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OBSTETRICAL TRANSACTIONS. 



VOL. XIV. 



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^j^roo 



TRANSACTIONS 




OBSTETRICAL SOCIETY 



LONDON. 



VOL. XIV. 
FOR THE YEAR 1872. 

WITH A LIBT OF OFFI0EB8, FELLOWS, ETC. 




LONDON: 
LONGMANS, GEEBN, AND CO. 
1878. 



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PBIKTBD BY J. E. ADLABD, BABTHOLOHBW OLOBB. 



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OBSTETRICAL SOCIETY OP LONDON. 



OFFICERS FOR 1873. 
Elbctbd January Ist, 1873. 



HOKOBABT 
PBESIDEKT. 



}lOCOCK, sir CHARLES, Baet., M.D. 
PEBSiDEirr. TILT, EDWARD JOHN, M.D. 

rCLAY, JOHN, Birmingham. 

COPEMAN, EDWARD, M.D., Norwich. 

GERVIS, HENRY, M.D. 
i MADGE, HENRY M., M.D. 

PLAYFAIR, W. S., M.D. 
tsCOTT, JOHN, F.R.C.S. 

TEEASUBER, MURRAY, GUSTAVUS C. P.. M.D. 



VICE- 
PEE8IDEKT8. 



HOKOEAET 
8E0EETAEIE8. 

flOKOEABT 
LIBEABIAIT. 

HOKOBAET 

MEMBEES 

OF COUKCU.. 



OTHEE 

MEMBEES 

OF COUNCIL. 



/PHILLIPS, JOHN J., M.D. 
lAVELING, JAMBS H., M.D. 

I WILTSHIRE, ALFRED, M.D. 

SMITH, WILLIAM TYLER, M.D. 

OLDHAM, HENRY, M.D. 

BARNES, ROBERT, M.D. 

DAVIS, JOHN HALL, M.D. 

HEWITT, GRAILY, M.D. 

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

rBLACK, JAMES WATT, M.D. 

I BRIGHT, JOHN MEABURN, M.D. 

BRODIE, GEORGE B., M.D. 

BRUNTON, JOHN, M.D. 

DAY, WILLIAM HENRY, M.D. 

DUNCAN, JAMES, M.B. 

EDIS, ARTHUR W., M.D. 

ELLISON, JAMES, M.D., Windsor. 

FOWLER, JAMBS, M.R.C.S., Wakefield. 

GOSS, SAMUEL DAY, M.D. 

KIRKPATRICK, JOHN RUTHERFORD, 
M.B., Dublin. 

MACKINDER, DRAPER, M.D., Gainsborough. 

NEWMAN, WILLIAM, M.D., Stamford. 

POTTER, JOHN BAPTISTE, M.D. 

RASCH, ADOLPHUS A. F., M.D. 

SEDGWICK, LEONARD WILLIAM, M.D. 

SMITH, HEYWOOD, M.D. 

SHARPIN, HY. WILSON, F.R.C.S., Bedford. 



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LIST OF PAST PRESIDENTS OF THE 
SOCIETY. 



1859 EDWARD RIGBT, M.D. 

1861 WILLIAM TTLEE SMITH, M.D. 

1868 HENBY OLDHAM, M,D. 

1866 ROBBET BARNES, M.D. 

1867 JOHN HALL DAVIS, M.D. 

1869 GRAILT HEWITT, M.D. 

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



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REFEREES OF PAPERS tOR THfe YEAR 1873 

Appointed by the Council. 



BERRY, SAMUEL, Esq., F.R.C.S., Birmiugham. 

CHAMBERS, THOMAS, Eaq. 

CHAVASSE, PYE HENRY, Esq., F.R.C.S., Birtningham, 

CLAY, CHARLES, M.D., MAachesler. 

DRA6B, CHARLES, M.D., Hatfield. 

DRUITT, WILLIAM, Esq., F.R.C.S., Wimborne. 

ORIMSDALE, THOMAS P., Esq., LWerpooL 

HADEN, FRANCIS SEYMOUR, Esq., F.R.C.S. 

MARCH, HENRY COLLEY, M.D., Rochdale. 

MEADOWS, ALFRED, M.D. 

NEWMAN, WILLIAM, M.D., SUmfbrd. 

NEWTON, EDWARD, Esq., F.R.C.S. 

RADFORD, THOMAS, M.D., Mancliestet. 

ROOERS, WILLIAM RICHARD, M.D. 

ROUTH, CHARLES H. F., M.D. 

8QUAREY, CHARLES B., M.B. 

SQUIRE, WILLIAM, Bsq. 

THORBURN, JOHN, M.D., Manehesier. 

WALKER, THOMAS JAMES, M.D., Peterborough. 

WOODMAN, WILLIAM BATHURSt, M.D. 



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STANDING COMMITTEES. 



BOARD FOR THE EXAMINATION OP MIDWIVES. 



CHAIBXAK. 



HOV. 8BCS. 
EZ-OFFIOIO. 



DAVIS, JOHN HALL, M.D. 

MEADOWS, ALFRED, M.D. 

WILLIAMS, ARTHUR WYNN, M.D. 

HOPE, WILLIAM, M.D. 
C PHILLIPS, JOHN J., M.D. 
I AVELINO, JAMES H., M.D. 



COMMITTEE FOR THE COLLECTION OF 
SPECIMENS OF PELVES, ETC. 



CHAIBlCAir. 



VX'OJtTlOlO. 

HOKOBAET 
8R0RETARISB. 



BARNES, ROBERT, M.D. 

BASSETT, JOHN, Birmingham. 

BLACK, JAMES WATT, M.D. 

BURZORJEE, BURZORJEE DORABJEB, 
Bombay. 

CHARLES, T. BDMONSTOUNB, M.D., 
Calcutta. 

GRIMSDALE, THOMAS F., L.R.C.P.Ed., 
Liverpool. 

HEAD, EDWARD, M.B. 

KIDD, OBOROB H., M.D., Dublin. 

LBISHMAN, WILLIAM, M.D., Glasgow. 

McCALLUM, DUNCAN CHARLES, M.D., 
Montreal. 

MARTIN, LAWRENCE J., M.D., Melbourne. 

PERRIGO, JAMES, M.D., Montreal. 

POTTER, JOHN BAPTISTB, M.D. 

PRICE. WILLIAM NICHOLSON, Leeds. 

ROBERTS, DAVID LLOYD, M.D., Man- 
chester. 

SAVAGE, HENRY, M.D. 

SHORTT, JOHN, M.D., Madras. 

S WAYNE, JOSEPH GRIFFITHS, M.D., 
Bristol. 

TRACY, RICHARD T., M.D., Melbourne, 
r TILT, EDWARD JOHN, M.D., Fresideni. 
< PHILLIPS, J. J., M.D., Hon. Sec. 
[ AVELING, JAMES H., M.D., Hon. See. 
S SMITH, HEYWOOD, M.D. 
I WILTSHIRE, ALFRED, M.D. 



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COMMITTEE 

FOB THB COLLBOnOH OV 

OBSERVATIONS ON TEMPERATURE 

DTTBINO 

PBBGNANCT, PARTUEITION, AND THE PUEEPEEAL 

STATE. 



CHAIBMAK. 



BX-OFFIOIO. 

HOKOBABT 
8BCBBTABT. 



SQUIRE, WILLIAM, M.R.C.P. 

BRODIE, aEORGE B., M.D. 

GERVIS, HENRY, M.D. 

INGLIS, ANDREW, Aberdeen. 

LEISHMAN, WILLIAM, M.D., Glasgow. 

MURRAY, G. C. P., M.D. 

SIMPSON, PROFESSOR ALEXANDER, 
Edinburgh. 

SKINNER, THOMAS, M.D., Liverpool. 

SMITH, HEYWOOD, M.D. 

SQUAREY, CHARLES E., M.B. 

WILLIAMS, JOHN, M.D. 

WOODMAN, WILLIAM BATHURST, M.D. 
f TILT, EDWARD JOHN, M.D., President. 
\ PHILLIPS, J. J., M.D., Han. Sec. 
I AVELING, JAMES H., M.D., Eon. Sec. 

} EDIS, ARTHUR W., M.D. 



COMMITTEE TO INVESTIGATE THE SUBJECT OP 
TRANSFUSION. 



cHAiBMAir. DAVIS, JOHN HALL, M.D. 

BLOXAM, WILLIAM, M.D. 
CLEVELAND, WILLIAM F., M.D. 
GERVIS, HENRY, M.D. 
MEADOWS, ALFRED, M D. 
MURRAY, GUSTAVUS C. P., M.D. 
ROUTH, CHARLES H. F., M.D. 
WELLS, T. SPENCER, P.R.C.S. 

{TILT, EDWARD JOHN, M.D., FreaidetU. 
PHILLIPS, J. J., M.D., Hon. Sec. 
AVELING, JAMES H., M.D., Hon. Sec. 

HOW. SBO. MADGE, HENRY M., M.D. 



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HONORARY LOCAL SECRETARIES. 



Baetrum, John S., Esq., F.R.C.S Bath. 

Berry, Samuel, Esq., F.R.C.S Birmingham. 

Hall, Alfred, M.D Brighton. 

SwAYNE, Joseph Griffiths, M.D Bristol. 

Wilson, Robert James, F.R.C.P. Ed St Leonard's. 

Clark, James Fenn, Esq Leamington. 

Hall, William, Esq Leeds. 

Skinker, Thomas, M.D Liverpool. 

Roberts, David Lloyd, M.D Manchester. 

Gopeman, Edward, M.D Norwich. 

Symomds, Frederick, Esq., F.R.C.S Oxford. 

Harrinson, Isaac, Esq., F.R.C.S Reading. 

Fowler, James, Esq Wakefield. 

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

BuRZORJEE, Burzorjbe Dorabjee, Esq Bombay. 

Charles, T. Edmonstoune, M.D Calcutta. 

Shoett, John, M.D Madras. 

Williams, David John, M.D Victoria, Australia. 

Fetherston, Gerald H., M.D Melbourne, Australia. 

Coward, John W., Esq Christchurch, New Zealand. 

Hodder, Edward M., M.D Toronto, Canada West. 

Burdett, David E., M.B Ontario, Canada. 

Miller, John Faure, E>q Paris. 



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OBSTBTR 



TRU81 

W. Tyler I 
Henry Oli 
Geo. Thom 



Elected 

1865 Bailey, Hi 

1862 Chubohili 
King's 
15, St( 

1862 McGlintoc 
iu Ho8 

1862 Duncan, « 
Lectur 
dren, S 

1870 Farre, Ar 

H.R.H 

Mayfai 

1862 Hall, Arcj 

sity of 

1871 Keiller, A 

Royal 

Disease 

Ediubu 



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xii FELLOWS OF THE SOCIETY. 

JEleeted 

1871 KiDD, George H., M.D., F.R.C.S.I., Obstetrical Surgeon 
to the Coombe Lying-in Hospital^ and Examiner in 
Midwifery at the Queen's University and Royal College 
of Surgeons of Ireland; 30, Merrion square south, 
Dublin. 

1871 Tracy, Richabd T., M.D., Physician to the Lying-in Hos- 
pital, Melbourne, Victoria. 

1870 West, Charles, M.D., F.R.C.P., Physician to the Hospital 
for Sick Children; 61, Wimpole street. Cavendish 
square. 



FOREIGN SUBJECTS. 

1872 Barker, Fordyce, M.D., Professor of Clinical Midwifery 
and Diseases of Women at the Bellevue Hospital 
Medical College, and Obstetric Physician to the Bellevue 
Hospital ; Consulting Physician to the New York State 
Woman's Hospital, &c. 

1863 Braun, Carl, M.D., Professor of Midwifery, Vienna. 

1862 Channing, Walter, M.D., late Professor of Midwifery in 

the University of Cambridge, 17> Blacon-street, Boston, 
U.S. 

1863 Defaul, Jean Anne Henri, M.D., Professor of Clinical 

Midwifery, Paris. 

1863 Faye, F. C, Professor of Midwifery in the University of 

Christiania. 

1864 Heokbr, C, Munich. 

1866 Hdgbnberoer, Thsodor, M.D., Professor at the Maternity 
of Her Imp. Highness Madame the Grand Duchess 
Helena Pawlowna, St. Petersburgh. 

1866 Lazarewitch, J., Rharko£f, Russia. 

1863 Martin, Eduard, M.D., Director of the Institute for 

Clinical Midwifery at the University, Berlin. 

1864 Pajot, Ch., M.D., Professor of Midwifery to the Faculty of 

Medicine, Paris. 
1866 Riezoli, Francesco, Bologna. 



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FELLOWS OF THE SOCIETY. XIU 

Elected 

1862 SoANZONi, F. W. VON, M.D., Professor of Midwifery, 
Wurzburg. 

1864 Sims, J. Marion, M.D., late Surgeon to the Women's Hos- 
pital, New York. 

1872 Sfiegelberg, Otto, M.D., Professor of Clinical Midwifery, 
and Director of the Gynaecological Clioique in Breslau. 

1866 Thomas, Abraham Eysrard Simon, Leyden. 

1872 Thomas, T. Gaillard, M.D., Professor of Obstetrics in the 
College of Physicians and SorgeoDs, New York. 

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



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ORDINARY FELLOWS. 

January, 1873. 



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



Elected 

1869 Adams, Thomas Rutherford, M.D., Surgeon to the 

Croydon General Hospital; 1, Ottoman villas, St. 
James's road, West Croydon. 

1872 Agnew, John Noble, M.D., Toronto, Ontario. 

1859 Aldersey, William Hugh, M.B. Lond., F.R.C.S., South 
Hay ling Island, Havant, Hants. 

1871 Alderson, Frederick H., 1, Avenue terrace, Bridge Avenue, 
Hammersmith. 

1861 Aldridge, John Petty, M.D., Shirley House, Dorchester. 

1859 Amsden, George John, M.D., 85, St. Paul's road, High- 
bury, N. 

1866 Andrews, Henry Charles, M.D., 1, Oakley square, N.W. 

1859 Andrews, James, M.D., 149, Camden road, N.W. 

1870 Appleton, Robert Carlisle, Toll Garel, Beverley. 

1859 Archer, John, F.R.C.S., 9, Carpenter road, Edgbaston, 
Birmingham. 

1871 Argles, Frank, L.R.C.P. Ed., Hermon Lodge, Wanstead. 

Essex. 
1861 Armstrong, John, M.D., Gravesend, Kent. 
1869 Avbling, Charles Taylor, M.B. Lond., F.R.C.S., 93, High 

street, Homerton, N.E. 
1859 Ayeling, James H., M.D., Physician to the Chelsea Hospital 

for Women; 1, Upper Wimpole Street, W. Council^ 

1865-66, 1872. Hon. Sec. 1873. 



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VELLOWS OF THE SOCIETY. XV 

Ulected 

1872 Aylino, Arthub H. W., 103, Great Portland street, W. 

1859 Ayling, William Henbt, L.R.C.P. Ed., 103, Great Portland 

street, W. 
1864 Bakeb, G. Benson, 42, Grove road, St. John's wood, N.W. 
1867 Baker, John C:, M.D., F.R.C.S. Ed. ; 132, Duke street, 

Liverpool. 
1859 Baker, John Wright, Snrgeon to the Derbyshire General 

Infirmary; 102, Friar gate, Derby. 
1859 Ballard, Thomas, M.D., 10, South wick place, Hyde park, 

W. 
1859 Bannister, John Henry, 436, Oxford street, W. 

1869 Bantock, George Granville, M.D., Physician to the 
Samaritan Free Hospital ; 44, Cornwall road. West- 
bourne park, W. 

1863 Barker, Edward, F.B.C.S., Senior Surgeon to the Mel- 
bourne Hospital, Victoria. 

1859 Barnes, Robert, M.D., F.R.C.P., Obstetric Physician to, 
and Lecturer on Midwifery at, St. Thomases Hospital ; 
31, Grosvenor street, W. Fice-Pres. 1859-60. Council. 
1861-62, 1867-73. Treas. 1863-64. Pres. 1865-66. 

1863 Ba&ratt, Joseph G., M.D., 8, Cleveland gardens. Bays- 
water, W. 

1871 Barrick, Eli James, M.D., Professor of Midwifery at 
Victoria University; 91, Bond street, Toronto, Ontario, 
Canada. 

1861* Bartrdm, John S., F.R.C.S., Surgeon to the Bath General 
Hospital; 41, Gay street, Bath. Hon, Loc. See. 

1867 Basan, Horace, F.F.P. & 8. Glasg., L.R.C,P. Ed., Prebyn, 
Bedford. 

1866 BA88BTT, John, Profesapr of Midwifery at the Queen's 

College, BinninghaBi ; 144, Hockley Hill, Birmingbam. 
1859 Bateman, Henrt, F.R.C.S., 32, Conapton terrace, Canon- 
bury, lalingtOD, N. 

1867 Batten, Batner W., M.D., Physician to the Gloucester 

General Infirmary; 1, Brunswick square, Gloucester. ' 



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XVI FELLOWS OF THE SOCIETY. 

JSlecied 

1859 Battye, Richard F., M.R.C.P. Ed., 6, Glouoeater street, 

Belgrave road, Pimlico, S.W. 
1871 Beach, Fletcheb, Medical Registrar, Children's Hospital, 

Great Ormond street, W.C. 
1871 Beadles, Asthub, 11, Park road terrace. Forest hill, 

Kent. 
1859 Beck, T. Snow, M.D., F.R.S., 7, Portland place, W. 
1868 Beioel, Hebmann, M.D., Lichtenstein Strasse, Vienna. 

1866 Belcheb, Henby, M.D., L.R.C.P. Ed.; 10, Pavilion 

parade, Brighton. 

1871 Bell, Robert, M.D. Olasg., 50, Woodland road, Glasgow. 

1867 Bennet, William Fobd, Westgrove House, Emsworth, 

UanU. 
1859 Bebby, Samuel, F.R.C.S., Consulting Surgeon-Accoucheur 
to the Queen's Hospital, and Professor of Midwifery 
and the Diseases of Women and Children in the 
Queen's College ; Hatfield House, 281, Hagley road, 
Edgbaston, Birmingham. Vtce-Fres. 1859. Han.Loe. 
See, 

1872 Bethune, Nobman, M.D., Professor of Anatomy, Trinity 

Coll^, Toronto. 

1859 BiLLiNGHXJBsr, Henby, M.D., Redwood House, Bromley, 
Kent 

1859 Bibd, Fbedebio, M.D., Obstetric Physician to, and Lec- 
turer on Midwifery and Diseases of Women at, the 
Westminster Hospital, Senior Physician to the West- 
minster Maternity Charity; 13, Grosvenor street, W. 
Council, 1859. 

1868 Black, James Watt, M.D., Obstetric Physician to the 

Charing Cross Hospital ; 15, Clarges street, Piccadilly, 
W. Council, 1872-3. 

1868 Blaib, John, Collins street east, Melbourne, Victoria. 

1861* Blake, Thomas William, Hurstbourne Tarrant, Andover, 
Hante. 

1859 Blake, Valentine W., F.R.C.S., Surgeon to the Birming- 
ham and Midland Counties Lying-in Hospital ; 6, Old 
square, Birmingham. 



FELLOWS OF titE SOCIETY. XVll 

Elected 

1872 Bland, Geoege, Park green, Macclesfield. 

1866 Blease, Thomas, Clairville, Altrincham, Cheshire. 

1860 Blood, Michael, 15, Portland place, St. Helier's, Jersey. 

1859 Bloxam, William, M.D., 21, Mount street, Grosvenor 

square, W. 
1868 BoGGS, Alexandee, M.D., late of H.M.'s Madras Army, 

13, Boulevard de Courcelles, Paris. 

1872 BoswoETH, John Routledge, Sutton, Surrey. 

1866 BouLTON, Peecy, M.D., Physician for Out-patients to the 
Samaritan Free Hospital ; 6, Seymour street, Portman 
square, W. 

1868 BousFiELD, Edwaed, L.R.C.P. Ed., Market place, Thetford, 

Norfolk. 

1869 Boyd, Heebeet, Assistant-Sui 

William, Calcutta [agents, 
65, Cornhill]. 

1859 Beace, William Heney, M.I 

Kensington, W. 

1872 Beacey, Chaeles J., M.B., S 
and Midland Hospital for ' 
square, Birmingham. 

1862 BUAITHWAITE, WiLLIAM, M.D,, 

Leeds School of Medicine ; 
road, Leeds. Council, 186 

1862 Beickwell, John, Sawbridgewc 

1872 Bridge watee, Thomas, M.B., 

1864 Beight, John Meabuen, M.! 
Sydenham, S.E. Council, 
1869 Beisbane, James, M.D., 30, Li 

1860 .Beitton, William Samuel, 

John's Wood, N.W. 
1871 Buockman, Edward Foestee, 
Hospital, Madras, and Profi 
Medical College, Madras. 

vol. XIV. 



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XVm FELLOWS OF THE SOCIETY. 

Elected 

1866 Bbodie, Geobge B., M.D., Physician to Qaeen Charlotte's 

Lying-in Hospital; 56, Curzon street, Mayfair, W. 

Council, 1873. 
1868 BfiOWN, Andrew, L.R.C.P. Ed., Elton villa, Bartholomew 

road, Kentish town, N.W. 

1865 Bkown, David Dyce, M.A., M.D., 22, Union place, Aber- 

deen. 

1866 Brown, George Dransfield, Henley villa, Uxbridge road, 

Ealing, Middlesex. 
1866 Brown, Thomas, M.D., 236, Kennington park road, S.E. 
1865 Browne, J. Lennox, 41, Welbeck street. Cavendish square, 

W. 

1865 Brunton, John, M.D., M.A., Surgeon to the Royal 

Maternity Charity; 21, Euston rond, N.W. Council^ 
1871-3. 

1866 Bryant, John Henry, 23a, Sussex square, Hyde park 

gardens, W. 
1863 Bryant, Thomas, F.R.C.S., Surgeon to Guy's Hospital; 

53, Upper Brook street, W. Council, 1866-67. 
1859 Bryant, Walter John, F.R.C.S., L.R.C.P. Ed., 23a, 

Sussex square, Hyde park gardens, W. Council, 1859. 

1870 Buck, Joseph Randle, L.R.C.P. Ed., Inkberrow, Eedditch, 

Worcestershire. 
1872 Buckingham, Charles E., M.D., Professor of Obstetrics 
in Harvard University ; 53, Worcester street, Boston, 
U.S. 

1871 BuLMER, Thomas Sanderson, M.D., Toronto; Taranaki 

street, Wellington, New Zealand. 

1861 Bunny, Joseph, M.D., Hon. Surgeon to the Newbury Dis- 
pensary ; Northbrook street, Newbury, Berks. 

1870 Burdett, David E., M.B., Belleville, Ontario, Canada. 
Hon, Loc. Sec. 

1867 Burnett, Charles, M.B., Biggleswade, Bedfordshire. 
1866 Burrows, John Cordy, F.R.C.S., Consulting Surgeon to 

the Brighton Hospital for Sick Children j 62, Old 
Steyne, Brighton. 



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IP^LLOWS OF THE SOCIETY. XIX 

Elected 

1862 BuBTON, John Moulden, F.E.C.S., Lee park lodge, Lee, 

Kent, S.E, Council, 1868-69. 
1870 BuBZOBJEE, BuBZOBJEE DoBABJEE, Graduate of Grant 

Medical College, Bombay. Hon, Loc. Sec. 

1864 BuTLEB, Fbedeeick John, M.D., Surgeon to Wincheater 

College and St. Cross Hospital, and to the Hants 

County Hospital, Winchester. 
1870 BuTLEB, John M., M.D., Physician to the Eoyal Kent 

Dispensary, and to the Woolwich Dispensary; 6, 

Queen's terrace, (28) Woolwich Common, S.E. 
1868 BuTLEB, William Haebis, L.R.C.P. Ed., 15, Thomas 

street, Woolwich. 

1868 Butt, William Fbedebick, 12, South street, Park lane, W. 

1862 Campbell, Chables, M.D., Kingston, Jamaica. [Agent: 

Mr. Lewis, Gower street.] 

1861 Candlish, Henby, M.D., Physician to the Alnwick In- 
firmary, Bondgate street, Alnwick, Northumherland. 

1861 Candy, John, M.D., Assistant-Surgeon, H.M.'s 109th Regi- 
ment at Mooltan, India. [Per Messrs. Price and 
Boustead, Army Agents, 34, Craven street. Strand, 
W.C] 

1872 Cabless, Edwabd Nicholls, M.B., CM., Lansdowne 
grove, Devizes, Wilts. 

1866 Cabless, John, M.D, Stratford lodge, Stroud, Gloucester- 
shire. 

1863 Cablylb, David, M.D., 2, The Crescent, Carlisle. 

1861 Cabteb, Albebt Pleydell, Wellington House, 43, London 

road, Gloucester. 
1872 Cabteb, Chables Henby, B.A., M.D., 8, Old Cavendish 

street. Cavendish square. 

1869 Caskie, John Boyd, M.D., 89, Goswell road, E.G. 

1869 Cass, William Cunningham, 20, " "* ' - -"- 

1865 Cassels, Thomas, M.D., 38, ] 

square, S.W. 
18/0 Causton, William Henby, He 
place, Hammersmith « 



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XX FELLOWS OF THE SOCIETT. 

Elected 

1863 Cayzbb, Thomas^ Mayfield, Aigbartb, Li?erpoo]. 

1864 Chambers^ Thomas, 2a, Satherland street, Warwick squai-e, 

S.W., and 2, Bolton row, Mayfidr. 

1859 Chance, Edward John, F.R.C.S., Surgeon to the Metro- 
politan Free Hospital and City Orthopaedic Hospital ; 
59, Old Broad street. City, E.C. 

1862 Chapman, Walter, F.R.C.S., Lower Tooting, Surrey. 
1867* Charles, T. Edmondstoune, M.D., Professor of Midwifery 

at the Calcutta Medical College, 10, Harrington street, 
Calcutta, Hon, Loc. Sec. 

1865* Charlton, Egbert, M.D., Fareham, Hants. 

1863 Chavasse, Pye Henry, F.R.C.S., 12, The Square, Bir- 

mingham. 

1868 Child, Edwin, New Maiden, Kingston-on-Thames, Surrey. 

1872 Chittenden, Charles P. Downey, L.R.C.P. Ed., As- 
sistant-Surgeon R.N., Haslar Hospital, and South 
Lodge, Lee park, Lee, Blackheath. 

1861 Church, William John, F.R.C.S., 22, Circus, Bath. 

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

1861 Clark, James, M.D., 57, Regent's park road, N.W. 

1859 Claek, James Fenn, 18, York terrace, Leamington. Hon. 
Loc, Sec, 

1862 Clarke, John, Lynton, North Devon. 

1872 Clarke, William Michell, late Surgeon to the British 
General Hospital ; 2, York buildings, Clifton, Bristol. 

1859 Clay, Charles, M.D., late Lecturer on Midwifery and 
Clinical Medicine in St. Mary's Hospital, Manchester ; 
Andenshaw Lodge, Andenshaw, near Manchester, and 
101, Piccadilly, Manchester. Council^ 1863-65. 

1859 Clay, John, Professor of Midwifery, Queen's College, 
Birmingham; Allan House, 138-9, Steelhouse lane, 
Birmingham. Council, 1868-69. Fice-Fres. 1872-3. 

1859 Clayton, Oscar, F.R.C.S., Extra Surgeon-in-Ordinary to 
H.R.H. the Prince of Wales, and Surgeon-in-Ordinary 
to H.R.H. the Duke of Edinburgh, 5, Harley street, W. 



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IBKLLOWS OF THE SOCIETY. XXI 

Elected 

1859 Cleveland^ William Fbederick, M.D., Stuart villa» 

199, Maida val^ W. Council, 1863-64. 
1861 Clogo, Stephen, East Looe, Cornwall. 
1865* CoATES, Charles, M.D., Physician to the Bath United 

General Hospital ; 10, Circus, Bath. 

1860 Cockell, Edgab, Holly lodge. Forest road, Dalston, N.E. 

1859 Cockell, Frederick Edgar, 1, Alma villas, Dalston, N.E. 

1861 Collingwood, William, 15, St. Thomas's street, Southwark, 

S.E. 
1866 Coombs, James, M.D., Bedford. 

1864 Cooper, George Henry C, M.D., Surgeon to the Hollo- 

way and N. Islington Dispensary ; Surgeon-Accoucheur 

to the Royal Maternity Charity ; 35, Compton terrace, 

Islington, N. 
1861 Cooper, John, M.R.C.P. Ed., Clapham rise, S.W. 
1872 CooTB, Michael, M.D., Quebec, Canada (and Grangewood 

Lodge, Burton -on-Trent). 

1865 CoPEMAN, Edward, M.D., Physician to the Norfolk and 

Norwich Hospital ; Upper King street. The Close, 
Norwich. Council, 1869-71. Vice-Free,, 1873. Hon. 
hoc. Sec. 

1866 Cornwall, James, F.B.C.S., Fairford, Gloucestershire. 

1860 CoRRY, Thomas Charles Steuart, M.D., L.R.C.P. Ed., 

Senior Surgeon to the Belfast General Dispensary ; 9, 
Clarendon place, Belfast. Council, 1867. Son. Loc, 
Sec. 

1859 Cory, Frederick Charles, M.D., Portland villa, Buck- 
• hurst hill, Essex. Council, 1867-69. 

1863 Coward, John W., Christchurch, Canterhury, J^ew Zea- 
land [agents : Messrs. Alfred Hill and Sons, 11, Little 
Britain]. Ho?i. Loc. Sec. 

1869 Cox, Richard, L.R.C.P. Ed., Theale, near Reading. 

1870 Craigie, John, M.D., 2, West Clifif cottages, Lyme Regis, 

Dorset. 
1859 Croft, J. McGrigor A. T., M.D., M.R.C.P., 8, ^hhey 

road, St. John's Wood, N.W. 
1866 Croft, Robert Charles, L.R.C.P. Ed., 204, Camden road, 

N.W. 



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XXU FELLOWS OF THB SOCIETY. 

Elected 

1861 Cboskeby, Hugh, L.B.C.S. Ireland; Clerk in Holy Orders, 

Government Medical Officer, Chapelton, Jamaica 
[agents : Messrs. Bm^oyne, Burbidges and Squire, 16, 
Coleman street, B.C.]. 
1860 Cross, Rioqabd, M.D., 5, Queen street, Scarborough, York- 
shire. 

1869 Cross, Robert Shackleford, Petersfield, Hants. 

1867 Croucher, Henry, West Hill, Dartford, Kent. 

1859 Culpeper, William Moe, 1, Brunswick terrace. Palace 
gardens, Kensington, W. 

1862 Cumbers ATCH, Laurence Trent, M.D., 35, Cadogan 

place, Belgravc square, S.W. Couneil, 1868-70. 

1867 CuoLAHAN, Hugh, M.D., 9, Grange road, Bermondsey, S.E. 

1859 CuRGENYEN, J. Brendon^ 11, Craveu hill gardens. Bays- 
water, W. Council, 1870-72. 

1868 Daly, Frederick Henry, M.D., 101, Queen's road, Dais- 

ton, N.E. 

1870 Daniel, William Abbot, Kingston-on-Thames. 

1859 Davis, John Hall, M.D., F.R.C.P., Obstetric Physician 
to, and Lecturer on Midwifery and Diseases of Women 
and Children at, the Middlesex Hospital; Physician 
to the Royal Maternity Charity ; Consulting Physician- 
Accoucheur to the St. Pancras Infirmary ; 24, Harley 
street. Cavendish square, W. Council, 1859, 1864-65, 
1869-73. rice-Pres. 1861-63. Pres. 1867-68. 

1863 Davis, Robert Alex., M.D., L.R.C.P. Ed. (exam.), Resi- 

dent Physician, County Asylum, Burntwood, near 
Lichfield, Stafibrd. 

J 859 Day, Willlam Henry, M.D., Physician to the Samaritan 
Free Hospital for Women and Children; 10, Man- 
chester square, W. Council, 1873. 

1866 Deans, John, 282, New Cross road, S.E. 

186r De la Mottb, Henry D. C, Swanage, Dorset. 

1869 Dempsey, Joseph Maldon, M.D., 27, Charterhouse square, 

B.C. 



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FELLOWS OF THE SOCIETY. XXIU 

Elected 

1872 Denton, George Bagsteb, Surgeon to the Ladies' Charity 
and Lying-in Hospital ; 2, Abercromby square, Liver- 
pool. 

1860 Dickenson, John, F.R.C.S., Hon. Surgeon to the Wrexbam 

Infirmary ; Wrexham, Denbighshire. 
1859 Dickson, Joseph, M.D., 56, Bath street, Jersey. 
1859 Dixon, John, M.D., 108, Grange road, Bermondsey, S.E. 
1859 Drage, Charles, M.D., Hatfield, Herts. Council, 1861-4. 
1859 Druitt, Robert, M.R.C.P., 37, Hertford street, Mayfair, 

W. Council, 1859-60. Fice-Prea. 1862-64. 
1859 Druitt, William, F.R.C.S., Wimborne, Dorset. 
1859 Duncan, James, M.B., 8, Henrietta street, Covent garden, 

W.C. Council, 1873. 
1859 Duncan, Peter Charles, M.D., 32, New Cross road, 

Hatcham, S.E. 
1867 Dunderdale, William, M.D., 80, Buttermarket street, 

Warrington, Lancashire. 
1859 Dunn, Robert, F.R.C.S., 31, Norfolk street, Strand, W.C. 

Council, 1860. Fice-Pres. 1861-62. 
1871 Eastes, George, M.B., F.R.C.S., Surgeon-Accoucheur to 

the Western General Dispensary ; 5, Albion place, Hyde 

park square, W. 

1866 Easton, John, M.D., 20, Connaught square, Hyde park, 

W. 

1867 Edis, Arthur W., M.D., Assistant-Physician to the Hos- 

pital for Women, Soho Square ; Physician to the British 
Lying-in Hospital ; 23, Sackville street, W. Council, 
1873. 
1862 Ellis, Edward, M.D., Physician to the Victoria Hospital 
for Children ; 28, Chapel street, Grosvenor place, S.W. 

1861 Ellis, Robert, Obstetric Surgeon to the Chelsea, Brompton, 

and Belgraye Dispensary; 63, Sloane street SW. 
Council, 1868-70. 

1862 Ellison, James, M.D., Surgeon to H.M.'s Household, 

Windsor; 14, High street, Windsor, Berks. Council, 
1873. 



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XXIV FELLOWS OP THE SOCIETY. 

Elected 

1871 Evans, Thomas Walter, 101, Hey worth street, Everton, 

Liverpool. 

1865 Faibbakk, Thomas, M.D., Surgeon to H.M. the Queen and 
the Royal Household, Windsor Castle ; Moulsey House, 
Sheet street, Windsor, Berks. 

1859 Faieoloth, Bichabd, F.R.C.S., Newmarket, Cambridge- 
shire. 

1867 Fairland, Edwin James, L.R.C.P. Ed., Staff Assistant- 

Surgeon, 2l8t Hussars, Lucknow, Oude [per Horace 
E. Golding, Esq., 1, Frederick's place, Old Jewry]. 
1869 Fabquhab, William, M.D., Surgeon, and Assistant Garri- 
son-Surgeon, Bangalore, East Indies [94, Earl's court 
road, Kensington]. 

1861 Fabb, Geo. F., L.R.C.P. Ed., 20, West square, Southwark, 
S.E. 

1868 Frgan^ Richabd, M.D., 1, Charlton park terrace. Old 

Charlton, Rent. 

1872 Febgusson, Alexandeb, F.R.C.S. Ed., Briarbank, Peebles, 

N.B. 

1859 Febgusson, Sib William, Bart., F.R.C.S., F.R.S., Sergeant- 

Surgeon to H.M. the Queen, Professor of Surgery in 
King's College and Surgeon to King's College Hospital, 
Consulting Surgeon to the Samaritan Free Hospital ; 
16, George street, Hanover square, W. Vice-Free. 
1862-63. 

1869 Febgusson, William Edwabd Laing, M.D., 45, Clare- 

mont square, Pentonville, N. 
1872 Febnie, Henbt Mobtlock, Park green, Macclesfield, 

Cheshire. 
1861 Fbthebston, Gebald H., M.D., L.R.C.P. Ed. ; Hon. 

Physician to the Melbourne Lying-in Hospital, Prahran, 

Melbourne, Victoria. Hon, Loc, Sec. 
1872 Field, Albebt Fbedebick, 18, Thistle street, and Marechal 

College, Aberdeen. 

1860 Fisheb, C. Holbbich, M.D., Sittingboume, Kent. 

1870 FisHBB, John Moobe, M.D., 29, Norfolk street, and 33, 

Arundel street. Strand, W.C. 



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FELLOWS OP THE SOCIETY. XXV 

Elected 

1868 Fletcher, Edward, Lygon street, Carlton, Melbourne, 

Victoria. 

1865 Fowler, James, F.S.A., Hon. Surgeon to the Clayton Hoa- 

pital and Wakefield General Dispensary; 13, South 
Parade, Wakefield. Council, 1872-3. Hon. Loc. Sec. 

1866 Fox, Cornelius Benjamin, M.D., Penquite lodge, South 

CliflF, Scarborough. 
1872 Fox, Edward Charlton, M.D., Bloomsbury, Birmingham. 

1862 Frain, Joseph, M.D., Hon. Surgeon to the South Sliields 

Dispensary ; Frederick street. South Shields. 
1861 Prankland, Thomas Thrush, Surgeon to the Ripon Dis- 
pensary. North House, Ripon, Yorkshire. 

1867 Freeman, Henry W., 24, Circus, Bath. 

1867 Fryer, Charles, L.K.Q.C.P. Ireland; Richmond place, 

Higher Openshaw, Manchester. 
1867 Fuller, Charles C, 29, Albany street, Regent's park, N.W. 

1863 Galton, John H., M.D., Three Oak villa, Thicket road, Upper 

Norwood, S.E. 

1872 Gardner, W., M.A., M.D., 470, St. Joseph street, Mon- 
treal. 

1863 Garman, Henry Vincent, Kent House, Bow road, E. 

1859 Gaskoin, George, 7, Westboume park, W. Council, 
1870-72. 

1869 Geikie, Walter B., M.D., F.R.C.S. Ed., Professor of the 

Principles and Practice of Medicine in the University of 
Trinity College, Toronto, Ontario, Canada. 

1859 Gervis, Henry, M.D., Assistant Obstetric Physician to, 
and Lecturer upon Forensic Medicine at, St. Thomases 
Hospital ; Consulting Physician to the Deaf and Dumb 
Asylum, and to the Asylum for Fatherless Children ; 
13, St. Thomas's street, Southwark, S.E. Council, 
1864-66. Jlon, Sec, 1867-70. Fice-Pres. 187' " 

1866 Gervis, Frederick Heudebourck, 1, Fellowes 
Hampstead, N.W. 

1866 GiDDiNGs, William Kitto, L.R.C.P. Ed., Shaftc 
House, Calverley, near Leeds, Yorkshire, 



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XXri VEIXOWS OF THB SOCIETT. 

Elected 

1860 Gill, Samubl Laweencb, L.R.C.P. Ed., 4, Campbell ter- 

race, Bow road, £. 
1869 Gill, William, 43, Wobum place, BuBsell square, W.C. 

1867 GiTTiNS, John, L.R.C.P. Ed., St. Olave^s Union, Parish 

street, Southwark, S.E. 

1871 GoDDABD, EuGEKB, 27, PentonviUc road, N. 

1869 GoDDEN, Joseph, L.K.Q.C.P. Ireland; Dasseldorf. 

1871 Godson, Clement, M.B. and CM., Senior Obstetric 

Assistant at St. Bartholomew's Hospital ; 56, Maddox 
street^ Bond street, W. 

1868 Godwin, AsHTON, M.D., 11, Pelham crescent, Brompton, 

1872 Gobnall, John Hankinsok, Sargeon to the Warrington 

Dispensary; Beech House, Winwick street, Warrington. 

1861 Goss, Samuel Day, M.D., F.R.G.S., 111, Kennington park 

road, S.E. Council^ 1871-3. 

1869 Goss, Tbegenna Biddulph, 31, The Paragon, Bath. 

1861 Gbeam, Geobgb Thompson, M.D., P.R.C.P., Physician- 
Accoucheur to H.R.H. the Princess of Wales ; 2, Upper 
Brook street, Grosvenor square, W. Council, 1862-63. 
Vice-Fres. 1864-66. 

1859 Gbbenhalgh, Robebt, M.D., Physician- Accoucheur to, and 
Lecturer on Midwifery at, St. Bartholomew's Hospital; 
Consulting Physician to the Samaritan Free Hospital, 
and to the City of London Lying-in Hospital ; 72, 
Grosvenor street, W. Council, 1863, 1867-69. Vice- 
Free. 1864-66. 

1863 Gbiffith, G. de GoBBEauEB, Physician to the Hospital for 
Women and Children, Pimlico ; Physician- Accoucheur 
to St. Saviour's Maternity ; 9,iLupus street, St. George's 
square, S.W. 

1869 Gbipfith, John T., M.D., Talfourd House, Camberwell. 

1859 Gbippith, Thomas Tatlob, F.R.C.S., Consulting Surgeon 
to the Wrexham Infirmary ; Wrexham, Denbighshire, 
Council, 1870-72. 



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FELLOWS OF THE 80CIETT. XXTll 

Uleeied 

1870 Gbiqg, Willla.m Chapman, M.D., Physician to Qaeen 
Charlotte's Lying-in Hospital ; 6, Curzon street, May 
fair. 

1859 Oeim3DAL£,Thos. F., L.B.C.P. Ed., Consulting Bargeon to 
the Lying-in Hospital, and late Lecturer on Diseases 
of Children, &c., at the Boyal Infirmary School of 
Medicine ; 29, Rodney street, Liverpool. Council, 
1861-62. 

1870 Gross, Reuben, M.D. [care of Messrs. J. and A. Macmillan], 

St. John's, New Brunswick, Canada. 

1865 GwYN, Geoboe F., Westcroft House, Hammersmith, W. 

1867 Hadaway, James, L.E.C.P. Ed., 47b, Welbeck street. 
Cavendish square, W. 

1859 Haden, Francis Seymoub, F.E.C.S., 62, Sloane street, S.W. 
Council, 1861-63, 1868-70. Vice^Pres, 1865-67. 

1859 Hall, Alfred, M.D., Senior Physician to the Brighton Dis- 
pensary ; 30, Old Steyne, Brighton. Council, 1864-65. 
Fice-Pres. 1866-68. Hon. Loc. Sec. 

1859 Hall, Fbeoebick, 1, Jermyn street, St. James's, S.W. 

1867 Hall, John Henry Wynne, L.R.C.P. Ed., 6, Portland place, 

(118) Wandsworth road, S.W. 
1862 Hall, William, Lecturer on Physiology and Diseases of 

Women and Children, Leeds School of Medicine ; 

Hillary place, Leeds. Son, Loc. Sec. 

1871 Hallo WES, Feepebick B., Redhill, Eeigate, Surrey. 

1860 Habdey, Key, Surgeon to the West City Dispensary; 4 

Wardrobe place. Doctors' Commons, B.C. 

1869 Habdinoe, Henby, M.D., Physician to the Great Northern 
Hospital; 18, Grafton street, Bond street, W. 

1872 Habdyno, William, F.R.C.S., 4, Percy street, Bedford 

square, W.C. 
1859 Habpeb, Philip H., F.R.C.S., 30, Cambridge street, Hyde 

park, W. 
1859 Harrinson, Isaac, F.R.O.S., Castle street, Reading, Berks. 

Council, 1862-65. Hon. Loc. Seo* 



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XXVIU FELLOWS OF THE SOCIETY. 

Elected 

1862 Harris, Charles, M.D., Northiam, Ashford, Kent. 

1871 Harris, Charles James, 54, Broad street. Golden square, 

W. 

1872 Harris, Henry, M.D., F.R.C.S., Trengweath place, Bedmth, 

Cornwall. 
1861 Harris, Herbert Robey, 52, Bolton street, Bory, Lanca- 
shire. 

1867 Harris, William H., M.D., Professor of Midwifery in the 

Madras Medical College, and Superintendent of the 

Lying-in Hospital, Madras [agent : Mr. H. K. Lewis, 

Gower street] . 
1861 Harris, William John, 13, Marine Parade, Worthing. 
1865 Harvey, Robert, M.D., Civil Surgeon of Bhurtpore, near 

Agra, India [wV/ Bombay]. [Per Alex. Harvey, M.D., 

228, Union street, Aberdeen.] 

1859 Harvey, William, 48, Lonsdale square, Islington, N. 

1861 Haviland, Edward Savage, M.D., 466, Edgware road, 

W. 

1868 Hay, Thomas Bell, L.E.C.P. Ed. ; 43, Caledonian road,N. 
1865 Hayes, Hawkesley Roche, Basingstoke, Hants. 

1862 Hayman, Charles Christopher, M.D., 22, Grand Parade, 

Eastbourne, Sussex. 
1864 Head, Edward, M.B., Obstetric Physician to, and Lecturer 

on Midwifery at, the London Hospital; 91, Harley 

street, W. Council, \S7 0-7 \. 
1867 Hembrouoh, John William, Waltham, Grimsby. 

1869 Hemsted, Henry, Whitchurch, Hants. 

1870 Henderson, Alexander, 2, Meadow Bank place, Rose vale, 

Partick, Glasgow. 

1860 Hess, Augustus, M.D., Physician to the Jews' Hospital, 

Norwood ; 14, Artillery place, Finsbury square, E.G. 
1859 Hewitt, Graily, M.D., F.R.C.P., Professor of Midwifery 
in University College, London, and Obstetric Physician 
to University College Hospital ; 36, Berkeley square, 
W. Ron, Sec. 1859-64. Treas. 1865-66. Fice^Pree. 
1867-68. Pres. 1869-70. Council, 1871-73. 



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FELLOWS OF THE SOClEtY. XXIX 

Elected 

1862 Hewiit, Tom Smith, M.D., Ivy Cottage, Winkfield, Wind- 
sor, Berks. 

1867 HiCKiNBOTHAM, James, L.R.C.P. Ed., 10, Park road, 

Nechells, Birmingham. 

1860 Hicks, John Braxton, M.D., F.R.C.P., F.R.S., Physician- 
Accoucheur to, and one of the Lecturers on Midwifery 
and the Diseases of Women and Children at, Guy's 
Hospital ; Physician to the Royal Maternity Charity ; 
24, George street, Hanover square. Council, 1861-2, 
1869, 1873. Hon, Sec, 1863-65. Fice-Pres. 1866-68. 
Treas, 1870. Pres. 1871-2. 

1860 HiGGS, Thomas Fbederic, L.R.C.P. Ed., 194, High street, 
Dudley, Worcestershire. 

1872 HiLLiABD, Eobekt Hancy, M.D., 5, Belgrave terrace. Upper 
Holloway, N. 

1868 Hime, Thomas Whiteside, M.B., 217, Glossop road, 

Sheffield. 

1865 HoDDBB, Edward M., M.D., Lecturer on Obstetrics, 

Toronto School of Medicine; Toronto, Canada West. 

Hon, Loc, Sec. 
1859 Hodges, Richard, M.D., F.R.C.S., 103, Gloucester place, 

Portman square, W. 
1864 Hopfmeisteb, William Carter, M.D., Surgeon to the 

Queen in the Isle of Wight ; Clifton House, Cowes, 

Isle of Wight. 

1871 Hogg, Francis Roberts, M.D., Assistant-Surgeon Royal 

Artillery, Woolwich. 

1859 HoLMAN, CoNSTANTiNE, M.D., Rcigatc, Surrey. Council, 

1867-69. Vice-Prea. 1870-71. 

1860 HoLMAN, Henry Martin, M.D., Hurstpierpoint, Sussex. 
1864 Hood, Wharton Peter, M.D., 65, Upper Berkeley street, 

Portman square, W. 

1872 Hope, William, M.D., Physician to Queen Charlotte's 

Lying-in Hospital ; 5, Bolton row, Mayfair, W. 

1866 HoRNiBLOW, Richard E. Brain, M.D., 24, Lansdowne 

place, Leamington. 



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IXX J^ElLOWS OJf THE SOCIETY. 

Elected 

1861 HoBTON, Qeobob Edwabd, Castle street, Dadley, Worces- 
tershire. 

1864 Houghton, Henbt Geoboe, L.K.Q.C.P. Ireland ; 6, Mount 
street, Grosvenor square, W. 

1872 Hunt, Albebt, Bridge road, Hammersmith. 

1859 Hutchinson, Jonathan, F.R.C.S., Surgeon to the London 
Hospital ; 4, Finsbury circus, E.G. Council, 1869-71. 

1870 HuTHWAiTE, Chables, L.R.C.P. Ed., Alfred street central, 
Nottingham. 

1861 HuTTON, Chables, M.D., Physician to the General Lying- 

in Hospital; 26, Lowndes street, Belgrave square, 

S.W. 
1859 Ilott, James William, Bromley, Kent. 
1859 Image, William Edmund, F.R.C.S., Senior Surgeon to the 

Suffolk General Hospital ; Bury St. Edmund's, Suffolk. 

Council, 1870-72. 
1870 IzoD, Fbeeman, Fletcher House, Tottenham, Middlesex. 
1864 Jackson, Edwabd, M.B., Surgeon to the Sheffield Hospital 

for Women ; Fern Bank, Glossop road, Sheffield. 
1864 Jackson, Robebt, M.D., 53, Netting hill square, W. 
1872 Jalland, Robebt, Horncastle, Lincolnshire. 
1868 James, Alfbed, M.D., Perry vale. Forest hill, S.E. 
1872 James, Edwin Matthews, Surgeon to the Melbourne 

Hospital, Victoria; 169, Collins street east, Mel- 
bourne. 
1859 James, Henby, F.R.C.S., Elmhurst, Weybridge, Surrey. 

Council, 1862-63. 

1862 Jay, Fbedeeick Fitzhebbbbt, Yuso villa. South Cliff, 

Scarboro', Yorkshire. 

1863 Jenkins, Robebt W., 13, Charlotte street, Bedford square, 

W.C, and 22, Philpot lane, E.C. 

1859 Jennings, Joseph C. S., Abbey House, Malmesbury, Wilts. 

1860 Jepson, Henby, F.R.C.S., Surgeon to the Kingston Dispen- 

sary ; Hampton, Middlesex, S.W. 

1861 Jones, Edwabd, M.D., The Park, Sydenham, Kent 



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tEtlOWS OF THt SOCIEtY. XXXI 

Elected 

1868 J0NBS9 Evan, Ty-Mawr, Aberdare, Glamorganshire. 
1859 J0NES9 Geoboe, 12, New Hall street, Birmingham. 
1868 Jones, John, 60, King street, Recent street, W. 

1866 Jones, Robert, 19, Stretford road, Hidme, Manchester. 
1870 Jones, "William, Greenfield House, Glynneath, Neath, 

Glamorganshire. 

1868 JoBDAN, William Ross, Manor House, Moseley, near Bir- 

mingham. 

1867 JuNKEB, F. Ethelbbrt, M.D. 

1859 Keele, Geobqe Thomas, 81, St. Paul's road, Highbury, N. 
1872 Kennedy, John Edwabd, M.B., Lecturer on Medical 

Jurisprudence^ Trinity College, Toronto. 
1865* Kebnot, Geobge Chables, M.D., 3, Chrisp street, Poplar, 

E. 
1872 Kebb, Nobman S., M.D., Markyate street, near Dunstable, 

Beds. 

1859 Kiallmabk, Henby Walteb^ 66, Prince's square^ West- 

bourne grove, W. 

1869 Kinosfobd, 0. Dudley, M.D., Upper Clapton, N.E. 

1860 Kinosfobd, Edwabd, F.R.C.S., Surgeon to the Sunbury 

Dispensary ; Sunbury, Middlesex. 
1862 KiBKPATBicK, John Ruthebfobd, M.B. Dubl., Examiner in 

Midwifery, Royal College of Surgeons, Ireland ; 32, 

Rutland square, Dublin. Council, 1872-3. 
1872* Kisch, Albebt, 2, Circus place, Finsbury, E.G. 
1867 Knaggs, Henbt Quabd, M.D., 72, Kentish Town road, 

N.W. 
1872 KonrAd, Mauk, M.D., The Vienna Hospital, Vienna, 

Austria. 
1867 Langfobd, Chables P., 187, Goswell road, E.C. 
1859 Lanomobe, John Chables, M.B., F.R.C.S,, 20, Oxford 

terrace, Hyde park, W. Ooundly 1861-64. Vice- 

Pree. 1869-71. 
1866 Langston, Thomas, L.R.O.P. Ed., 29, Broadway, West^ 

minster, S.W. 



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XXXU FELLOWS OP THE SOCIETY. 

Elected 

1862 Lanphieb, Richard, M.6. Dabl., Alford, Lincolnshire. 
1872 Lattey, James, 26, Upper Phillimore place, Kensington, 
W. 

1867 Leap, Waltek, Surgeon to the St. Marylebone General 

Dispensary ; 14, Furnivars Inn, Holbom, E.G. 
1859 Lee, Newton B. C, 26, Hanley road, Homsey rise, N. 

1859 Leech, Edwakd, Pallant, Chichester, Sussex. 

1860 Leishman, William, M.D., Physician to the University 

Lying-in Hospital, Eegius Professor of Midwifery in 
the University of Glasgow ; 156, Bath street, Glasgow. 
Council, 1866-68. Vice-Prea. 1869-70. 
1872 Leonard, Crosby, Surgeon to the Bristol Royal Infirmary; 
Rockleigh House, White Ladies road, Bristol. 

1868 Leslie, William Burnup, M.D., Stonehaven, Kincardine. 

shire. 
1870 Ligertwood, John, M.D., late Assistant-Surgeon, R.N., 
China Expedition ; Methlick, Aherdeenshire. 

1868 Llewellyn, Evan, L.R.C.P. Ed., 9, Mount place, London 

Hospital, E. 
1872* Lock, John Griffith, M.A., Lansdowne House, Tenhy. 
1859 LococK, Sir Chas., Bart., M.D., F.R.C.P., 26, Hertford 

street, Mayfair, W. Honorary President, 
1859 Lombe, Thomas Robert, M.D., Bemerton, Torquay. 
1870 Long, Mark, M.D., Surgeon to the Poplar Hospital ; 93, 

Richmond road, Dalston, N.E. 

1861 Love, Gilbert, Wimbledon, Surrey, S.W. 

1866 LovEGROVE, Charles, M.D., 18, Westbourne place, Eaton 

square, S.W. 
1872 LovEGROVE, James F., Ightham, Sevenoaks, Kent. 

1862 Lowe, George, F.R.C.S., Burton-on-Trent, Staffordshire. 

1869 Lowndes, Frederick Walter, 62, Mount Pleasant, Liver- 

pool. 
1866 LucEY, William Cubitt, M.D., Norfolk villas, Junction 

road. Upper Holloway, N. 
1869 Lydall, Wykeham H., L.R.C.P. Ed., 19, Mecklenburgh 

square, W.C. 



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FELLOWS OF THE SOClEtY. XXXlll 

Elected 

1868 Lynch, J. Roche, 41, Chepstow villas, Westbourne grove. 
1871 McBeath, William, M.D., Long street, Atherstone, 
Warwickshire. 

1871 McCallum, Duncan Campbell, M.D., Professor of Mid- 
wifery and Diseases of Women and Children, McGill 
University ; Physician to the University Lying-in 
Hospital; and Physician to the Montreal General 
Hospital ; Montreal, Canada. 

1871 M'CoNKEY, Thomas Clarkson, M.D., McGill Univ., 

M.R.C.S.E ; Barrie, Ontario, Canada. 

1859 Mackindeb, Draper, M.D., Consulting-Surgeon to the 
Gainsborough Dispensary ; Gainsborough, Lincolnshire. 
Council, 1871-3. 

1872 McMoNAGLE, Joseph, M.D., New Brunswick, Dominion of 

Canada. 

1872 MacMobdie,William Kirkpatrigk, M.D., 1 College square 
east, Belfast. 

1861 McVeagh, Dennis, L.K.Q.C.P. Ireland, 33, Bishop street^ 
Coventry, Warwickshire. 

1866 Madbeter, John Coombe, M.D., 19, Battery place, 
Rothesay. 

1859 Madge, Henry M., M.D., 32, Fitzroy square, W. Council^ 

1863-65. Fice-Pree. 1872-3. 

1871 Malins, Edward, M.D., 8, Old Square, Birmingham. 

1871 Manby, Alan Reeve, East Rudham, Brandon, Norfolk. 

1868 March, Henry Colley, M.D., 2, West street, Rochdale. 

1860 Marley, Henry Frederick, Padstow, Cornwall. 

1859 Marley, Richard, Bromyard, near Worcester, Hereford- 
shire. 

1869 Marriott, Osborne Delate, M.B., CM., Sevenoaks, 

Kent. 
1862 Marriott, Robert Buchanan, Swaffham, Norfolk. 
1859 Marshall, John Brake, Nightingale road downs, Clapton, 

N.E. 
Vol. xiv. c 



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Google 



XXXIV FELLOWS OF THE SOCIETY. 

Elected 

1871 Martin, Edward, Senior Surgeon to the Weston-super- 
Mare Hospital ; Victoria House, Weston-super-Mare. 

1864 Martin, Lawrence J., M.D., Physician to the Melbourne 
Lying-in Hospital ; 12G, Collins street east, Melbourne, 
Victoria. 

1871 Mathias, David, Pendre, Cardigan, South Wales. 

1866 Mattei, Antoine, M.D., Professor of Midwifery, Rue 

Th^r^se 4, Paris. 

1861 Matthews, John, M.D., 4, Mylne street, Myddelton 
square, E.C. 

1867 May, Henry, L.R.C.P. Lond., Fairfield House, Lichfield 

road, Aston, Birmingham. 

1859 Meadows, Alfred, M.D., Physician-Accoucheur to, and 

' Lecturer on Midwifery at, St. Mary's Hospital ; 

Physician to the Hospital for Women, Sohb square ; 

27, George street, Hanover square, W. Council, 1862-64. 

Hon. Sec. 1865-66. lion. Lib. 1865. Treae, 1867-69. 

1872 Mendenhall, George, M.D., Cincinnati, Ohio, U.S. 
1867 MicKLEY, Arthur George, M.B. Lond., late House 

Surgeon, General Hospital, 39, Derby road, Notting- 
ham. 
1871 Miller, Hugh, M.D., Assistant-Physician to the Maternity 
Hospital, Glasgow; 463, St. Vincent street, Glasgow. 

1871 Miller, John Faure, 28, Rue de Matignon, Faubourg St. 

Honors, Paris. Hon, Loc, Sec. 

1869 MiLWARD, James, 62, Crockherbtown, Cardiff. 

1869 Minns, Pembroke R. J. B., M.D., Thetford, Norfolk. 

1859 Mitchell, Joseph Thomas, F.R.C.S. [8, Percy place], 
176, Clapham road, S.W. Council, 1863-67. 

1867 Mitchell, Robert Nathal, M.D., 1, Amersham park 

villas. New Cross, Kent. 

1872 MoNDELET, William H., M.D., 776, Craig street, Mon- 

treal. 

1868 MooDELLY, P. S. MooToosAWMT, M.D., Native Surgeon^ 

Uncovenanted Service, Madras, Manargoody, Tanjore. 



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FELLOWS OF THE SOCIETIT. XXXV 

Elected 

1871 MooDELLY, Chittathoee Banloo, Graduate in Medicine 
and Surgery of the Madras Medical College ; Officiating 
Gillab Surgeon, of Cochin ; Trichiiiopoly. 

1869 Moobe, Joseph, M.D., 9, Linden villas, Blue Anchor road, 
Bermondsey, S.E. 

1859 Moobhead, John, M.D., Surgeon to the Weymouth lufir* 
mary and Dispensary ; Weymouth , Dorset. 

1863 MoBGAN, Edwabd, 15, Park street, Llanelly, Caermarthen- 
shire. 

1869 MoBGAN, W. H., Surgeon 23rd Regiment, Tinilon, Travan- 

core. 
1871 MoBBisoN, John R., L.R.C.P. Ed., b7t Cannon street road, 

E. 

1865 MosELEY, Geobgb, F.R.C.S., 51, Priory road, Kilburn, 

N.W. 

1859 MuBBAY, GusTAVUs Chables p., M.D., Obstetric Physician 
to the Great Northern Hospital; 17, Green street^ 
Grosvenor square, W. Council^ 1864-65. Hon, Sec, 
1866-69. Fice Free. 1870-72. Treas. 1873. 

1859 MusGBAVE, Johnson Thomas, L.B.C.P. Ed., Irlam villa, 
39, Finchley road, N.W. Council, 1859-60. 

1859 Nappeb, Albebt, Broad Oak, Crauleigh, Guildford, Surrey. 
Council, 1866-68 

1863 Nason, John James, M.B. Lond., 11, Bridge street, Strat- 
ford-on- Avon. 

1859 Nason, Richabd Bibd, Nuneaton, Warwickshire. 

1859 Neal, James, M.D., late Hon. Surgeon to the Lying-in 
Hospital, Birmingham ; Sandown, Isle of Wight. 

1866 Neild, James Edwabd, M.D., Lecturer on Forensic Medi- 

cine, Melbourne Uniyersity; 166, Collins street east^ 
Melbourne. 

1859 Newman, William, M.D., Surgeon to the Stamford and 
Rutland Infirmary; Barn Hill House, Stamfordi 
Northamptonshire. Council, 1873. 



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IXXVi FELLOWS OF THE SOCIEIIy. 

Ulected 

1859 Newton, Edwaed, F.R.C.S., 4, Upper Wimpole street, W. 

Council, 1865-67. 
1872 Niblett, Feancis D., L.R.C.P. Bd., The Grove, Hackney, 

N. 

1868 NiCHOLLs, James, M.D., Duke street, Chelmsford, Essex. 
1861 Nichols, Geoege W., Augusta House, Rotherhithe, S.E. 

1869 NoETON, Selby, M.D., Rye House, Putney hill, Surrey. 

1868 Oates, Paekinson, M.D., 164, Cambridge street, Pimlico, 

S.W. 

1859 Oldham, Heney, M.D., F.R.C.P., Consulting Obstetric 
Physician to Guy*B Hospital ; 4, Cavendish place. Caven- 
dish square, W. Fioe-Fres. 1859. Council, 1860, 
1866-1866, 1868-73. Treas, 1861-62. Pres. 1863-64. 

1859 Oldham, Jambs, F.R.C.S., Consulting-Surgeon to the 
Brighton Lying-in Institution; 53, Norfolk square, 
Brighton. Council, 1866-68. 

1869 Oed, Geoege Rice, Streatham hill, Surrey. 

1863 Oswald, James Waddell Jeffbies, L.R.C.P. Ed., 245, 

Kennington road, S.E. 

1869 OxLEY, Maetin G. B., L.K.aCP. Ireland, 80, Rodney 
street, Liverpool. 

1859 Palfeby, James, M.D., Assistant-Obstetric Physician to the 

London Hospital ; Physician to the General Lying-in 
Hospital, York road ; 18, Finsbury square, E.C. 

1867 Paeks, John, The Wylde, Bury, Lancashire, 

1872 Paee, Geoege, 18, Upper Phillimore place, Kensington, W. 

1865* Pateeson, James, M.D., Hayburn Bank, Partick, Glasgow. 

1860 Payne, Chaeles Heney, M.D., Wimbledon, Surrey. 

1866 Peacock, Albeet Louis, Townfield House, Great Harwood, 
Accrington. 

1864 Peabson, Dayid Ritchie, M.D., 23, Upper Phillimore 

place, Kensington, W. 

1871 Pedlee, Geoege Heney, 6, Trevor terrace, Rutland gate, 
S.W. 



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FELLOWS OP THE SOCIETY, XXXVU 

Elected 

1859 Peirce, RiCHAED Kino, SurgeoD to the Netting hill and 
Shepherd's Bush Dispensary, 16, Norland place, 
Netting hill, W. 

1871 Perrioo, James, M.D., 591, St. Catherine street, Montreal, 
Canada. 

1866 Phillips, John J., M.D., Assistant-Obstetric Physician to 
Gay's Hospital; Assistant-Physician to the Hospital 
for Sick Children ; Physician to the Royal Mater- 
nity Charity; 26, Finsbury square, E.G. Hon, Lib, 
1870. Hon, Sec. 1871-3. 

1871 Philps, Philip George, 4, Queen's road, Peckham, S.E. 

1866 Pilcher, William John, 43, High street, Boston, Lincoln- 
shire. 

1859 Pinchard, Benjamin, M.D., Cottenham, Cambridgeshire. 

1868 Platfair, George Ranken, M.D., Deputy Inspector- 
General, H.M.'s Indian Arnny. [Care of C.S. Leekie,E8q., 
2, East India avenue, B.C.] 

1864 Playpair, W. S., M.D., F.R.C.P., Professor of Obstetric 
Medicine in King's College, and Obstetric Physician to 
King's College Hospital ; 5, Curzon street, Mayfair, W. 
Council, 1867. Hon, Librarian, 1868-9. Hon. Sec, 
1870-72. Vice-Free,, 1873. 

1859* PoLLABD, William, Surgeon to the Torbay Hospital ; 
Southlands, Torquay, Devon. 

1860 Pollock, Timothy, M.D., 26, Hatton Garden, B.C. Coun- 

cil, 1866-68. 

1860 Porter, Charles, 54, Digbeth, Birmingham. 

1864 Potter, John Baptiste, M.D., Assistant-Obstetric Phy- 
sician to the Westminster Hospital ; 20, George street, 
Hanover square, W. Council, 1872-3. 

1859 Pound, George, Odiham, Hants. 

1863 Powell, Josiah T., M.D., 347, City road, E.C. 

1864 Price, William Nicholson, Lecturer on Mid? 

Leeds School of Medicine ; 7, East parade, 
1863 Price, William Preston, M.D., Surgeon to 
politan Infirmary for Scrofulous Children, \ 
Ethelbert Crescent, Margate. 



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Google 



XXXVm FELLOWS OF THE SOCIETY, 

Elected 

1859 Priestley, William 0., M.D., F.R.C.P., Consulting 
Obstetric Physician to King's College Hospital; and 
Consulting Physician- Accoucheur to the St. Marylebone 
Infirmary ; 1 7, Hertford street^ Mayfair, W. Council, 
1859-61, 1865-66. Fice^Pree. 1867-69. 

1859 Radfoed, Thomas, M.D., Consulting Physician to St. 
Mary's Hospital, Manchester; Moor field. Higher 
Broughton, Manchester. Fice-Pres, 1859. 

1859 Ramsay, John Allen, L.R.C.P. Ed., Great Shelford, Cam- 
bridge. 

1859 Randall, John, M.D., Lecturer on Medical Jurisprudence, 

St. Mary's Hospital Medical School ; Medical Officer, 
St. Marylebone Infirmary ; 35, Nottingham place, W. 
1872 Rankin, William Baily, Surgeon to Prince Alfred Hos- 
pital ; High street, St. Kilda, Melbourne. 

1860 Ransom, Robebt, M.D., F.R.C.S., 5, Jesus lane, Cam- 

bridge. 

1861 Rasch, Adolphus A. F., M.D., Physician for Diseases of 

Women to the German Hospital; Physician to the 
Training Hospital, Tottenham ; 7, South street, Fins, 
bury square, B.C. Council, \ 87 1-3. 

1870 Ray, Edwaed Reynolds, Dulwich. 

1860* Eaynee, John, M.D., Swaledale House, Quadrant road 

north, Highbury ^ew Park, N. 
1859 Eaynes, Heney, Gringley-on-the-hill, Bawtry, Yorkshire. 

1871 Read, Chables, M.B., 3, Rcthw^ell street, and 1, St. George's 

square, Regent's park road, N.W. 
1859 Reb, Heney Pawle, L.R.C.P. Ed., F.R.C.S., St. John's, 

Fulham, S.W. 
1859 Remington, Thomas, M.D., Visiting Medical Officer to the 

S. Lambeth and Brixton Dispensary; Grove House, 

194, Brixton road, S.W. 

1862 RiGHABDS, Dayid, 8, St. George's place, Brighton, Sussex. 
1859 Richaeds, Samuel, M.D., 36, Bedford square, W.C. 

Council, 1864-66. 
1862 Richaeds, S. Smith C, 36, Bedford square, W.C. 



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FELLOWS OF THE SOCIETY. XXXIX 

Mected 

1859 EiCHARDSON, Richard, L.R.C.P. Ed., Rhayader, Radnor- 

shire. 
18/2 Richardson, William L., M.D., 70, Boylston street, 
BostoD, Massachusetts. 

1871 RiCKARD, Frederick Marttn, Assistant-Surgeon 25th 

Madras Native Infantry, Cavanore. 

1872 RiODEN, George, Surgeon to the Canterbury Dispensary, 

Burgate street, Canterbury. 

1871 RiODEN, Walter, Resident Medical Officer, University Col- 
lege Hospital, Gower street, W.C. 

1871 Roberts, Arthur, 30, Kensington square, Kensington, W. 

1859* Roberts, David Lloyd, M.D., Surgeon to St. Mary's Hos- 
pital, Manchester; 23, St. John's street, Deansgate, 
Manchester. Council, 1868-70. Fice-Pres. 1871-2. 
Son. Loc. Sec. 

1867 Roberts, David W., M.D., 56, Manchester street, Man- 

chester square, W. 

1860 Roberts, Robert Price, Shamrock House, Rhyl, Flint- 

shire, 
1859 Robinson, Thomas, M.D., 35, Lamb's Conduit street, W.C. 

1868 KoBsoN, Hope F. A., M.D., Iver, near Uxbridge. 

1868 Rogers, Adah MacDougall, Surgeon, Bombay Army, 
Malabar Hill, Bombay. 

1859 Rogers, William Richard, M.D., Physician to the Sama- 
ritan Free Hospital ; 56, Berners street, Oxford street, 
W. Council, 1870-72. 

1871 RoosE, E. C. Robson, 32, London road, Brighton. 

1859 Roots, William Sudlow, F.R.C.S., F.L.S., Surgeon to the 

Royal Establishment at Hampton Court, Kingston-on- 
Thames. 

1860 RoPEB, Alfred George, 57, North End, Croydon, Surrey. 

1865 Roper, George, Bank House, Aylsham, Norfolk. 

1859 Rose, Henry Cooper, M.D., High street, Hampstead, 
N.W. 



Digitized by VjOOQ IC 



Xl FELLOWS OF THE SOCIETY. 

Sleeted 

1859 BouTU, Charles Henry Felix, M.D., PhvBicUn to the 
' Samaritan Free Hospital for Women and Children ; 52, 
Montagu square, W. Council, 1859-61. 

1869 BussELL, Charles James» Bose Cottage, Messingham, 

Lincolnshire. 

1870 EossELL, Logan D. H., M.D., New York; Camden, Wyo- 

ming, U.S. 

1866 Saboia, v., M.D., Bio de Janeiro [per Captain Argollo, 1, 
Princes terrace, Bayswater]. 

1864 Salter, John H., D'Arcy House, Tolleshunt D'Arcy, Kel- 
yedon, Essex. 

1868* Sams« John Sutton, St. Peter's Lodge, Eltham road, Lee, 

Kent. 
1872 Sanoster, Charles, 15, Lambeth terrace, S.E. 

1870 Saul, William, M.D., 4, Charlotte street, Fitzroy square, 
W. 

1863 Sataoe, Henry, M.D., Consulting Physician to the Sama- 
ritan Hospital for Women, Lower Seymour street, 
Portman square, W. Council, 1871-2. 

1872 Savage, Thomas, M.D., Surgeon to the Birmingham and 
Midland Hospital for Women ; Bordesley, Birming- 
ham. 

1859 Scott, John, F.E.C.S., Surgeon to the Hospital for Women, 

Soho square ; 49, Harley street. Cavendish square, W. 
Council, 1868-70. Vice-Prea, 1871-3. 

1870 Scott, John, M.D., New street. Sandwich. 

1870 Scott, John, M.D., Q7, Folsam street, San Francisco. 

1860 Sedgwick, Leonard Willlam, M.D., 2, Gloucester terrace, 

Hyde park, W. Council, 1871-3. 

1863 Sbqueira, Henry Little, 1, Jewry street, Aldgate, B.C. 

1866 Sequeira, James Scott, 34, Leman street, Goodman's 

fields, E. 
1860 Sewell, Charles Brodie, M.D., 7^, Guilford street, 

Bussell square, W.C, and 13, Fenchurch street, E.C. 



Digitized by VjOOQ IC 



FELLOWS OP THE SOCIETY. xU 

Elected 

1870 Seydewitz, Baron Paul von, M.D., late Senior Physician 
to the East London Hospital for Sick Children, and 
Dispensary for Women; 4, Coleherne road. West 
Brorapton, S.W. 

1872 Shapland, John Dee, Thornton Heath, Croydon. 

1862 Sharman, Malim, Surgeon to the Birmingham Free Hos- 
pital for Sick Children ; 18, New Hall street, Birming- 
ham. 

1859 SflARPiN, Henry Wilson, F.R.C.S., Surgeon to the Bed- 

ford General Infirmary, Bedford. Council^ 1871^3. 

1860 Shaw, George, Portland House, Battersea, S.W. 

1869 Shaw, Henry Sissmore, 88, Upgate, Louth, Lincolnshire. 
1859 Shearman, Edward James, M.D., F.R.C.S., F.R.S. Ed., 

Consulting Physician to the Botherham Dispensary ; 

Moorgate, Botherham, Yorkshire. 
1859 SflEEHY, William Henry, L.R.C.P. Ed., 4, Claremont 

square, Pentonville, N. 
1867 Shepherd, Frederick, L.R.C.P. Ed., 33, King Henry's 

road. South Hampstead, N.W. 

1859 Shipton, William Parker, Consulting Surgeon to the 

Devonshire Hospital ; Buxton, Derbyshire. 

1861 Shortt, John, M.D., Surgeon H.M. Madras Army, and 

Superptendent-General of Vaccination, Madras Presi- 
dency. Hon, Loc. Sec, [Agents: Messrs. I 
Brothers, 8, Bishopsgate within, E.C.] 

1860 Skinner, Thomas, M.D., Obstetric Physician to the 

in Hospital; Dunedin House, 64, Upper Pari 
street, Liverpool. Council^ 1865-66. Hon, Loc 

1859 Sleeman, Philip Rowling, F.R.C.S., Montrose ] 

Queen*s road, Clifton. 

1861 Slobtan, Samuel George, Farnham, Surrey. 

1861 Slyman, William Daniel, 26, Cavershara road, 1 
Town, N.W. 

1860 Smart, Thomas Tovey, L.E.C.P. Ed., South ViUi 

minster, Bristol. 



Digitized by VjOOQ IC 



Xlii FELLOWS OF THE SOCIETY. 

Elected 

1859 Smiles, William, M.D., Sargeon to the House of Correc- 

tioD, Cold Bath Fields ; 44, Bedford square, W.C. 
1870 Smith, Feancis William, M.B., Westbury, Wilts. 

1867 Smith, Heywood, M.D., Physician to the Hospital for 

Women, Soho square, and Physician to the British 

Lying-in Hospital; 2, Portugal street, Grosvenor 

square, W. Council, 1872-3. 
1859 Smith, Pbotheboe, M.D., Physician to the Hospital for 

Women, Soho square; 42, Park street, Grosvenor 

square, W. 
1859 Smith, William Johnson, M.D., Consulting Physician to 

the Weymouth Infirmary and Dispensary; Greenhill, 

Weymouth, Dorset. Councily 1869-71. 

1859 Smith, W. Tyler. M.D., F.R.C.P., Consulting Physician- 

Accoucheur to St. Mary's Hospital; 21, Upper Gros- 
venor street, W. Treamrer fy Fice-Pres. 1859-60. 
Pres. 1861-62. Council, 1863-73. 

1860 Snell, Edmund, L.R.C.P. Ed., 59, Stepney green, E. 

1866 SoPEB, William, Medical Officer, Jews' Hospital, Norwood 

4, Clapham rise [283, Clapham road], S.W. 
1869 Spaull, Baunabd, F.B.C.S., 5, Vale place. Hammersmith, 
W. 

1868 S?AULL, Barnabd E., 2, Vale place. Hammersmith, W. 
1872 Spence, James Beveridgb, M.D., County Asylum, Burnt- 
wood, Lichfield. 

1859 Spenceb, Geobge, 8, Kensington park road, W. 
1862 Spby> Geobge Fbedebick, M.D., Assistant-Surgeon, 2nd 
Life Guards, The Barracks, Windsor. 

1867 SaUABEY, Chables E., M.B., Assistant-Physician to the 

Hospital for Women ; 13, Upper Wimpole street, W. 

1859 Squibe, William, M.R.C.P., 6, Orchard street, Portman 

square, W. Council, 1866-68. 

1860 Stedman, Robebt Saviqnac, Sharnbrook Grange, Bedford. 
1866 Steele, Abthub Bbowne, L.K.Q.C.P. Ireland, Lecturer on 

Midwifery, Royal Infirmary School of Medicine ; 54, 
Koduey street, Liverpool. 



Digitized by VjOOQIC 



FELLOWS OF THE SOCIETY. xliii 

Elected 

1869 St£:el£» Henry Mubiiay, 132^ Stanhope streetj Hampstead 

road, N.W. 
1859 Stone, Joseph, M.D., 84, Bloomsbury, Oxford street, Man- 

Chester. 
1859 Stowebs, Nowell, 125, Kennington park road, Kennington, 

S.E 
1866 Strange, William Heath, M.D., 13, Belsize Avenue, 

Hampstead, N.W. 

1871 Stubges, Montague J., M.D.,Elm8tone House, Beckenham, 

Kent. . 
1859 Stutter, Frederick Augustus, M.D., Farnboro' House, 
Upper Sydenham, Kent, S.E. 

1870 SuMMERHAYES, WiLLiAM, Upper St. Giles's, Norwich. 

1862 Sutherland, William, M.D., 22, George street, Croydon, 

Surrey* 
1862 Sutton, Field Flowers, M.D., Balham hill, Clapham, 

S.W. 
1859 SwAYNE, Joseph Griffiths, M.D., Physician- Accoucheur 
. to the Bristol General Hospital ; Harewood House, 

74, Pembroke road, Clifton, Bristol. Council, 1860-6 1 , 

Vice^Pres. 1862-64. Hon. Loc, Sec. 

1850 Sweeting, George Bacon, M.R.C.F., Ring's Lynn, 
Norfolk. 

1859 Symonds, Frederick, F.R.C.S., Surgeon to the Radcliffe 
Infirmary; 35, Beaumont Street, Oxford. Council, 
1862-65. Son. Loc. Sec. 

1872 SzczYGiELSKi, JosEPH, M.D., St. Terska, No. 24, Warsaw 

Russian Poland. 

1871 Tait, Lawson, F.R.C.S. Ed. and Eng., L.R.C.P. Ed.; 

Surgeon to the Birmingham and Midland Hospital for 
Women, and to the Lying-in Charity; Consulting 
Surgeon to the Church Stretton Asylum for Ladies ; 
7, Great Charles street, Birmingham. 

1866 Tannahill, Robert Dunlop, M.D., Physician to the Lying, 
in Hospital ; 106, Bath street, Glasgow. 



Digitized by VjOOQIC 



Xliv FBLLOWS OF THE SOCIETY. 

SlecUd 

1871 Tanner, John, M.D., L.R.C.P. Ed., 1 18, Newington Cause- 
way, S. 

1859 Tapsob, Alfbei) Joseph, M.B. Lond., 35, Gloucester gar- 
dens, Westboume terrace, W. Oauncii^ 1862-64. 

1863 Tapson, Joseph Alfred, Surgeon to the Clapham General 
Dispensary ; 83, High street, Clapham, 8.W. 

1871 Tatler, Francis F., B.A. Lond., and M.B., Claremont villa, 
Lewisham road, S.E. 

1859 Taylor, Edward, South lodge, Clapham common, S.W. 

1870 Taylor, Arthur, M.6., 248, Kennington park road, S.E. 
1859 Taylor, Charles, M.D., Pine house, Camberwell green, 

S.E. Council, 1869-71. 

1859 Taylor, David, 180, Kennington park road, S.E. 

1869 Taylor, John, Earl's Colne, Halstead, Essex. 

1871 Taylor, John W., 28, Queen street, Scarborough. 

1862 Taylor, Thomas, F.R.C.S., 19, Bennett's hill, Birmingham. 

1872 Temple, James Algernon, M.D., Lecturer on Midwifery, 

Trinity College, Toronto. 

1862 Thane, George Dancer, M.D., 15, Montague street, 

Russell square, W.C. 
1872 Thomas, James Byer, Assistant- Surgeon H.M.'s Indian 

Army, Madras and Zillah Surgeon, Tinnevelly. 

1870 Thompson, John Ashburton, 207, Caledonian road, N. 
1867 Thompson, Joseph, Junr., 1, Oxford street, Nottingham. 
1869 Thompson, D. R., M.D., M.R.C.S., Officiating Civil Surgeon, 

26th Native Infantry, Trichinopoly. [Messrs. de 
Beaux & Co., Esplanade Dispensary, Black Town, 
Madras.] 

1867 Thorburn, John, M.D., Lecturer on Midwifery, Manchester 
Royal School of Medicine ; 333, Brighton place, Oxford 
street, Manchester. 

1867 Thorman, Thomas, 17, Oxford terrace, Hyde park, W. 

1860 Thornb, George Leworthy, M.D., Swanage, Dorset. 

1871 Thornb, William Bezly, 46, Harcourt terrace, Redcliffe 

square, South Kensington, S.W. 



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FUlLoWS of the SOCIEtY. xlv 

Elected 

1862 Thobnton, William Heney, M.D., Springfield terrace, 

Dewsbury, Yorkshire. 
1867 TflOENTON, William Heney, Surgeon to the Royal National 

Sea Bathing Infirmary ; Berkeley Lodge, Margate. 

1860 TiFi-EN, RoBEET, M.D., Wigton, Cumberland. 
1866 TiLLEY, Samuel, 70, Union road, Rotherhithe, S.E. 

1 859 Tilt, Edwaed John, M.D., Consulting Physician- Accoucheur 
to the Farringdon General Dispensary ; 60, Grosvenor 
street, W. Council, 1867-68. Fice-Pres. 1869-70. 
Treas. 1871-2. Pres. 1873. 

1859 Times, Hsnby G., 23, Manchester street, Manchester 

square, W. 
1872 ToLOTscHiNpFF, N., M.D. KieflF, Russia. 
1872 ToMKiNs, Aethue Wellesley, B.A., M.D., 11, Easton 

place, Leamington. 

1869 ToMKiNs, Chaeles P., L.K.Q.C.P. Ireland, Beddington 

park, Croydon. 

1870 TowNE, Alexandee, Junr., 354, Kingsland road, N.E. 
1865 Teend, Heney Geistock, L.R.C.P. Ed., 191, Southgate 

road, Islington, N. 
1872 Teenholme, Edwaed Henry, M.A., M.D., CM., Professor 

of Midwifery, University of Bishop's College, Montreal, 

Canada. 
1872 TucHMANN, Maeo, M.D., 148, Adelaide road, N.W. 
1865 TuENEE, John Sidney, Surgeon to the Anerley Dispensary, 

Woodside, Anerley road. Upper Norwood, Surrey. 

1861 Turnee, Richard, Surgeon to the Lewes Dispensary ; High 

street, Lewes, Sussex. 

1871 Tueton, Feedeeic, Ablow House, Wolverhampton. 

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

1872 Vandeesteaaten, Julian Louis, M.D., Civil Medical 

Service, Ceylon, 202, Euston Road, N.W. 

1860 Vaeennb, Ezekiel G., Kelvedon, Essex. 

1864 Wahltuch, Adolpub, Ml)., 280, Oxford street, Man- 
Chester. 



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xlvi FELLOWS OP THE SOCIBTV. 

Uleeied 

1860 Walbs^ Thomas Garnets, Jan., Downham Market, 
Norfolk. 

1869 Walker, Alfred, M.B., Physician to the East London 

Hospital for Sick Children; [abroad] 17«Throgmorton 
street, E.G. 

1866 Walker, Thomas James, M.D., Surgeon to the General 

Infirmary, Peterborough; 18, Westgate, Peterborough. 

1870 Walla.ce, Frederick, District Surgeon to the Royal 

Maternity Charity ; 243, Hackney road, N.E. 
1872 Wallace, John, M.D., Assistant- Physician to the Liverpool 

Lying-in Hospital ; 30, Great George square, Liverpool. 
1872 Waller, Charles Beaumont, Sydenham, S.E. 
1860 Waller, John Turpin, Flegg Burgh, Norfolk. 

1867 Walters, James Hopkins, Faringdon, Berks. 

1859 Wane, Daniel, M.D., 20, Grafton street. Bond street, W. 

1860 Ward, John, Penistone, Sheffield, Yorkshire. 

1859 Warden, Charles, M.D., Hon. Surgeon to the Birming- 
ham Lying-in Hospital; 39, Temple street, Birming- 
ham. 

1862 Watkins, Charles Stewart, 16, King William street. 
Strand, W.C. 

1861 Watts, George Henry, Thatcham, near Newbury, Berks. 
1867 Webb, Fred. E., 1 13, Maida vale, W. 

1859 Webb, Henry Speakman, Welwyn, Herts. 

1872 Webster, Thomas, Malvern House, RedlanS, near Bristol. 

1860 Welchman, Charles Edward Elliot, Bore street, Lich- 

field, Staffordshire. 

1867 Welleb, George, Forest lodge, Wanstead, Essex. 

1859 Wells, T. Spencer, [F.R.C.S., Surgeon in Ordinary to 
H.M.'s Household; Surgeon to the Samaritan Free 
Hospital for Women and Children ; 3, Upper Grosvenor 
street, W. Council, 1859. Fice-Pres. 1868-70. 

1859 Wbstmacott, John Guise, M.D., Medical Officer to the 
Paddington Provident Dispensary; 19, St. Mary's 
terrace, Paddington, W. 



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FELLOWS OF THE SOCIETY. xlvii 

Elected 

1870 Wheatcroft, Samuel Hansom, L.R.C.P. Ed., Lichfield 
street, Tamworth. 

1860 Wheeler, Daniel, Chelmsford, Essex. 

1860 White, Frederick George, L.R.C.P. Ed., Castle House, 

Chepstow, Monmouthshire. 
1859 Whitehead, James, M.D., Physician to the Manchester 
Clinical Hospital; 87, Mosley street, Manchester. 
Council, 1859-61. Fice-Pres. 1868-69. 

1870 Whitehead, John, M.D., 7, Poole's terrace. Seven Sisters 

road, Holloway, N. 

1865 Whitehead, Walter, F.R.C.S. Ed., Surgeon to St. Mary's 

Hospital for the Diseases of Women and Children ; 

Clareville, 248, Oxford road, Manchester. 
1864 Wuitmarsh, William Michael, M.D., Surgeon to the 

Hounslow Lying-in Charity : Albemarle House, Houns- 

low, Middlesex. 

1867 WiLBE, Richard Hatdock, M.D., York Lodge, 21, Finchley 
road, St. John's Wood, N.W. 

1871 Wilkinson, William Henry Whiteway, L.R.C.P. Ed., 

268, Caledonian Road, Islington, N. 

1861 Williams, Arthur Wynn, M.D., Physician to the Samari- 

tan Free Hospital ; 1, Montagu square, W. Council, 
1871. 
1861 Williams, David John, M.D., Queenscliff, Geelong, Vic- 
toria, Australia. Hon. Loc, Sec. [Per J. W. Voss, 
Esq., Yspitty works, Loughor, Llanelly. 

1864 Williams, Edward, M.D., Holt street House, Wrexham. 

1867 Williams, "Henry Llewellyn, M.D., 9, Leonard place, 
Kensington, W. 

1872 Williams, John, M.D., Assistant-Obstetric Physician 

to University College Hospital; 28, Harley street, 
Cavendish square, W. 

1860 Williams, Robert Hankinson, L.R.C.P. Ed., Great Ec- 

cleston, near Garstang, Lancashire. 
1860 Wills, John, M.D., St. Heller's, Jersey. 



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xlviii FELLOWS OP TtiE SOCIETY. 

Elected 

1859 WiLSOK, James Geobge, M.D., Professor of Midwifery 

in the Andersoninn University, Glasgow; Physician- 
Accoucheur to the Glasgow Lying-in Hospital and Dis- 
pensary; 9, Woodside crescent, Glasgow. Council, 
1863-64. Fice-Pres. 1865-67. 

1860 Wilson, Robert James, F.R.C.P. Ed., 7, Warrior square, 

St. Leonard's-on-Sea, Sussex. Hon, Loc, Sec. 

1865 Wilson, Thomas, L.R.C.P. Ed. (exam.), Alton, Hants, 

1868 Wilton, John, L.R.C.P. Ed., Chalk Pit House, Sutton, 

Surrey. 

1866 Wiltshire, Alfred, M.D., Assistant-Obstetric Physician 

to St.Mary's Hospital, and Physician for the Diseases of 
Women to the West London Hospital ; Physician to the 
British Lying-in Hospital ; 57, Wimpole street. Caven- 
dish square, W. Council, 1870. Hon. Lib,, 1871-3. 

1866 WiNTERBOTTOM, Henry, Consulting-Surgeou to St. Mary's 
Hospital, Manchester ; 56, Bury New road. Strange- 
ways, Manchester. 

1872 Wise, William Clunie, M.D., Gothic villa, Burrage road, 
Plumstead, S.E. 

1860 Wiseman, William Wood, Springstone House, Ossett, near 
Wakefield, Yorkshire. 

1872 Wood, Robert Arthur Henry, 102, Pembroke place, 
Liverpool. 

1860 Wood, William James, Brightwaltham, Wantage, Berks. 
1864 Woodman, William Bathurst, M.D., Assistant-Physician 

to the London Hospital ; 6, Christopher street, Finsbury 

square, E.G. 
1859 Worship, J. Lucas, Manor House, Riverhead, Sevenoaks, 

Kent. 
1871 Yarrow, George Eugene, M.D., 87, Old street, E.C. 
1^66 Yeamajj, George, M.D. 91, Sauchiehall street, Glasgow. 
1870 Yeates, George, M.D., Walthamstow, Essex. 

1861 Young, William Butler, 5, Castle street, Reading, Berks. 

1869 Yule, John S. C, 78, Walmsey road, Bury, Lancashire. 



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CONTENTS. 





PA&B 


List of Officers for 1873 


T 


List of Presidents .... 


Ti 


List of Referees of Papers for 1873 


vii 


Standing Committees .... 


viii, ix 


List of Honorary Local Secretaries 


X 


Trustees of the Society's Property 


xi 


List of Honorary Fellows 


xi 


List of Ordinary Fellows . . . . 


xiv 


Contents ..... 


xlix 


List of Plates . . . . . 


Iv 


Adyertisement .... 


M 



January 3rd, 1872— 

Annual General Meeting 

Specimen illustrating the changes in the Pedicle of an 

Oyarian Tumour when treated by Ligature (Dr. 

Bantock) ..... 
I. On the treatment of Empyema in Children. By W. 

S. Playpaib, M.D., F.R.C.P., Professor of Obstetric 

Medicine in Swing's College, and Obstetric Physician 

to King's College Hospital 
Annual Meeting. Officers elected for 1872 . 

Report of the Auditors 

Report of the Hon. Librarian 

Plan for the Examination of Midwives, with 

the discussion on its adoption . 
Annual Address of the President, J. Braxton Hicks, 

M.D.,P.R.S. . 

VOL. XIV. d 



4, 
19 
19 
20 

21-3 

25 



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1 CONTENTS. 

PAOB 

February 7th, 1872— 

Description of the Military Ljring-in Hospital at 

Woolwich (Dr. P. B. Hogg, R.H. A.) . 35 

Cedar Pencil, one end covered with a calcareous mass, 
extracted from the Bladder of a Girl (Dr. J. J. 
Phillips) . . .37 

II. On the probable Origin of certain forms of Cystic 
Diseases of the Ovary. By Alfbbd Meadows, 
MD., Physician-Accoucheur to, and Lectui-er on 
Midwifery at, St. Mary's Hospital . 39 

III. Case of Yaginal Thrombus. By Robert Jalland, 

M.R.C.S., Homcastle . . .43 

ty . On Retroflexion of the Uterus as a frequent cause of 
Abortion. By J. J. Phillips, M.D., Assistant- 
Obstetric Physician to Guy's Hospital . 45 
V. Cases in Practice (Accidental Hemorrhage, Placenta 
PrsBvia, Rupture of a Varix, and Destruction of the 
Uterus). By John Bassett, Professor of Mid- 
wifery in Queen's College, Birmingham . . 58 

March 6th, 1872— 

Cephalotribe invented by Professor Martin, of Berlin 
(Dr. A. E. Mabtin) , . . .65 

Pibro-cystio Disease of the Uterus (Dr. Braxton 
Hicks) . . .66 

Preparation of a Foetus at fourth month completely 
enclosed in a perfect Sac (Dr. Hbywood Smith) . 66 

Uterus of a Patient who died, after delivery of five 
months' Foetus, of secondary Post-partum Hsemor- 
rhage from Cancer of Cervix Uteri (Dr. Hbywood 
Smith) . . .67 

New Instrument called " Angular Scissors " (Dr. Het- 
wooD Smith) ,68 

Report on Dr. Meadows' case of Extra-uterine Foeta- 
tion. By Drs. Wynn Williams, J. H. Ayelino, 
and Alfred Meadows .70 

VI. Remarks on the Pelvis Collection, and on Pelvimetry 
in the Royal University Maternity of Berlin. By 
A. E. Mabtin, M.D., of Berlin . . .71 

VU. Fibro-cystic Disease of Uterus and both Ovaries; 
extirpation of the whole; recoveiy. By Thomas 
Bbyant, F.R.C.S., Surgeon to Guy's Hospital 79 



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CONTENTS. ll 

PAGE 

YIII. On the Treatment of certain forms of Menorrhagia 
and Uterine Hsemorrhage by means of the Sponge 
Tent, with reference to their oocnrrence in Women 
residing, in tropical climates. By Geobgb Gban- 
ynxE Bantock, M.D., Physician to the Samaritan 
Free Hospital .84 

April 3rd, 1872— 

Apparatus for immediate Transfusion (Dr. Avblino) 101 
"Angular Scissors," modification of, for remoral of 
polypi, &c. (Dr. Hbtwood Smith) . 103 

IX Inyersion of the Uterus after Childbirth in a Frimipara ; 
Amputation by ^craseur at expiration of ten months 
on account of Haamorrhage with great exhaustion. 
By J. Hall Dayis, M.D., Obstetric Physician and 
Lecturer on Obstetrics at the Middlesex Hospital . 104 
X. On the Essential Cause of Dysmenorrhooa, as illus- 
trated by cases of partial and complete retention. 
By Robert Babnbb, M.D., Obstetric Physician to 
St Thomas's Hospital . .108 

May 1st, 1872— 

Large- sized Mucous Polypus (Dr. Wtnn Williams) 135 

Modification of Hodge's Pessary, by Dr. James 
Blake, of San Francisco (Dr. Babnbs) . . 137 

Syphilitic Disease of the Placenta (Dr. Braxton 
Hicks, for Dr. (Jodfret) .137 

Foetus with peculiar Growth from the Mouth (Dr. 
Braxton Hicks, for Mr. Grieves) . 139 

Specimen of Deformed Footus (Mr. Worship) . 139 

XI. Cases in Practice (Acephalous Monster, and Mon- 
strosity with deficiency of left arm, a thumb and two 
fingers issuing from the shoulder, &/o,) By James 
MiLWARD, M.B.C.S., Cardiff .140 

Xn. Csasarean Section in 1866 ; subsequent pregnancy and 
deliyery per vias naturales ; recovery. By William 
Newmak, M.D., F.R.aS. . .142 

Xin. The Anatomy of the Human Placenta. By J. Brax- 
ton Hicks, M.D., P.R.S. .149 

Description of Dissections of Placenta in nUi, de- 
tached, diseased, and abortions, partly referred to in 
the foregoing paper .... 190 



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lii CONTENTS. 



June Sth, 1872— 

Scoop for remoying superficial portions of Malig^nant 
Disease of the Cervix (Dr. Munde, for Professor 
Simon) . . . . .209 

Report on the Specimen of Mr. Grieves, of Stam- 
ford (page 139). By Drs. J. Watt Black, and J. 
B. Potter . . . . .210 

Dr. Godfrey's case of Syphilitic Disease of Placenta, 
farther particulars .... 211 
XIV. Short account of the cases of throe Sisters in whom 
the Uterus and Ovaries were absent. By Ohables 
E. Si^iTABEY, M.B., M.B.C.P., Assistant-Physician 
to the Hospital for Women . . 212 

XY. Long delay of Labour after Discharge of Liquor 

Amnii. By J. Matthews Duncan, M.D. . 216 

XVI. Case of Uterine Fibroids complicating Pregnancy. 

By Henry M. Madge, M.D. ,227 

July 3id, 1872— 
XVII. Irregular Uterine Contraction. By E. H. Tren- 
HOLME, M.A., M.D., Professor of Midwifery and 
Diseases of Women and Children, University of 
Bishop's College, Montreal . . .231 

XVlil. On Post-mortem Parturition, with references to forty- 
four cases. By J. H. Avelino, M.D., Physician to 
the Chelsea Hospital for Women . . 240 

October 2nd, 1872— 

XIX. Case of Pelvic Hssmatoma, or Retro-uterine Hsema- 

tocele, with remarks, especially as to the source of 

the Haemorrhage. By T. Snow Beck, M.D., F.R.S., 

M.R.C.P. . . . .260 

XX. Statistics of Stillbirths. By Fred. W Lowndes, 

M.R.C.S. . . . . .283 

November 6th, 1872— 

XXI. Tumour of the Uterus complicated by Pregnancy. 

By J. Lucas Worship . . 305 

Pessary for treatment of Flexions of the Uterus (Dr. 

Wynn Williams) . . . 308 

Fibrous Tumour removed from the Anterior Wall of 

the Yagina (Dr. Barnes) . 309 

Modification of Neugebauer's Speculum (Dr. Barnes) 309 



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CONTENTS. liii 

PAOB 

XXn. Remarks on the treatment of some forms of Extra- 
uterine Gestation, with a case. By Alfbbd Mea- 
dows, M.D., Fhysician-Acconchenr to, and Lec- 
turer on Midwifery at, St. Mary's Hospital . 309 

December 4th, 1872— 

Instruments for the application of Medicated Tents 
to the Interior of the Cervix (Mr. Lawson Tait, 
per Dr. Wiltshibe) .... 323 
Report on Dr. Protheroe Smith's Case of Carcinoma 
Uteri. By H. M. Madob, M.D. . . .324 

XXin. Note on the mode of dealing with the Placenta where 
Grastrotomy is performed in order to remove the 
Foetus in Extra-uterine Gestation. By Robert 
Babnes, M.D. .325 

XXIV. On the Systematic Examination of the Abdomen, with a 
view to rectifying Malpositions of the Foetus in cases 
of Labour. By Abthtjb W. Edis, M.D., Physician 
to the British Lying-in Hospital, and Assistant- 
Physician to the Hospital for Women . . 331 
XX 7. Note on the treatment of Suppurating Ovarian Cysts 

by Drainage. By J. J. Phillips, M.D., Hon. See. 340 

XXYI. On the Causation of acquired Flexions of the Uterus, 
and their Pathology. By Chables E. Squabby, 
M.B., M.R.C.P., Assistant-Physician to the Hospital 
for Women ..... 344 



Index. . .361 

Additions to the Libi'ary .... 875 



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CORKIGBNDUM. 

LIST OF PLATES. 



PAG8 



For I. The Anatomy of the Human Placenta (Dr. B. Hiczs) 149 
Bead I. Origin of Cystic DiBease of the Ovary (Dr. Mbado ws) 39 
And II— yil. The Anatomy of the Human Placenta (Dr. B. 

