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OBSTETRICAL  TRANSACTIONS. 


VOL.    XL. 


TRANSACTIONS 


OF    THE 


OBSTETRICAL  SOCIETY 


OF 


LONDON. 

VOL.   XL. 
FOR   THE   YEAR   1898. 

WITH  A  LIST  OF  OFFICERS,  FELLOWS,  ETC 


EDITED    BY 

JOHN  PHILLIPS,  M.A.,  M.D.,  Senior  Secretary, 

AND 

PERCY   BOULTON,  M.D. 


LONDON : 

,  GREEN.  AND  CO. 

1899. 


PRINTED    BY    ADLARD    AND    SON,  BAETHOIOMEW    CLOSE,    E.C. 


i 


OBSTETRICAL    SOCIETY    OE   LONDO'N. 


OFFICERS    FOR     1899. 


PRESIDENT. 


DORAX,  ALBAN,  F.R.C.S. 
fBYERS,  JOHJS-  W.,  M.A.,  M.D.  (Belfast). 


VICE-  I  DAKIX,  WILLIAM  RADFORD,  M.D. 

PEEsiDENTS.    1  Dlj^CAX,  AYILLIAM,  M.D. 

HURRY,    JAMIESON    BOYD,    M.A.,    M.D. 

L      (Reading). 

TEEASTTEEE.        BLACK,  JAMES  WATT,  M.D. 

CHAIRMAN   OF 

THE  BOARD  FOR     L  BOULTON,  PERCY,  M.D. 

THE  EXAMINATION 
OF  MIDLIVES.       -' 

HONOEAET      ;  PHILLIPS,  JOHN,  M.A.,  M.D. 
SECEETARTES.    ^  SPENCER,  HERBERT  R.,  M.D. 

HONOEAET      l  jj^QUTH,  AMAND,  M.D. 

LIBEAEIAN.        -' 

OLDHAM,   HENRY,   M.D.    {Trustee  and  Past  Pre- 
sident) . 

WILLIAMS,  Sir  JOHN,  Baet.,  M.D.  {Trustee). 
POTTER,  JOHN   BAPTISTE,  M.D.  {Trustee  and 
Past  President). 

-{  PRIESTLEY,  SiE  WILLIAM  O.,  M.P.,  M.D. 

{Past  President). 
PLAYFAIR,  WILLIAM  S.,  M.D.  {Past  President). 
GERYIS,  HENRY,  M.D.  {Fast  President). 

CULLING  WORTH,  CHARLES  JAMES,  M.D. 

{Ex- President). 


EX-OFFICIO 

MEMBEES 

OF    COUNCIL. 


OTHEE 

MEMBEES 

OF    COUNCIL. 


^ 


ADDINSELL,  AUGUSTUS  W.,  M.B.,  CM. 

ANDERSON,  JOHN  FORD,  M.D. 

BARBOUR,  A.  H.  FREELAND,  M.D.  (Edin- 
burgh). 

BLACKER,  GEORGE  FRANCIS,  M.D. 

BOXALL,  ROBERT,  M.D. 

EDEN,  THOMAS  WATTS,  M.D. 

ERASER,  ANGUS,  M.D.  (Aberdeen). 

GILES,  ARTHUR  EDWARD,  M.D. 

HAYES,  THOMAS  CRAAYFORD,  M.D. 

HERMAN,  GEORGE  ERNEST,  M.B. 

McCAVV,  JOHN  DYSART,  M.D. 

NICHOLSON,  ARTHUR,  M.B.  (Brighton). 

PINHORN,  RICHARD  (Dover). 

REID,  AYILLIAM  LOUDON,  M.D.  (Glasgow). 

ROBERTS,  CHARLES  HUBERT,  M.D. 

ROBINSON,  GEO.  H.  DRUMMOND,  M.D. 

SINCLAIR,  AYILLIAM  JAPP,  M.D.  (Man- 
chester). 

STABB,  ARTHUR  FRANCIS,  M.B.,  B.C. 


z4-n 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

University  of  Toronto 


http://www.archive.org/details/transactions40obst 


LIST  OF  PAST   PRESIDENTS  OF  THE 
SOCIETY. 


1859  EDWARD  EIGBY,  M.D. 

1861  WILLIAM  TYLEE  SMITH,  M.D. 

1863  HENRY  OLDHAM,  M.D. 

1865  ROBERT  BARNES,  3I.D. 

1867  JOHN  HALL  DAVIS,  M.D. 

1869  GRAILY  HEWITT,  M.D. 

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

1873  EDWARD   JOHN   TILT,   M.D. 

1875  SiE  WILLIAM  OVEREND  PRIESTLEY,  M.D. 

1877  CHARLES  WEST,  M.D. 

1879  WILLIAM  S.  PLAYEAIR,  M.D. 

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

1883  HENRY  OERVIS,  M.D. 

1885  JOHN  BAPTISTE  POTTER,  M.D. 

1887  JOHN  WILLIAMS,  M.D. 

1889  ALFRED  LEWIS  GALABIN,  M.D. 

1891  JAMES  WATT  BLACK,  M.D. 

1893  G.  ERNEST  HERMAN,  M.B. 

1895  F.  H.  CHAMPNEYS,  M.A.,  M.D. 

1897  CHARLES  JAMES  CULLINGWORTH,  M.D. 


REFEREES  OF  PAPERS  FOR  THE  YEAR   1899 
Appointed  by  the  Council. 


BLACK,  J.  WATT,  M.D. 
CHAMPNEYS,  F.  H.,  M.A.,  M.D. 
CULLINGWORTH,  CHARLES  JAMES,   M.D. 
DAKIN,  WILLIAM  RADFORD,  M.D. 
GALABIN,  ALFRED  LEWIS,  M.A.,  M.D. 
GERVIS,  HENRY,  M.D. 
HANDFIELD-JONES,  MONTAGU,  M.D. 
HERMAN,  G.  ERNEST,  M.B. 
LEWERS,  ARTHUR  H.  N.,  M.D. 
MALINS,  EDWARD,  M.D.,  Birmingham. 
MEREDITH,  W.  A.,  M.B.,  CM. 
PLAYFAIR,  WILLIAM  S.,  M.D. 
POTTER,  JOHN  BAPTISTE,  M.D. 
ROUTH,  AMAND,  M.D. 
SUTTON,  J.  BLAND. 
WILLIAMS,  SiE  JOHN,  Baet.,  M.D. 


STANDING    COMMITTEES. 


BOARD  FOR  THE  EXAMINATION  OF  MIDWIVES. 


CHAiRMAi?.      BOULTON,  PERCY,  M.D. 

TATE,  WALTER  W.  H.,  M.D. 
POLLOCK,  WILLIAM  RIVERS,  M.B,  B.C. 
ROBINSON,  GEO.  H.  DRUMMOND,  M.D. 
OOW,  WILLIAM  JOHN,  M.D. 
r  DORAN,   ALBAN,  President. 
EX-oFFicio.  <^  PHILLIPS,  J.,  M.A.,  M.D.    ")  ^       ^ 

(SPENCER,  H.  R.,  M.D.  j  ^^"-  '^^^^• 


LIBRARY  COMMITTEE. 


CULLING  WORTH,  CHARLES  JAMES,  M.D., 

HERMAN,   G.  ERJSEST,  M.B. 

TATE.  WALTER  W.  H.,  M.D. 
fDORAN,  ALBAN,  President. 
I  BLACK,  J.   WATT,  M.D.,  Treasurer. 

EX-OFFICIO.^    PHILLIPS,    J.,    M.A.,  M.D.       \    jr  cr 

I  SPENCER,  H.  R.,  M.D.,  ]  ^^''^'  '^^^*- 

I  ROUTH,  AMAND,  M.D.,  Hon.  Lib. 


PUBLICATION    COMMITTEE. 


BLACK,  J.  WATT,  M.D. 

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

DAKIN,  W.  R.,  M.D. 

POTTER,  JOHN   BAPTISTE,  M.D. 

McCANN,  FREDERICK  JOHN,  M.D. 

EDEN,  THOMAS  AYATTS,  M.D. 
/DORAN,  ^hV>A.^,  President. 
\  BOULTON,  PERCY,  M.D.,  Editor. 
EX.oFFicio.  j  pjjjLLIPS,  J.,  M.A.,  M.D.,  )^       . 

CSPENCER,  H.  R.,  M.D.,  j  ^^'^'  ^^^^- 


HONORARY  LOCAL  SECRETARIES. 


Jones,  Evan Aberdare. 

Goss,  T.  BiDDULPH  Bath. 

Malins,  Edward,  M.D Birmingham. 

FuRNER,  Wii.LOUGHBY Brighton. 

RiGDEN,  George  Canterbury. 

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

Braithwaite,  James,  M.D Leeds. 

Thompson,  Joseph  Nottingham. 

Walker,  Thomas  James,  M.D Peterborough. 

Walters,  James  Hopkins  Reading. 

Keeling,  James  Hurd,  M.D Sheffield. 

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

Branfoot,  Arthur  Mudge,  M.B Madras. 

Peerigo,  James,  M.D IMontreal,  Canada. 

Takaki,  Kanaheiro  Japan. 


OBSTETRICAL   SOCIETY   OF   LONDON. 


trustees  of  the  society  s  property. 

Henry  Oldham,  M.D. 

Sir  John  Williams,  Bakt.,  M.D. 

John  Baptiste  Potter,  M.D. 


HONORARY  FELLOWS. 

BRITISH    SUBJECTS. 

Elected 

1892  Lister,  The  Right  Honorable  Lord,  F.R.S.,  LL.D.,  12, 
Park  crescent,  Portland  place,  W. 

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

FOREIGN    subjects. 

1895     Gusserow,  Professor,  Berlin. 

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

1872  Thomas,  T.  Gaillard,  M.D.,  Professor  o^  Obstetrics  in  the 
College  of  Physicians  and  Surgeons  ;  600,  Maaison 
avenue,  New  York. 

# 


Xll  FELLOWS    OF    THE     SOCIETY. 

Elected 

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

1895     VOX   WiNCKEL,  Professor,  Sonnenstrasse  16a,  Munich. 


CORRESPONDING    FELLOWS. 

18/3     Martin,  A.  E.,  M.D.,  Berlin.     Trans.  1. 

1876  BuDiN,  P.,  M.D.,  Professor,  4,  Avenue  Hoche,  Paris. 
Trans.  1 . 

1876  Chadwick,  James  R.,  M.A.,  M.D.,  Physician  for  Diseases 
of  Women,  Boston  City  Hospital ;  Clarendon  street, 
Boston,  Massachusetts, U.S. 


ORDINARY     FELLOWS. 

1899. 


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

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

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

Society. 


Elected 

1898     Aarons,  S.  Jeuvois,  M.D.Edin.,    l.o,  Devonshire  place, 

Cavendish  square,  W. 
1890t  AcKERLEY,    Richard,    M.B.,    B.S.Oxon.,    Croft   House, 

The  Hill,  Surbiton. 

189 1     Adams,  Charles  Edmund,  227,  Gipsy  road,  West  Norwood, 

S.E. 
l884*tADAMs,   Thomas   Rutherford,  M.D.,   119,    North   End, 

West  Croydon.     Council,  1894-7. 
1890     Addinsell,  Augustus   W.,    M.B.,    C.M.Edin.,  7,   Upper 

Brook  street,  W.     Council,  \S9^ -9.     Trans.  \. 

1895t  Albrecht,  John  Adolph,  L.R.C.P.  &  S.Edin.,  343,  The 
Cliff,  Lower  Broughton  road,  Manchester. 

I893t  Alcock,  Richard,  M.B.,  Burlington  crescent,  Goole. 
1883*tALLAN,    Robert     John,     L.R.C.P.Ed.,     The    Bungalow, 
Dulwich  hill,  Sydney,  New  South  Wales. 

1890t  Allan,  Thomas   S.,  L.R.C.P.   &   S.Ed.,  Fairfield  House, 

Falkirk. 
I873t  Allen,  Henry  Marcus,  F.R. C.P.Ed.,  1  7,  Palmeira  square. 

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

Whitechapel  road,  E. 
1875*  Anderson,  John  Ford,  .M.D.,C.M.,  4  1,  Beisize  park,  N.W. 

Council,  1882,  189S-9. 


XIV  FELLOWS    OF    THE    SOCIETY. 

Elected 

18o9     Andrews,  James,  M.D.,  1,  Prince  Arthur  road,  Hampstead, 

N.W.     Council,  1881. 
l870*tAppLETON,  Robert  Carlisle,  The  Bar  House,  Beverley. 
1884     Appleton,  Thomas  A.,  46,  Britannia  road,  Fulham,  S.W. 
1883t  Archibald,  John,  M.D.,  2,  The  Avenue,  Beckenhara. 

1871  Argles,  Frank,  L.R.C.P.Ed.,  Hermon  Lodge,  Wanstead, 
Essex,  E.     Council,  1886-7. 

1895  Arnold,  Edwin  Gilbert  Emerson,  L.E.C.P.Lond. 

1886  Ashe,    William    Percy,    L.R.C.P.  Lond.,    17,  Alexander 

square,  S.W. 
1898t  Auden,  George  k.,  M.B.,  B.C.Cantab.,  General  Lying-in 
Hospital,  York  road,  Lambeth,  S.E. 

1887  Bailey,  Henry  Frederick,  The  Holh'es,  Lee  terrace,  Lee, 

S.E. 
1897t  Bain,   William,    M.D.Durh.,    Stray thorpe,   York  place, 

Harrogate. 
I880t  Balls- Headlet,   Walter,   M.D.,   F.R.C.P.,    Lecturer  on 

Obstetrics    and   Diseases   of     Women,   University   of 

Melbourne,  4,  Collins  street  east,  Melbourne,  Victoria. 

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

1886*tSARBOUR,  A.  H.  Freeland,  M.D.Edin.,  Lecturer  on  Mid- 
wifery and  Diseases  of  Women,  Edinburgh  Medical 
School,  4,  Charlotte  square,  Edinburgh.  Council, 
1898-9. 

I884t  Barraclough,  Robert  W.  S.,  M.D.,  Glenbirnie,  Barn- 
staple, North  Devon. 

1896  Barrett,    Sidney    Edward,    M.B.,    B.C.Cantab.,     100, 

Bethune  road,  Stamford  hill,  N. 
1886t  Barrington,    Fourness,    M.B.  Edin.,    F.R.C.S.  Eng.,  23, 

Macquarie  street,  Sydney,  New  South  Wales. 
1891     Barton,   Edwin  Alfred,  L.E.C.P.Lond.,  35,   Cheniston 

Gardens,  Kensington,  W.  * 

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

Wye,  near  Hereford. 


FELLOWS  OF  THE  SOCIETY.  XV 

EJectf^d 

186l*tBAKTRLM,  John  S.,  F.R.C.S.,  Surgeon  to  the  Bath  General 
Hospital;   13,  Gay  street,  Bath.     Council,  1877-9. 

1893t  B.^TCHELOR,  Ferdinand  C.\mpion,  M.D.  Durh.,  Dunedin, 
New  Zealand. 

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

1895t  Beachcroft,  Francis  Seward,  L.R.C.P.Lond.,  The 
Chians,  Petworlh,  Sussex. 

J871  Beadles,  Arthur,  Park  House,  Dartmouth  Park,  Forest 
hill,  S.E. 

1892  Beauchamf,  Sydney,  M.B.,  B.C.Cantab.,  95,  Cromwell 
road,  S.W. 

1896  Belben,  Frank,  M.B.,  F.R.C.S.,  Hoo  Meavy,  Branksome 
Chine,  Bournemouth. 

1866*tBELCHER,  Henry,  M.D.,  28,  Cromwell  road,  West  Brighton. 

1871*tBELL,  Robert,  M.D.  Glasg.,  29,  Lynedoch  street,  Glasgow. 

I889t  Benson,  Matthew,  M.D.Bru.x.,  35,  Dicconson  street. 
Wig  an 

1894  Berkeley,  Comyns,  B.A.,  M.B.,  B.C.Cantab.,  Physician 
to  Out-patients  to  Chelsea  Hospital  for  Women ; 
53,  Wimpole  street,  W. 

I893t  Berridge,  William  Alfred,  Oakfield,  lledhill. 

1883t  Bertolacci,  J.  Hewetson,  Beaufort  House,  Knaphill, 
Surrey. 

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

l893*tBETENS0N,  William  Betenson,  L.R.C.P.Lond.,  Bungay, 
Suffolk. 

1894*  Betenson,  Woodley  Daniel,  L.R.C.P.Lond.,  26,  Caver- 
sham  road,  N.AV. 

189lt  Beville,  Frederick  Wells,  L.R.C.P.Lond.,  19,  New 
Cavendisii  street,  W. 

1887*tBiDEN,  Charles  Walter,  L.R.C.P.Lond.,  Laxfield,  Fram- 
lingham. 


JCVl  FELLOWS    OF    THE    SOCIETY. 

Elected 

1897  BiENEMANN,    ALFRED,    M.B.,    C.M.Ediii.,    Ivy    House, 

64,  Shepherd's  Bush  green,  W. 

1879     Biggs,  J.  M.,  Hillside,  Child's  hill,  N.W. 

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

1898  Blaber,  Percy  Leonard,  L.R.C.P.Lond.,  Sunny  Bank, 

Shoot-up  hill,  West  Hampstead. 

I890t  Black,  George,  M.B.,  B.S.Lond.,  Hurstpierpoint, 
Hassocks,  Sussex. 

1868*  Black,  James  Watt,  M.A.,M.D.,  F.R.C.P.,  Obstetric  Physi- 
cian to  the  Charing  Cross  Hospital  ;  15,  Clarges  street, 
Piccadilly,  W.  Council,  1872-4.  Vice-Pres.  1885-6. 
Chairman,  Board  Exam.  Midwives,  1887-90.  Pres. 
1891-2.     Treas.  1898-9. 

1893  Blacker,  George  Francis,   M.D.,  B.S.Lond.,  F.R.C.S., 

Assistant  Obstetric  Physician  to  University  College 
Hospital;  11,  Wimpole  street,  W.  Council,  1898-9. 
Trans.  2. 

1861*tBLAKE,  Thomas  William,  M.D.St. And.,  Hurstbourne, 
Bournemouth,  Hants. 

1872*f Bland,  George,  Consulting  Surgeon  to  the  Macclesfield 
Infirmary  ;  Pottergate  Lodge,  Lincoln. 

1894  BoDiLLY,  Reginald  Thomas  H.,  L.R.C.P.Lond.,  Wood- 

bury, High  road.  South  Woodford. 

1892^  Bond,  William  Arthur,  M.A.,  M.D.,  B.S.Cantab.,  10, 
Gray's  Inn  place,  Gray's  Inn,W.C. 

1883  Bonney,  William  Augustus,  M.D.,  100,  Elm  park  gardens, 
Chelsea,  S.W. 

1894t  BoRCHERDs,  Walter  Meent,  M.R.C.S.,  L.R.C.P., 
Worcester,  Cape  Colony. 

1893t  BoswELL,  Henry  St.  George,  M.B..  Edin.,  High  street, 
Saffron  Walden. 


FELLOWS    OF    THE    SOCIETY.  X\ll 

Elected 

1866*  BouLTON,  Peecy,  M.D.,  Physician  to  the  Samaritan  Free 

Hospital  ;     15,  Seymour  street,    Portman  square,  W. 

Council,  1878-80, 1885,  1896.     Hon.  Lib.  1886.     Hon. 

Sec.     1886-9.       Vice-Pres.     1890-2.       Board    Exam. 

Midwives,\S^(i-\.   Chairman,  \ ^9 7-^.  Editor,  1894-9. 

Trans.  4. 

1886t  BousTEAD,  Robinson,  M.D.,  B.C.  Cantab.,  Lieutenant- 
Colonel,  Indian  ^Medical  Service  ;  c/o  Messrs.  H.  S. 
King  and  Co.,  45,  Pall  Mall,  S.W. 

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

1884*  BoxALL,  Robert,  M.D.Cantab.,  Assistant  Obstetric  Physi- 
cian to,  and  Lecturer  on  Practical  Midwifery  at,  the 
Middlesex  Hospital ;  40,  Portland  place,  W.  Council, 
1888-90,  1894-5,  1899.  Board  Exam.  Midwives, 
1891-3.     Trans.  12. 

1897  Boyd,  John  Stewart,  L.R.C.P.Lond.,  Victoria  House, 
Custom  House,  E. 

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

1886f  Bradbury,  Harvey  K.,  181,  Horninglow  street,  Burton-on- 
Trent. 

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

1873t  Braithwaite,  James,  M.D.,  Obstetric  Physician  to  the 
Leeds  General  Infirmary ;  Lecturer  on  Diseases  of 
Women  and  Children  at  the  Leeds  School  of  Medicine  ; 
Little  Woodhouse,  Leeds.  Vice-Pres. IS77-9.  Trans.  6. 
Hon.  Loc.  Sec. 

1880t  Beanfoot,  Arthur  Mldge,  M.B,,  Rangoon,  Burmah. 
1887     Bridger,    Adolphus    Edward,  M.D.Ed.,    18,    Portland 

place,  W. 
1888*tBRiGGS,  Henry,  M.B.,  F.R.C.S.,  Surgeon  to  the  Hospital 

for    Women,   and    Hon.    Consulting    Med.   Officer  to 

the  Lying-in  Hospital,  Liverpool ;  3,  Rodney  street, 

Liverpool. 
VOL.    XL.  b 


XVlll  FELLOWS    OF    THE    SOCIETY. 

Elected 

1 894  Brinton,  Eoland  Danvers,  B.A.,  M.D.Cantab.,  8,  Queen's 
Gate  terrace,  S.W. 

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

1887t  Brodie,  Frederick  Garden,  M.B.,  Westmount,  Sandown, 

Isle  of  Wight. 

1866  Beodie,  George  B.,  M.D.,  Consulting  Physician-Accoucheur 
to  Queen  Charlotte's  Lying-in  Hospital ;  3,  Chesterfield 
street,  Mayfair,  W.  Council,  \37 3-5.   Fice-Pres.,  ISS9. 

1892     Brodie,  William  Haig,  M.D.,  C.M.Edin.,  F.R.C.S.Eng., 

Battle,  Sussex. 

1876  Brookhouse,  Charles  Turing,  M.D.,  Ashby  House, 
19,  Wickliam  road,  Brockley,  S.E. 

1889t  Brown,  Alfred,  M.A.,M.D.,C.M.  Aber.,Sandycroft, Higher 
Broughton,  Manchester. 

1868  Broavn,  Andrew,  M.D.  St.  And.,  27,  Lancaster  road, 
Belsize  park,  N.W.      Council,  1893-4.     Trans.  1. 

1894     Brown,  David,  M.D. Loud.,  Hamdon,  Taunton. 

1865*  Broavn,  D.  Dyce,  M.D.,  29,  Seymour  street,  Portman 
square,  W. 

1898t  Brown,  Haydn,  L.R.C.P.Edin.,  Buckhurst  hill,  Essex. 

1896  Brown,  John  Lewis,  M.B.,  C.M.Edin.,  86,  Windsor  road, 
Forest  gate,  E. 

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

1876  Brunjes,  Martin,  39,  Blenheim  gardens,  Willesden  green, 
N.W. 

lS95t  Buckley,  Samuel,  M.D.Lond.,  F.E.C.S.Eng.,  2,  Ebor 
villas,  Broughton  park,  Manchester. 

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

1885*tSuNNY,  J.  Brice,  L.R.C.P.  Ed.,  Warre  House,  Bishop's 
Lydeard,  Taunton. 


FELLOWS    OF    THE    SOCIETY.  XIX 

Elected 

1877t  J^URD,  Edward,  M.D.,  M.C.,  Senior  Physician  to  the  Salop 

Infirmary ;    Newport    House,    Shrewsbury.     Council, 

I88G.7.     Hon.  Loc.  Sec. 
1894     Burt,  Egbert   Francis,  M.B.,  C.M.Edin.,    124,  Stroud 

Green  road,  N. 
1888     Burton,  Herbert  Campbell,  L.R.C.P.  Lond.,  Lee  Park 

Lodge,  Blackheath,  S.E. 

1878  Butler-Smythe,  Albert  Charles,  L.R. C.P.Ed.,  Surgeon 
to  Out-patients,  Samaritan  Free  Hospital ;  76,  Brook 
street,  Grosvenor  square,  W.     Council,  1889-91. 

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

1886t  Byers,  John  W.,  M.A.,  M.D.,  M.A.O.  (Hon.  Causa),  Pro- 
fessor of  Midwifery  and  Diseases  of  Women  and  Chil- 
dren at  Queen's  College,  and  Physician  for  Diseases  of 
Women  to  the  Royal  Hospital,  Belfast ;  Dreenagh 
House,  Lower  crescent,  Belfast.     Vice-JE*res.  1899. 

189 If  Calthrop,  Lionel  C.  Everard,  M.B.  Durh.,  Gosberton 
House,  76,  Jesraond  road,  Newcastle-on-Tyne. 

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

]887t  Cameron,  Murdoch,  M.D.Glas.,  Regius  Professor  of  Mid- 
wifery in  the  University  of  Glasgow,  7,  Newton  terrace, 
Charing  Cross,  Glasgow. 

1894t  Campbell,  John,  M.A.,  M.D.Dubl.,  F.R.C.S.,  21,  Great 
Victoria  street,  Belfast. 

1892  Campbell,  John  William,  B.A.,  M.B.,  B.Ch. Cantab., 
Highclere,  Oakleigh  park.  Whetstone,  N.  {Winter, 
Casa  Rossa,  Mentone.) 

1888*tCAMPBELL,  William  Macfie,  M.D.Edin.,  1,  Princes  gate 
East,  Liverpool. 

1886t  Carpenter,  Arthur  Bristoave,  M.A.,  M.B.Oxon.,  Wyke- 
ham  House,  Bedford  park,  Croydon. 

1896  Carr^,  Louis  G.  E.,  M.D.,  The  Uganda  Relief  Expedi- 
tion, the  27th  Bombay  L.  I.  Regiment,  Kampala> 
Uganda,  Central  Africa. 


XX  FELLOWS    OF    THE    SOCIETY. 

Elected 

1887t  Case,  William,  Denmark  house,  Caister-on-Sea,  Nor- 
folk. 

I863t  Cayzek,  Thomas,  Suro-eon-Lieutenant-Colonel,  Mayfield, 
9,  Aigburth  road,  Liverpool. 

1875t  Chaffers,  Edward,  F.R.C.S.,  Broomfield,  Keighley,  York- 
shire. 

1894  Chaldecott,  John  Henry,  L.E.C.P.Lond.,  401,  Old 
Kent  road,  S.E. 

1876*  Champneys,  Francis  Henry,  M.A.,  M.D.Oxon.,  F.E.C.P., 
Physician-Accoucheur  to,  and  Lecturer  on  Midwifery 
at,  St.  Bartholomew's  Hospital ;  42,  Upper  Brook 
street,  W.  Council,  1880-1 .  Hon.  Lib.  1882-3.  Hon. 
Sec.  1884-7.  Vice-Fres.  1888-90.  Board Uxam.  Mid- 
wives,  1883,  1888-90;  Chairman,  1891-5.  Editor, 
1888-93.     Pres.  1895-6.     Trans.  16. 

1867*tCHARLES,  T.  Edmondston,  M.D.,  F.R.C.P.,  72,  Via  di 
San  Niccolo  da  Tolentino,  Rome.     Council,  1882-4. 

IS74*tCHARLESW0RTH,  James,  M.D.,  Physician  to  the  North 
Staffordshire  Infirmary ;  25,  Birch  terrace,  Hanley, 
Staffordshire. 

1890t  Childe,  Charles  Plumley,  B.A.,  F.R.C.S.,  Cranleigh, 
Kent  road,  Southsea. 

1897t  Chinery,  Edward  Eluder,  F.E.C.S.Edin.,  Monmouth 
House,  Lymington,  Hants. 

1863*tCHisHOLM,  Edwin,  M.D.,  Abergeldie,  Ashfield,  near  Sydney, 
New  South  Wales.  [Per  Messrs.  Turner  and  Hen- 
derson, care  of  Messrs.  W.  Dawson,  121,  Cannon 
street,  E.C.] 

1896  Chittenden,  T,  Hillier,  M.D.Durh.,  M.R.C.P.Lond., 
32,  Ovington  square,  S.W. 

1883  Clapham,  Edward,  M.D.,  29,  Lingfield  road,  Wimbledon. 
Council,  1892-4. 

1859  Claremont,  Claude  Clarke,  Millbrook  House,  I,  Hamp- 
stead  road,  N.W.     Council,  1896. 


FELLOWS    OF    THE    SOCIETY.  XXI 

Elected 

1897     Clark,  William  Gladstone,  M.A.Cantab.,  1,  North  road, 
Surbiton,  Surrey. 

1893  Clarke,  W.  Brlce,  F.R.C.S.,  Assistant  Surgeon  to  St. 
Bartholomew's  Hospital,  51,  Harley  street,  W. 

1889  Clemow,  Arthur  Henry  AVeiss,  M.D.,  CM.  Edin.,  101, 

Earl's  Court  road,  Kensington,  W. 

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

1882t  CoATES,  Frederick  \\^illiam,  M.D.,  Auckland,  New 
Zealand.     Council,  1891-3. 

1875  Coffin,  Richard  Jas.  Maitland,  F.R.C.P.  Ed.,  3,  West- 
gate  terrace,  Redcliffe  square,  S.W. 

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

1895t  Coles,  Alfred  Charles,  M.D.,  CM. Edin.,  Bradwardine, 
Branksome  terrace,  Bournemouth. 

1897t  Coles,  Richard  A.,  M.B.  &  Ch.Aber.,  Corsley,  War- 
minster, Wiltshire. 

1895  Collier,  Samuel  Ruddell,  M.D.,  13,  Hartfield  road, 
'Wimbledon. 

1888t  Collins,  Edward  Tenison,  12,  Windsor  place,  Cardiff. 
1866t  Coombs,  JaxMes,  M.D.,  Bedford. 

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

1890  Copeland,  William  Henry  Laurence,  M.B.Cantab.,  59, 

Warwick  road.  Earl's  Court,  S.W. 

1888t  Corby,  Henry,  B.A.,  M.D.,  19,  St.  Patrick's  place,  Cork. 

1875*tCoRDES,  Aug.,  M.U.,  M.R.C.P.,  Consulting  Accoucheur  to 
the  "  Misericorde  ;"  Privat  Decent  for  Midwifery  at  the 
University  of  Geneva  ;  12,  Rue  Bellot,  Geneva.   Trans.  \. 

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


XXll  FELLOWS    OF    THE    SOCIETY. 

Elected 

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

1877     Crawford,  James,  M.D.  Durh.,  Grosvenor  Mansions,  80, 

Victoria  street,  S.W. 
1896f  Creasy,  Rolf,  L.R.C.P.  Lond.,  Windlesham,  Surrey. 

1876f  Crew,  John,  Manor  House,  Higham  Ferrers,  Northampton- 
shire. 
1893     Cripps,  William  Harrison,  F.E.C.S.,  Surgeon  to  St.  Bar- 
.  tholomew's  Hospital ;  2,  Stratford  place,  W.     Trans.  1 . 

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

road,  Leeds. 
1881*tCRONK,   Herbert   George,   M.B.  Cantab.,   Kepton,  near 

Burton-on-Trent. 

1893  Crosby,  Herbert  Thomas,  M.A.,  M.B.,  B.C.Cantab.,  19, 

Gordon  square,  W.C. 

1895  Cross,  Ernest  W.,  L.R.C.P. Lond.,  The  Limes,  Wallwood 
Park,  Leytonstone. 

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

1898t  CuLLEN,  Thomas,  M.D.Toronto,  Johns  Hopkins  Hospital, 
Baltimore,  U  S.A. 

1875*  Cullingworth,  Charles  James,  M.D.,  D.C.L.,  F.R.C.P., 
Obstetric  Physician  to,  and  Lecturer  on  Obstetric 
Medicine  at,  St.  Thomas's  Hospital;  14,  Manchester 
square,  W.  Council,  1883-5,  1891-3.  Vice-Pres. 
1886-8.  Board  Exam.  Midwives,  1889-91.  Chair- 
man, 1895-6.     Pres.  1897-8.     Trans.  13. 

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

1894  Cutler,   Lennard,  L.E.C.P.Lond.,   1,  Kensington  Gate, 

Kensington,  W.     Trans.  1. 

1885  Dakin,  William  Eadford,  M.D.,  B.S.,  F.R.C.P., 
Obstetric  Physician  to,  and  Lecturer  on  Midwifery  at, 
St.  George's  Hospital;  18,  Grosvenor  street,  W. 
Council,  1889-91.  Hon.  Lib.  1892-3.  Hon.  Sec, 
1894-7.     Vice-Pres,  1898-9.     Trans.  3. 


FELLOWS    OF    THE    SOCIETY.  XXlll 

Elected 

1868     Daly,   Frederick    Henby,    M.D.,    185,    Amhurst   road, 

Hackney  Downs,   N.E.     Council,  1877-9.     Vice-Pres, 

1883-5.     Trans.  2. 
1882f  Dambrill-Davies,  William  R.,  Alderley  Edge,  Cheshire. 

1893  Dauber,    John     Henry,     M.A.    Oxon.,     M.B.,    B.Ch., 

Physician  to  the  Hospital  for  Women,  Soho  square  ; 
29,  Charles  street,  Berkeley  square,  "W. 

1892f  Davis,  Kobert,  Darrickwood,  Orpington,  Kent. 

1895     Davoren,    John,   L.R.C.P.I.,   CM.,   95,  Mitcham  lane, 
Streatham,  S.W. 

1877     Davson,  Smith  Houston,  M.D.,  Campden  villa,  203,  Maida 
vale,  W.     Council,  1889-91. 

1891     Dawson,  Ernest,  L.R.C.P.Lond.,   Linden  House,  High 
road,  LeytoUj  E. 

1889     Des   V(eux,   Harold    A.,    M.D.Brux.,   8,    James   street, 
Buckingham  gate,  S.W.     Council,  1896-8. 

1894  Dickinson,    Thomas   Vincent,  M.D.  Lond.,  33,   Sloane 

street,  S.W. 

1894  Dickson,  John  William,  B.A.,  M.B.,  B.C.  Cantab.,  42, 

Hertford  street,  Mayfair,  W. 

1895  DoDGsoN,   George   Stanley,   B.A.,    M.B.,   B.C.Cantab., 

Southleigh,  Headingley,  Leeds. 

1886t  Donald,   Archibald,   M.D.  Edin.,    M.R.C.P.,    Obstetric 

Physician    to     the     Royal     Infirmary,    Manchester; 

Honorary  Surgeon  to  St.  Mary's  Hospital  for  Women, 

Manchester;     Piatt    Abbey,    Rusholme,    Manchester. 

Council,  1893-5.      Trans.  1. 
1879*  DoEAN,  Alban  H.  G.,  F.R.C.S.,  Surgeon  to  the  Samaritan 

Free  Hospital ;   9,  Granville  place,  Portman  square,  W. 

Council,  1883-5.  Hon.  Lib.  1886-7.  Hon.  Sec.  1888-91. 

Vice-Pres.  1892-4.     Pres.  1899.     Trans.  18. 

1890t  DouTY,  Edward  Henry,  M.A.,  M.B.,  B.C.Cantab.,  Davos 
Platz,  Switzerland. 

1887     DovASTON,    MiLAVARD     Edmund,    Hova    House,    Hove, 
Brighton. 


XXIV  FELLOWS    OF    THE    SOCIETY. 

Elected 

1896  DowNES,  J.  LocKHART,  M.B.,  CM.  Edin.,  27,  Romford 
road,  E. 

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

1871t  Drake-Brockman,  Edward  Forster,  F.R.C  S.,  L.R.C.P. 
Lond.,  Brigade-Surgeon;  c/o  Messrs.  Richardson  and 
Co.,  East  India  Army  Agency,  25,  Suffolk  street,  Pall 
Mall,  S.W. 

1894t  Drew,  Henry  William,  F.E.C.S.,  Eastgate,  East  Croydon. 

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

O.F.  Duncan,  James,  M.B.,  8,  Henrietta  street,  Covent  garden, 
W.C.     Council,  1873-4.     Vice-Pres.  1895. 

1882  Duncan,  William,  M.D.,  Obstetric  Physician  to,  and  Lec- 
turer on  Obstetric  Medicine  at,  the  Middlesex  Hospital ; 
6,  Harley  street,  W.  Council,  1885-6,  1888-9.  Ron. 
Lib.  1890-1.  Hon,  Sec.  1892-5.  Vice-Pres.  1896-9. 
Trans.  2. 

1871*  Eastes,  George,  M.B.,  F.R.C.S.,  35,  Gloucester  terrace, 
Hyde  park,  \V.     Council,  1878-80. 

1896  Easton,  Erank  Edavard,  L.R.C.P.  Lond.,  12,  Devonport 
street,  Hyde  park,  W. 

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

1893  Eden,  Thomas  Watts,  M.D.,  M.R.C.P.  Edin.,  49,  Queen 

Anne  street,  W.     Council,  1897-9.     Trans.  3. 

1890  Ehrmann,  Albert,  L.R.C.P. Lond.,  6,  The  Terrace,  Camden 
square,  N.W. 

1894  Ellis,  Egbert  Kingdon,  M.B.,  B.Ch.Oxon.,  Lowdham, 

Notts. 

1873*tENGELMANN,  George  Julius,  A.M.,  M.D.,  336,  Beacon 
street,  Boston,  Mass.,  U.S.A. 


FELLO^yS    OF    THE    SOCIETY.  XXV 

Elected 

1898t  Evans,  David  J.,   M.D.McGill,    939,   Dorchester  street, 

Montreal. 
1897     Evans,  Evan  Laming,  M.B.,  B.C.Cantab.,  4e,  Hyde  Park 

Mansions,  W. 

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

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

1894     Fairweather,  David,  M.A.,  M.B.,  C.M.Edin.,  2,  Nightin- 
gale road.  Wood  Green,  N. 

1876t  Farncombe,  Richard,  183,  Belgrave  road,  Balsall  heath, 
Birmingham. 

1869*  Farquhar,  William,  M.D.,  Deputy  Surgeon-General,  40, 
Westbourne  gardens,  Bayswater,  W. 

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

1882t  Farrar,  Joseph,  M.D.,  Gainsborough.     Trans.  1. 

1894t  Fazan,  Charles   Herbert,  L.R.C.P.    Lond.,   Belmont, 
Wadhurst,  Sussex. 

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

1886     Fennell,  David,  L.K.Q.C.P.I.,  "  Castlebar,"  116,  Palace 
road,  Tulse  hill,  S.W. 

1883     Fenton,    Hugh,   M.D.,  Physician,    Chelsea   Hospital  for 
AYomen  ;  27,  George  street,  Hanover  square,  W. 

1893     Ferguson,  George  Gunnis,  M.B.,  C.M.Glas.,  62,  Holm- 
dale  road.  West  Hampstead,  N.W. 

1893t  FiNLEY,  Harry,  M.D.Lond.,  Wimborne  Minster,  Dorset. 

1892t  Finny,  W.   Evelyn  St.  Lawrence,  M.B.  Dubl.,  Kenlis, 
Queen's  road,  Kingston  hill. 

1877*tFoNMARTiN,    Henry    de,    M.D.,    26,    Newberry    terrace. 
Lower  Bullar  street,  Nichols  Town,  Southampton. 

1884t  Ford,  Alexander,  L.R.C.P. Ed.,  6,  Otteran  place.  Water- 
ford. 


XXVI  FELLOWS    OF    THE    SOCIETY. 

Elected 

1877*troRD,  James,  M.D.,  Hillside,  Exmputh,  Devon. 

1897t  FoTHERGiLL,  W.  E.,  M.B.,  C.M.Edin.,  200,  Oxford  road, 
Manchester. 

1884     FouRACRE,  Robert  Perriman,  58,  Tollington  park,  N. 

1886f  Fowler,  Charles  Owen,  M.D.,  Cotford  House,  Thornton 
heath. 

1898  Frampton,  Trevethan,  M.R.C.S.,  L.R.C.P.,  168,  Glou- 
cester terrace,  Hyde  park,  W. 

1875*fFRASER,  Angus,  M.D.,  Physician  and  Lecturer  on  Clinical 
Medicine  to  the  Aberdeen  Royal  Infirmary  ;  232,  Union 
street,  Aberdeen.      Council,  1897-9. 

1888f  Eraser,  James  Alexander,  L.R.C.P.  Lond.,  Western 
Lodge,  Romford. 

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

1886f  FuRNER,  WiLLOUGHBY,  F.R.C.S.,  13,  Brunswick  square, 
Brighton.     Council,  1894-6.     Hon.  Loc.  Sec. 

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

1888  Galloway,  Arthur  Wilton,  L.R.C.P.  Lond.,  7^t  New 
North  road,  N. 

1863*  Galton,  JohnH.,  M.D.,  Ghunam,  Sylvan  road.  Upper  Nor- 
wood,   S.E.      Council    1874-6,    1891-2.       Vice-Pres. 

1895-8. 

1881  Gandy,  William,  Hill  Top,  Central  hill,  Norwood,  S.E. 
Council,  1897-8. 

1886*tGrARDE,  Henry  Croker,  F.R.C.S.  Edin.,  Maryborough, 
Queensland. 

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


FELLOWS    OF    THE    SOCIETY.  XXVll 

Elected 

1894  Gardner,  H.  Bellamy,  M.R.C.S.,  L.E.C.P.Loiid.,  52, 
Beaumont  street,  Weymouth  street,  W. 

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

1872*tGARDNER,  William,  M.A.,  M.D.,  Professor  of  Gynaecology, 
McGill  University  ;  Gynaecologist  to  the  Royal  Victoria 
Hospital;   109,  Union  avenue,  Montreal,  Canada. 

1876t  Garner,  John,  21,  Easy  row,  Birmingham. 

1891t  Garrett,  Arthur  Edward,  L.R.C.S.,  &  L.M.Ed.,  Whit- 
acre  Lodge,  Leamington. 

1873*tGARTON,  William,  M.D.,  F.R.C.S.,  Inglewood,  Aughton, 

near  Ormskirk. 
1889*  Gell,  Henry  Willingham,  M.A.,  M.B.Oxon.,  36,  Hyde 

park  square,  W. 

1898t  Gemmell,  John  Edward,  M.B.,  C.M.Edin.,  12,  Rodney 
street,  Liverpool. 

1859*  Gervis,    Henry,    M.D.,    F.R.C.P.,    Consulting    Obstetric 

Physician  to  St.  Thomas's  Hospital ;  40,  Harley  street. 

Cavendish  square.     Council,    1864-6,   1889-91,   1893. 

Son.     Sec.     1867-70.       Fice-Pres.     1871-3.       Treas. 

1878-81.     Pres.  1883-4.     Trans.  8. 
1866*  Gervis,    Frederick    Heudebourck,     1,    Fellows     road, 

Haverstock  hill,  N.W.     Council,   1877-9.     Fice-Pres. 

1892.     Trans.  1. 
1875     GiBBiNGs,    Alfred    Thomas,    M.D.,  93,   Richmond   road, 

Dalston,  N.E.     Council,  1885-6,  1888. 

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

1894  Gibson,  Henry  Wilkes,  L.R.C.P.  Lond.,  11,  College 
crescent,  South  Hampstead,  N.W. 

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

Wight. 
1892     Giles,  Arthur  Edward,  M.D.  Lond.,M.R.C.P.,  Physician 

to    Out-patients,  Chelsea    Hospital  for  Women  ;    37, 

Queen  Anne   street.  Cavendish   square,  W.     Council, 

1898-9.     Trans.  7. 


XXVlll  FELLOWS    OF    THE    SOCIETY. 

Elected 

1869     GiLL;,  William,  L.K.C.P.  Lond.,  11,  Russell  square,  W.C. 

1891  GiMBLETT,  William  Henry,  M.D.Durh.,  Queen's  road^ 
Buckhurst  hill,  Essex. 

1894t  GoDDARD,  Charles  Ernest,  L.E.C.P.  Lond.,  Wembley, 
Harrow. 

18/1  GoDDARD,  Eugene,  M.D.  Durb.,  Nortb  Lynne,  106,  High- 
bury New  Park,  N.     Trans.  1. 

1871  *GoDSON,  Clement,  M.D.,  CM.;  9,  Grosvenor  street,  W. 
Council,  1876-7.  Hon.  Sec.  1878-81.  Vice-Pres. 
1882-4.  Board  Exam.  Midwives,  1877,  1882-86. 
Trans.  5. 

1893t  Goodman,  Roger  Neville,  M.A.,  M.B.Cantab.,  Elmside, 
Kingston-on-Thames. 

1893t  Gordon,  Frederick  William,  L.R.C.P.Lond.,  Manukau 
road,  Auckland,  New  Zealand. 

1883     Gordon,  John,  M.D.,  63,  Cheapside,  E.C. 

1869t  Goss,  Tregenna  Biddulph,  1,  The  Circus,  Bath.      Hon. 

Loc.  Sec. 
1891t  Gostling,  William  Ayton,M.D.,  B.S.Lond.,  Barningham,, 

West  Worthing. 

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

road,  N.W. 

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

in  charge  of  Out-patients,  St.  Mary's  Hospital ;  27, 
Weymouth  street,  W.  Council,  1893-5.  Board  Exam. 
Midwives,  1898-9.     Trans.  2. 

1893t  GowAN,  Bowie  Campbell,  L.R.C.P.Lond.,  Raven  Dene, 
Great  Stanmore. 

1893  Grant,  Leonard,  M.D.Edin.,  9,  Western  villas.  New 
Southgate,  N. 

1897  Grant-Wilson,  Charles  Westbrooke,  L.E.C.P.Lond., 
Heathfield  House,  Streatham  common. 

1890t  Gray,  Harry  St.  Clair,  M.D.  Glas.,  25,  Lynedoch  street,. 
Glasgow. 

1875t  Gray,  James,  M.D.,  15,  Newton  terrace,  Glasgow. 


FELLOWS    OF    THE    SOCIETY.  XXIX 

Elected 

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

I894t  Green,  Charles  Robert  Mortimer,  Captain,  Indian 
Medical  Service,  The  Eden  Hospital,  Calcutta. 

1887  Greenwood,  Edwin  Climson,  L.R.C.P.,  19,  St.  John's 
wood  park,  N.W. 

1863  *Griffith,  G.  de  Gorrequer,  34,  St.  George's  square, 
S.W.      Trans.  2. 

1879*  Griffith,  Walter  Spencer  Anderson,  M.D.  Cantab., 
F.R.C.S.,  F.R.C.P.,  Assistant  Physician-Accoucheur 
to  St.  Bartholomew's  Hospital ;  96,  Harley  street,  W. 
Council,  1886-8,  1893-5.  Hon.  Lib.,  1896-7.  Board 
Exam.  Midwives,  1887-9.     Trans.  9. 

1870  *Grigg,  William  Chapman,  M.D.,  Physician  to  the  In- 
patients, Queen  Charlotte's  Lying-in  Hospital ;  27, 
Curzon  street,  Mayfair.  Council,  1875-7.  Board 
Exam.  Midwives,  1878-9. 

1888*fGRiMSDALE,  Thomas  Babington,  B.A.,  M.B.Cantab., 
Surgeon  to  the  Hospital  for  Women,  and  Medical 
Officer  to  the  Liverpool  Lying-in  Hospital ;  29, 
Rodney  street,  Liverpool. 

I882t  Gripper,  Walter,  M.B.  Cantab.,  The  Poplars,  Wallington, 
Surrey. 

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

1896t  Groves,  Ernest  W.,  M.B.,  B.Sc,  Kingswood,  Bristol. 
1892     GuBB,  Alfred  Samuel,  M.D.  Paris,  29,  Gower  street,  W.C. 
1887t  Hackney,  John,  M.D.  St.  And.,  Oaklands,  Hythe. 
1881t  Hair,  James,  M.D.,  Brinklow,  Coventry. 

1889  Hale,  Charles  D.  B.,  M.D.,  3,  Sussex  place,  Hyde 
park,  W. 

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


XXX  FELLOWS    OF    THE    SOCIETY. 

Elected 

1894     Hamilton,  Bruce,  L.R.C.P.Lond./'ralklands,"9,Frognal, 

N.W. 

1894t  Hamilton-,  David  Livingston,  L.E.C.P.  Edin.,  260, 
Oxford  road,  IManchester. 

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

1883  Handfield- Jones,  Montagu,  M.D.  Lond.,  M.R.C.P.,  Phy- 
sician-Accoucheur to,  and  Lecturer  on  Midwifery  and 
Diseases  of  Women  at,  St.  Mary's  Hospital ;  35, 
Cavendish  square,  "W.  Council^  1887-9,  1896-7.  Board 
Exam.  Midwives,  1894-6.     Trans,  1. 

1889t  Hard  wick,  Arthur,  M.D.  Durh.,  Newquay,  Cornwall. 

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

1892     Harold,  John,  L.R.C.P.Lond.,  91,  Harley  street,  W. 

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

1877  Harper,  Gerald  S.,  M.B.Aber.,  40,  Curzon  street.  May- 
fair,  W.     Council,  1894-5. 

1898t  Harper,  John  Robinson,  L.E.C.P.,  3,  Union  terrace, 
Barnstaple,  Devon. 

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

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

1880*  Harrison,    Richard    Charlton,    19,    Uxbridge    road, 

Ealing,  W. 
1890t  Hart,  David  Berry,  M.D. Edin.,  Assistant  Gynaecologist, 

Royal    Infirmary,  Edinburgh ;    29,  Charlotte    square, 

Edinburgh. 

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

1886  Hartley,  Reginald,  M.D.  Durh.,  F.R.C.S.Ed.,  63,  Por- 
chester  terrace,  Hyde  park,  W. 

1894  Hartzhorne,  Bernard  Fred,,  M.R.C.S.,  Blenheim  Lodge, 
High  road,  Chiswick. 


FELLOWS  OF  THE  SOCIETY.  XXXt 

Elected 

1893t  Harvey,  John  Jordan,  L.R.C.P.  &  S.Edin.,  54,  Barking 
road,  Canning  Town,  E. 

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

1865t  Harvey,  Robert,  M.D.,  Abbottabad,  Punjab.  [Per 
Messrs.  Cochran  and  Macpherson,  152,  Union  street, 
Aberdeen.]     Trans.  1. 

1892t  Hawkixs-Ambler,  George  Arthur,  F.R. C.S.Ed.,  67,. 
Rodney  street,  Liverpool. 

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

1893t  Haydon,  Thomas  Horatio,  M.B.,  B.C.Cantab.,  22,  High 
street,  Marlborough. 

1873  Hayes,  Thomas  Crawford,  M.A.,  M.D.,  F.R.C.P.,  Ob- 
stetric  Physician  to  King's  College  Hospital,  and 
Professor  of  Obstetric  Medicine  at  King's  College  ; 
17,  Clarges  street,  Piccadilly,  W.  Council,  1876-8, 
1899.     Vice-Pres.   1890-1. 

1880  Heath,  William  Lenton,  M.D.,  90,  Cromwell  road, 
Queen's  gate,  S.W.     Council,  1891.     Trans.  1. 

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

1890t  Helme,  T.  Arthur,  M.D.Edin.,  258,  Oxford  road,  Man- 
chester. 

1867t  Hembrough,  John  William,  M.D.,  The  Moot  Hall,  New- 
castle-on-Tyne. 

1876*  Herman,  George  Ernest,  M.B.,  F.R.C.P.,  Obstetric  Phy- 
sician to,  and  Lecturer  on  Midwifery  at,  the  London 
Hospital;  20,  Harley  street,  Cavendish  square,  W. 
Cowwci7,  1878-9, 1898-9.  Hon.  Lib.  XS^QA.  Hon.Sec. 
1882-5.  Fice-Pres.  1886-7.  Board  Exa?n.  MidwiveSy 
1886-8.     Treas.  1889-92.      Pre*.  1893-4.     Trans. 2d. 

1892t  Hills,  Thomas  Hyde,  L.R.C.P.Lond.,  7,  St.  Peter's 
terrace,  Cambridge. 


XXXU  FELLOWS    OF    THE    SOCIETY. 

Elected 

1898     HiNDLET,  Godfrey  D.,  L.R.C.P.Lond.,  69,  Queen's  Road, 

Dalston,  N.E. 
1886t  Hodges,    Herbert    Chamney,    L.R.C.P.Lond.,   "Watton, 

Herts.     Trans.  1. 
1886t  HoLBERTON,      Henry     Nelson,     L.R.C.P'.Lond.,     East 

Molesey. 

1875  HoLLiNGs,   Edwin,   M.D.,    22,  Endsleigli   gardens,  N.W. 

Council,  1888-90.  -^Vice-Pres.  1893-4. 

1897  HoLLiNGs,  Guy  Bertram,  M.B.,  B.S.,  22,  Endsleigh 
gardens,  N.W. 

1859  HoLMAN,  CoNSTANTiNE,  M.D.,  26,  Gloucester  place,  Port- 
man  square,  W.  Council^  1867-9, 1895-6.  Vice-Pres, 
1870-1. 

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

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

1896t  Hopkins,  Gteorge  Herbert,  F.R.C.S.,  3,  North  Quay, 
Brisbane,  Queensland. 

1884  Hopkins,  John,  L.R. C.P.Ed.,  Hamlet  Court  road,  West 
Cliff,  Southend-on-Sea. 

1883*  HoRROCKS,  Peter,  M.D.,  F.R.C.P.  Lend.,  Assistant  Ob- 
stetric Pliysician  to  Guy's  Hospital  ;  45,  Brook  street, 
W.  Council,  1886-7.  Hon.  Lib.  1888-9.  Ho7i.  Sec. 
1890-3.     Vice-Pres.  1894-6.     Trans.  2. 

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

square,  W. 
1883     HosKiN,  Theophilus,  L.R.C.P.  Lond.,  1 ,  Amhurst  park,  N. 

1883     Houchin,   Edmund  King,  L.R.C.P.  Ed.,  Durham  House, 

Stepney,  E. 
1884t  Hough,  Charles  Henry,  Full  street,  Derby. 

1877*  Howell,  Horace  Sydney,  M.D.,  East  Grove  House,  18, 
Boundary  road,  St.  John's  Wood,  N.W. 

1879t  Hubbard,  Thomas  Wells,  Barming  place,  Maidstone. 


FELLOWS    OF    THE    SOCIETY.  XXXUl 

Elected 

1884*tHuRRY,  Jamieson  Boyd,  M.D.  Cantab.,  43,  Castle  street, 

Reading.        Council,    1887-9.        Fice.-Pres.      1897-9. 

Trans.  2. 

1878*  Husband,  Walter  Edward,  Grove  Lea,  Lansdown,  Bath. 

1895     Huxley,   Henry,    L.R.C.P.Lond.,   39,   Leinster   gardens, 
Hyde  park,  AV". 

lS94t  Ilott,  Herbert  James,  M.D.  Aber.,  b7,  High  street, 
Bromley,  Kent. 

1883t  Inman,  Robert  Edward,  Gadshill  Cottage,  Higham,  Kent, 

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

1883t  Jackson,  George  Henry,  Asbburton,  Carew  road,  East- 
bourne. 

1897  Jager,  Harold,  M.B.  Lond.,  6,  Darnley  road,  Royal 
crescent,  W. 

1873t  Jakins,  William  Vosper,  L.R.C.P.  Ed.,  14,  Collins  street 
East,  Melbourne. 

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

1890t  James,  Charles  Henry,   L.R.C.P.Lond.,  Captain,  Indian 

Medical  Service  ;  Lahore,  Punjab,  India. 
1895t  James,  Stanlake,  Violet  hill,  Simla,  India. 

1883*tJENKiNs,  Edward  Johnstone,  M.D.  Oxon.,  213,  Macquarie 
street,  Sydney. 

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

1882  Jennings,  Charles  Egerton,  M.D.  Durh.,  F.R.C.S.  Eng., 
Assistant  Surgeon  to  the  North-West  London  Hospital ; 
48,  Seymour  street,  Portman  square,  W. 

I877t  Johnson,  Samuel,  M.D.,  5,  Hill  street,  Stoke-upon-Trent. 
1894     Johnstone,  E.  W.,  M.D.,  B.Ch.,  175,  New  Bond  street, 
W. 

1868t  Jones,  Evan,  Ty-Mawr,  Aberdare,  Glamorganshire.  Council, 
1886-8.     Vice.-Fres.  1890-1.     Hon.  Loc.  Sec. 

1894     Jones,  Evan,  L.E.C.P.  Lond.,  89,  Goswell  road,  E.G. 

vol.  XL.  e 


XXXIV  FELLOWS    OF    THE    SOCIETY. 

Elected 

1895t  Jones,  George  Horatio,  Deddington,  Oxon. 

ISSlf  Jones,  James  Robert,  M.B.,  247,  Donald  street,  Winnipeg, 
Manitoba,  Canada. 

1894t  Jones,  John  Arnallt,  L.R.C.P.  Lond.,  Heathmont,  Aber- 
avon.  Port  Talbot,  Glamorganshire. 

1887t  Jones,  J.  Talfourd,  M.B.  Lond.,  Consulting  Physician  to 
the  Breconshire  Infirmary,  Rose  Bank,  South  terrace, 
Eastbourne. 

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

1885t  Jones,  P.  Sydney,  M.D.,  16,  College  street,  Hyde  park, 
Sydney.  [Per  Messrs.  D.  Jones  and  Co.,  122  and  124, 
Wool  Exchange,  Basinghall  street,  E.C.] 

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

1886f  Jones,  William  Owen,  The  Downs,  Bowdon,  Cheshire. 

I879t  Joubert,  Charles  Henry,  M.B.  Lond.,  F.R.C.S.  Eng. 
Lieut. -Col.,  Indian  Medical  Service,  Bengal;  Obstetric 
Physician  to  Eden  Hospital,  and  Professor  of  Mid- 
wifery and  Diseases  of  Women  and  Children,  Calcutta 
Medical  College ;   6,  Harington  street,  Calcutta. 

1884  Keates,  William  Cooper,  L.R.C.P.,  22,  East  Dulwich 
road,  S.E. 

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

1896  Keep,  Arthur  Corrie,  M.D.,  C.M.Edin.,  Surgeon  to  Out- 
patients, Samaritan  Free  Hospital ;  14,  Gloucester 
place,  Portman  square,  W. 

1890  Kj:iTH,  Skene,  M.B.,  C.M.Edin.,  42,  Charles  street, 
Berkeley  Square,  W. 

1894  Kellett,  Alfred  Featherstone,  M.B.,  B.C.Cantab.,  142, 
Lewisham  road,  S.E. 

1874*  Kempster,  William  Henry,  M.D.,  Chesterfield,  Clapham 
common.  North  side,  S.W. 


FELLOWS    OF    THE    SOCIETY.  XXXV 

Elected 

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

1879  Ker,  Hugh  Richard,  L.R.C.P.Ed.,  Tintern,  2,  Balham 
hill,  S.W. 

1895t  Kerr,  John  Martin  Muneo,  M.B.,  C.M.Glasg.,  28, 
Berkeley  terrace,  Glasgow. 

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

1878t  Khory,  Rustonjee  Naseewanjee,  M.D.,  M.E.C.P., 
Medical  Syndic,  Bombay  University  ;  Honorary  Physi- 
cian, Bai  Motlibai  Obstetric  and  Gynaecological 
Hospital  ;  Hormazd  Villa,  Khumballa  hill,  Bombay. 

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

I892t  Kingscote,  Ernest,  M.B.,  C.M.Edin.,31,  Lower  Seymour 
street,  Portman  square,  W. 

1872*  KiscH,  Albert,  61,  Portsdown  road,  W.     Council,  1896-7. 

1876t  Knott,  Charles,  M.R.C.P.  Ed.,  Liz  Ville,  Elm  grove, 
Southsea. 

1889  Lake,  George  Robert,  177,  Gloucester  terrace,  Hyde 
park,  W. 

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

I875t  Lawrence,  Alfred  Edward  Aust,  M.D.,  Consulting 
Professor  of  Midwifery  and  Diseases  of  Women,  Uni- 
versity College,  Bristol ;  Physician-Accoucheur  to  the 
Bristol  General  Hospital ;  19,  Richmond  hill,  Chfton, 
Bristol.  Council,  \88d-6,  1888.  Vice-Pres.,  1889-90. 
Hon.  Loc.  Sec.    Trans.  1. 

I894t  Lea,  Arnold  W.  W.,  M.D.,  B.S.Lond.,  F.E.C.S.,  Lecturer 

on  Midwifery  and  Diseases  of  Women,  Owens  College  ; 
274,  Oxford  road,  Manchester.     Trans.  2. 

1898  Lea,  Francis  James,  M.E.C.S.Eng.,  62,  Princes  road, 
Holland  park,  W. 

1894t  Leahy,  Albert  William  Denis,  M.D.  Durh.,  F.E.C.S., 
6,  Elysium  road,  Calcutta. 


XXXVl  FELLOWS    OF    THE    SOCIETY. 

Elected 

1884*tLEDiARD,  Henry    Ambrose,   M.D.,   35,  Lowther  street, 

Carlisle.     Coimcil,  1890-2.     Trans.  1. 
1894t  Lee,    Sidney  Herbert,  B.A.,   M.B.,    B.C.Cantab.,   The 

Moat,  Thame,  Oxon. 

1897  Leslie,  William  Murray,  M.D.  Edin.,  67,  Grosvenor 
street,  \V. 

1885  Lewers,  Arthur  H.  N.,  M.D.  Lond.,  M.R.C.P.,  Obstetric 
Physician  to  the  London  Hospital ;  72,  Harley  street, 
W.  Council,  1887-9,  1893.  Board  Exam.  Midwives 
1895-7.     Trans.  10. 

1885f  LiDiARD>  Sydney  Robert,  M.D.,  Park  View  House, 
Falmouth. 

1894  LiVERMORE,  William  Leppingwell,  L.li.C.P.  Lond.,  52, 
Stapleton  Hall  road,  Stroud  green,  N. 

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

1893f  Logan,  Roderic  Robert  Walter,  Church  street,  Ashby- 
de-la-Zouch. 

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

1894f  Loos,  William  Christopher,  L.E-.C. P.  Lond.,  c/o  Union 
Steamship  Co.,  Ltd.,  Southampton. 

1890  Low,  Harold,  M.B.Cantab.,  10,  Evelyn  gardens.  South 
Kensington. 

1893t  Lowe,  Walter  George,  M.D.  Lond.,  F.R.C.S.,  Burton- 
on-Trent. 

1878*tLYCETT,  John  Allan,  M.D.,  Gatcombe,  Surgeon  to  the 
Wolverhampton  and  District  Hospital  for  Women, 
Wolverhampton. 

1896t  Lyons,  A.,  M.B.,  Thames  Ditton. 

187 If  McCallum,  Duncan  Campbell,  M.D.,  Emeritus  Professor, 

McGill  University;  45,  Union  avenue,  Montreal,  Canada. 

Trans.  4. 

1890  McCann,  Frederick  John,  M.D.,  C.M.Edin.,  M.R.C.P., 
Physician  to  Out-patients  at  the  Samaritan  Hospital ; 
5,  Curzon  street.  May  fair,  W.  Council,  1897-8. 
Trans.  3. 


FELLOWS    OF    THE    SOCIETY.  XXXVll 

Elected 

1894t  McCausland,  Albert  Stanley,  M.D.  Brux.,  Church  Hill 

House,  Swanage. 
1890     McCaw,  John  Dysart,  M.D.,  F.R.C.S.,  Ivy  House,  Lincoln 

road,  East  Finchley,  N.     Council,  1898-9. 

1894t  McDonnell,   ^Eneas   John,    M.D.,  Ch.M.  Sydney,   Too- 

woomba,  Queensland. 
1896     M'DoNNELL,  W.  Campbell,  L.R.C.P.  Loud.,  Park  House, 

Park  lane.  Stoke  Newington,  N. 

1892t  McKay,  W.  J.  Stewart,  M.B.,  M.Ch.Sydney,  Australian 
Club,  Macquarie  street,  Sydney,  N.S.W. 

1897t  McKerron,  Robert  Gordon,  M.B.  Aberd.,  1,  Albyn  place, 
Aberdeen.     Trans.  1. 

1894t  McKiSACK,  Henry  Lawrence,  M.D.Dubl.,  15,  College 
square  east,  Belfast. 

1893     Maclean,  Ewen  John,  M.D.,  C.M.Edin.,  23,  Henrietta 

street,  Cavendish  square,  W. 
1886     McMuLLEN,  William,  L.K.Q.C.P.L,  319a,  Brixton  road, 

S.W. 

1S78  Macnaughton-Jones,  H.,  M.D.,  F.R.C.S.L  and  Edin., 
141,  Harley  street,  Cavendish  square,  W.     Trans.  1. 

1898  Macnaughton-Jones,  Henry,  M.B.,  B.Ch.,  29,  Charles 
street,  Berkeley  square,  W. 

1894f  McOscAR,  John,  L.B.C.P.  Lond.,  Hazelmere,  Goldsworth 
road,  Woking,  Surrey. 

1895t  Maidlow,  William  Harvey,  M.D.Durh.,  F.R.C.S.Eng., 
Ilminster,  Somerset. 

1884  Malcolm,  John  D.,  M.B.,  CM.,  Surgeon  to  the  Samaritan 
Free  Hospital ;  13,  Portman  street,  AV.   Council,  1894-6. 

187 It  Malins,  Edward,  M.D.,  Obstetric  Physician  to  the 
General  Hospital,  Professor  of  Midwifery  at  Mason 
College,  Birmingham  ;  50,  Newhall  street,  Birming- 
ham. Council,  1881-3.  Vice-Pres.  1884-6.  Hon. 
Loc.  Sec. 

1868*tMARCH,  Henry  Colley,  M.D.,  Portisham,  Dorchester. 
Council,  1890-2. 


XXXVlll  FELLOWS    OF    THE    SOCIETY. 

Elected 

1887  Mark,  Leonard  P.,  L.R.C.P.  Lond.,  61,  Cambridge  street, 
Hyde-park  square,  W. 

1860t  Marley,  Henry  Frederick,  The  Nook,  Padstow,  Cornwall. 

1862*fMARRioTT,  Egbert  Buchanan,  SwafFham,  Norfolk. 

1887t  Marsh,  0.  E.  Bulwer,  L.R.C.P.  Ed.,  Parkdale,  Clytha 
park,  Newport,  Monmouthshire. 

1890t  Martin,  Christopher,  M.B.,  C.M.Edin.,  F.E.C.S.Eng., 
Surgeon  to  the  Birmingham  and  Midland  Hospital  for 
Women  ;  35,  George  road,  Edgbaston,  Birmingham. 
Trans.  1. 

lS83f  Maurice,  Oliver  Calley,  75,  London  street,  Reading. 
Council,  1888-90. 

1890  May,  Chichester  Gould,  M.A.,  M.D.Cantab.,  Assistant 
Physician  to  the  Grosvenor  Hospital  for  Women  and 
Children  ;   26,  Walton  street,  Pont  street,  S."W. 

1884t  Maynard,  Edward  Charles,  L.R.C.P. Ed,,  Berkeley  house, 
Richmond  hill,  Surrey. 

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

1886     Mennell,  Zebulon,  1,  Royal  crescent,  Notting  hill,  W. 

1898     Menzies,  Henry,  M.B.Cantab.,  4,  Ashley  gardens,  S.W. 

1882  Meredith, William  Appleton,  M.B.,  CM.,  F.R.C.S.Eng., 
Surgeon  to  the  Samaritan  Free  Hospital  for  Women 
and  Children;  21,  Manchester  Square,  W.  Council^ 
1886-8.     Vice-Pres.  1891-3.     Trans.  3. 

1893  Mesquita,  S.  Bueno  de,  M.D.,  B.S.Lond.,  1,  Highbury 
New  park,  N. 

1893t  MiCHiE,  Harry,  M.B.  Aber.,  27,  Regent  street,  Notting- 
ham. 

1875*tMiLES,  Abijah  J.,  M.D.,  Professor  of  Diseases  of  Women 
and  Children  in  the  Cincinnati  College  of  Medicine, 
Cincinnati,  Ohio,  U.S. 

1895t  Miller,  James  Thomas  Eoger,  Castlegate  House, 
Malton,  Yorkshire. 


FELLOWS    OF    THE    SOCIETY.  XXXIX 

Elected 

1876*  MiLLMAN,    Thomas,   M.D.,   59,    Yonge    street,    Toronto, 
Ontario,  Canada. 

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

1892t  Milton,   Herbert    M.    Nelson,    Kasr-el-Aini    Hospital, 
Cairo,  Egypt. 

1869*tMiNNs,  Pembroke  R.  J.  B.,  M.D.,  Thetford,  Norfolk. 

1867*  Mitchell,  Robert  Nathal,   M.D.,  Brookwood,  Holling- 
ton,  St.  Leonard' s-on-Sea. 

1894t  Mondelet,  ^YILLIAM  Henry,  M.D.,  1,  Gladstone  terrace, 
Brighton. 

1893t  Montbeun,  D.  Antonio  de,  L.R.C.P.  Lond.,  Port  of  Spain, 
Trinidad,  AY. I. 

1877     Moon,  Frederick,  M.B.,  Bexley  house,  Greenwich,  S.E. 

1859t  Moorhead,  John,  M.D.,  Surgeon  to  the  Weymouth   Infir- 
mary and  Dispensary  ;  Weymouth,  Dorset. 

1888     MoRisoN,    Alexander,    M.D.    Ed.,    14,   Upper   Berkeley 
street,  Portman  square,  W. 

1895     MoRisoN,   Henry  Bannermann,   M.B.  Durh.,  Parkwood 
House,  Christchurch  road,  Boscombe,  Bournemouth. 

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

F.R.C.S.,  29,  Eccleston  street,  Eaton  square,  S.W. 

1883     Morris,  Clarke  Kelly,  Gordon  Lodge,  Charlton   road 
Blackheath,  S.E. 

1893     Morrison,  James,  L.K.C.P.  Lond.,  Camden  House,  Wylde 
green,  Birmingham. 

1893t  Morse,   Thomas  Herbert,  F.R.C.S.,    10,  Upper  Surrey 
street,  Norwich.      7'rans.  1. 

1891  Mortlock,  Charles,  L.R.C.P.  Lond.,  27,  Oxford  square, 

Hyde  park,  W. 

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


xl  FELLOWS    OF    THE    SOCIETY. 

Elected 

1896  MuGFORD,  Sidney  Arthur,  L.R.C.P.,  135,  Kennington 
park  road,  S.E. 

1893     MuiR,  Robert  Douglas,  M.D.,  286,  New  Cross  road,  S.E. 

1896t  Murphy,  James  Keogh,  L.R.C.P.,  35,  Princes  square, 
Bavswater,  W. 

1885  Murray,  Charles  Stormont,  L.R.C.S.  and  L.M.  Ed., 
85,  Gloucester  place,  Portman  square,  W. 

1893t  Murray,  Robert  Milne,  M.B.  Edin.,  11,  Chester  street, 
Edinburgh. 

1888  Myddelton-Gavey,  Edward  Herbert,  124,  Harley 
street,  W. 

1893t  Nairne,  John  Stuart,  F.R.C.S.  Ed.,  141,  Hill  street, 
Garnethill,  Glasgow. 

1897t  Nanavatty,  Byramgi  Hormayi,  L.M.  &  S.  Bomb.,  B.  J. 
School  of  Medicine,  Ahmedabad,  Bombay  Presidency. 

1887  Napier,  A.  D.  Leith,  M.D.  Aber.,  M.E.C.P.  Lond., 
F.R.S.Edin.,  North  terrace,  East  Adelaide,  South 
Australia.     Trans.  2. 

1896t  Nartman,  R.  T.,  M.D.  Brux.,  Parsi  Lying-in  Hospital, 
Bombay. 

1892t  Nash,  W.  Gifford,  F.R.C.S.,  36,  St.  Peter's,  Bedford. 

1859t  Neal,  James,  M.D.,  Parterre,  Sandown,  Isle  of  Wight. 

1882t  Nesham,  Thomas  Cargill,  M.D.,  Lecturer  on  Midwifery 
in  the  University  of  Durham  College  of  Medicine  at 
Newcastle-on-Tyne ;  12,  Ellison  place,  Newcastle-on- 
Tyne.     Council,  1889-91.     Vice-Pres.  1895-7. 

1859*tNEWMAN,  William,  M.D.,  Surgeon  to  the  Stamford  and 
Rutland  Infirmary ;  Barn  Hill  House,  Stamford, 
•  Lincolnshire.  Council,  1873-5.  Vice-Pres.  1876-7. 
Trans.  5. 

1889t  Newnham,  .  William  Harry  Christopher,  M.A., 
M.B.  Cantab.,  Physician-Accoucheur  to  the  Bristol 
Greneral  Hospital ;  Chandos  Villa,  Queen's  road, 
Clifton,  Bristol. 

1895t  Newstead,  James,  9,  York  place,  Clifton,  Bristol. 


FELLOWS    OF   THE    SOCIETY.  xH 

lElected 

1893t  NicHOL,  Frank  Edward,  M.A.,  :M.B.,  B.C.  Cantab., 
1 1,  Ethelbert  Terrace,  Margate. 

1873t  NiCHOLSOX,  Arthur,  M.B.  Lond.,  30,  Brunswick  square, 
Brighton.     Council,  1897-9. 

1894  NiCHOLSOX,  Edgar,  M.E.C.S.,  The  Laurels,  High  street, 
Fenny  Stratford,  Bucks. 

1879t  Nicholson,  Emilius  Rowley,  ^l.D.,  19,  Cornwallis 
gardens,  Hastings. 

1876*  Nix,  Edward  James,  M.D.,  11,  AVeymouth  street,  W. 
Council,  1889-90. 

I882t  Norman,  John  Edward,  Lismore  House,  Hebburn-on-Tyne. 

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

1895t  Ogle,  John  Gilbert,  M.D.Oxon.,  Reigate,  Surrey. 

O.F.f  Oldham,  Henry,  M.D.,  F.R.G.P.,  Consulting  Obstetric 
Physician  to  Guy's  Hospital ;  Cannington,  Boscombe, 
Bournemouth.  Vice-Fres.  1859.  Council,  1860j 
1865-6.  Trea^.  1861-2.  Pres.  1863-4.  Trans.  1. 
Trustee. 

1888  Oliver,  Franklin  Hewitt,  L.E-.C.P.  Lond.,  2,  Kingsland 
road,  N.E. 

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

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

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

1889*  Page,    Harry    Marmaduke,    M.D.Brux.,    F.R.C.S.,    26, 

Ashley  gardens,  Victoria  street,  S.W. 

189 If  Page,  Herbert  Markant,  M.D.Brux.,  16,  Prospect  hill, 
Redditch. 

1883  Palmer,  John  Irwin,  132,  Harley  street,  Cavendish 
square,  W. 


Xlii  FELLOWS    OF    THE    SOCIETY. 

Elected 

1877*  Paramore,  Richard,  M.D.,  2,  Gordon  square,  W.C. 
1867*tP-*^^KS,  John,  Bank  House,  Manchester  road.  Bury,  Lanca- 
shire. 
1887     Parsons,  John  Inglis,  M.D.Durh.,  M.R.C.P.,  Physician 

to  Out  Patients,  Chelsea  Hospital  for  Women,  3,  Queen 

street,  May  fair,  W.     Trans.  2. 
1880     Parsons,  Sidney,  78.  Kensington  Park  road,  W. 
1865*tPATERSON,  James,  M.D.,  Hayburn  Bank,  Partick,  Glasgow. 
1882*  Peacey,  William,  M.D.,    Rydal  Mount,  St.  John's  road, 

Eastbourne. 
1894     Peake,  Solomon,  M.R.C.S.,  118,  Percy  road.  Shepherd's 

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

place,  Kensington,  W.     Council^  1895. 
1871*  Pedler,  George  Henry,  6,  Trevor  terrace,  Rutland  gate, 

S.W.     Council,  1897-8. 
1880*tPEDLEY,  Thomas  Franklin,  M.D.,  Rangoon,  India.  Trans.  1. 

1898     Penny,    Alfred     Gervase,    M.A.,    M.B.,   B.C.Cantab., 
Queen's  Avenue,  Muswell  Hill,  N. 

1881t  Perigal,   Arthur,   M.D.,  New    Barnet,   Herts.      Council, 
1802-3. 

1893  Perkins,  George  C.  Steele,  M.D.,  85,  Wimpole  street, 

W. 
1871t  Perrigo,  James,  M.D.,  826,  Sherbrooke  street,  Montreal, 

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

1894  Petty,    David,   M.B.,   C.M.,Edin.,   6,  High   road,  South 

Tottenham,  N.E. 
1879     Phillips,  George  Richard   Turner,    28,    Palace   court, 

Bayswater  hill,  W.     Council,  1891. 
1882     Phillips,  John,  M.A.,  M.D.  Cantab.,  F.R.C.P.,  Obstetric 

Physician   to   King's   College   Hospital,   and  Lecturer 

on    Practical    Obstetrics    in    King's    College ;     68, 

Brook    street,    W.       Council,    1887-9,    1893.      Hon. 

Lib.  1894-5.    Hon.  Sec,   1896-9.     Board  Exam.  Mid- 

wives,  1892-4.     Trans.  ^. 


FELLOWS    OF    THE    SOCIETY.  xliii 

Elected 

1897  Phillips,  Llewellyn  C.  P.,  M.B.,  B.C.  Cantab.,  St.  Bar- 
tholomew's Hospital,  E.C. 

1878*  Philpot,  Joseph  Henry,  M.D.,  61,  Chester  square,  S.W. 
Council,  1891. 

1889t  Pinhorn,  Richard,  L.R.C.P.  Lond.,  5,  Cambridge  terrace, 
Dover.     Council,  1897-9. 

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

1893  Playfair,  Hugh  James  Moon,  M.D.Lond.,  Assistant  Phy- 
sician, Hospital  for  Women  and  Children,  Waterloo 
road;  9,  Cliveden  place,  Eaton  square,  S.W. 

1864*  Playfair,  W.  S.,  M.D.,  LL.D.,  F.R.C.P.,  Physician- 
Accoucheur  to  H.I.  &  R.H.  the  Duchess  of  Edin- 
burgh ;  Consulting  Obstetric  Physician  to  King's 
College  Hospital,  38,  Grosvenor  street,  W.  CounciU 
1867,  1883-0.  Son.  Librarian,  1868-9.  Hon.  Sec. 
1870-72.  Vice-Pres.  1873-5.  Pres.  1879-80.  Trans, 
15. 

1880  PococK,  Frederick  Ernest,  M.D.,  The  Limes,  St.  Mark's 
road,  Notting  hill,  W. 

1891  Pollock,  William  Eivers,  M.B.,  B.C.Cantab.,  Assistant 
Obstetric  Physician  to  the  Westminster  Hospital,  56, 
Park  street,  Grosvenor  square,  W.  Council,  1895-7. 
Board  Exam.  Midwives,  1898-9. 

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

189  If  Pope,  Henry  Sharland,  M.B.,  B.C.Cantab.,  Castle  Bailey, 
Bridgwater. 

1888*  Popham,  Robert  Brooks,  M.K.C.P.  Edin.,  L.R.C.P.Lond., 
Endyon,  242,  Camden  road,  N.W. 

1864*  Potter,  John  Baptiste,  M.D.,  F.R.C. P.,  Obstetric  Physi- 
cian to,  and  Lecturer  on  Midwifery  and  Diseases  of 
Women  at,  the  AVestminster  Hospital  ;  20,  George 
street,  Hanover  square,  W.  Council,  1872-6,  1890-2. 
Hon.  Lib.  \877-8.  Vice-Pres.  \S7 9-81.  Treas.  1882-4, 
1893-7.  Board  Exam.  Midwives, \S83-4.  Pres.\885-6. 
Trans.  1 .     Trustee. 


Xliv  FELLOWS    OF    THE    SOCIETY. 

Elected 

1894t  Pound,  Clement,  L.R.C.P.  Lond.,  High  street,  Odiham, 
Hants. 

1893  Powell,  Herbert  Edavard,  Glenarm  House,  Upper 
Clapton,  N.E. 

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

1893t  Pratt,  William  Sutton,  M.D.,  Penrhos  House,  Eugby. 

1880*  Prickett,  Marmaduke,  M.A.Cantab.,  M.D.,  Physician  to 
the  Samaritan  Hospital ;  27,  Oxford  square,  W. 
Council,  1892. 

1895  Priestley,  R.  C,  M.A.,  M.B.Cantab.,  81,  Linden  gardens, 
Bayswater,  W. 

O.F.*  Priestley,  Sir  William  0.,  M.D.,  LL.D.,  F.R.C.P.,  Con- 
sulting Obstetric  Physician  to  King's  College  Hos- 
pital; 17,  Hertford  street,  Mayfair,  W.  Council^ 
1859-61,  1865-6.  Vice-Pres.  1867-9.  Pres.  1875-6. 
Trans.  6. 

1893  Probyn-Williams,  Robert  James,  M.D.Durh.,  22,  Duke 
street,  Portland  place.     Trans.  1. 

1898t  PuRSLow,  Charles  Edwin,  M.D. Lond.,  192,  Broad  street, 
Birmingham. 

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

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

1897     Rawlings,  J.  D.,  M.B.Lond.,  The  Old  House,  Dorking. 

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

1894t  Eayner,  Herbert  Edward,  F.E.C.S.,  Harcourt  House, 
Camberley,  Surrey. 

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

1879  Read,  Thomas  Laurence,  11,  Petersham  terrace,  Queen's 
gate,  S.W.     Council,  1892. 

1879t  Reid,  William  Loudon,  M.D.,  Professor  of  Midwifery  and 
Diseases  of  Women  and  Children,  Anderson's  College ; 
Physician  to  the  Glasgow  Maternity  Hospital ;  7,  Royal 
crescent,  Glasgow.     Council,  1899. 


FELLOWS    OF    THE    SOCIETY.  xlv 

Elected 

1893t  Rexshaw,  Israel  James  Edward,  F.R.C.S.Edin.,  Gorse 
Lea,  Sale,  near  Manchester. 

1875*tEEY,  EuGENio,  M.D.,  39,  Via  Cavour,  Turin. 

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

1872t  Richardson,  William  L.,  M.D.,  A.M.,  Professor  of  Obs- 
tetrics in  Harvard  University  ;  Physician  to  the  Boston 
Lying-in  Hospital ;  225,  Commonwealth  avenue, 
Boston,  Massachusetts,  U.S. 

1889t  Richmond,  Thomas,  L. R.C. P.  Ed.,  22,  Holyrood  crescent, 
Glasgow. 

1872t  RiGDEN,  George,  Surgeon  to  the  Canterbury  Dispensary; 
60,  Burgate  street,  Canterbury.  Trans.  1.  Hon.  Loc. 
Sec. 

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

1892  Roberts,   Charles   Hubert,  M.D.Lond.,  F.R.C.S.  Eng., 

M.E.C.P.,  Physician  to  Out-patients  to  the  Samaritan 
Free  Hospital;  21,  Welbeck  street,  Cavendish  square, 
Council,  1897-9.     Trans.  2. 

O.F.*t  Roberts,  David  Lloyd,  M.D.,  F.R.C.P.,  F.R.S.  Edin., 
Consulting  Obstetric  Physician  to  the  Manchester  Hoyal 
Infirmary  ;  and  Lecturer  on  Clinical  Midwifery  and  the 
Diseases  of  Women  in  Owens  College;  11,  St.  John 
street,  Deansgate,  Manchester.  Council,  1868-70, 
1880-2.    Fice-Pres.  1871-2.     Trans.  5. 

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

I890t  Roberts,  Hugh  Jones,  Sea  View,  Penygroes,  R.S.O.,  N. 
Wales. 

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

1893  Roberts,  Thomas,  2,  Selborne  gardens,  York  road,  Ilford, 

Essex. 


Xlvi  FELLOWS    OF    THE    SOCIETY. 

Elected 

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

1892  Robinson,  George  H.  Drummond,  M.D.,  B.S.  Lond., 
Assistant  Obstetric  Physician,  West  London  Hospital ; 
84,  Park  street,  Grosvenor  square,  W.  Council,  1899. 
Board  Exam.  Midwives,  1898-9.     Trans.  1. 

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

1895t  RoBSON,  Alfred  William,  M.D.Brux,,  Kempstow  House, 
111,  Park  road,  Aston,  Birmingham. 

lS90t  RoBSON,  A.  W.  Mato,  F.R.C.S.,  7,  Park  square,  Leeds. 

1876t*RoE,  John  Withington,  M.D.,  Ellesmere,  Salop. 

1874*tRooTS,  William  Henry,  Canbury  House,  Kingston-on- 
Thames. 

1874  Roper,  Arthur,  M.D.St. And.,  Colby,  Lewisham  hill,  S.E. 
Council,  1886-8. 

1859  EosE,  Henry  Cooper,  M.D.,  16,  Warwick  road,  Maida 
hill,  W.     Council,  1875-7.     Trans.  4. 

1893f  Rosenau,  Albert,  M.D.,  Hotel  Victoria,  Kissingen, 
Bavaria.     (Winter,  Avenue  la  Costa,  Monte  Carlo.) 

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

1884t  Roughton,  Walter,  F.E.C.S.,  Cranborne  House,  New 
Barnet. 

1882*  RouTH,  Amand,  M.D.,  B.S.,  Obstetric  Physician  (with  care 
of  Out-patients)  to,  and  Lecturer  on  Practical  Obste- 
trics at,  Charing  Cross  Hospital;  14a,  Manchester 
square,  W.  Council,  1886-8,  1896-7.  Board  Exam. 
Midwives,  1893-5.     Hon.  Lib.  1898-9.     Trans.  4. 

•O.F.*  RouTH,  Charles  Henry  Felix,  M.D.,  Consulting  Physician 
to  the  Samaritan  Free  Hospital  for  Women  and  Children ; 
52,  Montagu  square,  W.  Council,  \Sb9-^\.  Vice-Pres. 
1874-6.     Trans.  13. 


FELLOWS    OF    THE    SOCIETY.  xlvii 

Elected 

1887*tRowE,  Arthur  Walton,  M.D.  Dur.,  1,  Cecil  street,  Margate. 

188 If  RowoRTH,  Alfred  Thomas,  Grays,  Essex. 

1886  Rushworth,  Frank,  M.D.  Lond.,  1a,  Goldhurst  terrace, 
South  Hampstead,  N.W. 

1888t  EusHWORTH,  Norman,  L.R.C. P.  Lond.,  Beeehfield,  Walton- 

on-Thames. 
I886t  RuTHERFooRD,    Henry   Trotter,    M.A.,    M.D.  Cantab., 

Salisbury       House,      Taunton.       Council^       1892-3. 

Trans.  1. 
1895t  Rutherford,  George  James,  L.R.C.P.Lond.  ;  Hastings, 

St.  Leonard's,  and  East  Sussex  Hospital,  Hastings. 

1866*tSABOiA,  Baron  V.  de,  M.D.,  Director  of  the  School  of  Medi- 
cine, Rio  de  Janeiro  ;  7,  Rua  doni  Affonso,  Petropolis, 
Rio  Janeiro.     Trans.  2. 

1864*tSALTEE,  John  H.,  D'Arcy  House,  Tolleshunt  d'Arcy,  Kel- 
vedon,  Essex.     Council,  1894-6. 

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

1886t  Sanderson,  Robert,  M.B.  Oxon.,  98,  Montpellier  road, 
Brighton. 

18/2     Sangstee,  Charles,  148,  Lambeth  road,  S.E. 

1872t  Savage,  Thomas,  M.D.,  Surgeon  to  the  Birmingham  and 
Midland  Hospital  for  Women;  133,  Edmund  street, 
Birmingham.     Council,  1878-80. 

1877  Savory,  Charles  Tozer,  M.D.,  25,  Grange  road,  Canon- 
bury,  N.     Trans.  1. 

1894t  Savory,  Horace,  M.A.,  M.B.,  B.C.  Cantab.,  Haileybury 
College,  Hertford. 

1890  Schacht,  Frank  Frederick,  B.A.,  M.D.Cantab.,  168, 
Earl's  Court  road,  S.W. 

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

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


xlviii  FELLOWS    OF   THE    SOCIETY. 

Elected 

1882     Serjeant,  David  Maurice,  M.D.,  1,  The  Terrace,  Cam- 

berwell,  S.E. 
1875     Seton,  David    Elphinstone,  M.D.,    1,  Emperor's  gate, 

S.W.     Council,  1884. 
1896t  Sharman,  Mark,  M.B.,  C.M.Glas.,  Rick  mans  worth. 
1894t  Sharpiis^,  Archdale  Lloyd,  L.E.C.P.  Lond.,  23,Kimbol- 

ton  road,  Bedford. 
1887     Shaw,  John,  M.D.  Lond.,  Obstetric  Physician  to  the  North 

West  London   Hospital ;   32,  New   Cavendish  street, 

Cavendish  square,  W.     Trans.  3. 
1891     Shaw-Mackenzie,   John    Alexander,    M.D.  Lond.,   31, 

Grosvenor  street,  W. 

1888t  Sinclair,  William  Japf,  M.D.  Aber.,  Honorary  Physician 
to  the  Southern  Hospital  for  Women  and  Children  and 
Maternity  Hospital,  Manchester ;  and  Professor  of 
Obstetrics  and  Gynaecology,  Owens  College,  Man- 
chester; 250,  Oxford  road,  Manchester.    Council,  1899. 

1881t  Sloan,  Archibald,  M.B.,  21,  Elmbank  street,  Glasgow. 

1876t  Sloan,  Samuel,  M.D.,  CM.,  5,  Somerset  place,  Sauchiehall 
street  west,  Glasgow. 

1890t  Sloman,  Frederick,  IS,  Montpellier  road,  Brighton. 

1861  Slyman,  William  Daniel,  26,  Caversham  road,  Kentish 
Town,  N.W.     Council,  1881. 

1867*  Smith,  Heywood,  M.D.,  18,  Harley  street.  Cavendish 
square,  W.  Council,  \^7 2-5.  Board  Exam.  Midwives, 
1874-6.     Trans.  6. 

1875  Smith,  Richard  Thomas,  M.D.,  Physician  to  the  Hospital 
for  Women,  Soho  square ;   117,  Haverstock  hill,  N.W. 

1886t  Smith,  Samuel  Parsons,  L.K.Q.C.P.I.,  Park  Hyrst, 
Addiscombe  road,  Croydon. 

1882t  Smith,   Stephen   Maberly,  L.R.C.P.  Ed.,    Keerie    Kara, 

Ryrie  Street,  Geelong,  Melbourne. 
1898t  Snell,  Sidney  Herbert,  M.D.,  B.S.Lond.,  Grays,  Essex  ; 

and  Gravesend,  Kent. 
1895     SoDEN,   Wilfred    Newell,   M.B.Lond.,    186,   Amhurst 

road,  Hackney,  N.E. 


FELLOWS    OF    THE    SOCIETY.  xlix 

Elected 

1895  Sparks,  Charles  Edward,  M.B.,  B.C.,  B.A.Cantab., 
Netherdale,  Church  End,  Finchley,  N. 

1868*  Spaull,  Barnard  E.,l,Stanwick  road,  West  Kensington,  W. 

1888*  Spencer,  Herbert  R.,  M.D.,  B.S.Lond.,  Professor  of  Mid- 
wifery in  University  College,  London,  and  Obstetric 
Physician  to  University  College  Hospital;  104,  Harley 
street,  W.  CowwciV,  1890-92.  Board  Exam.  MidwiveSy 
1896-7.     Hon.  Sec.  1898-9.     Trans.  /. 

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

1882  Spooner,     Frederick    Henry,    M.D.,   Maitland   Lodge, 

Maitland  place,  Clapton,  N.E. 

I876t  Spurgin,  Herbert  Branwhite,  82,  Abington  street, 
Northampton, 

1897  Stabb,  Arthur  Francis,  M.B.,  B.C.  Cantab.,  Assistant 
Obstetric  Physician  to  St.  George's  Hospital,  and 
Lecturer  in  Midwifery  in  the  University  of  Cambridge; 
109,  Harley  street,  W.     Council,  1899. 

1893  Stack,    E.     H.    Edwards,    M.B.,    B.C.Cantab.,    Royal 

Infirmary,  Bristol. 

1894  Stevens,   Thomas    G-eorge,   M.D.,    B.S.    Lond.,   8,    St. 

Thomas's  street,  S.E.     Trans.  2. 

1884t  Stevenson,  Edmond  Sinclair,  F.R.C.S.  Ed.,  Strathalian 
House,  Rondebosch,  Cape  of  Good  Hope.     Trans.  2. 

1877t  Stephenson,  William,  M.D.,  Professor  of  Midwifery, 
University  of  Aberdeen  ;  3,  Rubislaw  terrace,  Aberdeen. 
Councily  1881-3.     Vice-Prea.,  1887-9.     Trayis.  2. 

1875*tSTEWART,  William,  F.R.C.P.  Ed.,  26,  Lethbridge  road, 
Southport. 

1884t  Stiven,  Edward  W.  F.,  M.D.,  The  Manor  Lodge,  Harrow- 
on-the-Hill. 

1884  Stivens,  Bertram  H.  Lyne,  M.D.Brux.,  107,  Park  street, 
Grosvenor  square,  W. 

1883  Stocks,  Frederick,  421,  Wandsworth  road,  S.W. 
vol.  XL.  d 


1 


FELLOWS    OF    THE    SOCIETY. 


Elected 

1894t  Stott,  William   Atkinson,  M.K.C.S.,  L.R.C.P.  Lond., 

1,  Grove  terrace,  Leeds. 
1866*  Strange,    William    Heath,    M.D.,    2,    Belsize   avenue, 

Belsize  park,  N.W.     Council^  1882-4. 

1895  Stuck,  Sidney  Joseph,  M.D.,  Whitechapel  Infirmary,  E. 
1898t  Sturmer,    Arthur    James,   Lieut-Col.,    Indian   Medical 

Service,  Madras. 
1884     Sunderland,    Septimus,    M.D.,     11,    Cavendish    place. 

Cavendish  square,  W. 
1883*^  Sutherland,  Henry,  M.A.,   M.D.  Oxon.,  M.R.C.P.,   21, 

New  Cavendish  street,  W. 
1888     Sutton,  John  Bland,  F.R.C.S.,  Surgeon  to  the  Middlesex 

Hospital ;  48,  Queen  Anne  street,   Cavendish  square, 

W.      Council,  1894-5.     Trans.  5. 
1894     Swallow,  Allan   James,   M.B.,  B.S.   Durh.,  5,   Mount 

Edgecumbe  gardens,  Clapham  rise,  S,W. 

1896  Swan,  Charles  Atkin,  M.B.,  B.Ch.Oxon.,  4,  Devonport 

street,  Gloucester  square,  W. 

1893  Swayne,  Francis  Griffiths,  M.A.,  M.B.,  B.C.Cantab., 
15,  Church  road,  Norwood,  S.E. 

1859*tSwAYNE,  Joseph  Griffiths,  M.D.,  Consulting  Physician- 
Accoucheur  to  the  Bristol  General  Hospital ;  Emeritus 
Professor  of  Midwifery  in  University  College,  Bristol ; 
Harewood  House,  74,  Pembroke  road,  Clifton,  Bristol. 
Council,  1860-1.     Vice-Pres.  1862-4.     Trans.  9. 

1892t  SwAYNE,  Walter  Carless,  M.D.Lond.,  Obstetric  Phy- 
sician, Bristol  Royal  Infirmary ;  Lecturer  on  Practical 
Midwifery  in  University  College,  Bristol ;  8,  Leicester 
place,  St.  Paul's  road,  Clifton. 

1888*  Sworn,  Heney  George,  L.K.Q.C.P.  &  L.M.,  5,  Highbury 
crescent,  N. 

1883  Tait,  Edward  Sabine,  M.D.,  48,  Highbury  park,  N. 
Council,  1892-4.      Trans.  I. 

1879  Tait,  Edward  W„  10,  Ellerdale  road,  Hampstead,  N.W. 
Council,  1886-7. 

1871*tTAiT,  Lawson,  F.R.C.S.,  Surgeon  to  the  Birmingham  and 
Midland  Hospital  for  Women  ;  7,  The  Crescent,  Bir- 
mingham.    Trans.  15. 


FELLOWS    OF    THE    SOCIETY.  ll 

Elected 

1880*tTAKAKi,  Kaxaheiro,  F.R.C.S.,  10,  Nishi-Konyacho,  Kio- 
bashika,  Tokio,  Japan.     Hon.  Loc.  Sec. 

1859  Tapsoi^,  Alfred  Joseph,  M.B.Lond.,  Heath  Lodge, 
Hillingdon,  Uxbridge.  Council,  1862-4.  Fice-Pres. 
1891. 

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

Assistant  Obstetric  Surgeon  to  Guy's  Hospital,  6, 
St.  Thomas's  street,  S.E.     Council,  1895. 

1892  Tate,  Walter   William   Hunt,   M.D.Lond.,   Assistant 

Obstetric  Physician  to  St.  Thomas's  Hospital;  57, 
Queen  Anne  street,  Cavendish  square,  W.  Council, 
1895-7.     Board  Exam.  Midwives,  \89S-9.     Trans.], 

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

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

1890*tTAYLOK,  John  William,  F.R.C.S.,  Surgeon  to  the 
Birmingham  and  Midland  Hospital  for  Women ; 
Consulting  Surgeon  to  the  Wolverhampton  Hospital 
for  Women ;  22,  Newhall  street,  Birmingham. 
Trans.  2. 

1892     Taylor,  William  Bramley,  145,  Denmark  hill,  S.E. 
]885t  Taylor,  William  Charles  Everley,  M.R.C.P.  Edin.,  34, 
Queen  street,  Scarborough. 

1894t  Tench,  Montague,  M.D.  Brux.,  L.R.C.P.  Lond.,  Great 
Dunmow,  Essex. 

1890t  Thomas,  Benjamin  Wilfred,  L.R.C.P.  Lond.,  Welwyn. 
I887t  Thomas,     William     Edmund,     L.R.C.P.Ed.,     Pentwyn, 
Bridgend,  Glamorganshire. 

1867*tTHOMPSON,  Joseph,  L.R.C.P.  Lond.,  Surgeon  to  the 
General  Hospital  and  Hospital  for  Women,  Notting- 
ham ;  1,  Oxford  street,  Nottingham.  Trans  I.  Hon, 
Loc.  Sec.     Council,  1896-8. 

1878     Thomson,   David,   M.D.,   33,    Lowndes   street,   Belgrave 

square,  S.W. 
1873*  Ticehurst,  Charles  Sage,  Petersfield,  Hants. 
1866     Tillet,  Samuel.  . 


lii  FELLOWS    OF    THE    SOCIETY. 

Elected 

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

1895t  TiXLET,  William  Edwin  FALKiNGRiDGE,M.B.,B.S.Durh., 

Hildegard  House,  Whitby. 
1879t  TiVY,  William  James,  F.R.C.S.  Ed.,  8,  Lansdown  place, 

Clifton,  Bristol. 

1897  Todd-White,  Arthur  Thomas,  L.R.C.P.  Lond.,  Lancaster 

House,  Leytonstone. 
1872t  Tototschinoff,  N.,  M.D.,  Charkoff,  Russia. 
1884     Travers,  William,  M.D.,  2,  Phillimore  gardens,  W. 

1893t  Trethowan,  William,  M.B.,  CM.  Aber.,  care  of  Dr.  Mac- 
Williams,  Perth,  Western  Australia. 

1886t  Tuckett,  Walter  Reginald,  Woodhouse  Eaves,  near 
Loughborough. 

1898  Turner,  Arthur  Scott,  L.R.C.P.Lond.,  Stanton,  Anerley, 

S.E. 
1865*  Turner,  John   Sidney,  Stanton  House,  81,  Anerley  road, 
Upper  Norwood,  S.E.     Council,  1893-4. 

1891  Turner,  Philip  Dymock,  M.D.Lond.,  44,  Welbeck 
street,  W. 

188 If  TuTHiLL,  Phineas  Barrett,  M.D.,  27,  Northbrook  road 
Dublin. 

1861     Tweed,  John  James,  F.R.CIS.,   14,  Upper  Brook  street, 

W.     Council,  1896. 
1897     Twynam,  George  Edward,  L.R.C.P.Lond.,  31,  Gledhow 

gardens,  S.W. 

1890     Tyrrell,   Walter,  L.R.C.P.Lond.,    104,  Cromwell  road, 

S.W. 
1893     Umney,  William  Francis,  M.D.Lond.,  Heatherbell,  15, 

Crystal  Palace  park  road,  Sydenham,  S.E. 

1874*  Venn,  Albert  John,  M.D.,  70a,  Grosvenor  street,  W. 

1873*  Verley,  Reginald  Louis,  F.R.C.P.  Ed.,  St.  George's 
Club,  Hanover  square,  W. 

1892t  Verrall,    Thomas   Jenner,    L.RX.P.Lond.,    97,    Mont- 
,  pellier  road,  Brighton. 


FELLOWS    OF    THE    SOCIETY.  liii 

Elected 

1879t  Wade,  George  Herbert,  Ivy  Lodge,  Chislehurst,  Kent. 
Council,  1892-3. 

1894t  Wagstaff,  Frank  Alex.,  L.E.C.P.  Lond.,  Saffron 
Walden,  Essex. 

1860t  Wales,  Thomas  Garneys,  Downham  Market,  Norfolk. 

1898t  Walker,  Alfred,  M.D.,  B.C.,  M.A.'Cantab.,  12,  Ling- 
field  road,  Wimbledon. 

1894  Walker,  Thomas  Alfred,  L.E.C.P.  Edin.,  Greville  Lodge, 
Willesden  park,  N.W. 

1865t  Walker,  Thomas  James,  M.D.,  Surgeon  to  the  General 
Infirmary,  Peterborough  ;  33,  Westgate,  Peterborough. 
Council,  18/8-80.     Hon.  Loc.  Sec. 

1889     Wallace,  Abraham,  M.D.  Edin.,  39,  Harley  street,  W. 

1870  Wallace,  Frederick,  Foulden  Lodge,  Upper  Clapton, 
N.E.     Council,  1880-2. 

1897t  Wallace,  James  Robert,  M.D.Brux.,  50,  Park  street, 
Calcutta. 

1883  Wallace,  Kichard  Unthank,  M.B.,  Cravenhurst,  Craven 
park,  Stamford  hill,  N. 

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

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

1867*t^VALTEES,  James  Hopkins,  Surgeon  to  the  Royal  Berkshire 
Hospital ;  15,  Friar  street,  Reading,  Berks.  Council^ 
1884-6.     Trans.  1.     Ho?i.  Loc.  Sec. 

1873t  Walters,  John,  M.B.,  Church  street,  Reigate,  Surrey. 
Council,  1896-8.     Tra?i8.  I. 

1898*tWARD,  Charles,  F.E.C.S.I.,  M.R.C.S.Eng.,  Pietermaritz- 
burg,  Natal,  S.  Africa. 

1895  Warner,  Frederick  Ashton,  L.R.C.P.,  10,  Brechin 
place.  South  Kensington,  S.W. 


liv  FELLOWS    OF    THE    SOCIETY. 

Elected 

1898t  Watson,  C.  R,,  M.D.Brux.,  3,  Mount  Ephraim  road, 
Tunbridge  Wells. 

1884t  Waugh,  Alexander,  L.E.C.P.  Lond.,  Midsomer-Norton, 
Bath. 

1893t  Webb,  James  Eamsay,  M.B.,  B.S.Melbourne,  82, 
St.  Vincent  place  south,  Albert  park,  Melbourne. 

1894t  Webb,  John  Curtis,  M.A.,  M.B.,  B.C.Cantab.,  Colling- 
ham  place,  Earl's  Court. 

1886t  Webbee,  William  W.,  L.R.C.P.  Ed.,  Crewkerne. 
1893t  Webster,  Thomas  James,  Brynglas,  Merthyr  Tydvil. 

i897t  Weeks,  Courtenay  Charles,  L.R.C.P.Lond.,  Pinchbeck, 
Spalding. 

1887t  Wells,  Albert  Primrose,  M.A.,  L.R.C.P.  &  S.,  L.M., 
16,  Albemarle  road,  Beckenham. 

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

1888*  Weston,  Joseph  Theophilus,  M.D.Brux.,  Civil  Surgeon, 
Hissar,  Punjab  (care  of  Messrs.  Thacker,  Spink,  and 
Co.,  booksellers  and  publishers,  Government  place, 
Calcutta). 

1890  Wheaton,  Samuel  W.,  M.D.Lond.,  Physician  to  the  Royal 
Hospital  for  Children  and  Women ;  7^^  The  Chase, 
Clapham  common,  S.W. 

1889t  Whitcombe,  Charles  Henry,  F.R.C.S.  Edin.,  281, 
Queen's  road,  Halifax. 

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

1882  Wholey,  Thomas,  M.B.  Durh.,  Winchester  House,  50,  Old 
Broad  street,  E.C. 

1879t  WiLLANs,  William  Blundell,  F.R.C.P.  Ed.,  Much  Had- 
ham,  Herts. 

1894t  Williams,  John  D.,  M.D.Ed.,  B.Sc,  20,  Windsor  place, 
Cardiff. 


FELLOWS    OF    THE    SOCIETY.  Iv 

Elected 

1872  Williams,  Sir  Johx,  Bart.,  M.D.,  F.R.C.P.,  Physician- 
Accoucheur  to  H.R.H.  Princess  Beatrice,  Princess 
Henry  of  Battenberg ;  Consulting  Obstetric  Physician 
to  University  College  Hospital ;  63,  Brook  street,  Gros- 
venor  square,  W.  Council,  1875-6,  1892,  1894. 
Hoyi.  Sec.  1877-9.  Fice-Pres.  1880-2.  Board  Exam. 
Midwives,  1881-2;  Chairman,  1884-6.  Pres.  1887-8. 
Trans.  12.     Ti'ustee. 

1897  Williams,  Joseph  William,  L.R.C.P.,  128,  Mansfield 
road,  Gospel  Oak,  N.W. 

1890  Williams,  Regixald  Muzio,  M.D.Lond.,  35,  Kensington 
park  gardens,  W. 

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

I898t  Wilson,  Claude,  M.D.Edin.,  Belmont,  Church  road, 
Tunbridge  Wells. 

1892t  Wilson,  Thomas,  M.D.,  B.S.Lond.,  F.R.C.S.,  Assistant 
Obstetric  Physician  at  the  General  Hospital,  Birming- 
ham ;   22,  Temple  row,  Birmingham.     Trans. \. 

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

1896t  Winter,  John  Beadburt,  L.R.C.P,  28,  Montpelier  road, 
Brighton. 

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

1893     Wise,  Robert,  M.D.Edin.,  5,  Weston  park,  Crouch  End, 

N. 

1887t  Withers,  Robert,  Stenteford  Lodge,  Spencer  terrace, 
Lipson  road,  Plymouth. 

1890  WoRNUM,  George  Porter,  6,  College  terrace,  Belsize  park, 
N.W. 

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

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


Ivi  FELLOWS    OF    THE    SOCIETY. 

Elected 

1888*tWyATT. Smith,  Frank,  M.B.,  B.C.Cantab.,  British  Hospital, 
Buenos  Ayres. 

1871     Yarrow,    George    Eugene,   M.D.,    26,   Duncan   terrace, 
Islington,  N.     Council,  1881-3. 

1882*tYouNG,  Charles  Grove,  M.D.,  14,  Clapham  Mansions, 
Clapbam  Common,  S.W. 


Number  of  Fellows   ....     676. 


CONTENTS. 


List  ofOfficers  for  1899  . 

List  of  Presidents 

List  of  Referees  of  Papers  for  1899 

Standing  Committees 

List  of  Honorary  Local  Secretaries 

Trustees  of  the  Society's  Property 

List  of  Honorary  and  Corresponding  Fellows 

List  of  Ordinary  Fellows 

Contents 

List  of  Plates  and  Illustrations 

Advertisement  . 

Hours  of  Attendance  at  Library 


PAGE 

V 

vii 

.     viii 

ix 

X 

xi 
xi,  xii 
.  xiii 
.  Ivii 
Ixiii,  Ixiv 
.  Ixvii 
.  Ixvii 


January  5th,  1898— 

Malignant  Adenoma  (Carcinoma)  of  the  Cervix  Uteri, 
shown  by  Dr.  F.  J.  McCann 

Uterine  Myoma,  shown  by  Dr.  F.  J.  McCann 

Placenta  from  a  Case  of  Extra-uterine  Foetation ;  the 
Child  at  full  term,  and  removed  five  months  after 
Death,  shown  by  Dr.  John  Phillips 

Hydrocele  of  the  Canal  of  Niick  containing  a  por- 
tion of  the  left  Fallopian  Tube,  shown  by  Dr. 
Remfry         ..... 

Malignant  Growth  involving  the  Right  Uterine 
Appendages,  shown  by  Dr.  Cullingworth 


Iviii 


CONTENTS. 


PAGE 

I.  Adjourned  Discussion  on  Dr.  McKerron's  paper  on 
'*  The  Obstruction  of  Labour  by  Ovarian  Tumours 
in  the  Pelvis  .... 
II.  Incarcerated  Ovarian  Dermoid  obstructing  Labour 
Ovariotomy  during  Labour,  by  Dr.  Herbert  R 
Spencer        .  .  .  .  .14 

III.  Incarcerated  Ovarian  Dermoid  obstructing  Labour  ; 

Manual  Elevation;  Removal  seven  months  later, 

by  Dr.  Herbert  R.  Spencer    .  .  .22 

IV.  Incarcerated    Ovarian  Dermoid;    Csesarean    Section 

and  Removal   of  Tumour  at  the  end  of  the   first 
stage  of  Labour,  shown  by  Dr.  Boxall    .  .       25 


February  2nd,  1898— 

Annual  Meeting  .  .  .  .29 

Uterus  ruptured  during  Unobstructed  Labour  (with 
a  Microscopic  Section),  shown  by  Dr.  Dakin  .       29 

Uterine  Fibroid  clinically  resembling  Sarcoma,  shown 
by  Dr.  Dakin  .  .  .  .32 

Cancer  of  the  Body  of  the  Uterus,  shown  by  Dr. 
Handfield-Jones       .  .  .  .34 

Annual  Meeting — the  Audited  Report  of  the  Trea- 
surer (Dr.  Potter)       ...  35, 36 

Report  of  the  Honorary  Librarian  (Dr.  Grif- 


fith) for  1897  .... 

Report  of  the  Chairman  of  the  Board  for  the 


Examination  of  Midwives  (Dr.  Boulton) 

Annual  Address  of  the  President  (Dr.  CULLING- 

worth)  ..... 

Election  of  Officers  and  Council  for  the  year 

1898  ..... 

——  Bibliographical   Appendix   to  Annual  Address 
(Dr.  Cullingworth)  .... 


37 
37 

39 

89 
91 


March  2nd,  1898— 

Case  of  Deciduoma  malignum,  shown  by  Mr.  J.  H. 

