on cervical
stenosis, and capable of cure by dilatation or division
of the cervix and another equally eminent denies even the
existence of obstructive dysmenorrhoea, and so logically
enough repudiates all surgical inteiierence for its cnre,
there must surely be some explanation possible of the di-
vergence. Either our definitions must be faulty, or the
cases referred to by the several authors are only super-
ficially aud not really similar. What, indeed, we appear
to be in want of on many points is, if I may venture to
use two Greek words, iTrJ-yvwoic in contradistinction to
yvtHatQ simply ; a more precise and definite knowledge in
place of a knowledge which is vague, uncertain and often
rather traditional than true. Or possibly our failures arise
rather from the lack of that quality which by a distin-
guished writer has recently been denied to us as a nation
— the quality of "lucidity," But whichever of the sister
tongues best describes our need, whether it be of accurate
knowledge or clear expression, I fear we cannot shut our
eyes to its existence, and haw best to meet it is a matter
for gravest thought. Debate, apparently, does not always
INADOCBAL ADDBBSB.
55
succeed : sometimes, indeed, it eeema as if it did bnt ac-
centuate difEerences. Possibly, the more frequent appoint-
ment of committees to receive evidence, aift cases, conduct
investigation B, and prepare reports for transmission to the
Society, might do something, and perhaps much, towards
settling some o£ the points on which these differences of
opinion exist— differences of opinion from which, I am
afraid, our clients and ourselves must both necessarily
suffer. The principle of collective investigation, again, of
which much use was made by us in the report drawn up,
during Dr. Hewitt's presidency, on the subject of infan-
tile mortality, might be adopted in regard to many sub-
jects with distinct advantage. From snob a body of
practitioners as constitutes our Society methodical reports
on matters of common iuterest could, I believe, without
difficulty be obtained, and such work would indeed form
a fresh link between Fellows living at a distance and the
Society of which they form so important a part. And yet
one more suggestion would be to avail ourselves from time
to time, by such remuneration as our funds permitted, of
the services of specially qualified investigators, as we did
of Professor Schafer's work in connection with the sub-
ject of transfusion. It would certainly be a matter of
congratulation to us all it by one or other of these
methods, or by any other which might occur to any Fellow
of this Society, we were able to speak with as much cer-
tainty of the significance of flexion and the varieties of
djsmenorrhoDa as we can of the course of a parametritis
or the character and relations of a fibroid. It is more
than tempting, gentlemen, on such an occasion as this to
refer to many points besides those of practice, in which wo
are all interested, such as the insufficiency of the time
alotted to obstetrical teaching, the inadequate attention
given by students generally to the subject of gynsecology,
and the still imperfect representation which obstetricians,
as such, have in the higher councils of the profession ;
but time and your patience will scarcely permit. One or
two remarks, however, I would just ventare to make as
56
mADaOEAL ADDEE88.
possibly having aome common bearing upon each of these
questions. One ia, that we ourselves may be, after all, i
somewhat blameworthy iu the matter. Until the last
fifty years comparatively little of the work done in
obstetrics, in this country at least, had been done in the
spirit of exact scientific investigation, and our reputation,
withont doubt, correspondingly suffered. And secondly,
I cannot but think that the very modest estimate we have
been too generally accustomed to place on the value of our
services must have influenced somewhat the value accorded
them by others. When an edncated medical man is con-
tent to wait for some consecutive hours by the bedside of
a woman in labour, to conduct her delivery, assisting it
perhaps instrumentally, and then attend her subsequently
for many days, for the inadequate remuneration usually
given ; and when a consultant, as the phrase goes, is
satisfied to ask among well-to-do people but little more
than an ordinary consultation fee for the performance of
version or craniotomy, or the induction of premature
labour, we can scarcely wonder at an impression prevail-
ing that obstetricians of all ranks are something inferior
to, say, the oculist who charges one hundred guineas for
an iridectomy, or the rectal surgeon who expects fifty for
removing a pile or dividing the sphincter. I am clearly
of opinion that the fees for midwifery attendance and
operations require careful revision in our favour, and that
Buch revision would be alike beneficial to client and prac-
titioner. Of attendance upon midwifery cases among the
very poor I am, of course, not speaking. Such, I think,
would be best met by the more general employment of
educated roidwivcs. And, indeed, among the artisan class
those who could not offer a medical man an approximately
adequate fee (and there are probably but few who could
not do so by a very moderate amount of frugality and
thrift), should, I think, have their wives also attended by
midwives of the class I am referring to — trained women,
such as hold our examination certificates, or have been ju
the service of the Royal Maternity Charity. There would
INAUOHRIL ADDBBBB.
57
be, I believe, bat little difficaity ia the way of medical
men whose practice chances to be in the poorer districts
organiaing' for themselves, or id association with neigh-
bouring friends, a staff of such midwives to relieve them
from much of the tiring routine of ordinary attendance ;
while, as in the case of the Royal Maternity Charity, they
would be instructed to send at once for their chief in all
circumstances of difficulty and danger. In the tweaty*
four years I have been associated with the department of
obstetric medicine it has been my lot to make the acquain-
tance of too many medical practitioners who have prema*
turely died, and whose health was undoubtedly under-
mined by their harassing attendance on large numbers of
scantily paid cases of midwifery. Some such plan as I
have ventured to suggest, and towards the realisation of
which our Society, by its examinations of midwives, has
given valuable help, could not fail, I think, to at once
improve our professional position, lessen the strain on the
health of many of our brethren, and rather promote than
diminish incomes already too slender. The passing refer-
ence I made a few moments ago to surgeons practising
specially invites some allusion to the sabject of specialism
as it affects our department of medicine. It is quite un-
necessary for me to go over the ground so well occupied
by far abler pens than mine in the controversy which fol-
lowed the publication of Dr. Reynolds's address on
" Specialism " ; but there is one observation I should like
to make, which appears to me to tell in favour of special
practice, and it is this : that I have repeatedly known
cases of organic disease or defect (and I feel certain my
experience is that of many others) — cases ranging in
gravity from cancer of the uterus to congenital stenosis
of the cervix — either wholly ignored by the physician in
attendance, or treated without local examination, as func-
tional disorders simply, and, as a result, a certain curtail-
ment of life in the one case, and persistent dysmenorrhoea
with general ill-health and sterility in the other. One
could, indeed, occupy an evening, and perhaps not unpro-
S8
IITAUainUX ADDRESS,
fitably, with the narration of such cases, and they would
form an interesting commentary on the assertions of those
who disparage the parsuit of special practice. The field
of medicine is so large, that I helieve it is rather by the
development than the diminution of special investigation
and practice that the nuraerons problems still unsolved
will be cleared up and fresh advancea made. At the
same time, I willingly recognise the first importance of a
good general knowledge of medicine to all, and that ho
will probably make the best specialist who starts from the
broadest foundation of general attainments. One other
reference to the work of the Society I would make before
bringing to a conclusion these few remarks. In the
closing address of my gifted predecessor he spoke with a
justifiable pride of the varied and important contributions
which had been sent in during his tenure of office. I am
naturally anxious that when I vacate this chair I may have
a similar success to detail. But that this may be so,
gentlemen, I must ask yoa all, amid the pressure of a
daily work which I know to be great, to yet remember that
this Society, whose prosperity is, I am certain, dear to yon
nil, can only fulfil the great aims of its founders, and carry
on its useful and honourable work, aa you continue to
furnish it with the necessary material for discussion and
thought. I am induced to say this much, because I am
told that just noWj though our financiHl and numerical
prosperity is great, there is something of a dearth of those
contributions which form the true basis and indication of
our success. I appeal, therefore, to our senior Fellows,
who have so often instructed us before, to remember us
still and give us from time to time the benefit of their
matured experience ; I appeal to our younger Fellows, not
yet 80 pressed with the avocations of practice, to give ua
of the results of their energy and genius ; and I appeal,
indeed, to all to send us some records of their observation
and work, so that our Society may continue to flourish,
and each feel that in that success and its fruits he has a
personal interest and share, So numerous now are the
IKAtraDBAL ADDBBSS. bV
channels by which men may give the world the benefit o£
their work, that our older societies are apt to be at times
forgotten in the work of suburbanand provincial and annual
meetings, associations and congresses ; bnt the potentiality
for good of a society like this — with its regular meetings,
where subjects of interest can be adequately discussed ;
with its annual ' Transactions,' forming a permanent record
of work and an obstetric literature with which any Fellow
may feel proud to have hia name associated ; and with the
social and literary advantages of its reading-room and
library — is a force well worthy both of conserving and
developing. May I venture, in conclusion, to suggest
some few subjects on which, of late at all events, but few
contributions have been brought before the Society, and
yet about some of which much that is fresh has been
learned, though much yet remains to be known. The
diseases of the female bladder, for example, form a group
of cases, from chronic catarrh to intra-vesical tumours,
about which our knowledge is somewhat scanty and our
treatment too often unsatisfactory. We have had no dis-
cussion, if I remember rightly, about the ablation of the
uterus for cancer, and yet it is now an opei-ation which
has been largely performed, and by several of our Fellows.
The relations of chronic metritis, the areolar hyperplasia
of Thomas, the chronic parenchymatous inflammation of
Scanzoni, to subinvolution — if indeed, there be such a
malady apart from hyperjemic proliferation of connective
tissue — and its treatment both stand much in need of
elucidation. The relations of epithelioma to lacerations of
tiie cervix, the starting-point of epithelioma in the nulli-
para, and the pathogenesis of fibroids, are other points,
again, of singular interest, on which we should welcome
observations and research. The comparative physiology
of menstruation, which is being ably dealt with by Dr.
Wiltshire in the lectures he is pubhshing elsewhere, and
which I grudge much to tho pages of the ' British Medical
Journal,' would be a subject of high interest to bring
before the Society as a basis for the more exact and
60 IHADODBAL ADDBES5.
BcientiGc study of its pathology. And in the pathology
of meDstruatioDj it must be remembered, much more is
included than simply the painful performance of the func-
tion. The influence on the whole system is considerable,
as the eruptions, the neuroses, and the blood impairments
which its faulty performance induces sufGciently indicate-
Then, again, in the domain of obstetrics, the treatment of
extra-uterine fcetation, and the diseases of the ovum and
of the fa3tii8 in utero, are subjects of which for long we
have heard but little. As an illustration of the rather
general unfamiliarity with these matters which prevails, and
which discussion here would do much to mend, I may
mention that at the late M.B. honours examination at the
London University a considerable portion of the picked
men who were in for it hud never heard of a papyraceous
fcetuB, even although its synonym of secondary fcetus was
given. And one still not very infrequently comes across
a lingering belief in hydatids of the uterus as the equiva-
lent of vesicular degeneration of the chorion. In connec-
tion with that examination, also, I am reminded that a
careful study of the variations of the foetal pulse under
varying circumstances, during gestation as well as during
an ordinary and prolonged labour, would form a very
acceptable monograph to bring before the Society, for
most English text-books have but little about it, and that
little somewhat contradictory. And, lastly, the operations
of Porro, Freund, and Thomas, and in gyntecology of
Battey (who, I may mention, was a contributor to the
very first volume of our 'Transactions,' on the operative
treatment of vesico-vaginal fistula), must inevitably before
long come up for consideration and judgment.
Permit me now, gentlemen, to end as 1 began, by
expressing once more my sincere thanks for the great
honour you have conferred upon me, the greatest I can
over attain; and once more also to express my earnest
hope that neither the work nor the fame of our Society
may suffer any diminution during my tenure of ofBce.
TDRNINO IN CASES OF CONTKACTED BEIK. 61
A vote of thanks to the President for hia interesting
address was proposed by Dr. Robert BarneSj seconded by
Dr. Geailet Hewitt, and carried by acclamation.
TITRNING IN CASES OF CONTRACTED BRIM.
By P. L. Bdbchell, M.B.
I ODOHT, perhaps, to apologise for troubling yon at all
with the following crude remarks ; my excuse for so doing
is, that I have for many years observed that in certain
casea, my younger professional brethren are aometimea at
a loss, and in great doubt as to the best way to proceed.
I have, frequently, been consulted by friends in cases
where the labour has been so lingering, that great anxiety
haa resulted, and upon looking into my case-book, have
found tho details of as many as 45 cases, such as follow,
out of 8000.
A woman, who has bad several children, easily brought
naturally into the world, in about the sixth or seventh
labour finds herself unable to be relieved in the usual easy
manner ; and her medical attendant, no advance having
been made for many hours, is at last obliged to have
recourse to long forceps which often failing, subsequently
to craniotomy.
I find I have met with forty-five cases in wbioh a
contracted brim, resulting, as it appears to me, from a
deposit npon the promontory of the sacrum, after several
natural births, has necessitated some other than the
ordinary treatment. I will only give a brief account
of one patient, that may be interesting to some of my
younger colleagues, and the treatment adopted, useful for
their guidance.
What I am about to advance is now no new proceeding,
hot when I first practised it I believe it toas new, or at
any rate very rarely bad recourse to. The &rst that
62 TUBHINS IS OlaSB OP CONTaACTSD BBIU.
occurred to me, was a private patient of one ai the Royal
Maternity midwives (Mrs. Griggs), when I held the office
of one of the surgeoua (a good many years ago) ,
On Aug. 31st, 1856, Mra. B — , au immensely fat woman,
set, 38, had been in labour with her eighth child many
hours. Head above brim with a large " caput sncceda-
neum," pains had been very violent but were diminishing
in power, and the patient's strength beginning to fail, I
applied long forceps but did not succet'd in delivering, and
had recourse to the perfoi-ator ; she made a good recovery,
I found on inquiry she had always had easy delivcricB,
and the midmfe informed me she had had children qait«
as large as tho one I had just brought into the world,
and generally, she was in the house but a ehott time
previously to the birth.
At Mrs. B — 'a next confinement, which was on Jan.
12th, 1858, I was engaged, and when summoned found os
uteri very high up and dilated to the size of a crown-
piece, and very soft and dilatable ; so I at once deter-
mined to try delivery by turning, and brought a full-sized
child into the world alive, but not without some difficulty.
The same course I adopted in the same patient at two .
subsequent labours with the like result. Since which
period I have followed the same plan in forty-five cases
as stated, saving the lives of thirty-eight children and with
no fatal results to any of the mothers. I have been very
much surprised to find that this mode of practice has been
very rarely followed by the gentlemen (and some of great
experience) with whom I have had commuuicatiou upon
tho subject. I know several of our professors believe that
there frequently is a diminution in the capacity of the inlet
of the pelvis in women after bearing many children, quite
independently of ordinary disease.
Dr. Roper, if he be present, will remember one case, a
patient of his late lamented partner, Mr. Hopkins, that
came under my care, a few years since, of contracted brim,
in which I saved the life of the child by this treatment j
at the woman's previons labour its life was sacrificed, and
TUBinHO TN CA8BB 8F CONTBA.CTBD BBIU. 63
brought into the world with the greatest difficulty. I am
a great advocate of the use of long forceps in suitable
cases, but many such as I have just mentioned are better
treated by turning according to my experience.
Or. Barnes obBerred that turning in minor degrees of pelvic
uarrowiDg had been much resorted to since Sir James Simpson
advocated it. He himself had practised it largely and bad placed
turning between the forceps and craniotomy. Greater eiperi-
ouce, bowever, had led him to the conclusion that Tarnier's
forceps give a better chance of deliveriog a live child than did
turning, With the forceps in common use, turning in some cases
was better; but he believed the cases were very rare in which
Tarnier's forceps was not superior.
Dr. Chahpnbts said that he had two points to call attention to
in connection with Dr. Burchell's interesting cases. The first
was that increasing difficulty in successive labours was well known
and sufficiently explained by such facts as the increasing power-
lessiiess of labour, the increasing size of the children and the
increasing size and hardness of their beads. Such a theory as
progressive diminution of the pelvis was therefore unnecessary,
but it was also directly contrary to known facts. The growth of
bony tumours was very rare, and the direct measurement of the
pelvis by the whole hand — by which alone even approximate
accuracy could be attained, had not apparently been practised in
his cases. Where it was practised, no such result as that indi-
cated had been arrived at. With regard to the frequent use of
turning, it must be remembered that a fallacy surrounds the
frequent use of all operative procedures ; the practitioner who
turns all children or who puts forceps on all heads will of course
got the best percentage in the results of operation cases, but will
by no means save the most women and children.
APHTL 4th, 1883.
Hbnbt Geevis, M.D., President, in the Chair.
Present — 49 Fellows and 7 visitora.
Books were presented by Dr. B. F. Baer, Dr. H. W.
Acland, Dr. W. S. Playfair, and Mr. T. Spencer Wells.
Cliarles Davidson, M.R.C.S. ; Henry Roibnrgh Fnlier,
M.A.Cantab., M.R.C.S.; Theophilua Hoskin, M.R.C.S.;
Robert Edward Inman, M.R.C.S. ; Percy S. Jakina,
M.R.C.S., and H. Macnaughton Jones, M.D., were
admitted Fellows of the Society.
Patrick J. Cremen, M.D. {Cork} and Philip W. G.
Nunn, L.R.C.P. Loud. (Boumemontb) wore declared
admitted.
The following gentlemen were elected Fellows :—
Robert John Allan, M.R.C.S, ; John Edwin Cooney
L.R.C.P. Ed. (Fulham) ; John Gordon, M.D. (New Cross) ;
and Robert Percy Middlemist, L.R.C.P. Lond.
The following gentlemen were proposed for election : —
Alexander George Duncan, M.B. M.C.L. Aber. (Stam-
ford Hill) ; Peter Horrocks, M.D. ; Arthur Jukes
Johnson, M.B. Toronto (Ontario) ; Oliver Calley Manrice,
M.R.C.S. (Reading); John Irwin Palmer, M.R.C.S.
(Kingston-on-Thames) ; Francis Joseph Salter, L.R.C.P.
Ed. (Leeds) ; Henry Sutherland, M.A., M.D. Oson. ; and
Thomas Marshall Wilkinson, F.R.C.S. Ed. (Lincoln)
VOL. XIV. 5
DEAD FfETUS.
Db. Godson exhibited a foetus of about four months'
development with placenta attached, showing a knot in
the umbilical cord with atrophy of the cord on either side
of it. The patient from whom it had been expelled had
fallen down when four months advanced in pregnancy,
and from that time the womb ceased to increase in size.
No signs of abortion however occarred till three raontba
subsequently when the specimen shown was suddenly
expelled. Dr. Godson had seen the patient a fortnight ,
previously and had diagnosed a dead fostus in ulero. Tha
knot in the cord appeared to be the cause of death.
DERMOID CYST.
De. Edis exhibited a dermoid cyst he had removed from
a patient, set. 42, Married eleven years. Mother of six
children, youngest thirteen months. The patient had no
reason to suspect the presence of any tumour until just
after her last confinement, whyn the abdomen did not
return to its noi-mal size. She had a miscarriage iu July^
1882, about the fourth month, and from that time the
abdomen began to increase in size.
On examination a tumour was detected extending up to
nliout half way between the umbilicus and the scrobiculuB
cordis, apparently eemi-solid, giving only obscure signs of
fluctuation. Per vaginam the uterus was found to be
drawn up out of the pelvis, the cervix being on a level
with the symphysis pubis, and immediately behind this
the tumour occupying the greater portion of the pelvis, of
ftbout the siiEe of a fcotal head, continuous with the
tntuour felt in the abdomen.
She waa odmitt-ed to the Chelsea Hospital for Women
im February 20th, 1883. Ou the 23rd the tumour was
raiuovtHl by abdominal section. It proved to
deruioitl oy^t, composed of two portions, communicating
J
EKING F1BR0-Uy(
one with the other, regembling a figure of eight in shape,
containing large quantities of sebaceous matter, hair, and
B dirty blackish fluid. There were numerous adhesions
both to the uterus and neighbouring organs, aa also to the
pelvis. A separate ovarian cjst the size of an orange was
found attached to the right ovary. This was removed
together with both ovaries. Owing to the numerous
adhesions and the difficulty in arresting bleeding the
operation lasted one hour and a half.
The patient made an uninterrupted recovery.
On examination of the tumour it was extremely difficult
to determine from whence it had sprung. At the time
of operation it seemed to have a very extensive attach-
ment to the posterior portion of the fundus uteri. Both
broad ligaments were so much involved as to necessitate
removal, both ovaries as well.
UTERINE FIBRO-MYOMA.
Mr, Ehowslky Thohnton showed a large uterine fibro-
myoma, removed at the Samaritan Hospital on March
2lBt by snpra-vaginal hysterectomy. The patient was a
married woman with no family, tet. 34. The abdomen of
the patient had been opened some years before under the
impression that the tumour was ovarian, and when a soft
fibroid enlargement of the uterus was found, the incision
was closed. A hernia had resulted, and became very
large, and eventually ulcerated on the surface and bled.
The patient suffered constantly great pain and was at last
completely bedridden. Mr. Thornton believed the hernia
to be a mass of omentum adherent to the tumour and to
the parietes ; but it proved to be an actual hernia of the
fibro-myoma, the adhesions to the abdominal parietes
were so vascular that at one time there were twenty-six
pairs of compression forceps on about a third of the
circumference of the mass. After dissecting out the
hernia and freeing the mass from adhesions the broad
68 A PIBRO-MYOMA ASD NBW AXI9-TRACTI0N PORCEPS.
ligaments were transfixed and tied on each aide, and the
ovariea which were both greatly enlarged, one of them
being also cystic, were removed ; Koeberle's serre-noeud
was then applied in the usual way and the stump fixed ia
the lower angle of the wound. The masa weighed eleven
and a. half pounds. Mr. Thornton pointed out that the
case would have been a good one for cure by removal of
the uterine appendages, had the hernia and condition of
the old cicatrix not rendered it impossible to close the
incision without removing the uterus. The tumour waa
of the soft vascular kind which gives the best results
after this operation, and the ovaries and vessels in the
broad ligaments were greatly hypertrophied. A coil of
small intestine which was very firmly adherent to the
upper part of the old cicatrix, was carefully dissected off
and dropped into the peritoneum. The operation occa-
pied nearly three hours. Mr. Thornton believed the
Specimen (hernia of a fibro-myoma of the uterus) to bo
nniqne. In reply to the President he said that the
patient was convalescing satisfactorily, and in reply to
Dr. Aveling, he said that the ovaries not only could have
been easily removed, but were actually removed as a
preliminary to the application of the serre-noeud, the base
of the mass being too broad to allow of the wire being
made to include the broad ligaments as well as the uterine
stamp.
A FIBRO-MYOMA AND A NEW AXIS-TRACTION {
VULSELLUM PORCEPS.
Dr. Barnes oshibited a fibro-myoma, and a " New 1
Asia-traction Volaellum Forceps," which he had devLsed |
for the operation. The tumour waa sessile and partly J
embedded in the uterine wall. Before it waa possible to I
get a wire round its base, it waa necessary to partially i
enucleate and to drag it down. The preliminary freeing
of the tnmour was done partly by the knife partly by the
PLACENTA. 69
finger. Then tlie tumour seized by the axis -traction
Vulaollum was dragged down. The axis-traction by
carrying the instrument well back, not only brought the
tumour within easier reach, without undue or misdirected
force, but also left room in front for the manipulation
required to adjust the wire and watch the action of the
ficraseur. The ^craseur used was Weias's endless drum
^craseur. Dr. Bamea thought this application of the
principle of Tamier's obBtetric forceps would prove of
great value.
Dr. Heywood Suitu suggested that Dr. Barnes' forcepa
should be used with bis own fibrous tumour forceps with separable
blades to lock with midwifery forceps, as otherwise the deep
curve of Dr. Barnes might render them difSoult of introduction
in some L-ases.
Dr. AvKi.iHi} said the sigmoid form of forceps which permitted
axis traction was invented by himself and published ten yean
before Dr. Tamier's forceps of the same form were made known.
He was glad to have the opportunity of etatiug this fact, for the
priority of bis invention was Dot recognised to the extent be
would wiah.
PLACENTA.
Dr. J. Williams showed for Mr, Mark, a placenta from
case of Mra. W — , ait, 30, para 4, confined April 4th,
1883, at the General Lying-in Hospital. Labour natural.
Child female, full time.
On the ftetal surface of the placenta is a cyst about the
Bise of a Tangerine orange, two inches in diameter,
almost entirely surrounded by the amnion. It is soft and
flabby, its walls being of much the same thickness as thn
membranes. When opened, about two onnces of a dirty
brown fluid, somewhat like amniotic fluid, escaped. Its
base consists of a fibrous mass the size of an almond,
which is laminated, pale yellow in colour, and sinks into
the snbstance of the placenta fur about a quarter of an
inch.
70 THR PSEBSUKB OF THE FBllOOA AND ITS
Report of Committee on Tuvwur shown hy Or. Wynn
Williams at March Meeting.
On microscopical examination the tumour sent to me
by Dr. Wynn Williams appears to be made up of plain
muscular fibres mingled with a large amount of con-
nective tissue. — Alban DoRiN.
My examioation of a different section exactly accords
with this, — Clement Godson.
I have examined the tumour sent to me yesterday by
Dr. Wynn Williams and find it to be an ordinary fibroid
tumour. — F. A. CHiMPNEYS.
ON THE " PRESSURE OF THE FEMORA," AND ITS
INFLUENCE ON THE SHAPE OF THE PELVIS.
By Francis H. Champneys, M.A.. M.B. (Oxon.), F.R.C.P.
ETC., AND AaBISTART OSSISTKIO
B&FOBB discussing the subject of the present inquiry, it
will be necessary to state a few points in the history of the
question.
The history of pelvic literature shows a change in the
methods of study. The earlier anatomists, such as Cru-
Teilhier and Hyrtl, devoted their attention to the sacrum,
the action of which as a wedge was formulated by Dubois
and Gavarret ; this view was attacked by Matthews Dun-
can, and is now only found in anatomical text-books,
where it still survives, to the confusion and misinformation
of the student.
But all studies of the pelvis were vague and uncertain
until its normal position was known, and the determination
of the normal pelvic inclination was made by Naegele,
and that of the mechanism of standing and walking by
the brothers Weber and by Meyer. This work was so
important that it is hardly to be wondered at that the
IN^LUKNCB ON TH8 SHAPE OF THE PELVIS.
71
pelvis has been almoafc exclusively studied from this point
of view, and that other important postures have been
neglected.
The earliest pelvic studies were almost exclnsively
statical, and concerned already formed pelves, as modified
by the effects of gravity.
The dynamical effects of muscular action have formed
another branch of inquiry, which, however (with one
exception), has never been prosecuted with any great
accuracy, and which has to be gathered piecemeal from
the writings of Hubert and Valerius, Spiegelberg, Freund,
and others. In the work of Kebrer, however, we have
one of the most valuable sources of information in the
whole of pelvic literature.
A new era opens with the serious study of the pelvis
during its development, and the writings especially of
Fehling on the normal fcetal pelvis, and of others {e.g.
Shliephake) on the rickety ftetal pelvia, under his influ-
ence, have shown that the subject has to be to a great
extent reconsidered from this point of view. Indeed so
largely does this branch of study establish the claims of
growth and development to points which had long been
assigned to other causes, that it is almost necessary to say
a few words on the question.
In the classical work of Litzmann the causes of the
shape of the pelvis are thus enumerated :
1. Original design, development and growth of the parts
of the pelvis.
2. Body weight.
3. Resistance of bones and cartilages.
4. Traction and pressure of muscles.
Of these the first in the list has been the last to engage
the serious attention of pelvic students.
Before proceeding further, we must allude again
to the writings of Fehling and others. It has been gene-
rally taken for granted that the fostal pelvis was unex-
panded laterally, and that this expansion takes place after
birth. Fehling, liowever, has shown that arguments
72
TUB PBBBBITBE 07 THE FSUOBA AHB ]
drawn from dried fcetal pelves are quite untenable on
a<^colmt of the change of shape which occurs iu drying
He proves that the transverse espanaion of the britu is
present even at the third month of tcotal life, and that
the " long oval " form, formerly supposed to be normal in
the foetus and new-born child, is only seen as a rare
exception and is pathological. Sexual differences are
plainly seen in the five months' fcetns. The simple fiat
pelvis is seen in the fifth month also. The pelvis of the
male fcetus is deeper (vertically) and narrower ; that of
the female fcetus is shallower (vertically) and broader ;
the acetabula are further apart ; all these being supposed
to be adult sexual points. ' The form of the fcetal pelvis
is much more like that of the aduU than has been supposed,
The changes in shape cannot be due to gravity, they can
hardly be explained by ovoraction of muscles, the floating
foetus having no " point d'appui," and tho flattening
being BOeh in the third month, when the legs, and especially
th.eir muscles, are very slightly developed. Many peculi-
arities of the rickety pelvis are to be regarded as an arrest
in the foetal condition, some as an exaggeration of the
fcetal state, especially in view of the ftotal rickety pelvis.
The perpendicular position of the ilia is probably due to
the alightness of muscnlar action and of intra-abdominal
pressure ; in macerated children vfith swollen bellies the
ilia are much more horizontal.
Muscular action may be the cause of the approxi-
mation of the anterior superior iliac spines in the second
half of fcetal life. In the fostus the anterior inferior
spines are very small. Tho traction of the itio-sacral
ligaments is far less important than has been supposed,
the fcetal pelvis has its transverse development without it.
If the pelvis of the new-born child were so pliable that
the body weight actually bent the ilium, this would be
shown pre-eminently at the soft cartilaginous parts, e.g.
tho acetabula and alee of the sacrum. The acetabula
uhiiw no signs of indentation, and yet they are easily
indented in a uew-bom child without increasing the trans-
I
INFLHENCB ON THK SHAPE OP TEE PELVIS. 73
verse diameters. Again, the fulcrum {ala of sacrum)
should show signs of pressure ; on the contrary, the female
pelvis which ia particularly broad has particularly broad
sacral alae. The slenderest part of the brim is just ante-
rior to the sacro-diac joint, and yet the greatest curvature
is (in new-born children) further forward where the bone
ia thicker. If the pelvis of the uew-born child ia so soft
that in the £rst year the thick ilium is bent under mechan-
ical pressure, why is it so different from the malacosteon
pelvis, and why are rickets and malacosteon so different F
The exact limits of the eSeots of growth apart from the
inflaence of the body weight and traction of muscles must
be hereafter determined. Meanwhile Fehling concludes
1. The transverse expansion of the foetal pelvis depends
on original formation and appears very early. The
theory of its production by the body weight is at least
2. Sexual differences are generally present from the
fourth month onwards, and are perfectly distinct at birth.
3. The pelvis of the fcetus and new-boru child shows
transverse oxpanaiou and also marked axial curvature of the
eacrum.
4. The likeneas of this transverse expansion to that of
the rickety sacrum, besides some other points, inJicabo ia
this pelvis an arrest on a foetal grade ***,
Such are the conclusions of Fehling.
The fcetal rickety pelvis has been studied by Kebrer,
Shiiephake, and others.
Writing before Fehling, Kehrer remarks on the bad
logic of studying the folly developed pelvis and neglecting
the earlier forms. He considers what may be called his
favourite subject, the action of mnscles, and especially of
the psoas, middle fasciculi of the iliacus, erector spinie,
and finally all the muscles of the bip-joint together, con-
verging radially towards the upper end of the femur.
Ho concludes that many of the characteristics of the
rickety pelvis appear in the foetus and child not yet on its
tBS PEBSSQU I
• THB PBHOKA. AND ITS
t<ys» and c«BBOt therefore be the effects of the body -weight
•ai) 09lUt<^^ pressure of the feniora, but only of the action
fti HHIMiIm and ligaments. " It ia, therefore, proved for
nvktfts lh»t Ihe action of muscles plays a much greater
)iart than has been hitherto supposed. How far the body-
weight and counter- pressure of the femora can be held
irpmble after my observations for a plastic effect on
rioketv pelvis I will not further inquire. They can at
t be allowed to rank as auxiliary forces, together
ih the primary and self-sufficient action of the muscles."
Shliephake and others have described many ftetal
riukety pt-lves possessing the usual rickety points.
On the above extracts we will only remark that, although
fcVhliug'a conclusions can hardly be assailed, it must not
ho foi-gottbii that the relative force of growth, gravity,
and uiuaoiilar action can scarcely be estimated. Kehrer'a
ouuoluaionH, assigning to tho action of muscles and liga-
lueuts, the exclusive or almost exclusive right to rickety
livfurmity, is met by one of the observations of Fehling
quoted above. It may be remarked that Kohrer'a con-
(jluaiou starts on a false premiss, but tbis may perhaps be
Moused iu one who has done such excellent experimental
work on muscular action, and may, therefore, be pardoned
«tr being au enthusiast.
Tho puruaul of such work as Fehling's produces a sort
vi txivhim ot despair, and an impression that it has finally
ttiit^Mwuil vt all lutititiunical oonsidorations. Such a feeling,
luiviiDVtM', femn pauses off when the malacosteon pelvis is
v^UiiDiubuivd, u polviH in which all actions but those of
)^\\n> ut<H«Kiuiii,iii ait> luHHinnivrily eliminated, and which shows
ikMl juiti IU tbu iittluonce of growth must be remembered
V\vu <A koix^ it v>auuot bo [>ruvod, so tbo domain of mechanical
tullu(>uiH'« tf\tt>ud)i bavk from tlio malacosteon pelvis where
,t \ .'.1^ ,,...l..i.iiii>i| away, ovor the other pelves where it
■ . uultMUt ila action for the malacosteon
\ ".' d«nied.
'it ;.~. .. \t tnu'da wv will pass on to the considera-
INFLL'ENCE ON THE BHAPK OF THE FELVIS.
75
The influence of the "inward pressure of the femoraj"
widely invoked for the explanation of pelvic deformities,
has been taken so much for granted that it seems advisable
to subject it to some scrutiny.
And first of all, it is impossible to read mnch of the
literature of the subject and to study the figures by which
it iu illustrated, without being at once struck by the im-
pression that it has generally been taken for granted that,
not only does the direction of the neck of the femur
represent the direction of this force, but that it actually
explains it. The deformity in the "triangular" pelvis is
80 picturesque, and it is so easily explained by sayiug that
you get the downward pressure of the body weight behind
and the inward counter-proaaure of the femora at the
acetabula. A few words will suffice to shovr that this is
no explanation at all.
i. The shape of the femur, as long as the bone remains
a solid rod, has nothing to do with the transmission of
force through it. A bar may be formed into any curve
or combination of curves, but as long as it is rigid tho
force will be transmitted from "power" to "weight" a-s
if these were joined by a straight line. _ This principle is
utilised in Tarnior's forceps.
The weight of the body and the resistance of the earth
act through the foot and acetabulum as if these were
joined by a straight line. The neck of the femur esists
for the sake of freedom of motion of a ball and socket
joint and for the sake of leverage.
2. The arran(iement of the cancelU in the neck of tho
femur shows tho same fact.
The principal cancelli pass almost vertically from tho
head to the under surface of the neck which is very thick
and strong. From these vertical cancelli others ruu
transversely to the upper (surface of the nock which is
thin. These are evidently braces to secure the neck as
far as may be from downward displacement to which its
shape would expose it, and which actually takes place
when its texture deteriorates.
76
THE PBBSSOBB 09 THE PEUOEA. AND ITS
Finally, the upper end of the shaft consists of dome-
shaped cancelli.
The whole of these arrangements point to tlie vertical
transmission of force, in spite of the difficulties of the
direction of the neck, as the principal idea.
Are we then to conclude that there is no Bach thing
as the " inward pressure of the femora ? " It would be
impossible to maintain such a position in the face of nearly
all the uusymmetrical deformities of the pelvis, but espe-
cially the malacosteon pelvis, on which, as on a wax model,
the action of the principal forces is clearly impreeaod.
Still, the matter is so far from self-evident that it has
been thought well to consider it as regards certain pelves.
It will be well to consider in turn all possible sonrcea
of "pressure of the femora." These fall under two main
heads :
1, Passive resistances.
2. Active operations.
1. The Passive resistances act in opposition to the body
weight, and are exerted ;
(a) By the resistance of bones.
(b) By the resistance of ligaments.
(c) By the action of couples,
2, The active operations include the action of muscles.
These will now be considered in turn, as affecting the
parts connecting the femur and polvis, or parts of the
pelvis inter se.
I. (u) The Grst of the passive resistances to be con-
sidered is that of the symphysis pubis. It need only be
now observed that the resistance here is to the divarica-
tion of the pubic bones which would result from the
action of the iliac beams.
Into the question of the action of the iliac beam we do
not propose to enter ; not only haa this action been now
universally accepted, but it underlies the explanation of
nearly if not quite all deforrait'es of the pelvis after they
come under the operation of the body weight. Its author
INFLUENCE OK THE BHAPB OF THE PELVIS. 77
(loc. cit,, p. 66), however, Bpeaks thus of tlie passive reaiat-
ance of the symphysiB pubia i — " In the explanfttions which
follow, tho anterior arch will be left entirely ont of view ;
this fact (the fact of the union of the
npper and lower arch by cartilage only, during the deve-
lopment of the pelvis) and the slight mobility of the pnbio
joint, will almost, if not altogether, annul its inSuence in
modifying the development of the upper half of the pelvis,"
We cannot admit this aa a solid reason. Cartilage may
be as good a " tie-beam " aa bone within reasonable
limits ; but the objection is directly overruled by the
experiment of Freund (the only direct proof to our know-
ledge of the beam and lever theory), who suspended the
body of a child vertically, supported on the ilia ; the sym-
physis pubia was then divided, and tho pubic bones
became divaricated (' Monat. f. Geburtskuude,' Band xiii,
1859, S. 202). Tbia directly proves that the aymphysia
pubis is at least one of the opponents of the outward
thrust of the lower end of the iliac beam. In thia place
it will be well to aay a few words on the subject of
Scrooder's picturesque sketch of the development of the
pelvia. This conaiets in an assignment of their functions
in modifying the form of the pelvis to (1) the body
weight, (2) the resistance of the symphysis pubis, (3) the
lateral pressure of the femora ^ and is based on a com-
parison of the pelvis of the new bom child, the normal
female pelvis, the cleft pelvis, the fiat pelvis, tho rickety
pelvis, and the malacosteon pelvis. This sketch is
admirably written, and when first written was worthy of
all praise, but it is based on the assumption that the
pelvis of the new born child and fo^tns is destitute of lateral
oxpansioD, and disregards the fact of rickety pelves exist-
ing before birth with marked flattening. The conclusions
are therefore untrustworthy, as Fehling has pointed out.
The cleft pelvis in the same way, being due to a con-
genital deformity and existing therefore before the
operation of mechanical causes, cannot bo taken as
evidence of the operation of such causes.
78 TUB PBESSUHK OF THB PEMOEA AND ITS
In sayiDg tbis, however, we by no means reject the
forces, all of which can be otherwise proved to be in
operation, but merely state the fact that the examples
invoked do not prove their existence.
Hero, however, as elsewhere in this inquiry, we shnll
6nd the malacosteon pelvis has to bo considered.
In this case we start with a fully developed normal
pelvis, in which tlie acetabula are placed external to the
line of the body weight, and we end with a condition in
which this relation is reversed, the acetabula being
internal to the line of the body weight.
Whatever mere resistance to the outward thruat of the
distal end of the iliac beam may amount to, reaction can
never exceed action. This displacement cannot therefore
be due to the passive resistance of the symphysis pubis.
Hence the " ■pressure of the femora" is something more
than the regull of resistance at the aymphysis puhts.
(6) We have next to consider the passive resistance of
the ligaments contiecting the femur viith the pelvis.
Ligaments can only act passively, by means of the
resistance which they offer to movements whether mus-
cular or other, and they only come into play when the
normal movements tend to be exceeded.
Again, acting as they do by preventing divarication of
their origin and insertion, increased tension of them is '
marked in firm bones by either no deformity, or a more or
less limited deformity at their attachments, nith a more
extended action in proportion to the firmness of the bones
and their ability to operate a^ levers.
Lastly, their increased action is marked by bony hyper-
trophy of their points of attachment.
The only ligament of the hip-joint attached at any dis-
tance from the acetabulum (even though a small distance),
and the only one therefore capable of producing any
marked displacement of the acetabulum as a whole, is the
ilio-femoral band. This band, as is well known, is
attached to the anterior inferior iliac spine above and to
the anterior intertrochanteric line below, its action is to
INPLDEKCI! OS THE 8H4PB OF THK PELVIS. 79
limit the extension of the hip-joint, and is well seen in the
kyphotic pelvis where the diminished pelvic inclination
puts it on the atretch. The results are apparent not only
in the slight indentation of the acetabala, but in the
hypertrophy of the anterior inferior spine, and the rotation
of the OS innominatum round an axis running at right
angles to the band, through the acetabulum ; the upper
part of this bony mass being rotated downwards outwards
and forwards, the lower part upwards inwards and back-
wards. The rudimentary condition of the anterior inferior
iliac spine in the ftetus and new bom child shows the same
thing, this ligament having been shown by Meyer to
maintain the erect posture.
This action, however, concerns the whole of the oa
innominatum and is quite different from that of the
" pressure of the femora ;" moreover it cannot be said to
be opposite to the outward thrust of the iliac beam.
Lastly, it cannot be imagined capable of producing the
effect observed in the malacostcon pelvis, and nothing
short of this will satisfy our requirements.
We conclude, therefore, that the "pressure of the
femora " i» something more than the result of tite passive
resistance of the ligaments of the hip-joint,
(c) In searching for an explanation of this " inward
pressure of the femora " it is tempting to look for the
operation of a " couple of forces " between the point of
operation of the body weight and the point of resistance
at the acetabula. If the acetabula were to fall within the
line of action of the body weight near the posterior supe-
rior spines, such a couple would be found acting inwards
and tending more and more to invert the distal end of the
iliac beam. But in all normal and most abnormal pelves
the couple points outwards, the acetabula being external
to the line of action of the body weight, and yet the inver-
sion of the iliac beam is plain, being effected tn spite of
this outward -acting force.
In walking, the arm of the lever representing the
distance between the action of these two forces is indeed
80
THE PKEBSUKB O? TER FXUORA .
ehortened by the tilting of the pelvis downwards oa the
side on which the weight falls, but this incbnation falls
far short of eliminating, still less of reversing the actios
of this couple of forces.
Under this head should probably be discussed the
passages in which Dr. Matthews Duncan speats of the
" pressure of the femora" in his " Researches in Obstet*
rics." These passages, which are scattered, are as
follows :
P. 69, — " The force at the lower extremity (of the iliac
beam) is the reacting force of the weight of the body
pushing in a direction upwards and inwards, also towarda
the centre of the pelvic circle."
P. 79. — " During the whole period of growth, while the
pelvis is increasing in size, and while its joints are still com-
paratively loose, and the bones not solidified or consoli-
dated, it has ever and anon, in standing, walking, &o., &e.,
to undergo pressure from two great forces ; the one, that
of the weight of the body transmitted to the sacrum, and
from it to the posterior iliac tuberosities, or upper ends of
the iliac beams ; the other, the reacting pressure of the
same force, transmitted from the femurs to the ace-
tabula, or lower ends of the same iliac beams. Both of
these forces tend, as already pointed out, to drag the
extremities of these beams in a direction, more or less,
towards the centre of the pelvic cavity."
P. 83, — " In the production of deformities of the bones,
rendered incapable of their natural resistance by rickets or
malacosteon, there are two great causes to be considered,
namely, the efforts of the muscles attached to the bonos,
and that part of the weight of the body snperimposed on
the various bones in the erect position. The sequel to
this paper will justify the complete exclusion of the former
of these causes from any important place in the explana-
tion of the great deformities — at least, of tho character-
istic rickety and malacosteon pelves of the human female.
This conclusion might almost be arrived at on a jjriori
grounds alone. For if we compare the irregular action of
INFLUINCE OH THE 8aAFfl Of THI PELVIS.
81
any muscle or set of muselea, to the iii£ueiiCQ of the great
and steadily acting weight of the body, the unimportance
of the former will appear on account of ita comparative
slightness in physical force, its essentially intermittiog and
temporaiy character, as well as the antagonism of the
various muscles, not to speak of its utter inapplicability,
had it any imaginable force or duration, to explain the
changes in conformation actually produced."
P. 92. — " The natural pressure of the heads of the thigh
bones upwards and inwai-da drives the acetabula in that
direction."
But the following passage seems opposed to the former
quotations :
P. 105. — " To produce equilibrium, the reacting forcea
must be equal and contrary. They are applied to the lower
end of the iliac beam and the cotyloid cavity. In order to
resist the vertical force downwards, there must be a corro-
spouding reactionary force upwards ; and, in order to
balance the force throwing outwards the lower end of the
beam, there must be a force inwards. The combined forcea
will a«t in a direction upwards and inwards. The upward
force is easily accounted for ; it is the supporting of the
weight of the body. The inward force cannot be supplied
by the pubic bones ; these can only act to some extent as
a tie-beam to fix the lower ends of the iliac beams. The
direction of the conjoined forces is indicated by tliat of the
neck of the thigh-bone, and the inward force is supplied
by the enoi-mous muscles and some of the ligaments which
are in action in the erect position, and this with such force
aa to keep the head of the thigh-bone securely in the coty-
loid cavity, a result quite impossible without very powerful
inward pressure."
It must, however, be remembered that the atmospheric
pressure ia quite sufficient to support the whole weight of
the lower limb even after the removal of all muscles and
ligaments. Thia does not of course apply to the applica-
tion of violent or excessive force.
With the view that the counter-pressure to the body
VOL. XXV. 6
82 THE PBESSUBB O? THE FEHOB&. AME> 1T8
weiglit acts upwards and inwards we cannot agree. This
would in a sense be the case if the acetabnlum fell within
the line of the body weight, but it falls ivithout it. This
can be seen by studying any normal pelvisj and from Dr.
Duncan's own figure 7, p. 68, in wliich the acetabulum
can be seen to form the extreme outer end of the iliac
beam ; it can also be seen that in the normal adult female
expanded pelvis the acetabulum is altogether external to
the whole of the curve of the lateral part of the pelvic
brim, and cannot, therefore, conceivably produce any
flattening of this curve. It is true that the direction of
the neck of the femur represents the line of action of the
" inward pressure of the femora," but, as above remarked,
it does not explain it. With the question of muscular
action we shall deal later,
Kehrer (Beitrage, s. 14) deals with the same subject
with reference to the fiat pelvis. He says : " Let us
think oE the two dist. sacro-cotyl. as straight rigid
lines, on the point of junction of which a vertical force
acta downwards (the body weight), and on the lower
extremities of which parallel forces act upwards {the resist-
ance of the femora) . We can combine each of the lower
forces with the upper to form a " conple," and the upper
force can then be imagined as compounded of two forces.
Tlie parallel and opposite forces of each " couple " try to
rotate the rigid rod between them so as to move the ace-
tabulum upwards and outwards (at right angles to the rigid
rod), the upper end of the rod downwards and inwards.
As, however, the inward tendency of the upper extremity
of the rod is opposed by the equal and opposite action of
the other side of the body, the upper end can only move
vertically downwards, But the lower extremities of the rods
in diverging must necessarily expand the arch lying between
them (the inter-pubic angle between the horizontal rami) ■"
S. 22. — " The question whether in the living subject
the ilia are bent by the body weight (the heads of the
- femora being fixed and pressing in the opposite direction),
or by the pressures of the aoetabnla upwards, inwards, and
ISFLDENCE ON THE SHAPE OF THE PELVIB, 83
backwards, and the connterpreasure of tlie fixed base of
the sacrum, is to be answered in the sense that both arc
probably in operation. As long as the individual stands
or sits upright, the body weight must have full play,
and the resistance from the heads of the femora be in
operation. But in standing and balancing the pelvis,
the active pressure of the muscles of the hip must
come into operation. For let us imagine the pelvis
prevented from rising by the superincumbent body weight,
the muscles going from the ossa innominata to the
femora must press the heads of the femora against the
acetabula, and if the bone is softened drive it towards the
pelvic cavity. But probably the operation of these
muscles would soon limit their own effect by approxima-
ting their origins and insertions and producing relaxation,
still within certain limits they are quite competent to
approximate the acetabula to the promontory. Therefora
the sagittal bending of the ilia ia produced by the body
weight and the cotmterpressure of the addvcted femora,
but probably also by the pressnre of the muscles of the
hip," In the above quotation the word "adducted"
{underlined by us) must be noted, as it introduces a new
element, namely, muscular action. If the femora muEt be
adducted in a " rubber " decalcified pelvis to produce this
effect, it is plain that adduction is due to muscles. Of thia
we shall Epeak furtheron. It is plain from the first quotation
that Kehrer makes the couple of forces act outwards and not
inwards. This is in accordance with our own arguments
above.
We conclude, therefore, that the " preamre of the
femora " cannot be due to the action of the couple of
foTcen acting on the bar represented by the distance bettveen
the line of action of the body v:eight and the resifiiance in
the acetabula.
2. We now hsve to consider the actiofi of the mtiscles
joining the femur and pelvis.
And first we must premise that the action of musclea
[as well as that of ligaments) is exerted at both attach-
8-1
THH PBI3SCBB OF IHB fEUOBl JlSD ITS
I
menta. If the bones are firm we ahoald expect to find
either no sign or slight signs of displacement, but we aliould
probably find the frequent sign of bony hypertrophy at the
points of attachment (as in the case of the ilio-femoral band
in the kyphotic pelvis), but if the bones are soft, some
displacement should be apparent at origin, or insertion or
both, according to the mobility of the points of attachment.
The action of muscles (if these were the cause of the
"pressure of the femora") would be shown by the
approximation of origin and insertion. Their combined
action on the hip-joint would be to drive the head of the
femur and the acetabulum inwards and to drag their
origins from the pelvis outwards.
The great difficulty that seems to meet ua is that both
origins and insertions (as marked by the head of the
femur) appear at first sight to be displaced inwards in the
same direction, but on looking more carefully into the
matter two things at once strike ns.
(1) That many of the most powerful muscles rise from
near the middle line in front and behind; (2) that the
immediate neighbourhood of the acetabulum itself is com-
paratively free from muscles.
The result of (1 ) will be that the muscles of the two
sides of the body will oppose the divarication of their
origins ; the result of (2) will be that the opposition to
iuward pressure will be less near the acetabulum.
A difficulty occurs in the tuber ischii and adjacent rami
of pubes and ischium to which very powerful muscles are
attached. But here the malacosteon pelvis shows that
although the side of the pelvis is doubled in together, the
tuber ischii and adjacent parts are rehiiivphj ercrh-d,
marking the traction of the muscles rising from this region.
It is of course conceivable that this eversion should take
place in a softened bone itself doubled in by superior force.
The action of muscles has been the battlefield of some
contention.
Hubert and Valerius, speak thus (p. 744) : — " The
forces affecting the pelvis (considered ae a ring) oan be
IHFLHENCE ON THE SHAPE OF THE PELVIE
85
thus divided : — Ist. (Superior half-ring). Two sym-
metrical vertical forces placed to the right and left of the
sammit of the ring representing the traction exerted by
the weight of the sacrum and sacro-iliac ligamenta. Two
other forces, also eymmetrical, a little obliqne forwards,
and also directed from above downwards, balancing the
former (traction exerted by the ilio-psoas mnsclea on the
superior half-ring, bearing on the edge of the inferior
half-ring). These groups of forces, considered with
reference to the superior lialf-ring, evidently tend to
crash the arch formed by this superior half-ring, if the
heads of the femora or the acetabula are considered fixed.
This can be done as we shall see. 2nd. (Inferior half-
ring). This has to resist (1st.) the pressure exercised by ■
the last forces just mentioned, and which pass like ropes
over pulleys over the ilio-pectineal ridges, which they
consequently tend to depress and force into the interior
of the circle. (2nd.) (it has to resist) two groups of
forces applied to the descending rami of the pubes and
ascending rami of the ischia, and directed obliquely from
above downwards, from before backwards, and from
within outwards (the adductors of the thighs). These
forces, which oppose the eversion of the heads of the
femora, keep the extremities fixed, under the pressure
which the bony ring exerts on the extremities, that is to
say, are one of the principal agents by which the points of
support of the pelvis react on the acetabula. Their effect,
as far as concerns the pelvis during equilibrium, is there-
fore to draw the symphysis pubis towards the femora, that
is downwards and outwards. This action is directly con-
trary to the former. ... In short, the forces in
question would lend ... to increase the transverse
diameter of the brim, to depress the summit of the
superior curve, to straighten the anterior inferior arch,
by indenting the ilio-pectineal region, and drawing tie
symphysis pubis downwards and outwards."
This will be seen to be a plea for the action of special
mnscleB.
8G
THE PBESeUBE OF TSB FEMORA AKD ITS
The opinions of Dr. Matthews Duncan on the subject
have been quoted above. Except in one passage (which
seems to involve a change of opinion from the other quota-
tions) he pronouncesstrongly against the influence of mus-
cular action in producing the " pressure of the femora."
Spiegelberg (S. 144) says : — " The forces which act on
this ring are principally the body weight in the erect
positioUj also the traction exerted by the ilio-psoas and
adductor muscles. The latter act only on the inferior
half-ring, the most powerful force (the body weight) on
the superior; the ilio-psoaa muscles bend the vertebral
column towards the extremities and thus press the sacrum
towards the pelvic cavity, joining their action to that
exerted by the trunk. Besides, they also exert a direct in-
fluence on the inferior half -ring. The influence of the forces
acting on the superior half-ring is that the sacrum is approxi-
mated to the anterior wall of the pelvis, the transverse
diameter expanded, the wall above-mentioned flattened."
To this Freuud (' Mon. f. Geb.,' Band xiii, 1869, S. 186)
replies : — " Since the body weight iu the erect position
acts downwards and backwards ; since the action on the
(sacro-iUac) symphysis aud its ligaments of the pressure
afEecting the posterior pelvic wall does not exist in the
erect position; since the iliac muscles rather approximate
the two acetabula when the legs are fixed; since besides
the psoas muscles there also exist the latissimus dorsi,
quadratna lumborum, sacro-lumbalis, multifidus spinEe,
glutteus maximus muscles, we could (although remember-
ing the muscles which are also competent to pull the
sacrum forwards, namely the levator aui and pyriformis},
say with as much justice as Spiegelberg: 'the influence
of the forces acting on the superior half-ring is such that
the sacrum is drawn away from the anterior wall of the
pelvis, the transverse diameter is diminished, the wall in
question expanded.' "
Spiegelberg further says : — " The inferior half-ring has
to resist the superior; it sustains moreover the preasuie
of the ilio>psoas which passes over it on either side and
INFLUENCE ON THB SHAPE OF THE PBLV18. 87
which tries to press it inwards, and the influence of the
addnctorS) which in consequence of the direction try to
divaricate the puhic bones."
To this Freund replies : — " With regard to the preasnre
of the ilio-psoas muscles, I find it in no way confirmed by
the rickety pelvis. Since Spiegelberg can refer neither
the general flattening of the anterior wall, nor the more
nncommon occurrence of indentation of the pubic bones to
a pressure on the external boundary of the horizontal
ramus of the pubes, and since at the spot over which the
tendon passes, no special impression can be seen, I ask
wherein that pressure manifests itself; to such a pressure
moreover the pressure of the pectineus and obturator
extemus would be antagonists. The action of the
adductors (their traction outwards, downwardsj and back-
wards) is compensated by the sartorius and rectus femoria
and the muscles converging inwards from the tubera
ischii (aemitendinosns and semimembranosus), besides the
obturator intemus and levator ani. . , , The deter-
minatioD of the influence of muscles on the production of
the rickety pelvis is a difficult one, on account of so many
muscles rising from the pelvis and being inserted into it,
of partly antagonistic, partly similar, partly entirely
different action in different attitudes, and also from their
oonnection with parts bo moveable and so much moved."
The above controversy will be seen to centre round the
action of certain muscles. Spiegelberg's plea for the
action of these is met by Freund on the ground of the
action of their antagonists, probably by way of a
"reductio ad absurdum;" but it seems hardly fair to
quote such a muscle as the levator ani which has nothing
to do with progression or even the erect position.
Kehrer's opinions have been partly quoted above under
another heading. About the triangular pelvis he says,
(s. 25), " It it is asked finally what forces accomplish in
the living subject the adduction of the pubic bones, the
median components of the pressurea which are exerted on
the acetabula partly immediately by the heads of the
88 THE PBEB8UBB OF THB FBUOBA AHD ITS
femora pressing against them, partly mediately by the
entire mnscles of the hipa through the means of the heads
of the femora, are capable of producing a mutual approxi-
mation of the pubio bones. These forces, however, appear
in the living subject insufficient to approximate the ace-
tabala so strongly as is found in the "triangular pelvis;"
and I therefore conclude that besides the pressure of the
Lip-muacles on the hip-joint, the pressure of the bed on
the trochanters and therefore on the heads of the femora
and acetabnla, the lateral decubitus being changed, is
capable of plaj-ing a great part in the anomaly in
question."
It has already been remarked that no mechanical argu-
ments can be founded on the rickety pelvis, considering its
characteristic development in the fee tug, and therefore
before the possibility of mechanical influences either from
the body weight and its derivatives, or from the over-action
of any muscle or groups of muscles, the floating fcetus
lying perforce in an attitude determined by mnseular
equilibrium. The nutritional influence of muscular exer-
cise on bones is another matter.
Kehrer concludes (s. 34) that, " the traction and
pressure of muscles and the pressure of bones is a consid-
erable factor in the production of the shape of the pelvis j"
but lie adds {s. 3.5) that we do not yet know accurately
the action of muscles on iinsoftened bones.
Our opinion is that while the influence of mnscnlar
pressure and traction on a pelvis subjected to the influences
of standing, walking, &c., can hardly be denied, it is
impossible to assign to any muscle or groups of muscles
their individual effect, considering how with every move-
ment the resultant probably change.s. We must, therefore,
adhere to the general view enunciated above, and in
speaking of the -action of muscles we shall mean merely
their combined action, compounded among themselves and
also with other influences such as the body weight, which
cannot be eliminated, though its influence alone is incap-
able of explaining the "inward preBsare of the Eemors."
IKPLCENCE OH TUB 8HAPB OP THB PELVIS.
