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^/OV
OBSTETRICAL TRANSACTIONS.
VOL. XXXI.
TRANSACTIONS
OV TBB
OBSTETRICAL SOCIETY
OF
• . # -^
IrMViS
LONDON.
VOL. XXXI.
FOB THE YEAR 1889.
WITH A LIST or OFFICERS, FKLLOWS, KTC.
BDITBD BT
PEROT BOULTON, M.D., Sbniob Sbcbbtabt
AHD
F. H. GHAMPNETS, M.D.
LONDON:
LONOMANS, GEBEN. AND CO.
1890.
FBnrTXD BT ADLABD AND SON, BABTHOLOXBW CLOBB.
OBSTETRICAL SOCIETY OF LONDON.
OFFICERS FOR 1890.
Elkctbd Fkbruart 5th, 1890.
PRESIDENT.
VICE-
PBESIDEKT8.
TEEA8UBSB.
CHAmiCAN OP
TH£ BOAKD FOB
THE EXAMINATION
OP MIDWIVES.
HONOBABY
8ECBETABIES.
HONOBABT
LXBBABIAN.
BLACK, JAMES WATT, M.A, M.D.
HONOBABY
MEMBBB8
OP COUNCIL.
OTHEB
KEHBBBS
OP COUNCUi.
GALABIN, ALFRED LEWIS, M.A, M.D.
f BOULTON, PERCY, M.D.
CHAMPNEYS,FRANCIS HENRT,M.A.,M.D.
ELKINGTON, ARTHUR G. (Dep. Surg.-Gen.).
HATES, THOMAS CRAWFORD, M.D.
JONES, EVAN (Aberdare).
L LAWRENCE, A. E. AUST, M.D. (Clifton).
HERMAN, G. ERNEST, M.B.
1
r DOEAN, ALBAN.
1 HOESOCKS, PETBE, M.D.
1 DUNCAN, WILLIAM, M.D.
OLDHAM, HENRY, M.D. (TnuM).
BAENES, ROBEET, M,D. {Ihutee).
HEWITT, GEAILY, M.D.
HICKS, JOHN BEAXTON, M.D., F.E.8.
TILT, EDWAED JOHN, M.D.
PEIESTLET, WILLIAM C, M.D.
WEST, CHAELES, M.D.
WILLIAMS, JOHN, M.D,
WELLS, SieTHOS. SPENCBE,Babt. {Tnutee).
BOWKETT, THOMAS EDWAED.
BOXALL, EOBERT, M.D.
BUTLEE-SMTTHE, A. C.
DAKIN, W. EADPOED, M.D.
DAVSON, S. HOUSTON, M.D.
GBEVIS, HBNET, M.D.
GIBBONS, EOBEET ALEXANDER, M.D.
HALLOWES, FEEDEEICK. B. (EedhUl).
HOLLINGS, EDWIN, M.D.
'' LEDIAED, HENET A., M.D. (Carlisle).
MAECH,HENET COLLET, M.D. (Eochdale).
MAUEIGE, OLITEE CALLET (Reading).
MILSON, EICHAED HENET, M.D.
NESHAM, T. C, M.D. (Newcastle-on-Tyne).
NIX, EDWAED JAMES, M.D.
POTTEE, JOHN BAPTISTE, M.D.
SPENCEE, HEEBEET E., M.D.
L WEBB, HAEET SPEAEMAN (Welwyn).
LIST OF PAST PRESIDENTS OF THE
SOCIETY.
1869 BDWABD EIQBT, M.D,
1861 WILLIAM TTLBE SMITH, M.D.
1868 HENBT OLDHAM. M.D.
1865 BOBEBT BABNES, M.D.
1867 JOHN HALL DAVIS, M.D.
1869 GBAILT HEWITT, M.D.
1871 JOHN BRAXTON HICKS, M.D., F.B.S.
1878 EDWAED JOHN TILT, M.D.
1875 WILLIAM OVEBEND PBIESTLET, M.D.
1877 CHABLES WEST, M.D.
1879 WILLIAM S. PLATFAIB, M.D,
1881 J. MATTHEWS DUNCAN, M,D., P.B.S.
1888 HENBY OEBVIS, M.D.
1886 JOHN BAPTI8TE POTTEB, M.D.
1887 JOHN WILLIAMS, M.D.
REFEREES OF PAPERS FOR THE YEAR 1890
Appointed by the Council.
BLACK. J. WATT, M.A., M.D.
BOULTON, PERCY, M.D.
CHAMPNEYS, FRANCIS HENRY, M.A., M.D.
CULLINGWORTH, CHARLES JAMES, M.D.
DUNCAN, JAMES MATTHEWS. M.D., F.R.S.
DUNCAN, WILLIAM, M.D.
GERVIS, HENRY, M.D.
GODSON, CLEMENT, M.D.
HERMAN, G. ERNEST, M.B.
HEWITT, GRAILY, M.D.
HICKS, JOHN BRAXTON, M.D., F.R.S.
LEISHMAN, WILLIAM, M.D., Glasgow.
MALINS, EDWARD, M.D., Birmingham.
POTTER, JOHN BAPTISTE, M.D.
PRIESTLEY, WILLIAM 0., M.D.
STEPHENSON, WILLIAM, M.D., Aberdeen.
WELLS, Sib T. SPENCER, Babt.
WILLIAMS, JOHN, M.D.
STANDING COMMITTEES.
BOARD FOR THE EXAMINATION OP MIDWIVES.
CHAiBMAB. BLACK, J. WATT, M.A., M.D.
BOULTON, PEECT, M.D,
CHAMPNETS, PEANCIS HENET, M. A., M.D.
CULLINGWOETH, CHARLES JAMES, M.D.
/-QALABIN, ALPEED LEWIS, M.A,, M.D.,
»«»« J JPretident.
K-OEFioio. < DOEAN, ALBAN, \„ «,
(.HOEEOCKS, PETEE, M.D., ] ^^- **"•
LIBRARY COMMITTEE.
BLACK, J. "WATT, M.A., M.D.
CHAMPNEYS, PEANCIS HENEY, M.A.,M.D.
DUNCAN, J. MATTHEWS, M.D., P.E 8.
PHILLIPS, JOHN, M.D.
GALABIN, ALPEED LEWIS, M.A., M.D.,
„ _, HEEMAN,* G. EENEST, M.B., li-eaturer.
"-°'""°-1 DOEAN, ALBAN, \ rr c
HOEEOCKS, PETEE, M.D., 5 ■"*"*• *""•
l^DTJNCAN, WILLIAM, M.D., Son. Lib.
r
PUBLICATION COMMITTEE.
¥x-omoio. •<
GEEVIS, HENEY, M.D.
HEEMAN, G. ERNEST, M.B.
HEWITT, GEAILY, M.D.
PLAYPAIE, WILLIAM S., M.D.
POTTEE, JOHN BAPTISTE, M.D,
WILLIAMS, JOHN, M.D.
GALABIN, ALFRED LEWIS, M.A., M.D.,
President.
CHAMPNEYS, PEANCIS HENEY, M.A.,M.D,,
Editor.
DOEAN, ALBAN, 7 ^ „
LHOREOCKS, PETEE, M,D„ ) ^'^' *^'
HONORARY LOCAL SECRETARIES.
Jones, Etan Aberdare.
Goss, T. BiDDULPH Bath.
Shabfin, Henky W Bedford.
CoERT, Thomas C. S., M.D Belfast.
Malins, Edwabd, M.D Birmingham.
FURNER, WlIJX)UGHBY ) Bjjehton
Salzhann^ Fbedebick William ) ^
S WAYNE, Joseph Griffiths, M.D Bristol.
Lowe, Geobge Burton-on-Trent.
KiGDEN, Geobge Canterbury.
Lawrence, A. E. Aust, M.D Clifton.
Cablyle, David, M.D Carlisle.
FiTZGEBALD, Chables Egebton, M.D Folkcstoue.
Batten, Bayneb W., M.D Gloucester.
Bbaithwaitb, James, M.D Leeds.
Wallace, John, M.D Liverpool.
Thompson, Joseph Nottingham.
Walkeb, Thomas James, M.D Peterborough.
Walters, James Hopkins Beading.
CoATES, Fbedebick William, M.D Salisbury.
Wilson, Bobebt James St.Leonard*8.
Taylor, John W., M.D Scarborough.
Keeling, James Hubd, M.D Sheffield.
BuBD, Edwabd, M.D., CM Shrewsbury.
Childs, Chbistopheb, M.B Weymouth.
Harris, William John Worthing.
Harvey, Robert, M.D Calcutta.
Branfoot, Arthur Mudge, M.B Madras.
Perrioo, James, M.D Montreal, Canada.
Anderson, Izett W., M.D Jamaica.
Takaki, Kanaheiro Japan.
OBSTETRICAL SOCIETY OF LONDON.
trustees of the society's pboperty.
Henky Oldham, M.D.
RoBEBT Babnes, M.D.
Sir Thomas Spsnceu Wells, Bart.
HONORARY FELLOWS.
BRITISH SUBJECTS.
Elected
1862 Duncan, James Matthews, M.D., A.M., LL.D., F.R.S.
Physician-Accoacheur to, and Lectarer on Midwifery
and Diseases of Women and Children at, St. Bartholo-
mew's Hospital ; 71, Brook street, Qrosvenor square,
W. Couneily 1878-80, 1886-8. Pres. 1881-82.
Trana. 24.
1871 Keilleb, Alexandeb, M.D., F.R.S. Ed., Physician to the
Royal Maternity Hospital, Lectarer on Midwifery and
Diseases of Women and Children at Sargeons' HalJ,
Edinburgh; 21, Queen street, Edinburgh.
1871 KiDD» OxoBGE H., M.D., F.R.C.S.I., Obstetrical Surgeon
to the Coombe Lying-in Hospital; 30, Merrion square
south, Dublin.
1870 West, Chables, M.D., F.R.G.P., Corresponding Member
of the Academy of Medicine of Paris ; 55, Harley street,
W. Pw. 1877-8.
XU FELLOWS OF THE SOCIETY.
FOBSIGN SUBJECTS.
1872 Babkeb, Fobdtcb^ M.D., Professor of Clinical Midwifery
and Diseases of Women at the Bellevue Hospital
Medical College, and Obstetric Physician to the Bellevae
Hospital ; 85, Madison avenue, New York.
1863 Bbaun VON Fbbnwald, Carl, M.D., Professor of Midwifery,
Vienna.
1863 Faye, F. C, M.D., Professor of Midwifery in the University
of Christiania.
1866 Hcgenbebobb, Theodob, M.D., k la Matemite et auz
Enfants Troav^ H6pital des Accouchements, Moscow.
1866 Lazabewitch, J., M.D., Professor Ejmeritas and Physician
to the Maximilian Hospital ; Spaskaja, 2, St. Peters-
burg. Trans. 3.
1864 Pajot, Ch. M.D., late Professor of Midwifery to the Faculty
of Medicine, Paris.
1862 ScANZONi, F. W. von, M.D., Wiirzburg.
1877 Stoltz, Professor, M.D, Nancy.
1872 Thomas, T. Gaillabd, M.D., Professor of Obstetrics in the
College of Physicians and Surgeons ; 296, Fifth
avenue, New York.
1862 ViBcuow, Rudolf, M.D., Professor of Pathological Ana-
tomy in the University of Berlin.
7BLL0WS OF THE SOCIETY. XIU
CORRESPONDING FELLOWS.
Elected
1873 Mastin, a. E., M.D., Berlin. Trane. 1.
1876 BusiN, P., M.D., 129, Boulevard St. Germain, Paris.
Tram, 1.
1876 Ghaswiok, James R., M.A., M.D., Physician for Diseases
of Women, Boston City Hospital; Clarendon street,
Boston, Massachusetts, U.S.
1877 OooDSLL, William, A.M., M.D., Professor of Gynaecology
in the University of Pennsylvania; 1418, Spruce
street, Philadelphia, Pennsylvania.
1876 LusK, William Thompson, M.D., Professor of Obstetrics,
Belle vue Hospital Medical College ; New York.
1877 Stober, Hosatio R., M.D., Newport, Rhode Island, U.S.A.
ORDINARY FELLOWS.
1890.
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 Fellows" of the
Society.
Elected
1887 AoHARD, Albxandbs Louis, M.D., 10, Blandford street,
Portman square, W.
1884 Adams, Thomas Rutherford, M.D., Stamford House, 78,
St. James's road, Croydon.
1887 Alexander, Sidney R., M.D. Lond., Essex Lodge, Upper
Norwood, S.E., and Nice, France.
1878 Alford, Frederick Stephen, 61, Haverstock hill, N.W.
1883 Allan, Robert John, L.R.C.P. Ed., Victoria street. Ash-
field, Sydney, New South Wales. [Per Alexander
Allan, Esq., Olen House, The Valley, Scarborough.]
1873 Allen, Henrt Marcus, F.R.G.P. Ed., 20, Regency
square, Brighton.
1887 Ambrose, Robert, B.A., L.R.C.P. & S. Ed., 1, Mount place,
Whitechapel road, E.
1878 Anderson, Izett William, M.D., 95, Duke street. Kings-
ton, Jamaica. Trans. 1. Hon. Loe. See.
1875 Anderson, John Ford, M.D., CM., 1, Buckland crescent,
Belsize park, N.W. CouncU, 1882.
1S66 Andrews, Henry Charles, M.D., 11, Addison terrace,
Notting hill, W. Council, 1882-3.
FELLOWS OF THE SOCIETY. XV
Elected
1859 Andbbws, James^ M.D.« Everleigh, Green hill, Hampstead,
N.W. Council, 1881.
1888 Annaoker, Ernest, M.D. Berlin, St. Mary's Hospital,
Manchester.
1884 Afplsfobd, Stephen Herbert, L.B.C.P. Lend., 17, Fins-
bury circus, E.G.
1870 Appleton, Robebt Cabliblb, The Bar House, Beverley.
1884 Applbton, Thomas A., 46, Britannia road, Fulham, S.W.
1883 Abchibald, John, M.D., Woodhouse Eaves, Loughborough.
1871 Abgles, Fbank, L.R.C.P.Ed., Hermon Lodge, Wanstead,
Essex, N.E. Council, 1886-7.
1888 Armstrong, Jambs, M.B. Edin., 84, Bodney street, Liver-
pool.
1861 Abmstbong, John, M.D., Green street green, Dartford, Kent.
1886 Ashe, William Peroy, L.R.C.P. Lond., Ivy Bank, Ghisle-
hurst.
O.F. Atbling, James H., M.D., Senior Physician to the Chelsea
Hospital 'for Women; 1, Upper Wimpole street, W.
Council, 1866-66, 1872, 1884. Hon. Sec. 1878. Hon.
Lib. 1 874-6. Vtce-Pree. 1877-8. Board Exam. Mid^
wives, 1872, 1875-83 {Chairman, 1878-83). Trane. 9.
1872 Aylino, Abthub H. W., 94a, Great Portland street, W.
1887 Bailet, Henby Fbedebick, The Hollies, Lee terrace, Lee,
S.E.
1873 Bailet, James Johnson, M.D., F.B.C.S. Ed., Woodville
Cottage, Marple, Cheshire.
1887 Baker, Oswald, L.R.C.P. & S. Ed., Surgeon-Major, Indian
Army, Simla, India.
1880 Balls- He ABLET, Walteb, M.D., F.R.C.P., 5, Collins street,
Melbourne. Victoria.
1869 Bantook, Geobge Obanville, M.D., Surgeon to the
Samaritan Free Hospital ; 12, Oranville place, Portman
square, W* Council, 1874-6. Ih'ane. 2.
XYl FELLOWS OF THE SOCIETY.
Elected
1886* Babboub, a. H. Fseeland, M.D. Edin., 24, Melyille street,
Edinbargh.
O.F. Babnes, Robsbt, M.D., F.R.C.P., Consulting Obstetric
Physician to St. George's Hospital; 15, Harlej street,
Gavendish square, W. Fiee-Pres. 1859-60. Council,
1861-62, 1867. Treae. 1863-64. Free. 1865-66.
Trans. 32. Trustee.
1875 Babnes, R. S. Fancoubt, M.D., Physician to the Ghelsea
Hospital for Women ; 7, Queen Anne street, Gayendish
square, W. Council^ 1879-81. Board Exam. Mid*
wives, 1880-2. Trans. 2.
1877 Babnes, Thomas Henbt, M.D., 54, London road, Croydon.
1884 Babbaolough, Robebt W. S., M.D., 34, Dulwich road,
Heme hill, S.W.
1887 Babton, Henbt Thomas, 63, Harford street, E.
1887 Babton, William Edwin, L.R.G.P. Lond., Staunton-on-
Wye, near Hereford.
1861* Babtbdm, John S., F.R.G.S., Surgeon to the Bath General
Hospital; 13, Gay street, Bath. Council, 1877-9.
1866 Babsett, John, M.D., Professor of Midwifery at the Queen's
College, Birmingham; 144, Hockley hill, Birmingham.
Council, 1874-6. Fiee-Pres. 1880-2. J^ans. 3.
1885 Bastable, Daniel Hbbbebt, L.K.Q.C.P.I.
1873 Bate, Geobge Paddock, M.D., 412, Bethnal Green road,
N.E. ; and 2, Northumberland Houses, King Edward
road. Hackney. Council, 1882-4.
1886 Bates, Tom, L.R.G.P.Ed., 44, Foregate street, Worcester.
1867 Batten, Ratneb W., M.D., F.R.C.P., Physician to the
Gloucester General Infirmary; 1, Brunswick square,
Gloucester. Council, 1886-7. Hon. Loc, Sec.
1887 Baumgabtneb, Henby Spelman, M.B. Durh., 1, Pleasant
row, Newcastle*on-Tyne.
1871 Beaoh, Fletcheb, M.B., Darenth Asylum, Dartford, Kent.
PBLLOWB OF THE SOeiETY. XVU
Elected
1871 Beadles, Asthub, Park House, Dartmouth Park, Forest
hUl, S.E.
1885 Bbatty, William John, L.R.C.P. Ed., Stockton-on-Tees.
1866 Belcher, Henby, M.D., 28, Cromwell road. West Brighton.
1871 Bell, Robert, M.D. Glasg., 29, Lynedoch street, Glasgow.
1880 Benin OTON, Robebt Cbewdson, 5, Victoria square, New-
castle-on-Tyne.
1873* Bennet, James Henby, M.D., Mentone. Council, 1881-3.
Trans. 1.
1889 Benson, Matthew, M.D. Bruz., 35, Dicconson street,
Wigan.
1883 Bertolacci, J. Hewetson, care of Dr. March, Woodlawu,
Spencer park. New Wandsworth, S.W.
1889 Best, William James, 1, Cambridge terrace, Dover.
1887 Beswick, Robebt, 161, Bishopsgate street Without, E.C.
1887 BiDEN, Chables Walter, L.R.C.P.Lond., 11, St. Mark's
road, Peckham, S.E.
1879 Biggs, J. M., Hillside, Child's hill, N.W.
1889 BissHOPP, Fbancis Robert Bryant, M.A., M.B.,
B.C.Cantab., Belvedere, Mount Pleasant, Tunbridge
WeUs.
1868 Black, James Watt, M.A., M.D., Obstetric Physician to the
Charing Cross Hospital ; 15, Clarges street, Piccadilly,
W. Council, 1872-4. Fice^Pree. 1885-6. Chairman,
Board Exam, Midwivee, 1887-90.
1861* Blake, Thomas William, Hurstbourne, Bournemouth,
Hants.
1872 Bland, Geobge, Surgeon to the Macclesfield Infirmary ;
Park Green, Macclesfield.
1887 Bluett, George Mallack, L.R.C.P. Lond., 3, Priory road,
Bedford park, Chiswick.
1883 BoNNEY, William Augustus, M.D., 145, Beaufort street,
Chelsea, S.W.
vol. XXXI. b
XVlll FBLLOWB OF THB SOCIETY.
Sleeted
1866* BouLTON, Pjbbcy, M.D., PhyBician to the Samaritan Free
Hospital, 6, Seymour street, Portman square, W.
Council, 1878-80, 1885. Hon. Lib. 1886. Hon. See,
1886-9. Fiee-Pree. 1890. Board Exam. Midwives,
1890. Trans. 3.
1886 BousTEAD, Robinson, M.D., Surgeon-Major, Indian Army,
c/o Messrs. H. S. King and Co., 45, Pall Mall, S.W.
1877 BowKETT, Thomas Edward, 145, East India road, Poplar,
£. Council, 1890.
1884* BoxALL, RoBEBT, M.D., Assistant Obstetric Physician to,
and Lecturer on Practical Midwifery at, the Middlesex
Hospital; 6, Chandos street, Cavendish square, W.
Council, 1888-90. Tran^. 9.
1884 Boys, Abthur Henby, L.R.C.P. Ed., Chequer Lawn, St.
Albans.
1886 Bbadbuby, Habyey K., 9, Schubert road. Putney, S.W.
1877 Bradley, Michael Mc Williams, M.B., Jarrow-on-Tyne.
1873 Bbaithi¥ait£, James, M.D., Obstetric Physician to the
Leeds General Infirmary ; Lecturer on Diseases of
Women and Children at the Leeds School of Medicine ;
1 6, Clarendon road. Little Woodhouse, Leeds. Vice-
Pres. 1877-9. Trans. 4. Hon. Loe. Sec.
1880 Bbanfoot, Abthub Mudge, M.B., Superintendent of the
Government Lying-in Hospital, Madras, and Professor
of Midwifery and Diseases of Women and Children in
the Madras Medical College, Pantheon road, Madras.
Hon. Loe. Sec.
1875 Bbbweb, Alexandeb Hampton, 201, Queen's road,
Dalston, E. Trans. 1.
1887 Bbidoeb, Adolfhus Edwabd, M.D. Ed., 16, Orchard street,
Portman square, W.
1872 Bbidgwateb, Thomas, M.B., Harrow-on-the-hill, N.W.
Council, 1884.
1888* Bbiggs, Henby, M.B., F.R.C.S., 17> Rodney st., Liverpool.
1864 Bbight, John Meabubn, M.D., Ahaston, Park hill. Forest
hill, S.E. Council, 1873-74.
i869 Bbisbane, Jambs, M.D., 21, Park road. Regent's park,
N.W.
FELLOWS OF THE SOCIETY. XIX
Elected
1885 Briscoe, John Frederick, The Lammas, Esber, Surrey.
1887 Beodie, Frederick Garden, L.R.C.P. Lond., 4, Greenfield
place, Westgate street, Newcastle-on-Tyne.
1 866 Brodie, George B., M.D., Consulting Physician-Accoucheui
to Queen Charlotte's Lying-in Hospital ; 3, Chesterfield
street. May fair, W. Council, 1873-75. Fice-Pres., 1889.
1889 Brook, William Henry B., M.B. Lond., F.R.C.S., County
Hospital, Lincoln.
1876 Brookhouse, Charles Turing, M.D., 43, Manor road,
Brockley, S.E.
1889 Brown, Alfred, M.A., M.B., CM. Aber., Claremont, Higher
Broughton, Manchester.
1868 Brown, Andrew, M.D. St. And., 1, Bartholomew road,
Kentish town, N.W. Trans, 1.
1865 Brown, D. Dtce, M.D., 29, Seymour street, Portman
square, W.
1889* Brown, William Carnegie, M.D. Aber., Penang, China.
1876 Brunjes, Martin, 33a, Gloucester place, Portman square,
W.
1865 Brunton, John, M.D., M.A., Surgeon to the Royal
Maternity Charity; 21, Euston road, N.W. Council,
1871-3. Fiee-Pres. 1 882-4 . Board Exam. Midwives,
1877-82. Tram. 6.
1883 BuKSH, Uaheem, Liverpool House,Balaam street, Plaistow, £.
1882* Buller, Audlbt Cecil, M.D., Oxford and Cambridge
Club, Pall Mall, S.W.
1885* Bunny, J. Brice, L.R.C.P. Ed., Newbury.
1877 Burchell, Peter Lodwick, M.B., 2, Kingsland road, E.,
and Crofton Lodge, Theydon park, Theydon Bois, Essex.
Council, 1882-4. Fice.-Pres. 1885-7. Board Exam.
Midwives, 1884-7. Trans. 1.
1877 BuRD, Edward, M.D., M.C., Senior Physician to the Salop
Infirmary; Newport House, Shrewsbury. Council,
1886-7. Hon. Loc. Sec.
XX PSLLOWB 09 tHE SOCIETY.
Elected
1888 BuBTON, Hebbsrt Campbell, L.R.C.P. Lond., Lee Park
Lodge, Blackheath, S.E.
1878 Butleb-Smythe, Albebt Chables, M.R.C.P.Ed., 35, Brook
street, Grosvenor square, W. Council^ 1889-90.
1868 Butt, William Fbedeeick, L.R.C.P. Lond., 48, Park
street, Grosvenor square, W. Council^ 1876-78.
1887* Buxton, Dudley W., M.D. Lond., 82, Mortimer street,
Cavendish square, W.
1886 Byebs, John W., M.D., Physician for Diseases of Women
to the Royal Hospital, Belfast ; Lower crescent, Bel-
fast.
1883 Caldwell, William T. D., M.D., 209, Brixton road, S.W.
1887 Camebon, James Chalmebs, M.D., Professor of Midwifery
and Diseases of Infancy, McGill University; 941, Dor-
chester street, Montreal.
1887 Camebon, Mubdoch, M.D. Glas., 7, Newton terrace,
Charing Cross, Glasgow.
1888* Campbell, William Macfie, M.D. Edin., 1, Princes gate
East, Liverpool.
1861 Candlish, Henby, M.D., Physician to the Alnwick In-
firmary ; 26, Fenkle street, Alnwick, Northumberland.
1863 Cablyle, David, M.D., 2, The Crescent, Carlisle. Trans, 1.
Hon, Loc, Sec,
1886 Cabpenteb, Abthub Bbistows, M.A., M.B. Oxon., Wyke-
ham House, Bedford park, Croydon.
1872 Cabteb, Chables Henby, M.D., Physician to the Hospital
for Women, Soho square ; 45, Great Cumberland place,
Hyde park, W. Council, 1880-2. Trans, 4.
1890 Cabteb, Robebt James, M.B. Lond., Lock Hospital, Dean
street, Soho, W.C.
1877 Cabteb, Eustace John, 3, Fulham park villas, Fulham,
S.W.
1887 Case, William, 34, Westbourne road, Arundel square, N.
1869 Caskie, John Boyd, M.D., 19, Tyndale place, Isling-
ton, N.
?ELLOWB OF THE SOCIETY. XXI
Elected
1863 Cayzbb, Thomas, Mayfield, Aigburth, Liverpool.
1875 Chaffers, Edwaed, F.R.C.S., 54, North street, Keigbley,
Yorkshire.
1876* Ghampneys, Fbancis Hbnby, M.A., M.D. Ozon., F.E.C.P.,
Obstetric Physician to, and Lecturer on Midwifery at,
St. George's Hospital, 60, Great Cumberland place, W.
Council, 1880-1 . Hon. Lib. 1882-3. Hon. See. 1884-7.
Vice-Preg. 1888-90. Board Exam. Midwives, 1883,
1888-90. Trans. 16.
1859 Chance, Edwaed John, F.R.C.S., Surgeon to the Metro-
politan Free Hospital and City Orthopaedic Hospital ;
14, Sussell square, W.C.
1886 Chapman, Chaeles William, L.R.C.P. Lond., The Firs,
Cheam, Surrey.
1867* Charles, T. Edmondstoune, M.D., Cannes, France.
Council, 1882-4.
1874 Chableswoeth, James, 25, Birch terrace, Hanley, Stafford-
shire.
1886 Chabpentieb, Ambbose E. L., M.D. Durh., 129, High street,
Uzbridge.
1868 Child, Edwin, ''Yernham," New Maiden, Kingston-on-
Thames, Surrey.
1890 Childe, Chables Plumley, B.A., L.R.C.P. Lond., Camden
House, Kent road, Southsea.
1883 Childs, Chbistopheb, M.A., M.B. Ozon., 2, Royal terrace,
Weymouth. Hon, Loc. Sec,
1863* Ghisholm, Edwin, M.D., Abergeldie, Ashfield, near Sydney,
New South Wales. [Per Messrs. Turner and Hen-
derson, care of Messrs. W. Dawson, 121, Cannon
street, E.G.].
1885 Chittekden, Thomas Hillieb, L.R.C.P. Lond., Garden
House, Wheathampstead, Herts.
1883 Clapham, Edwabd, M.D., 29, Lingfield road, Wimbledon.
1859 Clabemont, Claude Glabke, Millbrook House, 1, Hamp-
stead road, N.W.
1879 Clabkb, Reginald, South Lodge, Lee park, Lee, S.E.
XXU FELLOWS OF THB SOCIETY.
Elected
O.F. Clat, Ghasles, M.D., 39, Queen street, Blackpool.
1876 Clay, George Langsfobd, West View, 443, Moseley
road, Highgate, Birmingham.
O.F. Clay, John, Professor of Midwifery, Queen's College, Bir-
mingham ; Allan House, Steelhouse lane, Birmingham.
Council, 1868-69. Fice-Fres. 1872-4.
1889 Clemow, Arthub Henry Weiss, M.D., CM. Edin., 2,
Talgarth road. West Kensington, W.
O.F. Cleveland, William Frederick, M.D., Stuart villa,
199, Maida vale, W. Council, 1863-64. Fiee-Pres.
1875-77, 1887-89. Trans. 1.
1881 Close, James Alex, M.B., P.O. Box 96, Summerfield, St.
Clair Co., Illinois, U.S.
1865* CoATEs, Charles, M.D., Physician to the Bath General
and Royal United Hospitals; 10, Circus, Bath.
1882 CoATES, Frederick William, M.D., St. John street, Salis-
hury. Hon, Loc, Sec.
1878 CocKELL, Frederick Edgar, Jun., 62, Forest road,
Dalston, E.
1875 Coffin, Bichard Jas. Maitland, F.B.C.P. Ed., 98, EarPs
Court road, W.
1878 Coffin, Thomas Walker, 22, Upper Park road. Haver-
stock hill, N.W.
1875* Cole, Richard Beverly, M.D. Jefferson Coll. Philad.,
218, Post street, San Francisco, California, U.S.
1888 Collins, Edward Tenison, Campden House, Oakfield
road, Selly park, Birmingham.
1884 Collins, William Job, M.D., B.S., B.Sc. Lond., P.R.C.S.
Eng., 1, Albert terrace, Gloucester gate, N.W.
1877 CoLMAN, Walter Tawell, Hon. Surgeon to the Brighton
Hospital for Women ; 87> Buckingham road, Brighton,
1885 Cook, Philip Inkerman, M.D., Stratton, Tyson road,
Forest hill, S.E.
1866 Coombs, James, M.D., Bedford.
1873 Cooper, Frank W., Gainsborough House, Leytonstone, E.
FBLLOWS OF THB SOCIETY. XXIU
Meeted
1874 CooFEB« Hebbebt, L.R.C.P. Ed., Thurlow House, Hamp-
stead, N.W.
1888 CooPBB, Peteb, L.11.C.P. Lond., Stainton Lodge, Black-
heath, S.E.
1888 Cobby, Hbnby, B.A., M.D., 62, South Mall, Cork.
1875* CoBDES, Aug., M.D., M.R.C.P., Consulting Accoucheur to
the *' Mis^ricorde ;" Pri?at Docent for Midwifery at the
Uniyersity of Geneva ; 12, Rue Bellot, Geneva. Trans. 1.
1883 CoBNBB, CuBSHAM, 113, Mile End road, E.
1888 CoBNiSH, Chables Newton, L.R.C.P. Ed., Bushey Heath,
Herts.
1860* Cobby, Thomas Chables Steuabt, M.D., Senior Surgeon
to the Belfast General Dispensary ; Ormeau terrace,
Belfast. Council^ 1867. Han. Loc, See.
1888 Goby, Isaac Rising, L.R.C.P. Lond., Shere, Guildford.
1875 CoBY, RoBEBT, M.D., Assistant Ohstetric Physician to St.
Thomas's Hospital; 73, Lambeth Palace road, S.E.
Cottwc*/, 1879-81, 1884-5. Ftctf-Pre*. 1887-88. Trans.l.
1886 Cox, Joshua John, M.D. Ed., St. Ronan's, Clarendon road,
Eccles, Manchester.
1869 Cox, Riohabd, M.D. St. And., Theale, near Reading.
Trans. 1.
1877 Cbawfobd, Jambs, M.D.Durh., 4, Iddesleigh Mansions,
Victoria street, S.W.
1882 Cbeasb, James Bobebtson, F.B.C.S. Ed., 2, Ogle terrace^
South Shields.
1881 Cbeasy, James Gideon, Rectory lodge, Brasted, Sevenoaks.
1883 Cbemen, Patbiok John, M.D., 4, Camden place, Cork.
1876 Cbbw, John, Manor House, Higham Ferrers, Northampton-
shire.
1889 Cboft, Edwabd Octayius, L.R.C.P. Lond., 8, Clarendon
road, Leeds.
1881 Cbonk, Hebbbbt Geobge, M.B. Cantab., Septon, near Bur-
ton-on-Trent,
XXIV FELLOWS OF THE SOCIETY.
Elected
1886* Cross, William Joseph, M.B., Horsham, Victoria, Aus-
tralia.
1889 Ckouch, Edward Thomas, Lee Hoase, Stoke road, Gosport.
1875* Cullingworth, Charles James, M.D., F.R.C.P., Obstetric
Physician to, and Lecturer on Obstetric Medicine at,
St. Thomas's Hospital; 46, Brook street, Grosvenor
square, W. Council, 1883-5^ Fice-Pres. 1886-8.
Board Exam. Midwives, 1889-90. Trans. 6.
1859 Cubgekyen, J. Brendon, 11, Craven hill gardens. Bays-
water, W. Council, 1870-72. Trans. 3.
1889 CuRSETJi, JehIngib J., M.D. Brux., 94, Chundunw&di,
Bombay.
1885 Dakin, W. Badford, M.D., Obstetric Physician to Out-
patients, Great Northern Central Hospital; 57« Wel-
beck street, Cayendish square, W. Council, 1889-90
Trans. 1.
1868 Daly, Frederick Henry, M.D., 185, Amhurst road.
Hackney Downs, N.B. Council, 1877-9. Fice-Pres
1883-5. Trans. 2.
1882 Dambrill-Dayies, William B., Alderley Edge, Cheshire.
1888 Dane, Robert, 86, Finchley road, N.W.
1884 Darwin, George Henry, M.R.C.P., The Cedars, Albert
park, Didsbury, near Manchester.
1889 Dayies, Fredebick Henry, M.B., C.M.Edin., Tilbury,
Essex.
1876 Dayies, Gomer. L.R.C.P. Ed., 9, Pembridge Yillas, Bays-
water, W,
1884 Dayies, John, 91, New North road, N.
1885 Dayies, William Morriston, M.D., 55, Gordon square,
W.C.
1877 Dayson, Smith Houston, M.D., Campden villa, 203, Maida
vale, W. Council, 1889-90.
1889 Dawson, William Edward, L.K.Q.C.P. & L.M., 29, Chis-
well street, E.C.
FELLOWS OF THE SOCIETY. XXV
Elected
1878 Day, Edmund Oyebman, AssistaDt Surgeon to the Royal
Infirmary for Children and Women, Waterloo Bridge
road ; 78, Waterloo road, S.E.
1880 Day, William Hankes, Surgeon to the City Prisons,
Norwich; 3, Surrey street, Norwich. Tram, 1.
1859 Day, William Henry, M.D., Physician to the Samaritan
Free Hospital for Women and Children ; 10, Man-
chester square, W. CownctV, 1873-75. Fice-Prw. 1885-6.
1889 Des V(eux, Habold A., M.D. Brnx., 1 1, Carlisle Mansions,
Ashley place, Victoria street, S.W.
1877 Dbwab, John, L.R.C.P. Ed., 132, Sloane street, S.W.
1885 D'MoNTE, DoMiNicK A., M.D., Bandora, Bombay.
1887 DoDSON, Abthub Edwabd, L.R.C.P. and L.M. Ed., Win-
dermere villas, Earlsfield, Tooting, S.W.
1879 DoLAN, Thomas Michael, M.D., Horton house, Halifax.
1886 Donald, Abchibald, M.A., M.D. Edin., 274, Oxford road,
Manchester. Trans, 1.
1879 DoBAN, Alban H. 6., F.R.C.S., Surgeon to the Samaritan
Free Hospital ; 9, Granville place, Portman square, W.
Council, 1883-5. Hon, Lib, 1886-7. Hon, Sec. 1888-90.
Tram, 9.
1890 DouTY, Edwabd Henby, M.A., M.B., B.C.Cantab,, 69,
Bridge street, Cambridge.
1887 DoYASTON, MiLWABD Edmdnd, 81, Queen's crescent,
Haverstock hill, N.W.
1880 Downes, Denis Sidney, L.K.Q.C.P. I., 55, Kentish town
road, N.W.
1884 Doyle, E. A. Gaynes, L.R.C.P., Colonial Hospital,
Port of Spain, Trinidad.
O.F. Dbaoe, Chables, M.D., Hatfield, Herts. Council, 1861-4.
Trans, 1.
1885 Dbaoe, Loyell, M.A., M.B., B.S. (Oxon), Burleigh Mead,
Hatfield.
XXVI FBLLOWS OF THB SOCIBTY.
Elected
1871 Dbake-Bbocrman, Edwasd Fossteb, F.R.C S,, L.R.G.P.
Lond., Surgeon-Major ; Saperintendent Eye Infirmaryy
Madras ; Professor of Physiology and Ophthalmology,
Madras Medical College. [^Per Messrs. Richardson
and Co., East India Army Agency, 25, SajQblk street,
PaU Mall, S.W.]
1884 Dbake, Chables Henby, 204, Brixton hill, S.W.
1884 Duke, John C, The Glen, Lewisham, S.E.
1883 Duncan, Alexandeb Geobge, M.B., 25, Amburst park,
Stamford hill, N.E.
O.F. Duncan, James, M.B., 8, Henrietta street, Govent garden,
W.C. Council, 1873-74.
1888 Duncan, William, L.R.G.P. & S.Ed., 17, Redland grove,
Bristol.
1882 Duncan, William, M.D., Obstetric Physician to, and Lec-
turer on Obstetric Medicine at, the Middlesex Hospital ;
6, Harley street, W. Council, 1885-6, 1888-89. Bon.
Lib. 1890. Trans. 1.
1871 Eastes, Geobge, M.B., F.R.C.S., 35, Gloucester place,
Hyde park, W. Oouneil, 1878-80.
1883 EccLES, F. RiCHABD, M.D., Examiner for the College of
Physicians and Surgeons, Ontario ; Professor of Phy-
siology, Western University ; 1, EUwood place. Queen's
avenue, London, Ontario, Canada.
1879 Eldeb, Geobge, M.D., CM., Surgeon to the Samaritan
Hospital for Women, Nottingham ; 1 7> Regent street,
Nottingham.
1879 Elkington, Abthub Guy, Deputy Surgeon-General, late
Grenadier Guards, 52, Gillingham street, Eceleston
square, S.W. Council, 1886-7. Fice-Pres. 1890.
1878 Elleby, Richabd, L.R.C.P.Ed., Plympton, Devon.
1873 Engelmann, Geobge Julius, A.M., M.D., 3003, Locust
street, St. Louis, Missouri, U.S.
1884 English, Thomas Johnston, M.D., 128, Fulham road,
S,W.
1875 Ewabt, John Henby, Eastney, Devonshire place, East-
bourne.
FELLOWS OF THB SOCIETY. XXYll
Elected
1876 Fabncombe, Richard, 40, Belgrave street, Balsall heath,
Birmingham.
1869 Fabquhab, William, M.D., Deputy Surgeon-General,
Goonoor, Neilgherries, Madras.
1861 Fabb, Geo. F., L.R.G.P. Ed., Slade House, 175, Ken-
nington road, S.E. Council^ 1885.
1882 Fabbab, Joseph, M.D., Gainsborough.
1868 Fegan, Richabd, M.D., Westcombe park, Blackheath, S.E.
1888 Fegen, Chables Milton, Devonshire House, Brandon,
Suffolk.
1886 Femnell, David, L.E.Q.G.P.I., 12, Devonshire terrace,
Hastings.
1883 Fenton, Hugh, M.D., 29, Brook street, Grosvenor square,
W.
1886 FiSHEB, Fbedebick Bazley, L.B.C.P. Lond., West Walk,
Dorchester.
1870 FiSHEB, John Moobe, M.D., 6, Pryme street, Hull.
1882 Fitzgebald, Chables Egebton, M.D., West Terrace,
Folkestone. Hon, Loc. See.
1877* Fonmabtin, Heutbt de, M.D., 1, Anchor Gate terrace,
Portsea.
1884 FoBD, Alexandeb, L.R.C.P.Ed., 9, Beresford street, Water-
ford.
1877* FoBD, James, M.D., Eltbam, Kent.
1884 FouBACBE, RoBEBT Pebbiman, 20, ToUington park, N.
1886 FowLEB, Chables Owen, M.D., Trevor Lodge, Thornton
heath, S.W.
1875* Fbaseb, Angus, M.D., Physician and Lecturer on Clinical
Medicine to the Aberdeen Royal Infirmary ; 232, Union
street, Aberdeen.
1888 Fbaseb, James Alexandeb, L.R.G.P. Lond., Western
Lodge, Romford.
1 886 Fbseland, Ebnest Habding, L.R.C.P. Lond., care of Penin-
salar and Oriental Steamship Company, Leadenhall
street, E.G.
XXVIU FBLL0W8 OF THB SOCIETY.
Elected
1867 Freeman, Henby W., 24, Circus, Bath.
1880 Fby, John Blount, Ashley Lodge, Esher, Sarrey.
1883 Fuller, Henry Roxburgh, M.D. Gantah., 45, Curzon
street. May fair, W. Trans. 1.
1886 FuRNER, WiLLOUQHBY, F.R.C.S., 2, Brunswick place,
West Brighton. Hon. Loc, See.
1874* Galabin, Alfred Lewis, M.A., M.D., Obstetric Physician
to, and Lecturer on Midwifery at, Guy's Hospital ; 49,
Wimpole street, Cavendish square, W. Council, 1876-
78. Hon. Lib. 1879. Hon. Sec. 1880-3. Vice^Pres.
1884. IVtfM. 1885-8. Free. 1889-90. Trans. 12.
1888 Galloway, Arthur Wilton, L.E.C.P. Lond., 79, New
North road, N.
1863 Galton, John H., M.D., Ghunam, Sylvan road. Upper
Norwood, S.E. Council, 1874-6.
1881 Gandy, William, Hill Top, Central hill, Norwood, S.E.
1886 G-ARDE, Henry Croker, F.B.G.S. Edin., Maryborough,
Queensland.
1887 Gardiner, Bruce H. J., L.R.C.P. Ed., Gloucester House,
Barry road, East Dulwich, S.E.
1879 Gardner, John Twiname, 6, Hillsboro' terrace, Ilfracombe.
1872 Gardner, William, M.A., M.D., Professor of Gynsecology,
McGill University; Gynaecologist to the Montreal
General Hospital; 109, Union avenue, Montreal,
Canada.
1876 Garner, John, 52, New Hall street, Birmingham.
1873 Garton, William, M.D., F.B.G.S., 5, Hawkshead street,
Southport.
1889* Gell, Henry Willinoham, M.A., M.B.Ozon., 43, Alhion
street, Hyde park, W.
1859* Gervis, Henry, M.D., F.R.C.P., Consulting Obstetric
Physician to St. Thomas's Hospital ; 40, Harley street.
Cavendish square. Council, 1864-66, 1889-90. Hon.
Sec. 1867-70. Fice-Pres. 1871-3. Treas. 1878-81.
Pres. 1883-4. Trans. 8.
nSlLOWS OF Tttlfi SOClBtY. XXIX
Sleeted
1866 Gebyis, Fbederigk Heudeboubgk, 1, Fellows road
Haverstock hill, N.W. Council, 1877-9. Trans, 1.
1884 GiBB, Ghables John, M.D., Westgate House, Newcastle-
on-Tyne.
1875 Gibbings, Alfbed Thomas, M.D., 93, Richmond road,
Dalston, N.E. Council, 1885-6, 1888.
1883 Gibbons, Robebt Alexandeb, M.D., Physician to the
Grosvenor Hospital for Women and Children; 29,
Cadogan place, S.W. Council, 1889-90. Trans, 1.
1874 Gibson, James Edwabd, Hillside, West Cowes, Isle of
Wight.
1877 GiPFABD, Douglas William, 5, Pavilion parade. Old
Steyne, Brighton.
1869 Gill, William, L.B.C.P. Lond., 11, Russell square, W.C.
1871 GoDDABD, Eugene, M.D. Durh., North Lynne, Highbury
New Park, N. Trans. 1.
1876 GoDFBAT, Alfbed Ghables, M.B., St. Helier House, Jersey.
1871 Godson, Clement, M.D., CM., Assistant Physician-
Accoucheur to St. Bartholomew's Hospital; 9> Gros-
venor street, W. Council, 1876-77. Hon. Sec. 1878-
81. Tice-Pres, 1882-4. Board Exam. Midwives,
1877, 1882-86. Trans. 5.
1868 Godwin, Ashton, M.D., 28, Brompton crescent, Brompton,
S.W.
1873 GooDCHiLD, Nathaniel, L.R.C.P. Ed., Sidney House,
Highgate road, N.W.
1883 GoBDON, John, M.D., 10, Amersham road, New Cross, S.E.
1869 Goss, Tbegenna Biddulph, 1, The Circus, Bath. Hon.
hoc. Sec,
1889 GouLLET, Chables Abthub, L.R.C.P. Lond., 2, Finchley
road, N.W.
1884 GowANS, William, F.R.C.S. Ed., 1, Victoria terrace. South
Shields.
1889 Graham, Abthub, L.R.C.P. & S. Ed., 4, Westbourne place,
S.W.
1885 Gbant, Ogiltie, M.D., Queen Mary's House, Inverness.
tXX PSLLOWS OJf THB BOCIlfiTY.
Elected
1890 Gbay, Habrt St. Glaib, M.D. Glas., 15, Newton terrace,
Glasgow.
1875 Gbat, James, M.D., 15, Newton terrace, Glasgow.
1884 Gbebnb, Walteb, L.B.C.P. Lend., Wallingford.
1887 Gbbenwood, Edwin Glimson, L.R.C.P., 19, St. John's
wood park, N.W.
1863 Gf^BiFFiTH, G. DE GoBBEauEB, 34, St. Georgc's square,
S.W. Trane, 2.
1869 Gbiffith, John T., M.D., Talfourd House, Gamberwell,
S.E. Council, 1884-6.
1879* Gbiffith, Walteb Spenceb Andebson, M.D. Gantab.,
F.R.G.S., M.R.C.P., Obstetric Physician to the Great
Northern Central Hospital ; Tutor in Obstetrics and
Gynecology at St. Bartholomew's Hospital ; 1 14,Harley
street, W. CotinctY, 1886-8. Board Exam, Midwiveet
1887-89. Trane, 3.
■
1870 Gbigo, William Chapman, M.D., Physician to the In-
patients, Queen Charlotte's Lying-in Hospital; Assistant
Obstetric Physician to the Westminster Hospital;
27, Curzon street, Mayfair. Obunct/, 1875-77. Board
Exam, Midunvee, 1878-79.
1888* Grimsdale, Thomas Babinqton, B.A., M.B. Cantab., 50,
Bodney street, Liverpool.
O.F. Gbim3Dale,Thos. F., L.B.C.P. Ed., Consulting Surgeon to
the Lying-in Hospital ; 29, Rodney street, Liyerpool.
Council, 1861-62. Vice-Prea. 1875-76.
1882 Gbipfeb, Walteb, M.B. Cantab., The Poplars, Wallington,
Surrey.
1880 Gbooong, Walteb Atkins, Berwick House, Broadway,
Stratford, E.
1 879 Gboye, William Bichabd, M. D., St. Ives, Huntingdonshire.
1887 Gbowse, William, L.R.C.P. Lond., Marton, near Rugby.
1885 Gbun, Edwabd Febdinand, 2, Lower Richmond road,
Putney, S.W.
1887 Hackney, John, M.D. St. And., Oaklands, Hythe.
PBLLOWS OF THE SOCIE'TY. XXXI
Elected
1867 Hadaway, Jaheb, L.RC.P. Ed., Dent-de-Lion Villa, Gar-
lioge, near Margate.
1876 Hadden» John, M.D., 31, West street, Horncastle, Lincoln-
shire.
1881 Hair, James, M.D., Brinklow, Coventry.
1889 Hale, Ghables D. B., L.R.C.P. Lond., 8, Sussex gardens,
Hyde park, W.
1859 Hall, Frederick, 1, Jermyn street, St. James's,, S.W.
1889 Hall, Frederick, M.D.St. And., St. Mark's Hoase, Leeds.
1871 Hallowes, Frederick B., Redhill, Beigate, Surrey. Coun-
cil, 1885-6, 1888-90.
1880 Hames, George Henry, F.R.C.S., 2, Queensborough ter-
race, W.
1887 Hamilton, John, F.R.C.S. Ed., Swadlincote, Burton-on-
Treut.
1883 Handfield-Jones, Montagu, M.D.Lond., M.R.C.P., Joint-
Lecturer on Midwifery at, and Physician Accoucheur
in charge of Out-patients to, St. Mary's Hospital ; 24,
Montagu square, W. Council, 1887-89. Trans, 1.
1860 Hardey, Key, Surgeon to the West City Dispensary ; 4,
Wardrobe place, Doctors' Commons, E.C.
1889 Hardwick, Arthur, M.D. Durh., Newquay, Cornwall.
1886 Hardy, Henry L. P., Holly Lodge, Richmond road,
Kingston-on-Thames.
1889 Harper, Charles John, L.R.C.P. Lond., Church end,
Finchley, N.
1877 Harper, Gerald S., M.B. Aber., 5, Hertford street, May-
fair, W.
1878 Harries, Thomas Dayies, F.R.C.S., Grosvenor House,
Aberystwith, Cardiganshire.
1867 Harris, William H., M.D., 78, Oxford gardens, W.
1861 Harris, William John, Church House, Heene, Worthing.
Han. Loc, Sec.
1880* Harrison, Richard Charlton, 13, Sandringham gardens,
Ealing, W.
XXxil YELLOWS OY THfi SOCIBTY.
Mected
1886 Hartley, Horace, L.R.C.P. Ed., Stone, Staffordshire.
1886 Hartley, Reginald, L.R.C.P. Ed., Kirkgate House, Thirsk.
1880 Harvey, John Stephenson, 69, Rue Faidherbe, Boulogne-
sur-Mer, France.
1865 Harvey, Robert, M.D., .52, Chowringhee, Calcutta.
[Per Messrs. Cochran and Macpherson, 152, Union
street, Aberdeen.] Trans, 1. Hon. Loe, Sec.
1886 Harvey, Sidney Fred., L.R.C.P. Lond., 42, Perham road.
West Kensington, W.
1888 Haycock, Henry Edward, L.R.C.P. Ed., Whitwell, Welwyn.
1865 Hayes, Hawkesley Roche, Basingstoke, Hants.
1873 Hayes, Thomas Crawford, M.D., F.R.C.P., Assistant Ob-
stetric Physician to King's College Hospital ; 1 7, Clarges
street, Piccadilly, W. Council, 1876-78. Fice-Prea.
1890.
1880 Heath, William Lenton, M.B., 88a, Cromwell road,
Queen's gate, S.W. Trans. 1.
1890 Helme, T. Arthur, M.D. Edin., St. Mary's Hospital,
Manchester.
1867 Hembrough, John William, Ivy Cottage, Waltham,
Grimsby.
1881 Hepburn, William Alex., Rosslyn House, Coxhoe, Co.
Durham.
1876* Herman, George Ernest, M.B., F.R.C.P., Obstetric Phy-
sician to, and Lecturer on Midwifery at, the London
Hospital; 20, Harley street. Cavendish square, W.
Council, \Q7S-79. Hon. Lib. \SSOA. Hon. Sec. 1882-5.
Fice-Pres. 1886-7. Board Exam. Midwives, 1886-88.
Treas. 1889-90. Trans. 19.
1887 Hewitt, Frederic William, M.D. Cantab., 10, George
street, Hanover square, W.
O.F. Hewitt, Graily, M.D., F.R.C.P., F.R.S. Ed., Consulting
Obstetric Physician to University College Hospital;
36, Berkeley square, W. Bon, Sec. 1859-64. Treas.
1865-66. Fice-Pres.\867 '68. Pres.l869'70. Trans.2l.
FELLOWS OF THE SOCIETY. XXXIU
Elected
I860 Hicks, John Bbaxtoit, M.D., F.R.C.P., F.R.S., Physician
Accoachear to, and Lecturer on Midwifery and Diseases
of Women at, St. Mary's Hospital ; 24, George street,
Hanover square. Council, 1861-2, 1869. Hon, See.
1863-65. Fice-Pres. 1866-68. Treas. 1870. Free.
1871-2. Trans, 37.
1860 HiGGs, Thomas Frederic, M.D., Beaconsfield House,
Dudley, Worcestershire.
1886 Hoar, Charles, M.B., CM. Aber., Bantony House, Hurst
Green, Hawkhurst (Railway Station Robertsbridge).
1886 Hodges, Herbert Chamney, L.R.C.P. Lond., Watton,
• Herts. Trans. 1.
O.F. Hodges, Richard, M.D., F.R.C.S., 36, Harewood square,
N.W. Trans. 3.
1887 HoDsoN, Henrt Algernon, L.R.G.P. Ed. & L.M., 23,
Brunswick square, Brighton.
1886 Holberton, Henry Nelson, L.R.C.P. Lond., East
Molesey.
1875 HoLLiNGs, Edwin, M.D., 4, Gordon street, Gordon square,
W.C. Council, 1888-90.
1886 HoLLOWAY, William George, B.A., M.B. Cantab., East
Sussex Hospital, Hastings.
1859 HoLMAN, CoNSTANTiNE, M.D., The Barons, Reigate, Surrey.
Council, 1867-69. Fice-Pres. 1870-71.
1880 HoNiBALL, Oscar Dunscombe, M.D., George Town, Deme-
rara, British Guiana.
1864 Hood, Wharton Peter, M.D., 11, Seymour street, Port-
man square, W.
1872 Hops, William, M.D., Physician to Queen Charlotte's
Lying-in Hospital ; 56, Curzon street. May fair, W.
Council, 1877-9. Board Exam, Mdwives, 1873-4.
1884 Hopkins, John, L.R.C.P. Ed., 93, Camberwell road, S.E.
1883* Horrocks, Peter, M.D., F.R.C.P. Lood., Assistant Ob-
stetric Physician to, and Demonstrator of Practical
Obstetrics at, Guy's Hospital ; 26, St. Thomas's street,
S.E. CouncU, 1886-7. Hon. Lib. 1888-9. Hon. Sec.
1890. Trans. 1.
TOL. XXXI. c
XXXIY FELLOWS OF THE SOCIETY.
JSleeted
1876 HoEBMAN, Godfrey Charles, 22, King street, Portman
square, W.
1883 HosKiN, Theophilus, L.R.G.P. Lend., 186, Amharst road,
N.E.
1883 HoucHiK, Edmukd Kino, L.R.G.P.Ed., 23, High street.
Stepney, E.
1884 Hough, Charles Henry, Full street, Derby.
1877 Howell, Horace Sydney, M.D., East Grove House, 18,
Boundary road, St. John's Wood, N.W.
1879 Hubbard, Thomas Wells, Lenham, Bromley, Kent.
1885 Hughes, Edgar A., L.R.C.P. Lond., 91, Onslow gardens,
S.W.
1889 HuMPHRYS, Charles Beyer, L.R.C.P. & S. Edin., The
Poplars, Horsmonden, Kent.
1884* Hurry, Jamieson Boyd, M.D. Cantab., 43, Castle street,
Reading. Council, 1887-9. Traru. 1.
1878 Husband, Walter Edward, 56, Bury New road, Man-
chester.
1882 HuTTON, Robert James, L.R.C.P. Ed., Carshalton House,
Stapleton Hall road, Finsbury park, N.
1883 Inman, Robert Edward, 243, Hackney road, E.
1884 Irwin, John Arthur, M.A., M.D., 427, Fifth avenue. New
York.
1887 Jackson, 6. K Corrie, F.R.C.S. Ed., 17, Poland street,
W.
1883 Jackson, George Henry, Lansdowne House, Totteuham.
1884 Jackson, James, 15, Huntingdon street, Bamsbury, N.
1 864 Jackson, Robert, M.D., 53, Netting hill square, W. Council^
1885.
1886 Jacomb-Hood, Charles John, L.R.C.P., Broadwater
House, Tunbridge Wells.
1873 Jakins, William Vosper, L.R.C.P. Ed., 165, Collins street
East, Melbourne.
1872 Jalland, Robert, Homcastle, Lincolnshire. Trans. 1.
1890 James, Charles Henry, L.R.C.P. Lond., General Lying-
in Hospital, York road, S.E.
FELLOWS OF THB 80CIBTT. ZXXV
JBleeied
1877 Jamieson, Patrick, M.A., 3, St. Peter's street, Peterhead,
i^berdeenshire.
1885 Jamibson, Eobert Alexander, M.D., Shanghai. [Per
Messrs. Henry S. King and Co., 65, Comhill, B.C.]
1886 Jamison, Arthur Andrew, M.D. Glas., 26, Lowndes
street, S.W.
)883* Jenkins, Edward Johnstone, M.B. Oxon., Australian
Club, Sydney. [Per H. K. Lewis, 136, Gower street,
W. C]
1877 Jenks, Edward W., M.D., 84, Lafayette avenue, Detroit,
Michigan, U.S.
1882 Jennings, Charles Egerton, F.R.C.S. Eng., Assistant
Surgeon to the North- West London Hospital ; 15,
Upper Brook street, Grosvenor square, W.
1889 Johns, Henrt Douglas, L.R.C.P., The Dispensary, Gates-
head.
1883 Johnson, Arthur Jukes, M.B., 52, Bloor street West,
Toronto, Ontario, Canada.
1888 Johnson, John George. L.R.C.P. Lond., Concrete House,
Swindon.
18/7 Johnson, Samuel, M.D., 5, Hill street, Stoke-upon-Trent.
1881 Johnston, Joseph, M.D., 24, St. John's Wood park, N.W.
1879 Johnston, Wm. Beech, M.D., 157, Jamaica road, Ber-
mondsey, S.E.
1868 Jones, Eyan, Ty-Mawr, Aherdare, Glamorganshire. Council,
1886-8. Vice.'Pres. 1890. Hon. Loc. Sec.
1878 Jones, H. Macnaughton, M.D., F.R.C.S.L and Edin.,
141, Harley street, Cavendish square, W.
1881 Jones, James Robert, M.B., 171, Donald street, Winnipeg,
Manitoba, Canada.
1868 Jones, John, 60, King street. Regent street, W.
1887 Jones, J. Talfourd, M.B. Lond., Rose Bank, South terrace
Eastbourne.
1876 Jones, Leslie, M.D., CM., Limefield House, Cheetham
Hill, Manchester.
1886 Jones, Lewis, M.D., Oakmead, Balham, S.W.
XXXVl YELLOWS OF THE SOCIETT.
JSlected
1885 Jones, P. Sydney, M.D., 16, College street, Hyde park,
Sydney. [Per Messrs. D. Jones and Co., 1, Gresham
buildings, Basingliall street, B.C.]
1873 Jones, Philip W., Silver street, Enfield.
1886 Jones, William Owen, The Downs, Bowden, Manchester.
1879 Joubert, Charles Henry, M.B.Lond., F.R.C.S. Eng.,
Snrgeon-Major, Bengal Medical Dept.,54, Chowringhec^
Calcutta.
1878 JuDSON, Thomas Robert, L.R.C.P. Lond., Hayman's
Green, West Derby, Liverpool.
1875 Jukes, Augustus, M.B., N. W, Mounted Police, Regina,
N.-W. Territory, Canada.
1878 Kane, Nathaniel H. E., M.D.> Lanherne, Kingston hill,
Surrey.
1884 Keates, William Coopeb, L.R.C.P., 2, Tredegar villas.
East Dulwich road, S.E.
1880 Kebbell, Alfred, Flaxton, York.
O.F. Keele, George Thomas, 81, St. Paul's road. High-
bury, N. Council, 1885.
1883 Keeling, James Hurd, M.D., 267« Glossop road, Sheffield.
Hon. Loc, Sec,
1874 Kemfster, William Henry, M.D., Oak House, Bridge road,
Battersea, S.W.
1886 Kennedy, Alfred Edmund, L.R.C.P. Ed., Chesterton
House, Plaistow, E.
1879 Keb, Hugh Riohard, L.R.C.P. Ed., Townsend House,
Hales-Owen.
1872 Kerb, Nobman S., M.D., F.L.S., 42, Grove road. Regent's
park, N.W.
1877* Kbbswill, John Bedford, M.R.C.P. Ed., Fairfield, St.
German's, Cornwall.
1878 KuoRY, Rustonjee Nasebwanjee, M.D. Brussels, L.Med.
Bombay, Physician to the Parell Dispensary, Bombay ;
Girgaum road, Bombay.
O.F. Kjallmabk, Henby Walteb, 5, Pembridge gardens, Bays*
water. Council^ 1879-80.
FELLOWS OP THE SOCIETY. XXXYll
Elected
1860 KiNGSFORD, Edward, F.R.C.S., Surgeon to the Sanbury
Dispensary ; Sunbury-on-Thames.
1872* EiscH, Albert^ 3, Sutherland gardens, Maida vale, W.
1876 Knott, Charles, M.R.C.P. Ed., Liz Ville, Elm grove,
Southsea.
1889 Lake, George Robert, 72, Gloucester crescent, Hyde
park, W.
1867 Langford, Charles P., Sunnyside, Hornsey lane, N.
1887 Lanqhorne, Thomas Grant, Millicent, S. Australia.
1883 Langlet, Aaron, L.R.C.P. Ed., 149, Walworth road, S.E
1886 Lankester, Herbert Henrt, M.D.Lond., 1, Elm park
gardens, South Kensington, S.W.
1886 Lauder, William, M.D. Edin., 260, Oxford road, Man-
chester.
1887 Law, William Thomas, M.D. Edin., 9, Norfolk crescent, W.
1875 Lawrence, Alfred Edward Aust, M.D., Physician-
Accoucheur to the Bristol General Hospital; )5,
Richmond hill, Clifton, Bristol. Cbtinct7, 1885-86,
1888. Vice-Pres,, 1889-90. Hon, Loc. See.
1878 Leachman, Albert Warren, M.D., Fairley, Petersfield,
Hants.
1884* Lediard, Henry Ambrose, M.D., 43, Lowther street,
Carlisle. Council, 1890. Trane, 1.
1887 Lees, Edwin Leonard, M.B., G.M. Ed., 2, The Avenue,
Redland road, Bristol.
1860 Leibhman, William, M.D., Physician to the University
Lying-in Hospital, Regius Professor of Midwifery in
the University of Glasgow ; 11, Woodside crescent,
Glasgow. Council, 1866-68. Vice-Pree. 1869-70.
Trans. 1.
1885 LswERS, Arthur H. N., M.D. Lond., M.R.G.P., Assistant
Obstetric Physician to the London Hospital; 60.
Wimpole street, W. Council, 1887-89. Trans. 5.
1890 Lewis, Ernest E., L.R.G.P. Lond., Middlesex Hospital ,W.
1877 Lewis, John Riogs Miller, M.D., Deputy-Surgeon General,
Markham Lodge, Liverpool road, Kingston hiill, Surrey.
XXXVUl FELLOWS OF THE SOCIETY.
Elected
1885 LiDiARD, Sydney Robert, L.R.G.P. Ed., 48, Charlotte
street, Hull.
1875 LiEBMAN, Carlo, M.D. Vienna, Principal Surgeon, Trieste
Civil Hospital, Trieste, Austria. Trans. 1.
1874 LiTHGow, Robert Alexander Douglas, M.R.C.P. Ed.,
27a, Lowndes street, Belgrave square,. S.W,
1868 Llewellyn. Eyan, L.R.C.P. Ed., The Limes, Bow road,
E.
1872* Lock, John Griffith, M.A., 2, Rock terrace, Tenby.
1859 LoMBEj Thomas Robert, M.D., Bemerton, Torquay.
1862 Lowe, George, F.R.C.S., 5, Horninglow street, Bnrtou-on-
Trent, Staffordshire. Council, 1887-89. Trana. 2.
Hon, Loc, See.
1873 Lush, William John Henry, M.D.Brussels, Fyfield House,
Andover.
1878* Lycbtt, John Allan, M.D.,The " Hollies," Graiseley, Wol-
Yerhampton.
1871 McCallum, Duncan Campbell, M.D., Emeritus Professor,
McGili University; 45, Union avenue, Montreal, Canada.
Trans. 4.
18S4 McCarthy, George Francis, L.K.Q.C.P., 138, Westmin-
ster Bridge road, S.E.
1879 Mackeough, George J., M.D., Chatham, Ontario, Canada.
1888 Mackern, John, B.A., M.D.Cantab., F.R.C.S., 30, Cam-
bridge street, Hyde park, W.
O.F. Mackinder, Draper, M.D., Consulting Surgeon to the
Gainsborough Dispensary; Gainsborough, Lincolnshire.
OouncU, 1871-3. Trans. 2.
1879 Maolaurin, Henry Normand, M.D., 155, Macqnarie
street, Sydney, New South Wales.
1886 McMullen, William, L.K.Q.C.P.L» 319a, Brixton road,
S.W.
1859 Madge, Henry M., M.D., 4, Upper Wimpole street, W.
Council, 1863-65, 1884. Fice-Pres. 1872-4. Trans.
15.
J884 Malgolm, John D., M.B.y CM., 24, Bryanston street, W.
FELLOWS OP THB SOCIETY. XXXIX
JElecied
1871 Malins, Edward, M.D., Obstetric Physician to the
General Hospital, Birmingham ; 8, Old square^ Bir-
mingham. Council, 1881-3. Fiee-Preg. 1884-6. Hon.
Loe. Sec.
1876 Manby, Fredebick Edward, 10, King street, Wolver-
hampton.
1868* March, Henry Colley, M.D., 2, West street, Roch-
dale. Council, 1890.
1887 Mark, Leonard P., L.R.C.P. Lond., 19, Upper Berkeley
street, Portman square, W.
1860 Marley, Henry Frederick, The Nook, Padstow, Cornwall.
1862 Marriott, Eobert Buchanan, Swa£Pham, Norfolk.
1887 Marsh, 0. E. Bulwer, L.R.C.P. Ed., Ventnor House,
Newport, Monmouthshire.
1890 Martin, Christopher, M.B., C.M.Edin., North Riding
Infirmary, Middieshorough.
1873 Martin, Henry Charrington, M.B., O.M., 11, 8omers
place, Hyde park, W.
1887 Mason, Arthur Henry, L.R.C.P. Lond., High street,
Walton-on-Thames.
1884 Massey, Hugh Holland, 2, North terrace, Camberwell«
S.E.
1884 Masters, John Alfred, L.R.C.P. Lond., Westall House,
Brook green, W.
1877 Maunsell, H. Widenhah, A.M., M.D., Pitt and London
street, Dunedin, New Zealand.
1883 Maurice, Oliver Calley, 75, London street, Reading.
Council, 1888-90.
1890 May, Chichester Gould, M.A., M.B.Cantab., 13, Fitz-
William square, Dublin.
1877 May, Lewis Jambs, Bountis Thorne, Seven Sisters road,
Finsbnry park, N.
1884 Maynard, Edward Charles, L.R.C.P. Ed., 11, Shellons
street, Folkestone.
1885 MsLLER, Charles Booth, L.R.C.P. Ed., Gowbridge, Ola-
morganrfiire.
Xi FELLOWS OF THE SOCIETY.
Elected
1886 Mknnell, Zebulok, 31, Shepherd's Bush road, W.
1882 Meredith, William Appleton, M.B., CM., Surgeon to
the Samaritan Free Hospital for Women and Children ;
6, Queen Anne street. Cavendish square, W. CounciL
1886-8. Trans. 2.
1875* Miles, Abijah J., M.D., Professor of Diseases of Women
and Children in the Cincinnati College of Medicine,
Cincinnati, Ohio, U.S.
1876 Millman, Thomas, M.D., 544, Spadina avenue, Toronto,
Ontario, Canada.
1880 Mills, Robert James, M.B., M.C., All Saints' green,
Norwich.
1886 MiLNBB, Samuel Geoboe, L.R.C.P. Ed., Hillside, Dnlwich
road, Norwood, S.E.
1876 MiLSON, BiGHARD Henby, M.D., 88, Finchley road, South
Hampstead, N.W. Council, 1890.
1869 Minns, Pembroke R. J. B., M.D., Thetford, Norfolk.
1867 Mitchell, Robert Nathal, M.D., Chester House, Wick-
ham road, firockley, S.E.
1868 MooTHOosAWMT, P. S., M.D., F.L.S., Tanjore, Madras
Presidency. 7Van«. 1.
1877 Moon, Frederick, M.B., Bexley house, Greenwich.
1673 Moon, Robert Henry, F.R.C.S., 160, Norwood road^
West Norwood, S.E.
1859 Mooehead, John, M.D., Surgeon to the Weymouth Infir-
mary and Dispensary ; Weymouth, Dorset.
1888 Morgan, George John, L.K.Q.C.P. & L.M., Dovaston
House, Kinnerley, West Felton.
1888 MoRisoN, Alexander, M.D.Ed., Dunnottar, 115, Green
lanes. Stoke Newington, N.
1883 Morris, Clarke Kelly, Gordon Lodge, Charlton road,
Blackheath, S.E.
1886 Morton, Shadforth, M.D. Durham, Wellesley villas,
Croydon.
1887 MosELEY, George Wilkinb, M.B., CM. Ed. {Travelling).
FELLOWS OF THE SOCIETY. xli
Elected
1879 MouLLiN, James A. Mansell, M.A., M.B., Assistant
Physician to the Hospital for Women and Children,
69, Wimpole street, Cavendish square, W. Trans, 1.
1878 MowAT, ^EOEGB, 49, St. Peter street, St. Albans. Trans. 1.
1885 Murray, Charles Stormont, L.R.C.S. and L.M. Ed.,
85, Gloucester place, Portman square, W.
1887 Murray, Horace H. C, 470, Hornsey road, N.
O.F. MusGRAVE, Johnson Thomas, L.E.C.P. Ed., Irlam Villa,
39, Finchley road, N.W. CouncU, 1859-60. Trans. 1.
1888 Myddelton-Gayey, Edward Herbert, 64, St. Matthew's
street, Ipswich.
1887 Napier, A. D. Leith, M.D. Aber., %7y GrosYenor street, W.
1859 Neal, James, M.D., Parterre, Sandown, Isle of Wight.
1882 Nesham, Thomas Cargill, M.D., Lecturer on Midwifery
in the University of Durham. College of Medicine at
I^ewcastle-on-Tyne ; 12, Ellison place, Newcastle-on-
Tyne. Council, 1889-90.
1859 Newman, Willlam, M.D., Surgeon to the Stamford and
Rutland Infirmary ; Barn HiU House, Stamford,
Lincolnshire. Council, 1873-75. Fice-Pres. 1876-77.
Trans. 5.
1889 Newnham, William Harry Christopher, M.A.,
M.B. Cantab., The General Hospital, Bristol.
1873 Nicholson, Arthur, M.B. Lond., 98, Montpellier road,
Brighton.
1 879 Nicholson, Emilius Rowley, M.D., 89, Camden road, N.W.
1876 Nix, Edward Jakes, M.D., 143, Great Portland street, W.
Council, 1889-90.
1882 Norman, John Edward, Lismore House, Hehhnm-on-Tyne.
1883 NuNN, Philip W. G., L.R.C.P. Lond., Maplestead, Christ-
church road, Bournemouth.
1884 Oakes, Arthur, M.D., Chiswick, Milnthorpe road, East-
bourne.
1880 Oa&lei, John, Holly House, Wood's end, Halifax, York-
shire.
Xlii FELLOWS OF THE SOCIETY.
Elected
18S6 OeLE, , Arthur Wesley, L.R.C.P. Lond., 90, Cannon
street, E.G.
1876 Ogston, Francis, M.D., Lecturer on Hygiene and Medical
Jurisprudence in the University of Otago ; Dnnedin,
New Zealand (per Richard W. K. Bain, 146, Union
street, Aberdeen).
O.F. Oldham, Henry, M.D., F.R.C.P., Consulting Obstetric
Physician to Guy*s Hospital ; 4, Cavendish place, Caven-
dish square, W. Fice-JPres, 1859. Oouncily 1860,
1866-66. Treaa. 1861-62. Pres. 1863-64. Trans. 1.
Trustee,
1888 Oliver, Franklin Hewitt, L.B.C.P. Lond., 2, Kingsland
road, £.
1889 Oliver, James, M.D., F.K.S. Edin., 18, Gordon square,
W.C.
1884 Openshaw, Thomas Horrocks, M.B., M.S., 21, Gower
street, W.C.
1869 Ord, George Rice, Screatham hill, Surrey. Council, 1881.
1880 Orton, Charles, M.D., Nelson place, Newcastle-under-
Lyme, Staffordshire.
1877 OsTERLOH, Paul Rudolph, M.D.Leipzio; Dresden.
1863 Oswald, James Waddell Jeffries, M.D., 245, Ken-
nington road, S.E. Trans, 4.
1889* Page, Harry Marmaduke, F.R.C.S., 4, St. Margaret's
road, Oxford.
1883 Palmer, Johk Irwin, 21, Henrietta street, Cavendish
square, W.
1877 Palmer, Montagu H. C, The Manor House, Newbury.
1886 Papillon, Thomas Alexander, L.R.C.P. Ed., Burley road,
Oakham.
1877* Paramore, Richard, M.D., 2, Gordon square, W.C.
1867 Parks, John, Bank House, Manchester road. Bury, Lanca-
shire.
1887 Parsons, John Inglis, M.D. Durh., 9, CoUingham place,
S.W.
FELLOWS OF THE SOCIETY. xUii
Elected
1880 Parsons, Sidnei;, 78, Kensington Park road, W.
1889 Pabsons, Thomas Edwabd, Paddock House, Ridgeway,
WimbJedon, S.W.
1865* Patebson, James, M.D., Hayburn Bank, Partick, Glasgow.
1882* Peacey, William, M.B., 214, Lewisham High road, S.B.
1864 Peabson, Dayid Ritchie, M.D., 23, Upper Phillimore
place, Kensington, W.
1871 Pedleb, Geobge Henry, 6, Trevor terrace, Rutland gate,
S.W.
1 880 Pbdley, Thomas Fbanklin, M.D., Rangoon, India. Trans. 1 «
1881 Pebigal, Abthub, M.D., New Barnet, Herts.
1871 Pebrigo, James, M.D., 163, Bleury street, Montreal,
Canada. Hon, Loe, See,
1879* Pesikaka, Hobmasji Dosabhai, 23, Hornby row, Bombay.
1883 Pettifeb, Edmund Henby, 32, Stoke Newington green, N.
1879 Phibbs, Robebt Feathebstone, M.R.O.P.£d., 130, Elgin
avenue, W.
1879 Phillips, Geobge Richabd Tubneb, 24, Leinster square,
Bayswater, W.
1882 Phillips, John, B.A., M.D. Cantab., M.R.G.P., Assistant
Obstetric Physician to King's College Hospital; 71>
Grosvenor street, W. Council, 1887-9. Trans, 5.
1878 Philpot, Joseph Henby, M.D., 1 3, South Eaton place, S.W.
1871 Philps, Philip Geobge, 21, Russell road, Kensington, W.
1876 PiCABD, P. Kibkpatbick, M.D., 59, Abbey road, St. John's
Wood, N.W.
1874 PiOG, Thomas, M.D., M.R.C.P., Physician to the Man-
chester Southern Hospital for Women and Children ;
98, Mosley street, Manchester.
1889 PiNHOBN, Richabd, L.R.CP. Lond., 5, Cambridge terrace,
Dover.
1889 Playfaib, David Thomson, M.D., CM. Edin., Redwood
House, Bromley, Kent.
Xliv FELLOWS OF THE SOCIETY.
Elected
1864 Playfair, W. S., M.D., LL.D., F.R.C.P., Physician
Accoucheur to H.I. & R.H. the Duchess of Edinburgh ;
Professor of Obstetric Medicine in King's College,
and Obstetric Physician to King's College Hospital;
31, George street, Hanover square, W. Council^ 1867.
1883-5. Hon. Librarian, 1868-9. Han. See. 1870-
72. Fice-Pres, 1873-5. Free, 1879-80. Trana. 14.
1880 PocoGK, Ebederick Ernest, M.D., The Limes, St. Mark's
road, Notting hill, W.
1883 PococK, Walter, Gwydyr House, 58, Brixton hill, S.W.
O.F.* PoLLABD, William, Surgeon to the Torbay Hospital ;
Southlands, Torquay, Devon.
1883 Poor, William John, L.R.C.P., 2, Hemingford road, N.
1876 Pope, H. Campbell, M.D.-, F.R.C.S., Broomsgrove Villa,
280, Goldhawk road, Shepherd*s Bush, W.
1888 PoPHAM, Robert Brooks, L.R.C.P. & S. Ed., 67, Bartho-
lomew road, Camden road, N.W.
1882 Porter, Joseph Francis, M.D., Helmsley, Yorkshire.
1864 Pottee, John Baptiste, M.D., F.R.C.P., Obstetric Physi-
cian to, and Lecturer on Midwifery and Diseases of
Women at, the Westminster Hospital ; 20, George
street, Hanover square, W. Council, 1872-6, 1890.
Hon. Lib. 18778, Fice-Pre*. 1879-81. Trea*. 1882-4.
Board Exam. Midwives, 1883-4. Pres. 1885-6.
Tran9. 1.
1875 PowDBELL, John, 160, Euston road, N.W.
1884 Powell, John James, L.R.C.F. Lond., Norwood Lodge,
Weybridge.
1863 Powell, Josiah T., M.D., 347, City road, E.C.
1885 Praeger, Emil Arnold, Nanaimo, British Columbia.
1886 Prangley, Henry John, L.R.C.P. Lond., 160, Anerley
road, Anerley.
1888 Pratt, George A., Eadcliffe Infirmary, Oxford.
1880 Prickett, Marmaduke, M.A.Cantab., M.D., Physician to
the Samaritan Hospital; 12, Devonport stveet, Glou-
cester square, W.
FELLOWS OF THE SOCIETY. xlv
Elected
O.F. Priestley, William 0., M.D., LL.D., F.R.C.P., ConBulting
ObBtetric Physician to King's Collpge Hospital; 17,
Hertford street, Mayfair, W. Council, 1859-61, 1865-
66. Vice^Prea, 1867-69. Prea. 1875-76. Trans. 6.
1884 Pbongeb, Chaeles Ernest, L.E.C.P., 1, Barkston man-
sions. South Kensington, S.W.
1876* Quirke, Joseph, L.R.C.P. Ed., The Oaklands, Hunter's
road, Handsworth, Birmingham.
1861 Rasch, Adolphus A. F., M.D., Physician for Diseases of
Women to the German Hospital ; 7, South street, Fins-
bury square, E.G. Council^ 1871-3. Trans, 6.
1878 Bawlings, John Adams, M.R.C.P. Ed., 4, Northampton
terrace, Swansea.
1870 Ray, Edward Reynolds, Dulwich, S.E.
1860* Bayner, John, M.D., Swaledale House, Quadrant road
north, Highbury New park, N.
1879 Read, Thomas Laurence, 11, Petersham terrace, Queen*s
gate, S.W.
1 874 Rees, William, Priory House, 129, Queen's crescent, Haver-
stock hill, N.W.
1890 Reid, Godfrey Forrest, M.D. Dubl., Bethlehem, Orange
Free State, South Africa.
1879 Reid, William Loudon, M.D., Professor of Midwifery and
Diseases of Women and Children, Anderson's College ;
Physician to the Glasgow Maternity Hospital ; 7> Royal
crescent, Glasgow.
1889 Remfry, Leonard, M.A., M.B. Cantab., The Grange,
Nightingale lane, S.W.
1889 Rentoul, Rorert Reid, M.D., 78, Hartington road,
Liverpool.
1875* Eey, Euqenio, M.D., 39, Via Cavour, Turin.
1886 Richardson, Thomas Arthur, 26, London road, Croydon.
1872 Richardson, William L., M.D., A.M., Professor of Obs-
tetrics in Harvard University ; Physician to the Boston
Lying-in Hospital; 225, Commonwealth avenue,
Boston, Massachusetts, U.S.
Xlvi FELLOWS OF THE 80CIBTT.
Elected
1889 Richmond, Thomas, L.R.C.P. Ed., 26, Burnbank terrace,
Glasgow.
1888 Riding, William Steeb, M.D. Edin., 25, Endsleigh gardens,
N.W.
1872 RiGDEN, George, Surgeon to the Canterbury Dispensary;
60, Burgate street, Canterbury. Trans, 1. Hon, Loe»
See.
1871 RiGDEN, Walter 16, Thurloe place, S.W. Council, 1882-3.
Trans, 1.
O.F.* Roberts, David Llotd, M.D., F.R.C.P., F.R.S. Edin.,
Obstetric Physician to the Manchester Boyal Infirmary ;
and Lecturer on Clinical Midwifery and the Diseases of
Women in Owens College ; 1 1, St. John street. Deans-
gate, Manchester. Council, 1868-70» 1880-2. Fice^
Pre*. 1871-2. Trans. 5.
1867 Roberts, David W., M.D., 56, Manchester street, Man-
chester square, W.
1883 Boberts, John Coryton, L.K.C.P. Ed., Avenue House,
Peckham rye, S.E.
1874 Robertson, William Borwick, M.D.; St. Anne's, Thurlow
park road, West Dulwich, S.E.
1887 Robinson, Hugh Shapter, L.R.C.P. Ed., 12, North Bridge
street, Monkwearmouth, Sunderland.
1884 Bobtnson, Luke, M.R.C.P. Lond., 217» Geary street, San
Francisco, California.
1886 Roe, Arthur Dumville, B.A., M.B. Cantab., West hill,
Wandsworth, S.W.
1876 Roe, John Within gton, M.D., EUesmere, Salop.
1874 Roots, William Henry, Canbury House, Kingston-on-
Thames.
1874 Roper, Arthur, Lewisham hill, Blackheath, S.E. Council,
1886-8.
1865 Ro?EB, George, M.D., Consulting Phjrsician to the Royal
Maternity Charity ; Oulton Lodge, Aylsham, Norfolk.
Council, 1875-77, 1883-5. Vice-Pres. 1879-81, 1889,
Board Exam. Midwives, 1880-1, 1883-5. Trans. 10.
FELLOWS OV THE SOCIETY. xlvii
Elected
1859 B08B, Henby CooFEBy M.D., Penrose House, Hampstead^
N.W. ConjiaZ, 1875-77. Trans. 4.
1887 Ro8ENAi7> Albbbt, M.D.» Webergasse, 15, Wiesbaden.
1880 Ross, Dayid Palmbb, M.D., Freetown, Sierra Leone.
1883 RossEB, Walteb, M.D., 1, Wellesley Yillas, Croydon.
1884 RossiTER, Oeobob Fbedebick, M.B., Sargeon to the
Weston-super-Mare Hospital; Cairo Lodge, Weston-
super-Mare.
1885 RouGHTON, Edmund Wilkinson, M.D., 28, Welbeck street,
Cavendish square, W.
1S84 RouGHTON, Walter, L.B.C.P. Lond., Station road, New
Baruet.
1882 RouTH, Amand, M.D., B.S., Assistant Obstetric Physician
to, and Teacher of Practical Obstetrics and Gynsecoiogj
at. Charing Cross Hospital ; 14a, Manchester square,
W. Council, 1886-8. Trane. 1.
O.F. RouTH, Charles Henry Felix, M.D., Consulting Physician
to the Samaritan Free Hospital for Women and Children ;
52, Montagu square, W. Council, 1859-61, Fiee-Pres,
1874-6. Trans. 13.
1887 Rowbothah, Hebbebt C, Yale House, Melbourne, Derby.
1887* Rowb, Abthur Walton, M.D. Dur., 1 , Cecil street, Margate.
1881 RowoBTH, Alfbed Thomas, Grays, Essex.
1886 RusHWOBTB, Frank, M.B. Lond., Langdale, Ooidhurst
terrace. South Hampstead, N.W.
1888 SusHwoRTH, Norman, L.R.C.P. Lond., Beechfield, Walton-
on-Thames.
1886 RuTHEBirooRD, Henbt Trotter, B.A., M.B.Cantab., 46,
Queen Anne street. Cavendish square, W.
1866 Saboia, Baron V. de, M.D., Director of the School of Medi-
cine, Rio de Janeiro ; 34, Rua do Visconde Maranguapo,
Rio de Janeiro. Trans. 2.
1883 Salter, Fbancis Joseph, L.R.C.P.£d., 9, Lyddon terrace,
Leeds.
Xlviii FELLOWS OF THE SOCIETY.
Elected
1864 Salter, John H., D'Arcy House, ToUeshunt D'Arcy, Kel-
▼edoD, Essex.
1875* Salzmann, Fredebick William; Senior Surgeon to the
Hospital for Women ; 18, Montpeilier road, Brighton.
Council, 1880-2. Hon. Loc. Sec.
1868* Sams, John Sutton, St. Peter's Lodge, Eitham road, Lee,
S.E.
1886 Sanderson, Robert, M.B. Oxon., 33, Montpeilier road,
Brighton.
1872 Sangster, Charles, 148, Lamheth road, S.E.
1 870 Saul, William, M.D., Lyndthorpe, Boscombe, Bournemouth.
1872 Savage, Thomas, M.D., Surgeon to the Birmingham and
Midland Hospital for Women ; 33, Newball street,
Birmingham. Council^ 1878-80.
1877 Sayory, Charles Tozer, M.D., 6, Douglas road. Canon-
bury, N. Trans, 1.
1870 Scott, John, M.D., New street. Sandwich.
1888 Scott, Patrick Cumin, B.A., M.B. Cantab., 38, Shooter's
Hill road, Blackheath, S.E.
1866 Sequeira, James Scott, 68, Leman street, Goodman's
fields, E., and Crescent House, Cassland crescent,
Cassland road, South Hackney.
1882 Serjeant, David Maurice, M.D., 1, The Terrace, Cam-
berwell, S.E.
1875 SsTON, David Elphinstone, M.D., 110, Cromwell road,
S.W. Council, 1884.
1860 Sewell, Charles Brodie, M.D., 21, Cavendish square,
W., and 13, Fenchurch street, B.C. Council, 1880-2.
1887 Shannon, R. Alexander, L.R.C.P. Ed., Crofton, Orping-
ton, Kent.
O.F. Sharpin, Henry Wilson, F.R.C.S., Surgeon to the Bed-
ford General Infirmary, Bedford. Council, 1871-3.
Tram, I . Hon, Loc. Sec,
1887 Shaw, John, M.D. Lond., Obstetric Physician to the North
West London Hospital ; 34, Queen Anne street, Caven-
iish square, W. Trans. 1.
FELLOWS OP THE SOCIETY. xllX
Elected
1867 Shbphbsd, Fbedesick, L.B.C.P. £d., 33, King Henry's
road. Primrose hill, N.W.
1890 Silk, John Fbedebick William, M.D. Lond., 6, Chandos
street, W.
1886 Simmons, Foubness, M.B. Edin., 30, Albert terrace,
Darlinghurst, Sydney, N.S.W.
1874 SiNCLAiB, Alexandeb Doull, M.D., Consulting Physician
to the Boston Lying-in Hospital ; 35, Newbary street,
Boston, Massachusetts, U.S.
1888 Sinclair, William Japp, M.D. Aber., Honorary Physician
to the Southern Hospital for Women and Children and
Maternity Hospital, Manchester ; and Professor of
Obstetrics and Gynaecology, Owens College, Man-
chester ; 268, Oxford road, Manchester.
1876 SiBiGNANO, GiosuE, M.D., 24, Strada Banchi Nuovi, Napoli.
1879 Slight, Geobge, M.D., 3, Clifford street. Bond street, W.
1881 Sloan, Abchibald, M.B., 272, Bath street, Glasgow.
1876 Sloan, Samuel, M.D., CM., 5, Somerset place, Sauchiehall
street West, Glasgow.
1861 Slym AN, William Daniel, 26, Caversham road, Kentish
Town, N.W. Council, 1881.
1867 Smith, Hetwood, M.D., 18, Harley street. Cavendish
square, W. Obunct'/, 1872-6. Board Exam, MidwiveSy
1874-76. Trana. 6.
1888 Smith, Howabd Lton, L.R.C.P. Lond., 8, High street,
Tring.
1875 Smith, Richabd Thomas, M.D., Physician to the Hospital
for Women, Soho square ; 53, Haverstock hill, N.W.
1886 Smith, Samuel Pabsons, L.K.Q.C.P.I., Park Hyrst,
Addiscombe road, Croydon.
1882 Smith, Stephen Mabebly, L.R.C.P. Ed., Yarra street,
Geelong, Melbourne. [Per Henry M. Smith, Holly
Lodge, Chillington, Kingsbridge, South Devon.]
1879 Smith, Wm. Hugh Montgomeby, L.R.C.P.Ed., 24, London
road. West Croydon, Surrey.
vol. XXXI. d
1 FELLOWS OF THE SOCIETY.
Elected
1876 Snell, Edmund George Cahbuthebs, 102, Bonner road,
Viotoria park, N.E,
1882^ Snell, Oeoboe, L.R.C.P. Ed., Fort Canje, Berbice, B.
Guiana.
1889 Solly, Ebnest, M.B. Lond., F.R.C.S. Eng., 79, Lambeth
Palace road, S.E.
1 868 Spaull, Babnabd E., 1, Stanwick road, West Kensington, W.
1888 Spencer, Herbert R., M.D., B.S. Lond., Assistant Obstetric
Physician to University College Hospital; 10, Mans-
field street, Cavendish square, W. Council, 1890.
Trans. 1.
1876 Spencer, Lionel Dixon, M.D., Brigade-Surgeon, LM.S.,
Bengal Establishment [care of Messrs. Grindlay and Co.,
55^ Parliament street].
1882 Spooner, Frederick Henry, M.D., Maitland Lodge,
Clapton, N.E.
1876 Spurqin, Herbert Branwhite, 82, Abington street,
Northampton.
1884 Stansby, Charles John, M.D., 10, Strand, Derby.
1886 Steavenson, William Edward, M.D. Cantab., M.R.C.P.,
39, Welbeck street, W. Trans, 1 .
1884 Stevenson, Edmond Sinclair, F.R.C.S. Ed., Strathallau
House, Rondebosch, Cape of Good Hope.
1877 Stephenson, William, M.D., Professor of Midwifery,
University of Aberdeen ; 297, Union Street, Aberdeen.
Council, 1881-3. Fice-Pres., 1887-89. Trans. 2.
1873 Stewart, James, M.D., 2, Skinner street, Whitby, Yorkshire.
1875* Stewart, William, F.R.C.P. Ed., Dyrock Cottage, Prest-
wick, near Ayr, N.B,
1884 Stiven, Edward W. F., M.D., The Manor Lodge, Harrow.
1884 Stiyens, Bertram H. Ltne, 11, Kensington gardens
square, W.
1883 Stocks, Frederick, 421, Wandsworth road, S.W.
O.F. Stowers, Nowell, 166, Clapham road, S.W.
1866 Stranoe, William Heath, M.D., 2, Belsise avenue,
Belsize park, N.W. Council, 1882-4.
FBLLOWS OF THE SOCIETY. li
Elected
1871 Stubges, Montague J., M.D., The Limes, Beckenham,
Kent.
1884 SuNDSBLAND, Seftihus, M.D., 155, Gloucester road, South
KensingtoD, S.W.
1886 Sdtcliffe, Abthur Edwin, 345, Stretford road, Man-
chester.
1883* Sutheblakd, Hekbt, M.A., M.D. Oxon., M.R.C.P., 6,
Kichmond terrace, Whitehall, S.W.
1862 Sutton, Field Flowers, M.D., fialham hill, Clapham,
S.W.
1888 Sutton, John Bland, F.R.C.S., 48, Queen Anne street,
CaTcndish square, W. Trans, 1.
1859 SwAYNE, Joseph Gbiffiths, M.D., Physician- Accoucheur
to the Bristol General Hospital ; Harewood House,
74, Pemhroke road, Clifton, Bristol. Council^ 1860-61,
Vice-Pres. 1862-64. Trans. 9. Hon. Loe. See.
1888* SwoBN, Henby George, L.K.Q.C.P. & L.M., 16, Albion
road, HoUoway road, N.
1883 Tait, Edward Sabine, M.D., 54, Highbury park, N.
Trans. 1.
1879 Tait, Edward W„ 54, Highbury park, N. Council, 1886-7.
1871 Tait, Lawson, F.R.C.S., Surgeon to the Birmingham and
Midland Hospital for Women ; 7, The Crescent, Bir-
mingham. Trans. 12.
1880 Takaki, Kanaheiro, F.R.C.S., 10, Nishi-Konyacho, Ki5-
bashika, Tokio, Japan. Hon, Loe. Sec.
1871 Tanner, John, M.D., F.L.S., Physician for Diseases of
Women, to the Farringdon General Dispensary; 19,
Queen Anne street, Cavendish square, W.
1859 Tapsob, Alfred Joseph, M.B. Lond., 36, Gloucester gar.
dens, Westbourne terrace, W. Oouncily 1862-64.
1863 Tapson, Joseph Alfred, Surgeon to the Clapham General
Dispensary ; Holmwood, The Grove, Clapham common,
S.W. Trans. 1.