Hicks) . . 159-183 

And alter position of Plate I accordingly. 



IV. Ditto ditto. Pigs. 9—11 . 179 

V. Ditto ditto. Pigs. 12— 13 . 181 

VL Ditto ditto. Pigs. 14-15 . 183 

Vn. Ditto ditto. Pig. 16 . . 183 



WOODCITTS. 

Measurements under Axilke and half inch below Nipples in 

cases of Empyema in Children (Dr. Platfair) . 9 
Apparatus of Bottle and Tubing for continuous dndnage without 

entrance of air in Empyema (Dr. Playfaib) 12 

Cephalotribe of Professor Mabtin, of Berlin . 66 

Angular Scissors (Dr. Heywood Smith) . . .69 

Inversion of the Uterus : portion removed consisting of fundus 
and upper two thirds of the body of the Uterus 
(Dr. Hall Davis) . . .107 

Acephalous Monster (Mr. James Milwabd) . 140 

Deformed seven and a half months' Child : deformities in hand 
and fingers, deficiency of left arm, &c. (Mr. James 
Milwabd) ..... 141 
Diagrams of the Placenta: foetal villi and maternal sinus 

(Dr. B. Hicks) . . .157 

Pessary exhibited by Dr. Wynn Williams . . 308* 

Pibroid Tumour removed from the Yagina (Dr. Babnss) . 308* 
Modification of Neugebauer's Speculum (Dr. Babnbs) . 309* 

Acquired Flexions of the Uterus, Pigures 1—3 (Dr. Squabby) 351 



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ADVERTISEMENT. 

The Society is not as a body responsible for the facts and 
opinions which are advanced in the following papers and com- 
munications read, or for those contained in the abstracts of the 
disoassions which have occurred, at the meetings during the 
Session. 



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OBSTETRICAL SOCIETY 



OF 



LONDON. 



SESSION 1871. 



ANNUAL GENERAL MEETING, 

JANUARY 3rd, 1872. 

John Braxton Hicks, M.D., F.R.S., President, iu the 

Chair. 

Present — 59 Fellows and 13 visitors. 

Books were presented from Dr. Spiegelberg, Dr. C. C. 
Lee, New York, Dr. Henry Miller, Louisville, and the 
Royal Medical and Chirurgical Society. 

Dr. Montague J. Sturges and Dr. Francis F. Tayler were 
admitted Fellows of the Society. 

The following gentlemen were elected Fellows : Thomas 
Bridgwater, M.B., Harrow; Edward Charlton Fox, M.D., 
Birmingham ; — Gardner, M.D., Montreal ; William 
Harding, F.R.C.S. ; Robert Hancy Hilli vd, M.D. ; Edwin 
Matthews James, M.R.C.S., Melbourne; Robert Jalland, 

VOL. XIV. 1 



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2 CHANGES IN PEDICLE OF OVARIAN TUMOURS 

M.R.C.S., Horncastle ; James Lattey, M.R.C.S. ; William 
Baily Rankin, L.R.C.S. Ed., Melbourne; Julian Louis Van- 
derstraaten, M.D. ; and William C. Wise, M.D., Plumstead. 

Dr. Bantock exhibited a specimen illustrating the changes 
which take place in the pedicle of an ovarian tumour when 
treated by ligature. It was obtained in the post-mortem 
examination of a patient on whom he performed double 
ovariotomy on 11th July, 1870. The patient died on the 
9th July, 1871, of cancer in stomach, liver, mesenteric 
glands, uterus, stump of one pedicle, and abdominal walls. 
She had made a very good recovery from the operation, and 
about three months afterwards cancer made its appearance in 
the site of the right pedicle (which was secured by external 
clamp), where it could be felt under the abdominal wall. 
The left pedicle was secured by a hempen ligature and the 
ends cut off short. 

When the parts were exposed no trace of the pedicle 
could be seen, and the upper border of the broad ligament 
formed a continuous line with the fundus uteri, but close to 
its edge could be felt a small body as large as a hemp seed, 
covered by peritoneum, and about an inch and a half from 
the uterus. A triangular piece was cut out, and the hard 
body was found to be formed of the knot of the ligature, the 
loop and ends having disappeared. What remained had lost 
its original characteristics. 

"■^^ ^antock referred to the experiments of Drs. Spiegel- 
d Waldeyer of Breslau, made with the view of 
ling the changes which take place in the case of 
of tissues within the peritoneal cavity. Their 
mts were made on the uterine horns of the bitch, 
ir results were confirmed by the specimen shown, 
ow that in this situation ligature of considerable 
of living tissue is not followed by sloughing of the 
•rtion except under the destructive influence of peri- 
)ut that by the eflTusion of plastic lymph and its 
;nt organisation, or, as they term it, by the rai)id 
)f cells, its vitality is maintained to a certain degree. 



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WH£N TREATED BY LIGATURE. 6 

Confining oneself to the specimen, the course of events 
would appear to be as follows: — When the ligature is 
applied it forms a deep constriction, which, by the bulging 
of the tissues on each side, causes the living to come in 
contact with the strangulated tissues, plastic lymph is 
thrown out, glueing together the opposing surfaces, and its 
organisation establishes a vital connection between the two, 
so that sloughing is prevented. This result is also favoured 
by the fact that by displacement of the tissues immediately 
embraced by the loop of the ligature, in course of time the 
loop ceases to exert any force ; and it is possible that the 
capillaries ultimately become pervious. No sooner has the 
organisation of the lymph taken place, and the capillaries 
have become pervious, than the absorbents begin their work 
and remove not only such portions of the tissues as are unable , 
to maintain their integrity, but the ligature itself yields to the 
forces at work. The experiments of Drs. Spiegel berg and 
Waldeyer show that this destructive action begins within a 
few weeks in the case of the ligature, and the specimen con- 
firms this; while it further shows that the strangulated 
portion also suflfers at an early period. Their experiments 
do not appear to have been continued to their fullest extent 
and to ultimate results, but the specimen furnishes a com- 
plete account. It shows how the growth of peritoneum 
completely obliterated all trace of the ligature and wound, 
and how the interruption of a through current interfered 
with the nutrition of the proximal portion of the pedicle and 
subsequently led to atrophy of the included Fallopian tube. 

Dr. Bantock concluded by stating that, while entertaining 
the opinion that the extraperitoneal method by clamp was 
absolutely superior to all other methods of treatment, his 
case demonstrated the safety of the ligature ,* and he should 
have less hesitation than formerly in adopting the ligature 
whenever the shortness of the pedicle prevented the applica- 
tion of the external clamp, or involved the risk of retrac- 
tion of the stump from destruction of adhesions. 



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ON THE TREATMENT OF EMPYEMA IN CHILDREN. 



ON THE TREATMENT OF EMPYEMA IN 
CHILDREN. 

By W. S. Playfair, M.D., F.R.C.P., 

FBOFB880B OF OBSTETBIO MBDICINB IK KI^g'S COLLEGE; OBSTSTSIC 

PHYSICIAN TO king's COLLEGE HOSPITAL, AND PHTSIOIAK 

TO THE ETELINA HOSPITAL FOB CHILDBEN. 

We were told in our late Presidents farewell address that 
the subject of diseases of children, which forms an important 
division of the work of the obstetrician, has not received 
sufficient attention in this Society. 

In deference to that hint I propose to bring under your 
notice to-night a point of great practical importance in con- 
nection with infantile disease. All who see much of chil- 
dren's diseases will admit that pleuritic effusion is far from un- 
common, and that it is frequently a very troublesome affection. 
In its slighter forms it is frequently overlooked, or mistaken 
for some other complaint. The graver forms, in which there 
is a large amount of fluid effusion, lead to very serious conse- 
quences — debility, emaciation, often lifelong deformity from 
contraction of the chest-wall over the flattened and unex- 
panded lung, and not unfrequently to secondary tuberculosis. 
It is of the utmost importance, therefore, that we should 
carefully study the best means of managing this affection, 
with the view of preventing, as far as possible, the very 
serious results which so frequently ensue. To enter at 
length, however, into the general question of the treatment 
of pleuritic effusions is impossible within the short limits into 
which it is necessary to compress this paper. 

I propose, therefore, to confine myself simply to the best 
mode of managing those cases in which there is a consider- 
able amount of fluid in the pleural cavity, and in which the 
fluid is purulent; to cases of empyema, in short, as contra- 
distinguished from simple serous pleurisy. In children, as ia 
well known, such cases are much more frequent than in 
adults. In them pleuritic effusion soon becomes purulent, 
and often is so from the commencement of the disease. Into 



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ON THE TREATMENT OP EMPYEMA IN CHILDREN* 5 

the general question of the advantages of paracentesis I shall 
not enter. This is a subject which has attracted much atten- 
tion^ and on which the views of the profession have been greatly 
modified. Of late years the opinion has been steadily gaining 
ground that even in simple serous effusion^ paracentesis, per- 
formed in such a way as to prevent the entrance of air into 
the chesty is not only a perfectly justifiable operation^ but 
one which may be considered practically harmless^ and likely 
to materially lessen the sufiering of the patient, as well as 
shorten the duration of the disease. This view I cordially 
endorse, but do not now intend to discuss. To those who 
wish to make themselves thoroughly acquainted with the 
arguments in its favour, I should recommend a perusal of my 
friend Dr. Anstie's admirable monograph on pleurisy in the 
third vol. of ^ Reynolds's System of Medicine/ where they will 
find all that can be said on the subject fully set forth. 

Very little consideration will show that paracentesis in 
serous pleurisy stands on a very difierent footing from the 
same operation in empyema. In the former the physician 
taps the chest not to remove the whole of the contained fluid, 
but so to diminish it as to admit of the remainder being more 
readily absorbed. That nature is capable in the majority of 
cases of effecting the entire absorption of the efl^used fluid is 
not doubted; but this often requires a long time, and 
involves a protracted illness. The operation is practised, 
therefore, to hasten the cure — to facilitate, as it were — 
nature's work. All that is required is, that it should be done 
in such a manner as to exclude as much as possible the 
entrance of air. For this purpose, no doubt, Bowditch's 
syringe, with which that physician has obtained such 
admirable results, or Dieulafoy's aspirator, which are recom- 
mended by Dr. Anstie, are the best instruments at our 
disposal. But they are complicated and expensive, and not 
always at hand, and, for all practical purposes, I believe that 
a small trocar and canula, with an elastic tube attached, 
opening under water, will answer quite as well. 

In empyema, however, the chance of the entire absorption 
of the pus, even when a portion of it has been removed, is 



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6 ON THE TREATMENT OF EMPYEMA IN CHILDREN. 

reduced to a minimum. I do not mean to say that the fact 
of the fluid being purulent precludes all hopes of a cure when 
tapping is not performed ; but the chances are comparatively 
small, and the evil efiects of protracted cases of this sort are 
familiar to all who have studied the subject. I believe that what 
we should seek by paracentesis in such cases is, not only to 
evacuate as much as possible of the fluid, but to secure the 
escape of all the pus subsequently formed ; to eficct, in fact, a 
constant drainage of the pleural cavity. Now, all the methods 
by which this is accomplished, save the one shortly to be de- 
scribed, involve the free admission of air into the sac of the 
pleura. The one most frequently adopted is, simply to treat 
the pleura like a large abscess, to lay it open freely by an 
incision in a depending position, and sometimes to promote 
the cessation of the discharge in the manner recommended by 
Trousseau, by washing out the pleura with a solution of iodine. 
It was a decided improvement on this rough-and-ready 
method to introduce a Chaissaignac^s drainage tube by two 
openings, so that the pus should drain away as soon as it was 
formed. 

The great advantage, however, of a plan by which this 

result could be obtained, and the entrance of air at the same 

time efi*ectually prevented, will be manifest to all. Whatever 

we may think of the germ theory, the practical good eflfect 

of completely excluding all access of air to the cavity of an 

abscess can hardly be doubted. How important must this be 

when the pus-secreting surface is so great as the whole 

serous lining of one side of the chest ! Again, one of the 

.i--_/. _i.i__i._ ^g gggj^ ^Q effect is, that the compressed and 

^ may again expand. The more completely it 

less will be the subsequent shrinking and 

the chest. Draw away the pus, and, provided 

, there is every hope of the lung regaining its 

isions, especially in children, in whom the lung 

nd down by false membranes, as frequently 

ults. But lay open the pleura, and subject the 

Ls or months to direct atmospheric pressure, as 

irhen the plans I have mentioned are adopted. 



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ON THE TREATMENT OF EMPYEMA IN CHILDREN. 7 

and you can scarcely be surprised at the permanent collapse 
of the lung so constantly observed under such circumstances. 
For these reasons I believe the plan I am about to describe, 
and for the first idea of which I am indebted to a conversa- 
tion with my friend Dr. T. J. Walker, of Peterborough, will, 
I feel confident, materially aid our treatment of these impor- 
tant cases ; and, should further experience confirm the good 
results already obtained, it will have the effect not only of 
greatly shortening the duration of the illness, but of leaving 
the patient in a much more favorable condition than has 
hitherto been possible. 

It will enable us to contrast the results following these 
various methods of treatment if I briefly relate the particu- 
lars of two cases, in one of which the old Galenic method of 
freely laying open the pleural cavity was practically, though 
not intentionally used, and in the other the continuous 
drainage with a Chaissaignac's tube, which ,was first era- 
ployed in this country, I believe, by Mr. de Morgan. The 
results in both were extremely satisfactory, insomuch as I 
believe that the treatment adopted actually saved the lives of 
both children, which were in extreme peril, but at a cost to 
their health far greater than in the cases treated by the 
method of subaqueous drainage. 

Annie Webb, set. 4 years, was admitted into the Pantia 
Ralli Ward in King's College Hospital on the 11th of July, 
1871, under the care of my colleague. Dr. Priestley. The 
general history of the case I need not relate, but it will 
suflSce to say that all the signs of extensive pleuritic effusion 
were well marked, the whole left side of her chest was dull, 
and the breath sounds distant and feeble. Appropriate 
general treatment was ordered, but the effusion continued to 
increase rather than to diminish, and the child was reduced 
to a state of extreme debility. This was her condition when 
she came under my care at the end of the first week in 
August, on Dr. Priestley's departure from town. At this 
time the dulness was almost universal, the intercostal spaces 
were distinctly bulging, and the heart displaced, so that the 



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8 ON THE TREATMENT OF EMPYEMA IN CHILDREN. 

apex beat was felt immediately below the right nipple* 
There was marked nocturnal hectic and profuse sweating. 
She refused food^ and had a furred tongue. 

On the 16th of August paracentesis was performed between 
the fifth and sixth interspaces^ the cauula being connected with 
a tube opening under water, but only a small quantity of thick 
pus escaped. Next day an erysipelatous rash commenced at the 
site of the puncture, which did not spread, but led to the 
formation of a small slough about the size of a sixpence. I 
attribute this to the extreme debility of the patient, and pos- 
sibly also, in part, to the fact that a preliminary incision was 
made in the intercostal space before the trocar was introduced, 
at the edges of which the sloughing commenced. This 1 
belicTC to be always unnecessary, and to be certainly preju- 
dicial when we attempt to prevent the entrance of air. This 
was treated with charcoal poultices, and next day a free dis- 
charge of pus took place (the slough haying made a free 
opening into the pleural carity) to the manifest relief of the 
patient. Pus continued to escape in considerable quantities, 
and during this time the child steadily improved in spite of 
the exhausting discharge. 

On September the 2nd, the pus still flowing as freely as 
ever, I directed the pleura to be syringed daily with a solu- 
tion of iodine, one part of the tincture to five of water. An 
immediate improvement commenced, and the discharge soon 
began to lessen in quantity. 

She continued to convalesce from this time without any 
further drawback, and on the 10th of October she was sent 
to the convalescent home at Clewer. Then the wound was 
nearly closed, but there was still a good deal of discharge, 
which I learn is still continuing.* The chest was contracting, 
and there will certainly be considerable deformity. {Vide 
Fig. 11.) 

The case in which Chaissagnac's drainage tube was inserted 
is as follows : 

James Busby, set. 8, was admitted into King's College 

* May, 1872. — The pleural fistula is still discharging pus freely. 



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ON THE TREATMENT OP EMFTKMA IN CHILDREN. 9 



UNDER AXILL>E. 




^ IN. BELOW NIPPLES 



I. 



JAS.BUSB\r 
AET.8 





II. 

ANNIE WEBB 
AET.4- 






III 

IHOS. OLIVER 
AET.Si- 



IV. 

THOS. KIRBY 

AET» 4-i- 





V. 

ALICE. RICKETS 

A£T. 6 





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10 ON THE TREATMENT OP EMPYEMA IN CHILDREN. 

Hospital under Dr. Priestley on the 6th of June, 1870, with 
extensive pleuritic effusion following scarlatina. The whole 
of the left side was dull, the dulness extending across the 
median line. The heart's apex beat was felt half an inch 
below the right nipple. The circumference of the left side of 
the chest was one inch and a half greater than that of the 
right. He got steadily worse, and was in extreme peril. 

On the 13th of July paracentesis was performed by Mr. 
Wood. Thirty-six ounces of thick pus were drawn off under 
water, immediately after which he breathed more easily, 
passed a good night, and next day was more comfortable than 
he had been for a month. 

On the 20th of July the pleura had filled again, and the 
boy was as bad as ever. Paracentesis was again performed, 
nine ounces of pus being removed, but with little benefit. 
Next day the dyspnoea was greater, the pus evidently point- 
ing, a bulging red and tender swelling having formed under 
the left nipple. 

On the 24th the child seemed on the point of death, and 
the house-surgeon opened the swelling with a bistoury. 
Eighteen ounces of pus gushed out, and for a week after- 
wards the discharge was very profuse, soaking the bedclothes 
three or four times a day. CEdema of the feet and intense 
diarrhoea came on, which resisted every treatment until the 
child was fed exclusively on raw meat. 

Early in August he came under my care. At this time 
his condition was as unfavorable as it well could be. He was 
almost at death^s door from exhaustion, and every day was 
expected to be his last, although the dyspnoea was by no 
means so great as formerly. 

About the 16th of August the discharge ceased, and pus 
again began to collect in the pleural cavity. I then asked 
Mr. Wood to make a counter-opening, and insert a Chais- 
saignac's drainage tube, one end passing through the former 
aperture. From that moment he began to improve steadily. 
There was no farther interference with the escape of pus, 
which began to diminish in amount daily. 

On September 16th a smaller tube was substituted, and on 



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ON THE TREATMENT OF EMPYEMA IN CHILDREN. 11 

October 20th, the discharge having nearly ceased, the tube 
was entirely removed. He was not able to leave the hos- 
pital, however, until November 4th. I saw the child a few 
weeks ago, nearly a year after his discharge, and found the 
chest greatly and, it is to be feared, permanently contracted. 
{Vide Kg. I.) The result, however, of the constant drainage 
in this case was most satisfactory. I certainly never saw a 
child recover after so severe and so exhausting an illness, 
in which death was for long almost hourly expected. 

It is to be observed, however, by way of contrast to the 
cases presently to be related, that, although both these chil- 
dren recovered, it was only after a very protracted illness. In 
one case close upon two months elapsed after the first 
tapping before the child was able to be sent to a conva- 
lescent home, with a pleural fistula still discharging; in 
the other it was close upon five months before the child 
could be removed from the hospital ; and in both there was 
considerable and permanent contraction and deformity 
of the chest, which is inevitable under such circumstances. 

I now proceed to describe the method of operating, to which 
I wish specially to call your attention. The object sought is 
to effect continuous drainage without the entrance of air. 
The procedure is nearly as simple as ordinary paracentesis, 
and the necessary apparatus is so inexpensive as to be within 
the reach of every one. All that is required is about six 
inches of the ordinary fine drainage tubing (a), and about six 
feet of ordinary caoutchouc tubing (A). These are attached to 
each other by about an inch of glass tubing, over each end of 
which one extremity of the tube is passed. The free extre- 
mity of the drainage tube lies within the cavity of the pleura ; 
that of the india-rubber tube passes through a perforated cork 
into a bottle half filled with water (see Woodcut). The mode 
of using the apparatus is as follows : — In a case of suspected 
empyema a puncture is first made with an exploring needle 
to determine the factof the contained Huid being purulent. For 
this purpose nothing is better than the ordinary syringe for 
subcutaneous injection, which resembles a pneumatic aspi- 
rator in miniature. Should it prove to be so a trocar is passed 



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12 ON THE TREATMENT OF EMPYEMA IN CHILDREN. 

in^ the canula of which is of sufBicient size to admit of the 
passage of the drainage tube. As soon as there is a free 
flow of pus this is passed into the pleural cavity through the 
canula^ which is then withdrawn over it. An assistant now 
pinches the tubing close to its entrance into the chest to stop 
the flow of pus through it until the other end of the drainage 



tube is attached to the small piece of glass tubing. The pus 
is now allowed to flow into the bottle of water, and the 
drainage tube is attached to the chest by passing round it a 
loop of fine wire (c), which is fixed by strapping. The tube 
remains permanently in the pleural cavity, and any pus that 
is formed drains away at once. The only way by which air 
can possibly enter is by the side of the tubing, but the 
chances of this are very small, and none was found to enter 
in the three cases in which this method has been used. It 



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ON THE TREATMENT OF EMPYEMA IN CHILDREN. 13 

would make assurance doubly sure were the puncture made 
through a layer of chloral ura wool, or some similar anti- 
septic dressing, which might be permanently retained round 
the seat of puncture. 

It may be thought that the tubing would prove exceed- 
ingly irksome to the child, who might pluck it away. I 
certainly feared this, but in none of the cases was there the 
least trouble of the kind. The tubing did not seem to in- 
commode the little patients in the least, who moved about in 
bed, played, sat up, and turned from side to side without the 
least difficulty, and without even disarranging the apparatus. 

A brief account of the three cases in which this system of 
continuous drainage was used will best illustrate its advan- 
tages. They all occurred in the Evelina Hospital for Sick 
Children. The first was under my own care, the other two 
under that of my colleague. Dr. Hilton Fagge, who adopted 
the method from observing its good effect, and who has 
kindly permitted me to make use of them. 

Alice Ricketts, set. 6 years. The previous history of this 
case it was found impossible to ascertain with accuracy, but 
the illness seems to have been of, at least, a month^s duration. 
On admission, all the signs of extensive pleuritic effusion 
were well marked. The left side of the chest was universally 
dull ; the intercostal depressions were obliterated, and the 
circumference of the left side measured three quarters of an 
inch more than that of the right. The heart was displaced, 
and the apex beat half an inch below the right nipple. 
Dyspnoea was urgent, and paracentesis was performed in the 
ordinary manner, the tube attached to the canula opening 
into a basin of water, about a pint and a half of thick pus being 
discharged, to the manifest relief of the patient. The pleura, 
however, rapidly began to fill again, and in eleven days the 
dyspnoea was worse than ever. At this time the pus was 
pointing under the left clavicle, where a large fluctuating 
swelling had formed, which was red on the surface and 
evidently on the eve of bursting. The system of subaqueous 
drainage I have described was now adopted, and nearly a 



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14 ON THE TREATMENT OP EMPYEMA IN CHILDREN. 

quart of pus flowed away at once into the bottle. Next day 
the child was better in every respect, had slept and ate well, 
and was breathing with ease. The swelling under the 
clavicle had disappeared. For the first few days about three 
ounces of pus were discharged daily into the bottle, and for 
some days more about an ounce. There never was a bad 
symptom of any kind, and the child rapidly gained flesh and 
strength. The apparatus was not removed until the twenty- 
second day after the operation, although there had not been 
any discharge for some time. The wound closed up in a day 
or two. The lung expanded completely, and there was no 
subsequent deformity beyond a little flattening under the left 
clavicle. 

This was as bad a case of empyema as could be met with, 
and the fact that paracentesis had been performed in the 
ordinary way without material benefit shows the advantages 
of continuous drainage in an eminent degree. In a few hours 
more the abscess below the clavicle would certainly have 
burst. {Vide Fig. V.) 

The second case, under Dr. Fagge, was admitted on Sep- 
tember 21st, 1871. 

Thomas Kirby, set. 4 years. His illness dated from a month 
back ; the physical signs were noted as follows : — Dulness 
over the whole of the right side, both anteriorly and pos- 
teriorly, except under the right clavicle, where the percussion 
was tympanitic. Breathing distinct and tubular. Total loss 
of vocal vibration. Intercostal spaces obliterated. Hearths 
apex beat outside left nipple. 

No improvement having taken place paracentesis with sub- 
aqueous drainage was performed on October 4th, and a large 
amount of pus (the quantity not being noted) poured away. 
Next morning the child was better in every way. The tem- 
perature had fallen 2|^ and remained normal until his dis- 
charge. He had slept well, and there was no dyspnoea. He 
now lies on his left side, which he was unable to do before. 
On the 10th of October, it was noted, " No absolute dul- 
ness now, but right side less resonant than left ; respiratory 



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ON THE TREATMENT OF EMPYEMA IN CHILDREN. 15 

sounds everywhere audible; about one ounce of pus dis- 
charged into the bottle daily/^ 

October 17th. — All discharge having ceased the tube was 
removed thirteen days after the operation. The wound now 
rapidly closed, and there was hardly any subsequent flatten- 
ing of the chest. {Vide Fig. IV.) 

The next case, also under the care of Dr. Fagge, is as 
follows : 

Thomas Oliver, set. 3^ years, was admitted October 23rd, 
1871, his illness being of three weeks^ duration. There is 
absolute dulness over the whole left chest. The heart is 
displaced, and the apex beat is felt between the seventh and 
eighth rib on the right side. There is marked bulging of 
the left side, which measures one inch more in circumference 
than the right. Intercostal spaces obliterated ; breathing 
distant and feeble. 

On the 28th, the dyspnoea being urgent, the operation 
was performed, and about a pint of pus escaped into the 
bottle. 

29th. — ^About twenty- five ounces more of pus had come 
away. He had passed a good night and eats heartily. 
Heart's apex beat in the normal position. The lung is ex- 
panding, and breath sounds are audible over the left front, 
and over the back as low as the angle of the scapula, The 
breathing is vesicular and normal, and the resonance is good. 
Vocal fremitus has returned. 

November 1st. — Respiratory sounds audible all over the 
left chest. During the last twenty-four hours scarcely an 
ounce of pus has passed. 

4th. — Seven days after the operation, no pus having come 
away for some time, the tube was removed. 

12th. — Perfectly convalescent with good breathing over the 
whole of the left side. ( Vide Fig. III.) 

These cases speak for themselves. I think they may 
safely challenge comparison with any other method of treat- 
ing an affection which at best has always involved a tedious 
and protracted ilbiess. 



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16 ON THE TREATMENT OF EMPYEMA IN CHILDREN. 

As I write Dr. Bouchut is publishing a series of papers in 
the ' Gazette des H6pitaux/ on the treatment of empyema 
in children. He strongly recommends the use of the pneu- 
matic aspirator as superior to every other method of treat- 
ment. As soon as the chest refills with pus he repeats the 
aspiration until no more pus can be obtained. He conceives 
his results to be excellent, and I beg your permission to 
condense the first three cases he narrates for the purpose of 
comparison with those in which continuous subaqueous 
drainage was employed. 

Case 1. — A boy, set. 10 ; extensive empyema; first opera- 
tion on February 18th. The chest having refilled, it was re-' 
peated in a week, and a third time after another week. 

In May the operation was performed three times ; in June 
nine times ; in July it was performed every third day. He 
was discharged cured on the 20th of August, after thirty- 
three operations, and with considerable chest deformity. 

Case 2. — A boy, set. 8. After six operations a hydro- 
pneumo- thorax formed. After nine months of treatment the 
child is still uncured, and is now tapped twice a week and 
has some pus drawn off. 

Case 3. — A boy, set. 7 ; extensive effusion into right side ; 
Dieulafoy^s aspirator was used ; in two days the chest filled 
again; at the second aspiration there was great diflBculty 
from blocking up of the tube, which had to be removed and 
reintroduced two or three times, and eventually no more pus 
could be got out. Bouchut intended to make a long free 
incision into one of the intercostal spaces on the next day, 
but during the night the child died. He concluded that the 
lung was bound down by adhesions which prevented its 
expanding to drive out the pus. 

Now here we have one case ending fatally, and one still 
under treatment after nine months^ continuous operations, 
the third being discharged cured after sixth months' treat- 
ment, and thirty-three operations. 



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ON THE TEBATMENT OP EMPYEMA IN CHILDREN. 17 

I have not picked these cases^ they are the first three 
published in illustration of the method recommended, and, at 
the time I write, no others have appeared. Now, in the 
three treated by the method I advocate, and to judge from 
description, they were quite as bad in every way as Bouchut's, 
the longest time required before the removal of the apparatus 
was a month, the other two being practically cured in 
thirteen and seven days. 

Surely any comment on these comparative results is un- 
necessary. 

Of course, I cannot say whether farther experience will 
confirm the favorable results already obtained, but, at least, 
they are such as to claim for this operation a fair trial in this 
most troublesome class of cases. 

The reason why no pus was obtained in Bouchut^s third 
case is worthy of a moment's consideration. His own ex- 
planation seems to me to be probably the correct one. He 
conceives that the lung was bound down by adhesions which 
prevented its expanding, and driving out the contained fluid. 
The chest would, under such circumstances, resemble a 
barrel in which a tap was placed without a hole being bored 
in it to admit of atmospheric pressure. In the case of Annie 
Webb something of the same kind happened, and 'there was 
little or no escape of pus until the slough had formed a free 
opening into the pleural cavity. 



Dr. Hilton Faoge felt bound to mention to the Society that 
he had recently had another case in which the same method had 
been employed, and with results not entirely so satisfactory. 
The pus had in this instance made its way by the side of the 
india-rubber tube, and continued to discharge. The patient was 
at present doing well, but there had not yet been time for the 
ultimate result of the case to be determined. It was of great 
importance that the tube should be tightly grasped by the skin, 
ana for this reason it was better to remove the canula before 
introducing the india-rnbber tube, which should be of the same 
diameter. This was the plan that had been adopted in all his 
cases. 

Mr. Tatlob related the following case in which paracentesis 
had been practised. Walter T — , 8Bt. 18, having been exposed 

VOL. XIV. 2 



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18 ON THE TREATMENT OF EMPYEMA IN CHILDREN. 

to cold some time previous, showed marked signs of empyema 
about June 5th, 1870. There was dulness over the whole of the 
left chest with loss of respiratory sounds and vocal fremitus, with 
displacement of the viscera, sweating, &c. On June 16th the chest 
was tapped through the sixth intercostal space with a syphon 
trocar. An india-rubber tube was affixed to the canula and carried 
into a basin of water. About thirty ounces of pus passed at the 
time. The canula with the tube was retained for twenty-four 
hours, a piece of elastic catheter with a smaDer india-rubber tube^ 
was then inserted through the canula, which was withdrawp. 
The patient's health was much improved immediately after the 
operation. After eight or nine days the discharge ceased, but 
the tube was retained till June 21st, that is, fifteen days, when it 
was withdrawn. The heart had come over considerably to the 
left, and breath sounds could be heard more or less all over the 
left chest. The patient had an excellent appetite, taking two 
meat meals a day with stout. The patient now passed from my 
charge temporarily. The chest refilled and the pus made its way 
through the chest wall near the left nipple. He has made a 
slow but good recovery. 

Dr. Sedowige approved very much of Dr. Playfair's plan of 
subaqueous paracentesis. He had himself occasionally^ during 
the last fifteen or sixteen years, carried out the same principle. 
He had used a canula, the tube of which projected externally 
an inch beyond the shield, on which he slipped a long india- 
rubber tube, with the other end dipping into a dish of water. 
Dr. Playfair's plan of introducing the india-rubber tube into the 
chest was ^ery much better than leaving the silver canula in, as 
possible injury to the lung was thereby avoided. Dr. Sedgwick 
had adopted the same plan as that described above in a case of 
paracentesis abdominis, where the patient was exceedingly weak 
and the abdominal walls were almost as thin as parchment. The 
enormous collection of fluid was creating great distress, but the 
patient was so weak that there appeared no possibility of her 
bearing a rapid removal of the fluid. The withdrawal was 
extended over a period of a week, the free end of the tube being 
always under water. The plan succeeded well. The rapidity of 
the flow was entirely under control by means of pressure on the 
tube. 

' The poB was allowed to flow tinder a yalve of carbolic oil on lint. 



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ANNUAL MEETING. 19 



Annual Meeting. 

The report of the scrutineers of the ballot for the election 
of oflBcers (Dr. Geo. Granville Bantock and Dr. W. C. Grigg) 
was read^ from which it appeared that the following list of 
office-bearers recommended by the Council had been unani- 
mously adopted. 

Honorary President. — Sir Charles Locock, Bart., M.D. 

President. — John Braxton Hicks, M.D., F.R.S. 

Vice-Presidents. — John Clay (Birmingham) , Henry Gervis, 
M.D., Henry M. Madge, M.D., Gustavus C. P. Murray, 
M.D., David Lloyd Roberts, M.D. (Manchester), John Scott, 
F.R.C.S. 

Treasurer. — Edward John Tilt, M.D. 

Honorary Secretaries. — W. S. Playfair, M.D., J. J. 
PhilUps, M.D. 

Honorary Librarian. — Alfred Wiltshire, M.D. 

Honorary Members of Council. — William Tyler Smith, 
M.D., Henry Oldham, M.D., Robert Barnes, M.D., John 
Hall Davis, M.D., Graily Hewitt, M.D. 

Other Members of Council. — James H, Aveling, M.D., 
James Watt Black, M.D., John Brunton, M.D., J. Brendon 
Curgenven, M.R.C.S., James Fowler, M.R.C.S. (Wakefield), 
George Gaskoin, M.R.C.S., Samuel Day Goss, M.D., Thomas 
Taylor Griffith, F.R.C.S. (Wrexham), William Edmund 
Image, F.R.C.S. (Bury St. Edmunds), John Rutherford 
Kirkpatrick (Dublin), Draper Mackinder, M.D. (Gains- 
borough), John Baptiste Potter, M.D., Adolphus A. F. Rasch, 
M.D., William Richard Rogers, M.D., Henry Savage, M.D., 
Leonard William Sedgwick, M.D., Heywood Smith, M.D., 
Henry Wilson Sharpin, F.R.C.S. (Bedford). 

The Report of the Auditors of the balance sheet for 1871 
(Drs. Squarey and J. Meabum Bright) was then read, from 



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20 ANNUAL MEETINjQ. 

which it appeared that the income of the Society during the 
past year was ^6774 17*. 2d., and its expenditure £634 7s. 9rf., 
leaving a balance of £140 9*. 5d.; of this £128 3*. 5d. had 
been invested in consols^ increasing the amount of the 
Society^s funded property to £1284 8*. 9rf. The adoption of 
the report was proposed by Mr. Scott, and seconded by Dr. 
AvELiNG, and carried unanimously. 



The following report of the Honorary Librarian was then 
read and adopted on the motion of Dr. Meadows, seconded 
by Dr. Rogers. 

Mr. President and Gentlemen, — I am happy in being 
able to assure you of the increasing usefulness and satis- 
factory condition of the Library and Museum. 

Since the last Annual Meeting the term for which the 
Society originally held the rooms has expired ; a new agree- 
ment has, however, been entered into with Mr. .Barkentin 
for a like period of three years at a slightly increased rental, 
which is rather nominal than real. 

The salary of our eflScient sub-Librarian, who is a member 
of the profession, has also been slightly augmented. 

Owing to the deplorable war between France and Germany, 
the number of foreign works added to our collection has been 
smaller than usual; but care has been taken to procure all 
that were obtainable. The additions to the Library have 
amounted to 175 volumes ; 33 of which were purchased, and 
the remainder presented. A very valuable donation of a few 
rare works on the pelvis has been promised by Dr. Arthur 
Farre, F.R.S. The number of visitors to the Library con- 
tinues steadily to increase. 

It may be remarked that, besides its ordinary uses, the 
Library is additionally useful to the Society for the purpose 
of holding extra-council meetings and meetings of special 
committees, such as the Temperature Committee, the Pelvis 
Committee, the Educational Committee, the Library Com- 
mittee, &c. It is also valuable as enabling the obstetricians 
of th6 metropolis to show a graceful courtesy to foreigners 



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ANNUAL MEETJNGi; 21 

and other strangers visiting London ; and I am authorised 
to say that many gentlemen who have availed themselves of 
the advantages the Library affords have highly appreciated 
the privileges they have enjoyed. 

It is further valuable as affording means for the formation 
of a museum which promises to become both important and^ 
in course of time, extensive. The Council has liberally 
made arrangements for the reception of select specimens, 
and it is hoped that many such will in due course be pre- 
sented to the Society. 

A few necessary articles of furniture have been procured at 
a trifling cost. 

The following plan for the examination of midwives re- 
commended by the Council, and involving an addition to the 
bye-laws, was then considered. 

ByB-LaWS CHAPTER XVl. 

I. — That an Examining Board be formed, consisting of 
Six Members ; viz. : — A Chairman, three ordinary 
Members, and the Honorary Secretaries, ex officio. 
(The Two Non-official Members of the Board 
longest in office to retire annually). 
II. — ^That Examinations be held at the Society's Library, 
on the second Wednesdays of the months of Janu- 
ary, April, July, and October, at Eight o'clock 
p.m., or at such times as the Board of Examiners 
may from time to time determine. 
III. — ^That Candidates for admission to the Examination be 
required to submit to the Honorary Secretaries of 
the Society Certificates of the following qualifica- 
tions at least fourteen days before the date of the 
Examination : — 
(a.) A Certificate of moral character. 
(6.) A Certificate showing that the candidate is not 
under Twenty-one years of age, and not 
over Thirty years of age; but that up to 
the year 1877, Candidates above Thirty 
years of age be admitted to Examination 



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22 ANNUAL MEETING. 

under special circumstanoes satisfactory to 
the Board of Examiners, 
(c.) Proof of having attended the practice of a Lying- 
in Hospital or Charity for a period of not 
less than six months; or of haying per- 
sonally attended not less than twenty-five 
labours under supervision satisfactory to the 
Board of Examiners. 
(rf.) Proof of having attended a course of Theoretical 
Teaching by Lectures or Tutorial Instruc- 
tion^ the details of which must be submitted 
to, and receive the approval of, the Board 
of Examiners. 
IV. — ^That the Candidates be required to pass — 

(1) A Written Examination. — (2) An Oral and Practical 
Examination, upon the following subjects — 
(a.) The Elementary Anatomy of the Female 

Pelvis and Generative Organs. 
(6.) The Symptoms, Mechanism, Course and 

Management of Natural Labour, 
(c.) The indications of Abnormal Labour, and the 

emergencies which may occur in practice, 
(rf.) A general knowledge of the Puerperal state, 
(e.) The management of new-born Children and 

Infants. 
(/.) The conditions as to Air, Food, Cleanliness, 

&c., necessary for health. 
{ff.) The duties of the Midwife with regard to the 
Patient, and with regard to the seeking of 
Medical advice. 
V. — yhat, on satisfying the Board of Examiners as to her 
qualifications, the Midwife should receive a Diploma 
certifying that she is a skilled Midwife, competent 
to attend natural labours. 
VI. — ^That the Fee for this Diploma be one Guinea ; and 
that unsuccessful Candidates be required to pay a 
Fee of Five Shillings. 

The adoption of the proposed addition to the bye-laws 



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ANNUAL MEETING. 23 

was proposed by Dr. Graily Hewitt^ who said that he 
had much pleasure in proposing to the Society a very 
important resolution^ to the effect that the Society should 
at once institute an examination for midwiyes. The 
Council of the Society began seriously to consider this sub- 
ject while he had the honour of holding the ofiSce of Presi- 
dent ; and the proposed plan was the result of the continuous 
and matured consideration of the matter by the Council, 
now happily, as he believed, to be concluded. The plan 
recommended involved the institution of an examining board, 
composed of six Fellows of the Society, the examination to 
be held quarterly, to consist of a practical testing of the 
competency of the candidates to practise as midwives, and of 
the possession on their part of such an amount of knowledge 
as would enable them to recognise the presence of difficulties, 
and the necessity for at once procuring competent professional 
aid for their patients. It could hardly be necessary for him 
to dilate on what was so well known to the profession, viz. 
the great ignorance and incompetence of vast numbers of 
practising midwives, nor of the loss of life which thus re- 
sulted ; the attention of the Society had been forcibly drawn 
to that in the reports on the subject of infantile mortality 
procured recently from London and the provinces. That a 
formal guarantee of the efficiency of practising midwives was 
urgently required no one could doubt. This examination 
would supply that. It might be said, possibly, that the 
institution of such an examination was the duty of the 
Government or of the Royal College of Physicians or Sur- 
geons, or the Society of Apothecaries. He was afraid that 
little was to be expected from Oovernment action at present, 
though ultimately it might be hoped that this action of the 
Society would result in legislation on the subject. Nor was 
it to be expected from the general governing medical bodies. 
In fact, what was every one^s business was the business of 
no one ; and, under these circumstances, this Society had 
stepped forward to initiate what was, he believed, universally 
admitted to be a laudable object, one, indeed, of pressing 
necessity. This Society was instituted for the purpose of 



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24 ANNUAL ADDRESS. 

promoting knowledge in all that relates to tbe subject of 
obstetrics^ and the diseases of women and children. The 
institution of this examination would^ he felt sure^ do very 
much practically to carry out those great objects. 

Dr. RouTH stated that his first impression was that this 
measure belonged more to some college than to the Society. 
On reflection, however, and judging from the long delay 
that the colleges would not take it up, he thought that some 
other learned body ought, and, if so, what body better 
qualified than this Obstetrical Society ? and how manifest the 
advantages of having well-educated midwives? Now-a-days, 
any woman (generally some ignorant mother of children) of 
the lowest ranks of society, who might not be able to read or 
write, and who was incapable of otherwise earning a living, 
might become a midwife. No examination, no test of know- 
ledge was necessary. What numbers of unfortunate women 
and children had been murdered through the ignorance of 
such midwives already. If every Fellow of the Society were to 
record his experience of such murders, the very hairs of our 
legislators (whom he could not certainly denounce so severely 
as had been done for their supineness in such matters) would 
stand up on end. Occasionally we did meet with educated 
midwives. He could speak of some educated by one Fellow 
of the Society — Dr. J. Hall Davis. The comfort of these 
midwives to himself he (Dr. Bouth) had found very great. 
It was notorious that many of these uneducated midwives could 
not even draw ofi" the water for a patient. There was. another 
reason for taking this step. Strong-minded women were on 
the increase, and sooner or later many would be found in 
the ranks of the profession. He only hoped when they were 
in it, there would be found more than the two French ladies 
whose names would be handed down to posterity with honour. 
He alluded to Madame Boivin and Madame Lachapelle. But 
if the better classes of strong-minded women entered our 
ranks, we might rest assured that they would find imitators 
in a lower strong-minded class — such would invade the 
province of midwifery. If so, it was important to test more 
accurately their knowledge, and certainly this Society could 




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ANNUAL ADDRESS. 25 

do it well. These resolutions of the Society would also, 
perhaps, induce smaller colleges and hospitals to open classes 
for teaching midwifery to these women. When our legis- 
lators found the machinery existing, and the good so done, 
then they would soon make such examinations compulsory as 
a matter of course. This Society, therefore, he (Dr. Bouth) 
thought, under the circumstances, did well to take the 
initiative. 

A discussion ensued, in which Drs. Heywood Smith, 
Aveling, Bantock, Grigg, Playfair, Mitchell, Wiltshire, 
Rogers, Phillips, and J. Hall Davis took part, after which 
the plan recommended by the Council was carried un* 
aniraously. 

On the motion of Dr. Tyler Smith, seconded by Dr. J. 
Watt Black, the following gentlemen were elected to serve 
on the examining board : 

Dr. J. Hall Davis, Chairman, Drs. Aveling, Meadows, and 
Leonard Sedgwick, with the Honorary Secretaries ex officio. 

A vote of thanks to the retiring Vice-Presidents, and to 
the office bearers of the Society, was proposed by Mr. 
Gaskoin, and seconded by Dr. Day Ooss, and carried un- 
animously. 

The President then delivered the Annual Address* 



ANNUAL ADDRESS. 

Gentlemen, — It has been said that the life of a man must be 
reckoned rather by the work he has done than by the number 
of his days ; and the same is true of such a Society as ours 
in these times of rapid progress. Sir Thomas Brown says. 



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26 ANNUAL ADDRESS. 

'^ He that early arriveth into the parts and pmdence of age, 
is happily old without the uncomfortable attendants of it ; 
and it is superfluous to live unto grey hairs^ when in a pre- 
cocious temper we anticipate the virtues of them." Can this 
be said of us? The answer it becomes us to leave to 
others. Still, it is well every year to see what we have 
done, and what we are doing. 

After the copious review of past work given by your late 
President, it is unnecessary for me to dwell on this point ; 
but so far as the papers and discussions of the past year are 
concerned, I think we may take credit for not being behind 
the former years both in work and interest — I mean, if we 
may take credit at all for doing our duty ; for, as Bacon 
remarks, '' I hold every man to be a debtor to his profession ; 
from the which, as men of course do seek to receive counte- 
nance and profit, so ought they of duty to endeavour them- 
selves, by way of amends, to be a help and ornament 
thereunto.'^^ 

But you must not judge of the whole work of the Society 
by that which appears in our ' Transactions / a large amount 
of action is quietly but vigorously carried on by the various 
committees. You who have not been on committees can 
hardly understand the amount of exertion which is required. 

You have already given your opinion on the work of one 
committee. As you have this evening heard, your Council 
felt, in consequence of movements in various directions, that 
they would not be carrying out the programme of advance it 
has laid out for itself, unless the question relating to mid- 
wives was put before you. A committee was formed, which at 
numerous meetings discussed this and collateral questions ; 
and with the assent of the Council it was thought best 
to put it into a definite shape, at any rate as a tentative 
measure. 

It will be seen that in the scheme the minimum of study, 
considered absolutely necessary, has been prescribed for 
women acting as midwives under medical supervision, or, as 
Miss Nightingale defines it, *' midwifery nurses.^' 

> « Maxims of the Law.' 



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ANNUAL ADDRESS. 27 

No doubt^ after experience gained by further practice and 
reading, they would be more reliable. But with this amount 
of knowledge they never could be trusted to act quite 
separately from, nor in antagonism to, fully qualified medical 
men. If ever it should come to pass that women are allowed 
to practise midwifery separately from us, then it will be 
necessary for them to be educated as fully and as com- 
pletely as men, in unity with them so far, at least, as 
that the professors of one are professors of the other, 
and not in separate schools. Either this, or simply 
helpers. 

Picture to yourselves half educated persons handling the 
sound, hysterotome, the crotchet, and other dangerous 
instruments of midwifery. Imagine their treatment of those 
dangerous complications which attend women in either 
pregnancy, parturition, or lying-in. Imagine the condition 
of a school of midwifery carried on by women, or by any 
one not thoroughly acquainted with general medicine or 
surgery, continuing the education of others in a similar 
manner. I need not point out the state of stagnation in 
which they would find themselves in a few years. 

Two standing committees have been formed on scientific 
subjects, one to gather information relative to the temperature 
of parturition and the puerperal state, under Mr. Squire as 
chairman, and Dr. Edis as secretary. This Committee has 
constructed a form for a reporting paper, which has been 
sent to those working on the subject, and will be forwarded 
to any one willing to assist in the matter on application to Dr. 
Edis or our honorary secretaries. The chairman has already 
given us one contribution on the subject, but we require still 
more extensive observations before we are in a position to 
arrive at the full knowledge of the natural temperature, and 
of the many causes of its variation. 

It only requires that each Fellow of this Society take one 
case thoroughly during the coming year, and by next anni- 
versary we should have sufficient to show the substantial 
advantage of a committee, and the power of association for 
the collection of facts. • 



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28 ANNUAL ADDRESS. 

The second Committee (under Dr. R. Barnes as chair- 
man, and Drs. "Wiltshire and Hey wood Smith as Secretaries) 
has devoted itself to the collection of pelves and foetal heads. 
It purposes first of all to obtain those of the healthy of 
various races of man ; and secondly, those which are deformed, 
together with their history as regards their origin and effect 
upon labour. They have communicated with the Obstetric 
Lecturers in the United Kingdom, and with many abroad. 
The time is too early for them to have materials sufficient 
for publication, but I may say that the answers already 
received are most satisfactory; and we have already a 
munificent donation from one of onr Honorary Fellows — 
Dr. Arthur Farre — of twenty -four normal and abnormal 
pelves, with illustrated works on these subjects. 

These committees have been selected chiefly from non- 
official Fellows; but as it is impossible to know all who 
would feel an interest in the subjects, our secretaries would 
be pleased to receive applications from any Fellows for the 
inclusion of their names. 

There are still many subjects upon which it is very de- 
sirable to obtain information. I might name one which 
should be the first to receive attention, namely, " the effect 
of zymosis, &c., on the pregnant and puerperal woman.'* 
For, although we have made some progress in this direction, 
yet much remains to be done. 

One thing has been learnt, and this one we cannot be too 
earnest in constantly proclaiming, namely, that we cannot 
be too careful in separating the lying-in women from all 
contact with zymotic diseases, and the contamination of 
other animal poisons. In whatever manner these act, there 
can be no doubt of their effect ; and we need not wait for 
the settlement of the germ theory to put our knowledge 
in practice. But, perhaps, for a short time we have as 
much work in hand as we can get through satisfactorily at 
once. 

Still, I may be permitted again to repeat, that while a 
Society like this gives opportunity for the expression of 
individual opinions, it is also ft powerful medium for the 



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ANNUAL ADDRESS. 29 

collection of facts with a rapidity and amplitade impossible 
by single hands. 

Tt may also be the means of obtaining an expression of 
combined opinion on a question of practice ; but I doubt 
whether we should gain much by a frequent repetition of 
this^ inasmuch as such an opinion^ possessing, as it would do, 
a kind of ex cathedrd force would, perhaps^ trammel practice 
for a longer time than desirable. The free expression of 
opinion/ such as occurs at our debates, will generally form 
a sufficient guide to enable intelligent men to distinguish 
the current line of practice, and to judge for them- 
selves. 

I am happy to say that our numbers have not decreased, 
indeed, they have slightly increased, reaching now 597. 

Our financial position is also equally satisfactory and 
stable, as you have had already shown to you. 

It is a subject of much congratulation that our volumes of 
'Transactions' continue to be so highly valued abroad. 
During the past year we have sold about 120 volumes, thus 
adding to our income £64. And this leads me to make an 
observation on a point which has more than once been 
brought under the consideration of your Council by Fellows 
who seldom have an opportunity of being present at our 
meetings, namely, that this disadvantage entitles them to 
a reduction of their subscription, because, they say, they 
only receive the volume of ' Transactions ' in return, 
* Gentlemen, these objectors forget to include at least two 
other important items. Is it nothing, in the first place, that 
they are in active association with a large number of their 
fellow practitioners ? and that, without further trouble, they 
can place themselves in communication with our Secretaries, 
in order to bring forward any interesting case which may 
occur to them ? 

Is it nothing that they can personally assist in the great 
work of progress, by adding the information they possess to 
our various Committees, such as those to which I have already 
alluded? 

Is the stimulus each •of us cannot tail to receive by the 



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30 ANNUAL ADDRESS. 

principle of association to be counted as nothings at a time 
when a man is remote in the country, and wearied by work ? 

In the second place, does he not receive something in the 
shape of return by the labours of the various committees ? 

Again, they forget that the Library is a lending one, from 
which they can have books transmitted to them for a very 
slight additional cost. Besides, should they be in London at 
any time, they have a room of call where they can read and 
write. 

While upon the finances I may remark that, although your 
Council have not laid by so much income as in the early 
years, considering that the amount already funded a nearly 
sufficient reserve, and that the sum could be more advan- 
tageously expended on the library and Committee work, yet 
they have placed £120 during the year in the funds. 

Death has been somewhat busy during the past year 
amongst us. We have lost two honorary, and six of our 
ordinary Fellows, and of these I will, as is our custom, and 
as is our only satisfaction, give a short notice. 

Honorary Fellows. 

Pietro Lazzaii, Director of the Milan Lying-in Hospital, 
died of apoplexy on 22nd March, 1871. He was a pupil 
of Lovati. Lazzati worked with the greatest energy and 
success. His practice has been faithfully illustrated and 
recorded by his assistant Dr. Gaetano Casati, in the annual 
reports of the before-named institution. He himself pub- 
lished many memoirs, among which the most remarkable is 
one on the * Mechanism of Labour by the Shoulder.' This 
monograph is one distinguished for clearness and accuracy of 
observation. He was, as a citizen, distinguished as a man of 
heart and active philanthropy, of excellent presence, and of 
frank and manly bearing. There is a good photograph of 
him in our library. 

M. le Baron Paul Dubois, Honorary Dean of the Faculty 
of Medicine of Paris, Senior Professor of Clinical Obstetric, 
Member of the Academy of Medicine, Commander of the 
Legion of Honour, &c., died at the age of 76 at Courteille, 



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ANNUAL ADDRESS. 31 

of bronchitis. M. Dubois did not share the fate of most of 
our great men ; he knew little of the difficulties which ac- 
company the start in the medical career, for his father 
Antoine Dubois^ who was Senior Surgeon to the Maternity, 
caused him to be appointed assistant-surgeon to that hospital in 
1820. Here he gained such experience that in 1825 his father 
retired in his favour^ and he became Professor and Senior 
Surgeon. In 1834 the Faculty thought it advisable that 
clinical instruction in obstetrics should no longer be excluded, 
and it was therefore decided to elect some one to fill that 
post. After a severe contest, M. Paul Dubois was elected^ 
and this choice was soon ratified by public opinion. Directly 
after his election he displayed those exceptional qualities — 
precision and elegance of language — which for twenty-five 
years made him such a distinguished professor. His voice 
was soft and harmonious, he lectured with method, and he 
liked to reproduce his ideas in a variety of forms — for he 
considered it before all things desirable to be understood. 
He was as skilful in obstetric operation as he was attractive 
in the lecture-room. His great principle was, before inter- 
fering, to leave a great deal to the efforts of nature, yet not 
to pass reasonable limits^ He also carried diagnosis to the 
highest degree of perfection possible. 

For nearly twelve years before his death a veil came over 
his great intellect, which, gradually becoming denser, and 
destroying one by one his many brilliant faculties, ended by 
annihilating them all, and permitting only a vegetative 
existence. When he found his memory failing him, he 
understood what would happen to him ; he put his afiuirs in 
order, and awaited his fate with courage. 

Being averse from writing, he was not a voluminous 
author ; nevertheless^ his memoirs on the ' Mechanism of 
Labours' stands as an evidence that he was as adroit in the 
art of writing, and as clear in description, as he was brilliant 
in lecturing. 



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32 ANNUAL ADDRESS. 

Ordinary Fellows. 

Thomas Hawkes Tannery M.D. St. Andrew's, M.R.C.S., 
Member Royal Coll. Physicians, Fellow of the Linusean 
Society, died on 7th July, 1871, at Brighton, after about 
three months' cessation from active practice. Dr. Tanner 
was educated at King^s College, and became M.R.C.S. in 1847. 
The next year he was appointed Physician to the Farringdon 
Street Dispensary. In 1850 he became a Member of the 
College of Physicians, and for a time lectured on Forensic 
Medicine at the Westminster Hospital. In 1857 he was 
elected Physician to the Hospital for Women in Soho 
Square, and held that office for six years. It was here he 
laid that foundation of the reputation he enjoyed later in life 
in the treatment of diseases peculiar to women. In 1858 he 
took an active part in the formation of this Society with Dr. 
Tyler Smith, Dr. Rigby, and Dr. Graily Hewitt, and acted 
as one of its Secretaries up till 1863. In 1860 he was elected 
Assistant Physician- Accoucheur at King's College Hospital, 
which appointment he held till 1863. 

He was Vice-President of this Society from 1863 to 1865. 
After this date his presence at our meetings was not so fre- 
quent. His practice had become by this time very large and 
laborious, though not exclusively special. This alone would 
have occupied the attention of most men, but such was his 
unconquerable energy that he found time for bringing out 
his works, of which editions followed editions with a rapidity 
which must have exceedingly taxed his vital powers. The 
principal of these are : — 

1. * Practice of Medicine -/ 

2. * On the Signs and Diseases of Pregnancy ;' 

3. ' Manual of Clinical Medicine ;' 

4. * Practical Treatise on the Diseases of Childhood ;' 

5. 'Memoranda on Poisons/ 

6. ' Index of Diseases ;' 

7. * Clinical Report of Female Sexual Organs.' 

And many articles and reviews contributed to the medical 
journals. 

In 1854 he had an attack of scarlet fever, which left 



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ANNUAL ADDRESS. 38 

evidence of renal congestion. This never entirely passed oflf; 
but it was not till within four months of his death that signs 
of Bright^s disease became unmistakeable. He gave up 
practice for a time^ as he thought, but in about a month 
before his death convulsions set in^ which^ continuing with 
increased frequency, terminated his life after great sujBTering. 
He was married in 1859, and left a widow with four 
children. 

His mind was remarkably clear, well ordered, and metho- 
dical; his memory excellent and well stored. As already 
shown, his mental energy was indomitable. It was owing to 
this that his vital powers were unduly taxed, and not allowed 
the necessary time for recovery after disease. Upon a large 
and complete success he had set his mind, but only at the 
expense of his life did he attain it. 

Alexander James Low, M.R.C.S., L.R.C.P. Lond., of St 
Breladeo, Jersey, was educated at St, Bartholomew's Hospital, 
dying at the early age of 80. 

John Griffith Goulstone, M.D., of 30, Clarence Street, 
Liverpool. He took his degree from the Georgetown Uni- 
versity, Washington, belonged to several medical societies, 
and took an active interest in many medical subjects, upon 
which he wrote. He died March 12th, 1871. 

Henry James Shirley, F.tt.C.S., of Ash, Kent, was elected 
Fellow in 1860, and died July 25th, 1871. 

Thomas M. Kendall, F.E.C.S., of King's Lynn, Norfolk, 
Surgeon to the Prince and Princess of Wales at Sandringham, 
was born in 1820, died 1871. He studied for the profession 
at St. George's Hospital ,- was House-Surgeon to the West 
Norfolk and Lynn Hospital, of which he continued surgeon 
for sixteen years afterwards, and shortly before his death was 
made Consulting Surgeon. He was an Alderman of the 
Borough of King's Lynn, and Member of the British 
Medical Association, and filled other appointments with 
great credit. 

John W. Middleton, of Brussels, L.R.C.P., M.R.C.P. Edin., 
having been for five years Fellow of this Society, passed from 
among us at the early age of 33. 

VOL. xiv. 3 



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34 ANNUAL ABDRSSS. 

Dr. Nathaniel Heckford was born at Calcutta in 1842. 
He pursued his medical studies at the London Hospital^ 
where his career was unusually brilliant. When cholera 
broke out in 1866 he threw himself with his accustomed 
energy into the work of combating that dire disease^ and 
worked both night and day, with his friend Dr. Bathurst 
Woodman, in the Children's Hospital at Wapping. In 1868 
he founded the East London Hospital for Children and Dis- 
pensary for Women, which was opened with ten beds, in a 
warehouse bought by him for £2000, the freehold of which 
he presented to the Committee of the Hospital in 1870. It 
rapidly increased to forty beds. How he and his wife worked 
for the welfare of this hospital has been graphically told by 
the late Charles Dickens, in his paper entitled '^ A Small Star 
in the East.^' It is not too much to say that his labours, 
and the consequent anxieties, laid the foundation of the 
pulmonary disease which proved fatal on the 14th December, 
1871. He published several papers, some of which appeared 
in our 'Transactions.' (The above brief sketch is taken from 
a notice in the ' Med. Press and Circular.') 

In conclusion, allow me to thank you for the support you 
have given me in the performance of my functions, to thank 
the Secretaries for the energy with which they have at all 
times rendered both me and you assistance, and to hope 
that this year may show that this Society still possesses that 
vitality which, by a kind of magnetic impulse, has hitherto 
descended from my predecessors. 

A vote of thanks to the President for his admirable 
Address was proposed by Dr. J. Hall Davis, and seconded by 
Mr. Mitchell, and carried by acclamation. 



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FEBRUARY 7th, 1872. 

John Braxton Hicks^ M.D., F.R.S., President, in the 
.Chair. 

Present — 37 Fellows and 6 visitors. 

Books were presented from Dr. A. Meadows, Miss 
Florence Nightingale, Professor Rizzoli, Dr. T. Zaaijer, and 
from the Royal Northern University of Christiania. 

The foUowiog gentlemen were admitted Fellows of the 
Society: — Dr. Robert Bell; Dr. Thomas Bridgwater; Mr. 
T. W. Evans; Dr. R. H. Milliard ; and Mr. Robert Jalland. 

The following gentlemen were elected Fellows: — J. N. 
Agnew, M.D., Toronto ; Norman Bethune, M.D., Toronto ; 
Charles H. Carter, M.D.; William Hope, M.D; Albert 
Hunt, M.R.C.S.; John E. Kennedy, M.B., Toronto; Mark 
Konr&d, M.D., Pesth; John Griffith Lock, M.A., L.R.C.P., 
Tenby; George Parr, M.R.C.S. ; William L. Richardson, 
M.D., Boston, Mass. ; John D. Shapland, M.R.C.S., Croy- 
don ; James Algernon Temple, M.D., Toronto; and N. 
Tolotschinoflf, M.D., Kieff. 

Dr. F. R. Hogg, R.H.A., exhibited photographs of the 
Military Lying-in Hospital at Woolwich. He said that at 
eight military stations there are hospitals for the wives and 
children of soldiers, chiefly intended for cases of parturition, 
consequently infectious diseases are not admitted under the 
same roof. Last year out of 832 deliveries 3 women died ; 
namely, at Aldershot, Colchester, and Portsmouth. Through 



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36 WOOLWICH MILITARY LTINO-IN HOSPITAL. 

the courtesy of Drs. Mackenzie^ AUen^ Macbeth^ Fergusson^ 
Good^ McNalty^ and Adcock^ he was able to state the number 
of deliveries at each. At Aldershot 358, Chatham 56, 
Colchester 67, Curragh 59, Portsmouth 63, Plymouth 44, 
Shomcliflf 47, and at Woolwich 138. Soldiers^ wives are 
wanderers, here to-day and off to-morrow, unable to form 
local ties. A woman very reluctantly leaves her home, her 
husband, and hpr children to the mercy of chance, to come 
, into hospital ; the children fall into the fire, the furniture 
is stolen, and the husband in solitary discomfort may take to 
drinking. A nursery to look after children when the 
mother is sick, or even when well, engaged increasing her 
income by washing, would be a great boon. At Aldershot 
the hospital is splendidly worked and greatly appreciated, 
the nursing conducted by sisters to whom the greatest 
credit is due ; they and the medical officer constitute one 
splendid piece of machinery equal to any emergency. As to 
the hospital at Woolwich the statistics of mortality occurring 
amongst women after childbirth show, during ten years, one 
per cent. ; but no rule can be deduced from this. In 1863, 
1864, 1865, out of 344 deliveries there were no deaths. The last 
fatal case here happened December 5th, 1870, that of a woman 
removed in labour from her home to hospital, there delivered 
of a putrid foetus, the placenta diseased, fever setting in. 
The next previous death was in December, 1869. So that 
out of the last 278 cases, calculating from December, 1869, 
to January, 1872, but one death has taken place. As to 
infantile mortality about 7 per cent, would almost represent 
the number. A woman has been confined one night and sailed 
for India the next. And another was confined on the gravel 
outside ; but as a rule they stop in bed ten days, returning 
home on the fourteenth. One woman aged 15, two aged 
16, and one aged 46, represent the extreme of ages. 

The hospital, a one-storeyed building, consists of two large 
wards, each with a smaller ward attached. There is a 
thorough communication between the two, but a passage 
where the doors are constantly open dilutes and diverts the 
current of air. The parturition ward, adapted for ten 



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EXTRACTION OF A CBDAB PENCIL 'PB6M THE BLADDER. 87 

patients^ is 40 feet long; 24 broad^ and 14 high. There is one 
fireplace and two gas burners provided with bottomless lanterns 
so that the products of combustion never enter the room. Each 
patient has 1483 cubic feet. The thermometer in July stood 
69° and in December 47° Fahr. on the average. There are 
many windows with ventilators between ; the walls are very 
thin. The evening temperature during the months men- 
tioned stood 71° and 50°. 

The general ward^ of the same height and width as the 
other^ is 67 feet long^ and has a stove in addition to the fire- 
place; the evening temperature in July stood 68°, in 
December 54°, and this is too cold for cases of bronchitis, 
pleurisy, pneumonia, phthisis, rheumatism, &c. In this 
ward 89 women and 54 children were treated last year. At 
various times injuries, bums, scalds, fractures, indeed, ex- 
cepting scarlet fever, variola or typhus, any cases are eligible, 
but for the reasons above stated the wards are seldom full, it 
is often a matter of surprise there are patients at all. A 
number of screens have been provided by generous ladies, 
which can be used round each bed on cold nights. He liked 
the low temperature; it prevents scarlet and other fevers 
being developed, many of the general cases unfortunately 
come in moribund. The Government defrays the lion's 
share of expense, and a fund amounting to £120 a year, 
collected in the garrison, does the rest. It is very dijfficult to 
retain good nurses in garrison towns, but there were sisters 
here under the matron, and a creche for children during the 
mothers* absence ; the hospital might be greatly improved, 
and in course of time one might with a certain feeling of 
pride say, '' Circumspice.^' 

Dr. J. J. Phillips exhibited a cedar pencil, four inches 
long, one end of which was covered with a large calcareous 
mass, which he had extracted from the bladder of a girl, 
set. 18. The pencil had been passed into the vagina six 
months before the patient came under observation, and she 
was unable to remove it. For the first four months it gave 
rise to no pain or inconvenience, but she then began to 



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38 EXTBACTION OP A CEDAB PENCIL PROM THE BLADDER. 

suffer from an irritable bladder^ and for six weeks there had 
been incontinence of urine. When admitted into Guy^s 
Hospital; under Dr. Phillips's care^ the urine was found to 
dribble away by the va^na ; one end of the pencil could be 
felt free in the vagina on the left side of the os uteri ; the 
other end had pierced the vaginal wall^ passing in a direction 
forward and to the right ; and by means of a sound in the 
bladder a rough body could be detected in it. An unsuc- 
cessful attempt had been made before admission to extract 
the pencil by the vagina ; a similar attempt in the hospital 
also failed. Two days afterwards the patient was placed 
under the influence of chloroform, and it was then found 
that the pencil had passed still further into the bladder. By 
gentle pressure on the vaginal end the whole of it passed into 
the bladder, the urethra was then rapidly dilated by Weiss' 
dilator, and the pencil seized with forceps and extracted. 
The part which had lodged in the bladder was covered with 
a large phosphatic calculus, a considerable portion of which 
broke down during extraction. On the second day the 
patient said she had a little control over the bladder. On 
the fourth day no urine escaped by the vagina, and she could 
hold her water for two hours or longer. The girl left the 
hospital ten days after the removal of the pencil, and was 
obliged to empty her bladder only three or four times in the 
course of the day. A small cicatrix could be felt in the 
vaginal wall, marking the position of perforation fipom the 
vagina into the bladder. 

The case was brought forward as an example of a rare 
accident. It did not appear that there were many similar 
cases on record. A case, under the care of Mr. Prescott 
Hewett, was published in the ' Medical Gazette ' for 1854, 
in which the neck of a glass bottle after long retention in 
the vagina had ulcerated into the bladder, a calculus then 
forming around its vesical end. The bottle was extracted 
by the vagina, and subsequently the calculus in the 
same manner. Mr. Poland remembered a case in Guy's 
Hospital many years ago, in which a vesical calculus had 
partly passed into the vagina ; the vesical and the vaginal ends 



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CYSTIC DISEASBS OF THE OVARY. 89 

of it then continued to increase by calcareous deposit^ while 
an intermediate part was of smaller diameter ; it thus formed 
what was called a *' bar-shot calculus/^ The case now reported 
seemed interesting also in showing the rapid closure of the 
vesico-vaginal fistula after the withdrawal of the foreign body ; 
and was a further illustration of the advantage of rapid dilata- 
tion of the urethra under chloroform. The patient after 
dilatation^ enough to admit two or three fingers into the 
bladder^ had on the third or fourth day no incontinence of 
urine. 



ON THE PROBABLE ORIGIN OF CERTAIN FORMS 
OP CYSTIC DISEASES OF THE OVARY. 

By Alfred Meadows^ M.D.^ 

PUT8I0IAN-AC00UCHBUB TO, AND LBOTXTBIS OK MIDWIPEBY AT, BT. KABT'S 
HOSPITAL; PHYSICIAir TO THE HOSFITAIi FOB WOMEK. 

There is still so much obscurity and doubt as to the 
origin and cause of ovarian dropsy that it is important^ I 
think^ in order to determine these questions^ so far as we 
are able to do so by examination of specimens, that we 
should record every fact which seems to bear upon the 
subject; and it is with this view that I venture to bring 
forward this case and preparation^ because I think that it 
seems to illustrate at least one of the probable causes of this 
disease. 

The patient from whom this tumour was removed was 
29 years of age^ single^ and had suffered from abdominal 
enlargement for about two years. The catamenia had 
always been regular^ occasionally painful^ moderate in 
quantity. I first saw her in the beginning of January, 1872, 
and had no dilSculty in diagnosing the existence of ovarian 
dropsy, fluctuation was so extremely distinct that I ventured 



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40 CYSTIC DISEASES OF THE OVARY. 

to predict a unilocular cyst, and as no pain whatever had 
been experienced I hoped that no adhesions would be found. 

I performed the operation for the removal of the tumour 
on the 3rd of February. The cyst proved to be unilocular, 
the fluid, amounting to one and a half gallons, was very thin 
and pale, the cyst itself was thin also ; there were no adhe- 
sions, and the collapsed cyst was drawn through an opening 
no more than three inches in length — ^hardly so much. The 
pedicle was tied with a ligature and returned into the pelvis. 
The patient made a complete and rapid recovery, being 
convalescent in a fortnight. 

On examining the tumour I found that the cyst was 
formed as it were at the root of the ovary ; that, in fact, it 
had been developed at its attached border, the rest of the 
ovary, including the whole of its free surface, being perfectly 
independent of the one cyst. All these points are very well 
seen in the annexed illustration. It will be observed that 
the ovary, with several Graafian follicles on its surface, is 
situate on one side of the cyst and is almost independent of 
it, the latter being, as it were, developed in the folds of the 
broad ligament at the root or attachment of the ovary. The 
Fallopian tube is represented as encircling the tumour for at 
least half its extent, a piece of silver wire was easily passed 
from its free or fimbriated extremity round to its cut end, as 
is shown in the drawing; and on close examination the 
fimbrise themselves could easily be traced in an exceedingly 
stretched and attenuated form over the cyst from the end of 
the tube nearly up to the ovary itself, fibres being spread 
out fan-shaped in all directions, but with a general inclina- 
tion towards the ovary. It is important to observe this 
relationship, because it is upon this fact that I ground the 
following hypothesis as to the probable origin of this and 
similar cases of ovarian disease : — 

We know that ordinarily in the healthy and normal per- 
formance of ovulation, the Graafian follicles make their way 
from the centre to the free surface of the ovary, where they 
escape into the Fallopian tube, the latter having grasped the 
ovary by its fimbria at the seat of rupture. We know 



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CySTIC DISEASES OF THE OVARY. 41 

nothing at present as to the law which governs this process, 
nor why it is, or how it comes to pass, that the ova do, as a 
matter of fact, ordinarily develope in the direction indicated. 
But it is not difficult to conceive of the possibility of some 
occasional interference or perversion of this process, by means 
of which ova, instead of developing towards the free sur- 
face of the ovary, take a contrary direction and work their 
way towards the attached instead of the free border of the 
organ. In such a cftse, supposing the Graafian follicle has 
reached the root of the ovary, and is at the junction of 
the broad ligament, it is obvious that its further progress 
will be barred by that structure, it cannot therefore escape, 
and one of two things may happen to it ; either it may die 
and be absorbed and nothing further come of it, or this 
happy termination may not occur, but it may go on develop- 
ing and developing from the formative power which is in- 
herent in it, and thus give rise to very serious structural 
lesions in the ovary itself. 

It is in the belief of such a possibility that I exhibit this 
specimen, because I think it is strongly suggestive of such a 
view. It is evident, I think, that this cyst was developed 
originally at the point I have indicated, and I see nothing 
improbable in the idea that it may have originated in the 
way I have suggested. There is another point which seems 
to me corroborative of the view here taken, viz. that the 
large cyst was lined with an epithelial or cellular layer 
precisely similar to that which was found in the interior of 
the Graafian follicles or cavities which are indicated on the 
surface of the ovary. 

Moreover, the view here taken is, I think, entirely con- 
sistent with other known facts in physiology and pathology. 
I believe that increased experience and observation will 
prove the close and intimate relationship which exists be- 
tween the physiology of a part or organ and its morbid pro- 
cesses or lesions. In this sense, pathology is only perverted 
physiology : and just as the so-called hydatiform degenera- 
tion of the ovum is but an enormously hypertrophied 
decidua, brought about by perverted physiological action, so 



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42 CYSTIC DISBASB8 OF THE OVARY. 

the ordinary Graafian follicle with its increased effasion of 
serous fluid may by the same process become an enormous 
ovarian cyst, or by the repetition of such a process, a multi- 
locular tumour may result. 

If we apply this reasoning to the case before us, the facts 
appear to me to be fairly reconciled, and I know of no more 
satisfactory explanation of the origin of these growths. It 
is clear that these unilocular and multilocular cysts of the 
ovary must have had an origin, and equally clear that in 
their early beginnings they must be of a very limited cha- 
racter. Looking at the ovary, as it appears in the drawing 
annexed, it does not require any very great stretch of imagi^ 
nation to suppose that a multilocular cyst might have 
developed from it as it is, there are indications of possible 
elements of mischief wanting only some slight impetus to 
set the morbid process at work, that impetus, as I believe, 
was given to the one cyst, it was happily wanting in the 
others. At all events, without claiming for this hypothesis 
anything more than an occasional and possible application, I 
venture to put it forward as one certainly not unreasonable, 
in the hope that it may at least help to elucidate a doubtful 
point in pathology, though I can hardly dare to hope, at 
least not in the present state of therapeutical science, that 
more accurate knowledge of pathological process, as applied 
to this particular disease, will help us to check, or control, or 
divert the morbid action when once it has begun. At the 
same time I am convinced that the only secure and rational 
basis of therapeutics must be founded upon an exact and 
accurate estimate of morbid process, seeing that the object 
of the healing art is to counteract such processes. It is in 
this way that pathology becomes of so much practical 
iniportance and is capable of affording such valuable help to 
clinical medicine. 



Dr. "WiLTSHiEB without wishing to throw doubt on Dr. 
Meadows' ingenious and not improbable explanation, asked 
whether the possibility of the cyst having arisen from the par- 
ovarium had been entertained by him. 



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CASE OF VAGTNAL TUB0MBU8. 43 

Dr. Baktooe believed the specimen to be one of cyst of the 
par-ovarium. He had recently removed from a patient a specimen 
which, in addition to its showing an admirable instance of pro- 
lapsus of the ovary (left), indicated' the pathology of these cases 
very clearly. It shows a cyst of the par-ovarium as large as a 
small walnut, encroaching on the ovarv, and it is easy to perceive 
how its enlargement must necessarily involve the ovary, and, 
perhaps, lead to cystic disease of that organ. On the opposite 
side is another about one eighth the size. His observation of a 
large number of ovariotomies led him to believe that when the 
disease originated in the ovary, such tubercular disease is always 
found, to a greater or less extent, while in the cases under con- 
sideration a single cyst, with the ovary at the base, is the most 
frequent if not invariable condition, the ovary retaining its 
functional activity to some extent. 

The President suggested that cysts originating from the 
par-ovarium would probably always be simple, and yet the Fallo- 
pian tube is found passing round the half of the tumour, both in 
compound and single cysts. He thought the explanation given 
by Dr. Meadows the most probable one ; at any rate, in the com- 
pound cysts. 



CASE OF VAGINAL THROMBUS. 
By Robert Jalland, M.R.C.S.^ Homcaatle. 

On the 22nd of September, 1871, 1 was called to a young 
girl in bar confinement. She was about 20 years of age, a 
primipara, unmarried, and had been in labour ten hours. 

On examination I found the head low in the pelvis, and 
the OS fully dilated, but the pains were weak and inefficient. 
I also noticed some enlargement of the right labium, and a 
fulness at the posterior part of the vagina, which latter I 
attributed at the time to a loaded condition of the rectum. 

Finding after a full dose of ergot that the pains did not 
improve; and, as my patient was becoming exhausted, I 
applied the short forceps, and extracted the child without 
the slightest difficulty. 



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44 CASE OF VAGINAL THROMBITB. 

A second child now presented (breech presentation) , which 
was expelled quickly in a few pains, and was shortly followed 
by the two placentae. Up to this time no haemorrhage had 
occurred. 

Upon making an examination to remove any portion of 
membranes or clot which might have remained in the vagina, 
I was surprised to find the vagina occupied by a globular 
tumour the size of my fist, projecting from its posterior 
wall; it was firm, smooth, and unyielding, and I was 
endeavouring to make out its extent and attachments when, to 
my horror, it appeared to suddenly burst in my hand, and in 
a moment the bed was deluged with dark venous blood, in 
such profuse quantity that my patient almost immediately 
became pulseless and unconscious. I at once gave a dose of 
ergot, and applied cold wet napkins to the abdomen and 
vulva, but the haemorrhage continued as profuse as ever, 
though the uterus itself was firmly and perfectly contracted. 
I then introduced my fingers into the vagina, and found a 
rent in the posterior surface about two inches and a half 
long, from which the blood continued to flow in a stream ; 
on each side of the rent the inner coat of the vaginal wall 
appeared to be separated for half an inch. Finding that I 
could restrain the haemorrhage by pressure upon the parts, I 
kept my fingers firmly applied for upwards of half an hour, 
after which no further bleeding occurred, and my patient 
gradually rallied. The following day I found her cheerful 
and comfortable. There had been no return of the haemor- 
rhage, and she was already suckling her two infants. 

On inquiry I learned that she had been sufi^ering from a 
varicose condition of the veins of the right labium, and 
superficial veins of right thigh, and had felt a fulness and 
sense of weight in the lower part of the vagina for some 
weeks before her confinement, which at times prevented her 
from taking exercise ; but, concluding it was nothing unusual, 
she had not made it known to her friends. 

I am pleased to say she has continued to make a good 
recovery. 

As is well known, a varicose condition of the labia and 



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ON RBTROFLEXION OF THE UTERUS. 45 

nymphse during pregnancy is not uncommon^ but there are 
peculiarities in this case which seem to make it worthy of 
recording. 

1st. The moderate size of the varicose tumour^ and the 
absence of further enlargement during the progress of 
labour. 2ndly. That it oflFered no hindrance to the expul- 
sion of the child. 3rdly. That there was no apparent increase 
in its size until the placentae were expelled. 4thly. The rapid 
enlargement and spontaneous rupture which followed the final 
contractions of the uterus, due probably to the sudden influx 
of blood from the uterine into the vaginal plexus of veins. 

On examining the patient about a month afterwards, I felt 
a roughness where there had been a rent in the vagina, the 
rent had healed up, and nothing abnormal could be detected. 



ON RETROFLEXION OF THE TJTERUS AS A FRE- 
QUENT CAUSE OF ABORTION. 

By J. J. Phillips, M.D. Loud., 

▲BSISTAirr 0B8TSTBIC PHYSICIAN TO OTTY'S HOSPITAL; ASSISTANT PHYSICIAN 

TO THB HOSPITAL POS SICK CHILDREN; AND PHYSICIAN TO 

THB BOYAL MATERNITY CHABITY. 

The object of this short paper is to elicit discussion on a 
cause of abortion which I believe to be a very common 
one, and which appears to be insufficiently noticed in most 
of the ordinary text-books on Midwifery. Reference will 
also be made to some cases of retroflexion of the uterus in 
which repeated pregnancies had terminated in abortion, but 
in which the recurrence of this accident was prevented in a 
subsequent pregnancy by simply restoring the uterus to, and 
maintaining it in, its natural position during the early months 
of gestation. 

The subject of retroversion of the gravid uterus appears 
to have first attracted attention in consequence of the 
patient's inability to empty the bladder ; and the existence 



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46 ON RETEOFLEXION OF THE UTERUS 

of thia displacement is now familiar to most practitioners 
in connection with retention of urine about the third or the 
fourth month of pregnancy. There probably is no obstetrical 
writer who does not refer to this complication^ and the 
statement is added by many authors that^ if the uterus 
remain in this position^ it becomes strangulated in the 
pelvis^ and abortion may result. This last is doubtless a 
common termination in those cases where the uterus does 
not regain its normal position^ though it must be admitted 
that many exceptional cases are on record in which the dis- 
placement continued to a late period of pregnancy^ and a few 
even in which it was persistent to the full time of gestation.^ 
Cases of retroversion of the uterus with retention of urine 
and terminating in abortion are therefore well recognised ; 
but it seems to me that a still larger number of cases of 
pregnancy is met with, resulting in repeated early abortions 
from the retroflected state of the uterus, but whose true 
nature is apt to be overlooked, as they are not neces- 
sarily accompanied by any severe or well marked urinary 
troubles. 

My attention was first directed to this subject by observing 
the large number of women attending as out-patients who 
gave the history of frequent abortions ; and although I was 
not sanguine enough to expect (considering the various and 
frequently complicated causes which lead to the premature 
expulsion of the ovum) that the cause of the accident could 
in all cases be made out, either from the history furnished 
by the patients, or from their condition when coming under 
observation, still, I have made it a practice among my 
out-patients to ascertain by a vaginal examination whether 
any marked disorder of structure, or of position of the 
uterus could be found to exist in such cases. The result of 
this practice has been very strongly to impress me with the 
belief that the chief factor in the production of a large pro- 
portion of the cases here referred to is a displacement of the 
uterus backwards. I am well aware that a source of fallacy 

1 Merriman, ' Diasertation on Retrovenion of the Womb/ 1810 ; Oldham, 
Obstet. Trans.,' Vol. I, Ac. 



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AS A FREQUENT CAtTSB OF ABORTION. 47 

is very liable to creep in here^ and that among those who 
attend the out-patient departments of hospitals^ it is a 
common practice to walk about soon after an abortion^ and 
that the enlarged uterus^ under such circumstances, is very 
liable to descend in the pelvis^ and in its descent to become 
then, for the first time, retroflected ; and, further, that this 
displacement after an abortion, as, indeed, after labour at 
full term, may, under favorable circumstances, become spon- 
taneously rectified with the completion of the process of 
involution. These, however, are not the cases here referred 
to, but rather those in which the retroflexion is a permanent 
condition, existing before the supervention of pregnancy, and 
continuing during the earlier months. 

It is not intended to be implied by these remarks that 
abortion is believed to be the almost invariable termination 
of pregnancies complicated with a retroflected state of the 
uterus, for it is not very uncommon to notice the ascent 
above the pelvic brim about the third or fourth month of a 
previously completely retroflected uterus, especially when 
certain precautions are observed by the patient, and, indeed, 
occasionally tmder conditions apparently most unfavorable 
for its restitution. Nevertheless, making due allowance for 
cases terminating thus favorably, retroflexion of the uterus 
appears to be so efficient a predisposing cause of abortion 
that it should occupy a leading position in an enumeration 
of the local disorders tending to the production of this 
accident. 

I cannot find any reference to this displacement as a cause 
of abortion in the well-known text-books of Churchill, 
Murphy, Milne, Miller, or Cazeaux. 

Dr. Ramsbotham, Dr. Tyler Smith, and Dr. Meadows, in 
their works on Midwifery, state that displacements of the 
uterus may lead to abortion, and retroversion is noticed by 
them, though not prominently, among the local causes, as 
the following extracts will show. 

After enumerating various causes. Dr. Ramsbotham says : 
" Prolapsus or retroversion of the uterus may cause premature 
expulsion of the ovum, so also may constipation if it exist 



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48 ON EETROFLEXION OF THE UTERUS 

in such a degree as that powerful straining is required for 
the evacuation of the bowels/' 

'^ Coitus^ plugging the os uteris disease of os and cervix^ 
procidentia, anteversion and retroversion^ may all cause 
abortion/' (Tyler Smith, ' Manual of Obstetrics/ p. 139.) 

" Among the other causes may be mentioned local diseases 
or displacements of the uterus, ulceration, chronic inflamma- 
tion, and hypertrophy of the cervix." (Meadows, ^ Manual 
of Midwifery,' p. 120.) 

Dr. Meadows, indeed, in speaking of repeated miscarriages 
mentions a case which appears to be a typical example of the 
class to which I refer. He says, ^^ In one instance which 
came under my own observation a lady had aborted seven 
times successively, when it was discovered that there was 
retroflexion of the uterus. This was cured, and the patient 
afterwards had a child at full time." (p. 120.) 

Dr. Barnes, in his lectures on obstetric operations, fully 
enumerates the various causes of abortion, and, under the 
head of mechanical anomalies, includes retroversion and the 
pressure of tumours outside the uterus. 

I have only quite lately carefully read a paper by Dr. 
Tyler Smith in the second volume of the Society's ^ Trans- 
actions,' probably the most valuable paper that has been 
published on the etiology of retroversion of the gravid uterus ; 
and, although the author is therein chiefly occupied in 
proving that this condition in most cases results from the 
impregnation of a previously retroflected uterus, yet he inci- 
dentally remarks in relating the history of one of the cases 
upon which the paper is based that, " the tendency to mis- 
carriage is so strong in cases of retroversion that I have little 
doubt some of the cases of habitual abortion met with in 
practice depend on this cause." A careful perusal of the 
cases recorded by Dr. Tyler Smith in illustration of the main 
point of his paper cannot fail to convince us also of the 
truth of the passage just quoted from that distinguished 
author. 

I am not able to furnish from personal observation any 
statistical data as to the comparative frequency of the various 



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AS A FREQUENT CAUSE OF ABORTION. 49 

Causes of abortion^ but so many cases in which this has 
repeatedly occurred about the third month have come under 
my notice in which I have found retroflexion of the uterus^ 
and a few with a similar history whose progress I have been 
able to watch during the early months^ that I think this 
displacement is second in importance to none of the local 
conditions which tend to the premature expulsion of the 
ovum. 

There is a great variety in the amount of local discomfort 
complained of by these patients during the first three or four 
months^ as^ indeed^ is found to be the case in the subjects of 
retroflexion and enlargement of the unimpregnated uterus. 
Generally, however, a sense of discomfort and weight in the 
pelvis, bearing-down pains, pain in the groins, frequent mic- 
turition, occasionally dysuria, and straining in defsecation, 
are the well-known symptoms of this condition; and it 
would be tedious to relate individual cases of the kind, 
though I have preserved records of several such. In some 
instances the patients referred their trouble to imperfect 
convalescence after a preceding labour, leading one to believe 
that owing to some interruption to the process of involution 
the uterus had then descended and become retroflected. I 
do not, however, in this paper speak of cases where abortion 
has resulted from the tying down of a retroflected uterus by 
perimetric adhesions. I have occasionally found that difficult 
micturition was not a very prominent symptom, the explana- 
tion in such cases probably being that the uterus was excited 
to the expulsion of its contents before it had attained such a 
size as of necessity to interfere mechanically with the passage 
of the urine. My impression is that many cases of this kind 
occur, especially among the lower classes, where retention of 
urine does not result, and consequently no medical advice is 
sought, and no local examination instituted ; cases, in short, 
in which women are generally said to have acquired the habit 
of aborting. 

There is one point in the clinical history of these cases 
which must be noticed, as it has some bearing on the treat- 
ment, and that is the fact that an uterus which has repeatedly 

VOL. XIV. 4 



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50 ON RETROFLEXION OF THE UTERUS 

shed its contents may in a subsequent pregnancy ascend 
above the pelvic brim without any artificial help^ the preg- 
nancy terminating in labour at term^ while again^ on still 
subsequent occasions^ a series of abortions may result. I 
cannot doubt that the retroflexion was the main cause of 
the abortion in the following case^ though an intermediate 
pregnancy was not interrupted in its course, 

Mrs. W — , set. 31, married nine years. Had three children 
at term. Then succeeded at least four abortions between 
the third and the fourth months. After this a living child 
was bom at the normal period^ but a subsequent pregnancy 
terminated in abortion at the third month. The patient 
again became pregnant^ and consulted me when advanced a 
few weeks^ complaining of uncomfortable bearing-down 
pains in the pelvis^ sickness^ and irritable bladder. I 
found the uterus much retroflected^ and it was enlarged, 
and up to the end of the third month there was no indication 
of its tendency to ascend. I have not lately seen this 
patient, and I fear she has again aborted. She said that 
she suffered from dysuria in each of her pregnancies after 
the first three; this symptom commenced early in the 
second month, and continued to the third or the fourth 
month, when with one exception, as stated^ the ovum was 
expelled. 

There are, indeed, but few conditions which theoretically 
seem more favorable to the production of abortion than 
this displacement. If the uterus do not ascend above the 
pelvic brim when large enough to fill the pelvic cavity, its 
ineffectual efforts to ascend during its growth have, at leasts 
in the great majority of cases, the effect of exciting the 
organ to expel its contents. Many of the cases^ however, do 
not proceed thus far, and in one of the last instances which 
has come under my observation, where from the history and 
physical conditions not much doubt could be entertained that 
this displacement was the cause of four successive abortions, 
not one of the pregnancies proceeded further than early in 
the third month. The increased susceptibility of the retro* 



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AS A FREQUENT CAUSE OF ABORTION. 51 

fleeted pregnant uterus to concussion from sudden movements^ 
the mechanical irritation to which it may be subjected^ the 
straining in micturition and defsecation^ often aggravated by 
the constipated state of the bowels in early pregnancy^ and the 
irritation which the abnormal position of the uterus sets up/ 
seem all to be very efficient excitors of uterine action. 
Further^ a not unimportant factor in the production of 
abortion may be found in the interference with the uterine 
circulation in some cases of marked retroflexion^ tending to 
the efiusion of blood between the uterus and the placenta^ 
and this in its turn exciting uterine action or leading to the 
death of the ovum. 

It remains for me briefly to notice two cases in which very 
simple treatment was effectual in preventing the recurrence 
of abortion. 

Mary C — j «t. 36, came under my care at Guy's Hospital, 
on August 13th, 1870. She was the mother of six children, 
all born at the full time. Since the birth of her last child 
she had aborted six times, all within the period of three 
years. Each of these abortions had occurred between the 
end of the second and the end of the third month of 
gestation. She complained of weight and bearing-down 
pains in the pelvis, straining at stool, and forcing in micturi- 
tion; and all these were aggravated each time she became 
pregnant. 

No constitutional cause of abortion could be made out. 
She was pale and appeared depressed, probably from the 
recurrent abortions. The uterus was retroflected, the cervix 
appeared healthy, and the body was not materially enlarged. 
Finding that the uterus remained retroflected I restored it, 
and introduced a Hodge's pessary. Soon after this she 
again became pregnant, and attended occasionally during the 
first two or three months of her pregnancy, but finding her- 
self suffering but little from her usual uncomfortable symp- 
toms, I did not see her again till she had arrived at the end 
• of the sixth month. I then found the uterus occupying its 
normal position in the abdomen, and I withdrew the pessary. 
The patient was confined at the proper time, and subse- 



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52 ON RETROFLEXION OF THE UTERUS 

quently presented herself at the hospital^ with her infant^ to 
report her satisfactory progress. 

Mary W — , set. 35, was admitted into Guy's Hospital 
under my care on the 8th February, 1870. She also was the 
mother of six children, all born alive at term. She had 
always enjoyed good health both during her maiden and 
married life until her last confinement, which took place in 
July, 1868. In the year 1869 she aborted twice at the 
tenth week of gestation, once in the month of July and again 
in November. Her complaints were of forcing pelvic pains, 
and of menorrhagia. I found the uterus larger than natural 
and retroflected. The cervical lips were superficially abraded, 
and a very small mucous polypus existed at the os uteri. 
No treatment was adopted except the removal of the small 
polyp and the introduction of a Hodge^s pessary. A few small 
doses of secale were also given at the menstrual period which 
occurred during her stay in the hospital, as this, like the 
preceding ones, was prolonged, and the loss of blood rather 
profuse. The patient left three weeks after her admission, 
feeling much relieved. After wearing the pessary for some 
time she desired to see whether she could dispense with it, 
but returned in a fortnight to have it replaced. The uterus was 
again retroflected. Soon after reintroducing the pessary the 
patient became pregnant, and felt very little discomfort during 
the early months. Between the fourth and fifth month I 
found the uterus reaching half way to the umbilicus, and, 
therefore, I removed the pessary. This patient lived in the 
country, and the last time I saw her she came up to the 
hospital to state that her pregnancy was proceeding naturally, 
and that she expected to be confined in a very few weeks. 

The treatment in cases such as the above, where the 
patients come under observation with the uterus at the 
time not tenanted, seems clearly indicated ; namely, to restore 
the misplaced uterus and maintain it in a position favorable 
for its ascent when pregnancy takes place. A diflSculty, 
however, presents itself in dealing with cases of retroflexion 
when pregnancy has already occurred ; and in the few such 
instances which have come under my care I have been con- 



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AS A FREQUENT CAUSE OF ABORTION. 53 

tent with giving general directions in reference to the 
bladder and the rectum^ and recommending the observance 
of the horizontal posture. That on the face or side, as 
advised by Dr. Tyler Smith, is evidently the best. I was 
guided in this by remembering cases of pregnancy in which 
I had observed the uterus previously retroflected and low in 
the pelvis spontaneously ascend even within a few days, and 
I feared lest my interference might accelerate that which I 
desired to prevent. The result of my practice, however, has 
been unsatisfactory enough, and a difference of opinion will 
doubtless exist as to how far it is advisable in cases under 
continuous observation to aid the uterus in its efforts to 
ascend by air pessaries or otherwise. 

There is another point of interest related to the subject of 
this paper, which, in conclusion, I would simply mention. 
I refer to the influence of retroflexion in causing imperfect 
deliverance in cases of abortion. My own experience has 
been too limited to enable me to form an opinion of its com- 
parative frequency, and I will merely state that some of the 
cases which I have seen of long retention of a portion of the 
ovum after abortion have been cases complicated with retro- 
flexion of the uterus. 



Dr. Tilt admitted tbat any considerable amount of uterine 
displacement was a cause uf abortion, but he asked Dr. Phillips 
whether his cases were instances of uncomplicated uterine dis- 
placement. Dr. Tilt had frequently seen chronic inflammation of 
the womb cause successive abortions, the liability to which 
ceased on the uterus becoming healthy, so he thought it would 
have been better if the author had stated the amount of patholo- 
gical complication, if any, that had been noticed in addition to the 
uterine displacement, for, if considerable, it should be admitted as 
lending its influence to the determining of abortion. 

Dr. Bantock could not agree with Dr. Tilt, for he had always 
believed that inflammation of the uterus was a decided bar to the 
occurrence of impregnation, but he agreed entirely with the 
accuracy of the observations made by Dr. Pliillips as to the 
frequent occurrence of abortion as a result of displacement of the 
uterus whether backwards or forwards. He took exception to the 
looseness with which the terms retroflexion and retroversion were 



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54 ON RETROFLEXION OF THE UTERUS 

employed bj the author as if synonymous. He had notes of several 
cases of abortion from displacement. The first occurred about six 
years ago, in a patient the subject of anteversion. The use of a 
Hodge's pessary with long anterior limbs carried the patient over 
the fatal period, but its removal at her request resulted shortly after 
in abortion. The last case was one still under observation, in a 
patient suffering from retroversion. This patient had passed into 
the fourth month, and was still wearing the instrument, and his 
intention was to leave it till the uterus had risen well out of the 
pelvis. In reply to Dr. Barnes, Dr. Bantock contended that true 
inflammation did very materially interfere with impregnation, that 
the cases of repeated abortion at short intervals were not cases 
of inflammation at all, and that rest alone sufficed to tide them 
over the fatal period. He had before his mind the case of a lady 
who could not bear a living child without lying up for about six 
months, and who, so surely as she did not take this precaution, as 
surely aborted. He complained of the looseness with which the 
term inflammation was used. 

Dr. EouTH thought the remarks made by Dr. Tilt were more in 
accordance with his experience that those of Dr. Bantock. The 
existence of sores, ulcerations, &c., during pregnancy was 
common, and if complicated with a diseased uterus and much 
congestion, perhaps subacute metritis, would alone suffice to pro- 
duce abortion. He had often met with such examples, and treated 
them. Flexions of the uterus, whether anteflexions, or retro- 
flexions, were, in his experience, much more frequently the causes 
of sterility than of abortion. He did not then recall a single case 
in which he knew that pure uncomplicated flexion had existed 
before pregnancy, and in which afterwards pregnancy occurred, 
where abortion followed ; but he was quite aware of cases where 
the flexion was complicated with ulcerations and congestions in 
which this had occurred. It appeared to him, therefore, that the 
flexion was not so much the cause of the abortion as was the 
complication which co-existed. This co-existence was, he thought, 
often the essential element to abortion ; because it was indubit- 
able that many women known habitually when not pregnant to 
have their uteri flexed, yet when pregnant, went the full 
term with several cbUdren, perhaps one after another, and never 
once miscarrying. In like manner ulcerations of themselves 
could not necessarily produce abortion. Many such cases got 
well. Besides, one observer, he thot^ht Dr. Henry Bennett, had 
called attention to the fact that in a large number of cases when 
menstruation existed during pregnancy this was due to abrasion 
or ulceration of the cervix co-existing, and yet these women had 
not necessarily aborted. Lastly, in the cases mentioned by Dr. 
Phillips of successive and repeated abortions, Dr. Phillips 
had not sufficiently insisted that such cases were not affected 



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AS A FREQUENT CAUSE OP ABORTION. 55 

with syphilitic taint, a common and well recognised cause 
of repeated miscarriages. He, Dr. Bouth, invariably in such 
habitually miscarrying cases gave small doses of bichloride of 
mercury, even in those instances where he had no certainty of the 
existence of syphilitic disease, and with the happiest results, even 
in cases of marked flexions. The class of cases related by Dr. Phillips 
were peculiar. He spoke of out-patients in hospital practice 
at Guy*s ; now, although Dr. Eouth felt bound to pay the highest 
tribute to G-uy's Hospital, which had produced some of the 
cleverest physicians and surgeons in the realm, yet the locality of 
Whitechapel and the Borough was notorious for the extent of 
syphilis prevailing there, and thus many of Dr. Phillips' cases 
might have been tainted. It was most important, therefore, that 
this source of fallacy should be especially noted in the cases 
brought forward as instances of abortion from flexions of the 
uterus. 

Dr. Basch said the thanks of the Society were due to Dr. 
Phillips for so ably briD£;ing forward this practical subject, but it 
would decrease its usefulness to the practitioner, if in its discus- 
sion other well-known causes of abortion, lii^e syphilis, were intro- 
duced. The subject of the paper was a certain well-defined 
mechanical cause of abortion, which must be familiar to all 
engaged in obstetric practice, and Dr. Basch could fully subscribe 
to the author^s views. In one point the paper might have been 
more distinct, as it affected therapeutics. The author had made 
no distinction whatever between two forms of retroflexion which 
to Dr. Basch seemed not without practical importance. He gave 
two cases as types, one of the simple traumatic or acute retro- 
flexion of the healthy gravid womb, produced by some external 
violence, with sudden retention of urine, in which repeated 
catheterism and one reposition cured the retroflexion acquired 
two days previously. A pessary was not necessary in this and in 
similar eases, and gestation was not interrupted. Different from 
these simple traumatic cases were those in which the retroflexion 
was due to alterations in the textures of the organ. Betention of 
urine was here no prominent symptom, in fact, Dr. Basch never had 
observed it. If the uterus were redressed it would almost invari- 
ably fall back again unless a pessary (Hodge's) was applied, which 
should be left up to the fifth month of pregnancy. Dr. Basch 
had not the slightest doubt that a great many abortions were thus 
prevented, especially if the patients he enjoined to lie on their 
knees and elbows whenever they feel uncomfortable as to the right 
position of the pessary. This prone position *he could not 
strongly enough recommend, the more so especially if air was 
allowed to enter the vagina in ttie way he had shown on another 
occasion. But it should be done daily for half an hour while in 
bed. Patients very soon found out the value and comfort of it and 



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S6 ON RETROFLEXION OF THE UTERUS 

practised it. Dr. Eaech's experience of retained placenta aftef 
abortion made him fully concur with the closing remarks of the 
author's paper, that retroflexion was a frequent cause of the reten- 
tion. 