89
"We conclude then that the aclion of the muscles joining
the femur and the pelvis is a true cause of the " inward
pressure of the femora."
Before leaving this part of our inquiry, it will be
well to imagine an outward thrust of the lower end o£ the
iliac beam and to consider its effects on the lower extrem-
ity J the changes produced by this outward thrust must bo
opposite in direction to the forces opposing or preventing
it, and some of these opposing forces may be themselvos
active forces in the production of the " inward pressure of
the femora." If the head of the femur is thrust outwards,
the foot remaining fixed, the changes produced in the limb
will consist of ;
(a) Relative adduction of the thighs.
{6} A tendency towards genu valgum.
(c) Relative ever.sioii of the foot.
(a) Relative adduction of the thighs is opposed by the
muscles and ligaments tending to abduct the thighs and
prevent their adduction.
(b) A tendency to genu valgum is opposed by the
resistance of the internal lateral ligament of the knee-
joint, Ac.
(c) Relative eversion of the foot is opposed by the
muscles and ligaments of the ankle-joint favouring inver-
sion and hindering eversion respectively.
(a) The action of the muscles and ligaments connecting
the femur and the pelvis has already been discussed.
(6) The action of ligaments in general has already been
discnssed, and it has been shown that tissues capable of
passive resistance only can never produce a reaction greater
than the force opposed.
(c) The action of the muscles favouring inversion of the
foot is not thus limited, and, since muacles are capable of
originating force, these muacles are capable (though at a
disadvantage) of exerting active inward pressure on the
acetabula.
Although this action is far from being stvikiag and
picturesque it can hardly be denied.
90
1 FBESSUBB OF THE FBUOBA. AND 1T8
We therefore conclude that one of the factors in pro-
ducing the "pressure of the femora" i« due to the action
of the muscles favouring inversion of the foot.
It moat be remembered also that with the increasing
width of the pelvis the distance between the knees and
feet does not correspondingly increase (aa compared in the
two sexes and in the infant and adalt). It is not denied
that a final cause also exists in the maintenance of balance
by this arrangement.
We therefore come to the conclusion that the chief
cause of the " inward pressure of the fetnora " in sym-
metrical pelves is muscular action, exerted principally
between the femur a?id pelvis, but also to some extent
between the foot and pelvis.
A corollary from this follows, viz. that use of the
lower limbs will increase the " inward pressure of the
femora."
It will be well at this point to say a few words on the
subject of the pelvis of osteomalacia. In this case we
start with a pelvis, presumably perfectly and normally
developed, foil grown, and in which there can be no ques-
tion of any but purely mechanical influences, growth
having ceased.
In the fully developed pelvis of osteomalacia we find
the sacrum driven downwards (and rotated in certain
ways not now to be considered), and the acetabula driven
inwards {reversing the normal action of the " couple of
forces"), the interpubic angle instead of being expanded,
greatly sharpened, and the inward pressure of the femora
(so to say) rnnning riot.
Here we wish to indicate a point not usually recognised,
but having its own significance, viz. that this " inward
pressure of the femora" does not indent the brim uni-
formly, but bends it most at its weakest point (not, let it
be remarked at a point of synostosis, but) at a point
about midway along the horizontal pubic ramus, which is
all but bent doable.
How do we account for this ?
INPLDBNCB ON THE SHAPE OF THE PBLVIB.
91
No doubt the softness of the bones ia the ultimate
cause, and this allows all pressures to act more or less
unopposed by the resistance of bones or their action aa
levers. Thus, the action of muscles drives the acetabulum
more and more inwards and backwards, unopposed or at
least unbalanced by the firmness of bones and by the
outward thrnst of the iliac beam, which as a beam can
hardly be said to exist.
The outward traction at the symphysis pubis which
usually expands the interpubic augle, is abolished for the
same reason.
Let us remark first that of the three principal origins
of the muscles (viz. from near the middle line in front
and behind, and from the tuber ischii and adjacent parts)
two are markedly dragged out, the symphysis standing
out as a beak, the tuber ischii and adjacent parts being
markedly everted; behind, the bones are less easily dis-
torted, but the distortion is visible. Here is a strange
coofirmatioa of oar explanation.
We must next speak of the reversed action of the
" couple of forces."
When the acetabulum has been driven inside the lino
of action of the body weight,
the arm of the lever points
inwards, and the " couple " acts
in the reverse direction. The
result may be considered from
two points of view :
In Fig. 1 the arc of the circle
represents a rigid body with
a pivot at B. A force acting
at p will act on a lever having
the length l e, i.e. the length
of a perpendicular drawn from
the fulcrum to the line of action
of the power (p), l e being
known as the "power's arm." It is easily seen that this
will produce rotation round i, and that ? rotating ronnd
FlQ. I.
92 THE FBEBBCBE OF TEE FEMOBA AKD ITS
K will increase the length of L K, which will act at rapidly
augmenting advantage.
To apply this : — If the acetabulum once gets displaced
within the line of action of the body weight, the distal end
of the iliac beam is rotated inwards with rapidly increasing
advantage. As the pivot e itself is not fixed but moves
downwards, in reality a conple of forces is produced, the
increasing length of whose arm has been just illustrated.
In Fig. 2 it is evident that at any point in the arc
{except at p^ where the
'^"^- -• direction of the force is
coincident with p^, and
p* where the direction
of tbo force is perpen-
dicular to the arc), the
vertically acting force p
may be split into two
forces (represented by
the parallelograms), one
coincident with the arc
and one perpendicnlar
to it. If the arc is
rigid, the force at right
angles to it alone can
act, and this is seen to
increase in the progress
from p' to p*. At p* the force being coincident with the
arc is not split; at p* the force being perpendicular lo
the arc is all expended at right angles to the arc.
To apply this : — Supposing the arc to be sufficiently
rigid to resist a force acting coincidently with itself, the
'orce (f) will simply be resisted by the equal and opposite
iorce of the rigidity of the bone at p' ; but in its progress
lowards p*, the perpendicular F B will steadily increase as
'*, where all the force p is at riglit angles to the arc.
f p is the pressure in the acetabulum, its power of
indenting the pelvic arch increases as the bone gives way
and becomes less perpendicular and more horizontal. The
crrLcxsci os thx aaum or thb rMLvts.
93
I
bone is snppoeed to be rigid, bat tke action of the
component coincident with the arc leaves its mark some-
times by the compression of the bone in its length daring
growth, especially by it^ action at the epiphyses. This
was pointed oat by the anthor in a description of an
imperfectly developed obliqaely contracted pelvis, where
the parts of the pelvic arch coincident with the pressure
were compressed compared with those at right angles to
the pressnre (' Obst. Trans.' vol. xxiv, p. 200),
The two above illnstrations show the effect of the
downward pressnre of the body weight and the upward
pressure of the acetabnla. \Vhether the acetabala are
external or internal to the line of the body weight the
principle is tme. When the acetabalam is external, the
pressnre acts against, when it is internal it operates
together with the " pressure of the femora " in its action
on the itiac beam. The less rigid the bone, the less this
connts.
Before considering the obliquely deformed pelves, other
principles mast be enunciated connected with the effect of
alteration of direction of the body weight acting on the
upper arm of the iliac beam.
1. If the body weight overhangs one side, the principle
enunciated with respect to the neck of the femur comes
into operation in so far as the connection between spiiio
and pelvis is sufficiently rigid to allow the whole bouy
mass to act as a rigid bar, viz. the body weight acts
doH-nwards though a line nearer to the fulcrum of the ittac
beam (the sacro-iliac joint}. The result of this is tlio
practical shortening of the posterior arm of the iliac beam
on the overhung side and its proportionate elongation on
the other.
2. If the direction of the lino of action of the body
weight be altered, another disturbance of balance between
the two sides will result.
Fig. 3, p. 95. If the weight a acts vertically down-
wards, its arm is A* ; if it acts at right angles to the iliac
beam (b), its arm is b'. Thua the more nearly the body
94
THE PEESeCRB OP THE ?BMOBA AND ITS
weight acta perpendicular to the iliac beam, the greater its
action; and the more obliquely it acts, the less its action.
(b) It is plain that this also results from the parallelo-
gram of forces. All forces acting obliquely to the iliac beam
may be split into two components (Fig, 2, p. 92), one at
right angles to the bone and the other coinciding with it.
(If the bone is rigid, the latter vanishes.) Thus the
action of the weight increases as the angle increases until
(when at right angles), the whole weight appears as the
component perpendicular to the beam. Thus, if the body
weight acts obliquely to one side, its action (as exerted on
the iliac beam), diminishes (while its action in compress-
ing the beam in the direction of its long axis increases}, on
the side towards which the weight acts, while on the
opposite Bide (viz. the side away from which the weight
inclines), the component at right angles to the beam
increases, the component parallel to the beam diminishes.
We now come to apply onr principles to the unsym-
metrical pelves, first premising that overweighting of the
affected side is undeniable in the presence of snch facts as
the increased size end curvatnre of the leg bones of the
affected side.
1. The side on which the weight falls is also naturally
the side of the greater action of muscles. If the "pres-
sure of the femora" is mainly due to muscular action in
symmetrical pelves, their increased action on one side will
produce increased "pressure of the femora" on that side.
2. As above described, the weight falling on one side
of the middle line practically diminishes the length of the
iliac beam on that side and increases it on the other.
(a) This alters the equal balance of the " couple of
forces " on each side (which in a symmetrical pelvis drag
the anterior pelvic arch, or in other words the symphysis
pnbis, each to its own side) and gives the advantage to the
couple on the side on which the weight does not fall.
The symphysis pnbis is dragged over to the less weighted
side, and this action increases rapidly.
(b) Together tvith this rotation or dragging, the aceta-
ISPLUENCE ON THE SHAPE OF THE PELVIS. 95
bulnm of the overweighted side oomes more and more
towards the middle Hue, or in other words moves round
the anterior pelvic arch.
The effects of this are that the component acting- at
right angles to the bone increasesj and has therefore
increasing power to indent the pelvis (see Fig. 2),
Again, if this action is excessive, both arms would
point the same way, and would not be antagonists but
associates ; thus rapidly increasing the original action.
(c) When the acetabulum of the overweighted aide is
drawn nearer to the middle line, the direction of the body
weight practically falls obliquely, thus shortening the
arm of the weight on the overweighted side, and increasing
that on the other side (Fig. 3) producing a similar action
to that above described (p. 94,
2 {a)]. The rotation of the F">- 3-
lumbar vertebral bodies to-
wards the affected side is no
douht duo to other causes,- —
causes shared by the rest of
the vertebral column, and
not specially germane to
the present inquiry — but, if
otherwise originated, it is no
doabt increased by the above
mechanical conditions, so that
the sacrom comes to rotate round a centre formed by the
greater resistance to its advance on the overweighted side.
All the above are probably included in the term " over-
weighting of the side of the scoliosis." The two principal
forms of obliquely contracted pelvis (scoliotic and Naegele
pelves) have more agreements than differences. The
differences are probably due principally to the presence or
absence of a sacro-iliac joint (scohotic and Naegele
pelves, ' Ed. Med, Jour.,' September, 1881, by the
author). In the pelvis of Robert (which must be always
considered in connection with that of Naegele) the peculiar
distortion is probably due principally to the " pressure of
9(J
THE PEBeBUEB O? THIS FBMOHA AND ITS
the femora " nnopposed by tte action of the iliac beams,
which ia abolished by their ankylosis.
We conclude, therefore, finally that in aymmetrUal
pelves and pehea in which the acetabula lie without tlte
line of the body weight, tli^ " inward -pressure of the
femora" is due to muscular action; in unsymmetrical
pelves and pehes in which one or both acetabula lie
within the line of the body weight, to this aiid other
causes above enuvierated ; and that in the phrase " tn-
ereaaed pressure of the femora on the affected eldo"
numerous and vanovs injlut
s are implied.
W0EK8 Rbfbbbed to,
Ohampneys, — Obat. Trans,, vol. xxiv, 1882, p. 200.
Champneys. — Ed. Med. Jour., Sep., 1880.
Gntveilhier. —Bescr. Anat. Paris, 1843-5, 1862-71. .
Dubois. — Traitt) complet de I'art des Accouchements,
Paris, 1849.
Duncan. — Researches in Obstetrics, Edinburgh, 1868.
Eugel.—'Wieri. Med. Woch., 1872, No. 40.
Fekling. — Die Fonn des Beckens beini Ftitus und
Neugeborenen (Arch. f. Gyn., Band x, 1876, S. 1).
Freund. — Ueber die Fortpflauaung des Druckea der '
BumpHast auf das Krenzbein (Monatss. f. Geburtskuude,
Bandxiii, 1859, S. 186).
Hubert and VaUrius. — Gaz. Med, de Paris, 185C, p. 722.
Hyrtl. — Handbuch der Topog. Anatomie, Wien, 1863
and 1857.
Kehrer. — Zur Entwickelungsgescliichte dee rachitischen
Beckens (Arch. f. Gyn., Band v, 1873, Heft 1, S. 55).
Kehrer. — Beitrage zur Vergleichondeu und Experimen-
tollen Geburtskande, Giessen, 1877, Drittes Heft,
Pelikologische Stndien, 1869.
Litzmann. — Die foi-men des Beckens, Berlin, 1861,
ra?LnENCB ON THE SHAPE (
97
Metjer. — Das aufrechte Stohen (Miiller'a Ai-ch,, 1853).
Naegeh. — Ueber das weibliche Becken, Carls rah e,
1825.
Bhli&^kake.^Arch. f. Gyn., Band xx. Heft 3, 1882,
Sehroeder. — Lehrbuch der Geburtahiilfe, v. Aufiage,
Bonn. 1881.
Spiegelberg. — Monatss. f. Gebartskunde, Band xii, 1868,
S. 143.
Weber. — (Wilh. u. Ed.) Meobanik der menschlichen
Gehwerkzeage, Gottingen, 1836.
Df. B.^an^s suggested that one factor in producing flattening
of the pelvis in the foetua might be the attitude with the thighs
doubled up. The preaBure from this attitude acting upon rickety
bones might be enough to produce deformity.
Dr. MATTHEwa Dltxcan had followed by a strong effort tiie
most of the quickly read and many detailed paper, and though
it controverted views to which ha was at one time attached, lie
agreed with it in the main. Thirty or forty years ago the doc
triuee regarding the construction of the pelvis were grossly
erroneous, and it was the work of that time to destroy these
errors and thus make way for the truth. He was glad to see
that Dr. Champneya adopted the chief physiological corrections
then made, as to the function of the sacrum and of the iliac
beam ; and these were great matters, coasideriug the cardiaul
character of the errors and their dilfusion in text books and
papers. Dr. Chanipneys bad given a valuable sketch of tbe
progress of this subject and especially of the work of Kehrerand
of!tehling. The action of muBcles bad been strongly insisted
upon in summary, and now Dr. Chacnpneys had made a special
study of the action of the femur on the acetabulum as a resuit
of body weight and of muscular force and a great contribution
o pelvic literature. After ail he (Dr. Duncan) would not give
muscular action a paramount position, and for that he still vin<
dicated the great force of body weight.
Dr. AvELiso wished to call the attention of Dr. Champneys
to a pelvis in the museum of the Society, the form of which
appeared to be normal although congenital dislocation of tbe
hip-joint was present.
Mr. Albas Doean observed that the theory attributing the
form of certain bones to the action of mueclea lu ftetal life was
hard to prove and formed a most dangerous basia for arguments
relating to tbe development and configuration of the pelvis. The
movements of voluntary muscles were but feeble m a mature
fcetus, but it needed far more force to bend a cartilaginous pelvis
VOL. XXV. 7
dS THE FBESSnSE OP THE FEUORJl, ETC.
tban to more a festal ami or leg. The allied muBcular actioa
must bt! either clonic or tonic. It is against all analogy to
suppoee that bones are pulled into ebapc by a Beries of codtuU
eive attacks affecting the eurrouading muBclcB. On the other
hand, the normal tension of a foetal muscle, not in action, can
hardly be strong enough to bend an osBifying cartilage, nor ia it
probable that striated muscular fibre can maintain itself in b
condition of extreme and permanent contraction, Bufficiently
powerful to alter the form of any part of the foatal sljeleton.
Dr. Cbampneys said that he must thank the Society for the
patience and kindness with which they had listened to his long
and he feared very dry paper. Dr. Duncan's remarks were
EBpecially valuable to him as those of an expert on the subject,
and while differing fro:n some of the couclusiona arrived at by
Dr. Duncon, he neither forgot that those conclusions were thirty
years old, nor that the chief result of Dr. Duncan's work (the
demoustrntion of the "iliac beam ") was univereally accepted and
formed the keystone of all argumentB founded on the mechanics
of the normal and abnormal development of the_ pelvis. Again,
while unable to agree that th& inward preaanfe of the femora
was a function of the body weight, he quite agreed with Dr.
Duncan that the greatest of all the mechanical forces acting on
the pelvis after the assumption of the erect poBition was that of
gravity. Pehling'a researches showed that the action of mechanics
had been pressed too far, but by no means upset it ; indeed, any
person who was unable to see the contrary from the study of the
pelvis deformed after being perfectly developed (such aa those
of malacosteon and kyphosis) would seem incapable of reasoning
and would deuy the persistence of force. With Dr. Barnes'
remarks he could nut agree. The fstal attitude, though it
would be one of constraint to an adult man or woman, is the
attitude of rest or equilibrium fur the fcetus ; it is seen quite
early, and long before the fcetus nenrly GUb the uterine cavity,
and is, therefore, no more a proof of unequal pressure than
ia the folding of a bud or of the frond of a fern. It cannot
therefore be held answerable for tlie trausverae espansion of the
f(Btal pelvis. The free flotation of the fcetus was alluded to
in the paper.
Dr. Babnes replied that he was speaking not of the normal
but of the rickety ftetal pelvis.
Dr. CuaMpneis could not see that that made any difference,
fhe pressure would be present or absent in both cases alike
whether the bones were healthy or not. To Mr.' Doran he
replied that the spasm of muscles in utero is unproved for the
ordinary fcetus, and again, apart from iho nutritional influence
of muscular action (referred to in the paper), would be at
least greatly limited by the absence of any point d' appiit for
the freely fioating fcetus. He supposed we oil agreed that we
I
1
»
LABOUR WITH ATRKBU TAGIN*.
came into the world nith pelres of a certain form, partly at least
beoause our grandfathers and grandmothers had somewhat
ainiilar ones before us, and the difference between the words
"congenital" and "atavism" in tbia connection seemed to
be principally that between a word of four and a word of
three sjIlableB. He begged to thank the Society once more for
their kind attention.
A CASE OF LABOUR WITH ATRESIA VAGINAE.
By Fancohht Barnes, M.D., M.R.C.P.,
ETBICIiH 1
>SFIIAL FOn WOUIK; ASatSTAST OBaXZTBl
PUTHICIAN
TO TH
E ORBAT KOBTHEBS HOSPITAL; PHTSICIAS
to IBB
The patient, M, A. M — , set. 21, primipara, had always
been healthy and Lad menstruated naturally.
On December i4tli, at 3 p.m., ehe went into her first
labour. Mrs. Taylor, one of the midwives of the Hoynl
Slaternity Charity, saw her, and sent for Mr. John Davies,
who, on examining by the vagina, Tras unable to detect
aoy opening into the uterus. He could only make out a
ail-de-sac of about one inch within the vagina. Thinking
the case might require Cfesarian section, he sent to Dr.
Hall-Davis, who sent the patient into the British Lying-in
Hospital.
When I saw the patient at 8 p.m. in the hospital, I
found, on examination, a short vaginal cul-tle'sac of about
an inch and a half in length, at the end of which no sign
whatever of any orifice or os uteri conid be made out by
the touch. Having syringed the vagina with a carbolic
lotion, I introduced a speculum, which enabled me to
discern a minute pin-hole at the bottom of the cul-dc-tmc,
from which a drop of blood and mucns was escaping.
This was evidently the orifice of a canal leading into the
uterus. It only admitted the entrance of a uterine sound,
and Bome preesurewas required to effect even this. Fur-
100
LABODB WITH ATBZSU VAOISE.
ther examination by the touch made it clear that a body
of at least two inches in thickness occupied the interval
between the pin-hole orifice and the mouth of the womb,
and that this mass of tissue was traversed by a canal of
the same diameter as that of the pin-hole orifice.
The condition just described was verified by my father,
Dr. Hobert Barnes, and by Dr. Edia. After consultation,
it was dotermined to endeavour to open up an entrance
through the vagina into the uterus, instead of resorting
to Caesarian section.
At 9.30 p.m., the patient having been placed under
chloroform by Dr. Edis, I passed a Priestley's dilator into
the orifice at the fundus of the vajfina and dilated it. I
was now able to introduce a Simpson's metrotome, with
which I made incisions on either side to the extent of
aboDt an inch.
The opening thus made was gradually extended upwards
for about two inches and a half on either side, until the
uterine cavity was reached. The canal thus constructed
was enlarged on either side by laceration with the finger.
The presenting hciid could uow bo felt. The membranes
having been ruptured, the first blade of Tariiier's forceps
was applied, but, owing to the extremely limited space, I
was unable to apply the second blade, the first blade was
therefore removed. I now applied, without any difficulty,
both blades of Barnes' long forceps to the presenting
head. Slow and steady traction was made, by which the
canal was gradually suflicieutly lacerated to admit the
passage of the festal head,
Considerable traction-power was required to effect the
delivery of the head, which was in the occipito-posterior
position. The child was a live male weighing seven pounds
and a half and was delivered at 10.30 p.m., the whole
operation having lasted a little over an Lour. The
placeuta was expressed ten minutes afterwards. There
was cocsiderablo hiemorrhage from the extensive area of
incised and lacerated tissue. The operation was performed
under tho carbolic spray. The patient was syringed out
UBODE WITH ATRESIA VAGIKS. lOl
twice daily with a 1 in 50 carbolic solutioDj during her
stay in the hospital.
The lying-in was unattended by any unfavorable sym-
ptom, the highest temperature reached being 101*2'' Fahr,
on the evening of the third day after deliverj', On the
evening of the fifth day after delivery the temperature was
normal, and remaiued bo until she lefb the hospital on
December 28, 1881. The day after delivery the patient
received the usual mixture, which is given in the hospital
during the lying-in, as follows ; — Quiuite gr. ij, Acid.
Phosphoric, dil. irix, Tinct. Opii i)i.v, E.'^t. Liq. ErgotsB
TH.X, water to Jj- Beyond a dose of 160 grains o£ sulphate
of magnesia on the fourth day, the patient required no
other medicines of any kind.
On examination three days before the patient left the
hospital, I found the os uteri at the end of a granulating
canal of about two inches and a half in length. Had the
patient not been about to return to married life, I should
have introduced a Hodge pessary to prevent the union of
the opposed granulating surfaces.
Cases of atresia vaginse complicating labour are rare.
When they arise they offer serious obstruction to labour,
and, ns in the case just described, necessarily require
operative interference. 1 regard this case ae illustrating
almost the last degree o£ atresia vaginsa in which delivery
can be effected through the pelvis.
Dr. Ems stated that the patient origiuaJlj presented herself
ae nn out-patient at Middleaes Hospital some few weeks after
her marriage, in order to ascertain if she were rightly formed,
as her husband told her she was not like other women. On
eiaminatioa a short eul-de-rac, scarcely an inch Ions, was dis-
covered in place of the ordinai-j vagina, a mere pin-hole aperture
being detected In the upper portion. She was advised to come
in for operation, but never returned. At the time of labour, at
term, the condition of the parts was almost identical with that
previously observed. There seemed to be a thick septum of
dense tissue between the cul-de-sac and the cervix uteri. It was
surprising how soon the obstruction (lisa]>peared after an incision
was made, and the aperture dilated with the finger.
102 LABOUR WITH ATBESU VAQINiB.
Dr. Heywood Smith reminded the Society of the case which
he had reported some time ago, where there was no orifice
whatever to be found, and where he opened the original roof
and delivered the child without much delay, but in his case the
vaginal roof was not so thick as in the case Dr. F. Barnes had
just related.
MAY 2kd, 1883.
Henrt Gebvis, M.D,, President, ui the Chair.
Present — 52 Fellows aud 2 visitova.
A book was presented by Mr. C. E. Jennings.
John Edwin Coouey, L.R.C.P. Ed., and W. H. Jones,
M.B.C.S., were admitted Fellows of the Society. John
Goi-don, M.D. (New Cross), was declared admitted,
The following gentlemen were elected Fellows : —
Alexander George Duncan, M.B. (Stamford Hill) ; Peter
Horrocka, M.D. ; Aithur Jukes Johnson, M.B. (Ontario) ;
Oliver Calley Maurice, M.R.C.S, (Reading) j John Irwin
Palmer, M.R.C.S. (Kingston-on-Thames) ; Francis Joseph
Salter, L.R.C.P. Ed. (Leeds) ; Henry Sutherland, M.A.,
M.D. (Oion) ; and Tbos. Marshall WUkiuson, F.R.C.S. Ed.
(Liuooln).
CASE OF EXTRA-UTERINE FCETATION.
By J. A. Mansbll-Moullin, M.B., M.R.C.P.
The patient from whom the accompanying specimen
was removed presentt-d herself among my uut-patii;nts at
tho Hospital for Women on April 9lh, 18S3. She was
suffering great pain at the time, aud was evidently
JOt
BXTBA-UTBEIKE PfETATIOV.
She was admitted at once into the
dangerously ill.
hospital.
The following is a brief account of the case : — The
patient, set. 36, had been married eleven years, but had
never been pregnant. Her general health had always been
gooa. Up to the first week in December, four months
previously, the catamenia had occuiTed every twenty-one
days and had been rather profuse, but unaccompanied by
pain. Since that date they had been entirely absent.
On a Sunday, sis weeks before my seeing her, while
exerting herself, she had been suddenly seized with
intense pain in the lower part of the abdomen and fainted.
Since then she had never been free from pain and was
getting worse. Two days before admission she had had
severe rigors.
On examination the signs of pregnancy were well
marked ; the breasts, naturally small, bad increased in
size, the nipples, large and dark, contained serous fluid ;
and the median line of the abdomen was darkly pigmented.
The abdomen itself was distended and tympanitic and
exceedingly tender. On the right side a mass could be felt
occupying the inguinal region and rising about four inches
above Pou part's ligament.
On bimanual examination the cervix was felt to be
slightly soft, but the uterus was firmly fixed and pushed
somewhat to the right side by some hard mass occupying
the left side of the pelvis. No fluctuation could be detected.
The sound showed the cavity of the uterus to be sbghtly
enlarged and empty.
The patient was seen by nay colleagues in consultation,
but was then in too exhausted a condition for any operative
interference and evidently sinking. She died within
eighteen hours of being first seen.
For the particulars of the post-mortem examination and
dissection of the specimen I am indebted to Dr. Bedford
Fen wick,
Poat-morUm (twenty-five hours after death}.— On open-
ing the abdominal cavity a small quantity of straw-coloured
OUul CAi/ity Ikiuttl- with df.
Cy»t Ua cr'» ilu-wr^i., ,
Oft ed^r !>/■ pU\.-f>\t^
OB;;Ti-:i'su-AL rRAN:^A>:T;C'K;. ■ k>i. xx v
EXTKi-CTERIKB F<ETATION, 105
Eerom escaped. The omentum and intestinea in situ were
Been covered by a thin layer of quite recent clot, whilst
there was a considerable quantity in each flauk, particu*
larly the left. Here and there the intestines showed
signs of old peritonitis, being studded with patches of
organised lymph. In the lower part of tho abdomen tho
intestine was firmly adherent to tho tumour, and in places
the calibre of the intestinal tract was so narrowed by tlm
constricting bands that on seotioo afterwards it would
hardly admit, at these points, an ordinary quill.
The pelvic cavity, more especially tho falso pelvia on
the right side, was occupied by a tumour apparently cystic,
and surrounded in great part by recent clot, especially at
the upper limits.
The uterus itself was drawn slightly to the right of tho
median line. The cystic mass with the uterus was removed
with gi-eat difficulty, being firmly attached to tho iutestincM
at the upper and posterior part, where tho intcstinos worn
matted together by old adhesious.
On closer esamination of the specimen, and ou oponing
the uterus, the thickened decidua was well seen. Tho
Fallopian tube on the right side was occluded just boyond
the comu of the uterus for the space of about halt iiii
inch, but afterwards became patent, and could bo triiccd
for some distance over the anterior wall of tho cyst.
The ovary on the right side could not bo found, but
an abscess cavity in the wall of tho cynt oooupiod the
region in which it might have been expected.
The ovary and tube of the leftside wore healthy except
for a patch of thickened mucous membrane in the middle
of its course.
On opening the cyst a foitus of about tho fourth month
was found attached by the cord to the lower and poftterior
wall of the cyst. The fcctal membranes were fastened to
the cyst walls by bands of adhesion.
Bcmarhs. — The pregnancy had advanced too far, and
the adheeioDB to neighbouring organs had become too com-
plicated to permit the character of the gestation to bo
106
BXTEA-trrBSTHB FfflTATION.
determined with certainty. Judging from the specimen
I am inclined to believe it commenced as a tubo-ovarian,
and then, secondarilyj became abdominal. The ovmn has
fonned for itself a cyst having the broad ligament and
the Fallopian tube in front, and the inteatines above and
behind, the whole being matted together by inflammatory
exudation and organised blood-clot. The htemorrhage
had taken place from the placental site-
Two points of special interest present themselves in the
case, first, that the patient should have recovered from
the shock and peritonitis incident on the first attack of
heemorrhage, which the post-mortem appearance showed
to have been considerable. Secondly, mth regard to the
treatment. Had the exhausted condition of the patient
allowed an exploratory incision, it would have been
found impossible to release the intestines without inter-
fering greatly with the placenta, and profuse haemor-
rhage must have resulted. Had she applied for relief at
an earlier period, when it was first evident that something
was wrong, and had the diagnosis been equally certain,
an exploratory incision would clearly have been the
proper course of treatment. The placenta must have in-
creased greatly during those six weeks.
The immediate cause of death was the htemoiThage
brought on by the exertion of the journey to the hospital.
Mr. Lawson Tait said he could uot accept the statement that
because the cyst was very adherent to some of the intestiuea no
operation was praclicahfe. Kocberle had laid do^ the nilo
some fifteen years ago that neither cyst nor placenta in such a
case should be inte^ered with. All that was wanted was the
removal of the fcetus and the drainage of the cavity. He for
one must regret that such a case had not been the subject of
surgical interference. He had operat«d seven times in such
lasea, and six of the patients made excellent and permanent
recoveries. The last time he was present at the Society a dis-
cussion was raised by Dr. Wiltshire as to the prtipriety of
operating in such cases at the time of rupture, and he (Mr.
Tait) had eipressed his determination to operate if ever he saw
another case of the kind. Since then he Had been called in to
two cases. In one the heemorrhage had been too serious to
I
£XTBA-DTIiBI»S F<£TATION.
hope for a successful result, and the patient died immediatelj
aft^r the oporation. In the second case, however, the operation
had been completely successful.
Dr. Hetwood Smith said the case was admitted under !.__
care, that he and some of his colleagues diagnosed it as a case
of estnuuterine foetation, but as the histor; of the rupture was
six weeks previouslj, and the woman was from a more recent
attack io a very low state, it was thought inadvisable to operate.
The post-mortem seemed to prove that any operation would
have failed, as the placenta was partly fixed to the pelvic wall,
and if any attempt hod been made to remove it the haemorrhage
would have proved formidable, and probably could not have
been arrested.
Dr. Braxton Hicks thought that the plau advanced by Mr.
Tait could scarcely be called a new departure, as the same had
been suggested and discussed frequently in this Society for some
years. Dr. Hicks agreed that where the tubal ftetatiou was
capable of being snored there would be no difficulty ; but the
records of eases in the Society's ' Transactions ' showed that the
majority were not isolated, but that the placenta would be
very difficult to remove, and the hffimorrhage very difficult of
restraint. Again, he could not agree that the shelling out of
the placenta by its dissolution was so safe as Mr. Tait had said ;
as he had found in a recent case he had operated on, where the
patieut three weeks after the operation, on the point apparently
of recovery, died in consequence of haemorrhage during the
exfoliation of the tost portions of placenta.
Dr. Edis thought the majority of those who practised
abdominal surgery were agreed as to the advisability of
ojieratjug in cases where the diagnosis was clear. The difficulty
usually met with, however, was in forming a correct diagnosis,
hence the delay. Dr. Edis thought that more care should be
taken in arriving at a correct diagnosis in all cases where
htemorrhage into the abdominal cavity was a prominent sym-
ptom. He quite agreed with Mr. Lawson Tait that in all cases
where the symptoms were sufficiently grave, and a fatal termi-
nation apparently inevitable, an exploratory abdominal incision
was perfectly justifiable with a view to deligating any bleeding
vessel or removing the cyst if such a course was indicated.
The Phesident, after referring to the comparative safety with
which, now that the principles of antisepticiam were better
understood, the peritoneal cavity might be opened either for
exploration or operation, said tbat while agreeing with Mr.
Tait that the adhesion of the intestine to the cyst need not be
considered a bar to operation, yet the condition of the patient
at the time she came under Dr. Moullin's care certainly appeared
adverse to any operative procedure.
CTSTIC DEOENBRATION, BTC.
Dr. CiAXUt saw tbe patient iu conaultatioD, but she wa.B then
ut & vei^ eihauet«d state, and he did not tbiak an; operative
ueMrfereocv justifiable ; the patient died ten hours after. From
lh» j»o«t>Uortem exaiuinatiou Dr. Carter did not think an
i^tenlioa would have l>oeu successful; the whole front of the
OTit VM eoTvrvd with intestines matted together by old adhe-
MYO-FIBBOMATA.
Th* Pkb8IPENT showed three myo-fibromata he had re-
UK>vvd a few diiyM pi-eviously from the interior of the
» o( a patieut who had suffered from severe metror-
rtMjftH fi.>i' ieveral years. They were not grouped together,
M HI mvrc oouimouly the case, but all separately embedded
M *uii pivjeotiujir from the inner surface of the uterine
I
CVSTIC UKGENERATION OF SUBPERITONEAL
t'IBROID OF THE UTERUS.
m. V***!"" whowed a fibroid tumour of the uterus which
Wl «wv)v(tr-'^*' (\vativ degeneration. It yvas removed a
«V»K «*('.> tv ftbilouiiual section from a patient, aged forty-
S'iWV u»utvil vW yoar. She had noticed firm enlarge-
iMMMt \4 *Kv •W**tt»>ii for three or four years, but during
^Xii i"-i i«.iK.> iii'kitths it had rapidly increased. The
»'. !. lunl irregularly distended ; there was
1 v'Vvr the left side of the abdomen, but
'■i.' right »iile ; it was supposed to be
rtto jwtiout's aspect was esceedingiy
.. s v'wr 120, Bud temperature of a night
1. <.> vtM iu ci>i>*tBnt pail). The tumour
„ '^. tt't'l )<Mi'it:>Ul wall, and had very wide
1. '.» U- iKv *nuf ntum, mesentery, and large
M-%*—^ -..w ,...«>H M tho omentum were large and
■^^^J^^f(^-fl^^f^ ^H4 'MC^ Ik* 9tU«>( tource of blood supply to
CYSTIC DIREASB OF BOTH OTAFIEa. 109
tte tnmonr. The pedicle, which r'.ise from the left side
of fundus uteri, was about IJ inch long and half inch in
diameter, was trans&xed and tied with silk ; the vessels
in it were small and few. The tatnonr weighed 3| lbs.,
and contained 7 pints of thick grumoua fluid, coloar of
light pea-soup, the whole weighing about 13 lbs. The
thickness of the walls of the tumour varies from half inch
to 3 or 4 inchea, and is made up of dense fibrous tissue ;
the inner surface is irregular and indented, and running
across it are several thick bands of fibrous tissne. On the
posterior wall of the uterus there was also a small sessile
fibroid tumour which was not touched. The ovaries were
natural. The patient has done well.
CYSTIC DISEASE OF BOTH OVARIES.
Dr. Cartbe showed the two ovaries removed a month
ago from a patient, tet. 28, married eight months.
Each tumour is made up of a large number of small
cysts varying in size from a grape to a duck's egg.
They now weigh respectively 1 lb. and 12 oz., but before
they could be drawn out through the abdominal incision
a great many of the cysts, which contained clear watery
fluid, had to be punctured, so as to reduce the size of the
whole mass. The cysts have not been examined to see if
ova are in them, as was found by Rokitansky in a like case.
Clinically the case was of much interest, as one of the
tamours {the right) was jammed down in the pelvis, dis-
placing the uterus forward against the pubic arch and
downwards, so that the cervix projected through the vulva.
Several of the small, rounded, tense cysts could be felt by
vaginal and rectal esamination as hard as fibroid nodules,
for which they were mistaken, The left ovarian tumonr
was lying in the abdominal cavity. Menstruation had
been for some time irregular as to the interval, which
varied from six to eight weeks, the flow lasting about a
110
PffiTAL MOH8TE08ITT.
week. The patient had applied for treatment on accoimt
of the low position of the uterus. She has naade a good
recoTery.
Mr. Lawhon Tait asked if ova had been found in the cyats,
tor the tumom-B had all the characters of a very rare kind of
tumour in which ova had heea found, first by Eokitaosky,
Becondlv by Ritchie, and thirdly by himself. The peculiarities
of this (Eokitan sky's) tumour was dealt with at length in a
book which he (Mr. Tait) had just issued from the press.
FffiTAL MONSTROSITY.
Me. F. CookelL) juii., exhibited a specimen of fcetal
monstrosity. He remarked that it is apparently acephalic.
No cranial bones can be felt, nor is there any sign of the
presence of hair ; two ridges are, however, risible on its
upper surface, which, from their shape, arc suggestive of
rudimentary ears. The right uppei' extremity is repre-
sented by a short digit ; the left, which is inserted at a
lower level, is longer and broader, and shows some
Attempt at the formation of a hand, possessing a thumb
nud little finger. The foetal extremity of the umbilical
cord shows a large solid protrusion. The penis is of fair
size ; there are no testicles, nor any orifice or depression
to indicate the position of the anus. The lower extremi-
ties, which at birth were verj- cedematous, are propor-
tionately well developed; the number of toes, however,
are deficient on each foot, and the feet themselves bent in
the position of talipes varus. In addition there is a
large defect in the back.
Dr. Herman, on comparing it with the descriptions in
the German text-book of Ahlfeld, regarded it as an example
of that form of Acardiac fcetus, to which the t-erm " Acar-
diacus acephalna " has been applied. (Plates from Ahl-
feld's Atlas, illustrating different varieties of this form
of foetus, were exhibited at the meeting).
TWIN FEMALE MONSTER.
De. Chalmeeb exhibited for Dr. Hurford a twin female
monster. It was born at nearly full torm, tbere being nothing
peculiar in the labonr, in the course of the pregnancy, nor in
former children. The child appeared normal and single
a3 far down as the lumbar region ; here it presented two
pelves, with two vaginas and two pairs of legs. By a
peculiar arrangement an extra pair of rudimentaiy hands
and arms, joined together at their upper extremity, were
attached by a common pedicSe of skin to the abdomen
just below the umbilicus.
Dr. Hebma-K BBid the monster appeared to he one of the kind
known as iachiopaguB parasiticus. Some Himilar specimens
were figured by AhKeld in his Atlas ('Die Missbilduugcti dea
Menschen '), plates from which he handed round.
HYDROSALPINX AND PTOSALPINX.
Mh. LiwaoN Tait briefly described three spocimons,
one of hydrosalpinx, which he had removed from a
patient four years after he had removed one of Rokitan-
Bky's tnmours. The patient had remained perfectly well
until last December, when she began to suffer from all the
symptoms of salpingitis with occlusion, and the physical
signs were in accord with the symptoms. But being
under the impression that some detached cysts adherent in
the pelvis represented the second ovary and its append-
ages, Mr. Tait thought it hardly possible that the condi-
tion conld be as he thought. In accordance with his
customary practice, he opened the abdomeu, found his
diagnosis perfectly correct, and removed with much diffi-
cuky a densely adherent and much distended Fallopian tube
with its ovary. The patient made an excellent recovery.
The second specimen was one of left pyosalpinx, occur-
112
HYDROSALPINX AKD PYOBALPINS.
ring in a recently married woman, and due, without doubt,
to the existence of a latent gonorrhcea in the husband.
The patient was most seriously ill from suppurating peri-
tonitis. The left Fallopian tube was found full of pus, and
it was remoTed; the cavity of the abdomen was cleaned
out and drained.
Concerning snch operations all that he could say was that
what troubled him was, not that they were done too often,
but that they were not done half often enough. There
must be hundreds of women in London suffering horribly
from pyosalpinx, and yet he had heard of no operations
being done for their relief. Pyosalpinx was a disease
absolutely incurable save by surgical operation, and with-
out it most of the Bofforers died.
The third specimen was a rotten and suppurating par-
ovarian cyst, completely buried in the pelvic tisanes, with
not even a sulcus of the peritoneal cavity round it. It
had to be completely enucleated over its whole area, an
operation of an extremely difficult kind, and accompanied
by severe haemorrhage.
The contents of the tumour consisted of very putrid pas,
which escaped in large quantity into the cavity of the
abdomen, owing to the rotten state of the cyst. The
peritoneum was carefully cleansed and drained, and the
patient made an excellent recovery.
Dr. Eoia called attention to a very exLauative paper by Dr.
Emil Noeggerath, in the first volume of the ' Amencan Gynfflco-
l<^ical Trtmsactions,' on "Latent Gonorrhoaa," in which the
question of iuflammatory mischief in the female shortly after
marriage was fully diacusBed. Such cases were of frequent
occurrence. Without any direct symptom of gonorrhcual dis-
charge the patients began to suffer from malaise, backache,
inability to walk, pain in lower abdomen, generally marked on
one side, and other well recognised Bymptums. Ko medical
treatment was of use, except in allaying pain temporarily.
Where we had reason to believe that there waa any purulent
or even mucous secretion in the tube, and the constitutional
symptoms were severe, operative interference ofEered the only
prospect of relieving the patient from a most distressing and
painful condition — unseidng. her more completely even than
EXTBA-UTBBINB GESTATION. 113
removal of tbe tubes, inaamuch as she was uufllted for tLo
duties of a. wife.
Dr. Pancoukt Babnes agreed that the result of Mr. Lawaon
Tfut's operation justified tbe undertaking. He wished to know
what were the eiact symptoms in such cases which led Mr. Tail
to operate.
A CASE OF EXTRi-UTERINE GESTATION SIMU-
LATING SO-CALLED MISSED LABOUR.
By Adolph R&scHj M.D.
Mrs. E. S — , fat, 29, of Enfield, began to menstruate
at 12 and was always regular up to 21, when she married.
Had five children, including twins, and one miscarriage
before her last child two years ago. Puerperal fever
after last child. Patient believea herself to have mis-
carried on January 7th, 1882, after six weeks' pregnancy.
Menstruated twice after, last time in March. After
Easter she had frequent vomiting. Quickened in August
and often felt fcetal movements. She got very stout, so
that her bigneas was much noticed.
On January 27th, 1883, when admitted to the Training
Hospital in Tottenham, she stated that thirteen weeks
ago when gone seven months in pregnancy, she had a
sudden attack of spasmodic pain in the lower belly ; hall
an hoar afterwards the child gave an awful plunge and
never moved again. Next morning a flow of bright
blood began from the vagina and continued two days.
InflamtnatioQ of the kidneys is said to have followed with
swelling of the legs and general cedema, and inflammation
of the lungs to have set in four weeks ago. A foul
discharge from vagina was noticed during the last two
months.
On examination the skin of the dark-haired patient
was found much pigmented, especially on abdomen, which
was of a brown colour. A fair amount of fat and some
VOL. XXV. 8
lU
EXTEA-nTlBINIt 0S8TATI0N
general cedema. Face sallow, mnch freckled. Pulao
110; resp. 40; temp. 99°. Heart's soonds normal but
feeble. Moist rales on both aides of cbest, but chiefly
at both bases.
Abdomen ; a hard, painful swelling occupies the lower
half of the belly up to nearly the umbilicus. The great
tenderness forbids deeply pushing in the exploring hand,
Os uteri high up in vagina against sacrum, cervix fixed,
of nearly normal size and shape, not patent. Two fcetal
metatarsi found in vagina and very foul bloody purulent
discharge. No fistulous opening in vagina. A tumour
cannot be distinctly felt from the vagina, the great ten-
derness then {and on all subsequent occasions) preventing
a thorough bi-manual examination.
Very fetid discharge from the rectum, in which no
fistulous opening could bo reached by the exploring
finger. Three motions passed this day are stated to have
been loose, fetid, quite black, and containing soft pieces
of decomposing tissue.
On January Slst, Mr. E. Davis, our resident surgeon,
to whose notes I am much indebted, after dilating the
OS with sponge tent, could only introduce the tip of the
finger, which felt some firm, conical mass. Sound entered
mx inches, and an elastic catheter was introduced to the
same extent. Nearly a pint and a half of carbolic solu-
tion (1"60) flowed in from the irrigator before .any fluid
returned. General condition improved. Dr. Raseh saw
the case for the first time and ordered a few drachm
doses of Ext. Ergot, liquid which caused no pains. When
repeated on February 3rd, severe pains set in and a soft,
brown mass came away, which was believed to be the
placenta, but which Dr. Rasch found to be a large
coagulum without any trace of placental structure.
{Patient now relates that the umbilical cord had come
away just before admission to the hospital.)
February 6th. — Verj' amemic ; pulse only just percepti-
ble. Hypogaatrium very tender. Patient gradually
getting weaker.
SIMDLATINO 80-CAlLBD HISSED LABOOB. 115
16th, — No power to retain feeoea or arine. Moist r&les
at right base.
20th, — A little blood passed from vagina. Erysipelas
faciei for the last two days. Deafness. False 120.
Yellow discharge, fetid.
24th. — Oa uteri in same position and condition as before.
Purulent fetid discharge from anus.
25th.— Death.
Post-mortem (February 27th, 3 p.m.). — Face swollen,
body fat. Dark veins on abdomen. A few ounces of
semm in pleural cavity, old adhesions. Lungs healthy
with the exception of slight emphysema. Heart flabby,
covered with fat, thin walls. Liver 6i pounds, of a
yellovrish* white, fawn colour, friable. Gall-bladdor con*
tains pas-like fluid and mulberry-shaped gall stones.
Abdomen : Omentum and upper part of intestines with
slight adhesions, A thin-walled cyst is opened which
occupies the abdominal cavity below the horizontal um-
bilical line and is inseparably connected with the abdominal
wall, the bladder, and the pelvic organs, bo that nothing
is seen except the blackish amniotic aac. A foetus
entirely detached, apparently of seven months, the skin
of which was macerated into a greyish, adipocerous pulp,
was lying across the lower part of the abdominal cavity ;
the bones pressed together into a long oval, the occiput
towards the left side. No trace of the placenta could be
found, nor any distinct sign of where it had been attached.
The cyst had a large opening into the sigmoid flexure
through a thickened mass in which the right ovary and
tube were with difficulty found embedded. A finger could
be easily pushed through this opening, which formed a
short channel, the walls of which were in apposition and
seeoied to have acted like a valve. Another opening at
the bottom of the cyst led into the uterus on its right
side through which a finger could be easily pushed. The
vieni* teas of normal size and oontained no trace of
decidna. Its cavity showed nothing unusual, Some-
thing resembling a corpus luteum was found on seotion in
116
EXTRA- UTERINE OEBTATIOK
the embedded right ovary. The kidneys were healthy.
Large clot in abdominal aorta.
I thought thia case of sufficient interest to deserve a
record in our ' Tranaactions,' which already contaia a
great deal of valuable material of a similar nature.
The close resemblance to so-called miesed labour is the
chief point in my case. After seven monthe' gestation the
foetus dies, hemorrhage sets in, but no labour follows. A
few weeks later a fetid discharge commences from the
vagina, followed (fen months after the coinmencement of
pregnancy) by sviall fceial bo7ies. No fistulous opening in
the vagina. The uterine sound passes six inches through
the OS uteri and a large quantity of fluid can be injected
apparently into the uterus.
At the first aspect I thought to have before me a
genuine case of missed labour as defined in Dr. Barnes's
excellent paper read before this Society, but my doubts
were soon roused by the fetid discharge from the rectum,
by the almost normal state of the cervix, the apparent
UghtnesB of the uterus, and the negative results from the
eshibited secale, I cousidered it highly probable that the
case was an estra-utcriue pregnancy, the sac communi-
cating after ulceration with the intestines and with the
uterus. I believed the sound had entered the amniotic
sac through a hole in the womb and that the fluid had
gono the same way. I therefore disadvised the further
use of the sound and had the case watched and treated
symptomatically. The post-mortem examination proved
this to be the right view of the case.
This case cannot, of course, prove that there is no
such thing in woman as retention beyond the natural term
of gestation of a fcetua which died after attaining viability,
but it shows again how cautious we have to be before
believing in an occurrence, of which until now only Dr.
Barnes's case seems to be evidence. And even this case
might be explained otherwise if one did not feel reluctant
to doubt the accuracy of so excellent an observer as Dr.
Barnes.
SIUCLATING SO-CALLED ICiaSED LABOITE. 117
If my own case had lived longer the large openicg at
the aide of the uterus would no doubt have become much
larger and the exploring finger would have entered a
large cavity or touched the fcetua which had ultimately
found its way into the uterus. The resemblance to Dp.
Barnes's case would then have been very striking. An
autopsy of an undoubted case of a belated fcetua in atero
remains at present the great desideratum.
Wise after the event, I much regret that I did not
perform laparotomy. It would have been remarkably easy
to remove the perfectly detached foetus without opening
the peritoneal cavity, as a reference to the post-mortem
report will show. It certainly would have given the
patient a chance, although the general state and tho
previous history were not encouraging.
The case presents other points of clinical interest which
on the present occasion it must suffice to have put on
record,
Mr Lawbok Taii said that this case emphasised in a ver}'
striking and practical manner the rule be had been endeavouring
to lay down, that in all cases of serious abdominal disease the
abdomen should be opened as long as there was niear evidence
that the patient was not sufferiug from hopeless malignant
disease, and he was particukrly gratified by Dr. Basch'e candid
confession of regret that he bad not adopted this rule in the caso
narrated by him.
Dr. Galabin bad met with one case which had been supposed
to be missed labour. This greatly resembled the case related by
Dr. Basch, eicept that there was no opening into tbe bowel.
The fcetus had died, and, some mouths after full term, there
was a somewhat foetid and sanious discharge escaping from
the cervix. Not only the sound, but a catheter passed easily
through the cervix a long distance into tbe cavity containing
the fcetus, and allowed more fluid to escape. The os not
admitting the finger, a t«nt was used to settle the diagnosis.
The finger then felt a round smooth opening, resembling the
internal os, about an inch and a half above the external, with a
part of the foetus there presenting. The patient died, and it
was found at the autopsy that the uterus was sharply retro-
flexed, and that there was a smooth opening from the uterus
into the extro-uterine sac on tbe convexity at the point of
great«8t flexion.
118
THB BBHAVIOOB OP THE OTEEOB
Mr. Philip JoNEa aaid, having had the case under my cara
previous to Dr. Kaach I will give the previous history. I was
called to see her the first week iu November. She had passed
soma blood and mucus, and was having paina in regular
intervala, increasing in severity and frequency. On exami-
nation the OS was with difficidty reached j scarcely dilated.
Paina continued about twelve hours, bat ceased after a dose of
opium. The abdomen greatly distended that it was imposaible
for the patient to lie flat in bed or on either aide, and waa
obliged to reumin in a half sitting posture. Two days after-
wards' the paina returned, but again relieved by opium. The
next day an attack of bronchitis occurred, lasting four weeks,
with a feeble pulse, and temperature 102° to 10^ ; the latter
part of the time there waa great cedema of the legs and labia,
that it was with great difficulty ahe passed her water. After
the bronchitis subsided I introduced a tent in the os, which
came away during the night with a dischat^e of fluid, which
gave great relief to the patient. From that day the distension
and swelling rapidly suDsided, so the patient was able to lie
down. A week afterwards ahe had another attack of bronchitis
and crepibition ; the discharge became more offensive, and a
diacharge from the rectum of a varied character, also bed-sores.
In four weeks the sorea had healed, and the bronchitis almoat
well, and now was able to send her to the Tottenham Hospital.
I should have adopted a more active treatment, but they were
unable to get a nurse, as she had suSei'ed from puerperal fever
in a previous confinement, and the house was very damp.
ON THE BEHAVIOUR OF THE UTERUS IN PUEK-
FERAL ECLAilPSIA, AS OBSERVED IN TWO
CASES.
By J. Beaston Hicks, M.D., F.R.S., &c.
The condition of the pregnant uterus during a series of
epileptiform attacks Las not been very closely nor pre-
cisely observed, so far as I gather from the examination
of the later text-books ; nor has it occurred to me to meet
with any paper on the snbject,
I find but little mentioned, excepting that the uterus
IH PCXRPKKAL 8CLAHFSU.
119
participates in the general excitement of the muscular
system, and the pains being severe often hasten the
labour. But some authors do not go so far as this. It
may be well, however, before proceeding farther to give
extracts from some.
Playfair says : — " If the convulsions come on during
pregnancy, we may look upon the advent of labonr as
almost a certainty, and if we consider the severe nervous
shock and general disturbance, this is the result we might
reasonably anticipate, If they occnr, as ia not un-
common, for the first time daring labour, the pains
generally continue with increased force and frequency,
since the uterus partakes of the convulsive action as well
as the other muscles of the body. It has not rarely
happened that the pains have gone on with such in-
tensity that the child has been born quite unexpectedly.
In many cases the advent of fresh paroxysms is asso-
ciated with the commencement of a pain, the irritation
of which seems sufficient to bring on the convulsions."*
Lunk, in ' Science and Art of Midwifery,' does not
enter into the matter. He considers the great mortality
of the fcetus in these cases to be owing to the great accn-
molation of carbonic acid in the system of the mother,
Schroeder only writes : — " Die Wehen sind bei der
Eklampsie meist«ns Eraftig, ja haufig geht die Geburt in
unerwartet kurzerZeit vor Bich."t
Leishman s8y8,J"^Tien rhythmical uterine contractions
and other symptoms have indicated the commencement
of labour before the manifestation of the convulsive
phenomena, the effect which ia produced upon the pro-
^ cess is naturally watched with much auxiety. In a certain
number of cases the obvioas result is an acceleration in
the progress of labonr, when delivery is sometimes com-
Lpleted with great rapidity." " The process of labour,"
says Baudeloque,-"in these cases, seems even more rapid
• PlnyUr, ' Mldwiferj,' 1st vditiou, vol. U, p. 27
t -Lehrbaeb der aeliort.liiilf>-.' 7ih ed., p. 711.
I ' UUwiforXi' page 475.
120
THB BBHATIOITR 0? THl TTBRI
than in otherSj ae the child has often been found between
the legs of the mother, although the instant before no
disposition to delivery had been remarked." "Inasmuch
as no facts have hitherto been recorded which prove the
muscular system of organic life participates in the tnrbn-
lent action of the muscles of animal life, it seems more
likely that the rapid expulsion in these instances is due
rather to deficient resistence of the latter than to abnor-
mal force of the former. It is quite possible, how-
ever, that the pains may, by a reflex action upon the
nervous centres — surcharged, as Barnes supposes, by an
excess of nerve force— excite the expulsive efforts to such
an extent as to induce this result. But this is widely
different, as will be observed, from a morbid super-
numerary force arising from convulsive action." " Some
have supposed that uterine contractions have an im-
portant share in the etiology of eclampsia. That the
disease may be manifested during pregnancy and after
delivery shows clearly enough that this is not an essential
condition, even although we may admit it as a possible
cause. But in truth uterine action is much more likely
to be the effect than the cause of eclampsia, for if there be
any truth in the theory — to which prominence has been
given in previous chapters of this work — that deficient
aeration of the blood is a cause of nterlne action, prema-
turely or at full term, we can have no difficulty in admitting
that this condition exists during the paroxysm of eclampsia
in a high degree."*
Roberts only remarks : " As a rule, an attack does not
accelerate the course of labour, but in some instances it
accelerates delivery in a marked degree." f
Meadows says, " In most cases the character and pro-
gress of the labour are in no way affected by these attacks ;
very often each return of pain brings with it a fresh con-
vulsive seizure, and in a few cases it has been noted that
{whether it is from the uterus partaking of the more
• Lemliman, ■ Syntein of Midwifcrj,' \i. 7G8.
t ' Prncticiil MiJwifcry,' IHTO, [i. !30.
IN PUERPERAL ECLAMPSIA.
121
violent character ot tlie clonic spasm or not) tlie labour is
much more quickly terminated."* Again, speaking of
the infant mortality in these cases, he remarks : — " The
cause of this high death-rate is probably due partly to the
violent contractions which occur during the fit, but chiefly
to the blood poisoning which the child receives through
the mother, and which may prove fatal by urEBmic con-
vulsions even after its birth."
K{ng,f Hubert,X and Byford,^ make no allusion to the
uterine condition during eclampsia.
Spiegelberg has the following :— " With regard to the
relation which the pains bear to the convulsions, they have
frequently been considered to stand in causal relation, and
Kiwisch has especially maintained that the eclampsia never
appears without labour pains. This is certainly not correct
as the numerous observations of eclampsia during preg-
nancy show, and when we consider the fact that one
has always to deal with premature labour, and that the first
weak contractions would be overlooked, therefore against
this objection can also be brought the contrary observa-
tions of convulsions in a perfectly quiet uterus. On the
other hand, it is also correct that labour soon follows
paroxysms during pregnancy, although these, as above
remarked, may come again to a standstill ; and further,
that in the established disease (that is, the intoxication)
labour pains determine the attack. I could observe this
with remarkable exactness after the expression of the child
and the afterbirth, if the uterus were mechanically irri-
tated to produce powerful pains, or the expulsion of the
afterbirth." "The pains themselves aro not influenced
in a definite way by this disease. But it appears to me '
rather frequently that the period of dilatation was more
slow than usual under like circumstances. On the other
hand, along with others, I have seen the period of
■ Me«cioK«, ' Hunai] of Midwifery,' 1876, p. 413.
t • M«ia«I of ObitetricB,' 18SB.