1871 Taylsr, Francis T., fi.A. Lond., M.B.> Ciaremont villa,
224, Lewisham high road, S.E.
lii FELLOWS OF THE SOCIETY.
Elected
1869 Taylor, John, Earl'B Colne, Halstead, EsBex.
1871 Taylor, John W., M.D., D.Sc, Rothsay HouBe, Prince of
Wales terrace, Scarborough. Hon, Loo, Sec.
1885 Taylor, William Charles Eybrley, M.R.C.P. Edin., 34,
Queen street, Scarborough.
1890 Thomas, Benjamin Wilfred, L.R.C.P. Lond., Welwyn.
1884 Thomas, George H. W., Orchard House, Teignmouth.
1887 Thomas, William Edmund, L.R.C.P. Ed., Bridgend,
Glamorganshire.
1882 Thomas, Hugh, The Grange, Coventry road, Birmingham.
1890 Thompson, Charles Herbert, B.A., M.D. Dnbl., 21, Half-
moon street, Mayfair, W..
1867 Thompson, Joseph, L.R.C.P. Lond., 1, Oxford street,
Nottingham. IVans, I. Hon. Loc. Sec,
1878 Thomson, Dayid, M.D., 37, Castle street, Luton, Bedford-
shire.
1874 Thomson, William Sinclair, M.D., CM., F.R.C.S. Ed.,
1, Palace court, Notting hill gate, W.
1860 Thorne, George Leworthy, M.B., Cheriton Fitzpaine,
Crediton.
1879 Thornton, J. Knowsley, M.B., CM., Surgeon to the
Samaritan Free Hospital for Women and Children, 22,
Portman street, Portman square. Council, 1882-3.
Hon, Lib, 1884-6. Hon. Sec. 1886. VicePrea. 1888.
Trans, 6.
1874 TicE HURST, Augustus Rowland, Silchester House, Peven-
sey road, St. Leonard' s-on -Sea.
1873 Ticehurst, Charles Sage, Petersfield, Hants.
1866 Tilley, Samuel, 6, Down street, Piccadilly, W.
O.F. Tilt, Edward John, M.D., Consulting Physician- Accoucheur
to the Farringdon General Dispensary ; 27, Seymour
street, Portman square, W. Council, 1867-68. Ftc«.
Pres, 1869-70. Treas. 1871-2. Pree, 1873-4.
Trans, 7.
1883 Tinker, Frederick Howard, F.R.C.P. Ed., Talbot House,
Hyde, Cheshire.
FELLOWS OF THE SOCIETY. Uii
Elected
1887 TiNLEY, Thomas, M.D.Durh., Hildegard Honse, Whitby.
1879 TiTY, William James, F.R.C.S. Ed., 8, Lansdown place,
Clifton, Bristol.
1872 ToLOTSCHiNOFF, N., M.D., Charkoff, Russia.
1869 ToMKiKs, Chables P., L.K.Q.G.P.I., Old Manor House,
Wallington.
1884 Tbayers, William, M.D., 2, Phillimore gardens, W.
1873 Tresteail, Henry Ernest, F.R.C.S.Ed., M.R.C.P. Ed.,
36, Westbourne gardens, Glasgow, W. Trans. 1.
1886 Tuckett, Walter Reginald, West Kent General Hospital,
Maidstone.
1865 Turner, John Sidney, Stanton House, 81, Anerley road.
Upper Norwood.
1881 TuTHiLL, Phineas Barrett, M.D.
1861 Tweed, John James, Junr., F.R.C.S., 14, Upper Brook
street, W.
1885 Undebhill, Edgar T., M.B. Ed., Bromsgrove.
1874 Venn, Albert John, M.D., Obstetric Physician to the
Metropolitan Free Hospital ; 122, Harley street, W.
1873 Verley, Reginald Louis, F.R.G.P. Ed., 28b, DeTonsbire
street, Portland place, W.
1879 Wade, George Herbert, Ivy Lodge, Chisleburst, Kent.
1860 Wales, Thomas Garnets, Downham Market, Norfolk.
1866 Walker, Thomas Jambs, M.D., Surgeon to the General
Infirmary, Peterborough ; 33, Westgate, Peterborough.
Council, 1878-80. Hon. Loc. Sec.
1889 Wallace, Abraham, M.D. Edin., 64, Harley street, W.
1870 Wallace, Frederick, 96, Cazeno^e road, Upper Clapton,
N. Council, 1880-2.
1872* Wallace, John, M.D., Assistant-Physician to the Liverpool
Lying-in Hospital; I, Gambier terrace, Liverpool.
Hon. Loc, Sec. Oouncil, 1883-5.
1883 Wallace, Richard TJnthank, M.B., Cravenhurst, Craven
park, Stamford hill, N.
liv FBLLOWS OF THE SOCIETY.
Elected
1879* Walteb, William, M.A., M.D., Surgeon to St. MaryU
Hospital, Manchester; 20« St. John street, Man-
chester.
1867* Walters, James Hopkins, Surgeon to the Royal Berkshire
Hospital; 15, Friar street, Reading, Berks. Council^
1884-6. Trans, 1. Hon, Loe, See,
1873 Waltebs, John, M.B., Church street, Reigate, Surrey.
1886 Wake, Geobge Stephen, L.R.C.P. Lond., Middlesex Hos-
pital, W.
1862 Watkins, Ghablbs Stewabt, 16, King William street,
Strand, W.C.
1887 Watson, John Adam, L.R.G.P.&S. Ed., 39, Bennington
park, West Hampstead, N.W.
1884 Watson, Pebciyal Humble, L.B.C.P. Lond., 72, Jesmond
road, Newcastle-on-Tyne.
1884 Waugh, Alexandeb, L.K.C.P. Lond., Midsomer-Norton,
Bath.
1889 Watte, John, M.A., M.B. Oxon., 98, North end, Croydon.
1867 Webb, Feed. £., 1 13, Maida vale, W.
O.F. Webb, Habby Speakman, New place, Welwyn, Herts.
Council, 1889-90.
1886 Webbeb, William W., L.R.C.P. Ed., Crewkerne.
1884 Wedmobe, Ebnest, M.B. Cantah., Obstetric Physician to
the Bristol Royal Infirmary ; 11, Richmond Hill,
Clifton.
1876 Weib, Abchibald, M.D., St. Mungho's, Great Malvern.
1867 Welleb, Geobge, The Mall, Wanstead, Essex.
1887 Wells, Albebt Pbimbose, M.A., L.R.C.P. & S., L.M.,
Bourneville, School road, Beckenham.
1876 Wells, Fbank, M.D., Hawes street, Brookline, Massachu-
setts.
O.P. Wells, Sib T. Spencer, Bart., F.R.C.S., Sargeon in Ordi-
nary to H.M.*s Household ; Consulting Surgeon to the
Samaritan Free Hospital for Women and Children ; 3,
Upper Grosvenor street, W. Council, 1859. Vice-
Pres, 1868-70. Trana, 5. Trustee,
FELLOWS OF THE SOCIETY. Iv
Elected
1886 West, Charles J., L.R.C.P« Loud., Beaminster, Kempshott
road, Streatham Common, S.W.
1888 Weston, Joseph Thbophilus. L.K.aC.P. & L.M., Civil
Surgeon, Northern Shan States, Lashio, nid Mandalay,
Burmah.
1886 Wharry, Robert, M.D. Aber., 6, Gordon square, W.C.
1876 Wharton, Henry Thornton, M. A. Oxford, 39, St. George's
road, Kilburn, N.W.
186Q Wheeler, Daniel, Chelmsford.
1889 Whitcombe, Charles Henry, F.R.C.S. Edin., Westerham,
Kent.
1890 White, Charles Perciyal, Queen Charlotte's Hospital,
Marylebone road, N.W.
1882 Wholey, Thomas, M.B. Durh., Winchester House, 50, Old
Broad street, B.C.
1883 Wicks, William Cairns, M.B., South View House, West
parade, Newcastle-on-Tyne.
1687 WiGAir,CHARLES Arthur, M.B.Durh., Portishead, Somerset-
1877 WiGMORE, William, 130, Inverness terrace, Hyde park, W.
1883 Wilkinson, Thomas Marshall, F.R.C.S. Ed., Surgeon to
the Lincoln County Hospital ; 7, Lindum road, Lincoln.
1879 WiLLANs, William Blundell, F.R.G.P. Ed., Much Had-
ham, Herts.
1879 WiLLETT, Charles Verrall, 3, Southdown road. Shore-
ham, Sussex.
1889 Williams, Arthur Henry, M.A., M.B., B.C. Cantab., 79,
London road, St. Leonard's-on-Sea.
1887 Williams, Charles Robert, M.B., CM. Ed., 15, Ivanhoe
terrace, Ashby-de-la-Zouch.
1872 Williams, John, M.D., F.R.C.P., Physician-Accoucheur to
H.R.H. Princess Beatrice, Princess Henry of Batten-
berg; Professor of Midwifery in University College,
London, and Obstetric Physician to University College
Hospital ; 63, Brook street, Gro8venor square, W.
Council, 1875-76. Hon, Sec. 1877-9. Fice-Pres, 1880-2.
Board Exam, Midwivee, 1881-2; Chairman, 1884-6.
Free, 1887-8. Trane, 12.
Ivi PELLOWS OP TH£ SOCIETY.
Elected
1881 Willis^ Julian, M.R.G.P. Ed., 64, Sutherland aveuue,
Maida vale, W.
1860 Wilson, Robert James, F.R.C.P. ESd., 7, Warrior square,
St. Leonard's-on-Sea, Sussex. Hon. Loc. See, Vice-
Pres, 1878-80.
1886 WiNTEEBOTTOM, Arthub Thomas, L.R.G.P. Ed., Lark bill,
SwintoD, Manchester.
1877 WiNTLE, Henry, M.6., Kingsdown, Church road, Forest
hill, S.E.
1887 Withers, Robert, Lawrence, Otago, New Zealand.
1880 Woodward, G. P. M.,M.D., 167, Macquarie street, Sydney,
New South Wales.
1890 WoRNUM, George Porter, 6, College terrace, fielsize park,
N.W.
O.F. Worship, J. Lucas, Manor House, Riverhead, Sevenoaks,
Kent. OwnciZ, 1875-77. Fictf-Pr««. 1883-5. Trans.^^,
1881 WoRTHiNGTON, Geoege Finch Jenninos, M.K.Q.C.P.,
Highden, Sidcup.
1876 Worts, Edwin, 6, Trinity street, Colchester.
1887 Wright, Charles James, Surgeon to the Hospital for
Women and Children, Leeds ; Professor of Midwifery
to the Yorkshire College ; Lynton Villa, Virginia road,
Leeds.
1888* Wyatt-Smith, Frank, M.B., B.C.Cantab., British Hospital,
Buenos Ayres.
1889 Wynteb, Andrew Ellis, L R.C.P. Lond., 30, Upper
Berkeley street, Portman square, W.
1871 Yarrow, George Eugene, M.D., Oakley House, 317, City
road, B.C. Council, 1881-3.
1885 Young, Adam, L.R.C.P.Lond., 34, High street, Sevenoaks.
1882* Young, Charles Grove, M.D., New Amsterdam, Berbice,
British Guiana.
1861 Young, William Butler, 10, Castle street, Reading.
CONTENTS.
List of Officers for 1890 .
List of Presidents
List of Beferees of Papers for 1890
Standing Committees
List of Honorary Local Secretaries
Trustees of the Society's Property
List of Honorary and Corresponding Fellows
List of Ordinary Fellows
Contents
List of Woodcuts
AdTertisement .
HoQTS of Attendance at Library
l*AGB
V
• •
Vll
• • •
VUl
ix
Zl
• • • •
Zl-ZUl
xiv
Ivii
Ixiii
Izvii
Izvii
Jannary 2nd, 1889—
Uteros, the subject of Sarcoma, removed by Hysterec-
tomy, and Microscopical Sections of the same, shown
by Dr. William Duncan
Acephalous Acardiac Monster, shown by Dr. W. S. A
Gbiffith ....
Mylacephalous Acardiac Twin, shown by Mr. H
Ebnest Tbbstbail .
Dissection of Mr. Trestniirs case of Mylacephalous
Acardiac Twin, with Notes of Acardiac Monsters in
the Museums of London Hospitals, by Mr. Alban
DOBAN
I. Methods of Craniotomy. By Abchibald Donald,
M.A., M.D. . . . .
2
2
2
4
28
VOL. XXZI.
6
Iviii CONTENTS.
PAQB
Februaiy 6th, 1889—
Annual Meeting . .51
Diseased FoBtal Membranes of Uncertain Nature in
Early Pregnancy, shown by Dr. John Phillips . 52
Anencephaloas Foatas, shown by Mr. Alban Do&an
for Dr. William Skene .52
II. Case of Porro's Operation. By A. L. Galabin,
M.A., M.D., F-RCP. . .57
Annual Meeting — the Audited Report of the Treasurer
(Dr. Galabin) ... 69, 70
Report of the Honorary Librarian for 1888 (Dr.
HO&KOGKS) . . .69
Report of the Chairman of the Board for the -
Examination of Midwives (Dr. J. Watt Black) . 71
Election of Officers and Council for the year 1889 72
Annual Address of the President (John
Williams, M.D.) .73
March 6th, 1889—
Dentigerous Bony Plates from a Dermoid Ovarian
Tumour, shown by Mr. Alban Doban . 86
Inaugural Address of the President (Dr. Galabin) . 88
III. On the Relation between Chlorosis and Menstruation,
an Analysis of 232 cases. By William Stephen-
son, M.D. ..... 104
April 3rd, 1889—
Fibro-sarcoma of the Right Ovary, shown by Dr. M.
Handfield-Jones .... 126
Yaginal cysts, shown by Dr. M. Hanbfielb- Jones . 129
Gangrene of the Bladder from Retroflexion of the
Gravid Uterus, shown by Dr. Rasch . . 129
Intra-peritoneal Hnmatocele and Intra-uterlne Poly-
pus, shown by Dr. W. S. Playpaib , 130
Anencephalic Foetus, shown by Dr. W. S. A. Griffith 134
Case of Retention of Urine, caused by Pressure of a
Dermoid Ovarian Cyst, shown by Dr. W. S. A.
Griffith ..... 136
lY. Case of CsBsarean Section for Contracted Pelvis. By
F. H. Champnbys, M.A., M.D.Oxon., F.R.C.P. . 136
CONTENTS. lix
May ] 8t, 18Sd— page
Bepoff of Committee on Dr. John Phillips's Specimen
of an Aborted Oram, showing Cysts in the Decidna
Vera ..... 161
on Dr. W. S. Playf air's Specimen of Small
Ovarian Cyst and HsBmatosalpinz 162
Complex Twistings of the Funis, shown by Dr. M.
Handfiblb-Jonbs .... 164
Fallopian Tube and Qyary, from a Case of Tubal Ges-
tation, shown by Dr. William Dttngan . . 165
AnencephaJous Foetus, shown by Dr. Pebioal 165
Y. Case of Inversion of the Uterus, sixteen months'
standing ; Replacement ; Recovery. By William
Newman, M.D. .... 166
YI. On Acute Non-septic Pulmonary Disorders, as Com-
plications of the Puerperium. By John Phillips,
B.A., M.D.Cantab. .171
June 5th, 1889—
Ruptured Fallopian Tube, shown by Mr. J. Knowsley
Thobnton for Dr. Cbaiq . 198
Two Uterine Fibro-oysts, shown by Mr. J. Knowblbt
Thobnton ..... 199
Fibroma of the Ovarian Ligament, shown by Mr.
Alban Doban .... 200
Primary Cancer of the Fallopian Tube ; Recurrence,
shown by Dr. Amand Routh . . 200
Shrivelled Foetus of the fifth month of Utero-gesta-
tion, shown by Dr. Clapham . . 202
Uterus, Heart, and Brain from a Case of Puerperal
Septicsemia, shown by Dr. William Duncan . 202
Anencephalic Foetus, shown by Dr. William Duncan 202
Instruments for Antiseptic Irrigation in Child-bed,
shown by Dr. Gbaily Hewitt . . 202
YII. The Diagnosis of Placenta Prssvia by Palpation of the
Abdomen. By Hebbebt R. Spenceb, M.D. . 203
Yin. Anterior Serous Perimetritis simulating Ovarian Sar-
coma when explored by Abdominal Section; Re-
covery with Disappearance of the Cyst. By Alban
Doban, F.R.C.S. .217
July 3id, 1889—
Solid Tumour of Ovary, shown by Mr. W. A. Mbbe-
bith ..... 225
Ix CONTENTS.
PAGB
HsBmatosalpiiK, shown by Dr. GuLLiNawoBTH . 226
GancerouB Uteras, removed bj Yaginal Operation,
shown by Dr. W. S. Playfaib . . 227
Rapture of Uterus, shown by Dr. Hobbooes . 228
Fragment of Membrane passed from the Uterus,
shown by Mr. Alban Doban . . 229
Dermoid Oyst of the Ovary of a Mare, shown by
Mr. 0. Stbwabt Pollock . 234
IX. Laceration of the Yagina in Labour. By J. Matthews
Dtjncan, M.D. . .236
X. Chorea in Pregnancy. By Montaou Handfield-
Jone8,M.D. ..... 243
October 2nd, 1889—
Report on Mr. Pollock's Specimen of Ovarian Der-
moid from a Mare, shown July 3rd, 1889 . . 253
Uterus, Rectum, and Left Kidney from a Woman who
died of Uraemia, shown by Dr. William Duncan . 255
Dermoid Ovarian Tumour, shown by Dr. William
Duncan ..... 255
Simple Ovarian Cyst, shown by Dr. William Duncan 255
Blue Urine ; Gyanuria, shown by Dr. John Phillips 256
HsBmatosalpinx and Intra-peritoneal Hsematocelefrom
Rupture of a Varicose Vein on the Inner Surface
of the Right Fallopian Tube, shown by Dr. GuL-
LINQWOBTH ..... 257
Acephalous Acardiac Monster of Six Months' Gesta-
tion, with Rudimentary Heart, shown by Mr.
WooDLBY Slyman for Mr. W. D. Slyman . 258
Douche Gan, shown by Dr. Shaw . . 262
XL Contribution to the Anatomy of the Pelvic Floor.
By G. Ebnbbt Hbbman, M.B.Lond., F.R.O.P. . 263
XII. On the Ohanges in the Pelvic Floor which accompany
the Slighter Degrees of Prolapse. By G. Ebnest
Hebman, M.B.Ijond., F.R.G.P. . . 276
November 6th, 1889—
Pelvic Hffimatoma following Delivery; Death four
hours after Labour, shown by Dr. Boxall . 303
Sections of Uterus at Different Periods of the Puer-
perium, showing Gomplete Absence of the Alleged
Fatty Ohanges, shown by Dr. W. S. A. Gbiffith . 308
CONTENTS. Ixi
PAOE
Uterus, Oyaries, and Tubes from a Case of GsBsarean
Section, shown by Dr. Gullinowobth . . 308
Retroflexion and Ectopia Yiscerum, shown by Dr.
Dakin . . . .308
Large Myoma of Left Broad Ligament, shown by Dr.
William Duncan .... 309
Bepart on Mr. Alban Doran's Specimen of Fragment
of Membrane passed from the Uterus, shown July
3rd, 1889 . . .310
Xlll. Case of Large Chylous Cyst of the Mesentery. By
Adolph Babcu, M.D. .... 311
XIY. Case of Yesico-utero-vaginal Fistula. By Chablbs
J. CULLINOWOBTH, M.D., F.B».C.P. . . 320
XY. Case of Lupus of the Yulva. By Abthub H. N.
Lbwbbs, M.D. .... 326
December 4th, 1889—
HsBmatosalpinz and Pyosalpinx, shown by Dr. WiL-
LiAM Duncan .... 332
Hydrosalpinx, shown by Dr. William Duncan . 332
Fibro-myoma and Abscess, shown by Dr. William
Duncan ..... 332
Cystic Ovaries and Hypertrophied Fallopian Tubes,
shown by Dr. John Phillips . . 332
Sponge Tents, shown by Dr. AusT Lawbbnce . 333
Some Specimens of OTarian Tumours, shown by Mr.
J. Bland Sutton .... 333
XYL Case of Inversio Uteri; Reduction; Recovery; Re-
marks. By J. Bbaxton Hicks, M.D. . 340
XYII. On Closure of the Ostium in Inflammation and Allied
Diseases of the Fallopian Tube. By Alban Doban,
F.R.C.D. . • . . . 344
XYIII. Notes of a Case of Hssmatemesis in a newly bom
Infant. By H. C. Hodges, L.R.C.P.Lond. . 365
Index ...... 371
Additions to the Libbaby .... 391
WOODCUTS.
PAQB
Dissection of Mr. Trestrail's case of Mylacephalons Acardiac
Twin, with notes on Acardiac Monsters in the Museums of
London Hospitals (Mr. Alban Doban)
Fig. 1. — Acardiacus Mylacephalus before Dissection 5
Fig. 2. — Ditto, ditto, after the Reflexion of the Integu-
ments . . .7
Fig. 3.— Ditto, ditto. Lateral View . . 9
Fig. 4. — Ditto, ditto, Complete Dissection . 11
Fig. 5. — Acardiac Twin (true Mylacephalus) . 20
Fig. 6. — ^Acardiacus Aoephalus .21
Fig. 7. — Acardiacus Anceps or Paracephalus . 25
Fibro-sarcoma of the Bight O^ary (Dr. M. Hakdfield- Jonbs)
Fig. 1. — Microscopical Section of Fibroma . . 127
Fig. 2.— Ditto, ditto ditto . . .127
Fig. 3.— Ditto, ditto of Sarcoma 128
Fig. 4.^Ditto, ditto of Myoma . . 128
Case of CflBsarean Section for Contracted Pelvis (Dr. Ohamp-
HBTS)
Temperature Chart .... 151
On Acute Non-septic Pulmonary Disorders as Complications
of the Puerperium (Dr. John Phillips)
Temperature Chart, Case I (John Phillips) . . 174
Ditto, Case U (Macdonald) .177
Ditto, Case III (Macdonald) . . .178
Ditto, Case V (Negri) . . .185
Ditto, Case YI (Andrew) . .186
Ditto, Case YII (Alexander Simpson) . 187
Ditto, Case Yin (John Phillips) . . .188
Ovarian Dermoid Tumour from a Mare (Mr. C. Stbwabt
Pollock) ...... 254
Acephalous Acardiac Monster of Six Months' G^estation« with
Rudimentary Heart (Mr. Woodlsy Slyman) . . 260
Ixiv WOODCUTS.
PAGE
Coatribation to the Anatomy of the Pelvic Floor (Dr. Hebmak)
Fig. 1. — Diagram showiDg Average Arrangement of
Parts forming Pelvic Floor . 267
Fig. 2. — ^Diagram to show one Extreme of normal
variation in arrangement of parts forming
Pelvic Floor . . .269
Fig. 3. — Diagram to show another Extreme of normal
variation in parts forming Pelvic Floor . 271
On the Changes in the Pelvic Floor which accompany the
slighter degrees of Prolapse (Dr. Hebmak)
Fig. 1. — Diagram showing Normal Descent of Pelvic
Floor, Descent of Uterus, and Shortening
of Yagina under Strain . . 284
Fig 2. — Diagram showing Prolapse of Pelvic Floor
without relative Displacement of Uterus . 285
Fig. 3. — Diagram showing Descent of Pelvic Floor,
with Slight Descent of Uterus . 287
Fig. 4.^Diagram showing Prolapse of Pelvic Floor,
with Slight Gystocele . . . 293
Fig. 5. — Diagram of Case of Slight Gystocele, with
Descent of Pelvic Floor and Retroflexion
of Uterus .... 296
Fig. 6. — Diagram showing Prolapse of Pelvic Floor,
with Slight Descent of Uterus, showing
Effect of Pessary . .297
Case of Yesico-utero- vaginal Fistula (Dr. Gullinqwobth)
Fig. 1. — Yesico-vag^al portion of the Fistula . 321
Fig. 2. — Yesico-uterine ditto, ditto. . . 321
Fig. 3. — Ditto ditto, ditto, after Division of the Ante-
rior Lip .... 322
Some Specimens of Ovarian Tumours (Mr. J. Bland Suttok)
Fig. 1. — An Ovarian Dermoid . 334
Fig. 2.— Ditto ditto . . .336
Fig. 3. — A Composite Series of Drawings showing the
Histological Diversity of the Solid Portion
of the Ovarian Tumour sketched in Fig. 2 337
Fig. 4.— A Tubo-ovarian Gyst . .339
On Glosure of the Ostium in Inflammation and Allied Diseases
of the Fallopian Tube (Mr. Alban Doban)
Fig. 1. — Ostium of Normal Fallopian Tube laid open . 348
WOODCUTS. IXV
PAGE
Fig. 2.— End of Tube with OBtimn laid open . 348
Fig. 3. — ^A Specimen Similar to Figs. 1 and 2 . 350
Fig. 4. — End of a Tube with Two Accessory Ostia . 350
Fig. 5. — An Ovarian Fimbria moderately developed . 351
Fig. 6. — ^An Ovary and Tube, showing Obstruction of
the Ostium by Perimetric Deposit . 358
Fig. 7. — Complete Obstruction of the Ostium, the
Result of Salpingitis . . . 358
Fig. 8. — An Obstructed and Dilated Tube laid open . 359
VOL. XXXI. /
ADVERTISEMENT.
This Society is not as a body resi>on8ible for the facta and
opinions which are advanced in the following papers and com-
mnnications read, nor for those contained in the abstracts of the
discassions which have occurred at the meetings during the
Session.
20, HANOVEB Si^UABE, W.
LIBRARY AND MUSEUM,
20, Hanovbb Squabb, W.
Hours of Attendance: Monday to Friday, 1.30 p.m. to 6 p.m.,
Saturday, 9 a. m. to 11 a.m., and in the Evenings on which the Society
meets, from 7.15 p.m. to 7.45 p.m.
R. W. SAVAGE,
Librarian.
OBSTETRICAL SOCIETY
07
LONDON.
SESSION 1889.
JANUARY 2nd, 1889.
John Wiluuis, M.D., President, in the Chair.
f
Present — 30 Fellows and 1 Visitor.
Books were presented by Dr. Aavard^ Dr. B. S.
Schaltze^ Dr. W. Japp Sinclair^ and the Westminster
Hospital Staff.
John Mackem^ B.A.^ M.B.Cantab.^ was admitted a
Fellow of the Society.
The following gentlemen were elected Fellows of the
Society: — William James Best, M.B.C.S. (Dover); Edward
Thomas Crouch, M.R.C.S. (Qosport) ; Arthur Graham,
L.R.C.P.&S.Ed.; Ernest Solly, M.B.Lond., F.R.C.S.Eng.;
and Andrew Ellis Wynter, L.R.C.P.
The following gentlemen were proposed for election :—
William Henry B. Brook, M.B.Lond. (Lincoln) ; Arthur
Henry Weiss Clemow, M.D., C.M.Edin. ; William Edward
Dawson, L.K.Q.C.P. and L.M. ; Henry Willingham GeU,
VOL. XXXI. I
2 MTLACEPHALOUS ACABDIAG TWIN.
M.A., M.B.Oxon. ; Charles D. B. Hale^ L.B.C.P.Lond. ;
Charles Beyer Huraphrys, L.R.O.P. & S.Edin. (Boume-
mooth) ; Robert B^id Rentoul, M.D. Qa. Univ. Ireld.
(Liverpool) ; and Leonard Remfry, L.R.C.P.Lond.
A UTERUS THE SUBJECT OP SARCOMA RE-
MOVED BY HYSTERECTOMY.
By William Duncan, M.D.
He also showed microscopical sections of the same,
which proved it to be a mixed small-cell sarcoma.
AN ACEPHALOUS ACARDIAC MONSTER PROM
THE MUSEUM OP ST. BARTHOLOMEW'S HOS-
PITAL (No. 3435a).
Shown by W. S. A. Geipfith, M.B.
CASE OP MYLACEPHALOUS ACARDIAC TWIN.
By H. Eknest Tbestbail, M.R.C.P., P.R.C.S., Aldershot.
On November 5th, 1888, at 9 a.m., I was called to see
the second wife of a sergeant-major in the Royal Engineers
(his first wife having died in her confinement), and was
informed that she had just completed the sixth month of
her first pregnancy, and had regular pains since 3 a.m.,
which came on daring her sleep, and for which she could
not account by anything she had done.
Upon examination, I found the feet presenting, the toes
pointing backwards. I ruptured the membranes, and de-
HYLACfiPHALOUS ACABDIAC TWIN. O
livered her of a living female child, perfectly formed,
which sarvived its birth aboat half an hoar.
The uterus contracted well, but as it appeared to me
somewhat larger than if it simply contained the placenta,
I made a vaginal examination, and found a rounded body
presenting, not unlike a fat shoulder. Upon following this
up I came to a cross cut (see part representing head), and
was at once convinced, as the body was freely moveable,
that I had to do with a monster. I proceeded, therefore,
to extract it at once. The placenta followed very shortly.
I kept up continuous pressure on the uterus, and there was
no hadmorrhage. There was only one placenta. The cord
of the monster was connected with that of the child, there
being only one insertion.
The patient made a rapid recovery. Her age is twenty*
six years. She had been married eleven months. She
was certainly somewhat larger than is usual at six months.
The labour lasted seven hours. Her husband says that
she was frightened by a parrot about the end of May.
His first wife was nineteen when she married. Her
first child was bom dead. She was confined a second
time in North America, and died on the tenth day of '^ in-
flammation of the womb.'^ A midwife of little experience
attended her, a doctor only seeing her shortly before her
death. The only symptoms the husband remembers are
that she had great abdominal pain, sickness, and was de-
lirious for the last day or two. The child was perfect, and
lived nine months.
4
DISSECTION OP MR. TRESTRAIL'S CASE OP
MTLACEPHALOUS ACARDIAO TWIN, WITH
NOTES ON ACARDIAO MONSTERS IN THE
MUSEUMS OP LONDON HOSPITALS.
By Alban Do ran.
Mb. Tsxstbail's specimen weighed thirteen ounces when
fresh. In long diameter it measured five inches and a half.
Its form is indicated in the annexed sketch, which I made
before dissection. The surface was of a dull pink colour,
like an infant's skin. By the aid of the lens I detected
short, &ae hairs, especially towards each extremity. There
was no trace of a hairy scalp, such as has been seen in
otherwise acephalous acardiacs. I cut a small square
piece out of the oedematous integument, and allowed the
specimen to soak for six days in equal parts of methylated
spirit and water. Sections were made of the square piece
of integument.
Owing to the extreme nature of the arrest of deyelop*
ment, the dissection proved difficult, as I feared through-
out that I might accidentally cut into some important
structure. I have to thank Prof. C. Stewart and Mr. P.
S. Eve for advice and assistance. I made a vertical inci*
sion along the side of the foetus where the umbilicus lay.
The incision was prolonged upwards, avoiding the umbilicus
and the fleshy wattle (Fig 1, Wat,) and curved round to-
wards the site of the head. . Then it was prolonged down-
wards towards the foot. The integuments were then re-
flected ; the subcutaneous tissue was very thick. The action
of spirit has made it look much thinner.
Close behind the umbilicus I came on a mass of dense
granular fat, and on dissecting through it I found a large
solitary kidney. This organ bore hardly any indications
of lobulation. Immediately in front of that organ was a
j
HTLACIPHAL0U8 ACABDIAC TWIN.
Fte. 1. — AOABOUOTH HTi^OKPnAtUB. Sketeliad before diNM-
tion. 17ib£. p*m. The two Teaeli (one uteij and one vrin) to
tba coid. 17*1. A«ra. Hernial ponch at attachment of cord
(H eontained the greater part of tbft large Inteatine). Wat.
Fleibj wattle, aattm ancertain. ITal, elrfl (lea Fig. 8).
Deep deft tn which external genitali and eloaca laj concealed.
Art. tUift. Snperflcial or utiflcial elef t, ditappekriDg on exten-
6 HTLACSFHALOUS ACABDIAC TWIN.
membranous pouch ; this I opened^ it proved to be peri-
toneum and contained intestine. The kidney lay in the
hollow of a curved cartilaginous body^ which ended ante-
riorly in a pointed extremity a little above and in front of
the umbilicus. Below the kidney the cartilage was pro-
longed forwards as a nodular mass^ bearing in front of it ;
immediately below the peritoneal pouch, a cartilaginous
bar, which was united to the nodule by a distinct articu-
lation (Fig. 2, Cart, artic.). A moveable articulation con-
nected the main cartilage with a long cartilage which
proved to be the femur. The fascia lata was conspicuous,
the muscles very pale, and the anterior crural nerve dis-
tinct ; a large vessel accompanied it.
On parting the edges of the deep natural cleft (Fig. 1)
I discovered a small fleshy elevation. One eighth of an
inch below it was a circular opening, into which a stout
bristle could be passed for nearly three quarters of an inch,
entering the rectum. The elevation was a clitoris and
prepuce (as the other twin was female, it may be concluded
that this monster was of the same sex). A deep groove
ran between the clitoris and the opening. Half an inch
behind the opening a firm point, a process of the main
cartilage, could be felt beneath the integument, and
appeared to represent the coccyx. The half-inch tract
may be considered as analogous to the perineum, not homo-
logous, since the rectum opened in front of it, not behind
(see Fig. 3).
I dissected up the kidney, and found behind it large
nerves issuing from the main cartilage and uniting to form
the great sciatic. A large vessel ran from the hilum to
the umbilicus. This vessel sent a few small branches to-
wards the main cartilage, backwards and downwards ; it
was the sole trunk-vessel in the whole subject. A single
narrow duct ran from the hilum of the kidney, and was
lost in the integuments behind the genital groove. It was
evidently the ureter.
The intestines consisted of the entire large intestine with
a well-formed mesentery. The greater part was in the
1IYLACEPBAL008 ACABDUC TWIN.
FlS. 2,— AciXDUoira Htluikfbalub. Skntched ifttr tb* r«-
fleslw of the intaffimisnti. Cart. C^Ttilaginont itrnetore*.
Cart, artie, CsitiUp Rjiparantlj nnited bj ft movMbU joint U>
tbou itractnrei. Fim. Femur, alio uticotited to earl. Sid.
Kidnej. Ptrit. FeTitoeeam, witb id iDcUion tipoting i»l.,
intMtine. Ant. gntr. If. Anterior craTal nerre.
8 HYLAOEPHALOUS ACAUDIAC TWIN.
hernial sac (Fig. 1, Umh. hem.), Theceecum and vermi-
form appendix were conspicnoas, a short piece of small
intestine was traced from the caBciim, it was lost in the
wall of the hernial sac. The rectam passed nnder the
peritoneam in a fossa in the main cartilage, and opened at
the cloaca (Fig. 3, Clo.).
After the exposed parts had become toughened in spirit
I directed Mr. Pearson, the professional dissector at the
College, to expose and clear the skeleton of the solitary
lower extremity. I then dissected the curved cartilagi-
nous body behind and above the kidney, and the nodule
below it. The appearances are indicated in Fig. 4.
Two bodies of lumbar vertebrae, with large interarti-
cular cartilages, were exposed. The anterior crural nerve
rose from between them on the left side. On the right
side of the upper vertebra was a distorted transverse pro-
cess turning upwards and resembling a rib. The sacrum
was large ; the left great sciatic nerve arose, in the usual
manner, from branches passing out from between its fora-
mina. The sharp point behind the cloaca (Fig. 3, Coc.)
was evidently the coccyx ; it lay immediately below the
sacrum. The right side of the pelvis was represented by
a piece of cartilage an eighth of an inch long, and curved
downwards at the end, evidently the crest and upper part
of the ilium. The left side of the pelvis was well deve-
loped. The crest of the ilium was high. The nodular
mass below the kidney (Fig. 2) proved to be the ischium,
the articulated cartilage in front of it was the os pubis,
the three elements of the innominate bone being, of course,
quite distinct from each other. The obturator foramen
was well marked. The femur was two and a quarter
inches long. The patella could be felt in the quadriceps
tendon. The tibia was an inch and three quarters long,
the shaft was straight. The fibula was well formed, the
external malleolus large. The tendo Achillis was stout.
There were four toes ; the great toe was well developed,
but rather short. Two other toes were long, with dis-
tinct articulations. The fourth lay between them, it was
UTLACKpaALOUS ACABDIAC TVriH.
Pl«. S.— AoiBDUOUi MTLACtTBAXVa. L*Ut»1 Ti«w, with tlie
eleft (Ilgr- 1> o^ ■^'f^) let op«n- CUt. Clitoris. Clo. Ootnn,
witli biutla, Coe. CoocTx, .P*r. Ftlie perineDm. Th« long
Ineiiion, mad* for inflecting the integnmenta, ii indicated.
10 MYLACBPHALOnS ACABDIAC TWIN.
thin and ill developed. Extreme talipes eqnino-vartis
existed.
The gap between the left os pubis and the point of the
mdimentary right innominate bone was filled up by the
rectum^ which was enclosed in a fairly developed muscular
sheath^ partly consisting of the levatores ani. The rectum
passed first through the imperfect pelvic brim in front of
the sacrum and behind the kidney. The single ureter
lay in the rectum^ and was lost in the integuments behind
the cloaca where the rectum opened. The kidney lay in
the hollow between the ilium and the lumbar vertebrae
and sacrum.
From the direction of the rudimentary right innominate
bone (Fig. 4, r. p.), the blunt-pointed upper extremity of
the fcetuSj overhanging the genital cleft (Fig. 1^ Nat. cleft),
must represent not the site of the head and thorax but
the rudiments of the left lower extremity.
Thus this acardiacus consisted of the left lower extre-
mity and left side of pelvis^ the sacrum and coccyx^ large
intestine pervious to its outlet at the cloaca^ and left
kidney, all complete. The lower lumbar vertebrae, right
side of pelvis, and small intestines were rudimentary, the
ureter ended in the integument, the clitoris overhung a
cloaca. The right kidney, the suprarenal capsules, bladder,
uterus, ovaries, upper abdominal viscera, upper lumbar
vertebrae, dorsal and cervical vertebrae, upper extremities,
and the thorax and its contents, with the cranium and its
contents, were absolutely wanting. A blant point of flesh
represented the right lower extremity.
I have classified this monster under St. Hilaire's sab-
class " mylacephalus,'* which lies between '^ amorphus "
and " acephalus.'' As the left leg was well formed it
could not be called '' amorphus.'' On the other hand,
'^ acephalus '' is generally understood to imply acardiacs
where both legs are fairly formed, or, at least, sireniform,
the pelvic and lower abdominal viscera being fairly deve-
loped. Mylacephalus implies that the head, or more or
UTLACEPHAL0D8 ACARDtAC TWIN.
fie.4. — AcABDUoui Htlaobphalvb. The dlMsction commencad
in Fig. 2 ii hen oompleU, S. Sacrom, with l«o Inmbar Tert«>
brs. tp. Halfonned tranivena proceu of a Inmbar Tertebia.
r.p. BodimeoUrj right tide of pelrig. il. Ilium, it. Iichinm
with oa pnbii above it. The femnr, pat«1U, Ubta, and flbnhi
Bic di^lajed. sc. Mai. Eitenial malleolai. int.mal. Internal
UMlleolnt. mI. Colon, Ijing on reflected flap of ikin which
inelodei intartioa of nrntnlieal cord. The encam and rermi-
form appendix lie orer the hernial ponch. «r. Dreter, iTing
on rectuiD, which cDrre* downwarda, and liei covered in m./.p,
HoacnUr floor of peine, on ita wa; to cloaca (Big. 8, Ch.),
12 MTLACEPHALOUS ACABDIAC TWIN.
less of the thoracic^ abdominal^ or pelvic viscera^ are badly
developed or entirely absent. The amorphous type, in
fact, prevails, as in this case.
I have managed to get two good sections of the oedema-
tons integument of the acardiacus prepared, and I exhibit
them this evening. The true epidermis is thin. A layer
of long fusiform cells beneath it seems to represent the
muscularis mucossa. The hair-follicles are ill developed.
The thick layer of subcutaneous tissue is condensed close
to the epidermis, thus accounting for the toughness of the
skin in this case. It is very loose in its deeper part. It
contains a great quantity of elastic fibres. The connec-
tive-tissue cells are very large and oval, with big nuclei.
In no part do I detect any tissue such as is seen in a true
myxoma. The structure in this case is essentially em-
bryonic, with somewhat atrophic epidermis. In this, as
in all other cases of acardiacus preserved in museums, the
action of spirit has caused the cedematous integument to
shrivel up, spoiling its original appearance.
Acardiacs are relatively rare. Forster (^ Die Missbil-
dungen des M«nschen,^ 1861) states that they formed 18
per cent, of his collected cases. There are good grounds
for believing that they are frequently overlooked through
being taken for '* fleshy moles '' or " false conceptions."
Dr. A. Bussel Simpson once ordered a suspected case to
be disinterred ('' The Acardiac Foetus,*' ' Trans. Edin.
Obstet. Soc.,* iv, 384. Contributions to ' Obstetrics and
Gyneecology,' 1880, p. 23). It proved to be what he ex-
pected, but many other cases must have been thrown away.
Some writers confound this form of monstrosity with anen-
oephalus, a totally difEerent condition, where the cranial
vault remains open and the brain is more or less deficient.
Anencephalus is common, and cannot escape the notice
of the midwife or obstetrician, as the aspect of the face is
peculiarly hideous, and the body often large. A monster
bom without any limbs (amelus), or with arms but no
legs (apus), must not be mistaken for the very rare acar-
MTLACEPBAL0U8 ACARDIAC TWIN. 13
diacus acormas. In amelus the pelvic and abdominal
viscera may be more or less deficient^ bat the head and
neck are well formed^ and the nmbilical cord is present.
Acormns, on the other hand^ consists of an imperfectly
developed head with a small amorphous bag of flesh ; the
cord is absent.
The distinguishing feature of the acardiacus, according
to Ahlfeld (' Die Missbildungen des Menschen/ 1880) , is
that it is connected^ either through its umbilical cord or
its umbilical vessels^ with the cord of a strong, generally
well-formed embryo, the heart of which carries on the
circulation in the acardiacas. It should therefore be more
correctly termed an allantois-parasite or placenta-parasite.
A rudimentary heart, atrophied through changes in the
circulation, is found in some cases.
Circumstantial evidence strongly confirms the prevalent
theory which explains the development of an acardiacus.
This monster is invariably a true twin, that is, an embryo
developed from the same ovum as its brother. In such
cases the sexes of the twins are said by authorities on the
subject to be invariably identical.'^ I find, however, that
Dr. W. H. Dickinson {" Description of a Foetus bom
without Heart, Brain, Lungs, or Liver,*' ' Med.-Ghir.
Trans.,' vol. xlvi, 1863, p. 141) notes a case, of which
more will presently be said, where a healthy female infant
was born, the acardiacus being a male. Sir Astley Cooper
was one of the first to detect an inversion of the circula-
tion in the acardiacus, its umbilical artery being a branch
of the same artery in the brother. Claudius and Ahlfeld
have further investigated this theory. When in one-yelk
twins the allantois of each brother reaches the chorion, a
* See Kleinw&chter^s valuable work on the physiologyi teratolog}', and
obstetrics of twins (' Die Lehre von den Zwillingen/ Prague, 1871). *' In
all those cases," he writes, " where the chorion is single, whether the amnion
be single or double, the embryos are of the same sex." Ameth claims one
exception. Meckel von Hemsbach believes that contrary assertions are based
on error or illusory appearances; Hunter also noting that in twin calves
developed from one yelk it not rarely happens that both are males, but that
in one the genitals are imperfectly developed.
14 XTLACKPHALOnS ACABDIAC TWIN.
common placenta is formed^ with the two cords inserted
far apart. Each twin has then an equal chance of develop-
ment. When the allantois of one embryo grows faster
than its brother's, the former allantois may more or less
completely monopolise the chorion. The losing allantois
can then only insert itself into the gaining allantois. The
vessels in each allantois are brought into communication
with each other. The umbilical cord of the twin whose
allantois reaches the chorion develops well. The cord of
the other twin fails to develop thoroughly, and forms a
mere branch of the perfect cord. As its vessels anas-
tomose with those of the perfect cord, the foetus to which
it is attached can only receive blood from its brother.
The heart of the brother with the perfect cord propels
blood into the vessels of the other twin, which is destined
to become an acardiacus. The current goes backwards
through the umbilical arteries, up the primitive aortsd to
the rudimentary heart. That organ cannot develop, and,
owing to the abnormal course of the circulation, only the
lower parts of the body have much chance of development
in the commoner varieties of acardiacus. When the cord
of the acephalus is inserted partially on the placenta or
into its brother's cord very near the placental attachment
of the latter, the monster will be fairly developed. The
nearer the attachment of the cord lies to the foetal inser-
tion of the normal twin's cord the more imperfect will be
the acardiacus. In very rare instances there is no cord to
the acardiao twin, its allantois having been so much inter-
cepted that the embryo only touches its brother by its
membranes. Circulation is then established through the
membranes, and only those parts which lie above the heart
can develop. Then the monster becomes an acormus, an
imperfect head without a trunk.
The circumstantial evidence in favour of the above
theory, lucidly demonstrated with the aid of diagrams by
Ahlf eld in his work already quoted, is strong. The para-
sitic nature of the cord of the acardiacus, a mere branch
of its brother's cord, has repeatedly been observed. It
MTLACEPHALOUS ACABDTAC TWIN. 15
existed in Mr. TrestraiPs case. The inversion of circula-
tion has been satisfactorily demonstrated. Hypertrophy
of the heart of the well-deireloped foetus has been noted.
This condition was observed in a case described by H.
Meckel^ where there was a third twin in a separate ovum.
The subject of close insertion of twins' cords into the
common placenta^ and its effects on development, is ably
treated by Schatz.*^
The inversion of the blood-current greatly affects the
venous circulation in the acardiaous ; hence much stasis and
consequent hypertrophy and oedema of the connective
tissue. Cavities form in that tissue, and sometimes con-
vert the monster into a shapeless mass. Acardiacs are
rarely bom in first labours (G-eoffroy St. Hilaire) ; bat the
mothers in Mr. Trestrail's case, and another in St. Greorge's
Hospital, were primiparae. The perfect twin is generally
bom first. The liquor amnii is usually abundant, t
Only two undoubted cases of acardiacas have been
shown before the Obstetrical Society (Dr. Schofield, vol.
xxi, Mr. F. Cookell, junr., vol. xxv) . The nature of Dr.
Gervis's " rare form of monstrosity '* in a twin (vol. x) is
not described. The " acephali," vol. viii, p. 316, and vol.
xvi, p. 140, were anencephalous monsters. Dr. Lusk, in
his well-known text-book, and Dr. A. B. Simpson (loc.
cit.), figure the most frequent form of acardiacus. Barer
forms are given in Forster and Ahlfeld's works.
Before describing specimens of acardiacus, I will briefly
explain the classification of its varieties. I feel bound to
reject allied forms of monstrosity, included by Ahlfeld,
such as epignathus (acardiac attached to the oral cavity
* ''Die Oefllssyerbindangen der Flacentakrebla&re eineiiger Zmllinge/'
'Arch. f. OynAkelogie/ voL xziv, p. 837, and vol. zziz, p. 419. Tbii mono*
gnpb it illoftnted bj fine coloured drawings of pUoentn.
f Mr. Treitrairi patient was " certainly somewhat larger than is usual at
sii months." See Schatz, " Ein besondere Art von Polybydramnie mit ander-
seitiger Oligobydramnie bei eineiigeu Zwillingen/' 'Arch. f. Qjn&k./ vol. xix,
p. 829. The influence of the relative amount of liquor amnii on the weight
of organs is very marked in bis tables. See also Kiistner, "Ueber Hydram-
BioB bei eineiiger Zwillingen," ib., vol. zzi, p. 1.
16 HYLACKFHALOUS ACABDIAC TWIN.
of the brother, a more extreme condition than that already
noted as explaining acormus. A cord may exist, running
into the brother's cranium). Otherwise it would be hard
to put aside some still more divergent types, as congenital
sacral tumour and parasitic foetus.
The varieties of acardiacus proper are :
Amobphus or Anideus.
Mtlacephalus.
ACOBMUS.
AcsFHALUS (var. sympua, monopua, diptia, monobr orchitis ,
dibrachius).
Ancefs, or Pabacsphalus.
^AcABDiAcns Ahobphus. — This variety forms a shapeless
mass covered with skin ; sometimes a tract of hairy scalp
is seen. The subcutaneous tissue is very cedematous, with
cystic cavities. Rudiments of the pelvis and adjacent
bones may exist, with a few coils of intestine, blind at each
end. The heart is never present. The cord is short, and
never bears more than two vessels, one artery and one
vein ; in some cases it is absent, the vessels running from
the brother through the membranes, as in acormus. I
can find no genuine amorphus in any London museum.
Sir W. Turner informs me that an amorphous sheep is pre-
served in the Museum of Edinburgh University. It forms
^' a rounded mass covered with wool, quite amorphous, but
with an umbilical cord.''
A. Mtlacxphalus. — ^Ahlfeld has discarded this variety,
I think without sufficient reason. It conveniently includes
all cases where the head is an amorphous or very rudi-
mentary process or even absent, one or both lower extre-
mities present or very rudimentary, the subcutaneous tissues
markedly cedematous, and the cord with two vessels as in
amorphus. The specimen 241-2 in the College of Surgeons
is a true mylacephalus. I have explained why I classify
Mr. TrestraiPs case under the same head. It is now in
the College Museum (240a, Terat. ser.).
A. AcoBMUs. — This variety should only include acardiacs
HYLACEPHALOUS ACASDIAC TWIN. 17
chiefly consisting of an ill-formed head^ directly connected
with the membranes and devoid of any umbilical cord.
Its physiology has been already explained. It is exceed-
ingly rare, no specimen exists in any London Museum."'*'
A. AcEPHALUS. — This is the commonest variety of acar-
diacus. All parts around and below the pelvis are more
or less distinctly developed, t and there may be a thorax,
always fissured in front, and even an imperfect heart. The
cord has two arteries and one vein, or one artery formed
by the junction of two distinct arteries at the umbilicus.
Acephalas generally appears as a ball of flesh with two
legs. The thighs are usually more cedematous at the
groin than at the knee, so that the limbs appear as though
dressed in the trunk-hose worn in the reign of James I.
Umbilical hernia is very common in this variety. Mr.
TrestraiPs case might be classified by some authorities
under a sub-variety, acephalus monopus ; but the rudimen*-
tary condition of the viscera and the vascular supply of
the cord refer it (and most cases of monopus similarly
undeveloped) to mylacephalus.
* In reply to a letter of inqairy concerning specimens of acardittcns in
Edinburgh University, Sir W. Turner described one example in that collec-
tion aa foUowi : — *' Head well developed ; neck present ; trunk abont size of a
small orange; no trace of extremities. Specimen not dissected/' To fresh
inqniries for more minute particulars, the same anatomist very kindly wrote
aa follows : — ** The specimen is the nearest approach to a trunkless foetus in
the human subject that we possess. The limbs show no trace of their pre-
sence on a surface view, but, as I stated in my former letter, the specimen is
not dissected, so that I cannot say if some rudiments may or may not be
present subjacent to the skin. For the same reason, I cannot say whether
the heart is there. It cannot be said to be without a trunk, for as much is
present aa is equal in size to a small orange. The bead, neck, and trunk
somewhat resemble iig. 697 in Vrolik's article, ** Teratology," in Todd's
' Cyclopflsdia,' only the upper limbs are absent. I see no trace of an umbilical
cord. The specimen is without history." I hope to have an opportunity of
examining this specimen. In some respects it appears to be an amelus (see
p. 12) rather than an acardiacus acormus. Vrolik's case, to which Sir William
Turner refers, was an apus, with a very long cord twisted round its neck.
t The liver is generally absent. This defect of development has not been
satisfactorily explained. Strange to say, as Dr. W. S. A. Griffith has pointed
out, meconium may be found in the bowels where no liver exists.
VOL. XX2I. 2
18 HTLACSPHAL0U6 ACASDIAC TWIN.
Ten specimens of aceplialas proper in the haman f oetus«
are to be found (1888) in London museums. [Royal Col-
lege of Surgeons^ Maseam, 238, 239^ and 240 (the last two
being sections of one specimen) . St. Bartholomews Hos-
pital^ 3435 and an unmounted specimen. St. Thomases
Hospital, LL 21, LL 21^ St. George's Hospital, 17 D and
23 B. Guy's Hospital, 2539**. London Hospital, O 79.]
AcARDiAcns Ancefs. — This variety includes acardiacs
with more or less perfect trunk and extremities, and with
a distinct trace of a head. Ahlfeld asserts that the heart
is always present, and that as columned carneas are found
there must be a double circulation, from the acardiac's
rudimentary heart and from the perfect heart of the
brother. An anceps is to be seen at St. George's Hos-
pital (23 A), but it has no heart (Fig. 7), Acardiacus
anceps (or paracephalus) must be distinguished from pero-
cephalas, where the trunk and limbs may be perfect, whilst
the head is reduced to a pair of ears or a trace of cranium
with a few facial bones. The heart is perfect, and the
monster is not necessarily a twin. True perocephalus is
almost, if not entirely, confined to the lower aniuLals. See
€hirlt, ' Missbildungen der Thieren.'
I will now give a short description of each of the speci-
mens of acardiacus in London museums. I must here
express my thanks to the curators and other gentlemen
for kind assistance in finding the specimens, and for grant-
ing me permission in some cases to draw them. In every
case I have inspected the specimens myself. Altogether
thirteen human acardiacs are to be found in London.
None are as yet at hand in the museums of Charing Cross,
Middlesex, St. Mary's, and Westminster Hospitals, nor in
University and King's Colleges.
AcABDiACUs Mtlacbphalus. (Museum of the Royal Col-
lege of Surgeons). — ^Pirstly, Mr. Trestrail's case, also No.
241—2, Teratological Series. Mr. B. T. Lowne has de-
* Of specimens from the lower animals I find : — Mylacephalus, R. C. S.,
243-4 (calf); acephalos, B. C. S., 245-6 (Iamb) ; St. Qeorge's Hospital, 17 £
(cat).
HTLACIPHALOUS ACABDIAC TWIN. 19
scribed this case very fnlly in his catalogue of the series.
It forms a large elongate^ ovate mass, with a hairy scalp
and distinct occipital bone, and a spinal column, the spines
of which form a long continuous rod of cartilage, a primi-
tive condition highly developed. (Fig. 5.) Tympanic
cavities exist ; the thorax is filled with ireolar tissue. A
pharynx, pervious oesophagus, stomach blind at the pylorus,
a quarter of an inch of small intestine blind at both ends
and entirely unconnected with the stomach, a large intes-
tine pervious at the anus, horseshoe kidney. Wolffian bodies
and bladder, aorta, pneumogastrics and sympathetic ganglia
exist, also an imperfect left lower extremity (242). The
development and size of the Wolffian body is very remark-
able. The sex is not indicated. The other twin was well
formed. This specimen, which is mounted in two sections,
is deserving of more study. Why so much is developed,
and at the same time so much undeveloped, in every region
of the subject, it would be interesting to discover. The
development of an acormns or an acephalus is far easier
to understand.
AcABDiACUS Acephalus. (Museum of the Boyal College
of Surgeons. — ^No. 238,* Terat. Ser., is a male foetus with
an oedematous trunk and rudimentary left arm ; the other
extremities are better formed. The spine has been ex-
posed behind ; it has a single curve with its convexity back-
wards, and consists almost entirely of cartilage. The
cord is displayed. The body has been distorted by bad
mounting.
239^0. A well-dissected specimen in two sections,
organs of generation too imperfect to denote the sex. The
right arm is ill-developed and ends in a single nail, the
leg bears three toes ; there is a left leg but no left arm.
* It iB not stated in the catalogue tbat this Bpecimen and 239-40 were
dereloped in twin pregnancies; hut that kind of gestation is implied in
Mr. Lowne's general obserTstions on amorphons foBtus (p. 69). Again, in
the description of some of the cases in the catalogues of other mnseoms,
nothing b said about twins, but only in cases where there is no history of
any kind.
Fis. fi.— ACAXDIAO Twin (true Miiacepbalos). JTm. B. C. S.,
Teratol. Ser., No. £41. Bight half. B. in. Bairf Scalp.
Oee. Occipital bone. J\/mp. eae. Tympanic cfivity, containiiiic
a glus Tod. Piar. Briatle pniaing into phArynz. Below Knd
atrave phsrjni it c«ooellon» tisiue {eane. liti.), probably wpre-
■entiog the jairi. £. C. Bod of cartilage repreieuting the
ipinom proceeeei of the vertebm, "probably the remains of tho
DDsegmented iaveetiiig mas* highly developed " {Lomim),
right umbilical artery. (Ef. CEaophagtiB. Aor, Aorta. If. Vag.
Right poeumagaatric nerve. Sgmp, Ganglion of aympntbetic.
St, Stomach. 8. t. Small inteatine. L. i. Large inteitine.
Meet. Rectum. K. Kidoey. Tbe Wolffian body and duct lis
bidden behind the intestinea, Hhich bulge into the peritoneal
cavity. U. ed. Dmfailioal cord; a thin-walled peduncDlat«d
cyit liea in front of its inierUon. Cy. Cjilic cavitiisa in mde.
inatoua t«Mne.
MTULCIPHAtODB ACAHDrAC TWTK.
Fis. 6.— ActBDUCTB AcKPHiLtre. Mm, St. Barthol. Sotp.,
Path. Ser., No. S43S. The rndimentary trnnk hu been laid
open and ronghl; diaaected, eipoaiog coib of intotiaa aod the
bjpogitlrie artery on the right tide; on the left oothing ia
*na except ■ veiul, and miuitlea cut acraa in an irregalac
mamieT. The relation of the nmbilicBl cord to the itrnctnrea
in the abdominal cBT[tj ii indUtinct. The penis and acrotnm
are Uattened and paibed to the left. The lower eitremitiee
•re almoat eqnally dereloped, the f«et tnnob defonned. Thia
■pccimen ia a good example of the moit frequent farm of acar-
22 HTLACEPHALOnS ACABDIAC TWIN.
The thoracic and abdominal cavities are not separated by
a diaphragm. The acardiac possesses a horseshoe kidney
with two ureters^ and a bladder. The intestine commences
as a blind sac in the cord and terminates in an impervions
rectnm. There is no liver, and the langs seem to be re-
presented (according to Mr. Lowne) by a dense mass of
connective tissue. There are twenty-two segments to the
vertebral colamn, and a cord. The pelvis is fairly deve-
loped. The head is represented by a knobbed proboscis.
St. Bartholomew's Hospital Museam, 3485. " An acepha-
lous human monster. There is no trace of any attempt
at the formation of a head or upper extremities. The
lower extremities are large and malformed, and a small
portion of intestine may be seen in the abdominal cavity.
Presented by Dr. Matthews Duncan.^' (Male, penis and
scrotum well developed. Long " trunk-hosed '^ lower ex-
tremities see p. 17), double varus, defective toes. (Fig. 6.)
Unmounted specimen. — Large acephalous foetus. ^' Trank-
hosed " lower extremities. Feet fairly formed. Left upper
extremity phocomelous, being represented by a left hand
with defective fingers, moanted on a short fleshy pedicle.
Certain fleshy wattles may indicate right arm ; vertebras
and ribs present ; thick oedematous tissue replaces head.
Vulvar aperture distinct. (I understand that Dr. W. S.
A. Griffith intends to exhibit this specimen (8485a) before
the Society, v. supra, p. 2).
St. Thomas's Hospital Museum, LL 21. "A monster
consisting of the lower half of the body '' (good descrip-
tion follows). Both lower extremities fairly developed,
double varus, toes imperfect on right foot. VertebrsD,
spinal cord, and some ribs present. Cyst in back ; it had
no connection with the spinal canal, and evidently resulted
from oedema (see p. 15). External (male) organs well
formed. No arms, no trace of head.
LL 21^. Large undissected acephalous monster, appa-
rently female. '* Trunk-hose ^' appearance very marked,
legs tapering to ankle. Double varus, three toes to feet.
Trunk very oedematous, almost spherical ; no trace of head
HYLACBPHALOUS ACABDIAC TWIN. 23
or arms. Umbilicus central and symmetrical^ double
hernial protrusion.
St. George's Hospital Museum^ 17 D. Legs and feet
large^ arms fairly developed. Male external organs well
formed. A tubercle indicates the bead.*^ Presented by
Dr. Blakeley Brown. This is the case where the normal
twin was sl female, described by Dr. Dickinson (see p. 13).
The patient^ as in Mr. TrestraiFs case^ was a primipara ;
this is unusual in cases of acardiacns.
As it is contrary to all experience that the amorphus
should be of a different sex to the normal twin^ I have
recently written to Dr. Dickinson^ who has very kindly
taken great pains to recall the facts of the case. In the
original paper in the forty-sixth volume of the ' Medico-
Chirnrgical Transactions' occur the following sentences
relative to the disparity of sex :
P. 141. '^ The beings like all others of the same
character^ was a twin. The mother^ an unmarried woman
pregnant for the first time, was delivered in Queen Char-
lotte's Hospital. A healthy female infant was first born,
the breech presenting." . . . After some words about
the monster, the author continues, '' The female child was
apparently in good health." Thus the sex of the normal
twin was dwelt upon. At page 142, in referring to the
monster. Dr. Dickinson states : ** The genital organs, which
were those of a male .... were natural."
Dr. Dickinson wrote to me, December 15th, 1888 :
" The foetus in question was brought to the museum by
the late Dr. Blakeley Brown, who, being dead, cannot be
appealed to. He was a very accurate man, and I took
down the particulars from his lips, and I should have no
* " On its (the trank's) front Buf ace, in the median line, at a short dia*
tance from the upper end, was a small prominence of a reddish coloor, which,
from the fact of its being clothed with papiUn, was believed to represent the
tongue." — Dr. Dickinson, loc. cit. The opinion that the ** tnberde " repre-
sents the head seems to have been deriyed from the author of the catalogue.
Perhaps the " tnberde " has been once more examined since Dr. Dickinson's
paper was written. It is quite unlike the soft round mass representing the
bead in the specimen of acardiacns anceps, 23 A, in the same museum.
24 MTLACKPHALOUS ACARDIAC TWIN.
doubt they could be relied on." The register for 1862 —
1863 at Queen Charlotte's Hospital only mentions the fact
of twin labour, without any comment. Dr. Dickinson's
evidence, however, is strongly in favour of disparity of
sex, for he twice employs the word female in reference to
the normal twin, and he notes the fact that the monster
was a male, as may be verified by inspection of 17 D.,
St. George's Hospital Museum. The possibility remains,
however, that Dr. Blakeley Brown might have taken a
male foetus with imperfectly developed external organs
for a normal female.* He would naturally take more
pains in examining the monster than in the inspection of
the live '' healthy female infant."
23 B. *' A foetus of about the sixth month, consisting
entirely of lower extremities and abdomen. The trunk
ends, a little above the umbilicus, by a rounded surface
covered with skin. The cord remains attached to the
umbilicus." Female sex, labia and clitoris well marked ;
this point is not indicated in the catalogue.
Guy's Hospital Museum, 2539*^. Head, thorax, and
arms wanting ; rudiments of intestine, including vermiform
appendix. Two kidneys. " Trunk-hosed " lower extre-
mities. Sex apparently female. Bather large specimen.
2539^. " Acephalous foetus," in catalogue. This speci-
men is no longer in the Museum. I understand that it
was rejected or exchanged many years ago by Dr. Hilton
Fagge.
London Hospital Museum, O 79. Acephalous foetus,
male. Phocomelous left upper extremity, as in the un-
mounted specimen in St. Bartholomew's Hospital Museum.
Two kidneys ; intestines rather long. " Trunk -hosed "
appearance of lower extremities.
AcABDiAcus Anceps, or Paeacephalus. (St. George's
Hospital Museum, 23 A.) — A soft round mass repre-
sents the head. The tongue is present. A large dorsal
vessel communicates with the umbilical cord, but there
appears to be no trace of a heart. (This is contrary, I
* See footnote, p. 13.
HYLACBrEALODS ACABDIAC TWIN.
Fis. 7. — AoABSUCOS Ahcbfh or Pakicifhalub. Aliu. St.
Oeorg^t Sorp., 28a. if. The bend, ft taberout; ioTeited with
wrinkled iDtegDineDt. I.Toogae. ti.ff. Thymoi gland. M.
Short Mind etnl of inteitine ; it hiii appirenttj been much dii-
placed Dpward* dnring diiaection. B. K.,L. £, Rig;ht and left
kidneia. *,p,,i,p'. Symphjna pnbia divided artificially, a.i.
Q^dematoDi integiunent, wrinkled tbrongli the action of ipirit.
There ii no trace of a right arm. L. A. Lett trm. U. C.
Stamp of umbilical cord. d.t. Doraal tcueI. «. s. Umbilicul
veiael. It is wid to have originallj communicated with the
doT«al *eN«), bnt haa af^rentl; been >epftrated from it* con-
necUona. $. k. ? Probable lite of heart.
26 HYLACEPHAL0U8 ACABDIAC TWIN.
admit; to Ahlfeld's definition of anceps.) There are two
kidneys. There is no right arm, and the left is imperfect.
The lower extremities are " trunk-hosed /' double varus ;
toes imperfect. (Fig. 7.)
The embryological aspect of the phenomenon of acar-
diacus in twin labours has already been discussed. A good
series of early twin ova is much to be desired. A precise
knowledge of the human allantois is difficult to obtain.
The latest work where that structure is described from
direct observation of an early human embryo is Von
Preuschen's ' Allantois des Menschen ^ (Wiesbaden, 1887).
Of the placenta in twin pregnancies much more is known.
I have already given references to papers on that subject.
The peculiarities of an acardiacus make us think of that
great biological theme, the immediate stimulant or agent
in development. Pretty theories about that harmonious
balauce between different organs which causes them to
grow in strict proportion must fall to the ground. The
existence of acardiacs proves that certain organs and
structures may develop perfectly without any harmonious
balance at all — indeed, without any other structures to
balance them, even unharmoniously. W. Vrolik, writing
of acormus in Todd's ' CyclopsBdia ' many years ago, ob-
served : " This shows that in the absence of all the cen-
tral organs, heart, lungs, skeleton, and brain, there may
be a well-constituted skin surrounding an amorphous mass
of cellular tissue, and only a single well-formed organ.
Therefore we may conclude that each part is
formed sponte sua, and that it is in its evolution quite in-
dependent of the rest of the body.*'
The entire suppression of the absent parts, a condition
quite distinct from atrophy, is strikingly displayed in
acardiacus. The ductus arteriosus and the obliterated
hypogastric arteries are never entirely effaced in the adult.
Yet in an acardiacus three quarters of the body may be
absent, and not represented even by a vestige of scar-
tissue. Scarcely less singular is the absence of some of
MTLACEPHALOUS ACABDIAC TWIN. 27
the commoner malformations in the few parts which are
present. Thus in Mr. Trestrail^s case the rectum was
patent inferiorly. One deformity, however, is exceedingly
common, namely talipes ; it was marked in the same case,
where there were large nerves in the leg, but no cord.
The evidence of acardiacs does not prove that afflux of
nutrition is the chief agent in the development of organs.
No doubt the upper parts, which lie in the direction where
the circulation is most impeded, are the most frequently
suppressed, whilst, when the head alone is present, blood
reaches it by the anastomosis of vessels in the twin's amnia,
and not through the cord. Still, in acephalous acardiacs,
we see the greatest variety in the development of struc-
tures below the umbilicus, where the arterial circulation
must be relatively free and active. In Dr. A. R. Simpson's
case there were two legs and two innominate bones, yet
the sacrum and coccyx were not to be found. In Mr.
Trestrail's, the skeleton of the left lower extremity, inclu-
ding the same side of the pelvic girdle, was almost per-
fect ; of the correspondiug parts on the right side nothing
was present excepting a rudiment of the ilium, yet the
sacrum and coccyx appeared to be well-formed. The
irregular suppression of different parts is probably due to
the relative nutrition of each anatomical region, but indi-
rectly. The collateral circulation must be very variable
after the reversal of the blood-current, and the action of
the brother twin's heart can seldom be of equal power in
different cases. The cedema of the integuments is also
variable ; it must greatly influence nutrition. Yet even
when it prevails so as to make the monster '' an indigested
and deformed lump,'' we may still find that the scanty
relics of viscera which are present, perhaps half an inch
of intestine and a couple of vertebras, may lie perfectly
developed in their bed of cedematous connective tissue.
28
METHODS OF CRANIOTOMY.
By Abchibald Donald^ M.A.^ M.D.^
HOKOBABY SUBGEOK TO 8T. MABY'B HOSPITAL VOB WOHBK, HAVCHE8TBB.
(RecAived October 19th, 1888.)
{AbstracL)
In this paper the discussion of the relatiye meiits of cranio-
tomy and Ceesarean section is avoided. It is pointed out that it
is of importance still further to improve the methods of cranio-
tomy, since there are certain cases in which the operation is
indicated and will continue to be performed even by those
holding the most advanced views in regard to CsBsarean section ;
for example :
1. When forceps has been tried for a long time without effect,
or when podalic version has been performed and the head cannot
be extricated.
2. When there is certainty or great probability that the child
is dead.
8. When the condition of the mother is such as would cause
Csesarean section to be almost certainly fatal.
4. In certain cases of deformity of the foetus.
A Table of eighteen cases of craniotomy is appended, and in
each case full details are given of the indications for the opera-
tion, the method adopted, and the subsequent history of the
patient.
Bemarks are then made on the method of craniotomy to be
preferred : (1) in the less marked degrees of pelvic contraction ;
(2) in cases in which the contraction is considerable.
In the first class of cases the method to be preferred depends
greatly on the nature of previous attempts at delivery. If the
axis-traction forceps has been used to the limits of safety and
MRTHODS OF CRANIOTOMY. 29
tlie bead does not come through, the vertex may be perforated
without removing the forceps, and the forceps used as a tractor
after a firm grasp of the head has been obtained by turning the
screw as far as possible.
The method recommended in the more severe degrees of con-
traction consists in (I) podalic version and extraction of the
body, (2) perforation through the roof of the mouth, (3) cepha-
lotripsy of the after-coming head, and (4) extraction of head by
means of cephalotribe, or by traction on the body and lower jaw
combined with supra-pubic pressure.
The advantages of this method are as follows :
1. The base of the skull is effectually broken up.
2. The head is well fixed during perforation and crushing.
3. The position of the head is easily altered, thus allowing
the cephalotribe to be applied in different directions or the head
to be brought down with its crushed diameter in the smallest
diameter of the pelvis.
4. The collapse and moulding of the head are often brought
about readily by combined traction on the jaw and body of the
child and supra-pubic pressure.
The difficulties of this method are discussed under the follow,
ing beads : Difficulty (1) in the preliminary version ; (2) in
extracting the body ; (3) in perforating and crushing the head.
During the last few years the field of craniotomy has
been narrowed in two directions : on the one hand the
introduction of axis-traction forceps has increased the
number of cases in which delivery by the forceps is possible,
and on the other hand the remarkable recent success of
Caesarean section has caused this operation to supersede
craniotomy in cases of extreme pelvic deformity. There
are, indeed, some who go so far as to say that craniotomy
is now unwarrantable, and that Csesarean section should
be performed in all cases of pelvic deformity in which
forceps or turning offers little chance of extracting a living
child.
It is not my intention to discuss here the relative merits
of the two operations or to compare them with the induc-
tion of premature labour. Even if we admit the justice
30 METHODS 07 CBANIOTOHT.
of tHe more advanced views, there still remains a large
number of cases in which craniotomy is indicated and will
continue to be performed. These we may classify thus :
1. Cases in which the forceps has been tried for along
time without effect, or in which version has been performed
and the head cannot be extricated. There are many cases
in which the forceps or version seems to offer a fair chance
of saving the child, but in which the undiminished head
refases to come through after prolonged efforts^ and in
which it would only be courting disaster to complete the
labour by CsBsarean section. It is a matter of great diffi-
culty in many cases to decide definitely beforehand whether
a living child can be extracted per viaa naturales. There
are many factors to be taken into account, and the most ex-
perienced may be deceived in this matter. Instances of
women who have had one or more living chUdren, and one
or more which had to be destroyed, come under the notice
of most practitioners.
2. Cases in which there is certainty or great probability
that the child is dead. It is seldom, apart from cases in
which the foetus is macerated, that one can be absolutely
certain of the death of the child ; but if the labour has
been very tedious, the waters have long escaped, and the
foetal heart is inaudible, there are few who would be rash
enough to do CaBsarean section. A prolapsed funis is fre-
quently associated with a contracted pelvis, and may give
us a good indication of the state of the foetus. Further,
severe accidental haBmorrhage (showing extensive placental
separation) renders the death of the foetus very probable.
3. Cases in which the condition of the mother is such
as would cause CsBsarean section to be almost certainly fatal,
6. g. the coexistence along with the pelvic deformity of heart
disease, nephritis, eclampsia, or severe hsBmorrhage.
4. Cases in which there is some deformity of the foetus,
such as hydrocephalus or spina bifida, which renders its
chance of surviving a very slender one. This deformity
may be in itself the obstruction to delivery or may exist
along with deformity of the mother's pelvis.
METHODS or CRANIOTOKT. 31
As long as the operation is called for in so many cases
it* is of importance that every effort should be made still
further to improve the methods. The accompanying Table
contains brief notes of eighteen cases in which I have per-
formed craniotomy. Most of these occurred in connection
with the extern maternity department of St. Mary's Hos-
pital^ Manchester.
The form of pelvic deformity demanding the operation
was, with one exception (a justo-minor pelvis), either the
flattened pelvis or the generally contracted flattened pelvis.
In all of the cases the method of mensuration employed
was that by which alone accuracy can be attained, namely,
by the introduction of the whole hand into the vagina
after the completion of the labour.
The cases arrange themselves naturally into two groups :
(1) those in which the contraction was considerable, and
(2) those in which it was less marked. In the first group
there are seven cases (1, 3, 8, 9, 14, 17 and 18). In all
of these the conjugata vera was under three inches, and in
all of them the question of Csesarean section as against the
induction of premature labour might be fairly discussed
in the event of future pregnancy. In all of them save
one, CsBsarean section was out of the question by the time
I saw them : — in Case 1 the child was probably dead ; in
Cases 14 and 18 the head alone was in the uterus ; and
in Cases 3, 8 and 9, the patients had been in labour many
hours and were much exhausted. The second group, in
which the contraction was not so marked (Cases 2, 4, 5,
6, 7, 10, 11, 12 13, 15 and 16), offers examples of cases in
which there is a reasonable prospect of saving the child
by forceps or version. In Cases 4 and 7 the pelves
were normal ; in one the head was perforated for hydro-
cephalus, in the other, on account of a rigid cervix, the
child being macerated. In Cases 10 and 11 the pelvic
contraction was further complicated by malposition of the
head, and in Case 5 there was severe accidental haemor-
rhage.
It may be remarked at once that these cases go to prove
32 METHODS OF CBANIOTOMT.
the safety of craniotomy as regards the mother. In only
three out of the eighteen was the convalescence more pro-
tracted than it would probably have been after a normal
labour^ and all of these made a complete recovery.
As regards the method of craniotomy^ the indications
are obvious in the less severe degrees of contraction^ and
depend in great measure on the nature of previous attempts
at delivery. If the case seems a suitable one for forceps^ there
are few who do not now prefer some form of axis-traction
forceps. If traction has been used to the limits of safety
and yet the head does not advance^ the plan that seems to
recommend itself as the simplest is to perforate the vertex
without removing the forceps^ then after obtaining a firm
grasp of the more or less collapsed head by turning the screw
as far as possible^ to use the forceps as a tractor. If version
has been the initial operation^ the aftercoming head may
be perforated, and then brought past the obstruction by trac-
tion on the body and suprapubic pressure. In other cases
it may be advisable after perforating to wait until the head
is moulded and delivered by natural powers.
The method to be preferred in graver cases is still very
far from being settled, notwithstanding the numerous in-
struments for diminishing or comminuting the head. The
resistance offered by the firm base of the skull after the
vertex has been demolished constitutes the main difficulty
of the operation. To overcome this difficulty Dr. Braxton
Hicks suggested, in a paper read before the Obstetrical
Society in 1 864, that the face should be brought down by
means of a hook fixed in the orbit, so that the base might
pass edgewise ; and this is now generally recognised as the
best mode of delivery after cranioclasm in cases of marked
pelvic contractioD. Dr. Barnes thinks that face presenta-
tion is more easily produced by the cranioclast. Since
then the cephalotribe has come into more general use in
this country, and this instrument is believed by many to
fracture and crush the base thoroughly when applied to
the forecoroing head. Even such an eminent authority
as Dr. Barnes says: — '^When this instrument is applied
METHODS Of CRANIOTOMT. 33
to the perforated head^ it may be made to partly crusli
the base^ imparting great plasticity ; then the base is tilted
edgewise/'* From observations made on many cases of
cephalotripsy, as well as from experiments on stillborn
children, I have come to the conclusion that the base is
rarely, if ever, crushed when the cephalotribe is applied
to the forecoming head. Still more recently Simpson has
introduced the basilyst with the intention of breaking up
the base^ and Tamier's basiotribe is furnished with a gim-
let for a similar purpose. The latter instrument is far
too complicated ever to come into general use ; the former
is simple, and no doubt might be of use in many cases,
were it at hand.
In the first two severe cases in the Table (Cases 1 and 3)
the greater portion of the vault of the skull was broken
up and removed, and then the base gave rise to great
difficulty. In each case I adopted the plan recommended
by Dr. Braxton Hicks and brought down the face.
Although I ultimately delivered in this way, I experienced
that the process was certainly not an easy one, or by any
means free from risk. It involves dragging on the skull
with a hook which is liable to slip if the necessary degree
of force is used. As a result of the trouble I had in these
two cases I decided to direct my attack chiefly against the
base of the skull in the next craniotomy case I had to deal
with^ and it occurred to me that it might be better if ver-
sion were first performed, and the head attacked from
below. I therefore adopted this plan in the next severe
case^ and was astonished at the comparative ease with
which the head was delivered, and have consequently pre-
ferred this method in all subsequent cases where the con-
traction was marked. If craniotomy was decided on in
any case, podalic version was first performed, and one leg
brought down. The body was delivered by traction^ care
being taken to prevent the chin turning forwards. The
arms having been brought down, the forefinger of the left
hand was passed into the mouthy and the chin was strongly
• 'Obttetric Operations/ 4th ed., p. 836.
VOL XXXI. 3
84 METHODS OF CBANIOTOMY.
depressed, so as to open the mouth widely and flex the
head as far as possible. Flexion of the head was also
promoted by traction on the legs, the direction of traction
being inclined toward the side of the pelvis to which the
occiput was directed. In most of the cases the head lay
with its long diameter nearly corresponding with the trans-
yerse diameter of the pelvis. The perforator was now
guided into the mouth, and having been forced through
the roof of the mouth as far back as possible, was opened
widely and crucially. The cephalotribe was then used to
crush the head in one or more directions, and the head
was ultimately delivered by using the cephalotribe as a
tractor, or by traction on the body and lower jaw com-
bined with supra-pubic pressure.
This method was employed in Cases 6, 8, 9^ 13, and 17,
and practically in Cases 10 and 15, which were breech
presentations. It was also employed in an imperfect
and rough manner in Cases 14 and 18, but in these cases
there was the great disadvantage of having no body to
steady the head with or pull on. In Case 17 the perforator
was introduced below the occiput as well as through the
mouth, thus securing more thorough fracture of the base.
In this case, which is a good example of a markedly con-
tracted brim, delivery was accomplished with comparative
ease in three quarters of an hour, and without appreciable
shock to the mother.
I believe this to be the simplest and safest method of
operating in the great majority of cases in which cranio-
tomy is required. For cases of comparatively slight con-
traction it is not necessary. Further, I do not recommend
it in extreme degrees of contraction, that is to say, where
the conjugata vera is less than two inches, or where along
with contraction of the conjugate there is also marked
contraction of the other diameters of the pelvis. In such
cases extraction of the body would undoubtedly only be
accomplished with great difficulty. Fortunately cases of
this nature are extremely rare. I have never had to deal
with them, but am inclined to think that Caesarean section
METHODS OF CBANIOTOMT. 35
would be as safe for the mother as any method of cranio-
tomy. I therefore believe that this method brings us to the
boundary line between craniotomy and Gsssarean section.
The advantages of craniotomy on the af tercoming as
compared with the forecoming head seem to me to be as
follows :
1. The base of the ahull is effectually broken up. If the
lower jaw is well drawn down and the perforator introduced
well back in the hard palate it will pierce the basi-sphenoid^
and when opened up in a crucial manner will thoroughly
disintegrate the most resistant part of the skull. I have
satisfied myself that this is so by a careful examination of
all the skalls I have perforated in this manner, and also
by experiments on full-time foetnses. If the cephalotribe
be now applied, the base does not tilt bat collapses in the
centre in a V-shape, and the bones forming the vault of
the skull are flattened against each other by the blades
of the instrument. It will be seen, therefore, that this
method has a different aim from craniotomy on the fore-
coming head. In the latter we aim at crushing the vault
and tilting the base ; in the former we fracture and double
up the base and compress the vault, the bones of which
readily lend themselves to this compression.
2. The head is well faed d/uring perforation and crush-
ing. — ^In severe pelvic contractions the difficulty of cranio-
tomy is greatly increased by the mobility of the head above
the brim. In the method above described, the head is
efficiently steadied by traction on the body and supra-
pubic pressure.
3. The position of the head is easily altered, thus allowing
the cephalotribe to be applied in different directions, or
the head to be brought down with its crushed diameter in
the smallest diameter of the pelvis. We are frequently
advised by obstetric authors to crush the head in different
directions with the cephalotribe. Now, all who have tried
to do this in head-first cases must have been struck with
the difficulty of rotating the head at the brim, and also
with the persistency with which the blades of the cephalo-
36 METHODS 07 CBANIOTOMT.
tribe fall into the grooves made at the first crushing. The
difficalty of rotating the head probably depends on the
fact that its movements are hampered by the body of the
child. This difficulty is not met with when the head comes
last^ for its position can be altered with comparative ease.
I prefer to do this with the cephalotribe, rotating the in-
strument through a quarter-circle^ and thus bringing the
crushed diameter of the head into the conjugate in the flat
pelvis. If the tips of the blades of the cephalotribe be
well buried in the f cetal head^ and the handles well drawn
back to the perineum^ there is little risk in this procedure ;
the pelvic curve of the instrument is so slight as not to
interfere with this rotation.
4. The collapse and moulding of the head is often readily
brought about by combined trax:tion on the jaw and body of
the child, and suprapubic pressure. We have a strong
" vis a fronte " and also a powerful " vis a tergo/' In
head-first cases traction can only be made by means of
crotchet, craniotomy forceps, or cephalotribe, and there is
always great risk of these slipping. Not only is our trac-
tion deficient in these cases, but supra-pubic pressure is
not nearly so advantageously applied as it is to the after-
coming head. In fact, all the arguments advanced in
favour of version as compared with forceps in flat pelves,
apply with greater force here.
There are three points which are likely to present them-
selves to many as possible difficulties in the way of this
method : — Ist, the difficulty of the preliminary version in
some cases ; 2nd, the difficulty in extracting the body ;
3rd, the difficulty in perforating and crushing the head.
Difficulty in version may arise from two causes^ namely,
uterine contraction and extreme pelvic deformity. The pre-
sence of either of these conditions to a degree sufficient to
prevent version is extremely rare in the class of cases
under consideration. Tetanus of the uterus rarely occurs
until the patient has been long in labour and expulsive
pains have set in. The contraction of the pelvis as a rule
prevents the head engaging, and the cervix from being
METHODS OP CRANIOTOMY. 37
distended, and the first stage is generally prolonged.
Tetanic contractions would be more likely to occur quickly
in cases of slight contraction, where the cervix has re-
tracted and the head is partially or completely engaged,
or in cases of transverse presentation, where the shoulder
is jammed down and expulsive pains have set in. Again,
in the class of cases in which craniotomy is most frequently
called for, the pelvic cavity and outlet are relatively large,
the pelvis is shallow, and the head is freely moveable at the
brim. If uterine action be suspended by deep anaesthesia
one will often succeed in turning by the bi-polar method.
I have been much struck with the facility with which this
operation is often performed, even when the waters have
escaped, and am convinced that failure is often due to
want of perseverence, and especially to the fact that
chloroform is not poshed far enough. In the event of the
bimanual method failing, the hand may be introduced into
the uterus : with a little care a moderately sized hand may
be passed through a brim much contracted.
In the more marked degrees of contraction there is
often considerable difficulty in bringing the body of the
child through the brim, but vnth steady and prolonged
traction, first on one leg and then with the assistance of
a finger passed over the other thigh, the breech and trunk
will generally pass the obstruction. In any case, we are
in a more favourable position for extracting the body than
in head-first cases, as we bring the smaller end of the
wedge through first. The arms generally become extended,
but as a rule there is sufficient room in the transverse to
allow one or two fingers to be passed up and to bring
down the arms, fracturing them if necessary.
It is not necessary to add much more as regards the
perforation and crushing of the aftercoming head. These
are generally regarded as very difficult operations, but the
difficulties are more theoretical than practical. I have
never experienced any real trouble in the seven cases I
have treated thus. One could conceive that these pro-
cesses might be very formidable in cases where the pelvis
88 MITH0D8 OF CRANIOTOMT.
was deep and contracted in the transverse^ bnt the reverse
of these conditions is nsually met with. There is one
point in connection with the perforation which I wish to
emphasise : the perforator mast be introdnced as far back
in the roof of the mouth as possible^ and with an inclination
backwards in relation to the festal head ; otherwise there
is a liability on opening the instrument for one of its points
to cut right through the alveolar edge of the lower jaw
and appear in the f ace^ in which case the uterus might be
injured.
It may be advanced as an objection to the method
advocated that the performance of version introduces an
additional element of risk in these cases. I believe that
the risk of version carefully performed under chloroform
and with rigid antiseptic precautions is almost nil in the
vast majority of cases^ and that certainly the risk involved
in the double operation is less than that attending the
single operation of craniotomy of the forecoming head.
The object of this paper is simply to draw attention to
the advantages of craniotomy of the aftercoming as com-
pared with the forecoming head. The operation has been
practised for centuries, yet in the majority of text^^books of
midwifery it is either not mentioned or is referred to as
an operation much more difficult and tedious than cranio-
tomy of the forecoming head, but which is sometimes un-
avoidable after version. Further, in most descriptions of
the operation we are advised to perforate either behind
the ear or below the occiput. Apart from making an
opening in the skull through which its contents may escape,
there is nothing gained in the former situation, while the
latter is inferior to the roof of the mouth from the fact
that the base is not so thoroughly fractured.
KSTHODS or CSANIOTOHT.
39
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METHODS OF CSANIOTOMY. 43
Dr. Champnbts said that Dr. Donald's paper was a welcome
contribution at the present time. It was long since craniotomy
had been discussed in that Society. The first thing that struck
him was the large number of craniotomies, in 1886 no less than
eleyen. He thought that the number of women requiring per-
foration in London was much less than this, and he spoke of
poor women in hospitals and maternities as well as patients in
prirate practice. He was not, however, criticising the paper as
regarded the necessity for perforation, Dr. Donald haying given
his justification in the measurements embodied in the paper, but
he thought there must be some hygienic reason to account for
it, and he asked Dr. Donald what was the common cause of the
deformities in his cases. From the description of the pelves it
was most likely rickets. One statement in the paper struck him
as being somewhat in advance of our present knowledge, namely,
the statement that the field of the forceps had been enlarged by
the introduction of axis traction. Granting the advantages of
axis traction, he did not think that it had yet been proved that
the dimensions of possible birth alive at term by forceps had
been extended by its introduction, in the hands of skilled opera-
tors'. In Case 17 he did not approve of the treatment. The
pelvis was generally-contracted — ^flattened. The conjugate was
only two inches and three eighths. Delivery was very difficult.
He thought that the proper treatment in such a case was not
perforation at aU, but Cssarean section. Very likely, however.
Dr. Donald had not conducted the case from its beginning, and
craniotomy was not an operation of election in this case, but
one of necessiiy after previous treatment. As regards the
question of the action of the cephalotribe, it was generally
stated in books that compression in one diameter (the trans-
verse) produced expansion in the opposite diameter (the antero-
posterior). He believed, however, that it had been shown that
no such compensatory expansion took place, but that the change
in the head consisted in its elongation vertically, just as in
traction by craniotomy forceps. Finally, he thought that the
result of this interesting and practical paper would be that the
hitherto unpopular perforation of the after-coming head would
require a new trial ; and, if it should be approved, the procedure
of forceps in the first instance, version in the second, and per-
foration of the after-coming head in the third might take the
place of our present practice in cases of slight contraction.
Dr. Hesuajt, after complimenting the author upon his paper,
said that, like a former speaker, he did not think that the range
within which the forceps was applicable had been increased by
the introduction of axis-traction forceps. He thought that in
the enthusiasm with which the introduction of this forceps had
been greeted, its advantages had been exaggerated. In a recent
discussion (May, 1886) of the subject in Paris (the birthplace
44 METHODS OF CRANIOTOMY.
of the axis-traction forceps), more than one speaker had main-
tained that it was inferior to the ordinary forceps. He observed
that the mortality in Dr. Donald's cases was nil. He did not see
any reason why the mortality after craniotomy (if done at the
proper time) should exceed that of normal labour. He bad
noticed with pleasure the way in which Dr. Donald had spoken
of the method of measuring the pelvis with the whole hand intro-
duced into the vagina after delivery. He had said it was the
only accurate way of measuring the pelvis, and in that he (Dr.
Herman) quite agreed with him. He (Dr. Herman) thought
that sufficient prominence was scarcely given to this metbod of
measurement in obstetric text-books. The fullest, most precise,
and he believed the first description of this mode of measure-
ment was that given by Mr. Kobert Wallace Johnson in his
' System of Midwifery,' published in 1769, and he thought this
method might appropriately and justly be spoken of as *' John-
son's method of measurement." He thought the comparative
ease of cephalotripsy and cranioclasm largely depended on the
amount of practice in the two operations which the operator had
had. An operator experienced in cephalotripsy but not in
cranioclasm would prefer the former, and vice versd. He' had
used the cepbalotribe both to tbe fore-coming and the after-
coming bead, and he did not think that advantages attended
the latter operation which compensated for the additional risk
of the preliminary version. He had never perforated through
the roof of the mouth, nor bebind the ear, but always below the
occiput. Perforation was a little more difficult in the case of
the after-coming head, because the space through which the per-
forator bad to be guided (between the fcetus and the maternal
soft parts) was smaller. He had not found greater difficulty
attended the extraction of the fore-coming head than the after-
coming head. He had not found the cepbalotribe, when pro-
perly applied (i,e. to the greatest diameter of the head) and
well screwed up, prone to slip ; and he thought the instrument
was constructed with a view to tbe prevention of slipping, in
that the blades were curved towards one another at the tips, so
that they could not slip if closely approximated. This was so in
the instrument which be had always used, that of Dr. Braxton
Hicks. Like previous speakers, be had found one good crushing
usually enough ; and he could corroborate also what had been
said about the tendency of the blades, when a second crushing
was attempted, to fall into the grooves made by the first crushing.
In extracting, he bad always, after well crushing the fore-coming
bead, rotated it so that the part crushed and held in the cepba-
lotribe should come to lie in the most contracted diameter of the
pelvis. He had not found difficulty in doing this. If the neck
offered resistance, from the position of the shoulders, it could
be overcome by external pressure on the sboulders, so as to push
METHODS OT CBANTOTOMT. 45
them in the required direction. He had always taught this
rotation of the head after cnishiug as an essential step in the
operation ; and at least in some text-books of midwifery it was
adyised. Dr. Donald had not speculated as to the cause of the
pelvic deformity in his cases. He (Dr. Herman) thought that
when there was not clear evidence in the skeleton of the exist-
ence of rickets, it was better to refrain from a diagnosis as to
the cause of the change in the bones, than to infer rickets merely
from slight peculiarities in the shape of the pelvis, as was some-
times done.
Dr. GAiiABiN fully agreed with the author in preferring the
cephaJotribe to all other forms of extractors after craniotomy.
He considered it equally adapted for simple and for difficult cases,
and available for all forms of contraction, for generally con-
tracted as well as for flattened pelves. Its great advantage was
that the pieces of bone remained covered by the scalp, and did
not tend to protrude so much as when seized by craniotomy
forceps. He was not, however, yet prepared to accept the view
that the after-coming head was preferable for perforation and
extraction. Doubtless the present paper should lead us to put
the matter still further to the test. But it appeared to him that
the author himself had not made fair or e^ectual trial of the
cephalotribe, as used in the best way on the fore-coming head.
In all the cases recorded by him the fore-c^miug head was
extracted by cranioclasm and removal of pieces of bone. This
was doubtless a troublesome and tedious operation, but was
almost always quite unnecessary. It was only required to get a
central grasp with the cephalotribe by passing the fingers high
up above the brim to guide the blades, if necessary. When this
had once been done, no repeated crushings were required. The
diameter grasped could be reduced to one and a half inches, and
the opposite diameter was not appreciably enlarged. The crushed
head could thus be brought through any brim through which
one could reasonably expect to extract the body without injury,
and it was of no consequence that the base of the skull was only
tilted and not broken up. Doubtless the after-coming head
could be easily perforated and extracted in ordinary cases, but in
very difficult cases he considered the operation less favourable
than that on the fore-coming head, as a large body of the child
might render the adjustment of the blades more difficult. The
two most difficult cases of extraction ever met with had occurred
after version, the difficulty commencing when the pelvis of the
child began to enter that of the mother. In one of them this
occurred, although the pelvis had a conjugate as large as two
and three quarter inches. In this instance version had been
performed in order to give the child a chance, as the mother had
only been married seven months, and asserted falsely that she
could not be pregnant for more than that time.