Dr. Wtnn Williams, whilst fully agreeing with the author of 
the paper to a certain extent, also agreed with those gentlemen 
who had already spoken. As regards the observations made by 
Dr. Tilt no onemr a moment could deny that ulceration and inflam- 
mation of the cervix uteri were opposed to impregnation and were 
occasionally the source of abortion, yet how often whilst treating 
diseases of the cervix do we find impregnation take place and the 
patient go the full time. Again, retroflexion and also other dis- 
placements of the uterus will act as a bar to impregnation, and are 
a frequent source, should impregnation take place, which no 
doubt occasionally does happen, of abortion, but not invariably. 
As to constitutional syphilis being a cause of abortion and pre- 
mature births, etery one connected with a public hospital could not 
fail to have observed it both in the '* east " and in the " west,'* 
and yet this is not always followed by abortion or we should have 
no congenitalsyphilis ; in fact, no hard and fast line can be laid 
down. Dr. Williams could relate a series of cases of displace- 
ments of the uterus where the displacement had been the cause 
of the abortion, but would content himself by stating that he, 
like the author of the paper, had long been in the habit of 
treating retroflexions of the uterus during the early months of 
pregnancy hj the introduction of a Hodge's pessary and leaving 
it in situ until after quickening, or, more properly speaking, until 
the uterus had risen above the brim of the pelvis. He would only 
relate one case, and that a case of retroversion — not retroflexion, 
and would here remark that he considered retroversion a much 
more likely cause of sterility than retroflexion, especially when 
the 08 gets jammed under the pelvis, as in complete retroversion. 
A young woman, married some time without family, was found to 
be suffering from complete retroversion. This was rectified and 
a Hodge's pessary introduced. Soon after she became prejrnant, 
and desired the pessarv might be removed ; this was unwillingly 
done. The uterus fell back into the old position, the patient 
aborting. A pessary was again introduced, and again she became 
pregnant and went the full time, the pessary having been left in 
until after the flfth month of utero-gestation. 

Dr. Barnes assumed that the author of the paper clearly 
meant retroflexion as distinguished from retroversion. His own 
experience entirely confirmed the author's conclusion that retro- 
flexion was a frequent cause of abortion. It had been observed 
by other speakers that retroflexion was a common cause of 
sterility. Both propositions, although seemingly contradictory, 
were undoubtedly true. It was necessary to bear in mind that 



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AS A FEEQUENT CAUSE OF ABORTION. 57^ 

there were two different forms of retroflexion. The first kind he 
belieyed to be congenital, at least it often came under observa- 
tion in joung women who had never borne children, and who 
were suffering from dysmenorrhoea. This form was very common ; 
it was often associated with narrow os externum uteri, and dys- 
menorrhcea and sterility were the consequences. These conse- 
quences were generally only cured by putting the uterus into its 
proper place and dilating the os. The other form was also not 
uncommon. It might be called acquired retroflexion. It arose 
generally afber a labour ; the heavy, imperfectly contracted and 
involved body of the uterus falling back whilst the parts were in 
a state of relaxation. In this case pregnancy would often occur 
and end in abortion. With reference to the suggestion of Dr. 
Tilt that the author might have overlooked inflammation of the 
cervix, or some other complication which might have been the 
cause of the abortion, he would observe that it was hardly pos- 
sible to find a pure case of retroflexion. This displacement 
necessarily induced morbid conditions of tissue, especially en- 
gorgement of the body of the uterus, and dilatation of its cavity. 
These secondary conditions might be concerned in producing the 
abortion, but still the retroflexion was the essential cause. Nor 
could he, Dr. Barnes, assent to the observation of Dr. Bantock,that 
inflammation or abrasion of the cervix uteri was a constant cause 
of sterility. It must be familiar that women frequently conceived 
whilst under treatment for this affection, and that, in fact, they 
often conceived so quickly that they had no chance of getting 
cured. The great remedy for retroflexion was Hodge's pessary. 
He always urged that it should be worn during the early months 
of pregnancy where there was retroflexion, in order to obviate 
abortion. He thought Dr. Phillips' paper would be useful in 
drawing attention to an important cliuicul fact. 

The President had little to add to the excellent remarks which 
had fallen from the last speaker (Dr. Barnes) except to say that 
from the position of the retrofleeted uterus a tendency to 
abortion might be a priori anticipated, for not only was the organ 
exposed to concussion from movements of the body, coitus, &c., 
but, in consequence of the dependent position, there were three 
inches addition to the column of blood, the gravitation of which 
would retard the return into the veins, and thus assist in extra- 
vas<ition and consequent death of the ovum. And, with regard 
to the increased diificulty in the discbarge of the dead ovum 
alluded to by the previous speakers, he could say that, so far as 
his experience went, he had found that in eight cases out of 
ten of abortion, to which he was called in consultation, there was 
a retrofleeted uterus. 

Dr. Phillips said the object of the paper had been fully 
attained in the interesting discussion which had taken place. He 



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58 CASES IN PRACTICE. 

was glad to find that the experience of sereral of the speakers 
agre^ with his own ; and the exoeUent remarks which had fiEdlen 
from Dr. Barnes were an answer to some of the objections raised. 
In reply to Dr. Bantock he said that the term " retroversion*' 
occurred in the paper in quotations from authors, and when 
reference was made to the cases described in the text books of 
retroversion about the fourth month with retention of urine, but 
elsewhere the word " retroflexion" was used, and this last con- 
dition as a frequent cause of abortion was the special subject of 
the paper. While he (Dr. Phillips) believed with Dr. Kasch, 
that some cases of retroflexion- occurred suddenly during preg- 
nancy, yet he thought these cases were few in number, and that 
the explanation oSered by Dr. Tyler Smith was the true one, that 
in the majority of cases the displacement existed before the 
supervention of pregnancy. It was to this latter class, and to its 
treatment, that the paper specially referred ; hence the omission of 
remarks on the treatment of the acute cases by simple ca- 
theterism, &c. He quite agreed with Dr. Bouth that syphilis was 
a frequent cause of abortion, but he had endeavoured, as far as he 
coulcC to exclude this cause and other constitutional causes from 
the cases, upon which the paper was founded ; and in the two 
cases given in detail, no antisyphilitic remedies were given and 
yet the recurrence of abortion was prevented by wearing a 
Hodge's pessary. 



CASES IN PRACTICE. 
By John Bassett^ Esq., 

PB07B880B OF MIDWIFEBY IK QUBEN'S COLLEOB* BIBMINOBAU. 

Accidental hamorrhaffe ; fatal in seven hours, without 
delivery. 

At 2.30 p.m. on the 4th of September, I was requested to' 
visit Mrs. E — , whom I found under the care of my friend Mr. 
Waterson. He informed me that his patient had been in 
her usual health up to 11 a.m., when, on her return from a 
walk, she informed her servant that she felt very unwell, with 
a pain in her stomach. From this time the symptoms grew 
rapidly worse, and when I saw her she was in an extreme 



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CASES IN PRACTICE* 59 

state of collapse. Her features were pinched ; the surface of 
the body was cold ; the pulse scarcely to be felt at the wrist. 
She complained of intense pain and tightness at the scro- 
biculis cordis^ with a feeling of impending suffocation. The 
symptoms were at this time those of internal hsemorrhage, 
but it did not appear quite clear as to where the blood was 
being poured^ since she had arrived at the eighth month of her 
third pregnancy without any unusual signs having manifested 
themselves. There was now no- evidence of uterine action, 
and an examination per vaginam did not detect anything 
unnatural in that quarter. The uterus, as examined through 
the abdominal wall, was of the size corresponding to the 
period stated. 

I visited her again after an interval of two hours, when I 
found most distinct uterine action had set in, and that blood 
had begun to trickle from the vagina. Pressure was now 
applied to the abdomen, the membranes were ruptured, and 
the ergot of rye administered. The collapse was so great 
that this was considered all that it was desirable to do. Time 
did not permit the os to be sufficiently dilated to introduce 
the hand. She died seven hours from the commencement of 
the symptoms, the labour having made no real progress. 

At a post-mortem examination it was found that a portion 
of placenta, about one third, had become detached; this 
part was the seat of disease; the lobes were flattened and 
hardened with a yellow deposit, so that they had not recently 
been the medium of nutrition to the child. The placenta 
was at its most common site ; the other part of it appeared 
quite healthy. The child, which was lying in the first posi- 
tion, was of average size, and fairly nourished. Several large 
coagula of blood lay behind the detached portion of the 
placenta, in a cul-de-sac, which they had formed for them* 
selves by pushing the uterine wall backward. The blood had 
not flowed forward at all, as the membranes over the whole 
of the front of the uterus were in apposition with the uterine 
wall, and were not stained by the haemorrhage. Death 
appeared to have resulted more from shock and pressure than 
from actual loss of blood. 



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60 CASES IN PRACTICE. 



Placenta pravia without hcsmorrhage at the time of delivery. 

So unique a circumstance as the occurrence of placenta 
prsevia without haemorrhage at the time of delivery deserves 
to be placed upon record. On the 28th of May, 1871, I 
attended Mrs. P — , who had previously borne several children. 
She came under observation on the 4th of April preceding, 
for a smart attack of haemorrhage which came on without 
pain or any warning about 4 a.m. It did not return, and in 
a few days she was enabled to resume her household duties. 
Early in the morning of the 13th of April I was again con- 
sulted for a similar attack. An examination externally and 
internally led to a negative result, but from the freedom and 
spontaneity of the haemorrhage it was judged to be due to 
placenta praevia. The patient rapidly recovered from the 
depression, and in a few days I met her walking in the 
street. From this time the haemorrhage did not return. 

On my being summoned to attend her in her confinement 
I found that regular uterine action had been established two 
hours. The os was then dilated to the size of a shilling; the 
placenta could be distinctly felt as far as the finger could 
reach ; there was merely a draining of blood. I decided to 
leave the case to nature, watching for ulterior symptoms. 
Delivery took place in six hours from the time when I first 
saw her, without anything worthy of note transpiring. The 
child, a male, was of fair size, but very thin. The placenta 
was found to be oval in shape. The small end of the oval 
had been over the 08, The lobes of this part had lost their 
soft, spongy character, were firm to the feel, whitish looking; 
only two of them retained their red colour ; they were consoli- 
dated and nearly bloodless. 



Rupture of a varix in the genital organs during pregnancy ; 
syncope ; recovery. 

On the 19th July, 1871, at 10.30 p.m., I was hastily sum- 
moned to attend Mrs. D — , who was said to have been seized 



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CASES IN PRACTICE. 61 

^ith a flooding. On my arrival I found that she had recently 
returned from a walk, during which she had been greatly 
frightened, and this caused her to hurry home. Shortly 
after her clothes were found to be deluged with blood. On 
my arrival she was blanched and faint. The nature of the 
case was at once suspected, from my having recently read in 
the ' Obstetrical Society's Transactions' of a fatal case which 
had occurred in the practice of Mr. Houghton, of Dudley. 
The patient was put carefully in bed ; the external genitals 
were examined, and found to be covered with blood, but no 
haemorrhage was then present, and no open vein could be 
seen. Cold and pressure were employed, and restoratives 
given internally. From this time no untoward symptom 
presented itself; the loss of blood was recovered from slowly. 
The pregnancy, which was approaching the sixth month, was 
not in any way interfered with. 



Destruction of the uterus by a severe labour. 

In June, 1871, I was consulted by Mrs. E — , who fur- 
nished me with the following history of her case. She was 
confined on the 4th of June, 1866, with her first child. For 
several weeks previous to the commencement of labour she 
was unable from her size and weight to take much exercise ; 
the labour set in on the third day before her delivery, by an 
escape of water ; the pains came slowly at first, but subse- 
quently increased in frequency and force, so that they were 
regular and strong on the second day. On the third day the 
pains were less powerful, and she was so exhausted that she 
was scarcely conscious of what took place. The accoucheur 
in attendance called in a friend, who effected the delivery by 
the forceps, of a large male child, which was dead. From this 
time she continued very ill for a month, with pain in the 
abdomen, feverishness, and a copious discharge of matter 
from the vagina. By the end of the third month the dis- 
charge had entirely ceased, and she had regained a fair 
amount of bodily strength. Since this time she has had no 



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62 CASES IN PRACTICE* 

menstrual period, and recently has not been troubled with 
*' the whites." At the times corresponding to the monthly 
period she has pain in the lower part of the abdomen and 
back, a sense of weight and fulness. The pain is sometimes 
severe, amounting to '' spasms/' and not unfrequently termi- 
nates in sickness or diarrhoea, and sometimes in both. At 
the end of twenty- four hours it usually subsides, and nothing 
further is perceived until the next epoch. 

A careful examination of this patient alone, and subse- 
quently assisted by my colleague Mr. Clay, revealed the fact 
that the uterus had been nearly destroyed by sloughing, 
ulceration, and cicatrisation. The speculum revealed the 
upper part of the vagina crossed by white lines, giving it the 
appearance of a cicatrix from a burn. A small nodule of 
reddened tissue, probably part of the cervix, projected beyond 
the white lines for half an inch ; no trace of the os uteri 
could be found, nor was their positive indication as to its 
former site. Mr. Clay thought he could feel the line of the 
fundus through the vaginal wall with his finger, but expressed 
his opinion that a large portion of the body of the uterus had 
been destroyed. The question of aflfording an exit for any 
monthly discharge which the remaining portion of the uterus 
might secrete was talked over, but as we could learn nothing 
as to the whereabouts of the cavity, it was thought better to 
let the case alone. 



I>r. Babkes, in answer to the President's question whether 
others had observed placenta prseyia without hsemorrhage, said he 
had himself seen such cases and had quoted cases of the kind from 
Mercier, Caseaux, and others. They illustrated his theory of the 
physiology of placenta prsBvia. It was one of his positions that 
haDmorrhage was not an absolute necessity when there was 
placenta prsBvia. In the particular case just read, the reason why 
there was no haemorrhage was probably because that part of the 
placenta which came within the lower zone of the uterus had 
tmdergone such alteration of structure that it had ceased to be in 
vascular relation with the uterus, whilst the remaining portion 
being attached to the middle zone did not become separated until 
after the birth of the child. In the case of ** accidental hsemor- 



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CAS£S IN PRACTICE. OO 

rbage/' the flooding might haye been due to the placenta growing 
within the lower zone, and thus being really a case of placenta 
prsvia, a circumstance often overlooked. But since the placenta 
was described as having undergone morbid change, this had pro- 
bably led to its premature detachment. It was, in fact, an 
illustration of what he had long ago pointed out, namely, that 
that fatty degeneration of the placenta was a cause of ** accidental 
haBmorrhage." 

Dr. WiLTSHiBE thought that in the first case narrated the use 
of Dr. Barnes's india-rubber dilator might have been of material 
service. He had found them invaluable in like cases. 



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MARCH 6th, 1872. 

J. Braxton Hicks, M.D., P.B.S. President, in the Chair. 

The following gentlemen were admitted Fellows of the 
Society :— Dr. C. H. Carter, Dr. W. Gardner, Dr. W. Hope, 
Mr. James Lattey, Mr. J. D. Locke, and Mr. J. D. Shapland. 

The following gentlemen were elected Fellows : — George 
Bland, L.B.C.P. Lond. (Macclesfield), Alexander Fergasson, 
F.B.C.S.Edin. (Peebles, N.B), Albert Kisch, M.B.C.S., Wm. 
H. Mondelet, M.D., and George Bigden, M.B.C.S. (Canter- 
bury). 

Dr. A. E. Martin presented the Cephalotribe invented by 
his father. Professor Martin, of Berlin, and said : — 

My father, an honorary fellow of your illustrious Society, 
desires me to present to you this specimen of his cephalotribe. 
The instrument was exhibited at your conyersazione in 1866, 
but as it is neither mentioned in the catalogue nor contained 
in your collection, although it has been proved during a long 
experience at Berlin to be a valuable instrument, my father 
begs you to accept it as an addition to your collection. 

The cephalotribe is composed of two blades joined by an 
English lock. The whole instrument is 43 centimetres long, 
the handles measuring 19 centimetres, the blades 24 centi- 
metres. The handles are covered with wood, and have trans- 
verse grooves for facilitating traction. The left carries the 
screw which approximates the blades. 

These blades have double curves : that for the pelvis 

VOL. xiv. 5 



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66 FCETUS ENCLOSED IN A PERFECT SAC. 

measuring 9 centimetres^ that for the head 3*8 cc. The 
broadest portion of the blades measures 3*6 cc. Both are 
fenestrated^ the fenestrse measuring 2 cc. The upper 
ends touch over an extent of 2*4 cc. The blades are 
carefully rounded and sufficiently strong, though not too 
heavy. 



We always perforate before applying the instrument, and 
it has neither failed in compression nor in traction when its 
use has been indicated. 

We recommend the instrument to your attention. 

The Fbesident said that the account given of the use of Dr. 
Martin's Cephalotribe showed conclusively that a tractor instru- 
ment was practically of great use in all cases, and he had no 
doubt that ultimately it would, in general practice, supersede 
almost entirely other instruments, after perforation, in delivering 
the head. 



The Peesident showed a specimen of Pibro-cystic Disease 
of the Uterus, the precise relations of which were doubtful. 
The specimen was referred to a committee consisting of Dr. 
Madge, Dr. Bantock, and Mr. Spencer Wells. 

Dr. Heywood Smith exhibited a preparation of a foetus 
at about the fourth month completely enclosed in a 
perfect sac, through the wall of which^ at about one inch and 



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CANCER OP CERVIX UTERI. 67 

a half from its abdominal attachment^ the cord passed to 
the placenta, which was separate, and had the remains of the 
membranes as usual at its edge. 

He said that as attention had been drawn in the ' British 
Medical Journal ' to the subject of " false waters '' indicating a 
separate fluid-containing cavity external to the amnion, or its 
inner layer, but within the chorion, he thought it would be 
not uninteresting to show the specimen, where the inner 
membrane, whatever it was, had shelled out. 

The President requested Dr. Heywood Smith to examine 
the membranes and report to the Society as to their nature. 

Dr. Heywood Smith next exhibited the uterus of a patient 
that had died four days after delivery of a foetus at about 
5 months^ of secondary post-partum haemorrhage, the cervix 
uteri having beea the subject of cancer. 

The patient was 39 ; married sixteen years, had had eight 
children, no abortions, and had been admitted as out-patient 
at the Hospital for Women, for pain in the left inguinal 
region, with a pale and oflfensive discharge. She believed 
herself to be about three months pregnant, but the physical 
signs were rather those of nearer six months. A vaginal 
examination revealed a growth about the size of a small 
orange filling the vagina, growing from the anterior lip of the 
cervix uteri ; the posterior lip was small and not entirely free 
from induration. She was admitted as in-patient, in about a 
fortnight's time, on December 2nd, for an attack of flooding, 
from 11 p.m. the previous day till 6 a.m. She was pretty well 
till the 12th, when, having had uterine pains all the previous 
night, the uterus was lower. In the afternoon, with some diffi- 
culty, because of the growth partly filling the vagina, the os 
uteri was slowly dilated under chloroform, the posterior lip 
yielding more than might have been expected, one foot brought 
down, and the foetus delivered alive ; in the delivery of the head, 
the carcinomatous mass was protruded from the vulva, and, 
as was thought best. Dr. Heywood Smith removed it with the 
ecraseur, as also a nodule on the posterior lip. The uterus con- 



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68 ANGULAR SCISSORS. 

tracted well ; an ergotine pessary was introduced. The patient 
did well till the third day^ when at 4.45 p.m. haemorrhage 
came on seyerely ; the pulse was reduced to a mere thread. 
The next day^ at exactly the same time^ it recurred^ though not 
to so great an extent : but as flooding took place again at 6 
p.m.^ though iron was injected and the vagina plugged^ she 
never rallied, but died at 12.30. The case was brought forward 
as it opened up a point for discussion, viz. which was the better 
practice in cases of severe cancer of the cervix uteri com- 
plicating pregnancy^ whether to induce premature labour to 
lessen the risk of the mother, or, if she is advanced, at all 
events to save the child's life by letting her go her full time, 
and if the disease precludes delivery per vias naturales, to 
perform the Csesarian section. 

Dr. Phillips said that each ease must be judged of on its own 
merits, but upon the whole he thought the former line of 
practice was the better one. He referred to two cases in which, 
notwithstanding considerable malignant infiltration of the cervix 
uteri, very slow dilatation by the elastic bags enabled delivery to 
be accomplished with a successful issue to the mother, as far as 
the labour was concerned. 

Dr. Heywood Smith exhibited a new instrument which 
he called Angular Scissors. When they are straight they 
constitute a pair of scissors similar to those of Marion Sims. 
They have, however, this advantage, that the small scissors 
can be bent at any angle with the handles up to nearly a 
right angle. To acomplish this it has been necessary to 
make on each leg of the scissors a complicated joint, con- 
sisting of three separate movements within the space of 
half an inch. The first of these is the ordinary pivot-joint 
to connect the scissors with the handles, and is the only 
joint in the legs (besides the central pivots) used when the 
scissors are straight. Next comes the hinge-joint, by which 
the scissors are bent at the required angle to the handles on 
either side. Then between the pivot joint and the handles 
is inserted a rotatory joint; for when the scissors are bent 
at an angle, and opened rather widely, there is a strain on 



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ANGULAR SCISSORS. 



69 



the hinge-joint that is not altogether compensated by the 
pivot-joint, but the rotatory-joint enables the legs of the 
small scissors to open with greater ease and without any 
strain. The reason for the necessity of this joint is thus 
explained. The short legs of the primary scissors (if they 
might be so called) on being opened describe arcs of a circle, 
as would also the legs of the secondary scissors, were they 
not bound to the primary scissors, and did not a compen- 
sation take place by the main pivots approximating. But 
where the scissors are bent at e ff, in right angle with the 




handles, the legs of the handles describe arcs in one plane, 
and the legs of the scissors describe arcs at right angles to 
the handles. But as these two members are bound together 
by the pivot while traversing arcs in different planes, it is 
necessary that one pair should rotate more or less at the 
point of connection of the two movements, hence the inser- 
tion of the rotatory-joint. One of the blades is prolonged 
into a director-point, in front of the other which has a blunt 
end. The advantage of the director-point is this : in using 



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70 EXTRA-UTEKINE FCETATION. 

ordinary scissors by the touch the finger has to guide and 
guard two separate points^ a proceeding that requires very 
great care^ and even the adjacent parts may be wounded, an 
accident that might also happen should the necessity arise of 
dividing a rigid os uteri over a presenting scalp ; but with 
the director-point, which is made flat to facilitate its in- 
troduction under any edge of tissue, one blade is easily 
passed and when its position is determined, then the other 
blade may be opened without any risk. Inasmuch as the 
scissors may be bent on either side they will be found 
useful in dividing the cervix uteri in any position both on 
the right and left side. 

The following report on Dr. Meadows^ case of Extra- 
Uterine Poetation was then read : 

There is little or nothing more to add to the description 
already given of the external appearances of the specimen 
than has been given, and depicted in the drawing by Dr. 
Meadows. 

The uterus, about three and a half inches in length, is of 
normal appearance as regards the left side, the Fallopian 
tube penetrating the uterus in its usual position near the 
fundus. The sound passes up the cavity to the fundus 
readily to the extent of three inches showing no unnatural 
distortion. The right Fallopian tube is almost lost in the 
mass of hypertrophied broad ligament. The connexions of 
the broad ligament of this side are much nearer the neck of 
the uterus than on the other and much more so than usual. 
After a very careful investigation the Fallopian tube was 
found imbedded in the broad ligament, and was seen to 
penetrate the external wall of the uterus nearly an inch below 
the fundus, and to run up the muscttlar structure of the wall 
several lines before penetrating into the cavity. 

Taking into consideration the natural relations of the left 
side of the uterus as also of the cavity, we are of opinion that 
the relations of the right Fallopian tube with the uterus is 
not induced, but is a congenital malformation, and that in 
all probability the non-passage of the ovum was due to this 
malposition of the tube. 



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ON THE PELVIS COLLECTION AND ON PELVIMETRY^ ETC. 71 

We are further confirmed in this opinion by the similarity 
the specimen under consideration bears to one depicted by 
Jahn, " Dissertatio de utero retroverso/' 1787, in SchegeFs 
*' Sylloge Operum Minorum/' a drawing of which may be 
seen in the third volume of the Society's 'Transactions/ 
p. 289, forwarded by one of the reporters. Dr. Aveling. 

A. Wynn Williams, 
J. H. Aveling, 
Alfred Meadows. 



REMARKS ON THE PELVIS COLLECTION AND 
ON PELVIMETRY IN THE ROYAL UNIVER- 
SITY MATERNITY OF BERLIN. 

By A, E. Martin, M.D., of Berlin. 

The collection of pelves in the Museum of the Royal 
University Maternity of Berlin contains mostly pelves of 
women whose cases have been observed during life in that 
institution. A few pelves of different races have been 
obtained firom various countries. There are also a few casts 
illustrating varieties of forms not observed till now in the 
Maternity. 

For some time all pelves have been put up as natural 
preparations, articulated specimens soon becoming useless 
for scientific purposes. The pelves are classified according 
to the plan of Professor Martin's ' Hand Atlas.' 

The first class comprises normal pelves, and is arranged in 
three divisions : 

(a) Adult pelves whose measurements fluctuate within 



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72 ON THE PELVIS COLLECTION AND ON PELVIMETRY 

the normal limits. This division comprises also the few male 
pelves that are in the collection. 

(b) Pelves showing gradations from the earliest foetal state 
up to adult age. To this division will shortly be added 
specimens of foetal heads at all ages. 

{c) Pelves of various races. Some of these have already 
been described by Dr. Carl Martin in his paper "Ueber 
Bacenbecken.'' 

The second class comprises pelves whose measurements 
exceed the physiological limits. We subdivide them into — 

(a) Pelves whose measurements are excessive in every 
direction^ viz., 

Conjugata vera exceeding 120 mm.. 
Transverse diameter exceeding 140 mm., 
and, proving their regularity, the difference of the oblique 
diameters must not exceed 10 mm., 

ip) Measurements of conjugata vera alone excessive, viz., 
Conjugata vera exceeding 125 mm.. 
Transverse diameter leas than 140 mm.. 
Difference between the oblique diameters must not exceed 
10 mm., 

{c) Measurements of tranverse diameter alone excessive, viz., 
Conjugata vera leas than 125 mm. 
Transverse diameter more than 140 mm. 
Difference between the oblique diameters less than 10 mm. 

The third class comprises pelves sequabiliter justo minor, 
i.e. pelves whose measurements are equally diminished in 
every direction or approximatively so. 

Among these we distinguish the following pelves : 
(a) Special diminution of brim measurements ; viz., 
Conjugata vera less than 110 mm. 
Transverse diameter less than 125 mm. 
Tubera ischise more than 100 mm. 
{b) Spedaldiminutionof outlet measurements; viz., 
Conjugata vera less than 110 mm. 
Transverse diameter less than 125 mm. 
Tubera ischiae less than 100 mm. 
The fourth, fifth and sixth classes comprise pelves with a 



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IN THE ROYAL UNIVERSITY MATERNITY OF BERLIN. 73 

special diminution of one diameter in an excessive degree^ 
the other diameters being seldom normal. 

In pelves of the fourth class the measurements of the 
conjugaia vera are specially diminished in consequence either 
of rachitis or of spondylolisthesis. This class is subdivided 
as follows : 

(a) Medium diminution^ viz.^ 

Conjugata vera under 105 mm.^ but over 80 mm. 

{b) Excessive diminution^ viz.^ 
Conjugata vera under 80 mm. 

In both of these subdivisions the transverse diameter 
exceeds 125 mm. ; the difference of the oblique diameters is 
less than 10 mm. 

In pelves of the fifth class the measurements of the trans- 
verse diameter are specially diminished. 

It has been found impossible to make the same objective 
subdivision in this as in the other classes, as some of the 
pelves are not amenable to similar rules. Pelves of this class 
are therefore arranged as follows : 

(a) Osteomalacic. 

(b) Pseudo-osteo-malacic : 

(c) Synosotical^ i, e. in which the transverse diameter is 
diminished by ankylosis of both sacro-iliac synchondoses. 

The sixth class comprises pelves having special diminution 
of one oblique diameter. We subdivide them in — 

{a) Pelves with ankylosis of one sacro-iliac synchondrosis 
(Naegele pelves). 

(6) Pelves with deviation of sacrum to one or other side. 
This is mostly occasioned by rachitis or by scoliosis of the 
lumbar vertebra. 

The seventh class comprises pelves not distinguished by 
extreme diminution of the measurementSj but by exostoses 
narrowing the calibre of the pelves. 

These pelves belong to the most fatal form of deviations ; 
the diagnosis of them being very difficult, if not impossible, 
and their treatment almost hopeless. 

They are subdivided as follows: 

(a) The edges of the os pubis are sharpened; generally 



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74 ON THE PELVIS COLLECTION AND ON FELVIMETKY 

the tubera of the ilio-pectineal line are pointed and project 
into the brim. 

(6) An exostosis covers the sacro-iliac synchondrosis either 
in part or wholly. 

(c) Under this head are comprised all other bony tumours 
of the pelves. 

The foregoing is the classification of the Berlin collection. 
The classification according to supposed causation has been 
renounced as not affording a means for comprehending the 
collection at a glance^ and besides, such a classific^ition would 
not be scientific. For instance, if we make a classification 
comprising all deviations depending on rickets, such classifi- 
cation will comprise nearly all the abnormal forms just 
referred to in that we have adopted. We know that short- 
ness of the conjugata vera is the most common conse- 
quence of rickets. The reason is that the conjugata vera - 
depends on the normal developing of the iliac bones, and 
rickets being most common in the age of this development, 
viz. first to fourth year. But besides this deviation, we 
know that rickets often produces other varieties, or the 
pseudo-osteo-malacic pelves, as the pseudo-Naegele pelves, 
and even pelves ubique justo minores, when a general 
hindrance in the development of the pelves is the result 
of the rachitical affection. How should all these different 
forms be classified under one head? 

Or to mention another objection, how would it be possible 
to classify those pelves in which an ankylosis of one or both 
sacro-iliac synchondroses has caused the deviation ? Is the 
cause of that ankylosis a vitium primse formationis or an 
inflammation of the synchondroses ? On this point we do not 
yet agree; and what should be done when we find out that 
sometimes the former, sometimes the latter, is the cause? 
We are convinced that the only scientific and reliable 
classification of pelves collections, which can be made, is 
one based not upon causation, but upon the deformities 
themselves. 

The basis of measurements in the university of Berlin is that 
afforded by the tables of Dr. Carl Martin in his ' Durchsch- 



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IN THE ROTAL UNIVERSITY MATERNITY OF BERLIN. 75 

nitdiche gebnrtshiilfliche und gynsekologische Maasse und 
gewichte/ etc These measarements were taken from living 
women in great numbers^ and from many of the jsame persons 
after death. The tables contain the measurements of adult 
women during life and those of prepared pelves^ the 
measurements and weights of new born infants and the 
placenta^ and a comparison of the ancient German measuring 
and weighing system with the decimal system. 

The measurements appear to be excessive according to 
recent measurements taken in other parts of Germany. This 
is probably owing to the latter having been taken from a 
smaller number of women, from corpses or from prepared 
pelves. The experience of many years has proved Carl 
Martin's average measurements to be very exact for Berlin 
and its neighbourhood. 

The practical worth of the tables has been acknowledged 
by their having been inserted in the ' Preussischer Medi- 
cinal Kalender^' which is a diary for physicians and surgeons 
based on official data, and largely used by German practi- 
tioners. 

The measurements are given in metres, as this system of 
measurement has long been adopted in Germany for scien- 
tific purposes and of late — ^the present year — for all purposes 
of ordinary life. All the neighbouring countries use the 
metrical system for scientific purposes, and we trust our 
illustrious brethren of England will soon follow our ex- 
ample in order to facilitate the communication of scientific 
ideas. 

Before referring to the specimens illustrating the various 
classes which I have with me^ allow me to explain the manner 
in which we take our measurements in Berlin. 

Every woman requiring the assistance of the institution, 
either at home or at the clinic, is measured in the following 
manner : 

The patient is undressed and placed on her back, measure- 
ments are then made of the distances between the spinous 
processes and cristse of the ilium. This is done with the 
portable pelvimeter which I now exhibit. 



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76 ON THE PELVIS COLLECTION AND ON PELVIMETRY 

The points of the instrument are taken betw^een the thumb 
and the forefinger of each hand^ and placed upon the spinous 
processes outside the insertion of the sartorius muscle on 
either side. 

The distance is easily read on the indicating scale. In 
measuring the cristse ilii the points are placed upon the 
widest parts of the bones which are usually found to be about 
two inches behind the spinous processes. We then proceed 
downwards to the trochanters whose measurement is read 
off in like manner. The trochanters are usually to be felt 
even through well developed panniculus adiposus. This done^ 
the women are placed on one side^ generally in the first place 
on the left. We then measure the conjugata externa^ which 
we find between the spinous process of the last lumbar 
vertebra and the upper edge of the symphysis pubes. In the 
same position we measure the left external oblique diameter^ 
which is taken from the posterior superior spine of the left 
ilium to the anterior superior spine of the right ilium. 
Generally the posterior superior spine is easily found because 
there we find in almost all women a slight depression formed 
by the adherence of the skin to the fasciae beneath. This 
depression was well known to the ancient artists^ who imitated 
it in their statues and torso^s of beauties^ especially those of 
Venus in which, it is to be seen in all museums and collec- 
tions. This depression enables us also to find the spinous 
process of the last lumbar vertebra, which is about an inch 
and a half above the level, and midway between the two 
depressions already referred to. After this the woman is 
turned to the other side, and we proceed to take the corre- 
sponding measurements. Should there be any doubt about 
the conjugata vera it is again measured. This done, the woman 
is placed on her back and the circumference of the pelves is 
taken by placing the tape just under the crest of the 
ilium. 

The conjugata diagonalis is then measured by the finger in 
the vagina. If possible the index and middle fingers of the 
left hand are introduced and the sacral promontory is en- 
deavoured to be reached. If it cannot be touched or if the 



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IN THE ROYAL UNIVERSITY MATERNITY OF BERLIN. 11 

foetal head has already passed it^ we are sure that the con- 
jugata vera is of sufficient width. When we can touch the 
promontory^ we mark the point of the pubic arch on the 
left index finger with the nail of the right. On withdrawing 
the fingers the measurements can easily be obtained by the 
pelvimeter. 

All these measurements are then reduced to the standard 
given by Dr. Carl Martin in the above-named tables. 

The general condition of the bony pelvis is found on 
examining for the foetal presentation. 

Some object to our external measurements that they 
cannot give an accurate idea of the brim. This question 
can only be decided by experience^ and our experience has 
proved favorable to our measurements^ although we know 
well that the relation betireen the internal and the external 
measurements fluctuate within certain linuts. 

Another objection I have to mention against our pelvi- 
metry is that it is not applicable in private practice. To this 
we partially assent ; but the experience gained in our lying- 
in houses and poli-clinic^ in which the women do not dare to 
refuse^ enables us to judge by a superficial manual examina- 
tion whether or no there is such an amount of deviation as 
to call for a more careful and exhaustive measuring^ in which 
case no woman would refuse to submit to that which is ob- 
viously for her own benefit^ and which causes her so little . 
inconvenience. 

Others object that our measurements are incomplete as 
long as we are unable to measure the foetal head. This 
cannot be denied^ and we endeavour to avoid this difficulty 
by the knowledge experience has given us as yet. We know 
that first children are smaller than subsequent ones, that the 
cranial bones of the foetus become harder each day towards 
termination of pregnancy^ the sutures become firmer^ and the 
moulding of the head more difficulty &c. All these points 
are to be remembered in cases of pelvic deviation. It is 
astonishing too how well the foetus supports compression of 
the head^ even when this is so great as to cause 'marked 
depression of the bones. And we hope that the ingenuity 



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78 ON THB PELVIS COLLECTION AND OX PELVIMETRY, ETC. 

of some one will furnish us with the means of measuring the 
foetal head in utero. 

We also measure all foetal heads directly after de- 
livery. Allow me to tell you how we do this with the 
pelvimeter. We take first the frontal or anterior transverse 
diameter by putting the points of the instrument on the ends 
of the coronal suture. The points are then put on the 
parietal protuberances to measure the posterior diameter. 
The antero-posterior diameter we measure from the frontal 
sinuses to the tuber of the occiput. We then measure the 
distance between the chin and the posterior fontanelle which 
we call the long oblique diameter. The short oblique 
diameter is measured between the frontal sinuses and the 
insertion of the ligamentum nuchse. The anterior level 
is a measurement taken from the mastoid process to the 
frontal sinuses, the posterior level from the mastoid process 
to the occipital protuberance. Measuring these levels we 
take the mastoid process in place of the anterior edge of 
the foramen magnum, which is the pivot of the head's move- 
ments forward and backward. The mastoid processes in- 
deed well answering to this edge in foetal heads. 

These two levels are of the highest importance in the 
mechanism of parturition and especially in the genesis of face 
presentation. Lastly, we take the circumference of the head 
• at the point of greatest measurement. 

In illustration of the foregoing remarks permit me to 
submit to you some photographs of interesting pelves and a 
few foetal heads. I have brought no casts of pelves as you 
invited us to do, being desirous of learning your wishes and 
ideas before having them made. The photographs will, I 
trust, enable you to form conclusions as to the pelves of 
which you would like to have casts or models made. 

The photographs which present different views are stereo- 
scopic, and convey a plastic idea of the pelves themselves. 
To all the photographs I have appended the various measure- 
ments, and to most of them an account of the circumstances 
of each case. 

These accounts I have translated with the kind aid of the 



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FIBRO-CYSTIC DISEASE OF UTERUS AND OVARIES. 79 

excellent Secretary of your Pelvis Committee, Dr. Alfred 
Wiltshire. 

I hope these remarks may be found worthy of your atten- 
tion, and I beg to thank you for the courtesy and kindness 
with which you have listened to me. 

The cordial thanks of the Society were unanimously given 
to Dr. Martin for his valuable donation of photographs. 



FIBROCYSTIC DISEASE OP UTERUS AND BOTH 
OVARIES; EXTIRPATION OF THE WHOLE; 
RECOVERY. 

By Thomas Bryant, F.R.C.S., 

BITBGBON TO Oirr'B HOSPITAL. 

Miss M — ^ set. 26^ a young unmarried lady^ residing in 
Surrey, consulted me in April, 1871, on the recommenda- 
tion of Dr. Oldham, for an abdominal tumour. She had 
been under Dr. Oldham's observation for some time> and he 
had watched the development of what he believed to be an 
ovarian tumour until he thought it was fitted for operation. 
In his note to me Dr. Oldham added, '' the uterus is too 
forward, but there is no pelvic swelling behind it ; upon the 
whole it is a favorable case.'' 

The young lady was in good health and had a large abdo- 
minal tumour ; she said it had been growing for three years, its 
growth having been gradual, although for the last six 
months it had been more rapid. She was about as large as 
a woman at her full term of pregnancy. The catamenia had 
been regular. The tumour was moveable but always profuse, 
and appeared polycystic, fluctuation in parts existing. 

On May 19th the operation was performed for its removal, 
Drs. Oldham, Phillips, and Waterworth assisting. A long 



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80 FIBRO-CYSTIC DISEASE OF UTERUS AND OVARIES. 

incision was made, and directly it was made the uterine 
nature of the growth was recognised by its vascular appear- 
ance. There were no adhesions^ some little ascitic fluid 
existed. The tumour on examination was clearly uterine^ 
both ovaries were about the size of walnuts from poly-cystic 
disease. The broad ligaments were then secured separately 
and the uterus at its neck ligatured in halves. Not feeling 
confident about the ligatures arresting bleeding, a good 
strong clamp was put in and the tumour excised. No 
bleeding took place. The wound was then brought together 
and a morphia suppository given. 

The patient passed a quiet nighty not having been troubled 
with any sickness ; she was free from pain. The suppository 
was ordered twice a day. Milk diet allowed. 

A daily report is unnecessary^ everything went on so well. 
On the fourth day the sutures were removed. On the twenty- 
fourth and twenty-fifth day some little diarrhoea gave cause 
for anxiety^ but this soon subsided ; it was probably caused 
by some ice cream she had taken. 

On June 2nd^ or fourteenth day, the clamp sloughed off^ 
the wound having nearly healed. In another week all the 
parts had united. At the end of the month she was 
up and about, and at the present time she is well in all 
respects. 

The tumour on removal weighed eight pounds and a half. 
The fluid that ran from it on reaching a section coagulated 
as it cooled. Half of the growth is at the College of 
Surgeons, the other in our Museum at Guy's. 



Report on Uterine Fibro-cystic TSimour. 

The portions of tumour given to me were as follows : 

1. A part with all the usual characters macro- and micro- 
scopic of uterine fibroid or myo-fibroma. 

2. Another part which had irregular cystic spaces in the 
same kind of tissue ; the cysts wearing the appearance of 
casual collections of liquid in the spaces of the tissue. 



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FIBRO-CYSTIC DISEASE OF UTERUS AND OVARIES. 81 

Under the microscope this showed the same structure as the 
other^ the fibrous element, however, preponderating ; there 
were also here many small collections of nucleated fibres, the 
nuclei small, this apparently representing the younger 
growth of the tumour. The formation of the cyst was well 
shown to be due to fatty disintegration of the fibrous tissue, 
with accompanying oedema of certain patches which thus 
took the form of gaps in the tumour filled with fluid. These 
characters correspond with those of *' fibro-cystic tumours of 
the uterus.'^ 

8. The ovary showed the same states very beautifully, a 
part in the middle of the ovary showing early fibro-cystic 
change very obviously ; the cysts here being quite different 
from those in the surface of the ovary, which were evidently 
Graafian follicles. 

W. MoxoN, 

Guy^s Hospital. 

Report on Fibro-Myoma of Uterus. 

The mass consists of half the uterus and its contained 
tumour. The outer surface is covered by a layer of perito- 
neum, and at its upper part is seen a portion of the broad 
ligament. Surrounding the tumour is a much hypertrophied 
uterine wall which averages an inch in thickness^ and is in 
some places even more than this. The muscle itself is 
apparently normal save for the hypertrophy. Within this is 
a large mass which fills the entire cavity of the uterus. 
It can be separated at places from the muscular wall, but 
no distinct traces of mucous membrane or glands are 
anywhere visible. 

The growth consists of isolated masses of solid growth, 
between which are large tracts of honeycomb, ragged-looking 
areolar tissue, in rather thick shreds. Histologically the 
solid growth consists of fibrous and organic muscular tissue, 
while the areolar material between these is made up partly 
of connective and partly of white fibrous structure. 

At first sight the general appearance of the tumour seemed 

VOL. XIV. 6 



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82 FIBRO-CYSTIC DISEASE OF UTERUS AND OVARIES. 

to indicate a true cystic disease^ thafc is to say^ a disease of 
which cyst with, distinct walls and epithelial lining fonn a 
part; this^ however^ was not so^ and the cystic appearance 
was merely due to an infiltration and separation of the fibres 
of connective between the large myomatous tumours. 
James P. Goodhart, 

Royal College of Surgeons. 

Remarks. — This case scarcely needs any comments. It 
was looked upon as ovarian &om the firsts no suspicion of its 
being anything else having ever rested in Dr. Oldham's mind^ 
and the patient being so young and single prevented such a 
careful pelvic examination being made as would otherwise 
have been done. I accepted the diagnosis upon Dr. Oldham's 
authority^ no symptoms being present to excite doubt. Had 
the diagnosis been made probably no better operation could 
have been performed. 

The success of the case was most gratifying. 

I may add that this is the fourth case in which I have 
removed the uterus for fibrous or fibro-cystic growths, but 
the first in which success followed. In two death followed 
within twenty-four hours from haemorrhage ; bleeding having 
taken place in one from a large pelvic vein which was split 
at the time of the operation ; in the second from some un- 
known cause ; in the third case no bleeding complicated the 
operation^ and a tumour upwards of twenty pounds in weight 
was taken away, the patient dying thirty-four hours after 
the operation, somewhat suddenly, apparently from the shock 
of early peritonitis or clot in the right side of the heart. 

Dr. Baittook complimented Mr. Bryant on the success of bis 
operation, a result so rare in this important operation. And he 
laid stress on the importance of the use of the uterine sound in 
the diagnosis of tumours of the pelvic organs, stating that in 
nineteen out of twenty cases this incident alone would decide 
the question as to the uterine or ovarian origin of the disease. 

The Fbebidevt remarked that the sound is not always 
reliable, as was shown in one of the cases mentioned by Mr. 
Bryant, which was recommended for operation by himself. In 
this case chloroform was given to explore the uterus. The sound 



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PIBRO-CYSTIC DISEASE OF UTERUS AND OVARIES. 83 

passed the usual length. As there was no reason to suspect 
uterine tumour, and as she was very distended, she was opjerated 
upon. When the tumour was found to be uterine it was 
removed with great skill, the cervix tied and the rest of uterus 
removed. It was then found that a pressure of part of the 
tumour had caused adhesion of the walls of cavity, above which 
menses had been retained in a cavity four or five inches beyond 
the adhesion. 

Mr. Sfekoeb Wells said that when there was a great pre- 
ponderance of the solid over the fluid portions of a tumour, that 
tumour was more likely to be uterine than ovarian. He had 
also found the uterine cavity of normal length in some cases of 
large fibroids, and in other cases such distortion that a metal 
sound could not be passed, although an elastic bougie would 
sometimes follow a tortuous canal. He had seen the uterine 
cavity elongated to seven inches by adhesion to an ovarian cyst. 
In many cases complete diagnosis was impossible without 
explanatory puncture or incision. He had only removed the 
enlarged uterus and both ovaries once, but he had removed very 
large fibroid outgrowths from the uterus, with more or less of 
the part of the uterus with which they were connected, alone or 
with one attached ovary. One case was completely successful, 
the fundus uteri having been transfixed by large harelip pins 
which served to keep the part of the uterus included in the 
ligature behind the pms outside the abdominal waU. There was 
some bleeding when the pins and ligature separated, but the 
patient is now in perfect health, menstruating regularly. In 
another case the patient was almost well, when more than a 
month after operation pysamic pneumonia proved fatal ; the cause 
having been an abscess in the abdominal wall, the intra-peritoneal 
conditions being quite satisfactory. In only one case was death 
due to hsBmorrhage, and there he had enucleated a large tumour 
after cutting into the substance of the uterus, ite hardly under- 
stood why these operations were not as successful as ovariotomy, 
and hoped that when the details of the different proceedings are 
better learnt success would increase. In answer to a question 
from Mr. Bryant, Mr. Wells said he thought the best way of 
securing the broad ligaments was by ligature. 



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84 THE SPONGE TENT IN THE TREATMENT OP 



ON THE TREATMENT OP CERTAIN FORMS OP 
MENORRHAGIA AND UTERINE HiEMORRHAGE 
BY MEANS OP THE SPONGE TENT, WITH 
SPECIAL REFERENCE TO THEIR OCCURRENCE 
IN WOMEN RESIDING IN TROPICAL CLL 
MATES. 

By Geo. Granville Bantock, M.D., &c., 

FHT8ICIAK TO THB BAHASITAN FBBB HOSPITAL. 

So much prominence has been given of late^ to the use of 
sea- tangle tent in uterine therapeutics^ though chiefly as an aid 
in diagnosis/ tending to the neglect of its elder brother the 
sponge tent^ that I am induced to recall attention to the use 
of the latter, and to point out its superiority in the treatment 
of certain diseases of the uterus. I do not, for one moment, 
wish to cast discredit on the former, but to endeavour to 
limit its use to appropriate cases by defining some at least, 
of those in which the sponge tent yields better results. For 
the purposes of dilatation simply I desire no better agent than 
the tangle tent, but as a remedial agent it is far inferior to the 
sponge. I express this opinion as the result of experience. 
But my object is not to enter on a discussion of the com- 
parative merits of the two. I content myself with the limits 
imposed by the heading of this paper. 

Before proceeding, however, to record the cases which 
illustrate the subject I may be permitted to ask the question — 
What is a sponge tent ? This may appear to many to be a 
trivial question, but I can assure them, if such there be, that 
it is an important one, and that much depends upon its right 
solution. There are at the present time, in the market, 
specimens, which, though in outward form they are very 
elegant, have no claim to the name of sponge tent except from 
the fact that they are seen to be made up of a piece, or pieces 

1 See paper by Dr. J. Braxton Hicks on •* Sea Tangle Tents," * Practitioner/ 
vol. iii. 



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MBNORRHAOIA AND UTERINE HEMORRHAGE. 85 

of sponge^ and whose use tends only to bring discredit on the 
instrument. Not long ago I introduced one of these into the 
uterus of a patient and I took the precaution to retain it in 
sM for several minutes, and to enjoin perfect quietude for an 
hour and a half. My injunctions as to rest were strictly 
obeyed, and water was freely used to ensure full dilatation. 
Nevertheless, twenty -four hours after, I had the mortification 
of finding that not only had the tent slipped into the vagina, 
but that it was scarcely larger than when first introduced. 
In view of such a circumstance I may be excused for shortly 
entering on the subject of their manufacture. 

In his original memoir on the " Detection and Treatment 
of Intra-uterine Polypi'' (published at p. 122 of his collected 
works by Drs. Priestley and Storer) the late Sir J. Y. Simp- 
son recommended that the sponge should be steeped in a 
solution of gum previous to compression ; but the editors 
were careful to append a note to the effect that experience had 
proved this to be unnecessary. This appears to have been 
overlooked by subsequent writers; for Dr. Black, in the 
recently issued volume of the same author adheres strictly 
to the original memoir. Dr. Marion Sims, admirable 
though his directions in other respects are, commits, what 
appears to me, a greater mistake in recommending that the 
sponge should be '^ thoroughly saturated with a thick mucilage 
of gum arabic.'' I have used tents apparently made in this 
way and have as often been disappointed with the results. 
The tent, when fully dilated, presents somewhat the 
appearance of a lump of jelly ; the gum forms a covering to 
the sponge and fills up the interspaces or canals, and this 
effectually prevents that action which is one of the principal 
objects, as will be hereafter explained. Good sound sponge 
of medium texture requires no addition of gum in the manu- 
facture of tents of all sizes. The fine and close Turkey sponge, 
as well as the '^honeycomb " sponge, is not suitable for the pur- 
pose, the former being deficient in resiliency and the latter in 
power. The only disadvantage attending the use of sponge 
tents made in the way recommended, is the readiness with 
which they absorb moisture. This is best met by carefully 



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86 THE SPONGE TENT IN THE TREATMENT OF 

selecting a tent that will readily enter the cervical canal^ and 
in some cases^ such as flexions and versions^ by using a 
suitable speculum, and fixing the uterus by means of Sims' 
hookj and, if necessary, straightening the organ. Whether 
a speculum be used or not it is necessary that the tent be 
covered with a thin coating of a mixture of wax and lard. I 
use the proportions of one of wax to three of lard . This coating 
should not cover more than half the sponge. Of late I have 
been in the habit of moistening the sponge, previous to com- 
pression with a watery solution of carbolic acid one in twenty, 
and I am satisfied that it prevents, in great measure, the very 
unpleasant smell which otherwise always attends the use of 
the sponge tent, 

I have thought it quite unnecessary to describe the exact 
process of manufacture seeing that as it has been so 
graphically done both by Simpson and Sims, every one must 
be presumed to be acquainted with it. 

I pass to the more immediate subject of this paper, viz., the 
treatment of certain forms of menorrhagia and uterine 
haemorrhage by means of the sponge tent. The following 
cases illustrate the subject : 

Case 1. — Mrs. C — , set. 30, mother of six children, was 
married at the age of 18, a year after her arrival in India. 
Four months after the birth of her second child she began to 
sufier from menorrhagia accompanied by great disturbance of 
the digestive system. She bore four children more, and the 
menorrhagia increased pari passu, so that at last she was 
compelled to leave the country. Several of her labours were 
accompanied by post-partum haemorrhage, especially the last. 
The periods recurred with tolerable regularity between the 
third and fourth week, but the quantity was so excessive that 
a fatal result was more than once apprehended. Ice and all the 
usual haemostatic remedies were of no avail. She came home 
by the Cape of Good Hope in a sailing vessel, and such were 
the beneficial efiects of the long sea voyage that the menor- 
rhagia ceased. Not so the derangement of the digestive 
system. Soon after her return to this country, and after being 



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MBNORRHAGIA AND UTE&INE HEMORRHAGE. 87 

for some time under the treatment of Sir James Simpson, 
she again became pregnant and was delivered at full term. 
The menorrhagia returned, and she was subjected to a variety 
of treatment both in Edinburgh and London ; she had her 
cervix divided for supposed fibroid tumour, and was subjected 
to another operation at the same time. I had an opportunity 
of examining her almost immediately after the division of the 
cervix, and could find no trace of fibroid tumour, or even 
induration. The menorrhagia was in no degree restrained 
by this operation, but, on the contrary, owing to the 
increased facility given to the escape of the blood, it 
was rather worse. The uterus was not larger than should 
have been expected in the case of a multipara, after a rather 
recent confinement ; its texture was devoid of that solidity 
which is characteristic of its normal state, it was soft and 
flabby, the os and canal of the cervix were patent so as 
almost to admit the tip of the index finger : a No. 13 catheter 
— ^gum elastic — readily entered the cavity and fluid injected 
through it returned in full stream alongside. She came 
under my care in February, 1857, at which time— some 
months after the date of my first examination — the con- 
dition of the uterus was substantially the same as above 
described, and the menorrhagia no better. Her general 
health corresponded. She was in a state of great anaemia, 
unable to walk a very moderate distance without great fatigue 
and prostration, and rarely left the recumbent position. 
During the menstrual periods she was confined to bed, and 
the free use of stimulants was required to ward off a distressing 
feeling of faintness. I tried all the haemostatic remedies 
such as iron, ergot, gallic acid, Indian hemp &c., internally 
and locally, the cold douche by continuous stream (San- 
som's douche), injection of Sol. Per. Perchl., &c. During 
this course of treatment she was seen by three of the most 
eminent obstetric physicians in London, at whose suggestion 
some of the above remedies, and in different forms, were 
administered. Still the menorrhagia went on. Residence at 
the sea-side produced very slight improvement in her general 
condition. Looking back at her history I suggested a sea 



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88 THE SPONGE TENT IN THE TREATMENT OF 

voyage^ but it was found impracticable. At last the idea 
occurred to me of trying the effect of a sponge tent. On her 
return to town from the sea-side^ and on the 1st of October^ 
1867^ I passed a large sized sponge tent^ recently made as 
I have already directed^ and rather more than two inches long^ 
through the internal os, and left it for twenty-four hours. 
The next period showed a decided improvement. On 
November 28th I passed another : the result was still more 
satisfactory^ all the former remedies were discontinued, the 
menstrual flow became reduced to a degree often exceeded by 
what is in some persons normal, and altogether she was so 
improved that she was able to return to India in the following 
October, having spent the preceding summer and autumn 
months in various parts of the country, without any treatment 
whatever. Previous to her departure she passed a fortnight 
in really hard work, purchasing, packing, &c. A few months 
after her return to India she again became pregnant, and 
was delivered at full term on May 18th 1870. The menor- 
rhagia returned, but not with its former severity. She is 
now in this country, having come back in July of this year^ 
1871^ and although her menstrual periods are abundant they 
are not sufficiently so to require any treatment. 

Case 2. — Mrs. W — came under my care as an out-patient 
at the Samaritan Free Hospital, suffering from excessive 
menstruation as well as intercurrent discharges of blood. 
She was the mother of several children, and until the 
commencement of her present symptoms had enjoyed good 
health. She had suffered from a slight increase of men- 
struation since the birth of her last child between two and 
three years ago, but it was within the preceding few months 
that it had acquired its greatest severity, and that she had 
become the subject of intercurrent discharges. There was con- 
siderable Ipucorrhoea, chiefly vaginal. She had gradually — 
more rapidly of late — become weak and anaemic, and could 
hardly bear the walk from Lisson Grove to the hospital. 

On examination the uterus was found to be slightly increased 
in volume : the cervix thickened but not indurated, the os 



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MENORRHAGIA AND UTERINE S^MORRHAOE. 89 

patulous^ its mucous membrane thickened, soft, spongy and 
granular. The passing of the sound caused rather free 
bleeding. I administered iron alone and in combination with 
ergot, gallic acid, &c., but without any efiPect on the bleeding. 
Local remedies such as cold douche and astringent injections 
were of no use. After some hesitation I determined to try a 
sponge tent, and accordingly I introduced one of medium 
size and the patient returned home.^ Next day, with some 
degree of anxiety and apprehension of the result — as it was 
the first time I had attempted the treatment in out-patient 
practice — ^I visited the patient at her own home and removed 
the tent. It had acted extremely well — whether this was due 
to its containing no gum, or whether the copious sero-san- 
guinolent discharge set up had washed it all out I am not 
prepared to say — and held its place firmly, its meshes inter- 
locking with the lining membrane of the cervical canal, and 
it was only by first passing the finger around the tent and 
successively pressing it away firom the opposing surface that 
I was able to withdraw it. There was a very abundant 
watery discharge, excessively offensive: the vagina was 
immediately washed out with a solution of chlorate of potash 
(5 grs. to oz.) ; she was ordered to keep her bed for a couple of 
days and to continue the Tr. Fer. Ferchl. which she was then 
taking. At the end of a week she presented herself at the 
hospital. 

From that time the intercurrent haemorrhages ceased, her 
menstrual periods assumed normal proportions, and in a few 
weeks she was discharged. I met her accidentally some 
months after and she stated that she was quite well. More 
recently she has been again under my care, but for 
dyspeptic symptoms. 

Case 8. — Mrs. T — , set. 24, a native of Calcutta of very 
dark complexion, from a considerable infusion of Indian 
blood, began to menstruate at the age of fourteen; the 
periods recurred very regularly every month, and lasted from 
six to eight days, the total amount of discharge being above 

1 I find that this tent was obtuned from Duncan and Flockhart, Edik. 



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90 THE SPONGE TENT IN THE TREATMENT OF 

the average, but unaccompained by clots. She married at 
the age of seventeen, and two months afterwards had a mis- 
carriage. Her next period assumed the character of menor- 
rhagia with clots. Repeated miscarriages at varying in- 
tervals took place, amounting to a total of seven, the last 
occurring in September, 1868, at the fourth month, after a 
voyage to the Mauritius for the benefit of her health. During 
her pregnancies she always suffered from slight haemorrhages 
at irregular periods. From the date of her last miscarriage 
the menorrhagia was so severe as to compel her to keep her 
bed for the whole period of from five to seven days. On the 
first day she usually complained of rather severe pain in the 
'^ waist /' on the third and fourth days large clots passed ; 
and at the end of the period she was in a state of great pros- 
tration, from which she had scarcely recovered before the 
next period was upon her. In addition to this she suffered 
from frequent attacks of pain of a sickening character in the 
lumbar region, during the intervals of menstruation, and 
these were usually accompanied by a more or less decidedly 
sanguineous discharge. She sought advice in various quarters 
and was subjected to a variety of treatment, local as well as 
general, but, deriving no benefit, and receiving no definite 
information as to the nature of her disease, it was determined 
that she should seek advice in London. The opinions pro- 
nounced on her case were various, one of them being that she 
was the subject of a tumour ; another was to the effect that 
she required an operation. The removal of the supposed 
tumour, or whatever condition required operation, was the 
cause of the long journey. She menstruated for the last 
time in India from the 26th to 31st March, 1871 (inclusive), 
passing many clots, and she was taken on board ship on 3rd 
April, per Suez Canal, — being then in a very weak state. 
There was a scanty discharge on the 20th and 21st April ; and 
again on 15th May there was a slight *'shew.^' On 25th 
May she landed in England. This patient came under my 
care on 10th June. She had not been unwell again but com- 
plained very much of the frequency and severity of the attacks 
of the pain above mentioned, but without discharge of any 



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MENORBHAOIA AND UTERINE HJBMORRHAGE. 91 

kind. Her general health was very good^ having undergone 
great improvement on the voyage. She had experienced a 
similar result from her voyage to the Mauritius, but the 
improvement was only temporary. On that occasion, it 
should be noted, her pregnancy extended to the fourth month. 

Diagnosis. — On external abdominal examination not even 
the suspicion of a tumour was aroused, but vaginal examina- 
tion revealed the following condition : — The uterus was of 
normal size, both as measured by the sound, and by the 
combined external and internal manipulation ; there was a 
slight anteflexion ; the os was patent ,- the whole cervix soft 
and flabby ; the mucous membrane of the anterior lip espe- 
cially, felt as if loosened in its submucous connections. 
Before placing her under treatment, and after having ex- 
plained the nature of her disease and the treatment I 
proposed, I recommended her to obtain the opinion of one 
skilled in the treatment of uterine disorders. Accordingly 
on the following day she accompained me to Mr. Spencer 
Wells. The result was a perfect agreement as to the absence 
of any tumour and the presence of the condition described. 
Nor was there any difierence on the question of operation, 
while we were agreed as to the treatment to be pursued. 

Treatment. — On 12th June, a small sponge tent was intro- 
duced and left for twenty-four hours ; another was introduced 
on the 19th and removed on the 20th, and on the latter day 
I prescribed 10-minim doses three times daily, of the Tr. Fer. 
Mur. and Extr. Ergot Liquid. The menses appeared on the 
29th and lasted three days, moderate in amount and not 
preceded by pain. There were no clots, nor was she com- 
pelled to keep her bed. She was allowed to pass over a 
month without another tent, and on 23rd July the menses 
again appeared. The quantity was greater, and there were 
several small clots. On this occasion I gave her a few doses 
of gallic acid. On the 29th she was complaining of the old 
pain and was rather disheartened. For this I prescribed 
gr. \ extract of Indian hemp to be taken every four hours 
while the pain lasted, and to be had recourse to on each re- 
currence. On 2nd August I passed a small tent, and on the 



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92 THE 8FONOB TENT IN THE TREATMENT OF 

following day another of larger size. Neither of these acted 
well as they were saturated with thick gum. On the 9th I 
introduced another of medium size^ of same make^ and next 
day had the mortification of finding it in the vagina little 
changed. However^ I replaced it by another^ and this by a 
third on the llth^ and the result was satisfactory. (These 
latter tents were made by myself for the occasion^ and the 
sponge was merely moistened with the solution of carbolic 
acid. They were quite devoid of unpleasant smell on extrac- 
tion.) To make sure work (as the patient limited me to 
time), I introduced another on the 16th. This acted perfectly, 
opening the cervix well. After the use of the sponge tents 
the vagina was washed out daily with a solution of ten grains 
of tannin in two ounces of water. The menses appeared on 
the 23rd and lasted three whole days; the discharge was 
moderate, and the patient was not confined to bed at all. 
From this time she ceased to complain of pain. On Sep- 
tember 21st she again became unwell, and the discharge 
ceased on the fourth day. During the whole of this 
menstrual period she went about sight-seeing daily without 
inconvenience of any kind. 

Result. — On the 10th October she sailed for Calcutta in a 
state of perfect health, rejoicing as much at the cessation of 
the attacks of pain as of the menorrhagia. During ^the last 
month all treatment, local and general, was suspended. 

Remarks. — These three cases are good examples of that 
form of uterine hemorrhage and menorrhagia to which I have 
desired to call attention, which is not described definitely in 
our text-books, and in the treatment of which the sponge 
tent is so valuable. There is no tumour, no fibroid thicken- 
ing or induration, nor is there a polypus. The condition is 
one of relaxation of the tissues of the uterine body to some 
extent, but especially of the mucous membrane lining the 
cervical canal, and probably that of the uterine cavity — if I 
may be allowed to adhere to the established nomenclature for 
the sake of convenience, without prejudice to the question 
whether it be a distinct membrane or a layer of soft tissue. 
This state of relaxation -permits congestion or stasis of blood 



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MENORRHAGIA AND UTERINE HiBMORRHAOE. 98 

to take place in the vessels of the submacous tissue (or layer 
of soft tissue), which, deprived of their necessary support, 
readily pour out their contents either under the influence of 
the menstrual molimen, or any influence acting locally or 
generally, and leading to congestion of the pelvic organs in 
their entirety, as occurs in the somewhat analogous case of 
hsemorrhoids. In all the cases which have come under my 
notice the patients have either resided in India, and have 
been more or less liable to miscarriages or post-partum 
hsemorrhages, or they have been resident in this country and 
have dated their illness A*om a miscarriage or delivery at 
term. These are not cases of subinvolution. I refer more 
particularly to the cases of residents in tropical climates (the 
term is not once mentioned by Dr. Tilt in his special chapter, 
to which I shall have occasion to refer more at length) ; for 
in Case 1 the uterus is described as being in no degree larger 
than is usual in women who have borne half a dozen children, 
while in Case 3 the size of the organ could be so easily 
measured by the combined external and internal manipula- 
tion, and the estimate thus formed was so exactly confirmed 
by the use of the sound that the idea of subinvolution could 
not be entertained. To the naked eye, when seen through 
the speculum, the everted mucous membrane of the cervical 
canal is seen to a much greater extent than usual, and its 
redness tends to lividity. Pressed with the sound or any 
hard substance, the tissues yield to a greater degree than in 
their normal state, and the passing of the sound often draws 
blood. As a rule there is decided leucorrhoea — in Cases 1 
and 3 it was not abundant — but I have never seen the os and 
cervical canal blocked up with glairy mucus, so characteristic 
of the so-called ^' catarrh " and inflammatory conditions of 
the uterus. Nor is there any increase of temperature. When 
examined by the finger the mucous membrane can be felt to 
slip over the subjacent tissues as if too loose. In Case 3 
this was so well marked as to lead to considerable increase 
in the size of the anterior lip ; and the disappearance of this 
condition was coincident with the cessation of the menor- 
rhagia. 



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94 THE SPONGE TENT IN THE TREATMENT 07 

The pathology of these eases calls for remark^ and in order 
to state my views it is necessary that I should advert to 
those entertained by writers on the subject. Dr. Oraily 
Hewitt, under the head of " Menorrhagia/' referring to those 
cases which occur in women who have resided in tropical 
climates^ such as India^ and which he describes as very 
obstinate, says, '^ the uterus and pelvic organs generally are 
found, in such cases, in a state of chronic congestion ; there 
is profuse menstruation together with leucorrhoea." His 
pathology is further indicated by his referring the reader to 
the treatment prescribed for chronic inflammation of the 
uterus as suitable to the cases under consideration. Dr. 
Tilt in his ' Handbook; of Uterine Therapeutics ' has dealt 
specially with the subject of menstrual derangement in a 
chapter on the " Influenqe of India on the Health of British 
Women,'' which he published in a separate form as late as 
October, 1868. One idea pervades the chapter from begin- 
ning to end, viz., that of inflammation. He says (at p. 18 
of the latter) '' So great is the tendency to uterine haemor- 
rhage in India that it has become a frequent practice for our 
countrjrwomen to return to Europe for their confinements, 
so as to avoid the profuse flooding by which it is so often 
accompanied in India." And he adds, very illogically it 
appears to me, '^ the fact is thus brought out that as tropical 
climates produce uterine inflammation, because habitually 
intense heat disturbs menstruation in those who are not 
bom under tropical influences ; so our countrywomen, when 
transplanted into India, become more liable to inflammation 
of the womb, as a result of pregnancy, abortion, and parturi- 
tion, than if they had remained in England." So predomi- 
nant is this theory in his mind that it is called in to account 
for a variety of diseases, for he goes on to say, " I pointed 
out that diarrhcea is sometimes a symptom of pregnancy ; 
that severe uterine inflammation generally gives rise to 
obstinate constipation, or to diarrhoea and other functional 
disorders of the large intestine and rectum; and this 
explains why, in India, for instance, diarrhcea is a more 
frequent symptom of pregnancy than in temperate countries. 



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MENORRHAGIA AND UTERINE HAMORRHAOE. 95 

and why dysentery often complicates pregnancy^ inducing 
abortion/' &c. 

Let ns see then what are the symptoms of inflammation 
of the uterus to which so much is attributed. Dr. Graily 
Hewitt^ limiting his description to chronic inflammation of 
the uterus^ says^ '' the changes and modifications in its ... • 
texture^ in its vascular condition^ and in its relations to the 
nervous centres^ produce discomfort of various kinds," " they 
interfere with the natural performance of the functions of the 
uterus, prevent the procreation of children,'' &c. The symp- 
toms, more directly stated, are pain low down in the pelvis, 
pain in the back^ both increased by walking, or chronic 
irritability of the bladder, undue discharge from the vagina ; 
'' pains radiating to the inner and upper part of the thighs, 
&c., are not rarely produced by it." " Sterility is a frequent 
efi^ect, the menstrual functions are almost always disturbed, 
the periods being painful and the loss often excessive, not 
invariably. " The physical changes most frequently resulting 
from this chronic inflammation are congestion, undue 
sensibility and hypertrophy." Further, the changes pro- 
duced are described as belonging to two stages ; the first is 
that of infiltration, in which the uterus is '^ simply 
engorged," " the consistence of the tissues ... is unchanged^ 
but the organ is large, and the walls thicker than they should 
be." The second is that of induration in which there is 
*' undue hardness and firmness of the uterine tissues, the 
uterus being also, as a rule, larger than customary." He 
does not describe acute inflammation in detail. Scanzoni, 
on the other hand, gives a minute description of this state, of 
which pains of various kinds, tenderness of the organ, local 
elevation of temperature, and cessation of the menses are 
prominent symptoms. In very rare cases the menstrual 
discharge is very abundant, constituting a real menorrhagia. 
Hence the name haemorrhagic metritis. 

In the chronic inflammation there is ''a disagreeable 
sensation of fulness and weight in the pelvis," " difficulty in 
micturition," ''pain in defaecation," and ''a mucous dis- 
charge from the genital organs." ''Sometimes, not very 



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96 THE SPONGE TENT IN THE TREATMENT OF 

abundant at others considerable/^ pains in the hypogastric^ 
sacral^ and inguinal regions^ which> though vague^ are very 
severe, continuing almost without interruption, but in- 
creasing from time to time ; augmented by a vertical posi- 
tion, and by walking or other shaking of the body. '' Any 
abdominal pressure in sneezing, coughing, or straining in 
defaecation, &c., is accompanied by an extraordinary and 
painful sensation, as if a heavy body would fall out of the 
pelvis/' " With some rare exceptions the disease is always 
accompanied by obstinate constipation/' '^ The menstrual 
flow is subject to numerous irregularities being ordinarily 
not very abundant y or of long duration, and is often accom- 
panied by painfiil symptoms (dysmenorrhosal)/' Some- 
times it ceases for months and even years, while, on the 
contrary, in rare exceptions, it may become very copious/' 

I need not go further in order to contrast these conditions 
with that described in the cases under consideration, or with 
the disease specially described by Dr. Tilt, and of which 
menorrhagia is the most prominent symptom. He nowhere 
speaks of the various pains, tenderness, constipation, sterility, 
&c., so insisted on by Drs. Graily Hewitt and Scanzoni, and 
I think I have a right to infer that the disease he treats of 
is essentially of the same nature as in Cases 1 and 8, and 
having nothing of the nature of inflammation. 

Notwithstanding the above quotations from Dr. Graily 
Hewitt I must join his name to Dr. Tilt's with regard to the 
disease under discussion, and I venture, with all diffidence, 
to dissent from the views of these writers, and to reject a 
pathology so exclusive, I might say so inclusive. I fail to 
find evidence conclusive of inflammation of the uterus in the 
pregnant state, such as rupture from inflammatory softening 
so called, adhesion of the placenta, &c., in numbers pro- 
portionately exceeding the frequency of their occurrence in 
this country, or in the puerperal state, as manifested by the 
symptoms above quoted. I entertain the hope that atten- 
tion having been pointedly called to the question, the views 
hitherto held having been challenged, and in sight of the 
successful results of what I may call a new method of treat- 



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MENOBBHAQIA AND UTERINE HiBMOBRHAGE. 97 

ment, we may ere long arrive at a more correct pathology 
and attain a more exact diagnosis, and that as a necessary 
result these cases may prove less "obstinate^' than they 
have hitherto done. These views are supported by the 
frequency with which women who are the subjects of menor- 
rhagia bear children in India^ a fact somewhat inconsistent 
with the existence of acute or chronic inflammation. Nor is 
it out of place to remark that acute inflammation in the 
puerperal state rather tends to the diminution of haemor- 
rhage than its increase. I might refer^ as bearing on this 
question^ to the very frequent occurrence of fibroid tumours 
of the uterus in women of hot countries^ not as evidence of 
inflammation — for I am not aware that any writer has 
attributed their production to this cause — but as pointing to 
an increased growth of tissue of low vitality^ of which in* 
flammation is usually regarded as destructive ; to the rarity 
of pelvic cellulitis (which is not even named by Dr. Tilt)^ and 
of adhesions of the uterus^ &c. 

I have already cited the excessive frequency of post-partum 
haemorrhage in India> which Dr. Tilt attributes to inflamma- 
tion^ but I fail to see why we should look for a difierent 
explanation from that which is ofiered for its occurrence in 
this country. Relaxation of muscular tissue is the grand foihs 
et origo mali. The whole system is debilitated^ the muscular 
tissue^ voluntary and involuntary^ loses its tone^ the tissues 
generally become relaxed^ passive venous congestions abound^ 
and the seeds of abundant disease are sown. In the female 
this may be ascribed partly to the direct influence of climate^ 
excessive heat^ and partly to the idle habits engendered. All 
authorities agree — and it is well shown by Dr. Tilt — that 
nothing conduces so much to good health in India as 
abundant exercise. 

I would not for one moment have it supposed that I call 
in question the frequent occurrence of inflammation in tropical 
countries — true inflammation of the uterus and its appendages. 
I wish it to be distinctly understood that I only oppose that 
view which attributes the excessive frequency of menorrhagia 
and uterine haemorrhage to inflammatory action. 

VOL. XIV. 7 



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98 THE SPONGE TENT IN THE TREATMENT OF 

I hardly need mention that neither Dr. Graily Hewitt nor 
Dr. Tilt makes any allusion to the sponge tent in the treat- 
ment of these cases. 

The mode of action of the sponge tent is probably me- 
chanical as well as vital. It acts mechanically by compress- 
ing the mucous membrane and its vascular system, emptying 
the over-distended blood-vessels, and removing the redundant 
epithelium; vitally, in restoring tone to the flabby blood-vessels 
by relief of over-distension, and in exciting growth of healthy 
tissue. Simple compression, as effected by the tangle tent, is 
not sufficient for these purposes ; the tent attains its maximum 
dilatation in a few hours, and on its withdrawal the granula- 
tions spring up again by mere force of elasticity. It is well 
known that the tangle tent produces less irritation than the 
sponge, but this is its disadvantage. In the case of the 
sponge tent the pressure is exerted more slowly, more gently, 
more continuously, and more efficiently ; the interstices of the 
sponge become interlocked with the inequalities of surface 
presented to it; pressure is exerted on the bases of and 
between the granulations, as well as on their summits, and 
thus their complete destruction is brought about. The forcible 
peeling off of the redundant epithelium paves the way for a 
new growth of more healthy tissue. The amount of discharge 
set up — usually watery — materially assists in relieving the 
congestion and removing exuberant growth of low vitality. 

Apart from the superior effects of the sponge the amount 
of pain caused by the two forms of tent is worthy of note. 
The sponge causes little or no pain, and never requires the 
accompanying administration of a sedative; the tangle, on 
the other hand, causes severe pain, lasting about five or six 
hours, or even more, according to the amount of resistance 
offered to it, and in all cases demanding the use of an 
anodyne. 

The powers of the sponge tent as a remedial agent have 
been well illustrated by Dr. Marion Sims in several cases, 
although it may be said of them that they were mere accidents 
— that is to say, they were not used with the intention of 
producing the results which they brought about. His most 



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.. "" 1,1. 1 A f 
MENORRHAGIA AND UTERINE HJEMORRHAOE. ^??^2J!?^^^ 

striking case is that which he calls fungoid granulations of the 
OS and cervix uteri, characterised by a profuse irritating 
leucorrhosa and menorrhagia. This case made a very strong 
impression on my mind, and although there was no resem- 
blance between the two, I believe it suggested to me the use of 
the sponge tent in Case 2. He sums up its powers in these 
words : — " It dilates the neck of the womb ; it softens it by 
pressure, and by a sort of serous depletion ; it reduces the 
size, not only of the neck, but of the body of a moderately 
hypertrophied uterus ; it destroys, not only fungoid granula- 
tions, but even large mucous polypi ; and in one instance I 
saw a sponge tent destroy wholly a fibrous polypus as large 
as a pigeon's egg/' He adds, " This was accidental/' In 
spite of this strong recommendation the sponge tent has 
suffered comparative neglect, and it has not yet attained that 
position which its powers demand. The late Sir J. Y. Simp- 
son, in the memoir already referred to, also speaks of cases 
of small vesicular polypi cured by the sponge tent alone, and 
even he does not appear to have recognised its capabilities, 
for I fail to find any special recommendation of it as a thera- 
peutical agent. 

Before concluding I may be permitted to draw attention 
to that remarkable influence which a sea voyage exerts on 
menorrhagia as it occurs in our countrywomen who have 
resided in India, to which reference has already been made. 
So much was I impressed with this that in the first case here 
recorded I had serious thoughts, before I had tried the 
sponge tent, of urging this as a means of cure. The subject 
is deserving of consideration, and I would suggest it to our 
brethren in India as worthy of experiment in a legitimate 
field. 

Hitherto the sponge tent has been employed too exclusively 
as a means of diagnosis. To rescue it from this inferior 
position and to place it on a higher footing as a means of 
cure is the principal object of this paper. I trust I have in 
some measure established its usefulness as such. 

Since writing the foregoing my attention has been drawn 



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100 MENORRHAQIA AND UTERINE HAMORRHAOE. 

to some papers published by Dr. Savage in the * Lancet' for 
1857, " On the Treatment of Menorrhagia by the Injection 
of Iodine after Dilatation by Sponge Tents/' Dr. Savage's 
treatment is founded on the theory that there is an antago- 
nism between the body and cervix of the uterus, and that 
this antagonism must be overcome by dilatation of the cervix, 
in order to render injection safe. It would therefore appear 
that he relied on the injection as the remedial agent, ignoring 
or rather overlooking the influence exerted by the sponge 
tent. 



Dr. Tilt expressed himself flattered that his account of the 
influence of tropical climates on uterine affections should have 
so deeply interested the author, and promised to give due 
attention to the author's criticisms when he had had a better 
opportunity of understanding them. 

Mr. Scott was unwilling that the discussion should pass 
without a word of warning on the use of sponge tents. He 
would not now enter into the question of their utility in the 
cases under consideration, but the possible occurrence of metro- 
peritonitis or cellulitis under their use should never be lost 
sight of. 

Dr. AvELiNO said that Dr. Bantock was in error in thinking 
that the pathological condition he had described was unknown. 
Hypersemia of the uterus was an abnormal state well understood 
and frequently described by writers. It had been described by 
him at some length in a paper upon " The Value of Arsenic in 
Menorrhagia and Leucorrhoea," read at the meeting of the 
British Medical Association at Plymouth, last autumn, and 

Eublished in the Journal, January 6th, 1872, p. 10. He 
ad found arsenic to be of the greatest service in tne treatment 
of this hypersBmic condition of the uterus, and would recom- 
mend its trial before having recourse to tents, the use of which 
he and others had known to be followed by a fatal result. 



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APRIL 8rd, 1872. 

John Braxton Hicks, M.D., F.R.S., President, in the Chair. 

Present — 44 Fellows and 9 visitors. 

The following gentlemen were admitted Fellows of the 
Society : — Mr. George Bland, Mr. Alex. Fergusson, Mr. W. 
Hardy, Mr. A. Kisch, Dr. T. C. McConkey, Dr. Mondelet, 
Mr. G. Parr, Mr. G. Bigden, Mr. Bobson Boose, Dr. Thor- 
burn, and Dr. Vanderstraaten. 

The following gentlemen were elected Fellows: — John 
Bontledge Bosworth,M.B.C.S., Sutton; C.E.Buckingham, 
M.D., Boston, U.S.; C. P. D. Chittenden, L.R.C.P. Ed., 
Lee, Kent; Thomas Savage, M.D., Birmingham; and A. 
Wellesley Tomkins, M.D., Leamington. 

Dr. AvELiNO exhibited his apparatus for immediate trans- 
fusion, which he has now modified by adding a tap at each 
end of the tube close to the nozzles. He had been called 
in a few days previously to transfuse blood into a lady dying 
of hsemorrhage after her confinement, and, he was happy to 
add, with a successful result. The present alteration was 
due to the experience he had then gained. He was also now 
able to answer an objection made to his apparatus when he 
first showed it to the Society in 1864, viz. that the person 
supplying the blood would faint from excitement or nervous- 



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102 APPARATUS POR IMMEDIATE TRANSPDSION. 

ness. In this case the coachman^ whose blood was trans- 
fused^ was cheerful and interested during the progress of the 
operation^ and made one or two useful suggestions. His 
arm afterwards gave him no trouble ; in fact^ he wished to 
drive the next day. Dr. Aveliug believed that the methods 
of preventing coagulation^ adopted when the mediate mode 
of transfusion was used^ were the cause of needless deteriora- 
tion of the blood and of unnecessary delay. 

Dr. Barkes thought the Society would receive Dr. Aveling's 
communication vith great satisfaction. It proved that his in- 
strument, portable and convenient, was also efficient. The great 
ohstacle to the diffusion of transfusion created by bulky apparatus, 
funnels, and defibrination, was obviated* He would suggest that 
instead of filling the syringe and tubes with warm water, it would 
be better to use a solution of phosphate of soda. This would 
tend to keep the blood fiuid, and the saline fluid itself would be 
beneficial to the patient. In reference to Dr. Playfair's observa- 
tion on defibrination, he would observe that, however carefully 
the filtration might be performed, it was still to be feared that 
in the filtrate some fibrin might coagulate, and act as minute 
emboli. 

Dr. Flaypair said that he had lately had the opportunity of 
performing transfusion in a case of post-partum hssmorrhage, in 
which he had used defibrinated blood. So for from there being 
any difficulty in defibrinating the blood, as Dr. Barnes suggested, 
that part of the operation was simple in the extreme, and answered 
admirably. If the blood was strained through a piece of fine 
muslin into a bowl fioatin^ in warm water, any possibility of 
pieces of floating fibrine being injected with it was effectually 
prevented. It seemed to him that this was not so certainly 
provided against in Dr. Aveling's instrument. At any rate, to 
prevent it the greatest despatch would be necessary. Whereas 
the great advantage of using defibrinated blood was that every 
step of the operation might be performed with the utmost leisure, 
and the necessity for any hurry or fuss was thus obviated. More- 
over, it was now a pretty generally admitted physiological fact that 
the fibrinous element of the blood is useless in transfusion, and 
that it is, for all practical purposes, better without it. He, 
therefore, was of opinion that defibrination was a most impor- 
tant step in advance, and better than any other means of re- 
taining the blood fiuid; of course he was quite prepared to 
admit that mediate transfusion might prove the simplest means 
after all. In his own case a gravitation instrument had failed to 
act satisfactorily, probably because there was not sufficient force to 



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ANGULAR SCISSORS. 103 

overcome the resistance of the yenous walls on the nozzle of the 
instrument. Therefore he thought some form of syringe more 
likely to prove generally useful. It should be more generally 
known than it is that transfusion with defibrinated blood, so far 
from being a difficult operation, is in reality a very simple 
one. 

Dr. CLEVXLAin) also wished to express a hope that the Society 
might be enabled to give directions for facilitating the operation 
of transfusion, and mentioned a case in which a lady, nher con- 
finement, was threatened with death from h$Bmorrh£^e, when he 
requested the assistance of a distinguished Fellow of the Society 
who had invented a suitable apparatus. A healthy young man 
was procured, and in waiting upwards of two hours ; but owing, 
as Dr. C — believed, to the uncertainty of the operation, com- 
bined with the lingering hope that the patient might rally under 
the means employed, an opportunity was lost, and she succumbed. 
He could not help thinking that with a safe means of transfusing 
the result might have been different. 

It was proposed by Dr. Bouth^ and seconded by Dr. 
Hey wood Smithy ''that the Council be recommended to 
form a Committee to investigate the subject of transfusion/' 

Dr. Heywood Smith showed a modification of his ''angular 
scissors/' which had been made since the last meeting. In 
these the small scissors had curved blades^ and when bent 
forwards would be useful for the removal of polypi^ and bent 
backwards for cutting the sutures after the operation for 
yesico-vaginal fistula. Dr. H. Smith thought this shape 
would prove of use in many operations^ such as paring the 
edges in difficult vesico-vaginal fistulse, cleft palate^ &c. 



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104 INVERSION OP THE UTERUS 



INVERSION OF THE UTERUS AFTER CHILD- 
BIRTH IN A PRIMIPARA. AMPUTATION BY 
ECRASEUR AT EXPIRATION OF TEN MONTHS 
ON ACCOUNT OF HAEMORRHAGE WITH GREAT 
EXHAUSTION. 

By J. Hall Davis, M.D., F.R.C.P., 

OB8TBTBIC FHYSIOIAIT AND LBCTUIUEB OK OB8TBTBIC8 AT THE KIDDLBSBX 

HOSPITAL; BZAMIKBB ON MIDWIFEBT AND THB DISBA8B8 OF 

WOICBN AT THB BOYAL OOLLBOE OF PHYSICIANS, 

LONDON; PHYSICIAN TO THE BOYAL 

MATBBNITT CHARITY. 

The patient from whom this uterus was removed, A. B — , 
is a young married woman aged twenty-two, of medium 
stature and good conformation, who was admitted under my 
care into the Middlesex Hospital February 20th, 1872. 

On admission, — I found her ansemic, emaciated, and in a 
state of great prostration from uterine haemorrhage, which was 
still continuing, with occasional vomiting. P. 100, T. 98°. 

On vaginal examination I discovered a polypiform body 
occupying the vagina, suspended from within the lower part 
of the cervix of the uterus by a neck of the thickness of my 
index-finger. Measures for the abatement of the hsemorrhage 
were taken ; the rectum, containing a faecal accumulation, was 
cleared out by a soap-and-water enema. After this I made a 
more minute investigation, to decide whether the body which 
I felt was a polypus, which it had been suspected to be, or 
an inverted uterus. The uterine sound passed through the 
orifice of the uterus upwards to a distance of not more than 
one and a half inch. I next introduced the finger into the 
emptied rectum high up, and on directing its point forwards 
in search of the fundus of the uterus I could not feel it. The 
protruded body was very sensitive when compressed, and softer 
than a fibroid polypus usually is, and less smooth on its 
surface. 

Previous history. — Her health previous to marriage, two 
years ago, had been good. Menstruation had commenced at 



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AFTER CHILDBIRTH. 105 

fourteen. She was delivered of her first and only child in April, 
1871. Her labour was tedious, and at length delivery was 
effected by the forceps of a living child, which still thrives. 
The placenta, being adherent, required artificial removal; 
much hsemorrhage ensued, and considerable pain in the lumbar 
and pelvic regions of a dragging and bearing-down character. 

The diagnosis. — This history and the above local examina- 
tion of the case led to the inference that it was one, not of 
poljrpus, as had been supposed, but one of inversion of the 
uterus, occurring at or soon after the delivery of the 
placenta. 

Treatment. — Reflecting on the patient's condition, one of 
extreme prostration from hsemorrhage, which had recurred 
at short intervals for the last ten months, I was convinced 
that her constitutional powers would not tolerate the treat- 
ment by persistent elastic pressure with a view to reduction. 
Moreover, the neck of the inverted portion of the uterus was 
too narrow to admit of the return through it of the fundus 
and body of the organ, at least not without long-continued and 
exhausting mechanical interference. The uterus had, more- 
over, undergone considerable involution, which set another 
barrier in the way of reversion. I therefore decided upon the 
only course left me under the circumstances — to remove the 
uterus, the displacement of which was the cause of the 
haemorrhage immediately threatening the life of the patient. 

The operation was performed on February 23rd. Of the 
different methods of extirpating the organ, that of ligature 
only I feared would cause great suffering, as it has done in 
many cases, and in my patient's condition would probably 
induce peritonitis and septicsemia; ligature foUowed by ex^ 
cision might be expected to produce like results ; excision only 
would most probably be followed by dangerous hsemorrhage ; 
extirpation by the Scrasevr only, being very rarely followed by 
haemorrhage in the case of polypi even with thick necks, 
especially if the division is slowly accomplished, was accord- 
ingly the method which I selected as the safest. I employed 
the single wire for the purpose, of the same kind which I have 
often used for the removal of polypi. I applied it without 



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106 INVERSION OF THE UTERUS 

first dragging upon the neck of the uterus^ thinking that if I 
avoided previous traction on the uterus^ often recommended 
before extirpation^ I should probably prevent^ at least not be 
favouring^ the sudden springing up into the peritoneal cavity 
of the severed cervical portion of the displaced uterus. Having 
applied the wire around the neck of the protruded body^ and 
given its first degree of tightening without chloroform^ the 
patient complained of agonising pain ; I therefore loosened the 
wire for a few moments while she was placed sufficiently 
under chloroform^ and then I completed the amputation slowly. 
No haemorrhage followed, nor did it again recur. 

On recovering ft*om anaesthesia my patient complained of 
severe pain in the hypogastrium ; on this account my 
obstetric assistant^ Mr. Lewis, administered, by my desire, a 
subcutaneous injection in the forearm of one third of a grain 
of morphia ; this was repeated during the first twelve days, 
every two, three, four, six and eight hours, day and night, at 
varying intervals, as was necessary, for I found that any 
suspension of its use was fcdlowed by severe uterine and 
ovarian pains and restlessness. After this, for a few nights, 
hydrate of chloral in twenty-grain doses was substituted at 
bed-time and produced relief irom pain and quiet sleep. 
Linseed poultices, sometimes containing laudanum, were kept 
steadily applied to the hypogastrium. The pulse was very 
small immediately after the operation, which was performed 
at 1.80 p. m., and the temperature at the same time fell to 97^. 
At 9 p.m. pulse 102, temp. 98"8°. The pulse mounted on the 
third night after the operation to 180, but the temperature 
reached its maximum, 102°, on the ninth day. After this both 
pulse and temp, fell gradually, the former to 72, the latter to 
98°, on March 10th. 

There were transient chills before the temperature and 
pulse rose, but no evidence of peritonitis appeared ; at least 
moderate pressure on the belly was tolerably well borne, and 
the abdomen did not become tense. The catheter was re- 
quired for the first three days ; the bowels were moved by a 
simple enema on the seventh day. The patient was watched 
day and night during the early days after the operation, re- 



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AFTER CHILDBIRTH. 107 

ceiving frequent small supplies of liquid nourishment ; for 
a time^ and while sickness occurred, this was administered 
per rectum ; brandy in small quantities was also allowed to 
the extent which feebleness indicated as necessary. On 
the eighteenth day she was permitted to leave her bed for a 
short time, and did so without any bad results ; a gentle 
aperient of compound rhubarb pill regulated the bowels 
sufficiently, and a chalybeate tonic given during the last 
fortnight of her stay in the hospital, added to her generous 
diet, advanced her strength. She was discharged convalescent 
on the thirty-second day, having a few days before had a 
slight sanguineous discharge per vaginam, apparently men- 
strual. She continues (July) in perfect health. 



The case here detailed and illustrated is one of partial inver- 
sion of the womb, the portion removed consisting of fundus 
and about the upper two thirds of the body of the uterus ; it did 
not protrude through the vulva, as in complete inversion, and 
its serous cavity does not contain the ovaries ; that I ascertained 
immediately after its removal. The uterus has been cut 
across from above downwards for the purpose of displaying 
the serous cavity containing part of the Fallopian tubes 
and ligaments^ and to show the thickness of the uterine 
walls. It is probable that in this case adhesion had taken 
place between the opposite serous surfaces of the inverted 
uterus at some point between the line of inflexion and the 
line of amputation, for on passing the point of my finger 



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108 ON THE ESSENTIAL 

into the opening left hj the ^raseur its progress was soon 
stopped by what appeared to be a firm closure of the tube^ 
cutting off^ as I believe, all communication with the general 
peritoneal sac. If that was the case, it constituted an 
additional safeguard against the occurrence of peritonitis. 

The drawing represents the actual size of the uterus as 
reduced by involution. 



ON THE ESSENTIAL CAUSE OF DYSMENORRHCEA, 
AS ILLUSTRATED BY CASES OF PARTIAL AND 
COMPLETE RETENTION. 

By Robert Barnes, M.D. Lond., 

OBSTETBIO PHYBIOIAK TO ST. THOMAS'S HOSPITAL ; EXAMimiB IN OBSTETBIC 

MBDIOINB TO THB TJNIYEB8ITY OF LONDON AND THB 

BOYAL COLLEaS OF SUBGEONS. 

I PROPOSE in this paper to search for the essential condition 
of dysmenorrhoea by the study of the various circumstances 
under which this symptom may arise. The analysis of these 
various circumstances may enable us to discover one condi- 
tion which all or many have in common ; that one condition 
will be the essential cause of dysmenorrhoea. In making 
this provisional statement I am far from wishing it to be 
implied that there is only one essential cause. There are 
cases which it is still difficult to refer to one cause. And it 
is one formidable obstacle to the progress of medical know- 
ledge^ from which our department is not more free than 
others^ that one idea will often get such absolute possession 
of the mind as to exclude every other idea^ forgetting that 
two or more truths cannot be antagonistic. I am anxious to 
guard myself against falling into this error^ and therefore 
press the conclusion I have arrived at no further than the 
clinical basis it is drawn from will justify. We apply to the 
study of dysmenorrhoea the usual methods of clinical inquiry^ 
namely^ first, the consideration of the subjective phenomena ; 
secondly, that of the objective phenomena, especially the 
investigation of the condition of the organs whose function 



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CAUSE OF BYSMENORRHCEA, 109 

is disturbed; and lastly, the observation of the results of 
treatment. It may be admitted that the means of treatment 
employed are sometimes empirical, that is, they are not 
directed by a clear comprehension of the cause of the dis- 
tress. But if we find that these means are frequently 
followed by success, this treatment, empirical though it be at 
first, will lead us to a clearer knowledge of the evil which it 
overcame, and thus in the end it becomes rational. 

Cases of dysraenorrhcea may be roughly classified under 
the following heads : — 1, neuralgic or sympathetic ; 2, con- 
gestive or inflammatory ; 3, due to obstruction of the Fallo- 
pian tubes ; 4, due to mechanical anomalies of the uterus ; 
5, due to ovarian disease. 

The simple study of the subjective phenomena will not 
enable us to distinguish cases of one kind from those of 
another kind. Indeed, so long as this very imperfect method 
was conclusively pursued all cases of dysmenorrhcBa were 
confounded together, or the distinctions made were arbitrary 
and fanciful, and treatment was at best empirical and gene- 
rally unsuccessful. Not many years ago dysmenorrhoea was 
almost universally looked upon and treated as a nervous 
affection of the uterus itself, or as sympathetic with disorder 
of distant organs, or an expression of constitutional debility ; 
and vague ideas of this kind still largely prevail amongst 
physicians who have not directed particular attention to the 
pathology of the ovaries and uterus. But in proportion as 
precise methods of investigation have been applied to the 
study it has been discovered that in most cases the nervous 
phenomena are associated with distinct morbid conditions of 
the uterus, or upon conditions which oppose a mechanical 
obstacle to the proper performance of the uterine function. 
If we still, therefore, retain the term " neuralgic dysmenar- 
rhaa" we must do so on the understanding that, although 
describing a really existing disorder, it is a convenient 
asylum ignoratUue under which we may provisionally class a 
number of cases the true pathology of which eludes our 
research. Extending observation will certainly contract this 
asylum more and more, if, indeed, we may not hope to close 



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110 ON TH£ ESSENTIAL 

it altogether. We may see a remarkable illustration of this 
in the history of what that admirable cUnical physician^ 
Dr. Gooch, called "the irritable uterus/* The late Dr. 
Robert Ferguson^ commenting on Gooch's description^ said^ 
*' This malady^ I believe^ is deeply rooted in the very essence 
of that complex organic function termed the generative^ 
which in its most comprehensive sense includes no incon- 
siderable portion of the moral as well as of the physical 
development of the female organization/' Ferguson recog- 
nised^ it is true, the fact that various morbid conditions of 
the uterus and ovaries were sometimes associated with the 
so-called irritable uterus. He says^ " There is a form of the 
disease not described by Gooch. In this the purely nervous 
aspect of the malady is masked by some obvious change in 
the uterus or its appendages, but this change is by no 
means a constant one, either in its seat or nature. Some- 
times there is a congested condition of the uterus, altering 
its shape into that of a retort^ the enlarged and curved fundus 
being exquisitely sensitive of pressure. At other times the 
cervix or some portion of the uterine walls is the seat of con- 
gestion, of varying consistency, and of pain The 

local changes have been the fluctuating^ the nervous affection, 
the constant element ; in it^ therefore^ and in no doctrine of 
a phlogistic origin can I place the essence of this strange 
disease.*' 

Dr. West included these cases under the "congestive" 
class. Dr. Henry Bennet assigned inflammation as the real 
pathological condition. Dr. Rigby thought many cases were 
due to a rheumatic diathesis, and other authors have from 
time to time, impelled by the accidental nature of their 
experience, or the bent which preconceived theories had 
imparted to their observations^ given prominent or exclusive 
importance to some one complication. 

If we postpone theory and carefully analyse a large number 
of cases, noting the complications and the effects of treatment, 
we shall find that the cases of "irritable uterus** resolve 
themselves into the following groups, namely — 1^ in which 
there is manifest enlargement from congestion of the uterus; 



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CAUSE OF DYSMENOR&HiEA. Ill 

2^ in which there is sabinvolntion with chronic inflammation 
of the uterus following labour or abortion ; 8, reclination or 
flexion of the uterus^ most frequently retroflexion ; 4^ a pro- 
jecting conical vaginal-portion^ with very small os externum 
uteri ; 5^ disorder of distant organs, attended or not by one 
or more of the preceding structural faults, and almost always 
with impaired sanguification and nutrition; 6, a morbid con- 
dition of the ovaries ; and lastly, a residuum of cases in 
which, whether from not pushing investigation to the proper 
point to discover the associated fault, or because there really 
is no physical fault, we are obliged to conclude that the 
dysmenorrhoea is simply the expression of nervous disorder. 
We may reasonably expect that advancing knowledge of 
uterine and ovarian pathology will still, further diminish this 
residuum. 