Targett  for  Dr.  Hellier         .  .  .     113 

Double   Monster    of   Dicephalous    Type,    shown    by 

Dr.  Owen  Fowler      ....     119 
Dermoid  Tumour  of  Both  Ovaries,  with  very  long 

Ovarian  Ligament  on  the  left  side,  shown  by  Dr. 

Rivers  Pollock         .  .  .    119 


CONTENTS.  lix 

PAGE 

A  case  of  Double  Pyosalpinx   in  which    the    tubes 

were  enormously    distended,   by   Dr.    C.   Hubert 

Roberts  .....  121 
Fibro- myoma  of  Vaginal  Wall  (with  microscopical 

slide),  shown  by  Dr.  John  Phillips       .  .    130 

Monstrosity  resulting  from  Amniotic    Adhesion  to 

skull,  shown  by  Dr.  John  Phillips  for  Dr.  Jaqer  130 
A  large  soft  Broad  Ligament  Fibro-myoma,  weighing 

fourteen  pounds,  shown  by  Dr.  Ewen  Maclean  .  134 
Cystic  Intra-ligamentous  Myoma  with  Double  Uterus, 

shown  by  Dr.  W.  J.  Gow  .  .  .134 

Report  on  Dr.  Heywood  Smith's  Specimen  shown 

March  3rd,  1897,  not  reported     .  .  .     135 

y.  Intermenstrual    Pain     (Mittelschmerz),    by    Dr.   A. 

Addinsell   .....    137 


April  6th,  189S— 

Uterine  Fibroid  with  Anomalous  Ovarian  Tumour, 
shown  by  Dr.  Macnaughton-Jones        .  .     154 

Rupture  of  an  Early  (Fifteenth  Day)  Tubal  Gesta- 
tion, complicated  by  Fibro-myomata  of  the  Uterus, 
shown  by  Mr.  Dawson  .  .  .     155 

Fibro-myoma  of  Uterus  projecting  into  Yagina,  re- 
moved by  Abdominal  Hysterectomy,  shown  by  Dr. 
W.  W.  H.  Tate  .  .  .  .159 

YI.  The  Menstruation  and  Ovulation    of  Monkeys  and 

the  Human  Female,  by  Mr.  "Walter  Heape  .     161 


May  4th,  1898— 

Double    Intestinal     Obstruction    following    Ovario- 
tomy, shown  by  Mr.  Targett    .  .  .     175 

Fibro-myoma  of  the  Uterus  with  Sarcomatous  Dege- 
neration, shown  by  Dr.  Horrocks  .  .178 

Haemorrhage  from  the  Fallopian  Tube  without  evi- 
dence of  Tubal  Gestation,  shown  by  Mr.  Doean  .     180 
YII.  A  Case  of  Primary  Carcinoma  of  the  Fallopian  Tube, 

by  Dr.  C.  Hubert  Roberts       .  .  .    189 

YIII.  Tables  of  Cases  of  Primary  Cancer  of  the  Fallopian 
Tube  reported  up  to  present  date  (April,  1898),  by 
Mr.  Alban  Doran      ....     197 


Ix  CONTENTS. 

PAGtEj 

June  1st,  1898— 

Report  of  Committee  on  Dr.  Macnaughton- Jones's 

Specimen  of  Tumour  of  the  Ovary,  sliown   April 

6th,  1898        .  .  .  .  .213 

Blood    Concretions    in    the    Ovary,   shown   by   Mr. 

Alban  Doran  ....    214 

Deformed  Foetus,  shown  by  Dr.  Burton  (introduced 

by  Dr.  Boxall)  .  .  .  .217 

Incarcerated  Ovarian  (Dermoid)  Cyst,  removed  during 

Pregnancy  |jer   vaginam,   shown   by   Dr.   Amand 

RouTH  .  .  .  .  .217 

Ruptured  Tubal  Gestation  (at  Fourth  or  Fifth  Week) ; 

Operation  ;    Recovery,    shown    by     Dr.    Amand 

RouTH  .  .  .  .  .220 

Report  on  Dr.  Routh's  Specimen  of  Ruptured  Tubal 

Gestation       .  .  .  .  .222 

An  Ovary  containing   a    Calcareous  Ball,  probably 

a   large  Calcified  Corpus  Fibrosum,  shown  by  Mr. 

J.  Bland  Sutton        ....    223 
Primary  Sarcoma  of  the  Body  of  the  Uterus  (Deci- 

duoma  malignum),  shown  by  Dr.  Lewers  .     225 

Complete  Incontinence  of    Urine  cured  by   Yentro- 

fixation  of  the  Uterus,  by  Dr.  Macnaughton- JoNES    226 
Large   Fibroid  Tumour  of   the    Uterus   undergoing 

Cystic  Degeneration,  shown  by  Dr.  Peter  Hor- 

ROCKS  .....    227 

IX.  Two  Cases  of  Fibro-myoma  of  the  Uterus  removed  by 

Operation  from  Women  under  Twenty-five  Years  of 

Age,  by  Dr.  Herbert  R.  Spencer  .  .    228 

July  6th,  1898— 

A  Case  of  Acute  Bedsore  following  Parturition,  by 

Dr.  G.  F.  Blacker      .  .  .  .247 

Five   Foetal   Sacs   from   the   Peritoneal  Cavity   of  a 

large  Rabbit,  shown  by  Dr.  Pembrey     .  .     253 

Cystic   Fibro-myoma    of    the    Uterus    complicating 

Pregnancy ;  Removal  at  four  and  a  half  months, 

shown  by  Dr.  J.  Dysart  McCaw  .  .     256 

Abortion    showing   Recent    Placental   Haemorrhage, 

shown  by  Dr.  Robert  Wise      .  .  .    257 

Carcinoma    of    Cervix  Uteri   in   which   the  Disease 

extended  upwards  into  the  Body,  shown  by   Dr. 

Walter  Tate  .  .  .  .258 


CONTENTS.  Ixi 

PAGE 

Incarcerated    Ovarian    Dermoid    in    the    ]\Iiddle    of 
Pregnancy  ;  Manual  Elevation ;  Removal   a  Fort- 
night after  Delivery  at  Term,  shown  by  Dr.  Her- 
bert R.  Spencer        ....    259 
X.  The  Sagittal  Fontanelle  in  the  Heads  of  Infants  at 

Birth,  by  Dr.  Arnold  W.  W.  Lea         .  .     263 

XI.  Note  on  some  DiflBcult  Cases  of  Fronto-anterior  Posi- 
tions of  the  Foetal  Head,  by  Dr.  George  Roper  .    271 


October  oth,  1898— 

XII.  Case  of  Puerperal  Septicasmia  treated  by  Antistrepto- 
coccic Serum,  by  Dr.  J,  Walters  and  Dr.  A.  R. 
Walters  .....  277 
XIII.  Earl}'  Ectopic  Gestation  (?  tubo-uterine)  complicated 
by  Fibro-myomata  of  the  Uterus,  by  Dr.  Culling- 
WORTH  .....     285 


November  2nd,  1898— 

Fibroma  of  Broad  Ligament  weighing  forty-four 
pounds  eight  ounces,  successfully  removed  from  a 
woman  aged  twenty-eight,  shown  by  Mr.  Alb  an 
DoRAN  .  .  .  .  .295 

Sarcoma  of  both  Ovaries,  shown  by  Mr.  Alban  Doran     296 

Tubal  Gestation ;  Incomplete  Tubal  Abortion ; 
Haemorrhage  ;  Operation ;  Recovery,  shown  by  Mr. 
A.  C.  Butler-Smythe  .  .  .    298 

(Edematous  Subperitoneal  Fibro-myomata  of  Uterus 
in  Right  Broad  Ligament  removed  by  Abdominal 
Hysterectomy,  shown  by  Dr.  Cullingworth         .     302 

Case  of  Sloughing  Fibro-myoma  of  Uterus  occurring 
in  a  patient  twenty  years  after  the  menopause, 
shown  by  Dr.  Walter  Tate      .  .  .    303 

Uterine  Appendages  showing  a  Haematosalpinx,  shown 
by  Dr.  Amand  Routh  .  .  .     306 

XIV.  On  a  Case  of  Tubo- abdominal  Pregnancy  in  which  a 
Living  Foetus  was  Extracted  by  Coeliotomy  after 
Term,  and   the   Mother's  Life    preserved,  by  Mr. 
J,  Bland  Sutton        ....    308 
XV.  On  some  Cases  of  Tubal  Pregnancy,  by  Mr.  J.  Bland 

Sutton  .....    313 


Ixii  CONTENTS. 

PAGE 

December  7tli,  1898— 

Large  Solitary  Subperitoneal  Fibroid  Tumour  of  the 
Uterus  with  Multiple  Fibroids,  shown  by  Dr. 
Lewers  .....     327 

Incarcerated  Ovarian  Dermoid  ruptured  during  De- 
livery by  Forceps  and  Version,  with  fatal  result, 
shown  by  Dr.  Herbert  R.  Spencer        .  .    329 

Incarcerated  Ovarian  Dermoid  removed  at  the  Fourth 
Month  of  Pregnancy ;  Delivery  of  a  Living  Child 
at  Term,  shown  by  Dr.  Herbert  R.  Spencer        .    330 

Three  Cases  of  Congenital  Tumour  at  the  Internal 
Os  Uteri  causing  Hydrometra  in  New-born 
Children,  shown  by  Dr.  Herbert  R.  Spencer      .    332 

Uterus   with   Interstitial    Fibroid,   from    a    Case    of 

Placenta  Prsevia  Centralis,  shown  by  Dr.  Robert 

BoxALL  .  .  .  .  .338  I 

XVI.  Studies  in  Obstetrics,  by  Dr.  C.  F.  Ponder  .    339  | 

Index  ......    341 

Additions  to  the  Library     ....    359 


Ixiii 


PLATES. 

PLATE  PAGE 

I.  Deciduoma  malignum   (Mr.  J,  H.   Targett,  for   Dr. 
Helliee)  : 
Fig.  1. — Section  of  edge  of  Uterine  Growth  .     118 

Fig.  2. — Section  of  growth  in  Ovary  .  .     118 

II.  Primary    Carcinoma   of  the    Fallopian    Tube    (Dr.  C. 

Hubert  Roberts)  ....    124 

III.  Monstrosity  resulting  from  Amniotic  Adhesion  to  Skull 

(with  outline  key  of  Plate  III)  (Dr.  John  Phillips)     132 

IV.  Tumour  of  the  Ovary  (Dr.  Macnaughton- Jones)         .     154 
Y.  Haemorrhage  from  the  Fallopian  Tube  without  evidence 

of  Tubal  Gestation  (Mr.  Alban  Doran)  : 

Fig.  1. — Haemorrhage    from    the    Fallopian    Tube 

without  evidence  of  Tubal  Gestation  .  .     182 

Fig.  2. — Haemorrhage  from    the    Fallopian  Tubes 
without  evidence  of  Extra-uterine  Gestation     . 
YI.  Primary    Carcinoma   of   the   Fallopian   Tube   (Dr.    C. 

Hubert  Roberts)  ....    194 

YIl.  Early  Ectopic  Gestation  (?  Tubo-uterine)  complicated 
by  Fibro-myomata  of  the  Uterus  (Dr.  Culling- 
worth)  : 

Yiew  from  the  front  and  above  .  .  .     290 

YIII.  Ditto  (ditto) : 

Yiew  from  below  and  behind      .  .  .     290 

IX.  Ditto  (ditto) : 

Yiew  on  section,  after  hardening  .  .     291 


Ixiv 


ILLUSTRATIONS. 

PAGE 

Incarcerated  Ovarian  Dermoid  obstructing  Labour :  Ovario- 
tomy during  Labour  (Dr.  Herbert  R.  Spencer)  .       19 
Annual  Address  (Dr.  Cullingworth)  : 

Diagram  sliowing  proportion  of  figures  relating  to 
mortality  in  the  Paris  Maternite  from  1858  to  1889 
during  periods  of  inaction,  isolation,  and  anti- 
sepsis  .  .  .  .  .82 

An  Ovary  containing  a  Calcareous  Ball,  probably  a  large  cal- 
cified corpus  fibrosum  (Mr.  J.  Bland  Sutton)  .  .    224 
Note  on  some  Difficult  Cases  of  Fronto-anterior  Positions  of 
the  Fcetal  Head  (Dr.  Roper)  : 

Diagram  of  instrument  ...  .     272 

On  a  Case  of  Tubo-abdominal  Pregnancy  in  which  a  Living 
Foetus  was  extracted  by  Coeliotomy  after  term,  and  the 
Mother's  life  preserved  (Mr.  J.  Bland  Sutton)  : 

The  Placenta  with  its  Amnion  in  relation  to  the 

Fallopian  Tube       .  .  .  .311 

On  some  Cases  of  Tubal  Pregnancy  (Mr.  J.  Bland  Sutton)  : 

Fig.  1. — A  Gravid  Mole  containing  Fallopian  Tube     315 
Fig.  2. — A  cluster  of  Decidual  Cells,  presumably 
derived  from   a  Chorionic  Villus,  from  a  Tubal 
Embryo  of  about  the  third  month  .  .     316 

Fig.   3. — Fallopian     Tube,    Ovary     (containing    a 
corpus  luteum),  and  Mole,  from  a  Case  of  com- 
plete Tubal  Abortion  .  .  .318 
Three  Cases  of  Congenital  Tumour  at  the  Internal  Os  Uteri 
causing  Hydrometra  in  New-born  Children  (Dr.  Herbert 
R.  Spencer)  : 

Fig.   1. — Uterus  and  Appendages   of  a  New-born 

Child,  showing  the  Tumour  at  the  Internal  Os     .     334 
Fig.  2. — Uterus  and  Appendages   of  a  New-born 
Child,   showing    Tumour    at    Internal    Os    and 
Polypi  in  Cervical  Canal  .  .  .     334 


ERRATA. 

Page  119,  line  6  from  toi>,  after  "cells"  insert  "(Plate  I 
fig.  1)." 

„  119,  line  7  from  top,  after  "ovary"  insert  "(Plate  I, 
fig.  2)."   . 

„  135,  line  14  from  bottom,  after  "  Specimen  "  read  "  of 
carcinoma  of  omentum  and  Fallopian  tube." 

,,  136,  for  "cystic  intra-ligamentous  mvoma  "  at  head  of 
page,  rertfZ  "carcinoma  of  omentum,  &c." 

„  154,  line  2  from  bottom,  after  "exhibited"  insert  "  (see 
Plate  IV)." 

„  154,  insert  as  a  fresh  paragraph,  after  last  line,  "  The 
specimen  was  referred  to  a  committee  for  exami- 
nation and  report.     (See  p.  213.)" 

,,  182,  line  13  from  toj:>,  after  "corpus  luteum "  insert 
"  Plate  V,  fig.  1." 

„  184,  line  6  from  top,  after  "  evening  "  insert  "  Plate  V, 
fig.  2." 

„  187,  line  4  from  bottom, /or  "presented.  There '^  read 
"  presented,  there." 

„  194,  line  1  from  toj:),  after  "  beneath "  insert  "  (Plate 
VI)  ;" 

,,  194,  before  Plate  VI  insert  the  Plate  erroneously  num- 
bered Plate  II,  and  now  placed  opposite  p.  124. 

„  214,  at  end  of  first  paragraph  insert  "  (See  PI.  IV, 
p.  154)." 

,,  255,  line  4  from  bottom,  transpose  "  The  President  said, 
&c.,"  to  the  end  of  the  paragraph  on  p.  256,  to 
p.  270,  where  it  should  be  inserted  as  a  separate 
paragraph,  immediately  above  Dr.  Lea's  reply. 


VOI-.   XL. 


i 


I 


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,  nor  for  those  contained  in  the  abstracts  of  the 
discussions  which  have  occurred  at  the  meetings  during  the 
Session. 

20,  Hanover  Square,  W. 


LIBRARY   AND   MUSEUM, 

20,  Hanover  Square,  W. 

Hours  of  Attendance :  Monday  to  Friday,  1.30  p.m.  to  6  p.m. ; 
Saturday,  9.30  a.m.  to  2  p.m. ;  and  in  the  evenings  on  which  the 
Society  meets,  from  7.15  p.m.  to  7.45  p.m. 

AGNES  HANNAM, 

Secretary  and  Librarian. 


J 


OBSTETEICAL     SOCIETY 


OF 


LONDON. 


SESSION  1898. 


JANUAKY  5th,  1898. 

C.  J.  CuLLiNQWORTH,  M.D.,  President,  in  the  Chair. 

Present— 29  Fellows. 

The  President  nominated  Mr.  Targett,  Dr.  Wise,  and 
Dr.  Gubb  as  Auditors  of  the  Accounts  for  1897. 

Books  were  presented  by  the  University  of  Geneva, 
the  Johns  Hopkins  Hospital  Staff,  the  St.  Thomas's 
Hospital  Staff,  and  the  Medical  Society. 

C.  W.  Grant-Wilson,  L.R.C.P.Lond.,  and  G.  E. 
Twynam,  L.R.C.P.Lond.,  were  admitted  Fellows  of  the 
Society. 

James    R.    Wallace,    M.D.    (Calcutta),    was    declared 

admitted. 

VOL.   XL.  1 


2    MALIGNANT  ADENOMA   (cAECINOMa)   OP  THE  CERVIX  UTERI. 

The   following  gentlemen  were  elected  Fellows  of  the 
Society  :— David     J.     Evans,     M.D.McGiJl     (Montreal) 
Alfred  Walker,  M.D.,  B.C.Cantab.  ;  Thomas  Cullen,  M.D 
Toronto    (Baltimore)  ;     Trevethan   Frampton,    L.R.C.P. 
Oeorge  A.  Auden,  M.B.,   B.C.Cantab. ;    Henry  Menzies 
M.B.Cantab.  ;   Henry   Macnaughton  Jones,  M.B.,  B.Ch. 
and  S.  Jervois  Aarons,  M.D.Edin. 


MALIGNANT    ADENOMA    (CARCINOMA)    OF  THE 

CERVIX  UTERI. 

Shown  by  Frederick  John  McCann,  M.D.,  CM. 

The  specimen  was  removed  by  vaginal  hysterectomy^ 
June  23rd,  1897,  from  a  patient  aged  46  years.  She  w^as 
discharged  well  twenty-eight  days  after  the  operation. 

The  body  of  the  uterus  was  much  enlarged,  the  cavity 
being  dilated  and  filled  with  mucoid  material,  which  was 
slightly  blood-tinged.  The  cervix  was  nodular,  and 
excavated  by  the  growth,  which  did  not  extend  into  the 
uterine  cavity.  Sections  made  from  the  cervical  growth 
show  that  it  is  composed  of  tubules  lined  by  a  single 
layer  of  columnar  epithelium,  the  interstitial  tissue  being 
of  a  fibro-cellular  character,  and  varying  in  amount. 

The  malignant  nature  of  the  growth  was  proved  by  the 
rapid  recurrence  in  the  pelvic  cellular  tissue.  When  the 
patient  was  seen  on  October  2nd,  1897,  hard  nodular 
infiltration  was  felt  posteriorly  and  laterally  in  the  pelvis. 

The  patient  died  on  December  19th,  1897,  from  starva- 
tion owing  to  constant  vomiting.  The  liver  was  enlarged 
and  nodular,  extending  below  the  level  of  the  umbilicus. 
No  post-mortem  was  obtained. 


PLACENTA  FROM  A  CASE  OF  EXTRA-UTEPJNE  FffiTATIOX.  3 

The  President  asked  Dr.  McCann  whether  he  was  quoting 
any  j^articular  authority  when  he  spoke  of  glandular  carcinoma 
as  being  a  specially  malignant  form  of  the  disease.  In  a  recent 
conversation  with  a  distinguished  pathologist  he  (the  President) 
was  informed  that  glandular  carcinoma  was  now  regarded  by 
pathologists  as,  generally  speaking,  the  least  malignant  form  of 
cancerous  disease,  the  least  rapid  in  its  course,  and  the  least 
likely  to  recur  after  timely  removal.  This  view,  he  was  told, 
was  based  on  the  results  of  rectal  surgery. 


UTERINE  MYOMA. 

Shown  by  Frederick  John  McCann,  M.D.,  CM. 

A  multinodular  myoma  weighing  6  lbs.,  removed  by 
abdominal  intra-peritoneal  hysterectomy  from  a  patient 
aged  44  years.  The  patient  had  suffered  for  eighteen 
months  from  attacks  of  retention  of  urine,  necessitating 
the  use  of  the  catheter.  She  made  an  uneventful  re- 
covery. 


PLACENTA  FROM  A  CASE  OF  EXTRA-UTERINE 
FCETATION  ;  THE  CHILD  AT  FULL  TERM, 
AND  REMOVED  FIVE  MONTHS  AFTER  DEATH. 

Shown  by  John  Phillips,  M.A.,  M.D.Cantab.,  F.R.C.P. 

Mrs.  C — ,  a  married  woman  with  three  children,  the  last 
born  nine  years  ago,  menstruated  normally  and  regularly 
up  to  and  during  November,  1896  (fourteen  months  ago). 
On  December  14th,  when  her  period  was  seven  or  eight 
days  overdue,  she  was  attacked  with  much  left-sided 
abdominal  pain,  accompanied  by  a  discharge  of  blood;  she 
was  ill  for  fourteen  days  with  abdominal  tenderness  and 
feeling  of  malaise.     Morning  sickness  now  commenced,  and 


4  PLACENTA    FROM    A    CASE    OP 

during  January  the  amenorrhoea  continued,  while  in  Febru- 
ary constant  abdominal  pain  was  present.  In  March  there 
was  a  three-day  hgemorrhage,  like  menstruation,  and  she 
still  continued  in  pain;  she  first  noticed  foetal  movements. 
In  April  she  had  retention  of  urine,  requiring  the  catheter. 
In  August  she  was  the  size  of  a  woman  at  term,  and  on 
the  5th  of  that  month  a  spurious  labour  occurred  ;  since 
then  she  has  got  smaller.  On  December  29th  she  began  to 
feel  very  ill,  with  shivering  and  headache.  Her  tempera- 
ture was  found  to  be  102°,  and  her  pulse  120,  with  a 
tender  abdominal  swelling.  Her  condition  became  worse^ 
and  I  saw  her  on  December  31st,  when  she  was  found  with 
a  large  tender  swelling  reaching  three  fingers  above  the 
navel  ;  also  with  a  hardish  rounded  swelling  cropping  up 
in  the  median  line,  two  fingers  above  the  symphysis  pubis. 
This  was  felt  to  contract  and  relax  at  intervals  ;  the  sound 
passed  3^  or  4  inches  directly  into  it. 

The  abdomen  was  opened,  and  a  full-term  dead  child 
removed  from  an  extra-uterine  sac  behind  the  uterus. 
The  Fallopian  tubes  and  broad  ligaments  were  quite 
normal,  and  showed  no  evidences  of  recent  rupture  or 
inflammation.  Tlie  placenta  was  attached  to  the  fundus 
of  the  sac,  was  pulled  off  with  some  difficulty,  and  no 
serious  haemorrhage  complicated  its  removal.  It  weighs, 
li  lbs.,  is  flattened  out,  and  putrid.  Its  maternal  surface 
is  not  lobulated,  otherwise  it  presents  much  the  appear- 
ance of  an  intra-uterine  placenta.  The  patient  was  con- 
valescent at  the  end  of  three  weeks. 


Dr.  Peter  Horrocks  related  a  case  in  his  own  practice.  The 
patient  carried  the  child  for  ten  months  after  the  cessation  of 
her  periods,  and  that  it  lived  ten  months  in  utero  was  borne  out 
by  the  size  and  weight  and  general  development  of  the  child 
when  it  was  removed.  Her  own  doctor  was  sent  for  when  she 
ought  to  have  been  in  labour,  but  nothing  happened.  Three 
months  later, — that  is,  thirteen  months  after  the  last  period, — she 
was  sent  to  Guy's  Hospital.  The  child  was  removed  by  abdominal 
section,  and  the  j^lacenta  removed  without  difficulty  and  with 
practically  no  haemorrhage.  The  wall  of  the  sac  was  sewn  to 
the  abdominal  wound.      Although  upwards  of  two  years  ago» 


EXTKA-UTEKINE    FCETATION.  O 

there  was  still  a  sinus  into  which  a  probe  passed  3  or  4  inches. 
An  abscess  formed  in  the  pelvis,  and  was  laid  open  per  vaginam. 
It  was  possible  then  to  wash  right  through  from  the  abdominal 
sinus  into  the  vagina.  The  opening  into  the  vagina  gradually 
closed,  but  the  sinus  still  secretes  pus.  It  has  been  dilated  and 
curetted,  without  curing  it  so  far.  At  first  a  lot  of  small  pellets 
of  hair  were  discharged,  probably  lanugo.  He  did  not  know 
quite  how  to  prevent  these  sinuses  in  such  cases. 

The  President  said  the  chief  interest  of  cases  like  that  of 
Dr.  John  Phillips  centred  in  the  difficulty  of  knowing  how  to 
deal  with  the  placenta.  If  it  could  be  known  with  certainty 
that  at  a  given  time  after  the  death  of  the  full-grown  foetus  the 
placenta  could  be  removed  without  risk  of  haemorrhage,  the 
problem  would  be  greatly  simplified.  But,  unfortunately,  the 
time  varied.  It  might  be  within  the  recollection  of  some  of  the 
Fellows  present  that  he  had,  a  few  years  ago  ('  Trans.,' 
vol.  xxxv),  brought  before  the  Society  a  case  in  which  he  had 
been  able  to  remove  the  placenta  with  little  or  no  haemorrhage 
one  month  after  the  death  of  the  child.  On  the  other  hand,  a 
case  had  been  recorded  where,  four  months  after  the  death  of 
the  child,  separation  of  the  placenta  was  accompanied  with 
alarming  haemorrhage.  In  Dr.  Phillips's  case  the  child  had 
been  dead  five  months,  and  the  haemorrhage  amounted  to  little 
more  than  an  insignificant  oozing  from  the  veins.  A  point  of 
exceptional  interest  in  Dr.  PhilHps's  case  was  the  fact  that  both 
Fallopian  tubes  were  traced  out  and  found  unaltered.  It  would 
be  rash,  in  face  of  the  accumulating  evidence  against  the  occur- 
rence of  abdominal  pregnancy  as  a  primary  condition,  to  accept 
the  integrity  of  the  tubes  in  this  case  as  proof  that  the  preg- 
nancy had  not  originally  been  tubal.  If  there  had  been  rupture, 
no  doubt  evidence  of  it  would  have  been  forthcoming.  But  it 
was  not  necessary  to  suppose  that  if  there  had  been  tubal  gesta- 
tion there  must  have  been  rupture  of  the  tube  to  permit  the 
escape  of  the  ovum  into  the  abdominal  cavity.  The  ovum 
might  have  escaped  from  the  free  end  of  the  tube  and  have 
maintained  its  vitality  after  its  extrusion.  Supposing  gestation 
to  have  occurred  close  to  the  outer  extremity  of  the  tube,  it  was 
quite  conceivable  that  the  tube  had,  in  the  months  that  followed 
the  escape  of  the  ovum,  recovered  its  normal  size  and  appear- 
ance. Referring  to  a  remark  made  by  Dr.  Horrocks  as  to  the 
difficulty  of  dealing  with  sinuses  in  the  abdominal  scar,  he 
expressed  the  opinion  that  a  sinus  always  meant  that  there  was 
something  that  must  come  away — usually  a  ligature,  sometimes 
a  small  slough  or  a  little  mass  of  hair,  and  that  it  was  therefore 
useless  to  endeavour  to  bring  about  the  closure  of  such  a  sinus 
either  by  dilatation  or  scraping  until  the  source  of  suppuration 
had  been  expelled. 


HYDROCELE  OF  THE  CANAL  OF  NUCK  CON- 
TAINIlSra  A  PORTION  OF  THE  LEFT  FAL- 
LOPIAN TUBE. 

Shown  by  Leonaed  Remfey^  M.A.,  M.D, 

De.  Wheelee_,  of  Higli  Wycombe^  had  seen  the  patient 
three  years  ago^  and  then  found  a  small  swelling  like  a. 
gland  above  Poupart^s  ligament.  He  next  saw  her  in 
December,  1898^  the  original  mass  having  increased  to 
the  size  of  an  egg.  It  was  tense^  cystic,  irreducible. 
Dr.  Wheeler  incised  the  sac,  an  amount  of  clear  fluid 
escaping.  The  sac  was  thin  for  the  most  part,  but  its 
floor  was  rather  solid,  and  presented  some  dark  red  fleshy 
projections  and  some  gelatinous  material.  A  pedicle  was 
made  and  the  cyst  was  removed.  The  stump  appeared  to 
have  a  lumen. 

On  examination  Dr.  Remfry  found  that  the  lumen  was 
that  of  a  Fallopian  tube,  and  the  solid  projections  spoken 
of  must  have  been  the  fimbriated  extremity.  The  tube 
was  much  thickened. 


MALIGNANT  GROWTH  INVOLVING  THE  RIGHT 
UTERINE  APPENDAGES. 

Shown  by  Chas.  J.  Cullingwoeth,  M.D. 

This  specimen  was  shown  because  it  appeared  not  im- 
probable that  it  might  prove  on  dissection  to  be  an 
example  of  j^rimary  carcinoma  of  the  Fallopian  tube, 
in  which  case  it  would  be  desirable  that  it  should  be 
placed  on  record. 


MALIGNANT   GROWTH  INVOLVING  EIGHT   UTERINE  APPENDAGES.     7 

It  was  afterwards  found  to  be  a  round-celled  sarcoma, 
too  far  advanced  for  any  definite  conclusion  to  be  formed 
as  to  its  seat  of  origin.  It  was  therefore  considered  un- 
necessary to  describe  it  further. 


8 


ADJOURNED  DISCUSSION  ON  Dr.  McKERRON^S 
PAPER  ON  "  THE  OBSTRUCTION  OF  LABOUR 
BY  OVARIAN  TUMOURS   IN   THE   PELVIS.'' 

Dr.  Herman  said  that  Dr.  McKerron's  paper  was  the  fullest 
account  of  the  complication  of  labour  with  ovarian  tumours  that 
had  yet  been  given.  He  (Dr.  Herman)  agreed  in  the  main  with 
Dr.  McKerron's  advice  ;  but  there  was  one  method  of  treatment, 
the  credit  of  which  he  believed  Dr.  McKerron  had  given  to 
Pritsch,  which  he  thought  deserved  fuller  consideration  and 
commendation  than  Dr.  McKerron  had  given  to  it,  viz.  the 
making  an  incision  into  the  cyst  through  the  vagina,  and 
stitching  the  opening  in  the  cyst  to  the  margins  of  the  vaginal 
incision.  In  this  way  the  emptying  of  the  cyst  contents  outside 
the  peritoneum  was  secured.  If  the  cyst  were  a  dermoid,  as 
many  of  the  cysts  which  obstructed  labour  were,  simple  tap^^ing 
was  attended  with  much  danger  of  the  cyst  contents  escaping 
into  the  peritoneal  cavity  and  setting  up  peritonitis.  (Of  the 
forty- three  cases  in  Dr.  McKerron's  paper  treated  by  tapping  or 
incision,  twenty-four  died).  This  danger  was  avoided  by 
Fritsch's  procedure.  He  (Dr.  Herman)  did  not  advise  this  for 
tumours  that  could  be  pushed  up,  nor  for  those  which  came 
under  the  care  of  experienced  operators  in  circumstances  suit- 
able for  the  performance  of  ovariotomy.  But  many  of  the 
cases  occurred  in  the  practice  of  accoucheurs  having  little  or  no 
experience  in  ovariotomy.  The  time  at  which  the  reposition  of 
an  ovarian  tumour  became  impossible  was  in  the  second  stage 
of  labour,  when  the  tumour  was  driven  down  by  the  advancing 
presenting  part  of  the  child.  At  this  time  prompt  treatment 
was  needed  ;  there  was  not  time  to  place  the  patient  under  the 
care  of  an  experienced  surgeon.  In  such  circumstances  he 
thought  incision  and  suture  was  the  best  course  which  an 
accoucheur  inexperienced  in  operating  could  follow.  If  such  a 
case  came  under  the  care  of  an  experienced  operator,  he  inclined 
to  agree  with  Professor  Spencer  in  thinking  the  abdominal  mode 
of  operating  better  than  the  vaginal.  If  the  tumour  was  driven 
down  into  the  pelvis,  there  was  usually  tension  of  its  pedicle ; 
and  tension  of  the  pedicle  called  for  extreme  care  in  tying  it, 
produced  risk  of  the  knots  slipping,  and  the  compression  of  the 
vessels  being  imj^erfect,  with  haemorrhage  as  the  result ;  and 
such  after-haemorrhage  it  would  be  almost  impossible  to  stop  by 
vaginal  treatment. 

Dr.  Playfair  said  he  regretted  not  having  been  present  when 
Dr.  McKerron's  valuable  paper  had  been  read.     Through  the 


OBSTRUCTION   OF    LABOUR  BY   OVARIAN   TUMOURS.  9 

courtesy  of  tlie  secretaries,   however,  he  had  been  able  to  look 
through  it,  and  had  been  much  struck  with  the  complete  way  in 
which  the  author  had  dealt  with  this  important  topic.     Twenty 
years  had  elapsed  since  he  had  communicated  to  the  Society  the 
paper  he  had  himself  written  on  the  subject.     In  that  he  had 
collected  thirty-five  cases,  which  Dr.  McKerron  had  incorporated 
^-ith  his  own.    He  had  tabulated  the  details  of  126  more,  making 
183  in  all,  which  conclusively  showed  that  this  serious  complica- 
tion of  labour  was  by  no  means  so  rare  as  might  be  anticipated.  If 
in  the  comparatively  short  period  of  twenty  years  126  cases  were 
recorded,  then  certainly  it  behoved  practitioners  to  be  thoroughly 
prepared  to  deal  with  such  cases,  which  might  at  any  time  be  met 
with  in  practice.  It  was  a  curious  and  important  fact  that  the  ex- 
istence of  ovarian  tumour  was  only  suspected  in  18  per  cent,  of 
the  cases  before  labour.     Of  course,  if  we  did  diagnose  it  during 
pregnancy  it  was  a  now  admitted  rule  of  practice  that  ovariotomy 
should  be  performed  without  delay,  but  unhappily  the  figures 
showed  that  this  was  only  exceptionally  possible.  The  explanation 
of  this  is  probably  that  it  was  only  very  small  and  freely  mobile 
tumours  that  could  engage  in  the  pelvis,  and  become  impacted 
in  front  of  the  presenting  part.     If  they  were  of  any  considerable 
size  they  would  probably  rise  up  with  the  uterus,  and  lie  in  the 
abdominal  cavity.     This  he  had  pointed  out  in  his  paper.     He 
did  not  doubt  that  where  it  was  feasible  the  best  and  safest 
practice  was   to    remove   the   tumour,  either  by  abdominal  or 
vaginal  ovariotomv.     This  seemed  now  to  be  clearlv  the  most 
scientific  practice.     The  reason  why  he  had  not  recommended 
this  in  his   former   paper   was    obviously   because   ovariotomy 
twenty  years  ago  was  on  an  entirely  different  footing  from  the 
operations  in  the  present  day.     Then  antiseptic  operation  was 
unknown  or  in  its  infancy,  and  laparotomy  was  a  much  more 
serious  business  than  it  is  now.     To  do  it  during  the  actual 
2>rogress  of  labour  was  a  procedure  that  had  never  been  con- 
sidered a  possibility.    He  might  illustrate  this  by  relating  a  case 
he  had  about  that  time  of  an  ovarian  tumour  detected  in  a  lady 
in  the  seventh  month  of  pregnancy.     The  case  was  one  which 
gave  rise  to  much  anxiety,  and  he  had  urged  Sir  Spencer  Wells, 
who  saw  the  case  with  him,  to  undertake  its  removal  by  ovari- 
otomy.    This  he  positively  declined  to  do,  so  formidable  was  the 
procedure  then  considered,  and  ])remature  labour  was  induced, 
unhappily  with  a  fatal  issue.     Our  knowledge  and  experience 
having  so  much  increased,  he  had  no  doubt  at  all  that,  when 
feasible,  the  removal  of  the  tumour  should  be  undertaken.     He 
should  himself  prefer  abdominal  ovariotomy.     There  was,  how- 
ever, a  good  deal  to  be  said  in  favour  of  the  vaginal  method.    It 
was  to  be  noted  tliat  the  tumours  were  necessarily  small,  and 
therefore  probalily  non-a<lherent.     Moreover,  in  sucli  cases  there 
would  be  a  long  thin  pedicle,  for  if  the  pedicle  were  short  the 


10  THE    OBSTRUCTION    OF    LA130UK 

tumour  would  not  have  prolapsed  into  the  pelvic  cavity,  but 
would  have  been  carried  upwards  into  the  abdomen  with  the 
enlarging-  uterus.  Therefore  the  operation  would  probably  be 
easv,  and  of  late  vears  our  knowledo-e  of  the  vao'inal  method  of 
operating  had  much  increased,  in  consequence  of  experience  in 
such  operations  as  total  extirpation,  anterior  colpotomy,  and  the 
like.  Our  decision  would  doubtless  be  guided  by  the  relations 
and  character  of  the  tumour  observed  at  the  time.  But  while 
admitting  that  ovariotomy  was  the  best  course,  he  felt  there 
must  always  be  cases  when  it  could  not  be  judiciously  practised. 
It  was  obvious  that  this  plan  required  experience  in  operating, 
suitable  surroundings,  nursing,  instruments,  &c.,  which  could 
not  always  be  got.  He  did  not  envy  the  practitioner  who  had 
no  experience  in  abdominal  surgery  suddenly  called  on  to  perform 
such  an  operation.  It  behoved  us,  therefore,  when  ovariotomy 
was  not  feasible,  to  decide  what  was  the  next  best  course  to 
pursue.  Obviously  the  one  thing  that  should  not  be  done  was 
to  leave  the  case  alone,  in  the  hope  that  the  foetus  might  be 
pushed  or  drawn  past  the  obstructing  tumour.  Dr.  McKerron's 
tables  showed  that  in  all  such  cases  the  mortality  had  been 
dreadful,  viz.  50  per  cent.  The  explanation  of  this  was  probably 
that  the  contusion  and  bruising  of  the  cyst  walls  reduced  the 
case  to  a  condition  very  like  that  of  a  strangulated  hernia, 
resulting  in  a  fatal  form  of  peritonitis.  In  his  paper  he  had 
recommended  that  such  tumours  should  be  punctured,  so  that 
their  size  should  be  lessened  as  much  as  possible.  When  this 
had  been  done  the  results  had  been  much  more  satisfactory,  the 
mortality  having  been  only  18  per  cent.  Dr.  McKerron  did  not 
seem  to  approve  of  this  plan  except  in  cystic  tumours.  He  (Dr. 
Playfair),  however,  did  not  know  how  a  cystic  tumour  was  to 
be  diagnosed,  except  by  puncture.  Certainly  it  could  not  be 
done  by  digital  examination.  He  was  therefore  inclined  to  think 
that  that  was  the  proper  course  to  pursue  in  all  cases  tightly 
jammed  down  in  front  of  the  presenting  jDart.  Of  course,  if  the 
tumour  was  high  up  and  mobile,  reposition  might  be  j^referable, 
but  there  must  always  be  a  risk  in  returning  into  the  abdominal 
cavity  a  cystic  groAvth  which  had  been  long  subjected  to  incar- 
ceration and  contusion.  Dr.  Herman  had  suggested  that  the 
tumour  should  be  incised,  its  contents  evacuated,  and  the  cyst 
walls  stitched  to  the  vagina.  The  proposal  was  new  to  him, 
and  he  therefore  criticised  it  with  hesitation,  but  it  did  not 
commend  itself  to  him,  because  if  a  large  vaginal  incision  was 
made  it  would  surely  be  preferable  to  attempt  vaginal  ovariotomy, 
while  a  large  open  cyst  stitched  to  the  vagina  would  be  very 
dangerous  from  a  septic  point  of  view.  Practically  no  risk  of 
that  kind  attended  a  simple  puncture  or  aspiration  practised 
with  proper  antiseptic  precautions.  Dr.  McKerron  gave  a 
valuable  series  of  rules  for  the  after  management  of  these  cases, 


r.Y    OVARIAN    TUMOURS    IN    THE    PELVIS.  11 

which  would  always  be  a  matter  of  anxious  consideration.  These 
seemed  to  him  very  judicious,  and  they  greatly  added  to  the 
value  of  his  important  paper. 

Dr.  Heywood  Smith  regretted  that  he  was  not  present  when 
Dr.  McKerron's  paper  was  read,  as  otherwise  he  might  have 
added  the  follo"v\'ing  case  to  his  valuable  list.  In  1884  he  saw  a 
lady,  aged  24,  who  had  a  small  ovarian  tumour  behind  and 
on  the  right  of  the  uterus.  In  April  she  married  and  became 
pregnant.  During  the  pregnancy  he  several  times  pushed  the 
tumour  above  the  uterus,  but  it  would  not  remain.  Labour 
began  December  26th,  when  the  tumour  came  down  in  front  of 
the  head,  obstructing  delivery.  He  aspirated  the  cyst,  and  the 
child  was  born  alive.  She  next  became  pregnant  after  a 
period,  October  23rd  to  26th,  1885.  He  performed  ovariotomy 
December  5th,  and  she  was  confined  of  a  living  child  Julv  20tli, 
1886. 

Dr.  Peter  Horrocks  thought  the  paper  valuable,  but  the 
statistics  of  cases  quoted  were  historically  interesting  rather  than 
having  any  bearing  upon  modern  treatment,  because  the  fact  that 
in  these  days  of  aseptic  operations  one  could  open  the  abdomen 
without  ill  effects  rendered  the  question  of  what  to  do  in  cases 
of  tumours  obstructing  labour  capable  of  being  answered  quite 
differently.  Twenty  years  ago  and  less  it  would  have  been 
wrong  to  do  abdominal  section  in  such  cases,  simply  because  the 
operation  itself  would  have  been  fatal  in  the  majority  of  cases 
from  sepsis,  and  such  sepsis  we  now  know  was  due  to  the  want 
of  knowledge  of  how  to  attain  asepsis  in  operating.  Whereas 
now  he  did  not  think  any  one  could  fail  to  acknowledge  that  the 
proper  and  scientific  treatment  of  such  cases  was  to  do  abdo- 
minal section,  pull  the  uterus  out  of  the  abdomen  if  need  be, 
remove  the  tumour,  put  back  the  uterus,  and  sew  up,  allowing 
labour  to  proceed.  Like  Dr.  Playfair,  he  failed  to  see  why  Dr. 
Boxall  did  Caesarean  section  in  his  case.*  The  method  adopted  by 
Dr.  Herbert  Spencer  was  more  scientific  and  l)etter  in  every  way 
for  the  patient. t  With  regard  to  the  question  of  vaginal  t'ers/<s 
abdominal  operation  he  certainly  thought  the  latter  was  prefer- 
able, because  even  in  the  non-pregnant  case  vaginal  ovariotomy 
was  often  most  difficult  and  perplexing,  and  when  pregnancy 
complicated  it  all  the  vessels  became  enlarged,  and  hence  the 
haemorrhage  might  easily  become  alarming,  when  it  would  be 
difficult  and  perhaps  impossible  to  catch  the  bleeding  points 
from  the  vagina.  With  regard  to  the  question  of  diagnosis  he 
pointed  out  that  when  a  cyst  is  very  tense  it  feels  quite  hard 
and  solid,  like  a  fibroid  tumour.  He  related  an  instance  where 
a  woman  was  in  lal)our  at  Guy's  with  a  tumour  in  the  pelvis 
which  was  examined  by  several,  and  all  of  them  thought  it  was 
a  solid  tumour,  probably  a  fibroid,  basing  their  opinion  on  the 
*  See  p.  25  et  spq.  f  See  p.  14  et  seq 


12  THE    OBSTRUCTION    OF    LABOUR 

liLirdness  of  it.  Certainly  no  fluctuation  could  be  felt.  A  small 
needle  was  puslied  into  it  and  a  few  drops  of  pus  withdrawn ; 
then  a  trocar  and  cannula  were  used,  and  several  ounces  of  pus 
were  withdrawn.  A  septum  was  felt  and  punctured,  and  then 
another,  and  so  at  least  three  loculi  were  emptied,  and  sufficient 
room  was  obtained  to  permit  of  delivery.  Subsequently  another 
loculus  of  this  multilocular  suppurating  cyst  opened  near  the 
umbilicus,  but  the  subsequent  history  he  could  not  give,  as  the 
patient  was  afterwards  under  the  care  of  Dr.  Galabin.  In  these 
days  such  a  case  would  be  treated  by  abdominal  section  at  once. 
He  quite  agreed  that  where  an  accoucheur  was  unskilled  in 
abdominal  surgery,  or  where  help  could  not  be  obtained  or 
asepsis  guaranteed,  then  it  might  be  a  question  what  to  do  to 
tide  over  the  immediate  difficulty.  Such  cases,  however,  ought 
to  be  very  rare,  considering  how  easy  jt  was  to  attain  asepsis  by 
means  of  boiling  water,  &c.  Still  no  doubt  they  would  occur, 
and  when  they  did  he  thought  that,  after  first  using  a  small 
needle  and  syringe  to  find  out  if  there  were  fluid  contents,  a 
free  incision  through  the  vaginal  wall  with  subsequent  emptying 
of  the  cyst,  washing  it  out,  and  sewing  it  to  the  vaginal  wall, 
as  Dr.  Herman  and  Fritsch  had  recommended,  seemed  better 
than  merely  aspirating.  For  not  only  was  one  better  able  to 
deal  with  the  contents,  which  were  not  always  very  fluid,  but  one 
could  also  easily  feel  septa  and  open  up  separate  loculi.  To 
merely  aspirate  them,  or  use  a  trocar  and  cannula  permitted  the 
contents  to  escape,  and  so  fatal  peritonitis  might  be  set  up  or  at 
least  adhesions  would  form.  In  answer  to  the  President  and 
Dr.  Spencer,  he  pointed  out  that,  as  a  rule,  these  tumours  were 
driven  well  down  into  the  pelvis  until  they  got  near  the  vaginal 
orifice,  so  that  it  was  not  necessary  to  open  them  through  the 
roof  of  the  vagina ;  they  could  be  opened  low  down  within  easy 
reach,  and  so  it  was  not  difficult  to  sew  them  to  the  vaginal 
wall. 

Dr.  Spencer  expressed  his  appreciation  of  the  high  value  of 
the  paper,  which  had  entailed  a  large  amount  of  careful  and 
laborious  research.  He  was  glad  to  find  a  general  agreement 
that  the  best  treatment  for  incarcerated  ovarian  tumours  which 
could  not  be  pushed  up  was  ovariotom3\  Csesarean  section 
inflicted  an  injury  on  the  patient,  which  in  ordinary  cases  was 
quite  unnecessary,  though  it  had  been  recommended  in  this 
Society  as  recently  as  1892.  He  thought  the  opinion  of  the 
Society  should  go  forth  that  ovariotomy  was  the  proper  treat- 
ment when  practicable.  If  an  incision  were  made  into  the 
tumour — tapping  would  usually  be  of  no  use — he  was  not  in 
favour  of  stitching  the  cyst  to  the  opening  in  the  vagina ;  this 
would  be  a  difficult  operation,  and  had  been  found  to  be  imprac- 
ticable during  labour  owing  to  the  child's  head  coming  down. 
He  thought  under  these  circumstances  the  tumour  should  be 


BY    OVARIAN    TUMOURS    IN    THK    PKLVIS.  13 

removed  as  soon  as  possible  after  the  labour,  either  by  the 
vagina  or  by  the  abdomen.  As  a  temporary  measure  he  would 
prefer  plugging-  the  cyst  vrith  iodoform  gauze  to  stitching  it  to 
the  vagina.  He  begged  to  thank  the  various  speakers  for  the 
remarks  they  had  made  upon  his  own  two  cases. 

The  President  said  that  it  was  greatly  to  be  regretted  that 
the  author  of  the  paper  had  not  been  able  to  be  present  at  the 
adjourned  discussion.     The  Fellows  would  then  have  had  the 
great   advantage   of   hearing   his  reply.     He   agreed  with  Dr. 
Horrocks  that  in  drawing  conclusions  from  past  experience  it 
was  necessary  to  have  continually  in  mind  the  very  different  con- 
ditions under  which  operations  were  performed  before  and  since 
the  introduction  of  antiseptics.     As  a  large  proportion  of  the 
ovarian   tumours  that  had  been  met  with  as  obstructions   to 
delivery  had  proved  to  be  dermoids,  it  seemed  doubtful  whether 
tajjping  would  always  succeed  in  effecting  such  a  diminution  in 
size  as  would  suffice  to  overcome  the  obstruction.     Undoubtedly 
the  ideal  treatment  was  the  removal  of  the  tumour  there  and 
then  by  abdominal   section.     Where  this  was  impracticable,  the 
proper  course,  if  the  tumour  could  not  be  pushed  out  of  the  way, 
was  to  endeavour  to  deal  with  it  temporarily  by  tapping  or 
incision  per  vaginam,  and  to  perform  ovariotomy  as  soon  as  pos- 
sible after  the  labour  was  over.     He  did  not  think  the  alternative 
of  Csesarean  section  should  be  adopted  unless  under  very  excep- 
tional circumstances.     He  concluded  by  calling  attention  to  a 
case  he  (the  President)   had   published  in  the  '  St.  Thomas's 
Hospital  Reports'  for  1887  (p.  143),  in  which  abdominal  section 
had  been  performed  on  a  patient,  nineteen  weeks  after  delivery, 
for  the  removal  of  a  dermoid  tumour  of  the   ovary  that  had 
caused  serious  obstruction  to  delivery,  and  that  had  subsequently 
undergone  suppuration  and  discharged  per  vaginam  through  a 
rent  in  the  posterior  wall  of  the  cervical  canal. 


14 


INCARCERATED  OVARIAN  DERMOID  OBSTRUCT- 
ING LABOUR  :  OVARIOTOMY  DURING  LABOUR. 

By  Herbert  R.   Spencer^  M.D.,   B.S.Lond.^ 

PKOPESSOR   OF   OBSTETRIC    MEDICINE    IN    UNIVERSITY    COLLEGE,    LONDON; 
OBSTETRIC    PHYSICIAN   TO    UNIVERSITY    COLLEGE    HOSPITAL. 

(Received  November  15th,  1897.) 

{Abstract.) 

In  the  case  recorded  the  patient,  aged  20,  had  had  one  dead 
child  previously  without  difficulty.  With  the  second  child  the 
labour  was  obstructed  by  an  ovarian  dermoid  weighing  sixteen 
ounces,  incarcerated  in  the  pelvis.  As  the  tumour  could  not  be 
pushed  up,  laparotomy  was  performed,  the  uterus  withdrawn 
from  the  abdomen,  the  tumour  removed,  and  the  child  delivered 
by  forceps  applied  in  the  dorsal  posture.  Mother  and  child 
recovered.  In  the  treatment  of  ovarian  tumour  obstructing 
labour  the  author  thinks  that  the  tumour  should  be  pushed  out 
of  the  pelvis  if  possible ;  but  discards  version,  forceps,  crani- 
otomy, and  simple  incision  or  tapping  of  the  tumour,  on  account 
of  their  danger.  Caesarean  section  will  very  rarely  be  necessary 
if  the  uterus  be  withdrawn  from  the  abdomen.  The  author  dis- 
cusses the  merits  of  vaginal  and  abdominal  ovariotomy,  and  con- 
siders that,  on  the  whole,  the  latter  is  the  preferable  operation. 

E.  G — ,  aged  20,  had  had  one  stillborn  child,  which 
was  born  without  difficulty  as  a  vertex  presentation  on 
June  1st,  1896.  She  recovered  well,  but  noticed  a 
swelling  of  the  abdomen  after  she  got  up,  and  attended 
as  an  out-patient  at  a  hospital,  where  the  obstetric  phy- 
sician passed  a  catheter  to  see  if  the  swelling  was  formed  by 
the  bladder  ;  he  told  the  patient  to  return  in  a  fortnight, 
but  as  she  felt  quite  well  she  did  not  do  so. 


INCARCERATED  OVARIAN   DERMOID  OBSTRUCTING  LABOUR.    15 

On  July  lOtli^  18f>7,  at  3  a.m.,  she  came  on  in  labour  at 
term  with  the  second  child,  and  Avas  attended  from  Uni- 
versity College  Hospital.  During  the  pregnancy  she  had 
had  no  unusual  symptoms  except  an  occasional  sharp  pain 
in  the  right  side  of  the  abdomen  for  the  first  three  months. 
At  11  a.m.  the  cervix  was  partly  dilated,  and  at  8.30  p.m. 
the  obstetric  assistant  ruptured  the  membranes,  the  os 
being  fully  dilated,  and  applied  forceps  with  difficulty 
owing  to  the  presence  of  a  tumour  in  the  pelvis,  which  he 
took  to  be  a  cyst  of  the  vaginal  wall.  As  traction  pro- 
duced no  effect  I  was  summoned.  I  happened  to  be 
temporarily  engaged,  and  as  the  case  appeared  urgent. 
Dr.  Walter  Tate  kindly  saw  the  patient  for  me  ;  he  found 
that  the  tumour  was  an  ovarian  cyst,  and  had  chloroform 
administered  with  a  view  of  endeavouring  to  push  up  the 
tumour.  I  saAv  the  patient  a  few  minutes  later,  at  10.30 
p.m.,  and  when  the  patient  was  anaesthetised  it  was  found 
that  the  tumour  could  not  be  pushed  up  out  of  the  pelvis. 
The  general  condition  of  the  patient  was  good.  The 
labour  pains  were  violent,  the  abdomen  was  unusually 
prominent,  and  the  recti  w^ere  separated.  There  was  a 
swelling  above  the  pi:rt)es,  formed  by  the  bladder  lying- 
in  front  of  the  child's  head.  Above  this  was  a  depression 
formed  by  the  ring  of  Bandl,  and  the  lower  segment 
appeared  to  be  thin  at  this  spot,  but  closely  fitted  to  the 
child's  body.  The  limbs  of  the  child  were  felt  in  front, 
and  the  child  was  lying  with  its  back  posterior.  On 
either  side  of  the  lower  segment  was  heard  a  short  sharp 
uterine  souffle.  The  foetal  heart-sounds  could  not  be 
heard,  though  they  had  been  audible  a  few  minutes 
previously.  On  vaginal  examination  the  finger  came 
upon  a  softish,  evidently  fluctuating  tumour  of  the  size  of 
a  large  fist,  lying  in  Douglas's  pouch  and  bulging  the 
posterior  wall  of  the  vagina  forwards.  In  front  of  the 
tumour  and  very  high  up  was  felt  the  head,  and  the 
anterior  lip  of  the  cervix  could  just  be  touched  ;  the  pos- 
terior lip  could  not  be  felt.  It  was  decided  that  the  best 
thing  to   do    was   to  perform  ovariotomy.      The  liusband 


16  INCARCERATED  OVARIAN  DERMOID 

having  after  some  hesitation  given  liis  consent,  the  patient 
was   removed   to   University  College  Hospital  in   a  four- 
wheeled  cab  at  11.30  p.m.,  and  the  operation  was  at  once 
performed.      The    instruments    having   been   boiled   while 
waiting    for   the    arrival    of    the    patient,    the    abdomen, 
which  was  very  dirty,  was  washed  with  soap  and  water, 
turpentine  and  carbolic   lotion  (1  in  20),  and  the  vagina 
was   douched   with  carbolic  lotion   (1  in  40),  and  chloro- 
form Avas  administered  for  the   third  time.      An    incision 
about  six  inches  long  was  made  over  the  prominent  part 
of  the  uterus  in  the  middle  line.     The  abdominal  wall  here 
consisted  of  practically  nothing  but  skin  and  peritoneum, 
and    notwithstanding    great   care    the    peritoneum  of    the 
uterus  was  scratched  by  the  knife  on  opening  the  abdomen, 
but   the    scratch    did   not   bleed.      The    uterus   was  then 
brought  through  the  incision  by  tilting  it  on  its  side,  and 
was  pulled  forwards  over  the  pubes.      Then  the  top  of  the 
tumour,  rising  to  the  level  of  the  pelvic  brim,  was  seen  in 
the  space,  about  an  inch  and   a   half  wide,  between   the 
sacral   promontory   and   the   back  of    the  lower  segment. 
As   there   was   no   room   for    the  hand  to    pass    into    this 
space  to  grasp  the  tumour  it  was  seized  with  forceps,  but 
on  making  slight  traction  upon  it  it  burst,  and  sebaceous 
material  escaped.      The  tumour  was  then  drawn  up  out  of 
the  abdomen,  and  removed  after  tying  the  pedicle  tightly 
with   floss   silk   in   the    usual   way.      After   cleansing  the 
peritoneum    the    uterus    was   turned   back   to   lie  on   the 
abdominal  wall,  so  that  its  axis  was  approximately  in  that 
of  the  pelvic  brim  (it  could  not  be  pressed  through  the 
wound  again  into  the  abdomen),  and  the  wound  was  drawn 
together   around  the   uterus   and   covered  with   sponges. 
The  forceps  Avas  then  applied  while  the  patient  lay  in  the 
dorsal  position,  the   head  having  been  pressed  down  into 
the  pelvis  by  a  hand  of  an  assistant  on  the  fundus,  and 
the  child  was  easily  delivered  alive   with  the  face  to  the 
pubes.      The   perinseum  was   ruptured,    the   tear  slightly 
involving  the    sphincter.      After  the  child  was  born   the 
uterus  was  kneaded,  but  as  a  little  hgemorrhage  occurred 


OBSTRUCTING    LABOUR.  17 

the  placenta  was  expressed ;  there  was  some  loss  of  blood 
afterwards,  about  a  pint  in  all.  The  uterus  was  returned 
to  the  abdomen,  and  contracted  well  after  the  injection  of 
ergotin.  The  abdominal  wound  was  sewed  up  with  silk- 
worm gut,  and  fine  silk  for  the  skin.  The  perinaeum 
was  stitched  with  three  silkworm-gut  sutures.  Carbolic 
gauze  was  applied  to  the  abdomen,  and  iodoform  gauze 
to  the  vulva.  The  operation  took  sixteen  minutes  till 
the  tumour  was  removed,  twenty-eight  minutes  till  the 
wound  was  stitched,  and  forty  minutes  till  the  perinaeum 
was  repaired  and  the  patient  put  to  bed. 

After  the  operation  the  patient  was  much  collapsed, 
and  a  hypodermic  injection  of  ether  was  given,  and  later 
half  an  ounce  of  brandy  by  the  mouth  ;  this,  however,  was 
soon  vomited.  The  patient  was  very  restless  on  coming 
out  of  the  influence  of  the  anaesthetic,  tossing  about  till 
7  a.m.  The  extremities,  at  first  cold,  soon  became  warmer, 
and  at  3  a.m.  the  pulse  was  better  than  after  the  opera- 
tion, 112  to  the  minute,  weak  and  of  low  tension,  though 
it  had  recovered  from  the  marked  irregularity  it  showed 
after  the  operation.  The  pulse  and  respirations  remained 
frequent,  though  gradually  slowing  for  the  first  five  days 
after  the  operation,  and  the  patient  had  a  slight  attack 
of  sapraemia,  due  apparently  to  the  retention  of  a  small 
fragment  of  membrane  and  clot  which  was  passed  on 
July  17th.  The  highest  point  reached  by  the  temperature 
was  103'2°  on  July  13th.  From  this  it  gradually  declined 
to  normal,  and  remained  practically  normal  during  the 
rest  of  her  stay  in  the  hospital.  Flatus  was  passed  spon- 
taneously on  the  day  of  the  operation,  and  the  bowels 
were  opened  by  liquorice  powder  on  July  14th. 

After  the  rather  alarming  collapse  following  the  opera- 
tion the  general  appearance  of  the  patient  was  good. 

On  July  18th  the  patient  appeared  quite  well.  The 
deep  abdominal  stitches  were  removed  ;  the  wound  had 
healed  by  first  intention  ;  there  was  no  distension  nor 
tenderness  of  the  abdomen ;  the  uterus  rose  three  and  a 
half  inches  above  the  pubes.      The  perinaeal  stitches  were 

VOL.  XL.  2 


18  INCARCERATED    OVARIAN    DERMOID 

removed  on  July  22nd.      The  sphincter   had   united,  but 
the  perinasum  was  only  three-quarters  of  an  inch  long. 

On  July  24th  the  superficial  sutures  were  removed ;  on 
August  7th  the  patient  got  up,  feeling  strong,  and  on 
August  14th  she  left  the  hospital  with  her  child,  which 
she  had  suckled,  both  being  quite  well. 

The  child  was  a  well-developed  female,  weighing  at  birth 
85  lbs.,  and  measuring   21  inches  in  length, 
dimensions  were — 

Head-girth 

Yertico-mental  diameter 
Occipito-f  rental       „ 
Cervico-bregmatic  „ 
Suboccipito-bregmatic  diameter 
Fronto-mental  diameter 
Bi-parietal  „ 

Bi- temp  oral  „ 

Bi-mastoid  „ 

The  chief  external  measurements  of  the  mother's  pelvis 
were — 

Sp.  il.         .  .  .        94  inches. 


Length. 

The  other 

.      15 

inches. 

.        5i 

.       41 

.    ^ 

.       3§ 

3| 

.       4 

.       3 

.       21 

Cr.  il.  .  .  .10 

Conj.  ext.  ...        7 


The  child  had  a  high  temperature,  varying  between 
100°  and  105*2°,  for  the  first  nine  days  after  birth.  It 
also  had  a  blood-stained  discharge  from  the  vagina  (pro- 
bably uterine  in  origin)  from  the  14th  to  the  17th  of  July. 
It  nevertheless  remained  well  in  appearance,  and  weighed 
9  lbs.  5  oz.  when  it  left  the  hospital. 

The  tumour  was  an  ovarian  dermoid  of  the  right  side, 
containing  sixteen  ounces  of  sebaceous  material  and  hair. 
It  measured  4^  x  4^  x  3  inches.  Its  position  in  the 
pelvis  and  its  size  are  accurately  shown  in  the  diagram. 
It  should  be  stated,  however,  that  the  pelvis  in  the  case 
recorded  was  probably  slightly  smaller  and  the  child 
larger  than  those  from  which  the  drawing  has  been  made. 


OBSTRUCTING    LABOUK. 


9 


The  position  of  the  child  with  its  back  posterior  is  of 
some    obstetric    interest.      A   reference    to    the   diagram^ 


seems  to  show  that  in  dorso-posterior  positions  the  head 
can  sink  lower  into  the  pelvic  cavity  than  in  dorso- 
anterior  positions,  when  the  occiput  meets  the  resistance 
of  the  pubic  bones,  which  would  probably  turn  it  back- 
wards. In  the  classical  illustration  of  Ramsbotham's 
(2nd  edit.,  p.  186)  the  child  is  represented  as  lying  in  the 
third  vertex  position. 

The  question  of  the  treatment  of  these  cases  of  incarce- 


*  The  diagram  is  reduced  by  photography  from  one  obtained  by  com- 
bining a  Braune  section  of  the  pelvis  with  a  tracing  on  ghiss  of  the  tumour 
and  a  foetus  in  their  relative  positions. 


20 


INCAECERATED    OVARIAN    DERMOID 


OBSTKUCTING   LABOUR.  21 

rated  ovarian  tumour  during  labour  is  an  important  one. 
In  my  judgment  the  difficulty  should  not  be  overcome  by 
operating  upon  the  child^  whether  by  forceps,  version,  or 
craniotomy.  If  the  tumour  can  be  pushed  up  out  of  the 
pelvis  by  the  vagina  or  rectum  in  the  lateral  or  genu- 
pectoral  position,  that  is  the  practice  which  I  should  adopt, 
and  have  successfully  adopted.  If  the  tumour  cannot  be 
pushed  up,  simply  tapping  or  incising  it  is  too  dangerous 
an  operation  to  be  recommended.  Caesarean  section  will 
only  be  required  if  the  ovarian  tumour  be  malignant  or, 
possibly,  hydatid.  For  adhesions  it  will  rarely,  if  ever, 
be  necessary  if  the  uterus  be  brought  out  of  the  abdomen. 
The  operation  which  offers  the  best  chance  to  mother 
and  child  is  ovariotomy,  either  vaginal  or  abdominal.  In 
lessening  shock  and  avoiding  an  abdominal  wound,  with 
the  possible  supervention  of  hernia,  the  vaginal  operation 
has  advantages  ;  and  if,  as  is  unfortunately  not  the  case, 
the  diagnosis  of  the  nature  of  the  tumour  and  its  freedom 
from  adhesions  could  be  made  with  absolute  certainty,  it 
would  be  the  preferable  operation  for  simple  cases ;  but 
the  operation  would  be  liable  to  be  followed  by  extensive 
laceration  of  the  vagina  if  the  birth  of  the  child  took 
place  before  the  operation  was  completed,  and  in  an 
adherent  case  it  might  be  impossible  :  the  liability  to 
infection  Avould  also  be  increased.  I  think,  therefore, 
notwithstanding  the  disadvantages  alluded  to,  that  the 
best  treatment  is  abdominal  ovariotomy  when  the  os  is 
well  dilated.  As  far  as  I  know,  the  operation  of  abdo- 
minal ovariotomy  during  labour  has  been  hitherto  success- 
ful, though  it  has  only  been  performed  three  times  "^ — all 
at  University  College  Hospital.  Two  of  the  patients  were 
operated  upon  by  Sir  John  Williams,  and  the  third  is  the 
subject  of  this  paper. 

*  Dr.  McKerron  has  since  kindly  informed  me  of  a  fourth  case,  also 
successful,  published  by  Spaeth  in  the  '  Medicinisches  Correspondenz-Blatt ' 
for  July  3rd,  1897.  (A  copy  of  this  publication  is  now  in  the  Society's 
Library.) 


22 


INCARCERATED  OVARIAN  DERMOID  OBSTRUCT- 
INC  LABOUR;  MANUAL  ELEVATION;  RE- 
MOVAL  SEVEN  MONTHS  LATER. 

By  Heebert  R.  Spencer,  M.D. 

(Abstract.) 

A  DERMOID  ovarian  tumour  which  was  incarcerated  in  the 
pelvis  and  obstructed  labour.  The  tumour  was  pushed  up  out 
of  the  pelvis  under  chloroform,  the  child  delivered  by  forceps, 
and  ovariotomy  performed  seven  months  later. 

The  tumour  shov^n  is  a  dermoid  of  the  left  ovary  of  the 
size  of  a  double  fist,  containing  fat  and  hair.  In  its  v^alls 
can  be  felt  three  thin  plates  of  bone.  It  has  one  main 
cyst  with  tv^o  small  secondary  cysts  in  its  wall,  and  hang- 
ing in  its  interioi-  by  a  pedicle  of  the  thickness  of  whip- 
cord is  a  mass  of  tissue  of  the  size  of  an  almond  shell, 
containing  fat,  skin,  and  apparently  a  tooth ;  from  this 
mass  depends  a  long  lock  of  dark  brown  hair.  The 
possibility  suggested  itself  of  diagnosing  a  bone-containing 
ovarian  dermoid  during  life  by  the  Rontgen  rays  ;  but  it 
will  be  seen  in  the  skiagram  of  the  tumour  that  the  bony 
plates  are  too  thin  or  too  ill-ossified  to  give  distinct  dark 
shadows.  The  "  tooth,^^  however,  is  sharply  defined, 
being  thicker  than  the  bony  plates.  The  history  of  the 
patient  from  whom  the  tumour  was  removed  is  as 
follows  : 

Mrs.  D — ,  aged  32,  had  had  a  child  in  May,  1894,  the 
labour  lasting  five  days  and  the  child  being  stillborn.  A 
tumour  was  discovered  at  this  labour.  A  second  child 
was  born  without  difficulty  by  the  breech  in  December, 
1895,  but  was  also  stillborn. 

On  May  17th,  1897,  at  9  p.m.,  I  saw  the  patient  in 
consultation  at  Ealing.      She  had  been  in  labour  all  day, 


INCARCERATED  OVARIAN   DERMOID   OBSTRUCTING  LABOUR.      23 

and  it  had  been  found  to  be  impossible  to  deliver  her 
(although  an  attempt  had  been  made  with  forceps)  on 
account  of  a  tumour  of  the  size  of  a  double  fist  which 
occupied  Douglas's  pouch,  and  prevented  the  head  from 
entering  the  pelvis.  The  tumour  was  of  hard  consistence, 
but  appeared  to  contain  fluid,  and  I  thought  it  was  an 
ovarian  dermoid.  The  child's  back  was  towards  the  front, 
the  cervix  fully  dilated,  the  head  presenting.  Under 
chloroform  I  pushed  up  the  tumour  out  of  the  pelvis 
without  much  difficulty,  and  then  found  that  the  cord  was 
prolapsed  and  its  pulsations  very  slow,  about  thirty  or 
forty  to  the  minute.  Quickly  applying  forceps  I  easily 
delivered  a  large  female  child,  which  soon  breathed  and 
survives.  The  tumour  at  once  came  down  again  into 
Douglas's  pouch,  and  after  the  placenta  was  expressed  it 
was  found  that  the  uterus  was  irregular  in  shape,  and  the 
tumour  appeared  to  be  adherent  to  it.  I  thought,  there- 
fore, I  had  made  a  mistake  in  the  diagnosis,  and  that  the 
tumour  was  a  fibroid.  I  advised  the  patient  to  come  and 
see  me  after  the  puerperium  in  order  to  settle  the  dia- 
gnosis. The  patient  recovered  well  from  the  confine- 
ment, and,  as  she  felt  quite  well,  she  did  not  come  and 
see  me  till  December  4th,  1897,  when  I  found  her  in  good 
health  and  free  from  pain.  A  tumour  could  be  felt 
rising  up  out  of  the  pelvic  brim  to  a  height  of  three 
inches  above  the  pubes.  The  uterus  was  pressed  for- 
wards, upwards,  and  to  the  right  of  the  tumour,  the  lower 
end  of  which  lay  in  Douglas's  pouch,  and  could  be  felt  to 
contain  two  plates  of  bone.  It  was  clear  that  the  tumour 
was  a  dermoid  of  the  left  ovary  ;  it  could  not  be  pushed 
upwards  to  any  considerable  extent,  owing  apparently  to 
adhesions.      The  right  ovary  felt  normal. 

On  December  9th,  1897,  I  removed  the  tumour,  which 
occupied  the  left  ovary,  and  was  bound  by  strong  adhe- 
sions to  the  rectum,  and  by  slighter  adhesions  to  the  back 
of  the  pelvis.  The  pedicle  was  twisted  one  whole  turn  by 
the  tumour  rotating  from  left  to  right.  The  operation 
occupied   forty    minutes.       Kecovery    was   uneventful   for 


24     INCARCERATED  OVARIAN  DERMOID  OBSTRUCTING  LABOUR. 

the  first  eighteen  days,  the  temperature  not  rising  above 
100°,  and  the  pulse  not  above  80.  The  stitches  were  re- 
moved on  the  eighth  day,  union  having  taken  place  by 
first  intention. 

On  December  26th  the  patient  had  a  little  exudation 
in  the  left  inguinal  region,  accompanied  by  pain,  and  the 
temperature  rose  and  remained  up  for  the  next  few  days, 
on  one  occasion  reaching  103°.  It  has  now  fallen  to 
normal,  and  the  patient  appears  quite  well. 


25 


INCARCERATED  OVARIAN  DERMOID  ;  CESA- 
REAN SECTION,  AND  REMOVAL  OF  TUMOUR 
AT  THE  END  OF  THE  FIRST  STAGE  OF 
LABOUR. 

By  Robert  Boxall,  M.D.,  M.R.C.P. 

The  tumour  shown  comprises  a  portion  of  the  right 
Fallopian  tube,  and  a  semi-solid  ovarian  tumour  4^  inches 
in  diameter.  The  portion  of  tube  in  the  fresh  state 
presented  some  thickening,  and  around  the  fimbriae  four 
small  cysts  containing  clear  fluid.  The  outer  wall  of  the 
cyst  is  smooth.  On  section  the  main  part  of  the  cyst  is 
found  to  be  occupied  by  light  brown  hair  held  together 
by  very  little  fatty  material.  Towards  the  part  to  which 
the  Fallopian  tube  is  adherent  is  seen  a  projecting  mass, 
the  size  of  an  unpeeled  walnut,  attached  in  two  places. 
This  consists  chiefly  of  fat,  in  which  is  embedded  bone, 
cartilage,  and  vessels.  The  surface  is  covered  with  skin 
bearing  hairs. 

On  March  23rd,  1896,  I  saw  the  patient  from  whom 
this  tumour  was  removed,  with  Dr.  Mason  of  Osnaburgh 
Street,  on  account  of  a  mass  in  the  pelvis  obstructing 
labour.  The  following  history  was  obtained.  B.  D — , 
aged  29,  the  wife  of  a  postman,  primipara,  pregnant 
eight  months.  Between  twelve  and  thirteen  years  of  age 
she  had  a  slight  show,  but  for  one  day  only.  The  cata- 
menia  were  regularly  established  between  fourteen  and 
fifteen,  the  flow  being  often  accompanied  by  pain,  chiefly 
on  the  left  side,  and  sometimes  by  faintings.  She  had 
suffered  from  anaemia  from  eighteen  to  twenty-two  years 
of  age,  but  with  the  exception  of  three  attacks  of  influenza 
in  the  last  seven  years  her  health  had  otherwise  been 
good.  She  was  married  July  6th,  1895.  The  last  period 
had  occurred  July  11th — 16th,  and  the  flow  was  more  free 
than  usual.  During  pregnancy  she  had  some  pain  in  the 
left  ovarian  region.     When  seen  at  5.30  p.m.  on  March  23rd 


26  INCAKCE RATED    OVARIAN    DERMOID. 

the  cervix  was  dilated  to  the  size  of  a  florin ;  the  pains 
were  moderate.  The  membranes  had  ruptured  two  nights 
before,  and  slight  pains  commenced  next  day,  but  did  not 
come  on  regularly  till  about  8  a.m.  on  the  23rd.  The 
tumour  would  just  admit  the  passage  of  two  fingers  be- 
tween it  and  the  symphysis,  and  gave  the  impression  both 
jper  vaginam  and  per  rectum  of  a  semi-solid  mass  like  an 
cedematous  fibroid.  Keposition  was  attempted,  but  it  was 
deemed  advisable  not  to  make  a  prolonged  attempt. 
Arrangements  were  made  for  the  immediate  removal  of 
the  patient  to  the  Middlesex  Hospital.  In  consultation 
with  Dr.  Duncan,  and  after  a  further  cursory  attempt 
under  an  anaesthetic  to  raise  the  tumour  out  of  the  pelvis, 
Caesarean  section  was  decided  upon.  At  8.30  p.m.  an 
incision  was  made  through  the  abdominal  wall,  and  the 
anterior  aspect  of  the  uterus  exposed  to  view.  An  in- 
cision was  then  made  into  the  uterus,  and  the  placenta 
was  seen  to  bulge  into  the  wound.  This  was  torn  through, 
and  the  child  was  seized  by  the  right  foot  and  rapidly 
extracted.  The  placenta  and  membranes  were  then  re- 
moved, and  uterine  haemorrhage  was  arrested  by  means  of 
compression  and  hot  sponges.  On  examination  of  the 
pelvis  a  large  semi-solid  ovarian  tumour  was  found  at- 
tached by  an  elongated  pedicle  to  the  right  side  of  the 
uterus.  The  tumour  was  non-adherent,  and  by  drawing 
the  uterus  upwards  and  forwards  it  was  released  from  the 
pelvis.  The  pedicle  was  ligatured  with  silk  in  two  pieces 
and  the  tumour  removed.  The  uterine  wound  was  then 
sewn  up,  silkworm  gut  being  used  for  the  muscle,  and 
fine  silk  to  bring  into  apposition  the  peritoneal  surfaces 
over  the  uterine  incision.  The  abdominal  wound  was 
then  closed.  The  patient  was  rather  sick  after  the  opera- 
tion, and  for  the  next  few  days  had  a  cough  and  some 
physical  signs  of  broncho-pneumonia.  These  rapidly 
passed  off,  and  at  the  end  of  a  week  the  temperature 
became  normal.  The  patient  made  a  good  recovery.  The 
child  was  strong  and  healthy,  being  well  developed  for 
eight  months^  gestation.      On  May  28th,  1896,  the  abdo- 


INCARCERATED    OVARIAN    DERMOID.  27 

minal  wound  was  well  united,  but  it  was  noted  that  the 
scar  was  deeply  pigmented,  as  were  also  the  cicatrices  of 
the  stitch-holes  on  either  side  of  the  middle  line.  When 
seen  about  three  weeks  ago  the  wound  showed  no  sign  of 
yielding,  but  the  pigmentation  had  entirely  disappeared. 
The  catamenia  have  been  re-established  regularly.  The 
child  continues  to  thrive. 

Remarks. — From  the  size  of  the  tumour  in  this  case, 
natural  delivery,  forceps,  version,  or  even  craniotomy  was 
impracticable.  Reposition  of  the  tumour  was  twice  at- 
tempted, first  without,  then  with  an  anassthetic ;  but  in 
neither  case  were  prolonged  efforts  made.  Owing  to  the 
solid  feel  of  the  tumour  vaginal  puncture  seemed  decidedly 
contra-indicated,  for  the  impression  which  it  gave  was  that 
of  a  fibro-myoma.  As  it  happened,  even  if  the  tumour 
had  been  punctured,  little  or  no  diminution  in  size  could 
have  been  effected.  Even  if  delivery  could  have  been 
effected  after  puncture,  the  tumour  itself  would  have 
remained  as  a  source  of  danger  and  require  to  be  dealt 
with  subsequently. 

The  patient  was  living  at  no  great  distance  from  hos- 
pital, and  it  was  consequently  easy  to  arrange  for  the 
operation  before  the  patient  had  become  exhausted  by 
prolonged  labour  ;  and  as  no  protracted  attempts  had  been 
made  to  push  the  tumour  out  of  the  pelvis,  or  by  puncture 
or  incision  to  reduce  its  size,  the  operation  could  be  under- 
taken with  a  reasonable  chance  of  success,  the  patient 
safely  relieved  of  the  tumour  and  delivered  of  a  living 
child. 

Vaginal  incision  with  the  object  of  removing  the  tumour, 
though  it  might  in  this  case  have  been  successfully  accom- 
plished, would,  to  my  mind,  have  been  taking  a  leap  in 
the  dark,  as  it  affords  a  less  certain  means  of  determining 
the  state  of  the  pelvic  organs  than  the  abdominal  method. 

Finally,  it  may  be  noted  that  the  pain  complained  of  at 
the  periods  and  during  the  pregnancy,  was  situated  on  the 
opposite  side  to  the  tumour,  and  probably  had  its  origin 
in  a  constipated  condition  of  the  lower  bowel. 


ANNUAL    MEETING. 

February  2nd,  1898. 

C.  J.  CuLLiNGWORTH,  M.D._,  President,  in  the  Cliair. 

Present — 53  Fellows  and  1  visitor. 

Books  were  presented  by  Professor  von  Winckel  and 
Mr.  Walter  Heape. 

S.  Jervois  Aarons,  M.D.Edin.,  and  Trevethan  Frampton, 
L.R.C.P.,  were  admitted  FelloAvs  of  the  Society. 

George  A.  Auden,  M.B.,  B.C.Cantab.,  was  declared 
admitted. 

The  following  gentlemen  were  proposed  for  election  : — 
Percy  Leonard  Blaber,  L.R.C.P.Lond.  ;  Charles  Edwin 
Purslow,  M.D.Lond. ;  Arthur  James  Sturmer,  Surgeon- 
Lieutenant-Colonel,  I.M.S. ;  and  Claude  Wilson,  M.D. 
Edin. 


UTERUS    RUPTURED    DURING     UNOBSTRUCTED 
LABOUR   (WITH    A    MICROSCOPIC   SECTION). 

Shown  by  W.  R.  Dakin,  M.D. 

The  patient  from  whom  the  specimen  was  obtained  was 
an  11-para  aged  40.  Slio  was  admitted  into  the  General 
Lying-in  Hospital  on  January  10th,  1898,  at  10  p.m.,  and 


30  UTERUS    RUPTURED   DURING 

was  in  the  first  stage  of  labour,  which  had  then  lasted 
about  nine  hours.  Former  labours  had  been  normal. 
During  her  present  pregnancy  she  had  been  underfed, 
but  beyond  this  no  past  medical  history  could  be  obtained. 
Her  urine  contained  one  eighth  albumen.  The  pelvis  was 
of  normal  dimensions,  and  the  child  was  in  the  first  vertex 
position.      She  was  in  fairly  good  condition. 

The  pains  were  of  the  ordinary  character,  but  occurred 
at  long  intervals.  At  6  a.m.  on  the  11th  she  had  a  few 
sharp  pains,  and  on  examination  the  os  was  found  to  be 
the  size  of  a  two-shilling  piece.  Slight  bleeding  now 
appeared.  She  got  off  the  couch  at  her  own  request  to 
pass  water,  and  the  membranes  ruptured.  The  slight 
bleeding  then  ceased.  The  pains  became  stronger,  and 
the  OS  dilated  completely.  At  11.30  a.m.  she  was  rather 
pale,  and  her  pulse  had  risen  to  100.  She  was  soon 
after  this  easily  delivered  by  the  forceps,  the  head  having 
descended  into  the  cavity  of  the  pelvis,  and  the  os  being 
above  the  greatest  circumference  of  the  head.  The  child 
was  dead.  There  was  no  bleeding,  and  the  woman  seemed 
well.  In  a  quarter  of  an  hour  or  twenty  minutes  attempts 
were  made  to  express  the  placenta,  but  were  unsuccessful. 
Dr.  Watson,  the  house  physician,  then  introduced  his 
hand  into  the  uterus.  He  found,  a  little  distance  above 
the  external  os,  a  rent  on  the  right  side,  and  the  placenta 
halfway  through  it.  He  extracted  the  placenta,  and 
then  severe  collapse  occurred.  He  sent  for  Dr.  Dakin, 
and  administered  stimulants  and  a  saline  rectal  injection, 
but  the  patient  died  in  ten  minutes. 

The  abdomen  was  found  full  of  blood  when  it  was 
opened.  The  uterus  was  well  contracted.  On  its  being 
removed  from  the  body  it  was  seen  that  the  tear  extended 
from  a  point  a  little  above  the  internal  os  and  three 
quarters  of  an  inch  below  the  retraction  ring  to  the  angle 
between  the  origins  of  the  right  Fallopian  tube  and  round 
lio-ament,  and  measured  4f  inches.  The  front  of  the 
right  broad  ligament  was  thrown  back,  and  the  round 
ligament  forwards.      The  tear  in  the  thinned  lower  seg- 


UNOBSTRUCTED    LABOUR.  31 

ment  was  at  its  lowest  part  almost  horizontal  ;  it  then 
became  oblique^  and  in  the  retracted  upper  segment  ran 
vertically.  The  placental  site  was  torn  through  by  the 
rupture.  The  peritoneal  surface  of  the  uterus  was  covered 
with  shreds  of  fairly  old  lymph. 

A  microscopic  section  of  the  muscle  of  the  lower  seg- 
ment was  shown.  The  tissues  were  seen  to  be  infiltrated 
with  fat,  and  the  muscle-fibres  to  be  abnormally  friable. 
The  muscular  wall  of  the  upper  segment  was  normal. 

The  case  was  interesting  on  account  of  the  absence  of 
any  sign  of  rupture  before  the  placenta  was  extracted  and 
the  tear  discovered.  In  a  series  of  seventeen  cases  of 
ruptured  uterus  recorded  by  Ashburton  Thompson  {'  Ob- 
stetrical Journal  of  Great  Britain/  vol.  iii)  the  pains  in 
nine  only  had  been  found  to  cease  entirely,  and  in  three 
labour  ended  without  assistance,  showing  that  marked 
signs  of  rupture  by  no  means  necessarily  occur  during 
labour  when  this  accident  happens.  There  was  no  possi- 
bility in  this  case  of  the  tear  having  been  caused  by  the 
forceps,  for  the  head  was  in  the  pelvic  cavity  and  the 
cervix  above  the  greatest  circumference  of  the  head  when 
the  forceps  was  applied. 

It  was  possible  to  account  for  this  rupture  by  the  mal- 
nutrition of  the  woman,  who  had  albuminuria,  and  whose 
uterine  muscle,  of  the  lower  segment  at  least  (in  which 
the  tear  no  doubt  began),  was  in  a  degenerated  condition. 
The  previous  peritonitis,  perhaps,  had  some  influence  in 
causing  the  degeneration,  and  she  had  had  ten  children 
before  this  one. 

It  was  fortunate  that  no  operation,  such  as  version, 
had  to  be  performed  in  her  case,  for  the  operator  would, 
no  doubt,  have  blamed  himself  had  any  laceration  then 
occurred. 

Dr.  Ilott  asked  Dr.  Dakin  how  long  the  patient  had  been  in 
labour  when  forceps  was  used,  particularly  as  to  whether  the 
first  stage  of  labour  had  been  unduly  prolonged.  It  occurred 
to  him  that  rupture  might  have  been  averted  by  a  more  timely 
employment  of  forceps. 


32  UTERINE  FIBROID  CLINICALLY  RESEMBLING  SARCOMA. 

Dr.  John  Phillips  had  encountered  a  somewhat  similar  case 
seven  years  ago.  The  woman  was  a  healthy  multipara  with 
normal  pelvis.  After  having  been  in  labour  six  hours  she  was 
suddenly  seized  with  pain  and  faintness.  The  head  was  found 
in  the  perinaeum,  and  was  quickly  delivered  with  the  forceps,  and 
on  passing  the  hand  into  the  vagina  a  large  rent  was  found  in 
the  posterior  cul-de-sac  through  into  the  peritoneal  cavity. 
The  patient  was  in  such  a  bad  condition  that  any  interference 
beyond  stimulant  was  impossible,  and  she  died  shortly  after. 
No  post-mortem  was  allowed. 

Dr.  Handfield-Jones  quoted  a  case  which  had  come  under 
his  notice,  and  which  presented  some  features  of  similar  interest. 
The  woman,  a  multipara,  of  stout,  flabby  build,  succeeded  after 
a  long  and  severe  second  stage  in  expelling  the  head  of  the 
foetus,  then  pains  ceased  and  collapse  set  in  before  the  shoulders 
could  be  born.  The  midwife  sent  for  his  assistance,  but  death 
ensued  within  a  few  minutes  of  his  arriving  at  the  patient's 
house,  and  before  any  measures  of  relief  could  be  adopted.  The 
child  was  of  great  size,  and  was  delivered  with  difficulty  after 
death.  At  the  post-mortem  the  womb  was  found  to  be  ruptured 
low  down  and  posteriorly.  The  muscular  tissue  of  the  uterus 
was  in  a  condition  of  marked  fatty  degeneration. 


UTEEINE    FIBEOID    CLINICALLY    RESEMBLING 

SARCOMA. 

Shown  by  W.  R.  Dakin,  M.D. 

Thp:  specimen  v^as  removed  by  vaginal  hysterectomy 
from  a  patient  aged  38.  She  had  had  two  children  and 
one  miscarriage,  the  miscarriage  in  the  last  pregnancy 
having  occurred  eight  years  ago.  For  two  years  she  had 
had  some  menorrhagia,  but  for  the  last  nine  months  she 
had  continuously  bled,  at  times  very  freely.  The  bleed- 
ing was  accompanied  by  severe  pain  in  the  pelvis.  A 
mass  was  found,  apparently  growing  from  the  posterior 
uterine  wall  near  the  fundus.  It  was  the  size  of  an 
orange,  and  was  diagnosed  as  a  fibroid.  On  dilating  the 
cervix,    however,    and    introducing    the    finger    into    the 


UTERINE  FIBROID  CLINICALLY   RESEMBLING  SARCOMA.  33 

uterus,  there  was  felt  in  the  posterior  wall,  at  a  point 
corresponding  to  the  centre  of  attachment  of  the  tumour, 
a  soft  slightly  raised  surface,  and  on  pressing  the  top  of 
the  finger  here  it  was  found  to  pass  through  soft  tissue 
into  what  appeared  to  be  a  cavity  filled  with  pulp,  and 
there  was  free  bleeding.  A  microscopic  examination  of 
some  small  masses  of  the  substance  which  came  away 
showed  granulation  tissue  only.  Dr.  Dakin  suspected 
sarcoma  and  removed  the  uterus.  It  appeared  to  him  to 
be  impossible  to  enucleate  the  tumour  supposing  it  to 
have  been  a  fibroid.  It  turned  out  to  be  a  fibroid,  com- 
pletely softened  in  the  centre,  and  beginning  to  slough. 
The  patient  made  an  uninterrupted  recovery. 

The  specimen  was  shown  entirely  on  account  of  its 
clinical  interest.  A  sloughing  fibroid  Avas  not  considered 
a  probable  diagnosis  because  of  the  interstitial  position  of 
the  tumour,  its  small  size,  and  the  absence  of  any  possi- 
bility of  its  having  sustained  any  damage.  The  woman 
was  angemic  to  the  last  degree,  and  this  no  doubt  was  the 
cause  of  the  nutrition  of  the  fibroid  being  sufficiently 
diminished  to  lead  to  its  sloughing  even  under  the  favour- 
able conditions  in  which-  it  grew. 

Dr.  Champneys  said  that  he  had  had  a  very  similar  case 
lately.  The  patient  suffered  from  severe  menorrhagia  with  an 
elongated  uterine  cavity,  which  was  curetted  without  benefit. 
The  cervix  was  dilated  a  second  time,  and  on  this  occasion  was 
easily  expanded  to  admit  the  finger,  which  was  not  possible  on 
the  first  occasion.  The  finger  entered  the  uterine  cavity,  and 
on  the  posterior  wall  entered  what  felt  like  a  cavity  with 
definite  edges.  The  idea  of  a  perforation  from  the  dilators,  as 
also  of  a  double  uterus,  suggested  themselves.  Further  exami- 
nation, however,  found  that  the  cavity  was  occupied  by  a  soft 
solid,  which  was  removed  piecemeal,  but  completely,  by  forceps, 
leaving  a  smooth  cavity.  The  material  proved  to  be  a  softened 
cedematous  fibro-myoma,  not  sloughing,  but  quite  sweet.  The 
involution  of  the  uterus  proceeded,  and  the  patient  is  quite  well. 

Dr.  Arthur  Giles  thought  the  following  case,  which  was  in 
some  respects  similar  to  Dr.  Dakin's,  might  be  of  interest  to  the 
Fellows.  A  single  woman,  aged  40,  had  a  myoma  of  the  uterus. 
It  had  grown  very  rapidly,  for  he  had  had  the  opportunity  of 
observing  it  from  the  first.  Owing  to  excessive  haemorrhage  he 
VOL.  XL.  3 


34         CANCER  OP  THE  BODY  OF  THE  UTERUS. 

decided  to  dilate  the  cervical  canal,  in  order  to  explore  the 
uterine  cavity.  In  the  course  of  the  dilatation,  which  presented 
no  difficulties,  he  had  reached  the  size  of  a  No.  14  Hegar,  when 
there  was  a  sudden  rush  of  clear  fluid  from  the  uterine  cavity. 
His  first  thought  was  that  the  bladder  had  been  perforated  ;  but 
he  proceeded  with  the  dilatation  till  the  finger  could  be  intro- 
duced. He  then  found  that  in  the  posterior  wall  of  the  uterus 
there  was  a  hole  through  which  the  finger  passed  into  a  roomy 
cavity  with  rough  surface  and  thick  walls.  It  was  evidently  a 
fibro-cystic  mass  which  had  thus  been  inadvertently  tapped. 
The  proper  uterine  cavity  passed  in  an  upward  and  forward 
direction  behind  the  pubes.  Any  possibility  of  injury  to  the 
bladder  was  set  aside  by  the  subsequent  course  of  the  case, 
which  was  in  every  way  satisfactory  while  the  patient  remained 
in  hospital.  About  six  months  later  she  developed  the  symptoms 
and  signs  of  an  acute  pelvic  inflammation  which  proved  fatal. 
Unfortunately  no  post-mortem  examination  was  allowed. 


CANCER  OF  THE  BODY  OF  THE  UTERUS. 

Shown  by  M.  Handfield-Jones^  M.D. 

The  patient,  a  multipara  aged  56,  had  her  meno- 
pause about  fifty,  but  eighteen  months  ago  began  to 
suffer  from  uterine  hgemorrhage.  A  year  ago  the  uterus 
was  curetted,  and  the  scrapings  were  examined  and  re- 
ported to  be  in  favour  of  non-malignancy.  On  examina- 
tion the  body  of  the  uterus  was  found  to  be  enlarged  to 
the  size  of  an  orange  and  moveable.  At  the  operation 
the  cervix  was  freed  from  its  attachments,  the  uterine 
arteries  tied,  and  both  the  anterior  and  posterior  fornices 
opened.  On  passing  a  finger  high  up  in  the  peritoneal 
pouch  it  was  found  that  omentum  and  intestine  were 
adherent  to  the  right  cornu  of  the  uterus.  The  abdo- 
men was  then  opened,  the  omentum  peeled  off  the  womb, 
and  a  knuckle  of  small  intestine,  which  had  become  fixed 
to  the  right  cornu  by  a  small  portion  of  the  disease  per- 
forating the  peritoneum  at  the  spot,  dissected  off  and  set 


ANNUAL    MEETING.  35 

free.  The  patient  was  too  collapsed  to  allow  of  resection 
of  tlie  small  piece  of  infected  intestine,  but  as  a  week  had 
passed  since  the  operation  and  the  patient  was  conva- 
lescing satisfactorily  it  was  hoped  that  this  might  be  done 
later. 

It  was  interesting  to  note  in  this  case  that  the  patient 
was  a  multipara,  and  that  the  microscopical  examination 
of  the  scrapings  removed  by  the  curette  had  proved 
decidedly  misleading.  The  combined  vaginal  and  abdo- 
minal operation  was  not  often  required,  but  it  was  of  the 
greatest  value  where  any  suspicion  of  intestinal  adhesions 
to  the  uterus  existed. 


Annual  Meeting. 

The  audited  balance-sheet  of  the  Treasurer  (Dr.  Potter) 
was  read. 

In  moving  the  formal  vote  of  thanks  it  was  seconded 
by  Dr.  W.  H.  Tate,  and  carried  unanimously — ^'  That  the 
audited  report  of  the  Treasurer  just  read  be  received, 
adopted,  and  printed  in  the  next  volume  of  the  ^  Trans- 
actions /  and  that  the  most  cordial  thanks  of  the  Society 
be  accorded  to  Dr.  Potter  for  his  valuable  services  during 
his  term  of  office.^' 

Dr.  Champneys  said  that  in  Dr.  Potter  the  Society  had 
one  of  the  most  devoted,  unselfish,  and  public-spirited 
officers  that  it  had  ever  had  the  good  fortune  to  possess. 
As  Treasurer  his  services  had  been  of  the  greatest  value. 
Although  it  had  been  thought  that  his  election  to  the 
office  of  Trustee  made  it  desirable  that  another  Treasurer 
should  be  appointed,  the  Society  would  not  lose  his  ser- 
vices.     In  the  new  Treasurer,  Dr.  Watt  Black,  it  would 


36 


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ANNUAL    MEETING.  37 

have    an    able    and   experienced   financier,    wlio    had   for 
many  years  taken  an  active  interest  in  its  welfare. 

Report  of  the  Honorary  Librarian, 

I  have  to  report  that  during  the  past  year  131  volumes 
have  been  added  to  the  Library  ;  43  of  these  were  pre- 
sented and  the  remainder  purchased. 

759  visits  were  made  by  Fellows  to  the  Library. 

Walter  S.  A.  Griffith. 

It  was  moved  by  Dr.  Horrocks,  seconded  by  Dr. 
McCann,  and  carried — "  That  the  report  of  the  Hon. 
Librarian  be  received,  adopted,  and  printed  in  the  ^  Trans- 
actions.'' '^ 


Report  of  the  Chairman  of  the  Board  for  the  Examination 

of  Midwives. 

The  number  of  candidates  presenting  themselves  for  the 
certificate  of  the  Society  is  still  on  the  increase.  During 
1897,  590  women  have  applied,  which  is  an  increase  of  89 
on  the  previous  year,  and  nearly  six  times  as  many  as  came 
up  in  1886 — a  rate  of  growth  which  shows  how  greatly  the 
distinction  of  our  Certificate  is  appreciated.  Of  these  590, 
523  passed,  49  failed,  and  18  were  absent. 

From  the  year  1872  to  1896  the  total  number  of  candi- 
dates was  3426,  of  whom  2943  passed,  436  failed,  and 
47  were  absent. 

The  total  number  now  on  the  Register,  including  those 
admitted  in  January,  1898,  is  3604. 

It  is  felt  that  the  time  has  come  when  the  duties  of 
these  midwives  should  be  defined,  and  the  Board  is  at  the 
present  time  engaged  in  drawing  up  rules  and  regulations 
for  their  guidance. 

It  speaks  well  for  the  class  of  women  on  our  Register 


38  ANNUAL    MEETING. 

that  so  few  cases   of   misconduct  or   errors   of  judgment 
come  to  the  knowledge  of  the  Board. 

Percy  Boulton. 

Dr.  J.  Watt  Black  moved — ''  That  the  report  of  the 
Chairman  of  the  Board  for  the  Examination  of  Midwives 
be  received,  adopted,  and  printed  in  the  '  Transactions.'  '' 

This  was  seconded  by  Dr.  Leonaed  Rempey  and  car- 
ried. 

The  Peesident  then  delivered  the  Annual  Address. 


39 


ANNUAL  ADDRESS. 

Ix  selecting  a  subject  for  his  address  on  taking  office^ 
your  President  lias  full  liberty  of  choice.  It  is  not  so 
when  it  comes  to  the  address  at  the  close  of  the  Session. 
Tradition  and  custom  have  here  marked  out  certain  definite 
lines  which  it  behoves  him  to  follow.  It  is  his  duty  to  lay 
before  the  Fellows  a  statement  of  the  present  condition  of 
the  Society,  a  re\aew  of  its  work  during  the  past  session, 
and  some  account  of  the  life  and  labours  of  the  Fellows 
whom  death  has  taken  from  us  during  the  year. 

First,  then,  permit  me  to  say  a  few  Avords  as  to  the 
present  condition  of  the  Society.  At  the  beginning  of 
the  year  I  ventured  to  give  expression  to  my  belief  that 
we  should  have  a  peaceful  session.  It  seemed  likely  that 
certain  burning  questions  would,  at  least  for  a  time,  be 
allowed  to  rest.  I  am  happy  to  say  that  this  prediction 
has  been  fulfilled.  During  the  past  year  the  Society  has 
not  been  disturbed  by  any  of  those  menaces  from  without 
that  two  years  ago  led  my  predecessor  to  compare  the 
Society  to  ^^  Andromeda  chained  to  a  rock  and  momentarily 
expecting  destruction.^^ 

The  Report  of  the  Chairman  of  the  Board  for  the 
Examination  of  Midwives  has  shown  that  the  alterations 
made  in  the  Society's  Certificate,  to  meet  the  wishes  of 
the  General  Medical  Council,  have  not  had  the  effect  of 
diminishing  the  number  of  candidates.  So  far  from  this 
being  the  case,  the  work  devolving  upon  our  Examiners 
is  continually  increasing,  and  the  Society's  Certificate  is 
in  greater  demand  than  ever.  This  is  to  be  accounted 
for  partly  by  the  fact  that  the  Certificate  of  this  Society, 
being  granted  after  an  examination  conducted  not  by  the 
candidates'  own  instructors,  but  by  an  independent  body 


40  ANNUAL    ADDRESS. 

of  Examiners,  is  found  to  be  a  more  valuable  possession, 
by  applicants  for  public  appointments,  than  any  other 
Miclwives'  Certificate  granted  in  England,  and  partly  also 
by  the  increasing  proportion  amongst  the  candidates  of 
women  of  intelligence  and  education,  who,  when  once  they 
have  made  up  their  minds  to  qualify  themselves  for  exami- 
nation, are  not  content  until  they  have  obtained  the  Certi- 
ficate that  stands  the  highest  in  professional  esteem. 
But  notwithstanding  the  success  that  has  attended  the 
scheme  of  voluntary  examination  instituted  by  the  Society, 
it  must  be  clearly  understood  that  the  Society  undertook 
the  work  merely  as  a  temporary  expedient,  and  from  a 
sense  of  public  duty,  after  having  tried  in  vain  to  induce 
the  Grovernment  to  move  in  the  matter ;  and  that  it  will 
only  be  too  glad  to  relinquish  it  whenever  the  State  can 
be  prevailed  upon  to  take  upon  itself  functions  that  pro- 
perly belong  to  it,  and  that  it  alone  can  adequately  fulfil. 
The  number  of  Fellows  on  our  roll  has  somewhat  dimin- 
ished during  the  past  year.  On  January  1st,  1898,  the 
total  number  was  711,  comprising  8  Honorary  Fellows, 
3  Corresponding  Fellows,  and  700  Ordinary  Fellows.  On 
January  1st,  1897,  the  total  number  on  our  list  was  741. 
During  the  past  year  9  Fellows  have  died,  24  have  resigned, 
and  20  have  had  their  names  removed  for  non-payment  of 
their  subscription.  On  the  other  hand,  only  23  new  Fel- 
lows have  been  elected.  This  is  too  small  a  number  to 
fill  the  gaps  occasioned  by  the  various  circumstances  which 
I  have  indicated,  and  which  are  inevitable  in  every  human 
society.  I  sincerely  hope  that  we  shall  all  of  us  during 
the  coming  year  endeavour  to  enlist  in  our  ranks  at  least 
one,  if  not  more,  of  our  younger  brethren.  The  harvest 
is  plenteous,  and  more  labourers  are  needed.  The  unsolved 
problems  and  unexploded  errors  in  obstetrics  and  gynae- 
cology are  still  legion,  and  this  Society  will  always  give 
a  hearty  welcome  to  good  scientific  work,  by  which  alone 
these  problems  can  be  solved  and  these  errors  rectified. 
Nothing  in  the  way  of  official  application  or  canvass  can 
ever  be  so  effectual  as  the  personal  appeal  of  one  friend 


ANNUAL    ADDRESS.  41 

to  another,  and  I  earnestly  beg  those  of  you  who  have 
yourselves  felt  the  benefit  of  the  stimulus  of  association  to 
try  to  induce  at  least  one  friend  to  follow  your  example 
and  join  our  Society  during  the  current  year. 

The  Society  has  during  the  year  1897  lost  two  of  its 
Trustees, — one,  Sir  Spencer  Wells,  by  death  ;  the  other. 
Dr.  Robert  Barnes,  by  resignation.  Of  the  life  and  work 
of  Sir  Spencer  AYells  I  shall  speak  presently.  With 
regard  to  the  resignation  of  Dr.  Barnes,  I  am  quite  sure 
that  I  shall  only  be  expressing  the  feelings  of  every 
Fellow  of  this  Society  when  I  characterise  that  occurrence 
as  an  event  that  from  every  point  of  view  is  greatly  to  be 
regretted.  As  one  of  the  leading  British  obstetricians  of 
the  latter  half  of  the  present  century,  as  an  original  Fellow 
and  past  President  of  this  Society,  and  as  a  contributor  to 
its  ^  Transactions  ^  of  no  fewer  than  thirty-two  papers.  Dr. 
Barnes  is  rightly  held  to  have  been  one  of  the  most  distin- 
guished Fellows  whose  names  have  appeared  on  the  Society^s 
roll.  It  was  therefore,  as  you  may  imagine,  ^vith  much 
sorrow  that  your  Council  received  the  announcement  of 
Dr.  Barneses  wish  (for  reasons  doubtless  satisfactory  to 
himself)  to  resign  his  Fellowship,  and  to  be  relieved  of 
his  office  as  Trustee.  Dr.  Barnes  was  urged  to  re- 
consider his  decision,  but  as  he  was  unable  to  see  his  way 
to  do  this  the  Council  had  no  alternative  but  to  accept 
the  resignation.  The  two  vacant  Trusteeships  were  filled 
by  the  election  of  Sir  John  Williams  and  Dr.  J.  Baptiste 
Potter,  both  of  them  past  Presidents  of  the  Society, 
warmly  attached  to  it,  and  ever  ready  to  watch  over  and 
defend  its  interests. 

The  papers  read  during  the  past  year  may  for  con- 
venience be  classified  into  obstetrical  and  gynaecological. 
The  obstetrical  papers  were  six  in  number. 

1.  The  first  was  a  paper  on  "  Breech  Presentation  with 
Extended  Legs,^^  by  Dr.  W.  S.  A.  Griffith  and  Dr.  Arnold 
Lea,  read  at  the  January  meeting.  Notes  were  given  in  the 
paper  of  seventeen  cases  of  this  presentation,  and  remarks 
were  made  upon  the  diagnosis,  the  course  of  labour,  the 


42  ANNUAL    ADDRESS. 

meclianrsm  of  delivery^  the  frequency  of  its  occurrence, 
the  prognosis  mth  regard  to  the  child,  and  the  manage- 
ment. An  interesting  discussion  followed,  which  was 
greatly  facilitated  by  the  admirably  concise  manner  in 
which  the  authors  summarised  their  conclusions  at  the 
close  of  their  communication. 

2.  "  The  Treatment  of  Placenta  Praevia  by  Champetier 
de  Ribes^  Bag  "  formed  the  subject  of  a  paper  by  Dr.  Gr. 
F.  Blacker,  read  at  the  April  meeting.  The  author  gave 
the  details  of  five  cases  treated  by  himself  in  this  way, 
and  seventeen  cases  similarly  treated  by  others.  The  bag 
was  employed  by  introducing  it  into  the  amniotic  cavity 
after  rupture  of  the  membranes.  In  only  one  case  did 
severe  haemorrhage  occur  after  its  introduction.  Of  the 
mothers,  one  died  of  septicaemia,  probably  contracted 
before  admission  to  the  hospital ;  five  had  an  insignificant 
elevation  of  temperature  during  the  puerperium,  and  the 
rest  made  an  uninterrupted  recovery.  Of  the  twenty-two 
children,  eight  were  born  dead,  and  four  died  subse- 
quently, giving  a  total  mortality  of  54' 5  per  cent.  No 
difficulty  was  experienced  in  introducing  the  bag,  and  pre- 
liminary dilatation  of  the  cervix  was  found  unnecessary. 
The  author  enumerated  the  advantages  claimed  for  this 
mode  of  treatment,  including  especially  a  diminution  in  the 
foetal  mortality,  and  concluded  by  a  consideration  of  the 
objections  that  had  been  raised  against  it.  In  the  dis- 
cussion that  followed  the  speakers  expressed  themselves 
as  disposed,  for  the  most  part,  to  regard  this  mode  of 
treatment  with  favour,  as  a  preferable  alternative  to 
version  in  certain  cases. 

3.  At  the  May  meeting  Mr.  J.  W.  Taylor  of  Birming- 
ham contributed  a  paper  on  "A  Second  Case  of  Abdominal 
Pregnancy  successfully  treated  by  Removal  of  Child  and 
Placenta  three  months  after  Death  of  Child  at  Term.^^ 
The  pregnancy  had  progressed  to  full  term  within  the 
abdomen  of  the  mother,  protected  only  by  the  thin  sac  of 
the  amnion,  and  without  being  accompanied  by  any  of  the 
usual  symptoms  of  rupture,  such  as  pain,  sudden  illness,  or 


ANNUAL    ADDKESS.  43 

fainting.  By  securing  all  the  pelvic  attachments,  either 
by  Doyen^s  elastic  forceps  or  ligature  before  separation, 
the  placenta,  Avhicli  weighed  3  lbs.,  was  removed  without 
any  loss  of  blood. 

4.  In  a  paper  on  ^^  Parturition  during  Paraplegia,  with 
Cases,^'  Dr.  Amand  Routh  availed  himself  of  the  excep- 
tional opportunity  for  physiological  observation  that  had 
been  afforded  him  by  the  occurrence  of  a  case  of  complete 
paraplegia  which  he  had  been  able  to  watch  not  only 
during  labour,  but  during  the  preceding  months,  and  also 
during  the  puerperium.  The  patient  experienced  a  pain- 
less labour.  The  uterine  contractions  were  ill-defined, 
often  without  intermission,  and  occasioned  no  distress 
beyond  a  feeling  of  tightness  at  the  epigastrium.  The 
first  stage  lasted  ten  hours,  the  second  two  hours  and  a 
quarter.  There  was  no  undue  haemorrhage,  in  spite 
of  retraction  being  for  some  hours  unsatisfactory,  and 
the  processes  of  involution  of  the  uterus  and  lactation 
were  quite  normal.  The  author  discussed  the  various 
views  that  have  been  held  as  regards  the  physiology  of 
parturition,  and  described  cases  by  other  observers,  and 
some  experiments  on  animals  bearing  on  the  question. 
An  interesting  and  most  instructive  discussion  followed, 
in  which  the  Society  had  the  advantage  of  hearing  the 
opinions  of  several  distinguished  physiologists,  all  of 
whom  bore  testimony  to  the  value  of  Dr.  Routh^s  paper, 
and  the  admirable  manner  in  which  he  had  discussed  the 
physiological  questions  involved. 

5.  At  the  July  meeting  Drs.  Giles  and  Maclean  con- 
tributed a  paper  on  "  Two  Unusual  Cases  of  Tubal 
Gestation — the  one  causing  Chronic  Intestinal  Obstruction, 
and  accompanied  by  a  Haematosalpinx  of  the  Non-gravid 
Tube ;  the  other  simulating  Retroversion  of  the  Gravid 
Uterus."  The  lessons  to  be  drawn  from  these  cases  are 
that  ''  if  a  tubal  gestation  be  diagnosed  before  rupture 
takes  place,  the  possible  train  of  disasters  will  be  best 
averted  by  immediate  operation  ;  ^'  and  that  any  "  pelvic 
tumour  which   does   not  conform  to    recognised  types  in 


44  ANNUAL    ADDRESS. 

regard  to  its  signs  and  symptoms  should  be  dealt  with 
surgically  at  once,  and  not  treated  by  the  expectant 
method/^ 

6.  "  The  Obstruction  of  Labour  by  Ovarian  Tumours 
in  the  Pelvis  '^  was  the  subject  of  a  valuable  paper 
by  Dr.  R.  Gr.  McKerron^  of  Aberdeen,  read  at  the 
December  meeting.  In  addition  to  giving  the  details 
of  two  hitherto  unpublished  cases  the  author  had  pre- 
pared tables  of  183  collected  cases  of  this  complication, 
and  drew  attention  to  some  features  of  interest  in  the 
clinical  histories.  From  a  study  of  the  cases  and  of 
the  literature  of  the  subject  he  deduced  the  following 
practical  observations  in  regard  to  treatment : — ^'  Reposi- 
tion should  in  all  cases  be  first  attempted.  Where  it 
failed  a  selection  according  to  circumstances  should  be 
made  from  the  following  operative  measures  : — puncture, 
Caesarean  section,  abdominal  or  vaginal  ovariotomy. ^^ 
The  paper  concluded  with  remarks  on  the  after-treat- 
ment in  those  cases  where  the  tumour  had  not  been 
removed  during  labour.  The  discussion  on  this  paper 
was,  owing  to  the  lateness  of  the  hour,  adjourned  to  the 
January  meeting  of  the  present  year,  when  one  or  two 
other  communications  bearing  on  the  subject  were  sub- 
mitted, and  were  followed  by  a  spirited  and  useful  debate, 
marred  only  by  the  unavoidable  absence  of  the  author  of 
the  paper,  which  deprived  the  Societ}^  of  the  advantage  of 
hearing  his  reply. 