46 METHODS OF CBANIOTOMY.
Dr. Gbbyis joined the preceding speakers in thanking Dr.
Donald for his interesting paper. Dr. Donald's Bn^estion of
perforating the liead after the axis- traction forceps was applied,
and then using the forceps as a tractor to complete the deliyery,
in lesser cases of contraction, he thought worthy of further trial,
as well as his more important proposal to perforate the after-
coming head through the roof of the mouth after the perform-
ance of yersion. In his own experience he had not found version
in contracted pelves so difficidt as had been suggested. In
many cases of flat pelvis with a conjugate of three or even a
little more he had easily completed delivery by version after
perforation through the cranial vault in the ordinary way, taking,
of course, the greatest care that there were no protruding or
loose spiculsB of bone. He entirely concurred with Dr. Galabin
and Dr. Herman as to the great value of the cephalotribe, and if
care were taken to pass the tips of the blades well above the
base, he rarely found any trouble arise from the instrument
8li))ping.
Dr. EouTH was glad to hear an obstetrical paper read before
the Society of so much practical value, and congratulated the
author thereon. He thought, however, that should there be any
difficulty in perforation or using the cephalotribe in footling
cases, or where turning bad been previously had recourse to,
from the presence of the large body of a child, this could be
remedied by a plan he had seen carried out in Vienna with great
success many years back. It was to practise decapitation close
up to the foramen magnum. This could be readily done by the
large curved decapitating scissors used in that hospital. These
were bent at an obtuse angle, and like bone forceps, owing to
their long bandies, were very powerful and readily effected the
object in view. Either perforation or cephalotripsy could then
be readily and easily adopted, the head being steadied by
pressure from above, assisted by any uterine contractions.
Secondly, he had himself seen in that Society Dr. Eobert Barnes
cut through a child's head, and in different directions, by means
of the 6craseur wii*e. During this process the very tightening of
the wire caused all spiculsB of bone to be turned in, covered with
skin, so that danger of wounding the soft parts, in extracting the
pieces so cut, was reduced to a minimum, and should never occur
in the hands of a qualified accoucheur. Lastly, be believed
no comparison between London cases and Lancashire ones,
because of the frequency of pelvic deformity in the latter, was
just. The girls there were mostly factory girls, hard-worked
almost from infancy, much more so formerly than now. Their
mode of living was also very defective. The necessity of per-
foration in these localities was therefore due to their habits of
life, and not left to the option of the practitioner.
Dr. William Duncan wished to emphasize the importance of
UBTHODS OF CBANIOTOMT. 47
yersion in cases of contracted pelvis before resorting to perfora-
tion. He considered that several of Dr. Donald's cases could
probably have been delivered by this means. With regard to
yersion as a means of delivery after perforation, he could endorse
what had fallen from Dr. Gervis as to its value, having success-
fully employed it in some cases. The suggestion by one of the
speakers that decapitation should be done where the head was
impacted after version was, he thought, one that should not be
adopted, owing to the difficulty of operating on the head after
the Dody of the child had been removed.
Dr. HoBKOCKS pointed out that the subject of the paper was
a comparison of the methods of craniotomy, and therefore it was
scarcely fair to drag into the discussion the use of axis-traction
forceps or the relative merits of Cssarean section. Like previous
speakers he had found the cephalotribe a splendid instrument,
indeed, he had never yet been obliged to resort to cranioclasm,
and had never seen that operation performed, the cephalotribe
answering every purpose. Dr. Donald did not mention certain
cases where perforation of the fore-coming head was an advan-
tage, for example, in hydrocephalus, the head presenting. A
careful inspection of the cases brought forward showed that
where the pelvis was only slightly narrowed, perforation of the
fore-coming head had been performed and delivery successfully
accomplished. It was Iq the cases of considerable narrowing
that Dr. Donald had carried out the novel procedure of per-
forming version and then perforating the aiter-coming head.
Dr. Horrocks did not think that in some cases where labour
bad been going on a long time, version could be performed
without great danger. He mentioned two cases in which it had
been attempted, with the result that the mothers as well as the
children were lost. The advantage of perforating and crushing
the after-coming head was that it could be held firmly, and so a
good hold could be obtained, for it must be admitted that in
applying the cephalotribe to the fore-coming head it not infre-
quently slipped off the globe of the head as it was being screwed
up tightly.
Dr. BouTH, in explanation, said : In speaking of the use of
the decapitating scissors, he had not spoken, like Dr. W. Duncan,
from theory, but from experience, and he denied that the decapi-
tated head was not steadied. The pressure on the abdomen from
above and the uterine contractions conjointly made it very
steady.
Dr. CuLLiNOWOKTH hopod that, amidst the numerous side-
issues that had been raised during the discussion, the point of
main interest in the paper would not be allowed to drop out of
view. He felt that, after the experience of Dr. Donald, as to
the relative merits of perforation of the fore-coming and of the
after-coming head in certain cases of pelvic deformity, and after
48 METHODS OF CRANIOTOMT.
the careful experiments he had made upon the dead foetus, it
was clearly desirable that obstetricians should give the latter
method a fair trial. He quite agreed with Dr. Champnejs in
thinking it not by any means improbable that the result of this
paper would be to bring about a change of practice. Some
surprise had been expressed at the number of cases requiring
craniotomy that had occurred in Dr. Donald's practice. The
facts were these: The maternity department at St. Mary's
Hospital, Manchester, was almost entirely an out-door depairt-
ment, the women being attended at their own homes by a staff
of trained midwives ; the average number of cases attended
annually was about 3000. In all cases of difficulty or danger
it was the duty of the midwife to send for the resident obstetric
assistant, who usually held office for three years. The cases
tabulated in the paper occurred during Dr. Donald's tenure of
this office. He might add that St. Mary's Hospital was not
only the oldest, but, until quite recently, the only lying-in
charity of any importance in Manchester, and that the area of
its operations was a yery wide one, including the greater part of
both Manchester and Salf ord, of which the combined population
exceeded half a million.
Dr. W. Gbiffith described a method, often employed at Queen
Charlotte's Hospital, of delivery by the cranioclast in cases of
considerable contraction. After perforation the head is seized
by a powerful cranioclast, and while traction is made rotation is
also slowly performed, the effect being that the base of the
skull is broken up into fragments, in a way that no cephalotribe
can accomplish, the crushing of the base being caused by its
forcible rotation in the contracted brim, and apparently without
injury to the soft parts of the mother. Dr. Griffith used both
the cephalotribe and the cranioclast, and belieyed them both to
be invaluable instruments.
Dr. Donald, in replying, believed that the percentage of
craniotomy in Manchester was not so high as Dr. Champneys
had inferred. Sixteen of the cases recorded in the Table had
occurred in the extern maternity department of St. Mary's
Hospital, and in two of these cases the operation bad been per-
formed in a perfectly normal pelvis on a dead or non-viable
foBtus. During the period of time over which these cases
extended there had occurred in the extern department of the
hospital almost exactly 10,000 confinements, so that the pro-
portion of cases of craniotomy for deformed pelvis was about
one in 700 labours, not a very large proportion in the practice
of a hospital which had to deal with patients of the very poorest
class. As to the statement in regard to axis traction to which
Dr. Champneys and Dr. Herman had taken exception, he could
only give it as his personal experience that delivery had been
brought about by axis-traction forceps with comparative ease in
METHODS OF CRANIOTOMT. 49
many cases in wliich the ordinaiy forceps had failed in his
hands, and in which craniotomy seemed to be the only other
resoaroe. In reference to the criticism on Case 17, he did not
perform version with the view of saying the child, but, believing
craniotomy to be inevitable, he preferred to do it on the after-
coming head. He agreed with Dr. Champneys in thinking that
Oeesarean section was the better treatment in this case. He had
had an opportunity of examining the patient at her second con-
finement, and had been confirmed in the opinion that the patient
could never be delivered of a viable child per vias naturales.
While sharing the preference expressed by Dr. Galabin and
other speakers for the cephalotribe as compared with the cranio-
dast, he did not think the former instrument was perfectly
satisfactory in cases of extreme pelvic deformity when applied
to the fore-coming head. In spite of the theoretical excellencies
pointed out by Dr. Heiman, cases frequently occurred in which
it slipped when it was used as a tractor. This, he believed, was
due to the tilting of the base of the skull. Further, it was in
many cases a matter of the greatest difficulty to rotate the fore-
coming head by means of the cephalotribe. The body of the
child had never offered any great obstacle in any of the cases in
which he had crushed the after-coming head. If the legs and
trunk of the child were drawn well up towards the abdomen of
the mother there was no difficulty in passing the whole hand, or
at any rate the four fingers, behind the diild into the pelvic
cavity, which in the flattened pelvis was relatively large. It
was a positive advantage to be able to apply traction on the body
so as to steady the head in perforating and crushing, and to
assist in extracting. He had adbpted in one case the method
advocated by Dr. G^rvis and Dr. William Duncan, and had
performed version after perforating the vertex. He objected to
this method because the base of the skull was undiminished,
and also because spicules of bone and portions of connective
tissue and brain substance were liable to be left inside the
uterus. He had already discussed in his paper the objection as
regards the difficulty in version, but might further state that in
the course of his experience ho had only met with two cases in
which, after deep auaesthesia had been mduced, it seemed to bo
dangerous to attempt version. Still, tlie treatment must vary
according to the special features in each case, and if the lower
segment of the uterus was found to be thinned out and retracted,
then the vertex should be perforated in preference to the method
advocated.
VOL. XXXI.
ANNUAL MEETING.
Pbbkuakt 6th, 1889.
John Williams, M.D., President, in tHe Chair.
Present — 48 Fellows and 6 Visitors.
THe President declared tHe Ballot open for one Hour,
and appointed Dr. Glapham and Dr. Jamison as Scruti-
neers.
Books were presented by Dr. Bantock, Dr. Barbour,
Mr. Alban Doran, Dr. Port, Dr. Jacobi, Dr. Playfair, Sir
T. Spencer Wells, the Clinical Society of London, the
Guy's Hospital Staff, and the St. Bartholomew's Hospital
Staff.
Arthur Graham, L.R.C.P. & S.Ed., was admitted a
Fellow of the Society.
William James Best, M.R.C.S. (Dover); Edward T.
Crouch, M.R.C.S. (Gosport) ; and William Duncan,
L.R.C.P. & S.Ed. (Bristol), were declared admitted.
The following gentlemen were elected Fellows of the
Society : — ^William Henry B. Brook, M.B.Lond. (Lincoln) ;
Arthur Henry Weiss Clemow, M.D., C.M.Ed. ; William
Edward Dawson, L.K.Q.C.P. & L.M. ; Henry Willingham
Gell, M.A.,M.B.Oxon. ; Charles D. B. Hale, L.R.C.P.Lond. ;
Charles Beyer Humphrys^ L.R.C.P. & S.Ed. (Bourne-
52 ANBNCSPHALOCS F(ETUS.
moath) ; Bobert Reid Rentoul, M.D. (Liverpool) ; and
Leonard Bemfry^ L.B.C.P.Lond.
The following gentlemen were proposed for election : —
Matthew Benson, M.D. (Wigan) ; Jehdngir J. Cursetjee,
L.P.P.S.; Charles Arthur GouUet, L.B.C.P.Lond.; and
John Wayte, M.B.Oxon. (Croydon).
DISEASED PCETAL MEMBBANES OP UNCEBTAIN
NATUBB IN EABLT PBEGNANCT.
By Dr. John Phillips.
Beferred to a Committee.
ANENCEPHALOUS FCETUS.
By Alban Doran, for Dr. William Skbne, of Cardiff.
This monster was bom on November 22nd^ 1888. Dr.
Skene writes : — " I never saw the woman^ Mrs. E — , till
I Was called to attend her daring her confinement. I
found her in strong labour. On examination, a large bag
of membranes was protruding, and was ruptured during
the first pain she had after my arrival, and the child almost
immediately followed. The quantity of liquor amnii was
enormous. She had been pregnant, including this, five
times during the last seven years. Three children were
bom alive (males), and are still alive and healthy ; the
other was an abortion. Mrs. E — tells me that she has
experienced nothing unusual during this pregnancy, except
that about two months ago she had an attack of hsBmor-
rhage, unattended by pain, which lasted for three days,
very considerable at first, then slight, but for which she
ANINCKPHALOOS 1HBTU8. 53
had no medical attendance ; rest sufficed. She had not
had any fright^ blow^ or fall. Her circamstances appear
comfortable. Until two years ago she suffered, during a
period of six years, from epileptic convulsions/' The
family history included no evidence relevant to this case.
The mother's husband was ^^ a very healthy looking man.'^
The f cetus weighed one pound thirteen ounces. It mea-
sured from the frontal eminence, the highest point in
the monster, to the coccyx, six and a half inches ; from
the same eminence to the right heel, the leg being drawn
straight, ten inches. In general form and the position of
the limbs it resembled a frog. The head was strongly
extended, the occiput and back of the neck not existing ;
the space between the chin and sternum was abnormally
wide. The face looked straight upwards, the features
were large. The vault of the skull was entirely deficient.
The integuments joined the dura mater along a line repre«
senting the lower limits of the frontal plate of the frontal
bone and the lower part of the parietals. The basilar
portion of the sphenoid projected upwards; the corre*
{(ponding part of the occipital was ill developed, and bent
downwards from its junction with the sphenoid almost at
a right angle. Posteriorly the integ^mental line ran along
each side of the widely opened lamin» of the cervical and
dorsal vertebrae, and joined in the dorsi-lumbar region.
The lumbar vertebrae were similarly deficient, but were
covered with cicatricial integument. Projecting from the
base of the cranium, so as to rest on the upper part of the
back, was a mass which consisted of the cranial hemispheres,
small and covered with pia mater.* This mass was par-
tially decomposed when I received the specimen, and I
was obliged to remove it. The medulla appeared to be
* In this, and in other retpeoU, the moniter reeembled a specioien figured
in Ahlfeld'e ' MiMbildnngen,' pi. zlTiii, fig. 18. In reference to that epecimen
the author atatet that» in the oomparatiTely few eaiee of anencephaloa where
a diftinct traoe of the hrain it preaent (aa in Dr. Shone'a monater), the rudi-
mentary encephalon liee on the bach, owing to the eharacteriattc poature of
the head.
54 ANSNCEPHALOUS FOCTUS.
represented hj a Y-shaped tract of nerve tissue^ each arm^
about one fifth of an inch thick^ uniting below with its
fellow to form a short flattened nerve, gradually lost on
the spinal dura mater. In fact, the cord had become
flattened out and atrophied.
The thoracic viscera were healthy, the heart was very
large. The caecum and ascending colon appeared to be
included in the mesentery. A distinct transverse, de-
scending, and sigmoid meso-colon existed. The uterus,
tubes, ovaries, and vulva were well formed ; the anus was
distinct and open. The large intestine was distended with
meconium. The fingers and toes were perfect. There
appeared to be distinct talipes calcaneo- valgus of the right
foot, an unusual congenital condition.'^ On close obser-
vation, however, the distortion of the foot was found to
be due to extreme flexion of the ankle-joint, increased by
the action of alcohol.
Anencephalus is one of the best known of all the forms
of monstrosity which occur in the human fcetus. The
hideous appearance of the features, the absence of neck,
and the open cranial cavity, a well-formed trunk and ex-
tremities often co-existing, make an anencephalus very
conspicuous. A monster of this kind cannot be overlooked.
St. Hilaire has described and figured an Egyptian mummy
anencephalus. No doubt the birth of such a monster was
once looked upon with superstitious awe. The significance
of the general aspect of the head is easy for any anato-
mist to understand. It is the imperfect development of
the upper part of the orbits that gives so ugly an appear-
ance to the face and profile.
Specimens of anencephalus abound in our museums.
* The rarity of talipes and deficiency of the fingers and toes in anen-
cephaluSf compared with its frequency in acardiacos acephalus, is noteworthy.
In the latter no heart exists, and the extremities are ill-nourished by the
feeble circnlation derived from the brother twin's heart. In anencephalus
that organ is generally large and well-formed. It appears to nourish the
trunk and limbs in spite of its necessarily imperfect innervation, a mystery
which we may leave the physiologist to solve.
AMBNCEPHAL0U8 F(ETU8. 55
This form of monstrosity must not be confounded with
acardiacns. I fally described the latter variety at the
January meeting of the Society this year (p. 4) • It is deve*
loped in one-yelk twin pregnancy ; the chief reason why it
is often mixed up with anencephalns is becaase the common-
est type of acardiacns is called acephalns. Anencephalns,
again, is not identical with perocephalns or simple arrest
of development of the head — ^a condition rarely if ever seen
in onr species.
Some good descriptions of anencephalons monsters are
to be found in our Society's 'Transactions.' Dr. Lloyd
Roberts's case (vol. x) closely resembled Dr. Skene's
which I show to-night. The drawings (ib. figs. 7, 8, pp.
270, 271) might serve for Dr. Skene's specimen, except
that ectopia of the abdominal viscera existed in Dr.
Boberts's case. Dr Langston's case, in the same volume,
is illustrated by a good woodcut. Mr. Milward's speci-
men (vol. xiv, p. 140) was an anencephalns ; it is described
as *' acephalus." Dr. Uvedale West (vol. i, p. 107) in
describing a case of anencephalns, noted the abundance
of liquor amnii, a phenomenon also recorded by Dr. Skene.
Anencephalns has nothingto dowith twin gestation. Once
it was attributed to adhesion of the amnion to the primor-
dial skull, so that the pressure of the adherent and un-
yielding amnion interferes with its development. Ahlfeld
(' Missbildungen des Menschen ') has shown that adhesion
of the amnion, not a rare condition, produces distinct facial
and cranial deformities, as repulsive as those seen in anen-
cephalns, but of a character essentially different.'^
Anencephalus or hemicephalia arises most probably from
the rupture of a hydrocephalic skull at about the fourth
week. Schlegel figures a case where he found such a
skuU, just about to burst, in a very early embryo (Ahlfeld,
loc. cit., pi. xlviii, fig. 1). Sudolphi figures a case (ibid.,
* The adherent amnion prerenta the cloaing of the embryonal defta in the
face. For an extreme caae, quoted by Ahlfeld and othera, aee " A Cnriona
Monater which lived for lome time after Birth,** by Dr. W. Boaa, 'Trana.
Obatet. Soc.,' yol. ix, p. 81, and pi. i.
56 ANKN0EPHALOU8 FCETUS.
fig. 2) where the bursting has just occurred, and the re-
mains of the fleshy vault adhere to the base of. the skull.
The solid cerebral matter rapidly breaks up and disap-
pears, in extreme cases, to be replaced by a mass of carer-
nous tissue occupying the base of the skuU.'^ A similar
disintegration of burst structures is seen in the early stages
of ectopia vesicfe, which is believed, according to Ahlfeld,
to be due to bursting of the allantois. Mr. Shattock, it
must here be noted, traces ectopia vesicae to quite a diffe-
rent origin.
The base of the skull being freed from the pressure of
the cranial contents, its own development undergoes modi-
.fications easy to understand. Extreme convexity of the
middle part (well seen in the present case at the junction
.of the basi-sphenoid and basi-occipital), great shortening
of the upper boundaries of the orbits, and especial arrest
of development of the occiput and the cervical vertebr®,
are the main features in anencephalus. They account
respectively for the shallow base of the skull, the staring
eyeballs, and the absence of neck posteriorly. Some well
prepared skulls of these monsters are to be seen in the
Teratological Series, Museum of the College of Surgeons.
Thus anencephalus is due to changes which originate
entirely within the affected foetus, quite independently of
twin gestation. Acephalus, or, more properly, acardiacus
acephalns, is due to changes which originate entirely out-
side the affected fcetus, and invariably in association with
twin gestation.
* Thus Ahlfeld's theory is based on fair evidence. Mr. Bland Sutton traces
anencephalus to morbid conditions which prevent the development of the
enoephalon almost from the first. His theory would not account for cases
like the present, where a small, ill-formed brain exists.
57
A CASE OF PORRO'S OPERATION.
By AiFRBD Lewis Galabin, M.A., M.D., F.R.C.P.,
OBSTRBIO 7HT8ICIAK AKD LBCTUBXK OK MIDWITBBT TO eVT'S HOSPITAL.
(Received Jinnary 80th, 1889.)
On September 16tb, 1886^ during the absence from
town of my colleague^ Dr. Horrocks^ I received a sammons
at about 11 p.m. stating that a patient who had been two
days in labour, and who was said to have extreme pelvic
deformity, was being sent up from Woolwich to Guy's
Hospital, and was then on her way. On my arrival at
the hospital, I found that she was already there.
The patient, Anne P — , aged 28, 'had last menstruated
on November 29th, 1885, the period lasting three days
from that date. She had been married eleven months,
and the present was her first pregnancy. Labour came
on on September 14th, about a week after the date which
calculation would give as the probable full term. She
stated that the labour pains had been severe, extending
to the back and down the legs, for two days and two
nights. The liquor amnii had escaped about twenty-four
hours before her admission.
The medical man who was first in attendance appears
not to have fully recognised at first the extent of the de-
formity, probably in consequence of the high position of
the promontory of the sacrum. Attempts were made to
apply long forceps, but it was found impossible to do so.
It afterwards appeared that the scalp of the child had been
abraded by the blades. Two other doctors were then
called in consultation. It was decided that the contraction
of the pelvis was so great that delivery through it would
58 POERO'S OPBRATION.
be very difficulty if not impossible^ and it was decided to
send tbe patient off by carriage to Guy's Hospital.
On her arrival sbe was suffering intense continuons
pain in the back and down tbe back of the legs^ bat
rhythmical uterine contractions had ceased. She was of
short stature^ and showed evidence of rickets in the shape
of bowed tibiaa. She stated that her legs were weak in
childhood^ and that she could not walk until she was five
years old. She had also suffered in childhood from en-
larged glands in the neck^ and from an affection of her
joints which her doctor had considered to be strumous.
The following were the measurements of the pelvis :
Between anterior superior spines of ilia . 9^ inches.
Maximum transverse diameter of crests . lOf ^^
External conjugate diameter . - 3| j^
Diagonal conjugate diameter . . 2i „
The foetal head was resting high above the brim. The
cervix was fairly^ but not quite completely^ dilated ; the
walls of the cervix were very unusually thick. Passing
the whole hand into the vagina^ it was possible to measure
the true conjugate diameter directly^ by passing two
fingers as far as there was room for them to go. It was
found that the available true conjugate^ as reduced by
the thick walls of the cervix^ was only an inch and a
half. The bony true conjugate was estimated at about
two inches. The cervix could not be pushed up above
the brim.
It is worthy of note that the external conjugate dia-
meter was but slightly below normal in comparison with
the true conjugate. The diminution of the latter must
therefore have been due to great thickness of the sacrum.
Moreover, the classical sign of a rachitic flattened pelvis^
namely, the altered relation of the transverse measurements
between the spines and that between the crests of the ilia^
was here absent.
The uterus was found to be somewhat anteverted, and
in a condition of continuous action. The pulse was 110
— 120, but the general appearance and condition of the
POBRO'S OPEBATION. 59
patient were fairly good, considering the long duration of
labour, and the tetanic condition of the uterus. The urine,
however, was found to contain a large amount of albumen,
forming a deposit of nearly half its bulk in the test-tube
after boiling. Subsequent examination showed that tube-
casts were present in abundance, and there were also blood-
corpuscles; sp. gr. 1032.
I decided that, even without assuming that the favour-
able results of modem Csesarean section justify a great
extension of the limits of that operation in comparison with
craniotomy, in this case at any rate Csssarean section would
probably give the patient a better chance than the attempt
to extract through the pelvis, since the available conjugate
was equivalent to the absolute minimum through which it
has ever been considered possible to effect extraction. I
chose Porro's operation because labour had been already
so protracted, and attempts had been made with forceps,
which might have caused some bruising to the uterus.
There was a chance for the child, as the festal heart was
audible, though slow and feeble.
The operation was performed at 4 a.m. on September
17th, The carbolic spray was used, in view of the possi-
bility that there might be a special liability to injurious
microbes in the hospital air. Ether was given as anaos-
thetic. The abdominal wall haying been divided from a
point two inches above the umbilicus to one and a half
inches above the pubes, the uterus was incised in situ.
The uterine wall was unusually thick. No very serious
bleeding took place from it, although no elastic ligature
was used. The placenta was situated on the posterior
wall. The child was extracted by the leg. Some artifi-
cial respiration was required to induce it to breathe.
In a former Caesarean section I had found that a uterus
in a condition of continuous action after very prolonged
labour was not, as might be expected, ready to retract,
but the contrary, and was apt to allow serious haemorrhage
from the placental site. I therefore directed the anaes-
thetic to be given to somewhat less than the full surgical
1
60 PORRO'S OPKRATION.
deg^ee^ hoping so to secure a better retraction of tlie
uterus. This led to the only difficulty of the operation.
Just as the child was being extracted there was straining,
and a considerable length of intestine became extruded,
and exposed to the carbolic spray. It could not be re-
turned until the patient had been brought completely under
the ether, and this occupied some little time.
The uterus was clamped with a Eoeberle's serre-noeud,
and uterus and ovaries cut away. The great thickness of
uterine wall rendered the stump very large. It was fixed
in the wound by two pins above the wire of the ^craseur, no
sutures being passed through the peritoneum of the stump.
The patient suffered from a good deal of febrile dis-
turbance for more than two weeks after the operation.
She never had any sign of peritonitis, notwithstanding the
prolonged exposure of intestines. The urine continued to
contain a considerable quantity of albumen, although by
the third day the proportion after settling was reduced
from one half to one quarter. Both on the second and
third day the pedicle was found to be vascular above the
constricting wire, and it was necessary further to screw
up the serre-noeud to cut off the circulation. Later on,
there was some sloughing of the pedicle below the level
of the wire, and this appeared to be the cause of the
high temperature. It may be accounted for, partly by the
very tight constriction which had been found necessary,
partly by the constitutional state of the patient, consequent
upon the severe nephritis from which she was suffering.
Temperature gradually rose till September 21st, when
it reached 103^. It continued high till the 26th, when it
fell to 99^; but there were occasional sudden rises after this,
even so late as October 11th. The fever was treated by
large doses of quinine, and by Leiter's ice*water cap
placed upon the head.
The stitches were removed from the abdominal wound
on September 24th ; the pedicle separated on September
27th. By October 4th the proportion of albumen in the
urine was reduced to one tenth. The cavity left by the
POBBO'S OPERATION. 61
pedicle did not entirely close up until October 28th. The
patient remained extremely anaemiC) and on November 4th
a swelling appeared below the right nipple. This eventu-
ally formed an abscess whicb was opened on November
15th. There were also some small suppurating ulcers in
the right axilla. After this she regained strength and
coloar^ but the urine was still slightly albuminous when
she left the hospital on November 30th. The abrasion on
the child's scalp healed in about ten days. He did well^
and is now living.
The mother's urine was watched from time to time. A
year and a half after the operation it was first found to
be- free from albumen, and it has remained free since. As
the albuminuria was so persistent, it was feared that an
acute nephritis had ended in producing granular degenera-
tion of the kidney. Two years after the operation the
patient states that she does not think that she is destitute
of, or has lost, sexual feeling, but that intercourse, which
was always more or less painful to her from the first, has
been more so since the operation. So far as could be
ascertained, this condition appeared to be due to some
vaginismus and tenderness of the vaginal outlet, but especi-
aUy to pressure of the vaginal wall against the projecting
sacrum in coitus. She has been advised to come into the
hospital again, to see if any treatment would improve this
condition, but has not cared to do so.
It was solely on account of the prolonged labour and the
probably damaged condition of the uterus that in this case
I chose Porro's operation in preference to Caesarean section
according to Sanger's method. I consider that the latter
operation had, even at the time of my operation, established
it superiority for all cases in which the operation is selected
by previous choice, and in which the operator is practised
in abdominal surgery, or has even merely had the oppor-
tunity of seeing similar operations.
According to Harris's statistics up to August, 1888, in
130 Csosarean sections according to Sanger's method per-
formed in various countries the mortality was 26'9 per
62 POKBO^S OPERATION.
cent. In sixty-five operations performed in German cities^
it was 13*8 per cent. In twenty-three operations performed
in America it was no less than 60*8 per cent. Bat in the
last twelve of these it was only 41*6 per cent.^ showing a
decided improvement.''^ It is remarkable that in Britain^
although strong remarks have been made in some addresses
and speeches delivered at various times within the last
few years on the murderous character of the operation
of craniotomy^ few cases of Caesarean section have yet
been recorded.
But to learn the mortality of the operation under the
most favourable circumstances it is necessary to take the
statistics of operations at Dresden and Leipzig, where it
was performed more frequently than elsewhere. These
give thirty-three operations, with three deaths, a mortality
of only 9'0 per cent. They include the results of a con-
siderable number of operators ; but all operated in one or
other of the two cliniques, in which the operation has been
mainly brought to perfection, and had thus had the oppor-
tunity of studying it practically.
These results appear to prove not only that Gaesarean
section according to Sanger's method is superior to all
others forms of Gaesarean section when performed early
in labour as an operation of first choice, but that, under
similar circumstances, it should be preferred to craniotomy
where pelvic contraction is so extreme that there is con-
siderable risk in extracting through the pelvis.
The originality of Sanger's method appears to mainly
consist in the application to the uterus of Lembert's intes-
tinal suture, by which the edge of the peritoneum is
pierced twice on each side, and in the use of numerotis
sutures, arranged in two sets, deep and superficial. He
was not altogether original in insisting on the importance
of uniting edges of the peritoneum, or that of including
only muscular wall, and not mucous membrane, in the
deep sutures. Practical improvements of minor importance
* As quoted by Lusk from private oommunicatioD, '*The New CsBsarean
Section," * GynsBCoIogical TranBactions/ vol. ziii, 1888.
POSBO'S OPBBATION. 63
are the plan of placing sutares ready to close the upper
part of the abdominal wound before the uterus is incised^
and that of turning the uterus out of the abdomen to
insert the sutures. The expedients of cutting away a
wedge-shaped slice of the muscular wall, and that of
undermining the peritoneum, to facilitate the turning in
of its edges, have been found unnecessary, and have been
omitted in most of the more recent operations.
It is difficult to make a fair comparison of Porro's ope-
ration with that of Sanger as regards mortality, for of
late most operators have considered, as I did in the in-
stance now recorded, that those cases only are suitable for
Porro's operation in which labour has been long protracted,
or attempts have been made to extract by other means,
and which are, therefore, most un&vourable as regards
prognosis. In the statistics collected by Dr. Godson* up
to 1884, at which time Sanger^s method had hardly come
into use, the mortality was 56*6 per cent, in 152 opera-
tions. Although the results might be expected greatly
to improve, it can hardly be supposed that they would
compare with the mortality of only 9 per cent, attained by
Sanger's operation at Dresden and Leipzig.
Although it seems clear that Sanger's operation is to
be preferred when a primary choice can be made, and the
operation can be performed by a skilled specialist, there
are two other questions which experience does not yet
enable us, perhaps, fully to answer. 1. Which operation
is preferable if labour has been already protracted ? 2.
Which should be chosen by a family practitioner if circum-
stances compel him to perform one, and how far is he
justified in selecting one or other of them as an alterna-
tive to craniotomy 7
As regards the first question, it may be that, in future,
Sanger's operation may establish its claim to be regarded
as the safer, even in those unfavourable cases in which
labour has been already protracted. Thus Luskf selected
• 'BritUh Medical Journal,' Jan. 17th, 1885. |
t "The New CsBearean Section," * Gynecological Trans.,' vol. liii, 1888.
64 POKRO'S OPKBATION.
it in a case of this kind, where the patient had been in
labour six and a half days^ the membranes having raptured
the day before operation. He scraped away a necrosed
decidua with the fingers^ and washed out the uterus with
a disinfectant. The patient recovered^ though she had a
very narrow escape^ and the pulse for some days varied
from 130 to 160.
As regards the second question, it is worthy of note
that the mortality of all Sanger's operations, sixty -five in
number, performed out of Germany up to August, 1888,
is 40 per cent. ; that of all operations in America, even
excluding those performed before June, 1887, it is 41*6
per cent. It is clear, therefore, that unless the general
results are found greatly to improve as time goes on, some
caution should be used in recommending the operation to
practitioners in general as an alternative to craniotomy,
except in very severe degrees of pelvic contraction. The
mortality of craniotomy, since modem improvements in
antiseptic midwifery, ought to be very slight indeed in
flattened pelves having a conjugate exceeding two and a
half inches. And, when deaths do occur, it is probable
that they are rather attributable to efforts made to extract
a living foetus by forceps or version than to the craniotomy
itself. Thus, in the last report for twelve years of the Guy's
Hospital Lying-in Charity, out of 23,591 deliveries, from
1863 to 1875, there were eighteen cases only of craniotomy.
The mortality of these was 6, or 33*3 per cent. But in
none of the fatal cases was there a conjugate diameter
less than about three inches, and probably, therefore, in
none of them, even at the present day, would GsBsarean
section have been decided on as a primary choice. All
the patients who had the more extreme contractions of the
pelvis recovered.
I do not therefore consider that, as yet, either Sanger's
or Porro's operation should be recommended as an alter-
native to craniotomy with a pelvis exceeding two and a
half inches conjugate diameter, unless there is marked
transverse contraction as well.
posbo'b operation. 65
If a family practitioner does nndertake CaBsarean sectioiii
there are certain advantages in favour of Porro's opera-
tion as compared with Sanger's which may tarn the scale
when labour has already been protracted^ and when there
is therefore an advantage in removing the possibly already
damaged uterus. The operation is easier and much shorter.
It is not necessary to have a Koeberle's serre-noeud^ but *
the pedicle may be constricted by india-rubber tubing, as
in the method of hysterectomy described in H6gar and
Kaltenbach's ' Gynecology.' It is easy to improvise a pin
to transfix the pedicle above the wire. A knitting-needle,
as suggested by Mr. Lawson Tait, would answer the
purpose.
The uterus removed in the case now recorded was shown
to the Society when fresh. Unlike most specimens of the
Porro uterus, the placenta does not remain entirely adhe-
rent^ but is partly detached, and that detachment is at the
lower border. This circumstance appears to me to favour
the view that the normal detachment of the placenta is due
partly to detrusion by the uterine action, in addition to
shrinking of the placental site, and to be against the theory
lately put forward by Dr. Berry Hart, that detachment is
due to expansion of the placental site in the third stage of
labour during the interval of pains. For the shrinking of
the placental site will cause a radial strain on the attach-
ment of every point on the placenta, the strain increasing
from centre to circumference. If to shrinking of the
placental site is added detrusion of the whole placenta by
uterine contraction, the strain on points on the upper
margin will be relieved, and that on points on the lower
margin will be increased by the same amount. Hence the
lower margin will be separated first, as happened in the
present instance.
It is obvious that detrusion must be much interfered
with by the incision in the anterior uterine wall. Hence,
perhaps, the reason why the placenta generally remains
attached to the Porro uterus. It may be that separation
VOL. XXII. 9
66 POBBO'S OPERATION.
kad comDaeiiced in tlie present specimen^ because the uterus
was unusually thick and strong.
Dr. Matthews Duncan, agreeing thoroughlj with the general
tenor of Dr. Qalabin's paper, regarded it as novel and likely to
prove disadvantageous to introduce into questions of treatment
variations according to the grade of the practitioner. Meantime
at least, and probably for a long time to come, it is best to con-
sider and decide on what is the proper treatment by the best
practitioner, leaving variations in any particular case to be
decided by the good sense of the practitioner in immediate
attendance. The great successes of Porro and of Sanger and
Leopold had naturally opened up grand prospects for the obstet-
rician. not only in lessened mortality of Ctesarean section, but
still more in avoidance of cramotomy. For more than a genera-
tion obstetricians had been hoping for the avoidance of cranio-
tomy, and much vain sentimental talk had been expended on the
subject. But craniotomy held its place still, because it was still
much safer to the mother than any form of OsBsarean section.
Now, however, a real ground of hope showed itself, and this hope
all trusted would soon come to realisation. The hope rested
exclusively, at present, on the still further reduction of the mor-
tality of CaBsarean section. That reduction miizht soon come,
and expel the horrid craniotomy from our work. In his zeal U>
reach the goal, Leopold had introduced into medical morals a
new factor in the decision of questions of treatment, namely, the
wish or opinion of mother, husband, and friends. He (Dr.
Matthews Duncan) regarded this wish or opinion as absolutely
powerful negatively. They might say ** No " to any operation,
but they had no voice'in advising or deciding what should be done.
Were it so, medicine and surgery would be launched at once into
chaos; thus most injurious proceedings might get justification.
The surgeon decides what operation should be done and how it
should be done. The patient may adopt the advice or may
refuse it. She has no place in giving the advice or modifying
its essentials. Leopold defended his substitution of Csesarean
section for craniotomy in some cases on the ground of the wish
of the mother and husband and friends, and such defence could
not be sustained. He (Dr. Matthews Duncan) hoped that soon
his friend Leopold would need no such argument, and be able to
say, Caesarean section is more successful, in respect of maternal
mortality, than craniotomy ; and he believed that the time was
not far off.
Dr. Herman quite agreed with Dr. Galabin and Dr. Duncan
as to the far greater safety for the mother of craniotomy than
Csesarean section. Dr. Galabin had quoted the results of
Csesarean section in those lying-in hospitals in which it had been
POBBO'S OPEBATIOK. 67
brought to the greatest perfection, as data from which conclu-
sions as to its risk might be drawn. He (Dr. Herman) thought
that, in order that the comparison might be a fair one, the mor-
tality of craniotomy should also be estimated from cases operated
on under the most favourable circumstances. He therefore called
attention to the results of craniotomy in the Berlin Ljing-in
Institution, given in a paper by Wyder (* Arch, fur Gyn.,' Band
xxxii). This showed the at first sight surprising fact that after
craniotomy in the slighter degrees of pelvic contraction the mor-
tality was greater than in cases of high degrees of deformity.
This was because in the slighter cases craniotomy was only done
after the patient's strength had been exhausted and her tissues
injured by delay and attempts at delivery in other ways. In the
cases of greatest deformity, where the impossibility of delivering
a living child was recognised from the first, and craniotomy done
early by a skilful operator, and with all proper precautions, the
mortality was nil.
Dr. AusT Lawrence (Clifton) remarked on the importance of
obstetric physicians performing abdominal operations generally,
as they then were in the best position to meet the emergency which
had been so successfully faced by Dr. Gkblabin. He also laid
great stress on the early and thorough examination of the pelvis
by the hand in all cases requiring instrumental aid, as frequently
an obstacle could be recognised which the forceps could not over-
come, and in which it should not be tried. If an obstacle to
delivery by forceps is recognised at a comparatively early stage
of labour, then craniotomy or its alternatives could be performed
with a very good chance of success. Dr. Aust Lawrence con-
sidered that the great mortality in craniotomy cases and in
Cesarean section by Porro's operation was mainly due to futile
attempts to delivery by other means having been tried for too
long a time, the patient becoming exhausted.
Dr. Qalabin said he was glad to have Dr. Herman's confirma-
tion of his own observations that the mortality of craniotomy
chiefly occurred in those cases of slight contraction in which an
effort was made to save the child, and that, short of very rare
and extreme forms of distortion, there was hardly any mortality
in the more difficult cases. With regard to Dr. Matthews
Duncan's criticism of his mention of family practitioners, he had
no intention to suggest that anyone should be called upon to
take any other course than that which he himself considered
best. Li point of fact, he should himself adopt exactly the
treatment which he recommended. But he considered that
it did make a great practical difference to a serious operation
whether it could be performed with all hospital facilities or only
in a small, incommodious, and perhaps insanitary house. And
he certainly considered it a wise course which many practitioners
adopted, when certain rare and difficult operations were called
68 POSBO'S OPERATION.
for, to send the case to a hospital rather than operate them-
selves. He agreed in the main with Dr. Dancan's remarks
on the ethical side of the question, espeoiallj as regards the
paramount importance of the mother's life iu comparison with
that of the child. But where the risk of the two operations
appeared to be almost evenlj balanced, he did think that a cer-
tain regard should be paid to the life of the child, and even that,
in such a case, the wishes of the mother and her husband should
be taken somewhat into account.
\
69
Annual Meeting.
The aadited balance-sheet of the Treasurer (Dr. Galabin)
was read; its receipt and adoption were moved by Dr.
Grailt Hewitt^ seconded by Dr. Glsyslakd, and carried
unanimously.
The report of the Honorary Librarian (Dr. Horrocks)
was then read ; its adoption was moved by Dr. J. Watt
Blace^ seconded by Dr. CvLUNOWOBTH^and carried nem. con.
Report of the Honorary Librarian.
it
During the past year 144 additions have been made
to the volumes in the Library. These are made up as
follows : — Eighty-three books^ of which 46 were by dona-
tion^ and 37 by purchase ; 3 volumes^ containing 41 pamph-
lets^ of which 24 were given and 17 bought ; 58 volumes
of periodicals. The total number of books in the Library
now amounts to 4004.
'' A manuscript copy of Wolveridg^'s ' Speculum M^-
tricis^ or the expert Midwives^ Handmaid^' containing
beautiful etchings^ was presented during the year by
J. Lee Jardine, Esq. It is a most valuable addition to the
Library^ and the original copy^ which .is dated 1669^ has
been since presented by the same donor to the Boyal Col-
lege of Surgeons.
" The third or back room has been furnished as a Com-
mittee room, so that meetings can be now held without
interfering with the ordinary use of the Library.
" The number of Fellows who have used the Library
during the past year has increased, and this has been the
case especially with writers of papers who wished to look
up works of reference.
" P. Horrocks.'^
70
BALANCB-SHEET.
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1^
BEPOBT OF BOARD FOB EXAMINATION OF MIDWIVBS. 71
The report of the Chairman of the Board for the
Examination of Midwives (Dr. J. Watt Black) was read^
after which its reception and a vote of thanks to the
Chairman and Board of Examiners was moved by Dr. J.
Bbaxton Hicks^ seconded hj Mr. Abthub Bopeb^ and
nnanimously carried.
Annual Report of the Board for the Examination of
Midwives.
'' Daring the year 1888 there have been 149 candidates *
examined by the Board. Of these 127 passed and 22 were
rejected. This gives a percentage of 14*7 failures^ or a
proportion of 1 in about 6^.
'' The number of candidates continues to increase from
year to year^ having risen from 125 in 1887 to 149 in 1888.
The number examined from 1872 to the end of last year
is 747^ and the number rejected 129^ or about 17 per cent.
The total number of diplomas granted by the Society up
to the end of 1888 amounts to 618.
*' Last February the Council received a complaint of the
conduct of a midwife who held the diploma of the Society.
Having doubts as to their jurisdiction, the Council ap-
pointed a Committee, with power to take legal advice, to
inquire into the position of the Society towards the mid-
wives who have obtained its diploma. The Committee
drew up certain questions and submitted them to the
solicitor of the Society for his opinion. The solicitor held
that the Society possessed the right to strike a midwife^s
name off its register, but that, having made no contract
with the midwives, it could not in any case require the
surrender of the diploma. The Council and the Com-
mittee considered the question at various subsequent meet-
ings, and the Council resolved that in future all successful
candidates for the diploma should be required to sign a
declaration or sponsio, in a book to be kept for that pur-
pose. In this declaration the midwife agrees to submit to
the jurisdiction of the Council in all matters relating to
72 OVFICIBBB AND COUNCIL.
her conduct as a midwife^ and to give up her diploma if
the Council shall consider her conduct such as to render
her unworthy to hold it. In order to keep the midwives
mindful of their obligations^ it was further resolved that
the declaration should be placed on the face of the diploma
itself^ immediately over the midwife's signature.
'' It also appeared to the above-mentioned Committee
and to the Council that the regulations for the examina-
tion of midwives stood in need of revision. Those regu-
lations have accordingly been amended by the Council.
" On behalf of the Board,
" J. Watt Black,
" Chairmcm.''
The Scrutineers retired, and on their return the Presi-
dent declared the result of the Ballot for officers and
C6uncil for the ensuing year :
President, — ^Alfred Lewis Galabin, M.A., M.D.
Vice-Presidents. — George B. Brodie^ M.D. ; Francis
Henry Champneys, M.A., M.D. ; William Frederick
Cleveland, M.D. ; A. B. Aust Lawrence, M.D. (Clifton) ;
George Boper, M.D. ; William Stephenson, M.D. (Aber-
deen).
TreoMtrer. — G. Ernest Herman, M.B.
Ohairman of the Boa/rdfor the Ea^aminatian of Midwives.
—James Watt Black, M.D.
Honorary Secretcmes, — Percy Boulton, M.D. ; Alban
Doran.
Honorary Librarian. — Peter Horrocks, M.D.
Members of OotmdL — Robert Bozall, M.D. ; Albert
Charles Butler-Smythe, M.R.C.P.Bdin. ; William Duncan,
M.D. ; W. Radford Dakin, M.D. ; S. Houston Davson,
M.D. ; Henry Gervis, M.D. ; Robert Alexander Gibbons,
M.D. ; Frederick B. Hallowes (Redhill) ; Montagu Hand-
field-Jones, M.D. ; Edwin HoUings, M.D. ; Jamieson Boyd
Hurry, M.D. (Reading) ; Arthur H. N. Lowers, M.D. ;
George Lowe (Burton-on-Trent) ; Oliver Calley Maurice
(Reading) ; Thomas Cargill Nesham, M.D. (Newcastle-on-
ANNUAL ADDBB6S. 73
Tyne) ; Edward James Nix, M.D. ; John Phillips, B.A.,
M.D. ; Heniy Speakman Webb (Welwyn) .
The President then delivered the Annual Address.
ANNUAL ADDRESS.
OiHTLSXEN, — ^I have again to congratulate yon upon the
satisfactory state of your Society.
Our diploma for midwives is sought by a continually
increasing number of candidates. During the past year
149 women have presented themselves for our examination,
of whom 127 passed, raising the whole number upon the
Begister to 618.
The number of volumes in the Library amounts now to
4004, 144 having been added during the year.
The total number of Fellows on December 31st was 746.
Thirty-seven new Fellows were elected during the year,
while 81 were lost by resignation and erasure^ and 11 by
death.
The Fellows removed by the hand of death were : John
Stuart Hutton, M.B.j Walter John Bryant, F.R.C.S. ;
Hugh Miller, M.D. ; Arthur Cresswell Rich, M.D. ; John
Bickwill, M.B.C.S.; Isaac Harrison, F.B.C.S.; William
Nicholson Price, M.B.C.S. ; John Chalmers, M.D. ; Edwin
Jackson, M.B. ; Philip Addis, M.B.C.S. ; Thomas Boyle^
M.B.C.8., and Joseph Frederick Eyeley, L.B.C.P.
John Stuart Hutton died, according to our ideas, at too
early an age— five and twenty — for one who had shown
ability and capacity for work, for from his career as a
student a bright future might not unreasonably have been
anticipated for him had he lived. He was bom at Harro-
gate in 1863, and educated at the Tonbridge School. He
74 ANNUAL ADDBE8S.
entered at St. Thomas's Hospital in 1880^ and obtained
the Entrance Scholarship in Science. He was a distin-
guished student of the school and graduated M.B. in
honours in the Uniyersity of London in 1886. In the
following year he was appointed Medical Oj£cer to the
hospital in George Town^ Demarara — ^the home of yellow
fever. His health broke down and he was about to return
to England^ but while on a trip up country he was attacked
with yellow fever and succumbed on 6th February, 1888,
Walter John Bryant, P.E.C.S. and M.E.C.P., was an
Original Fellow of the Society. He died at his residence
— High Woods, Beading — at the age of seventy-six. He
was born in 1813 and was apprenticed to his father, who
was in practice in the Edgware Bead. In 1834 he entered
at University College and afterwards joined his father.
In 1840 his father retired from practice, and Mr. Bryant
removed to Sussex Square ; and he had a large practice in
Bayswater for many years. In 1870, finding himself un-
equal to the calls made by his connection, he took up his
residence near Beading, coming up to town three or four
days a week. This he continued to do until the end of his
life. He was Surgeon to the Bucks Yeomanry and Con-
sulting Physician to the Hospital for Incurable Children.
Hugh Miller, M.D., graduated in Glasgow in 1864. He
held a prominent position as an Obstetric Physician in that
city. He was for some years Obstetric Physician to the
Glasgow Maternity Charity, and was Consulting Physician
to that institution at the time of his death. He was the
author of several papers on subjects in obstetric medicine
which were published in the medical journals.
Arthur Cresswell Bich, M.D., died on May 15th at the
early age of thirty-one. He was educated at the Liver-
pool School of Medicine and at St. Thomas's Hospital, and
graduated in honours in the University of London. He was
afterwards appointed House Surgeon, and subsequently
Pathologist, to the Liverpool Boyal Infirmary, and his
work in both these offices is spoken of in terms of high
praise. Dr. Carter states that he was a man of quiet and
ANNUAL ADDBB8S. 75
nnostentatious piety^.ever anxious during his short and
busy life to help in any good work.
William Nicholson Price^ M.B.C.S.^ was a leading prac-
titioner in Leeds^ and devoted more especially to the culti-
vation of obstetric medicine. He was the son of a naval
surgeon who had taken an active part in founding the
Leeds School of Medicine. He was educated at this
school and at the Middlesex Hospital. He was elected a
lecturer in the Leeds Medical School in 1857^ and in 1863
became Lecturer on Midwifery^ then in conjunction with
Mr. Samuel Wright. From this post he retired in 1884.
He took great interest in the school, was for some time
secretary to it^ and twice its president. He was also a
liberal donor to it. He was an active member of the
Council of the Leeds Philosophical Society until his death^
which took place on June 25th.
Edward Jackson, M.B., died at Newcastle-on-Tyne at
the age of sixty-two. He was bom in Sheffield, and edu-
cated at University College, London, where he was knowu
as an able student devoted to clinical work. He gradu-
ated in the London University in 1851, and became a
Member of the Boyal College of Surgeons in 1853. He
then settled in Sheffield, where he devoted himself more
especially to obstetric medicine, and soon became the re-
cognised leader in this branch. He cultivated the surgical
side of gynsBcology when this was less recognised than it
is now, and published papers on vesico- vaginal fistula and
ovariotomy. He was active in founding the Sheffield
Hospital for Women, to which he was surgeon for many
years.
Dr. John Chalmers died at his residence in Keppel
Street on November 9th. He was a student of the Uni-
versity of Glasgow, and like many others of Scotland's
successful sons he had a hard struggle to obtain that edu-
cation which he coveted. During his student days he
was obliged to earn by literary and other work the means
of living and of educating himself. He graduated M.B.
in 1867, and then spent some time as an assistant to a
76 AHK0AL ADDBKBfl.
practitioner in Yorkshire. Thence he removed to London,
and settled in Stoke Newington, bat subseqaently re-
moved to the north-western district, where he continued
to practise until his death. In the coarse of his practice,
while attending a case of labour, he was poisoned in his
finger, and from the effects of this it appears that he never
quite recovered.
A writer in the ' Lancet ' says of him, " To those who
knew him well there was a peculiar charm in Dr. Chalmers'
character. His information was most varied, and, when
he chose, he could talk in a way which made him a delight-
ful companion, for he had a considerable fund of that
somewhat grim humour which is so marked a trait in the
Scottish people.^' For some years he had been engaged
in making observations on certain points connected with
vaccination. He died of septica9mia, acquired in all
probability indirectly through the practice of his profession.
During the year the work done in the Society has been
large and of exceptional interest and excellence. Much
of it is markedly original in character, pursued on strictly
scientific lines, and tending to correct views of adtiology
and practice which have hitherto been thought to be
established on a sound basis. Much of it has an imme-
diate bearing on the daily conduct and practice of every-
one engaged in the pursuit of obstetric medicine. Among
such I may mention Dr. BoxalFs papers on '' Scarlatina in
Pregnancy, Labour, and the Puerperal State,'' and on
" Mercurialism in the Lying-in State ; " that of Dr. Herman
and Dr. Fowler '^ On the Effect of the Administration of
Ergot on the Involution of the Uterus ; " that of Dr.
Donald on '' Methods of Craniotomy ;" the discussion on
Electrolysis ; and Dr. Phillips's paper on the " Value of
Pilocarpine in Pregnancy, Labour, and the Lying-in State."
Others are concerned with the rarer events which occur in
practice such as Dr. Lewers's paper on ^' Extirpation of the
Uterus for Cancer ; " those of Dr. Ghampneys on " Vesico-
uterine Fistula j " of Dr. Matthews Duncan and Mr. Mere-
dith on " Locked Fibroids," and of Dr. CuUingworth on
ANNUAL ADDBX8S. 77
'' Extra-nterine Foetation ; *^ while others are of a purely
scientific character^ as that of Mr. Bland Sutton on the
glands of the Fallopian tubes^ and that of Mr. Alban Doran
on myoma and fibroma.
Many specimens — some of which were of great interest —
were shown. Mr. Sidney Harvey showed a rare specimen
of interstitial pregnancy ; Dr. Griffith, myxoma fibrosum,
glands of the Fallopian tubes, acardiacus acephalus ; Dr.
CuUingworth, a large cyst (probably hydatid) behind the
uterus, and localised sloughing of the fundus uteri due
to acute septicaemia; Dr. John Phillips, congenital sar-
coma ; Mr. Doran, glandular structure in the substance
of a primary cancer of the Fallopian tube ; and, in con-
junction with Mr. Trestrail, acardiacus mylacephalus.
Dr. Bozall's observations were made under peculiarly
advantageous conditions ; conditions which were non-exist-
ent a dozen years ago, conditions which rendered it com-
paratively easy to eliminate the common sources of error,
which often render it so difficult to discover the cause of
puerperal fever in a given case, and the relation of the
disease to other acute diseases ; for they were made in a
lying-in hospital from which puerperal fever had been
practically banished.
It is almost superfluous to state that no inferences of
any value can be arrived at with regard to the relation of
puerperal fever to scarlet fever, except under conditions
in which puerperal fever arising from other causes than
scarlet fever can be excluded. These conditions were pre-
sent when Dr. Boxall carried on his observations, and this
is one of the reasons why so great a value must be attached
to his work.
Another reason why a high estimate should be placed
upon it is that the cases which came under his observa-
tion were watched throughout the whole of their course,
and followed until they had completely recovered. Very
few cases so fully observed have been placed on record.
In addition to the record of cases, these papers contain
discussions on several important questions, such as the
78 ANNUAL ADDBE8S.
Liability of Pregnant and Parturient Women to Scarla-
tinal Infection and the Duration of the Incubation Period ;
the Relation of Scarlatina to Menstruation ; Clinical Course
of Scarlatina during Pregnancy and in the Puerperal State ;
Effect of the Scarlatinal Poison on the Course of Labour
and the Puerperium, and on the Mammary Secretion ; and
the Clinical Relation of Scarlatina to Puerperal Septica9mia.
The conclusions arrived at by Dr. Boxall are too many for
me to even enumerate^ but there are three of them which
I must mention :
1. That the agency of scarlet fever as a cause of puer-
peral fever has been greatly over-rated.
2. That scarlet fever breeds true in the pregnant and
puerperal woman ; that it produces scarlet fever which runs
the ordinary course of that disease^ and not puerperal
fever.
3. And incidentally the priceless value of antiseptics in
midwifery.
This work has been carried out on a strictly scientific
method, and any future work on this subject^ to be of
any value^ must be carried out on similar lines. It should
be noted that soon after Dr. Bozall^s papers were read
before the Society^ a monograph on the same subject was
published by Dr. Meyer^ of CopenhageUi in which conclu-
sions similar to those of Dr. Boxall were arrived at.
In the paper on the " Conditions which favour Mercu-
rialism in Lying-in Women," Dr. Boxall concludes that
absorption may take place on the inner surface of the
uterus, as well as from lacerated surfaces in the cervix,
vagina, or perinaeum, and indeed on the intact mucous mem-
brane. The means which he suggests for the prevention
of mercurialism is closure of lacerations, care that none of
the injection be allowed to remain in the passages, and the
promotion of elimination through the kidneys by the ad-
ministration of diluents, and through the intestines by the
administration of saline aperients.
Drs. Herman and Fowler made observations on two
series of puerperal women in the General Lying-in Hos-
ANNUAL ADDBB8S. 79
pital. To one set of cases ergot was administered three
times daily for a fortnight after labour ; to another set
one dose only was given after labour. They found that
the uterus diminished in size more rapidly in those to whom
ergot was administered three times a day than in those to
whom one dose only was given. They found, further, that
the administration of ergot had no appreciable effect on
the duration of the lochia.
Dr. Donald's paper on '^ Methods of Craniotomy " is of
great interest and value. He discussed the method of
craniotomy to be preferred : (1) in the less marked degrees
of pelvic contraction ; (2) in cases in which the contraction
is considerable. In the first class of cases he appeared
to prefer to apply the axis-traction forceps, to perforate
the skull while the forceps is in position, then to screw
the blades of the forceps as tightly as possible so as to
obtain a firm grasp of the head, and to deliver by its
means. But it is in the method he advocated under the
second class of cases, that is, when the contraction is
considerable, that his views are novel and subversive of
practice that was thought to be well established. Under
these circumstances he recommended podalic version and
extraction of the body ; perforation of the after-coming
head through the roof of mouth; cephalotripsy ; and the ex-
traction of the head by means of the cephalotribe, and trac-
tion on the body and jaw, combined with supra-pubic pres-
sure. The advantages he claimed for it are that the base
of the skull is well broken up, the head is well fixed during
perforation and crushing, the position of the head can be
easily altered so that the cephalotribe can be applied to
different diameters of the head, and the collapse and
moulding of the head is more readily brought about by
traction on the jaw and body of the child and pressure
above the pnbes. The cephalotribe when used to crush
the base of the skull in vertex presentations has proved
somewhat disappointing, and the method proposed by Dr.
Donald appears to render the instrument more efficacious
in this respect, and deserves a careful trial.
80 ANNUAL ADDRESS.
The discassion on electrolysis was introdnced by four
papers by Dr. Steavenson^ Dr. Lovell Drage^ Dr. Gibbons,
and Dr. Shaw. It occapied two meetings, the second
being an extra meeting especially called for the adjourned
discussion. The subject was warmly debated, and great
differences of opinion as to its value were expressed.
Dr. John Phillips read an elaborate paper '^ On the Value
of Pilocarpine in Pregnancy, Labour, and the Lying-in
State." After an exhaustive inquiry Dr. Phillips arrived
at the conclusion that the drug has no special value in
these conditions.
Dr. Lewers read a report of a case of total extirpation
of the uterus for cancer. The patient lived sixteen months
after the operation, and Dr. Lewers thought that the
operation had prolonged the patient's life, and she cer-
tainly had had ten months of freedom from suffering.
Dr. Ghampneys described a new operation which he
had performed for the cure of utero- vaginal fistula, which
will probably prove easier in its performance and more
certain in its results than the old operation for this lesion.
Mr. Matthews Duncan described and defined a rare con-
dition — the locking, retroversion, and strangulation of
fibroid tumours in the pelvic cavity, and Mr. Meredith
read a case in which a locked fibroid had been successfully
removed by operation.
Dr. Gullingworth described a case of extra-uterine foeta-
tion in which secondary abdominal section had been per-
formed.
The work, of which I have given a brief summary, is
such as any Society may well be proud of, for it is work
of permanent value, which extends the boundaries of our
knowledge, enlarges the domain of science, and increases
our power of doing good. No one could occupy the chair
at meetings where such work was done without legitimate
feelings of pride and pleasure.
In vacating the chair in favour of Dr. Galabin, whom
you have elected this evening as your President, I vacate
it in favour of one who is qualified to preside over your
VOTES OF THANKS. 81
meetings by learnings ability^ and practice^ and I feel that
in his hands the dignity of this chair and the interests of
the Society will be thoroughly maintained.
In conclnsion^ I would express my thanks to the Hono-
raapy Secretaries^ — ^to Dr. Boulton for the great help which
he has given me^ and the solicitude which he has shown
for the well-being of the Society ; to Mr. Doran^ not only
for his assistance but also for the readiness with which
he has acceded to and carried out my least wish. To have
been associated with Dr. Ghampneys — the late Senior
Secretary — whose devotion to the interests of the Society
cannot be adequately known except to those who have
worked intimately with him— is a privilege which I shall
always prize^ and I can wish no greater boon to the
Society than an uninterrupted succession of such officers
imbued with unselfish devotion to its interests.
Dr. Matthews Duncan felt that it was quite unnecessary
to say anything with a view to recommend to the meeting
the motion which he had the honour to propose^ so well
known and so highly esteemed by all was their President^
Dr. John Williams. His position as a medical practitioner
was among the highest and best. In this hall his position
as a man of science was of more importance^ for the Society
was devoted to the advancement of obstetrical and gynsd-
cological science^ and the many contributions of Dr. John
Williams^ valuable in themselves^ were marked by the ad-
herence to true scientific method. They showed the real
scientific spirit ; and without scientific method followed in
a scientific spirit contributions had better not be made at
all, not even attempted. What Dr. Williams was as the
President of the Society and Chairman of our meetings
they all knew by experience. His urbanity, wisdom, and
firmness could not be excelled. But, above all, he was
a great and good man. In him you had fine manhood
{virhu), and without that quality of manhood, great prac-
tice, greatness in science, excellence as a president^ were
poor and of small utility. He proposed '' that a vote of
VOL. XXXI. 6
82 VOTES OF THANKS.
thanks be given to Dr. John Williams for his very excel-
lent address^ with a request that he would allow it to be
printed in the next volume of the 'Transactions/ and
further thanks for the very efficient way in which he had
presided over the meetings of the Society during his term
of office/'
Dr. Ghahpneys said that the terms in which Dr. Matthews
Duncan had proposed this vote left little for him to do.
Stilly as one who had had the honour as well as the plea-
sure of serving under Dr. John Williams in a subordinate
capacity — ^that of Secretary — ^he had something to add.
No one who had not acted in this relation to Dr. Williams
could have any idea of the devotion to the best interests
of the Society^ of the unselfish work^ of the mastery of de-
tails, which had characterised his whole career in the
Society. No society ever had a more admirable President,
and he viewed his inevitable retirement from the chair
with sincere regret. He begged most cordially to second
the vote of thanks to the retiring President, Dr. John
Williams.
The vote was carried with enthusiasm.
Dr. Platvais had great pleasure in proposing a vote of
thanks to the retiring Treasurer, Dr. Gkilabin. He might,
under other circumstences, have offered his condolence to
the Society on losing his valuable services in the thankless
office he had so long ably filled, but, knowing that he is
only changing it for one more honourable, which he was
sure to adorn, he would content himself with a merely
formal statement of the motion entrusted to him.
The motion was seconded by Dr. Aust Lawrence, and
carried.
Dr. Herman proposed a vote of thanks to the retiring
Vice-Presidents, and other Officers of Council. He said
that it was not possible for the business of the Society to
be carried on without the punctual and regular attendance
of Members of Council. For their attendance, which was.
yOTBB OV THANKS. 88
no doubt^ often at some inconyenience to themselves^ and
for their carefnl consideration of the matters coming before
them^ the thanks of the Society were due to the retiring
Vice-Presidents and Members of Gonncil.
This was seconded by Dr. Hobbocks^ and carried nam.
con.
MARCH 6th, 1889.
Altrid L. Galabin, M.D., President, in the Gliair.
Present— 54 Fellows and 1 Visitor.
Books were presented by Dr. Matthews Dnncan, the
Middlesex Hospital Staff, and the St. Thomas's Hospital
Staff.
Arthnr H. W. Olemow, M.D. ; Leonard Remfry,
L.R.O.P.Lond. ; and Ernest Solly, M.B.Lond, P.R.O.S.,
were admitted Fellows of the Society.
William Henry B. Brook, M.B.Lond. (Lincoln) ; Charles
B. Hnmphiys, L.R.G.P.Ed. (Boamemonth) ; and Robert
Beid Bentonl, M.D. (Liverpool), were declared admitted.
The following gentlemen were elected Fellows of the
Society : — Matthew Benson, M.D.Bmx., L.R.C.P.Lond.
(Wigan) ; Jeh&ngir J. Cursetjee, L.F.P.S., and L.M. & S. ;
Charles Arthnr Gonllet, L.R.C.P.Lond. ; and John Wayte,
M.A., M.B., B.Ch.Oxon. (Croydon).
The following gentlemen were proposed for election : —
William Carnegie Brown, M.D.Aber. (Penang) ; Frederick
Hall, M.D.St.And. (Leeds) ; and Henry Douglas Johns,
L.R.C.P. (Boston).
VOL. XXXI. 7
86 DSNTIGBSOUS BONY PLATES
DENTIGBBOUS BONY PLATES PROM A DERMOID
OVARIAN TUMOUR.
By A LB AN DORAN.
The upper plate^ as the specimen is monnted^ forms a
orescentio sheet of poroas bone measoring two and a half
inches from tip to tip. One half is thicker and more
irregolar in outline than its fellow. This plate contains
nine teeth^ resembling molars in form ; some consist only
of crowns, few have perfect roots. The way in which
they are inserted differs greatly. Some lie with their
crowns almost covered with bone, others are placed at the
extreme edge of the plate, with long roots yet hardly any
socket. Other teeth were attached to the plate by inte-
gument only, when the specimen was fresh. Teeth with
sockets of flesh are frequent in dermoid cysts.
The lower plate forms a very irregular mass. The in-
ferior portion is highly cancellous, resembling a tarsal bone ;
the upper is a spiky piece of porous but hard bone, such
as is seen in the normal cranium of a cod or salmon. The
greater part of the entire plate is studded with teeth,
mostly like large molars, but a few resemble bicuspids,
and at least one is an incisor. Some are buried in the bone.
This specimen is exhibited for two reasons. In the
first place, the presence of bone was readily diagnosed
during life. The patient was twenty-six years old, and the
tumour had existed for three years. It was almost solid,
and the bony plate placed uppermost in the specimen could
be plainly felt through the abdominal walls, forming a hard
crescentic ridge arching over the umbilicus. On first touch
it suggested disintegration of foetal bones after ectopic
gestation, but there was a history of twisting of the pedicle,
and the tumour and pelvic condition indicated dermoid
cyst. On January 25th I removed the tumour. A very
long abdominal wound had to be made, and numerous
FROM A DESMOID OVARIAN TUMOUR. 87
omental adhesions required ligature ; otherwise the opera-*
tion presented no difficulties. The pedicle was twisted.
The opposite (left) appendages were healthy. The patient
made a good recovery.
The other purpose for which I exhibit the specimen is
to demonstrate how easily these beautiful masses of bone
and teeth may be prepared^ at little cost of time. I ope-
rated in the morning ; at three o'clock I began to prepare
the specimen^ and by four it was practically ready for
mountings although I took a further precaution. In pre-
paring the bones I followed Dr. Junker's plan described
in Sir Spencer Wells's book^ ' On Ovarian and Uterine
Tumours/ edition of 1882^ p^tgo 43^ with simplifications.
The soft parts were first roughly cut away^ and the perios-
teum raised at two or three points. Then the bones were
placed in boiling water containing one drachm of commercial
hydrochloric acid to the pint. After lying in the water
(which was not kept boiling) for a quarter of an hour^ the
bones were taken out and placed under a gentle stream of
cold water from a tap for the same space of time. The soft
parts were then removed with ease. The bones were next
placed in a saucepan^ and boiled in a solution of caustic
potash (one drachm to the pint of water) for a quarter of an
hour. When taken out they were put under the tap again
for a few minutes; then I washed them with Hudson's paste
placed on a nailbrush. At the end of an hour after I began
to prepare the bones they were ready to mount. I let
them lie in absolute alcohol till the next morning, but now
I do not think that was necessary.
The greater part of the above process can easily be done
by a porter or other assistant. No tedious ^dissecting off
of the periosteum is necessary if it be treated in the way
just indicated, so as to let the water and chemicals get to
the bone. The soft parts can be pulled off with the fingers
or forceps in two or three minutes. The specimen belongs
to the Museum of the College of Surgeons.
88
INAUGURAL ADDRESS.
Gentlemen, — My first duty is to thank you heartily for
the honour which you have done me in electing me as
your President — the greatest honour which can be con-
ferred upon an obstetric physician. I enter with diffidence
upon the duties of an office my predecessors in which have
been such distinguished men, and such successful Presi-
dents ; and trust only that, if there be any shortcoming
on my part^ the Society may not be the sufEerer.
In evidence that our Society has never occupied a more
prosperous position than at present as regards the number
of its Fellows, I need only recall the fact that, during the
four years of my treasurership which have just elapsed,
its funds have increased by as much as £600, while during
that time it has published the most valuable and costly
volume of ' Transactions,' from the number of its litho-
graphic plates, which has ever appeared. The activity of
its Fellows in scientific work has been no less manifest
both by the quality of the papers contributed, and by the
necessity, which has arisen for the last two years, for
holding extra meetings in order that no papers might
remain unread.
Of the two branches of medicine which form the main
field of our Society's work — ^midwifery and the diseases of
women — midwifery has for many years been furthest
advanced on the way toward scientific perfection. A
large part of its province has to do with questions of
mechanics, which are both readily open to observation
and experiment, and can in some measure be decided by
rigorous mathemQ>tical deduction. Gynaecology, on the
IKAUOTJRAL ADDRESS. 89
other hand^ has been a field for conflicting opinions, for
theories often accepted without adequate proof, and for
changing and evanescent fashions of treatment. It is in
the diseases of women, therefore, that the greatest activity
of work and the greatest progress of discovery might be,
if not ezpect-ed, at any rate desired. Nevertheless, it
must, I think, be said, on a fair review of the work of
the last few years, that midwifery has made even more
striking advances than gynsBCology. In one of the most
notable of these Germany has taken the lead ; I mean in
the revolution which has taken place with regard to
CaDsarean section. Only about six years ago the mortality
of Gflssarean section was variously estimated at from 70
to 90 per cent. It even appeared that its mortality had
actually increased as years went on, & result which could
only be explained by supposing that operators were less
bold than formerly in undertaking timely operations.
Moreover, of the few who survived the operation, the
majority were women living in the country. Oompara-
tively few cases were successful in great cities, or in the
hands of eminent obstetricians or surgeons. It appeared
as if only country robustness could &ce so great a risk.
Not many years before, an unusually successful operator,
for that time, had contended that it was wrong to place
sutures in the uterine walls at all, and that the uterus, in
virtue of its contractile properties, would writhe until it got
free from whatever sutures could be applied.
Now, the improved Cesarean section, as performed
under the most favourable circumstances at Dresden and
Leipzig^ shows a mortality over the whole series of only 9
per cent. The latter part of the series gives promise of
a result for the future still surpassing this. The improve-
ments in the operation introduced by Sanger, especially
the adaptation to the uterine wound of Lembert^s intes-
tinal suture, are doubtless of great value. But an impor-
tant part also of Sanger's work has been that he has popu-
larised the operation, has led obstetricians to practically
study it, and undertake it as a first choice, in cases of
90 INAUGURAL ADDRESS.
contracted pelyis, at the most favonrable stage of labour.
The importance of this element is shown by the relatively
nnfavonrable result of Sanger^s operation elsewhere^ and
especially out of Germany. Its general mortality for the
last four years is thus raised to 26*8 per cent. The cir-
cumstance of greatest promise for the future is that the
success has not been merely that of one or two operators
of transcendent skiU or unusually wide experience. Al-
though it has been won mainly in German cities, and,
above all, in two of them, the number of actual operators
has been considerable, even at Dresden and Leipzig.
Even throughout the whole of Germany the average success
attained has been remarkable ; seventy-four operations by
thirty-four operators within the last four years giving a
mortality of only 14*8 per cent. These figures I give from
the latest statistics, as communicated to me by Dr. B.
P. Harris, of Philadelphia.
As yet, indeed, the result does not justify the claim
which some enthusiasts have priematurely made, that
craniotomy should be cast aside as a murderous proce-
dure, and CsBsarean section in all cases substituted for it.
This may, indeed, now be hoped for as a future triumph,
but a greater and^-more important still — ^a more universal
reduction of mortality must first be secured. Meanwhile,
it is much that foetal life is already being saved, and the
field of craniotomy reduced to those cases in which the
risk of tbat operation to the mother in skilful hands is
trivial.
An opprobrium to the obstetric art as great as GsBsarean
section has been the impossibility of guarding patients
having an extra-uterine foetation from the enormous risks
of that condition, either by waiting upon Nature, or by
primary operation. Here, also, much progress has been
made, though more yet remains in the region of hope. In
G89sarean section Germany may, perhaps, always retain
the lead which she has obtained, partly on account of the
greater frequency of contracted pelves in that country
than in England or America ; partly because, on the Con-
INAUOUBAL AODBBSS. 91
tinent^ it has been nsiial to estimate more highly than in
Britain the valne of foetal lif e^ as balanced against a degree
of increased risk to the mother. In the treatment of
extra-nterine f cetation we may claim that this country has
taken as leading a position as in other departments of
abdominal surgery. I remember it being urged not many
years ago^ in this Society — ^not as a fact ever tested by
experience, but only as a theoretical proposition — ^that^ in
a ruptured tubal f oetation^ the right treatment would be
to perform abdominal section and remove the foetal sac.
Kow cases so treated with success are being multiplied.
In most of them, it is true, the operation has been per-
formed after the primary collapse has passed off, and the
patient has been saved from subsequent secondary risks,
rather than from immediate death by hsBmorrhage. But
there have been cases of success, even in the stage of
primary bleeding. We have already advanced so far that
the risks of extra-uterine foetation may be regarded as
greatly reduced, provided only an early diagnosis can be
made.
Even in the far more formidable case of extra-uterine
foetation in the latter months of pregnancy, opinions are
turning again in favour of the primary operation, which
had been almost abandoned as too disastrous to attempt.
Only five years ago it was estimated that out of twenty-
four primary operations at such a stage of pregnancy, only
one mother had survived. This was the patient operated
on by Mr. Jessop, who had a very narrow escape. But
many of these cases, although they seem to tell in statistics
against a primary operation, ought really to. be regarded
as in favour of it, because they were undertaken only
because the patient had become moribund under the ex-
pectant plan. Recently our late President has given us
an excellent example of success to follow. This much can
already be said with assurance, that, whenever the foetal sac
can be opened without the peritoneal cavity, or when the
opening in it can be securely stitched to the abdominal
wall, results ought to be far more favourable in future.
92 INAUGURAL ADDRESS.
One or other of these possibilities may be reckoned on in
these cases of intra-ligamentous pregnancy^ which have
only lately been recognised as a separate and compara-
tively common variety^ and which do not yet appear in
the nomenclature of the Royal College of Physicians.
Where the f ootas is found free among intestines^ or covered
only with a thin amnion ^ probably the risk from decompo-
sition of the placenta^ if not from haamorrhagCj must always
remain very great.
I should claim little for the treatment of extra-uterine
f oetation in the earlier months by faradization^ though it
has been so highly praised in America. Since diagnosis
is then often uncertain^ and since an extra-uterine footus
often dies without any treatment^ this is a case in which
I think that less importance should be attached to so-called
positive evidence than to the negative evidence that^ when
footal life is proved^ the most vigorous and persevering
attacks may be made upon it by faradization without im-
pairing its vigour in the smallest degree, as I have myself
tested.
Another advance, which must be regarded as of greater
importance than either of those which I have mentioned,
in view of the posesibly widespread saving of maternal life
which it may effect, is the application of antiseptics to
midwifery. A series of improvements culminated in the
use of perchloride of mercury as an antiseptic, and the
transformation as regards lying-in hospitals is already com-
plete. It used to be considered, with justice, that it was
safer for a woman to be delivered in the most miserable
and insanitary hovel than in the most palatial and well-
regulated lying-in hospital. Now it has been found pos-
sible to reduce the total mortality in lying-in hospitals as
low as 5 or even 4 per 1000, with an almost complete
banishment of septic disturbances, and they are, therefore,
as safe as any other place for delivery.
There is, however, a curious chapter in the history of
the mortality of lying-in hospitals which has, I think,
generally escaped notice, and which deserves attention,
INAUGURAL ADDBB88. 93
althoagh I am unable to offer any explanation of it. In
the closing years of the last century a remarkable improve-
ment was attained in the death-rate of^ at any rate, some
lying-in hospitals. It was ascribed to the improved know-
ledge of hygiene, and was celebrated in glowing terms,
such as might now be applied to the results of the most
fashionable modem antiseptics. At the British Lying-in
Hospital the deaths per 1000, which for the decennial
periods between 1749 and 1788 had varied from 16*5 to
28*6, fell in the decennium 1 789—1800 to 8-2, though the
number of women delivered was greater than before,
namely^ 6677, a result which surpasses even the best at-
tained in lying-in hospitals at present.'^ At the City of
London Lying-in Hospital, the mortality from 1790 to 1800
was only 5*7 per 1000, from 1800 to 1810 only 4*3 per
1000. The following quotation from Dr. Guy's ' Lectures
on Public Health,'t ^^ show how these facts were re-
garded:
" Perhaps I cannot better exhibit the improvement that
took place in the latter half of the (eighteenth) century
than by giving you the figures of the British Lying-in
Hospital for the first and last twelve years of that period
of fifty years. There died in the first twelve years more
than 1 in 15 children, in the last twelve less than 1 in 82.
And, as I have before me the deaths of the mothers for
the same year, I may state that while the death-rate for
the first twelve years was 1 in 38, it was only 1 in 318
for the last twelve. These figures show a reduction of
mortality in an institution which must have commanded
the best medical skill and best nursing of the whole period
under review, of more than fivefold for children, and more
than eightfold for their mothers. In this reduction sani-
tary improvements in space, ventilation, and cleanliness
must have borne a very considerable part.''
• "The MorUUtj of Hospitals, Qeneral and Special, in the United King-
dom, in Times Past and Present," by Dr. Steele, 'Journal of the Statistical
Sodety,' Jnne, 1877.
t Op. dt, p. 19.
94 IJSAJJaVRAL ADDBBBB.
Yet these brilliant results proved only transitory, and
puerperal fever soon resumed its fatal ravages. In 1865—
75 the mortality of the British Lying-in Hospital was
again as high as 19*4 per 1000, that of the City of London
Lying-in Hospital was 14*3 per 1000, that of Queen Char-
lotte's Lying-in Hospital 22*3 per 1000. At the Rotunda
Hospital, Dublin, the improvement was not so marked in
proportion to the old results, but the retrogression was
quite as manifest. In 1791 — 1800 the mortality was only
8*8 per 1000, in 1801—1810 only 9*7 per 1000, but in the
decennia from 1811 to 1875 it varied from 13*1 to 82*7
per 1000.
We who are believers in antiseptics must be somewhat
startled at these results obtained in the period from 1790
to 1810 by ordinary cleanliness and hygiene, before 8em-
melweis had enlightened the world as to the true nature
of puerperal fever, and be puzzled to explain why they
could not be maintained. With our present views of the
nature and treatment of puerperal fever, we can scarcely
suppose that the low mortality depended upon the treat-
ment then in vogue for that disease, when it had arisen.
The midwifery text-books of the day recommend bleeding
and emetics at the outset ; later, antimony in the form of
James's powder, and purging to the extent of producing four
or five stools daily. The following passage occurs both in
the 1798* and in the 1832 edition of Denman's ' Practice of
Midwifery.' " I have very rarely attempted to inject medi-
cines of any kind into the vagina or uterus, though, from
a consideration of the probable state of the parts and of
the fetid humours discharged it is reasonable to think that
emollient or gently detergent injections might sometimes
be useful. But the helpless state of the patient is such as
to render the operation itself very troublesome ; and, if
they are advised, great caution will be necessary both in
their composition and administration ; but fomentations to
the external parts have, I think, sometimes afiForded com-
fort and been of service.'*
* Op. oit.» p. 626.
IKAUOURAL ADDBBB8. 95
Whatever may be the explanation of the retrogression
in iiie sanitary condition of the lying-in hospitals after
1810^ it can hardly be donbted that we are now npon a
firmer foundation. The improvement is far more wide-
spread in different countries^ and the means by which it
is attained are better understood. The hope may now be
entertained that modem antiseptic methods would suffice
to render healthy even a lying-in ward in a general hos-
pital^ though it is premature to speak positively on the
subject until the experiment has been tried. It is need-
less to say how valuable a small ward of this kind would
be in a great medical school both for the advance of
science and the education of students. Many medical
men must look back with somewhat of horror upon their
first attendance upon a case of midwifery. A student is
fortunate if^ through the aid of his fellow-students in
charge of cases, he has learnt practically beforehand to
discover the os uteri in labour. Happily Nature suffices
for delivery in normal cases, and skilled aid is readily pro-
cured ; so the patients do not suffer, as the statistics show.
But if students could be instructed practically in the pro-
cess of labour by competent teachers before taking charge
of a case, they would be likely to make better use of their
experience afterwards.
It is a far more important question how iskv the exten-
sion of antiseptic midwifery is likely to obtain for the
country at large a reduction of puerperal mortality and
morbility at all comparable to that secured in lying-in hos-
pitals. So g^eat a reduction is not indeed likely, because
the lying-in hospitals were the favourite home of puerperal
fever. But even throughout the country, acknowledged
puerperal fever, as returned to the Begistrar-G^neral, is
responsible for more than half of the whole childbed
mortality ; and it may reasonably be suspected that septi-
cesmia has to do with other deaths, not so diagnosed or
not so returned. A reduction in puerperal septicsBmia is
therefore of enormous importance.
I think it probable that the decision of this question
96 INAUGURAL ADDBE88.
may throw light upon points yet obscare in the nature of
puerperal fever. It by no means solves the question com-
pletely to say that puerperal fever is simply septicssmia.
Of the microbes capable of multiplying in the body, those
which can enter without a wound have naturally more fre-
quent opportunities for displaying their effects ; and, pro-
ducing generally a definite set of symptoms, constitute
some named zymotic disease. Microbes which can only
enter through a wound are all massed together as yet
under the titles of septicasmia and pyssmia, though as
many as fifteen different species of microbes at least
have been described as the essential cause of different
forms of septicsemia in men and animals.
The recognition of the importance of microbes in puer-
peral fever has led many to regard as obsolete the old
classification into autogenetic and heterogenetic puerperal
fever ; and doubtless it is now the most important lesson
to impress upon practitioners that all puerperal fever is,
in a sense, heterogenetic, since the germs must have come
orig^inally from without. Yet it remains a question of
vital importance whether microbes constantly or commonly
present, or on]y rare and virulent ones, are the active
agents ; and again, whether common microbes, which are
generally innocuous, can be so cultivated in fertile soil as
to become virulent.
Experience has shown that, in abdominal surgery, it is
not of so much importance to destroy microbes as to avoid
leaving any nidus for them in the shape of damaged tissue,
or sanguineous effusion. It should not be forgotten that
the same principle has its application in midwifery. Not
even the use of the most fashionable antiseptic of the day
would be a sufiioient compensation for allowing unneces-
sary lacerations of cervix or perineum, for omitting to
secure good contraction of the uterus, for leaving a rup^
tured perinsDum unsewn, or for bruising tissues needlessly
in operations. But the special success in lying-in hospitals
of the one particular antiseptic, perchloride of mercury,
beyond all others, seems to indicate that the balance of
INAUGURAL ADDBKBB. 97
importance is Bomewhat different in midwifery and in ab-
dominal seotionB ; and tbat^ in lying-in hospitals at any
ratOj tliere are likely to be vimlent microbes^ which ought
to be destroyed.
Whether the same principle applies to the prevention
of sporadic cases of puerperal fever in private practice
can only be ascertained by a trial of antiseptic midwifery
by aU practitioners on a scale which has not, I believe^
been attempted in this country. The use of perchloride
of mercury for internal douches^ as employed in lying-in
hospitals, would indeed probably involve the risk of doing
more harm than good^ through its occasional poisonous
effects. Fortunately there is reason to believe that this
is not the most important part of antiseptic midwifery.
We are told that a drop of normal mucus from the cervix
of a woman at the end of pregnancy^ when drawn with a
sterilised platinum rod across nutrient jelly, may produce
as many as two hundred colonies of various forms of bac-
teria. All who have tried to render the vagina aseptic,
in the sense of being sterilised, for gynaecological opera-
tions, will know how di£Bicult this is to accomplish.
This is brought out strikingly by the recent researches
of Steffeck.*^ No number of douches of perchloride of
mercury will render the vagina aseptic at the end of preg-
nancy. To effect such a result, it is necessary to scrub
vigorously with two fingers not only the vagina but the
inside of the cervix, while a douche of at least a litre of
the antiseptic is being used. Even this produces only a
momentary effect, unless it is followed up afterwards by
the use of at least four or five douches at intervals. It
may be doubted if the vagina is ever sterilised so as to
satisfy the more severe practical test of leaving therein
for several days a glass tube containing bloody discharge,
without decomposition occurring in it.
I think we may conclude that the microbes commonly
present are generally innocuous, and that, in lying-in
• " Ueber Dednfeotion des Weiblichen Genital Canals," yon Dr. P. Steffeck,
'ZdtMhzift for OobnrtihiUfe tmd GynSkologie,' Band zv, H. 2, 1888.
98 INAUOUSAL ADDBBBB.
hoBpitals at leasts and probably elsewhere as well^ what
has to be done is to prevent the entrance of vimlent ones.
I would yentnre to urge on all practitioners the impor-
tance of providing for themselves and the nurse the most
efficaeions antiseptic known^ namely^ perohloride of mer-
cnry, of a strength not less than 1 in 1000. This shoold be
nsed for hands^ catheters^ and any cotton-wool or sponges
ased for external washing ; disinfection of the accoucheur^s
hands being the most important thing of all. Even the
most complete nnbelievers in antiseptics^ if any such re-
main^ must admit that this cannot possibly do any harm^
and involves merely a little extra trouble. One practical
detail is of importance. No one should trnst to any tablets
or powders of perchloride of mercury without testing them
in dilute solution in the water of the district. It is obvious
that, if the slightest milkiness is produced, it is impossible
to tell how much of, or whether any of, the antiseptic re-
mains efficacious. A concentrated solution made with a
little glycerine and dilute hydrochloric acid in distilled
water is more reliable, and has the advantage of the in-
creased efficacy which the acid gives to the antiseptic in
the presence of organic matter. The trouble of carrying
a liquid is hardly greater than the trouble of dissolving
tablets. As regards vaginal douches, my own view is
strongly in favour of their routine use, with some effica-
cious but less poisonous antiseptic, such as carbolic acid ;
but I admit that this matter is open to difference of opinion,
and that they are better omitted in normal cases, unless
they can be used regularly by a competent person.
In most of the States of Germany stringent laws have
been enacted for the use of antiseptics by midwives ; and
there is a general impression among German obstetricians
that the conveyance of puerperal septicsemia has much
diminished in consequence. I am informed, however, by
Professors Leopold and Sanger, that, in Saxony at any
rate, there has not as yet been manifest any appreciable
diminution of the general puerperal mortality. Nearly
one half of the deaths in childbed are still ascribed to
INAUGURAL ADDSBB8. 99
septiosdmia. Fisohel''^ infers from Dolim's statisticB that
the laws relating to midwives have not yet produced an
improvement in dbildbed mortality in any German State
as a whole^ though they may have done so in individual
towns. It is an obvious consideration that no laws can
enforce the efficient use of antiseptioSj however much they
may prescribe them. We may at any rate console our-
selves with the reflection that^ unless death registration is
more delusive in England than abroad^ our childbed mor-
tality remains lower than that of either Germany or Austria.
Though the returns of the Begistrar-General in England
are thought not to indicate the whole mortality, they may
afford some basis for comparison of different periods.
They seem to show some improvement of late. The mean
mortality of childbirth for thirty-nine years, 1847 — 1885, is
given as 4*82 per 1000, but for the last ten years of that
period as only 4*45 per 1000. Yet as regards puerperal fever
the report is not altogether satisfactory. Since the year
1881, when a more stringent system was introduced by the
Begistrar, of sending for further information as to previous
parturition, whenever the death of a woman was returned
as due to peritonitis, considerably more than half of the
total mortality in childbirth is set down to puerperal
fever, the minimum for the years 1881-^1885 being 2*58
per 1000. I think this affords ample ground for urging
a more stringent use of antiseptics.
Meanwhile, a valuable experiment may be tried in the
maternity charities of our great medical schools, the con-
ditions in which approximate to those in private practice.
In the charities of Guy's and St. Thomas's Hospitals, and,
I doubt not, in others also, the use of perchloride of mer-
cury is already being enforced. It must not be forgotten
that the results here obtained, without any constant or
systematic use of antiseptics, already equal or surpass even
the best results of antiseptics in lying-in hospitals, and
have steadily improved. Thus the mortality for the last
t " Die praktiichen Erf olge dir Modenen Oebnrteliilfe/' von Dr. ll^Uielm
Itebet ' Centralblatt fiir GynJIkologie,' 1888, No. 82.
100 INAUGURAL ADDBBSS.
ten years in the Guy's Charity was 3*4 per 1000^ for the
preceding twelve years 4'4 per 1000^ for the first twenty-
one years recorded 7*1 per 1000. But here again more
than half the deaths are still set down to pnerperal fever.
If a material reduction of this mortality through a more
stringent antisepsis can be proved^ it will be an enormous
stimulus to the adoption of similar precautions by all
practitioners.
Another problem not yet fully solved with regard to
puerperal fever is its relation to zymotic diseases. Though
it has been a widespread opinion in this country that puer-
peral fever may originate from the infection of scarlatina^
this opinion must be regarded as shaken by recent evidence.
It is worthy of note that recent researches attribute the
secondary lesions of scarlatina itself ^ such as those of the
ear and the joints^ to a mixed infection by another species
of microbe. It is possible that^ in the theory of mixed
infection^ may be found some solution of the problem.
Dr. Boxall's account of scarlatina in the Greneral Lying-in
Hospital suggests the hope that^ if complicating septicsemia
can be excluded^ scarlatina may lose much of its terror
for the lying-in woman. Yet further evidence is to be
desired. For a single epidemic may be of mild type;
and even long before the days of antiseptic midwifery^ a
series of nine cases of scarlatina in Queen Charlotte's
Lying-in Hospital was recorded by Brown^ in which there
was no mortality^ and from which no septicssmia resulted.
I would suggest that records of erysipelas occurring in
lying-in women are especially desirable; for erysipelas
has been thought to be yet more closely allied to septi-
C89mia and puerperal fever than scarlatina^ and yet it is
a zymotic disease, and is considered to depend upon a
definite and discoverable microbe.
We have still to look to bacteriologists for some light
upon the infectious character of puerperal fever. We
hear of Staphylococcus pyogenes aureus, Streptococcus
ten/uis, and Staphylococcus pyogenes alhus being found.
But these are comparatively common microbes, found fre-
INAUQUBAL ADDRBBB. 101
qaently in mild and local suppurations. Unless they can
acquire virulence by their growth in the puerperal woman^
it is difficult to understand that they can account for such
intense infection that^ in the days before the need of
caution was recognised, instances occurred like that of the
midwife, who, within one month, delivered thirty-one
women, of whom seventeen died of puerperal fever.*
To the progress of gynaecology one of the greatest
obstacles has been the difficulty of studying the morbid
anatomy of the diseases of women. Most of these dis-
eases are chronic complaints, which rarely prove fatal.
Moreover, women much more rarely die during the active
period of sexual life than men of a similar age, unless it
is either from the effects of conception, from some acute
zymotic disease, which modifies the tissues, or from chronic
phthisis, which suspends the sexual functions ; hence the
difficulty which has been found in obtaining accurate evi-
dence, even of the physiological states of the uterine
mucous membrane during the menstrual cycle. Another
difficulty of pathological study has been the fear of
obstetricians that they might carry infection from the
post-mortem room to their patients.
The recent extension of abdominal section in the treat-
ment of diseases of women, while it has not been free
from drawbacks and exaggerations, has, at any rate,
advanced our knowledge of many complaints and put
many popular theories to the test. We have learnt much,
not only about inflammatory diseases of the Fallopian
tubes, but about tubo-ovarian cysts, papilloma of the Fal-
lopian tubes, and the pathology of ovarian growths in
their earliest stages. Even if the enthusiasm of a surgeon
for new and heroic modes of treatment leads him to ope-
rate needlessly, though some patients are the sufferers,
science is not always without some compensatory advan-
tage. Yet further improvement of our knowledge of
pathology is to be expected from this direct mode of
exploration in certain diseases.
* RobertiOD, ' London Medical Gazette/ January, 1840.
VOL. XXXI. 8
102 INAUGUIUL ADBBISB.
In connection with this subject^ I may congratulate the
Society upon a reform which has taken place in London^
and^ I believe^ in the provinces also^ namely^ the removal of
restrictions upon the performance of abdominal operations
by obstetric physicians at many of our great hospitals.
Within the last four years such restrictions have been re-
moved at five important medical schools in London, and
there remains only one great hospital in which they are
still perpetuated. Such a change, I believe, could not but
happen sooner or later, in consequence of the extended
field of abdominal section both in midwifery and the dis-
eases of women ; but the manner in which it has come
about is a source of gratification in two respects. In the
first place, it has been due, I believe, in all instances, not
to any intervention of governors or other lay authorities, but
to the good feeling of our medical and surgical colleagues.
In the second place, the argument which has told most
powerfully with our colleagues has been the favorable
results obtained by those obstetric physicians in London
who were earlier in obtaining the concession. Although,
with perhaps almost an excess of modesty, they published
no lists of their achievements, their success became known,
and proved that it could not be maintained that obstet-
ricians need be less competent operators than surgeons.
Science can hardly fail to be tiie gainer through the
increased number of observers. We shall have the less
excuse if we fail to hold the balance fairly between the
tempting prospect of rapid cure, at the expense of some
physiological drawback and some risk of life, and the often
wearisome treatment by less heroic means.
There are other subjects in which our knowledge of
pathology is still defective, but in which further informa-
tion can be obtained from the post-mortem room alone.