I think observation warrants this general conclusion:-* 
The healthy well-formed uterus is rarely an ^^ irritable 
uterus '' or associated with dysmenorrhoea. Or the case may 
be stated as follows : — For menstruation to occur healthily and 
easily, the genital canal, from its commencement at the fim- 
briated extremity of the Fallopian tubes to the vulva, must be 
freely pervious. In the course of this canal there are three 
natural constrictions, namely, at the os uterinum of the Fallo- 
pian tube on either side, at the os internum uteri, and at the 
OS externum uteri. It is at these points especially that 
difficulty is apt to arise. But if extreme narrowing occur at 
any other part of the canal, as in the vagina, similar results 
will follow. If the closure be complete, and menstruation 
takes place, of course there will be retention. If the closure 
be incomplete there will be partial retention, the expression 
of which is dysmenorrhoea. This partial retention and dys- 
menorrhoea we know is extremely common. Its phenomena 
should, I think, be studied in connection with those of com- 
plete retention. We shall find in this study endless illustra- 
tions of the proposition that one essential condition of 
dysmenorrhoea is retention of menstrual secretion. There is 
another condition to which retention of secreted matter is 
not necessary. In many cases where there is congestion of 



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112 ON THE ESSENTIAL 

the uterus combined with extreme nervous susceptibility^ the 
pain is most marked at the onset of the period^ that is^ in all 
probability^ before any pouring forth of blood into the uterine 
cavity has taken place. The pain is explained by the sudden 
distension of the morbid uterine tissue by the gathering of 
blood in the vessels preliminary to secretion. A close ana- 
lysis will^ however^ resolve these cases also into the same 
class as the first. In both there is retention^ the difference 
being that in the one case the menstrual blood is retained in 
the cavity of the uterus after secretion^ and that in the other 
case the blood is retained in the tissues of the uterus. The 
point which brings both cases together is that there is diffi- 
cult excretion^ causing distension of the uterine fibre and 
nervous irritation. 

The residual cases^ which do not fall under one or the other 
descriptions of retention^ are rare indeed. 

Let me now invite attention to a series of clinical illustra- 
tions. 

Case 1. — Cicatricial closure of the vagina follomng labour; 
at first partial, then complete retention of menstrual 
fluid; dysmenorrhoea ; operation; cure. 

In January, 1867, 1 met Mr. Powell, at Weybridge, in the 
case of Mrs. W — . Twelve years before, she had been de- 
livered by instrumepts of twins after severe labour. From 
that time she had suffered more or less difficulty in menstrua- 
tion. This had increased gradually and in a marked degree 
during the last two years. During the last three months 
her condition has become very serious. At each menstrual 
period severe colic with expulsive pains set in. An enlarge- 
ment has been felt, rising considerably above the pubes. 
Partial relief has been obtained by the escape of blood and a 
very offensive ichorous discharge. At times retention of 
urine, calling for the use of the catheter, has occurred. The 
introduction of the catheter was difficult, owing to the urethra 
being compressed and deviated by the tumour. A period 
came round two or three days ago, with increased suffering 
and complete retention of the menses. The enlargement 



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CAUSE OF DYSMENORRHCEA. 113 

of the uterus was rapid ; it rose nearly to the umbilicus in 
twelve hours. There was great prostration and small pulse. 
We found the vagina quite occluded by contracted, dense, cica- 
tricial tissue, extending from the meatus urinarius to the anus, 
nothing but a scarred furrow marking the site of the vulva. 
There was a minute red point, which seemed to be the 
opening of a fistulous track, but not even a small probe 
would pass into it. It is probable that this had been really 
the opening of a fistula which had on previous occasions 
given difficult and partial escape to the accumulated fluids 
above, but had now become quite closed. I determined to 
try and open up the vaginal canal next day. She passed a 
bad night from severe colic and efforts at expulsion, and on 
the following morning I found the uterine tumour just as 
large and firm as before. It was directed a little to the left. 
It was also felt per rectum, as a pouch projecting within the 
pelvis. 

The patient was placed in lithotomy position. I passed a 
flexible male catheter into the bladder, and one finger into 
the rectum. I could then feel the hard dense column of 
cicatricial tissue between the bladder and rectum, which 
represented the obliterated vagina. I then, thus guided, 
made careful incisions into the cicatrix, and at about an inch 
above the outer surface struck the sac. A quantity of offen- 
sive ichor, mingled with dirty white clots, escaped. I then 
felt a small dense ring at the bottom of my incisions, no 
doubt the upper part of' the cicatrix. This I enlarged by a 
Simpson's metrotome and a fine knife, until I could pass my 
finger through it. Then I found, beyond this ring, a widely 
distended pouch, formed by the dilated fundus of the vagina; 
at the extremity of this pouch I felt the os uteri slightly 
open, very soft. I could not reach into the uterus, but it 
was clear that the uterus also was distended, forming the 
supra-pubic tumour, as this gradually subsided as more and 
more of the ichorous discharge came away. The patient felt 
great relief, A compress and bandage being applied to the 
abdomen, she was put to bed comfortable. 

Three days afterwards I had a letter from Mr. Powell, 

VOL. XIV. 8 



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114 ON THE ESSENTIAL 

saying '^ she was going on favorably ; did not suffer much 
pain ; the discharge was decreasing ; she was very low ; the 
catheter was used night and morning ; no sign of inflamma- 
tion, but be feared pyaemia; in fact, he thought she had been 
for some time past suffering from it to a degree/' 

It was my intention at a later period to restore the vagina 
more completely, but the patient, being relieved, refused 
further treatment. She got quite well. 

Here was a case in which menstruation was healthily per- 
formed before there was stenosis of the genital canal, dysme- 
norrhoea beginning when the canal began to contract, in- 
creasing in severity as the stenosis increased, merging in 
retention when the stenosis passed into complete atresia, and 
disappearing when the atresia and stenosis were cured. 

Let us compare with this case, which bears all the features 
of a well-devised course of experiments, one of dysmenorrhoea 
from partial retention of another kind. 

Case 2. — Mrs. A — , a well-proportioned lady, had her 
first child three years ago, under a midwife in India; has 
never been strong since ; never having suffered dysmenor- 
rhoea before, she now suffers acutely at the onset of the 
period. When in India the flow was profuse ; since she has 
been in England it is moderate. In addition to the dysme- 
norrhoea she suffered also from constipation, pelvic bearing- 
down pains, and her general health was much prostrated. I 
found the uterus three and a quarter inches long^ the body 
enlarged, tender to touch, and decidedly retroflected. 

On the 20th December last I applied a Hodge's pessary. 

On the 24th January she was wearing the pessary with 
comfort ; she was able to take exerdse with ease ; there was 
no leucorrhoea. She had menstruated without the usual 
distress. The uterus was in its normal position, and mea- 
sured three inches only. I applied a stick of sulphate of 
zinc inside the uterus, and replaced the pessary. 

On the 13th March her report was that she had men- 
struated regularly without pain or excess ; that she was able 
to take exercise freely, and felt quite well. The uterus wa 



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CAUSE OF DTSMENOBBHOSA. 115 

exactly two and a half inches in size, and in its normal 
position. 

Such cases as this I have no doubt most of my hearers can 
parallel by dipping into their note-books or calling upon their 
recollections. They are common. It is for this reason I 
introduce it here, to show, by comparison with the rarer 
cases of retention of menstrual fluid, that the cause of dys- 
menorrhoea is purely retention. 

In this case we see a woman, well formed, menstruating 
normally until after childbirth, when the uterus became 
retroflected, then suffering from dy^menorrhoBa, and cured 
simultaneously with the cure of the retroflexion. 

Case 3. — ^The next case illustrates the same proposition in 
another way. Mrs. H — had always suffered dysmenorrhoea ; 
this had increased after marriage, which remained sterile 
some years. Her medical attendant, finding the os externum 
uteri very smaU, dilated it by laminaria tents on several 
occasions. Each time the succeeding menstruation was 
comparatively easy, but the trouble returned with the con- 
traction. I found a conical vaginal-portion, with small os, 
just admitting the sound. The uterus was normal in direc- 
tion and size. I divided the vaginal portion bilaterally, and 
inserted a Wright's intra-uterine pessary. After that she 
menstruated without pain. 

The next case is one of partial retention cured by opera- 
tion. 

Case 4. — Mrs. W — hAs been married three years without 
becoming pregnant. She is well developed in frame. Two 
years ago she had yellow fever in South America; her 
health has been indifferent ever since. She had always 
menstruated regularly, at times in advance of the period 
due, and lasting four or five days ; not excessive in quantity. 
There had been dysmenorrhoea before marriage and since, 
but not constantly. But latterly, and especially since the 
fever, the dysmenorrhoea has been very severe, and has 



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116 ON THK ESSENTIAL 

evidently undermined her health and wrought a serious 
degree of despondency and other nervous symptoms. 

Under these circumstances she came to England for 
advice. She saw two medical men in town, who told her there 
was nothing to be done. She came to me in October last, 
very discouraged, but determined not to go back to South 
America until she was either relieved or well assured that 
her case was hopeless. I found the vagina was a wide 
shallow cul-de-sac, not an inch deep. There was no pro- 
jecting cervix uteri and no solid body in the roof of the 
cul-de-sac where the uterus might be expected to be found. 
About the middle of the cul-de-sac, however, was a small 
round hole, which just admitted the point of the sound. 
This had been taken to be the os uteri externum. The case 
looked unpromising, as no uterus could be felt in connection 
with it. I submitted her to further examination under 
chloroform. Then having passed a sound into the bladder 
and a finger into the rectum, I ascertained that for at least 
two inches above the vaginal cul-de-sac there was no uterus, 
nothing but the wall of the rectum and the wall of the 
bladder intervened. But about three inches beyond the 
anus I could feel a solid rounded mass, which I concluded 
to be the uterus retroverted. On passing the sound through 
the small opening in the vaginal cul-de-sac t found it pro- 
ceeded two inches along the septum, between the bladder 
and the rectum, towards the solid body which I believed to 
be the uterus. I was now, therefore, in a position to con- 
clude that there was atresia or closing of the vagina from a 
little above the vulva upwards along its whole extent. I 
am unable to determine whether this obliteration of 
the canal was congenital or acquired. It may possibly 
have been a sequel of the fever she suffered two years 
before. 

The position of things being recognised by Drs. Aveling 
and Hewer, who assisted me in the operation, I determined 
to open up the obliterated tract of the vagina so as to 
establish a free communication with the body above, which I 
took to be the uterus. This was done under chloroform. 



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CAUSE Oif DTSMENORRH(EA. 117 

assisted by Dr. Aveling and Dr. Hewer, at two diflferent 
sittings at an interval of a month. Starting from the 
minute opening in the vaginal cul-de-sac^ I separated the 
bladder from the rectum, partly by incising, partly by tearing 
with my fingers, until I could fairly touch the solid body 
through the new canal. When this was done I ascertained 
that this body was the uterus ; it was more rounded than 
natural, its fundus was directed forwards, it was the cervix 
directed backwards which was felt through the anterior wall 
of the rectum. It was now clear that there had been a 
small cavity representing the upper part of the vagina, into 
which the cervix uteri opened ; that this small cavity was 
closed in just below the cervix uteri by the fusion of the 
vaginal walls, if such had ever existed ; that a fine devious 
fistulous tract ran from this upper vaginal cavity to open 
into the lower vaginal cul-de-sac; that the menstrual dis- 
charge had with great difficulty made its way along this 
fistula, which was always in danger of closing. 

(The state of the parts was illustrated by a sketch.) 
I did not succeed in getting a sound into the os uteri, 
but this will probably be effected at some future time. To 
maintain the new vagina I have applied a small elongated 
Hodge's pessary, the upper arch of which, under the leverage 
which is the principle of the action of this most useful 
instrument, is carried high up into the restored vaginal roof. 
A month after the last operation the vagina was well 
preserved, and examining by a Fergusson's speculum during 
a period I could see the menstrual fluid being poured into the 
summit of the vagina. For the first time she was men- 
struating without pain, and her health and spirits were 
already improved. She has now menstruated healthily 
several times, and her health is fairly restored, and there is 
no return of contraction of the vagina. 

The following case is also one of retention relieved by 
operation. 

Case 5.— On the 18th July, 1862, the following case 
came under me at the London Hospital. 



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118 ON THE ESSENTIAL 

J. F — , »t. 28; had one child eight years ago; men- 
struated until seven months ago, when she had typhoid^ 
since then no menstruation. Was in hospital under Mr. 
Critchett; presumed to have some form of syphilis. I found 
the vagina represented by a short cul-de-sac, the roof of 
which was quite smooth, no cervix or os felt projecting, nor 
could the uterus be distinctly made out between the finger 
in vagina and the hand above pubes. I concluded that there 
had been sloughing of cervix uteri and vagina and closure by 
granulation and cicatricial contraction. By speculum was 
seen at the highest point of the roof a cicatrix-like spot* 
She suffered nearly every day from pains ^^like labour- 
pains,'' which were commonly appeased by hot flannels. 
No pain on defecation. On the 25th her state was the 
same. I advised her to come in, but this she postponed 
doing. 

On the 8th August she came, suffering acute abdominal 
and pelvic pains, and was admitted. Aided by Mr. Little^ 
I proceeded to open up the obliterated vagina. All that 
remained of vagina was a shallow cul-de-sac close behind the 
nymphse. The perinaeum being retracted by a duck-bill 
speculum, I made cautious incisions with a pointed bistoury 
through the middle of the white cicatrix ; partly stretching 
by fingers, partly by small nicks, I made a canal an inch 
long and wide enough to admit the tip of my finger. After 
the first incision I was guided in further progress by causing 
the fundus uteri, which was plainly felt as a large globe 
above the pubes, to be pressed downwards and backwards, 
so as to throw the cervix downwards and forwards. By 
this means the cervix was felt to project at the bottom 
of the wound. The operation had now lasted an hour, 
and it was considered desirable to postpone further pro- 
ceedings. 

On the 10th the operation was proceeded with. A catheter 
in the bladder, held well under the pubic arch, kept the 
neck of the bladder away from the knife. The finger in the 
rectum felt the lower segment of the uterus distended. 
Cautious nicks were again made, taking care to work in the 



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CAUSE OF OYSMENORRHCEA. 119 

cicatricial tissue a little forwardj so as to avoid puncturing 
Douglases sac* Presently the os uteri was tapped^ as was 
manifested by the oozing of a thick^ tenacious^ brown-black 
blood. So tenacious was it that it could be drawn out 
in a string by forceps. It was not considered right to seek 
to empty the uterus ; the organ was left to empty itself by 
its gradual contraction. An opium suppository was placed 
in the rectum^ and a compress was applied to the abdomen 
to press the uterus down in the pelvis. In the course of 
two days the uterus emptied itself. She had not a bad 
symptom. 

On the 9th the uterus could not be felt above the pubes. 
I was unable to pass a sound into the os uteri. The patient, 
feeling well^ insisted on going out. 

On the 16th September pain occurred at the menstrual 
period and subsided without any discharge. She was re- 
admitted. The upper part of the vagina had closed again^ 
excepting a small round canalj which admitted the sound 
three quarters of an inch. By bistoury and stretching I 
opened this up again. She went out again relieved. She 
was a recalcitrant patient, who rejected treatment as soon as 
she was released from urgent distress. 

I am unwilling to lengthen the paper by detailing other 
cases of dysmenorrhoea from partial or complete retention 
due to stenosis and atresia. I may simply add that I have 
seen all the phenomena of dysmenorrhoea passing into re- 
tention in a case of gradual closure of the cervix uteri 
following on amputation of the cervix uteri for malignant 
disease. 

It would lead us too far to attempt here to trace the 
complete history of stenosis and atresia of the genital canal. 
On several occasions the subject of retention from imper- 
forate hymen has been well illustrated by cases and discus- 
sion in the Society. I need, therefore, do no more here 
than offer such reflections upon this form of retention as will 
serve the purpose ip hand. 

Imperforate hymen being a congenital fault, we have not 



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120 ON THE ESSENTIAL 

the same opportunity of tracing dysmenorrhoea into reten- 
tion as in cases of acquired or gradually forming atresia. 
But the lessons drawn from cases of retention from congenital 
atresia have also their value. In these cases there is appa- 
rent amenorrhoea; but as there is actual secretion of the 
catamenia^ a more correct term would be " occult menstrua- 
tion.'' Retention begins with the first secretion^ and pain^ 
often severe, attends. This remits, and is renewed or exacer- 
bated periodically under the ovarian stimulus. The patient, 
in fact, has attacks of dysmenorrhoea ; but how, it may be 
asked, is it that, retention of menstrual fluid being continuous, 
the attacks of pain are not persistent also ? The explanation 
is this : — There are certain compensatory processes which 
bring temporary relief, and which avert or postpone the 
catastrophe which is always impending in these cases. 
These accommodating processes are — 1. The gradual yield- 
ing and growth of the uterus and vagina, enabling them to 
hold a larger quantity of fluid without stretching the uterine 
fibre. 2. The watery part of the blood is absorbed, hence the 
inspissated treacly character of the fluid that flows when the 
obstructing barrier is removed. But as every monthly in- 
crement of blood is thrown in more or less suddenly, the 
uterine fibre is stretched, and dysmenorrhoeal symptoms 
recur. 3. After a time the obstruction often leads to difficulty 
of secretion, perhaps to inactivity of the ovaries, so that a 
diminished quantity of blood is secreted at each period. 

Hence it is that the enlargement of the uterus and abdomen 
is so gradual, so far from corresponding to what might be 
estimated from the addition of the full amounts of all the 
monthly secretions. 

The following case presents a close analogy to dysmenor- 
rhoea. It is one of frequent occurrence. 

Case 6. — Mrs. D — , aged over 50, never pregnant, has 
latterly fallen into wretched health; has frequent attacks of 
vomiting; has become emaciated and nervous; has a dis- 
charge tinged with blood, and at times offensive, preceded by 
uterine colic. She was referred to me by the physician 



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CAUSE OF DYSMENORRHCEA. 121 

whom she came to town to consult. I found the vagina and 
vulva small, undergoing some degree of senile atrophy ; the 
vaginal-portion projected somewhat; the os externum was 
quite occluded. I could not get a sound to pass in. There 
was acquired atresia, partly the result of original stenosis, 
partly of advancing senile contraction, and partly of aggluti- 
nation by inspissated secretions. I penetrated the closed os 
by a fine knife, carried in a sheath, such as is used for 
dividing stricture of the male urethra. The sound then 
readily went the normal length; relief quickly followed. 
. Some pent-up mucus escaped. Some weeks later she had 
continued to improve, and there had been no return of 
discharge or colic. 

It is not necessary to adduce similar cases in which long- 
standing dysmenorrhcea was cured by incision of the os 
externum, relapse occurring when the os contracted again, 
and a permanent cure was obtained when the os was kept 
patent. 

In cases of anteversion and anteflexion without stenosis 
dysmenorrhcea has been time after time relieved or 
averted by the passage of a sound a day or two before the 
onset of menstruation. By this means and rest the uterus 
was redressed for the occasion, and the obstruction and 
retention were averted. If this measure was at any time 
omitted the dysmenorrhcea was sure to come, and the body 
of the uterus became very sensibly enlarged. Permanent 
cure has constantly followed permanent restoration of the 
uterus to its proper position. 

Another cause of dysmenorrhcea, and often of haemorrhage, 
is the fixing of the uterus by perimetric deposits, coming on 
after labour or abortion, or other conditions. The fixing of 
the uterus, although commonly attended by patency of the 
cervix, seems to me to cause dysmenorrhcea by preventing 
the uterus from contracting, and also by favoring engorge- 
ment of its tissues. 

Dysmenorrhcea is a not uncommon attendant upon fibroid 
tumours, which either produce obstruction by twisting or 



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122 ON THE B88ENTIAL 

compressiiig the cervical canal^ or by keeping up a state of 
congestion, or by interfering with the effective r^olar con- 
traction of the uterus. Dysmenorrhcea from the first cause 
is frequently relieved by dilating the cervical canal either by 
tents or incisions. 

Many other instances will occur of pain analogous to that 
of dysmenorrhoea produced by the retention in the uterus of 
blood-clots, as after labour and abortion, of intra-uterine 
polypi, of the exfoliated mucous membrane in the dysmenor- 
rhoea membranacea, or, in fact, of anything which distends 
and irritates the uterine cavity. The difference in the 
symptoms and the degree of severity depend, not so much 
on the nature of the substances retained, as upon the com- 
pleteness of the retention and the nervous susceptibility of 
the patient. 

A further proof that dysmenorrhcea is due to retention 
lies in the changes the menstrual fluid undergoes, and the 
characters it presents when discharged. In some cases, 
especially those in which there is such excess of blood as to 
deserve the designation of menorrhagia; the escape being 
impeded, and the mucous secretions of the cavity of the 
uterus being insufficient in proportion to preserve the normal 
liquid state, clots form. In other cases, in which there may 
be no excess of quantity, the retention is so protracted, or the 
quantity of catarrhal mucus mixed with it so large, that the 
fluid, when discharged, closely resembles in its syrupy con- 
sistency and dark colour that which is pent up by an 
imperforate hymen. This is markedly so in some cases of 
temporary retention from compression of the cervical canal 
by a fibroid tumour. But it is not uncommon in obstruction 
from retroflexion and from stenosis of the os externum. The 
discharge is often also offensive to the smell. 

With all this variety of illustrations concentrated into one 

frk/>nfi VTA aYiaII Ykfk liiAflfipH in rPTlPAtinflr f.TlA nmnrftaifirkTi urifli 



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CAUSE OF DT8M£NOBBH(EA. 123 

some which I should hesitate to consign to the neuralgic 
asylum. We meet with cases every now and then in which 
the dysmenorrhcBal symptoms are yery severe^ although there 
is no obvious stenosis. In some of these I have found the 
uterus small^ perhaps inclined to onq side^ set in a short non- 
distensible vagina; sometimes the os externum is preter- 
naturally small^ but even after freely dilating this the dys- 
menorrbcea pernsts. 

The subjects of this kind of imperfect development, for such 
it is, are commonly of a highly nervous temperament, acutely 
sensitive of pain, and it would be easy to say they suffer from 
''irritable uterus^' or neuralgic dysmenorrhoea. But this 
refage seems unsatisfactory. In some of the subjects it is 
certain that the hypersesthetic condition has been gradually 
developed, caused by the frequent pain and imperfectly per- 
formed function, and was not a primary condition. In some 
cases I have seen great improvement, even cure, from the use 
of Simpson's intra-uterine galvanic pessary. 

There is a feature in the history of stenosis and atresia of 
the genital canal which it i^ interesting to describe on 
account of its bearing on treatment. Under the condition 
of stenosis or atresia long persisting this canal obeys the same 
law which rules over other canals or hollow organs. It under- 
goes retrograde dilatation above the seat of stricture. This is 
the almost inevitable consequence of the fatile attempts of 
the muscular coat to expel the retained contents.^ This 
effect is seen in the most marked form in cases of imperforate 
hymen. The vagina, being the most distensible part of the 
canal, dilates first, forming a large pouch ; then the cervix 
uteri is distended, then the cavity of the body of the \iteru8f 
and, lastly, the Fallopian tubes. This dilatation, conservative 
in its effect by accommodating the contents which cannot be 
evacuated, has its limits. When these are reached, the 
danger of rupture or perforation at the weakest part is great. 
But before this comes to pass there are two events which may 

' Thii sacceMive ascending dilatation of vagina, cervix, body of nteros, and 
tabes, were illnstrated in sketches taken from preparations in Guy's, St. 
George's, and the Badcliffe Museums. 



i 



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124 ON THE ESSENTIAL 

happen. The first is transudation of the more fluid part of 
the contents under the concentric compression to which it is 
subjected. Dr. Matthews Duncan has shown that under a 
certain degree of hydraulic pressure air or liquids penetrate 
the entire wall of the uterus. This is the old Florentine 
experiment of the metal globe applied to organic tissues. His 
experiments^ of course, were performed on dead tissues. But 
it appears to me that there is good reason to believe that the 
force which the living uterus exerts in its efforts to expel 
what may be in it, whether it be a foetus or imprisoned fluids, 
is enough to drive fluid through its walls in the form of a 
fine oozing or dew, which hangs on the peritoneum. It seems 
to me probable that it is in this way that some cases of 
puerperal pelvic peritonitis are produced, and I have seen 
cases of septicaemia and peritonitis occurring from retention 
of menstrual fluid greatly resembling puerperal fever, in 
which there was no rupture and no escape of fluid by the open 
ends of the Fallopian tubes. 

Supposing that the structures retain their integrity, it is 
natural that the concentric compressive force should drive 
the contents along any passage that may be pervious. Hence 
the escape by preference along the tubes. This is rendered 
more likely by the dilatation which commonly takes place at 
their uterine ends. 

This compressive force is exerted with most effect imme- 
diately after the puncture of the closed hymen. The sudden 
collapse of the walls of the uterus ensuing upon the partial 
escape by the opening excites the uterus to contract. This 
contraction drives the contents along all the three canals, 
and some will probably escape through one or other of the 
tubes into the peritoneal cavity. 

The more common event, however, is the laceration of the 
tubes at the weakest place, caused by the sudden dragging 
upon them by the retreating uterus, the tubes being, perhaps, 
held back by adhesions. 

It has frequently been discussed in this Society and else- 
where, how this catastrophe of sudden escape of the uterine 
fluid into the peritoneal cavity can best be averted. Some 



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CAUSE OF DYSMENORRHCEA. 125 

have contended that it is better to make a very small opening 
in the hymen and let the fluid drain away gradually, hoping 
that in this way the suddenness of the collapse of the uterus 
might be diminished. This is the plan I have hitherto 
followed. But others have preferred making a free incision 
at once^ and even proceeding to wash out the cavity. I am not 
sure that this is not the best plan. A free external outlet 
would make it easier for the contracting uterus to expel its 
contents by this route^ and thus take olSTthe pressure towards 
the tubes. On the other hand^ the rapid retreat of the uterus 
would favour laceration of the tubes if held back by adhesion. 
The balance of advantages and of drawbacks of either plan is 
difficult to strike, and it is to be apprehended that cases will 
continue to occur in which a fatal result will follow any 
method of treatment. 

A plan which I should be disposed to try is to draw off a 
little at a time by the aspirator trocar, so as to effect a very 
gradual diminution of the cavity before finally freely dividing 
the obstruction. In any case absolute rest should be rigidly 
enforced. 

When these cases of retention have been relieved and have 
apparently recovered, it must be remembered that the Fal- 
lopian tubes do not at once, perhaps not for a long time, 
recover their normal calibre. Some degree of abnormal 
dilatation remains. This is certainly the case in the partial 
retention due to stenosis of the cervix and to retroflexion. The 
knowledge of this fact is of the highest importance in practice. 
The long-continued obstruction having entailed dilatation of 
the uterine cavity and catarrh of its mucous membrane, with 
very often a disposition to monorrhagia, the physician is 
tempted to inject astringent fluids into the uterus. It is well 
known that fatal accidents have followed this practice, and 
much discussion has taken place as to the immediate cause 
of these accidents. The prevailing idea is that the injected 
fluid is driven along the tubes by the force of the syringe, its 
return by the cervix being stopped by the injecting tube 
which fills it. I am disposed to believe that where there is 
unusual patency of the Fallopian tubes this may occasionally 



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126 ON THE ESSENTIAL 

be the case. But the more common mechanism I am con- 
vinced is that which I have jnst explained as occurring in 
retention from imperforate hymen. The astringent fluid 
thrown into the uterine cavity acts primarily as an irritant 
and constringent. This action is forcible and rapid. The 
cavity instantly contracts and pumps on the fluid along the 
patent Fallopian tubes. 

That this was what occurred in a case in which a solution 
of perchloride of iron was injected into the uterus on account 
of haemorrhage from retroflected uterus in the London 
Hospital seems to me beyond doubt. The tubes were found 
patulous^ and fluid had run along them into the peritoneal 
cavity. 

It is important^ then^ to recognise it as a general fact that 
whensoever the uterus has long been subjected to stenosis or 
flexion there will very probably be patency of the Fallopian 
tubes^ and consequently facility for the transmission of fluids 
from the uterine cavity into the peritoneal sac. 

Bearing this danger in mind^ I am not satisfied with 
observing the rule, very properly insisted upon by Dr. Bouth 
and others, of obtaining free patency of the cervical canal 
before injecting ; I prefer not to inject at all, but to apply 
styptics, either by swabbing or in the solid form. For 
example, a suitable intra^uterine pessary can be made by mixing 
perchloride of iron with cocoa-nut butter, or, the cervix being 
open, we can paint the inner wall of the uterus with a glass- 
brush steeped in chromic acid. Of course I am here speaking 
of the non-pregnant uterus. To control post-partum flood- 
ing, I still employ the method of injecting. 

There is another consequence of the dilatation of the 
cavity of the uterus which is interesting. Dilatation is 
extremely likely to be attended by catarrh ; indeed, some 
authors say that catarrh is the cause of dilatation. The 
mucus resulting collects in the cavity until this is filled, when 
it ''causes irritation and expulsive pain resembling an attack 
of dysmenorrhcea. This is commonly relieved by the discharge 
of a quantity of mucus which the patient will often describe 
as '' matter from the bursting of an abscess.'^ Supposing the 



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CAUSE or DY8MENOBRHCEA. 127 

secretion of this catarrhal mucus to go on^ as it mostly does, 
at a tolerably uniform rate, the uterus will be filled in a given 
fixed time, say in a week or a fortnight. Hence the 
periodicity, more or less exact, which is sometimes observed 
in these cases. If the attack returns midway between the 
menstrual periods, it may be called " intermenstrual dys- 
menorrhcBa.^^ The term is a bad one, although it may seem to 
be justified by a little blood being mingled with the discharge. 
This is not uncommon, and may be explained by the conges- 
tion which complicates these cases. 

The facts narrated and the reflections I have ventured to 
express bear so directly upon the treatment that I think it 
unnecessary to enter at length upon the discussion of this 
the true end of every clinical investigation. I have done this 
partially on former occasions, and so have other Fellows of the 
Society. I will not, therefore, do more than simply point to 
the logical deduction from the theory of the essential cause 
of dysmenorrhcea set forth. 

The indication to remove the obstruction, whether this be 
complete or incomplete, is so obvious as not to need discussion. 
At least no one disputes the necessity of doing this if 
obstruction be complete, and the expediency of doing the 
same thing when the obstruction is incomplete rests upon 
the same logical basis, the difference being that in the 
latter case the necessity of operating is less imperative. In 
the first case life is in imminent peril, in the latter life is 
not immediately imperilled. It is a question of relieving 
suffering and of restoring the organs to their natural healthy 
functions. 



Dr. Flatfaib said that every one would willingly admit the 
^at value of the paper which Dr. Barnes had read, and the 
interest of many of the cases he had brought forward. The view 
which he so strongly advocated had been equally strongly upheld 
by Bemutz and Goupil, and other writers. It would, no doubt, 
be very satiefactory if we could explain the suffering connected 
with dysmenorrhooa by the presence of one condition aloue. It 
would UDquestioDably greatly simplify our study of the affection. 
Unfortunately, however, it appeared to him that clinical facts 



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128 ON THE ESSENTIAL 

were not in accordance with a theory so seductiye from its sim- 
plicity. He had no wish whatever to throw the least doubt upon 
the mechanical theory as explanatory of a large number of cases. 
On the contrary, he believed it to be a very frequent cause 
indeed, and an important one. Many of the cases Dr. Barnes had 
brought forward conclusively proved this. But then several of 
these were of quite an exceptional character, such as only come 
under the observation of a nractitioner of his great experience. 
Others, such as flexions of tne uterus, fibroids, &c., are, no doubt, 
active causes of the painful menstruation, and can only be reme- 
died by the removal of the obstructing cause. But besides these 
he was inclined to think that there are a far larger number of cases 
than Dr. Barnes allowed where nothing of the kind can be found. 
Take for example those, so frequently met with, which have been 
classed under the head of congestive dysmenorrhcsa. Here the 
pain is entirely or chiefly felt before the menstrual secretion is 
established ; the moment that comes on the bleeding relieves the 
congestion and the pain vanishes. Clearly there can be no 
menstrual retention in the ordinary sense here, but even these 
cases Dr. Barnes refers to the same category by an hypothesis 
which, to say the least of it, seems a very remarkable one. He 
says these cases resolve themselves into the same class as the 
others, " the difference being that in the one case the menstrual 
blood is retained in the cavity of the uterus after secretion, and 
that in the other case the blood is retained in the tissues of the 
uterus." But surely there is all the difference in the world 
between pain which' results from the efforts of the uterus to 
expel what is practically a foreign body in its cavity, and pain 
which results from the presence of an undue amount of blood in 
the vessels of the organ ? Pain of the latter class is common, 
not only in the uterus, but all over the body, and it is just such 
a condition that produces the pain of a gum boil or some similar 
affection, and here, as elsewhere, the pain is relieved as soon as 
loss of blood relieves the loaded vessels. No doubt, in the large 
majority of these cases there is some local condition of the uterus 
which explains the congestion, and which should be carefully 
searched for, such as chronic inflammatory condition of the 
uterus or a morbid state of its lining membrane. It is because 
these exist that the congestion of the menstrual nisus produces 
paiu, which it should not do in a healthy state of the uterine 
structures. It should be noted, too, that in many of these cases 
the cervical canal is found to be morbidly patulous rather than 
constricted. Then there is a class of cases of some importance 
to which Dr. Barnes makes no allusion, which may be oescribed 
in cases of ovarian dysmenorrhoea. In these the pain has pro- 
bably nothing to do with the uterus at all, but would seem to 
depend on the changes going on in the ovary in connection with 




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CAUSES OP DYSM£NORRU(EA. 129 

maturation of the Graafian follicle, and the discharge of the 
ovum. In these the pain is more or less distinctly referable to 
the site of the ovaiy, and not infrequently the enlarged and 
tender ovary can be felt on vaginal examination immediately 
before, after, or during the menstrual period. While, therefore, 
fully admitting the importance of mechanical causes of dysme- 
norrhoea, he believed that we should be taking a more philo- 
sophical and correct viev^ of the affection if we did not try to 
force our explanation of them too rigidly into one groove. 

Dr. Snow ££GE quite agreed with the remark that this paper 
was founded on erroneous principles, which, if adopted, would 
lead to improper practice, especially in the virgin. Pain, or in- 
creased pain, at the menstrual period — dysmenorrhosa as it 
was termed — was an attendant on most of the diseases of the 
uterine organs, and one of the distressing ailments, often a most 
troublesome one, from which the female frequently sought relief. 
It would be impossible to go over, at the present time, the 
various diseases which induce this pain, many of which had little 
relation to each other. But it might be stated broadly that it 
was induced by any defect in the menstrual secretion, either 
congenital or acquired, or by any alteration of the uterine organs 
from a condition of health, either congestive, inflammatory, or 
structural. Not unfrequently it arose from deficient develop- 
ment of the uterine organs, apart from any mechanical obstruction 
to the menstrual flow, and sometimes appeared to depend upon 
an unusual nervous susceptibility of the individual. No doubt 
it every now and then was caused by a mechanical obstruc- 
tion to the menstrual flow, whether this arose from con- 
genital defect, or from an acquired alteration, the result of some 
previous disease. But these were only exceptional cases when 
compared with the frequency with which it was met with as a 
svmptom of other diseases. The idea of this mechanical obstruc- 
tion was a very seductive one ; had been frequently taken up by 
different observers, and as frequently dropped after further expe- 
rience as being a very inadequate explanation. He was unable 
to understand the statement that when the obstruction did not 
occur in the natural cavities of the organ it was caused by 
obstruction in the tissues. Dr. Barnes did not mention the par- 
ticular types or tissues in which this supposed obstruction 
occurred, or the changes in these tissues by which it was accom- 
plished. It was, he suspected, one of those imaginary state- 
ments too often indulgea in and made without any sufficient 
foundation in ascertained facts. Some of the classes of cases met 
with in everyday experience were alluded to to show that in 
most of them there was no clinically observed facts sufficient to 
justify the statement that obstruction was "essentially" the 
cause of this pain. The case mentioned by Dr. Barnes, where 

VOL. XIV. 9 



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130 ON THE ESSENTIAL 

a lady, after her confinement, complained of pain during men- 
struation, and on examination the sound passed 34 inches, did 
not afford any evidence of obstruction. Since attention had been 
directed to these cases they were found to be of too frequent 
occurrence. The whole of the uterus remained enlarged, the 
external orifice often so patent as to admit the end of the finger ; 
the cavity of the neck was large ; the sound readily passed the 
internal orifice, and, by the freedom of the motion allowed, 
evidently entered an enlarged cavity in the body. The vagina 
also was generally large and ample, and the menstrual flow came 
away freely and without the least evidence of any coagula, yet 
was attended with great pain. No doubt, in many of these cases, 
there was a bending of the uterus forwards or backwards, but the 
attending pain was not greater in those cases than in others 
where the organ was found to be straight. Sometimes relief was 
afforded by passing the sound through the internal orifice, which 
was followed by the escape of a small amount of blood ; but where 
this proceeding succeeded once it failed in the large majority, aud 
was often so painful that the women after a few trials declined to 
have it further repeated. Again, these enlargements of the uterus 
were every now and then met with where the menstruation 
appeared naturally, and without any increase in the usual incon- 
venience; and the absence or presence of the attending pain 
appeared to depend upon the condition of the blood-vessels. In 
the examples where the pain was increased all the vessels were 
enlarged ; the arteries, the veins and the capillaries, and the 
organs were greatly congested ; where there was little attending 
pain the enlargement of the organs existed without the accom- 
panying congestion. He suspected it was these latter cases 
which had been described as fibroid enlargement of the whole of 
the uterus. In other cases met with in the virgin and in women 



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CAUSES OF DYSMENORBHCEA. 131 

the virgin as well as in the married female, the pain arose from 
irritation, or chronic inflammation, of the vagina, where obstruc- 
tion was totally out of the question. In these cases the pain came 
on two, three, or four days previous to, and ceased, or was much 
relieved, on the appearance of the menstrual flow, was of a con- 
stricting character, attended with shooting pains up the vagina 
and bearing-down feelings, the pain being seated deep in the 
hypogastrium, in the groins and lower part of the back. He was 
aware that those cases were usually described as of ovarian origin, 
but was convinced that this error arose from want of careful 
observation. That these symptoms arose from affections of the 
vagina was well shown in the case of a young lad^, which proved 
fatal, and was published by the late Mr. Obr6 in the ' Joritish . 
Medical Journal' for 1857. In another class of cases this 
vaginal irritation or congestion appeared to depend upon great 
constipation of the bowels, and was often met with in the virgin. 
Pain in the head, want of appetite, distress after taking food, and 
general languor were the attending symptoms, when on inquiry 
the bowels were found much constipated, being relieved once or 
twice a week and insufficiently. Ghradually pain came on at each 
menstrual period, deep in the hypogastrium and lower part of the 
back, with shooting pains and bearing down. All of which 
symptoms passed away after a time when free and regular evacu- 
ations of the bowels were obtained, aided by cold and soothing 
vaginal injections. It was in these cases that guaiacum, 
which had been long recommended for painful menstruation, 
appeared to be of much service. Again considerable congestion 
of the rectum accompanied with hsBmorrhoids, but without any 
noticeable affection of the uterus, was attended with great pain 
during each menstrual period, which appeared to be induced by the 
increased congestion of the pelvic veins accompanying the men- 
strual period. In fiEust, nearly all acquired, as distinct from 
congenital, alterations of the uterine organs from a state of 
health was attended with more or less increased pain during 
menstruation, and some affections of the neighbouring organs 

fave rise to a similar increase of pain. The subject of 'The 
rritable ITterua ' was too long and too complicated to be con- 
sidered at the present time. In conclusion, he had no hesitation 
in expressing his belief that obstruction to the exit of the 
menstrual flow formed but a small proportion of the cases at- 
tended with increase of pain during menstruation, and that the 
treatment directed *' essentially *' to this object would in the large 
majority of instances be attended with unfavorable results. 

Dr. KOGEBS said that he must dissent from the conclusion, 
as far as he understood it, which the author of this most ex- 
cellent and practical paper appeared to have arrived at, and must 
agree with the opinion of the preceding speakers that dysme- 



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132 ON THE ESSENTIAL 

DorrbcBa was not a disorder depending solely on obstructive causes. 
Those who, like himself, had been in the practice of their pro- 
fef^sion over five and twenty years, and beiore the theory of ob- 
struction was acknowledged and taught to be a cause of this 
affection, must have cured undoubted cases of dvsmenorrhoBa, 
and have known such cases cured in the practice of others. He 
had been for years physician to the Samaritan Hospital, where at 
an early period obstruction was recognised to be an important 
cause of dysmenorrhoea, and several of his colleagues have even 
invented instruments for operative treatment of such cases, and 
he had on many occasions used these instruments when other 
means have f&iled, and the case required it ; and he had operated 
in cases similar to those brought before the Society by Dr. 
Barnes. In his opinion many cases occur from other causes, 
such as ovarian, rectal, or pure neuralgic disorders. It may be 
remembered by the Fellows that his colleague, Dr. Bouth^ had 
read papers before the Society with cases on a form of dysme- 
norrhoea arising from what he called fiindal endometritis, where 
every care had been taken to eliminate all obstructive cause, and 
yet the dysmenorrhoea persisted. 

Dr. Tilt thought the author had failed to make good his 
aasumption that dysmenorrhoea was always caused by the re- 
tention of the menses in the uterine cavity, and Dr. Tilt thought 
it was unjustifiable to give cases of menstrual retention by 
vaginal occlusion as illustrative of dysmenorrhoea. He thought 
the most frequent cases of obstructive dysmenorrhoea were those 
in which the obstruction was clearly spasmodic ; cases in which dark 
blood and blood clot were passed after two or three belladonna-and- 
opium suppositories had been introduced into the rectum; the 
cervical canal freely admitting the uterine sounds forty-eight hours 
after menstruation. He said he had repeatedly met with cases in 
which dysmenorrhoea was intense, although the cervical canal 
was perfectly free, the discharge of a flond colour and without 
clots. The dvsmenorrhoea in those cases sometimes depended 
on chronic inflammation of the menstruating surface, sometimes 
on morbid ovulation and subacute ovaritis ; whereas, in excep- 
tional cases, the complaint would only be considered as a 
neuralgia of the menstruating womb. 

Mr. SpEircEB Wells believed that a very large proportion of 
cases of true dysmenorrhoea depend upon mechanical impedi- 
ment to the free escape of the menstrual fluid, and are curab^ by 
removal of the obstruction. Sympathetic pains in the breast, or 
elsewhere, and nervous symptoms common at the menstrual 
period should not be confounded with true dvsmenorrhcea. He 
narrated cases in which severe obstructive dysmenorrhoea had 
been cured by replacement of the flexed uterus, by dilatation cf 



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CAUSES OF DYSM£XORRH(£A. 133 

the cervical canal, and by opening a closed vagina. In the last 
case careful inspection is much safer than using a trocar. 

Dr. Babkes, in reply, thanked the speakers for their criticism, 
which would be exceedingly useful to nim. There was no time 
left to answer each in detail. The criticisms with which he had 
been &voured had excited in him some surprise. He had an- 
ticipated rather being found fault with for bringing before the 
Society propositions too trite, and which no one disputed. He 
had not expected to hear so many expressions of dissent. The 
general tenor of the observations made was to attribute to him a 
more absolute reference of cases of dysmenorrhcea to retention 
as the cause than the paper justified. He admitted that there 
were other causes ; he had expressly cited ovarian conditions ; 
but he could not assent to the conclusion that because in many 
cases of dysmenorrhoea pain was referred to the region of the 
ovaries, the cause in these cases was necessarily due primarily 
to ovarian diseases. It was just to remember that Henry Bennet 
long ago pointed out that ovarian pain was symptomatic of in- 
flammatory condition of the uterus. It was also symptomatic of 
other diseases of the uterus. When these diseases were cured 
the ovarian pain vanished. Dr. Playfair missed the true appli- 
cation of the cases of complete atresia to the question under 
discussion. Certainly they were rare, but such a case as the one 
of the woman menstruating easily whilst the genital canal was 
healthy, menstruating with increasing difficulty and pain as the 
closure of the vagina advanced, then suffering all the ills of 
.retention when the closure was complete, and laistly being cured 
of her dysmenorrhoea when the vagina was restored, afforded a 
series of proofs to which the best designed series of experiments 
that could be devised could add little, that dysmenorrhoaa was 
due to incomplete retention. Dr. Snow Beck's anxiety lest the 
adoption of this theory of retention should lead to mischievous 
treatment might be allayed by the reflection that if no cause of 
retention were discovered there would be no operation neces- 
sary to remove it. One rule indeed flowed from the clinical ob- 
servationSf namely, that in cases of dysmenorrhcBa persisting and 
injuring the patient's health, examination of the condition of the 
organs whose functions were impaired should be made. 



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WEDNESDAY, May 1, 1872. 

John Braxton Hicks, M.D., P.R.S., President, in the 

Chair. 

Present — 35 Fellows and 3 visitors. 

Books were presented from Dr. H, J. Bigelow, Dr. Ousse- 
row, Dr. H. Lohlein, Dr. E. A. Martin, Dr. Sanger, D r. 
William Turner, Dr. Paul Zweifel, and the * Gesellschaft fUr 
Geburtshiilfe zu Leipzig.' 

The following gentlemen were admitted Fellows of the 
Society : — Mr. J. R. Bosworth, Dr. W. L. Richardson, Dr. 
Thomas Savage, Dr. Algernon Temple, Dr.Wellesley Tomkins, 
and Dr. W. C. Wise. 

The following gentlemen were elected Fellows : — Michael 
Coote, M.D. (Quebec) ; N. S. Kerr, M.D. (Liverpool) ; 
Jos. McMonagle, M.D. (St. John's, New Brunswick) ; W. 
K. MacMordie, M.D. (Portadown, Armagh) ; F. D. Niblett, 
M.B. (Hackney) ; and John Wallace, M.D. (Liverpool). 

Dr. Wynn Williams exhibited a large-sized mucous 
polypus he had removed the same day from a patient at the 
out-department of the hospital. He considered it interesting 
more on account of the history of the case than for itself, 
for although large for a mucous polypus, there was apparently 
nothing extraordinary in its character. 

Mrs. B — , set. 45, mother of two children, the younger 
ten years of age. Three miscarriages since birth of the 



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136 MUCOUS POLYPUS. 

last child. She has for the last six years suffered more or 
less from excessive losses. Stated she had not menstruated 
since 18th of December last, but has suffered from a dis- 
charge of bloody matter. On placing the hand on the abdo- 
men, there could be no doubt that she was about seven 
months pregnant. Examination per vaginam with the 
finger revealed, it might be said, nothing ; the os was felt 
swollen, soft, and open. It would have been most difficult 
to have diagnosed the case without using the speculum. A 
rugose and vascular-looking mass, the size of three fingers, 
was seen hanging by a pedicle out of the os. There was also 
a small mucous polypus attached lower down near the os. 
Dr. Williams at once proceeded to remove the larger growth, 
drawing it slightly downwards ; a ligature was placed on the 
pedicle just within the os, the interior of the uterus being 
disturbed as little as possible, and the polypus divided with 
a pair of scissors below the ligature. The smaller one was 
then removed by torsion, and the parts swabbed with a satu- 
rated solution of tannin in spirit of wine, which completely 
arrested the very slight bleeding. 

In answering the remarks made on the case, Dr. Wynn 
Williams considered that the patient would stand a much 
better chance of completing the full time of utero-gestation 
after the removal of the growth, than if it had been left 
alone, remarking that it should not bQ forgotten that the 
patient had aborted on three previous occasions. In answer 
to Dr. Heywood Smith, he considered that if the larger 
growth had been removed by torsion, springing, as it evidently 
did, high up in the neck, the contents of the uterus would have 
run a much greater risk of being disturbed and abortion 
produced than by the means adopted for its removal. 

Dr. Phillips said that he had removed a polypus in a similar 
case a few days previously. The patient was under his care in 
Guy's Hospital, and bad a good-sized muco-oellular polypus 
attached to the cervix uteri, and she was six months pregnant. 
The hflBmorrhage to which it gave rise was enough to induce him 
to remove it. The question of greatest interest suggested by 
Dr. Williams' case and bis own was the advisability of removing 



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SYPHILITIC DISEASE OF THE PLACENTA. 137 

polypi during pregnancy. It seemed necessary in deciding the 
question to take into consideration the amount of disturbance to 
which the polypus gave rise; but generally he thought that 
abortion was less likely to be induced by the remoTal of a polypus 
han^^ out of the os uteri than by allowing it to remain. The 
resmt in the case to which he referred had been in eyery way 
satisfactory. 

Dr. EouTH said he had some time back seen a similar case in 
the country with a practitioner. He was called in in consequence 
of the hsdmorrhage, and to know whether he could advise arti- 
ficial labour to be induced. On examination, a polypus some- 
what larger than that of Dr. Williams' case was found projecting, 
and by the use of the speculum was seen distinctly. Dr. Bouth 
felt an operation might induce labour, nevertheless, he con- 
sidered this should be brought on, and then the polypus removed 
to prevent a recurrence oi bleeding. The lady, however, for 
some reason or other delayed the operation, and labour came on 
in two or three days. The polypus, however, was not found, and 
probably was torn away with the head of the child. The practical 
point was not, however, settled in Dr. Williams' case, as he did 
not know yet if his operation would or would not bring on a 
miscarriage. It was m his (Dr. Bouth's) mind quite safe to 
remove a polypus. 

Dr. Barnes exhibited, for Dr. James Blake^ of San 
Francisco, a modification of Hodge^s pessary, consisting in 
the substitution of watch-spring for the usual solid Lich- 
bars. This modification gave elasticity to the pessary, which, 
whilst it increased the eflBcacy of its leverage action, dimin- 
ished the risk of shock or concussion. 

The President exhibited a specimen of syphilitic disease 
of the placenta from a case which had occurred in the 
practice of Dr. Godfrey, of Enfield, of which the following 
history was given : — 

A. B — , aet. 24, the picture of health up to the time of 
marriage, which occurred on the 8th of June. Menstruated 
last on 10th July (one month after). The second week in 
September I was called to see this lady. She then had a 
secondary rash all over her arms, chest, ulcerated tonsils, 
and a primary sore upon the vulva. I put her under blue 
pill, five grains, three times a day. The mouth soon became 



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138 SYPHILITIC DISEASE OF THE PLACENTA. 

sore. I kept her under the action of mercury up to the 
25th of October. In January I put her again under the 
influence of blue pill; copper-coloured blotches again ap- 
pearing. 

On the 17th of April she gave birth to a living male child, 
and the dead foetus which is now attached to the placenta. 
Her labour lasted for about twelve hours^ and severe haemor- 
rhage came on before the placenta was expelled. 

History of the husband. — This was his second wife^ the 
first having died in labour^ from haemorrhage, some ten 
years ago, she having Bright's disease. He is scarred with 
the remains of venereal disease upon the face and neck. 

Query, — ^Was not the Bright's disease probably caused by 
syphilis ? Lardaceous disease of kidney is such a common 
result of the venereal poison. 

I have seen many of these venereal patches in placentae, 
and in every case profuse haemorrhage took place before the 
expulsion of the placenta. I believe it to be not an un- 
common cause of death after labour. 



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DEFORMED FOETUS. 139 

Bore could be contracted from a person supposed to be the subject 
of tertiary syphilis, as was propounded in tne present instance P 

The President exhibited for Mr. Greives, of Stamford, a 
foetus with a peculiar growth springing from the mouth. 
The specimen was referred to a Committee consisting of Drs. 
Black and Potter. 

Mr. Worship exhibited a specimen of deformed foetus^ of 
which he gave the following history : — 

Mrs. S — , set. 84, the mother of five children. I have 
attended her in all her previous labours, which have been 
natural, but slow. 

She has been more unable to attend to her usual occupa- 
tion during this pregnancy than in any former one, from her 
much greater size, and from very considerable oedema of her 
legs. 

I was called to her at 1 a.m., April 10th; but being at 
another case, my partner (Mr. Dunlop) saw her, but found 
the OS only slightly dilated, but there had been a discharge 
of an unusually large quantity of liq. amnii. 

I was sent for to her at noon, and then found her with very 
violent labour pains; the os was fully dilated, and the child 
still above the brim of the pelvis ; this continued for four 
hours without any perceptible change in the position of the 
child. 

The pains getting weaker, and she feeling very exhausted, 
I requested Mr. Dunlop to bring his forceps at 5 p.m. 

With some considerable trouble I applied the long forceps, 
and for some little time tried by steady traction to effect 
delivery, but neither could I nor Mr. Dunlop make any dif- 
ference in the position of the child. 

Under chloroform I tried to turn the child, but I could 
not reach a foot, and the size of the head and the strength 
of the pain prevented my more than feeling the tip of the 
toes. 

We determined then to perform craniotomy ; this I did, 
perforating the skull, and applied a blunt hook. After 



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140 CASES IN PRACTICE. 

the head descended somewhat I applied short forceps^ which 
had the effect of getting rid of the greater part of the brain^ 
and by dint of a further long pull with the blunt hook we 
managed to get the child away. 

The cause of the difficulty was very evident from the 
peculiar angular prominent occiput^ and after the head was 
reduced in size, by the very large body of the child. The 
arms and legs are also very deformed. The woman has 
made^ thus far, an uninterrupted good recovery. 



CASES IN PRACTICE. 

By James Milward, M.R.C.S., Cardiff. 

Case 1 is that of an acephalous monster. The mother 
had been in labour two days when the gentleman in attend- 
ance requested me to see her. I found the face presenting 



and something soft and pulpy besides which I could not make 
out. There was very little pain, but the woman was getting 
tired of the protracted labour. Passing my hand into 
the vagina, I got the neck between my fore and middle 
fingers, and pulling against the angles of the jaw, brought 
down the head, and delivery was completed. The mother did 
well. The sketch shows the condition of the child. There was 



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CASES IN PRACTICE. 141 

no calvarium whatever, and the skin that should have covered 
it was lying on the upper surface of the base of the skull. 
Growing from the centre, by a small neck, towards which the 
skin was rather puckered, was a circular nodulated tumour, 
about two and a half inches in diameter, and soft in texture, 
having somewhat the appearance of brain substance, but of a 
dark purple colour. The child was born at the full time, 
was of ordinary size, skin white and sound, and presented no 
appearance of having been long dead. 

I r^ret that an examination was not permitted. 

Case 2. — A young woman, recently married, engaged me 
to attend her confinement, and in course of time sent for me, 
saying that she was in labour. On examination I found that 
she was not even pregnant, the abdomen was merely dis- 
tended with flatus, which in about a month after was quite 
gone, and the patient became well. Shortly afterwards she 



was really pregnant, and when about one month advanced 
she went to a fair at Gloucester, and in a show there, saw a 
man without hands writing with his feet. This " gave her 
quite a tum,'^ and the impression of disgust remained very 



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142 CiBSAREAN SECTION. 

yividly stamped upon her mind throughout the whole of the 
pregnancy. At about seven and a half months or rather 
more the child was born, and the accompanying sketch 
represents him. 

The right arm was perfect ; the hand was divided into two 
parts, on the one of which was a rudimentary thumb, and 
one large finger, made up of two with a sulcus, but not a 
perfect division between them ; the other part was made up 
of the ring and little fingers in a natural condition. 

Left arm there was none, but issuing from the shoulder 
were a thumb and two fingers, the thumb and one finger 
standing out straight when at rest, the second finger flexed 
upon the shoulder. The child lived in good health for two 
months, when he died of a four days' attack of diarrhoea. 

I do not wish to lay too much stress upon the story of the 
show, but give her statement as I had it. But I must say my 
experience seems to point to the conclusion that, while 
infinite nonsense is talked about mothers' marks, still strong 
maternal impressions at an early period of utero-gestation 
may be so far stamped upon the offspring as to arrest the 
development of parts beyond the condition in which they are 
at the time of the receipt of the impression. 



CJSSAREAN SECTION IN 1866: SUBSEQUENT 
PREGNANCY AND DELIVERY PER VIAS 
NATURALES: RECOVERY. 

By William Newman, M.D. Lond., F.R.C.S. Eng. 

Mrs. O — , aet. 82, residing at Cottesmore, Rutland, under- 
went the operation of Csesarean section in July, 1866, and 
recovered. A full account of the case appeared in * Obstet. 
Trans.,' Vol. VIII, 1867. 

The local conditions which obstructed labour and led to 



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CiBSAREAN SECTION. 143 

the diagnosis of epithelial disease of the lower part of the 
uterus are thus described from notes taken at the time : 

The normal tissue of the cervix, as ascertained by touch, 
is replaced by a very unusual hardness, circular, uniform, 
and infiltrated apparently into body of uterus in every direc- 
tion, for more than an inch in extent ; beyond this distance 
the uterine tissue feels normal, is influenced by the uterine 
contractions, and through the normal tissue resistance resem- 
bling the child's head can be felt. The cervix is eaten away 
at its posterior lip into a deep sulcus, into and around which 
the finger passes readily, the anterior lip is as hard as the 
posterior, irregular, with a hard nodulated or granulated 
feeling to finger, but not exhibiting to the touch any very 
distinct hollow or tissue destruction. The os l^s a well- 
marked edge anteriorly, merging into the sulcus behind, but 
yet has there an edge which stands up to finger, and in great 
measure bounds the sulcus ; feels to finger as if it were an 
opening cut out of a piece of cartilage, perfectly hard and 
resisting, and beyond some half an inch in depth, the tip of 
my forefinger cannot be made to penetrate. 

A silver catheter, and then a very large gum-elastic 
catheter, could be slipped through the deeper and more 
closely narrowed part of the os ; some liquor amnii escaped 
on this being done. 

At last to make myself quite sure as to the appearances, I 
introduced a large size (Fergusson's) speculum, and could 
readily bring into full view the deep sulcus, the small narrow 
orifice, and the thickened anterior lip, throughout denuded of 
epithelium, granulated, and furnishing watery oozing and 
sanious fluid, leaving no question in my mind that we had to 
deal with extensive epithelioma of the cervix and lower part 
of the body of the uterus. 

After her recovery in October, 1866, I made a careful 
examination and took the following notes : 

To digital examination the uterus is larger and more heavy 
than it should be, but perfectly movable. The cervix uteri 
has reassumed in some measure the ordinary tapering form ; 
it is in the normal position. It is very hard in its whole 



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144 CiBSAREAN SECTION. 

extent, and prolongations, so to speak, of hardened tissue can 
be made out extending in every direction into the textures of 
the lower segment of the uterus. 

As seen through the speculum, the anterior lip appears 
comparatively sound, i.e. with no actual destruction of tissues. 
The posterior lip is irregular and in great part eaten away ; in 
this the sulcus (noted before the operation) may still be 
found though not so markedly. The os uteri is a very small 
puckered opening, appearing about a quarter of an inch in 
diameter, and its edges are like cartilage to the touch. Both 
the OS and cervix exhibit a surface almost entirely denuded 
of epithelium, granular and irregular in outline, and have, 
with the imperfect light at command, much of the naked-eye 
appearance of epithelial disease. 

I had not for some time seen her when, August 1, 1871, 
she came to my house. 

History. — She has been in fair health, menstruation fairly 
regular until commencement of April, 1871. Twice since 
(May and June) she has been slightly unwell. Some, not 
much, morning sickness. She fears she may again be 
pregnant. 

External examination. — The recti muscles are widely 
separated down near to the pubes, and when she stands up 
there is some, but not large, hernial protrusion. 

When the hand is more deeply inserted, so as to get in 
some degree behind the muscular walls, an enlarged uterus, 
at all events a hard body of some size, can be felt, the size of 
a foetal head. 

Vaginal examination shows that the tumour to be felt in 
the abdomen and the lower segment of the uterus are con- 
tinuous. 

The OS and cervix are hard, otherwise very nearly natural. 
Some feeling of deep lines of hardness about the whole lower 
part of the uterus, not, however, well defined. 

In all probability she is about three months pregnant. 

August 80, 1871. — Dr. Barnes was so good as to give me 
the benefit of his opinion, and saw her with me in town. He 
advised that the pregnancy, which probably existed, should 



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CESAREAN SECTION. 145 

not be interfered with unless urgent symptoms should declare 
themselves. 

January 2nd, 1872. — Admitted under my care into the 
Stamford Infirmary. A day or two after admission I made 
a careful vaginal examination. 

Cranial presentation: os slightly open; into each iliac 
region runs a line of firm cicatrix, very hard and resisting, 
and, indeed, radiating in every direction; from the os, as a 
centre, can be felt lines of hardened tissue ; the thickness of 
the uterine tissues covering the head of foetus would seem to 
vary somewhat — ^thick near the os, becoming irregularly 
thinner towards the sides of the pelvis. 

No detectible breach of surface ; some redness just within 
the lips of OS to be seen with the speculum. 

Foetal heart distinctly audible on left of midline, and about 
two inches below umbilicus. 

The anterior coverings (abdominal and uterine wall) are 
very thin, and the limbs and position of the foetus can be 
readily traced by the fingers from without. 

January 9th. — No special change until this evening. 
She has been and is in fair general health throughout; 
complains at times of weight and local uneasiness. 

Pains occur irregularly both in back and abdomen ; there 
is some increase of vaginal moisture. 

10th. — Mr. Gibbings (the house surgeon) noted that 
the OS was slightly more open ; pains continued through the 
day and became more severe and more regular in recurrence. 

11th, 11 a.m. — ^Evidently labour has well set in, the 
pains are regular and markedly infiuence the uterus; the 
external os is open to nearly size of a shilling, with edges 
which feel very firm and hard. The local hardness before 
noted is very evident, and when uterine contraction comes it 
is to be felt standing out almost in ridges under the finger. 

4 p.m. — Os now about size of a shilling ; external orifice has 
given way, but the internal os is very firm, like a ring of whip- 
cord or cartilage, and does not appear to give at all ; unbroken 
bag of membranes to be felt through the os. The pains are de- 
cided, recur every five or ten minutes, and are not well borne. 

VOL. xrv. 10 



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14<; CiESAREAN SECTION. 

I introduced at once the smallest size of Dr. Barnes' elastic 
bags, though with some little difficulty, and as the hard ring 
of the 08 gave to the water pressure, I employed two larger 
sizes. In little over an hour (5.30 p.m.) the bag last intro- 
duced escaped. 

6 p.m.— Os now size of crown piece or rather larger; edges 
not so hard or resisting, but thick, and do not easily yield to 
pressure of finger; liquor amnii drains away since last bag 
escaped; pains less effective. A wide abdominal bandage 
was very firmly applied. 

7 « m. Os a little larger and more dilatable; pains not of 

much avail. Now, however, she complains of much abdominal 
tenderness on pressure, and speaks of an exceeding soreness 
and feeling of burning internally when uterine contractions 
come on ; says that she first felt this about 5 p.m, and that 
it is now much more intense. 

8 p.m.— Mr. Heward (my colleague) kindly saw her with 
me • for last hour she has had little pain, but complains much 
of the burning sensation in midline of the abdomen. Os 
dilatable, head high up above brim of pelvis. 

With Mr. Heward's full concurrence I applied Simpson's 
long forceps ; os uteri just large enough to allow the blades 
to be introduced ; very little force was employed, and this 
only at intervals, when pains were feebly present. The os gave 
way after a little time ; the vaginaV tissues and perinseum 
offered no resistance, and in about twenty-five minutes from 
first application of forceps I extracted a living male child at 
full time of utero-gestation ; face directed to left foramen ovale. 

The placenta was easily pushed off by some tolerably firm 
abdominal pressure; hot much haemorrhage. 

The uterus, after expulsion of contents, was found to present 
on its anterior surface a very well-marked and rather deep 
sulcus in which (so to speak) two fingers might be placed 
side by side, this doubtless corresponding to line of union of 
divided uterine wall. 

I applied the long forceps so soon as I could introduce the 
blades, because by so doing I should supplement ineffective 
uterine action, and save the poor woman needless suffering. 



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CiBSAREAN SECTION. 147 

but most of all because the persistent burning pain in the 
abdomen seemed to point very decidedly to an undue stretch- 
ing, and, therefore, to a not impossible giving way of the 
cicatrix in the wall of the uterus. 

The after progress needs no comment ; it was in all points , 
satisfactory. The woman was able to nurse her child, and 
finaUy left the infirmary February 6, 1872 (twenty-sixth day 
after delivery). 

I have brought this sequel before the Obstetrical Society 
as an interesting pendant to the operation of 1866. 

That operation was undertaken with the approval of others 
and in the honest belief that we were doing what was right 
and best for our patient. The history and the appearances 
all seemed to warrant the diagnosis of epithelial disease^ and 
on this impression the abdominal section was made. 

The subsequent history here given^ with the successful 
instrumental delivery, will not be, I trust, without some 
permanent value. 

Dr. Babites said, when he bad tbe opportunity of examining 
the woman with Dr. Newman be found no distmctive mark of 
malignant disease, only a cicatricial condition of the os. As he 
thought this might be overcome by incisions and hydrostatic 
dilatation he had advised letting her go on to term. It had 
been suggested to him that the real disease which obstructed 
labour when the Csssarean section was performed might have been 
pelvic cellulitis. The cure of extensive malignant disease was so 
rare that this suggestion seemed worthy of consideration. On 
the other hand, it was shown that the uterus was moveable, 
which was consistent with cancer affecting the cervix only, but 
hardly with cellulitis ; and, moreover, the characters described by 
Dr. Newman seemed very precise. The complete elimination of 
cancerous disease was not unexampled. Thus, Dr. Habit relates 
a case in which a mass of cancerous tissue was cast off by 
sloughing, and recovery with cicatricial atresia followed. 

Dr. Platfaib said that he had once seen a case in which the 
CsBsarean section was necessitated by circumstances not described 
in text-books as possibly indicating the operation. The patient 
was a native woman in Calcutta, who was brought into the 
Medical College Hospital there, under the care of Dr. Wilson, 
the Professor of Midwifery. She had been manv days in strong 
labour, and the pelvic cavity was found to be so blocked up with 
exudation, probably from pelvic cellulitis, that it was found 



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148 CiBSAREAN SECTION. 

absolutely essential to perform the Cnsarean section. In Dr. 
Newman's case there was evidently some serious obstruction 
present at the time, which might possibly have been a chronic 
inflammatory induration of the cervix. In all probability the 
diagnosis of epithelioma was erroneous. This was likely not 
only on account of his patient's subsequent complete recovery, 
but because the physical signs described in his paper were 
certainly not those characteristic of that disease. The cervix is 
described as being hard, irregular, and cartilaginous, a descrip- 
tion that might apply to the ordinary forms of carcinoma uteri, 
but certainly not to the soft, sprouting, cauliflower-like condition 
met with in epithelioma. However this might be, the necessity 
for the operation, carefully considered by most competent 
authorities, was obvious ; and this interesting case, in connec- 
tion with the one he had mentioned, was calculated to teach us 
that there might be undescribed forms of dylltocia from morbid 
conditions of the soft parts calculated to give rise to the most 
serious difficulty in dehvery. 

Dr. EoGEBS said he could not concur in the opinion of the 
author of the interesting case just read ; he rather believed it to 
be analogous to one he nad recently under his care. It was that 
of a Swiss lady, about 40 years of age, in labour of her first child. 
After labour, accompanied with severe pains, had gone on for 
some hours, he discovered on examination a hard, irregular 
cervix unopened. Above two drachms of laudanum were injected 
into the vagina ere these pains ceased and sleep was induced. 
From time to time during the following night pains accompanied 
by sickness returned, which only produced a change on the cervix 
sufficient to allow the finger to pass into it, giving the feel of a 
hard, rigid, thick tube. The head was felt presenting during the 
second day ; the pains were continuous and steady, and, aided by 
Dr. Barnes' dilators, the os was opened to the size of a shilling ; 
some rest and cessation of pain was produced at night by injec- 
tions of laudanum and the use of chloroform ; the patient would 
only allow instruments to be used while under chloroform, as the 
passage of the finger into the vagina gave great pain, so but 
little advancement in the dilatation of the os by her pains and the 
dilators was produced. Dr. Bogers felt it advisable to scarify 
and incise carefully the thick, rigid, unyielding cervix on the third 
day, and again applied the dilator, which now caused the ring to 
yield to some extent, and then it tore into irregular warty pieces, 
allowing the scalp tumour to come down and aid the fnrther 
' dilatation ; the amniotic fluid had drained away early in labour. 
Under the use of liq. secale labour pains continued strong, and 
the head descended steadily. He endeavoured to apply the 
forceps to abridge the time of labour, but the head was so large 
that it wholly mled the brim, and it could not be used. At last 



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ANATOMY OF THE HUMAN PLACENTA. 149 

a living male child was bom after more than seventh-two hours' 
labour ; the placenta came away readily, and the patient is doing 
well. Doubtless, on examination of the cervix, some points of 
interest will be noted which he vnll make known to the Society. 
The child weighed over twelve pounds. 

Dr. BouTH said that Dr. Barnes' observations were entirely 
opposed to his experience. So far from believing that pregnancy 
cured or retarded cancer, he believed the very reverse. As in 
the case of fibroids, pregnancy hastened the development. He 
remembered a case of cancer of the os in the Lying-in Hospital 
at Vienna. After a very long labour the cervix came away en- 
tirely as a hard ring, being torn off by the child's head. It was 
incapable of dilatation. The woman died the second day. In 
another case it was torn across, and death followed a little later. 
In the case in question the description did not apply to simple 
epithelioma, but might to ordinary carcinoma. Still, it could 
apply equally; to a case of chancre, the circular part eaten away, 
being the original situation of the chancre, which might have 
become phagedenic. Hard crevices were frequently evidence, not 
of cancer^ but of syphilis, and differed in this respect. In time 
they were dilatable. Was there any history of syphilis in this 
case?* 



THE ANATOMY OF THE HUMAN PLACENTA. 
By J. Braxton Hicks^ M.D., F.R.S. 

So much has been written on the structure of the human 
placenta^ and such distinguished anatomists have been 
engaged on the subject, that it might seem superfluous on the 
one hand and arrogant on the other to endeavour to add to 
the literature of the subject. Still, having had many oppor- 
tunities of examining the organ not only detached, but in 
sii^, and at various stages of its deyelopment, and having 
arrived, through these, at a belief that the now commonly 
received opinion is not borne out by these examinations, I 

* The author of the paper gives the most decided negative to the supposi* 
tion that syphilis existed in the patient — not one single symptom of the 
disease could he found on the closest inquiry. 



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150 ANATOMY OF THE HUMAN PLACENTA. 

venture to bring forward that which appears to me as the 
correct view. 

It will be of no advantage here to go through the entire 
history of the subject. This will be found by reference to 
the numerous works on the placenta ; a list of the various 
authors up to 1792 is given by Soemmering ('Icones 
Embryonum Humanorum ') ; by Dr. F. Adams of Banchory 
(in a Pamphlet reprinted from the 'Medical Times') in 
1858 ;* and by Dr. Priestley in his work on ' Gravid Uterus.' 

A careful revision, however, of the opinions of authors 
both before and since will show that they may be ranged into 
two divisions : namely, those who favour the Hunterian or 
sinus-system theory, and those who oppose it. For we must 
regard those two other observers who seem to have made 
apparently independent discoveries, Reid and Goodsir, to be 
really only supporters of the Hunterian theory, — Reid de- 
scribing the villi as penetrating into the sinuses in the uterine 
walls; Goodsir not adding original observations on the 
maternal sinus-system, but utilising Hunter's opinion as an 
exemplification of the cell theory of nutrition and decay. It 
is true he has described bands which he says pass from one 
villus to the other, and which he considers proofs of the 
existence of maternal vessels in the placenta, but beyond this 
he has only accepted Hunter's opinion. 

Hence it will occur that in the following remarks particular 
stress will be laid on Hunter's theory, because if that be incor- 
rect then those who accept it as their basis, at any rate, will be 
incorrect. I must refer the reader who may wish a full account 
of the method he adopted to his own clear account of it in his 
' Animal (Economy,' second edition, p. 163, but I may here 
give a summary. The body of a woman who had died in 
labour undelivered was injected from the aorta first, and then 
from the vena cava by wax injection of yellow and red colours. 
After this was cold the uterus was taken out and dissected. 
In the placenta between the villi both yellow and red wax 
was found in '' irregular mass of injected matter." On lifting 
carefully the uterus from this, he ^' observed regular pieces of 

* Brown & Co., Publishers, Aberdeen. 



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ANATOMY OP THE HUMAN PLACENTA. 151 

wax passing obliquely between it and the uterus^ whicli he 
broke off^ leaving part attached to that mass ; and on atten- 
tively examining the portions towards the uterus^ they plainly 
appeared to be a continuation of the veins passing from it to 
this substance^ which proved to be the placenta/' He then 
describes the appearance of the irregular mass^ which he says 
showed that it was contained in cells^ and was evidently of 
regular kind^ not like extravasation. He also observed that 
the arterial injection returned into the venous openings. 
Thus was laid the foundation of the sinus-system of the 
human placenta. 

But from the opinion thus arrived at by Hunter^ namely^ 
that a sinus-system exists^ now commonly received as the 
correct view, I am forced to differ. For neither my own 
observations, nor a careful review of those of others, tend to 
confirm that opinion, but, on the contrary, lead to an opposite 
conclusion. 

In the following pages I shall endeavour to describe the 
anatomy of the placenta, discussing, at the same time, the 
probabilities of a sinus-system ; and in doing so I shall 

1st. Criticise the arguments used in favour of a sinus- 
system. 

2nd. Endeavour to show that if a sinus-system exists, there 
is no period of a transitional state. 

8rd. That from dissections early or late in pregnancy there 
is no evidence of the existence of such a system. 

(a) That there is no blood normally in the intervillal 
space ; 

(b) That no openings from blood-vessels into that 
space exist; 

(c) That the curling artery expends itself by its 
ramification into the decidua of each lobule ; 

4th. Describe the anatomy of the placenta and its growth, 
as shown by dissection. 

5th. Advance arguments against the sinus-system drawn 
from pathological conditions.— 

I. Criticism of the arguments used in favour of a sinus- 
system. 



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152 ANATOMY OF THE HUMAN PLACENTA. 

And at the commencement I must take exception to 
the mode of demonstration employed by Hunter^ for upon 
this rests principally its value as proof of the existence of the 
sinus-system. There is no doubt but that if the ii?ax arrived 
at the inner surface of the uterus^ it would penetrate into the 
space between the villi, whether there be natural channels or 
not for it to pass through. Because, if as I believe I shall 
hereafter be able to prove, there are no openings naturally at 
the line of the placental decidua, but that there is only the 
delicate lining membrane of the blood-vessels interposed as 
they come in contact with the villi in the course of their 
ramifications over the inmost layer of the uterus opposed to 
the placenta, then it is very easy to see how injections 
of such coarse material as wax, driven with force through 
the vena cava and aorta, would break down these attenuated 
barriers and burst into the intervillal space, and diffusing 
itself amongst the villi assume a definite form according 
to the space between (which indeed is very limited), 
and even return by another opening by the breaking down 
another thin membrane from within. The only difficulty 
under such circumstances would be to explain the reason 
why it would not, and therefore I hold the evidence derived 
from that source as of no critical value ; and I would extend 
this observation to all injections of any density, e,g, made 
with size, and propelled with any but the most delicate touch. 
I would therefore, because of the inconclusive character 
of the evidence they afford, exclude all observations made by 
means of injections from the maternal side, as proofs of the 
presence of natural openings into the space between the villi. 
This, however, of course does not prevent our holding injec- 
tions as proofs against their existence ; because, if, notwith- 
standing the use of injections, no distinct channel can be 
made evident, it is to be inferred that such do not exist. 

Further, Hunter says, that when he pushed a pipe into the 

on filled 
through 
^e italics 
narks it 



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ANATOMY OF THE HUMAN PLACENTA. 153 

may be gathered that the same answer would be equally 
applicable^ namely^ that the wax would burst through any 
delicate membrane forming the wall of the vessels which 
opposed it^ and thus it would enter the vessels. But if the 
same experiment be made with coloured water^ the result 
stated by Hunter does not occur. I am^ of course^ not aware 
what amount of pressure he put on the piston, nor the size 
of the syringe; but employing no more force than would be 
requisite to drive the water through natural openings had 
they existed^ I have repeatedly and universally failed to cause 
the coloured water to escape through any of the vessels of the 
decidua of the placenta. The only openings through which 
the coloured water has escaped are those which occur from a 
deficiency in the placenta decidua (serotina). It is exceed- 
ingly rare to find a placenta having this portion perfect ; 
besides fissures produced in the process of detachment, there 
are spaces through which the naked villi can be seen, because 
the serotina has been left attached to the uterine surface. It 
is only through these vacuities and rents that coloured water 
injected into the substance of the placenta escapes. 

The coloured water like the wax fills the whole intervillal 
space, but this proves nothing for nor against the existence of 
the sinus-system. 

It might be rejoined that this non-escape of the injected 
water through the blood-vessels opposed the objection just 
brought forward, that the wax had broken back into the 
vessels after filling the placenta. But a little consideration 
will show that the conditions are different. In the one we 
have the placenta in sittl; and the wax cannot escape, as in 
the case where the water is injected in a detached placenta, 
by which escape the pressure is removed to a certain extent 
and the breaking down of the thin membrane less liable. 
Still if natural channels exist the injected water would surely, 
notwithstanding tension being somewhat lessened, flow 
through them and appear on the surface. 

If the possibility of error in relation to Hunter's method 
above alluded to be admitted, then a door is opened for free 
discussion on the subject, and an opportunity afforded for the 



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154 ANATOMY OF THE HUMAN PLACENTA. 

facts I have to adduce to Have their fall weight ; but if^ on the 
contrary, it is still maintained that Hunter could not have 
been deceived in this matter, then that which follows will be 
without influence, and the time spent in its perusal thrown 
away. 

The same remark also applies to the use of probes, bristles, 
or hairs, which by some have been employed to substantiate 
Hunter's opinion, because, and for the reason given above, 
there is no resistance to sensibly oflPer opposition. 

It may be asked why does not the cardiac impulse suffice 
to break down this membrane, if it is so readily destroyed 
by iujections. This I think it is not difficult to explain. 

No doubt the counter-pressure of the contents of the uterus 
is sufficient for all .ordinary purposes; the amnial fluid secures 
the constant adaptation of the placenta at all times. But 
there is a great difierence between the pressure of injection 
and that of the cardiac impluse, which cannot be very 
intense by the time it reaches this last turn in the curling 
arteries; for it must be remembered that when injections 
are made, only one set of vessels are under pressure at one 
time, the others being flaccid, and thus less general support 
is given. Again, the circulation is not altogether carried on 
by mere pressure of the cardiac impulse, but is largely 
assisted by chemical action in the capillaries and by the 
traction (if we may so call it) towards the right side of the 
heart. Still further, after death the healthy vital contractility 
of the uterine tissues is absent, whereby the counter-support 
from its contents is lost. 

But when venous congestion arises it may be asked, why 
does not effusion of blood take place amongst the villi P The 
fact is that it frequently does occur producing either abortions, 
or the solid moles, or otherwise destroying the integrity of 
the ovum ; it is into the intervillal space the blood is effused 
and there coagulated. Still it may be said that the blood is 
not always poured into the cavity of the placenta to any great 
extent. To this it may be replied that there is another part 
at which the vessels may also give way, and that is at the line 
of separation of the decidua of the placenta (decidua sero- 



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ANATOMY OF THE HUMAN PLACENTA. 155 

tina) and the uterine serotina;'^ so as to allow effusion of blood 
between the placenta and uterus. At this part the vessels are 
very unprotected, and liable to be ruptured by concussions, &c., 
or by venous congestions, producing the separation more or 
less of the placenta well known to obstetricians. 

I will examine another argument which has been adduced 
in favour of the maternal sinus-system. 

It has been said if you place a newly delivered placenta 
on a plate or other flat surface, and wipe it dry from adhering 
blood, that in the course of one or two hours a considerable 
quantity of blood has escaped. This it is argued has come 
from within. I quite admit it does, indeed it can scarcely be 
otherwise. 

It flows from two sources — 

1st. From the sinuses (maternal) of the placental decidua 
which are plentifully found in the decidual processes, which 
have not quite emptied themselves. 

2nd. From the blood which during the expulsion of the 
placenta has entered through the openings just above de- 
scribed in the placental decidua. And I may here state that I 
have in the examination of a very large number of placentae, 
found that the amount of blood which is found in the inter- 
yillal space after delivery, is in the direct ratio to the amount 
of these openings : so that in the vary rare case of an almost 
perfect decidual covering, scarcely a trace of blood is found 
within that placenta. 

Let us for a moment assume the absence of the sinus- 
system and suppose that the space between the uterus and 
chorion is occupied by nothing but the villi. Let us suppose 
(which is really the case) that the villi are in such close con- 
tact with each other that only capillary sized interspaces 
exist between them, and consider the action of labour on a 
placenta of this construction. 

It has been already detached from the uterine surface, and 
now remains in the uterus ready to be expelled. Some few 
ounces of blood are poured out from the uterine surface 
during this interval, and therefore the placental decidua is 

* As named by Profeflsor BollMton. 



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156 ANATOMY OF THE HUMAN PLACENTA. 

bathed by it. By capillary attraction some blood is drawn in 
or by uterine action is forced in amongst the villi through 
openings already mentioned^ and thus is diffused throughout 
the interior of the placenta. 

It seems therefore not unreasonable to say that should the 
circumstances lead us to believe in the absence of a sinus- 
system the occurrence of blood amongst the villi need not form 
an insuperable objection to our rejection of it. The same may 
be said of the after-flow from the decidual sinuses. 

Again^ in support of the opinion that a sinus-system exists^ 
the statements of Dr. Reid have been quoted^ where he says 
that he had seen villi penetrating into sinuses beyond the 
exact limits of the line of separation. 

But here again the explanation is easy without our requir- 
ing the assistance of such a system. 

Under any arrangement there are to be found sinuses which 
are situated at the line of separation^ partly encroaching on the 
placental and partly on the uterine side^ and not in the placenta 
strictly speaking ; under either arrangement the villij growing 
vigorously as they do^ particularly towards full term, press in 
all directions and dip into inequalities or any yielding portion 
they find, and thus push into these sinuses. When the 
placenta separates the ends of the villi in some cases remain 
behind. The fact mentioned by Reid is the result of pressure 
in consequence of the enormous growth of the villi. It occurs 
towards full term of pregnancy, and in the more robust 
placentae. Thus Dr. Beid's observations, it seems to me, need 
not be adverse to the rejection of the sinus-system. Indeed 
his words, quoted by Dr. Carpenter, seem rather to be in 
favour of the opposite view, for he says '* the tufts of the villi 
dip down into the uterine sinus, where they are still covered 
and held in their places by reflexions of the same membranes.'' 
Now this same membrane is, as I shall expect to be able here- 
after to prove, the dilated wall of a sinus, which, being in the 
decidua of the placenta, abuts towards the villi, and these 
pressing against it, indent it deeply, and being adherent to it, 
as all villi are more or less on the inside of the decidua sero- 
tina, their tips remain behind when the placenta is removed. 



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ANATOMY OP THE HUMAN PLACENTA. 157 



I. — Diagram of the placenta on the supposition of placental maternal 
sinus, showing that the secondary hranches cannot unite to the neigh- 
bouring villi, t^. if the tips penetrate between the maternal network at 
the beginning. 

a. Foetal villi. 

b. Maternal sinus. 



n. — Diagram of placenta on the supposition of placental maternal 
sinus, showing that the secondary branches cannot unite by their tips, 
where they push their ends against the walls of the sinus, unless they 
cause the two layers of maternal sinus to unite. 

a. Foetal villi. 

b. Maternal sinus. 



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158 ANATOMY OP THE HUMAN PLACENTA. 

II. That there is no period of transition if a sinus-system 
exist. — Having now considered the most weiglit7 arguments in 
favour of a sinus-system^ I will proceed to inquire into the 
time at which the sinus-system has been supposed by its 
supporters first to make its appearance; and this inquiry 
is important^ because on the clear understanding of it^ our 
opinion as to the existence of the system much depends. 

For if when the decidua reflexa first envelopes the ovum 
there is merely the attachment of the villi by their tips^ and 
if at mature pregnancy the sinus-system is complete^ it is 
self-evident that one of these three conditions must have 
occurred, either — 

1. That at some intermediate period this arrangement 
must have been in a transition state, or — 

2. That from the earliest formation of the villi and from 
their earliest attachment to the uterus the process of inter- 
weaving of villus and maternal capillary must have been going 
on ; so that the outer surface of the chorion, whence the 
villi spring, was always in contact with the capillary 
walls, or — 

3. That at some period or other the blood is extravasated 
into the inter- villal space, by the breaking down of the walls 
of the dilated capillaries, according to the theory of Van der 
Eolk and some others. 

Let us examine the first supposition. Most of the writers 
who have believed in the sinus-system have not handled the 
subject at all clearly. Hunter himself was not explicit. 
Ooodsir, much quoted in this matter, says, when describing 
the process of growth or development, " when the ovum has 
arrived at a certain stage of its growth, * * * at this 
period the ovum has approached the thickened mucous mem- 
brane, or that usually described as the decidua serotina. 
About the same time the allantois bearing the umbilical 
vessels, applies itself to the internal surface of that portion 
of the chorion opposite to the decidua serotina, and the villi 
of that portion become vascular.'' 

Thus it is pretty clear that Goodsir considered that the 
change took place early, not long after the entrance of the 



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OBSTETRICAL TRANSACTIONS VOL XI\^ 




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DESCRIPTION OP PLATE H. 

Tigs. 1 and 2. Dilated yenous sinus and curling arteries in decidual 

procesaes. 
Fig. 3, a. Termination of idllus, small portions of decidua remaining 

attached to it. 
h, YiUuB at seat of rupture, like appearance described by 

Goodsir as attachments to adjoining yilli. 



I 

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ANATOMY OP THE HUMAN PLACENTA. 159 

ovum into the uterus. He* then goes on to say " that the 
decidual vessels enlarge and assume the appearance of sinuses^ 
encroaching on the space formerly occupied by the cellular 
decidua^ in the midst of which the vUli of the chorion are 
imbedded. This increase in the calibre of the decidual capil- 
laries goes on to such an extent that finally the villi are 
completely bound up or covered by the membrane which con« 
stitutes the walls of the vessels^ this membrane following the 
contour of all the villi^ and even passing to a certain extent 
over the branches and stems of the tufts.'' 

Thus it appears that he did not consider the bases of the villi 
to be covered by the dilated capillaries ; it follows^ therefore^ 
that there should be found at some point between the chorion 
and the tips of the villi a distinct membrane^ which should 
show the limit to which the maternal portion of placenta 
extended. It may here be remarked that Ooodsir describes 
the dissection of an unopened pregnant uterus^ undertaken 
in the manner adopted by Professor Owen^ namely^ by fol- 
lowing the course of a sinus through all its windings by means 
of a probe. Concerning the deception which must arise from 
this plan I have already remarked^ and need not repeat the 
arguments here^ further than to say that the closer we 
approach the placenta^ the more delicate and easily lacerable 
do the tissues become. The excitement to the cell growth which 
made the decidua pulpy extends also some distance into the 
uterine walls. 

Ooodsir also laid much stress upon certain bands^ which 
he says he noticed in this dissection^ passing from the tip 
of the villi to the parietal decidua ; and also from the tip of 
one villus to another. These bands he considered to prove the 
existence of the maternal venous system. That they do exist 
between the villi and decidua is clear enough in those villi 
which are implanted into it^ both in the plain surfaces of the 
decidua and into the decidual processes (Fig. 3 a), which 
dip deeply into the placenta in the later months of pregnancy ; 
but that they exist to any great extent between the villi them- 
selves can be proved to be not the case by any one who will 
carefully examine for himself; they do so occasionally^ but 



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160 ANATOMY OP THE HUMAN PLACENTA. 

the appearance is much imitated by the laceration of the villi^ 
the ruptured end tailing off very like that figured by Goodrir 
(Fig. Sb). Besides^ setting that aside and admitting that 
these bands are to be found everywhere, it is difficult to see 
how it proves the existence of the sinus^system. Where the 
villi pass between the meshes of the network of capillaries it 
is clear that each villus must be sepao'ated from the other villus 
by two layers of maternal blood-vessel wall, which of course 
do not adhere (Fig 4i). Stipposing, then, that a process is 
pushed laterally, there is still a covering of two layers of 
maternal blood-vessel wall between the tip of the lateral 
branch and the neighbouring villus (Fig. 4 ii). How, then, can 
any attachment take place between them, I mean arising 
necessarily out of their anatomy ? 

It is clearly then only the tips of the villi which implant 
themselves into the foetal surface of the decidua serotina that 
can by this explanation of Ooodsir's have the bands of 
maternal tissue passing from them. Indeed it is not possible, 
under Goodsir's mode of explanation, that bands should be 
found on a large number of the villi, for it is self-evident that, 
surrounded as every portion of the villus is according to his 
theory by a layer of maternal tissue, there would be no union 
of one wall of the sinus to the other except as an accidental 
occurrence. 

I would submit, therefore, that if bands are to be found 
joining villus to villus, and tuft to tuft, it would be rather a 
proof that there was nothing between the villi of a maternal 
kind. I shall hereafter show how the processes of decidua 
arise and how the appearance related by Ooodsir can be 
explained. 

Again, I have in one instance removed a mature placenta 
from the uterus without the slightest effort, which was 
wholly devoid of any serotinal layer. When placed in water the 
villi floated out like red seaweed, without the slightest attach- 
ment to one another. Were there any bands from one secon- 
dary villus to another like Ooodsir mentions, it would seem 
impossible that this free floating out could have occurred. So 



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ANATOMY OF THE HUMAN PLACENTA. 161 

it might be considered if we could find some subsequent 
date at the line or boundary of the sinuses. 

Now, as before remarked, if the maternal sinus-system is 
not formed till a certain period after the formation of the 
villi, there must be a time when a portion of the base of each 
villus is not covered by it, therefore a membrane of the 
maternal vessels ought to be readily found, on one side of 
which blood will be present, and on the other towards the 
chorion none will be seen. 

Dr. Priestley in his " Lectures on the Gravid Uterus *' (p. 
62) has described and figured minute vessels, passing in 
between the villi to a considerable degree, but not fully down to 
. the chorion ; they were still small and defined, not dilated as the 
commencement of sinuses. This occurred in a two months' 
ovum. He considered this (which had not been before noticed) 
as the intermediate stage of the formation of the placental 
sinuses. 

But it is here important to note the difference between Dr. 
Priestley's account and that by Goodsir, because according to 
the former there is no interlacing of the network of capillaries 
till after the second month, while with Goodsir it begins at 
an earlier period. In any case the intermediate condition 
ought not to be difficult to recognise, if we examine the villi 
from their roots on the chorion to their extremities. 

But this after many opportunities I have been unable to 
discover. I have carefully examined human ova from the age 
of a month up to the full period without any trace of any such 
appearance. I have dissected from the base of the villi, t6 
the extremity and sideways from the edge of the indicated 
placenta, without finding anything to warrant us in supposing 
that any intermediate stage exists in the formation of the 
maternal portion of the placenta. If there be no such line 
or division, then it follows, either that the interlacing of villi 
and maternal capillary took place ah initio, t. e. coincident 
with the formation of the villi, as believed by Van der Kolk, or 
that there is no sinus-system at all. It may be difficult to 
say what conditions were those which led to the appearance 
described by Dr. Priestley, but a probable explanation was 

VOL. XIV. 11 



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162 ANATOMY OF THE HUMAN PLACENTA. 

furnished by two ova, aborted in the fifth or sixth week of 
pregnancy ; in one an appearance closely similar was observed 
by me when viewed through the decidua, a network of blood- 
vessels seemed to dip in between the villi. The appearance 
was produced by blood showing between the closely applied 
villi, but which was readily washed away by water. In the other 
case the blood had the same appearance, but, being coagulated, 
gave an appearance exceedingly like that described by Dr. 
Priestley. However this may be, the condition is certainly 
not a constant one. 

There are many facts which seem much to militate 
against the supposition that the sinus-system is complete at 
a very early period. The villi in early ova appear perfectly 
free from each other; when detached fronl the maternal 
surface, they float about in water as loosely as possible, 
certainly with no signs of any attachment. 

Then, if we examine the inside of the decidua, where they 
were attached, we shall find it so unchanged that it seems 
nearly impossible to believe that it could have undergone the 
change implied by the sinus-system even in its incipient stage. 
The little opaque, effete, bulbous tips of the early villi which 
attach themselves to the surface of the decidua are readily 
found, quite on the surface of that membrane, with, perhaps, 
an overlapping layer of decidual cells, by which it is assisted 
to be moored (as it were) to the decidua. This layer has 
been regarded by Goodsir as evidence of existence of sinuses, 
considering it, indeed, the wall of a maternal blood-vessel. 
But I think careful examination will show that it is merely 
decidual cells which do not run down the villus. It is, indeed, 
drawn out into a band, particularly at a later period, but this 
is the result of the exuberant growth of the lateral branches of 
the villi, in a manner to be hereafter pointed out (p. 180). 

There was one specimen which showed a condition militating 
very much against the commonly received opinion. It occurred 
in an ovum of about two months' development, which had 
been shed perfect, with all the decidual coverings, no opening 
existing in the part to which the future placenta was 
attached (see Appendix, p. 204). I opened the space between 
the chorion and decidua very carefully ; not one drop of blood 



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ANATOMY OP THE HUMAN PLACENTA. 163 

or even a tint of blood was to be found within amongst tbe 
villi or their trunks. It might be thought the blood might 
have escaped, but blood surely must have been there in some 
quantity were it naturally there, the tendency being, when 
submerged in blood, for the cavity to admit rather than expel 
blood. Should it be suspected that it might have escaped 
through the veins, then it was found that the decidual vessels 
were full, but no signs of communication between these 
vessels and the cavity were observable. 

Again, I found the appearance of the surface of thedecidua 
to which the villi were attached was unchanged from that of 
the exterior, the openings of the uterine follicles being dis- 
tinctly marked, though larger, of course, than those of the other 
decidua, nor was there any sign that the superficial capillary 
network had been changed so as to surround the villi. It 
might be thought that this was an exceptional case, but upon 
consideration for a moment it will be seen that one such fact 
is worth a large number to the contrary, because, as has already 
been pointed out, the chances for blood to enter a cavity or 
space like that of the placenta or this one just alluded to, 
are so great that it is a wonder that it is ever absent at all. 

But this is really not an exceptional case; I have found 
other early ova in which no trace of blood has been found, 
and at a later period of pregnancy I shall hereafter show that 
total absence of blood is not so uncommon when the plaoenta 
is examined insittlf and without injection through the vessels. 

Again, if we open the decidual cavity in which the ovum is 
lodged we shall find the villi running from chorion to the 
inner surface of the chamber ; but I have never been able to 
find any sign in any part which showed that one portion of 
a villus differed, excepting in size and vascularity, from the 
other part. If ova are taken at any period of pregnancy 
while the villi still are recognisable generally over the chorion 
surface, the same absence of difference is noticeable ; and 
even at more advanced periods, although the margin of the 
placenta is strongly defined, if the chorion beyond the margin 
be separated from the inner surface of the decidua reflexa, 
there cannot be found any distinct line of separation from the 



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164 ANATOMY OF THE HUMAN P1«ACENTA. 

active vascular villi and those which have become effete ; all 
that can be clearly made out is that the chorion and decidua 
have become more closely and firmly united, and that 
the effete villi extend some distance away from the placenta 
from their attachment to the chorion (PI. Ill, fig. 8). 

Hence, if these observations are correct, it seems difficult 
to understand either that there is a transition state in the 
formation of the sinus-system before the second month of 
pregnancy, or any blood present between the villi up to the 
formation of the placenta proper ; or, in other words, that 
there is a sinus-system complete or incomplete. 

It will be, therefore, important to consider whether after 
this period of pregnancy there be any evidence of the existence 
of this system. If we at any time carefully open the margin 
of the placenta, whether in sittl or after detachment in natural 
labour, and with the utmost circumspection lift up the 
decidual layers from the chorion, we shall cause the villi to be 
somewhat straightened, so that if any membrane, however 
delicate, exists, it would readily be detected. 

This I have done in every stage of pregnancy in numerous 
specimens, but have been unable to detect any structure 
whatever. I have separated it from within to without the 
margin, and from without to within, without success ; and 
yet, if a maternal element existed, there must be somewhere 
near the margin an external limit of the sinuses ; as also, if 
it extended only partly down the villi, there should be a limit 
somewhere between their extremities and the base. But no- 
where can such a limit to the maternal element be made out. 
Nor has it, I believe, been ever noticed by authors. 

Up to at least the seventh month it is not difficult to find 
outside the placental margin the non-vascular effete villi ; 
their tips are attached very firmly to the decidua, at the inside 
of the base of the decidua reflexa. They radiate from the 
margin to a considerable distance (fig 8), and doubtless serve 
to hold the villi on to the decidua with considerable firmness. 
But if one gradually lifts away the decidua while external to 
the margin, and looks towards the interior of the placenta, 
there is no separation of any kind by any membrane, so that 



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DESCRIPTION OF PLATE lit 

Fig. 4. Appearance of inside and outside of deddua reflexa at 

base ; a, angle of reflexion. 
Fig. 5. Cup-like depressions of the attachment of bulbous ends of 

viUi. 
Fig. 6. Ends of effete yilli at and beyond margin of placenta. 
Fig. 7. Section of uterine follicle. 
Fig. 8. Margin of placenta. Chorion lifted up, showing effete and 

active villi intermixed, with recurrent branches. 



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PLATE HL. 



OBSTETETCAl. TRANSACTIONS X)L XIV 




Pag. 



Fig. 6 



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V»' *Yca: i c'' c/w Lu/ 



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ANATOMY OF THE HUMAN PLACENTA. 165 

it may be said the intervillal space (placental cavity) is coq« 
tinuous with the space intervening between chorion and in- 
side of decidua reflexa all round the ovum. 

In any case of pregnancy^ supposing there was a placental 
cavity formed from the maternal vascular system^ as Hunter 
maintains^ and that this outer limits supposing it also to exists 
were lacerated^ the blood must necessarily be poured out 
between ovum and decidua ; and then^ supposing the decidua 
lacerated^ it would be difficult to understand how the patient 
should not succumb to haemorrhage. But if there was 
no bloody but simply a transparent fluids then the loss of a 
small portion daily is but of moderate moment ; and^ indeed^ 
this would serve to explain the discharge of fluid which some- 
times takes place during pregnancy^ where the amnial 
membrane has not been ruptured, the occurrence of which 
fluid has been hitherto difficult to explain. 

In relation to this outermost membrane of a sinus-system 
there is an assertion of some anatomists^ as Van der Kolk^ &c.^ 
which requires notice, namely, that the lobules are separated 
by septa from one another, and they instance iu proof that 
injections thrown into the cavity of the placenta do not run 
everywhere, but are restricted to certain portions. Now, 
although I must, as before mentioned, refuse evidence of this 
kind as a proof, still I may answer that the like result has 
not attended my experiments ; I have always invariably found 
that the injected fluid permeates all the spaces between the 
villi equally in all directions. This experiment I have tried 
very many times, always with the same efiiect ; there was no 
evidence of any limit in any way. 

From the consideration of these facts I feel warranted in 
asserting that from the beginning to the end of pregnancy 
there is no evidence of the sinus-system being in a transition 
state. It must either exist ab initio or not at all. 

The discussion of the latter alternative will now occupy our 
attention. 

III. That from dissections early or late in pregnancy there 
is no evidence of the existence of a sinus-system, — Although 



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166 ANATOMY OF THE HUMAN PLACENTA, 

the placenta is generally said to be distinctly formed at about 
the end of the second month of pregnancy^ yet in reality 
there is no definite period at which it can be said to be formed, 
because if we carefully examine the ovum at a much earlier 
period we notice the villi at a particular part are larger than 
the rest, so much so that even a month after conception it 
may be known at what spot the future placenta will appear. 
From that time till the completion of full term careful 
observation has failed to show me any essential difference in 
its structure, excepting in the addition of the decidual pro- 
cesses. It will also be noticed that the total amount of 
original villi included in this change is not so great as one 
might suppose from our inspection of a fully grown placenta. 

The area of the placenta seems, from numerous observations, 
to be determined by the extent of the allantois, although I 
have found one ovum where the vessels of the allantois were 
only to be noticed on that part of the ovum which had no 
villi. 

It is a matter yet of uncertain explanation why the 
allantoic aspect of the ovum should nearly always be applied 
to the surface of the uterus on which it rests ; but though 
it is not a part of the present paper to inquire into this 
subject, it may be remarked that possibly abnormalities in 
the adaptation of the allantois to the portions of chorion 
well covered by villi, and in the apposition of that facet of the 
ovum to the uterus, may be the source of some abortions. 