The  other  papers  read  during  the  past  session,  also  six 
in  number,  were  gynaecological. 

1.  The  first  of  these  was  on  "The  Cyclical  or  Wave 
Theory  of  Menstruation^  with  Observations  on  the  Varia- 
tions in  Pulse  and  Temperature  in  Relation  to  Menstrua- 
tion,''  by  Dr.  Giles,  read  at  the  March  meeting.  The 
author's  investigations  led  him  to  conclude  that  the 
cyclical  theory,  as  ordinarily  stated,  is  an  insufficient 
explanation  of  the  origin  of  menstruation.  In  a  modified 
form,  however,  he  thought  it  might  be  accepted  as  giving 
a  connected  idea  of  the  meaning  of  menstruation,  which 


ANNUAL    ADDKESS.  45 

mig'lit  be  looked  upon  as  a  repeated  preparation  for  the 
reception  and  nutrition  of  a  fertilised  ovum.  Failing  the 
arrival  of  such  an  ovum  menstruation  had  been  correctly 
described  as  a  '^  missed  pregnancy/' 

2.  The  next  paper  was  on  '^  Chronic  Axial  Rotation  of 
an  Ovarian  Cyst  giving  Rise  to  Extreme  Twisting  of  the 
Elongated  Uterus/'  by  Dr.  Thos.  Wilson^  of  Birmingham, 
read  at  the  May  meeting-.  The  literature  of  the  subject 
was  referred  to,  but  the  author  had  been  unable  to  find 
any  reported  case  in  which  rotation  of  an  ovarian  cyst  had 
caused  an  equally  extreme  amount  of  twisting  of  the 
uterus.  On  the  other  hand,  extreme  twisting  of  the 
uterus,  even  to  the  extent  of  complete  separation  of  the 
body  from  the  neck,  had  been  met  with  several  times  in 
connection  with  fibro-myoma  of  the  uterus  itself. 

3.  At  the  June  meeting  Dr.  Lewers  contributed  a 
paper  on  ^^  A  Case  of  Primary  Sarcoma  of  the  Body  of 
the  Uterus  in  a  Patient  Twenty-four  Years  of  Age, 
treated  by  Yaginal  Hysterectomy.''  The  growth  had 
been  examined  by  several  competent  pathologists,  and 
had  been  pronounced  to  be  identical  mth  what  had  been 
described  under  the  name  of  ^'  deciduoma  malignum." 
But  although  the  patient,  who  had  been  married  a  year, 
believed  that  she  had  had  three  miscarriages,  the  author, 
after  considering  the  evidence,  expressed  some  doubt  as  to 
whether  conception  had  ever  occurred. 

4.  A  paper  by  Mr.  Doran  on  '^The  Management  of 
True  and  False  Capsules  in  Ovariotomy  "  was  read  at  the 
October  meeting.  Where  the  capsule  was  formed  by  mesen- 
tery, omentum,  or  inflammatory  deposit  the  author  termed 
it  a  false  capsule  ;  where  it  was  formed  by  the  mesosalpinx 
alone  he  termed  it  a  true  anatomical  capsule  ;  and  where 
it  involved  the  lower  part  of  the  broad  ligament,  the 
parietal  peritoneum,  or  the  parametrium,  a  false  anato- 
mical capsule.  The  treatment  of  the  first  variety  he 
described  as  a  simple  breaking  down  of  adhesions.  The 
treatment  of  the  second  and  third  varieties  was  a  more 
complicated  matter.      AVlien  the  capsule  was  healthy  lie 


4G  ANNUAL    ADDRESS. 

advised  tliat  it  should  be  cut  away  if  possible.  When 
no  pedicle  could  be  formed,  the  tissue  of  the  capsule 
being  healthy,  and  the  haemorrhage  being  under  control, 
the  capsule  might  be  let  fall  into  the  pelvis.  But  where 
under  similar  conditions  the  capsule  showed  advanced 
inflammatory  changes,  or  hemorrhage  was  hard  to  control, 
he  recommended  fixation  of  the  capsule  by  stitching  it  to 
the  lower  end  of  the  abdominal  wound  and  drainage.  In 
the  interesting  discussion  that  followed  the  speakers  ex- 
pressed a  general  concurrence  with  the  author^ s  views. 

5.  At  the  November  meeting  a  paper  by  Mr.  Bland  Sutton 
was  read  on  "  Abdominal  Hysterectomy  for  Myoma  of  the 
Uterus,  with  brief  Notes  of  Twenty-eight  Cases. ^^  The 
author  considered  that  the  time  had  arrived  when  it  had 
become  a  medical  adviser^s  duty  to  point  out  to  patients  with 
uterine  myomata  that  early  removal  involved  less  opera- 
tive danger  and  a  diminished  peril  to  life.  He  avoided 
the  removal  of  the  ovaries  and  tubes  during  the  operation 
wherever  it  was  possible.  He  thought  the  proper  place 
for  the  clamp  and  serre-noeud  was  a  corner  of  the  museum 
devoted  to  obsolete  instruments,  and  he  regarded  the  sub- 
sequent use  of  an  abdominal  belt  as  a  foolish  following  of 
a  useless  custom. 

These  iconoclastic  observations  were  not  allowed  to 
pass  without  some  notes  of  dissent,  and  several  of  the 
speakers  who  took  part  in  the  subsequent  debate  ex- 
pressed the  opinion  that,  as  a  large  number  of  uterine 
fibroids  remained  stationary  and  harmless,  early  operation 
was  not  to  be  universally  recommended.  Ovarian  and 
uterine  tumours,  it  was  contended,  were  not  comparable 
as  regards  the  necessity  for  operative  interference.  Mr. 
Sutton  wound  up  the  debate  with  a  spirited  reply. 
Readers  of  this  discussion  will  do  well  to  supplement  it 
by  a  reference  to  that  which  followed  the  paper  on  a 
similar  subject  read  in  1896  by  Mr.  Harrison  Cripps. 

6.  A  paper  on  "  Three  Cases  of  Pyometra  complicating 
Cancer  of  the  Cervix  Uteri  ^^  was  contributed  at  the 
December  meeting  by  Dr.  Walter  Tate.      Out  of  twenty- 


ANNUAL    ADDRESS.  47 

eight  cases  of  vaginal  hysterectomy  the  author  had  met 
with  pyometra  on  no  fewer  than  three  occasions.  In  the 
discussion  that  followed  Dr.  Amand  Routh  pointed  out 
the  importance  of  the  fact  to  which  the  author's  cases 
bore  witness,  that  pyometra  might  exist  without  stenosis 
of  the  cervix. 

The  exhibition  of  specimens  has  ahvays,  to  my  mind, 
formed  a  very  important  and  valuable  part  of  the 
Society's  work.  Since  there  has  been  introduced  into 
our  regulations  a  little  more  elasticity  in  regard  to  the 
time  allowed  for  these  minor  communications,  the  number 
and  value  of  them  have  decidedly  increased.  I  purpose 
following  the  example  of  some  of  my  predecessors,  and 
enumerating  the  chief  specimens  shown  during  1897,  not 
in  the  order  of  their  exhibition,  but  arranged  in  groups 
according  to  the  subject  intended  to  be  illustrated — a 
method  which,  I  think,  adds  to  the  interest  and  usefulness 
of  this  annual  resume.  Taking  first,  then,  the  subject  of  the 
physiology  of  menstruation,  at  the  December  meeting 
Dr.  Arnold  Lea,  of  Manchester,  showed  some  microscopic 
sections  of  uterine  mucous  membrane  made  immediately 
before  and  immediately  after  a  menstrual  period. 

Mr.  Targett  showed  in  May  an  interesting  ana- 
tomical abhormality  in  the  shape  of  accessory  adrenal 
bodies  in  the  broad  ligament,  and  made  some  valuable 
remarks  on  the  frequency  of  their  occurrence. 

The  comparative  anatomy  of  pregnancy  was  illustrated 
by  the  exhibition  of  Dr.  R.  Wise  at  the  October  meeting 
of  a  pregnant  horn  from  the  uterus  of  a  cat. 

The  pathology  of  uterine  pregnancy  and  labour  in  the 
human  female  was  illustrated  by  the  following  specimens. 

(1)  An  abortion  sac  with  ha3morrhages  into  the  foetal 
membranes,  shown  by  Dr.  Robert  Wise  at  the  October 
meeting. 

(2)  An  intra-pubic  joint  producing  diminution  of  the 
pelvic  inlet,  shown  by  Mr.  Targett  for  Dr.  Williamson  at 
the  meeting  in  November. 

(3)  The   uterus  from  a  case  of  Porro's  operation  with 


48  ANNUAL    ADDEESS. 

intra-abdominal    treatment    of   the  stump^    shown   by   Dr. 
W.  J.  Gow  at  the  January  meeting. 

(4)  A  uterus  ruptured  during  premature  labour^  and 
removed  by  abdominal  section^  shown  by  Dr.  John 
Phillips  in  October. 

(5)  Euptured  gestation  in  an  imperfect  uterine  horn, 
shown  by  Mr.  Targett  in  February. 

Four  teratological  specimens  were  exhibited,  viz.  a 
foetal  monstrosity  by  Dr.  John  Phillips  in  February,  a 
monster  (mth  skiagraph)  by  Dr.  Lowers  in  April,  and  in 
the  same  month  a  deformed  foetus  and  a  foetus  com- 
pressus  by  Mr.  Bottomley. 

The  ever  fascinating  subject  of  ectopic  gestation,  which 
still  needs  for  its  full  elucidation  all  the  light  that  obser- 
vation can  shed  upon  it,  received  illustration  from  the 
following  specimens  : 

(1)  A  ruptured  tubal  pregnancy  with  haematosalpinx  of 
the  opposite  side,  shown  by  Dr.  Lewers  in  June. 

(2)  Early  ectopic  gestation  (tubo-uterine)  with  escape 
of  the  foetus  into  a  diverticulum,  and  complicated  by 
fibro-myomata  of  the  uterus,  shown  by  myself  at  the 
November  meeting. 

(3)  Ectopic  pregnancy  going  nearly  to  term  in  the 
peritoneal  cavity,  the  operation  for  its  removal  having 
been  undertaken  under  the  belief  that  it  was  a  fibroid, 
shown  by  Dr.  Herman  in  April. 

(4)  A  decidual  cast  of  the  uterus  from  a  case  in  which 
there  was  no  evidence  of  extra-uterine  gestation,  shown  by 
Dr.  Eden  in  April. 

Inflammatory  and  tuberculous  affections  were  illustrated 
by  the  following  four  specimens  : 

(1)  Encysted  tuberculous  peritonitis  shown  in  April  by 
Mr.  Targett,  who  made  some  remarks  on  the  effects  pro- 
duced by  tuberculous  peritonitis  upon  the  female  pelvic 
viscera.  (2 — 4)  Three  cases  of  pyosalpinx  :  one  shown  in 
March  by  Dr.  W.  Duncan ;  one  complicated  by  multiple 
abscesses  of  the  ovary,  the  pus  from  which  has  since  been 
examined  by  Dr.  McCann  with  the  result  of  demonstrating 


ANNUAL    ADDEESS.  49 

the  presence  in  it  of  gonococci^  shown  in  February  by 
myself ;  and  one  complicated  by  an  enlarged  bladder, 
shown  in  December  by  Dr.  Macnaughton  Jones. 

As  one  would  expect,  tumours  and  new  growths  con- 
stitute a  considerable  proportion  of  the  specimens  ex- 
hibited. Beginning  A\ath  those  of  the  uterus,  at  the 
December  meeting  Dr.  McKerron  showed,  for  Prof. 
Stephenson  of  Aberdeen,  a  peculiar  mucous  polypus  or 
pedunculated  adenoma  of  the  cervix  uteri.  At  the 
January  meeting  Dr.  Amand  Routh  showed  a  malignant 
papilloma  of  the  uterus.  The  number  of  specimens  of 
uterine  fibro-myomata  exhibited  to  the  Society  affords 
marked  evidence  of  the  special  interest  at  present  attach- 
ing to  these  tumours  and  their  treatment.  Some  were 
shown  to  illustrate  some  particular  method  of  operating, 
as  in  the  case  of  the  specimens  presented  at  the  March 
and  November  meetings  by  Dr.  W.  Duncan,  that  shown 
by  Dr.  Lewers  in  April,  and  those  exhibited  at  the  De- 
cember meeting  by  Dr.  Macnaughton  Jones.  Others  were 
brought  forward  on  account  of  some  point  of  pecu- 
liarity or  interest  in  the  specimen  itself,  in  the  history, 
or  in  the  patient.  Thus  Mr.  Bland  Sutton  at  the  May 
meeting  illustrated  the  subject  of  fibro-myomata  of  the 
neck  of  the  womb,  whilst  Dr.  W.  Duncan,  in  November, 
showed  a  specimen  in  which,  along  with  a  large  fibro- 
myoma  of  the  uterus,  there  had  become  developed  a 
tumour  of  the  left  ovary. 

The  question  of  age  in  reference  to  these  tumours  was 
illustrated  by  a  specimen  which  Dr.  A.  F.  Stabb  showed 
for  me  at  the  March  meeting,  where  the  patient  was  only 
twenty-six,  and  by  Dr.  Galabin's  specimen  shown  at  the 
June  meeting,  where  the  tumour  had  developed  rapidly  in  a 
patient  aged  sixty-three — long,  therefore,  after  the  meno- 
pause. As  affording  illustration  of  the  modes  in  which 
fibro-myomata  may  destroy  life,  I  showed  in  connection 
with  Mr.  Bland  Sutton's  communication  in  Kovember,  a 
specimen  in  which  an  interstitial  fibro-myoma  had  become 
gangrenous,    and    another    in    which    a   subserous    fibro- 

VOL.  XL.  4 


50  ANNUAL    ADDEESS. 

myoma  liad  pressed  on  the  rectum^  caused  obstruction, 
and  ultimately  been  tlie  cause  of  death  from  thinning  and 
eventual  giving  way  of  the  dilated  intestine  above  the 
seat  of  obstruction. 

Malignant  disease  of  the  uterus  was  exemplified 
by  four  specimens — one  each,  curiously  enough,  of  car- 
cinoma of  the  cervix,  carcinoma  of  the  body,  sarcoma 
of  the  body,  and  sarcoma  of  the  cervix.  The  specimen 
of  carcinoma  of  the  cervix  was  shown  by  Dr.  Playfair  in 
November,  the  interesting  point  about  it  being  that  two 
years  previous  to  the  operation  for  its  removal,  the 
patient  had  had  both  ovaries  and  Fallopian  tubes  re- 
moved. The  specimen  of  carcinoma  of  the  body  was 
shown  by  Dr.  Dauber  in  December,  and  was  interesting 
from  the  disease  having  occurred  in  a  uterus  already 
myomatous.  The  uterus  was  removed  by  the  operation 
of  so-called  pan-hysterectomy.  The  specimen  of  sarcoma 
affecting  the  body  of  the  uterus  was  shown  by  Mr. 
Targett  for  Dr.  Williamson  in  November.  The  disease 
had  been  followed  by  inversion  of  the  uterus.  The 
specimen  of  sarcoma  affecting  the  cervix  was  exhibited 
by  Dr.  McCann  at  the  meeting  in  October. 

New  growths  springing  from  the  ovary  and  parovarium 
were  illustrated  by  several  specimens. 

In  April  Dr.  Drummond  Eobinson  showed  cystic  ovaries 
removed  by  the  operation  of  anterior  colpotomy.  In 
January  (1897)  Dr.  Arnold  Lea,  of  Manchester,  showed 
a  parovarian  cyst  with  axial  rotation.  Dr.  C.  H.  Roberts, 
Mr.  Doran,  and  myself,  each  showed  a  specimen  of  fibroma 
of  the  ovary.  In  Dr.  Roberts's  case,  shown  in  January, 
the  tumour  had  undergone  calcareous  degeneration.  In 
Mr.  Doran' s  case,  shown  in  February,  the  patient  had 
ascites,  and  the  tumour  before  removal  had  become  im- 
pacted. My  own  specimen,  which  occurred  in  a  young 
subject  and  was  of  large  size,  was  shown  in  November, 
and  will  be  fully  described  in  the  '  Transactions.' 

The  remaining  specimens,  all  of  them  new  growths, 
consisted  of  a  molluscum  fibrosum  of  the  labium  majus. 


ANNUAL    ADDRESS.  51 

shown  in  June  by  Dr.  Giles,  and  two  tumours  shown  by 
Mr.  Doran  in  February,  viz.  a  lipoma  of  the  lumbar  region, 
four  pounds  in  weight  and  of  twenty  years^  growth,  and 
a  fibroma  of  the  abdominal  wall  which  had  undergone 
considerable  increase  in  size  during  pregnancy,  and  had 
been  removed  by  Mr.  Doran  five  weeks  after  the  patient's 
delivery. 

It  will  thus  be  seen  that  there  has  been  no  lack  either 
of  interest  or  variety  in  the  specimens  brought  before  the 
Society  during  1897. 

The  Society's  death-roll  for  the  past  year  contains,  so 
far  as  we  have  information  at  present,  the  names  of  six 
ordinary  Fellows  and  three  honorary  Fellows.  Of  the 
six  ordinary  Fellows  one  at  least  was  of  such  world-wide 
fame  as  to  call  for  a  somewhat  extended  notice.  I  allude 
of  course  to 

Sir  Thomas  Spencer  Wells. 

Spencer  Wells,  as  he  was  more  familiarly  called,  was 
born  on  February  3rd,  1818,  and  was  the  eldest  son  of 
the  late  Mr.  William  Wells,  of  St.  Albans,  Hertfordshire. 
He  was  apprenticed,  after  the  fashion  of  the  time,  to  the 
late  Michael  Thomas  Sadler,  of  Barnsley,  in  Yorkshire, 
"  an  unusually  able  and  worthy  man.''  After  this  fortu- 
nate experience  he  went  to  Leeds,  and  while  still  a  youth 
of  seventeen  held  for  a  little  more  than  a  year  the  posi- 
tion of  unqualified  assistant  to  one  of  the  parish  surgeons. 
During  this  time  he  saw  much  practice  in  the  Leeds 
Infirmary,  always  one  of  the  foremost  provincial  hospitals 
in  operative  surgery.  He  also  attended  the  lectures  of 
the  second  William  Hey  and  the  elder  Teale.  To  the 
teaching  of  both  these  eminent  men  he  always  referred 
with  expressions  of  the  warmest  appreciation.  From 
Leeds  he  went  to  Trinity  College,  Dublin,  and  whilst 
there  he  worked  under  Graves,  Stokes,  Sir  Philip 
Crampton,  and  Beattie.  In  1839  he  proceeded  from 
Dublin    to    London,    and    entered    as    a    student   at    St. 


52  ANNUAL    ADDEESS. 

Thomas's  Hospital^  where  he  had  the  advantage  of 
working  under  several  distinguished  men^  notably  Joseph 
Henry  Green,  Benjamin  Travers,  and  Frederick  Tyrrell, 
whose  manipulative  skill  in  ophthalmic  surgery  especially 
delighted  him.  At  the  end  of  his  first  session  he  secured 
the  prize  offered  for  the  most  complete  and  detailed 
reports  of  the  post-mortem  examinations  made  in  the 
hospital  during  the  session.  After  another  year  spent  at 
St.  Thomas's  he  obtained  his  diploma  of  membership  of 
the  Royal  College  of  Surgeons  of  England,  and,  led  no 
doubt  by  his  love  of  travel  and  his  fondness  for  a  sea- 
faring life  he,  in  the  same  year  (1841),  entered  the  Royal 
Navy  as  an  assistant  surgeon.  For  the  next  six  years  he 
served  in  the  naval  hospital  at  Malta.  His  practice  in 
that  island  was  not  limited  to  his  hospital  work ;  the 
civil  population  also  benefited  by  his  advice  and  operative 
skill,  and  his  ophthalmic  practice  is  said  to  have  been 
considerable.  In  1848  he  left  the  navy  and  proceeded  to 
Paris  in  order  to  study  pathology.  The  medical  school  of 
Paris  was  at  that  time  the  most  famous  in  Europe.  The 
galaxy  of  brilliant  teachers  to  be  found  there  attracted 
students  and  medical  practitioners  from  all  countries.. 
Majendie  was  then  at  the  zenith  of  his  popularity,  and 
Claude  Bernard  was  rapidly  coming  into  notice.  Spencer 
Wells  was  always  fond  of  alluding  to  his  residence  in 
Paris  as  being  the  period  when  his  attention  became 
directed  for  the  first  time  to  the  subject  of  ovarian  dis- 
ease. Amongst  his  English  fellow-students  in  Paris  was 
the  late  Dr.  Edward  Waters,  of  Chester,  with  whom  he 
often  joined  in  friendly  debate  on  professional  topics. 
The  ultimate  result  of  their  many  discussions  on  the 
particular  question  of  operation  in  ovarian  disease  was  an 
agreement  in  opinion  that  as  surgery  then  stood  ovari- 
otomy was  an  unjustifiable  operation.  At  this  time  Wells 
had  not  only  never  witnessed  the  operation,  but  had  never 
to  his  knowledge  seen  a  single  case  of  ovarian  disease. 

He  finally  settled   in  London  in  the  year  1853,  and  in 
the  following  year  he  became   attached  to  the  Samaritan 


ANNUAL    ADDRESS.  53 

Free  Hospital  for  Women^  wliicli  liad  then  only  been  in 
existence  for  about  seven  years,  and  consisted  merely  of 
an  out-patient  department.  It  was  about  tliis  time  that 
he  became  for  a  short  period  the  editor  of  the  '^  Medical 
Times  and  G-azette.^  In  this  capacity  he  was  brought 
into  close  personal  contact  with  many  of  the  more  promi- 
nent members  of  his  profession.  In  April,  1854,  Spencer 
Wells  was  present  when  Mr.  Isaac  Baker  Brown,  assisted 
by  his  friend  Mr.  Thos.  Xunn,  performed  his  eighth 
ovariotomy.  It  was  the  first  operation  of  the  kind  he  had 
seen.  The  case  ended  fatally  from  peritonitis,  and  indeed 
Baker  Brown's  mortality  was  so  heavy  (seven  cases  out  of 
the  first  nine)  that  that  skilful  operator  gave  up  all  hope 
of  being  able  to  establish  the  legitimacy  of  the  operation. 
The  needed  stimulus  to  Spencer  Wells  was  destined  to 
come  from  an  unexpected  quarter. 

Shortly  after  the  Crimean  war  had  broken  out  he 
obtained  leave  of  absence  at  the  Samaritan  Hospital,  and 
relinquishing  for  a  time  both  his  hospital  and  private 
practice  went  out  to  Smyrna,  where  he  was  appointed 
surgeon  to  the  British  Civil  Hospital.  Both  here  and 
afterwards,  when  he  was  closely  associated  with  the  late 
Dr.  Parkes,  he  had  unusual  opportunities  of  studying 
the  effects  of  gunshot  wounds,  especially  those  of  the 
abdomen.  He  was  greatly  impressed  with  the  amazing 
tolerance  of  the  peritoneum.  He  noticed  that  the  abdo- 
minal walls  might  be  lacerated  by  fragments  of  shell,  that 
the  intestines  might  protrude  for  hours  and  be  covered 
with  dust  and  dirt,  and  yet  that  if  the  cavity  was  care- 
fully cleansed  and  the  wounds  accurately  closed,  recovery 
was  by  no  means  impossible.  Thus  he  gained  knowledge 
which  became  of  much  use  to  him  in  his  subsequent 
work,  and  he  frequently  stated  in  after  years  that  it 
was  his  experience  in  the  Crimea  that  in  great  measure 
encouraged  him  to  persevere. 

Before  leaving  England  for  the  Crimea  in  1854  Spencer 
Wells,  finding  that  there  was  no  chance  of  his  obtaining 
a  surgical  appointment  at  any  of  our  large  general  lios- 


54  ANNUAL    ADDRESS. 

pitals,  had  attached  himself  to  one  of  the  best  private 
medical  schools^  the  Grrosveiior  Place  or  Lane^s  School^ 
close  to  St.  George^s  Hospital^  which  at  that  time  had  no 
anatomical  department  immediately  connected  with  it. 
At  this  school  he  lectured  on  surgery  in  conjunction  with 
Mr.  Geo.  Pilcher.  He  gave  to  his  lectures  the  character 
of  a  conversation  with  his  class,  interspersing  his  remarks 
with  questions  suddenly  addressed  to  individual  students. 
This  innovation  rendered  his  lecture-room  exceedingly 
popular.  On  his  return  from  the  Crimea  in  1857  he  re- 
sumed his  teaching  (his  friend  Mr.  Wm.  Adams  having 
acted  as  his  deputy  during  his  absence).  Eight  years 
later  the  Grosvenor  Place  medical  school  became  merged 
in  the  school  of  St.  George^s  Hospital. 

It  was  in  the  year  1857  that  Spencer  Wells  performed 
his  first  ovariotomy.  Baker  Brown  assisted  him.  The 
operation  could  not  be  completed.  Wells,  however,  did 
not  allow  himself  to  be  discouraged,  and  in  the  following 
year  he  operated  a  second  time,  and  on  this  occasion  with 
success.  From  this  time  forward  Spencer  Wells  consti- 
tuted himself  the  champion  of  the  operation  of  ovari- 
otomy, and  all  the  world  knows  how  completely  he  suc- 
ceeded in  converting  opponents  and  establishing  the 
operation  on  a  recognised  basis.  "  On  taking  up  this 
subject,^^  he  says,  '^  as  a  matter  of  study  and  trial,  just  at 
the  crisis  when  obloquy  was  the  thickest  and  opposition 
the  strongest,  I  felt  that  nothing  but  the  most  open  frank- 
ness would  carry  conviction  of  success,  or  in  case  of 
failure  justify  the  operation.  I  therefore  pledged  myself 
to  make  known  through  the  press  all  that  I  did  and  all  that 
befel  me.'^  This  pledge  he  loyally  fulfilled.  Case  after 
case  was  recorded  in  the  medical  journals,  and  eventually 
the  cause,  to  the  furtherance  of  which  Spencer  Wells  had 
with  characteristic  determination  and  force  of  will  devoted 
himself,  won  its  way  to  recognition  and  final  triumph. 
^^  The  complete  history  of  ovariotomy/^  wrote  Mr.  Nunn 
in  1886,  '^  might  be  described  as  a  thirty  years'  war  of 
fact   and  experience   against   venerable    and   multifarious 


ANNUAL    ADDRESS.  55 

prejudice/^  In  this  long  and  liard-f ought  struggle  Spencer 
Wells  bore  by  far  the  most  laborious  and  conspicuous 
part.  His  ultimate  success  in  vanquishing  prejudice  and 
in  securing  recognition  for  ovariotomy  as  a  legitimate  and 
beneficent  addition  to  the  resources  of  the  operating  sur- 
geon Avas  the  result  of  indomitable  perseverance,  of  strong 
personal  conviction,  of  minute  attention  to  detail,  and  of 
the  fearlessness  that  comes  from  absolute  honesty  and 
singleness  of  purpose.  He  was  helped,  as  Mrs.  Garrett 
Anderson  has  well  said,  ^^  by  a  temperament  of  quite 
amazing  cheerfulness  and  elasticity.  He  knew,^'  she  con- 
tinues, ^^  that  he  was  doing-  his  best  to  perfect  the  opera- 
tion and  to  save  life,  and  he  did  not  allow  himself  to  be 
discouraged  by  failure  in  whatsoever  shape  it  came.  He 
had  the  courage  to  be  hopeful  and  confident  and  encou- 
raging in  the  face  of  a  number  of  disappointments  which 
would  have  made  many  other  equally  good  surgeons  more 
or  less^  discouraged  and  self-distrustful.  Wells  always 
gave  a  patient  the  impression  that  he  was  quite  sure,  and 
that  she  might  be  quite  sure  that  all  would  be  well  Avith 
her  in  his  hands.  Not  that  he  blinked  facts  and  sta- 
tistics. Everything  was  honestly  told,  but  his  radiant 
optimism  was  infectious,  and  the  patient  forgot  there  was 
any  risk  to  speak  of  in  what  he  was  about  to  do.  Nothing, ^^ 
concludes  Mrs.  Anderson,  ^^  is  more  contagious  than 
optimism,  and  to  a  medical  practitioner  it  is  a  weapon 
of  the  greatest  value,  always  provided  that  he  can  keep 
his  own  eyes  out  of  the  sunlight  sufficiently  to  see 
straight.  ^^"^ 

In  1865  Spencer  Wells  published  a  record  of  114  cases. 
This  was  followed  in  1872  by  an  account  of  500  cases, 
and  again  in  1882  by  a  report  of  1071  cases.  His 
literary  career  began  by  the  publication,  a  year  or  two 
after  his  term  of  service  in  the  navy  had  expired,  of  a 
useful    '  Scale   of   Medicines   for   Use   in    the    Mercantile 

*  "  On  tbe  Progress  of  Medicine  in  the  Victorian  Era."  Presidential 
Address  to  the  East  Anglian  Branch  of  the  British  Medical  Association. 
Macmillan,  London,  1897,  pp.  IC,  17. 


56  ANNUAL    ADDRESS. 

Marine/  This  was  followed  in  1854  by  a  dissertation  on 
^  Grout  and  its  Complications/  His  first  work  in  book  form 
on  the  subject  with  which  his  name  is  chiefly  associated_, 
appeared  under  the  title  of  ^  Diseases  of  the  Ovaries '  in 
1865.  About  the  same  time  he  published  a  ^Note-book 
for  Cases  of  Ovarian  and  other  Abdominal  Tumours/ 
intended  as  an  aid  towards  increasing  the  knowledge  of 
these  diseases.  In  1882  he  issued  a  larger  work^  em- 
bodying the  substance  of  the  two  publications  already 
mentioned,  and  containing  an  accurate  and  detailed  ac- 
count of  his  personal  work  up  to  that  time.  In  1884  he 
delivered  an  historical  address  on  the  revival  of  ovari- 
otomy. A  chronological  list  of  his  numerous  contributions 
to  medical  literature  will  be  found  in  the  appendix  to 
this  address. 

He  was  a  strong  advocate  of  the  disposal  of  the  dead 
body  by  cremation,  and  wrote  a  forcible  and  outspoken 
letter  on  the  subject  to  the  ^  Times/  in  which  he  pointed 
out  the  enormous  advantages  of  the  system  from  a  sani- 
tary point  of  view. 

In  1844  Spencer  Wells  received  from  the  Royal  College 
of  Surgeons  the  honorary  Fellowship  of  the  College.  He 
was  one  of  the  original  Fellows  of  this  Society,  served  on 
its  Council  in  1859,  held  the  office  of  Vice-President  from 
1868  to  1870,  and  at  the  time  of  his  death  was  one  of  its 
Trustees.  He  contributed  several  papers  to  its  ^  Trans- 
actions/ 

In  1871  he  was  elected  a  Member  of  the  Council  of 
the  Royal  College  of  Surgeons,  in  1877  he  became  Hun- 
terian  Professor  of  Surgery  and  Pathology,  and  in  1879 
he  was  advanced  to  the  position  of  Vice-President.  In 
1883  he  was  elected  President  of  the  College,  and  in  the 
same  year  he  delivered  the  Hunterian  Oration  before  the 
College.  A  few  years  later  he  Avas  appointed  Morton 
Lecturer  on  Cancer,  and  in  1890  he  delivered  the  Brad- 
shaw  lecture,  choosing  for  his  subject  "  Modern  Abdo- 
minal Surgery. ^^  In  this  lecture  he  took  occasion  to 
raise  his  voice  against   rash   and  unnecessary  operations 


ANNUAL    ADDRESS.  57 

on  the  organs  of  the  female  pelvis,  and  was,  perhaps, 
somewhat  too  sweeping  in  his  condemnation.  He  did 
not  sufficiently  discriminate  between  operations  under- 
taken merely  for  the  relief  of  ^^ain  and  those  very  diffe- 
rent operations  performed  for  the  removal  of  organs 
obviously  and  hopelessly  diseased.  For  him,  all  tubal 
operations  and  all  operations  for  ovarian  disease  other 
than  new  growth  were  mischievous  and  unjustifiable. 
He  regarded  them  as  in  the  same  category  with  opera- 
tions for  the  removal  of  the  healthy  ovaries  as  a  means 
of  curing  nervous  affections.  This  attitude  on  the  part 
of  one  who  had  himself  in  his  earlier  days  fought  bravely 
for  the  recognition  of  ovariotomy,  of  which  all  these  later 
operations  were  the  direct  and  inevitable  outcome,  was 
the  subject  of  regret  to  many  of  his  admirers.  It 
was,  however,  recognised  as  an  expression  of  honest  con- 
viction and  as  simply  one  more  proof  that  men  Avith  even 
the  most  vigorous  intellects  may  become,  when  past  a 
certain  age,  unable  to  assimilate  new  ideas  or  adequately 
to  appreciate  new  developments,  even  in  the  branch 
of  work  which  they  themselves  have  laboured  to  advance. 

The  list  of  honours  conferred  upon  Sir  Spencer  Wells 
is  a  long  one.  He  was  an  honorary  Fellow  of  the  King^s 
and  Queen^s  College  of  Physicians  in  Ireland,  and  received 
the  honorary  degree  of  M.D.  from  the  Universities  of 
Leyden,  Bologna,  and  Charkof.  He  was  a  Knight  Com- 
mander of  the  Norwegian  Order  of  St.  Olaf.  He  was 
elected  an  honorary  Fellow  of  the  American  G-ynecological 
Society,  and  a  Member  of  the  Medical  Societies  of  Paris, 
Moscow,  and  Stockholm,  and  of  the  Obstetrical  and 
Gynaecological  Societies  of  Berlin  and  Leipzig.  He  held 
the  appointment  of  Surgeon  to  the  Royal  Household 
until  a  very  short  time  before  his  death  ;  and  in  May,  1883, 
Her  Majesty  the  Queen  conferred  upon  him  the  dignity 
of  a  baronet  'Mn  recognition  of  his  services  to  medical 
science  and  to  humanity." 

Sir  Spencer  took  great  interest  in  public  questions, 
and  was,  when  in  his  prime,  always  attracted  by  move- 


58  ANNUAL    ADDRESS. 

ments  of  progress.  He  was  a  most  genial  companion, 
and  an  excellent  host. 

Wlien  travelling  in  India  about  four  years  ago  lie  was 
attacked  witli  influenza,  and  paralytic  symptoms,  chiefly 
affecting  the  speech,  slowly  developed.  But  almost  to 
the  last  he  was  to  be  seen  at  the  principal  gatherings  of 
the  medical  profession.  Two  months  before  his  death  he 
went  with  two  of  his  daughters  to  the  south  of  France. 
On  the  morning  of  Sunday,  January  31st,  1897,  he  was 
seized  with  apoplexy  whilst  staying  at  Cap  d^Antibes,  near 
Cannes.  He  died  the  same  evening,  just  within  three 
days  of  his  seventy-ninth  birthday. 

More  fortunate  than  many  pioneers,  he  lived  to  see  his 
principal  life-work  crowned  with  the  most  abundant 
success.  He  lived  also  to  see  his  claim  to  recognition  as 
a  great  surgical  benefactor  acknowledged  throughout  the 
world. 

I  now  pass  on  to  speak  of  the  other  deceased  Fellows, 
taking  them  as  far  as  possible  in  the  order  in  which  the 
deaths  occurred. 

Thomas  Edward  Parsons 

was  a  popular  and  successful  general  practitioner  at 
Wimbledon,  where  he  joined  his  brother  in  partnership 
twenty-five  years  ago.  He  had  studied  medicine  at  St. 
Mary's  Hospital,  and  had  become  qualified  in  1869.  He 
was  a  laborious  worker  at  his  profession,  and  exemplary 
in  all  his  domestic  relations.  The  extra  work  entailed  by 
the  severe  epidemic  of  influenza  which  visited  Wimbledon 
some  three  winters  ago  made  serious  inroads  upon  his 
health,  and  for  many  months  before  his  death  he  was 
known  to  be  suffering  from  diabetes.  He  took  a  long 
holiday  abroad  in  the  summer  of  1896,  and  returned  to 
work  feeling  considerably  better.  But  the  anxieties  and 
fatigues  of  practice  soon  told  upon  him  prejudicially,  and 
at  Christmas  he  again  left  home  for  a  six  weeks'  sojourn 


ANNUAL    ADDEESS.  59 

at  Mentone.  Tlie  regard  in  wliicli  lie  was  held  by  his 
friends  and  patients  was  shown  by  their  sending  him 
whilst  abroad  a  letter  of  sympathy  along  with  a  purse 
containing  a  hundred  sovereigns.  He  wrote  home  cheer- 
fully and  expressed  himself  as  feeling  much  better,  but 
when  he  returned  to  Wimbledon  at  the  beginning  of 
March,  1897,  it  was  only  too  evident  that  he  was  in  a  very 
serious  condition.  It  was  his  earnest  desire  to  die  in 
harness,  and  this  wish  was  gratified,  for  when  he  died, 
peacefully  as  though  he  Avere  falling  asleep,  on  the  17th 
of  March,  he  had  only  been  confined  to  bed  for  twenty- 
four  hours.  He  was  attended  professionally  by  Dr. 
Mitchell  Bruce  and  Sir  Wm.  Broadbent.  His  Fellowship 
of  the  Society  dated  from  1889.  At  the  time  of  his 
death  he  had  just  completed  his  fifty-first  year. 

William  Gtaedner 

became  a  Fellow  of  our  Society  in  1892.  He  graduated 
at  Glasgow  in  1874,  and  took  his  degree  of  M.D.  in  J876. 
For  many  years  he  was  recognised  as  the  leading  surgeon  in 
Adelaide,  South  Australia,  and  more  recently  had  held  a 
distinguished  position  as  a  surgeon  in  Melbourne.  At 
the  recent  Intercolonial  Medical  Congress  held  in  Sydney, 
Dr.  Gardner  presided  over  the  surgical  section.  He  was 
joint  founder  with  Dr.  D.  Grant  of  the  '  Intercolonial 
Medical  Journal,'  and  had  made  a  distinct  mark  in  the 
annals  of  Australian  surgery  by  his  contributions  on  the 
subject  of  the  surgical  treatment  of  hydatids.  He  was 
returning  home  after  a  visit  to  Europe,  undertaken  for  the 
benefit  of  his  health,  when  he  died  suddenly  of  paralysis 
at  Naples,  at  the  age  of  fifty,  on  the  1st  of  April,  1897. 

Keginald  Clarke 

was  the  son  of  a  well-known  London  architect  and  writer. 
He  was  educated  at  Uppingham,  and  afterwards  entered 
as    a    student    at    the   medical    school   at   King's    College 


60  ANNUAL    ADDRESS. 

Hospital^  where  lie  held  the  appointment  of  resident 
accoucheur.  He  became  a  Licentiate  of  the  Society  of 
Apothecaries  in  1876,  and  received  the  diploma  of  mem- 
bership of  the  Royal  College  of  Surgeons  in  1878.  He 
succeeded  to  the  practice  of  Mr.  Chittenden^  of  Lee^,  where 
he  carried  on  his  profession  up  to  the  time  of  his  death. 
He  was  surgeon  and  anaesthetist  to  St.  John's  Hospital^ 
Lewisham.  Being  an  old  King^s  man  he  had  known  as  a 
student  the  Nursing  Sisters  of  St.  John  the  Divine,  and 
when  in  1883  this  community  established  the  LcAvisham 
Hospital  he  renewed  his  friendship  with  them,  and  ren- 
dered them  great  assistance,  remaining  their  staunch  friend 
to  the  end  of  his  life.  He  was  also  divisional  surgeon  to 
the  police  and  district  surgeon  to  the  post  office.  His 
kind  and  genial  disposition  rendered  him  popular  both 
with  his  patients  and  his  fellow-practitioners.  He  was 
generally  known  as  Mr.  Pickwick,  from  an  absurd  likeness 
to  that  eminent  character  as  delineated  in  the  well-known 
illustrations.  He  took  a  great  interest  in  rare  and  diffi- 
cult cases,  and  was  in  the  habit  of  trying  all  the  new 
remedies  that  he  read  about.  He  rarely  prescribed 
according  to  the  Pharmacopoeia.  He  was  a  great  lover 
of  dogs  and  horses.  He  took  a  house  at  Bexhill,  and 
lived  there  a  good  deal  during  his  later  years.  He  had 
already  been  himself  for  some  months  in  failing  health 
when  the  death  of  his  wife,  under  somewhat  painful  cir- 
cumstances, seemed  to  give  him  a  great  shock,  and  to 
deprive  him  of  all  self-control.  He  died  soon  after  her, 
rather  suddenly,  at  the  age  of  fifty  or  thereabouts,  on 
August  19th,  1897.  He  had  been  a  Fellow  of  our  Society 
for  seventeen  years. 

John  Scott 

had  been  a  Fellow  of  the  Society  since  1870.  He  was 
born  at  Annan,  in  Dumfriesshire,  in  1881,  and  at  the  time 
of  his  death  on  November  2nd,  1897,  had  been  in  practice 
at  Sandwich,  in  Kent,  for  thirty-three  years.    His  work  lay 


ANNUAL    ADDRESS.  61 

chiefly  amongst  the  poorer  classes^  by  whom  he  was  held 
in  great  repute.  He  had  at  one  time  a  very  large  practice, 
and  was  to  the  end  exceedingly  popular. 


Henry  Wm.  Freeman 

was  a  man  of  strong  individuality,  and  was  widely  known. 
In  medical  circles  he  was  almost  invariably  alluded  to  as 
Freeman  of  Bath,  and  not  without  reason,  for  no  man  had 
more  thoroughly  identified  himself  Avith  the  interests  of 
the  town  in  Avhich  he  practised,  or  had  laboured  harder 
to  restore  to  Bath  something-  of  its  old  attractiveness, 
prestige,  and  popularity. 

Born  at  Westward  Ho,  in  Devonshire,  in  the  year  1842, 
he  received  his  education  at  the  Bideford  Grammar  School, 
and  afterwards  entered  as  a  medical  student  at  the  Middle- 
sex Hospital,  where  he  took  several  prizes,  and  held  more 
than  one  resident  appointment.      He  became  qualified  in 
1864,    and    in    the    same    year    was    appointed    resident 
medical  officer  to  the  Royal  United  Hospital,  Bath.      He 
soon    afterwards    commenced    practice    in    Bath,    and    at 
length,  in  1881,  was  appointed  one  of  the  honorary  sur- 
geons to  the  hospital.      In  1882  he  received  the  diploma 
of   Fellow  of   the  Royal  College  of   Surgeons  of  Ireland. 
Wlien  the  new  Queen's  Baths  were  opened  by  the  Duchess 
of  Albany  in  1888,  Mr.  Freeman,  who  was  made  Mayor  of 
Bath  that  year,  presented  a  beautiful  statue,  representing 
^^  The  Angel  at  the  Pool.''    This  has  been  placed  over  the 
fountain  in  the  pump-room.      Mr.  Freeman  was  very  fond 
of  horses,  and  was  the  owner  of  an  extensive  thoroughbred 
stud   at   Weston.      For   some   time    his    health    had   been 
failing,  but  his  fatal  illness  dated  from  or  soon  after  the 
opening  of  the  new  pump-room  in  October.      He  died  at 
his  residence  in  Bath,  November  28th,  1897,  at  the  age  of 
fifty-five  years.      He   had  been  a  Fellow  of  this  Society 
since  1867,  and  was  a  member  of  its  Council  from  1891 
to  1893. 


62  ANNUAL    ADDRESS. 

Our  list  of  honorary  Fellows  lias  never  been  a  long 
one.  It  contained  at  the  time  of  the  last  annual  meeting 
only  eleven  names,  and  that  number  has  now  been  reduced 
to  eighty  owing  to  the  deaths  of  Dr.  Lusk^  of  New  York, 
Dr.  Braxton  Hicks,  of  this  city,  and  Professor  Tarnier^  of 
Paris,  of  each  of  whom  it  now  becomes  my  duty  to  give  a 
more  or  less  detailed  account. 

William  Thompson  Lusk 

was  born  in  Demerara,  British  Gruiana,  on  May  23rd_,  1838. 
Most  of  his  early  life  was  passed  in  Norwich,  Connecticut, 
whither  his  family  removed.  In  1855  he  entered  as  a 
freshman  at  Yale  University _,  but  left  college  on  the  com- 
pletion of  his  first  year.  For  three  years  he  studied 
medicine  at  Heidelberg  and  at  Berlin.  In  1861,  while 
still  a  medical  student,  the  outbreak  of  the  War  of  the 
Rebellion  fired  him  with  military  ardour,  and  he  enlisted 
as  a  private  in  a  regiment  of  Noav  York  volunteers. 
Within  two  years  he  rose  to  the  rank  of  lieutenant. 
Shortly  afterwards  he  was  made  a  captain,  and  finally 
was  appointed  assistant  adjutant-general.  As  a  soldier 
he  is  said  to  have  been  distinguished  by  his  coolness  and 
his  valour.  In  1864,  after  a  service  of  three  years  in  the 
Federal  army,  he  took  his  degree  in  medicine  from  the 
Bellevue  Hospital  Medical  College  in  New  York.  After 
his  graduation  he  again  visited  Europe  for  further  study, 
and  spent  the  years  between  1864  and  1868  in  the  hos- 
pitals of  Edinburgh,  Paris,  Prague,  and  Vienna.  On  his 
return  to  the  United  States  he  was  appointed  professor  of 
physiology  in  the  Long  Island  College  Hospital,  and  con- 
tinued to  occupy  that  chair  until  1871.  During  the  last 
year  of  that  professorship  he  was  also  lecturer  on  phy- 
siology in  the  Harvard  Medical  School.  In  1871  he 
became  professor  of  obstetrics,  diseases  of  women,  dis- 
eases of  infants,  and  clinical  midwifery  in  the  Bellevue 
Hospital  Medical  College.  This  chair  he  continued  to  hold 
to  the  time  of  his  death.      In  1890  he  succeeded  the  late 


ANNUAL    ADDRESS.  63 

Dr.  Isaac  E.  Taylor  as  president  of  the  College.  He  was 
consulting  surgeon  to  the  Maternity  Hospital,  the  Skin 
and  Cancer  Hospital,  and  the  New  York  Foundling 
Asylum.  He  was  one  of  the  founders  of  the  American 
Grynecological  Society,  and  was  its  president  on  the  occa- 
sion of  its  meeting  in  Washington  in  1894.  He  was  also 
at  one  time  president  of  the  New  York  State  Medical 
Association,  and  of  the  New  York  Obstetrical  Society. 

As  a  teacher  he  is  said  to  have  had  few  equals,  espe- 
cially in  the  art  and  science  of  obstetrics,  of  which  he  was 
indeed  a  master. 

For  two  years  and  a  half  (July,  1871,  to  December, 
1873)  he  was  editor  of  the  '  New  York  Medical  Journal.^ 
It  was  the  publication  in  1881  of  his  excellent  text-book, 
^  The  Science  and  Art  of  Midwifery,^  that  first  brought 
his  name  prominently  before  the  profession  of  this  country. 
That  work  at  once  established  the  author^s  fame  not  only 
in  his  own  country  and  this,  but  in  all  the  countries  of 
Europe.  It  quickly  passed  through  a  number  of  editions, 
and  was  translated  into  French,  Italian,  and  Spanish. 
It  was  the  best  exposition  of  the  obstetric  science  and 
practice  of  the  day  that  had  yet  appeared.  It  was  emi- 
nently readable  Avithout  being  too  diffuse,  displayed  an 
intimate  acquaintance  with  the  literature  of  obstetrics, 
and  was  enriched  with  copious  and  valuable  references. 
It  was  studiously  moderate  and  conservative  in  its  general 
tone.  The  rules  of  treatment  it  laid  down  were  sound, 
avoiding  on  the  one  hand  too  great  an  eagerness  to  inter- 
fere, and  on  the  other  too  absolute  a  reliance  on  the 
unassisted  powers  of  nature.  The  chapters  on  puerperal 
fever  were  at  the  time  the  best  in  the  language,  and 
contained  an  account  of  the  most  recent  researches  on 
the  subject,  with  a  thoroughly  scientific  discussion  of  the 
nature  of  the  disease,  its  pathological  anatomy,  its  clinical 
manifestations,  its  causes,  and  its  treatment.  Several  of 
the  foremost  teachers  of  midwifery  in  this  country  at 
once  adopted  Dr.  Lusk's  treatise,  and  recommended  it  to 
their  pupils  as  their  text-book.      Dr.  Lusk's  contributions 


64  ANNUAL    ADDRESS. 

to  tlie  Transactions  of  the  societies  and  tlie  current 
medical  literature  were  marked  by  the  scientific  spirit 
and  sobriety  of  judgment  that  characterised  his  book. 
Though  he  never  attained  as  a  gynaecologist  to  the  same 
eminence  that  he  had  achieved  as  an  obstetrician_,  his 
judicious  teaching  did  much  to  check  the  tendency  to 
indiscriminate  operating  which  at  one  time  was  in  danger 
of  discrediting  operative  gyngecology.  He  welcomed 
progress^  but  with  a  distinct  leaning  towards  a  wholesome 
conservatism. 

"  He  was  a  man/'  writes  Dr.  Polk^  "  of  singularl}^ 
pure  character.  His  unselfishness  naturally  brought 
about  him  many  friends  .  .  .  and  the  attitude  of 
the  profession  of  New  York  and  of  America  toward  him 
was  that  of  confidence  and  esteem.^'  He  possessed  a 
diffident,  unassuming,  and  yet  fascinating  manner,  and  in 
the  midst  of  his  busy  life  and  grave  responsibilities  always 
found  time  to  be  courteous  to  strangers  and  genial  in  the 
company  of  his  friends.  He  retained  his  youthful  figure 
and  appearance  in  a  most  remarkable  degree.  Endowed 
with  "  an  abounding  vitality ''  and  a  spare  build,  he 
seemed  the  unlikelist  person  in  the  world  to  be  struck 
down  prematurely  by  an  attack  of  apoplexy.  Though 
still  to  all  appearance  in  perfect  health,  he  had  betrayed 
for  some  months  an  increasing  nervousness  and  irrita- 
bility of  manner  that  had  given  warning  to  his  more 
intimate  friends  of  failing  powers.  And  so  when  the  end 
came,  on  June  12th,  1897,  it  was  perhaps  less  of  a  sur- 
prise to  them  than  it  was  to  the  public.  But  to  all  it  was 
a  severe  shock  to  learn  that  the  melodious  voice  of  this 
useful  and  gifted  man  had  been  heard  for  the  last  time. 
Dr.  Lusk  died  in  the  fifty-ninth  year  of  his  age.  His 
eldest  son.  Dr.  William  Chittenden  Lusk,  though  still 
quite  young,  is  chief  of  the  surgical  clinic  at  the  Bellevue 
Medical  School. 


ANNUAL   ADDRESS.  65 


John  Beaxton   Hicks. 

In  endeavouring  to  give  an  adequate  account  of  the 
life  and  work  of  Dr.  Braxton  Hicks  in  the  short  time  at 
my  disposal,  I  feel  I  have  before  me  a  difficult  task.  He 
was  one  of  the  founders,  and  for  many  years  one  of  the 
most  active  supporters  of  our  Society,  a  past  President, 
a  recently  elected  Honorary  Fellow,  and  a  contributor  of 
no  fewer  than  forty  papers  to  its  ^  Transactions ; '  on 
these  grounds  alone  it  would  be  fitting*  that  the  annual 
address  should  contain  as  full  an  account  as  possible  of 
his  personality  and  his  career.  But  when  it  is  also 
remembered  that  the  science  and  art  of  obstetric  medicine 
owe  to  him  several  of  the  most  important  advances  of 
recent  years,  and  that  his  name  has  taken  a  permanent 
place  amongst  those  of  the  most  distinguished  British 
obstetricians,  there  is  still  more  abundant  reason  why 
our  records  should  contain  a  more  than  usually  full 
appreciation  of  the  man  himself  as  well  as  of  the  work  of 
his  life. 

John  Braxton  Hicks  was  born  at  Rye,  in  Sussex,  in  the 
year  1823.  He  was  the  second  son  of  Mr.  Edward  Hicks, 
of  Lymington,  who  was  at  one  time  a  banker,  and  for 
many  years  held  the  position  of  chairman  of  the  bench  of 
county  magistrates.  From  the  age  of  twelve  to  fifteen 
Braxton  Hicks  was  educated  as  a  private  pupil  of  the 
Rev.  J.  0.  Zillwood,  of  Compton  Rectory,  near  Winchester. 
He  became  apprenticed  to  a  medical  practitioner  in 
the  town  where  he  lived  in  1842,  and  at  the  age  of 
eighteen  he  entered  as  a  medical  student  at  Guy^s  Hos- 
pital. He  was  a  favourite  both  amongst  his  teachers  and 
his  fellow-students.  "  I  shall  never  forget,"  writes  an 
old  fellow-student,  Dr.  Daniel  Hooper,  ^^  his  amiable, 
cheerful  expression,  bright,  piercing  eyes  and  noble  fore- 
head ;  his  alacrity  was  remarkable  ;  he  was  always  busy — 
I  never  saw  him  idle  for  one  moment — he  would  hurry 

VOL.  XL.  5 


66  ANNUAL    ADDRESS. 

with  a  very  quick  step  to  tlie  lecture  theatre,  literally  run 
down  the  steps  (a  huge  volume  of  Pereira,  perhaps,  under 
his  arm)  to  the  bottom  bench,  and  there  sit  motionless  and 
attentive  till  the  lecture  was  over.'^  He  took  first  prizes 
in  anatomy,  materia  medica,  practical  chemistry  and 
botany,  and  he  also  won  a  medal  for  double  sculling  given 
by  the  hospital  boat  club.  He  was  very  fond  of  botany^ 
and  in  the  summer  vacation  collected  specimens  from  the 
New  Forest.  In  1844  he  passed  the  first  examination  for 
the  degree  of  Bachelor  of  Medicine  at  the  London  Uni- 
versity, taking  honours  in  every  subject,  and  carrying  off 
the  exhibition  and  gold  medal  in  materia  medica.  In 
1847  he  passed  the  final  M.B.  examination,  obtaining 
honours  in  physiology  and  comparative  anatomy,  medi- 
cine, and  surgery.  He  soon  afterwards  received  the 
diplomas  of  the  Royal  College  of  Surgeons  and  the 
Apothecaries^  Society,  and  in  1851  took  the  degree  of 
M.D.  at  his  university.  Wishing  to  marry  and  to  settle 
in  practice,  he  entered  into  partnership  with  the  late 
Mr.  W.  Moon,  of  Tottenham,  and  became  a  highly 
respected  general  practitioner.  But  in  1859  he  was 
invited  by  his  old  hospital  to  accept  the  post  of  assistant 
obstetric  physician,  whereupon  he  relinquished  general 
practice  and  came  to  reside  in  the  Borough. 

In  the  same  year  he  passed  the  examination  for  the 
membership  of  the  Royal  College  of  Physicians,  of  which 
he  was  elected  a  Fellow  in  1866. 

In  1870  he  was  appointed  senior  obstetric  physician  to 
Guy^s  Hospital,  and  lecturer  on  obstetrics  at  the  school. 
These  appointments  he  continued  to  hold  until  1883, 
when  he  was  elected  consulting  obstetric  physician. 
Feeling  that  the  age  limit  at  his  own  hospital  had  cut 
short  his  career  as  a  teacher  somewhat  prematurely,  he 
acceded  in  1888  to  a  request  to  become  obstetric 
physician  to  St.  Mary's  Hospital  in  succession  to 
the  late  Dr.  Meadows,  the  then  assistant  obstetric 
physician  being  considered  at  the  time  a  little  too 
young    for    the    full    responsibility    of    the    senior    post. 


ANNUAL    ADDEESS.  67 

This  appointment  Dr.  Hicks  held  for  several  years, 
doing  his  hospital  work  conscientiously  and  taking  a 
share  of  the  systematic  teaching  in  the  school.  But  he 
never  forgot  that  he  was  a  Guy^s  man,  and  that  his  early 
successes  and  interests  were  connected  mth  that  hospital. 
He  was  for  several  years  examiner  in  obstetric  medicine 
at  the  Universit}''  of  London,  and  held  a  similar  position 
at  the  Eoyal  College  of  Physicians  from  1872  to  1878,  and 
again  from  1889  to  1893.  For  many  years  Dr.  Braxton 
Hicks  was  physician  to  the  Royal  Maternity  Charity,  and 
he  was  also  for  a  time  physician  to  the  Royal  Hospital  for 
Women  and  Children  in  Waterloo  Road. 

Dr.  Braxton  Hicks  was  all  his  life  a  devoted  student  of 
natural  science,  and  many  contributions  from  his  pen 
appear  in  the  ^  Proceedings  of  the  Royal  Society,^  in  the 
'  Transactions  of  the  Linnean  Society,'  and  in  the  ^  Journal 
of  Microscopical  Science.'  On  the  5tli  of  June,  1862,  he 
was  elected  a  Fellow  of  the  Royal  Society.  I  have  been 
favoured  by  the  clerk  of  that  Society  with  a  copy  of  his 
nomination  jDaper,  which  I  here  reproduce  not  only  on 
account  of  the  interest  attaching  to  the  names  of  his  pro- 
posers, but  as  showing  the  precise  grounds  on  Avhich  that 
great  distinction  was  conferred  upon  him.  He  is  de- 
scribed as  residing  at  No.  6,  Wellington  Street,  London 
Bridge,  and  as  being  the  author  of  the  following  scientific 
papers  : 

^^  On  Certain  Sensory  Organs  in  Insects  hitherto  un- 
described,''  read  before  the  Royal  Society,  and  published 
in  abstract  in  the  '  Proceedings  '  May  26th,  1859. 

"  On  New  Organs  of  the  Antennae  of  Insects,"  and 
'^  On  Organs  on  Nervures  of   Wings,''  two  papers  in  the 

*  Transactions  of  the  Linnean  Society.' 

'^  On  New  Organs  on  the  Halteres  of  Diptera,"  in  the 

*  Proceedings  of  the  Linnean  Society.' 

''On    a .  New     Species  of    Draparnaldia "    and    ''On 

Amoeboid  Conditions  of  Volvox  globator/'  '  Microscop. 
Journ.,'  April,  1860. 

"  On  the   Development  of   the  Gonidia  of   Lichens  in 


68  ANNUAL    ADDRESS. 

Eelation  to  Unicellular  Alg^/'  '  Microscop.  Journ./  Oct., 
1860. 

'^  New  Sensory  Organs  in  Insects/^  in  the  ^  Linnean 
Society's  Transactions/  1860. 

"  On  the  Homologies  of  the  Eye  and  its  Parts  in  In- 
vertebrata/'  read  before  the  Royal  Society,  Januar}^,  1861. 

He  is  lastly  spoken  of  as  part  author  of  a  little  work 
published  by  Yan  Voorst,  and  entitled  '  Humble  Creatures 
[the  Earth  worm  and  House-fly] ." 

The  following  names  of  Fellows  of  the  Society  are 
attached  to  the  document : — W.  B.  Carpenter,  J.  Lub- 
bock, G.  Busk,  E.  Lankester,  F.  Currey,  J.  J.  Bennett,. 
J.  Hilton,  A.  S.  Taylor,  T.  Bell,  C.  Ansell,  and  E.  W. 
Brayley. 

It  will  thus  be  seen  that  it  was  mainly  his  contributions 
to  entomology  and  botany  that  obtained  for  him  the 
coveted  blue  ribbon  of  science.  His  interest  in  these 
studies  continued  to  the  end  of  his  life,  and  many  other 
papers  relating  to  them  appeared  from  time  to  time  in 
the  journals  and  transactions  to  which  they  were  specially 
appropriate.  To  us,  however,  his  work  in  connection 
with  our  own  Society  and  the  science  of  obstetrics  must 
necessarily  have  the  chief  interest,  and  of  this  I  must  now 
speak.  He  was  one  of  the  founders  of  the  Obstetrical 
Society  of  London,  and  took  an  active  interest  in  it  from 
the  first.  He  twice  served  on  the  Council,  namely,  in 
1861  and  1862,  and  again  in  1869.  He  held  the  office  of 
Hon.  Secretary  from  1863  to  1865,  was  Vice-President 
from  1866  to  1868,  became  Treasurer  in  1870,  occupied 
the  presidential  chair  during  the  years  1871  and  1872, 
and  was  elected  an  Honorary  Fellow  in  1896.  To  the 
'  Transactions  '  of  the  Society  he  contributed,  as  I  have 
already  said,  no  fewer  than  forty  papers.  He  was  a 
close  and  accurate  clinical  observer,  and  many  of  his 
])apers  which  record  single  cases  or  groups  of  cases  are 
models  of  what  such  contributions  should  be.  To  these 
I  shall  not  have  time  further  to  refer  ;  their  titles  will  be 
found  in  the  bibliography  appended  to  this  address.      But 


ANNUAL    ADDRESS.  69 

of  some  of  liis  more  important  papers  I  must  speak  a  little 
more  at  length. 

In  the  month  of  July^  1860^  there  appeared  a  paper  in 
the  '  Lancet  ^  on  '^  A  New  Method  of  Version  in  Abnor- 
mal Labour/^  in  which  were  described  "  five  cases  of 
placenta  prasvia  in  illustration  of  its  peculiar  applicability 
to  that  formidable  complication  of  labour.^ ^  In  the  same 
journal  for  February  9th,  1861,  cases  were  given  ot  other 
forms  of  labour  to  which  the  new  method  had  been  suc- 
cessfully applied.  It  was  by  these  papers  that  Dr. 
Braxton  Hicks  first  brought  before  the  profession  his  now 
celebrated  method  of  version  by  combined  external  and 
internal  manipulation.  He  chose  that  mode  of  communi- 
cating the  method  to  the  profession,  in  preference  to 
laying  it  at  once  before  a  society,  because  he  considered 
that  the  subject  was  too  new  for  its  merits  to  be  then 
discussed  "with  satisfactory  results.  When,  however,  he 
had  had  more  experience  of  the  method,  and  had  tested 
and  proved  its  value,  he  made  it  the  subject  of  a  paper 
which  was  read  before  this  Society  in  November,  1863. 
In  the  following  year  the  paper  reappeared  in  a  revised 
form  as  a  thin  octavo  volume  of  72  pages,  published  by 
Longmans  and  Co.,  with  the  title  "  On  Combined  External 
and  Internal  Version,"  Up  to  within  a  very  few  years 
of  this  period  the  operation  of  turning,  whether  the 
object  was  to  bring  down  the  head,  breech,  knee,  or  foot, 
had  involved  the  introduction  of  the  whole  hand  into  the 
uterus.  Cephalic  version  was  very  seldom  adopted  on 
account  of  the  difficulty  of  grasping  the  head  and  retain- 
ing it  at  the  os  uteri ;  whilst  in  regard  to  the  other  forms 
of  version,  foot-turning  had  almost  entirely  taken  the 
place  of  the  older  method  of  breech-turning.  All  these 
methods,  however,  required  the  introduction  of  the  whole 
hand,  and  generally  part  of  the  arm,  within  the  uterus,  a 
process  which  added  materially  to  the  painfulness  and 
difficulty  of  the  case,  not  to  mention  the  valuable  time 
often  lost  whilst  waiting  until  the  os  and  cervix  had 
become  sufficiently  dilated   for  the    operation   to   be  per- 


70  ANNUAL    ADDRESS. 

formed.  In  a  few  cases  men  like  Collins^  of  Dublin^  and 
Dr.  Robert  Lee,  of  St.  G-eorge^s,  had  occasionally  short- 
ened this  period  of  delay  by  pushing  the  child  round  with 
the  finger_,  but  the  practice  was  only  now  and  then  suc- 
cessful. Dr.  Robert  Lee  had  also  pointed  out  that  in 
some  cases  of  transverse  presentation  it  was  unnecessary 
to  pass  more  than  two  fingers  into  the  os  uteri  in  order 
to  seize  the  knee,  a  plan  which  he  named  "  two-finger 
turning."  Meanwhile  several  Grerman  observers  had 
demonstrated  the  possibility  of  turning  the  child  m  utero 
from  the  outside.  Braxton  Hicks  showed  how,  by  the 
combination  of  these  two  methods,  each  acting  upon  oppo- 
site ends  of  the  foetus,  there  was  obtainable  a  certainty 
and  a  celerity  of  which  neither  plan  was  capable  when 
employed  alone. 

Li  the  discussion  which  followed  Dr.  Hicks^s  paper  at 
this  Society,  Dr.  Robert  Barnes  stated  that  an  admirable 
memoir,  in  which  the  principle  of  turning  by  external  and 
internal  manipulations  was  fully  described,  had  been 
published  by  Wigand  in  1807.  Not  having  any  know- 
ledge of  A¥igand\s  paper,  Dr.  Hicks  was  unable  at  the 
time  to  call  this  statement  in  question,  but  before  the 
paper  and  discussion  Avere  printed  he  acquainted  himself 
with  the  precise  purport  of  Wigand\s  essay,  and  em- 
bodied the  result  in  an  appendix.  He  bore  generous 
testimon}^  to  the  value  of  Wigand^s  suggestions,  but  he 
showed  that  they  were  by  no  means  identical  with  his 
own.  "Wigand  had  discovered  that  pressure  upon  the 
exterior  would  make  the  foetus  move  to  a  considerable 
extent,  and  that  by  pressing  on  both  poles  of  the  child  in 
opposite  directions,  he  could  bring  that  end  which  was 
nearest  into  the  os  uteri,  but  he  only  employed  the  inner 
hand  to  guide  and  receive  the  head  or  breech  into  the 
OS.  The  difference  is  important,  for  while,  by  his  method, 
Wigand  was  merely  able  to  rectify  abnormal  presentations, 
the  adoption  of  Hicks' s  plan  enabled  the  operator  to 
accomplish  version  in  any  manner,  whether  partial  or 
complete,    podalic   or   cephalic.       Wigand  never   contem- 


ANNUAL    ADDRESS.  71 

plated  complete  version,  and  lie  expressly  mentioned  that 
his  method  was  not  applicable  to  cases  of  haemorrhage,  or 
of  prolapse  of  the  funis,  or  of  convulsions  ;  in  other  words, 
the  most  important  cases  requiring  version  could  not  be 
treated  by  the  method  he  suggested.  The  plan  described 
by  Hicks,  on  the  contrary,  combined  the  power  of  recti- 
fying abnormal  presentations  with  that  of  performing 
complete  version.  It  differed  from  all  previous  methods 
in  enabling  the  operator  to  produce  cephalic  or  podalic 
version  at  will,  and  in  being  capable  of  application  as 
soon  as  the  os  uteri  was  sufficiently  dilated  to  admit  one 
or  two  fingers.  The  advantages  thus  gained  are  obvious. 
It  permits  early  intervention  in  such  cases  as  neck, 
shoulder,  and  transverse  presentations ;  it  furnishes  a 
new  and  safe  resource  in  cases  of  convulsions  in  which 
the  introduction  of  the  hand  is  attended  with  much  risk, 
and  in  which  speedy  delivery  is  desirable  ;  it  dimi- 
nishes the  dangers  of  turning  in  those  cases  of  contracted 
pelvis  in  which  turning  is  the  most  appropriate  treatment ; 
and  it  removes  from  the  operation  the  risk  of  producing* 
fatal  shock  when  it  is  necessary  to  turn  the  child  under 
circumstances  of  extreme  depression  on  the  part  of  the 
mother.  But  it  is  especially  in  the  treatment  of  placenta 
praevia  that  it  has  proved  of  the  greatest  service,  both  in 
saving  life  and  in  diminishing  professional  anxiety.  When, 
summoned  to  a  case  of  severe  haemorrhage  from  this 
cause,  the  medical  attendant  found  the  cervix  only  suffi- 
ciently expanded  to  admit  one  or  two  fingers,  he  had 
hitherto  been  compelled  to  wait  for  hours  whilst  en- 
deavouring to  dilate  the  os,  or  to  content  himself  with 
plugging  the  vagina  and  endeavouring  to  press  the  head 
on  to  the  placenta  by  exerting  pressure  on  the  fundus 
uteri.  "Anything,"  to  use  Dr.  Hicks^s  own  forcible 
words,  "  which  gave  the  practitioner  some  power  of 
action  was  to  be  earnestly  welcomed ;  anything  better 
than  to  stand  with  folded  arms,  incapable  of  rendering 
assistance  for  hours  and  even  days,  every  moment  of 
which  might  be  carrying  the  sinking  and  suffering  patient 


72  ANNUAL    ADDRESS. 

nearer  to  the  grave /^  By  tlie  new  method^  not  only 
would  bleeding  be  arrested,  but  time  could  be  saved  to 
an  extent  of  which  the  value  can  scarcely  be  over-esti- 
mated. As  soon  as  the  os  uteri  would  admit  two  fingers, 
version  could  be  performed  and  the  os  effectually  plugged 
by  drawing  through  it  the  foot  and  leg,  and  exerting 
such  gentle  traction  as  the  mere  weight  of  the  operator's 
arm,  in  retaining  hold  of  the  limb,  is  sufficient  to  supply. 
Henceforth  the  case  could  be  watched  with  as  little 
anxiety  as  an  ordinary  case  of  breech  presentation. 
Rapid  extraction  is  not  only  unnecessary,  but,  as  favour- 
ing post-partum  hasmorrhage,  extremely  dangerous.  Dr. 
Hicks  was  very  emphatic  on  this  point.  "  What  is  the 
use,"  he  says,  "  of  hastily  delivering  before  the  os  is  well 
dilated  and  before  the  system  has  time  to  rally  from  the 
effects  of  flooding  and  of  the  version  ?  Many  of  the 
deaths  following  placenta  praevia  may,  I  believe,  be  fairly 
attributed  to  too  rapid  delivery.  How  much  must  the 
collapse  be  increased  and  the  uterus  injured  by  endeavour- 
ing to  drag  the  head  through  the  yet  rigid  os  !  Turn,  and 
if  you  employ  the  child  as  a  plug,  the  danger  is  over. 
Then  wait  for  the  pains,  rally  the  powers  in  the  interval, 
and  let  nature,  gently  assisted,  complete  the  delivery." 

Dr.  Hicks  had  to  wait  many  years  before  he  had  the 
satisfaction  of  finding  his  suggestions  adopted.  In  spite 
of  his  fecundity  as  a  writer,  the  advertising  instinct  was 
wanting  in  him.  Had  it  been  otherwise,  he  would  have 
been  long  ago  recognised  by  all  the  obstetricians  of  the 
civilised  world  as  one  of  the  greatest  benefactors  of 
lying-in  women  that  this  age  has  produced.  When,  after 
the  lapse  of  time,  obstetricians  did  awake  to  the  value  of 
his  work,  the  mortality  from  placenta  praevia  at  once  fell 
from  30  per  cent,  to  something  near  5  per  cent. 

In  the  year  1867  Dr.  Braxton  Hicks  made  a  still  more 
valuable  contribution  to  the  literature  of  obstetrics  ;  I 
refer  to  his  paper  "  On  the  Condition  of  the  Uterus  in 
Obstructed  Labour,"  probably  one  of  the  most  admirable 
communications   that  has  ever  appeared  in  our  ^  Transac- 


ANNUAL    ADDRESS.  73 

tions/  The  greatest  confusion  and  ambiguity  had  hitherto 
existed  as  to  the  precise  meaning  of  the  terms  "  cessa- 
tion of  the  pains/^  "  powerless  labour/'  and  '^  exhaustion/' 
and  the  interpretation  and  significance  of  the  train  of 
symptoms  which  these  terms  were  used  to  denote. 

There  were  but  two  British  writers  on  obstetrics  who^ 
up  to  that  time,  appear  to  have  observed  the  real  condi- 
tion of  the  patient  in  obstructed  labour,  viz.  Dr.  Murphy 
and  Dr.  Rigby.  These  authors  had  noticed  that,  when 
any  obstacle  prevents  the  exit  of  the  foetus,  the  pains 
after  being  suspended  for  a  time  returned  with  a  totally 
different  character ;  they  became  short  and  extremely 
severe,  and  never  entirely  passed  off  in  the  intervals. 
These  writers  had  further  noticed  that  if  the  hand  was 
placed  on  the  abdomen  the  uterus  was  felt  to  be  as  hard 
and  contracted  during  an  interval  as  during  a  pain,  and 
so  sensitive  that  the  patient  could  scarcely  bear  to  be 
touched.  In  other  words,  they  had  observed  that  a  state 
of  continuous  action  was  substituted  for  the  rhythmical 
pains.  This  condition  they  attributed  to  inflammation 
consequent  upon  the  injury  done  to  the  soft  parts.  Dr. 
Hicks  was  the  first  to  appreciate  the  importance  of  this 
observation,  but  he  did  not  accept  Murphy  and  Eigby's 
explanation.  He  pointed  out  that  even  in  a  normal  labour 
the  demand  made  on  the  nervous  force  bv  the  action  of  the 
uterus,  the  largest  involuntary  muscle  in  the  body,  is  so 
enormous  that,  if  it  Avere  not  for  the  replenishing  that 
takes  place  during  the  intervals,  the  constitutional  effects 
would  be  disastrous.  He  showed  that,  if  from  any  cause 
the  length  of  the  ordinary  intermissions  was  curtailed,  the 
powei's  of  the  system  would  soon  undergo  a  serious  drain ; 
and  that,  if  matters  went  further  and  uterine  action  became 
continuous,  symptoms  of  dangerous  exhaustion  would  in- 
evitably supervene.  In  short,  he  showed  the  state  of 
tonic  contraction  of  the  uterus  and  the  constitutional 
phenomena  that  accompany  it  to  be  the  result  of  nervous 
exhaustion,  the  true  source  of  danger  in  all  cases  of 
obstructed  labour. 


74  ANNUAL    ADDRESS. 

He  went  on  to  show  that  there  are  two  distinct  classes 
of  cases  in  which  the  pains^  having  once  been  vigorous, 
cease  to  be  rhythmical  or  apparently  subside,  and  that  it 
is  of  the  utmost  importance  to  distinguish  between  these 
classes  in  order  to  be  guided  to  the  proper  treatment. 
'^  The  first  and  simplest  form,"  he  says,  ''  is  well  known, 
and  is  that  in  which  the  uterus  is  simply  quiescent,  rest- 
ing passively  for  a  time  while  the  nervous  power  is  being, 
so  to  speak,  collected  ;  after  a  time  the  uterus  begins  to 
act,  and  the  labour  is  accomplished.  In  this  case  there 
is  no  rise  in  the  pulse ;  generally,  on  the  contrary,  it  is 
weak  and  feeble  ;  nor  are  there  any  untoward  symptoms 
but  languor  and  some  faintness.  The  reflex  function  is 
deficient,  and  its  action  sluggish,  and  therefore  the  de- 
mand on  the  constitution  to  sup|)ly  nerve  force  is  propor- 
tionately small."  Here  we  have  the  first  clear  description 
of  what  Scanzoni  called,  and  is  now  known  as,  secondary 
inertia  of  the  uterus.  ''The  second  form  of  subsidence 
of  the  pains  is  ...  of  the  opposite  character.  The 
uterus  becomes  gradually  irritated,  so  that,  although  some 
of  the  pains  still  occur  at  irregular  intervals,  the  uterus  is 
really  in  more  action  than  before,  tightly  compressing  the 
child,  falling  into  the  inequalities  of  its  form,  whereby 
the  foetus  is  prevented  from  escaping,  every  indentation 
of  the  uterus  forming  as  it  were  a  ledge  past  which  it  is 
difficult  to  draw  the  child,  or  to  pass  the  hand  if  we 
desire  to  turn.  When  this  condition  .  .  .  has  once 
been  fairly  established  it  is  rare  that  the  rhythmical  pains 
ever  recur  with  such  force  as  to  expel  the  foetus;  as  a 
rule  the  continuous  action  remains,  and  sooner  or  later 
symptoms  set  in  telling  one  of  the  necessity  for  inter- 
ference." What  a  graphic  picture  of  tonic  contraction  of 
the  uterus  from  obstructed  labour !  It  is  to  Braxton 
Hicks  that  we  are  indebted  for  a  simple  and  yet  certain 
means  whereby  to  distinguish  between  these  two  classes 
of  cases.  In  the  one  we  find  on  placing  the  hand  upon 
the  uterus  that  the  uterine  walls  are  lax  and  flabby,  the 
foetus  being  readily  felt   'Svithin   it  floating  about   with 


ANNUAL    ADDRESS.  75 

ease/^  So  long  as  this  condition  lasts  we  need  feel  no 
anxiety,  and  there  is  no  occasion  for  manipulative  inter- 
f^reuce.  In  the  other  class  we  find  the  uterus  continu- 
ously hard  and  firm,  and  tightly  moulded  to  the  form  of 
the  foetus,  which,  contrary  to  what  is  found  in  the  former 
class,  cannot  be  moved  about,  the  whole  mass,  consisting 
of  the  uterus  and  its  contents,  being  more  or  less  fixed. 
Under  such  circumstances  we  may  feel  sure  that  it  is 
worse  than  useless  to  postpone  assistance.  It  is  impos- 
sible to  over-estimate  the  importance  of  this  teaching. 
There  was  another  matter  of  equal  importance  to  which 
Hicks  in  this  paper  was  the  first  to  call  attention,  viz.  the 
risk  of  haemorrhage  from  want  of  response  on  the  part  of 
the  uterus  if  the  labour  be  unduly  hastened  and  the  child 
extracted  while  the  uterine  walls  are  relaxed  ;  that  is,  when 
the  case  is  simply  one  of  secondary  inertia.  On  the  other 
hand,  where  there  is  continuous  action  extraction  is  the 
proper  and  only  safe  treatment. 

I  am  glad  to  know  that  this  invaluable  paper  is  likely 
soon  to  be  reprinted,  along  with  some  other  of  Braxton 
Hicks^s  contributions  to  obstetrics,  by  the  New  Sydenham 
Society.  The  lessons  it  enforces  have  long  since  become 
part  of  our  common  stock  of  knowlege,  but  it  is  well  to  be 
reminded  that  we  owe  them  to  the  exceptional  powers  of 
observation  of  a  Fellow  of  our  own  Society.  I  had 
intended  had  time  permitted  to  give  a  resume  of  some 
other  of  Braxton  Hicks's  papers,  especially  those  on  the 
rhythmical  contractions  of  the  uterus  during  pregnancy, 
to  which  he  was  the  first  to  call  attention. 

In  looking  through  the  list  of  his  obstetrical  and  gynae- 
cological contributions  one  feels  that  there  must  be  few 
subjects  on  which  he  has  not  written  something.  There 
are  papers  on  the  anatomy  of  the  human  placenta,  on  the 
behaviour  of  the  pregnant  uterus  in  chorea,  on  pregnancy 
associated  with  ovarian  disease,  on  the  induction  of  pre- 
mature labour,  on  face  presentation,  on  hydatidiform 
degeneration  of  the  chorion,  on  transfusion,  on  rupture  of 
the  vagina  in  labour,  on  rupture  of  the  uterus,  on  inver- 


76  ANNUAL    ADDRESS. 

sion  of  the  uterus^  on  concealed  accidental  ligemorrliage, 
on  the  cephalotribe  (his  modification  of  which  instrument 
became  the  one  almost  exclusively  employed  in  this 
country)^  on  Caesarean  section^  on  extra-uterine  and  intra- 
mural gestation,  on  the  temperature  during  parturition 
and  in  the  puerperal  state^  on  puerperal  diseases^  on 
eclampsia,  on  labour  obstructed  by  abnormal  conditions  of 
the  foetus,  on  prolapsed  funis,  on  labour  with  twins,  on 
the  best  mode  of  delivering  the  foetal  head  after  perfora- 
tion, on  acephalous  monsters,  and  on  an  outbreak  of 
diphtheria  in  the  obstetric  wards.  Turning  to  gynaecolo- 
gical subjects  we  find  him  writing  on  retention  of  menses, 
on  uterine  polypi,  on  proliferous  cysts  of  the  ovary,  on 
sloughing  fibroid  of  the  uterus,  on  the  treatment  of  malig- 
nant disease,  on  tension  of  the  abdomen,  and  many  other 
subjects.  His  series  of  lectures  on  some  of  the  diseases 
of  the  female  urethra  and  bladder,  published  in  the 
'Lancet'  in  1867,  still  remains  the  best  systematic 
account  of  these  diseases  in  our  language.  He  was  not  a 
finished  writer  or  an  effective  speaker.  His  papers  have 
no  charm  of  style.  His  sentences  are  often  ill-arranged  ; 
his  meaning  is  occasionally  obscure.  But  his  papers 
are  always  worth  reading ;  for  he  was  a  clinical  observer 
of  the  first  rank,  and  he  never  wrote  merely  for  the  sake 
of  writing.  Sure  of  his  ground,  and  therefore  free  from 
hesitation  in  his  statements  of  /acf,  he  was  studiously 
guarded  in  his  expressions  of  opinion,  suggestive  rather 
than  dogmatic.  In  some  of  his  essays,  and  notably  in 
that  on  obstructed  labour,  he  showed  great  originality, 
and  that  wide  grasp  of  his  subject  that  enables  a  man  to 
harmonise  apparently  discordant  phenomena,  and  to  con- 
struct out  of  chaotic  materials  an  orderly  presentation  of 
facts  and  a  workable  hypothesis  in  explanation  of  them. 
If  I  were  asked  which  of  his  contributions  I  consider  to 
deserve  the  highest  place,  I  should  select  the  two  of  which 
I  have  endeavoured  to  give  a  synopsis  this  evening, 
namely,  those  on  obstructed  labour  and  on  combined 
version,  and  I  should  add  for  a  third  the  series  of  papers 


ANNUAL    ADDRESS.  77 

on  tlie  rliytlimical  contractions  of  the  uterus  during  preg- 
nancy. These  were  all  characterised  by  a  rare  origin- 
ality ^  and  are  contributions  to  obstetric  knowledge  of 
which  the  value  is  likely  to  be  permanent. 

It  was  difficult  for  those  who  only  knew  Braxton  Hicks 
in  his  later  years  to  realise  that  this  mild-mannered, 
chatty,  beaming  little  old  gentleman  was  the  man  whose 
name  was  associated  with  so  many  advances  in  the  science 
and  art  of  obstetrics.  He  was  in  no  sense  one  of  those 
who  either  look  or  talk  like  a  leader  of  men.  But  his 
wide  interests,  his  keen  love  of  nature,  and  his  gentle 
unassuming  manner  made  him  a  most  interesting  com- 
panion. He  continuall}'  displayed  a  quite  unexpected 
acquaintance  with  the  most  out-of-the-way  subjects,  and 
his  mind  was  a  storehouse  of  general  information.  He  had 
read  much,  and  observed  much,  and  thought  much.  He 
was  a  good  draughtsman,  and  drew  accurately  on  stone 
from  the  microscope.  He  was  a  large  collector  of  Wedg- 
wood and  oriental  china,  and  had  in  his  house  typical 
examples  of  different  makers.  He  was  fond  of  architec- 
ture, and  indeed  of  art  generally.  He  was  a  deeply 
religious  man,  and  a  sincere  member  of  the  Church  of 
England.  He  was  always  ready  to  give  help  to  those 
who  needed  it,  whether  in  the  form  of  advice  or  money, 
or,  if  necessary,  of  both  ;  but  it  was  all  done  so  quietly  that 
few  knew  him  for  the  charitable  man  he  really  was.  His 
character  had  the  charm  of  simplicity.  Utterly  free  him- 
self from  all  that  was  base  and  sordid,  he  judged  others 
to  be  the  same  ;  hence  he  never  expressed  himself  un- 
kindly of  his  fellow  men.  He  died  at  his  residence,  the 
Brackens,  Lymington,  August  28th,  1897,  at  the  age  of 
seventy-four,  from  heart  failure  after  a  long  illness  fol- 
lowing an  attack  of  influenza.  He  had  retired  from  the 
active  practice  of  his  profession  about  three  years  pre- 
viously, and  had  gone  back  to  the  home  of  his  childhood, 
where  he  settled  down  to  the  quiet  enjoyment  of  his 
garden  and  his  books,  and  the  peaceful  pleasures  of  a 
country  life,  and  where  his  friends  had  vainly  hoped  for 


78  ANNUAL    ADDRESS. 

liim  '^  a  long  and  mellow  eventide  tliat  the   niglit  should 


linger  to  disturb. 


)i 


Etienne  Stephane  Tarnier 

was  born  at  Aiserey^  a  village  near  Dijon^  on  April  29th, 
1828.  His  father,  a  modest  country  doctor,  soon  after- 
wards removed  to  Arc-sur-Tille,  where  Tarnier  spent  his 
childhood,  and  where,  as  a  student  in  later  years,  he 
loved  to  occupy  himself  during  his  holidays  in  assisting  his 
father  in  his  practice.  He  received  his  earlier  education 
in  the  schools  of  Dijon,  and  at  the  age  of  twenty  pro- 
ceeded to  Paris  to  study  medicine.  Almost  at  the  outset 
his  studies  were  for  a  time  interrupted,  owing  to  a  severe 
outbreak  of  cholera  in  his  native  district,  during  which 
he  went  to  assist  his  father.  Returning  to  Paris  he  re- 
sumed his  course  of  medical  instruction,  and  in  1856, 
having  determined  to  equip  himself  for  practice  by  a 
year's  residence  at  the  Maternite,  he  entered  as  an 
interne  at  that  hospital.  Grradually,  under  the  influence 
of  Delpech  and  Danyau,  he  became  attracted  to  the  science 
of  obstetrics,  and  devoted  himself  energetically  to  its 
pursuit.  He  commenced  his  special  studies  with  an 
inquiry,  conducted  in  association  with  Vulpian,  into  the 
changes  that  the  liver  undergoes  during  pregnancy,  and 
he  followed  this  up  by  a  series  of  communications  to  the 
Societe  Anatomique  on  metastatic  abscesses  in  the  kidney 
in  puerperal  septicaemia,  &c.  But  a  much  larger  question 
soon  absorbed  him.  At  that  time  the  mortality  from 
puerperal  fever  in  the  Paris  hospitals  was  frightful. 
Nothing  was  known  as  to  its  true  nature,  and  the  only 
means  then  available  of  checking  an  epidemic  was  to 
close  the  hospital  doors.  Between  the  1st  of  April  and  the 
10th  of  May,  1856,  when  the  Maternite  was  closed,  of  347 
women  delivered  no  fewer  than  64  died,  rather  more  than 
one  out  of  every  six.  It  is  true  that  Ignatius  Semmel- 
weishad  already  made  his  great  discovery  of  the  part  played 
in  puerperal  infection  by  putrid  material  carried  on  the 


ANNUAL    ADDRESS.  79 

liands  of  students  and  teachers  coming  direct  to  the  lying- 
in  wards  from  the  post-mortem  and  the  surgical  dressing- 
room,  and  of  the  marvellous  diminution  in  the  pueriDeral 
mortality  that  followed  a  systematic  disinfection  of  the 
hands,  by  the  use  of  chloride  of  lime,  before  making*  a 
vaginal  examination.  But  all  the  world  knows  how  viru- 
lently Semmelweis's  views  were  opposed  even  in  Vienna, 
where  his  discovery  was  made,  and  beyond  Vienna  they 
were  almost  unnoticed,  and  for  all  practical  purposes  were 
unknown.  (It  should  be  mentioned  in  this  connection  that 
Semmelweis's  views  were  first  brought  before  the  notice 
of  the  profession  in  this  country  by  Dr.  C.  H.  F.  Eouth, 
a  pupil  of  Semmelweis,  in  a  paper  read  before  the  Royal 
Medical  and  Chirurgical  Society  in  1848;  see  ^  Med.-Chir. 
Trans.,'  vol.  xxxii,  p.  27.)  The  surgeons  of  the  Paris 
Maternite  were  in  despair,  and  there  is  a  legend  to  the 
effect  that  one  of  them,  meeting  on  the  Boulevard  Port 
Royal  a  poor  woman  on  her  Avay  to  the  hospital,  cried 
out  to  her,  ^'  Do  not  come  in  here  unless  you  wish  to 
die."  Tarnierfelt  a  burning  desire  to  solve  the  problem, 
and  he  soon  became  con\4nced  that  puerperal  fever  was 
spread  by  contagion.  It  was  necessary,  however,  that  he 
should  prove  it.  With  this  object  he  made  inquiries,  and 
he  ascertained  that  whilst  the  mortality  from  puerperal 
fever  in  the  Maternite  during  1856  was-  1  in  19,  the 
mortality  in  the  district  immediately  surrounding  the 
hospital  was  only  1  in  882  ;  in  other  words,  the  mortality 
in  the  hospital  was  seventeen  times  greater  than  in  the 
district  outside.  He  came  to  the  inevitable  conclusion 
that  the  comparative  isolation  of  the  women  delivered  in 
their  own  homes  ensured  their  safety  by  limiting  the 
chances  of  contamination.  To  us,  at  this  day,  it  is  diffi- 
cult to  conceive  a  condition  of  things  in  which  such  a 
seemingly  self-evident  proposition  could  be  regarded  as 
startling  and  dangerous.  But  when  Tarnier  came  to  for- 
mulate his  views  in  his  inaugural  thesis,  and  otherwise  to 
submit  them  to  the  criticism  of  the  obstetrical  leaders  of 
Paris,  so  far   from  convincing  them  he  met    with   deter- 


80  ANNUAL    ADD U ESS. 

mined  opposition.  Meanwhile  liis  tenure  of  office  at  the 
hospital  came  to  an  end,  and  he  had  to  decide  how  he 
was  to  earn  a  living.  He  determined  to  remain  in  Paris. 
Taking  rooms  in  a  house  in  the  Eue  de  Eivoli,  he  became 
physician  to  the  Bureau  de  Bienfaisance,  and  endeavoured 
to  make  a  livelihood  without  drawing  upon  the  meagre 
resources  of  his  parents.  He  met  with  so  little  success 
that  he  was  on  the  point  of  relinquishing  a  medical 
career,  when  an  event  occurred  which  changed  the  aspect 
of  affairs.  A  discussion  on  the  nature  of  puerperal  fever 
took  place  at  the  Academie  de  Medecine,  which  extended 
over  four  months  of  the  year  1858.  The  thesis  of  Tarnier 
was  constantly  quoted.  Dubois  became  interested,  and 
promised  Tarnier  that  he  Avould  instal  him  as  chef  de 
clinique ;  whereupon  Tarnier  set  to  Avork  with  renewed 
ardour,  and  wrote  a  fresh  monograph  on  puerperal  fever 
as  observed  at  the  Maternite.  This  was  published  at  the 
end  of  1858.  When  he  presented  himself  to  the  pub- 
lisher with  his  manuscript,  Mons.  J.  B.  Bailliere,  glancing 
from  the  title  to  his  unknown  visitor,  exclaimed,  ''  I  know 
only  one  man,  sir,  in  Paris,  who  is  competent  to  deal  with 
such  a  subject."  ''  Who  is  that  ?  "  ''  Dr.  Tarnier.'^  ''  I 
am  Dr.  Tarnier."  Already,  therefore,  he  was  recognised 
as  an  authority  on  the  subject. 

In  1861  Tarnier  became  cJief  de  clinique  to  Dubois,  in 
fulfilment  of  the  promise  the  latter  had  made  to  him 
three  years  previously,  and  in  1867  he  succeeded  Trelat 
as  chief  surgeon  and  director  of  the  Maternite.  This 
position  he  continued  to  hold  for  twenty-two  years,  with 
ever-increasing  devotion  to  the  interests  of  that  great 
institution  and  to  the  well-being  of  its  inmates.  From 
what  has  already  been  said  it  will  be  readily  understood 
that  the  researches  of  Pasteur  and  Lister  had  a  special 
fascination  for  Tarnier  as  opening  a  prospect  of  new  and 
trusty  weapons  wherewith  to  fight  against  puerperal 
infection.  With  what  success  he  introduced  antiseptic 
midwifery  into  the  Maternite  is  probably  well  known  to 
most  of  my  hearers,  but  the  story,  which  Tarnier  himself 


ANNUAL    ADDRESS.  81 

was  never  tired  of  tellings  will  well  bear  to  be  repeated^ 
and  I  think  ought  to'  be  repeated  here.  He  was  in  the 
habit  of  dividing  into  three  periods  the  interval  between 
the  year  1858  and  the  year  1889,  when  he  quitted  his 
post  in  order  to  succeed  Pa  jot  in  the  chair  of  theoretical 
teaching.  The  first  period  embraced  the  years  1858  to 
1869;  the  second,  1870  to  1880;  and  the  third,  1881  to 
1889. 

In  1867,  when  he  entered  the  Maternite  in  the  capacity 
of  Surgeon-in-Chief,  no  changes  had  been  made  in  the 
method  of  conducting  the  work  of  the  hospital  since  the 
time  when  he  was  intejiie,  and  in  spite  of  his  protests 
things  remained  as  they  were  up  to  1870.  This  he  called 
the  period  of  inaction.  In  the  hope  of  promoting  disin- 
fection the  walls  were  from  time  to  time  washed  over 
with  lime,  and  each  ward  was  left  unoccupied  for  a  few 
days  now  and  then  in  order  that  the  mndows  might  be 
opened  and  the  air  of  the  apartment  thoroughly  renewed. 
But  these  were  the  only  measures  adopted  until,  in  1870,  the 
hospital  was  reorganised  by  the  authorities  in  accordance 
with  Tarnier's  recommendations.  The  healthy  lying-in 
women  were  for  the  first  time  kept  apart  from  the  sick. 
The  moment  that  a  patient  exhibited  the  slightest  sign  of 
illness,  she  was  removed  to  the  infirmary.  In  order  to 
render  the  separation  as  complete  as  possible,  Tarnier 
never  visited  the  infirmary,  and  the  medical  officer  in 
charge  of  the  infirmary  never  entered  Tarnier's  wards. 
Each  department  had  its  own  resident  staff,  and  no  officer 
or  attendant  was  allowed  to  pass  from  the  one  department 
to  the  other.  The  transport  of  infectious  germs  was  thus 
reduced  to  a  minimum.  From  1858  to  1869  the  mean 
mortality  had  been  9'31  per  cent.;  that  was  during  the 
period  of  inaction.  Immediately  after  the  adoption  of 
measures  of  isolation  the  mortality  fell  to  2*32  per  cent. 
This  Tarnier  called  the  period  of  struggle  against  con- 
tagion. With  1881  commenced  the  third  period — that  of 
antisepsis.  The  mortality  then  fell  still  lower,  viz.  to 
1*05  per  cent. 

VOL.   XL.  6 


82 


ANNUAL    ADDRESS. 


Mortality  in  the  Paris  Maternite. 

Per  cent. 

Proportion. 

1858—1869 

Period  of  inaction                      ...     931     . 

..     1  in  10| 

1870—1880 

„           hygienic  measures     ...     2'32     . 

..     1  in  43 

1881—1889 

,,           antisepsis                    ...     1*05     . 

..     1  in  95 

The  measures  for  ensuring  isolation  continued  to  be 
carried  out,  and  the  marvellous  diminution  that  followed 
the  introduction  of  antiseptics  showed  what  could  be 
accomplished  when  isolation  and  antisepsis  were  com- 
bined. 

In  order  to  convey  the  full  significance  of  these  figures, 
I  have  reproduced  a  diagram  of  Tarnier's,  in  which  are 


1 


1858—1869. 


1870—1880. 


1881—1889. 


represented   three    columns,    accurately   corresponding-  in 
height  to   the   proportion  which   the   figures  just  quoted 


ANNCAL    ADDRESS.  83 

bear  to  each  other.  The  tallest  represents  the  mortality 
during  the  period  of  inaction ;  the  middle  one  that 
during  the  period  of  isolation ;  and  the  shortest  that 
during  the  antiseptic  period. 

I  should  say  that  these  figures  represent  the  total  mor- 
tality of  the  hospital,  not  the  deaths  from  puerperal 
fever.  It  was  Tarnier's  rule  to  include  in  his  statistics 
every  death  that  took  place,  from  whatever  cause.  He 
believed  that  any  scheme  by  which  an  endeavour  is  made 
to  show  separately  the  deaths  which  could  reasonably  be 
attributed  to  infection  caught  within  the  hospital,  was  too 
full  of  temptations  to  self-deception  ever  to  be  safe  from 
error.  Even  in  the  extreme  case  of  a  woman  who  jumped 
out  of  the  window  in  an  attack  of  mania  almost  the 
moment  she  entered  the  hospital,  the  death  was  included 
in  the  statistics  of  the  year.  It  was  the  same  with  all 
deaths  from  haemorrhage,  eclampsia,  rupture  of  the  uterus, 
and  the  rest.  He  desired  that  his  statistics  should  be 
unassailable. 

But  I  must  continue  my  narrative.  During  the  years 
that  he  was  at  the  Maternite,  in  addition  to  this  great 
work  of  slaying  the  dragon  of  puerperal  infection,  a  work 
on  which  I  have  intentionally  dwelt  at  some  length  (for 
I  regard  it  as  by  far  his  most  important  achievement), 
Tarnier  found  the  time  and  energy  to  invent  or  modify 
various  obstetric  instruments  and  methods  of  treatment. 

In  an  admirable  obituary  notice  of  the  late  Dr.  Alex. 
Keiller,  of  Edinburgh,  Dr.  Watt  Black,  one  of  my  prede- 
cessors in  this  chair,  discussed  the  vexed  question  of  priority 
in  regard  to  the  invention  of  dilatable  bags  for  expanding 
the  OS  uteri,  and  concluded  that  the  merit  of  that  invention 
undoubtedl}'  belonged  to  Dr.  Keiller,  who  introduced  his 
bags  to  the  notice  of  the  profession  in  1859.  So  far  as 
Great  Britain  is  concerned,  that  conclusion  was  correct,, 
but  there  is  evidence  to  show  that  Tarnier  had  invented  a 
similar  contrivance  seven  years  earlier.  His  dilating  ball, 
still  in  every-day  use  in  French  obstetric  practice,  was 
described  by  him  in  1852.      There  is  no  reason  to  suppose 


84  ANNUAL    ADDEESS. 

that  Keiller  knew  of  it.  It  is  probably  another  instance 
of  an  idea  occurring  independently  to  more  than  one  mind  ; 
and  even  if  it  should  hereafter  be  shown  that  some  other 
inventive  genius  had  anticipated  Tarnier^  it  need  not 
prevent  us  from  crediting  him  with  an  original  idea,  any 
more  than  his  priority  detracts  from  the  originality  of 
Keiller. 

It  is,  however,  with  the  invention  of  the  axis  traction 
forceps  that  Tarnier's  name  is  most  frequently  associated. 
For  many  years  "  there  had  been  a  steadily  growing  con- 
viction in  the  minds  of  many  obstetricians  that  the  long 
double-curved  forceps  was  not  an  altogether  satisfactory 
instrument.  The  addition  of  the  pelvic  curve  had  ensured 
the  more  equable  distribution  of  the  grasp  of  the  blades 
over  the  foetal  head,  and  so  had  removed  one  of  the  great 
objections  to  the  straight  forceps,  but  it  had  not  altered 
the  direction  of  the  tractile  force.  Let  the  handles  of  the 
instrument  be  carried  as  far  back  as  the  perinaeum  can  be 
stretched,  the  direction  of  the  traction  can  still  never 
correspond  Avith  the  axis  of  the  pelvic  inlet.  This  axis, 
along  which  the  mass  of  the  foetal  head  must  enter  the 
brim,  is  coincident  with  a  line  drawn  between  the  umbi- 
licus and  the  coccyx.  If  traction  could  be  made  in  this 
line  there  would  be  no  misdirection  of  the  force,  it  would 
all  be  available  for  the  purpose  aimed  at ;  but  exactly  in 
proportion  as  the  line  of  traction  diverges  from  the  axis 
of  the  genital  canal,  so  some  of  the  force  is  expended  in 
driving  the  head  of  the  child  against  the  anterior  wall  of 
that  canal,  and  is  therefore  not  simply  wasted,  but  acts  to 
the  detriment  of  the  maternal  tissues.  With  the  ordinary 
forceps  it  is  anatomically  impossible  for  traction  to  be 
made  directly  in  the  pelvic  axis,  so  that  a  certain  amount 
of  the  force  expended  is  ineffective.  From  the  year  1860 
forwards  several  attempts  were  made  to  remedy  this 
defect,^ ^^  but  none  proved  satisfactory  until  Tarnier,  in 
the  year  1877,  brought  out  his  axis  traction  forceps,  an 

*  From  a  paper  on  "  The  Axis  Traction  Forceps/'  by  the  author.     '  Lancet/ 
December  10th,  1892. 


ANNUAL   ADDRESS.  85 

instrument  wliicli  though  not  by  any  means  faultless,  ad- 
mirably fulfilled  most  of  the  requirements.  I  need  not 
describe  it,  for  its  essential  features  are  familiar  to  you 
all.  The  traction-rods  permitted  traction  to  be  made  in 
the  axis  of  the  pelvis,  and  so  ensured  that  all  the  force 
expended  by  the  operator  was  exerted  usefully,  and  that 
the  maternal  tissues  were  not  exposed  to  any  unnecessary 
pressure.  This  advantage  Tarnier^s  instrument  shared 
with  some  of  its  predecessors — Hubert's,  Aveling's,  and 
some  others — but  there  were  other  advantages  that  no 
other  forceps  possessed.  These  were  (1)  that  the  applica- 
tion handles  move  forward  as  the  head  descends  in  such  a 
way  as  to  furnish  a  constant  guide  to  the  direction  in 
which  traction  should  be  made,  in  order  that  it  may  be 
exercised  with  most  effect,  i.  e.  the  direction  proper  to  the 
plane  of  the  pelvis  through  which  the  head  is  passing  ; 
and  (2)  that  the  transverse  handle  enables  the  operator 
to  keep  up  a  steady  pull  with  a  minimum  of  muscular 
fatigue,  and  therefore  with  the  power  of  estimating  with 
some  approach  to  accuracy  the  amount  of  force  he  is 
expending. 

The  instrument,  as  first  introduced,  was  unnecessarily 
complicated  and  unwieldy.  Critics  saw  and  made  much 
of  its  faults,  and  overlooked  its  merits.  Yet  the  former 
were  for  the  most  part  accidental  and  removeable  (Tarnier 
himself  corrected  many  of  them),  whilst  the  latter  were 
unmistakable  and  permanent.  "Let  who  will,''  says  Prof. 
Alex.  Simpson,  "  continue  to  use  ordinary  curved  forceps  ; 
an  obstetrician  who  has  used  the  Tarnier  forceps  in  a  few 
test  cases,  will  no  more  think  of  reverting  to  the  other 
than  a  man  who  can  afford  to  keep  a  carriage  will  con- 
tinue to  practise  as  a  peripatetic.  He  may  use  the 
defective  instrument  occasionally  to  keep  muscle  and  mind 
in  exercise,  or  because  the  case  is  so  easy  that  it  can  be 
finished  with  anything,  as  he  may  walk  to  some  patient's 
house  for  the  sake  of  his  own  health,  or  because  she  lives 
in  the  same  street ;  but  in  the  general  run  of  his  work,  and 
in  all  his  difficult  cases,  the  axis  traction  forceps  becomes 


86  ANNUAL    ADDRESS. 

for  him  a  valued  necessity/^^  I  have  elsewhere  recorded 
my  own  conviction  that  the  axis  traction  forceps  constitutes 
"  the  most  important  improvement  that  has  been  made  in 
the  construction  of  the  instrument  since  the  introduction 
of  the  pelvic  curve/'  and  that  its  general  adoption,  in 
principle  at  least,  in  this  as  in  other  countries  is  merely  a 
question  of  time. 

In  the  year  1883  Tarnier  brought  out  another  obstetric 
instrument — the  basiotribe.  He  had  already  modified  the 
saw  forceps  of  Van  Huevel,  and  had  improved  the 
cephalotribe.  The  basiotribe  was  entirely  original.  It 
was  devised  for  the  purpose  of  breaking  up  the  base  of 
the  skull,  so  as  permit  the  extraction  of  the  foetal  head 
after  perforation,  in  those  difficult  cases  in  which  the 
necessary  reduction  in  size  cannot  be  easily  eifected  either 
by  the  cephalotribe  or  the  cranioclast.  It  is  said  (by 
M.  Paul  Bar)  to  combine  the  strength  of  the  former  of 
these  instruments  with  the  firmness  of  grasp  of  the  latter, 
and  to  be  now,  since  certain  modifications  were  made  in  it, 
an  almost  perfect  instrument. 

Tarnier's  name  is  also  associated  with  improvements  in 
embryotomy  instruments  and  in  the  artificial  incubator. 
The  idea  that  in  1880  found  expression  in  his  "  couveuse  '' 
was  not  new.  Other  somewhat  similar  methods  of  keep- 
ing up  the  temperature  of  prematurely  born  children 
were  already  employed,  but  to  Tarnier  is  due  the  credit 
of  having  introduced  a  convenient  application  of  the  prin- 
ciple into  the  Maternite,  and  popularised  its  use  through- 
out France. 

When,  at  the  beginning  of  the  academic  year  1888—9, 
Tarnier  left  the  Maternite  to  succeed  Pajot  at  the  Clinique 
des  Accouchements,  his  activities  by  no  means  ceased. 
He  gave  admirable  courses  of  clinical  lectures,  many  of 
which  were  published.  One  course  in  particular  was 
afterwards  amplified  and  published  in  book  form  by  his 
pupil  Potocki.      I  refer  to  the  remarkable  series  of  lec- 

*  "Agaiu    on    Axis    Traction    Forceps,"    *  Edin.    Med.    Journ.,'    October, 
1883. 


ANNUAL    ADDRESS.  87 

tures  delivered  in  the  summer  of  1890  on  ^'  Asepsis  and 
Antisepsis  of  Obstetrics/^  and  published  in  1894  as  a  large 
octavo  book  of  upwards  of  800  pages,  certainly  the  most 
complete  and  masterly  treatise  on  the  subject  that  has 
yet  been  written. 

Tarnier  had  many  honours  showered  upon  him.  He 
was  a  Commander  of  the  Legion  of  Honour.  In  both 
the  Academie  de  Medecine  and  the  Societe  de  Chirurgie 
he  had  passed  the  presidential  chair.  The  Societe  Obstet- 
ricale  de  France,  of  which  he  was  one  of  the  founders, 
made  him  its  first  president.  But  what  gave  him  most 
satisfaction  was  the  feeling  that  it  was  owing  to  his  influ- 
ence that  new  maternities  had  been  opened,  new  refuges 
established  for  pregnant  women,  and  new  asylums  for 
women  who  had  been  recently  delivered.  The  public 
authorities  marked  their  appreciation  of  his  influence  and 
work  by  deciding  that  the  hospital  in  which  he  carried  on 
his  teaching  during  his  later  years  should  henceforth  be 
known  under  the  name  of  the  ^'  Clinique  Tarnier.'^ 

In  his  capacity  as  professor  his  manner  was  restrained, 
calm,  and  dignified.  He  arranged  his  materials  admir- 
ably, and  laboured  above  all  things  to  be  clear  and  exact. 
He  treated  the  work  of  others  with  respect,  and  if  he  had 
occasion  to  differ  from  them  in  opinion  he  expressed  him- 
self without  acrimony,  and  in  terms  of  studied  moderation. 
He  wrote  several  articles  in  the  ^  Nouveau  Dictionnaire  de 
Medecine  et  de  Chirurgie  pratiques,^  and  edited  several 
editions  of  '  Cazeaux\s  Midwifery,^  adding  such  copious 
notes  as  to  transform  the  original  treatise  into  a  new 
book. 

He  was  engaged  up  to  the  last  in  revising  the  proofs  of 
the  third  volume  of  his  own  monumental  '  Traite  de  Fart 
des  accouchements.'  In  the  preparation  of  that  work  he 
associated  with  himself  several  of  his  former  pupils — 
Chantreuil,  Budin,  Paul  Bar,  Bonnaire,  Maygrier,  and 
Tissier  ;  but,  throughout,  the  inspiration  came  from  him, 
and  the  book  remained  essentially  his  own. 

He  died,  after  a  short  illness,  on  the  23rd  of  November, 


88  ANNUAL    ADDRESS. 

1897.  ^^  With  liim/^  as  was  truly  remarked  by  M.  Budin 
in  his  funeral  oration,  ^'^  there  disappeared  one  of  the 
greatest  medical  figures  of  our  epoch. ^^  Through  his  in- 
fluence France  has  probably  made  greater  obstetric  pro- 
gress during  the  past  quarter  of  a  century,  than  any 
other  country  in  the  world. 

And  now,  gentlemen,  to  use  the  words  of  our  old 
favourite,  Oliver  Wendell  Holmes,  ^'  my  show  of  ghosts  is 
over."  It  only  remains  for  me  to  apologise  for  keeping 
you  so  long,  and  to  thank  you  for  the  patience  with 
which  you  have  listened  to  me. 

Mr.  Alban  Doran^  in  proposing  a  vote  of  thanks  to  the 
President,  said  that  he  was  glad  that  attention  had  been 
turned  in  the  Annual  Address  to  the  value  of  the  speci- 
mens exhibited.  The  Fellows  wished  yet  to  know  what 
kind  of  small  fibroid  was  likely  to  grow  and  require  early 
hysterectomy,  and  what  kind  was  likely  to  remain  sta- 
tionary and  require  no  operation ;  they  also  wished  to  be 
perfectly  sure  that  there  was  such  a  disease  as  deciduoma 
malignum.  A  patient  study  of  specimens,  such  as  the 
President  encouraged,  could  alone  solve  such  questions. 
The  President  had  wisely  shown  how  the  greatest  special- 
ists have  the  best  general  training.  All  the  four  great 
deceased  authorities  whose  lives  he  had  related  had  been 
something  more  than  that  for  which  they  were  famed. 
Tarnier  understood  sanitation  from  the  first,  Lusk  had 
been  a  soldier,  and  Sir  Spencer  Wells  through  army  sur- 
gery learnt  how  to  do  abdominal  operations  on  women, 
and  succeeded  as  a  specialist  in  those  operations.  He 
and  his  followers  taught  the  general  surgeon,  who  before 
had  been  frightened  of  the  peritoneum.  Lastly,  Braxton 
Hicks  had  played  three  parts  very  distinct  in  character, 
— the  pure  scientist,  the  general  practitioner,  and  the 
specialist.  All  these  great  men  were  the  better  for  their 
versatility  and  varied  experiences,  and  the  President  was 
well  advised  in  holding  them  up  as  an  example  in  this 
respect.      Mr.  Doran  moved — "  That  the   thanks    of  the 


ANNUAL    ADDRESS.  89 

meeting  be  given  to  Dr.  Cullingwortli  for  liis  most  inter- 
esting address^  and  that  lie  be  requested  to  allow  it  to  be 
printed  in  the  next  volume  of  the  ^  Transactions.'  '^ 

This   was    seconded   by  Dr.   Pollock_,   and  carried  by 
acclamation. 