Abdominal section has revealed much about the ovaries
and Fallopian tubes — comparatively little about the uterus.
But little is known of the histology of corporeal endo-
metritis, apart from that form of it which causes hemor-
rhage. It is still a matter of dispute how far it is right
INAUGURAL ADDBB8B. 108
to describe such a disease as chronic metritis^ apart from
endometritis.
Other problems, agttin, cannot be solved by abdominal
section alone, without careful comparison with the results
of observations in the post-mortem room. I refer to such
questions as the following : How far does chronic ovarian
pain, in the presence of some disorder also of the uterus,
justify a diagnosis of chronic ovaritis f To what extent
are ovaries enlarged by many dilated follicles, or small
and indurated with atrophy of follicles, to be regarded as
pathological conditions, and as the source of important
symptoms f
I have ventured to point out some subjects on which I
think research especially desirable ; but, in looking forward
to the work of the year, I know that the active workers,
BO many of whom our Society is proud to possess, need no
guidance, and that the contributions of the future will not
fall short of those of the past in their scientific value.
Dr. MATTflsws Duncan said the Society had had, in past
years, ample evidence of the great accomplishments and
diligence of Dr. Galabin. Especially had he distinguished
himself by mathematical contributions to the mechanism
of midwifery, and his remarkable speech on a paper of Dr.
Hermanns on the development of the pelvis was fresh in
the memory. Now we had the honour of being presided
over by him, and this evening had had experience of his
ability in this great o£Bice. The inaugural address which
he had just delivered was of a most interesting and instruc-
tive character, and he moved that the Society record a
hearty vote of thanks to him for it, and request his per-
mission to have it printed in the ' Transactions.'
Dr. Gbailt HicwiTT seconded the motion.
104 ON THI UIATION BBTWBIK
ON THE RELATION BETWEEN CHLOROSIS AND
MENSTRUATION. AN ANALYSIS OF 232
OASES.
By Wm. Stsfhenson, M.D.^
FBOFB880B OP lOSWITBBY, U1I1VJIB8ITT, ASESDEBM,
(Received November let, 1888.)
{Abstract,)
In the rapid progress of uterine specialism chlorosis, in its
relation to menstruation, has been too much n^lected. This
constitutional disease has been investigated by the physician
and the pathologist but not by the gynscologist. The paper is
based on an analysis of 232 cases carefully noted by the author.
The cases are divided into two groups ; the first, where the ill-
ness was primary and occurred before the twenty-third year,
comprising 183 cases ; and the second, where the attacks were
of the nature of relapses after a period of good health, these
number 49 cases. Chlorosis is regarded as due to a constitu-
tional state ; but it is shown that the diathesis is not necessarily
associated with an impairment of the development of the body ;
and is not, to any marked degree, connected with defective health
previous to the onset of the disease.
First is considered the influence of the chlorotic constitution
on menstruation before chlorosis sets in. Tables are given
which show that the tendency of the chlorotic diathesis is to
accelerate the age at which menstruation first appears, and that
chlorosis by itself is not a cause of retarded appearance of the
catamenia. At the same time, in one half of the cases, the
functional activity is defective, and is chiefly characterised by
lengthening and irregularity of the intervals and scantiness in
the amount of the flow.
CHL0B0SI8 AKD MBNBTBUATION. 105
The author's staidfltics are against the opinion that there is a
menorrhagic form of chlorosis. In 96*6 per cent, the effect was
to diminish the activity of the function, the remaining fraction
were complicated with ovarian irritation. In 587 per cent,
menstruation became scanty and irregular, and in many cases
painful, while in 37*8 per cent, there was amenorrhcBafor various
periods.
Chlorons and age. — ^A table is given which shows that there
are two marked chlorotic periods ; the one, of primary attacks,
from 14 to 21 ; the other, of secondary attacks, from 24 to
31. The number of cases of the disease presents a regular
curve, beginning at 14 and rising steadily to a maximum
between 18 and 19, then rapidly falling to disappear altogether
at 22. The tendency to secondary attacks manifests itself
first at 24, rises to a maximum between 26 and 28, to again
disappear at 32. That there may be a third period is probable,
as two cases are recorded at 39 and 41. This law applies
to attacks of the disease with distinct intervals of good health
between, as distinguished from the simple relapses, after periods
of imperfect convalescence, frequently met with after a primary
attack.
The curve of menstrual age compared with the curve of the
onset of chlorosis, do not bear out the opinion that, " foremost
in etiological importance is the period of the first appearance of
the catamenia." The fact of a periodicity in the attacks is
also against it. The cause of this periodicity is considered ; and
the general conclusion arrived at is, that imperfect evolution of
menstruation, as evidenced by scantiness of the flow and irregu-
larity of the periods, is as regular a feature of chlorosis as the
imperfect evolution of the red corpuscles of the blood. That
these constants are not related to each other as cause and effect
but are independent one of the other. At the same time there
is a close relationship between them whereby the reproduction
and development of the red corpuscles of the blood is governed
by, or forms part of, the menstrual cycle ; and that both are
influenced by a greater rhythmic action which determines the
time and activity of development, growth, and reproduction.
■^^w"
106 ON THB BBLATION BBTWBBN
Thi rapid progress of nterine specialiBni^ of which we
are so proud^ has its debit as well as credit side. Under
the former must be placed the diminished attention which
has been paid to the constitntional aspects of the diseases
of women. Thns^ chlorosis is a constitutional disease in
which menstmation is always affected^ yet none of onr
works on gynsscology devote a chapter to it. Its individ-
uality^ as marked as that of rickets in childhood^ is ignored.
The affection is spoken of as chlorosis or ansemia^ as if the
two terms were synonymous. The loss of strength is
regarded as the weakness due to the injurious influence of
occupation or mode of life ; leaving unexplained the fact
that the same agencies do not produce like symptoms in
all. But for the special chapter devoted to amenorrhoea,
chlorosis would be hardly mentioned ; the symptom is dis-
cussed^ not the disease. Chlorosis has been investigated
by the physician and the pathologist, but not by the gynas-
cologist. In an indefinite manner it is regarded as asso-
ciated with puberty^ or the approach of the female organ-
ism to sexual maturity. At the same time it is stated that
it occurs most frequently between the years of fourteen
and twenty-four. It is difficult to see how the changes of
puberty can be the cause, and it is more reasonable to
suppose that chlorosis influences menstruation, than that,
as Zimmerman puts it, '' foremost in etiological import-
ance is the period of the first appearance of the catamenia.
What the influence is, or what is the true relation between
chlorosis and menstruation has yet to be determined.
Chlorosis is very common in Aberdeeuj whether more
so than in other towns I cannot say, but I do not think it
likely. In the three years during which I have conducted
this investigation, I have seen 232 cases in the consulting
room, notes of which have been taken at each visit. This
is not, however, an estimate of general practice, for this
favourable field of observation is the result of a reputation
in the treatment of the disease, due to the use of Bland's
pills, and the special character of my practice. As a lesion
of a nerve throws light on its function, so an analysis of
f9
I
CHLOJBOBIB AND MBNSTBUATION. 107
these cases may increase our knowledge of the function of
menstruation.
As the reliability of statistics is dependent on the care
exercised in their collection^ I would state that I have
excluded all cases of anssmia where the cause might be
associated with chest affections^ or there was reason to
suspect a phthisical tendency. Also where the debility
was but part of a weakly state of health beginning in child-
hoodj and where the condition was therefore doubtful in
character. Cases only have been accepted which presented
the constants of chlorosis. These are, the loss of the natural
healthy colour, and the development of the chloro-anaemic
expression, characterised by a waxy transparency of tint,
or a yellowy grey hue ; together with ready fatigue and
shortness of breath on exertion. A change in the charac-
ter of menstruation, or where the catamenia had been,
from the first, irregular or scanty, should also be regarded
as a constant ; but as this is a point to be proved, it has not
been taken as a means of selection. There might also be
added a confirmatory test, the invariable, and generally
rapid improvement under treatment with Bland's pills.
With these conditions there were, of course, associated, in
varying number and degree, other symptoms met with in
the chlorotic, and confirming the diagnosis ; but as this
investigation is at present confined to the relation between
chlorosis and menstruation, these need not here be dis-
cussed. In investigating this subject it is advisable to
divide the cases into two classes. The first, where the
illness was primary and occurred before the twenty-third
year, and the second, those above twenty-three years of
age, and where the attacks were of the nature of relapses,
after an interval of good health. Whether a primary
attack never occurs after twenty-three is a subject requir-
ing examination, and is not here asserted ; but in con-
sidering the question of menstruation there are advanvages
in limiting the cases as indicated.
Before entering on the analysis it is important to keep
in view that the chlorotic condition must be regarded as
108 ON THE BBLATION BBTWBKN
due to a special diatliesis ; that is^ tbat it is primarily
dependent upon a peculiarity of the constitution, whereby
adverse influences, common to the female popnlation as a
whole, develop chlorosis in those only who have inherited
or acquired this peculiarity. In all questions regarding
menstruation, the general state of health and development
of the body must be considered. If the tendency of the
chlorotic diathesis be to retard development and interfere
with nutrition, then the derangements of menstruation may
be the effect, or part of the faulty state of the body. My
statistics show that this is not the case. Of the 183
patients in the first division of the cases, 76 per cent,
enjoyed good health before the onset of chlorosis, and 24
per cent, had previously been not robust. The height
and weight of 101 of the patients were taken, with nearly
the same result. 79 per cent, were of, or above, the
typical standard, and 22 per cent, were under the typical
weight for their height. The chlorotic diathesis, there-
fore, is not necessarily associated with an impairment of
the development of the body, and is not to any marked
degree connected with defective health previous to the onset
of the disease. On the contrary, many of the cases had
a fine physique and had enjoyed robust health. The defec-
tive health met with in 24 per cent, of the oases may fairly
be considered as due to other influences.
Character of Menstruation in Chlorotic Patients before
Chlorosis set in.
In a great majority of cases chlorotic symptoms do not
manifest themselves till three, four, or more years after
the appearance of menstruation. If, then, the chlorotic
tendency exercises any influence on the menstrual func-
tion, apart from the faulty condition of the blood when
chlorosis is established, its influence should be traceable
before debility has set in.
\
OHLOBOBIB AND MIKBTBUATION. 109
Does the ohlorotio diathesis influence the age at which
menstruation begins ?
Table I gives the respective numbers and the percent-
ages of the cases menstruating first at each respective
year. To ascertain the influence of the chlorotic diathesis^
these must be compared with statistics of the general
population. For this purpose I have taken the researches
of Dr. More-Madden^ of Dublin^ and Dr. Whitehead^ of
Manchester. They differ from one another^ but the former
are probably more nearly parallel with my own^ whilst the
latter^ probably taken largely from the operatives of a
large manufacturing town^ represent the effect of a dif-
ferent set of agencies. The Table clearly proves that the
tendency of the chlorotic diathesis is to accelerate the age
at which menstruation first appears.
Is the chlorotic constitution ever the cause of delayed
menstruation ?
In the 183 cases there were but four who had not men-
struated. Their respective ages were 15^ 16^ 17^ 17.
Out of 220 cases 12 per cent, only menstruated from the
seventeenth year onwards; in More-Madden's cases 15
per cent.j and in Whitehead's 25 per cent. These num-
bers^ taken together with the decided tendency to accele-
rate the menstrual age^ seem to indicate that chlorosis by
itself is not a cause of the retarded appearance of the
catamenia.
Next we may inquire whether the chlorotic diathesis
influences to any degree the character of menstruation
from the first and before the impairment of the general
health. Three elements enter into the question : 1. The
regularity of the periods ; 2, the amount of the discharge ;
and 8^ the absence or presence of pain.
1. Regularity of the periods. — In 70*6 per cent, the cata-
menia were regular^ in 29*8 per cent, they were irregular.
In every case the intervals were increased^ in none were
they under the four weeks.
2. Amount of the discharge. — In 54*6 the quantity was
ordinary in amount^ in 40*8 it was scanty^ and in 4*6 it
110 ON THB BILATION BBTWSEN
1
was inclined to be free. In no case^ however^ was there
what oould be called menorrhagia.
3. Tam. — In 155 cases where the subject of pain was
noted^ 61*2 per cent, had no pain to complain of^ 26'4 had
a varying amount of pain^ but not snch as to cause incon-
venience, whilst 12*2 per cent, suffered severely.
These three elements were variously grouped in indivi-
dual cases. The result may be generally stated as follows t
In 47'5 per cent menstruation was normal; in 20*7 per
cent, there was a slight defect ; in 26*7 it was markedly
defective; in 2*7 menstruation was imperfectly estab-
lished ; and in 2*1 there was primitive amenorrhcea. In
fully one half of the cases^ therefore^ the chlorotic charac-
ters^ that of scantiness in amount of the discharge and
increase in the interval between the periods^ were stamped
upon the menstrual function before the development of
active chlorosis.
The general conclusion^ therefore^ may be drawn that
the chlorotic constitution^ apart from the change in the
bloody tends to accelerate and not retard the age of men-
struation ; at the same time^ in one half of the cases^ the
functional activity is defective^ and is chiefly characterised
by lengthening and irregularity of the intervals and scanti-
ness in the amount of the flow.
Jn/It<6nce of Ohlorosia on the Oharacter of Menatruation.
Begarding the influence of chlorosis on menstruation^
my experience is at variance with those who^ following the
lead of Yirchow and Trousseau^ make two varieties of the
disease^ an amenorrhoeic and a menorrhagic. In 177 cases^
in which menstruation was fully established^ there is not
one where there has been profuse menstruation^ either
before or after the development of the disease. In one
case only after chlorosis was the discharge rather free^
and in three it was too frequent^ but at the same time
scanty. All these cases were complicated with ovarian
0HLOBO8I8 AND MlirSTBVATION, 111
irritation, to whicli the peculiarity in charaoter was donbt-
lesB attribntable. They therefore do not warrant the
opinion that there is a menorrhagic form of chloroBis, or
that the disease by itself is ever associated with monor-
rhagia.
In two oases only is it noted that there was no change
in the charaoter of the catamenia. In both they had pre-
vionsly been normal.
There remain 171 cases, or 96*6 per cent., where the
effect of the chlorosis on menstruation was in a variable
degree to diminish the activity of the fanction. In 58*7
per cent, menstruation became scanty and irregular, and
in many cases painful, whilst in 37*8 per cent, there was
amenorrhcBa for two months to two years. Amenorrhoea,
therefore, is less frequent than irregular and scanty men-
struation. It is therefore evident that diminution in the
activity of the menstrual function must be considered a
regular and not an occasional symptom merely of chlorosis,
as constant in fact as the change in the blood itself.
Chlorosis cmd Age.
Important as bearing on the relation of chlorosis to men-
struation is the fact that the large majority of attacks
occur between the ages of fourteen and twenty-two ; or
during the years from the beginning of menstruation to
the time when the uterine development is complete. This
gives a prima fcLcie basis for the opinion that the strain of
puberty is the chief cause of chlorosis. To determine the
true relationship, however, it is necessary to investigate
more carefully and fully than has yet been done the rela-
tion of chlorosis to age.
Some authors state that they have met with the affec-
tion in childhood, but doubts may well be entertained of
the true nature of such cases. With twenty-five years of
continuous connection with children's hospitals, I have
never seen such a case. Chlorosis occurs most frequently
112 ON THS RELATION BBTWESN
between the ages of fourteen and twenty-two^ but secon-
dary attacks are not infrequent in later years. After the
menopause it does not seem to appear. I have met with
one well-marked instance at forty-three years of age.
Chlorosis therefore must be regarded as peculiar to the
menstrual period of life. It must also be accepted as a
disease peculiar to women. There must therefore be some
relationship between chlorosis and menstruation.
To determine first the relationship with age it is essen-
tial to take the age of the patient^ not at the time of visits
but when the chlorotic symptoms first manifested them-
selves. In seven of the cases this could not be ascertained
with certainty^ but in the others it was determined with a
reliable degree of accuracy.
From the Tables it will be seen that with reference to
age there are two marked chlorotic periods^ the one of
primary attacks from 14 to 21 years of age, the other of
secondary attacks from 24 to 81 years. The number of
cases of the disease presents a regular curve, beginning
at 14, and rising steadily to a maximum between 18 and
19, then rapidly falling, to disappear altogether at 22.
The tendency to secondary attacks manifests itself first at
24, rises to a maximum between 26 and 28, to again dis-
appear after 82. That there may be a third period is
probable, as two cases are recorded at 89 and 41. This
law applies to attacks of the disease with distinct intervals
of good health between, as distinguished from simple
relapses after periods of imperfect convalescence. Such
relapses are common after a primary attack, during the
first chlorotic period, and may recur for two, three, or more
years.
We have now a curve representing the age of first men-
struation, and another the age of the onset of chlorosis.
These enable us to estimate the influence of the one event
upon the other. Were it true that " foremost in etiological
importance is the period of the first appearance of the
catamenia,'' these two curves should nearly correspond one
with the other. But they do not. The largest number
CfiLOBOSlS AND MBKSTBOATION. 113
of chloritic patients menstrnate in the fourteenth and
fifteenth years; the largest number of first attacks of
chlorosis occnr in the eighteenth and nineteenth years.
Taking cases individually there appears to be no relation-
ship between the menstrual age and the time when chlo-
rosis appears. That eyent seems to be determined by
age in the same manner as menstruation^ but independently.
The fact^ moreover^ of a periodicity in the attacks^ as evi-
denced by the increase of cases between twenty-seven and
thirty-one, goes still further against the etiological import-
ance of the first appearance of the catamenia. At the
same time it must be borne in mind that the function of
which menstruation is but the outward evidence, is not
fully established at puberty, and that maturity is not
attained till after the twenty-second year. The chief
chlorotic period is from seventeen to twenty- one. It is
evident therefore that it is not with the beginning of men-
struation that chlorosis is related, but with the period of
maturing of the function. This, however, is only as re-
gards time, the real connection is not explained thereby,
and the cause of the recurrence of the malady between
twenty-seven and thirty- one is unaccounted for.
Is there any relationship between them as cause and
effect ? Since scantiness of discharge and irregularity in
the periods are features in the chlorotic constitution met
with in half of the cases before the change in the blood
has manifested itself ; and since impairment of menstrua-
tion, so constant in chlorosis, precedes in some of the cases
the other marked symptoms, the disturbances of menstrua-
tion cannot be considered as the result of the changes in
the blood. On the other hand, the fact that chlorosis is
met with only during menstrual life, and is closely asso-
ciated in time with the maturing of the reproductive func-
tion, would make it appear that this function is an important
factor. The defective menstruation, however, cannot be
regarded as the cause of the change in the blood-corpuscles.
The more probable view is that the two *' constants ^' of
chlorosis are common but distinct effects of a constitutional
114 OK THB RBIATIOK BBTWBBN
state ; just as the affection of the bones and the mnscnlar
debility in rickets are both expressions of a diathetic cofi-
dition. As the two^ however^ are so constantly linked
together we have indicated a close relationship between
them. In plants we know that there is a morphological
connection between the chlorophyl-prodncing structures
and the reproductive organs. Our knowledge of the origin
and development of the red corpuscles of the blood is still
imperfect^ but it is not too much to assume that there
exists a similar connection between the hsBmoglobin-pro-
ducing bodies and the function oE reproduction in animals.
Facts might be advanced in support of this^ but it is a
subject too extensive to be entered on here^ and its im-
portance^ as advancing our knowledge^ demands a thorough
investigation.
There remains to be explained why the two chlorotic
periods occur^ the one between the years of seventeen and
twenty-one^ and the other between twenty-seven and
thirty-one. These facts belong to a law which governs
the two great physiological processes of growth and re-
production. In the ' Lancet ' of September 22nd^ 1888^
I have shown that the rate of growth in the body presents
a well-marked curve^ the apex of which corresponds in
girls with the thirteenth and in boys with the sixteenth
year. It then gradually falls till eighteen or nineteen.
After the initial growth of the body comes the function of
reproduction. In reference to this subject Dr. Matthews
Duncan* remarks, " The fecundity of the average indivi-
dual woman may be described as forming a wave which,
from sterility, rises gradually to its highest, and then,
more gradually, falls again to sterility '^ (p. 43). " The
climax of initial fecundity is probably about the age of
twenty-five years " (p. 33). Dr. Boutht states, *' The age
of greatest fecundity in males is from thirty-one to thirty-
three, in females twenty-six.^' Here, then, we have evi-
dence of a wave of vital activity, attaining its apex in girls
• ' Fecnndity, Fertility, and Sterility/ Bdinburgh, 1871.
t " On Procreative Power/' * Lond. Joom. of Med./ 1860, vol. ii, p. 840.
0HLOBO8IB AND MBNSTBUATION. 115
at thirteen and in boys at sixteen, falling thereafter and
again rising to a maximum at doable these periods, namely,
twenty-six and thirty-two. That it again manifests itself,
at a second multiple, is highly probable, but has not been
demonstrated. Now, the chlorotic periods correspond with
the trough of the waves, or when vital activity may be
considered at ebb. The essential character in chlorosis is
defect of power in functional evolution, and that defect
becomes most manifest when vital activity is lowest. This,
I believe, is the true explanation of the occurrence of
chlorosis at special ages. A knowledge of these facts will
be found to have considerable clinical importance.
The conclusion to which the above examination of the
subject leads is that imperfect evolution of menstruation,
as evidenced by scantiness of the flow and irregularity of
the periods, is as regular a feature of chlorosis as the im-
perfect evolution of the red corpuscles of the blood ; — that
these constants are not related to each other as cause and
effect, but are independent one of the other. At the same
time there is a close relationship between them, whereby
the reproduction and development of the red corpuscles of
the blood is governed by, or forms part of, the menstrual
cyclci and that both are influenced by the greater rhythmic
action which determines the time and activity of develop-
ment, growth, and reproduction.
116
OK THB RELATION fiSTWESK
Tablb I. — Showing ths numbers and percentages of 220
chlorotic patients who menstruated first at the respee^
tive yea/rs and the percentages of the general popular
tion.
Age.
No.
IS
18
14
16
66
16
17
18
11
90
1
Total.
220
J Chlorotic .
^*' Ritients .
10
25
63
30
21
4
1
Per
4-6
11-8
28-6
29-6
13-6
9-5
1-8
•4
•4
—
cent.
B. More-Madden
M
8*4
lo-
19-
27-7
21-1
13-
2-
—
—
497
0. Whitehead.
»
3-4
ss
15-9
19-
24*
12*5
9-8
3-7
1-8
4000
Table II. — Showing the numbers who menstruated first at
the respective years, and the numbers who had a first
attack of chlorosis at the respective ages.
Chlorotic age.
14
1
•
16
1
2
6
4
16
2
1
1
6
7
6
1
22
12-5
17
2
6
11
10
6
1
1
87
18
2
6
16
13
2
4
42
19
2
6
16
11
6
8
43
24-4
90
1
6
2
6
91
1
1
1
1
99
98
Totals.
Per-
centage
men-
stniated.
Noprevioas
menrtma-
tioD
12
A 18
i> 14
-3 16
1 16
"S 17
—
1
1
2
1
2
4
9
20
66
63
23
16
1
1
6-
111
31-2
29-6
12-8
8-9
-6
•6
—
1
g 18 -
S 19 —
20-
—
^^^
Totals . 1
18
13
4
—
1
•6
7
183
Totals.
Per cent. -5
chlorosis 1
7-8
21-
23-8
7-3
2-2
—
—
Table III. — Showing the numbers of secondary attacks
beginning at the respective ages,
24 26 26 27 28 29 30 31 82 89 41
Age
Nos.
2 8 9 10 9
4 2
CHLOBoaiB AHD ailN8TBnA.TI0N .
118
ON THI RftLATIOK BBTWEBN
Table IV. — Sluymng the number of cases at the respective
ages at the time of visiL
. 16 16 17 18 19 20 21 22 28 24 25 26
Age .
Nof. •
Age .
N08. .
. 6 12 28 84 86 24 22 15 9 4 8 6
. 27 28 29 80 31 82 88 84 88 40 48
.5 10 490414111
Table V. — Showing the numbers that menstruated first at
the respective ages and the character of tlie menstrua-
tion from the first.
Age.
Nonnal.
Minoinonnal. DefectiTe
Imperfectly
' ettabliflhed.
Primitive
amenorr.
Total of
menttmationi.
12
2
4
3
—
—
9
18
11
4
5
—
—
20
14
34
14
8
—
—
56
15
28
9
14
2
1
58
16
8
5
9
1
1
28
17
2
2
10
2
2
16
18
1
—
—
—
1
19
—
—
—
—
• • • ^■■«
—
20
1
—
—
—
1
Totals
87
38
49
5
4
—
Per
cent.
47-5
20-7
V
26-7
... 2-7
... 21
31*5
J
52-2
Normal » Regular, ordinary amount, and none or only slight pain.
Minns normal = Regular, scanty, and no pain, or
Regular, ordinary amount, and severe pain.
Defective » Never regular, scanty, with or without pain.
Dr. John Phillips inquired if the blood had been examined
in any of the cases related. He thought that an accurate dis-
tinction between so-called chlorosis and ansBmia could not be
drawn otherwise. In chlorosis the average hsBinoglobin richness
per corpuscle is very much reduced, while in an»mia there is
almost total abolition of corpuscle formation or there is very
little power of hsemoglobin absorption. In the former iron is
always beneficial, if not absolutely curative ; in the latter harmful.
Great improvement is often noticed after exhibition of arsenic.
Dr. Leith Napieb directed attention to one or two points
involved in the paper. He thought that climatic conditions
CHLOBOSIB AND MBNSTBUATION. 119
were of some importance. When he practised in Aberdeenshire
he saw fully twice as many cases of chlorosis in five years as his
subsequent nine years' larger experience of practice in the South
of Scotland afforded him. In London he thought chloro-ansemia
rarer than in the North. He could not quite understand Dr.
Stephenson's idea in referring chlorosis to a diathesis. Did
Dr. Stephenson contend that chlorosis was a disease truly distinct
from ansemia, or was he of opinion that there were some
peculiar constitutional changes as distinctive features between
these varieties of anaemia P One clinical observation was note-
worthy, viz. that chlorosis and tuberculosis occurred rarely,
if ever, in the same patient. Further, with regard to etiology
many theories, all unsatisfactory, have been broached, as, for
instance. Zander's idea, referring chlorosis to a deficiency of
HCl in the blood. This, as well as many other fanciful beliefs,
now obtained no credence. A few months ago, Sir Andrew
Clark expressed his views on the question in a paper submitted
to the Clinical Society. The gist of this paper was, that chlorosis
was due to constipation, and that the retention of feeces favoured
the production of ptomaines and leukomaines in the blood.
Now, doubtless constipation was found associated with many
chlorotic cases, but it seemed impossible to accept this theory as
a satisfactory explanation universally applicable. Referring to
Dr. Stephenson's eulogy of '* Blaud's " pills, he thought these
answered very well with some patients, but from an extended
use of a still more simple ferruginous preparation combined
with a saline and simple laxative, he had seen still better results.
This preparation was a mixture of equal parts of iron filings,
cream of tartar, and liquorice powder. As much of the mixed
powder as would cover a shilling was given thrice daily. The
prescription was got from an old Bei'wickshire surgeon, who had
used it in treating chlorosis and ansemia with more tiian local
fame for over fifty years. Dr. Leith Napier agreed with the
statement that chlorosis was generally accompanied by absolute
or partial amenorrhoea.
With reference to the author's opinion that there is no hsemor-
rhagic form of chlorosis. Dr. Claphajc remarked that two years
ago a well-marked case of chlorosis in a girl aged 18, came under
his care who also had menorrhagia. On one occasion the hsemor-
rhage was so profuse that it caused syncope, vomiting, dilated
pupils, jactitation, and the girl appeared moribund. A solution
of perchloride of iron was applied to the interior of the uterus
and the hemorrhage ceased, but recovery was very slow and
tedious. Subsequent periods were less severe, and the patient
passed from observation.
Mr. Alban Do&an remembered that about ten years ago a
very anaemic girl, aged 16, was admitted into the Samaritan
Hospital under the care of Dr. Bouth. She was suffering from
120 ON THB BSLATION BETWEEN
profuse metrorrhagia, and notwithstanding all kinds of local
treatment and transfusion she died. The patient had men-
struated regularly from the age of twelve or thirteen, the flow
being very scanty till shortly before death, but chlorosis had
existed for over a year. A post-mortem examination wa^ made,
and Mr. Doran caused sections to be made of the uterus and
appendages. He could find none of the morbid conditions de-
scribed by Dr. Percy Kidd in his " Contribution to the Pathology
of Hcemophilia " (' Med-Chir. Trans.,' vol. xliii, 1878). On the
contrary, the small vessels were quite healthy. The ovaries
were remarkable for the very small number of follicles which
they contained. Their surfaces were unusually smooth, even
for so young a subject. The pathology of chlorosis and severe
monorrhagia in young girls was so obscure that every fatal case
ought to be carefully examined by a competent pathologist.
Some relation probably existed between the two diseases, not-
withstanding the great difference in the symptoms. Dr. Boutb's
case lent countenance to that supposition.
Dr. EuTHEBFOOBD wished to know, as a chlorotic diathesis
had been spoken of, whether Dr. Stephenson had made any ob-
servations in his series of cases as to the occurrence of chlorosis
in the parents of his patients ? Dr. Eutherf oord was of opinion
that monorrhagia did at times take the place of amenorrhcea
and might assume serious proportions. He had seen profuse
monorrhagia in two sisters both suffering from well-marked
chlorosis. He thought a third period should be added to the
times at which chlorosis generally appears, namely, at or about
the '* dodging " time. He believed that eventually the disease
would be regarded as neurotic in origin, and the changes in the
blood merely secondary phenomena.
Dr. EoTJTH well remembered the case to which Mr. Doran had
referred, and the sorrow he felt at finding that all attempts to
bring about recovery failed. It was not a case when there was
general tendency to bleeding after wounds, but purely one of
menorrhagic chlorosis. When transfusion was about to be per-
formed she died. Many years a^o he was present at a discussion
on this subject before the Medical Society of Paris. He then
stated, and the French and English doctors seemed to concur
in his views, that it was not only ansemia and amenorrhoBa, but
a blood poison. The colour of the skin^ like that in jaundice,
malaria, cancer, <&c., showed it was something more, probably
fsBcal absorption, these fseces being often very offensive and ab-
normal in appearance. Someone had suggested that it might be
due to absorption of some ptomaines formed in the body. It
might be so, but fsBcal absorption, as he had shown in a
paper on fsecal fermentation, might and did produce symptoms
sometimes not unlike chlorosis in men. There was an excellent
old book, ' Hamilton on Purgatives * where were detailed several
CHLOBOSIB AND MENSTRUATION. 121
such cases cured by purgatiyes. This would seem to prove that
once the offensive motions were removed, the poisoning ceased and
recovery followed. These were also mostly neurotic individuals,
in whom nutrition was defective. In nearly all we had dyspepsia,
possibly due to ineffective action of the nerves presiding over
that function. Now, he had met with several cases where this
symptom was the prominent one, and he had been surprised on
miding that by applying the continuous current to the vagi
nerves in the neck (as he had seen Dr. Apostoli do in Paris),
the indigestion disappeared after two or three applications, and
the patients did well thenceforward. Arsenic and iron were of
course efficient remedies, but pure food properly digested was
the first nne qud non, and the second was purification and
cleansing out of the alimentary canal by efficient purgatives.
This done, recovery was the usual result.
Dr. Playfais said that although he was certain that the
menorrhagic form of chlorosis was exceedingly rare, yet he was
sure Dr. Stephenson was mistaken in supposing that it did not
exist. Some years ago he bad seen, with Dr. Walker, of Peckham
Bye, a very interesting example of it in a markedly chlorotic girl
in whom tne hemorrhage was so great that she nearly died from
it. He could have wished that Dr. Stephenson had given them
some information as to the causation of chlorosis in young girls,
because it was evident that if we were to deal with it scientifi-
cally we must go behind the mere symptoms and find out the
morbid conditions which had originated them. As to the so-
called " chlorotic diathesis '' of which Dr. Stephenson spoke, he
himself knew nothing, and he greatly doubted if anything of the
kind existed. Certamly he had never seen any evidence to lead
him to think that there was such a thing as an hereditary or
constitutional predisposition to chlorosis. As to climatic influ-
ences, to which Dr. Stephenson attributed the prevalence of the
disease in Aberdeen, he thought it likely enough to be influen-
tial. He had been struck, for example, with the number of
cases of chlorosis he had seen in young ladies from Australia,
which was quite out of proportion to the number who visited
this country. It would be interesting to learn if it was pecu-
liarly prevaJent in our Australian colonies. Another common
cause, and one of great importance, to which Dr. Stephenson had
not referred, was over- work and pressure in the high-class schools
for girls which seem now so numerous. This operated shortly
after menstruation was established, when the female economy
was most susceptible to unwholesome conditions. He had also
seen several very well-marked cases in girls who had been sent to
school in (Germany. Here probably dietetic influences were
superadded to over- work, since the girls were there generally put
upon an insufficient and innutritions diet, altogether difterent
from that to which they had been accustomed. These facts all
122 ON THB BBLATION BETWEEN
>
pointed to the conclusion that the basis and essence of the dis-
ease was a profound alteration of the general nutrition, and in
many cases a neurotic element was the predominant one. If
this be so, then a successful treatment must have for its object
the improvement of the nutrition by every means at our dis-
posal. Blaud*s pills, to which Dr. Stephenson pinned his faith,
were no doubt an admirable way of administering iron, but they
certainly were not a universal panacea. He used them gene-
rally, but he had seen many cases in which they had been taken
by almost bucketf uls without avail, nor could any one drug be
expected to be uniformly successful. In the worst type of case,
which had resisted every other form of treatment, he nad never
failed to effect a cure by a regular course of systematic treat-
ment by rest, massage, and over-feeding. The rapidity with
which the bodily nutrition improved in this way was sometimes
quite marvellous. That was his specific, and he believed it to
be a better one than Dr. Stephenson's, although doubtless he
would not agree with him.
Dr. Gbailt Hewitt believed that the fundamental condition
in cases of chlorosis was imperfect and inadequate nutrition.
Even in the higher grades of society insufficiency in regard to
dietary was not at all uncommon. A knowledge of this fact was
very important in regard to treatment, the main object being to
restore nutritional activity. As medicines, mild aperients and
iron were required.
Dr. T. C. Hayes thought the symptoms of chlorosis were
dependent upon a blood change, the corpuscles being affected
and iron deficient. For treatment he had tried many forms of
iron, and found the disease was curable by any of them if only
taken in sufficiently large doses and for a certain time. He had
never seen menorrhagia with chlorosis properly so called. He
had never seen chlorosis developed after marriage ; in his expe-
rience married women might be ansBmic butnotchlorotic, unless
the chlorosis existed before marriage.
Dr. Dyce Bbown thought that the idea of a chlorotic diathesis
was quite untenable, and that the only tenable view of the cause
of chlorosis was the neurotic one ; that there was a profound
but only functional disorder of the nerve-centres which regulated
nutrition and blood formation. The fact that chlorosis is caused
by nervous shock, anxiety, and disappointed love, together with
the whole train of symptoms, pointed clearly in this direction.
The malnutrition was only in certain spheres, as chlorotic patients
were not unfrequently fat. No notice had been taken by Dr.
Stephenson, or any previous speaker, of the state of the tempera-
ture. His experience was that in all cases where the tempera-
ture was above normal, however little, iron was of no use, and
was positively hurtful. It is in such cases that arsenic, espe-
cially the iodide of arsenic, was so valuable ; and the remedy —
CHLOB08I8 AND MBNSTKUATION. 123
one of the so-called *' new " remedies, but one which had been
in use by homoeopaths for nearly a century — pulsatilla, was of
much serrice in these cases. It influenced the nervous system,
and then digestion, and promoted a more healthy condition after
the catamenia.
Dr. Heywood Smith said that with regard to Dr. Stephen-
son's argument by analogy from the chlorophyll of plants to
the hffimoglobin in the human subject, as illustrating the
blanching in cases of chlorosis, he would draw attention to the
blanching of the majority of old persons who had passed the
age of sexual activity. He did not know whether any observa-
tion had been made on the blood of old persons.
Dr. HoBBOCKS said that in his experience chlorosis was so
generally associated with diminution or cessation of the menses,
that in any apparent exception to this rule there was probably
some other cause at work, although not perhaps discoverable.
He believed chlorosis was quite a different thing from the
anaemia caused by loss of blood. The menses in the latter cases
were not always diminished. The nervous system undoubtedly
played an important part in the production of chlorosis and in
the cessation of the menses. The latter was a good thing for
the patient so long as she was weak and pale from the disease
itself. He found any iron salt was efficacious, but particularly
the carbonate. The powdered saccharated carbonate of iron
was not so unpleasant to take, and was very successful in curing
the patient.
APBIL 3bd^ 1889.
An BED L. GalabiNj M.D.^ President^ in the Chair.
Present— 45 Fellows and 9 Visitors.
Books were presented by Dr. Gullingworth, Dr. Aug
Martin, Dr. Montaga Murray, and La Soci6te ObstStricale
et Gyn^cologiqne de Paris.
William Edward Dawson, L.K.Q.C.P. & L.M. ; Henry
Willingham 6ell, M.A., M.B.Oxon. ; Charles A. Goullet,
L.E.C.P.Lond. -, and Charles D. B. Hale, L.E.C.P.Lond.,
were admitted Fellows of the Society.
The following gentlemen were elected Fellows of the
Society : — ^William Carnegie Brown, M.D.Aber. (Penang) ;
Frederick Hall, M.D.St. And. (Leeds) ; and Henry Douglas
Johns, L.B.C.P. (Boston).
The following gentlemen were proposed for election : —
Edmund Octavius Croft, L.B.C.P.Lond. (Leeds) ; Harold
A. Des Voeux, M.D.Brux. ; Charles John Harper,
L.B.C.P.Lond. (Finchley) ; George Bobert Lake, M.B.C.S.;
Bichard Pinhom, L.B.C.P.Lond. ; David Thomson Play-
fair, M.D., C.M.Edin. (Bromley, Kent) ; Abraham Wallace,
M.D.Edin. (Upper Norwood) ; Charles Henry Whitcombe,
F.B.C.S.Edin. (Westerham) ; and Arthur Henry Williibns,
M.A., M.B., B.C.Cantab. (St. Leonard's-on-Sea) .
126
PIBRO-SAROOMA OF THE RIGHT OVARY.
By M. Handfield-Jones^ M.D.
Dr. M. Handfield-Jonss showed a solid ovarian tumour
which he had removed three weeks previously. The
patient, aged 21, had noticed a small growth in the right
iliac region for the first time on getting up after her con-
finement eighteen months ago. The g^wth had steadily
increased without causing pain or affecting. the general
health. Wheu first seen a month ago the tumour reached
one finger's breadth above the umbilicus, was freely move-
able, and of a stony hardness. The monthly courses had
continued quite regularly, and were not accompanied by
pain. At the operation about a pint of clear ascitic fluid
was found in the abdominal cavity; the growth sprang
from the right ovary and had the right Fallopian tube much
hypertrophied passing round its lower portion in front.
There were no adhesions. The convalescence proceeded
without interruption, and the patient was sent home cured
on the eighteenth day. Microscopical sections taken from
various parts of the tumour showed that the growth was
principally a fibroma of the ovary, but here and there
patches of sarcomatous tissue were found, and in some
spots the microscope demonstrated the presence of
myxoma. There was no evidence to prove that the
tumour had led to any infection of neighbouring tissues or
organs. The annexed microscopical drawings show well
the appearances presented at different sections of the
growth.
Mr. Alban Dosan observed that five days ago he had re-
moved a very similar solid ovarian tumour from a woman aged
51. It was remarkable, like Dr. Handfield-Jones's case, for
its extreme hardness, and also for its great weight. Although
it was small, it weighed three pounds. As is usual in these
cases, though not invariable, its pedicle was formed by the
ovarian ligament, the Fallopian tube hanging to one side. In
Fig. 1.— Fibroma.
Fis. 2. — Fibconu.
7
'f"- >
Fie. ^—Hjrxoma.
OANOBBNB OF THS BLABDBB. 129
some solid ovarian tmnoars he had found the tube in the same
relation to the growth as in an ordinary multilocular cjst. Solid
tumours of the kind exhibited to-night should always be removed
as soon as detected. The operation is not difficult, and the
tendency to recur less marked than in similar sarcomata of other
organs. When allowed to grow large, these tumours became
clinically if not pathologically malignant.
VAGINAL CYSTS.
By M. Handfield-Jonbs^ M.D.
GANGRENE OP THE BLADDER PROM RETRO-
PLEXION OP THE GRAVID UTERUS.
By Adolph Rasch, M.D.
Dr. Adolph Rasch exhibited a specimen of gangrene
of the bladder due to retroflexion of the gravid uterus^
from a married woman who was brought dying to the
Training Hospital^ Tottenham.
The patient, whilst scrubbing the floor a fortnight before,
had felt something give way in her abdomen. There was
complete retention of urine for thirty-six hours, followed
by dribbling of urine up to her entrance into the hospital.
Two medical men attending her and consulting together
had neither examined her nor introduced a catheter. Dr.
PerguBon, the resident physician, at once diagnosed the
case, introduced a catheter, and drew off one pint of
bloody urine, but finding the patient totally collapsed,
abstained from any attempt at reposition. The patient
died after a few hours.
At the post-mortem the bladder was found filled with
blood, the walls black and sloughing in several places
close to the peritoneum. There was no pei*foration.
180 INTRAPEBITONBAL RSHATOCBLB.
Fresh peritoneal bands were found in front. The uterus,
free from adhesions, could be pushed up without the
slightest difficulty. There was no fluid in the peritoneal
cavity.
Dr. Basch was anxious to have the case published, as
it sadly showed the still too prevalent neglect to make a
proper vaginal examination and use the catheter in sus-
picious cases. From his experience in consulting practice
he knew that these cases were not so very rare, and very
often not even suspected, and some members of the
Society would have had similar experience. No doubt
they were oftentimes buried with a certificate of fancied
inflammation of the bowels or something equally alien
from the real cause of death.
Dr. Hbbman asked Dr. Easch whether the peritoneal adhe-
sions of which he had spoken in relating his case were old or
recent.
Dr. Basch said the peritonitis was recent.
INTRAPERITONEAL HEMATOCELE AND
INTRA-UTERINE POLYPUS.
By W. S. Playfair, M.D.
Dr. Platvair exhibited two specimens which illustrated
the fact, familiar to all gynaecologists of experience, of the
occasional existence of grave conditions of which no sym-
ptoms existed, and which could not possibly have been
suspected.
The first occurred in a married woman, 35 years of age,
who was admitted into King's College Hospital on account
of severe pelvic pain, of which she had complained for
more than a year, and which was so intense as to com-
pletely incapacitate her from following her usual avocations.
She had always menstruated very profusely, and it is
specially to be noticed, in view of the conditions subse-
INTRAPBBITONRAL HJEMATOCELE. 131
qnently found to exists that there was no history of any
sudden or acute illness. Her pain had commenced gradu-
ally and steadily ingravesced, and that was her only com-
plaint. On abdominal palpation nothing abnormal could
be felt. Per vctginam, in the region of the left broad
ligament there was a rounded elastic swelling, about the
size of a small orange. On the right side there was an
indefinite sense of resistance but no obvious swelling.
She was kept in the hospital for about a month, when, no
improvement showing itself, it was determined to perform
laparotomy, the growth on the left side being diagnosed
as either a pyosalpinx or a small ovarian cystoma. On
opening the abdomen it was found to be a rounded ovarian
tumour, the size of a large orange, placed deeply in the
pelvis, and universally adherent. On separating the ad-
hesions considerable hsdmorrhage occurred, which could
only be controlled by sponge-pressure.
On the right side a totally unsuspected condition was
found. There were large masses of old formed blood-clots
lying loose in the peritoneal cavity, and not in any way
encysted. Several handf uls of these coagula were removed.
In the midst of them lay the right Fallopian tube, much
thickened and enlarged, and containing one large old
coagulum, the size of a big walnut, which was attached to
the interior of the tube by what seemed to be a fleshy
pedicle, a quarter of an inch in length. There was nothing
whatever in the history of the case which threw any light
on the formation of this considerable intraperitoneal
hsdmatocele, and yet it was difficult to imagine that it
oould have been formed without serious constitutional
symptoms. The enlarged tube was ligatured and removed,
the coagula cleared out as far as possible, the pelvis re-
peatedly washed out with warm water, and a glass drainage-
tube inserted. During the operation the shock was very
severe, and the patient became so collapsed that it was
hardly expected that she could be got alive off the table.
Fortunately she made a good rally, and recovered without
a single bad symptom.
132 INTRA-UTERINE POLYPUS.
The second case was that of a patient who was sent
home from one of the West India Islands^ under the im-
pression that she had a uterine fibroid, with the view of
being treated by electricity. Her only symptom was
excessive hadmorrhage, which had reduced her to a condi-
tion of the utmost prostration. The removal of the ute-
rine appendages had been proposed, but to this she would
not consent. Examination showed a uniformly enlarged
uterus, freely mobile, the sound entering four inches, but
no definite fibroid. The existence of an intra-uterine
polypus was suspected, and the cervix was dilated with
Hegar^s dilators. A large pediculated fibroid polypus,
about the size and shape of a Jargonelle pear was found.
It was not possible to get the tip of the ^craseur round this,
and it had to be removed in slices. The patient appeared
to bear the operation well, but the next day she suddenly
collapsed and died in a few hours. It was feared that the
somewhat prolonged manipulations which had been neces-
sary had caused a laceration of the uterus. Post-mortem
examination showed that there was no traumatic lesion,
and that the polypus had been cleanly and entirely re-
moved. The left Fallopian tube, however, was distended
into a large sac, containing pus, which had ruptured and
discharged its contents into the peritoneal cavity. It was
estimated to contain five or six ounces of pus, and had
doubtless burst in consequence of the traction to which
the uterus had been subjected. Now, there was absolutely
nothing in the history of this case which could have led
anyone to diagnose the existence of the large pyosalpinx.
The patient complained of no pain, nor was there any marked
symptom except constant metrorrhagia. No circum-uterine
tumour was felt, probably because the enlarged uterus had
lifted the tube up beyond the reach of the examining
finger. It was afterwards remembered that the tempera-
ture had varied between 99^ and 100^, but to this no
special importance had been attached.
Dr. W. Griffith said that the probable explanation of that
amount of blood being found in hard masses free in the peri-
INTRA- UTEEUIO: POLTPUS. 133
toneal cavity and without having caused any important symptoms,
was that it had occurred gradually, perhaps at the menslrual
periods, as the result of structural change in the Fallopian tube.
The appearance of the distended and thickened tube were not
those of tubal gestation, the lining membrane being smooth and
its contents purely blood-clot.
Mr. Alban Doban thought that the subject of hsemorrhage
into the peritoneal cavity from an open fallopian tube was of
great importance. As a rule, the ostiiun was closed in all
inflammatory affections of the tube and neighbouring part of
the peritoneum, and in hssmatosalpinx. Yet twice within the
past week, and once in 1888, Mr. Doran had witnessed the
removal of a tube, with masses of oi*gani8ed and unorganised
clot filling the peritoneal cavity .around a widely gaping ostium.
The appearance of the fimbriae and ostium was very diaracteristic
and similar in all three cases. In two, the clot had organised
around its periphery ; thus the tube appeared to open into a c^st
full of dark coagulum. In all three there was a strong suspicion
of early tubal gestation. Positive evidence of ectopic pregnancy
is often wanting ; an early embryo is no doubt readily destroyed,
especially if shot out of its ruptured cyst into the peritoneum.
The absence of an embryo in hisBmatocele of this kind, however,
may signify that no embryo ever existed. In other words, we
are not warranted in attributing hsematosalpinx with intraperi-
toneal hssmatocele to abnormal gestation alone.
Dr. HoBBOCKS said that both specimens were of great clinical
and pathological interest. He thought that one explanation
offered by Dr. Griffith was more likely to be true regarding the
first specimen than the hypothesis of extra-uterine foetation, for
there was no post-mortem evidence of rupture of the tube and
no clinical fact supporting such an idea. He asked whether the
ovary removed had been examined, and if so what condition had
been found. Begarding the second specimen he asked whether
the patient had acute peritonitis of a general character, and also
whether the ovar^ on the same side as the pyosalpinx was in a
suppurating condition.
VOL. XXXI. 10
134
ANBNOBPHALIO PGBTUS.
By W. S. A. Griffith, M.B.
Dr. Griffith exhibited a specimen of a monstrons fcetas
with adhesion of the placenta to the skull, and other
deformities, which had been recently presented to the
mnsenm of St. Bartholomew's Hospital by Dr. C. B.
Walker (3451»).
The foetus, a male, is generally well developed and was
bom at term. The placenta is proportionately large, and
appears to be normal in stmcture. The cord is very short,
measuring five inches ; its structure and the arrangement
of its vessels appear to be normal.
The fcBtus is anencephalic and has a large meningocele
in the right limb of the lambdoidal suture. It has also a
double harelip and cleft palate, with macrostoma. Both
eyes are defective, and the eye-slits are very small.
A portion of the amnion, with the umbilical cord at the
point of its insertion into the placenta, is attached to the
upper part of the base of the skull by a broad and firm
band of membrane, the line of attachment running along
the upper part of the hard palate.
There is well-marked left lateral curvature of the spine.
The heart is partly ectopic and contains three cavities,
a large left auricle, a rudimentary right auricle, and a com-
mon ventricle, the apex of which is prolonged upwards
through a fissure in the sternum, and is attached to the
base of the skull immediately to the right of the single
nostril ; it is hollow and contains columnas camesd, and is
covered by skin derived from the thoracic walls, and at
birth was seen as a pulsating rod attached at its extremi-
ties and free in the middle.
On the inner side of the right arm, half an inch above
the bend of the elbow, is a small, fleshy papilla, from which
ANBNCBPHALIC VCBTUS. 185
passes a thin membranous band to the right gam of the
upper jaw.
The abdominal viscera and the remaining thoracic organs
appear to be natural. There is a conus arteriosus^ but the
branches of the aorta are normal.
The mother had previously borne one healthy living
child. Nothing abnormal was noticed before the birth of
the monster. The labour, which was easy, lasted six hours.
About one pint of liquor amnii escaped. The fcotus pre-
sented by the anenoephalic head ; the placenta was expelled
with the foetus and without haamorrhage.
Instances of this monstrosity are rare. A somewhat
similar displacement of the heart with great stretching of
its substance is figured in Ahlfeld's ' Missbildungen des
Menschen' (pi. xxx, fig. 12). Dr. Houel records four
specimens in the Dupuytren Museum in Paris, in a paper
in the volume for the year 1857 of the ' MSmoires de la
Soci^tS de Biologic,' series ii, vol. iv, p. 55.
He says there are only two parts of the body to which
the placenta and membranes have been found adherent,
namely, the cranium and the abdominal wall, of which
attachments to the cranium are the more frequent. A short
cord, lateral curvature of the spine, and hernia of the
brain, if it is present, and of some of the abdominal viscera
are also always present.
A CASE OF RETENTION OP URINE CAUSED BY
PRESSURE OF A DERMOID OVARIAN CYST.
By W. S. A. Gbiphth, M.B.
136
A CASE OF CESAREAN SECTION FOB CON-
TRACTED PELVIS.
By Francis H. Champnbys, M.A., M.D.Oxon., F.R.O.P.,
OBSTBTBIO FHYSIOIAir TO ST. GBOBeR'S HOSPITAL.
(Reoeived December llth^ 188a)
{Abstract.)
The patient was a secundipara, having had a child in 1882
delivered by induction of premature labour and craniotomy at
seven months. She came under notice on this occasion at the
end of the seventh month.
She was a dwarf, with well-developed trunk and stunted but
otherwise well-formed extremities, without any signs or history
of rickets. Her height 44| inches. Her pelvis of the generally
contracted flat variety, with a conj. vera of an inch and three
quarters.
CsBsarean section (after SaDger) was performed about three
and a half hours after the beginning of labour at term, the os uteri
being about the size of a florin. There was no bleeding. The
operation lasted eighty minutes — ^fortj minutes to the begin-
ning of the sutures, forty minutes to the end of the operation.
The sutures were deep silver and superficial silk.
The ovaries were not removed, but the patient was sterilised
by tying (and cutting through) both' tubes with kangaroo
tendon. The child is alive and healthy.
There was no shock after the operation. The temperature
(with the exception of slight reaction on the second and third
days) resembled a normal Ijing-in. Recovery was uninter-
rupted, and the patient is now quite well.
Remarks on Sanger's method and on Dr. Leopold's recent
dSSABBAN 8ICTI0N TOR OONTBAOTID PILTI8. 137
work are appended, and the q^aestions of sterilising the patients
and of the limits of the operation are discussed.
Margabst T — f aged 21^ single, 2-paraj living at home
(at Lamboome, near Romford), was sent to me by Mr. E.
B. Turner, of Sussex Place, January 24th, 1888, at St.
Oeorge'a Hospital.
She was reported as of temperate habits, and as having
always had sufficient food. She was well nourished, a
light brunette, and in good health.
Her height was forty-four and three quarter inches
standing, and twenty-eight and a half inches sitting ; her
head large and square, the forehead square and protube-
rant, the frontal and parietal eminences strongly marked.
Bridge of the nose flattened. Teeth rather crowded, but
well formed. Extremities very small, but well formed, no
curvature of long bones ; no enlargement of epiphyses.
The patient was sharp and intelligent, though she did
not look BO, and was industrious and active both at home
and in the hospital.
Family history, — Father and mother both alive and
healthy. (Mother seen ; a middle-sized, well-formed woman,
with none of patient's physical peculiarities.) Patient has
a brother living, Ave feet eight inches in height, and a
sister, also of full height, and both healthy. Mother has
had no miscarriages, her first child was stillborn, then
came twins, one of whom died of convulsions at twelve
months, the other is the brother mentioned above ; then
came the sister, who is living ; then there was another child
which died soon after birth^ and lastly, the patient.
Prevuma history regarding patient* — ^The mother states :
'' That the child appeared normal at birth, was suckled
for eleven months, had measles when a few months old,
slightly ; has nev^r had any other illness, never had a
bad cbugh.'^' Mother first noticed that the child did not
grrow properly when about two years old. Patient never
sweated at night as a child, or threw off the bed-clothes.
She was not late or backwi^rd in walking. She never had
138 OJBSABBAN 8SGTI0H FOB CONTBACTBD FBLYIS.
Measv/rementa of bones. Ma/rga/ret T — .
Cknielet.
BiffJU. Left*
4 inches. 4 inches.
Htmeri.
7i inches (acromion to est. 7i inches (same points),
condyle).
BadU.
6| inches. Very rongh and Scinches. Same rough ridge
prominent ridge in centre Same ridges on lower end.
of shaft. Bidges on lower
end for tendons well
marked
6| inches. 6| inches.
8tenmm.
4| inches. Curved anteriorly.
Femora.
9 inches. Trochanter to condyle. Both 9 inches.
curved with convexity forwards.
7i inches. Inner tuberosity to inner 7i inches,
malleolus. Both curved outwards.
FUmlm.
8i inches. Heads to malleolL Both 8} inches.
curved outwards.
Spinal column.
Vertebra prominens to coccyx (sitting posture). 22 inches. Slight curve In
dorsal region with convexity to left.
Sead.
Parietal and frontal bosses well marked and very prominent. Whole vault
of skull large and well developed compared with other bones of body.
Bridge of nose depressed.
Measuremente wUh ealUpen,
Subeccipito-bregmatic . . . . . 6t inches.
Fronto-ocdpital . . , , • 6f „
Mento-occipital , . , . • 9| „
Bi-parietal . . • . , . 6 „
Bi*temporal • • , . • 6| »
Wiih meaeure.
Circumference round chin and occiput . . . 24| inches.
„ of head over bosses . . . 22 ,^
„ ro^nd pbin and vertex behind bregma .28 „
CJESABBAN 8B0TI0N FOB CONTBAOTED PELVIS. 139
any discharge from the nose^ did not have snufBes or rashes
as a baby or since^ never had anything the matter with
her eyeS; was not backward in teething. When the mother
was about five months pregnant with her^ she was thrown
from a trap^ after which she had to lie up for four months^
the doctor telling her that she had a displacement of the
child in the womb. When patient was bom the head was
rather large^ and labour was very long^ but not instru-
mental. The weight at birth is not known^ but she was
'' heavier than some babies at birth^ but did not seem to
grow/'
Menstrual history. — Catamenia began at thirteen^ lasting
four dayS; quantity small, regular in rhythm, no pain except
slight aching across loins. The same ever since, except
during pregnancy.
Previotts labow. — ^Five and a half years ago, August
3rd, 1882, craniotomy was performed in the seventh month
of pregnancy at Queen Charlotte's Hospital. Patient made
a good and rapid recovery.
Present pregnancy. — Last catamenia ended June 21st,
1887, having lasted four to five days, and being normal
in all respects. She had no idea of the date of concep-
tion j f OBtal movements about two months ago (November,
1887) . Health good throughout.
March 26th, 1888 = 278 days from last day of last
period.
Condition on admission. — Patient appears healthy;
breasts and nipples well formed, deeply pigmented, con-
taining serous secretion. Abdomen slightly distended,
well formed, not pendulous, no divarication of recti, navel
flat, a few bluish strias above the pubes, no varicose veins
or oedema of legs or feet ; abdominal walls firm, containing
a tumour obscurely elastic, within which was a sponta-
neously moving body ; dextral uterine obliquity well marked.
Foetal back felt on the right, small moveable parts in the
right hypochondrium and to left of navel, head felt as a
small, round, moveable body above the brim.
Vaginal examination. — Cervix low down, deeply cleft
140
CJCSABIAN 8ICTI0N FOB COMTB&OTKD PKLTI8.
8 inoheR.
74
15
74
74
314
84
84
li
6
bilaterally as far as vaginal reflection. A slight bony
ridge rans along the back of the symphysis pubis. Trans-
verse diameters of pelvis seem decidedly diminished^ but
not so much as the antero-posterior. Promontory of
sacrum slightly to left side^ and very plainly felt. No
prominence of bodies of sacral vertebras or straightness
of sacrum.
Measurements.
Left sp. il. to navel
Bight sp. il. to navel
Ensiform to pubes
Ensif orm to navel
Navel to pubes •
Circumference at navel
Spp. n.
Crr. II. % . •
Conj. vera (actual)
Oonj. ext. (D. B.)
It was decided to wait till labour set in, and perform
CaBsarean section as near the end of the first stage as pos-
sible. The patient, perhaps naturally, expected her child
to be again destroyed, but this I absolutely declined to
do, telling her that, if she wished it, she must go else-
where. The patient, on having the matter explained to
her, freely consented, and awaited the operation with great
courage.
On March 21st, 1888, 9.30 a.m., pains began. At 11
a.m. the os internum was the size of a florin, and a small
bag of membranes protruded. It was decided to operate
at 1 p.m.
The vagina having been previously washed out with
two quarts of corrosive sublimate (1 in 2000) and the
cervix and vagina well scrubbed with a swab of cotton-
wool soaked in the same solution, the abdominal wall was
well washed with soap and water, and covered with a pad
of gauze soaked in corrosive sublimate (1 in 1000).
At 1.10 p.m. an incision was made in the anterior abdo-
OJBBABflAN SECTION fOB CONTRACTED PELVIS. 141
minal wall six inclies in lengthy two above and four below
the navel^ three silk sntures were inserted into the upper
two inches of the wound^ and temporarily held by clip
forceps.
The uterus was centered^ {. e. all obliquity was oblite-
rated, and its middle line brought into coincidence with
the wound.
The closer attachment of the peritoneum to the lower
uterine segment was marked.
An elastic india-rubber tube was laid loosely round the
lower uterine segment. A flat sponge was laid behind
the upper part of the wound, and the uterus covered with
a towel wrung out of hot corrosive sublimate solution.
The uterus was then incised in the middle line, begin-
ning at the fundus^ and stopping short of the closer
attachment of the peritoneum, so as to avoid the lower
uterine segment. No hurry was made in the incision;
layer after layer was divided by the knife, the fibres
retracting as divided, and no serious hasmorrhage occur-
ring* The tissues were very juicy and succulent.
Before the membranes had been quite reached, the re-
traction of the uterine fibres gently tore through the inner-
most layer of the uterine wall, and the membranes bulged.
The incision was completed upwards and downwards, and
the membranes ruptured, a little liquor amnii escaping,
but little if any going into the peritoneal cavity, as the
assistant hooked up the upper and lower angles of the
uterine wound, and kept the uterus against the abdominal
incision.
The foetal head could not be easily brought upwards, so
a foot was seized and the child extracted without difficulty.
It was during this time that the only bleeding of any con-
sequence occurred, but the whole loss was estimated at not
more than eight ounces. The placenta was on the poste-
rior wall.
As soon as the foetus was extracted, a sponge was placed
in the lowest part of the cavity, the elastic tube was
tightened round the lower uterine segment, and at once
142 OiBSABlBAN BBOTION FOB COMTBAOTKD PBLYIS.
completely controlled the hasmorrliage* The placenta was
found detached; and^ together with the membranes^ was
easily removed, the inner walls of the ntems being
thoronghly sponged with an antiseptic sponge^ and several
sponges being packed into the uterus.
The suturing of the uterine wound was then proceeded
with. The peritoneum was quite loosCj and no resection
of the uterine wall was necessary.
Some ten silver sutures were inserted through the
uterine wall^ avoiding the cavity by some eighth of an
inch; and emerging some half an inch on each side of the
incision. The elastic ligature was then removed^ a little
oozing taking place into the uterine cavity, and a very
little from the uterine wound. The ligature had caused a
well-marked hour-glass contraction, which had to be
dilated with the fingers before the sponge could be
removed from the lowest part of the cavity. On removing
it; it was found covered with membranes. The other
sponges were removed; the uterine cavity was well
scrubbed with an antiseptic sponge, and a douche of •! in
2000 corrosive sublimate, at a temperature of 112°, was run
through the cervix and out through the vagina into a bed-
bath. The cavity of the uterus was, lastly, well dusted
with iodoform. The silver sutures were then closed by
one tie and about four twists, and were then cut short.
About four fine silk interrupted sutures were inserted
between each pair of deep sutures, transfixing the perito-
neum twice (Czemy-Lembert), and were tied and cut off.
It was found that they completely buried the silver sutures,
and it would have been possible to have buried these again
by others above them, so slack was the peritoneum.
It was also observed that there was no tendency to
hssmorrhage, though the uterus was comparatively flabby.
An aneurysm needle was passed round each tube about
half way along its course, where it was still round and
narrow, and before it began to expand into the ampulla.
The aneurysm needle was armed with kangaroo tendon,
and tied tight, the ligature cutting completely through the
OMBASMAS BBOTION fOB CONTBAOTBD FBLTIB. 148
tabe. The broad ligament was macli bypertrophied and
looBO, and the vessels^ thongh enlarged^ left wide spaoea
almost eyeiywherOj throngh which one or two fingers
mighty if neeessary^ haye been thmst withont encountering
a visible blood-vessel. The aneurysm needle included no
visible vessel or other structure^ and when the tube was
cut through by the ligature there was no bleeding.
The uterus was replaced anteverted^ with bowels behind,
the uterine incision was dusted with iodoform^ the abdo-
minal incision closed by sutures of salicylic silk and dusted
with iodoform ; pads of dry carbolic gauze^ covered by
cotton-wool^ secured by strappings more cotton- wool and
then a many-tailed flannel bandage completed the dressing.
The time from the first incision to the beginning of the
sutures was forty minutes. From the beginning of the
sutures to the end of the operation was forty minutes more.
Two points were forgotten during the operation :
(1) The uterus was not turned out of the abdomen and
the upper sutures closed behind it.
(2) It was intended to leave an Ehrendorfer's iodoform
bougie in the uterus.
The omission of closing the upper abdominal sutures
caused the omentum to get entangled with them^ and they
had to be inserted afresh.
On another occasion I should probably use chromic
catgut for the uterine indsions altogether^ thicker and
interrupted for the deep^ and finer and continuous for the
superficial sutures^ and I should turn the uterus entirely
out of the abdominal cavity before incising it.
Mr. Ot. B. Turner assisted^ and Mr. Pick also lent me a
hand.
The child was a female^ 20^ inches long^ and weighing
(twenty-one hours after birth) 6 lbs. 11^ oz.
Meoiurements of head {in inches).
Mareh 28. April 17.
Bi-parietal • • . • 3f ... 8|
Bi-temporal . • • • 2| ... 3^
144
CJiSABSAN BKOTIOK FOB OONTBAOTIED PII.TI8.
MwchSS.
April 17
2i
21
4f
4i
41
H
31
4
41
4|
13i
14
13i
15
ISi
14
Bi-mastoid .
Fronto-occipital
Mento-oocipital
Snboccipito-bregmatic
Suboccipito-frontal
Ovrcvmferences :
Fronto-occipital
Mento-occipital .
Saboccipito-frontal
On April 6tli the sagittal sature and upper inch of
right limb of lambdoid suture were seen to be separated to
the extent of ^ — k inch. Eyes not prominent. No mal-
formation ; no bulging of sutures or fontanelle. On
May 16th J however^ there waano unusual separation of
any suture.
The child would not take the breast^ and had to be fed
by the bottle.
Subsequent cov/rse of the case.
Shock. — None.
T&mferature, — This was subnormal for a few hours
after the operation^ rose on the second day to 100*7°, on
the third day to 101°, on the fourth day it became norma],
on the fifth day it rose to 100° (the breasts becoming full),
on the sixth day to 100°, on the seventh day to 99*4°, on
the eighth day to 99*2°, from which time it never rose
above 99°.
PuUe. — For a short time after the operation the pulse
was 140, on the second day it varied between 136 and 128,
on the third day between 128 and 100, on the fourth day
between 96 and 86, on the fifth day between 88 and 80,
on the sixth day between 100 and 86 (breasts full), o^
the seventh day between 104 and 82 (same cause), on the
eighth day 88, on the ninth day between 88 and 80, after
which time it varied between 88 and 68. It was never
feeble. ....
JBe^pira^WV.— Never rapid..
CJB8ABIAN 810TION fOB CONTKAOTBD PXLVI8. 145
Lochia. — Never oSensive^ at first smelling strongly of
iodoform. Bed and scanty for two days, after whioh
there was motliing bat a slight pink staining till the fifth
day, when the quantity became less scanty, though still
scanty^ and red instead of pink. On the sixth and seventh
days slightly brownish, on the eighth day absent, on the
eleventh day a slight brownish discharge till the fourteenth
day, when they finally ceased.
Vomiting. — Patient vomited slightly for some four hours
after the operation, again, very slightly, on the third day.
On April 18th (a month after the operation) she had a
transient bilious attack.
Pain. — There was a little pain in the abdomen, for the
first two days, at intervals, and probably due to uterine
contractions (after-pains) intensified and excited by the
presence of sutures. From this time, for a few days, there
was occasional complaint of slight pain, but no tenderness,
and the abdominal walls moved well on respiration.
Bowels. — On the third day the patient had three doses
of white mixture (Mag. Sulph. 5j, Mag. Garb. gr. xx),
without effect ; on the fourth day an enema was given, and
was followed by eight loose motions, after which the bowels
became spontaneously quiet. After this they were opened
as after a natural confinement, medicine being given when
required
Micturition. — The urine was passed naturally on and
after the second day, when it was densely crowded by
lithates as usual.
Diet. — An ounce of cold water in the evening of the
operation, and eleven ounces of hot water during the night;
on the second day very small quantities (5J) of milk, water
and tea. On the third day, milk four ounces, beef-tea
four ounces, tea two ounces, water two ounces. On the
fourth day, milk one pint, beef -essence two pints, one egg,
bread, a tin of Brand's essence. From this time ordinary
diet.
Medicines. — A little morphia sub cutem the first two
days ; after this nothing but aperients.
146 CJBSABEAN 8BCTI0N FOB CONTRACTED PELVIS.
The Swrgical Progresa.
»
On April 6tli (seyenteentli day) the incifiion was foand
completely healed, measuring 4| inches, 2 inches of which
were above the navel. The stitches were removed.
Per hypogasi/rvum. — Somewhat to the right side, rising
somewhat above the level of the right anterior superior
spine, is a rounded, displaceable, insensitive tumour, prob-
ably the uterus.
Per vaginam (rectum loaded). — Cervix far forwards,
immediately behind the middle of the symphysis pubis.
Os pointing downwards ; cervix short, and its involution
complete, not admitting finger.
Bimanually. — The body felt per hypogastrium is the
uterus. It appears to be 4 inches long.
The wound was dressed with iodoform and iodoform
gauze over which broad strips of strapping, and a many-
tailed flannel binder over all.
On April 17th (twentieth day) the uterus felt of the
unimpregnated size.
On April 24th (thirty-fifth day) patient and baby went
to the Convalescent Hospital at Wimbledon.
On May 16th on her return (eight weeks after opera-
tion) :
Per hypogastrvum. — Above the body of the right pubic
bone rising nearly midway to the navel is a rounded, not
tender body, apparently the uterus.
BimamAially. — Uterus small, freely displaceable in its
present situation ; a hard ridge is felt on the front of its
upper part (? the sutures).
Sotmd. — Concavity forwards, 8 inches ; can be freely
rotated, does not grate against anything.
The patient left home the same day, very grateful for
her own welfare, but less grateful for that of her child.
The progress of the case will be seen to have resembled
in essentials that of a healthy lying-in.
Subsequent history. — On October 25th, 1888, in answer
to inquiries, the patient states that the catamenia returned
OASABBAM SECTION ffOB COKT&ACTBD PBLTIB. 147
the first week in June (eleyenth week after operation) and
have returned the first week in every month since, lasting
four or five days, moderate in quantity, exactly as before
the operation. The patient says she is as well and strong
as ever, the only difference being that she sometimes feels
a pain at the bottom of the abdomen which she never had
before the operation (? the sutures). The baby is quite
well and a fine baby ; the sutures are '' nearly closed ''
{u e. they are not separated) •
Bemarha on Sa/nger'a Method.
The latest authoritative writing on this subject is from
the pen of Dr. Leopold, of Dresden (' Der Kaiserschnitt,'
Stuttgart, 1888), and a few remarks on this paper are here
appended.
With regard to the sutures. Dr. Leopold has given up
silk for chromic catgut, for two reasons : (1) in view of
the future wel&re of the uterine scar, (2) in view of the
'' subsequent pregnancies which are to be hoped for,'' the
great defect being that none of the women in whom silver
sutures were used have become pregnant again.
This view will strike the English reader as peculiar.
We read accounts in Dr. Leopold's paper of women
who appear to regard a second CaBsarean section without
apprehension, indeed apparently with pleasant anticipation.
Whether this depends on exuberant pbilo-progenitiveness
on the part of Saxon women, on the comfort of their sur-
roundings in hospital, or on the skill and management of
the operator, it would be hard to say.
It seems, however, quite contrary to the ideas which are
generally entertained, and I felt it my duty to do my best
to sterilise my patient. To do this it is not necessary to
remove the uterus by Porro's operation, nor to spay the
patient, but simply to render the Fallopian tubes impervious
is enough. This was done in my case by tying a kan-
garoo tendon ligature tightly round each. The tissue of
148 0JB8ABEAN SECTION FOB COVTBACTKD PILTIB.
the tube was cut through by the ligatare, and I think it
inconceivable that its calibre should be re-established.
Dr. Leopold's mortality has been two out of twenty-
three^ or 8*6 per cent.^ a most excellent result^ due chiefly
to three causes^ namely^ timely operation^ the method of
suturing, and antiseptics.
A point which requires explanation is the time at which
the operation was performed. In several cases this was
many hours after the escape of the waters, and this again
is bound up with another question, the size of the pelves.
In three of his cases the indication consisted in the
presence of new growths, fibroid in one, cancer of the
cervix in two. In the remaining twenty cases the indica-
tion consisted in pelvic contraction.
The advancing success of Cassarean section has practi-
cally put an end to its limitation to cases of '^ absolute ''
contraction, that is to cases where delivery per vias naivr-
rales is impossible, and its limits have extended upwards
into the class of " relative " contraction, that is, of diffi-
cult extractions after cephalotripsy or cranioclasm. The
settlement of this limit is a matter of great ethical diffi-
culty. If it can be shown that Cassarean section in a
given case is no more dangerous than craniotomy, CsBsarean
section should be done. But it is doubtful how far
'^ desire for offspring '' renders it justifiable where crani-
otomy is safer, except in those difficult and painful cases
pf cancer where the mother is doomed to certain death,
and is therefore, to all intents and purposes, moribund.
In England the opportunities for CaBsarean section are
sure to be limited in comparison with many parts of the
Continent, on account of the comparative absence of the
" English disease," which accounts for the vast majority
of deformed pelves. Craniotomy is really very rare. I
should like to ask the Fellows present how often they
have perforated in their lives, how often in a year, how
often in the same patient. The perforating obstetrician,
who is pictured for us from time to time, is altogether out
of date, extinct as the dodo, and only survives in the
CiBSABEAN SECTION FOB COKTUACTED PELVIS. 149
trathful minds of those who '' have seen hundreds of sach
oases/' and who '' never lost a patient/'
What the limits of CsBsarean section are cannot now be
laid down. They may expand as the operation improves.
We do notj in the meanwhile^ agree with the view that
CsBsarean section is likely ever to abolish craniotomy
within the limits of between three and two and a half or
even two inches. For if it be conceded that increased
experience is likely to rednce still farther the risks of
GsBsarean section^ the same mast be allowed as regards
craniotomy within those limits^ for a certain number of
women do actually die after^ though not necessarily in
conseqaence of> craniotomy. If it be conceded that the
mortality of timely craniotomy is even now nil, CsBsarean
section must^ it would seem^ always remain the more dan-
gerous.
In Dr. Leopold's paper Csssarean section is defined as
" absolutely " or " anconditionally " indicated at full time
(S. 151) with a conjugate of 5^ — 6. cm (practically = 2^
inches) or less ; " relatively " or " conditionally " with
a conjugate between 5^ — 6 cm. — 7^ cm. (2^ — 3 inches).
Two of his cases (Nos. 15 and 19, SS. 142 and 144) had
a true conjugate of 3 inches.
Considering that 3 inches in the conjagate is the usual
limit of live birth at full time, the above definition seems
to shut out craniotomy altogether.
This is not the conclusion of Dr. Leopold, whose paper
forms one of a series comparing the relations of induction
of premature labour, turning and extraction, perforation,
and CaBsarean section in contracted pelves, and who leaves
the question of their relations still open.
The maternal deaths (S. 172) in each are as follows :
Induction of premature labour 1 : 45 = 2*2 per cent.
Turning and extraction . 4 : 88 = 4*8 „
Perforation . . .2:71 = 2-8 „
CaBsarean section . . 2 : 23 = 8*6 „
Into this question of the choice between these various
modes of delivery we do not purpose here to enter. We
VOL. XXXI. 11
150 CiBSABEAN SECTION FOB CONTBACTED PBLYIS.
woald merely point oat that there is some maternal mor-
tality even in the induction of premature laboar and cranio-
tomy. We have, however, no doubt that the days of
delivery by craniotomy and any mode of extraction in
pelves of a serious amount of contraction (say a conjugate
below 2^ inches) are past. In saying this we refer to flat
and generally-contracted-flat pelves ; in other forms the
argument applies even more forcibly. We do not think
that CsBsarean section has, however, proved its rights over
pelves whose conjugates measure more than 2^ inches,
though we do not deny that in some cases it may be justi-
fiable.
Lastly, a question arises as to the nature of the pelvic
deformity.
On looking at the patient, and seeing her short stature
and the shape of her head and face, the first suggestion is
rickets. But rickets is so common a cause of short stature
and pelvic deformity that it is natural to think of it first.
On examining the patient's skeleton, moreover, no
further sign of rickets are seen, the only possible indica-
tion being the prominent ridges on the radii noted above.
The bones are not strongly curved, there is no enlarge-
ment of the epiphyses, there is no sign of rickets in the
pelvis, except smallness, and flattening, which may be
accounted for by unequal growth.
As regards her history, the mother is positive that she
did not sweat at night, that she was not late or backward
in walking, nor in teething.
The skeleton corresponds with the deformity called by
Foerster (Missbildungen, S. 64) *^ micromelus," in which
the extremities are well formed but small, a rare condition,
and one not equally distributed, in most cases, over the
skeleton. In this case the trunk was that of a fairly
grown woman, the extremities those of a child. The
extremities include (of course) the shoulder and pelvic
girdles. In this connection it was noted that there was
no pendulous belly.
OABABEAN BICTION FOR CONTBACTID PXLTIB. 151
The history also excluded coDgenitol syphilis. There
wore never any rasheB, snaffles, or affections of the eyes.
The patient is the youngest child in the family, oil the
others heing well grown and healthy.
The qaestion arises as to the accident which befel her
mother when about five months pregnant. This might
coooeivedly have disordered development, and it does not
belong to the class of matem^ impressions, which, more-
over, nsnally concern a period of pregnancy which is too
late to effect the deformities laid to their charge.
We conclude that the skeleton is that of a micromelas
that is a person with well-grown trnnk, bat stonted
extremities.
A Table oopied from Leopold, for convenience of refer*
ence, and a temperature chart, are appended.
152
CfSABEAN SECTION rOR COMTBAOTED PELVIS.
^1
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CJESABfiAN SXCTION FOB CONTRACTED PELVIS. 153
Dr. Platfaib congratulated Dr. Champneys on the result of
his interesting case, which was altogether beyond criticism.
There was no fact in modem obstetrics more interesting than
the revolution in our estimate of the risks and possibilities of
the CflBsarean section, which had been effected by the application
to it of the antiseptic principles of modem surgery. From being
a despairing resource only resorted to in the last extremity, with
little real hope of success, it was now legitimately performed,
often as an operation of selection, and with results in the hands
of such men as Leopold and Sanger which were really brilliant.
To Professor Sanger gpreat credit was due for impressing on his
profession t^e importance of his antiseptic principle in this ope-
ration. He doubted, however, if the custom, now so prevalent,
of calling this " Sanger's operation/' as if it was something new
and altogether different from CsBsarean section, was justifiable.
The question as to the performance of Ceesarean section as an
operation of election when craniotomy was possible, was one of
great difficulty. It is not to be forgotten that a rigid antisepsis
may lessen the risks of craniotomy also, and, on the whole, it is
not likely that the latter operation will be supplanted by the
former, the performance of which, in the method now alone
admissible, implies considerable surgical experience and aptitude.
Dr. Playfair was inclined to agree with Dr. Champneys that the
uterine suture could be quite safely made by strong chromic
gut, which was perfectly reliable and quite unyielding. He had
never been able to divest himself of apprehension as to the ,
safety of leaving a number of unabsorbable metallic sutures in
the uterine tissues. Dr. Champneys' method of sterilising the
patient by dividing the tubes was ingenious and original. He
was not, however, sure that it was (]^uite free of subsequent risk
to the patient, for the Graafian folhcles would mature, and dis-
charge their contents into the peritoneal cavity, the maternal
oviducts being obliterated, from which one could easily imagine
mischief, such as hsBmatocele or pelvic peritonitis, might result.
The removal of the ovaries and tubes would scarcely add at all
to the risk of the operation. He was quite in accord with Dr.
Champneys as to the advisability of sterilising the patient under
such conditions, and could see no valid objections to its being
done, but he would prefer to remove the ovaries as well as the
tubes.
Dr. Hbbmak said that Dr. Champneys had mentioned as an
** omission" in his operation that he did not turn the uterus out
of the abdominal cavity. The advantages of turning the uterus
out of the abdominal cavity were, the more sure prevention of
blood and amniotic fluid entering the peritoneal cavity, and the
greater ease of suturing, but it had the disadvantage of entailing
long exposure of the uterus, and prolonged exposure of viscera
154 CiSSARBAK SliCTIOK FOB CONTRACTED FELYld^
was, as Olshausen had showii, iniaiical to good recoyery. Dr.
Champneys had eyidentlj succeeded, in spite of the difficulty, in
keeping the peritoneum £ree from the entrance of foreign matters,
and in putting in the sutures, although he did not turn out the
uterus, and he (Dr. Herman) thought that this " omission "
must really haye contributed to success. He did not see what
adyantage was gained, if the patient were stenlised, by leaying
the oyaries, and he thought the sterilisation would haye been
more certainly effected if the uterine appendages had been com-
pletely remoyed. The question as to the ulterior efEect of re-
moyal of the oyaries was a yery large one, and our knowledge
about it was imperfect, but so far as he was aware, no ill effects
had been proyed to follow the remoyal of the oyaries in adult
women beyond those that resulted from their being sterilised.
If the oyaries after sterilisation were left they could not fulfil
their main function, and were, so far as our knowledge went,
useless superfluous organs, but they were still liable to disease.
By remoyal of the oyaries the patient was not only effectually
sterilised, but protected from oyarian tumours and other diseases
of these organs.
Dr. W. Gbupfith wished to criticise one statement of Dr.
Champneys, namely, that in future he would use chromicised
gut in place of silyer wire. He asked Dr. Champneys what where
the fundamental points in the method of operating which had
reyolutionised the results P They were rigid cleanlmess and the
use of a suture in the uterine wall that would remain safe in spite
of the frequent contractions and relaxations of the uterine wall.
No details were so important as these, and there was no safety
for the women without them. He had seen the disastrous
results in one case in which at the post-mortem examination only
the lower two of eighteen sutures remained tied ; the rest were
all completely untied, and the uterine wound was widely gaping.
Silyer wire and silk are known to be safe in this respect ; each
had its disadyantages, but silver wire was probably best for most
operators, whose chances of doing this operation must be very
few.
Dr. Lbwebs (who was present at the operation referred to by
Dr. G-riffith) asked Dr. Griffith if the catgut used was ordinary
carbolised catgut, or chromic catgut, as it made all the differ-
ence which was used. His own recollection of the case was that
the sutures were of ordinary carbolised catgut, and not of
chromic catgut.
Dr. HoBBOOKS congratulated Dr. Champneys on the great
success of his case. He belieyed the time was coming when a
patient would elect Sanger's operation as less dangerous to
nerself than craniotomy performed on the child. The number of
times obstetric physicians were called upon to perform craniotomy
CJSSABBAK SECTION FOB CONTBACTED PELVIS. 155
was Terj small, and as a matter of fact it was found that the
same patient had craniotomy performed time after time. He
qnoted a case where he had pe^ormed cephalotripsj in a woman
who had had it performed twice by Dr. Braxton Hicks, and
twice by Dr. G-alabin. In another case he performed cephalo-
tripsy in the last confinement but one of a woman with a very
narrow pelvis. At her last confinement Dr. Galabin induced
labour at the seventh month, but found it impossible to deliver
without mutilation. This woman was again pregnant nearly
four months, and he had asked her to go on to full term and
then have Sanger's operation performed, but she positively
refused, and therefore it was decided to bring on a miscarriage.
He agreed with Dr. Herman that it was better to leave the
uterus inside the abdomen during the operation, not only for the
reasons already given, but also because when lifted outside it
got into anteversionmore or less, and so the placental site would
be more probably cut down upon. He considered the elastic
ligature one of the most important improvements in the ope-
ration as it controlled the hemorrhage completely, and he asked
for further details as to its mode of application. He could not
agree with Dr. Herman and Dr. Playfair that removal of the
ovaries and tubes would be preferable to ligattiring the tubes as
had been done in this case ; for in the first place it would take a
longer time, — ^there was more risk of hamorrhage and of subse-
quent inflammation, and above all the woman, as a woman,
was much more damaged by the loss of these appendages
than by the mere ligaturing of the Fallopian tubes, and yet
this was undoubtedly quite efficacious in sterilising her, an efEect
which it seemed justifiable to obtain. As regarded- the ligature
of the tubes it was very interesting physiologically to note that
the patient had begun to menstruate again in a perfectly regular
manner, each period lasting three or four days as before the ope-
ration. It had been asserted that menstmation was afEected
very much by a nerve or nerves running alongside the Fallopian
tubes to the uterus, and there would have been included in
the ligature at least some of them almost certainly, and hence
the value of the clinical observation after this quite original
operation.
Dr. BsAXTON Hicks remarked that this case did not decide
the point, as regards the mother, which of the two operations
was better, for in the first labour craniotomy was successful,
and the second was also Csesarean section. Of course the life of
the child would be an important point in guidmg our decision.
But in this case, with a conjugate of one and three quarter inches,
there wotdd be considerable difficulty in delivering unless in
experienced hands, and Ceosarean section would be much easier
and probably safer.
156 CJE8ABEAN SECTION FOR CONTBACTSD PELVIS.
Mr. Albak Doran said that, as regarded the ligature of the
tubes, Dr. Champnejs no doubt did this with skill and care ;
still, meddling with the uterine appendages was very dangerous,
especiallj in pregnancy. Several immediate or distant evil con-
sequences might follow. Mr. Doran believed that complete
removal of the appendages was preferable to this new method
in eveiT respect.
Dr. Mbywood Smith considered one of the most important
points of the paper was the novel method of sterilising the
patient by ligaturing the oviduct, and he also, as Dr. Horrocks
had done, woiQd draw special attention to the position of the
ligature, associated as it was with the persistence of menstruation,
as it tended to throw some light on the investigation going on
in another Society on the question of the causation of menstrua-
tion. He considered that the removal of the appendages would
have added a fresh, though slight, risk to the operation, as there
would have been the danger of the ligatures slipping. He wished
to ask why in this case Porro's operation was not performed ?
It was less risky than Cesarean section, and, which is an advan-
tage in these cases, could be performed much more rapidly. He
was strongly of opinion that when a pelvis was so deformed that
parturition exposed the woman to very grave danger and the
foetus to certain death, some method of sterilising the woman
should be had recourse to, whether by Porro's operation or some
other method. It seemed useless to threaten, or warn, or exhort
some women in this matter, and it must have been within the
experience of many who had held appointments in lying-in hos-
pitals that in spite of all that had been said to them, some
women, especially among the uneducated, obstinately persisted
in going their full time with the mistaken idea that, being
more natural, it was the safer plan. If a patient came under
observation siiter the third month, he should recommend her
going the full time, and then having Porro's operation performed
as likely to save two lives and prevent further risk of mischief.
Dr. John Phillips mentioned a case under his own care.
Owing to a large fibroid in the posterior uterine wall becoming
impacted in the pelvis, this mode of delivery was rendered neces-
sary. Eventration and the use of the elastic ligature were here
impossible, and yet control of hsmorrhage and insertion of the
stitches was quite easy. He did not lay so much stress there-
fore upon these two steps as others had done. Two sizes of silk
were used for the sutures, and post mortem the uterine incision
was found perfectly united. Death was due to causes apart
from the question under consideration. He preferred sUk to
the silver suture. His own experience of chromic catgut had
not been satisfactory.
Dr. CuLLiKGwoBTH inquired what objection there was to the
CiiSABBAN SECTION FOB CONTRACTED PELVIS. 157
use of silk ligatures for suture of the uterine wound. In the
case which he communicated to the Society in 1887, he used
stout silk for the deep sutures and fine silk for imiting the peri-
toneum. The patient unfortunately died (from disease of the
kidneys) twenty-nine hours after the operation. On examining
the body the edges of the wound were found in perfect apposi-
tion, all the sutures having remained tight. In the case men-
tioned by Dr. Phillips, the evidence in favour of the reliability
of silk was even stronger, as the patient in that instance had
survived the operation four days, and still all the sutures were
found absolutely secure. He could not help feeling to have
more confidence in silk than in catgut, on account of its greater
durability and the less liability of its slipping. Mr. Ballance
had made some important experiments as to the comparative
durability of the various materials of animal origin used as
ligatures, and had obtained some very striking results which
would no doubt be published very shortly, and would be of the
greatest possible value to operators. With regard to lifting the
uterus out of the abdomen during the operation, the desirability
of which was doubted by Dr. Herman, he could only say that in
his case he found it greatly facilitated the necessary manipula-
tions, especially the suturing of the uterine wound. He would
like to ask Dr. Champneys if any particular object was served
by making the uterine incision slowly, instead of quickly, as was
generally advised. He thought Dr. Champneys would be able
to give a very good reason for preferring, in this instance,
Siiagei^B operation to Porro's.
The Pbbsidbnt said that, with regard to the choice between
Sanger's and Porro's operation, he had been led to believe,
with Dr. Champneys, from the results obtained at Dresden and
Leipzig, that Sanger's operation was^lways to be preferred
unless the uterus was already dama^d by prolonged labour,
and that it might establish its claim to preference even in that
case. He was rather surprised, however, at recent statistics as
reported to him in a letter from Dr. Harris, of Philadelphia,
which ran as follows: — "In 1887 there were 47 Sanger-
Cssarean operations with 10 deaths. The record of 1888 as
far as collected shows 45 cases with 13 deaths. Thus far the
record of the last four years shows a mortality under the Porro-
CsBsarean operation of about 19 per cent. The record of the
same perioa for the Sanger-Cesarean cases is 138, with 37
deaths, or a mortality of over 26 per cent." These statistics
therefore showed the advantage to lie on the side of the Porro
operation in general, though it could not compete with the
results of the Sanger operations at Dresden and Leipzig. Butit
must be remembered that of late it had been generally chosen
in unfavourable cases, when labour had been prolonged, and that
1^3 CiESABSAJff SECTION FOB CONTBACTED F^LYtS.
it had not been deyeloped and cultiTated in one or two hospitals
like the Sanger operation. In Britain, of five Porro operations
within the last three years all had been successful, while the
Sanger operation had not yet had such success. He should still
prefer the Sanger operation as a primary choice, but he thought
that these figures showed that, under certain circumstances,
much might be said for the other alternative.
In reply Dr. Champkeys said that he hoped that the opinions
expressed by Dr. Playfair with regard to the credit due to
Sanger for the improvements in the operation of CsBsarean
section would not go forth as the judgment of the Society. It
was, of course, true that antiseptic sux^eiy was not Sanger's
invention, nor was the musculo-muscular and sero-serous suture,
B,XLd it may have occurred to others that it was hardly fair to
postpone CflBsarean section till the woman was in a condition of
neglected labour. Still, it was not until Sanger called attention
to principles and details, and acted on his own method, that
improvement began, and he thought it was highly unjust to
attempt to deprive him of the crecQt, or to refuse to associate
his name with the improved operation. If anyone were still in
doubt, let him compare statistics before and after Sanger's
writings. He would answer the questions regarding the sutures
together. He used silver because it was the material recom-
mended by the most successful operators up to that time. He
had not then seen Leopold's paper, in which it is stated that
Dr. Leopold has changed the deep sutures from silver to chromic
gut, and that they have answered perfectly. He thought that
silver was perfectly unobjectionable, as the experience of some
years had shown, and the objection of Leopold, that it seemed
to prevent subsequent pregnancy, was (if valid) a real advantage.
He thought that Dr. GrifSth had for the moment confused
chromic with carbolic gA, the behaviour of the two being quite
different. Silk for the deep sutures seemed to him inferior
both to silver and chromic gut ; it was rather apt to cut, and he
should never employ it for the deep sutures. For the deep
sutures the choice lay between silver and chromic rat, for the
superficial sutures between chromic gut and silk. As to tying
the tubes (and this was really the most interesting part of the
operation, being a physiological experiment, though, he thought,
a perfectly safe one) he thought some of the speakers had some-
what erroneous notions of the condition of the broad ligament
at the end of pregnancy. It was much hypertrophied, very
loose, and the vessels, although enlarged, left great spaces almost
everywhere, through which a finger or fingers might, if necessary,
be thrust without encountering a visible blood-vessel. He
chose a spot about half-way along the tube, where it was small
and round, and before it began to expand towards the ampulla.
CJiSABEAN SECTION FOB CONTRACTED PELVIS. 159
There was plenty of room to pass an aneurysm needle round
the tube close to it, without including any vessel or other Tisible
structure. As to the removal of the ovaries he could not agree
with Dr. Herman that that was a matter of indifference. It
was true that some women might be better without ovaries,
others might be as well without them, but he thought that
there could be no doubt that in some cases their removal was
followed by profound and disastrous changes, not only mental.
He thought Mr. Doran was unnecessarily apprehensive of the
results of ligaturing the tubes, and could not but think it a far
less serious matter than removing the ovaries. The plea for
their removal with a view to pi'eventing disease (cystic or other)
would, if carried out logically, deprive persons of both sexes of
most of their accessible viscera. He thought it would be quite
time to deprecate ligature of the tubes when harm followed,
and he should do the same od any future occasion unless some-
thing untoward occurred to this patient. Turning the uterus
out of the abdomen was, he thought, a distinct improvement.
It was not hard to keep it warm by warm towels, it was much
easier to keep fluids out of the peritoneal cavity, and also to
insert the sutures. The upper abdominal sutures should be
closed as soon as the uterus is turned out, and there is plenty
of room to replace it after it is emptied. To Dr. Horrocks he
replied that he did not refuse to procure abortion in this case,
but the patient did not present herself till the seventh month.
The choice in a pelvis of this size seemed to be between early
abortion and Csesarean section. The elastic ligature was a
piece of rubber-tubing about the size of the little finger. It was
tied in a single knot and the ends were clipped by a pressure-
forceps. He removed all sponges before closing the uterus. As
to bleediug there was none (not a teaspoonful) during his
deliberate incision through the uterus ; it was not till rupture
of the membranes relieved the pressure that bleeding began.
On removing the elastic ligature he was surprised that no
bleeding took place. The uterus was not hard, nor was it small.