Now, if we should find instances in which no blood is 
present amongst the villi, or, in other words, that the interior 
of the placenta does not furnish a trace of blood after the 
most careful examination, it appears to me that such evidence 
would be conclusive against the existence of the sinus-system ; 
because, for the reasons I have already pointed out, one such 
fact is worth a hundred arguments to the contrary. For I 
may again repeat, when we consider the great number of 
chances there are against any cavity similar to the placenta 
being expelled from the uterus by compressive force, having 
one side porous, it would seem almost impossible for blood 
not to enter and not to be diffused by capillary action and 



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ANATOMY OF THE HUMAN PLACENTA. 167 

the compression of the uterus throughout the whole intervillal 
space. And^ ag^in^ when we consider the tenderness of the 
walls of the dieted maternal vessels of the decidua and their 
liability to be ruptured under uterine force, under states of 
hypersemia^ shocks, &c., it is a wonder that the placenta is 
ever expelled without containing blood, and this would explain 
why it is so commonly the case that the intervillal space con- 
tains blood after expulsion. 

I have already alluded to the comparative absence of 
blood in those placentae which are the most perfectly free 
from openings in their decidua. If in objection to this it is 
remarked that the blood might have been expressed during 
expulsion, then it ought to be borne in mind how very 
unlikely it is that that blood, once within, could be expelled so 
fully. But a much more complete answer to the objection 
would be given if it could be shown that when the placenta 
is examined in situ no blood can be found in the intervillal 
space. If to this it were also objected that the blood had 
flowed from the sinus-sytem into the veins after death, the 
answer would seem sufficient that it would be next to im- 
possible that blood should flow from these sinyses (if they 
exist), and yet remain in every other vein of the uterus, which 
is notably the case. 

And even if we were to admit that no sinus-system existed, 
yet, considering the tender nature of the vascular walls sur- 
rounding the cavity, as I assert, it should not be surprising 
if blood were occasionally to appear in the intervillal space 
whilst still attached to the uterus, after violent concussions, 
in cases of hsemorrhagic tendency, or in the throes of death, 
or in the efforts of labour. 

And this brings me to the consideration of an argument 
used by those who have supported the sinus-system, namely, 
that it is impossible to conceive the action of endosmosis to go 
on in the placenta at the extreme distance from the maternal 
surface, so that they argue the villi which were near the 
chorion would be useless. But the worthlessness of this 
argument is apparent at once when we consider that when 
the blood has once entered among the villi its position differs 



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168 ANATOMY OF THE HUMAN PLACENTA. 

exceedingly little from that of a fluid placed independently 
of the circulation in the same position. The small size of the 
supplying arteries (ciirling) would always limit to a great 
extent the freedom of circulation^ when it entered the intra- 
yillal space. So that although a slight movement were 
obtained^ stilly it would be so sluggish that the principal 
change between foetus^ and mother would be carried on in 
the same manner as it would upon the supposition of the 
absence of the sinus-system. Dr. Arthur Farre^ in the article 
" Uterus ^^ ('Todd's Encyclopaedia Anat. and Phys.'), has 
pointed this out, although he supports the Hunterian theory.* 
If the placenta be opened in sitil it will be seen that even 
then the space between the villi is much less than the calibre 
of the villi. Indeed, there is every reason to suppose that 
the villi are in absolute contact, so that the only true 
vacancies between them are in the triangular space between 
each neighbouring villi. This narrow space, doubtless, 
facilitates the diflusion of the fluids by capillary attrac- 
tion. But in any case the argument which has been 
adduced against the uselessness of the villi next the chorion 
is to an almost equal extent applicable to the sinus-system. 
Again, those who have found a difficulty in the distance to 
which endosmosis acts have overlooked the fact that in the 
placenta in extra-uterine foetation there is no union of 
maternal and foetal elements in the manner supposed in a 
sinus-system. The villi are merely applied to the surface of 
the mucous membrane of the Fallopian tube. This, I suppose, 
is now well recognised. For my own share in the description 
of the actual state of the arrangement I have shown, in 
• Guy's Hospital Reports ' (1860, p. 272), that the ciliated 

* I may here add tbat the peristaltic action of the utems which has heen 
known to exist at the latter months of preg^ncy extends also to the whole of 
the period of pregnancy during which we have the power of examining the 
uterus, that is to say, from the third month. This I have made clear to myself 
by hundreds of examinations. This movement is recognised by its becoming 
alternately relaxed and contracted at intervals varying from ten to thirty 
minutes. (' Obstet. Trans./ Loud., 1871.) The value of this is, no doubt, great 
in causing a circulation of the fluid which doubtless exists either as blood or 
serum in the intervillal space. 



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ANATOMY OF THE HUMAN PLACENTA. 169 

columnar epithelium can be detected on the surface of the 
mucous membrane in Fallopian pregnancy, while the villi 
adhere by a small amount of lymph to the surface, the ciliated 
epithelium occupying the space between them, the mucous 
membrane being unchanged. I have also shown that the 
membrane supposed by Dr. R. Lee to be an ovular structure 
in a specimen of extra-uterine foetation in Guy's Hospital 
Museum was nothing more than fibrillated blood. 

Now, in extra-uterine conception the foetus frequently grows 
to the full size of intra-uterine pregnancy, and therefore it is 
plainly evident that the sinus-system in this instance is not 
an absolute necessity, and therefore that endosmotic action 
can go on through the whole depth of the placenta consis- 
tently with the perfect nourishment of the foetus. Hence (to 
repeat), if we admit that even with the sinus-system the 
difSculty of the exchange by endosmosis is nearly as great as 
without it, and that as a matter of fact in extra-uterine foeta- 
tion exchange by endosmosis does actually go on without 
detriment/ we shall have no argument a priori in favour of 
the necessity of a sinus-system. 

But in truth the distance at which endosmosis is really 
obliged to exert its influence is not so great as here supposed, 
because the processes of decidua (as will hereafter be shown) 
bring down towards the chorion the vessels contained in them 
to a much nearer point than the full thickness of the placenta. 

We shall now be in a position to inquire what proof 
have we of the existence of the sinus-system ab initio. 
It will, of course, be admitted that if there always were 
a complete dovetailing of the maternal with the foetal 
vascular system, we should upon all occasions find blood 
amongst the villi from early to completed pregnancy. And 
it will by all, I suppose, be also granted that if in any case 
blood be not found in that position, in not the slightest trace, 
we may conclude that it never had been there. For, as has 
been above advanced, it would seem an impossibility to suppose 
that had blood been amongst the villi, and after death to have 
emptied itself so completely as to leave no trace behind what- 
ever. To say the least, there is infinitely more difficulty in 



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170 ANATOMY OF THE HUMAN PLACENTA. 

understanding how the intra-placental space should^ having 
once contained bloody have become quite empty, absolutely 
so, than to understand that, surrounded on all sides by blood, 
it should, after the process of delivery, or after careless 
handling, or after death accompanied by venous engorgement, 
contain more or less blood. But is there really blood in this 
intra-placental space while the placenta is yet attached to the 
uterine wall ? 

In four dissections made on uteri pregnant from the fourth 
to sixth month I found two wholly free from blood (see 
Appendix, p. 190, et seq.). 

In those two in which I found some the quantity was 
small. In one of them it was scarcely a trace, in the other 
rather more. The cause of the blood in these two will be 
explained further on. But in neither did the quantity at all 
approach to such as one is accustomed to see in those 
placentce which are expelled by the natural action of the 
uterus. 

The plan adopted in dissecting these specimens was by care- 
fully opening the uterus from the os till the placental site 
was made out ; the direction of the opening was then carried 
laterally, so as to enable me to clearly see and readily reach 
the whole of the amnial surface of the placenta, without 
touching its margin. 

The amnion and chorion were then carefully divided at a 
part free from the vessels. This was not an easy matter, the 
blood-vessels (villi) being so numerous. Another difficulty 
also arose from the readiness with which the villi within are 
wounded when the chorion is divided, for some of the villi 
adhere to the placental aspect of the membrane, and others are 
in so close a relation with it that it is difficult to avoid them. 
However, by proper precautions these obstacles can be over- 
come, and the result was I found that two out of four had no 
trace of blood amongst the villi. 

In one of the specimens without blood a very diffusible 
injection was used through the blood-vessels of the uterus of 
fine size and Prussian blue. Now, although at the outset of 
this paper I asserted that if injection be found in the inter- 



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ANATOMY OP THE HUMAN PLACENTA. 171 

villal space it fails to prove the existence of ready-made 
openings^ yet the non-entry of injection is by no means 
without considerable value as evidence of their absence. 
In this case in only one place did any injection enter^ and 
this was diffused indiscriminately in indefinite portions 
amongst the villi — not a trace of its being limited in any 
portion^ nor of its taking any definite form. 

In one of the specimens in which blood was present the 
quantity was so small, and the fluid so scantily supplied with 
blood-corpuscles, that not more than half a drachm could 
have been diffused altogether, and when water was injected 
into the intervillal space through one hole, and allowed to 
flow out of another at some distance, it came out scarcely 
tinged. In examining the placenta throughout, at one 
spot a small clot of blood was found extravasated amongst 
the villi, from which it was clear the small quantity of blood 
generally diffused had originated. 

But, we may fairly ask, why should a clot of blood be 
found isolated amongst the villi if maternal blood were a 
normal element of the active living placenta? It appears to 
me an impossibility that a dot should be found in one little 
spot and only a few drops altogether in the other part, and 
yet the whole space had been preoccupied by blood. 

In the second case where blood was found within, upon 
examining the placenta throughout, a considerable patch of 
extravasated blood amongst the villi was found in one spot, but 
whether this had been derived from a ruptui:e of the villi 
themselves or of the maternal vessels it was difficult to 
ascertain, though, from the effects of injection through the 
funic vessels, it appeared that there had been a rupture of the 
villi. 

So much for the evidence yielded by dissection of placentae 
in situ. 

But allusion has been already made to the corroborative 
evidence given by placentae which have been expelled by 
uterine contractions. If they are carefully examined it will 
be found that the amount of decidual tissue on their uterine 
surfaces varies considerably. In some it is so perfect that 



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172 ANATOMY OF TBE HUMAN PLACENTA. 

scarcely a fragment of villus is exposed, while in some nearly 
half the villi are denaded. 

These openings, therefore, in a proportionate degree^permit 
egress and ingress of blood. Now, as far as my observations 
have extended, namely, to about forty placent« carefully 
examined, I have found the larger quantity of blood in those 
placentae which have the more numerous apertures, whilst in 
those where there have been few, perhaps only one, the blood 
contained is much less, and in one or two specimens scarcely 
a trace, and water injected through an artificial aperture 
has flowed from another nearly colourless. 

Would not the contrary be the case if the intervillal space 
were originally filled with blood ? 

But we may also derive much help in solving the difficult 
problem by observing the various diseases of the placenta (see 
Appendix 202) . Take the so-called ^' fatty degeneration of 
the placenta ^' where it is expelled of a pale yellow colour. 
Here we find the capillaries of the viUi empty of blood, the 
result of some change either primarily in them or in the 
foetus. At any rate the villus is not pink^ as it is in health. If 
there be a maternal element filled with blood, should we not 
expect to find it still remaining amongst the villi ? But instead 
of this there is not a trace. The mass is of a pale yellow 
tint throughout, and this without blood having escaped from 
it to cause its blanching (see Appendix) . 

Again, look at the "apoplectic" ovum, or mole, its 
placenta full. of clots in all directions. Why should we find 
death of the foetus to arise from what we may call embolia in 
a cavity where its presence is normal ? I do not mean to say 
such could not be the case, but is it not much more easy to 
comprehend that local coagulation should be owing to the 
entrance of blood into an abnormal position, than to under- 
stand how such a change could take place if blood were 
normally so situated ? 

Under whatever view we look upon the structure of the 
placenta, we must all admit that the tortuousness and thus 
increased length of the curling arteries is of great service in 
preventing sudden pressure of blood on the intervillal space; 




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ANATOMY OF THE HUMAN PLACENTA. 173 

but there is another condition which materially adds in ex- 
treme cases to the prevention of sudden and powerful acces« 
sion of force in that direction, namely, the unsupported con- 
dition of the blood-vessels at the line of separation between 
the placental decidua and the uterus. This, of course, it will 
be remembered, is on the proximate side of the curling 
arteries, and therefore the blood-vessels are. liable at this 
point to give way before the impulse has reached the curling 
arteries. Practically this is known to obstetricians as a cause 
of " accidental haemorrhage," and is largely instrumental in 
more or less completely shutting off the foetus from its nourish- 
ment, causing its death or enfeeblement. 

For what reason, it may be asked, would all this provision 
be made to prevent unusual impulse of blood acting on the 
intervillal space, if that space were filled already by blood, 
according to the sinus-system theory ? 

But if it be answered that even in that case it would be 
very useful, then it must be rejoined that in a much greater 
degree it will be serviceable under the supposition that no 
blood naturally is present in that position. 

IV. Description of the anatomy of the placenta and 
its mode of growth, based upon dissections. Having thus 
endeavoured to show that there is no stage of the 
placental growth at which the sinus-system can be detected 
in an intermediate condition^ and, further, that there is no 
evidence to show that it existed ab initio, but that direct 
evidence and inference from various conditions tend all to 
show its absence, I shall now proceed to explain my views as 
to the structure of the placenta, as far as I have been able to 
decypher this difficult structure. 

And first I may say that if we endeavour to unravel its 
structure from the dissection of the mature organ we shall 
be very liable to fall into error, for at the full period of preg- 
nancy the various parts have assumed totally different relative 
positions as well as proportions. Therefore, although it is 
easy to say, after we have followed its development upward 
gradatim to what parts certain portions belong, yet if we. 



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174 ANATOMY OF THE HUMAN PLACENTA. 

in our endeavours to make out its structure^ begin at the 
mature state, we shall find such difficulties as are almost if 
not quite insuperable, the more especially because we find an 
enormous difference in the relative proportions of the various 
parts at that period in different placentae, as just stated. 

For these reasons it is necessary that we go back to the 
time when the organ is in its simplest state, and then watch 
the changes as they proceed. 

In a general way we shall find it sufficient to take the 
placenta at the fourth month, for although the changes which 
become afterwards very marked may be then existing, yet 
they will not be so advanced as to interfere with the recogni- 
tion of the true arrangement and how the changes take 
place. 

Still, we shall find it best to take it at a very early date^ 
say at a month and a half advanced, because, although the 
placenta is said not to be fully formed till a later period, we 
cannot deny that, although the chorion-villi generally sur- 
round the whole chorion surface, yet in that part beneath 
which the foetal vessels ramify, the villi are larger and 
longer, over this defined area, than at any other part, and 
the future placenta is distinctly indicated even at a month's 
advance from conception. 

Now, at this early period the whole arrangement is really 
very simple, as far as I am able to make out. Within the 
now closed-in cup formed by the growth of the decidua-cells 
the ovum is placed surrounded with its villi. The ends of 
these villi adhere to the inner surface of the decidual cup, to 
a certain degree all over, but particularly and more firmly 
the base of the cup on which the ovum rests. The end of 
each villus was originally slightly bulbous ; this appearance it 
still retains, but it becomes opaque, and thus it is readily 
recognised at a very late period of pregnancy. 

This dilatation is attached to the inner surface of the uterus 
by the assistance of a slight quantity of plastic material, but 
principally by the exuberant growth of the cells of the inner 
surface of the mucous membrane (now decidua) which over- 
lap and envelope it sufficiently to retain, but not so much so 



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ANATOMY OP THE HUMAN PLACENTA. 175 

as to render it invisible without dissection. This extremity of 
the villus^ from its tip down to the last branchy becomes more 
or less effete^ serving only to fix the ovum to the uterine wall. 
This has been also described by many previous authors. Now^ 
on this point Goodsir has made some special remarks^ and 
lays much value upon his description of the minute anatomy 
of this part, as tending very conclusively in his opinion to 
prove the truth of Hunter's theory. 

He represents the layer of cells which I have just now 
mentioned as enveloping the bulbous tips of the villi as being 
derived from the maternal capillaries, so that they not only 
cover these extremities but invest the whole villus and its 
branches, and of necessity the chorion itself from which they 
spring. 

But there are two facts which appear to militate very 
strongly against his description. 

1st. If we examine successively, from early pregnancy to 
the fourth month at least, the inner surface of the cup of the 
decidua, in which the ovum rests and to which the villi are 
attached, we shall find that its appearance is the same as on 
the outside, to which there is no such attachment. That is 
to say, there are the same enlarged oval openings (the folli- 
cular openings, altered in shape only by the deciduid growth) 
on the outside as on the inside of the decidual cup ; and if the 
villi are carefully drawn off the aspect of both is so nearly 
alike that it forms a very clear evidence against the old notion 
that the ovum entered the uterus from behind the mucous 
membrane, and pushing it before it, and also compels us to 
ask, how is it that, if the whole capillary network has been 
converted into the sinus-system, so little change has taken 
place in the surface that no difference is noticeable ? Nor 
can any membrane be noticed running across the follicular 
openings. These openings run the whole depth of the thick- 
ened decidua obliquely, and look like cavities, and when 
filled with blood, might readily be, and probably have been, 
mistaken for vascular sinuses (PI. Ill, fig. 4). 

The suggestion put forward by some, that the villi origi- 
nally enter these follicular openings, is not borne out by my 



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176 ANATOMY OP THE HUMAN PLACENTA. 

observations^ for on no occasion have I detected one so 
entering in a case of early pregnancy ; but later on, when the 
lateral branches of the villi develope themselves with great 
vigour, they doubtless do press into them, and thus in one 
manner lead to the appearance described by Beid, of the 
passage of the villi into the uterine sinuses. 

May the opinion be has^rded that these follicles perform 
the important function of pouring forth fluid into the intra- 
vUlal space for absorption by the villi ? 

When the placenta is advanced to the fourth or fifth month 
their appearance readily misleads, and as the vessels of the 
mucous membrane ramify around these openings and along 
their canals (PI. Ill, fig. 7), it is easy to understand that should 
these vessels become dilated they would encroach on their 
canals ; and that if these dilatations gave way they would 
cause great difficulty (as they, doubtless, have] done) as to 
determining whether large openings of the vascular system 
did not naturally exist into the intra-placental space. 

If, then these openings remain without any membrane 
across them, without any blood within them, and the branches 
of the villi are found in the intermediate space, merely 
attached to the inner surface of the lining membrane of the 
uterus, we have strong evidence against the sinus-system^ 
and a condition very readily explained without the necessity 
of so elaborate a theory as that required by that idea. 

2nd. If the outer membrane or layer of cells which covers 
the villi is carefully examined it will, I think, be seen that 
there is no diflFerence between it and that on the villi of an 
extra-uterine foetation. That no sinus-system exists in the 
latter mode of foetation has been already pointed out. 

If this be so, then any argument founded on the contrary 
assumption will be without point and worthless, and the 
division of the coats of the villi into the maternal, decidual, 
and fcetal, are without foundation in fact, and this is not a 
difficult matter for any observer to prove to himself when any 
fresh specimen of extra-uterine foetation presented itself. 

But if we carefully read through Goodsir's account of the 
placenta, it appears to me that he was not so much endeavour- 




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ANATOMY OP THE HUMAN PLACENTA. 177 

ing to elucidate the general structure of the organ^ as to com- 
bine the cell theory of nutrition with the Hunterian doctrine 
of its anatomy. He assumes^ apparently^ that theory as being 
the true one^ and upon it builds up his theory of nutrition 
for the foetus. It is true he has carefully examined the 
microscopical structure^ and made it coincide with the opinion 
of Hunter^ and then combined with these the cell theory of 
nutrition, but from the tenor of his paper I think he has 
not occupied himself so much to prove or disprove Hunter^s 
opinion as to state that opinion and combine it. Hence^ 
although his opinions might be quoted as to the microscopic 
anatomy, I think they cannot be brought forward so much as 
corroborating the existence of the sinus-system as assenting 
to it. 

The formation of the placenta gradually proceeds in this 
manner. When the size of the ovum has exceeded that of 
the area by which it is attached to the uterine wall (although 
this area expands simultaneously with it) the decidua reflexa^ 
which becomes nearly consolidated with the chorion except 
on that area^ presses on the decidua uterina and ulti- 
mately becomes closely adherent to it. But the angle of 
reflexion is formed, not merely by the two membranes, but 
also by the most thickened portion of the decidua, namely, 
the base of the decidua reflexa. Thus it is that the outer margin 
of the area on which the ovum rests becomes the most solid 
portion of all, and the process of separation which gradually is 
proceeding throughout pregnancy between the decidua and 
uterus is here but slightly marked, so that this ring is, as is 
well known, the most solid and firmly attached of any portion 
of the placenta, serving, doubtless, largely to retain the 
ovum and its placenta in sit4 under concussions and violent 
actions of the body. 

At this part also the adhesion of the chorion to the decidua 
is more firm than elsewhere, for it will be noticed on care- 
ful dissection that just beyond the vascular villi of the 
placenta proper are to be found old effete villi, of more than 
an inch long, branching, but not like the vascular kinds, and 
their branches interlace. They are all firmly attached to 

VOL. XIV. 12 



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178 ANATOMY OP THE HUMAN PLACENTA. 

the decidua^ and serve much to hold the two membranes 
together. They run always in a direction away from the 
placenta, so that the decidua must have expanded more than, 
this part of the chorion grew^ whether as the consequence of 
its own growth or of the stretching produced by the growth 
of the ovum is not very certain. In any case it assists in the 
retention of the chorion to the surface of the decidua about 
the point of reflexion. At this point we ought^ as I have 
before remarked, to find the limit of the sinus-system, which, 
after numerous dissections on placentae, both in sitU and 
recently expelled, I have failed to observe. 

This margin it is which prevents by its firm attachment 
any blood which may have entered the intervillal space from 
passing between chorion and decidua reflexa. 

We will now suppose that by the means just before 
described the area of the placenta has gradually been clearly 
defined, and that the villi are vigorously growing. We thus 
have a placenta of simple construction : — 1st, A membrane 
(chorion) on the inner side; 2nd, the mucous membrane 
of the uterus (decidua serotina) on the outer ; and, Srdly, 
villi passing between these, springing from the chorion, 
branching as they pass to the decidua, into which their ex- 
tremities become rather firmly planted. Amongst these villi 
most probably a small quantity of serous fluid exists to 
assist osmosis. 

As pregnancy advances the vessels of the mucous mem- 
brane of the uterus, at the seat of the placenta, increase in 
size, becoming more or less varicose, showing their natural 
tortuosity very markedly. This is especially noticeable on 
the external or uterine aspect of the placental decidua^ which 
can be exposed by careful peeling it ofi* the line of future 
separation (see Appendix, p. 197). 

This placental decidua from the third to the fifth month of 
pregnancy is of considerable thickness (about one third 
of an inch), but as pregnancy advances the more the vessels 
enlarge and the decidual elements become relatively less. 
But it must be admitted that at this time, and at all periods 



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PLATE 3V. OBSTETRICAL TRANSACTIOl^S YOL XIV. 



PiA.lO. 



D-ark. cUL-D-Westm^xcott a«-«- W Wrnf itr'> U^ 



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DBSOBIPTION OF PLATE IV. 

Fig. 9. a, Main stem of yilli attached to o, serotina ; b, lateral ter- 
minal branch recurrent. 
Fig. 10. Becnrrent branches. 
Fig. 11. Ditto. 



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ANATOMY OF THE HUMAN PLACENTA. 179 

of pregnancy^ the quantity of blood flowing through these 
vessels of the placental decidua is amply sufficient for the 
wants of the foetus^ if we first of all recognise the possibility 
of the nourishment being carried on without the necessity of 
maternal blood in the intervillal space. After the fourth 
month another arrangement takes place^ which counteracts 
the disadvantage of the increasing depth of the placenta. 

The growth of the villi^ always vigorous, becomes still more 
so as the placenta advances to maturity, but the main 
increase of the bulk of the placenta takes place, not so much 
from the elongation of the original trunks of the villi, as 
from the great and multitudinous development of the lateral 
branches. The number of the original trunks is not so great 
as one might be led to imagine from the bulk of the organ, 
but the secondary branches are very numerous, some extend- 
ing somewhat parallel to the main trunks, but principally in 
a lateral direction. These lateral branches, which spring 
from the main stem close to the uterine surface, sometimes 
run along the surface adherent to it for some distance; and 
then the branches of this portion, because they cannot proceed 
further, by reason of the opposition from neighbouring 
branches, direct their course back towards the chorion, and, in- 
deed, I have been surprised to find them extend half way 
towards that membrane (PL IV, figs. 9, 10, 11 ) . So that when 
the placenta is detached from the uterus, the passage of these 
vessels full of blood along the inner side of the placental decidua 
gives an appearance as if they were blood-vessels of the decidua 
rather than of the foetus, and, as the branches passing back- 
wards to the chorion, might readily give rise to the supposition 
that the maternal capillaries themselves had produced villi. 

This fact adds much to the difficulty in recognising a sinus- 
system, because although I freely admit that it is a possibility, 
yet this pushing backward is a much greater change than 
the mere lateral branching is. The ease with which it can be 
explained without this theory is thus very simple. At the 
same time the fact cannot stand as a distinct objection to the 
sinus-system. 

This exuberant growth of the villi it is which gives rise to 



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180 ANATOMY OF THE HUMAN PLACENTA. 

an appearance which has been not hitherto rightly compre- 
hended^ I mean to the mode of the formation of the decidual 
processes. 

If a mature placenta be carefiiUy examined it will readily 
be noticed that in certain parts the villi do not elongate so 
much as at others (of which more hereafter). The effect of 
the general growth is of course^ to push the chorion further 
from the uterus ; if^ therefore, the elongation of some villi does 
not correspond to that of the lateral increase, it is obvious 
that either the chorion itself must be restrained or that the 
decidua at those positions would be drawn away from the 
uterine surface. Principally it is this latter effect which 
occurs, although^ doubtless, some slight influence is felt on the 
chorion. Thus it is that gradually, in certain points and lines, 
the placental decidua is drawn off the uterus, and the so-called 
decidual processes are formed (PI. V, figs. 12, 13). It will be 
seen that it is not by the growing of the processes towards 
the chorion, as would seem to be implied by the writings of 
authors, it is the exuberant growth of the lateral branches 
exceeding the linear growth of the original trunks that 
produces the effects just described. 

Included in this retracted portion are sinuses formerly the 
capillaries, some of them as large as goose-quills. Some of 
these dilatations abut on the villi, and so far are in actual 
contact with them ; and these villi, in the vigour of their 
growth^ doubtless here, as on the other portions of the decidual 
surface, press in upon these dilatations, and thus give rise to 
the appearance that they have penetrated the sinuses. But 
the effect of the retention of these portions of the decidua is 
to keep the maternal blood in the near neighbourhood of the 
villi, thus facilitating the supply of blood for osmosis. This 
fact half answers the objection which some have made to the 
absence of the sinus-system, as to the distance some of the 
villi are removed from the uterus at full term of pregnancy. 

But I have now to point out at what parts this retraction 
takes place, in other words, at what points the linear growth 
of the main stems of the villi are less vigorous. 

Before I can make this clear I must allude to a feature. 



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PLATE V. 



OBSTETRICAL TRANSACTIONS ^/DL.:Xiy. 



F .1 ^ 13 



■-^^^ ' 



1^ r^ 



DTHuJc* d^^ Dr WMt»»ux£oa oUrex . 



W. West t C ? cVont 



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DESCRIPTION OF PLATE V. 

Fig. 12. Section of uteras, decidua, and villi of an early ovum, 
showing the adhesion of the yilli to the mucous membrane 
of uterus, and commencement of the formation of decidual 
processes, some of the lateral branches removed. 

Fig. 13. Section of a lobule. 

a. Depression or process where curling artery is 

situated. 
6. Where venous sinus is placed. 



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ANATOMY OF THE HUMAN PLACENTA. 181 

already noticed by most authors^ to be observed in the com- 
position of the placenta. 

If a placenta at almost any period of pregnancy be laid on 
its amnial surface, the uterine aspect will be seen to be made up 
of a number of lobules^ which generally are hexagonal^ but 
towards the circumference^ where they less encroach on each 
other^ they are more or less circular. In the mature placenta 
they, are about one inch in diameter. They may have the 
deep sulci between them or not. Generally^ as before men- 
tioned^ the sulci are bridged over^ so that the line of division is 
more or less obliterated. However^ though it may be difficult 
to distinguish the boundary^ it is nearly always easy to make 
out the centre^ for this is marked by the curling artery^ of 
which more will be said hereafter. Now, it is at the circum- 
ference of each lobule that the less vigorous growth of the 
villi may be observed most particularly, but it is also to be 
noticed at the centre where the curling artery appears to enter, 
(PI. V, fig. 13, a and b) . Generally by this means the artery 
is retained, so that in some very large and coarsely grown 
placentae (for their size and thickness vary much) the decidua 
at this point is held down, including the artery, thus giving 
rise to the appearance that this vessel opened right into the 
cavity of the placenta. And this appearance is still more likely 
thus to deceive, for the curling artery at its last curl passes 
within the inmost layer of the lining membrane of the uterus 
(decidua serotina), and then ramifies over the inner surface 
of the decidua (PI. VI, figs. 14, and PL VII, 16 i, ii, in), 
against which I have already mentioned the villi press and 
often adhere. This curling artery and its branches, in rami- 
fying over the inner surface, is slightly covered, but at this 
point very slightly so ; though around it at this last curl the 
decidua is generally thickened. At this point it is that the 
decidua is held down by the villi, which seems, for some 
reason not apparent, less vigorous in growth, so as to form a 
projection towards the placenta. The decidual process, instead 
of being of a linear form, as elsewhere, is here funnel-shaped 
and sometimes a short tube, including in it the curling artery, 
which does not always occupy the centre, but in its gyrations 



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182 ANATOMY OP THE HUMAN PLACENTA. 

is found on one side or the other on the yilH^ while on the 
other side the two layers of the decidua forming the funnel 
are in contact^ sometimes even adherent. 

The wall of the artery^ as it abuts on the villi^ is so delicate 
that^ unless care be used^ it will break down, so that blood es- 
capes among the villi, and if the blood in the vessel be gently 
washed away the villi may be readily seen through. 

Thusj it will not be difficult to perceive how it was that the 
supposition arose that the blood passed from this point 
(called the open mouths) straight into the intervillal space 
supposed to contain maternal vascular elements. 

To employ probes^ bristlesj or even a jet of water with any 
force^ is to ensure the rupture of this delicate wall. It is only 
by careful dissections under water, viewed by a lens^ that 
the real structure can be made out. Therefore it was that at 
the outset I stated that results of injections could not be 
relied upon as a crucial test. 

The next position where the decidual processes are to be 
found is at the circumference of each lobule (fig. 13 b), where 
one touches its neighbour. There the villi seem to have 
elongated less than in the space which intervenes between 
it and the curling artery, and the remarks which were made 
on this vessel will apply to the vessels found in these processes 
of the circumference, but they are more liable to variation in 
size, and they do not run the markedly tortuous course of the 
artery, being in all probability the veins of the return 
current of these arteries (Schroeder van der Kolk describes 
them as veins) — (PL II, figs. 1 and 2), and theur innermcst 
wall is in contact with the villi, where frequently they dilate 
to a quarter of an inch in diameter. If, then, this delicate 
membrane is broken forcibly through, blood readily escapes 
within the placenta, or if injection be employed it is extrava- 
sated in the same position. 

That this membrane can be seen intervening between the 
eye and the villi is to me quite a certainty, and can be seen 
without difficulty if great care be taken to open these dila- 
tations and water be poured very gently so as to float away the 
blood. Otherwise here, as in the case of the last bend of the 



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PLATE VI. 



OBSTETRICAL l-RANSACTIOKS YOL XF. 



F J ^ 14 . 







Fi^. 15 




JD'^Hldc* d«L*PrWMtma£ott aLu^«^ 



\C9 6hr.UaL 



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DESCRIPTION OF PLATE VI. 

Fig. 14. External view of a lobule, with entry and branching of 

Curling artery. 
Fig. 15. Curling artery with branch on ovular aspect. 



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PLATE m. 



OBSTETRICAL TRANSACTIONS VOL.XK'. 



¥i.^. 16. 



m. 




X 



R 



DriihcU <W;t.Dr WwtmotcotfccUrex- 



WWe9bftC*e»u-lUJi- 



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DESCRIPTION OF PLATE VII. 

Fig. 16 I. Marg^ of a placenta with detached lobules, a, a. Each 
has a curling artery, e, with ramifications over it on the 
uterine side. Three funic vessels proceed to the foetal 
aspect, b. Fluid injected into each lobule passes by the 
side of these vessels, between the serotina and chorion. 
II. Separate lobule. 

III. Curling artery after last curling when it has reached the 
inner surface of serotina, passes along its inner aspect to 
ramify there. 



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ANATOMY OF THE HUMAN PLACENTA. 183 

curling artery, if this membrane be unobserved or broken 
down^ the appearance is exactly like that of '' open mouths/' 
so frequently described by Hunter and his followers, and 
which really appear of the size of a " goose-quill " in many 
parts. 

It may also be constantly noticed that the curling artery 
does not end at the point of its supposed entry into the 
placenta. 

If the villi of a placenta, say at the sixth or seventh month 
of pregnancy, be removed carefully, and a portion of 
placental decidua held up to the light, it will readily be 
observed that the curling artery ramifies from the centre of 
the lobule, so freely that, comparing their calibres, it certainly 
must have expended itself in ramifying over the inner surface 
of the lobule ; in other words, the branches seem sufficiently 
numerous and large enough to carry off its blood without the 
further demand of a sinus-system in the intervillal space (PI. 
VI, figs. 14, and PL VII, 16, ii). 

In one injection I made in the pregnant uterus with 
glycerine and Prussian blue the injection could readily be 
traced ramifying on the inside of the placental decidua, 
while in a neighbouring part the same injection had burst 
through and had become extravasated in the intervillal 
space. 

Besides the two positions of the decidual processes which 
have been described as dependent on the lobules, there are 
other places where they occur, but not regularly, either in 
position or in extent. In some, indeed in most, placentae, 
irregular deep depressions are found most frequently follow- 
ing a line between the lobules, but never, I think, through 
one. These sulci, caused by the detention of this portion of 
the decidual process, are in general partly obliterated by 
layers of new cell-tissue, which bridge over the depressions 
in three or four layers, formed evidently at different intervals. 
Should blood happen to pass inside these layers, which is fre- 
quently the case, the appearance is very like that of a sinus ; 
careful examination, however soon, reveals the true nature 
of the appearance (PL V, fig. 13 i). However, inasmuch 



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184 ANATOMY OP THE HUMAN PLACENTA. 

as these decidual processes draw in these capillaries which are 
naturally in it, and as these vessels, as in the other decidual 
process, become dilated, these dilatations and their abutment 
on the villi, will cause appearances even more marked than, 
but similar to, those already described. 

There is a form of the human placenta not infrequently to 
be observed which appears to confirm the above points to a 
remarkable degree. In fig. 16 1, taken from a placenta in a 
twin gestation, will be noticed a number of the lobules above 
described separate from the main mass of the placenta, in 
some cases nearly three quarters of an inch. This appearance 
may be noticed in a minor degree in many placenta, but in 
the one from which this drawing was made there were many 
all round— so many minute separate cotyledons. 

The drawing is taken from the uterine surface. In the 
centre of each — the " curling artery " — its last curve is seen 
just before apparently entering the lobule. When the decidua 
was carefully lifted up, as free from the villi as possible, it was 
noted that it opened, not abruptly into the intervillal space, 
but turned suddenly along the inner or ovular surface of the 
decidua (PL VII, fig. 16 iii) , branching into considerable rami- 
fications, which spread out over this surface of the decidua. 
But these branches were not the only filaments given ofi^ to 
this decidua ; before making the last curl very free branches 
were given ofiT to the uterine aspect of the layer, so that it is 
clear to me that the aggregate of these many branches would 
suffice to carry off the blood of curling artery without 
requiring any further drain on it , which the supplying of a 
sinus-system would necessarily require. 

But, again, the three branches of the funic vessels could be 
seen passing into these lobules (fig. 16 ib). When water was 
gently injected, by inserting the end of the syringe into one 
of the other lobules, that is, into the intervillal space, it was 
noted that the fluid passed along the sides of the three funic 
vessels, and distended these detached lobules, without any 
reappearance of the fluid at their uterine surface. That is to 
say, no fluid whatever came through these " curling arteries,'' 
which it should have done had these arteries opened at once 



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ANATOMY OF THE HUMAN PLACENTA. 185 

into the intervillal space. Of course, for this to have been 
accomplished under the idea of a sinus-system, the maternal 
wall of the sinus must have been broken down first on the 
circumference of the lobule where the funic vessels entered ; 
but inasmuch as the lobule, was fully distended, this must 
have occurred had there been such a wall, in which case the 
fluid ought to have come out from the curling arteries. 
This it appears to me to be very strong proof that the inter- 
villal space is free throughout the whole placenta, and, further^ 
that it has no communication with the interior of the curling 
arteries nor the veins. 

By whatever explanation we may suppose this detachment 
of the lobules to have taken place, whether by the very rapid 
enlargement of the interplacental area of the uterus or by the 
atrophy of the intermediate villi, each of these separate lobules 
must be considered to be a minature placenta and that which 
is true in the one must of necessity be true in the other. 
The freedom of communication between them in the line of the 
funic vessels shows that no sinus-system could exist, other- 
wise upon slight pressure blood should have flowed freely 
in the same line, which certainly was not the case in this 
specimen. 

The period of pregnancy at which the decidual processes 
begin to appear in a distinctly recognisable condition is about 
the fourth month. It really commences before, but none of 
the peculiar features are ordinarily readily perceptible before 
that date. I have found about the fourth or fifth month dis- 
eased placentae having the appearance of placentae at full term 
by reason of the deep sulci over their uterine surfaces in con- 
sequence of the destruction of some of the villi by so-called 
inflammatory deposit ; but in a normal placenta at fourth 
month of development it requires a section to show the process 
above described at all. 



V. Considerations from pathological conditions. — Be- 
sides the above remarks, there are some , other con- 
siderations which are derived from the pathological con- 



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186 ANATOMY OF THE HUMAN PLACENTA. 

ditions of pregnancy which lead one to the same conclu- 
sions. 

If^ in certain cases^ the intervillal space of the placenta be 
opened^ we do not find any haemorrhage of necessity arise. 
If a fissure be made in detachment^ or a penetration^ as in 
placenta prsevia^ no serious haemorrhage results^ although if 
a sinus-system existed a large and probably continuous one 
would necessarily occur. This is a fact which can be proved 
very readily. 

The great variability of the amount of haemorrhage upon 
partial detachment of the placenta is explained by the above 
account I have given. For if the placenta be detached partly 
through a decidua process it will be readily seen how freely 
blood could flow ; but if it be separated away from this pointy 
and if no supplying vessel be left partially torn through^ then 
very little bleeding ensues. 

Again^ if a portion of the placenta be torn off and left 
behind^ if any portion of the piece have any opening of a 
vessel into it^ as understood by the sinus-system, then 
haemorrhage should flow continuously, which is certainly not 
always the case. But should a sinus be partially torn 
through, then a liability to bleeding would be found. If, 
also, a curling artery be also opened at the margin of the 
laceration, then, again, a certain amount of oozing would 
take place. 

But, in reality, I may say that very few placentae can be 
detached without an exposure of the intervillal space, so that 
if a partial separation occur the blood which flows in by the 
attached part would in a sinus-system flow freely out of the 
openings, and in every case a severe flooding would occur 
unless the whole placenta was very firmly compressed by the 
uterus. But in practice we do not, in detaching the placenta, 
meet with any formidable fiow of blood. 

There is also a condition of the ovum known as the 
''apoplectic,'* caused by the interposition of blood-clots 
amongst the villi between chorion and decidua. These are 
formed successivelyj in many instances pressing in the 
membranes towards the centre of the amnial cavity, till 



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ANATOMY OF THE HUMAN PLACENTA. 187 

sometimes the cavity is almost obliterated. If blood were 
always to be found amongst the villi^ how^ it may be asked, 
comes it that it coagulates, and acts as a foreign body? It 
might be answered that, like as coagula may occur in the 
heart when the circulation is yery slow, so the same may 
occur in this position. Of course no answer can be made, 
because of the difficulty of the case. But supposing that 
it were already admitted that naturally there is no blood in 
the intravillal space, then the coagulation of blood upon its 
entry is a circumstance very easy to be comprehended. 

From the consideration of the aboye-named facts I consider 
that the sinus-system theory projected by Hunter, and as 
now commonly received, rests upon unstable foundations; 
that it is difficult to reconcile it with the facts now adduced, 
and that where it is employed to explain certain phenomena, 
such as uterine haemorrhage in pregnancy, it appears to fail ; 
and also that when it has been used to clear up other theories 
it has been strained to the highest degree. 

The whole of these difficulties vanish when the more simple 
explanation of the formation of the placenta I have just put 
forth is accepted. This I will endeavour now concisely to 
restate. 

We will assume, with Bischoff, that the decidua has 
formed first a cup, and then wholly, or almost wholly, en- 
closed the ovum, by the upgrowth of the decidua (now 
decidua reflexa). 

The villi nearest the uterine wall increase more than the 
rest, similar to the mode generally described. Gradually 
these become vascular, are firmly attached to the decidual 
surface, and by a slight growth of decidual cells their tips 
become imbedded for a very short distance. 

The growth of the ovum within causes the base of decidua 
reflexa to overlap the decidua vera, and ultimately at this 
part they become intimately blended, forming a firm circum- 
ferential margin to the villi, thus defining the outline of the 
placenta. The villi continue to grow, but principally by 
their lateral branches. Their length increases, but not 
sufficiently to make up for the lateral growth ; thus it is 



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188 ANATOMY OF THE HUMAN PLACENTA. 

that pressure is exerted on the chorion in a direction away 
from the chorion, and tension is consequently put upon 
the decidua to which the older villi are attached. At these 
positions, therefore, the decidua is drawn off from the inner 
surface of the uterus to a corresponding distance, corre- 
sponding to difference of growth of old trunks of villi and their 
branches, and a decidual process is formed. But as the 
growth of the placenta increases, so does that of the lateral 
villi increase over that of the original trunk ; and thus 
the decidual processes become relatively longer ; not nearer, 
however, the chorion, rather the reverse. 

After the decidua has been drawn away a certain distance 
from the uterus a layer of smaller cells is formed across it ; 
in the deeper processes this layer is repeated two or three 
times, bridging, as it were, across it. If blood should pass 
between, the appearance of a sinus is well imitated. 

But these processes observe, as is well known, certain lines. 
These are dependent on the position of the vascular struc- 
ture of the decidua, in other words on the arrangement of 
the curling arteries. There are two situations where the 
lateral villus-growth does not take place so vigorously as at 
others, namely, where the curling artery abuts on the inner 
surface of the decidua, and where its branches terminate at the 
centre and circumference of each lobule ; at these situations, 
if the placenta be detached from the uterus, it will be seen that 
sulci occur. This is best shown about the sixth month ; after 
that date other sulci occur, formed by a union of some of these 
in one line. All can be seen best in the large, highly deve- 
loped placentae; accidental sulci occur at a later period 
bridged over in most instances by a layer of cell-growth. 

The whole of the interior of the placenta is one continuous 
space. Water injected in at one side would reach the whole 
interior without rupture of any tissue. 

The uterine surface of its decidual layer is divided in the 
above-mentioned lobules ; in the centre of each is a curling 
artery; on the circumference are the venous sinuses. 
These sinuses are drawn in with the processes, and, being 
rather varicose than regularly dilated, they project towards 



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ANATOMY OF THE HUMAN PLACENTA. 189 

the villi and touch them. Their walls are very thin 
and transparent^ and are in parts actually touching the 
villi. If slight force be used these walls break down and 
thus an opening is made into the intervillal space^ giving the 
appearance of a natural opening. The last turn or two of the 
curling arteries are also drawn in towards the chorion, not 
generally so much, but still so as to give rise to deception, for, 
its walls being also thin, if pressure be used it yields and 
the villi are exposed to view. The side of both artery and 
venous sinus being smooth, cover the processes in parts, 
and thus give the appearance as if the opening were normal 
and lined by the wall of the blood-vessel. 

It remains to add that, instead of the curling artery 
opening into the intervillal space, it divides into branches 
which ramify on the inner surface of the decidua so far as 
each lobule extends; as it makes its last curl it is there that 
generally the villi can be seen through the wall. This is 
shown at PL II, figs. 1, 2. 

By the ramifications of the curling artery and by the 
indrawing of the sinuses it will be seen that a provision 
is made for the approximation of the maternal vascular 
system to that of the foetus, so as to assist the osmosis neces- 
sary for the foetal existence. 

I should add that the existence of a sinus-system has been 
disputed by Louth, Velpeau, Leiler, Coote, Radford, Bams- 
botham, Millard, Noble, Adams, and Madge. 



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190 ANATOMY OP THE HUMAN PLACENTA. 



DESCRIPTION OF DISSECTIONS OP PLACENTA IN 
SITU, DETACHED, DISEASED, AND ABORTIONS. 

PARTLY REFERRED TO IN THE FOREGOING PAPER. 

1. Dissection of a utems at the sixth month of pregnancy. 

It had been opened and the foetus removed. The placenta 
then occupied more than one third the internal surface of the 
uterus, extending from nearly the fundus to nearly the os 
uteri. 

The decidua vera was still rather firmly attached to the 
uterus. Montgomery's cups were barely visible. On sepa- 
rating decidua refiexa from the chorion delicate fibres, 
probably effete villi, were seen stretching from one to the 
other. 

The effete villi just outside the true placenta ramified over 
the internal surface of the decidua refiexa for nearly two 
inches ; when detached, they left an impression on the decidua 
in which they were half involved. 

The decidua serotina was then detached by most delicate 
touch of a light ivory handle, merely by its weight. Every 
portion was watched under an eye-glass of considerable power. 
The attachment was very feeble, and was sustained by two 
structures. 

The first being slight bands of connective tissue, not 
muscular^ holding scattered groups of single nucleated cells, 
very translucent, oval or round in form, by which the bands 
were separated. 

The second connection was by blood-vessels of very small 
diameter, evidently the original blood-vessels of the mucous 
membrane ; they were about one tenth of an inch diameter at 
the line of demarcation. Some were tortuous ; others wavy, 
and here and there the spiral or curling arteries were seen. At 
this line, namely, that of future separation, all the structures 
were more or less tender, requiring much care lest they should 
be ruptured. No blood whatever issued from any part of the 



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ANATOMY OF THE HUMAN PLACENTA. 191 

line of separation^ except where these small vessels were 
broken through, and this only in very minute quantity. I 
was unable to detect any sinus whatever passing out firom or 
into the placenta through the decidua serotina^ such as 
described generally. The only approach to them was in 
two similar instances where^ in the separation^ I opened a 
sinus in the uterine tissue beneath. This sinus^ on being 
traced, ran in two directions into the deeper layers of the 
uterine wall, and had during its course abutted against the 
line of demarcation and was opened accidentally; a transparent 
layer of delicate tissue had been ruptured thereby. 

The decidua serotina was not quite so thick as the 
decidua vera, but at the points where the vessels passed from 
the non-deciduous serotina to the deciduous there the tissue 
was markedly more solid and thickened. 

On carefully inspecting the uterine surface of the decidua 
serotina I was struck by the appearances of blood-vessels 
running along the interior of the serotina and then dipping 
deeply into the substance of the placenta. On carefully 
examining the specimen, I found that these were lateral 
branches of the chorion villi, which, branching firom the 
villi near their insertion into the decidua, had run along its 
placental surface, and then, the pressure of the exuberants of 
the branches of the neighbouring villi preventing them going 
further laterally, they turned backwards towards the chorion. 
They gave me at first the impression that the maternal blood- 
vessels furnished villi, but no connection could be traced 
between the maternal vessels and them, and after the exami- 
nation of a number of placentae at full term it was very clear 
that their real nature was as just described. 

So far did these recurrent branches extend that in some 
instances of coarse-grown placentae also examined they 
reached nearly to the chorion. Indeed some of the branches 
springing from about the middle of the villi sent back branches 
which came into contact with the chorion, and, indeed, made 
slight attachment to it. When charged with blood, and running 
along the decidual surface, nothing is easier than to mistake 



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192 ANATOMY OF THE HUMAN PLACENTA. 

these branches for the vascular ramifications of the maternal 
vessels. 

There was in this specimen no appearance on the true villi 
of any other structure than their true coating. They were free 
and clear from attachment everywhere. But on carefully exa- 
mining the intervillal space not the slightest trace of blood was 
to be found within it, neither was any sinus-system to be found 
in the decidua. It is true an appearance of one might be made 
by partially separating the deciduous from the non- deciduous 
serotina ; the pseudo-cavities thus made, if blood flowed into 
them, would, to a superficial observer, give the appearance of 
sinuses. 

It was, however, very certain that, supposing an injection 
had been used, all these tender and feebly supported structures 
would readily have yielded upon very moderate force, and 
then that the infiltration of the injection would have given 
some colour to the opinion that a sinus-system existed. 

The same remarks would apply also to the effects of injec- 
tions upon the blood-vessels dilated on the placental surface 
of the deciduous serotina, and the consequent infiltration 
amongst the villi. 

I further noticed that the tips of the original trunks of the 
villi hooked themselves by their bulbous extremities on to 
the decidual surface, and that they there became inbedded 
slightly by the overlapping of a fine layer of cells, which, 
however, did not run down the trunks, but were evidently 
the epithelium of the decidua. These ends became effete, as 
far as their vascular portion was concerned, down to the last 
branch, and this, and generally also the next two, spreading out 
laterally, came in contact with the decidua serotina, and 
coursed along its inner aspect, partly, where in contact, over- 
lapped by the layer of cells just above mentioned. 

The chorion was now separated from the decidua reflexa at 
the margin of the placenta. 

The two membranes were united by a very delicate but 
apparently structureless membrane. The old effete chorion- 
villi were found for two inches or more, as already noticed, 
beyond the margin, firmly attached to the decidua, of a white 



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ANATOMY OP THE HUMAN PLACENTA. 193 

colour^ being torn oflFwith difficulty, running on the surface, 
dividing at places, and ending in little bulbous extremi- 
ties, interlacing sometimes. Nearer the placenta I found 
some villi .attached to the decidua by their ends, which 
gave off branches Ijiterally, and these, instead of attach- 
ing themselves to the decidua, ran inwards to the placenta 
among the trunks of the villi, but not adherent to 
any part whatever, similar in a measure to the recurrent 
branches of the other portion. When the two mem- 
branes were separated at this point the villi-stems looked 
like trunks of trees in a forest, free and clear from any 
covering whatever, either fragmentary or entire. It was 
among these trunks that the recurrent villi projected 
themselves. (PL III, fig. 8.) 

The direction the trunks took were in a radiating form from 
the funis to the margin of the placenta. 

But the separation between decidua and chorion at the 
margin was apparently so slight that it appeared to me that 
upon any pressure or disturbance blood would, if it existed in 
the intervillal space, find no difficulty in passing beyond the 
niargin into between the decidua and chorion. But this is 
an exceedingly rare occurrence and is only observed in early 
states, where it assists to form the solid carneous mole, and 
where we at the same time find blood extravasated into the 
intervillal space. 

As far as I was able to decipher the arrangements, I 
could at this point find no formation which would stand as 
the representative of a maternal sinus, and yet somewhere 
about this margin the outer wall or boundary of some kind 
of the sinus-system should have been recognisable. 



2. Dissection of a pregnant uterus at about the third month. 

The walls were about half an inch thick ; sinuses were well 
marked everywhere, at the neck quite as much as elsewhere. 

The cervix and wall anteriorly was slit up to fundus. The 
decidua vera was still attached to the uterus. It was very 

VOL. XIV. 13 



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194 ANATOMY OF THE HUMAN PLACENTA. 

pulpy and thick near the cervix^ with whose mucous membrane 
it was continuous^ although this cervical membrane had not 
undergone the change common to the interior of the uterine 
cavity. 

The decidua reflexa was dense at it9 base where it was in 
contact with the vera and serotina^ but became rapidly 
thinner, indeed almost a transparent layer, as it approached 
the portion of the ovum opposite its attachment to the uterus. ' 
It was firmly attached to the chorion, with which it seemed 
to form only a single layer. 

The placenta was situated posteriorly, its upper edge being 
at the fundus. 

It was carefully opened on its amnial surface, not a trace 
of blood was within amongst the villi ; water was poured in, it 
diflFused itself all through the interior, but no blood nor bloody 
water escaped. 

The arteries had been injected with blue glycerine injec- 
tion. There was a small portion of this found amongst the 
villi, loosely extravasated amo4gst theni, which had entered 
from a ruptured vessel. 

Now, had any blood been within, some surely must havQ 
been visible. But further, the colour of the placenta was 
almost in every part absolutely white. 

The arteries of the decidua, into which the villi were 
implanted, were injected, but I could trace none whatever 
into the placenta; on the contrary, they could be seen rami- 
fying, and thus expending themselves on the inner surface 
of the deciduous serotina, as I have noticed also in many 
cases. 

From the margin to the placenta inwards I dissected off 
the villi from the deciduous serotina, but I could find no part 
at which this decidua left its original plane. Here and there 
the decidua seemed to rise up to the villi in a more abundant 
state, but it seemed merely the excited growth of the cells of 
its inner surface, caused by the implantation of the ends of 
villi, and the consequent local excitement. 

The villi themselves were very clean, all their parts distinct, 
not enclosed in a general membrane, as found in some de- 



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ANATOMY OF THE HUMAN PLACENTA. 195 

scription. The velvety appearance at this stage^ when seen by 
the naked eye or a low power, was not owing to anything upon 
them, but to the numerous small buddings of villi found on 
the surface of the older villi. The extremities of the villi 
were more bulbous than at a more advanced stage, and these 
dilatations were covered all over by small pendulous buds, 
filled with solid cell-growth at first. 

The decidua reflexa inside was smoother and less marked 
with the oblique openings of the uterine glands at the 
part most distant from the uterus than it was at its lower 
third (that is, near the uterus). At this part the openings 
to the glands were much enlarged obliquely in form, from 
the stretching of the decidua during growth, so that they 
might be readily mistaken, if filled with blood, for the openings 
into the sinuses. These openings thus show that the face 
of the decidua refiexa had not altered its character, except 
by the general growth of the whole membrane upon the 
same plan as the uterine growth. 



3. Dissection of a pregnant utertis about the fourth month. 

Length, 7 inches ; breadth, 5 inches. The patient had died 
after operation for hernia. The uterus was opened from 
below upwards, without injuring the placenta. 

After opening the amnial sac the amnial surface of the 
placenta was examined. Its colour varied from light pink 
to deep purple, the latter occurring in patches, looking 
somewhat like varicose veins. 

Two openings were made some little distance from one 
another ; bright blood flowed from them in small quantities. 
Water was then injected into one hole, which issued from 
the other tinged with blood ; as this indicated the presence 
of blood amongst the villi, and was apparently of too deep a 
tinge than would have come from wounded villi, I sought 
for a further explanation for its presence. 

On carefully examining the interior of the placenta it was 
found that the purple patches noticed from the amnial 



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196 ANATOMY OP THE HUMAN PLACENTA. 

surface were coagula of blood situated and extravasated 
amongst the villi. But the source of these coagula could 
not be satisfactorily ascertained, whether it occurred from a 
rupture of the villi or came from the maternal side. In any 
case, had blood been normally present in the intervillal 
space, there would have been blood universally, either fluid 
or coagulated, disseminated among the villi, not localised 
in patches as here noticed. 

From the distension of one of these patches when the 
funic vessels were injected with water, I am inclined to think 
that the effusion of blood had taken place from rupture of 
the villi, 

A dissection was then made through the uterine wall to 
the placenta, and at the point of attachment of the villi to 
the deciduous serotina. This portion of the mucous mem- 
brane of the uterus was found highly vascular here, as also 
it was in other parts (deoidua vera). The curling arteries 
were excessively well marked, and the venous branches 
were large and varicose, full of clotted blood in many parts. 
Taking into account the large quantity of blood in these 
vessels of the decidua, and the very small quantity found 
amongst the villi, it was difficult to understand why, the 
large spaces amongst the roots of the viUi capable of being 
filled and of holding three or four ounces without much 
distension, there was not a large flow of blood when the 
intervillal space was opened, or a quantity observed within. 



4. Dissection of a pregnant uterus at three and a half months 
of pregnancy, the woman dying of chorea. 

On slitting up the walls of the uterus, from the os towards 
the fundus, on a director, it was noticed that no decidua 
was visible on the cervical portion, the mucous membrane 
being still firmly attached to the muscular portions of the 
cervix. 

Above the inner cervix the decidua vera gradually became 
more separable firom the uterine wall. The director passed 



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ANATOMY OP THE HUMAN PLACENTA. 197 

readily between the uterus and the decidua^ but still more 
readily between the latter and the ovum. 

The walls of the uterus were then thrown open so as to 
expose the uterine aspect of the decidua vera. On that 
aspect were noticed to ramify in it a network of large veins 
full of dark clotted blood. The largest were about an eighth 
of an inch in diameter. They anastomosed in every direc- 
tion with various sized veins^ the arrangement being very 
complexj particularly marked just above the os internum. 

Montgomery's cups were but slightly noticeable^ their 
position being indicated by their lighter colour^ giving a 
mottled appearance to the surface^ irrespective of the net- 
work of blood-vessels. The uterine wall was then dissected 
back from the margin of the placenta to the centre, for one 
and a half to two inches. The difference of the aspect of the 
decidua serotina from that of the decidua vera above 
described was merely in the increased size of the vessels in 
the various layers. Indeed, such was the abundance and 
size of these networks, that it appears (judging of the neces- 
sities of the case) that the blood furnished by them would be 
amply sufficient for the requirements of the foetus. 

Some of the veins were found to run parallel to the line of 
separation for a considerable distance (one inch and a half) 
before dipping into the decidua, much in the same manner 
as is to be observed in the course of the deeper uterine 
sinuses, of which they are branches. The decidua serotina 
was then examined with reference to its thickness. It 
was found that the ends of the villi were more or less exposed 
in some parts, or so slightly covered in others as to be liable 
to be so upon slight movements. 

Being anxious to ascertain if any blood were in the inter- 
villal space, the decidua serotina was slightly lacerated with 
much care ; upon this a slight oozing of watery blood took place, 
which pressure somewhat increased. It is impossible to say 
what amount of blood might have entered the intervillal 
space during the separation. Water was gently used to 
wash that which seemed likely to enter ; probably only a 
small quantity succeeded in entering. 



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198 ANATOMY OF THE HUMAN PLACENTA. 

The placenta was then opened on the amnial surface as 
carefully as possible^ and a small quantity of blood was 
seen to exude ; and then^ in order to see whether this came 
from villi cut through^ or firom the intervillar space^ the 
funis was injected with blue^ and it was found that, not- 
withstanding the great care taken to avoid wounding the 
foetal vessels and the villi, one had been cut through, and 
from this the blue injection poured forth freely. 

The quality of the blood in the foetal vessels was then 
compared with that of the uterine, and then both these 
with the watery blood in the inter-placental space. It wad 
found under the microscope that the relative quantity of 
blood-corpuscles in the maternal and foetal blood was about 
the same, whereas in that in the inter-placental space the 
relative numbers were about 500 times less. So marked a 
difference one would think could not have existed had a 
sinus-system permitted the entry of blood into that space. 
Half a dozen drops of blood into the space would, I should 
suppose, be sufficient to produce the same result. 

The reflex decidua was then separated from the margin of 
the placenta, beginning at some slight distance from it. 

The effete villi, for an inch or so from the true placenta, 
passed from the chorion upwards along the inner surface of 
the base of the decidua reflexa, running between the latter 
membrane and the chorion, with both of which they were in 
contact. Their tips were bulbous and opaquely white, firmly 
rooted into the decidual surface, spreading out into four or 
five branches, the ends of which, also, were firmly attached 
to the decidual surface. These effete villi were about one 
eighth to one tenth of an inch apart, and between them the 
proper or active villi passed, having doubtless extended there 
by their growth and the inward pressure. At this point 
nothing of a maternal character could be seen between 
chorion and decidua reflexa, nor between the villi, the cavity 
of the placenta being apparently continuous with the space 
between the chorion and decidua reflexa, when these two 
were separated. 



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ANATOMY OP THE HUMAN PLACENTA. 199 



5. Dissection of a uterus pregnant at fourth month. 

The patient had died in a fit ; the membranes were ruptured 
and the leg of the foetus drawn through the os uteri before I 
received it. 

The utel'us was carefully slit up from below, and it was 
then found that the lower edge of the placenta had already 
been detached from the uterus for about one sixth to one 
eighth of its total area. This, of course, prevented the 
formation of any decision as to whether blood was to be 
found in the intervillal space, because an opening already 
had exposed this space to the exit of its blood as well as to 
its invasion. Blood was certainly found amongst the villi, 
but its source was not made out. 

The inner surface of the decidua serotina was rugous, and 
the old apertures of the follicles well shown, between which 
the villi-tufbs pushed themselves, but no processes of decidua 
were to be seen. Capillary vessels were seen running over 
the inner surface of the decidua, like those I have noticed in 
more mature placenta. 

The margin of the placenta showed the extension of the 
old effete chorion villi an inch beyond the junction of the 
decidua reflexa and vera. 



6. Dissection of a placenta. 

It was delivered at full term, and was large and firm with 
yellow albuminoid deposits in some parts. The deciduous 
serotina was firm and irregular, the sulci between the lobules 
in many parts much levelled up, and agglutinated together 
by a deposit of new tissue. In certain parts of the large 
lobules relics of old sulci were found completely closed over, 
the only indication remaining being the opening of the 
veins. These were found after careful search to pass very 
obliquely, and then, when traced by cautious separation of the 
agglutination, were found in many instances enlarging and 



200 ANATOMY OF THE HUMAN PLACENTA. 

dilating. They passed sometimes so deeply into the placenta 
that it seemed as if they opened into the middle of its interior 
amongst the villi ; but this was not the case, as was seen upon 
still more careful inspection. It was then seen that^ although 
these dilated veins accompanied the decidual processes^ yet 
there was a very delicate membrane (the wall of the vessel) 
which separated the villi from the maternal blood. So 
delicate it was^ as may be supposed^ that had a probe or 
bristle been employed in tracing it^ it would instantly have 
given way^ and the probe would have passed amongst the 
villi. As these dilatations were situated on the placental sur- 
face of the decidual processes^ and as each process was really 
a double layer^ the dilated vessel had these two layers on 
the one side and the villi on the other. 

So far^ the villi were in contact with the maternal vessels. 

The decidual process could be seen to be produced by the 
shorter condition of the trunks of the villi inserted into the 
serotina at this part. The lateral branches^ growing vigorously^ 
put pressure on the chorion^ which^ yielding^ draws upon the 
serotina^ and of course the shorter trunks act most markedly^ 
and thus gradually the deciduous serotina is drawn away from 
the uterus^ including with it, of course^ its blood-vessels^ 
dilated more or Jess. In some parts the dilated vessels are 
well marked, in others they are but slightly, and this is 
noticed to vary in different placentse, the dilated vessels in 
some being very scanty, while in others it is strongly 
marked. 

7. Ea^aminaiion of a mature placenta* 

It was a '^ battledore '' shape, i.e. the funis inserted into the 
margin. Very little haemorrhage accompanied the shedding 
of it. The medical attendant said very little, if any, exuded 
before he gave it to me. He had slightly washed it with 
water to remove adhering blood, and rolled it up in a cloth. 
This cloth, when I opened it the next day, had no stain of 
blood on it. 

Five openings were made, about three inches from one 



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ANATOMY OF THE HUMAN PLACENTA. 201 

another. No blood flowed from either. Water was injected 
through one hole by a syringe ; it flowed out from the other 
perfectly free from colour. This was done fireely^ and, to 
make still more sure that the whole intervillal space was free 
from blood, I passed the injection tube down to the serotina 
with the same result. The water fliowed freely throughout the 
whole organ, raising it up throughout. The placenta was then 
turned over, and injected with water with the same result. 
The fluid was retained well within the serotina, not flowing 
out at any spot except at the few parts where the deciduous 
serotina was wanting. 

It is clear that at that time there was no trace of blood, 
even supposing it had flowed out before being placed in the 
cloth, yet then it is almost incredible that no trace whatever 
of it should have remained, when we consider the large cavity 
and the small apertures through which it could escape. 

The fluid which did appear on the serotinal surface did 
not flow through the curling arteries, nor dilated veins, which 
it ought to have done had they been the natural channels 
in and out of the intervillal space, and it was particularly 
noticed that over one large portion of the deciduous serotina 
no fluid at all appeared, there, being no denudation of the 

vim. 

The deciduous serotina was most highly injected in every 
spot by a very complete network of blood-vessels, seen 
easily by a low power, on the uterine surface. Besides these 
the curling arteries ramifying very obliquely, as usual, with 
all uterine vessels. 

There were deep sulci in places, in one very marked, 
extending nearly down to the chorion. This had not prevented 
the water from passing equally throughout the whole in- 
terior. 

The decidual processes were double, readily seen on sepa* 
ration; but if care was not taken, the layer was readily 
broken through, giving the appearance of a natural opening 
having been reached, inasmuch as the villi were exposed. 

As in other placentse, these processes were produced by the 
slower growth of the original trunks of the villi, compared with 



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202 ANATOMY OP THE HUMAN PLACENTA. 

the rapidity of their lateral branches^ which push the chorion 
away^ and thus draw off the deciduous serotina from the non- 
deciduous. If this were compared with the placenta at earlier 
stages^ the effect of this exuberant growth could be readily 
traced. 

The layers of new membrane which bridged over the sulci 
often hid the sulci^ and if blood was effused amongst the 
layers the resemblances to sinuses would be much increased. 

8« Examination of a mature placenta in the state called 

''fatty." 

The foetus had been alive within a week before deli- 
very; very little blood had come from itj not enough to 
soil the wrapper which enclosed it. A very little escaped 
during its delivery. It was in the same state then as when 
I received it as to colour and consistency. It was sulcated 
deeply. In the centre of each lobule was seen a curling 
artery^ which penetrated ai variable depth in the various 
lobules^ about i inch at the deepest. A little blood was in 
each vessel ; but with the exception of this there was no tint 
whatever of blood. The contrast was very marked between 
the curling artery with the contained blood and the pale yellow 
bloodless villi. 

In the mass the placenta looked like a cake of fat as to 
colour^ and the deciduous serotina over its maternal surface 
gave it a smooth surface^ something resembling the fat of the 
kidneys. 

Upon opening the intervillal space no trace of blood was 
visible amongst the villi. The villi were themselves in nearly 
every part bloodless^ their interior was occupied by cells which 
had solidified them; some were undergoing fatty degeneration^ 
but in the greater number abnormal cell growth was the 
cause of the change in character of the villi. Supposing that 
there were blood normally amongst the villi^ how could the 
change in the villi explain its total absence ? Amongst the 
roots of the villi there are places from which blood could 
not have exuded so as to leave no trace behind. 



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ANATOMY OP THE HUMAN PLACENTA. 203 



9. Description of the so-called '^ fatty " placenta. 

The child had been liying up till a fortnight previous to 
labour^ which took place at full term. 

The placenta was pale in colour^ without a trace of blood 
between the villi. The curling arteries were rather more 
varicose than usual^ and very distinct. Some could be traced 
ramifying by their branches on the placental aspect of the 
deciduous serotina; these branches were in contact with the 
villi, but not dipping amongst them; and although they 
were engorged with blood, not the slighteert quantity ex- 
tended beyond their walls. 

The vilU had but little remains of the foetal blood in their 
capillaries; here and there a slight appearance to indicate 
their course. There were no fatty globules within them, 
merely a nearly entire absence of blood in the foetal capil- 
laries. This state rendered the absence of blood in the 
intervillal space a matter of complete certainty. 



10. Examination of a mature placenta in the condition called 

''fatty/' 

The child ^as bom dead, but well nourished, atid had not 
been dead long. 

The general aspect of the placenta was pale and fatty in 
appearance. It was very markedly sulcated ; the sulci deep. 
The surface showed very dilated veins, and also curling 
arteries. Some of the veins dipping into he sulci were ^ of 
an inch across. Some of the curling arteries were filled with 
black blood; they were highly raised and very tortuous. 
The whole of the maternal vessels were in marked contrast 
with the pallor of the villi, on which no foetal blood was 
present. On carefully tracing the curling arteries they 
were found to enter into the placenta, dipping down half way 
towards the chorion, being about -I- to i of an inch in diameter. 
Indeed, it appeared at first sight that they were enclosed in a 



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204 ANATOMY OF THE HUMAN PLACENTA. 

vessel with a thick wall^ but on carefully examining it was 
found that the spot where the artery was situated was 
drawn in by the shortness of the villi-trunks implanted there, 
so as toform a tube of the deciduous serotina in which theartery 
was curling. This tubular sulcus was bridged over by ad- 
ventitious layers^ in the same manner as the other sulci, so that 
it was quite concealed from view when seen from the outside. 
But outside this blood-vessel so situated, that is, in the inter- 
villal space, there was not a trace of blood, as was seen in 
the ease just before described. 

AVater was thrown in, but not a sign of blood appeared in 
it as it again escaped. 



11. Description of an aborted ovum, which came away com-> 
plete with the decidual coverings. 

The true ovum was about one inch in diameter. The 
decidua vera about a quarter inch thick. The Montgomery 
cups were scarcely marked. The inner or free surface was 
somewhat velvety, lobulated, and generally smooth. 

A protusion about one and a quarter inch long projected 
into the interior of the decidual or uterine cavity, without any 
aperture, covered with decidua reflexa. This reflex covering 
was evidently of the same structure as the vera, but of unequal 
thickness ; nearer the uterine wall it was much denser than at 
the opposite part ; within this projection into the uterine cavity 
the ovum was situated, and, indeed, could be readily seen iS 
viewed through the part of the projection which had been in 
contact with the uterus, namely, through the deciduous 
serotina. This latter layer was of very uniform texture 
throughout, slightly opaque, rather denser than the chorion, 
so transparent that the ovum and its foetus within could be 
distinctly made out. It was slit up, and found to be smooth 
on its ovular surface up to the base of the decidua reflexa, with 
which it was continuous. 

No chorion vi/Zi opposed this layer (the deciduous serotina), 
not even a trace of one ; it was simply a transparent mem* 



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ANATOMY OF THE HUMAN PLACENTA. 205 

brane through which the ovum could be seen in the amnial 
fluid. 

On tracing the internal surface of the cavity formed by the 
decidua serotina and reflexaj it was found to be generally 
smooth ; but openings of an oblique outline^ readily recognis- 
able as the openings of the uterine follicles^ were found on 
the inner surface of the decidua reflexa. The openings were 
much larger than in the unimpregnated state^ but were more 
like a slit. 

Chorion vUU were only found attached to the base of the 
interior of decidua reflexa, having a vascular arrangement^ 
and the chorion and decidua were in dose contact^ only 
permitting the running of the villi between them, which did 
not pass perpendicularly to the decidua from the chorion, but 
passed radiatingly along between the two membranes and in 
close contact with both. 

There was not the slightest appearance of any dilated 
vascular element ; the villi did not crowd each other, nor come 
into close contact. There was no dovetailing of the foetal and 
maternal vascular system, nor any process from the decidual 
surfaces which could lead up to any sinus-system. 

The villi, it was noticed readily, did not enter the openings 
of the uterine follicles, nor was there any attempt at such an 
arrangement, the openings of the follicles being a quarter of 
an inch in many instances. The whole position was so readily 
examined under water that no such a plan as necessary on 
the supposition of an incipient sinus-system could have been 
overlooked. I need to this hardly add that no blood existed 
between the chorion and decidua layers. 

The villi were covered with a layer of flat cells, irregularly 
hexagonal, like Van der Kolk has given, but they could not 
be seen on the chorion surface so markedly, but on tracing 
down the trunk of a villus from apex to the junction with 
chorion a gradual change took place, without any mark of a 
sudden break, so that the layer on the chorion was continuous 
with that on the extremity of the villus, and apparently 
was the exo-chorion, which was pushed out during the 



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206 ANATOMY OF THE HUMAN PLACENTA. 

sproutmg of the villi, and became more developed at the seat 
of functional activity, namely at the ends of the villi. 

This ipras the '^ so-called ^' maternal layer of the villi. I 
would name it the exchchorion. I should add it was found 
also on the lateral branches of villi. The walls of the villi 
were also, inside this layer, composed of irregular cells. 

The funis of the foetus was spirally twisted. The funic 
vessels passed towards the side of the chorion villi, i.e. not, 
as usual, to the serotina, which is a fact of much interest, as 
helping to determine the cause of the situation of the 
placenta. 

I mi»y add that the eye was partially developed. The 
crystalline lens was developed and opaque, adherent to the 
cuticle, composed of numerous cells (whose shape if as not 
easily seen), enclosed in a capsule. The pigipent was slightly 
developed around cells, like as may be seen early in the 
develgpment of the eye in invertebrata. It y as difficult from 
the state of the specimen to make out more. The umbilical 
vesicle was well lyiarked. 



12. Examination (jf an ovum expelled seven weeks after last 
menstrual epoch. 

It was entirely closed in the decidua, which came away 
perfect. The ovum was half an inch in diameter. The 
decidua serotina and reflexa seemed equally dense through- 
out. Blood-vessels, well injected with their blood, were to 
be seen ramifying over every portion of the bag of decidua 
reflexa^ except at the central portion opposite the serotina. 

On opening the decidua serotina the ovum was seen 
within. The chorion villi altogether were less numerous 
than usually figured in works on the subject; they were 
spare on the serotinal aspect, but closely in contact on about 
one fourth of the surface of the ovum, namely, about the 
base of the decidua reflexa. Their extremities were attached 
to the inner surface of the decidua ; but although the vessels 
were seen on this surface, there was not the slightest 



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ANATOMY OF THE HUMAN PLACENTA. iXfl 

evidence that any distension of the maternal vessels had 
surrounded the villi anywhere. The villi were so distinct 
that the sinuses must have been seen had they been present. 
It is to be noted that had they been present the maternal 
elements must have undergon<B three times the development 
of the villi^ in consequence of the distance between the 
trunks. No blood was found amongst the villi. I could not 
trace any foetal vessels to the villi. 

13. Examination of a mature placenta. 

It was battledore shape^ but nothing in general ^pect 
different from the average. The whole deciduous serotina 
was very thin. It was very vascular^ but no large sinus 
was visible anywhere. The curling arteries were readily 
seen running between the layer of the thin serotina^ and 
then on to the inner aspect. Blood-vessels could be seen 
through the serotina branching right and left for an inch i|^ 
many instances. Careful investigation showed them to be 
the lateral branches of the villi> which, impinging on the 
inner surface of the serotina, after a certain distance bent 
inwards again towards the chorion some distance. On the 
trunks of the villi the appearance — a network of capillaries 
injected with blood — ^was well marked, such as ha^ been 
described by Van der Kolk. 

A small quantity of blood was found amongst the villi. 
There were many fissures in the serotina. Water injected 
in the intervillal space, through the uterine aspect, came 
indiscriminately through the whole placenta, but flowed out 
again, not through any curling artery or sinus, but through 
the fissures in the serotina. The latter fact I have fre- 
quently found in other placentae. 

Dr. Madge said that he had worked a good deal at the sub- 
ject. He gave a short statement of his vievirs. He felt con- 
vinced that the Hunterian doctrine respecting the utero-placental 
vessels was a mistaken one. 



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JUNE 5th, 1872. 

John Braxton Hicks, M.D., F.R.S., President, ia the 

Chair. 

Present — 41 Fellows and 11 visitors. 

Books were presented from Professor Karl Schroeder, 
Jott. Cesare Belluzzi, Dr. Francis Hogg, R.H.A., and the 
Massachusetts Eye and Ear Infirmary. 

The following gentlemen were declared admitted as 
Fellows of the Society : — Dr. Brock mann. Dr. Charles E. 
Buckingham, Dr. Charlton Fox, Mr. John E. Kennedy, Dr. 
Norman S. Kerr, Mr. F. M. Rickard (Cannanore), and Dr. 
John Wallace. 

The following gentlemen were elected Fellows : — Charles 
J. Bracey, M.B., Birmingham ; Geo. B. Denton, M.R.C.S., 
Liverpool; Henry Mortlock Fernie, M.R.C.S., Macclesfield; 
Crosby Leonard, M.R.C.S., Bristol; Maro Tuckmann, 
M.D.; and Charles B. Waller, M.R.C.S. 

Dr. Munde exhibited for Professor Simon, of Heidelberg, 
a scoop for removing superficial portions of malignant 
disease of the cervix when more complete measures oonld 
not be entertained. 

Dr. Bi.8CH, induced bv Professor Simon's visit and paper on 
the subject, scraped off the vegetations in a case of uterine cancer. 
Little blood was lost at the operation, and relief followed for some 
time. That was all that rrofessor Simon promised* and it 
certainly is enough to justify on extensive trial of his handy little 
instruments. 

VOL. XIV. 14 



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210 SECONDARY F(£TUS. 

Dr. Baskes assented generally to the principle of dealing with 
cancer by removing the superficial proliferating portions which 
were the seat of the most immediately dangerous symptoms, as 
haemorrhage and foul discharges. The iDstrument of Professor 
Simon, although different in form, did not differ in its use from the 
curette of Dr. Marion Sims, which he had frequently employed to 
scrape off the the active vascular proliferating layers ot* malignant 
growths. The principle was the same as that of removing by 
galvano-caustic'or wire-ecraseur cauliflower excrescences from the 
cervix uteri, even in cases where we did not hope to remove the 
substratum of malignant tissue. The patient gamed comparative 
respite for a time from hemorrhage and pain, and he had seen 
marked diminution of the cancerous cachexia follow. One caution 
he had to suggest in the use of the actual cautery. If the disease 
extended into the body of the uterus, the application of the actual 
cautery to this part was apt to cause thrombosis in the vessels 
just at the level of their entrjr into the broad ligament. This and 
the attendant inflammation was likely to induce phlegmasia dolens, 
which, in cancer, was usually soon followed by death. 

The following report on the specimen exhibited by Mr. 
Grieves, of Stamford^ was then read : 

The foetus, a premature one^ is naturally formed and 
measures thirteen inches in length. An irregular lobulated 
growth, nearly as large as the head of the foetus, hangs from 
the mouth by a short pedicle. The pedicle is attached to 
the roof of the mouth, but is found on dissection to spring 
from the body of the sphenoid bone. The growth consists 
externally of a number of soft roundish lobes^ which have 
been so injured by desiccation, &c., that their structure 
cannot be satisfactorily ascertained. They have thin plates 
of bone interspersed through their substance and are loosely 
filled with dried blood-clots. 

The central part of the growth is composed of numerous 
pieces of bone and cartilage, united together into a compact 
mass^ with here and there little deposits of fat. None of the 
bones can be identified. 

We are of opinion that the above growth probably repre- 
sents a secondary foetus. 

J. Watt Black, 
J. B. Potter. 



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SYPHILITIC PLACENTA. 211 

Dr. Wiltshire said that the report agreed in every eaaential 
particular with one Mr. ThomaB Smith and himself had made to < 
the Pathological Society on an almost identical case. 

The following letter from Dr. Godfrey, of Enfield, giving 
further particulars of his case of syphilitic disease of the 
placenta, was then read : 

Dear Sir, — I enclose you further particulars of the case 
of syphilis to which you kindly refer. The husband has 
given me these details. 

I remain, yours very sincerely, 

B. OODFREY. 

He contracted syphilis three years and a half ago. Had 
a primary sore, the scar of which I have seen. There is no 
sign of disease upon him now. He has had constant 
connexion with his wife since she has been under treatment. 
He thought that he was cured before he married, and got 
the permission from his medical man. He evidently had 
tertiary syphilis. The wife had two primary sores upon the 
vulva, with hardened base, and a secondary rash all over her 
arms and neck, when I first saw her in September. There 
was also the general malaise of syphilis. 

I put the infant upon Hyd. c. Cret& bis die a few days after 
it was^bom, and have continued it up till now, so that one 
cannot see any vestige upon the child. 

The husband's face is scarred as if smallpox had attacked 
him. This, he says, was from skin disease, which lasted a 
long time. It is like the scar of secondary syphilis. 



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212 



A SHORT ACCOUNT OF THE CASES OF THREE 
SISTERS IN WHOM THE UTERUS AND 
OVARIES WERE ABSENT. 

By Charles E. Squarey, M.B., M.R.C.P., 

A88IBTANT PHYSICIAN TO THB HOSPITAL PO& WOKEN, 80H0 8QVABK ; 
PHT8ICIAN-ACC0UCHEUB TO THB 8T. MABTLBBONB 
GENBBAL DI8PBM8ABY. 

The following three cases of absence of the ntems and 
ovaries occurring in three sisters^ aged respectively 26^ 
18, and 16 years, I bring before the Society, not that I have 
anything to offer in explanation, but rather as a curious fact 
in congenital malformation which is worthy of being placed 
on record. 

The congenital defect seems to have been derived from the 
mother's family, she having a sister in whom the catamenia 
have never appeared, and also three aunts who, though 
married, never had any family ; but of the condition of the 
catamenia in her three aunts or of the uterus and its appen- 
dages in either of the cases^ I have not been able to obtain 
any exact knowledge. 

The mother of these girls is a strong, healthy woman, 
aged 56. She has always enjoyed good health, and does not 
know of anything to account for the malformation in her 
children. The catamenia made their appearance in her when 
she was twelve years old and ceased at forty-six. She was 
always regular, excepting during her pregnancies. She has 
had five children ; two died young, a boy and girl, and both 
were, as far as she knows, well formed. 

The father died of consumption. He was married twice, 
and by his first wife had children, some of whom have 
married and borne children ; by his second wife, the mother 
of these three cases, the five children above referred to. 

The occurrence of the same malformation in various 
members of the same family is so frequent that it is hardly 
worth noticing, as also the direct transmission of such mal- 
formations from parent to child, but in the case before us 



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ABSENCE OV UTERUS AND OVARIES. 213 

the tendency to malformation was evidently latent in an 
otherwise perfectly healthy woman^ and was so strong as to 
maintain its influence throughout a period of ten years from 
the birth of the first to the last child. 

It would have been very interesting to know for certain 
the condition of the boy who died youngs whether congenital 
deficiency existed in his case or whether it was only limited 
to the female members of the family. The mother most 
positively asserts that he was well formed, and her evidence 
with regard to the perfect development of the male generative 
organs might, I think, be very well relied on. We know 
that in other malformations and in disease it is not un- 
common to find the mother transmitting them to the 
daughters, the sons being healthy, and, vice versd, the father 
transmitting them to the sons, the daughters being un- 
afiected. 

The following is a short account of the conditions of the 
three girls, 

M. A. P — , set. ,26, a well-formed girl, following the 
occupation of laundress, came under my care at the Hospital 
for Women, in Soho Square, in August, 1871, complaining 
that she had a contracted womb and that her catamenia had 
never appeared. Generally she has had pretty good health, 
never very strong, but is not getting weaker now. She 
sufiers from pain across the back occasionally and headache, 
but not at all regularly. 

On examination the vagina was found to be represented 
by a cul-de-sac about 1^ or 2 inches long, fairly capacious. 
No sign of a uterus discoverable, either by vaginal or rectal 
examination or by the conjoined vaginal or rectal examina- 
tion. By the latter the fingers could be made to meet 
easily over the whole of the lower part of the pelvis. No 
solid mass could be detected with the sound in the bladder. 
No tenderness on examination. 

The pubes was entirely devoid of hair, but there were a 
few hairs scattered round the vulva. The labia were of a 
dark violet colour. The breasts were well developed. 

E. F — , set. 18. Complains of occasional headache and 



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214 ABSENCE OF UTERUS AND OVARIES. 

giddiness^ but not at all severe. She has no periodical 
pains. The catamenia have not yet appeared. Vaginal 
examination^ conducted as on her sister^ disclosed exactly the 
same conditions, except that the vaginal cul-de-sac was 
somewhat shorter and smaller. 

J. P — y set. 16. A fair-haired, rather pretty girl, well- 
formed figure for her age, says that she has never been very 
strong, but has had on the whole very good health. Suffers 
from headache occasionally and cramping pains in the 
stomach, but neither are periodical in their occurrence. 

The same conditions as in her two sisters were found on 
examination. 

With regard to all three, there was nothing in their out- 
ward appearance to lead one in any way to suspect any such 
malformation in the generative organs. The two elder 
sisters said that they had occasionally very slight desires for 
coitus. 

I may add that I have taken care to see that these cases 
have not been published before. 



Dr. Phillips stated that in 1870 there were two sisters under 
his care at Guy's Hospital in whom no trace of a uterus could be 
found. The one was twenty years of age, of dark complexion, 
rather diminutive in stature. The external genitals were per- 
fect, the pubes was covered with hair, and the mammary 
glands were well developed. The vagina was represented by 
a short but dilatable canal,|about an inch long, terminating as 
a cul-de-sac, A careful pelvic examination failed to detect any trace 
of a uterus, and, as far as an examination during life could decide, 
there were no ovaries. She had been subject since her marriage 
at seventeen to pain in the loins, sickness and headache, and she 
thought these were worse for a few days every month. There 
had never been any discharge of blood from the vagina. The 
patient stated that one of her sisters had never menstruated, and 
when the latter presented herself it was found that a malformation 
similar in every respect to that in the former case existed. She 
idso was married, was twenty-one years old, very like her sister 
in appearance, but taller, and she complained of the absence of 
sexual feeling. It was worthy of notice that in Dr. Squarey's 
cases and his own the breasts were well developed. It was, of 
course, possible that the ovaries existed ; but this seemed very 



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ABSENCE OF UTERUS AND OVARIES. 215 

improbable in one case which he had seen, in which although, the 
breasts were large, the whole of the internal genital organs seemed 
absent. The urethra was natural, but there was no external 
opening between it and the rectum. With a catheter in the urethra 
and a finger in the rectum, the urethro rectal septum was found 
to be about the natural thickness of the recto- vaginal. The 
finger in the rectum and the hand above the pubes met easily. 
The patient was twenty-four years old, and had come up from the 
country to ascertain whether she was fit for marriage, as menstrua- 
tion had never appeared. 

Dr. Hbtwood Smith said that about five weeks ago a similar 
case came under his care at the Hospital for Women. A woman 
nearly 30 had not menstruated, and on examination there was 
found merely a small knob about the size of half a filbert to repre- 
sent the uterus. Some years ago he had under his care a Jewess, 
who, as far as he could ascertain, had no uterus, a very short 
vagina, a urethra wide enough to admit the tip of the little finger, 
and who menstruated througn her bladder ; and another case where 
there was a normal uterus but total absence of menstruation 
and that girl had full whiskers and beard. 

Dr. BooERS had had three cases of absence of the uterus in 
otherwise well- formed and healthy women, the vulva, labia and 
mammsB being well developed ; he had seen two more in the prac- 
tice of his colleague. Dr. Bouth. In his own cases there were small 
vaginsB large enough to admit half a finger, and which could have 
been dilated had it been necessary. They all stated they felt 
sexual excitement. Most likely the ovaries were present, though not 
felt. The most careful examination, even with the hand in rectum, 
while the patient was under chloroform, failed to find a trace of 
the uterus Two of these cases contemplated marriage, and not 
having ever menstruated desired to know whether they ought to 
be married or not. Dr. Kogers' opinion was against their 
contracting such ties under their peculiar circumstances. 

Dr. Tilt was not prepared to admit that the ovaries were 
absent in women who owned to sexual feelings and presented a 
normal development of the mammary glands ; he preferred to 
admit that in such cases the ovaries were placed beyond the reach 
of the observer's finger. Dr. Tilt remindect the Fellows that, as a 
rule, in healthy women who had borne children it was not possible 
to identify the ovary unless the pelvis be unusually shallow or unless 
the ovaries had descended lower down, from having been made 
larger and heavier by chronic inflammation. 

Dr. Barnes said that it was not to be too readily assumed that the 
uterus or ovaries were absent on the negative evidence of examina- 
tion during life. Kussmaul declared that these organs were rarely 
altogether absent, some rudimentary representative could almost 
always be found on careful dissection. At the same time there was 



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216 LONG BELAY OF LABOUR 

distinct evidence to prove that they might be absent. There was a 
preparation in IJniyersity College Hospital from a girl aged 21 
who had never menstruated ; no ovaries could be seen, and the 
uterus retained the characters of that of a young child. In several 
cases where the uterus and ovaries were absent or imperfectly 
developed he had found no vagina. In one such case he dissected 
up an artificial vagina a year ago, and a few days ago this vaigina 
existed well preserved. The patient habitually wore an elastic 
dilator ; if she omitted this for several days there was a tendency 
to contract. In this instance there was no hereditary association ; 
ahe had married sisters who had borne children. 

Dr. WiLTSHiBE agreed with Dr. Phillips in thinking such cases 
were not very rare. He suggested that some information or 
guide might be obtained by external measurements of the pelvis 
and by observation of the condition of the breasts. He mentioned 
cases where patients had borne children after treatment of mal« 
formations supposed to be irremediable. 



LONG DELAY OF LABOUR AFTER DISCHARGE 
OP THE LIQUOR AMNII. 

By J, Matthews Duncan, M.D. 

Mrs. S — . set. 22, mother of two healthy children born at 
the full time, was unfortunate in her third pregnancy, the 
events of which I now relate. She had her last monthly illness 
in the end of September, 1871, and expected her confinement 
in June, 1872. On February 23rd she quickened, and stirrage 
continued to be felt till the child was born. The size of the 
child when born and the date of the quickening render it 
probable that conception did not occur till near the end 
of October. On March 10th there occurred during the 
night a copious flow of liquor amnii and slight irregular 
pains were felt. The uterus at this time was bulky, filled 
the lower belly, and its upper margin was considerably 
above the level of the umbilicus. The liquor amnii con- 
tinued to discharge freely, but not constantly, and irregular 
slight pains were often felt, generally during the night. 
The uterus gradually diminished in bulk and increased in 



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AFTER DISCHARGE OP THE LIQUOR AMNII. 217 

hardness, and at last^ and not later than a fortnight after 
March lOth^ it felt not much bigger than a large adult 
foetal head^ as hard as a fibroid^ and did not occupy 
the whole hypogastric region^ but lay much inclined to the 
left side^ its fundus being somewhat below the level of the 
umbilicus. For more than a week before the coming on of 
labour Mrs. S — thought that the uterine tumour was 
slightly increasing in size. On the 20th April some shortening 
of the cervix could be felt by the examining finger^ and this 
shortening slowly became greater without any increase of the 
occasional sensible pains. On the night of April 25 th regular 
pains came on. The child presented the breech. No bag of 
membranes could be felt^ and no gush or considerable quantity 
of liquor aranii was discharged during labour. When the 
breech distended the orifice of the vagina the child was 
extracted alive. The placenta was soon taken away thereafter ; 
it was carefully examined and found to be natural^ presenting 
the characters of the afterbirth of one child. The mem- 
branes also were natural^ and were ruptured at the anti- 
placental pole of the ovum. The child was of the size and 
had the characters of a six months' foetus. It cried feebly 
and made violent respiratory struggles ; but from the weak- 
ness of the thoracic skeleton they were nearly quite in vain^ 
for the sternum and its adjacent costal cartilages were at each 
inspiratory effort violently drawn in, and as a consequence a 
great depression formed in the epigastric and sternal regions. 
The child lived for a short time. Its lungs were found to 
contain a little air, which could be squeezed out of them under 
water and so seen, but no part of the lungs floated in water. 
The child weighed 1 lb. 15 oz., and was thirteen inches in 
length. Its eyelids were closed ; the vernix was everywhere 
rubbed away except on the nucha; the testicles had not 
descended into the scrotum. When born, it lay with its legs 
extended on the thighs and the thighs bent so that the limbs 
were adpressed to the body. Besides this position the limbs 
and features of the child showed signs of compression, 
can scarcely be described, except so far as the auricl 
concerned. These were pressed flat on the skull and 



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218 LONG DELAY OF LABOUR 

vemix caseosa made to adhere so closely that a careless 
observer might have thought them absent. 

There appeared to me no doubt as to the facts of this case. 
So far as possible^ everything came under my own direct 
observation. Pregnancy must therefore be regarded as having 
continued for forty-five days after the rupture of the mem- 
branes and the discharge of some of the waters. This long 
delay of the coming on of labour is not the only remarkable 
feature of the case^ but also the circumstance that the foetus 
continued to live in a uterus so contracted as this was for 
weeks before its birth. In these respects the case is in- 
structive. 

Numerous similar cases are recorded^ but most of them 
are defective in the supply of such circumstantial data as 
contribute not only to their fulness but to their confirmation. 
In a matter like this^ where various explanations of the source 
of the discharge may be suggested^ and where there is much 
room for error^ it is necessary^ in order to the greatest suffi- 
ciency of a recorded case^ that every detail which can con- 
tribute thereto be pressed into its history. Some cases are^ 
indeed^ so remarkable and so rare that in the mean time no 
amount of circumstantial or indirect evidence is sufficient to 
ensure their being received as true representations of nature. 
Among such I place the following^ which I give in the words 
of Burns (' Principles of Midwifery/ tenth edition, p. 283) : — 
'' Dr Pentland relates a very distinct case, where the liquor 
was, in the third or fourth month, discharged in a fit of 
coughing. The belly fell, but she still went on to the full 
time, and had a good labour. (' Dublin Medical and Phys. 
Essays,' No. 1, art. 3.)" In order to explain such extraordinary 
long interval between the discharge of the liquor and the 
coming on of labour. Burns resorts to an hypothesis which 
appears to me to be not only without any rational grounds, but 
contrary to all we know, and the resort to it is good evidence 
against the reality of the occurrence which he so attempts to ex- 
plain. The hypothesis is that the torn membranes may be 
healed or the hole in them closed ; and it is said to be necessary 
to suppose such healing, because, when labour comes on, a dis« 



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AFTER DISCHARGE OF THE LIQUOR AMNII. 219 

charge of liquor amnii takes place. '^ The aperture (says 
Bums) seems to close^ if gestation go on for during labour 
a discharge of water takes place/' At present I believe that 
obstetricians would reject all such hypotheses^ and hold that 
entirety of membranes is a sign that they had never been 
ruptured and that the discharge of liquor amnii in any con- 
siderable quantity during labour affords at least a presumption 
against the belief that the rupture of the membranes had 
taken place long before labour began. 

Dr. Pentland's case is^ indeed, a good example of an incom- 
plete and unsatisfactory report, for there is room for sup- 
posing that the water came from the bladder. -The waters 
are described as bursting in a fit of coughing, and the urine 
as coming away involuntarily by the force of coughing when 
the patient was in the horizontal posture. After delivery 
the urine was discharged involuntarily : and there is no 
account of the state of the membranes in early labour. 

Among recent cases of long interval between dischai^e of 
liquor amnii and the coming on of labour are the following : 
— Mr. Bradley, of Manchester (' Brit. Med. Joum.,* vol ii, 
1871, p. 612), relates a case of six weeks of interval, the child 
being described as if born alive. Mr. Norton, of London 
(' Brit. Med Joum.,' vol. ii, 1871, p. 667), relates a case of 
seven weeks' interval. Mr. Bassett, of Birmingham, relates 
a case (' Brit. Med. Joum.,' vol. i, 1872, p. 155) where the 
interval was six weeks. Dr. Swayne, of Bristol (^ Brit. Med. 
Journ.,' vol. i, 1872, p. 184), gives a case of a month's interval. 
Mr. Cox, of Winchcombe (' Brit. Med. Joum.,' vol. i, 1872, p. 
367), gives a case of delay of labour for thirty -three days after 
rupture of the membranes. Dr. Thorburn, of Manchester, 
records a case of six weeks' delay, after which the child was 
bom alive ('Brit. Med. Joum.,' May 18th, 1870, p. 520). 

There are various conditions which may be mistaken for 
premature or periodical evacuation of liquor amnii. Among 
these are discharges of urine from the bladder, watery dis- 
charges such as are sometimes observed iu virgins, and whose 
source may be Cowper's glands or the cervix uteri, discharges 
from the uterus of a fluid occupying the anatomical position 



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220 LONG DELAY OF LABOUR 

of hydroperionic fluids discharge of liquor chorii or false 
waters ; discharge of the liquor amnii of one ovum in a case 
of plural pregnancy; discharge of the fluid in a cyst 
described as occurring between the chorion and the amnion. 
Examples of these discharges I have observed in circum- 
stances- which showed that there was much doubt and diffi- 
culty as to their source^ or even positive error. In the case 
which I have related it appears to me impossible to accept 
any of these views as to the source of the fluid evacuated. 
That it was the liquor amnii is proved by the subsidence of 
the uterine tumour, by the diminution of its bulk, by the 
increase of its hardness, by the complete absence of discharge 
of liquor amnii at the time of labour, by the compressed 
state of the child, and by the almost complete rubbing off of 
the vemix caseosa. Another occasionally present item of 
evidence described by Bums was absent in my case. ^'I 
have known (says he) a discharge of the water take place at 
short intervals for some weeks, and then the funis umbilicalis 
protruded, without any exertion or any pains to rupture the 
membranes, which is a demonstration that the membranes 
had been previously open and that the discharge of liquor did 
not speedily excite labour.*' 

There is abundant evidence to prove that, as a general rule, 
the discharge of the liquor amnii is followed by labour within 
a few days. But some authors, and among these Dr. Rad- 
ford, very recently ('Brit. Med. Journ.,' February 3rd, 1872, 
jp. 127) record it as the result of their experience that the 
rule which I have designated general is invariable, and throw 
doubt on the accuracy of observations which are adduced as 
evidence of the occasional prolongation of pregnancy for 
several weeks after such partial evacuation of the uterus. 
That such prolongation of pregnancy does occasionally occur 
can be absolutely proved. A medical friend of my own, in 
charge of a ward for diseases of women in a great public 
institution, mistaking a pregnancy for an ovarian dropsy, set 
about the operation of paracentesis in the usual way, and 
only desisted after a large quantity of liquor amnii had been 
drawn off, admonished by the motions of the foetus striking 



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AFTER DISCHARGE OF THE LIQUOR AMNII. 221 

against the canula. The woman and her child were none the 
worse of the operation. The uterus again enlarged^ and 
pregnancy was continued for about a month afterwards. 
This is not the only case of the kind that I have known ; and, 
indeed, reflecting on such cases of error and on others of 
intentional tapping of the uterus through the abdominal wall, 
I have more than once contemplated a like operation in cases 
of hydramnios. 

It appears to me to be probable that in the common cases 
of rupture of the membranes and discharge of liquor amnii 
where labour does not supervene at once or within a few 
hours the delay is only until the evacuation is almost com- 
plete, or, in other words, till the uterus is in close contact 
with the foetus and irritated by its hard irregular surface and 
perhaps by its movements. The liquor amnii, as in the case 
which I have narrated, and in others which I could cite, is not 
always all or nearly all discharged at once. Several days may 
elapse and many gushes occur before the discharge is as 
nearly complete as it can be without complete evacuation of 
the uterus. If the uterus in action causes the rupture of the 
membranes it will then probably evacuate itself almost com- 
pletely of liquor amnii, and labour will probably be com- 
menced very soon. But when the discharge takes place 
under other circumstances there may be retention of a con- 
siderable portion of the liquor, and its partial discharge in 
successive gushes may be produced by continued contraction, 
the result of the ordinary uterine contractions of pregnancy 
described by Braxton Hicks ('Transactions of Obstetrical 
Society of London,' vol. xiii), or by other causes, such as 
change of position, bearing down, or other muscular exertions. 