The  President  announced  that  the  Officers  and  Council 
shown  on  the  printed  list  as  recommended  by  the  Council 
were  duly  elected. 

President. — Charles  James  Cullingworth^  M.D. 

Vice-Presidents. — William  Duncan,  M.D.  ;  John  H. 
Galton,  M.D. ;  William  Radford  Dakin,  M.D. ;  Jamieson 
Boyd  Hurry,  M.A.,  M.D.   (Reading). 

Treasurer. — James  Watt  Black,  M.D. 

Chairman  of  the  Board  for  the  Examination  of  Midivives. 
— Percy  Boulton,  M.D. 

Honorary  Secretaries. — John  Phillips,  M.A.,  M.D.  ; 
Herbert  R.  Spencer,  M.D. 

Honorary  TAhrarian. — Amand  Routh,  M.D. 

Other  Members  of  Council. — A.  H.  Freeland  Barbour, 
M.D.  (Edinburgh) ;  John  Walters,  M.B.  (Reigate)  ;  Joseph 
Thompson  (Nottingham)  ;  George  Francis  Blacker,  M.D.  ; 
Arthur  Nicholson,  M.B.  (Brighton)  ;  Richard  Pinhorn, 
(Dover)  ;  Thomas  Watts  Eden,  M.D.  ;  John  Dysart 
McCaw,  M.D.  ;  Frederick  John  McCann,  M.B.,  CM.  ; 
William  Gandy ;  George  Henry  Pedler ;  Augustus  W. 
Addinsell,  M.B.,  CM.  ;  John  Ford  Anderson,  M.D.  ; 
Arthur  Edward  Giles,  M.D.  ;  Angus  Eraser,  M.D. 
(Aberdeen)  ;  Harold  H.  Des  Voeux,  M.D.  :  Charles 
Hubert  Roberts,  M.D.  ;   George  Ernest  Herman,  M.B. 

It  was  moved  by  Dr.  Hayes,  seconded  by  Dr.  Boxall, 
and  carried — "That  the  thanks  of  the  meeting  be  given 
to  the  retiring  Vice-President,  Dr.  Nesham,  and  to  the 
other  retiring  members  of  Council,  Dr.  Adams,  Mr.  Kisch, 
Dr.  Amand  Routh,  Dr.  Handheld  Jones,  Dr.  Rivers  Pollock, 
Dr.  Kanthack,  and  Dr.  Tate.'' 


90  ANNUAL    ADDRESS. 

It  was  moved  by  Dr.  Potter^  seconded  by  Dr.  Handfield- 
JoNES,  and  carried — "  That  the  best  thanks  of  the  meet- 
ing be  given  to  the  retiring  Hon.  Secretary,  Dr.  Dakin, 
and  the  retiring  Hon.  Librarian,  Dr.  Griffith,  for  their 
valuable  services  to  the  Society  during  their  respective 
terms  of  office.^* 


91 


BIBLIOGRAPHICAL    APPENDIX    TO 
ANNUAL   ADDRESS. 

PREPARED  BY  C.  J.  CULLIXG WORTH,  M.D. 


Part  I. 

List  op  Sir  Tbomas  Spencer  Wells's  Poblished  Writings^ 
arranged  chronologically. 

1.  The  scale  of  medicines  with  which  merchant  vessels  are  to 
be  furnished,  by  command  of  the  Privy  Council  for  Trade,  .... 
with  observations  on  the  means  of  preserving  the  health  and 
increasing  the  comforts  of  seamen ;  directions  for  the  use  of  the 
Medicines  and  for  the  treatment  of  various  accidents  and  diseases. 
16mo,  London,  1851. 

2.  The  cure  of  squinting  by  the  use  of  prismatic  spectacles, '  Med. 
Times  and  Gaz,,'  vol.  ii,  1853,  p.  216. 

3.  On  a  new  ophthalmoscope,  ibid.,  pp.  264-5. 

4.  Navy  Medical  Reports,  ibid. 

(1)  On  an  epidemic  of  variola  at  Corfu  in  1852,  pp.  32-4. 

(2)  On  the  treatment  of  ulcers  by  galvanism,  pp.  84-6. 

(3)  On  the  relative  prevalence  of  phthisis  at  Malta  among 

seamen,  the  land  forces,  and  natives,  pp.  133-4. 

(4)  Extracts  from  a  report  on  the  ventilation  of  ships,  p.  547. 

5.  Lecture  on  cases  observed  among  the  out-patients  at  the 
Samaritan  Hospital,  ibid.,  1854,  pp.  459-61. 

6.  Practical  essays  on  plastic  surgery,  ibid.,  pp.  9-10,  32-3,  55-6, 
109-10,  210-12,  262-3,  661-2. 

7.  Drawings  of  the  appearance  of  the  surface  of  the  heart  in  two 
cases  of  purpura,  '  Trans.  Path.  Soc.,'  vol.  v,  1853-4,  p.  115. 

8.  Urinary  calculus  discharged  through  the  rectum,  ibid., 
pp.  202-3. 

9.  Malignant  growth  from  the  dorsum  of  the  ilium,  ibid.,  pp.  247-8. 


92  BIBLIOGRAPHICAL    APPENDIX    TO 

10.  Practical  observations  on  gout  and  its  complications,  and 
on  the  treatment  of  joints  stiffened  by  gouty  deposits.  12mo, 
London,  1854,  xv-288  pp. 

11.  On  the  radical  cure  of  reducible  inguinal  hernia  by  a  new 
operation  (Wiitzer's),  with  cases  and  remarks,  'Med.-Chir.  Trans.,' 
vol.  xxxvii,  1854,  pp.  75-85. 

12.  On  the  practical  results  of  quarantine,  'Assoc.  Med.  Journ./ 

1854,  pp.  831-4. 

13.  Introductory  address  at  the  first  meeting  of  the  Smyrna 
Hospital  Medico- Chirurgical  Society,  '  Med.  Times  and  Gaz.,'  vol.  i, 

1855,  p.  430-33. 

14.  Introductory  lecture  at  the  Grosvenor  Place  School  of  Medicine, 
ibid.,  vol.  ii,  1856,  pp.  335-7.  (Abst.)  '  Assoc.  Med.  Journ.,'  1856, 
pp.  856-7. 

15.  Some  account  of  the  ecraseur  of  M.  Chassaignac, '  Med.  Times 
and  Gaz.,'  vol.  ii,  1856,  pp.  364-5. 

16.  Necrosis  after  frost-bite, '  Tr.  Path.  Soc.,'  vol.  viii,  1856-7,  p.  299. 

17.  Fracture  of  the  os  calcis,  ibid.,  pp.  299-300. 

18.  Tumour  from  the  flexor  tendon  of  a  forefinger,  ibid., 
pp.  379-80. 

19.  On  a  grooved  hook  for  tracheotomy,  '  Med.  Times  and  Gaz  .,* 
vol.  i,  1857,  pp.  209-10. 

20.  Lecture  on  cancer  cures  and  cancer  curers,  ibid.,  pp.  27-3  2. 

21.  Lecture  on  incomplete  paralysis  of  the  lower  extremities 
connected  with  disease  of  the  urinary  organs,  ibid.,  pp.  493-7. 

22.  On  the  administration  of  cod-liver  oil  and  substances  soluble 
in  it  in  capsules,  ibid.,  p.  577. 

23.  Lecture  on  the  radical  cure  of  reducible  inguinal  hernia,  ibid., 
vol.  i,  1858,  pp.  79-83. 

24.  Lecture  on  Pirogoff's  amputation  at  the  ankle-joint,  ibid., 
pp.  288-90. 

25.  On  dilatation  of  the  female  urethra  by  fluid  pressure,  ibid., 
vol.  ii,  1858,  pp.  84-5. 

26.  Ovarian  tumours  and  ascites  ;  ovariotomy ;  successful  result, 
ibid.,  pp.  602-3. 

27.  Multilocular  ovarian  cyst  successfully  removed  by  ovario- 
tomy, '  Trans.  Path.  Soc.,'  vol.  ix,  1857-8,  pp.  321-2. 

28.  Cystic  tumour  of  the  cervix  uteri  removed  by  the  ecraseur, 
ibid.,  pp.  332-4. 

29.  Epithelioma  of  the  female  breast,  ibid.,  pp.  375-7. 

30.  Eight  cases  of  ovariotomy,  with  remarks  on  the  means  of 
diminishing  the  mortality  after  this  operation,  '  Dublin  Quarterly 
Journal  of  Medical  Science,*  vol.  xxviii,  1859,  pp.  257-98. 


ANNUAL   ADDRESS.  93 

31.  Three  cases  of  ovariotomy,  '  Med.  Times  and  Gaz.,'  vol.  ii, 
1859,  pp.  11-13,  31-3,  and  59. 

32.  Three  cases  of  ovarian  disease ;  ovariotomy ;  iodine  injection  ; 
simple  tapping,  ibid.,  pp.  159-61. 

33.  Two  cases  of  ovariotomy,  ibid.,  pp.  605-7. 

34.  Communication  between  the  aorta  and  left  bronchus,  '  Trans. 
Path.  Soc.,'  vol.  X,  1858-9,  pp.  71-3. 

35.  Cyst  of  the  broad  ligament,  ibid.,  pp.  189-90. 

36.  Ovarian  cyst  removed  successfully,  ibid.,  pp.  187-8. 

37.  Ovarian  cyst  which  had  contained  seventy-two  pints  of  fl  uid, 
ibid.,  p.  189. 

38.  Pseudo-colloid  ovarian  tumour,  ibid.,  pp.  197  and  200. 

39.  Two  ovarian  cysts  ruptured  spontaneously,  ibid.,  p.  196. 

40.  Fibrous  tumour  of  the  ovary,  ibid.,  p.  199. 

41.  Invasion  of  the  sanctity  of  private  practice  by  a  medical 
journal  (Letter),  *  Lancet,'  vol.  i,  1859,  pp.  146-7. 

42.  Personal  observations  on  the  results  of  the  Rev.  Hugh  Reed's 
treatment  of  cancer,  '  Med.  Times  and  Gaz.,'  vol.  i,  1860,  pp.  596-8 
and  619-22. 

43.  Recto-vaginal  fistula ;  septum  ruptured  at  the  consummation 
of  marriage  ;  operation  ;  cure,  ibid.,  pp.  61-2. 

44.  Multilocular  ovarian  cyst ;  ovariotomy ;  cure,  ibid.,  pp.  189-90. 

45.  Case  of  ovariotomy,  ibid.,  pp.  235-7. 

46.  Five  cases  of  ovarian  cysts  successfully  treated  by  iodine 
injection,  ibid.,  pp.  549-50. 

47.  Four  cases  of  ovariotomy,  ibid.,  vol.  ii,  1860,  pp.  178-80. 

48.  Case  of  ovariotomy,  ibid.,  p.  531, 

49.  Specimen  of  spunous  hermaphroditism,  '  Trans.  Path.  Soc.,' 
vol.  xi,  1859-60,  p.  158. 

50.  Three  cases  of  tetanus  in  which  "  woorara"  was  used.  16  pp., 
8vo,  London,  1860. 

51.  A  lecture  on  the  revival  of  the  Turkish  or  ancient  Roman 
bath.  16  pp.,  8vo,  London,  1860;  also  'Med.  Times  and  Gaz.,' 
vol.  ii,  1860,  pp.  423-7. 

52.  Cancer  cures  and  cancer  curers.     93  pp.,  12mo,  London,  1860. 

53.  Case  of  large  congenital  encephaloid  tumour  not  impeding 
delivery,  '  Trans.  Obstet.  Soc.  Lond.,'  vol.  ii,  1860,  pp.  27-8. 

54.  Twelve  ovarian  cysts  and  tumours  removed  by  ovariotomy, 
'  Trans.  Path.  Soc.,'  vol.  xi,  1859-60,  pp.  165-71. 

55.  Specimens  showing  the  condition  of  the  abdomen  nine  months 
after  ovariotomy,  ibid.,  pp.  171-2. 

56.  Pelvis  and  nerves  from  a  patient  who  died  of  tetanus,  ibid., 
p.  281. 


94  BIBLIOGRAPHICAL    APPENDIX    TO 

57.  Female  bladder,   showing  the  results  of  retention  of  urine 
after  delivery,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  iii,  1861,  pp.  354-5. 

58.  Compound  ovarian  cyst ;  ovariotomy  ;  recovery,  '  Med.  Times 
and  Gaz.,'  vol.  i,  1861,  p.  145. 

59.  Three  cases  of  ovariotomy,  ibid.,  pp.  545-7. 

60.  Five  cases  of  ovariotomy,  ibid.,  vol.  ii,  1861,  pp.  528-9. 

61.  Lecture  on  some  remediable  causes  of  sterility,  ibid., 
pp.  601-4. 

62.  Lecture  on  vesico-vaginal  and  recto-vaginal  fistula,  Samaritan 
Hospital,  '  Brit.  Med.  Journ.,'  vol.  ii,  1861,  pp.  223-5,  250-52,  275-7. 

63.  Hydropathy  and  homceopathy  at  Malvern  (Letter),  ibid., 
pp.  423-4. 

64.  On  the  treatment  of  large  ovarian  cysts  and  tumours,  ibid., 
pp.  656-8,  679-81. 

65.  Ovarian  cysts  and  tumours  removed  by  ovariotomy,  '  Trans. 
Path.  Soc.,'  vol.  xii,  1860-61,  pp.  156-7  ;  vol.  xiii,  1861-2,  p.  172;  and 
vol.  xiv,  1862-3,  pp.  204-6. 

66.  Ovarian  cyst  which  proved  fatal  by  spontaneous  rupture,  ibid  , 
vol.  xii,  1860-61,  pp.  155-6. 

67.  Tumour  and  portion  of  lower  jaw  removed  by  excision,  ibid., 
pp.  217-19. 

68.  Multilocular  ovarian  cyst ;  twelve  tappings  ;  ovariotomy ;  re- 
covery, '  Med.  Times  and  Gaz.,'  1862,  vol.  i,  pp.  8-9. 

69.  How  to  stop  bleeding  by  acupressure  (Letter),  ibid.,  p.  303. 

70.  Clinical  remarks  on  seven  cases  of  ovariotomy,  ibid.,  vol.  ii, 

1862,  pp.  27-8,  75-7,  (Letter)  155,  (Letter)  186. 

71.  Five  cases  of  ovariotomy,  all  successful ;  clinical  remarks  ; 
Samaritan  Hospital,  ibid.,  vol.  i,  1863,  pp.  267-9. 

72.  Seven  cases  of  ovariotomy  in  private  practice,  ibid.,  pp.  314-16. 

73.  Five  cases  of  ovariotomy,  Samaritan  Hospital,  ibid.,  pp.  586-8. 

74.  Case  of  vesico- utero-vaginal  fistula  cured  at  one  operation, 
ibid.,  pp.  58-9. 

75.  Gratuitous  medical  advice  to  insurance  companies  (Letter), 
ibid.,  pp.  117-18. 

76.  Eight  c  ases  of  ovariotomy,  Samaritan  Hospital,  ibid.,  vol.  ii, 

1863,  pp.  560-62,  585-87. 

77.  On  the  history  and  progress  of  ovariotomy  in  Great  Britain, 
with  observations  founded  on  personal  experience  of  the  operation 
in  fifty  cases,  '  Med.-Chir.  Trans.,'  vol.  xlvi,  1863,  pp.  33-55. 

78.  Account  of  a  patient  upon  whom  ovariotomy  was  perfoi-med 
twice,  ibid.,  pp.  161-7. 

79.  Intussusception  of  caecum  and  colon,  replaced  by  gastrotomy, 
'  Trans.  Path  Soc.,'  vol.  xiv,  1862-3,  pp.  170-71. 


ANNUAL    ADDRESS.  95 

80.  Cancer  of  the  right  kidney, '  Trans.  Path.  Soc.,'  vol.  xiv,  1862.3, 
pp.  179-80. 

81.  Fibro-cystic  tumour  of  the  uterus,  ibid.,  p.  204. 

82.  A  thigh  and  leg  removed  by  amputation  at  the  hip-joint  [for 
malignant  tumour  in  biceps],  ibid.,  pp.  2^)8-9. 

83.  Syphon  trocar  and  hooked  cannula  for  ovariotomy  (Letter), 
'Brit.  Med.  Journ.,'  vol.  ii,  1863,  p.  651. 

84.  Two  cases  of  ovariotomy,  Samaritan  Hospital, '  Med.  Times  and 
Gaz.,'  vol.  ii,  1864,  pp.  567-8. 

85.  Celibacy  and  marriage  in  relation  to  uterine  tumours  (Letter), 
*  Lancet,'  vol.  i,  1864,  p.  23. 

86.  Case  of  ovariotomy,  and  reply  to  a  statement  respecting  it 
made  by  Mr.  Baker  Brown,  *  Trans.  Obstet.  Soc.  Lond.,'  vol.  iv,  1864, 
pp.  89-90. 

87.  Two  cases  of  exfoliation  of  the  female  bladder,  *  Trans.  Path. 
Soc.,'  vol.  XV,  1863-4,  pp.  140-42. 

88.  Three  specimens  of  cancer  of  the  ovary,  ibid.,  pp.  170-75. 

89.  Tubercle  of  the  ovary,  ibid.,  pp.  175-6. 

90.  Six  cases  of  ovariotomy,  Samaritan  Hospital, '  Med.  Times  and 
Gaz.,'  vol.  i,  1864,  pp.  587-8,  613-14. 

91.  Four  cases  of  ovariotomy,  three  successful,  Samaritan  Hos- 
pital, ibid.,  vol.  ii,  1864.  pp.  59-61. 

92.  Ova  in  ovarian  cyst  (Letter),  ibid.,  p.  160. 

93.  Some  causes  of  excessive  mortality  after  surgical  operations 
(Paper  read  at  the  Brit.  Med.  Assoc,  Cambridge),  'Brit.  Med.  Journ.,' 
vol.  ii,  1864,  pp.  384-8  ;  '  Med.  Times  and  Gaz.,'  vol.  ii,  1864,  pp.  349-52. 

94.  Diagnosis  between  ovarian  dropsy  and  ascites,  Samaritan 
Hospital,  'Med.  Times  and  Gaz.,'  vol.  ii,  1864,  pp.  327-9. 

95.  Diagnosis  of  ovarian  from  uterine  tumours  (Letter),  'Brit. 
Med.  Journ.,'  vol.  i,  1864,  pp.  519-20. 

96.  Practical  details  in  ovariotomy  (Letter),  ibid.,  pp.  676-7. 

97.  Statistics  of  ovariotomy  (Letter),  ibid.,  vol.  ii,  1864,  p.  322. 

98.  Extracts  from  lectures  clinical  and  systematic.  I.  On  innocent 
and  malignant  tumours,  ibid.,  pp.  685-6. 

99.  Second  series  of  fifty  cases  of  ovariotomy,  with  remarks  on 
the  selection  of  cases  for  the  operation, '  Med.-Chir.  Trans.,'  vol.  xlviii, 
1865,  pp.  215-26. 

100.  Diseases  of  the  ovaries;  their  diagnosis  and  treatment.  In 
two  volumes.  Vol.  I,  xvi-376  pp.,  8vo.,  London,  1865  ;  Vol.  II,  xxiv- 
478  pp.,  London,  1872. 

101.  Acute  traumatic  peritonitis  [after  ovariotomy]  ;  venesection; 
recovery,  Samaritan  Hospital,  '  Brit.  Med.  Journ.,'  vol.  i,  1865,. 
p.  242. 


96  BIBLIOGRAPHICAL    APPENDIX    TO 

102.  Dr.  Richardson's   suggestion  for  the  treatment  of  ovarian 
tumours  (Letter),  'Brit.  Med.  Journ.,'  vol.  i,  1865, p.  258. 

103.  Results    of    ovariotomy    (Letter),   '  Lancet,'  vol.    i,    1865, 
pp.  271-2. 

104.  Dr.  M.  Sims  on  hysterotomy  (Letter),  ibid.,  p.  578. 

105.  Semi-solid  ovarian  tumour,  '  Trans.  Path.  Soc.,'  vol.  xvi, 
1864-5,  pp.  206-7. 

106.  Fatty  tumour  from  the  recto-vaginal  septum.  New  mode  of 
preserving  morbid  preparations,  ibid.,  pp.  277-8. 

107.  Lecture  on  the  results  of  the  surgical  treatment  of  cancer, 
*  Med.  Times  and  Gaz.,'  vol.  i,  1865,  pp.  137-9. 

108.  Cases  of  ovariotomy,  Samaritan  Hospital,  ibid.,  pp.  9-10, 
466-7,  491-3,  546-7;  vol.  ii,  1865,  pp.  11-12,  116-18,  255-6;  vol.  i, 
1866,  pp.  62-4, 145, 307, 339-40, 590-91,  615-16  ;  vol.  ii,  1866,  pp.  340-42, 
582-3;  vol.  i,  1867,  pp.  714-15;  vol.  ii,  1867,  pp.  8-9,  63-4,  120-21; 
vol.  i,  1868,  pp.  10-11,  144-5,  202-3,  577-9,  635-6;  vol.  ii,  1868, 
pp.  32-3,  93-4,  239-40,  364-5. 

109.  Six  cases  of  ovariotomy  in  private  practice,  ibid.,  vol.  i,  1865, 
pp.  302-4,  355-7. 

110.  Cases  of  ovariotomy  in  private  practice,  ibid.,  vol.  ii,  1865, 
pp.  465-6,  518-19,  570-72,  652-4. 

111.  Successful  case  of  ovariotomy  complicated  by  Csesarean 
section,  ibid.,  pp.  359-62. 

112.  On  excision  of  enlarged  spleen,  with  a  case  in  which  the 
operation  was  performed,  ibid.,  vol.  i,  1866,  pp.  2-5. 

113.  Two  cases    o£  ovariotomy  (operated   upon  at  the   Chester 
General  Infirmary) ;  clinical  remarks  on  different  modes  of  dealing 

with  the  pedicle  in  ovariotomy,  delivered  at  the  General  Infirmary, 
Chester,  *  Brit.  Med.  Journ.,'  vol.  ii,  1866,  pp.  352-3  and  377-9. 

114.  Two  fibrous  tumours  of  the  round  ligament  of  the  uterus, 
'  Trans.  Path.  Soc.,'  vol.  xvii,  1865-6,  p.  188. 

115.  Fibro -cystic  tumour  with  diseased  uterus  and  ovary,  ibid., 
pp.  202-4. 

116.  Enlarged  spleen  excised  during  life,  ibid.,  pp.  294-8. 

117.  Uterine  epistaxis  in  cholera,  fever,  and  inflammation  (Letter), 
*  Med.  Times  and  Gaz.,'  vol.  ii,  1866,  p.  237. 

118.  Use  of  the  catheter  after  operating  on  vesico-vaginal  fistula 
(Letter),  ibid.,  p.  514. 

119.  Case  in  which  ovariotomy  was  twice  successfully  performed 
on  the  same  patient,  '  Med.-Chir.  Trans.,'  vol.  1,  1867,  pp.  1-13. 

120.  Third  and  fourth  series  of  fifty  cases  of  ovariotomy,  with 
remarks  on  the  situation  and  length  of  the  incision  required  in  this 
operation  ibid.,  pp.  543-60. 


ANNUAL   ADDKESS.  97 

121.  On  the  diagnosis  of  renal  from  ovarian  cysts  and  tumours, 

*  Dubl.  Quart.  Journ.  Med.  Sci.,'  February,  1867,  No.  85,  pp.  128-41. 

122.  Review  of  a  year's  progress  in  ovariotomy,  '  Med.  Times  and 
Gaz.,'  vol.  i,  1867,  pp.  2-3. 

123.  Remarks  on  ovariotomy  at  Prof.  Gross's  Clinic,  Jefferson 
Medical  College,  Philadelphia,  ibid.,  vol.  ii,  1867,  pp.  576-8. 

124.  Cystoid  enlargement  of  the  kidneys,  'Trans.  Path.  Soc.,* 
vol.  xviii,  1866-7,  pp.  167-71. 

125.  Renal  calculi  from  a  large  renal  tumour,  ibid.,  p.  181. 

126.  Note-book  for  cases  of  ovarian  and  other  abdominal  tumours, 
25  pp.,  8vo,  Lond.,  1868. 

127.  Improved  method  of  exposing  vesico-vaginal  fistula,  '  Brit. 
Med.  Journ.,'  vol.  ii,  1868,  p.  202. 

128.  Notes  of  an  autumn  holiday  in  America,  ibid.,  vol.  i,  1868, 
pp.  48-9  and  118. 

129.  Recent  experience  in  ovariotomy,  clinical  remarks  at  the 
Samaritan  Hospital,  'Med.  Times  and  Gaz.,'  vol.  ii,  1868,  pp.  605-8. 

130.  Fatty  tumour  of  mesentery  removed  during  life,  '  Trans. 
Path.  Soc.,'  vol.  xix,  1867-8,  p.  243. 

131.  A  third  series  of  one  hundred  cases  of  ovariotomy,  with 
remarks  on  tapping  ovarian  cysts,  '  Med.-Chir.  Trans.,'  vol.  lii,  1869, 
pp.  197-209. 

132.  On  the  complication   of  pregnancy  with   ovarian  disease, 

*  Trans.  Obstet.  Soc.  Lond.,'  vol.  xi,  1869,  pp.  251-63. 

133.  On  hydrate  of  chloral  and  its  use  in  practice,  '  Med.  Times 
and  Gaz.,'  vol.  ii,  1869,  pp.  346-7  and  408. 

134.  Who  introduced  the  use  of  the  clamp  in  ovariotomy  ?  (Letter 
from  '  Boston  Med.  and  Surg.  Journ.'),  ibid.,  vol.  i,  1869,  p.  280. 

135.  On  operations  for  the  cure  of  vaginal  fistulae,  *  St.  Thomas's 
Hospital  Reports,'  new  series,  vol.  i,  1870,  pp.  307-29. 

136.  Further  hospital  experience  of  ovariotomy;  clinical  remarks, 
'  Med.  Times  and  Gaz.,'  vol.  ii,  1870,  p.  265  ;  vol.  i,  1871,  pp.  186-9, 
336-7. 

137.  Successful  extirpation  of  one  kidney  (Letter),  ibid.,  vol.  i, 
1870,  p.  45. 

138.  On  atresia  vaginae,  ibid.,  pp.  88-90. 

139.  Election  of  council  at   the   College   of  Surgeons   (Letter), 

*  Lancet,'  vol.  i,  1870,  p.  636. 

140.  A  fourth  series  of  one  hundred  cases  of  ovanotomy,  with 
remarks  on  the  diagnosis  of  uterine  from  ovarian  tumours,  '  Med.- 
Chir.  Trans.,'  vol.  liv,  1871,  pp.  263-78. 

141.  Exfoliation  of  the  bladder,  '  Brit.  Med.  Journ.,'  vol.  ii,  1871, 
pp.  8  and  9. 

VOL.  XL.  7 


98  BIBLIOGRAPHICAL   APPENDIX    TO 

.     142.  Hsemorrliage  after  ovariotomy  (Letter),  '  Brit.  Med.  Journ.,' 
vol.  ii,  1872,  p.  82. 

143.  On  the  varieties  of  fever  wliicli  follow  surgical  operations, 
'  Med.  Times  and  Gaz.,'  vol.  i,  1872,  pp.  93-4,  483-4. 

144.  On  antiseptic  dressing  after  amputation  of  the  breast,  ibid., 
pp.  707-8. 

145.  Ovariotomy  in  Sweden  (Letter),  ibid.,  vol.  ii,  1872,  pp.  527-8. 

146.  Fifth  series  of  100  cases,  with  remarks  on  the  results  of  500 
cases  of  ovariotomy,  '  Med.-Chir.  Trans.,'  vol.  Ivi,  1873,  pp.  113-28. 

147.  Ovariotomy  successful  in  a  girl  eight  years  old,  '  Brit.  Med. 
Journ.,'  vol.  i,  1874,  pp.  342-3. 

148.  Pyaemia  in  private  practice  (in  discussion  at  Clinical  Society), 
ibid.,  pp.  380-81 ;  and  '  Trans.  Clin.  Soc.,'  vol.  vii,  1874,  pp.  98-102. 

149.  Ovariotomy  in  Holland,  '  Med.  Times  and  Gaz.,'  vol.  i,  1874, 
pp.  642-4. 

150.  Opening  and  concluding  remarks  on  the  relation  of  puer- 
peral fever  to  the  infective  diseases  and  pysemia  (in  discussion  at 
the  Obstetrical  Society),  '  Trans.  Obstet.  Soc.,'  vol.  xvii,  1875, 
pp.  90-101  and  265-72  ;  '  Brit.  Med.  Journ.,'  vol.  i,  1875,  pp.  501-3 
and  p.  563,  and  vol.  ii,  1875,  pp.  105-6;  'Med.  Times  and  Gaz.,' 
vol.  i,  1875,  pp.  436-9,  and  vol.  ii,  1875,  pp.  134-6. 

151.  Surgery,  past,  present,  and  future.  Excessive  mortality 
after  surgical  operations.  (Revised  reprint  of  two  addresses  to  the 
British  Medical  Association,  1864  and  1877),  8vo,  Lond.,  1877.  {See 
Nos.  93  and  156.) 

152.  Additional  cases  of  ovariotomy  performed  during  preg- 
nancy, '  Trans.  Obstet.  Soc.  Lond.,'  vol.  xix,  1877,  pp.  185-92. 

153.  Three  hundred  additional  cases  of  ovariotomy,  with  remarks 
on  drainage  of  the  peritoneal  cavity,  '  Med.-Chir.  Trans.,'  vol.  Ix, 
1877,  pp.  209-28. 

154.  Remarks  on  the  case  of  Miss  Martineau,  '  Brit.  Med.  Journ.,' 
vol.  i,  1877,  p.  543  ;  '  Med.  Times  and  Gaz.,'  vol.  i,  1877,  p.  517. 

155.  The  case  of  Miss  Martineau  (Letter),  *  Brit.  Med.  Journ.,' 
vol.  ii,  1877,  p.  785. 

156.  Address  in  surgery  (annual  meeting  of  Brit.  Med.  Assoc), 
*Brit.  Med.  Journ.,'  vol.  ii,  1877,  pp.  189-94;  'Med.  Times  and 
Gaz.,'  vol.  ii,  1877,  pp.  145-50. 

157.  Twenty  years'  work  in  the  Samaritan  Hospital,  1857-77, 
shortly  reviewed,  '  Brit  Med.  Journ,,'  vol.  ii,  1877,  pp.  837-8. 

158.  Observations  on  the  successful  removal  of  a  solid  uterine 
fibroma  weighing  seventy  pounds,  ibid..  May  11th,  1878,  p.  674. 

159.  Lectures  on  the  diagnosis  and  surgical  treatment  of  abdo- 
minal tumours,  delivered  at  the  Royal  College  of  Surgeons,  ibid., 


ANNUAL   ADDRESS.  99 

vol.  i,  1878,  pp.  853-6,  883-6, 925-8  ;  vol.  ii,  pp.  1-4,  45-9,  85-8, 129-32  ; 

*  Med.  Times  and  Gaz.,'  vol.  i,  1878,  pp.  641-5,  669-72,  697-700 ;  vol.  ii, 
1878,  pp.  18-21,  41-6,  63-6,  91-4. 

160.  History  of  ovariotomy  in  Italy,  '  Brit.  Med.  Journ.,'  vol.  i, 
1878,  pp.  363-4;  vol.  ii,  1878,  p.  762. 

161.  Excision  of  a  fibro-cystic  uterine  tumouv,  ibid.,  vol.  ii,  1878, 
pp.  865-6. 

162.  Clinical  remarks  on  ovariotomy  at  the  Samaritan  Hospital, 

*  Med.  Times  and  Gaz,,'  vol.  i,  1878,  pp.  4-6. 

163.  The  syphon  trocar  for  tapping  and  ovariotomy  (Letter),  ibid., 
vol.  ii,  1878,  p.  204,  and  '  Brit.  Med.  Journ.,'  vol.  ii,  1878,  p.  270. 

164.  Remarks  on  forcipressure  and  the  use  of  pressure  forceps  in 
surgery,  '  Brit.  Med.  Journ.,'  1879,  vol.  i,  p.  926  ;  vol.  ii,  p.  3. 

165.  Removal  of  both  ovaries  for  dysmenorrhcea,  '  Trans.  Amer. 
Gyn.  Soc.,'  vol.  iv,  1879,  pp.  198-207. 

166.  Vivisection  and  ovariotomy,  '  Brit.  Med.  Journ.,'  vol.  ii,  1879, 
p.  794. 

167.  Antiseptic  surgery  and  its  statistics,  ibid.,  vol.  i,  1880,  p.  72. 

168.  Notes  of  an  Easter  holiday  trip  to  Madeira,  ibid.,  p.  767. 

169.  Cremation  or  burial  (paper  read  at  '  Brit.  Med.  Assoc,  Cam- 
bridge, August,  1880),  ibid.,  vol.  ii,  1880,  pp. 461-3;  also  'Med.  Times 
and  Gaz.,'  vol.  ii,  1880,  p.  226.     (See  No.  185.) 

170.  Recent  improvements  in  the  mode  of  removing  uterine 
tumours, '  Brit.  Med.  Journ.,'  vol.  i,  1881,  p.  909. 

171.  Porro's  operation  in  England,  ibid.,  vol.  ii,  1881,  p.  714. 

172.  Recent  advances  in  the  surgical  treatment  of  intra-peritoneal 
tumours,  '  Trans.  Internat.  Med.  Cong.  1881,'  vol.  ii,  pp.  225-8 ;  also 
^Brit.  Med.  Journ.,'  vol.  ii,  1881,  p.  358. 

173.  Two  hundred  additional  cases,  completing  one  thousand  cases 
of  ovariotomy,  with  remarks  on  recent  improvements  in  the  opera- 
tion, '  Med.-Chir.  Trans.,'  vol.  Ixiv,  1881,  pp.  167-83. 

174.  Case  of  excision  of  a  gravid  uterus,  with  epithelioma  of  the 
cervix,  with  remarks  on  the  operations  of  Blundell,  Freund,  and 
Porro,  ibid.,  vol.  Ixv,  1882,  pp.  25-37. 

175.  On  ovarian  and  uterine  tumours  ;  their  diagnosis  and  treat- 
ment. xxx-530  pp.,  8vo,  London,  1882.  (A  second  edition  of  the 
work  published  in  1872,  but  rewritten  and  enlarged.) 

176.  Remarks  on  holiday- making  and  the  health-resorts  of  Norway, 

*  Brit.  Med.  Journ.,'  vol.  ii,  1882,  p.  504. 

177.  Note  on  mesenteric  cysts  and  tumours,  ibid.,  pp.  113-18. 

178.  The  Hunterian  oration,  delivered  Feb.  14th,  1883,  at  the 
Royal  College  of  Surgeons  of  England,  ibid.,  vol.  i,  1883,  pp.  291-4; 
also  '  Lancet,'  vol.  i,  1883,  pp.  263-7. 


100  BIBLIOGRAPHICAL    APPENDIX   TO 

179.  Ovariotomy  statistics  (Letter  to  Prof.  Gross),  '  Med.  Times 
and  Gaz.,'  vol.  i,  1883,  p.  253. 

180.  Case  of  excision  of  a  large  cancerous  kidney,  '  Med.-Chir. 
Trans.,'  vol.  Ixvi,  1883,  pp.  305-9. 

181.  Successful  removal  of  two  solid  circumrenal  tumours,  '  Brit. 
Med.  Journ.,'  vol.  i,  1884,  p.  758. 

182.  On  early  and  late  removal  of  abdominal  tumours,  '  Med. 
Times  and  Gaz.,'  vol.  ii,  1884,  p.  1. 

183.  The  revival  of  ovariotomy,  and  its  influence  on  modern  sur- 
gery. The  inaugural  address  of  the  session  1884-5  of  the  Midland 
Medical  Society,  November  5th,  1884,  31  pp.,  8vo,  London,  1884 ; 
also  '  Lancet,' vol.  ii,  1884,  pp.  811-15,  857-60;  'Med.  Times  and 
Gaz.,'  vol.  ii,  1884,  pp.  637-42 ;  and  '  Brit.  Med.  Journ.,'  vol.  ii,  1884, 
pp.  893-949. 

184.  Pneumotomy,  '  Brit.  Med.  Journ.,'  vol.  i,  1884,  p.  1117. 

185.  Cremation  or  burial  .^  (Revised  reprint  included  v*rith  Sir 
Henry  Thompson's  '*  Cremation,"  70  pp.,  8vo,  London,  1884),  pp.  39- 
49.     {See  No.  169.) 

186.  Diagnosis  and  surgical  treatment  of  abdominal  tumours. 
vi-216  pp.,  8vo,  London,  1885. 

187.  Address  on  cremation,  *  Med.    Press  and  Circ,  vol.   xxxix„ 

1885,  pp.  367-9. 

188.  Inaugural  address.  Sanitary  Institute  of  Great  Britain,  Con- 
gress at  York.     20  pp.,  8vo,  London,  1886. 

189.  Castration  in  mental  and  nervous  diseases.  A  symposium 
(Spencer  Wells,  Hegar,  and  Battey),  '  Internat.  Journ.  Med. 
Sciences,'  October,  1886,  pp.  455-71. 

190.  Solid  tumours  of  the  mesentery  (Letter),  *  Lancet,'  Feb.  20th, 

1886,  p.  375. 

191.  Introductory  note  to  Erichsten  (Hugo),  '  The  cremation  of 
the  dead,  considered  from  an  aesthetic,  sanitary,  religious,  his- 
torical, medico-legal,  and  economical  standpoint.'  8vo,  Detroit,  1887. 

192.  Comparison  of  the  Csesarean  section  with  Porro's  operation, 

♦  Brit.  Med.  Journ.,'  vol.  ii,  1887,  p.  928. 

193.  Notes  of  a  case  of  Porro's  operation,  ibid.,  vol.  i,  1887,  p.  1267. 

194.  Notes  on  a  visit  to  Pistyan,  ibid.,  vol.  i,  1888,  p.  945. 

195.  Remarks  on  the  electrical  treatment  of  diseases  of  the 
uterus,  ibid.,  pp.  995-7. 

196.  A  note  on  methylene  and  other  anaesthetics,  ibid.,  p.  1211. 

197.  Remarks  on  splenectomy,  with  report  of  a  successful  case, 
'Med.-Chir.  Trans.,'  vol.  Ixxi,  1888,  pp.  255-63. 

198.  Case  of  splenectomy,  *  Lancet,'  vol.  i,  1888,  p.  724. 

199.  Cases  of  ovariotomy  performed  twice  on  the  same  patient, 

*  Trans.  Amer.  Gynec.  Soc.,'  vol.  xiii,  1888,  pp.  101-9. 


ANNUAL    ADDEESS.  101 

200.  The  Morton  Lecture  on  cancer  and  cancerous  diseases,  de- 
livered at  the  Royal  College  of  Surgeons  of  England,  November  29th, 
1888.  47  pp.,  8vo,  Lond.,  1889;  also  'Brit.  Med.  Journ.,'  vol.  ii, 
1888,  pp.  1265-9. 

201.  Historical  note  on  ovariotomy  in  Spain,  ibid.,  vol.  i,  1889, 
p.  833, 

202.  An  address,  on  the  progress  of  cremation  in  England, 
delivered  at  Hastings,  ibid.,  p.  1280. 

203.  A  case  of  splenectomy;  with  a  history  of  the  disease  by 
W.  N.  Maccall ;  and  with  a  report  on  the  blood  a  year  after  the 
operation  by  J.  Dreschfeld,  ibid.,  vol.  ii,  1889,  p.  55. 

204.  Death  forty-seven  years  after  ovariotomy  (Letter),  '  Lancet,' 
November  9th,  1889,  p.  975. 

205.  Death  during  the  administration  of  methylene  (Letter), 
'  Lancet,'  October  25th,  1890,  p.  898. 

206.  Note  on  mesenteric  and  omental  cysts,  'Brit.  Med.  Journ.,' 
vol.  i,  1890,  p.  1361. 

207.  Address  on  national  health,  ibid.,  vol.  ii,  1890,  pp.  771-7.  {See 
No.  208.) 

208.  Introductory  address  [on  national  health,]  delivered  at  the 
opening  of  the  session  1890-91  of  the  medical  department  of  the 
Owens  College,  Manchester.  8vo,  Lond.,  1890.  (Revised  reprint  of 
No.  207.) 

209.  Resultats  eloignes  de  I'ablation  des  annexes  de  I'uterus  dans 
les  affections  non  neoplasiques  de  ces  organes,  '  Congres  fran9ais  de 
Chirurgie,'  5e  session,  Paris,  1891,  pp.  157-9. 

210.  Modern  abdominal  surgery  :  the  Bradshaw  Lecture  delivered 
at  the  Royal  College  of  Surgeons  of  England,  December  18th, 
1890,  with  an  appendix  on  the  castration  of  women.  8vo,  Lond., 
1891 ;  also  '  Brit.  Med.  Journ.,'  vol.  ii,  1890,  pp.  1413  and  1465. 

211.  Personal  experiences  of  aseptic  and  antiseptic  surgery,  ibid., 
vol.  i,  1892,  p.  1178. 

212.  Failure  or  cure  ?  (two  Letters),  '  Lancet,'  January  31st,  1891, 
p.  275,  and  February  14th,  1891,  pp.  392-3. 

213.  The  prevention  of  preventable  disease  (an  address  to  the 
Glasgow  Obstetrical  and  Gynaecological  Society),  '  Glasgow  Med. 
Journ.,'  vol.  xl,  1893,  pp.  1-17. 

214.  Disposal  of  the  dead  (in  conjunction  with  F.  W.  Lowndes), 
article  in  Stevenson  and  Murphy's  '  Treatise  on  hygiene  and  public 
health,'  vol.  ii,  8vo,  Lond.,  1893,  pp.  671-729. 

215.  Childbirth  after  splenectomy,  '  Brit.  Med.  Journ.,'  vol.  i, 
1893,  p.  205. 

216.  The  end  of  a  practical  cure,  ibid.,  p.  398. 


102  BIBLIOGRAPHICAL    APPENDIX    TO 


Paet  II. 
List  of  De.   J.  Braxton  Hicks's  Published  Weitings, 

AEEANGED    ChEONOLOGICALLY. 

I.  Medical  Papers,  &c.,  with  Subject-Index. 
II.  Scientific  (Non-medical)  Papers,  &c. 


I.  Medical  Papers,  &c. 

1.  Case  of  ruptured   uterus   during   parturition,   '  Guy's   Hosp. 
Bep.,'  vol.  V,  1859,  pp.  84-8. 

2.  Remarks  on  two  cases  of  extra-uterine  foetation,  ibid.,  vol.  vi, 
1860,  pp.  272-80. 

3.  On  a  new  method  of  version  in  abnormal  labour,  '  Lancet,' 
July  14tli  and  21st,  1860,  pp.  28-30  and  55. 

4.  On   concealed  accidental   hsemorrbage   at   tbe   latter  end  of 
pregnancy  and   during   labour,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  ii, 

1860,  pp.  53-78. 

5.  Remarks  on   kiestine   and   its   existence   in   the   virgin   and 
sterile  states,  '  Guy's  Hosp.  Rep.,'  vol.  vii,  1861,  pp.  102-8. 

6.  On  cauliflower  excrescence  of  the  os  uteri,  ibid.,  pp.  241-56. 

7.  New  instruments  for  the  removal  of  uterine  polypi,  '  Trans. 
Obst.  Soc.  Lond.,'  vol.  iii,  1861,  pp.  346-9. 

8.  Cases   of   retention   of    menses   (from   malformation),   '  Med. 
Times  and  Gaz.,'  August  17th,  1861,  pp.  163-4. 

9.  Further  illustrations  of  the  new  method  of  version,  '  Lancet,' 
February  9th,  1861,  pp.  134-6. 

10.  Cases  of  induction  of   prematui'e  labour,  ibid.,  October  5th, 

1861,  p.  331,  and  '  Med.  Times  and  Gaz.,'  December  14th,  1861, 
p.  609. 

11.  Five   cases   of    vaginal   closure,    '  Trans.    Obst.   Soc.   Lond.,' 
vol.  iv,  1862,  pp.  228-42. 

12.  Two    cases   of  extra-uterine   foetation   treated   by   abdominal 
section,  '  Guy's  Hosp.  Rep.,'  vol.  viii,  1862,  pp.  127-41. 

13.  Notes  on  two  cases  of  uterine  polypi,  ibid.,  p^D.  142-6. 


ANNUAL    ADDRESS.  103 

14.  On  combined  external  and  internal  version,  *  Ti'ans.  Obst. 
Soc.  Lond.,'  vol.  v,  1863,  pp.  219-59 ;  Appendix,  pp.  265-6. 

15.  Three  cases  of  labour  obstructed  by  abnormal  condition 
of  the  foetus,  witli  some  other  points  of  interest,  ibid.,  pp.  285-90. 

16.  On  the  glandular  nature  of  proliferous  disease  of  the  ovary, 
with  remarks  on  proliferous  cysts,  *  Guy's  Hosp.  Rep.,'  vol.  x,  1864, 
p.  238. 

17.  On  combined  external  and  internal  version.  Lond.,  1864, 
72  pp. 

18.  An  inquiry  into  the  best  mode  of  delivering  the  foetal  head 
after  perforation,  '  Trans,  Obst.  Soc.  Lond.,'  vol.  vi,  1864,  pp.  263- 
303. 

19.  Three  cases  of  obstructed  labour;  forceps  and  craniotomy 
employed  in  former  labours  in  each ;  delivered  readily  by  version, 
'  Med.  Times  and  Gaz.,'  vol.  i,  1864,  p.  425. 

20.  Introductory  address  at  Guy's  Hospital  (abstract),  ibid., 
October  8th,  1864,  pp.  378-9;  'Brit.  Med.  Journ.,'  October  15th, 
1864,  pp.  436-7. 

21.  On  two  cases  of  face-presentation  in  the  mento-posterior 
position,  with  remarks,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  vii,  1865, 
pp.  57-67. 

22.  On  cystic  or  hydatidiform  disease  of  the  chorion,  '  Guy's 
Hosp.  Rep.,'  vol.  xi,  1865,  pp.  181-5. 

23.  On  a  rare  form  of  extra-uterine  foetation,  '  Trans.  Obst.  Soc. 
Lond.,'  vol.  vii,  1865,  pp.  95-8. 

24.  Large  fibrous  tumour  of  uterus;  spontaneous  sloughing; 
death  from  peritonitis,  ibid.,  pp.  110-12. 

25.  Remarks  on  the  use  of  fused  anhydrous  sulphate  of  zinc  to 
the  canal  of  the  cervix  uteri,  ibid.,  vol.  viii,  1866,  p.  220. 

26.  Notes  on  cases  connected  with  obstetric  jurisprudence,  '  Guy's 
Hosp.  Rep.,'  vol.  xii,  1866,  pp.  471-8. 

27.  Contribution  to  the  pathology  of  puerperal  eclampsia,  *  Trans. 
Obst.  Soc.  Lond.,'  vol.  viii,  1866,  pp.  323-34. 

28.  On  amputation  of  the  cervix  uteri  and  other  methods  of  local 
treatment  in  cases  of  malignant  disease  of  the  uterus  and  vagina, 
♦  Guy's  Hosp.  Rep.,'  vol.  xii,  1866,  pp.  365-80. 

29.  On  a  rare  case  of  intra-mural  foetation,  'Trans.  Obst.  Soc. 
Lond.,'  vol.  ix,  1867,  p.  57. 

30.  The  cephalotribe,  'Brit.  Med.  Journ.,'  October  19th,  1867, 
pp.  337-8. 

31.  Case  of  extra-uterine  foetation  treated  by  abdominal  section, 
'  Trans.  Obst.  Soc.  Lond.,'  vol.  ix,  1867,  p.  93. 

32.  Dissections   of   acephalous    monsters    without   bead,   heart, 


104  BIBLIOGRAPHICAL    APPENDIX    TO 

lungs,  or  liver  (with  J.  Bankart),  '  Guy's   Hosp.    Rep.,'  vol.  xiii, 

1867,  pp.  456-61. 

33.  On  the  condition  of  the  uterus  in  obstructed  labour ;  and  an 
inquiry  as  to  what  is  intended  by  the  terms  "  cessation  of  labour 
pains,"  "  powerless  labour,"  and  "  exhaustion,"  *  Trans.  Obst.  Soc. 
Lond.,'  vol.  ix,  1867,  pp.  207-27  ;  Appendix,  pp.  229-39. 

34.  Report  of  forty-one  cases  of  uterine  polypi,  with  remarks, 

*  Guy's  Hosp.  Rep.,'  vol.  xiii,  1867,  pp.  128-51. 

35.  Lectures  on  some  of  the  diseases  of  the  female  urethra  and 
bladder,  'Lancet,'  vol.  ii,  1867,  pp.  449,  479,  and  509  (October  12th, 
19th,  and  26th). 

36.  Case  of  Csesarean  section,  *  Trans.  Obst.  Soc.  Lond.,'  vol.  x, 

1868,  pp.  45-9. 

37.  Oration,  annual,  before  the  Hunterian  Society,  '  Med.  Times 
and  Gaz.,'  March  21st  and  28th,  1868 ;  and  (abstract)  '  Lancet,* 
February  22nd,  1868,  p.  260. 

38.  Case  of  face  presentation  in  which  delivery  was  effected  by 
the  cephalotribe,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  x,  1868,  p.  144. 

39.  On  transfusion  (abstract  and  discussion),  '  Brit.  Med.  Journ.,' 
August  8th  and  22nd,  1868,  pp.  151  and  203-4. 

40.  Cases  of  transfusion,  with  some  remarks  on  a  new  method  of 
performing  the  operation,  *  Guy's  Hosp.  Rep.,'  vol.  xiv,  1868, 
pp.  1-14. 

41.  Further  remarks  on  the  structure  of  the  growths  within 
ovarian  cysts,  ibid.,  p.  145. 

42.  On  rupture  of  the  vagina  in  labour,  '  Lancet,'  January  23rd, 

1869,  p.  119. 

43.  Some  remarks  on  the  cephalotribe, '  Trans.  Obst.  Soc.  Lond.,' 
vol.  xi,  1869,  pp.  43-52. 

44.  Vesical  absorption  (memorandum),  *  Brit.  Med.  Journ.,' 
March  16th,  1869,  p.  235. 

45.  Case  of  Caesarean  section,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  xi, 

1869,  pp.  99-102. 

46.  Cases  of  pregnancy  associated  with  ovarian  cystic   disease, 

*  Trans.  Obst.  Soc.  Lond.,'  vol.  xi,  1869,  pp.  263-5. 

47.  Remarks  on  the  use  of  the  intra-uterine  douche  after  labour, 
where  offensive  lochia  exist,  as  a  rule  of  practice, '  Brit.  Med.  Journ.,' 
November  13th,  1869,  p.  527. 

48.  The  cephalotribe  (Letter),  '  Brit.  Med.  Journ.,'  October  15th, 

1870,  p.  425. 

49.  Cases  of  successful  version  after  failure  of  the  forceps, 
'  Guy's  Hosp.  Rep.,'  vol.  xv,  1869-70,  pp.  501-8. 

50.  On  the  formation  of  a  Royal  Academy  of  Medicine  (Letters), 


ANNUAL    ADDRESS.  105 

'  Med.  Times  and  Gaz.,'  March  12th,  19th,and 26th,  1870,  pp.  295,  318, 
and  347. 

51.  A  contribution  to  our  knowledge  of  puerperal  diseases,  being 
a  short  report  of  eighty-nine  cases,  with  remarks,  *  Trans.  Obst.  Soc. 
Lond.,'  vol.  xii,  1870,  pp.  44-]  13. 

52.  Some  observations  on  an  outbreak  of  diphtheria  in  the  ob- 
stetric wards,  *  Guy's  Hosp.  Rep.,'  vol.  xvi,  1870-71,  pp.  165-70. 

53.  Inaugural  address  [on  election  as  President], '  Trans.  Obst.  Soc. 
Lond.,'  vol.  xiii,  1871,  pp.  27-37. 

54.  Medical  treatment  of  uterine  fibroids  (note),  *Brit.  Med. 
Journ.,'  April  8th,  1871,  pp.  370-72. 

55.  Abdominal  puncture  in  tympanites  (two  memoranda),  ibid., 
November  4th  and  11th,  1871,  pp.  526  and  556-7. 

56.  Remarks  on  tables  of  mortality  after  obstetric  operations 
(with  J.  J.  Phillips,  M.D.),  '  Trans.  Obst.  Soc.  Lond.,'  vol.  xiii,  1871, 
pp.  55-85. 

57.  A  record  of  observations  of  temperature  during  parturition 
and  in  the  puerperal  state,  '  Guy's  Hosp.  Rep.,'  vol.  xvii,  1871-2, 
pp.  447-64. 

58.  On  the  contractions  of  the  uterus  throughout  pregnancy, 
their  physiological  effects,  and  their  value  in  the  diagnosis  of  preg- 
nancy, '  Trans.  Obst.  Soc.  Lond.,'  vol.  xiii,  1871,  pp.  216-31. 

59.  The  education  of  women  in  midwifery  (Letter), '  Med.  Times 
and  Gaz.,'  November  25th,  1871,  p.  659. 

60.  Annual  (Presidential)  address,  *  Trans.  Obst.  Soc.  Lond.,' 
vol.  xiv,  1872,  pp.  25-34. 

61.  A  form  of  concealed  accidental  haemorrhage,  '  Brit.  Med. 
Journ.,'  February  24th,  1872,  pp.  207-8. 

62.  Some  remarks  on  the  anatomy  of  the  human  placenta, '  Journ. 
of  Anat.,'  vi,  1872,  pp.  405-10. 

63.  The  anatomy  of  the  human  placenta,  *  Trans.  Obst.  Soc.  Lond.,' 
vol.  xiv,  1872,  pp.  149-207. 

64.  Four  cases  of  inversion  of  the  uterus,  '  Brit.  Med.  Journ.,' 
May  4th,  1872,  p.  470. 

65.  Two  cases  of  chronic  inversion  of  the  uterus,  ibid.,  August  31st, 
1872,  pp.  237-8. 

66.  Observations  on  pathological  changes  in  the  red  blood-cor- 
puscles, '  Quart.  Journ.  Micr.  Sci.,'  vol.  xii,  1872,  pp.  114-17. 

67.  Annual  (Presidential)  address,  'Trans.  Obst.  Soc.  Lond.,' 
vol.  XV,  1873,  pp.  16-27. 

68.  Address  at  the  opening  of  the  section  in  obstetric  medicine, 
British  Medical  Association,  *  Brit.  Med.  Journ.,'  Aug.  16tb,  1873, 
pp.  184-7. 


106  BIBLIOGRAPHICAL    APPENDIX    TO 

69.  Case  of  delivery  by  the  forceps  in  face  presentation  in  the 
mento-lateral  position, '  Trans.  Obst.  Soc.  Lond.,'  vol.  xv,  1873,  p.  39. 

70.  Cauliflower  excrescence  of  os  uteri  (Letter),  '  Brit.  Med. 
Journ.,'  December  20tli,  1873,  pp.  738-9. 

71.  A  case  of  cephalotripsy,  witb  short  remarks,  '  Trans.  Obst. 
Soc.  Lond.,'  vol.  xv,  1873,  p.  41. 

72.  Note  on  the  muscular  sussurrus  in  relation  to  the  foetal 
heart-sounds,  *  Trans.  Obst.  Soc.  Lond.,'  vol.  xv,  1873,  p.  187. 

73.  Post-partum  haemorrhage,  '  Brit.  Med.  Journ.,'  January  17th, 
1874,  pp.  74-6. 

74.  Pyaemia  in  private  practice  (speech),  ibid.,  February  21st, 
1874,  pp.  235  and  237-8. 

75.  Local  treatment  of  cystitis  in  women,  ibid.,  July  11th,  1874, 
pp.  29-30. 

76.  Application  of  galvanic  cautery  in  gynaecology,  ibid.,  No- 
vember 28th,  1874,  pp.  672-3. 

77.  Lecture  introductory  to  '  Dystocia'  delivered  at  Guy's  Hospital, 
*  Med.  Times  and  Gaz.,'  1874,  pp.  201-3  ;  reprinted  as  pamphlet,  12  pp. 
8vo.  Lend.,  1888. 

78.  (Letter  on)  the  risks  of  obstetric  practice  [apropos  of  a  case, 
Reg.  V.  Peacock,  in  which  a  medical  man  was  charged  with  having 
cut  away  a  portion  of  intestine  which  had  become  prolapsed  during 
labour  through  a  rent  in  the  vagina],  '  Lancet,'  March  27th,  1875, 
p.  454. 

79.  Report  of  three  cases  of  cephalotripsy  (with  two  casts), 
'  Trans.  Obst.  Soc.  Lond.,'  vol.  xvii,  1875,  pp.  49-54. 

80.  Remarks  in  discussion  on  puerperal  fever,  ibid.,  pp.  108,  148, 
195,  209. 

81.  Note  on  a  dissection  of  a  uterus  pregnant  about  three  and  a, 
half  months,  the  placenta  being  prsevia  and  fibroids  extensively 
developed  in  the  walls  of  the  uterus,  ibid.,  p.  298. 

82.  Reposition  of  the  prolapsed  funis  umbilicalis,  '  Obstet.  Journ. 
Great  Britain,'  vol.  iii,  1875-6,  p.  84. 

83.  The  uterus  of  Harriet  Lane  referred  to  at  the  trial  of  Wain- 
wright,  with  statistics  of  measurements  of  nulliparous  and  multi- 
parous  uteri,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  xviii,  1876,  pp.  70-74. 

84.  On  the  displacement  of  the  uterus  by  the  distension  of  the 
bladder,  as  shown  by  experiments  on  the  dead  body  (with  J.  F. 
Goodhart,  M.D.),  ibid.,  pp.  194-205. 

85.  Duration  of  quarantine  required  after  puerperal  fever,  *  Brit. 
Med.  Journ.,'  January  22nd  and  April  1st,  1876,  pp.  101  and  407-8. 

86.  Haemorrhage  from  the  retroflected  uterus,  and  its  treatment, 
ibid.,  October  6th,  1877,  pp.  469-70. 


ANNUAL    ADDRESS.  107 

87.  Phantom  employed  for  class  purposes  in  midwifery,  *  Trans. 
Obst.  Soc.  Lond.,'  vol.  xix,  1877,  p.  231. 

88.  On  the  very  frequent  connexion  between  eczema  and  diabetes 
mellitus,  '  Lancet,'  March  31st,  1877,  p.  456. 

89.  Sex  in  disease.  Croonian  Lectures,  Royal  College  of  Physi- 
cians, '  Med.  Times  and  Gaz.,'  March  24th,  31st,  April  21st,  1877, 
pp.  305-6,  331-4,  411-15. 

90.  Case  of  Gsesarean  section,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  xx, 
1878,  pp.  106-9. 

91.  Puerperal  scarlatina  (memorandum),  'Brit.  Med.  Journ.,' 
February  2nd,  1878,  p.  153. 

92.  Scarlatina  and  surgery  (memorandum),  ibid.,  November  30th, 
1878,  p.  796. 

93.  Scarlatinoid  rash  of  ichorrhsemia  and  septicaemia  (memo- 
randum), ibid.,  January  4th,  1879,  p.  11. 

94.  Remarks  in  discussion  on  the  use  of  the  forceps,  '  Trans. 
Obst.  Soc.  Lond.,'  vol.  xxi,  1879,  pp.  218-26. 

95.  Three  cases  of  very  large  polypi  of  the  uterus,  in  which  the 
usual  modes  of  diagnosis  were  unattainable,  removed  successfully, 
'  Obst.  Journ.,'  vol.  vi,  January,  1879,  pp.  609-17. 

96.  Note  on  the  supplementary  forces  concerned  in  the  abdominal 
circulation  in  man,  '  Roy.  Soc.  Proc.,'  vol.  xxviii,  1879,  pp.  489-94. 

97.  Note  on  the  auxiliary  forces  concerned  in  the  circulation  of 
the  pregnant  uterus  and  its  contents  in  woman,  ibid.,  pp.  494-7. 

98.  On  nursing  systems,  '  Brit.  Med.  Journ.,'  January  3rd,  1880, 
p.  11. 

99.  On  recording  the  fcetal  movements  by  means  of  a  gastro- 
graph,  '  Trans.  Obst.  Soc.  Lend.,'  vol.  xxii,  1880,  p.  134. 

100.  Case  of  extra-uterine  fcetation  about  the  seventh  month  of 
pregnancy;  urgent  symptoms;  removal  of  foetus  by  abdominal 
section  ;  death,  ibid.,  pp.  141-50. 

101.  Case  of  congenital  abnormality  of  the  uterus  simulating 
retention  of  menses,  ibid.,  pp.  260-4. 

102.  Case  of  pregnancy  with  double  uterus  and  vagina,  ibid., 
vol.  xxiii,  1881,  p.  23. 

103.  Vertical  septum  in  lower  part  of  vagina  impeding  labour, 
ibid.,  p.  24. 

104.  Case  of  twins,  short  funis  in  both,  ibid.,  p.  253. 

105.  Further  remarks  on  the  use  of  the  intermittent  contractions 
of  the  pregnant  uterus  as  a  means  of  diagnosis,  '  Trans.  Intern. 
Med.  Congress.,'  Lcmd.,  1881,  vol.  iv,  p.  271. 

106.  Illness  of  the  Duchess  of  Connaught  (Letter),  'Brit.  Med. 
Journ.,'  March  25th,  1882,  p.  441. 


108  BIBLIOGRAPHICAL    APPENDIX    TO 

107.  Cases  in  which  the  whole  or  part  of  the  placenta  was 
retained  for  a  longer  time  than  usual, '  Brit.  Med.  Journ.,'  July  22nd, 
1882,  pp.  123-5. 

108.  The  government  of  Guy's  Hospital  (Letter),  ibid.,  November 
18th,  1882,  p.  1021. 

109.  On  the  behaviour  of  the  uterus  in  puerperal  eclampsia,  as 
observed  in  two  cases,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  xxv,  1883, 
pp.  118-25. 

110.  The  tension  of  the  abdomen  and  its  variations,  *  Trans.  Med. 
Soc.  Lond.,'  vol.  vi,  London,  1884,  pp.  325-42. 

111.  Clinical  memoranda  of  two  cases  of  chronic  vaginitis,  with 
remarks,  '  Lancet,'  vol.  i,  1885,  pp.  610-611. 

112.  A.  condition  of  the  inner  surface  of  the  uterus,  after  the 
birth  of  the  foetus,  of  practical  importance,  'Brit.  Med.  Journ.,' 
October  10th,  1885,  p.  696,  and  January  23rd,  1886,  p.  145. 

113.  Notes  of  cases  in  obstetric  jurisprudence,  '  Lancet,'  August 
1st,  8th,  and  15th,  1885,  pp.  198,  243,  and  285. 

114.  The  treatment  of  placenta  prsevia,  '  Med.  Press  and  Circular,' 
September  9th,  1885,  p.  223. 

115.  Puerperal  diseases  :  an  explanation,  '  Amer.  Journ.  of  Ob- 
stetrics,' May,  1886,  pp.  474-81. 

116.  On  a  cause  of  uterine  displacement  not  hitherto  mentioned 
contra-indicating  the  use  of  pessaries,  '  Lancet,'  vol.  i,  1886,  p.  537. 

117.  On  the  spontaneous  rupture  of  the  uterus  during  pregnancy 
(Letter),  '  Med.  Press  and  Circular,*  November  17th,  1886,  p.  441. 

118.  Management  of  placenta  praevia  (Letter),  '  Brit.  Med.  Journ.,' 
January  1st,  1887,  p.  42. 

119.  (Two  Letters)  on  the  treatment  of  placenta  praevia,  '  Lancet,' 
vol.  i,  1887,  pp.  648  and  749. 

120.  On  the  influence  of  bodily  movements  over  septic  absorption, 

*  Intern.  Journ.  Med.  Science,'  July,  1888,  pp.  38-43. 

121.  Case  of  inversio  uteri ;  reduction ;  recovery ;  remarks, 
•Ti-ans.  Obst.  Soc.  Lond.,'  vol.  xxxi,  1889,  pp.  340-42. 

122.  (Two  Letters)  on  the  best  mode  of  delivering  the  fcetal  head 
after  craniotomy,  '  Lancet,'  vol.  i,  1889,  pp.  197  and  400. 

123.  Why  does  the  uterus  contract  during  pregnancy  ?  (Letter), 

*  Lancet,'  vol.  i,  1889,  p.  765. 

124.  Puerperal  fevers  and  septicaemia  (Letter),  '  Brit.  Med. 
Journ.,'  March  30,  1889,  p.  742. 

125.  On  the  treatment  of  placenta  praevia  (introduction  to  dis- 
cussion), ibid.,  November  30th,  1889,  p.  1205. 

126.  The  best  mode  of  delivering  the  foetal  head  after  craniotomy 
(Letter),  ibid.,  February  9th,  1889,  p.  328. 


ANNUAL    ADDRESS. 


109 


127.  On  the  non-retention  of  urine  in  women  (Letter),  *Brit. 
Med.  Journ.,'  November  16th,  1889,  p.  1091. 

128.  A  case  showing  the  behaviour  of  the  pregnant  uterus  in 
chorea,  '  Trans.  Obst.  Soc.  Lond.,'  vol.  xxxiii,  1891,  p.  486. 

129.  Puerperal  eclampsia  (Letter),  *  Brit.  Med.  Journ.,'  October 
3rd,  1891,  p.  766. 

130.  Further  contribution  to  the  clinical  knowledge  of  puerperal 
diseases,  'Trans.  Obst.  Soc.  Lond.,'  vol.  xxxv,  1893,  pp.  412-19. 

131.  Our  knowledge  of  puerperal  diseases  (Letter),  'Brit.  Med. 
Journ.,'  December  9th,  1893,  p.  1307. 

132.  On  intermittent  contractions  of  uterine  fibromata,  and  in 
pregnancy,  in  relation  to  diagnosis,  'Med.  Press  and  Circular,' 
May  9th,  1894,  p.  481. 

133.  In  memoriam  Sir  Thomas  Spencer  "Wells,  Bart.,  F.R.C.S., 
*  Trans.  Amer.  Gyn.  Soc.,'  vol.  xxii,  1897,  pp.  313-18. 


SUBJECT-INDEX  TO    SOME    OF    THE    PRINCIPAL    PAPERS    IN 

THE    ABOVE    LIST. 


Addresses,  20,  37,  53,  60,  67,  68. 

Caesarean  section  (cases),  36,  45,  90. 

Cephalotribe,  30,  43,  48,  71,  79. 

Cervix  uteri,  cauliflower  excrescence 
of,  6,  28,  70. 

Contractions,  uterine,  during  preg- 
nancy, 58,  105,  123,  132. 

Diseases  of  urethra  and  bladder  in 
women,  35,  44,  75,  127. 

— ,  puerperal  (febrile),  51,  74, 80, 85, 
91,  92,  93,  106,  115,  120, 124, 130, 
131. 

Displacements  of  uterus,  84,  86,  116 

Eclampsia,  puerperal,  27,  109,  129 

Face  presentatiou,  21,  38,  69. 

Fibroids,  uterine,  24,  54,  (in  preg- 
nancy) 81. 

Forces,  auxiliary,  in  abdominal  cir- 
culation, 96,  97. 

Gestation,  ectopic  (cases),  2,  12,  23, 
31,  100,  (intra-mural)  29. 

Haemorrhage,  concealed  accidental, 
4,61. 


Head,  delivery  of  fcetal,  after  perfo- 
ration, 18,  122,  126. 

Inversion  of  uterus,  64,  65,  121. 

Jurisprudence,  cases  in  obstetric,  26, 
78,  83,  113. 

Labour,  obstructed,  33,  (cases)  15, 19. 

Malformations  of  female  genital 
organs,  8,  11,  101,  102,  103. 

Menses,  retention  of,  8,  11,  101. 

Ovary,  proliferous  cysts  of,  16,  41, 
(in  pregnancy)  46. 

Placenta,  anatomy  of,  G2,  63,  (pla- 
cental site)  112. 

—  praevia,  treatment  of,  81,  114, 
118,  119,  325  (see  also  J'ersion). 

Polypi,  uterine,  7, 13,  34, 95,  (instru- 
ments for)  7 
Rupture  of  uterus,  1,  117. 

—  of  vagina,  42. 
Sex  in  disease,  89. 
Tension,  abdominal,  110. 
Version,  3,  9,  14,  17,  19,  49. 


110  BIBLIOGRAPHICAL    APPENDIX    TO 


II.  Scientific  (Non-medical)  Papers. 

1.  On  a  new  organ  in  insects  (1856),  'Linn.  Soc.  Journ.,'  vol.  i, 
1857  (Zool.),  pp.  136-40. 

2.  Description  of  a  new  Britisli  species  of  Draparnaldia,  ibid., 
(Bot.)  p.  192. 

3.  Further  remarks  on  tlie  organs  found  on  the  bases  of  the 
halteres  and  wings  of  insects,  '  Linn.  Soc.  Trans.,'  vol.  xxii,  1857 
(part  2),  pp.  141-6. 

4.  On  a  new  structure  in  the  antennae  of  insects,  ibid.,  pp.  147-54. 

5.  Humble  creatures  :  the  earthworm  and  the  common  house- 
fly. In  eight  letters  (jointly  with  J.  Samuelson).  With  microscopic 
illustrations  by  the  authors.     8vo,  Lond,  1858,  pp.  78. 

6.  Further  remarks  on  the  organs  of   the   antennae  of  insects, 

*  Linn.  Soc.  Trans.,'  1859,  pp.  383-99. 

7.  On  certain  sensory  organs  in  insects  hitherto  undescribed, 
'Roy.  Soc.  Proc.,'  vol.  x,  1859-60,  pp.  25-6;  'Linn.  Soc.  Trans.,' 
vol.  xxiii,  1862,  pp.  139-53. 

8.  Contributions  to  the  knowledge  of  the  development  of  the 
gonidia  of  lichens,  in  relation  to  the  unicellular  algae,  '  Microsc. 
Journ.,'  vol.  viii,  1860,  pp.  239-44;  vol.  i,  1861,  pp.  15-23;  vol.  ii, 
pp.  90-97. 

9.  On  the  amoeboid  conditions  of  Volvox  glohator,  '  Microsc.  Soc. 
Trans.,'  vol.  viii,  1860,  pp.  99-102. 

10.  The  honey-bee :  its  natural  history,  habits,  anatomy,  and 
microscopical  beauties  (jointly  with  J.  Samuelson).  8vo,  Lond., 
1860,  pp.  166. 

11.  On  the  homologies  of  the  eye,  and  of  its  parts,  in  the  Inverte- 
brata,  '  Roy.  Soc.  Proc.,'  xi,  1860-62,  pp.  80-84. 

12.  On  the  diamorphosis  of  Lyngbyn,  Schizogonium,  and  Prasiola, 
and  their  connexion  with  the  so-called  Palmellaceae,  '  Microsc. 
Journ.,'  vol.  i,  1861,  pp.  157-66. 

13.  On  the  motionless  spores  (statospores)  of  Volvox  glohator^ 
ibid.,  pp.  281-3. 

14.  On  the  nerve  proceeding  to  the  vesicles  at  the  base  of  the 
halteres,  and  on  the  subcostal  nervure  in  the  wings  of  insects  (1861), 

*  Linn.  Soc.  Trans.,'  xxiii,  1862,  pp.  377-9. 

15.  Observations  on  the  gonidia  and  confervoid  filaments  of 
mosses,  and  on  the  relation  of  their  gonidia  to  those  of  lichens  and 
of  certain  fresh-water  algae,  ibid.,  pp.  567-88. 

16.  Observations  on  vegetable  amceboid  bodies,  '  Microsc.  Journ.,' 
vol.  ii,  1862,  pp.  96-103. 


ANNUAL   ADDRESS.  Ill 

17.  Remarks  on  Mr.  Archer's  paper  on  algse,  '  Quart.  Journ. 
Microsc.  Sci.,'  vol.  iv,  1864,  pp.  253-9. 

18.  On  the  difficulties  in  identifying  many  of  the  lower  kinds  of 
algse,  '  Pop.  Sci.  Rev.,'  vol.  iv,  1865,  pp.  335-42. 

19.  On  the  Volvox  glohator, '  Pop.  Sci.  Rev.,'  vol.  v,  1866,  pp.  137-44. 

20.  On  the  mode  of  growth  of  some  of  the  algas,  ibid.,  vol.  vi, 
1867,  pp.  1-9. 

21.  On  fresh-water  algse,  '  Quart.  Journ.  Microsc.  Sci.,'  vol.  vii, 
1867,  pp.  4-8. 

22.  On  Draparnaldia  cruciata,  mihi,  ibid.,  vol.  ix,  1869,  pp.  383-5. 

23.  On  the  similarity  between  the  genus  Draparnaldia  and  the 
confervoid  filaments  of  mosses  (1869),  '  Linn.  Soc.  Trans.,'  xxvii, 
1871,  pp.  153-4. 


I 


MARCH  2nd,   1898. 
C.  J.  CuLLiNGWORTH,  M.D.,  President,  in  the  Chair. 

Present — 42  Fellows  and  4  visitors. 

Books  were  presented  by  Professor  von  Winckel, 
Professor  Kleinwachter,  Dr.  Herman,  Sir  H.  W.  Acland, 
Dr.  Wilson,  the  Clinical  Society,  and  the  New  York 
Academy  of  Medicine. 

Henry  Menzies,  M.B.Cantab.,  was  admitted  a  Fellow 
of  the  Society. 

Alfred  Walker,  M.A.,  M.D.  (Wimbledon),  and  Thomas 
Cullen,  M.B.  (Baltimore),  were  declared  admitted. 

The  following  gentlemen  were  elected  Fellows  of  the 
Society  : — Percy  Leonard  Blaber,  L.R.C.P.Lond. ;  Charles 
Edwin  Purslow,  M.D.Lond. ;  Arthur  James  Sturmer, 
Surgeon-Lieutenant-Colonel,  I. M.S.  ;  and  Claude  Wilson, 
M.D.Edin. 


CASE    OF    DECIDUOMA    MALIGNUM. 

Shown  by  J.  H.  Targett,  for  Dr.  Hellier. 

E.  P — ,  married,  aged  39,  7-para,  residing  in  Leeds  in 
the  manufacturing  portion  of  the  city,  and  practically  at 
the   bottom   of   the  Aire   valley,   was   admitted  into   the 

VOL.  XL.  8 


114  DECIDUOMA    MALIGNDM. 

Hospital  for  Women  at  Leeds  under  my  care  on  June  1st, 
1897.  She  seems  to  liave  enjoyed  good  health  up  to  the 
time  of  her  last  confinement,  which  took  place  on  January 
20th_,  1897.  Her  previous  labours  had  been  normal.  On 
the  19th  December,  1896,  she  had  slipped  and  broken  her 
right  leg.  This  kept  her  in  bed  up  to  the  time  of  con- 
finement, but  the  bone  united  well  and  the  general  health 
was  not  impaired. 

Labour  seems  to  have  been  neither  difficult  nor  ab- 
normal. The  placenta  came  away  in  ten  minutes ;  there 
was  some  considerable  loss  of  blood  post  partum.  She  re- 
mained in  bed  for  three  weeks,  and  had  each  day  a  good 
deal  of  coloured  discharge.  The  discharge  seems  to  have 
continued  more  or  less  up  to  admission  on  June  1st.  It 
was  usually  red  in  colour,  but  was  sometimes  dark  brown, 
and  in  the  middle  of  May  it  became  extremely  offensive ; 
also  she  was  now  confined  to  bed  again.  She  had  very 
little  pain,  and  none  on  defa3cation.  Two  weeks  before 
admission  she  began  to  have  a  bad  cough,  and  she  felt 
very  ill. 

On  admission  (June  1st). — Obviously  very  ill,  sallow, 
anaemic,  but  not  emaciated.  Temp.  99° ;  pulse  82,  feeble 
but  regular ;  respirations  28.  She  was  expectorating 
brownish  mucus  tinged  with  blood.  There  was  a  loud 
systolic  bruit  heard  at  the  left  base  of  the  heart,  and  con- 
sidered to  be  h^mic.  There  were  crepitant  rales  heard 
over  the  bases  of  the  lungs  with  dulness,  most  marked 
on  the  left  side.  Urine  sp.  gr.  1018,  no  albumen  and  no 
pus.  The  abdomen  presented  no  irregularity  of  outline, 
the  walls  contained  a  good  layer  of  fat,  they  were  not 
distended,  and  there  was  very  little  tenderness.  Liver 
dulness  not  increased  ;  resonance  normal  except  just  above 
pubes,  where  the  enlarged  uterus  reached  halfway  from 
symphysis  to  umbilicus. 

On  vaginal  examination  the  enlarged  uterus  was  felt 
bimanually,  the  cervix  occupying  a  normal  position.  The 
OS  was  patulous,  the  fornices  free.  The  finger  readily 
passed  into  the  cervix,  but  no  new  growth  could  be  reached  ,- 


DECIDUOMA    MALIGNUM.  115 

examination  caused  no  pain^  but  the  finger  was  withdrawn 
covered  with  reddish-brown,  highly  offensive  discharge. 
It  seemed  probable  that  the  case  was  one  of  retained 
placental  tissue  with  septic  infection,  but  the  possibility 
of  the  presence  of  malignant  disease  was  also  considered. 

On  June  6th  the  patient  was  placed  under  ether  in  the 
lithotomy  position.  The  uterus  was  considerably  enlarged, 
reaching  halfway  to  the  umbilicus.  The  os  admitted  the 
finger  without  other  dilatation,  the  cervix  being  held  with 
vulsellum.  Soft  granular  material  could  be  felt  in  the 
uterus,  and  this  material  was  removed  by  a  large  scoop. 
It  came  away  piecemeal,  was  dark  red,  soft,  and  offensive, 
and  looked  like  placental  debris.  There  was  a  fair 
amount  of  hasmorrhage.  The  uterus  was  washed  out  with 
carbolic  lotion  and  packed  with  iodoform  gauze.  She  was 
alarmingly  prostrate  in  the  after  part  of  the  day. 

7th. — Pulse  very  feeble,  respiration  rapid,  tempera- 
ture not  above  100 •4°.  Extension  of  mischief  in  lungs, 
prognosis  very  bad.  Uterus  douched  daily  with  iodine 
lotion  ;  iodoform  vaginal  suppositories. 

It  may  be  sufficient  to  summarise  the  after  history  by 
saying  that  she  lived  four  days  longer.  The  discharge 
from  the  uterus  was  highly  offensive.  There  was  pneu- 
monic consolidation  in  both  bases,  especially  the  left ;  the 
sputum  was  thin  and  slightly  viscid,  and  contained  dark 
brown,  highly  offensive  masses.  The  pulse  grew  exceed- 
ingly feeble,  the  respirations  rapid  and  shallow.  She  had 
rigors  on  the  7th  and  10th.  The  temperature  was  never 
found  above  101°  except  after  the  first  rigor,  when  it 
reached  101*6°.  There  was  no  great  abdominal  tender- 
ness, pain,  or  distension.  She  died  on  June  11th,  twenty 
weeks  after  the  confinement.  At  no  time  after  admission 
could  the  possibility  of  a  radical  operation  be  entertained. 

The  post-mortem  was  made  by  my  house  surgeon,  Mr. 
C.  B.  Pierson.  On  account  of  an  obstetric  case  I  felt 
obliged  to  be  absent. 

Post-mortem, — On  opening  the  abdomen  the  uterus  was 
found  to  be  much  enlarged,  and  the  seat  of  new  growth. 


116  DECIDUOMA    MALIGNUM. 

which  involved  the  appendages,  welding  them  into  a  large 
mass  on  the  left  posterior  aspect  of  the  uterus.  The 
rectum  also  was  involved  here. 

The  transverse  colon,  omentum,  last  part  of  the  ileum, 
and  the  appendix  vermiformis  were  all  firmly  adherent  to 
the  upper  part  of  the  uterus,  and  could  be  separated  only 
with  the  greatest  difficulty.  Immediately  above  the  trans- 
verse colon  was  a  mass  surrounded  by  small  intestines, 
which  appeared  to  consist  of  a  secondary  deposit  with  pus 
and  debris.  The  pouch  of  Douglas  contained  about  one 
ounce  of  turbid  yellow  fluid.  The  liver  was  large  and 
exceedingly  friable.  The  capsule  was  quite  smooth.  On 
section  the  liver  presented  a  nutmeg  appearance.  The 
spleen  was  exceedingly  soft,  the  kidneys  were  pale,  with 
capsules  adherent  in  some  places.  In  the  stomach  and 
other  abdominal  viscera  no  pathological  changes  were 
noticed.  The  uterus,  appendages,  and  rectum  were  re- 
moved en  masse  for  further  examination. 

The  lungs  were  removed  with  the  greatest  difficulty, 
owing  to  very  firm  pleuritic  adhesions,  which  corresponded 
to  nodules  of  deposit  in  the  lungs.  Along  the  anterior 
margin  of  the  right  lung,  and  scattered  in  irregular 
manner  through  the  left,  were  found  nodules,  reddish 
brown  in  colour,  round  or  oval  in  shape,  and  measuring  a 
quarter  to  one  and  a  half  inches  in  diameter  ;  one  of  these 
was  removed  for  microscopic  examination. 

There  was  pneumonic  consolidation  of  the  lower  two 
thirds  of  the  left  lung,  and  some  similar  change  in  the 
right  base.  The  bronchial  glands  were  enlarged,  hard, 
and  black.  One  nodule  of  new  growth  invaded  the  peri- 
cardium and  caused  a  patch  of  dulness  upon  its  inner 
surface.  The  pericardium  contained  two  drachms  of  fluid. 
The  heart  was  pale  pink  in  colour ;  the  walls  were  thin, 
and  the  seat  of  fatty  degeneration.  A  well-marked 
striation  could  be  seen  almost  over  the  whole  inner  surface 
of  the  left  ventricle.  A  portion  of  heart  muscle  was  found 
on  microscopic  examination  to  show  marked  fatty  degene- 
ration. 


DECIDOOMA    MALIGNUM.  117 

On  examining  the  pelvic  organs  the  uterus  was  found 
to  measure  4^  inches  in  length.  The  cavity  of  the  fundus 
was  lined  by  a  mass  of  new  growth,  which  at  certain  parts 
could  be  separated  from  the  uterine  wall,  but  elsewhere 
was  firmly  blended  with  it. 

The  growth  was  soft,  greyish  brown,  ulcerated  and 
sloughy  upon  the  surface,  and  highly  offensive.  It  in- 
vaded the  posterior  uterine  wall,  perforating  this.  On  the 
left  and  posterior  aspect  of  the  fundus  uteri  was  a  large 
mass  consisting  of  a  deposit  of  the  neoplasm,  to  which  the 
rectum  was  adherent.  Within  the  mass  was  a  cavity 
irregularly  ulcerated,  and  communicating  with  the  interior 
of  the  uterus  through  a  fistulous  opening  in  the  left 
lateral  wall.  At  the  upper  part  the  cavity  also  commu- 
nicated by  a  small  aperture  with  the  sigmoid.  The  right 
ovary  was  infiltrated  with  new  growth. 

I  am  indebted  to  Mr.  Targett,  of  the  Clinical  Kesearch 
Association,  for  the  following  report  upon  the  parts  re- 
moved. 

Report  on  Dr.  Hellier^s  Specimen. 

The  specimen  consists  of  the  uterus  and  its  appendages 
with  the  adjacent  portion  of  the  sigmoid  colon.  The 
uterus  has  been  laid  open  anteriorly.  It  measures  nearly 
5  inches  in  extreme  length,  and  the  cavity  is  4^  inches 
long,  of  which  2  inches  may  be  apportioned  to  the  canal 
of  the  cervix  uteri.  In  the  posterior  and  left  lateral 
walls  of  the  cavity  near  the  fundus  uteri  there  is  a  large 
oval  aperture,  measuring  1^  inches  in  its  chief  diameter. 
The  margins  of  this  aperture  are  surrounded  by  a  new 
growth,  which  projects  above  the  level  of  the  mucous  sur- 
face of  the  uterus  in  the  form  of  a  raised,  nodular,  everted 
edge.  The  aperture  leads  into  a  large  cavity  behind  and 
to  the  left  of  the  uterus.  This  cavity  is  situated  between 
the  layers  of  the  left  broad  ligament,  the  Fallopian  tube, 
ovary,  and  round  ligament  of  which  are  stretched  over  it. 
On  the  back  of  this  cavity  is  seen  an  adherent  coil  of 
sigmoid  flexure  and  the  mesosigmoid  ;   externally  it  must 


118  DECIDUOMA  MALIGNUM. 

have  been  in  contact  witli  the  pelvic  wall,  and  internally 
it  is  adherent  to  the  whole  length  of  the  body  of  the 
uterus.  The  dimensions  of  this  cavity  are  4  inches  from 
side  to  side,  3  inches  from  above  downwards,  and  2  inches 
from  before  backwards.  The  interior  is  partially  filled 
with  new  growth  and  blood-clot,  the  former  being  directly 
continuous  with  that  which  is  in  the  wall  of  the  uterus. 

The  right  Fallopian  tube  and  mesosalpinx  are  normal, 
but  in  the  situation  of  the  right  ovary  there  is  a  secondary 
mass  of  growth  which  is  somewhat  globular  in  shape,  and 
measures  2  inches  in  diameter.  The  greater  part  of  this 
mass  is  situated  between  the  layers  of  the  right  broad 
ligament,  but  it  has  extended  through  the  hilum  into  the 
substance  of  the  ovary,  the  outline  of  which  can  be  recog- 
nised on  the  upper  surface  of  the  tumour.  A  narrow 
strip  of  apparently  normal  broad  ligament  exists  between 
the  right  side  of  the  uterus  and  the  tumour  itself.  The 
pouch  of  Douglas  proper  is  not  encroached  upon,  but  the 
space  behind  the  body  of  the  uterus  is  much  diminished 
by  the  adhesions  of  the  sigmoid  flexure  and  the  size  of  the 
tumour  in  the  right  broad  ligament. 

After  hardening,  the  specimen  was  further  dissected, 
and  the  following  details  may  be  added  to  the  above 
description  : — The  extension  of  the  new  growth  to  the  left 
of  the  uterus  is  undoubtedly  between  the  layers  of  the 
left  broad  ligament,  the  left  ovary  being  displaced  up- 
wards, flattened  out,  and  invaded  through  its  hilum  as  on 
the  opposite  side.  The  cavity  formed  here  by  the  breaking 
down  of  the  growth  not  only  communicates  with  the  uterus, 
but  by  a  small  fistula  with  the  sigmoid  colon,  and  by  a 
ragged  aperture  in  the  mesosigmoid  with  the  general 
peritoneal  cavity. 

Microsco'plcal  examination. — In  structure  this  growth 
corresponds  so  closely  with  those  already  recorded  in  the 
'  Transactions  ^  of  this  Society,  that  it  will  be  unnecessary 
to  describe  it  in  detail.  Sections  of  it  are  largely  com- 
posed of  blood-clot,  laminated  fibrin,  inflammatory  cells, 
and  necrotic  tissue.    Where  it  invades  the  uterine  wall  the 


Plate  I. 


Obstet.  Soc.  Trans.,  \'ol.  XL. 


Fig.  I.— section   OF   EDGE   OF    UTERINE   GROWTH. 


Fir..  2.— SECTION   OF   GROWTH   IN   OVARY. 


Printed  and  Engrovid  by  Bale  d  Danichson.  Ltd  .  London. 


DERMOID  TUMOUR  OP  BOTH  OVARIES.         119 

growth  consists  of  two  classes  of  cells,  the  one  polyhedral 
in  shape  with  large  round  vesicular  nuclei,  the  other  plas- 
modia  or  large  irregular  masses  of  granular  material  con- 
taining many  nuclei,  and  often  vacuolated.  The  uterine 
tissue  in  advance  of  the  growth  is  infiltrated  with  small, 
round,  inflammatory  cells.  The  secondary  growths  in  the 
right  ovary  and  lung,  though  very  necrotic,  resembled 
that  of  the  uterus.  In  spite  of  the  obscurity  of  its  astio- 
logy,  the  histological  features  of  deciduoma  malignum  are 
so  peculiar  that  the  growth  may  be  easily  recognised  under 
the  microscope,  and  may  justly  claim  a  distinctive  title. 

J.  H.  Targett. 

Dr.  Eden  said  that  Mr.  Targett  had  very  kindly  given  him 
an  opportunity  some  time  ago  of  examining  the  microscopic 
specimens  from  this  case,  and  he  quite  agreed  with  him  that  the 
growth  was  of  the  same  nature  as  those  described  under  the 
name  of  deciduoma  malignum  by  Continental  writers.  At  the 
same  time  he  saw  no  reason  to  depart  from  the  view  he  had 
previously  advanced,  that  these  tumours  did  not  differ  in  any 
essential  particular  from  rapidly  growing  sarcoma  occurring  in 
other  parts  of  the  body  than  the  uterus. 


DOUBLE    MONSTER    OF    DICEPHALOUS    TYPE. 
Shown  by  Dr.  Owen  Fowler. 


DERMOID  TUMOUR  OF  BOTH  OVARIES,  WITH 
VERY  LONG  OVARIAN  LIGAMENT  ON  THE 
LEFT    SIDE. 

By  Dr.  Rivers  Pollock. 

Mrs.  K — ,  aged  48,  had  three  pregnancies  and  three 
children  ;  the  youngest  was  born  in  1882. 

Mrs.  K —  was  first  seen  on  December  14th,  1897,  when 


120  DERMOID    TUMOUR    OP    BOTH    OVARIES. 

well-marked  carcinoma  of  the  cervix  uteri  implicating  the 
surrounding  parts  was  found.  The  patient  was  not  seen 
for  some  weeks,  when,  not  being  so  well,  she  was  anxious 
to  return  to  the  hospital,  and  drove  from  Richmond  for 
readmission,  but  died  within  two  hours  of  uraemia  and 
asthenia. 

Post-mortem. — In  both  ovaries  there  was  a  dermoid 
tumour ;  the  left  ovary  was  lying  over  the  right  in  the 
right  iliac  fossa,  and  was  fixed  there  by  a  piece  of  omentum, 
which  was  again  fixed  deep  down  to  the  ileum.  The  left 
ovarian  ligament  was  much  stretched,  being  6^  inches 
long.  The  pelvis  of  both  kidneys  and  both  ureters  were 
dilated,  the  disease  implicating  the  bladder  where  the 
ureters  run  within  its  walls.  This  had  much  impeded  the 
flow  of  urine,  which  for  the  past  four  or  five  days  had 
been  very  scanty. 


121 


A    CASE    OF    DOUBLE    PYOSALPINX    IN  WHICH 
THE  TUBES  WERE  ENORMOUSLY  DISTENDED. 

By  C.  Hubert  Roberts,  M.D.,  F.R.C.S. 

The  following  are  the  notes  of  a  case  of  double  pyo- 
salpinx  which  is  somewhat  remarkable,  owing  to  the  extreme 
size  to  which  the  tubes  were  distended. 

The  case  occurred  at  the  Samaritan  Hospital  under  the 
care  of  Mr.  Meredith,  who  kindly  allows  me  to  publish  the 
notes  of  the  case. 

R.  T — _,  33  years  old,  married  twelve  and  a  half  years ; 
no  children,  no  miscarriages. 

History  of  present  condition. — '^  Inflammation  of  the 
bowels  ^^  at  twenty-one.  Seven  years  ago  had  a  fall  from 
a  chair  on  her  back,  which  caused  much  general  bruising 
and  shock.  When  she  began  to  get  about  again  she 
noticed  for  the  first  time  severe  pain  in  the  right  iliac 
region  ;  for  this  she  was  examined  by  a  doctor,  who  told 
her  there  was  something  wrong  with  the  womb.  A  pessary 
was  inserted,  but  it  caused  so  much  pain  that  she  discon- 
tinued it  at  the  end  of  three  months.  After  this  she  went 
to  the  country  and  rested,  and  in  about  twelve  months  was 
well  again. 

Four  years  ago  she  had  an  attack  of  pelvic  inflammation 
with  recurrence  of  the  pain  on  the  right  side ;  the  attack 
lasted  two  to  three  weeks.  She  did  not  notice  any  purulent 
discharge  up  to  April,  1897.  She  was  fairly  well  when 
she  again  had  an  attack  of  "  inflammation,"  and  great 
pain  in  the  same  region  {i.  e.  the  right  side). 

In  July,  1897,  another  attack,  and  at  the  same  time  a 
right  inguinal  hernia  appeared.      As  neither  the  pain  nor 


122  DOUBLE    PYOSALPINX  ' 

the  hernia  improyed^  she  came  to  the  Samaritan  Hospital 
under  the  care  of  Mr.  A.  C.  Butler- Smy the  as  out-patient 
in  September,  1897.  She  improved  somewhat,  but  finally 
he  advised  her  admission  as  an  in-patient,  and  she  came  in 
under  Mr.  Meredith  on  December  15th,  1897.  The  case 
was  then  regarded  as  one  of  chronic  inflammation  of  the 
appendages,  but  at  the  time  the  tubes  were  not  markedly 
enlarged,  though  they  were  very  fixed,  and  examination 
caused  her  much  pain.  There  was  some  discharge  of 
muco-pus,  but  nothing  in  her  history  pointing  markedly 
to  gonorrhoeal  or  septic  infection  beyond  the  sterility 
(twelve  and  a  half  years). 

The  patient  stated  on  admission  that  she  had  lost  flesh 
lately,  but  that  she  had  never  noticed  any  lump  or  swelling 
in  the  abdomen  beyond  the  hernia. 

She  complained  of  painful  and  frequent  micturition  for 
some  weeks  past,  but  has  had  no  trouble  with  defsecation. 

Since  the  original  onset  of  her  trouble,  seven  years  ago, 
her  periods  have  been  painful,  and  have  recurred  too  fre- 
quently ;  before  this  time  she  had  been  quite  regular. 

Condition  on  admission  (December  1 7th,  1897). — Rather 
pale,  fairly  well  nourished ;  tongue  coated  and  indented ; 
bowels  very  constipated ;  appetite  fair ;  sufi'ers  much  with 
indigestion  and  flatulence.  Pulse  84,  volume  fair  ;  nothing 
abnormal  in  chest ;   temp.  98*8°. 

Family  history. — Consumption  in  two  maternal  uncles 
and  one  aunt ;  one  brother  is  phthisical ;  patient  had 
scarlet  fever  at  eighteen.  She  states  that  she  had  inflam- 
mation of  the  bowels  when  she  was  twenty-one,  i,  e. 
shortly  after  marriage,  but  that  she  was  at  work  up  to 
seven  years  ago."^ 

On  examination  a  double  or  bilobed  tumour  extends 
upwards  from  the  pelvis  to  a  point  about  three  fingers' 
breadth  above  the  symphysis,  and  laterally  2\  inches  to 
the  right  and  2  inches  to  the  left  of  the  middle  line. 
Percussion  over  the  tumour  is  dull  except  at  the  upper 
and  lateral  borders,  where  it  is  overlapped  by  intestine. 

*  I  shall  refer  to  this  attack  again  later. 


DOUBLE     PYOSALPINX.  123 

Per  vaginam. — The  cervix  lies  to  the  left  of  the  middle 
line,  and  behind  this  are  apparently  two  more  or  less 
distinct  swellings  lying  behind  the  uterus  in  Douglas's 
pouch,  and  which  are  identical  with  the  swellings  or 
swelling  felt. 

On  abdominal  examination  the  mass  on  the  left  is  very 
closely  connected  with  the  back  of  the  uterus,  and  the 
uterus  rises  -svith  the  swelling  when  this  is  moved.  To  the 
right  of  this,  at  the  top  of  the  right  vaginal  fornix,  is 
another  rounded  and  larger  mass,  which  is  evidently 
somewhat  elastic,  and  part  of  the  swelling*  felt  above  the 
symphysis,  and  which  is  about  the  size  of  a  small  orange  ; 
it  moves  independently  of  the  left-sided  tumour,  against 
which  it  lies  in  close  proximity,  and  which  is  much 
smaller.  It  is  difficult  to  say  on  pelvic  examination  if  the 
two  swellings  are  quite  distinct,  but  they  are  elastic.  The 
uterus  lies  apparently  in  the  centre  of  the  mass  which  is 
felt  above  the  sjrmphysis,  but  it  is  not  enlarged.  The 
sound  passes  2  finches;  the  mass  to  the  right  lies  in  front 
of  the  uterus,  above  the  brim. 

Bimanual  examination  confirms  the  opinion  that  the 
two  bodies  in  Douglases  pouch  are  identical  with  those 
in  the  abdomen.  The  masses,  from  their  shape,  suggest 
enlarged  tubes  ;   they  are  very  fixed. 

Rectal  examination  also  confirms  the  above. 
Urine  contains  a  very  faint  cloud  of  albumen ;  other- 
wise it  is  normal. 

Since  her  admission  into  the  hospital  her  condition  has 
not  improved,  though  for  nearly  a  fortnight  after  her 
admission  the  pelvic  condition  remained  unchanged  and 
her  temperature  normal,  /.  e.  up  to  January  14th,  1898. 

On  January  15th  patient  complained  of  feeling  very  ill 
and  faint,  and  a  period  which  had  come  on  suddenly 
ceased ;  it  was  at  first  thought  this  was  due  to  a  bath 
which  she  had  taken,  but  she  became  worse,  and  her 
temperature  rose  to  101*8°,  with  severe  abdominal  pain. 
On  the  16th  her  temperature  was  102*2°,  dropping  in  the 
morning  and    rising  at   night,    and   of   the   hectic  type. 


124  DOUBLE    PYOSALPINX. 

Simultaneously  with  this  a  remarkable  change  took  place 
in  the  abdominal  swelling,  which  up  to  the  present  time 
had  only  reached  about  3  inches  above  the  symphysis ;  it 
was  found  to  have  rapidly  and  enormously  increased,  and 
on  the  21st  of  January  had  reached  the  navel,  the  swelling 
being  most  marked  on  the  right  side.  On  January  21st 
her  temperature  was  103°,  and  she  was  evidently  much 
worse,  and  in  considerable  pain  at  times.  The  question 
now  arose  as  to  the  condition,  whether  the  mass  was  an 
inflamed  fibroid,  or  peritonitis  around  diseased  tubes. 
During  the  next  few  days  patient  was  better,  but  her 
temperature  kept  up  and  down,  varying  between  101 
and  103°,  and  of  a  hectic  type.  On  January  27th  the 
abdominal  mass  reached  one  inch  above  the  navel  on 
the  right  side,  and  was  very  tense  and  tender,  and  the 
whole  abdomen  more  distended.  There  was  a  reddish 
discharge  jper  vaginam. 

Operation  was  decided  on,  and  performed  on  January 
28th  by  Mr.  Meredith.  Time,  2.15—3.40  p.m.  I  had 
the  pleasure  of  assisting.  Anassthetic,  chloroform.  Anti- 
septic, phenol. 

Details  of  operation. — On  opening  the  abdomen  the 
omentum  was  found  adherent  to  a  tumour,  and  to  the 
parietes  low  down  in  front.  This  was  carefully  separated 
and  pushed  up,  when  the  subjacent  mass  could  be  recog- 
nised as  a  greatly  distended  tube,  the  enlarged  succulent 
fimbriae  being  seen  at  its  outer  extremity.  It  was  next 
carefully  turned  up  into  the  abdominal  incision  and  lifted 
out  on  to  the  abdominal  wall  without  rupture,  when  its 
great  size  was  evident.  It  was  attached  to  the  right  side 
of  the  uterus.  This  connection  was  secured  by  trans- 
fixion with  silk  in  two  loops,  and  followed  by  a  final 
outside  loop  before  division.  No  leakage  of  any  material 
was  seen.  The  right  ovary,  unenlarged,  was  closely 
adherent  to  the  posterior  surface  of  the  broad  ligament 
below  the  place  where  the  ligatures  were  placed.  It  was 
left  undisturbed.  The  left  tube,  also  converted  into  a 
very  large  tumour,  was  next  discovered  buried  in  Douglas's 


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DOUBLE    PYOSALPINX.  125- 

pouch  beneath  adherent  intestine,  and  was  further  closely 
but  not  firmly  fixed  there  by  recent  adhesions.  With 
care,  and  after  much  trouble,  it  was  also  brought  up  un-^ 
ruptured ;  the  pedicle  was  ligatured,  and  it  was  removed 
together  ^vith  its  ovary.  There  was  tolerably  free  oozing^ 
from  the  pelvic  adhesions,  so  the  abdomen  was  washed  out 
with  sterilised  water  and  closed,  leaving  the  abdomen  full 
of  water. 

There  was  very  little  shock,  and  the  patient  has  made- 
an  uninterrupted  recovery.  Her  temperature  fell  the 
same  evening  to  99°,  and  on  the  30th  January  it  was 
normal,  and  remained  so  afterwards. 

Pathology. — The  two  tumours  removed  were  the  enor- 
mously dilated  Fallopian  tubes.  I  also  show  two  draw« 
ings  exact  size  from  nature,  drawn  the  same  evening, 
which  give  an  idea  of  the  shape  and  size  of  the  dilated 
tubes  ;  also  photographs.  They  exhibit  the  usual  features 
of  dilated  tubes,  but  are  of  unusual  size.  They  both 
contained  pus. 

The  right  tube,  which  is  much  the  larger  of  the  two,, 
has  the  following  dimensions  : — length,  6  J  inches  ;  breadth, 
3 J  inches ;   girth,   lOf  inches   at  greatest  circumference ; 
weight,    28   oz. ;    measurement  along  its  outside  margin,. 
14J  inches. 

The  left  tube  : — length,  5  inches  ;  breadth,  3  inches  ; 
girth,  9 J  inches;  weight,  13^  oz.  ;  outside  margin,  11 
inches. 

The  right  tube  exhibits  in  a  very  marked  way  the  great 
hypertrophy  of  the  fimbriated  extremity,  and,  when  fresh, 
these  fimbriae  were  a  brilliant  scarlet  colour.  The  closure- 
of  this  extremity  is,  therefore,  of  the  salpingitic  variety 
•  as  described  by  Mr.  Doran.  The  ovarian  fimbria  is  well 
seen  (see  Diagram  I)  on  the  under  surface,  and  the  large 
extent  and  breadth  of  the  pedicle  is  also  very  marked. 
The  uterine  end  of  the  tube  is  quite  normal,  though  the 
wall  of  the  tube  itself  very  near  to  it  is  greatly  thickened. 
The  enlargement  of  the  vessels  of  the  tube  and  their  cir- 
cular distribution  are  indicated  in  the  drawing. 


126  DOUBLE    PYOSALriNX. 

The  left  tube^  though  not  so  greatly  distended^  exhibits 
much  the  same  characters  ;  the  fimbriated  extremity  is 
very  much  hypertrophied,  but  it  is  closed  in  the  same 
salpingitic  way  as  the  right.  The  ovary  in  this  case  is 
seen  very  close  to  the  spot  where  the  ligature  was  applied, 
and  it  was  removed  with  the  tube. 

The  specimens  have  been  mounted  for  me  by  Dr. 
Morley  Fletcher,  the  Curator  of  St.  Bartholomew's  Hos- 
pital Museum,  and  are  preserved  in  formalin  and  glycerine. 

Dr.  F.  W.  Andrewes,  our  pathologist  at  St.  Bartholo- 
mew's, has  also  very  carefully  examined  the  pus  from 
both  tubes,  and  he  reports  that  it  contains  neither  tubercle 
bacilli  nor  gonococci,  although  many  slides  were  searched. 
There  were  cocci  in  plenty,  but  they  stained  well  by 
Grram's  method,. — even  those  that  were  intercellular,  which 
of  course  gonococci  do  not.  Dr.  Andrewes  made  cultures, 
but  they  were  all  sterile,  therefore  such  cocci  were  pro- 
bably dead.  It  is  of  course  possible  that  the  original 
infection  may  have  been  of  a  blennorrhagic  type,  as  the 
primordial  gonococci  may  have  perished. 

The  photographs  were  made  for  me  by  the  St.  Bartho- 
lomew's Photographic  Society. 

Remarlis. — The  case  is  of  interest  chiefly  on  account  of 
the  very  great  distension  of  the  Fallopian  tubes,  showing 
to  what  a  great  size  they  may  grow  without  rupture,  a 
thing  which  is  supposed  by  some  commonly  to  take  place 
with  a  fatal  event.  This  case  appears  to  contradict  such 
theories,  though  one  spot  on  the  left  tube  was  very  thin. 
It  is  remarkable,  too,  how  very  great  must  be  the  hyper- 
trophy of  the  walls  of  the  tube ;  and  although  both  con- 
tained pus,  and  were  acutely  inflamed,  how  such  inflam- 
mation was  limited  to  the  tubes,  and  how  comparatively 
slight  was  the  surrounding  peritonitis,  which  only  showed 
itself  by  recent  adhesions.  Personally  I  believe  that  fatal 
rupture  into  the  general  peritoneal  cavity  in  such  cases 
is  extremely  rare,  and  that  if  rupture  take  place  it  is 
into  some  adjacent  viscus,  such  as  bowel,  bladder,  or 
vagina. 


DOUBLE    PYOSALPINX.  127 

The  specimens  were  both  removed  unruptured,  a  great 
point  in  such  cases,  as  fouling  of  the  peritoneum  is  thus 
avoided  ;  although,  as  was  shown  hj  the  bacteriological 
examination,  the  pus  was  sterile. 

One  point  in  such  cases  of  great  interest  must  be  the 
cause  j  you  have  heard  already  the  results  of  the  micro- 
scopical and  bacteriological  investigations,  and  though 
the  pus  was  reported  free  from  gonococci  I  do  not  think 
that  such  infection  is  out  of  the  question  in  this  case ; 
and  the  history  rather  points  to  it,  viz.  an  attack  of 
'^  inflammation  of  the  bowels  '^  when  she  was  tAventy-one, 
i.  e.  three  to  four  months  after  marriage,  then  a  life  of 
sterility,  then  a  series  of  attacks  of  pelvic  inflammation 
culminating  in  a  final  severe  suppuration  of  both  tubes. 
Nor  do  I  think  that  the  absence  of  gonococci  from  the 
pus  of  these  large  pyosalpinges  necessarily  disproves  such 
infection ;  of  course  I  am  open  to  admit  that  the  infection, 
though  septic,  may  have  been  of  a  simpler  or  different 
type.  Tubercle  was  considered,  but  no  bacilli  have  been 
found  ;  all  cultures  of  the  pus  that  were  tried  proved  also 
sterile. 

The  remarkable  and  sudden  increase  in  the  size  of  the 
tumours  subsequently  to  her  admission,  with  great  increase 
in  the  severity  of  her  symptoms,  was  very  noteworthy. 

Dr.  Roberts  thanked  Mr.  Meredith  for  allowing  him  to 
publish  the  notes  of  the  case.  Dr.  Morley  Fletcher  had 
kindly  mounted  the  specimens,  and  Dr.  Andrewes  had 
examined  the  pus  bacteriologically. 

Mr.  Alban  Doran  uoted  that  a  big  pyosalpinx  with  a  long 
history  of  repeated  recurrence  of  pelvic  inflammatiou  could 
often  be  removed  with  perinaueut  benefit.  He  bad  operated  on 
several  such  cases,  all  bilateral,  with  tbe  most  enduring  good 
results.  Yet  when  tbe  operation  was  performed  during  a  first 
attack  of  inflammation,  the  obstructed  tube  being  relatively 
small  and  tbe  operative  manoeuvres  quite  easy,  the  patient  often 
fared  very  badly.  Abscesses  full  of  infective  germs  developed 
around  the  ligature  in  tbe  stump,  and  fresh  pelvic  inflammation 
ensued.  Hence  many  Continental  operators  removed  tbe  entire 
uterus  as  well  as  the  appendages,  so  as  to  take  away  a  long 


128  DOUBLE    PYOSALPINX. 

suppurating  tract,  wliich  included  the  still  patent  uterine  end  of 
the  tube  and  the  endometrium.  This  was  an  extreme  measure, 
and  experience  showed  that  a  first  attack  of  inflammation  of  the 
tubes  and  ovaries  would  yield  to  rest  and  appropriate  medical 
measures.  On  the  other  hand,  when  inflammation  of  the  tube 
recurred,  as  in  Dr.  Hubert  Eoberts's  case,  the  pus  became 
sterile,  and  the  uterine  end  of  the  tube  was  usually  sealed  up ; 
the  uterus,  too,  was  often  healthy.  Hence,  provided  the  uterus 
was  healthy,  the  patient  was  restored  to  permanent  good  health 
when  the  suppurating  tube  was  removed,  for  no  suppurating 
tract  was  left  behind,  and  the  tissues  of  the  stump  were  free 
from  infective  germs. 

Dr.  Drummond  Eobinson  had  made  cultures  from  the  pus 
in  cases  of  chronic  pyosalpinx,  and  had  always  found  it  sterile. 
The  gonococcus  was  a  delicate  organism,  and  after  a  time  it 
could  no  longer  be  cultivated  from  the  pus  of  a  pyosalpinx  of 
gonorrhoeal  origin.  In  many  cases  of  gonorrhoea!  pyosalpinx 
the  gonococcus  was  the  only  organism  present  in  the  pus,  but 
sometimes  streptococci  and  staphylococci  were  found  associated 
with  it.  These  latter  organisms  also  perished  after  a  prolonged 
stay  in  pus. 

Mr.  Bland  Sutton  remarked  that  this  form  of  tubal  disease 
was  very  rare  ;  he  had  examined  four  specimens  previously,  one 
of  them  (removed  by  Mr.  Butler- Smy the)  accompanied  his 
Jacksonian Essay,  and  is  preserved  in  the  museum  of  the  Royal 
College  of  Surgeons.  He  believed  that  they  had  a  different 
mode  of  origin  from  the  common  forms  of  pyosalpinx,  and  were 
not  secondary  to  septic  changes  in  the  uterus  or  gonorrhoea. 
The  patients  are  usually  virgins,  and,  if  married,  sterile.  The 
tubes  are  converted  into  huge  banana-like  cysts,  which  not  only 
rise  out  of  the  pelvis,  but  may  even  reach  as  high  as  the  navel. 
The  abdominal  ostium  is  occluded,  but  the  fimbriae  are  usually 
obvious.  The  disease  rarely  causes  inconvenience  until  the 
enlargement  of  the  tubes  produces  marked  swelling  of  the 
belly.  Adhesions  are  rare,  but  the  tubes  generally  require  to  be 
enucleated  from  the  peritoneal  investments  formed  by  the 
broad  ligaments.  In  describing  this  kind  of  tubal  trouble  in  the 
second  edition  of  his  work  on  '  Diseases  of  the  Ovaries,'  p.  214, 
Mr.  Sutton  expressed  the  opinion  that  the  distension  probably 
depended  on  non-inflammatory  (perhaps  congenital)  stenosis  of 
the  abdominal  ostia  of  the  tubes. 