I ' Conrs d'AccouchMnenU,' 1873.
§ ' Tbeory and PrtcticB of Midwifery,' 1B73.
122
THX SSEATIOUB OP THE HTSBnS
expulsion violently hnrried, bnt I have never found a
tonic spasm of the womb participating in the motor irri-
tation." *
For myself I mast confess that, relying on the general
idea conveyed in the above opinions and that the irrita-
tion of the uterus by the presence of the fcetua or by mani-
increased the convulsions, I had not made any
1 observations till in the last two cases which have
come before me.
Having in these had opportunity of carefully noticing
the action of the uterus, I think it well to bring the facts
before the notice of the Society in order to stimulate further
examinations into this matter.
A lady, oet. 40, multipara ; in the sixth month of
pregnancy was seized with a severe epileptiform attack
early in the morning after a very busy day. Though she
had been cedematous she said she had never felt better.
The attacks continuing, I saw her about twelve hours
after the first. She had repetitions of them every two
hours, with nearly complete insensibility between, and
deep stertor during and some time after each attack. The
OS uteri was expanding slowly, but not more than one finger
could pass through. I waited for twelve hours and was
able to notice the state of the uterus during and between
the seizures. The uterus contracted gently every ten or
fifteen minutes as it does during pregnancy and in early
labour ; relaxing after a minute or so, and becoming
quite soft ; the fcetal form readily felt. When an attack
of convulsions came on, the uterus became intensely
firm, and so remained for the space of ten to fifteen
minutes without any change, after which it slowly sub-
sided into the ordinary conditions of gentle contraction
ivith relaxation.
- The symptoms of coma increasing with a small, rapid
puUe, 1 thought it best to deliver, which I did by gently
dilating the oswith the fingers, turning by bipolar method,
and withdrawing the fcetus by gentle traction.
■ ■ Lelirbach der acburtsbiilte,' p. 509.
^ in tl
^H prob
IN PDERPERAL BCtAMPSlA. 123
It was worthy of notice that notwithBtanding I employed
a free, though not violent mauipulation, no convulsions
occurred during the removal of the fcetns nor for four
hours after ; two or three mild attacks followed at long
intervals, and the patient made a satisfactory recovery.
I may incidentally remark that the stertorous breathing
which followed each convulsion was relieved, not increaaodj
by the exhibition of chloroform.
The second case, which was in a nervous girl of 19,
primipara, who had attacks of convulsions every twenty
minutes, so far as the relation of the convulsions to the
contractions of the uterus presented the same phenomena,
only the uterus contracted more frequently m its quieter
action and after the convulsion did not remain 80 long
firm as iu the previous case, but still very much longer
than when no convulsion was present.
The OS uteri when I saw her, eight hours after the
first attack, was the size of a half-crown, dilatable, and
the head pressing into it. I drew off the liq. aninii, which
was stained much with meconium, and advised the inhala-
tion of chloroform, recommending assistance to be given
by forceps as soon as the state of the os uteri permitted
it. This was carried out and delivery easily accomplished
by the forceps about twenty-two hours after the first attack.
In this case, however, it was important to note that
neither the evacuation of the liquor amnii, nor fcetns,
nor placenta, nor the use of chloroform seemed to produce
any immediate marked effect. I saw her agoiu eight
hours after delivery and the convulsions wore as frequent
as before though slightly less prolonged. I found the
uterus properly contracted and exceedingly firm, more so
than usual, all the time of this visit.
Whether more extended observations will show that
the uterus does become powerfully and prolongedly con-
tracted coinei den tally with a convulsion it is difficult to
say, still, when the marked manner in which it occurred
in these two cases is considered, it seems more than
probable that it will be found to be an ordinary occurrence.
124
THE BEHAVIOUE OP THE UTERUS
I am not able to state tKe exact relationship, as to tKe
time, of these two conditions ; in the cases narrated cer-
tainly the uterus was found very firm, thongh I examined
it the moment I had notice of the attack of a convulsion,
A. question naturally arises, is this powerful action of
the uterus a cause of the convulsion, or the effect of it ?
or is the uterus simply participating in the general
muscular irritation f
That it is of itself alone the cause appears to be con-
tradicted by the observations of cases of labour SrSsociated
with either clonic or tonic contractions, for I have never
seen in the most violent instances any kind of eclampsia
produced ; nor have I ever observed in the most pro-
longed or difficult case of turning anything of the kind.
And though it may be objected that this may be true in
ordinary states , yet in these cases a higher degree of ex-
citability may be present as an additional factor in the case.
With regard to its being an effect of the convolsions, it
has been suggested by Dr. Leishman that the increased
force of the pains might be owing to the carbonic intoxi-
cation produced by the larj-ngeal obstruction. This may
be true if there is a general increase o£ force in the pains,
but as to the particular increase at the time of the con-
vulsions the almost immediate supervention of the con-
traction on the paroxysm precludes the idea that any
increase of carbonic gas could have so quickly arisen as a
cause of this particular contraction.
But the quietness of the pains nhich occurred between
the convulsions in these cases scarcely bears out the
arguments based on the assumption that the pains are
generally intensified, be it either by the ursemic or
carbonic intoxication or by the generally exalted excita-
bility of the nervous system.
I think we can hardly assent to Dr. Leiahman's remark
that "wo have no facts which prove the muscular system
of organic life participates in the turbulent action of the
muscles of animal life ;" because when we observe
attack of eclampsia we have evidence of disturbances of
Ji
IK FUESFKaAL ECIAUPSIA. 125
the heart, vascniar system, and very visibly in the often
rapidly cbaugiug states o£ the pupil of the eye. If, then,
we were to add the uterus-action we should have suffi-
cient evidence to show that the muscles of organic life are
liberally affected during a paroxysm of eclampsia,
^t is not necessary for me to enlarge on the advantage
of accurate knowledge. In regard to the mother the
point may appear rather as an interesting pathological
question, but to the fcetus it is one of much importance.
If we admit, as I believe we generally do, that the longer
the attacks continue before the birth of the child the more
danger it incurs by reason of the general intoxication of
the mother acting on the foetal blood ; by so much more
must we consider the danger increased if with every con-
vulsion we find that a prolonged and very forcible trismus
of the uterus takes place. And if this be the case, this
increased danger is in direct proportion to the frequency of
the recurrence. So that the abstraction of the fcetns from
these influencee at the earliest possible moment, compatible
with the safety of the mother, would be the clear rule of
practice ; and that while still the assistance of anassthetics
like chloroform would be advantageous in mitigating the
force of the attacks and their frequency, stilt, shonld it
not produce an arrest of the powerful and prolonged action
coincident with a convulsion, we should be scarcely
justified in waiting passively for delivery should the utema
be in a state fit for giving assistance.
I may again call attention to the fact that in the second
case the grip of the uterus was severe enough in the early
stage of the case, before the rupture of membranes, to
express meconium, so much so that I expected the child
was already dead, but it was bom alive.
Dr. B^BNEs regarded this paper, coming as it did from an
observer so practical and so phdosopbical as Dr. Hicks, aa of
extreme value. He himself did not doubt that the immediate
cause of the uterine contraction was due to the convulsion.
Marshall Hall and Brown-S^quard had both shown that
126
THE BBHAVIODR OF THE OTEBUS
carbonic acid escited contraction in involuntary muscle, and
under the tracheliBmus and coma of the convulsion blood
charged with carbonic acid waa carried to the uterus. The
risk to the child was not alone due to the hjpercarboniaed
blood, but partly also to the continuous compression of the
uterus upon the child. Dr. Hicks' obseryations led him to the
reconsideration of a rule he had arrived at after great experience
in these cases. That waa to reject the old plan of the aecowche-
mettt forei, from which he had seen the most disastrous results.
But under chloroform gradual dilatation and improved operative
proceedings we might uow cany out delivery earlier and witli
greater saiety. But we must always subordinate regard for the
child to the safetj- of the mother.
Dr. Orailt Hewitt acknowledged the great and scientific
'^value of the observations made by Dr. Braxton Hicks. The
obaervations were novel and important, In his own practice
he had been strongly impressed with the notion that the
mechanical pressure of the gravid uterus on the renal organs
exercised a powerful influence in causing puerperal eclampsia.
The pressure thus exercised produced great disturbance of
the abdominal circulation, and especially they acted on the
renal circulation. He had in several cases found the greatest
benefit derivable from taking steps by horizontal treatment
of the patient, and by unloading the bowels to diminish this
pressure. The dssociation of albuminuria with the eclampsia
present in so many cases was, of course, well known. He thought
that in any explanation of the occurrence of eclampsia these facts
would have to be regarded.
Dr, EouTH stated, in confirmation of what had fallen from
Dr. Graily Hewitt, that some sixteen years ago he had attended
a case of convulsions in a parturient woman, Chloroform was
given for hours, with very little if any amendment. In the
course of the labour, however, the cord prolapsed. He there-
fore, following the teaching of 8ir J. Simpson, placed the
woman on her belly and knees to reduce the cord. The effect
was marvellous; not only was the cord reduced as he expected,
but all couvulsions ceased from that moment. This seemed to
show that the convulsions were due to pressure on the kidneys.
Dr. Beaiton Hickb, in reply on his paper, said he hoped the
Society would not think that be advocated force in delivering the
child in eclampsia ; because although we might forward delivery
we nowadays had many helps at our command, viz. the dilatation
of OS by the hydrostatic bags, version by the bipolar plan, -
chloroform to relax the passages so that gentle traction ueed
only be used to deliver in two or three hours. But although we
might wait for spontaneous deliveiy often, yet when the serious
symptoms continued to increase the time would arrive when
assistance must be given, and this would be given earlier if ve
IN PUIBPIBAL ECLAMPSIA. 127
knew that the utems was at eveiy oonyolsion poweifollj and
spasmodically contracted. Begarding the excess of carbonic
«cid in the blood, it could not be regarded as the initiatory
catlBe of the convalsion, because the latter preceded the intoxi-
cation, and in regard to the remark that the pressure of the
uterus was a cause of albumen, he had shown that the urine of
a pregnant woman did not contain albumen naturally, nor was
there albumen in many cases of convulsions before the first
attack. As there were so many factors in these cases which
still required inyestigation he had thought it useful to call the
attention of the Society to the examination of the state of the
uterus in eclampsia.
»
Heney Gervis, M.D., President, in the Chair.
Present — 63 Fellows and 5 visitors.
Books were presented by Dr. Hickman, Dr. Paul P.
Mund^, Mr. Lawson Tail, Mr. Ilngli Thomas, and the
New York Academy of Medicine.
Raheem Buksh, M.R.O.S., Peter Horrocks, M.D., and
Henry Sutherland, M.D., were admitted Fellows.
Francis Joseph Salter, L.R.C.P. Ed. (Leeds) ; and
Thomas Marshall Wilkinson, F.R.C.S. Ed. (Lincoln) j
were declared admitted.
The following gentlemen were proposed for election : —
Charles Taylor Aveling, M.D. (Clapton) ; Robert Alex-
ander Gibbons, M.D. ; Charles Hurford, L.R.C.S. I.;
James Hurd Keeling, M.D. (Sheffield) ; iVaron Langley,
L.R.C.P. Ed. ; Clarke KoUy Morris, M.R.C.S. (Spalding) ;
Annndo Lall Sandel, M.B, Glas. (Calcutta) ; and Frederick
Howard Tinker, L.R.C.P. Ed. (Hyde).
SPURIOUS HERMAPHRODITISM.
Da. CHALUEBa exhibited an infant living, the anbject of
a spurious hermBphroditism or hypospadias. It was snffi-
ciently marked to leave one in doubt as to the true
VOL. 3CSV. 9
130 SARCOMA OF OVABT.
gender of the child, and it was further remarkable aa being I
the second of the kind that the mother had given birth I
to. The gen ito- urinary organs of tho former child, which I
died at a month old, were shown to the Society about i
year ago. They were thoso of a femalo with a clitoris 1
enlarged to the dimensions of a penis. The external I
organs of the second child resembled the other in every-
thing bnt that the groove on the under surface of the j
clitoris (or penis) was towards its base completed into i
channel so as to form a kind of urethra about two eighths I
of an inch long and through which the child urinated.
Ko testicles could be found in the labia.
SARCOMA OF OVARY.
By G-EOSGE Eldeb, M.D.
The specimen now shown to the Society was removed |
by me a fortnight ago from a woman ret, 55. Its first I
detection by patient was eighteen months ago, when its I
size was small — a closed fist — and not accompanied by
any discomfort or disturbance of health. Prior to her
being referred to me, she had for some months been losing |
flesh and strength ; but what most troubled her was
weight while walking and pain referred to tumour accom-
panied with dyspnoea. Whilst for a considerable time it
had remained stationary as to size, latterly it has rapidly
grown, until it has attained its present dimensions.
There was a distinct ascitic wave on examination, and \
the tumour was freely mobile. Its attachment was so j
close to uterus, in fact, almost continuous with it, that I 1
was doubtful whether it was uterine or ovarian in origin,
but inclined to the belief that it was the latter. Its size ■ I
was rather against its being a fibroma; still tho nature ]
of its anpetficies, its history, the fairly good condition of I
health of the patient inclined me to this view, although I
CON0E8TIVE HTPERTHOPHT OF THI DTBKDS. 131
at times the poBsibilitj of its being a sarcoma flashed
across my mind.
At the operation it was found to be attached quite up
to uterine body on right side and wit}i a wide connection
to broad ligament. It was evidently the right ovary
which had undergouo degenerative change.
Under the niioroscope it showed the spin die -celled
structure of a sarcoma.
GENERAL AND CONSIDEBABLE CONGESTIVE
HYPERTROPHY OF THE UTERUS WITH
ACUTE ANTEFLEXION AND PRESENCE OF
AN OVARIAN CYST.
Exhibited jointly by Dr. Grailt Hewitt and Mr. A. Q.
SiLcocK, M.D., F.R.C.a
Deecriptimt of the epceimen by Mr. Silcoce, amimentary
avd remarftg by Dr. GEiiLy Hewitt.
The specimen exhibited consists of the utems and
appendages from a patienl, Jane M — , set. 40, who was
under the care of Di-. Hand fie Id Jones in St. Mary's
Hospital. She was admitted on March 27th, 1883, and
sQCcambed four days afterwards to an attack of peri-
oarditie and pleuro- pneumonia probably septic in origin.
It appears that she had been suffering from what was
considered to be a "cold" for about two months before
admission. The specimen was removed after death by
Mr. Silcook, Pathologist to St. Mary's Hospital, who has
obtained particulars of the illuess of the patient and who
has made a careful examination, general and microscopical,
of the specimen.
Dr. Handheld Jones has kindly given his consent to
the publication of the case.
Mr. Biloock brought the specimen under my notice
CONGESTIVE HTPBRTEOPHT OF THH DTEBnS.
thinking it, as it proves to be, a very unique and interest-
ing one.
I much regret that little information concerning the
previous history of the patient is forthcoming. It appears
her age was 40. She had been twice married, but had
never had a child. It is known that she had for some
time — " all her life " it is stated by an acquaintance^
" suffered from some internal complaint," and it is known
that she had been a pjitiout of two hospitals. Possibly
further details may hereafter be elicited,
ITr. Silcock, who made the post-mortem examination,
states that, with the exception of the heart and lungs, the
other viscera were comparatively healthy.
The following is Mr. Silcock's description of the state
of the pelvic organs, aud having carefully examined the
specimen together with Mr. Silcock, I am able to testify
to its accuracy :
The uterus, with an ovarian cyst adherent thereto,
almost completely filled the pelvic cavity, to the walls of
which it was firmly houud by old fibrous adhesions. The
whole organ from its great weight Lad sunk in the pelvis,
pressing upon and displacing the rectum, and pushing the
bladder upwards and forwards. Both uterus and bladder
were adherent to it, but in other respects normal. The
internal iliac vessels of both sides were involved in
adhesions to the uterus and surrounding parts ; the pelvic
veins were greatly distended and enlarged ; they are seen
to be so at several points in the specimens shown, although
they have been for the most part dissected away. The
cyst connected with the left ovary was about the size of
a cocoa-uut, multilocular, and firmly adherent to the
fundus and posterior surface o£ the uterus. It projected
slightly above the brim of the pelvis and contained turbid,
serous-like fluid. The right ovary is seen to be in an
early cystic condition, about the size of a large chestnut, '
appearing as a sessile, multilocular cyst, attached to the |
right extremity of the fundus.
The broad ligaments were encroached upon by the
CONGESTIVE HYPEETEOPHY OP THE LTERtlS. 133
enlarged uterus, shoi-tened, involved in old adhesions, and
barely recognisable as such. The round ligaments are
enlarged, their muscular structure being evidently hyper-
trophied, bo contributing to their increase in size. The
left Fallopian tube is much dilated, and its walls thickened ;
the right tube seems to be represented by a fibrous cord,
which was dissected out of the adhesions aronnd it, but
03 the fimbriated extremities of both were lost during the
removal from the body, it cannot be identified with cer-
tainty. Their course through the uterine walls have not
been traced, but a bristle could not be made to pass through
the dilated tube (left) into the uterine cavity.
Examination of the halves of the uterus (specimens
shown) — the section having been made as nearly as pos-
Bible in the middle line — shows at once that its body is
enormously hypertrophied — the original shape and sym-
metry of the part being nearly maintained — and acutely
flexed at an angle somewhat less than a right angle upon
the cervix, at the level of the oa internum. The actual
measurements of the parts are as follows :
Length of canal above bend
„ „ below „
Width of uterine cavity at upper end
Greatest width of anterior wall .
„ „ posterior „ .
Width o£ roof ....
Greatest transverse diameters .
„ antero-posterior „
Weight = 2002 (20 ounces).
H in.
i „
Before the uterus was cut up a bent probe passed into
the cavity for a distance of 21 in. above the os externum.
The walls of the body of the uterus are composed of
fibrous tissue and muscular fibre, exactly resembling, to
the naked eye and microscopically, a hard iiiyo-fibroma.
The fibres run in all directions, the most external, how-
ever, as in the natural state of things, being chiefly longi-
tudinal. Many patent veins are seen on the face of ihe
134 CONQEBTIVB HTPEETEOPUV OF THE OTaBUS.
sectioDB, having been cub across in various directioiia, A
number of small veins are especially noticeable at the
angle of flexure in the anterior wall, and a large one
filled with thrombus in the posterior wall at the corre-
sponding point. The walls of the cervix with the
mucous membraue lining them appear to be unaffected,
making allowance for the traction to which they have
been subjected. The anterior lip of the oa externum is
tiattened out and merged into the anterior wall of the
vagina, whilst the posterior lip, less raised than naturally,
is drawn backwards and continuous with the posterior
vaginal wall, the posterior vaginal cul-de-sac being en-
tirely obliterated. On neither lip are there any scars or
The cavity o£ the uterus contained recent blood-olot,
the mucous membrane being partially thrown off and
disintegrated. Microscopical examination of sections
from various portions of the organ showed that in struc-
ture it did not materially differ from the normal, except
in the numerical hypertrophy or hyperplasia of its elements,
with perhaps an excess of connective tissue relatively to
muscular fibre ; the difficulty of distinguishing the young
spindle-cells of connective tissue from those of muscular
fibre should be borne in mind however. At the bend
itself there did seem to be an excess of fibrous tissues,
and to a greater extent on the convexity than on the con-
cavity. Nowhere, either in body or neck, was there any-
thing like an inflammatory cell-proliferation ; nor was
there any fatty or granular matter to be seen. The
mucous membranes of the body seemed healthy ; that of
the cervix was not completely examined. As regards the
vascularity, as judged by the number of blood vessels seen
in the sections looked at, it was probably less than natural.
At first sight the specimens resemble a uterus, the body
of which is the seat of a fibro-cystic tumour, but the loca-
lisation of the cysts to the ovaries, and the general and
syimuetrical characters of the enlargement both of the
walls of the body and its cavity, negative this supposition.
C0N0B8TIVB HTPHETEOPHY OF THE DTBRD8.
135
Hetnarks on the case by Dr. Oraily Heioiti. — This is un-
doubtedly a case of advanced hypertrophy of the whole
uterus affecting every part of the organ about equally.
The organ is acutely auteflesedj and the whole organ so
much enlarged tliat it must have left little space in the
pelvis for the other pelvic organs. It rested on the floor
of the pelvis. I consider it pretty certain that the
anteflexion and hypertrophy had existed for several years.
The case resembles some which I have had under ob-
servation during life, although I have never seen a case
of simple hypertrophy in which the uterus was so large
as in the present instance.
I would refer to a case figured at page 273 of the 4th
edition of my work on ' Diseases of Women,' which repre-
sents a uterus in many respects like the one now shown ;
also to another described in the same volume at page 270.
In both of these cases there was great hypertrophy. In
one case the patient, sat. 51, had beeu more or less an
invalid for years. lu the other, eet. 36, the disease had
probably existed for fifteen years. The drawings of these
two cases {figs. 82 and 8-1) may be usefully compared with
the admimble photograph of Mr. Silcock's specimen now
exhibited.
The canal of the uteroa in Mr. Silcock's specimen
appears to be much dilated just above the angle of ilexion,
It is evident from consideration and description of the
specimen that the cervical canal was subjected to great
compression from the mass of the uterus above. This is,
of course, not shown iu the photograph, hot it is probable
that when the organ was in situ the exit of the contents
of the cavity of the body of the uterus was materially
hindered by the compression in qnestion, and thus occa<
aioned a virtual obstruction.
The very great distension of the venous plexus around
the uterus, of which the specimen gives evidence, is
interesting as showing a condition capable of impeding
materially the circulation of the uterus. Doubtless the
whole organ was in a sate of clironic extreme congestion.
1 'uiftwilf DMiAi* tfeas lis onsntt cjrrt
i..(M^w m ipr»ir. Thn ifgrnrtinn if tfi-rr
E [-iiu-uiM of paiatngtlw
a ^u « pr«be, oat in UMS
I'T. Huwitt whien lie drew
"f^ltv " of tha atenu and
, j-dw apfVATuice of Dr.
. jiy clixwdj [ceembled tho
. '-k.<f« ^f«iijcd to be ft small
COKGESTITB HYFEKTBOFHY OS TH£ DTERUS.
137
I>r. Hebman pointed out that in the specimen from University
College Museum exhibited by Dr. Graily Hewitt the bit of glasa
tubing employed to keep the two halves of the section apart was
inaerted into the uterine cavity, and it could be seen, from the
indentation where the bit of glass pressed, that the pressure of
thiB tubing did force asunder tho walls of the cavity, and pro-
duce &n appearance of slight dilatation. When the section' was
freshly made (before this bit of glass was put in) the anterior
and posterior walls of tbe uterine cavity were no further apart
than is usual iu uteri which are not flexed.
Mr. LA.WSON Tait agreed with the President, and if the case
bad come under his own care he would not have troubled to
construct so elaborate a theory for the case, but would have
regarded it as an ordinary uterine myoma. The presence of
cysts of the ovary confirmed this, for the views which be bad
advanced concerning the association of cystoma of the ovaries
and uterine myoma had been amply confirmed by subsequent
observers. He agreed with Dr. Barnes that the patient had
probably suffered a good deal from menorrhagia, and he was of
opinion that the cysts ought to have been removed, as by this
means the uterine tumour would have been cured.
Dr. Heney Bennet could testify to the value of iodine in the
treatment of chronic inflammation, with hypertrophy, of tbe
cervix uteri, extending or not to the body of the uterus. He
had constantly used iodine for more than thirty years with
benefit in such cases, principally in the form of tincture, simple
or combined with iodide of potassium. He had never witnessed
any unfavorable result. It was worthy of notice that when used
to produce counter- irritation on the walls of the cheat in phthisical
disease, so long and so continuously as to render the skin as
rugous OS the t«rk of a tree, iodine never produced permanent
mischief. When suspended, in the course of a few weeks, tbe
skin recovered itself, and became perfectly white and natural.
This cUnical fact inclined him to prefer iodine to other agents
to produce counter-irritation in these cases in young females
Tartar emetic ointments, even leeches and blisters, often left
unseemly marks for years or for life. In using solutions of
iodine in the local treatment of ut«rine disease be introduced
them freely into the cervical canal, but did not inject them into
the uterine cavity proper. He bad a fatal case from peritonitis
early in life owing to the injection of a medicated solution into
the cavity of the uterus of a young female aggrandised by the
presence of a fibrous tumour. This case hitd made him very
careful. He thought that a great deal, if not most, of what
had been written about lajectiug the cavity of the uterus in
uterine disease applied only to the injection of the cavity of the
cervix. Between the two cavities there woe a regular sphinater,
which he was the first to describe, closed in health, which
138 SPBCIMBNB OP PYOSALPINX.
preveated an injectiou penetrating unless the cannula was
actually passed beyond it. When this precaution was taken,
when the nozzle of the injectory cannula actually entered the
uterine cavity, paBslog through the os internum, the injection of
fluids was not free from lisk, Be hod repeatedly, in his own
practice, had seiiona symptoms after it — acute abdominal pEtin,
&c. Probably the fluid in these cases parsed through the
Fallopian tubes into the peritoneal cavity.
Dr. MuBEAT did not consider injecting tlie uterine cavity free
from great risk. He mentioned a case where this procedure
gave rise to instant pain and subsequent inflammation, the
result most probably of the fluid passing thi'ough the Fallopian
tube. The late Dr. Tyter Smith had mentioned a similar
instance to him.
POLYPUS ADHERENT TO VAGINA.
Dk. Pottee showed a polypoid growth adherent to the
vaginal wall, from a patient who died in the Westminster
Hospital on May 27th. She was admitted in a tembly
ansious condition, having suffered from menorrhagta since
the birth of her last child six years ago. She had been
in several hospitals and discharged incurable. She was
in such a low condition, and examination set up so much
hsemorrhage, that nothing could be done, and she died a
few days after her admission. At the post-mortem exa-
mination the uterus and appendages were found deeply in
the pelvis and closely adherent to the adjacent strnctnrea.
The ovaries both cystic, the uterus not much enlarged.
The mass felt during life was closely adherent to the.
vaginal wall, and about the size of a small hen's egg, and
was connected with the interior of the body of the uterns
by a short thick pedicle. It was inseparably fixed to the
vaginal wall.
SPECIMENS or PTOSALPINX.
Mb. Lawson Tait showed four specimens of pyosalpinx
which he had removed from two patients since the last
aPBOlMENS OP I'YOSALPIKX.
139
meeting of tho Society. One was a very remarkable case,
as there was no history whatever to point to a source of
origin, and the severe ayuiptoms, which had brought the
patient within measurable distance of death, had been in
existence only a few weeks. Yet it was clear that the
organs must have been diseased for a very long time.
In the second case the illness dated from the patient's
only confinemeut some ten years previous to the operation.
She had suffered from constant paiu, aggi-avated by men-
struation and marital intercourse. Within the last two
years menstruation had become very profuse, marital
intercourse had to be discontinued, and the patient had
three distinct attacks of peritonitis, one of which nearly
proved fatal.
In both cases the diagnosis was made unhesitatingly,
and both patients are recovering.
November 16th, 1883. — The first patient made a very
tedious convalescence, bat a month after the operation a
faical fistula formed and discharged for about a fortnight.
It slowly healed, and in about sis weeks patient was able
to leave her bed. She is now convalescent.
The second patient made an easy and rapid recovery,
and ie now in perfect health.
PT08ALPINX.
Ma. Knowsley Thoknton showed two Fallopian tubes
greatly distended with pus (pyosalpinx), removed from a
siugfe woman of thirty, sent to him by Dr. Roper. There
was little history, the patient merely complained of pain
in the back and hips at the periods. Two irregularly-
shaped tumours were plainly visible in the iliac regions,
they were very hard and very mobile. One tube waa
opened during removal, aud contained fully half a pint of
pus ; tho other was removed entire ; the ovaries were left
behind.
140 UTOXAHA^TOCS DKOENEKAIIOIf OF UTEBINE FIBBOIDB,
November \&th, 1883. — Tlie patient made a good re-
covery and has menstruated regularly since ; there was
much pain at tbe periods at first, but this is now less,
MenBtrnation is, as before operation, scanty.
MYXOMATOUS DEGENERATION OF UTERINE
FIBROIDS.
Dfi. Godson showed s specimen which he had removed
in the morning from a woman, fet. 61.
Happening to be in the district where she lived in
January last, the vicar of the parish asked him to see a
poor woman believed to be dying from cancer of the
womb. He found her to be in a state of great emaciation,
complaining of a profuse, watery, foetid discharge from
the vagina, with much pain in the lower abdomen. She
had been discharged from tbe Soho Hospital for Women
six weeks previously after an operation. Dr. Godson
found a mass of substance, very soft, occupying the vagina,
which protruded through the oa uteri. He gave her an
admission to St. Bartholomew's Hospital, and on January
20th removed with his fingers and his ovary-forceps a
mass which he detached from the anterior wall of the
uterus ; it was semi-transparent, and gelatinous or mucous
in appearance, and had all the characters of a myxoma
under the microscope. The patient left the hospital on
February llth convalescent, free of discharge, but with a
considerable tumour in the anterior wall of tbe uterus. A
few days since she again presented herself, suffering from
the same symptoms as when first seen, and a sloughing
mass was found between the labia, protruding from the
vagina. After admission to the ward this was found, as
before, to be attached to the anterior uterine wall, from
which it was removed by the wire Icraseur. It would be
seen that the lower portion was myxomatous, whilo the
ACUTK QAKOBEKB 07 THR TITLVA.
141
upper portion preaented all the charactera o£ au ordinary
sloughing fibro- myoma.
Dr. Godson considered that myxomatona degeneratioB of
fibroids was extremely rare, it was the only case o£ the
kind that had come under hia observation.
A CASE OF ACUTE GANGRENE OF THE VULVA
IN AN ADULT, WITH REMARKS.
By G. Eenest Heeuah, M.B. Lond., M.R.C.P. Lend.,
F.R.C.S. Eng.
Toe case which I am about to relate seemed to me
worth bringing under the notice o£ thia Society, on
account of the rarity of the form of disease of which it is
an example. So few cases of a similar kind are on
record, that I shall describe thia one at length, giving
many details of which the precise significance or impor-
tance may not at present be obviona.
I narrate the case from notes taken by Dr. W. B.
Violette, my clinical clerk at the time.
E. H — , tet. 37, admitted into the London Hospital,
November -ith, 1S81.
Family history. — Father lived to age of 81, mother to
83. Of three brothera and nine sisters all are dead but
one. One sister died from "ulcer of the womb," one
from long disease, and another in a lunatic asylum.
Personal hiatory. — Menstruation began at the age of 11,
and returned regularly, except during pregnancy, every
three weeks, until seven months ago, when it became very
irregular, the interval varying from two to four weeks,
and the discharge being more profuse than nsoal, and
142
ACDTB OANGRBNE OF THE V0LVA.
attended -with increaBed pain. She was married at the
age of 17, and had one child. She then became a widow,
and since the age of 23 had cohabited with a man who
pasBed as her huehandj but had never been pregnant by
him. Wlien he was in employment she did nothing
beside the hoase-work of her home, but for the past
twelve months she had worked as a charwoman and
washerwoman. Lately she had been living very badly;
had had no regular food ; had drank about two pints o£
beer per diem. About five or six months ago was in a
■ sick asylum for a week, for an illness in which she spat
blood ; she was said to have been picked up in a fit.
Before her marriage she had been subject to hysteria.
Had never had smallpox, scarlet fever, or typhus fever.
For most of the facts relating to her illness before
admission I am indebted to Dr. E. M. Talbot, Medical
Office of Health for Bow, and his assistant, Mr. R, C.
Moore. I have especially to thank Dr. Talbot for the
trouble taken by him in investigating the patient's sur-
roundings, and Bearching out possible sources of contagion.
Dr. Talbot's account of her previous surroundings is the
following : — " She lived in one room, not more dirty than
thousands of others. Just an occasional case of scarlet
fever in this district, none that I can hear of near her
house, Cases of diphtheria being reported, none near her.
Cases of typhoid occasionally cropping up. Smallpox in
the house five mouths ago. Drains and watercloset said to
smell very badly, therefore examined by me; no water in
closet, but otherwise in order. A young woman living in
the house, aged eighteen, who had been a prostitute since
the age of fifteen, was lately attending a hospital for her
throat. She lived with a yonng man who came to me on
November 7th with a superficial ulcer on the penis, bat no
enlarged glands, or other symptoms of constitutional
syphilis. This had quite healed on November 13th."
Present illness. — On October 25th, after finishing wash-
ing, she felt a sudden pain which extended up the right
side of the neck to the right ear, and to the right temporal
I
ACDTB OANOHBNH 0? THE VULVA.
143
bone. In about three quarters of an hoar a discharge of
blood came from the ear, and she was pi'evented from
sleeping that night hj pain which she described as
" agonizing." Next morning a discharge of " corruption "
came from the ear. On the 27th the pain extended to her
back and as far as her ankles, and on the 28th she came
to Dr. Talbot's surgery tor advice. She was seen by his
assistant, Mr. Moore, who found her so ill, that he told
her to go home and go to bed. She complained of severe
pain in the lumbar and iliac regions, of shirerings, and
pains in the limbs and joints; also of pain in the car,
which was discharging. The tongiie was thickly furred
aad tremulous; the pulse was 150, and temperature 101.
Throughout the illness she had been menstraatiug. When
Dr. Talbot saw her, he found considerable tenderness over
the right temporal and mastoid regions ; there were blood
stains on the pillow, and dried blood about the angle of
the jaw. At the apex of the left lung there was some
fine crepitation. She was given Tr. Aconiti, n\_ v, every
two hours. On October 30th Mr. Moore saw her. She
complained of acute pain, which she had first felt the night
before, in the "privates," and said she was still unwell.
The labia were swollen and red, but on sepai-ating them no
ulceration could be seen. There was no sign of herpes.
On November 4th she was admitted into the hospital.
On November tilh the following note was made by Dr.
Fenton Jones, Resident Acconcbeur: — "The patient is quite
conscious, has not been delirious, no headache. No rash,
no desquamation of skin, no suffusion of conjunctiva.
Tongue tremulous, and coated with dirty brown fur. No
appreciable congestion of fauces. Patient is somewhat
anaemic ; only slightly, if at all, wasted. There is a dis-
charge of pus from the right ear. On the vulva there is
a large ulcer, the surfaeo of which is covered with bWk
slough, and its margins red, swolleu, and erysipelatous-
looking. It extends on the right side to within an inch,
on the left to within half an inch of the anterior commis-
sure, and posteriorly to back of anns. Externally the
144 ACTITE GANGBBNB OP THB TDLVA,
slough involves the labia majora, and internally the vagina
is ulcerated as far as the finger can reach. No dyspucea,
a little rattling as the patient breathes, respirations 18 per
minute, pulse 112. On the evening of admission the urine
was withdrawn by the catheter, it was of apecific gravity
100-j, cloudy, contained a few epithelial and pus cells, a
very slight trace of albumen, no sugar.'"
On the evening of admission the edges of the ulcer were
touched with Paquelin's cautery, and the sloughing surface
was dressed with linseed poultices moistened with a dilute
solution of Liquor Carboiiia Detergens {Jj ad Oj). On
November 6th this was changed for wool soaked in Tp.
Benzoin. Co., but this appearing rather to irritate the part,
it was left ofE the next day, and tho poultices renewed.
The gangrene progressed slightly after the caaterizatioD,
but after November 7th it ceased to extend.
November 9th. — Sloughs began to separate, and during
the morning there was free oozing of blood from the sur-
face beneath, only controlled by firm pressnre. About
one o'clock in the day the bleeding became considerable
from a pocket in the left labium majua ; this was chocked
by a plug of ferridized cotton pressed firmly in, and kept
in position by a bandage.
10th. — The bulk of the slough was removed in one
piece, consisting of a large portion of each labium ma]us,
a cast of the lower part of the vagina, the labia minora,
part of che uretlira, the skin of the perineum, and the skin
round the anus. Since then she has lost control over the
bladder, but retains power over the rectum.
14th. — The following note was made. The mucous
membrane around the anus ia much swollen. The skin
around has sloughed, leaving a ring of granulations, tha
hindermost part of which is about an inch behind the anus,
with the exception of a strip of skin to the left of tho
anus, about half an inch wide, which has escaped. On
examination per vaginam the walls of the canal feel
granular for about an inch and a half from the vidva!
orifice. Above this the vagina feels smooth and healthy.
ACUTE OANOHENE OF THE VULVA. 145
The margins of the urethra are swollen and granular, as if
there had been sloughing here. The edge of the granu-
lating surface is well defined, and the skin around healthy,
the snrronnding inflammation having ceased. The patient
complains of much pain, and there is tenderness in the loft
iliac region.
From this time the surfaces left by the separation of
the alongha progi-essed steadily towards healing by granu-
lation. In the sixth week after admission an attempt
was made to accelerate repair by skin grafting, but
without success, o^ving to the difficulty of keeping the
grafts in position.
The temperature on admission was 103°. It gradually
sank till on the sixth day it fell to 99°. During the next
four weeks it fluctuated irregularly between normal and
102°, usually, however, being below 101'^. After the fifth
week the temperature did not exceed 100°.
The treatment of the case consisted in, beside the local
measures already mentioned, at first quinine and opium,
with free stimulation. On November 13th she was put
on a meat diet, with a quinine mixture. She kept her
bed until December 20th, and was discharged on January
15th, 1882, the healing process being still not quite
complete.
The blood was examined to see if the moving bodies
discovered in cases of noma by my colleague, Dr. Sansom,
were present; and Dr. Sansom was good enough, a few days
after the patient's admission, himself to examine the blood ;
but no moving bodies were found.
The patient when first admitted (November 4th) was
placed in a room by herself. On November 27th she was
removed into a large ward where there were other patients.
Soon after her arrival there, several patients already in
the ward suffered from elevation of temperature, rash,
sore throat, and other febrile symptoms. Thnsou Decem-
ber 11th the temperatnro of a patient admitted for
dysmenorrhcea rose to 101^ In another case, that of a
patient awaiting operation for ruptured perinenm, the
VOL. ssv. 10
ACUTH QASOfUHB OK' THB VULVA.
temperatnre on December 13th rose to 100°. In anotherJ
case, on December 7th, a temperature ol 102'4° was conifj
bined with a roseolous rash. In a fourth (
cember 8th, a similar rash appeared ivithout i
temperature. There were two other instances of similar
symptoms, making six in all. In none of them did the
pyrexia last longer than two days, nor was there anything
in their course or symptoms to confirm the suspicion of
a specific fever. I can offer no explanation of their
occurrence.
Gangrene of the vnlva in the adult receives little more
than mention in most works on gynfecology, in some, not
even that ; and no author, so far as I know, has attempted
to put together the recorded facta which illustrate the
Bnbject. I have, therefore, collected such published cases
of acute gangrene of the vulva in adults as I have been
able to find. They are too few to make it possible to
establish any general propositions concerning them j but
I think it will not be unprofitable to compare them with
one another, and with the case just related. I do not
propose to refer otherwise than incidentally to noma as it
occurs in the child. The disease which I shall attempt
to illustrate is acute gangrene of the vulva in the adult.
In the case I have described, the first cause of gan-
greue which it seems necessary to eliminate, is phagedtena,
a source of the gangrenous process which is suggested by
the fact ascertained by Dr, Talbot, that the patient lived
in a house also inhabited by a woman probably having a
contagious venereal sore. Contagion from this source is,
however, only a possibility. The gangrene was quite
acute, rapidly producing a large slough, and then ceasing
spontaneously ; it was preceded by inflammatory cedema ;
and it was almost symmetrical. It was not, like phage-
diBna,* a spreading ulceration, starting from a point of
inoculation, and slowly advancing, crumbling down the
tissues in its way. Therefore, even if inoculation from a
" For B full accoant of tbe pecaliaritiei of phigedDna, see Jamea, on
Inflammution, 163S, p. 480, et teq.
ACDTI aAHOBaNa Of TBI VULVA.
U7
case of venereal disease be assumed, I do not think it
accounts for the peculiarities of the morbid process.
It is scarcely necessary to point out that the distribu-
tion of the gangi'eoe waa not such as could be accounted
for by embolism or thrombosis of any particular vessel or
vessels.
The patient was not diabetic, and I can find no instance
of gangrene of the vulva occurring as a consequence of
diabetes, although erythema of the vulva is known to
occur in this disease.*
I cannot offer any theory of the connection, if any,
between the inflammation of the ear and the gangrene of
the vulva in this case.
The symptoms characteristic of any of the specific
fevers were carefully looked for, but found absent.
The cases of acute gangrene of the vulva (other than
phagedasnic) in adults that I find recorded, may be
divided into four classes. 1. Those associated \vith acute
specific diseases. 2. Epidemic puerperal gangrene. 3.
Cases like the one related in this paper, acute superficial
inflammatory gangrene arising sporadically and inde-
pendently of known cause. 4. Gangrenous erysipelas.
I. The published cases of gangrene of the vulva occur-
ring in the course of acute specific diseases are not only
few in number, but mostly so briefly described, as to be
of little importance except from an etiological point of
Gangrene of the vulva is stated in some text-books
to occur occasionally in connection with cholera and
the specific fevers. I can find no published case of
its occurrence with typhoid, scarlet fever, intermittent
fever, or cholera. Goodevef mentions having seen after
the latter disease gangrene of the analogous parts in the
male, the penis and scrotum, and gangrene of the
scrotum in intermittent fever has been described by
• Mnrcbal (de C«lvi), ■ Bechercliea fntlei Hfcidenli dinbetiquct,' 186*.
t - KeyDolds'i Sjil«m ot Medicine,' vol. i. 2ii<J clitiuu, p. G98.
148
ACUTE QAKGBEME OP THE VDLTA.
Sclitschastny.* Marsoii-f- saya that he has seen one case
of gangrene of tlie female genitals following smallpox ;
the patient was a barmaid, and had a vaginal discharge
prior to the illnesa, poasibly gonorrhcea. Noma of the
vulva as well as of the face" following measles in children,
13 of course well known. LangeJ gives three cases occur-
ring during the course of typhus. In one of them both
labia majora aud minora and the perineum ; in one,
one nympha only ; and in the other, the labia majora and
minora aud the entrance to the vagina were affected.
The patients were aged 18, 19, and 28 respectively, and
the genital affection was noticed on the sixteenth day in
the first mentioned, on the twenty-second day in the
second, and in the third its time of commencement is not
recorded. Two of the cases occurred at nearly the same
time; the other ten months before them. Sander§ gives
two cases of gangrene of one nympha in the course of
typhus; one patient was aged 16, the other 18, and the
gangrene took place in the Eormer during the second,
and in the latter during the first week of the disease.
So far, therefore, aa these few cases go, they appear to
show that gangrene of the vulva in adults suffering from
typhus fever is apt to occur in young patients ; that it
may begin at any period of the disease j and that it varies
widely in extent.
2, Epidemic puerperal gangrene, — Chavanne,|| in 1852,
described an epidemic of this disease at Lyons. The
gangrene came on three or four days after delivery, and
was preceded by feverishness and prostration. The first
local sign was cedematous swelling of the labia. Then
grey patches appeared on the inner surface of the labia
and on any tear that there might be of the fourchette, and
around these patches there was erysipelatous redness.
• ' Centralblatt fur Chirurgie," Kr. 8, 1874.
t ' RejiioMs' System of Medicine,' vol. i, 2ud cditioi
I 'DeutBcbe Klinik,' 1860, S. 265.
g * Deutsche Klinik,' Nr. 7. 1881.
II ' Qszctto Medicule de Paris,' 18S2, p. 250.
ACDTE OANORENE OP TUB VDLVA.
149
At tke end of two or three days these patches became
limited either spontaoeoualy or as a result of treatment
(cauterisation). At the end of the first week or the
beginning of the second, the eschars fell off, leaving
superficial ulcerations which cicatrise naturally. In four
cases the gangrene extended to the womb. Other cases
occurred in which there was simply vulvitis with general
Bymptoms like those of the gangrenous cases. Chavanue
classes the disease with diphtheria. He could find no
canse, either in the surroundings of the patients or the
condition of the town. Out of 26 cases, 9 were out of
health, debilitated ; 17 were well, and of good constitution.
The labours were natural in 20, instrumental in 6 cases.
In some of the cases the labour was very easy ; and some
very difficult labours were not followed by gangrene.
Bat it was observed that after difficult or instrumental
delivery the swelling was more inflammatory, and the
sloughing quicker. Ghavanne attributes the disease to
"epidemic influence," and remarks on the regular
characters of the invasion and progress of the disease,
and the identity of the phenomena iu the different cases.
A similar epidemic which occurred in the Charite
Hospital in Paris in 1869, has been described by Humbert.*
The disease appears to have been identical in its pheno-
mena vrith that described by Chavanue. Humbert de-
scribes 11 cases {which were all that he saw) out of 21
which occurred. In each of them, round or oval greyish
sloughs appeared in the inner surface of the labia, and
after falling off, left surfaces covered with healthy granu-
lations. They were accompanied with febrile symptoms.
In one case, after healing had begun, the edges of the
wound again became gangrenous, the gangrene spread,
and the patient died. Four others of the 21 died, 1
from peritonitis, 2 from " puerperal fever." Of the 11
cases personally observed by Humbert, one was delivered
by forceps, in each of the others the labour was nataral,
2 of them being premature.
• ■ Arelii»B8 de Totologie,' 18"fi, p. 47-1.
150 ACDTB QANGBBNB OF THE VULVA.
Dubois * baa described a.ii epidemic whicli prevailed in
I'Hfipital dea Cliniqaes, Paris. The patientB were taken
ill within two or three days after delivery, with rigora fol-
lowed by febrile Bymptotna. Then followed an appearance
as of eccbymosia on the inner aspect of the labia, in cases
where there had been no laceration, nor unusual prolonga-
tion of labour, nor instrumental delivery, in multiparse
as well as in primiparm. Then the raucous membrane at
these spots perished, and was replaced by ulceration.
which only stopped after destroying to a greater or less
extent the parts involved. In one case the perineum was
attacked, the destruction extending from the fourehette
to two inches behind the anus. In another the greater
and lesser labia were destroyed, and the vaginal mucouB
membrane completely exfoliated.
Otto t gives an account of cases observed in Copen-
hagen, which corresponds with the descriptions just cited
of other epidemics. There was swelling of the labia,
Bometimes combined with ulceration, which began on their
inner surface. It went on with delivery, forming black
crusts which were soon cast off, while the ulceration spread.
It arose after natural, as well as after instrumental labour.
It was only seen in the lying-in hospital, never in the
town. Otto did not think it epidemic, because lie could
not trace contagion from case to case.
The close correspondence between the clinical pheno-
mena o£ these epidemics, makes it clear that the same
disease was prevalent in each of them. Tlie form of
gangrene observed in them was clearly not ordinary
eloughing from pressure during labour ; for independently
of the fact that these gangrenes occurred after easy, and
even premature labours, as well as after difficult ones,
the pressure of the head on the maternal structures would
not, in each case, kill isolated round or oval spots on the
inner side of eacli labium, I shall not speculate upon
the connection of the disease with diphtheria, suggested by
• ' Ontettc del Ufipitaui,' 16&3. p. G4S.
t ' Schmidt'i Jnhtbncli,' Bd. xxW, 1BS9, d- ISA-
AC0T8 OANOBENE OF THB VULVA. 151
diBvanne. Humbert remarks that the morbid process was
clearly not simply diphtheria, for this disease, although it
afEects wounds, does not produce sloughing of unwounded
mucous membrane. It seems to me unprofitable to theorise
as to the origin and nature of the disease present in these
epidemics, because there is no opportunity at present of
testing by observation any conclusions which might be
formed ; and some may think that, thanks to Mr, Lister,
such epidemics are now of historical interest only. I
have quoted them for the purpose of comparing them
with the sporadic cases of acute superficial gangrene.
3. In my case (recorded in the beginning of this
paper), the gangrene was superficial, affecting only skin
and mucous membrane, not the deeper structures ; it was
self -limiting, it was acute, and preceded by inflammatory
appearances j and these were preceded by febrile sym-
ptoms, accounted for by inflammation affecting the ear
and the lung. There was nothing to indicate any specific
fever.
A case which seems to me in most respects similar, is
recorded by Lange.* His patient was aged 24 and was
iu the fifth month of her first pregnancy. She was taken
ill with symptoms described as those of " gastric fever
with constipation." On the sixteenth day the symptoms
are said to have assumed a typhoid type. Ou the twenty-
second day there was pain in the neck, and irritability of
the palate and tonsils, and on the twenty -third day the
affection of the genital organs was noticed. The process
began with inflammatory oedema of the labia, upon each
of which an ulcer formed. By the fourth day after the
first complaint of pain in the vulva, the labia were con-
verted into a large slough, the appearance of which tlie
reporter compares to that of black bacon rind. Ha
remarks that it presented the characters of noma, except
that the part bounding it was not hard, not glistening,
nor swollen. The part was cauterised with strong pyro-
ligneous aoid, but the gangrene progressed after the
• Op-dt,
152
ACirn flAHSBBKB OP THB VWLTJi.
application, and subsequently limited itself. The patient
died on the thirty-second day of the illness, the ninth of
the genital affection. The gangrene -was quite superficial,
being only a line and a half deep ; another point in which
difference from noma may be noticed. It seems to me
impossible from the account given to feel sure what was
the nature of the illness which preceded the gangrene. It
is spoken of first as " gastric fever," then as " typhoid,"
and is headed " typhus." The length of the illness, and
the absence of any account of crisis, seem to me against
its being typhus ; and on post-mortem examination, the
internal organs were found healthy, except that the spleen
was enlarged, which makes it doubtful whether the illness
was typhoid,
A case apparently independent of any previous morbid
condition, but in other respects resembling the foregoing,
is recorded by Komm.* The patient was aged 20, and
after being much heated by dancing, complained of feverish
symptoms with headache, and at the same time consider-
able burning pain in the labia, which became very red
and swollen. On the fifth day of the illness she went to
a medical man, who treated it as syphilis; under this
treatment she got very much worse, the genitals became
gangrenous, and she came to the hospital, The sloughs
gradually separated, and under water dressing the wounds
completely healed at the end of thirteen weeks, the
external genitals having been totally destroyed.
A case of the same kind of gangrene following abortion
is described by an anonymous reporter in the ' Gazette
des H6pitaux.'t A young woman miscarried without
known cause when she was between two and a half and
tliree months pregnant. She was then (the exact interval
is not stated) seized with an acute infiammation of the
vulva, which on the third day had produced gangrene of
the labia majora, the labia minora remaining intact. The
patient recovered well. She is said to have been of a
• ■ Sohmidt'i Jahrtnch,' Sppl., Dd, i, 1836, S. 410.
t 1850, p. 143.
ACUTE GANGEENB OF THE VULVA.
153
good coaatitation, aud to have lived under good hygienic
conditions ; and no causa could be discovered for the
gangrene.
A case which seems to me like the preceding, except
that it followed delivery instead of abortion, is described
by Williamson.* The patient was aged 22. The private
parts began to be painful a fortnight after a natural
labour. A week afterwards {that is, three weeks after
delivery) the labia were found " in a mortified condition,
coal black." The diseased action extended deeply into
the vagina. After the slougha had separated " the raw
surface extended from the symphysis pubis to within a
quarter of an inch of the anns." The os uteri was free
from disease. The patient did well, except for contraction
of cicatricial tissue. The disease was attributed to
neglect, the patient having, for three weeks after delivery,
had no change of linen, even of napkins. There was no
erysipelas in the neighbourhood, bnt the patient said that
several inmates of the house were suffering from typhus
fever.
The cases just quoted all resemble one another as to
certain features of the morbid process. They present an
acute inflammation of the labia going on to gangrene, the
process being bilateral, forming a large, black, superficial
slough, and quickly ceasing spontaneously. In these
points the morbid process differs from that of noma of the
vulva as met with in children, for this disease {so far as
I can find out from the accounts in books, and from con-
versation with those who have seen cases of it, which I
have not) presents itself as an inflammation attended with
much induration, and beginning in the cellular tissue,
usually on one side, and producing not a black superficial
slough, but deep and extensive ulceration. Kinder Wood,f
whose description of noma of the vulva is quoted by
most writers on the subject, draws a clear distinction
between erysipelas infantilis going on to mortification and
• ' Edinborgli Medical and Snrgical Journal,' IS&S. Case Bool, p. SS.
t * Medico-Chimrgic*! Tianuctiooi,' vol. Tii, 1816, p. 94.
154
ACCTB GASQEBNB OP THE VDLVi.
noma ; aiid it appears to me that the cases I have cited,
occarring in adults, resemble the former rather than ths
latter affection.
The kind of gangrene they exemplify appears to differ
esBentiallyj in that it is preceded by, and the consequence
of, inflammation, both from senile gangrene, and from the
form of spontaneous gangrene described by Raynaud,*
which is associated with phenomena not of inflammation,
but of " local asphyxia," that is, of deficiency in the supply
of oxygenated blood to the affected part ; a condition quite
different from the swelling and redness which ushered in
the morbid process in the cases quoted.
When we compare the description of the sporadic cases
of acute superficial gangrene with the accounts of epi-
demic pnerperal gangi-ene, we see that they differ first in
the important fact that in the one we have no evidence of
origin or extension by contagion, while the other appears
to prevail epidemically. Secondly, in the distribution of
the local disease. In both the gangrene is preceded and
accompanied by inflammatory phenomena, but while in the
epidemic form the process is first manifested by the for-
mation of circumscribed grey sloughs on the inner aspect
of the labia (the gangrene, from its situation, being ,
moist), in the nou-epidomic cases the external integument
seems to chiefly suffer, a comparatively dry black slough
being the result. Although both forms of gangrene lead
to the same destructive conseqnences, yet iu their circum.
stances of origin and mode of commencement they seem
different.
The morbid process to which the sporadic cases of
acute superficial gangrene seem to me most closely allied,
is that of erysipelas of the vulva. A case of this foi-m of
disease occurring after labour is described by Hardy and
McClintock.t These authors state that it is the only case
that they or Dr. Johnson had seen. I have seen one case,
• ' Da I'ftspliyiie locale et de In gangriue Bymitriqoo dea aitrdinitM, Parii,
1862
t ' Practicnl OlxmrntlOBB in Midwifery,' p. 46.
ACUTE aANOBGHE i
155
bIho after labour. Dr. Matthews Duncan* says that ery-
sipelas of the pudendum ia not nncommon, aod is
extremely dangerous in lying-in women. Erysipelas ia a
disease not very constant in its features ; there are forms
of inflammation which there is good reason to think are
related to erysipelas, yet do not present all the features
characteristic of that disease in its usual form.f A rela-
tionship between gangrene of the vnlva and erysipelas is
suggested by the occurrence in the epidemic described by
Chavanne of cases of inflammation of the vulva without
gangrene ; and it offers an explanation of the cases of rash
on the skin with febrile symptoms which followed the
entrance of my patient with gangrene of the vulva into
the general ward. The inflammation in these gangrenous
cases should perhaps rather be called erysipelatoid than
erysipelas, for in it there does not appear the tendency to
spread which is generally considered one of the essential
features of erysipelas. I find, moreover, on record a case
of true gangrenous erysipelas affecting the genitals. It is
reported by Ott.f In this case the husband was first
affected, then the wife, with gangrenous erysipelas de-
stroying both skin and cellular tissue, first of the genital
organs, then spreading up over the abdomen, its progress
being here arrested by the patients' death.
I may add, for the sake of completeness, another case
of acute gangrene of the vulva, which I cannot classifj'
with either of the above-mentioned forms. It is given by
Hardy and McCiinlock,^ and was one of long- con tinned
neglected venereal disease. There was extensive chan-
crouB ulceration and condylomata. Death took place on
the seventh day ; the mucous membrane of the vagina
and cervix uteri was converted into a mass of slough.
The gangrene may in this case have been due to pressure
• ■ Clininl Lectom,' 2nd edition, p. 16S.
t See Hatcbincon, " Oti Certain DiieBie* allied to EcyeipeUs," ' Ueil, Tiiuef
*Bd Ouette.' Jan. 6th, 18S3. p. i.
J • Phlladelphi* Medical Timei,' May 17. 1873. p. 617.
§ Op. cit., p. 46.
IM ICUIX (UXOKBKI or TBI VULTA.
,|j_. . 11. .._ >:i;!]y borne by unhealthy tissues, or to
■ ■ ■ . 'T to a combinatioii of these caases.
1 ' . t tu a& to causes which lead to sloagbing
^KMNiury. — In the present paper a case has been re-
CL>;'Utr>i <.'i acute gatageeHQ ot the skin of the labia, peri-
Utiuui, uml uiarj^in of auus. and the mucous membrane of
the lywoi' pai't of vagina and urethra, occurring in an
a^Julb withuul discoverable cause, the gangrene being pre-
cvUvU by iudauuualory phenomena, and presumably due
W tho iateaaity of the inflammatory process.
t^>jiiaiaatiou of thg published cases of acute gangrene
•A ihi vulva iu adults, occurring independently of venereal
p>w^i.'dwuuj ^howii that they may be divided into four
classes: — I. Thoso occurring in patients saffering from
cvrliklii i»cuto dweftaea, viz. the specific fevers and cholera.
i. Kjjideuiic puerperal gangrene. This occurs in hospitals
t>ulv, and '>cglus as isolated round or oval sloughs on the
iniior iurface of the labia, the process usually stopping
whcu th^- aluughs separate, although sometimes going on
to Lxtt-abive destruction of the parts, 3. Acute gangrene
xCi'iirrimf in Jepciidfently of contagion, and beginning with
auuto iuflttuimatioa of the external genitals probably allied
|,M -.iy-lj.,.lii>, iu ita nature. 4. Rapidly spreading gan-
t. .'-.-., affecting skin and cellular tissue, and
1 11 »i'i'ii in other parts of the body.
Ill tu lue tliat there is sufficient evidence
1 iHvo iHiucluaion whether the differences
;. Hal's un> fSHential differences in the
■ timi'i.'ly differouces due to the circum-
l>»l pi\>l>nbty the latter is the case.