It seemed to him to illustrate the condition a few hours after
delivery, when the uterus is large and not hard, and yet there
is no bleeding. Dr. CuUingworth called attention to the author's
" very slow incision," but he had not intended to convey this
impression. He did not hurry himself, as he knew that the
uterus did not bleed at this time, and he could not see what
was to be gained by a rapid incision — there could not have been
less than no bleeding. When the uterus was completely opened
then he did hurry. To Dr. Heywood Smith he replied tluit he
thought we had nothing whatever to do with the question of
the woman's moral responsibility for becoming pr ^n ant with a
pelvis which would not let a viable child pass. We gave our
160 CA8ABSAN SECTtOK TOtL CONT&AOTSD PSLYIS.
patients adyice ; if they did not follow it we had nothing to do
with appraising their moral responsibility, but our duty was to
get them ont of their difiScnlty. To the President he replied
that the statistics of Csesarean section and Porro's operation
were just now in a very confusing condition. He should prefer
in the meanwhile to compare series performed by a competent
operator, but he might say that the statistics of Csesarean sec-
tion in good hands were so good that he thought Porro's opera-
tion shoiQd be restricted to damaged uteri. He begged to
thank the Society for the attention which they had given to his
paper.
MAT iBT, 1889.
Alfbbd L. G-ALAfiiN^ M.D., President^ in the Chair.
Present. — 85 Fellows and 8 Visitors.
Henry Douglas Johns^ L.B.G.P., was admitted a Fellow
of the Society.
William Gnmegie Brown, M.D.Aber. (Penang) ; Frede-
rick Hall, M.D.St. And. (Leeds) ; and John Wayte, M.A.,
M.B.Oxon. (Croydon), were declared admitted.
The following gentlemen were elected Fellows of the
Society: — Edward Octa^ius Croft, L.B.C.P.Lond. (Leeds) ;
Harold A. Des Yoeux, M.D.Braz. ; Charles John Harper,
L.B.C.P.Lond. (Finchley); George Bobert Lake, M.B.C. 8.;
Bichard Pinhorn, L.B.C.P.Lond. ; David Thomson Play-
fair, M.D., C.M.Edin. (Bromley, Kent) ; Abraham Wal-
lace, M.D.Edin. (Upper Norwood) ; Charles Henry White-
combe (Westerham) ; and Arthar Henry Williams, M.A.,
M.B., B.C.Cantab. (St. Leonard's-on-Sea).
Report on a Specimen of an Aborted Ovum exhihited on
February Qth^ 1889, hy Dr, John Phillips, showing Oysts
in the Decidua Vera.
The specimen comprises the fcetas and the fcetal and
maternal membranes, at about the third month of preg-
nancy.
162 SHALL OVABIAN CYSf AND HJEHATOSALPINX.
The only part requiring special investigation is the
decidna vera, which exhibits on its deep surface numerous
cysts of the size of small peas, and some mach smaller.
Owing to decomposition, microscopical examination is
useless, but the cysts are evidently such as are frequently
found of a smaller size in the decidua. They have been de-
scribed by Montgomery (' Signs and Symptoms of Preg-
nancy,' 1837, p. 183, plate ix, fig. 1), and have been in-
vestigated by Sir W. Turner (' Lectures on the Compara-
tive Anatomy of the Placenta,' 1875, p. 32), who concludes
that they are not dilated glands, but depressions for the
reception of chorion villi.
F. H. Chaxfnibts.
John Phillips.
Walter S. A. Gbitfith.
Report on Br. Playfair^s Specimen of Small Ovarian Cyst
and Eaematoaalpinx.
The small cyst of the left ovary measured two inches
in the long, and one-and-a-half in a vertical diameter. It
was unilocular, but a band ran across from one side to the
other, completely traversing the cavity. This band repre-
sented a septum. On the surface of the cyst ran the Fal-
lopian tube, no mesosalpinx separating the two structures.
The fimbriad were effaced, and the ostium was closely
applied to the surface of the cyst. A crescentic, valve-
like fold of the inner wall of the cyst lay opposite the point
of adhesion of the ostium. There was no actual commu-
nication between the tube and the cyst, although after
slight pressure against the valve a probe could be passed
into the canal of the tube. This specimen represented a
stage in the formation of tubo-ovarian cysts. The ovary
had been reduced to a mere shell, the tube had swollen
SHALL OVARIAN CYST AND HiBHATOSALPINX. 168
and forced asunder the layers of the mesosalpinx so as to
toach the cystic^ degenerate ovary, and a commanication
had been formed between them. This '* permanent adhe-
sion due to adhesive inflammation '' is described at length
in Dr. Griffith's paper on " Tubo-ovarian Cysts '' in the
Society's 'Transactions/ vol. xxix, 1887, p. 273. The
stages of those changes in chronic inflammation of the ute-
rine appendages which cause the development of a tubo-
ovarian cyst are described by Mr. Doran in the ' Transac-
tions of the Pathological Society/ vol. xxxviii, 1887, p.
241, and ibid., vol. xxxix, 1888, p. 203. In the latter
page, an account will be found of incipient communication
between a dilated tube and a cystic ovary, appearing as a
crescentic valvular elevation on the inner wall of the
ovarian cyst, precisely as in Dr. Playfair's case.
The portion of the right appendages which was removed
by operation consisted solely of the tube. The uterine end
was not dilated. The middle part was distended so as to
form a cystic cavity an inch in long diameter, containing
a firm, spherical clot. This clot was adherent only at the
point where the uterine end of the tube entered the cyst.
The walls of the dilated part of the tube were thin..
The infundibulum was distended so as to form another
sac which originally contained blood. It communicated,
by a circular orifice, with the cystic part of the tube just
described.
Probably hsdmorrhage first took place in the tube, dis-
tending its canal and its ostium. Blood then escaped into
the peritoneal cavity, as was proved by the appearances
seen at the operation. Three specimens of distended ostium
in association with hadmatosalpinx bave recently been pre-
sented to the Museum of the Royal College of Surgeons
and tbey bore a general resemblance to the present case.
The clinical history and peculiar appearances in all four
depended on the fact that the ostium was open. In the
great majority of instances of distension of the Fallopian
tubes by pus or mucus the ostium is dosed. Whether
closure of the ostium be the rule or the exception in
t64 COMPLEX TWISTn^OS OF THE FUNIS.
hsBmatosalprnz is ancertain. There is no evidence of
tubal gestation.
W. S. Platfair.
Alban Do&an.
Walter S. A. G-biffith.
COMPLEX TWISTINGS OF THE FUNIS.
By M. Handfibld-Jones, M.D.
Db. M. Handfjsld-Jones showed two newly-born infants
in whom the umbilical cord had been twisted round the
foetal limbs in a curiously complicated manner. In the
first case the foetus was hydrocephalic^ and had a well-
marked spina bifida ; the large size of the head rendered
the application of the long forceps and strong traction by
its means necessary. When the feet were bom a curious
condition was revealed, the ankles were crossed one over
the other, and each foot closely applied to the lower leg
of the opposite side ; firm and intricate twistings of the
cord lashed the feet and legs tightly and immoveably in
this position. The windings of the cord were drawn so
closely that the funis was dragged out into a thin, ribbon-
like ligature, and it was a matter for surprise how the
circulation could possibly have been carried out through
such a flattened structure. When loosened the feet were
found to be seriously deformed, flattened, and in a position
of talipes varus.
In the second case, which occurred in the practice of
Mr. Clarke, of Beigate, and which was illustrated by
photographs taken by that gentleman, the ceilings of the
cord were still more remarkable. The case was one of
twins, and the first foetus passed out naturally, then, delav
taking place, the hand was introduced into the uterus and
came in contact with the abdomen of the second child.
It was then found, by passing the hand still further into
ANSNCEFHAIiOnS FOBTUS. 165
the cavity of the utems^ that the arms and legs were fixed
behind the back of the infant and retained there by firm
twists of the cord which sorroonded each limb and then
passed off to embrace the arm or leg adjoining. By un-
winding the coils from each limb in succession^ and then
taming^ delivery was rendered possible. This child also
was hydrocephalic. The frequent co-existence of spina
bifida and hydrocephalus was briefly touched upon^ and a
suggestion made as to obstruction in the f linic circulation
beiug concerned in the production of the hydrocephalus.
FALLOPIAN TUBE AND OVARY PROM A CASE
OP TUBAL GESTATION.
•t.
By Wm. Duncan, M.D.
ANENOEPHALOUS PCETUS,
By A. PiBiOAL, M.D.
VOL. XXXI. 12
166
A CASE OP INVERSION OP UTERUS, SIXTEEN
MONTHS' STANDING; REPLACEMENT; RE-
COVERY.
By W, Newman, M.D.Lond., P.R.C.S.BDg.,
BUB6I0V TO THB STAIOOBD XimBMABT.
A. B — , housewife, aged 23, was admitted into the Stam-
ford Infirmary November 20th, 1888.
Married May, 1886. Confined for first time July 22nd,
1887 ; was attended by midwife. For some time exces-
sively ill. No clear history could be obtained of her then
condition.
Slowly recovered, but ever since has been very weak
and unable to attend to her usual housework. Is exces-
sively pale ; all tissues ansdmic^^ She has had almost con-
tinuous loss of blood, not, however, as a rule to any great
extent.
Present uterine condition as follows : — The os is widely
dilated with a large globular mass projecting through it,
and filling up the vagina. The sound is arrested all round
at a depth of about three quarters of an inch from margin
of OB. Uterus absent, by careful bimanual examination,
from its proper position.
On introducing a Sims' speculum, the large vascular
prominence is readily seen ; it bleeds on the slightest touch.
Towards the right lower margin is seen a small depression,
probably the orifice of the corresponding Pallopian tube.
November 24th, 10 a.m. — ^AveUng's repositor was intro-
duced, disc an inch and a quarter in diameter. The
instrument was fitted with shoulder straps and waistband
of linen, and four india-rubber bauds (previously tested
to a strQtohin^ limit of 2 lbs, with a spring balance) con-
IMVXBSION OF UTERUS. 167
neoted these to the stem of the instrument. 9 p«in., temp.
97*2^^ pulse 12S. No speoial abdominal pain, some sick-
ness. The disc had slipped slightly to one side ; free
hssmorrhage since the morning. Hypodermic morphia
injections.
25th, 10 a.m. — ^Disc had again slipped, one margin
embedded in the uterine cavity. Beplaced. Pressure
increased to about 8 lbs. Throughout the day there was
a good deal of pain j patient became faint and collapsed.
Low temperature, 96*4°. Some free hasmorrhage. 5 p.m.,
pain and hssmorrhage have continued. Bepositor has
again slipped to one side ; it would seem that the disc is not
sufficiently large. The instrument was definitely removed.
27th. — ^The decided haemorrhage noted above has now
practically ceased. Patient is not now suffering, she takes
food better, and is in better general condition.
December 4th. — Hsdmorrhage has ceased. It may
have been that the attempt at replacement coincided with
the periodical return of the menses.
9th. — ^No haemorrhage for the past five days ; the patient
has regained a little colour. 4.30 p.m, the repositor was
again employed. A wide belt of soap plaster on moleskin
was applied just below the iliac crests to give a firm basis
for fixing the instrument. Four rings at proper distances
were fastened by loops of tape to this belt, and to these
rings, in turn, the elastic bands were also fastened. Pres-
sure 8 lbs. A larger wooden disc, two inches and three
quarters in diameter, was used. 9 p.m., the instrument
was found to be in good place and just within the lips of
the OS.
10th, 10 a.m. — Bad night. Instrument removed. The
globular projection returns, but is not so large. After
hot vaginal injection, the instrument replaced. 4.80 p.m.,
disc more distinctly buried within the os, and with some
difficulty dislodged. The smaller disc, an inch and a
quarter in diameter, was substituted. For next hour con-
siderable pain. Pressure employed = 4 lbs. Sickness,
but not so much of collapse.
168 INYXB8I0N or UTSRTO.
llth^ 9.80 a.m. — Disa well buried, together with an inoh
to an inch and a half of stem. The instmment was finally
removed, and this with difficulty. Uterine soond passes
three inches. On bimanual examination uterus can be
felt above pubes. There has been very little haemorrhagej
but on both occasions on removing the large disc some
quantity of blood-stained serum escaped,
12th. — No pain, a little mucous blood-stained discharge.
16th. — ^No pain, discharge has ceased.
18th. — Hsdmorrhage commenced this morning und
lasted for twenty-four hours.
29th. — Condition much improved, os uteri i patulous.
Sound moves freely in cayity of uterus. Mopped out
with iodized phenol.
January 6th, 1889.— Has been taking Fern et Am. Git. ;
regained colour, looks well.
12th. — Uterine hssmorrhage for four days, i^ normal
period.
20th. — ^Vaginal examination shows os utefri rather patu-
lous, torn transversely. Lips readily separated by sound,
which passes in three inches. No abrasion. The thick**
ening about the lips of os, noticeable until a month ago
by touch and sight, has now quite disappeared. . The
uterus is freely moveable, normal in position, and painless.
29th.— Went home, perfectly well.
Bema/rka.-^It was unfortunately not possible to obtain
any reliable history. Directly after admission, for purposes
of cleanliness and as a means of checking loss of blood,
hot injections 110^ — 115° of boracic acid solution (gr. x, ad
3j) were used morning and evening with the usual douche.
They were continued practically throughout the whole of
the treatment. The failure in the first attempt at reposi-
tion was to be traced probably to two causes ;
(a) Small size of the disc, an inch and a quarter.
{b) Imperfect counter-fixation of the repositor by the
shoulder straps and belt.
The difference when the belt of plaster was employed
INVSSSION OF UTISU6. 169
was very marked. I would suggest that this last expedient
is worth adopting in any paraUel case.
Dr. William Dvncak said that in effecting reduction by
means of Ayeling's repository it was essential to jaack round the
cup BO as to prevent its slipping. He mentioned a case where
chronic inversion had existed for uine years, and where he
effected reduction with the repositor, the cup had passed into
the uterine cavity* and the cervix contracted on the stem, so
that a good deal of difficulty was experienced in removing it.
He emphasized the necessity for watching a case carefully, so
that the cup could be removed as soon as reposition of the in-
verted uterus had been effected.
Dr. Mattkbws Duncan said that since the time of Tyler
Smith and of West, when the great principle came to be recoe-
msed that an inverted uterus should be replaced, not by the old
taxis, or any efforts at a single sitting, but by continued pres-
sure^ he had found no difficulty of importance m the cases whidi
had come under his care, and they had amounted to about one
each year. In Dr. Newman's case the uterus was of extraor-
dinary sise, filling the vagina. This he had not seen in a chronic
inversion, and it led him to suspect that there was in the uterus
a fibroid in some form or other. A great deal was nowadays
said about subinvolution of the uterus, and in connection with
this subject it should be remembered that a uterus inverted
after parturition was rapidly and completely involuted. In
chronic cases he had always found it small, completely involuted.
He would point ot^t that the modem contraction ring, near as
it was to the internal os uteri, was the commencement of diffi-
culty in replacement. He said the contraction ring, because it
appeared highly probable that its function in inversion was the
same as in or aSter parturition. There was no great difficulty
in replacement ariung from the narts below the contraction
rinff. Difficulty began there. Beplacement of the uterine body
took place suddenly, and was known to the patient and the
nurse Dy the new pain, and bv the slackening of the bands of
the repositor. Betention of the disc of the repositor was from
contraction of the cervix, and was overcome by prolonged trac-
tion without much delay.
Dr. M. Handfield-Jonbs pointed out that in cases treated
by Aveling's repositor, where after reduction of the inversion
^e disc of the repositor was retained in utero by closing down
of the cervix, the proper course to pursue was to apply elastic
traction to the stem of the instrument, and thus secure its with-
drawal by gradual dilatation of the lower uterine zone.
Dr. Basnxs said that the merit of initiating the treatment of
chronic inversions of the uterus by sustained air-pressure cer-
170 IN71EB8I0N or UTKBUB.
tainly beloneed to Tyler Smith. Dr. Charles West followed.
Dr. JSames drew attention to the strict definition of acute and
chronic inversion. The distinction was ruled by the inyolution
of the uterus. This was ^nerally accomplished within a month
after deliyery. Thus dunng the month succeeding deliyery in-
version is acute, and during that period restoration was not
usually difficult. After that time the inversion is chronic, and
there is greater difficulty in reduction. He (Dr. Barnes) had
contrived an elastic pad to a thin repositor to carry out the
scheme of sustained elastic pressure. This had answered per^
fectly in several cases. Dr. Aveling added the perineal curve.
In a paper published in the ' Med.-Chir. Trans.' Dr. Barnes
related a case in which, to fadlitate reduction, he had prac-
tised incisions of the constricting neck. It was successful.
With further experience he now thought this proceeding would
very rarely be required. In the Museum of the College of Sur-
geons was a Hunterian preparation of an inverted uterus due to
a fibroid tumour. In a similar case which occurred to Dr. Barnes
he had felt it necessary to amputate the uterus. The case did
well He could not conclude without remarking how far ahead
we were in this country of the German practice. In their most
recent works, reduction by sustfiined elastic pressure was barelj
referred to, but the amputation was carefully dwelt upon. Here
this mutilation had been abandoned as unjustifiable.
Dr. Newman, in replying to the preceding speakers, said that
he did not think that local packing round the disc of the repositor
would have been of much value. Such a procedure had occurred
to him, but was dismissed. The smaller disc first used doubt-
less slipped because it covered such a sniall portion of the
convexity of the inverted organ. He had certainly not detected
any embedded fibroid growth. If such were, as time went on,
found to declare itself, he would gladly report the fact for later
publication. The plan adopted for obtainmg fixed points, from
which the elastic pressure wotdd act with greater certainty, and
the recording of the exact amount of pressure employed, would
constitute, perhaps, a sufficient reason for his having brought
the case forward.
171
ON ACUTE NON-SBPTIO PULMONAEY DISORDERS
AS COMPLICATIONS OP THE PUERPERIUM.
By John Phulips, B.A., M.D.Cantab., M.R.C.P.,
PHTSIOIAir TO THB BBITISH LTIKChlV BO0PITAX..
(Receired January 30th, 1889.)
{Abstract,)
Thb author draws attentioii to what he considers a special
group of cases, which may be denominated "acnte non-septic
pnlmonary disorders/' occurring during the lying-in state.
He divides a total of eight cases into two groups, each pre-
senting peculiar characteristics. In Oroup I are included four
cases, pne of which was a personal experience. He considers
that the three first eases detailed have peculiar physical signs
and symptoms, viz. rapid formation of dulnoss, absence of fine
crepitation, and frequent sequence of phlegmasia. The author
calls attention to the peculiar course of the temperature and to
the occurrence of temporary or permanent yalvular cardiac
disease.
Group II consists also of four cases, in which the onset of
labour appeared to act as a stimulus to a pre-existing pulmonary
lesion, rendering a chronic ailment an acute one.
The septic and embolic theories are discussed and negatiyed.
The probable pathology of these cases is stated.
Mt purpose in the following contribution is to endea-
vour to prove that there is a certain natural class of cases
existent, which may be conveniently grouped under the
denomination of '' acute non-septic pulmonary disorders/'
these being peculiar to the lying-in period.
Under this heading I would propose to include pneu-
172 ACUTS NON-SSFTIC P0LMOKABY DtSOBDKBd
monia, pleuro-pneumonia^ bronchitis^ and pleurisy, occur-
ring under the modified conditions accompanying the
lying-in state.
The difficulties which must necessarily be encountered
to prove the limits of this class are manifestly great,
and I prefer to give the few oases I have been enabled
to meet with and then to formulate my reasons for having
so done.
The material at my disposal is scanty in the extreme,
but the eight cases which I append are all carefully ob-
served, and present many interesting and I think novel
features for future observers.
It will be more convenient to divide them into two
groups :
Group I. — Consisting of cases in which pneumonia or
pleuro-pnemonia has arisen in the course of the puerperium
after a perfectly normal labour and in a patient otherwise
in good health both ante- and intra-partum (four cases).
Gsoup II. — Consisting of those cases in which plenro-
pneumonia, bronchitis, or pleurisy have arisen during the
lying-in, but having had as a predisposing cause some
pre-existent chronic pulmonary or vascular trouble (four
cases).
It is to Group I that I have paid the greater atten-
tion, as it seems to consist of a variety of pneumonia or
pleuro-pneumonia, which I might almost say is absolutely
peculiar to the lying-in condition.
The first case related under Group I occurred in my
own practice, and caused me considerable doubt as to its
real nature until I met with Cases II and III in the litera-
ture of the subject, which entirely corroborated my own
observations.
Group I.
Casb L— A primipara, aged 24, six and a half
months pregnant ; premature labour was brought on by a
long and fatiguing railway journey. Her labour lasted
AS OOilTLICATIONS OF Tl^B PtJIB^BltrM. 1^3
seyen hours^ and was normal in erety way. While catty-
ing the child she was tronbled daring the last' two
months with a great deal of pain in the left thigh along
the line of the femond vein.
The pnerp^rittm was passed through withont' any dis^*
tnrbance except for a few hoars on the third day with the
incoming of the milk. Her temperattire and poise were
normal thronghont^ and the lochia! discharge entirely
ceased on the eighth day. She was allowed ap on the
sofa on the fonrteenth day (Jdnd 17th^ 1887).
19th (sixteenth day of pnerperinm). — She was suddenly
seized with a slight but distinct attack of shivering^ accom-
panied by pain through the right shoulder blade and down
the right side ; it was worse on taking a deep inspiration.
Temp. 101^^ pulse 120, resp. 30. There was a slight defi-
ciency of breathing over the lowest two interspaces, but
no other physical signs ; the uterus was painless and freely
mobile, and there was no abdominal tenderness. .
20th (xvii). — ^Dover's powder gr. x gave her a fairly
good night, and she felt so well that she got up, but
getting out of breath lay down again, and when I saw
her I found her with a temperature of 104^, pulse 132,
and respirations 32 per minute, but not distressed. Eyes
sparkling, cheeks flushed, and a slight hacking cough.
There was well-marked dulness over the lowest two right
interspaces, with a faint respiratory murmur. The heart-
sounds were quite normal.
21st (xviii), 9 a.m. — Dulness has extended up to the
angle of the scapula and into the axilla, and is of a pecu*
liar leaden character. Over the whole of the dull area
there is loud bronchial breathing and bronchophony, ex*
cept over the two lowest interspaces, where the breath*
sounds still remain f eebte, and there is an occasional cackle
on deep inspiration. The tongue is loaded and the breath
offensive. Urine scanty^ containing no albumen but aban«
dant lithates.
10 p.m. — ^The dulness has still farther increased, chiefly
in front up to the level of the right nipple ; there is well*
174
AOUn RON-SXPTIO PUUtOHAKT StSOBDIM
marked Tocal fremitiiB over the dall area ; no crepitation.
Compensatory exaggerated expiration over left long.
22nd (xix) .^Temperature down to 99"6*'. Tongne
cleaner ; anorexia ; Blight coogh ; etiU gets ont of breath
on moving. Pulmonary sounds as yesterday.
28rd (xx). — Slight expectoration, and this is viscid and
rusty coloured ; the breath-sounds are entirely absent over
the two lowest interspaces.
Cui I (John Phillipi).
or, pain throagh right *" Pain in rigbt bip and thigh.
' bUoe. tt Apical mnnnnr flnt datected.
t FhTHcal dgni of plearo-paenoioiiU. tX Leg alightly swollen.
t Bottj ■pntnni firtt appeared. 4 Slight pain in left leg.
24th (zzi). — Cough mnch less, expectoration scanty,
but still of pneumonic type ; an occasional crepitation at
the end of deep expiration can be heard over dull area.
The pulmonary condition gradnally improved, the dul-
ness diminishing and the expectoration lessening, but
there was a marked absence of the " crepitatio rednix " so
AS COMPLICATIONS OF THS PUBBPBBIUM. 175
weU known in connection with ordinary croupons pneu-
monia. Heart-sounds perfectly normal; temperature
ranging between 100^ and 101^.
26tli (zxiii)^ 10 p.m. — ^Not so well^ lias a sensation of
pain and aching in right hip and groin and down the
inner surface of the thigh; some tenderness along the
sheath of the femoral vessels. Nothing abnormal was dis-
covered by vaginal examination. Her temperature was
102^^ but without any corresponding increase in the
respirations.
27th (xxiv).— The pain is still severe, and has extended
into the popliteal space. No swelling of the leg nor
cedema of the foot. The cough has returned, and there
is a slight viscid expectoration, but not blood stained.
Breath-sounds are distinct over the lowest interspaces.
The heart's apex-beat is in its normal situation^ but there
is a decided soft systolic murmur localised over a small
space around the apex.
In the evening the pain was so acute as to require a
subcutaneous injection of morphia gr. ^. The temperature
rose to 103^
The pain continued very severe all through the next
day, and was exactly like that experienced in the left leg
(only greatly intensified) during her pregnancy.
29th (xxvi). — Leg slightly swollen especially about
thigh and calf ; some cedema of instep. The swelling is
hard and brawny and not cedematous ; the pain is much
less, and localised over the femoral and external saphena
veins. Tongue clean and moist, and she is able to take
plenty of nourishment.
The right leg was wrapped in hot moist fomentations,
the flannel being sprinkled with Tinct. Opii.
The apical murmur remains as before, the right leg is
quite free from pain. Circumference of thigh an inch
above upper border of patella fourteen and a half inches.
July 1st (xxviii). — Catamenia appeared; normal in
quantity and character. The pain in right leg has entirely
ceased. Circumference of thigh has increased to seventeen
1?6 ACUTS N0N-8BPTIC PULMONABT DiSOBDBttS
and a half, inches ; swelling has a less brawny sensa-
tion.
July 7th (xxxiv). — Some pain for three or four hours
in the left leg^ but there is no tenderness along femoral
sheath ; slight loedema of instep. The circumference of
right thigh has diminished to fourteen and three quarter
inches. The heart-sounds are to-day quite normal^ no
trace of the apical murmur being detected.
Convalescence was rapid and normal from this time,
and in August I could not trace any remains of the pul-
monary trouble.
I have given this case somewhat in detail and from
copious notes taken at the time. The others being pub-
lished elsewhere in full, I have condensed them, drawing
attention, however, to the more salient points in their
course.
Cass II (Macdonald) .^ — The patient, aged 26, a 2-para,
was confined after a rapid labour on the evening of
September 10th, 1876. She did well until the evening
of the 15th, when she had a distinct rigor, the temperature
rising to 108^ ; she slept well, however, and felt better in
the morning. On September 17th, or the seventh day of
the puerperium, she began to suffer pain on the right side
just below the nipple. Pleurisy, with pneumonia of the
right lower lobe, was made out. The dulness increased
rapidly and ceased progressing when on a level with the
superior angle of the scapula ; the left base became slightly
affected on the ninth day. Becovery took place by crisis
on the twelfth day of the puerperium. On the fourteenth
day a distinct soft systolic murmur was heard at both
apex and base which continued for six weeks. On the
eighteenth day she complained of pain and stiffness in the
left leg and groin, accompanied by a considerable rise in
temperature, which resulted in well-marked phlegmasia
four days later. On the twenty-^eighth day of the puer-
• ' Obstetrical Journal,' 1877-8, vol. ▼, p. 888, and ' Heart Disease during
Pregnancy/ &o.
AS COXPUCATIOMB OW THI FDXBPXBmX.
periom the right groin became very pajofnl, which was
followed by some tendemeas along the femoral rein, the
Cm II (Uudonald).
temperatare rising to 102 j° ; no brawny swelling appeared.
The patient made a good recovery.
Cass III (Macdonald).* — A 2-para, aged 86, was de-
livered by forceps December Srd, 1876, t^e head pre-
senting. On the evening of the next day the patient felt
a atitch below the border of the hiss ribs, on the left side
posteriorly ; on the morning of the second day of the
pnerperinm, the pain was the same, while slight dnlness at
the extreme left base with friction sonnds were discovered.
Ko rigor had been noticed. The friction-Bonnds increased
considerably daring the next twenty-four honrs. On the
fourth day of the pnerperinm, pneamonia was evidently
' Ibid., p* 898, tt ttq.
178 ACUTE MOM-SXPTIC FULHOHABT DIBOBDKBfi
present with ezpector&tion of a few montliinlB of bloody
sputam.
The next day the right base became affected with
pneumonia, the temperature rising to 103*4°, the palse to
132. There was a slight soepicion of tenderness over the
nteras, but the lochia were normal in every way.
SHSshssslll
A. distinct basic cardiac mnrmnr (endocardial), harsh
and grating in character, was heard on the seventh day,
which remained audible for a month after, though it
bectune softer. The patient gradually and nninterruptedly
improved from this time, no phlegmasia developing,
Cabi IV (Leopold) .* — The patient a 6-para, aged 40,
was confined of her sixth child, dehvery being normal in
every way. On the third day after delivery she had a
• ' Cenbmlblatt Kt Qynilc./ 1B86, Bd. iv, 8. aSS, " 8lt«ang«bericlit dcr
gjnUotog. Qe««ll. in DreadeQ."
AB 0OMPLI0ATION8 OF THB PUIRPBBIOM. 179
rigor, the temperature rising to 103*1^ Fahr., with a
quickened pulse. Some abatement of both these occurred
the next day, but the signs of acute croupous pneumonia
of the right inferior lobe manifested themselves, the tem-
perature again rising, and the respirations reaching 46
per minute. The pneumonia spread rapidly towards the
apex on the right side, while on the sixth day the left
base became affected. The temperature descended by
crisis on the eleventh day and recovery was rapid ; no
phlegmasia.
It will be seen at a glance that Cases I, II, and III pre-
sent many features remarkably in common, and I must here
add three other very similar ones, of which I could only
obtain meagre particulars. They are mentioned by Dr.
Playfair,"^ and are considered by him as '^ cases of pleuro-
pneumonia occurring in connection with the puerperal
state, but not distinctly associated with septicadmia.'' Of
these three one died, while two of them were complicated
by phlegmasia dolens.
Dr. Paul Mund6t in 1875 said that in none of the
books or periodicals at his disposal had he been able to
find any mention of '^ puerperal pneumonia'' occurring
primarily and idiopathically during the puerperal state.
He saw a case of double pneumonia in a puerpera coming
on during the fifth day, and going on to resolution and
recovery without any outward symptoms, and without
differing in the least from the disease as seen in non-
puerperal women or men. Scanzoni, who saw the case,
took a gloomy view of it, but no reason was given. Case
lY may have been like this ; no accurate physical signs are
given in the description, and it may be an instance of
pneumonia coming and going without in any way being
influenced by the condition of the woman. This is of
course merely conjecture, and I have for many reasons
included it in Group I.
• * Sdenoe and Praotioe of Midwifery/ 7th edition, toL ii, p. 889.
t < American Joorn. Obttet./ 1876-6, vol. viii, p. 686.
180 APUTB MOK-BKFTIQ fCJLXQNA9Y .DISOBDBBS
. The first objection I must i^atarall; meet will be thi^;
How is the qae^tion of septiQaainia ,to be eluninated from
the above oa^s ? ,
lu Cas(9 I the mischief com^n^enoc^d on the sixteenth day
of tlv? lying-in^ pulse. aaid temperature up to that time
being absolutely normal. All discharge had ceased ^t
least a. week^ and it would naturally be inferred that all
the uterine venous sinuses would be absolutely aud herme-
tically pealed* In Playfair's cases it arp^e on the ^f teenth,
twenty-eighth^ and thirty-fifth days of the puerperium
respectively. Experience shows that septicemia does not
oo^mienoe so .late as this^^as a rule^ in the puerperium;
noF SQ early as the second day as in Case II. Cases III
and IY9 commencing on the fourth day^ and Munde's on the
.fifths arejof conrse.open to objection. There were no general
isymptoms preceding the local ones^ a& is usual if there
is peptic poisoning ; the attacl^ in each case began
by pain over a well-defin^ situation^ and was evidently
:pleiii!itio:and preceding the onset of the pneumonia. Ex-
cept in Case III the attack was ushered in by the usual
slight rigor or. leeUng of .ohilliness^ but no repetition of this
pheiQtiomenon occuired^ as is nearly always the case in
septic pneumonia. On examining the temperature charts
it will be seen that the initial rise was fairly rapid and
was in each caoe acconnteid fpr by the lung complication,
while after oonsolidation had taken place a rapid fall by
crisis took place; these are not generally recognised as
signs of septicaemia.
i In my own case every antiseptic precaution was taken
by myself and the patient's nurse, and the same is indi-
cated as having been carried out by Macdonald in his
cases.
On comparing an undoubted septic case of pneumonia
with one of the above, the difference is at once evident.
.QarePs* case is. an instance, where the patient was attacked
by parametritis, pneumonia, and finally suppuration about
the sacrum and left internal ea^.
• • Lyon MWealf' 1884, voL zlri, p. 480, with temperature chart.
AB COHPLICATIONS Of THB PITBBPBRIUlf. 181
The second objection will be that all the peculiar sym-
ptoms detailed in Cases I^ 11^ and III could be accounted
for by supposing the existence of multiple emboli in the
minute pulmonary arterioles.
For the moment I propose to delay answering this ob-
jection until I have entered more fully into the peculiari-
ties attendant on these cases^ especially I, II, and III.
Enumerating them briefly, they appear to be :
(1) The commencing pleurisy with pain over a localised
spot.
(2) The rapid formation of dulness, this dulness being
of a peculiar leaden character.
(8) Absence of fine crepitation, both at the onset of
the pneumonia and during the resolution stage, nothing
but a few coarse r&les being heard. This rather points to
the idea that the pulmonary air-cells are not filled with
fibrinous exudative material as in true croupous pneumonia.
(4) The entire absence of any history of sudden dys-
pnoDa. True, a certain amount of breathlessness was
noticed, but it developed gradually, and was easily
accounted for by the physical signs present.
(5) The left-sided endocardial murmur, in two cases
heard at the mitral orifice and in the other over the aortic
opening. In my case the murmur seemed functional,
similar in character to those heard so often in choreic
cases, and which are evidently due to irregular contrac-
tions of the papilliform muscles. I shall, on the other
hand, however, presently relate two cases by Andrew and
Simpson, in the latter of which a post-mortem was ob-
tained, and showed distinct warty vegetations on the
mitral valve of recent origin. In Macdonald's two cases
the murmurs lasted a considerable time, and in his first
case the physical signs certainly pointed to permanent
mitnd valvular lesion.
(6) The entire absence of metritis and parametritis.
No disease of the right side of the heart was discovered,
and no pre-existing phlegmasia was found.
(7) A peculiar red-currant-jelly sputum was expec-
VOL. XXXI. 18
182 AOUTS VON«pSFTIC l^yLHONABT D1S0BDSB8
toratied in large quantities in Case 11^ less in Case HI, while
in^^piy own case it was of a well-marked rasty-red colour,
very viscid, but scanty.
(8) The occurrence of phlegmasia dolens of the leg at
a distinct interval after the onset of the pneumonia ; in
my case on the twenty-sixth day after labour, and on the
eighteenth in Macdonald's.
Many observations show that the natural sequence of
phlegmasia dolens may often be pulmonary infarction and
its sequelfio, pneumonia and pleurisy, sooner or later.
Begbie,'!' however, was the first to call attention to their
near relationship. He found also that some cases of
pleurisy were followed by swelling (quite indistinguishable
from puerperal phlegmasia) of the leg on the corresponding
side. Other observers have since confirmed this view,
and it may be therefore fairly permissible to conclude that
there may be some intimate coniiectjion (although its nature
is at present undecided) between pleurisy and phlegmasia,
quite exclusive of any septic process. Dr. Matthews Duncan
tells me he has met two cases of undoubted simple pleu-
risy occurring in the puerpera, which ran a normal course
and made easy recoveries. He hfis also given me two
instances, where the pleurisy was complicated by peri-
metritis, but I feel bound to look on cases such as these
latter with sus^c^op,; ^^d have ^therefore excluded them.
Hanot and., Mathi^t,, relate, a very interesjbing case of
chlorosis, which wasjcomplicate^d by phlegmasia dolens of
the leg in a nulliparous patient. The blood was examined,
and presented many of the features of that found in the
pregnant condition, which supported the theory of Trous-
seau, '' that in cachexias such, as chlorosis, there is a special
condition of the blood which favours coagulation in the
veins, apart from all question of inflammation.'^ Willcocks}
has shown that a more or less considerable diminution of
hsemoglobin in a given volume of blood exists in both
• EdinbiirghM6d.Joiimal>'lS86, ToLiz^p. 1096.
t ' ArchiYM Q^ntelM de M^ecin^' 1877, toL ii, p. 676.
X * LanceV I>ec. Srd, 1881, " The Blood of ChloroBit and PregDanoy."
AS OOMPLtCATIOKS OT THIB PUBBPBBIUM. 183
pregnancy and chlorosis^ especially in the latter^ the blood-
state in healthy pregnancy being due to a large relative
increase in the waiter of the plasma^ owing to the progres-
sive enlargement of the vascular area during pregnancy.
This condition must continue for some time after labour
has taken place^ and it is evident that phlegmasia dolens
may occur entirely apart from any question of septicsBmia.
I am fully aware I am stating here what is opposed to
general teaching, viz. that phlegmasia in the lying-in
woman is almost certainly septic. Indeed, Dr. Tyler
Smith'^ looks upon a woman attacked with it as having
made *' a fortunate escape from the greater dangers of
diffuse phlebitis or puerperal fever."
There appear to be three theories to account for the
occurrence of pleuro-pneumonia in the puerperium : —
1. Exudation of fibrinous material into the pulmonary
air-cells, as in true croupous pneumonia. This was evidently
the case in Leopold's patient (Case lY), and probably in
MundS's, in other words the attack was one of ordinary
acute lobar pneumonia running a natural course, as it
would have done in the non-puerpera.
This theory does not account for the absence of fine
crepitation at the onset and termination of the disease. I
think that with the form of pleuro-pneumonia under con-
sideration the air-cells are not directly implicated.
2. That minute non-septic emboli, pass along the pulmo-
nary arterioles, and so produce minute infarctions.
This would account for the rapid formation of dulness,
the absence of oxepitation, and the currant-jelly sputum.
l^ut on the other hand, in the cases given there was no
disease on the right side of the heart, and certainly none
pointing to the presence of vegetations on the tricuspid or
pulmonary valves. In addition there was no pre-existing
phlegmasia. Had this been so, I think that there would
have been no doubt as to the correctness of this theory.
It must be also borne in mind that the possibility of minute
emboli being norir^eptic is somewhat problematicaL
• ' Muwa of Obttetrici,' p. 688.
184 ACTTTS NOK-SEFTIC PULMONARY DISOBDl&SS
3. The theory which, to my mind, seems to entirely
accord with the pulmonary state at present under con-
sideration, is that there is a general thrombosis of the
minute pulmonary venules, produced by the same condi-
tion of the blood which is productive of phlegmasia dolens
later on. Ukrge numbers of these vessels would become
plugged, pulmonary oedema and blocking of the lymphatics
would ensue, and a condition exactly similar to that in
phlegmasia result.
The air-cells, instead of being filled with fibrinous mate-
rial, would be pressed upon, and, as a result, would collapse
and thus account for the absence of the fine crepitation,
which is so noticeable a feature in this group of cases.
The presence of this exudation around the air-cells
would set up a certain amount of inflammation of the
mucous membrane lining them and a few coarse r&les, pro-
duced in those which remained slightly patent, would from
time to time be the consequence.
I will now pass on to Group II, which consists of four
cases, and although these do not present such marked fea-
tures as those in Group I, still they give additional support
to the theory I have brought forward.
Case V (Negri).* — A 3-para, aged 31, was admitted
December 30th, 1884. Her two previous labours had been
quite normal. She lived in a marshy district. When first
seen the splenic area was much increased in every direc-
tion, but chiefly vertically. Three weeks after admission
she was confined of a living child, her labour being per-
fectly normal. Immediately before and after parturition
the temperature, pulse, and respiration were normal. The
temperature the same evening rose to 99*8°, the pulse to
84, but the respirations remained normal. The next day
(second of puerperium) the temperature rose rapidly after
a short rigor and reached 103*2® on the third day ; there
was a slight cough. The uterus and lochia normal. Liver
enlarged, and the spleen so much increased in size as to
• ' Annali di Ostet. Ginecol. e Fed./ Milano, 1885, vol. vii, p. 117.
AS COHPLICATIONS OF THE PDBBPEfilDU. 185
reach to the left iliac fossa. On the fourth day there was
paLa at the right pulmonary base behind, shivering sensa-
tion all day, with dry tongae j respirations qoickened to
30. The pain and cough continned on the fifth day, and
Ciai V (Negri).
• Short rigor.
t 8pl«en much enlu-ged.
t P>in right bsM bahiad.
tt Knitx ipntnm.
a short rigor occurred in the evening ; two lamps of rasty
spntom coi^hed up (spnto craceo). The next day the
oongh was incessant bnt the pain less prononnced ; there
was distant crepitation at the right base behind.
The temperature descended by crisis on the eleventh
day. No phl^masia.
Cabi TI (Andrew).*— a 7.para, aged 89. After the
birth of the sixth child she had a sharp attack of bronchitis
commencing on the second day after labour ; she was ill
five weeks. She was confined a^ain November 4th, 1879,
havii^, as she thinks, caught a chill the day before, being
• ' OUtetrinl JoanuJ,' 1880, toL tIU. p. 21.
186 ACUTE NON-BCPTIC F0LHOHABT DISOBDEBB
otherwise quite well. There was no aign of any palmonaiy
miscliief at her labour, bat tweuty-foar bonrs afterwards
slight congh with pain in the right hypochondrimn ap-
peared } the abdominal signs were all normal. At the
beginning of the third day of the puerperiam, slightly
Cui TI {Andrew).
* P^D right ude, cough. I Delirioiu.
■* Well-markod dgi» of bronchitii (donbl«) and
Load tjitolic *iacal nmrmnr.
msty sputa were expelled, bat no physical signs of pneu-
monia or pleurisy could be detected. In the afternoon of
the same day well-marked double bronohitiB and right-
sided pneumonia was made ont. In addition, a loud mitral
eyetolic murmur. The consolidation inoreaaed up to the
tenth day ; then a crisis occurred. The cardiac murmnr
was heard for a month, but gradually declining in dis-
tinctness.
Cabb Vn (Alexander Simpson).* — A 2-para, aged 30,
was attacked with acute bronchitis a week preriouBto admia-
* ■ Gdinbnr^h Med. Jonnul,' 1881-2, p. 1000, and printa «
AB COHPLICATIOMB OW THK FUKBFXBIDH.
187
Mon, Seven hoan after a normal labour the patient was
flnshed and reatless, with pain over the base of the left
lung, especially on taking a deep breath. She had all the
signs of pneumonia of the left side tor eight days, when
prostration rapidly set in ; four day8 later she had repeated
rigors, and gradually sank.
Ciii Tit (Alexanaer Simpwa).
A post-mortem showed the left lung adherent to its
pleura at the base. The lower lobe of the left lung was
solid from croupous pnenmonia in the red hepatisation
stage ; the upper lobe congested, but not pneumonic. The
left kidney contained a large recent infarction, a lar^
branch of the renal artery being occluded by a decolorised
tenacious thrombus. Attached to the posterior cusp of the
mitral valve on its inner aspect was a large btmch of
recent vegetations. The spleen contained three infarc-
tions. A piece of placenta two inches long foand adhe*
rent to the aterine mucous membrane.
188 ACUTE KON.8BPTIC PCLHOMABT III80BDBBB
The lochia were uorm&l all through, the placenta bein^
expelled naturally and with no hiemorrhage.
Cabb VIII. — Occurred in the out-paiient maternity ef
the British Lying-in Hospital. It may be BummariBed
very shortly. The patient, a 6-para, aged 84 and very
stout, was first Been December 1st, 1882. She had for
six or seven years always suffered from a winter cough,
* LeeohM below u
and had one as usual this year. She had a normal con.
finement, if anything being after her time, and was
attended by a midwife, who reported all well until the
evening of the second day. She then found the patient
with a quick pulse and rather laboured respiration. I
saw her the same evening and found no well-marked
physical signs. The next day, however, doable bron-
chitis was evident, with patohes of broncho-pnenmonia
over the base of the left lung. On the evening of the
fourth day I found her rather bine about the lips and
AS COMPLICATIONS OF THE PUIBRPXBIUM. 189
fingers. I therefore applied two leeches at the angle of
each scapula. The cyanosis increased^ however^ in spite
of all treatment, and she dded after a rapid collapse on
the seventh day. The lochia were normal throughout,
and there was at no time any uterine tenderness. The
patient had been quite well up to the time of her
confinement, and no rigor ushered in the illness.
Here there are four cases in which there coald be no
doubt that the labour was the exciting cause of the
trouble ; enlarged spleen followed by pneumonia in Case
Y^ and acute broncho-pneumonia being the sequence of
chronic bronchitis in Gases VI, VII, and VIII.
Case V is particularly interesting as the temperature
evidently shows that the labour started a temporary
quotidian ague, producing a rigor and rise of tempera-
ture at night, in addition to the pneumonia, which seemed
rather of the croupous variety, as in Case IV. A certain
condition allied to chlorosis must have existed in the
patient, as indicated by the behaviour of the spleen, and
have acted as a predisposing cause to the pneumonia.
In Gases VI, VII, and VIII I think all idea of septic
mischief may be put aside, and the question arises whether,
if any surgical operation had been performed on either
of these women, a similar complication would not have
arisen.
There was an entire absence of all the peculiar phy-
sical signs so marked in Gases I, 11, and III, and phleg-
masia did not follow in any of them. There is no
history of cold or exposure, and I think the predisposing
cause must be limited to the already existing bronchitis.
A loud mitral murmur developed in the case related by
Andrew, which gradually disappeared as in Cases I and
III. Death in Simpson's case seemed to be due to the
kidney and splenic infarction, and although placental
remains were found after death Dr. Simpson thinks that
the disease began too soon after the labour for anything
septic to have arisen. Broncho-pneumonia is regarded
l9b ACflTTS NOK-SEPTIC PtTLMOKABT DISOBDEBS
by Bai^es''^ as a symptom of or part of puerperal fever.
He thinks that in many cases the fever is masked, or is
60 slight that it escapes observation, the attention of the
observer being fixed upon the pulmonary symptoms
alone. All the patients were doubtless at fall term, and
I have especially avoided mention of those cases in which
the onset of labour was precipitated by the lung mis-
chief as they come under the subject of '^ pneumonia
during pregnancy/' which has already been thoroughly
elucidated by Pasbender, Wemich, Gussorow, and Coli.
The question of treatment does not seem to call for
special comment. In my first case I gave carbonate and
spirits of ammonia, and added digitalis as the pulse
increased in rapidity, but I cannot say that their adminis-
tration appeared to have any beneficial effect upon the
course of the disease. The phlegmasia was treated
locally in order to relieve pain and tension. Although
the cases given are so few I think the following conclu-
sions may be drawn :
(a) That there is a form of non-septic pleuro-pneu-
monia peculiar to the puerperium which can be recognised
by certain physical signs and symptoms, these being,
rapid formation of dulness, absence of fine crepitation,
and frequent sequence of phlegmasia dolens of the ex-
tremities. In addition there is a rapid initial rise of
temperature, then temporary irregularity followed by a
more or less rapid crisis ; should phlegmasia occur there
is gradual rise fbr sotne days before the actual swelling
appears. The heart is affected temporarily or perma-
nently as indicated by the occurrence of valvular mur-
murs.
(jS) That there is a form of pneumonia which follows
the exact course of ordinary croupous pneumonia, and is
probably that disease, but coincident with the lying-in,
at the same time neither affecting nor being affected by
the puerperal condition. The same holds good with
• *< Broncho-pnenmonia of Lying-in Women/' *Obftet Tnins,/ 1868, vol.
Wy p. 66.
AS COMPLICATIONS OF THE PUEBPIBIUM. 191
simple pleurisy ; f acts^ however^ do not point to any
special physical signs with regard to this condition.
(y) That any previous chronic pulmonary or vascular
disorder is very likely to be excited into an acute one by
the advent of labour^ producing acute bronchitis and
broncho-pneumonia^ and in some cases with serious re-
sults. Cases of this kind are rare^ and the reasons for
their occurrence are at present not elucidated.
(S) That the pathology of those cases peculiar to the
lying-in condition is probably a thrombosis of a more or
less extensive character in the small pulmonary veins^
which is followed by oedema and blocking of the lymph-
atics, and that this is due to the same blood condition
which is observed in cases of phlegmasia dolens of the
extremities.
Additional Bibliography.
Fasbbkdeb. '^ Ueber Pneumonic als Schwangersch.
Complicat.," Berlin, klin. Wochen., 1874, SS. 226, 227.
Wbbnich. Beitrage zur Geburts., Bd. iii, 1874, S. 56.
GussBBOW. " Pneumonie bei Schwangeren,'* Monat-
schrift fiir Geburtsk., Bd. xxxii, 1868, S. 87.
GoLi. Inaug. Dissert. Kivista Glinica, February, 1885.
Pbixstlxt. " Intra-TJterine Death,*' Lumleian Lec-
tures, 1887.
JuBOBNSBN. Ziemssen's Handbuch d. spec. Pathol,
und Therap., 1877, Bd. v, SS. 28, 127, Leipzig.
Wblls. Journal Amer. Med. Assoc, 1886, vii, p. 667.
Gbisollb. Traits de la Pnuemonie, Paris, 1841, p. 470.
Dr. HxBKAK said that the great trouble Dr. Phillips had
taken in bringing together all the literature relating to his sub-
ject made his paper one which would always be valuable for the
purpose of reference. Although he highly appreciated not only
Dr. Phillips's labour, but also his thoughtfumess and ingenuity
in argument^ yet he regretted to say that he was unable to follow
Dr. Phillips in the main conclusion which it was the object of
the paper to establish. He had had under his own care in the
192 ACUTE NON-SEPTIC PULMONABY DISORDERS
General Lying-in Hospital one case of pneumouia during the
lying-in period. That case did not present any features that
he was able to distinguish from pneumonia as it occurs in non-
puerperal women or in men. It ended in recoyery. He might
mention in passing that it illustrated a point which had been
mentioned in former discussions of the Society, viz. that after
the pyrexia had lasted a day or two the lochia became foetid.
There was no foetor before the pyrexia, and antiseptic douches
were used throughout. He had also recently had under his care
in the same hospital a case of severe bronchitis, with emphysema
and cardiac dilatation, present at the time of delivery. There
was no eyidence of valvular disease, the cardiac dilatation seem-
ing to be due to the condition of the lungs. In that case there
was no fever, and the patient's condition steadily improved
throughout the lying-in. The course of the illness did not pre-
sent any peculiarity that could be thought due to the patient's
having been delivered of a child. Dr. Phillips had dwelt upon
certain peculiarities in his cases, which he considered to warrant
the belief that their pathology was distinct and different from
that of ordinary pneumonia. He (Dr. Herman) was unable to
attach the same importance to these as did Dr. Phillips. The
time during which fine crepitation lasted in pneumonia was vari-
able, and was sometimes short, and if the crepitation were not
heard, it did not follow that it had never been present, but only
that it was not present at the time the chest was auscultated. The
'' peculiar leaden character of the dulness " was a sign that
could only be detected by a most accomplished ear, and he
thought that, if characteristic, it was too difficult of recognition
to be of practical use. He did not think the number of cases
was large enough to make the coincidence of some of them with
phlegmasia an argument of weight. Nor, in view of the great fre-
quency of cardiac murmurs in the puerperal state (as had been
shown by Dr. Money in a paper read before the Boyal Medical
and Ghirurgical Society) did he attach much importance to the
presence of such murmurs in Dr. Phillips's cases. He did not
think that the features on which he had commented were suffi-
cient to warrant the conclusion that the pneumonia in Dr.
Phillips's cases was something different from pneumonia as it
occurs in non-puerperal women and in men. In one subordinate
point he was happy to find himself in accord with Dr. Phillips.
He thought, and he gathered that Dr. Phillips did so too, that
in some Uterature of the day it was too often assumed that any
illness occurring in a patient who had been exposed to the
chance of septic infection was septic in character. It seemed to
him that the tendency of recent research was towards showing
that septicemia, or septic infection, was a disease with a course
and phenomena as dennite as those of any other infectious dis-
AS COHPLICATIOKS 01* THI PUSBPEBIOM. 193
order, and he thought that unless a morbid condition were pre-
ceded by the manifestations of general septic»mia or pjsemia, it
should not be spoken of as septic. He saw no ground for sup-
posing that Dr. Phillips's cases were septic, nor did he think that
phlegmasia dolens of the ordinary kind was of septic origin.
Phlegmasia dolens occurred most often in women who had been
exposed to septic infection, and therefore sometimes coincided
with septicsdmia or pjsBmia ; but these were complicated and ex-
ceptional cases, — the ordinary form had nothing to do with septi-
Cffimia.
Dr. Babhxs said in his paper in the ' Obstetrical Transactions '
referred to by Dr. Phillips he had expressly described a form of
broncho-pneumonia as a phase of puerperal fever, distinct from
the form described by Virchow as due to minute emboli carried
to the lungs. Be f uUy accepted Virchow's description as of great
importance in explaining some cases of broncho-pneumonia, but
it did not explain all. Dr. Barnes's paper was a brief supplement
to a more elaborate memoir on thrombosis. He demurred to the
proposition that thrombosis occurred independently of septic
influence. But in making this statement a distinction must be
drawn. In every case there was present some noxious element,
not necessarily septic in the sense so much dwelt upon of late,
implying the absorption of septic matter from the genital canal,
or introduced from without. There was another source of
noxious matter, which arises in the patient's own system from
repressed excretion. During inyolution an enormous quantity
of effete matter was rapidly thrown into the circulation, and if it
were not as rapidly discharged by excretion pysBmia and feyer
resulted. And in this way thrombosis, as well as broncho-pneu-
monia, might result. Two factors were required to produce
thrombosis : the puerperal blood highly charged with fibrin, and
noxious stuff to cause coagulation. This was found either in
sepsis or in the retained matter that should be excreted. As for
" spontaneous " thrombosis, there could be no such thing, — as
weU might we talk of effect without cause. Spontaneous patho-
logy did not exist. Dr. Barnes had noted that in most of the
cases related by Dr. Phillips the broncho-pneumonia broke out in
the winter or under the noted influences of cold. Dr. Barnes
had shown that by far the largest number of cases of puerperal
feyer occurred in the winter, and imder the influence of cold and
damp. In this respect Dr. Phillips's cases confirmed the conclu-
sion that arrest of excretion was an important factor in puer-
peral fever. He thought the fact stated by Dr. Phillips, that
in one case the sjrmptoms did not appear until the sixteenth day,
strongly supported his conclusion that they were not due to
septic infection. Dr. Barnes submitted that the meteorological
reuitions of puerperal disease were too much neglected. He
194 ACUTS N0N-8BPTIC PULMOKABT DISORDERS
proposed that a column should be added to the tables kept for
registering the temperature and other conditions of the patient,
in which should be noted the coxurse of the meteorological pheno-
mena out of doors and indoors. As illustrating the influence
of cold, Dr. Barnes drew attention to a recent most interesting
memoir by Dr. Bristowe in which it was shown by direct experi-
ment that exposure to cold almost immediately caused hemo-
globinuria. He could not conclude without expressing his sense
of the yalue of Dr. Phillips's paper. It would certainly help to
arrive at more accurate ideas as to puerperal diseases.
Dr. LsiTH Napibb said his desire to be brief must excuse
seeming dogmatism. He held that a puerpera might suffer from
any true acute inflammation without the occurrence of septi-
csBmia. Peritonitis might undoubtedly happen during puerpery
without septic complication, and this being so, why not pneu-
monia also P Acute non-septic pneumonia was rare ; he could
only recall one case, which occurred in 1881. The patient was
rheumatic, and had a very distinct mitral regurgitant murmur.
She had a rigor followed by hyperpyrexia of sudden deyelopment.
On the fifteenth day of the puerperium she recovered. Dr.
PhilU^s, iu Case I, gave a notably well-recorded example of the
condition, but Dr. Napier thought that the subsequent onset
of phlegmasias suggested septicity. The cases quoted from
Angus Macdonald were published at the end of his work on
' Cardiac Disease in Pregnancy,' and it was worthy of remark
that these lung affections mignt be, in some degree, related to
pre-existing valvular disease. The second class of cases men-
tioned in the paper was much more common. Within the last
ten days he had seen in consultation a case of acute bronchitic
asthma, with complete blocking of one side of the chest ; this
illness came on during the fifth day of the puerperium. There
was neither septic nor peritoneal complication. Before pregnancy
the patient had been, at times, liable to such attacks. On the
present occasion the heart's action was very weak and irregular,
and the gravest apprehensions were entertained. After a sharp
non-septic illness she recovered. He appreciated Dr. Phillips's
excellent paper very highly ; the one word of criticism he would
venture to pass was that it seemed to attempt to prove too much.
Dr. Matthews Dunoan, recognising the value of Dr. Phillips's
paper, had expected that he would describe and illustrate the
pneumonia and pleurisy of l^ring-in women, simple inflammations,
which he believed occurred in this connection as in pregnancy. He
had seen such simple inflammations, and they were etiologically
unaccounted for. The cases of Dr. Phillips were, in his opinion,
mostly illustrations of a well-known, but imperfectly understood
disease in which pleurisy or pleuro-pneumonia or pneumonia
occurred with swelled leg of the same side. The combination
AS COMPLICATIONS OF THI FUBBPSBITJM. 195
was almost enough to show that such were not simple inflamma-
tionSy but were to be classed with the swelled leg of fever, a
disease which had been described by Christison and Begbie. He
(Dr. Matthews Duncan) often found in puerperal fever inflam-
matoiy oedema of the lung without the usual signs and sym-
ptoms of pneumonia. And he r^arded this as resembling the
inflammatory oedema, sometimes found, in such cases, in the
limbs or tnmk, forming tender masses, often of great size, which
did not suppurate.
Dr. Gibbons remarked that although these cases were classi-
fied as non-septic, he did not gather from the paper that the
ordinary etiology of pneumonia had been eliminated. He pre-
sumed that this was because they were considered to belong to a
special group, but he stated that he had had imder his care three
cases of pulmonary trouble during the lying-in period, having
undoubtedly the ordinary cause for their origin. Two of these
were pleuro-pneumonia, and occurred towards the end of the
second week after delivery. It was beyond doubt that they
could be distinctly attributed to cold, and were not septic. In
the third case the evidence was also clear that the pneumonia
was due to prolonged chill ; it began on the same day as the
commencement of labour. In the cases brought forward by Dr.
Phillips, the first two were accompanied by phlegmasia dolens.
Dr. G-ibbons believed that the vast majority of those who had
experience of this latter disease believed it to be of septic origin.
Of the other cases detailed, the symptoms in all began within
the first few days. It was well known that the most serious
trouble in the puerperal state frequently arose during the first
few days. He considered, therefore, whilst agreeing that the
paper was a most valuable contribution, that, with the evidence
before the Society on this subject, they were not warranted in
agreeing with the conclusions of Dr. Phillips that his cases were
non-septic.
Dr. BozALL remarked that the pulmonary disorders referred
to by Dr. Phillips as complications of the puerperium were un-
doubtedly rare, so much so, indeed, that it was difficult at pre-
sent to offer a complete criticism on the propositions which he
had laid down. Dr. Phillips had, however, done well to direct
special attention to such cases, and it was to be hoped that his
paper would set on foot the collection of further material. Among
the 866 cases of pneumonia in the female sex included in the
' Collective Investigation Becord,* vol. ii, 1884, mention is made
of seventeen in connection with pregnancy, puerpery, and lacta-
tion. In ten cases pneumonia supervened during pregnancy, in
one four days after miscarriage, and in six after delivery.
Though in none of the cases are the reports given with sufficient
detail to eliminate the septic element, the period after delivery
196 ACDTV KON-dBFTIC t^ULMONABt DI80Bl>£B8, ]BTC.
at whicli the attack of pneumonia supervened may be of interest.
The following dates are given : — "two days after confinement/'
" fourteen days after labour," " had been confined five weeks,"
and in the remaining three less definite terms are employed :
" weak from lactation," " suckling an ailing baby," ** came on in
an otherwise normal puerperium." In the second of these cases
mention is made of phlebitis of the left leg on the tenth, and of
the right leg on the thirteenth day of the fever. In gauging the
association of phlegmasia dolens with pneumonia during puer-
pery, the occasional occurrence of a similar complication when the
disease is met with under ordinary circumstances, should not be
lost sight of. In the report above referred to an instance is
given of ** phlegmasia dolens of the left leg " in a male subject ;
and in women *' lymphangitis of the right calf " and " oedema
of both legs from thrombosis, lasting one month," are recorded
as sequeks to pneumonia. Moreover, the occurrence in other
cases of '* muscular rheumatism of calf " and '* rheumatic pains "
suggest the possibility of thrombosis of deep-seated vessels.
Such cases are interesting, for, given the conditions necessary
for thrombosis, extension of the plugging so far as to implicate
the main trunks of the limb may be reckoned a mere fortuitous
circumstance.
Dr. JoHK Phillips said that in his paper he had endeavoured
to prove the possibility of pneumonia, even if complicated by
phlegmasia dolens in the lying-in woman, beins not always of a
septic nature, and he thought that some of those present had
certainly corroborated his theory. It was naturally impossible
with so few cases at his disposal to lay down anv opinion dog-
matically, but by calling attention to the subject something
might result towards dissipating the too generally accepted idea
that all this class of cases were of a septic nature.
JUNE 5th, 1889.
Alfred L. Galabin, M.D., President, in the Chair.
Present — 44 Fellows and 4 Visitors.
Books were presented by Dr. Badin, Dr. Playfair, the
Council of University College, the Editor of the Glasgow
Medical Journal, and the American Association of Obstet-
ricians and Gynecologists.
Charles Henry Whitcombe, P.R.C.S.Ed. (Westerham),
was admitted a Fellow of the Society.
Matthew Benson, M.D.Bmx. (Wigan) ; Edward Octa-
yius Croft, L.B.C.P.Lond. (Leeds) ; Joh6ngir J. Cursetji,
M.D.Brux. (Bombay) ; and David Thomson Playfair, M.D.^
CM.Edin. (Bromley, Kent) were declared admitted.
The following gentlemen were proposed for election : —
Francis Bobert Bryant Bisshopp, M.A., M.B., B.S.Cantab.
(Tunbridge Wells); Alfred Brown, M.A., M.B., CM.
Aber. (Manchester) ; Frederick Henry Davies, M.B.,
CM.Edin. (Tilbury) ; and William Harry Christopher
Newnham, M.A., M.B.Cantab. (Bristol).
VOL. XXXI. 14
198
RUPTUEED FALLOPIAN TUBE.
By Dr. Cbaig.
Me. Knowslby Thornton showed for Dr. Craig, of
Beckenham, a ruptured Fallopian tube (f tubal pregnancy) .
A married woman, aged 38, mother of one child six years
of age, believed herself to be six weeks pregnant. When
standing in the kitchen she was seized with sudden pain in
her lower abdomen with faintness and collapse. In spite of
stimulation she died in sixteen hours. The abdomen was
found to contain two pints of blood, and the pelvis was also
full of clot. No foetus could be found, but the right tube
close to its entrance to the uterus contained a small round
hole with thinned edges, aud this was evidently the seat
of the h89morrhage. The tube was thickened to about the
size of a small hazel nut. Mr. Thornton presented it to
the Society just as received, so that the small size of ,the
hole and its thin edges might be seen by the Fellows.
He remarked on the situation of the opening so near the
uterus that the complete removal of the tube aud ovary
would have been somewhat difficult, especially in unusually
soft and hyperasmic tissue, and he suggested that in such
cases the mere passage of a couple of fine silk sutures so
as to stop the haemorrhage without removing anything
would be a better operation than removal of the ovary
and tube, — it would be quicker and altogether less serious
for a woman already in a state of collapse from excessive
loss of blood.
In answer to a question from the President he expressed
the great difficulty he had in deciding in his own mind
whether these cases should be at once operated upon in
view of the numerous undoubted recoveries without inter-
ference. On the whole he was inclined to advocate an
immediate operation ; he did not fear operating during col-
lapse, but on the contrary would expect the collapse to
TWO UTEBINE FIBRO-CYSTS. 199
cease directly the flow of blood was stopped^ and he in-
stanced a case in which this actually happened in hsBmor-
rhage from slipping of ligature on an ovarian pedicle.
Dr. AiCAiirD South alluded to the importance of diagnosing
whether the hsBmorrhage was intra-peritoneal or into the meshes
of the broad-ligamient connective tissue. In the former case
immediate operation was required as soon as rupture had occurred.
He mentioned a case of tubal gestation which ruptured at the.
twelfth week, and was admitted under Mr. Blosam at Charing
Cross Hospital. Here yaginal examination showed the uterus to
be pushed over to the right by a large hard mass in the left broad-
ligament region, and the pouch of Douglas was found to be
empty. It was decided not to interfere, as the haemorrhage was
clearly localised and encysted, and the woman made a perfect
recovery.
Dr. Matthews Dvvcain had not seen a case of intra-uterine
gestation rupture into the broad ligament. Such a hsBmatoma
as would be thus produced would be easily diagnosed. No doubt
such cases occurred. He had been so impressed by the recent
successes of laparotomy in rupture of extra-uterine pregnancy in
an early stage that he was now easily moved to favour the pro-
ceeding. But it was not to be forgotten that the large majority,
probably the very large majority, of such peritoneal ruptures with
bleeding and collapse did well. Becently he had had at least half
a dozen such cases, diagnosed by several eminent medical men,
where recovery took place without operation or any interference.
In some of them he had recommended operation, in one, opera-
tion was successful at an advanced period of pregnancy.
TWO UTERINE FIBRO-CYSTS.
By J. Knowsliy Thornton, M.B., CM.
These tumours were removed quite recently from patients
in the Samaritan Hospital, together with the uteri and
appendages, and were brought before the Society as
illustrating the early stage and advanced stage of this
somewhat rare disease. The very large cyst in the one
case simulated ovarian tumour as these fibro-cysts so often
do. The smaller and more solid tumour was full of small
200 PBIMAEY CANCER OF THE FALLOPIAN TUBE.
serous cysts (dilated lymph spaces), but in each on closer
examination a similar process of breaking down could be
traced. The latter case had been treated by electrolysis
to the great pain and annoyance of the patient, whose
abdomen was scarred with bums. She stated that the
tumour had distinctly enlarged under the treatment, and
that she had suffered much pain during and after the appli-
cation. Both patients have done well.
FIBROMA OP THE OVARIAN LIGAMENT.
By Alban Doran.
PRIMARY CANCER OP THE PALLOPIAN TUBE ;
RECURRENCE.
By Amand Routh, M.D.
Db. Amand Routh showed a specimen to represent the
sequel to a case of primary cancer of the Pallopian tube
reported by Mr. Alban Doran last year and published in
the ' Obstetrical Transactions ' for 1888, p. 194, and in the
' Trans. Path. Soc' for the same year.
The lady, aged 49, had had a watery sanious discharge
per vaginam for over two years, and came under Dr. Routh's
observation in October, 1886. In January, 1887, medicines
and intra-uterine applications having failed, the uterus was
dilated and its lining membrane, which was pulpy, was
freely curetted, but the discharge continued. About three
weeks after this date the patient had acute inflammation
in the left side of the pelvis, and in about a month a tumour
became palpable on the right side of the womb. Mr.
Thornton removed the tubes on March 1st, 1888, the left
being bound down by inflammatory adhesion, and the right
PBIMAEY CANCER OF THE FALLOPIAN TUBS. 201
being the seat of the carcinoma. She remained well till
five months afterwards^ when she was attended by Dr.
Blake^ of Yarmonth^ for intestinal obstruction. The fol-
lowing month Dr. Bouth found a large tamoar sarroanding
the uterus^ the whole being mobile^ and extending more to
the left side of the pelvis.
She then came under the care of Dr. Calthrop^ of Homsey,
and died on January 25th^ 1889^ eleven months after the
operation^ her death being preceded by severe sickness and
vomitings with partial suppression of urine and albuminuria
pointing to anaamia. At the autopsy^ assisted by Mr. E.
A. Snape^ Dr. Bonth found the whole pelvis to be a solid
mass of cancer^ in which the viscera were embedded.
Secondary deposits studded the lining membrane of the
uterus^ the bladder and the vagina.
The stump of the right (cancerous) tube was free from
deposit^ showing that the operation was delayed too long.
Mr. Knowslet Thornton pointed to the fact that the tube
which contained the primary cancer had been so cleanly removed
that there was no recurrence in the stump, the death of the
patient being due to recurrence in parts secondarily affected by
the disease, parts in which it was lound impossible at the time
of operation entirely to eradicate the disease. He wished to call
especial attention to this point as emphasising the importance of
early operation in such cases, and the great danger of secondary
peritoneal infection.
Mr. Alb AN Doran had fully described the pathological features
of the primary disease ('Trans. Path. Soc./ vol. zxxiz, 1888, p.
208) and of the secondary deposits (* Lancet ' and ' Brit. Med.
Joum.,' May lltb, 1889) at two meetings of the Pathological
Society. Dr. Amand Bouth deserved great credit for the care
with which he had followed up this important case and obtained
a necropsy. The right tube was cancerous, the left was removed
with the left ovary at the same time being disorganised by chronic
perimetritic changes. Mr. Doran examined the left tube directly
after Mr. Thornton operated, and found it quite free from cancer.
The recurrence of the growth on the stump of the left, or non-
cancerous, tube was remarkable. Mr. Doran then briefly men-
tioned the evidence, which appeared to prove that in this case, and
in two others described by Kaltenbach and Orthmann, the Fallo-
pian tube was the seat of primary cancer.
202
A SHRIVELLED PCETUS OP THE FIFTH MONTH
UTBRO-GBSTATION.
By Dr. Clapham.
THE UTERUS, HEART, AND BRAIN PROM A
CASE OP PUERPERAL SEPTIC-^MIA.
By Wm. Duncan, M.D.
Dr. William Duncan showed the uteras, heart, and
brain of a woman who was seized with acnte mania eleven
days after delivery of a five months' footns, and died
three days lafcer of septicaBmia. The mania was violent,
without fixed ideas or delusions, alternating with Incid
intervals, and sleep. Post-mortem examination revealed
extensive suppuration beneath the arachnoid and extend-
ing from the base of the brain upwards over both sides of
the vertex. There was a perforation of one aortic valve,
with a collection of some purulent material in another.
AN ANENCEPHALIO PCETUS.
By Wm. Duncan, M.D.
INSTRUMENTS FOR ANTISEPTIC IRRIGATION
IN CHILD-BED.
By Graily Hewitt, M.D.
203
THE DIAGNOSIS OP PLACENTA PREVIA BY
PALPATION OP THE ABDOMEN.
B7 Hebbbbt R. Spencib^ M.D.^ B.S.Lond., M.R.C.P.^
ABSI8TAKT OB8TBTBIO PHTBIOIAlf TO VNITBBSITT OOLLBOE HOSPITAL.
(B«eeived April Idth, 1889.)
{AbatracL)
Hatikq described shortlj two cases in illustration of the
possibility of determining the site of the placenta by abdominal
palpation when it is situated in the upper segment of the uterus,
the author gives in detail seven cases of placenta prsBvia (all
the cases he has investigated from this point of view) in which
he has been able by palpation of the abdomen to diagnose the
presence of the placenta in, or its absence from, the front wall
of the lower segment before a vaginal examination was under-
taken, the diagnosis being subsequently verified by vaginal and
intra-uterine examination.
The seven observations were all made in multiparsB with
head presentations*, before the membranes were ruptured, with-
out the employment of an anesthetic, and in the absence of
pains.
In three of the seven cases the exact site of the placenta on
the front wall of the lower segment was determined by abdominal
palpation, and in two of these the pUcenta was felt at a time
when it was impossible to feel it by the vagina.
In the remaining four cases the placenta was diagnosed by
abdominal palpation to be absent from the front wall.
In making the examination it is recommended that the patient
lie on her back, the bladder having previously been emptied ;
the examination should be gentle, made in the absence of pains,
and prolonged over several minutes, or repeated if necessary.
204 THE DIAQNOSIB OF PLACENTA PBJE7IA
The following rules for making the diagnosis are formulated :
In an ordinary vertex presentation (placenta in the ujpfer
segment) the occiput, forehead (at a higher level), and side of
the head can, under favourable circumstances, be distinctly felt
in the lower segment of the uterus bj means of abdominal pal-
pation.
In a case of placeida presvia in which the head presents, the
head is not felt where the placenta is situated, it is distinctly
felt where the placenta is absent. In cases where the placenta
is in front the organ is felt as an elastic mass of the consistence
of a wetted bath-sponge, which keeps the examining fingers off
the head. Its edge may be felt and has the shape of the seg-
ment of a circle ; within the circle all is obscure to the touch ;
outside the circle the head or other part of the child is plainly
felt. Impulses to the head are not clearly felt through the
placenta ; impulses to the head through the placenta are dis-
tinctly felt at the spot from which the placenta is absent. The
same applies to combined vaginal and abdominal examination.
The author believes the method of diagnosis he has described
to be of some practical importance and solicits a more extended
trial of its value.
In the following paper I wish to bring before the
Society a means of detecting the presence of placenta
prsBvia by palpation of the abdomen before or during
labour, to place before the Society the evidence on which
the suggestion is based, and to solicit a, more extended
trial of its value.
I have on one or two occasions seen my master and
colleague, Dr. John Williams, demonstrate to his class of
students what he believed to be the placenta situated upon
the front wall of the upper segment of the uterus ; but at
the time of making the following observations I was not
aware that anything had been written upon the subject of
palpation of the placenta by the abdomen. On referring
to the literature of the subject, however, I find that in
1867 Pfeiffer,* of Demmin, in a short paper before the
• 'Monatsichrift fur QebarUhalfe,' Bd. xixi.
BY PAL?ATION OF THE ABDOMEN. 205
Gesellscliaft fiir Gebnrtslinlfe in Berlin^ states that he has
frequently been able to feel the placenta in the front wall
of the bodj of the uterus ^' like a segment of a smaller
globe situated upon a larger spheroid ;'' '* it is of tense
elastic consistence,*' " corresponds perfectly with the con-
sistence of a spongy body, filled, for the most part, with
circulating blood/' My own observations agree so fully
with PfeifFer's that I believe he did really feel the
placenta, but he offers little evidence and no proof of his
having done so. Only one piece of negative evidence
does he adduce in a case in which, before a Cassarean
section, he diagnosed the absence of the placenta from
the front wall of the uterus, and the operation verified
his diagnosis.
I believe I have, on several occasions, by means of
palpation of the abdomen, felt the placenta situated in the
upper segpnent of the uterus, but I have proof of having done
so in two instances only, and in one of these the placenta
was felt post mortem, under conditions, therefore, which
render it of little value for my present purpose ; but, as
the observations have some bearing upon the subject of
this paper, I give them here.
Observation I. — Mrs. K — , pluripara, at the full term
of pregnancy, applied at University College Hospital on
account of some indefinite symptoms. I carefully exa-
mined the abdomen. At the upper left side of the front
of the uterus was a circular swelling distinctly raised above
the general surface of the uterus, of the consistence of a
wetted bath-sponge. Under this circular swelling, which
measured about seven inches across, the sensation to touch
was much less distinct than elsewhere, where the child
could be plainly felt. The edge of the circular cake-like
mass could be felt, though not very distinctly, but below
what seemed the edge the limbs of the child were plainly
felt. The back of the child was to the right. On account
of the presence of a well-marked funic souffle I went to
see the labour through. After the child was born and
206 THB DIAGNOSIS OF PLACENTA PBiEVIA
waiting for a quarter of an hoar tlie placenta was not
delivered and coald not be expressed. My assistant in-
troduced his hand into the uteras and found the placenta
adherent. I asked him^ without telling him where I had
diagnosed the placenta to be^ to state where it lay. He
described the exact position in which I had diagnosed it
by the abdomen. The placenta had to be peeled off the
uterine wall.
Observation II. — A patient seven and a half months
pregnant was dying of heart disease and pneumonia. I
examined her abdomen^ but could not do so very tho-
roughly on account of her condition. I did not^ however^
notice any placenta on the front wall of the uterus. A
few hours later this patient died^ and next day I made the
post-mortem examination. I carefully palpated the abdo-
men. The child was plainly felt. The head was below^
flexed^ and lying almost in the transverse diameter of the
brim ; the breech above^ the back to the right, the limbs
to the left. The child was so clearly felt that I expressed
the decided opinion that the placenta was not in front. I
then just made a prick in the uterine wall, and an ounce
or two only of liquor amnii escaped, when it struck me it
would be more satisfactory to determine where the placenta
was as well as where it was not. Accordingly I placed
my hands under the uterus, and behind, on the right side
of the upper part of the uterus, the placenta and its edge
were clearly distinguished. On opening up the uterus
the child was lying exactly as diagnosed, and the placenta
in the situation where it had been recognised.
These two cases, though not directly connected with
the purpose of this paper, are quoted as showing that it
is possible, in certain cases, by palpation of the abdomen,
to feel the placenta situated in the upper segment of the
uterus.
This paper is, however, more immediately concerned with
the diagnosis of placenta prasvia by abdominal palpation.
BT PALPATION OF THE ABDOMBN. 207
Pfei£Fer (op. cit.) says that it is very diffionlt or impossible
to feel the placenta when situated in the lower segment
of the uterus. The lower segment of the uterus is, how-
ever, thinner than the upper ; it is smaller and therefore
more easily and completely palpated ; it is more fixed ;
it admits of bimanual examination ; impulses to its con-
tents are more easily transmitted to the opposite wall and
(which is most important of all) it usually contains, even
in placenta prsevia, the most easily recognisable and most
resistant of all parts of the child — the head. These
reasons would lead us a priori to suppose that the lower
segment of the uterus, instead of allowing us with great
difiiculty or not at all to palpate the placenta, would
permit us more easily than the upper segment to do so.
The following observations, I believe, will show the prac-
ticability of feeling the prsBvial placenta through the abdo-
minal walls.
Case 1. — The first case in which I felt the praevial
placenta by abdominal palpation occurred when I was
obstetric assistant at University College Hospital in 1883.
On examining the abdomen of a pregnant pluripara with
a history of uterine hsBmorrhage I was struck with the
marked prominence of the lower segment of the uterus on
the right side as compared with the left. In this situation
there was to be felt a thick spongy mass through which
no parts of the child could be made out. Above the brim
on the left side the child's head could be plainly felt.
The edge of the mass could be recognised passing obliquely
up from the left to the right. I came to the conclusion
that this mass must be the placenta. The examining
finger, passed through the cervix, felt the edge of the
placenta covering half the os on the right side, and partly
to the front, exactly corresponding with the situation of
the mass felt by the abdomen. I turned and delivered.
After delivery the placenta did not come away ; the uterus
remained larger on the right side ; the hand introduced
into the uterus found that the placenta was adherent, and
208 THE DIAGNOSIS OF PLACENTA PBJSVIA
that it was the mass described above. The placenta was
removed by the hand in the uterus.
Case 2. — ^Mrs. S — (aged 38, four children, no mis-
carriages) bled when five months pregnant. I saw her a
fortnight afterwards and felt what I believed to be the
placenta on the left side of the lower segment of the
uterus. The os was closed, and nothing definite could be
made out by the vagina.
She again bled at seven and a half months, but only
sent to the hospital when eight months of pregnancy had
passed. The bleeding was not excessive. I was called
by the obstetric assistant to see a case of placenta prasvia
which he said I had already seen ten weeks previously.
The following was made oat by the abdomen. The
child was lying longitadinally with the breech upwards,
and near it a foot. The back was to the right side, the
left knee at the umbilicus ; the occiput was clearly felt at
the pelvic brim on the right side. The whole of the left
lower segment of the uterus was occupied by a mass of
soft elastic consistence, and through it no part of the child
could be felt. The edge of the swelling was of circular
form ; it reached upwards to within an inch of the
umbilicus, to the right as far as the edge of the right
rectus, to the left it passed backwards out of touch, below
it disappeared behind the pubes. This mass was diagnosed
as placenta. By vaginal examination it was shown to be
so ; the edge of the placenta covered half the os on the
left side and in front.
Case 8. — ^Mrs. R — , the mother of four children, bled
to the extent of about a pint for the first time the day
before I saw her at seven and a half months of pregnancy.
The hasmorrhage had quite ceased. The child was lying
longitudinally with the breech up. The head could not
be made out below by the abdomen. A thickened mass
of spongy consistence could be felt in the lower segment
in front, but the edge could not be distinctly felt. The
BY PALPATION OF THE ABDOMEN. 209
os^ which was very high up and far back, just admitted
the tip of the finger^ and through it the head was clearly
felt, but no placenta. The head could not be felt through
the anterior cul-de-sac. It was decided that the placenta
was situated in front, though not projecting over the nearly
closed OS. Hasmorrhage recurring on the following day,
the patient at once sent to the hospital, according to
instructions. Chloroform was administered; the os was
dilated by Barnes's bags to the size of a crown, and the
placenta was now felt projecting over the os anteriorly.
During the delivery the placenta was found to be situated
exactly in front.
Cask 4.^ Mrs. W — (aged 40, six children, three mis-
carriages). The three miscarriages all occurred in the
course of the year 1887.
Patient bled when three months pregnant, again at five
and a half months, and this continued till I saw her at the
sixth month on June 30th, 1888. The abdomen was
flaccid ; the uterus extended to a point one inch above
the umbilicus. The child's back was felt to the right,
the limbs to the left. The head could not be well felt
below by the two hands, on account of its small size, but
balottement was so distinct as to make sure there was no
placenta in front. The diagnosis made was that, if the
placenta was in the lower segment, it was absent from the
front wall. The fcetal heart- sounds were not heard^ and
there was no uterine souffle ; foetal movements were felt.
Per vaginam the uterus was high up ; the os admitted
three fingers with difficulty ; the internal os gripped the
fingers ; the cervix was dilatable. Through the os the
placenta was felt as a thick rough mass posteriorly cover-
ing half the os ; it extended slightly to the left side ; but
by far the greater part was exactly posterior. The mem-
branes were intact. The head presented very high up
with both hands, and a loop of cord passing between the
hands, beating 144 to the minute. Slight pain^ recurred
every few minutes. On the return of bleeding the os was
210 THE DIAGNOSIS OF PLACENTA P£JSViA
in fifteen minutes dilated to the size of a crown, bimanual
version was performed, the membranes ruptured and the
child easily extracted without further hemorrhage.
Case 5. — ^Mrs. R — (aged 22, one child, no miscarriage),
eight months pregnant. She has had no pains. Five
hoars before delivery she bled slightly for the first time
during her first pregnancy and for a few minutes only.
The child is in the first cranial position. By abdominal
palpation the head was plainly felt in front and at the
sides, and I concluded, therefore, that the placenta could
not be in front. Per vaginam the placenta was felt cover-
ing the whole os, which was soft and of the size of a
florin ; the placenta was attached behind, and its anterior
edge just reached to the anterior lip of the cervix. The
finger passed into the os found the bag of membranes in
front. After dilatation with Barnes's bags till the os was
as large as a crown piece, bipolar podalic version was per-
formed, and a leg brought down into the vagina. As the
cervix was now rigid the case was watched and left to
nature, and delivery occurred three hours later, without
further hasmorrhage.
Case 6. — Mrs. — (aged 31, four children, one miscar-
riage), seven months pregnant, had been bleeding on and
off for a week. On abdominal examination I could feel
the head of the child clearly all over the front of the lower
segment of the uterus above the pubes. I concluded that
the placenta was behind. Per vaginam the cervix, soft
and dilatable, was about the size of a crown, the posterior
half of the os was covered by placenta, none was felt in
front or at the sides. The child was presenting in the first
cranial position. As the head rotated the placental edge
was pushed a little to the left, but the main part remained
behind. Pains were present, and there was no further
haemorrhage. As soon as the os was a little more dilated
the membranes were ruptured and the delivery left to
nature.
BY PALPATION OF THE ABDOMEN. 211
Case 7. — ^A multipara^ pregnant about seven months^
seen in consultation. The patient bad been bleeding
copiously for three weeks^ but had refused to call in
medical assistance. She was almost pulseless on my
arrival and extremely anaBmic. The fcetal heart-sounds
could not be heard. By abdominal palpation the head
could be felt plainly through the front wall of the lower
segment^ and I diagnosed that there was no placenta in
front. The os was high up^ of the size of a florin ; through
it no placenta could be felt till the hand was introduced
into the vagina, when a marginal insertion of the placenta
was easily made out, the placenta being situated poste-
riorly. The cervix, which was soft, was dilated by the
hand and internal version performed, and the child ex-
tracted without further hasmorrhage.
The above seven cases are all the cases of placenta
prasvia in which I have made observations by palpation of
the abdomen with a view to feel the organ. In each
instance the observation has been correct. In three cases
the placenta was found, by abdominal palpation, to be
situated in the front part of the lower segment — once on
the right side, once exactly in front, and once in front
and on the left side. In the remaining four cases the
evidence was negative, the diagnosis being that the
placenta was not in front.
In two cases I made a correct positive diagnosis by the
abdomen, which was impossible by the vagina. In every
case the diagnosis was made in the presence of others
before a vaginal examination was undertaken. All the
observations were made in multiparas with head presenta-
tions, before the membranes were ruptured, without an
anaesthetic and in the absence of pains.
It only remains for me to indicate the method of exam-
ination.
The patient lies on her back in the usual way. As a
rule, little advantage is obtained by drawing up the knees
in examining by the abdomen a uterus in the later months
212 THE DIAQN08J8 OF PLACENTA PBJBVIA
of pregnancy. It is very important that the bladder
should be emptied. The examination is to be made between
the pains.
In an ordinary vertex presentation (the placenta being
in the upper segment of the uterus) the head lies almost
transversely at the beginning of labour^ and the occiput
and the forehead (at a higher level) are to be easily and
distinctly felt by the fingers of the two hands laid out flat
outside the recti with the points downwards. Sometimes
the nose is f elt^ and I have felt an ear ; but the occiput,
the forehead, and the side of the head are to be clearly
made out in the majority of cases under favourable cir-
cumstances.
If, however, placenta praavia be present, and the placenta
be in front or at the side, an unusual swelling may be
noticed, and the head is no longer felt where the placenta
is situated ; in lateral placenta prsBvia the head may be
even more distinctly felt on the opposite side than in a
normal labour. Where the placenta is placed it feels as
if the fingers were kept off the head by a mass of elastic
consistence something like that of a wetted bath-sponge ;
there is nothing hard or even firm about it. In some cases
a distinct edge is to be felt. The edge is shaped like the
segment of a circle. Within the circle all is obscure to
the touch. Outside the circle the head or other parts of
the child are distinctly felt. Impulses to the head are not
distinctly perceived through the placenta, whereas impulses
to the head through the placenta are plainly felt at the
spot from which the placenta is absent ; this applies also
to the combined vaginal and abdominal examination. In
doubtful cases it is important that several examinations
should be made, and it is constantly to be borue in mind
that the placenta always keeps the same position. The
examination should be conducted gently, and often a con-
siderable time — ^several minutes — may be necessary to
satisfy oneself of the presence of the placenta. But if the
head is anywhere plainly and distinctly felt it may be
safely decided that the placenta is not at that spot. If a
BT PALPATTON OF THB ABDOKKN. 213
donbtfal spot remainSi a subsequent examination may dear
up the difficulty.
In conclusion, I believe the method I have suggested of
diagnosing placenta prsBvia by palpation of the abdomen
to be of some practical value, and it is in the hope that
its usefulness may be more extensively tried that I have
ventured to lay it before the Fellows of the Society.
Dr. Beaxtof Hioks said we were indebted to the author for
having done something to remove the slur cast by the French and
others that we do not teach abdominal palpation in England.
Dr. Hicks said his experience quite confirmed the observations
of the aathor of the paper, and, indeed, he had taught much the
same for many years, and incidentally in writing he had stated
that in many cases the seat of placenta coald be identified by the
hand, the placenta being on one side and the foetus on the other
of the relaxed uterus. In a case of placenta prsBvia he had dia-
gnosed the position some weeks before it was confirmed during
delivery.
Dr. Idabites thought the paper was a valuable contribution to
the art of scientific diagnosis. It was observed by others, and he
had himself confirmed the observation that, when the placenta
was seated in the upper zones and in front of the uterus, the
wall was thickened and raised at the seat, forming a hillock
rising above the level of the general smooth surface of the uterus.
This was also confirmed by auscultation.
Dr. Matthews Dxtkoait had long and often sought to dia-
gnose the position of the healthy placenta during pregnancy by
palpation, and had always fiuled. Meantime he did not believe
it could be done ; but what he had heard to-ni£;ht would make
him return again to the subject, and he was ready to learn. To
know what was to be expected or felt it was necessary to divest
the mind of the perception of the feeling of a born placenta and
learn the feeling of an attached living placenta in utero. The
bom placenta was a thrombosed cake. Tracing the cord in utero
as in a version, you came to the placenta and felt it ill-defined,
soft, and having a fretted vesicular surface. At first you might
suppose it not to be there, so ill-defined was its feeling compared
with that of the placenta when bom. Placenta pnevia was not
the best condition in which to study this supposed palpation.
It should be looked for in the far more favourable conditions of
advanced healthy pregnancy in a multipara with a relaxed uterus
and thin abdominal wall. If it were ever made out it would be
then. He had never made it out.
Dr. Cham£NSYS asked Dr. Hicks and Dr. Barnes whether, in
VOL XXXI. 15
214 THIS DIAQKOSrS 07 PLACENTA PfiJEYIA
the cases in which they stated that they had felt the placenta
from without, they had verified their diagnosis by internal pal-
pation, or whether they felt something which the]^ believed to
DC placenta. The ralne of Dr. Spencers paper lay in this verifi-
cation, though the cases were row. Dr. Champneys was sur-
prised to hear Dr. Barnes speak of diagnosis of the placental site
by auscultation. In two or three cases of advanced extra-
uterine pregnancy, in which the placenta could be plainly felt,
and in which the diagnosis was established by subsequent abdo-
minal section, no sound was ever heard over it, though repeatedly
sought for. For these and all other reasons he believed that
auscultation was no guide whatever to the situation of the
placenta.
Dr. JoHH Phillips thought that if further evidence showed
the facts laid down in the paper just read to be correct, a valu-
able method of diagnosis would result; firom personal experience,
however, he was inclined to doubt them. In a case of CsBsarean
section which had occurred in his practice, on exposure of the
uterus every attempt was made by auscultation and palpation to
discover the situation of the placenta. The evidence was nega-
tive, and the conclusion was necessarily drawn that the placenta
was situated at some distance from the line of incision. How-
ever, on making the iucision it was found immediately beneath.
This experience would, in his opinion, rather militate against
the possibility of diagnosing the position of the placenta through
the abdominal walls.
Dr. HxBMAN had two remarks to make on Dr. Spencer's
Saper. First, he noticed that in all the cases reported the fostal
ead occupied the lower uterine segment. It would be much
easier to appreciate thickening of the lower part of the uterus
when the nard head filled it than when it was only occupied by
softer and more moveable parts of the foetus. Second, in the
cases reported, the placenta was described as an *' elastic mass,"
the edge of which could be felt. It was exceptional for a prsBvia
placenta to possess these characters, for it was well known* that
such placent® were generally thinner than usual, and expanded.
Thus Dr. Barnes had described one that enveloped the fostus like
a sac, and Dr. Hicks one that occupied almost the whole inner
surface of the uterus. He (Dr. Herman) shared in the surprise
that former speakers had expressed at hearing Dr. Barnes speak
of ascertaining the position of the placenta by auscultation. He
thought it was now conclusively proved that the uterine souffle
had nothinfj^ whatever to do with the placenta. In extra-uterine
pregnancy it was so uncommon to hear it that its absence had
been asserted to be a sign that pregnancy was extra-uterine.
Dr. William Duitoan thought it must be very difficult to
* For facts in demonstration see MQUer's work on placenta previa.
BT PALPATION OF THE ABDOMEN. 215
diagnose the position of the placenta by external palpation, and
in support of this he mentioned a case in which he performed
Porro's operation a few months ago; there, on opening the
abdomen and exposing the anterior uterine wall, there was no
bulging forward of it, as Dr. Spencer maintained there would be
if the placenta were in front, neither did there appear to be any
deepening in the colour, rather the reverse. And yet on plunging
the knife in it cut through the placenta.
Dr. BozALL said that though he made it an invariable rule to
examine the abdomen with all the precautions advocated by Dr.
Spencer, he had rarely found palpation of any avail in determining
the placental site. He had, however, investigated the position
of the placental implantation by other methods, the details of
which he would not now enter upon. These observations, which
he had commenced five years ago, led him to the conclusion that
while the sides, front, and back were about equally favoured, the
placenta tends very distinctly to avoid the two poles of the uterus.
At the same time, considering that generally speaking a point
somewhat nearer the upper than the lower pole is the selected
site, and that the placenta is very rarely attached quite low down
in the uterus, Dr. Boxall was not a little surprised to find the
relative frequency with which the lower or dangerous zone was
encroached upon, and that without of necessity entailing hsBmor-
rhage. He could, however, call to mind no case in which, when
proved by other means to be implanted low down on the anterior
wall, it had been possible to map out the position of the placenta
by palpation of the abdomen.
Dr. G-ALABnr agreed with Dr. Spencer that it was sometimes
possible to make out the position of the placenta by external
palpation, but not that this could be done invariably, or as a
general rule. He did not think that the placenta could ever be felt
from without as a firm mass, a mass with definite outlines, or even
a mass at all, but rather as the absence of a mass, and a masking
of the outlines of the foetus. After the rupture of the mem-
branes, he had sometimes made out the placenta as a localised
convexity of the surface of the uterus, elastic and soft, and gene-
rally yielding no sound to auscultation. He had specially
observed this in cases of hydramnios, in which the placenta was
relatively large, and in one such instance had verified afterwards
the position of the placenta as agreeing with that diagnosed.