In the case which I have narrated the discharge of liquor 
amnii, in occasional gushes, continued till labour came on, 
and long after it was evident that the uterus had been, for 
the time, as completely evacuated of this fluid as it could be. 
But this circumstance is easily explained by the accumulation 
of newly secreted liquor amnii. Indeed, while excessive 
secretion may have been the cause of the rupture of the 
membranes, continued secretion must have been the source 



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222 LONG DELAY OP LABOUR 

of the discharges which took place after the uterus reached 
its smallest dimensions. The amniotic membrane, whose 
structure has been recently so signally illustrated by the 
histological researches of Winkler (' Textur, Structur, und 
Zelleben in den Adnexen des Menschlichen Eies/ Jena, 
1870), has the power of secretion and absorption in a high 
degree, and clinical examples of both of these processes are 
not infrequent. That freshly secreted liquor amnii may 
accumulate in the uterus is not more remarkable than its 
only partial evacuation in cases of accidental rupture of the 
bag during pregnancy or of ordinary rupture in the early 
stage of natural labour, or than the accumulation of urine 
in the bladder in some cases of yesico-vaginal fistula of con- 
siderable size. In my case the child survived while there 
was evidence of continued secretion by the amnion, and pro- 
bably the life of the foetus and its amnion is a necessary 
condition of continued secretion, but the settlement of this 
question by direct observations is desirable. 

Two difficulties in the way of accepting the evidence 
adduced in favour of long delay of labour after nearly com- 
plete discharge of the liquor amnii are forcibly expressed by 
Mr. Bradley and Dr. Whitehead ('Brit. Med. Journ.,' 
January 20th, 1872). They consist in the belief that such 
sudden and nearly complete discharge of amniotic fluid would 
certainly bring on labour, and that the death of the foetus 
should sJways follow such evacuation of the uterus before many 
days have elapsed. The former view is expressed by Mr. 
Bradley in the following words : — '' I should think it most 
likely that one essential condition of such cases is that the 
rent in the membranes should be situated high up, so that all 
the liquor amnii does not drain away at once; for if such 
were the case, and the uterus were to firmly embrace the 
contained foetus, it can scarcely be doubted that uterine con- 
tractions would ensue, followed by expulsion of the child.'' 
Bradley's opinion is confirmed and the latter view also 
expressed by Whitehead in the following terms : — '^ I do not 
think the foetus could live many days in a sac without fluid 
and compressed by firm, tonic, muscular action." 



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AFTER DISCHARGE OF THE LIQUOR AMNII. 223 

Against such difficulties it is sufficient to adduce the 
evidence of well-attested facts^ including those of uterine 
tappings which I have in this paper mentioned. It is admitted 
that cases of prolongation of pregnancy after discharge of the 
liquor amnii for more than a few days are rare. It is only 
the occurrence of rare cases that has to be proved and^ as far 
as possible^ accounted for. Now^ so far as the nearly complete 
absence of liquor amnii and the firm compression of the foetus 
are concerned^ we have an analogical illustration in a rare set 
of cases of which I have seen unmistakable instances, and of 
which many examples are recorded. These are cases of missed 
abortion, missed miscarriage, missed labour. In such the 
liquor amnii becomes absorbed ; the uterus diminishes in bulk, 
becomes harder ,* the foetus and membranes are compressed, 
not, however, by "firm tonic muscular action,'' and the 
supervention of labour may be delayed for weeks or months. 
In these cases the foetus is, so far as I know, invariably dead 
and decomposed. 

The survival of the foetus in the cases which I have 
recorded or referred to is certainly very remarkable, and it 
would, no doubt, have been impossible if the uterus had been 
firmly and actively contracted. Firm tonic muscular action 
of the uterus after discharge of the liquor amnii would, no 
doubt, soon destroy foetal life, and it would also lead, 
without much delay, to evacuation of all the uterine contents. 
That it was not firmly and actively contracted is proved by 
the absence of labour and the continuance of foetal life. Firm 
compression of the foetus may take place without active 
uterine contraction, and it is firm compression by active 
uterine contraction that is incompatible with the continuance 
of pregnancy or of foetal life for any considerable time, not 
such mere firm compression as is seen in a case of missed 
miscarriage or missed labour. In such there is only the con- 
tinued contraction necessary to keep the organ in contact with 
its diminishing contents, a kind of contraction that is observed 
during delivery and is distinct from active uterine pains. 
^ A high position of a rent in the membranes and some sort 
of valvular action are cited by some authors in order to explain 



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224 LONG DELAY OF LABOUR 

the partial discharge of the liquor amnii and its repeated dis- 
charges ; and it is well known that^ with a view to desirable 
obstetric results^ it has been recommended to puncture the 
membranes high up in order to secure only partial discharge 
of amniotic fluid. But such explanations are^ I believe, 
chimerical. I know of no evidence whatever to show that 
accidental high rupture of the membranes was ever followed 
by the partial and repeated discharges supposed or expected 
to ensue. On the contrary I have known high puncture of 
the membranes^ as in the cases of paracentesis of the pregnant 
uterus previously spoken of, followed by no discharge at all 
along the natural genital passages. It is easy to suppose a 
high puncture of the membranes and partial withdrawal of 
the liquor amnii ; but that explains nothing whatever in the 
cases under consideration, for in them the dischai^e was 
effected spontaneously, and such spontaneous high rupture 
and discharge is at least very unlikely to occur, and has never 
been, so far as I know, shown to have occurred. Its 
occurrence may be admitted to be possible. I have already 
stated my views as to the explanation of partial evacuation of 
the uterus and repeated discharges, on a basis that appears to 
me better than a mere admission of possibility of high rupture 
and valvular action. 

In the subject which has been discussed in this paper the 
great question for decision is. Why does not labour come on ? 
Why do conditions which generally induce labour fail to do 
so in these rare cases ? The same question, forces itself on us 
in the remarkable conditions caUed missed abortion, missed 
miscarriage^ missed labour. In our present state of utter 
ignorance as to the cause of the coming on of natural labour 
it is not to be wondered at that we cannot tell the cause of 
its failing to come on. But the two subjects may well be 
studied together, for it is highly probable that he who dis- 
covers the cause of natural labour coming on will also be at 
the same time able to explain why, in the rare abnormal 
cases to which attention has been here drawn, labour does not 
come on. 

Numerous lines of inquiry have been followed with a view 



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AFTER DISCHARGE OF THE LIQUOR AMNII. 225 

to discoTering the cause of the coming on of labour. To me 
there appears at present no more likely way of achieving this 
grand result than the circuitous one of endeavouring to dis- 
cover the cause of labour not coming on. In physiology we 
desiderate the cause of natural labour. In pathology we 
desiderate the cause of labour occasionally not supervening 
soon after discharge of the liquor amnii; occasionally not 
supervening soon after the death and discharge of the foetus 
in the early months^ not supervening even when the secun- 
dines are already putrid ; occasionally not supervening soon 
after death of the foetus or after absorption of the liquor 
amnii in advanced pregnancy ; occasionally not supervening 
although the uterus is distended by a hydatigenous ovum 
which is forcing it to grow and expand at a rate of excessive 
and almost incredible abnormal quickness. 



Dr. Snow Beck mentioned two cases where evacuation of the 
liquor amnii had taken place some time previous to labour. One 
case occurred some years ago ; a lady, about forty years of age, 
who had had four children, when about six months pregnant was 
suddenly taken with a copious discbarge of clear watery fluid, 
accompanied with some oains in the stomach like the commence- 
ment of labour-pains. No cause could be assigned for this dis- 
charge, which occurred in the middle part of the day whilst she 
was m her bedroom. She considered that labour was coming on 
and sent for her medical attendant, who had great experience in 
midwifery and who also considered that a premature confinement 
was at hand. The usual preparations were made, the lady was 
not left all day, and the gentleman remained in the house during 
the night. The next day was also spent in watching, the lady 
being kept in bed, with moderate diet. It was ascertained that 
the head presented. Nothing further, however, took place ; the 
lady was first visited night and morning, then each day, and, as 
time progressed, after an interval of some few days. The lady 
did not experience any further inconvenience than being kept in 
bed, appeared in good health, and afterwards got up each day and 
lay upon a couch in the bedroom. Matters went on in this way 
for three months, when the lady calculated she was at the full 
period. Labour-pains gradually came on as at her previous confine- 
ments. Dr. Snow Beck was in attendance ; the orifice of the 
uterus dilated, and the finger came directly against the hairy scalp 
of the child. No escape of amniotic fluid took place, the vagina 

VOL. XIV. 15 



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226 DELAY OF LABOUR AFTER DISCHARGE OF LIQUOR AMNII. 

was lubricated with the usual amount of mucous secretion, the 
child was bom without assistance, the placenta came away natu- 
rally. The lady made a usual recovery ; the child lived and grew 
up. The case was the cause of much anxious watching and many 
consultations, and there was not any reason to doubt the fact that 
the liquor amnii had escaped three months previous to the con- 
finement without producing any perceptible alteration in the 
course of the pregnancy. 

The other case occurred in a lady thirty-six years of age, who 
had had six children and two premature confinements. She had 
suffered from phlegmasia dolens after the last two previous con- 
finements, followed by enlargement of the uterus. She was from 
four to five months pregnant, and during this period had suffered 
much from frequent mscharge of blood, which varied a little 
as she rested or took exercise, the last being said to sometimes 
amount to as much as a pint after walking a little distance. 
There was also considerable dyspeptic derangement and much 
general distress. On October the 18th or 19th, 1871, she was 
suddenly seized with a discharge of two or three quarts of 
perfectly clear pure water, which did not produce faintness, 
and continued more or less all night, requiring the use of two 
dozen diapers, but ceased the following morning. She was 
about all the following day as usual, but about 5 p.m. the 
gradual flow of blood returned, continued all night, and ceased 
in the morning. This continued to recur each day about the 
same time, continuing during the night and ceasing each morning, 
with the interval of one week, until December 19th, when 
she was prematurely confined, and died from hsBmorrhage two 
hours after the removal of the placenta. During the week of 
intermission nothing but thick black and very offensive matter 
came away, both day and night. Very little or scarcely any dis- 
charge took place at the confinement, which was rather more than 
ten weeks after the sudden escape of the first two or three quarts. 
It is difficult to say where this nuid came from, which passed away 
each night for so long a period and in such abundance. The lady 
suffered much from inward piles, the uterus and vagina were 
much congested, and the external parts greatly swollen the last 
six or seven weeks. It is scarcely possible to suppose that the fiow 
came from the inner surface of the foetal membranes, and if, as is 
more probable, it was an exudation from the vagina, it may 
be supposed that the great venous congestion of the pelvic organs 
was reueved by the rest during the night and was again increased 
by being about during the day, which increased congestion induced 
the watery discharge each night. There is no reason to suppose 
that either set of glands in the uterus was involved in the produc- 
tion of this nightly flow. 

Dr. Easch said he found the characteristic smell of the liquor 



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UTERINE FIBROIDS COMPLICATING PREGNANCY. 227 

amnii a very valuable help to diagnosis in cases of alleged discharge 
of the waters. 

Dr. Barnes observed that this able paper suggested abundant 
material for reflexion and discussion. The case of Dr. Snow Beck 
might be explained as follows. It was well known that cases 
occurred in which copious watery discharges were rapidly poured 
off in non-pregnant women as well as in the pregnant, llegar 
had described an hypertrophied condition of the glands of the 
uterine mucous membrane as existing until an advanced period of 
gestation. When there was an hypertrophied condition of the 
mucous membrane in the non-pregnant state the glandular 
structure probable partook of the hypertrophy, and thus became 
fitted to torow out a large quantity of watery fluid. He was 
satisfied that it was in this way that many cases of hydrorrhoea in 
pregnancy arose, especially in the early months, whilst there still 
existed a free decidual sunace. It was not very uncommon for a 
copious discharge of water to escape two, three, or more weeks 
before labour, and when labour did occur the membranes burst 
and discharged liquor amnii as usual. He did not believe in the 
rupture of the membranes and the rent healing. He might offer 
a speculation in relation to the cause of labour. Why labour did 
not so readily come on under provocation as from rupture of the 
membranes before the natural term of gestation, was because the 
nervous centres had not yet attained that remarkable degree of 
irritability which characterised them at the full term. There was 
a less ready response to excito-motory stimulus. Hence when 
the uterus settled down upon the foetus the contact failed to 
excite in the non-irritable nervous centres active reflex contrac- 
tions, as it almost surely would do at term. The necessary 
irritability seemed to be acquired in women in whom labour was 
habitually induced prematurely. 



A CASE OF UTERINE FIBROIDS COMPLICATING 
PREGNANCY. 

By Henry M. Madoe^ M.D. 

Mrs. R — , set. 40, primipara, married about twelve 
months, always enjoyed good health, consulted me in 
September, 1870, for a gradually increasing enlargement of 



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228 UTERINE FIBROIDS COMPLICATING PREGNANCY. 

the abdomen^ which she said was not due to pregnancy. On 
examination I found the abdomen occupied by a series of 
tumours of sizes varying from that of a walnut to a large 
orange, all springing from an enlarged womb. She was 
rather a thin woman^ and I was enabled to make out eight 
distinct swellings besides the womb. Three of the smaller 
ones were pedunculated, and when touched through the 
abdominal walls receded from the finger, just as a child's 
foot or arm would do when floating in the liquor amnii. The 
larger ones were more or less sessile, the largest being 
entirely so. This was nearly as large as the womb itself and 
was somewhat fixed in the left iliac region. After a few 
visits to the patient I was enabled to detect the foetal heart. 
She had consulted several medical men, and^ owing to the 
anomalous symptoms in the earlier stages of the pregnancy, 
various opinions were arrived at. She was told that it was 
a case of extra-uterine pregnancy ; that the smaller swellings 
were the child's limbs and the lai^e swelling the head. She 
was also told that she was not pregnant at all, and that she 
might ultimately require an operation for the removal of the 
tumours. The usual signs of pregnancy, as regards the 
catamenia, morning sickness, and appearance of the breasts^ 
were not well marked. The sounds of the foetal heart, 
however, set the matter at rest. Meeting with such a large 
crop of fibroids associated with pregnancy I determined to 
watch the case with the view of noting their changes and 
behaviour before, during, and after labour. As the 
pregnancy advanced all the tumours increased in size, except 
the one on the left side^ which was at first the largest. This 
remained throughout without much change. In the last 
month the abdomen was enormously distend^^ and presented 
irregularities on its surface corresponding to the site of the 
fibroids. The patient suffered but little pain or inconveni- 
ence except from the child's movements, which became very 
vigorous. Labour set in on January 12th, 1871 ; distinct 
uterine action came on very slowly, and in the afternoon of 
the 13th, although the head was low down, the os uteri was 
only about the size of a crown-piece. In the evening I gave 



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UTERINE FIBROIDS COMPLICATING PREGNANCY. 229 

Tr. Opii 5S8^ but notwithstanding this the pains were con- 
tinuous^ though weak and irregular, all night. Some of the 
tumours seemed to contract and get harder^ like the uterus^ 
during the pains. On the 14th^ the os uteri being pretty 
fully dilated^ I used the forceps and soon delivered the 
patient of a living child. After delivery the abdomen 
remained very large^ as if there were another child^ but as I 
was obliged to introduce my hand into the womb to remove 
the placenta I was able to satisfy myself that this was not 
the case. The walls of the uterus appeared to be full of 
nodosities and irregularities^ and a good deal of blood was 
lost from imperfect contraction. Eventually the patient did 
well and was able to sit up on the tenth day. At this time 
the abdomen was only slightly reduced in size^ but subse- 
quently the reduction became more rapid. At the end of 
three months I could still count all the tumours that I had 
previously felt. The womb was still enlarged^ and the 
tumour on the left was nearly as large as a cocoa-nut ; all 
the other tumours were much smaller. In six months three 
of the smaller tumours had disappeared. The womb and 
the large tumour^ with which it seemed to be now almost 
continuous, formed a mass above the pubes about the size of 
the womb immediately after delivery. The four smaller 
tumours had been lessened in size about one half since the 
last examination. I examined the patient a few weeks ago 
— rthat is^ about sixteen months from the date of delivery. 
The uterus, with the larger fibroid attached, was still easily 
felt above the pubes, and, compared with the last report, only 
slightly lessened in bulk. Two of the smaller tumours, 
springing from the body of the womb, were still distinctly 
made out, but only traces of the others remained, one such 
trace being about the size of a bean. The patient is in good 
health and suffers no inconvenience from the presence of the 
tumours. She was quite imconscious of their existence 
before pregnancy. Unless she becomes pregnant again they 
will probably give her no further trouble, but in the event of 
pregnancy they would, no doubt, run the same course of 
growth and decay as before. Besides the tumours I have 



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230 UTERINE PIBROIDS COMPLICATING PREGNANCY. 

described I have no doabt, from the feeling conveyed to my 
hand whilst in the womb^ that there were several interstitial 
tumours, and it seems probable that so many abnormal 
growths, by altering the course of the uterine fibres, must 
have interfered with their contractile efforts and led to the 
feeble and irregular uterine action observed during the 
labour. When only one or two fibroids exist I have often 
seen labours completed in a comparatively easy and natural 
manner. 

That in this case some of the tumours should have subse- 
quently disappeared and some remained shows, I think, that 
they were not all exactly of the same nature. 



Dr. Platpair said that Dr. Madge's case was of great interest 
to him, as affording farther corroborative evidence of the possi- 
bility of spontaneous absorption of fibroid tumours of the uterus, 
a subject on which be had formerly read a paper before the 
Society, and, farther, of the important influence or pregnancy, or 
rather of the involu^on of the uterus after delivery, in &vouring 
the process, a point on which he had particularly insisted in his 
paper. It was satisfactory to find so carefully recorded a case 
brought forward, on the diagnosis of which the most sceptical 
could hardly throw any doubt. Although all the tumours had 
not disappeared in this case, some of them had, and the rest had 
materially diminished in size, showing that they had undergone 
the same process of involution as the rest of the uterine tissue, 
which, considering their identity of structure, was, after all, not so 
surprising. The number of carefully recorded instances of the 
spontaneous absorption of uterine fibroids was now so great that 
the possibility of the occurrence seemed to him ^Dr. Fkyfair) as 
conclusively proved as any fact could be, or reqmred to be. 



V 



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JULY 3bd, 1872. 

John Braxton Hicks^ M.D., F.R.S., President, in the Chair. 

Wm. Michell Clarke, M.R.C.S. (Clifton), and James 
Ryer Thomas, L.R.C.P. Lond., L.R.C.S. Edin. (Tinnevelly, 
Madras), were elected Fellows of the Society. 



IRREGULAR UTERINE CONTRACTION. 
By E. H. Trenholme, M.A., M.D., B.C.L. ; 

PB0VX8S0B OF ICIDWIPEBY AlO) DI8BABB8 07 WOMEN AKD OHILDBBK, 

UNITBBSITT OF BISHOP'S OOLLEOB; ATTENDINO PHYBIOIAK TO 

THB MONTBEAL DI8FBKBABY, ETC. 

The practical importance of the subject which I have the 
honour to lay before jou this evening must be fmy excuse 
for occupying your time. I trust that each member will 
thoroughly investigate and criticise what may be advanced, 
as it is well known that correct deductions for guidance in 
the treatment of disease can only be made from correct 
premises, the result of accurate observation. 

Spasmodic contraction of the uterus is naturally divided 
into irregular contraction during the birth of the child, and 
irregular contraction during the delivery of the placenta. 

1st. Irregular contraction of the uterus during the ex- 
pulsion of the foetus is recognised by short, partial spasms of 
the walls of the organ. These contractions accomplish but 



i 



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232 IRREGULAR UTERINE CONTRACTION. 

little in the way of dilating the os or advancing labour. 
They do not occur regularly, either in respect to the space 
of time intervening between their return or their duration. 
By placing the hand upon the abdomen over the uterus we 
can frequently detect irregular and partial muscular contrac- 
tion of the organ. The pains are of a short, sharp, and 
painful character, and also usually cause the patient intense 
anxiety and distress. 

Upon making a vaginal examination you will find but 
slight bulging of the foetal membranes during the pains, also, 
not unfrequently, an unequal dilatation of the muscular 
layers of the os uteri. The internal layer is least dilated, 
sometimes not more than half the extent of the external 
layer. 

With regard to this last statement, I may say that the 
diagnosis is not always so easy as one would naturally 
suppose, as the internal layer of muscular fibres is thin, and 
might be mistaken for a thickened decidua. 

When the finger has reached the os, and is attempted to 
be passed between the neck and the membranes, we encounter 
adhesion more or less firm and extensive between the opposed 
surfaces. 

When the adhesions are on one side the os is found, not 
in the median line of the pelvis, but drawn away from the 
centre toward that side on which they exist. As a necessary 
consequence of such a condition of things there are 
obliquity of the womb and irregular oblique presenta- 
tion of the presenting part at the brim of the pelvis, 
together with retarded engagement and its consequent 
results. 

The existence of these adhesions is ascertained with but 
little difficulty, as the finger readily detects their presence, 
and also shreds of muscular fibres attached to the decidua. 
In these cases the membranes can be scraped by the finger- 
nail and the portions detached preserved for microscopic 
examination. I have upon many occasions removed in this 
way shreds from that part of the decidua which had been 
adlierent to the uterus, both during the dilatation of the os 



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IRREGULAR UTERINE CONTRACTION. 233 

and after the removal of the placenta^ and found them to be 
composed of muscular tissue. 

The existence of the adhesions is also recognised by the 
fact that, when they are broken up by the finger, the pro- 
truding portion of the membranes increases in size rapidly ; 
the uterus, which was oblique, soon returns to its central 
position ; the presenting part engages ; the irregular, ineffec- 
tive, spasmodic contractions become regular and powerfully 
expulsive, and a tedious, lingering labour becomes a normal 
one, and is speedily brought to a satisfactory conclusion. I 
have but little doubt that more extensive and correct obser- 
vation will demonstrate that the great majority of oblique 
presentations are due to this cause. 

The manner in which these abnormal adhesions are pro- 
duced, and the way in which they cause irregular spasmodic 
contractions of the uterus, are worthy of remark. In speak- 
ing of this matter we can arrive at probable conclusions only, 
and I shall therefore submit that these adhesions may be 
due to — 

1st. A pathological condition of the inner surface of the 
uterus existing previous to conception ; or, 

2nd. To injuries of the parts concerned during gesta- 
tion; or, 

3rd. Result from partial, instead of complete, separation 
of the decidua having taken place before term, t e, that the 
ripening of the decidua has not been uniformly accom- 
plished; or, 

4th. To a combination of two or more of these causes. 

We will now consider the value of these different 
hypotheses. 

1st. In favour of the idea that these adhesions may be due 
to a diseased state of the internal surface of the uterus 
existing previous to gestation we have the well-established 
fact that a part or tissue once the seat of diseased action 
seldom or never regains its original state of perfect healthy 
and is liable to subsequent derangement. 

Experience teaches us to be careful in effecting the delivery 
of the placenta in those cases where we have encountered 



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234 IRREGULAR UTERINE CONTRACTION. 

strong adhesions in a previous labour^ as we know such 
patients are obnoxious to them on a subsequent occasion. 

2nd. Adhesions may occur during gestation as a result of 
local extravasation, either from shock, a plethoric state of 
the system in general and the uterus in particular, or by 
direct violence applied over the parts affected, as by a blow 
upon the abdomen ; or, possibly, by injury to some part of 
the neck or lower segment of the uterus upon the brim 
of the upper strait of the pelvis. Such an injury as this 
might be caused by a false step, jump, or fall. For my 
own part I am of opinion that this is not an uncommon 
cause of such adhesions. This view is confirmed by the 
fact that in most of the cases of retarded labour due 
to irregular uterine contraction that I have met with 
the adhesions were situated within a short distance of 
the OS. 

3rd. The adhesions may be due to a partial ripening or want 
of that cell maturation by means of which the decidua is 
separated from the internal surface of the womb at term in 
natural labour, and which, by the way, is, I have no doubt, the 
determining cause of labour. 

The strength of the attachment will determine the 
extent of the irregular contractions, and consequent pain 
and delay in parturition. The induction of labour at all where 
these adhesions exist is probably due to the separation already 
mentioned having taken place to a sufficient extent to cause 
uterine irritation and subsequent muscular contraction of the 
waUs of the uterus. This view of the case does not require us 
to look for or suppose a pathological state of the membranes 
of the uterus or the surface of the uterus itself, but regards 
it simply as due to a lack of that perfected development of 
the mucous membrane which is usually completed at the end 
of the ninth month. 

4th. Lastly, these adhesions may be the result of two or 
more of the above-named causes. There may be a predis- 
posing plethora of the vascular system, accompanied by shock 
or blows, or, a weakened state of the walls of the uterus the 
result of former disease or injury, and this by a subsequent 



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IRREGULAR UTERINE CONTRACTION. 235 

injury^ may be the cause of local inflammation^ effusion of 
plastic lymph^ and subsequent adhesions. 

As the probable causes of adhesions have been alluded to^ 
it is necessary now to say a few words as to the manner in 
which they probably cause irregular spasmodic contrac- 
tions of the uterus and retard labour. 

The irregular action spoken of may be due to some ab- 
normal condition of the nerves of the uterus or of its mus- 
cular structure. 

Ist. The nerves may be at faulty i,e. there may be hyper- 
sesthesia of some branches of the nerves^ thus inducing hasty 
irregular contraction^ or there may be paralysis of some of 
the nerve branches^ and in this way allow of irregular muscular 
action; or, 

2nd. The cause of the spasmodic contraction may be due 
to some abnormal condition of the muscular tissue, apart from 
any fault in the nerves, by which it fails to respond, in parts, 
to the ordinary nerve stimulus ; or, 

3rd. The cause of the irregular action may be due to adhe- 
sions of the apposed surfaces of the decidua and uterus. Thus, 
the decidua being closely applied to the muscular surface, and 
the adhesions preventing the membranes from protruding, 
might act in a mechanical way and thereby check the shortening 
of the muscular fibre, the attempt at contraction being met by 
the countei^xtension of the decidua; or, perhaps, the mus- 
cular structure connected at the points of adhesion may, by 
being lacerated or irritated during the pains, cause unequal 
and undue tension of some muscular fibres, the parts thus 
injured acting as direct excitants, and in this manner causing 
that unequal short spasmodic form of uterine contraction 
which characterises tedious labour. 

Of these hypotheses I am inclined to think that the last is 
most probably the correct one. I suppose it will be conceded 
by every one that the whole uterus responds equally and 
regularly to the stimulus that induces labour, unless there is 
some abnormal condition of the organ, such as defective 
innervation, excessive innervation, or muscular change of some 
part of the organ, as before mentioned. 



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236 IRREGULAR UTERINE CONTRACTION. 

As to defective innervation I shall not speak. The 
fact that tedious labour^ with adhesions^ &c., occurs with 
women who both before and afterwards have natural labour^ 
shows that it cannot be due to nerve disease. Where 
one good and sufficient cause for the production of any 
phenomenon is known to exist there is no need to go be- 
yond it^ and recognised tension and laceration of the inner 
layer of muscular fibres, at the points of adhesion^ are enough 
to account for irregular action of the uterus. The effect of 
these adhesions, where they exist — say on the right side and 
near to the os — ^is to interfere with the regular action of the 
muscular contraction, for the reasons already mentioned, and 
at the same time cause a very incomplete and imperfect ex- 
pulsive effort. The steady protracted bearing-down pains 
so desiderated are wanting, and grinding pains take their 
place. 

We all know that the decidua with its contents must be 
elongated in order to adapt itself to the diminished capacity 
of the uterine cavity during a spasm ; that the waters must 
escape or the membranes be protruded through the os and 
a pouch of fluid occupy the vagina before any progress is 
made towards the delivery of the foetus. 

This being the case, lateral adhesions must interfere with 
the descent of the membranes, and cause the bag of waters 
to be formed at the expense of the membranes, which slip 
down from the side on which there are no adhesions. 

The formation of this pouch in this manner in its turn 
necessarily carries the lower segment of the uterus, with the 
OS, toward the side on which the adhesions exist. Thus, in a 
first vertex presentation of this kind the left side of the pre- 
senting part would be driven into the cavity of the pelvis and 
made to occupy a lower level than in normal cases. The ex- 
pulsive effort of the uterus is lost to a great extent, on account 
of the foetus not being made to engage in the axis of the brim 
of the pelvis. When we consider the irregularity of the 
contractions, and the great disadvantages under which the 
expulsion of the foetus has to take place, we find abundant 
cause, not only for the prolongation of labour, but also for the 




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IRREGULAR UTERINE CONTRACTION. 237 

anxious and exhausted state of the patient herself. The 
labour-pains in these cases are most severe^ and this in my 
opinion is due to the muscles acting contrary to each other 
and tearing themselves asunder^ as has been already men- 
tioned when speaking of the unequal dilatation of the os. The 
irregularity of the contractions continues till the adhesions 
are separated^ or the dilatation of neck has been slowly and 
painfully accompanied by the inoperative contractions of the 
organ ; or until the membranes have been ruptured^ so as to 
permit the child to glide over the membranes^ seeing the 
membranes will not glide over the surface of the uterus^ as 
they should do^ to allow the child to be bom. 

To break up the adhesions is an easy matter in those cases 
where they are situated near the os. The finger gently 
introduced around the neck^ between the membranes and the 
uterus^ readily accomplishes the desired result. 

Where the adhesions are beyond the level of the finger I 
do not think it advisable to attempt the separation by instru- 
mental means^ but rather to rupture the membranes at once^ 
as by this means we effect the chief thing to be desired, viz. 
*the supervention of normal labour. In some cases, after the 
adhesions have been broken up as far as the finger will reacb» 
you will find that the os will rapidly dilate, and in a few 
minutes the finger can be still further introduced and the 
detachment completed. 

The following case is given, one out of many, by way of 
illustrating what has been said : 

Mrs. L — , set. 20, first pregnancy, has been in labour 
last four and a half hours ; pains irregular and spasmodic, and 
accompanied with intense suffering. On examination found 
OS dilated to the size of a shilling-piece ; membranes adherent 
on the right side, and neck of uterus turned the same way. 

A somewhat thick layer of muscular fibres covered the 
membranes spread over the dilated os. As I could not reach 
all the adhesions, the membranes were ruptured, after which 
the pains became regular and powerfully expulsive, the os 
dilated rapidly, and the child was born in less than two 
hours. 



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238 IRREGULAR UTBRINE CONTRACTION. 

By way of illustrating another class of adhesions, I give 
the case of a Mrs. R — , set. 21, first confinement. 

On examination found the womb almost on the floor of the 
pelvis, and os dilated to size of a shilling-piece ; has bad 
grinding pains; little expulsive power for the last eight hours. 
On introducing the finger no adhesions were felt between the 
mucous membrane and uterus. Being somewhat in doubt as 
to the cause of the irregular contractions, I examined more 
carefully, and then found that there were adhesions between 
the posterior part of the neck of the uterus and vagina. The 
adhesions did not exist over the anterior third of the neck. 
The separation of the parts was easily accomplished, when 
the expulsive power of the pains was greatly increased, the 
OS dilated more rapidly, but the membranes did not protrude. 
With the dilatation of the os the womb descended upon the 
floor of the pelvis. I then found adhesions between the 
mucous membrane and the uterine surface, and when these 
were broken up the labour progressed more rapidly, although I 
was finally obliged to deliver by the forceps, as the head pre- 
sented in the third position (vertex) and the woman was too 
weak to complete the labour alone. This case is mentioned, 
not only on account of its unusual character, but also because 
it shows that external adhesions may interfere with labour as 
well as adhesions between the mucous membrane and the 
inner surface of the womb. 

Before closing these imperfect remarks it might not be 
amiss to say that the cause of gestation being of shorter 
duration in first pregnancies is probably due to a more rapid 
cell degeneration of the decidua, combined with a sensitive 
state of the muscular surface of the cavity of the womb 
which favours the induction of muscular contraction before 
the decidua is completely detached. It also explains why we 
have trouble in delivering the placenta in many instrumental 
cases. 

The adhesions render the contractions abnormal and 
inefficient, and this condition renders the forceps necessary to 
complete the delivery, while the adhesions remain as before 
stated, to give us further trouble. 



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IRREGULAR UTERINE CONTRACTION. 239 

The effects of adhesion upon the delivery of the placenta are 
worthy of consideration^ but as I have not had any cases 
illustrating my views upon the subject I shall not longer 
occupy your attention. We would have no difficulty in 
attributing hour-glass and spasmodic contractions of parts of 
the uterus upon the placenta^ or itself, to the same cause that 
induced such contractions during the first and second stages 
of labour. In addition to the cause of such contractions 
which have been spoken of already, we find there is the 
possible irritating effect of the placenta when adherent to the 
uterus. The mass of the placenta being somewhat firm, and 
the uterus contracting upon it, might easily cause laceration 
of muscular tissue, and thus originate the hour-glass con- 
tractions. Also, the contractions might be due to the effect 
of lacerations of the tissue of the muscular surface during 
labour, which had left the parts irritable and ready to contract 
as soon as opportunity offered. 

As to the treatment of retained placenta I have nothing 
special to say. We should follow the recognised mode of 
dealing with such cases, and, when possible, effect the detach- 
ment and removal of the entire mass with its membranes. 



The Fbesident considered Dr. Trenholme*s paper opened 
up a new point for clinical investigation well worthy of further 
attention. He had no doubt but that the adhesion in retained 
placenta was the determiner of the position of uterine irregular 
contractions ; it was contracted almost always below this. But 
there was also a condition which was not dependent on placental 
adhesion. He had several times noticed m passing the hand 
within the uterus that the walls would be in one part hard and 
firm, while at another relaxed and flabby ; and then gradually 
the firm part became relaxed, while the relaxed part would become 
firm. 



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240 



ON POST-MORTEM PARTURITION WITH RE- 
FERENCES TO FORTY-FOUR CASES. 

By J. H. AvELiNG, M.D., 

PHTBIOIAN TO THB CHELSEA HOSPITAL VOB WOMEN. 

Cases of parturition occurring after death, without manual 
interference, are very rare. So rare, indeed, are they that 
when one takes place even medical men have sometimes 
doubts as to whether such a phenomenon has ever before 
been observed. 

A case which happened in Ireland in March of the 
present year has again directed the attention of the profes- 
sion to this subject, and many letters containing additional 
information have appeared in the medical journals. Perhaps, 
as the Fellows have not yet, at any previous meeting, 
directed their attention to post-mortem parturition, and as 
there are many points of interest upon which their opinions 
would be of great value, the time of the Society might not be 
unprofitably employed in glancing rapidly at the recorded 
cases and examining the accuracy of the deductions which 
various authors have made concerning them. 

Cask 1. — Rudolph Camerarius^ tells us of a Spanish 
inquisitor who caused a pregnant woman to be hanged in 
1551. Four hours after the death of the unhappy mother, 
while still hanging on the gibbet, two living children fell 
from her womb. 

Case 2. — Diomedes Comarius* writes of a certain woman 
of Madrid, of the illustrious family of Lasso, who, having 
been reputed dead, was carried to the place of sepulture 
and there shut up and left. Some months afterwards, the 
tomb being again opened, the corpse was found in the 
position in which it was left, and, besides, a dead infant which 
had been born since the burial. 

^ * Silloge Memorabiliam Mediciu.' 

' Nymmanas, * De Yifca Foetus/ &c., p. 29. 



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POST-MORTEM PARTURITION. 241 

Case 3. — O. A. Reiss^ says the wife of Frangois Arevallos 
de Suesso fell ill in that town towards the last months of 
her pregnancy. Being dead a few days, or having been 
reputed so^ she was buried. The husband, who had been 
diligently sought for in a distant place where he had gone 
on business^ arrived towards the middle of the night, 
learning that his wife, whom he loved much, was buried, he 
wished the satisfaction of seeing her once more. He went 
to the church and caused her to be exhumed. Scarcely 
was the coffin opened when the cries of a child were heard. 
Every one was seized with astonishment : the justice, the 
priests, and many others were called, and when the shroud 
was lifted the head of a child was seen, who was endea- 
vouring to extricate the rest of its body. It was taken away 
alive, and lived long after uader the name of '^ Fils de la 
terre." 

Case 4. — Dr. Harvey* asserts the following *' A certain 
woman here amongst us (I speak it knowingly) was (being 
dead over night) left alone in her chamber, but the next 
morning an infant was there found between her legs, which 
had by his own force wrought his release/' 

Case 5. — Rolfinkius' relates the case of Anna H — which 
occurred in Silesia. She began to be in labour at 5 o'clock 
in the morning on the 14th February. During its progress^ 
which was difficult and painful, she was seized with an 
epileptic paroxysm, and died before the child was boru. The 
body was placed in a cellar until the day of burial, which 
was to take place on the 19th. On that day two well- 
formed children, a boy and girl, were found dead upon the 
bier. 

Case 6. — ^Bartholin* tells us of a woman who died un- 
delivered, three mid wives having exhausted their art iu 

1 ' Elysias Corpus Jaeandarnm qaiertionani.' 

* ' Anatomical Exercitations,' 1663, p. 492. 
' ' Dissert. Anatom./ c. xxx. 

* * Ephemerid Germ., D. 1, An. 111. 

VOL. XIV. 16 



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242 POST-MORTEM PARTURITION. 

attempting to deliver her. She was washed and laid out in 
the usual way, when behold, forty -eight hours after death, 
the abdomen so swelled as to rend the graveclothes in which 
the body was sewed and a copious flow of lochia was 
observed. The women standing by, astonished, separated 
the legs of the corpse and saw a dead but perfectly formed 
male child in the act of coming forth. 

Case 7. — Bonetus^ tells us of a case which occurred in 
Brussels in 1633. The woman died undelivered in convul- 
sions on Thursday. On Friday froth flowed from the mouth, 
and the abdomen was observed by those sitting near to move. 
On Sunday, about 10 a.m., a flow of blood caused those 
attending to uncover the corpse, when between its thighs 
a child still warm was found hanging out. 

Case 8. — Percival Willughby* writes, '' Emma, the wife of 
Thomas Toplace was five days in labour. The sixth day shee 
had a medicine given to her to ease her pains by a doctor of 
divinity (Dr. Kettleby), pretending some small skill in 
physick. After the tiding of the medicine in the evening 
shee was supposed to bee dead, and after nine o'clock that 
night shee was buried. As shee was carried to the grave 
some thought they heard a rumbling in the coffin. A 
noise was heard like the breaking of a bladder, after which 
followed a noisome smell. She had an ill-conditioned man 
to her husband, that frequently gave her evil words and oft 
blows with them. Her husband, with his mother and the 
midwife, with some other women, made haste to bury her, 
having, among other things, filled her mouth with hurds 
(tow). Several women were much troubled at her hasty 
burial, and thought she was not dead. Among this company 
there was one, Anne Chadwick by name, that returned to 
the grave, and laying her ear to the ground shee heard a 
sighing, as it might be of one dying in that grave. A 
souldier being with her heard the same, and he affirmed, 

1 «Med. Septentz./ P. II, Obs. xxx. 

* MS. Copy of ' Country Midwives' Opos-colam/ in tho possession of tbe 
writer. 



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POST-MORTEM PARTURITION. 243 

besides the sighing^ that hee heard the crying of a child. 
They went to Mr. Legg^ a justice of the peace in that town, 
and told him of it^ as also the minister and others*^ what 
noise was heard in the grave^ and Anne Chad wick said that 
shee believed that the woman was alive. The earth was cast 
off from the coffin, and the coffin was found somewhat 
opened where formerly the bords were joined together with 
a ridge at the top, and the coffin was hot. After that it was 
opened the woman's hand was seen bare, and some saw 
hnrds lying on her breast and in her hand, with which her 
mouth had been stopped by her husband's friends. And it 
was believed that the buried woman had pulled those hurds 
out of her mouth with her own hand after that shee was 
interred. Another woman put down her hand and found a 
child delivered in the coffin, and descended as low as her 
knees or lower, with one hand in the mouth and the other 
extended by the side ; and the after-burden was also come 
from her. Her husband, with his mother and the midwife, 
with others which laid her forth (after her supposed death), 
were much displeased that the grave was opened, and at the 
murmuring of the people he gave threatening words against 
some of the company ; but at last hee thought that it was 
his best way to bee quiet and to let all their wprds and deeds 
sleep with his deceased wife. Elizabeth Shent, with her 
mother, Anne Chadwick, with' others, affirm these passages 
to be true, and the coffin was left open all night that the 
bodies of the mother and the child might be seen by all those 
that would look upon her. Mr. Abraham Mercer (who was 
lecturer at Ashburn in Darbyshire where this occurrence 
happened) also took a certificate out of the parish register 
book, where it was thus recorded: * April ye 20, 1650, was 
buried JEmme the wtfe of Thomas Toplace, who was found 
delivered of a child after she had lain two hours in the 
grave.^ " 

Case 9. — Hermann of Berne^ cites the case of a young 
woman who died of nervous fever in the sixth month of 

1 *Med. Chir. Zeitang. von Salzburgh/ 1824. 



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24^ POST-MORTEM PARTURITION. 

pregnancy ; on the eve of burial, when her body had far 
advanced in putrefaction, a loud sound was heard and an 
unbroken ovum containing twins was found to have been 
discharged. The placenta also showed signs of putrefaction. 

Case 10. — Dr. Naumann^ mentions a woman who died 
during labour in the summer of 1802. No attempt was 
made at delivery, and putrefaction of the body of the mother 
commenced. On the evening of the second day the child 
and placenta were found expelled. 

Case 11. — In Stark's Archives is a case of spontaneous 
evolution and birth of the child taking place after the death 
of the mother. 

Case 12. — Dr. Richter, of Weissenfels,' reports the case of 
a woman, set. 45, who was seized on Monday at 8 p.m., in 
August, 1861, with fits which occurred every five minutes. 
At midnight, after a remission of two hours, she was 
attacked with severe pain and tried to jump out of bed. She 
was held back and remained unconscious till 5 a.m. on 
Tuesday, when she died. Labour had not commenced. The 
body was washed and laid out, and in the evening was 
removed to another room. Putrefaction set in rapidly, and 
a watery discharge appeared beneath the legs of the corpse. 
The nurse separated the thighs on Thursday evening, sixty 
hours after death, but found nothing unusual. On the 
following day, the fourth after death, when arrangements 
were made for placing the body in the coffin, there was found 
lying between the thighs of the corpse the dead body of a 
child in a partially putrefied state. It was well developed 
and about the eighth month of gestation ; with it were lying 
the umbilical cord and placenta. Some water had flowed 
from the outlet. The body was livid, and the abdomen, 
though smaller in size, was still distended with gas. 

Case 13. — Johannes Mathseus^ recites the case of the wife 

1 'Hafeland'B Jour.,' Band 23. 

' * Casper's Vierte^ahrachrift,' &c., vol. xix, p. 163. 

' * G. NymmaoB de vita foetus/ &c,, p. 30. 



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POST-MORTEM PARTURITION. 245 

of Simon Kreuter, of Weissembourg^ who died during labour 
and was buried undelivered. After some hours a sound was 
heard about the tomb. It was immediately opened and the 
mother was found dead^ but the child^ a girl, was discovered 
almost rolled down to the feet of the corpse, alive and well. 

Casb 14. — Henricus Stapedius ^ writes to G. Fabricius of 
a pregnant woman who died suddenly of an acute disease and 
was placed in a coffin. The next day a foetus was found 
between the thighs of the mother dead, but whose life, the 
author thinks, might have been preserved. 

Case 15. — Schenkius ^ mentions a woman who died about 
5 o'clock in the afternoon, and 3 o'clock the next morning 
the bystanders heard a great crack, when a child was born 
dead, having two fore teeth. 

Case 16. — ^E. Hagendorn ^ says a woman died in labour on 
January 12th, 1683, and some hours after a living child was 
bom and was baptized. 

Case 17. — ^Veslingius^ reports the case of a woman who 
died on the 6th of January, 1630, of an epilepsy, and on the 
eighth day a child was born. 

Case 18. — Georgius Dethardingius '^ mentions a healthy 
diild which was bom half an hour after the mother's 
decease. 

Case 19. — Ido Wolfins * says a woman died in labour in 
July, 1667. Six hours after her death the husband perceiving 
a motion in the abdomen called others to see it, and would 
have had the Cesarean operation performed, but was 
hindered by them. A child, however, was brought forth 
dead eighteen hours after the woman's decease. 

^ < G. Nymmaus de yita fcetos,' &c p. 80. 
> * Obs. Medic/ Lib. lY, de Parta, Obe. 14. 
s • Hist. Med. Physic,' Cent 8, Hist 18. 
4 ♦ Obs. Anatom^' 7. 

• « M. N. C./ Dec 8, An. 7 & 8, Append., p. 77. 

• * Obe. Chimrg. Medic/ Lib. I, Obs. 41. 



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246 POST-MORTSM PARTURITION. 

Case 20. — Dr. Hoyer,^ of Mulhausen^ speaks of a woman 
who died in labour^ and whilst being conveyed to the grave 
expelled, with noise and a great quantity of water^ a child, 
having its mouth open and tongue protruding. 

Case 21.»— On Sunday, August 12th, 1759, the wife of 
one Edw. K — , of Warwick, was taken in labour about 
5 o'clock in the morning; the midwife who attended her, 
after giving her all the assistance in her power, believed her 
to be dead, and then left her. About 5 in the afternoon the 
dead woman was put into a coffin, with a shroud over her. 
The next morning, the nurse going into the room where the 
corpse lay, she fancied she saw something move the shroud up 
and down in the coffin ; she ran away much frightened to 
acquaint the people of the house below, who immediately went 
upstairs with her to examine what it could be ; when, turning 
down the shroud, to their great astonishment, they saw a live 
child grovelling in the sawdust, which had delivered itself from 
the corpse as it lay in the coffin. As soon as their surprise 
was over they wrapped the child in flannel and took all possible 
care to preserve it, but it died before they could dress it. 

Case 22. — Valerius Maximus' tells us that Gorgia Epi- 
rota's mother, having died undelivered, was being carried to 
the grave, when a sound was heard which induced those 
present to open the coffin, when between the legs of the 
mother, who had been a long time (jam diu) dead^ a live 
child was found, who was called Grorgia, whence arose 
the proverb, " Grorgiam prius ad fiinus datum, quam natum 
fiiisse.'' 

Case 23. — Bums ^ says, *' An instance is lately related by 
Dr. Ebel where the uterus expelled a child after the inter- 
ment of the mother, and the fact was discovered by raising 
the body for examination owing to a suspicion of murder. 

» • Foder^' vol. ii, p. 11. 

' * Qentlemaii'B Mag./ voL zzix, p. 890. 

* Lib. 1, cap. ultimo. 

* * Manual of Midwifexy/ 1841, p. 266. 



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POST-MORTEM PARTURITION. 247 

Case 24.i — " The wife of a gamekeeper^ near Reigate^ a 
girl of fifteen years old, being with child and hourly in 
expectation of being brought to bed, was seized on Sunday 
morning last with convulsion fits, in which dreadful situa- 
tion she remained till the Monday morning following, when 
she died; the fourth day after her decease the child was 
bom perfect, but dead/' 

Case 25.* — "An inquisition was taken on the body of 
Hannah H — , wife of Mr. H — , of 65, Tummill Street, 
Clerkenwell. She was in the eighth month of her pregnancy, 
and was in good health and spirits on the Saturday night, 
when she went to bed without any complaint. On Sunday 
morning, between 6 and 7 o'clock, she awoke and complained 
of the cramp in her legs ; but she got better in a few minutes 
by haying them rubbed. At 7 o'clock she arose, and was in 
the act of getting out of bed, when she exclaimed, ' Oh ! my 
stomach,' and fell on the bed and expired. Mr. Austin, 
surgeon, of Red Lion Street, came directly and bled her, and 
other means to recover her were used, but without success. 
About the middle of the day of Monday the body was seen, 
and was then undelivered, nor were there any signs of it. 
Between 6 and 7 o'clock on Monday night Ann Terry was 
walking on the side of the bed on which deceased lay, and 
observed the body move and the clothes lifted up. She was 
so terrified that she fell into a chair almost insensible; she 
was taken out of the room and told that what she said she 
saw was only her fancy. No one went to see the deceased 
until the next morning, when she and another person took 
the clothes off the deceased and found she was delivered of a 
child, which was lying on the right side of her quite dead 
and cold. On Tuesday the body of the deceased and child 
were quite black and so changed that the features of the face 
of the former were scarcely distinguishable. 

''The late Dr. John Clarke in his lectures on the physio- 
logy of the uterus relates a somewhat similar circumstance ; 

1 'Bell's Weekly Messenger/ September 26, 1802, No. 887. 
' 'Medical Repository/ 1817, voL viii, p. 868. 



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248 POST-MORTEM PARTURITION. 

but we do not remember the particalars attending the 
case." 

Case 26. — Ryan quotes a case from a French medical 
journal^ in which ^^ several witnesses attested that a woman 
who died at 7 o'clock a.m., and appeared so in the evenings 
was found to have given birth next day to an infant.^' 

Case 27. — Dr. Bedford,* of Sydney, reports the following 
case : On the 3rd June, 1864, he examined the body of a 
woman, aged 37, who died on the 27th May, thirty-four 
miles from Sydney. She had died undelivered of her seventh 
child, and the body had been exhumed, a question of mal- 
practice having been raised. The abdomen was found much 
distended and the body of a male child was discovered 
between the thighs of the deceased — the head towards the 
feet of the mother and the feet under the uterus, which was 
inverted, with the placenta attached. Transverse rupture of 
the uterus about six inches long had taken place above the 
cervix ; the uterus was not contracted. 

Case 28. — ^Mr. F. J. Dillon Lanigan ^ has lately recorded 
the case of a woman who was in labour on the 23rd October, 
1862. " The doctor was sent for, but on the road to see her 
he was informed the woman was dead and undelivered. 
Her husband solemnly and confidentially told me afterwards 
that she, as customary, was after death washed, laid out, 
and waked for two days, and when going to coffin her, on 
removing the covering the child was found in the bed.'' 

Case 29. — Mr. C. H. Roach ^ gives the following case : — 
'^ On the 4th January, 1869, 1 was called to remove a child 
from Mrs. R — ^ who died at 3 a.m. undelivered ; being in- 
clined to take advantage of the dissection, I attended 
immediately, but some members of the family of the deceased 

» • Principles of Midwifery,' 1828» p. 446. 

> < Jour. Univ. Med. det Sc. Med./ torn. 7, p. 240. 

8 * Guy*B Hospital Reports,' 1864, vol. x. 

< < The Medical Press and Circalar,' April 8, 1872. 

' Ibid., April 17, 1872. 



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POST-MORTEM PARTURITION. 249 

objected to the operation^ consequently I did not interfere. 
Prom what I could learn, the woman, aged 35 years, primi- 
para, was forty-eight hours in labour; the pains were severe 
and quick in the beginning ; grew weaker and less frequent 
until they ceased altogether in the morning she died; she 
then fell into an apparent sleep or syncope from exhaustion, 
from which she never recovered. At 9 a.m. on the following 
day (thirty hours after death), when the body was being 
placed in the coffin, there was expelled a fully developed child 
with secundines/' 

Casb 30. — Dr. A. C. Swayne ^ published in March of the 
present year the following case: — "On the evening of 
Thursday, the 14th of March instant, Eliza M — ^ the wife of 
a farmer residing near Eilronan, and the mother of seven 
children, was seized with the pains of labour. The midwife^ 
who had attended her in all her previous confinements, was 
sent for, and was with her soon after. She continued in 
attendance during the night and until about twelve noon on 
the following day, when tbe sick woman call^ out for the 
priest and doctor. They were both sent for> and arrived in 
the course of two hours, and on their arrival they were 
informed that Eliza M — was dea4> and that she died un. 
delivered. It subsequently appeared that xieither gentlemen 
saw the deceased. On the following Sunday^ the 17th, the 
deceased was interred, contrary to the advice of the police, 
in Kilronan graveyard. In the meantime information was 
conveyed to J. P. Peyton, Esq., one of the coroners for 
Bosscommon, and he decided on holding an inquest. Ac- 
cordingly, on Monday, the 18th inst., a jury assembled; the 
body was exhumed and duly inspected by them. The 
coroner directed me to make an examination. I proceeded 
to do so under the full impression that the woman was un- 
delivered. On raising the shroud in which the body was 
enveloped, I was much surprised to find a well-developed 
male infant lying on and parallel to the lower limbs of the 
deceased, with the head towards the feet of the latter, and 

1 < The Medical PreM and Circular/ April 8, 1872. 



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250 POST MORTEM PARTURITION. 

the feet of the infant about eight inches from the. vulva. 
The cord and placenta were attached to the infant^ but 
entirely unconnected with the mother. On examining the 
mother^ who appeared to be a large^ well-made woman of 
about forty years or so, I found the uterus prolapsed and a 
large rent extending from the os for about fire inches 
through its body. The abdomen was much distended^ ap- 
parently with gas. Six apparently credible witnesses swore 
positively that the woman died undelivered^ and that the 
body was washed after deaths that she was then undelivered, 
that she was placed in her coffin undelivered, and one witness 
swore that after deceased was coffined she (witness) was 
sitting near the coffin, when she heard a dull rumbling noise 
proceeding from inside the coffin, and that this was followed 
by a gush of blood through the latter. This latter evidence, 
however, does not appear to have been corroborated by the 
other witnesses who were in the room at the same time.'' 

Foder^^ says several labours have taken place spontaneously 
after the decease of the mothers by the expulsive force alone 
of the uterus, in which the organic action is conserved after 
death has taken place in the rest of the body. Bemfer has 
reported eleven examples. Hunter^ (William) two cases, and 
Hartemann ' one. 

The writer has not had the opportunity of reading the 
fourteen cases mentioned by Foder^; the foregoing, however, 
are more than sufficient to prove that a foetus may be ex- 
pelled from the uterus after the death of the mother without 
the intervention of art. Granting this fact, then, let us 
examine the mechanism of post-mortem parturition. 

Three theories have been propounded : — First, that it is 
produced by the ordinary contractions of the uterus, which 
retains its vitality later than the other parts of the body. 
Second, that it is due to the muscular contraction called 
rigor mortis. Third, that it is the result of pressure upon 

^ ' Medline Legale,' yoL u, p. 11, note, 

* * Bulletin de Sc. M^/ torn. 6, No. 82, p. 839. 

' * Act Natur. Carios./ Decnria II, An. 8. 



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POST-MORTEM PARTURITION. 251 

the uterus caused by the accumulation of gases of decompo- 
sition in the abdomen. 

Either the first or last of these theories is usually adopted. 
The second is not so plausible^ for^ granting that a contrac- 
tion of the uterus may take place after death similar to that 
which occurs in the muscles of the limbs^ this contraction 
would scarcely be sufficiently persistent to cause extrusion of 
the foetus. 

The most frequent cause is doubtless that which results 
from the process of putrefaction^ which often commences 
rapidly when death has been sudden. Its mode of action is 
very obvious. It [is simply the mechanical displacement of 
fluid and solid matters by gaseous accumulations similar to 
the post-mortem expulsion of fseces and urine^ or the projec- 
tion of a shot from a gun. 

In support of the third theory many interesting facts have 
been recorded. 

Baudeloque^ found on opening the body of a woman that 
he had delivered immediately after death the womb con- 
tracted upon the placenta^ which he had not thought it 
necessary to extract with the child. Arbeiter^^ three 
quarters of an hour after a woman had died undelivered, 
extracted a child by turning and took out the placenta. 
During the operation the uterus was flaccid; when emptied, 
however, it contracted to the hard ball usual after normal 
delivery. Leroux^ says that he perceived, in delivering a 
woman who had been dead more than a quarter of an hour, 
that the womb contracted as the child left it, and that it 
preserved as much solidity as if the woman had been alive. 
When he proceeded to extract the placenta the neck of the 
uterus so much resisted the introduction of his hand as to 
lead him to doubt the reality of her death. Bums^ also 
states his belief that '' the uterus may live longer than the 
body/' and Nysten has shown that irritability of the 

> * Dictdonnaire dee Science M^cales,' toL xix, p. 388. 

* * MonaUsch. f. Gebartsk./ AprU, 1862. 

' ' Traits des pertes de sang.' 

« * Principlea of Midwifery/ p. 446. 



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252 POST-MORTEM PARTURITION. 

muscular fibres may exist after death for forty-five minutes 
in the stomachy an hour and a half in the oesophagus, and 
still later in the heart. It is not improbable that this same 
contractile irritability may exist in the uterus even later 
still, but it is difficult to conceive what excites it to action 
unless it be, as Harvey thought, the struggling of the 
imprisoned foetus. Most writers limit the time during which 
parturition may take place after death from vital muscular 
contractility to two hours. 

A question of great interest and one intimately connected 
with the present subject is the length of time a child can 
live after the death of its mother without breathing. Dr. 
Brunton^ gave us, last year^ an account of a foetus rescued 
aUve after having been confined in the membranes a quarter 
of an hour after birth ; and Wrisberg^ cites three cases of 
infants who were bom enclosed in the membranes; they 
lived, the one seven minutes and the two others nine, while 
thus enveloped. The membranes having been torn they 
began to breathe. Bufibn and Schierig have made many 
experiments upon the lower animals, to find out how long 
their young can remain alive enveloped in the membranes 
when removed from their mothers. The latter observed that 
the pups of a dog shut up in their membranes lived half an 
hour, and that when they were plunged into tepid water, 
still enclosed in their membranes, that their pulses continued 
to beat for many hours. 

Harvey* knew of this life-retaining power of the foetus, 
for he asks, ^' How oometh it to pass that the foetua being 
new borne, and continuing yet covered over with his entire 
membranes, and abiding still in his water, can subsist for 
some hours' space without any danger of sufibcation, if he 
have but once attracted the air into his lungs, he eannot 
afterwards live a minute without it ?" A most remarkable 
story, apropos of this subject, is told by Peter Stalpert.* 

1 * Trans. Obst. Soc Loud.,' yoI. xiii, p. 88. 

* ' Dictionnaire des Sc. Med./ voL xix, p. 888. 
' * Anatomical Exercitationt.' 

* * Dissert, de Feet. Nutoit.,' p. 46. 



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POST-MORTEM PARTURITION. 253 

At the siege of Bergen op Zoom (aot the last) a soldier's 
wife near her time was getting some water and was cut in 
two by a cannon-ball^ insomuch that the child in its mem- 
branes fell into the water^ where it continued for some time^ 
and then* was found by a soldier, who observing something 
to move took it up. The child, by order of one Cordua, was 
taken out of the membranes and christened Albertus 
Ambronus. 

This viable condition of the foetus in the membranes exists 
the same when the whole are enclosed in the uterus of the 
dead mother. Dolceus^ tells us that a woman eight months 
gone with child died of a fever, and the next day the by- 
standers observed the child to move for twelve hours. 
Semertus' says the midwife and bystanders observed a child 
move in the womb five hours after the mother's death. But 
perhaps the most extraordinary and best authenticated case 
is that of the Princess of Schwartzenberg, whose death 
occurred in Paris in 1810. She was one of the gay party 
participating in the pleasures of a ball given by her brother- 
in-law, the Austrian Ambassador. During that night of 
festivity there was an appalling conflagration which, together 
with other victims, caused the death of the Princess, who 
was far advanced in gestation. On the day succeeding her 
death a living child was removed by the Csesarean opera- 
tion. 

There seems to have been an impression in the minds of 
people of all ages that when a woman died undelivered her 
child did not die at the same moment. In 1820 a council 
held at Cologne sanctioned the placing of a gag in the mouth 
of a pregnant woman dying, hoping thereby to prevent the 
suffocation of the infant. The learned Carolus Stephanus,' 
in the sixteenth century, advises that something should be 
placed between the teeth of women dying undelivered, and 
that the midwife should divide the legs of the corpse and 

1 < M. N. C./ Dec 11, An. 6, Ob«. 187, p. 279. 
* ' Pract. Medic/ Lib. IV, part U, cap. S, p. 437. 
s 'Seimeitas Med. Pract.,' Lib. iv, Sec 6. 



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254 POST-MORTEM PARTURITION. 

keep the vagina open ulitil a surgeon could be .found to 
perform the Csesarean operation.^ 

There has also existed a popular belief that women buried 
undelivered may afterwards pass through the parturient 
process. Sue^ informs us that it is the custom of certain 
ignorant women^ who enshroud those dying pregnant," to . 
shut up in the coffin with the corpse a needle, scissors, and 
thread, which, he says, is a proof that experience has con- 
vinced them that women can be delivered after death. 

Numa Fompilius^ enacted a law which commanded 
physicians to open the bodies of pregnant women after death 
with the intention of preserving the citizens of the state 
A. c. 600. The same law prevailed in Venice in 1608 and 
1722; and in 1749 the King of Sicily punished medical 
attendants with death who omitted the operation on women 
soon after they expired. 

In a medico-legal point of view post-mortem parturition 
is of great interest, and as Dr. Taylor* truly remarks, '' A 
medical practitioner may be placed in great peril by an 
occurrence of this nature, unless the facts are known and 
can be deposed to by eye-witnesses. A woman might die 
undelivered during the attendance of a medical man. Her 
condition might be such as to justify the employment of 
instruments brought for the purpose, but not used, either 
from her sinking state or her sudden death. Under these 
circumstances the discovery after death of a dead child 
between the legs of a female, with the uterus lacerated and 
inverted, the placenta and umbilical cord lying near, and a 
large effusion of blood in the abdomen, are facts which at 
first sight do not appear to be reconciled with the effects of 
spontaneous changes in the dead body. There are' probably 
some medical practitioners who, from not having heard of 
such cases, would not hesitate to deny the impossibility of 

^ It is strange that such an accurate observer as Roderic k Castro should 
have held a contrary opinion. ' De Morb. Mulier./ Lib. iv, cap. 8. 

* ' Anat. Exeroitations,' 1658, p. 492. 
» • Legregia Diget./ lib. xx. 

* * Guy's Hospital Reports,' 1864. 



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POST-MORTEM PARTURITION. 255 

their occurrence. It is to them that cases of this description 
convey a serious warning.'* 

From all the facts which have now been brought forward 
the following conclusions may be drawn : 

1. Expulsion of the contents of the uterus may take place 
after death without the aid of art. 

2. This may occur in cases in which no symptoms of 
natural parturition can be discovered before death. 

3. Many of the manoeuvres and accidents which take 
place in labour during life may occur in post-mortem partu- 
rition; such as expulsion of the placenta^ spontaneous 
evolution of the foetus^ and prolapsus^ inversion, and rupture 
of the uterus. 

4. Expulsion of the uterine contents and accidents which 
accompany labour may be caused after death either by the 
contracting power which persists in the uterus after the 
death of the rest of the body, or by the pressure exerted 
upon the uterus by gases of decomposition pent up in the 
abdomen. 

5. Of these causes the latter is the more frequent. 

6. After the death of its mother a child may continue to 
live in the uterus for many hours. 

7. After the death of a woman undelivered no time should 
be lost in removing the foetus. 



The President differed from Dr. Sasch in respect of post- 
mortem uterine contraction. He had observed in two cases, one 
of complete and one of partial inversion of uterus, where death 
had bccuned about one hour previously, that the organ was firm 
and in one so much so as to defy aU efforts at remiction. He 
added that when we called in rigor mortis to explain the post- 
^ mortem parturition we must also take into account the fact that 
* rigor mortis would also affect the rigiditv of the passage ; the ques- 
tion would be. Would the uterine rigor last longer than that of the 
passages P In answer to Dr. Snow Beck he said the contraction 
Lasting an hour would point to a post-mortem cause. K it were 
to be considered only the relic of the contraction which had 
occurred before death, then there was no way of distinguishing 
between it and the ri^or mortis. But the subject under con- 
sideration was this, Was the foetus expelled by the uterine con- 



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256 POST-MORTEM PARTURITION. 

traction, which contraction lasted after the death of the mother P 
If there were no contraction, as Dr. Basch thought, then it is hy 
some other means, hut that there is a post-mortem contraction 
the President was certain. 

Dr. Snow Beok thought it might be desirable to add one or two 
particulars to the cases related as tending to show the amount of 
imagination which had been introduced into the records of them. 
Thus, in one case the corpse was said to have been found some 
months afterwards " having a dead infant in the right arm ;" and 
in another, " with a dead girl lying on the bosom of the dead 
mother on the bier." It is more than 200 years ago since these 
cases were published, and at that time many fanciful notions 
were entertained as to the process of parturition, one being that 
the child was not expelled by the contractions of the uterus, but, 
in the words of Harrey, " it forced its way out by its own exer- 
tions." It was impossible to withhold the conviction that we 
were indebted chieny to the imagination of the recorder for the 
details of these early cases of post-partum parturition. Some 
years ago he had seen a case of partial expulsion of the child 
from the dead body of the mother, in conjunction with Dr. 
William Merriman, from whose notes, made at the time, the 
following facts were taken. On September 1st, 1858, at 11 a.m., he 
was requested to see Mrs. D — , residing in the Waterloo Eoad, 
who had been in labour for two nights and one day. She was 
greatly exhausted ; the pains had nearly ceased ; the countenance 
very anxious ; the abdomen swollen and tender, but not particu- 
larly so ; the pulse very rapid and fluttering, but no vomiting had 
occurred, nor any sensation of anything having given way, nor 
any appearance to indicate that anything serious had taken place. 
The head presented and descended into the pelvis, but not so low 
as to press upon the perinsBum ; no movements of the child had 
been felt for some time, and it was believed to be dead. It was 
decided to apply the short forceps, but before doing so the woman 
was asked to take some refreshment. She sat up in bed to take 
some gruel, almost immediately became convulsed, and in about 
five minutes died, having previously vomited some coffee-ground 
fluid. The body was examined the following day at 5 p.m. The 
abdomen was tense and much distended with flatus, and the head 
of the foetus, much decomposed, was projecting beyond the vulva. 
On opening the abdomen the uterus was found to be ruptured on 
the left side, and the nates to have passed into the peritoneal 
cavity through this rupture. Some coagulated blood was also in 
the abdomen. The conviction at the time was that the rupture 
had taken place during the lifetime of the mother, and that the 
head of the child had been forced through the lower part of the 
pelvis and beyond the vulva by the pressure of the natus deve- 
loped in the abdomen after death. The position of the nates of 



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POST-MORTEM PABTXJBITION. 257 

the child through the laceration in the uterus seemed to preclude 
the poBsihilitj of any contraction of this organ beins the cause of 
the extrusion which had taken nlace. With regara. to any con- 
traction of the uterus after the death of the mouier, it should be 
borne in mind that this is only assumed as a probable occurrence, 
reasoning &om the analogy of what has been seen in other organs, 
but that no one, so far as he knew, had observed any such con^ 
traction. The movements of the heart, after removal firom the 
body of an animal directly after death, were well known, and it 
was assumed, but it was only an assumption, that similar move- 
ments might take place in the uterus after the death of the 
woman. In certain conditions of the system movements of the 
voluntary muscles could also be excited by a local stimulus, as after 
death firom cholera. But all these after-death movements were 
very feeble and devoid of that power or force which would be 
essential to force the child through the pelvis, as well as to over- 
come the resistance of the pennteal muscles, which, being volun- 
tary muscles, became rigid from aft^r-death contraction or rigor 
mortis. He could not admit the cases mentioned by Dr. B. 
Hicks of an inverted uterus being so firmly grasped by the sur- 
rounding contractile tissue as to prevent it being readily returned, 
as any evidence of rigor mortis having taken place in the contrac- 
tile tissue of this organ. For at most it was merely the contrac- 
tion which had taken place during the life of the woman, not 
having become relaxed after death, which is a totally different 
thing to the contraction or rigor mortis which takes ^lace aflier 
the death of the individual. As an eminent reviewer has 
remarked, ''He mistakes his own convictions for facts, and reasons 
upon them accordingly." Upon the whole, all the evidence in these 
cases upon which any reliance can be placed leads to the condu- 
sion that the extrusion of the child after the death of the mother 
has been caused by the distending force of the gas rapidly evolved 
in the abdomen during the process of decomposition, which in 
some conditions of the system may take place at a very early 
period after dissolution. 

Dr. Madob said, in the event of a woman in labour dying un- 
delivered, it would be an important point to determine how soon 
after her death one would be justified in opening the womb with 
the view of saving the child. Dr. Lever has receded that he had 
on several occasions seen the movements of the foetus in utero 
half an hour aft;er the mother's death, and was only restrained 
from interfering by objections raised by the relatives. It is 
probable, however, that as a rule, a half hour's delay would be 
too great. In a case where he (Dr. Madge) had attempted to 
save the child in this way the operation was performea about 
twenty minutes after the mother's death ; but the child was dead, 
killed probably by the action of the abdominal muscles during 

VOL. XIV. 17 



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258 POST-MORTEM PARTURITION. 

the mother's eonyulsions from pressure and disturbanoe of the 
utero-placeDtal circulation. Something similar has been observed 
to happen in pregnant women suffering from the cramps of 
cholera. He said that in his case, although convulsions came on 
during labour, there were no signs of uterine action after the 
mother's death, and on removing the child the womb remained 
in its uncontracted state. 



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OCTOBER 2nd, 1872. 

John B&axton Hickjs, M.D., F.B.S., President, in the 

Chair. 

Present — 38 Fellows and 2 visitors. 

Books were presented from Dr. McClintock, and Professors 
Chiari, Fabbri, Hngenberger, Bizzoli, and Verardini; and 
from the Smithsonian Institution and the American Medical 
Association. 

A collection of works on Deformities of the Pelvis were 
presented by Dr. Arthur Farre. 

The following gentlemen were declared admitted as Fellows 
of the Society:— Mr. W. M. Clarke, Bristol; Mr. G. B. 
Denton, Liverpool ; and Dr. Wm. K. MacMordie, Belfast. 

The following gentlemen were elected Honorary Fellows 
of the Society : — Fordyce Barker, M.D., Professor of Clinical 
Midwifery and Diseases of Women at the Bellevue Hospital 
Medical College; Otto Spiegelberg, M.D., Professor of 
Clinical Midwifery, and Director of the Gynaecological 
Clinique in Breslau; and T. Gaillard Thomas, M.D., Pro- 
fessor of Obstetrics in the College of Physicians and Surgeona 
of New York. 

The foUowing gentlemen were elected Fellows of the 
Society : — John Hankinson Gomall, M.R.C.S., Warrington ; 
James Beveridge Spence, M.D., Lichfield; Edward Henry 
Trenholme, M.D., Montreal ; and Thomas Webster, M.B.C.S., 
Bristol. 



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260 CASE OF PELVIC HiEMATOMA^ 



CASE OF PELVIC HEMATOMA, OR RETRO- 
UTERINE HEMATOCELE, WITH REMARKS— 
ESPECIALLY AS TO THE SOURCE OP THE 
HEMORRHAGE. 

By T. Snow Beck, M.D. Lond., F.R.S., 

MBMBSB OF THB BOFAL OOLLBOS OF PHT8ICIAK8* LOITDOV. 

Mrs. B — f set. 40, tall and well made, had enjoyed ex- 
cellent health until the last four years, when she suffered firom 
pain at the hypogastrium after eating; much flatulency; 
confined bowels, seldom being reUeved except by the aid of 
medicine; sometimes severe pain in the stomach, with fre-, 
quent and rather violent vomiting. Two or three years ago 
had a lengthened attack of very painful piles, which came 
outwardly each time the bowels were moved, and obliged her 
to lie down some time before they could be returned, and 
frequently passed a wineglassful of blood. Married several 
years, but never pregnant. Catamenia always regular, 
usually continued a fortnight, always had a great quantity, 
being '^sometimes nearly drowned with it;" never had any 
pain either before or during the period, but of late frequently 
had pain deep in the left iliac region afterwards. For the 
last few months had suffered from great feeling of faintness ; 
unable to bear any fatigue ; much pain at the top of the, 
head, with dreadftU giddiness; vomiting of sour fluid after 
almost every meal, preceded by pain at the epigastrium ; no 
appetite; offensive taste in tiie mouth; much flatulency; 
confined bowels, but no piles; pain about the middle of the 
abdomen^ and deep in the left iliac region. 

July 7, 1871. — Received a note stating she had been 
suffering from dreadful pain in the lower part of the stomach, 
with profuse discharge of blood during the menstrual period 
accompanied with large clots. I saw her on the following 
day. 

8th. — ^^Lying on the back with knees slightly drawn up; 
face pale; expression calm; complains much of the heat. 



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OR RETRO-UTKBINE HiEMATOCELE. 261 

skin cool, perspiring; pulse 80, soft, regular; tongue moist, 
a little dirty white fur in the centre ; vomited some watery 
sour fluid with a good deal of straining ; bowels moved last 
evening, when the bowel came down very much, and was 
returned with difficulty ; no difficulty in passing the urine ; 
no pain as lying in bed. Since yesterday a lump has ap- 
peared at the hypogastrium, a little to the left of the median 
line ; the previous pain suddenly ceased, and has not been 
felt since this has appeared. The lump oval, about the 
size of a duck^s egg ; distinctly circumscribed ; firm, some- 
what elastic ; firmly pressed against the walls of the abdo- 
men, and continued into the pelvis; no tenderness on 
handling ; no fulness in either iliac region ; dulness on 
percussion over whole pelvic region ; considerable tenderness 
on gentle pressure into the pelvis. The vagina natural, 
moistened with a copious flow of deep red coloured fluid, 
more like ordinary haemorrhage than catamenial flow; no 
coagula ; a soft elastic swelling, bulging forward the posterior 
wall of the vagina, and occupying the space between the 
uterus and the rectum, which allowed the fingers to pass up 
at each side, and apparently to define the recto^vaginal 
pouch; softest and most prominent at the centre; no 
tenderness during the examination. The orifice of the 
uterus high up against the pubis ; the uterus pressed up and 
lying against the abdominal walls ; sound passed readily, and 
without pain into the uterine cavity, when the oval lump, 
which was distant from the pelvic swelling, cordd be mov^ 
from or pressed against the hand placed on the hypogastrium. 
l%e flow from the uterus was profuse last night, and never 
had been in the least interrupted, though now on the 
decline. 

Best in bed ; iced soda water, with a little brandy, to 
relieve the thirst ; bismuth, bicarbonate of soda, and ammonia 
twice a day, were prescribed. 

12th. — ^The menstruation had nearly ceased ; the lump was 
less distinct, and not so high in the abdomen. The dulness 
on percussion diminished, and no indication of any inflam- 
matory action. 



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262 CASE OF PELVIC HiEMATOMA, 

15th. — On sitting down to pass water a good deal of port- 
wine coloured blood, with some dark coloured dots, passed 
from the bowel with a gush. 

16th. — About a small teacupful of dark blood, with some 
clots, passed at the time the bowels were moved. 

August 7th. — ^Was much improved, and walking in the 
garden each day ; some return of the symptoms of disordered 
digestion. 

September 7th. — Was further improved. The catamenia 
returned profusely a fortnight ago, and passed off without 
any recurrence of the swelling in the pelvis. 

April 4th, 1872. — Has continued well up to this date. 

July 15th. — Continues improving; vaginal discharge, and 
all unpleasant odour ceased. 

In this case there can be little doubt that an effdsion of 
blood suddenly took place in the pelvis near the end of the 
catamenial period, which had been unusually profuse, and 
attended with great pain deep in the left iliac region. This 
pain had been gradually increasing, after menstruation, for 
about eighteen months, had been present this time during 
the period, and suddenly ceased on the occurrence of the 
effusion of blood. The Isidy had enjoyed excellent health till 
thirty-six years of age, indulging in the pleasures of the table 
perhaps more than she ought to have done, but never feeling 
any inconvenience from it; had been married several years, 
though never pregnant, and from the first appearance of the 
catamenia had always had a profuse flow. For the last four 
years she had suffered from great derangement of the 
digestive organs, which, in spite of medical treatment, had 
increased, and latterly the general health had been affected. 
She had also suffered fnnn more than one severe attack of 
haemorrhoids, with protrusion of the rectum when the bowels 
were moved, and frequent loss of blood to the amount of 
a wineglassfol. The old questions then arise — ^Where 
did the effused blood come frt>m? into what part was it 
effused? 

It would not be possible to say decidedly where the 



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OR RBTRO-UT£RINK HiBMATOCELE. 263 

eflfiised blood was situated^ but it is more than probable that 
it was in the cellular tissue of the pelvis, and not in the 
cavity of the peritoneum. The tension of the swelling, the 
firm and immovable way in which the uterus was pressed 
against the walls of the abdomen directly the effusion took 
place, the circumscribed nature of the swelling which did not 
apparently involve the uterus, and the soft and elastic 
portion in the centre immediately behind the orifice of the 
uterus, appear to indicate that the effused blood was con- 
tained in a circumscribed and distended cavity ; whilst the 
absence of all constitutional symptoms and of all pain, the 
small amount of tenderness on handling the tumour, and the 
early evacuation of the contents by the rectum — the seventh 
day — further confirm the previous objective symptoms. The 
arrangement of the different fascia in the pelvis covering the 
various muscles and converging to a central part at the neck 
of the uterus and the upper part of the vagina, is very 
complicated, and often presents a weak point behind the 
orifice of the uterus, into which the end of the finger can be 
pressed, and through which a hernial protrusion often occurs^ 
producing one form of supposed prolapsus of the uterus. 
This point was indicated by the soft elastic portion in the 
centre of the swelling as noted at the vaginal examination ; 
and with regard to the situation of these swellings, as Sir 
James Simpson has remarked, '^ there is almost no limit to 
the variety of situations in which a pelvic thrombus or 
hematoma may be found, for the veins may give way in any 
part of the pelvis, and the blood which escapes may fill some- 
times one fascial loculament only of the pelvis, at other times 
several at once.*'^ 

The effiised blood in pelvic hsematoma, or hsematocele, is 
said to come, from various sources, but practically it comes 
from only three. Some of the reputed sources — " essentially 
a form of ovarian or Fallopian menstruation '' (Tyler Smith, 
Ondly Hewitt)— appear to be stated without any reliable 
observation. Whilst effusion of blood into the peritoneal sac 
from rupture of the gravid uterus, extra-uterine gestation 
1 'Medical llmet and Oaiette,' Aiigu8t» 1859. 



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264 CASE OF FBLVIC HEMATOMA, 

cystSj or aneuriBm, cannot properly be considered as belong- 
ing to this class of blood effusions. 

The sources of the effused blood are^ (a) rupture of an 
ovary which has previously undergone some process of de- 
generation^ and been partiaUy converted into soft^ dark-red 
tissue capable of pouring out a considerable amount of blood ; 
{b) rupture of a Fallopian tube or an escape of blood from 
the congested vessels of the part without any apparent lesion 
of their coats. The great vascularity of the Fallopian tubes 
would account for a considerable escape of blood after any 
rupture or any great congestion of the vessels ; whilst the 
small supply of sentient nerves to the ovaries or Fallopian 
tubes accounts for the fact that great alteration of these 
structures may occur without communicating any pain or 
other unusual sensation to the individual. But haemorrhage 
from both of these sources almost always takes place into the 
peritoneal cavity^ and hence must be excluded in this case. 
Another source is^ (c) rupture of some varicose vein. The 
veins of the pelvis are lai^e and numerous, and liable to 
become varicose from various causes. Those contained in 
the broad ligament often become large and varicose in 
women who have borne children, and in whom the uterus 
remains enlarged. Sometimes they are so congested as to 
give a dark-purple appearance to the whole of the structures. 
When in this state the veins of the broad ligament some* 
times give way, apparently in consequence of the little 
support the walls receive from the loose tissue by which tiiey 
are surrounded, and efiusion of blood takes place into the 
cavity of the peritoneum. But the coats of the vein may 
give way without any laceration of the peritoneum, and the 
blood is then extravasated into the loose cellular tissue in the 
broad ligament, and immediately surrounding the middle 
and lower part of the uterus. Other veins of the pelvis may 
also become congested and varicose, and give way during the 
general congestion usually attending the catamenial period, 
when the blood becomes extravasated into one or more of 
the '' fascial loculi,'' forming swellings of various shapes and 
sizes. It is more than probable that one (^ the pelvic veins 



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OB RETRO-UTERINE HiEMATOCELE. 265 

gave way in the case recorded^ considering the great amount 
of congestion which was present at the lower part of the 
rectum, and the pain deep in the left iliac region, which 
for some months had increased after each catamenial period, 
was very severe, immediately preceding the extravasation, 
and suddenly ceased when it took place. The more probable 
explanation of this pain, which differed from the pain 
generally attending menstruation, and did not appear to be 
of uterine origin, being that it arose from congestion of the 
pelvic veins associated with the hsemorrhoidal plexus, which 
congestion became intensified at each recurring period. 

There is a reputed source from which the blood is derived 
in these effusions into the pelvis which will require to be 
examined with some care, on account of the general assent it 
has received. The extravasations are said to be in some way 
connected with the menstrual flow, '' generally consequent 
on some disorder of the menstrual function, often on its 
temporary suppression'' (Dr. West); or ''the result of a 
morbid discharge from all, or part of the genital organs in 
the virgin state, some of the fluid being effused accidentally 
into the peritoneal cavity, while the rest escapes as metror- 
rhagia from the vulva /'^ or, in the more precise language of 
Sir James Simpson, ''the blood regurgitating along the 
Fallopian tube into the peritoneal cavity, having escaped 
from the cavity of the uterus'' during menstruation.' Some 
authorities admit this as a not unfrequent occurrence ; but 
others consider it so highly improbable that it could only be 
admitted upon being clearly shown to have taken place. 

Dr. A. Meadows in a recent paper considers " these form 
a clearly marked group,'' and endeavours to explain how 
such an occurrence may take place. He remarks, "of 
course such a thing is not possible in the ordinary and 
natural state of the parts ; but there can be no doubt ot the 
easily dilatable character of the Fallopian tubes, for all 
erectile tissue has that property, and they are pre-eminently 
erectile. There must, however, in all cases be previous 

' Bernuti and Qonpil, ' Diseases of Women,' Syden. Soc. edit.,yoL i, p. 207. 
) 'Med. Times and Gas./ Angost, 1859. 



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266 CASE OF PELVIC HiBMATOMA, 

distension of the uterus before its contents are forced 
along the Fallopian tubes, but when once the current 
sets in in that direction its continuance is^ I believe^ a 
matter of little difficulty /^^ I cannot^ howeyer^ concur 
in this explanation. The Fallopian tubes are^ no doubt, 
highly vascular bodies^ and assume on certain occasions 
an erectile character. At these times the vessels become 
distended and the size of the tubes is enlarged, but 
the enlargement takes place in all directions, inwardly as 
well as outwardly, and it by no means follows that the small 
canal in the centre is perceptibly increased in size. But 
there is a more fatal objection to this explanation. The 
vascularity of the tubes does not extend throughout their 
whole extent, and does not include the portion contained 
within the walls of the uterus. Hence this portion, to about 
the extent of half an inch, would be unaffected, and, as it is 
the narrowest portion of the canal, would as effectually 
prevent any regurgitation from the uterus as at any other 
time. Moreover, there is no proof that any distension of 
the uterus occurs in the great majority of these cases, which 
it is admitted must take place before the contents are forced 
along the Fallopian tubes. 

These remarks do not, of course, apply to those cases 
where the outward flow of the catamenial fluid is prevented 
by a mechanical obstruction^ either congenital or acquired, 
when the uterus gradually becomes greatly distended, and 
the efforts to expel the contained fluid become very great. 
Different cases are recorded which show that with the 
distension of the accumulated menstrual fluid the Fallopian 
tubes also become distended, and the contents extravasated 
into the cavity of the peritoneum; or, where an obstruction 
exists in their canal, they become much distended and 
finally ruptured with extravasation of their contents. Still 
it is remarkable, considering the number of cases of 
mechanical obstruction, how few there are on record where 
the retained menstrual fluid has been clearly shown to be 
forced along the canal of the tubes ; whilst in others the 
1 < Obstet Trans.,' vol. ziu, p. 169. 



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OR RETRO-UTERINE HiEMATOCELE. 267 

fundus of the uterus has even been ruptured before this 
could be effected. Other cases^ again^ are recorded where 
the Fallopian tubes have been so occluded at both extremities 
as to prevent the passage of any fluid, and where the tubes 
have become so distended by the effusion in their interior as 
to become ruptured. A case similar to this is recorded by 
Bemutz : — '' A girl, aged 26, began, when twenty, to suffer 
symptoms of retained menstruation, which had recurred 
every month since for four or five days. On examination 
there was found to be complete occlusion of the vagina at 
about its middle. An abdominal timiour, the size of a foetal 
head, was felt over the uterus, it was tender on pressure ; 
fluctuation was felt at the vaginal obstruction; the mem- 
brane was incised and about eight ounces of black coagu- 
lated blood mixed with mucus was evacuated ; pressure on 
the tumour favoured this evacuation* Peritonitis set in and 
death on the second day. 

'^ On making a post-mortem examination there was found 
peritonitis with sero-purulent effusion mixed with a little 
putrid blood in the left iliac fossa; the uterus was about the 
size of a fist ; the Fallopian tubes were adherent by mem- 
branes to the posterior part of the ovaries and were dis- 
tended with black blood. The left tube was the size of a 
turkey's egg and had ruptured ; the right about the size of 
a nut ; the ovaries showed several cicatrices and ovules in 
various stages ; several ovules the size of a millet-seed were 
found in the left Fallopian tube.''^ 

It must be added that '^ the tubes communicated with the 
uterine cavity by an extremely small canal. '^^ Hence, 
though there was not complete occlusion of the uterine ends 
of the tubes, yet the opening being so extremely small as 
not to permit the passage of an ovule, it is fair to infer that 
little or no blood passed from the uterus to the tubes, and 
that the blood found in these organs had been secreted from 
the inner surface, had distended their canals, and caused 
rupture of the left tube. 

^ Syden. Soc edit, toL i, p. 19. 
' Parb aditioD. 



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268 CASE OP PELVIC HJBMATOMA^ 

Whilst there can be no doubt that in obstinate mechanical 
obstruction the menstrual secretion may be extravasated 
into the peritoneum through the medium of the Fallopian 
tubes, it remains to be shown whether this can take place in 
the ordinary condition of the uterine organs, and in the 
absence of any decided mechanical obstruction. I entirely 
agree with Dr. Meadows in the remark — ^" Of course such a 
thing is not possible in the ordinary and natural state of the 
parts/' But other authors entertain a contrary belief, and 
have recorded cases where they consider this to have taken 
place. 

M. Bernutz has recorded or quoted from other observers 
fourteen cases, but none of these, so far as I can perceive, 
are satisfactory. 

In the case recorded by Dr. W. P. Barlow,^ a young woman, 
set. 22, aborted at the sixth month in a second pregnancy. 
She afterwards had an attack of purpura, and died five days 
after delivery. At the autopsy the skin and the mucous mem- 
brane of the stomach and intestines were much marked with 
purpuric spots ; some on the peritoneum and pleura. The 
condition of the body generally exsanguine. A large 
quantity of blood was effused into the abdomen and pelvis, 
mostly coagulated but partly fluid. Solid coagula were 
observed protruding from the open orifices of the Fallopian 
tubes. The tubes themselves were filled with blood and 
distended at a short distance from the uterus up to the distal 
extremity. The uterus was smaller than is usual a week 
after delivery. Its cavity presented nothing remarkable, 
except that a clot occupied part of the cervical canal and was 
situate over the orifice ; it seemed also to have been com- 
pressed by it. 

The absence of all blood in the cavity of the uterus and 
the Fallopian tubes to a short distance from the uterus 
appears conclusive that it did not come horn, this organ; 
whilst the tubes being filled and cUstended with blood to a 
short distance frt>m the uterus affords equally strong 

1 < London and Edinb. Monthly Jonmal,' 1841. 



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OR RKTRO-UTBBINB HiBlCATOCELE. 269 

evidence that the blood was poured out from the inner 
surface of the tubes themselves. 

In another case reported by M. A. Proust^ a married 
woman^ set. 28, who had had three children, was admitted 
into the^Hdpital S. Antoine suffering from jaundice. The 
liver was diminished in size; she became comatose and 
vomited thirty or forty ounces of blood. Soon after this 
premature labour came on at the fifth month, attended with 
a great deal of haemorrhage, which recurred once or twice, 
and from the effects of which she died. At the autopsy the 
cavity of the peritoneum contained some reddish serum. 
The liver was scarcely more than half its usual size, soft and 
very red. The kidneys healthy. The uterine cavity was 
filled with blackish coagulated blood, which was continued 
into the inner half of each Fallopian tube ; the outer half 
was empty and smaller than the inner portion. Their walls 
were healthy, but the mucous membrane near the inner 
orifice was injected, ecchymosed, and slightly softened. The 
peritoneal surface of the tubes near the uterus was also 
finely injected. Small ecchymosed spots existed beneath the 
peritoneum. Small extravasations of blood also existed in 
the cellular tissue of the broad ligaments. The ovaries were 
healthy.^ 

It cannot be supposed that any obstruction existed to the 
outward flow of the blood so soon after an abortion at the 
fifth month; whilst the recurring haemorrhage not im- 
probably arose from a relaxed condition of the uterus. The 
coagulated blood was confined to the inner half of the 
Fallopian tubes, which were larger than the outer half, were 
also much congested, and the mucous membranes ecchymosed 
and softened. It appears more probable that the blood 
found in the inner half of the tubes was effused frt>m their 
inner surface, than that it came from the uterine cavity, 
especially as the outer portions, .which were not congested, 
were empty. With the open state of the external orifice 
of the uterus there is nothing to justify the inference 

> Bernntz and Ooupil, ' Maladies des Femmes/ Paris edition, p. 487. 



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270 CASE OF PELVIC HiEMATOMA^ 

that sufficient force could be exerted on the blood in the 
uterine cayity to force it into the inner half of the Fallopian 
tubes. 

A third case^ reported by Dr. Scanzoni : — ^A young girl^ 
22 years of age^ while suflPering from an attack of measles^ died 
during menstruation with acute peritonitis. On post- 
mortem examination haemorrhage was found to have pro- 
ceeded from the left Fallopian tube, which was distended 
to the size of the index finger, and contained about two 
ounces of blood, partly fluid, partly coagulated. Through 
its abdominal orifice as much as sixteen ounces of blood had 
escaped. 

Again, there is no evidence that the blood came from any 
other part than the Fallopian tube ; the condition of the 
uterus not being mentioned. 

Of the remaining cases eight ended in recovery, so that 
the source of the blood could not be ascertained. Two 
terminated in death, the diseases being of so complicated a 
character as to prevent the source of the haemorrhage being 
determined. 

Several cases have also been recorded by Dr. Robert 
Barnes^ in a paper entitled ''Cases Illustrating the Clinical 
History and Pathology of Effusions of Blood into the Perito- 
neum, with special reference to the so-called Retro-uterine 
Hsematocele.'' Under the head " Menstrual disturbance or 
difficulty, leading to effusions of blood into the peritoneum,'* 
he observes, " This group includes by far the largest propor- 
tion of cases. ... It may be stated as a general rule 
that, whenever there is any impediment to the free dis- 
charge of menstrual blood by the natural route, if the 
quantity of the blood exuded in the uterine cavity be ex- 
cessive, or suddenly increased by accident, by emotion, or 
other causes, escape may take place by the Fallopian tubes 
into the peritoneum." It is with much regret I am obliged 
to differ from Dr. Barnes, but I have very carefully examined 
all the cases reported, and have failed to discover any 
facts recorded which maintain or justify these remarks. 
1 'St. Thomas's Hospital Reports/ 1870. 



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OR HETRO-tTTEBINB HiEMATOOBLE. 271 

The particulars of twenty-seven cases are given, arranged 
under five sub-groups, and the general result of these cases 
is unusual: — {a) the large number of twenty-four cases 
recovered, and of the three deaths which took place, neither 
arose from the effects of any effusion of blood; {b) in no 
6ase was there any distinct evidence— by post-mortem ex- 
amination, by puncture of the swelling, or by sudden 
evacuation of grumous, or otherwise altered, blood by the 
rectum or the vagina — that any hsematocele had ever taken 
place. Of the three deaths recorded, one (43) arose '' under 
symptoms ascribed to malignant disease of the stomach ;'' 
another (39) after operation ^' for ovarian dropsy, but did 
not succeed ;** a third (29) " after peritonitis with ascitic 
effusion, proceeded rapidly/' And with respect to the evacua- 
tions of the contents of the swelling, though it is stated 
(p. 48), '^the blood coagulates, and may be discharged in 
mass by an opening in the vagina or rectum, as in Cases 
... 85, 36, 40," yet neither of these cases contain the 
usual evidence of this having occurred. No. 35 ''had a 
sanguino-purulent discharge about a week after I saw her. 
. . . The discharge became offensive, and was corrected 
by carbolic acid lotions." No. 40 " was steadily improving. 
Oozing of dark fluid slimy blood set in ; this continued some 
time/' The character of these discharges rendering it more 
than probable that they were secreted by the mucous mem- 
brane of the vagina. And in No. 36 '' the flow (menstrual) 
then returned, and there has been slight sanguineous dis- 
charge ever since of a grumous character/' It is further 
added (p. 48), '' It (the blood) may without coagulating, or 
after coagulating and breaking up be evacuated slowly by a 
small opening into the rectum or vagina.'' But there is no 
proof of this in any of the cases, aud I do not know of any 
instance where such a mode of evacuation has been shown to 
have taken place. In No. 47 " a fr**^ iiia^i*-*.^^ ^^ kir^*i 
thick and black, took place from the 
for a fortnight," but this is not refe 
and will be considered subsequently. 

It can scarcely be said that this e 



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272 CASE OF PELVIC HJEBiATOliA^ 

show that " escape of blood may take place by the Fallopian 
tubes into the peritoneum/' and as it would be impossible to 
go over each case, I must endeavour to select three or four 
such as may give a fair idea of the whole. 

The first case (No. 27) is arranged under '' Probable 
Fallopian Gestation.^' A young lady, who had no children, 
exceeded her menstrual period by one week, was exposed to 
cold, and taken with pelvic and abdominal pains and vomit- 
ing, followed by haemorrhage from the vagina. The pains 
continued, and at one time suggested peritonitis. She was 
weak, not very anaemic; pulse 90; can move her limbs; 
some tenderness in pressing deep in pelvis on left side« 
Uterus pressed rather low down; cervix small, hard; os 
hard, scarcely at all open, its mobility is impeded; the 
vaginal roof on the left is lowered and resisting ; pressure 
gives pain. " Diagnosis, — Retro-uterine or intra-ligamentous 
effusion of blood exciting pelvic peritonitis, produced by 
interrupted menstruation, and the attendant congestion of 
the ovaries or Fallopian tubes, or by escape into the perito- 
neum of a very early Fallopian ovum,'* 

It may fairly be asked upon what evidence is this diagnosis 
founded ? I am unable to perceive any evidence of an early 
Fallopian ovum; of such ovum having escaped into the 
peritoneum ; of congestion of the ovaries or Fallopian tubes, 
or of pelvic peritonitis. Delayed menstruation for one week; 
the vague terms pelvic and abdominal pains, with vomiting 
and some tenderness on pressing deep in the pelvis, are 
not sufficient to indicate the existence of any of these con- 
ditions, nor can I perceive any signs or symptoms that 
effusion of blood had taken place. 

The four following cases form the sub-group ^'Mecha- 
nical Impediment,'' the first two being each headed " Men- 
strual Betention.'' 

No. 28. — A girl, set. 13, who had not menstruated ; for 
some days had suffered from pelvic and abdominal pain; 
fever; rapid pulse. Saw her at night; intense fever; coun- 
tenance expressive of intense pain; draws her legs up; 
th^ abdomen, especially near the pelvis, very tender on 



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OR KETRO-UTERINE HiEMATOCELE. 273 

pressure^ not much swollen ; the finger passes the hymen ; 
cervix felt with difficulty ; full examination prevented by the 
acute pain. 

No. 29. — A girl, aet. 14^, had never menstruated ; of a 
tubercular family; apparently in good health three weeks 
ago. Fourteen days ago peritonitis appeared. Peritonitisi 
with ascitic effusion, proceeded rapidly. A firm, round 
tumour^ rising above the pubes. It increased in size, was 
as large as the uterus at three months' gestation ; but the 
pain and distension from effusion was so great as to forbid 
minute exploration ; hymen permitted finger to pass ; vagina 
fair size ; a somewhat firm mass was felt at brim of pelvis ; 
the OS uteri could not be clearly made out; the cervix 
seemed distorted and compressed by the tumour. The whole 
was slightly moveable in connection with the tumour above 
the symphysis. Fluctuation everywhere in the abdomen, 
and dulness in front. Pulse 120 to 140 : countenance ex- 
pressive of pain; prostration; tongue dry. Dr. Stevens, 
having regard to family history, thought there was tubercular 
peritonitis. The symptoms seemed too rapid for this. The 
abdominal shocks and inflammation indicate some sudden 
injury. She died the next day. No autopsy could be 
obtained. 

'' These two preceding cases,'* observes Dr. Barnes, " appear 
to me of remarkable interest. Under the hyperaemic turges- 
cence attending the onset of the first ovulation, and the 
attendant menstrual flux, there is a rapid transudation of 
blood from the mucous membrane of the uterus. This 
organ, comparatively immature and unused to the duty it is 
called upon to perform, does not readily expand to accom- 
modate the blood poured into its cavity, and which is retained 
by an imperfect development of the cervix from being 
discharged by its natural outlet. There is consequently re- 
flux along the Fallopian tubes, hsematocele, and peritonitis. 
There can scarcely be a doubt that this is the explanation of 
some, at least, of those apparently obscure attacks of peri; 
tonitis which sometimes seize young girls at their entrance 
upon the ovarian epoch.'' 

VOL. XIV. 18 



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274 CASE OF PELVIC HiEMATOMA, 

I am not aware of any facts which juatify the statement 
that ''a rapid transudation of blood" takes place from the 
so-called ''mucous membrane of the uterus*' at a first 
menstruation ; and when this is made in relation to an im- 
perfect development the statement becomes even more doubts 
ful. A profuse menstrual flow^ no doubt, every now and 
then occurs at a first and subsequent menstruation; but 
when this is the case the attendant symptoms show that it 
takes place from the mucous membrane of the vagina. Again, 
it is a novel doctrine that it is '' the duty '* of the uterus to 
expand and accommodate itself to the menstrual secretion, 
which secretion usually flows away as it is exuded. When 
severe obstruction is present the uterus certainly '' does not 
readily expand to accommodate the blood poured into its 
cavity/' but does so after much resistance, and distress to 
the individual. An '' imperfect development of the cervix,'' 
even supposing it to exist, would not prevent the flow '' from 
being discharged by the natural outlet." But what proof is 
there that any obstruction did exist in either of these cases ? 
The statement — ''There is consequently reflux along the 
Fallopian tubes, hsematocele, and peritonitis," scarcely ap- 
pears to be justified by the facts. The usual signs of " hse- 
matocele and peritonitis " are not recorded, and it cannot be 
intended that these serious conditions ^could exist without 
giving rise to any signs or symptoms. Omitting the con- 
sideration of No. 29, which presents some complications. No. 
28 appears to have been acute congestion of the uterus 
and vagina, which every now and then is developed at the 
period of puberty, or shortly afterwards. The " acute pain " 
on passing the finger into the vagina" was strong evidence 
of this, and no sign of either " hsematocele or peritonitis." 

No. 80.— May 21, 1864.— Mrs. F— , at. 23, married eight 
months; always regular, not profusely. Husband says there 
has never been perfect connection ; the attempt gives great 
pain. The last menstrual flow did not appear when due, but 
a slight coloured discharge has continued for the last ten 
days. Was out yesterday, and seemed well this morning. 
Was suddenly taken with severe abdominal pain ; vomiting ; 



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OB BETBO-UTEBINE HJSMATOCELE. 275 

collapse result of shocks seemed moribund. Dr. Giles 
thottglit there was intestinal hcemorrliage. Saw her two 
or three hours after the attack; was still in collapse but 
rallying; pulse 130^ full; does not bear pressure on abdo- 
men ; some fulness ; breasts said to have been fuller than 
usual^ but they show no areola. The uterus is very low in 
the pelyis; cervix conical^ curved forwards; the uterus 
is set fast; pressure on cervix gives acute pain in 
pelvis ; there is fulness on either side of the cervix. Dia- 
gnosis. — Effusion of blood in pelvis from Fallopian tubes or 
ovaries. 