The  President  said  the  specimen  was  one  of  unusual  interest. 
The  tubes  had  much  more  the  shape,  size,  and  general  appear- 
ance usually  found  in  hydrosalpinx  than  in  pyosalpinx.  He 
asked  whether  in  the  case  of  the  larger  tube  the  fimbriated  end 
was  closed  by  sealing  of  the  tube  itself,  or  by  adhesion  of  the 
fimbriae  to  adjacent  tissues.  He  would  also  be  glad  to  learn 
whether  there  was  any  history  of  acute  purulent  vaginitis  or 


DOUBLE    PYOSALPINX.  129 

other  evidence  of   gonorrlioea.      A  case  somewhat   similar  in 
regard  to  size,  shape,  and  contents  had  been  published  a  few 
years  ago  by  Mr.  Butler- S  my  the.     He  himself  had  also  pub- 
lished a  case  resembling  that  of  Dr.  Roberts,  wtiere  the  tubes, 
without   having   reached   so   large    a   size,   were    nevertheless 
unusually   large,    and    had    precisely   similar    contents.      Mr. 
Shattock  regarded  that  case  as  in  all  probability  tubercular 
in  origin,  but  no  bacilli  were  found  on  microscopical  examina- 
tion, and  the  true  nature  of  the  case  remained  obscure.     He 
(the  President)  agreed  with  Mr.  Doran  in  his  remarks  as  to  the 
general  advisability  of  abstaining  from  operative  interference 
during  the  first  acute  attack  of  salpingitis.     It  was  impossible 
to  decide  at  that  stage  whether  spontaneous  recovery  would  or 
would  not  take  place.     No  single  indication  of  the  need  for 
surgical  measures  was  of  so  much  value  as  recurrent  attacks  of 
pelvic  peritonitis  associated  with  a  persistent,  fixed,  irregular 
swelling  in  one  or  both  posterior  fossae  of  the  pelvis.      This 
combination    almost    invariably   pointed   to   the   existence    of 
chronic  suppuration  in  the  appendages.     Experience  seemed  to 
be  leading  to  an  approximation  in  our  rules  of  treatment  of  in- 
flamed Fallopian  tubes  to  those  which  guided  surgeons  in  their 
treatment  of  cases  of  diseased  appendix  vermiformis. 

In  reply  to  the  President,  Dr.  Egberts  said  that  the  fim- 
briated extremity  was  certainly  closed  in  both  tubes,  as  the  pus 
was  under  great  tension  when  the  tubes  were  punctured  for 
examination  of  the  pus  by  cultivation.  Great  care  had  been 
taken  to  eliminate  the  question  of  tubercle,  and  the  history  of 
the  case  had  been  taken  especially  with  the  view  of  ascertaining 
the  question  of  gonorrhoeal  infection  ;  no  further  conclusion 
had  been  arrived  at,  but  it  was  most  probably  a  case  of  this 
kind. 


VOL.  XL.  9 


130 


FIBRO-MYOMA    OF    VAGINAL    WALL    (WITH 
MICROSCOPICAL    SLIDE). 

Shown  by  John  Phillips,  M.A.,  M.D.,  F.R.C.P. 

The  patient  from  which  the  growth  was  removed  was 
aged  49,  and  single.  For  three  years  the  swelling  had 
been  noticed  to  be  gradually  increasing.  It  was  situated 
in  the  anterior  vaginal  wall,  and  when  operated  upon 
extended  from  the  internal  opening  of  the  urethra  to  just 
above  the  pelvic  brim.  The  uterus  was  retro  verted  and 
retropronated  as  well  as  being  pushed  up  out  of  the  pelvis. 
The  patient  complained  of  increasing  bladder  irritation, 
and  an  offensive  discharge  for  a  short  time ;  this  was 
found  to  be  due  to  retained  menstrual  fluid  in  the  upper 
part  of  the  vagina. 

The  vaginal  wall  was  incised,  and  the  growth  enucleated. 
It  weighed  10|  ounces,  and  the  cavity  from  which  it  was 
removed  measured  6  inches  in  length  by  nearly  4  inches 
in  breadth.  The  patient  made  an  easy  and  afebrile  re- 
covery. 

The  microscopic  section  shows  fibrous  and  plain  muscular 
tissue,  the  former  being  in  excess.  The  rarity  of  this 
condition  was  considered  a  sufficient  reason  for  bringing 
the  specimen  forward. 


MONSTROSITY     RESULTING      FROM     AMNIOTIC 
ADHESION    TO    SKULL. 

Shown  by  John  Phillips,  M.A.,  M.D.,  F.R.C.P.  (for 

Dr.  Jager). 

This   specimen  was  shown  in  the   fresh  condition ;    it 
occurred  in  the  practice  of  Dr.  Harold  Jager.     The  patient, 


MONSTROSITY  RESULTING  FROM  AMNIOTIC  ADHESION.      131 

a  young  primipara,  when  four  months  pregnant  had  seen 
(when  seated  on  the  top  of  an  omnibus)  a  child  run  over 
by  another  omnibus,  the  head  being  crushed ;  the  accident 
affected  her  very  much  at  the  time.  Labour  was  at  term 
and  of  five  hours^  duration.  The  breech  presented,  there 
was  great  excess  of  liquor  amnii,  and  delivery  of  the 
placenta  was  by  expression.  The  child  cried  loudly  for 
an  hour  after  birth,  and  then  died. 

There  is  an  amniotic  adhesion  over  the  frontal  bone, 
and  above  this  there  has  been  no  further  bone  development. 
An  encephalocele  and  a  meningocele  are  present.  Dr. 
Phillips  considered  this  an  instance  of  a  rare  condition  in 
which  adhesion  of  the  amnion  had  interfered  with  develop- 
ment. He  asked  the  President  to  appoint  a  committee 
to  dissect  the  specimen  and  make  a  further  report. 

A  sub-committee  was  appointed  consisting  of  Dr.  Hubert 
Eoberts  and  Dr.  John  Phillips. 


Report  of  Siih -committee. 

The  foetus  is  of  male  sex,  and  is  apparently  perfect 
except  for  the  peculiar  deformity  of  the  upper  part  of  the 
cranium,  face,  and  vault. 

Length,  12^  inches  from  buttocks  to  apex  of  cranial 
mass. 

The  anus  is  perforate. 

Penis  and  scrotum  small ;  the  former  is  short,  curved, 
and  hypospadic. 

Testes  undescended,  but  epididymis  present  on  each 
side. 

The  chief  part  of  the  deformity  consists  in  the  attachment 
of  the  placenta  by  its  membranes  directly  in  the  form  of  a 
sac  to  the  top  of  the  foetal  head. 

The  auricles  are  normal  in  appearance  and  situation,  as 
are  the  lower  jaw  and  tongue. 


132      MONSTROSITY  RESULTING  PROM  AMNIOTIC  ADHESION. 

In  the  situation  of  the  normal  cranial  vault  are  three 
swellings_,  which  protrude  from  the  upper  part  of  the 
calvarium. 

1.  The  largest  swelling,  springing  from  the  region  of 
the  squamous  portion  of  the  left  half  of  the  occipital  bone, 
is  a  pear-shaped  sac  5J  inches  long  and  4  inches  wide 
in  its  broadest  portion.  It  consists  entirely  of  membrane 
which  is  continuous  with  the  ordinary  scalp,  and  is  not 
covered  with  hair.      See  outline  figure  (a). 

On  incising  it,  it  is  found  to  contain  fluid  of  a  brownish 
colour,  and  its  base  is  connected  by  a  large  circular 
aperture  with  sharp  edges  admitting  three  fingers  into 
the  cranial  cavity,  through  which  brain  substance  is 
directly  protruding.      It  is  without  doubt  a  meningocele. 

2.  A  smaller  swelling  springing  from  the  region  of  the 
right  half  of  the  squamous  portion  of  the  occipital  bone ; 
it  is  similar  to  the  swelling  (1)  above  described,  but 
smaller,  being  the  size  of  a  small  Tangerine  orange.  The 
covering  consists  (like  swelling  1)  of  skin,  uncovered  with 
hair.  It  has  also  on  opening  it  a  circular  sharp-edged 
aperture  admitting  one  finger,  which  also  is  directly  con- 
tinuous with  the  general  cavity  of  the  cranium,  through 
which  brain  substance  is  protruding,  nearly  filling  the  sac. 
It  is  also  a  meningocele. 

3.  The  third  swelling,  which  occupies  the  parietal  and 
frontal  regions  of  the  skull,  is  remarkable  in  having  the 
amnion  directly  continuous  with  it,  and  forming  its  outer 
covering  extending  to  the  base  of  the  swelling  (6). 

The  swelling  itself  is  solid,  and  not  a  membranous  sac 
(like  swellings  1  and  2).  It  is  the  size  of  an  orange, 
irregularly  lobed,  and  consists  of  convolutions  of  brain 
matter  covered  by  dura  mater,  with  which,  apparently  all 
round  the  base  of  the  swelling,  is  fused  the  amnion  (c) . 

The  swelling  is  an  encephalocele  with  amniotic  adhe- 
sions. 

The  base  of  the  swelling,  which  is  quite  sessile,  passes 
almost  imperceptibly  to  be  continuous  with  the  skin  of 
the  face  in  the  supra-orbital  regions  of  the  foetus  on  either 


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MONSTROSITY    RESULTING  FROM  AMNIOTIC  ADHESION.      133 

side  just  at  the  base  of  the  nose,  and  is  continuous  ex- 
ternally with  the  outer  canthus  of  the  left  eje_,  to  which  it 
is  firmly  attached. 

Below  this  the  face  is  also  considerably  deformed,  the 
whole  of  the  nasal  bones  and  premaxillae  being  strangely 
distorted  and  pushed  forwards ;  as  seen  in  the  photo- 
graph, the  upper  lip  is  distorted  and  short,  and  the  nose 
itself  is  somewhat  oblique. 

At  the  outer  angle  of  the  mouth,  which  is  abnormally 
broad,  a  sort  of  furrow  extends  upwards  {d),  and  outwards 
in  the  direction  of  the  outer  canthus  of  the  eye  in  the  situ- 
ation of  the  mandibular  cleft  of  the  embryo. 

The  orbit  is  much  deformed,  as  is  also  the  eyeball,  which 
is  pushed  outwards  on  either  side,  and  stands  out  of  the 
orbit  in  a  condition  of  proptosis  ;  the  orbito-nasal  cleft  is 
evidently  imperfectly  closed. 

The  upper  eyelids  are  absent,  but  the  lower  is  present 
on  either  side,  but  is  not  in  contact  mth  the  eyeball. 

Covering  in  the  upper  portion  of  the  orbit  on  either 
side  above  are  the  folds  of  skin,  passing  upwards  to  the 
base  of  swelling  (3). 

The  same  condition  exists  at  the  root  of  the  nose,  the 
skin  at  once  passing  upward  to  be  continuous  with  swell- 
ing 3  {i.  e.  the  encephalocele  with  amniotic  adhesions) . 

The  ^placenta  (p)  itself  is  of  the  usual  circular  shape,  Avith 
nearly  central  attachment  of  the  cord,  which  is  partially 
velamentous.  Its  maternal  surface  is  normal  (6  x  6^ 
inches).  The  foetal  surface  is  normal.  The  chief  pecu- 
liarity of  the  placenta  consists  in  the  attachment  of  the 
amnion  to  swelling  3,  so  that  the  placental  membranes  are 
directly  continuous  Avith  the  foetal  head. 

The  cord  [h)  itself  is  excessively  short  (10  inches).  It  is 
only  very  slightly  t^visted ;  on  section  it  shows  the  usual 
arrangement  of  vessels.  There  is  no  abnormality  until 
within  3  inches  of  the  placental  attachment ;  here  it 
becomes  continuous  with  a  large  funnel-shaped  protrusion 
of  the  amniotic  sac,  on  which  the  vessels  of  the  cord  do 
not  break  up  except  at  its  extreme  base,  where  they  enter 


134  CYSTIC   INTRA-LIGAMENTOUS   MYOMA. 

the  placenta.  No  vessels  can  be  seen  traversing  the  surface 
of  this  funnel-shaped  protrusion  of  the  amnion  towards 
the  foetal  swelling  8. 

The  amniotic  cavity  is,  therefore,  directly  continuous  by 
a  large  opening  with  the  coverings  of  the  swelling  3,  the 
amniotic  protrusion  being  merged  into  the  encephalocele, 
the  brain  matter  within  being  separated  only  by  its  own 
coverings  from  the  cavity  of  the  amnion  itself. 

The  specimen  is  evidently  one  of  retarded  development 
of  the  anterior  and  upper  portions  of  the  foetal  skull  by 
amniotic  adhesions.  To  us  the  meningoceles  appear  as  the 
results  rather  than  the  direct  cause  of  the  abnormality. 

John  Phillips. 
C.  Hubert  Egberts. 


A  LARGE  SOFT  BROAD  LIGAMENT  FIBRO-MYOMA, 
WEIGHING  FOURTEEN  POUNDS. 

Shown  by  Ewen  Maclean,  M.D. 


CYSTIC   INTRA-LIGAMENTOUS    MYOMA    WITH 
DOUBLE    UTERUS. 

Shown  by  W.  J.  Gow,  M.D. 

The  tumour  was  removed  by  abdominal  hysterectomy 
from  a  single  woman  aged  32.  The  right  broad  ligament 
is  occupied  by  a  tumour  which  showed  extensive  cystic 
changes.  On  cutting  into  the  mass  a  quantity  of  clear 
yellow  fluid  exuded.  The  lower  half  of  the  tumour  was 
very  soft  and  sponge-like  in  texture,  and  was  of  a  yellowish- 
brown  colour,  as  if  the  tissues  of  the  myoma  were  infiltrated 
with  altered  blood.  Many  spaces  of  irregular  size  exist 
in  this  part  of  the  tumour.      The  upper  half  of  the  tumour 


CYSTIC  INTRA-LIGAMENTOUS  MYOMA.  135 

contained  recent  bright  red  blood-clot  in  an  irregular 
cavity.  The  appearances  suggest  that  the  irregular  spaces 
met  with  are  due  to  extensive  haemorrhage  into  the  tumour, 
and  throw  some  light  on  the  origin  of  cystic  degeneration 
in  fibroids. 

A  uterus  normal  in  shape  and  size  is  seen  lying  in  con- 
tact with  the  left  side  of  the  tumour,  and  running  obliquely 
upwards  and  to  the  right  of  this  is  situated  another  uterus, 
larger  than  the  first,  and  shaped  like  a  spindle.  Into  the 
upper  and  outer  angle  of  this  uterus  the  right  Fallopian 
tube  opens,  and  the  round  ligament  can  be  traced  up  to 
the  same  point. 

This  second  uterus  communicates  with  the  one  on  the 
left  side  at  the  level  of  the  os  internum. 

The  diagnosis  of  the  case  was  not  clear,  and  it  was  at 
first  thought  that  the  tumour  was  an  ovarian  or  broad 
ligament  cyst.  The  mass  was  removed  in  the  ordinary 
manner  after  ligation  of  the  ovarian  and  uterine  arteries, 
and  the  stump  was  dropped  back  into  the  abdomen.  The 
patient  made  a  good  recovery. 


Rejport  (7)1  Dr.   Seyiuood   Smith's  Specimen  shown  March 
Srd,  1897  {not  reported). 

The  specimens  were  two  pieces  of  oviduct  and  one  of 
omentum  from  the  same  case. 

Suitable  portions  were  removed  from  each,  and  after 
hardening  were  embedded  in  celloidin,  cut,  and  stained 
(haematein  and  neutral  orcein,  and  polychromic  methylene 
blue). 

All  the  specimens  were  in  a  well-marked  carcinomatous 
condition.  The  omentum  was  made  up  almost  entirely  of 
cancer  cells,  with  bands  of  fibrous  stroma  between ;  much 
of  it  was  in  almost  the  last  stage  of  malignant  transforma- 
tion, and  occasionally  one  could  trace  the  further  degenera- 
tion  into  amorphous  unstainable  material.      The  oviduct 


136  CYSTIC    INTRA-LIGAMENTOUS    MYOMA. 

f 

had  evidently  been  invaded  from  the  exterior,  as  it  was 
here  that  the  carcinomatous  transformation  was  oldest. 
It  is  remarkable  that  the  columnar  epithelium  lining  the 
tube  had  not  proliferated  at  all,  but  that  the  cancerous 
process  had  advanced  right  up  among  the  mucous  folds. 
The  oviducts  were  probably  the  last  places  invaded. 

Waltee  D.  Severn. 


137 


INTERMENSTRUAL  PAIN   (MITTELSCHMERZ). 
By  Augustus  W.  Addinsell,  M.D. 

(Received  Xovember  3rd,  1897.) 

{Abstract.) 

The  author  di-aws  attention  to  a  condition  of  recurrinsf  inter- 
menstrual  pain  which  he  believes  to  be  more  frequent  than  is 
generally  supposed. 

He  describes  the  clinical  history  of  four  cases  which  have 
occurred  in  his  own  practice,  and  discusses  cases  quoted  by 
previous  authors. 

He  points  out  that  a  marked  feature  in  the  great  majority  of 
cases  is  the  presence  of  a  clear  watery  discharge. 

He  shows  that  in  nearly  all  the  recorded  cases  a  tubal  lesion 
is  present,  which  he  believes  to  be  salpingitis  proceeding  to 
hydrosalpinx. 

He  draws  attention  to  the  pathological  analogy  between  this 
condition  of  tubal  colic  and  appendicular  colic  of  the  vermiform 
appendix. 

He  endeavours  to  explain  the  periodicity  of  the  phenomena 
by  suggesting  the  existence  of  a  secondary  intermediate  dis- 
charge of  nerve  energy  operating  upon  diseased  tubes  in  certain 
individuals. 

A  table  is  drawn  up  of  all  the  hitherto  recorded  cases. 

In  the  '-British  Medical  Journal/  Oct.  19th,  1872,  there 
is  an  account  by  Sir  William  Priestley  of  a  paper  read 
before  the  Royal  Medical  and  Chirurgical  Society,  entitled 
''  Intermenstrual  Dysmenorrhoea,''  wherein  he  described  a 
series  of  cases  in  which  the  prominent  symptom  was  pain 


138  INTERMENSTEUAL    PAIN. 

occurring  at  regular  intervals  between  the  monthly  flow. 
But  although  the  cases  I  am  about  to  describe  are  similar 
in  character,  I  prefer  the  title  given  by  the  Germans  to 
this  disorder,  as  the  term  dysmenorrhoea  is  misleading,  in  so 
far  as  it  is  generally  associated  with  a  flow  of  blood  accom- 
panied by  pain.  My  object  to-night  is  to  invite  the  atten- 
tion of  the  Society  to  a  condition  which  I  believe  to  be  not 
infrequent,  but  which,  as  far  as  I  can  gather,  has  received 
somewhat  limited  attention,  the  chief  characteristic  of 
which  is  pain,  varying  in  intensity,  referred  to  the  ovarian 
regions,  recurring  with  marked  regularity  fourteen  days 
after  the  normal  menstrual  period. 

The  first  case  is  that  of  Miss  Gr — ,  aged  29,  unmarried. 
I  first  saw  her  in  December,  18^5.  She  was  a  delicate, 
anasmic-looking  woman.  She  complained  of  great  pain 
in  the  hypogastric  region,  extending  over  the  whole  of 
the  lower  part  of  the  abdomen.  This  pain  lasted  for  two 
or  three  days.  It  recurred  with  perfect  regularity  on  the 
twelfth  to  fourteenth  day  after  her  normal  period,  and 
had  increased  in  intensity  for  the  last  four  or  five  years. 
At  the  end  of  the  first  day  it  would  markedly  diminish, 
and  on  the  second  or  third  day  the  pain  was  gone,  but  she 
was  left  with  a  feeling  of  weakness  and  exhaustion.  The 
menstrual  period  was  regular,  the  amount  was  profuse, 
accompanied  by  clots  and  shreds,  and  she  suffered  from 
dysmenorrhoea  and  leucorrhoea.  She  herself  attributed 
this  middle  pain  to  indigestion,  and  had  been  treated  for 
that  complaint  by  several  physicians.  On  vaginal  exami- 
nation I  found  erosions  of  the  os  uteri,  the  uterus  ante- 
flexed,  and  a  distinct  elongated  swelling  in  the  left  broad 
ligament.  The  left  ovary  was  large  and  tender ;  the 
right  was  normal.  On  inquiry  I  learned  that  she  had 
been  in  good  health  up  to  five  years  previously,  when  she 
suffered  from  a  severe  attack  of  influenza  whilst  she  was 
menstruating,  which  confined  her  to  bed  for  a  fortnight, 
with  sudden  arrest  of  the  period,  and  what  she  described 
as   "  internal  inflammation.'^      Since  then  the  periods  had 


INTERMENSTRUAL    PAIN.  139 

been  profuse  and  painful,  and  this  intermenstrual  pain 
had  gradually  increased.  After  consultation  with  Dr. 
W.  Playfair  I  decided  to  dilate  and  curette  her,  and  did 
so  five  days  after  her  period  had  ceased.  The  curette 
removed  a  considerable  quantity  of  adenomatous  growth. 
A  week  after  the  curetting,  while  still  in  bed,  I  was  sent 
for.  I  found  her  in  great  pain,  which  she  described  as 
her  usual  attack.  The  next  morning  the  nurse  in  charge 
of  the  case  informed  me  that  the  patient  had  passed 
a  considerable  quantity  of  thin  watery  discharge,  after 
which  the  pain  gradually  ceased.  On  examination  I  found 
the  swelling  in  the  left  broad  ligament  had  disappeared  to 
such  an  extent  that,  had  I  not  known  of  its  previous 
existence,  I  should  have  detected  nothing  abnormal.  The 
next  period  was  much  less  profuse,  and  the  dysmenorrhoea 
was  improved  by  the  curetting,  but  the  mittelschmerz 
returned  in  due  course.  In  May,  1896,  I  examined  her, 
and  found  the  swelling  had  again  increased  in  the  left 
broad  ligament.  She  went  for  six  weeks  to  Schwalbach, 
where  she  derived  considerable  benefit.  She  went  for 
another  course  this  year,  and  is  now  much  improved,  the 
pain  being  less,  and  some  months  entirely  absent. 

The  second  case  is  that  of  a  lady  aged  31,  unmarried, 
whom  I  first  saw  in  January,  1896.  She  was  a  sister  in 
a  religious  order,  and  complained  of  complete  inability 
to  perform  her  duties  in  consequence  of  increasing  ill- 
health,  Avhich  had  been  getting  steadily  worse  for  the  last 
nine  years. 

Her  period  was  profuse,  lasting  eight  days,  the  first 
two  days  being  accompanied  by  pain.  She  passed  shreds 
and  clots,  constipation  was  so  marked  that  she  was  uever 
able  to  have  an  evacuation  of  the  bowels  without  mechan- 
ical assistance  ;  but  what  she  complained  of  most  was 
the  fact  that  no  sooner  had  she  got  over  the  effects  of  her 
period  than  she  was  subject  to  a  severe  pain  far  exceeding 
that  of  her  period,  which  recurred  always  about  the 
fourteenth  day,  lasting    for    two    or   three    days,   during 


140  INTERMENSTRUAL    PAIN. 

which  she  was  completely  incapacitated,  and  had  to  lie  in 
bed  with  hot  fomentations  applied.  The  constant  pain  and 
severe  loss  was  quickly  reducing  her  to  a  condition  of 
chronic  invalidism.  She  was  unable  to  stand  for  any 
length  of  time,  walking  was  out  of  the  question,  and  her 
life,  instead  of  being  devoted  to  usefulness,  was  spent  upon 
the  sofa.  On  examination  I  found  the  uterus  acutely 
retroflexed  with  several  prominent  fibroid  nodules ;  the 
sound  passed  four  and  a  half  inches ;  the  left  ovary  was 
prolapsed  and  enlarged  and  matted  to  the  side  of  the 
uterus;  the  right  ovary  was  enlarged  and  tender.  She 
was  curetted  without  any  real  benefit.  Being  very  anxious 
to  resume  her  work,  I,  after  consultation  with  Mr.  Bland 
Sutton,  in  September,  1896,  removed  both  ovaries  and 
appendages,  and  performed  hysteropexy.  Both  ovaries 
had  numerous  cysts;  the  right  was  nearly  twice  its 
normal  size,  the  uterus  was  studded  with  fibroid  nodules, 
and  the  left  Fallopian  tube  was  much  thickened.  The 
patient  is  now  perfectly  well,  she  has  had  no  pain  or  period 
since  the  operation,  and  she  has  resumed  her  life  of  activity. 

The  third  case  is  that  of  Miss  D — ,  aged  28.  First 
seen  in  December,  1894,  she  consulted  me  for  recurring 
attacks  of  pain  in  the  left  ovarian  region,  which  came  on 
twelve  or  thirteen  days  after  her  period,  and  gradually 
spread  over  the  lower  part  of  the  abdomen,  but  always 
started  at  a  point  midway  between  the  symphysis  pubis 
and  the  anterior  superior  iliac  spine.  The  menstrual  flow 
was  normal  as  to  regularity  and  quantity,  and  was  quite 
painless.  There  was  a  slight  leucorrhoea,  but  she  in- 
formed me  that  on  several  occasions  she  had  passed  during 
these  attacks  of  pain  a  considerable  quantity  of  clear 
watery  fluid.  She  had  never  passed  blood  on  these 
occasions. 

On  examination  I  found  the  uterus  markedly  retro- 
flexed  and  bulky  ;  a  sound  was  not  passed ;  there  were 
two  fibroid  nodules  about  the  size  of  a  large  walnut ;  the 
left  ovary  was  tender,  and  there  was  a  soft  elastic  swelling 


INTERMENSTRUAL    PAIN.  141 

in  the  left  broad  ligament ;  nothing  abnormal  was  detected 
on  the  right  side.  Hot  douches  were  advised,  but  made 
very  little  difference.  This  patient  is  the  subject  of 
advanced  cardiac  disease,  and  is  now  dying  of  ulcerative 
endocarditis.  In  May,  1895,  and  in  December  of  the  same 
year,  and  again  in  July,  1896,  she  passed  considerable  quan- 
tities of  clear  watery  fluid  during  her  attacks  of  middle 
pain.  I  saw  her  quite  recently.  She  has  not  menstruated 
for  six  months,  neither  has  she  had  an  attack  of  pain.* 

The  fourth  case  is  that  of  Miss  S — ,  aged  33.  She 
first  consulted  me  in  October,  1897,  for  recurring  pain,  so 
severe  as  to  necessitate  her  remaining  in  bed.  This  pain 
is  always  confined  to  the  right  side.  She  was  examined 
three  years  ago  by  a  gynaecologist  for  dysmenorrhoea. 
This  she  continues  to  suffer  from. 

The  uterus  is  anteflexed ;  there  is  an  increased  fulness 
in  the  region  of  the  right  broad  ligament ;  both  ovaries 
appear  normal.  For  the  last  nine  months  this  middle 
pain  has  increased.  It  is  sometimes  accompanied  by 
discharge  of  clear  fluid,  never  by  any  coloured  discharge. 
Sometimes  it  is  sharp  and  acute,  and  her  own  words  are 
"it  is  deep-seated,  and  goes  right  through  to  the  back, 
and  is  always  most  severe  when  I  have  a  watery  discharge 
with  it,  and  then  it  gets  much  better. ''  She  accounts  for 
what  she  terms  this  "  new  development ''  by  catching 
cold  and  getting  her  feet  wet  at  the  time  of  her  period, 
which  suddenly  became  arrested,  and  then  she  was  ill  for 
some  weeks.  This  occurred  five  years  ago,  and  since  that 
time  she  has  been  in  increasing  ill-health.  The  only 
treatment  suggested  so  far  has  been  hot  douches  between 
the  periods,  increased  in  frequency  at  the  time  of  the 
middle  pain. 

In  vol.  xxi  of  the  '  Transactions  of  the  Edinburgh 
Obstetrical  Society  '  there  is  a  paper,  with  notes  of  a  dis- 

*  Since  this  paper  was  written  the  patient  has  died.     Unfortunately  a  post- 
mortem examination  was  refused. 


142  INTERMENSTRUAL    PAIN. 

cussion  following,  by  Dr.  Halliday  Croom,  under  the  title 
''  Mittelschmerz.'' 

In  two  out  of  three  of  Dr.  Croom^s  cases^  in  the 
majority  of  the  cases  quoted  by  subsequent  speakers^  in 
all  of  the  four  cases  quoted  by  Sir  W.  Priestley,  and 
certainly  in  all  of  my  four  cases,  there  has  been  observed 
a  fulness,  if  not  a  distinct  swelling,  in  the  broad  ligament 
on  the  side  which  has  been  the  seat  of  pain.  In  a  certain 
number  there  has  been  noted  the  discharge  of  clear  fluid, 
sufficiently  copious  to  be  remarked  by  the  patient,  and  to 
be  distinguished  from  a  severe  leucorrhoea.  This  was  the 
conspicuous  feature  in  a  case  of  Fasbender's  referred  to 
by  Dr.  Croom  ;  and  though  this  author  tells  us  that  he  did 
not  notice  anything  abnormal  about  the  appendages,  yet 
it  is  possible  that  a  slight  fulness  on  one  side  or  the  other 
may  have  been  overlooked. 

In  a  fair  proportion  of  the  recorded  cases  of  this  dis- 
order there  has  been  noted  anteflexion,  so  much  so  as  to 
give  rise  to  the  belief  on  the  part  of  some  that  this 
mittelschmerz  is  the  result  of  anteflexion ;  but  I  think  it 
will  generally  be  admitted  that  we  all  know  of  many  cases 
of  anteflexion  where  there  is  no  mittelschmerz,  and  there 
are  a  sufficient  number  of  cases  of  middle  pain  now  re- 
corded where  there  has  been  sometimes  retro-  and  some- 
times anteflexion.  In  my  own  four  cases  the  honours  are 
divided. 

The  pathological  interest  of  this  disorder  may  be  prac- 
tically narrowed  down  to  the  question  of  whether  it  be 
due  to  ovulation  and  menstruation  not  being  coincident, 
or  whether  it  be  necessary  for  a  tubal  lesion  to  exist. 

Dr.  Croom  has  suggested  three  different  classes  : 

1.  Pain  existing  without  any  discharge. 

2.  Pain  accompanied  by  clear  discharge. 

3.  Pain  accompanied  by  coloured  discharge. 

With  regard  to  the  third  class  of  cases,  I  do  not  think 
it  need  be  taken  into  consideration,  for  they  are  probably 
cases  of  endometritis  in  which  the  discharge  of  shreds  and 
clots    causes    painful    uterine    contractions.       But    there 


INTERMENSTRUAL    FAIN.  143 

remains  a  number  of  cases  which  occur  probably  to  most 
of  uSj  where  the  prominent  feature  is  a  true  mittelschmerz. 
In  many  of  these  cases  there  has  been  noted  the  escape 
of  clear  fluid,  and  in  most  a  fulness,  and  in  some  a  distinct 
swelling,  which  varies  in  size  at  different  times.  I  believe 
that  if  a  careful  history  of  these  patients  be  taken  we 
shall  always  be  able  to  elicit  the  fact  that  there  has  been 
a  definite  cause  of  inflammation  of  the  endometrium  with 
extension  into  the  tubes.  But  it  may  be  urged,  and 
rightly,  many  cases  of  salpingitis,  and  even  pyosalpinx 
and  hydrosalpinx,  occur  in  which  there  has  been  no  true 
definite  mittelschmerz.  There  is  of  course  the  pain  usually 
associated  with  these  disorders,  wherein  it  is  manifestly 
tubal  but  not  cyclical ;  but  that  is  not  the  character  of 
pain  now  under  discussion.  How  then  are  we  to  account 
for  this  periodicity  in  these  cases  of  mittelschmerz  ? 

It  is  probably  easy  to  admit  that  the  pain  is  due  in 
some  cases  at  any  rate  to  an  effort  on  the  part  of  the  tube 
to  expel  its  contents.  In  three  of  my  cases  this  expulsion 
was  followed  by  relief  of  pain,  though  this  latter  fact  is 
not  noticed  by  an}'  authorities  I  have  quoted. 

In  Sir  W.  Priestley's  remarks  upon  the  pathology  of  his 
cases  he  disregards  entirely,  and  makes  no  comment  upon, 
the  recognised  pathological  condition  of  the  tubes,  but 
attributes  the  mittelschmerz  to  maturation  of  the  follicle 
not  being  coincident  with  menstruation,  and  he  suggests 
that  the  pain  is  induced  by  activity  of  the  follicle  in 
endeavouring  to  approach  the  cortex  of  the  ovary,  and 
that  this  activity  causes  a  congestive  condition  of  the 
uterine  appendages.  The  oversight  of  the  fact  that  in 
so  large  a  proportion  of  cases  there  is  some  tubal  lesion 
makes  us  hesitate  before  accepting  the  view  that  it  has  a 
purely  ovarian  origin. 

It  is  suggested  that  this  intermenstrual  pain  is  due  to 
ovulation  not  being  coincident  with  menstruation,  or  that 
the  dehiscence  of  the  follicle  through  a  thickened  capsule 
is  painful,  and  that  the  condition  of  the  tubes  has  nothing 
to  do  with  the  periodicity  of  pain. 


144  INTEEMENSTRUAL    PAIN. 

In  answer  to  that  I  think  the  weight  of  evidence  is  in 
favour  of  some  tubal   disorder  always  accompanying  this 
particular  character  of  pain  ;  it  may  be^  and  probably  is, 
that  in  some  cases  the   distension  is  slight   and  the   dis- 
charge proportionately  small,  and   so  escapes  observation 
as  a  prominent  symptom ;  but  in  many  this  has  been  very 
marked,  and  a  study  of   the   cases  shows   clearly  that  in 
nearly  all  some  alteration  of  the  tubes  is  noticed ;  at  the 
same  time  some    cyclical    discharge    of    nerve    energy   is 
necessary  to  account  for  the  marked  periodicity.      In  my 
case,  where  I  removed  the  whole  of  the  appendages,  the 
operation    was    performed — after    due    deliberation — on 
account  of  the  serious  condition  of  the  patient^s   health, 
in  consequence  of  the  severe  loss  caused  by  the  hasmor- 
rhagic  fibroids.      Nothing  is  proved  except  that  the  patient 
is  cured;  in  the  other  case,  where  the  pain  and  menstrua- 
tion is   arrested   by  the   profound   exhaustion    of   a  pro- 
tracted illness,  nothing  is  proved;  and  in  my  other  two 
cases  the  improvement,  if  any,  is  due  probably  to  allaying 
the  irritation  in  the  tubes.      Dr.  Ritchie,  in  the  discussion 
following  Dr.  Croom^s  paper,  attributed  the  whole  of  the 
symptoms  to  an  intermediate  discharge  of  nerve   energy. 
Here  I  think  he  attempts  to  prove  too  much ;  for  if  there 
were  no  tubal  or  ovarian  lesion  there  would  probably  be 
no  pain,  for  in  a  typically  normal  menstruation,  which  is 
due  to  a  discharge  of  nerve  energy  occurring  at  a  cycle 
of  twenty-eight  or  thirty  days,  accompanied  by  a  manifes- 
tation of  blood,  there  is  no  pain  ;  why  then  should  there 
be   pain   at   the   lesser   intermediate    discharge   of  nerve 
energy  ? 

This  is  not  the  occasion  to  enter  into  a  discussion  of  the 
cause  of  menstruation  ;  but  in  a  paper  by  Dr.  Marsh  on 
^^Intermenstrual  Phenomena,'^  which  appears  in  the 
'American  Journal  of  Obstetrics'  for  July,  1897,  he 
draws  attention  to  the  observations  of  Dr.  Stephenson,  of 
Aberdeen,  on  the  rise  and  fall  of  blood-pressure  occurring 
in  cycles  of  twenty-eight  days  in  the  pelvic  viscera ;  this 
rise  reaches  its  maximum  every  twenty-eight  days,  and 


4 


INTERMENSTRUAL    PAIN.  145 

the  menstrual  flow  is  coincident  with  this  maximum ;  this 
is  followed  hy  a  corresponding  fall,  producing  an  ansemic 
condition.  This  alteration  of  blood-pressure  is  due  to  a 
cyclical  discharge  of  nerve  energy.  There  is  nothing  un- 
usual in  this  periodicity ;  for  there  are  in  most  organs 
periods  of  activity  alternating  with  periods  of  rest,  for 
instance,  the  rhythmical  beating  of  the  heart  and  the 
rhythmical  contractions  of  the  spleen.* 

I  have  no  difficulty  in  accepting  the  view  of  Dr.  Marsh 
and  Dr.  Ritchie  that  there  may  be  a  secondary  intermediate 
wave  of  pelvic  congestion  caused  by  a  secondary  wave  of 
nerve  energy,  but  in  face  of  the  fact  that  we  have  but 
comparatively  little  evidence  of  ovarian  lesions,  and  we 
have  plenty  of  evidence  of  tubal  lesions,  I  think  it  is  to 
the  latter  that  we  must  assign  the  exciting  cause  of  this 
intermenstrual  pain.  There  has  been  a  growing  tendency 
to  regard  many  cases  of  supposed  ovaritis  as  really  tubal 
congestion,  and  the  careful  observations  made  after  abdo- 
minal sections  seem  to  confirm  this  view. 

In  Fasbender^s  case,  whilst  he  accepts  Pfluger^s  theory 
of  menstruation,  he  lays  marked  emphasis  upon  the 
copious  discharge  of  mucus,  and  discovered  nothing  ab- 
normal about  the  appendages,  and  regards  the  pain  as 
due  to  a  premature  summation  of  nervous  stimuli  to  the 
ovary,  with  ovulation  as  a  consequence,  induced  by  a  patho- 
logical condition  of  the  ovary.  I  cannot  help  thinking 
that  there  is  here  also  a  too  great  tendency  to  theorise 
without  due  regard  to  clinical  facts  ;  for  he  has  to  suppose 
a  pathological  condition  of  ovary,  and  yet  admits  he  dis- 
covered none.  This  is  of  course  perfectly  easy  to  under- 
stand, but  he  offers  no  explanation  of  the  flow  of  mucus. 

The  precise  pathology  of  this  somewhat  unusual  dis- 
order it  is  perhaps  impossible  to  determine  with  our  present 
knowledge,  and  it  is  rendered  more  difficult  by  our  having 

*  This  periodic  congestion  of  the  ovaries  is  illustrated  by  a  case  quoted  by 
Priestley,  in  which  the  ovaries  had  descended  into  the  inguinal  canal,  and 
every  twenty-one  days  were  found  to  be  enlarged  and  tender  for  a  period 
lasting  three  or  four  days. 

VOL.  XL.  10 


146 


INTERMENSTRUAL    PAIN. 


no  records  of  post-mortem  examinations  made  with  the 
object  of  elucidating  this  question ;  but  it  seems  to  me,  in 
weighing  the  evidence  of  observed  facts,  that  the  tubes 
play  a  very  important  if  not  an  essential  part.  An  exa- 
mination of  the  thirteen  cases  which  have  been  recorded 
shows  that  in  no  less  than  ten  there  has  been  a  distinct 
tubal  lesion — in  some  a  marked  swelling,  in  others  a  ful- 
ness ;  and  excluding  Sir  W.  Priestley^s  cases,  where  no 
comment  is  made,  of  the  remaining  nine  I  find  that  in 
six  there  is  a  note  of  a  mucous  discharge,  and  in  two 
cases  in  which  the  tubes  have  been  removed  hydrosalpinx 
has  been  observed.  We  cannot,  therefore,  look  upon  the 
ovaries  as  the  sole  offenders ;  I  think  we  must  come  to  the 
conclusion  that  there  are  a  certain  number  of  women  who, 
from  some  cause  or  another,  have  developed  a  tubal  lesion, 
and  being  subjects  in  whom  the  physiological  cycle  of  pelvic 
congestion  occurs  with  increased  frequency,  there  is  painful 
effort  on  the  part  of  the  tube  to  expel  its  contents. 


Case. 

Nnme 

of 

observer. 

Condition  and 

position  of 

uterus. 

Clinical  note  of 
appendages. 

Condition 
found  at 
operation. 

Nature  of 
discharge 
(if  any). 

1 

Sir  Wm. 
Priestley 

Not  noted 

Elastic  swelling  in 
broad  ligament 

None 

None  noted. 

2 

>) 

>' 

»j 

»» 

>i 

3 

>j 

j> 

Fulness  in  region 
of  broad  ligament 

>> 

» 

4 

)y 

>> 

>i 

» 

j» 

5 

Fas- 
bender 

Anteflexion 

Nothing  abnormal 
observed 

)i 

Copious  clear 
mucus. 

6 

Groom 

Normal 

a 

» 

None  noted. 

7 

>• 

Enlarged  to 

3i  inches; 

submucous 

fibroid 

Right  ovary 

cystic ;  tube 

thickened ; 

left  ovary 

normal ; 

hydrosalpinx 

Sometimes 

clear, 

sometimes 

blood-stained. 

INTERMENSTRUAL    PAIN. 


147 


Case. 

Name 

of 

observer. 

Condition  and 

position  of 

uterus. 

Clinical  note  of 
appendages. 

Condition 
found  at 
operation. 

Nature  of 
discharge 
(if  any). 

8 

Croom 

Enlarged ; 
retroflexed 

— 

On  left  side 
hydrosalpinx 

— 

9 

Marsh 

Retroflexion 

and 
endometritis 

"  Inflamed 

ovaries;"  tubes 

uoc  noted 

None 

Mucous 
discharge. 

10 

Addinsell 

Anteflexion 

Elongated  swelling 
in  left  broad  liga- 
ment ;  left  ovary 
tender;  right 
normal 

>> 

Copious 
mucous  dis- 
charge. 

11 

>> 

Retroflexion; 
enlarged  to 
4^  inches; 

several  "fibroid 
nodules 

Left  ovary 
prolapsed  and 

matted  to 
uterus;  tube 
found  much 

thickened 
after  removal 

>> 

1 
i 

12 

» 

Retroflexion ; 
fibroid 
nodules 

Soft  elastic 
swelling  in  left 
broad  ligament 

None 

Frequent 

discharges  of ' 

clear  waterv 

fluid. 

13 

it 

Anteflexion 

,  Fulness  in  right 
broad  ligament 

» 

Slight,  clear, 
and  watery. 

Dr.  Herman  believed  that  this  was  the  first  time  that  the 
subject  of  so-called  **  intermediate  dysmenorrboea  "  had  been 
discussed  by  the  Society.  He  agreed  Avith  Dr.  Addinsell  in 
thinking  that  it  was  incorrect  to  apply  the  term  ''dysmenorrboea'* 
to  a  pain  which  only  occurred  when  the  patient  was  not  men- 
struating. At  the  same  time  he  did  not  think  they  need  resort 
to  German  for  a  name.  **  Middle  pain,"  the  literal  translation 
of  "  Mittelscbmerz,"  he  did  not  think  a  happy  coinage.  "  Inter- 
mediate monthly  pain  "  was  a  correct  designation  of  the  sym- 
ptom. He  had  not,  like  Dr.  Addinsell,  found  that  the  pain 
always  recurred  fourteen  days  after  menstruation.  He  had 
found  that  the  date  of  its  recurrence  varied.  The  feature 
common  to  all  the  cases  was  that  the  pain  recurred  on  a  fixed 
day  between  menstruations ;  the  patient  knew  when  to  expect 
it ;  it  always  recurred  on  or  about  the  same  day  in  the  same 
patient,  but  it  recurred  on  different  days  in  different  patients. 
He  was  accustomed  to  accept  the  explanation  of  the  pain  put 


148  INTERMENSTRUAL    PAIN. 

forward  bv  Sir  W.  Priestley,  viz.  tliat  it  was  due  to  monthly 
recurring  painful  ovulation.  The  evidence  of  abdominal  sec- 
tions showed  that  Graafian  follicles  might  ripen  and  burst  at 
any  time  of  the  menstrual  cycle,  although  they  usually  burst 
near  the  time  of  menstruation.  In  most  of  the  cases  he  had 
seen,  as  in  Dr.  Addinsell's  cases,  there  were  physical  signs  of 
old  inflammation  of  the  uterine  appendages.  In  most  such 
cases  there  were  adhesions  around  both  ovary  and  tube  ;  and  it 
was  not  possible  to  say  that  the  tube  was  diseased  and  the 
ovary  healthy.  In  most  of  the  cases  he  had  seen  the  pain  had 
the  characters  of  ovarian  pain,  a  dull  aching  or  burning  con- 
tinuous pain  referred  to  the  situation  of  the  ovary.  If  the 
ovary  were  surrounded  by  adhesions,  that  offered  a  ready  ex- 
planation of  why  ovulation  was  painful.  He  thought  that  for 
diseased  and  distended  tubes  to  empty  themselves  into  the 
uterus  was  a  very  rare  event.  When  at  operations  such  tubes 
were  pulled  up,  and  so  straightened  out  and  even  pressed  upon, 
any  lessening  in  their  size  by  passage  of  their  contents  into  the 
uterus  was  a  thing  hardly  ever,  if  ever,  seen.  In  the  case 
described  by  Dr.  Addinsell  in  which  this  was  supposed  to  have 
happened,  the  size  of  the  swelling  by  the  side  of  the  uterus 
showed  that  the  retained  fluid  could  only  have  been  a  very 
small  quantity.  It  was  common  for  increase  in  leucorrhoeal 
discharge  to  accompany  intermediate  pain.  He  had  seen  one 
case  in  which  the  intermediate  pain  was  evidently  due  to 
uterine  contractions.  The  patient  had  fibroids  ;  the  pain  was 
like  that  of  spasmodic  dysmenorrhoea,  except  that  it  was  not 
present  when  the  patient  was  menstruating  ;  it  was  made  worse 
by  ergot,  was  a  little  relieved  by  bromides,  and  was  removed  by 
dilating  the  cervix.  After  a  few  months  it  returned,  and  was 
again  cured  by  a  repetition  of  the  dilatation.  He  could  offer 
no  explanation  of  this  case.  He  had  seen  other  cases  of  inter- 
mediate pain  without  any  physical  signs  of  disease  of  the  uterus 
or  its  appendages.  He  thought  the  Society  was  indebted  to 
Dr.  Addinsell  for  his  careful,  laborious,  and  thoughtful  paper. 

Mr.  Bland  Sutton  remarked  that  Dr.  Addinsell's  j^aper 
interested  him  especially  on  account  of  the  effort  to  associate 
the  pain  with  lesions  of  the  Fallopian  tubes.  He  had  long  held 
the  view  that  fluid  distensions  of  the  tubes  did  not  discharge 
themselves  into  the  uterus,  and  the  old  notions  of  intermitting 
hydro-  and  pyosalpinx  were  not  sustained  by  reliable  evidence. 
It  was  of  course  impossible  to  say  that  fluid  from  a  distended 
tube  never  escaped  into  the  uterus,  but  he  was  convinced  that  it 
was  of  very  exceptional  occurrence.  Very  free  discharges  of 
fluid  may  and  do  take  place  from  the  vagina,  but  that  was  no 
reason  for  attributing  their  origin  to  the  Fallopian  tubes. 
Dr.  Addinsell's  paper  would  serve  a  useful  purpose,  for  it  is 
clear  that  intermenstrual   pain   has  not   received   the   clinical 


INTERMENSTRUAL   PAIN.  149 

recognition  it  needed,  and  now  attention  had  been  so  promi- 
nently directed  to  it,  some  light  would  perhaps  soon  be  shed  on 
its  causation. 

Dr.  Amand  Routh  saw  no  difBicultj  in  explaining  this  inter- 
menstrual pain  if  once  it  could  be  assumed  that  in  certain 
cases  there  was  an  intermenstrual  cycle  as  well  as  a  men- 
strual one.  All  that  was  then  required  was  to  have  some  pelvic 
organ,  such  as  a  distended  tube,  an  ovary  with  thickened  capsule, 
or  a  growing  encapsuled  fibroid,  for  in  each  case  the  pain 
of  increased  tensioyi  would  be  present.  He  had  now  under 
observation  a  lady  with  small  multiple  fibroids,  with  this  inter- 
menstrual pain  occurring  ten  days  before  the  "  period,"  and  in 
her  case  he  was  able  to  prove  by  vaginal  examination  that  the 
fibroids  underwent  an  increase  in  size  and  tension  both  at  the 
menstrual  and,  more  markedly,  at  this  intermenstrual  ejDoch. 

Dr.  BoxALL  was  of  opinion  that  we  are  far  from  being  able 
at  present  to  fix  the  cause  of  intermenstrual  pain  on  any  one 
pelvic  lesion.  He  instanced  a  case  in  which  periodic  inter- 
menstrual jDain,  commencing  fourteen  and  ceasing  three  days 
before  each  period,  was  a  marked  feature.  No  intermenstrual 
discharge  was  noticed  in  association  with  it.  In  that  case  the 
uterus  at  first  was  unusually  small  and  anteflexed  and  low  in 
the  pelvis,  the  patient  sterile.  Four  years  after  marriage  the 
cervix  was  dilated  under  an  anaesthetic.  The  prolapse  was 
corrected  by  wearing  a  pessary  for  a  short  time.  The  pain  was 
for  a  time  relieved.  Subsequently  both  ovaries  were  found  to 
be  prolapsed  but  not  enlarged,  and  the  uterus  was  retroverted, 
but  there  was  from  first  to  last  no  sign  of  tubal  disease.  The 
pain  returned,  but  again  disappeared  as  the  tone  of  the  pelvic 
organs  was  regained.  Two  and  a  half  years  after  the  dilatation 
this  lady  became  pregnant,  but  miscarried.  Before  this  it  was 
noticed  that  the  uterus  was  irregularly  enlarged  by  a  fibroid,  and 
the  periods  were  somewhat  excessive.  The  fibroid  enlargement 
persists.  The  patient  is  now  pregnant  again,  and  has  nearly 
reached  the  full  time ;  but  since  her  previous  miscarriage  she 
has  had  little  or  no  intermenstrual  pain.  The  permanent  dis- 
appearance of  the  pain  in  this  case  appeared  to  be  due  to  im- 
provement of  tone  in  the  pelvic  organs  associated  with  a  general 
improvement  in  health. 

Dr.  Heywood  Smith  said  that,  in  spite  of  what  had  fallen 
from  previous  speakers,  looking  to  the  list  of  cases  and  noting 
that  in  the  majority  there  was  some  lateral  swelling  and  also  the 
evacuation  of  some  fluid,  he  considered  the  disease  under  con- 
sideration was  associated  with  intermittent  tubal  hydrorrhoea. 
The  oviduct  during  menstruation  was  not  only  swollen,  but  its 
lumen  was  enlarged,  becoming  then  the  seat  of  inflammation ; 
in  these  cases  the  inflammation  did  not  go  on  to  the  extent  of 
closure  of  the  ends  of  the  oviduct,  such  as  took  place  in  cases  of 


150  INTERMENSTRUAL    PAIN. 

hydrosalpinx,  but  the  fluid  thrown  out  had  a  way  of  escape  by 
the  uterine  orifice.  In  these  cases,  however,  or  the  majority  of 
them,  there  existed  some  condition  of  flexion.  What  took  place 
then  was  that  the  flexion,  altering  the  relative  position  of  the 
oviduct,  produced  a  kink  at  the  junction  of  the  oviduct  and  the 
uterus,  thereby  preventing  the  free  escape  of  the  fluid  and  giving 
rise  to  the  pain,  until  its  accumulation  partly  straightened  out 
the  oviduct  and  allowed  the  fluid  to  escape.  A  case  came  under 
his  observation  some  years  ago  where  there  was  a  distinct 
swelling  in  one  lateral  cul-de-sac,  which,  after  the  evacuation  of 
some  fluid  discharge  per  vaginam,  used  to  disappear.  In  this 
case  he  removed  the  appendages,  and  the  case  was  cured. 

Dr.  Arthur  G-iles  thought  that  the  name  "  intermenstrual 
pain "  was  not  altogether  a  happy  one,  as  it  rather  suggested 
that  the  pain  in  question  had  something  to  do  with  menstrua- 
tion or  ovulation,  which  was  an  hypothesis  by  no  means  proved. 
He  was  inclined  to  look  at  it  from  another  point  of  view,  and  to 
dwell  on  the  facts  which  came  out  in  Dr.  Addinsell's  table,  viz., 
firstly,  the  almost  constant  association  of  this  pain  with  tubal 
mischief,  or  at  least  with  a  condition  pointing  to  disease  of  the 
annexa  ;  secondly,  its  frequent  and  remarkable  association  with  a 
copious  watery  discharge  from  the  uterus.  True,  the  condition 
of  intermittent  hydrosalpinx  was,  as  Mr.  Sutton  and  Dr.  Herman 
had  pointed  out,  very  rare ;  but  there  were  cases  where  the  dis- 
charge could  not  well  be  explained  on  any  other  supposition. 
If  a  condition  of  intermittent  hydrosalpinx  were  present,  it  was 
not  unreasonable  to  suppose  that  the  swelling  of  the  uterine 
mucosa  during  menstruation  might  lead  to  temporary  occlusion 
of  the  uterine  ostia  of  the  tubes.  Consequently  the  secreted 
fluid  would  accumulate,  leading  to  pain  due  to  distension  of 
the  tube.  It  would  take  some  days  for  a  distension  to  occur 
sufficient  to  cause  pain.  Once  the  congestion  of  the  mucosa  had 
subsided  after  menstruation  had  ceased,  the  temporary  obstruc- 
tion might  be  relieved,  with  the  result  of  a  discharge  of  clear 
fluid  and  cessation  of  pain.  In  this  way  the  rhythmical 
character  of  the  pain  would  be  sufficiently  accounted  for,  without 
falling  back  on  the  somewhat  difficult  supposition  that  ovulation 
was  painful.  It  was,  however,  clear  that  more  observations  of 
this  interesting  condition  would  be  required  before  any  pro- 
nounced opinions  could  be  held  concerning  it. 

The  President  congratulated  the  author  of  the  paper  on 
having  brought  forward  a  very  interesting  subject.  It  was 
evident,  both  from  the  paper  itself  and  the  remarks  of  the 
various  speakers  who  had  taken  part  in  the  discussion,  that  the 
cause  of  the  phenomena  described  was  still  far  from  being 
understood.  None  of  the  theories  that  had  been  put  forward 
appeared  satisfactory.  Taking,  for  example,  the  theory  that  the 
pain  was  due  to  tubal  distension,  and  the  serous  vaginal  dis- 


INTERMENSTRUAL    PAIN.  151 

charge  to  escape  of  the  contents  through  the  uterine  end  of  the 
tube,  he  would  not  say  that  this  never  took  place,  but  we  had 
as  yet  no  indisputable  evidence  of  such  an  occurrence.  If  it 
ever  did  occur  it  must  be  an  event  of  extreme  rarity.  The 
author  had  stated  that  "  in  nearly  all  the  recorded  cases  a  tubal 
lesion  is  present,  which  he  believes  to  be  salpingitis  proceeding 
to  hydrosalpinx."  An  examination  of  the  table  did  not  seem  to 
warrant  that  statement.  In  only  three  out  of  the  thirteen  cases 
were  the  tubes  known  to  have  been  diseased.  In  one  of  these 
three  one  tube  was  thickened,  in  one  both  tubes  were  thickened, 
and  in  the  third  there  was  a  hydrosalpinx.  In  two  cases  there 
was  no  abnormality  of  any  kind  observed.  In  one  case  the 
ovaries  are  said  to  have  been  inflamed,  and  the  condition  of  the 
tubes  was  not  noted ;  whilst  in  the  remaining  seven  the  pre- 
sence of  a  tubal  lesion  was  a  mere  matter  of  inference,  some 
fulness  or  an  elastic  swelling  having  been  discovered  in  the 
region  of  the  broad  ligament.  The  association  of  salpingitis 
with  the  phenomena,  therefore,  rested  on  a  very  slender  basis. 
With  regard  to  the  discharges  of  clear  fluid  from  the  vagina,  he 
would,  without  in  any  way  impugning  their  genuineness  in  the 
cases  cited,  point  out  that  such  discharges  should  not  too  readily 
be  regarded  as  having  any  pathological  significance,  or  we  might 
be  led  into  fallacies.  He  mentioned  cases  in  illustration.  In 
one  the  discharge  proved  to  be  urine,  in  another  plain  water 
that  had  become  pent  up  in  the  vagina  whilst  the  patient  was  in 
her  bath.  He  suggested  that  the  table  might  with  advantage 
be  altered  so  as  to  show  in  separate  columns  the  physical  signs 
and  the  conditions  actually  seen  during  operation  or  in  the 
post-mortem  room.  These  were  at  present  included  under  one 
heading.  Their  diagnostic  value,  however,  was  so  different  that 
they  should  be  tabulated  separately.  The  paper  and  discussion 
would  no  doubt  arouse  interest  in  the  subject,  and  lead  to  further 
investigation. 

Dr.  EwEN  Maclean  asked  Dr.  Addinsell  if  he  had  had  oppor- 
tunity in  any  of  his  cases  of  examining  during  the  menstrual 
period,  and  if  so,  were  the  physical  signs  at  that  time  similar  to 
those  found  at  the  time  of  the  mittelschmerz.  If  such  a  simi- 
larity did  exist,  it  was  possible  some  of  these  cases  might  be 
regarded  as  an  attempt  at  double  menstruation  resulting  from 
the  overlapping  of  two  menstrual  cycles.  Such  anomalies  had 
been  definitely  traced  in  the  varying  tyj)es  of  ague. 

Dr.  Addinsell  thanked  the  President  for  his  suggestions  as 
to  the  alteration  of  the  table  of  cases,  and  he  undertook  to 
arrange  a  separate  list  which  would  show  at  a  glance  the  cases 
supported  by  clinical  evidence  only,  and  those  in  which  an 
operation  had  been  performed.  He  shared  the  scepticism  of  the 
President  as  to  placing  any  reliance  upon  the  patient's  descrip- 
tion of  vaginal  discharge,  and  he  fully  recognised  the  importance 


152  INTEEMENSTEUAL    PAIN. 

of  the  criticisms  of  Dr.  Herman,  Mr.  Bland  Sutton,  and  the 
President  with  regard  to  the  question  of  the  patency  of  the 
uterine  ostium  and  the  possibility  of  the  fluid  contained  in  a 
dilated  tube  passing  through  the  ostium  into  the  uterus  and 
out  by  the  vagina.  As  he  understood  the  position,  these  three 
authorities  denied  this  possibility,  or  at  any  rate  thought  it 
extremely  rare ;  with  this  view  Dr.  Addinsell  could  not  agree. 
He  had  satisfied  himself,  after  very  careful  examination,  that  a 
swelling  existing  on  one  or  other  side  of  the  uterus  might,  and 
in  his  experience  in  some  cases  did,  disappear  after  the  copious 
discharge  of  clear  mucus  accompanied  by  pain.  He  cited  a  case, 
reported  by  Dr.  G-alabin  in  the  '  Transactions '  of  1893,  in  which 
a  recurrent  hsemorrhagic  discharge  was  present,  and  where  a 
swelling  appeared  and  disappeared.  He  maintained  that  the 
patency  of  the  uterine  end  of  the  Fallopian  tube  was  fully 
recognised  by  competent  observers ;  and  he  quoted  Dr.  G-riffith 
and  others  who  had  demonstrated  this  condition.  In  his  opinion 
the  case  quoted  by  Mr.  Sutton  was  not  germaine  to  the  point. 
In  the  cases  under  his  own  observation  he  failed  to  see  how  the 
phenomenon  could  be  explained  by  any  other  hypothesis  than 
the  one  he  had  suggested,  and  he  was  supported  in  this  view  by 
the  fact  that  in  the  one  case  he  had  operated  uj)on  the  tube  was 
found  to  be  distended  and  thickened.  He  admitted  that  the 
evidence  was  inconclusive  in  regard  to  recorded  cases  verified  by 
operation  and  post-mortem  examination,  but  he  maintained  that 
the  few  cases  that  had  been  operated  on  and  the  whole  of  the 
clinical  evidence  were  entirely  in  his  favour. 


APRIL  6th,  1898. 

C.  J.  CuLLiNGWORTH,  M.D._,  President,  in  the  Chair. 

Present — 39  Fellows  and  4  visitors. 

Books  were  presented  by  La  Societe  de  Medecine 
de  Rouen,  the  Boston  Lying-in  Hospital  Staff,  Dr.  J.  A. 
Shaw-Mackenzie,  and  Dr.  Herbert  R.  Spencer. 

Henry  Macnaughton-Jones,  M.B.,  B.Ch.,  was  admitted 
a  Fellow  of  the  Society. 

.  Claude  Wilson,  M.D.Edin.  (Tunbridge  Wells)  ;  A.  J. 
Sturmer,  Surgeon  Lieutenant-Colonel,  I. M.S.  (Calne, 
Wilts)  ;  Claude  Edwin  Purslow,  M.D.Lond.  (Birming- 
ham) ;  and  David  J.  Evans,  M.D.McGill  (Montreal),  were 
declared  admitted. 

The  following  gentlemen  were  proposed  for  election  : 
John  Edward  Gemmell,  M.B.,  C.M.Edin.;  John  Robinson 

Harper,  L.R.C.P.  ;   Godfrey  D.  Hindley,  L.R.C.P.Lond.  ; 

Alfred  Gervase  Penny,  M.A.,  M.B.,  B.C.Cantab.  ;    Sidney 

Herbert    Snell,   M.D.,    B.S.Lond.  ;    and   Charles    Robert 

Watson,  M.D.Brux. 


154 


UTERINE  FIBROID  WITH  ANOMALOUS  OVARIAN 

TUMOUR. 

Shown  by  Dr.  Macnaughton-Jones. 

Dr.  Macnaughton-Jones  showed  a  large  uterine  fibroid, 
together  with  a  solid  ovarian  tumour  of  an  anomalous 
character,  which  was  associated  Avith  it.  The  patient,  a 
widow,  nulliparous,  aged  47,  was  sent  for  examination  in 
consequence  of  an  obscure  affection  of  the  left  hip,  in 
which  for  four  months  she  had  suffered  constant  pain, 
attended  by  some  swelling  of  the  thigh,  with  occasional 
difficulty  in  walking.  The  catamenia  had  been  regular, 
and  she  had  not  suffered  from  any  haemorrhage.  Exami- 
nation revealed  the  tumour  exhibited,  which  filled  the 
pelvis  and  reached  almost  to  the  umbilicus.  Intra-perito- 
neal  hysterectomy  was  performed  on  February  2nd,  when 
the  ovarian  tumour,  having  the  appearance  of  a  multiple 
fibromatous  mass  larger  than  an  orange,  was  discovered. 
The  right  ovary  was  healthy.  The  patient  made  a  rapid 
recovery  without  any  complication. 

The  interesting  clinical  feature  in  the  case  was  the  dis- 
covery of  the  cause  of  the  symptoms  in  the  hip  and  thigh, 
as  revealed  by  the  detection  of  the  uterine  tumour,  doubt- 
less aggravated  by  the  solid  left  ovary,  which  was  jammed 
downwards  and  to  the  left  side.  The  pathological  point 
of  interest  lay  in  the  anomalous  nature  of  the  ovarian 
tumour,  a  section  of  which,  prepared  by  Mr.  Targett,  was 
exhibited.  As  he  was  present,  he  would  state  his  views 
as  to  the  pathological  features  of  the  tumour. 


Plate  IV. 


Obstet.  Soc.  Trans.,  Vol.  XL. 


Printed  nnd  Enaravrd  bv  Bn/r  d  Doniclsson.  Ltd  .  Londor 


155 


EUPTURE  OF  AN  EAELY  (FIFTEENTH  DAY) 
TUBAL  GESTATION  COMPLICATED  BY  FIBRO- 
MYOMATA  OF  THE  UTERUS. 

Shown  by  E.  Rumley  Dawsox. 

The  specimen  which  I  show  to-night  was  obtained  post 
mortem  from  a  woman  to  whom  I  was  called  at  10.30 
p.m.  on  Monday,  March  7th,  1898. 

I  found  her  cold  and  collapsed/ but  quite  conscious,  with 
great  pain  in  the  lower  abdomen,  which  she  ascribed  to  the 
approaching  onset  of  her  menstrual  period,  which  was  due 
that  day,  but  had  not  yet  aj^peared. 

She  had  that  day  done  a  heavy  washing,  but  denied 
having  in  any  way  hurt  or  strained  herself. 

The  diagnosis  made  was  internal  haemorrhage,  probably 
a  menstrual  hgematocele,  or  rupture  of  a  vein  of  the  pam- 
piniform plexus,  induced  by  the  hard  work  done  at  a  time 
when  the  vessels  were  congested  by  the  approaching 
onset  of  menstruation. 

As  she  had  been  quite  regular  on  February  6th,  there 
was  no  missed  period  to  help  to  a  correct  diagnosis,  and  the 
possibility  of  pregnancy  seemed  quite  negatived.  She 
gradually  got  worse,  complained  of  frequent  desire  to 
micturate  and  defaecate  ;  and  in  spite  of  what  she  was 
told,  insisted  on  getting  out  of  bed  to  make  attempts  at 
both. 

There  was  a  slight  show  of  blood  per  vagituim  previous 
to  death,  which  occurred  at  3  a.m.  on  March  8th. 

The  patient  was  a  nullipara,  married  five  months, 
reputed  age  82,  but  looking  much  older. 

The  patient^s  husband,  aged  28,  had  just  been  nursed 
through  a  sharp  attack  of  influenza  by  the  patient,  and  it 
was  while  seeing  him  on  Sunday,  February  6th,  that  I 
became  aware  that  the  wife  was  menstruating  by  her 
complaint  of  pain  and  diarrhoea,  which  were  to  her  usual 


156       RUPTURE  OF  AN  EARLY  TUBAL  GESTATION. 

accompaniments.  The  husband's  illness  began  on  Feb- 
ruary 4th,  i.  e.  two  days  previous  to  this  period,  which, 
beginning  on  February  6th,  lasted  four  days,  and  was 
quite  normal  in  amount. 

Owing  to  the  illness  of  the  husband,  no  sexual  inter- 
course took  place  till  February  20th,  and  then  on  one 
occasion  only.  This  gives  fifteen  days  only  from  insemi- 
nation to  death  on  the  early  morning  of  March  8th.  The 
day  of  her  seizure  was  the  date  the  next  period  was  due, 
viz.  March  7th.  She  was  in  no  way  ill  until  8.30  p.m., 
i.  e.  about  an  hour  after  having  tea,  when  she  started 
vomiting,  and  speedily  became  collapsed,  and  died  as 
stated  at  3  a.m.  next  morning. 

The  post-mortem  was  made  on  March  9th. 

The  breasts  were  quite  virginal.  There  were  several 
pints  of  fluid  blood  in  the  peritoneal  sac,  and  some  half- 
dozen  handfuls  of  clotted  blood  in  the  pelvis,  and  around 
the  uterus.  Probably  the  pressure  of  this  blood  on 
rectum  and  bladder  explains  the  constant  desire  experi- 
enced to  empty  them. 

The  right  Fallopian  tube  had  ruptured  near  its  uterine 
end ;  from  the  rupture  was  protruding  a  brownish-pink  or 
raw  cocoa-coloured  flocculent-looking  clot,  which  was  un- 
fortunately lost  among  the  blood  and  clots  in  removing  the 
uterus  from  the  pelvis. 

The  uterus,  as  will  be  seen,  is  considerably  enlarged, 
more  so  than  can  be  ascribed  to  the  period  of  gestation ; 
but  the  numerous  fibro-myomata  present  undoubtedly 
furnish  the  trae  cause.  The  cervix  was  plugged  with 
mucus.  On  opening  up  the  uterus  a  large  purple -coloured 
(in  the  fresh  state)  decidual  membrane  was  seen. 

The  right  ovary  contained  a  corpus  luteum. 

The  following  points  seem  to  make  the  specimen  unusu- 
ally interesting  : 

(a)  The  very  early  period  of  rwpture,  i.  e.  fifteen  days 
after  impregnation  ;  most  cases  have  missed  two  periods. 

(6)   The  patient   was   a   nullipara.      It  is  rare  for   the 


RUPTURE  OF  AN  EARLY  TUBAL  GESTATION.       157 

first  pregnancy  to  be  extra-uterine  unless  a  long  period  of 
sterility  had  followed  marriage. 

(c)  The  presence  of  multiple  fihro-myomata  in  the  uterus, 
causing  its  enlargement. 

[d)  The  large  decidual  membrane  for  the  period  of  ges- 
tation. 

Dr.  Herbert  Spencer  said  Mr.  Dawson's  specimen  was  one 
of  great  interest  on  account  of  the  early  period  of  pregnancy  at 
which  rupture  had  taken  place.  He  had  operated  on  a  case  in 
which  the  gestation  sac  could  not  have  been  more  than  two  or 
three  weeks  old,  the  tubal  swelling  being  even  smaller  than  in 
Mr.  Dawson's  specimen.  He  operated  on  the  patient  when 
suffering  from  extreme  collapse  owing  to  the  large  quantity  of 
blood  which  had  escaped  from  the  ruptured  tube ;  the  patient 
made  a  good  recovery.  The  specimen  in  which  the  tubal 
swelling  was  not  larger  than  a  pea,  and  another  somewhat 
larger,  were  in  University  College  Museum,  and  they  and  Mr. 
Dawson's  specimen  were  the  smallest  ruptured  tubal  gestation 
sacs  he  had  seen.  With  reference  to  Mr.  Dawson's  remark  as 
to  the  rarity  of  tubal  pregnancy  in  primiparse  he  had  recently 
seen  two  cases,  in  one  of  which  there  were  strong  reasons  for 
believing  the  patient's  statement  that  it  occurred  after  the  first 
and  only  coitus,  and  in  the  other  after  the  first  coitus  for 
several  years. 

Dr.  Peter  Horrocks  asked  why  the  patient  had  not  been 
operated  upon.  However  desperate  these  cases  seemed,  it  was 
worth  while  giving  them  a  chance,  and  he  advocated  in  appa- 
rently moribund  cases  that  intra- venous  injection  of  saline  fluid 
should  be  carried  on  at  the  same  time  as  laparotomy.  Great  as 
was  the  haemorrhage  from  an  apparently  small  slit  in  the  rup- 
tured Fallopian  tube,  it  was  no  greater  than  took  place  from  a 
small  piece  of  placenta  left  behind  in  the  uterus  in  some  cases 
of  miscarriage.  It  has  appeared  to  him  that  it  was  partial 
separation  that  caused  this  excessive  haemorrhage,  and  that  if 
the  whole  product  of  gestation  in  the  uterus  came  away,  or,  if 
in  the  tube,  if  it  escaped  into  the  abdominal  cavity,  then  there 
was  but  little  bleeding,  the  parts  being  able  to  contract  and 
retract.  He  had  made  use  of  this  in  operating  in  extra-uterine 
cases.  When  the  placenta  was  detached  a  little  the  haemorrhage 
was  sometimes  alarming,  but  if  the  whole  placenta  was  boldly 
detached  the  bleeding  became  much  less,  and  was  more  easily 
controlled. 

Dr.  Herman  pointed  out  that  there  were  no  adhesions,  and 
that  in  cases  of  ruptured  tubal  pregnancy  there  seldom  were. 
This  made  the  operation  in  such  cases  usually  an  easy  one,  and 


158       EUPTURE  OF  AN  EARLY  TUBAL  GESTATION. 

if  done  in  time,  and  with  clean  hands  and  instruments,  it  would 
generally  be  successful.  It  was  so  important  that  it  should  be 
done  early,  that  it  would  often  have  to  be  done  by  the  doctor 
who  first  saw  the  case. 

Mr.  Dawson,  in  reply  to  Dr.  Horrocks  as  to  why  no  operation 
was  performed,  said  that  the  entire  absence  of  symptoms  of 
pregnancy,  and  the  very  recent  and  regular  menstruation,  so 
apparently  negatived  the  j^ossibility  of  extra-uterine  pregnancy 
that  in  spite  of  her  very  grave  condition,  and,  owing  to  the  late- 
ness of  the  hour,  the  impossibility  of  summoning  the  aid  of  a 
specialist,  he  should  undoubtedly  have  attempted  an  operation 
had  he  known  then  what  they  could  all  see  now  by  examining 
the  specimen.  The  difficulty  of  diagnosing  a  fifteen-day  old 
extra-uterine  pregnancy  must  be  admitted  by  all,  for  the 
President,  Dr.  Cullingworth,  had  himself  had  to  admit,  in  a 
case  ruptured  at  the  fourth  week,  that  **  there  had  been  no 
missed  menstrual  period  to  help  to  a  correct  diagnosis."  As  to 
the  statement  just  made  that  haemorrhage  was  only  slight  if  the 
ovum  came  away  completely  on  rupture  of  the  tube,  and  exces- 
sive if  only  partially  detached,  the  present  specimen  showed 
just  the  opposite,  for  the  ovum  was  completely  detached,  and 
the  haemorrhage  so  excessive  as  to  be  fatal  In  answer  to  Dr. 
Cullingworth' s  criticism  of  the  statement  that  first  pregnancies 
were  rarely  extra-uterine  unless  sterility  had  existed  for  a  long 
time  previously,  Mr.  Dawson  had  looked  through  the  Society's 
*  Transactions '  for  the  last  six  years,  and  had  only  found  one 
case  recorded  of  the  first  pregnancy  soon  after  marriage  being 
extra-uterine,  viz.  by  Dr.  Playfair  in  July,  1895.  Dr.  G-alabin's 
case,  February,  1896,  was  the  second  pregnancy,  although  within 
a  year  of  marriage.  Dr.  Cullingworth  had  himself  shown,  in 
Ai^ril,  1895,  a  first  pregnancy  being  extra-uterine,  but  after  over 
fifteen  years'  sterility.  Dr.  G-iles  had  shown  one  after  thirteen 
years'  sterility.  The  dilated  portion  of  the  tube  where  the  ovum 
was  arrested  was  roughly  an  ovoid,  measuring  half  an  inch  by 
a  quarter  of  an  inch,  and  the  length  of  the  tear  was  a  quarter  of 
an  inch  in  the  long  diameter  of  the  tubal  swelling.  The  specimen 
when  mounted  will  go  to  the  Westminster  Hospital  Museum. 


159 


FIBRO-MYOMA  OF  UTERUS  PROJECTINa  INTO 
VAGINA,  REMOVED  BY  ABDOMINAL  HYS- 
TERECTOMY. 

Shown  by  Waltee  W.  H.  Tate,  M.D. 

The  specimen  shown  was  the  uterus  and  appendages 
removed  by  abdominal  hysterectomy.  The  patient,  a 
single  woman  aged  40,  had  suffered  from  severe  and 
increasing  monorrhagia  for  three  years,  associated  with 
great  pain  and  some  difficulty  in  micturition.  On  exa- 
mination the  tumour  was  found  to  extend  upwards  to  a 
level  of  85  inches  above  the  umbilicus.  The  vagina  was 
occupied  by  a  smooth  rounded  mass,  the  size  of  a  foetal 
head,  which  reached  to  within  an  inch  of  the  vulva.  No 
evidence  of  any  pedicle  could  be  made  out  as  high  as  the 
finger  could  reach,  nor  could  the  position  of  the  cervix  be 
identified. 

As  it  was  evident  that  the  mass  in  the  vagina  was  con- 
tinuous with,  and  a  part  of,  the  tumour  in  the  abdomen, 
it  was  decided  to  perform  abdominal  hysterectomy  by  the 
intra-peritoneal  method. 

The  tumour  removed  weighed  5  lbs.  12  oz.,  and 
measured  9  inches  long  by  6  inches  across  the  broadest 
part.  The  part  of  the  mass  which  occupied  the  vagina 
measured  4^  x  4^  inches. 

Dr.  Peter  Horrocks  said  that,  looking  at  the  specimen,  it 
might  be  thought  that  it  would  have  been  an  easy  matter  to  cut 
pieces  out  of  the  part  projecting  into  the  vagina  until  the  whole 
of  this  had  been  removed,  and  then  to  have  tried  to  enucleate 
the  part  remaining  in  utero,  but  this  was  not  always  free  from 
danger.  There  was  little  or  no  haemorrhage  when  such  a 
fibroid  was  cut  in  that  way,  but  when  the  adhesions  between  the 
fibroid  and  the  uterine  wall  came  to  be  separated  the  haemor- 
rhage was  apt  to  be  serious  and  uncontrollable.  He  mentioned 
a  case  at  present  under  his  care  where  the  patient  lost  so  much 
blood  when  the  lower  part  of  the  tumour  had  been  separated 


160  PIBRO-MYOMA    OF    UTERUS. 

from  the  uterine  wall,  manipulating  jper  vaginam,  that  the 
operation  had  to  be  abandoned  and  plugging  had  to  be  resorted 
to,  and  also  intra- venous  saline  injection  of  4|^  pints.  The 
patient  was  recovering  slowly  at  the  present  time  from  the 
dangerous  state  she  was  in,  and  later  he  proposed  to  operate 
through  the  abdomen.  But  instead  of  removing  the  whole 
uterus  he  intended  to  put  an  elastic  ligatuie  round  it,  open  the 
uterine  cavity  and  shell  out  the  tumour,  stop  the  haemorrhage, 
and  sew  up  the  uterine  wall  as  in  a  case  of  Csesarean  section. 

In  reply  to  remarks  by  Dr.  Horrocks  and  Dr.  Eenton,  Dr. 
Tate  replied  that  in  cases  like  the  present,  where  a  fibroid 
tumour  of  considerable  size  exists  in  the  abdomen  associated 
with  a  mass  projecting  into  the  vagina,  which  shows  no  evidence 
of  pedunculation,  the  safer  treatment  is  to  perform  abdominal 
hysterectomy,  rather  than  subject  the  patient  to  the  risk  of  a 
difficult  and  probably  incomplete  enucleation  per  vaginam. 


161 


THE  MENSTRUATION  AND  OVULATION  OF 
MONKEYS  AND  THE  HUMAN  FEMALE. 

Shown  by  Walter  Heape,  M.A., 

TEINITY   COLLEGE,  CAMBEIDGE. 

Introduced  by  W.  S.  A.  Griffith,  M.D. 

Menstruation. 

Since  1894^  when  I  had  the  honour  of  bringing  before 
you  a  brief  notice  of  my  work  on  the  menstruation  of 
Semnopithecus  entellus,  I  have  investigated  that  pheno- 
menon in  Macacus  rhesus,  and  I  find  that  histologically 
the  process  is  practically  identical  in  both  species. .  The 
same  periods  of  rest,  growth,  degeneration,  and  recupera- 
tion are  seen  in  M.  rhesus  as  I  described  to  you  before  in 
S.  entelluSj  and  the  same  stages  of  growth  of  stroma  and 
increase  of  vessels,  of  a  breaking  down  of  the  congested 
vessels  and  the  consequent  formation  of  lacunge,  which 
come  to  lie  close  beneath  the  uterine  epithelium ;  of 
degeneration  of  the  superficial  mucosa  and  subsequent 
rupture  of  the  lacunae ;  and  of  denudation  of  the  super- 
ficial portion  of  the  mucosa  and  the  consequent  formation 
of  a  menstrual  clot,  are  clearly  shown  in  M.  rhesus  to  be 
identical  with  the  same  stages  which  I  before  described 
in  similar  words  as  occurring  in  8.  entellus. 

I  am  glad  of  this  opportunity  of  recounting  the  similarity 
which  is  thus  shown  to  exist  in  these  two  species  of 
monkeys,  for  when  I  read  my  former  paper  I  felt  that 
you  might  well  demand  further  proof  that  the  process  I 
described  was  not  confined  to  the  species  I  had  at  that 
time  alone  thoroughly  investigated. 

VOL.    JL.  11 


162  MENSTRUATION   AND    OVULATION    OF 

I  had,  indeed,  at  that  time  made  some  investigations  on 
M.  rhesus,  and  felt  fairly  sure  that  I  should  be  in  a  posi- 
tion to  show  that  the  process  of  menstruation  in  M.  rhesus 
was  practically  identical  with  that  process  in  S.  entellus  ; 
but,  in  view  of  the  researches  of  Mr.  Bland  Sutton,  it  was 
necessary  that  I  should  make  sure  of  my  opinion,  and  this 
I  am  now  in  a  position  to  assure  you  I  have  done. 

As  in  S.  entellus,  so  in  M.  rhesus,  the  congestion  and 
rupture  of  the  superficial  vessels  of  the  mucosa  is  followed 
by  the  formation  of  lacunge,  by  degeneration  of  the  super- 
ficial portion  of  the  mucosa,  and  by  denudation  of  that 
tissue  and  the  formation  of  a  menstrual  clot. 

Mr.  Sutton  was  of  opinion  there  was  no  disintegration 
of  the  mucous  membrane  in  M.  rhesus,  and  that  blood 
emerged  from  the  congested  mucosa  in  much  the  same 
way  as  blood  escapes  from  the  nasal  or  buccal  cavities  in 
man  during  congestion. 

It  may  well  be  that  Mr.  Sutton  was  misled  in  his  con- 
clusions on  account  of  the  conditions  under  which  the 
specimens  he  worked  at  lived. 

Captivity,  and  the  unfavourable  climate  of  this  country, 
very  probably  check  the  free  exercise  of  the  menstrual 
function  in  monkeys,  which  are  accustomed  to  a  very 
active  life  and  a  more  congenial  atmosphere  ;  and,  judging 
from  the  specimens  I  kept  in  Cambridge,  it  may  be  that 
menstruation  is  at  any  rate  partially  suppressed,  and  that 
normal  menstrual  phenomena  were  not  to  be  found. 

In  India,  however,  M.  rhesus  does  menstruate  in  the 
same  way  as  8.  entellus,  and  the  specimens  to  be  seen 
under  the  microscopes  will,  I  think,  definitely  prove  that 
fact. 

There  is  little  to  add  to  the  histological  account  I  laid 
before  you  on  the  occasion  of  my  first  paper  ;  in  M.  rhesus 
the  mucosa  is  somewhat  thicker,  the  protoplasmic  network 
denser,  and  the  glands  more  numerous  and  more  branched 
than  in  S.  entellus  ;  but  these  are  the  only  histological 
differences  of  moment  to  be  seen  during  the  resting  stage. 
The   same   may  be   said   during  all  the   other  stages  of 


MONKEYS  AND  THE  HUMAN  FEMALE.  163 

menstruation,  and,  bearing  in  mind  the  slight  differences 
mentioned  above,  the  sections  of  uteri  of  M.  rhesus  might 
well  be  taken  for  those  of  S.  entellus  throughout  the 
menstrual  process. 

In  the  human  female  I  have  two  uteri,  which  it  will,  I 
think,  be  interesting  to  compare  mth  monkeys. 

Sections  of  these  uteri  are  exhibited  under  the  micro- 
scopes at  the  table.  The  first  of  these  was  obtained  from 
Dr.  Lloyd  Jones,  of  Cambridge.  I  have,  however,  no 
details  of  the  case. 

When  I  examined  the  uterus,  which  was  brought  to 
me  intact,  there  was  nothing  in  it ;  the  mucosa  was 
smooth  and  fresh-looking,  it  was  highly  congested,  and 
the  surface  exhibited  a  crowded  network  of  brilliant 
vessels. 

Sections  showed  that  the  vessels  throughout  the  mucosa 
were  greatly  congested,  and  it  is  noticeable  that  many 
large  vessels  lie  close  under  the  epithelium  of  the  uterus. 

Here  and  there  the  epithelium  is  broken  away,  but  I 
have  little  doubt  that  this  is  due  to  bad  preservation  and 
faulty  manipulation. 

It  is  noticeable  that  the  vessels  in  this  uterus  are  larger 
and  more  congested  than  those  in  either  Semnopithecus  or 
Macacus  ;  but  they  are  vessels  bounded  by  epithelial  walls, 
and  as  yet  they  have  not  broken  down,  and  no  blood  is 
extravasated. 

I  judge  this  specimen  to  exhibit  an  early  stage  of  men- 
struation, comparable  to  Stages  III  and  IV  of  monkeys. 

The  second  specimen  was  obtained  by  Dr.  Maxwell,  and 
forwarded  to  me  by  Dr.  Champneys. 

The  case  was  admitted  to  hospital  on  September  9th,  and 
died  September  10th,  after  twelve  hours^  coma,  from  cere- 
bellar abscess.  Post-mortem  showed  that  the  subperi- 
toneal tissue  covering  the  uterus  and  broad  ligaments  was 
deeply  congested ;  so  also  was  that  portion  lining  the 
bottom  of  the  utero-vesicular  and  utero-rectal  pouches. 
At  the  brim  of  the  pelvis,  however,  the  congestion  faded 
away,  and  the  subperitoneal  tissue   there,  and  also  at  the 


164  MENSTRUATION  AND  OVULATION  OF 

back  of  the  abdomen,  was  normal.  The  uterus  was  strongly 
retroflexed,  the  fundus  lying  at  the  bottom  of  Douglases 
pouch. 

On  examination  of  the  uterus  I  found  therein  a  men- 
strual clot  composed  of  blood-corpuscles  and  mucosa 
tissue,  epithelium,  and  stroma  tissue.  Sections  showed 
congested  vessels  in  the  mucosa,  extravasated  blood,  and 
denudation. 

This  specimen,  then,  I  judge  to  be  comparable  to  Stage 
yil  of  monkeys'  menstruation. 

The  torn  edges  of  the  mucosa  are  not  apparently  so 
ragged  as  is  shown  in  the  Semnopithecus  specimen,  but  it 
must  be  remembered  the  uterus  was  preserved  with  the 
menstrual  clot  in  situ,  and  with  the  walls  of  the  uterus 
closely  pressing  upon  it,  and  this  would  no  doubt  tend,  by 
contraction  of  the  muscular  tissue  during  preservation,  to 
flatten  down  the  torn  tissue. 

These  two  specimens  are  interesting,  and  they  certainly 
show  congestion  and  denudation.  Specimens  showing  the 
formation  of  lacunae  are,  however,  wanting  to  me  as  yet, 
and  I  cannot  show  whether  lacunae  are  really  formed,  or 
whether  those  large  congested  vessels  which  we  see  in  the 
first  specimen  lying  close  beneath  the  epithelium  break 
through  the  epithelium  and  disgorge  their  blood  straight 
into  the  uterine  cavity. 

The  only  evidence  which  my  specimens  show  against  this 
view  is  the  existence  of  large  quantities  of  uterine  epithe- 
lium and  stroma  tissue  in  the  menstrual  clot,  and  it  is 
difficult  to  see  why  this  material  should  be  discarded  if  the 
blood  is  poured  straight  from  the  vessels  into  the  uterine 
cavity.  Specimens  of  the  intermediate  stages  are,  how- 
ever, necessary  in  order  to  definitely  show  this  point. 

I  may  perhaps  mention  here  that  I  see  no  sign  in  these 
specimens  of  the  decidual  tissue  described  by  Overlach 
(^  Arch.  f.  mik.  Anat.,'  vol.  xxv,  1885)  and  others.  One  can- 
not help  thinking  that  the  specimen  he  saw  was  one  of  early 
miscarriage  at  a  menstrual  period,  and  in  support  of  that 
view  I  may  add  that  I  found  decidual  tissue  in  a  menstrual 


MONKEYS  AND  THE  HUMAN  FEMALE.  165 

clot  which  was  submitted  to  me  for  examination,  and  in 
that  case  the  probability  of  miscarriage  was  acknow- 
ledged. 

In  my  former  paper  before  this  Society  I  drew  attention 
to  the  external  signs  of  menstruation  and  to  the  menstrual 
discharge.  I  do  not  think  I  have  anything  to  add  now  on 
these  points.  There  is_,  however,  a  point  to  which  I  would 
draw  your  attention,  and  that  is  the  fact  that  menstruation 
occurs  in  animals  which  have  a  definite  breeding  season. 

Saint-Hilaire  and  Cuvier  describe  a  regular  discharge  of 
blood  from  the  generative  organs  of  Cercopithecus,  Cynoce- 
phalus,  and  Macacus.  Sutton  says  the  Macacus  which  he 
investigated  menstruated  fairly  regularly  (he  obtained  them 
from  the  Zoological  Gardens  in  London) .  The  late  Mr.  Bart- 
lett,  of  the  Zoological  G-ardens  in  London,  and  Mr.  Sanyal, 
Superintendent  of  the  Zoological  Gardens  in  Calcutta,  both 
assured  me  that  monkeys  menstruate  regularly  in  their 
establishments,  and  the  specimens  of  Semnopithecus  en- 
tellusj  Macacus  rhesus  and  cynomolgus,  and  Cynocephahis 
porcarius,  which  I  had  under  observation  at  Calcutta,  men- 
struated regularly  for  the  few  months  I  w^atched  them ; 
and,  be  it  noted,  that  time  was  not  the  breeding  time. 

There  is,  then,  good  reason  to  believe  that  monkeys 
menstruate  regularly,  though  doubtless  it  would  be  satis- 
factory to  have  further  confirmation  of  the  fact. 

That  monkeys  have  a  definite  breeding  season  there 
seems  to  be  little  room  for  doubt.  Dr.  Aitchison  assures 
me  that  M.  rhesus  in  Simla  breeds  about  October.  I 
got  most  of  my  specimens  of  the  same  species  from  the 
plains  near  Muttra,  and  a  very  large  proportion  of  these 
bore  advanced  embryos  in  utero  during  January  and 
February,  while  in  March  most  of  them  had  undergone 
parturition,  thus  showing  that  on  the  plains  M.  rhesus  has 
also  a  definite  breeding  season,  though  at  a  different  time 
of  the  year  from  individuals  of  the  same  species  at  Simla. 
Again,  Semnopithecus  entelhis  in  the  jungles  on  the  south 
bank  of  the  Hugli,  from  whence  the  specimens  came  at 
which  I  worked,  have  also  a  definite  breeding  season.      I 


166  MENSTBUATIOX  AND  OVCLAIIOX  OF 

was  assured  of  that  fact  by  the  collectors,  and  am  very 
sure  the  specimens  I  saw  were  not  breeding  at  the  time  I 
was  in  the  countiy  from  December  until  April. 

That  monkevs  should  have  different  breedino:  times  in 
different  parts  of  the  continent  of  India  is  not  surprising. 
M,  rhesus  J  for  instance,  lives  over  an  area  between  latitude 
34°  and  17°,  longitude  73^  and  90^,  from  sea  level  to  an  alti- 
tude of  10,000  feet,  and  the  variations  in  climate  and 
food  are  sufficient  to  account  for  all  possible  variations  in 
breeding  seasons.  I  think,  then,  we  are  justified  in  con- 
cluding that  some  monkeys,  at  any  rate,  have  a  definite 
breedino^  season. 

Thus  certain  monkevs  menstruate  all  the  vear  round, 
althouofh  thev  breed  onlv  at  certain  times,  and  this  seems 
to  me  to  be  a  fact  of  considerable  importance. 

In  this  particular  they  differ  fi'om  all  the  lower 
mammals  as  far  as  is  known,  who  breed  only  at  times 
of  ''  heat,"  and  who  experience  '^  heat "  only  at  certain 
times,  although  those  times  may  recur  with  more  or  less 
fi'equency,  and  extend  over  a  variable  length  of  time. 
They  diff'er  also  from  most  of  the  higher  Primates,  who  are 
capable  of  breeding  at  all  times.  But  there  are  certain 
human  females  who  breed  only  at  particular  times  also  ; 
and  although,  as  Mr.  Doran  pointed  out  when  discussing 
the  last  paper  I  read  before  you,  the  cessation  of  breeding 
amoDgst  the  northernmost  Esquimaux,  during  the  long 
ai'ctic  winter,  is  accompanied  by  a  cessation  of  menstrua- 
tion during  that  time  also,  still  in  Queensland,  where  I  am 
assured  a  special  breeding  season  is  observed  by  some  of 
the  natives,  there  seems  no  reason  to  conclude  that  they 
do  not  menstruate  reofularlv. 

Monkeys,  then,  occupy  an  intermediate  position  between 
man  and  the  lower  mammals  in  this  particular  :  although 
they  differ  fi*om  the  latter  inasmuch  as  they  menstruate 
regularly,  they  resemble  them  in  ha^*ing  special  breeding 
seasons ;  and  while  they  resemble  man  inasmuch  as  they 
menstruate  regularly,  they  differ  from  him  in  their  limited 
breeding  season. 


MONKEYS  AND  THE  HUMAN  FEMALE.  167 

This  is  an  interesting  connection,  and  when  it  is  shown, 
as  I  have  good  reason  to  believe  from  my  own  observa- 
tions it  will  be  shown,  that  the  histological  changes  which 
take  place  in  the  uterus  of  the  lower  mammals  during 
^^  heat  '^  resemble  very  closely  the  changes  which  take 
place  in  the  earlier  stages,  at  any  rate,  of  menstruation, 
this  connection  mil  be  strengthened,  and  the  homology  of 
'^  heat ''  and  menstruation  established. 


Ovulation. 

The  relation  between  ovulation  and  menstruation  has 
given  rise  to  much  controversy.  On  the  one  hand  the 
view  is  held  that  ovulation  occurs  at  each  menstrual  period, 
while  on  the  other  it  is  maintained  that  ovulation  and 
menstruation  are  independent  of  each  other.  Again,  on 
the  one  hand  ovulation  and  menstruation  are  believed  to 
be  both  due  to  the  same  active  cause,  while  on  the  other 
they  are  believed  to  be  two  distinct  processes  due  to 
independent  stimuli,  each  following  their  own  recurrent 
cycle,  and  coincident  only  by  accident. 

In  S.  entellus  I  examined  forty-two  menstruating 
specimens,  and  not  one  of  them  had  a  recently  discharged 
follicle  in  either  ovary. 

In  M.  rhesus  I  examined  forty-three  adult  females  ; 
twenty-two  of  these  had  no  sign  of  a  discharged  follicle 
in  either  ovary  (fourteen  were  menstruating,  and  eight 
were  not),  and  twenty-one  had  a  more  or  less  prominent 
discharged  follicle  in  one  or  other  of  their  ovaries.  Six- 
teen were  pregnant,  or  had  recently  borne  or  aborted 
joung,  one  was  doubtful,  but  had  probably  aborted,  one  was 
non-pregnant  and  non-menstruating,  and  three  only  were 
menstruating. 

Thus  in  M.  rhesus  only  three  out  of  seventeen  menstru- 
ating females  were  found,  in  the  ovaries  of  which  there 
was  any  sign  of  a  discharged  follicle,  and  of  these  three, 
two  were  not  of  recent  origin,  and  but  one  remains,  which 


168  MENSTRUATION   AND    OVULATION    OF 

had  been  recently  discharged,  and  it  was  present  in  the 
ovary  of  a  female  killed  during  Stage  VII,  i.  e.  during  the 
formation  of  the  menstrual  clot. 

This  one  is  undoubtedly  a  newly  discharged  follicle ; 
it  is  prominent,  and  the  ovarian  epithelium,  attenuated  over 
the  greater  part  of  the  swelling,  is  absent  altogether  at 
the  point  where  the  actual  rupture  took  place.  But  when 
exactly  the  rupture  of  this  follicle  took  place  is  difficult 
to  say ;  those  who  hold  that  menstruation  and  ovulation 
are  coincident  would  doubtless  unhesitatingly  assert  that 
the  rupture  took  place  during  the  menstrual  period  going 
on  at  the  time  of  death,  but,  in  view  of  the  fact  that  in 
sixteen  other  menstruating  females  there  is  no  sign  of  a 
recently  discharged  follicle,  one  must  exercise  caution  in 
making  such  an  assertion. 

My  experience  of  recently  ruptured  follicles  in  the  rabbit 
teaches  that  this  follicle  has  not  just  ruptured,  it  has  had 
time  to  heal,  and  I  am  not  prepared  to  say  the  rupture 
did  not  take  place  before  menstruation  began,  and  that  is 
all  I  can  say. 

The  only  other  case  which  might  be  interpreted  to  be  a 
follicle  which  had  burst  during  a  menstrual  period  is  that 
of  the  non-pregnant,  non-menstruating  monkey.  This  also 
is  a  prominent  discharged  follicle  ;  the  ovarian  epithelium, 
however,  covers  the  whole  of  the  swelling,  and  the  point 
of  rupture  no  longer  exists  as  such.  A  considerable  period 
must  have  passed  since  this  follicle  ruptured ;  hypertrophy 
of  the  wall  of  the  follicle  has  taken  place,  and  an  unbiassed 
observer  would  certainly  find  no  data  for  deciding  that 
this  follicle  had  ruptured  during  a  menstrual  period.  I 
merely  draw  attention  to  this  specimen  because  certain 
writers  on  the  subject  habitually  take  it  for  granted  that 
a  comparatively  recently  discharged  follicle,  found  in  the 
ovary  of  a  woman  at  the  intermenstrual  period,  must 
necessarily  be  interpreted  as  evidence  of  the  fact  that  it 
ruptured  during  the  last  menstrual  period.  In  the  same 
way  they  will  describe  a  supposed  ripe  follicle  as  a  follicle 
which  will  rupture  at  the  next  menstrual  period.      I  think 


MONKEYS  AND  THE  HUMAN  FEMALE.  169 

it  cannot  be  too  strongly  insisted  that  such  deductions  are 
not  justified  in  the  present  state  of  our  knowledge  of  the 
subject^  and  it  is  mth  that  in  mind  I  draw  attention  to 
the  point. 

In  monkeys^  then^  ovulation  and  menstruation  are 
certainly  not  necessarily  coincident^  menstruation  can  and 
does  take  place  frequently  without  ovulation. 

With  regard  to  the  human  female,  Leopold  and  Miranoff 
(^  Arch,  fiir  G-ynakologie/  vol.  xlv_,  1894)  state  that,  in 
spite  of  regular  menstruation  '^  periods/'  a  follicle  does 
not  always  rupture  ;  further  they  add  that  a  corpus  luteum 
may  form  when  menstruation  does  not  coincide  with  its 
formation  ;  and  finally,  they  say  that  ripe  follicles  may 
rupture  and  conception  take  place  at  any  time. 

We  may  summarise  the  facts,  then,  as  follows  : 

For  man  and  monkeys — (1)  ovulation  and  menstruation 
are  not  necessarily  coincident ;  (2)  menstruation  may  take 
place  without  ovulation.  For  man  alone — (3)  ovulation 
may  occur  without  menstruation. 

While  these  results  are  in  accord  with  Leopold  and 
Miranoff's  statements,  I  should  add  that  these  authors 
seek  to  show  that  in  the  majority  of  cases  menstruation 
and  ovulation  do  fall  together.  They  examined  forty-two 
cases,  comprising  examples  of  almost  all  stages  of  the 
menstrual  cycle,  and  they  say  that  in  twelve  of  them 
menstruation  occurred  without  ovulation,  while  in  the 
remaining  thirty  cases  ovulation  happened  during  men- 
struation. 

This  may  be  so,  but  these  authors  give  no  figures,  and 
one  would  like  to  see  the  specimens  which  they  interpret 
as  newly  discharged  follicles.  They  assert,  moreover, 
that  a  certain  follicle,  seen  in  an  ovary  excised  some  days 
after  menstruation,  would  have  ruptured  at  the  next 
menstrual  period  ;  and  one  feels  that  such  a  statement 
can  only  be  made  by  observers  who  hold  a  brief,  so  to 
speak,  for  the  usual  concidence  of  ovulation  and  men- 
struation. 

Thus,   while   one   may  feel   sure   that  twelve   cases   of 


170  MENSTRUATION    AND    OVULATION    OF 

menstruation  without  ovulation  occurred,  one  cannot  be 
so  certain  that  in  all  the  remaining  thirty  cases  ovulation 
and  menstruation  happened  at  the  same  time. 

As  an  illustration  of  what  I  mean,  I  found  in  the  case 
of  a  human  female  whose  uterus  was  highly  congested 
(the  one  from  which  the  section  was  taken  which  shows 
great  congestion  of  the  mucosa,  and  which  is  under  one 
of  the  microscopes  to-night)  a  bright  red  raised  spot  in 
the  left  ovary. 

This  was  a  follicle  with  congested  outer  wall,  and  might 
have  been  taken  for  a  newly  discharged  follicle,  whereas 
on  examination  it  was  found  to  be  a  degenerate  follicle, 
which  certainly  had  not  been  ruptured  at  all.  Other  folli- 
cles in  the  ovaries  of  this  case  also  show  degeneration. 

With  regard  to  the  histology  of  the  corpus  luteum  in 
M.  rhesus,  there  are  three  points  which  are,  I  think,  of 
interest. 

In  the  first  place,  no  blood-clot  was  seen  in  any  of  them, 
and  this  circumstance,  while  at  variance  with  the  usual 
description  of  a  human  corpus  luteum,  is  in  accord  with  the 
phenomena  exhibited  by  discharged  follicles  in  the  rabbit. 

In  the  second  place,  the  first  change  which  takes  place 
in  the  newly  discharged  follicle  is  the  thickening  of  its 
wall  by  hypertrophy.  As  far  as  I  am  aware  this  cause 
of  the  thickening  has  not  been  elsewhere  described  except 
by  Sobotta  {^  Arch.  f.  mik.  Anat.,^  vol.  xlvii,  1896),  whose 
work  on  the  corpus  luteum  of  the  mouse  I  did  not  see  until 
after  my  observations  had  been  recorded. 

While,  thirdly,  the  cavity  of  the  discharged  follicle  is 
first  filled  with  a  loose  reticulated  tissue  chiefly  derived 
from  the  cells  of  its  wall,  it  then  gradually  becomes  re- 
duced by  the  growth  inwards  of  that  wall,  and  finally  the 
branched  cells,  of  which  the  wall  was  originally  composed, 
gradually  undergo  change,  and  eventually  become  indis- 
tinguishable from  the  ovarian  stroma  tissue. 

I  think  the  specimens  under  the  microscopes  will  suffi- 
ciently illustrate  these  points. 


MONKEYS   AND    THE    HUMAN    FEMALE.  171 


Origin  of  Menstruation  and  Ovulation. 

I  do  not  feel  able  as  yet  to  advance  sufficiently  con- 
nected views  to  claim  for  tliem  the  dignity  of  a  theory _, 
but  I  should  like,  with  your  permission,  to  lay  before  you 
certain  facts  which,  in  my  opinion,  bear  upon  the  subject 
of  the  origin  of  menstruation  and  of  ovulation. 

That  both  menstruation  and  ovulation  are  closely  con- 
nected with  and  largely  influenced  by  congestion,  there 
seems  no  room  for  doubt ;  but  the  origin  of  that  conges- 
tion, the  stimulus  which  induces  congestion,  is  not  clearly 
shown. 

I  do  not  myself  now  hold  the  view  that  ovulation  and 
menstruation  are  such  distinct  processes  as  some  observers 
maintain.  We  know  that  either  of  them  may  occur  without 
the  other,  but  we  know  also  that  they  do  occur  together ; 
and  when  it  is  remembered  that  in  many,  possibly  in  most 
of  the  lower  mammals,  though  not  in  all  of  them,  ovula- 
tion and  "  heat  ^'  are  indissolubly  connected,  we  may  feel 
certain  that  in  the  primitive  condition,  at  any  rate,  they 
were  both  due  to  the  same  cause. 

In  a  recent  paper.  Beard  ['  The  Span  of  Gestation,^ 
Jena,  1897)  has  sought  to  show  that  "  heat  '^  in  the  lower 
mammals  is  brought  about  by  ovulation ;  his  elaborate 
arguments  in  this  connection  are  very  ingenious,  but  it  is 
essential  for  his  argument  that  "  heat  '^  and  menstruation 
should  be  shown  to  be  different  processes,  for  if  menstrua- 
tion can  occur  without  ovulation  it  cannot  be  dependent 
thereon,  and  as  Leopold  and  Miranoff  have  shown,  in 
man,  at  any  rate,  ovulation  does  not  always  occur  with 
menstruation,  and  cannot,  therefore,  induce  it. 

Strassmann  (^  Arch.  f.  Gynakologie,'  vol.  lii,  1896)  has 
also  suggested  that  the  ovary  is  the  seat  of  the  stimulus 
which  induces  both  "  heat  ^'  and  menstruation.  He  sug- 
gests that  the  pressure  exerted  by  the  growing  Graafian 
follicle  on  the  sensory  nerve-endings  in  the  ovary  is  the 
exciting   cause  of   the   reflex  action  which   brings   about 


172  MENSTRUATION    AND    OVULATION    OF 

congestion    of   the    genital    organs,    i.e.   menstruation   or 
"  heat/' 

There  are  several  facts  which  are  opposed  to  his  theory. 
It  must  be  granted  that  a  large  follicle  may  exert  the 
requisite  pressure  his  theory  demands  without  resulting 
in  the  rupture  of  that  follicle,  so  that  one  cannot  dispose 
of  this  theory  by  pointing  out  that  menstruation  may 
occur  without  ovulation  ;  but  in  almost  all  the  monkeys  I 
examined  there  was  no  sign  of  any  large  follicles  in  the 
ovaries  of  menstruating  specimens  ;  it  was  not  the  breeding 
season,  follicles  were  not  growing  at  the  time,  and  yet 
menstruation  regularly  took  place. 

This  fact  alone  would  seem  to  be  enough  to  show  that 
Strassmann  is  wrong ;  but,  if  I  am  not  mistaken,  menstru- 
ation may  occur  after  ovariotomy  has  been  performed, 
and  I  do  not  notice  that  he  has  attempted  to  explain  this 
equally  conclusive  objection  to  his  theory. 

Thus  it  would  seem  easy  to  show  the  unsatisfactory 
nature  of  any  theory  which  seeks  to  relegate  to  the  ovary 
the  responsibility  for  the  necessary  stimulus  which  induces 
^^  heat ''  or  menstruation.  In  the  same  way  it  can  be 
shown  that  the  uterus  is  not  responsible  for  ovulation, 
since  ovulation  may  take  place  without  the  coincidence  of 
menstruation. 

We  are,  then,  obliged  to  look  deeper  for  the  origin  of 
this  stimulus,  and  I  would  venture  to  suggest  that  to  the 
capacity  for  storing  up  an  excess  of  nutriment,  a  capacity 
which  would  seem  to  be  present  in  females  of  all  classes 
of  animals,  and  to  the  effect  under  satisfactory  conditions 
of  the  loading  of  the  system  with  nutriment  which  must 
result  therefrom,  we  must  look  for  the  origin  of  the 
stimulus  which  induces  both  ovulation  and  menstruation 
or  ^^  heat.'' 

The  importance  of  this  subject  is  obvious  to  those  whose 
business  it  is  to  combat  both  sterility  and  the  diseases  of 
the  ovary  and  the  menstrual  organ,  and  I  indicate  the 
direction  towards  which  my  own  work  has  pointed,  with 
the  hope  that  the  matter  may  be  of  interest  to  you. 


MONKEYS  AND  THE  HUMAN  FEMALE.  173 

Dr.  Peter  Horeocks  said  that  in  women  there  was  incon- 
testable evidence  that  ovulation  could  and  did  occur  without 
menstruation.  For  it  was  a  well-known  fact  that  a  woman 
might  conceive  without  menstruating.  For  example,  girls  in 
India  not  infrequently  conceived  and  bore  a  child  before  ever 
menstruation  began.  A  woman  during  the  amenorrhoea  asso- 
ciated with  lactation  occasionally  conceived  again  without 
menstruating.  He  had  known  instances  where  a  woman  had 
not  menstruated  for  many  years  after  her  marriage,  because  she 
conceived,  bore  a  child,  conceived  again  during  lactation  with 
amenorrhcea,  bore  another  child,  and  so  on  for  six  or  more  succes- 
sive pregnancies.  Obviously  to  conceive  an  ovum  was  necessary, 
and  an  ovum  implied  ovulation.  He  did  not,  however,  know 
any  facts  which  proved  that  menstruation  could  take  place 
without  ovulation.  It  was  true  that  after  the  climacteric  women 
occasionally  had  a  loss  of  blood  from  the  uterine  cavity.  But 
even  bleeding  from  the  uterus  was  not  necessarily  menstruation, 
and  he  did  not  look  upon  such  post-climacteric  haemorrhages  as 
menstrual  periods.  Sloreover  it  was  a  well-known  fact  that 
when  the  ovaries  were  removed,  or  if  they  became  wholly 
degenerated,  or  if  they  ceased  their  function,  then  menstruation 
ceased.  The  question  whether  menstruation  in  women  was  the 
same  thing  as  the  heat  or  rut  in  animals  was  of  great  interest 
and  importance.  He  could  not  help  feeling  that  it  was  not.  If 
it  were,  then  civilisation  seemed  to  have  converted  a  period  of 
heat  into  a  period  of  cold,  for  women  were  much  more  averse  at 
those  times  than  in  the  intermenstrual  periods.  He  believed 
that  ovulation  was  the  first  to  take  place,  that  the  ovum  having 
escaped  from  the  Graafian  follicle  travelled  do^vn  the  Fallopian 
tube  to  the  uterine  cavity,  and  if  it  were  not  fertilised  then  it 
was  expelled  along  with  more  or  less  of  the  mucous  membrane 
of  the  uterus,  constituting  the  phenomenon  of  menstruation.  In 
this  view  menstruation  was  a  miniature  parturition,  and  must  be 
compared  with  the  laying  of  an  unimpregnated  egg  rather  than 
with  the  heat  or  rut  of  animals.  He  thought  that  some  of  the 
facts  brought  forward  by  the  author  of  the  paper  pointed  in 
the  same  direction, — for  instance,  that  monkeys  menstruated  fre- 
quently without  ovulating ;  that  is,  they  had  these  periods  of 
heat,  which  were  quite  different  from  the  menstruation  of  women, 
which  were  associated  with  and  dependent  upon  the  integrity  of 
the  ovulating  process. 

In  further  reply  to  remarks  by  Dr.  Griffith,  Dr.  Horrocks 
said  that  because  a  married  woman  ceased  having  children  long 
before  she  ceased  menstruating  was  no  proof  at  all  that  she  had 
ceased  ovulating.  In  fact,  we  knew  positively  that  as  long  as 
she  menstruated  she  ovulated,  because  the  corpus  luteum  corre- 
sponding could  always  be  made  out  or  nearly  so. 