In answer to Dr. Ghampneys' question, Dr. Hioks said he had
not put down categorically the cases, but he had for many years
had such proofs from time to time as led him to feel certain that
the position of the placenta could be made out by palpation not
infrequently, and in regard to Dr. Matthews Duncan s observa-
tions ne would add that though in man^ cases it may be difficult
to recognise this, yet he thought that if this paper led to more
extendi observations, the wishes of Dr. Spencer that they would
216 THE DIAaNOSIS 07 PLACKNTA PBufiYIA.
fructify would be reftUsed in the recognition of this matter, for
he would beg to remind the Society, that it was not so very long
a^ that he (Dr. Hicks) first pointed out that the uterus auring
the whole of pregnancy was intermittently contracting and relax-
ing, a fiict now mlly recognised.
In reply to Drs. Matthews Duncan and Ghampneys, Dr. Babiteb
said that of course he accepted their account that the placenta
could not be made out by palpation, as it applied to themselves ;
but he objected that they were not entitled to deny that others
could do it.
Dr. Spbkgxb, in reply, said he was glad to hare the support of
the President. He had stated in his paper that the placenta was
not firm to the feel. He had likened its consistence to that of a
wetted bath-sponge for want of a better simile ; it was a soft
elastic swelling. He was rather surprised to hear that Dr.
Braxton Hicks and Dr. Barnes had long been feeling the placenta
by abdominal palpation, and had not recorded their cases. From
observation of the uterine souffle in normal cases and in placenta
prsBvia, he could not admit that information of diagnostic value
could be obtained by auscultation. He would be very surprised
if Dr. Matthews Duncan, with one hand in the uterus and the
other on 'the abdomen for counter-support, could not feel the
normal placenta. The living placenta did not differ from the
dead in consistence only; the living placenta was larger than
the dead. Having had many opportunities of examining one of
Dr. John Williams's cases he could confirm Dr. Ghampneys* state-
ment as to the ease with which the placenta could be felt in some
cases of extra-uterine gestation. The Gsdsarean section and the
Forro's operation cited by Dr. John Phillips and Dr. William
Duncan were not examined under the conditions which he had
stated in his paper to be essential, and they were not cases of
placenta prsBvia. He agreed with Dr. Herman that it ^as pro-
bably easier to feel the placenta (prsvia) when the head pre-
sented (as was usually the case) ; he had indicated this in his
paper. From actual measurement of specimens he did not think
the prsBvial placenta was unusually thin or spread out. The pre-
senting part varied much (chiefly as a result of examination or
of apoplexy). In one of his cases (at the eighth month of preg-
nancy) the part felt by the abdomen was an inch and a hfuf
thick near the edge.
217
ANTERIOR SEROUS PERIMETRITIS SIMULATING
OVARIAN SARCOMA WHEN EXPLORED BY
ABDOMINAL SECTION. RECOVERY WITH
DISAPPEARANCE OF THE CYST.
By Alban Dosan.
(Received April 6th, 1889.)
R. L — ^ aged 16^ domestic servant^ was sent to me on
May 8rd, 1887, by my friend Dr. Ilott, of Bromley, Kent,
who informed me that he had discovered that she was
suffering from some form of abdominal tamour.
The patient was rather tall and slender, dark haired,
and of a pale, unhealthy complexion. I could find no evi-
dence of chronic tonsillitis or enlargement of the cervical
glands. Her family was of a delicate constitution ; a
younger brother had recently died of tuberculosis. In
the middle of April, 1887, her period did not appear.
The abdominal swelling was then discovered, and preg-
nancy suspected. She admitted to her mother that she
had frequently had connection with a youth of about her
own age. In three weeks the tumour became very large.
I found the patient's abdomen distended. There was
resonance in the flanks, and also along the middle line
from the ensiform cartilage to a little below the umbilicus.
The lower part of the abdomen was filled by a soft fluc-
tuating tumour. Its upper border extended to the um-
bilicus above the lowest level of resonance.
Measurements on May 8rd : Umbilical level, 30 in.
Two inches below umbilicus, 81 4 in. Ensiform cartilage
to umbilicus, 6 in. Umbilicus to symphysis pubis, 7^ in.
218 ANTSBIOB SEBOUB PSBIMSTBITIS.
Bight anterior saperior spine of iliam to umbilicus^ 7^ in.
Left ditto to umbilicus^ 7f in.
The vagina was capacioas, the ragSB effaced. The ateros
lay high in the pelvis ; the cervix was small. The sound
could be introduced for nearly three inches. The uterus
was quite moveable, but every movement of the tumour
was communicated to the sound. The tumour did not
descend into the pelvis.
The patient's tongue was bright red and glossy. Her
appetite was peculiar ; she preferred chewing pills to swal-
lowing them. The mammas were well formed, but showed
no signs of enlargement.
I saw her once more on May 31st. The fluctuation in
the tumour was less distinct, and it felt harder along its
right and left limits. Measurements : Umbilicus, 29 in.
Two inches below umbilicus, 29^ in. Ensiform cartilage
to umbilicus, 5f in. Umbilicus to symphysis pubis, 8^ in.
Bight spine of ilium to umbilicus, 7 in. Left ditto to
umbilicus, 7 in. Thus the tumour had decreased in bulk,
except in one direction, having gained one inch between
the umbilicus and the pubes. I took care to measure the
abdomen myself on every occasion.
On June 16th she was admitted into Mrs. Mann's
Nursing Home, Devonshire Street. Once more the tumour
had undergone alteration. Fluctuation was again distinct.
Measurements : Umbilicus, 31 ^ in. Two inches lower,
32i in. Ensiform cartilage to umbilicus, 6f in. Umbilicus
to symphysis pubis, 9 in. Bight spine of ilium to um-
bilicus, 9 inches. Left ditto to umbilicus, 8f inches.
Thus the measurements had increased in every direction,
exceeding their extent on May 3rd. The bulging below
the umbilicus alone had steadily increased. The girth had
increased after diminishing. The flank measurements
showed the greatest proportional and absolute increase.
The temperature was 99^, pulse 84. The catamenia had
never appee^red since March. The patient looked more
cachectic than in May.
I determined to explore by abdominal section. I believed
ANTEBIOB BKBOOS PSBIHETRITIS. 219
that the tumour was most probably a cystic sarcoma of
the ovary with a short pedicle. The disease is not rare
in young girls, and is generally attended with amenor-
rhoea, as Leopold and others have noted. The tumour
was so distinctly circumscribed, apparently moveable, and
not complicated by any of the pelvic symptoms of peri-
metritis or parametritis that I could not bring myself to
believe that it was a product of inflammation or abnormal
gestation, and not a new growth.
On June 18th I operated, assisted by Drs. Bantock and
Ilott; chloroform was administered by Mr. Stormont
Murray. In dividing the transversalis fascia, the peri-
toneum, which could be recognised by the urachus, was
found to be extremely thick. When divided, some rather
firm spongy tissue was incised. It was of a dull yellow
colour and oozed freely. These appearances tended to
confirm my previous impressions. As the peritoneum was
adherent to, or rather incorporated with, the growth, and
as the pelvic symptoms indicated close connection with
the uterus, I thought it best to close the abdominal wound,
and in this decision I was supported by the gentlemen
who assisted me.
The young girl made a rapid recovery, her temperature
never exceeding 99*6^, nor her pulse 84. Flatus passed
freely on the second day, and there was no trouble when
her bowels were opened on June 25th. Her tongue re-
mained very red, and she suffered occasionally from heart-
bum during convalescence, but she was subject to dys-
pepsia, and the hot weather (for the operation was per-
formed in Jubilee week) was trying to her. On June 30th
she left the Nursing Home in improved general health.
I gave her mother a gloomy prognosis.
On September 21st, 1888, fifteen months after the opera-
tion, to my great surprise, I saw the patient once more.
Her mother told me that profuse vaginal discharge occurred
shortly after she left the Nursing Home. The swelling
then diminished, but the patient grew weaker. Dr. Ilott
recommended her to see me again. The catamenia had
220 ANTSBIOB SXBOUfi PEBIMETBITIB.
never reappeared^ nor have tHey yet been seen (Aprils
1889).
Tlie patient had grown and gained flesli^ but was still
ansBmic^ and made herself out to be unfit for any employ-
ment. The tongue was still very red and glossy.
On examination, I found that no trace of the tumour
could be detected. The uterus was bulky^ auteverted^
and fairly^ but not freely^ moveable. There was a sensa-
tion of fulness on each side of the cervix.
The patient has remained under my observation since
October. On March 26th^ when last examined^ the uterus
was anteflexed^ the body slightly enlarged and displaced
to the left. No tumour nor any uncircumscribed deposit
could be detected in tbe abdomen. I did not introduce
the sounds as on every occasion when I saw the patient
she had to retam at once by train to Bromley. I believe^
on substantial grounds^ that the soand may do much barm
under such circumstances. The girl complained of pain
some time after taking liquid food^ a frequent symptom
when old peritoneal adhesions exist.
In this case an exploratory operation was not sufficient
for diagnostic purposes. I succeeded in detecting the
outer surface of the parietal peritoneum^ and I made out
that it was much thickened. The thickening was probably
even greater than was apparent. What looked on section
so like the sarcomatous strongly-adherent wall of an
ovarian tumour was really either the deeper part of the
parietal portion of the peritoneum or omentum^ altered by
old inflammation. Had I cut a little deeper I might have
come upon a collection of fluids and then the diagnosis
would have been different and the exposed cavity could
have been drained. From experience^ however^ I know
tbat meddling with a growth which appears malignant is
very dangerous. I once laid open a secondary cyst in a
large ovarian tumour which was malignant and irremov-
able. I removed all the solid growtbs from the wall of the
cyst^ sewed its edges to the abdominal wound^ and drained.
Though the patient recovered and lived several months^
AMTIBIOB SXBOUS PXBIMXTBITI8. 221
the case gave me mnoh anxiety. In tHe present instance
the tnmoar was not bulky as in the case jnst noted^ and
there was no object in lessening its bulk. Had I recog-
nised the true nature of the present case, the sequel proves
that emptying the fluid would have been unnecessary^ if
not dangerous. The temperature was low ; there was no
clear evidence of abscess. Lastly, I might have cut through
more important structures had I proceeded further. The
exploration did no harm ; perhaps it hastened resolution
of the fluid ; perhaps the cutting of the thickened serous
membrane proved beneficial.
The true nature of the '^ tumour " merits consideration.
Was it a sarcoma which underwent spontaneous cure?
This is against all pathological and clinical experience.
Was it a soft fibroid which disappeared f Dr. Matthews
Duncan has noted the disappearance of fibroids^ but the
age and history of the case at least contradict such a
hypothesis. After seeing the patient again in October^ I
thought^ for a time^ that the tumour might have been an
extra-uterine sac, the sarcoma-like tissue being degenerate
placenta. The history before and after the exploration
was^ however^ quite unlike the course of events in ectopic
gestation. There was no acute pain, the pelvis was free
from any objective sign of abnormal gestation^ fluctuation
is rare in a foetal sac, and, lastly, the foetus and placenta
would hardly disappear so as to be impalpable fifteen
months after exploration.
In cases of anterior parametritis where the sub-perito-
neal connective tissue between the pubes and the umbilicus
is involved, a cuirass-like deposit rather than a circum-
scribed cystic tumour is felt. In my case the urachus
was plainly seen on the anterior surface of the thick layer,
which was divided by the scalpel. Hence that layer could
not have been subserous connective tissue. The uterus
was freely moveable at the time of exploration, a very un-
usual, if not impossible, condition in parametritis.
The after-history contra-indicates tubercular disease of
the abdominal or pelvic viscera. The patient is still a
222 ANTKBIOB 81ROU8 PBBIMITHITIS.
delicate girl^ bnt tnberonlar peritonitis would hardly have
undergone spontaneous cure under tHe circumstances^ for
her general health remains weak^ and she has not been
leading a very healthy life. In fact^ had the disease in
1 887 been tubercular she would have hardly lived till now^
or at least would have most probably g^wn worse.
I believe that the disease was anterior serous perito-
nitis. I employ the term as understood by Dr. Matthews
Duncan. I think that the tumour was a circumscribed
collection of fluid bounded by thickened peritoneum and
extremely thickened omentum''^ anteriorly. This condi-
dition was brought about by some uterine trouble^ pos-
sibly originating in early abortion or gonorrhosa. I do
do not think that it was unconnected with uterine disease ;
in other words^ it is more correctly to be termed " serous
perimetritis ** than '' encysted dropsy. '^
In the twenty-ninth volume of the Society's * Transac-
tions ' (1887) y p. 149^ is an interesting woodcut repre-
senting a case of anterior perimetritis. The specimen
was exhibited by Dr. W. S. A. Ghriffith. In my own case
the condition was^ I suspect^ very similar. The absence
of any vesical trouble was remarkable^ irritability of the
bladder being almost constant in subacute and chronic
forms of anterior perimetritis. The most doubtful feature
in my case was the absence of any part of the tumour from
the pelvis. In Dr. Griffith's illustration just noted^ the
serous collection has forced its way downwards in a sin-
gular manner. Indeed^ the lower limits of the utero-
vesical pouch appear to have absorbed the cellular tissue
between the bladder and cervix^ so that it reaches the
anterior vaginal wall. This condition is described as
'' extension of abscess into anterior parametric region " —
the contents of the cyst being evidently purulent. In
my case the lower part of the tumour did not descend
into the pelvis. Perhaps some intestine^ occupying the
* Specimens in the Pathological Collection, Mub. R. C. 8., Bories zzi,
« Ix^oiiet and Diieafes of Peritoneum/' show how greatly the omentum may
be altered by disease.
AMTKRIOB SSBOUS PIBIMITBITIS. 228
atero-vesical poucli^ lay below tHe encysted fluid. More
probably the poach was effaced by adhesive inflammation.
The profuse vaginal discharge might have been pus or
serum escaping through the Fallopian tube^ but the patient
was not under the care of any medical man when it
occurred, so that no accurate exploration of the pheno-
menon could be obtained.
The case bears a resemblance in some respects to
another recorded by Forget, of Strasburg, and quoted
by Dr. Matthews Duncan in his 'Practical Treatise on
Perimetritis and Parametritis.' The patient died of cancer
of the body of the uterus at the age of sixty-two. Seven
years before death ovarian dropsy was diagnosed, and she
was tapped four times. After death an ovoid cavity was
discovered, full of '^ a yellow limpid serosity.'' Its ante-
rior boundary was the great omentum thickened and
adherent to the parietal peritoneum. It represented ante-
rior perimetritis and must have preceded the cancer,
whatever may have been its cause.
Mr. Sjstowblst Thornton thought the case would probably
turn out to be tubercular. He heS met with several apparent
cures firom exploratory incision in like cases. The ameuorrhoBa
would streuffuien this view, as it was commonly present with
tubercle of the peritoneum in young girls. The time which had
passed since the operation without nesh outbreak did not, in his
opinion, at all contra-indicate tubercle.
Mr. Alban Doban said, in reply, that from the description of
the operation it could be seen that the operator was unable to
ascertain the condition of the tubes. Owmg to the habits of the
patient before her illness, salpingitis following abortion or gonor-
rhcea was veryprobable. On the other hand, considering the family
history, Mr. l^omton's belief that tubercular disease existed was
very reasonable. Mr. Doran admitted that his own arguments
against that theory were inconclusive. Were the theory absolute
truth, the morbid condition must be termed anterior serous
tubercular peritonitis. It must not be forgotten that gonor-
rhoea and other inflammatory affections appeared to predispose
patients to tubercle of the genito-urinary tract.
JULY 3bd, 1889.
Alfrbd L. Galabin^ M.D.^ President^ in the Chair.
Present.— 41 Fellows and 12 Visitors.
Books were presented by Sir H. W. Acland^ K.C.B.,
Dr. Barbour^ Dr. Calderini, Dr. Frommel, an! Dr. Rentoul.
Harold A. Des Yoeox, M.D.Bmz. ; Greorge B. Lake,
M.B.C.S. ; and Abraham Wallace, M.D.Edin., were
admitted Fellows of the Society.
The following gentlemen were elected Fellows of the
Society : — Francis Robert Bryant Bisshopp, M.A., M.B.,
B.S.Cantab. (Tunbridge Wells); Alfred Brown, M.A.,
M.B., CM. Aber. (Manchester) ; Frederick Henry Da vies,
M.B., C.M.Edin. (Tilbury) ; and William Harry Christopher
Newnham, M.A., M.B.Gantab. (Bristol).
SOLID TUMOUR OF OVARY.
By W. A. Mebedith, M.B., CM.
Mb. MiBEDiTH showed two specimens of solid ovarian
growth, recently removed by abdominal section from a
patient under his care in the Samaritan Free Hospital,
twenty-two years of age. The right ovary with tube
attached constituted a somewhat reniform tumour of irre-
gular contour, weighing six and a half pounds. On section
it was seen to be solid throughout with deeply seated areas
226 HJBMATOSALPIKZ.
of oommencing mucoid degeneration. Microscopically its
stracture was tHat of a fibro-sarcoma^ characterised by
abundance of fibrous tissue witb numerous interspaces
containing masses of large round nucleated cells^ some of
wbich also lay scattered in the substance of tbe inter-
vening fibrous bundles. The left ovary, weighing one
and a balf pounds, consisted of two masses of which the
larger had been firmly adherent in the true pelvis. Its
structure resembled that of the right ovary, but was of
somewhat less firm consistence, with a larger proportion
of cell-elements. The uterus was small and healthy in
appearance ; and no traces of secondary deposits else-
where were discovered at the operation. The specimens
were of some interest from a clinical point of view as evi-
dence of the fact that advanced sarcomatous disease of
both ovaries does not necessarily tend to induce amenor-
rhoea. The catamenia in this instance had continued per-
fectly regular, the flow having latterly increased in amount,
lasting on an average seven days instead of only three or
four, as had formerly been the case. The patient was
convalescing satisfactorily.
H/RMATOSALPINX.
By G. J. CULLINOWOBTH, M.D.
Db. Cullinowobth exhibited a hsBmatosalpinx removed
by abdominal section seven days previously. The patient,
after a slight continuous hasmorrhage lasting five weeks,
and not preceded by any menstrual irregularity, was sud-
denly seized on June 8rd with severe " bearing-down "
pain, vomiting, and extreme faintness. The acute sym-
ptoms abated in a few hours, but the patient remained
blanched and ill. The external hasmorrhage became more
profuse, and she applied for admission to the hospital.
Eight days after admission, viz. on June 16th, she had
CANCEBOUS UTBKUS BT VAQINAL OPERATION. 227
a recurrence of tHe alarming symptoms^ and again a week
later. There was an ill-defined swelling in the hypo-
gastriam^ and a soft tongne-shaped swelling in Douglas's
pouch. The uteras was normal in size^ and though embedded
in the sapra-pubic mass was fairly moveable. The case was
thought to be one of recarring intraperitoneal hemorrhage
with hasmatosalpinx. On opening the abdomen the tumour
was found to consist of fluid and clotted bloody to the
amount of thirty ounces^ surrounding the right Fallopian
tube^ which was distended with blood-clot. The free end
of the tabe was widely open^ and dark clots protruded
from it. The extravasated blood was shut off from the
upper part of the peritoneal cavity by a thick roof com-
posed chiefly of firm clot and thickened omentum. The
tube was removed and the blood cleared oat. The patient
is making a good recovery.
The portion of tabe removed measures three inches by
two inches. It has an outer coat of firm adherent blood-
clot. The uterine end is normal. The opening at the free
end has a diameter of an inch ; the fimbrisB are folded
back upon the tube.
CANCEROUS UTERUS REMOVED BT VAGINAL
OPERATION.
By W. S. Playpaie, M.D.
228
RUPTURE OP UTERUS.
By P. HoBROCKs, M.D.
Thb patient from whom tHe specimen was taken was a
poor woman, multipara, and had been delivered by version,
performed on acconnt of a transverse presentation with
prolapse of funis. Considerable difficulty was experienced
in delivering the child, which was dead, and it was pro-
bable that the rupture was the direct result of traction
upon the child. There was no particular collapse, and the
placenta was expressed in the usual way. The uterus was
syringed out with a solution of perchloride of mercury,
but as the fluid did not return an examination was made,
and the rupture discovered.
Dr. Horrocks was sent for and had the woman removed
at once into Guy^s Hospital, which was close by. Chloro-
form was administered, and the peritoneal cavity was
washed out very thoroughly with abundance of hot water
(105° P.). There did not seem to be any bleeding, the
rent was sewn up as far as was possible by drawing down
the uterus with tenacula. The patient lived twenty-two
hours.
At the post-mortem very little blood was found in the
peritoneal cavity, but there was recent peritonitis. The
rent had extended from the os externum through the right
side of the cervix, and for three inches along the posterior
wall of the aterus near the right side. The ligature had
drawn the edges together somewhat, bat still there was a
gaping wound above leading from the peritoneal cavity
into the uterine cavity.
Dr. Horrocks mentioned another case in which the
vagina had been torn from the uterus posteriorly, in efforts
made at version. In that case he sewed it up from the
vagina, but the patient only lived two days.
He regretted that he had not opened the abdomen and
FBAOMSKT OF MSMBBANie PASSIBD FROM THE UTBBUS. 229
operated from above^ either removing the whole uteras
(Porro's operation) or if possible sewing up the rent from
within^ bringing the peritoneal surfaces together.
Dr. PLA.YFAnt said that Dr. HorrockB's cases were of great
practical interest, and seemed to him to require some comment,
since the important subject of the proper treatment of lacerations
of the uterus had not, so &r as he could remember, been discussed
in the Societj. It was of great importance that the principles of
treatment should be thoroughly understood. Dr. Horroc&s had
attempted to sew up the rent from the vagina. He had himself,
however, stated his doubt as to the propriety of this course, and
he (Dr. Playfiftir) was therefore encouraged to say how he
believed it should be a settled rule that whenever the uterus was
so torn that the peritoneal cavity was laid open, the abdomen
should be opened, the peritoneal cavity thoroughly washed out,
and the laceration either sewn from above, or the entire uterus
removed. Indeed it should be treated exactly as in the case of
the improved CsBsarean section or Porro's operation. This seemed
to him the only procedure which gave the patient any reasonable
hope of recovery. Every considerable laceration must be attended
with the escape of much blood and liquor amnii into the peri-
toneal cavity. To leave this to decompose in the abdomen seemed
to him to preclude anv chance of recovery.
In answer to Dr. Playfair, Dr. Hobbocks said that plain water
was used to wash out the peritoneal cavity, and that he preferred
plain water to wash out the uterus in midwifery cases, where it
was thought desirable to irrigate at all, as after instrumental
delivery.
FRAGMENT OP MEMBRANE PASSED FROM THE
UTERUS.
By Alban Doban.
The distinction between the substance passed in mem-
branous dysmenorrhoea and the decidua in abortion is a
subject of high importance. On that account this frag-
ment is now exhibited.
The patient is a lady aged 39. She has borne four
children ; the last confinement occurred fifteen years ago.
VOL. XXXI. 1 6
2S0 FBAOMBNT OF MIMBRAKJB
She is now liying with her second hnsband. Last year
the ovaries and tabes were removed^ it is said^ in the pro-
vinces. No benefit followed^ indeed the patient grew worse.
She had previously suffered from enlarged uteras and
monorrhagia. Menstmation continued after the operation
with severe pain. During one of these attacks of pain the
fragment now exhibited came away. The medical atten-
dant to the patient believed that it was dysmenorrhoeal
membrane. Sir Spencer Wells^ to whom I am indebted
for the specimen^ sent it to me for examination. It is
clearly not an entire cast of the uterine cavity. One side
is fleshy and relatively smooth^ the other is extremely
flocculent. In the microscopic sections prepared by Dr.
Penrose^ the cells in the stroma appeared large^ as in the
decidua vera. No epithelium of any kind could be de-
tected^ — any that may have existed must have been de-
stroyed by maceration. The size of the cells is hardly
sufficient to settle the diagnosis of the case. The precise
nature of the fragment must remain doubtful.
The fragment strongly resembles No. 4602^ in the
Pathological Series^ Mus. B.G.S.^ presented by Dr. Ghamp-
neys. The patient was for some time under his observa-
tion and my own in the out-patient department of the
Samaritan Hospital in the year 1881. She was a married
woman aged 43. For eighteen months she had suffered
from severe pains during the menstrual period^ which re-
curred with perfect regularity. At each period fragments
similar to those preserved and numbered 4602, and to
those exhibited this evenings were expelled. The patient
had not been pregnant for several years.
Much was said concerning the expulsion of membranous
shreds during the catamenial period in Dr. J. Williams's
communication " On the Natural History of Dysmenor-
rhoBa '* (' Trans. Obstet. Soc./ vol. xxiv, 1882). Especially
important in relation to this question is the theory that
each expulsion of the villous fragments or entire casts of
the uterine cavity represents a very early abortion. The
patient; according to this theory^ becomes impregnated
PASSED FROM THE UTBBUS. 231
between each catamenial period. A oase related by Dr.
Oory ('Trans. Obstet. Soo./ vol. xx, 1878) strongly sup-
ports the theory. A married woman passed membranes^
often " very perfect casts of the uterine cavity/' monthly
with severe pain of a forcing and intermittent character.
Dr. Cory found that on two occasions^ when the patient
was away from her husband, no membranes were passed.
After™L Bhe Uved in tk. <iu..„ .p,^ from h» hLw
for nine months^ and during that time she menstruated
regularly without any membrane appearing. In the
course of the discussion on Dr. Cory's case^ it was sug-
gested by Dr. Aveling that the membrane did not repre-
sent a product of impregnation^ for a hyperssmic condition
leading to membranous dysmenorrhoea might have been
caused by the irritation of sexual intercourse.
The absence of the ovum in all cases of the kind is
an effectual bar to proof positive or negative. We have
no means of ascertaining whether an early ovum disappears
the more rapidly when shed into the vagina^ where it must
decompose^ or when dropped into the peritoneal cavity^
where it is probably absorbed. In both cases disappear-
ance of the ovum must occur very rapidly. The fact re-
mains^ in respect to the fragment shown to-night^ that
no ovum could be found. There may or there may not
have been an ovum. Though both appendages were said
to have been removed^ menstruation continued and^ accord-
ing to the theory above noticed^ impregnation took place.
The extent^ however^ to which the appendages were re-
moved must remain obscure.
All who are interested in the subject of membranous
dysmenorrhoea should study the beautiful preparations
illustrating that condition in the museum of St. Thomas's
Hospital. Our opinion as to their character as defined in
the catalogue must be qualified^ for reasons given above ;
unfortunately^ moreover^ no history is given in any case.
282 FRAGMENT OF MEMBRANB
Specimena in the Museum of 8t. Thomas's Hospital.
GO. 4. " A fibrinous cast of the ateras^ taken from a
case of dysmenorrhoea/' A perfect triangular sac laid
open. The cast is thinner than the fragment exhibited
this evening.
GO. 4^ (MSS. note) Cast consisting of the mucous
membrane of the uterus. A perfect triangular sac laid
open. The lower part is almost as thick as the tissue of
the present specimen.
GO. 5. Pieces of dysmenorrhoeal membrane. They are
as flocculent as the surface of the present specimen.
HH. 7^. Decidna with ovum, expelled three months after
last period. The uterine surface is far more flocculent
than that of the present specimen. The presence of the
ovum and the evidence that it is at least over one month
old make this specimen quite different in character from
the preceding. In Dr. Cory's case the patient volunteered
the statement that when she went a day or two over her
time the membranes seemed larger.
I must thank my friend, Mr. Shattock, for permission
to examine these specimens closely. As a good example
of the kind of membrane more commonly expelled in mem-
branous dysmenorrhoea, preserved in a museum, I may
note No. 4601, Path. Series, Mus. B.C.S. The specimen,
presented by Dr. Bantock, is described as '' a collection
of thin membranous structures, expelled, within the course
of a few months, from the uterus of a young woman at
each time of menstruation. This was always attended
with severe pain.'' The membranous structures do not
present the villoas appearance so marked in the fragment
exhibited to-night, and in the specimens above described.
Since the above notes were prepared, my attention has
been turned to a monograph of great importance by
Charles- Sedgwick Minot, of Harvard Medical School,
entitled '' Uterus and Embryo : I. Rabbit ; II. Man." It
will be found in the ' Journal of Morphology ' (Boston,
U.S.A.) for April, J 889, and contains most valuable reports
PASSED FUOM THB UTEBUB. 233
of microscopic preparations of the human cord^ allantois^
amnion, chorion, and uterus in menstruation and pregnancy
and after abortion. In the summary to that part of the
monograph which concerns the subject of the above notes
it is stated that '^ the menstruating uterus is characterised
by hyper»mia, by hyperplasia of the connective tissue of
the mucosa, and by hypertrophy of the uterine glands ;
the upper fourth of the mucosa is loosened and breaks
off : there are no deddnial cells.^^ This latter assertion is
of special importance in relation to microscopic appear-
ances of doubtful fragments expelled from the uterus.
Dr. Minot states that in his article on the decidua in
Buck's ' Reference Handbook of the Medical Sciences,' ii,
p. 890, is a summary of the changes occurring during
menstruation, and stress is there laid upon two points
emphasised by previous writers, namely, the increase in
the number of leucocytes and the presence of decidual
cells. Since Dr. Minot' s own observations have failed to
confirm these statements he can no longer accept them.
The proliferated connective-tissue cells are those, pro-
bably, which become decidual cells when the decichia men-
atrualis is changed into the decidua graviditatis. He
then turns attention, for the sake of comparison with his
description of the uterus during menstruation, to his
account of the uterus one month pregnant. If decidual
cells be absent in normal menstrual decidua it does not
follow that they are absent in dysmenorrhoeal membrane.
Dr. JoHK Williams said that Mr. Doran had misunderstood
his view with regard to the structure of the decidua of pregnancy.
He had not stated anywhere that the decidua of menstruation
contained the large cells which were seen in the decidua vera.
On the contrary, he agreed with Wyder in holding that the
large decidua cells offered means of distinguishing the two struc-
tures. The membranes passed in so-called '' membranous dys-
menorrhoea " were of different kinds. Some were membranes of
early abortion. Such was proved to be the case in the well-
known case of Tyler Smith. Most were cases in which there
had been no conception. That the membrane was shed in
virgins had been amply proved. He had observed it in several
instances.
234 CYST OF OVABT OF MABB.
Dr. G-BiFFiTH said that a cursory examination of a single sec-
tion nnder the microscope was not sufficient to form an opinion
as to the nature of the mass. He asked Mr. Doran whether the
patient had passed similar masses on other occasions or not, as it
was at least unlikely that it was an example of a dysmenorrhceal
membrane if this was the only occasion.
Mr. AxBAir DoBAK, in reply to Dr. Griffith, laid stress on the
fact that the membrane was only passed on one occasion. He
maintained that every specimen of doubtful membrane of this
kind should be preserved and carefully examined. The distinc-
tions between dysmenorrhceal membrane and the decidua of preg-
nancy and between the latter and normal menstrual decidua had
not been accurately determined. In addition to these questions,
the present specimen might throw light on the nature of changes
in tne endometrium after total or imperfect removal of the
oyaries and tubes. Any suspicion of impregnation might surely
be dismissed, for both tubes must have been tied. Mr. Doran
had not intended to imply that Dr. Williams professed to speak
authoritatively on the minute anatomy of the menstrual decidua
in his paper on dysmenorrhcea. The author simply quoted the
opinions of authorities current seven years ago, wnen that paper
was written.
OTST OP THE OVARY OF A MARE.
By G. Stbwabt Pollock.
This specimen was removed from a bay mare, aged 11,
a hunter and hack, never known to be in foal. She had
varicose veins on the inner and outer side of the right
thigh. While standing in the stable she was suddenly
seized with violent colic ; she had great pain for two days,
passing nothing. After this she twice staled copiously,
and was relieved. She was killed the morning of the
third day.
Post-mortem, — There was a tumour of the right ovary,
evidently loosened from its attachments and strangulating
the upper part of the rectum. The tumour, with both the
ovaries and Fallopian tubes, was preserved.
CTST OF OTABY OF MABB. 235
The tumoar is hard and heavy, and has numeroas
nodules. It weighs two pounds, and measures thirteen
inches in circumference. On section it shows the charac-
teristics of a dermoid, the cartilage is mostly hollowed
out into cysts containing grumous material, probably
lining membrane, but neither bone, hair, nor teeth, were
found.
The specimen was referred to a Committee consisting
of Mr. Pollock, Mr. Bland Sutton, and Mr. Doran.
Dr. Cletelakd inquired if the mare had shown a strong pro-
clivity to sexual intercourse, as evidenced by what is termed in
the stable ** much horsing."
Mr. Albak DoBAir, in reference to Dr. Cleveland's observa-
tions, said that whatever might be the case in mares, dermoid
cysts appeared to exert no iiidluence on the sexual physiology in
women. The great majoritj of ovarian cysts removed from chil-
dren, long before the development of the sexual instinct, were
dermoid.
286
LACEEATION OP THE VAGINA IN LABOUR.
By J. Matthews Duncan, M;D.
(Received April 8th, 1889.)
{Abstract.)
Db. Matthbws Duncan htui recently observed two cases of a
remarkable vaginal abscess in women recently confined and
having alarming symptoms. He attributes them to laceration
of submucous cellular tissue, and consequent hsBmatoma. They
were characterised by a rounded opening admitting the tip of
the finger, which when pressed entered a cavity as big as a
walnut.
Thb injuries to which I now draw attention are lacera-
tions in the length of the vagina, produced spontaneously,
that is, not directly by instruments nor the hand of the
accoucheur. They have nothing in common with those
transverse lacerations high in the canal, described by
Goldson, which are often confused with rupture of the
uterus and are indeed closely allied to it in all respects.
They are to be distinguished from those not uncommon
longitudinal lacerations which are continuous with lacera-
tions beginning in the margin of the cervix and generally
leave an easily felt cicatricial band. They are also to be
distinguished from those lacerations of the lower part of
the vagina which are continuous with lacerations of the
hymen or of the vaginal orifice, and of which most are in-
cluded under the designation of laceration of the perinaeum.
The passage of the foetus through the vagina from os
LAOBBATIOK OF THI VAGINA IN LABOUR. 237
externum uteri to vaginal orifice is^ no doabt, as asnally
described, easy and without injury to the vagina ; but
vaginal injuries, not at either end of the passage, are sel-
dom looked for, and I believe they are more common than
is generally supposed. That they do happen we have evi-
dence in the occurrence of recto-vaginal laceration and in
some cases of central rupture of the perinsBum, both of
which accidents I have described in my book on ' The
Female PeiinaBum/
Laceration by the forceps may be of two kinds, direct
and indirect. Direct laceration or cutting has nothing to
do with the subject of this paper. It is frequently ob-
served and may be high up posteriorly or anteriorly, or it
may be along either side of the vagina, or it may be near
the orifice and down to the ischio-pubic ramus. Sach in-
juries by forceps are more or less incision-like wounds, and
their importance does not need to be insisted upon. They
are, for the most part, the result of bad application or bad
working of the forceps ; sometimes they are inevitable.
Indirect laceration by forceps is well known and is
familiarly exemplified in the laceration of the perinsdum,
often produced by its working. Though produced by its
working, the laceration might have been quite as great
had forceps not been used. In like manner laceration of
vagina higher up, that is between cervix and os vaginas,
is well seen when forceps is used, and when this instru-
ment had no direct action in causing it.
It is natural to expect laceration of the vagina in its
course more frequently and more severely when forceps is
used than when it is not used, for the cause of the lace-
ration and the need for forceps assistance naturally go
together. The lacerations not caused directly by forceps
are known by their situation where forceps did not act and,
in the peculiar laceration specially under consideration, by
the character of the injury.
The researches of Tamier show that the soft parts have
much more to do with the mechanism of delivery than has
been generally held, and this leads as to be more expec-
288 LACBBATION OF THB YAaiMA IN LABOUR*
tant of injury in doing their work. The vagina may be
nndilatable and stretched transversely^ may be lacerated
longitudinally. If the forceps is used to pull the head
through an undilatable vagina, laceration, not directly by
the forceps, is likely to occur. Besides, laceration directly
by the forceps is more likely to occur than when the
vagina is soft and capacious. I have not observed a
vagina rigid as well as undilatable, and consequently refer
the laceration to mere want of capacity, to overstretching,
and this remark applies to the perinaaum as well as to the
vagina.
In some cases the laceration is not accounted for, and
here I may mention that I know of two cases where the
urethra was unaccountably lacerated in the middle of
its course. In one of these the mother died with ente-
ritic symptoms and albuminuria, and her child about two
days afterwards with a diphtheritic patch on the glans
penis.
I have spoken of indilatability of the vagina, and, in
this connection, it is proper to direct attention to the
demonstrations of Hecker and of others that the well-
known lacerations of the perinsBum have no direct rela-
tion to the bulk of the foetal head. As in the case of the
perinseum so in that of the vagina, mere bulk is an essen-
tial element in the causation, but there is no reason to
hold that the frequency of the laceration is in direct pro-
portion to the mere bulk of the passing head.
Now I come to the peculiar cases which give the title
to this paper. In them there is found in the vagina, on
its side, high up or low down, a rounded aperture, having
a sharp margin. When the finger is passed or pressed
through this aperture it enters a capacious cavity. In
two cases which I have seen recently, both within a few
days after delivery by short forceps, the injury was not
to be explained by direct action of the instrument. The
cavity or abscess was as big as a chestnut or walnut. In
one of the cases the cavity was full of foetid pus, while in
the discharges no foetor was to be detected; no other
LACIBATION OT THE VAaiKA IV LABOUB. 239
cause of fever was discoverable; she died. In another
case with high fever and alarming symptoms there was
at no time foetor of discharges nor of the pus in the
abscess cavity ; she recovered. In the latter case there
was free hsemorrhage after delivery ; it was of short dura-
tion^ not from the uterus^ and was referred to vaginal
laceration. The only peculiarity demanded in treatment
was to keep the contents of the little cavity strictly aseptic.
In the greatest case of thrombus of the vulva^ or rather
hsBmatoma of a labium^ which I have seen> the tumour
was at least as big as the head of a six months' foetus.
In its vaginal aspect there was a lacerated opening an inch
and a half long. It came on at the end of parturition.
The large cavity was emptied of clot and freely suppu-
rated. The woman did well. It appears to me that the
cases now under special consideration own a similar history.
Florinski and others have shown the variations in lacera-
bility of different tissues^ and the same is practically
attested in the post-mortem theatre ; for^ dissecting
women dying soon after delivery^ I have repeatedly found
ecchymosis or small thrombus or hematoma beneath the
mucous membrane of the vagina ; the submucous cellular
tissue had given way while the mucous membrane over it
was entire.
For the production of such cavities as I am here
describing it is only necessary to suppose the occurrence
of such an ecchymosis or hsBmatoma of the vagina and its
suppuration. The opening into the suppurating cavity
may be formed after suppuration or simultaneously with
the formation of the hematoma. In the hematoma of the
labium which I have mentioned^ the lacerated large open-
ing was certainly present^ while the blood was accumu-
lating and distending the labium. If the hasmatoma does
not suppurate it will cause no trouble.
Dr. Hayxs thought the explanation of these interesting cases
was valuable and suggestiye. He had not long ago seen a case
which lent it support. A primipara, over thiriy years of age,
240 LACBRATIOK OF THE VAGINA IN LABOUR.
Bome few days after her coiiflnement, which had been slow but
normal, complaiDed of pain in the vagina and vulva. There was a
short perineal tear. Slight febrile disturbance arose, and vaginal
pain became erfcreme. Upon further examination a semi,
fluctuating swelling the size of a Tangerine orange was felt
in the vagina not far from the orifice. Subsequently a well-
known surgeon was consulted, who thought it was an abscess,
but upon opening, its contents proved to be chiefly blood-clot
mixed with some purulent grumous fluid. Of course Dr. Duncan's
cases might have had a septic embolic origin.
Dr. Glevelaiid was at a slight loss to understand one of the
author's remarks. It appeared that in both cases short forceps
were used, and yet it was thought that in neither could the
laceration be attributed to them. If the author himself had
operated there would have been no need to raise the question,
but he submitted that a strong guarantee was requisite, under
the circumstances, for excluding the probability of a wound
having been accidentally inflicted.
Dr. Hebman had seen one curious case of laceration of the
vagina, one of a class to which allusion was made in the paper,
although that class was not the main su^ect of the paper. It
occurred in a patient with a flat pelvis. The head entered the
brim with its long diameter transverse, and was delivered with
forceps, the forceps being applied in the sides of the pelvis.
After delivering the head and removing the forceps, he was
waiting for some indication of uterine action that he might assist
in the delivery of the shoulder, when he saw the hand protrude
through the anus, the uninjured perineum being between the
hand and the head. Then uterine action came on, and the
shoulder was driven down, tearing through the recto-vaginal
septum from above downwards.
Dr. Champnets had met with two cases, both some years ago,
both in hospital practice, and both fatal from septicffimia. In
one case the forceps was used to terminate labour, for eclampsia,
very little force was necessary. In the other, labour was natural,
and apparently easy. In both, the openings were round and
unlike lacerations. In the latter of the two cases the cavity
looked unhealthy, and the veins starting from the placental site,
and also the internal iliac veins, were full of pus. The cases
struck him as unusual, and he remembered them well.
Dr. BoxALL said that the interesting observation of Dr.
Matthews Duncan brought to his mind a case which occurred at
the General Lying-in Hospital at the beginning of 1884. Though
the first stage was prolonged the labour was otherwise normal
and easy. The patient was a weakly primipara. She died seven-
teen days after delivery. Vaginal examination on the eleventh
day revealed the prebence of a tliickeniug at the roof of the
LACBRATION Of THE VAGINA IN LABOUR. 241
vagina fixing the cervix, but no laceration. In the post-mortem
examination, quite at the upper part of the vagina, and imme-
diately in front of the cervix, were found two holes with clean-
cut edges, each the size of a sixpence, one on either side of the
middle line, and a similar but smaller hole of sufficient size to
admit a goose-quill below and between them. They were found
to intercommunicate, and to lead to a cavity situated beneath
the mucous membrane, and large enough to accommodate a
crown piece. The walls of this cavity were infiltrated with red-
dish yellow material of a creamy consistence. No cause could
be found to account for this condition at the time, and one was
disposed to attribute it to traumatic influence, though no history
pointing to such could be ascertained. The punched-out character
of the holes in a syphilitic subject led one to entertain the possi-
bility of specific ulceration, but no definite conclusion was
reached. Dr. Boxall was now disposed, in view of the observa-
tions of Dr. Matthews Duncan, to consider the cavity as origina-
ting in a hematoma, which had subsequently suppurated and
opened into the vagina spontaneously.
Dr. HoBBOCKB said he had seen two cases bearing on the
question. One was with Dr. Lynn, of Woolwich, in which
tnere was a hematoma between the vagina and the rectum, which
broke down and opened by a pin-hole orifice into the vagina. It
was freely incised, and soon got well. The other was a case in
which the patient complained of great pain on defaecation, and
on examination a lump was felt in the submucous tissue of the
posterior wall of the rectum. He asked if this might not have
been caused by pressure during parturition, the intervening
structures not being lacerated.
Dr. Spsnoeb had seen two instances of the injury described
by Dr. Matthews Duncan. They occurred in primiparsB delivered
naturally. In one (infiammation in the usual situation being
absent) there was induration of the recto-vaginal septum low
down in the middle line, attended by high fever and followed by
the discharge of pus and blood into the vagina from a ragged
cavity by a hole of the size of a pea. This had led him to the
diagnosis of suppurating thrombus. The other case was similar
in situation, but was not observed to the end. If patients were
systematically examined some time after labour, injuries of the
vagina, sometimes unaccompanied by symptoms, would, even in
careful hands, be found more frequently than was generally
supposed.
Dr. Matthews Dttkcan had dissected in Paris several puer-
peral fever cases, and was astonished with the frequency of sub-
mucous vaginal ecchymosis or thrombus. The case of thrombus
of the labium mentioned in his paper showed that blood
might so accumulate to a very great extent while there was a
242 LACIBATIOH OV THB TAaiHA IV LABOUR.
large opening for ite exit. These fiustB were the basiB of his
theory of the peculiar abBceeseB deecribed. He waB familiar with
longitudinal laoerationa of the vagina, spontaneooB and by forceps,
seeing numy of them in consultation when alarming ^mptoms
superrened post partum, and baying obserred them in his piivate
practice. Such lacerations could not be confused with the lesion
ne now described, for in these latter there was no eyidence of
laceration.
243
CHOREA IN PREGNANCY.
By Montagu Handfield-Jones^ M.D.Loiid.,
LBGTVRBH OV MIDWISSBT AHB DIBBA8BB OF WOXBN TO 8T. XABT'S
HOSPITAL KBDIOAL SCHOOL.
(Received May 22nd, 1889.)
The causes which lead to the production of choreic
symptoms are probably numerous^ and the various theories
which have been formulated to explain the causation of
the disease may probably each have their application in
different cases. In this communication the author is de-
sirous of drawing attention to the disease solely when it
occurs in pregnant women^ and even then of illustrating^
by two cases about to be recorded^ only one pathological
process by which the symptoms of the disease maybe caused
and by which they may reasonably be accounted for.
It would seem reasonable to consider chorea occurring
in pregnancy by itself^ since in all such cases there exists
one common groundwork viz. an unstable condition of
the nervous system — a condition always present in and
forming an integral part of the gravid constitution.
Case I . Chorea dnirmg 'pregnancy ; onset ofa^mte mania ;
induction of labour ; recovery. — M. T — y aged 25, married,
primipara, was admitted to St. Mary's Hospital under the
care of Sir Edward Sieveking on April 4th, 1887, suffering
from chorea.
Family history good, no trace of mental unsoundness ;
the patient has never had rheumatism nor any acute illness.
Mrs. T — is said to have had a severe fright a few days
before the onset of the first symptoms of chorea. The
first appearances of the disease were noticed about four
244 CHOBIA IM PBBGNANCT.
weeks previous to admission; at that time she became
'' extremely nervous^'' felt very f atigned^ and at the same
time began to lose flesh ; she foand herself constantiy
dropping things when carrying them in her hands.
When admitted she had severe chorea mainly limited
to the left side^ she was mentally restiess and much troubled
with sleeplessness^ her appetite was very poor and there
was marked evidence of emaciation. Heart normal. Urine
normal. Slight evidence of commencing phthisis in the apex
of the left long. The catamenia had been absent for five
months^ and pregnancy of a corresponding date was found
to be present.
The patient was at first treated with bromide of am-
monium and arsenic^ but she became steadily worse ; the
chorea^ which was at first limited to the left side^. became
general^ her sleeplessness increased^ her appetite failed yet
f urther, and she was manifestly becoming more emaciated.
April 18th.— Thirty grains of bromide of ammonium
with one fiftieth of a grain of hyoscyamine were adminis-
tered three times a day. For a time this led to improve-
ment of the general healthy the patient eating and sleeping
better, though the chorea remained as severe as ever.
May 3rd. — ^As the disease showed no signs of abating
arsenic and iron were prescribed but without effecting any
improvement. About this time the patient began to com-
plain that the patients on the opposite side of the ward
were always watching her and laughing at her ; nothing
availed to persuade her that she was mistaken. Gradually
her restlessness and sleeplessness increased^ the severity
of the choreic movements became more intense^ and great
difficulty was experienced in getting her to take any food.
10th. — Patient's delusions have continued since last re-
port. This morning she became very excited and began
to shout wildly and continuously ; constant watch had to
be kept in order to prevent her getting out of bed and
rushing out of the ward. Once she succeeded in escaping,
and was only captured when half way down the male
medical ward opposite. It was noticed that with the onset
OHOBBA IN FBBGNAHCT. 245
of mental unsoandneBB a distinct change took place in the
choreiform movements ; violent mascalar movements were
constantly present^ but these were the restless stmgglings
of ordinary delirium and not the purposeless jactitations
of choreic origin.
Morphia gr. ^ hypodermically only increased her ex-
citement; hyoscyamine gr. -j^th injected under the skin
soon quieted her and caused her to fall into a deep sleep.
After a few hours she suddenly awoke and began to
rave as wildly as ever^ talking most excitedly^ and
struggling with such maniacal strength to get free that
it required the united efforts of several persons to keep
her in bed. During the night she was only kept quiet
by the repeated administration of hyoscyamine subcu-
taneously.
The day following (May 11th) the maniacal condition was
still more acute^ and the temperature^ which had hitherto
been normal^ rose to 102*8° Fahr. ; the pulse became very
frequent and feeble^ and the patient refused to take food
in any form. Although by repeated administration of
hyoscyamine it was possible to keep the patient under con-
trol^ yet it was evident that this drug was not exerting
any curative influence^ and it soon became clear that the
patient must inevitably die of exhaustion unless further
relief could be obtained. At 10 p.m. the patient's condition
was so critical that Sir Edward Sieveking requested Dr.
Montagu Handfield-Jones to see the patient with a view
to the induction of labour.
For the above notes I am indebted to the courtesy of
Mr. Caley, house physician to Sir Edward Sieveking.
When seen on May 11th at 11.45 p.m. the condition
of the patient was as follows : — G^eneral condition that of
acute mania; at times slight choreic movements were noticed
affecting the face and upper limbs^ the body was emaciated,
the skin sallow, the pulse 140.
As the patient's excited state rendered all examination
impossible, ether was administered, and a careful investi-
gation of the abdomen and pelvis earned out. The ex-
VOL. XXXI. 17
246 CHOUA IN PBSGNANCT.
istenoe of pregnancy advanced to the sixtli month was
dear^ the cervix was small^ the external os not patnloos^
and nothing abnormal could be noted. Signs of early
phthisis existed at the apex of the left long.
As the patient's condition was clearly becoming worse
and any delay could only render the case more hopeless^ it
was decided to empiy the uterus at once.
At 12.30 a.m. on May 12th^ after a vskginal douche of
carbolic lotion^ dilatation with Hegar's dilators was com-
menced ; the cervi:i? proved extremely rigid and great
difficulty was experienced in rendering the canal sufficiently
patulous to admit the smallest size of Barnes's bags. The
rigidity of the cervix rendering further advance almost
impossible^ the Barnes's bag was withdrawn^ and the vagina
having been syringed out^ a soft catheter was passed be-
tween the membranes and the uterine wall and sustained
in dtu by plugging the vagina with antiseptic wool.
Throughout the day the patient seemed somewhat quieter^
but the mania and occasional choreiform movements were
still well marked. Evening temp. 100*9^ Fahr.
May 13th. — ^At 4 a.m. labour had commenced^ the
maniacal symptoms had almost disappeared^ while the
choreic movements were somewhat more marked. The
temperature had risen to 102^ Fahr.
At 8.45 a.m. a severe rigor commenced and lasted for
half an hour^ the temperature rising to 106*8^ Fahr. At
10 a.m. the patient was quite rational^ the choreic move-
ments were less marked^ and uterine contractions had com*'
menced. At 2.15 p.m. the foatus was bom ; it had appa-
rently been dead some time and was highly offensive. After
delivery of the placenta and membranes the uteras was
washed out with carbolic lotion (1 in 100)^ and a mixture
of quinine and ergot was prescribed ; at 10 p.m. aU choreic
movements had ceased^ the woman was perfectly rational
and expressed herself as feeling comfortable^ she took food
exceedingly well and had a temperature of 100^ Fahr. only.
Next day (May 14th) the temperature fell to normal in
the morning and remained there some hours^ but later in
CHOBBA IN PBEGNANCT. 247
the day it rose to 108^ Fahr and remained there till 10 a.m.
on the 16th ; on this last date the lochia became offensive
and all the signs of puerperal septicsemia showed them-
selves. Under the influence^ however^ of intra-nterine
douches^ quinine^ and Warburg's tincture these symptoms
disappeared and a good recovery ensued.
During the height of the septic attack the beneficial
influence of half -ounce doses of Warburg's tincture was
very marked^ — ^they invariably lowered the temperature and
improved the condition of the pulse.
On May 19th the following note was made : — ^' Patient
says she feels quite strong, and wants to go out. The
choreic movements have slightly returned^ especially in the
face ; they occur feebly at times in the hands and arms.
The speech is slow and somewhat indistinct.'' Four days
later appetite was good^ flesh was being put on rapidly,
and the patient was sent back to the medical side.
On June 8th the woman returned to her home perfectly
free from chorea, in her usual mental condition, and im-
proving daily in general health, in spite of the evidence of
early phthisis in her left apex.
Case 2. Chorea d/wring pregnancy, delirium and delv^
sums, paralysis^ recovery, — ^Mrs. L — , aged 19, admitted to
St. Mary^s Hospital November 13th, 1872, suffering with
chorea. She is two months advanced in her first preg-
nancy. About six weeks ago she first noticed unsteadi-
ness in her face, then her hands and shoulders became
affected, then the legs. At present she has continual move-
ments of her limbs and face, and is not free from jumps
and starts in her sleep. Bowels regular; heart-sounds
normal ; rapid pulse ; is losing flesh ; appetite very poor ;
has never had rheumatic fever. Family history good.
November 15th. — Last evening from 7 to 9 p.m. patient
was greatly excited and quite delirious, had delusions, and
informed her mother that she had been dreadfully beaten
and would not stay. Under the use of opiates and bromides
this mental excitement became quieter, and by the 18th
248 CHOBBA IN PBIGNANCT.
she was again rational. Under the administration of
stimulants^ tonics, and generous diet the chorea rapidly
disappeared, and by January 2nd, 1873, she was reported
as well. Soon after this date she left the hospital, but
almost immediately after one arm (left) became paralysed
and remained so until her confinement. After delivery
the paralysis rapidly disappeared, and on July 8th, 1873,
mother and infant are reported to be thriving.
Disorders of the nervous system commonly arise in the
course of pregnancy, especially in the earlier months, but
it is certainly difficult to come across examples in which
severe and varied manifestations of disordered nervous
function are better illustrated than in the cases just re-
corded. The onset of acute mania in the first half of preg-
nancy is rare, still more rare in the disease associated
with or excha^d for chorea. The variation or exchange
of the channels by which nerve force was discharged,
seems to constitute the real interest of this communication.
In pregnancy the nervous system is in a condition of
exalted sensibility, its equilibrium is certainly unstable,
and a slight shock may disturb its working balance. In
Mrs. T — ^'s case a fright seems to have acted as an ex-
citing cause, and soon afterwards evidence of disordered
function was manifested in the motor areas ; this persisted
for over two months, and then, without any apparent reason,
the choreiform movements (which pointed to the motor
centres as the parts affected) gradually ceased, and pa/ri
'passu the higher intellectual centres were attacked and
exhibited signs of violent derangement of function. Soon
after the onset of acute mania indaction of labour was com-
menced; by this means the violent nerve-storm which
shows itself in the phenomena of labour was established,
and it is exceedingly interesting to note that with the onset
of labour pains, both the mania and the remaining choreic
movements abated, and soon entirely ceased; in other
words the outflow of nervous energy had been diverted
into a fresh channel. With the close of pregnancy the
nervous system retamed to its normal condition of more
CHOBBA IN PBiCONANCY, 249
or less stable eqailibrinm^ and farther evidences of dis-
ordered nerve-force ceased.
In the case of Mrs. L — chorea, complicated with de-
lirium and delusions, was present, but yielded to treat-
ment ; here the motor and intellectual centres seem to have
been affected at the same time. Later in the pregnancy
a motor centre is again attacked, but this time ^* disordered
function *' is exchanged for '* arrest of function.** Both
cases would seem to teach the same truth, viz. that dur-
ing pregnancy chorea may arise independent of any organic
lesion, — ^it is the working method of the centre which is
affected and not the tissue structure. The chorea is in
fact a deterioration of function, and may manifest itself by
irregular muscular spasms, by mania and delusions, or by
absolute paralysis.
Dr. JoHis Phillips had seen many cases of severe chorea at
the Erelina Hospital for Children. Two methods of treatment
were usually adopted which had not been mentioned in the
paper just read : nie warm wet pack, which had as a rule a most
marvellons effect in quieting the movements, and forcible feeding
by Faley's bottle if much exhaustion from the disease was pre-
sent. There seemed no reason why these methods should not be
of some service when chorea is complicated by pregnancv.
Dr. HoBBOCKS did not know what deterioration of function
implied except deterioration of the part in action. He considered
there must be some physical basis for the deterioration. The
phenomena in chorea were neuro-muscular, but the pathology
was obscure. Supposing the seat of lesion to be in the nerve-
centres, these might show deterioration of function either by
alteration in themselves or by alteration in the blood supply.
It was his opinion that chorea was a blood disease in its origin.
Its relation to rheumatism was well known, and in rheumatism
there were undoubtedly blood changes; there were in many
instances fibrinous tears on the valves of the heart, and some
authors considered them to be the cause of the chorea through
being washed up to the brain. In works on medicine, pregnancy
was given as one of the causes of chorea, and in pre^ancy the
blood is certainly altered. Fright was a potent factor m the pro-
duction of chorea as it was in the production of hystero-epilepsy,
and he had known it produce genuine epilepsy in a girl where
there was no hereditary predisposition.
Dr. Jahissok doubted if the theory of the preceding speaker
250 CHOBiA nr pbbgvavct.
oonld be correct that chorea is a blood disease, as he knew of
many cases due to friehty the symf^toms coming on immediately
after the shock, and he gare details of sereru cases following
injuries in glass-works to pregnant women, and also of cases
occurring in the wires of colliers whose husbands or relatives
had been injured in colliery accidents. With regard to treat-
ment he strongly advocated large doses of conium, and related a
very severe case he had seen in consultation with Dr. fiicketts,
of Southport, where the use of this remedy had been most
marked in its immediate benefit after the trial and Culure of
arsenic, iron, and many other drugs.
Dr. Hbbicah had been taught as a student that when chorea
occurred in the adult female it was always either in a patient who
had already suffered from it in childhood or who was pregnant.
This fact pointed to a connection between pregnancy and chorea ;
and if pregnancy had anything to do with the production of
chorea, one would expect the emptying of the uterus to be bene-
ficial. He believed that in the majority of cases of chorea in
pregnancy the induction of abortion or premature labour was
followed by marked improvement. This did not occur in all;
and we at present had no criteria by which to distinguish the
cases that abortion or premature labour would benefit from those
that it would not. Such criteria could only be ascertained by
the comparison of carefully reported cases such as those con-
tained in Dr. Handfield-Jones's valuable paper. He could not
follow Dr. Handfield-Jones in his bold statement that there was
no organic change. There might be no change that we as yet
had the means of detecting, but he could not conceive that such
symptoms could exist without some organic change. Such
phrases as " exalted nerve sensibility," and the like, did not seem
to him to convey any instruction ; they were merely saying in
other words that there was something the matter. He could not
at all concur with Dr. Horrocks in thinking that chorea was " a
blood disease." He thought it was a generally accepted law in
pathology that the phenomena of all blood diseases were sym-
metrical. Chorea was usually a one-sided disease. How could a
unilateral change be possibly due to a condition of the blood
which circulated through both sides of the body P
Dr. Amaitd Routh related a case very like Dr. Handfield-
Jones's first case, which was admitted into Charing Cross Hos-
pital under Dr. Pollock in May, 1885. Three days before admis-
sion, the girl, aged 20, unmarried, suddenly developed choreic
movements, and became delirious at night. On admission, there
were violent bilateral choreic movements, dull intellect, indistinct
articulation, but no pyrexia, albuminuria, cardiac disease, nor
paralysis ; there was no previous history of chorea, rheumatism,
or fright. The movements were worse above the waist. Taking
OHOBBA IS PBSGNANCY, 251
food and sleep were alike impossible. She speedily became
exhausted and lay in a typhoid state, but there was no cessation
of the movements except under chloroform, all other drugs
proving useless. At Dr. Pollock's request Dr. Bouth saw the
patient, and finding she was pregnant, determined to try the
effect of Copeman's digital dilatation of the cervix, which had
proved successful in a case of Dr. Makins' Q Obstet. Soc. Trans./
1880). In doing this Dr. Bouth found the fcatus to be lying
transversely tn utero with no membranes intervening, so hooked
down a knee and the fostus came away in a few hours, a fatty pla-
centa following. The fostus was offensive, having evidently been
dead some time. As soon as the uterus was emptied the cnoreic
movements abated, and her mind gradually cleared. In spite of
1 per 1000 intra-uterine mercurial douches the temperature rose
on first day to 101^, and on third day to 104*5^, but was normal
on fourteenth day, and in six weelu she was discharged, being
then free from all twitching, but still very stupid and dull.
The form of puerperal insanity here was one of stupor and low
delirium, coming and going pari pa98u with the chorea. He
thought that the blood-theory of chorea causation as originally
propounded by Trousseau, and alluded to to-night by Dr.
Horrocks, was disproved by the fact that most cases of chorea in
pregnancy occurred during the first three months, when the blood
state was but little altered.
Dr. Matthiewb DuircAir had recently seen a patient in whose
two only pregnancies there was severe unilateral chorea, so
exhausting as to demand induction of labour, in the second preg-
nancy. £i the first, twins were bom alive at the fiftih month.
In both attacks there was no anxiety except on account of weak-
ness. No rise of temperature; no signs of cardiac or renal
disease. Medicine did no good. Becovery after the premature
delive]7 was rapid.
Dr. M. Hakdeibu)- Jokes, in replying, pointed out that in his
communication he had not attempted to discuss the possibility
of chorea depending in some instuices on blood conditions or on
organic changes in the nervous structures; his cases were
quoted solely to show that the chorea of pregnancy was sometimes
an outward sign of deranged function of nervous centres, and
existed quite apart from any appreciable pathological change in
those tissues. He was quite prepared to admit that chorea was
sometimes only one item in the rneumatic series, as Dr. Cheadle
had pointed out in his recent Harveian Lectures, but it could
hardly be shown that this point had any application to the cases
now under consideration. If the chorea had depended on any
lesion of tissue, the interchange between insanity of the muscles,
delirium of the higher inteUectual centres, and paralysis could
hardly have taken place so rapidly.
OCTOBER 2nd, 1889.
Alfred L. Galabin, M.D., President, in the Chair.
Present — 31 Fellows and 2 Visitors.
Books were presented by Dr. Minot, Dr. Oliver, Dr. B.
S. Schnltze, Mr. Lawson Tait, Dr. Tracon, the Council of
University College, the American Gynecological Society,
and the Smithsonian Institution.
Francis B. B. Bisshopp, M.A., M.B.Cantab. (Tunbridge
Wells) ; Frederick Henry Davies, M.B., C.M.Edin. (Til-
bury) ; Charles John Harper, L.R.C.P.Lond. (Finchley) ;
William H. C. Newnham, M.B.Cantab. (Bristol) ; and
Bichard Pinhorn, L.R.C.P.Lond. (Dover), were declared
admitted Fellows of the Society.
The following gentlemen were proposed for election : —
George Henry Burford, M.B., M.C. ; Arthur Hardwick,
M.D.Durh. (Newqnay); James Oliver, M.D., F.R.S.Edin. ;
Harry Marmaduke Page, F.R.C.S. (Wimbledon) ; Thomas
Edward Parsons, M.R.C.S. (Wimbledon) ; and Thomas
Richmond, L.R.C.P.Ed. (Glasgow).
Report on Mr. Pollocks Specimen of OvaHan Dermoid
from a Mare {Exhibited July, 1889).
The ovary maintains its normal shape, and is enlarged
about fonr times the natural size. It is oval in shape,
VOL. zxzi. 18
254 OTABUK DIKMOID PBOM A HASM.
meammng four and s half iocbes in tlie major, and three
and a hait in tbe niiDor axis. A sagittal section sbowe tbe
eDlargement is conliaed to the oopboroo; paroopboron is
Ad OTirian dermoid rrom a iDare.
C. CartiUge.
O. OOphoroo.
p, Faroophoron.
X. A loenla* containing black, c
or tail.
One fourtli tbe size of nature.
le hair, like that of tbe m
of ijormal size, thongb somewhat stretcbed by tbe growth.
Thr (lophoron is composed of cystic spaces ; the walla of tbe
cyst are composed of hyaline cartilage. Some of tbe locali
1
SPECIMENS. 255
are composed of pigmented skin^ three of them contain black
hair of the consistence of the normal hair of the mane or
tail. The hair on the body of the mare was of a dark
chestnut colour. One cavity^ much larger than the rest^
lodged a tuft of coarse black hairs^ many of which sprouted
from the walls of the cyst^ others were free. This parti-
cular cyst measured one inch in diameter. A few of the
cavities were filled with sebaceous material unmixed with
hair. Some large pieces of bone^ with very dense can-
cellous tissuCj invested with very thick periosteum^ were
lodged in the tumour^ so that a saw was necessary in
dividing it for examination. No teeth were detected. The
general appearance of the ovary suggests the notion that
as the ovary became cystic, the cyst walls became trans-
formed into hyaline cartilage. The paroophoron is free
from the cystic growth.
Signed J. Bland Sutton.
0. Stewart Pollock.
Alban Do ran.
SPECIMENS.
Dr. William Duncan showed —
(1 ) The uterus^ rectum^ and left kidney of a woman aged
52^ who died of uraemia. There was complete occlusion
of the cervical canal^ the uterine cavity was distended
with twenty-two ounces of pus ; there was pus in the
Fallopian tubes. The rectum showed extensive syphilitic
ulceration. The kidney was the subject of pyelo-nephritis,
and the left renal artery was thrombosed.
(2) Dermoid ovarian tumour removed from a patient
aged 26.
(3) Simple ovarian cyst.
256
BLUE URINE. CYANURIA.
Shown by John Phillips, B.A., M.D.
The patient^ aged 28^ and recently married^ had been
ander observation for six years^ and daring that period
had had three attacks o£ passage of blue arine ; the first
had been observed when in its decline^ the second and
third through their whole course^ and the specimen shown
was drawn by catheter daring the last attack.
The first indication of the approach of the trouble was
a greenish-brown- coloured urine^ when passed, which de-
posited^ on cooling, a similar-coloured precipitate; the colour
deepened^ and at the end of a week became bright cobalt
blue, and then faded gradually again to a greenish-brown
tint.
For the purpose of preservation, the specimen was
boiled immediately on drawing it off, and the cork of the
bottle covered by cotton wool. There was no possibility
of deception being practised. Moreover, the patient was
herself most anxious about her condition and was con-
stantly under the surveillance of her mother. She was
taking no drugs at the time of either attack, and there
was no connection between their onset and the catamenial
discharge.
An exhaustive examination by Mr. Stillingfleet John-
son proved the dry colouring matter to be probably an
indigo, possibly produced by transformation of an unusu-
ally large quantity of Indican. Braconnet, who first de-
scribed this condition, believed it to be a transformation
of uric acid, less oxidized than urea.
Dr. Cleveland asked Dr. Phillips how long the attacks of
cyanuria lasted.
Dr. Phillips replied a fortnight.
257
HEMATOSALPINX AND INTRA - PERITONEAL
HEMATOCELE PROM RUPTURE OF A VARI-
COSE VEIN ON THE INNER SURFACE OF
THE RIGHT FALLOPIAN TUBE.
By C. J. CULLINGWOETH, M.D.
Db. Cullinowobth, in exhibiting the specimen^ stated
that it had been romoved by abdominal section from a
patient^ aged 26, under his care at St. Thomases Hospital.
Five weeks before her admission she was suddenly seized,
while walking in one of the parks, with severe faintness
and loss of consciousness. She had not menstruated for
ten weeks and believed herself to be pregnant. On
reaching home she discovered that a slight haemorrhage
was taking place from the vagina. This continaed up to
her admission, at no time exceeding in quantity or differ-
ing in character from the ordinary menstrual flow. On
admission there was discovered a considerable swelling
behind and to the right of the uterus ; the swelling in the
middle gave the physical signs of a haBmatocele, that on
the right of the uterus was smooth and rounded, and was
diagnosed as a hasmatosalpinx. On opening the abdomen
seven ounces of soft dark clot were found behind the
uterus, encysted by recent peritoneal adhesions. The
inner portion of the right Fallopian tube was of normal
calibre ; the outer inch-and-a-half was dilated and funnel-
shaped, the dilatation being greatest at the fimbriated
extremity, which was wide open. This dilated portion of
the tube was filled with a firm dark clot, the clot hang-
ing from the open end of the tube and being continuous
with the intra-peritoneal effusion.
On the inner surface of the dilated tube was a circular
opening, a third of an inch in diameter, with raised edges
and lined with adherent blood-clot. On careful dissection
this was found to be due to rupture of a varicose vein. There
258 ACEPHALOUS AOABDIAC MONSTIB.
was a second and somewhat similar^ bat smaller and older^
opening on another part of the mucons lining of the tube^
which, on dissection^ was found to lead to a small cavity
with blood-stained walls. No vessel could be traced com-
municating with this cavity. It was suggested that this
might be of similar origin to the more recent lesion^ the
vein having become occluded, and that in all probability
it bore the same rela.tion to a retro-uterine hasmatocele for
which the patient had been under treatment at St. Thomas's
three years previously^ as the more recently ruptured vein
did to the present attack. The uterus was of normal size
aud empty. The clot was carefully examined for festal
products^ with negative results.
Dr. Amakd Bouth drew attention to the fact that this speci-
men showed clearly that intra-peritoneal hematocele may occur
apart from rupture of an extra-uterine fcetation, which is denied
by some recent writers on the latter subject.
AN ACEPHALOUS ACARDIAO MONSTER OF SIX
MONTHS' GESTATION, WITH RUDIMENTARY
HEART.
By Mb. Woodlky Slyman for Mk. W. D. Slyman.
Mas. A. B — , a Jewess, aged 83, a fine, well-grown
woman, good looking, with black hair, and healthy. Former
children well formed and healthy. This is her third ges-
tation. Last menstruation January 5th, 1889. No mis-
carriages.
On July 4th, 1889, a slight sanguineous discharge, no
pains, and she continued her duties as a shopkeeper.
On the 18th Mr. Slyman was sent for at 9.30 a.m.
Scarcely any pains, and on vaginal examination the cavity
was found distended with membranes containing fluid ; the
ACEPHALOUS ACABDIAC M0N8TKR. 259
OS could not be reached^ nor any presentation diagnosed.
The aterus and contents were high up and normal in the
abdomen.
At 11 a.m. the membranes ruptured^ and copious dis-
charge of liquor amnii (about three quarts) followed. On
vaginal examination no presentation could be detected^ but
apparently a second bag of membranes.
At 1 p.m. foetus No. 1 expelled, breech presentation
with a funis remarkably small and about three inches in
length.
1.15 p.m. a second foetus was expelled, also breech
presentation ; hydrocephalic but otherwise normal.
A single placenta (not large), to which both cords were
separately attached, was expelled after an interval of
twenty minutes. No hssmorrhage and very few after-
pains. The mother made a good recovery.
Description of foetus* — Length seven inches. Like its
twin, of the male sex. It was born at the sixth month.
The skin over the whole body was smooth at birth,
though it is now corrugated by action of the spirit, and
has beneath it a layer of gelatinous connective tissue
measuring half an inch in thickness. The connective
tissue forms a thick pad over the thorax.
The monster has well-developed legs, except that the
toes are only four in number on the left foot and two on
the right. The upper extremities are absent, and do not
seem to be represented by even a cartilaginous rudiment.
The umbilicus is well formed, and has projecting from
it the remains of the umbilical cord. An inch above the
umbilicus are two apertures placed symmetrically on either
side, about a quarter of an inch from the middle line.
That on the right side is small, and appears to end blindly,
as a bristle can only be passed into it about one tenth of
an inch. On the left side the aperture is larger, and con-
tains a f oliaceous mass of tissue.
The thorax is rudimentary, and consists of six or seven
ribs on either side ; there is no sternum, and there are no
thoracic organs in situ.
260 ACBPHALODS ACABDIAC HOMBTBB.
The heart (r. h.] is situated in the gelatinous tisBueforming
the body wall and upon the right side. It lies in a cavity
which is hollowed oat o£ the tissue surrounding the organ,
and consists of a solid mass which is roughly fashioned
into the semblance of two rudimentary auricles and a single
ventricle.
A small and bent canal leads from the upper part of
the pericardial cavity into the surrounding tissue. It has
no connection with the heart, though it appears to be a
vascular channel, possibly representing the primitive aorta.
A single delicate band of tissue traverses the pericardial
sac. The intestine begins' blindly, the blind extremity
being attached by a ligament to the axis of the foetus.
The blind extremity appears to correspond with the dao-
dennm.
ACBPEALOUS ACABDIAC MONSTBB. 261
The small intestine is well developed ; there is a vermi-
form appendix and also a caDcum which is as usual situated
on the right side. The large intestine is of usual length
and terminates in an anus.
There is a large gland occupying the whole of the upper
and back part of the thorax and abdomen^ which has coming
off from it two ureters^ one from either sideband is therefore
a fused kidney.
The testes are situated in the abdomen immediately
above the internal abdominal ring. The bladder is pre-
sent and terminates in the urachus. There is a well-
developed penis and scrotum. The spleen is extremely
small and lies above and to the left side of the kidney.
There is no trace of the suprarenal bodies^ liver^ stomachy
or pancreas.
Lying in a cleft in the median line of the kidney is an
elongated and apparently solid gland which does not ap-
pear to have any duct. This gland is one inch long and
lies in the long axis of the abdominal cavity.
The spinal column is well formed and terminates in a
round extremity situated at the upper limit of the thorax.
Its cavity encloses a cord enveloped in membranes. The
intestines are filled with epithelial cells^ fat, and a great
many kreatin crystals.
The specimen is preserved in the Museum of St. Bar-
tholomew's Hospital, Teratological Series, No. 3435 B.
Mr. Albak DoBAir was glad to find that Mr. Slyman had
recorded both the circumBtances attending the delivery of the
monster, and also its anatomical characters, with such minute-
ness. Mr. Doran had given a demonstration of acardiac monsters
in January. It was published in the current volume of the
' Transactions,' p. 4. Mr. Slyman's monster was an example of
acardiacus anceps or paracephalus, and, as is the rule in that
variety, a rudimentary heart was present. The cord of the
monster was inserted into the placenta near the attachment of
its brother's cord, and not into its brother's cord direct. Hence
its circulation must have been carried on through anastomoses
between its umbilical vessels and those of its brother in the
placenta. This accounted for the relatively high degree of
262 ACBPHALOUS ACAEDIAC MONSTBB.
development iu the monster, especiallj as regarded its circula-
tory system.
He further maintained, contrary to the opinion of another
speaker, that a monster of this class was still an acardiacus,
although it had a rudimentary heart. A scientific term was a
symbol, a means of denomination, and not a definition. The
term "acardiacus" was applied to a certain class of monster
which was always a twin, and always connected through its cord
or umbilical vessels with the cord of a strong, generally well-
formed embryo, the heart of which carried on the circulation in
the monster. The fact that a rudimentary heart existed in the
anceps or paracephalus variety was well known, and scientific
authorities never hesitated to include that variety in the group
of acardiac monsters.
DOUCHE CAN.
By John Shaw, M.D.
263
A CONTRIBUTION TO THE ANATOMY OF THE
PELVIC FLOOR.
By G. Ernest Herman, M.B.Lond., F.R.C.P.,
OBBTBTBIO PHYBIOIAIT TO TBB LONDON HOSPITAL.
(Received Jane 25th, 1889.)
{Abstract.)
Ik this paper measurements are detailed which show the great
normal variations in the conformation of the parts which form
the floor of the pelvis. It is shown that the projection of the
pelvic floor varies from none at all to as much as two inches, and
that in healthy nuUipane the distance between the coccyx and
anas, the length of the perinsum, the distance between the
foorchette and the symphysis pubis, and the length of the
vagina, are subject to wide variations. It is pointed out that
since these variations exist in healthy nuUipane, peculiarities
observed in parous women should not be assumed to be changes
due to childbearing unless it has been ascertained that they were
not present previous to pregnancy. The clinical importance of
these anatomical variations, in their bearing on the liability to
rupture of the perimeum and to prolapse^ the adjustment of pes-
saries, aud some forms of dyspareunia and sterility, is pointed
out.
I have made a number of measurements in order to de-
fine more accurately the changes in the pelvic floor which
are the initial stage of prolapse. Measurements of change
imply a normal or standard condition, of which the change
is an alteration. In this paper I propose to state what
my measurements teach as to the normal or statical anatomy
of the pelvic floor. In a subsequent communication I
264 ANATOMY OF THE PBLYIC FLOOR.
shall put before the Society what they show as to its
changes under increased pressure from above.
All the measurements summarised in this paper were
made while the patient was at rest and recumbent in the
left lateral position.
First, as to the projection of the pelvic floor. This means^
using the words of Foster,* " the distance from the plane
of the pelvic outlet to the most prominent part of the over-
lying soft parts/' The only measurements to determine
this with which I am acquainted are those of Schroeder
and of Foster. Schroedert measured from the coccyx to
the pubes with callipers, thus getting the direct line, or
the chord of the arc, and then measured with a tape over
the soft parts. The average chord he found to be 8*72
cm. : the average measurement over the soft parts 13 cm.
Foster, drawing a diagram from these measurements,
and measuring the projection on this diagram, finds it
amount to 4*1 cm. Foster"^ has measured in a more ac-
curate way, with callipers specially constructed for the
purpose. His estimate is 2 cm. He therefore thinks
Schroeder's too high. Dickinson^ gives the result of
some measurements, he does not say how many, according
to which it is 2*6 cm. and increased by tight corsets to
3-7 cm.
My measurements were made with the primary intention
not of determining the actual projection, but of ascer-
taining the behaviour of the pelvic floor under strain ; and
for this purpose it was more important that different
measurements in the same case should be made between
the same points, than that they should be from identical
points in different cases. Therefore I measured, not from
the same point in every case, but from the point most
easily identified in the particular case, and this point
was often behind the coccyx. There was another reason
for measuring from a point behind the coccyx, viz. the
• < American Journal of Obstetrics/ vol. xiii, 1880, p. 36.
t * Archiv fiir Gyn./ Band ix, S. 80.
I * New York Med. Journal/ 1887, vol. ii, p. 518.
ANATOHT 07 THE PBLYIC FLOOB. 265
fact that the tip of the coccyx sometimes descended during
effort^ and therefore that if this bone were used as a point
for measurement^ the fnll amount of descent might be pre-
vented by the pressure of the end of the measuring tape
on the coccyx.
For these reasons many of my measurements are from
points a little above the plane of the outlet^ and an esti-
mate of the projection of the pelvic floor based on them
errs by being a little too high. It is erroneous to a very
slight extent^ becanse owing to the sacro-coccygeal curve
the lower end of the sacrum and the coccyx run so nearly
in the plane of the pelvic outlet that often a point a good
deal behind the tip of the coccyx is yet very little above
the plane of the outlet. The projection which is obtained
from my measurements is therefore (keeping as closely as
possible to the words of Foster's definition) the distance
from the plane of the pelvic outlet, or one a little above it,
to the most prominent part of the overlying soft parts,
I have measurements of forty-seven cases^ taken both
directly^ with callipers^ between the points measured
from, and also over, the soft parts, with a tape. The
average distance from the lower part of the symphysis
pubis to the point of the sacrum or coccyx from which the
measurement was taken is 10*66 cm. The average distance
over the convexity of the soft parts is 13*3 cm. I have
made a diagram from these figures, as Foster has done
from Schroeder's, and find the projection to be calculated
about 3'2 cm."^ But, as I have said, this is erroneous in
* This method of obtaining the projection, by drawing a diagram of the
chord, the arc, and the perpendicular, and measuring, is a very rough one.
But it is not certain that the curve of the pelvic floor is a segment of a
circle : the measurements of the chord and the arc cannot be made with
mathematical accuracy ; and such accuracy is not at all necessary. It requires
a long and intricate calculation to find the length of the perpendicular, the
chord and the arc being given. The formula for calculating it (for which I
am indebted to Mr. R. A. Herman, M.A.) is A = chord; B=arc; D^perpen-
dicuUr; then D= i ^ 6 B (B-A) (l— ^ 5=^).
In the case given this would give a result (supposing the curve to be the
segment of a circle) correct to within *001.
266 ANATOMY OF THE PELYIO FLOOR.
making the projection appear too great. I am therefore
inclined to agree with Poster in thinking Sohroeder's
measarements exceptional, and the estimate of the projec-
tion based on them too high.
But a close examination of the figures shows that the
constraction of averages, however rough, is of little use as
a representation of what is normal^ because individual
cases differ so widely from one another. Just as in dif-
ferent people there are differences in the conformation of
the nose, the ears, the hands, the feet, &c., so are there
in the construction of the pelvic floor.
Thus in one case there was no projection at all, the
soft parts running in a straight line from one bony point
to another, the measurement with callipers being the same
as that taken with a tape over the soft parts. In another
the direct measurement with callipers was 13*4 cm., and
that over the soft parts 18'1 cm., a proportion of 1 to 1'35,
giving a projection of about 5*4 cm. It may be that in
this case the apparently high projection was due to the
measurement being taken at a point above the pelvic
outlet. But in another the direct measurement with
callipers was 9*5 cm. (one which cannot have been much
above the pelvic outlet), and that over the soft parts
14*7 cm., a proportion of 1 to 1*55. These measurements
give roughly a projection (calculated) of 4*65 cm.
The general conclusion to which I come is that while
Foster's result probably nearly represents the average,
yet there are very wide differences between different
cases, ranging from no projection at all to a projection of
two inches or more. One of the conditions on which these
differences depend is the amount of fat present. A slight
projection is seen in thin subjects.
Foster* has taken the trouble to measure the perinaeum
in 133 cases, sixty -five nulliparous, sixty-eight parous
women. The length of the perinaeum in parous women,
being modified by the greater or less extent of laceration
during delivery, does not show what can be considered a
normal state of things. Foster found the average length
• Op. dt.
ANATOMY or TBB FELTIC PLOOB.
Mtamrtmenli.
I. Along cOTTe of aoft purls .
. Pelvic floor projection
. Coccyx to inoB .
. Perinaum . . . .
268 ANATOMY OF THB PELVIC FLOOR.
of periti89um in sixty-five nulliparas to be 2*7 cm., the
longest being 4'6, the shortest 1*6 cm. I find the average
of twenty-seven nulliparae to be 3'7 cm., the longest being
5*5 cm., the next longest 5*1 cm., the shortest 2*4 cm.
In sixty-eight parous women Foster found the average
length to be 2*5 cm., the longest being 4*4 cm., the shortest
1*2 cm. In thirty-eight parous women (cases of rupture
into rectum being excluded) I found the average length
was 2*6 cm., the longest being 4*7 cm., the shortest 1*5 cm.
' Quain^s Anatomy ^* gives the length of the perinasum as
about an inch. Hart and Barbourt give the antero-pos-
terior measurement of the perinsBum as three quarters of
an inch. Bamesf gives it as " an inch or more.^^ Spiegel-
berg§ says it rarely measures more than 3 cm. Leishman||
puts it as " usually an inch and a half .^' Cazeaux^ says
'' scarcely an inch to an inch and a half.''
The measurements here adduced show that the perineum
is subject to variations, like other parts of the body, and
that its length varies from five eighths of an inch to two
inches, the average being about an inch and an eighth.
They also show that the diminution in length produced by
the unavoidable injury in labour is, as a rule, very slight.
Foster has measured in a number of cases the distance
between the coccyx and the anus. He finds 4*5 cm.
as the standard distance from the tip of the coccyx
to the anus in the well-formed adult nullipara, and 4*7
cm. in women who have born children. Most of my
measurements, for the reason already given, do not afFord
information on this point. I have measured seven to
compare with Foster ; four nulliparae, in whom it averaged
5*4, three parous, in whom it averaged 4*5. It varied from
6*75 to 2*5.
To complete the picture of the parts closing in the pelvis
* Ninth edition, p. 699.
t ' Manual of Gynsecology/ 3rd edition, p. 38.
X * Diseases of Women/ Ist edition, p. 63.
§ * Midwifery,' N. S. S. Trans., p. 25.
II ' Midwifery,' 3rd edition, p. 40.
f * Midwifery,' trans, by Bullock, p. 67.
AHITOKT OF TBI FKLTIO ILOOB.
Fis. S.— DUgnm to ihow one extreme of normal vuiktion in
■mngement of ptitM fonnitig pelvic floor. Drawn to icale from
■nouureiMnta in a patient, oninanied, nt. SI.
Maatmrt m a m tt,
S. Coeoyi to pnbei direct .8 ba. Point on lacmm to anu . t
S. P<dnt on lacnim to polMt, a d. Ferinanm . . .4
dn«ct ■ ■ .12 Anterior opening . C
B. Point on ucmm to pobci, V, Ueatni urinarioi I'S em. in
over wft part* . . 14'S front of poaterior border
Fn^eotion • • . Z'B of lymplijiii pnbii.
270 AMAHOMY or THS PKLTIC lUMK.
below^we want similar preciBi0ii as to tihedistaaioe between
the f ourchette and the symphysiB pabis, or what I may
call the acterior opening of the pelTie floor. Foster's
measorements do not help as to estimate this. I find
that in thirty-six nullipara this distance aTeraged 2*19 cm.^
in seventy-fonr parous women 2'9 cm. This difference
between the parous and the nnlliparous is cleaily due to
shortening of the perinapnm from injury during childbirth.
The average recession of the fonrchette from the pubes
due to childbirth is^ according to these measurements,
about '7 cm. The average shortening of the perinsBum
from child-bearings according to my measurements and
Foster's^ is about *41 cm*, so that shortening from lacera-
tion does not entirely expkkin this recession. Foster found
that in parous women the distance from coccyx to anus
was on the average lengthened by about '2 cm. This
lengthening is probably due to a small amount of the
stretching which the part undergoes during labour re-
maining permanently. The stretching during labour is
not only in the antero-posterior direction, but also trans-
versely. If we assume some of this transverse stretching
to permanently remain, it will account for the recession of
the fourchette from the symphysis pubis. The differences
which call for this explanation are very slight, and it is
possible that they may be fortuitous, but the explanation
is so probable that I think they are real, and produced
in the manner suggested.
But the differences in the size of this anterior opening
in different cases are quite as great as those in the length
of the perinsBum and the projection of the pelvic floor.
In some cases the fourchette was so close to the pubic
arch that the measurements from sacrum to fourchette
and from sacrum to pubic arch were identical ; and in others
the distance from fourchette to .pubic arch was 1, I'l,
1*2, and 13 cm. On the other hand, in one nnlliparous
woman the fourchette was 5'5 cm. from the pubic arch.
This, as might be expected, was associated with shortness
of the perin89um^ which here only measured 2*4 cm«
AHATOUY or TBB PBLVIC 7L00B.
Via. S. — Diigntm to ihow «aother eztrsm* or normkl tuUUod
in pRrt* ronnioff pilf io Boor. Drawn to Male from meamremsDta
Id a patient, nnmarried. Est. 23.
AfeaMamnenU.
B B. Point on eoccjx to pabei,
diract . . . .9-5
a s. Point on coccyx to pnbea,
over aoft parti . . 12-S
) 1. Point on coceji to ai
t 1. Perinsum .
I D. AnterioT openiug
272 AHATOMT or THC PSLTIC FLOOB.
Putting together the averages of nnlliparsB, we get the
following as the average construction of the pelvic floor :
Coccyx to anuB (Foster)^ 4*5 cm. ; perin»am (Foster and
Herman)^ 2'9 ; anterior aperture (Herman)^ 2*4 (Fig. 1).
But taking extreme measurements we get the following
contrasted conditions : Coccyx to anus (Fost-er)^ 8 cm. ;
perinfl9nm (Foster)^ 1*6 ; anterior aperture (Herman)^
5*5. Opposed to this is the following: Coccyx to anus
(Foster)^ 6*1 ; perinssnm (Herman)^ 4*5 ; anterior opening
(Herman)^ (Figs. 2 and 3 are diagrams taken from
measurements of actual cases showing these contrasted
conditions).
I think these differences have some clinical importance,
although I cannot at present adduce measurements in exact
demonstration.
1. We find in practice that the amount of difficulty in
finding a vaginal pessary of a shape which can be retained
and will support the uterus varies very much. In some
cases almost any kind of pessary will remain in the vagina
without pressing injuriously. In others most pessaries
slip out. I believe that the difference between the two
kinds of cases here alluded to somewhat depends upon
the conformation of the pelvic floor. The further forward
the perinasum extends, and the more nearly the axis of the
vagina approaches the horizontal, the more easily will it
retain a pessary.*
2. Various changes have been described as due to
injuries of the pelvic floor produced in childbirth. The
wide differences in the conformation of the parts forming
the floor of the pelvis which these measurements demon-
strate to exist, make it evident that no inferences as to
the connection of a particular conformation of the pelvic
floor With a special parturient injury should be accepted
unless the patient has been examined before as well as
after parturition.
• In the ' Lancet/ 1888, yol. i, p. 895, is a notice of a paper by Dr. Rafael
Weisi, amnmarizing measurements made by bim on coloured women. I hare
not been able to read the original.
ANATOMY OF THB PELVIC ILOOB. 273
8. Barnes mentions as a cause of dj^sparennia in his
experience''^ that '' the pubic arch was unusually deep, and
continued so far back that the vulvar fissure was carried
far behind the normal seat/' It is not clear what the
precise change was which these words are intended to
indicate ; but looking from this point of view at the
measurements I have submitted^ it will be clear that the
closeness with which the posterior segment of the pelvic
floor approaches the symphysis pubis must affect the
greater or less difficulty with which coition is accom«
plished. I think it is also one of the conditions which
has to do with the phenomenon known as '' profluvium
seminis/'
4. It is also probable that the liability to rupture of
the perinsBum in delivery^ and especially to the form known
as central rupture of the perinnum, may vary with the
distance forward to which the fourchette extends.
I have measured also the length of the vagina. This
was done by pushing a spatula as far as it would go into
the anterior and posterior vaginal cul-de-sacs respectively.
Then^ having allowed the elastic recoil of the parts to push
the spatula back as much as it would^ the distance to
which the spatula entered was measured by applying
the back of the last phalanx of the thumb to the perinsBum,
and the thumb-nail to the spatula. In this way the distance
from the vulval orifice to the vaginal cul-de-sac was ob-
tained.
In seven fey-three parous women the average length of
the anterior vaginal wall was 7*5 cm., that of the posterior
9'8 cm. The longest vagina measured 10*8 cm. along the
anterior wall, 14 cm. along the posterior. The shortest
was 5'2 cm. along the anterior, 7 cm. along the posterior
wall. In thirty-two nulliparss the average length of the
anterior wall was 7 cm., of the posterior 9*4 cm. The
longest measured 9*5 cm. along the anterior wall, 12*1
cm. along the posterior. The. shortest was 5*3 cm. along
the anterior wall, and 8 cm. along the posterior.
* ' Diseases of Women/ 1st edition, p. 104.
274 AKATOKT OF THI PILTIC 7L00B.
It tlms appears tliat pregnancy produces on the average
a slight increase in the length of the vagina; in other
words, that a slight degree of snbinyolation of the vagina,
as well as of the nteras, is common.
Different authors give different figures for the length of
the vagina. Thus, according to Spiegelberg, the anterior
vaginal wall is 5 to 5'5 cm. ; posterior, 7 cm. Hart and
Barbour, anterior, 5 ; posterior, 7*5. Leishman, anterior,
4 inches; posterior, 5 to 6 inches. Sappey (quoted by
Oourty), anterior, 7*5 cm. ; posterior, 9'5 cm.
Measurement of the vagina has some practical utility,
I find that, as a general rule, the size of a ring pessary
which will suit a patient is one having a greatest diameter
one inch shorter than the posterior vaginal wall. This
rule does not universally hold good, but it does of most
cases. No such rule can be devised for any pessary that
is variable in shape, for in such the shape given to them
modifies the extent to which they stretch the vagina.
Those who are practised in the use of pessaries can gene-
rally judge pretty correctly without measuring, but persons
inexperienced in the use of pessaries may find the rule I
have given useful.
The chief worth of the measurements summarized in this
contribution is that they may help to make current repre«
sentations of the ai^atomy of the parts more correct, by
showing the variations in the construction of the pelvic
floor in different subjects. There is no part of the body
in which we find absolute uniformity in all subjects. The
uterus, for instance, may be straight or anteflexed, and it
may be nearer one side of the pelvis than the other. The
measurements here given show that the vagina varies in
length, the perinsQum varies in length, the distance of the
anus from the coccyx varies, the closeness with which the
fourchette approaches the pubic arch varies. The usual
limits of these variations are here defined more exactly
than has been done before.
ANATOMY or THE PKLVIC FLOOR. 276
Table of Meaauremenie,
Maximuni. Mininmni. Avenge.
Ftojection of pelric floor ... ... 6*4 less than 8-2 cm.
PerinsBam (nuUipare) ... ... 6-6 2-4 87 cm.
w (pww) ... ... 4*7 1-6 2-6 „
Coccyztoaniif ... ... ... 6*76 2-6 4*6
Foarchette to pubic arch (nullipara) ... 6*6 2*19
» », (pKna) ... 6*4 '2 2*9
Anterior Taginal wall (nnllipara) ... 9*5 6*8 7
» M (V^rtd) ... 10-8 5*2 7*5
Posterior „ (nnlliparo) ... 12*1 8 9*4
M f» (para) ... ... 14 7 9*8
M
Schnltze, in his work on ' Uterine Displacements ' (tr. by Macan, p. 87),
gives meaenrements of 30 cases, 15 pregnant, 15 not, made to determine the
difference between the direct measarement and that taken over the soft
parts. He has not estimated the projection. His measurements are not
strictly comparable to mine, for he measured from the extremity of the
coccyx to the preputinm clitoridis — a point more variable and less definite than
the lower border of the symphysis. He gives the average of his measure*
ments, but no account o£ the variations. The average distance from coccyx
to anus he finds 5*9 cm., average length of perinsBum 8*8 cm. I regret that
I have omitted mention of this in the proper place.
276 OH TBI CHAHGIS JX TEX PSLVIC ILOOB WHICH
ON THE CHANGES IN THE PELVIC FLOOR WHICH
ACCOMPANY THE SLIGHTEE DEGEEES OP
PROLAPSE.