" .1 iMtf ho wiiB but eipressing the general
!H:iiiViiig Dr. Herman for his able,
H'lir on a rare malady. Bare, how-
' !>' lliat Bouie present had met nith
. I 11'^- l»r. Herman's, and that further
■t^kt^k,..;.. .,.,^ht )<>»■ <-■ moilu to tbe material so carefullv
■de its Mf ft mw aet, m^ai
l»fefrM*i» ami ta wti AalBd? CcJfai-
Stia IB otter partiaas «( tte M^ loag cAen pnidaeed bj out*
Di^ ItusmvB Obvcax irfeimd to tte do^^B^ edfaifilM «C
diMMs in tW mle hftd beead
hesadottea had neoried a
emeihj'Uabamaad Paget, uad
» in Ihe ftwiU Heladseen
of the Tvln with crstitia;
ft eaae « pwiiiiiil aofigiai^ of tte Tun wila CTBtitu ; it
nanaUed V^"**' pasraae^ wd pnrred bdaL After ordinuy
Umm IB fiBiiyiw ■cubing ck the bfBcn was often aeeo.
■ad doB^iBg of t>c* ^ lacnated tianw at the TUginal and
Tnhar wnifn^fc fBnBfihing «C the pciineam oocnrned in aome
t deep Wwrtk in of the Tagina abore it, and he luiid
sd a cue «( tinear ngittal doogbing after a difficult
lahoar, the iigon haTtne the afipeamtee of a Bimplj Ucented
periBnaD. Lutv* ^ "^ "^^^ ^""^ ^^ gangrenous from
the protnuioD Ol a large fibnid with conaeqa«nt injurioos
4
Dr. HiCEiVBOTHjjt (Birmingham) said he hod seen tvo cases,
ODe occumng in the case of a woman whose children werv in the
same room nifFering from scaxlet fever, and the other in a
womao whose husbsjid woa the subject of erj^Gipolas of the
scalp ; in both instances the attacks were exteusiTe, and involved
mueh loan of tissue.
Dr. Hebmax did not think a mere chill was alone sufficient
to catue a morbid change of such magnitude. The gaugreue in
his case, and in some of those he had quoted, was quite super-
ficial, primarilv affecting the skin, and not appearing to com-
mence in the cellular tissue. It waa different from the disease
described bj Dr. Duncan* under the title of " progressive gan-
grene." He had therefore not referred in bis paper to Dr.
• ■ Crmlul Lectarei on the Disenec* of Womcu,' InJ edition, |>. 170.
It ^m sMjti iiMs ims%; Aiongiiiiig of
« '|MM^}^M«idOiBBiiv,'JS98,i.|w«&
JULY 4th, 1883.
Heksy Gebvis, M.D., President, in the Chair.
Present — 16 Fellows and 1 visitor.
Books were presented by Dr. Barnes, Dr. Breisky, Dr.
B. P. Harris, Professor Macari, Dr. Routb, and the
Middlesex Hospital Medical Staff.
Dr. John Gordon and Dr. Gichard Uuthank Wallace
were admitted Fellows of the Society.
The following gentlemen were elected Fellows of the
Society ;— Charles Toylor Aveling, M.D. (Clapton) ; Robert
Alexander Gibbons, M.D. ; Charlea Harford, L.R.C.S.I.
& L.M. ; James Hurd Keeling, M.D. (Sheffield) ; Aaron
Langley, L.R.C.P. Ed. ; Clarke Kelly Morris, M.R.C.8.
(Spalding) ; Aruudo Lall Sandel, M.B. {Calcutta} ; and
Frederick Howard Tinker, L.R.C.P. Ed. (Hyde).
The following gentlemen were proposed for election : —
John Archibald, M.B. ; Cursham Corner, M.R.C.S. ; J.
King Keer, M.D. (Leytonstoue) j Edmund King Hout-hio
L.B.C.P. Ed, (Stepney) ; Walter Roaaer, M.D. (Croydor
and Frederick Stocks, M.R.C.S.
HEMORRHAGIC EFFUSION.
Dr, Barnes exhibited a specimen of hfemorrhagic
effusion into an ovorian cyat and the corresponding Fallo-
pian tube. He believed tbat the hremorrhago was due to
twisting of the pedicle.
SEPARATION AND EXPULSION FROM THE
UTERUS OF THE PLACENTA.
De. Champkeys showed two demonstrations (illustrating
(1) the separation, (2) the expulsion from the uterus of the
placenta), which he had used in lecturing since May, I8S2,
and found useful.
1. To illustrate the separation of the placenta, two
india-rubber bags with taps were taken, one was distended
largely with air, the other not. To each had been
attached with paste a piece of cardboard coloured red, to
represent the placenta,
(n) The bag which had been distended was allowed to
collapse, the "placenta" was detached by the shrtnlcing
of the " placental site " from the placenta, as in the third
stage of ordinary labour. The " placental site " was seen
at the same time to be greatly reduced in size.
The undistended bag was now inflated, and the placenta
was detached by crpansion of the " placental site " as in
placenta prEe^na ; the "placental site" was seen at the
Eame time to be greatly increased in size.
2. To illustrate the mechanical advantage of the edge-
wise presentation of the placenta as against its presenta-
tion flat, fcetal surface forwards. A retort-stand with
three rings, four, three, and two inches in diameter, was
used. The placenta was placed flat on the largest ring
(placed uppermost), and could with difficulty be forced
through it. Through the second ring it could not be
mCODB FIBROID.
forced. On folding it edgewise, fcetal eurface inwards, it
easily passed by its own mere weight through all three
. OVARIAN TUMOUR.
Da. Alfbbd Meadows exhibited a specimen which he
had removed from a lady, wt. 65, who subseqnently
recovered without a bad symptom. The specimen con-
Bisted of a large ovarian tumour which coiitained nearly
forty pints of fluid, together with a fibroid tumour of the
uterus weighing six and a half pounds, and also the whole
of the uterus, except a small portion of the cervix which
had been employed as the pedicle, the remaining healthy
ovary, together with both Fallopian tubes, being abo
removed.
SUBMUCOUS FIBROID.
The President exhibited a uterus containing a large
submucous fibroid which had undergone acute necrosis.
The patient, set. 38, married, without family, was
admitted into St. Thomas's on the 6th of June with a
large intra-uterine fibroid, the uterus reaching to the
umbilicus. There was a history of raeuorrhagia extending
over many years. Quite recently she had had increased
abdominal pain, and for this she came to the hospital.
This peritonitic attack, as it proved to be, gradually got
better, until quite suddenly, a fortnight after her admi3>
eion, a large slough protruded from the vulva. This was
ppeedily followed by severe peritonitis, collapse and death.
Post-inortem examiuation showed a large submucous
fibroid attached to the posterior wall and fundus of the
uterus in a state of complete slough, and double pyo-
VOL. ixv. 1 1
169 HTDATIDIFOlat MOIB.
salpinx, with rupture of the right tube. This waa pro-
bably the Lucident which immediate 1; preceded her sadden
fatal peritonitis and death. The suddemiess and complete-
ness with which this large fibroid sloughed without any
obvious cause or premonitory symptoms, were points
which appeared worthy of note.
SPURIOUS HERMAPHRODITISM.
Db. Csauurs exhibited the genito-uriuary organs of I
the child of doubtful sex (living) which ho showed to the I
Society at its previous meeting, with a diagram of the 1
same. The chief interest of the case lay in the difficulty \
of deciding to which sex the child belonged. From the
clitoris beiug well developed and having apparently a
portion of tho urethra intact, the prevailing opinion seemed
to be that tho child was a boy the subject of a hypo-
e^wdiaa, but the child died, and a post-mortem examina
tion produced the uterus, and other appendagea of
female.
HyUATIDIFORM MOLE.
Pk, W. a. Ddncah exhibited part of a hydatidifona I
luoltf, which ho romoved from a patient whose history was |
*.i pt,-cuU&r thai ho ventured to bring the case before the I
iiL-tii.t) «f ihu Society.
The pativut i» fifty-one years of age, has niue childreuj I
thv y\'UUgv!*t of whom is six years old; subsequent to last I
c<'ttftu-.*a*ti>u» the wtamenia appeared with perfect regu- I
Uvuy mi hi iKn^ tuuuths ago, but since then they hare I
l><.vu (>tv{\)»i»; twu mouths ago the period was excessive I
wiiUt'Vtt \>bviv>tis CMUSo; one month ago patient had a I
llomltUK which hvr medical attendant attributed to tha|
Ht3TERECT03IY.
163
vaginal
climacteric as uothing abuoriual was felt
examination.
On June 23rd (twelve days ago), wliilst trying to get
something oS a shelf beyond her reach, she had a profuse
loss ; the doctor now found the os uteri as large as a
crown-piece with a mass projecting through it.
Dr. Doncan being called iu consultation found the
patient blanched from haemorrhage ; the abdominal walls
were thick so that the uterus could not be felt, but there was
resonance all over. Examination with a Sims' speculum
revealed a dark red, somewhat friable, and granular mass
protruding through the oa, this was considered to look
very auspiciously malignant j on passing the hand into
vagina and three fingers into the uterus the growth was
found to have a rather extensive attachment to the fundus
uteri ; with some difficulty it was cut off with an ^craseur
as close to the base as possible, ou trying to remove it
with clutch forceps it tore, and the surface appeared
studded with small cysts, which on tea2:iiig out iu water
presented the typical appearance o£ a hydatidiform mole.
The interior of the utems was then scraped with a curette
and aevoral pieces removed. Since the operation there
has been uo heemorrbage or pain and the patient is making
an uninterrupted recovery. She distinctly saya she was
quite regular up to three mouths ago, and since tbea has
been losing a good deal ; there has been not a single sym-
ptom of pregnancy nor any swelling of the abdomen.
After some remarks from Dr. Barnes, tlie President,
and Dr. Duncan, the specimen was referred to a committoo
consisting of Sir, Alban Doran, Dr. Champueys, and Dr.
W. A, Duncan.
HTSTEBECTOMY.
Mb. Knowsley Thobhtok showed the parts removed T.
hysterectomy from a lady, set. 56. She had long been a
101
HYSTEllECTOMT.
uterus block- I
llftH in hv T)i-. \
patient of Dr. Murray's with fibroid of the uterus I
ing the pelvis. When Mr. Thornton was called in by Dr.
Murray there was a cystic tumour in the abdomen and the
uterns was out of reach by vaginal examination. There
had been constant coloured discharge for more than a
year. Mr. Thornton removed the ovarian cyst and then
found that it was impossible to get a satisfactory ovarian
stump and therefore removed the large fibroid uterus and
other ovary applying a serre-noend so as to include the
whole pedicle. When the uterus was cut open it was
found to be full of soft growth, hence the constant dis-
charge. Mr. Thornton had not yet been able to examine
this growth microscopically. He hoped to bring full
details of the case before the Society in conjunction with
Dr. Murray at some future date. The patient ten days
after the operation was going on very satisfactorily.
Mr. Thornton also showed an ovarian cyst highly con-
gested from acute twisting of pedicle, removed duiing
acute peritonitis from a lady, eet. 53, who was also pro-
gressing satisfactorily.
In connection with this specimen he remarked that the
cyst sent round by Dr. Barnes seemed to him to be a
beautiful specimen of the effects of twisted pedicle, the
blood poured into the cyst in this case having become
partly organised. He could not agree with Dr. Barnes
that the case was one variety of retro-uterine hasmatocele.
Mr. LxwsoN Tait asked if Mr. Thornton's specimen was
taken from the right side, as he (Mr. Tait_) had advanced an
eiplanation of asial rotation of ovarian and parovarian tumours
which depended on the action of the rectum, and he found that
in nearly all auch cases the tumour grew from the right side.
He was quite of opinion that Dr. Barnes's apecimen belonged to
this group, the rotation having been sufficient to strangle the
tumour and produce the effusion of blood, but not enough to
cause its death. Subsequent absorption of the effused blood
caused the appearances seen in the specimen.
FIBRINOUS POLYPUS.
Me. Grifpith showed a specimen, with a drawing, of a
fibrinous polypus in utero, adherent by its posterior sur-
face to the posterior wall of the body of the nteras and
extending by a free portion into the cavity of the cervix.
The polypus measured four inches in leogth, and was
composed of blood clot undergoing organisation at the
seat of adhesion where it extended into the uterine
sinuses. No trace of chorionic or decidual structure had
been found in three separate parts examined, and the
microscopical appearances of the uterine fibres and sinuses
were strongly in favour of the riow that no recent preg-
nancy had occurred.
The specimen was taken from n widowj mt. 27, who
died on the day of admission to St. Bartholomew's
Hospital, under the care of Dr. Duncan, before any
accurate examination had been made or a full history
obtained. She stated that her last pregnancy hnd
occurred two and a half years previously) that menstrua-
tion, which had been regular until five months before
admission, had ceased, and that she had been losing blood
and suffering from beariug-down pains a week.
She died somewhat suddenly from the bursting of a
large perinephritic abscess into the peritoneum, the ureter
being blocked close to the cervix by a large calculus.
Mr. Doran had a few minutes previously told him of a
somewhat similar specimen in the Museum of the College
of Sni^ODS, otherwise he knew of no other.
HTPEETROPHIED LEFT NTMPHA.
Db. Fakcockt Babnss showed the hypertropLied left
nympba which he had removed from a single woman, ret.
46. There was no history to account for the growth.
Pr. Burnet had examined the tumour and found it con-
sisted of hypertrophied connective tissue.
THE OBSTETRICS OF THE KYPHOTIC PELVIS.
ByFHANCisH. Champnets, M.A., M.B. (Oxon.), F.R.C.P.,
The course of labour in the kyphotic pelvis is still
imperfectly knowa, in spite of the fact that this pelvis is
not extremely rare. Thia is no doubt partly due to the
ease with which hump-backed women are ofteu delivered
(which led to Levret'a saying that women who are hump-
backed have easy labours), and perhaps partly to the
mistake by which contraction of the pelvic oijtlet dao to
kyphosis was laid to the charge of supposed osteo
malacia.
However this may be, it is certain that we have still
something to learn on the subject, and it has been tliought
well to review briefly a certain number of cases of de-
livery through the kyphotic pelvis, especifilly with the
view of ascertaining their course as influenced by the
altered mechanism.
In spite of Levi^et's saying, delivery through the kyphotic
pelvis is by no means altogether an easy or a safe process,
as will hereafter be shown in speaking of the results to
mother and child ; but here we may observe that it calls
not seldom for craniotomy and sometimes even for
CGSsarian section.
Ceesarian section was performed in the cases related by
Lange end by Jenny, Martin's case ('Zeit. f. Geb. u.
Fraaenkr.,' 1, 2, 2875, S. 339), was one of a kyphoscoliotic
pelvis.
Several cases on record required craniotomy. Thus
in that related by EJeinwaekler, where kyphosis had fol-
lowed injury, the head was high in the pelvis, in the
first vertex position, the small fontanelle to the left and
OBaTETBlOS OF THB KYPHOTIC PELVIS.
167
in front, tlie sagittal satnre in tlie right oblique diameter.
The head had to be delivered by cephalotripsy after
perforation.
Braun'e caBB required craniotomy.
In SchtneiiUer'g case the head was in the third vertex
position, the forehead anterior ; no rotation followed.
Perforation was necessary.
These cases, however, are quickly passed over, inas-
much as perforation at once puts a stop to all questions of
mechanism, which is our chief inquiry at present.
In the remaining cases which I have collected, the
measurements of the pelvis and fcetal skull are too few to
enable any definite laws to be laid down, and the accounts
are often meagre. Still, sufficient information can be
extracted from them to show at least the points of interest.
Herbiniavj^'s case was one of dorao-lumbar kyphosis,
but it seems not unlikely that some scoliosis was also
present, as the right ilium is said to have been two
lingers' breadth higher than the left.
The child's face presented towards the left iliac fossa
(second position) : during labour a loud crack was heard,
and the pubic bones were found loose after delivery.
The Bubaequent mechanism is not described. The child
was bom alive.
In CMari's case a living child was bom after a natural
labour. It was noted that the head retained a transverse
position deep in the pelvis.
Breslau relates two labours in the same woman. In
the first labour the child was bom alive after an easy
forceps operation.
The second labour was prematurely induced in the
thirty-fourth week. The child presented by the head,
but spontaneous turning occurred and it was bom foot-
ling. During labour the pubic arch (but not the tubera
ischii) is said to have become expanded, though before
labour it could not be expanded by the fingers ; after
labour it recoiled.
Birnhaum relates in all three cases, which aro not,
168 OBBTETSICS OF THB KYPHOTIC FILTIS.
however, qaite to oar purpose, ks they refer to a pelvia
which was virtually a " pelvis obtecta," the head having i
passed through two distinct straits, one above the brim,
one at the outlet. Something, however, may be leamt
from the course of the head through the pelvis.
In his first case (I para) the head presented with the
occiput to the right {secoud position) and sank deep in
the pelvis ; forceps then became necessary, the head
rotating during their application posteriorly (from the
second to the third position), towards the right sacro^iliao
joint. The right (posterior) side of the head was flat-
tened, the left (anterior) side protuberant, and on the
right parietal bone, towards the anterior part, was a nearly
quadrilateral indentation with fractured bone beneath it.
The child was etillbom.
In the second labour of the same woman the small
fontaneile presented to the left (first vertex position) and
the head was much flexed. The child was delivered
(stillborn) by forceps. The head was indented on the
right (anterior) side, and over the right anterior " lateral
fontaneile ; the left side of the head was protuberant. The
pressure marks on the anterior side of the head were
attributed to pressure of the symphysis (?)
In his third case (in another woman) the head pre-
sented in the second position, was persistently transverse, ,
and was incessantly pressed into the hollow of the sacram.
Tho child was delivered (stillborn) with forceps, the skull
being fractured. The mother died.
Moot relates the history of four labours in the same
woman.
In the first labour a living child was delivered by forceps.
In the second labour, which was induced at the thirty-
fourth or thirty- fifth week, the head presented, but
spontaneous version occurred and the left foot came down
from the right side, with the toes pointing forwards.
Tlie body followed spontaneously as far as the shoulders,
the back posterior. The pubic arch (as measured by the
fingers side by side) was proved to expand during labour,
OnSTETEICS OP THE KYPHOTIC PELVIS.
169
and to recoil after labour so aa to leave it narrower than
before labour. The lie ad was flattened trausverselj,
elongated aiitero -posteriorly, no fissures or indentations.
So traction was usedj and the child was stillborn.
In the third labour the face presented and a living
child was born spontaneously.
In the fourth labour tha head presented, with the
occiput to the right ; the uterus ruptured spontaneously.
The patient died.
Hvgenberger gives two labours in the same woman (who
had previously been delivered, apparently without assist-
ance, of two living children).
1 (third labour). Head presented with occiput to right
Bide behind (third position), some flexion being present,
and was delivered by forceps without any rotation. The
forceps had seized the head, the left blade on the right
cheek, the right blade on the left aide of the occiput and
adjacent part of the nape of the neck. There were also
marks " of the front wall of the pelvis " on the left frontal
emioence.
2 (fourth labour). The occiput presented in the fourth
position (left occipito-posterior) . Under traction by the
forceps the occiput turned somewhat forwards and became
more transverse, the flexion of the head was also increased ;
the shoulders followed in the right (opposite) oblique
diameter, with difBculty. The child was bom alive. The
left blade of the forceps had marked the posterior third
of the right parietal bone and the right half of the occiput,
the right blade had marked the left superior maxillary
and labial region. The mother died.
Sladfeldt gives two cases. In the only account acces-
sible to me the details are somewhat scanty.
In the first case no mechanism or presentation is
recorded. The head was perforated and the mother died.
Of the second case it is recorded that a child's head,
the transverse diameter of which was eighty-five milli-
metres, passed through a pelvis, the intertuberous diameter
of which was sixty-five millimetres (implv-ing an expan-
170 OBSTETRICS OF TBB KYPHOTIC P1LVI8.
sion of the pnbic arch to the extent of two centimetres |
(twenty millimetres).
Hoening relates that in bis case before labour the bead I
had a more or less transverse position (due as usual to ]
the shape of the uterus) . As soon as the cervix was j
passable for one fiuger the head was found to occupy
the second oblique diameter with the small fontanelle to
the right and in front, but the sagittal suture was more
nearly antero- posterior than transverse {secoud position) ;
and the lower it descended the more antero-posterior it
became, passing the narrowest part quite antero-posteriorly,
As to the termination, the accounts are not quite clear,
for on p. 03 it is said to have become quite antero-
posterior before it was bom, while on p 8 it is said that I
the posterior part of the left parietal bone passed first i
under the symphysis pubis and the face passed over the
perineum. Forceps was then removed, the small fonta-
nelle pointed to the right side and anteriorly and then
turned so that the small fontanelle pointed to the right
side and posteriorly, turning through more than a right
angle; the arms had to be freed and the shoulders passed
in the same obliqno diameter as the head. Perhaps the
two statements mean that the posterior rotation of the
head followed its passage out of the ligameutoua pelvis,
and was in fact external rotation due to the passage of
the shoulders in the same instead of in the opposite
oblique diameter. The left (anterior) parietal overlapped
the right. The left blade of the forceps lay over the
external side of the left frontal bone and over the external
angle of the left eye. The child was bom alive but soon
died. The mother also died.
Ghuntrevil relates two cases.
The first case was one of dorso-lumbar kyphosis {more
dorsal than lumbar). The interiachiadic diameter, as
measured with callipers, was nine centimetres. A child
weighingI740grammes was spontaneously and prematurely
born. The height of the patient was 1 metre 26. There
was no scoliosis, no trace of rickets, no sign of abscesses.
OBSTETRICS OP THE KYPHOTIC PELVIS.
171
The child's biparietal diameter was eight centimetres.
No account is given of the labour except that it was
qnick and easy. The mother died.
In the second case no account is given of the labour
except that it occurred prematurely at {probably) the
eighth month and was natural and rapid. The sagittal
suture was nearly an tero- posterior. The mother died.
Kezmarszhy relates that in his case the small fontanelle
was to the right and that forceps was used.
Champhets' Case.
Jane H — , admitted to the General Lying-in Hospital
February 23rd, 18S3, let. 35, 3 para; married six years ;
pregnancies three, confinements two (both premature),
miscarriages one {second pregnancy).
Family history. — Mother died while patient was n child.
Father died ten years ago from " old age." Patient has
two brothers and four sisters alive, and has lost fonv
others from smallpox. She is the seventh child in hep
family ; all the living brothers and sisters are healthy,
except that one sistep has abscesses in the neck. Does
not know when she began to walk.
Previous illvefses. — Measles a^t, 12 j scarlet fever tet.
12 also. Never had smallpox. After puberty had
abscesses in the neck. Generally has a winter cough.
When five or six years old had some necrosis of the meta-
carpal bones of the left hand, and also abscesses in the
calves and neap the left elbow, which discharged for about
three months. When quite young, before she could walk,
one o£ her sisters who was carrj-ing her let her drop j the
abscesses in the legs seemed to follow this, and the back
began to get curved, but it has not got worse as long ago
as she can remember.
. Menstrual history. — Menstrualed fii-st at about thirteen,
duration about four days, quantity moderate, pain slight
in back, preceding the flow ; no shreds, occasional clots as
172
ODSTETKICa OF THE K?PH0T1C PELVIS,
large as a walnut; recurrence as a rule monthly or a few
days more. Ho change up to the present time.
History of previous confinements (from husband and
sister after her confinement). — She was confined on May
27th, 1880, and on June 4th (the eighth day) "went off
her head ;" she was kept at home for a month and then
sent to Wandsworth Asylum, During the month at home
ahe was sometimes violent, would not take her food, and
had to he held in bed. Once she jumped out of tha
window, and the husband " just saved her by catching
hold of the hair of her head," After that (about July
4th) she was sent to the asylum ; she left it " cured "
on September 1st., 1880.
Next came a miscarriage.
On Dee, 17th, 1881, ahe was confined prematurely of
twins. On December 26th (ninth day) she " went off her
head" again. She was attended at home for a while
but was so difficult to manage that she was again sent to
Wandsworth on February 1st, 1882, and remained there
till March 25th (seven weets) . The husband always knew
when she was going off her head by her " wild look."
Usually she is a very quiet woman and a good wife.
Last time in the asylum she " set fire to her nurse."
She is quite herself betweon her confinements.
The first child was bom just over the eighth month.
She was in labour about four hours. The child was
delivered alive with instruments, and died of " thrush "
at two months old.
The second labour was spontaneous ; she was delivered
prematurely, at a little over seven and a half months, of
twins, both of whom died the following day.
Present pregnancy. — The last menstruation began June
22nd, 1882, and ended June 25th; it was in all respects
as usual. When seen she was in the thirty-fifth week.
The date of quickening had not been observed. During
her pregnancy she had been fairly well, and her only dis-
comfort had been occasional morning sickness.
In view of her deformity ahe was advieed by a medical
OBSTETRICS OP THE KYFHOTIC PELVIS.
173
man to apply to the hospital, and she came to be seen on
February 21st, 1883.
Present condition.— -On admission elie was seen to be a
qaiet, rather delicate woman, dark blonde, of very short
stature, face somewhat prognathic. Legs, arms, and
clavicles quite straight, and presenting no signs of rickets.
Her belly was very pendulous, and bung down in front of
her thighs.
The back preseuted the following peculiarities : — The
"vertebra prominena" unusually prominent, forming the
most projecting part of a curve convex backwards, com-
mencing apparently half way down the cervical region and
extending to about the fourth or fifth thoracic vertebra,
which was the deepest point of a deep hollow {concavity
backwards). From this point, again, another curvature,
having its convexity backwards, began, and culminated at
the second lumbar spine. There was no angle, the curve
being gradual. Ko marks of abscesses, &c. The bottom
of the lowest curve (convexity backwards) ceased about
the upper part of the sacrum. There were thus two con-
vexities and one concavity in the back, the first a back-
ward convexity involving the lower cervical and upper
thoracic regions, the backward concavity occupying the
middle thoracic region, and the lowest backward convexity
occupying the lowest thoracic and lumbar regions. The
spines in the last of these curves were very slightly to
the left of the middle line but hardly perceptibly so. The
ribs were modified in accordance with these arrangements,
they seemed perfectly symmetrical on both sides.
The symphysis pubis was felt to form a rathor pro-
minent beak. There was the scar of an abscess in the
left groin {said to date from about five years of age),
bounded iuternally by the tendon of the adductor longug,
which was unusually well marked and prominent on the
left side. (She said she had been treated for this as an
out-patient at some hospital.) Lower false ribs almost
touching crests of ilia.
Per hypogaelritnn. — The back of the child apparently
174
OBSTBTEICa OW THB KYPHOTIC PHLVlfl,
to the right, small moveable parts to the left above ; head'
could not be diatinctly felt.
Per vaginam. — The rami of the pubea ivere felt to meet
together at the symphysia pubis at a very acute angle, in
which the urethra was felt as a smooth, round cord,
larger than the middle finger. Following the descending
i-ami of the pubea the tubera ischii were felt to bs very
close together, but the patient was not thin enough for
an external measurement. Their inner borders were
tuberous. The promontory of the sacrum could not be
reached. The ioelioed planes of the ischia could be plainly
felt to alope downwards and inwards, and the great sciatic
notch could be plainly explored as far as the spine of the
ischium on both sides. The coccyx projected markedly"
into the pelvic cavity, but the sacrum could not be felt
high enough up for its curve to be described. The lesser
sacro-sciatic ligaments could be felt on both sides, espe-'
cially on the left, where the upper and lower borders
could be plainly felt as sharp bands.
Cervix uteri lay high up and far back. No foetal part
could be- reached. An attempt to divaricate the tubera \
ischii led to no tangible results; pain was caused at the' I
points of pressure but not in the region of the sacro-
sciatic joints.
Two days later (February 28rd) the cervix was found
passable for the finger, soft ; through the os internum the
head could be felt but no suture. From the os estemam
to the head lying on the os internum measured one and
three quarter inches.
Auseultalioii. — Fcetal heart 160, loudest six inches from
navel upwards and to right, towards lower end of ninth
and tenth riba. Uterine bruit faintly heard four inches to
left of navel, on a level with navel.
The following measurements were taken :
Height 4 ft. li in.
Peloic inclinaiiuH.
1. Standing :
Height of periJondicular of triangle. , 3 „
^^^^r OBSTETBICS OT THE ETFHOTIC PELTI3.
175
^^^H Leugth of hypothenuse (conj. ext.)
6} in.
^^^H Pelvic inclination
25°
^^^K 2. Sitting:
^^^F Height of perpendicular of triangle
IJ „
V Length of hypothenuse (conj. est.) .
6} ,.'
■ Pelvic incliaation
= 15°
1 . Base of ensiform cartilage to uppei- border
1 of pubea (tape)
8i „
1 Ditto ditto callipers
' „
1 Navel to base of enaiform cartilage
94 „
P Greatest abdominal girth ....
37 „
1 Height of navel above pubes (tape) .
63 „
Height of fundus (about 1 inch below tip of
ensiform cartilage) ....
H.,
Greatest girth roiind pelvis. (N.B.— Diffi-
1 cult to measure on account of pendulous
be%)
28J „
Spp-Il
8j„
Cr. n
9 ,.
Trochaut
10 „
Conj. ext
6}„
Left oblique {external) ....
8 „
Right oblique (external) ....
8 „
Conj, diag. cannot be uieasared.
Bight ant. sup. Bpino to rostrum o£ pubes .
5 „
Left
5i„
(These measures are doubtful.)
Right ant. sup. spine to right of post. sup. spine of „ ^|
Left „ left
.5},, ■
Between post. sup. spines
.31,, I
Left post. sup. spine to lat saoral spine .
.1},, ■
Right „ „
■H.. ■
From upper border of 1st sacral spine to tip
■
coccyx (arc)
J
176 OBSTETRICS OF THE KYPHOTIC PELVIS.
J'rom 2iid lumbar spine {the most prominent) to
right ant. Bup. spine . . . . . 8^ in.
Ditto to left ant. sup. Bpine . . 8 „
Ditto ,j right post. sup. spine . 3J „
Ditto „ left „ , . SJt „
Antero-post. diam. of ontlet . . . - 3| i
Between tubera ischii (measured with fingers
side by side) ... . . 2i ,
In view of the measurements, especially the internal
measurement between the tubera ischii, it was decided to
induce labour by the method of Kiwiacb (vaginal douche),
■with carholised water (1 in 80) at a temperature of 110° F.,
from an irrigator (such as is in use at the hospital) sus-
pended so as to give a fall of about ten feet, for a
quarter of an hour three times a day.
February 23rdj 8 p.m. — Douche for quarter of an hour.
24th, 8 a.m. — Douche repeated. During the process
the uterus was felt to contract very firmly and the foetal
movements to be vigorous. No fcetal heart heard by
house physician.
25th. — Douche has been repeated five times in all ;
during the last irrigation the uterine contractions were
much stronger and fcetal movements vigorous, and after
it the OS externum was found dilated to the size of a
florin. The head was distinctly felt with a suture running
transversely. From the os externum to the head mea-
sured about li inches. Cervix freely secreting. No
foetal heart heard by house physician.
26th, 4 a.m. — Sharp pains in back, running round
abdomen.
6 a.m. — Strong pains every twenty minutes.
8 a.m. — Vaginal douche repeated. Movements of ftetus
unusually vigorous (they were not felt by observers or by
mother after this).
10 a.m. — Pains every ten minutes. Cervical canal
about one inch long. Suture os before, no fontanelle
0B8TETEIC8 01 THE KYPHOTIC PBLTI8, 177
could be felt. Large bag of waters protruding during
pains. No foetal heart heard.
11 a.m. — Head well engaged in brim. Pains very
strong, lasting five minutes and recurring with only one
minute's interval. Portio vaginalis flattened, edges of os
sharp, size equals half a crown.
11.56. — Membranes rnptnred daring examination, the
08 retreated at once beyond reach except in front ; head
well engaged in pelvis. Small fontanelle close to right
tuber ischii, sagittal suture lying in left oblique diameter,
large fontanelle out of reach (second vertex position with
much flexion).
1 p.m. — Head had been down on the perineum for
about an hour pressing strongly against sacrum and
coccyx. Caput succedaneum almost hiding small fonta-
nelle. Large fontanelle just within reach. In front the
finger could be passed up easily between head and pubes
as far as the neck, leaving an unusually large space
behind the pubes. Bones of head rather soft, and at
small fontanelle pressed into a cone.
2 p.m.— Temp. 98-2°, pnlse 108, resp. 40. Some
oedema of fourchette and posterior part of labia. Pos-
terior part of perineum about anus and coccyx distended
in an unusual way. Pains very strong.
3 p.m. — Pains almost incessant since 1 p.m. Patient
in great distress.
Forcejis applied, some difficulty iu locking, the blades
tending to separate towards the concave or anterior side.
When locked, the left blade was slightly anterior to the
right. The head passed out of the ligamentous pelvis in
the second position, and did not become antero-posterior
till " out of the bones," but in passing over the perineum
it assumed this position. The head was born in three or
four tractions, the handles being relaxed in the intervals.
No difficulty with the shoulders. A tear an inch and a
half long in the perineum and in the mucous membrane of
the posterior vaginal wall was repaired with three silver
sutures, the ends being fastened into a long coil. The
VOL. XXV. 12
178
OfiSTBTKICS Of THE KYPHOTIC PBLVI3.
perineum about the tear was cedenmtous bab did no4
appear braised. CMld stillborn.
Fmtal head. — The marks of the forceps are seen in i
direction coinciding with the occipito-mental diameteiff
(good flexion of head), the end of each blade lying oal
the cheeks and the anterior edge of each blade lying over I
the front of each ear. An incised wound over left frontal |
bone about half an inch long, running vertically above |
the external extremity of the eye, starting about an inch (
above it, reaching to i\\& bone. No injury to the bono l
felt. There was a similar mark nearly over the occipital I
protuberance, a little to the left of the middle line, about
half an inch long, reaching to the bone, which cannot be
felt to be injured. Continuous with this, towards the
left side of the neck, was au indentation apparently due
to the forceps. Neither of the wounds corresponded with
the eventual position of the forceps,
Shears. — The right half of the head is on a higher level j
vertically ; right frontal bone anterior to left. Bight 1
frontal and parietal bones overlap the left. Frontal and i
occipital bones beneath parietals. Bight parietal and 1
frontal more convex than left.
Caput fuccedaneiivi on postterior part of left parietal I
and adjacent part of right parietal.
Wrmnds. — Distance between two wounds described j
aboveequain 3| inchon. But the scalp easily slides so that 1
the distance ia reduced to 2^ inches, which is the space j
between the tubera ischii.
Measurevienta.
Child : male.
Length 20 inches. Weight 5 lbs. 10 o
Head.
Biparietal 3^ in. (can be compressed to i
Bitemporal 3 in. (can be compressed to 2^).
Bimastoid 2| in.
Fronto-oocipital 4 in.
Suboccipito-bregmatic 3 in.
Men to -occipital 4|[ in.
OBSTETRICS OP THE KYPHOTIC PKLVIS. 179
Circuiiiferen ceg.
Fronto -occipital 13| in.
Suboccipito-bregmatic Hi in.
Length of sagittal suture 3^ in,
Course of lying-in. — Temperature on first day 98'ti°,
pulse 84, resp, 20.
Temperature rose on the second day to 102" P., pulse
100, resp. 24.
On third day to lOS-l" F., pulse 100, resp. 24. Patient
was now in a state thus described in the house physician's
notes;
' She is now in a very queer state, refusing to speak,
answer questions, or put out her tongue. She stares
vacantly before her and does not flinch when her con-
junctivte are touched. Some twitching of right eyelids ;
left eyebrow occasionally drawn up."
On fourth day, temp. lOO'*", pulse 124, resp. 32.
State same as yesterday, together with determined refusal
to take food ; struggling when fed ; sleep during night
much interrupted ; more twitching of face ; fidgetting
with bands. General condition of perineum very good.
Patient fed by soft catheter passed by nostril into pharynx.
On fifth day temp. 99'2'', pulae 112, resp. 32. Tem-
perature sank probably after movement of bowels for first
time since labour.
Yesterday eveniug fed herself and answered qaestions.
This morning quite herself.
From this time all went well. Lochia were quite
normal from the first ; they ceased on the ninth day.
The perinenm healed completely.
On twelfth day a thorough examination was made.
Per aj>eculnm, vagina healthy.
Per vaginavi, exactly opposite the posterior edge of
each tuber ischii, about the insertion of the great sciatic
ligament is a distinct cicatrix over which the mucous
membrane is adherent to the bone. No deposit.
Intertuberous diameter again measured opposite the
180 OBSTETRICS OF TSE KYPHOTIC PBLTIS.
■
cicatrices by three fingers thnist in side
by side
and ^H
found to bo rather less than two inches.
^H
She was discharged qaite well on the fourteenth
d.;. H
On April 17tli she was quite well and at work.
^1
Analysis of Table (p. 188).
H
Total labours 32.
- ^H
Total women 20.
^H
Presentations.
^H
Vertex ....
27 ^H
Face
1 ^M
Not recorded
^H
Tertex cases.
^1
Right occipito-iliac
12 ^1
Left occipito-iliac .
3 ^M
Third position
3 ^H
Fourth position
I ^H
Not recorded
12 ^H
Changes during labour.
^1
Deep transverse position of head
(N.B.
^H
with Schmeidler's = 7)
6 ^H
Marked ante ro- posterior position of head .
^1
Posterior rotation .
2 ^M
Spontaneous versions
2 ^M
Spontaneous premature labours
3 ^M
Expansion of pubic arch (proved)
3 ^M
Expansion of pubic arch (sappoBod)
1 ^1
Cases in which interischiadic diamete
was
^1
less than bitemporal or biparietal
6 ^M
Diffe
encB
^^1
OreateiC.
Least. ^H
Uiitop . . . G-5 cm. .
. 5 c
.„. H
Brt-sku. 2 „ .
. l'2o
" 1
Moor (second labour) 3 „
. 2-25
JStnUfvldt 2 „ .
i.
-1
J
0B8TKTKI03 OP THE KTPnOTIC PELVIS. 181
DilTcrence.
Hoening . . 4'6 „ ... 3*75 „
Champneys (third labour} 3'5 „ ... 2 „
N.B. — Cases only inclnded in which the head passed
imdestroyed.
Moulding of fatal skull noted in 9 cases.
Greatest apparent pressure on posterior side
of head. ■■..,, 4
Greatest apparent pressure on anterior side
of head. ...... 2
Other conditions . . . .3
Operative procedure*.
Caesarian section . . , , .2
Craniotomy ...... 6
Induction of premature lahonr . . .4
Forceps 12
Forceps alone .... 9
Forceps after indnction of prematnre labour 3
Results to children.
Death to child in 1 3 out of 32 labours = 40*6 per cent.
Results to mothers.
Death to mother in 9 ont of 32 labours = 28'! per cent.
46 per cent, of mothers died.
Besult not recorded 1.
Before discussing the question as a whole, it -will be
well to briefly mention the opinions of some of those who
have written on the subject.
Moor (S. 67) says that the head of the child will not
take a tranvesrse position at its entrance into the pelvis,
or will soon leave it and adapt itself to the upper and
middle part of the pelvic canal in the direction of the
elon^ted conjugate. In this position, vertex, face or
breech will be able to descend without difBcnlty nearly to
the outlet. {S. 68) Aa a further favourable condition for
i82
OBSTBTBICe yP THE KTEHOTIC PSLYIE.
labour may ''& mentioned the great mobility of the sacrt
iliaf aod pubic symphyaes. Without this mobility neithra
the spontaneoua birth of a full-time child nor
extraction by the forceps would ever have been possiblej!
Even a premature head cannot be seized nor extracted bjH
forceps or cephalotribe on the dried pelvis. Nutation c
the sacmm round its transverse axis is mentioned.
(S. 69) The difficnlties are concentrated at the outlet
The pubic arch is too narrow for the occiput or forehet
it is best adapted to the chin.
(S. 73) A large fcetat part (e.g. the head) can descend
in a sagittal direction as far as the peh-ic floor, wheres
difficulty begins ; the labour may end spoDtaneouslyT^
through the mobility of the joints. This cannot, how-J
ever, be relied on, Premature labour may profitably
induced. At full time the head ghould be allowed i
descend to the pelvic floor. Fopcepa, perforation, Oseaariu
section may be necessary,
Hugenberger (S. 32) says that the child generall;^
presents with its back backwards, aud that this is pi'O-a
bably due to the encroachment on the abdominal (
by the compensating lordosis producing pendulous bellyj
the foetus lying more comfortably uuder these circum*!
stances with its back backwards. The first difficulty^
arises low down in the pelvis, and in severe cases '
rotation of the head will be impeded. At the outlet tlw
larger parts (foi'ehead and occiput) will not be able 1
pass. The chin adapts itself best to the pubic arch (conf J
Moor's third labour).
With regard to operative procedures (S. 3-1) these mni
vary. In tlie higher degrees of contraction the induction)
of premature labour is especially indicated. At full time I
the arrest of a large foetal part must be watched for andi]
forceps attempted, or perforation or cephalotripsy per-
formed. In view of Moor's labour No. 2, turning may be
performed, the head having been laterally compressed mors '
easily than if it had come first. Ciesarian section is pro-
bably never indicated.
0BSTBTEIC8 OF THE KYPHOTIC PEIVIB, 183
Eoening sayg (S. 52] that the progaosis depends od the
position of the kj-phosia, the lower this is, the worse ia the
prognosis. The head (S. S3) engages the brim more or
leBB transverse, in accordance mth its position in the
uterus. The further progress of labour will be influenced
by mechanical conditions according to which (Spiegelberg)
the bead will accommodate itself to the shape of the pelvis
and will sooner or later become an tero -posterior. " In all
cases of vertex presentations in this kind of pelvis it ia
remarked that the head stood in an oblique diameter."
(Afterwards becoming nearly or quite antero -posterior.)
" Although the passage of the head through the narrow
place must bo considered a necessary condition for
delivery," Hugenberger has pointed out another modifica-
tion of vertex presentations (in these cases), viz. the back
pointing backwards, explaining it by the encroachment of
the compensating lordosis. His explanation is not quite
obvious, it is not evident that the foetal movements are
more confined when its back is forwards than when it is
backwards. Moreover Hugenberger's cases include one
of face presentation in which delivery would naturally
have been impossible with the chin backwards (back
forwards) j in this case it is not mentioned to which side
the chin originally pointed. Hugenberger's explanation
loses much force when it is noted tliat the small fonta-
nelle pointed backwards only once in hft occipito-iliac
posilione (unusual direction), whereas it twice pointed for-
wards in right occifito-Hiac jjosittons (unusual direction).
On the other liand the " 3rd " position is generally as
common as or commoner than the "2nd." Hoening's
explanation is that when the occiput is originally posterior,
its forward rotation is prevented, and that the occiput at
the outlet may even become posterior.
The shoulders often pass in the same oblique diameter
as the head (HoGniug's case, Birnbaum's first case, and a
third case in the Bonn Hospital).
As to treatment (S. 55) all depends on the degree of
contraction. The looseness of the pelvic joints must be
184
OBSTBPTBfCB OP THH KYPHOTIC PBLTI8.
remembered. It is quite reasonable to indnce premature
labour in cases in which, if rickety, Caesarian section |
would be absolutely indicated.
The proposal of Hugenberger to turn is not good.
First, the head desceuda low so soon that turning would be
contraindicated ; secondly, the delay of the aftercoming
head tella the same way, especially as it occura low down,
when the placenta is probably useless. Besides, to turn
is to give up the advantage which the slow expansion of the ,
pelvic outlet affords to the persistent pressure of the bead.
Turning is not then to be recommended ; we cannot I
produce face preeentatious at will, and are left with j
Cassarian section, perforation, and forceps.
In spite of Hugenberger' s opinion, GEesarian section is 1
sometimes indicated ; impaction of the bead would bo far j
contraindicate it.
For forceps this pelvis is particularly adapted, on ]
account of (1) the mobility of the joints; (2) the action o£ |
the forceps as a wedge ; (3) the remoteness of the bladder '
and peritoneum from the points of injury ; (4) the position |
of the blades on the child's head laterally, in the diameter I
to be compressed.
Conclusions (Hoening) ;
1. Turning is not to be done when the head presents.
2. Geesarian section is indicated when the transrerse j
diameter of the outlet is less than S cm. and the head is \
moveable, ao as to be easily extracted from above.
3. If an operation is required and the transversal
diameter of the outlet exceeds 5 — 6 cm., the forceps is I
indicated; even if it is less than 5 cm. it may be tried 1
with caution if the bead is impacted, but if traction ib I
unavailing perforation must follow.
Schroeder (' Geburtshiilfe,' 4te AuHage, 1874, S. 554) |
agrees practically with the above conclusions. He doea \
not mention turning. Ho says that induction of pre-
mature labour is indicated in the majority of cases,
Cs3sarian section is quite exceptionally necessary. He |
mentions thirty-six labours in eighteen women (to which j
0BBTSTEIC9 Ot THE KTPHOTIC PELVIS.
185
he does not give references). Premature labour was
induced eight times and completed by forceps four timeg.
Spontaneous premature labour occurred once and was
ended by a severe forceps operation. Mature children
were born naturally four times ; forceps was used ten
times, in two of these cases perforation was necessary ;
perforation was also performed in nine other cases. One
woman died undelivered. Ciesarian section was performed
twice, once with success. Of twenty-three vertex presenta-
tions the occiput was backwards in six cases (it is not
stated on which side). Twenty-three children died during
OP in consequence of labour, only thirteen (including two
GEBsarian sections} survived. Twenty-eight labours ended
in recovery of the mother, eight mothers died. Thus,
eight out of eighteen mothers or —
44"4 per cent, of mothers died.
22"2 per cent, of labours were fatal to the mother.
63'8 per cent, of the children died before or soon after
birth.
Schroeder remarks that these statistics are probably too
high, as only the severe cases are generally recorded.
Spiegelberg ('Lehrbuch,' 1878, S. 485) says that little
reliance must be placed on the mobility of the pelvic
joints, Cfesarian section is seldom indicated. The child's
back is often backwards, " doubtless " in consequence of
the pendulous belly (Hugenberger's explanation). He
recommends leaving the labour alone and using the for-
ceps, or if necessary the perforator. Turning is only
indicated in abnormal presentations, or where immediate
perforation seems more difficult and dangerous than that
of the aftercoming head. In the generality of cases the
indaction of premature labour is justifiable.
General Beu&bks.
Presentations. — It will be seen that the vertex com-
monly presents. This would be naturally expected from
the ease with which the bead can engage the pelvis.
The right occipito-iliac position ia much commoner than
OBBTETBICB Of '
KYPHOTIC PELVIS,
the left- The cause of this needs explanation. The head i
is usually more or less transverse (Moor says the reverse).
Changes during labour. — The occiput rarely turns for-
words, deep transverse position is common, and posterior
rotation not uncommon.
In commenting on this we cannot accept Hugenberger'a I
explanation, even though endorsed hy Spiegelberg, and
think Hoening'a far better. The fact is that the head
meets with great resistance from the front part of the
pelvis, which prevents its rotation and may even produce
posterior rotation, and this ezplaimtion tallies with the
great frequency of right occipito-iliac presentations, iu
which the occiput is frequently posterior. Marked antero-
posterior position of the head, which, according to some
authors, ought to occur frequently, is far from common.
It is probable that the expansion of the pubic arch,
though proved in some cases, has been made answerable
for too much, and this is made more probable by the six
cases {see Table, p. 180} in which the head apparently
passed uudimiuisbed through a space lees than itself.
The key to the explanation wilt be found in our own |
case, in which the head passed out of the ligamentous
pelvis completely posterior to the hibera ischii which appa- I
rently left their marks on it, being themselves injured in \
their turn. In such cases the head acts as it does in some
cases of oblique contraction, it entirely neglects the use-
less part of the pelvis (this implies what is called in the
obliquely contracted pelvis the " extramcdian position").
It therefore adapts itself to the space behind the tubera '
ischii in front, and in front of the sacrum and coccyx |
behind, and there is little doubt that this space is capable
of considerable expansion by the " nutation of the sacrum."
It is far from unlikely that in some of the cases in
which an eventual antero-posteriov position of the head is
mentioned, this was not its position when it emerged from
the ligamentous pelvis, but was assumed by it during its
passage over the perineum (as in our case), and that in
many, if not in most cases, it emerges from the ligamen-
OBSTETRICS OF THE KYPHOTIC PELVIS.
187
tons pelvis transverse or oblique (as it did in our case), in
which position it fiuds most room. After the passage of
the head " out of the bones " space may be gained by the
neck passing between the pubio rami.
If this is the case the inter-ischiadie diameter is no
accurate criterion of the possibility of delivery, except as
implying a degree of other deformity. Nor is the antero-
posterior diameter of the outlet. The measure we really
want {but which can hai-dly be obtained) is the space
between the tubera iscbii in front {i.e. from a line joining
them) to the tip of the sacrum (or the coccyx] behind,
enlarged by the nutation of the sacrum. Of such a space
the transverse diameter, as bounded by no bone (except
to a small extent by the ischial spines), would probably
be the greatest dimension, and therefore the best suited
for the long diameter of the head. The inter-ischiadic
diameter in the living woman should always be measured
by the fingers side by side, and not by callipers. Its
expansibility cannot be practically measured before labour,
but should be remembered. Spontaneous premature
labour is not uncommon ; the cause of this is not known,
but it may bo remarked that premature labour seems in
these cases to be easily induced — a verj- fortunate circum-
stance, since there is great variety in this respect.
The moulding of lliefcetal skull gives no constant resnlts,
the shears are often considerable, but the data are insuffi-
cient. The fact is that the bead meets with much resistance
from the (practical) front as well as from the back wall of
canal ; it never, however (as implied by Bimbanm and
Hugenberger), comes in contact with the symphyeis pubis,
on account of the narrowness of the pubic arch,
Progtwais. — This pelvis has in general treatises been
made too unimportant, while it is probable that our accu-
rate data are from severe cases. Still an immediate
fcetal mortality of 40'(5 per cent, and a maternal mortality
of 28' 1 per cent, make it sufficiently serious, in spite of the
position of probable ijjjuries low down and far away from*
* ContiDned oo p. 192.
r
^
1SS
oMnrucs ttr tu cttbotic pkltib.
1
FMalikdL
^K "v
Ct,tiipliiriHfl>)>au.
.,.. 1 —
-Af«b. f. QiB^' Snlraux
NonerMorfrf
Kotgina
Budi,iJ^3H
*«*
UMd
"
■'
tUliiljIli
•Arth. f. OjB^
IH venci
Perfomtioo
tlUdi.ii.iM
«»»•
IbUto. Bud iii*
MM
Riglit
owpito-iliM
arfTWtet
il«i.*.0«b,'B«id
TSa rotation.
.11.!. Hi-ftl. S.M
/mta. f. Oeb. n
Sod tcrt«x
Child born in 2nd ver-
Sent. 1 S-Ecm
i.jB,'B»ndv,a.2a
tex pmilion {lamoar in
hollairufHFrnm.BijBpe
andtiieofakidnej-).
1
ll^f^rnKM^
I'luui lui itiverb
Right
Separation of pubic
NomemM
•^
bone* with a loud
bori#w.* Mum i,
noi<e.
f.Vti, K.u>«ll«.
mccuuii
'm
<,\i*rl. Bimtin, ond
J*ol woorded
"
tf
.1.11 ■■ .;,■)..,' lUuU
■ 't,'> V. I860,
Uoad; no
details
No detailj.
-r-Scm-e-TSem.
«■
He«d
Spontaneoni version i
,cipaD«<ra of pubic arch
.^J*™, tkuJ *v.
^^H^
|L
^--iftMiS
OM!iliil<»-ili»U| tioa ; poaterior rota-
tion Qiiiler forcepi;
tame obliqae di.aioteT u bead
1^
Left
Uucb flexion of bead.
f
(Kvivito-iliw)
L
-«*v'«' "^
Uight
m
w'Viuto-UiH
tlon; bead MmUau-
W
allj preesing against
L
... . .n.^V^
UmJ
Not not^
P
&
.^?-^- 1 took b«llw.rdii M.
7'6cn).
»nm.
L 1 jHMuion of pnbic irch.
■^ IhM (oUn Kol noted.
■ (!n.
M^
PP^ l!»>»l>)
Ukih Willi |{Bnptare of nteras).
^"^ Mtili&'llM
■
L
^M
0B8TE1'B1CS OF THE ETPHOTIO PBLVIS. 18{
4
Felric oollet.
Op.™-^.
UonldiDg of fatal ikBU
Eeitill
1
ABt.-pOil.
lalcr-lic)..
loeluld.
lomolli...
Not BiT«n
8-8 em.
CtNuian «ec-
Hon
(Cmwu Motion)
AUve
Death.
7 cm.
9 cm.
„
„
„
^1
Not given
6-Scm.
Bern.
(Cnmiotomj)
Death
Eocovery.
■
> uCTuro 10 cm. 1
. coctji 8 cm. ;
Rem.
1-5 cm.
Premature la-
bour mdaced,
uo other lid
Not ip«oialty noted
Alive (aooD
died)
■•
1
No meamrei
Nona
Not noted
AlivB
•■
1
m.m
Nktonl U.
bonr
Emj forceps
-
"
^^
K..^..™
5-6 cm..
Premature la-
bour indaced
Forcepi
(FooUing)
Flattening and in>
jury of posterior
lide of bead, pro-
tCTior tide
Indentation of an
terior, protuber-
ance of poBterior
aide
Fracture of akuU
StiUboro
.. m
DeMth.
1
-
Kotnottd
Liring lUcovary.
1
mm) 12-3 cm.
ificm.-
lodoction ol
Bibtcral aompren-
tiou, no fiunrea
Stillboni 1
B
Nona
Not noted Living
1 'Itb Ubonr.
^H
1
90
JSatBTRICB OF THE KYPHOTIC PELVIS. 1
: FoUlikoU. 11
AaUior.
ittaoM,.
FrMutatiDii.
ChMK during Ubo«r.
II
Bipar.
Biti.^
SugtiAirger
Eiu kjpliotlwh-
ard vertei
Flexion 1 Jeep trans-l 8 cm,
Mem.
querTorenckM
6eck<Mi,*St. PeMM-
borg, 1S68
Idtm.
IhUMn
4tb verUi
der forcep., with it..
wasBed flexion ;
ihonlder* in oppotitc
abliqae diameter vritli
difflcolty.
None reoorded.
11 cm.
Tew.
Staiiftm
Med.-Cl,ir. Rev.;
(3 previoa»
Nomea«.ree 1
No. l«x», Jan.,
craniatomiu)
1
1869. p. 24 (8 la-
i
lionrs)
1
IdODI.
Ibidem. July, 1871,
p. 275
Beitr. sur Uhre
Haul
Implied expanaion of
pubic arch.
Sagittal suture more
85 cm.
Notnotd
Sotning
2ud vertex
Sent.
SSScm.
vom Kyphotiich-
antero-poiterior tban
TBcengtenBcoken,'
oblique; pasBsd nar-
Bomi,lB70
roweat place quite an-
tero-posterior ; poste-
rior rotatiou roUowed ;
ihoulders in same ob-
lique diameter as head.
On*. Hebd.,' 2me
l^idm
Head (?)
Labour quick and easy.
8 cm.
I«otgiven
tdem.
H»>d
8-5 cm.
qniukandeaay; aagit-
tal intnre nearly a&-
Knmamkg
Wira.M8d.Woeb..
Bigbt
No III
■rare*
1872. No. 2, S. 33
11
In tliU p.pet
H«>d
labonr; easy forcopi
deliTcry.
Idem.
"
Not recorded
Spontaneous premature
Ubour oF tvins.
Idem.
..
Right
Premitare labour iu-
oedpito-iliac
dnced; deep trani-
■9 mu.
T-Sem.
vecse poaition ; head
pawed oat of ligamau.
tons pelrii in left ob-
lique diameter ; much
flexion curly in labourj
much preuure of head
■gunat ucrum and
p
7^
■
HPPPBHIH
OBSTBTElCa OF THE SYPUOTIC PELVIS, 191
f p*...».
!l«Qll
0^^« iMouldUitofteUlitnU.!
ARL-poft.
Intn-Ueh
' to child. tomeiha.
[
(2 p«vioiu~l
Marts on po»te-^ (2 previous (2 previous
b
labon™
rior-lyiug fore-
1
■pontane-
OMlj)
Foreeps
llORd
Alive Recovery.
MCTum 11'7 cm.)
9-6 cm.'
Flattened in ob-.
lique diameter
"
Deatli.
■ncruw9-5cm.l
coccyi T'Bcin./
7-5 cm..
(2 previooa'
(Craniotomj) ■
(2 previous
stillborn)
Stillborn
Deatb
lot reoorded
6-5 cm. Notrecoried
Not recorded
AUve 1 Not re-
1
corded
•acram) 9-5 cm.
*6cm.
Forceps .Anterior pari eta
Aii™ (soon
Death.
OTcrUpped p«
died)
b
terior
r
«.cnim)9'5i!m.l
coccyi) B em /
-{
None (pTema
tore. Bpon
taneoDs)
Alive (?)
"
rtpTen
10 cm.
Forcepi (pre
mature apon
taneoui Is
boDT
Alive
■■
H«m»«»«*
Foreep*
„ »P0I1
jtaneoDi pre-
Protuberance of
anterior parietal
Sot recoided
Becovory.
Imitnre labour'
SpontaaeoDs
labour
StiUbom
Hem.
5'5 cm.
Ubour, fo^
' overlaps anterior
po.t«rior ride of
head more convex,
cepi
anterior lids flat
t«ned
J
193
r THS ETPfiOTlC PELVIS.
Experience lias not borne on*
—Our opinions agree gene-
IV w rtlwi W i l M»ii eoM<l»sione.-
nlly with ihaso of Hoeuing.