Dr.  Herman  thought  Dr.  Heape's  valuable  paper  went  to 


174       MENSTRUATION    AND    OVULATION    OF    MONKEYS,  ETC. 

show  how  very  imperfect  our  knowledge  was  of  the  physiological 
changes  that  went  on  in  the  ovary.  He  still  thought  that  men- 
struation depended,  if  not  upon  ovulation,  yet  upon  some 
ovarian  function.  He  based  this  opinion  on  the  broad  clinical 
facts  that  when  the  ovaries  were  absent  or  ill-developed  men- 
struation was  never  present,  and  when  both  ovaries  were 
removed  menstruation  always  stopped.  He  regarded  cases  in 
which  it  was  said  that  menstruation  continued  after  removal  of 
the  ovaries  either  as  instances  of  pathological,  not  menstrual 
haemorrhage,  or  as  cases  in  which  a  bit  of  ovarian  tissue  had 
been  left  behind. 

The  President  made  reference  to  the  recent  death  of 
Dr.  Remfry,  Assistant  Obstetric  Physician  to  St.  Greorge's 
Hospital,  and  of  Dr.  Charles  West,  a  past  President  and  an 
Honorary  Fellow  of  the  Society,  and  it  was  agreed  that  a 
suitable  letter  of  regi^et  and  condolence  should  be  for- 
warded in  the  name  of  the  Society  to  Mrs.  Remfry  and 
Mrs.  West. 


MAY  4th,    1898. 

C.  J.  CuLLiNGWOETH,  M.D.,  President,  in  the  Chair. 

Present — 29  Fellows  and  1  visitor. 

Books  were  presented  by  the  Middlesex  Hospital  and 
the  Johns  Hopkins  Hospital  Staffs. 

Robert  D.  Muir,  M.D.,  was  admitted  a  Fellow  of  the 
Society. 

The  following  gentlemen  were  elected  Fellows  : — John 
Edward  Gemmell,  M.B.,  C.M.Edin.  ;  John  Robinson 
Harper,  L.R.C.P.  ;  Godfrey  D.  Hindley,  L.R.C.P.Lond.  ; 
Alfred  Gervase  Penny,  M.A.,  M.B.,  B.C.Cantab. ;  Sidney 
Herbert  Snell,  M.D.,  B.S.Lond.  ;  and  Charles  Robert 
Watson,  M.D.Brux. 


DOUBLE    INTESTINAL    OBSTRUCTION 
FOLLOWING    OVARIOTOMY. 

Shown  by  J.  H.  Targett,  M.S. 

Clinical  history. — Mrs.  J — ,  aged  49,  was  admitted  to 
a  hospital  for  an  abdominal  tumour,  which  was  first 
noticed  three  months  previously.      She  had  been  getting 


176  DOUBLE    INTESTINAL    OBSTRUCTION. 

thinner,  but  there  was  no  pain.  Menstruation  regular 
until  four  months  ago,  when  it  ceased  abruptly.  No 
vaginal  discharge.  Micturition  and  defgecation  normal. 
Urine  normal. 

On  admission  the  lower  half  of  the  abdomen  was  much 
distended  by  a  tumour  reaching  a  little  above  the  umbili- 
cus. The  veins  in  the  abdominal  wall  were  much  dis- 
tended over  it,  and  the  outline  of  the  tumour  was 
lobulated  as  in  a  multilocular  ovarian  tumour.  There 
appeared  to  be  a  localised  collection  of  ascitic  fluid  in  front 
of  the  tumour. 

Abdominal  section  was  performed,  and  bilateral  ovarian 
tumours  found.  They  were  about  equal  in  size,  and  5 
or  6  inches  in  diameter.  Their  structure  was  that  of  the 
multilocular  growth,  the  loculi  being  filled  with  thick 
gelatinous  contents.  The  veins  over  the  cysts  were  much 
dilated,  and  on  the  surface  of  the  right  tumour  there 
were  soft  nodules  of  growth  due  to  perforation  of  the 
capsule.  These  nodules  were  gelatinous  in  appearance, 
and  similar  deposits  were  observed  on  the  omentum  and 
mesentery,  from  which  they  could  be  peeled  without 
difficulty. 

Recovery  was  uninterrupted,  and  the  patient  was  dis- 
charged three  weeks  after  the  operation. 

Six  months  later  Mrs.  J —  returned  to  the  hospital 
with  extreme  distension  of  the  abdomen.  She  had  had 
attacks  of  diarrhoea,  but  lately  the  bowels  had  not  acted 
well,  and  at  the  time  of  readmission  there  had  been  com- 
plete intestinal  obstruction  for  four  days.  A  large  hard 
mass  was  felt  behind  the  uterus  bulging  into  the  rectum, 
and  the  distended  coils  of  intestine  were  visible  through 
the  abdominal  wall.  Left  lumbar  colotomy  was  at  once 
performed,  but  this  afforded  no  relief.  As  the  patient 
seemed  moribund,  nothing  further  was  attempted.  How- 
ever, she  lingered  on  for  three  weeks  after  the  colotomy, 
contrary  to  expectation. 

Autopsy. — On  opening  the  abdomen  the  surface  of  the 
intestines,  omentum,  and  mesentery  was  seen  to  be  studded 


DODBLE     INTESTINAL    OBSTRUCTION.  177 

with  small  discs  of  new  growth.  They  were  situated 
entirely  in  the  serous  coat^  and  did  not  invade  the  sub- 
jacent structures.  The  abdominal  distension  was  due  to 
obstruction  of  the  lower  end  of  the  ileum.  The  pelvic 
cavity  was  occupied  by  growth  and  adherent  viscera.  On 
the  right  side  a  coil  of  ileum  was  adherent  to  the  pouch 
of  Douglas  below  the  right  ovarian  pedicle,  and  this  adhe- 
sion had  caused  obstruction  by  kinking  of  the  ileum  about 
ten  inches  above  the  ileo-csecal  valve.  The  ileum  was 
enormously  distended  above  this  obstruction,  but  the  whole 
length  of  the  large  intestine  was  contracted.  The  sig- 
moid flexure  was  closely  coiled  up  behind  the  uterus,  and 
adherent  to  it  by  growth.  In  the  rectum  about  the  level 
of  the  cervix  uteri  there  was  a  large  mass  of  growth  which 
had  surrounded  the  calibre  of  the  bowel,  and  by  fungating 
into  its  lumen  had  caused  a  second  obstruction.  The 
ligature  of  the  left  ovarian  pedicle  was  not  absorbed,  but 
there  was  no  special  recurrence  of  growth  in  either  pedicle. 
Probably  dissemination  had  occurred  through  the  serous 
membrane  and  its  adhesions.  Microscopical  examination 
of  the  deposits  in  the  peritoneum  showed  that  they  were 
columnar-celled  carcinomata  which  had  undergone  very 
extensive  colloid  degeneration. 

The  case  is  of  interest  from  the  existence  of  two  separate 
obstructive  lesions  in  the  intestinal  tract,  which  led  to 
difficulties  in  diagnosis  and  treatment.  It  cannot  be  said, 
however,  that  the  obstruction  was  directly  due  to  the 
antecedent  ovariotomy,  for  the  intestines  were  adherent 
to  parts  other  than  the  pedicles  of  the  ovarian  tumours. 
The  ileum  was  obstructed  by  a  sharp  kink,  the  rectum  by 
the  pressure  of  a  collar  of  new  growth,  which  also  fungated 
into  its  lumen  ;  and  the  possibility  of  a  third  obstruction 
existed,  for  the  transverse  colon  was  drawn  down  to  the 
pelvis  by  firm  adhesions  of  the  great  omentum  to  the 
pelvic  organs.  The  comparatively  rapid  and  wide-spread 
infection  of  the  peritoneum  by  colloid  carcinoma  through 
the  medium  of  peritoneal  adhesions  is  also  a  noteworthy 
feature. 

VOL.  XL.  12 


178  FIBRO-MYOMA    OF    THE    UTERUS. 

Dr.  John  Phillips  mentioned  a  somewhat  similar  case  which 
had  come  under  his  observation  in  1892,  and  details  of  which 
with  a  figure  had  been  given  in  the  '  Lancet,'  1892,  vol.  ii,  p.  607 
("  The  remote  effects  of  peritoneal  adhesions  consequent  on 
removal  of  the  ovaries").  Strangulation  of  intestine  had 
occurred  ten  months  after  an  operation  for  removal  of  both 
ovaries  and  tubes.  At  the  post-mortem  the  following  condition 
was  found : — "  From  the  uterine  stump  to  the  small  intestine, 
just  before  its  entrance  into  the  csecum,  a  thick  adhesion  an 
inch  and  a  quarter  long  was  found  extending  ;  it  was  broader 
at  the  intestinal  end,  and  thinned  off  to  a  point  at  its  insertion 
into  the  uterine  stump.  Immediately  below  this  was  a  knuckle 
of  small  intestine  eight  inches  in  circumference,  dark  and  con- 
gested, but  not  of  a  chocolate  colour.  Beneath  the  intestine 
again  was  found  the  vermiform  appendix,  much  thickened  and 
3^  inches  long  ;  its  distal  end  was  attached  just  above  the 
uterine  stump  to  the  small  intestine,  and  peritonitis  was  just 
commencing  there."  The  adhesion  and  displaced  appendix 
enclosed  an  elongated  slit  between  them,  through  which  a 
knuckle  of  intestine  had  obtruded  itself  and  become  incar- 
cerated. 

Dr.  Heywood  Smith  suggested,  in  view  of  the  great  import- 
ance of  guarding  against  such  a  misfortune  as  intestinal  ob- 
struction through  adhesion  to  the  stump,  whether  it  would  not 
be  advisable  to  sew  the  peritoneum  over  the  stump  in  every 
case. 


FIBEO-MYOMA   OF  THE    UTERUS   WITH 
SARCOMATOUS    DEGENERATION. 

Shown  by  Dr.  Peter  Horrocks. 

Dk.  Peter  Horrocks  showed  a  uterus  and  tumour 
removed  by  abdominal  hysterectomy.  The  lady,  a  patient 
of  Dr.  Cock  of  Peckham,  was  6Q  years  of  age.  At  the 
time  of  operation  some  difficulty  was  experienced  in 
getting  the  tumour  out  of  the  pelvis,  owing  apparently  to 
the  sarcomatous  growth  pinning  it  down  to  the  bottom  of 
the  pelvis.  There  was  some  haemorrhage  from  the  parts 
from  which  it  was  forcibly  separated.      She  made  a  good 


FIBRO-MYOMA    OF    THE    UTERUS.  179 

recovery,  and  was  at  the  present  time,  two  months  or  more 
after  the  operation,  in  good  health.      The  interest  of  the 
case   was   rather  pathological.      Some   said   that   a   fibro- 
myoma  of  the  uterus  might  become  sarcomatous.      In  fact, 
Mr.    Doran  had    shown   a   specimen   at    the   Pathological 
Society  of  such  a  tumour  undergoing  sarcomatous  degene- 
ration, and  he  was  under  the  impression  that  Mr.  Doran 
had    then   thought   that   the    muscular   fibres    themselves 
underwent  this  change.      Now,  whilst  believing  that  in  a 
few  rare  cases  fibro-myomata   of  the   uterus  did  become 
sarcomatous,  he  believed  that  it  was  the  connective  tissue 
of  the   fibro-myomata  that  became  affected,  at  all  events 
primarily.      In  other  words,  a  fibro-myoma  might  become 
sarcomatous  just  as  the  uterine  wall  might,  but  precisely 
in    the  same  way,  and  that  there  was  no   such    thing  as 
sarcomatous    degeneration    of    the    muscular   fibres    of    a 
fibro-myoma    except    by   extension    from    the    connective 
tissue. 


Mr.  Doran,  in  reference  to  his  case  of  myoma  of  the  uterus 
becoming  sarcomatous,  published  in  the  forty-first  volume  of 
the  '  Transactions  of  the  Pathological  Society,'  observed  that  he 
could  not  find  any  indication  of  the  precise  origin  of  the 
sarcoma  cells.  Since  there  was  much  connective  tissue  in  many 
uterine  myomata  it  was  hard  to  deny  that  sarcoma  probably 
developed  from  that  tissue,  but  he  endeavoured  to  show  in  his 
report  that  sarcoma  cells  might  actually  replace  plain  muscle 
cells  arising  from  the  same  elements.  When  the  growth  of 
such  a  tumour  has  much  advanced  the  origin  of  its  malignant 
elements  can  hardly  be  traced  by  the  microscope. 


180 


HEMORRHAGE   FROM   THE   FALLOPIAN   TUBE 
WITHOUT  EVIDENCE  OF  TUBAL  GESTATION. 

Shown  by  Alban  Doran,  F.R.C.S. 

The  presence  of  blood  in  the  peritoneal  cavity  of  a 
woman  is  a  matter  of  high  importance,  not  only  from  a 
clinical  standpoint,  but  also  for  medico-legal  reasons.  The 
very  mention  of  this  condition  suggests  extra-uterine 
pregnancy.  Experience  has  shown  that,  putting  aside 
accidents  in  uterine  pregnancy  and  parturition,  that 
abnormal  form  of  gestation  is  almost  invariably  the  cause 
of  the  haemorrhage.  Are  there  any  exceptions  ?  I 
believe  that  there  are,  and  that  this  specimen  may  be 
classed  amongst  them.  Hence  I  may  be  pardoned  for 
dwelling  on  the  appearances  which  it  presents  at  some 
length. 

A.  C — ,  aged  25,  was  admitted  into  the  Samaritan  Free 
Hospital  on  November  4th,  1897.  She  was  well  nourished 
but  markedly  anaemic.  Two  and  a  half  years  ago  she 
was  married,  and  had  only  once  been  pregnant,  miscarrying 
at  the  third  month  in  May,  1896.  Menstruation  was 
never  regular,  the  flow  varying  greatly  in  amount. 
Twelve  weeks  before  admission  severe  bearing-down  pains 
set  in,  with  free  show  which  could  not  be  checked.  On 
October  6th  Dr.  Frederic  McCann  saw  her  for  the  first 
time,  and  detected  a  mass  in  the  right  fornix.  No  history 
of  the  passage  of  any  structure  like  a  decidua  could  be 
obtained. 

The  patient  was  sent  into  my  wards  because  the  mass 
had  distinctly  increased  in  size  since  October  6th.  I 
found  no  changes  Qharacteristic  of  pregnancy.  There 
was  an  elastic  and  distinctly  tender  mass  in  the  right 
fornix.      The   uterus  was  hardly  enlarged,  and  lay  in  its 


HiEMORRHAGE    FROM    THE    FALLOPIAN     TUBE.  181 

normal  axis.  I  would  not,  under  the  circumstances,  pass 
a  sound.  There  was  much  sanious  discharge  from  the  os. 
The  pulse  was  84,  regular  and  small ;  the  temperature 
remained  normal  between  November  4th  and  13th.  The 
urine,  drawn  off  with  the  catheter  to  avoid  the  blood 
which  constantly  oozed  from  the  os  uteri,  was  almost 
colourless,  very  acid,  sp.  gr.  1006,  and  free  from  albumen 
and  excess  of  phosphates.  The  patient  had  never  been 
laid  up  Avith  severe  illness,  and  after  the  miscarriage  in 
May,  1896,  she  kept  her  bed  for  a  fortnight  and  recovered 
completely,  so  that  she  had  evidently  not  neglected  her- 
self. 

A  week^s  rest  produced  no  effect  whatever  on  the  local 
condition.  The  tenderness  was  noteworthy,  as  the  sequel 
showed  that  the  mass  was  a  nerveless  structure,  so  that  it 
was  its  surroundings  that  were  tender. 

On  November  IBth,  1897,  I  made  an  exploratory 
incision,  the  patient  being  placed  in  Trendelenburg's 
position.  I  saw  a  mass  of  small  intestine  adherent  to 
something  to  the  right  of  and  behind  the  uterus.  On 
freeing  the  gut  I  exposed  a  reddish-brown  solid  mass,  into 
which  the  right  Fallopian  tube  appeared  to  run.  Poste- 
riorly the  mass  adhered  to  the  sigmoid  flexure  and  rectum. 
I  passed  my  hand  carefully  under  the  mass,  and  succeeded 
in  drawing  it  up  with  the  tube  and  ovary  ;  they  were  then 
removed  together.  The  left  ovary  was  large  and  succulent, 
as  usual  in  a  healthy  young*  woman,  the  left  tube  quite 
normal.  There  was  no  sign  of  any  effusion  of  blood  into 
the  peritoneal  cavity  beyond  the  mass,  or  into  the  para- 
metrium. Convalescence  proceeded  steadily,  and  the 
patient  was  quite  strong  when  she  left  the  hospital. 

I  sent  the  right  tube  and  ovary  and  the  attached 
tumour,  now  exhibited,  to  the  College  of  Surgeons.  On 
cutting  open  the  tumour  it  appeared  to  consist  of  clot.  A 
section  was  made  close  to  its  attachment  to  the  fimbriae  of 
the  tube,  including  tubal  tissue.  Under  the  microscope 
no  chorionic  villi  nor  decidual  cells  could  be  found. 

The  tumour,  as  now  seen,  forms  a  pyramidal  mass  with 


182  HJCMOERHAGE     FROM    THE    FALLOPIAN    TUBE 

convex  surfaces.  The  apex  is  firmly  incorporated  with 
the  fimbria  of  the  tube  above  the  ostium;  the  base 
measures  2^  inches.  The  interior  appears  on  section  as 
solid  coagulum,  old  and  firm  towards  the  base,  soft  and 
recent  at  the  apex,  which  lies  close  to  the  tubal  ostium. 
The  fimbriae  of  the  tube  are  normal,  the  canal  shows  no 
sign  of  dilatation  or  inflammation,  and  the  ostium  is  not 
dilated.  The  mesosalpinx  is  perfectly  free  from  any 
abnormal  condition.  The  ovary  is  large,  two  inches  in 
vertical  and  an  inch  and  a  half  in  transverse  diameter. 
On  its  cut  surface  are  several  follicles  about  an  eighth  of 
an  inch  in  diameter,  full  of  half-decolourised  clot,  but  I 
could  not  find  a  corpus  luteum.  (j^i^-lO 

The  most  positive  feature  in  this  case  is  the  haemorrhage 
from  the  tube,  self-evident  after  a  glance  at  the  specimen. 
This  accident  is  usually  the  result  of  tubal  gestation.  In 
this  case  there  was  no  positive  clinical  evidence  of  gesta- 
tion. The  irregularity  of  the  catamenia,  which  had  been 
present  for  years,  greatly  obscured  diagnosis.  Intra- 
uterine pregnancy  ending  in  very  early  abortion  was 
possible,  but  could  not  be  proved ;  no  decidua  was  ever 
detected,  nor  was  there  evidence  of  enlargement  of  the 
uterus.  Early  tubal  gestation  was  at  once  suggested  by 
the  haemorrhage.  But  the  tube  looked  absolutely  normal. 
Many  months  after  a  tubal  abortion  a  tube  might  con- 
ceivably undergo  perfect  involution.  In  this  instance  the 
local  disturbance  was  quite  recent,  yet  the  tube  appeared 
healthy  as  it  lay  in  the  pelvis,  and  was  proved  healthy 
when  examined  after  removal.  Above  all,  the  ostium  was 
not  dilated.  Again,  as  the  ostium  was  as  free  from  any 
sign  of  obstruction  as  it  was  free  from  any  trace  of 
dilatation,  the  question  of  haematosalpinx  {"  sactosalpinx 
haemorrhagica,^'  as  Martin  and  Orthmann  call  it)  is 
precluded. 

Whence  then  came  the  blood  ?  Was  it  an  exudation 
from  the  surface  of  a  congested  mucous  membrane,  or  was 
it  the  result  of  uterine  haemorrhage  passing  into  the  tube 
instead  of  into  the  vagina  ? 


DESCRIPTION    OF    PLATE    Y. 

Fig.  1. — Hsemorrliage  from  the  Fallopian  tube  without  evidence  of  tubal 
gestation. 

Pia.  2. — Hsemorrhage  into  the  Fallopian  tube  and  uterus  (St.  Barth. 
Hosp.  Mus.,  No;  2934a),  showing  the  clot  in  the  tube  protruding  from  the 
ostium  owing  to  the  action  of  spirit  on  the  tubal  walls  after  death. 

(Inscriptions  intended  to  be  placed  under  Figs.  1  and  2,  PI.  V,  p.  182, 
•  Trans.  Obst.  Soc.,'  vol.  xl,  1898,  pt.  2.) 


Plate  V. 


Obstet.  Soc.  Trans.,  Vol.  XL. 


H/EMORRHAGE   FROM   THE    FALLOPIAN  TUBES   WITHOUT   EVIDENCE 
OF  EXTRA-UTERINE   GESTATION.      (Aluan  Doran.) 


BaU,  Sans  tt  DanidMon,  UdL,  Litk, 


WITHOUT    EVIDENCE    OF    TUBAL    GESTATION.  183 

I  must  admit  that  I  am  very  suspicious  of  alleged  cases 
of  haemorrhage  from  the  tube  into  the  peritoneum  not  due 
to  ectopic  gestation.  On  the  ground  of  accurate  observa- 
tion modern  teaching  encourages  that  suspicion.  To  take 
the  opinion  of  two  distinguished  teachers  who  have  issued 
treatises  within  the  present  year^  we  find  that  our  old 
president^  Dr.  Herman,  says,  "  1  am  not  satisfied  that 
there  is  such  a  condition  as  metrorrhagic  haematocele, 
meaning  by  that,  haemorrhage  from  the  uterus  escaping  by 
the  Fallopian  tube  into  the  peritoneum.  I  think  that 
cases  appearing  to  be  such  are  either  tubal  gestation,  or 
cases  of  haemorrhage  from  the  tube  itself  of  unknown 
causation. '^"^ 

Labadie-Lagrave  insists  on  the  very  valid  objections  to 
Bernutz  and  Guerin^s  theory  of  reflux  of  blood  into  the 
peritoneum  from  the  uterus.  Trousseau  and  Fernerly 
traced  haemorrhage  out  of  the  ostium  to  a  kind  of 
epistaxis,  an  abnormal  increase  of  anatomical  oozing. 
Labadie-Lagrave  attaches  no  importance  to  this  hypo- 
thesis.t 

The  earlier  theories  were  very  plausible,  monorrhagia 
from  the  tube  or  epistaxis  sounding  quite  natural,  but 
they  were  advanced  before  the  days  when  the  microscope 
was  made  to  reveal  chorionic  villi  in  clots. 

Yet,  though  it  is  admitted  that  the  great  majority  of 
cases  of  haematosalpinx  are  due  to  tubal  gestation,  and 
that  nearly  all  cases  of  haemorrhage  from  the  ostium 
signify  tubal  abortion,  exceptional  conditions  are  possible. 
I  made  use  of  the  term  "  epistaxis  "  above.  Dr.  Walter 
Griffith  showed  us  here  ten  years  ago  the  internal  organs 
from  a  single  nulliparous  girl,  aged  18,  who  died  from 
uncontrollable  epistaxis  and  monorrhagia.  J       The  uterine 

*  •  Diseases  of  Women/  1898,  p.  308. 

t  Lab:idie-Lagiave  et  F.  Legueu,  'Traite  Medico-Chirurgical  de  Gyne- 
cologic.' 1898,  pp.  1119,  1120,  and  1122. 

X  "  Haematoraa  and  Haematosulpinx,"  '  Trans.  Obstet.  Soc.,'  vol.  xxix, 
p.  397.  The  specimen  is  in  the  musenm,  St.  Bartholomew's  Hospital,  Path. 
SerieJ!,  No.  2934a.     The  next  specimen,  No.  2934b,  is  very  similar.     A  tri- 


184  HiEMOERHAGE    FROM    THE    FALLOPJAN     TUBE 

cavity  contained  a  blood-clot  which  extended  along  the 
Fallopian  tubes^  and  on  the  right  side  projected  beyond 
the  fimbriated  extremity.  As  the  patient  was  a  young 
nulliparous  girl,  the  tube  was  much  smaller  and  less 
developed  than  in  the  example  which  I  exhibit  this 
evening.   (71^'- 2.) 

In  the  catalogue  of  specimens  in  the  museum  of  St. 
Bartholomew's  Hospital  *  there  is  an  important  piece  of 
evidence  not  included  in  Dr.  Griffith's  original  report  : 

"  This  projection  of  the  clot  (beyond  the  fimbriated 
extremity)  is  due  to  the  narrowing  of  the  calibre  (of  the 
tube)  owing  to  the  action  of  the  spirit,  as  it  did  not  occur 
in  the  fresh  specimen.^' 

On  examining  the  specimen  I  find  that  a  vermiform 
clot,  about  two  inches  long,  hangs  out  of  the  ostium. 
Even  if  it  had  protruded  from  the  tube  before  death,  it 
would  in  no  way  have  resembled  the  large  clot  seen  in  the 
example  of  tubal  hsemorrhage  which  I  exhibit  this  evening. 
Again,  with  the  kind  permission  of  Dr.  Calvert  I  have 
been  able  to  look  up  the  original  report  of  the  case  from 
which  Dr.  Grriffith's  specimen  was  taken,  and  find  that  the 
peritoneum  is  reported  as  ^'  normal,''  and  it  is  clear  that 
not  a  drop  of  blood  escaped  into  its  cavity. t 

This  fact  is  really  admitted  by  Dr.  Griffith,  for  though 
he  does  not  state  that  the  clot  hanging  from  the  ostium 
was  squeezed  out  after  death  by  the  action  of  spirit,  he 
remarks  quite  reasonably  that  ^' there  was  no  hematocele 
in  this  case,  but  a  little  more  haemorrhage  would  have 
caused  one."      In  short,  his  case  clearly  shows  that  there 

angular  clot  occupies  the  uterus  and  extends  into  both  tubes.  The  patient, 
a  virgin  aged  20,  died  of  uterine  haemorrhage.  See  *  St.  Bart.'s  Hosp.  Rep.,' 
vol.  XXV,  1889,  p.  334. 

*  This  specimen  is  described  under  "Specimens  added  to  the  Museum,"  in 
the  'St.  Bart.'s  Hosp.  Rep.,'  vol.  xxii,  1886,  p.  399;  also  'Catalogue  of 
Museum  :  Addenda,'  pt.  5,  No.  2934a. 

t  '  St.  Bartholomew's  Hospital  Register  Book  of  Complete  Cases,'  vol.  xii, 
folio  10.  The  stomach  and  intestines  are  also  reported  "normal."  There 
was  no  visible  disease  of  the  internal  organs  except  the  haemorrhage.  Dr. 
Griffith  (loc.  cit.)  states  that  no  history  of  haemophilia  could  be  obtained. 


WITHOUT  EVIDENCE  OF  TUBAL  GESTATION.       185 

can  be  blood  in  a  tube  which  is  not  the  seat  of  an  ab- 
normal pregnancy,  and  should  the  ostium  remain  open, 
that  blood  might  easily  be  poured  into  the  peritoneal 
cavity. 

I  admit  that  such  a  condition  must  be  very  rare,  but  the 
above  observations  suggest  that  it  is  possible.  Our 
President"^  has  admitted  that  "  the  time  has  not  yet 
arrived  for  drawing  a  hard  and  fast  line  between  blood  effu- 
sions into  the  tube  caused  by  tubal  pregnancy,  and  such 
effusions  due  to  other  causes. ^^  The  main  explanation  is 
that  the  effusions  are  very  rarely  due  to  other  causes.  I 
have  endeavoured  to  show  that  this  case  appears  to  be  one 
of  those  rare  exceptions.  It  maybe  reasonably  suspected 
that  some  of  the  blood  which  issued  from  the  uterus  as  the 
result  of  some  local  condition  other  than  gestation  was 
forced  not  into  the  vagina,  but  along  the  tube  and  out  of 
the  ostium. 


With  reference  to  tbe  question  of  bsemorrbage  from  the 
oviduct  otherwise  than  from  tubal  erestatioii,  Dr.  Heywood 
Smith  narrated  the  following  case.  On  Sunday  week  Lie  was 
called  to  a  child  aged  15,  who  was  taken  with  sudden  pain  iu 
the  lower  abdomen  in  church.  The  next  morniui;  he  examined 
the  abdomen,  and  found  a  hard  tender  lump  above  the  right 
inguinal  region.  The  girl  had  never  menstruated,  and  he 
thought  it  might  be  either  appendicitis  or  some  ovarian  trouble. 
As  tbe  abdomen  became  more  swollen  and  tender,  and  the 
temperature  and  pulse  were  rising,  he  sent  her  into  the  Middle- 
sex Hospital.  On  Friday  (29tb)  she  was  operated  upon,  when 
there  was  found  a  quantity  of  dark  viscid  blood  in  the  riijht 
pelvic  fossa,  and  further  examination  revealed  an  imperforate 
hymen,  tbe  vagina  and  uterus  being  filled  with  similar  fluid,  so 
that  the  attack  was  a  menstrual  molimen  with  retrogression  of 
the  fluid  from  the  uterus  along  the  oviduct  and  out  at  its 
fimbriated  extremity.     The  child  was  doing  well. 

The  President  said  that  the  case  brought  forward  by  Mr. 
Doran  was  of  great  interest  to  him,  for  it  well  illustrated  the 
conclusions  at  which  he  himself  had  arrived  after  a  careful  and 
critical  inquiry  into  the  atiology  of  these  haemorrhagic  effusions. 

*  Cullingworth,  "'Effusions  of  Blood  into  the  Fiillopian  Tube,"  'St. 
Thomas's  Hosp.  Kep.,'  vol.  xxi,  1893,  p.  23.  When  the  ostium  is  closed  he 
speaks  of  the  condition  as  "  haematosalpiux,"  whatever  the  cause  may  he. 


186  HJIMORRHAGE    FROM    THE    FALLOPIAN    TUBE 

The  paper  in  tlie  'St.  Thomas's  Hospital  Reports'  (1893),  to 
which  Mr.  Doran  had  made  kind  reference,  was  based  on  seven- 
teen cases,  all  verified  by  operation.  In  three  out  of  the  seventeen 
the  haematosalpinx  was  not  the  direct  result  of  tubal  gestation. 
In  the  remaining  fourteen  there  was  no  snch  decided  negative 
evidence.  The  probabilities  were,  indeed,  in  favour  of  tubal 
gestation  being  the  source  of  the  effusion  in  all  of  them  ;  but 
there  was  a  considerable  proportion  in  which  the  most  careful 
examination  by  one  of  the  most  competent  of  living  pathologists, 
Mr.  Shattock,  failed  to  discover  any  microscopic  evidence  of  the 
presence  of  chorionic  villi  or  other  undoubted  products  of  con- 
ception. In  bis  (the  President's)  opinion  Mr.  Bland  Sutton  had 
gone  somewhat  further  than  the  facts  of  clinical  experience 
warranted,  when  he  stated  that  in  every  case  of  blood  effusion 
in  the  tube  due  to  tubal  gestation  chorionic  villi  could  be  found 
if  carefully  looked  for. 

In  regard  to  the  remai'k  made  by  Mr.  Doran  as  to  the  nega- 
tive evidence  afforded  by  the  absence  of  dilatation  of  the  tube, 
he  related  the  following  particulars  of  a  case  that  had  recently 
occurred  in  his  own  practice,  where  the  clinical  evidence  in 
favour  of  tubal  gestation  was  very  strong,  notwithstanding  that 
the  calibre  of  the  suspected  tube  was  normal. 

Ten  days  ago,  in  obedience  to  a  telegraphic  summons,  he  had 
visited  what  was  described  as  a  serious  abdominal  case,  with  a 
practitioner  a  few  miles  out  of  London.  The  patient  was  a 
married  lady  aged  27,  the  mother  of  one  child  five  months  of 
age.  She  had  last  menstruated  seven  weeks  previously,  and  had 
been  in  perfect  health  up  to  the  evening  before,  when  she  felt 
a  little  unwell.  At  half  past  eight  in  the  morning  of  the  day  I 
saw  her  she  had  been  seized,  on  re- assuming  the  erect  j^osture 
after  the  act  of  micturition,  with  severe  pain  in  the  right  iliac 
region.  She  went  back  to  bed,  and  quickly  became  very 
alarmingly  ill.  On  the  doctor's  arrival  at  11.30  a.m.  she  was 
already  in  a  state  of  collapse,  quite  conscious,  but  in  very  severe 
pain,  and  with  a  pale  cold  surface  and  imperceptible  pulse. 
Morphia  was  administered  and  relief  given  to  the  pain,  but 
otherwise  the  condition  did  not  improve.  The  abdomen  was 
extremely  tender,  but  not  swollen.  Examination  by  the  vagina 
gave  negative  results.  At  one  o'clock  the  pulse  had  become 
imperceptible.  It  was  then  that  the  telegram  was  sent.  The 
consultation  took  place  at  four  o'clock  in  the  afternoon.  The 
pulse  was  still  imperceptible  at  the  wrist.  The  diagnosis  was 
ruptured  tubal  gestation,  and  the  question  arose  whether  the 
abdomen  should  be  opened  at  once,  or  operation  delayed  in  hopes 
that  the  condition  might  improve.  He  decided  that  the  risk  of 
waiting  would  be  greater  than  that  of  immediate  operation. 
The  doctors  in  attendance  acquiesced,  and  the  consent  of  the 
patient  and  her  friends  having  been  obtained  arrangements  for 


WITHOUT    EVIDENCE    OP   TUBAL    GESTATION.  187 

immediate  operation  were  quickly  made.  At  5.30  the  patient 
was  anaesthetised  and  the  abdomen  opened.  Two  and  a  half 
pints  of  blood  were  found  in  the  peritoneal  cavity.  There  was 
no  evidence  of  even  an  attempt  at  adhesion  either  in  the  pelvis 
or  elsewhere,  and  no  abnormal  swelling  was  present  on  either 
side  of  the  slightly  enlarged  uterus.  The  right  Fallopian  tube 
and  right  ovary  were  quickly  brought  into  view,  and  on  the 
upper  surface  of  the  tube  close  to  its  uterine  end  was  what  ap- 
peared to  be  a  ragged  rent,  with  a  fragment  of  tissue  or  pale 
blood-clot  lying  in  it.  This  was  removed  and  set  aside  for  exa- 
mination. The  tube  was  of  normal  calibre,  and  the  part  (about  4 
inches  in  length)  external  to  the  rent  appeared  perfectly  healthy. 
The  ovary  also  had  an  absolutely  normal  appearance.  The 
right  tube  was  divided  at  a  point  between  the  rent  and  the 
uterus  and  removed.  The  left  appendages  were  examined  and 
found  perfectly  healthy.  The  effused  blood,  partly  fluid  and 
partly  consisting  of  dark  soft  clot,  was  removed  from  the  pelvis  by 
the  hand  with  a  very  little  help  from  a  sponge,  and  the  incision, 
three  inches  in  length,  was  closed.  The  patient  was  still  pulse- 
less when  put  back  to  bed,  but  otherwise  was  not  in  worse  con- 
dition than  before  the  operation.  Strychnia  was  injected  and 
warmth  applied  to  the  extremities.  In  the  course  of  the 
evening  she  gradually  rallied  ;  the  pulse  returned  after  having 
been  imperceptible  altogether  for  six  hours,  and  the  patient  had 
so  far  made  an  uninterrupted  recovery.  On  the  fourth,  fifth, 
and  sixth  days  she  passed  portions  of  thick  (decidual  ?)  mem- 
brane per  vaginam.  A  curious  fact,  however,  remained  to  be 
told.  The  portion  of  tube  removed  was  carefully  examined  by 
Dr.  A.  r.  Stabb  and  Dr.  L.  Jenner,  and  was  reported  by  them 
to  present  no  evidence  of  rupture.  It  was,  to  all  appearance, 
both  externally  and  internally  j^^^^^tlj  normal.  He  (the 
President)  could  only  explain  this  by  supposing  that  the  seat  of 
rupture  was  just  internal  to  the  place  at  which  the  tube  was 
divided,  and  so  had  been  left  in  the  stump.  The  point  he 
wished  to  emphasise  was  the  normal  calibre  of  the  tube.* 

The  case  was  of  course  not  exactly  parallel  with  Mr.  Doran's, 
but  if  he  was  right  in  regarding  this  as  an  instance  of  ruptured 
tubal  gestation,  and  in  spite  of  the  pathologist's  report,  he  was 
unable  to  conceive  of  any  other  way  of  explaining  the  phenomena 
presented.  There  was  here  a  tube  that  had  contained  a  gestation 
sac,  and  that  within  a  few  hours  of  rupture  had  assumed  its 
normal  calibre. 

He  regretted  having  taken  up  so  much  of  the  time  of  the 

*  Since  these  remarks  were  made  the  portion  of  tissue  found  adhering  to 
the  edges  of  the  rent  has  been  examined  microscopically,  and  chorionic  villi 
have  been  found  in  abundance.  This,  of  course,  settles  the  question  of  tubal 
gestation  in  the  affirmative. — C.  J.  C. 


188  HEMORRHAGE    PROM    THE    FALLOPIAN    TUBE. 

meeting,  but  trusted  that  the  various  interesting  points  that  the 
case  presented  would  be  accepted  as  some,  if  not  as  a  sufficient 
justification. 

Mr.  DoRAN  in  reply  observed  that  Mr.  Bland  Sutton  so  often 
found  chorionic  villi  in  clots  from  tubes,  that  he  naturally 
believed  that  when  not  found  they  might  have  been  destroyed 
or  overlooked.  On  the  other  hand,  Walter  of  Giessen  had  given 
us  reason  to  suppose  that  small  fragments  of  fibrin  in  clots  from 
a  hsematosalpinx  have  been  taken  for  chorionic  villi.  In  the 
President's  case  of  haemorrhage  in  one  tube,  where  its  fellow  was 
the  seat  of  a  foetal  sac,  the  blood  might  have  arisen  from  the 
latter  and  passed  through  the  uterus  into  the  opposite  tube. 
Dr.  Heywood  Smith's  case  was  seemingly  an  instance  of  haemor- 
rhage from  the  ostium  due  to  atresia,  bsematoceles,  and  hsemato- 
metra.  In  Dr.  Griffith's  case  there  was  uterine  bsemorrhage  in 
a  young  girl  where  the  vagina  was  not  closed,  some  of  the  blood 
entered  the  tube.  The  President's  case  of  free  intra-peritoneal 
hsemorrhage  from  the  tube  was  like  Mr.  Doran's  if,  as  Mr.  Stabb 
made  out,  there  was  no  rupture  of  the  tubal  wallf;  but  in  Mr. 
Doran's  no  decidual  membrane  was  passed,  nor  at  the  operation 
or  afterwards  was  there  any  suspicion  of  rupture  of  the  tube. 


189 


A  CASE  OF  PRIMARY  CARCINOMA  OF  THE 
FALLOPIAN  TUBE. 

By  C.  HuBEET  Roberts,  M.D.,  F.R.C.S.,  M.R.C.P., 

PHYSICIAN   TO   OUT-PATIENTS,    SAMAEITAX   HOSPITAL  ;    LATE    DEMONSTEATOB 
OF  PRACTICAL   MIDWIFEEY,   ST.   BAETHOLOMEW'S   HOSPITAL. 

(Received  February  12th,  1898.) 

(Abstract.) 

Female  set.  43.  No  children,  no  miscarriages.  Married 
seven  years.  Well  till  March,  1896;  then  violent  attack  of 
abdominal  pain  and  discharge  j:^er  vaginam.  Another  attack, 
July,  1896.  A  third,  November,  1896.  Watery  gushes  of  fluid 
noted. 

Out-patient,  Samaritan  Hospital,  Mr.  Butler-Smythe,  Novem- 
ber, 1896.  Admitted  in-patient,  Mr.  Meredith,  February,  1897. 
Diseased  appendages  on  the  right,  ?  pyosalpiux.  Operation 
necessary. 

Condition. — Thin. 

Local. — Uterus  displaced  to  left  by  mass  in  right  fornix, 
fixed,  not  tender ;  size  hen's  egg ;  watery  vaginal  discharge. 

Operation. — February  24th,  1897.  Right  tube  enlarged  = 
Bologna  sausage,  and  removed ;  full  of  papillomatous-looking 
growth.    Ovary  healthy.    Left  appendix  inflamed  and  removed. 

Specimen  J  and  sections  and  drawings  =  primary  carcinoma  of 
right  Fallopian  tube. 

Remarks. — Reference  to  published  cases. 

Treatment  and  prognosis. 


190  PRIMARY    CARCINOMA    OF    THE    FALLOPIAN    TUBE. 

Owing  to  the  extreme  rarity  of  primary  carcinoma  of 
the  Fallopian  tubes_,  the  following  case  may  be  of  in- 
terest. 

H.  R — ,  aged  43,  was  admitted  to  the  Samaritan 
Hospital,  February  10th,  1897,  under  the  care  of  Mr. 
Meredith. 

She  had  been  married  seven  years.  No  children,  no 
miscarriages  ;  catamenia  began  at  sixteen,  regular  in  dura- 
tion— three  to  four  days ;  loss  average,  no  pain.  During 
the  last  twelve  months  periods  were  more  frequent. 

Patient  had  been  in  fairly  good  health  up  to  March, 
1896,  when  she  was  seized  with  coldness  and  shivering  ; 
next  morning  there  was  much  pain  in  the  lower  abdomen. 
No  doctor  was  sent  for,  but  the  patient  treated  herself  for 
a  week  till  the  pain  left  her,  but  a  thick  profuse  ^^  yellow  ^^ 
discharge  from  the  vagina  took  its  place.  She  saw  a 
doctor  later,  who  treated  her  for  leucorrhcea.  The  yellow 
discharge  soon  after  became  thin  and  watery,  but  was  not 
foul. 

In  July,  1896,  there  was  a  second  attack  of  violent  pain 
all  over  the  abdomen ;  this  lasted  two  hours,  and  was  said 
to  be  acute  indigestion.  The  watery  discharge  was  again 
noticed. 

In  November,  1896,  she  had  a  third  '^attack,"  which 
was  very  acute,  and  lasted  three  to  four  days.  Since 
then  there  has  been  no  pain.  With  each  attack  of  pain 
patient  has  noticed  she  has  had  watery  discharges  from  the 
vagina ;  these  seemed  to  follow  the  attacks  of  pain  in  the 
abdomen.      She  has  not  noticed  any  tumour. 

Since  November,  1896,  she  has  had  no  further  attacks. 
In  November,  1896,  she  came  under  the  care  of  Mr. 
Butler-Smythe  in  the  out-patient  department  of  the 
Samaritan  Hospital,  in  consequence  of  excessive  vaginal 
discharge  and  general  debility.  She  was  under  Mr. 
Butler-Smythe  up  to  February,  1897  ;  her  general  health 
improved,  but  the  discharge  did  not  lessen,  and  there  was 
some  general  enlargement  of  the  appendages,  which   did 


PRIMARY    CARCINOMA    OF    THE    FALLOPIAN    TUBE.  191 

not  improve.  Consequently  she  was  admitted  as  an  in- 
patient in  February,  1897.  After  admission  the  discharge 
did  not  cease,  and  though  it  varied  from  time  to  time  it 
was  always  thin  and  watery,  and  sometimes  blood-stained. 
No  large  gushes  of  fluid  were  noted. 

Patient  had  been  losing  flesh  slightly,  especially  about 
the  face  and  neck.  Her  general  health  was  about  the 
same,  but  she  had  "  fainting  attacks.^' 

Except  for  the  three  occasions  above  mentioned  there  has 
never  been  any  marked  pain  or  tenderness  in  the  abdo- 
men or  pelvis. 

General  condition  on  admission, — Patient  rather  thin 
and  pale-looking.  Tongue  coated.  Constipation  trouble- 
some. Chest,  heart,  and  lungs  normal.  Pulse  72,  temp. 
99°,  resp.  20.  Slight  oedema  of  the  ankles.  Urine  turbid, 
no  pus,  sp.  gr.  1014,  acid ;  contains  slight  trace  of  albu- 
men, and  a  few  epithelial  cells. 

Abdominal  examination. — Bight  kidney  mobile.  No 
abdominal  tumour.      No  tenderness  anywhere  on  pressure. 

On  vaginal  examination  the  cervix  was  healthy,  but 
displaced  to  the  left  by  a  hard  irregular  swelling  occupy- 
ing the  right  fornix,  which  seemed  more  or  less  closely 
connected  with  the  uterus,  and  to  occupy  the  right  side 
of  Douglas's  pouch.  It  was  almost  immoveable  and  pain- 
less. Its  outline  suggested  a  tube,  but  it  could  not  be 
well  defined.  The  left  fornix  was  healthy.  The  uterus 
was  not  enlarged,  sound  passed  2\  inches.  The  uterus 
was  anteverted. 

On  bimanual  examination  the  swelling  to  the  right 
of  the  uterus  could  not  be  pushed  up  to  be  thoroughly 
examined  by  the  external  hand.  It  appeared  to  be  the 
size  of  a  hen's  egg,  and  was  not  elastic.  There  was  a 
watery  discharge  in  the  vagina,  but  none  was  observed 
coming  from  the  cervix.  The  uterus  itself  had  lost  some 
of  its  mobility. 

Operation  was  decided  on,  and  took  place  on  February 
24th,  1897.  Mr.  Meredith  performed  the  operation  and 
I  assisted  him.      Duration  of  operation  =  1^  hours.      The 


192  PRIMARY    CARCINOMA    OF    THE     FALLOPIAN    TUBE. 

anaesthetic  was  chloroform.  The  abdomen  was  opened, 
and  a  swelling  which  proved  to  be  the  right  tube,  equal 
in  girth  to  a  Bologna  sausage,  was  found  firmly  fixed  in  the 
bottom  of  Douglases  pouch  by  close  adhesion  to  the  pelvic 
wall  at  the  back  of  the  right  broad  ligament  and  posterior 
surface  of  the  uterus. 

After  gradually  separating  these,  in  addition  to  several 
bands  of  omentum,  it  was  found  impossible  to  raise  the 
mass,  owing  to  a  very  tight  band  of  omental  adhesion  to 
the  outer  extremity  of  the  tube.  This  was  finally  brought 
into  view  and  secured  by  transfixion  before  division. 
The  tube  could  now  be  brought  up  sufficiently  to  deal 
with  the  pedicle,  which  was  secured  close  to  the  uterus  by 
transfixion,  and  tied  before  division.  The  ovary  was 
small  and  cystic,  and  was  removed  together  with  the  tube. 
The  left  appendages  were  very  adherent,  the  tube  closed 
and  inflamed,  but  the  ovary  was  not  enlarged.  The  left 
appendages  were  removed,  both  as  a  precautionary  measure 
and  in  view  of  the  patient's  age. 

The  cavity  of  the  peritoneum  was  flushed  out  with 
sterilised  water,  and  the  abdomen  left  full.  The  incision 
was  closed  in  the  ordinary  way.  There  was  no  drainage 
used. 

Pathology. — On  cutting  into  the  enlarged  right  tube, 
which  up  to  the  present  time  had  been  thought  to  be  a 
pyosalpinx,  it  was  found  to  contain  a  villous  or  papillo- 
matous-looking  growth  which  entirely  filled  and  distended 
the  lumen  of  the  tube  with  the  exception  of  one  inch  of 
its  uterine  extremity,  which  was  patent,  and  quite  free 
from  growth. 

The  fimbriated  extremity  was  closed,  but  amid  the 
adhesions  externally  the  fimbriae  could  still  be  made  out. 

The  papillomatous  condition  involved  the  whole  of  the 
lumen  of  the  distended  tube,  and  broke  down  easily  under 
the  finger.  Everywhere  the  growth  was  sessile,  and  in 
parts  the  wall  of  the  tube  was  thickened  and  evidently 
infiltrated  with  the  same  growth,  but  it  had  not  spread 
to  the  exterior,  nor  was  the  ovary  involved.      'J'he  same 


I 


PRIMARY    CARCINOMA    OF    THE    FALLOPIAN    TUBE.         193 

serous  watery  fluid  was  found  in  the  tube  as  that  described 
by  the  patient  as  being  passed  j^er  vaginam. 

There  did  not  appear  to  be  any  involvement  of  the 
surrounding  peritoneum  or  glands^  nor  was  there  any  free 
peritoneal  fluid.  The  condition  was  recognised  as  papil- 
loma or  carcinoma  of  the  Fallopian  tube,  and  Mr.  Meredith 
said  that  ^^  the  periodical  sanious  and  watery  'discharges 
per  vaginam  should  have  suggested  papilloma/^  though 
the  condition  was  not  diagnosed  before  operation. 

The  left  tube,  though  inflamed  and  closed,  did  not 
contain  any  growth  ;  the  left  ovary  was  small  and  cystic. 

Subsequently  the  patient  did  perfectly  well,  and  was 
discharged  from  the  hospital  on  the  13tli  March,  1897. 

She  came  to  show  herself  in  January,  1898,  and  was 
then  quite  well. 

Mr.  Meredith  kindly  gave  me  the  specimen,  and  allowed 
me  to  use  the  notes  of  the  case  which  I  now  publish. 

The  right  tube  has  since  been  carefully  examined  and 
drawn,  and  the  preparation  is  in  the  museum  of  St. 
Bartholomew's  Hospital,  No.  29,389,  where  it  is  described 
as  '^  a  specimen  obtained  by  operation  from  a  woman 
aet.  43  years,''  and  shows  a  malignant  growth  which  had 
sprung  from  the  wall  of  the  right  Fallopian  tube.  The 
latter  has  been  laid  open,  and  is  seen  to  be  filled  by  a 
papillomatous  growth  which  microscopically  proved  to  be 
a  columnar-celled  carcinoma.  The  specimen  is  an  instance 
of  primary  carcinoma  of  the  Fallopian  tube  (for  Histo- 
logical Records  see  slides  xlii,  29,389). 

Dr.  Kanthack  kindly  examined  the  sections  for  me 
very  carefully,  and  reports  that  it  is  an  undoubted  carci- 
noma. 

The  sections  show  a  very  advanced  papillomatous 
condition  which  springs  from  the  wall  of  the  tube.  The 
normal  plicae  are  very  much  exaggerated  and  their  contour 
lost ;  the  epithelium  consists  of  large  columnar  cells  of 
irregular  shape,  and  the  deeper  layers  and  walls  of  the 
tube  are  involved  by  similar  irregular  clusters  of  car- 
cinomatous cells  gathered  in  irregular  lacuna)  and  spread- 

VOL.   XL.  13 


194  PRIMARY    CARCINOMA   OF    THE    FALLOPIAN    TUBE. 

ing  into  the  connective  tissue  beneath  ;  there  are  degenera- 
tive changes  in  the  superficial  portions  of  the  growth„ 

The  involvement  of  the  deeper  portions  of  the  tissues  by 
the  carcinomatous  cells  is  everywhere  evident. 

The  growth  is  limited  strictly  to  the  tube  itself^  which 
is  generally  affected. 

Remarks. — "  Primary  cancer  '^  of  the  Fallopian  tube  is 
sufficiently  rare  to  justify  a  report  of  every  case. 

There  is  no  doubt  that  such  cases  occur,  though  up  to 
quite  lately  most  cases  were  quoted  as  "  secondary. ^^ 

An  excellent  account  of  this  condition  by  Mr.  Alban 
Doran,  with  a  complete  bibliography,  will  be  found  in 
Allbutt  and  Playfair's  '^  System  of  Gynaecology/  pp.  812 
et  seq.j  to  which  I  refer  the  reader.  Apparently  two  forms 
may  be  recognised  : 

(a)  Carcinoma  developing  in  the  mucous  membrane  of 
a  normally  formed  tube. 

(6)  Developing  in  a  tube  which  is  malformed,  bearing 
a  cyst  not  connected  with  the  ovary  into  which  the  ostium 
opens. 

The  case  quoted  above  seems  to  be  an  instance  of  the 
first  variety,  and  difficult  as  it  is  to  distinguish  papilloma 
from  carcinoma,  after  the  most  careful  examination  I  have 
come  to  the  conclusion  that  the  case  is  undoubtedly 
carcinomatous,  and  I  have  also  the  more  valuable  testi- 
mony of  Dr.  Kanthack. 

I  am  not  able  to  state  whether  such  carcinoma  deve- 
loped from  a  papilloma,  but  there  seems  to  be  evidence 
in  her  history  of  chronic  inflammation,  a  point  which 
Doran  insists  on ;  in  fact,  the  diagnosis  was  that  of  a 
distended  inflamed  tube  before  operation,  and  even  when 
the  abdomen  was  opened  and  the  tube  exposed  it  was 
believed  to  contain  pus.  In  recorded  cases  this  has 
frequently  happened.  The  age  of  the  patient  is  another 
point  (forty-three  years),  as  primary  cancer  is  unknown 
in  youth  ;  in  fact,  "  when  a  patient  who  has  reached  her 
forty-first  year,  and  has  been  subject  to  pelvic  inflam- 
mation, shows  a  sudden  or  steady  aggravation  of  subjec- 


Plate  VL 


Obstet.  Soc.  Trans.,  Vol.  XL. 


PRIMARY   CARCINOMA    OF   FALLOPIAN   TUBE.  (Roherts.) 


bile,  So  114  it  DanieLion,  Ltd.y  Lith. 


PRIMARY    CARCINOMA    OF    THE    FALLOPIAN    TUBE.  195 

tive  and  objective  symptoms,  cancer  may  be  suspected  '^ 
(Doran) . 

The  most  marked  features  in  the  above  case  were  the 
repeated  discharges  of  sanious  fluid  per  vaginam,  three 
distinct  attacks  being  noted  by-  the  patient.  First  she 
had  attacks  of  pain,  which  Avere  followed  by  these  watery 
gushes.  The  so-called  hydrops  tubae  profluens,  with 
gushes  of  profluent  tubal  discharge,  has  also  been  noted  in 
papilloma  of  the  tube,  congenital  tubo-ovarian  cysts,  and 
simple  hydrosalpinx.  It  is  certainly  a  symptom  worth 
noting  in  such  cases,  and  may  help  in  the  diagnosis. 

I  presume  the  attacks  of  pain  in  this  case  were  due  to 
the  accumulation  of  the  discharge  distending  the  tubes, 
the  tension  increasing  till  the  uterine  end  of  the  tube  was 
opened  up,  allowing  its  escape.  But  besides  this  the 
patient  had  a  more  or  less  continuous  watery  discharge, 
which,  I  take  it,  leaked  away  from  the  tube. 

On  section  of  the  diseased  tube  in  this  case  it  almost 
exactly  resembled  Mr.  Doran' s  picture  in  Prof.  Clifford 
Allbutt's  ^  System,^  p.  814,  the  whole  lumen  of  the  tube 
being  filled  with  cancerous  growth  springing  from  the 
inner  surface  of  the  tube ;  but  in  my  specimen  the  ovary 
and  broad  ligament  were  not  involved,  though  the  muscular 
coat  of  the  tube  certainly  was.  I  would  refer  my  readers 
to  Mr.  Doran's  tables  in  Allbutt  and  Playfair's  book. 

Of  the  second  class  of  case,  viz.  cancer  occurring  in  a 
malformed  tube  bearing  a  cyst  into  which  the  ostium 
opens,  there  are  very  few  authentic  cases  on  record, 
though  Martin,  Essex  Wynter,  and  Rentier  report  cases 
of  this  kind. 

Dr.  Cullingworth's  (No.  11,  Doran's  series)  case  was 
one  of  primary  cancer  of  the  tube,  which  was  lying  on  the 
surface  of  a  cystic  ovary. 

Sarcoma  of  the  tube,  i.  e'.  primary  sarcoma,  is  said  to 
occur,  but  at  present  it  is  a  subject  highly  obscure, 
whilst  deciduoma  malignum  of  the  tube  appears  to  be 
still  more  so. 

There   is   no    doubt   that   the  greatest   care    should    be 


196  PRIMARY    CARCINOMA    OF    THE    FALLOPIAN    TUBE. 

taken  to  report  most  accurately  all  cases  of  malignant 
disease  of  tlie  Fallopian  tubes_,  and  that  a  detailed  exami- 
nation of  tlieir  histological  and  pathological  conditions 
should  be  made  to  guide  us  to  a  more  thorough  knowledge 
of  this  obscure  condition. 

Treatment. — There  is  no  doubt  that  there  is  but  one 
treatment,  viz.  removal,  the  great  difficulty  being  the 
question  of  diagnosis.  Even  in  papilloma  removal  should 
be  undertaken. 

In  this  case  the  patient  reported  herself  well  in 
January  of  this  year  (1898),  but  she  was  not  examined. 

I  should  like  to  point  out  that  the  abdomen  Avas 
purposely  left  full  of  sterilised  water  after  the  operation, 
and  I  think  many  patients  find  great  comfort  from  this 
subsequently.  It  is  a  practice  Mr.  Meredith  frequently 
pursues. 

The  ultimate  prognosis  of  such  cases  is  uncertain,  but 
in  face  of  published  statistics  the  outlook  is  by  no  means 
gloomy. 

[For  discussion  on  this  paper  see  p.  208.] 


I 


TABLES  OF  CASES  OF  PRIMARY  CANCER  OF 
THE  FALLOPIAN  TUBE  REPORTED  UP  TO 
PRESENT  DATE   (APRIL,  1898). 

By  Alban  Doran,  F.R.C.S., 

SURGEON   TO  THE    SAMAEITAN   FEEE    HOSPITAL. 

(Received  April  14th,  1898.) 

(Abstract.) 

As  my  colleague  Dr.  Hubert  Roberts  Las  brougbt  forward  a 
valuable  report  of  a  case  of  primary  cancer  of  the  tube  under 
his  own  observation,  I  think  that  these  tables  may  be  of  interest 
to  the  Fellows  of  the  Society,  and  may  aid  them  in  the  study  of 
Dr.  Roberts's  communication.  Orthmann  j^ublished  the  first 
report  of  a  case  of  the  disease  in  question  just  ten  years  since. 
Shortly  afterwards  I  recorded  another  case,  and  a  year  later 
was  enabled  to  furnish  the  after-history.  I  prepared  with  that 
after-history  the  first  tables  *  of  cases  of  this  rare  disease  ever 
published.  Many  more  examples  of  the  malady  were  shortly 
afterwards  reported.  Fearn  (see  No.  9)  was  able  to  issue  more 
copious  tables.  In  1894  Sanger  and  Barth  as  well  as  myself 
prepared  simultaneously  tables  yet  more  up  to  date.  The  w^ork 
of  the  German  observers  was  published  first,  but  I  had  the 
advantage  of  being  able  to  add  several  important  after-histories 
kindly  sent  to  me  by  the  original  reporters  or  their  successors 
(see  "  private  correspondence  "  in  tables,  under  heading  "  Refer- 
ence"). This  second  series  of  tables  prepared  by  myself 
appeared  in  Allbutt  and  Playf air's  *  System  of  Gynaecology.* 
In  the  present  tables  four  more  complete  reports  are  included, 

*  '  Trans,  Path.  Soc.,'  vol.  xl,  p.  221. 


198  CASES  OF  PRIMAEY  CANCER  OF  THE  FALLOPIAN  TUBE. 

whilst  No.  13  (Von  Rosthorn's)  is  tabulated  from  a  more  com- 
plete report  issued  since  the  former  tables  appeared  in  print. 
I  have  also  corrected  a  few  errors. 

The  latest  report  (No.  19)  before  that  prepared  by  Dr. 
Koberts  was  read  appeared  recently  in  the  '  Archiv  filr  Gynii- 
kologie.'  Dr.  Hofbauer,  the  rej^orter,  declares  that  the  patch 
of  epithelioma  in  the  cervix  (its  surface  was  smooth  and  healthy) 
was  quite  independent  of  the  columnar  cancer  in  the  tubes. 
The  original  report  must  be  carefully  studied  :  unfortunately 
there  seems  to  be  no  after-history. 

Several  operators  removed  the  uterus  with  the  cancerous 
appendages,  a  reasonable  practice  from  many  points  of  view. 
But  the  uterine  end  of  the  cancerous  tube  may  be  free  from 
disease  (No.  8,  Sanger),  whilst  too  often  adjacent  viscera  are 
infected.  In  such  cases  simple  removal  of  the  diseased  tube  is 
the  best  surgery.  Abdominal  section  is  preferable  to  vaginal 
operations  in  suspected  cases  of  this  disease,  as  it  is  important 
to  see  if  any  other  parts  are  involved. 

I  indicated  the  fallacies  into  which  the  pathologist  may  fall 
when  examining  a  cancerous  tube  in  a  short  note  recently 
published  in  these  '  Transactions.'* 

I  refrain  from  presenting  tables  of  sarcoma  of  the  tube  to  the 
Society,  as  no  trustworthy  cases  have  recently  been  reported. 
For  the  same  reason  I  will  say  nothing  about  papilloma  clearly 
not  malignant,  t 

*  "  An  Unreported  Case  of  Primary  Cancer  of  the  Fallopian  Tube  in  1847," 
*  Trans.  Obstet.  Soc.,'  vol.  xxxviii,  1896,  p.  322. 

f  Watkins  (loc.  cit.,  tables.  Case  18)  describes  a  case  of  non-malignant 
primary  papilloma  of  the  Fallopian  tubes,  comparing  it  with  a  malignant 
case  (No.  18).  The  ovary  was  involved.  The  opposite  ovary  bore  papillo- 
matous growths,  from  which  the  corresponding  tube  was  free,  and  it  is  not 
clear  that  the  disease  was  primary  in  the  other  tube. 


TABLE   OF   CASES. 


200   CASES  OF  PRIMARY  CANCER  OF  THE  FALLOPIAN  TUBE. 


Cases  of 

Primary  Carcinoma 

of  the 

Fallopian  Tuhe. 

Age, 

Children; 

Side 

Duration  of 

No. 

married 

menstrua- 

of 

Chief  symptoms. 

symptoms 
before 

Result  of  operation. 

orsingle. 

tion. 

tumour. 

operation. 

1* 

46, 

Abortion 

B. 

Tumour  to  right  of  ucerus 

About 

Died  6th  day 

M. 

(?)H  years 

after  convalescence  fronti 

1^  years 

(3yrs.) 

before 
operation 

typhoid;  then  moderate 
leucorrhcea;  encysted  se- 
rous perimetritis  to  left 

2 

48, 

1 

R. 

San ious, watery  discharge; 

3  years 

Lived  10  months 

M. 

(22  years); 
6  months^ 
menopause 

perimetritis  after  curet- 
ting;   then    tumour    to 
right  of  uterus 

3  weeks 

3 

50, 

Sterile; 

R.  and 

Sanious, watery  discharge; 

4  years 

Recurrence  within 

M. 

6  months' 
menopause 

L. 

club  -  shaped       swelling 
right   fornix,    and    pain 
8    weeks   before    opera- 
tion; elastic  tumour  left 
fornix ;  small  subperito- 
neal uterine  myoma 

18  months  (von 
Herff,  Dec,  1894) 

4 

36, 

Sterile ; 

L. 

Hypogastric  pains,  fever, 

"  For  a 

Free  from  recurrence 

M. 

? 

swelling  in  left  side  of 
pelvis 

long 
time  " 

and  in  good  health 

nearly  7  years  after 

(Veit,  Jan.,  1895) 

5 

46, 

Sterile ; 

R. 

Uterus  pushed  to  right  by 

Hypo- 

Recovery. 

M. 

regular 

a    left   hydrosalpinx;    a 
tumour     right    side    of 
pelvis;  hypogastric  pain 

gastric 

pain 
2  years 

Recurrence  within 

10  months.     "The 

patient  must  have 

died  soon  afterwards" 

6 

46, 

1  child  ; 

R.  and 

Free    watery    discharge ; 

About 

"  Lived  for  about  a 

M. 

still 
regular 

L. 

abdominal  pain ;  emaci- 
ation; two  tumours  felt 
through  parietes 

9  mouths 

year  and  a  half" 
(Zwcifel,  Dec,  1894) 

7 

45, 

1  child  (20 

R.  and 

Hypogastric    pain ;     me- 

1 year 

Recovery. 

S. 

years);  still 
regular 

L. 

trorrhagia  ;     tumour    in 
right  side  pelvis;  smaller 
to  left  and  above  uterus 

Recurrence  2  months. 
Death  in  5  months. 

8 

45, 

1  child  (20 

R. 

Five  months'  sanious  dis- 

5 months 

Recovery.     No 

M. 

years) ;  still 

regular, 

scanty 

charge  ;      symptoms     of 
"  pan-salpingitis."    Ute- 
rus dilated  shortly  before 
operation;  nothing  found 
in  it 

recurrence  7  months 
later 

*  Renaud' 

s  case  (1847)  is  apparently  genuine  (as  primary  cancer),  and  if  so  is  the  earliest 

ever  figured, 

though  no  full  report  accompanied  the  sketch.     See  '  Trans.  Obstet.  Soc.,' 

vol.  X 

xxviii,  ] 

3.  322,  wher 

e  the  sk 
1 

etch  is  reproduced. 

* 

1 

CASES  OF  PRIMARY  CANCER  OP  THE  FALLOPIAN  TUBE.   201 


A.    Cancer  in  a  naturally  developed  Tube. 


Character  of  tumour. 


Cancerous  papillomatous 
growths  in  abdominal 
end  of  tube ;  ostium  com- 
municated with  a  pus 
cavity 

Large,  soft,  cancerous 
mass  growing  from  tubal 
walls;  ostium  closed; 
sanious  serum  iu  tubal 
canal 


Medullary  masses  in  both 
tubes.  Possibly  innocent 
papilloma  at  date  of  ope- 
ration 


Cancerous    papillomatous 
masses  inside  pyosalpinx 


Other  parts  involved. 


Cancerous  nodules  in 
vesico  -  uterine  pouch ; 
enlarged  pelvic  glands ; 
large  abscess  of  right 
ovary ;  suppuration  of 
left  tube  and  ovary 

Right  ovary  small,  cancer- 
ous ;  old  inflammation 
left  appendages;  recur- 
rence in  stump  of  left 
appendix ;  secondary  de- 
posits uterus,  bladder,va- 
gina,  and  lumbar  glands 

None  at  operation.     Re 
currence  on  both  sides, 
chiefly  left 


No  other  parts  involved 


Right  tube  contained  mass  At     operation    no    other 
of  true  medullary  cancer    parts  cancerous ;  pint  of 


(large  alveoli  and  scanty 
stroma) 


sanious  fluid  in  left  tube, 
which  was  not  removed. 
Ten  months  later  hard 
secondary  deposits  in  ab- 
domen ;  ascites 
Soft    villous     masses    in  Uterus,   ovaries,   and  ad- 
dilated    tubes;    "  carci-    jacent      parts      healthy 
noma  papilloniatosum  "  |  (uterus  removed  at  the 

I  (operation) 
Papillomatous    cancer   of  At  operation  right  ovary 
tubes;    cystic  degencra-I  involved;  at  death  endo- 
tion  of  ovaries  and  tubesj  metrium,  pelvic  glands, 

liver 
Papillomatous    cancerous;None;  right  ovary  "  nor 
mass,  "  as  big  as  a  kid-|  mal    except    for     adhe 
ney,"    iu   outer  part  of,  sions" 
tube;  the  uterine  end  of 
tube   free    from    disease 
for  an  inch  and  a  half 


Operator. 


Martin, 
Berlin 


Thornton 


Kaltenbach 


Reporter  and  reference. 


J.  Veit 


Landau 


Zweife 


Wester 
mark 


Sanger 


Orthmann, 
Geburtsh.,' 
212. 


Zeitschr.    f. 
vol.    XV,    p. 


Doran, '  Trans.  Path.  Soc.,' 
vol,  xxxix,  p.  208,  and 
vol.  xl,  p.  221. 


Kaltenbach, '  Centralbl.  f. 
Gyniik.,'  1889,  p.  74 ;  id. 
and  Eberth,  '  Zeitschr. 
f.  Geburtsh.  u.  Gyniik.,' 
vol.  xvi,  1889,  p.  357; 
Von  Herff,  private  cor- 
respondence, Dec,  1894. 

Veit,' Zeitschr.f.Geburtsh. 
u.  Gynak.,'  vol.  xvi,  1889, 
p.  212;  private  corre- 
spondence, Jan.,  1895. 

Landau  and  Rheinstein, 
*  Archiv  f.  Gyniik.,'  vol. 
xxxix,  1891,  p.  273,  and 
private  communication. 


Zweifel,  '  Vorlesungen 
iiber  kiln.  Gyniik.,' 1892, 
p.  139,  and  private  cor 
respond  en  ce. 

Westermark  and  Quensel, 
'Nordiskt  med.  Arkiv,' 
vol.  xxiv,  1892,t  and 
private  correspondence. 

Siinger,  Martin's '  Krank- 
heiten  der  Eileiter,'  1895, 
p.  253. 


t  Westcrmark's  case  is  reported  in 
p.  1197),  by  different  writei's. 


Centralbl.  f.  Gyniik.,'  vol.  xvii,  twice  (p.  272  and 


202       CASES  OF  PRIMARY  CANCER  OF  THE  FALLOPIAN  TUBE. 


Age, 

Children ; 

Side 

Duration  of 

No. 

married 

menstrua- 

of 

Chief  symptoms. 

symptoms 

Result  of  operation. 

9 

or  single. 

tion. 

tumour. 

IICIUX  c 

operation. 

56, 

Sterile ; 

R. 

Sanious  serous  discharge ; 

il  years 

Recovery.     "  Alive 

M. 

regular 

dysuria.    Large  tumour, 
feeling  like  a  myoma,  on 
right  side 

and  free  from 

recurrence  1  year 

and  7  months  after 

operation  " 

10 

55, 

? 

? 

R. 

Hypogastric  pains;  bloody 
discharge.      Fluctuating 
tumour     right    side    of 
pelvis,  right  iliac  fossa, 
and  Douglas's  pouch 

2  months 

Recovery.   Free  from 

recurrence  a  year 

later;  "afterwards 

lost  sight  of" 

11 

60 

Sterile ; 

menopause 

52 

R. 

Attacks  of  pain  right  iliac 
iossa;    nodulated  swell- 
ing in  hypogastrium ;  no 
discharge 

4  months 

Recovery. 

Recurrence  in 

6  months.   Death  one 

year  after  operation 

12 

43, 

3  children; 

R.  and 

Pain,  fever,  and  dysuria 

? 

Death  3  weeks,  a  few 

S. 

meuor- 

rhagia 

3  weekly 

L. 

after   exertion,   19  days 
before  operation ;    small 
hypogastric  tumour  de- 
veloped;   torsion   of   an 
ovarian  pedicle  suspected 

hours  after  second 
abdominal  section  for 
intestinal  obstruction 

13 

59 

? 

R. 

Purulent,  acrid  discharge; 

2  months 

Recovery.     Death 

menopause 

(and 

escape  of  pus;  tumour  to 

6  months  later, 

at  53 

L.?) 

right  like  a  pyosalpinx; 
inguinal  glands  enlarged 

fortnight  after 

excision  of  enlarged 

inguinal  glands 

14 

58, 

1  child ; 

R. 

18  years  swelling  of  ab- 

18 years 

Incomplete  opera- 

M. 

menopause 
12  years 

domen  ;    recently    pain, 
ill-health,    and   increase 
in  size  of  tumour 

tion  ;  convalescent 

when  report  was 

published 

■ 


CASES  OF  PRIMARY  CANCER  OP  THE  FALLOPIAN  TUBE.   203 


Character  of  tumour. 


Large       sausage  -  shaped 
tube;  exuberant  papillo 
raatous  cancerous  masses 
on  inner  walls 


V^illous  epitlielioinatous 
mass  springing  from 
tubal  mucosa ;  much 
clot  and  serum  in  dilated 
canal  of  tube 

Spongy   mass   cancer  in 
side  tube,  which  was  ob- 
structed   at     abdominal 
end  and  connected  with 
a  cystic  ovarian  tumour 


Papillomatous  cancer  of 
both  tubes ;  right  "tubo- 
ovarian  cyst"  (see  text) 


Papillomatous  cancer  of 
right  tube  removed  with 
entire  uterus  (left  tube 
and  ovary  too  adherent 
for  removal);  pus  in  tube 


Papillomatous  cancerous 
mass  in  dilated  tube, 
which  communicated 
with    a    large     ovarian 

cyst 


Otlier  paits  involved. 


Xo  other  parts  involved; 
right  ovary  atrophied ; 
no  trace  of  cancer  in  its 
substance 


No  evidence  of  any  exten- 
sion of  cancer;  uterus 
and  opposite  appendages 
normal 


'  Evidence  of  infection 
beyond  the  limits  of  parts 
removable  by  operation;" 
cancer  on  surface  of  ova- 
rian cyst.     No  necropsy 


Ovaries  and  uterus  free 
from  cancer.  No  trace 
of  malignant  disease 
found  in  abdomen  after 
death 


Inguinal  and  retro- peri- 
toneal glands;  left  tube 
secondarily  (?)  affected 
after  operation;  it  con- 
tained pus.  See  original 
report 


No  sign  of  cancer  in 
opposite  appendages, 
uterus,  and  peritoneum 


Operator. 


Reporter  and  reference. 


Leopold 


Anger 


Culling 
worth 


Warneck 


Von 

Rosthoru, 
(vaginal  ex- 
tirpation of 
uterus  and 

right  ap- 
pendages ; 
left  tube  not 

removed) 

Chrobak 
(uterus  and 
appendages 
removed, 
but  a  piece 
of  the 
ovarian 
cyst  could 
not  be  re- 
moved, and 
was  fixed  to 
stump  of 
uterus  in 
abdominal 
wound) 


Fearn,  '  Arbeiten  aus  dei 
koniglich.  Frauenklinik,' 
vol.  ii,  p.  337;  Leopold, 
private  correspondence 


TufSer,  *  Annales  de  Gyne- 
col, et  d'Obst.,'  vol.  xlii, 
1894,  p.  203,  and  private 
correspondence. 


Cullingworth  and  Shat- 
tock,  '  Trans.  Obst.  Soc.,' 
vol.  xxxvi,  1894,  p.  307 ; 
private  communication, 
and  personal  inspection 
of  specimen. 

Warneck,*  Nouvelles  Arch. 
d'Obstet.  et  de  Gynec.,' 
1895.  p.  81. 


Von  Rosthorn,  '  Pragei 
Zeitschriftf.  Heilkunde,' 
vol.  xvii,  1896,  p.  177. 


Knaner,     '  Centralbl.     f. 
Gyuak.,'  1895,  p.  574. 


204 

CASES  OF  PRIMARY  CANCER  OP  THE  FALLOPIAN  TUBE. 

Age, 

Cliildren ; 

Side 

Duration  of 

No. 

married 

menstrua- 

of 

Chief  symptoms. 

symptoms 
before 

Result  of  operation. 

orsiugle. 

tion. 

tumour. 

15 

operation. 

46, 

3  children ; 

R. 

2    months     amenorrhcea. 

8  months 

Recovery ;  8  months 

M. 

period 

and 

then      uterine     haemor- 

after operation    a 

3-weekly 

L. 

rhage    and    hypogastric 
swelling,      disappearing 
after  colicky  pain ;  free 
"  serous      leucorrhoea ;" 
mass    filling    both    for- 
nioes      and      Douglas's 
pouch 

mass  the  size  of  a 
fist  in  the  pelvis 

16 

40, 

1  abortion  ; 

R. 

Yellow  discharge  7  mos.; 

Over 

Recovery ;  died 

M. 

regular 

and 

hypogastric  pain;  period 

7  months 

7  months  after 

before 

L. 

ceased   3    months,   then 

operation;  no 

illness 

came    on    again  ;     oval 
tumour    reached    above 
umbilicus 

necropsy 

17 

45. 

Sterile ; 

L. 

Dysmia ;  pain  in  defseca- 

1  month 

Recovered  (left 

M. 

period 

tion ;  hypogastric  swell- 

appendages 

20  yrs. 

irregular ; 

dysmenor- 

rhoea 

ing  ;     large    pelvic    tu- 
mour,     very       tender ; 
uterus    anteverted    and 
fixed 

removed)  ;  well  a 
few  months  later 

18 

45, 

1  child. 

R. 

Dysuria ;  pain ;  fluctuat- 

14 days 

Recovery  after 

M. 

23  years ; 

and 

ing  mass  on  each  side  of 

removal  of  uterus 

pregnancy 

L. 

a  fibroid  uterus  ;  no  dis- 

and appendages ; 

normal 

charge;    high  tempera- 
ture 

death  7  months  later 
from  recurrence 

19 

46, 

3  children, 

R. 

Leucorrhoea  and  pains  in 

Over 

Recovery  (?)  from 

M. 

last  23 

and 

left   iliac   fossa  ;    swell- 

1 year 

removal  of  uterus 

years ; 

L. 

ings      in     each     lateral 

(hypo- 

and appendages. 

menor- 

fornix 

gastric 

June  2nd,  1897 

rhagia 

pains 

3  years 

3  years) 

20 

43, 

0 

R. 

Leucorrhoea  after  rigor  (?) ; 

Over  10 

Recovery ;    no  recur- 

M. 

4  months  later  abdominal 
pain ;  watery  discharge ; 
similar    attack    over    3 
months          afterwai'ds ; 
swelling  of  both  f  ornices ; 
free  watery  discharge 

months 

rence  detected  on 

examination  14 

months  later. 

CASES  OF  PRIMARY  CANCER  OP  THE  FALLOPIAN  TUBE.   205 


Character  of  tumour. 


Papillomatous  cancer  of 
tubes,  which  were  di- 
lated and  full  of  sero- 
sanguineous  fluid  ;  chon- 
drification  of  part  ol 
wall  of  left  tube 


Papillomatous  cancer  of 
tubes;  right  tube  formed 
a  large  cyst ;  left  tube 
could  not  be  removed  ; 
it  was  united  by  malig- 
nant deposit  to  adjacent 
structures 

Malignant  papilloma  of 
left  tube;  left  ovary, 
right  tube,  and  right 
ovary  healthy 


Each  tube  formed  a  large 
convoluted  tumour  full 
of  malignant  papilloma 


"  Carcinoma  villosum 
cylindrico-epitheliale"  of 
both  tubes ;  left  most 
affected ;  ovaries  healthy 


Other  parts  iuvolved. 


No    sign    of     cancer    in    Lebedeff* 
adjacent  organs  at  ope- 
ration 


Operator. 


Metastatic  deposits  on 
visceral  peritoneum  and 
omentum ;  a  little  ascites 


Adherent  small  intestine, 
possibly  infected 


Intestine     probably 
fected  through  "  numer 
ous      firm      adhesions ' 
separated  at  operation 


Fischel 


Eckardt 


in-     Watkins 
(Chicago) 


A  small  area  of  cancer  in 
canal  of  cervix,  which 
Hofbauer  declared  to  be 
independent  of  the  tubal 
disease.     See  original 


Schauta 


Right    tube     size    of     a, None 
Bologna  sausage,  full  of 
malignant  papilloma 


Meredith 


Reporter  and  reference. 


Miknoff,  Pean,  '  Diag- 
nostic et  Traitement  des 
Tumeurs  de  TAbdomen,' 
vol.  iii,  1895,  p.  564. 


Fischel,      *  Prager  med. 

Woehenschrift    f.  Heil- 

kunde,'    vol.   xvi,  1895, 
p.  143. 


Eckardt/ Arch.f.  Gynak.,' 
vol.  liii,  1897,  p.  183. 


Watkins,  Amer.  Gynec 
and  Obstet.  Journal,' 
vol.  xi,  1897,  p.  272. 


Hofbauer,  'Archiv  f 
Gynak.,'  vol.  iv,  1898, 
p.  316. 


Hubert  Roberts,  see 
'  Trans.  Obstet.  Soc," 
present  volume,  p.  189. 


206       CASES  OF  PRIMARY  CANCER  OP  THE  FALLOPIAN  TUBE. 


B.   Cancer  partly  in  Cyst 


No. 

Age, 
married 
orsingle. 

21 

22 
23 

50, 

S. 

60, 
M. 

58 

Children  ; 

Side 

menstrua- 

of 

tion. 

tumour. 

0(?); 

E. 

menopause 

not 

established 

Sterile; 

L. 

50 

1  child 

? 

CJiief  symptoms. 


Discharge  of  blood  for  a 
few  months ;  hypogas- 
tric pain  for  3  days 
before  death 


Abdominal  swelling  ;    2  years 

escape  of  quantities  of 
yellow  fluid  from  vagina; 
swelling  diminishing ; 
phlebitis  of  left  leg 


Hypogastric  inflammation  18  years 

30  years  before;  for  18  tumour; 
years  a  stationary  swell-     acute 
ing  of  abdomen ;  1  year      sym- 

hypogastric     pain     and  ptoms 

cystitis ;     at     operation  1  year 
cyst  filled  pelvis 


Duration  of 

symptoms 

*  before 

operation. 


"IIP' 4 
months 


Result  of  operation. 


No  operation 


Recovery  from 

operation  (Nov. 

22nd,  1892) ;  case 

lost  sight  of 


Well  3  months  after 
operation 


N.B. — Incomplete  cases  of  primary  cancer  of  the  tube,  reported  by  Smyly, 

Note. — Since  the  above  tables  were  printed,  I  have  found  reports  of  two  more  cases, 
thirty-two  years,  sterile;  menopause  at  forty-seven;  three  months'  pains  in  left  iliac  fossa, 
ages,  recovery ;  death  from  recurrence  seven  months.  The  left  tube  was  a  cyst  full  of 
Monatshefte,'  June,  1897).  No.  25,  patient  aged  45,  catamenia  irregular.  For  six 
diagnosed;  tumour  developed  in  left  fornix.  Vaginal  hysterectomy,  including  appendages, 
which  was  recently   performed  (Falk,  '  Deutsche  med.  Wochenschr.,'  March  31st,  1898, 


CASES  OF  PRIMAEY  CANCER  OF  THE  FALLOPIAN  TUBE.      207 


connected  icith  Ostium. 


Character  of  tumoiir. 

Other  parts  involved. 

Operator. 

Reporter  and  reference. 

Mass  of  medullary  cancer 

No   extension    to   neigh- 

None 

W.Essex  Wynter,  'Trans. 

in  ostium  of  tube,  com- 

bouring or  distant  parts 

Path.     Soc.,'    vol.    xlii. 

municating  with  a  cyst 
(external  to  the  tube  and 
ovary)    as    large    as   an 
ostrich's      egg ;        cyst 
seemed  to  communicate 

p.  222 ;  and  Doran,  in 
Allbutt  and  Playfair's 
*  System  of  Gynaecology/ 
p.  821. 

with     cavity    of     tube, 

which  was  full  of  blood 

Cancerous    papilloma    in 

No     other     parts      were 

Eoutier 

Routier,     '  Bulletins     et 

walls   of    tube ;    ostium 

found  involved 

memoires  de  la  Soc.  de 

opening  into  a  cyst   as 
large  as  an  adult  head ; 

Chirurg.  de  Paris/  vol. 
xviii,  1892,  p.  73  ;  *  An- 

ovary    not    found    (see 
text) 

nales  de  Gynec.  et 
d'Obstet./  vol.  xxxix, 
1893,  p.  39,  and  private 
correspondence. 

Tubo-ovarian  cyst  with  a 

Firm  adhesion  of  cyst  to 

Savor 

Savor,  "  Cystitis  crouposa 

primary  cancer  adjacent 
to  it 

adjacent  parts;    a   por- 
tion was  left  behind 

bei  sauerem  Ham," 
*  Wiener  klin.  Wochen- 
schrift/  vol.  viii,  1895, 

p.  775. 

Zvveifel,  Westermark,  Jacobson,  and  others,  are  not  included  in  the  above  tables. 

•oth  by  Falk  of  Berlin,  and  both  come  under  Class  A.  No.  24,  patient  aged  53,  married 
anions  discharge,  big  swelling  in  left  fornix.  Vaginal  hysterectomy,  including  append- 
left  ovary  and  uterus  healthy.     Caecum  involved  in  recurrence  (Falk,  •  Therapeut. 


ancer 


nonths  serous  discharge,  cyst  in  right  fornix  aspirated,  bloody  serum  escaped,  cancer  then 
Primary  cancer  of  cystic  right  tube  discovered.  The  patient  recovered  from  the  operation, 
upplement,  p.  43). 


208        CASES  OF  PRIMARY  CANCER  OF  THE  FALLOPIAN  TUBE. 

Dr.  Peter  Horeocks  pointed  out  that  carcinoma  of  the 
cervix  was  common,  and  nearly  always  occurred  in  parous 
women;  carcinoma  of  the  body  of  the  uterus  was  much  rarer, 
and  occurred  chiefly  in  women  who  had  not  borne  children  ; 
whilst  carcinoma  of  the  Fallopian  tubes  was  the  rarest  of  all, 
and  again  occurred  in  sterile  women  chiefly.  He  thought 
clinical  evidence  showed  that  tissues  that  were  used  much  and 
were  liable  to  damage  were  more  prone  to  carcinoma  than  others, 
witnessing  carcinoma  of  lips,  tongue,  oesophagus,  pylorus,  rectum, 
scrotum,  cervix  uteri,  &c.  He  thought  this  rather  favoured 
the  idea  that  carcinoma  was  due  to  or  in  some  way  associated 
with  a  microbe  acting  as  a  germ  or  exerting  possibly  a  spermatic 
influence  upon  the  part  affected.  In  this  way  one  could  see 
that  such  a  microbe  travelling  along  the  genital  canal  would 
meet  with  the  cervix  uteri  first,  and  if  that  had  been  damaged 
by  one  or  more  parturitions  (split  cervix,  &c.),  it  would  elect 
the  damaged  part,  as  it  were,  for  its  growth.  But  if  it  were  a 
nulliparous  cervix,  then  it  might  extend  into  the  body  of  the 
uterus,  and  so  develop  there,  and  in  still  rarer  cases  travel  along 
the  Fallopian  tube  and  develop  there.  He  thought  that  removal 
of  primary  carcinoma  from  whatever  part  was  affected  was 
followed  at  the  present  day  by  a  longer  period  of  immunity  than 
was  the  case  formerly,  and  although  he  did  not  know,  he  had  a 
strong  impression  that  such  increased  length  of  time  before 
recurrence  was  due  to  the  aseptic  methods  now  employed, 
whereby  every  vestige  of  the  cancer  was  got  rid  of  by  washing, 
&c.  He  also  considered  that  it  was  better  to  oj)en  the  abdomen 
in  cases  of  doubtful  diagnosis,  such  as  primary  cancer  of  the 
Fallopian  tube,  because  it  was  so  much  easier  to  command  the 
vessels,  to  extirpate  the  disease,  and  to  obtain  a  general  survey 
such  as  could  not  possibly  be  obtained  by  colpotomy. 

Dr.  Amand  Routh  alluded  to  the  difliculty  of  diagnosis.  In 
Case  2  in  Mr.  Doran's  resume,  which  had  occurred  in  his  own 
practice,  and  in  the  majority  of  those  in  the  table,  there  was 
usually  continuous  pelvic  pain,  coming  on  as  an  early  symptom, 
simulating  acute  salpingitis  with  slight  perimetric  extension ; 
and  when  this  was  associated  with  sanious,  often  offensive 
discharge,  together  with  a  tubal  swelling,  the  diagnosis  of  some 
new  growth  in  the  tube  was  probable.  If  the  additional  pre- 
caution was  taken  to  exclude  the  uterus  from  being  the  cause  of 
the  discharge,  by  a  preliminary  dilatation,  the  diagnosis  could 
be  made  with  fair  certainty. 

Dr.  Addinsell  drew  attention  to  the  fact  that  in  nearly  all 
the  recorded  cases  the  most  noticeable  clinical  features  were 
pain  and  the  presence  of  a  watery  discharge,  and  remarked  upon 
the  importance  of  this  last  sign  as  an  additional  evidence  of  the 
patency  of  the  uterine  ostium  of  the  Fallopian  tube ;  and  he 
pointed  out  that  the  presence  of  this  discharge  could  not  be 


CASES  OP  PRIMARY  CANCER  OF  THE  FALLOPIAN    TUBE.        209 

considered  pathognomonic  of  either  primary  carcinoma  of  the 
tube  or  papilloma,  as  it  occurred  in  some  cases  of  hydrosalpinx, 
and  was  sometimes  accompanied  by  pain. 

Dr.  Arthur  Giles  called  attention  to  the  unfavourable 
prognosis  in  cases  of  cancer  of  the  Fallopian  tube.  This  feature 
came  out  clearly  in  the  excellent  table  comjDiled  by  Mr.  Doran. 
Of  the  twenty- three  cases  on  the  list,  in  two  no  operation  was 
done,  or  it  was  incomplete ;  in  two  the  operation  was  fatal ;  in 
two  which  recovered  from  oj^eration  the  patient  was  lost  sight 
of.  This  left  seventeen  cases  to  furnish  after  results ;  and  of 
these  recurrence  took  place  in  ten  with  a  fatal  result,  the  time 
of  recurrence  averaging  six  to  eight  months  after  operation. 
Even  the  serious  procedure  of  removing  the  uterus  and  both 
appendages  appeared  to  be  no  safeguard  against  a  return  of  the 
disease,  since  in  one  of  the  two  cases  in  which  this  was  done 
the  patient  died  of  recurrence  in  seven  months.  Of  the  seven 
cases  reported  as  remaining  well  up  to  date  there  was  only  one 
that  could  be  safely  pronounced  as  cured,  inasmuch  as  seven 
years  had  elapsed  since  the  operation.  In  the  others  the  time 
was  too  short  to  allow  of  a  positive  statement,  the  longest  time 
being  nineteen  months.  These  considerations  did  not,  however, 
affect  the  question  of  operation,  inasmuch  as  it  was  impossible 
in  most  cases  to  arrive  at  a  diagnosis  until  after  the  removal  and 
examination  of  the  tumour. 

In  reply  to  various  speakers,  Dr.  Roberts  thanked  the 
President  and  Fellows  for  the  kind  way  in  which  they  had 
received  his  paper.  Also  he  begged  to  thank  Mr.  Doran  for 
having  prepared  a  complete  list  of  recorded  cases  which  had 
been  placed  before  the  Society,  and  which  greatly  added  to  the 
interest  of  the  case  which  Dr.  Roberts  reported  to-night.  With 
regard  to  Mr.  Doran' s  remarks  on  the  treatment  of  such  cases, 
as  to  whether  the  whole  uterus  and  appendages  should  always 
be  removed,  in  the  present  case  this  was  not  done,  as  there 
seemed  to  be  a  margin  of  healthy  tube  between  the  disease  and 
the  uterus.  The  other  tube  was  removed  as  a  precautionary 
measure,  and  on  account  of  the  patient's  age  (forty-three).  Dr. 
Roberts  had  not  suggested  that  the  watery  discharge  from  the 
vagina,  the  so-called  hydrops  tubse  profluens,  was  pathognomonic 
of  cancer  or  papilloma,  but  it  seemed  to  be  a  symptom  worth 
consideration.  Evidently  the  diagnosis  of  cancer  of  the  tube 
was  a  very  difficult  problem  before  the  abdomen  was  opened. 
In  the  present  case  the  diagnosis  was  that  of  j^yosalpinx. 
Sterility  Dr.  Roberts  thought  was  certainly  another  point  in 
many  of  the  recorded  cases,  as  was  also  the  age  of  the  patient, 
generally  in  late  life.  Dr.  Roberts's  case  was  aged  forty- 
three.  Dr.  Roberts  felt  that  iu  his  reply  to  many  of  the 
speakers  he  would  like  Mr.  Doran' s  assistance,  owing  to  his 
great  experience. 

VOL.  XL.  14 


210       CASES  OF  PRIMARY  CANCER  OF  THE  FALLOPIAN  TUBE. 

Dr.  Horrocks  brought  forward  the  question  of  irritation  and 
multiparity  in  cancer  of  the  cervix,  as  opposed  to  sterility  and 
nulliparity  in  cancer  of  the  body  and  tubes.  But  Dr.  Eoberts 
thought  that  the  question  was  hardly  one  of  sterility  and 
nulliparity  as  a  cause,  but  one  of  effect,  viz.  that  it  seemed  from 
reported  cases  that  cancer  did  arise  in  tubes  subject  to  chronic 
inflammation  and  irritation,  as  in  the  case  just  reported  of  which 
the  history  had  been  read.  Dr.  Roberts  did  not  feel  himself 
qualified  to  suggest  anything  farther  than  Dr.  Horrocks  had 
done  about  the  protozoon  of  cancer.  Still,  he  admitted  that  it 
would  be  better  to  remove  such  tubes  whole,  and  to  take  the 
strictest  antiseptic  precautions  against  local  infection.  As 
regards  the  point  of  abdominal  section  or  vaginal  section  for 
the  removal  of  such  tubes.  Dr.  Eoberts  had  no  hesitation  in 
advising  the  abdominal  method  very  strongly.  In  the  case  just 
read  the  adhesions  could  never  have  been  dealt  with  by  the 
vaginal  method,  or  the  pedicle  treated  with  any  degree  of  safety 
whatever. 

In  answer  to  Dr.  Routh  the  author  quite  agreed  that  diagnosis 
was  the  difficult  point,  and  that  we  needed  further  careful 
research  on  this  point.  As  before  stated,  Dr.  Roberts  said  that 
in  his  case  the  diagnosis  was  not  made  till  the  abdomen  was 
opened  and  the  tube  incised  after  removal.  Nearly  all  cases 
hitherto  had  been  diagnosed  as  "  inflammation."  Dr.  Wise 
asked  as  to  cancer  in  the  family.  Dr.  Roberts  had  no  special 
report  on  the  subject,  but  he  would  make  inquiries  when  he 
saw  the  patient  again.  He  did  not  think  it  was  a  very  grave 
point.  Dr.  Addinsell  had  asked  with  regard  to  the  pain  of 
such  cases.  In  Dr.  Roberts's  case  the  report  was  of  several 
attacks  of  pain,  each  preceding  the  escape  of  watery  fluid  per 
vaginam.  He  suggested  that  such  attacks  were  due  to  the  dis- 
tension of  the  tube,  which,  after  reaching  a  certain  tension, 
escaped  into  the  uterus,  and  the  pain  ceased.  Examination  of 
the  uterine  end  of  the  tube  had  not  discovered  any  abnormal 
dilatation.  The  fimbriated  extremity  was  of  course  closed. 
Dr.  Stevens  had  asked  as  to  the  possible  origin  of  carcinoma 
and  papilloma  from  Wolffian  relics  in  the  tubes.  Dr.  Roberts 
was  of  course  aware  of  such  relics,  and  Doran  had  referred  to 
them  in  his  article  on  diseases  of  the  tubes  in  Clifford  Allbutt's 
'  System  of  Gynaecology.'  Dr.  Roberts  thought  that  evidence 
rather  pointed  to  the  origin  of  carcinoma  from  the  mucosa  of 
the  tube  in  most  cases,  at  least  in  those  which  had  reached  a 
normal  development.  He  thought  Mr.  Doran  more  competent 
to  answer  that  point.  Dr.  Giles  had  pointed  out  that  the  prog- 
nosis seemed  from  reported  cases  to  be  very  gloomy,  though 
Mr.  Doran  did  not  think  so.  Dr.  Roberts  thought  he  had 
hardly  a  sufficient  number  of  cases  to  go  on.  His  case  was 
alive  fourteen  months  after  operation  with  no  recurrence.     She 


CASES  OP  PRIMARY  CANCBR  OF  THE  FALLOPIAN  TUBE.       211 

had  been  carefully  examined  on  May  4th  at  the  Samaritan  Hos- 
pital. Dr.  Roberts  hoped  that  as  our  methods  of  early  diagnosis 
and  prompt  treatment  improved  the  outlook  would  be  better. 

Mr.  Alban  Doean,  in  reply,  made  notice  of  a  further  case, 
reported  by  Jacobson  of  St.  Petersburg  ('  La  G-ynccologie/ 
April,  1898).  The  patient  was  forty-five,  there  was  uterine 
discharge  and  a  mass  in  the  left  fornix  ;  this  mass  proved  to 
be  a  cancerous  tube,  which  was  removed  through  a  vaginal 
incision.  As  in  Cases  2  and  7  in  the  tables,  the  uterine  end  of 
the  tube  was  free  from  cancer.  The  patient  was  sterile :  let 
it  be  noted  that  in  the  tables  many  cases  were  so,  whilst  only 
three  had  borne  so  many  as  three  children.  Mr.  Doran  had 
recently  operated  on  a  woman  aged  45  who  had  been  twelve 
times  pregnant.  On  March  13th  she  had  an  attack  of  labour- 
like pains ;  a  similar  seizure  occurred  two  days  later.  With 
each  pain  much  water  escaped,  till  at  length  she  was  drenched 
as  in  an  ordinary  labour.  Inflammatory  symptoms  set  in,  and 
a  large  tender  mass  developed  in  the  right  fornix  and  a  smaller 
body  on  the  opposite  side.  The  symptoms  suggested  paj^illoma 
or  cancer  of  the  tubes,  but  Mr.  Doran  found  those  structures 
tough,  tortuous,  and  with  very  thickened  walls  adherent  to 
adjacent  structures.  The  canals  were  not  dilated.  As  for  villi 
or  papillae,  Kaltenbach  and  himself  working  independently  had 
found  that  the  eai'liest  condition  in  papilloma  and  cancer  of 
the  tube  was  a  villus  or  papilla.  Primary  cancer  seemed  com- 
moner than  papilloma  of  the  tube,  or  at  least  the  latter 
seemed  very  prone  to  undergo  malignant  degeneration.  Of 
seven  authentic  cases  of  paj^illoma  two  had  died  of  the 
operation,  and  one  was  very  recent,  so  that  they  afford  no 
evidence  on  that  point;  whilst  Kaltenbach' s  case,  taken  at  first 
for  cancer  (tables.  No.  3),  was  on  further  microscopic  examina- 
tion made  out  as  an  innocent  papilloma.  Unfortunately  the  first 
opinion  proved  true,  and,  as  Mr.  Doran  had  found  on  inquiry, 
recurrence  occurred.  On  the  other  hand,  the  earliest  recorded 
case  of  papilloma  (Spencer  Wells  and  Bickersteth)  exhibited 
the  gravest  clinical  symptoms  when  the  tumour  was  removed  in 
1879,  but  the  patient  was  alive  and  well  in  1897.  These  facts 
show  the  extreme  importance  of  seeking  for  after-histories  when 
the  report  is  incomplete,  and  Mr.  Doran  had  freely  communicated 
with  the  authors  of  cases  on  that  account.  He  agreed  with  Dr. 
Stevens  that  cancer  of  the  tube  might  arise  from  tubular 
Wolffian  relics,  such  as  von  Recklinghausen  had  detected  even 
in  healthy  tubal  walls  ('Die  Adenoma  der  Uterus,'  &c.,  189G). 
This  theory  seemed  to  account  for  the  tubular  structure  which 
Mr.  Doran  had  detected  and  figured  in  a  section  from  No.  2  in 
the  tables  ('Trans.  Path.  Soc.,'  vol.  xxxix,  pi.  xiv,  fig.  3, 
and  Playfair's  'System  of  Gynajcology,'  fig.  2,  p.  815).  The 
surgery  of  the  disease  in  question  was  important.    Mr.  Meredith 


212       CASES  OF  PRIMARY  CANCER  OP  THE  FALLOPIAN  TUBE. 

was  right  in  removing  the  opposite  tube,  as  the  disorder  some- 
times proved  to  be  bilateral.  Removal  of  the  tube  alone  through 
a  vaginal  incision  was  questionable,  as  the  state  of  surrounding 
parts  could  not  readily  be  ascertained.  Panhysterectomy,  in- 
cluding the  appendages,  seemed  right  when  the  disease  was 
clearly  bilateral  or  bad  already  invaded  the  uterus.  Watkins 
(18)  had  adopted  this  course,  but  in  his  case  the  uterus  was 
myomatous,  and  Schauta  (19)  removed  the  uterus  as  well  as 
the  appendages  because  that  organ  was  the  seat  of  cancer  in 
the  cervix,  independent,  according  to  Hofbauer,  of  the  cancer 
in  the  tubes.  But  the  uterine  end  of  the  tube  was  free  from 
cancer  in  many  cases  (2  and  8,  for  instance),  whilst  the  outer 
end  usually  adhered  to  adjacent  structures  which  were  speedily 
infected.  Hysterectomy  in  such  cases  involved  useless  dangers. 
Careful  and  thorough  removal  of  the  diseased  tube  was  usually 
the  only  course  open  to  the  surgeon.  The  commonest  error  of 
diagnosis  after  operation  occurred  when  cancer  from  an  ovary 
invaded  a  dilated  and  obstructed  tube. 


JUNE  1st,  1898. 

C.  J.  CuLLiNGWORTH,  M.D._,  President,  in  the  Chair. 

Present — 39  Fellows  and  3  visitors. 

Books  were  presented  by  the  Society  of  the  New  York 
Hospital  and  Dr.  Pnrefoy. 

Sidney  Herbert  Snell,  M.D.,  B.S.Lond.,  was  admitted  a 
Fellow  of  the  Society. 

Charles  Robert  Watson,  M.D.Brux.  (Tunbridge  Wells), 
was  declared  admitted. 


Report  of  Committee  on  Dr.  Maciiaughton- Jones' s  Specimen 
of  Tumour  of  the  Ovary,  shown  April  Qth,  1898. 

The  growth  measures  2^  x  2  inches,  and  is  situated  in 
the  substance  of  the  ovary  at  its  outer  end,  wdth  the  ovarian 
capsule  stretched  over  it.  Its  surface  is  smooth  and  nodular, 
and  on  section  the  cut  surface  has  the  general  appearance 
of  a  fibro-myoma.  The  part  of  the  ovary  not  involved  in 
the  growth  appears  to  be  normal,  and  contains  a  corpus 
luteum. 

On  microscopic  examination  the  tumour  consists  chiefly 
of  well-developed  fibrous  tissue  arranged  in  intersecting 
bundles.      Sections  taken  from  different  parts  all  show,  in 

VOL.  XL.  15 


214  BLOOD    CONCRKTIONS    IN    THE    OVARY. 

addition,,  numerous  widely  distributed^  well-defined  spaces, 
filled  witli  epithelial  cells.  These  spaces  are  irregularly 
oval  or  elongated^  occasionally  branching,  and  show  no 
lumen.  There  is  no  sign  of  invasion  of  the  surrounding 
fibrous  tissue  by  the  epithelial  cells,  and  no  small-celled 
infiltration.  The  stroma  immediately  surrounding  some 
of  the  spaces  is  dense  and  hyaline  in  appearance. 

We  are  of  opinion  that  the  tumour  is  not  malignant,  and 
that  the  arrangement  of  the  epithelium  most  nearly  re- 
sembles that  met  with  in  some  forms  of  adeno-fibroma  of 
the  breast.  We  recommend  that  the  drawing  accompany- 
ing this  report  be  published. 

H.  Macnaughton -Jones. 

Herbert  E.  Spencer. 

J.  H.  Targktt. 

T.  W.  Eden. 


BLOOD  CONCRETIONS  IN   THE    OYARY. 
Shown  by  Alban  Do  ran. 

These  bodies  were  taken  from  the  right  ovary  of  a 
single  woman  aged  43.  She  had  a  moderate-sized  fibroid, 
which  gave  her  trouble  as  she  was  a  cook  and  had  to  stand 
about  a  great  deal.  As  the  appendages  were  very  easily 
removed  entire,  and  the  growth  chiefly  in  the  fundus,  I 
thought  oophorectomy  preferable  in  this  case  to  removal 
of  the  uterus.  Indeed,  the  chief  trouble  was  due  to  peri- 
metritis ;  the  fimbriae  of  the  right  tube  and  the  correspond- 
ing ovary  adhered  to  the  uterus  rather  firmly.  The  ovary 
contained  a  large  blood  cyst,  which  burst  during  extraction. 
The  operation  was  performed  on  February  3rd,  and  the 
patient  has  done  well  up  till  the  present  date. 

The  right  ovary  was  considerably  enlarged.  The  col- 
lapsed blood  cyst  measured  an  inch  and  a  half  in  diameter  ;. 


BLOOD    CONCRETIONS    IN    THE    OVARY.  2 15 

it  has  shrunken  considerably  since.  When  I  examined  it 
after  operation  all  the  fluid  blood  had  escaped  from  its 
cavity  and  no  semi-solid  clot  remained,  but  four  solid 
bodies  of  a  dark  claret  colour  fell  out.  The  largest  was 
lens-shaped  and  a  quarter  of  an  inch  in  diameter,  the 
next  in  size  was  spindle-shaped  and  under  a  quarter  of  an 
inch  long,  the  remaining  two  were  smaller  and  irregular 
in  form.  I  exhibit  them  this  evening  mounted  as  a 
specimen,  now  belonging  to  the  museum  of  the  Royal 
College  of  Surgeons. 

These  concretions  are  clearly  of  the  same  character  as 
the  specimens  exhibited  by  Dr.  Hector  Mackenzie  at  a 
meeting  of  the  Pathological  Society  in  October,  1888.^  I 
have  adopted  the  term  which  he  made  use  of  in  his  case, 
which  he  declared  to  be  unique.  These  concretions  are 
certainly  rare,  I  have  never  detected  any  amongst  the  large 
number  of  ovaries  removed  in  the  Samaritan  Hospital  since 
1877,  so  I  think  that  they  are  worth  exhibiting  before  the 
Society. 

As  in  my  own  case.  Dr.  Mackenzie  reports  that  his 
specimen  was  from  a  case  of  uterine  fibroid.  The  Society 
will  note  with  interest  that  Dr.  Mackenzie's  patient  died  in 
Dr.  Gervis's  wards  from  cardiac  failure  clearly  due  to  uterine 
haemorrhage,  which  had  lasted  for  two  years.  A  broad- 
based  submucous  myoma  filled  the  uterus,  and  on  its  sur- 
face was  a  vascular  patch,  apparently  the  source  of  haemor- 
rhage.  In  my  own  case,  however,  there  was  practically 
no  haemorrhage,  and  only  occasional  menorrhagia.  The 
myoma  was  certainly  interstitial. 

As  it  happens,  I  have  been  particularly  careful  to 
examine  all  ovaries  which  I  have  removed  either  with  or 
from  myomatous  uteri  for  several  years,  and  have  never 
found  these  concretions  in  any  other  case.  I  also  have 
failed  to  find  any  report  of  a  third  instance  of  these  blood 
concretions  in  an  ovary  under  any  circumstance.      A  care- 

*  "Blood  Concretions  in  the  Ovaries,"  *  Path.  Soc.  Trans./  vol.  xl,  1889,. 
p.  198.  They  are  figured  in  Mr.  Bland  Sutton's  *  Surgical  Diseases  of  the 
Ovaries  and  Fallopian  Tubes/  2nd  edit.,  189G,  fig.  14,  p.  24. 


216  BLOOD    CONCRETIONS    IN    THE    OVARY. 

ful  histological  examination  of  ovaries  associated  with 
fibroids  has  been  reported  by  Papow  and  also  by  Bulius, 
and  Labaudie-Lagrave  agrees  with  them."^ 

Great  proliferation  of  the  parenchyma  and  cystic  dila- 
tation of  the  Graafian  follicles  takes  place,  so  that  the  bulk 
of  the  ovary  increases.  Ultimately,  these  authorities 
declare,  the  follicles  atrophy  and  disappear,  sclerosis 
setting  in  around  them.  From  my  own  experience  I  am 
not  certain  that  these  changes  always  go  on  in  the  same 
order. 

The  increase  in  bulk,  in  some  of  my  own  cases,  appeared 
due  to  oedema,  not  proliferation,  and  I  fancy  that  the  fol- 
licles may  atrophy  from  the  first,  never  undergoing  dilata- 
tion. Again,  inflammatory  changes  are  frequent  in  the 
ovaries  when  myoma  of  the  uterus  exists,  and  not  rarely 
the  tube  contains  septic  mucus,  so  that  when  performing 
hysterectomy  I  avoid  dividing  the  tube  whenever  possible. 
Only  yesterday.  May  31st,  I  succeeded  in  removing  an 
obstructed  and  dilated  right  tube,  with  the  ovary,  without 
separating  them  from  the  fibroid  uterus.  But  these  in- 
flammatory changes  in  the  tube  and  ovary  in  cases  of  uterine 
myoma  are  certainly  accidental. 

So  different  is  the  relation  of  the  uterine  tumour  to  the 
appendages,  so  varying  is  the  degree  of  obstruction  to  the 
vessels  supplying  the  ovary  in  individual  cases,  that  it  is 
almost  impossible  to  determine  the  true  significance  of 
these  changes  in  the  ovary  or  to  feel  sure  how  far  they 
are  a  result  of  the  development  of  the  uterine  growth, 
and  how  far  they  may,  on  the  other  hand,  be  an  influence 
in  its  development.  Hence  in  this  matter  pathology  can- 
not as  jei  aid  us  in  therapeutic  treatment,  nor  guide  us  in 
the  choice  of  an  operation  for  the  relief  of  uterine  fibroid ; 
but  as  this  pathological  question  remains  so  obscure, 
all  things  associated  with  it,  such  as  these  remarkable 
concretions,  deserve  attention,  as  their  study  may  end  some 
day  in  lightening  our  darkness. 

*  Labaudie-Lagrave  et  F.  Legueu,  '  Traite  Medico-Chirurgical  de  Gyne- 
cologie/  1898,  p.  846. 


INCAECERATED    OVARIAN    (dERMOID)    CYST.  217 

Mr.  Bland  Sutton  said  these  blood  concretions  are  rare ;  in 
June,  1898,  he  removed  an  ovarian  cyst  as  big  as  a  football  from 
a  woman  thirtj-five  years  of  age.  It  was  full  of  blood,  due  to 
twisting  of  tlie  pedicle,  whicb  had  happened  probably  four  or 
five  months  before  the  operation.  A  large  number  of  solid 
particles  escaped  with  the  blood,  and  the  recesses  of  the  cyst 
contained  many  of  these  concretions.  In  separating  the  cyst 
from  the  rectum  it  was  necessary  to  leave  a  piece  of  the  cyst 
wall ;  as  the  cyst  was  cut  some  blood,  with  many  more  concre- 
tions, escaped  into  the  pelvis  and  were  subsequently  picked  out 
one  by  one.  The  concretions,  which  numbered  more  than  one 
hundred,  varied  in  size  from  a  split  pea  to  a  bean  ;  some  were 
flattened  and  smooth,  others  were  irregular  in  shape  but  with 
smooth  contours,  whilst  a  few  were  irregular  and  rough.  It 
was  difficult  to  account  for  the  formation  of  these  concretions, 
or  to  offer  any  suggestion  in  regard  to  the  chemical  or  physical 
conditions  which  would  favour  their  formation. 

Mr.  Alb  AN  Dor  an  replied  that  Mr.  Sutton's  case  showed 
that  blood  concretions  in  the  ovary  were  not  necessarily  asso- 
ciated with  uterine  myoma.  They  were  probably,  like  the  pill- 
like pellets  of  fat  in  an  ovarian  dermoid,  due  to  some  purely 
mechanical  aofencv. 


DEFORMED   FOETUS. 

Show^n  by  Dr.  Burton  (introduced  by  Dr.  Boxall). 

A  COMMITTEE  Consisting  of  Drs.  Dakin,  Giles_,  and  Eden 
was  appointed  to  report  on  this  specimen. 