By G. Ernkst Hkbhan, M.B.Lond., F.R.C.P.,
OBSTITBIC PHT8ICIAV TO THB LOHDOV HOBFITAI^
(Beceiyed June 25th, 1889.)
{AbstrCLct.)
Ths author describes the descent of the peMc floor which
takes place during effort in health, and is morbidly increased in
prolapse. Measurements are given which show that this descent
in health probably does not exceed three quarters of an inch.
This descent takes place partly by stretching of the sacral seg-
ment of the pelvic floor in an antero*poBterior direction, and
partly by its recession downwards and backwards from the sym-
physis pubis, a movement which implies transverse stretching.
In the antero-posterior stretching, the perinsBum and the part
posterior to the anus take part to about the same proportionate
extent. This normal descent of the pelvic floor is accompanied
with descent of the uterus into the vagina to the extent of about
five eighths of an inch. These changes may be morbidly in-
creased, and their relative extent morbidly altered. The descent
of the pelvic floor may exceed two inches. This morbid increase
of descent of the pelvic floor may be present without increased
descent of the uterus into the vagina. In other cases it may be
accompanied with descent and protrusion of the anterior seg-
ment of the pelvic floor, with or without the uterus. In such
cases, when a protrusion at the vaginal oriflce has taken place,
further effort increases this protrusion, but does not increase the
descent of the sacral segment of the pelvic floor. Backward dis-
placement of the uterus is often present without more descent
ACG0MPAK7 THE BUOHTSB DEGREES OF PROLAPSE. • 277
of the uteniB or of the pelvic floor than is present in most
healthy women ; hut in most cases of backward displacement of
the uterus the descent of the uterus and pelyic floor is increased.
Backward displacement of the uterus is not associated with
shortness of the vagina.
Although the symptoms of descent are usually relieved by
suitable mechanical supporti yet the amount of descent of the
uterus or of the pelvic floor is not the measure of the severity of
the symptoms. There may be symptoms with slight descent in
some patients ; much descent without symptoms in others ; and
in the same patient the symptoms may be present at one time
and absent at another, although the amount of descent has not
varied ; showing that the symptoms are conditioned more by the
state of the nervous system than by the local mechanical changes.
The well-marked clianges of the larger degrees of pro-
lapse and procidentia have been often described^ and are
familiar to the profession.
The difFerences of opinion which exist about the patho-
logical importance of versions and flexions of the uterus
centre a good deal round the questions whether these so-
called displacements are frequently associated with descent
or not. Some think that they are almost always associated
vnth descent^ and that the descent is the cause of the
symptoms ; others, that the versions and flexions often
cause symptoms vnth out descent. The descent in the
cases about which there is dispute is admittedly slight,
and because it is slight there are two opinions about its
existence.
There is a certain amount of descent which is physio-
logical. With respiration there is a slight regular ascent
and descent of the pelvic floor, and during muscular effort
a more considerable descent. The amount of this descent
is different in different persons, and I think probably also
in the same person at different times. Prolapse is the
condition in which this physiological yielding is increased.
The changes usually produced under great increase of the
intra-abdominal pressure are in this condition brought
278 ON THB CHANGES IN THE PELVIC FLOOB WHICH
about by only sliglit increase of pressure ; and great in*
crease of pressure produces further changes which do not
occur in a normal state of things.
Disputed questions about the frequency of pathological
descent can only be settled by measurement of the amount
of descent in diiferent cases, and by ascertaining what is
the amount of descent which normally takes place.
It is the object of the present paper to describe more
exactly than has been hitherto done the slighter degrees
of descent, and to show how they may be measured and
recorded. I prefer to speak of the '' slighter degrees '^
rather than of the '' beginnings '^ of prolapse ; because to
speak of the " beginning " implies that the process is a
progressive one, and with the slighter degrees of prolapse
this is not always the case.
It has been recognised by some, but not with equal
clearness by all, that there is no such thing as descent of
the uterus by itself. Descent of the uterus implies change
in other parts of the pelvic floor. Sometimes the pelvic
floor descends without much change in the relation of its
component parts to one another. In other cases the uterus
or the bladder is the part which first and most descends.
The present paper is based upon measurements made
in order to ascertain the amount of these changes with
greater precision than has been done before. The cases
which I first selected for this investigation were such as
came for treatment on account of symptoms such as go
with prolapse. I afterwards included other cases in which
no symptoms of that kind were present, and some in which
there were no symptoms at all referable to the pelvic organs.
The cases averaged do not include any in which the uterus
was outside the vulva. The measurements were made
while the patient was lying on her side. The distances
between the different points were first measured without
any special instructions being given to the patient. Then
she was told to bear down as much as she could, and then,
at the height of this effort, the distances between these
points were again measured.
ACCOKFAMY THE BLIOHTKB DEGBKES OF FBOLAPSB. 279
It is not pretended that tHese measurements are more
than approximately correct. The parts measured are not
bounded by such definite lines that small differences can
be much insisted on. The amount of alteration produced
by straining depends on the vigour of the effort ; and
this depends not only upon the patient's will, but also
on her nervous and muscular tone at the time. The
increase in the intra-abdominal pressure which the patient
can produce by straining while lying on the side^ without
the reflex stimulus of a body calling for expulsion^ can
seldom if ever be so great as that produced during strong
effort in the erect posture. Therefore I do not regard
the increase in the pelvic floor projection which my
measurements .show as representing the maximum which
takes place. But this consideration does not invalidate
conclusions drawn from the comparison of different cases
measured in the same way. In some few cases, either
from the patient's not understanding what she was asked
to do, or from timidity, or from weakness, she could not
be got to strain enough to make any alteration in the
measurements. These cases are not included in the
averages which follow. Although perfect accuracy in the
measurement of these changes is impossible, yet a de-
scription expressed in figures, and checked by as close
measurement as possible, gives a clearer and more nearly
correct picture than can be obtained in any other way.
I shall first speak of the cases collectively, and then
of the differences between different classes of cases.
The average increase, under strain, in the measure*
ment of the pelvic floor over the soft parts, from a point
low down on the sacrum, or on the coccyx, to the sym-
physis pubis, in 110 cases, was 3*04 cm. This increased
projection of the pelvic floor takes place in two ways : (1)
there is stretching of the posterior segment of the pelvic
floor (from coccyx to fourchette) in the antero-posterior
direction ; (2) there is movement of the posterior seg-
ment of the pelvic floor backwards and downwards. This
movement can only take place by stretching of the
280 ON THI CHANOEB IN THE PELVIC FLOOR WHICH
posterior segment from side to side. It enlarges the
anterior opening of the pelvic floor^ and makes room for^
or rather is produced hj, a downward movement of the
anterior segment of the pelvic floor. The behaviour of
the posterior segment of the pelvic floor is just like what
takes place in labour^ but to a less extent^ and with the
difference that instead of being pushed down by the foetal
head^ it is pushed down by the anterior segment, which
in labour is pulled up to make way for the child.
In 103 cases I have records of the relative extent to
which each of these changes took place. The average
amount of stretching in the antero*posterior direction was
1*62 cm. ; the average amount of movement downwards
and backwards of its anterior edge was 1*45 cm. The
amount of stretching in each direction, antero-posteriorly
and transversely, seems therefore to be nearly equal, but
the antero- posterior stretching rather greater.
The degree to which the increased projection of the
pelvic floor takes place respectively by antero-posterior
stretching, and by movement downwards and backwards,
seems to depend a little upon how far this segment
extends forwards. In the communication which preceded
this I have shown the wide differences that there are
between different subjects in this respect. The further
forward the posterior segment extends, the closer it comes
to the pubes ; and therefore the smaller the anterior
opening, the greater is the relative extent of its move-
ment downwards and backwards away from the pubes,
enlarging the anterior opening, and the less relatively is
the antero-posterior stretching. Thus in sixteen nulli-
parae in whom the antero-posterior stretching exceeded
the movement backward and downwards, the average
distance from the fourchette to the pubic arch was 2*44 cm.,
and the average length of perinaeum 3*35 cm. In nine in
whom the amount of movement backwards and downwards
exceeded that of antero-posterior stretching, the average
distance from fourchette to pubes was 2*01 cm., and the
average length of perinsdum 4*17 cm. The difference in
ACCOKPANT THE BLIGHTBB DKOBSSB OF PB0LAF8B. 281
the parous women is less marked^ bat is in the same
direction. In thirty-seven parons women in whom the
antero-posterior stretching was the greater^ the average
distance from fourchette to pnbes was 3*06 cm.^ and
average length of perinaanm 2*44 cm. In 29 in whom the
movement backwards and downwards was the greater, the
average distance from fourchette to pubes was 2*66 cm.^
the average length of perinadum 2*88 cm.
But in this matter, while the differences between
averages are slight, the differences between individual
cases are verj wide. Thus in one case, a parous woman,
the antero-posterior stretching amounted to 4 cm., and the
movement backwards and downwards to only *5 cm. ; the
distance from fourchette to pubes here was 4 cm. In
another case> a nullipara, there was no stretching in the
antero-posterior direction, but a movement downwards and
backwards of 2*5 cm, ; the distance from fourchette to
pubes here was 2*9 cm.
In the stretching of the posterior segment of the pelvic
floor, both the perinsQum and the part lying between the
anus and sacrum take part, and that to about the same
extent. The average elongation of the whole posterior
segment by stretching was in the proportion of 1 to 1*2.
The elongation of the part behind the anus was as 1 to 1*21,
the elongation of the perinadum as I to 1*18. The average
amounts of elongation were — sacro-anal part 1*13 cm.,
perinsBum *52 cm. The average length of the posterior
segment as measured was 8*16 cm., the sacro-anal part
averaging 5*34 cm., the perinaaum 2*82 cm. On strain-
ing this was increased to 9*81 cm.-^the sacro-anal part
stretching to, on the average, 6*47 cm., the perinasum to
3*4 cm.
During effort, with this descent of the pelvic floor there
goes descent of the uterus and shortening of the vag^a.
This descent of the uterus takes place partly by the upper
part of the vagina becoming inverted into the part next
below it, and partly by the vaginal rugaa being pressed
together^ t. e. by increased wrinkling and actual shortening
282 ON THE CHANQES IN THE PELVIC FLOOR WHICH
of the macouB tract. In many women there occars slight
inyersion of the lower part of the vagina, which thus pro-
trades slightly when the patient strains ; bat this is not
nsaal in the nullipara. Bat the fact of shortening of the
distance from the valva to the vaginal f ornices is the only
one appreciable by measurement.
In the preceding paper I have described the method by
which I have measured the vagina. I have measured it
first daring rest and then daring effort in ninety-six cases.
The average descent daring straining of the anterior vaginal
cul-de-sac was 2*3 cm.^ that of the posterior cal-de-sac
2*03 cm. There is here a considerable difference between
the parous and the nalliparous. In seventy-five parous
women the average descent of the anterior vaginal cal-de-
sac was 2*62 cm.^ and of the posterior 2*28 cm. In twenty-
one nuUiparaa the average descent of the anterior cul-de-sac
was 1*15 cm., that of the posterior 1*3 cm. The differ-
ence is that in the parous the amount of inversion is
greater, and also that while in nuUiparas the posterior
cul-de-sac was more shortened during straining than the
anterior, in the parous the anterior was more shortened
than the posterior. This is in accordance with what we
might expect. We know that the uterus as it descends
moves in the axis of the pelvis — ^that is, roughly speaking,
in a curve having a centre in or near the symphysis pubis ;
and it is obvious that by a movement of this kind (assum-
ing the parts to be in a healthy condition, and altered only
by the movement of the uterus) the posterior cul-de-sac
would be more shortened than the anterior. This is what
the measurements show takes place in the nullipara.
On the other hand, we know that prolapse is more fre-
quent among the parous, and that in prolapse the anterior
vaginal wall is the part which most commonly comes down
first. This is a sufficient explanation of the greater in-
version of the anterior vaginal wall among the parous, for
among the cases measured there were a considerable
number of slight prolapse.
The foregoing averages are based upon the cases taken
ACCOMPANY THE SLIGHTJIB DEGREES Of PBOLAPSE. 283
ooUectively. I now come to consider them more in
detail.
In seventy-two cases there were symptoms of prolapse
(backache, bearing-down pain, &c., relieved by lying
down). In these the average increase in the measure-
ment over the soft parts when the patient strained was
8*54 cm. In thirty- four patients, who came for treatment
for ailments not attended with symptoms of this kind, the
average increase was 1*93 cm. In these latter the increase
took place more by movement backwards and downwards
than by antero-posterior stretching. The average extent
of movement backward and downward was 1*17 cm., the
average antero-posterior stretching was *8 cm. The average
descent of the anterior vaginal cnl-de-sac was 1*45 cm. ; of
the posterior, 1*37. The degrees of change indicated by
these figures may, therefore, be taken as normal, as con-
sistent with health and comfort, not requiring treatment.
Fig. 1 is a drawing from the measurements in a patient of
this class.
Dickinson'^ has also measured the increase on straining.
He does not say in what class of patients, or in how many.
The increase of projection he found 1*4 cm., but in women
wearing light corsets, in whom the initial projection while
at rest was more, it was *6 cm.
Looking more in detail at the cases described in the
foregoing paragraph under the broad term of prolapse, I
find twenty- three in which, although there were symptoms
of prolapse, viz. backache,, dragging, bearing-down pain,
&c., relieved by lying down, also relieved in some cases by
a pessary, in others by a support to the perinasum, yet
there was no displacement of the uterus backwards, no
protrusion at the vulva, and no greater descent of the
uterus into the vagina than was present in some of those
who made no complaint. In these the average elongation of
the pelvic floor was 5*1 cm., the antero-posterior stretching
was2*23,themovement backwards and downwards averaged
2*16 cm. The average descent of the anterior vaginal
• 'New York Med. Jonmid/ vol. ii, 1887» p. 618.
284 OH THH CHAKaSB IN TBI FKLTIC FLOOB WaiOH
Via. 1. — Dnwn to (cile from iiMMnrem«nta In ■ nullipu*, at. 19;
■abject of imill avviin tDmoor. Sbowiag normtl dewent of palTio
floor, deuent of otenu, tod ■hortdDing of ngiua noder ttnio.
ChkngM in the axia «nd ibape of the ««giiu are not repreaentMl
beeauM not meuared, either in thii or following diignuni.
B. Direct . .7-8
B. 0»or eoft parti . 11
D B. At TBit .
B. „ .. on ■training 12-6
D' B'. On ilruning .
0. At Kwt . . . . *
D B. At Teet .
0'. On .twining . . . *5
B' B*. On itnining . .
s. At net . . . .42
ACCOHPANT THB SLIOHTRB DSaKEaS 07 PBOLAPSB.
6-para. Relieved bjr perineal rapport.
ll»iumrtm«ntt.
D B . On BtmniDg .
D t. U reit .
d' f'. On itnining .
286 ON THK CHANGES IN THE FELYIO FLOOR WHICH
cal-de-sac was 3*5 cm.^ of the posterior 3*11. In some of
these there was descent of the pelvic floor with less than
usaal shortening of the vagina. Thas in one^ a patient
aged 28, who had had two children^ the elongation of the
pelvic floor was 3*9 cm.^ made up of antero-posterior
stretching 2*4 cm., and movement backward and down-
ward 1*5 cm.^ with descent of anterior vaginal fornix
amounting to 1 cm. ; of posterior^ 1*8 cm. This patient was
relieved by a perinasal support. In another^ aged thirty-
seven, mother of six children, the elongation of the pelvic
floor was as much as 8*3 cm., made up of antero-posterior
stretching 1*4 cm., and movement backwards 6*9 cm.
The descent of the anterior vaginal fornix was 1*8 cm.,
and that of the posterior *6 cm. A perinasal support gave
relief. Fig. 2 is a drawing from the measurements in
this case.
I have published a clinical description of this class of
cases in the ' British Medical Journal,' 1884, vol. ii, p. 64,
under the title " Descent of the Pelvic Floor without
Relative Displacement of the Uterus.^' I may give the
measurements of another case in which prolapse of the
pelvic floor was combined with slight relative descent of
the uterus. Here the increase in measurement was 10*8
cm., formed of antero-posterior stretching 6*5, movement
back and down 4*3, descent of anterior vaginal cul-de-sac
3*9 cm., of posterior 6*1. This patient was a nullipara,
aged thirty-four, with hymen entire. Her discomfort was
lessened, but not removed, by a perinsdal support. The
want of complete relief was probably accounted for by
the fact that she had some hasmorrhoids. This case is
illustrated in fig. 3.
The only authors, so far as I know, who have described
changes in the pelvic floor are Schatz and Skene.
Schatz^ has described subcutaneous, or rather sub-
mucous laceration of the muscles forming the pelvic floor
(more particularly of the levator ani) occurring during
labour. These he has ascertained by palpation per
• ' Archiv ftir Gyn./ Bd. xxii, 1884, 8. 298.
ACCOMPAtlY THE BLIOHTEB DEOSfiES OF PBOUF8B.
I. Orer wlft paitl
I. On itndning .
>'. On ttrainiug .
288 ON THB CHANQBS IN THB FELYIO FLOOB WHICH
vagina/m, by which gaps between the muscular bundles
can be felt ; and these gaps he assumes to have been pro-
daced by the tearing through of other bundles which
ought to have filled these spaces. He has not verified by
dissection the changes which he has described. He says
that such ruptures lead to descent^ prolapse, &c. I have
felt gaps between the muscular bundles such as Schatz
describes, but I have failed to trace any clear connection
between the presence of these gaps and descent. Descent
of the pelvic floor and prolapse of the uterus may occur
in the virgin ; and the perinseum may be torn through the
sphincter ani, and the injury remain unrepaired for years
without prolapse occurring.
Skene* has also described subcutaneous or submucous
laceration of the pelvic floor during delivery. He does
not refer to Schatz^ s paper, although this was published
a year before. He describes not only rupture, but fatty
degeneration, atrophy, and paralysis of the torn muscular
fibre. He does not say that he has verified either the
ruptures or the degeneration by dissection, his description
being, as it appears to me, an effort of the imagination
founded on the appearance of the parts during life. He
describes the anus being dragged forwards or backwards
as a result of changes in the pelvic fioor ; but it does not
appear, from what is said in the paper, that he has in any
case compared the state of the parts before child-bearing
with their state after ; and without such a comparison I
do not see how it can be ascertained with certainty that
the peculiarities Dr. Skene regards as changes due to
parturient injuries are really changes at all. In the
paper which preceded this I have pointed out that the
position of the anus is different in different subjects.
Skene has, however, correctly described the symptoms
which prolapse of the pelvic floor produces, and he says,
also as I think correctly, that the symptoms are not
different from those of other forms of prolapse. But his
description of the diagnosis of these injuries does not seem
* 'New York Med. Journal/ March 14th, 1885.
ACGOMPANT THE SLI6HTEB DEGBBE8 OF PBOLAPSB. 289
to me one from which it is possible to demonstrate an ab-
normal condition. He says^ ^' The displacement can be
demonstrated upon the subject by placing one finger upon
the pubes and the other on the tip of the coccyx^ and ob-
serving the extent to which the pelvic floor projects
between these two points/' " In the most pronounced
cases the parts project downwards almost on a line with
the nates/' In other words, the amount of projection of
the pelvic floor while the patient is at rest is the index
of the amount of injury it has sustained. This is not the
case : for there may be in the virgin much projection of
the pelvic floor with little if any increase of that projec-
tion during effort, and no symptoms of prolapse ; while
there are other cases in which while the patient is at rest
there is little or no projection of the pelvic floor, and yet
there is great descent when the patient strains. A com-
parison of figs. 1 and 2, both drawn from measurement,
will illustrate this ; for the greater projection is here seen
in the healthy nullipara. Whether the perinsBum is nearly
in a line with the nates or not, depends more on the
amount of adipose tissue in the buttocks than on the
amount of descent of the pelvic floor.
Kelly* describes '' relaxation '' as " the most important
of all injuries'' of the perinsdum and pelvic floor. He
says that the prominence given to it (in his article) '' will,
it is hoped, if at first questioned, gain general acceptance,
and thus hundreds of sufferers may secure relief who are
to-day looked upon by gynecologists as having sound peri-
nsBums." His description of the injuries of the pelvic
floor is based upon that of Schatz ; and he says nothing
to indicate that he has verified by dissection the injuries
he describes, any more than has Schatz. Writing as to
their diagnosis, he says, ^* A careful inspection now shows
that the anal cleft, as pointed out by Schatz, is no longer
a sharp, deep furrow, but is flat and shallow ; and the
anus, in place of being drawn up under the pubic arch, lies
• * American System of Qyneoolog^ and Obstetrics/ art. *' Injuries and
Lacerations of the PerinsBam and Pelvic Floor."
290 ON THE CHANGES IN THE PELVIC FLOOR WHICH
flat^ exposed^ and dropped back. The perinaBum is actually
deeper than normal ; instead of being from two to three
centimetres in depth it is often four or five/' I cannot ac-
cept these signs as indicating injury. The depth or shallow-
ness of the anal cleft depends principally on the fatness
of the buttocks ; and I have already pointed out that we
cannot safely infer that peculiarities in the disposition of
the parts forming the floor of the pelvis are the result of
changes produced by injury, unless we can compare the dis-
position before child-bearing with that after child-bearing.
Kelly describes in much detail changes in the perinsdum
due to relaxation. Now, it is quite certain that the
perinasum may be quite destroyed without producing
either prolapse or any symptoms except incontinence of
fsBces. A fortiori, then, still less can minor changes in
its conformation per se produce these effects.
I find twenty-two in which, with symptoms like those of
prolapse, retroversion or retroflexion of the uterus was
present. In these the average elongation of the pelvic
floor was 3*0 cm. ; the average antero-posterior stetching
being 1*49 cm., and movement backward and downward
1*58 cm. The average descent of the anterior vaginal
fornix was 1*82, of the posterior 1*66.
Comparison of these with the groups of cases previously
mentioned shows that as compared with those who were
free from symptoms of prolapse, and as compared with
the general average, the amount of descent of the pelvic
floor was increased. But it was not increased so much as
in the cases of descent of the pelvic floor without relative
displacement of the uterus. And among these cases of
backward displacement of uterus there are some in whom
the amount of descent of the pelvic floor was very small.
Thus in one case, a patient aged thirty-five, who had had
eight children, and in whom the uterus was retroflexed,
the measurement of the pelvic floor was increased on
straining by only 1*4 cm.; the descent of the anterior
vaginal cul-de-sac was 1*7 cm., that of the posterior 1*3
cm. This patient was not benefited by a perinsdal support,
ACCOMPANT THE SLIGHTXB DEGBBE8 OF PROLAPSE. 291
but was relieved by a ring pessary. In another^ a patient
aged thirty-two, who had bad eight children, who came
complaining of " dropping of the womb/' and whose uteras
was retroflexed, the elongation of the pelvic floor on
straining was 1*2 cm., the descent of the anterior vaginal
cul-de-sac was 1*4 cm., that of the posterior 1 cm. This
patient was relieved by a ring pessary. In a third, a
patient aged twenty-two, who had had one child, who
came complaining of bearing down, dragging pain, &c., and
whose uterus was retroverted, the elongation of the
pelvic floor was 1*9 cm.; there was no appreciable descent
of the anterior vaginal cul-de-sac, and that of the pos-
terior vaginal cul-de-sac was only 1 cm.
These latter individual cases appear to show that back-
ward displacement of the uterus may be present without
more descent of the pelvic floor or vagina than is present
in most healthy women. The average of the whole shows
that backward displacement of the uterus usually is accom-
panied with descent of the pelvic floor.
Shortness of the vagina has been assigned as a cause
of backward displacement of the uterus. To test this, I
have ascertained the average length of the vagina in thirty
cases of retroversion and retroflexion. The average
length of the anterior vaginal wall was 7*47 cm., that of
the posterior vaginal wall 9*44 cm. These figures give
no support to the view that shortness of the vagina is a
common cause of backward displacement of the uterus.
The measurements made during effort show that, as a
rule, in cases of backward displacement of the uterus the
inversion of the upper part of the vagina is not increased
in proportion to the increased descent of the pelvic floor.
I find thirteen cases in which with symptoms of pro-
lapse there was cystocele. In most of these the cystocele
was only slight. The average elongatiou of the pelvic
floor in these was 8*4 cm., produced by antero-posterior
stretching to the extent of 1*78 cm., and movement back-
wards and downwards 1*6 cm. (In the cases in which the
cystocele was large this measurement was not taken over
292 ON THB OHANOBS IN THB PELVIC FLOOB WHICH
the protnuaion, but by its side). The average descent of
the anterior vaginal cul-de-sac was 5*6 cm.^ that of the
posterior 3*74 cm.
These figures show that the descent of the pelvic floor^
although increased in cystocele, yet is not increased so
much as in the cases of descent of the pelvic floor without
relative alteration of its parts. Gystocele may be said to
indicate that the weak spot in the pelvic floor is the ante-
rior vaginal wall. As this descends, it presses the pos-
terior segment downwards and backwards, enlarging the
anterior opening j but when room enough has been thus
gained to allow the cystocele to bulge externally, the effect
of straining is to increase this bulging, but not to produce
further elongation of the posterior segment. Weakness
of the anterior segment of the pelvic floor does not neces-
sarily imply weakness also of the posterior segment. I
give the measurements of cases in illustration. First, one
of slight cystocele (fig. 4). Descent of pelvic floor on
straining 3*4 cm., made up of antero-posterior stretching
1*7 cm., movement backwards and downwards 1*7 cm.
The anterior opening was 3*5, so that on effort this was
increased to 5*2 cm. Measurement over cystocele 5*5 cm.
Descent of uterus 1*3 cm. This was in a patient aged
thirty-eight, the mother of eight children, the last bom
six months ago. There had been a slight rupture of the
perinsdum, which only measured 1*6 cm. in length. In
this case relief was given by a cradle pessary. A peri-
nsdal support failed to do good. I give next the measure-
ments in a case of large cystocele. The patient was aged
thirty-one, and had had five children, the last six months
previously. The elongation of the pelvic flodr, measured
over the cystocele, was 15*6 cm. Stretching of posterior
segment 1*7. Descent of anterior vaginal cul-de-sac
7*5 cm., and of posterior 6*6 cm.
The relation of cystocele to descent of the posterior seg-
ment of the pelvic floor may also be described in another
way. When the posterior segment descends as well as the
anterior, the anterior segment does not protrude, but re-
AOCOKPANT TBB SUaHTXB DB0KEI8 OT PK0LAP6S.
Meat»rgmenti.
A (f. On itnininf
O S. At TMt .
ty o'. On itniQiDg .
D 9. At reit ....
d' b. On itraining (oTer cjito-
D B. (To fnndnt uteri) at rot .
D"!'. On It--'-'--
294 ON THE 0HAN6XB IN THE PELVIC TLOOB WHICH
mains covered by the labia. If the posterior segment
does not descend^ then the anterior vaginal wall forms a
visible protrusion.
In some cases I have measured before and after the in-
troduction of a vaginal pessary. The results show that
the presence of a vaginal pessary does not alter the amount
of descent of the pelvic floor. It extends the vagina^ and
makes it longer even when the patient is at rest^ and it
prevents the shortening of the vagina which takes place
under straining efforts from being so great as it is with-
out the instrument. The extent of these effects depends
so much upon the amount of shortening of the vagina pre-
sent before the application of the pessary, and upon the
size and shape of the pessary, that the compilation of
averages does not seem likely to give useful information.
Gases in which the symptoms are wholly due to descent
of the pelvic floor are at once relieved by perinasal support.
The utility of these appliances has long been known to
the profession, and found out by many patients for them-
selves, although the cases in which they give relief had
not been defined prior to my paper on the subject. But
I do not propose to discuss details of treatment in the pre-
sent paper.
These measurements teach a clinical lesson of great
importance, viz. that the amount of descent is not the
measure of the amount of discomfort caused ; that the pre-
sence of symptoms does not depend upon the amount of
descent.
This is shown in two ways — (a) by the comparison of
different cases with one another, and (6) by observation
of the same case at different times.
(a) In some of those patients who complained of no
symptoms that could be referred to descent of the pelvic
organs, there was an amount of descent greater than in
some of those who complained of symptoms such as pro-
lapse produces, and whose symptoms were relieved, or
were said to have been relieved, by a mechanical support.
(6) In some patients in whom there was considerable
ACCOMPANT THE SLIOHTIB DSaSBBS Of PB0LAP8X. 295
descent the symptoms have diminislied and disappeared
without appreciable alteration in the amount of descent.
I append a diagram (fig. 5] of a case in which, after
eight weeks' residence in hospital, all symptoms had dis-
appeared, but the amount of descent was not appreciably
altered. Another diagram (fig. 6) shows the same thing,
and I have endeavoured also to show in it the effect of a
pessary, as ascertained by measurement.
The fact that in some cases with symptoms there was
backward displacement of the uterus but only very slight
descent, and the symptoms were relieved by mechanical
treatment, seems to point to the inference that backward
displacement of the uterus without descent may cause
symptoms. I do not propose here to discuss this very
difficult question. I will only say that although some of
the cases measured point to this conclusion, yet inferences
drawn from the statements of patients are so liable to be
incorrect that I think they can only be relied on when
very numerous as well as harmonious.
There are two sources of fallacy which here render
judgment difficult. The first is that the estimate of the
amount of descent may be incorrect. This source of error
I have already meutioned. It only applies to the cases
in which, although there were symptoms of prolapse, yet
only slight descent was perceived by measurement. The
second is, that in the cases in which relief was apparently
due to mechanical support, it may have really resulted
from other causes. The mere fact that a patient thinks
that she has been benefited by a support is no proof that
such benefit could not have been obtained without it.
There are no problems in medicine so complicated as the
correct estimation of the effect of treatment ; and this task
is especially difficult when that effect consists in the re-
moval or lessening of painful sensation, as to the reality
or severity of which the patients' statements are the only
evidence. On the other hand, in judging of the effect of
treatment in relieving discomfort we have no other guide
than the patients' statements, fallacious as they may be.
ON THB CUANOXB IN TBB PILTIC FLOOB WHICH
Fie. 6.— Diagnm drawn to wtle from meaiarenieiiU, of cue of
ilight eyitocele with deicent of pelvic floor and retrofleiion of
atenu. Sjmplonii all removed b; two months' reat, slthongh con-
ditioQ (d pitfta ihown b; meuorement to he the lame.
I'd i/ v*. On strsiDing
ACCOMPANT TBI BUQHTBB DBaSIIS (
Fia. S.— Prolapie of peine Boor with lUght deKeot of ntenu,
■bowing eSect of peMuy. Symptomi relieved neither bj pemay
DOT bj perinokl inpport, bnt relieved bj reit in hoapit*], tlthongb
amoant of descent not altered.
Cocc]'! to pnbe*
A B. Direct
A B. On w>ft part* .
A B. On itraining
A c'. On BtrainiDg .
OD. . . .
o' D'. On itraiDing .
298 ON THS CHANGES IN THE PELVIC FLOOR WHICH
and we mnst perforce rely on them. Wlien they are
nnmerouB and harmonious^ and predictions based on in-
ferences drawn from them are found to be almost inva-
riably fulfilled, we may at least accept them as a sufficient
basis for practice.
I think the true explanation of the facts that in some
cases slight descent seems to produce symptoms, while in
others much descent causes none ; and that in the same
patient symptoms are sometimes present and sometimes
absent, although the amount of descent remains the same,
is this, that the amount of trouble which these slight altera-
tions in the pelvic floor produce depends greatly upon
the nervous tone of the patient. In a subject who has a
weak, sensitive nervous system, a slight displacement will
cause what may even be described as considerable sufiFering;
while in a robust patient, whose nervous system is healthy
and strong, the disagreeable sensations produced would
be, to her, nothing. And in the weakly patient, when
the tone of the nervous system has been improved, the
local troubles cease to annoy. The slighter the mechanical
alterations, the more will the symptoms depend upon the
state of the nervous system.
In an oration delivered before the Hunterian Society,
and published in the ' British Medical Journal,' June 1st,
1889, I have pointed out the resemblance between the
changes in the pelvic floor described in this paper, and
other diseases due to weakness of muscles and ligaments,
such as the slighter cases of lateral curvature of the spine,
knock-knee, flat-foot, hypermetropia, &c.
The observations which have been summarized in the
foregoing pages show the following general conclusions.
1. That probably in all women there is, under the in-
crease of the intra-abdominal pressure which accompanies
muscular efiFort, some descent and elongation of the pelvic
floor, and descent of the uterus into the vagina, by inver-
sion of the upper part of the vagina, and probably
shortening of that canal by increased wrinkling. In health
the elongation of the pelvic floor probably does not
ACCOMPANT THE BLIQHTBE DBGRBBS OF PB0LAP8B. 299
usaally exceed three quarters of an incb^ and the shortening
of the vagina by descent of the ntems into it about five
eighths of an inch. Change to this extent is compatible
with absence of discomfort.
2. The elongation and descent of the pelvic 6oor takes
place by stretching of the posterior segment both trans-
versely and antero-posteriorly. The stretching in the trans-
verse direction permits it to move backwards and downwards
and recede from the symphysis pubis. In the antero-
posterior stretching both the perinsdum and the portion pos-
terior to the anus take part^ and to about the same pro-
portionate extent. The posterior segment of the pelvic
floor is pressed downwards and backwards by the pressure
of the anterior segment upon it.
3. These changes may be morbidly increased^ and their
relative extent morbidly altered.
4. In some cases the elongation of the pelvic floor is
increased^ with comparatively little alteration in the rela-
tive position of the uterus and other parts. The elongation
in such cases may amount to more than three inches.
5. In other cases^ beside increased elongation and
descent of the pelvic floor, there is increased descent of
the uterus into the vagina.
6. In other cases the anterior segment of the pelvic
floor is the weaker part. In such, when the posterior
segment has been pressed far enough downwards and
backwards to allow the anterior vaginal wall to protrude,
further effort increases this protrusion, but does not in-
crease the stretching or displacement of the posterior
segment.
7. Backward displacement of the uterus is often present
without more descent of the uterus or of the pelvic floor
than is present in most healthy women. But in most cases
of backward displacement of the uterus the descent of
the uterus and of the pelvic floor is increased.
8. The amount of descent of the uterus or the pelvic
floor is not the measure of the severity of the symptoms.
Slight descent may go with symptoms in some patients.
300 ON THE CHANGB8 IN THE PELVIC FLOOR WHICH
mucli descent without symptoms in others ; and in the
same patient the symptoms may be present at one time^
absent at another^ although the amount of descent has not
varied.
Dr. G-BAiLT Hewitt considered Dr. Herman deserved much
credit for his analysis of the various and complex phenomena
observed in cases of slighter degrees of prolapsus. The subject
was of vast importance, for the sufferings and effects producea by
so-called minor displacements, although not indicating danger
to life, often destroyed all enjoyment of it. These sufferings also
deserved attention as they not infrequently tended to gradual
inteuBification, the result being that m later years serious im-
pairment of the functions of the uterus was often found to be the
result of neglect and want of appreciation of symptoms of minor
displacements in their primary steles. Dr. Herman's study of the
normal variations in the conformation of the parts forming the
floor of the pelvis was an interesting and trustworthy contribution.
The secoud paper, on the changes in the pelvic floor accompany-
ing the slighter degrees of prolapse, contained facts and observa-
tions of interest. He was glad to find himself in agreement with
Dr. Herman on many points in reference to descent of the
uterus, and its effects in producing suffering. He believed, how-
ever, that in these cases the principal cause of the suffering was
the exaggeration and intensification of the version or fiexion of
the uterus more frequently associated with descent of uterus.
Descent of the uterus, pure and simple, was rare, but descent ac-
companied with flexion or version very common. In estimating
the effects of the displacement it would be necessary to flnd out
how much of the suffering was due to the mere descent, and how
much to the increased flexion or version. So far as backward
displacement was concerned. Dr. Herman noted descent to be
increased by it. Nothing was said in the paper of anteflexion s.
He believed that although anteflexion not yet rigidly set in that
shape, with the uterus still fairly moveable, might be regarded as
not abnormal, it was quite a different thing when the organ was
sharply bent forwards, the fundus low down, and uterus flrmly re-
sisting alteration of shape and position. He noticed Dr. Herman
had several cases of cystocele. It was probable that in these
cases anteflexion was a very important causative element, and
he (Dr. G. Hewitt) mentioned a case illustrative of this connec-
tion. In conclusion, he would state his impression to be that
descent of the pelvic floor was chiefly important because it
brought about increase of flexion and consequent increase of dis-
comfort.
ACCOMPANT THE SLIOHTEB DE6BBE8 OF PROLAPSE. 301
Dr. Hebmak differed from Dr. Hewitt in many points, but
could not on the present occasion occupy time in giving fully
his reasons for venturing to do so. Anteflexion he regarded as
one of the natural shapes which the uterus might have. He had
investigated the frequency of anteflexion in the healthy, and put
the results before the Society ('Transactions,' vol. xxiii).
Yedeler had made a similar research, and got substantially the
same result, viz. that acute anteflexion was very common in
health. No one else had investigated the question. Backward
displacements of the uterus, he thought, caused symptoms in a
small minority of cases only, and in these he thought not by any
effect of the bending of the uterus, but by the torsion and pres-
sure on the broad ligaments, which returned the blood from the
uterus. In justification of his difference from Dr. Hewitt here,
he would point to Fig. 5, which illustrated a case of retroflexion.
This patient was kept in hospital for two months, and all her
symptoms went away, although the retroflexion was exactly as
when she came in, showing that this was not an important fea-
ture of her case. In reply to the President, Dr. Herman said
that the representation of the vagina was only diagrammatic,
and made no pretence to accuracy except in the matter of length ;
and this was stated in the description placed beneath Fig. 1 of
his second paper.
VOL. XXXI. 21
NOVEMBER 6th, 1889.
Alfred L. Galabin, M.D., President, in the Chair.
Present— 42 Fellows, and 7 visitors.
Books were presented by Dr. Onllingworth, the Clinical
Society of London, the Council of University College, and
the Edinburgh Obstetrical Society.
Alfred Brown, M.A., M.B., C.M.Aber. (Manchester),
was declared admitted as a Fellow of the Society.
The following gentlemen were elected Fellows of the
Society : — ^Arthur Hardwick, M.D.Durh. (Newquay) ;
James Oliver, M.D.,F.B.S.Edin.; Harry Marmaduke Page,
F.E.C.S. (Wimbledon) ; Thomas Edward Parsons, M.R.C.S.
(Wimbledon) ; and Thomas Bichmond, L.B.C.P.Edin.
(Glasgow) .
PELVIC HiEMATOMA FOLLOWING DELIVERY.
DEATH FOUR HOURS AFTER LABOUR.
By BOBBBT BOZALL, M.D.
Dr. Boxall showed the pelvic organs of a woman, aged
80, who had died in her fifth confinement four hours after
the completion of labour on the 30th ult. She was not a
robust subject, but had carried fairly well till within
nearly a fortnight of the expected date of delivery. Her
304 PELVIC HEMATOMA FOLLOWING DELIVKBY.
husband then had a fit. To the shook thus produced she
attributed the hsamorrhage which took place on the fol-
lowing day and recurred every three or four days^ until
the full time of pregnancy was reached. On each occa-
sion the loss was slight^ and ceased after she had lain
down for a few hours. Once only did she think it neces-
sary to apply to the hospital for assistance^ and then the
maternity clerk reported the loss as triflings and as having
already ceased on his arrival.
When labour began on the morning of the 29th the
bleeding again recurred. At 11 a.m. some clots were
removed from the vagina. The bleeding ceased^ and the
pains died away. Towards evening the bleeding came on
again. At 10 p.m. Dr. Boxall saw her ; she still had no
pains. The cervix was about two inches in diameter,
soft and dilatable, situated high up and far back, with
difficulty reached by the finger. The vertex was pre-
senting above the brim, and could everywhere be distinctly
felt. The abdomen was penduloas, the child's movements
vigorous. A binder was applied in order to rectify the
the anteverted state of the uterus, and the membranes were
then ruptured. The haamorrhage ceased forthwith. Regular
pains came on half an hour later, and for a time the pre-
sentation advanced. At 11.30 p.m. the pain began to
die away, and the head in consequence became arrested in
the cavity of the pelvis. Two hours later the woman was
becoming exhausted ; dark fluid blood was escaping freely
from the vagina ; pulse 100. No progress being made,
at 2 p.m. the forceps was applied and delivery was easily
effected, the head not being impacted. The child was
alive. Immediately following delivery of the trunk a
copious loss of dark semi-coagulated blood took place,
succeeded by fluid blood of a brighter hue. Compression
failing to bring away the placenta, the hand was intro-
duced, the attached portion peeled off, and placenta and
membranes removed entire. The uterus remained like a
flaccid bag, and free hsBmorrhage followed. Ext. Ergot.
Liq. 5ij had been given by mouth. Ergotin. gr. x was
PILVIO HJEMATOMA FOLLOWING DEUVEBY. 805
injected into the bnttock^ and a hot intra-uterine douche
of weak sublimate administered. Though the haamorrhage
was checked^ it did not stop until 3 a.m.^ and even then
the uterus seemed inclined to relax. The ergot by mouth
and intra-uterine douche were repeated. Up to this point
the total loss which had taken place since the beginning
of labour was estimated at twenty to thirty ounces. The
patient was not particularly blanched^ did not feel faint^
but answered questions in a fairly strong voice. The
pulse^ which had been as high as 140 per minute^ had now
sunk to 98^ and half an hour later to 88. Another dose
of ergot was given as a precautionary measure before the
patient was left. She was then asleep^ and continued to
sleep from 4 till 6 a.m. When she awoke she said she felt
as if she were sinking through the bed^ and knew she was
dying. She asked to see her husband^ and in a few
minutes she was dead.
Meanwhile there had been no external haemorrhage j
the diaper put on at 3 a.m. had been barely stained. The
only clue to the state of affairs revealed by the autopsy
was the oedema of the perinsBum^ which came on about
half an hour after labour^ though no laceration had taken
place.
The autopsy was made twenty-eight hours after death.
Except that the lungs were somewhat adherent at their
apices and the left showed traces of old tubercular mis-
chief in the same part^ all the organs were healthy though
bloodless. The right side of the heart contained four to
five ounces of fluid bloody but the pulmonary arteries^ like
the left side of the hearty were empty. On raising the
intestines and drawing the uterus forwards^ an extensive
blood effusion was seen running along the sacro-uterine
ligaments on either side^ and following the course of the
ureter to the lower border of the kidney^ being rather
more pronounced on the left than on the right side. On re-
moving the organs from the walls of the pelvis the effusion
was found to infiltrate the cellular tissue^ particularly deep
down in the cavity and on the left side. It surrounded
306 FBLVIC HJBMATOMA TOUiOWINO DELIYBBT.
the rectum and extended into the peritoneal fold of the
sigmoid flexure. In front it was limited by the attach-
ment of the pelvic fascia to the bone at the upper part of
the obturator foramen on either side^ and below it was
found to extend to the perinsaum^ thereby causing the
swelling which had been noticed soon after delivery. The
blood had infiltrated the ischio-rectal fosssB as far back
as the anus, and on the left side had extended even behind
it. On opening the uterus it was found to contain barely
an ounce of clotted blood. The placental site was situated
on the front wall^ its lower edge extending to within two
inches of Bandies ring and three and a half inches of the
external os. A slight tear was found on the left side of
the cervix^ but not more than one third of an inch deep.
The right ovary contained a corpus luteum about the size
of a haricot bean ; the left ovary was much flattened out.
Dr. Boxall had seen a case of death from internal
haBmorrhage following delivery some years ago^ which in
some respects resembled this. The patient sank in the
same unexpected manner^ and an effusion of blood had
taken place also beneath the peritoneum. But in that
case the peritoneal coat had been dissected off from the
posterior uterine wall by the effusion^ and it seemed pro-
bable from its situation that some vessel had given way
at the back of the cervix. In the present instance^ how-
ever^ the main part of the effusion was below the cervix
altogether ; and though^ as in the other case^ no open vessel
could be discovered^ it seems probable^ considering the
extent and distribution of the effusion^ that a vessel of
no inconsiderable size had given way between the vagina
and rectum to the left of the middle line^ and that &om
this point the blood had forced its way downwards to the
perinadum^ and infiltrating the cellular tissue of the pelvis
had travelled upwards along the ureters to the lower end
of the kidney. Though the ovarian vessels were sur-
rounded by clot, they were found to be quite empty and
their walls intact. Had the patient suffered from varicose
veins it would have been easy to understand how, by the
PBLVIC HJBMATOMA VOLLOWIKO DELIYEBT. 807
implication of a vessel in one of those tears external to
the vagina^ saoh as Dr. Matthews Duncan has described^
an effusion of such an extensive character could be pro-
duced^ but in this case, no varicose veins were detected
either in the vagina or elsewhere. The amount of effusion
was estimated at a pint at least.
Three years ago Dr. Boxall exhibited another specimen^
in which the heart had been forced during vomiting
through a congenital deficiency in the pericardium into
the left pleural cavity^ causing torsion and strangulation
of the vessels at its base^ an accident which was followed
by fatal consequences three days after delivery. Such
cases as these^ in which^ as far as we could see^ the acci-
dent could neither be prevented nor remedied^ nor its
nature ascertained with any degree of certainty during
lifOj Dr. Boxall considered should emphasize the advisa-
bility of obtaining a post-mortem examination in all cases
where death occurred within a few days after delivery.
Dr. Matthews Dim cak referred to cases lately published by
Prof. Ogston. In one of them a severe pressure injury below
the knee caused effusion of blood and serum as high as Ihe
navel. So great was the disruption of tissue that the hand and
arm could be passed from the knee to the navel beneath the
skin. Ever since these cases appeared, he had looked for some
similar accident in connection with the pressure injiuries by
forceps, however justly and skilfully used ; and he suggested to
Dr. Boxall the possible analogy of his remarkable case and
Ogston's. The cases which he himself had published, and to
which Dr. Boxall had referred were, in his opinion, not in the
same category with Ogston's and the present case of Boxall ; he
regarded them as submucous injuries or lacerations, the mucous
membrane being entire ; the bleeding or submucous hematoma
being confined to the seat of the laceration. Such deep lacera-
tions, without injury of surface, were known to occur.
Dr. Babkes said that he had long ago called attention to a
point in the history of labour, which was that, even in normal
labour, and a fortiori in difficult labour, the head, in its descent
through the pelvis, carried before it the mucous membrane of
the posterior wall of the vagina, stretching and even lacerating
the subjacent connective tissue. This sliding or glacier-Uke
308 BBTBOFLEXION AKD ECTOPIA VIBCEBUM.
action inyolved laceration of small yessels in the connective
tissue, entailing more or less hsemorrhage. It was easy to
understand that even considerable haemorrhage might occur if
a large vessel were ruptured. Another condition arising from
this glacier-like process was the e;ffu8ion of a considerable
amount of serous fluid in the connective tissue. This he had
always observed in the autopsies he had seen of women dying
within a few days of labour. This effused fluid was rapidly
absorbed, as it was one element in the blood-degradation of
pregnancy.
SECTIONS OF UTERUS AT DIFFERENT PERIODS
OF THE PUERPERIUM, SHOWING COM-
PLETE ABSENCE OF THE ALLEGED FATTY
CHANGES.
By W. S. A. Griffith, M.D.
THE UTERUS, OVARIES, AND TUBES FROM A
CASE OF CESAREAN SECTION.
By C. J. CULLINOWOETH, M.D.
RETROFLEXION AND ECTOPIA VISCERUM.
By W. R. Dakin, M.D., B.S.
Db. Dakin showed a foetus which was the subject of
retroflexion and ectopia viscernm. It had also consider-
able lateriflezion to the right, talipes valgus in both feet,
and the left arm was ill-developed, with a web at the
elbow, and only two digits. Its sex was doubtful, but
was probably female. He intended to dissect it, and pre-
sent a further report to the Society.
It was one of twins, and the mother was about eight
months pregnant. This confinement took place under the
UTERUS AT DIFFERENT PERIODS OF THE FUERPERIUM. 809
care of a midwife, who was a very intelligent woman,
and gave Dr. Dakin the following account. She had mp-
tnred the membranes^ as the first stage seemed very long,
and one child presented by the head and was bom.
Immediately after, with no separate bag of membranes^
something that she took for a scrotam, but which turned
out to be a liver, presented. The foetus to which this
belonged — ^the present specimen — then came down doubled
up backwards, the head and heels descending at the same
level as, and applied to, each other.
There was no cord in this case, but a '^ string of mem-
brane,'' which was stretched up the vagina, and was
attached to the corresponding placenta ; this latter when
it was born being seen to be closely approximated to, and
in fact to form part of, the anterior abdominal wall.
Both placentae were said to be embedded in the same
amnion at a distance of half an inch from each other.
The placenta belonging to the first child was of the
normal size, but that of the specimen was about four
inches in diameter and very thin.
The placenta had been thrown away, and the abdominal
coverings, viz. amnion and continuation of peritoneum,
mnch torn, but the umbilical vessels were plainly visible
running between these two. The child gasped and its
heart beat for an hour or two after delivery. The other
child was well formed, but small. It died seemingly
from asphyxia on the third day. The mother had had
two children before, was aged twenty-four, and was said
to be healthy.
LARGE MYOMA OF LEFT BROAD LIGAMENT.
By William Duncan, M.D.
310
Report on Mr. Alban Dorcm^a Specimen of Fragment of
Membrane passed from the Uterus (p. 229).
The fragment when examined nnder the microscope
displayed an abundance of small spindle-cells^ broad in
the middle^ mingled with round cells in smaller quantity
and with blood-corpuscles. The stroma was homogeneous
and transparent^ and the small oval and circular openings
devoid of any epithelial lining.
From the naked-eye and microscopic appearances of the
fragment there could be no doubt that it was altered
uterine mucous membrane. Its precise character, how-
ever, could not be determined.
John Williams.
Waltbb S. a. Geiffith.
Alban Doban.
311
A CASE OF LARGE CHYLOUS CYST OF THE
MESENTERY.
By Adolph Rasch, M.D,,
PHTBIOIAN VOB DIBSABBS OP WOMBN TO THX aBBMAN HOSPITAL;
PHT8I0IAK TO THB DBAOONBBBBB* HOSPITAL AT TOTTBKHAM.
Received September 80th, 1889.
Fa. H — , aged 21, single^ was admitted into the Deacon-
esses' Hospital on February 9th^ 1889. She had always
been in good healthy some discomfort at the otherwise
normal menstrual periods excepted.
Three weeks before^ and a whole week after lifting a
heavy tmnk^ she went to bed quite well^ but was wakened
in the middle of the night by severe pain in the left side
of the belly^ which continued more or less for three weeks
in spite of medical treatment. Dr. Rasch^ who was called
in on February 7thj detected a tumour in the left side^ and
had her admitted into the hospital.
State on admission. — ^Well-nourished but anaamic girl
of dark complexion (Jewess). Lungs^ liver^ hearty show
nothing abnormal. Dark pigmentation of the middle line
of abdomen. A large roundish swellings elastic, almost
fluctuant^ occupies mostly the left side of the abdomen.
Right border an inch and a half to the rights left border
four inches to the left of the median line^ reaching equally
down to the pelvis. The rounded top of the swelling
about two inches above the horizontal umbilical line.
Slightly moveable.
Uterus not enlarged^ freely moveable^ not connected
with tumour. Uterine sound entered easily two inches and
a half in normal direction. Little could be felt of the
tumour per vagvnam.
812 LABGl OHTLOUS CYST OF MISBNTEBT.
Patient was kept qaiet in bed. Pains were moderate^
appetite indifferent.
February 13th. — Same measurements^ only the tumour
had extended more towards the chest. Patient finds that
in rising from bed it bulges oat most in the left flank.
Pains in side and back have increased. Temperature up
to the operation varying from 97*4° to 99°. Never
trouble from the bladder.
Operation on March 22nd. The case being supposed
to be a parovarian cyst^ the usual incision of three inches
was made in the middle line^ the peritoneum (as is my
usual practice in abdominal sections) secured to the cut
skin on each side by a temporary suture^ and then the
peritoneum fully slit open. The appearance of the tumour
at once struck all present ; it was of a pale pink and very
glossy^ unlike any cyst I had seen before. No adhesions
could be felt anywhere. On piercing it with a large tro-
car a perfectly milk-like fluid squirted out with great f orce^
but little entered the peritoneal cavity. I first thought it
might be very thin pus^ having a very distant likeness to
the fluid I once found in a large hydatid tumour which
extended from behind the liver and peritoneum down to
the broad ligament. To get a clearer view I enlarged the
incision to a little above the umbilicus ; now drawing the
walls of the cyst gently out and emptying it^ it became evi-
dent that what appeared to be a cyst was the two layers
of the mesentery separated from each other by that milk-
like fluid. The small intestine^ of perfectly normal ap-
pearancCj was connected with it in the normal way. The
hand inside came down to the region of the spine^ the usual
insertion of the mesentery. The inside of the cyst was
intensely congested^ looking dark red and freely oozing.
I cut out only a small piece (about one inch square) for
examination.
Uterus^ ovaries^ and left broad ligament were perfectly
healthy; on the right broad ligament^ however^ otherwise
quite healthy^ was a very thin-skinned translucent cyst^ the
size of a walnut^ qnite superficial as if it were only perito-
LARGE CHYLOUS CT8T OF MBBBNTBST. 813
neam raised by flaid. It was tied and cat away. The
fluid was faintly straw-coloured^ almost like water.
The cyst cavity was sponged clean and^ like the peri-
toneal cavity^ washed out with warm boracic lotion. The
opening of the cyst was carefully stitched to the abdominal
wound, which in the usual way was closed as far as con»
yenient with silk sutures. A long roll of iodoform gauze
was introduced into the cyst to stop oozing and to act as a
drain, the whole covered with sublimate gauze after dusting
with iodoform. Usual bandage applied over all.
Six pints of the cyst contents were collected, and part
kept for examination.
The patient was rather collapsed towards the end of the
operation. Two severe attacks of sickness in the middle
of it had prolonged it to eighty minutes (from beginning
of chloroform) . Brandy subcutaneoasly administered had
a good effect. Coming to, the patient complained much of
pain in abdomen, and was very restless ; gr. ^ morph.
under the skin gfave her a good night.
The flwid was examined by Dr. Ferguson two hcMirs after
the operation, and also by Dr. Michels, of the Grerman
Hospital, next day. Dr. F. found the white of the fluid
then changed into a pinkish colour, and there was a
decided quantity of firm pinkish clot. Sp. gr. 1015.
Reaction alkaline. Microscopical examination showed
lymph-corpuscles, a few blood-corpuscles, and few oholes-
terine crystals^ fat globules, and moving over the field of
vision were some very fine molecules. Adding ether to
some of the fluid in a test-tube it cleared up, and the
microscope showed then no more fat globules. Dr.
Michels found the same characteristics of true chyle.
I may here add at once that a later examination of the
piece cut out showed that there was no epithelial lining,
nothing like a true cyst wall. Only the outer peritoneal
layer and the fibrinous subserous structure somewhat
thickened. The cyst, if I may use that word, was there-
fore formed by the mere separation of the two layers of
the mesentery by the chyle.
314 LABGB CHTLOUe CYST OF MBSBNTEBT.
Not willing to occupy too macli time of the meetings I
shall condense the notes of the progress of the case as
much as possible. Patient had a &irly qniet night after
the operation, and was sick several times in the early
morning, bringing np green flnid. Weak. Irrigated with
boric solution. Temp. 99^, morning ; 100'5, evening.
March 24th. — Good night. Not sick. Takes milk.
Temperature, 100^ ; eyening, 100*4^* Bandage not soaked
yet.
25th. — Good night. Considerable discharge, serous, no
smell. Temperature normal.
26th. — Some milky discharge (containing some pus cells
and fat globules). Temperature normal.
30th. — Upper stitches removed ; good union.
April 2nd. — Considerable milky discharge. All sutures
removed. Temperature normal.
5th. — Irrigated with boric solution.
6th. — Discharge of milky flnid more copious.
10th. — Catamenia appeared. Had some fish the last
two days.
23rd. — Got up for the first time.
24th. — The discharge of milky fluid undiminished; cavity
stuffed with iodoform gauze.
25th. — ^Temp. 100*8^. Pain in the stomach, the plug
had caused retention ; removed and tube put in. Weight
of patient, 7 st. 6 lb. (on admission 9 st. 8 lb.) .
May 9th. — ^Tube has been gradually shortened. Dis-
charge of same character and quantity. Pain in abdomen.
Temperature henceforward quite normal.
15tli. — Discharge much less. Difficulty to get the more
shortened tube in.
17th.— Weight 7 st. 13 lb.
26th.— Weight 8 st. 2 lb.
28th. — ^Tube came out at night. Thin probe enters.
Wound now closed perfectly. Good cicatrix. Patient
discharged quite well after a short time ; continues well.
Bemarks. — As far as I have been able to ascertain, no
case of a chylous cyst of the mesentery in a woman has been
LABGB CHTLOUS CT8T OF HBSBNTEBT. 815
published yet, and I hope^ therefore, this short paper will
need no apology in a society many members of which are
distingaished abdominal surgeons.
The qnestion now is. How does sach a cyst originate f
and on the answer to it depends the prognosis and, in no
little way, the treatment. Obstrnction of the thoracic
duct and consecntive distention of the lymphatic vessels
have been foond by Bokitanski, Yirchow, and others to be
the cause of little lymph cysts in different parts of the
body. The lymphatics of the small intestine have been
found enlarged like strings of beads. Winiwarter (' Mit-
theil. a. d. Rudolph's Hosp. Jahresberichte/ ii« 821) found
a very large swelling in a weakly child aged four months,
in the right hypochondrium, and evacuated on seyeral occa-
sions about six pints of milk-like fluid. He ascribed the case
to obstruction of the thoracic duct. Dr. Killian (' Berl.
klin. Woch./ 1886, 407, ff.) operated successfully on a very
large postperitoneal lymph-cyst situated in the right renal
region, which he had previously tapped (five pints) and
which had refilled. He thinks also that it might be due
to obstruction.
The perfectly normal appearance of the adjoining small
intestine in my case and the perfect health of the patient
up to a certain time seem to speak against a similar
cause. I am rather inclined to believe the cyst origi-
nated from the rupture of a chylous vessel of the mesentery,
very likely caused by the liftdng of a heavy trunk. It is
a mere supposition, but supported by the pathological
observations of others, that at that time a distention of
that vessel, a small lymphangioma, was already present
and burst, and so caused a rapid separation of the two
layers of the mesentery.
Diagnosis. — Can we diagnose such a chylous cyst of the
mesentery before opening the abdomen f That I did not
do so I have already stated. I had no idea that such a
disease existed, and I may be pardoned for that ignorance,
as I had never found any mention of it in all the gynsdco-
logical and other works I had read. Sir Spencer Wells,
316 LASaS CHTLOUB CT8T OV ME8EMTBRT.
as i sobfleqnently f onnd in the new edition of Us work^
has published two eases of cysts in the mesentery {not
chylous cysts) which he had not been able to diagnose
before the operation.
Pean (' Tnmears de 1' Abdomen ') , in his excellent work^
gives the details of two cysts of another nature in the
mesentery^ and for diagnosis lays stress on what he thinks
is a constant fact^ viz. that tamonrs of the mesentery^ as
long as they are of moderate size^ are always f onnd in the
umbilical region, quite symmetrical^ and have free trans-
verse but little yertical mobility. My case does not bear
him out, as it was undoubtedly lateral. Prof, von Berg-
mann's case''^ of a chylous cyst of the mesentery in a male
aged sixty-three is well in harmony with Plan's opinion.
The patient himself had found a round tumour in the
umbilical region, and von Bergmann found it there too,
fluctuatiug and freely moyeable from side to side. He
therefore with great probability expected to find an
echinocooeus cyst of the mesentery or peritoneum. The cyst
contained chyle, and seems to be the first ever published.
In a woman the uncertainty of diagnosis must be infi-
finitely greater, especially when such a cyst has attained
a considerable size, as in my case. The intestine connected
with it will be pushed high up and behind the tumour,
and the cyst itself will reach down to the broad ligfaments.
Still I now think it might be possible, by raising the pelvis
very high, in a future case to make the tumour roll down-
wards towards the chest, and so clear the broad ligaments.
A mistake for a broad ligament or ovarian cyst might so
perhaps be prevented.
To diagnose the contents as chyle seems impossible to
me at present, as I, with I hope the majority of ovarioto*
mists, abhor tapping.
The prognosis of these cases seems favourable if we may
judge from three cases (I include Killian's case, though
situated in a different place). But the good result
depends on —
• * Arch, f . kiln. Chimrgie/ von Langenbeck, 1887, S. 201, ff.
LASQB CHTLOUS CTST OF MBSBNTEBT. 317
The treatment. — It woald be a fatal mistake to try to
enucleate or excise such a cyst, as by so doiug the mesen-
tery would be removed and the vital supply to the intes-
tine connected with it cut off. It seemed to me that the
only proceeding which promised success was to empty the
fluid, allow for the free outflow of any that might be poured
out afresh, and avoid any traction on the intestine when
stitching the mesentery to the abdominal wound.
It was with great satisfaction that I subsequently learned
that Prof. V. Bergmann had doae exactly the same in his
case.
My only fear was that the ruptured chylous vessel, or,
to speak less hypothetically, the place from where the
chyle had poured out, might remain open and, continuing
to flow, imperil the health if not the life of the patient.
As is seen from the notes, this fear for a number of weeks
was well grounded, for the flow continued copious^ and
the patient lost in weight. Still I trusted to careful
drainage, and was rewarded by perfect recovery. Mildly
antiseptic, cautious irrigation kept wound and cavity safe.
The object of this paper is only to bring a chylous cyst
of the mesentery before the Society, otherwise I might be
tempted to say that the above treatment seems to promise
better results for other cysts of the mesentery than extir-
pation or emptying without subsequent drainage (as in
one of Sir Spencer Wells's and in one of Pean's cases).
I shall feel greatly rewarded for the little trouble I
took with this paper if it will elicit similar cases from the
Fellows present, or if any member will kindly direct me
to pablications that I have overlooked.
Dr. William Duncan suggested that the tumour might well
be dermoid and not chylous.
Dr. BoxALL could scarcely see how the escape of chyle into the
loose cellular tissue of the mesentery could produce a cyst, but
he thought that the possibility of a chylous cyst in that situa-
tion originating in an echinococcus cyst should be entertained.
Hydatid cysts are sometimes barren; and if blood and bile
VOL. XXXI. 22
318 LAJBOX CHTU>U8 CT8T Of KB8SHTBST.
ooold find tbeir way into them, there were primd fade gronndB
for beliering that in a sitnatioii in which lactealB abound chjle
might do the same and distend the cjst, so that all trace of its
pristine nature misht eventnallj disappear.
Dr. Cabtsb said he had reported in the 'Brit. Med. Jouni^'
1883, a case dE cyst of the mesentery mmulating an OYarian
monocyst. At the operation the oyaries and uterus were free
from the cyst and healthy ; the fluid was clear and opalescent,
of Tery low specific gravity, without albumen, but abundant
chlorides; it was not a hydatid. The cyst sprang from the
insertion of the mesentery on the left side of the spine, and was
surrounded with the coils of intestines. He quite agreed with
Dr. Basch in the way such a cyst should be treated, never enu-
cleated, but stitched to the abdominal walls and drained. In
his case enucleation was attempted, but abandoned, as the
haemorrhage was great from ruptured large veins ; it was then
stitched to the abdominal walls. The patient died from septi-
csmia, through the extravasation of blood between the c^st wall
and the layers of the mesentery.
Mr. Albak Dosak considered that Dr. Basch's definition of
his tumour was perfectly reasonable and probably correct. He
believed that, excepting certain cases where dermoid cysts deve-
loped in connection with the pelvic viscera in males, as noted in
the ' Medico-Chirurgical Transactions,' vol. Ixiii, 1880, by Dr.
Ord, non-ovarian dermoids of the abdomen were very rare.
Whenever the pelvic viscera had been satisfactorily explored, it
was proved that a dermoid lying free from those organs was of
ovanan origin, the pedicle having become atrophied by torsion,
ultimately disappearing.
Dr. Matthews Duncan mentioned a case of his in which
Mr. Thornton had removed a large mesenteric cyst, with clear
contents. It had been diagnosed as probably ovarian. The
operation showed no connection with the uterus and broad liga-
ments. He referred also to a case of his, operated on by Mr.
Langton in St. Bartholomew's Hospital. In this case, which
was published imperfectly, both ovaries were removed, both
being dermoid cysts. A third cyst, the size of an egg, having
hair growing from its inner surface, was removed from between
the layers of the mesentery ; it had no connection with either
ovary. In both of these cases there was good recovery, so that
the precision attainable by autopsy was not obtained.
Mr. Doban noted that an exogenous growth on an ovarian
tumour might become completely severed from its parent. He
had seen such a growth adherent to the vermiform appendix.
Hence the third tumour was not necessarily non-ovarian.
Dr. Basch, replying, said that after the several careful
examinations made of wall and contents no doubt was left of its
natui'e. Echinococcus, as stated in the paper, was before the
LABGE CHTLOaS CT8T OF MESENTBBY. 319
mind of the operator, but was readily excluded by the micro-
scopic examinations ot the fluid and the piece cut out. That
any one should believe this case to be a dermoid cyst of the
mesentery he had certainly not expected, even if one admitted
the possibility of a dermoid cyst forming between the serous
layers of the mesentery. Dr. Basch felt much gratified that
such an excellent authority in these matters as Mr. Doran so
fully supported his views.
820
A CASE OP VESICO-UTBRO-VAGINAL FISTULA.
By Charles J. Cullinqworth, M.D., P.R.C.P.
Beoeived June 28tb, 1889.
A MARRIED woman^ aged 37^ residing at Braintree^ Essex,
was admitted into St. Thomas's Hospital, Pebruary 7th,
1889, for incontinence of urine, first noticed after her
third confinement, twelve months ago. The patient was
a healthy woman, of small stature and feeble intelligence.
It was difficult to obtain a coherent history, but the fol-
lowing facts were elicited. She had been married six
years, and had borne three children. All her deliveries
were instrumental. The first and third children were
bom dead, having been destroyed during delivery. The
second child was delivered by forceps, and lived two
years. The patient cannot say whether the urine began
to pass involuntarily the day following her confinement,
or not until a week after.
A vesical fistula was found in the middle line of the
anterior vaginal wall, running transversely immediately
in front of the cervix, in the furrow formed by the re-
flection of the mucous membrane from vagina to cervix
(Pig. 1). The fistula admitted the tip of the finger up to
the first joint. The portion of the cervix projecting into
the vagina was intact, but on passing the finger through
the fistulous opening, a laceration, with ragged edges,
was detected higher up in the posterior wall of the bladder,
extending into the cervix (Pig. 2) . On passing a uterine
sound into the cervix, the point passed through the lacera-
tion into the bladder. On Pebruary 14th the anterior
lip of the 08 uteri was divided, when the cervical lacera-
tion at once gaped widely (Pig. 3), and by elevating the
VESlCO-nTBRO-TAQINAL PI8TUU. 321
Fie. 1. — Taico-TaginBl portion of the flttnla, litnated &t tlie
viginal raSectioD, itt edge* held apart b; hooking ap iti
anterior border.
Fjs. 2,^Verico-nterine portioa of ftttolti (diaframnintic).
322
VBSICO-UTEBO-VAGINAL FISTULA.
Pio. 3.— Vetico-ateiine portion of fistula after division of the
anterior lip (diagrammatic).
anterior margin of the vaginal portion of the fistula
with a hook^ could be seen to extend obliquely upwards
and to the left^ to tbe distance of about an inch. The
edges of the laceration were now carefully freshened by
cutting away a strip of tissue on each side with the scissors,
and were then united by three or four sutures of silk-
worm gut^ passed from the outer aspect of the cervix^
most of them being tied within the bladder. The ends, left
long enough to reach the vulva, were brought through
the vaginal portion of the fistula, the repair of which was
reserved for a future occasion. The necessary manipula-
tions for the repair of the cervical laceration were facili-
tated by keeping the anterior border of the vaginal fistula
hooked well forward all the time. Milk was now poured
into the bladder by means of a glass funnel and india-
rubber tube ; no oozing appeared from within the cervix.
The vagina was douched with solution of corrosive subli-
mate (1 in 8000). The operation lasted au hour and
three quarters. The bowels acted at the end of a week.
On the 26th (thirteenth day) the stitches were removed,
and the wound appeared to have healed throughout.
VESICO-UTEBO-VAOINAL FISTULA. 328
On March 2nd the patient was examined. No oozing
appeared at the os uteri when milk was poured into
the bladder. Two sounds passed^ the one into the cervix
and the other into the bladder^ did not touch one
another. There being some inflammation about the
margin of the vaginal fistula^ where it had been held open
by the blunt hook^ further operation was postponed for a
few days.
On March 29th the repair of the vaginal portion of
the fistula was proceeded with. It had undergone a
considerable amount of contraction^ and its long axis was
now fortunately found to be no longer transverse, but
nearly parallel with the axis of the vagina. The margin
was denuded freely in the usual way, and the fistula closed
by five sutures of silkworm gut, the ends of which were
left long enough to reach the vulva. During the operation
the vagina was exposed by a broad perinaeal spatula and a
fenestrated vaginal elevator in front ; while the cervix
was drawn well down by means of a volsella in the posterior
lip. Haemorrhage was checked by occasional douching
with hot boracic solution. Pledgets of cotton wool, satu-
rated with solution of corrosive sublimate (1 in 1000),
were used instead of sponges. After the sutures were
tied some milk was poured into the bladder ; none found
its way into the vagina. The bladder was therefore washed
out with boracic solution, and an iodoform tampon placed
in the vagina in contact with the wound, orders being given
to remove it the following morning. The patient was
allowed for the first few days to pass water, without assist-
ance, every two hours. This plan, however, did not answer.
The draw -sheet was found slightly soiled with urine on
the evening of the second day, and continued to be so for
two days. An examination was then made with the view
of inserting another stitch if necessary. The patient
meanwhile maintained that the leakage came from the
urethra, and this proved to be the case. Milk was poured
into the bladder, and, as none escaped through the wound,
the patient was sent back to bed. The catheter was now
324 YE8ICO-UTIRO-VAOINAL FISTULA.
ordered to be passed every four hours^ and there was no
further leakage.
On April 5th (eighth day) the sutures were all re-
moved. All had held firmly^ without any trace of ulcera-
tion or suppuration along their track. The catheter was
discontinued on the ninth day^ and the patient allowed to
sit up in bed to her meals.
On April 18th she was discharged well^ with complete
control over the bladder.
Bemarhs. — The character, shape, and position of the
fistula seem to me to point rather to its having been the
result of laceration than of sloughing. Unfortunately the
patient was by no means clear as to how soon after de-
livery the urine began to escape, so that its mode of
causation must remain matter of surmise. I consider my-
self fortunate in having succeeded in closing the cervical
portion of the fistula so easily. Had the first operation
not succeeded, I intended to dissect up the bladder from
the cervix, and deal with the uterine fistula in the manner
recently suggested and successfully practised by Dr.
Ghampneys. The only point in the treatment to which I
wish to call special attention is the leaving the ends of
the sutures sufficiently long to hang down in the vagina.
This plan greatly facilitates removal, and avoids irritation
of the vaginal mucous membrane.
Dr. Gbiffith had recently operated on a similar case by the
usual operation ; everything apparently went well, the bladder
remaining water-tight, but he bad heard that the menstrual
blood, since the operation, passed entirely into the bladder.
He had offered to put this right, but the patient was so pleased
with the freedom from the ordinary inconvenience of menstrua-
tion that she declined to have anything done.
Dr. William Duncan always used silver sutured in vesical
fistulse ; fastened them with coils and shot to facilitate removal,
and passed all the sutures through a piece of india-rubber tubing
to prevent irritation of the vagina.
"Dr. CuLLorowoBTH apologised for occupying the time of the
Fellows with the narration of a single case. He desired to draw
the attention of all those interested in the subject of vesical
YSSICO-UTEBO-YAOINAL FISTULA. 825
fistulffi to a short paper of singular value, published in the last
volume (vol. xvii, for 1887) of the 'St. Thomas's Hospital
Beports/ by Mr. Milton, of the Civil Hospital at Cairo. Mr.
Milton's experience was, he ventured to think, unique. In three
years he had performed the operation for vesical fistula in fifty
cases, several of these having required to be operated upon more
than once. The paper consisted of a summary of these opera-
tions, and a clear statement of the conclusions at which the
author had arrived as the result of his exceptional experience.
The large number of cases was explained by the fact that the
poorer native women had no assistance during labour; they
simply waited until the child came, whether that happened in a
few hours or whether it took a week or more. Hence urinary
fistulsB were exceedingly frequent. Lacerated perinsBum, on the
other hand, was scarcelv ever seen. Mr. Milton's extreme
modesty had, unfortunately, prevented him from yielding to the
solicitations of his friends to reprint his paper. It was, there-
fore, in great danger of being overlooked.
326
A CASE OF LUPUS OF THE VULVA.
By Aethue H. N. Lbwbes, M.D.Lond., M.B.C.P.Lond.,
A8BI8TANT OB8TBTBI0 FHTBIOIAH TO THB lOlTPOV HOBPITAIi.
G. W — , aged 22^ has been married six years^ but has
had no cbildren or miscarriages ; she was admitted to
Davis ward of the London Hospital on August 24th^ 1888^
complaining of having a swelling in the private parts.
History of the present illness, — She had a yellow dis-
charge from the vagina two years ago. Soon afterwards
she noticed a small growth in the vnlva^ which has gra-
dually increased to its present size.
When the yellow discharge began^ the private parts
swelled up suddenly^ and she had pain in passing water.
No history of buboes. Of late there has been no pain
or trouble in micturition.
The catamenia began at fifteen^ and have always been
irregular^ and accompanied with pain.
The family history was of no special interest.
Present state, — On inspection of the vulva there is seen
a somewhat spherical pendulous lump^ smooth and of a
whitish colour on its inner surface^ irregular and some-
what nodular on its outer aspect, which has a brownish
tint.
The measurements of the growth are as follows :
Extreme antero-posterior diameter = 8^ inches.
Maximum transverse diameter - = 2 ,,
Greatest circumference - - = 8 „
Projection from the vulva - - = 2| „
The tumour grows from the left labium minus^ but its
attachment is a broad one^ and also involves the anterior
upper part of the right nympha and the prepuce of the
clitoris.
LUPUS OF THB VULVA. 827
Anteriorly and externally there is a secondary pro-
jection^ the size of half a walnut^ from the general surface
of the growth.
The labia majora are thickened by a kind of solid
oedema^ so that each one measares one inch across. They
do not pit on pressure.
Behind and externally the labia majora are studded
with small warty prominences^ and there are similar ones
on the perinaBum^ extending as far back as the anus.
There is also one the size of a halfpenny on the mons
Veneris.
Where the affected surfaces are in contact there is su-
perficial ulceration.
The parts are not tender.
The vagina is healthy as far as the finger can reach.
The glands in the groins are not tender^ and are not
enlarged.
There is no history of syphilis to be obtained^ nor are
there any signs of it about the patient. She distinctly
says the cause of the yellow discharge was that ^' her hus-
band gave her the bad disorder^'' and there is every reason
to believe that by this she means gonorrhoea^ and not
syphilis.
Operation. — ^August 28th the patient was put under
ether^ and the pedicle of the tumour was clamped with two
pairs of Wells's large pressure forceps. The pedicle was
then cut through with Paquelin's cautery.
All the small warty prominences already described were
also burnt off.
The large pressure forceps were then taken off^ and
the cut surface of the pedicle thoroughly seared with the
cautery. There was some bleeding even when this was
done^ and as the tissue of the pedicle seemed too rotten
to bear a ligature^ two pairs of small pressure forceps were
left on the bleeding points for twenty-four hours.
The patient did quite well, and left the hospital in about
three weeks' time. The hypertrophy of the labia majora
remained as before.
328 LUPUS OF THE VULVA.
The patient came up to the hospital regularly to see me^
and although the labia majora remained hypertrophied as
before^ there were no ulcerations seen till the beginning of
January^ 1889. There was then found to be a lump the size
of an almond lying beneath the mucous membrane^ just
inside the vulva^ on the right side. It was hard^ and the
surface was red and ulcerated.
The patient was readmitted^ and after trying the appli-
cation of iodoform to the patch without benefit^ she was
put under ether, and the lump pinched up and dissected
out with Paquelin's cautery.
The wound healed up soundly^ and the patient went
home. I have seen her frequently since ; the labia majora
remain in the hypertrophied condition already described,
and up to about the end of May, when I last saw her, there
had been no recurrence ; but I think this may be expected,
sooner or later.
Remarks. — The large growth appears to be made up of
an enormously hypertrophied labium minus, as suggested
by the whitish inner surface, and the pigmented outer sur-
face. Sections of it show that it is chieiBy made up of
fibrous tissue.
The tendency of the disease in this case is towards hy-
pertrophy combined with ulceration, and there has been
recurrence after an apparently complete removal of the
hypertrophied and ulcerated tissue. The general health
of the patient seems to have been almost, or completely,
unaffected by the local disease*
Dr. WiLLLAJi Duncan reminded the Fellows that in the dis-
cussion on Dr. Matthews Duncan's paper on ** Lupus of the
Vulva/' Mr. Jonathan Hutchinson expressed his opinion that
the cases were syphilitic and not lupous. With this opinion
Dr. W. Duncan strongly coincided, and he considered Dr.
Lewers' case was one of hypertrophic syphilide, exactly similar
to several he had under his own care ; he asked if Dr. Lewers
had put the patient under a course of strong antisyphilitic
remedies.
LUPUS OF THE VULVA. 329
Dr. Matthews Duncan was of opinion that the case was one
of hipus, and had no resemblance to any syphilitic growth.
Dr. Lewebs said that it would be in the recollection of the
Society that when Dr. Matthews Duncan read his series of
papers on '* Lupus of the Vulva " it was admitted on both sides
that the administration of antisyphilitic remedies would not
decide whether the conditions in question were to be regarded
as syphilitic or as the manifestations of a special disease, because
late results of syphilis were often unaltered by these remedies.
Dr. Lewers thought that no one would be justified in classifying
the specimen shown as syphilitic (as Dr. W. Duncan had done)
unless he had himself seen several times an exactly similar
growth in patients who had undoubtedly suffered from syphilis.
In Dr. Lowers' case there was not the slightest evidence of
syphilis, either in the patient's history or in her physical con-
dition. Taking into account her humble position in life, the
probability would be that, if she had had syphilis, she would
not have been so carefully treated from first to last as to have
no trace of the disease about her. Moreover, she gave her
history freely and unreservedly, and there was every reason to
think that if she had suffered from any of the secondary effects
of syphilis she would not have denied it. Dr. Lewers mentioned
that an appearance identical with that seen in the case described
in his paper is figured in Winchet's ' Diseases of Women ' as
elephantiasis of the vulva.
DECEMBER 4th, 1889.
Alfred L. Galabin, M.D., President, in the Chair.
Present — 35 Fellows and 4 visitors.
Books were presented by Dr. Cullingworth, Dr.
Matthews Duncan, Dr. Frommel, Dr. Playfair, the Medical
Society of London, and the Medical and Chimrgical
Faculty of the State of Maryland.
Thomas Edward Parsons, M.B.C.S. (Wimbledon), and
Arthur Henry Williams, M.A., M.B., B.C.Cantab. (St.
Leonards-on-Sea), were declared admitted as Fellows of
the Society.
The following gentlemen were proposed for election : —
Robert J. Carter, M.B.Lond. ; Charles Plumley Childe,
B.A., L.B.C.P.Lond. (Southsea) ; Edward Henry Douty,
M.A., M.B., B.C.Cantab. (Cambridge) ; Harry St. Clair
Gray, M.D., C.M.Glas. (Glasgow) ; T. Arthur Helme,
M.D.Edin. (Manchester) ; Charles Henry James, L.B.C.P.
Lend. ; Ernest E. Lewis, L.B.C.P.Lond. ; Chichester
Gould May, M.A., M.B.Cantab. (Dublin) ; Godfrey Forrest
Beid, M.D., Dublin (Orange Free State) ; John Frederick
William Silk, M.D.Lond.; Charles Herbert Thompson, B. A.,
M.D., Dublin ; and Charles Percival White, M.R.C.S.
The President nominated the following gentlemen as
auditors of the accounts for the year : — Dr. Boulton, Dr.
Champueys, Dr. Amand Kouth, Dr. Boxall, and Mr.
Malcolm.
832
HJEMATOSALPINX AND PYOSALPINX.
By Wm. Duncan^ M.D.
HYDROSALPINX.
By Wm. Duncan, M.D.
FIBRO-MYOMA AND ABSCESS.
By Wm. Duncan, M.D.
CYSTIC OVARIES AND HYPERTROPHIED FALLO-
PIAN TUBES.
By John Phillips, B.A., M.D.Cantab., M.R.C.P.
Db. John Phillips liaci removed the above from a patient
aged 25 years, single, who had been nnder the observa-
tion of her medical attendant for six years with metror-
rhagia, monorrhagia, and dysmenorrhoea ; daring the
past six months they had all increased, the pain being
almost intolerable. On examination per vaginam there was
felt a fixed fluctuating swelling, with some hard mobile
bodies amidst its contents ; the left ovary, enlarged and
very tender, was also made out.
On opening the abdomen there was found a universally
adherent cystic right ovary ; on breaking down the ad-
hesions a half-pint of grumous blood welled up into the
wound, and four hsematoliths of the size of a sixpenny piece
were removed : one of them, shaped like a button, had
OVARIAN TUMOUBS. 388
ulcerated its way almost into the peritoneal cavity. A
glass drainage-tnbe was necessary for twenty-four hours.
The patient made an easy and normal convalescence.
SPONGE TENTS.
By AusT Laweencb^ M.D.
Db. Aust Lawrence (Clifton) exhibited some specially
prepared sponge tents. The tents were made from very
fine sponge rendered aseptic by having been soaked in 1
in 2000 corrosive sublimate before being made up, and
after they were made they were coated with a solution of
corrosive sublimate (1 in 1000) in gelatine. This coating
not only preserves the tent^ but renders its introduction
into the uterus very much easier than when not coated, as
the point of the tent does not soften and turn as most
tents are liable to do in their introduction. Tents prepared
like this are very easily passed, and owing to the smooth
surface a very much larger tent can be used, which of
course gives a much fuller dilatation. Dr. Aust Lawrence
considered the use of these tents in suitable cases and
with proper precautions to be absolately harmless, but he
laid stress on the importance of absolute cleanliness in the
details of manipulation.
SOME SPECIMENS OP OVARIAN TUMOUBS.
By J. Bland Sutton, P.R.C.S.
1. A UNILOCULAR ovarian dermoid, occupying the
oophoron. The cyst equals in size a fowl's egg, and
presents on its inner wall a patch of piliferous skin. In
a previous communication to this Society I attempted to
VOL. XXXI. 23
334 OTAEIAH TOMOPEB.
show that dermoids of the ovary arone in the oophoron,
hut increAsiag in size they early caused ahsorption of the
paroophoron. This specimen is instructiTe, for it is ex-
tremely rare to find the paroophoron intact when a cyst
has attained snch proportions as in the present case.
Dermoid. P. pHroOphor
2. An orarian tnaionr with the Fallopian tnhe, removed
hy Dr. Bantock. The tnmcmr equals a cocoa-nut in size,
and consists of two portions, as shown in Fig. 2. The
smaller portion is a thin-walled cyst, with a patch of pili-
fepous skin on its iuner wall. The larger portion is nearly
solid, and constitutes the most important and interesting
part of the tumour. On section this presented the usual
naked-eye characters of an ovarian adenoma, but when
OTABIAN IimOUBB.
Pi«. 2. — An omrian dennoid. h. A delicHte tntt of Isnngo-lika
huT ; the aectioiu from which Fif;. 3 was prepared were Uken
from near its baie. Mat. liie.
336 OVARIAN TUMOURS.
cxamiDod microscopically it presented an interesting variety
of structure, as illustrated in Pig. 3. The piece of tissue
from which the sketches were made was taken from near
the delicate hairy tuft marked h in the drawing. Fig. 2.
I selected this spot because it contained a deposit of dark
pigment. The following parts were crowded together in
a piece of the tumour less than half an inch square :
(a) a developing tooth, with its enamel organ and
dentine papilla ; running from the neck of tlie enamel
organ upwards to the free surface, which represents the
wall of a loculus, is a tract of cells representing the guber-
naculum. Other developing teeth in a more advanced
stage were seen in the same section, in which the centre
of the enamel-organ was occupied by the typical stratum
intermedium.
(b) This is a typical epithelial pearl, and consists of an
encapsuled collection of epithelium. Here and there
similar pearls are met with in which the central cells
seem to have undergone transformation into horn. These
pearls are instructive ; occasionally we find loose in the
cavity of ovarian dermoids rounded bodies resembling the
boiled lens of the eye of a fish, or a silver-coated pill.
Such bodies are doubtless epithelial pearls which have
been dehisced from the walls of the cyst.
(c) A portion of the wall of a loculus. It is lined by
definite epithelium, arranged in a manner characteristic
of epidermis of the skin. In one part of it two developing
hairs may be seen, with rudimentary sebaceous glands ap-
pended to them. Near them is a small bay filled with
epithelium. Should this be completely embedded, it
would form an epithelial pearl.
(d) An ill-formed mass of glandular tissue, the acini of
which are lined with a regular layer of columnar epithe-
lium, whilst the acini are filled with a delicate form of
connective tissue. Such a mass of glandular tissue is ex-
tremely puzzling ; it resembles equally a simple adenoma,
a cancer, or an epithelial odontome. Dotted irregularly
OTABIAN TUUOCtBa. 337
thronghont the specimens are sweat-glands seen in sec-
tion, r.
— A compinite wriei of dniwiags ghowiDg the hiitological
diTenitjr of the wlid portion of the avarisD tumoar sketched
ID Tig 2 A Developing teeth B An epithelial pearl.
C Badnneatarj hun anil •ebmeou gUndi s Glandular
liMue z A baj filled with epithelmin r Sweat-gUadi in
tecbon*.
(e) Lastly, it is suggestive to thmk that the cluster of
epithelium lodged in the bay e may become either an
epithelial pearl, as m (b), of if associated with a papilla it
conld stand for an enamel organ , associated with a mar
Itgnant tumonr it suggests the birds'-nest of an epithe-
338 OYABIAN TUMOURS.
lioma, and is not unlike epithelial layers sometimes found
in sebaceous cysts (formerly called cholesteatomata).
3. A tubo-ovarian cyst. A. M — , aged 43 years, was
admitted into the Middlesex Hospital under my care. She
had been suffering for two years from a tumour which
occupied the right side of the pelvis, and extended into
the abdomen as high as a line drawn across the belly at the
level of the highest point of the iliac crest. The tumour
was rounded, well defined, and elastic. Per vaginam a
swelling could be detected low down in the pelvis, and
presented all the clinical characters of a tumour occupying
the right broad ligament.
The patient, though married for seventeen years, had
never been pregnant, and her periods had of late been
very irregular. Sometimes a menstrual period would
last for a month, and not reappear for two or even three
months.
On opening the abdomen I enucleated from the right
broad ligament a cyst which contained three pints of clear
fluid. The cyst was intimately associated with the Fal-
lopian tube, which was removed with it. The left ovary
and tube were adherent to surrounding structures, and it
was deemed advisable to leave them. The patient's re-
covery was somewhat prolonged, in consequence of a
hsBmatocele which slowly formed in the broad ligament.
Eventually she left the hospital in a very satisfactory con-
dition, and has been able to report herself as in excellent
health and strength.
On dissecting the specimen the Fallopian tube was
found dilated and contorted ; its distal end communicated
with the interior of the cyst by an oval aperture. The
wall of the cyst near this opening presented a series of
ridges continuous with similar ridges in the Fallopian
tube.
It was clearly a tubo-ovarian cyst. The walls of the
tube, near its junction with the cyst, were examined mi-
croscopically, but no lining epithelium could be detected ;
it is probable that the epithelium had disappeared by
OTAKIAM TDKOUBS.
atrophy, induced by the stretching of the tube. It is a
point of some importance, and one in which Dr. Griffith,
in his elaborate paper on tnbo-ovHrian cysts, is eiloDt, viz.
Fia. 4. — A tabo-ovuiMt cyit.
V. Utenu- F. Falb^an tube-
tbat the cyst lay between the layers of the broad ligaments.
True ovarian cysts are outside this structure, and it is ex-
tremely difficult to account for this position of tbe cyst
supposing it to arise in the orary.
340
A CASE OF INVERSIO UTERI ; REDUCTION ;
RECOVERY; REMARKS.
By J. Beaxton HigeSj M.D., P.R.S.
(Beceived July 31rt, 1889.)
I WAS called on January 22nd, 1887, by Dr. Buchan to
assist in the redaction of an inversion of the uterus under
the following conditions.
A primipara, aged 26, was delivered apparently natu-
rally, but with rather free hsBmorrhage following. The
placenta came away without assistance, and she went on
well till the third day, when, on rising to urinate, some-
thing *^ came down,'' appearing externally. Dr. Buchan
was sent for, and recognising the accident, endeavoured
to reduce the inversion, but found it impossible, having
no ansBsthetic. He therefore asked me to meet him. I
found the uterus within the vagina, which it distended ; it
was soft, and had layers of coagula over portions of its
surface. The patient was placed under chloroform with
ether added, and I endeavoured, after compressing the
uterus so as to reduce its bulk, to restore it by pressing the
mass upward ; but I was resisted by the cervical portion,
which was firmly contracted. I used as much steady
force as I thought could be borne by the vagina, supporting
it by the hand externally placed, but without success. I
then proceeded to return it by impressing the fundus, and
having at hand a speculum with an obturator I pressed
it against the inverted fundus, cupping thereby this part.
This was gently and steadily pressed up, till by the hand
placed externally I felt the fundus uteri gradually distend-
ing the cervical portion. The external hand made counter-
INTBBBIO UTXBI. 841
presBure on the now enlarging ring of the cervix, and thns
in the space of ten minutes I found the major part of the
uterus restored. I then withdrew the speculum, and
introduced the obturator of a larger one, so as to give
more room at the point of flexion. In another minute I
was pleased to find the uterus in its normal condition. I
again introduced the former speculam with an obturator^
and left it within the cayity to prevent relapse. This was
removed in a few hoars, and the patient recovered without
a bad symptom. There was no bleeding at all during the
reduction or after.
Bamarhs. — Obstetric authors differ in the methods they
recommend for treating recent inversion of the uterus.
For instance. Dr. M'Clintock (' Diseases of Women ') ob-
jects to fundal replacement, pointing out a mechanical
reason, and recommending the plan of Dr. Montgomery,
namely, *' replacing that part first which came down last:''
Dr. Aveling following M'Clintock, in his ' Inversion of
the Uterus,' 1886, says, " Fundal reposition may be
attempted by pressing on the fundus with the object of
driving it through the cervix. It is the most unscientific
method of replacing an inverted uterus, as it demands un-
necessary dilatation of the neck.'' . . . '' Lateral repo-
sition is a very effective plan of reducing recent inversion ;
cervical reposition is the mode of reducing chronic inver-
sion." In recent cases he recommends the plan of lateral
replacement ; the very worst plan is the fundal method.
Lusk, however, recommends the fundal method, and
gives a case in which it answered very well, but speaks
approvingly of the lateral (Noeggerath's) plan.
Barnes (' Obstetric Operations ') recommends fundal
pressure for the immediately recent cases, but where the
OS has become contracted, then to grasp the portion just
below with the hand, and push the mass slowly and firmly
against the constriction, following up the uterus as it re-
cedes. He points out the state of the os as being an
important factor.
The above extracts show that there is much diversity
342 INVEB6I0 UTEKI.
in the recommendations as to treatment of cases of recent
inversion. The condition of the os and inverted cervix
doubtless is the chief cause of this difference. With a re-
laxed OS and cervix, restoration is easily accomplished by
pressing upward the whole mass, so that reduction com-
mences with the cervix. I have published a case where
six days after the accident I was able very easily to restore
the uterus to the natural state. But when the cervix is
firmly contracted, it is more or less difficult, if not impos-
sible, to effect this, and then other methods must be tried.
Notwithstanding that fundal reposition has been con-
demned as unscientific, yet in this case it succeeded, I
may say easily, while the other did not, owing to the
firmly contracted state of the cervix, and the bulkiness of
the uterine mass. The speculum, with its obturator, being
smaller than the knuckles or fist, seems more convenient
f 6r fundal replacement ; and if the obturator be employed
only, the objection of the duplication (if it has any reality)
is done away with. But can this objection be sustained f
In any case the uterine equator must pass the cervix : if
the cervix be relaxed, it passes easily ; if contracted, with
difficulty. When in fundal replacement the fundus passes
the cervix there is no duplication, neither when the
equator passes is there any. By this time the restoration
is mainly accomplished, and all that the rest has to do is to
follow suit. In recent cases, as the lower part of the uterus
has within a few days allowed a full-term child to pass, the
principal point is to get something within the cervix to
gently dilate it, which in this case could be watched by
the outside hand with the greatest clearness. The cervical
method puts considerable strain on the vaginal tissues,
and the same might be said of the fundal pressure as
regards the uterine walls. But counter-pressure on the
ring through the abdominal walls much facilitates either
method.
Dr. HoBRocKS asked if the uterus was completely inverted
or whether a small portion of the cervix remained unchanged,
INVEB8I0 UTKBI. 343
because this might make a considerable difference in the success
of the method of treatment adopted. If the uterus was com-
pletely inverted probably the ** f undal method " of replacement
might be better than the other, and there would not be the
same objection to the method, because the thickness passing
through the inverted os would not.be greater than in the ordinary
method of restoring the uterus.