1. In » &ra) latboar, if tlie bead presents, wait and act
MC<.vr^ti&^ to ctrcuutstauces. This implies forcepsj cranio-
Wtu,v, or Cawariaa section, which should always be con-
!ud«i'ti«i in the above order.
3, If the head presents never turn.
S. 1& subsequent labours, where the history of the
tu-bt Ubour seems to indicate it, premature labour may be
inUuved with guod hope.
i. No known measurements give us any sore indication
iw forceps, turning, Ciesarian section, or the date of the
iuduutiuu i>t premature labour.
b. The mobility of the pelvic joints implies a prognosis
alwAju luoit) favourable than measurements would lead us
to itupptuie.
0, U is probable that in many cases the head entirely
uv^t«ota tho anterior half of the pelvic outlet, and emerges
hxmx it trouHVerae or at most oblique. Antero- posterior
uuvrgfuce is the exception.
7. K»ch succeeding difficult labour increases the liability
of thu uiurus to rupture, as in other forms of pelvic
diuortivu.
The fHUUUJCMT expi-otised the thanks which at! present must
Iftei VtK dui} to l>r. Ohampueya for his interesting and valuable
Tc
;. CtAiJkBiN thoutfhl that it was worthy of note that in the
V4avs ii.'oordvd by Iti'. Champueya the positiou of the long
Jaiiji-.'.-.i' 'i (I)'. Iiiml did w-A correspond to the largest diameter
■u' tiausverse than usual, instead of
■iiorior. It was generally considered
■■•'■\ the long diameter of the head
. ^liamoter of the pelvis on entering
. Ury^st, or one of the largest, dia-
- I ti Mif t partH, It was also generally
.^.>v, lliat to find the eagittal suture
'lA^u ivt^ than usual when the head was
ithWM^M^ of trtUHverse contraction of the
OB8THTEIC8 OF THE KYPBOTIC PBLVI9.
193
pelvis ; and to find it persistently remaining in the tiunsvei'se
diameter oE the pelvis a sign of contraction of the conjugate
diameter. He asked Dr. Champneys how he explained it that
in these cases the bead did not adapt itself at all to the shape
of the pelvic brim ?
Dr. EopEB remarked on a point of great interest in Dr.
Champneys" case, viz. the mechanism of delivery, the fcetus
not passing under the pubic arch, hut behind the tuberosities of
the ischia. This resembles the mechanism of delivery in the
lower animals ; for in these there is no pubic arch. The fcetus
always passes behind or rather above the tuberosities of the
ischia. In the pelvis described by Dr. Champneys delivery is
not BO difficult as might be expected, because the axis of the
outlet corresponds vrith that of the brim. There is no curve o£
Cams to be traversed as when the foatus has to pass under the
pubic arch. In all cases of antero-posterior curvature of the
spine, the lower ribs approach the crests of the ilia, and
conset^uently the capacity of the abdominal cavity is greatly
diminished in a vertical direction. The uterus in its develop-
ment cannot sufficiently grow in an upward direction ; it is
forcibly thrust forwards, and the anterior abdomiuiil wall
becomes so stretched as to give rise to an extreme form of
pendulous belly — so much so that the uterus seems to be con-
tained in a hernial sac. This extreme anterior obliquity causes
a difficulty to the entrance of the foetal presentation into the
pelvic brim, which without intelligent observation may be
supposed to be caused by contraction of the brim. He had
seen a ease of this kind in which a patient had been in three
previous labours delivered by craniotomy. In her fourth labour
she became a patient of the Royal Maternity Charity. In the
absence of Dr. Boper Dr. Herman attended her in labour at full
term, and easily delivered her, with forceps, of a liring child.
The day following she was in extreme suffering, with a quick
pulse and high temperature. On removing the bandage to
examine the abdomen the uterus was hanging down in the
abdominal pouch, and her sufferings were caused by the uterus
having been bandaged to the anterior surface of the symphysis
pubis. lu Dr. Boper's experience he had found that contrac-
■ tlons of the outlet of the pelvis formed greater obstacles to the
■ safe delivery of children than did corresponding degrees of
H contraction of the pelvic brim.
H Dr. Hebuak said that, so far as he remembered the case to
H which Dr. Eoper had alluded, there was no great difficulty in
H the passage of the head through the pelvis. He thought with
I Dr. Champneys that many cases had been published on account
H of their difficulty, and that from the literature of the subject it
H would be thought that delivery in the kyphotic pelvis was more
^1 often attended with difficulty than it really was.
^^ VOL. xzv. 13
I
»
I
t tlu. b*i4i4«, m4 Ui stadj «( Ac UiiftT or oion
> «/) w/OmMI iMm <U« MC Zfl ucver to1>r.
N r«OH to Ih* tmwrcnc portinn of tbe bead at
.., u.f., ■„•■ ■•>'■ i-nMif/a (4th9 bead at Utcatd of pregnancy
ima (t*(«fN<iu»l t'X llfA K/lafitaticfii of tbe wbok oraio in tbe
f'fH«l u<lit<t'1« t// f,bi< nt^-niw KAwhj, wkicb waa wider from liom
l'( li"rrt iliHd fr'tii U<i'ir>< tnuikwudt. In aceordance with thiii,
wri'l (•^iiHiiiln'rlfiK tti'i 'J^ilral oltIi/|uitj and •]«xtra] toniou of
l)ii< tilj<riia, IIk- >'(u'Ii ft,*, tli'i (M^ijnit) at tbia time most
'"iitiriMriily |i'iliil<''t t'l fli'i l''ft ttii'l a little ifi front (firat ['osition
I'f Niu<K<''l"fi "r t" <)i" riid't and k Uttln iMtbind (wcond jioiition
Iff NtwK'iliif . Wlii'ii lalHriir iM'^aii, a now ict of conditioDB aros^,
iiiiiiit'lT, Uii> Kjlitirtullriii iif tlix licail to tlin briiu, but no attera-
ll'Ui >it |iiiilll"ii wniiM Ulci' \i\iuM iiiiluii* tlio lioad in on' or leas
llMi'il UiK liiliii. Niiw III iiiuat kyjihotic [k-Wgi (which but for
tlixlr iliifiii'MiUv wni'd tfiiod iwItoi enough, and not UBtmlly
ilwiii'ft'il llliii mki'Ly iii>lv<i«J, nlthouKh tho conjugate wu larger
l.ltiiii l.liii lmu>vi'i'»ii dlaiiiotur uf tho brhn, thero was plenty of
I'liiiin fill' lliu liicitf diainiitiir of the Lend in tho (loHser) Iraus-
viirin illnniclKi' of l)in brim, and thci'i* wai therefore no force to
nhiiiiKn til iiimllioii. Thii nlliiiitil fait* tallied with this. Tbo
(('■I'lulilitninia bolwi'i'ii DiIn jidviN ivnd that of tbe quad ru)>edB *
iiiiilii' llin |ii>liili> III vi'li'iiiiiirv 111 mto tries mentioned by Dr.
Ki.pi I i^r i.iii'iv.l. ('I\> llir I'lv.hinil.) 11 seemed to him (Dp
t'liiini]im'i«l <liiil I'rii.liilinii. Iu'llv nuNiiroiUiced by any deformity
•linHi'iiiiiK llii> iibiliniiliiiil I'ltviiv, ftjiart from the question or
t>lii'iiiiti>liiiit<iil by till' vHti'biw, aiul was seen in bypboui.
tithtosU, niid wMlltil*, tlii> ntenis (irowiui; in the only direotwn
fiw IM It.
A NOrK VtN UTKIUNK MYOMA, IT8 PATHOLOGY
ANU TRKATMKNT.
U.V UwsvtK Tait. F.R.C.S.
I iHt \\o\ kiA«>w Hixjrthiutir wKioh kaa doiM uon to eon*
(um> t^ur (wlKtsUyit- ttiatt iW frMjoMt altoratton ol p*thiK
K^i«<<it w«\Mw«v>UWnf wmI iW *aio|>tkw of ckssinl «0(4i
t\vr W ww> wMlaiwt tW » %t ii — > w I mw w to thnr imI
«MM«tti^ TtiiM Iki* tWM*iin wMcli ia ov juttMhi ia^
UTERINB MYOMA.
196
were claseiBed nnder various menningless bnt perfectly
understood and well associated terms are now grouped as
surcMiiiitii of various kinds, thongh it is perfectly certain
tbat many of them have few features in common. Why
the word (inp£ should be introduced as it has been in
pathology I cannot in the least underatand, einco it is per-
fectly clear that the Greeks meant by it only wliat is
vnlgarly included in the word " flesh," by this the skin
being particularly indicated. The constant prefix of the
adjectire Xeucoc '{AivKtiv iSairToi' napKa t>iq SvSainofoc]
shows this and «Iao proves that we have no right whatever
to have coined such a word aa narcovw, which, if it can
mean anything at all, can only mean a swelling of the
skin. The terms "fibroma" and "fibroid" are con-
venient but as barbarous to the classic ear as well can be,
but I imagine that it is of little use objecting to them now.
Still, as we have a clear notiou as to what a fibre is, and as
we restrict the term fibrous to a particular kind of tissue
of which muscles are constructed only to a very limited
extent, it is perfectly certain that we should not designate
purely muscular tnmours as "fibroid." The Greeks used
the word fiixuv to mean what we now call muscles {Apiii|''
rnro fiviuvwv, avo ^'otmov a/pfC "pofc) J any tumour consist-
ing of ranscular tissue should be called a " myoma,"
The very common disease of the uterus which is to be
found accurately described by some of the earliest surgical
writers should therefore be called " uterine myoma " and
not " fibroid tumour of the uterus." I daresay there may
be such a thing as a uterine fibroma, but I have never
seen one ; nor do I think that the facts of its history, the
natare of its pathology, nor the requirement" of its treat-
ment can be such as I am about to advance.
For clinical purposes the most convenient division of
uterine myoma is into the classes of the single tumour and
the multiple. Great prominence has hitherto been given
to another and triple subdivision, submucous, intramunil,
and subperitoneal, but I think the prominence lias been
unduly insisted upon. It is based entirely on the acci.
iM
f^fWM irrMfA,
rt*wt lit *l(* fi'Atft *it /tf)((5« '/f tit* hitntmt nf >*« wy
f«#U iwl H^A tiifnt't.itffi In ttlrMlf '.^Af IfiM")* in th*
fffttnt lit »Mf Mfftwf-U, MitA «*« Ih "«#t f/'rfwl "f iMf »rMi*#
WW(f )* (rtw UhU ft HI itnp'ftinfi'*!: 'ft*" ttfrnth i/t tifiUmtfr
Hiiifitw uifhUfH i» »hiuilHl*'\f )I««)M (/. 0r* p-fi'fl '4 Urn
MMiifii ttjf «ft#««l •"♦Iftif , **»r (i'» '/«« ham tfnmiM ihn
liUfiun HM twffHK tiMH u}imttih(\ tiMtittf ptihtftijf, MiA W0
ktt'iw ftr«A H fii^ff 'irinUinlMH itttt-f l.h'< rn'<n"fmifM, mnI
flfttA |.|r« IfiMNr w^mhH m»r1ii Mt« mf rMft frf lln tirnwUt wium
H tfni f<rfrvl"ti«lr «)lr|iMttfM^. Miff/ "f ffio "flmr f#>«i(.Hn#.|
»*1((<'ll MHlf'ifWrIc '■Jiwd'-t'^UH lU ftfMHUm tiiiii finiff
/«(((! wf whhii / oliflll •fffolt #f. tfituiU hyf ««') f/t*j «(i7<
fhii lii'iii^Umiitu llinf (I: I* A /(iMfrttOH x««'(i*l«(iijj ttilti Mi*
imimkHHi hiiii*i,iiiu, 'irittUmtliin iihM>i\if in f|i« vKwiiilHr
«<!«'■ llMff I At((, N«N""lHfM^ wlllt iif ni'VUiiuie uji'imirmiUm,
Mfi'l 'ft "11 pri<hn\i\\Uf Un \itiimtf mim** l« I" li« fiiitritl It
(.fiH ttorviiiiii twM)/ wlili'lr I'ttHftliily «"'"•'■"<' tl't* ■lw((iil»f
fHN'>U"rf, TIlN »\HiMUuUi» fflllcll t icn III li""k« Ulftt tht
fir'iiliii'UiiK 'if iilf'i-liiH itijr'iiiift In fN*MiiM«l liy I'nUUmf, \tf
lnn^^)t^n^^, hj wm |ii<IiiI|(»hi«h In i<hi* xixiiitl \mt>ii\nn nni ^
iif*tr'ih>iil\a>'*f>*'* Ik >I<x "ti'i"! ' illiiiilHi) l>"''niiiifi 111*); MM
(«»illlHI'llt>l'i<-,t, Xd'l Ili'i'iKlif t llMVKMKMIi ll«llilllK III tliydWI
)il*'lliiH (" (iii|i|«ic^ ntiy nf ^Ih'Iii,
I Imlle fll MHtHM lIlO-HHUMMIMll. Itl iJiM lltKIIVlrMIKl In**
HtlHlilNHl fiif- lliH |ifiti1<ii«H'm lit Mio iIImhum', HHil Mill miiTHii
iir H tiili'MHilHC liiKlliuil i>r ll« I'liiH linn, I lliliib, ««Ulilli)iml
him ini||'n«fli«» iif ItiK ))lii<r'll<iii nr hiy -MMfiili, llioiiNtli I (lu
(iMti Imlliivi) I liiivh ^i<|. <l|iii>iiriii'i'il lliii iilMiiiiilK i>H,iii«i.
ti'linf «r nil 14 iiiK Nlitli' iiif <'<iiioIm*|hii>i ii>«i'tiliif( Ultl
fiitii<il*m. liitNiiii^H MiiMiiHiit'l'DMNi-iitih'ilMiniiMxiir Kniinvtii
tlKi'ltNiitt Hilt! >\\\mn ill Niiiiiiiifli i<f Mm vli>w lliiil Hut riiiio>
Hxil >\t iiHituH'ni Htiil Mii<il«l>l'imHi)ti nvii ijiitlK liiil(>|iprii|itii(i
(iF iiiii* itiitiiliKi', fttt* xiinfiHtvy N><t>iti« III liii iiiiiti' Hi>i>H)i)'tii],
(Mill t\>m Hiti Inil|tt1llt|« i>f lilt) titll'i'Miil lull UiinUn th WiDtIti
nltiii>iil> Hmiimt' «■ if U ltn>l ii»«iii' li»"ii itlajtiiittil, 1 li(ti>iiin*
ttittiM Hllil l)li>Vt> tHHilti'il llmf III Hii* (lix IxKihi iiit) i|iim
wiiiiitf, mill Mint iii»<iuh'iiHHtiM Hint nviiltiHixi, t)tnii|tli Oiiy
liHvi* III! i(|t|mvitn(! toimiHinilt^ <tf |iiic)i»*ii kdiI ti»i')m)i* mit|
I
tt U lUl ItWIlatVUttlltttt U tt«t tW|Wtt)Uht <>tt UVtilKlliMt, f\\\-
WllhV HlliMl »l\jt'll HH'H»lM(«tUilt tW|lt<tul« U »!«W(i IH »«" l«
U, HtPtt'ti.Vi', H»»W lit' Hit llHHIiiiUHitt iHtHiW h«l' MtW'lH*'
itf lliti fnlli>|vtnH liilwo, luiil till* ItHR jr^( to W UiVfaMHAtmli
(tiH |>ot'Fiiii|l> illnMiink HDil «ii, Vvi'^ t>nvil, !■ Mul I l')>Hh»l>ltL.
It) ftir ilif iHKiit iiitiiiiiiin SHVlt'l)' In Mliiit' I vhII Mih
tiiiiUilHi* loyiilim, VrliiUl llio iillifl In i)iitli< iiiiiiiiiihI It lintmMl
It i> iii>l tnvti. 1 |ii<i>|<i>«t< till' II lli» imiiHi »f " t't>iii)iiiili'lii
llijrxltiH" Hliil I «liiill t)t>nl lUtU II Ill'-L
Tliv fiM'iit ut till iit'Piili'lii iiij'iiiim l« lo'i'tfi-ll)' «iii«<it(li
HUtl MVuUl, ll ooiimIiiIn iif H iiiiKtii'iii |i}|iMt1iii|ilty tit Mm
iiiUMniUi' Hwrn i>t lliv iUi>riiH In Miii mliUt' tit *rlili<li (tii>
iiit>rii)i> I'liim) llfM I'fiiliiilly lit' iiMKi'lj* mi, If lliu liiiiiinir
liNtml llii ifli II will III! ri'iiHil l<> li« iivifiu'll) iiiiUmmii
mill t\f»t rnilii uiij liiiilliUl' nii'(ili)|i*lili<lll, Un l|a«lli> la
liiiiiiti Hiiil iiaiiully V(>i7 iMiluiniiliiiii, »« llml wlii'U i>iil' Hiln
MiK MiniMi iliKliiN KHiiy fhiiii II Mini lliii liitiiinii' iilii'ltiliH
|tl1>lllly III llup, Ir H IiMI-ImkII) fl't>«ll Hl>|i||llll lllM'llli lljl Mill
trcPHliiU )iiiit>iiHN, Hiiil |iiHt)iitrl)' mIi'hIhimI, Itm IUmih will In*
(llllllll Ml lllllllllll' of H tllHON lit t||*l(l>l'lll IikHn llHVllItt lllll
uttHrHiiiMiiNllii i'(ii|iiilin|iuil iiiii'Ul 'I'lic liilHi'imltiilni' h|iHi<I'«
Hr» Wtill iiiuikcil.llilN lii'liiir N vi'iy iIi-IKikI Ini«<. In llm
Hi'i'nii||i-iMi>iil ut IliM MiiiiKiiiiiiii III II iMtiliilni' iii,|iiiiiii I
I'Hiiiiiil iimliD iiiii Hiij- ilHlliiltiii iii'HiiiHi'Mii'lii III (liK kdIU <iF
(IiIn fiinii, Hill' hiivp I ai'Mii »ii| liiilliiRlltiii iliiid Ih Um a
198 creeiNe utoua.
specific method of gromlli other than a general increase at
all points oE the normal muscular tissue of the central
layers of the uterus.
The oedema of this variety is a very remarkable feature
and presents a great difficulty in its surgical treatment.
Immediately under the peritoneum and immediately out-
side the mucous coats are denser layers of muscular tissue,
varying in thickness in difEerent specimens ; but betweea
these the whole mass consists of muscular trabeculie, the
interspaces filled with fluid being often large enough to be
visible to the naked eye. The length aud diameter of the
uterine canal seems to be increased proportionately to the
general dimensions of the diseased organ, but its relations
and diameter are only similarly altered in this respect,
there being a very striking contrast again to the condi-
tions of nodular myoma.
Of the nodular myoma I propose two sub^varietiea, the
simple and the multinodular, because they have very
marked clinical differences.
The appearance of a nodular myoma is so very well
known that it hardly needs description, yet some of its
essential features seem to me to have been so completely
missed that I must speak of them somewhat in detail. In
the simple form it is most commonly seen in the ordinary).,
polypoid myoma that I may take that as the usi
type.
Turning over the notes of coses made years ago, wh(
I had time to examine fully all the tumours which
under my notice, I find records of eleven simple nodu!
myomata removed as polypi, and of these observations the
following conclusions form an abstract. They had all
narrow pedicles formed of true uterine tissue aud lined
externally with a tube of the normal mucous membrane of
the uterus. Over the surface of the tumour the mucona
layer could be discerned in patches in all but two, and in
one it formed a uniform covering, in this case the tumour
being very amall. Underneath the mucous membrane
layer, or the remains of that layer, was a capsule con-
i
UTBBINB MTOBU.
199
tinnoua with tlie true nterino tissue of tbe pedicle in whicli
the elements of the uterine tissue were discernible. Thia
capsule was iu every case separable from the tissne of the
nodule in the neighbourhood of the pedicle and sometimea
for a considerable distance from it, so that theve could be
no doubt whatever that the original site of the nodule was
underneath the mucous coat and also underneath a layer
of greater or less thickness of true uterine tissue.
In the pedicle there was always one large arterial
trunk ; in one or two instances there were in addition two
or three smaller vessels ,but it is so clearly noted in one
observatiou that the smaller vessels were branches of the
larger that I conclude that it is so in all. A few days
ago I removed a small polypus by a snip of the scissors,
and I happened to cut the artery just where it branched,
so that I am confirmed in ray conclusiou. The branches
supply the capsule, whilst into the nodule itself the artery
■enters without division.
In four of my specimens I was able to make a com-
plete injection with Seitel's blue, dissolved iu size and
made colourless by Liquor Potassse. When the mass was
hardened in chromic acid, the capsule assumed an intense
blue whilst the nodule was only streaked here and there.
This completely substantiates the fact declared long ago
by clinical experience that uterine myoma has a very
faiot vitality, and it explains this feature by demon-
strating the scant supply of blood.
The dissection of the nodules injected was a very
tedious and diffirull process, and perhaps was not very
satisfactorily done, but the general results were tolerably,
uniform.
The main facts were that the one aitery which entered the
nodule seemed rapidly to lose anything like a distinct mus-
cular wall, that it ran centrally, seemed to have extremely
few branches and near the middle of the tumour it became
lost in an extraordinary way. By microscopic section of the
injected nodule 1 never could establish anything like a capil-
lary system, and could see nothing but an occasional wall*
200 UTERINE UTOUA.
less canal dilated into irregular ampullte, and Buch canals
probably represented the original capillaries which returned
the blood to the efferent vein. So scattered were the
Teasels of this kind that it was quite impossible to arrive
at any conclusions regarding their continuity. Prom the
fact of the vascular poverty of these nodules, it is certain
that the htemorrhage, which is their chief symptom, does
not come from them, but from the thickened uterine walls.
I cannot find any note of my having looked for nerves
in these nodules, certainly there is no reference to my
having found any.
The examination of the tissue of the nodules was con-
ducted in a great variety of ways, and in some of the
conclusions there are apparent contradictions, but these
are not upon points of importance. The one uniform con-
clusion is that the entire bulk of the tumours consisted of
fusiform muscle-cells, and I doubt very much if there was
any real fibrous stroma observed at all, though in two of '
the earlier observations it is noted. This mistake, as I
believe it to be, was probably due to my iuexperience.
In the later notes it is recorded positively that there was
a complete absence of any true fibrous tissue, and that
the appearance of it was due to the section of certain
cells being such as to deprive them of that part containing
the characteristic nuclei, leaving only an attenuated
extremity. This fallacy was exposed by the double-
staining process of carmine and hsematoxylin, or where
the hcematoxylin stain was reduced by nitric acid. The
same methods, assisted by the accidents of sections
showed clearly that there was a very definite method in
the arrangements o£ the fibres into bands, for groups of
nuclei were shown in transverse lines indicating that a
band had been cut across, and they were also seen in
horizontal planes in some favorable instances to be
arranged on a definite plan, the bundles being always
curved with their concavities towards the centre of the
nodule. In fact it seemed to me that the arrangement of
a myomatoQB nodule roaud its central artery is very much
UTERINE UYOHA.
201
like that of a wasp's nest round a twig of a gooseberry basli,
or rather, like the arrangement in a cross-wound spool
of cotton round the central bobbin. This conclusion was
amply confirmed by a special esamination I made of a few
subperitoneal bads growing on a large multinodular
myoma which I was fortunate enough to succeed in inject-
ing perfectly. In the araall buds the growth was recent
and therefore the details were more clearly made out.
Of one conclusion I am certain, that these growths are
endogenous. The arrangements of the cells and their details
were always more clear and definite the nearer the centre of
the nodule. The further away from the centre, the more
compressed and attenuated, the more fibre-like became the
cells and the more indistinct their nuclei. This conclu-
sion ia maintained by the fact that if a nodule is found to
have undergone calcification it is always at the circumfer-
ence that the change is visible, and that any injury of the
periphery of a myoma involves its death with great cer-
tainty. These facts can be understood only on the sup-
position that the vitality of a nodule ia weakest at its
periphery, and this is explained by the statement I have
already made, and corroborated by all my observations,
that blood-vessels do not enter the nodule from its cap-
sule save at a very limited number of points, I think
generally at one only.
The connective tissue between the nodule and its matrix
can hardly bo said to be vascular, and what nutriment it
conveys to the nodule must be limited to a supply by its
" Saftkanalchen," and perhaps some by mere transfusion.
From these conclusions it may be seen, therefore,
that my view of the method of production of a myo-
matous nodule is that it proceeds from within outwards by
reason of a growth of cell-elements near to the vascular
supply, and that the deranged production of muscle-cells
is due to, or dependent upon, some error of the nerve
influence which governs menstruation.
This is clearly proved by the fact of which I have
already published abundant evidence, that the progress of
202
DTK HIKE My OKA,
& Dodnlar myoma may be entirely checked by the arrest
of iiienHtruattou. Thiu ia to be accomplished by the
removal of the uterine appendages, chiefly the Fallopian
tubes. Not ouly iu this way may the growth of the
tumonr be arrested, and the hfemorrhage, which is a chief
symptom, controlled, but if the patient be under forty-five
years of age, the tumonr will shrink in size, and may
even disappear entirely. I have seen many instances ia
which tiimourH have entirely disappeared after removal o£
the appendages within a few months, tumours which must
havu weighed many pounds at the time of the operation.
Certain it is that removal of the ovaries alone has little, if
auy, influence in bringing about this result, whilst removal
of the tubes does. I have in several cases deliberately
loft the ovaries because they could be removed only by
the application uf a second pair of ligatures, and the
results have been quite as satisfactory as those in which
the ovaries have also been removed. Nearly two years
ago I operated on a patient (sent by Dr. Cuthbertson, of
Droitwich) who had a veiy large multinodular myoma,
pi-ohably it would have weighed fifteen pounds if it had
been removed. I removed the tubes only, as the ovaries
wero awkwardly placed, and I really stripped the tubes
oS tho tumour and tied them at their uterine insertion, so
that there was nu question of tying the uterine arteries.
The patient was forty-threo years of age at the time of
tho operatiuu, has never lost a drop of blood from the
uterus Htnce, ami when I examined her last, April 5th,
11^63, she was iu pei-fect health, and not a trace of the
tumour was tu be felt. I'his is an instance which I could
multiply, but as I have already published several I do not
think it necessary.
Ilut there are ca^eti in which complete removal of the
appendages does not aiTest menstruation and I have
under observation a case iu which I removed the greater
part of tho fundus uteri as well, yet menstruation has
continued for more than a year through the vagina and
from the stump. Here, then, as everywhere else in the
^
UTBBINE MYOUA.
203
domain of our art, we can lay down no hard and fast
lines outside o£ whtcli exceptions do not occur.
So far as I have gone, I can find no exception to the
rule, which is almost universally accepted, that the
nodular myoma ceases to grow at the arrest of menstrua-
tion. But I find there is a very common error aa to the
time of the arrest of menstruation in women who suffer
from uterine myoma. The general impression is that the
climacteric U completed with them, as with others, between
the agea of forty-nine and fifty. But 1 have had abundant
evidence that the presence of a uterine myoma may and
often does delay the climacteric indefinitely. When we
see a patient suffering from severe hcemorrhage from a
myoma at the age of forty-seven, we have been accus-
tomed to tell her to wait a few months and everything
would be well. But I have watched them for years after
that with regularly recurring menorrhagia, with singular
fluctuations in the size of the tumour, and protraotod
hopes of recovery deferred till our hearts were sick. So
tliat, amongst many other changes of opinion which have
been effected by the advance of gynecology during the last
five or six years, there must stand this, that the climacteric
is sometimes delayed by the presence of a myoma for a
long time after the usual period of the menopause, and
that sm-gical interference on this account may be neces-
sary after fifty. I need not say that it must be under-
taken only after such experience in each case as will
justify the surgeon in saying that all other means have
failed to benefit the patient.
My experience in dealing with uterine myoma by
removal of the appendages since 187S amounts to fifty-four
cases with three deaths, or a mortality of 5*5 per cent.
This of course puts any question of discussing what Dr.
Bautock calls " oophorectomy versus hysterectomy " out
of the possibilities altogether if we are to go by primary
results. So far as I can find recorded, my experience of
this proceeding exceeds that of all other operators put
together, and if I take the largest recorded experience of
204 DTEeiN£ UTOKA.
hysterectomy, that of Sir T. Spencer Wells as contrast, I
find the mortality of hysterectomy to be over 50 per cent-
It cannot, therefore, be & matter of surprise if I say
that I do not agree with my friend. Dr. Granville Bantocb,
when he characterises the proposal to remove the uterine
appendages as a preliminary to removal of the tumour aa
"unscientific and irrational." Dr. Bantock, in the paper
from which I quote ('Lancet,' April 14lh, 1883), uses
the argument against the removal of the uterine append-
ages that in the " great majority of the cases of large
tnmonrs, the ovaries cannot be reached at all, or one may
be within reach and the other not." But I have not
found this to be the case. I have never failed to remove
the appendages in a case of myoma where, after I had
carefully examined the tumour, I had found no reason to
desist on account of clear evidence of the tumour being
malignant. In one case I removed only the appendages
of the left side because I made certain there was neither
tube nor ovary on the right side, and as my patient is
cured, my experience by this exception is amply confirmed.
Again, Dr. Bantock argues : •' nor should we ever
dream of resorting to oophorectomy in a case of pedun-
culated fibroid on large multiple fibroids." Assuming
that by " oophorectomy " (a term I have entirely dis-
carded) he means removal of the uterine appendages ;
and that by "fibroid " he means " myoma," here, again,
I entirely differ from him, for it is precisely in such cases
that my most brilliant results have been obtained, and
my whole experience is diametrically opposed to his when
.he says " experience has shown it to be useless in these two
cases."
Finally, and this is the point to which the whole of the
present paper tends, Dr. Bantock says ; '" I believe we
are already in a position to determine which are the cases
Buitable for oophorectomy and which for hysterectomy."
I think I may be forgiven if I say that here I think
Dr. Bantock is somewhat premature, and even with my
own very large experience I am not inclined to dogmatise
tITERINB MYOMA.
205
on the subject, I am, however, of opiniou that I
approaching a position from which some light will
thrown upon the question, though I am not at all
to argue it as merely a question of one operator versus
another.
Out of my fifty -one cases of recovery I know that there
are six oases of faiJurej that is, the secondary results of
the operation are not satisfactory. There may be others,
for with all the care I can give to the subsequent his-
tories of my patients, I find it impossible to keep all of
them under notice. Very likely cases of failure of which
I have lost sight will turn up in the practices of other
surgeons. Bat I do know that in thirty-eight cases
absolute cures have been effected ; and, leaving out those
of date too recent for my present porpose, I can make ont
only four in which there is any possibility of there being
failures not known to me.
Of the six failures actually within my knowledge, three
have died of cancer, that is, the tumours have turned out
to be malignant, and possibly were so at the lime of the
operation. This of course is a difficulty which covers the
whole of our surgical work and is no argument whatever
oue way or the other in the present case. These cases
would all have died of cancer whether the operation was
removal of the appendages or hysterectomy.
The three remaining cases of failure have more interest
because I think they point to the class or classes of cases
in which hysterectomy will have to follow or to supersede
removal of the appendages. In all these cases the
tumonrs are growing, though there is complete arrest of
menstruation, and I think it almost certain the tumours
are not malignant. They are either fibro-cystic, or, what
I think more likely, of the soft oedematous variety of
myoma. The esperienee which Dr. Bantock has recently
placed on record proves conclusively, I think, that the
fibro-cyatic tumours will not be arrested by removal of
the appendages. This is as might have been expected,
and when I find a tnmonr of the ntems to be cystic I
1
206 OTBEIKK MTOMA.
always remove it. But it is not always possible to tell a
fibro-cystic tnmonr of the uterus, even by an exploratory
incision, and therefore failures to cure uterine tumours by
removal of the appendages are aare to occur occasionally
from this reason.
I believe this will also be the case with the soft
cedematous myoma. It is not a malignant disease, for
the biggest and best example I have seen was removed by
me nearly seven years ago, and the patient is now in robnst
health. So edematous was it that an effort wns made to
tap it, by Mr. Furneaux Jordan, under the belief that it
was an ovarian cystoma.
But I have had abundant evidence that the arrest of
menatmation does not affect the gi'owth at all, for I have
removed four well marked and rapidly growing examples
from women in whom menstruation had ceased. In one
case the tumour had groi>'n altogether after the meno-
panse. Therefore, if I see good reason to believe that a
tumour belongs to this variety I remove it, as the indirect
evidence is to the effect that removal of the appendages
will not avail. But here, again, mistakes will be made.
The soft cedematous myoma has an invariably even ovoid
outline, and its deceptive feeling of fluctuation gives it
the character of a cyst, but even after an exploratory
incision it will every now and then be quite impossible to
decide whether a given tumour belongs to this class or
not. Considering, however, (hat hysterectomy has at
present, and as the use of the clamp in this operation is
inevitable, is ever likely to have a very heavy mortality,
I think we are bound in all cases of doubt to give our
patients the beneBt of that doubt and resort to the less
formidable operation in the first instance.
We may take it, therefore, that like every other
operation, removal of the oterine appendages for myoma
will meet with a certain proportion of failures, but it is
no more to be condemned on this account than is excision
of the knee because many snoh cases have ultimately to
Bubmit to amputation.
OTERIKE M70HA.
207
The President was hardly prepared to accept Mr, Tail's
clasBiScatioD of fibroids ia place of the one in commoa use,
the basia on which Mr. Tait'a classificatjon was founded being
on the histology of the tumours instead of on their position
in the ut«riue walla; the two were, however, not necessarily
antagonistic. With Mr. Tait'a view as to the delay in the
occurrence of the climacteric in these cases he entirely agreed,
and so with the inference as to tbe unadvisability of deferring
operation in cases demanding it with the hope of the occurrence
of the menopause. Mr. Tait's description of tbe vascalar
arrangements of myomas and his su^geatious as to the starting
points of these tumours were full of interest, but he would Ulte
further evidence as to the assumed sole, or even large, iuflueuoe
of the tubes in the phenomena of menstruation.
Dr. Herman had published a case in which the symptoms
due to a fibroid polypus appeared first at the age of sixty-four,
thirteen years after the menopause.* The after histories of
patients on whom operations such as those described by Mr.
Tait had been performed were of the utmost importance, for
the operator was liable, unless he inquired carefully into the
subsequent course of each case, to think that more benefit was
conferred by the operations than was the fact ; for patients who
found themselves not improved by the trealmeut naturally con-
sulted some one else, often without informing their discarded
adviser, who, unless he made inquiry, might think that they did
not come to him because they were well. Error of this kind
might be avoided if, in compilmg tables of cases, there were put
after each cose the date of the latest positive information con-
cerning the patient's health,
Mr, Dkwab asked Mr. Tait (1) whether he, in removing the
uterine appendages for fibroids, was careful to tie the uterine
artery P (2) Whether it was enough to remove the Fallopiau
tubes, leaving behind the ovary or ovaries, and whether such a
proceeding In a menstruating woman was not attended with
danger ? He had seen one case where the uterine appendages
had been removed two years previously (without benefit) to
a hysterectomy, this latter operation being necessitated on
account of luemorrhage.
Dr. Meadows thought that the system of classification of
these fibroid growths which has been generally accepted was
preferable to the one suggested by Mr. Lawson Tait, inasmuch
as while that which he recommended was based merely on
anatomical considerations, and was of little or no clinical value ;
tbe classification of these tumours as regards their site quoad
■ ' Obetetriral Joamul,' vol. vi, p. 14. A ipeaker having Burgelfed that
powibly tliii poljpiiB wai malignaat. Dr. Herman, otter the raevting, iuqnirrd
of thi^ patient's medical nttendant (Dr. Timotlijr KichnrdKoi, Comiii«rtru]
Itond), wbo sKeitaiDed tbnt ihe nm in good bmlth.
rmm mtosa.
Oh sleriae walls «w ««e fMad«d on dni
■irflf , m4 ••• «b« w < i>ifc of the gmteat pradkal nine, Bst
calf M HfMd* diigpowt, bat iIm ia refereaee to tnaiaeat,
t>IBH» tfaat the NiBCalrand thtfrfore cnratirg, twf ent of
■M( ba goKfiwd bj dimeal obaemtioa of the
I MiMMacnt dJagaOM of their nte. He alaa
t ■oaaBBiM of the aatbor'i rtateawa^ thrt
nnaonl of Um FaOoptao tube* wm of mem imfiortaaee thaa
lim imaortX of the orariei to regard to the o ewti on of the
■MiMtiittl toaOioa tnd the rmiltitnt atrophj of theae growthi,
ttjr he believed, on tbe ecmtivr, thitt tbe or&riee uid oot the
fftlloi/iaD tobee Are tbe prime rocrrtrri in meDatnutvm, and be
related a eaee io wbieb be bad remored I^th oTmriea, and left
tbe 7aJloffias tttbce, for tbe core of & uterine fibroid, and in that
eaee neutraation ocaeed and nerer retomed. He further
tlotibUd vbetber it wae at preeent perfectl; eatabliBbed that
uterine DT/romata nnitormly ceaaed to giovf after the cessation
of inonNtmation. It roii(lit be tb<- rule, but be felt gatitified that
tberu went many ficoptioDi, and while agreeing with the
Kntlior in tbo bi){h rate of mortality which occurred in opera-
tion! for tbe alidomioal removal of these tumours as compared
with 'iTariotomy, he yet preferred tbia mode of treatment to
that which soutcht for their cure merely by tbe removal of the
orarios.
Mr. rjAWNon Tait. — Beferrin^ first to the remarks of Dr.
i/tvivliivn 'HI th« iii«i«NNity of using the clamp, be would potut
out tbal in Dr. Moudowii's caxe the patient was aiity-fire years
"f ut(i'. and the tisNUVs bad all become abrivellcd and consoli-
dated, so thai a uU-rino pddicli) might be trusted to a ligature
us cnrtiiiiily ns that of an ovarian tumour. But if the patient
bad Ihicu under or near the climacteric it would have been very
dllTtiruiit. At that time of life a uterine pedicle sbniok away
from tbo ligature iu a few hours by the exudation of serum,
and It needed little more than tbe examination of Sir Spencer
Weill's list of cases to convince every one of the fatality of the
ligature when applied to uterine pedicles. Another point
rvfvrn'd t.u was tuu growth after tbe menopause. Nothing
duftiiito could bo said on this point until the exact nature of tbe
lumour was dt>termined by microscopic examination. As said
in tbo pajwr, Mr. Tait believed true myoma did not grow after
tbo m(>no[iaus(i. All uterine tumours, tbe nature of wbicb he
Itiiew, wbicb bad so ^rown were either maliguant or fibro-cystic.
Purlbcr aud vorT careful examination wa« wauted on this point.
Tbero was no <ioubt that oecaaioually removal of the ovaries
alonv did arrest rot'natniation, but according to his eipe-
rioncn it was tbe exceptiou. In answer to Dr. Herman he
would say that ho had never knowiosly tied the ovarian artery,
aud bo bolioved that to tie it would be a most difficult and
UTEBiNB MTOMA. 209
dangerous operation, if he might judge from a preparation
exhu)ited by Sir Spencer Wells at the International Medical
Congress. There could be no doubt that the after history of
any untraced cases of failure was a difficulty, but as they would
probably fall into the hands of other surgeons there would be
every facilitj and disposition to disclose all the facts concerning •
them.
VOL. XXV.
U
OCTOBER 3bd, 1883.
Henet Gbbvis, M,D., President, in the Chair.
Present — 51 Fellows and 1 viaitor.
Books were preaeuted by Mr. C. E. Jennings, Dr. J.
PouUetj the Council of University College, La Society des
Sciences Medicales de Lyon, and the G-esellschaft Eiir
Gebnrtshiilfe in Leipzig.
Cbarlea Taylor Aveling, M.D., Robert Alex. Gibbons,
M.D., and Albert Charles Butler- Smythe, M.R.C.P. Ed.,
ivero admitted Fellows of the Society.
Arthnr Jukes Johnson, M.B. (Toronto) ; James H.
Keeling, M.D. {Sheffield) ; Clarke K. Morris, M.R.C.S.
(Spalding) ; Antindo L. Sandel, M.B. (Calcutta) ; and
Frederick H. Tinker, L.R.C.P. Ed. (Hyde) ; were declared
admitted.
The following gentlemen were elected Fellowa: — John
Archibald, M.B. ; Cursham Comer, M.R.C.S. ; J. King
Keir, M.D. (LeytonstoneJ ; Edmund King Houchin,
L.R.C.P. Ed. (Stepney) ; Walter Rosser, M.D. (Croydon) ;
and Frederick Stocks, M.R.C.S.
The following gentlemen were proposed for election : —
William T. D. Caldwell, M.D. ; George Henry Jackson,
M.R.C.S. {Tottenham) ; Edward Johnstone Jenkins,
M.B. {Oxon.) (Sydney) ; Edmund Henry Pettifer, M.R.C.S.;
and Alesander Walker, M.D., CM. (Pntoey).
CASE OF HYPERTROPHY OF THE BREASTS.
By J. A. Mansell Moullin.
The patient is a thiu strumoua-looking girl, eigliteen
years of age, uumarried. The breasts began to enlarge
Rt the age of fourteen, the time of puberty, and have
continued to increase in size ever since. They are heavy,
pendulous, very soft, and flaccid, and are affected sym-
metrically. The nipples are small, while the area of the
areola is greatly extended. The patient complains of
pricking and shooting pains darting through the breasts,
which are somewhat tender, and it gives her pain to raise
them up. There is no irregularity in the menstrual
function and her general health is good. The parents
and rest of the family are healthy except one brother
who has spinal disease.
LARGE FIBRO-CELLULAR TUMOUR.
Db. W. a. Duncan showed a large fibro-cellular tumour ]
(of five years' growth) involving the clitoris and both
rymphsB, the whole of which he removed, He also i
showed a multiloculor compound ovarian tumour, one of '
the cysts having been ruptured during esaniination,
cuusing intense collapse and peritonitis. The patient '
died without having sufficiently rallied for ovariotomy to
he performed.
ARRESTED DEVELOPMEXT OF ONE TWIN.
DOUBLE PLACENTA.
Db. Edis exhibited the placenta and a shrivelled fcetus
which was retained for nearly two mouths, the older
twin fcetus being born alive. He was indebted to Dr.
Grinson for the opportunity of showing this interesting
specimen to the Fellows,
M. W — , fflt. 32, married seven years ; mother of foiip
children, youngest ten mouths, all boi-ii at full term,
living, ceased to menstruate the first week in Fehruaryj
1883, quickened early in June. She espected her con-
finement about the first week in November. Wheu
between four and five months advanced in pregnancy she
bathed in the sea, beyond this she could assign no cause
for the death of one fa3tua. There was no attempt at
miscarriage, and until the delivery was accomplished had
no reason to suspect anything unusual.
On August 26th, at 3 a.m., she was confined preraatui-ely
of a shrivelled fuctus, and at 10.26 p.m. of the same day
the second child was born. This latter appeared to be
about the sixth and a half or possibly the seventh month
of iotra-aterine development, the exact calculated time
being twenty-nine weeks. It survived its birth seven
days, cried lustily, and at first seemed likely to live and
thrive.
The placenta bad been examined carefully by Mr.
Sutton of the Middlesex Hospital.
It was double, the placentae being attached at their
margins, the right one the larger, five inches in diameter,
with a portion of cord attached. The smaller one, four
inches in diameter, presents a shrivelled appearance and
is firm to the touch as though it were indurated. The
umbilical cord is scarcely thicker than twine, and is
attached to the placenta near its border, but to the
opposite side to that of its fellow. Each placenta is
214 PLACBNTA sncCXHTUSUTA.
sharply defined from its neighbour by a raised margin
where the two amniotic membranes come into contact.
The foetus appears to be about the fifth month of
development.
Dr. M&LiNS remarked that he had seen a similar case where
the one child was bom Uving at the eighth mouth, and its fellow
flattened and shrivelled at the same time, its growth baring '
been arrested at about the fourth month. The case was |
interesting as showing the power of toleration exhibited by the
uterus in carrying one child to a viable period with the other as
a foreign body, and also from a medico-legal poiut of view in
relation to the time of conception and delivery. He mentioned
that Cruveilhier had given an illustration of the same condition
iu a plat* the description of which corresponded very closely J
with the specimena shown by Dr. Edis.
PLACENTA SUOOENTURIATA.
Dr. Champnbys showed a placenta ivith an accessory
placenta or " placenta succentnriata." This ia liable to <
be left behind, and its retention may be quite impossible
to diagnose from an examination of the nfterbii-th. It '
WB8 with this view that he showed it.
Dr. Dalt said that the specimen eibibited by Dr. Cbuujpueys
had au important medico-legal interest. Some years back he
was called oy another medical man to see a womau who expired
immediately on his arrival at her house. She had been attended
in her confinement by an unqiialified man about a week pre- '
viously. She had died of repeated hromorrhages. There was
no doubt the imquahfied man had failed to remove the placeota.
The case gave rise to a prolonged inquiry by the coroner, and* I
the defence of the unqualified man was that he had removed a '
placenta at the time of delivery, and tliat, therefore, the one i
which my friend discovered and removed, and which I saw, was I
a supernumerary placenta. The jury accepted this jJea.
GANGRENE OF THE THIGH DURING THE
SEVENTH MONTH OF PREGNANCY.
By Joseph Gkipfiths Swayne, M.D,,
PKYBICIAH ACCODCHEint TO TBB BKIaTOL OEMERAL SOSFltll.
LECTi;SB& OH UIDWIFEBI it TBE BBIS
The case I am about to relate was obscure in its origin
and rapidly fatal in its termination. The exciting cause
of it is still to me a profound mystery ; but possibly
others here present, who have had a more varied and
extensive experience than mine, may be able to throw
some light upon it.
On Wednesday, April 4th, 1883, between 6 and 6 a.m.,
I received an urgent note requesting me to go into the
country about eleven miles from Clifton to see a lady
who had been suddenly taben with symptoms of premature
labour. I went without delay in the caiTiage sent for
me, but when I arrived at the house I found that the
lady had been confine<l about a quarter of an hour before
my arrival and that she had been attended by Mr. Salmon
of Thombury, who lived about a mile from the place.
Mr. Salmon told me that the patient, Mrs. H — (whom I
had not previously seen), was about thirty-two years of
age, had been married nine months, and was scarcely
seven months pregnant. She expected her confinement
in rather more than two months and was coming up to
London for the event, having engaged Dr. Brodie of
Curzon Street, Mayfair, to attend her. She had, during
last March, been travelling with her hugbaud from the
South of France dnriug the bitterly cold weather which
prevailed at that lime. She then stayed two or three
days in London before she went to her father's house
near Tbornbury, where she arrived on Saturday, March
Slst. On the night of her arrival she complained of
pain in her right groin, and there was a hardness about
the size of a half crown on the upper and inner part of
the right thigh, just over the adductor muscles.
216 GANQBBN& OV TBS IHIOS OUBIHO PfiKOHANCI.
On the following day she was violently sick for some j
hours. Mr. Salmon was sent for and prescribed some I
medicine. There was at that time little or no swelling I
o! the part affected. On Monday, April 2nd, there was a I
more perceptible enlargement of the part, and on Tuesday,
April 3rd, Mr. Salmon stated that there was a more
diffused swelling in the limb, with hardness at the poa- J
terior and upper part of the thigh which he thought!
would end in suppuration.
As I mentioned before, the labour came on on the I
following day, Wednesday, Api'il 4th, and terminated 1
before my arrival. The labour commenced about 1 i
and terminated at 7 a.m. the same morning. The child I
was of scarcely seven months' development. It was i
male and only survived its birth sixteen hours. Mr. I
Salmon told me that during the labour he was obliged to 1
separate the kneea widely with a pillow, so as to guard I
the swelling on the thigh from pressure as it was theal
very tender. "When I saw the patient, the chief thing ^
which I noticed was that her face was much flushed (she
was usually pale) and her manner somewhat excited, I
then examined the swelling. It was about the size of a
man's fist and was situated on the inside of the right
thigh about three inches below the saphenous openiug.
There was no discoloration of the part or fluctuation, bat
great tendemesa on pressure, and a peculiar sort of boggy
feeling to the touch. The confinement appeared to have
been very favorable and was attended with no post partura
hfflmorrhage. The pulse was but little above the ordinary
standard. The temperature from 100^ to 102^
On the following day (April 5th) I received a telegram
requesting me to see her as soon as possible, as she had
been much worse during the ntght. On arriving at the
house Mr. Salmon told me that she had been delirious
during the night, that there had been considerable elevation
of the pulse and temperature, that the urine had been
retained so that he had to use the cnthetcr, and that he
believed that mortification had come on iu the swelling.
OXNQBBME Of TEE THIOH ■ DURIMQ PBBOKAXCT.
217
On examinmg it I found that this was the case. The
nurse told me that early in the morning she noticed dis-
colopation like that of a bruise in the part, and that
abont an hour after this the skin rose up in a bladder,
which Mr. Salmon punctured. The skin then peeled off
and left a dark brown, sloughy -looking surface, as I then
obseryed. The nurse told me also that during the night
after the confinement the lochial discharge became very
scanty and offensive ; by the time I saw her it had nearly
ceased. Her pulse was then 134°, somewhat irregular, and
very deficient in power; temperature 104°. Abdomen
Tery tympanitic, with frequent hiccough ; there was no
uteriae tenderness. We prescribed ether, ammonia,
brandy, and frequent stimuli, with nourishing food at
short intervals, such as milk, beef tea, egg-Qtp, &c., and
also a barm poultice to the part. The vagina to be
syringed with Condy's fluid and water. I then left lier.
On the following day (April Gth) I went to see her in
the morning about eleven, and found lier much worse.
She was then pulseless, scarcely conscious, and moribund.
The whole of the upper and inner third of the thigh pre-
sented a, dark discoloured appearance, and a distinct line of
demarcation could be perceived between the sound and
unsound portions. Dr. Brodie had been telegraphed for,
and arrived from London shortly before me. However,
ahe died about 12.30 p.m., before we left the house.
The history of this case shows evidently that the mor-
tification was not a result of the labour, but rather that
the labour was a result of the mortification, for the pain
and swelling, which ended in gangrene, existed some days
before any symptoms of labour were present. Yet the
occurrence of labour had probably the effect of still further
increasing the virulence of the symptoms. The cause of
such very unusual symptoms must, I fear, ever remain
doubtful. There was no history of any injury to the part
affected, there was no infiammatory blush or other sym-
ptoms of erysipelas, and it is difficult to imagine that
plugging of any veesels would be sufficient to induce gan-
218 OANOBBini OF THB THI(3B DVBISQ FBEaHANfiT.
grene in a part so freely supplied with arteries. Unfop-1
tunately we bad no opportunity of making a post-mortem
examination, bo that the details of the case are necessarily
incomplete, so much bo that I should not havo brought it
forward had not its extreme rarity appeared to me i
render it worthy of record.
Dr. BuBCHELL said that though the detail of aymptoma v
not sufBciently clear to lead to a positive opinion, he could i
help believing that the disease was one of " strangulated feu
hernia ;" the position of the swelling below the saphenous o
iiig not being conclusive against that decision.
i>r. Herman asked if the case was not one of gangrenoi
caibuiicular inflaonniation — the form sometimes called "jnal'
iiant carbuncle " ? He did not think the gangrene could be d
to embolism (as a previous speaker had suggested), for i
extent and limit was not that of the parts supplied by ai^
particular vessel or vessels.
Dr. Swathe, in reply, said that he still felt quite at a loss a
the cause of gangrene in this case. The most probable sug
tion, he thought, was that of Dr. Barnes, who attributed i
undue pressure on the vessels of the part affected. The patiei
he had been told by one of her friends, had been remarkable fi
an excessively small waist. If this pecubarity of figure we
due to tight lacing he could easUy understand how the gravi
uterus might be forced down so as to make very^ injurioi
pressure on the external and internal iliac vessels of the ri
side, especially during a long aud very fatiguing journey in v
cold weather, and when in all probability a constrained positi
was maintained for many hours. The situation of the tumoid
precluded the idea of etrangulated femoral hernia, which hai
been thrown out in the course of the discussion; the absence a
diffused redness at the onset that of phlegmonous erysipela
and the vesicatioa and absence of any head that of malignai
carbuncle ; whilst at the same time the history of the caee \i
opposed to either of these suppositions.
ON THE OS UTERI INTERNUM, ITS ANATOMY,
PHYSIOLOGY, AND PATHOLOGY.
By J, Henry Benket, M.D.,
The facta which I wish to bring before tlie Obstetrical
Society are not new to me, iaasmucli as I published tbeni
ia the second edition of my work on ' Uterine Inflammation '
in 1849, thirty-four years ago. They appear, however, to
have been lost sight of, or not to be recognised by recent
writers on gynaecology, so I once more bring them pro-
minently forward. They are most important, and have a
direct bearing on various points in uterine therapeutics.
(They will be found more m extenso in the fourth edition
of my work, 1861.)
The uterine cavity ia in reality formed by two cavities,
that of the cervix and that of the uterus proper, each
being about an inch and a quarter in length. As the oue
passes into the other there is a narrowing, or contraction,
usually called the os uteri internum or isthmus uteri.
This OS internum is not merely a narrowing or isthmus,
but a sphincter, like the sphincter ani or the pylorus. It
ia formed by the transverse, circular, annular fibres, which
enter so largely into the structure of the cervix uteri.
The anatomical examination of the structure of the cer%'ix
shows that the number and density of the circular or
annular fibres in this region is such as to render the
existence of a vital sphincter quite feasible. Its existence
has been admitted by various authors, and in France it
was long called by my name — " Bonnet's sphincter."
The ordinary physiological state of circnlar muscles,
which close cavitie.s, such as those of the anus and pylorus,
is contraction. Such I believe to be the normal rest state
of the uterine sphincter, contraction, closure. If an
attempt is made to pass the metallic uterine sound into the
220 OH THE 08 DTBRI INTBEHITM.
uterine cavity in a healthy woman, free from ante-flexioijl
or retro-flexion, ante-veraion or retro -version, especially
in a nulliparons woman, it is all but universally arrested
at the OS internum, either by the naturally closed state of
the sphincter, or by a vital contraction occasioned by the
contact of the sound. Generally speaking, a considerable
amount of pressure is required to overcome this contrac-
tion in the young, perfectly healthy, menstruating female.
If, instead of using the ordinary metallic sound, a small
wax bougie is used, warmed and passed very gently
through the cervical canal to the os internum, it generally
passes through the latter as far as the fundus of the uterus,
and that in the very cases in which the attempt to pass
the metallic sound has failed. The sphincter relaxes to
the gentle pressure of a warm soft bougie. The difference
of result is illustrated by what occurs when an attempt is
made to dilate rapidly by the finger the sphincter ani ; it
resists brusque pressure, but gives way, relaxes, yields to
gentle pressure.
It was in experimenting in this manner with small
wax bougies in 1846, that I discovered that the uterine
canal in nulliparous women ia not straight, anatomically,
as was supposed, I believe, by all anatomists, but curved
with an anterior curvature. The was bougie, if left a
couple of minutes m sitij, takes and retains a slight curva-
ture of this description. This congenital anterior curva>!U
ture of the uterus was later recognised in sifu by ]
Boullard, of Paris, and was demonstrated byfreeezing th|
pelvis in America. It is now, I believe, generally recog.
nised. In some congenital cases it is very much exagg(
rated, giving rise to a congenital and irremediable antt
version of the body of the uterus of a very marfceSl
I ■ character. In su'ih cases the uterus may be quite crescent**
shaped. I have known many instances in which fomalesfl
have been absolutely tortured in the vain effort to remedy!
or modify this natural congenital condition, which eveafl
pregnancy does not always change. I would remark that^
when I thus use a small wax bougie I employ the speca-(
I
ON THB OS ITTBBI IMTEBKUU. Zil
lum in the dorsal or lithotomy position, as the warmth of
the vagina softens the Bmall bougie so as to make it
useless.
As pregnancy advances the cavity of the cervix and the
OS externum gradually expand and open, but the cavity of
the uterus remains closed by the vital action of the
ephincter which constitutes the os internum. This
sphincter is no doubt greatly strengthened by the deve-
lopment during pregnancy of the circular or annular
fibres that form it, and its functions are then self-evident.
There is a large cavity, which requires closing like that of
the stomach and of the rectum, and the existence of a
strong sphincter becomes an anatomical necessity.
There are other " physiological " evidences of the
existence of a sphincter at the os uteri internum, endowed
with the ordinary intermittent vital functions of sphincters
in general. It usually relaxes before, during, and after
menstruation. At these epochs it is much easier to
penetrate into the uterine cavity, either with the metallic
Bound or with a wax or gum-elastic bongie ; the sphincter
evidently relaxes physiologically. Probably the same
phenomenon takes place during congress, to admit of the
entrance of the spermatic fluid into the uterine cavity.
I may, 1 trust, be pardoned for going a long way
back in order to fully explain how I arrived at the above
conclusiouB.
I commenced practice as an accoucheur and gynseco-
logist in 1843, just forty years ago, and in 1845 published
the first edition of my work on ' Uterine Inflammation,'
then all but unknown to, and ail but disregarded by tho
profession. That such was the case will be at once recog-
nised on referring to the works of Ashwell and Lever,
the classical treatises of the day, the accepted guides of
practitioners in uterine pathology and therapeutics, A
few months afterwards Sir James Simpson, already cele-
brated as au author and a practitioner, and the Professor
of Midwifery at Edinburgh, called on me. He told me that
be had procured my book as soon as it had appeared, had
ON THE 09 UTERI INTEBHDV.
read it carefully throagh twice, had tested toy statementi
in his public and private practice, and had found them toa
be correct in every respect. He was in London to attends
a noble lady in her confinement, and remained in towsfl
several weeks, during which time I aaw him constantly.'^
He then told me that he had made what he consideredfl
a great discovery, viz. that sterility was to be attrij^
bnted in most cases to apasmodio or morbid closure ovj
contraction of the 03 uteri internum, and that he hai
contrived an instrument for dividing the os iDtemam;^
which he had named metrotome. This operation, he aaid,-i
had proved a radical care in his hands in many case&a
When ho left he gave me his own metrotome, adding thi
it had been a great friend to him, and that he hoped iti^
would prove the same to me.