" 23rd. — Better. Pulse 100 ; skin moist ; can extend her 
1^8 without pain ; respiration easy. A firm mass is felt in 
the left iliac r^on. She recovered completely .'' 

"This lady/' remarks Dr. Barnes^ "came under my 
observation again two years afterwards on account of the 
continued impediment to intercourse. This and the charac- 
teristic sterile cervix satisfied me there had been no preg- 
nancy. The source of hsematocele, therefore, was menstrual 
blood probably escaping during influence of sexual excite- 
ment.'' 

These symptoms might lead to the inference that effusion 
of blood had taken place into the peritoneum ; but there are 
serious objections to this view. It is most unusual to meet 
with these effusions in a lady twenty-three years of age 
without children, and they do not cause, in two or three 
hours, so much tenderness in the abdomen and acute pain 
in the pelvis on pressure of the cervix, with only fulness on 
either side of that part. The absence of the physical signs 
of any swelling appears conclusive aguinst the existence of 
any effusion, whilst the " firm mass in the left iliac region " 
two days, later with previous tenderness, pointed rather to 
some inflammatory deposit. However, the existence of 
hsematooele is assumed, and it is added, the source, "there- 
fore, was menstrual blood, probably escaping under influence 
of sexual excitement." Impediment to intercourse, attended 
with great pain, almost alvrays results from some affection of 
the sensitive parts of the vulva or vagina, and induces 



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276 CASE OF PELVIC HJBMATOMA^ 

opposition or repugnance to intercourse — the antipodes of 
excitement. But assuming excitement to have been present^ 
how could that cause reflux of the menstrual blood along the 
Fallopian tubes into the peritoneum? The menstrual flow 
" did not appear when due/' " was not profuse/' no obstruc- 
tion is noted at the uterine orifice^ and it is not suggested 
there was any distension of the uterine cavities. Moreover, 
excitement being an action of the cerebro-spinal system 
might be induced through the sensient nerves of the vulva or 
vagina ; but how could it cause contraction of an empty un- 
impregnated uterus so as to force blood along the Fallopian 
tubes ? The motor nerves supplied to the uterus or the 
Fallopian tubes are very small in amount, and any influence 
reflected to them from the nerves of the vulva or vagina 
would not be likely to produce strong contraction of these 
organs. 

No. 31, — A lady, who had been married twenty years 
without being pregnant, was taken rather suddenly ill with 
acute pain in the pelvis and prostration fourteen days ago. 
Signs of peritonitis followed. I found the uterus fixed, the 
OS small, and a firm mass behind the uterus. The recent 
symptoms had subsided. She got well. 

" Here probably/' observes Dr. Barnes, " blood had been 
poured out from the ovaries or Fallopian tubes from impeded 
menstruation, the two factors being the narrow os uteri and 
sudden congestion. The long-enduring sterility is further 
evidence of menstrual obstruction." 

Why long-enduring sterility should be any evidence of 
menstrual obstruction it would be difiScult to say, seeing 
that sterility arises from so many causes. Even life-enduring 
sterility is frequently produced by simple antiversion of the 
uterus without any disturbance of the menstrual function. 
How "the narrow os uteri" could have any effect with 
^' sudden congestion," assuming it to exist, so as to induce 
an outpouring of blood from the ovaries or Fallopian tubes, 
appears equally difficult to perceive ; moreover, " a firm mass 
behind the uterus/' without any other symptom, is scarcely 
sufficient to establish the existence of hscmatoccle. 



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OR RETRO-UTERINE HiEMATOCELE. 277 

Before concludiug the criticism I have ventured to make^ 
I am desirous to take one case where the signs of hsema- 
tocele were most marked. The facts have been slightly 
rearranged. 

No. 47. — S. W — came to the hospital as an out-patient in 
July^ 1870; married eight years without being pregnant; 
had been getting stout for the last three years, especiidly the 
last year; menstruation was suspended for eight months, 
attended with frequent vomiting, when a free discharge of 
blood, thick and black, took place from the bowel ; clots also 
passed by vagina. This continued for a fortnight attended 
with great pain, so that she could not lie down. When the 
suspension began there was acute pain in the abdomen, which 
used to swell up ; had five or six acute attacks of the kind 
every month. The uterus fixed ; os, cervix, and the body 
pushed forwards, near to the symphysis. A firm, rounded 
edge, like a collar, behind the cervix. 

'' In this case,'' Dr. Barnes remarks, '' no doubt, a retro- 
uterine hssmatocele was formed, and remained in a more or 
less indolent state for eight months, when it was discharged 
by the rectum.*' 

The symptoms which occurred eight months ago were 
suspended menstruation, with acute pain in the abdomen 
and firequent vomiting, and if these be admitted as the 
symptoms of the formation of hsematocele, then there must 
have been from forty to fifty separate effusions of blood, 
seeing that she had five or six acute attacks of the kind every 
month, and yet was enabled to attend at the hospital as an 
out-patient. At the end of eight months a discharge of thick 
and black blood took place from the rectum, and clots from 
the vagina, attended with great pain, which continued for a 
fortnight; this again is so different from the manner by 
which a hsematocele is discharged that such an explanation 
can scarcely be accepted. In the absence of all signs of 
any distinct swelling, it is much more probable that these 
symptoms arose from great disorder of the digestive organs, 
accompanied by congestion of the veins of the rectum, as in 
the first case recorded, than that they were caused by the 



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278 CASE OF PELVIC HiEM ATOMA^ 

formation of a haematocele^ recurring fire or m times each 
month for a period of eight months. 

The result of this examination^ then^ appears to lead to 
this : — whether we take the general facts deducible from the 
whole of these cases^ or the facts recorded in each case 
separately^ the conclusion appears to be the same^ that there 
is no evidence of any reflux of blood from the uterus into the 
peritoneum through the medium of the Fallopian tubes, 
except in those cases where there has been permanent ob- 
struction to the outward flow of the menstrual secretion 
and consequent great distension with enlargement of the 
uterine cavities.^ 

With respect to the treatment this appears to be pretty 
obvious from the various cases which have been recorded. 
In many, as in the case first related, the actions set up by 
the presence of the effused blood lead to its removal with- 
out any artificial assistance ; and, so long as the swelling 
does not increase, does not become more tender than at first, 
and no constitutional symptoms appear in the individual, it 
may be safely left to the unaided efforts of nature ; com- 
plete rest in bed being enjoined and any accidental compli- 
cation being attended to. But in other cases this satisfactory 
course does not take place, and it becomes necessary to render 
assistance in the removal of the blood, in order to avoid the 
serious consequences which are known to follow, either by 
the rupture of the cyst and the escape of the contents into 
the cavity of the peritoneum, the extension of inflammation to 
the neighbouring veins and consequent pyaemia, or gradual 
exhaustion and hectic symptoms. In these casea there can, 
I think, be no doubt as to the propriety of making an arti- 
ficial opening into the cyst and letting out the contents. 
And then occur the questions— When is the proper time to 
interfere? where ought the opening to be made? As a 
general rule, the cyst should be punctured; when some 
weeks have elapsed without any signs of decrease in the 

1 I have been obliged to omit aU reference to the cures published by Dr. 
TuckweU, of Oxford, in consequence of the book being out of print and not 
being in any of the public libraries. 



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OR RETRO-UTERINE HiBMATOCELE. 279' 

swelling ; when the swelling increases in size^ becomes moro 
tense^ more tender^ and more painful ; when the temperature 
increases^ the complexion becomes of a dirty-yellowiah hue^ 
or more decidedly jaundiced, the abdomen swells and be- 
comes tense, with gradual emaciation and increasing weak- 
ness ; when there is repeated shivering, frequent vomiting, 
rapid pulse, night sweats, or other symptoms of constitutional 
disturbance. And as to the seat of the opening, the part 
most frequently selected by nature — the rectum — appears the 
most appropriate. Occasionally, when the swelling points 
prominently in the vagina this part should be preferred. 
Usually it is sufficient to puncture the cyst with a full-sized 
curved trocar, taking care that it be directed to the centre 
of the swelling and passed sufficiently deep to enter the 
cavity. Sometimes a small trocar, to which an exhausting 
syringe has been attached, may be preferred ; and now and 
then it becomes necessary to enlarge the opening, remove 
any coagula, and even wash out the cavity with an 
antiseptic fluid. Sir James Simpson strongly insisted 
upon making a free opening : — '' To open the hsematoma 
effectually you must make an incision into it with the 
tenotomy knife, and then freely dilate the opening still 
further with the fingers .... For it is not enough, in a 
case of this kind, to make an opening into the cyst. You must 
introduce the finger through it and break down the septa 
and blood coagula, so as to ensure their complete removal.'^^ 
But this appears only necessary in exceptional cases. 



Dr. Basch said the value of Dr. Beck's elaborate paper might 
have been enhanced bv devoting some spare time to diagnosis, 
and especially to the differential diagnosis from cellulitis. We 
had seen on a former occasion that there was still some difference 
of opinion amongst the learned members of this Society. It 
would, in Dr. Basch's opinion, be an important help to diagnosis 
if what he found in a few well-marked cases should on more 
extended observation prove the rule, viz. the low temperature 
(subnormal) in the fint days of the disease, or longer. In an 

1 ' Medical Hmes and Qasette/ Aagvat, 1869. 



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280 CASE OF PELVIC HEMATOMA, 

exquisite ease, which came very early under Dr. fiasch's care, the 
temperature was for some time between 96° and 97° E., and 
never rose beyond the normal temperature. K we find, more- 
over, fainting, sudden ansemia, and rapid appearance of a doughy 
tumour near the womb, our diagnosis was clear enough. Dr« 
Basch had found that the womb, though displaced by the 
hematocele, was not so immovable as in cellulitis, and considered 
this a valuable difference in aid of a proper diagnosis. All these 
remarks, of course, were made with regard to those cases where 
no great inflammatory reaction had set in. Dr. Itasch had, until 
now, resisted the temptation to puncture the hsematocele, his 
cases getting better with rest and an ice bag in the beginning, 
both to counteract a further hemorrhage and inflammatory re- 
action ; and he thought it right not to interfere as long as there 
were no urgent symptoms to call for an incision. It would be 
interesting to know how far an incision had to account for the 
offensive discharges that have in some cases been observed. Dr. 
Easch had not seen such a case yet. 

Mr. Scott felt much obliged to Dr. Snow Beck for again 
bringing forward a subject of deep interest and much obscurity. 
The various opinions which had been expressed as to the true 
nature of the cases published as cases of hsBmatocele, indicated in 
some degree the difaculty of arriving at a correct diagnosis. He 
had seen cases in which, after a few liours of acute cellulitis, col- 
lections of fluid had taken place, which would have been difficult 
to distinguish from hematocele, and which yielded, on tapping, 
clear serous fluid onlv. If Mr. Scott understood Dr. ^Beck's 
aper aright, he stated that no regurgitation can occur from the 
ody of the uterus through the Fallopian tubes, unless there be 
complete occlusion of the os and cervix. Mr. Scott took excep- 
tion to that proposition, inasmuch as he thought it could not be 
doubted that in acute flexions, especially anteriorly, where 
dysmenorrhoDa was very marked, regurgitation through the 
!Fallopian tubes was very possible. If, as stated by Dr. Beck, all 
cases of hematocele arose from rupture of varicose veins of the 
uterus or its appendages, we should have to do mostly with £Ektal 
cases. 

Dr. Platpaib said that the question raised by Dr. Easch as to 
tbe differential diagnosis of pelvic hematocele and inflammatory 
affections in the neighbourhood of the uterus was one of great 
importance. Dr. Basch, however, it seemed to him, has fallen 
into a common mistake in talking of the affection to be diagnosed 
as " pelvic cellulitis." It was not in cases of true pelvic cellulitis, 
or peri-uterine phlegmon, or para-metritis, as they were otherwise 
called, that any difficulty arises ; th^ are generally sufficiently 
easy to distinguish from hematocele. But it is in pelvi-peritonitis, 
or peri-metritis that it is difficult to distinguish, and it is to be 



I 



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OK RETRO-UTERINE HEMATOCELE. 281 

regretted that the difference between the two classes of cases is 
even yet not sufficiently recognised. The points Dr. Basch 
seemed to rely on were, that in hsematocele the temperature was 
not heightened, the attack came on suddenly, with pain and shock, 
and the uterus remained freely moyable. The second point was 
unquestionably of great value, but he believed Dr. Basch to be 
mistaken in stating that the uterus remained movable in 
hematocele. It mi^t be so at a very early stage of the affection, 
but very soon after the blood was effused it would coagulate, and 
the uterus in the ^reat majority of cases became quite fixed and 
immovable. An important point, not mentioned by Dr. Basch, 
was that the uterus was apt to be much more displaced and 
pushed out of its central position in hematocele thiui in pedvi- 
peritonitis. With regard to treatment, he felt obliged to take 
exception to Dr. Beck's opinion, that it was frequency advisable 
to introduce the finger into the blood-sac after an opening had 
been formed, and forcibly break down and remove the contained 
clots. It was only quite exceptionally that this was necessary, 
and he believed it to be a practice attended with a certain 
amount of risk, and not to be carelessly or frequently adopted. 

Dr. Heywood Smith remarked that the points brought forward 
as to the differential diagnosis of pelvic hematocele were of great 
value. He did not think sufficient stress had been laid upon the 
information that may be elicited by the double touch or recto- 
vaginal examination. It was much to be remtted that Dr. 
Barnes' absence from the meeting prevented their hearing his 
explanation of certain points which had been put forward as 
discnrepancies b^ the author of the paper. In some of the cases 
quoted the vaginal examination seems to have been relinquished 
because of the youth of the patient or from excessive pain, and 
no mention is made of the result of the rectal examination. 
Mobility in itself should not be insisted upon as a point of value, 
as that might vary in degree according to the interval of time 
that had elapsed subsequent to the supervention of the symptoms. 
Doubtless a normal, or nearly normal, temperature is a mark of 
some value, as the presence of constitutional disturbance would 
point to other diseases. In cases of small ovarian cysts we might 
find similar conditions to those presented to us in pelvic hema- 
tocele, viz. a somewhat fluid, elastic swelling posteriorly and 
towards one side of the uterus, some mobihty of the uterus, 
together with low temperature. With regard to the soft portion 
referred to on the anterior aspect of the post-uterine swelling in 
these cases of hematocele, he asked if it might not be due to 
the interspace between the two portions of the sacro-uterine 
ligament. 

Dr. Skow Beck, in reply, said that he did not consider the 
questions of diagnosis between pelvic hematoma and pelvic cellu- 



282 CASE OF PELVIC HJBMATOMA. 

litia or pelvic peritonitis, because the paper was already too long, 
and these questions did not arise in the case recorded. There 
not bein^ any constitutional symptoms, the pulse quiet, and no 
lo<»l indications of inflammation, there would not be a question 
of either of these diseases. He was aware that effusions of blood 
in this situation had been called hssmatooeles from some supposed 
analogy between the reflections of the peritoneum in the female 
and the formation of the tunica vaginalis in the male, and that 
they were at first limited to effusions of blood into the cavity of 
the peritoneum, which must gravitate into the recto-uterine 
poucn. But effusions of blood also occurred outside the peri- 
toneum, and sometimes between the manv layers of the pelvic 
fascia, as he believed had taken place in the case first recorded. 
Hence pelvic hematoma appeared to be a better designation. 
He did not think those imaginary cases, where a small quantity 
of blood was supposed to be discharged from the Fallopian tubes 
into the peritoneum, could properly be considered as instances of 
disease. It was impossible to prove they ever took place, and 
equally impossible to disprove their occurrence. And if they did 
take place, the small amount of blood was readily absorbed 
without producing an^ inconvenience to the individual, and 
without calling for any mterference from the medical practitioner. 
With respect to waslung out the cavity left by the effusion after 
the blood had been evacuated, he did not see how this could be 
productive of any misdiief ; but, of course, it would only be 
employed in exceptional cases. He had in recolleetion a case 
where this was done apparently with much benefit. It was a 
considerable effusion, probablv into the cavity of the peritoneum, 
and after evacuation through the rectum, the discharge was 
offensive, with symptoms indicating injurious impregnation of the 
general system. A catheter was passed into the cavity through 
the rectum each daj, ai|d washed out with water and McDougal's 
carbolic fiuid, which was composed of carbolate of lime and 
sulphate of lime. During the use of this lotion the offensive 
discharge ceased, the cavity dried up, and the patient recovered, 
but, of course, other means were employed at the same time. 
"From the cases on record there could be no doubt that one of the 
litfffe and numerous veins in the pelvis was sometimes ruptured, 
and blood became effused. But there was no case record^, that 
he knew of, wMch showed that any fiexion of the uterus could 
produce sufficiently permanent obstruction to the escape of any 
blood through the orifice of the uterus, so as to cause aistension 
of the uterine cavities, and force the blood along the very small 
canals of the Fallopian tubes. 



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STATISTICS OF STILLBIRTHS. 283 



STATISTICS OF STILLBIRTHS. 
By Fred. W. Lowndes, M.R.C.S. Eng., 

HONOSIST ABSISTAHT SUBGBOH TO THB XJYBBPOOL LADIBS' OHABITY AND 
LTDTChDr HOSPITAL. 

The absence in this country of any registration of stillborn 
infants has often been regretted, but more, as it seems to me, 
on medico-legal than on any other grounds. Our art concerns 
the lives of two individuals; we have to a certain and very 
considerable extent, opportunities afforded to us of ascertaining 
how fiur the cultivation of obstetrics as a science and art has 
affected one of these individuals, and it is gratifying to know 
that maternal deaths during the puerperal period are much less 
than they used to be. Doubtless much remains yet to be done 
in this direction, aijid it must have struck most at those who 
read the ''Tables of Mortality after Obstetric Operations,'' 
published in this year's ' Transactions,' what a considmUa 
number of lives have been lost from want of timely assistance. 
I propose this evening to draw your attention to the case of 
the other individual whose life is entrusted to our care — 
I mean the infant. Statistics are doubtless dry and weary 
to wade through and write about, and perhaps still more 
weary to listen to; but as it is from statistics we have 
learned so much of what has been valuable material in 
enabling us to CqIIow out the old adage — '' Prevention better 
than cure,'' I make no further apology for so occupying 
your time, more especially as these statistics possess many 
features of interest, and are eispedally important and likely 
to be of practical use as the registration of stillbirths in 
this country is contemplated. But it is as affecting our 
practice that I wish to consider this subject, and especially 
as regards the more frequent employment of the forceps. 
Your late President, in his Annual Address, lays great stress 
on this point, and says, '' Unquestionably this Society has 
still work to do in urging this point on the attention of the 
profession." 



/Google 



284 



STATISTICS OP STILLBIRTHS. 



Let US first examine the statistics of stillbirths in those 
countries where a systematic registration of such obtains. 
In the 'Lancet' for 13th July^ 1869^ page 52^ is a medical 
annotation entitled '^ Stillborn/' giving the following in- 
teresting statistics of stillbirths in different Continental 
States — 



Netherlands 


. 5-64 per cent 


Belgium 




. 4-72 


** 


France 




. 4-63 


i$ 


Saxony 




. 4-49 


w 


Norway 




. 4-46 


n 


Prussia 




. 4-83 


9f 


Hanover 




. 4- 


»f 


Bavaria 




. 3-74 


a 


Italy 




. 1-94 


i3 


Austria 




• 1-64 


i9 


J j".»." 


1 j_j._*i_ . 


• ^» 


xl^ _ 



Some additional details are given respecting the numbers 
in Italy^ the proportion in which^ as will be seen, is lower 
than any other European State, except Austria. The total 
numbers are^ for the year 1864, as follows — 



Births . 


. 845,454 


Mort-n& (stillborn) 


. 14,209 


Of these latter the sexes were— 




Males 


8269 


Females . 


5940 


Or 138 males to 100 females. 




Legitimate stillbirths 


• 1*85 per cent. 


Illegitimate ,, 


. 6-59 „ 


Children found exposed 


. 2-61 „ 


All categories 


1*94 „ 



One cannot help being struck with the remarkable dis- 
crepancies in the above figures, taking the highest and 
lowest average; and at the same time with the great even- 
ness (so to speak) of the figures between these two extremes. 
Thus, in six different states the figures range from 4 to 4*72 



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STATISTICS OF STILLBIRTHS. 286 

per cent. The greater predominance of males over females 
is a matter well known to us^ and probably due to the larger 
size of male children. The greater number of illegitimate 
stillbirths is also a matter of note^ and just what we should 
expect to find when we consider the circumstances that 
generally attend the births of these unfortunates^ a secret 
delivery, the absence of many measures which would be 
adopted in the case of a legitimate infant^ and if not down- 
right unfair play by wilful omission^ certainly no regret on 
the part of those immediately concerned that the infant has 
not survived its birth. 

It must be remembered, however, that the arrangements 
prevalent on the Continent for the registration of stillbirths 
are not uniform. Thus, in 1867, the Paris Statistical Society, 
taking advantage of the presence in their city of savants and 
statists from all parts of the world, who were visiting the 
exhibition, proposed that at one of their public seances the 
following question should be discussed: ''What is under- 
stood by 'stillborn?' Should the term apply exclusively 
to infants born before, during, or within a specific interval 
after the accouchement, or should it include infants pre- 
sented dead for registration by the civil officer ? Does the 
number of stillborn increase proportionally to the total 
births? Admitting the increase of stillbirths, is that in- 
crease observable in towns and country alike V*^ 

From a paper published by M. Loua on the " Stillborn in 
Paris,'' in 1865, the following particulars are extracted : — 
In France it is the practice to include under the designation 
of mort-nA, not only infants bom dead, but also those born 
alive who die before the legal declaration of birth. The 
numbers were as follows : — 

Total number of births • . . 55,157 

Mort-nes ..... 4410 
Or 8 per cent. 

Number of conceptions . . . 59,567 

' 'Lancet,' Aog. 17, 1867, p. 202. 



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286 STATISTICS OF STILLBIRTHS. 

Or 108 conceptions to 100 births, and 7*4 stillbom to 100 
conceptions. 

From 1817 to 1863 the proportion of mort-nes to concep- 
tions had increased from 5*58 to 7*09, and in 1865 to 7*40 
per cent. Of the two sexes the males {hrnish by far the 
greatest number of mort-n^, and the issue of illegitimate 
connexions more than those of marriage. Thus, to every 
100 conceptions, of each sex there were 8'26 males and 6*48 
females stillbom; to every 100 legitimate births 6*70, and 
to 100 illegitimate births 8*53 stillbom. Another way of 
looking at these facts shows that taking 100 births of each 
class as the basis, there were 109 male, 107 female, 109 
illegitimate and 107 legitimate conceptions. The ratio of 
female to male mort-n£ was as 100 to 134. M. Loua 
notices that the stillbom seem to follow the order of general 
mortality in respect of their frequency in any season of the 
year; and he recognises in the coincidence of the maximum 
of mort-n^ with the acm^ of cholera the indirect action of 
that epidemic. He also notices that in nine times out of 
twelve the barometer is much lower at the dates when the 
births are most numerous than when they are fewest. He 
asks, '^ Faut il voir, dans ce fait, Tindice que les accouche- 
ments sont favoris^ par les jours pluvieux ?''^ 

The following particulars are furnished respecting the 
retums of mort-n^ in Paris so recently as June, 1871 
(which, it will be remembered, was soon after the termina- 
tion of the late war). 



Recorded during June, 1871. 
Total number of stillbirths . . .182 



Of these 4 were in the . 


. 3rd month 


4 


. 4th „ 


6 „ 


. 5th „ 


18 


. 6th „ 



' Lancet/ Jan. 6, 1867, p. 20. 



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STATISTICS OF STILLBIRTHS. 287 

27 were in the . • 7th month 

26 ^^ . • 8th f, 

13 cases period unknown. 

The large proportion of stillbirths in the ninth month is 
very remarkable and contrary to what we should expect 
under ordinary circumstances. Every one who has had any 
experience will^ I am sure^ agree with me that premature 
birth accounts for a larger proportion of stillbirths than any 
other cause. But considering the state of Paris shortly 
before these returns were published^ and remembering how 
much the life of the infant is affected by maternal impres- 
sions and other circumstances, I think we are justified in 
considering the above as exceptional. 

The following statistics are from the ' British and Foreign 
Medical Review/ page 593 : 

In Prussia the ratio of stillbirths 
Sweden ,, j, 

Saxony „ „ 

Hanover „ „ 

Mecklenberg-Schwerin „ 
Schleswig and Holstein „ 
St. Petersburgh, 1805 „ 
„ 1806 „ 

Russia generally „ 

These are very remarkable statistics : it would appear that 
the higher we ascend in the scale of civilisation the greater is 
the proportion of stillbirths. Appeuded to the above are the 
following additional particulars: — ''There are mcnre still- 
births of illegitimate than of legitimate children ; it has 
been calculated that where 8*166 per cent, of the legitimate 
are stillbirths, 4*959 of the illegitimate are stillbirths. 
According to the calculations of Bickes — 

Of legitimate male children 8*559 per cent, are stillborn. 
Ditto female ,, 2749 „ ,, 



3-29 per 


cent- 


2-64 


f> 


4-43 


99 


4-22 


99 


3-70 


99 


4-60 


99 


0-20 


99 


0-70 


99 


0-80 


9t 



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y 



288 STATISTICS OP STILLBIRTHS. 

Of illegitimate male children 5*277 per cent, are stillborn. 
Ditto female „ 4-682 „ „ 

During the twenty-five years — ^from 1801 to 1825 — ^the 
proportion of stillbirths to children bom alive, was in Leipsic^ 
1 to 17f . 

In 1822 it was— 

In the district of Liegritz, 1 to 15 

Amsberg, 1 to 28 

Coblentz, 1 to 27 

Elberfeld, 1 to 17 (about 16 per cent.) 
Magdeburg, 1 to 18 

Dusseldorf, 1 to 26 (about 4 per cent.) 

Minden, 1 to 37 

Stndsund, 1 to 44^ 

Erfurt, 1 to 30 

Mersebui^, 1 to 21 

Posen, 1 to 49 (about 2 per cent.) 

Paris, 1 to 30 

Saarlouis, 1 to 16 

Vienna, 1 to 36^J- 

In 1821 in Berlin, 1 to 19 

Gotha, 1 to 10 (exactly 10 per cent.) 

The highest average is thus 1 to 10, and the lowest 1 to 
49 ; the general average is about 1 to 20. 

Although from the want of a uniform system the above 
figures must be considered as open to exception, they suffice 
to show the necessity of a more uniform system. The great 
disproportions strongly suggest the question, '^ Whether 
stillbirths may not be considered to a considerable extent as 
preventible ?* 

Let us now examine the statistics of stillbirths in this 
country so far as we are in a position to do so. 

The first statistics to which I shall refer are those pub- 
lished by the late Dr. F. H. Ramsbotham in the appendix 
to his ' Obstetric Medicine and Surgery.' 



i 



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STATISTICS OF STILLBIRTHS. 



289 



Daring the period of 1828 to 1850 (both inclasive)^ being 
a period of twenty-three years^ the numbers were — 

Total number of children bom . . 49,538 

Of these there were bom alive . 47,716 

f, stillbom . • 1822 

Proportion 1 stillbirth to 26|th living births, or 8*678 per 
cent. 



Tern 




Total Urtba. 


Stillbirtha. 




Froportion. 


1828 


( • • 


2422 


106 




4-876 


1829 


!•• 


2230 


95 




4-26 


1830 


., 


2247 


79 




3-5 


1831 


... 


2179 


88 




404 


1832 


• •• 


2377 


90 




3-79 


1833 


» • • 


2641 


85 




3-218 


1834 


t •• 


2473 


79 




319 


1835 


• •• 


2327 


86 




3-7 


1836 


• •. 


2292 


9Q 




4- 


1837 


• •• 


2166 


87 




401 


1838 


> • • 


2161 


85 




4. 


1839 


• •• 


2097 


85 




405 


1840 


»•• 


2200 


80 




3-636 


1841 


• » 


2194 


87 




8-965 


1842 


• • 


2110 


69 




8-27 


1843 


» • • 


2025 


72 




3-555 


1844 


,. 


1959 


60 




3-062 


1845 


• • 


1842 


64 




3-474 


1846 


• • 


1800 


58 




3-222 


1847 


• • 


1767 


62 




8-509 


1848 


• • 


1987 


69 




8-47 


1849 


,. 


2166 


88 




4-065 


1850 


. • 


1887 


59 




8-13 


High 


est 


average, 4'37€ 


) ; lowest dittOj 


,3-062. 



The proportion of stillbirths is^ as will be seen, very low, 
much lower than the general average of those countries from 
which the details we have given above have been derived. I 
have given the numbers for each year of the whole period of 

VOL. XIV. 19 



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290 



STATISTICS OP STILLBIRTHS. 



twenty-three years^ and also made a calculation to show the 
▼arying percentage of the stillbirth ratio. It will be observed 
that the first year of the series famishes the highest average 
(4-876) y while the last year famishes the lowest average with 
one exception. 

Of the stillbirths— 
478 were premature 



230 


11 


putrid at full time 


253 


11 


breech presentations 


97 


>f 


transverse presentations 


50 


ff 


under placental presentations 


85 


9J 


ii accidental hsemorrhage 


17 


»» 


forceps cases 


60 


11 


craniotomy 


18 


93 


bom under convulsions 


62 


yj 


„ very lingering labour 


9 


3> 


^, ruptured uterus or vagina 


128 


J9 


,^ prolapsed funis 


11 


f9 


„ face presentation 


30 


99 


monstrous 



Although I have a very strong opinion that for a fully- 
matured child to be born dead when the head presents and 
there is no unnecessary delay is comparatively rare^ yet T 
cannot but consider the above figures as most exceptionally 
favorable. I look upon a mortality of 4 per cent, as the 
lowest we can reasonably expect even in these days^ where 
the more frequent and earlier application .of the forceps 
must conduce very much to a reduction of the number of 
infants bom dead. Of the above number the following must 
be considered as the numbers of unavoidable stillbirths : — 



Premature 


. 478 


Putrid 


. 280 


Placental presentations 


. 50 


Accidental htemorrhage 


. 85 


Craniotomy . 


. 60 


Ruptured uterus, &c. 


9 



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STATISTICS OP STILI"'" 



Prolapsed funis 
Monsters 



or a percentage of 2*159 on the tot 
derable proportion of the following 
partly unavoidable : — 



Breech presentations . 
Transverse 
Convulsions . 
Face presentations 



leaving the following as what may hi 
cases of stillbirths : — 

Forceps cases 

Very lingering labour 



Of course I am fully aware that 
exception. Thus^ premature birth 
not necessarily fatal to the infant ; 
had Dr. Bamsbotham been living 
small number of stillbirths might 
still. But I am here dealing with 
I am paying a proper tribute to the 
experience by presuming that eve 
exercised in order to preserve the 
mother. 

I will now give the statistics of tb 
in Charity as detailed by the 1 
* Reports ' of that hospital 1841 an 
tennial period comprises the years 1 
sive^ and the first few years show tfa 



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292 



STATISTICS OF STILLBIRTHS. 



Tem. 


Total birthf. 


StUllniths. 


Percentage. 


1838-4 


174 


18 


7-471 


1884-5 


478 


84 


7113 


1885-6 


680 


84 


5-4 


1886-7 


648 


26 


4043 



During the whole period of seven yean the numbers 
were — 



Children bom alive 
•• stillborn 



Total 



4432 
263 

4695 



the proportion being 5*6 of stillbirths to every 100 children 
born. Dr. Lever contrasts this with Dr. Collins' statistics 
of the Dublin Botunda Hospital, which show a percentage of 
6'7 in a total of 16^651 births^ and with Casper's statistics 
of foreign states which vary from 11 to 86 births for 1 still- 
birth. Dr. Lever proceeds to give the following details 
respecting the above 263 stillborn children : — 



Vertex presentations . 


ft yf^^uu. 




. 103 


Face 






6 


Premature labour 






40 


Breech presentations 






30 


Foot 






16 


Arm and shoulder 






8 


Arm with fiinis 






2 


Funis presentation . 






4 
7 
1 


„ with perforation 






Hydrocephalus 




* 


1 


Delivered by vectis . 






1 


„ forceps . 






5 


„ perforator 






24 


„ secale . 






4 



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STATISTICS OF STILLBIRTHS. 



293 



Ruptured uterus 

Flooding 

Twins 



3 
2 
6 



Total 



263 



The statistics of the second septennial period comprise the 
years 1840-47^ both inclusive, with the following results : — 



Children bom alive 
.. stillborn 



. 6805 
. 358 



Total 6658 

or at the rate' of 53 stilllHrths in a total of 100 births. The 
cause of stillbirth for the second period is as follows : — 

Second septennial period. 



Vertex presentations 


• 






186 


Pace 


, 






4 


Premature labours 


, 






19 


Perforation after induction of premature 


s labour 


2 


Breech presentations 








UQ 


Feet . . . 








25 


Knee 








1 


Shoulder and arm 








5 


Arm and funis 








3 


Funis 








7 


Placenta . 








5 


Thorax . 








1 


Vectis 








1 


Forceps . 








e 


Perforator 








32 


Flooding before delivery . 








] 


Convulsions „ 








5 


Twins 








20 


Triplets . 






Total 


1 
353 




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294 



STATISTICS OF STILLBIRTHS. 



There is^ as will be seen^ a slight improvement in the 
ratio of stillbirths for the latter period^ though only at the 
rate of *03 per cent. It seems to me that the rate of infan- 
tile mortality must be very considerably affected by the 
treatment adopted in the second stage of labour; if pro- 
longed^ the result must be hazardous to the child. 

Let us look at the proportion of cases^ where the foreq[>8 
were applied^ in Dr. Bamsbotham and Lever's statistics 
repectively. 





ToUl birthi. 


Fbrcepi 
caset. 


Children 
living. 


Childran 
dead. 


Royal MateinityChtfity 

Gny's LyiDg-in dittos first septen- 
nial period «•..•.* 


49,588 
4^6d6 
6,668 


73 

9 

23 


56 

4 
17 


17 
5 


Ditto, ditto, second septennial 
period 


6 






Total 


60,891 


106 


77 


28 







Let us now turn from the statistics of town practice to 
those of country practitioners. Very candid and full ones 
are given in the 'Lancet' for 12th November, 1859, by the late 
Dr. B. Uvedale West, to whose memory so graseful a tribute 
was paid by your late President in his annual address. The 
lubject we are now considering attracted considerable atten- 
ion thirteen years ago, and the following passage occurs in 
I leading article of the ' Lancet ' for the 22nd October in that 
^ear 1869. 

'' In the Dublin Lying-in Hospital a record is preeorved of 
itillbirths, and the important distinction is noted between 
children bom dead and those bom dead and putrid. During 
}even years the proportion of stillbirths in this institution 
was 1 in 14. Of the total number as nearly as posmble one 
balf were both dead and putrid ; but hospital practice is but 
% fallacious test of what obtains in the homes of the popula- 
bion. Thus, in a clinical report of the Royal Maternity 



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STATISTICS OF STILLBIRTHS. 



295 



Charity of London^ addressed by Dr. Barnes to the Dublin 
Obstetrical Society^ in which this question is examined^ it is 
shown that in the practice of this Charity the stillbirths 
stood in the proportion of 1 in 34 only/' (This it will be 
seen is a lower rate than that given by Dr. Bamsbotham as 
existing nine years previously^ where the rate was 1 in 27.) 
The article proceeds^ *^ Taking this as the basis of his calcu- 
lation he estimated that there were not less than 2658 still- 
births annually in Jjondon^ no account being taken of abor- 
tions. It is an object of the highest importance to test'this 
conclusion by comparison with the experience of other insti- 
tutions^ and still better with the experience of private practi- 
tioners. If a certain body of medical men^ such as those who 
constitute the Obstetricid Society of London, would collect 
their individual results^ we might at once be in possession of 
facts on a scale sufficiently large to be enabled to define with, 
some precision the prevalent rate of stillbirths.'^ In oonse* 
quence of the above remarks Dr. West published his statistics. 



Total births. 


. 2998 


Stillbirths .... 


111 


Or 1 in 27, or 3-7029 per cent. 




Of these 111 stillbirths there were:— 




Putrid at birth 


. 50 


Craniotomy cases 

Footling cases . 

Funis prolapsed 

Placenta prwvia 

Protracted labours left to nature 


. 8 
. 7 
. 7 
3 
. 6 


Forceps cases . 

Monstrosity 

Accidentally suffocated before arrival . 

Imperfectly developed head . 

Anasaroous and ascitic 


. 2 
. 2 
, 2 
.2 
. 1 


Hemorrhage during labour . 
Convulsions ^i » • 


. 4 
. 2 


Latent compression of funis 
Arm presentation and turning 


. 1 
. 1 



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296 STATISTICS OF STILLBIRTHS. 

Mothers moribund . .3 

Placenta putrid or diseased . .3 

No apparent cause . . .7 

Total . Ill 

In the concluding paragraph Dr. West^ with a candour 
which reflects the greatest honour on his memory^ says, 
** I have thought it important in the study of the causes and 
frequency of the mortality of childr^i during labour to 
insert in my taUe the number of each case. It may thus 
be seen at a glance how far the inexperience of a young 
practitioner may contribute to an increase of such mortality. 
Let us for example examine the number of cases oi cranio- 
tomy. It wiU be seen that all the cases that I was exclusively 
responsible for fall within the first 1000. How far a gradu- 
ally acquired ability in the use oi the vectis and forceps 
may have enabled me to discard this wilful murder firom my 
practice I leave to the judgment of my readers^ pointing out 
at the same time that pari passu with what I may call the 
abolition of craniotomy^ or at any rate the greatly diminished 
frequency of the practice, the fcetal mortality from unassisted 
protracted labour disappears also from my practice. These 

are matters for grave consideration I have 

fearlessly and without any extenuation given my experience 
of stillbirths, as invited by the leading article quoted. It is 
obvious that nothing but a sense of public duty, and a regard 
for the interests of absolute truth, can have induced me to 
parade, as I have here done, the shortcomings of my early 
career — ' lAberavi animam meam* '* 

•A percentage of 4 per cent, is, according to Dr. West, 
the highest proportion which average county practices should 
exhibit. Dr. West's example was followed by Dr. Anderson 
Smith,^ who gives a percentage of 4*924 stillbirths out of a 
total of 1320— 

1 * LanceV Nov. 1% 1859, p. 481. 



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STATISTICS OF STILLBIRTHS. 



297 



Total births 
Stillbirths . 
Or 4*924 per cent. 

Forceps cases . 
Craniotomy • 
Version 



1820 



25 
3 

4 



Cauies of Stillbirth. 

Putrid . 

Malpresentation and position 
Prolapsed fimis 
Craniotomy . 
Haemorrhage before delivery 
Compound presentation 
Premature 
Unaccounted for 



24 
10 
6 
3 
10 
1 
5 
6 



Total 



65 



The relative proportion of living and dead children deli- 
vered by the forceps is not stated. 



By Mr. Hadaway^ who shows a ratio of 10 per cent, in 732 
cases — 

Total births in the five years 1855*9, both inclusive 732 

72 



stillborn . 


. 


• • 


• • 


Or 10 per cent. 








Detailed as follows — 






Tw. 




Birth*. 


Staibirthi. 


1855 




93 


6 


1856 




139 


16 


1857 




171 


20 


1858 




169 


18 


1859 




170 


la 



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298 



STATISTICS OF trTILLBIRTBS. 



Causes of the 12 stillbirths tn 1859. 

Premature (seventh month) . .4 

Footling and cord . • 1 

Supposed fright to mother . . .2 

Unknown . . . . .5 

Total . 12 



Mr. Lamhden, who gives a ratio of 3*319 in 482 



Tear. 
1855 
1856 
1857 
1858 
1859 



Birth*. 

90 
114 

88 
101 

89 



Stillbirtiia. 
4 
1 
2 
3 
6 



482 
Or 8-819 per cent. 

Details of the above 16 cases of stillbirth : 
1855 Putrid 



1856 
1867 

1858 



1859 



Turning 
No cause 

Putrid 

Arm and fiinis 
Placenta pnevia 

Placenta pnevia 
No cause 
Turning 

Putrid 
No cause 
Version 



16 



1 
2 
1 

1 

I 
1 

1 
1 
1 

8 
2 
1 



Dr. Smith cites his number of forceps cases, 25 in 1320^ 
as high, but states that no ill effect followed. I think we 



k 



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STATISTICS OF STILLBIRTHS. 299 

are all agreed that a much higher percentage of forceps 
cases would not only fail to startle us^ but would very pro- 
bably enable us to dispense with unaccounted cases altogether, 
or considerably to reduce their number. 

To sum up the results of the foregoing we find that conti- 
nental statistics give a general average of rather less than 
5 per cent., which must be considered small when we re- 
member that this ratio includes abortions in some countries, 
and premature children bom alive in others ; while in the 
statistics of British practice, which I have been able to 
procure, the stillbirths, pure and simple, range from 8 up to 
10 per cent. I have already alluded to the small number of 
forceps cases in the statistics given by Dr. Bamsbothamj of 
the Maternity Charity practice, and by Dr. Lever, of those 
of the Guy's Lying-in Charity. The former gentleman 
attributes 62 stillbirths as due to '' very lingering labour,'' 
and it is lamentable to contemplate the fact that of 49,588 
births the forceps cases numbered only 78, while the cases of 
craniotomy reached 60. Again, Dr. Lever gave us 9 cases 
of forceps and 24 cases of craniotomy in 4695 births ; while 
in 6658 births he gives 28 cases of forceps and 82 of crani- 
otomy. Out of the first series we have 108, out of the 
second 186, together 289 stillbirths where the vertex pre- 
sented, which were neither forceps nor craniotomy cases, and 
which were, no doubt, cases of lingering labour. From Dr. 
Churchill's statistics I find that the forceps cases in British 
practice were as 1 in 171 ; in French practice^ 1 in 140; in 
Oerman practice, 1 in 106; and the results to the children 
bom are shown as follows : 





Forceps cases. Children lost 


PereeDtage, 


Dr. Ridler . 


. 4228 ... 


684 


• . • 


16197 


Dr. Siebold 


. 812 ... 


47 


• • a 


15064 


Dr. Harper 


. 302 ... 


43 


... 


14-238 


Dr. . 


. 232 ... 


28 


• •• 


1207 


Drs. Johnston 


and 








Sinclair 


200 ... 


29 


• • a 


14-5 


Prof. Schwerer 


. 194 ... 


48 


• • . 


24-472 



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300 



STATISTICS OF STILLBIRTHS. 



Dr. Beatty, senior 
Madame Boivin . 
Dr. Pagan . 
Madame Lachapelle 
Dr. F. Ramsbotham 
Dr. Smellie . 
Dr. Boberton 
Dr. B. Lee 
Dr. Ameth 
Mr. Smart 
Dr. Brunatti 
Dr. Lawrence 
Dr. Merriman 
Dr. Bitgen 
Dr. Boer 
Mr. Perfect 



Forceps caaes. Children lost. Percentage. 



Ill 
96 
82 
79 
73 
52 
43 
42 
45 
30 
23 
28 
21 
20 
19 
18 



Drs. Hardy and M'Clintock 18 
Dr. Hall Davis . 15 

Edinburgh Lying-in 

Hospital . . 15 

Dr. Churchill . 9 





20 

19 

23 

17 

9 

7 

31 

14 

13 

6 

4 

6 

4 

5 

4 

8 

3 

5 




20-883 

231708 

29114 

23-287 

17-308 

16-28 

73-81 

31111 

43-333 

26-08 

14-285 

28-571 

20- 

26-816 
22-222 

20- 

83-333 



It will be seen at a glance that^ with few exceptions^ 
the percentage is lowest where the number of forceps 
'^-^es is the highest^ and Mr. Harper has shown this very 
adusively in a paper read before this Society thirteen 
urs ago on '^ The Use of the Forceps as a Means of Lessen- 
l Mortality/' The results to the children are thus 
[nmarised by Mr. Harper^ who contrasts his practice with 
eit of Drs. Collins^ Hardy^ and Johnstone respectively : 



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STATISTICS OF STILLBIRTHS. 



301 



Forceps caaei. 


FoBtal deaths. 




Forceps duration. 


Collins 1 in G94 


Iin26 
1 „ 20 
1 ,. 35 
1 .. 47 


lin 329 
1 „ 334 
1 .. 502 
1 „ 1490 


38 hours. 


Hardy 1 in 355 


35i „ 
29i ,. 
16 


Johnston 1 in 60 


Haroer 1 in 26 







I have preferred to give the results of practitioners of 
experience in preference to any of my own, which comprises 
too small a number of cases and too short a period upon 
which to form data. But, speaking generally, I may say 
that I have invariably been able to account for stillbirth after 
a labour at the full time with a vertex presentation, by delay 
in seeking medical assistance, and I hope on a future occasion 
to bring the results of my experience before this Society. 
But for the present I think enough has been said to show 
conclusively that a more frequent employment of the forceps 
must tend to reduce the number of children stillborn. 

From inquiries I have made at the local cemeteries and 
burial grounds I find that the number of stillborn infants 
annually interred there amounts to at least 6 per cent, on 
the total number of births occurring annually within the 
borough, but this must be considered as below the actual 
number, as it must be impossible for any one but an o£Bcial 
inquirer to acquire full and accurate information. 

I have already stated that the registration of stillbirths in 
this country is contemplated and under the consideration of 
the president of the Local Government Board. I trust that 
the Fellows of this Society will agree with me that it behoves 
us to anticipate this proposed measure, and make such 
suggestions as shall enhance the value of the returns made. 
The registration of stillbirths is desirable on three grounds — 
1, medico-legal; 2, obstetrical; 8, statistical; which maybe 
again subdivided as follows : 



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802 . STATISTICS OF STILLBIRTHS. 

1. Medico-legal. 

(a) To place a check upon abortion^ foeticide and 
child murder^ by preventing the burial of any stillborn 
infant unless full particulars of the birth were furnished 
to the district registrar. 

{b) To prevent frauds upon the authorities at ceme- 
teries and burial grounds by false certificates of still- 
birth. 

2. Obstetrical. 

(c) To enable us to judge of how far stillbirths are 
preventible by 

{d) The proportionate ratio in the practice of 
medical men and midwives^ and the qualifications of 
the latter ; 

(e) The relative ratio in town and country, and in 
different districts of the same town and country ; 

(/) The proportion of stillbirths due to syphilis ; 

(ff) The effects of premature, protracted, complex, 
and instrumental labour upon the stillbirth rate. 

3. Statistical. 

(A) To obtain more accurate returns than at pre- 
sent is possible of children actually bom living or 
dead. At present children bom liring are interred aa 
stillborn to an extent quite unknown, and sufficient 
to make a considerable difference in the returns of 
birth. 

(i) To enable us to compare our returns with those 
of continental and other states. 

Many other advantages may be looked for from this pro- 
posed amendment of our Registration Act, but the above 
are sufficient to recommend it to the legislature on the one 
hand and to ourselves on the other, as calculated to afford us 
material of great use to us in an obstetric point of view. I 
hope the subject will be considered of sufficient importance to 
justify me in asking that a committee may be formed of 
Fellows of the Society, whose duty it shall be to collect 



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STATISTICS OF STILLBIRTHS. 303 

statistics of stillbirths as at present known ; to consider how 
the proposed registration may be effected so as to ensure all 
the desired information ; to suggest the necessary forms of 
certificates for medical practitioners and midwives ; and to 
urge upon the President of the Local Gtoyernment Board 
that no further delay may take place in securing for the 
country by compulsory measures the registration of all births 
whether of living or of dead children. 



Dr. Plaivaib said that it was to be regretted that the late 
hour of the evening did not admit of a proper discussion of Mr. 
Lowndes' paper, since no subject was more worthy of the con- 
sideration of the Society. The paper was a most valuable one, 
displaying much labour and research. It was unfortunate that, 
in considering the statistics of private practice, the author had 
overlooked the very remarkable results obtained by Dr. Hamilton, 
of Falkirk, which would have materially stren^bened his posi- 
tion that the number of stillbirths diminished in exact ratio to 
the frequency with which the forceps were applied. That gentle- 
man habitually used the forceps in about the ratio of one to every 
seven or eight labours, and he has obtained the entirely un- 
precedented result of as many as 731 consecutive labours without 
a single stillbirth. When we compare this with the average 
fcBtal mortality of 4 per cent., which Mr. Lowndes arrives at, the 
result is startung inaeed, and seems to point strongly to the con- 
clusion that many fcetal lives are sacrificed to a neecUess dread of 
timel;^ interference. He (Dr. Flayfair) believed that the modern 
teaching, that the labour should not be allowed to drag on many 
weary hours in the second stage, was thoroughly correct, and if 
more developed, would materially diminish the general average of 
infantile mortality, without in any way increasing the risk to the 
mother. 



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NOVEMBER 6th, 1872. 

John Bbaxton Hicks, M.D., F.B.S., President, in the 
Chair. 

Present— 50 Fellows and 8 Visitors. 

Books were presented by Dr. Lombe Atthill, Dr. Graily 
Hewitt, Dr. F. Hogg, R.H.A., Dr. Lloyd Roberts, Mr. 
Spencer Wells, Dr. Emil Noeggerath, Dr. F. Verardini, the 
Clinical Society, the Royal College of Surgeons, &c. 

The following gentlemen were elected Fellows of the 
Society: Arthur H. W. Ayling, L.S.A.; Albert F. Meld, 
M.R.C.S.; Henry Harris, M.D., Redruth; George Men- 
denhall, M.D., Cindnnatti; and Joseph Szczygielski, 
Warsaw. 



TUMOUR OF THE UTERUS COMPLICATING 
PREGNANCY. 

By J. Lucas Worship, Esq. 

C. C — , set. 85, married two years and a half. Generally 
enjoyed good health. Has lost eight brothers and sisters in 
early life. Has five sisters living, all at present in good 
health, and having, many of them, large families. Can trace 
no history in her family, on either paternal or maternal side, 
of any tumour or cancer. 

VOL. XIV. 20 



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306 TUMOUR OF THE UTERUS COMPLICATING PREGNANCY. 

Six months after her marriage had very severe pain in the 
left iliac fossa ; there was no enlai^ement^ and^ although at 
times the pain was yery acnte, she continued in service^ acting 
as charwoman^ and sought no medical advice. Last catamenial 
period five months ago, August Ist. Three months ago observed 
slight enlargement of the abdomen, but did not think she was 
pregnant, and the pain became much worse. She now saw a 
medical man who, I believe, considered her to be suffering 
from ovarian disease. I saw her on August 1st, the abdomen 
was then the size of a woman in the seventh month of preg- 
nancy. I examined her per vaginam and failed to discover 
anything abnormal ; the os uteri was very high up and back 
towards the sacrum, the cervix was not elongated, and I did 
not think she was pregnant. The mammae showed no signs of 
enlargement nor any increase of areola round the nipple. She 
could only lie on her left side, and her only complaint was of 
the acute pain in the left groin, difficulty in breathing, and 
constant vomiting. Pressing the tumour laterally it gave 
one the impression of a solid mass, quite inelastic and very 
painful to the touch. I thought there was little doubt, from 
the rapidity of its growth and the intense pain, that it was a 
malignant tumour of the left ovary. 

Beyond giving her morphia and medicine to try and allay 
the sickness, I adopted no treatment, feeling sure that 
beyond alleviating pain no good could either be done by 
medicine or surgery* 

She gradually became worse and worse, retaining nothing 
many minutes on her stomach, and often the character of the 
matter ejected was stercoraceous and exceedingly offensive. 
She was much emaciated and died on October 4th. 

On October 6th, in the presence of my friends Messrs. 
Thompson and Fearless, I made a post-mortem examination. 
On opening the abdomen we found a large tumour, reaching 
from the pubis to the diaphragm, of a yellowish colour and 
of the shape of an hourglass, the upper division being very 
much larger than the lower. We took out the uterus as the 
specimen here shows, and found the os uteri filled with 
the usual plug of pregnancy, and on slitting up the organ 



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TUMOUR OP THE UTERUS COMPLICATING PREGNANCY. 307 

found an unruptured bag of liquor amnii of a deep clarety 
colour, and the foetus in it. The skin of the foetus appeared 
shrivelled, as if it had been dead some little time. On the pos- 
terior surface of the uterus are some solid tumours. We then 
made an incision into the tumour, which was very tough and 
full of cysts containing a greenish^ viscid fluid. The ovaria 
appeared healthy and in their natural positions^ but very 
small. 

The Frbsidekt referred to a case of labour complicated with a 
large fibroma, attended by Mr. D. Taylor, in which the labour 
was perfectly normal. 

Dr. I^iLLiPS said that large fibroid masses at the fundus 
uteri generally interfered materially with efficient uterine action. 
The specimen exhibited was interesting as another illustration of 
the difficulty of diagnosing between fibrocystic disease of the 
uterus and multilocular ovarian tumour. He asked whether 
fibrocystic tumours of the uterus had ever been noticed to sup- 
purate and discharge at regular intervals. There was now at 
Guy's, under his care, a case of uterine tumour extending high 
above the umbilicus but at intervals, generally of about four or 
six months there was a profuse discharge of blood and then of 
pus, and the tumour dimmished to about half its size. The sub- 
sequent increase was gradual, and a similar increase and decrease 
had been noticed on several occasions, as the patient has been 
under observation for some years. 

Dr. Fbotheboe Smith said, to aid Dr. Phillips's inquiry as to 
the probable escape per vaginam of the fluid contents of fibro- 
cystic growths of toe uterus, he would mention by way of illustra- 
tion three cases, the first was a patient of Dr. Blackburn of St. 
Bartholomew's Hospital who had a single abdominal tumour 
which became diminished in size and tension on the escape of con- 
siderable quantities of watery discharge per vaginam at irregular 
intervals. Having left town without any alteration in her case 
he lost sight of her. Another patient afflicted with the same 
aymptoms of hydrometra of the uterus measured four inches by 
ten round, has experienced a like increase and diminution of a 
tumour continuous with the uterus which at one time reaches to 
the umbilicus and at another is felt only two inches above the 
pubes, and the condition has existed more or less for seventeen 
years. The third case, with much less uterine enlargement, gave 
a similar history, but though admitted into the Hospital for 
Women for three months there was during this time no aischarge 
of water. In these and other cases, however, he had not the 
opportunity of ascertaining the fact by autopsy. 



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808 PESSARY FOR FLEXIONS OF THE UTERUS. 

Dr. Wynn Williams exhibited a pessary for fhe treat- 
ment of flexions of the aterus^ more especially ante- and 
latero-flexions. He was led to adopt the mode of treatment 
recommended through hearing the late Dr. Beaty^ of Dublin^ 
at the meeting of the British Association at Plymouth^ re- 
commend after the introduction of a stem into the uterus 
the placing of a round boxwood pessary for it to rest upon in 
the vagina^ which preyented the extrusion of the stem^ and 
on which it moved in a circular groove. This mode of pro- 
cedure Dr. Wynn Williams found very inconvenient. The 
introduction of the boxwood pessary into the vagina of a 
virgin was no easy matter, and when there you could not 
ascertain the exact position of the stem and consequently of 
the uterus. To obviate this Dr. Wynn Williams got Messrs. 
Krohne and Sesemann to fit a diaphragm of india rubber, so 
as to fill up the centre of an ordinary Hodge's pessary^ or^ if 
preferred^ Dr. Greenhalgh's modified Hodge. The one exhi- 
bited is Dr. Greenhalgh's^ and in the unmarried it is certainly 
the one to be selected on account of its being much more 
readily introduced. Having adopted the usual measures and 
introduced a stem according to the fancy of the operator (the 
one used by Dr. Wynn Williams being a simple light vul- 
canite one), the pessary exhibited is introduced and placed 
in front of the stem. The position of the uterus can be 
readily ascertained by feeling the button of the septum 
through the india-rubber septum, and if too high can be 
easily coaxed downwards by the finger, and vice versd. The 
septum makes a very safe elastic bed for the button of the 
stem to rest upon, and when fixed in position the depression 
made by the button prevents any movement beyond that 
allowed by the elasticity of the thin septum of india rubber. 
The retention of the discharge is obviated by perforations in 
the diaphragm. 

Mr. Scott thought the instrument an ingenious one, but had 
himself used with success a simple Hodge's pessary for the 
purpose of keeping the os in the required axis after the intro- 
duction of an intra-uterine stem in cases of ante- or retro- 
flexion. 



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I 



PIBB( 



308* 



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309* 






i 



neugkbauer'b speculum, {p. 309.) 



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EXTRA-UTERINE GESTATION. S09 

Dr. Barnes exhibited a fibrous tumour the size of a large 
orange which he had removed a fortnight before from the 
anterior wall of the vagina. Its attachment began just 
above the meatus urinarius^ extending along the course of 
the anterior wall, but leaving a space of an inch quite clear 
below the os uteri. It had been extended outside the vulva. 
It was removed at St. Thomas's Hospital by the galvano- 
caustic wire. The woman did perfectly well. It was shown 
as an example of a comparatively rare affection. 

Dr. Barnes also exhibited a modification of Neugebauer's 
speculum, which he had devised to obviate one or two 
practical objections to Neugebauer's excellent instrument. 



REMARKS ON THE TREATMENT OF SOME FORMS 

OP EXTRA-UTERINE GESTATION, 

WITH A CASE. 

By Alfred Meadows, M.D., 

PHYSIOIAir-AOCOUOHlUB TO, Ain> LBOTVBSB OK MIDWIVBBT AT, ST. HABT'S 
HOSPITAL; PHT8I0IAK TO THB HOSPITAL POB WOMBK. 

In the last volume of our ' Transactions' I recorded a 
case of extra-uterine fetation of the so-called ventral variety^ 
and in the remarks which I made in regard to the treatment 
of that condition^ I advocated more frequent resort to surgical 
interference in the way of gastrotomy^ not ao much in order 
to arrest hsemoirhage^ and so to try and rescue the patient 
from a perilous condition^ in those cades where rupture of the 
cyst has occurred^ but rather with the object of anticipating 
that rupture, and of averting the calamity which generally 
happens under these circumstances. I may remind the 
Society that in the case referred to a so-called ventral preg- 
nancy was diagnosed during life and was revealed by post- 
mortem examination ; rupture occurred at about the eighth 



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310 TREATMENT OF SOME FORMS OF 

month of gestation^ death from haemorrhage resulted, and it 
was then found that the placenta was formed by or upon the 
enormously hypertrophied fimbriated extremity of one of the 
Fallopian tubes, part of which had burst. My contention 
was that, in such a case, as well as in many others of the 
tubal variety, the obstetric rule should be, when once the 
diagnosis is clearly established, to open the abdominal 
cavity, and treat the case surgically, as we would do an 
ovarian or other tumour where removal was possible, the 
avowed object being to anticipate and so to avert the 
almost inevitably fatal rupture of the cyst and death firom 
haemorrhage. On that occasion I expressed my intention, 
should any similar case occur to me, of following this practice. 
Such a case has occurred and is the subject of this com- 
munication, and although in my absence it came under the 
care of my colleagues. Dr. Squarey and Mr. Scott, they have 
kindly agreed to my bringing it under the notice of the 
Society, in order that I may again advocate what I sug- 
gested last year ; with, however, some modifications which 
the experience of this case seems to me to support. 

It may appear strange that I should bring forward a case 
in which I had only a nominal share ; but instances of the 
kind fall so seldom to the lot of any of us, that were I to wait 
for another, it may be that I should have no opportunity of 
suggesting what I now do; and if there be any worth in the 
proposal others may perchance be inclined to adopt it, in the 
event of any similar case occurring in their practice* 

The case is as follows : 

E. F — came to me as an out-patient at the Hospital for 
Women, March 22nd, 1872. She was 23 years of age, had 
been married two years, but had had no children, and since 
her marriage had suffered rather severely during menstrua- 
tion ; it was for this she came to the hospital. On examining 
per vaginam I found that the uterus was rather low in the 
pelvis, the cervix being near the vulvar orifice, while the 
fundus was directed to the sacral cavity ; there was slight 
retrofiexion ; the os was small and circular, and the parts 
generally were rather tender. 



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EXTRA-UTERINE GESTATION. 311 

On April 5th she came again^ when the following note 
was made : '^ Last menstruation was very profuse ; since the 
last visit pain has been severe ; expects the catamenia in a 
week/' She did not come to the hospital after that, but I 
learned jbhat the expected catamenial period did not occur, 
nor did it afterwards reappear. Her subsequent history is 
thus described by Dr. Macpherson^ of Mildmay Park, under 
whose care she was. He writes," On the 12th May she had 
severe abdominal pain which lasted about a week. On 
recovering she felt remarkably well up to September 25th, 
when she called on me at my house complaining of pain. 
This continued at intervals, but was at first unaccompanied by 
fever. The abdomen was tender to the touch, and there was a 
slight red discharge — just a drain at intervals. The pain was 
not continuous at first ; there was vomiting ; the bowels and 
bladder acted freely and easily. From the time when I first 
saw her I noticed that the tumour in the abdomen could 
easily be pushed up by pressure with the finger in the vagina, 
but it gradually came back again on to the finger. The 
small swelling noticed in front was not always present to the 
eye.*' 

As the patient continued to get worse, Dr. Macpherson 
sent for me, and in my absence Dr. Squarey went on the 5th 
of October, 1872. From him I received the following notes. 
Since the cessation of the catamenia in March last the 
patient has suffered more or less constantly from cramping 
pains in the abdomen ; from that date she noticed also that 
the abdomen has steadily increased in size, and she herself 
believed that she was pregnant ; at first she was very sick, 
and has been so more or less throughout : from the frequency 
of the cramp-like pains she had for some time thought that 
things were not quite straight. When first seen by Dr. 
Squarey she was suffering most intense pain in the abdomen, 
and this had been going on since September 26th, though it 
was much worse when Dr. Squarey was consulted. 

On examination the abdomen was much distended and of 
an oval shape ; there was dulness over the whole anterior 
surface of the abdomen up to within two or three inches of 



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312 TREATMENT OP SOME FORMS OV 

the enaiform cartilage, where it was resonant, as also in both 
flanks ; no fluctuation existed low down on the left side; the 
abdomen was seen to become locally prominent every now 
and then^ when the pain was severe. On careful manipula- 
tion of this swelling a small tumour could be distinctly felt 
there ; it was slightly movable from side to side^ and seemed 
to roll a little over the larger and deeper tumour. The 
smaller swelling was believed to be the uterus enlarged^ but 
the abdomen was altogether so tense and tender that no solid 
mass could be diagnosed per vaginam ; a hard and at first 
somewhat elastic mass could be felt filling the whole of the 
posterior part of the pelvis, and pushing the uterus forwards 
against the pubes. The hard mass to the left was movable 
to some extent, but pressure caused so much pain that this 
was not thoroughly tested. The cervix uteri was soft and 
spongy as in pregnancy, the os was patulous^ and the iSnger 
could be passed in some distance within the cervix ; while 
there the tumour behind the uterus could be distinctly felt, 
and gave the impression of being entirely outside the nterus. 
The breasts were somewhat enlai^ed and the areolar changes 
distinct. 

The diagnosis arrived at was extra-uterine pregnancy, 
founded upon the size of the abdomen, the absence of the 
catamenia, the constitutional disturbance, and the vaginal 
examination. The mass behind the uterus was believed to 
be the foetal head. 

By Dr. Sqnarey's advice the patient was at once admitted 
into the Hospitid for Women, and, not wishing himsdif to 
operate, should an operation be deemed advisable, he sent for 
my colleague, Mr. Scott, who, finding the patient compara^ 
tively free from pain under the influence of a subcutaneous 
injection of morphia, determined to wait for a time. A 
careful examination was, however, made of the condition of 
the abdomen, the result of which was to confirm in all 
essentials, the diagnosis arrived at by Dr. Squarey. No 
foetal heart could anywhere be heard, but a loud bruit 
synchronous with the maternal pulse was audible over the 
right side of the abdomen. 



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EXTRA-UTERINE GESTATION. 313 

In a few hoars' time the effect of the morphia passed off, and 
very severe pains of a distinctly intermitting character^ like 
those of labour^ came on. During these pains the tumour in 
the vagina became so very tense as to suggest the probability 
of its rupturing. The uterine sound vras used^ and the uterus 
found to measure fully five inches, the sound passing in the 
direction of the tumour on the left side of the abdomen, 
where its point could be distinctly felt. After anxious con- 
sultation^ the condition of the patient being indicative of 
extreme peril, it was decided to perform gastrotomy with the 
view of recovering the foetus and its containing cyst. The 
patient was accordingly placed under chloroform, and a free 
incision was made through the abdominal parietes a little to 
the right of the mesial line, so as to avoid what was believed 
to be the uterus on the left. On opening the abdomen the 
uterus was exposed, lying in front and to the left of the 
gravid cyst, and it was seen to contract firmly and regularly 
as if in labour. The cyst was adherent along the whole right 
side of the uterus by means of a firm fleshy band, but on the 
left side the hand could be easily passed between it and the 
cyst. The latter was seen to be intensely vascular, and 
though adherent to the abdominal wall the adhesions were 
but slight and were easily broken down^ though the bleeding 
which followed was so free as to cause very alarming symp- 
toms; several vessels — chiefly veins — ^had to be tied during this 
part of the operation. An incision was then made into the 
cyst^ and a well- formed living foetus was removed^ having 
all the characters of at least seven months' gestation. 
The ftinis was tied in the usual way, and on examination 
the placenta was found attached deep down in the cyst 
in the direction of Douglas's pouchy and on the right 
side. After some difficulty it was removed^ but the 
haemorrhage during this time was so severe that at one time 
it was feared the patient would not survive the operation. It 
was observed, however^ that as soon as the placenta was 
detadied all bleeding ceased^ though it seems doubtful 
whether this was due to the detachment^ or whether it 
resulted firom the syncopal condition of the patient consequent 



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314 TREATMENT OP SOME PORMS OF 

upon the loss of blood. An attempt was now made to re- 
move the cyst^ but this could only be partially effected and 
that with very great difficulty ; a large part of the cyst was 
necessarily left owing to the firmer adhesions to the intestines^ 
to the uterus^ and to the pelvic wall. The cavity was now 
carefully cleared out, the CKlges of the abdominal wound were 
brought together in the usual way, and the patient put to 
bed, stimulants being freely administered. The shock, how- 
ever, was so severe and the haemorrhage so excessive that 
consciousness hardly returned, and the patient sank five 
hours after the operation. The child died next day. 

A post-mortem examination showed little or nothing more 
than had been made out during the operation. No haemor- 
rhage had occurred after it; death was, therefore, the result 
of shock and of the loss sustained in the operation. The 
cyst which had contained the foetus was situated, as before 
described, on the right of the uterus, and was formed below 
by Douglas's pouch, where the placenta had been attached. 
The uterus, much enlarged in all directions and measuring 
fully five inches in length, was pushed to the left of the 
pelvis ; the ovary and Fallopian tube on the left side were 
perfectly normal. Those on the right side had been removed 
with part of the cyst during the operation, but it seemed 
likely that the right Fallopian tube had been in some way 
involved in the accident, as the portion which still remained 
was so dilated that its uterine orifice readily admitted the 
passage of the sound. The mucous membrane of the uterus, 
especially about the fundus and upper part of the body, was 
enormously hypertrophied so as to look almost like a duster 
of mucous polypi. 

Remarks. — ^Now, it may perhaps be thought that the only 
lesson to be learnt by this case, distressingly sad as it is in 
every aspect, is that it would be far wiser under similar 
circumstances not to interfere, at least not by any surgical 
proceeding, and certainly not to resort to gastrotomy. That, 
on the contrary, the rule should be to stand by and wait, 
until either rupture has occurred and the life of the patient 
is in imminent danger, when and when only gastrotomy 



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EXTRA-UTERINE GESTATION. 315 

sfaoold be performed ; or else that we should try to temporise^ 
combat the eflfects of the shock of rupture^ if rupture occurs^ 
in the hope that^ after the death of the foetus^ it may again, 
if it has before escaped into the peritoneal cavity, become 
encysted in the process of inflammation, and gradually be 
absorbed — so far, at least, as that is possible ; or, lastly, if 
happily rupture does not occur, and nature, as we call it, 
msikes no violent effort to rid the patient of her unnatural 
offspring, then we may hope that time will render that 
innocuous, and recovery ensue, though it be the work of 
years. 

Of course either of these three courses is open to us, and 
each will probably have advocates, because much may be 
urged in its favour. I believe that the operation which was 
performed in the case just related was in strict accordance 
with obstetric rule ; the patients sufferings were extremely 
severe, rupture was threatening, severe haemorrhage must 
then have ensued, and no one can pretend to say that under 
such circumstances the patient's chances of life would have 
been better than they were by resorting to the operation 
before the rupture occurred. But, if the danger to the patient 
in the performance of gastrotomy be, as I contend it is, 
considerably greater after than before the occurrence of 
rupture, there is another and, to my mind, a very cogent 
reason why this operation ought not to be delayedi namely, 
the hope liiat in the one case we may rescue a living child, 
while in the other there is very small chance of it. To me 
it seems an imperative duty that when we know we have not 
only a living but, according to all experience, a viable child, 
say at the seventh month and upwards, we should do our 
very utmost to rescue that life from its position of danger; 

and I do not think we are justified by the very sb " *^ 

of recoveries in cases where the foetus has remai 
abdomen, in standing by and doing nothing. 

If, then, resort to gastrotomy is to be, as I ho 
recognised and orthodox rule, in all cases c 
central or other form of extra-uterine pregnane} 
child is living and has arrived at what is termed i 



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316 TREATMENT OP SOME FORMS OF 

it becomes a question of the deepest importance to know 
whether we can by any means lessen the formidaUe character 
of the operation and diminish its fatality. I believe that 
we can, and in the following way. It will be, perhaps, in 
the recollection of some of the Fellows that, when speaking 
on this question last year, I threw ont the suggestion that 
inasmuch as after the removal of the foetus there is no longer 
any physiological necessity or use for the placenta, we might 
safely leave this to be afterwards atrophied and absorbed, 
taking care to tie the cord and cut it off as near to its attach- 
ment as possible. I advocated this on the ground that by 
so doing we should obviate one of the greatest, if not the 
greatest, source of danger, viz. the haemorrhage which results 
from the attempt to detach it. Since I made this suggestion 
I have thought much about it, and I still fail to see any 
valid reason against at least making the experiment. The 
experience of this last case has led me still further in this 
direction. There cannot be a doubt, I think, that this poor 
woman died of haemorrhage; much of that haemorrhage 
came from the placental surface, but a great deal of it also 
came firom the attempt which was made to remove the cyst 
in which the foetus had been developed ; a great part of that 
cyst was removed, but much still remained, and I believe it 
will be found probably in every case absolutely impossible to 
remove it all. It is this great danger resulting from the 
adhesions which exist everywhere in all directions, and the 
attempt to separate which has always added so enormously 
to the difficulties of the operation, and to its danger from 
haemorrhage, that has, I believe, deterred most operators from 
resorting to it. Why not then make a virtue of a necessity, 
and leave it alone ? I see no reason why this should not be^ 
and surely if we can trust some cases to the absorption of 
all the absorbable part of the foetus itself, i fortiori may we 
leave the highly organised cyst and the still more highly 
organised placenta to the same process. It seems to me that 
this high organisation is a strong point in favour of this 
method, because it would probably favour absorption, and 
maintain its vitality till that process were completed. It 



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KXTRA-UTEBINB GESTATION. 317 

needs no argument to prove that if this suggestion be at all 
feasible^ and if experience should demonstrate its practicability, 
the operation of gastrotomy will not only be the rule, but it 
will be one which can be carried out with the greatest ease, 
for it will present, comparatively speaking, few difficulties 
and will be shorn of its greatest danger. It will only be 
necessary to make the incision through the abdominal wall, 
then through the cyst, remove the foetus, tie and cut the cord 
as near the placenta as is convenient, remove any bloody or 
other fluid, taking great care not in the least to detach or 
otherwise disturb the placenta, secure any vessels that may 
be cut in the incision, and close up the wound in the ordinary 
way, as after ovariotomy, treating the patient subsequently 
in the same manner. 

Should this method not be found to answer, it might be a 
question whether the abdomen, with the cyst attached to the 
edges of the wound, should not be left open. The former 
plan, however, seems to me to offer the best chance of a 
successful issue ; and I trust if the occasion occurs to any 
of the Fellows they may be willing to put it in practice, pro- 
vided that what I have said in its favour commends itself 
to their judgment as it certainly does to mine. 

Note. — Since writing the above my attention has been 
called to a paper by Mr. Cooke on a case of uterine and 
extra-uterine pregnancy, progressing simultaneously to the full 
period of gestation, in the fifth volume of our ' Transactions,' 
in which it is suggested '* whether, supposing the existence of 
extensive adhesions to be admitted, it is advisable to remove 
the foetus with the prospect of some portion of the liquor 
amnii, finding its way into the peritoneal cavity, and with 
the possibility of the placenta becoming encysted (the cord 
being brought through the abdominal incision), an^ ^-^-- 
thrown off at a future period.*' And in the discussio 
followed it was suggested by our present President 
Braxton Hicks) that in cases where the child was li^ 
would be an important question whether it should 
recovered by abdominal section, in the manner sugg 



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318 TREATMENT OF SOME FORMS OF 

the above paper^ stitcliing the edges of the opening of the 
cyst to those of the outer wound before removing the child, 
leaving the placenta to come away of itself." It thus appears 
that an idea something similar to, but not identical with, 
the suggestion I now make has occurred to others before. 
I venture to think, however, that my proposal to close up 
the abdomen after extraction of the child, and to leave both 
cyst and placenta to future atrophy and absorption, offers 
a better chance of success, is in strict accord with the teach- 
ings of physiology, and does no violence to any known 
pathological law. As such I trust its adoption may hereafter 
be found practicable. 



Mr. Scott. — In the case under discussion the danger of rap- 
ture of the cyst was imminent. As to the nature of the opera- 
tion which should be performed in a similar case of advanced 
foBtation, looking at the extensive and firm character of the 
adhesions in every direction, he had no hesitation in giving his 
entire approval to Dr. Meadows' view as far as leaving the cyst 
was concerned. With regard to the placenta he did not feel so 
assured. It was a remarkable fact in this case, which he could 
not explain, that after the entire removal of the placenta all 
bleeding within the cyst ceased. 

The PBESTDEirr observed that in a previous discussion he had 
pointed out the danger of removing the cyst, and that in three cases 
m which he had operated the foetus only had been removed. 

Dr. Murray thought there was too much risk incurred in 
completely closing the abdominal opening and leaving the pla- 
centa behind without any chance of escape. In the case reported 
there seemed no doubt that the cyst containing the foetus showed 
signs of contraction ; it might therefore be fairly presumed that 
the same contractions noticed might continue after the removal 
of the foetus, and by this means the placenta could be partially 
or whollv separated, and give rise to serious trouble and danger. 
He would certainly prefer leaving an openine; with the umbilical 
cord passing through it, similar to the method of dealing with 
the pedicle m ovariotomy when it is clamped, which would meet 
fully and more safely the difficulty in question. 

Dr. Basnsb observed that Dr. Meadows' case was scarcely 
required in order to prove that the removal of the cyst or 

?lacenta was bad practice. This had been settled by experience. 
)r. Eamsbotham especially insisted upon this at an operation 
performed by his advice in the London Hospital by Mr. Adams 



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BXTRA'UTBaiNS GESTATION. 319 

at which Dr. Barnes was present. The placenta was left un- 
touched, and the woman made a good recovery. The adhesions 
of the placenta to intestines was often so intimate, there heing 
sometimes no definite sac, that the attempt to detach it must 
necessarily inyoke considerahle risk, and experience has shown 
that, if left in nt4, it would be removed safely by natural pro- 
cesses. 

Dr. Pbotheboe Smith said that Dr. Meadows justifies his 
plea for the adoption of gastrotomy in t^e cases under dis- 
cussion, when the child is viable, by the hope of saving one if 
not two lives which are imperilled, and he fully admitted the 
correctness of his conclusion. Dr. Barnes had, however, remarked 
that under any circumstances demanding such surgical inter- 
ference, the less done the better. Agreeing to some extent with 
this observation. Dr. Frotheroe Smith begged to make another 
suggestion by which we may rationally ho^ to aid those natural 
efforts to effect that process by which this abnormal condition 
has been often brought to a favorable issue. The bulk of the 
swelling and the tension of the cyst may be easily reduced by the 
use of the aspirator without risk of the admission of air ; and 
thus, bv a very simple operation devoid of all danger, one is 
enabled to aid that compression of the foetus and its appendages 
which is best calculated to lead to those changes and results 
which are known to terminate in restored health to the patient. 

Dr. Madob said that in extra-uterine pregnancy the placenta 
was bound by adhesions to the part to which it was fixed. To 
break up these adhesions by forcibly separating the placenta and 
exposing the enlarged and highly congested vessels in apposition 
with its maternal surface, would — from hsmorrhage into the 
abdominal cavity — itself be sufficient to cause death. He there- 
fore strongly urged that in future operations of a similar nature 
the placental attachment should be left undisturbed. 

Dr. Snow Beob: observed that on looking at the preparation 
the right Eallopian tube was divided about the middle, and 
inquired what had become of the outer half, when it was stated 
the tube had been ligatured and the outer half removed with the 
cyst at the time of the operation. He remarked that the uterus 
and Fallopian tubes were lined by a tissue which appeared to be 
suiaenerii, and it was a question whether any other tissue of the 
body would respond to the stimulus of the impregnated ovum, 
and form the maternal portion of the placenta. Should this 
view on further observation be found to be correct, it resulted 
that there was but one form of extra-uterine fcstation, which 
would occur in some part of the Eallopian tube. Not unfre- 
quently the ovum was arrested at the fimbriated extremity, 
when the fimbriie became enormously enlarged, formed the 
principal part of the sac, and the inner surface was developed 



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320 TREATMENT OF SOME FORMS OF 

into the maternal portion of the placenta. This took place in 
the ** Case of Extra-TJterine Q^tation,'* reported by Dr. A. 
Meadows in vol. ziii of the 'Transactions.' Sometimes the 
ovum escaped from the Fallopian tube as it became developKed 
and lay loose in the cayitj of the abdomen surrounded by its 
membranes, as in the '' Case of Uterine and Eztra-TJterine 
(Fimbrial) Pregnancy " reported by Mr. L. E. Cook in vol. v 
of the ' Ihransactions/ where '^ the placenta occupied the inner 
surface of the fimbria of the right Fallopian tube which had 
expanded into a shallow capsule for its attachment, leaving the 
containing membranes of the foetus free from any covering " 
(p. 150). In the present case it was probable that the fimbriated 
end of the tube was expanded over, and formed part of, the 
containing sac, which formation would account for the tension 
observed in the contained fluid and caused by the contraction of 
the contractile tissue of the tube. This tension, which was 
described as resembling the tension of the membranes during a 
contraction of the uterus, would be difficult to account for 
unless the sac contained some contractile tissue, which was pro- 
bably derived from the Fallopian tube, as no development of the 
cellular or fibrous tissue in the neighbourhood would produce 
the effect described. If this explanation was correct^ then 
the tissue at the inner surface of the tube would be developed 
and form the maternal portion of the placenta, as in the 
preceding cases referred to. 

Dr. Wykn Williams considered it advisable in all cases to 
follow the operations of nature as closely as may be ; on various 
occasions nature has got rid of the more solid parts of the foetus 
such as the bones, &c., by the several outlets of the body, the soft 
}art8, such as the sac and placenta, forming a harmless mass. The 
)lau recommended by the President would appear to be the 
learest approach to what nature does and tne most feasible, 
lamely, to remove the foetus, not to interfere with the placenta, 
md to stitch the walls of the sac to the sides of the incision in 
;he abdominal walls, taking care to pass the stitches through the 
)eritoneum as in ovariotomy. There would then be a communi- 
»tion with the sac for the escape of any offensive matter, whilst 
;he peritoneum would be completely protected from external 
nflueoces. 

Dr. Phillips, while admitting that simple tapping had been 
[uccessful in some cases, feared from what was Known of the 
lecreting power of the amnion that it would not in all cases be 
kufficient ; and even if it led to the death of the foetus, the 
shild's body had still to be disposed of by long and exhausting, 
hough occasionally very successful processes. 

Dr. Edib remarked that there was one mode of procedure that 
lad not been alluded to, and that was incision through the vagina 



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CtTRA-tTERINE OESfATtOK. 821 

And extraction of the fcetus by means of the forceps. In the case 
under consideration the head was situated low down in the pelvis 
in Douglas's pouch, within easy reach, and in any similar case he 
thought it would be well to bear in mind the possibiUty of deliver- 
ing by this means — the advantage being that the general cavity 
of the peritoneum would not be interfered with and so one impor- 
tant source of danger avoided. The placenta might be left, and 
should subsequent separal^on of it ensue, its extraction could be 
readily accomplished. The vaginal wound should be kept patent, 
and the cyst injected with some disinfectant. Dr. OreenhaJgh had 
recorded a case where he extracted a dead fcstus, some months 
after the full period of gestation, in this manner. The cyst con- 
tracted gradually and the patient recovered peHectly. 

Dr. WiLTSHiBE was sorry to hear Dr. Meadows say he would 
close the abdominal wound after gastrotomy for extra-uterine 
fotation. He thought such a procedure open to grave objec- 
tion, since no means of escape were provided for discharges 
or decomposing placental or other tissues. He considered 
Kcdberle's plan decidedly preferable. It consisted in leaving an 
opening at the inferior angle of the wound through which dis- 
charges or disintegrated tissues might escape or be removed ; or if 
the closure of the abdominal wound was insisted on, then some 
means of escape through the roof of the vagina might be resorted 
to. Or there was Peaslee's plan of treating some ovarian cases 
which might be found useful, viz. washing out the cavity by 
means of salt and water, a drachm to a pint. Dr. Wiltshire gave 
particulars of a case of his own where he had intended operating, 
but the cyst burst and, after a sharp attack of peritonitis, the 
patient recovered. 

Dr. Meadows was very much surprised at the statement made 
by Dr. Barnes that the practice advocated in the paper had long 
been the recognised and established rule. If this were so^ 
it was very remarkable that no obstetric writer that he knew 
of laid down any such rule; and certauoly the one Dr. Barnes 
had quoted as favorable to the practice in question, vis. 
Dr. Kamsbotham, was absolutely silent on the subject, if 
indeed he did not actually discountenance it. Dr. Meadows 
regretted, therefore, that Dr. Barnes had given no reference to 
authorities where the supposed rule existed; he was glad, however, 
to find such a general concurrence of opinion as ute paper had 
elicited in favour of the practice recommended, at all events as 
regards the desirability of performing gastrotomy before the 
occurrence of rupture, m order to anticipate that, and at the same 
time to rescue, if possible, the life of the child. He believed, with 
Dr. Snow Beck, that in the majority of these cases the placenta 
was attached to the fimbria or some part of the Fallopian tube, but 
in the case now cited, though this might hare been so in part^ it 

VOL. XIV. 21 



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822 TREATMENT OF EXTEA-tTTERlNE GESTATION. 

certainly was not altogether, for the great bulk of the placenta 
had been attached to, and, during the oneration was removed from, 
the interior of the cyst deep dovm in Douglas's pouch, and quite 
independent of the Fallopian tube. 



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DECEMBER 4th, 1872. 

John Braxton Hicks, M.D., F.R.S., President, in the 
Chair. 

Present — 54 Fellows and 11 Visitors. 

Books were presented by Dr. Arthur Parre, Dr. Demarquay, 
Dr. F. M. Robertson, Dr. W. M. H. Sanger, Dr. Henry Ply 
Smith, the Royal Medical and Chirurgical Society, the St. 
Andrew^s Medical Graduates' Association, and St. Bartho- 
lomew's Hospital. 

Dr. Joseph McMonagle (St. John's, New Brunswick) was 
admitted as a Fellow of the Society. 

The following gentlemen were declared admitted: — Dr. 
Henry Harris, Redruth ; Mr. E. M. James, Melbourne ; Dr. 
George Mendenhall, CiDCinnati, U.S.; Mr. Wm. Bailey 
Rankin, Melbourne; and Dr. Joseph Szczygielski, Warsaw. ; 

The following gentlemen were elected Fellows of 
Society : — Edward Nicholls Carless, M.B., Devizes ; Jame 
Lovegrove, M.R.C.S., Sevenoaks; Charles SaDgster,M.R.C 
John Williams, M.D., and Rt. A. H. Wood, M.R.C 
Liverpool. 

Dr. Wiltshire exhibited, for Mr. Liiwson Tait, a c 
containing instruments for the application of various mc 
cated tents to the interior of the cervix uteri. 



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324 CABCINOMA UTERt. 



Report on Dr. Protheroe Smith's case of Carcinoma Uteri. 

On coming into my hands I find the preparation has been 
kept for a few weeks in a weak solution of chromic acid^ and 
some portions are not well preserred. It consists of the 
uterus and its appendages. The weight of the whole is six 
ounces. Length of uterus^ 3^ inches; width at fundus^ 
3 inches ; peritoneal covering everywhere smooth and healthy. 
Ovaries small and shrivelled ; on laying them open the only 
morbid appearance is a small cyst in the stroma of the left, 
containing a little dark cretaceous matter^ apparently the 
remains of an ovisac. Fallopian tubes natural in appearance^ 
open at their fimbriated extremities^ but closed for about an 
inch at their uterine. Ligaments free from thickenings or 
adhesions. On turning the uterus inside out the whole of its 
internal surface, except the neck^ appears to be the seat of 
disease^ the darker spots and appearances being probably 
owing to some of the remedies employed ; surface torn and 
uneven ; in some places there are bulging masses not unlike 
the post-mortem appearances of cauliflower excrescence. 
Near the fundus the mucous membrane and the subjacent 
uterine tissues have been destroyed by disease nearly through 
to the peritoneal covering ; other parts of the uterine walls 
are abnormally thick ; on the posterior aspect of the uterus 
there are two small subperitoneal nodules^ and towards the 
left side a larger nodule; the diseased surface terminates 
abruptly at the os internum. After removing portions of the 
preparation for microscopical examination^ it was placed in 
Goadby^s solution. 

Microscopical examination, — The bulging masses spoken 
of appear to be made up of a variety of elementSj such as 
are usually met with in cases of epithelioma^ namely^ minute 
granules^ oil-globules^ epithelial cells^ and other cells of an 
irregular and nondescript character, and a little earthy matter^ 
all contained in a stroma of connective tissue. The thicken- 
ing of the walls of the uterus and even the small nodules 



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BEMOYAL OF TBS PLACSNTA^ ETC. S25 

mehtionedj as far as can be made out with the microscope^ 
appear to be due rather to inflammatory infiltration and 
fibrinous deposit than to any special morbid elements. The 
state of chronic metritis that the organ had been so long 
subject to woidd seem to favour this opinion. Looking at 
the history in connection with the foregoing examination 
the case appears to me to be one of rare occurrence^ that is, 
epithelial cancer attacking the lining mucous membrane of 
the body of the uterus, and destroying portions of the 
uterine substance without affecting the cervix. 

Henry M. Mapge, 



NOTE ON THE MODE OF DEALING WITH THE 
PLACENTA WHERE GASTROTOMY IS PER- 
FORMED IN ORDER TO REMOVE THE FOETUS 
IN EXTRA-UTERINE GESTATION. 

By Robert Barnes, M.D. 

Before resorting to the operation of gastrotomy in cases of 
extra-uterine gestation it is of grave importance to have 
settled opinions as to what to do with the placenta. Having 
studied the subject with some care, I had acquired the con- 
viction that it had become generally recognised as a rule in 
practice not to attempt the removal of the placenta if it at all 
adhered. It was therefore with some surprise that I heard 
Dr. Meadows^s description^of an operation for gastrotomy to 
remove a living fostus, in which he not only removed the 
placenta, but tried to remove the cyst also. My surpri 
was increased on hearing, not that he had arrived at the co; 
elusion that the placenta ought not to be removed, for li 
own case led irresistibly to that conclusion, but that 1 
laid it down as a rule in practice which was new. 

In reply to my observations on this point. Dr. Meadoi 



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826 EEMOVAL OF THE PLACENTA 

expressed his surprise at my statement that it was an already 
recognised rule in practice not to touch the placenta, and 
that there was no mention of it in Dr. Bamsbotham's works, 
whose authority I had quoted. 

It would appear from this diflference of opinion that the 
propriety of leaving the placenta alone is not yet fully recog- 
nised. It is with the desire to remove all doubt upon this 
point that I trouble the Society with this note. 

My statement was based upon the following grounds, some 
of which I expressed to the Society : 

1. A perusal and comparison of the recorded cases of 
gastrotomy in extra-uterine gestation could not fail to con- 
vince the reader that the attempt to remove the placenta 
had proved disastrous, whilst leaving it alone had been 
followed by fair success. 

2. Most of the recent operators, acting, as it seemed to me, 
on the conclusion thus drawn, had taken care not to touch 
the placenta. This was certainly so in the case operated 
upon by Mr. Adams under Dr. Ramsbotham's advice. I 
freely accept Dr. Meadows's statement that the rule is not 
expressed in Bamsbotham's writings. I did not quote from 
his writings ; I spoke, having been his colleague, from having 
assisted at the consultation and operation on the case referred 
to. The operation was performed on Dr. Ramsbotham's 
diagnosis, on his advice, and under his direction throughout. 
He emphatically insisted that the placenta should not be 
touched, and the patient's recovery shows the wisdom of his 
advice. 

3. The case was published by Mr. Adams in the ' Medico- 
Chirurgical Transactions' for 1860. The following apposite re- 
marks are quoted from this report : — ^' The only circumstance 
in connection with the operation requiring particular remark 
— and I believe the observation refers to almost all cases of gas- 
trotomy for extra-uterine gestation — ^relates to the placenta. 
From the few recorded cases of the operation it appears that 
wherever any rude attempts have been made to extract the 
placenta the cases have invariably been fatal. Nevertheless 
it ought to be examined by very gentle traction of the funis. 



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IN EXTIU-UTERINE GESTATION. 837 

to see if it is loose and can be removed with facility^ other- 
wise it is better to leave it alone^ with the hope that it will 
be separated and come away in the discharges. Dr. Barnes^ 
in the quarterly report on midwifery in the fifty-second 
volume of the 'British and Foreign Medico-Chirurgical 
Review/ quotes a case of extra-uterine gestation operated upon 

by Dr. Goodbrake, of Clinton^ Illinois The operation 

was performed exactly two years and nine months from the 
end of her full period. The sac was traced to the right iliac 
fossa^ to which^ and to a considerable extent of the parietal 
peritoneum on the right side^ it was firmly adherent. There 
were no adhesions anteriorly, nor to the intestines. A small 
incision was made into the sac, and a foetus was found in a 
good state of preservation. The cord was still attached to a 
very small placenta, of a cartilaginous character, seated low 
down in the pelvis, and immediately over the space where 
the sac was adherent to the broad ligament. The cord and 
as much of the placenta and sac as could be got away without 
lacerating the peritoneum were removed, the parts carefully 
sponged, and the incision brought together by the interrupted 
suture. The patient died on the fifth day from prostration. 
I cannot,'' concludes Mr. Adams, ''conceive this violent 
procedure to be justifiable/' 

4. In 1860, subsequently to the occurrence of the case of 
Bamsbotham and Adams, Mr. Hutchinson collected all the 
cases accessible to him, and published them in an exhaustive 
series of reports in the ' Medical Times and Gazette/ He 
discusses the question of operating whilst the foetus is living, 
describing this as the primary operation, and concludes with 
Campbell in favour of deferring the operation until some 
months after the child's death. As to the placenta, he con- 
cludes as follows : — ^" The lesson of facts is very strongly in 
favour of the precept laid down by Dr. Bamsbotham in Mr. 
Adams's recent case — ^not to remove the placenta unless the 
latter structure be found quite loose." 

Again, this accomplished surgeon, in his article " Surgical 
Measures in Extra-uterine Pregnancy," in the first edition 
of Holmes'^ System of Surgery/ published in 1864, says. 



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S28 ESMOYAL OF THE PLACENTA 

Unless tlte placenta be found detached^ it ought not to be 
removed^ but left to come away afterwards. The attempts 
to detach it might very possibly tear through the cyst, and 
open into the peritoneal cavity/' 

Hohlj in his ' Lehrbuch der Geburtshiilfe/ second edition, 
1862, a work of high authority in Germany, says, with 
reference to the primary operation, that '^gastrotomy is only to 
be performed when the foetus is mature, when the heart-beat 
declares it to be in vigorous life, and when the mother has 
made up her mind for the operation, and her condition 
during pregnancy and at the time justifies the hope of 
recovery/* With reference to the placenta, he says, " Most 
obstetric practitioners teach in this case to separate and 
remove the parts which can be detached. We are not of this 
opinion. As to the consequences, it is indifferent whether 
only a part or the whole placenta remain behind. When 
the ovum is surrounded by a firm sac one would do well to 
leave it untouched, when it cannot be easily removed because 
the surrounding parts are intimately adhering to it. 

In a recent excellent monograph (1872) on the subject. 
Dr. Keller, first relating two cases operated upon by Koeberle, 
of Strasbourg, in both of which this eminent surgeon 
designedly left the placenta in siiit, and both of which ended 
in recovery, thus expresses himself on the question of how to 
deal with the placenta : — " In gastrotomy for extra-uterine 
gestation none of the favorable conditions present in Caesarian 
section (which dictate removal of placenta) are present. 
The placenta is almost always much spread out, and some- 
times very adherent. Moreover, if the extraction of the 
placenta were possible, would it be prudent to effect it ? The 
placental insertion is not endowed with contractility, as in 
uterine gestation ; the maternal sinuses will remain gaping, 
and haemorrhage will be great. This objection (to gastro- 
tomy whilst the child is living) loses some of its force if the 
attachments of the placenta are religiously respected, as the 
greater number of operators have understood the necessity 
for doing. (Cette objection tombe en partie si Ton a soin de 
religieusement respecter les attaches du placenta, comme du 



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IN EXTEA-UTBRINE GSSTAO'ION. 829 

reste I'ont compris la plupart des op^rateun.) The elimina- 
tion is thus effected slowlv, and the maternal vessels have 
time to contract and to become obliterated/' From this 
passage it will be seen that Keller^ who reproduces Koeberl^'s 
views on l:he subject^ argues for the primary operation^ and 
shows that^ in this operation^ as others have done in the case 
of the secondary operation/ the placenta should not be 
touched. Indeed^ if it be unwise to meddle with the placenta 
in cases where the child has long been dead^ and where con- 
sequently all active vascularity has ceased^ ^ fortiori is it 
unwise to meddle with it when the vascular communication 
is at the height of activity. 

I trust the preceding quotations are sufficient to show that, 
at least since I860, the date of Bamsbotham's and Adams's 
case, there has been a general consent as to the rule not to 
touch the placenta when gastrotomy is performed to remove 
a foetus, dead or alive. I admit that my own decided opinion 
upon the subject is greatly based upon this case, and my 
respect for Bamsbotham's judgment, which I knew was 
based upon experience. It could not be expected that Dr. 
Meadows should be so deeply impressed by this experience 
as I am. It is, however, gratifying to find that his own 
experience has led him to the same conclusion ; and he will 
not, perhaps, regret to find that he is amply supported by the 
experience and judgment of many eminent men, although 
they have anticipated him in his conclusion. 



Dr. MsADOWB was very glad that Dr. Barnes had brought 
this subject again under the notice of the Society in the note 
just read, and he wished to thank him for the courteous way in 
which he had referred to his (Dr. Meadows's) paper, and also for 
kindly allowing him to read the note before Drmging it to the 
Society. Dr. Meadows*s sole object in introducing this subject 
would, he felt quite sure, now be attained by the discussion 
which his paper had elicited, and by the authoritative expression 
of opinion that the correct practice in these cases is to leave the 
placenta alone, and to make no attempt whatever to remove it. 
He was convinced that the great danger hitherto attending the 
operation of gastrotomy in these cases was due to the attempt 



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380 BBMOVAL OF THE PLACENTA^ ETC. 

made to remoye the placenta ; if this were once recognised as 
bad and unnecessary practice, then he was sure that gastrotomj 
would become the rule in all cases of extra-uterine pregnancy 
where a living and viable child existed, and the lives of many 
children would thus be saved which now are allowed to be lost. 
It was, after all, a matter of very small importance who first 
advocated such practice, or who attempted its revival after it had 
become obsolete ; the highest ambition of us all is the grand 
object of saving life, and without that this Society would have 
no raUon iPStre, In view of such a thought he cared very little 
whether or no the practice inculcated was or was not laid down 
in any of our obstetric works, especially as he had no doubt that 
after this discussion it would be expressly formulated. To this 
end Dr. Barnes's note was a most valuable contribution, for it 
showed conclusively that the practice advocated was sound and 
true. Dr. Meadows felt constrained, however, in justice to him- 
self, to repeat his former statement that no obstetric writer that 
he knew of had expressly laid down the rule now sought to be 
established in any work on midwifery. Dr. Barnes's note was, 
he thought, conclusive as to the practice in cases where the 
foetus was dead, but in nearly all of them the operation was not 
only not attempted, but was intentionally deferred till after the 
death of the child, and this appeared to be the rule that was 
generallj adopted. In the few cases where gastrotomy was per- 
formed m oraer to save the child attempts had generally been 
made to remove the placenta, and this had led to such fearful 
hemorrhage that the practice had been generally abandoned. 
It was in order to obviate this that he (Dr. Meadows) had 
brought forward his paper. With reference to the note just 
read by Dr. Barnes, there occurred two important errors which he 
would notice. In the first place, he (Dr. Meadows) had not 
operated in the case which he had brought forward ; the operation 
was performed in his absence by his colleague, Mr. Scott; 
secondly, Dr. Barnes appeared to think that Mr. Hutchin- 
son had, in his report and in his article in ' Holmes's Surgery,* 
considered the whole subject of the treatment of the placenta in 
all cases where gastrotomy was performed for extra-uterine foeta- 
tion, whether tne child was living or dead. This, however, is 
not the case. His report is " On the Treatment of Cases of 
Extra-TJterine FoDtation extending beyond the full period of 
Pregnancy," and he expressly limits it to those cases where the 
foDtus had died. The terms " primary " and *' secondary " he 
thus explains : — '^ In all the cases given in the first table suppura- 
tion had occurred in the cyst, and the operation consisted in 
enlarging the opening already made by ulceration and then 
extracting the foetus. Operations of this class may suitably be 
termed * secondary ' abdominal section, the term * primary ' being 



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SYSTEMATIC EXAMINATION OF THE ABDOMEN. 331 

resepyed for those of the class contained in the second table, in 
which no abscess had jet opened. ^No cases have been included 
in either table in which the foBtus had not advanced to nearly its 
full time before death, and in a large majority the natural period 
had been completed." All his remarks subsequently show that 
he only contemplated the performance of gastrotomy in cases 
where the foBtus was already dead, and his report was limited to 
them ; he expressly states, indeed, that " whoever will carefully 
examine the cases will come to the conclusion that the longer the 
interval allowed to elapse between the death of the foQtus and 
the operation the less is the risk attending the latter." It was 
important to note this as it had a bearing upon the point in 
dispute between Dr. Barnes and himself, and though Dr. 
Meadows entirely concurred in Dr. Barnes's opinion that if it be 
sound practice to leave the placenta in cases where the foatus is 
dead, a fortiori is it where the foetus is living; still, the fact 
remained that, so far as he knew, this practice had nowhere been 
explicitly advocated. He had no doubt, however, that when this 
discussion became widely known it would soon be added to the 
precepts of our obstetric text-books. 



ON THE SYSTEMATIC EXAMINATION OF THE 
ABDOMEN, WITH VIEW TO RECTIFYING MAL- 
POSITIONS OF THE F(ETUS IN CASES OF 
LABOUR. 

By Arthur W. Edis, 

rnYSIOIAN TO THB BBITISH LYIKG-nr HOSPITAL, ENDELL STBEBT ; ASSIBIAST 
rnYSICIAN TO TUB HOSPITAL FOB WOMEN, BOHO SQUABB. 