Dr. Griffith noticed that the case was reported as being one
of spontaneous inversion, and he wished to ask if any Fellow of
the Society had himself actually witnessed inversion of the
uterus occur in connection with the third stage of labour, under
circumstances which could be called absolutely ** spontaneous."
344 ON CLOSUSB OF THB OSTIUM IN INITLAMMATION
ON CLOSURE OF THE OSTIUM IN INFLAMMA-
TION AND ALLIED DISEASES OF THE FAL-
LOPIAN TUBE.
By Alban Dosan.
(Received September 26th, 1889.)
{Ab8tra4it)
Thb author, in tbis communication, dwells on the frequency
of closure of the ostium in salpingitis ; but the obstruction is
often temporary. Obstruction of the uterine end is due to
swelling of the mucous membrane or to the development of
" Chiari's bodies " from that membrane. Permanent closure of
the tube is almost synonymous with closure of the ostium.
Salpingitis and perimetritis are the causes of closure of the
ostium. Three essential factors in relation to the subject are
considered at length. 1. The nature of the ostium and its
fimbnes. 2. The nature and varieties of salpingitis, and also of
perimetritis as far as it affects the tube. 3. The precise maimer
in which the ostium is closed in perimetritis and salpingitis.
In adhesive perimetritis the fimbrise of the tube are boimd down
by bands, which thus obstruct the ostium. In salpingitis the
ostium is obstructed, incompletely at first, by the swelling of
the mucous membrane which involves the fimbrioB ; but perma-
nently in bad cases by great infiltration of the submucous tissue
and middle coat, which swell over the ostium and cover in the
fimbrisB. The perimetritic and salpingitic varieties of closure of
the ostium, often blended, are demonstrated by specimens and
diagrams. The question of timely conservative operations on
obstructed non-suppurating tubes is discussed. Dr. Skutsch's
''salpingostomy,*' where a small piece of the tube is excised,
appears to be a promising step in that direction.
AND ALLIED DISEASES OF THE FALLOPIAN TUBE. 345
Temfobabt or permanent closure of the Fallopian tnbe
at the ostium is certainly the rale in salpingitis, and in
perimetritis in the immediate neighbourhood of the ostium.
In appendages removed for old inflammatory disease of the
ovary the tube is often found thickened and tortuous,
whilst the ostium appears to be open. Nevertheless the
canal is more or less obstructed by the swelling of its
mucous membrane. On the subsidence of this inflamma-
tion this source of obstruction would, no doubt, disappear
in similar cases where the tube is not removed, and where
the inflammatory process, so far as it affects the tube, pro-
ceeds no further. In this manner must end many mild cases
of salpingitis, cases where the symptoms are hardly severe
enough to cause more than a trifling amount of discomfort
to the patient. The uterine end of the tube is very prone
to obstruction, through swelling of the mucous membrane
in salpingitis, just as the nasal fossss are obstructed in
coryza and influenza. The tumefied mucous coat bulges
freely when the walls of the diseased tube are cut through.
That this swelling, and with it the obstruction, should dis-
appear together with the inflammation is not surprising.
Stricture of the uterine end of the tube, after the manner
in which the ostium is so often closed, is impossible owing
to the anatomical characters of the part ; though a peri-
metric band pressing on the tube near its uterine end
may obstruct the canal at that extremity. Chiari's bodies,''^
which may cause obstruction, are results of salpingitis.
There is no evidence that they fail to undergo atrophy
as the inflammation subsides.
With the ostium the case is different. When it is
closed, changes more serious and more frequently perma-
nent than swelling of the complicated mucosa occur, al-
though that swelling is probably constant. Hence closure
of the tube is all but synonymous with closure of the
ostium. Exceptional cases where the ostium remains
open may be dismissed. I dwelt upon this rare condition
* ** Zur pathologiBchen Anatomie des Eileiterkatarrhs/' ' Prager Zeitschrift
fur Heilknnde/ vol. viii.
346 ON CLOSURE OF THE OSTIUM IN INFLAMMATION
in a commnnication published in a recent volume of the
Society's ' Transactions/ * Salpingitis and its complica-
tions must not be confounded with haematosalpinx^ where
the ostium is often not only open, but also dilated.f Tubal
gestation usually causes sufficient inflammation to seal up
the ostium ; but in a recent case I found the ostium open^
and the fimbriss almost normal.
The cause of closure of the ostium is salpingitis or peri-
metritis. In cases of solid and cystic tumours of the
ovary and uterus it is never closed unless one or both of
these conditions be also present; otherwise the tube is
elongated and stretched, but not obstructed. In tumours
of the parovarium and broad ligament this stretching of
the tube is extreme. The fimbrisB are involved, the ovarian
fimbria attaining a length of two, three, or four inches —
indeed, I have seen it even longer. The ostium, so far
from being closed, is abnormally patulous.
In relation to the subject of this paper, some of the
pathological changes occurring in salpingitis and perime-
tritis must be carefully consideried. By salpingitis I
mean inflammation of the tube ; by perimetritis I wish to
signify inflammation of the peritoneum in its neighbour-
hood. Three essential factors must be duly considered in
detail.
1. The nature of the ostium and its fimbrisB.
2. The nature and varieties of salpingitis, and also of
perimetritis as far as it affects the tube.
3. The precise manner in which the ostium is closed in
perimetritis and salpingitis.
When the first and second are clearly understood, the
third factor, the subject of this communication, !s not
difficult to explain. Before they are understood we can-
not hope to attempt the conservative surgical treatment
of diseased tubes. The ultimate aim of surgery in this
* " Papilloma of the Fallopian Tabe, and the Relation of Hydroperitoneam
to Tubal Disease/' vol. xzviii, 1886, p. 229.
t See " Report on Dr. Playfair'B Specimen of Small Ovarian Cyst and
Hematosalpinx/' in the Society's * Reports/ vol. xxxi, p. 162.
AND ALLIED DI8KASBS OF THB FALLOPIAN TUBS. 347
respect shoald be the removal of the obstruction without
amputation of the tube.
What is the ostium^ and what are its fimbrisB ? Dr.
Arthur Parre's classical article in Todd^s ' CyclopsBdia ^
contains a description of the naked-eye appearances of the
tube which has never since been surpassed^ and a series
of drawings of that structure which could not be excelled,.
The manner in which the serous coat joins the mucous
membrane of the tube^ the transitions of the plicsB of
the tubal canal into the fimbrisB outside the ostium^ and
the precise nature of the ovarian fimbria^ are described
and depicted with equal fidelity. To Richard^ however,
must be given the credit for the illustrations of the tube
which adorn Dr. Farre's admirable monograph. Dr. Parre
did wisely in selecting such woodcuts as IHgs. 404, 405,
407, and 408, for they demonstrate what Richard had al-
ready discovered, the great variety in the development of
the fimbriae, especially the ovarian fimbria.
Nevertheless we must not rely on literature and art
alone, even when sanctioned by so high an authority as
Dr. Parre. On that principle I have made a fresh series
of dissections, and taken sketches of them, or caused
drawings to be prepared by Mr. Lewin ; for Richard's
woodcuts, especially Fig. 405 in Dr. Parrels monograph,
err through being a trifle too diagrammatic.
I made the sketch. Fig. 1, from a well-developed tube
attached to an ovary which was removed as it showed
signs of cystic disease. The opposite ovary had become
a large cyst. The tube was split open and sketched under
water when fresh ; for alcohol causes the plicae and fim-
briae to become pale and shrink. The plicae are, as
Richard long ago demonstrated, elevated and ineffaceable
folds of mucous membrane, like the valvulae conniventes,
excepting that they run in the long, not the short, axis
of the canal in which they lie. As they pass beyond the
ostium they become larger and multiply ; sometimes two
fimbriae formed by division unite again. After close
inspection of many hundreds of specimens I have come
348 ON CLOSUBI or THB OBTIDH IM IsniAlflfATIOK
Fia. 1. — Oatium of DOrmal Fallopian tube laid open, shoiring
the continuation of plies into flmbriN, and the diohotomons
ditriiion of the flmbrira. The ovftruD flmbrik u well formed.
Fie, 8.— End of tnbe with ostium laid open. The plici
longed ■■ in Fig. 1, and continued to the end of th
flmbrift.
AND ALLiED DISEASES OF THE FALLOPIAN TUBE. 349
to the conclusion that this multiplication is mainly by
dichotomous division. I have indicated the division in
Fig. 1 ; it is best seen near the free extremities of the
fimbriae. I admit that a plica sometimes appears to spring
up from the mucous membrane beyond the limits of the
ostium. This condition, however, probably represents
atrophy of a portion of an intratubal plica behind it, for
a plica of this class, ending bluntly at or behind the
ostium, is generally to be found in a straight line with a
plica which appears to lie entirely outside the ostium.
Careful examination of the grooves between the plicae will
enable the observer to trace the particular intratubal plica
to which each fimbria belongs. There is another order,
so to speak, of secondary plicae which spring from the
sides of the primary plicae forming the fimbriae. They give
rise to the arborescent appearance seen in microscopic
sections of the tube at the ostium. On the other hand,
the two divisions of a primary fimbria may join again, as
is often seen above the ostium within the tubal canal.
In Fig. 2, where the tube has also been laid open for
some distance above the ostium, the extension of the plicae
into the fimbriae is further demonstrated. In Figs. 1 and
2 it is seen that the plicae are prolonged on to the ovarian
fimbria. Fig. 3, a fine sketch by Mr. Lewin, shows
extreme subdivision of the plicae beyond the ostium. Some
of the fimbriae are prolonged as slender, thread-like bodies.
These long filaments, together with true accessory fimbriae
springing from the broad ligament, play a conspicuous
part in some cases of perimetritis and salpingitis, binding
down the tube to neighbouring organs.
The anatomist can readily understand why, when the
plicae pass outside the ostium, they attain large dimen-
sions^ blossoming into fimbriae. No longer cribbed and
confined within the firm and narrow walls of the tube,
they expand freely in the peritoneal cavity. A similar
condition is seen in accessory ostia. The plicae bulge
freely through these abnormal orifices (see Fig. 4; see
also *' Malformations of the Fallopian Tube/' ' Trans.
VOL. XXXI. 24
OH CLOBDBB O? TUB OSTIUM IN INVLAUHATION
Fie. 3.— A apecimen ilmilar to Vigi. 1 and 2. Some ot the Am-
brim are prolonged ao ai to torm Slameiitoiu Btructaraa.
5^/ v'
Fifl. 4. — End of a tube witb two ncceaaory OBtia, a\ a\ through
which the plies balge, forming Smbriie m at the niwinal oatiom
(m.) The ovarian Ainbria ia redaced to a thin band above (<^),
and highly developed below (q/').
AND ALLIES
OF THE FALLOPIAN TUBE.
351
Obat. Soc.,' vol. xiviii, 1886, Fig. 5, p. 173). This bulging
of the plicaa is important io relation to "aalpingoatomy."
Wbeo an artificial opening is made and the tube collapses,
the plicEB may possibly bnlge out of it, after a time, as
they bulge from accessory ostia.
The ovarian fimbria, which mns along the free border
of the broad ligament to be attached to the surface of the
ovary, being placed in the beet positioo for free develop-
ment, is often large and conspicuous. There is a cod-
spicnously well-developed variety of the ovarian fimbria,
bearing three, four, or more secondary plicee which are
sometimes contiunons with intratnbal plicse, an in Fig. 2,
sometimes entirely cut off from the tube, as in Fig. 4. The
peritoneal attachment may atrophy more or less completely,
so that the ovariau fimbria forms a loOp (Fig. 4). In
its commonest variety the ovarian fimbria forms a fringe
like an elongated leaf, the peritoneal attachment usually
running close to one of the free borders of the fimbria
(Fig. 5). A third or atrophic type of ovarian fimbria
/*'
Fio. 6. — An ovarun fimbris moderately developed; about aix
time* natural aize. The pticm ore dlitiiict but lotr. Tlie dotted
linea, pa, reprewnt tlie itbachment of the edge of the perito-
neum, nhich liei clOBfl to one (yJ'> of the free borders (/i',/6')
of the ftmbris. on, aniy.
is not rare. The fimbria is redoced to two or three
wattles lying along a groove in the border of the broad
852 ON CLOSURE OF THE OSTIUM IN INFLAMltATION
ligament ; a doable row of these wattles is often seen on
the surface of a thin-walled broad ligament cyst between
the ostium and the ovary. Each row may be separated
by the distance of half an inch when the cyst is full, and
between them the plicaa of this fimbria often form long
red streaks. The ovarian insertion of the fimbria forms
a cord-like structure, not always devoid of the evidence
of plicae.
As Miiller's duct, originally closed, undergoes cleavage
to form the ostium, the ovarian fimbria represents the
opened-out canal of the duct along the line of cleavage.
The liberated plicas bloom into fimbrias in the manner
already indicated. A reversal of this process takes place
when the ostium is closed.
On inspecting the tube sideways its peritoneal coat is
seen to end abruptly along a line corresponding to, or
rather representing, the ostium. This line runs obliquely
from above downwards and outwards, ending inferiorly
at the beginning of the ovarian fimbria. The outer
borders of the primary plicae forming the fimbriae are
attached to this line of peritoneum. In rare instancesj
as Farre has already noted, the peritoneum is prolonged
on to the base of a fimbria for some distance. This rela-
tion of the peritoneum to the fimbriae and ostium is im-
portant to understand before we study the closure of the
tube in disease. It will be shown further on how the
swollen fimbriae, in the early stage of salpingitis, project
abnormally beyond the ostium, and how, later on, the walls
of the tube, infiltrated with inflammatory products, bulge
over the fimbriae along the line where the serous coat ceases.
The natural relations of the fimbriae to the ovary will
presently be discussed.
The normal characters of the fimbriae which surround
the aperture termed the ostium having been considered,
the two diseases, perimetritis and salpingitis, which so
often cause the closure of the ostium, must next be taken
into account.
By perimetritis I signify what general pathologists
AND ALLIED DI8BA8E8 OP THE FALLOPLAN TUBE* 353
would term pelvic peritonitis, and what precisians among
specialists might prefer, as far as the subject of this paper
is concerned, to call perioophoritis or even perisalpingitis.
I have selected the expression perimetritis, as employed
so conveniently by Dr. Matthews Duncan. Perimetritis,
as here understood, may be either an anatomical district,
so to speak, of a wide area of generalised adhesive peri-
tonitis, or an absolutely localised adhesive inflammation
of the peritoneum, arising from various causes. I limit
the term simply to the adhesive form. This perimetritis
may be secondary to any uterine disease, to oophoritis, to
salpingitis, or to inflammation of a pelvic cyst or solid
tumour.*
Adhesive perimetritis binds down the tube to the ovary,
crumpling up, as it were, the mesosalpinx or portion of
broad ligament between those structures. EfiFacement of
the mesosalpinx in this manner is of necessity due to peri-
metritis, even when that disease is secondary to salpin-
gitis. This fact must not be forgotten. Another form
of effacement of the mesosalpinx will presently be de-
scribed ; it is essentially the direct result of dilatation and
hypertrophy of the tube. In perimetritis thin but dense
bands may bind down the tube at one or more points,
causing more or less complete obstruction. Accessory
fimbri89 often play a share in this process. Most perti-
nent to the main question, however, is the fact that peri-
metritis often closes the ostium by direct means. A band
of adhesion grows over the fimbrias or holds them down.
Of this complication more will be said.
As to salpingitis, a fall description of its different
varieties would be out of place. I have examined over a
hundred diseased tubes, and find that the varieties of sal-
pingitis, as described by Martin, Orthmann, and others,
often but not always represent early or late stages of the
same disease. The mucous membrane is, as a rule, first
involved in the inflammatory process which extends to
* I have seen, eipecially in one case, very old perimetrifeic deposits covering
all the pelvic viscera, yet neither tobe was obstructed.
354 ON CLOSUBB OF THB OSTIUM IN INFLAMMATION
deeper stractures. Tet an almost purely interstitial sal-
pingitis^ where the tube is tbick^ hard, yet nnobstmcted,
certainly exists, and so little is the mucous membrane in-
volved that the disease in question may be considered as
primary. Hydrosalpinx and pyosalpinx are complications
secondary to closure of the tube.
In salpingitis the inflamed mucous membrane becomes
swollen, hence the plic89 appear thickened very early in
the disease. The fimbrisd are soon involved in this pro-
cess, and often seem as though half strangulated at the
ostium. This appearance, very conspicuous at operation,
is rapidly destroyed by the action of spirit. Lymph exudes
freely from the inflamed surface, forming bands which
bind fimbriaB together. This suggests a delicate patho-
logical subtlety, as to whether these bands be salpingitic
or perimetritic. Putting aside technical terms, it may be
said that the effusion of organised lymph is due to inflam-
mation of the tube at first, for it is seen in the plicae within
the tube, protected from perimetritic changes, as well as
in the fimbriae. As this process, however, goes on in a
region where an inflamed mucous surface opens on to a
serous membrane, the latter must soon become involved,
throwing out organised lymph. This swelling and semi-
strangulation of the fimbriae cause more or less obstruc-
tion, never permanent unless complicated by conditions
which will presently be described. Even in mild cases
of catarrhal salpingitis this swelling is never entirely
absent,* hence more or less temporary obstruction of the
ostium must occur.
Within the tube yet another change is observed in sal-
pingitis of more or less severity. The submucous tissue
is involved, it becomes oedematous. The swelling extends
more or less to the connective tissue of the muscular coat
and to the subserous coat. This represents the " inter-
* Here the observer must be reminded that the tube must be examined in
the subject in order to see this swelling. After removal of the tnbe, the
bluod draining away, the engorgement of the fimbriss disappears. For rea-
sons given above, spirit preparations throw no light on this subject.
AND ALLIED DISEASES 01* THE FALLOPIAN TDBB. 355
stitial salpingitis " of Martin and Orthmann. The inflam-
matory infiltration is especially important at the line of
demarcation between the peritonenm and the fimbrice at
the ostium. Here^ as will presently be farther demon-
strated, it causes the most essential and permanent form
of closure of the ostium. The process also accounts for
the disappearance of the fimbriae.
In relation to occlusion of the tube two more subjects
are worth consideration, namely, the approximation of the
occluded and distended tube to the ovary and the natural
and the abnormal relations of the ostium to the same organ.
The manner in which the tumour is approximated to the
ovary by perimetritic adhesions has been described. The
crumpling up of the mesosalpinx is easily demonstrated.
That portion of the broad ligament may be unrolled, as it
were, when the specimen is examined by the pathologist,
if it has not been already torn away from its adhesions to
the ovary during the process of removal of the parts at
operation or after death. Salpingitis with obstruction
brings the tube and ovary into more intimate relations.
The distended tube opens up the layers of the mesosalpinx
until its walls touch the ovary, just as a burrowing ovarian
cyst opens up the same serous layers until its walls touch
the tube. A broad ligament cyst burrows in the same
manner till it touches the tube above and the ovary below.
This process, which may be termed the burrowing of the
tube, can be readily demonstrated on an ordinary hydro-
salpinx. Monprofit, who has described the process with
great accuracy,'^ terms it le dedoublement du mSsoaalpinx.
The tube does not float above the ovary in the living
subject, with its fimbriaa mostly pointing upwards, back-
wards, and forwards, the ovarian fimbria running directly
downwards. That position is purely diagrammatic. The
tube forms a high arch over the ovary, which lies in the
pelvis with its long axis not horizontal but more or less
oblique, according to the position of the uterus. The
uterine half of the tube rises, the outer half descends and
• ' SalpiDgites et Ovftritet/ Paris, Steinheil, 1888.
356 ON CLOSURE OF THE OSTIDM IN INrLAMMATlON
bulges freely behind and external to tbe ovary. Thus the
ovarian fimbria runs upwards towards its insertion on the
ovary. The outer aspect of the ovary is covered by the
other fimbrisd. Those which are represented in diag^ms
as the highest are naturally the lowest. The ostium looks
inwards towards the ovary. HencCi when obstructed by
the special changes which occur in salpingitis, it is found
more or less closely applied to the swollen ovary. The
mesosalpinx, passing across the arch made by the tube,
forms a kind of veil or cover to the upper part of the
ovary, to which it may often be seen adherent by peri-
metritic bands.
Were the tube really placed in its diagrammatic rela-
tions, it would assume a very different appearance when
obstructed and dilated. It would form a pyriform tumour,
the narrow end being close to the uterus, the broad end
looking upwards and outwards. The ovary would be
pulled up by the ovarian fimbria. The reverse change of
position actually occurs. The obstructed extremity of the
dilated tube presses against the ovary ; in extreme dila-
tation it coils round the outer aspect of that organ, and
may even extend downwards and inwards below it.
This bulging of the outer end of the tube around and
even below the ovary is the cause of great confusion in
many cases of tubal gestation, where the changes in the
tabe outside the foetal cyst are essentially salpingitic.
The fcetus appears to lie far from the tube, apparently in
or outside the ovary, when in reality it lies within the outer
part of the tube. This fact must not be forgotten when
we read accounts of '^ undoubted ovarian gestation.'^ The
relations of the fimbria? are best displayed when the fellow-
ovary to an ovarian cyst is inspected in the live subject,
an inspection I have had the advantage of noting several
hundred times. The subject is fully demonstrated in Prof.
His's " Lage der Eierstocke ^' {' Archiv fiir Anat. u. Phys.,*
Anat. Abtheil., 1881).
After the above facts relating to the tube and its dis-
eases are recognised, the precise manner in which the
AND ALLIED DISEASES OF THE FALLOPIAN TUBE. 357
ostium is more or less permanently closed is easily ex-
plained. It is occluded either by bands of lymph which
cover in the fimbriad^ or by changes within the walls of the
tube^ which cause much swellings so that the walls bulge
and close in over the fimbrias. The first process is essen-
tially a part of the pathological changes constituting peri-
metritis. I shall therefore term it^ for the sake of sim-
plicity, " perimetritic closure of the ostium." The second
process is a part of the condition known as salpingitis, and
may be termed '^ salpingitic closure of the ostium." As
perimetritis and salpingitis are often combined, both gene-
rally take a share in closing the ostium.
Perimetritic closure is the simpler form. A little de-
posit covering the delicate fimbriaa as they lie on the sur-
face of the outer aspect of the ovary is suflScient to bind
them down, and then the ostium necessarily becomes
closed as soon as the deposit is organised. In operations
for chronic disease of the appendages the early stage of
\ the process is often observed. Sometimes, on scraping
\ away the bands of lymph, the fimbria come in sight,
well-formed, succulent, and bright red, being full of blood.
In that case little or no salpingitis is present.
The accompanying sketch (Fig. 6) represents an ex-
tremely typical example of pure perimetritic closure of the
ostium of the right tube. The fimbriae, well formed and
exuberant, were stufFed into a deep pouch on the outer
side of the ovary, formed by a stout band of membrane.
In the drawing, the fimbriae are displayed as they appeared
after I pulled them half out of the pouch. A black
bristle passes out of the ostium into the pouch. Before
the parts were disturbed the ostium lay deep in the pouch,
looking towards the ovary, and of course completely
obstructed. The tube was tortuous, and kinked by some
firm perimetritic bands. The patient was married and
thirty-six years of age ; her youngest child was over four
years old. For a year she had been subject to severe
monorrhagia, ending in incapacity for work, and great
pain during an action of the bowels. The appendages
358 ON CI.080RB 09 TBB 08TIDH IN INrLAHHA-riON
FlO. 6. — An ovary and tobe, ahowLng obitruction o( tha Mtinm
by perimetritic depoait whiob formi a deep poacb. The flmbrin
have been partlj pulled ont of tbe poach. A briitle puM* into
tbe poach ont of tbe oftiom.
Fia. 7.— Complete obrtrnctioo of the mtinm, the remit of lalpin-
gilJi. Tbe end a( the tnbe hu been detactied from the ovarj
below and the oetinm forcibly opened ; n bristle pamet ont of
its oHBce. The tiunes of tbe tnbe hnve swollen over theoatinm,
completely concealing the finibriie, excepting the ovarinn flmhria
which is aeen below the bristle. Behind and above the bristle
are perimetritic bands, which must not be mistaken forflmbrin.
AND ALIitRD DISEAB8S OF THE PALLOFIAM TUBE. 351:1
were removed by Dr. Bantock in March, 1888. The right,
represented in Fig, 6, lay high in the hypogastrium, and
were not bonnd to any adjacent structnre. The left tube
and ovary were adherent to the peritoneum deep down in
Donglas's poach.
Salpiogitic closure of the ostiam is well displayed in
Fig. 7. At a glance its distinction from the perimetritic
form becomes evident. The end of the tube has been
peeled off the ovary, to which it adhered, and lifted np-
wards so as to display the obstruction. No fimbriie can
be seen excepting the ovarian fimbria. A bristle occu-
pies the ostium, which has been forced open. Around the
bristle the tubal walls, extremely thickened, bulge freely.
The fimbriEe now lie within the tubal canal, as may be
seen in Fig. 8 ; in fact, they have been reduced to plicae.
Pia. 8.— An obatrnctad and dilated tube laid opea. Tlie flmbrin
nre seen, enUrely inclnded nithin iti cavitj.
They have not retracted — indeed, they could not retract,
like the tentacles of a sea-anemone ; the infiltrated tubal
walls have closed over them. Before the parts were dis-
turbed in Fig. 7, the bulging extremity lay i^ainst the
outside of the ovary ; the oedematous ovarian fimbria
360 ON CLOSUBB OF THE OSTIUM IN INFLAMMATION
running upwards. In more advanced cases that fimbria
becomes reduced to a thin band. Perimetritic bands are
seen on the surface of the tube in Fig. 7,* but they take
no direct part in closing the ostium. The patient^ also
under the care of Dr. Bantock^ was twenty-three years of
age ; the symptoms were very similar to those in the last
case, whence Fig. 6 was taken.
The next drawing. Fig. 8, shows the position of the
fimbriae in salpingitic closure of the ostium. The external
appearances resembled those in Fig. 7. Part of the wall
of the tube has been cut away, displaying the distended
canal. The remains of the fimbrias are seen lying close to
the side of the ostium. They are continuous with the
plicdB, or rather are reduced to plicaa through lying within
the tube, just as plicaa become fimbriaa when they protrude
beyond an accessory ostium. The pressure of the fluid
contents of the distended tube has caused them to atrophy.t
This condition, whether it occur in salpingitic or peri-
metritic closure of the ostium, must be taken into account
in relation to conservative operations on diseased tubes.
If the plicae and fimbriae be destroyed, it is hard to see
how the tube can ever become available for its functions.
If the plicae and fimbriae reappear after the obstruction to
the tube has been relieved, we may reasonably hope that
the tube may become as sound as before the earliest onset
of salpingitis. The inner wall of a long-distended tube
generally consists of a glossy cicatricial tissue. This does
not offer a favourable prospect for the restoration of the
mucosa. Yet the epithelium is not so rapidly destroyed
as the observer might at first be led to believe. In a
pair of tubes greatly dilated and disused for many years
I found papillomata covered with well-formed columnar
epithelium,! nor, I find, is the epithelial investment of
the mucosa always absent in a very tense hydrosalpinx.
* One fluch band lies close behind the bristle, and must not be mistaken
for a bunch of flmbrise.
t Simple stretching of the tubal wall cannot efface the pUcie.
X See ' Trans. Path. Soc.,' vol. xxzix, pi. xii, fig. 3.
AND ALLIED DISSASBS OF THB FALLOPIAN TUBS. 361
The natural tendency of an obstructed tube is doubtless
towards cure by relief of the obstruction^ but the liability
of the patient to repeated attacks of pelvic inflammation
too often prevents cure in this manner. The tube being
spoilt^ in the sense above indicated^ it tends to undergo
changes such as I have described in two recent communi-
cations to the ' Transactions of the Pathological Society/*
Uniform cystic degeneration of tube and ovary is the
typical ending of chronic disease of the appendages, but
surrounding complications are infinite, and interfere with
the steady reduction of tube and ovary to a double
or even single cyst. It is clear that in advanced stages
of tubal disease where the ovary is thus disorganised the
tube is spoilt ; indeed, if it could be restored to its func-
tions it would be useless.
We must lastly consider the chances of restoring the
tube to its uses before it is spoilt. I have witnessed ope-
rations where the peritoneal cavity has been opened, and
diseased tubes freely handled, the fimbria being carefully
inspected as the best landmarks to guide the operator in
distinguishing the relations of the parts much confused by
disease. In each of these particular cases the surgeon,
fearing to remove the tubes, closed the abdominal wound,
and the patient made a good recovery, declaring herself
cured long after the operation. In some of these instances
the cure may have been due to thorough (though hardly
intentional) opening of the ostium, no perimetritis or sal-
pingitis following the operation so as to close the ostium
once more. Still, evidence on this point is very doubtful,
for there are many sources of fallacy. The freedom from
former bad symptoms after the operation does not, in these
cases, necessarily prove that the tubes have been restored
to their functions, for these good results often follow total
removal of the tube, and sometimes ensue when the tubes
are left absolutely untouched. The incomplete or conser-
* "A Pair of Chronic Inflamed Uterine Appendages, illtutrating the
DeYelopment of Tabo-ovarian Cysts," vol. xzxFiii, p. 241 ; " Papilloma of both
Fallopian Tabes and Ovtaiw" vol. xzxix, p. 200.
362 ON CLOSURE OF THB OSTIUM IN INFLAMMATION
vative operation above noted leaves too much to chance^
for the breaking down of adhesions around the ostium is
likely to cause enough irritation to set up fresh iDflamma-
tion^ which would rapidly seal ap the ostium again. The
dangers of any incomplete operation are cousiderable^ even
in simple cases of recent obstruction. In pyosalpinx no
such proceeding could be justified. Lastly^ the pains and
dangers to which the patient is exposed in diseases of the
tube may not be entirely due to tubal obstruction.
The draining of a pyosalpinx through an abdominal
incision may prove satisfactory in some cases^ but it does
not restore the tube. The most promising method of
restoring an obstructed^ non-suppurating tube to its func-
tions is perhaps that suggested by Dr. Skutsoh^ of Jena^
and carried into effect by him in one case with fairly
satisfactory immediate results. He has devised an opera-
tion which he terms ^' salpingostomy." It was described
before the third meeting of the Deutsche Gesellschaft fiir
Gynakologie at Freiburg in June^ 1889 (see ' Centralblatt
fiir Gynak./ No. 32, 1889). He operated upon a sterile
patient^ aged thirty-eight, with moderate dilatation of both
tubes, which is said to have caused great pain, the ovaries
and uterus being apparently free from disease. Some of
the fluid contents of each tube were first withdrawn by
means of a Pravaz syringe, and found to consist of clear
yellow serum free from pus. The ostium was then laid
open, the fluid allowed to escape^ and an oval piece of the
wall, about one square centimetre in size, cut away. The
mucous membrane and serous coat were united along the
margin of the artificial aperture by fine silk thread.
Lastly, a sound was passed through the aperture along
the tubal canal into the uterus. Convalescence was un-
interrupted. " From the day of the operation forward
the woman was free from pain."
The principle of salpingostomy is sound, and should the
plicae be restored through the relief of tension, it is highly
probable that those near the artificial opening would ulti-
mately bulge and form fimbriae, just as is seen, as already
AND ALLIED DI8BASB8 OF THB FALLOPIAN TUBE. 363
described^ in accessory ostia. Dr. Skatsch recognises the
dangers of the operation and the necessity for farther
experience. Its benefits must be restricted to a small
number of cases where alone it can be justifiable. The
stage of salpingitis where it can be performed can hardly
be diagnosed excepting by opening the peritoneum with a
view to more radical measures if necessary.
Dr. HosBOCKS spoke of tbe importance of the paper as an
original contribution to the pathology of a part of the body
about which we wanted more light. He pointed out that tbe
orifices of the body, mouth, lips, tongue, pharynx, anus, rectum,
vulva, vagina, cervix, where most friction took place, were more
affected pathologically than other parts, such as the general
surface of the skin, layers of muscle, &c, ; that the ostium
abdominale was unique, in that it was an orifice where a mucous
membrane became continuous with a serous membrane. More-
over, it was a very tiny opening, and had to catch and transmit
the ovmu as it came out of the G-raafian folhcle. A priori, one
might expect to find frequent pathological changes about this
orifice ; and, considering its minuteness, it was almost a wonder
it was not more frequently obliterated. He thought Mr. Doran's
classification a gooa one, but whilst admitting the not infrequent
origin of perimetritic inflammation from a salpingitis, due per-
haps to gonorrhoea, or some uterine cause, yet he thought the
stfurting-point of inflammation was more frequently in the ovary.
In Figs. 7 and 8 he did not quite see how Mr. Doran proved
that the closure of the ostium was due to salpingitis, and not to
perimetritic adhesions outside the tubes.
Dr. BuTHKBFOOSD considered Mr. Doran's paper a very valu-
able one, as it demonstrated the di£Ferent ways in which the
tubes become occluded. He thought it possible the paper might
help to explain the occurrence of those fringes which were occa-
sionally found floating freely in tubo-ovarian cysts. It seemed
to him the fimbnss, which were contained within a tube owing
to salpingitic swelling ajid closure,' might be carried into the
ovarian cyst when the two cavities opened into each other,
especially if the opening occurred from the side of a distended
tube. In salpingitis the fimbriss generally became retracted,
and in some cases completely inverted, though he imagined
complete inversion to be rare. He had met with such a condi-
tion two or three times, but the fimbrisB were generally thickened
and somewhat adherent to each other. Mr. Doran's specimen.
No. 8, was very fine, and showed the delicate fimbriss completely
inverted, hardly thickened, and more or less distinct from each
364 ON CLOSURE OF THE OSTIUM IN INFLAMMATION.
other. Such a specimen be had not jet met with. The classifi-
cation into salpingitic and perimetritic closure was very good
and simple, but in the majority of cases Dr. Butherfoord
thought the inflammatory process started from the tube, which
was itself only secondarily infected.
Mr. Alban Doban, in reply to Dr. Horrocks, expressed his
belief that in the majority of cases disease of the tube spreads
from below, that is, from the mucosa of the vagina and uterus,
the genital tract bearing poisonous material developed in leucor-
rhoeal, gonorrhoBal, and lochial discharges. Nevertheless he
admitted that infection might travel to the tube by another
path ; in other words, inflammation of the ovary might set up
salpingitis. Mr. Doran maintained that Figs. 7 and 8 were very
fine examples of salpingitic closure of the tube, although peri-
metritis was also present. The dilatation in Fig. 8 was, of
course^ secondary to the closure of the tube, and caused the
walls to become thin, although at first thickened by inflamma-
tion. In reply to Dr. Rutherfoord, Mr. Doran maintained his
theory that tubo-ovarian cysts generally represented a very late
degenerative change in chronic disease of the tube and ovary.
He admitted, however, that in rare instances a tubo-ovarian
cyst might represent a congenital malformation, as Dr. Griffith
and Mr. Sutton appeared to believe.
365
NOTES OF A CASE OP H^MATEMBSIS IN A
NEWLY BORN INFANT.
By H. C. HoDGBs, L.R.C.R
(Received October 7th, 1889.)
Fboh the comparative rarity of these cases, and the still
greater rarity of their recovery^ I hope that the accoant
of a case which occurred under my father's care may be
of interest^ more especially as it seems to throw a possible
light upon other cases.
On April 23rd^ 1888, Mrs. N — , wife of a clergyman,
was delivered of her third child at 5 a.m., after a per-
fectly natural and somewhat easy labour. Both mother
and child were left apparently quite well at 7 a.m.
At 11 a.m. came a very urgent message to go over at
once — they lived four miles away — as the child "had
haomorrhage.^'
My father went, expecting to find that the ligature of
the cord had become loose or insecure, and was surprised
to find the child blanched and with very faint pulse, and
all the surrounding clothes, which had by that time been
removed, saturated with bright blood which the child had
vomited.
Fortunately the nurse was a woman with a large share
of common sense, and, moreover, had seen a similar case —
which ended fatally — several years before, and she had
done everything possible for the arrest of the hasmorrhage.
The child had been put to the breast without result, and
was troubled with constant hiccough. It was ordered to
be kept absolutely quiet, and given ten minims of hazeline
every two hours.
VOL. zzzi, 25
366 a^MATKHSSIS IN A NBWLT BOBM INVAKT.
I saw the child at 7 p.m., and found it improving. No
farther hasmorrhage, bat about a table-spoonful of blood-
stained mucus was vomited at 5.80 p.m. Nothing since.
Hiccough constant, but not so severe as in the morning.
One rather copious evacuation containing blood, besides
the ordinary meconium.
There seemed to be slight lividity of the skin of the
left ear, but no discharge. Treatment continued.
24th. — General condition improved. Hiccough less.
Some slight serous discharge from left ear, and subcon-
junctival hasmorrhage in left eye.
25th. — Ear discharging serous fluid fairly copiously.
Internal strabismus of left eye. No paralysis of limbs.
26th. — Condition much the same. Strabismus more
marked. Discharge from ear less. Appetite good. No
sickness. Bowels normal.
From this time the child steadily improved. The aural
discharge gradually ceased. The strabismus disappeared,
and at the end of three weeks could scarcely be noticed.
At times, when the child laughed, it was thought that the
movements of the left side of the mouth were imperfect,
but this became gradually less distinct, and at the end of
a month the child was perfectly well, and has continued
so without interruption to the present date.
Three points strike me as of especial interest in this
case:
1. The main fact of recovery after the loss of a large
quantity of blood, recoveries being, so far as I can gather
from the scanty mention of the cases in the text- books, not
more than 50 per cent.
2. The value of hazeline as a styptic in internal and
obscure hasmorrhage. In this case I certainly believe
that it contributed greatly to the arrest of the hasmor-
rhage ; and as it is not unpleasant to the taste, and is quite
innocuous so far as toxic effects are concerned, it is easily
taken by children.
3. The fact of the discharge from the ear, the strabis-
mus, and the partial facial paralysis, seem to point to in*
HAHATBUEBIS IN A NSWLT BORN INFANT. 367
jury to the base of the skull involying a vessel or vessels^
if not actnal fracture. This^ with even an easy labour^
seems to be quite within the bounds of possibility^ and^
considering the bright colour of the bloody I think it not
improbable that the hsBmorrhage did not come from the
stomach at aU^ but from the posterior part of the pharynx
or the palate^ and that some of the blood having been
necessarily swallowed^ gave rise to the hiccough and occa-
sioned the condition of the stools.
The reason why I am of opinion that this may have been
the cause in other cases is the entire absence of cause
found on post-mortem examination^ with the exception of
one case mentioned by West (^ Diseases of Children ^), in
which subsequent hasmorrhage occurred into the arachnoid^
causing apoplexy.
So far as I am aware^ the cerebral symptoms above
described have not been observed in other cases ; but^ on
the other hand^ many of them have been so rapidly fatal
that there has been no opportunity of judging; and^ in the
absence of any known cause^ it strnck me this theory might
be worth consideration.
Dr. W. Griffith said that opportunities for investigating the
pathology of some forms of hsBmorrhage not uncommon in new-
born infants were rare. He had some time ago received from
Dr. Uhthoff, of Brighton, the generative organs of an eight
months female infant, a week old, which had suffered from a
vaginal discha^e of blood, beginning on the second day, until its
death from an independent cause. Blood was found both in
the uterus and vagina. The parts had been imperfectly pre-
served for histological examination, and Dr. Griffith had not
been able to determine whether the surface changes in the
mucous membrane, which in the new-bom fcetus is extremely
delicate, were due to decomposition or to a denudation similar
to that described as occurring during menstruation. There was
no extravasation of blood into the mucous membrane, but just
above the cervix on the posterior wall was a minute circum-
scribed area, having the appearance of an ulcer, but without
histological evidence of iuBammation.
Dr. Dakin said Mr. Hodges' communication was a valuable
addition to our knowledge on the subject of hsemorrkages in the
868 hj:uatbmebi8 in a nbwlt bobn infant.
newly bom, as to the causes of whicb so little was ascertained.
He was disposed to agree with the author as to the cause in this
case, not only on account of the evidence produced in support of
this in the paper, viz. subconjunctival eccnymosis and otorrhcea,
but also, and mainly, because the bleeding occurred within six
hours of birth. The strabismus and doubtful facial paralysis were
very untrustworthy symptoms in such a young child. Btemor-
rhages of one kind and another had been numerously recorded
as happening to children during the first few weeks of life, and
were, in his opinion, expressions of a general condition some-
times existing then, which had been called " hsBmophilia neona-
torum," but which had really nothing to do with hsemophilia
strictly speaking. He alluded to a state of the system in which
hsBmatemesis, epistaxis, subcutaneous hsamorrhages, bleeding
from the vagina or rectum, from the navel, and other places
occurred, apparently spontaneously. These seldom or never
happened before the fifth or sixth day, so that, although the
labour was an easy one, it was likely that the cause in this case
was directly traumatic. The large quantity of blood reported
to have been lost, however, made it perhaps a little doubtful
whether this was a complete explanation of the matter. On
account of the date of its occurrence, he demurred to the
author's conclusion that the same cause was to be assigned to
other cases of hsBmatemesis, as in the recorded cases in Dr.
Dakin's recollection no bleeding of this kind occurred at so
early a period as within the first twenty-four hours of life.
Dr. BoxALL said that in the only case of copious vomiting of
blood in early infancy which he could call to mind the source of
the hssmorrhage was not the stomach nor the infant at all. In
the absence of pallor in the child, he was led at once to examine
the breast of the mother from which the child had lately been
suckled. He then discovered a fissure at the base of the nipple.
On attempting to draw the breast through a glass shield,
blood was seen to issue freely from the fissure instead of milk
from the nipple. This possible source of blood should be borne
in mind in similar cases.
Dr. Hbbbebt Spbngbb believed vomiting of blood from a
diseased stomach to be exceedingly rare in the new-bom. From
the accompanying symptoms he had little doubt that the blood
in this case came from a fractured base of the skull. He had
several times seen such fractures, causing hsemorrhage beneath
the periosteum.
Dr. BouTH said it was not to his mind clear that the cause of
the hssmorrhage in Dr. Hodges' case was the other injury in the
ear. It might be so, but, as had been correctly stated by a
previous speaker, the mucous membranes of babies were pecu-
liarly thin and tender, and the hsemorrhage might have been
produced by the forcible suction attempted. He instanced a
RBXATBHB8I8 IN A NBWLT BOBN INFANT. 369
case of a ladj whom lie bad attended some years back and con-
fined of twins, with similar hsBmorrliage from the mucous mem-
brane of the mouth. The twins were premature, scarcely seven
months, and she, being a silly, nervous mother, had tried to
compel them to suck, with the result of producing hsBmorrhage
from the mouth. He thought children should be fed, under
these circumstances, with raw beef juice or milk, gently squirted
into the mouth ; the hazeline, he could quite understand,
would be clearly a great help, but he had not, unfortunately,
employed this agent. He would like to ask Dr. Hodges whether
the cluld in his case was premature, and if any careful examina-
tion had been made of the mouth to trace, if possible, the exact
source of the hssmorrhage.
INDEX.
PAOB
Abdomen, palpation of the, the diagnosis of placenta prsBvia by
(H. B. Spencer) ... 203
Abdominal section, anterior serous perimetritis simulating
ovarian sai'coma when explored by (Alban Doran) . 217
Aborted OTXim, showing cyst^ in tiie decidna vera (John
Phillips) . . . .161
Abscess and fibro-myoma (William Duncan) . 332
Acardiac monsters, notes on, in the museums of London hos-
pitals (Alban Doran) . .4
— acephalous monster (W. S. A. Griffith) . 2
of six months' gestation, with rudimentary
heart (Woodley Slyman) . .258
mylacephalous twin (H. E. Trestrail and Alban Doran) . 2, 4
Acephalous acardiac monster (W. S. A. Griffith) • 2
of six months' gestation, with rudimentary
heart (Woodley Slyman) . . .258
Address {Annual) of the President, John Williams, M.D., Feb-
ruary 6th, 1889 .73
— (Inaugural) of the new President, A» L. Galabin, M.D.,
March 6th, 1889 .88
Anatomy, contribution to the, of the pelvic floor (G. E.
Herman) ...... 263
Anencephalous foBtus (Alban Doran) .52
(W. S. A. Griffith) .134
(A. Perigal) . . .165
(William Duncan) .202
Annual General Meeting, February 6th, 1889 51, 69
Antiseptic irrigation in child-bed, instruments for (Graily
Hewitt) ..... 202
372 INDEX.
PAGE
Babhbs (Robert), BemarJca in discuBsion on W. Newman's
paper on a case of inversion of the ntems . 169
in discassion on John Phillips's paper on acute
non-septic pulmonary disorders as complications of the
puerperium ..... 193
in discussion on H. R. Spencer's paper on the dia-
gnosis of placenta prsBvia by palpation of the abdomen 213, 216
in discussion on R. Boxall's specimen of pelvic
luBmatoma following delivery .... 307
Black (J. Watt), Report as Chairman of the Board for the
Examination of Midwives .71
Bladder, gangrene of the, from retroversion of the gravid
uterus (A. Rasch) ..... 129
Blue urine ; cyanuria (John Phillips) . . . 256
Bony plates, dentigerous, from a dermoid ovarian tumour
(Alban Doran) . . . .86
BozALL (Robert), pelvic hasmatoma following delivery ; death
four hours after labour (shown) . . . 306
BemarJca in discussion on John Phillips's paper on acute
non-septic pulmonary disorders as complications of the
puerperium ..... 195
in discussion on H. R. Spencer's paper on the dia-
gnosis of placenta prasvia by palpation of the abdomen . 215
in discussion on Matthews Duncan's paper on lace-
ration of the vagina in labour . . 240
in discussion on A. Rasch's paper on a case of large
chylous cyst of the mesentery . . . 317
in discussion on H. G. Hodges' notes of a case of
hsBmatemesis in a newly bom infant . 368
Brain, uterus, and heart from a case of puerperal septicsBmia
(William Duncan) . . . .202
Broad ligament, large myoma of (William Duncan) . . 309
Bbown (Dyce), EemarJca in discussion on W. Stephenson's
paper on the relation between chlorosis and menstruation 122
Bryant, Walter John, F.R.O.S., of Reading, obituary notice of 74
CsBsarean section, case of, for contracted pelvis (F. H. Ghamp
neys) .....
— uterus, ovaries, and tubes from a case of (G. J. Gulling
worth) . . . . •
Cancer, primary, of the Fallopian tube (Amand Routh)
136
308
200
iNDix. 878
PAOS
CanoeroQB utems removed by Yaginal operation fW. B.
Playfair) . . . . . .227
Oabteb (G. H.)f Bemarka in diaooBdon on A. Baaob's paper on
a caae of large cbyloas cyat of tbe meaentery . . 318
Oenrix, aee Uierua (eervim of).
Obalmera, Jobn, M.D., of Keppel Street, W.0.» obituary
notice of . . . . . .75
Ohaupnbys (F. H.)» BepoH on apecimen of an aborted ovnm
showing cyata in the decidna vera, abown by Jobn Pbillipa 161
caae of Cseaarean aection for contracted pelvia . . 136
BemarJca in reply ..... 158
in diacosaion on Archibald Donald'a paper on
methoda of craniotomy . .43
in diacoaaion on H. B. Spencer'a paper on the dia-
g^oaia of placenta prsBvia by palpation of the abdomen . 213
in diacuaaion on Matthewa Doncan'a paper on lacera-
tion of the vagina in labour .... 240
Ohild-bed, inatrumenta for antiaeptic irrigation in (Qraily
Hewitt) . . . . . .202
Ohloroaia and menatmation, on the relation between (W.
Stephenaon) ..... 104
Ohorea in pregnancy (M. Handfield-Jonea). . 243
Ghyloua cyst of the meaentery (A. Baach) . . 311
Olapham (Edward), ahrivelled foetua of the fifth month utero«
geatation (ahown) ..... 202
Rema/rJea in diacuaaion on W. Stephenaon'a paper on the
relation between chloroaia and menatmation . 119
Glsybland (W. F.), Betnarka in diacuaaion on G. S. Pollock'a
specimen of cyat of the ovary of a mare . 235
— in diacuaaion on Matthewa Duncan'a paper on lacera-
tion of the vagina in labour .... 240
— in diacuaaion on John Phillipa'a apecimen of blue
urine ...... 256
Gomplex twiatinga of the funia (M. Handfield-Jonea) . 164
Gontracted pelvia, caae of Gasaarean aection for (F. H.
Ghampneya) ..... 136
GsAio (Jamea), aee Thornton.
Graniotomy, methoda of (Archibald Donald) . 28
GuLLiNOWOBTH (G. J.), hsBmatoaalpinz (ahown) . 226
-»» — and intra-peritoneal hsBmatocele from rupture of a
varicoae vein on the inner aurface of the right Fallopian
tube (ahown) ..... 257
374 INDBX.
PAGB
OxTLLiNawOBTH (0. J.)» ntems, ovaries, and tubes from a case
of CflBsarean section (shown) .... 308
case of vesico-utero-vaginal fistula . 320
Bemarka in reply ..... 324
— ^ in discussion on Archibald Donald's paper on
methods of craniotomy . .47
— ^ — - in discussion on F. H. Ohampneys' paper on a case
of GsBsarean section for contracted pelvis . 156
Oyanuria ( John PhilHps) .... 256
Oysts, see Ovarian,
— see Tumourt.
Dakin (W. B.), retroflexion and ectopia viscerum (shown) . 308
Bemarka in discussion on H. G. Hodges' notes of a case
of hffimatemesis in a newly born infant. . . 367
Decidua vera, aborted ovum showing cysts in the (John Phillip?) 161
Dentigerous bony plates from a dermoid ovarian tumour ( Alban
Doran) • • • . . .86
Dermoid ovarian cyst, case of retention of urine caused by
pres8ureof(W.S. A. Griffith) . . .135
— tumour (William Duncan) . . 255
(J. Bland Sutton) . . . .333
dentigerous bony plates irom (Alban Doran) . 86
Diagnosis of placenta prsvia by palpation of the abdomen
(H. B. Spencer) . . . .203
Diseased foetal membranes of uncertain nature in early preg-
nancy (John Phillips) .52
Dissection of Mr. Trestrail's case of mylacephalous acardiao
twin, with notes on aoardiac monsters in the museums of
London hospitals (Alban Doran) .4
Donald (Archibald), methods of craniotomy 28
— Eemarha in reply . . .48
DOBAN (Alban), for William Skene, anencephalous fostus
(shown) . . . . .52
— Eepori on specimen of small ovarian cyst and hsBmato*
salpinx, shown by W. S. PlayfiEur . . 162
on specimen of ovarian dermoid from a mare, shown
by G. Stewart Pollock .253
dentigerous bony plates from a dermoid ovarian tumour
(shown) . . . .86
fibroma of the ovarian ligament (shown) . 200
fragment of membrane passed from the uterus (shown) . 229
iHDix. 875
PAOB
DoBAH (Alban), Bemarha in reply . 234
— Report of Oommittee .... 310
— dissection of Mr. Trestrail's case of mylacephalons aoardiao
twin, with notes on aoardiac monsters in the mnseama of
London hospitals .4
anterior serous perimetritis simulating ovarian sarcoma
when explored by abdominal section ; recovery with disap-
pearanceof the cyst .... 217
— Bema/rks in reply ..... 223
on closure of the ostium in inflammation and allied dis-
eases of the Fallopian tabe .... 344
^emar Aw in reply ..... 364
— in discussion on W. Stephenson's paper on the rela-
tion between chlorosis and menstruation . 119
— in discussion on M. Handfield-Jones' specimen of
fibro-sarcoma of the right ovary . . .126
in discussion on W. S. Play&ir's specimen of intra-
peritoneal hematocele .... 133
— in discussion on F. H. Ohampneys' paper on a .case
of CaBsarean section for contracted pelvis . 156
— * in discussion on Amand Bouth's specimen of primary
cancer of the Fallopian tube .... 201
in discussion on G. S. Pollock's specimen of cyst of
the ovary of a mare ..... 235
— in discussion on Woodley Slyman's specimen of
acephalous acardiac monster of six months' gestation,
with rudimentary heart .... 261
— in discussion on A. Basch's paper on a case of large
chylous cyst of the mesentery . 318
Douche can (John Shaw) .... 262
DuNOAH (Matthews), laceration of the vagina in labour . 236
— - Remarks in reply ..... 241
^— in discussion on A. L. Gkilabin's paper on a case of
Porro's operation . .66
— > in discussion on W. Newman's paper on a case of
inversion of the uterus . . . 169
in discussion on John Phillips's paper on acute non-
septic pulmonary disorders as complications of the puer-
perium ...... 194
in discussion on J. Elnowsley Thornton's specimen
of ruptured Fallopian tube .199
376 INDEX.
PAGE
Duncan (Matthews), AemarA;^ in discussion on H. B. Spenoer's
paper on the diagnosis of placenta prsBvia by palpation of
the abdomen ..... 218
— * r in discussion on M. Handfield- Jones' paper on
chorea in preg^nancy .... 251
in discussion on B. Boxall's specimen of pelvic
hsBmatoma following delivery . . 307
in discussion on A. Basch*s paper on a case of large
chylous cyst of the mesentery . . . 818
— — in discussion on A. H. N. Lowers' paper on a case
of lupus of the Yulya .... 329
DmrcAN (William), anencephalic foetus (shown) . . 202
— dermoid ovarian tumour (shown) . 255
Fallopian tube and ovary from a case of tubal gestation
(shown) ...... 165
fibro-myoma and abscess (shown) . 332
hsBmatosalpinz and pyosalpinz (shown) . 332
-— hydrosalpinx (shown) .... 332
large myoma of left broad ligament (shown) . 309
—- simple ovarian cyst (shown) .... 255
uterus the sulrject of sarcoma removed by hysterectomy
(shown) . . .2
— heart, and brain from a case of puerperal septicsBmia
(shown) ...... 202
rectum, and left kidney from a woman who died of
ursBmia (shown) ..... 255
— BemmrJca in discussion on Archibald Donald's paper on
methods of craniotomy . . . .46
— in discussion on W. Newman's paper on a case of
inversion of the uterus .... 169
in discussion on H. B. Spencer's paper on the dia- *
gnosis of placenta prsevia by palpation of the abdomen . 214
— *- in discussion on A. Basch's paper on a case of large
chylous cyst of the mesentery . . 317
— in discussion on 0. J. Oullingworth's paper on a
case of vesico-utero-vaginal fistula . 824
...... iji discussion on A. H. N. Lewers' paper on a case of
lupus of the vulva ..... 328
Ectopia viioerom and retroflexion (W. B. Dakin) . 308
mecHons of New FeUovoa 1, 51, 85, 125, 161, 225, 303
IKDK. 87V
PAGE
Extra-uterine pregnancy, Fallopian tube and ovary from a case
of tabal gestation (William Duncan) . 165
Fallopian tube, on closure of the ostium in inflammation and
allied diseases of the (A.lbanDoran) . . 344
primary cancer of the (Amand Routh) . 200
ruptured (J, Knowsley Thornton) . 198
hsBmatosalpinx and intra-peritoneal bsBmatocele from
rupture of a varicose vein of the inner Bwiieuoe of the
(0. J. Oullingworth) . . .257
hypertrophied, and cystic ovaries (John Phillips) 332
•— — and ovary from a case of tubal gestation (William Duncan) 165
uterus, and ovaries from a case of Oessarean section (0. J.
Oullingworth) .308
Fellows, see ListSf Elections,
Fibro-cysts, uterine (J. Knowsley Thornton) . 199
Fibroids, see Tuynov/rs (fibroid).
Fibroma of the ovarian ligament ( Alban Doran) 200
Fibro- myoma and abscess (William Duncan) . 332
Fibro-sarcoma of the right ovary (M. Handfield- Jones) . 126
Fistula, case of vesico-utero-vaginal (G. J. Oullingworth) . 320
FoBtal membranes, diseased, of uncertain nature in early preg-
nancy (John Phillips) . .52
Fodtation, see Pregncmcy,
FcBtns, anencephalous (Alban Doran) .52
(W. S. A. Griffith) .134
(A. Perigal) ..... 165
(William Duncan) . . . .202
shrivelled, of the fifth month utero-gestation (E. Olapbam) 202
the subject of retroflexion and ectopia visceram (W. B.
Dakin) ...... 308
Funis, complex twistings of (M. Handfield- Jones) 164
Galabin (A. L.), Bepofi as Treasurer for 1888 69, 70
Inaugural Address as President, March 6th, 1889 88
case of Porro's operation . .57
Bemarha in reply . . . . .67
in discussion on Archibald Donald's paper on me-
thods of craniotomy. . . .45
in discussion on F. H. Ohampneys' paper on a case
of OsBsarean section for contracted pelvis . • 157
378 INDEX.
FAas
GALA.BIN (A. L.)« Bemarka in discussion on H. B. Spencer's
paper on the diagnosis of placenta prsBvia by palpation of
the abdomen ..... 215
Gangrene of the bladder from retroversion of the gravid ateros
(A.Rasch) . . .129
Gebyis (Henry), Bemarhs in discussion on Archibald Donald's
paper on methods of craniotomy .46
Gestation, see Pregnancy,
Gibbons (B. A.), Remarks in discussion on John Phillips's
paper ola. acute non-septic pulmonary disorders as compli-
cations of the puerperium .... 195
Gbiffith (W. S. A), Report on specimen of an aborted ovum
showing cysts in the decidua vera, shown by John Phillips 161
on specimen of small ovarian cyst and hsBmato-
salpinx, shown by W. S. Playfair . . 162
— on specimen of fragment of membrane passed from
the uterus, shown by Alban Doran . . 310
— acephalous acardiac monster (shown) . .2
anencephalic fostus (shown) .... 134
case of retention of urine caused by pressure of a dermoid
ovarian cyst (shown) .... 135
sections of uterus at different periods of the puerperium
showing complete absence of the alleged fatty changes
(shown) ...... 308
Bemarks in discussion on Archibald Donald's paper on
methods of craniotomy . . . .48
in discussion on W. S. Playfair's specimen of intra-
peritoneal hsematocele .... 132
in discussion on F. H. Champneys' paper on a case
of Cesarean section for contracted pelvis . . 154
in discussion on Alban Doran's specimen of fragment
of membrane passed from the uterus . . . 234
in discussion on G. J. Cullingworth's paper on a case
of vesico-utero- vaginal fistula. . . 324
— in discussion on J. Braxton Hicks's paper on a case
of inversio uteri ..... 342
— — in discussion on H. G. Hodges' notes of a case of
heematemesis in a new-bom infant . 367
Hsematemesis, notes of a case of, in a newly bom infant (H. G.
Hodges) . .365
Hflsmatocele, intra-peritoneal (W. S. Playfair) 130
iKDU. 879
PAGE
Hematocele, intra-peritoneal, and haamatosalpinx from rupture
of a varicose vein on the inner surface of the right
Fallopian tube (0. J. Cullingworth) . . . 257
HsBmatoma, pelyio, following delivery (B. Boxall) . . S03
HaBmatosalpinx (0. J. Cullingworth) . . . 226
and intra-peritoneal haamatocele from rupture of a varicose
vein on the inner surface of the right Fallopian tube (G. J.
Cullingworth) ..... 257
and ovarian cyst (W. S. Playfair) . . 162
and pyosalpinx (WiUiam Duncan) . 332
Handfiblb-Joneb (M.)> complex twistings of the funis
(shown) ...... 164
fibro-sarcoma of the right ovary (shown) . 126
vaginal cyst (shown) .129
chorea in pregnancy .... 243
Bemarks in reply ..... 251
in discussion on W. Newman's paper on a case of in-
version of the uterus .... 169
Hates (J. C), Aemar^ in discussion on W.Stephenson's paper
on the relation between chlorosis and menstruation . 122
in discussion on Matthews Duncan's paper on lacera-
tion of the vagina in labour .... 239
Heart, rudimentary, in a case of acephalous acardiac monster
of six months' gestation (Woodley Slyman) . 258
uterus, and brain from a case of puerperal septicaBmia
(William Duncan) . . . .202
Hbbman (G. E.), contribution to the anatomy of the pelvic floor 263
Bemarhs in reply ..... 301
on the changes in the pelvic floor which accompany the
slighter degrees of prolapse .... 276
BemarJcs in reply ..... 301
in discussion on Archibald Donald's paper on
methods of craniotomy . . .43
in discussion on A. L. Galabin's paper on a case of
Porro's operation . . . . .66
in discussion on A. BASch's specimen of gangrene
of the bladder from retroversion of the gravid uterus . 130
in discussion on F. H. Champneys' paper on a case
of CsBsarean section for contracted pelvis . . 153
... in discussion on John Phillips's paper on acute non-
septic pulmonary disorders as complications of the puer-
perium ...... 191
380 tKDBX.
PAGB
Hebman (G. E.)> Bemarha in discnssion on H. B. Spencer's
paper on the diagnosis of placenta prsBvia by palpation of
the abdomen ..... 214
in discussion on Matthews Duncan's paper on lacera-
tion of the vagina in labour .... 240
in discussion on M. Handfield- Jones' paper on
chorea in pregnancy .... 250
Hewitt (Graily), instruments for antiseptic irrigation in child-
bed (shown) . . .202
Bemarhs in discussion on W. Stephenson's papers on the
relation between chlorosis and menstruation . 122
— in discussion on Q. E. Herman's papers on the
anatomy of the pelvic floor, and on the changes in the
pelvic floor which accompany the slighter degrees of pro-
lapse ...... 300
Hicks (J. Braxton), case of inversio uteri ; reduction ; reco-
very; remarks ..... 340
Bemarhs in discussion on F. H. Ohampneys' paper on a
case of OsBsarean section for contracted pelvis . . 155
in discussion on H. B. Spencer's paper on the
diagnosis of placenta prsQvia by palpation of the abdo-
men ..... 213,215
HoDGBB (H. C), notes of a case of hsBmatemesis in a newly
bom infant ..... 365
HoBBOCKB (P.), Report as Honorary Librarian for 1888 69
rupture of uterus (shown) .... 228
— Remarks in reply ..... 229
in discussion on Archibald Donald's paper on
methods of craniotomy . . .47
in discussion on W. Stephenson's paper on the rela-
tion between chlorosis and menstruation . 123
in discussion on W. S. Playfair's specimens of intra-
peritoneal hsdmatocele and intra-uterine polypus . 133
— in discussion on P. H. Ohampneys' paper on a case
of Cesarean section for contracted pelvis . 154
— in discussion on Matthews Duncan's paper on lacera-
tion of the vagina in labour .... 241
in discussion on M. Handfield-Jones' paper on
chorea in pregnancy .... 249
in discussion on J. Braxton Hicks's paper on a case
of inversio uteri ..... 342
INDEX. 381
PAGE
HoBBOCKB (P.), Bema/rha in discussion on Alban Doran's paper
on closure of the ostium in inflammation and allied diseases
of the Fallopian tube .... 363
Button, John Stuart, M.B., of Demerara, obituary notice of . 73
Hydrosalpinx (William Duncan) . . ' . . S32
Hysterectomy, uterus the subject of sarcoma removed by
(William Duncan) . . . .2
Instruments for antiseptic irrigation in child-bed (Graily
Hewitt) . . . . .202
Intra-peritoneal hsDmotocele (W. S. Playfair) . . 130
and hsBmatosalpinx from rupture of a yaricose vein
on the inner surface of the right Fallopian tube (0. J.
Oullingworth) ..... 257
Intra-uterine polypus (W. S. Plajrfair) . 130
Inversion of uterus, sixteen months' standing ; replacement ;
recovery (W. Newman) .... 166
case of; reduction ; recovery ; remarks (J. Braxton
Hicks) . . . . .340
Irrigation, antiseptic, in child-bed, instruments for (Graily
Hewitt) . . . .202
Jackson, Edward, M.B., of Newcastle-on-Tpie, obituary
notice of . . . . . .75
Jamison (Arthur A.), Bemarhs in discussion on M. Handfield-
Jones' paper on chorea in pregnancy . . 249
Kidney, uterus, and rectum of a woman who died of unemia
(William Duncan) ..... 255
Labour, see Parturition.
Laceration of the vagina in labour (Matthews Duncan) . 236
Lawbencb (Aust), sponge-tents (shown) . . 333
-— ^ Bemarh8 in discussion on A. L. Galabin's paper on a case
of Porro's operation . . .67
Lbwbbb (A. H. N.), case of lupus of the vulva . 326
EeTnarks in reply ..... 329
in discussion on F. H. Ghampneys* paper on a case
of CsBsarean section for contracted pelvis . 154
List of Qjficers elected for 18S9 . .72
of diMofor ISdO . . v
of past Presidents • . vii
of Beferees of Papers for ISdO . viii
TOL. xm. 26
382 INDEX.
PAGB
LUt of Stcmdmg Committees . ix
of Honorary Local Secretaries . x
- of Honorary Fellows . . . xi
^— of Corresponding Fellows .... xiii
of Ordinary FeUows .... xiv
of Deceased Fellows [with obituary notices, which see] 73 — 76
Malformation, see Monster,
case of Cesarean section for contracted pelvis (F. H.
Ghampneys) .136
Mare, cyst of the ovary of a (0. S. Pollock) . . 234
Membrane, fragment of, passed from the utems (Alban Doran) 229
Membranes, diseased foetal, of uncertain nature in early preg-
nancy (John Phillips) .52
Menstruation and chlorosis, on the relation between (W.
Stephenson) ..... 104
Me&bdith ( W. a.), solid tumour of the ovary (shown) • 225
Mesentery, case of large chylous cyst of the (A. Basch) . 311
Methods of craniotomy (Archibald Donald) . 28
Miller, Hugh, M.D., of Glasgow, obituary notice of . .74
Monsters, acardiac, notes on, in the museums of London hos-
pitals (Alban Doran) .4
acephalous acardiac (W. S. A. Griffith) . . 2
— of six months' gestation, with rudimentary
heart (Woodley Slyman)
- anencephalous foetus (Alban Doran)
(W. S. A. Griffith)
(A. Perigal)
(William Duncan)
258
52
134
165
202
Myoma of left broad ligament (William Duncan) . 309
«
Napibb (Leith), Bem^arks in discussion on W. Stephenson's
paper on the relation between chlorosis and menstruation 118
in discussion on John Phillips's paper on acute
non- septic pulmonary disorders as complications of the
puerperium ..... 194
Newman (William), case of inversion of uterus, sixteen months'
standing; replacement; recovery . . 166
Remarks in reply ..... 170
ObUuary notices of Deceased FeUows,
Button, John Stuart, M.B., Demerara . .73
Bryant, Walter John, F.B.O.S., Beading . 74
INDEX.
883
PAGE
Obituary notices of Deceased Fellows (continued).
Miller, Hugh, M.D., Glasgow .
Rich, Arthur Cresswell, M.D., liverpool
Price, William Nicholson, M.B.O.8., Leeds
Jackson, Edward, M.B., Newcastle- on-Tyne
Chalmers, John, M.D., Keppel Street, W.C.
Ostium, on closure of the, in inflammation and allied diseases
of the Fallopian tube (Alban Doran) .
Ovarian cyst (William Duncan) .
— ^ — and hsBmatosalpinx (W. S. Playfair)
dermoid cyst, case of retention of urine caused by pres
sure of (W. S. A. Griffith)
tumour (William Duncan)
ligament, fibroma of the (Alban Doran)
sarcoma, anterior serous perimetritis simulating, when
explored by abdominal section (Alban Doran) .
— tumours, some specimens of (J. Bland Sutton) .
— dermoid, dentigerous bony plates from (Alban Doran)
Ovaries, cystic, and hypertrophied Fallopian tubes (John
Phillips) ......
— uterus, and tubes from a case of Oassarean section (0. J.
Oullingworth) . . . . .
Ovary, fibro-sarcoma of (M. Handfield- Jones)
solid tumour of the (W. A. Meredith) .
of a mare, cyst of the (0. S. Pollock) .
and Fallopian tube from a case of tubal gestation (William
Duncan) ......
Ovum, aborted, showing cysts in the decidna vera (John
Phillips) ......
74
74
76
76
76
844
266
162
136
266
200
217
333
86
332
308
126
226
234
166
161
Palpation of the abdomen, the diagnosis of placenta pnavia by
(H. B. Spencer) .203
Parturition, see Flaeenia,
laceration of the vagina in (Matthews Duncan) . . 236
— pelvic hematoma following (B. Boxall) . 303
Pelvic floor, contribution to the anatomy of the (G. E. Herman) 263
._ on the changes in the, which accompany the slighter
degrees of prolapse (G. E. Herman) . 276
hematoma following delivery (B. Boxall) . 303
Pelvis, contracted, case of Oiesarean section for (F. H. Ohamp*
neys) ...... 136
384 INDEX.
PAOB
PebioaXi (A.)> anencephalons foBtus (shown) . 165
Perimetritis, anterior serous, simulating ovarian sarcoma when
explored by abdominal section (Alban Doran) . 217
Phillips (John), blue urine, cyannria (shown) . . 256
Bemarha in reply ..... 256
cystic ovaries and hypertrophied Fallopian tnbes (shown) 332
— diseased foetal membranes of uncertain nature in early
pregnancy (shown) . . .52
Beport on . . . 161
-— — on acute non-septic pulmonary disorders as complications
of the puerperium ..... 171
— Bemcvrka in reply ..... 196
— in discussion on W. Stephenson's paper on the rela-
tion between chlorosis and menstruation . 118
in discussion on F. H. Ghampneys' paper on a case
of OsBsarean section for contracted pelvis . . 156
— in discussion on H. R. Spencer's paper on the dia-
gnosis of placenta prsavia by palpation of the abdomen 214
in discussion on M.Handfield- Jones' paper on chorea
in pregnancy ..... 249
Placenta previa, the diagnosis of, by palpation of the a'bdomen
(H. R. Spencer) ..... 203
Platfair (W. S.), cancerous uterus removed by vaginal opera-
tion (shown) ..... 227
— — intra-peritoneal hsDmatocele (shown) . . 130
Report ...... 162
— intra-uterine polypus (shown) . . 130
Bmnarks in discussion on W. Stephenson's paper on the
relation between chlorosis and menstruation . 121
in discussion on F. H. Ghmpneys' paper on a case of
OsBsarean section for contracted pelvis . . . 153
in discussion on P. Horrocks's specimen of rupture
of the uterus ..... 229
PoLLOOK (0. Stewart), cyst of the ovaiy of a mare (shown) . 234
— Beport of Committee .... 253
Polypus, intra-uterine (W. S. Playfair) . 130
Forro's operation, case of (A. L. Galabin) . . .57
Pregnancy, chorea in (M. Handfield- Jones) . . 243
the diagnosis of placenta previa by palpation of the
abdomen in (H. R. Spencer) .... 203
diseased foBtal membranes of uncertain nature in early
(John Phillips) . . .52
iNDSx. 885
PAGE
PregnaBoy, extra-nterizid, Fallopian tube and ovary from a case
of tubal gestation (William Duncan) . . . 165
sbriyelled fodtns of the fifth month, ntero-geatation (E.
Glapham) ...... 202
Price, William Nicholson, M.B.O.S., of Leeds, obituary notice of 75
Prolapse, on the changes in the pelvic floor which accompany
the slighter degrees of (G. E. Herman) . . 276
Puerperal septicssmia, uterus, heart, and brain from a case of
(William Duncan) . . . . .202
Puerperium, acute non-septic pulmona^ disorders as complica-
tions of the (John Phillips) .... 171
sections of the uterus at different periods of the, showing
complete absence of the alleged fatty changes (W. S. A.
Griffith) . . . . . .308
Pulmonary disorders, acute non-septic, as complications of
the puerperium (John Phillips) . . . 171
Pyosalpinx and hsBmatosalpinx (William Duncan) . . 332
Basch (Adolph), gangrene of the bladder from retroversion
of the gravid uterus (shown) .... 129
Bemarka in reply ..... 130
case of large chylous cyst of the mesentery . • 311
BemarJcs in reply ..... 318
BeeeipU and Expenditure of the Society for 1888 . . 70
Rectum, uterus, and leffc kidney from a woman who died of
ursBmia (William Duncan) .... 255
BepoH {audited) of the Treaewrerfor 1888 . . 69, 70
of the Hon. Librarian for 188S . . . .69
of the Chairman of the Board for the Examination of Mid-
vn/ves .,...•
of Committee on epeeimen of an aborted ovum showing eyete
in the deeidua vera, ehovm by John PhiUips on February Sth^
1889 . . . . -161
— on epeeimen of emaU ovarian cyst and heemaiosaJpina,
shown by W. 8. Playfair on April 3r(2, 1889 . 162
— * on specimen of ovarian dermoid from a mare, shown
by C. StewaH PoUoch on July 3rd, 1889 . . 253
on specimen of fragment of msmhrane passed from the
uterus, shoum by AlbanDoran on Ju^f2rd,lS89 . . 310
Retention of urine caused by pressure of a dermoid ovarian
cyst (W. S. A. Griffith) .135
Retroflexion and ectopia viscerum (W. R. Dakin) 308
71
886 INDEX.
PAOS
BetroTerdon of the gravid nteroB, gangrene of the bladder
from (A. Basch) . .129
Rich, Arthur Oresswell, M.D., of Liverpool, obituary notice of 74
BoTJTH (Amand), primary cancer of the Fallopian tube (shown) 200
-»— Remarks in discussion on J. Knowsley Thornton's sped*
men of ruptured Fallopian tube • 199
in discussion on M. Handfield- Jones' paper on chorea
inpregnancy . . 250
i^-— — in discussion on 0. J. Oullingworth's specimen of
hsBmatosalpinx and intra-peritoneal haamatocele. . 258
BouTH (0. H. F.)» Bema/rha in discussion on Archibald
Donald's paper on methods of craniotomy 46, 47
— — in discussion on W. Stephenson's paper on the rela-
tion between chlorosis and menstruation . 120
— — in discussion on H. 0. Hodges' notes of a case of
hsBmatemesis in a newly bom infant . . 368
Rupture of the uterus (F. Horrocks) . . 228
BuTHEBTOOBD (H. T.), Bemarhs in discussion on W. Stephen-
son's paper on the relation between chlorosis and men-
struation ...... 120
._ in discussion on Alban Doran's paper on closure of
the ostium in inflammation and allied diseases of the
Fallopian tube ..... 363
Sarcoma, fibro-sarcoma of the right ovary (M. Handfield-Jones) 126
ovarian, anterior serous perimetritis simulating, when
explored by abdominal section (Alban Doran) . 217
-— — uterus the subject of, removed by hysterectomy (William
Duncan) . .2
Septictsmia, puerperal, uterus, heart, and brain from a case of
(William Duncan) . .202
Serous perimetritis, anterior, simulating ovarian sarcoma when
explored by abdominal section (Alban Doran) . 217
Shaw (John), douche can (shown) . . 262
Skene (William), see Doran,
Slyman (William D.), see Woodley Slyman,
Sltman (Woodley), for W, D. Slyman, acephalous acai*diao
monster of six months' gestation, with rudimentary heart
(shown) ...... 258
Smith (Heywood), Bemarhs in discussion on W. Stephenson's
paper on the relation between chlorosis apd menstmatioii 123
INDEX. 387
PAGE
Smith (Heywood), jBemar^in disoassioii on F. H. Obampneys*
paper on a case of Oflbsarean section for contracted pelvis . 156
Spenceb (Herbert B.)* the diagnosis of placenta prsBvia by pal-
pation of tbe abdomen .... 203
— Bemarhs in reply . . * . 216
— in discussion on Matthews Duncan's paper on lacera-
tion of the vagina in labour .... 241
^— ^— in discussion on H. C. Hodges' notes of a case of
hsBmatemesis in a newly bom infant . 368
Sponge tents (Aust Lawrence) .... 333
Stephenson (William), on the relation between chlorosis and
menstruation; an analysis of 232 cases . 104
Sutton (J. Bland), Beport on specimen of ovarian dermoid
from a mare, shown by 0. Stewart Pollock • 253
^— some specimens of ovarian tumours (shown) . 333
Tents, sponge (Aust Lawrence) .... 333
Thobnton (J. Knowsley), for James Craig, ruptured Fallopian
tube (shown) ..... 198
two uterine fibro-cysts (shown) 199
Bemarka in discussion on Amand Bouth's specimen of
primary cancer of the Fallopian tube . . 201
— in discussion on Alban Doran's paper on anterior
serous perimetritis simulating ovarian sarcoma when ex-
plored by abdominal section .... 223
Tbestbail (H. E.), mylacephalous acardiac twin (shown) 2
Tubal gestation. Fallopian tube and ovary from a case of
(William Duncan) . .165
Tubo-ovarian cyst (J. Bland Sutton) . 338
Tumours, aborted ovum showing cysts in the decidua vera
(John PhiUips) .161
— anterior serous perimetritis simulating ovarian sarcoma
when explored by abdominal section ; recovery with disap-
pearance of the cyst (Alban Doran) . 217
— chylous cyst of the mesentery (A. Basch) . . 311
cyst of the ovary of a mare (G. S. Pollock) . 234
cystic ovaries and hypertrophied Fallopian tubes (John
Phillips) . . .332
dermoid ovarian (William Duncan) 255
dentigerous bony plates from (Alban Doran) 86
cyst, case of retention of urine caused by pressure
of (W. S. A. Griffith) .135
OBSTETRICAL SOCIETY.
ADDITIONS TO THE LIBRARY
BY DONATION OR PURCHASE DURING THE YEAR 1889.
Fresented hy
American (The) System of Ojnecology and Obstetrics,
see Mann, Mirst.
Apobtoli (Georges). See Bigelow, Gynecological
Electro-Therapeutics.
Abdottin (Maurice). Contribution k Tfitude des D6-
chirures Yagino-perin^ales.
fooodcuts, 8vo. Paris, 1889 Purchased.
AsHBY (Henry A.) and Q. A. Wbight. The Diseases
of Children, Medical and Surgical.
woodcuUj 8vo. Lond. 1889 Ditto.
Ashley (William Henry). A Practical Treatise on
Vesicular Hydatids of the Uterus. Dr. Matthews
sm. 8yo. Lond. 1856 Duncan.
AvYABD (A.). Travaux d'Obst^trique.
8 vols, woodcuts, 8vo. Paris, 1889 Author.
Bahtook (G^rge Oranville). On the Treatment of
Rupture of the female Perineum immediate aud
remote. Second Edition.
woodcuts, 8yo. Lond. 1888 Ditto.
Bab (Paul). Recherches ezp6rimentales et cliniques
Sour seryir k I'histoire de I'Embryotomie c6pha-
que. woodcuts, 8yo. Paris» 1889 Purchased.
Babbovb (A. H. F.). The Anatomy of Labour, in-
cluding that of full-time Pregnancy and the
first days of the Puerperium, . exhibited in
frozen sections reproduced ad naturam.
plates, la. folio, Edin., 1889 Author.
392 ADDITIONS TO THE LIBBABY.
Presented by
Babbottb (A. H. F.). The Anatomy of Labour as studied
in frozen sections and its bearing on clinical
work. pUteg, 8vo. Edin. 1889 Author.
BEBGMiLNN (Wilhelm). XJeber Hydrocele feminae.
Diss. Inaug. 8vo. Bonn, 1887 Purchased.
BiEBNAOKi (Miecislaus yon). Ein retrorectale Der-
moidcyste als Oeburtshindemiss. Diss. Inaug.
8vo. Berlin, 1887 Ditto.
BiGELOW (Horatio B.). Gynecological Electro-Thera-
peutics; with an Introduction by G-eorges
Apostoli. woodcuts, 8vo. Lend. 1889 Ditto.
BoKKECAZE (Armand). Yaleurs et Indications de
I'Incision vaginale appliqu6e h Tablation de
certaines petites Tumeurs de TOvaire et de la
Trompe. 8vo. Paris, 1889 Ditto.
Bttdik (Pierre). Le9onB de C Unique Obst^tricale.
iooodcutSi 8vo. Paris, 1889 Author.
Bttbke (Thomas Travers). The Accoucheur's Yade Dr.
Mecum ; or modem guide to the practice of Matthews
Midwifery. 12mo. Lond. 1840 Duncan.
Caldebiki (G.). Di alcune Laparotomie. (Est. dalF
'' Ateneo Medico Parmense.") 8vo. Parma, 1889 Author.
Catalogue of Books added to the Kadcliffe Library Sir H. W.
during 1888. 4to. Oxford, 1889 Acland
K.C.B.
Chattebji (K. p.). See Flayfair^a Science and Prac-
tice of Midwifery (translated).
Cheadle (W. B.). Principles and Conditions of arti-
ficial Feeding, and the Diseases which arise
from faults of Diet in early life.
sm. 8vo. Lond. 1889 Purchased.
Clat (Charles). The Complete Handbook of Obstetric Dr.
Surgery. Third Edition. 12mo. Lond. 1874 Matthews
Duncan.
Covjs (Bain6n Serret). See Flayfair^s Science and
Practice of Midwifery (translated).
CoKQVEST (J. T.). Outlines of Midwifery ; a new
edition by James M. Winn.
woodcuts, 12mo. Lond. 1854 Ditto.
Datjbiob (Paul). Htude clinique et traitement chirur-
gicfd de la Tuberculose g6nitale chez la femme.
8yo. Paris, 1889 Purchased.
ADDITIONS 'TO THB LIBRARY. 398
Presented hy
Dictionnaire des Sciences Medicales, pabli6e sous la
Direction de A. Dechambre et L. Lereboullet.
Tomes 1—100. 8vo. Paris, 1869—1889 Purchased.
DoRAir (Alban). Primary Cancer of the "Fallopian
tube. ('Trans. Path. Soc. Lond.' 1888.)
plates^ 8vo. Lond. 1888 Author.
Papilloma of both Pallopian tubes and ovaries.
(* ^frans. Path. Soc. Lond.' 1888.)
plate, 8vo. Lond. 1888 Ditto.
D^HBSBEN (Alfred). TJeber die Behandlung der Blu-
tungen post partum. Q Yolkmann's Sammlung/
No. 347.) 8vo. Leipzig, 1889. Purchased.
Dtjkoan (J. Matthews). Clinical Lectures on the
Diseases of Women. Fourth Edition.
8vo. Lond. 1889 Author.
DuBB (Henri de la). Des Fractures des membres du
FoBtuB pendant ['Accouchement.
8yo. Paris, 1889 Purchased.
EiSBiTLOHB (Wilhelm). Das interstitielle Vaginal-,
Darm- und Harnblasenemphysem zurdckgefiihrt
auf gasentwickelnde Bakterien. {Ziegler^s ' Bei-
trage zur pathologischen Anatomic,' <&c.. Band
iii, Heft 1, 1888.) platet, 8vo. Jena, 1888. Ditto.
Emhikghatts (H.). Die psychischen Storungen : Get'
hardtf Kinderkrankheiten, Nachtrag n.
Fehlhto (H.). Die geburtshiilfliche Operationen:
Muller, Oeburtshulfe, Band iii, 1889.
FssDY (Hans). Die Mittel zur Yerhiitung der Con-
ceptioD. Dritte Auflage. 8yo. Berlin, 1889 Ditto.
Febgttsok (J. Haig). See JIaultain, Handbook of
Obstetric Nursing.
FoEBSTBB (A.). Ein seltener Fall von TJteruskrebs.
plate, 8vo. Wiirzburg, 1860 Ditto.
FoBT (J. A.). Nouveaux faits confirmant I'efficacit^
de I'Electroljse lineaire dans le traitement des
r6tr6cissements de rXTr^tbre. 8?o. Paris, 1888 Author.
Fbxtjnd (Wilh. Alex.). Zwei Falle yon Haematometra
und Haematokolpos lateralis bei Atresia eines
rudimentaren Scheidenkanals eines Uterus
duplex. OBeitr. z. Ghjnak. u. Gteburtsh.')
platee, 8?o. Beriiu, 1882 Purchased.
394 ADDITIONS TO THB* LIBBABT.
Presented 2y
Fbeund (Wilh. Alex.)* TJeber Akromegalie. (^Yolk-
mann's Sammlung/ Nob. 329, 330.)
plateSf 8vo. Leipzig, 1889 Purchased.
Fbitsoh (Heinrich). Sechzig Ealle yon Laparomyo-
motomie mit epikritischen Bemerkungen iiDer
die Methoden dieser Operation. (' Yolkmann's
Sammlung,' No. 339.) 8yo. Leipzig, 1889 Ditto.
G-erichtliche Oeburtshiilfe : Muller, G>eburts-
hiilfe, Band iii, 1889.
Ebohmsl (Eichard). See ReportSy Jahresbericht neber
der Geburtshilfe und G-ynakologie.
OsBHABDT (C). Handbuch der Kinderkrankheiten.
8yo. Tubingen, 1889
Band V.
Zweite Abtheilang.
Kramkheiten der Muaheln — det Geh6rorffanei-'''de»
A%ge9,
Krankheiten des Angles («7ff2tM JftcM).
Nachtrag^ II.
Die psychiflchen Stdningcin (K, JEmminffhaui),
HABTEirFPLTJO (Bod.). XTeber Vaginal Myome. Diss.
Inaug. 8yo. Jena, 1888 Ditto.
HATTLTAnr (Francis W. N.) and J. Haio Eebottsov.
Handbook of Obstetric Nursing.
plates and woodcuts, 8yo. Edin. 1889 Ditto.
Hblme (T. Arthur^. Histological Obseryations on the
muscular fibre and connectiye tissue of the
Uterus during Pregnancy and the Puerperium.
(^ Trans. Eoy. Soc. Edin./ yol. zxxy, part 2.) Dr.
plate, 4to. Ediu. 1889 Cullingworth.
Hewbb (Annie M.). Antiseptics, a Handbook for
Nurses. 12mo. Lend. 1888 Purchased.
HiLLEB (A). Zur Eenntniss der Nierenaffectioa der
Schwangeren. ('Zeit. f. klinische Medicin/
Band ii, Heft 8.) plate, 8yo. Berlin, 1880 Ditto.
HiBST (Barton Cooke). A System of Obstetrics by
American Authors. Vol. ii.
woodeuts, 8yo. Edin. 1889 Ditto.
HorMEiBB (M.). See Schroeder, Die Sorankheiten der
weibl. Geschlechtsorgane. Neunte Auflage.
Htibby (J. B.). See Spiegelberg, Text-book on Mid-
wifery (translated).
IsAAO (Hermann). Ein Fall yon Conception bei
Atresia yaginalis und Blasenscheidenfistel. Diss.
Inaug. 8yo. Berlin, 1885 Ditto.
ADDITIONS TO THI LIBRABY. 395
Presented hy
Ibbatjbat (A.). Le Sinus iiro-g6mtal, bob d^veloppe-
ment, sea anomalies. 8vo. Paris, 1888 Purchased.
Jaoobi (A.). Contributions to the Anatomy and
Pathology of the Thymus G>land. (' Trans. Ass.
Amer. Physicians.') 8yo. Phila. 1888 Author.
Jamin ( Anthelme). De TEngagement dans les Bassins
r6tr6cis ; Etude anatomique.
plates^ 8yo. Lyon, 1889 Purchased.
Kehbeb (Ferd. Adolph.). Beitrage zur klinischen und
ezperimentellen Oeburtskunde und Ghynakologie.
Band ii, Heft 4. plates^ 8to. Qiessen, 1890 Ditto.
Krankheiten des Wochenbettes : Muller^ Ore-
burtshulfe, Band iii, 1889.
KiBiTH (Skene). Introduction to the Treatment of
Disease by Oalvanism.
woodcuts, 8vo. Lond. 1889 Ditto.
See 2Jhomas Keith, Surgical Treatment of Tu-
mours of the Abdomen.
£eith (Thomas) and Skene £eith. Contributions to
the Surgical Treatment of Tumours of the Abdo-
men. 8vo. Edin. 1889 Ditto.
Part II. Electricity in the Treatment of Uterine Tn-
monrs.
E^btneb (Otto). Die yom Fotus abbaogenden Schwan-
gerschafts- und Oeburtsstorungen : MulleTf Qe-
burtshiilfe, Band ii, 1889.
Die Verletzungen des Kindes bei der GFeburt :
MulleTf G>eburtshiilfe, Baud iii, 1889.
Lahayb ( — ). Du Cancer primitif du Vestibule de la
Yulve. These. 4to. Paris, 1888 Ditto.
Lakdatj (Leopold). Zur Diagnose und Therapie des
G>ebarmutterkrebses. (* Yolkmann's Sammlung,'
No. 838.) 8vo. Leipzig, 1889 Ditto.
Leopold (Christ. Qerh.). TJeber die Annahung der
retroflektirten aufgerichteten Oebarmutter an
der yordem Bauchwand. ('Yolkmann's Samm-
lung,' No. 333.) 8?o. Leipzig, 1889 Ditto.
Mabgokhteb (Joseph). Zur Malignitat der Ovarien-
tumoren. Diss. Inaug. 8yo. Berlin, 1883 Ditto.
Mabooulispe (B.). Contribution k i'£tude de la
Yariole contracts par le FoBtus dans la cayite
uterine. 8yo. Paris, 1889 Ditto.
396 ADDITIONS TO THB LIBRARY.
Presented by
Martin (August) . TJeber die Lappen • Dammoperation .
(Separat-Abdr. aus 'Berliner klin. Wocben-
schrift; 1889, No. 6.) 8vo. Berlin, 1889 Author.
TJeber partielle Ovarien- und Tubenexstirpation.
(' Yolkmann's Sammlung,' No. 343.)
8vo. Leipzig, 1889 Purchased.
Mauhsell (Henry). The Dublin practice of Mid- Dr.Matthews
wifery. Second Edition. 12mo. Lond. 1856 Duncan.
Michel (Julius). EIrankheiten des Auges : Oerhardt,
Kinderkrankheiten, Band v.
MiKOT (Charles Sedgwick). Uterus and Embryo.
I. Babbit. II. Man. (' Journal of Morpho-
logy,' 1889.)
plates and woodeuts, 8vo. Boston, 1889 Author.
MoLDTAS (F. Garcia). See Flai/fair^s Science and Prac-
tice of Midwifery (translated).
Mi^LLER (P.). Handbuch der Geburtshulfe. 3 vols.
woodcuts, 8vo. Stuttgart, 1888-89 Purchased.
Band II, Hftlfte 2.
Die vom Fdtos abh&ngenden Schwangenchafts- and
GebnrtsstOrangen {Otto Kuttner),
Die BeEiehnngen der Allgemeinleiden and Organ-
erkrankungeu za Schwangencbaft, Gebort and
Wocbenbett (P. MUller).
Band III.
Die gebortsbalflichen Operationen {R, FehUu^),
Die Verletzangen des Kindes bei der Gebart {Otto
KMner).
Erankbeiten des Wocbenbettes {Ferd, Ad, Kehrer),
Gericbtliche Gebartabiilfe {Snnrich Fritschy
Die Beziehungen der Allgemeinleiden und
Organerkrankungen zu Schwangerschaft, Geburt
und Wocbenbett : Muller, Q^burtshiilfe, Band ii,
1889.
Nerlinoer (Hermann). tTber die Epilepsie und das
Portpflanzungsgescbaft des Weibes in ihren
gegenseitigen Beziehungen.
8vo. Heidelberg, 1889 Ditto.
Oliver (James). Deductive Evidence of a Uterine
Nerve centre and of the location of such in the
Medulla Oblongata. ('Proc. Roy. Soc. Edin.,'
1889.) 8vo. 1889 Author.
OsLER (William). The Cerebral Palsies of children.
8vo. Lond. 1889 Purchased.
ADDITIONS TO THE LIBBAET. 397
Freiented hy
Pajot (C). Travaux d*Ob8t6trique et de Q-ynecologie,
Er^c^d^s d'elements de pratique obst^tricale.
^euzi^me Edition. woodcuts, 8yo. Paris, 1889 Purchased.
Platfaib (W. S.). Treatise on the Science and Prac-
tice of Midwifery; translated into Bengali, by
K. P. Chatterji.
plates and woodcuts, 2 vols. Svo. Bhowanipur,
1886 Author.
Treatise on the Science and Practice of Mid-
wifery. Seventh Edition.
plates, 2 vols. Svo. Lend. 1889 Ditto.
Tratado te6rico y prdctico del Arte de los
Partes ; version JSspanola del Bam6n Serret
Comin, revisada por F. Garcia Molinas.
2 vols, plates and woodcuts, 8vo. Madrid, 1890 Ditto.
Pbbusohen (Franz von). Die AUantois des Menschen.
plates, 8vo. Wiesbaden, 1887 Purchased.
Pbochowniok (L.). Massage in der Frauenheilkunde.
woodcuts, 8vo. Hamburg, 1890 Author.
Sektoul (Eobert Beid). The Causes and Treatment
of Abortion, with an Introduction by Lawson
Tait. plates and woodcuts, 8vo. Ediu. 1889 Ditto.
EicHABD (Q-ustave). Anatomic des Trompes de I'Ut^rus
chez la femme. Th^se. plates, 4to. Paris, 1851 Purchased.
SizKALLAH (Alexandre). Etude critique du traitement
des Salpingites et en particulier la valeur du
Curettage de TUt^rus dans la Salpingite Dr.
catarrhale. Th^se. 4to. Paris, 1889 Cullingworth.
BoLLiN (Francis). Des Hemorrhagies de TOvaire.
8vo. Paris, 1889 Purchased.
SoHTTLTZE (B. S.). The Pathology and Treatment of
Displacements of the Uterus ; translated by
Jameson J. Macan and edited by Arthur Y.
Macan. woodcuts, 8vo. Lend. 1888 Author.
'Lehrbuch der Hebammenkunst. Neunte Auflage.
woodcuts, 8vo. Leipzig, 1889 Author.
ScHBOEDEB (Carl). Die Krankheiten der weiblichen
Geschlechtsorgane. Neunte Auflage, von M.
Hofmeier. (v. Ziemssen's ' Handbuch,' Band x.)
woodcuts, 8vo. Leipzig, 1889 Purchased.
Skeke (Alexander J. C). Treatise on the Diseases of
Women. plates and woodcuts, 8vo. Lend. 1889 Ditto.
VOL. XXXI. 27
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