Professor Simpson communicated to me his enthnsiasta J
on this subject. I found the condition he described— • I
closure of the os intemnm on slight pressure with tie 1
metallic sound — in all or nearly all the sterile women X j
examined. Concluding that this was the philosopher's J
BtouQ in the treatment of sterility, on the faith of Professor fl
Simpson, for two or three years I divided the oa nterij
internum in nearly all the sterile women I met with,
followed the Professor's vidcIhs operandi, but first made iti
a rule to examine the patient with the speculum, and )
remove all inflammatory lesions that might co-exiBt
When the closed os internum in a healthy female, or xdA
one rendered healthy by preliminary treatment, did i
admit the end of the metrotome I dilated the cervi
canal, using the Protessor'a compressed sponges, whid
he also at that time introduced to my notice. I invai
ably made two small incisions, one on each side, inste
of one deep one, to avoid hEsmorrhage. There are,
were, traditions at Edinburgh of patients having diea
from hajniorrhage after division of the os internum, but 1
never had any serious accident of the kind. I remembeivl
however, having on several occasions plugged the rnrvimJ J
canal ou the occurrence of rather free bleeding, a pro^l
tta
oedMnwUek I heli— I «aa Oe fint to pnpOM Mid to
adopt, n OeosTttl tamai iawM fUu^i « *ha iwg
I raooaunaid, vitb p bJ g B to oF c o t toB ramniifl ts aad
tied to Strang tlir— di, h wgH ambaim fcr cabsmjamt
grtiwctkn BhoBld tfay aol be spoataaeomty expellc<t
widiin l»wij-<B«r bcMO^ aariona hwPiTh^a tn non<
pnguat wiMMM beooBce n^KNaaUeL In d e e d^ if Uus
p roee Jiim n ■iiyliji m vlerine laaiBorr h agB bom «h»t-
enr <■■* ao — prigwmt wonaa B«ed dw^ BrMt in
prpgMinfy » ite m^ stage tins mods of pining i» Um
best tnstaat ■ ike cms oI smvn luraiORtMige in oou-
nectiaa mA iHpMfag kbortioB, tint is, whan »U hop*
(tf a«vag Ab fati tsB been given np.
I nerar had say sabsetprat wddente — metritis. i.n-anti3>
or aJhaeras of Ae btetal ligaoieotB, altbon^ I treetci] the
wbole bnsineas as a Balneal triSe, which it wna in luy
eye^ as in thoGo o£ Prcdessor SimpsiiD. I asunlly
operated in my consnlting room, sent the patients home
in a cab soon after, very seldom went to see them at
their own boose onle&s they sect for me, merely titking
the ordinary fee. This immanity from subseqaeuC acci-
dent I attribote to my never operating except on a
perfectly healthy atems and cervix, and to mj ahvnys oper-
ating aboDt six d^iyH after meDStroation, when I conld calcu-
late on a foil fortnight of uterine rest between tiie operation
and the molimen hjemorrhagicum of menstrnation. Many
uterine operations are performed, I am well aware, wlu-n
the cervix and uterus are the seat of chronic inflammntiou,
under the idea that the operation will remove the indanimn-
tory disease. Instead of doing so it not uufrcquontly fircn
I the train, and leads to all kinds of pelvio complioatious.
I nearly always used Professor Simpson's stem posHnriea,
giving them a gentle anterior curvature, after tbo opera*
tion. I introduced the first twenty-four Iiouth after the
operation, gradually increasing the size. Uy this modo of
treatment I naually obtained the roauiti foroMhadowod by
Professor Simpson in his convernationfl with mo. At tbo
end of two or three weeks there was a free communioatioa
I
234
OD THS OS rTBRt IKTEBNtltt.
between the cavity of the cervix and the cavity of the
uterusj through the os internum or isthmus, the metal
sound passing freely from the one to the other.
I was greatly pleased, thought the patients permanently-
cured of the presumed stricture, and concluded their
impregnation was all bat certain- to take place in the
course of a few months. I therefore dismissed them,
exacting, however, a promise that they would- call on me
again in from six to twelve months' time " that I might
see if the cure was a permanent one." This is a pre-
caution that ought always to be taken iu uterine thera-
peutics, and especially iu surgical therapeutics. I am
constantly reading reports of successful treatment in
uteriue pathology, which I cannot accept as conclusivej
because this precaution has not been taken. Women
sufteriug from uterine ailments are so nervous, so
hysterical, so fanciful, so anxious to get better, so prone
to thiuk themsetvea better for a time, especially if they
esteem and like the doctor who attends them, that little
reliance can be placed on their first impressioDS and state-
ments. This is more especially the case in some of the
minor forms of uteriue surgery, incisions, sewing up, and
replacements. The celebrated gyusecologist comes with a
flourish of trumpets, performs the operation which is to
radically cure years of .uterine sufiering, to modify pro-
found and chronic morbid functional activity o£ the uterine
orgauB, aud then soon withdraws, on the " veni, vidi, vici "
principle, perhaps never to see the patient again. The
only test, however, of his real success is the actual condi-
tion of the patient six months or a year after the
operation.
Tested in this crucial way I generally found that I had
not cured the sterility, or permanently modified the con*
ditiou of my patients, even anatomically, when they
returned, as requested, six, eight or twelve months after |
the operation. In the very great majority, indeed in
nearly all, the sterility had persisted, and the uterine ail-
ments and deficiencies were either pretty much the same
I
ON THE OS DTBSl INTBRNnU. 225
as before, or the improvement wag to be accounted for by
the previous removal of inflammatory lesions. In most
cases, especially if the incisions made had been deep ones,
the closure of the os uteri internum was more decided,
more difficult to overcome than before, evidently from
cicatricial tissue. When the sphincter ani ia divided to
relieve spasmodic constriction it is found necessary to
divide the entire thickness of the sphincter to obtain a
permanent cure. The partial division of its fibres is, I
believe, seldom followed by a permanent cure. In the
case of the cervix uteri, only a very few of its oirculai-
fibres can by any surgical possibility be divided. The
great mass of these fibres must remain undivided.
Thus a long series of observations and esperimeuts,
undertaken most enthusiastically and hopefully, under the
guidance of Professor Simpson himself, led me to the
results enunciated and foreshowed in the preceding pages.
Firstly, that closure of the os uteri internum, when not
carried to an extreme degree, is not a morbid but an anato-
mical and physiological condition. Secondly, that the
surgical division of the os internum is not the radical cure
for sterility, &o. that Professor Simpsou and his followers
supposed it to be, does not give permanent patency to the
08 and is best replaced by other modes of treatment.
Such are compressed sponges, and gradual dilatation by
bougies, when it is thought advisable to dilate on other
and rational grounds. A patent state of the os iuternum, a
I condition which allows the metallic sound to penetrate
freely and easily into the uterine cavity, in my esperieuce,
rather indicates disease than health, except at the mec-
Etrual period. The os ateri internum relaxes, opens,
when there ia endometritis, or even severe endocervitis,
the muscular fibres being paralysed by the inflammation
of the mucous membrane, as in enteritis. It also relaxes
and opens when there is structural aggrandisement of the
body of the uterus from the presence of a fibrous growth,
as also from chronic inflammation and hypertrophy of the
tisaues of the uterus. It necessarily relaxes after deaths
z
236
OH THE oe irraBi iwtbhhuk.
BR does the sphincter ani. The tonic vital contractility j
of all sphincters and of organic muscular tissue disappears 1
when life is brought to a close.
That these physiological and anatomical facts have a
most important bearing on uterine therapeutics becomes
self-evident on the slightest consideration. Setting aside
the various modes in which they apply, I will again refer
to the question of sterility. It ia generally assumed that
one in five, six, or seven married females remains per-
manently sterile. In the census of 1860 there were half
a million of married conplea ivithout progeny. If closure I
of the 08 uteri is a physiological not a pathological con- |
dition, all these women on examination would erronmnsly
be pronounced sterile from a pathological caose — stricture
of the cervix uteri internum — by those who do not accept
the views I bring forward. They would consequently
be all, except the older ones, considered fit subjects for
surgical treatment, more or less severe, according to
individual views. What a fine field for those who profess
epteiftlly to treat and to cure sterility ; nearly half a
millioQ of women to operate on !
This question, like all other anatomical ones, is very
ensy of solution. Let my hearers use the metallic sound
and wax bougies with the nnlliparons women they may
have to examine during the next few weeks, taking all
the precautions I have indicated. It seems impossible to
mo that they should not arrive at the same conclusions as
myself ; my uterine practice of any one week during the
last thirty-aix years would lead to them. The women
exau)inpd, however, must not present the patbologioal
conditions which, as I have stated, relax the uterine
sphincter.
In conclasion I would emphatically remark that I do
not wish or mean to condemn dilatation of the os uteri
jutcrnum in o\-cry possible instance. So far from that, I
ni\-!:c1f occAsioually rosort to it. There are cases of
os»gg«ratecl or spAsmodie oonstriotion, organic or vital,
ot {ttoudo^nsnibranoHS dysmfiiiorrbtBa, of confirmed st?ri>
ON THE 08 UTEBl INTEfiNDM. 227
lity in yontbfnl snbjeets, in which an abnormal dilatation
of the nterine iathmus may be the best treatment to be
employed. I merely assert that a closed state of the oa
uteri internum is the natural condition of the region;
whilst a, patent condition is generally the indication of a
morbid condition of the uterine organs, and that to insti-.
lute surgical treatment in order to remove a physiological
state is a gross surgical error, and leads and has led to
very erroneous and, in my eyes, nnjustifiabte practice.
Dr. Oaiabik said that he had no doubt that Dr. Bennet's
view was perfectly correct, that the internal os formed the chief
sphincter of the uterine canal, and one of considerable power.
Tbia was proved by the sharp couBtriction often found at this
point upon a laminaria tent, and by the mode in which the
internal os often closed up again rapidly after being dilated by
tents or other means. But he was not prepared to go so far as
Dr. Bennet in saying that the internal oa was normally com-
pletely closed. No doubt it often resisted the passage of the
ordinary sound with a bulbous end, but it would allow a some-
what smaller one to pass. He was accustomed himself to use a
sound without any bulb at the end and one eighth of an inch in
diameter. He very rarely found any difficulty or resistance in
passing this through the internal os if once the direction of the
uterine canal had been hit upon, although a bitch might often
arise at this point in consequence of flexion of the canal. He
thought further evidence waa much to be desired with regard
to the cure of sterility by incision or dilatation of the cervix.
Though be could not give actual numbers his impression was
that he had not seen such a lai-ge proportion of pregnancies
follow after incision aa described by Dr. Barnes, but a greater
i-elative number after dilatation by bougies, which would affect
the whole canal, ' He thought it would be of great value if some
of thoGO who performed the operation often would give the
number of pregnancies following in a complete series of con-
secutive cases. The only such series he remembered was one
recorded by Dr. Fallen, of New York, in which out of more
than 300 operations pregnancy followed in thirteen or fourteen
cases only. This did not seem at all a greater number than
might be accounted for by coincidence merely, if incision of the
cervii had no tendency to cure sterility.
The Fbebidest expressed his sense of the indebtedness of the
Society to Dr. Bennet for giving them so hi storically interesting
and valuable a paper. On the point raised by Dr. Barnes as to
the greater advantage of dividing the outer os rather than the
228 ON THE 08 DTERI IKTEKNUM.
inner in cases of narrow cervical canal, he would like to say that
formerly he very largely followed Dr. BaroeB's practice, and
rarely incised the inner OS. But of late years, in cases where
there was evident constriction of the inner os, and of the
existence of such cases he had no doubt, he had divided the
inner os with the single-bladed metrotome, and his results bad
been decidedly better. On the other hand, where the inner os
was fairly patulous, and the dysmenorrhcea and sterility were
the result of constriction affecting the os externum alone, he was
quite satisfied with its division, and the resulting shortening
and opening up o£ the cervical canal.
Dr. Hetwood Smith said that as the discussion on the paper
was turning upon incision of the cervix he wished to protest
against the use of scissors for that operation ; for with acisaors
the incision was usually made too extensive. He agreed with
what bad been said against the use of the double hysterotome,
and thought the most scientific method of procedure was to
place the patient in a semi-prone position, hook down the uterus
to the vulval orifice, and make the necessary incision from
within outwards with Sims' narrow knife, as then the extent of
the incision could be better regulated, and the natural functiou
of imbibition possessed by the external os not destroyed as was
often done by too free a division.
Dr. PLA.VFAIK said he bad no intention of entering into the
general subjects of the paper with which Dr. Beunet had
favoured this Society. Were it not that some speakers had
already expressed their belief in the frequent occurrence of
stricture of the internal os uteri as a frequent cause of sterility
be would have been inclined to say that Dr. Bennet was slaying
the slain in arguing against it. For his own part he believed
very little in its existence at all, and certainly not at all in
incision of this part for the cure of sterility. That incision of
the external orifice occasionally in well- selected cases was
followed by impregnation he was quite ready to admit. What
he wanted, however, to point out was that in many cases, and
this point had not been alluded to by previous speakers or by
the author of the paper, it acted not only by enlarging a pin-
hole OS, but by remedying the congenital conical cervix so often
associated with it. This was probably more often the cause of
sterility than stenosis. The operation was no doubt legitimate,
and sometimes successful, but he believed it to bave^>een far
too often and too indiscriminately performed. With regard to
an observation that had been made as to the possibility of too
deep an incisiou subsequently requiring trachf:]o-raphe that
indicates an eutire misapprehension of the proper scope of that
operation, which was never requu-ed except in cases of traumatic
laceration of the cervix leading to secondary morbid states of
the cervix and uterus.
I tTTKKI INTEHHTHr.
229
Dr. Chamfneys wiahed to point out a fallacy in the diagnosis
of st^Qoeis of the oa intemum bj the passage of the sound. When
difficulty is encountered in passing the sound thiq fact is gene-
rally considered sufficient, and a, diagnosis of stenosis is made.
But this by no means follows ; this difficulty may be due to
passing the sound in the wrong aiis, and it often bappens that
the point catches on a fold of mucous membrane, especially if
the cervical cavity is dilated and rendered dome-shaped rather
than cylindrical, and that even when the os internum is proved
to be larger than usual. When, however, the sound has been
passed, and the knob is gripped as it is withdrawn, it follows
that the passage at that point is smaller than the knob.
Dr. AvEiiNG said he was sure the contraction causing dys-
menorrfacea and sterility was sometimes to be found at the os
internum, and he believed division gave more permanent relief
than dilatation. He did not use intra-uterine stems after the
operation, having found it sufficient to open up the divided
surfaces by passing the sound once a day for the first week, and
then at longer intervals until healing had taken place.
Dr. Edis, in reply to Dr. Bennet's statement in his paper that
scarcely anv modem authors on g^ynsacology alluded to the con-
dition of tlie internal os uteri, stated that he (Dr. Edis) had
l>iven the subject full consideration in his work on ' Diseases of
Women.' He agreed with the President in his remarks that
although division of the external os uteri was in many cases
sufficient to overcome dysmenorrhcea and even sterility, there
were instances in which division of the internal os uteri as well
was requisite. Each case must l* treated on its merits. Na
general rule could be laid down applicable to all cases. Division
of the external os with dilatation of the internal os, and the
wearing an tntm-uterine stem for a short time, the patient being
kept quiet and carefully watched, was the treatment he usually
adopted for the condition spoken of as conical cervix with pin-
hole OS, the internal os being also constricted.
Dr. MuBBAT considered Dr. Bennet's remark a true one,
that time alone can show the value of one method of treatment
over another. He thought the operation of dividing the os
uteri, more or less, /or sterility alone of doubtful utility. Many
cases had come under his notice where this practice had been
carried out without good results. It ought not to be resorted to
simply at the request of the patient, who Is anxious that some-
thing more should be done. The operation was by no means
free of risk to life, and when performed required great care
throughout.
Dr. Henkt Bexhbt thanked the President. Dr. Barnes and
other members for the very cordial and flattering mann
which they bad spoken of bis past gyntecological career,
gathered from all that had been said that his views respecting
1
230
: OS O'lBRI INTBItKUU.
the exiBtencti of a real sphiBcter at the istlimua uteri, and of its
pbyBiology aud pathology, were generally accepted, although
some might not go so far as he did. His object in bringing
them again forward was to counteract the teachings and practice
of those who held contrary views. The late Sir James Simpson,
up to the end of his career, and his pupils, among whom were
many American gynrecologista, Dr. Marion Sims in particular,
considered the natural coarctation he described to be a morbid
condition. In their eyes it is one of the principal causes of
sterility, and the origin of many other uterine ailments. This
doctrine led to more or less severe surgical practice, dilatation
or division of the os uteri more or less complete. The operation
of deep division was formerly, aud is still, he believed, much too
frequently performed by some practitioners, under the very
erroneous impressiou that by establishing patency of the os a
complete aud favorable change takes place in the state of the
patient. Neither this nor any other operation can or does
change the nature and condition of a female who may have
been suffering for years from uterine and ovarian pathological
conditions. In such cases not unfrequently the constitution is
defective, ovulation and the uterine functions are, and remain,
stormy until they cease, whatever surgical treatment is pursued.
In them theveni, vidi, vid surgical treatment signally fails. He
was glad to find one speatier endorsing the opinion he bad
cspressed that at least six months or a year should elapse after
any uterine treatment before its results could be fairly appre-
ciated. There are waves of opinion in gynsecology as in every-
thing else, scientific and non-scientific, and perhaps, as Dr.
Playfair had suggested, he was partly slaying the slain. The
abuse of surgical treatment in gyncecology might be on the wane
ill England, but it certainly was not so elsewhere. It was
desirable, therefore, to remove erroneous views respecting the os
uteri internum, and to establish its anatomy, physiology, and
pathology on a sound basis to prevent unnecessary surgical
treatment being resorted to. Other waves of opinion were
setting in equally exaggerated in their character. As for
instance, in America the unjustifiable sewing up of the lacerated
cervix uteri for insignificant lesion, easily cured by the simplest
local treatment, and with us the abuse of pessaries. In
his winter home at Mentone he was constantly picking out
pessaries from the vagina of females who had been travelling
all over Europe with them for many months, a year or more,
turned over to their husbands, and suffering fi'om all sorts of
concomitant or subsequent inflammatory complications. These
complications had either been overlooked when the pessary was
introduced or had been created and exaggerated by its presence
under such unfavorable conditions.
NOVEMBER Txa, 1883.
Eenbi Ge2V18, M.D., PresiiJent, in tlie Chair.
Present — 56 Fellowa and 8 visitors.
Booka were presented b^ Dr. G. de G. Griffith, Dr.
Lewis D. Mason, Dr. WtihUuch, and tlie Smithsonian
Institution.
Charles Harford, L.H.C.S.I., and Aaron Langley,
L.R.C.P., Ed. were admitted Fellows of the Society,
J. King Kerr, M.D. (Leytonstone) j Oliver Calley
Mam-ioe, M.R.C.S. (Reading) ; J. Inrin Palmer, M.R.C.8.
(Kingston-on-Thames) ; and Walter Rosser, M.D. (Croy-
don) were declared admitted.
The following gentlemen were elected Fellowa ; —
William T. D. Caldwell, M.D. ; George Henry Jackson,
M.R.C.S. (Tottenham) ; Edward Johnstone Jenkins, M.B.
Oxon. (Sydney) ; Edmund Henry Pettifer, M.R.C.S. ; and
AJeiander Walker, M.D. (Pntney).
The following were proposed for election : — J. Hewet-
son Bertolacci, L.S.A, (New Wandsworth); Charles
Hamilton Hone Cameron, L.R.C.P. Lond. (Harlesden) ;
F. Richard Eccles, M.D. Toronto (Ontario) ; Montagu
Handheld Jones, AI.R.C.P. Lond. ; Arthur Newsholme,
M.D. (Clapham) ; Walter Pocock, M.R.C.S. (Briiton) ;
and Adolphns J. Richardson, M.B. Cantab.
SUBPEBITONEAL UTERINE FIBROIDS.
De. Alfhed Meadows exhibited two specimens of sab-
peritonea I uterine fibroids whicb lie had successfully
removed from two patients, complete recovery resulting in
both c&ses ; in one the tumour weighed about half a pound,
in the other it weighed about five pounds. Dr. Meadows
also exhibited a fcetua which had apparently reached
about the seven month and which ho had removed by
abdominal incision in a case of ventral pregnancy, the
patient also making a complete recovery. The operation
was performed in consequence of severe constitutional dis-
turbance arising from auppuratiou within the cyst. The
cyst wall was attached by interrupted sutures to the
abdominal wall and carefully washed out until it con-
tracted down to a mere sinus and finally healed, The
pregnancy occurred about fifteen raontha previously.
OBLIQUE RACHITIC PELVIS.
Mk, W. S. a. Geiffith showed an oblique rachitic
pelris from a nulliparous woman, set. 47. From the
absence of marked spinal curvature and from the appear-
ance of the specimen, Mr, Griffith held that the obliquity
was due to the unequal length of the distorted legs, the
left (the side of the obliquity) being one inch shorter than
the right and more bent.
The specimen corresponded closely with the description
by Leopold, quoted by Dr. Ghampneys in his paper on
"Scoliosis" in vol. zviii of the 'St. Bartholomew's Hos-
pital Reports.'
Mr. Grifl5th also showed, for the sake of comparison,
specimens of rachitic, scolio-rachitic, and scolio non-
rachitic distortion.
HYDATIDIFORM HOLE. libd
The President remarked on the interest of the apecimew, and
called attention to the £aet that the left half of the sacrum was
smaller than the right, although no synoatoaiB of the saoro-iliae
articulation existed.
Dr. Basnes observed that he had figured in an early volume
of the ' Obstetrical Transactions ' a pelvis in which the two sides
were unequally developed owing to unequal length o£ the legs.
DYSMENORRHCEAL MEMBRANE.
Db. Wynn Williams exhibited a fibrinous cast o£ the
DteruB (dysmenorrhoeal membrane) passed by a patientj
tet. 32, admitted into the Samaritan Hospital October
16th; married eleven years, three children, age of
youngest seven years. Has complained o£ pain off and
on since laat confinement. Ten days before admittance
had severe pain in stomach with sickness, which recom-
menced the day previous to admittance. On examination
a suppurating cyst was found in the right labium, which
was dissected out on the 17th. On the 20th period com-
menced, on the 23rd passed the membrane, which is hollow
and a complete cast of the uterus. It was discovered by
the nurse, the patient having passed it without pain or
even being aware of it. It could not be ascertained that
she had ever passed such a membrane previously.
Report on Hydatidiform Mole shown by Dr. W. A, Duncan
at July Meeting.
Having examined the specimen shown by Dr. W. A.
Duncan, we are of opinion that it is an early stage of
hydatid disease of the chorion.
F. H. Champnets.
Alban Do&ak,
w. a. duncak.
* i^bMMMV ft^ # wMVv MtlttuS tffa i^^B
«Am» AMMMM* My fteMi
'"•••- Hi*** i» W9 •ft-
»/• ■ ' ' ' fHtMif Ih'm tiy mmftt
lililtfii'^i'iti,
W. A, OUKCIM.
<rillll'llll lUNMM OK I'YOMAIJ'IN.S.
MjH Uawiiin nil, 1MI,(',N,
t ilMH ttliVMily ni'lllKii itiiil >»i<l H u.x'il ilrnl i>n thu
llttvH«Hlltl|| llUt*H<il> »IU)'lt t¥>illU ri^oiu lilt liidnuuDuUiry
tttwtuoitm Hf titift |tVlti>|ktHti htWi Hiul kuuni) H» |7U> or
jCASBB of PSOeAliFIHZ.
235
liydrosalpmx according to the nature of the contents of
the cysts there found.
The subject is dealt with in short papers published by
the Pathological and Obstetrical Societies, in various
papers in the ' Medical Times and Gazette,' ' British
Medical Journal,' ' Birmingham Medical Review,' and
several American journals, yet it seems difficult to per-
suade eome of the members of the profession that the
disease is a very serious one, that it causes intolerable
suffering, is very often fatal, that it is wholly incurable
save by surgical operation, and that the operation for its
cure has had in my hands absolutely no mortality at all.
Up to the present moment I have operated on sixty-two
cases of this kind, and not only has there been no death,
but I know of only one case which has not been cured of
all her suffering. Two of the patients are since dead,
one of acute English cholera of twelve hours' duration,
and one of self-imposed starvation due to acute mebin-
cholia. Six of the patients I have lost sight of, but of
all the others I can give an account ap to a very recent
date.
The disease is not new, as it was fully described and
figured many years before I was bom. That it is a very
fatal disease we have abundance of evidence on such good
authorities as Bemntz and Wilks, and the literature of
peritonitis affords numerous instances of death due to
general infiamuiation of the abdominal cavity arising from
ruptured Fallopian cyst.
The great majority of the cases which hare come
under my care for this disease belong to tho very nume-
rous class of suffering women who wander about from one
consulting-room to another seeking relief and finding
none, except in laparotomy. Very many of them have
been subjected to all sorts of devices, as division of the
cervix, to innumerable tortures by pessaries and many
other contrivances useless in their disease. In one case
the medical attendant tells me this amusing story. She
sent for him, and on her table lay a tray covered with
■ ■ ' ■ I .iir. tiLwIiitclj-
'■Ml|ii.| li. tu|i|,ir!« llll MlHi llBlllM!, mill Icii'Ulilioi, to
'.'MKH or ITOMALPINX.
237
Bocnre t)iat. tliiiro "liiitl lut no iili'iitificaiiDii of iho ca^o.
■ Tlw reaifon of tliit will houii bocomo ovideut, but I havo
[ jdftOAd iu t)io handx of tlio I'reitideiit all theso faots,
together with tho Hurgioal rouurd of the case, ta order
thivt thoro may bo no room for a captious critic inclined to
dispute my utatemeata.
Some naontha ago I was visited by a practitioner very
well known for his attachment to the gyntecological de-
partment o£ medical practice and for bis skill therein.
He was in great distress concerning a patient iu whose
uterus he had placed a stem pessary. She had been
married for many years and had had no children. Her
menstruation during that time had been profuse, more
frequent than normal, and always accompanied by pain so
severe aa to keep her in bed tor several daya, She had
been under the care of many medical advisers special and
general, and had been treated for ulceration of the womb
and other local conditions of more or less fanciful nomen-
clature. The only result was that she got gradually
worse. My friend's written description of her pelvia
when he first saw her is as follows :
" With the exception of some tenderness in the hypo-
gastrium, external examination only gave negative results.
Vaginal examination revealed the uterus lower in the
pelvis than normal and retrofiexed, the fundus directed
rather to the left. The abnormal position of the uterus
was easily rectified by the gentle introduction of the
sound through a channel freely patent, the uterus being
thus proved to be moveable and the cavity of normal
length. To the right there was a sense of resistance and
some tenderness. Her sufferings were relieved by the
administration of morphia, hot vaginal injection, and
opiate stupes. A few days after the cessation of the
catamenia the pain and tenderness diminished, and I (the
doctor whose case it was) introduced a Wynn-Williams
pessary with intra-nteriue stem to rectify the malposition,
this being done with antiseptic precautions. Eight days
afterwards I saw her and found that for the previous two
2S8 CABSS OF PTOBUPINX.
days she had pain recurring at frequent intervals, that
her pulse was 100 and her temperature 100'', I sent her
to bed and removed the peBsary, For some days the
temperature and pulse became normal^ though the pain
and tenderueas did not wholly disappear. To the right
of the uterus I found a decided fulness, giving the sense
of being fluid, and I decided to introduce an aspirator
needle. But early next morning (before aspiration was
performed) I was hurriedly summoned to her ; I found
her condition much altered, the pain having increased and
become general over the abdomen. There was frequent
violent retching and retraction of the knees towards the
abdomen. The features were sharp and pallid, the eye-
balls shrunken and glassy, the pulse small and rapid, and
the temperature 105°.
" I saw that no time was to be lost if her life was to be
saved, and I was fortunate in obtaining your immediate
attendance with the result tliat she rapidly rallied from
her alarming and collapsed state, pain and retching
instantly ceased, and the temperature gradually subsided, J
becoming normal late in the evening."
The gist of what is given above, save the last 8ent«nce>
was communicated to me iu my consulting room on the
morning of the access of the alarming symptoms, and I
had no difficulty in deciding, and I communicated my
views there and then to my friend, that his patient had been
Buffering for years from chronic pyosalpins, that the pessary
had started it into an acute form, that the tube had burst,
that she was now Buffering from general peritonitis, and
that the only hope of saving her was in abdominal section.
He accepted my recommendation, and we started off by .
train as soon as my preparations could be made. I found 'I
the patient just as he described with abdominal distension J
and evidence of fluid in the peritoneum. I opened the '
abdomen and gave exit to a large quantity of fetid,
flocculent, purulent fluid. I found the right tube densely
adherent, that it had been distended ^vith fluid and had i
burst. I removed it along with the ovary, and the right |
OASIS Of PTOsiLpmx. 239
ovary being sdherent in tlie mUde-sac, I removed it aa
well. I cleaned and washed out the abdomen as well as
I could and inserted a drainage tube.
Her recovery was somewhat tedious bat it is complete.
I do not think I can comment upon this case better
than by quoting the words with which my friend closes his
account to me of this interesting and most instructive case.
" In reviewing this case, I cannot but attribute to the
mechanical treatment the consequences which followed it,
though this is the first time after a prolonged employment
of uterine stems that I have had such a mishap. It has,
however, taught me a lesson inasmuch as it shows me
how difficult it is sometimes to discriminate the cases
where they can be safely employed, and also the dan-
gerons results to which they are capable of giving rise
BometimeG."
I can only endorse these words. I have at least one
bitter lesson in my own practice as to the mischief done
by intra-uterine sterna, and the more I see of them the
more I distrust them and the less frequently do I employ
them.
Case 2. — The following account of this instance is taken
from a paper published in the ' British Medical Journal '
of February 17th, 188S, and I introduce it here chiefly in
order to give tlie subsequent history :
" On the 7th of November last, Dr. Pike, of ilalvern,
telegraphed for me to go over and make an exploratory
incision in a patient under his care. When I got there I
found that the patient, a young lady of twenty, under the
joint care of Dr. Wadhams and Dr. Pike, had symptoms
of intestinal obstruction with undoubted peritonitis. Dr.
Pike had a suspicion which he expressed before the opera-
tion, that it really was a case of acute peritonitis from
some trouble with the right Fallopian tube, symptoms of
that having been in existence for two years, ever since
the patient had been chilled whilst skating. Dr. Pike's
diagnosis proved quite coiTect. I removed a large
quantity of pomloit flnid from the abdomen, and I found
240 CASE3 OP PYOSAIPINX.
the contents of the pelvis all glued together with purulent
lymph. There waa no obstruction of the intestines, but
the right Fallopiau tube contained pus and had burst, I
removed it, drained the peritoneal cavity, and she recovered
perfectly. Now the abdomen and pelvis are perfectly
healthy, but within the last three weeks she has begun to
suffer from some mysterious symptoms of which we can-.
not make any satisfactory explanation save that they are
probably spina!."
This last sentence was written as the result of a visit
made with Dr. Pike to the young lady early in February,
At that visit I found her greatly emaciated and suffering
intense pain high up on the right side of the back. This
pain was not constant in its situation, and there was no
physical sign to give us a clue to its origin or its nature.
We set it down as spinal, and from the exhausted
condition of the patient wo believed she had not long to
live. I made a vaginal examination to satisfy myself
that there waa nothing wrong in the pelvis and I found
nothing wrong, but the examination caused the patient
some pain. From that moment, strange to say, her pain
in the back vanished, she began to eat, and ia now in
perfect health. What I did I do not know, but I suspect
I unwittingly undid some adhesion, and thus ended the
patient's sufferings and restored her to health.
Case 3. — In this instance I am again prevented from
giving any indication of identity in order that I may give
full details of the case.
The patient waa quite young, barely twenty, and had
been married about seven weeks to a young gentleman
about two years her senior. Previous to her marriage
she had enjoyed perfect health. About five years before
his marriage her husband had contracted gonorrhcea of a
comparatively mild character, and I am informed by the
surgeon who treated him for it that he was completely
cured. The young husband also declared that this gonor-
rhcea was the only thing of the kind he ever had, and I
think there is no reason to doubt his truthfulness.
CA8EH or FTOSAI.PINS. 241
The newly- married couple weut on the usual honoj'inooii
and for the first week intercourse was extremely frequent,
but about the eighth day it became painful to both, and
to the husband's horror he discovered he was again snf-
foring from gonorrhcea. There is not tho slightest reason
io believe that the wife was other than perfectly virginal
at the time of marriage, the account given by the husband
making this quite certain. She began on the ninth day
after marriage to suffer from paiu and scalding in passing
water, the parts became swollen and tender, and severe
pelvic pain was felt. Medical assistance was called in
but unfortunately nothing was said to the doctor about
vaginitis. She was kept in bed for about ten days with
fever and incrensing pain, and during that time a period
came and passed over. After the period she felt much
better and got up and went about. In the fourtli week
of their married life intercourse was renewed, the husband
feeling much better as the result of a resumption on his
own responsibility of the treatment which had originally
cured him, that being the use of the oil of yellow sandal
wood and the sulphate of zinc injection. ' Renewed
intercourse brought on a relapse of the .symptoms in both
parties, and the use of the sulphate of zinc injection by
the wife was followed by what was doubtless an attack of
acute pelvic peritonitis. For this no medical assistance
was summoned. She got well enough to move towards
home in about ten dayp, but was again attacked at a
house where they rested on a visit for a few days. Thi
she was attended by two medical gentlemen for nearly a
fortnight.
She had the following symptoms : distension of the
abdomen, vomiting, intense pelvic pain, night swea
delirium for two days, pulse running as high as 120, and
a temperature occasionally of lO-l^. Tho most severe
time of the symptoms was again during a period. I s
her first myself just after the cessation of this, and
satisfied myself of the existence of effnsion in the peri-
toneum and of the existence of a tender mass to the left
VOL. XXV. 16
/ "
, . ^
CASKS OP PYOSALPINS.
My second remark is to the effect that these cases exist
in large numberR, that they wander about seeking relief
and find it in one way only.
Br. Wtsh Williams rose to protest against the insertion of
a stem in such a case as that mentioned in the paper. He
should never have dreamed of doin^ so. He had again and
again stated that his stem and shield were only applicable in
cases of autefleiion, and if medical men would continue to
insert them in such cases as that related they must take the
blame on themselves, and not lay it on the ingtrument. Again
he repeated that a stem cannot with any degree of safety be
inserted into a retrofleied litems without a siipi>ort to the
fundus. He presumed that in Case No. 1 the author did not
attribute the pyosalpinx to the insertion of the sti'm, as the pns
must have been present previous to its insertion, the abscess
being ruptured by its insertion, probably a fortunate occurrence
for the patient.
Mr. Alban Doban believed that there was yet another
cause of suppuration of the Fallopian tube not mentioned by
Mr. Tait, namely, the introduction of a foul sound into the
Uterine cavity. In the out-patient departments of latge hospitals
it often ha|>i)ens that the same sound was used in the examina-
tion of a uirge number of women within the limits of two or
three hours. Under such circumstances it was extremely diffi-
cult to ensure the perfect cleansing of the sound after every
examination. Morbid mucus or discharges would lodge in
small depressions upon the surface of the sound, and septic
products might adhere to the oil or vaseline with which the
sound had been lubricated. In this manner unhealthy material
was introduced into the uterine cavity, and could thus set up a
low form of inflammation of the mucous membrane of the body
of the uterus, which might in many cases spread to one of the
tubes, especially if its uterine orifice were dilated. In answer
to Dr. Braiton Hicks, Mr. Doran had examined the fluid con-
tents of several of the tubes sent by Mr. Tait to the museum of
the Eoyal College of Surgeons within three days after their
removal, and had found the contents to l)e pus and not broten-
dowQ epithelium floating in mucus.
Dr. Babnes said that Mr. Lawson Tait had opened out a new
field in abdominal surgery. No doubt there would be some
opposition to his views — timid opposition, on the one hand, from
the far niente school ; violent from the dogmatic. The results
published by Mr. Tait were sufficient to show that cases existed
which were eminently amenable to surgical treatment. Every
one most have seen cases of women drifting into danger, and
214 CASES OF rVOSAI.PINX.
whoso livoB wero rendered wretched from conditions simtlftr to
those desoribetl nnd operftted upon by Mr. Lawson Tuit.
Dr. W. A. Duncan snid he would be glad to know from Mr.
LaWBoii Tait wbothcr Id manr of his cases the distended tubes
weij lixed by adhesions, and if so, whether the operation was
coUBPC|ueiitly rendered much more difficult P Dr. Duncan
nientiuuod two cases bo hs-d recently eeon ; in one there was a
double pyosal|>ini, the left lube boioj; fixed by pelric oellulitis,
and its contents ultimately rupturea into the vagina; iu the
other case, after two attacks ot peWie cellulitis, a rery oharac-
teristio left pyosalpiiix altogether disappeared.
The .t^RBSiDBHT thought Mr. Tait took somewhat too gloomy
a Ticwof the general prognosis iu cases of tubal distensioa
9onio r.ertainly, though possibly they were the cases of hydro-
salpinx rather than pyosalpinx, got better without operative
iutorforenee; as iu the case just referred to by Dr. W. Duncan,
As regarJs the causes, pTOBftl|iinx being generally a sequela of
endometritis, it might oe accept^jd as a rule that whatever
induced endometritis might lead to consequent tubal inflamma-
tion, although puerperal troubles and gonorrhcea were certoJuly
ainoug the most frequent causes. He would like to ask Mr.
Tait if iu his answer he could give them any further informa-
tion on the subject of diagnosis. Most writers spoke of the
dia^jnosis, at all events, of the smaller fluid collections as ex-
ti-cniuly difficult. On the general question be was hardly pre-
pared to say more than that while this operation was the latest
It was not the least important of that surprising aeries of opera-
tjona associated with abdominal surgery which began with
OTwiotomy.
Dr. HoRROCKB asked how it was that If these cases were ao
frequent and so invaiiably fatal one did not oCtener meet with
them on the imst-uiortem tables of large hoapituls. He did not
know of any Ciiae having been seen at Guy's Hospital during the
litst eight years. Therefore if these cases were so frequent as
Mr. Lawaon Tait would have us believe, was it not highly
probable that the great majotily of tbeni get well without
operative interference P
Dr. Fancodbt Barnes congratulated Mr. Tait on his valuable
paper. He now recognised, ivi the light thrown l>y Mr. Tait,
Kevcral cases of pvosalpinx. He ttelicved he had at the present
time in bJa wards at the Chelsea Hospital for Women such a
Dr. Grailt Hewitt believed the affection described by Mr.
Lawsop) Tait in bis valuable paper not a common one. Anotber
cause not mentioned waa occlusion of the canal of the cervix
utpi'i. He mentioned the CAse of a lady who had a painful
tuuiiiur in situatiou of loft Fallopian tube, which was treated by
a).vuing the occluded cervix uteri by the sound, and relief
OASSS Ot PTOaitPlMX.
followed together with escape of puriform fluid.
diagnosis made was p;osalpiux.
Mr. Kkowslbt Thornton wished to know from Mr. Tail tho
respectiTe numbers of the cases of hydro- aud pyo-salpinx in
this total of aiity-two or sixty -five. In one part of the paper
Mr. Tait gave the total as sixty-two and in another as sixty-five.
This was a matter of great importance, because while moat of
the Fellows would probably admit the gravity of cases of pyo-
ealpinx, he for one could not admit the gravity of cases of hydro-
salpinx. He bad come across many cases of the latter patho-
logical condition in the performance of ovariotomy, and so far as
his experience went it tvas a condition giving nsc to little if any
trouble to the patient. Probably the rupture of an ordinary
hydrosalpinx into the ijeritoueum would cause little if any distur-
bance, and very likely this was one of nature's commonest methods
of cure. Cases of pyosalpinx were much more serious, though
he beheved that many of tbem were cured by discharging into
the uterus. Still rupture into the peritoneum was a recognised
accident and cause of death, and the two pathological conditions
stood on a very different footing. The relative proportion of cases
of each in Mr. Tait's large experience was therefore of great
imiK)rtance, and of sUU greater importance was the differential
diagnosis of the two conditions. If a pyosalpiux could be cor<
>ctiy diagnosed, then an operation for its removal was certainly
' jati£jible as many other surgical operations, but he doubted
e same could be said of hydrosalpinx, Would Mr. Tait tell
the Fellows how he diagnost^ these conditions p He himself
had only twice operated for pyosalpinx, and in neither case were
there any adhesions except a few filmy bands to neighbouring
organs, though in one case the tubes were very largo, and
formed abdominal tumours.
Mr. 3. Matthew Owkks, — Having during the past year seen
some ninety-eight cases of abdominal section done by Mr. Tait,
and amongst lUem some fifteen or so of pyosalpinx, I can vouch
for the great good done by this operation. It wilt be found that
many cases of so-called hysteria now prove to be diseases of the
Fallopian tube. I well remember that one case, in which Mr. Tait
thought he was going to do a genuiue " Battey " (though he
was doing it under protest), turned out a very severe case of
pvosalpini, but all her symptoms were so masked that every
doctor whom she consulted called it "hysteria," and even Mr.
Tait was himself deceived. One speaker (Dr. Horrocks) asks why
do we not see these cases on tho post-mortem table F My answer
to that is this, that those who die from this disease are said to
have died of acute perit'>iiitis which is caused by rupture of the
diseased tube. I must confess that one drawback in these coses
is the difficulty of diagnosis, but if when a case whose constitu-
tional symptoms all ]>oint to pus in the tul'cs, but in wbom the
as jus
if tiie
246 CASES or ftobalpihs.
plijaical signs are wanting, then I saj open the abdomen and
see, for the risk in exploratory inciaions is absolutely nil, and if
it should happen to be a pyosalpins the result is brilliant.
Dr. Galabik asked whether the drainage tube used by Mr,
Tait was a glass one, and whether the fluid used for washing
out the peritoneal cavity was plain water or what other fluid.
Dr. MuBRAT also considered the minute diagnoaia of such
cases should be given to obviate unnecessary operations. He
congratulated Mr. Tail on his successes, and thought that
perhaps the Lock Hospital might afford opportunities for
verifying the influence of gonorrhoea.
Dr. Heywood Smith asked Mr. Lawaou Tait whether if a
diagnosis was made of hydrosalpinx it would not be as well to
aspirate instead of proceeding to the major operation.
Mr. Lawson Tait, in reply, said that he must assure Dr.
Wynn Williams that the implied condemnation of hia stem
pessary was not in bia (Mr. Tait'e) words. It was the expres-
sion of opinion of the gentleman whose words Mr. Tait had
quoted, the medical attendant of the patient. In reply to Mr.
Xlban Doran, Mr. Tait thought it possible that inflammatory
mischief, such as might lead to pyosalpinx, might be introduced
by a foul aound. He knew of a case where gonorrhcBa had been
given by a dirty speculum, and he tiought it might be given by
a dirty sound. Concerning Dr. Barnes's question as to whether
he would operate in such mischief during the puerperal state,
he would answer emphatically in the affirmative. If he saw a
case sufficiently early to promise a good result he would most
undoubtedly open the abdomen of a woman suffering from
puerperal peritouitia, wash her out, and drain the cavity. So
far he had not had such a chance. In reply to the President,
he might say that ho had no doubt that many cases of hydro-
salpinx and probably some of pyosalpinx were cured by natural
processes. Of the former he knew this was true, and now that
attention was being drawn to the subject probably pathologists
would find old cheesy maaaes in the Fallopian tubes, remains of
pyosalpinx cured, just as chalky masses in the lungs indicated
cured cavities. As to the diagnosis, he depended largely on the
history, in which a clearly indicated point of starting of the
disease in some inflammatory attack was generally given, Then
there was pain, more or less constant, aggravated by movement,
and particularly by intercourse. Menorrhagia was an almost
constant aymptom. Finally, there was the phyaicol evidence of
alterations in the pelvis, without which he (Mr. Tait) very rarely
cared to operate. In the matter of diagnosis there was, as eveiy-
where else, a considerable amount of speculation. He thought
he was wrong perhaps once in ten times, but the mistake in the
tenth ease always taught Mm valuable lessons. In two recent
cases mistakes were made of a curious and most interesting
CASES 0¥ FIOSALnNS. 247
kind. The first was a case in »hich Dr. Cleiiieut Godaou, Sir
Spencer Wella, and bimaelf coucurred in the view tliat a young
lady aufEered from jjyosalpim on the right Bide, The only
thing wanting was the initial point in the history, Tbe cause
of the auSerlng turned out to be a small dermoid tumour of the
right ovary, not bigger than a Tangier orange. In the second
caae, a patient from Germany, exactly the same thing was found,
and he had now quite a group of cases of these aniatl dermoid
tumours causing agonising pain. Dr. Horrocks saJd these cases
wei-o not seen in London, but they nevertheless eKisted there,
for many of his cases came from London, some even had been
in-patients at Guy's Hospital, and the great majority of tbem
had. been in London for treatment at some time or other. These
cases are not seen in the post-mortem room for a very simple
reason that when they are killed by fatal peritonitis tbey are
genei-ally not inmates of hospitals, and dying in the hands of
practitioners not habitually performing post-mortem cjtamina-
tions, they are recorded as cases of idiopathic peritonitis. But
the records afford numerous cases of post-mortems where the
rupture of a Fallopian or ovarian abscess has been found to be
the source of peritonitis, which would have been inexplicable but
for the post-mortem, A few of the cases have been attacked by
peritonitis due to rupture during residence in hospital, but they
are exceptional, as might have been expected. In answer to Mr,
Knowsley Thornton's questions, he might reply from a general
impression that hydrosalpinx and pyosalpinx occurred in the
proportion of three to two, hydrosalpinx being relatively an un-
important disease, as far as danger to life is concerned. But we
cannot stop short of dealing with matters which affect life only.
Hydrosalpinx is a frequent cause of the most intense suffering,
and therefore he would, and did, remove it by surgical operation
without hesitation. He did not believe that the rupture of
hydrosalpinx would ever be likely to prove fatal. In fact he
had watched one for a long time which ruptured periodically.
The patient died suddenly of heart disease, and post-mortem
examination proved the diagnosis to have been perfectly correct.
The specimen is now in the Hunterian Aluseum. The differen-
tial diagnosis between the two conditions cannot be made, as it
is not unusual to find pus in one tube and serum in the other.
The drainage tubes he used were of glass, and he washed the
abdomen well out with plain water, without any antiseptic
(Listerian) mixtures. He need hardly say that his sense of
gratification at the reception given to his pa{>er by the Society
was extreme, and now the somewhat harsh criticisms and the
occasional misrepresentations to which his work bad beon sub-
jected would probably end.
CASE OF IDIOPATHIC GANGRENE OF THE
UTERUS.
By Lawbos Tatt, F.R.C.S.
E. W — , set. 34, was admitted to the Hospital for
Women, on account of vague pelvic pain and offensive
watery discharge, on November 25tli, 1880. The uterus
felt soft and flabby, and was not fixed. The patient had
feverish symptoms, a furred tongue and swollen abdomen.
Quinine and mineral aeid were given, but as no exami-
nation by speculum or operative proceedings of any kind
were permitted by the patient, no clear idea could be
formed as to the nature of the case.
At her own request she was sent home on January 2nd,
1881, and she died on January 4th.
A post-mortem examination was made by Dr. 8aundby>
on January 6th, and the foUomng is a copy of his report:
" The liver was fatty, spleen and kidneys normal ; the
intestines looked normal ; the omentum was blackened ;
the uterus was firmly adherent to the right side of the
pehHs, and in removing it, it was unavoidably torn.
" On section it presented the appearance of a jet-blaok
sloughing stinking mass, with only about a square inch of
normal looking uterine wall at the fundus."
After the uterus had soaked in spirit for some days
I examined it carefully. I found that it was gangrenoiiB
as described by Dr. Saundby, but I could discover no
reason for the occurrence of this remarkable change.
Certain that the patient had serious pelvic mischief during
her residence in the hospital, I had proposed abdominal
section to her, but this she declined. It would have
probably been quite easy to determine the nature of the
case by an exploratory incision, and the dead uterus might
have been removed.
AN UNDESCRIBED DISEASE OF THE FALLOPIAN
TUBES.
By Lawbon Tait, F.B.C.S.
Os January 10th I was asked by Dr. Clibborn to see a
patient who had been under his care for a long time suffer-
ing from pelvic pain, bo severe as to render her entirely
unfit for her household work. She was thirty-six years
of age, and had been married about ten years having had
three children. She had been under many medical advisers,
including myself, as I had treated her some years before
as a hospital outpatient, but froui none had she obtained
any relief. Her sufferings consisted of constant aching
in the pelvis, referred to both sides, exaggerated by the
erect position, and increased to intense suffering during
menstruation and after marital intercourse. She had
become very much emaciated and looked haggard and ill.
She was covered with an acne eruption, the result of the
prolonged and fruitless use of bromide of potash, and her
groins bore marks of repeated blisters,
Dr. Clibborn had called me to see her for the purpose
of discussing the removal of the uterine appendages. On
examination I found nothing in the pelvis, but it was
evident that the examination gave the patient a. great
deal of pain, so that, even in the absence of physical signs,
I was quite satisfied that there was something wrong, which
justified us in making an exploratory incision.
This was done on January Slst. I found the fimbrite
ot the tubes adherent by curious little nodules which felt
in the fingers exactly like hard seeds like millet. The
left tube was thus fastened to the ovary and the right to
the pelvic wall. This seemed to me to be a pathological
change quite sufGcient to justify removal of the appendages,
and this I did. The result has been complete relief of
the patient from all her symptoms, and ahe is now, bix
.
250 UNDISCBIBBD DISBASB OF THB FALLOPIAN TUBBS.
months after the operation^ completely restored to health
(June 9th, 1882).
I sent the appendages to Mr. F. S. Eve, of the College
of Surgeons Museum, and he has been kind enough to
&your me with the following report on the structures, the
preparations of which are now mounted in the museum.
'' The specimens of nodules on the Fallopian fimbriae
are interesting. Sections of the nodules present the fol-
lowing appearances : — Each nodule contains two, three, or
more circumscribed, structureless (except for the occasional
appearance of faint lamination), yellow masses, apparently
in part calcified ; the edges of some of the nodules are
crenated. The surrounding connective tissue is very rich
in large round cells.
" Of the nature and mode of origin of these masses I
can offer no opinion. They are neither cartilage nor
bone.**
DECEMBER 6th, 1883.
Hknrt Gerv!3, M.D., President, in the Chair.
Present — 57 Fellows and 6 visitors.
Books were presented by Dr. Branfoot, Dr. Charles,
the Royal Medical and Chirurgical Society, and the Edin-
burgh Obstetrical Society.
John Archibald, M.B., Edmund King Honchin,
L.R.C.P. Ed-, and Frederick Stocks, M.R.O.S., were
admitted Fellows of the Society. Gleorge Henry Jack-
son, M.E.C.S. Eng. (Tottenham), was declared admitted.
The following gentlemen were elected Fellows : — J.
Hewitson Bertolacci, L.S.A. (New Wandsworth) ; Charles
Hamilton Hone Cameron, L.R.C.P. Lond. (Harlesden) ;
F. Richard Eccka, M.D. (Ontario) ; Montagu Hand6eld
Jones, M.R.C.P. Lond. ; Arthur Newaholme, M.D. (Clap-
ham) ; Adolphus J. Richardson, M.B, Cantab. ; and
Walter Pocock, M.R.C.S. (Brixton).
The following gentlemen were proposed for election : —
Robert Boxall, M.D.; Arthur Henry Boys, L.R.C.P. Ed.
(Bristol); George Henry Darwin, M.R.C.P. (Manchester);
Edwards Angel Gaj-ues Doyle, M.R.C.S. (Trinidad) ;
John Challen Duke, M.R.C.S. (Lewisham) ; James Oub-
bins Fitzgerald, M.R.C.S. (Balham) ; Alexander Forsyth,
M.D. (Greenwich) ; John Alfred Masters, L.R.C.P. Lond. ;
Asutosh Mitra, L.R.C.P. Ed. (Calcutta) ; and Bertram H.
Lyne Stevens, M.R.C.8. Eng.
THE CAUSATION OF LATERAL OBLIQUITY OF
THE FtETAL HEAD.
Db. Galabih showed three diagrams intended to illns<
trate the views which he had brought before the Societ^^
on a former occasion as to the causation of lateral obliquity!
of the fcetal headj namely, that whenever the head is i
Ebaped that lateral obliquity secures a mechanical advant-9
age by bringing a smaller diameter of the head into thsv
opposed diameter of the pelvia, and when also the head iai
Bubjected to lateral pressure, the effect of the pressure ia.]
to bring about such a lateral obliquity.
In the diagrams the fcetal head is supposed to be one i
with somewhat prominent parietal tubera, so that thofl
biparietal diameter {G H) is greater than obliqae diameters. I
(sabparieto-superporietal diameters), inclined at a slight:]
angle (o it, drawn from a point a little above the parieta
tnber on one side to a point a little below it on the oth6r.!|
This is generally the case with the fcetal bead before t
has undergone moulding; and, when it is so, a slighl
lateral or biparietal obliquity of the head, brought about b^a
a rotation on its antero-posterior axis, brings into opposi-r
tion with any diameter of the genital canal a smaller dia-l
meter of the head than the large biparietal diameter whioha
previously occupied it, and thus secures a mechamcall
advantage.
In Fig. 1 the dotted outline (a b d) represents a ver- 1
tical transverse section through the parietal tubera of ]
fcetal head, shaped as already described, and engaged ii
the pelvis, whose walls are a' o, h h' . The propulsive 1
force (p) is assumed to act in the axis of the pelvis, and J
its direction will therefore be along D s, the central line 1
of the section.* The biparietal diameter (g h) hes exactly 1
* The directioii of tbe propulaive farce does not acttmlly lie in the plH
of thediiigram; but iti projection upoo that pUne may be taken u repr
■enliog it, HO far as regards tlie lateral luovemenl ander coneideratioi
diitancc abaro or below the plane, or any inctinalioD it loa; have to t
plane, will affect only tbe movement of Beiion or eilensioii of the bead.
LATERAL OBLIQUITY OP THE P(ETA1, HBAD.
253
across the pelvis, p and 2 are the pressures at q, h, the enda
of this diameter, and are equal to each other, the propulsive
force not heing inclined toward either side. The plane
outline A s' b' represents the same section of the head
when displaced by rotation on its antero-posterior axis to
a biparietal obliquity of about 7°. p', the displaced pro-
pulsive force, will act approximately along d' k, a line
parallel to d b, its former direction, e', S are the pres-
sores on a', h*, the points of the section which are now
closest to the pelvic wall, p', 2', like p, S, are equal to each
other, and perpendicular to the pelvic wall, c is the pro-
jection on the plane of the section of the centre of gravity
of the head, and lies on the line D B, c' is the same when
displaced, c' L H is drawn parallel to D B, s' K, and there-
fore perpendicular to a' L, b' x.
The effect of any force to increase or diminish the dis-
placement is measured by its "moment" about c' the
projection of the centre of gravity of the head, that is to
say, by the product of the force and the perpendicular
from c' upon its direction.
254
LATERAL OBLIQUITY OF THE FffiTAL HEAD.
The effect of the pressure p' tending to diminish i
displacemeDt is therefore represented by the prodw
p' X c' L, that of the pressure S' to increase the diaplai _
ment hy the product S' x c' k. Of these the latter is the
greater. The difference of the two is the product p' x l M,
p' and S' being equal. Hence, in the intervals of pains
the pressures tend to increase the lateral obliquity.
The pi-opulsive force p' also tends to increase displace-
ment, its effect being measured by the product p' x □' s.
The frictions at g', h' {not shown in the figure) will act
along the pelvic wall, and are equal to each other, the
pressures p' and S' being equal. The friction at o' tends
to increase displacement, that at h' to diminish it. If b
be the magnitude of the friction, R x o' L represents the
effect of the friction at o', r x h' m that of the friction at
n'. Hence the frictions will have a very slight eSec
tending to increase displacement measured by the prodaq
K X {g' L — h' m) or e X 2 s l.
Therefore the tendency is to increase displacement, botl
in the intervals of pains and during the pains. It follow
that, although the head ia in equilibrium when the biparieta
diameter lies precisely across the pelvic canal ; yet, i£ i
is displaced in the slightest degree from that position I
any small obliquity of the propulsive force, or any othei
cause, the forces at work will increase the displacement Qpl
to and beyond an angle of 7^. "With a head thus shaped^T
therefore, an exactly straight or "synclitic" position :
one of unstable equilihriinn,, and the head can never looi
remain in such a position.
In Fig. 2 the same sections of the head are represente
except that the section of the head indicated by the plani
outline a' a' b', is now represented as displaced throngh.'l
an angle of about 16° of biparietal obliquity. The figure ii
drawn exactly as before, except that the point h', whei
the section is closest to the pelvic wall, now lies above s
and the point m falls above c', the projection of the cent^
of gravity. This inclination of the head represents r
that at which the greatest meohan'- ' ' "uitage is gained
LATERAL 08110011? OF THE F(ETAL HEAT.
255
with a section throngh the parietal tubera shaped as in
the figure.
The effect of the pressure p' tending to diminish the
diaptacement ia now measured by the product p' x c' l,
that of the pressure 2' tending to diminish displacement
by the product 2' x c m. The sum ia equal to p' x m l,
tending to diminish displacement, p' and 2' being equal.
Hence, in the interval of pains the pressures now tend to
diminish lateral obliquity.
The propnlsive force f', however, still tends to increate
displacement, its effect being measured by the product
f' X c' K, which is greater than before. The frictions, as
before, will have a slight influence tending to increase dis-
placement, the effect being measured by the product
B X 2 N L.
Hence, if the propulsive force p' is considerable in pro-
portion to the pressures p*, 2', the lateral obliquity may
still be increased during the paints, until it is arrested bf
266 LATERAL OBLIQUITY Of THE FfETAL BBAD.
the base of the skull or the neck coming into contact with
the uterine wall.