INCARCERATED  OVARIAN  (DERMOID)  CYST.lRE- 
MOYED  DURING  PREGNANCY  FER  V AGIN  AM. 

Shown  by  Amand  Rooth,  M.D. 

Patient  was  a  primipara  of  23,  four  months  pregnant, 
who  had  attended  Mr.  Targett's  Out-patient  Clinique  at 


218  INCARCERATED    OVARIAN     (dERMOID)     CYST. 

tlie  Samaritan  Free  Hospital.  When  first  seen  by  liim 
the  cyst  could  be  pushed  out  of  the  pelvis,  but  now  was 
impacted,  and  it  was  evident  that  labour  was  impossible 
without  its  removal.  Mr.  Targett  had  diagnosed  the 
probable  nature  of  the  cyst,  and  had  very  kindly  sent  the 
patient  to  me  with  a  view  to  vaginal  ovariotomy.  I  did 
not  at  once  coincide  with  this  method  of  treatment,  think- 
ing that  the  inevitable  drawing  down  of  the  cervix  might 
detach  some  of  the  foetal  membranes,  and  lead  to  "abortion 
before  the  vaginal  wound  was  healed.  However,  on  May 
9th  the  operation  was  done.  The  posterior  vaginal  cul- 
de-sac  was  opened  by  a  crucial  incision,  and  the  connec- 
tive tissue  was  seized  by  long  Spencer  Wells  forceps,  and 
separated  by  the  fingers  till  the  peritoneum  could  be  felt. 
The  forceps  were  then  transferred  to  the  peritoneum, 
which  was  loosened  a  bit  from  its  connections  and  drawn 
to  the  vulva  and  opened.  This  gave  one  a  tube  of  peri- 
toneum to  work  through  instead  of  one  of  mucous  mem- 
brane. The  cyst  was  seized,  a  few  flaky  adhesions  being- 
separated,  and  it  was  then  punctured,  liquid  fat  coming 
away.  It  was  then  drawn  down,  and  found  to  have  a 
short  pedicle,  which  could  hardly  be  reached  owing  to  the 
height  of  the  uterine  cornu.  The  uterus  was  depressed 
as  far  as  possible,  and  a  ligature  applied  by  transfixion  to 
the  ovarian  pedicle. 

It  will  be  seen  that  some  of  the  cyst  wall  has  been 
left,  and  that  the  inner  wall  has  been  slightly  button- 
holed. This  was  snipped  off  after  the  cyst  was  cut 
away,  and  will  not  influence  the  permanent  recovery  of 
the  patient. 

Her  recovery  was  satisfactory,  her  temperature  rising 
next  day,  and  again  on  the  twelfth  day,  to  100°  F., 
omng  to  bowel  disturbance. 

She  was  allowed  to  get  up  on  May  25th,  and  was  to  have 
left  the  hospital  on  the  31st,  when  without  any  known  cause 
she  had  a  rigor,  and  her  temperature  ran  up  to  106°  F. 
This  was  probably  partly  neurotic,  but  whether  as  cause 
or  effect  the  foetus  perished   and  abortion  followed,  the 


INCARCERATED    OVARIAN     (dERMOID)     CYST.  219 

temperature  then  beino-  104*6°  F.  Six  hours  after  the 
temperature  was  normal.  There  was  nothing  visibly 
septic  in  the  foetus  or  its  membranes. 

Dr.  Herbert  Spencer  said  that  in  tbese  cases  the  question 
arose  as  to  whether  the  tumour  should  be  removed  during 
pregnancy  or  after  labour.  In  Dr.  Routh's  case  it  would 
probably  have  been  easy  to  push  up  tlie  small  tumour  under 
anaesthesia.  Still  he  had  hitherto  practised  the  immediate 
removal  of  these  tumours  by  the  abdominal  route  when  they 
were  found  in  the  first  half  of  pregnancy,  owing  to  the  well- 
known  non-tendency  to  abort ;  but  in  the  latter  half  of  preg- 
nancy he  thought  it  better  to  push  the  tumour  up  and  remove 
it  after  delivery ;  this  he  had  done  in  two  cases.  It  was 
probable  that  the  interference  with  the  uteiTis  during  the 
vaginal  operation  would  render  abortion  more  liable  to  occur, 
and  in  fact  it  had  occurred  in  both  Dr.  Routh's  and  Dr. 
Kobinson's  cases,  so  that  on  that  ground  he  would  still  prefer  the 
abdominal  route.  Besides  the  difiiculty  of  dealing  with  the 
pedicle  by  the  vagina  there  was  the  danger  of  the  ligature 
slipping.  It  was  also  in  some  cases  of  somewhat  advanced 
pregnancy  impossible  to  feel  a  small  ovarian  tumour  lying 
behind  the  uterus,  and  thus,  if  the  vaginal  operation  be  per- 
formed, a  tumour  might  easily  be  left  in  the  other  ovary.  He 
should  therefore  continue  to  perform  the  abdominal  operation, 
which  had  given  him  good  results,  all  the  patients  recovering 
Avell,  and  the  only  case  which  aborted  being  a  case  of  bilateral 
dermoid  which  had  had  several  uterine  haemorrhages  before  the 
ovariotomy.  He  would  like  to  hear  how  Dr.  Routh  closed  the 
crucial  incision  in  the  vagina. 

Dr.  Drummond  Robinson  had  recently  had  a  case  under  his 
care  that  was  in  some  respects  similar  to  Dr.  Routh's.  This 
patient  had  a  moveable  tumour  in  Douglas's  pouch.  While 
under  observation  she  missed  two  periods  and  thought  herself 
pregnant.  The  periods,  however,  returned,  and  pregnancy  was 
thought  to  be  out  of  the  question.  Posterior  colpotomy  was 
performed,  and  the  uterus  was  then  retroverted  and  pulled 
through  the  vaginal  wound.  The  tumour,  which  proved  to  be 
a  dermoid  cyst  of  the  right  ovary  as  large  as  a  Tangerine 
orange,  was  easily  removed  intact.  A  few  hours  after  the 
operation  the  patient  experienced  considerable  pain,  and  a  typical 
carneous  mole  was  expelled.     Convalescence  was  uneventful. 

Mr.  Alban  Doran  admitted  that  a  dermoid  ovarian  cyst  in 
a  pregnant  woman  ought  to  be  removed  without  waiting  for 
labour,  which  often  entailed  grave  complications,  especially  as 
regards  the  tumour.  The  great  aim  of  the  operator  in  such  a 
case  was  to  get  the  dermoid  out  of  the  abdomen  entire ;  for 


220  RUPTURED    TUBAL    GESTATION. 

rupture  of  a  dermoid  necessitated  careful  cleansing  of  the  peri- 
toneum by  methods  very  liable  to  cause  abortion.  He  operated 
last  June,  in  the  presence  of  Dr.  Amand  Eouth,  on  a  woman  in 
the  fourth  month  of  pi'egnancy.  As  dermoid  ovarian  tumour 
had  been  diagnosed,  Mr.  Doran  purposely  made  a  four-inch 
incision  so  as  to  get  out  the  tumour  entire.  This  was  easily 
effected,  as  the  tumour  was  small  and  he  took  care  not  to  open 
it  till  after  the  operation.  The  wound  was  speedily  closed, 
and  the  patient  was  delivered  of  a  live  child  at  term,  five  months 
later.  The  cyst  was  full  of  grease,  hair,  and  spikes  of  bone. 
Mr.  Doran  would  have  objected  to  remove  such  a  tumour 
through  the  vagina.  Abdominal  section  seemed  clearly  the 
right  operation  under  the  circumstances. 

In  reply.  Dr.  Amand  Eotjth  said  that  he  had  chosen  the 
vaginal  method  of  operating  knowing  there  were  no  strong 
adhesions,  as  the  cyst  had  been  able  to  be  pushed  up  till  quite 
recently.  If  he  had  pushed  the  cyst  up,  it  could  not  have  been 
reached  per  vaginam,  and  twisting  of  the  pedicle  might  have 
resulted.  The  vaginal  wound  was  sutured  with  catgut,  and 
healed  by  first  intention. 


RUPTURED  TU:BAL  GESTATION  (AT  FOURTH  OR 
FIFTH  WEEK) ;  OPERATION ;  RECOVERY. 

Shown  by  Amand  Routh,  M.D. 

On  May  9th,  I  was  asked  to  see  a  patient  of  Dr.  Howard 
Clarke^Sj  with  a  presumed  diagnosis  of  ruptured  tubal  ges- 
tation or  ruptured  ovarian  cyst.  On  arrival  at  the  house 
I  was  told  the  following  history. 

Mrs.  L— ^  a  tailoress,  aged  29,  married  four  years. 
Has  had  two  children,  the  first  child  born  eleven  months 
after  marriage,  the  second  on  May  27th,  1897.  Parturi- 
tion was  always  normal.  Her  catamenia  began  at  sixteen, 
and  were  always  regular. 

A  few  days  after  the  birth  of  the  second  child  she 
noticed  a  small  lump  at  the  navel,  which  has  increased  in 
size.      She  suckled   her  second   child   till   the   middle   of 


RUPTUEED  TUBAL  GESTATION. 


221 


Marcli^  when  she  weaned  it,  and  states  that  during  lacta- 
tion she  menstruated  three  times  at  irregular  intervals. 

On  March  25th  she  seems  to  have  had  a  regular  though 
scanty  period,  lasting  four  days.  She  then  went  thirty- 
four  days  without  seeing  anything,  and  thought  she  might 
be  pregnant,  but  as  she  began  to  lose  blood  on  May  2nd, 
she  had  given  up  the  idea  of  pregnancy.  She  continued 
to  lose  slightly  till  May  7th,  when  it  became  profuse,  but 
no  clots  passed.  On  that  day  she  felt  severe  pain  in  the 
lower  abdomen.  On  May  8th,  although  in  some  pain, 
she  w^ent  for  a  walk,  but  finding  movement  hurt  her  she 
returned  and  went  to  bed.  Dr.  Howard  Clarke  saw  her 
next  day.  May  9th,  and  believing  she  was  suffering  from 
internal  haemorrhage  asked  me  to  see  her. 

She  had  been  told  she  had  an  ovarian  cyst,  so  that  in 
addition  to  tubal  rupture  the  possibility  of  a  ruptured 
cyst  had  to  be  entertained. 

The  patient  was  quite  conscious,  in  great  abdominal 
pain,  and  her  pulse  was  a  very  rapid-running  and  almost 
imperceptible  one,  and  she  was  evidently  dying  of  internal 
haemorrhage.  The  abdomen  was  distended  greatly,  and 
there  was  a  large  umbilical  hernia  of  bowel  and  omentum. 
No  tumour  could  be  felt.  Per  vaginam  nothing  definite 
could  be  detected.  It  was  probable  that  her  only  chance 
was  abdominal  section,  but  she  was  so  extremely  collapsed 
that  I  am  not  sure  that  I  should  have  advocated  it  if  I 
had  not  been  encouraged  by  the  recital  of  Dr.  Culling- 
worth^s  case  at  this  Society  on  the  previous  Wednesday, 
when  he  described  so  graphically  a  case  where  he  had 
successfully  operated  when  the  patient^s  pulse  was  imper- 
ceptible. 

I  explained  to  the  patient  and  husband  the  position, 
and  Dr.  Clarke  entirely  agreed  with  me.  We  obtained  the 
assistance  of  Mr.  Hilliard  for  the  anaesthetic. 

We  could  get  no  nurse  at  once,  but  an  old  woman,  the 
patient's  mother,  acted  as  such.  Sterilised  water  could 
only  be  got  from  a  small  kettle,  but  immediate  operation 
was  essential,  with  all  these  disadvantages. 


222 


KUl^TUEED    TUBATi    GESTATION. 


When  the  abdomen  was  opened  black  and  bright  red 
blood  welled  out^  and  as  the  woman  was  very  stout  and 
the  uterus  small,  the  tubes  could  not  be  at  first  seen; 
but  on  palpating  them  the  right  was  normal,  and  a 
nodule  the  size  of  a  small  filbert  could  be  felt  on  the  left 
tube,  near  the  left  cornu.  Believing  this  was  the  seat  of 
rupture,  I  clamped  it  on  each  side  by  long  angular 
Spencer- Wells  forceps,  and  then  cleared  out  the  blood- 
clot.  Ligatures  were  then  applied  outside  these  forceps, 
during  which  procedure  the  hgemorrhage  was  clearly  seen 
to  be  coming  from  a  tear  on  the  anterior  surface  of  the 
nodule.  The  patient  was  now  in  an  extremely  bad  state, 
so  I  filled  up  the  abdomen  with  the  water  from  the  kettle, 
cooled  by  tap  water,  and  she  somewhat  revived.  After 
suturing  the  abdominal  wound,  and  I  hope  curing  the 
hernia  at  the  same  time,  the  pulse  w^as  again  very  bad, 
so  two  pints  of  brandy  and  water  were  administered 
per  recturrij  and  were  almost  at  once  absorbed,  with  most 
remarkably  rapid  improvement  of  the  pulse.  This  was 
repeated  in  three  hours  time,  and  since  then,  with  the 
exception  of  an  abscess  along  one  of  the  stitches,  the 
patient  has  done  excellently. 

The  following  is  Mr.  Targett's  report  upon  the  speci- 
men. The  specimen  also  bears  out  what  Mr.  Taylor  of 
Birmingham  has  stated,  that  in  all  cases  where  the  tube 
ruptures  very  early,  the  rest  of  the  tube  is  small  and 
atrophic. 


Report    on    Dr.    RouWs    Specimen    of    Ruptured    Tubal 

Gestation. 

The  specimen  consists  of  the  Fallopian  tube,  ovary,  and 
adjacent  portion  of  the  broad  ligament.  The  ovary 
measures  an  inch  in  its  long  diameter,  and  contains  a 
recent  corpus  luteum.  There  are  a  few  thin  adhesions 
on  the  convexity  of  the  ovary,  and  on  both  aspects  of 
the  mesosalpinx. 


OVARY  CONTAINING  A  CALCAREOUS  BALL.       223 

The  Fallopian  tube  at  a  spot  three  inches  from  its 
abdominal  ostium  is  dilated  with  an  oval  C3^st,  which  now 
measures  |  inch  in  its  chief  diameter.  The  walls  of  this 
cyst  are  very  thin  and  raggedy  in  places  consisting  of 
little  more  than  serous  membrane.  The  abdominal  ostium 
is  patent  and  not  dilated  ;  the  ampulla  and  isthmus  are 
also  normal  in  appearance.  A  bristle  can  be  passed 
along  the  tube  into  the  ruptured  cyst.  The  interior  of 
the  cyst  is  uneven,  and  has  a  little  blood-clot  attached  to 
it.  A  portion  of  its  ragged  wall  was  removed  for  micro- 
scopic examination ;  it  consisted  of  oedematous  muscular 
tissue  and  blood- clot.  The  muscle  fibres  were  enlarged, 
and  unduly  separated  by  oedema  and  small  round  cells. 
By  effusion  of  blood-clot  the  muscle  fibres  were  separated 
into  strands  near  the  cavity  of  the  cyst.  In  this  way  it 
appeared  the  muscular  coat  of  the  tube  had  been  broken 
up  and  largely  destroyed,  thus  explaining  in  |)^i't  the 
thinness  of  the  wall  of  the  cyst.  Yery  little  clot  adhered 
to  the  interior  of  the  cyst,  but  in  this  there  were  a  few 
typical  chorionic  villi  seen  in  longitudinal  and  transverse 
sections.  They  were  surrounded  by  compressed  fibrin, 
and  in  the  vicinity  of  the  larger  villi  many  buds  were 
visible,  consisting  of  nucleated  masses  of  protoplasm. 
The  two  layers  of  epithelium  were  recognisable  on  the 
largest  villi.  The  histological  evidence  of  gestation  is 
thus  assured. 

J.  H.  Targett. 


AN  OVARY  CONTAINING  A  CALCAREOUS  BALL, 
PROBABLY  A  LARGE  CALCIFIED  CORPUS 
FIBROSUM. 

By  J.  Bland  Sutton. 

The  specimen  is  a  left  ovary  and  adjacent  part  of  the 
mesosalpinx  with  the   outer  half  of  the   Fallopian  tube. 


224 


OVARY    CONTAINING    A    CALCAREOUS    BALL. 


The  ovary,  shown  in  section,  is  converted  into  a  cyst  (see 
figure)  containing  clear  fluid.  A  hard  spherical  mass 
projects  from  the  wall  of  the  cyst,  and  contains  an  encap- 
suled,  lobulated  piece  of  hard,  bone-like  tissue.     Fragments 


An  ovary  in  section  displaying  a  rounded  calcific  mass  projecting 
from  the  wall  of  a  cyst.  The  lower  figure  represents  a  portion  of 
the  circumference  of  the  calcific  mass  which  has  been  macerated 
to  show  its  gross  structure. 


of  this  tissue  were  calcified,  and  on  microscopic  examination 
exhibited  a  laminar  arrangement  resembling  the  whorls 
found   on   the    cut   surface    of   a  calcified   uterine   fibro- 


PRIMARY   SARCOMA  OF  THE   BODY   OF  THE   UTERUS.  225 

myoma ;  here  and  there  the  earthy  matter  is  grouped  in 
spherules.  A  portion  of  the  circumference  of  the  hard 
nucleus^  which  has  been  macerated,  presents  the  coral-like 
character  of  the  calcific  masses  found  in  old  uterine  fibro- 
myomata. 

This  ovary  was  removed  by  c celiotomy  from  a  single 
(sterile)  woman  58  years  of  age.  The  hard  tumour  could 
easily  be  felt  on  vaginal  examination,  and  was  considered 
to  be  either  a  calcified  fibro-myoma  with  a  long  stalk  or 
an  ovarian  dermoid  with  calcified  walls.  Recovery  was 
uneventful. 

Mr.  Alban  Doean  suggested  that  the  calcified  mass  was 
originally  a  myoma.  lu  Mr.  Sutton's  specimen  there  was  a 
small  ovarian  cyst  with  the  calcified  structure  immediately  be- 
low it.  Precisely  the  same  relations  were  seen  in  Mr.  Doran's 
case  of  cyst  of  the  ovary  with  a  true  myoma  attached  to  it, 
figured  in  the  '  Edinburgh  Medical  Journal '  for  May,  1898. 
Myoma  of  the  uterus  was  apt  to  calcify  if  its  vascular  suj^ply 
were  for  long  obstructed.  In  myoma  of  the  ovary  attached  by 
a  narrow  base  to  a  small  ovarian  cyst  such  obstruction  was 
highly  probable. 


PRIMARY    SARCOMA    OF     THE    BODY    OF    THE 
UTERUS    (DECIDUOMA    MALIGNUM). 

Shown  by  A.  H.  N.  Lewers,  M.D. 

Dr.  Lewers  showed  the  uterus  removed  by  vaginal 
hysterectomy  in  his  case  of  primary  sarcoma  of  the  body 
of  the  uterus  (deciduoma  malignum)  which  formed  the 
subject  of  his  paper  read  before  the  Society  in  July,  1897, 
for  the  purpose  of  reporting  the  subsequent  progress  of 
the  patient.  The  operation  was  performed  on  February 
11th,  1897.  The  patient  was  kept  under  observation  till 
June,  1897,  but  was  then  lost  sight  of  for  some  time,  and 
Dr.  Lewers  feared  that  as  she  did  not  come  up  to  show 


226  COMPLETE    INCONTINENCE     OF    URINE     CURED. 

herself  the  disease  had  perhaps  recurred.  He  was  glad 
to  say^  however^  that  in  answer  to  a  letter  she  came  up 
to  the  London  Hospital  on  May  19th^  1898,  and  he  exa- 
mined her.  She  was  in  perfect  health,  and  there  was  no 
sign  of  any  recurrence  ;  the  scar  at  the  top  of  the  vagina 
was  quite  sound. 

In  Dr.  Spencer^s  paper  that  appeared  in  the  '  Quarterly 
Medical  Journal  ^  for  July,  1896,  forty  cases  of  deciduoma 
malignum  were  tabulated.  Of  these  only  seventeen  were 
treated  by  hysterectomy,  and  two  of  these  cases  died  of 
the  operation,  three  others  died  about  six  months  after 
the  operation,  and  ''  twelve  remained  well  at  various 
intervals  up  to  eighteen  months  after  the  operation. ^^  In 
Dr.  Lowers'  case  the  interval  since  the  operation  was  now 
sixteen  months,  and  the  patient  had  remained  quite 
well.  So  far  as  he  was  aware,  the  only  other  case  of  this 
disease  treated  by  vaginal  hysterectomy  in  this  country 
was  the  one  reported  by  Dr.  J.  Rutherford  Morison  in 
vol.  xxxviii  of  the  Society's  '  Transactions/  and  in  that 
case  the  patient  had  died  exactly  seven  months  after  the 
operation  with  clinical  evidence  of  secondary  mischief  in 
the  lungs. 


COMPLETE    INCONTINENCE    OF    URINE    CURED 
BY    YENTRO-FIXATION    OF    THE    UTERUS. 

By  H.  Macnaughton- Jones,  M.D. 

The  brief  note  I  present  to  the  Society  of  this  case  is 
furnished  to  show  the  clinical  value  of  ventro-fixation  of 
the  uterus  for  the  cure  of  incontinence  of  urine  when  this 
symptom  is  due  to  pressure  from  an  enlarged  and  ante- 
verted  uterus.  Hysteropexy  and  various  fixation  opera- 
tions as  a  cure  for  backward  displacements  are  matters  of 
constant  practice^   but   the   operation   for   the   purpose   I 


LARGE    FIBROID    TUMOUR    OF    THE    UTERUS.  227 

have  specified  is  not  commonly  performed  nor  referred  to 
in  gyngecological  works.      Briefly,  my  case  was  as  follows  : 

A  lady  aged  48  consulted  me  in  February  of  this 
year  for  incontinence  of  urine,  she  having  been  for  some 
time  obliged  to  wear  a  urinal.  The  trouble  had  begun 
over  a  year  previously  with  frequent,  and  had  gradually 
passed  on  to  constant  micturition,  finally  ending  in 
incontinence.  During  my  examination  the  urine  was 
flowing  from  the  bladder.  I  found  a  uterus  enlarged, 
anteflexed,  with  a  cavity  3^  inches  in  length,  the  fundus 
lying  directly  forward  on  the  neck  of  the  bladder.  There 
was  slight  anterior  vaginal  prolapse.  I  tried  a  well- 
fitting  Galabin^s  bar  pessary,  but  it  gave  only  slight  relief, 
so  I  recommended  operation.  I  thought  to  perform  a 
posterior  and  lateral  colporrhaphy,  but  was  doubtful  of 
the  degree  of  benefit  that  would  follow.  On  talking  the 
case  over  with  Mr.  Bland  Sutton,  he  suggested  trying 
ventro- fixation. 

I  operated  on  March  the  3rd.  On  March  the  6th  she 
passed  her  urine  naturally,  and  there  was  five  hours' 
interval  in  the  emptying  of  the  bladder.  From  that  time 
to  the  present  she  has  passed  water  naturally  and  with 
comfort,  retaining  it  for  seven  hours  without  distress. 


LAEGE     FIBROID     TUMOUR     OF     THE     UTERUS 
UNDERGOING   CYSTIC   DEGENERATION. 

Shown  by  Peter  Horrocks,  M.D. 


228 


TWO  CASES  OF  FIBEO-MYOMA  OF  THE  UTERUS 
REMOVED  BY  OPERATION  FROM  WOMEN 
UNDER    TWENTY-FIYE    YEARS    OF   AGE. 

By  Heebert  R.  Spencer^  M.D._,  B.S.(Lond.)^ 

PEOFESSOR   OP    OBSTETEIC    MEDICINE    IN   UNIVERSITY    COLLEGE,   LONDON  ; 
OBSTETRIC   PHYSICIAN   TO    FNIVEESITY    COLLEGE    HOSPITAL. 

(Received  November  13th,  1897.) 
{Abstract.) 

The  author  records  two  cases  of  fibre -myoma  of  the  uterus 
removed  by  operation  from  women  aged  24  and  23.  The 
diagnosis  of  the  nature  of  the  tumour  was  verified  by  exami- 
nation with  the  microscope,  and  the  age  of  the  patients  by 
obtaining  their  certificates  of  birth.  In  the  first  case  the 
tumour  weighed  4  lbs.  9f  oz.,  and  was  removed  by  amputation 
after  laparotomy,  the  pedicle  being  treated  extra-peritoneally. 
In  the  second  case  the  tumour  with  the  uterus  weighed  16^  oz., 
and  was  removed  by  vaginal  hysterectomy  after  the  peritoneum 
had  been  opened  in  an  attempt  to  enucleate  the  tumour.  The 
patients  were  in  good  health  two  ye^rs  and  one  year  after  opera- 
tion. A  brief  abstract  is  given  of  forty  recorded  cases  of  fibroid 
tumours  occurring  in  women  under  twenty-five  years  of  age.  In 
at  least  eleven  of  the  cases  the  diagnosis  was  clinical,  and  in  only 
four  cases  was  the  diagnosis  verified  by  examination  with  the 
microscope.  The  author  concludes  that  uterine  fibro-myoma  is 
rare  before  the  age  of  twenty-five  and  very  rare  before  the  age  of 
twenty,  and  that  there  is  no  satisfactory  record  of  its  occurrence 
before  the  age  of  puberty. 


FIBRO-MYOMA    OF    THE    UTEEUS.  229 

I  HAVE  been  taught  by  Sir  John  Williams  (to  whom  I 
am  indebted  for  the  two  cases  about  to  be  described)  that 
the  occurrence  of  fibroids  in  the  uterus  before  the  age  of 
twenty-five  is  very  rare.  As  the  subject  is  one  of  some 
scientific  and  practical  importance  I  have  endeavoured  to 
gain  an  approximate  idea  of  the  degree  of  its  rarity  by  a 
search  through  the  chief  depositories  of  gyngecological  lore, 
and  I  append  a  list  of  the  cases  I  have  been  able  to  find 
recorded  of  fibroids  occurring  in  women  under  twenty-five 
years  of  age.  The  list  does  not  pretend  to  be  an  exhaustive 
one^  but  I  believe  it  contains  all  the  cases  recorded  in  the 
works  alluded  to.  If  any  have  escaped  my  notice  I  need 
only  ask  pardon  from  those  who  have  not  conducted  such 
a  tedious  and  uncongenial  research. 

I  have  been  unable  to  find  any  case  of  fibroid  of  the 
uterus  occurring  in  a  woman  before  the  age  of  twenty-five 
in  the  ^  Index  Medicus^  under  the  heading  ^^  Tumours  of 
the  Uterus.'' 

The  ^  Catalogue  of  the  Library  of  the  Surgeon  General's 
Ofiice,  U.S.  Army/  contains  under  the  same  heading  a 
reference  to  one  case,  viz. — 

BedfoTiVs  case. — '^  Submucous  fibrous  tumours  of  the 
uterus  in  a  married  woman  twenty-three  years  of  age." 

Nelson's  '  Northern  Lancet,'  Plattsburg,  New  York,. 
1852— 3,  vi,  67 — 74.  I  have  been  unable  to  see  the  original 
paper,  and  cannot  therefore  say  anything  as  to  the  cir- 
cumstances under  which  it  was  observed. 

The  ^  Archiv  fiir  Gynakologie  '  contains  the  following 
cases  : 

Leopold's  case  (vol.  xiii,  p.  190). — The  patient  was  aged 
24.  There  was  a  painful  uterine  myoma  completely  filling^ 
the  pelvis  and  reaching  to  the  navel.  Two  years  later, 
after  the  administration  of  ergotin,  it  was  of  the  size  of  a 
small  orange.      No  operation  was  performed. 

Leo}iold's  case  (vol.  xiii,  p.  192). — The  patient  was  aged 
22.  An  interstitial  fibroid  about  the  size  of  a  walnut  was 
situated  in  the  anterior  upper  wall  of  the  cervix.  No 
operation  was  performed. 

VOL.  XL.  16 


230  FIBRO-MYOMA    OF    THE    UTERUS. 

Leopold's  case  (vol.  xxxviii,  p.  54). — The  patient  was 
aged  21.  A  submucous  myoma  reached  to  the  navel. 
The  operation  of  oophorectomy  proved  fatal^  and  the 
tumour  was  found  to  be  in  part  born  into  the  vagina.  No 
microscopic  examination  is  given. 

Fefiling's  case  (vol.  xlviii,  p.  109). — The  patient  was 
aged  21.  There  was  an  interstitial  myoma  reaching 
within  two  fingers'  breadth  of  the  navel.  Oophorectomy 
was  performed,  and  eight  months  later  the  tumour  was 
smaller. 

The  '  Centralblatt  f iir  G-ynakologie  '  contains  the  follow- 
ing cases  : 

N.  EcWs  case  (vol.  1878,  p.  287). — The  patient  was  aged 
19.  The  uterus  reached  up  to  the  navel,  and  was  20  cm. 
long.  The  tumour  was  enucleated  after  laparotomy.  No 
microscopic  examination  is  given. 

L.  MicheVs  case  (vol.  1881,  p.  368).— The  patient  was 
aged  21,  and  had  been  married  five  years.  T]ie  tumour 
is  said  to  have  been  a  case  of  myoma  telangiectodes.  No 
operation  nor  post-mortem  examination  is  mentioned. 

Eowitz's  case  (vol.  1883,  p.  423). — The  patient  was  aged 
13.  The  case  is  published  under  the  heading  "  Acht 
Laparotomien  wegen  Uterusfibrom  '^  (quoted  from 
'  Gynakolo  og  obstetr.  Meddel,'  Bd.  iv,  Hefte  1,  2).  It 
is  stated  that  before  operation  it  could  not  be  made  out 
whether  the  tumour  was  a  fibro-myoma  or  an  ovarian 
cyst.  It  is  also  stated  that  the  right  ovary  was  left 
behind.  Nothing  is  said  as  to  the  left  ovary.  It  appears 
possible  that  the  tumour  may  have  been  ovarian. 

Wilde s  case  (vol.  1884,  p.  206).— The  patient  was  a 
negress  23  years  of  age,  who  had  aborted  three  years 
before.  The  diagnosis  was  "  interstitial  fibroma  uteri.'' 
Laparo-hysterectomy  was  performed,  and  the  patient 
recovered. 

Wilhelm  Hager's  case  (vol.  1886,  p.  650). — The  patient 
was  aged  22.  The  tumour,  of  the  size  of  an  adult  head, 
rose  midway  between  the  ensiform  cartilage  and  the  navel. 
The   sound  passed  19    cm.       The   tumour   weighed    1750 


I 


FIBRO-MYOMA    OF    THE    UTERUS.  231 

grammes^  and  was  examined  by  Dr.  E.  Frankel,  and 
proved  to  be  a  pure  fibro-myoma.  It  was  enucleated  from 
the  posterior  wall  of  the  uterus  after  incision  of  the  anterior 
wall  by  laparotomy. 

Karstroni's  case  (vol.  1887^  p.  648). — The  patient  was 
aged  24  (it  is  not  clear  whether  at  the  time  of  observation 
or  four  years  previously).  The  tumour  weighed  half  a 
kilogramme,  and  was  removed  by  enucleation  after  lapa- 
rotomy.    No  mention  is  made  of  microscopic  examination. 

BandVs  case  (vol.  1889,  p.  80). — The  patient  was  aged 
22.  The  tumour  was  enucleated  from  the  uterus  without 
opening  its  cavity  after  laparotomy.  No  mention  is  made 
of  microscopic  examination. 

R.  BuJcowski^s  case  (vol.  1890,  p.  688). — The  patient 
was  a  virgin  aged  18.  The  tumour  vveighed  1280 
grammes.  It  was  a  fibro-myoma  of  the  posterior  wall, 
and  was  enucleated  after  laparotomy.  No  mention  is 
made  of  microscopic  examination. 

SclimaVs  case  (vol.  1891,  p.  749). — The  patient  was  aged 
21  j  but  though  the  paper  is  headed  ^'  Ein  seltener  Fall 
von  Fibro-myoma  uteri,"  the  author  concludes  that  it  was 
a  sarcoma. 

Miinde's  case  (vol.  1892,  p.  484). — The  patient  was  a 
nullipara,  aged  23.  Thirty-four  fibroids  were  enucleated. 
No  mention  is  made  of  microscopic  examination. 

R.  Chrohah's  case  (vol.  1893,  p.  470). — The  patient  was 
aged  23.  Three  subserous  and  many  interstitial  tumours 
(weighing  800  grammes)  were  removed.  No  mention  of 
microscopic  examination. 

BrohVs  case  (vol.  1895,  p.  1115). — The  patient  was  a 
virgin  aged  18.  Multiple  myomata  of  the  body  and 
cervix  of  the  uterus  were  removed  by  laparotomy.  No 
microscopic  examination  mentioned. 

The  ^  Zeitschrift  fiir  Geburtshiilfe  und  Frauenkrank- 
heiten  ^  contains — 

Jordan's  case  (p.  163). — The  patient  was  24  years  of 
age.  The  tumour  was  of  the  size  of  the  fist,  and  was 
enucleated  after  dilatation  of  the  cervix. 


232  FIBKO-MYOMA    OF    THE    UTEKUS. 

The  '  Zeitsclirift  fiir  Greburtshiilfe  unci  Gynakologie ' 
contains  tlie  follomng  cases  : 

Engelmann's  case  (vol.  i,  p.  138). — The  patient  was 
ao-ed  22.  The  tumour  was  of  the  size  of  a  wahiut,  and 
situated  in  the  anterior  wall.  Neither  operation  nor 
microscopic  examination  was  made. 

Engelmann's  case  (vol.  i,  p.  140). — The  patient  was 
aged  23-^.  The  tumour  was  a  subserous  fibroid  of  the 
size  of  an  orange  growing  from  the  fundus.      No  operation. 

Engehnann's  case  (vol.i,  p.  140). — The  patient  was  aged 
19.      The  tumour  rose  above  the  symphysis.      No  operation. 

Engelmann's  case  (vol.  i,  p.  140). — The  patient  was 
aged  21.  There  was  a  submucous  fibroid  of  the  size  of 
the  fist  in  the  posterior  wall  of  the  retroverted  uterus. 
No  operation. 

F.  Benicke's  case  (vol.  iv,  p.  283). — The  patient  was 
20  years  of  age.  The  tumour  was  an  interstitial  fibro- 
myoma  of  the  cervix ;  it  was  enucleated  and  examined 
with  the  microscope. 

Lamer' s  case  (vol.  ix,  p.  288). — The  patient  was  aged  21. 
A  tumour  of  the  size  of  a  child^s  head  and  three  submucous 
tumours  were  enucleated  by  laparotomy.  There  is  no 
mention  of  microscopic  examination. 

Schroeder's  case  (vol.  xi^  p.  150). — The  patient  was 
aged  22.  A  myoma  rose  up  to  the  navel.  The  patient 
had  a  child,  and  when  she  was  23|  years  old  the  tumour 
was  as  big  as  the  uterus  at  term.  Neither  operation  nor 
microscopic  examination  is  mentioned. 

Paul  Wehmer's  case  (vol.  xiv,  p.  122). — The  patient 
was  aged  24.  The  uterus,  of  the  size  of  a  man^s  head^ 
contained  numerous  subserous,  interstitial,  and  submucous 
fibromata.  It  was  removed  by  supra-vaginal  amputation. 
There  is  no  mention  of  microscopic  examination. 

S.  Archer's  case  (vol.  xx,  p.  312). — The  patient  was 
aged  22.  A  subserous  myoma  of  the  size  of  an  apple  was 
removed  by  operation.  Microscopic  examination  not 
mentioned. 

S.  Archer's  case   (vol.   xx,  p.    322). — The   patient   was 


FIERO-MYOxMA    OF    THE    UTEHUS.  233 

aged  24.  An  enormous  tumour  removed  by  abdominal 
hysterectomy.  There  is  no  mention  of  microscopic  exami- 
nation. 

Ludwig  Kleinicdchter's  case  (vol.  xxv_,  p.  171). — The 
patient,  aged  24,  had  a  growth  in  the  cervix  of  the  size 
of  a  cherry.  This  case  should  not  be  counted,  as  neither 
operation  nor  microscopic  examination  was  performed. 

Luchviy  Kleinwdchter's  case  (vol.  xxv,  p.  174). — The 
patient  was  23  years  of  age,  is  said  to  have  been  married 
12  years  (!),  and  had  four  children.  The  uterus  was 
enlarged  in  toto  and  was  harder  than  normal ;  in  the 
anterior  wall  of  the  corpus  was  a  tumour  of  the  size  of  a 
hen's  egg.  No  operation  was  performed,  and  there  was 
no  microscopic  examination. 

Von  Meyer^s  case  (vol.  xxvii,  p.  542). — The  patient  was 
aged  23.  The  tumour  was  a  fibro-myomatous  polypus 
with  lymphangiectasis,  cavernous  vessels,  and  haemorrhages. 
It  measured  10  cm.  x  7  cm.  x  3  cm.  No  definite 
statement  is  given  that  the  tumour  was  examined  micro- 
scopically. 

Hofmeier^s  case  (vol.  xxx,  p.  240.) — The  patient  was 
aged  23.  In  the  narrow  external  os  was  a  suppurating 
disorganised  tumour  of  the  size  of  the  fist.  Microscopic 
examination  not  mentioned. 

A.  Martinis  case  (vol.  xxxv,  p.  139). — The  patient  was 
19  years  old.  The  uterus,  of  the  size  of  the  organ  at  the 
third  month  of  pregnancy,  and  filled  with  polypoid  fibrous 
growths,  was  removed  by  vaginal  hysterectomy.  The 
growths  were  examined  by  the  microscope,  and  were  of  a 
hard  fibrous  structure. 

The  ^  Obstetrical  Transactions '  contains  records  of  two 
cases  : 

Playfair's  case  (vol.  x,  p.  105). — The  patient  was  22 
years  of  age.  On  vaginal  examination  a  firm  globular 
tumour,  the  size  of  a  large  orange,  could  be  very  distinctly 
made  out,  attached  behind  and  to  the  right  side  of  the 
uterus.  Eight  months  later  the  most  careful  examination 
failed    to   enable   the  author  to  detect  any  trace    of    the 


234  FIBEO-MYOMA    OF    TBE    UTERUS. 

tumour.  This  case  is  given  as  an  instance  of  the  absorp- 
tion of  fibroid  tumours  of  the  uterus. 

BoxalVs  case  (vol.  xxxv,  p.  410). — The  patient  was  23 
years  of  age.  Part  of  the  uterus  and  the  appendages 
were  removed  by  abdominal  section  on  account  of  a  soft 
rapidly  growing  fibro-myoma  in  the  left  broad  ligament. 
The  author  informs  me  that  the  tumour  arose  in  the 
uterus,  and  grew  into  the  broad  ligament. 

In  the  ^  West  London  Medical  Journal/  October,  1897, 
Mansell  Moullin  records  a  case  in  which  a  pedunculated 
fibroid  was  removed  by  laparotomy  from  a  patient  aged 
24.      There  is  no  mention  of  microscopic  examination. 

In  the  ^  Annales  de  Gynecologic/  vol.  xxvi,  p.  241, 
Tillaux  records  a  case  of  a  fibroid  tumour  of  the  cervix  of 
the  size  of  a  nut,  which  was  removed  by  amputation  of 
the  affected  lip  from  a  girl  of  19.  The  tumour  is  said  to 
have  caused  symptoms  for  six  years.  There  is  no  note 
as  to  microscopic  examination. 

West  {'  Diseases  of  Women,'  1858,  p.  275)  states  that 
he  found,  post  mortem,  a  fibroid  tumour  in  a  woman  aged 
24,  who  died  of  puerperal  peritonitis. 

Winchel  (^  Diseases  of  Women,'  English  translation, 
p.  409)  says  that  of  forty-four  autopsies  on  persons  the 
subjects  of  myoma,  two  occurred  in  young  women  21 
years  of  age. 

The  above  cases,  forty  in  number,  are  the  only  ones  I 
have  been  able  to  find  recorded  in  which  fibroid  tumour 
of  the  uterus  affected  women  under  twenty-five  years  of 
age.  Yet  Gusserow  {^  Die  Neubildungen  des  Uterus,'  1886, 
p.  39)  says  that  amongst  953  collected  cases  of  uterine 
fibroid,  in  no  less  than  15  the  patient  was  under  twenty 
years  of  age.  Winchel  found  9  patients  and  Schroeder  2 
patients  under  twenty  years  of  age. 

Graily  Hewitt  {'  Diseases  of  Women,'  fourth  edition, 
p.  622)  gives  a  table  which  includes  six  cases  occurring 
in  women  under  twenty-five  j^ears  of  age. 

A.  Roehrig  (^Berliner  klin.  Wochenschrift,'  1877,  p.  433) 


FIBRO-MYOMA    OF    THE    UTERUS.  235 

says  that  one  of  his  patients  with  fibroid  tumour  was 
between  fifteen  and  twenty,  and  six  were  between  twenty 
and  twentj'-five  years  of  age. 

And  Beigel  ('  Die  Krankheiten  des  weiblichen  Ge- 
schlechts/  p.  40)  says  that  amongst  146  patients  with 
fibroids  and  polypus  he  found  no  less  than  20  under  twenty- 
five  years  of  age,  the  youngest  being  ten  (!). 

None  of  these  last-named  authors,  however,  give  any 
details  of  their  cases,  nor  do  they  state  whether  the 
diagnosis  was  made  clinically,  or  after  an  operation  or 
autopsy.  Their  statements,  therefore,  cannot  be  submitted 
to  criticism,  and  are  not  available  for  a  scientific  inquiry. 

The  same  remark  applies  to  many  of  the  40  cases  of 
which  I  have  given  abstracts.  In  at  least  11  of  the 
cases  the  diagnosis  was  not  made  after  operation  or 
autopsy,  and  in  only  four  of  the  series  (Hager's,  SchmaFs, 
Benicke^s,  Martin's)  is  it  stated  that  the  nature  of  the 
tumour  has  been  decided  by  microscopic  examination. 
Nor  does  it  appear  that  any  attempt  was  made  to  verify 
the  ages  of  the  patients,  which  I  have  done  in  my  own 
cases  by  obtaining  the  certificates  of  birth. 

In  my  opinion  the  records,  to  be  of  value,  should  state 
the  exact  age  of  the  patient  at  the  time  the  observation 
is  made ;  the  observation  should  be  made  by  a  medical 
man  at  an  operation  for  the  removal  of  the  tumour,  or  at 
an  autopsy  ;  the  tumour  should  be  submitted  to  examination 
with  the  microscope,  and  the  after-history  should  be  given 
when  possible.  The  following  two  cases  fulfil  these 
conditions,  and  may  therefore  be  worth  recording. 

The  conclusion  to  which  the  study  of  the  subject  of 
early  uterine  fibroids  has  led  me  is  that  uterine  fibro- 
myoma  is  rare  before  the  age  of  twenty-five,  and  very 
rare  before  the  age  of  twenty,  and  that  there  is  no  satis- 
factory record  of  its  occurrence  before  the  age  of  puberty. 

Case  1. — J.  H — ,  24  years  of  age  (born  on  June  8th, 
1870),  was  sent  to  me  for  operation  by  Sir  John  Williams, 
and    was    admitted    to    University   College    Hospital    on 


236  FIBRO-MYOMA    OF    THE    UTERUS. 

January  21st_,  1895,  complaining  of  pain  in  the  left  side 
of  the  abdomen  since  the  spring  of  1894,  and  swelling 
of  the  abdomen  for  two  years. 

The  family  history  and  personal  past  history  were  good, 
there  being  no  tumours  in  the  family  to  the  patient's 
knowledge.  The  patient  herself  had  always  been  very 
healthy. 

Menstruation  began  at  the  age  of  thirteen,  and  had 
always  been  perfectly  regular  up  to  the  time  of  her  ad- 
mission. The  periods  recurred  every  four  weeks,  and 
lasted  a  week,  and  required  fifteen  diapers. 

The  patient  first  noticed  that  the  abdomen  was  enlarged 
four  years  ago,  but  thought  this  was  due  to  her  growing 
stout.  Two  years  ago  she  noticed  that  the  left  side  of  the 
abdomen  was  larger  than  the  right,  but  there  was  no  pain 
nor  inconvenience.  The  enlargement  had  been  increasing 
up  to  the  time  of  admission. 

She  first  suffered  pain  in  connection  with  the  swelling 
in  May,  1894 ;  since  then  it  has  been  constant,  though 
usually  not  severe  except  at  the  periods.  There  was  an 
appreciable  increase  in  size  of  the  tumour  during  the 
periods,  and  diminution  afterwards. 

The  present  state  on  January  22nd  was  as  follows  : — 
The  patient  was  well  developed  and  well  nourished,  and 
not  anaemic.  The  abdomen  was  distended  as  by  the  uterus 
at  the  fifth  month  of  pregnancy.  The  abdominal  girth 
was  34^  inches.  The  distension  was  due  to  a  tumour 
which  rose  to  a  point  9  inches  above  the  pubes,  and  3 
inches  above  the  umbilicus.  There  was  dulness  up  to  the 
umbilicus.  The  flanks  were  resonant.  The  tumour  felt 
firm,  like  a  uterine  fibroid  in  consistence.  A  uterine  soufile 
could  be  heard  2  inches  above  and  a,t  right  angles  to 
Poupart^s  ligament.  The  tumour  was  fairly  regular  on 
the  surface,  and  its  limits  easily  defined.  It  was  not 
moveable  to  any  great  extent  from  side  to  side,  but  felt 
as  if  this  immobility  were  due  to  rigidity  of  the  abdominal 
wall.  The  hymen  was  intact.  The  uterus  felt  as  if  it 
were  anteflexed  and   not  enlarged.      On  the  top  of  it  and 


FIBKO-MYOMA    OF    THE    UTEEUS.  237 

attached  to  it  was  the  growth  felt  by  the  abdomen,  which 
moved  as  one  vdth  the  uterus.  Behind  the  uterus  was  a 
roundish  lump  which  appeared  to  be  the  lower  end  of  the 
tumour  felt  by  the  abdomen.  The  case  appeared  to  be  one 
of  uterine  fibroid. 

Ten  days  later  the  patient  was  examined  under  ether, 
and  the  diagnosis  confirmed.  The  sound  was  then  passed 
with  antiseptic  precautions  for  3^  inches.  It  showed  the 
uterus  to  be  slightly  retroverted,  and  the  tumour  to  be 
growing  from  the  fundus  at  its  anterior  surface. 

On  account  of  the  large  size  of  the  tumour  and  the  pain 
to  which  it  gave  rise  it  was  decided  to  perform  abdominal 
hysterectomy. 

On  February  25th,  1895,  the  patient  was  given  gas  and 
ether,  and  a  median  vertical  incision  about  7  inches  in 
length  was  made  through  the  umbilicus,  about  two  thirds 
of  the  incision  being  below  and  one  third  above  this  point. 
There  was  1^  inch  of  fat  in  the  abdominal  wall.  A  large 
soft  tumour,  evidently  a  fibroid,  was  found  occupying  the 
centre  and  lower  two  thirds  of  the  abdomen  behind  the 
great  omentum.  Over  the  fundus  of  the  tumour  the 
descending  colon  was  adherent  for  a  space  of  about  6  inches 
X  2  inches.  This  bowel  was  so  adherent  that  it  had  to 
be  dissected  off  the  tumour  Avith  the  scalpel,  and  from 
this  raw  surface  on  the  bowel  very  free  oozing  occurred  ; 
it  was  temporarily  checked  by  forceps  and  sponge  pressure, 
but,  as  it  still  continued  after  the  removal  of  the  pressure, 
the  raw  surface  was  lightly  packed  with  three  strips  of 
iodoform  gauze,  Avhich  were  brought  through  the  wound 
near  the  umbilicus.  The  tumour  was  removed  by  passing 
the  wire  of  the  serre-noeud  around  its  pedicle,  which  was 
the  fundus  of  the  uterus  ;  the  pedicle  was  treated  extra- 
peritoneal ly  in  the  ordinary  way.  The  wound  was  closed 
with  silk  except  Avhere  the  gauze  and  the  pedicle  lay,  and 
was  dressed  with  iodoform  gauze  and  wool,  and  a  many- 
tailed  bandage. 

The  operation  lasted  seventy-three  minutes,  and  the 
amount  of  shock  was  very  considerable. 


238  i'JBRO-MYOMA    OF    THE    UTERUS. 

The  tumour  measured  7 1  inches  x  6^  inches_,  and 
weighed  4  lbs.  9 J  ounces. 

Microscopic  examination  showed  it  to  be  a  typical  fibro- 
myoma  (specimen  and  sections  exhibited). 

In  the  first  two  days  after  the  operation  the  patient 
suffered  a  good  deal  of  pain,  for  which  small  doses  of 
morphia  Avere  injected  hypodermically. 

On  February  26th  two  of  the  pieces  of  gauze  which 
plugged  the  bleeding  surface  on  the  colon  were  removed^ 
and  on  the  27th  the  remaining  piece.  On  this  day  the 
temperature  rose  to  103°,  and  the  pulse  to  148  ;  but  the 
temperature  fell  next  day  to  100"8°  at  the  highest  point. 

The  further  progress  of  the  case  presented  little  that  is 
noteworthy. 

The  stitches  Avere  removed  on  March  4th,  and  the 
wound  had  healed  except  where  the  gauze  had  been  and 
where  the  stump  lay.  On  March  12th  the  greater  part 
of  the  stump  was  cut  away  ;  on  March  14th  the  wire  was 
removed.  The  gauze  track  had  healed  up  by  the  21st, 
and  the  whole  wound  was  conijDletely  cicatrised  on  April 
28th,  and  the  patient  left  the  hospital  on  April  30th,  1895, 
looking  and  feeling  quite  Avell.  She  has  married,  and 
has  enjoyed  the  most  blooming  health  since  the  operation. 

On  March  18th,  1897,  I  found  the  remains  of  the  uterus, 
small  and  adherent  to  the  scar. 

In  September  of  this  year  she  told  me  that  she  had  been 
quite  well  and  regular  since  the  operation. 

Case  2. — A.  M — _,  23  years  of  age  (born  February  18th, 
1872),  Avas  sent  to  me  by  Dr.  Wood,  of  Cambridge,  on 
October  9th,  1895,  complaining  of  excessive  haemorrhage 
and  pain  at  the  periods.  The  patient  had  been  married 
for  ten  months,  and  during  that  time  the  bleeding  had 
increased  considerably,  but  for  the  last  six  months  the 
loss  had  been  very  great,  lasting  fourteen  days ;  and  OAving 
to  this  and  the  pain  the  patient  had  been  so  collapsed  that 
she  had  been  compelled  to  take  to  her  bed. 

Menstruation  began  at  the  age   of   fourteen,  and   Avas 


FIBRO-MYOMA    OF    THE    UTEEUS.  239 

never  regular,  the  intervals  varying  from  three  to  five 
weeks,  and  the  flow  lasting  for  five  days.  About  three 
years  ago  the  period  lasted  seven  days,  and  continued  to 
do  so  up  till  marriage,  since  which  the  loss  had  been 
excessive,  as  stated  above.  Menstruation  had  always 
been  painful. 

The  health  of  the  patient  had  been  fairly  good  pre- 
viously to  the  last  few  months,  though  she  had  been 
treated  for  anaemia  for  several'  years.  The  patient^s 
mother  had  died  at  the  age  of  sixty  of  ''  cancer  in  the  back 
passage  ;  "  the  father,  at  the  age  of  forty-two,  of  Bright^s 
disease.      There  was  no  history  of  phthisis  in  the  family. 

On  October  12th  the  state  of  the  patient  w^as  as 
follow^s  : — There  was  marked  anasmia  and  a  soft  systolic 
heemic  murmur  over  the  base  of  the  heart.  There  was  a 
little  fulness  of  the  abdomen  above  the  pubes,  where  a 
tumour  could  be  felt  rising  out  of  the  pelvis  to  a  height 
of  4  inches  above  the  symphysis  pubis,  and  measuring 
nearly  4  inches  transversely ;  the  tumour  was  fairly 
regular  on  the  surface,  and  hard  like  a  fibroid.  The 
hymen  was  torn  posteriorly,  the  cervix  was  small,  the  os 
easily  admitted  a  sound.  The  uterus  was  hard,  distended 
to  the  size  of  the  pregnant  organ  at  three  and  a  half 
months,  somewhat  irregular,  but  fairly  smooth  on  the 
surface.  The  sound  was  easily  passed,  at  first  in  a 
forward  direction  for  3^  inches,  and  then  backwards  for  a 
distance  of  5  inches  in  all ;  the  cavity  of  the  uterus  was 
enlarged,  and  there  was  roughness  on  its  anterior  wall. 

On  October  ]5th  the  uterus  was  curetted,  and  after 
dilatation  with  Hegar^s  sounds  was  explored  with  the 
little  finger.  A  submucous  tumour  was  found  bulging 
into  the  uterine  cavity,  and  attached  to  the  fundus  and 
left  and  posterior  walls.  It  was  decided  to  endeavour  to 
enucleate  this  tumour  when  the  patient  had  recovered  her 
strength. 

Accordingly  on  October  29th  the  uterus  was  dilated 
up  to  20  Hegar,  which  caused  a  slight  laceration  of  the 
left  side  of  the  cervix.      Then  the  capsule  was   cut  with 


240  FIBRO-MYOMA    OP    THE    UTERUS. 

scissors,  and  an  attempt  was  made  to  enucleate  the  tumour ; 
this   was  found  to  be    very    difficult    on    account   of    the 
toughness    of    the    tumour   and    the   presence    of    several 
small  cavities  in  its  substance.      An  attempt  was  therefore 
made    to    remove    it    in    pieces    by   strong   volsella   and 
scissors,    but    after    a    handful    of    fragments    had    been 
removed  in  this  manner  a  ragged,  lacerated  mass  about 
the  size  of  the  fist  remained  firmly  fixed  in  the  posterior 
and  left  wall  of  the  organ.      In  attempting  to  enucleate 
this   the    peritoneal   cavity    was  opened,    and,    as    it    was 
impossible  to  remove  the  whole  of  the  ragged  tumour,  it 
was    decided    to    perform     vaginal     hysterectomy.       The 
bladder  was  therefore  separated  in  the  usual  way,  and  the 
vesico-uterine  pouch  opened  ;  then  the   anterior    wall    of 
the  uterus  was  incised  up  to  the  fundus,   and    V-shaped 
fragments  were  removed  by  scissors ;    finally,  the  tumour 
and  posterior  wall  of   the  uterus  were   cut  through  in  the 
sagittal  plane.      Each  half    was  then   delivered   into   the 
vagina,  a  silk  ligature  was  placed  upon  the  upper  part  of 
the  right  broad  ligament,  and  Doyen's  forceps  were  then 
placed  from  above  down  upon  each  broad  ligament  outside 
the  ovaries,  and  the  uterus  was   cut    away.      Two   broad 
strips  of  iodoform  gauze  were  then  placed  in  the  peritoneal 
cavity,  and  the  patient  returned  to  bed.      The  removal  of 
the   uterus   occupied  only   a  few  minutes,  but   the  whole 
operation  had  taken   an  hour  and  three  quarters,  but  at 
the  end  the  patient  was  in  very  fair  condition  considering 
that     she    was    at    first    very    anaemic,    and    had    lost    a 
large  amount    of    blood    during    the     enucleation.       The 
parts  removed  weighed    16^    ounces.      The    tumour   con- 
tained   several    small    cavities   of   the    size   of   peas    and 
cherries,  and  in  the  centre  a  hard  solid  fibroid  mass  about 
an  inch  and  a  half  in  diameter.      Microscopic  examination 
of  the  tumour  showed  it  to  be  a  typical  fibro-myoma  of 
the  uterus  (specimen  and  section  exhibited). 

During  convalescence  the  temperature  rose  to  102 "4  on 
the  third  day,  and  to  104' 6°  (the  highest  point)  on  the 
fifth  day,  and  did  not  return  to  the  normal  for  a  fortnight. 


FIBEO-MYOMA    OF    THE    UTERUS.  241 

This  access  of  fever  was  associated  with  an  exudation  in 
the  right  broad  ligament  around  the  silk  ligature^  which 
was  removed  on  the  sixteenth  day.  The  general  condition, 
of  the  patient  remained  good  throughout.  The  gauze 
plugs  were  removed  on  the  fourth  day,  and  the  scar  had 
completely  cicatrised  on  December  3rd^  when  the  patient 
got  up,  having  regained  colour  and  being  quite  well. 
She  left  the  hospital  on  December  11th.  A  year  later, 
on  October  27th,  1896,  I  examined  the  patient.  She 
appeared  to  be  in  robust  health,  had  a  florid  complexion, 
and  had  had  no  pain  nor  trouble  of  any  kind  since  she 
left  the  hospital,  except  that  there  was  occasionally,  but 
not  always,  slight  pain  on  coitus.  There  were  a  few 
brownish-red  patches  in  the  vestibule.  The  vagina 
measured  3  inches  along  its  posterior  wall,  and  easily 
admitted  two  fingers.  The  patient  had  flushes  four  or  five 
times  a  day,  but  did  not  sweat  after  the  fiushes.  She 
weighed  7  st.  11  lbs.  (a  year  previously  7  st.  12  lbs.), — 
that  is  to  say,  adding  the  weight  of  the  uterus,  she  was  of 
exactly  the  same  weight  as  before  the  operation. 

Dr.  Duncan  pointed  out  how  well  one  of  the  author's  re- 
corded cases  emphasised  what  Dr.  Duncan  had  said  a  few 
meetings  previously,  viz.  that  euucleation  of  fibroid  tumours  was 
a  very  dangerous  procedure,  and  should  not  be  resorted  to. 
Hysterectomy  was,  in  his  opinion,  safer  and  more  scientific. 

Dr.  BoxALL  was  now  able  to  furnish  details  of  the  case 
referred  to  by  Dr.  Spencer,  which  at  the  time  this  specimen  was 
shown  before  the  Society  he  could  not  do,  as  it  was  then  the  sub- 
ject of  legal  investigation.  The  patient  was  born  on  August  9th, 
1870.  She  was  therefore  just  twenty-three  years  of  age  when  she 
came  under  observation  in  August,  1893.  Six  months  previously, 
during  a  menstrual  period,  she  fell  while  dancing  on  the  stage. 
The  flow  stopped,  and  returned  ten  days  later.  Symptoms  of 
peritonitis  supervened  ;  the  temperature  reached  104°  F.  Under 
treatment  the  acute  symptoms  subsided,  but  the  pain  and 
tenderness  in  the  lower  abdomen  returned  when  attemj^ts  were 
made  to  get  up.  The  courses  began  between  fourteen  and 
fifteen,  and,  except  for  some  irregularity  during  the  first  year, 
had  continued  regularly  up  to  the  time  of  the  fall,  and  had 
shown  no  disposition  to  increase.  Her  previous  health  had  been 
good.  When  first  examined  in  August  the  uterus  was  found  to 
be  a  little  enlarged  and  irregular  in  shape,  with  some  tenderness, 


242  PIBRO-MYOMA    OF    THE    UTERUS. 

ill-defined  tliiclieniug  and  partial  fixation  on  the  left  side,  but  none 
on  tlie  right.  A  further  period  of  absolute  rest  in  bed  with  hot 
douches  was  enjoined.  When  examined  again  in  October  the  swell- 
ing had  increased  to  the  size  of  a  five  months'  gestation.  The 
tenderness  had  not  subsided,  and  the  temperature  continued  to 
rise  from  half  to  one  degree  above  normal  for  days  together, 
and  on  attempting  again  to  get  up  the  pain  and  tenderness  had 
returned  acutely.  An  exploratory  operation  was  decided  upon. 
All  the  parts  on  the  left  side  of  the  pelvis  were  adherent, 
especially  about  the  ovary.  The  uterus  was  displaced  to  the 
right,  and  intimately  connected  with  it  was  an  elastic  mass  in 
the  left  broad  ligament,  as  large  as  the  ball  of  an  oil  flask.^  Two 
•other  fibroid  nodules  not  larger  than  a  nutmeg  were  visible  on 
the  abdominal  surface  of  the  uterus  near  the  fundus.  The 
adhesions  were  separated,  the  main  mass  enucleated  from  the 
broad  ligament,  and  together  with  the  body  of  the  uterus  and 
appendages  was  removed,  a  pedicle  formed  by  the  cervix  being 
secured  by  a  clamp  outside  the  abdomen.  The  main  mass  gave 
the  impression  of  an  abscess  with  thickened  walls,  but  on 
-cutting  into  it  after  removal  it  proved  to  be  of  uniform  consist- 
ence, and  to  be  composed  of  involuntary  muscle  springing  from 
the  left  side  of  the  uterus.  Under  the  microscope  it  exhibits 
the  ordinary  characters  of  a  fibro -myoma.  The  cavity  of  the 
uterus  was  not  enlarged,  and  from  first  to  last  the  periods  were 
not  increased,  so  that  the  presence  of  a  fibroid  was  not  suspected. 
The  patient  married  at  the  beginning  of  1895,  and  continues 
in  good  health.  In  Dr.  Spencer's  second  case  the  mother  died 
of  cancer.  In  this  case  also  the  mother  has  recently  died  of 
cancer,  recurring  two  years  after  vaginal  hysterectomy  for 
disease  of  the  cervix  spreading  into  the  body. 

Dr.  Herman  said  that  his  opinion  as  to  the  practicability  of 
•enucleation  in  the  case  of  the  tumour  shown  by  Dr.  Duncan  at 
the  November  meeting  of  the  Society  ('  Transactions,'  vol.  xxxix, 
p.  291)  remained  the  same  as  it  was  in  November.  He  did  not 
think  that  Dr.  Duncan  had  shown  (as  was  stated  in  the  '  Trans- 
actions')  that  the  uterus  might  easily  have  been  perforated 
had  enucleation  been  attempted.  He  thought,  on  the  contrary, 
that  by  morcellement  the  fibroid  could  easily  and  stifely  have 
been  removed.  This  was  an  old  and  good  method  of  removing 
such  tumours.  There  were  limits  to  its  use.  If  the  tumour 
were  so  large  that  its  relation  to  the  uterine  cavity  could  not  be 
clearly  made  out,  then  it  was  difficult  to  say  whether  enucleation 
w^ould  be  practicable  or  not.  As  a  rule,  the  size  of  a  foetal  head 
represented  the  size  of  the  largest  tumours  that  could  be  easily 
removed  by  this  method,  although  larger  tumours  than  this 
could  sometimes  be  so  disposed  of.  Had  Dr.  Duncan's  tumour 
been  removed  in  this  way  the  patient  would  have  recovered 
capable  of  every  function,  instead  of  being  minus  her  uterus. 


FIBRO-MYOMA    OF    THE    UTERUS.  243 

He  did  Qot  tliiok  Dr.  Spencer's  case  showed  that  any  greater 
danger  attended  enucleation,  for  his  patient  recovered  as  well 
as  she  could  have  done  after  abdominal  hysterectomy,  and 
without  the  disadvantage  of  an  abdominal  scar.  There  was 
one  point  upon  which  he  ventured  to  criticise  Dr.  Spencer's 
method  of  dealing  with  his  case.  It  was  essential  for  the 
performance  of  enucleation  that  the  cervix  should  be  so  dilated 
that  it  would  admit  easily  two  fingers.  Room  was  rec[uired  for 
a  finger  to  guide  and  an  instrument  to  work.  He  (Dr.  Herman) 
thought  this  was  most  safely  done  by  dilatation  with  tents, 
protracted  over  some  days, — first  one,  then  several  tents  being 
used.  Hegar's  dilators  when  used  to  produce  such  great  dila- 
tation were  apt  to  tear  the  cervix.  Dr.  Spencer  dilated  up 
to  No.  20,  which  was  very  little  larger  than  would  admit  one 
finger  (No.  17  would  just  admit  a  finger).  With  tents  much 
more  room  could  have  been  gained,  and  the  oj^eration  would 
have  been  easier.  He  fully  concurred  in  the  commendations 
of  Dr.  Spencer's  paper  which  had  been  expressed  by  former 
speakers. 

Dr.  Peter  Horeocks  did  not  think  that  the  paper  was  in- 
tended to  provoke  a  discussion  on  the  relative  merits  of 
enucleation  of  fibroid  tumours  of  the  uterus  and  their  treat- 
ment by  hysterectomy.  The  title  of  the  paper  indicated  that 
it  was  to  show  that  real  cases  of  fibroid  tumours  of  the  uterus 
did  exist  in  women  under  tw^enty-five  years  of  age.  AVhy 
twenty-five  and  not  twenty-four  or  twenty-six  was  selected 
was  not  apparent.  It  had  been  said  before  that  Society  some 
time  ago  by  Mr.  Alban  Doran  that  these  tumours  never 
occurred,  or  at  all  events  were  practically  unknown,  before 
the  age  of  twenty-five.  The  two  cases,  details  of  which  had 
been  given  so  minutely  by  Dr.  Si3encer  to-night,  and  the  cases 
he  heard  Cjuoted  by  other  observers,  showed  that  they  were  not 
unknown.  It  would  have  been  simpler  if  one  could  have  said 
that  fibroids  of  the  uterus  never  occurred  before  twenty-five,  for 
then,  given  a  case  with  a  pelvic  tumour,  one  would  have  been 
able  to  say  if  the  patient  was  under  twenty-five  that  ipso  facto 
it  could  not  be  a  fibroid.  But,  unfortunately,  clinical  experience 
everywhere  exhibited  exceptions  which  rendered  dogmatic  teach- 
ing impossible.  Still,  it  must  be  admitted  that  true  fibroids 
(that  is,  fibro-myomata)  of  the  uterus  were  rare  before  twenty- 
five  and  unknown  before  puberty.  They  were  also  much  com- 
moner in  single  than  in  married  women,  and  in  women  who 
had  never  been  pregnant  than  in  women  who  had.  Moreover 
the  tumours  began  to  atrophy  as  a  rule  after  the  climacteric. 
All  these  facts  proved  that  in  some  way  fibroids  were  asso- 
ciated with  active  menstrual  life,  and  whether  they  were  pro- 
duced by  a  kind  of  deflection  of  a  vis  nervosa  or  not  it  was 
difiicult  to  say. 


244  FIBRO-MTOMA    OF    THE    UTERUS. 

Dr.  Lewers  agreed  with  tlie  I'emarks  that  had  been  made  by 
Dr.  Herman  as  to  enucleation.  He  considered  that  the  justi- 
fiability of  enucleation  _2:»er  vaginam  bv  morcellement  depended 
chiefly  on  the  exact  position  of  the  fibroid  in  relation  to  the 
uterine  wall.  When  the  fibroid  was  so  situated  that  its  largest 
diameter  projected  free  in  the  uterine  cavity,  and  only  a  moderate 
proportion  of  the  tumour — one  third,  for  instance,  or  less — still 
remained  embedded  in  the  thickness  of  the  uterine  wall,  then 
iu  skilled  hands  he  thought  enucleation  per  vaginam  by  morcelle- 
ment was  free  from  any  great  risk,  and  was  the  proper  treatment 
for  the  case.  AVheu,  however,  examination  after  full  dilatation 
of  the  cervix  showed  that  the  largest  diameter  of  the  tumour 
was  still  in  the  thickness  of  the  wall  of  the  uterus,  he  regarded 
enucleation  as  exceedingly  dangerous,  and  considered  that  if 
operative  treatment  was  indicated  on  account  of  the  severity  of 
the  symptoms,  the  proper  course  was  to  perform  either  removal 
of  the  uterine  appendages  or  abdominal  hysterectomy,  according 
to  the  circumstances  of  the  particular  case. 

The  President  expressed  his  high  appreciation  of  the  value 
of  Dr.  Spencer's  paper.  He  knew  something  of  the  labour 
such  papers  cost.  In  the  course  of  a  discussion  upon  a  specimen 
of  fibroids  of  the  uterus  in  a  o^irl  of  twenty-six  shown  for  him 
(the  President)  by  Dr.  A.  P.  Stabb  fifteen  months  ago,  Mr. 
Doran  had  remarked  that  a  monograph  on  the  subject  of 
fibroids  in  early  life  was  much  wanted.  Such  a  monograph  had 
now  been  produced,  characterised  by  the  thoroughness  they 
were  accustomed  to  expect  in  all  Dr.  Spencer's  work.  No 
papers  enriched  the  Society's  '  Transactions  '  more  than  those 
which  gave  a  careful  summary  of  the  literature  of  a  subject, 
provided  that,  as  in  the  paper  just  read,  the  inquiry  had  been 
of  an  exhaustive  character.  It  was  to  be  hoped  that  Fellows 
would  henceforth  recognise  the  importance  of  recording,  on  the 
lines  Dr.  Spencer  had  laid  down  as  essential  for  scientific 
accuracy,  all  cases  that  came  under  their  observation  of  uterine 
fibro-myomata  occurring  in  young  subjects.  In  reference  to 
the  cases  that  Dr.  Spencer  himself  had  contributed,  he  would 
be  glad  to  hear  the  reasons  that  had  led  the  author  to  adopt 
the  plan  of  plugging  with  iodoform  gauze  in  preference  to 
other  means  of  arresting  the  bleeding  from  the  raw  surface 
left  after  separating  extensive  aud  intimate  intestinal  adhe- 
sions. G-auze  plugging  was,  no  doubt,  very  effective,  but  it 
was  a  method  that  he  always  adopted  unwillingly,  on  account 
of  the  disturbance  of  the  wound  when  the  plug  had  to  be 
removed.  He  thought  the  extra-peritoneal  method  of  dealing 
with  the  pedicle  in  abdominal  hysterectomy  could  scarcely 
now  be  correctly  spoken  of  as  "the  usual  way,"  but  per- 
haps the  words  were  used  with  another  meaning.  Much 
difference  of  opinion  had  been  expressed  by  previous  speakers 


FIBRO-MYOMA    OF    THE    UTERUS.  245 

as  to  the  value  and  safety  of  the  treatment  of  fibro-myomata  of 
moderate  size  by  the  method  of  enucleation  per  vaginam.  He 
was  bound  to  say  that  in  his  exj^erience  this  method  had  proved 
more  dangerous  than  removal  of  the  entire  uterus,  not  only 
from  the  risk  of  injuring  the  peritoneal  surface  of  the  uterus,  but 
from  the  difficulty  in  many  cases  of  completing  the  enucleation. 
If  fragments  were  left,  they  were  almost  certain  to  become 
necrotic,  and  thus  exposed  the  patient  to  grave  risk  from  se]3tic 
absorption.  He  was  of  opinion  that  this  method  should  only 
be  employed  by  experienced  and  dexterous  operators.  He  would 
be  sorry  if  what  had  been  said  should  have  the  effect  of  leading 
the  inexperienced  to  choose  a  method  of  treatment  so  dangerous 
and  so  liable  to  land  them  in  all  manner  of  unforeseen  difficulties. 
It  was  possible,  of  course,  that  an  improved  technique  might 
overcome  these  objections,  but  enucleation  as  he  had  hitherto 
seen  it  practised  was  certainly  not  a  method  to  be  indiscriminately 
recommended. 

Dr.  Herbert  Spencer,  in  reply,  thanked  the  President  and 
the  other  speakers  for  their  kind  remarks  on  his  paper,  the 
object  of  which  was  to  show  by  undeniable  evidence  that  fibro- 
myoma  of  the  uterus  did  occur  in  women  before  the  age  of 
twenty-five,  and  to  form  an  estimate  of  its  rarity.  The  reason 
for  taking  the  age  of  twenty-five  was  indicated  in  the  paper 
and  in  the  remarks  of  other  speakers,  including  Dr.  Horrocks. 
Every  one  knew  that  after  twenty-five  the  disease  became  com- 
paratively common,  whereas  before  that  age  its  rarity,  judged 
by  published  records,  was  shown  by  the  fact  that  Dr.  Boxall's 
was  the  only  other  case  which  he  had  been  able  to  find  fully  and 
satisfactorily  recorded  by  an  English  author.  He  had  not  dis- 
cussed the  treatment ;  but  he  entirely  agreed  with  Dr.  Herman's 
remarks  on  the  specimen  shown  by  Dr.  Duncan,  and  generally 
with  his  remarks  on  enucleation  per  vaginam,  which  in  his 
opinion  was  an  extremely  valuable  operation,  and  yielded  very 
good  results.  The  preliminary  dilatation  was  an  important 
matter.  It  was  usually  important  to  have  the  os  dilated 
sufficiently  to  admit  two  fingers  ;  this  he  had  generally  done  by 
Hegar's  dilators  and  the  fingers — there  were  certain  special 
risks  in  the  prolonged  use  of  tents  in  these  cases, — but  he  thought 
that  perhaps  plugging  with  iodoform  gauze  would  be  a  more 
satisfactory  method  of  dilating  the  canal.  He  did  not  limit  the 
size  of  the  tumours  suitable  for  enucleation  per  vaginam  to  that 
of  a  foetal  head,  and  the  limitation  proposed  by  Dr.  Lowers  was 
also,  in  his  opinion,  too  strict.  He  had  successfully  removed, 
at  one  sitting,  a  sessile  tumour  weighing  2  lbs.  2  oz.,  through  a 
cervix  undilated  before  the  operation,  and  had  successfully 
removed  much  larger  tumours  at  several  sittings — a  method, 
however,  which  he  did  not  recommend.  During  the  operation 
he  had,  in  one  other  case,  accidentally  opened  the  peritoneum ; 

VOL.  XL.  17 


246  FIBRO-MYOMA    OP    THE    UTERUS. 

in  tliat  case,  after  completely  removing  the  tumour,  he  stitched 
up  the  hole,  and  the  patient  recovered  well.  It  was  obvious 
that  even  if  vaginal  hysterectomy  had  to  be  performed,  the 
patient  would  be  better  off  than  if  she  had  an  abdominal  scar, 
not  to  mention  the  smaller  risk  of  the  vaginal  operation.  He 
was  very  satisfied  with  the  iodoform  gauze  for  checking  the 
severe  bleeding  from  the  adherent  surface  of  the  colon.  The 
President  would  see  on  reading  the  details  of  the  case  that  the 
ordinary  methods  of  checking  haemorrhage  were  quite  inappli- 
cable to  a  surface  measuring  six  inches  by  two  inches  which 
bled  profusely  from  innumerable  small  vessels.  In  saying  that 
he  treated  the  pedicle  in  his  first  case  "  by  the  extra-peritoneal 
method  in  the  usual  way  "  he,  of  course,  did  not  mean  "  in  the 
usual  way  by  the  extra-peritoneal  method,"  but  "in  the  usual 
way  (of  performing  the  extra-peritoneal  operation)."  The 
President's  concluding  remarks  showed  that,  notwithstanding 
his  personal  objections  to  enucleation  jjer  vaginam,  he  kept  an 
open  mind  on  the  subject ;  and  he  (Dr.  Spencer)  ventured  to 
predict  that  this  would  lead  him  yet  to  recommend  this  old 
operation,  which  in  properly  selected  cases  was  one  of  the  safest 
^nd  most  valuable  of  all  the  major  gynaecological  operations. 


JULY  6th,  1898. 
C.  J.  Cdllingworth,  M.D._,  President,  in  the  Chair. 
Present — 27  Fellows  and  3  visitors. 

Books  were  presented  by  the  Societe  Obstetricale  et 
Gynecologique  de  Paris,  the  Staff  of  the  Presbyterian 
Hospital  in  the  City  of  New  York,  and  Messrs.  Steinheil 
and  Co. 

Percy  Leonard  Blaber,  L.P.C.P.,  and  Alfred  Gervase 
Penny,  M.B.,  B.C.Cantab.,  were  admitted  Fellows  of  the 
Society. 

John  Robinson  Harper,  L.R.C. P.  (Barnstaple),  was 
declared  admitted. 

The  following  gentleman  was  proposed  for  election  : — 
Francis  James  Lea,  M.R.C.S.Eng. 


A    CASE    OF    ACUTE    BEDSORE    FOLLOWING 
PARTURITION. 

By  C.  F.  Blacker,  M.D. 

The  occurrence  of  an  acute  bedsore  in  cases  of  para 
plegia,    leading    within    a    few    days    to    the    extensive 


248       ACUTE  BEDSORE  FOLLOWING  PAETURITION. 

destruction  of  tissue,  is  a  fact  that  has  been  well  known 
for  a  number  of  years,  and  has  been  specially  called 
attention  to  by  Charcot  amongst  others. 

The  occurrence,  however_,  of  an  acute  bedsore  in  a 
patient  without  any  nervous  lesion  is  of  such  rarity  that 
I  have  thought  the  following  case  worthy  of  being  put 
on  record. 

The  patient,  twenty-six  years  of  age,  a  multipara,  was 
confined  in  the  extern  maternity  department  of  University 
College  Hospital  on  July  29th,  1897. 

The  child  presented  by  the  vertex,  and  was  of  medium 
size.  The  labour  lasted  about  eight  hours,  and  was 
perfectly  normal  up  to  the  end  of  the  second  stage. 

After  the  birth  of  the  child  there  was  a  good  deal  of 
haemorrhage,  the  placenta  having  to  be  extracted  by  hand, 
and  about  two  and  a  half  pints  of  blood  Avere  lost.  The 
bleeding  was  checked  by  hot  douches,  but  not  before  the 
loss  had  caused  a  considerable  amount  of  faintness. 

During  the  labour,  to  relieve  the  pains,  the  lower  part 
of  the  back  was  supported  by  the  knee  of  the  student 
attending  the  case.  This  support  was  continued  inter- 
mittently for  about  one  hour.  He  asserts  that  the  amount 
of  pressure  employed  was  not  greater  than  that  he  was 
in  the  constant  habit  of  employing  with  other  patients,  an 
amount  which  he  had  never  noticed  to  be  attended  by 
any  subsequent  ill  results.  He  admits,  however,  that  in 
this  case  he  noticed  after  delivery  that  the  upper  part  of 
the  sacrum  was  rather  red. 

On  the  first  day  of  the  puerperium  the  skin  over  the 
sacrum  was  found  to  be  bruised  over  an  area  three  inches 
by  two  inches,  the  bruise  being  surrounded  by  a  number 
of  small  vesicles  containing  watery  fluid. 

On  the  second  day  the  bruise  was  more  marked,  and 
looked  as  if  about  to  sloagh,  and  at  this  time  the  skin 
over  the  left  trochanter  was  also  noticed  to  be  a  little 
reddened. 

On  the  third  day  a  small  sinus  formed  about  one  inch 
in  depth,  leading  down  to  the  sacrum,  and  the  whole  of 


ACUTE     BEDSORE    FOLLOWING    PARTURITION.  249 

the  bruised  area  in  tlie  course  of  tlie  next  few  days 
formed  one  large  slough,  which  did  not,  however,  extend 
beyond  its  original  confines. 

The  condition  remained  about  the  same  until  the 
eleventh  day,  when  the  patient  was  admitted  into  the 
hospital. 

On  admission  the  follomng  note  was  made. 

The  patient  is  a  pale,  well-nourished,  but  flabby-looking 
woman,  who  was  confined  tAvelve  days  ago,  and  is  suckling. 
Over  the  middle  of  the  upper  part  of  the  sacrum,  extend- 
ing more  to  the  left  than  to  the  right  of  the  middle  line, 
is  a  large  bedsore,  which  has  destroyed  the  tissues  down 
to  the  fascia  over  the  bone,  the  latter  presenting  a  shreddy 
sloughy  surface  of  a  light  yellow  colour.  The  sore  is 
roughly  circular,  measuring  about  three  inches  across  by 
two  inches  deep.  It  is  almost  wholly  occupied  by  a  dirty 
yellow  offensive  slough,  which  is  removed  entire  without 
difficulty.  The  skin  edges  are  ulcerated,  and  the  sides  of 
the  wound  are  in  part  sloughing  and  in  part  granulating, 
while  the  base  is  sloughing  ;  the  whole  sore  looking  very 
acute,  as  if  a  large  mass  of  tissue  in  the  form  of  a  cylinder 
had  suddenly  necrosed  from  skin  to  bone. 

The  slough  removed  was  found  to  be  composed  of  skin, 
fat,  fascia,  and  some  of  the  fibres  of  the  gluteus  maximus 
muscle.  There  was  no  evidence  of  any  growth  in  the 
slough,  which  was  composed  solely  of  the  altered  tissues 
of  the  part.  On  pelvic  examination  there  was  a  good 
deal  of  purulent  discharge  from  the  cervix,  but  otherwise 
the  uterus  and  appendages  were  found  to  be  normal  for 
the  period  of  the  puerperium  reached. 

There  was  no  evidence  of  any  injury  to  the  vagina  or 
cervix,  and  no  sign  of  any  exudation  or  abnormal  tender- 
ness in  the  pelvis.  There  was  no  paralysis  or  rigidity  of 
the  lower  limbs,  and  no  loss  of  sensation.  The  knee-jerks 
were  a  little  exaggerated,  but  no  ankle-clonus  could  at 
this  time  be  obtained. 

On  the  fourteenth  day  after  admission  the  greater  part 
of  the  slough  had  separated,  and  the  wound  presented  a 


250  ACUTE    BEDSORE    FOLLOWING    PARTURITION. 

healthy  granulating  appearance.  After  this  the  sore 
rapidly  granulated  up^  and  was  quite  soundly  healed  when 
the  patient  left  the  hospital  after  a  stay  of  two  months. 

Before  she  left  some  doubtful  physical  signs  were 
discovered  at  the  right  apex  of  the  lung,  but  no  tubercle 
bacilli  could  be  detected  in  the  sputum. 

The  nervous  system  was  carefully  examined  upon  several 
occasions,  and  was  found  normal  except  that  the  knee- 
jerks  were  a  little  excessive,  more  so  on  the  right  than  on 
the  left  side,  and  ankle-clonus  could  at  times  be  obtained 
in  the  right  leg. 

Tactile  sensation  and  appreciation  of  heat  and  cold 
were  perfect  in  both  lower  limbs. 

The  patient  Avalked  well,  and  no  wasting  of  the  muscles 
of  the  lower  limbs  could  be  detected.  Rhomberg^s  sign 
was  absent.  She  had  enjoyed  perfect  health  up  to  the 
time  of  her  labour,  and  had  not  been  confined  to  bed. 
No  history  of  syphilis  could  be  obtained,  and  she  had 
never  had  any  form  of  pelvic  inflammation. 

The  case  presents  several  points  of  interest.  There 
can  be  no  doubt  that  the  occurrence  of  the  bedsore  was 
determined  by  the  pressure  exerted  upon  the  back  during 
delivery,  and  had  it  run  the  ordinary  course  of  a  pressure 
bedsore  the  case  would  not  have  presented  any  special 
features.  But  the  close  resemblance  that  the  case  bore 
to  one  of  acute  decubitus  could  not  fail  to  strike  every  one 
who  saw  it,  and  this  was  especially  marked  in  the  acute- 
ness  of  the  onset,  in  the  rapidity  of  its  course,  and  in  the 
extensive  destruction  of  tissue  to  which  it  gave  rise.  And 
yet  a  most  careful  examination  of  the  patient  upon  several 
occasions  failed  to  elicit  any  nervous  or  other  lesion  which 
might  have  explained  the  striking  resemblance  that  the 
ulcer  bore  to  one  following  a  traumatic  lesion  of  the  spine. 

I  have  not  been  able  to  find  any  definite  reference  to 
such  a  complication  of  labour,  nor  any  record  of  any  other 
cases  except   one   described   by  Balkow  ^  in    1837.      He 

*  Balkow,    *  Sanitats.     Bericli.    der    Prov.    Brand.,'    1837,    Berlin,     1840, 
p.  106. 


ACUTE    BEDSORE    FOLLOWING    PARTUEITION.  251 

records  the  case  of  a  woman  whom^  in  lier  sixth  confine- 
ment^ he  had  to  deliver  with  forceps  on  account  of  the 
laro-e  size  of  the  child's  head,  a  considerable  amount  of 
force  being  employed. 

For  the  first  three  days  the  patient  did  very  Avell. 
During  the  following  night  she  was  seized  with  very  acute 
pain  in  the  right  leg^  so  severe  that  any  examination  Avas 
quite  impossible. 

Four  days  later  a  bedsore  was  found  to  be  present  upon 
the  sacrum^  covering  an  area  the  size  of  the  palm  of  the 
hand.  The  sore  rapidly  healed,  and  as  it  ceased  to  spread 
the  pain  disappeared.  There  was  no  evidence  of  any 
septic  infection  in  the  case.  It  is  not  quite  clear  that 
this  was  a  case  of  acute  bedsore,  but  the  author  appears 
to  imply  that  the  sore  had  been  present  for  some  few 
days  before  it  was  discovered  upon  the  seventh  day  after 
delivery. 

Of  recent  years  a  good  deal  has  been  written  upon  the 
subject  of  acute  bedsore  following  operations  upon  the 
pelvic  organs,  and  especially  vaginal  hysterectomy. 

Segond  ^  records  the  case  of  a  woman  thirty  years  of 
age  laparotomised  for  pehac  suppuration.  On  the  third 
day  the  temperature  became  elevated,  the  patient's  con- 
dition grave,  and  in  a  few^  hours  an  eschar  as  large  as  the 
hand,  comprising  all  the  tissues  down  to  the  bone,  formed 
over  the  sacral  region.      The  patient  made  a  good  recovery. 

He  also  mentions  a  case  of  Pinard's  occurring  in  a 
patient  who  had  had  the  operation  of  ischio-pubiotomy 
performed. 

Terrier  and  Hartmann  f  record  three  cases  in  a  table  of 
thirty-six  cases  of  hysterectomy  performed  for  cancer. 

Baudron  %  found  six  cases  of  acute  bedsore  occurring  in 
542  cases  of  hysterectomy  performed  for  pelvic  suppura- 
tion, fibroma,  and  carcinoma  of  the  uterus.      Of  these  six 

*  Segond,  "  Le  Decubitus  Acutus,"  *  Rev.  de  Gynecol,  et  de  Cliir.  abd.,' 
No.  1,  1897,  p.  59. 

t  F.  Terrier  and  Hartmann,  '  Rev.  de  Chir.,'  Paris,  1892,  p.  296. 
+  E.  Baudron,  '  These,'  Paris,  1893-4,  No.  276,  p.  77. 


252  ACUTE    BEDSORE    FOLLOWING    PARTURITION. 

cases  all  were  operated  upon  for  inflammatory  lesions  of 
the  pelvic  organs,  suppurating  in  four,  non-suppurating  in 
two. 

The  operation  was  long  and  difficult  only  in  one  case, 
while  in  five  of  the  six  the  pelvic  inflammation  was  of 
long  standing. 

Baudron's  description  of  the  bedsores  and  of  their 
course  agrees  ver}^  completely  with  what  was  observed  in 
my  own  patient,  and,  as  he  says,  it  is  evident  that  the 
process  corresponds  very  closely  to  that  consecutive  to 
traumatic  lesions  of  the  spinal  cord.  All  the  six  patients 
made  a  good  recovery.  He  points  out  that  at  any  rate  in 
these  six  cases  the  occurrence  of  the  acute  bedsore  could 
not  be  attributed  to  a  long  stay  in  bed,  nor  to  the  length 
or  difficulty  of  the  operation,  nor  to  the  pressure  of  the 
table.  He  is  inclined  to  regard  it  as  due  to  damage 
inflicted  upon  some  of  the  nerves  of  the  pelvis  by  com- 
pression or  stretching  during  the  course  of  the  hysterec- 
tomy. 

Segond,  however,  thinks  that  possibly  in  these  cases 
the  causation  of  the  acute  bedsore  is  in  some  way  con- 
nected with  the  pelvic  inflammation.  He  calls  attention 
to  the  fact  that  in  all  six  cases,  with  one  exception,  the 
patient  had  had  long-continued  inflammatory  trouble  in 
the  pelvis,  and  he  thinks  it  possible  that  such  a  condition 
may  produce  some  irritative  lesion  of  the  pelvic  nerves, 
and  that  this  by  disturbing  their  functions  may  lead  to 
the  formation  of  a  trophic  lesion  in  the  shape  of  an  acute 
bedsore. 

Similar  cases  have  been  recorded  by  Leprevost  ^  and 
Morestin  t  as  occurring  after  extirpation  of  the  rectum  by 
the  sacro-coccygeal  method,  and  also  after  extirpation  of 
the  uterus  in  the  same  way. 

In  these  cases,  however,  it  is  extremely  likely  that 
some  injury  to  the  skin  over  the  sacrum  or  some  inter- 

*  Leprevost,  '  Congr.  Fran?,  de  Chir.,'  6tli  session,  Paris,  1892,  p.  52. 
t  Morestin,  'These,'  Paris,  1894,  No.  112,  p.  227. 


FOETAL   SACS   FOUND  IN   FERITONEUM  OF  A   RABBIT.  253 

ference  with  its  blood  supply  occurs  to  a  sufficient  extent 
to  explain  the  occurrence  of  the  lesion. 

As  Morestin  points  out,  there  are  three  possible  causes 
for  such  a  bedsore,  iscliBemia,  sepsis,  or  a  lesion  of  a 
trophic  nerve. 

In  the  case  recorded  in  this  paper  the  occurrence  of  the 
bedsore  must  be  attributed  to  ischaemia  of  the  part,  due  to 
the  pressure  exerted  upon  the  sacrum  during  delivery. 
It  is  impossible  to  see  how  any  undue  pressure  or  injury 
could  have  occurred  to  the  pelvic  nerves  during  the  course 
of  what  was  a  perfectly  normal  labour,  and  there  was  no 
evidence  at  any  time  of  any  septic  infection. 

It  must  be  concluded,  therefore,  that  the  amount  of 
interference  with  the  circulation  produced  by  the  inter- 
mittent pressure  was  sufficient  in  a  feebly  nourished 
woman,  further  debilitated  by  a  considerable  amount  of 
post-partum  hemorrhage,  to  produce  an  acute  bedsore. 

Dr.  Herman  said  he  had  uot  seen  a  case  like  that  of  Dr. 
Blacker,  but  he  bad  seen  and  brought  before  the  Society 
instances  of  acute  gangrene  of  parts  supplied  by  the  same 
system  of  vessels, — acute  gangrene  of  the  vulva  ('  Trans.,' 
vol.  xxv),  and  gangrene  of  the  upper  part  of  the  vagina,  the 
cervix  uteri,  and  base  of  bladder  ('Trans.,'  vol.  xxix).  In  these 
cases,  as  in  Dr.  Blacker's,  the  gangrene  was  not  part  of  a 
spreading  inflammation.  He  (Dr.  Ilerman)  thought  it  must 
be  due  to  some  condition  affecting  the  circulation,  for  it  was 
symmetrical.  Tro2)hic  changes  due  to  affections  of  peripheral 
nerves  were  generally  unsymmetrical. 


FIVE    FGETAL    SACS    FROM     THE     PERITONEAL 
CAVITY    OF  A  RABBIT. 

Shown  by  M.  S.  Pembrey,  M.D. 

Dr.  Pembrey  exhibited  five  cake-like  bodies  which  were 
found   free    in    the    peritoneal    cavity   of   a    large   rabbit. 


254  FCETAL    SACS   FOUND   IN   PERITONEUM   OF  A  RABBIT. 

These  bodies  were  about  7  or  8  cm.  in  lengthy  4  or  5  cm. 
in  width,  and  2  cm.  in  thickness.  The  largest  contained 
four  foetuses,  the  development  of  which  showed  that  they 
were  at  full  term  ;  in  each  of  the  other  sacs  one 
foetus  was  found.  The  sacs  were  formed  from  the 
amnion  greatly  thickened  by  connective  tissue ;  the  pla- 
centa could  be  seen,  but  its  maternal  surface  had  been 
completely  smoothed  over  by  the  growth  of  connective 
tissue.  The  amniotic  fluid  had  been  absorbed,  and  the 
foetuses,  although  showing  no  signs  of  putrefaction,  were 
somewhat  macerated. 

The  abdomen  of  the  mother  showed  marked  signs  of  old 
peritonitis,  but  there  were  no  points  of  attachment  for  the 
placenta.  The  genital  canal  of  the  mother  showed  no 
naked -eye  signs  of  rupture.  The  foetuses  had  evidently 
been  retained  for  months  in  the  abdominal  cavity,  for  the 
mother  had  cast  four  litters  during  the  time  she  was 
under  observation  by  Dr.  Pembrey. 

The  specimens  support  the  view  held  by  Bland  Sutton, 
that  these  cases  are  not  due  to  extra-uterine  pregnancy, 
but  to  rupture  of  the  uterus  and  extrusion  of  the  foetal 
sacs  into  the  abdominal  cavity. 

Mr.  Bland  Sutton  observed  that  the  question  of  extra-uterine 
foetuses  in  the  lower  mammals  was  one  of  great  interest,  and  he 
was  able  to  state,  as  the  result  of  an  investigation  extending 
over  many  yeai^s,  that,  with  one  doubtful  exception,  there  was  no 
evidence  of  the  occurrence  of  tubal  pregnancy  except  in  woman. 
The  doubtful  case  occurred  in  a  baboon  (Cynocephalus  hama- 
dryas)  which  died  in  the  Zoological  Gardens,  Berlin,  and  was 
reported  upon  by  Waldeyer  (vide  'Cent.  f.  Gi-yn.,'  1893).  The 
way  that  foetuses  in  their  membranes  find  a  way  into  the  belly 
is  very  interesting,  and  he  had  followed  it  out  most  closely  in 
bitches.  When  a  bitch  accommodates  a  dog  far  above  her  size 
she  runs  two  great  risks: — (1)  The  dog's  penis  sometimes  per- 
forates the  vagina,  and  may  cause  death  in  about  thirty-six 
hours.  (2)  Should  the  bitch  escape  this  danger  and  conceive, 
then  the  pups  are  inordinately  large,  and  delivery  is  impossible. 
In  such  cases  rupture  takes  place,  usually  near  the  junction  of 
the  uterus  and  va^jjina,  and  the  pups  escape  into  the  belly. 
Many  such  events  terminate  fatally  ;  others  survive  even  this 
grave    accident,  for   the   uterus,  after    expelling    its  contents, 


FOETAL   SACS   POUND  IN   PERITONEUM  OP   A   RABBIT.  255 

rapidly  contracts,  Leuce  a  slit  wHcli  allowed  the  extrusion  of  a 
pup  at  the  full  time  rapidly  becomes  reduced  to  an  opening  of 
very  small  dimeDsions,  and  quickly  lieals.  The  intra-peritoneal 
pups  may  become  sequestered  in  tlie  recesses  of  the  belly,  or 
form  adhesions  to  peritoneum  or  intestines,  and  cease  to  give 
trouble.  When,  months  later,  these  encapsuled  foetuses  are 
found  by  a  veterinary  surgeon  or  an  anatomist,  they  naturally 
excite  astonishment,  and  an  account  of  them  may  perchance 
find  its  way  into  periodical  literature  as  examples  of  extra- 
uterine gestation  ;  bat  now  we  tnow  the  way  the  foetuses  obtain 
an  entrance  the  old  view  that  they  are  due  to  oosperms  (ferti- 
lised ova)  dropping  into  the  coelom  (general  peritoneal  cavity) 
falls  to  the  ground.  Even  the  facts  of  the  cases  rarely  support 
such  a  view,  for  it  is  quite  clear  that  an  embryo  cannot  live  upon 
itself  and  grow,  for  one  must  fall  back  on  such  a  supposition  to 
explain  the  existence  of  foetuses  in  their  membranes  which  are 
found  tumbliuo-  looselv  about  the  bellv.  Much  that  is  erroneous 
in  relation  to  supposed  extra-uterine  gestation  in  mammals 
arises  in  the  very  frequent  error  of  mistaking  the  elongated 
uterine  cornua  for  Fallopian  tubes,  which  in  the  majority  of 
double-horned  utei'i  are  narrow,  thin,  and  often  coiled  ducts. 
Mr.  Sutton's  conclusions  in  regard  to  intra-peritoneal  foetuses 
are  founded  on  a  close  study  of  the  accident  in  dogs,  ewes,  jackals, 
cows,  and  cats.  It  is  also  worth  remembering  that  a  gravid 
uterine  comu  may  be  ruptured  from  external  forces,  kicks, 
blows,  &c.  :  and  occasionallv  a  s^ravid  cornu  mav  underiro  axial 
rotation  and  complete  detachment.  This  unusual  accident  has 
been  observed  in  the  hare  (Hutchinson),  in  the  cat  (Vivier),  ilie 
ewe  and  guinea-pig  (Ercolani).  Although  Mr.  Sutton  empha- 
sised the  fact  that  up  to  the  present  time  he  knows  of  no 
undoubted  case  of  tubal  gestation  in  a  mammal  except  woman, 
he  does  not  deny  its  existence.  Of  course  it  is  possible,  but  its 
occurrence  awaits  demonstration. 

The  President  thanked  Dr.  Pembrey  in  the  name  of  the 
Society  for  his  most  interesting  communication,  and  hoped  that 
it  would  be  followed  in  due  course  by  a  report  of  the  further 
investigation  which  the  author  had  expressed  his  intention  of 
carrying  out.  There  could  be  no  doubt  that  the  solution  of 
many  disputed  questions  in  human  obstetrics  would  be  greatly 
facilitated  by  a  better  knowledge  of  the  conditions,  normal  and 
abnormal,  met  with  in  the  study  of  the  gestation  process  in 
animals.  Dr.  Pembrey's  communication  had  been  fitly  supple- 
mented by  the  valuable  remarks  of  Mr.  Bland  Sutton,  to 
which  the  Fellows  had  listened  with  scarcely  less  interest  than 
they  had  listened  to  the  communication  itself.  The  President 
said  it  would  no  doubt  have  been  C[uite  as  much  a  surprise 
to  the  Fellows  generally  as  it  had  been  to  him,  to  learn  that  a 
genuine  sagittal  fontauelle  had   been  found  in  so  large  a  per- 


256  CYSTIC     FIBRO-MYOMA    OF    THE    UTERUS. 

centage  of  the  cases  in  which  it  had  been  looked  for.  Now 
that  attention  had  been  called  to  the  subject  no  doubt  other 
communications  would  be  forthcoming,  confirming  or  otherwise 
the  conclusions  of  Dr.  Lea  as  to  the  frequency  of  the  condition. 
He  thought  the  liability  of  this  extra  fontanelle  to  be  mistaken 
for  a  fracture,  the  result  of  violence,  had  an  important  medico- 
legal bearing  which  ought  not  to  be  lost  sight  of. 


CYSTIC  FIBRO-MYOMA  OF  THE  UTERUS  COM- 
PLICATING PREGNANCY— REMOVAL  AT  FOUR 
AND  A  HALF  MONTHS. 

Shown  by  J.  Dysart  McCaw,  M.D. 

This  tumour  Avas  removed  on  the  6th  October^  1897, 
from  a  patient  aged  34  years,  then  four  months  and 
a  half  pregnant  with  her  first  child.  She  had  been 
married  eight  years,  and  beyond  slight  dysmenorrhoea, 
and  occasional  attacks  of  migraine,  always  enjoyed  fairly 
good  health  from  marriage  until  she  was  pregnant  about 
a  month,  when  urgent  vomiting,  which  was  almost 
continuous,  commenced.  The  sickness  was  accompanied 
by  very  severe  abdominal  pain  which  was  intermittent, 
and  by  constipation  with  tympanites.  The  patient  was 
at  times  in  great  distress,  pulse  quick  and  weak,  but  the 
temperature  was  never  over  99°  F.  The  presence  of  the 
tumour,  owing  to  the  tympanitic  distension,  was  unnoticed 
until  between  the  third  and  fourth  months  of  pregnancy, 
when  the  irregular  shape  of  the  abdomen  suggested  it, 
and  a  growth  was  then  discovered  occupying  the  left  side 
of  the  abdominal  cavity  from  the  margin  of  the  ribs  down 
to,  and  into,  the  pelvis.  Dr.  Cullingworth  and  Mr. 
Henry  Morris  saw  the  patient  with  me  during  the  last 
week  of  September.  The  diagnosis  was  extremely  diffi- 
cult from  the  fact  that  this  subperitoneal  myoma  had  fallen 
backwards  ;    an'd  having  small  intestine   over  part  of  its 


ABOETION   SHOWING  RECENT   PLACENTAL   HEMORRHAGE.        257 

front  surface,  and  not  moving  with  the  uterus  nor 
causing  movement  of  the  uterus  when  itself  was  moved, 
it  gave  the  impression  of  being  a  retro-peritoneal  growth, 
and  presumably  a  fibro-lipoma  in  the  neighbourhood  of  the 
kidney.  Immediate  removal  of  the  growth  was  decided 
on,  and  Mr.  Morris  w^as  asked  to  operate,  w^hicli  he  did 
on  the  6th  of  October,  1897.  The  tumour,  which  proved 
to  be  a  cystic  fibro-myoma  of  the  uterus,  was  reached 
through  the  linea  semilunaris,  the  pedicle  being  cut  away 
in  a  wedge-shaped  manner  from  the  uterine  wall,  and  the 
cut  surfaces  brought  and  retained  together  by  silk  sutures. 
No  drainage-tube  was  required,  and  scarcely  any  blood  lost.. 
The  tumour  weighed  4  lbs.  The  patient  made  a  rapid 
recovery.  I  delivered  her,  with  the  aid  of  forceps,  of  a 
living  male  child  on  the  24th  February,  1898,  chloroform 
being  administered  by  my  neighbour  Dr.  Harper,  a  Fellow 
of  this  Society. 

At  this  date  (July,  1898)  both  mother  and  child  are  in^ 
perfect  health. 

The  President  said  that  when  he  saw  Dr.  McCaw's  patient 
he  certainly  came  to  the  conclusion  that  the  tumour  was  renal. 
Mr.  Henry  Morris  was  thereupon  consulted,  and  as  he  formed 
a  similar  opinion,  it  was  arranged  that  he  should  operate  for  its 
removal.  On  the  abdomen  being  opened,  both  Mr.  Morris  aud  he 
proved  to  have  been  wt'ong.  The  tumour  was  a  large  subperi- 
toneal fibroid,  springing  from  the  fundus  uteri  by  a  thick  pedicle. 
The  case  was  of  interest  not  only  on  account  of  the  difiiculty 
of  diagnosis,  but  as  a  good  illustration  of  an  operation  upon  the- 
pregnant  uterus  not  interfering  with  the  pregnancy. 


ABOETION    SHOWING    RECENT   PLACENTAL 
H^MORKHAOE. 

Shown  by  Robert  Wise,  M.D. 


258 


CARCINOMA  OF  CERVIX  UTERI  IN  WHICH  THE 
DISEASE  EXTENDED  UPWARDS  INTO  THE 
BODY. 

Shown  by  Walter  Tate,  M.D. 

The  patient  was  a  married  woman  aged  40,  who  had 
had  two  '  children .  Catamenia  were  regular  up  to  the 
middle  of  April,  1898.  Continuous  hgemorrhage  then 
commenced,  and  on  examination  six  weeks  later  the  cervix 
was  found  to  be  hard  and  infiltrated,  bleeding  very  much 
when  touched.  The  uterus  was  freely  mobile,  and  the 
broad  ligaments  were  not  implicated.  It  appeared  to 
be  a  very  favourable  case  for  operative  treatment. 
Vaginal  hysterectomy  was  performed  on  June  2nd,  but 
the  operation  was  rendered  very  difficult  o^ving  to  the 
friable  condition  of  the  cervix,  and  to  the  cellular  tissue 
between  the  bladder  and  cervix  being  diseased.  The 
question  arose  of  abandoning  the  operation,  but  it  was 
decided  to  endeavour  to  separate  the  tumour  from  the 
bladder.  During  the  separation  the  bladder  wall  was 
injured,  but  after  the  removal  of  the  uterus  the  opening 
was  closed  by  silk  sutures,  and  gave  rise  to  no  further 
trouble.  On  opening  up  the  uterus  after  removal  the 
disease  was  found  to  have  invaded  the  whole  thickness  of 
the  cervix,  and  extended  upwards  into  the  body  to  within 
half  an  inch  of  the  fundus.  Another  interesting  point  in 
the  case  was  the  extensive  amount  of  disease  present  in 
spite  of  the  short  history  of  haemorrhage .  The  fact  that 
the  patient  had  not  been  living  with  her  husband  for  a 
year  would  probably  account  for  the  late  occurrence  of 
the  haemorrhage.  The  case  also  illustrates  the  difficulty 
of  deciding  what  may  or  may  not  be  a  suitable  case  for 
operation.  The  presence  of  infiltration  of  the  cellular 
tissue  between  the  bladder  and  cervix  is  a  fact  which  it  is 
usually  only  possible  to  discover  after  the  operation  has 


OVARIAN    DERMOID    l^    MIDDLE    OF     PREGNANCY.  259 

iDeen  commenced^  as  it  does  not  necessarily  cause  any 
impairment  of  mobility  of  the  uterus,  and  cannot  be  made 
out  by  bimanual  examination. 


IISrCARCE  RATED  OVARIAN  DERMOID  IN  THE 
MIDDLE  OF  PREGNANCY;  MANUAL  ELEVA- 
TION; REMOVAL  A  FORTNIGHT  AFTER 
DELIVERY    AT    TERM. 

Shown  by  Herbert  R.   Spencer,  M.D. 

The  specimen  shown  is  a  dermoid  tumour  of  the  left 
ovary  measuring  4|-  x  3^  x  24-  inches,  and  possessing 
interest  from  the  circumstances  in  which  it  was  observed. 

M.  M — ,  aged  38,  had  had  nine  children,  the  first  eight 
of  which  were  born  easily  as  vertex  presentations,  but  the 
last  (June,  1896)  with  difficulty  by  the  breech. 

The  patient  was  sent  into  University  College  Hospital 
on  October  4th,  1897,  by  Dr.  Blacker,  who  had  diagnosed 
pregnancy  complicated  by  an  ovarian  tumour  incarcerated 
in  the  pelvis.  The  patient  was  four  and  a  half  months 
pregnant,  having  last  menstruated  at  the  end  of  May. 
Since  that  time  she  had  complained  of  pain  of  a 
"  niggling  and  gnawing ''  character,  situated  in  the  left 
loin  and  spreading  to  the  sacral  region.  The  pain  was  at 
first  intermittent,  but  had  been  constant  of  late.  During 
the  pregnancy  she  had  been  obliged  to  take  medicine  on 
account  of  constipation. 

On  the  patient's  admission  the  pregnant  uterus  rose  up 
for  seven  and  a  half  inches  above  the  pubes.  The  cervix 
was  high  up  and  pushed  forwards  by  a  tumour  of  the  size 
of  a  fist,  which  occupied  the  left  posterior  quarter  of  the 
pelvis,  was  almost  fixed,  somewhat  irregular  on  the  surface, 


260  INCARCERATED    OVARIAN    DERMOID 

and  generally  quite  hard,  tliougli  tliere  was  one  spot  at 
Avliich.  it  felt  rather  soft,  but  nowhere  could  fluctuation  be 
detected.  The  tumour  lay  in  front  of  the  rectum,  and 
movement  of  the  uterus  caused  slight  movement  of  the 
tumour,  which,  however,  could  not  be  pushed  upwards 
without  an  aDsesthetic.  Misled  by  a  case  I  had  recently 
seen,  I  was  inclined  to  regard  the  tumour  as  a  uterine 
fibroid  rather  than  an  ovarian  cyst. 

On  October  7th  I  easily,  under  an  ana3sthetic,  pushed 
up  the  tumour  out  of  the  pelvis  ;  it  then  lay  in  the  left 
hypochondriuHi.  In  this  situation  it  was  difficult  to 
examine,  but  it  could  be  made  out  to  fluctuate^  and  was 
thought  to  be  an  ovarian  dermoid. 

As  from  the  history  the  patient  Avas  four  and  a  half 
months  pregnant,  and  judging  from  the  size  of  the  uterus 
more  advanced  than  that,  it  was  thought  best  to  allow  the 
pregnancy  to  go  on  to  full  term,  and  to  remove  the  tumour 
after  delivery.  The  patient  wore  an  abdominal  binder 
during  the  rest  of  the  pregnancy,  and  had  no  recurrence 
of  the  pain  from  which  she  had  suffered  when  the  tumour 
was  incarcerated  in  the  pelvis. 

On  February  9tli,  1898,  the  patient  was  again  admitted 
into  the  hospital.  The  tumour  caused  some  bulging,  and 
fluctuated  in  the  left  flank  ;  the  half -girth  at  the  umbilicus 
was  twenty-one  inches  on  each  side.  The  child  was  lying 
in  the  first  vertex  position.  Labour  set  in  definitely  at 
midnight  of  March  5th— 6th.  Pains  were  good.  The  os 
was  fully  dilated  by  2.15  a.m.,  and  the  child,  which 
weighed  8  lbs.  13  oz.,  was  born  easily  at  2.45  a.m.  on  the 
6th,  in  the  first  vertex  position.  After  delivery,  which 
was  quite  normal,  the  tumour  lay  above  the  uterus,  and 
reached  up  for  five  and  a  half  inches  above  the  pubes. 
The  puerperium  was  normal,  the  temperature  and  pulse 
only  once  reaching  100. 

On  March  21st,  1898  (fifteen  days  after  delivery),  I 
removed  by  laparotomy  the  tumour  shown.  It  had  appa- 
rently not  increased  at  all  in  size  during  the  five  months 
it  had  been  under  observation.      The  pedicle  was  twisted 


IN    THE    MIDDLE    OF    PREGNANCY.  261 

lialf  a  turn  by  the  tumour  rotating  in  the  opposite  direc- 
tion to  that  of  the  hands  of  a  clock  when  the  tumour  was 
held  and  viewed  by  the  operator  standing  on  the  patient^s 
right.  The  convalescence  was  uninterrupted_,  the  tempe- 
rature not  rising  above  100'4°_,  and  the  pulse  not  above  108. 
The  patient  suckled  her  infant  from  the  first  day  after  the 
operation^  and  left  the  hospital  quite  well  on  April  16th 
with  the  infant,  which  was  thriving,  and  weighed  10  lbs. 
5  oz. 

I  think  that  most  experienced  ovariotomists  will  agree 
that  apart  from  pregnancy  ovarian  tumours  should  be 
removed  as  soon  as  practicable  after  the  diagnosis  is  made, 
and  that  generally  the  same  rule  applies  in  the  first  half 
of  pregnancy ;  during  the  second  half  of  pregnancy  there 
will  be  a  difference  of  opinion  as  to  its  applicability  in  the 
case  of  a  small  tumour  which  either  is  in  the  abdomen,  or 
can  be  safely  pushed  up  out  of  the  pelvis.  In  the  latter 
half  of  pregnancy  the  risk  of  premature  labour  and 
perhaps  of  slipping  of  the  pedicle  ligature  is  greater,  a 
longer  incision  may  be  necessary,  and  there  is  more 
difficulty  in  accurately  suturing  the  wound,  and  increased 
risk  of  hernia  at  the  scar  from  the  continual  increase  in 
the  tension  of  the  abdomen.  In  the  case  of  a  large 
tumour  or  of  a  small  incarcerated  tumour  which  cannot 
safely  be  pushed  up  into  the  abdomen  these  increased 
risks  should  be  taken ;  but  for  small  moveable  tumours  I 
believe  the  practice  adopted  in  the  above  case  is  generally 
to  be  preferred. 