In bringing this subject prominently before the attention 
of the Society, it is not with the idea of advancing any novel 
mode of procedure, but of inculcating more earnestly the 
universal adoption of this simple expedient. 

Most of the recognised works on midwifery in France and 
Germany describe fully the process, but few of our English 
authors lay sufficient str 
subject. 

The more extended app 
midwifery would, I feel su; 
foetal as well as materns 



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832 8T8TBMATIC EXAMINATION OF THE ABDOMEN 

advocated by our systematic authors and clinical teachers^ 
until every student shall learn to consider it as his duty to 
examine carefully the position of the fcetus in utero on first 
visiting his patient^ and^ if need be^ rectify any malposition 
that may occur. 

In the thirty-second report of the Registrar-General for the 
year 1869^ over 2000 mothers are stated to have died from 
accidents of childbirth^ exclusive of more than 2000 others 
who succumbed to puerperal fever and other complications. 
Churchill estimates that the superior extremities present 
once in every 243 cases ; that about one half the children and 
about 11 per cent, of the mothers are lost. 

With these facts before us^ surely any plan is worthy 
of consideration that will tend to diminish this sad mor- 
talityj more especially when that suggested is a simple 
operation which involves no risk to either mother or child^ 
and which any one qualified to attend the lying-in chamber 
may perform. 

Natural labour may terminate favorably in the midst of 
inactive ignorance ; unnatural requires action guided by an 
enlightened judgment ; and the sooner the latter is brought 
to bear upon the former the less will be the risk and sufier- 
ing incurred by both mother and child. 

The advantage of detecting malpositions in the early stage 
of labour is considerable, for whilst the membranes are stUl 
intact very little effort is required in rectifying the presenta- 
tion, and little or no danger is incurred by the mother or 
fcetus, for it is not a question of passing a hand into the 
uterus and bringing down a foot, necessitating the adminis- 
tration of chloroform and subjecting the patient to the 
attending risks of shock to the system, or even rupture of 
the uterus, but the process is so simple that an intelligent mid- 
wife could perform it ; it is merely a question of substituting 
the head or normal presentation for the abnormal one by 
external manipulation alone, thereby lessening considerably 
the risks to both mother and child. 

Wright, in his prize essay ' On DiflScult Labours and their 
Treatment,' written in 1864, states that — 



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FOIt MALPOSITIONS OF THE FCETUB IN LABOUR. 383 

'^1. At an early period of labour^ and especially if called 
before the membranes are ruptured^ a shoulder may be con- 
verted into a vertex presentation more easily than turning 
by the feet is ordinarily performed. 

"2. That although the membranes may have been long 
ruptured^ turning by the head can be a;ccomplished with 
great facility. 

'^3. That delivery by cephalic version may be speedily 
effected after repeated and ineffectual efforts have been made 
to turn by the feet. 

'^4. That cephalic version should receive a prominent^ nay 
leading place^ as a means of expediting delivery in shoulder 
presentations. 

'^ He advises that turning by the head should be selected in 
all cases where difficulty arises from malposition merely; 
or in convulsions^ haemorrhage^ or prolapse of the funis^ if 
the uterus should be engaged in vigorous expulsive efforts ; 
turning by the feet being preferred in cases of inefficient 
uterine action^ or in exhaustion from long continuance of 
labour^ in haemorrhage^ or in any case in which there may 
be a demand for speedy delivery.'' 

Yet although this was written eighteen years ago^ the 
subject has not. attracted anything like the attention its 
importance demands. 

Dr. Barnes^ in his invaluable work on obstetric operations^ 
states that^ " a head presentation is the type of natural labour^ 
it follows that to obtain a head presentation is the great end 
to be contemplated by art. No one will dispute that the 
chance of a child's life is far better if birth takes place by 
the head than if by the breech or feet. Yet delivery by the 
feet is almost invariably practised when turning or the sub- 
stitution of a favorable for an unfavorable presentation has 
to be accomplished. Why is this ? The answer is not entirely 
satisfactory. It rests chiefly upon the undoubted fact that 
in the great majority of instances at the time when a mat- 
presentation comes before us, demanding skilled assistance, 
turning by the feet is the only mode of turning which is 
practicable.'' 



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334 SYSTEMATIC EXAMINATION OF THE ABDOMEN 

Dr. Braxton Hicks, in Iiis work on ' Combined External 
and Internal Version/ 1864, states — 

'* Again, to perform complete version entirely from the 
outside requires considerable opportunities of practice, more 
than fall ordinarily to the fate of practitioners ; and even in 
the most skilful and practised hands it has much of uncer- 
tainty ; and what is more, for practical purposes it will fail 
us when we most stand in need of it, namely, in actual 
labour, for few medical men have the opportunity, in private 
or outdoor practice, of carefully examining the condition of 
the presentation before labour has commenced; and even did 
they possess every facility, it would be very impracticable, 
and I may say to a certain extent unnecessary, for it is 
evident to any one who has taken the trouble to examine the 
position of the child before birth that it is frequently altering 
its position in utero, more commonly oscillating between the 
transverse and cephalic, and that it is not until the early 
pains set in that its presentation is finally fixed.'' 

Now, it is to meet the difficidty Dr. Barnes speaks of, 
namely, '^ at the time when a malposition comes before us, 
demanding skilled assistance, turning by the feet is the only 
mode of turning which is practicable '' at the same time, 
with all due deference and respect for our worthy President, 
to dissent from his statement regarding the '' difficulty and 
uncertainty " of external manipulation alone, that I venture 
to inculcate the universal adoption of systematic examination 
of the abdomen in all cases of labour, believing that many 
lives may thus be spared as well as much anxiety saved to 
the practitioner; and although one cannot expect that 
all will attain proficiency on first commencing, still, like 
everything else, it only requires learning and is by no 
means so difficult as might be imagined. I have taught several 
intelligent pupils the method, and I have already had proofs of 
the advantage of so doing. 

The subject has been forced more especially upon my 
attention of late owing to being called in consultation in 
cases where the arm was prolapsed and the membranes 
ruptured, where the patient herself had noticed that '' she 



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?0K MALPOSITIONS OF THE FOETUS IN LABOUR. 335 

had carried the child diflferently to before/' but the atten- 
dant had failed to utilise the hint thus given until it was too 
late. 

The question will naturally be asked^ are we to examine 
the abdomen of every parturient woman ? I answer unhesi- 
tatingly^ yes. The advantage of so doing is greats for we 
have emphatically everything to gain and nothing to lose ; 
should the position of the foetus be normal no harm whatever 
is done^ and should it not be so we are in a position to 
rectify it with the minimum amount of risk and trouble^ 
for with ordinary skill every one can accomplish it, and the 
sooner the method becomes general the better for both 
patient and attendant. 

In ordinary cases the best position to ascertain the situa- 
tion of the foetus is for the patient to lie on her back, with 
the shoulders raised and the knees drawn up. Supposing we 
find that the head occupies the left iliac region, dorso- 
anterior, the right shoulder presenting, by turning the 
patient on her left side and gently pressing up the breech in 
the right side, with some little counter-pressure upon the 
foetal head downwards and inwards, by external manipu- 
lation alone, rectification of the abnormd position is readily 
accomplished, and if no pelvic deformity exists and there be 
no great excess of liquor amnii the foetus will probably 
retain its normal position and labour advance in the 
usual way. Should there be any tendency for the mal- 
presentation to recur, the opportunity must be taken to 
rectify it when the osis dilated; rupture the membranes and 
retain the head at the brim until fixed by firm contractions 
of the uterus. 

The principle, being understood, it remains with the practi- 
tioner to modify the position of the patient and direction of 
the pressure according to the exigencies of the case. Efibrts 
at restitution should only be made between the pains in those 
cases where labour has already commenced. 

DifiSculties may occasionally arise from the large size of 
the foetus^ deformity of the pelvis, small amount of liquor 
amnii, a9cites, abdominal tumours, &c. 



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386 SYSTEMATIC EXAMINATION OF THE ABDOMEN 

It is a fortunate coincidence, or consequence, more properly 
speaking, that transverse presentations occur more frequently 
in multipara than in primipara, as it is hardly necessary to 
state the operation is more readily performed in the former 
than in the latter. An extension of this principle to cases 
of placenta prsevia, where ordinarily we have " to turn and 
deliver/' lessens cogasiderably the risk to both mother and 
child. 

Again, in those cases 'of slight pelvic deformity where we 
may succeed in delivering by bringing the breech down in 
place of the head, the risk is also considerably diminished, 
for it is as easy to bring down the one as the other when the 
membranes are still intact, although in normal conditions of 
the pelvis, and where no special reasons exist to the con- 
trary, cephalic version is the one to be employed. 

I cannot, in conclusion, do better than quote from W. L. 
Richardson's pamphlet, who says— 

'* To sum up briefly the advantages to be derived from the 
application of external manipulation to obstetric practice, 
we find — 

'^ 1st. That the diagnosis of the foetal position can be made 
out before labour begins, and while the membranes are 
unruptured. 

'^ 2nd. That the examination, thus conducted, can be made 
with less discomfort to the patient and less trouble to the 
physician than attends a vaginal examination. 

'' That as regards the treatment of obstetric cases there are 
many very decided advantages to be derived from the use of 
external manipulation. 

" 1st. That version can be performed before labour begins, 
thus enabling us to convert with the greatest ease to our- 
selves and safely to our patient an unnatural into a natural 
presentation. 

'' 2nd. That version can also be performed during labour 
with much less danger to both mother and child than is 
possible by any other method. 

''3rd. That by this treatment cephalic version can be 
performed as easily as either podalic or pelvic. 



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FOR MALPOSITIONS OF THE FCETXTS IN LABOUR. 837 

''4th. That in cases of placenta prsevia we can interfere at 
a very early stage of the labour^ and adopt a form of treat- 
ment which offers far better chances to both mother and 
child than any other. 

'' 5th. In cases of prolapsed fiinis^ by adopting this method, 
we can terminate a case of labour much earlier than if we 
were obliged to wait until the os should dilate sufficiently for 
us to introduce our hand. 

''6th. In cases of accidental hsemorrhagCj or conyulsions, 
we are enabled to interfere earlier, and terminate the labour 
more rapidly than haa hitherto been thought possible^ 

To those who may care to study the subject more in 
detail I append a list of those who have written on the 
subject — 

' Consolation for Pregnant Women.' Jacob Bueff, of 
Zurich, 1554. 

Wigand, J. H., 'Turning by External Manipulation/ 
Hamburg, 1807. 

D'Outrepont, J., ' Spontaneous Evolution and Cephalic 
Version.' Wurzburg, 1817. 

Wright, M. B., Prize Essay on 'Difficult Labours and 
their Treatment.' Cincinnatti, 1854. 

Smith, Dr. Tyler, "Abolition of Craniotomy," ' Obst. 
Trans.,' vol. i, p. 43. 

Brisch, ' Abhandlungen,' &c. 1826. 

Schmidt's ' Jahrbuch,' 1857, Band xcv, p. 66. 

Braxton Hicks, Dr., " On Combined External and Internal 
Version," 'Obst. Trans.,' vol. v, p. 219; 'Lancet,* July 
14th and 21st, 1860; February 9th, 1861, and separate 
Treatise, 1864. 

' AUgen. Wien. Med. Ztg.,' December, 1863, No. 58. 

C, Hecker, ' Klinik der Geburtsk,' Band ii, p. 141. 

' Monattschr. f* Geburtsk,' Band xxvii, p. 219. 

Hohl, 'Lehrb. de. Geburtsk,' 2 Aufl. Leipsic, 1862, 
p. 784. 

Caaseaux, ' Theoretical and Practical Midwifery,' p. 789, 
1866. 

VOL. xiv. 22 



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388 8Y8TBMATIC KXAMINATION OF THB ABDOMEN 

Whittaker, Jas. J., ' American Practitioner/ vol. i, 1870. 

Richardson^ W. L. ' External Manipulation in Obstetric 
Practice. Boston^ 1871. 

Barnes^ Robert^ Dr.^ ' Lectures on Obstetric Operations/ 
1871, p. 90. 



Dr. Madge said that some French authors have stated it to 
be possible to make out the position of the foetus in utero by aus- 
cultation, and he thought that it should at least be employed as 
an important] aid in such an examination. The position could 
bv this means be made out with tolerable accuracy; but the 
child's frequent movements and changes of position made the 
knowledge of but little practical value. 

Dr. Playpaib said that his attention had long been directed 
to the ease with which the position of the foetus could be made 
out by abdominal palpation combined with auscultation. In a 
paper read before the Society last year " On Irritable Bladder 
in the latter months of Pregnancy/' he had shown how it could 
be turned to practical account, as by altering the abnormal 
position of the foetus this distressing symptom could often be 
removed. Dr. Edis did not describe at length how the position 
of the foetus could best be made out. The method ne (Dr. 
Playfair) used and taught his class was first to ascertain the 
direction in which the long diameter of the uterine tumour lay. 
If this was from above downwards the presentation must be 
either the head or the breech. In the former case the foetal 
heart would be heard beating below the umbilicus, in the latter 
ahove it. When the long axis of the uterus did not correspond 
to the long axis of the abdomen, but lay more or less obliquely 
across it, the presentation was transverse. A hard prominence 
would be found at either of its extremities, corresponding to the 
head and breech. The foetal heart could be heard loudest near 
the extremity at which the head lay. These facts being made 
out, the position of the child could be altered at pleasure, and 
with great ease. He differed from Dr. Edis, however, in thinking 
that any examination need be made for the purpose of detecting 
the exact position of the foetus until labour had actually com- 
menced. The position in which the foetus lies is constantly 
altering, and it would be found practically useless to change it 
artificially until labour had begun, as most probably it would 
soon find its way back to its former position. In sevend of his 
cases in which he had detected transverse position some time 
before delivery, the head presented naturally when labour 
came on. 



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FOR MALPOSITIONS OF THE FCETUS IN LABOUR. 339 

The PBESiBEirr remarked that he would be the ]a^ to throw 
any cold water on the use of the external hand in midwifery. All 
his teachings and writings had been directed to the inculcation of 
its use, and yet it was firom a practical knowledge of the diffi- 
culties of turning whoUj from the exterior that he had made the 
remarks he had done m his work on ^ Combined External and 
Internal Version.* It was a difficult mode even for those skilled 
in its use. He thought the cases in which the rectification was 
needed were few, much fewer than the advocates of rectifications 
before labour thought. The proportion of cases in which their 
plans were carried out were far in excess over the occurrence of 
transverse presentations in actual labour. The uterus by the 
gentle early contractions rectified most of the oblique positions 
of the foetus. At the same time he fully coincided with the 
opinion that we should at all times fully acquaint ourselves with 
the conditions of the uterus and its contents^ so that when 
labour set in, and as soon as the os uteri admitted a finger or two, 
we should be prepared, if an error of presentation existed, to 
rectify it at once by combined external and internal version, and 
this, he thought, would be in nearly every case sufficient to meet 
the exigiencies of labours, and as much as was possible in 
ordinarv* private practice. 

Dr. Edis, in reply to Dr. Murray's remark that Dr. Braun, of 
Vienna, employed the process not so much with the view of 
remedying malpositions as of being ready at the earliest moment 
to give assistance, thought that this scarcely expressed it. The 
process was employed distinctly to obviate errors of position. 
As regards Dr. Madge's remark about auscultation not having 
been mentioned. Dr. £!dis replied that he had purposely omitted 
it from his paper, though he always employed it in his practice, 
so as not to divert attention from the main object of the paper. 
Dr. Flay&nr had misunderstood the time at which Dr. Edis pro- 
posed resorting to examination ; he only intended employing it 
during labour, and had never found any obiection urged by the 
patient. It was true, complete version of the fioBtus by external 
manipulation alone was somewhat difficult, but as cephalic version 
was tne method insisted on, this would seldom be requisite. He 
quite agreed with Dr. FhiUips that in most, so-called, transverse 
presentetions, the head rested on one or other iliac fossa, and the 
axis of the uterus was oblique — all the more reason why 
cephalic version should be employed by external manipulation 
alone before the membranes had ruptured. 



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840 ON THE TREATHBNT OF SUPPURATING 



NOTE ON THE TREATMENT OP SUPPURATING 
OVARIAN CYSTS BY DRAINAGE. 

By J. J. Phillips, M.D. 

So much success has of late followed the complete removal 
of suppurating ovarian cysts that the operation of ovario- 
tomy will probably in future be more frequently resorted to 
in such cases. Exceptional instances will, however, occur in 
which the removal of the tumour cannot be effected, or in 
which the attempt to extirpate it may be considered unde- 
sirable. Under such circumstances the practice of freely 
laying open the cyst, and stitching its walls to the margins of 
the abdominal wound, or the treatment by the drainage tube^, 
will probably be considered to afford the best chances of 
success. In the case to be mentioned the drainage tube was 
used, the cavity of the cyst being daily washed out; and this 
note is recorded to illustrate one source of danger accom* 
panying that plan of treatment. The point may indeed be 
familiar to the more experienced members of the Society, but 
I have seen no reference to it in any treatise on the subject, 
and it may therefore be worthy of brief notice. 

Harriet W-r-, set. 80, was admitted into Guy's Hospital, 
under my care, in the summer of the present year. She 
was the subject of an ovarian tumour, and had been twice 
tapped at a provincial hospital. The abdomen was tensely 
distended, prominent and globular in form, with distinct fluid 
vibration from side to side. A vaginal examination revealed 
the posterior. part of the pelvis to be occupied by a tense 
elastic swelling receiving no impulse from the abdominal 
tumour. The os uteri was high up in front, the uterus normal 
in length. The patient's general condition was unfavorable. 
She was a good deal wasted, perspired much at night, face 
pinched, eyes sunk, tongue raw. The temperature on the 
morning after admission was 101^ Fahr., and on the few 



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bVARIAN CYSTS BY DRAINAd£. 341 

following mornings it varied from 99-8° to 100-8^, while 
the evening temperature was about 102®, on one occasion 
102*7®. The pulse beat 120 per minute, and the respirations 
averaged 22 per minute. She complained of no pain, and 
there was no tenderness over the abdomen. It seemed pro- 
bable that there was suppuration of the contents of the cyst ; 
and on tapping it thirteen pints of pus were withdrawn. A 
small solid mass was found on the right side, and the 
evacuation of the abdominal cyst had no effect on that con- 
tained in the pelvis. My colleague Dr. Hicks kindly saw 
the case, and we decided not to recommend excision, but to 
introduce a drainage tube and wash out the cyst daily with a 
weak solution of iodine. The cyst in the pelvis might, it 
seemed, be treated subsequently by vaginal drainage. The 
improvement in the patient's condition became very marked. 
The temperature on the evening of tapping fell to 1007°, 
on the third evening it was normal, and continued so, except 
for a few days when there was a little suppuration about the 
wound, until the supervention of the unfavorable symptoms 
six weeks after paracentesis. A note made three weeks 
after the operation stated that the patient continued to 
improve, gaining flesh, and taking food well. The cyst was 
evidently contracting, pushing the tube gradually out, and 
not containing more than five or six ounces of the iodine 
solution. One evening thred weeks later she became very 
feverish, face flushed, pulse 140 per minute. This was 
followed by abdominal pain, a temperature varying from 
103° to 105°, all the signs of acute peritonitis, and death in 
six days. At the post-mortem examination the left ovary 
was found to form a single cyst, the size of a cocoanut, which 
lay in the pelvis behind the uterus ; this contained a brown, 
rather viscid fluid. The abdominal tumour was formed by 
the right ovary, and was composed chiefly of the cyst which 
had been injected during life. It was now so much reduced 
in size that it would hardly have held a cricket-ball. Its 
lining membrane was slightly discoloured, and covered here 
and there with specks of cheesy matter ; its walls were every^ 
where perfect, and there was no indication whatever that it 



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342 ON THE TREATMENT OF SUPPURATING 

had given rise to the peritonitis. The explanation of thi0 
was, however, readily found. The chief adhesions were on 
the right side, and the small mass of compound cysts felt 
there during life contained gelatinous material^ while their 
walls had undergone calcareous degeneration. There was, 
however, one small cyst the contents of which were purulent; 
this was firmly adherent to the mesentery, and its wall 
around the adhesion was thin and shreddy, and had an 
opening in it, through which pus had escaped into the peri- 
toneal cavity, and could then he made to exude on pressure. 
It seemed evident that the contraction of the chief cyst had 
caused such dragging on the adhesion between this small 
suppurating cyst and the mesentery as to cause a gradual 
wasting of the cyst wall and its subsequent rupture, an 
accident probably also favoured by the contents being puru* 
lent. The other organs of the body were healthy, except 
that the right lung, below its apex, contained an old vomica 
filled with cheesy stuff, and that there were some calcified 
scattered tubercles in the summit of the left lung. 

The case brings to my recollection another case of suppu- 
rating ovarian cyst treated by drainage, and which ulti- 
mately did well. The patient was seized, several weeks after 
tapping, and when the cyst had contracted to a small size, 
with rather severe peritonitis of several days' duration, the 
cause of which appeared obscul^. I think it not improbable 
that rupture of a small secondary cyst occurred, produced 
perhaps in a similar manner to that in the case now recorded ; 
but that its contents were not of such a character as to set 
up so severe a form of peritonitis as to prove fatal. 

I may add that it does not appear probable that the unto- 
ward termination in the case just reported could have been 
averted if the case had been treated from the first by a fi*ee 
incision ; for had any attempt been made to break down the 
compound cysts the small suppurating adherent cyst would 
not have been reached owing to the dense calcareous mass 
which intervened between it and the cavity of the main 
cyst. 



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OVARIAN CYSTS BY D&AINAOE. 343 

• Dr. Tilt related that , in a case of ver^ TolaminouB monolocular 
cyst, he was told by Becamier to establish three issues at the pit 
of the stomach with potassa fusa. As the abdominal walls were 
thin, one of these issues perforated the cyst, and one morning it 
was found that a glutinous fluid had been oozing out of the cyst, 
saturating three mattresses, and that it had largely collected on 
the floor. When the contents of the cyst became offensive Dr. 
Tilt injected tepid water into the cyst every day, without any 
accident, except once, when pain and an alarming state of 
collapse made him fear for the patient's life. The gradual re- 
traction of the cyst was shown by the diminution in the quantity 
of water required to fill the cyst. The patient made a good 
recovery, and fairly enjoyed life, but she had to inject a 
few ounces of water every morning. She died of intestinal 
obstruction some eight years after the accidental rupture of 
the cyst, and Dr. Tilt believed that the remnant of the tumour 
somehow caused the obstruction. In 1847 Dr. Tilt proposed 
that we should attempt to cure monolocular ovarian cysts by 
doing intentionally what occurred accidentally in this case ; but 
the magnificent results of ovariotomy bar the thought of any 
other plan for the radical treatment of ovarian chronic tumours. 

Dr. Skow Beck inquired upon what evidence the fluid with- 
drawn from these cysts was said to be **pus." Not unfrequently 
it had been stated that pus was discharged from ovarian cysts, or 
that suppurating; cysts nad burst, &c., but he much doubted the 
correctness of these statements. The fluid contained in ovarian 
cysts was often of a thin pea-soup appearance, and contained 
multitudes of cells, which had great resemblance to the pus-cells, 
yet were apparently distinct from it. The cells from the ovarian 
cysts had, like the pus-cells, a thin cell wall, and contained two 
or three nuclei, but they differed from the pus cell in beiog of 
different sizes, being somewhat irregular in form, and having 
many bright molecules adhering to some part of the cell wall. 
At different times he had been at issue with excellent observers 
upon this point, and thought it important to decide, if it could 
be done, whether the cells in the fluid were the usual and ordi- 
nary formations of these cysts, or whether they were really pus- 
cells, in which latter case they might be considered as the result 
of some inflammatory action induced in the ovarian cyst. 

Dr. Bantock did not gather whether Dr. Phillips had, on 
post-mortem examination, come to the conclusion that the 
tumours could not have been removed by operation at the time 
the treatment was begun. Some years ago he saw a patient die 
from exhaustion, the result of suppuration of an ovarian cyst, 
which opened near the umbilicus, in which, after death, the cyst 
was found adherent as a partly collapsed sac to the extent of 



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344 ON THE CAUSATION OF 

about three to four incheB across, the remainder of the sate basing 
quite free from adhesions, and presenting an admirable pedicle; 
More recently he had seen a patient die from the same cause, in 
which case also the tumour could have been removed very easily 
during life. From what he had seen of suppurating ovarian 
cysts, he believed it would be much safer to perform ovariotomy 
under such circumstances than to attempt drainage^ seeing thi^ 
it was impossible to ascertain the exact relations and nature (^ 
the tumour without opening the abdomen, while the results <^ 
operation were eminently satisfiiu^ry. In the treatment by 
drainage one necessarily works in the dark. 

Dr. Phillips, in reply to Dr. Bantock, said that the post- 
mortem appearances showed that extirpation would, in the case 
reported, have been attended with great difi^ulty. He was 
far from depreciating ovariotomy in such cases, and his case 
pointed out an additional source of danger in the treatment by 
drainage. In answer to Dr. Snow Beck, he did not remember 
that a microscopical examination of the fluid had been made. 
The fluid, however, whether pus or not, discharged from the 
small ruptured cyst, was irritating enough to set up fatal 
peritonitis* 



ON THE CAUSATION OP ACQUIRED FLEXIONS 
OF THE UTERUS, AND THEIR PATHOLOGY- 

By Charles E. Squabst, M.B. Lond., M.R.C.P., 

ABSIBTAJVT-PHTBIOIAV TO THB HOSPITAL TOB WOXBH, SOHO 8QXTASB; 

PHYBIOIAK-ACCOUOHSUB TO THB MABXLBBONB OBKBBAL 

DZBPBNSABT. 

Dr. Graily Hewitt says in his new work, page 207, '' I 
can draw no absolute conclusion from what I have observed 
as to the effects of particular accidents or special antecedents 
producing a flexion of the uterus backwards instead of for- 
wards ; for I have known the same kind of accident produce 
different results in this respect." 

It is the object of this paper to clear up this point ; to 
explain why in two cases, the same causes and conditions 
apparently existing, an anteflexion is found in the one, a 
reU'oflexion in the other. 



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ACQUIRED FLEXIONS OP THE UTERUS. 346 

I was led to consider this flubject from being so fre- 
quently asked to explain it by students and oihet gentlemen 
attending my out-patient room at the Soho Hospital ; and 
having now for the last seven or eight months given the 
explanation contained in this paper^ and it having been 
considered reasonable by all to whom I have given it^ I have 
ventured to bring it before this Society for still further 
discussion and criticism. 

It will be weU to introduce the subject by noticing very 
briefly the anatomical position of the uterus^ its ligaments^ 
and its position in the pelvis. 

The uterus is situated in health high up in the pelvis^ the 
fundus being slightly above a line drawn from the promontory 
of the sacrum to the top of the pelvis^ and its axis being at 
right angles to the plane of the brim of the pelvis. It is 
supported by the vagina and by its ligaments^ and is main- 
tained in its position centrally in the pelvis by its attachment 
anteriorly to the base of the bladder^ and posteriorly by that 
portion of the peritoneum which forms the base of Douglas's 
pouchy and which passes from the uterus behind to the rectum 
and sacrum beyond — ^the utero-sacral ligament. 

These join the uterus at the upper part of the cervix^ at 
that part corresponding very nearly to the situation of the 
internal os. The fundus uteri and the cervix are, compared 
to this partj freely movable backwards and forwards, less so 
from side to side, as the broad ligaments prevent lateral 
motion of the fundus to any great extent. The fundus being 
thus free and the uterus being a more or less pliable organ, 
the fundus may be, under various conditions, more or less 
altered in its position ; that is, it may become more or less 
verted or flexed, but the healthy uterus possesses sufiScient 
rigidity or tone to recover its normal position directly the 
conditions causing the flexion or version are removed. 

The above is corroborated by the following, taken from a 
lecture given by Graily Hewitt at University College Hos- 
pital. *' The axis of suspension of the uterus is represented 
by a horizontal line passing through the uterus from side to 
side, about the situation of the internal os uteri ; this leaves 



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346 ON THE CAUSATION OF 

half the uterus above the pointy half below it. The lower 
half is effectually fixed^ the upper half is very ineffectually 
fixed except in reference to lateral motion^ which is not 
allowed except to a slight degree/' But besides this antero- 
posterior and lateral moyement of the fundus^ there is 
another^ the rising and falling of the whole uterus in the 
pelvis ; which is very important, and in which, I think, lies 
the whole explanation as to the direction which the fundus, in 
any case of flexion, may take. It is a well-recognised fact 
that all the solid organs in the body vary in position some- 
what, according to the position of the patient ; thus the 
liver occupies a somewhat lower position when a person is 
standing than when lying down. So the uterus; it falls 
slightly from the same cause, and may do so to a considerable 
extent even in health. As a proof of this, if necessary, we 
may refer to the ease with which on examination the uterus 
may be pushed up with the finger, or drawn down by a hook 
when necessary for operation. Again, the patient herself can 
by deep breathing considerably alter the position of the 
uterus in this respect. This point I do not suppose any one 
will contradict, but the following one on which I lay great 
stress may be questioned, and I wish to call especial atten- 
tion to it. It is this, that when the uterus so alters its 
position by such an ascent or descent in the pelvis, it alters 
also the direction of its axis ; so that in whatever place in 
the pelvis the uterus may be situated, its axis is at right 
angles to that plane, and by looking at these Uizee xoogfa 
drawings which I have made you will, I think, not only see 
what I mean, but see also and at once how much the direc- 
tion the fundus in a flexion takes depends on the situation or 
height of the uterus in the pelvis at the time that the flexion 
is produced. 

What first directed my attention to this alteration in the 
direction of the axis of the uterus was the direction the 
uterine sound took in cases of prolapsus, when the uterus 
was not much enlarged and only just extruded from the 
vulva. It invariably went backwards, in a direction quite 
opposite to the normal. Then I noticed in cases where the 



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ACQUIRED FLEXIONS OF THE UTERUS. 347 

Uterus felt low in the pelvis and yet in which no flexion nor 
version existed (at least when the patients were lying down)^ 
that the sound went in perfectly straight^ towards the 
promontory of the sacrum. Thus I noted that when the 
uterus was situated low down^ at the outlet of the pelvis, 
when in the middle plane, and when in its normal position, 
its axis was regularly altered, and in fact agreed entirely 
with the axis of the pelvis ; and thus I first clearly (as I 
think) saw why the same causes might produce such opposite 
conditions as anteflexion and retroflexion. 

And when we think of the uterus in its relation to the 
pelvis, and of its normal up and down movements with re- 
spiration and ordinary exertion, we can see, I think, what 
trouble it would give were it to sink and maintain, when it 
had reached the middle plane of the pelvis, the same direc- 
tion as when high up. It would in such a case lie directly 
across the pelvis, pressing on the rectum behind and the 
bladder in front ; it would, in fact, be anteverted, which all 
allow to be an abnormal position. 

The reason, then, why in diffSsrent cases the same cause 
produces sometimes anteflexion and sometimes retroflexion 
is, according to these views, simply this:— That when an 
anteflexion is produced the uterus is, at the time that the 
cause comes into action, situated high up in the pehria, 
occupying its normal position, the axis being forwards, as 
in No. 1 ; so that any force striking it from above would 
impinge on the posterior and upper surface of the fundus, 
and so force it forward and produce anteflexion ; that when 
a retroflexion is produced the uterus has sunk more or less 
deeply in the pelvis, with the axis directed more or less 
backwards, as in No. 3 ; and in this case any force striking 
it from above would impinge on the anterior and upper 
surface of the fundus, and so force it backwards and pro- 
duce retroflexion. 

To prove the truth of these views I purpose, first very 
shortly to run over the causes of flexions generally, and 
then to bring forward cases to exemplify the facts stated ; 
and these I do not take from my own out-patient room, but 



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348 ON THE CAUSATION OF 

from Graily Hewitfs work^ as those quoted by him without 
regard to these views support them just as well as any cases 
that I might have picked out from my own patients. 

Flexions generally^ then^ according to Graily Hewitt^ are 
predisposed to by the following causes : 

1. An unhealthy state of the body generally. 

2. A previous pregnancy. 

In the first the tissues of the body imperfectly or badly 
nourished are relaxed and wanting in tonicity. The circu- 
lation in the blood-vessels is retarded under these circum- 
stances ; it is sluggish and imperfect^ and the tissue changes 
take place with greater slowness than under ordinary circum- 
stances and in a state of health. The effect of this state 
of things upon the uterus is most marked; it increases in 
size^ its circulation becomes slow^ and as a necessary 
mechanical result of this there occurs a diminution in the 
rigidity or tonicity of the uterus itself^ which is one of the 
most important agents in preserving the uterus intact ; in 
other words^ the uterus becomes pliable in an unusual degree. 
This is a state of things which constitutes a strong predis- 
position to changes of shape in the uterus. 

The other predisposing cause is pregnancy. After labour 
involution in untoward circumstances goes on in a very 
inactive manner, leaving the uterus larger for some con- 
siderable time than it should be, and also of necessity more 
pliable. The increased size affects not so much the cervix 
as the body of the uterus^ which, as already stated, is from 
its want of connection more predisposed to a change of 
position. 

Now," the truth of these remarks cannot be controverted. 
But besides the uterus being so affected, we must remember 
that the whole body is affected by these conditions. All the 
pelvic organs as well as the uterus get into a relaxed, atonic 
condition ; the vagina and the ligaments of the uterus are 
relaxed, and this favours descent of the uterus, which, as 
this paper is intended to prove, most strongly pr^sposes to 
retroflexion. The muscular coats of the bowels lose tone. 



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ACQUIRED FLEXIONS OF THE UTERUS. 349 

constipation results^ and more or less congestion of the 
hsemorrhoidal vessels exists. 

Then as to pregnancy. The increased size and weight of 
the subinvoluted uterus, existing as it does with loss of tone 
of the vagina and of the uterine ligaments, tend to cause, 
more or less, descent of the uterus also ; and, as it descends, 
its axis alters, and a tendency to retroflexion exists. 

Again, with regard to exciting causes, Oraily Hewitt says, 
''It may be simply an exaggeration of the predisposing 
ones, thus pregnancy in a feeble womaii may give rise to it ; 
or it is produced by strains, falls, jolts, remaining in a con- 
strained position for any length of time, especially when 
associated with tight clothing around the waist.'' But let 
us divide these exciting causes into those producing flexions 
suddenly (traumatic flexions. Meadows), and those producing 
them gradually, and then consider their pathology. 

1. The traumatic causes are those accidents causing a 
sudden jolt (as strains or sudden muscular efforts) to the body, 
especially those bringing into violent action the abdominal 
muscles, such as the violent straining sometimes necessary to 
relieve the bowels. 

These may produce flexions in people in comparatively good 
health; therefore they are much more likely to do so in 
those who are predisposed to them. 

2. The exciting causes bringing on flexions gradually are, 
constrained positions mantained for a long time, such as the 
sitting position in needle and sewing-machine work; or 
positions not constrained, such as standing all day long, day 
after day, or any kind of work having a tendency to cause 
pressure downwards into the pelvis. Continued constipation 
may be mentioned as a cause; but for this to have any 
effect it is necessary that the patient should be predisposed 
to flexions. 

Now let us take three cases of traumatic flexion where, in 
Case 1, an anteflexion has been produced in a girl previously 
healthy; Case 2, where a retroflexion has been produced 
after confinement by the slight jolting of a feeble patient ; 
Case 8, where a retroflexion has been produced in a virgin 



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350 ON THE CAUSATION OF 

predisposed to flexions hj some of the conditions enumerated 
above. And let me again^ before relating these cases^ 
repeat that the explanation of these various flexions being 
produced bj the same cause lies in the fact^ that the uterus 
may under different circumstances occupy a very different 
position in the pelvis ; that its height in the pelvis^ and con- 
sequently the direction of its axis, varies very much. 

The first case ia taken firom a lecture given by Oraily 
Hewitt. 

A young, unmarried lady previously in good health, 
having been dancing for five or six hours the night before, 
does not feel very well the next morning ; and, in coming 
down stairs, she slips and falls two or three steps and receives 
a violent jerk. She experiences intense pain, and a few days 
afterwards on examination acute anteflexion is discovered. 

Again, another case of Dr. Hewitt's. 

A lady, four days after parturition, in the absence of the 
nurse gets out of bed and walks across the room to fetch 
something. She experiences sudden, severe pain and 
returns to bed. After a few months of continuous discom- 
fort an examination is made and retroflexion of the uterus 
is discovered. 

In these two cases there is the same cause ; though in the 
case of the young lady it is the jolt of the fall, in the elder 
lady merely the slight jolting caused by the tottering walk 
of a weak woman. In the one case anteflexion, in the other 
retroflexion is produced; and I explain it thus. 

In the young lady the uterus is high up, in its normal 
position ; the axis is forwards, the fundus looking forwards,, 
as in diagram No. 1. The jolt causes pressure downwards, 
and this, impinging on the upper and posterior surface of the 
fundus uteri, pushes it down, forwards, in the direction in 
which it was lying, and so causes anteflexion. 

In the elder lady just confined, immediately she gets out of 
bed, firom relaxation of all the tissues and increased weight of 
the uterus, the uterus becomes prolapsed and descends to 
the position represented in diagram 3. The pressure down- 
wards, produced by the mere jolting of walking, impinging 



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ACQUIRED FLEXIONS OP THE UTERUS. 351 



2 






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352 ON THE CAUSATION OF 

as you see it would here^ ou the anterior aud upper surface 
of enlarged^ subiuToluted uterus^ is amply sufficient to force 
the fundus backwards and produce retroflexion. 

Again^ take the third case^ where retroflexion is produced 
by habitual constipation in a weakly virgin. The tissues of 
the pelvis^ vagina^ uterus^ with its ligaments, Sec., have got 
relaxed from preyious bad health ; she suffers^ most likely^ 
firom a leucorrhoeal discharge ; her bowels are constipated, 
and she strains a good deal every two or three days when the 
bowels act and has done so most likely for two or three 
years. This straining at stool is the exciting cause. It 
forces down the whole of the pelvic viscera time after time ; 
the uterus has become enlarged and lost its tonicity from the 
derangement of the general health, and gradually comes to 
occupy a position either as in No. 2 or No. 8 diagram. At 
last a rather harder strain than usual on going to stool occurs, 
the fseces are suddenly expelled, the whole of the force is 
exited on the fundus uteri, which, having now nothing to 
support it behind, is pushed back into the retroflexed 
position. 

Now these cases might be repeated to any number; 
scarcely an out-patient day of mine passing without 
examples of such condition, presenting themselves. 

Statistics, too, compiled without regard to these views, also 
support them, that is, anteflexions are much more common 
in young adults, and in the virgin state, and in those who 
have not had children ; whereas retroflexion is much more 
common in older women, and in women who have borne 
children. That is, in virgins and in young adults, in whom 
there has been no or very little tendency to the production of 
any amount of prolapse, by enlargement of the uterus or 
relaxation of its tissue, by pregnancies, and various other 
conditions — ^in whom, in fact, the uterus retains its normal 
position high up in the pelvis — anteflexion is more common. 

In older women, and especially in those having borne 
children, the uterus is larger and has been exposed to all the 
influences which tend especially to produce more or less pro- 
lapse; and in them retroflexions are more often produced. 



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ACQUIRED FLEXIONS OT THE UTERUS. 353 

Again^ when retroflexions exist in virgins, the history of 
the case will almost invariably disclose the existence of 
leucorrhoea for some considerable time^ indigestion^ constipa* 
tion, &C.9 and the patient is ansemic. All these conditions 
have gradually lowered her general health, and caused relaxa* 
tion of all her tissues, some enlargement of the uterus and 
consequently some prolapsus, with its accompanying altera- 
tion in the direction of the uterine axis. 

This explanation of the causation of flexions is hinted at 
in Thomas's work on ' Diseases of Women.' At page 327, 
when treating of prolapsus, he gives a diagram showing the 
alteration of the uterine axis in the various stages of pro* 
lapsus. Again, at page 401, when treating of retroflexions, 
he asks why endometritis with areolar hyperplasia so fre- 
quently results in retroflexion as well as in anteflexion ; and 
he says that ''it does so because the first effect of the 
increased uterine weight attending that disease is descent of 
the uterus* This relaxes the round ligaments, tends to bring 
the uterine axis in coincidence with that of the middle of the 
pelvis, and favours retroflexion/' 

According to Savage, he is certainly not right in thus 
speaking of the relaxation of the round ligaments ; for in 
Savage's work, Plate XI, on the structures supporting the 
uterus and opposing its prolapse, he shows that neither the 
broad nor the round ligaments are at all stretched till very 
considerable prolapse has taken place. In describing Plate XI, 
fig. 2, Savage says that complete prolapse is effected only 
after the yielding of the pelvic reflexions of the broad 
ligament. This occurs from behind forwards, the round 
ligaments being the last to be put on the stretch. 

I have not referred to these remarks of Thomas's before 
because these views of the causation of flexions were written 
in the beginning of this year, before I had seen his work. In 
no other book can I find any reference to this subject. 

Pathology of Flexiong of tfie Uterus, 

In considering the pathology of flexions^ we must divide 
VOL. XIV. 23 



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354 aN THE CAUSATION OP 

them into those produced suddenly in uteri previously 
healthy^ traumatic flexions ; and into those which have been 
brought on in people previously predisposed to them, in 
whom the flexion may be due to simply an increase of the 
predisposing causes ; and we will consider the latter firsts as 
the explanation of their pathology seems to me to be the 
easier. 

All predisposing conditions, as we have just seen, tend to 
cause an enlargement of the uterus and a loss of its tone, 
with also a loss of all the uterine supports ; allowing the 
uterus to sink in the pelvis and to get into such a position 
that the least extra force is sufficient to cause retroflexion. 

In these cases the uterus is gradually pushed over, or, one 
might say, falls over into a flexed or verted condition, on 
account of the loss of tone of the whole of its tissue render- 
ing it too weak to uphold the fundus uteri, increased as it is 
in its size, weight, and consistence. 

It falls into the retroflexed position rather than the ante- 
flexed, because its increased size and the loss of support, 
from the atony of the uterine ligaments, has allowed it to 
sink into the pelvis. As it has descended, the direction of 
its axis has changed from directly forwards to directly back- 
wards, and any force applied to it from above, as in straining 
at stool, or lifting heavy weights, &c., impinges on the 
anterior and upper surface of the fundus, and so forces it into 
the retroflexed position. 

Once pushed over, once flexed, it is unable to recover itself, 
and remains in its abnormal position mechanically and by 
gravitation ; simply from the loss of that elasticity and tone 
which has been gradually brought about by the predisposing 
causes. There is no necessity to ascribe its position to 
pressure from above ; its increased size and tihe atony of its 
tissue is sufficient. 

Of course I am here referring to cases of simple flexion ; 
cases where the uterine sound can be introduced easily 
(though curved) without pain ; and where the flexion can be 
reduced without pain ; showing that there are no adhesions 
keeping it flexed. Those cases where the flexion is bound 



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ACQUIRED FLEXIONS OP THE UTERUS. 855 

down by peritoneal adhesions^ hardly oome under the 
classification of simple flexions of the uterus. 

In many cases of this kind no symptoms except those due 
to its prolapsed condition^ that is^ bearing-down pains and 
weight in the pelvis, exist ; there is not even any dysmenor- 
rhoea, though between the periods the flexion feels sufficiently 
acute to contract to a great extent the canal. But I believe 
the absence of pain during menstruation in these cases is 
due to the increased flow of blood to the uterus at this time 
being sufficient to straighten the uterus to a certain extent^ 
and so reduce the constriction which exists between the 
periods. The uterus, in fact, becomes erect, and therefore 
straight, during the menstrual period. 

The maintenance of the flexion I consider, therefore, in these 
cases to be simply mechanical ; but in those cases where a 
flexion is brought on suddenly, by a sudden strain, &c., in a 
uterus previously healthy (traumatic flexion), what keeps the 
uterus in its flexed position ? 

In the cases we have just discussed we have seen that it 
was due to loss of tone of uterine tissue ; but in these cases 
no loss of tone has occurred. Up to the time of the accident 
the patient was perfectly well, and had not suffered in any 
way from any uterine trouble. 

When it is retroflexed it is explained, by some, by the 
pressure of the superincumbent intestines, which before were 
behind the uterus in Douglas's pouch, and so helped to 
maintain it in its normal position ; but which, by the sudden 
strain, were forced from there by the flexed uterus, and have 
since rested on the uterus, and so prevented its returning to 
the normal position. 

Allowing this to be the case, for the moment, in cases of 
retroflexion what is the cause of anteflexion, produced 
suddenly, being maintained ? Here we have at all times the 
weight of the intestines on and behind the uterus; but to 
compensate this there is the bladder before, tending by its 
occasional filling to push up and replace the uterus. 

Again, the tendency of the uterine tissue is always to 
recover itself and to return to its normal position, immediately 



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356 ON THE CAUSATION OF 

the offending cause is removed. There is in many of the 
cases no loss of tone^ no congestion^ and conseqo.ent enlarge- 
ment of the fundus uteri to explain it ; for these accidents 
with these attendant results may occur in women previously 
healthy and who have never suffered^ as far as they know^ 
from any uterine ailment^ and yet the uterus remains after 
these accidents in a flexed condition. Inflammatory adhe-* 
sions have not had time to form ; and' therefore in the first 
early stage the flexion cannot be maintained by them* 

In these cases, then, as in the others, it seems to me that 
the flexion must be maintained by loss of tone of the uterine 
tissue, and in these traumatic cases the loss of tone is, I 
believe, due to some rupture of the uterine fiblres, accom« 
panied by a more or less extensive effusion of blood into the 
uterine tissue; the extent of the rupture, &c., depending 
entirely on the severity of the cause. These accidents, I 
believe, cause a bruising of the uterine tissue and rupture of 
some of its fibres and blood-vessels, much in the same way 
as they may affect the other muscular and fibrous tissues 
of the body ; and thus they completely destroy for the time 
being the elasticity of the uterine wall, and consequently its 
power of righting itself. 

The symptoms which accompany these accidents, such as 
acute pain, increased by movement of any kind, also point to 
such an injury having occurred. After accidents of this kind 
the patient is always more or less severely ill for some time ; 
that is, the injury has set up a certain amount of inflamma- 
tion, metritis. As this subsides the ruptured fibres heal; 
and, unless the uterus has been restored to its normal position, 
and this very rarely happens, from the patient not being seen 
soon enough, or when seen from there being too much con- 
stitutional or local disturbance present to advise mechanical 
interference, they heal in such a way as to maintain the 
existence of the flexion; and as time goes on some con- 
traction of this newly-formed tissue generally takes place 
and causes the flexion to become still more marked. 

I have not, I am sorry to say, any pathological specimens 
to show as a foundation for this theory of the maintenance of 



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ACQUIRED FLEXIONS OF THE UTERUS. 857 

acute flexions ; and^ taking a uterus in one's himd as it is met 
with after deaths it may seem impossible that such a tough 
though pliable organ could be injured to such an extent by 
such accidents. But it must be remembered that during life, 
and especially at the menstrual periods^ the condition of the 
uterus is very widely different to that seen after death ; that 
at all times^ though it is a soft and pliable organ^ yet it 
possesses a certain amount of rigidity which renders it liable 
to be bruised by sudden^ sharp strains ; and that during men- 
struation^ when distended and engorged with blood, when in 
fact in an erectile condition, it is yet still further predisposed 
to such injuries. 

One clinical point which makes me believe in such a rup- 
ture occurring is, that in numerous cases the fundus is fixed 
in its relation to the cervix : I mean that by the finger you 
cannot straighten the uterus ; pressure on the fundus causes 
movement of the cervix, and vice versd; and attempts tQ 
reduce the uterus by means of the sound give great pain. 
At the same time the uterus altogether is not fixed in th6 
pelvis. All this, I think, points to the fact that there exists 
some alteration in the uterine tissue itself, maintaining the 
flexion. 

In the absence of any fresh pathological specimen I bring 
forward the following fact; that is, that in uteri flexed for. 
some time there has been found post-mortem atrophy of the 
uterine tissue at the flexed part ; chiefly on the concave side, 
but also on the convex side ; showing that degeneration of 
tissue has taken place. This has been demonstrated micro* 
scopically by Virchow and others. Now, atrophy having been, 
proved to exist at the point of flexion, may this not have 
originated in such an injury to the uterine fibre as I have 
described as caused by an accident ? 

. In conclusion, let me again say that I have not brought 
these views hastily before the Society ; but that for the whole 
of the past year I have been considering and discussing them 
in my out-patient room at the Soho Hospital ; and the 
favourable reception they have met with there has tempted 



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858 ON THB CAUSATION OF 

me to bring them here^ thi^t tbey may be more thoroughly 
and severely criticised. 
I beg to thank the Society for their kind attention. 



Dr. GsAixx Hbwitt had listened with much pleasure to Dr, 
Squarey's paper, and he thought the explanation given by 
the author of the fact that strains and accidents sometimes 
produce anteflexion, and at other times retroflexion of the uterus, 
mgenioQS and sati^bctory^ and that D!r. Squarey had supported 
those views in a very able manner. In reference to a suggestion 
made by the author, that laceration of the uterine muscular 
tissue actually sometimes occurred, and that this was the first 
step in the atrophy of the wall found in some cases of flexion, 
he was dispoised rather to look on this atrophv as the result of 
the pressure produced by the flexions; pathodogieal facts were 
wanting to support the author's hypothesis in that particular. 

Dr. £ouTH said he did not agree with all Dr. Squarey's con- 
elusions, although he could not but admit them. Eirst, in regard 
to anteflexions. They were more common in young unmarried 
people, not necessarily because the nterus was high up, but 
because in these the normal uterine position was one of partial 
anteversions, converted at once into anteflexions by fatigue, long 
walks, falls, &c, Anteversions occurred also in uteri high up. 
Betroversions were more common in older women, not neces- 
sarily because the uterus was low down, but because in cases of 
uninvoluted or congested uteri (the fundus being the part chiefly 
top heavy, and the patients generally selecting to rest themselves 
in position on the back) the top heavy organ naturally fell 
backwards. These flexions often depended also on the 
position taken by patient. He had seen that by urging a 
patient to lie not on her back but on her belly a retroverted 
organ became anteflexed, and yet in both the uterus was low 
down ; but it was in favour of Dr. Squarey's view (and which 
could be realised in most cases if watehed from day to day) that 
the uterine congestion once relieved by leeching and other de- 
pletive measures, and become lighter, the retroflexed organ 
might become anteflexed. But as women grew older, whether 
murried or not, and in whom uterine congestions occuired, ante- 
versions were not uncommon, although retroflexions most com- 
plete, and yet in both the uterus was low down. 

Dr. Keywood Smith said that although the experience of 
others seemed to be difierent, yet in a large out-patient practice 
he had found that among the unmarried and sterile anteflexion 
was the most frequent flexion ; and though cases of retroflexion 



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ACQUIRED FLSXI0N3 OP THE UTERUS. 359 

were found in the nuUiparouB, it was nevertheless comparatively 
rare. 

Dr. BAirrooK was not prepared to accept the explanation oi 
the causation of flexions of the uterus offered by Dr. Squarey. 
He had seen a considerable number of cases of retroflexion at all 
periods of menstrual life without presenting the necessary con- 
ditions. He agreed with Dr. Bouth in assigning the relative 
greater frequency of anteflexion to the natural tendency to that 
condition in the young subject. He could not at all accept Dr. 
Squarey's theory as to the cause of traumatic anteflexion. A 
force applied to the posterior aspect of the fundus uteri would 
necessarily cause rupture of tissue (assuming such an accident 
to be possible) on the concavity of the bend* ». 0., on the posterior 
aspect of the junction of body and cervix. The swelling from 
effused blood, Ac., would doubtless at first cause the uterus 
to bend forwards, but the subsequent atrophy of ruptured 
muscular fibre and contraction of fibrous tissue .wou'd reduce 
the primary displacements, and lead to the opposite condition, 
the thinning of the concave aspect, describea as existing in 
anteflexion being necessarily on the opposite side. 

The President, after complimenting the author upon his first 
and very carefully written paper, thought that hardly sufficient 
stress had been laid upon the action of the bladder in the produc- 
tion of retroflexion. He pointed out that the antagonists to the 
backward displacement of the fundus by a full bladder were the 
round ligaments. If these were relaxed or overstretched, and 
the attachment of the neck of the uterus to the base of bladder, 
and by it to the symphysis pubis remained Arm, then the dis- 
tension of the bladder acting for a long time, as in women who 
hunted, or were unable from other circumstances to micturate^ 
would tend to cause retroflexion. This effect would be added to 
by the straining of constipation or other exertion. 

Dr. Squarey replied, in answer to Dr. Qraily Hewitt, that 
he thought that atrophy of tissue from pressure at the point 
flexed was more likely to occur if the tissue had been injured at 
that part than if not. Atrophy had been proved to exist at this 
spot, but whether it originated in healthy or bruised tissue had 
not been proved. To Dr. Mum^, — ^that this paper was not 
intended to discuss the relative frequency of anteflexion and 
retroflexion, at the same time his experience quite agreed 
with what Dr. Murrav stated, retroflexions being much the 
most ^quent; but when a retroflexion occurred in a young 
unmarried woman, the history of her case would always reveal 
the existence of predisposing causes to flexions, as ansmia, con- 
stipation, leuoorrnoBa, &c., aU of which tended to cause a certain 
amount of prolapse of the uterus, with the consequent alteration 
in the direction of the uterine axis. In answer to Dr. Boutb, 



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SJO CAUSATION OF aCQUIKKD FLEXIONS OF TH£ UTERUS. 

Br. Squarey said that he did not for one moment believe that 
Ijring on the back had anything to do with the production of 
retroflexion. He did not believe that it alone would ever cause 
it, however much a woman might be predisposed to flexion. 
Again, with regard to pressure downwards by the intestines, ho 
did not believe they exerted pressure to a sumcient extent either 
to cause a flexion, or to maintain one after it had been caused ; 
always coutaiuing more or less air, he believed the intestines to 
be almost self-supporting. And in answer to Dr. Braxton Hicks, 
he stated that the round ligaments being inserted into the 
cellular tissue over the pubes, he did not think, as this was not 
a fixed point, that occasional distension of the bladder would 
cause stretching of them to such an extent as to favour retro- 
flexion. 



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IKDEX 



TAOS 

Abdomen, Bjstematio examination of, for rectifying malposi- 
tions of the f OBtns in labour (Dr. Edis) . • . 881 
—— ditto, bibliography of the subject • . 887 
Abortion, on retroflexion^ of the atems as a freqnent cause of 

(Dr.PhiUips) . . .45 

Acephalous monster (Mr. J. Milward) . . 140 

Address of the President (J. Braxton Hicks, M.D., F.B.S.), 

January 8rd, 1872 . .25 

Amputation of inverted uterus on account of hsBmorrhage (Dr. 

H. Davis) . . . . .104 

Awmual Oenerdl Meeting, January 8rd, 1872 . . . 1, 19 

AvBiiiNG (Dr.), modified apparatus for immediate transfusion . 101 
— — Discussion on ditto . . . 102 

— on post-mortem parturition, with references to forty-four 

cases 
— — Disoussion on ditto ..... 
— - Eeport on Dr. Meadows's case of extra-uterine f (station 
Bemarks on the use of arsenic in menorrhagia^ &c. 



Bantook (Dr. G. G.) specimen illustrating the changes in the 
pedicle of an ovarian tumour when treated by ligature 

'— on the treatment of certain forms of menorrhagia and 
uterine hesmorrhage by means of the sponge tent, with 
special reference to their occurrence in women residing in 
tropical climates « « « . 

«— — Disoussion on ditto . 

Bemarks on the origin of ovarian cysts from the par 

ovarium ..... 

— — - on Dr. Phillips's paper on retroflexion as a cause 

abortion ..... 

on Mr. Bryant's case of extirpation of uterus and 



ovaries in fibro-cystic disease 



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362 iNOBX. 

PAqB 

Baittock (Dr. G. G.)> on the remoral of oyarian cysta bj 

oyariotomj in preference to treatment bj drainage . 343 

_ — — on Dr. Sqoarey's paper on the causes of flexion of 

the ntenis .....* 359 
Barker (Dr. Fordyce) election as an Honorary Fellow • 259 

Babkbb (Dr.) on the essential cause of dysmenorrhcea as illus- 
trated by cases of partial and complete retention . 108 

Diseussion on ditto . . • . . 127 

fibrous tumour from the anterior wall of vagina. . 309 

— — a modification of Neugebauer's speculum • . 309 

aee Blake. 

mode of dealing with the placenta where gastrotomy is 

performed IfO remove the fostus in extra-uterine gestation . 325 

Discussion on ditto ..... 329 

Bemarhs on retroflexion as a frequent cause of abortion . 56 

•— on cases of placenta pxievia without hamorrhage . 62 

on Dr. Aveling's modified apparatus for immediate 

transfusion ...... 102 

on the various causes of dysmenorrhoaa . 133 

on syphilitic disease of the placenta . . 138 

^ on Dr. Newman's case of natural pregnancy subse- 
quent to CsBsarean section .... 147 

— on Prof. Simon's scoop for remoYing superficial 

portions of cancer of the uterus . . 210 

■ ■■ on the rarity of entire absence of uterus or ovaries . 215 

— ^- on copious watery discharges long before pregnancy, 

not being those of the liquor. amnii,.and on the irritability 

of the nervous centres at lull term . . 227 

on the danger of removing the placenta in operation 

for extra^uterineqsregxuau^ . . . 318 

Babsbtt (Mr.. John) gmteHr in fwaetice : accidental hnmorrhage, 

fatal in sevens hours, without delivery . .58 

— placenta prsvia without hsBmoiThage at the time of 

delivery . . . . . • . 60 

V ~- rupture of a varix in the genital organs during pi*eg- 

nancy, syncope, recovery . . .60 

destruction of the uterus by a severe labour . 61 

— ■: Discussion on ditto ... .62 

Bbck (Dr. Snow) .case of pelvic hismatoma cur retro-utenne 
haamatocele, with remarks on the source of the hsamor- 
rhage, &c. .... .260 

— — Discussion on ditto . . 279 



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INDEX. 863 

FAes 

Beck (Dr. Snow), BemarJcB on Dr. Bamee's paper on tbe cause 

of dysmenorrhcea . . ^ . . 129 

on casee of discharge of liquor amnii long previous 

to labour ...... 225 

— on the doubtful evidence in favour of cases of post- 
mortem parturition . . « . . 256 

on extra-uterine foetation occurring only in some 

part of the Fallopian tube, and the formation of the 
maternal portion of the plaoettta from the inner surfiioe of 
its fimbriffi ...... 319 

— on the non-purulent character of the fluid in ovarian 

cysts ••••.. 843 

Black (Dr. Watt) Beport on Mr. Grieves's case of a f cBtus with 

growth from the mouth .... 210 

Bladder, cedar pencil extracted from that of a girl set 18 (Dr. 

(Phillips) . . . . . .37 

Blake (Dr. James) per Dr. Bamea, modification of Hodge's 

pessary ...... 137 

Blood, see Transfunan, 

Bbtant (Mr. Thomas) fibro-cystic disease of uterus and both 

ovaries, extirpation of the whole, recovery . 79 

— — Discussion on ditto • . . . .82 

CsBsarean section in 1866, subsequent natural pregnancy and 

delivery (Dr. W. Newman) . . . .142 

Cancer of the cervix uteri causing poet-partum hsBmorrhage 

(Dr. H. Smith) . . . . .67 

Carcinoma uteri, Beport on Dr. P. Smith's case of (Dr. Madge) 324 
Cases in practice (Mr. Bassett) . . . .58 

ditto (Ml-. J. Milward) . . .146 

Cephalotribe invented by Prof Martin, of Berlin . 65 

Chorea, dissection of uterus of a woman dying of . 196 

Cleveland (Dr.) BemarJcs on the operaticm of transfusion . 103 
Contraction, irregular uterine (Dr. Trenholme) . 231 

Cystic disease of ovary, see Ovary. 

Datis (Dr. Hall) inversion of the uterus after childbirth in a 
primipara: amputation by ^craseur at expiration of ten 
months on account of hsBmorrhage with great exhaustion 104 

Diaphragm, india-rubber, and pessary for treatment of flexions 

of the uterus (Dr. Wjnn Williams) .307 



J 



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364 INDEX. 



PAQB 



Drainage, on the treatment of suppurating oyarian cysts by 

(Dr. PhilHps) . . . .340 

Dubois (Baron Paul) obituary memoir \ . . .30 

Duncan (Dr. Matthews) long delay of labour after discharge 

of the liquor amnii • . • . . 216 

—*- DiscuMion.on ditto . .... 225 

Dysmenorrhoea, on the essential cause of, as illustrated by cases 

of partial and complete retention (Dr. Barnes) . . 108 
from cicatricial closure of yagina following labour • 112 

Edis (Dr. Arthur W.) on the systematic examination of the 
abdomen with a view to rectifying malpositions of the foetus 
in cases of labour ..... 331 

Di8CU88i4)n on ditto ..... 338 

— — Bemarha on incision through the vagina and extraction of 

foetus by forceps in extra-uterine pregnancy . . 320 

Eledum of New Fellowe 1, 35, 65, 101, 135, 209, 231, 259, 305, 323 
Election of New Sanorary Fellows [Drs. Pordyce Barker, Otto 

Spiegelberg, and T. Gaillard Thomas] . . .259 

Empyema^ on the treatment of, in children (Dr. Playfair) . 4 

PAoas (Dr. Hilton) Bemarha on the treatment of empyema in 

children . . . . . .17 

Pergfuson (Dr. Bt.) on the irritable uterus (quoted) . . 110 
Pibroids, uterine, complicating pregnancy, case of (Dr. Madge) 227 
Pibro-cystic disease of the uterus (Dr. Hicks) . . 66 
of uterus and ovaries, extirpation, recovery (Mr. T. Bryant) 79 

— tumour of uterus, Report on (Dr. Moxon) . . 80 
Pibro^myoma of uterus, Ee^ort on (Mr. Groodhart) • . 81 
Plexions, see Uterus, 

Poetusat fourth month enclosed in a perfect sac (Dr. H. Smith) 66 

malposition o^ in labour, systematic examination of ab* 

domen for rectifying (Dr. Edis) . . . 331 
ditto, bibliography of the subject . , 337 

— deformed (Mr. Worship) . .139 

Gestation, extra-uterine, see Pregnancy. 

GODFBBY (Dr. B.) per Dr. B. Sicks, specimen of Cfyphilitic 

disease of the placenta «... 137 

— Cfyphilitic disease of placenta, farther particulars . 211 
CtoODHABT (Mr. J. P.) Beport on fibroid myoma of uterus 81 



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INDEX. 865 

PAaB 
Oonktone (Dr. John Griffith) obitoaiy notice . ,38 
Gbieyes (Mr.) fodtus with a peculiar growth from the mouth • 139 
'. jBepor* on ditto by Dr. Watt Black and Dr. Potter . 210 

HsBmatocele, retro-uterine, case of, with remarks on the source 

of the hsdmorrhage (Dr. Snow Beck) . • .260 

Hnmatoma, pelvic, or retro-uterine hssmatocele, case of, with 

remarks on the source of the hsBmoirhage, &o, (Dr. Snow 

Beck) . . . .. . ,260 

Hsemorrhage, placenta prsBria, without, at time of deliyery (Mr. 

Bassett) . . . .60 

— — on the source of, in retro-uterine hasmatocele (Dr. Snow 

Beck) . . . . .260 
accidental, fatal in seyen hours, without deliTery (Mr. 

Bassett) • • . • • ,58 
uterine, treatment of certain forms of, by the sponge tent, 

with reference to women residing in tropical climates (Dr. 

Bantock) . . . . . .84 

<-«— amputation of inyerted uterus by ^craseur on account 

of (Dr. H. Davis) . . . . . 104 
secondary post-partum, death from, after deliyery of a 

five months' fostus (Dr. H. Smith) « . .67 

Heckford (Dr. Nathaniel) obituaiy notice . . .34 

Hewitt (Dr. Graily) on chronic congestion of uterus in women 

residing in tropical climates (referred to) . .94 

— — Bemarhs in favour of the adoption of the plan for the 

examination of midwives . .23 
on the production of flexions of the uterus, by strains 

and accidents . > . . . 358 
Hicks (Dr. Braxton) Address as President, January 3rd, 1872 . 25 
specimen of fibro-cystic disease of the uterus (referred to 

Committee) . . . .66 

the anatomy of the human placenta • . 149 

— «ee Oodfrey, Grieves. 

— «^marJb on Dr. Meadows's explanation of the origin of 

ovarian cysts . • * . - . . .43 

— on retroflexion as naturally a cause of abortion . 57 

..... on Dr. Martin's cephalotribe . . .66 

on Mr. Bryant's case of extirpation of uterus and 

ovaries in fibro-cystic disease • . . .82 

• on Dr. Trenholme's paper on irregular uterine con- 



traction ...... 239 



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306 rNDEX. 

PAOB 

HiOKS (Dr. Braxton), Bemarha on post-mortem parturition - 255 

Beferei^cd to a case of labour oompHeated with a large 

fibroma . • • • ^^ 

Bemcwhs on the danger of removing the cyst in extra-uterine 

gestation ....•• 318 

■■ on abdominal examination' for rectifying malpositiona 

offoBtiur ...... 339 

- on the action of the bladder in causing retroflexion 



of the uterus ..... 359 

Hooo (Dr. F. B.) acoount of the Military Lying-in Hoqntal at 

Woolwich . . . . .35 

Jalulkd (Mr. Robert) case of yaginal thrombus 43 

Kendall (Mr. Tho. M.) of King's Lynn, obituary notice 33 

Labour, see ParturiUon, 

Lazzati (Dr. Pietro) obituary notice . .30 

lAJtn'cmj of the 8odet^BepcH<miU progress, 1%11 . 20 

Ligature, changes in the pedicle of an OTarian tumour when 

treated by (Dr. Bantodc) . . . .2 

Liquor amnii, long delay of parturition after discharge of (Dr. 

M. Duncui) . . . . .216 

List of Offioers elected for 1S72 . .19 

ditto /or 1873 . . . . . v 

€f Honorary FeUows . . . . xi 

of Ordinary Fellows ..... xiv 

of deceased FeUows, 1871 [with obituary notices, which see] 30-34 

of past Presidents . . . . vi 

of Referees of Papers . . . vii 

of Standing Committees . . viii, ix 

of Honorary Locdl Secretaries , x 

Low (Alexander James) of Jersey, death of . . .33 

Lowndes (Mr. F. W.) statistics of stillbirths . . 283 

Lying-in Hosf^tal (Military) at Woolwich, account of (Dr. 

Hogg) . . . . . .35 

Mabgb (Dr. H.) case of uterine fibroids complicating pregnancy 227 

Report on Dr. Protheroe Smith's case of carcinoma uteri . 324 

Remarhs on syphilitic disease of the placenta . . 138 

on the duration of life in the foetus after the death of 

the mother ... . , . 257 



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INDEX. 367 

PAGB 

Madob (Dr. H.)y Bemarks on the danger of removing the plaeenta 

in operations for ertra-nterine pregnanoy . . 319 
on auBcnltf 

nteroB 
Malpositions, see Foetu 
Ma£tin (Dr. A. E.) d< 

Martin, of Berlin 
■ Bemarks. OIL the j 

Royal University 

gift df photograph 

Meadows (Dr. A.) on 

cystic disease of t] 

DiacvMum on diti 

case of extra-ntei 

Report on, 

Meadows • 
on the treatment 

with a case 

Disctiseion on diti 

Bemarhe on Dr. 

with the placenta i 
Meeting, Annual Chner 
Menorrhagia, treatmei 

with reference to ' 

Bantock) . 
Middleton(Dr. J.W.) 
Midwives, Examinatio 

rehxtive to the sanu 
Bemarks of Dr. 

of the adoption of 
MiLWABD (Mr. Jas.) 

and monstrosity t 

two fingers issoinj 
Monster, acephalous Q 
Monstrosity, left arm 

issuing from the s 
MoxoN (Dr.) Beport o: 
MuNDE (Dr.) see Stmt 
MuBBAT (Dr. G. 0. P 

abdominal openin 

nancy 



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Google 



868 INDEX, 

PAQB 

Nbwman (Dr. Wm.) OflBearean section in 186^, snbeeqnent 

pregnancy and delivery per yias natorales, reooyery . 142 

-— — Diaoussion on ditto ..... 147 

Obituary notices of Deceased Fellows (Honorary) :— 

Pietro Lazzati, M.D., of Milan . .30 

Baron Panl Dubois, of Paris • . . .30 

— ditto (Ordinary) : — 

Thomas Hawkes Tanner, M.D. . .32 

Alexander James Lowe, M.B.O.S. (Jersey) . 33 

John Griffith Gonlstone, M.D. (Liverpool) . 33 

Henry James Shirley, P.R.O.S. (Ash, Kent) . . 33 

^omas M. Kendall, F.B.C.S. (King's Lynn) . . 33 

John W. Middleton, M.B.C.P. Ed. (Brosseb) . 33 

Nathaniel Heckford, M.D. • . . .34 

Ovaries, account of the cases of three sisters in whom the, and 

the uterus were absent (Dr. Squarey) . . . 212 

cystic disease of, on the probable origin of certain forms 

of (Dr. Meadows) . ' . . • .39 

fibro-cystic disease of, extirpation, recovery (Mr. Bryant) 79 

Ovarian cysts, suppurating, on their treatment by drainage 

(Dr. Phillips) • . • . .340 

tumour, changes in pedicle of, when treated by ligature 

(Dr. Bantock) . . . . .2 

Ovum, aborted, description of one which came ai^y complete 

with the decidual coverings .... 204 
' examination of one expelled seven weeks after last men- 
strual epoch . • . . « 206 

Parturition, destruction of the uterus in a severe (Mr. Bassett) 61 
^— -^ long delay of, after discharge of the liquor amnii (Dr. M. 

Duncan) . . . . . .216 

on post-mortem, with references to forty-four cases (Dr. 

Aveling) . . . . . .240 

Pedicle of an ovarian tumour, changes in, when treated by liga- 
ture (Dr. Bantock) . . , . .2 
Pelvimetry, on (Dr. Martin) . . . .71 

Pelvis collection of the Boyal University Maternity of Berlin 

(Dr. Martin) . . . . .71 

Pencil, cedar, four inches long, covered with a calcareous mass, 

extracted from the bladder of a girl set. 18 (Dr. Phillips) . 37 
Pesscuries (medicated) for interior of cervix uteri (Mr. L. Tait) 323 
Pessary, Hodge's, modification of (Dr. J. Blake) . . 137 



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INDEX. 369 

PAGB 

Pessary with india-rubber diapbragm for treatmeDt of flexions 

of tbe uterus (Dr. Wynn Williams) . . . .303 

Phillips (Dr. J. J.) cedar pencil, four inches long, coTered 
with a calcareous mass, extracted from the bladder of a 
girl set. 18 . . . . . .37 

on retroflexion of the uterus as a frequent cause of abor- 
tion . • . . . .45 

— ^ Discussion on ditto . . . . .53 

on the treatment of suppurating ovarian cysts by drainage 340 

Discussion on ditto ..... 343 

Befnarhs on the removiJ of a muco-cellular polypus 

attached to the cervix .... 136 
on cases of absence of uterus and ovaries . . 214 



on the difficulty of diagnosing fibro-cystic disease of 

uterus from multilocular ovai-ian tumour . . 307 

. on the insufficiency of simple tapping in extra-uterine 



pregnancy ...... 320 

Placenta, anatomy of the human (Dr. B. Hicks) . . 149 

— references to where lists of authors on the subject of its 
anatomy may be found . . . 150 

criticism on the Hunterian theory relative to a sinus 

system in . . . . . 150, &c. 

argument that there is no period of transition if a sinus 

system exist . . * « 158 

ditto that from dissections early or late in pregnancy 

there is no evidence of the existence of a sinus system . 165 

description of the anatomy and mode of growth of pla- 
centa, based on dissections .... 173 

considerations from pathological conditions . . 185 

description of dissections of placenta in sUHi, detached, 

diseased, and abortions, referred to in Dr. Hicks's paper . 190 

^— dissection of a . . . 199 
examinations of mature, in so-called " fatty " con- 
dition ..... 200-207 

mode of dealing with, in gastrotomy for removing the 

foetus in extra-uterine gestation (Dr. Barnes) . . 325 

syphilitic disease of (Dr. Godfrey) . . 137, 211 

Placenta prsevia without haemorrhage at the time of delivery 

(Mr.Bassett) . . . . .68 
Platfaib (Dr.) on the treatment of empyema in children . 4 
Discussion on ditto . . . . .17 

— Eemarks on the defibrination of blood in transfusion . 102 
VOL. XIV. 24 



dro INDEX. 



PAGB 



FuLTFAnt (Dr.) Remarka on Br. Barnes's paper on the cause 

of dysmenorrhoea ..... 127 

— — on Dr. Newman's case of natural pregnancy subse- 
quent to Osesarean section .... 147 
- on Dr. Madge's case of uterine fibroids complicating 



pregnancy ...... 230 

> on Dr. Basch's opinion as to temperature in the dia- 



gnosis of pelvic bsematocele and pelvic cellulitis . . 280 

. on Mr. Lowndes's paper on the statistics of stillbirths 303 



— on abdominal palpation for rectifying malposition 



of the uterus . . . .338 

Polypus, large-sized mucous (Dr. Wynn Williams) . . 135 

FOTTBB (Dr. J. B.) Report on Mr. Grieves's case of a foetus with 

growth firom the mouth . • . • 210 

Pregnancy, natural, and deliyery, subsequent to Caesarian sec- 
tion (Dr. W. Newman) . . . .142 

— case of uterine fibroids, complicating (Dr. Madge) . 227 
— — tumour of uterus complicated by (Mr. Worship) . 305 
rupture of a yarix in the genital organs during (Mr. 

Bassett . . . .60 

-— - extra-uterine, on the treatment of some forms of (Dr. 

Meadows) . . . . .309 

....^ .....^ mode of dealing with the placenta in gastrotomy for 

(Dr. Barnes) . . . . .325 

Rabcb (Dr.) EenwrkB on Dr. Phillips's paper on retroflexion as 

a cause of abortion . . . . .55 

— — — on Prof. Simon's scoop for removing superficial 

portions of cancer of the uterus . . . 209 

— — — on the smell of liquor amnii as diagnostic in alleged 
discharge of the waters .... 226 

*— — — on temperature as a help to diagnosis in retro- 
uterine hcematocele ..... 279 

BieeeypU and Expenditure of the Ohdetrieal Society, 1871 20 

B^port of the Auditors for 1S71 . . .19 

Beport of (he Eon. Librarian • . . .20 

Betroflexion of the uterus as a frequent cause of abortion (Dr. 

Phillips) . . . . . .45 

BOGSBS (Dr.) Bemarhs on Dr. Barnes's paper on the cause of 

dysmenorrhoea ..... 131 

*— on a case of difficult parturition, from a hard, rigid, 

and unyielding cervix, &c, , . $ . 148 



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INDEX. 371 

PA6B 

BoGEBS (Dr.), BemarJcs on cases of absence of nteros . 215 

RouTH (Dr.) Remarks in favour of the adoption of the plan for 

the examination of midwives . . . .24 

— on abortions being caused more by syphilitic taint 

than from any flexions of the uteiTis . . .54 

on a case of mucous polypus . . . 137 

— on pregnancy as hastening, not retarding, the 

development of cancer .... 149 

• on the relative frequency of ante- and retro-flexions 



of the uterus ..... 358 

Scissors, angular (Dr. H. Smith) . . . .68 

modification of ditto by Dr. H. Smith . . .103 

Scott (Mr.) BemarJcs on the danger of metroperitonitis from 

the use of sponge tents . . . .100 

on Dr. Snow Beck's paper on retro-uterine hsematocele 280 

— — on Dr. Wynn Williams's pessary for flexions of the 

uterus ...... 308 

■ on Dr. Meadows's paper on extra-uterine gestation . 318 



Sedgwick (Dr.) BemarJcs on Dr. Playfair's plan of treatment 

for empyema in children . . . .18 

Shirley(Mr. H. J.)of Ash, Kent, deathof . . .33 

Simon (Prof.) of Heidelberg, per Dr, Mwnde, scoop for removing 

superficial portions of malignant disease of the cervix . 209 
Sims (Dr. Marion) on the remedial powers of the sponge tent 

(referred to) . . . . .98 

Smith (Dr. Heywood) preparation of a foetus at fom*th month 

enclosed in a perfect sac . . . ,66 
uterus of a patient who died, four days after delivery of a 

five months' foetus, of secondary post-partum hsemorrhage 67 

angular scissors . . . . .68 

modification of his " aogular scissors " . . 103 

BemarJcs on cases of absence of uterus, &c. . . 215 

on temperature and other means of differential 

diagnosis of pelvic hsematocele . . . . 281 

- on the frequency of anteflexions of the uterus . 358 



Smith (Dr. Frotheroe) BemarJcs on the escape per vaginam of 

the fluid contents of fibro-cystic growths of the uterus . 307 

on the treatment of extra-uterine gestation without 

operation ...... 319 

case of carcinoma uteri, Beport on (Dr. Madge) . . 324 

Speculum, a modification of Neugebauer's (Dr. Barnes) . 309 



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372 iKbEX. 

t±Qn 
Spiegelberg (Dr. Otto) election as an Honorary Fellow . 259 

Sponge tent, treatment of certain forms of menorrhagia and 

uterine hsemorrhage by, with reference to women residing 

in tropical climates (Dr. Bantock) . . .84 

Squabby (Dr. 0. E.) short account of the cases of three 

sisters in whom the uterus and ovaries were absent . 212 

DwcuMton on ditto ..... 214 

— — on the causation of acquired flexions of the uterus, and 

their pathology ..... 345 

— DiacusMwn on ditto . . . . . 368 
Stillbirths, statistics of (Mr. Lowndes) . . . 283 
Syphilitic disease of the placenta (Dr. Gk>dfrey) 137, 211 

Tait (Mr. Lawson) per Dr. WiUshire, instruments for applica- 

tion of medicated tents to the interior of the cervix uteri . 323 

Tanner (Dr. Thomas Hawkes) obituary memoir . . 32 

Tatlob (Mr.) BemarJea on a case of paracentesis for empyema 17 

Thomas (Dr. Gaillard) election as an Honorary Fellow . 259 
Thrombus, vaginal, case of (Mr. Jalland) . . .43 
Tilt (Dr.) Bemarka on Dr. Phillips's paper on retroflexion as a 

cause of abortion . . . . .53 

— on Dr. Bantock's paper on uterine hemorrhage . 100 

on Dr. Barnes's paper on the cause of dysmenorrhoBa 132 

'— on the difficulty of diagnosing absence of ovaries . 215 

on a case of voluminous monolocular cyst treated by 

drainage and iigection .... 343 
—^ on menstrual derangement in women who have resided in 

India (referred to) . . , . ,94 

Transfusion, apparatus for immediate (Dr. Aveling) . . 101 

— Motion far a Committee to inveetigate the eubject of . 103 
Tbbnholme (Dr. E. H.) irregular uterine contraction . 231 
Tumour of the uterus complicated by pregnancy (Mr. Worship) 305 
" fibrous, from anterior wall of vagina (Dr. Barnes) . 309 

— see Uterus. 

tJterus, dissection of, at sixth month of pregnancy « , 190 
—^— ditto, at about the third month . . . 193 
— — ditto, at about the fourth month . . 195, 199 
ditto, at three and a half months, the woman dying of 

chorea . . . . *. « 196 
"— account of the cases of three sisters in whom it and the 

ovaries were absent (Dr. Squarey) . , 212 



Digitized by VjOOQIC 



INDEX. 873 

uterus, irregrUar contraction of (Dr. Trenholme) . , 231 

destruction of the, by a severe labour (Mr. Bassett) . 61 

— — flexions of, pessary with india-rubber diaphragm for treat- 
ment of (Dr. Wynn Williams) . , . 303 

acquired flexions of, on the causation and the pathology 

of(Dr.Squarey) . . . . 345,353 

inyersion of, after childbirth in a primipai*a, amputation 

by 6craseur on account of haemorrh^ (Dr. H. Davis) . 104 

retroflexion of, as a frequent cause of abortion (Dr. 

Phillips) .45 

carcinoma of, BepoH on Dr. P. Smith's case of (Dr. 

l^^^ge) . . . , .324 

• tumour of, complicated by pregnancy (Mr. Worship) . 305 

fibroids of, complicating pregnancy (Dr. Madge) . 227 

— fibro-cystic disease of (Dr. Hicks) . . .66 
— — — ■ extirpation, recovery (Mr. T. Biyant) . . 79 

— — B^ort on (Dr. Moxon) . . .80 

— fibro-myoma of, Beport on (Mr. Goodhart) . 81 
— — cervix uteri, cancer o( causing post-partum hasmorrhage 

(Dr. H. Smith) . . . ,67 

Yagina, cicatricial closure of, following labour, retention of 

menstrual fluid, dysmenorrhcsa . . . 112 

fibrous tumour from anterior wall of (Dr. Barnes) . 309 

Yaginal thrombus, case of (Mr. Jalland) . . .43 

Yarix, rupture of a, in the genital organs during pregnancy, 

syncope, recovery (Mr. Bassett) . ,60 



Wells (Mr. Spencer) BemarJcs on Mr. Biyant's case of extirpa* 

tion of uterus and ovaries in fibro-cystic disease • . 83 

on the causes of dysmenorrhcea . , . 132 

W1LLL/LM8 (Dr. Wynn) large-sized mucous polypus . , 135 

pessary with india-rubber diaphragm for treatment of 

flexions of the uterus .... 308 

Beport on Dr. Meadows's case of extra-uterine foatation . 70 

— - BemarJcB on Dr. Phillips's paper, andon retroversion as a 

more frequent cause of sterility than retroflexion . 56 

— on the natural and safest mode of operation in extra- 
uterine pregnancy ..... 320 
WiLTSHiss (Dr.) Bemarkt on the origin of cystic disease of the 
ovary from the par ovarium . .4 



Digitized by VjOOQIC 



S74 INDEX. 

PAOB 

WiLTSHlBE (Dr.), Bemarka on the use of Dr. Barnes's india- 
rubber dilator in placenta prsBvia . . .63 

— — on syphilitic placentitis . . . 138 

— on Mr. Grieves's case of foetus with growth from the 

mouth ...... 211 

— on cases of malformation of uterus . . 216 

against the closure of the wound after gastrotomy for 

extra uterine foetation .... 321 

see TaU (L.). 

Woolwich, account of the Military Lying-in Hospital at (Dr. 

Hogg) . . . . .35 
WOBSHIP (Mr. J. L.) specimen of deformed foetus . . 139 
tumour of the uterus complicated by pregnancy . 305 



-^ 



\ 

\ 



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Akdbeii^i (R.). See Bizzoli, Clinique Chirurgicale (tra- 
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AiTKEB (G.). Etude des causes de la Mortalite exces- 
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Akstie (Francis E.). Neuralgia and the Diseases that 

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Babquissau (Stephane). De TEclampsie Puerpfirale. 

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Bbeisky (A.). ITeber die Behandlung der puerperalen 

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Chabpektieb (A.). De Tinfluence des divers traite- 

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Chiaba (Prof. D.). Osservazione di Cefalotrissia per 
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Dawson (Benjamin P.). See KloVa Pathological Ana- 
tomy, AC. (translated). 

Demabqitay ( — ), De TOst^omy^lite dans ses rapports 

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Depatjl (J. A. H.). Lecons de Clinique Ohst^tricale 
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Debpeybotjx (Henri). Etude but les ITlc^rations du 
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coloured plate, 8vo. Paris, 1872 Purchased. 

DoHBiir (Rudolf). ITeber Beckenmessung. 

(Yolkmann's Sammlung, No. 11) roy. 8yo. Leipzig, 1870 Ditto. 

Dubois (Paul). Querverengte Becken, see Bdbert (P.). 

E50ELHABDT (C. Y.). Die Eoteutiou des Qebarmutter- 
vorfalles durch die Kolporrhaphia posterior. 

8vo. Heidelberg, 1871 Ditto. 

Fabbbi (Ercole Pederico). Compressione del Punicolo 
ombelicale ayyolto al Collo, e considerazioni sul 
Meccanismo del Parte nelle posizioni posteriori. 

plate, 8vo. Bologna, 1872 Author. 

Pabbbi (Oiambattista). Descrizi(^ne di una Pelvi ob- 
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alle cause e al mode di prodursi delle Deformity 
che vi Bono. 4to. Bologna, 1861 Dr. A. Farre. 

Another copy. Dr. 

Meadows. 

Biunione ossea di alcune Fratture entro-capsulari 

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■ Idrorrea dell* Utero Gravido e sua eventuale 

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4to. Bologna, 1871 Author. 

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Gleitn (Robert George). A Manual of the Laws 

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GuEEiK (Alphonse). Maladies des Organes G^nitaux 

Extemes de la Femme. 8yo. Paris, 1864 Ditto. 

QussEBOW (A.). Zur Lehre vom Stoffwechsel des Foetus. 

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imp. 8ro. St. Petersburg, 1870 Ditto. 

Habtmaiw (Karl). Ein Fall von Extrauterin-Schwan- 

gerschaft. 8yo. Tiibingen, 1871 Ditto. 

Harveian Oration, 1872, see Farre. 

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Hewitt (Qraily). The^ pathology, diagnosis, and treat- 
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Leipzig, 1872 Purchased. 

Hogg (Francis E.). Sick Children, a Lecture at the 
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8vo. Lend. 1872 Author. 

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die Geburt. 2. Ehacbitis und Osteomalacic ihre 
Identitiit und Einwirkung auf das Becken und die 
Geburt. plates, 4to. Leipzig, 1852 Dr. A. Farre. 

Holmes (T.). See Swrgery (System of). 

Hooper (Eobert). Morbid Anatomy of the Human 
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Organic Diseases to which those viscera are 
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HUGEITBERGER (Th.), Sen. Ein kyphotisch querve- 
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KiLiAK (Hermann Friedrich). Schilderungen neuer 
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Kleikwaohter (Ludwig). Die Lehre von den Zwillin- 

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Klob (Julius M.). Pathological Anatomy of the Female 
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Lake (Samuel A.). See Cooper's Dictionary of Surgery. 

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MiOHELS (Louis). The Chronic Diseases of Women, 
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MuBPHY (Edward William). Lectures on the Principles 
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Museum. — Museo Ostetrico di Q-. A. Galli, see Fahbri» 

Nadaud (P. A. Hilaire). Paralysies Obstetricales des 

Nouveau-n6s. 8vo. Paris, 1872 Ditto. 

Naeoele (Pranz Carl). Das Schrag verengte Becken, 
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plates, 4to. Mainz, 1850 Dr. A. Parre. 

Nolly (M.). Manuel d'Obst^trique. 

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NiOHTnroALE (Florence) . Introductory Notes on Lying- 
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Noeooebath (Emil). Die Latente Q-onorrhoe im Wei- 
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Schadel des neugeborenen Kindes (Yolkmann*s 
Sammlung, No. 8) roy. 8vo. Leipzig, 1870 Purchased. 

Ueber puerperale Parametritis und Perimetritis, 

(Yolkmann's Sammlung, No. 28) 

roy. 8vo. Leipzig, 1871 Ditto. 

Pelvis. — Pour Drawings of a Female Pelvis of a Dwarf, 
with MS. Description (from the Madras Medical 
Begister). 

QuiNQXTAun (Euffene). Essai sur le Puerperisme In- 
fectieux, chez la femme et chez le Nouveau-n^. 

woodcuts, 8vo. Paris, 1872 Ditto. 



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ADDITIONS TO THE LIBRARY. 



Fresented hy 



Eamsbotham (Francis H.). Principles and Practice of 
Obstetric Medicine and Surgery in reference to 
the process of Parturition ; fifth edition. 

plates, 8vo. Lond. 1867 Purchased. 

Eantiee (L.). See Cornil et Eanvier (Histologic). 

KiTTEB von Eittershain (0-.). See Joumtals (Oester- 
reichisches Jahrhuch^v Paediatrik). 

EizzoLi (Francesco). Frattura artificiale accavallata del 
Femore destro per togliere una claudicazione a 
sinistra, &c. plates, 4to. Bologna, 1871 Author. 

Clinique Chirurgicale : Memoires de Chirurgie et 

d'Obstetrique, traduits de Tltalien par E. Andreini. 

woodcuts, 8vo. Paris, 1872 Ditto. 

EoBEET (F.). Ein durch mechanische Verletzung und 
ihre Folgen querverengtes Becken im Besitze von 
Herrn Paul l)ubois. plates, 4to. Berlin, 1853 Dr. A. Farre. 

Egberts (D. Lloyd). Historical and Critical Sketch of 
the various methods of Treating the Pedicle in 
Ovariotomy (from Manchester Med. Eeports). 

8vo. Lond. 1871 Author. 

Eobertsok (F. M.). Modification of the Obstetrical 
Forceps, with practical observations on their 
application. 8vo. New York, 1872 Ditto. 

Eooee (Henri). Eecherches cliniques sur les Maladies 

de TEnfance. 8vo. Paris, 1872 Purchased. 

Tome 1. 

EouBAUD (Felix). Traits de Tlmpuissance et de la 
Sterilite chez Thomme et chez la femme ; deuxi^me 
edition. 8vo. Paris, 1872 Ditto. 

Sanger (W. M. H.). Ilandboek der Verloskunde. 

plates, 8vo. Q-roningen, 1873 Author. 

Sohroedeb (Karl). Ueber das Verhalten des Hymen. 

8vo. 1871 Ditto. 

Lehrbuch der Geburtshiilfe, mit Einschluss der 

Pathologic der Schwangerschaft und des Wochen- 
bettes ; dritte Auflage. 

woodcuts, 8vo. Bonn, 1872 Ditto. 

Ueber Aetiologie und intrauterine Behandlung 

der Deviationen des Uterus nach vorn und hinten. 
(Volkmann's Sammlung, No. 37) 

roy. 8vo. Leipzig, 1872 Purchased. 

■■ Another copy. 8vo. Leipzig, 1872 Author. 



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ScHTJLTZB (Bemhard S.). Ueber ZwillingsBchwanger- 
Bcbaft. (Volkmann's Sammlung, No. 34) 

roy. 8vo. Leipzig, 1872 Purchased. 

Sektsx (Louis), fitude statistique et clinique sur les 
Positions Occipito-Post^rieures (Ouvrage couronn^ 
pap TAcad^mie de Medecine). Svo. Paris, 1872 Ditto. 

SiMPSOK (Alexander R.). See Simpson (J. Y.) On 
Diseases of "Women. 

Simpson (Sir Jas. T.), Clinical Lectures on the Diseases 
of Women; edited by Alexander E. Simpson 
(vol. 3 of Works). tooodcuts, 8vo. Edin. 1872 Ditto. 

Smith (Henry Ply). The Handbook for Mid wives. 

woodcuts, 12mo. Lond. 1872 Author. 

Smith (W. Tyler). Parturition, and the Principlea and 

Practice of Obstetrics. 12mo. London, 1819 Purchased. 

Spiegelbero (Otto). Uebor das Wesen des Puerperal- 
fiebers (Volkmann's Sammlung, No. 3). 

roy. 8vo. Leipzig, 1870 Ditto. 

■ Zur EntstehuDg und Behandlung des Vorfalls der 

Scheide und Gebarmutter (Berliner Klin. 
Wochenschrift). Breslau, 8vo. 1872 Author. 

Steiner ( Johann) . Compendium der Kind erkrankhei ten 

fiir Studirende und Aerzte. 8vo. Leipzig, 1872 Purchased. 

Surgery. — A System of Surgery, theoretical and practical, 
in Treatises by various Authors ; edited by T. 
Holmes ; second edition. 

plates, 6 vols. 8vo. Lond. 1870-1 Ditto. 

Vol. 1. — General Pathology. 

„ 2. — Local Injaries. 

„ 3. — Diseases of the Eye and Ear, of the Organs 
of Circalation, Muscles and Bones. 

„ 4. — Diseases of the Organs of Locomotion, of 
Innervation, of Digestion, of Bespiration, 
and of the Urinary Organs. 

„ 5. — Diseases of the Qenitol Organs, of the Breast, 
Thyroid Qland, and Skin. Operative Sur- 
gery. Appendix. 

Sykkesttedt (A. S. D.). En Anatomisk Beskrivelse af 
de paa over-og underextremiteterne forekommendo 
BursfiB MucosflD, udgivet ved Dr. J. Voss. University of 

plates, 4to. Christiania, 1869 Christiauia. 

Taohabd ( — ). De I'filectricite appUquee k TArt des 

Accouchements. 8vo. PariSi 1871 Purchased. 



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Presented by 
Thomas (Abraham Eterard Simon). Das schraeg- 
verengte Becken von seiten der Theorie und 
Praxis, nach deoi gegenwaertigen Stand der Wissen- 
schaffc. plates, 4to. Leyden, 1861 Dr. A. Farre. 

Thomas (T. Quillard). A Practical Treatise on the 
Diseases of Women ; third edition. 

iooodcutSy Svo. Philad. 1872 Purchased. 

Thorburn (J.). On the Treatment of Tedious Labour 

in the Second Stage. Svo. Lond. 186G Author. 

Eemarks on One hundred and thirteen eases of 

Forceps Delivery. Svo. Lond. (1871) Ditto. 

Tripier (A.). Lesions de forme et de situation de 
rUt^rus ; leurs rapports avec les Affections Ner- 
veuses de la Femme et lenr Traitement. 

Svo. Paris, 1871 Purchased. 

TuRKER (William). On Malformations of the Organs of 
Generation, 1st and 2nd Series. 

woodcuts, 8vo. Edinb. 1865-6 Author. 



On the Gravid Uterus, and on the Arrangement 



of the Foetal Membranes in the Cetacea (Orca 
Gladiator). 

(from Edinb. Eoy. Soc. Trans., vol. 26) 

plates, 4to. Edinb. 1871 Ditto. 

Valeitta (Alois). Die Catheterisatio Uteri als wehener- 
zeugendes und wehenverbesserndes Mittel. 

Svo. Wien, 1871 Purchased. 

Veit (G.). Krankheiten der Weiblichen Geschlechts- 
organe. Puerperalkrankheiten ; zweite Auflage 
( Virchow's Handbuch der Pathologie, Band 6, 
Abth. 2, Heft 2). woodcuts, Svo. Erlangen, 1867 Ditto. 

Verardh^i (Ferdinando). Studi monografo-clinici in- 

tomo TErnia Diaframmatica. Svo. Eoma, 1870 Author. 



- Eettificazioni storico-critiche intomo il Parte 
Forzato o Parte Istantaneo Artificiale per le vie 
natural! nelle morte incinte e nolle presunte tali. 

Svo. Bologna, 1872 Ditto. 

- Sul Crampo degli Scrittori e sopra un nuovo 

Porta mano. Svo. Bologna, 1872 Ditto. 

- Elenco delle sue Opere scientifico-pratiche. 

Svo. 1872 Ditto. 



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Presented hy 
Yolkmavn's Sammlung Elimsclier Yortrage. 
See under the names in italicB. 

8. SpiegeXbergt Paerperalfieber. 

8. OUkanuen, Yerandening am SchadeL 

11. Dohm, Beckenmessung. 

14. Breitky, Paerperalen Blutnngen, 

20 1 

03] I* I^tzmawn, Enge Becken* 

28. Ohhausen, Parametritis. 

82. JEKldehran^t, Katarrh der Geschlechtsorgane. 

84. SchuUzej ZwiUingsschwangenchaft. 

87. Sekroeder, Deyiationen des Uterus, 

Yoss (J.). Inversio YesicaB UrinarisB og Luzationes 

Femorum congenitsB hos samme Individ. UniverBitj of 

plates, 4to. Ghristiania, 1857 Christiania. 



See Synnestvedt (Bursas Mucos®), 



Walter (Johannes G-.). De Dissectione Synchondroseos 
ossium Pubis in partu difficili (Lat. et G^rm.). ' 

plate. 4to. Berolini, 1782 Dr. A. Farre. 

WsiOHTiCAK (Hugh). The Law of Marriage and Legi- 
timacy ; with especial reference to the Legitimacy 
Declaration Act. 8yo. Lond. 1871 Purchased. 

Wells (T. Spencer). Diseases of the Oyaries, their 

Diagnosis and Treatment, 8vo. Lond. 1872 Author. 

West (Charles). De PeM Muliebri ejusque in partu 

id et dignitate : Diss. Inaug. 4to. Berolini, 1887 Dr. A. Farre. 

Whitehead (Walter). Cases and Notes on the Sur- * 

gery of Prolapsus Uteri and Elongation of the 
Cervix, 8vo. 1872 Author. 

WurcKEL (F.). Die Behandlune der Flexionem des 
Uterus mit intrautennen Elevatoren. 

platesy 8vo. Berlin, 1872 Purchased. 

Zaaijsr (Tennis). Beschrijving van twee Yrouwen- 
bekkens uit den Oost-Indischen Archipel. 

plates^ 8vo. Leiden, 1862 Author. 



— »— - Untersuchungen ueber die Form des Beckens 

Javanischer Fniuen. plates, 4to. Haarlem, 1866 Ditto. 

ZwEiTEL (Paul). Inaug, Diss. : Ueber Ovariotomie. 

diagram, Svo. Zurich, 1872 Ditto. 



VOL. XIV. 25 



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TRANSACTIONS. 

Presented by 
Ameeicak Mebioal Associatiok — 

See in G-SNBRix Cataloqttb (Nomenclature of 
Diseases). 

Andrew's (St.) Medical Gbaduatks' Associatiok — The 

Transactioiis, 1871. 8vo. Lond. 1872 Association. 

Clinical Society — 

Transactions, vol. 6. 8yo. Lond. 1872 The Society. 

Royal Medical and Chiburqical Society — 
Medico-Chirurgical Transactions, vol. 55. 

8vo. Lond. 1872 Ditto. 
Smithsonian Institution — 

Annual Report for 1870. The 

8vo. Washington, 1871 Institution. 

Gesellschapt fCjb Gebfrtshulfe zu Leipzig — 

Mittheilungen, 1870-1. 8vo. Leipzig, 1871 



JOURNALS. 

Braithwaite's Retrospect of Medicine. Vols. 23 to 55. 

12mo. Lond. 1851-67 Turchased. 
British and Foreign Medico-CSiirurgical Review (from 

1862 to 1867). 8vo. Lond. 1862-7 Ditto. 

New York Medical Journal. 8vo. New York, 1872— 

"Western Lancet (The), a Monthly Journal devoted to 
Medicine, Surgery, and the Collateral Sciences. 

8vo. San Francisco, 1872 The Editors. 



Gtizette des H6pitaux civils et militaires. 

4to. Paris, 1872— 

Union Mfedicale, 8vo. Fans, 1872 — 



Archiv fur GyiWBkologie, redigirt von Cred6 und Spiegel- Dr. 

berg. Band III, 8vo. Berlin, 1872 Spiegelberg. 

Jahrbuch (Oesterreichisches) fur Paediatrik, herausgege- 
ben von G. Ritter von Rittershain, und Maxiimlian 
Herz. Jahrgang, 1870— 8vo. Wien, 1870— Purchased. 



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REPORTS. 

Presented by 
Ete A.ND Eab Ikfirm^iby — MasBachosetts. Surgeon of 

46th Annual Report. 870. Boston, 1872 Infirmary. 

Hospitals — St. Bartholomew's Hospital Reports The Hospital 

Vol. viii, 8vo, Lond. 1872 Staff. 

Garrison Female Hospital, Woolwich. 

Statement of Accounts, Rules, &c. Dr.F.R.Hogg, 

12mo. Woolwich, 1872 R.H.A. 

Lying-in Hospitals — Qotunda Lying-in Hospital ; 
third Clinical Report, by George Johnston, M.D. 

8vo. 1872 Dr. Johnston. 



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