In FigB. 1, 2, it has been assumed that the pelvic walls
are parallel at the ends of the biparietal diameter. This
will be nearly true when the biparietal lies in the oblique
diameter of the pelvis. The genei-al effect will, hoi
be the same if the pelvic walls slightly diverge or slightly
converge, provided the head is still pressed upon near the I
parietal tubera.
If the slight divergence of the displaced propelling force
(p') from parallelism with its original direction (f) be taken
into account, the tendency to increase lateral displacement
will be slightly increased, since the line p' k will fall some-
what further away from o' the projection of the centre of
gravity.
li the propelling force (p) be not acting in the axis of
the pelvis, but inclined to it, the foregoing demonstration
will still bold good for the component of the propulsive
force resolved in the axis of the pelvis. The component
resolved perpendicular to that axis, with the reaction of
the pelvic wall which it calls out, will form a " couple "
of equal and opposite forces. The effect of this couple
will be either to promote or to resist the biparietal i
obliquity according to the direction of the obliquity of the I
propelling force.
In Fig. 3 is represented a different state of things,
namely, a section through the parietal tubera of a foetal
head, shaped as beiocerttrrested above a pelvic brim, the
opposed diameter of which (o h) is a little too small to
admit the biparietal diameter. The dotted outline abb
shows the head in an exactly straight or synclitic position.
The plane outline a' b' b' shows it displaced to a biparietf^ .
obliquity of about 18".
F is the propulsive force assumed to be acting in the 1
axis of the brim, p' is the displaced propulsive force I
acting approximately parallel to its former direction, so I
that d' k is parallel to D 8. Let p' and S' be the resist- 1
ances to the displaced head at the points o, h, p' and i'T
UTKEAI, OBLIQUITT OP THE F(KTAL HEAD. 2S7
disregarding frictions) act perpendicularly to the surface
of the head and at right angles therefore to Q n, H v, the
tangents to the section of the displaced head at a h.
Let the directions of p', 2', meet in the point t. The
resultant r of the forces p' ^ must pass through the point
T, and it must also, like the propulsive force f*, act in the
direction of the pelvic axis, anlesa the head is being
pushed bodily to one side or other, t n, the direction of
E, is therefore parallel to v' & and d s. Through c', the
displaced centre of gravity, draw n c' k perpendicnlar to
T N, D e, d' k.
The effect of the propulsive force p' tending to increase
displacement, is measured by the product p' x o* K. The
effect of E, the resultant of the pressures p' and S" tending
to increase displacement, is measared by the product
E X c' N. Hence, in all cases, the displaced propulsive
force tends to increase the displacement. The resi.-itanc«s
VOL. UT. 17
J
258
THE MECHANISM OF L&BOUB.
1 the figure, ^^1
tend also to increase it with a head shaped
and will always do so unleBS the head is so shaped that
the tangent to the displaced head h v is more inclined
to the pelvic axis D s than the tangent a v. It friction
be taken into acconnt, the effect will be diminished, bnt
will be still of the same kind. Therefore, when the head
is arrested above a brim too small to quite admit its bi-
parietal diameter, the tendency is for biparietal obliquity
to be increased even beyond an angle of 18°, and until
is arrested by the base of the skull or the neck comi
into contact with the uterine wail. Biparietal obliquit]
is likely therefore to be greater in such a case than vfhi
the head is engaged in the pelvia.
If the biparietal diameter has been so diminished by
moulding that it is smaller instead of greater than the
oblique subparieto-superparietal diameters slightly inclined
to it, the pressures, when the head is engaged in the
pelvis, tend to diminish any displacement instead of]
increasing it, and the " synclitic " position of the heat
becomes one of stnbic eqnilibriuni.
bi-
lity^H
ilif^H
V
k1
1
ON THE MECHANISM OF LABOUR MORE ESPE-
CIALLY -WITH REFERENCE TO NAEGELE'S
OBLIQUITY AND THE INFLUENCE OF THE
LUMBO-SACRAL CURVE.
By RoBEKT Barngs, M.D. J
NoTHiKQ conduces more to the sure progress of acienoefl
than frequent examination of its foundations. This con-
sideration must be my apology for obtrnding upon the
Society a discussion upon the mechanism of labour, espe-
cially upon that part which concerns the relations of thl
fcetal head to the pelvis.
From the time when the memorable essay of Fr. I
Naegele was published, the doctrine set forth in it r
THE KBCHANISH OF IJkDODB.
259
generally in Germany, France, and England, until it was
shaken by Velpeau (1835), Caseanx (1S41), R. TJ. West
(1857), Duncan (1861), Paterson (1862), Leishman (1864),
and especially by Kiineke (1869), It was enthusiastically
advocated by Edward Bigby, who published a translation
of his master's essay in 1829, and adopted by Tyler Smith.
At the present moment teaching as regards this point is
unsettled.
It will be useful in setting out the case to describe
briefly ihe three obliquitiee of the head as given by Kiineke.
The first m Roederer'a, or the occtpito-frontal obliquity.
The head may be imagined as rotating on its transverse axis
BO that the occiput drops and therefore dips in the pehns,
standing at a lower level than the sinciput. We are only
incidentally concerned with this obliquity.
The seeond is Solayres', who, in 1771, demonstrated
that the head entered the pelvis iu an oblique diameter of
the pelvis. Solayres' obliquity then refers to the relation
of the head to the pelvic diameters.
The third or Naegete's obliquity is that upon which the
greatest diversity of opinion prevails. It is that which it
is the design of this memoir to illustrate. It is best
to define this in Naegole's own words. He says : " In
that presentation of the head which occnrs most frequently,
the head presents not with the occipat bnt with the
vertex; in fact, with the right parietal bone, the posterior
fontanelle being turned towards the left acetabulum.
Upon examination at the beginning of the second stago
of labour {i.e. when the os uteri is opening), and in those
who have bad children, the finger introduced in the
direction of the central or middle lino of the pelvic cavity,
and brought in contact with the head, will touch the
right parietal bone in the Hcinity of its tubes ; the two
fontanelles are mostly fonnd situated at an equal height,
sometimes the anterior, but more frequently the posterior
one a little lower. At the entrance of the pelvis the
head does not take a perpendicular but a perfectly oblique
direction. So that the part which lies lowest or deepest
260 TFE MECRAKISM OP UBOITB,
is neither the vertex nor the sagittal suture, but the right 1
parietal bonp. The sagittal suture is much nearer to the
promontorium than to the os pubis, and divides the
uteri, which projects backwards and generally somewhat
to the left across, into two very unequal segments."
Naegele enforced this statement by the observation
the caput succedaneum which forms upon the posterior
and upper quarter of the right parietal bone (the firsi
position being underatoodl, and if delayed at the outli
then covering the right parietal bone and a part of the
occiput.
Naegele also insifited that the head preserved somewhat
of the Solayres' obliquity even at the outlet of the pelvis
and during its exit. This, which was not generally recog- ■
nised at the time when he wrote, is now, I believe,,
universally admitted, Kuneke alone excepted. Butl
Naegele further showed that his own obliquity was also
preserved to the end. He says : " When the head haa
sunk completely into the cavity of the pelvis and ap-
proaches the external opening, the posterior fontanelle ia
still found corresponding to the left foramen. If the
finger be introduced nearly in the centre of the pubal
arch, in the direction of an imaginary median line of the
pelvic cavity continued forwards or outwards, its point
will touch pretty exactly upon the middle of the superior
and posterior quarter, sometimes the middle of the pos-
terior half of the right pflrietal bone. . . The
posterior fontanelle at last gradually moves itself in a
direction from left to right (frequently more or less from
above downwards), and the occipital bone advances from
the side of the pelvis under the arch of the pubes. It is ■
not, however, the centre of the occiput that advances
under the pubal arch, but the head approaches the oa
exteraum (vulva) with the posterior and superior part of
the right parietal bone, and remains in this position until
it has passed through the outlet of the pelvis with the
greatest circumference which it opposes to it. It is, iti;
short, the posterior and upper part of the right pariel
bat
'I
A
THE UECHANISU OF LABOCK.
261
bone which passes through first at the os externum.
The right tuber parietale will be felt distinctly
clearing the labia before the left," There must, then, be
obliquity of the head at this stage.
E. Rigby sums up the case thus: "the head enters,
passes through, and emerges from the pelvis oblitjuely ;
and this is the case not only as to its transverse diameter,
but also as to the axis of its brim, the side of the head
Iwing always lowest or deepest in the pelvis. This shows
the beautiful mechanism of the process for, on account of
its oblique position, there is no moment during the whole
labour at which the greatest breadth (still less length) of
the head is occupying any of the pelvic diameters,"
Naegele examines the cases of other presentations of
the head and of the breech, and shows that all are subject
to the same law. Throughout the following argument, I
assume the typical position recognised in this country as
the first, that is, the right occipito-anterior.
Tarnier,* who does not. admit Naogele's obliquity, thus
explains the condition observed : " The opinion (that the
anterior parietal protuberance waa lowest in the pelvis)
rested upon the fact that the anterior parietal is more
easily reached than the posterior parietal when, the head
entering the brim, the vaginal touch is practised. The
fact is true, but it is badly interpreted. If the right
parietal is more accessible than the left . . . this is
owing to the cur\'e of the pelvi-genilal axis. The axis of
the vagina is not parallel to the axis of the brim ; on the
contrary, it is rather perpendicular. One understands,
therefore, tliat the head placed perpendicularly at the
brim, the exploring finger, following the direction of the
vagina and of the inferior part of the pelvic caua), strikes
immediately upon the anterior parietal."
We will now examine the tlteoi-t/ of the coincidence of the
three a.res which Kuneke, Duncan, and others assume to
be true, an assumption which is the very foundation of
the objections urged against Noegele's obliquity.
■ Tnrnicr H Chintrenll. ■ Tnili ie I'Art de> AcKiacbdueiiU,' 188S.
262
THE MECHANISM OF U^ODB.
Kiiueke bases his assDmed refntation of Naegele upon
the description of the pelvis given by Bakker.* This
description and the drawing of it are nudonbtedly accarate, '
Bakker says : " Axis pelvis, qnalem proposuit Levret,
ad perpendicnlmn projecta per mediam panem conjugatfe
superioris incidit in os coccygisj et in horizontalem pro-
tracta facit 30", sive 60° cnni linea perpeadiculari. No-
tandam quod hacce linea coincidat fere axis uteri gravidi,
seu linea mediana, in quam colligantur vires expellentea
ah omnibus uteri punctis demissce, quarum directio
plurimnm facit ad partus mechauismura consUtnendum."
Bakker's description of the incliuatioD and axis of the
peh*is has received the sanction of Naegele himself .f Nae-
gele traces the history of the subject, shows that Hein-
ricb Von Deventer, Joh. Jac. Miiller, Smellie, Roderer,
Levret, Camper, Stein, and others have arrived at conclu-
sions upon the subject more or less approaching accuracy.
He then describes his own researches. He tells ua
that in a letter written to Froriep in 1810, basing upon a
small number of observations on the living, he described
the iucliuati on -angle of the brim as 55°, but after further
measurements he made it 59° — 60°,t That ia, he con-
linus Bakker, The figure he gives is well known, it
agrees with Bakker's.
After this description of the pelvis it is not without
surprise that we find so careful and conscientious a teacher
as Leisbman expressing the following criticism. " In
admitting the general accuracy of most of Naegele'a
descriptions, I assume that the fundamental error from
which more than any other his mistake arose, was igno-
rance at the time he wrote hia essay on the subject of the
great obliquity of tho brim in respect to the horizon.
There must, I think, hft\-e been i-emaining in his mind
some remnant of the old idoa of the horizontal brim, for
4
* ' Dcicripliu icuiii" |>c1vi> (rnilnliiRs' tlroniuiivu, 18K
t ' Uiu weiUicbcn Urckm lir|nir)il«l Lii B«ilohung auf leme Stclli
lie Kichtnng winei HbhW liM,
: 'Me<l..Clitr. Zd|UB|(,'IH18^*»<)'l>Mii»iUkli«B«k<Mi,-lSiS.
^^
run, tor ^H
cllaug unil ^^H
THE UECHAHISU OF LABOUR. 263
it must be reiuembered that hia attention was not directed
to the relation which the pelvis bears to the trunk and
limba until some years after the publication of hia paper
on the mechanism of labour."
But we have just seen that the views upon this subject
arrived at by Naegele from independent observations,
correspond closely with those of Bakker, upon which
Kiineke, Duncan, and Leishman base their own deductions.
Thus, Naegele began by establishing the true relations
of the pelvis, and then he, upon that knowledge, studied
the mechanism of labour. He did not jump from the
determination of the relations of the pelvis to conclusions
as to the mechanism of labour.
Tarnier's conjecture as to the cause of the error of
obseiTation imputed to Naegele seems to be the same as
that of Leishman.
Ail seem to agree then in accepting the accuracy of
B&kker's and Naegele'a description of the pelvis. It is
the basis alike of those who affirm and of those who deny
the lateral obliquity of the head.
The lirst divergence takes place in the strnctures built
npon this basis. Bakker, Eiineke, and those who follow
Kuneke affirm that the axis of the pelvic brim nearly
coincides with the axis of the uterus. But they give no
evidence whatever to justify this, the fundamental condi-
dition of their case.
Kuneke reasons thus :
The inclination of the pelvic brim to the horizon is CO"" ;
and, further, the ntems and its contents do not He perpen-
dicular to the horizon, but at about 30** of inclination.
Now since the direction of the inclination of the pelvis aud
that of the uterus stand in opposite relation to the horizon
and the two projected angles 60°+30°=90° or a right
angle, so must the third angle of the triangle resulting
therefrom be a right angle. Where the two inclination-
directions intersect at the brim-plane and so make a
triangle with the horizon, so also the vertical line of the
skall must fall perpendicular upon the brim.
264
THE VECOAKISX OF LUOEB.
I. The head-plane then (represented by its base) masj
also lie at 60° to the horizon.
Hence it follows —
1. That the sknll is absolntelj iacliiied to the horizon.
2. It is parallel with the brim ; and therefore Naegele*i
obliqoitT does not exist.
3. The law thns found is constant, and calls for u
deviation of the normal bearing of the head.
This is a strking example of the petitio principii.
The first point of Kuneke's argument namely, that th4
plane of the brim stands — the woman being erect — at an'
inclination of 60° to the horizon is beyond dispute. To
contest that the three ang;Ies of a triangle are equal to
right angles would be to contest a demonstration of |
Euclid; but to contest the conclusions based upon thts.1
elementary truth, namely, that, therefore, the axis of the
uterus and the aiis of the fostas must stand at right
angles with the pelvic brim, is not to contest a demon-
stration of Euclid, although these conclusions are put for«j
ward with as much confidence as any axiom or obvioiu;
corollary.
This assumed coincidence of the head and pelvic planes
constitute eyncUttsm. So presenting, the head progresses
in a straight line that is the axis, in what Kiineke calls
ortkophoric jirogreagUm. There is always, he affirms^
excess of room in the pelvic diameters to permit of this
direct progression.
When the basis o£ the head has cleared the brim the
head undergoes three different movements, namely, one o£
progression and two rotatory. The first or progressive is<
slso synclitic, that is, the plane of the basis of the skuU
maintains parallelism with the pianos of the pelvis which i
it successively enters. He describes as pelvic cavity all that
part of the canal which lies between the brim and outlet.
When the head has reached the fioor of the pelvis, and
is proceeding in its passage through the oatlet, Kuneke
parts company with Duncan, Leishman, and Tamier j io-.
short he stands alone. As we have already seen, he do(
1
THS UECHASIBH OF LAfiOUB. 265
not admit that the head emerges from the vulva obliquely.
He says those who affirm with Naegele that the head does
emerge obliquely are deceived by confounding two
BOCCGssive stages in the advance of the head. Thus
Kiineke is synclitic throughout ; others are synclitic as
far as the floor of the pelvis, and thenceforward become
asynclitic, and full in with Naegele — that is if I under-
stand them correctly — for some of their statements are not
tree from ambiguity or inconsistency.
This remarkable divergence of opinion, exactly at the
point where the head's relations to the pelvis are within
easy reach of the finger, and partly within sight, suggests
the presumption that if Naegele is right for the outlet, he
may be right for the brim.
Let us proceed to examine the facts as to the second
assumption, namely, that the axis of the uterus coincides
with the axis of the pelvic brim.
In the first place during pregnancy and down to the
very moment of labour the relation of the axis of the
uterus to that of the axis of the brim is certainly not con-
stant. The frequent inclination of the uterus to the left
or right is incontestable. In the second place, the
inclination of the uterus to the horizon differs in different
women, and in the same woman in successive labours, and
even in successive stages of the same labour, under the
varying relations of several factors, the most obvious of
which are :
1. The stature of the woman.
2. The attitude of the woman.
3. The length of the uterus,
4. The tonicity of the abdominal walls.
In primiparse of fair stature, the uterus is well embraced
by the strong abdominal walls which carry the fundus
back towards the spine. In such cases — the most typical
and most genuine to this inquiry — the uterine axis is
carried behind the perpendicular, sometimes to a consider-
able angle, that is, of 15 or more.
In pluriparae the abdominal walls admit of the uterus
THB UECHANISH 07 LABODB.
:i8 to "VI
ward
jeet- ^11
bagging forward from cotnoidetice with the pelvic axis t
a very considerable angle in front of it. This forward
baggiug is increased in women of short stature who cannot
find room for the mature gravid uterus except by project-
ing the abdominal wall.
But it is contended that when labour sets in the uten
becomes erect and then cornea into more direct relation!
with the plane of the brim. This is undoubtedly true to
some extent. But when the abdominal walls are brought
into play their action is to carry the fundus and body of
the uterus upwards and backwards towards the spine, that-J
is, behind the axis of the pelvic brim.
Then there is the inexorable law of accommodation, '
which compels the uterus to adapt itself more or less nearly!
to the convexity of the lumbo-sacral portion of the spinal ¥
column. The efiect of this is that the uterus is com- I
monly bent back, adjusting itself to the convex spine by a 1
posterior concavity. The uterine cavity, and therefore the I
uterine axis, is not a straight line, bnt a curved line, aa J
is seen in the figure, which shows what may be described I
as the " parturiejit ciirve,"
In 1868 Dr. Friedrich Schatz, of Leipzig, published an 1
excellent memoir on this subject.* He contends that the \
direction of the united uterine force is nearly that of the
uterine axis, and that it cleviates from this as soon as the i
greater part of the child's head has left the uterus.
Purthep, the direction of the abdominal pressure deviates
fi'ora the axis of the inlet by an angle backwards of lO"
or more. Again, the direction of the combined expelling ■
force can never be in front of the uterine axis, may I
rarely coincide with it, but almost always is behind it,
and so forms an angle with the axis of the inlet behind.
The uterine axis already deviates from the axis of the inlet
before the partial emptying of the uterus during bearing-
down pressure, by an angle of from 5° to 10° backward.
Now comes the third postulate : the axis of the foetus \
coincides with that of the uterus and that of the pelvic brim.
* > DiT OeburtimecliRnismiu dcr Kopfeodlngiiii,' 1868.
THK UBCHAKISM OF LABOUS.
267
Inasmuch aa the axis of the fcDtus ia, under the hypo-
thesis, governed by the axis of the uterus, it follows that,
if the axis of the uterus does uot nocessarily or usually
coincide with the axis of the pelvic brim, neither can the
A D, Axis of brim of pelvii.
Aba. Ad^U of divergence of nterina
fB. Plane of brim.
p C. Plane of caritj.
p D, PUne of outlet.
ff. Barnes' curve.
g h. Cams* carve,
PC. Parturient curve.
axis of the fcstas. Bat ve may go further, and we bhall
see that the axis of the child does not necessarily coincide
with that of the uterus. That is, the uterine axis might
268 TEE HECHANtSH OF LABOUR.
coincide with that of the brim, and still the axis of the child3
may stand at an angle. Not to speak of the decided devia-l
tions which constitute or merge into oblique or transverse
presentations, there must he numerous degrees of obliqait*
between these and the normal obliquity deBcribed bv{
Naegele.
Thus Schatz* found in Braune's section that the devia>l
tion between the pelvic extremity and the head of thel
foetus was measured by an angle of 30°j and between thBU
head and trunk on a line with the shoulders by an anglal
of 13°. The child's body does not represent a straight!
line. It is always curved, adapting itself more or lessl
nearly according to the presence or absence of liquor'l
amnii and other conditions, to the " parturient curve."
We may now safely conclude that the coincidence ctfl
the three axes is not demonstrated. And as it cannot be I
taken for granted, the cardinal point upon which thai
objection to Naegele's obliquity turns must be abandoned, f
The supra-pelvic portion of the parturient canal is curvedj',
and therefore the child's body must also bo curved.
We will now proceed to the study of the question by I
the examination of the anatomical and physiological facts.f
We possess two anatomical pieces of incontestable TaloeJ
those of Braune and of Chiara.
Braune's plates are taken from nature. A womaiijl
about 3oj drowned herself during labour ; she was a well- 1
built woman, her pelvis normal. The body was frozen I
and a section made. The head had entered the pelvio 1
cavity, and was in the second position. The natural rota- 1
tions of the head had begun, and the labour was at the ]
beginning of the expulsive stage. The occiput i
little elongated under the moulding process of labour.J
Braune points out that the uterus has its long axis nearlyM
perpendicular to the plane of the brim.
If we now remove the foetus, as Braune has done (see J
Fig.), we see :-^l. Again the angle, which the axis of.l
the uterus forms behind the axis of the pelvic brim =
' ' Archiv fur Of Dikologie,' Buid vi. p. 413.
L
THE MEOHASISM OP LABOUR. 269
7'50°. 2, If we draw two longitmliEal parallel planes
(a b) from promontory of sacrum to tip of coccyx, and
(o d) behind the symphyais pabis, we see that these planes
are not parallel to the axis of the brim, that is, they could
not receive between them the advancing head, and there-
fore the head must deviate from the asis of the inlet.
The head, descending under the promontory, must at
once deviate from the axis of the brim in order to find
room. At the stage here reached, the head near the out-
let, the uterine and foetal axes would be at their nearest
approach to coincidence with the axis of the brim. But
still there is not coincidence.
Reference to Braune'a figure shows the head in the cavity
and : — 1. That the axis of the uterus and oC the foetus
nearly coinciding form an angle of 12° with the axis of
the brim. 2. That the greater part of the head lies in
front of the axis of the brim prolonged to the pelvic floor.
3. That the anterior side of the head is at a lower level
than the posterior.
These features are even more clearly seen in Chiara's sec-
tion. The subject was a woman who, in her fourth labour, was
brought to the Milan Hospital, where she died soon after
admission ; the left arm protruded. The body was frozen
and section made ; the pelvis was quite normal, the uterus
represents a sigmoid curve, the " parturient curve " corre-
sponds ; the axis, which the axis of the uterus forma
with the perpendicular of the brim-plane, is 27°.
If we take the minimum conjugate, that a little above
the middle of the symphysis, instead of that from the
upper edge, we find the axis of the uterus falls at an
eren greater angle behind the axis of the brim, namely,
34°.
It is a characteristic feature of the true pelvis of woman
that it forms a decided curve. This curve is usually
represented by a circle, or rather a parabola, the centre
or centres of which are at the symphysis pubis ; this is
Caras' curve. Now, if we describe another circle from
the symphysis aa a centre, with a radios that touches the
272 THE HKCBANI8H OP LABOUR.
I believe, the main factor in produciDg the dorso-anterioi
sttitnde of the fcetus. The spine of the foetns firm and i
little bowed coming in contact with the lumbo-sacra
curve is necessarily deflected, and its yielding, incurveQ
anterior' aspect adapts itself to the Inmbo-sacral curve/
This property and disposition of the f cetns permit the con4
taining uterus also to execute a similar adaptation or monldJ
ingupon the lower part of the spine ; that is, to be carrie«
upward and backward behind the axis of the pelvic brim J
The true factor to consider is not the direction of thflf
oterus and fcetus, but the resulting axis of the drivinjp
forces. It may be true that this force-axis dependrfj
greatly upon the relation of the axes of the uterus and,
fcetus to the pelvis, but it is not necessarily identical.
We have seen that the axis of the uterus stands at ;
angle of more than 10° behind the axis of the brim.
Assuming that the axis of the expelling force of the utems
is coincident with its own axis, we have already a
deviation of 10° or more behind the brim-axis. Then we
have to add the driving-force of the abdominal musclea.J
The first action of the abdominal muscles is to push the I
uterus further back, increasing its angle of deviation. T
The resultant effect of these two forces is to produce aafl
axis of driving- force behind the axis of the brim. The!
pressure of the abdominal muscles telling more upon the 1
upper part of the uterus, thrusts this part especially baokf
upon the spine, and therefore bends the child's body inl
greater convexity forwards, that is, it increases thai
obliquity of the head as it enters the brim. This bending J
of the child's trunk will be more marked if the liquor J
amnii have escaped. If the head present at the brim with f
its biparietal plane inclining ever bo little — say at anl
angle of 5° only — it must infallibly, under driving-force i
transmitted along the fcetal spine, increase this obliquity, ]
the base representing a lever of equal transverse arms^r
any excess of force bearing upon one arm will lower thiaf
arm, that is, the bead will cant over on its side.
For the head to enter synclitically we have to imagine •]
THB MBCHAinaM OF LABODB. 273
two conditions : first, the he&d presenting in absolute
parallelism ; secondly, the driving-force bearing with
absolute precision npon the centre of tbe base of the
fcetal skull. These two conditions severally and com-
bined can hardly exist; and, in fact, wo have seen they
do not exist.
It resalts from all this that the utems forms a curved
canal, especially marked in primiparse when labour ia at
hand, when the lower segment of the ntems coataiuing
the head is lodged in the pelvis.
To complete the parturient canal we must then take
into account the supra-pelvic portion. We shall find
that each of the two curves, Barnes' and Carus', represents
an elementary part of this canal. The first merges into
second at the point of intersection in the pelvic cavity,
The resultant double or sigmoid curve is the true purtii'
rient curve. This curve the head and body of the foetus
must take.
The lower part of this curve, the iutra-pelvio is constant ;
the upper or supra-pelvic part is variable.
In proportion as the projection of the lumbo-sacral
curve, including the promontory increases, Barnes' curve
is more pronounced and the greater is the curve which
the head must describe in order to enter the pelvis.
The planes of the uterus and the other soft parts as factors
in determining the position of the head.
It the attention of those who have studied this problem
have been almost exclusively bent upon the true pelvis,
taking little or no account of the supra-pelvic spine,
scarcely has more attention been paid to the part played
by the uterine planes or valves. Yet the part these play
in the mechanism of labour is of the first importance. I do
not now speak of the driving force of the uterus, that, in
connection with the driving force of the abdominal walls,
has been considered. I now refer especially to what I
VOL. XXV. 18
274
TOE IfECHANIBM OP LABOUR,
Iiave called iu the ' Obstetric Operations * the upper or
anierior or ulerine, and the lower posterior or perinteal
valves or planes.
In primiparffi especially, the head often deecenda far
into the cavity of the pelvis before the oa and cervix uteri
expand. The anterior wall of the lower segment of the
nteriie contributes a much larger part for the accommoda-
tion of the head than does the hinder part ; it forms a
distinct pouch. The os uteri therefore is rarely found in
the axis of the pelvic brim, it is almost always directed
somewhat backwards towards the sacral hollow. The
anterior wall then cari'ied down before the head-globe,
although it may stretch out before the on-pressing head,
permitting the anterior side of the head to descend, still
acts as an inclined plane partly supported by the anterior
wall of the pelvis, and so guides the head at first back-
wards under the promontory, where there is accommoda-
tion for it. This anterior plane acts especially when the
equator of the head has passed the brim. In fact, just as the
posterior wall of the uterus, supported by the lumbo-sacral
curve guides the head forwards to pass the extreme point
or cape of the promontory, so this anterior wall then takes
up its function and guides the head under the promontory
which is now doubled. The resistance offered by the
posterior wall of the lower segment of the uterus when
the head has entered the pelvis is rarely considerable. It
has commonly retreated before the anterior segment has
slipped up above the occiput. This stage reached, the
head immediately encounters the posterior or perineal
valve, that is, the floor of the pelvis. The influence of
this valve or plane has been more generally appreciated.
Hart especially has dwelt upon it. It takes an important
share in changing the dbection of the head into the lower
part of the oibit of Carus* curve towards the outlet. Thus
to summarise : — The posterior wall of the uterus supported
by the extra-pelvic part of the Inmbo-sacral curve directs
the head obliquely into the brim, through the upper part
of the orbit of Barnes' curve ; then the ant-erior uterine
THE USCHANISH OP UBOtTB. 275
valve directs the head backwards under the promontory
through the remaining part ot Barnes' curve ; then comes
the perineo! plane into play to direct the head forwards
under the symphysis pubis in Cams' curve.
We may thus see in the mechanism of labour at the brim,
the counterpart of the better understood mechanism of
labour at the outlet. If there is obliquity of the head at
its exit there will be, from the operation of analogous
causes, obliquity at the brim.
We may now better appreciate the theory of " ayn-
elUitm," which lies at the root of the doctrine that the
three axes coincide.
The best idea we can form of eyncHticism is to take
for illustration a pump or syringe. Here we have a disc
accurately fitted to a straight cylinder set at a right angle
to the axis of the cylinder ; the disc itself thus represents
the plane of each part of the cylinder as it moves up or
down ; there is perfect adaptation of the moving to the
containing body, the driving force bears with constant
exactness upon the centi-e of the disc, and there is eqnal
uniformity of resistance to every part of the circumference
of the disc, that is, there is stable equilibrium.
Now, if we suppose a cylinder that is curved, whose
planes therefore are not parallel, whose diameters are un-
equal, and then that there is applied to such a cylinder a
disc that is irregular in shape, that does not exactly fit
the cylinder, and that the dri\-ing force, which represents
the rod of the piston, is not set in the centre of the disc, and
is moreover set into the disc by a pivot-joint capable of
bending in any direction, it must be obvious that there
can be no stable equilibrium from the moment that the
disc is made to move. If we suppose what is difficult to
realise, that the disc stands in parallelism with the plane
of the mouth of the cylinder, the moment driving force is
applied the disc will encounter an excess of friction on one
^ide, that is, the equilibrium is destroyed, the disc will
cant ; there is asynclitism.
Without straining this comparison, we cannot avoid
276 TBI ncKunsa ow liboob.
Tccogmaag analogotu conditiooB in the pelvis and foetal
head in their reUtkois to each other
Again, we find that in labonr ihe driving-force is pro-
pagated throngh the child'^ body, that is, throa^ ■
flexible rod, which acinally bends.
Taking all these things together: a carved oanal, of '
Tarring calibre, not cylindrical, a travelling body of irre-
gnlar shape that has to adapt itself to the shape of the
canal, and a driving-force transmitted through a flexible
rod not set ceDtrally in the travelling body, we hare a
EnmnutiT' of the conditions of the problem. Under such
conditions it woald be marvelloas for synclitism to exist
or endare. It is hard to imagine, still more to prove,
Buch a happy concnrrence of compensating conditions a^
will eonnteract the inevitable tendency to obliqnity.
I take the alternative view to Xaegele's, as stated by
Galabin :* — " The alternative view, as maintained by Don-
can and others, is that the head enters the brim directly
with its vertical diameter at right angles to the plane of
the brim, and maintains this position in passiog through
the first half of the pelvic canal ivhose shape is ahnoat
eylindrical." The error of this is palpable. The first
half of the pelvic canal is not nearly cylindrical. If we
compare the outline of the brim with the ontline of the
cavity we see at a glance that the brim forms a heart-
shaped strait, whilst the cavity expands with a nearly
circular shape. Moreover the circumference, and there-
fore the capacity, of the cavity exceeds that of the brim
by about an inch. It is, as 41'o0 cm, for the cavity to
39 cm. for the brim, or as lo-SOin. to ]4-60 in.
Dr. Galabin further illustrates this point by showing
that " the sacral promontory lies within the circumference
of a perfect circle equal in area to the pelvic brim, whilst
the symphysis pubis lies outside it."
We will now examine Me shape of the head. And we
must take the head as it ia found above the brim before it
hag encountered any moulding from the forces of labour, j
* Obstetrical Triaractions.
THE MECHANISM OF L1.G0DR. 27?
Naegele, as expounded hj Kigby, maintains, as we have
seen, that the head assumes the oblique position in order
that the greatest transverse diameter, the biparietal, may
not be brought into relation with the diameter of the
pelvis which the head enters. Kiineke objects that there
is always plenty of room. Duncan says " theve ia no
appreciable gain from obliquity." Leishman puts the
" cui bono." In the first place, Kiineke's statement is
at once disposed of by the fact that the head can rarely
enter the brim without moulding, that ia, there is diffi-
culty. In the second place, actual measurements of the
foetal skull prove the fact that the diameter obtained by
Naegele'a obliquity is less than the biparietal. Dr.
Galabin shows that a slight lateral Hexion "of the head
will diminish the diameter of the head presented to each
diameter of the brim. He measured heads and found
that, measured at au angle of al)out 20" with the biparietal
between two points at equal distances of about "6 inches
above the left and below the right parietal tuba, this
diameter was in all cases less than the biparietal. It
was much greater in a head which passed last and had
EufEcred no distortion." Thero is, thus, an immediate
advantage in a flexion of nearly 30 .
This observation I can confirm by numerous meaaure-
menta taken with care. It is in accordance with what is
ob8er\'ed as the effect of labour, namely, the biparietal
diameter is somewhat levelled down by moulding.
It is very true that the extreme biparietal diameter can
hardly enter exactly in the conjugate diameter. One im-
mediate effect of the hinder parietal protuberance impinging
upon the promontory is to deflect it to the left ; and this
turning aside is attended by a deflection slightly upwards,
that is, there is canting of the base of the skull, its fore
side bending downwards. Thus the smaller dimenaiona
of the head are brought into relation with the smallest
diameter of the pelvis by the double obliquity, that of
Solayrea and that of Naegele ; the one is sb necessary as
the other ; both being in obedience to the law of accoin-
tl»
]
Tkete
pn^t^iim *A Urn fmm a mmj,
ugmt aif/nt Z!t, who M turn, bai beiote bbovr, (
mm'U. Tlw VmI/ wm boMS aad netioB nade.
IVM sliffbi M»l»ofii. The tnu eoi^agato m e aawa
ff & c«nl. Tlw nwdtsa ooDJagBte 12 cent, ometiBSBilf
IIm i:hj\ij i4 Xit» pelrii expands in tbe antero-poBtenor
lUtmlU/n nuurlf i>at> foartb in excem of the brim ; mad
tlilit iiMpitnnUm in almoMt onttroly formed under tbe jotting
yrvnutntoty.
To im«« ill)) tip[>{>r ntmit., tho bead muRt enter obliqnely.
Tlid [fiiritilal liuiiu ii[i[jliuil to tho prumoutory is so forcibly
iiiiiii|)riiiiNiiil ntfftiiiMt it llial a Hnltcniiig depression or
liiil"iilitiK in iiivnriiihly olinorvud under Himilur conditions,,
wliilib Hid |iiiljitl puHolitl cummonly prosorvea in a great
ilnKt'oti itii )iriirinl glinpo. Tlio mtianing <jf this is obvious.
Tliti itlilo iif llui Imml wliioli IIoh iigainat tbe promontory
U Um iiiin'o llxpd of Mil) two ; tliodriviiig-fort-e will there-
IiHH lii|| l!H>i'it ii»liiii>inlly H|H>u tho otiior end of the trans-
viiv«ii h*i»il-li>vi'r 1 »nd, thwri-fort', this end, ibo pnbal aide
will liinVt' diiwii lull) Hip jielvio cavity first. As aoon as
\\\\> vi\\viiiw '>f lliv litmil liM I'lvArtMl tbo brim, tho rotation
wt (hit \\i<in\\ ttil it* \\.\n\t nxia ta iuoreaaed ; the head becomes
■till tHttiv M«,VM>'U|ii> M tho hind»r sido rolls np under the
)W\s]««tiiH|t )tr\Mt»^Htvtv,v <whw« il finds flcvouiuiodatiou.
Hi^ttwU )«>mtli out thitt lh« i\>t»tion <.>f the head on its
l>sV\g ft\u >iv iw lb* trftn»v(*rw> axis of Ibo pelvie, is not
lh«i i-M^V (VMRMt «H,v lh» «nt»nor pMWal is deeper than
tW t*><"t«^'*<^ Iwt llmt it «l»o dips Kxnvr on account of
(H ».'V«s\itv *>t h-wii, lb* Mcntl wdt' bviu^ more flattened,
«> iWt lki» W<n«) tMmprHsnn of tb« b««d resnUing in
«k<)i^|<MtsMt itMMtdmtir aidvof UwbcBd is more elongated
Kfi
THE aiBCBANISU OF LABOUR. 279
than tlie other. The like condition ]ie adds obtains iu a
lesser degree in the frontal bones. This ia well shown
in Branne'a figures (CD).
Obviously, this greater descent of the anterior or pubal
side of the head takes place mainly as the head is passing
or has passed through the brim. Still this observation
of Schatz brings strong evidence in support of the theory
of primal lateral obliquity of the head.
In the lesser degrees of conjugate contraction of the
brim which admit of delivery by the forceps, the line of
traction is more distinctly behind the axis of the pelvic
brim than in uormal labour, What is called " axis-
traction " in such a case means traction well behind and
ander the jutting promontory in order to bring the head
past it. The head makes a semi- I'e volution within a
smaller sphere ; the sacral side of the head describes a
much smaller circle than does the pubal side ; it is the
more fixed, whilst the pubal side moving more easily gets
lower in the pelvic cavity. It is for want of clear
apprehension of this that the opponents of Tamier's
forceps continue to trust to imperfect instruments, of
inadequate length, and wanting the perineal curve, and
thuB bring vicious pressure upon the anterior wall of the
pelvis, running the dangers of injuring the bladder and of
failing in delivery.
The lower relative position of the anterior side of the
head when the head is on the brim, is demonstrated by
the impressions made by the blades upon the head. If
the forceps be introduced as I have taught — I am not now
defending this teaching — the blades are passed up one
on either side of the pelvis, and so they adapt themselves
to the head. When adjusted, the blades lie in the oppo-
site oblique diameter of the brim to that occupied by the
head, and grasp the head also somewhat obliquely, so
when the head is delivered, one blade leaves its impres-
sion on the anterior quarter of the parietal and adjoining
part of the frontal bones, the other blade leaves its
impression on the opposite side of the head, that ia on tha
MiWr^^/ '^li^ ml\l t* fcl— id *P affW C fc J I M i W MB jhehiie
v4 til* psal«mr U»ae. H^ »
Aa ..e m4» 111 At hmi «w k«er at Oe
ili. r«ts*< «tfB *e vdwr, daft M, tiw he^
J« U«« mwfaMwa vf IaImv Mth Iwd lw< t^3d, ma in
t/r«*^ |ir«MM«U'Mu>^ «r imimBg, ve ftod fairtho' illiuCia-
tmi >4 tlui atNUW thmut. In • trvU^^nned pdvis ind bead
f/ WAtC'lj, wtuNj t)Mi tMM4 lA tti^ LmmI nf/prxAcite* the brim,
it irHA."/ijuUm tliw rMutioff forward iucline of tbe lumbar
»|i)»w i tltu •lil« uwrot ihu iiwlint impinffeti upoa it, and
uttciiHtil-uvnuf a gieaUtr 'i«|fr£e of friction than ie
iiliii"Mli''<'ruil hy t,\ui atitorior »)■!'} (4 the bead — which finds
Uw Qimvut Nliall'tw u( Ilia anteriiT boundary of the brim
rutidj' III luoiifvii it — iiiuvo* moro nlowly; and bo the
frfliUl miilu, ruviilviuif uutra frouly in a larger circle, dips
mill inititl'N lllii lil'iui, thu biiHti proioQting a cant or
Mlilli|iiit}. If wu nm (iallud upon tu attNiHt the deliver; by
Iriiuliolti Wu Hud thai, aw with the foroopa, the line of
tmi'tinu lutiol, i( Wo wmiUi uconomiiio force and minimise
iVaUUtUnti, \>v dl)-uiiti>d liuukwavda iitidor the promontorj',
UtH^ U) ill IttivitUM' oiii'vo. Tldii ia still more uecessary
wlivu thuiv ii iH>uti-«otii>u <>f thd britu.
lu m»<.» v>( liiMnd-Uai laWura if the he^d is of moderate
Mv Kud iiw \v\vi» i\MMuy, lutd thia ralo of Inctkui be
J|ll\|)v^^u*l,v t>ttM>rvv4> ihu h««d uwy oune tluouglt wiib
llUK> V* iw wottkivu^, thwl Ui it iu«^ pnaaat its original
t^vi'iMl htiu U\t1 if th<«« cvuUiltgtts b« vM pnaaol,
MUtt v'^ttw^uUl^v if iHo ^ia ia i.x>uW*oto^ 4«a tkm aide oC
VW h^sl u<Miv«4 ibM ^iIviiivMmj b aao M M hMwad «r
|uUm.^<.1. •^'^''->.^ vvUjhwi.'O M otlMMf ■» WWiM att iipwi Bti a n .
I ib«t tb« wHftl aidb gf tbe kemi. b^i
1
. u i>I: it^ifiMliBC to m t kn Innt n ~mrf
THI UECBANISM OF I^BOOB.
281
greater expenditure or waste of power and diminisliing the
chance of delivering a live child.
As we advance to the more decided cases of contraction
in which it becomes necessary to perform craniotomy, we
still see evidence of the work of the same law. The pro-
montorial projection being mora pronounced, it overhangs
the cavity of the pelvis, and so the entering part of the
child is compelled to revolve sharply backwards. Hence
the importance of an axis-traction crantotomy-forceps or
cephalotribe on the model designed by Dr. Fanoonrt
Barnes.
^ We may now see how far the objections which have
been brought against Naegele's doctrine have been stutuined.
These principal objections may be stated aa follows :
1, The fundamental objection urged by Kiineke, and
relied upon by Duncanj Leishman, and others is that the
three axes of the plane of the brim, of the uterus and of
the fcBtus coincide. This we have seen is a fundamental
error. The axes do not coincide.
2, Subsidiary to the first objection ia the assertion of
Lcishman that Naegele was ignorant of the inclination of
the pelvis to the horizon. This is in direct opposition to
Naegele's demonstration.
3. That the obliquity in question is not observed.
Duncan afBrming that " Naegele fell into error from not
making the observations relied upon at the brim of the
pelvis, and then only." This is simply an arbitrary
assumption. Naegele expressly says that he kept his
finger on the presenting point at and from the beginning
of labour.
4. That it is impossible to find a mechanism to account
for it (Duncan) ; that it would answer no useful purpose
(Leishman) ; that there ia always present plenty of room
for the head to pass directly (KiJneke). These objections,
in fact, resolve themselves into the same thing. We
have seen amply adequate meclianism in the form of the
parturient canal, in the jutting promontory, in the narrow
conjugate diameter of the brim, in tho expanding cavity
262 TRI MI0IUKJ8M Of LABOUB.
pf the pelvis lt«low the promontory, in the shape of the
henil, and in Ihe tuition of tho ntEirinG plani^a. We have
Bwn thnt the lieml is widcgt itt itH ))i[iari(^tal diameter, and
DiHi a i<lpar gain is olitained by Bnbstituting the oblique
Biilip»noto-Bn|n>riiarii'lal dinrnotiM' ((Jahibin).
fi. Leinhiniui ni'ges against Naegeto his statement ttiat
" the lijghei- tiie hend io, tho nioru ublitjue in its direction,
for which I'OHNon t)io ear can generally bo felt behind the
jHihes without difficulty, which ct-uild not bo tho case if
the head hnd a sti'aigtit dirt^otion." Wu might grant that
the oblii|uity is nut greater in proportion to the height of
tlio head, still it wnuld not follow Lhnt the head ie not
iib1it|iic at the brim.
tt. 1'lio sitiiAtion of tho caput sHCCCiJaneum as seen
Bftor birth, in-roked by Naegele, is objected to because
this swelling v»rio« noeording to the stage of labour, so
thnt what is produced at the end of labour may be mis-
taken KB the product of c«uaos acting at the commence-
Micnt. There i« some force iu this ailment, but still it
w not contended that tlie caput sucoediuieutn as usually
obffervi?d is iuoonsisteut with JJaegcle's theory, and I
nnbmit that, hftvtng made oarcftil observations upon this
(Kiint, both in propitious labours and in labours effected
mainly by t*ie fopocps, I am in a jjositioa to affirm th«t
the head seired near «tr on the brim has been broi^t
thiMugh the pehHs, }>reserTing the c»\mi succcdanenm as
11 OMginally formed over the nght mb«r and posterior
angle of the pariet*!, no complioaiing ch«ii^ subsequently
occurring,
ThroQghotit this inquiry 1 have not thought it neodssary
to do more than touch incidenralhr npon the evidence
that, might be dra«^ from direot claiic»l i>beervaticjn.
The directlj' eontradictorj^ testimony borne by different
obsm^'on, soin« affirming ihat they have frh ihe head
prow>nliag oblii{a«ly, ethers ibM it never does, is enoogb
to prow the diffio»lty of nettling the qaesnon in Has way.
ThoM> ^-ho affirm will probably oostinue to affins ; du»e
who denj- vill ooMJuoe lo d«ay. It might be oi^ed that
THE UECHANISU OF LABOliE. 283
those who deny, howsoever competent they may be to
deuy for themselves, are hardly competent to deny that
others have felt what they themselves could not feel. Bat
in the presence of the difficulty of reconciling conflicting
statements as to subjective perceptions, it is obvious that
the most philosophical mode of inquiry is to examine the
anatomical, physiological, and mechanical factors of the
problem.
I have purposely limited this inquiiy to the position
and movements of the head whilst above the brim, in its
passage through the brim, and in its course in the upper
half of the pelvic cavity. To have extended the inqairy
beyond this would have been to weary the Society over-
much ; nor is it necessary, since there is almost universal
consensus of opinion in favour of Naegele's description
froirLthis stage onwards to complete delivery.
,^1 therefore suhmit the conclusioiis :
1. That Naegele's obliquity ia a real, and probably
nearly constant phenomenon in natural laboar.
2, That it is a necessary result of the combined action
aud relations of the factors working in the mechaniBm of
labour, namely, the lumbo-saciul curve ; the adaptation of
uterus and fcetns to this curve through the backward
pressure of the abdominal walls ; the consequent throwing
back of the fundus, and therefore of the axis of the
uteru8 behind the axis of the brim of the pelvis; the
jutting of the promontory forwards contracting the con-
jugate diameter below that of the biparietal diameter of the
foetal head ; the consequent facilily gained for the head
to enter the brim by the substitution of a lesser or oblique
diameter ; the expansion of the pelvis below the promontory
to a nearly circular form, compelling the head in obedience
to the law of accommodation to adapt itself to the space
under the promontory guided by the anterior uterine plane.
The Presidhnt felt sure he was but eipreasiiig the general
feeling in tendering the thanks o£ the Society to Dr. Bamed
for Ma erudite, iuteresting, and imttortaut paper. In hie
own earlier years, influenced much by the teaching of Dr. Tyler
TirK UBCIIitlltlll or LABODB.
win iL rlfi(u> follower of Nnagele anil Kifthj. be
> liriiii <iUii|iiit.y ; after a while, influenced by the
IniU* ut' Dr. Duiicim uinl of Tji-iMlimaii, he held this view
III )■>', ril: III! Dvctiti, uiiiirovi'd. But after hearing Dr. 0£ila,bin'§
viiliKiM" nu'innir on tb« mihject itomo years ago Ue had come to
thi' conoliHion Ihat in the ease of a tyiiicnl well-formed pelvis
iind himJ of averiini) kIeu the heiul entered the brim i>erp6ndicu-
liirly 1.11 1.hi' j'laiie of the Virim, that indeed there was no object
III \i» oiittU'iii^ ill any other way j but that where the entrance
ijf the liulvi* wan modified by any undue projection of thepro-
iiioiitoi'V, even the ilighteit, new oonditionB prevailed, and thei«
Wi'illtl oil a Rain by the tuibstitution of the eub-parieto-Buper-
arielnl tlinmetor for the traiiBVcrse, which would be attained
V thi< Utortil tiltin^t which occurred in the obliquity of Naegele,
'I'Utiy were furtituute in linrin^ inosent this ovening in Dr.
|)iii»'iiii one of tho chief exponents of the view that Naegele's
K erroucoui, and lie could only hope that the result
iMRioii luiirht Im to ptaco the matter finally at r^st.
Hi'fiin> Hitling down iw might perhaps l)o allowed to express the
^ml ill en I ion ho vnw certniu wiut fi^lt by all Fellows present at
pr^>iiiil Dr. Wilinliiro again auioug them after his recent severe
tlluoM.
Vr. MiTTMSwa DvNci.N rcptnlcil it as very desii&ble todiacusa
luid Mltlu till! iuiH;haui«a) of delirvri' in lu^ral labour without
MOK r«tw«uco to thu ot ubiMtunu Ubour than was neoessaij
lor th» atwl; ot Uw ronuer, utd b« lewded the two as having
JVIJ llttk in conunon irith a mw to na^le's obliquity. To
Uk%**rum ot tht faW piuiuoutory" or Barnes's curve, to which
lib* author gan aa iin)M>nani i^^. be (Dr. Uatihews DttBcaii)
ItmtM gi*» WMM al all in uatund parturition. In the ordiaarr
Aht imVia th* Inad lollowwl the lower part of th« cvm. and in
ft MMT whkh h« (Dr. Uat>b»ws D«»oan> nad to thk Soaetr in
lin ^0« tk» lUfTClntioM o( ^ IVBtal HmmI in paniM tkcwigh
ft Bnh MMnMed oftljr in Uw Ooftjvgal* tHamUKi* he had
' thia MrnvMrt. Bat ^ mm amwMa oC the
ift dMww of ^ Kacfcb «hfiqaitT at Oe hna m eaitj
Smv ift Mlund MMOt asd to thai aloiw
atMAitw. Ift A lh«i» ««»ald Mt W oyccled avvthng fHx
aMtlMwUhal MOWtMwa. XT* tmUi «■!; dwtwc the aattcr
(!iNM|««at»v«tr ^N■chtT, dirirt isnMMM hcMie. «( eona^ anw
(««• and MMlaalt^r otcftmif . Hw, it «•> Mid that the rieht
Mrirtak ift Mt au iy ft airt ii i w i mu IiiiI the hris Wte«
tWMti«»dt^«MftManw«(«te(nBtMft. VeiknddMK
J
THE HBOHANISM Oy LABOHH.
285
In confirmation of the occurrence of Naegele obliquity state-
ments had been made regarding tbe caput euccedaneum. Kow
this also was matter of factj and he would assert that in earlv
labour it was not the case, as atated by the author, that a caput
succedaneum was formed upon the upper and posterior part of
the parietal bone. A caput succedaneum of this stage was over
the vertex. The head had not yet flesed, and it was only in the
advanced second stage that a caput succedaneum was formed on
the upper and posterior part of the right parietal bone. The
caput succedaneum of the first stage of labour was the only one
that threw light on this matter ; it was upon the vertex, and
could not be made to support, only to oppose, the Naegele
obliquity. It was where it should be if the head entered syncli-
tically with the plane of the brim.
In describing his views Dr. Barnes had sjjoken of the posterior
wall of the uterus pushing the posterior side of the fcetal bead,
and of the anterior wall subsequently pushing the anterior or
right side of the head. Such description Ee (Dr. Duncan)
thought entirely erroneous, and without any anatomical ground
whatever. The uterus acted as a whole, not one part of it at a
time and then another part. Besides, even if one psirt acted while
the rest did not that would make no difference, for the acting
part would tighten the whole dome, and produce as a resultant
force the name propulsion as if all acted at once. Besides, even
if this view of Barnes's as to the action of parts of the uterus
were correct it would not ex]>lain the Naegele obliquity.
The author had truly said that a cardinal question in this
subject was the coincidence or noncoincideuce of the axis of the
brim of the pelvis, of the uterus, and of the fcetus. While Dr.
Barnes adopted the view of Schatz and others as to a posterior
obliquity of the uterus and fcetus, he (Br. Matthews Duncan)
held that tbey were, if not with mathematical exactness, yet
practically coincident. On this point Dr. Barnes had appealed
to the sections of Braune and Chiara as giving incontestable
evidence. Kow be (Dr. Matthews Duncan) thought their
evidence on this point was misleading. If the drawings of these
authors, most valuable and admirable in many respects, wore
examined it would be found that tbey were not faitnful repre-
sentations of the state during life. This was shown by the
position of the intestines in front of the nterus, the flattening of
abdomen, and the downward displacement of the perineum.
But he (Dr. Matthews Duncan) regarded the evidence of
Braune's drawings as in favour of the coincidence of the axes of
the three — uterus, fcetus, and pelvic brim.
During early labour, when the ovum had descended, and the
base of the skull was passing the brim, the abdomen already
partially emptied, the uterus proper partially emptied, this
organ was free to erect itself under pains, assume a dome-like
«iA Ast of tfe fataa. OftUs
> wmmm ta AmU. II «m the
t VM Hacpde'* ofmaom. It «bc
M-4wB M&a of the ncd maadtm fcttmed the aotnior
flattcoed. TU>,itns alkge^wBs done I7 eontmctiou of the
ncd iBBedMi Ifov tin* CBor ms the nsolt of mn inconplete
view «C the bcsrii^-dowB action. It waa effected br the woiiii^
vt a dMBe as eKtanre aa the nlvita itadf. Of this actire done
the teet) mmelea Conned a part, bat the cnna of the diapfanigiB
and the whole of that maMle acted nmnltaneonalj as wdl. If
the recti acted alone then vould be flattening of the beUv ; but
bearing dovn waa am aetioa of a whole dome snpportnig the
BteniB and aanstiBg it, and increasing tbe genemi contents
presrare of the ntenu proper. This dome was not all in contact
with the uterine dome, bat directly or indirectlj it all acted on
the uterine dome proper.
Dr. 6AI.ABJX said that eight rears ago he had advocated
before the Society the doctrine of the Nae^e obliqoitr being of
not tmfreqaent occurrence, though some of the chief obstetric
autboritiefl were opposed to it. He was glad to find this view
supported by the great authority of Dr. Barnes. Spiegelberg
nl»o described a Naegele obliquity, though Dr. Galabin was
unable to undeTstand the cause to which he ascribed it. Differ-
ing somewhat from Dr. Duncan as to the matter of fact, he should
say from his own observation that Naegele obliquity was not un-
frefiuently observed, not indeed in easy labours, but yet in cases
which could hardly V« regarded as other than normal labours, in
which there waa no pelvic deformity, but the head met with
considerable resistance. He ascribed the chief effect to the
lateral pressures on the head in the pelvis when the parietal
tubera were prominent and firmly ossified, If the demonstra-
tion which he had attempted to give in the diagrams presented
that evening were correct, even the pressure of soft parts near
tho ends of the biparietal diameter might cause lateral obliquity.
A bead with a large biparietal diameter thrown exactly across
tbo genital canal was in a position of unstable equilibrium, like
a bead in a position of brow presentation with its maximum
THE UeCBAIflSU 07 LABOITR.
297
men to- occipital diameter thrown exactly across the canal. The
head could never possibly pass through the canal in a positiou of
brow presentation, but alwaya became either flexed or extended in
its advance, and it very rarely even became arrested in such a posi-
tion (only twice in more than 35,000 cases in the Guy's Hospital
Lying-in Charity). So with the biparietal diameter when larger
than adjacent oblique diameters. But after moulding and
fiatlening of the tubera it was often no longer larger, and the
pressures then tended to resist and remedy biparietal obliquity.
In the third diagram handed round it was shown that, when
the head was arrested above a brim too small to admit the
biparietal diameter, not only the displaced propulBive force but
the resistances tended to increase latersj obliquity even beyond
the point at which it secured b. mechanical advantage, and until
it was checked by the neck meeting the uterine wall. He
thought that this agreed with experience, for he had sometimes
found the sagittal suture within an inch of the promontory of
the sacrum with the head arrested above the brun. He could
not quite understand how Dr. Barnes considered that obliquity
of the uterus had an effect. It appeared to him that posterior
obliquity of the uterus in reference to the axis of the brim
would produce opposite effects at different stages. Before
resistances were in action, and so far as the head accommodated
itself to the position of the trunk, tilting of the fundus utori
and breech of the child backwards would tend to tilt the sagittal
suture /onoarrf, and produce the opposite of Naegele obliquity.
When resistances came Into play, however, the opposite effect
was produced. The component of the propulsive force resolved
perpendicularly to the axis of the brim, pushed the condyles
f&rusard, and produced a reaction of the anterior pelvic wall,
pushing the centre of the head backward, eo that a "couple" or
pair of equal and opposite forces vras produced, tending to cause
Naegele obliquity. He did not think, however, that ix>sterior
obliquity of the uterue was nearly so great as might appear
from frozen sections. Besides the prolonged effect of gravity in
the dorsal position on the relaxed uterus, these showed tlie body in
a position of expiration, whereas before a bearing-down effort a
deep breath was taken, the diaphragm descended, and so threw the
fundus uteri more forward. But if the effect were mainly due to
the resistances a very slight posterior obhquity of the uterus would
be sufficient to determine that Naegele obliquity, and not its
opposite, should arise. And he thought that in this Dr. Barnes
had probably found the correct explanation for many cases.
He had pointed out in his former paper that, with the head in
the first position, posterior obliquity of the Uterus would pro-
duce Naegele obliquity, and the usual right obliquity would
counteract it, when resistances were in action ; and bad suggested
the inference that in cases in which Naegele obliquity appeared
THB HECHAN18M OP LABOCB.
too great to havo any meobanieal advantage, it might be a good
plan to plac« the woman on her right side, and ao encourage the
right obliquity of the uterus. He could not accept Dr. Barnes's
account or the action of the anterior uterine valve, for he did
not think that displacement of the os uteri backward was a
regular occurrence, although in occipito- anterior positions the
anterior Up was pushed in advance at the stage when the occiput
had not quite escaped from the os. With this exception he
thought that the anterior lip was generally most noticeable
merely because the examining finger was introduced nearly at
right angles to the axis of the uterus. The effect of obliquity of
the uterus in causing lateral obliquity of the head was only in
operation so far as the propulsive force was transmitted through
the condyles. The force transmitted through the liquor amnii
still retained (the so-called "general contents pi-essure") always
acted in the axis of the part of the pelvis in which the head was
engaged, independent of any obliquity of the uterus, and had no
tendency to produce lateral obliquity. This might be one reason
why lateral obliquity was not observed in easy labours.
Dr. Champneys had intended to make the same comment on
the eflect of posterior uterine obliquity on obliquity of the head
as already been luade by Dr. Galabin, viz. that its first effect
should be to produce jioglerior instead of anterior obliquity of
tbe head. He would also add that the condition known as
pendulous belly, or " anteversion of the gravid uterus," was
generally recognised as a cause of exaggerated Naegele obliquity.
It would therefore need explanation how it came to pass that two
opposite conditions (anterior and posterior deflection of the
uterus) could produce the same immediate effect, viz. anterior
parietal obliquity.
Dr. EopEB remarked that the unsettled question of Naegele's
obliquity of the ftetal head, though possessing great interest
in a physiological and scientific point of view, had not much
importance in actual practice. The oblique transverse diameters
of the head, as measured from a line drawn from a point above
tbe parietal protuberance on one side to a point below the pro-
tuberance on tbe other side, were less than the direct transverse
diameter through the parietal bosses ; hence a slight advantage
would be gained in facilitating the head through the pelvic brim
by tbe obliquity of Naegele. In the case of a contracted con-
jugate Naegele's obliquity (if admitted) would be of very small
Talue, Other obliquities are here of infinitely greater import-
ance, as the substitution of flexion of tbe bead for extension.
The mechanism of this movement bas been well described by Dr.
Goodell.
Dr. Barnes, replying, expressed his gratification at the atten-
tion the Society had given to his paper, and his acknowledgment
of the spirit in wbicfa it bad been discussed by the several
TUB UeCHlNISM OF LAROUB. 2o!^
speakers. Dr. Duncan thought the curve of the promontory,
howsoever important in the case of " the curve of the false pro-
montory," was not important in the case of the normal curve.
Dr. Barnes, however, held that it was simply a question of
degree. The condition vras present in all cases. With reference
to the action of the posterior wall of the uterus. Dr. Barnes did
not contend that it acted by any special force, but mainly by
forming an inclined plane resting upon the liimbo-sBcral curve.
It guided the head downwards and forwards in the upper or
extta-pelvic portion of Barnes's curve. Dr. Duncan contended
that for " practical purposes the three ams coincide ;" but abso-
lute coincidence was necessary to produce perfect synclitism
the slightest deviation of the uterine or fcetal axis from the axis
of the brim was enough to destroy synclitism. He did not
insist upon any particular or large angle, an angle of ten
degrees or even less vas enough to cause obliquity of the head.
Dr. Duncan held that Braune and Chiara's figures were not true
representations of nature. It was true that, as Dr. Oalabia
pointed out, the bodies were frozen after expiration and after
lying in dorsal posture, but they were still essentially true; they
were drawn from nature by consummate artists i the condi-
tion of the soft parts at the outlet pointed out by Dr. Duncan
had no bearing upon the brim of the pelvis at which part the
interest centred ; the figure especially objected to by Dr. Duncan
was one of contracted pelvis shown simply for the purpose
of contrast; the other figures of normal subjects showed the
presence of space for the intestines behind the uterus. As to
the erection of the uterus. Dr. Barnes had referred to this in his
paper as tending to bring the uterine axis into coincidence with
the axis of the pelvic brim ; but he maintained that this co-
incidence was not efTected ; he knew of no evidence to prove that
the crura of the diaphragm contracted in such a way as to drive
the fundus of the uterus forward, certainly the diaphragm could
have no jwwer to resist the powerful contraction of the abdominal
muscles. If we took note of the direction of the force exerted
in the act of turning when the hand was introduced into the
uterus we should find that the line of traction waa necessarily in
a lino with the " parturient curve," that is, behind the axis of
the pelvic brim, and that the traction was performed at first
downwards and forwards to get into the pelvis, then round the
promontory and backwards. Dr. Barnes was especially pleased
to find his views found support in the researches of a wrangler ;
Dr. Galabin had indeed anticipated him in some points. The
observation of an asymmetrical bead found on Caisariau section
by Budin, referred to by Dr. Wiltshire, Dr. Barnes thought
must have been an example of malformation. In the children
delivered by the section be himself had seen, as well as in those
in which the head was delivered last, and so escaped moulding,
VOL. XXV. 19
290 THI MSCHAKISM OT LABOUR.
be had always found the head nearly sphericaL In conclusion
he repeated his confidence in the original observations of
Naegele. He himself had enjoyed opportunities which justified
him in trusting to his own clinical touch. He had lived two
years in a lying-in hospital having to teach students how to
examine and to recognise the presentations; he had, after
Naegele's manner, kept his finger on the presenting part from
the commencement of labour. In ordinary London practice the
opportunity of examining at the beginning of labour was rare ;
but in the hospital patients came two or three days before labour,
and he examined at the yeiy onset.
INDEX.
AbdominBl secUon in b case of fibroid tumoar of the ovary
(John Winiains) .....
fibroid tamonra ot the utems removed by (G. G. Bantook)
Ab«5«8B. retro-uterine perimetric (W, S. A. Griffith) .
Addrett (Annual) of the Preiidenl, J. Matthews Doncan, M.D,,
February 7th, 1883 .....
(rnauyurai) of tin new FrMidenl, Henry QerviB, M.D.,
March 7th. 1883 .....
Anatomy, physiology, and pathology of the os uteri mt«muni
(J. H. Bennet) . . . , 1
Annual Oeneral Meetiag, Fobnuiry 7th, 1883
AnteQexion, acute, of the utvrue with congestive hypertrophy
and presence of an ovarian cyst (Graily Hewitt and A Q.
Bilcoct) ......
' of the Dtcros, notes of a specimen of (W. S. A. Griffith) .
Atresia ragi&aj, case of labour with (Fascourt Barnes)
AvKLiNO (J. H), if«porf as Chairman of the Board for the
Examination of Midwivea ....
cast of female bladder (shown)
1^ ■ Remark* in discussion on J. Knowsley Thornton's case of
eitirpation of utems and appendages for epithelioma of
the cavity ......
' in discussion on tt. Barnes's new axis-traction »ul-
eeUam forceps .....
■ M» discussion on F. H. Champneya' paper on the
pressure of the femora, and its infiuenM on the shape of
the pelvis ......
' in discussion on J. H, Bennel's paper on the os uteri
internum, its anatomy, physiology, and pathology .
Bahtock (O. 6,), dermoid cyst of the ovary (shown)
Bantock (G. G.), Fallopian tubes witt right ovary, showing
hydro-aalpini or dropsy of the Fallopian tube (shown)
fibroid tiimourB of the nteniH, removed by abdominal
sectiOD, conatitating the operation of hysterectomy (shown)
Semarks in reply .....
in diaoaasion on W. S. A. Griffith's Bpeeimen of ante-
flexion of the uterus .....
in diacusaion on J. Knowaley Thornton's caoe of
extirpation of uterua and appendajfes for epithetioma of
the cavity .....
Babhes (Fanconrt), case of labour with atresia vaginro
hypertrophied left nympha (shown)
Bemarks in diacussion on Heywood Smith's caae of utema
remored by Porro'a operation
in discussion on Lawaon Taifs Hpecimena of hydro-
aalpins and pyoRulpinx
in diacuaaion on Laweon Tait's paper on three
ofpyoealpinx ....
Ba&neb (Robert), fibro-myoma and a new axia-traction vul-
Bellnm forceps (shown)
hsmon-bagic effuaion (shown)
on the mechaniam of labour more eepecially with reference
to Naegele's obliquity and the influence of the f umbo-sacral
Bemarks in reply .....
in diacussion on F. L. Burohcll's paper on turning
in cases of contracted brim ....
■ in discussion on F. H. Champaeya' paper on the
pressure of the femora, and its influence on the shape of
the pelvis . . . . . .3
^■^ in discussion on J. Braxton Hicks's paper on the
behaviour of the uterus in puerperal eclampsia, oa observed
□. Graily Hewitt's and A. Q. Sitcock's
'e hypertrophy of the uterus
A. Griffith's apeclmen of
1
in discussion o
specimen of congeativ'
. in discussio:
obliqne rachitic pelvii
. in discussion o:
of pyosalpinx
Bekskt (J. Henry), on tho os uteri interanro, its anatomy,
physiology, and pathology ....
Bmnurla in reply .....
a LawBon Tcut's paper on three cases
Bkhbet (J. Hcairj), Bemarki in diBcassion on Orall; Hewitt's
and A. Q. SUcock'B Bpecimen of congestiTe hypertrophj of
the nterua ......
Bladder, female, cast of (J. H. Aveling)
Breasts, hypenropby of the (J. A. Mansell Moullin)
BuRCHKLL {P. L.), tnrning in caaes of contracted brim
Remarka in diHcuasion. on J. G. Swajne's case of gangrene
of the tbigh during the seventh month of pregnane;
Batlcr, Frederick John, bt.D., of Wincbeater, obituary notice of
Cartes (0. H.), cystic degeneration of aubperitoueal fibroid of
the uterus (shown) .....
cystic disease of both ovaries [shown) .
Bemarki in discussion on J. A. ManseU UonlHn's case of
extra-uteiine fcetation ....
Causation of lateral obliquity of the fixtalhead (A. L. Galubin)
Cervix, see Vterwi (cervix of).
CHAUiBBa (J.), for Charl«i Harford, twin female monster
(.lc.-»)
sparions hermaphroditism (shown) . 129,
Champneys (F. H.), od the " pressure of the fenicra," and its
influence on the shape of the pelvis
Remarki in reply .....
the obstetiics of the kyphotic pelvis .
Remark* in reply , . . . .
separation and eipnlaion from the uterus of the placenta
(sbovm) ......
— ■ - placenta succenturiata (shown) . . !
Stmarka in discussion on P. L. Burchell's paper on tum<
ing in cases of contracted brim
in discnssion on J. R. Bennut's paper on the os uteri
internum, its anatomy, physiology, and pathology . ',
• in discussion on R, Barnes's paper on the mechanism
of labour, more especially with reference to Naegela's
obliquity and the inBuence of the lumbo-sacral curve . !
' Report as Hon. Librarian for 1883
on tumour shown by Wynn Williams
on bydatidiform mole shown by W. A. Duncan . '.
Clevblakd ( W. F.), Remarki in discussion on G. E. Herman's
case of acute gangrene of the vulva in an adult . . ]
Coccyx, outgrowth from end of, in foitus (Heywood Smith)
COCKELL (F. £,, jun.), fcetal monstrosity (shown) . . ]
P 294 1HDKX.
^
PISB
_L Uontracted biim, tnming in cases of (P. L. Burcbell)
61
IK Orora, Richard, M.D., of Sca,r boron gb, obituarj notice of
29
^H OfHtic degeneration of subperitoneal fibroid of tbe nterua (0.
^K H. Carter). . . . . .
108
^H OjaUc diaease of both ovaries (O.H.Cajter)
109
^H djata, see Ovarian.
^^1 see Tumourg.
^H Daly (F. H.). Bemarlcs in discussion on P. H. Champneys'
^^H specimen of placenta snccenturiata
214
^^H Development, arrested, of one twin, double placenta (A. W.
1 Edis) ......
213
1 Dkwae (John), Remarks in discussion on Lawson Taifs paper
207
[fc DOBAN (AJbon), RemarJa in discussion on Q. G. Bantock's
t^H specimens of fibroid tumours of the uterus removed by
i 1 tomy ......
M
— in discussion on P. H, Cbampneys' paper on the
presaure of tbe femora, and its influence on the shape of
the pelvis ......
97
^^ in discussion on Lawson Tait's paper on tbree cases
243
Beport on tumour shown by Wynn Wiitiams .
70
233
^K on ruptured ovarian cyst shown by W. A. Duncan .
234
^H DtTHCAH (Uatthewsj. Annual addrest at PreHdent. February
^P. 7th. 1883 ......
29
Bemarfc* in disenssion on J. Knowsley Thornton's case of
eitirpntion of uterus and appendages for epithelioma of the
cavity ......
16
in discussion on P. H. Champneys' paper on the
the pelvis ......
97
in dJEcassion on G. E. Herman's case of acute gan-
grene of tbe vnlva in an adult
157
■ in discussion on B. Barnes's paper on the mechanism
of labour, more especially with reference to Naegele's
obliquity and tbe inSuence of the lumbo-socral curve
284
Ddhcan (W. a,), hydatidifonn mole (shown)
162
large fibro-celluiar tumour (shown) .
212
— — ovarian tumour (ohowit) . ,
k
1
DiTHCAK (W. A.). Semarla in discuBBion on Lawson Toit'a
paper on three cases of pyosalpiiix . . . '
Beport on hydatiform mole . . . , !
on niptared ovarian cjet . , . !
Djamenorrbteal membrane (Wjnn Williams) . . !
Eclampsia, pnerperul, bebaYionr of the uterus in, ae obaeiTed
in two cases (J. Braiton Hicks) . . , '.
Edis (A. W.), dermoid cyst (shown)
arrested detelopment of one twin, double plneenta (sbown) 1
Bemarla in discussion on J. Knowsley Thornton's case
of extirpation of uterus and appendages for epithelioma of
the cavity ..,.,.
in discussion on 0. Godson's case of epithulioma of
cervii removed by Scraseur wire during pregnancy without
causing abortion .....
in discussion on Fancourt Barnes's coae of labour
with atresia vagina) . . . . , '.
in discussion on J. A. Mansell UouUin's case of
extra-uterine fwtation . - . . ]
■^^ in discussion on Lawson Tait's specimens of hydro-
salpinx and pyosalpinz . . . . ]
. in discussion on J. H. Bennet's paper on the os uteri
intemntn, its anatomy, physiology, and pathology . i
Effusion, baemorThagic (Bobert Barnes) . . . ]
Eldbk (George), sarcoma of ovary (shown) . . ]
EhclioH of Sew FtUcwi 1. 17. 33. 65, 103, 159. 211. 231, S
Epithelioma of the cavity, eitii'pation of uterus and appendages
for (J. Knowsley Thornton) . . , ,
of cervix, remored by 6crasenr wire during pre^ancj
without causing abortion (G. Godson) .
Extirpation of uterus and appenduges for epithelioma of the
cavity (J. Knowsley Thornton)
Extra-uterine fcctation (J. A. Mansell Uoullin) . , I
gestation, simulating so-called missed labour (A. Bascb) 1
pregnancy, fcBtus in a case of (A. Meadows) . , 2
Fallopian tubes with right ovary, showing hydro-salpinx or
dropsy of the Fallopian tube (O. Q. Bautock)
distended with pus [pyosalpinx] (J. Knowsley Thornton) 1
an undescrifaed disease of the (Lawson Talt) . . 2
Fellows, see L'uitt. Election.
:;
ihape ]
Femora, on the preBavre of the, tmA its inflaence on the shape
of the pelvis (F. H. ChampneyB) . , .70
Fibro.cellular tumour (W. A. Duncan) . . . 212
Fibroid, see Tumourg (fibi-oid).
FcBtaJ haad, cauBation of lateral obliquity of the (A. L. Galabin) 252
— monstrosity (F. B. Cockell, jun.) .110
Fcetation, see Pregnancy.
Ftetus with outfpTDwth from end of coccyi (Heywood Smith) . 2
nith placenta attached showing knot in umbilical cord (0.
Godson) . . . .66
in a case of ventral pregnancy (A. Meadows) . . 232
Forceps, a new azia-traction vnlaellnm (B> Barnes) . , 68
Galabin (A. L), causation of lateral obliquity of the fcetal head
(diagramB shown) ..... 252
Bemarhs in discussion on A. Ranch's case of eitra-nterine
gestation simulating so-called missed labour . . 117
in discnsBion on F. H. Champneja' paper on th«
obstetrics of the kyphotic pelvis . . . 192
in discussion on J. H. Bcnnet'e paper on the OS
uteri internum, its anatomy, physiology, and pathology . 227
in discussion on Lawson Tait's paper on three cases
of pjosulpiux ..... 246
in dificuBsion on B. Bamea's paper on the mechanism
of labour more espei^ially with reference to Naugele's
obliqnily and the influence of the Inmbo-sacral curve . 286
Gangrene, case of acute, of the vulva in an adult, with remarks
(G.E.Herman) . . . . .141
case of idiopathic, of the uterus (Lawaon Tait) . . 248
of the thigh during the seventh month of pregnancy (J.
G. Swayne) . .215
Qebtis (Henry), Inaugural Addrett a* PrendeiU, March 7th,
1883 . .47
myo-fibromata of the uterus (shown) . . 108
BubmucouB fibroid of the uterus (shown) . IGl
Remarks in discussion on John 'Williams's case of fibroid
tumour of the ovary removed by abdominal section . 37
■ in discussion on J. A. Uansell MouUin's case of
axtra-uterine flotation .... 107
in discussion on Qraily Hewitt's and A. Q. Silcock's
specimen of congestive hypertrophy of the uterus
Okbvis (Bemj), BmtorAv in diBcaaaion on G. E. Hertaan'e case
of acute gangrene of the vulva in an adult
in diBCDSsion on LawBon Tait'a paper on uterine
mjoma, ila pathology and treatment
in discnssioD on J. H. Bennet'a paper on the oa uteri
internum, ite anatomy, phjsiologj, and pathology . !
in diecuBsiun on W. S. A. Qriffith'e specimen of
oblique rachitic pelvis ....
in diacuHBion on Xiawson Taif 8 paper on tliree cases
of pyosalpinx ...
in diacnHsion on R. Barnes's paper on the mechanism
of labour, more especially with reference to Naegele'a
obliquitj and the influence of the lumbo-aacral curve
Gestation, see Pregnancy.
GoDaoM (Clement), epithelioma of cerrii, removed by ecraseor
wire during pregnancy without causing abortion
fistna with placenta attached showing knot in umbilical
cord (shown) .....
myiomatoUB degeneration of uterine fibroids (shown )
Rrporl on tumour shown by Wynn Williama
Gbivfith ( W. S. a. ) , notes of a Bp«cinien of anteflexion of the
ut«ruB (ahown) . • . . .
HemaTki in reply .....
retro- uterine perimetric abaceu (shown)
flbrinouB polypus of the uterua (ahown)
oblique rachitic pelvis (shown)
Ha;morrhagic effusion (.Robert Barnea)
Hebman (O. E.j. caae of acute gangrene of the vulva in an
adult, with remarks .....
Renarht in reply . . . , ,
in discussion o
flexion of the utema .
in discussion o;
cervix removed by ecraseDr w
causing abortion .....
in discussion on J. Chalmers' specimen of twin female
monster ......
in discussion on Graily Hewitt's and A. Q. Silcock's
specimen of congestive hypertrophy of the uterus
in discussion on F. H. Cbsmpneys' paper on the
obstetrics of the kyphotic pelvis , ,
a W. 8. A. Griffith's specimen ofante-
n C. Godson's case of epithelioma of
re during pregnancy without
ocogMtiTc kjpotnjihf ai the ■leras milk »emt» sato-
icKioB lad pccMBoe of as orariaa t^rt (•hows)
— £«Marb n diMOMOM oa W. & A. Gtifith*
aatedeiioa of Um nteraa
in diacvMon on J. Btmxton Hicka'e pa
bcbaviovT of Uie ■tem>inpiMipendeelamp«a,.
in diacnaaton on lAiraon ^bit'a p^)er on i
ofpjoaalptnx
I BiCKUBOTHAii (J.), Remwk* in discossibn on G. E.
caae of acute gangrene of the valra in an adu)t
BjCK8(J.Braiton), on the behaviour of the ateriia in paerperal
eclampsia, aa obaerred in two caaea
Bemark* in replj
■ in disciuBion on J. A. UanBell Moollin's case of
eitra-Qterine fcetation
I HoBXOCKS (P.), Jtrrmarkt in discussion on LawsoD Tait's paper
on three cases of pjosalpinx .
HcBFOBD (Oharles), eee Chalraert.
Hjdatidiform mole (W. A. Duncan)
Hjdro-salpinx (LawBon Tait)
■ or dropsj of the Fallopian tube (G. G. Bantook)
Hypcrtrophied left nympba (Faucourt Barnes)
Bfpertropbj, oonj^estive, of the utema and acat« onteflexioa
and presence of an ovarian cjst (Grail; Hewitt and A. L.
Bilcock) ....
■^— of the breasts (J. A. Manscll Uonllin)
Hysterectomy (J. Knowsky Thornton)
■^— removal of libroid tnmoars of the nteraa by abdominaj
flection (0. O. Bujitouk) .
JoNBB (Fenton),Bc?nart«in discussion on G. E. Herman's case
of acute gangrene of the vulva in an adult
JONKB (Philip), lUmarkM in diacnasioB on A. Bascb's case of
eitra-ntorino gestation simulating so-ealled miaaed laboor
Ejphotio pelvis, the obfitetrics of the (F. H. Ohampncya)
Labour, bm ParturUion.
LUt of OgieeT* elected for 1883
of ditto for 1984 .
ofpa»l Pretidenit
ofRefereet ofPapertfor 1884
(j^ Standing Committeet
of Honorary Local Seerttariet
of Honorary FellotcM
of Correfponding Fellow*
of OrdiTtary Fellow*
of Dcreaned Fellow* [with obituary notices, whiab aee]
Lambo-aacral cnn-e, influaoce of the, in the mccbaniam of
labonr (B. Barnes) .....
MaUbrmatioD, fceta] monstrosit; (F. E. Gockell, jun.)
fa:tu8 with outgrowth from end of cocojx (Hejwood
Smith) ......
epurioua hermaphroditism (J. Chalmers) . 129,
—~' twin female monster (J. Chalmers) . ' ,
UkLIira (Edward), Remarki in discuseion on A. W. Edis'i
of arreated development of one twin, with double placenta '
Habx (L. p.). see John Williamt.
Hkadows (Alfred), ftetus in a caae of ventral pregnancy
(shown) . . . . . 1
ovarian tnmonr (shown) . . , !
subperitoneal ut«rine fibroids (sbown} . !
lUmark* in dJ»cTiBHion on Lawaon Tait'a paper on uterine
myoma, ita pathology and treatment . . . I
Ueohanism of labonr, on tbe, more especially with reference to
Naegele's obliquity and the influence of the Inmbo-aacral
ctirve (R. Barnes) . . . . . !
lirtUng, Annwd General, February 7th, 1883
Uttmbrane, dysmenorrhcBal (Wynn Williams) . . ;
Missed labonr, eitra-uterine gestation simolating so-called (A.
Eaach) ......
Hole, hydatidiform (W. A, Duncan)
MoDLUH (J. A. Mansell), case of eitra-uterine fatatiou
(shown) ......
caae of hyperlropbj of the breasta (shown)
ICOBBAT (O. G. P.), Rrmarkt in discuBsion on Qraily Hewitt's
and A. Q. Silouck'e specimen of congestive hypertrophy of
the utcrua ......
jSjj
r
MtJKSAY (G. C. p.), Bemarkt in discussion on J. H. Bennet'a
paper on the os uteri internum, its anatomy, physiolog;,
and patbologj .....
in discussion on Lawson Tait's paper on three caaea
of pyosalpinx .....
Ujo-fibrom&ta of the ntfirus (H. Gervie)
Myoma, a note on uterine, its pathology and treatment (Laweon
Tail) .....
uterine fibro- {J. Knowaley Thornton)
fibi-o-, and a new axis traction Tulsellum forceps (R.
Barnes) .....
MyiomatoHsdegenerationof uterine fibriods (Clement Godson)
Naegele'a obliquity and the influence of the lumbo-sacral curve
in the mechanism of Ubour (H. Barnes)
Nympba, hypertrophicd (Fancourt Barnes) . .
Obituary notices of deceased FeUows.
Sutcliffe, John, Denmark Hill
Croft, Robert Charles, L.R.C.P. Ed.. Camden Road
Yeatea, George, M.D., Walthamstow .
Butier, Frederick John, M.D.. Winchester
Dean, Marshall, M.P., M.D,, Ontario .
White, Frederick George, L.B.O.P. Ed- Bieter .
Hopkins, Alfred Boyd, Shorediteh
Gross, Richard, M.D., Scarborough
Obli(|iiity, causation of lateral, of the festal bead (A. L. Galabin) '.
Obstetrics of tbe kyphotic pelvis (F. H. Cbamneys) .
Ob ut«n internum, its anatomy, physiology, and pathology (J.
H. Bennet) . . . . . !
Ovarian cyst (J. Knowsley Thornton) . , ]
presence of, in a case of congeBtire hypertrophy of
tbe nterus with acnte anteflotion (Graily Hewitt and A.
Q. Silcockl ....
tumour (A, Meadows)
(W. A. Duncan)
Ovaries, cystic disease of both (C. H. Carter)
Ovary and Fallopian tubes, showing hydro-salpini or dropsy of
tbe Fallopian tube (G.G. Bantock) .
dermoid cyst of the (G. G. Bantock) .
Gbroid tumour of the, removed by abdominal section
tJobn Williams) ....
larcoma of iQ. Elder)
QwZNi (8. tfatthew], BtmarJct
papur on three cases of pjoBolpini
Parovarian cyst {Laweon Tait) ....
Fartiiritiou, see Placenta.
ease of labonr with atresia vagiiue (Fancourt Barnes)
doable placenta in a case of arrest«d development of one
twin (A. W. Edie) .....
placenta auccenturiata (P. H. Champneys)
— ~ on the mechanism of labonr more especially with reference
to Naegele'a obliquity and the influence of the Inmbo-aacral
cnrve (R. Barnes) ....
Pelvis, kyphotic, the obahstrics of the (F. H. Champneys)
oblique rachitic (W. S. A. Griffith)
on the pressure of the femora, and ite inflaenee on the (F.
H. Champneys) ....
turning in caaes of contracted brim (P. L. Burchell)
Perimetric, retro -ate rine, abscess (W. S. A. Griffith)
Placenta, double, in a case of arrested derelopmeut of <
twin (A. W. Edia) ....
with cyst (John Williams)
■ ■ with fixtus attached, showing knot in umbilical cord (C
Godson) .....
separation and expulsion of the, from the nterus (F. :
Ohampneye) ....
■^— auccenturiata (F. H, Champneys)
Plattaie (W, S.), Bemarltt in discuBBion on C. Godson's case
of epithelioma of cervix removed by ecrasenr nire during
pregnancy without causing abortion
in discussion on J. H. Bennet's paper on the os uteri
internum, its anatomy, physiology, and pathology
~ Report on ruptured ovarian cyst shown by W. A. Duncan
Polypus adherent to vagina (J. B. Potter) ,
fibrinous, of the uterus (W, 8. A. Griffith)
fleshy or mucous, of the uterus (Wynn Williams)
Porro's operation, utems removed by (Heywood Smith)
PoTTBE (J. B.), polypus adherent to vagina (shown)
Beport as Treasurer for 1882 ... 25
Pregnancy, causation of lateral obliquity of the fcetal head (A.
L.Galabin) . . . ' .
epithelioma of cervix removed by ecrasenr wire during,
without causing abortion (0. Godson) .
eitra-uterine fcetation (J. A. Mansell Uoullin) .
803
IKDEX.
rxsB
Fregnancf, extra-uterine gestation simnlating BO-callecl tniased
labour (A. Eaaoh) . . . . .113
fatuB with placenta attached showing knot in nmbOicBl
cord (C. Godson) . . . . .66
gangrene of the thigh doring the seventh month of (J. Q.
Bwajne) . . . . . .215
ventral, fcetns in a case of (A. Meadows) . . 232
Pressure of the femora, on the, and its inflaence on the sbapa
ofthepelvi8(F. H. ChampnejB) . . .70
Puerperal eclampsia, behaviour of the uteros in, ae observed in
two cases (J. Braitoa Hicks) . . . .118
Pyosalpini (Lawson Tait) . . . Ill, 138
(J. Knowaley Thornton) ... . 13B
three oaaea of {Lawson Tait) ... . 23*
Rascb (Adolph). case of extra-uterine gestation simulating ao-
called missed labour . . . .113
Beeeiplt cmd Expenditure of the 8ocie(y . . .28
Be-poTt.{audUed) qf the Treasurer for 18S2 . . .25-28
of Ike Hon. Librarian for 1882 . . . 2S
of the Chairman of the Board for the Ezamination of Mid-
wivet . . . . S7
Beport of Comimittee on Tumour sftoum by Wynn Willianu on
March 7lk. 1883 . . . . .70
Hydatidifcmn mole thown by W. A. i>unean Jvly 4(4,
1883 . . . . . .833
on ruptured ovarian eyit ihovm by W. A. Duncan
October 3rd, 1883 ..... 234
Betro-aterine perimetric abscess (W. S. A. Griffith) . . Jg
BoOEKB (W. B.), Remarks in discuHsion on C. Godson's cnseof
epithelioma of cervix removed by ^craseur wire during
pregnancy without causing abortion . . .84
BoPKB (George), Remarka in diacnseion on P. H. Champoeja'
paper on the obstetrics of the kyphotic pelvis . I93
— • in diacnssion on B. Barnes's paper on the mechanism
of labour more especially with reference to Xaegele's
obliquity and the influence of the lumbo-sacral curve . 288
Booth (C. H. P.), Jtemarki in discnssion on W, S. A. Griffith's
epecinf^ of anteflexion of the utems . ,7
' in discusBion on C. Godson's case of epithelioma of
the cervii removed by dcraseur wire during pregnancy
without causing abortion . . . .22
EODTH (0. H. F), BeToarlcB in diBciusian on G. G. Bantock's
Bpt^imeua of fibroid tamonrB of the uterns removed bj abdo-
minal section, conatitotiug tbe opci-alion of hyalerectiinij
in diecusaion on Wynn Williuma' apedmeu of flesliy
or mucouB polypua of the uteroe
in diacuBBton on J. Braxton Hicks's paper on the
behaviour of theuterag in puerperal eQlampBia.asobectTed
Sarcoma of ovary {G. Elder) . .
Sataob (Henry), Bemarka in diacusBion on G. G. Bantt>ck'a
specimens of fibivid tiunoura of the utenia, removed by
abdominal section, constituting the opei'atiou of hyaterec-
SiLCOCK (A. Q.) and Gbaily Ebwitt. general and consider-
able congeative hypertrophy of uterus with acute nnte-
fieiion and preaence of an ovarian cyst (ahown)
SuiTH (Heywood), foetns with out-growth from end of coecyi
(ahown) ....
nterua removed by Porro'a operation (ahown)
Bemarka in diacuBBion on B. Barnes's new axis-tracllon
vulsella m forceps
in discDseion ■
with atresia vaginie ....
iQ discuaaion on J. A. Manaell Moullin'a
extra-otorine fiEtation
in discuBsion on J. H. Bonnet's paper on the
internum, its anatomy, pbyatology, and pathology
in diacneeion on Lawaon Toit'e paper on tlir
of pyoealpini ....
Submucons fibroid of the utems (H. Gervis)
Sabpefitoneal uterine fibroids (A. Headowa)
SwATVE (J. G.), gangrene of the thigh during tbe aercnth
month of pregnancy
B«mark» in reply ,
1 Fancourt Bamea'a
a of labour
Tait (Lawson), hydro-aalpini (ahown)
pyosalpi&i (abown)
■ parovarian cyst (shown) •
a not« on uterint) myoma, its pathology and treatment
Semarkf in reply
— — three caaea of pyoaalpinx .
Tait (Lttweon), Remarks in reply ,
■ caae of idiopathic gangprene oF the ulenis
an undeecribiid diseaae of the Fallopian tubes
Remarks in discaaaion on J, A. Uaneell Moallin
extra-uterine tcBtntion
in diHCuaaion
disease of both i
in discussion i
gestation simulating i
in dii
0. H. Carter's epecimen of cjsti
n A. Ranch's case of citra-ut«rine
□■called missed labour
Oraily Hewitt's and A. Q. Silcock'
i hypertrophy of the uterus
J. Knowsley Thornton's specimen
specimen of hicuiorrliagic
;nth mouth of pregnancy
specimen of congest!
in discussion i
of ovarian cyst, and R. Barm
effusion
Thigh, gangrene of the. during the
(J. G. Swaync) ....
Thoenton (J. Knowsley), case of eitirpalion of uterus
appendagea for epithelioma of the cavity
uterine fibro.myoma (shown)
Fallopian Cubes distended with pus [pyosalpinx] (she
hysterectomy ....
ovarian cyst (shown) .
■ Remarks in discussion on G. G. Bantock's specime:
fibroid tumour of the uterus removed by abdominal
tion, constituting the operation of hysterectomy
• in discussion on Lawson Tail's paper on threa (
of pyosalpinx ....
Tumour, cystic degeneration of subperitoDcal fibroid of the
nterus (0. H. Carter)
cystic disease of both ovaries {0. H. Carter)
— - dermoid cyst (A. W. Bdis) .
fibrinous polypus of the nterus (W. S. A. Griffith)
fibro-cellular (W. A. Duncan)
fibroid, of the ovary removed by abdominal section (John
Williams) .
of the nterns (Wynn Williams)
• of the nterus, removed by abdominal section (G. Q.
Bantock) .....
fleshy or mncons polypus of the uterus (Wynn Willi
myo-fibromata of the uterus (H. Gervis)
myxomatous degeneration of uterine fibroids (Clement
God»on) .
moiiT, oTarian (A. Meadows) ....
(W. A. Duncan) ....
cjst (J. Knowgley Thornton)
presence of, in a case of congeBtive hypertrophy
of the nteniB with acute antcfleiion [Graily Henitt and A,
Q. Siieock) ....
parovarian cyst {Lawaon Tait)
placenta with cjst (John Williama)
polypns adherent to vagina (J. B. Potter)
sarcoma of ovary (G. Elder) .
BubmucouB fibroid of the uterus (H. Gervis)
subperitoneal uterine fibroids (A. Meadows)
uterine fibro. myoma (J. Knowsley Thornton)
" — ■ and a new aiis-tractiun vulseilum forceps (B.
Barnes) .....
myoma, a note on, its pathology and treatment
{LawBon Tuit) ....
Twin, arrested development of one, double placenta (A, W.
Edis) .....
female monster (J, Chalmers)
Umbilical cord, foetna and placenta attached showing knot in
(C. Godson) .....
Uterine myoma, a note on, its pathology and treatment (Law-
son Tait) ......
tumonra, see Uterat, tumours of.
Uterus, on the behaviour of the, in puerperal eclampsia, as
observed in two cases (J. Braxton Hiots)
■ separation and eipulsion from the, of tho placenta (F. H.
Cbampneys) .....
removed by Porro'a operation (Heywood Smith) .
• and appendages, eitirpation of, for epithelioma of the
cavity (J. Knowsley Thornton)
congestive hypertrophy of, and acute anteflexion and
preienoe of an ovarian cyst (Graily Hewitt and A. Q.
Siloock) ......
Botea of a specimen of anteflexion of the (W. 8. A, GrifGtb)
idiopatbio gangrene of the (Lawson Tait)
cystic degeneration of subperitoneal fibroid of the (C. H.
Carter) ......
flbrinons polypns of the (W. S. A. Griffith)
fibro-myoma of the (.1. Knowsley Tbotnton)
TOL, XXV. 20
tJtemB, fibro-in;otii& of the, andanew azie traction vnlsellUiu
forceps {B. Bamea) ....
fibroid tumours of the (Wynn Williams)
^— of the, removed by abdominal section (G. G. Bantock)
• flcHhy or mucous polypus of the (Wynn WiUiama)
myo-fibroDiata of the (H. Gervis)
myxomatous degeneration of uterine fibroids (Clement
Grodson) .....
BubmncouB fibroid of the (H. Gervis) .
— — aee HysterecUnny.
' (MTvii uteri, epithelioma of, removed by fcrasenr wii
during^ pregnancy without causing abortion (C. Godson)
■ OS uteri internum, i ta anatomy, physiology, and pathology
(J. a Bennet) ....
Vagina, polypus adherent to (J. B. Potter)
atresia vogince, case of labour with (Fancourt Barnes)
Tentral pregnancy, fcetua in a case of (A. Meadows)
Tulva, case of acute gangrene of the, in an adult, with remar
(G. E. Herman) '. . . .
Waltbbs (J. Eoptdns), Remarit on J. H. Aveling's specimen
of cast of female bladder
WiixiAus (John) for L. F. Marli, placenta with cyst (shown)
• fibroid tumour of the ovary removed by abdominal section
(shown) .....
Williams (Wynn), fibroid tnmour of the uterus (shown)
— — fleshy or mucous polypus of the ntoma (shown)
dyamenorrhoial membrane (shown) .
BoKorka in disouBsion on G. G. Bantocli's specimens
fibroid tumours of the uterus removed by abdominal sec-
tion, constituting the operation of hysterectomy
' in discussion on Lawson Tait's paper on three
ofpyosalpini ....
OBSTETBIOAL SOCIETY.
ADDITIONS TO THE LIBRARY
BT DONATIOS OB PITECHASB DDBINO THE YEAR 1883.
Preiented l»f I
Atthii-l (Lotnbe). Clinical LcetureB on DieeaBeHpecu-
liar to Women. Seventh edition.
Koodeult, 8vo. Dublin, 18S3 Parchued.
Bakb (B. F.). Ad AnalysiB of twenty- seTen operations
for the reatoratiou of the Lacerated Cervii Uteri,
with special reference to the effect of the opera-
tion on Fertility and Labor. (From ' The Medical
News," Feb. 24, 1883.)
em. 8to. Pbiladelphia, 18S3 Author.
Balakdik (J.)- KliniBche Vortrage aue dem Gebiete
der Geburtabilfe und Oynoecologie auf Orundlage
elgener anatomiacher und kliaische Beobach-
tungen. Heft 1. ptatfs. 4to. St. Peleraburg, 1883 Ditto.
Babatte (Gmile). De la FievreTyphoidedanalaOruB-
Beaae. These. 4to. FariB, 1882 Furchawd.
Babdes (Robert). On Hernia of the Ovary and Obaer-
vatione on the Physiological relations of the
Ovary, with tlie relation of caseB observed by the
Author. ('Amer. Jl- Obstet.,' Jan., 1883.) 8vo. Author.
A Synoptical Quide to the Study of Obstetrics.
8vo. Lond. 1883 Ditto.
Barb (James). Reduplication, or Doubling of the
Cardiac Sounds. (From ' Liverpool Medico-
Chirurgical Ji.,' July, 1882.)
8vo. Liverpool, 1882 Ditto.
Bastard (Henri). De la Thrombose veineuee dans les
Tumeurs fibreuses de rUterus. 8vo. Paris, 1882 Purchased.
BtLlOK (Paul Eugene). £tude clinique sur les Accua
de Fii'vre Palustre survensnt aprL'S I'accouuhe-
ment. These. 4tu. Paris, 1882 Ditto.
I
ADDITIONS TO THE LIBRARY,
4
BtAcnE (R.). Estraita de Patholonfie InfaDtile do
Blache et Gueraant, avec une Preface de M. le
Docteur Archanibault. Svo, Paris, 1883 PurchsRed,]
Bonn (Heiorich). Die Hautkrankheiten. OerJiardt,
Kinderkrackheiten, SiipplemeDt I. 188^
BsiOHET ( — ). See Playfair.
BitEiaur (Dr.). Kechtaseitige Parovarialcysto mit
Acheendrehung des Stielea. Svo. Prag. 1883 Author,
BuLKLEY (L. Duncan). Analj-Hia of eight thousand
eases of 8kia Disease. (From ' ArchiveB ol' Der-
matology,' vol. viii, 1882.) Svo. New York, 1882 Ditto,
CisTASEDA T Tbiana (Tiburcio). Des Kyatea dea
Ligaments Urges. These. Svo. Paris, 1882 Purchaaed. ,
Catalogue of Books added to the Radeliffe Library Dp. H. W.
during 1882. 4to. Oiford. 1SS3 Aelund.
of the Library of the Eoyal Medical and Chirur-
gical Society. Supplement II. — Additions to the
Library, 1881-82. Svo. Lond, 1883 The Society,
Catla (Andre). Contribution a I'^tude de I'Ovario-
tomie pratiquce pendant la GrosaeBse. Theae.
4lo. Paria, 1882 Purcliaaed,
CnAUSBELEVT (Jules). Biecherchea sur le passage dea
elSaienta figures a travera le Placenta, auiviea do
conaid^ratione but la Variole fcelale et la Vaccina-
tion congeuitale. Svo. Paria, 1882 Ditto.
Chahlkb (N.). De la Vaccine. Svo. Liege, 1SS3 Ditto.
Cearfestier (A.). Traite pratique des Accouclie-
mente. Tome II, icoodcuU, la. Svo. Paris, 1883 Ditt«.
CoCRTT (A,). Practical Treatiae on the Diacasea ofthe
Uterus, Ovaries and Fallopian tubea. Trans-
lated from the third edition by Agues M'Luren,
with Preface by J. Malthewa Duncan. Dr. Fancouij
woodcutt. 8vo. Lond. 1882 Barnes,
Cboou (J. Haltiday). Manual of the Minor Gyneco-
logical Operations and Apptianeea Second
edition. platen and icoodculi, Svo. Edin., 1883 Purchased,
D'Antin (Emile). £tude eur I'Epith^lium Ovarien.
These. Svo. Paris, 1882 Ditto,
DEI.OHE ( — ) ET A. LuTACD. Trsit^ pratique de I'art
des Accouchements. woodculu, Svo. Paria, 1SS3 Ditto,
Desdc^ (P.). Traite clinique de rinversion UttTine.
teoodcuU, Svo. Parii, 1883 Ditto.
I
Treaented bg
Depikrris (Jean Gabriel Abel). Easai but TEinbryo-
tome dans lea preaentationB du tronc. Deeuriptioa
d'un Douvel appareil pour pratiquer cette Opera-
tioD. 8vo. Paris, 18S3 Puruhaaed
DKVI1.LIBBB (C). Keceuil de Memoires et d'Obaerva-
tioDB Bur leB Accouche men ts (Pbysiologie, Patbo-
logie, M^decine legate) et eur lea Maladies des
PemroeB. Tome I. leoodcu/t, 8vo. Paris, 1862 Ditto.
Dictionaaire Eacyclop^ique des Sciences Medicales. Ditto.
Ire Scrie, Tom. XXVIII. 2me pnrtia, XIIX, le
2me „ „ XVIIl. 3me parti?, XIX, le partie.
Sma „ „ XI, 2ine parlici, XII.
Imu „ „ IX. Eme partie.
DiETEHLES f — ). De r Accouchement naturel chez I^b
primipareB. 8vo. Paris, 18S2 Ditto.
DoRAK (Albon), Papillary Cysts of the Ovary. (* Trans.
Path. Hoc. Loud.,' 1882.) plate, Svo. Author.
DuHCiN (J. Matthews). Clioical Lectures on the
Diseasre of Women, delivered iu Saint Bartholo-
mew's Hospital. Second edition.
Svo. Lonil. 18S3 Ditto.
DuTEBTBK (A, B. M.). De Temploi du Cbloroforme
daoa lee Accouchements uaturela. (Physiologie)
These. 4to. Paris, 1S82 Purchased.
Ekcolaxi (G. B.). Nuovi Beeherche di Anatomift nor-
Diale B pBtologica suU' iotima Struttura dcUa
Placenta nella Doddb e uei Mamtuiferi.
Svo. Bologna, 18S3 Author.
FABaES (Andre). Contribution a I'^tude de la Dystocie
dans les cm de MBlformation Uterine. These.
4ta. Paris, 1882 Furvhssed.
Fehlino (H.). Lelirbuch der Geburtshiilfe fur He-
bammeD. plate*, ipoodovtt, 8vo. Tiibingen, 1883 Ditto.
Pbaibse (G. J. M ). Stude sur la disjonctiou de la
Sympbyae Pubieone dans 1' Accouchement. Tbt'se.
4t«. 1882 Ditto.
FsAiTfOiB (J. M. Stephane). De la Dilatation naturelle
et artificielle du Col vers la fiu de la grossesee.
tPOoieuU, 6ro. Paris, 1883 Ditto.
Fbahicel {E.). Diiig:DOBe und operative BL-baiidluug
Bitrauterinachwangerscbaft (' Volkmann,
Sun.,' 217). bvo. Leipzig, 1882 Ditto.
.2^1
810 ADDITIONS TO THE LIBS&EY.
Fbitsch (Heinrich), Ueber einige Indic&tionea inr
CraoiocUatei traction. (' Volkmana, Sam.,* 231)-
8vo. Leipiig. 1883
Ueber Laparomyatoinie. (' Breslauer aritlichen
ZeitBchrift. ) 8¥o. Brealau, 1883
FCbst (Camillo). Klinische Mittbeilungen uber Qeburt
und Wochenbett mit riichsicht aufderen Behaad-
luDg. AuB der Kliaik dea Prof. Oustav Braun ia
Wien wabrend der Jabre ISSl uod 18S2.
8to. WicD, 1833
Geiiiiabdt (C). Handbucb der Kbderkrankheiten.
8 TO. Tubingen, 1883
Snpplemetit I.
InSaenu E. Kormant,
Die Haatkrankheitea Heinriek Sohm.
GxBUAix (Clement- Victor). Ctude de I'Ergot du Diss.
■ These. 4to. Paris, 1882
QBlTBAr (Charles). Etude clinique et pathogenique
sur TAscite dite idiopatbique et en particulier sur
I'Aacite desjeunea miea. These. 4 to. Par ia, 1882
GuEBSANT ( — ). See Blaeke.
IIarbis (Robebt P.), The Heviva) of Sympbiaiotomy
in Italy. (' Amer. Jl. Med. Sc.,' Jan., 1883.
8vo. Phita. 1883
IIeitzuann (J.). Die Entziinduag dea Beckenbauch-
fells beim AVtibe. woodcitU, Svo. Wien, 1883
HtCKMAiT (William). Addreaa on tbe aids and hind-
rances to the general Pbjaician or general Practi-
tioner of Medicine, delivered at the Annual
Meeting of the Ilarveian Society of London, 18th
January, 1883. 8to. Lond. 1883
IliJE (P. -A,). Sur la Pcritonite aiguo geaiiralia^e com-
pliquant les Kyatea de I'Ovaire. Svo. Paris, 1883
Imbeht (Guatave). Cdvelloppetnent de rUt^rua et du
Vagin. 8to. Paris, 1883
Jekkb (Edward W.). Modified Listerism in Ovario-
tomy, with h Report of five recent operations,
(From 'Michigan Medical Newa,' Dec. 11, 1882.
la. 8to. Chicago
jKNNDfQa (Charles Egerton). Tranafusion: its Ki a lory,
Indications, and Modea of Application.
woodcult, Svo. Lond. 188.3
On Tranafuaion of Blood and Saline Pluide.
Second edition. leoodcuta, Svo. Lond. 1883
Preitnied 5j
]
ParchaBod.!
Author. I
Purcbaaed.
Ditto.
Ditto,
Ditto.
Author.
Purchased.
Author.
Purchased. <
Ditto. .
Ditto.
Ditto.
ADDITIONS TO TDE L1DEAI!T.
JoiTBSST (M.), Essai but lea Hematoceles Utcrin^s
intra- peritomJales. Svo. Paris, 1883
JuNGBLTfTH (Hermann). ZurBt^handluDgder Placenta
preevia. (' Volkmann, Satn.,' 235.)
8vo. Leipzig, 18S3
KoBM*VN (Emst). Influenza. Oorhardt, Kinderkrauk-
beiten, tjupplement I, 18S3.
Lehrbuch der GeburtBhilfe fur Arzteutid Studie-
rende. woodcuts, 8vo. Tiibingen, 1884
LalleiiIekt (Henri). Etude Bur rAuatotnie et de la
Pathologie des Ligaments largee. Tli^ee.
4to. Paris
LcTArD (A.). See Delore.
Macabi (F.). Clinica e Muaeo Oetetrico della K. Unl-
ver«it4 di Genova. 8?o. QenovB, 1833
M'Laiien (Agnee). See Courty't Diseases of the Uterus,
Ovariee, and Fallopian Tubes (translated).
Mahtin (Henri). Bechercbes Anatomo-pathotogiquea
Burles InflammationB M^taetatiques suppuratives
a la Buite de la Gouorrhco. These.
8vo. Geneve, 1882
Mai'siac (Charles). Lemons sur les Maladies Vouuri-
ennes, profeBsces k rH5pital du Midi.
8vo, Paris, 1883
Matorisb (Charles), Dee Formes diversesd'Spid^mies
puerpe'rfcles. Thtw. 8vo, Paris, 1883
MoURET (S.). Des Kystei de la grande Levre et do
leur traitement par la Ligature elastique, Th^-ie.
4to. Paris, 1SS2
MvNof (Paul F.). The_ Etiology and Treatment of
certain forms of Non-puerpenil Uterine Hemor-
rhage. (Eeprinled from the 'Medical Record,'
February lOth, 1883.) 8vo. New York, 1«83
The Immediate Removal of the Secudioes after
Abortion. (' Amer. Jl. ObstetB.,' vol. svi.)
8to. New York, 1883
■ Secondary Puerperal Hemorrhage. (' Arcbiiea
of Medicine,' Feb.. 1883.) 8vo. New York, 1883
Nais (Hugues). De la Dystocie par procidence des
membres inferieurs. Tbi-se. ito. Paris, 1882
NoRDAC (Max.). De la Castration de la Femme.
8vo. Paris, I8t*2
Pretented 6y
Purchased.
Ditto.
Ditto.
Author.
Purchased.
Ditto.
Author.
Ditto.
Ditto.
FurcliBBed.
Ditto.
iDnrnmni ni thv umbuct.
SrrflintAim* (L- A.). Buurb Tom iiber die a
Vs^iwlaaht aim Mittel Beaeininins dea (Myir-
n»tt*FVfir£>lU. i ' L'entnUbbtt t ^ijuakoiosxe^'
IHJUl,) ' ■ifo.
' On Ancient ^r^uoU xad ObBtetriod Apoiancea
fonoAiBtht! Bmnan Ruinaof Pampeu uui IIe>ca-
iamtnm. (In Pott^.f
waaJemtM, im. Vfama.tn, 1862
IFiiCm fjulio B.). filaitw rar lea vien iIb ounfinn*-
tion de I'Urtthre dux i» &ma0. deae.
9*ol Psmif I8bS J
Pawue (K«rt). Zor FrageilerBefaftodlan^derlltenw-
eMniuttne. (' Wlcocf Slimk,' Decmtb^, I!i!^2.)
^TO. Wten, 1982
PltcifOAT fC'L.). Dea TT>iiwiiili«j;ii« pnerpenilea
" ~ A f5S2 EMM
Ttsxmo (Luden). Guiile P c» tf qi» ds l'Aaeaiii:iieur at
1a Ssge-Feauoe. Sixiente Sdttitni.
wandeatM, 12nia. Paria, 1883
PurrATB fW. 9.). Th« Systematu: Treatment afSarrB
ProMnCioa ud H^Bteria. Sto. Lorni. 1883
" fipoiflem^it N«TTeoi et Hyaterie son traiceownt
wj^timabt^w, tnduit par le Dr. BncheC
Sto. Phis. IS!!3
Plom CH. HO- Zur GeMlkiekte, ToHiratang trad
M«tlH>d« d«r Frucbnbtnibuat
8*0. Jm^mf, lasa :
1'otLi.aT (J.). Dea direraea CTp w ea de Pmwps, Iran
arantagea et leurs mcont^nieDta.
woodeuU, Sto. Paris, 1SS3
PkOOMoWHiCK (L.). ITeber Feaaarien. (' Volkmann,
Sam.; 225.) 8to. Leipiig. 1&S3
KuitautiT- DlflBttoNEB (Albsn). De la D^livnuice par
travtioDB et par eipreseion. The«e.
woodcuU and diagrami, Sto. Parta, 18«3
Bovm (C H. F.)- On the Difficulty of Diagnoeing
Thw Syphilitic Diaeaae in Women, afld the
?tMttt»'«f ita Contagion. ('Med. Preaa and
'" ■ " em. 8vo. Lond. 1SS3 Autho^
id), ContribiitioD K I'l^tude des
Mtioii dfl I'Anus et du Kectum
brAiiiuvulvDire,Boa truitement.
4to. Ainions, ISS2 Purchased.
ADDinOUa TO THE IjaRiRV.
ScA-NZOiri (F. W. von), Lehrbuch der Krnukheitender
weiblichea Sexual- orgs ne. Fuaf le Auflage.
woodoult, fiva. Wien, 1875 PurcKased,
•ScUNElDEB (Anton). Das Ei und aeiue BRfruchtung.
woodeuisand platet, 4to, Breslau, 1883 Ditto.
Smith (E. Noble). Curvatures of the Spioe.
tooodcalt, 8to. Lond. 1883 Author.
HrAUi, (Karl) Geburtshiilflicha Operationalebre. Ztreite
Auflage. 8vo. Stuttgart, 1883 Purchased.
yTARKWEATUER (GeoFge B.). The Law of Sei ; being
an exposition of the natural law by which the
Sex of Offspring is controlled iu Man and the
Lower Animals. Anil giving the yulution of
various social problems, plates, 8vo. Lond. 1883 Ditto,
TiiT (Laweon). The Pathology and Treatment of
Diaeaaea of the Oi'ariea'. (Being the Hastings
Esaay for 1873.) Fourth Edition, reivritten and
greatly enlarged.
woodcutt, 8vo. Birmingham, 1SS3 Author.
TnoUAs (Hugh). Caae of Uterine Hydatida accom-
Eanied with Icterus. (Reprinted from ' Birming-
am Med. Hev.,' vol. liii.)
8vo. Birmingham, 1883 Ditto,
Valenta (A.). Gangran der Ilarnblase mit Perforation
in lien DUnndarm.reap. Bildung eiiier Harnblaaen-
Dijiindarmfiatet be! Betrofleiio uteri gravidi V.
meusia. (Beiz'a " Memorabilien," 1883, 1, Heft,)
8vo. 1883 Ditto.
nfluence de la Tempera*
ie du Fcctus. These.
4to Paris, 1881 Purchased.
Volxuash's SammluQg klinische Tortrage :
130. H'eil, Ueber den gogcnwirtigea Stiad der Leliri-
TOD der Veterbungdcr Sypliili*.-
£17. Fratkel, Dio^oic uiid npemlive Ucbandluiig der
Kitrantcrin.icliwaDgGnclinfc.
226. Proehownick, Upber Peuarien.
231. Frituck, (JebKreinige IndicatioDcn »ur Craniockit-
235. JunghUtK, Zur Beh«Ddlaog der PUceuta prairin.
Wablukost (E.). Traiti! de !a Vaccine et de la Vacci-
natiou humoine et animale, 8vo. Paris, 1SIS3 Ditto.
Weil (A.). Ueber den gegcawjirligen Stand der Lehra
von der Vererbuug der Syphilis. (' Volkmann,
Sam.,' 130). 8vo. Leipzig, 1878 Ditto,
VOL. XXV, 21
314 ADSITIOKB TO THE LIBRARY.
Presented bg
Wells (T. Spencer). Tlie Ilunterian Oration, delivered
I'ebruary 14t!i, 1S83, at the Eoyal College of
Surgeona of England. 8vo. Lood. 1383 Authoi
TRANSACTIONS.
Lion — Society des Sciences Medicalea, £o. Memoirea
et Comptes-reudua, tome xx, 1880.
8vo. LyoD, ISSl Societ
Leipzio— Goaetlacliaft fur Geburtshulfe in Leipzig,
Mittheilungen, 1882. 8to. Leipiig, 1883 DittoJ
Medical (Royal) and Cuiruboical Society —
TraQBactions, vol. Ixvi. Uvo. Lond. 1883 Ditto,|
Nbw York Academt of Medicibe —
TranBactiouH, 2nd Seriea, vol. iii.
8yo. New York, 1883TheAciw:
ODSTBrBiOit BociiiTY (Edlnbursh) —
TraQBucliona, Seasioa 1882-83, vol. viii.
Svo. Ediu. I8S3 SocietyJ
SUITUSOHIAN IirSTITCTIOH
Annual Keport of the Board of Rcgente fur 1881.
Svo. WaahtngtoD, 1883 Institutjij
JOURNALS.
Calendar of PuiverBitj College, Londou, for 1883-4. Council of
Svo. Lond. 1883 the College.
Bulletin gi-oi-TBl de Tb 6 rape uti que mod Scale, cbirurgicale
et obstetricale, tome cv- Svo. Faria, 1883- Editon
Journal de Medecine de Paria, Revue g^niSrale de la
Preaae iiiedicale Fran^aiae 6t Etrangere. Publie
sous tadirectiondoMM. A.Leblondet A. Lutaud,
vol. 1- 8vo. PnriB, 1881- Editon
Arcbiv fiir Kinderbeilkunde, lierauageben von A. Bagiu-
iky, M. Ilorz, and A Monli, Band i-
Svo, Stuttgart, 1880- Purcbaae^
Moitataacbrift fiir Geburtskunde und frauenkrankhoiteD,
vola. 1 la 14. 8vo. ISerlio, 1853-5y Ditto.
ADDITIONS TO THE UBR&BT. 315
REPORTS.
Presented hy
Hospitals — St. Bartholomew's Hospital Beports ; vol. Hospital
xviii. 8?o. Lond. 1882 Staff.
Middlesex Hospital Beports for 1880.
8?o. Lond. 1883 Ditto.
University College Hospital. Beport of the Council of
Surgical Begistrar for 1881. 8vo. Lond. 1882 the College.
Ltinq-in Institutions — Madras Government Lying-in
Hospital. Annual Medical Beport for 1882. Dr. A. M.
folio, Madras, 1883 Branfoot.
lraiirTBI> HT J. B. ADLARD, BABTHOLOMRW CL08E.
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