Dr.  Peter  Horrocks  pointed  out  that  cystic  tumours  when 
under  great  pressure  became  so  tense  as  to  simulate  solid 
tumours,  in  that  they  felt  quite  hard,  and  no  thrill  and  no 
fluctuation  could  be  obtained.  This  was  very  clearly  shown  in 
this  case,  because  after  the  dermoid  cyst,  which  felt  solid  whilst 
under  pressure  in  the  pelvis,  had  been  pushed  up  into  the 
abdomen  and  so  relieved  of  the  pressure,  it  at  once  became 
obvious  that  it  was  cystic,  and  fluctuation  was  easily  obtained. 
He  mentioned  a  case  of  a  multilocular  suppurating  ovarian  cyst 
which  obstructed  labour  at  term,  and  which  was  diagnosed  as  a 
fibroid  owing  to  the  solid  feel  of  it.     It  was  tapped  and  subse- 

VOL.  XL.  18 


262  OVARIAN    DERMOID    IN    MIDDLE    OP    PREGNANCY. 

quently  more  freely  opened  'per  vaginam,  and  emptied  sufficiently 
to  allow  of  delivery  of  the  child.  This  case  occurred  mauy  years 
ago,  and  the  patient  subsequently  had  a  discharge  of  pus  through 
the  abdominal  wall  and  per  rectum  which  exhausted  her.  He 
did  not  think  any  rigid  rule  could  be  made  with  regard  to  the 
best  time  for  removing  tumours  when  complicated  by  pregnancy. 
Each  case  must  be  considered  on  its  merits ;  but  he  certainly 
thought  Dr.  Spencer  had  done  the  best  thing  in  this  case  by 
waiting  until  after  parturition  before  doing  abdominal  section. 
Dr.  Spencer  in  reply  said  he  quite  agreed  with  Dr.  Horrocks 
as  to  the  difficulty  of  distinguishing  between  cystic  and  solid 
tumours  in  the  pelvis  during  pregnancy.  Fibroid  tumours, 
ovarian  cysts,  and  hydatid  cysts  closely  resembled  each  other 
under  these  circumstances,  and  the  diagnosis  between  them  was 
only  easy  for  the  inexperienced.  He  noticed  that  Dr.  Horrocks 
had  some  years  ago  tapped  a  suppurating  tumour,  but  he  was 
sure  that  now-a-days  Dr.  Horrocks  would  remove  the  tumour. 
Suppuration  not  uncommonly  occurred  in  ovarian  tumours 
after  labour,  either  from  bruising  or  strangulation  or  external 
infection.  Should  suppuration  occur  or  threaten  he  would  at 
once  remove  the  tumour ;  he  had  done  this  in  five  suppurating 
ovarian  tumours  after  labour,  with  recovery  in  each  case.  He 
saw  no  objection  to  operating  as  early  as  a  fortnight  after 
delivery,  or  earlier  if  necessary. 


263 


THE  SAaiTTAL  FONTANELLE  IN  THE  HEADS 
OF  INFANTS  AT  BIRTH. 

By  Arnold  W.  W.  Lea,  M.D.,  B.S.,  F.R.C.S. 

(Received  December  18th,  1897.) 

Abnormal  fontanelles  have  been  known  to  be  present 
occasionally  in  the  head  of  the  foetus  at  birth  for  many 
years.  Several  of  these  membranous  spaces  are  described, 
and  of  these  there  is  one  which  is  of  some  interest  to 
obstetricians,  namely,  the  sagittal  fontanelle. 

The  head  of  the  infant  at  birth  is  usually  completely 
ossified  except  along  the  lines  of  the  sutures,  and  at  the 
anterior,  posterior,  and  lateral  fontanelles.  If,  however, 
a  systematic  examination  of  the  heads  of  children  at  birth 
be  made,  areas  of  deficient  ossification  will  be  found  to  be 
not  uncommon.  This  is  more  especially  to  be  observed 
along  the  course  of  the  sagittal  suture  and  over  the  region 
of  the  parietal  bones,  but  at  times  other  membranous  spaces 
are  found. 

The  following  observations  are  based  upon  the  examina- 
tion of  500  consecutive  cases  at  birth. 

Four  abnormal  fontanelles  have  been  described. 

1.  The  naso-frontalj  a  small  space,  first  described  by 
Henry  in  1869,  between  the  lower  inferior  angles  of  the 
frontal  bone  and  the  nasal  bones. 

2.  The  cerebellar,  of  which  an  instance  is  also  recorded 
by  Henry.  It  is  situated  in  the  median  line,  close  to  the 
base  of  the  occipital  bone. 


264  SAGITTAL    FONTANELLE    IN    THE 

3.  The  medio-frontalj  situated  a  little  above  the  root  of 
the  nose,  between  the  two  frontal  bones.  According  to 
Gerdy,  this  is  met  with  in  one  per  cent,  of  cases  examined 
at  birth,  and  may  persist  for  some  months,  as  in  a  case 
recorded  by  Hemy. 

These  fontanelles  are  extremely  rare.  In  this  series  of 
cases  I  have  observed  one  example  of  the  medio-frontal 
space,  and  none  of  the  cerebellar  or  naso-frontal.  They 
are  of  no  obstetrical  importance,  and  we  need  not  further 
consider  them.  They  may,  however,  at  times  become  the 
seat  of  a  meningocele. 

4.  The  ,sagittal  fontanelle  was  first  accurately  described 
by  Gerdy  in  1837. 

It  is  remarkably  constant  in  position,  being  situated  two 
centimetres  in  front  of  the  posterior  f ontanelle,  and  is  always 
on  a  transverse  line  drawn  between  the  two  parietal  emi- 
nences. The  size  and  shape  of  the  fontanelle  vary  con- 
siderably. In  a  typical  case  it  is  lozenge-  or  diamond- 
shaped,  the  long  diameter  being  transverse,  and  its  ex- 
tremities directed  towards  the  parietal  eminence  on  each 
side.  The  average  length  is  IJ  cm.  (f  of  an  inch),  and  it 
is  1  cm.  or  f  of  an  inch  in  width.  The  size,  however,  is 
subject  to  great  variation.  In  very  slight  cases  it  may  be 
little  more  than  a  mere  notch  in  the  course  of  the  sao-ittal 
suture  ;  whereas  in  other  instances  the  space  may  extend 
laterally  almost  to  the  parietal  eminence,  forming  then  a 
membranous  space  as  large  as  the  anterior  fontanelle. 
Again  it  may  only  be  developed  unilaterally.  It  then 
forms  a  triangular  membranous  space  of  variable  extent. 
This  was  described  by  Grerdy,  and  one  instance  is  recorded 
I)y  M.  Hemy.  The  edges  of  this  membranous  space  are 
usually  formed  of  well-developed  bone,  but  at  times,  as 
will  be  seen,  there  is  deficient  ossification  of  the  posterior 
parts  of  the  parietal  bones  in  addition. 

Frequency. — In  500  consecutive  cases  a  well-marked 
sagittal  fontanelle  was  found  to  be  present  in  22  instances, 
thus  giving  a  frequency  of  4*4  per  cent.  This  agrees 
fairly  well  with  the  percentages  observed  by  others. 


HEADS    OF    INFANTS    AT    BIETH.  265 

In  eacli  of  tliese  cases  a  well-marked  membranous 
space  was  present.  Cases  which  showed  only  a  notch  in 
the  parietal  bone  in  this  region  were  more  frequent^  and 
were  not  included  in  the  table.  The  fontanelle  was 
lozenge-shaped  and  bilateral  in  seventeen  cases.  It  was 
unilateral  and  triangular  in  five  cases.  In  four  instances 
the  membranous  space  extended  up  to  the  parietal 
eminences  on  each  side. 

Period  of  closure. — The  fontanelle  usually  closes  within 
the  first  three  months  of  life.  It  has  not  been  possible 
to  verify  this  for  all  the  cases^  inasmuch  as  some  of  the 
children  were  observed  in  hospital,  and  were  not  seen 
after  three  weeks.  It  is,  however,  by  no  means  uncommon 
for  the  fontanelle  to  be  present  in  children  at  a  much 
later  period  of  life.  I  have  at  present  under  observation 
five  cases  in  which  the  fontanelle  is  present,  the  ages  of 
the  children  being  as  follows  :  two  aged  4  months,  one 
aged  5  months,  and  two  aged  8  months. 

The  space  is  usually  closed  in  by  extension  of  bone 
formation  from  the  parietal  bones.  Occasionally  a  Wor- 
mian bone  is  developed  in  this  situation. 

Development. — The  parietal  bone  is  developed  in  mem- 
brane. During  the  eighth  week  two  bony  centres  appear 
in  the  region  of  the  parietal  eminence,  and  from  this 
point,  radiating  osteogenic  fibres  pass  towards  the  borders 
of  the  .bone.  These,  however,  leave  a  gap  for  a  time  in 
the  region  of  the  parietal  fontanelle,  forming  thus  a 
membranous  space.  This  is  usually  closed  at  the  end  of 
the  third  month  of  foetal  life.  In  most  cases,  however, 
even  at  the  end  of  the  fifth  month  a  trace  of  this  fon- 
tanelle will  be  found. 

The  parietal  fontanelle  may  persist  throughout  life, 
forming  then  the  well-known  parietal  fissures  ;  and  the 
parietal  foramina,  present  in  the  majority  of  adult  skulls, 
and  transmitting  a  small  vein,  are  the  remains  of  this  lon- 
tanelle.  M.  Broca,  in  1875,  read  a  paper  on  this  subject 
of  the  parietal  fissure,  and  showed  several  skulls  in  which 
a  large  membranous  space  existed  in  this  region,  and  others 


266  SAGITTAL    FONTANELLB    IN    THE 

showing  a  large  circular  parietal  foramen  on  each  bone. 
M.  Grratiolet  has  also  pointed  out  that  in  the  ancient 
troglodyte  skulls  these  fissures  and  large  parietal  foramina 
are  very  common.  They  are  also  now  met  with  more 
frequently  in  the  lower  races  of  mankind. 

Significance. — The  parietal  fontanelle  has  a  certain 
amount  of  importance  in  practical  midwifery. 

In  the  first  place,  the  presence  of  a  large  sagittal 
fontanelle  may  cause  difficulty  in  diagnosing  the  position 
of  the  child's  head  in  the  pelvis.  In  fact,  it  was  this 
difficulty  which  fi.rst  drew  my  attention  to  this  subject. 
When  well  developed  this  space  closely  resembles  the 
anterior  fontanelle,  and  can  only  be  distinguished  from  it 
by  careful  palpation  of  a  considerable  area  of  the  child's 
head.  It  is  found  to  be  situated  within  one  inch  of  the 
small  posterior  fontanelle,  and  there  is  also  no  tendency 
for  the  bony  margins  of  the  space  to  override  as  in  the 
case  of  the  anterior  fontanelle. 

Secondly,  it  is  certain  that  deficient  ossification  in 
this  region,  and  especially  the  presence  of  a  sagittal 
fontanelle,  is  an  important  factor  in  the  moulding  of  the 
child's  head  during  labour.  Budin  has  shown  that  in 
vertex  presentations  the  parietal  bones  become  more 
convex  in  an  antero-posterior  direction,  forming  an  arc  of 
a  circle  of  continually  diminishing  radius.  It  will  be 
found,  if  the  child's  head  be  examined  immediately  after 
labour  (in  occipito-anterior  presentations) ,  that  the  summit 
of  the  longitudinal  convexity  of  the  parietal  bones  is  at 
the  position  of  the  sagittal  fontanelle. 

Thirdly,  in  cases  when  this  fontanelle  is  large,  and 
more  especially  if  it  is  unilateral,  it  may  be  thought  that 
the  skull  has  sustained  a  fracture  during  natural  delivery, 
or  by  the  use  of  the  forceps.  Sometimes  a  haematoma  is 
developed  in  this  situation,  which  in  one  instance  showed 
distinct  pulsation  transmitted  from  the  cerebrum. 

I  have  not  been  able  to  find  any  recorded  instance  of 
meningocele  having  been  observed  in  this  situation. 


HEADS    OP    INFANTS    AT    BIRTH.  267 

Note  on  Deficient  Ossification  of  the  Parietal  Bones. 

It  mil  be  observed  from  the  table  of  cases  that  the 
parietal  fontanelle  is  frequently  associated  with  deficient 
ossification  of  the  posterior  parts  of  the  parietal  bones. 
Thus  in  six  cases  more  or  less  bony  deficiency  was 
observed,  i.  e.  in  27*2  per  cent,  of  cases.  This  is  un- 
doubtedly a  much  larger  proportion  than  is  observed 
generally  in  the  heads  of  infants  at  birth,  and  points  to 
the  conclusion  that  the  parietal  fontanelle  must  be  con- 
sidered as  an  abnormal  condition,  the  result  of  delayed 
ossification. 

There  does  not  appear  to  be  any  connection  between 
the  presence  of  the  parietal  fontanelle  and  the  nutrition 
of  the  mother  or  foetus. 

The  vast  majority  of  the  infants  were  well  developed 
in  every  other  respect,  and  of  average  weight. 

In  only  one  case  was  there  any  evidence  of  congenital 
syphilis. 

Conclusions, 

(1)  The  sagittal  or  parietal  fontanelle  is  present  in  4'4 
per  cent,  of  infants  at  birth. 

(2)  It  is  usually  bilateral  and  lozenge-shaped  (76  per 
cent.),  more  rarely  it  is  unilateral  and  triangular  (24  per 
cent.). 

(3)  It  closes  within  the  first  two  months  of  life,  but  at 
times  may  remain  open  for  at  least  eight  months  after 
birth,  and  possibly  longer. 

(4)  It  is  frequently  associated  Avith  deficient  ossification 
of  the  posterior  parts  of  the  parietal  bones. 

(5)  Its  presence  does  not  appear  to  be  associated  with 
any  constitutional  condition  of  the  infant  or  the  mother. 

(6)  During  delivery  it  may  lead  to  error  or  confusion 
in  diagnosing  the  presentation. 

(7)  It  is  probably  of  some  use  in  facilitating  the 
moulding  of  the  head  in  vertex  presentations. 

(8)  It  may  simulate  fracture  or  injury  of  the  skull. 


268  SAGITTAL    PONTANELLE    IN    THE 

List  of  Cases  in  which  the  Parietal  Fontanelle  was  present. 


No. 

Period 

of  gesta- 
tion. 

Weight 

of 
infant. 

1 

Full 
term 

6  1b. 

7  oz. 

2 

j> 

7  1b. 
5  oz. 

3 

S^mos. 

5  lb. 

4 

Full 
term 

7  1b. 
5  oz. 

5 

55 

5  lb. 

6 

55 

7  1b. 
6oz. 

7 

55 

7  1b. 
1  oz. 

8 

55 

7  lb. 
4  oz. 

9 

Full 
term 

7  lb. 
3  oz. 

10 

» 

7  1b. 
5  oz. 

11 

>i 

7  1b. 
10  oz. 

12 

>t 

6  lb. 
3  oz. 

Cliaracter 

of 

labour. 


Description  of  fontanelle. 


Forceps  |  Unilateral  fontanelle  (rigbt)  Primi-        — 
recognised  during  first  stage    para, 
of  labour  set.  32 


Natural 


Low 
forceps 

Natural 


Low 
forceps 


Natural 


Natural 


Mater- 
nal 
history. 


Remarks  on 
condition 
of  motlier. 


Unilateral  fontanelle  (right); 
deficient  ossification  in  pos- 
terior part  of  rigbt  parietal 
bone;  haematoma 

Bilateral  tontanelle 


Bilateral  fontanelle  (observed 
during  labour) 


Bilateral  fontanelle 


Bilateral  fontanelle;  deficient 
ossification  of  posterior  por- 
tion of  right  parietal  bone 
(observed  before  applying 
forceps) 

Unilateral  fontanelle 


Unilateral  fontanelle  extend- 
ing almost  to  parietal  emi- 
nence 

Bilateral  fontanelle 


Bilateral  fontanelle 


Bilateral  fontanelle 


Primi-      Very- 
para,    anaemic, 
set.  19 


Primi-        — 
para,  [ 
set.  22 

Primi-'  Develop- 

para,  ' ed  acute 
set.  30     mania. 

Primi- 1       — 
para,  | 
set.  22 

Primi-*  Syphilis, 
para,  ! 
ait.  27 : 


4-para i 


■para 


Primi- 

para,  i 
set.  17 

3-para,        — 
ffit.  27 , 
t 
2 -para.      Had 
set.  28   phthisis. 


BiUiteral     fontanelle;     bony  Primi-        — 
deficiency  of  posterior  part:  para, 
of  both  parietal  bones  (ob-  set.  35 
served  during  labour) ;  has 
also  talipes 


HEADS    OF    INFANTS    AT    BIETH. 


269 


No. 
13 

Period 
of  gesta- 
tion. 

Weight 

ot 
infant. 

Character 

of 
labour. 

Description  of  fontanelle. 

Mater-  Remarks  on 
nai      ;   condition 
history.  I  of  mother. 

i 

8  m  08, 

5  lb. 

» 

Large  bilntei'al  foutauelle 

Primi - 

13  oz. 

para 

14 

»j 

4  1b. 

j> 

Bilateral  fontanelle;  deficient 

Primi-       Had 

2  oz. 

ossification  of  posterior  por-    para,      mitral 
tions  of  both  parietal  bones  set.  25    stenosis. 

15 

Full 

71b. 

>> 

Large     bilateral     fontanelle  Primi-        — 

term 

reaching  parietal  eminence 

para, 
iet.  31 

16 

j» 

7  1b. 
10  oz. 

)> 

Bilateral  fontanelle 

Primi- 
para 

— 

17 

>• 

5  lb. 
8  oz. 

>' 

Bilateral  fontanelle;  deficient  Multi- 
ossification   over  both  pari-    para 

— 

etals  posteriorly  (has  spina 
bifida) 

18 

>j 

6  1b. 
12  oz. 

j> 

Bilateral  fontanelle;  deficient 
ossification   of  left  parietal 
bone,  with  hsematoma 

Multi- 
para 

— 

19 

j> 

7  1b. 

Forceps 

Large  bilateral  fontanelle 

Multi- 
para 

— 

20 

„ 

6  1b. 
4  oz. 

Natural 

Unilateral  fontanelle 

Primi- 
para 

— 

21 

)t 

71b. 

» 

Bilateral  fontanelle 

Primi- 
para 

— 

22 

>t 

— 

jj 

Bilateral  fontanelle 

Multi-        — 

para 

1 

Keferences. 

AuGiER. — '  Sur  les  Trous  parietaux/  These  de  Paris. 

Broca. — ^Bullet.  Soc.  d'Aiithropologie  de  Paris/  1875. 

BuDiN.— 'Tete  du  Foetus/  p.  170. 

Cazeadx. — '  Art  des  Accouchements.^ 

Gerdy. —  ^  Recherclies  d' Anatomic/  &c.,  These  d& 
Paris,  1837. 

Hemy. — '  Fontanelles  anormales  du  Crane  humain/ 
Paris,  1871. 

Quain. — '  Anatomy/  vol.  i,  p.  2. 


270   SAGITTAL  FONTANELLE  IN  INFANTS^  HEADS  AT  BIRTH. 

Dr.  Herman  thouglit  the  Society  was  to  be  congratulated  on 
having  the  laborious  and  careful  investigation  of  Dr.  Lea. 
Two  practical  points  ai'ose  out  of  it.  The  first  was  that  a 
sagittal  fontanelle  might  mislead  one  who  diagnosed  the  foetal 
position  by  feeling  the  sutures  and  fontanelles.  But  this  would 
not  trouble  one  who  was  accustomed  to  diagnose  the  position 
by  abdominal  palpation.  The  second  was  that  a  sagittal 
fontanelle  indicated  backward  ossification,  which  would  enable 
the  head  to  undergo  considerable  moulding ;  its  presence,  there- 
fore, might  invite  a  trial  with  forceps  in  a  case  which  with  a  very 
bard  head  would  call  for  perforation. 

Dr.  Herbert  Spencer  was  surprised  to  hear  that  the  fonta- 
nelle had  been  found  in?  4*4  per  cent,  of  the  cases  examined. 
He  asked  Dr.  Lea  whether  his  observations  were  clinical  or 
post-mortem.  He  (Dr.  Spencer)  was  well  acquainted  with 
fissures  in  the  parietal  bone,  which  were  common,  and  every 
obstetrician  knew  how  depressible  the  upper  edge  of  the  parietal 
bone  often  was;  what  was  really  only  a  fissure  might  therefore 
appear  under  pressure  of  the  finger  as  a  space;  but  having 
carefully  examined  the  skulls  of  over  300  new-born  infants 
post  mortem,  he  had  not  met  with  one  instance  of  a  sagittal 
fontanelle  at  all  comj^arable  to  the  anterior  fontanelle.  He  had, 
however,  met  with  a  fenestra  on  two  occasions,  and  also  with 
insular  ossification  and  total  absence  of  ossification  in  the 
parietal  bones  of  mature  foetuses.  He  gathered  that  Dr.  Lea's 
observations  were  made  on  the  living  infant,  but  he  (Dr. 
Spencer)  had  no  doubt  that  as  a  considerable  anatomical  space 
the  sagittal  fontanelle  occurred  with  much  greater  rarity  than 
that  given  by  Dr.  Lea  as  a  result  of  his  clinical  observation. 

Dr.  Lea  stated  that  the  percentage  of  cases  of  parietal 
fontanelle  observed  by  him  was  similar  to  that  of  Mr.  Hemy. 
In  many  infants  the  fontanelle  became  much  smaller  a  few  days 
after  birth,  but  in  children  some  months  old  instances  in  which 
it  remained  open  were  not  uncommon.  He  had  examined  two 
cases  in  which  the  infants  died  soon  after  delivery.  In  one 
instance  a  linear  fracture  extended  from  the  fontanelle  out- 
wards over  the  parietal  eminence,  the  result  of  injury  during 
delivery. 


271 


NOTE  ON  SOME  DIFFICULT  CASES  OF  FRONTO- 
ANTERIOH  POSITIONS  OF  THE  FGETAL  HEAD. 

By  Gi-EORGE  Roper,  M.D., 

CONSULTING    PHYSICIAN    TO    THE    EOYAL    31ATEENITY   CHAEITY. 

(Received  March  7th,  1898.) 

After  an  extensive  experience  in  difficult  labours,  I 
never  felt  satisfied  with  the  knowledge  I  had  of  the 
nature  and  correct  treatment  of  the  difficulties  connected 
with  the  fronto-anterior  positions  of  the  foetal  head  in 
labour.  Given  a  child  of  ordinary  size  and  a  fairly 
formed  pelvis,  most  of  these  cases  will  end  naturally. 
But  with  a  child  beyond  average  size,  or  with  a  small  or 
slightly  misshapen  pelvis,  considerable  difficulties  occur. 
It  was  not  till  reading  Dr.  Herman's  remarks  in  his 
book  on  ^  Difficult  Labour  '  that  the  problem  was  solved 
to  me. 

Dr.  Herman  particularly  calls  attention  to  the  position 
of  the  foetal  trunk,  ahdomino-anterior,  and  gives  directions 
for  its  diagnosis  by  abdominal  palpation  when  conditions 
are  favourable  for  such  an  examination,  as  the  absence  of 
a  thick  layer  of  abdominal  fat.  But  diagnosis  by  this 
method  is  not  necessary,  for  if  we  can  feel  the  foetal  head 
in  a  fronto-anterior  position,  this  is  a  certain  index  that 
the  trunk  is  in  a  position  abdomino-anterior.  Dr. 
Herman's  directions  as  to  rotating  the  trunk  into  an 
abdomino-posterior  position  are  of  first  importance,  and  if 
possible  rotation  should  be  effected.  For  its  successful 
performance  we  require — 


272  ON    SOME    DIFFICULT    CASES    OF    FROISTO-ANTEEIOE. 


POSITIONS    OF    THE    FCETAL    HEAD.  273 

(1)  An  abdomen  not  thickly  covered  by  fat. 

(2)  Unruptured  or  but  recently  ruptured  membranes. 

(3)  A  non-contracted  state  of  the  uterus. 

If  the  trunk  can  be  rotated,  rotation  of  the  head  will 
follow.  If  there  is  failure  in  rotating  the  trunk,  the  head 
must  be  dealt  with. 

Dr.  Herman  sums  up  the  treatment  : 

A.  To  pull. 

B.  To  flex. 

c.  To  rotate. 

In  many  of  these  difficulties  delivery  is  not  effected 
by  any  of  these  proceedings.  Long-continued  and 
forcible  traction  with  forceps  will  fail.  The  instrument 
cannot  be  easily  fitted  to  the  head  in  the  fronto-anterior 
position.  There  is  difficulty  in  locking  the  blades  without 
injurious  pressure  on  the  foetal  head.  The  instrument 
will  often  slip  (unless  each  blade  is  pushed  up  beyond 
the  occipital  pole,  and  then  the  head  is  grasped  in  its 
widest  diameter — bi-parietal),  and  hence  hurtful  pressure 
on  the  cranium  may  result."^ 

It  is  evident  that  the  position  of  the  head  is  dependent 
on  that  of  the  trunk.  I  hope  to  demonstrate  by  reports 
of  two  cases  that  the  greater  difficulty  in  delivery  is  due 
to  the  dorso-posterior  position  of  the  trunk,  and  that  the 
position  of  the  head  is  a  minor  factor  of  the  difficulty. 
The  dorsal  surface  of  the  foetus  is  composed  of  parts  which 
are  firm  and  incompressible.  They  are  the  upper  part 
of  the  dorsal  spine,  the  scapulas,  the  backs  of  the  ribs,  and 
the  backs  of  the  shoulder-joints.      These  parts  pressed  on 

*  I  have  seen  iutra-cranial  haemorrhage  from  such  pressure.  I  was  once 
called  to  the  assistance  of  an  experienced  and  careful  practitioner  in  such 
a  case.  Severe  pressure  had  been  made  on  the  head  to  secure  the  locking  of 
the  forceps.  Long-continued  and  forcible  traction  had  been  used  with  no 
good  result.  On  attempting  to  withdraw  the  forceps  one  blade  came  away 
easily  but  the  other  could  not  be  withdrawn.  I  passed  my  hand  along  the 
blade  and  found  a  compound  dislocation  of  the  posterior  inferior  angle  of  the 
parietal  bone.  The  sharp  point  of  bone  had  passed  through  the  fenestra  of 
the  blade  and  fixed  it.  When  the  angle  of  bone  was  pushed  back  the  blade 
was  easily  withdrawn. 


274  ON    SOME    DIFFICULT    CASES    OP    FRONTO-ANTERIOE 

the  lower  lumbar  vertebrae  throw  the  trunk  into  a  state 
of  extension ;  the  shoulders  are  thrown  back  or  squared, 
the  distance  from  point  to  point  of  them  being  increased; 
the  foetus  cannot  be  folded  into  a  compact  ovoid  form  as 
in  the  abdomino-posterior  position.  So  far  as  I  know 
none  of  the  text-books  refer  to  these  conditions  as  consti- 
tuting the  difficulty. 

Case  1. — Mr.  Perry,  surgeon  of  Reepham,  Norfolk, 
asked  me  to  assist  him  in  a  case  of  difficult  labour.  The 
patient  was  a  young  woman  in  labour  with  her  second 
child.  Her  first  child  was  born  alive  after  a  very  hard 
labour.  The  abdomen  was  loaded  with  fat,  the  liquor 
amnii  had  been  long  discharged,  so  there  was  no  hope  of 
rotating  the  trunk.  The  head  was  fronto-anterior,  and 
the  scalp  much  swollen.  Long-continued  and  forcible 
efforts  had  been  unsuccessfully  made  with  forceps.  The 
patient  was  much  exhausted.  Perforation  was  decided 
on.  The  head  was  reduced  to  the  smallest  dimensions  by 
the  cephalotribe.  Traction  with  this  instrument  firmly 
secured  on  the  remains  of  the  head  failed  to  bring  the 
shoulder  through  the  pelvic  brim.  The  craniotomy  forceps 
and  crochet  were  used  without  success.  Podalic  version 
was  attempted,  and  with  some  little  difficulty  a  foot  was 
secured  and  brought  down  as  far  as  the  brim.  A  loop  of 
cord  was  passed  round  the  ankle,  and  by  traction  on  this 
and  pushing  the  head  upwards  version  was  completed.^ 

Case  2. — This  same  patient  in  her  third  labour  again 
had  a  fronto-anterior  presentation.  This  time  she  was 
attended  by  Dr.  Bansall  of  Aylsham,  Norfolk.  The 
conditions  in  this  labour  were  much  the  same  as  in  the 

*  In  podalic  version  of  this  kind  there  is  some  difficulty  in  bringing  down 
the  foot,  as  the  head  occupies  the  brim.  Many  years  ago  Messrs.  Krohne 
and  Sesemann  made  an  instrument  for  me  for  snaring  a  foot.  Armed  with  a 
stifE  kind  of  material — as  a  piece  of  leather  boot-lace,  whipcord,  or  catgut 
(I  prefer  these  materials,  as  they  do  not  become  soaked  by  fluid  as  tape  does)  — 
a  noose  is  easily  slipped  over  the  foot,  and  by  a  few  turns  of  the  instrument  is 
securely  fixed  round  the  ankle.     The  idea  is  taken  from  Braun's  instrument. 


POSITIONS    OF    THE    FCETAL    HEAD.  275 

former  one.  Forceps  had  been  used  to  tlie  utmost  extent 
as  regards  botli  duration  and  force.  Dr.  Bansall  asked 
me  to  see  lier,  and  I  decided  to  deliver  by  podalic  version. 
The  hand  was  passed  up  one  of  the  sacro-iliac  angles,  and 
a  foot  brought  down  to  the  pelvic  brim  and  snared  as  in 
the  former  case.  The  child  livedo  and  the  mother  made 
a  good  recovery. 

I  have  recorded  the  first  case  to  demonstrate  that  as 
the  crushed  head  could  not  have  been  the  obstacle  to 
delivery,  this  obstacle  must  have  been  the  shoulders  at 
the  brim,  the  trunk  being  dorso-posterior.  So  far  as  I 
know,  no  text-book  refers  to  this  position  as  the  cause  of 
the  difficult  delivery,  except  what  is  given  in  Dr.  Hermanns 
work.  But  in  treatment  he  says  nothing  about  podalic 
version. 

In  performing  this  operation,  if  in  gently  bringing 
down  a  foot  the  toes  are  directed  towards  the  mother's 
back  the  abdomen  will  readily  turn  in  the  same  direction. 
It  is  important  that  the  trunk  should  be  rotated  into  an 
abdomino-posterior  position.  The  cases  I  have  recorded 
are  only  two,  and  it  may  be  remarked  that  they  are  not 
sufficient  for  a  correct  conclusion  to  be  drawn  from  them ; 
but  I  could  give  many  others  which  occurred  to  me  during- 
my  term  of  office  in  the  Royal  Maternity  Charity.  I 
believe  that  in  such  cases,  after  a  moderate  trial  with 
forceps,  podalic  version  is  the  correct  mode  of  delivery 
in  the  interest  of  both  mother  and  child.  In  future  I 
should  prefer  to  call  these  cases  ahdoTnino-anterior  rather 
than  fronto-anterior,  to  emphasise  the  importance  of  the 
position  of  the  trunk  in  making  labour  difficult. 

Dr.  Herman  thought  that  Dr.  Roper  had  done  service  in 
calling  attention  to  the  fact  that  the  mechanism  of  delivery  did 
not  depend  only  upon  the  relation  of  the  head  to  the  j)elvis.  The 
position  of  the  trunk  affected  that  of  the  head  when  the  occiput 
was  behind,  in  that  the  foetal  spine,  having  opposed  to  it  the 
lumbar  convexity  of  the  mother's  spine,  was  apt  to  become 
extended.  This  extension  carried  the  occij^ito-spinal  joint  in 
front  of  the  line  along  which  the  foetal  axis  pressure  acted,  and 


276         FRONTO-ANTERIOE    POSITIONS  OF  THE   FCETAL   HEAD. 

tliiis  led  to  extension  of  the  head.  He  could  also  understand 
that,  as  Dr.  Roper  pointed  out,  when  the  foetal  spine  was  flexed, 
and  its  concave  abdominal  aspect  applied  to  the  mother's 
lumbo-sacral  convexity,  it  would  enter  the  pelvis  more  easily 
that  when  the  reverse  condition  obtained. 

Dr.  Peter  Horrocks  quite  agreed  with  Dr.  Herman  and  Dr. 
Koper,  both  in  regard  to  the  fact  that  the  uterine  forces  tended 
to  drive  the  head  into  increased  extension,  and  to  the  probable 
explanation  that  it  was  owing  to  the  spine  of  the  child  being 
thrust  forwards  by  the  convexity  of  the  lumbar  spine  of  the 
mother.  But  he  thought  this  only  obtained  when  the  head  bad 
descended  a  little  way  only.  After  its  descent  still  further  into 
the  pelvis  the  body  of  the  child  got  thrown  further  forwards, 
and  the  uterine  forces  then  tended  to  flex  the  head.  The 
various  conditions  enumerated  by  Dr.  Roper  in  regard  to  the 
possibility  of  rotating  the  child  resolved  themselves  really  into 
one  thing,  namely,  the  mobility  of  the  foetus  in  uterd.  Where 
there  was  good  mobility,  as  when  the  membranes  were  un- 
ruptured, or  only  recently  ruptured,  then  the  proper  thing  to 
do  was  to  rotate  the  child  so  as  to  bring  the  occiput  in  front. 
Where  the  mobility  was  not  good,  but  was  still  present  to  some 
degree,  as  when  the  liquor  amnii  was  scanty,  or  where  it  had 
drained  away  for  some  time,  then  rotation  might  be  impossible, 
but  version  might  be  possible.  Lastly,  when  there  was  very 
little  or  no  mobility,  as  when  the  liquor  amnii  had  drained  away 
almost  entirely,  and  the  uterus  had  contracted  down  on  the  child, 
then  it  would  be  highly  dangerous  to  attempt  either  rotation  or 
version,  and  the  23ro23er  thing  to  do  was  perforation  and  dimi- 
nution of  the  bulk  of  the  child's  head  by  cephalotripsy  if  need 
be. 


OCTOBER  5th,  1898. 

C.  J.  CuLLiNGWORTH,  M.D.,  President,  in  the  Chair. 

Present — 28  Fellows  and  1  visitor. 

Books  were  presented  by  Dr.  Playfair,  Prof.  Ahlfeld, 
Dr.  G.  Porter  Mathew,  the  St.  Bartholomew's  Hospital 
Staff,  and  the  University  at  Christiania. 

Godfrey  D.  Hiudley,  L.R.C.P.Lond.,  was  admitted  a 
Fellow  of  the  Society. 

John  Edward  Cemmell,  M.B._,  C.M.Edin.  (Liverpool), 
was  declared  admitted. 

Francis  James  Lee,  M.R.C.S.Eng.,  was  elected  a 
Fellow. 

The  following  gentlemen  were  proposed  for  election  : — 
Arthur  Scott  Turner,  L.R.C.P.Lond.  ;  Ha3^dn  Brown, 
L.R.C.P.Edin.;  Charles  F.  Ward,  F.R.C.S.I.  (Pieter- 
maritzburg). 


CASE  OF  PUERPERAL   SEPTICEMIA  TREATED 
BY  ANTISTREPTOCOCCIC   SERUM. 

By  J.  Walters,  M.B.,  &c.,  Reigate,  and  A.  R.  Walters, 
L.R.C.P.,  &c.,  Reigate. 

Mrs.  F — ,  multipara,  a3t.  34.  A  stout  florid  woman  of 
phlegmatic  type,  liable  to  winter  cough,  with  empli}'- 
seuiatous  chest.      Her  last  child  was  born  in  April,  1895. 

VOL.  XL.  19 


278  PUERPERAL    SEPTICEMIA    TREATED 

She  made  a  fair  recovery,  but  had  more  or  less  continuous 
loss  for  six  months  afterwards.  She  was  quite  regular 
after  that  time  till  March,  1897,  when  she  missed  a  period, 
and  in  May  had  severe  flooding",  but  did  not  call  in 
medical  assistance.  When  the  flooding  ceased  she  went 
about  again  as  usual,  but  had  more  or  less  almost  constant 
loss  till  the  following  October  ;  after  this  she  had  a  foul 
yellow  discharge,  occasionally  blood-stained.  In  November 
she  again  had  a  severe  loss,  followed  by  irregular  haemor- 
rhages till  April  last,  when  she  was  seen  by  Mr.  A.  E,. 
Walters.  He  found  the  uterus  enlarged  and  tender  ;  the 
OS  oedematous,  surrounded  by  unhealttiy  granulations  with 
a  foul  3^ellow  discharge.  In  consultation  with  him  it 
was  decided  to  dilate  the  os  and  explore  the  uterus  ;  this 
was  done  on  May  9th  with  strict  antiseptic  precautions  ; 
after  dilating  the  os  with  Godsends  dilators  the  uterus  was 
freely  curetted  ;  a  large  quantity  of  granulation  tissue  was 
removed,  and  portions  of  a  macerated  foetus  ;  there  was 
pretty  free  bleeding  at  the  time.  After  the  uterus  ap- 
peared to  be  completely  empty  it  was  swabbed  out 
several  times  with  carbolic  lotion  and  then  with  Lin. 
lodi.  The  patient  bore  the  operation  very  well  ;  she  was 
put  on  liquid  diet  with  ergotin  gr.  ij  every  four  hours, 
and  hot  iodine  douches  twice  a  day. 

May  10th. —  Patient  comfortable,  discharge  slight,  tem- 
perature normal. 

11th. — Temp.  98*8'^,  slight  pain  in  right  side. 

12th. — Discharge  slightly  offensive  ;  passed  the  remains 
of  a  macerated  foetus  of  about  two  months.  Temperature 
a.m.  100*5°,  p.m.  99*6°;   pulse  85. 

13th .^ — Patient  more  comfortable,  discharge  less  offen- 
sive.     Temperature  a.m.  98*4°,  p.m.  99°;  pulse  80. 

14th. — Patient  going  on  well,  discharge  health3^  Tem- 
perature a.m.  98*2°,  p.m.  100°.  In  the  evening  she  passed 
a  large  fibrinous  clot  the  shape  of  the  uterine  interior. 

15th. — Discharge  somewhat  offensive,  but  patient  free 
from  all  pain  or  discomfort.  Temperature  a.m.  99^,  p.m. 
98-5° ;   pulse  80. 


BY    ANTISTREPTOCOCCIC     SERUM.  279 

16th. — Complained  in  the  evening  of  intense  headache  ; 
an  urticarial  rash  appeared  on  the  body  ;  the  discharge 
was  more  offensive.  Temperature  a.m.  98*5  ,  p.m.  102*5  ; 
pulse  100.  The  uterus  was  washed  out  with  perchloride 
of  mercury  (1  in  2000)  ;  ordered  quinine  gr.  iij  every 
four  hours.  10.30  p.m.,  had  a  severe  rigor  ;  tempera- 
ture 104-5°,  pulse  120. 

17th. — Patient  apathetic  and  dull,  had  passed  a  very 
restless  night  ;  intense  headache,  tongue  dry  and  brown, 
objects  to  food,  no  discharge.  Temperature  8  a.m.  101°, 
skin  dry.  At  4.30  p.m.  the  temperature  had  gone  up  to 
103°,  pulse  120.  The  patient  was  evidently  suffering 
from  puerperal  septicaemia.  10  c.c.  of  antistreptococcic 
serum  (supplied  by  Messrs.  Burroughs,  Wellcome  and  Co.) 
was  iujected  over  the  abdomen.  8.30  p.m.,  patient  bright 
and  cheerful,  skin  moist.  Temp.  98  ,  pulse  80  ;  headache 
gone,  discharge  commencing  again. 

18th. — 8  a.m.  temp.  98*8°,  pulse  Sd> ;  headache  return- 
ing, discharge  becoming  offensive.  12  noon,  temp.  100*4°, 
pulse  100  ;  headache  intense,  tongue  dry,  discharge 
stopped.  4.30  p.m.,  pulse  100,  temp.  100*5°;  headache 
worse,  skin  and  tongue  dry.  10  c.c.  of  serum  was  again 
injected,  and  the  uterus  again  washed  out  with  per- 
chloride. 8.30  p.m.,  patient  bright  and  cheerful,  skin 
moist,  tongue  moist  at  edges,  headache  gone.  Pulse  75, 
very  weak ;  temp.  98°. 

19th. — Patient  had  a  good  night.  Temp.  97°;  pulse 
72  ;  is  free  from  headache,  but  very  weak  and  depressed; 
takes  no  interest  in  any  thing  ;  discharge  healthy.  Ordered 
as  much  liquid  nourishment  as  she  could  take, — cham- 
pagne, &c. 

20th. — Patieut  much  the  same,  takes  nourishment 
better.      Temp.,  p.m.,  99°. 

21st. — Much  the  same. 

22nd. — Is  not  nearly  so  depressed,  and  takes  food  well. 
Temp.  98°  ;  discharge  nearly  stopped. 

26th. — Patient  beyond  being  extremely  weak  seems 
quite  well  ;   no  pain  or  discharge,  takes  food  well. 


280  PUERPERAL    SEPTICAEMIA    TREATED 

Since  this  date  no  fresli  symptoms  have  arisen,  and 
she  has  been  able  to  move  back  to  her  own  home. 

This  case  has  been  recorded  simply  to  illustrate  the 
value  of  antistreptococcic  serum  in  a  very  serious  case  of 
puerperal  septicaemia  ;  there  can  be  no  reasonable  doubt 
that  the  patient's  recovery  was  entirely  attributable  to  its 
use. 

The  injection  of  the  second  dose  was  followed  by  very 
great  depression  for  several  days,  so  much  so  as  to  give 
rise  to  considerable  anxiety  ;  there  was  also  transitory 
albuminuria. 


Dr.  Amand  Eouth  congratulated  the  author  on  the  success 
of  his  treatment.  It  was  difficult,  however,  to  be  sure  in  any 
given  case,  where  several  methods  had  been  adopted,  that  the 
successful  ending  was  due  to  any  one  of  the  methods,  and  he 
could  say  that  only  one  out  of  five  or  six  cases  treated  by  himself 
had  definitely  recovered  from  the  septicseniia  as  a  result  of  the 
antistreptococcic  serum  alone.  This  case  was,  however,  a 
typical  one  of  general  septicaemia,  with  fixation  of  the  uterus 
from  septic  perimetritis.  She  was  seen  by  him  on  the  fifth  day 
of  the  disease — the  eighth  day  after  labour — and  she  was  appa- 
rently dying  and  too  exhausted  to  justify  any  local  treatment 
whatever.  He  gave  10  c.c.  of  antistreptococcic  serum  at 
once,  and  more  was  obtained,  and  the  injection  repeated  the 
same  evening ;  and  instead  of  dying  that  night,  she  rapidly 
improved,  and  finally  got  well,  though  she  had  a  pelvic  abscess 
which  opened  into  the  vagina  some  days  afterwards.  He  did  not 
think  it  wise  to  inject  so  j^otent  an  agent  as  antistreptococcic 
serum,  and  it  certainly  was  not  a  scientific  proceeding  unless  it 
had  been  previously  ascertained  that  the  infection  in  the  case  was 
due  to  the  presence  of  streptococci;  and  he  asked  if  it  had  not 
been  shown  that  injection  of  the  wrong  serum  had  caused  very 
dangerous  symptoms.  Even  if  the  infection  was  known  to  be 
by  streptococci,  he  hoped  that  the  ordinary  modern  methods  of 
dealing  with  early  septicaemia  would  not  be  omitted,  and  he  espe- 
cially urged  that  uterine  exploration  should  be  digitally  made, and 
all  placental  and  decidual  debris  removed  by  the  finger  or  by 
curettage. 

Dr.  Eden  said  he  thought  that  the  point  raised  by  Dr.  Eouth 
as  to  the  advisabilii^y  of  determining  the  nature  of  the  infection 
before  resorting  to  the  use  of  the  serum  was  a  very  important 
one,  for  antistreptococcic  serum  was  a  remedy  for  streptococcus 
infection  only.     A  series  of  three  interesting  cases  had  recently 


BY   ANTISTKEPTOCOCCIC    SERUM.  281 

been  recorded  by  Dr.  Haultaiu,  of  Edinburgh,  in  Avliich  a 
different  form  of  infection  was  present  in  each  case.  In  the  first 
case  he  obtained  pure  cultures  of  Zoeffler's  bacillus  from  the 
uterine  cavity,  and  the  case  was  accordingly  treated  with  the 
diphtheria  antitoxin  with  the  most  successful  results.  In  the 
second  case  cultures  showed  a  mixed  infection  of  streptococcus 
and  Bacillus  coli,  and  although  the  antistreptococcic  serum  was 
used,  no  beneficial  result  followed,  and  the  patient  died.  The 
third  case  was  one  of  simple  strej^tococcus  infection,  and 
in  this  the  serum  was  entirely  effectual.  Evidence  was  accumu- 
lating that  cases  in  which  the  Bacillus  coli  was  present  were  all 
of  a  grave  type  ;  and  although  at  present  we  were  not  in  posses- 
sion of  an  antitoxin  for  this  organism,  its  recognition  was 
important  as  a  factor  in  prognosis,  and  later  on  the  means  of 
treatment  might  come  to  hand.  If  the  first  of  Dr.  Haultain's 
cases  had  not  been  correctly  diagnosed,  and  the  antistreptococcic 
serum  employed  on  the  off  chance  of  its  being  the  right  one,  the 
result  might  have  been  very  different,  and  doubt  might  have 
been  unfairly  cast  upon  the  value  of  the  scrum  treatment. 

Dr.  Drummond  Eobinson  quite  agreed  that  it  would  be 
highly  interesting  to  ascertain  what  microbe  was  producing  the 
disease  in  every  case  of  puerperal  sepsis,  but  he  feared  that  this 
would  be  practically  impossible.  He  had  investigated  a  number 
of  cases  bacteriologically,  but  the  results  had  been  unreliable. 
Owing  to  the  kindness  of  Dr.  Cbampneys  and  others,  he  had  had 
opportunities  of  treating  seven  cases  of  puerperal  sepsis  with  the 
antistreptococcic  serum.  Five  of  these  patients  died,  the  treat- 
ment apparently  having  no  effect.  Two  of  the  cases  recovered. 
In  one  of  these  the  only  effect  of  the  injections  was  that  the 
patient  seemed  to  sleep  better  afterwards.  In  the  other  case 
the  injections  seemed  to  have  a  strikincfly  beneficial  effect.  This 
patient,  seen  with  Dr.  Arthur,  of  Shepherd's  Bush,  on  the 
eleventh  day  after  confinement,  appeared  to  be  in  extremis.  She 
had  been  attended  by  the  nurse,  who  refused  to  send  for  the 
doctor,  and  who  had  (as  was  afterwards  discovered)  a  suppu- 
rating wound  on  the  finger.  On  the  third  day  the  temperature 
rose,  and  remained  at  about  103^.  On  the  eleventh  day,  when 
the  serum  was  first  used,  the  whole  vagma  was  covered  with  a 
thick  white  membrane.  Pulse  120  ;  temp.  104°;  diarrhoea  was 
constant.  As  membranous  vaginitis  is  produced  by  the  Strepto- 
coccus pyogenes,  injections  of  antistreptococcic  serum  were 
advised,  and  they  were  followed  immediately  by  a  fall  of  tempe- 
rature and  an  amelioration  of  the  other  symptoms.  The  patient 
rapidly  convalesced. 

Dr.  McCann  said  that  it  was  most  important  to  have  all  the 
cases  carefully  recorded  where  this  method  of  treatment  had 
been  adopted.  The  whole  subject  was  at  present  in  the  experi- 
mental stage.     As  it  was  probable  that  more  than  one  variety  of 


282  PUERPERAL  SEPTICEMIA  TREATED 

microbe  was  tlie  cause  of  puerperal  septicaemia,  so  we  would 
require  to  use  more  than  one  antitoxic  serum.  The  important 
poiDt,  however,  was  that  the  serum  treatment  should  be  com- 
menced at  an  early  stage  of  the  disease,  and  not  after  all  other 
methods  had  been  tried  and  found  to  fail.  By  this  means  the 
effect  of  the  poison  already  absorbed  would  be  counteracted, 
while  the  usual  remedies  were  applied  locally  at  the  seat  of  pro- 
duction. The  early  use  of  an  antitoxic  serum  had  given  brilliant 
results  in  diphtheria,  yet  in  most  cases  of  puerperal  sepsis  the 
mitistreptococcic  serum  had  only  been  used  as  a  last  resource. 
Dr.  McCann  suggested  that  antistreptococcic  serum  should  be 
used  as  a  preventive  (injected  subcutaneously)  in  cases  where 
sepsis  would  be  likely  to  follow  a  miscarriage  or  full-time  labour, 
e.  g.  retention  of  decomposing  pieces  of  placenta  requiring 
removal  post  abortum,  and  in  j^atients  suffering  from  offensive 
vaginal  discharges  before  or  during  labour,  these  latter  cases 
bemg  found  frequently  among  the  lower  classes  and  those 
suffering  from  svphilis. 

Dr.  John  Phillips  had  administered  antistreptococcic  serum 
in  several  cases,  but  in  one  only  was  he  certain  that  the  patient's 
recovery  could  be  attributed  to  its  use.  He  thought  that  in 
every  case  of  septicaemia,  before  injecting  the  serum,  the  uterine 
cavity  should  be  explored.  The  patient  to  whom  he  alluded  was 
ill  for  many  weeks  with  acute  septicaemia;  curettage,  although 
performed  twice,  failed  to  produce  any  benefit ;  the  scrapings 
showed  large  quantities  of  streptococci.  As  many  as  twenty 
injections  were  given  in  the  course  of  a  twelve  weeks'  illness. 
The  temperature,  which  was  very  high,  was  always  lowered,  the 
delirium  ceased,  the  skin  acted,  the  effect  lasting  for  a  few  hours. 
Towards  the  end  of  the  illness  rapidly  appearing  and  disappear- 
ing skin  rashes  showed  themselves,  and  were  probably  due  to 
some  impurity  in  the  serum.  The  patient  ultimately  made  an 
excellent  recovery,  after  passing  through  a  sharp"^  attack  of 
broncho-pneumonia.  Dr.  Phillips  thought  that  examination  of 
the  scrapings  was  of  the  greatest  value  ;  in  this  case  repeated 
examination  of  the  discharges  found  in  the  vagina  for  strepto- 
cocci gave  a  negative  result. 

Dr.  Walter  Tate  had  seen  several  cases  of  j^uerperal  septi- 
caemia treated  by  antistreptococcic  serum ;  in  some  of  them  the 
results  certainly  appeared  to  be  good.  In  one  case  the  first  two 
or  three  injections  of  the  serum  were  followed  by  improvement 
in  the  patient's  condition,  but  after  this  further  injections  failed 
to  give  relief;  it  seemed  possible  that  this  may  have  been  a  case 
of  mixed  infection.  Some  of  the  most  virulent  forms  of  septi- 
caemia followed  the  removal  of  placental  polypi,  which  were 
sloughing.  In  spite  of  every  antiseptic  precaution,  the  opera- 
tion for  removal  of  these  was  in  many  cases  followed  by  a 
severe  and  protracted  form  of  septicaemia.  The  suggestion  of  one 


BY    ANTISTREPTOCOCCIC    SERUM.  283 

speaker  tbat  an  injection  of  antistreptococcic  serum  should  be 
given  prior  to  operation  as  a  prophylactic  measure  was  valuable. 
The  President  said  that  althousrh  it  was  alwavs  difficult  to  be 
certain  that  improvements  in  a  patient's  condition  were  due  to 
the  treatment  employed,  there  seemed  in  Dr.  Walters'  case  very 
little  room  for  reasonable  doubt  that  the  antistreptococcic  serum 
had  saved  a  life.  He  did  not  quite  agree  with  the  opinion  that 
had  been  expressed  that  the  serum  ought  not  to  be  administered 
until  it  had  been  definitely  ascertained  that  the  offending  microbe 
in  the  case  under  observation  was  the  streptococcus.  He  called 
attention  to  an  important  paper  in  the  last  (80th)  volume  of 
the  '  Medico-Chirurgical  Transactions,'  by  Mr.  Herbert  Durham, 
**  On  the  Clinical  Bearing  of  some  Experiments  on  Peritoneal 
Infections,"  and  read  some  extracts  from  it  which  went  to  show 
that  the  streptococcus  was  more  frequently  present  in  these  affec- 
tions than  any  other  microbe.  "Much  evidence,"  says  Mr. 
Durham,  ''has  been  adduced  to  show  that  peritonitides  and 
abscesses  arising  during  the  puerperium  or  after  abortions  are  to 
be  ascribed  to  streptococcal  infection.  .  .  .  Tavel  and  Lanz 
.  report  twenty-eight  cases  with  streptococci  out  of  a 
total  of  forty-one.  .  .  .  There  is  much  evidence  that  ^aciZ/ws 
coll  is  pathogenic  for  man  (abscesses,  empyemata,  &c.),  and  I 
am  far  from  denying  that  it  may  have  a  role  in  certain  cases  of 
peritonitis,  either  of  itself  or  as  a  participator  in  mixed  infec- 
tions. However,  in  a  large  proportion  of  the  cases  examined 
cocci  (especially  streptococci)  were  a  prominent  feature."  This 
being  the  case,  and  the  antistreptococcic  serum  being  at  present 
the  only  antitoxin  available  for  use  in  these  affections  (no  similar 
solution  having  yet  been  prepared  from  the  staphylococcus  or 
Bacillus  coll),  it  seemed  to  him  (the  President)  that  we  ought  to 
give  our  patients  the  benefit  of  the  doubt  and  administer  the 
antistreptococcic  serum  in  cases  of  puerperal  septicsemia  without 
waiting  for  bacteriological  investigation.  In  the  first  place  the 
delay  might  involve  the  loss  of  valuable  time,  and  in  the  second 
place  it  was  only  in  the  hands  of  an  expert — if  always  even  then 
— that  the  results  of  such  an  investigation  could  be  accepted  as 
conclusive.  We  had  learnt  now  how  to  prevent  [)uerperal 
infection,  and  were  gradually  acquiring  trusty  weapons  where- 
with to  combat  the  results  of  puerperal  infection  when,  in  spite 
of  our  care,  it  made  its  appearance.  The  safe  rule  of  prac- 
tice, whenever  we  found  ourselves  face  to  face  with  symptoms 
of  blood-poisoning  after  labour  or  after  abortion,  was,  firstly,  to 
make  sure  by  digital  exploration,  under  an  anaesthetic,  that  there 
were  no  decomposing  clots  or  fragments  of  adherent  tissue  in 
the  uterine  cavity ;  and  if,  after  the  uterus  had  been  by  this 
means  emptied  or  proved  to  be  empty,  the  symptoms  persisted, 
to  administer  the  antistreptococcic  serum  without  delay.  It 
might   be  that  in  the  near  future  other  antitoxins  would  be 


284  PUERPERAL    SEPTICAEMIA. 

placed  in  our  hands,  but  in  the  meantime  it  was  our  bounden 
duty  to  avail  ourselves  of  the  one  we  already  possessed.  He  had 
himself  seen  several  cases  in  which  there  seemed  the  strongest 
reason  to  credit  the  antistreptococcic  serum  with  the  saving  of 
life.  It  had  been  said  that  it  might  do  harm  instead  of  good. 
This  he  doubted.  In  the  only  instance  in  which  he  had  person- 
ally known  unfavourable  symptoms  to  follow  its  administration, 
inquiry  had  elicited  the  fact  that  the  preparation  used  was  not 
fresh ;  it  had  been  kept  for  some  time,  and  had,  no  doubt,  under- 
gone deleterious  change.  He  desired  to  utter  a  word  of  warning 
against  placing  reliance  on  the  intra-uterine  douche  as  a  means 
of  ensuring  the  removal  of  decomposing  debris  from  the 
uterine  cavity.  When  such  debris  was  present  it  was  usually 
adherent  to  the  wall  of  the  cavity,  and  no  amount  of  douch- 
ing would  separate  and  remove  it.  The  habitual  use  of  the 
finger  for  this  purpose  was  necessary  to  success,  and  the  general 
recognition  of  this  fact  would  be  an  enormous  step  in  advance. 
He  complimented  Dr.  Walters  on  the  success  of  his  case,  and 
thanked  him  for  having  brought  it  before  the  Society.  He  was 
sure  that  the  discussion  it  had  elicited  would  have  beneficial 
results  upon  practice,  and  could  not  be  otherwise  than  gratifying 
to  the  authors  of  the  paper. 

Dr.  J.  Walters,  in  reply,  said  he  wished  to  thank  the  Presi- 
dent and  Fellows  for  their  favourable  reception  of  his  paper. 
He  entirely  agreed  with  the  opinion  of  the  President  that  in 
cases  of  this  kind,  if  such  measures  as  thoroughly  emptying  the 
uterus  a,nd  douching  with  perehloride  of  mercury  failed  to  check 
the  symptoms,  the  only  resource  was  serum  injection,  and  he  was 
only  too  glad  to  have  such  a  measure  to  fall  back  on  m  these  most 
distressing  cases.  With  regard  to  the  serum  employed,  in  the 
absence  of  bacteriological  investigation,  which  was  impossible  in 
a  country  district,  owing  to  the  loss  of  time  it  would  require  to 
submit  a  scraj^ing  from  the  uterus  to  a  skilled  bacteriologist,  he 
considered  the  use  of  antistreptococcic  serum  most  likely  to  be 
followed  by  beneficial  results.  The  end  justified  the  means 
employed,  for  he  had  no  doubt  whatever,  considering  the  imme- 
diate improvement  that  followed  the  use  of  the  serum  on  both 
occasions,  that  the  patient's  life  was  saved  by  the  injections. 
He  was  glad  to  be  able  to  report  that  the  patient  was  now  in 
excellent  health. 


285 


EAELY  ECTOPIC  GESTATION  (?  TUBO-UTEMNE) 
COMPLICATED  BY  FIBRO-MYOMATA  OF  THE 
UTERUS.      (See  Plates  VII,  VIII,  and  IX.) 

By   ChAS.   J.   CULLINGWOETH,   M.D. 

It  mav  be  in  the  recollection  of  the  Fellows  that  I  ex- 
hibited  at  the  meeting  held  in  November  of  last  year 
(1897)  a  specimen  consisting  of  the  uterus  and  append- 
ages, removed,  by  the  operation  of  abdominal  hysterectomy, 
for  ectopic  gestation  complicated  with  fibro-myomata  and 
what  was  thought  to  be  a  pelvic  haematocele.  The  mass 
that  had  been  taken  for  a  hasmatocele  proved  to  be  a  sac 
containing  blood-clot  and  an  embryo  of  about  the  middle  of 
the  third  month.  The  head  and  both  lower  extremities  of 
the  embryo  protruded  from  one  end,  and  the  sac  was  con- 
nected by  a  narrow  pedicle  with  a  soft  swelling  at  the 
right  cornu  of  tlie  uterus  which  had  not  then  been 
opened,  but  which  was  believed  to  be  a  gestation  sac 
formed  partly  of  the  uterus  and  partly  of  the  Fallopian 
tube.  It  appeared  as  though  the  foetus  had  effected  a 
bloodless  escape,  there  being  no  extravasated  blood,  en- 
capsuled  or  otherwise,  in  the  peritoneal  cavity. 

The  specimen  was  shown  in  order  that  the  Fellows 
might  have  an  opportunity  of  seeing  the  parts  exactly  as 
they  were  when  removed  from  the  body,  before  being  in 
any  way  disturbed.  I  promised  to  furnish  the  Society,  at 
a  future  meeting,  with  a  further  account  of  the  specimen 
and  a  detailed  history  of  the  case.  In  accordance  with 
this  promise,  I  have  now  the  pleasure  to  communicate  the 
following  particulars. 

A  married  woman,  aged  33,  by  occupation  a  shirt  collar 
dresser,  was  admitted  into  St.  Thomas's  Hospital  on  the 
4th  September,  1897,  said   to  be  suffering  from  retrover- 


286  EARLY  ECTOPIC  GESTATION. 

siou  of  the  gravid  uterus.  Attempts  had  been  made  at 
home  to  reduce  the  supposed  displacement,  but  without 
success.  The  history  given  by  the  patient  was  briefly  as 
follows  : 

The  catamenia  commenced  at  the  age  of  twelve. 
Nineteen  years  ago,  while  still  unmarried,  the  patient 
gave  birth  to  a  full-term  living  child.  Breast  abscess 
and  some  other  troubles  followed,  necessitating  a  long 
confinement  to  bed,  but  there  is  no  evidence  of  any 
abdominal  or  pelvic  complication.  She  was  married 
thirteen  and  a  half  years  ago,  but  has  not  again  become 
pregnant  until  the  present  occasion.  She  last  menstru- 
ated during  the  last  week  of  April,  1S97.  Five  weeks 
after  that,  when  a  week  over  her  usual  period,  she  fell 
down  some  steps  and  had  pain  in  the  back  and  abdomen. 
This  passed  off,  but  returned  about  three  weeks  later  and 
continued,  gradually  increasing  in  severity.  A  fortnight 
before  admission  she  passed  some  blood-clots,  and  since 
then  there  has  been  a  slight  pinkish  offensive  discharge. 
For  the  past  five  weeks  sickness  has  occurred  every 
evening. 

The  house  physician  finding  a  tumour  in  Douglas's 
pouch,  in  which  he  thought  he  could  detect  foetal  parts, 
accepted  the  diagnosis  of  the  patient's  medical  attendant, 
and  made  another  attempt  under  an  anaesthetic  to  raise 
the  mass  out  of  the  pelvis.  He  reported  that  he  had 
only  partially  succeeded,  an  unreduced  portion  still 
remaining  in  the  pouch  of  Douglas,  though  the  limbs  and 
solid  parts  of  the  foetus  had  been  released.  The  patient 
on  this  occasion  only  remained  four  days  in  the  hospital. 
Before  she  left  I  examined  her,  and  made  some  further 
attempts  at  complete  reduction,  by  drawing  down  the 
cervix  with  a  volsella,  and  at  the  same  time  pressing  the 
posterior  mass  upwards,  but  without  success.  I  was 
somewhat  puzzled  to  understand  the  reason  for  these 
repeated  failures,  but  did  not  at  that  time  seriously  sus- 
pect the  correctness  of  the  diagnosis.  There  was  no  dis- 
charge during  her  stay  in  the  hospital.      The  temperature 


EARLY    ECTOPIC    GESTATION.  287 

varied  from  98°  to  99' 6°.  Some  abdominal  pain  was 
complained  of  during  tlie  whole  time. 

On  October  1st  the  patient  was  readmitted,  complain- 
ing of  severe  and  increasing  pain  in  the  lower  part  of  the 
abdomen,  constipation,  difficult  and  painful  micturition, 
and  a  dark-coloured  haemorrbagic  discharge,  not  offensive. 
These  symptoms  came  on  two  days  after  patient  left  the 
hospital,  and  have  continued. 

On  October  5th  she  was  examined  under  an  anaesthetic. 
The  cervix,  sufficiently  patulous  to  admit  the  index  finger 
as  far  as  the  os  internum,  pointed  downwards  and  slightly 
backwards,  Eesting  upon  the  anterior  vaginal  wall  was 
a  solid,  rounded,  slightly  moveable,  firm  swelling,  estimated 
as  equal  in  size  to  a  small  orange,  and  continuous  above 
with  the  uterus.  This  was  obviously  the  anteflexed  body 
of  the  uterus  or  a  growth  connected  with  the  anterior 
wall.  With  some  misgivings  I  determined  to  settle  the 
matter  by  passing  a  sound.  The  sound  passed  up  almost 
vertically,  and  behind  the  mass  described,  a  distance  of 
four  and  a  half  inches.  This  showed  that  the  swelling 
was  a  solid  tumour  in  the  anterior  wall  of  the  uterus,  and 
that  the  uterus  was  empty.  Occupying  Douglases  pouch 
was  a  firm,  soft,  elastic,  smooth  swelling,  incapable  of  being* 
raised,  or  of  being  separated  from  the  back  of  the  cervix. 
This  swelling  caused  slight  depression  of  the  vaginal  roof 
posteriorly.  It  appeared  to  be  continuous  with  a  mass 
that  occupied  and  filled  the  left  posterior  fossa  of  the 
pelvis.  No  swelling  could  be  felt  in  the  right  posterior 
fossa.  The  inference  I  drew  from  this  examination  was 
that  the  former  diagnosis  had  been  erroneous,  that  the 
uterus  was  enlarged  from  the  presence  of  one  or  more 
fibro-myomata,  and  that  the  mass  felt  posteriorly  was 
a  pelvic  ha^matocele,  due  to  an  arrested  tubal  gestation. 
I  determined  to  watcli  the  case,  and  to  interfere  only  if 
the  swelling  behind  the  uterus  failed  to  undergo 
diminution.  Careful  mensurements  were  taken  from  time 
to  time. 

On  October  6th  the  distance  from  the  top  of  the  pubes 


288  EARLY  ECTOPIC  GESTATION. 

to  the  upper  limit  of  the  abdominal  swelling  was  six 
inches,  and  to  the  umbilicus  seven  inches.  The  distance 
from  the  umbilicus  to  the  ant.  sup.  iliac  spine  on  the 
right  side  was  six  and  a  quarter  inches,  on  the  left  six 
inches.  Above  the  pubes  was  a  hard,  round,  solid  tumour, 
about  4  in.  x  3  in.  This  was  the  growth  in  tlie  anterior 
wall  of  the  uterus  already  alluded  to  as  resting  upon  the 
anterior  wall  of  the  vagina.  In  the  left  lumbar  region 
was  another  hard,  round,  solid  swelling,  situated  more 
deeply,  and  of  somewhat  smaller  size.  This  was  con- 
tinuous with  the  bod}^  of  the  uterus,  which,  as  defined  by  the 
sound,  was  situated  in  the  middle  line.  Behind  and  to  the 
right  of  the  body  of  the  uterus  was  a  softer,  less  defined 
swelling,  rising  above  the  level  of  the  fundus,  and  extend- 
ing outwards  to  a  distance  of  three  inches  from  the 
middle  line.  No  foetal  heart-sounds  were  audible.  A 
souffle  was  heard  on  the  right,  midway  between  the 
umbilicus  and  the  anterior  superior  iliac  spine.  There  was 
dulness  on  percussion  over  the  most  prominent  and  lower 
swelling.  Elsewhere  the  note  was  resonant  throughout. 
No  fluid  could  be  expressed  from  the  breasts,  which  were 
flaccid.      The  urine  was  normal. 

Durinor  the  next  fortnioht  the  measurements  remained 
practically  unaltered.  There  were  attacks  of  pain,  occa- 
sionally severe.  A  slight  vaginal  discharge  of  dark  red 
colour  occurred  continuously.  The  temperature  was 
normal,  and  the  general  condition  satisfactory.  An 
exploratory  operation  was  now  proposed  and  assented  to. 

On  October  21st  an  incision  five  inches  long  was  made 
below  the  umbilicus  in  the  median  line.  A  small  quantity 
of  free  clear  watery  fluid  escaped.  Some  superficial 
adhesions  were  easily  separated.  On  introducing*  the 
hand,  the  main  mass  of  the  swelling  was  felt  to  consist  of 
the  uterus  with  solid  outgrowths.  In  the  situation  of 
the  right  cornu  was  a  large,  tense,  soft  swelling,  with  the 
characters  of  a  haematosalpinx.  Passing  the  hand  down 
behind  the  uterus,  another  soft  swelling  was  found 
occupying  Douglas's  pouch  and   universally  adherent  to 


EARLY    ECTOPIC    GESTATION.  289 

its  walls.  On  the  top  of  this  and  projecting  from  it  in 
front  was  a  small,  irregular^  round  body^  the  size  of  a 
large  marble,  giving  to  the  examining  finger  a  very 
peculiar  sensation.  This  proved  afterwards  to  be  the 
head  of  a  foetus.  After  careful  separation  of  the  mass  in 
Douglas's  pouch,  the  abdominal  incision  was  enlarged, 
and  the  whole  mass  brought  out  of  the  wound  into  view. 
The  part  that  had  been  lyiug  in  the  pouch  of  Douglas 
was  now  seen  to  be  a  foetus,  surrounded  by  membranes, 
the  head  and  low^er  limbs  alone  protruding.  (See  Plates 
VIII  and  IX.)  There  was  no  free  blood  in  the  pelvis  or 
in  the  abdominal  cavity.  A  band  of  tissue  connected  the 
foetus  with  the  swelling  at  the  right  cornu. 

It  being  now  evident  that  there  had  been  ectopic 
gestation,  with  escape  of  the  foetus,  and  it  being  im- 
possible to  remove  the  gestation  sac  without  removing 
the  uterus,  it  was  decided  to  perform  abdominal  hj^ste- 
rectomy,  removing  the  uterus  at  the  junction  of  body 
and  cervix,  along  with  the  gestation  sac,  myomata,  and 
uterine  appendages.  The  broad  ligaments  having  been 
transfixed,  tied,  and  divided  in  the  manner  I  usually 
adopt,  and  the  uterine  artery  on  each  side  having  been 
secured,  anterior  and  posterior  flaps  were  dissected  off 
the  uterus,  and  the  whole  mass  was  cut  nwnj  immediately 
above  the  cervix.  No  bleeding  occurred,  except  from 
the  left  ovarian  artery,  which  was  found  to  have  escaped 
from  the  ligature  and  had  to  be  tied  afresh.  A  second 
ligature  was  also  placed  upon  the  right  ovarian  artery  as 
an  additional  safeguard.  The  stump  was  covered  in  by 
turning  in  the  flaps  and  stitching  them  together  over  it. 
The  cut  edges  of  the  broad  ligament  were  stitched 
together  on  each  side,  the  cavity  of  the  pelvis  was 
cleansed,  and  one  or  two  bleeding  points  in  the  right 
broad  ligament  were  secured.  The  abdomen  was  then 
closed  by  through  and  through  sutures  of  silkworm  gut, 
a  continuous  catgut  suture  having  been  passed  through 
the  edges  of  the  rectal  sheath  before  the  through  sutures 
were  tied.      The  operation  occupied  about  two  hours. 


290  EARLY  ECTOPIC  GESTATION. 

Description  of  parts  removed. — The  mass  removed  con- 
sists of  the  body  of  the  uterus  with  its  appendages. 
Suspended  from  it  posteriorly  is  a  membranous  sac,  con- 
taining a  foetus  (and  probably  some  blood-clot),  the  head 
and  lower  limbs  of  the  foetus  protruding  from  one  end  of 
the  sac  (Plate  VIII).  The  whole  uterine  mass  is  roughly 
heart-shaped.  It  measures  six  inches  in  breadth,  five  inches 
from  above  downwards,  and  two  and  a  half  inches  from 
before  backv/ards.  The  length  of  the  uterine  canal  is 
two  and  three  eighths  inches.  The  distance  between  the 
two  Fallopian  tubes  at  wh?«t  appears  to  be  their  uterine 
origin  is  four  inches.  The  distance  between  the  two 
round  ligaments  at  their  uterine  origin  is  three  and  a 
quarter  inches.  The  distance  between  the  uterine  origin 
of  the  Fallopian  tube  and  that  of  the  round  ligament  is 
five  eighths  of  an  inch  on  the  left  side,  and  on  the  right 
side  two  inches.  The  length  of  the  straightened  out 
Fallopian  tube  on  the  left  side  is  over  five  inches,  on  the 
ricrht  side  eight  inches.  Both  Fallopian  tubes  are  normal 
in  appearance  near  their  uterine  end,  but  dilated  and 
convoluted  as  they  pass  outwards.  Their  abdominal 
ostia  are  closed  by  adhesion  to  the  ovaries.  The  right 
tube  is  considerably  more  dilated  than  the  left.  The 
ovaries  are  of  full  size  ;  the  right  contains  several  small 
cysts  into  which  hemorrhage  has  occurred  (Plate  YII). 

There  is  a  subserous  myoma  the  size  of  a  small  orange 
growing  from  the  lower  part  of  the  anterior  aspect  of  the 
body  of  the  uterus.  Another  about  the  size  of  a  hen's 
Qgg  springs  from  the  posterior  and  left  aspect  of  the 
fundus.  Both  are  sessile.  There  are  several  others  vary- 
ing in  size  from  a  pea  to  a  marble.  At  the  uterine  end 
of  the  right  Fallopian  tube  is  a  soft  rounded  swelling  with 
fluctuating  contents,  equal  in  size  to  an  orange  (Plate  VIJ) . 
This  swelling  appears  to  contain  blood,  and  to  be  formed 
partly  at  the  expense  of  the  intra-uterine  portion  of  the 
tube,  and  partly  at  the  expense  of  the  portion  of  tube 
immediately  outside  the  uterine  wall. 

From  this  swelling  projects  a  band  of  tissue  an  inch  in 


DESCRIPTION  OF  PLATE  VII. 

Illustrating  Dr.  Chas.  J.  Cullingworth's  case  of  Early 
Ectopic  Gestation  (?  tubo-uterine)  complicated  by 
Fibro-myoma  of  the  Uterus. 

View  from  the  front  and  above. 

A.  Interstitial  fibro-myoma  in  anterior  wall  of  uterus. 
B  and  c.  Gestation  sac  filled  with  blood-clot,  forming  projections  similar 
in  appearance  to,  but  softer  in  consistence  than,  those  formed  by  the 
fibro-myomata. 

D.  Interstitial  fibro-myoma  in  posterior  wall  of  fundus  uteri. 

E.  Right  Fallopian  tube  (8  inches). 
¥.  Left  Fallopian  tube  (5  inches). 
G.  Right  ovary. 

H.  Left  ovary. 

J.  Right  round  ligament,  with  point  of  uterine  origin  displaced  out- 

w^ards  by  the  gestation  sac. 
K.  Left  round  ligament,  normal. 

(Drawn  by  R.  E.  Holding.) 


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DESCRIPTION   OF   PLATE  VIII. 

Illustrating  Dr.  Chas.  J.  Cullingworth's  case  of  Early 
Ectopic  Gestation  (?  tubo-uterine)  complicated  by 
Fibro-myoma  of  the  Uterus. 

View  from  below  and  behind. 

A.  Sac,  with  head  and  limbs  of  foetus  protruding  from  one  end,  found 

lying  in  Douglas's  pouch.     See  Plate  IX,  fig.  2. 

B.  Small    interstitial   fibro-myoma   in    posterior   wall    of    uterus.      See 

Plate  VII,  D,  and  Plate  IX,  fig.  1,  c. 
c.  Gestation  sac  filled  with  blood-clot.     See  Plate  VII,  b  and  c,  and 
Plate  IX,  fig.  1,  E. 

D.  Band  of  tissue,  with  central  canal,  connecting  A  with  C.     See  Plate  IX, 

fig.  2,  D. 

E.  Left  Fallopian  tube. 

F.  Right  Fallopian  tube. 

G.  Left  ovary. 
H.  Right  ovary. 

J.  Bristle  passed  into  uterine  canal  at  junction  of  corpus  and  cervix. 
K.  Cut  surface  of  uterus,  showing  plane  of  division  at  level  of  isthmus. 
Uterine  body  enlarged  by  fibro-myoma  in  anterior  wall. 

(Drawn  by  R.  E.  Holding.) 


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DESCRIPTION  OF  PLATE  IX. 

Illustrating  Dr.  Chas.  J.  Cullingworth's  case  of  Early 
Ectopic  Gestation  (?  tubo-uterine)  complicated  by 
Fibro-myoma  of  the  Uterus. 

Fig.  1. — View  on  section,  after  hardening-. 
A.  Fibro-myoma  in  anterior  wall. 
B  and  c.  Smaller  interstitial  fibro-myomata. 

D.  Cavity  of  right  cornu  of  uterus  laid  open,  with  bristle   in   uterine 

aperture  of  right  Fallopian  tube. 

E.  Blood-clot,  filling  gestation  sac. 

F.  Right  Fallopian  tube. 
Q.  Right  ovary. 

H.  Compressed  cavity  lined  by  amnion. 

Fig.  2. — Sac  (containing  foetus)  laid  open,  wall  turned  down. 

A.  Interior  of  sac. 

B.  Wall  turned  down  to  display  interior. 

c.  Bristle  passed  through  connecting  band,  showing  direct  communica- 
tion with  original  gestation  sac.     See  Fig.  1,  h. 

D.  Connecting  band. 

E.  Umbilical  cord  passing  across  back  of  foetus  and  attached  near  b  to 

inner  wall  of  sac. 

F.  Head  of  foetus. 

G.  Limbs  of  foetus  protruding  from  sac. 

(Drawn  by  R.  E.  Holding.) 


EARLY    ECTOPIC    GESTATION.  291 

lengthy  connecting  it  with  the  membranous  sac  ah'eady 
described  as  containing  the  foetus. 

January  10th,  1898. — The  specimen  having  been  hard- 
ened in  spirit  was  submitted  to-day  to  further  examination 
by  Mr.  Shattock.  A  section,  made  through  the  centre  (see 
Plate  IX,  fig.  1),  showed  the  soft  swelling  to  consist  of 
blood-clot,  containing  in  the  midst  of  the  clot  the  remains 
of  a  cavity  lined  by  a  distinct  membrane,  and  now  com- 
pressed and  empty,  with  its  surfaces  in  close  apposition. 
The  right  Fallopian  tube  was  cut  across  at  a  distance  of  an 
inch  from  the  swelling.  A  bristle  passed  along  the  tube 
in  the  direction  of  the  uterus  showed  that  immediately  out- 
side the  gestation  sac  the  tube  was  occluded.  The  right 
cornu  of  the  uterine  cavity  could  be  traced  as  far  as,  but 
not  into,  the  gestation  sac.  Uterine  tissue  is  continued  over 
the  gestation  sac  to  the  extent  of  about  one  fourth  of  its 
entire  circumference,  viz.  for  a  distance  of  an  inch  and  a 
half  on  its  lower,  aud  half  an  iuch  on  its  upper  surface.  A 
probe  passed  into  the  cavity  in  the  midst  of  the  clot  in  the 
direction  of  the  pedicle  enters  and  passes  completely  through 
the  pedicle  into  the  membranous  sac  containing-  the  foetus. 
On  laying  open  this  sac  (see  Plate  IX,  fig.  2),  it  is  found  to 
be  lined  by  a  membrane  directly  continuous,  through  the 
pedicle,  with  the  membrane  lining  the  compressed  cavity 
already  described  in  the  midst  of  the  gestation  sac,  and 
to  contain  a  quantity  of  blood-clot  and  the  whole  of  the 
foetus  except  the  head  and  lower  limbs,  which  project 
through  a  rent  at  one  end.  Part  of  the  foetus  projects 
into  the  interior  of  the  sac,  and  the  rest  is  adherent  to 
the  sac  wall.  The  umbilical  cord  lies  entirely  within  the 
foetal  sac,  no  part  of  it  extending  into  the  pedicle.  The 
cord  can  be  traced  up  to  a  point  where  it  becomes 
adherent  to  and  lost  in  the  sac  wall,  without  any  indica- 
tion of  placenta.  It  passes  across  the  back  of  the  foetus 
and  under  its  left  axilla.  The  foetus  is  acutely  bent 
upon  itself,  its  back  presenting  a  rounded  surface,  convex 
towards  the  interior  of  the  foetal  sac. 

The   section   passes  through  the  cavity  of    the   uterus 


292  EARLY    ECTOPIC    GESTATION. 

and  throTigli  three  fibroid  tumours  in  its  walls.  Two  of 
these  liave  been  ah-eady  described.  The  third,  about  the 
size  of  a  marble,  is  situated  in  the  left  part  of  the  anterior 
wall,  and  is  interstitial. 

The  conclusion  arrived  at  is  that  the  gestation  was 
originally  tubo-uterine,  in  the  sense  of  being  partly  inter- 
stitial and  partly  extra-uterine  and  wholly  tubal.  The 
presence  of  a  distinct  amniotic  sac  in  the  midst  of  the 
clot  seems  to  show  that  the  foetus  had  been  extruded 
either  into  a  diverticulum  of  the  tube  or  into  the  abdo- 
minal cavity.  The  apparent  continuity  of  the  pedicle 
externally  with  the  wall  of  the  gestation  sac  on  the  one 
hand  and  the  wall  of  the  foetal  sac  on  the  other,  and  the 
fact  that  a  probe  can  be  passed  along  the  pedicle  from 
the  interior  of  one  sac  into  the  interior  of  the  other, 
support  the  former  of  these  hypotheses.  The  size  of  the 
foetus  (three  and  a  half  inches  from  the  crown  of  the 
head  to  the  lower  end  of  the  spine,  and  therefore  four 
and  a  half  to  five  inches  in  total  length),  compared  with 
the  size  of  the  aperture,  suggests  that  the  foetus  continued 
for  a  time  to  live  and  grow  after  its  extrusion,  and  that 
the  cord,  if,  as  seems  certain,  it  has  been  ruptured,  under- 
went rupture  not  at  the  moment  of  extrusion,  but  later. 
The  foetus  evidently  carried  with  it,  when  extruded,  a 
process  of  amnion.  The  pedicle  leaves  the  gestation  sac 
about  the  centre  of  its  posterior  surface,  just  beyond  the 
point  to  which  a  covering  of  uterine  tissue  can  be  traced. 

Mr.  Alban  Doran"  observed  that  in  pure  tubal  pregnancy  the 
foetus  and  placenta  have  been  found  to  lie  in  separate  dilatations. 
This  M^as  the  case  in  Chaput's  patient,  as  recorded  in  the  '  Bulle- 
tin de  la  Societe  Anatomique  de  Paris  '  for  July.  Between  the 
dilatations  was  an  inch  of  open  tubal  canal.  Hence  in  the 
President's  case  the  foetus  possibly  lay  in  a  true  diverticulum  of 
the  tube,  the  little  canal  or  pedicle  being  still  tubal,  though  not 
the  homologue  of  the  channel  of  communication  in  Chaput's 
case.  On  the  other  hand,  it  seemed  possible  that  in  the  Presi- 
dent's case  rupture  of  a  tubo-uterine  sac  had  occurred  early,  but 
the  membranes  had  partly  protruded,  so  as  to  stop  up  the  leak, 
and  the  foetus  had  slipped  into  the  protruding  part,  the  placenta 
remaining  behind. 


EARLY  ECTOPIC  GESTATION.  293 

Dr.  Amand  Eouth  tliouo^ht  that  Mr.  Doran's  explanation  was 
probably  correct,  that  the  gestation  had  been  primarily  an  inter- 
stitial one  which  had  ruptured.  He  thought  that  the  foetus  had 
been  expelled  through  the  rent,  still  attached  to  the  placental 
site  by  the  umbilical  cord,  which  had  permitted  the  foetus  to 
continue  growing.  Both  the  foetus  in  its  amnion  and  the  cord 
had  gradually  become  enveloped  in  a  pseudo-membrane  or  cyst 
wall.  The  manipulations  bad  snapped  the  umbilical  cord,  and 
it  bad  become  drawn  out  of  its  covering,  which  had  formed  the 
pedicle,  leaving  it  patent,  as  found  subsequently. 

Dr.  Arthur  Giles  observed  that  the  mode  of  attachment  of 
the  umbilical  cord  to  the  inner  wall  of  the  sac  was  a  very  curious 
one,  and  from  an  examination  of  the  specimen  the  explanation 
that  seemed  to  him  most  probable  was  that  the  cord,  instead  of 
passing  direct  to  the  placenta,  had  a  velamentous  insertion,  and 
that  the  portion  of  the  sac  nearer  the  uterus  had  become 
encroached  upon  by  the  hsemorrhage  that  had  taken  place 
between  the  amnion  and  the  chorion  until  it  had  become  almost 
obliterated,  and  had  left  the  narrow  channel  contained  in  the 
pedicle.  The  case  had  many  points  of  interest,  clinical  as  well 
as  pathological.  One  of  the  most  instructive  of  the  clinical 
features  was  the  simulation  of  retroversion  of  the  gravid  uterus. 
This  was  not  a  usual  thing  in  ectopic  pregnancy,  but  he  had  met 
with  an  instance  in  a  case  reported  to  the  Society  in  1897.*  It 
was  an  important  thing  to  remember  that  the  tumour  in  a  case 
of  ectopic  pregnancy  might  occupy  the  pouch  of  Douglas  instead 
of  the  classical  position  to  one  or  other  side  of  the  uterus. 

Dr.  CuLLiNGwORTH,  in  reply,  said  that  this  was  the  first  case 
that  had  occurred  in  his  practice  in  which  a  tubal  pregnancy  had 
involved  the  intra-mural  portion  of  the  tube.  Mr.  J.  W.  Taylor, 
of  Birmingham,  an  authority  of  much  experience,  had  expressed 
the  opinion,  after  examining  the  preparation,  that  the  pregnancy 
had  originally  taken  place  in  the  isthmus  of  the  tube,  and  had 
invaded  the  intra-mural  portion  later  in  the  course  of  its  develop- 
ment. Upon  this  point  he  did  not  feel  competent  to  offer  an 
opinion.  It  was  certain  that  the  gestation  sac  was  now  sur- 
rounded over  a  considerable  portion  of  its  circumference  by  a 
fairly  thick  layer  of  uterine  tissue.  He  reminded  the  Society  of 
two  other  instances  he  had  brought  forward,  in  which  part  or  the 
whole  of  the  ovum  in  a  tubal  pregnancy  had  escaped  into  a 
diverticulum  of  the  tube.  Both  specimens  were  in  the  museum  of 
St.  Thomas's  Hospital.  He  believed  that  this  is  what  happened  in 
the  case  before  them,  the  diverticulum  having  gradually  acquired 
a  pedicle,  and  retaining  through  the  pedicle  (which  remained 
pervious)  a  direct  communication  with  the  main  channel  of  the 

*  "  Two  Unusual  Cases  of  Ectopic  Gestation,"  by  A.  E.  Giles  and  E.  J. 
Maclean,  '  Obst.  Trans.,'  1897. 

VOL.  XL.  20 


294 


EARLY    ECTOPIC    GESTATION. 


tube.  The  extrusion  of  the  head  and  lower  hmbs  of  the  foetus 
through  the  wall  of  the  diverticulum,  he  thought,  was  probably 
the  result  of  manipulation  before  operation,  when  attempts  were 
made  to  reduce  what  was  then  believed  to  be  a  retroversion  of 
the  gravid  uterus.  He  thanked  the  Fellows  for  the  interest 
they  had  shown  in  the  case,  and  apologised  for  the  minuteness 
of  detail  in  its  narration,  which,  however,  in  a  case  of  that  nature^ 
was  necessary. 


NOVEMBER  2nd,  1898. 
C.  J.  CuLLiNGWORTH,  M.D._,  President,  in  tlie  Chair. 
Present — 39  Fellows  and  8  visitors. 

The  following  gentlemen  were  elected  Fellows  of  the 
Society  : — Arthur  Scott  Turner,  L.R.C.P.Edin. ;  Haydn 
Brown,  L.R.C.P.Lond.  ;  Charles  F.  Ward,  F.R.C.S.I. 
(Pietermaritzburg) . 


FIBROMA  OF  BROAD  LIGAMENT  WEIGHINa 
FORTY-FOUR  POUNDS  EIGHT  OUNCES, 
SUCCESSFULLY  REMOVED  FROM  A  WOMAN 
AGED    TWENTY-EIGHT. 

Shown  by  Alban  Doran,  F.R.C.S. 

This  tumour,  about  wliicb  I  propose  to  say  more  in 
detail,  was  removed  on  September  27th  from  a  young 
married  woman,  whose  last  child  was  born  six  years  ago; 
then  a  year  later,  when  she  was  twenty-three,  a  swelling 
appeared  in  the  left  iliac  fossa.  She  was  long  under  the 
observation  of  Mr.  T.  W.  Mead  of  Portsmouth,  and  of 
Dr.  Ward  Cousins  of  Southsea,  who  pushed  the  tumour  out 
of  the  pelvis  two  years  ago,  as  it  was  impacted.  Latterly 
it  grew  rapidly.  At  the  operation  I  took  care  to  secure 
all  the  vessels   on  the   capsule   thoroughly,   both   on   the 


296  SARCOMA   OF   BOTH    OVARIES. 

distal  and  proximal  side,  by  ligature,  dividiug-  them 
■with  tlie  adjacent  part  of  the  capsule  and  then  pulling 
the  proximal  ligatures  very  firmly.  When  all  the  vessels 
were  secured,  the  incisions  in  the  capsule  were  prolonged 
till  they  were  united  all  round,  then  enucleation  was  effected 
without  the  loss  of  a  drop  of  blood.  The  cervix,  stretched 
over  the  front  of  the  tumour,  was  secured  by  the  serre- 
noeud  early  in  the  operation.  The  cut  edge  of  the 
capsule  was  brought  down  to  the  lower  end  of  the  abdo- 
minal incision  by  a  purse-string  suture.  As  the  serre- 
noeud  held  the  stump  of  the  cervix  well  and  was  really 
far  from  the  peritoneum,  lying  inside  the  capsule,  I  left 
it  on.  The  capsule  was  packed  with  iodoform  gauze, 
removed  in  forty-eight  hours.  To-day,  ISTovember  2nd, 
just  five  weeks  after  the  operation,  the  patient  is  in 
good  health.  The  cavity  of  the  capsule  has  shrunk  to  a 
granulating  pit  about  an  inch  deep. 

(The  patient  was  in  good  health  on  January  18th,  1899  ; 
the  abdonainal  wound  had  healed  well.) 


SARCOMA  OF  BOTH  OVARIES. 

Shown  by  Alban  Doean,  F.R.C.S. 

The  chief  feature  of  interest  about  these  tumours  was 
their  close  resemblance,  before  operation,  to  uterine 
fibroids.  I  exhibit  them  now  because  they  are  fresh, 
having  been  removed  yesterday,  November  1st.  The 
patient  was  aged  45,  married  eighteen  years,  five  times 
pregnant.  The  last  pregnancy  ended  in  an  abortion  at 
the  third  month,  in  June,  1898.  A  swelling  was  then 
felt  above  the  pubes  ;  it  took  to  increasing  very  rapidly. 
The  periods  remained  regular  and  the  show  was  never 
free.  Two  lobulated  tumours  filled  the  abdomen  from 
the  pubes  to  two  inches  above  the  umbilicus.      They  felt 


SAECOMA    OF    BOTH    OVAEIES.  297 

very  elastic^  and  anteriorly  was  a  cystic  projection  simu- 
lating a  dilated  bladder,  but  the  catheter  only  passed 
four  inches  and  not  near  the  cyst.  The  cervix  was  high, 
and  the  left  tumour  came  down  behind  it  in  Douglases 
pouch.  The  uterine  cavity  measured  three  and  a  half 
inches.  The  two  tumours  and  the  uterus  moved  together, 
but  were  not  very  moveable.  Taken  as  a  whole,  I 
thought  that  the  tumours  were  uterine.  At  the  operation 
some  deep  red  ascitic  fluid  escaped,  and  then  on  drawing 
out  the  right  tumour  I  found  that  it  was  attached  by  a 
short  but  anatomically  normal  ovarian  pedicle  to  the 
right  side  of  the  uterus.  There  were  intimate  and  very 
vascular  adhesions  to  the  small  intestines.  The  left 
tumour  was  more  solid  than  the  right,  its  pedicle  was 
anatomically  normal,  but  with  extremely  dilated  vessels. 
Neither  pedicle  seemed  infected  with  the  new  growth, 
but  both  were  short.  The  two  tumours  weigh  5  lbs.  15  oz., 
and  look  like  myxo-sarcomatous  growths.  On  section 
they  appeared  reddish  brown  and  gelatinous  like  a  kidney^ 
or  still  more  like  a  polished  red  pebble. 

Six  years  ago  I  wrote  some  notes  on  '^  Two  Cases  of 
Small  Ovarian  Tumours  simulating  Uterine  Fibroid" 
('Brit.  Med.  Journ./  1892,  vol.  i,  p.  1180).  Since  then 
I  have  seen  a  large  number  of  these  doubtful  solid  and 
semi-solid  tumours.  As  a  rule  diagnosis  is  not  attended 
with  difficulty,  but  lobulated  soft  solid  ovarian  growths 
with  short  pedicles  cannot  always  be  distinguished  from 
multiple  uterine  fibroids  without  the  aid  of  an  exploratory 
incision.  Clinical  and  physical  symptoms  are  very  mis- 
leading. I  dwell  on  the  question  of  incision  because  I 
consider  it  the  right  step.  Waiting  may  result  in  a 
correct  diagnosis,  but  should  the  tumour  prove  to  be  an 
ovarian  sarcoma  the  patient  will  be  clearly  exposed  to 
increased  risk  by  such  delay. 

(The  patient  recovered,  and  was  in  good  health  Janu- 
ary 2nd,  1899.) 


298 


TUBAL  GESTATION;  INCOMPLETE  TUBAL 
ABORTION ;  H^MOERHAGE  ;  OPERATION ; 
RECOVERY. 

Shown  by  A.  C.  Butler-Smythe,  F.R.C.S.E., 

SUEGEOK  TO   THE   aROSVENOR   HOSPITAL  FOR  WOMEN,   WESTMINSTER; 

SURGEON    TO    OUT-PATIENTS,    SAMARITAN    FREE    HOSPITAL   FOR 

WOMEN,   LONDON. 

This  specimen  was  taken  from  a  patient  who  was  sent 
to  me  by  Dr.  Wright  of  Romford,  Essex.  Her  history 
was  as  follows  : — Age  29,  married  eight  and  a  half  years. 
One  child  born  afc  the  seventh  month.  One  miscarriage 
two  years  and  two  months  ago  at  the  third  month.  She 
had  been  quite  regular  up  to  the  middle  of  July,  when, 
nine  days  after  her  usual  period  had  ceased,  she  came  on 
again  with  a  rush  of  blood,  which  lasted  three  days  and 
then  almost  stopped,  but  for  a  month  there  continued  a 
slight  show.  About  this  time  her  breasts  became  swollen 
and  painful,  and  she  had  attacks  of  pain  in  her  abdomen, 
accompanied  by  sickness  and  fainting  which  led  her  to 
believe  that  she  was  pregnant,  though  she  had  never 
missed  a  period  or  even  gone  over  her  usual  time.  The 
following  month,  however,  her  period  came  on  at  the 
usual  date  and  in  the  usual  manner,  the  flow  lasting  four 
or  five  days.  It  then  stopped  for  three  days,  after  which 
there  was  a  slight  show  for  a  few  days,  and  this  was 
followed  by  severe  pain  in  her  abdomen,  retching  and 
faintness,  and  by  a  great  loss  of  blood  from  the  vagina 
which  continued  for  three  days. 

She  was  kept  in  bed  and  as  quiet  as  possible  for  some 
weeks,  but  a  few  days  previous  to  our  consultation  another 
attack  of  pain  came  on,  followed  by  a  rush  of  blood  to- 
gether with  fainting  and  sickness,  and  she  then  passed 
from  the  vagina  what  she  described  as  "  a  piece  of  skin 
or  flesh.^' 

On    examining  her  abdomen  externally,  some  dulness 


TUBAL    GESTATION,    ETC.  299 

and  tenderness  was  noticeable  in  the  left  iliac  region, 
where  a  distinct  swelling  could  be  made  out.  Bimanually 
the  cervix  uteri  was  felt  to  be  cushiony,  and  the  os 
patulous.  The  uterus  was  enlarged  and  pushed  to  the 
right  side  and  somewhat  downwards  by  a  swelling  on  the 
left  side  of  the  abdomen  which  reached  halfway  to  the 
umbilicus,  and  seemed  to  curl  over  the  fundus  uteri. 
This  I  took  to  be  the  left  Fallopian  tube  much  enlarged 
and  adherent  to  the  top  of  the  uterus.  No  swelling  could 
be  made  out  jper  vaginam  in  Douglas's  pouch  or  at  either 
side,  and  there  was  a  marked  absence  of  tenderness 
around  the  cervix  uteri. 

I  diagnosed  tubal  gestation  on  the  left  side,  and  at  the 
request  of  the  patient  I  explained  the  condition  discovered 
to  herself  and  to  her  husband,  at  the  same  time  urging 
her  to  stop  in  town  and  go  straight  to  a  nursing  home. 
They  decided,  however,  to  go  home  first,  promising  to 
return  with  the  least  possible  delay.  A  room  was  there- 
fore at  once  engaged,  and  I  wrote  to  Dr.  Wright,  giving 
my  opinion  and  advising  immediate  operative  interference. 

On  the  morning  of  the  29th  September  I  had  a  wire 
snying  ^'  the  patient  would  be  at  the  home  by  1  o'clock.^' 
At  1,15  another  wire  arrived,  asking  me  to  ^^  come  down 
at  once  ready  to  operate,  as  the  patient  had  collapsed  on 
her  way  to  the  station.'^  On  my  arrival  I  ascertained 
that  the  patient  had  started  to  drive  five  miles  in  a 
dog- cart  from  her  home  to  the  railway  station.  She  was 
then  perfectly  well  and  cheerful,  but  when  about  half  a 
mile  from  the  town  she  suddenly  felt  faint  and  sick,  and 
before  they  could  reach  the  doctor's  house  she  completely 
collapsed.  Dr.  Wright  and  his  partner  being  out,  the 
nearest  medical  man.  Dr.  Fraser,  was  sent  for,  and  he 
had  the  patient  lifted  out  of  the  cart  into  the  house. 
She  was  then  absolutely  collapsed,  and  was  thought  to  be 
dying.  Under  appropriate  treatment,  however,  she  rallied 
somewhat,  and  on  Dr.  Wright's  arrival  she  was  removed 
on  an  ambulance  to  the  Cottage  Hospital. 

When  I  saw  her  there  in  consultation  with  Drs.  Wright, 


300  TUBAL    GESTATION^    ETC. 

Fraser,  and  S.  Wright,  she  was  blanched,  cold,  and  pulse- 
less at  both  wrists.  Her  pupils  were  widely  dilated,  her 
respiration  sighing,  and  she  was  sweating  profusely  and 
very  restless.  Her  temperature  was  97°,  and  she  seemed 
to  me  to  be  passing  from  one  fainting  condition  into 
another,  and  was  evidently  then  bleeding  internally. 
The  case  seemed  hopeless,  but  I  decided  to  open  her 
abdomen,  and  having  explained  the  patient's  condition  to 
her  husband  he  gave  his  consent  to  the  operation. 

When  placed  on  the  table  it  was  doubtful  if  she  could 
take  any  anaesthetic,  but  Dr.  Fraser  decided  to  make  the 
attempt  with  the  A.C.E.  mixture,  and  very  well  it  acted. 
As  the  bleeding  had  evidently  been  extensive  I  decided 
to  have  a  saline  solution  passed  into  the  rectum  by  means 
of  a  funnel  and  tube,  and,  if  possible,  continued  through- 
out the  operation.  Dr.  Wright,  jun.,  attended  to  this,  and 
Dr.  Wright  kindly  assisted  me  at  the  operation.  On 
opening  the  peritoneum  dark  blood  and  clots  gushed  out 
with  considerable  force.  The  omentum  was  adherent  in 
front  to  the  tumour,  the  uterus,  and  to  the  top  of  the 
bladder,  and  the  last-named  organ  was  drawn  up  half- 
way to  the  umbilicus,  and  narrowly  escaped  being  in- 
jured when  the  peritoneum  was  incised.  The  adhesions 
were  separated  and  the  bladder  pushed  down,  and  the 
opening  was  enlarged.  It  was  then  seen  that  the  abdo- 
men was  full  of  large  clots  and  recent  blood.  The  cavity 
was  flushed  out  with  warm  water  and  the  clots  removed, 
when  bright  blood  was  noticed  coming  from  the  left  side 
of  the  uterus.  The  tube  on  that  side  was  at  once 
clamped  close  to  the  left  cornu,  and  the  tumour,  which 
was  adherent  to  the  intestine  and  curled  round  the 
fundus  of  the  uterus,  was  separated,  brought  to  the  sur- 
face, ligatured,  and  removed.  The  abdominal  cavity  was 
again  thoroughly  flushed  out  and  a  drainage-tube  in- 
serted and  fixed  in  the  lower  part  of  the  wound,  which 
was  then  closed,  leaving  the  abdomen  full  of  clear  warm 
water.  The  patient  was  next  removed  to  bed  and  sur- 
rounded by  hot  water  bottles,  and  five   minims  of  Liq. 


TUBAL    GESTATION^    ETC.  301 

Stryclininae  were  injected  subcutaneously.  An  hour 
later  a  feeding  enema  was  given,  and  tlie  patient's 
condition  was  much  improved.  The  after  history  was 
unaccompanied  by  any  drawback.  The  drainage-tube  was 
removed  within  twenty-four  hours,  and  the  wound  healed 
almost  by  first  intention.  On  the  evening  of  the  opera- 
tion the  temperature  rose  to  100*8°,  this  being  the 
highest  point  recorded  during  her  convalescence.  The 
pulse  for  the  first  three  days  kept  about  120,  and  then 
gradually  slowed  down  to  normal.  The  silkworm-gut 
sutures  were  removed  on  the  tenth  day,  by  which  time 
the  patient  was  convalescent. 

RemarJis. — No  embryo  was  discovered  among  the  clots 
removed  from  the  abdomen,  but  the  search  was  anything 
but  exhaustive.  Chorionic  villi  were,  however,  found  in 
abundance  in  a  section  cut  for  me  by  my  colleague,  Mr. 
Corrie  Keep.  I  thiuk  the  recovery  of  this  patient  was 
due  in  a  great  measure  to  the  use  of  the  saline  solution 
administered  by  the  rectum  throughout  the  operation,  and 
also  to  the  fact  that  the  abdominal  cavity  was  left  full  of 
warm  water  when  the  abdomen  was  closed.  Had  I  to 
operate  again  on  a  case  where  the  haemorrhage  had  been 
extensive  I  should  use  the  saline  solution  in  the  peri- 
toneal cavity,  knowing  that  the  healthy  peritoneum  would 
absorb  it  rapidly.  In  this  case  the  result  was  remarkable, 
for  though  the  patient  was  pulseless  at  both  wrists  when 
placed  on  the  table  the  pulse  gradually  returned  during 
the  operation,  and  was  of  fair  volume  at  its  close. 
My  best  thanks  are  due  to  the  staff  of  the  Romford 
Cottage  Hospital  for  the  valuable  assistance  rendered  at 
the  operation,  and  for  their  courtesy  in  allowing  me  to 
visit  the  patient  subsequently  in  consultation. 


302 


GEDEMATOUS  SUBPERITONEAL  FIBRO-MYO- 
MATA  OF  UTERUS  IN  RIGHT  BROAD  LIGA- 
MENT REMOVED  BY  ABDOMINAL  HYS- 
TERECTOMY. 

Shown  by  C.  J.  Cullingworth^  M.D. 

The  specimen  consisted  of  a  uterus  witli  three  sub- 
peritoneal fibro-myomata^  removed  October  20th,  1898, 
by  abdominal  hysterectomy  from  a  single  woman  aged  36. 
One  of  the  tumours,  measuring  2^  x  2  x  2  inches, 
formed  a  sessile  projection  from  the  posterior  surface  of 
the  uterus,  and  was  irregularly  nodular,  firm,  and  hard. 
The  other  two  were  of  larger  size,  and  had  burrowed 
between  the  layers  of  the  right  broad  ligament  and 
beneath  the  peritoneal  covering  of  the  pelvic  floor.  They 
were  remarkably  soft  from  extensive  oedema,  and  retained 
their  connection  with  the  uterus  by  bands  of  muscular 
tissue,  so  soft  and  so  inconsiderable  in  size  as  to  be  only 
detected  on  careful  examination.  The  larger  one  was 
somewhat  pyriform  in  shape,  and  measured  7^  x  5  x  3| 
inches.  The  smaller  was  discoid  in  shape,  and  measured 
3j  X  3|^  X  14  inches.  Their  pedicles  were  about  equal 
in  size  to  the  little  finger  of  an  adult. 

The  right  Fallopian  tube  and  right  ovary  were  re- 
moved. They  were  both  healthy,  but  were  too  extensively 
disturbed  in  their  relations  for  it  to  be  possible  to  save 
them.  The  left  appendages  were  left  intact.  The  uterus 
was  removed  at  the  level  of  the  os  internum;  its  walls 
were  of  normal  thickness,  and  its  cavity  of  the  average 
size  and  length. 

The  patient  had  been  subject  for  several  months 
to  attacks  of  pain  and  nausea.  She  first  noticed  an 
abdominal  swelling  nine  or  ten  months  ago.  The  swell- 
ing, on  her  admission  into  St.  Thomas's  Hospital  on 
October    12th,    extended    from    the    pubes    upwards    to 


SLODGHING    FIBRO-MYOMA    OF    UTERUS.  303 

witliin  one  and  a  half  inches  of  the  umbilicus.  The  cervix 
was  drawn  up  to  the  left;  there  was  no  projection  of 
cervix  into  the  vagina,  the  os  being  on  a  level  with  the 
horizontal  ramus  of  the  os  pubis.  Both  vagina  and 
rectum  were  much  encroached  upon  by  the  lower  part  of 
the  abdominal  swelling.  The  bladder  "'.vas  displaced 
backwards  and  to  the  left. 

The  operation  involved  an  extensive  enucleation,  and 
left  a  large  gap  in  the  connective  tissue  on  the  right  side 
of  the  pelvis.  The  peritoneal  flaps  of  broad  ligament,  &c., 
were  allowed  simply  to  fall  together,  their  divided  edges 
being  united  by  a  few  fine  silk  sutures.  The  ovarian 
arteries  and  the  right  uterine  artery  w^ere  ligatured  in  the 
usual  w^ay  as  a  preliminary  step  of  the  operation.  The 
left  uterine  artery  lay  concealed  by  the  growths.  It  was 
easily  secured  at  the  moment  of  its  division  during  the 
operation. 

The  patient's  recovery  had  been  quite  uneventful. 

The  interest  of  the  case  lay  in  the  successful  issue  of 
what  appeared  to  be  a  somew^hat  formidable  undertaking, 
and  in  the  fact  of  tw^o  of  the  three  tumours  having  under- 
gone extensive  cedematous  infiltration,  whilst  the  third, 
with  a  broader  base  of  connection  with  the  uterus,  had 
escaped. 


CASE  OF  SLOUGHIXG  FIBRO-MYOMA  OF 
UTERUS  OCCURRING  IN  A  PATIENT  TWENTY 
YEARS  AFTER  THE  MENOPAUSE. 

Shown  by  Dr.  Walter  Tate. 

The  specimen  shown  ^vas  removed  from  a  single  woman 
aged  67.  Menstruation  had  always  been  rather  profuse, 
lasting  seven  or  eight  days;  it  ceased  at  the  age  of  forty- 
seven.  She  remained  free  from  any  discharge  till  three 
months  before  her  admission,  when  she   began  to  have  a 


304  SLOUGHING    FIBRO-MYOMA    OF    UTERUS. 

continuous  blood-stained  discliarge.  At  tlie  end  of  tlie 
first  month  the  discharge  became  much  more  profuse,  and 
was  accompanied  by  pain  and  considerable  loss  of  flesh. 
These  symptoms  continued  up  to  the  time  of  admission  to 
St.  Thomas's  Hospital.  On  abdominal  examination  a 
firm,  smooth,  rounded  tumour  was  found  occupying  the 
hypogastric  region,  reaching  to  within  two  and  a  half 
inches  of  the  umbilicus.  Per  vaginam  the  cervix  was 
healthy,  and  the  tumour  was  found  to  fill  the  pelvis,  and 
depressed  the  anterior  vaginal  wall.  On  the  12th  Octo- 
ber, 1898,  the  cervical  canal  was  dilated,  and  on  digital 
exploration  the  anterior  wall  of  the  uterus  was  found  to 
be  the  seat  of  an  irregular  sessile  growth  projecting  into 
the  cavity  of  the  uterus.  The  uterine  wall  in  the  im- 
mediate neighbourhood  of  the  tumour  felt  nodular.  The 
gTOwth  bled  very  freely  on  examination,  the  discharge 
being  slightly  offensive.  From  the  age  of  the  patient, 
and  the  irregular  surface  of  the  growth,  the  tumour  was 
thought  to  be  carcinomatous,  and  it  was  decided  to 
remove  the  whole  uterus.  As,  however,  the  vagina  was 
small,  it  was  thought  best  to  commence  the  operation  of 
hysterectomy  by  the  vaginal  route,  and  complete  it  by  an 
abdominal  incision. 

On  the  19th  October  hysterectomy  was  performed. 
The  usual  incision  through  vaginal  mucous  membrane 
was  made,  and  the  bladder  separated  from  the  cervix. 
The  cellular  tissue  posteriorly  was  opened  up  to  the 
reflection  of  peritoneum,  and  two  ligatures  were  then 
passed  on  each  side  securing  the  lower  part  of  the  broad 
ligament.  The  abdomen  was  then  opened,  and  the  upper 
part  of  the  broad  ligament  was  ligatured  on  each  side, 
the  ligatures  being  cut  short.  After  opening  the  perito- 
neal reflection  in  front  of  and  behind  the  uterus,  the 
middle  portion  of  the  broad  ligament  on  the  left  side  was 
firmly  secured  with  a  silk  ligature,  and  the  uterus  was 
then  free.  The  abdominal  wound  was  closed  and  a  plug 
of  gauze  inserted  into  the  vagina. 

Patient  suffered  very  little  shock,  but  at  the  end  of   a 


SLOUGHING    F1BR0-MY0M\    OF    UTERUS.  305 

week  began  to  suffer  from  bronchitis,  which  was  followed 
by  hypostatic  congestion,  and  made  the  prognosis  un- 
favourable. 

The  tumour  after  removal  was  found  to  be  a  ses- 
sile sloughing  fibroid,  measuring  3^  x  3  inches.  Its 
attachment  extended  over  the  anterior  wall  of  the  uterus 
from  the  fundus  to  the  internal  os. 

Note. — The  patient  died  on  November  3rd_,  1898.  At  the 
autopsy  there  was  found  extensive  pelvic  peritonitis,  with 
one  or  two  loculi  of  pus  between  the  adjacent  coils  of 
intestine.  In  the  upper  part  of  the  abdomen  the  peri- 
toneum was  quite  healthy.  The  visceral  pleura  of  the 
left  lung  was  completely  ensheathed  by  a  coat  of  yellow 
lymph  which  could  be  peeled  off.  Both  lungs  were 
oedematous.      The  kidneys  were  markedly  granular. 


Mr.  Bland  Sutton  remarked  that  the  specimen  shown  by  Dr. 
Tate  was  of  some  interest,  inasmuch  as  it  showed  that  although 
the  patient  waited  till  the  menopause,  with  the  hope  of  losiug 
the  myoma,  the  tumour  placed  her  life  in  the  gravest  peril.  Mr. 
Sutton  had  recently  seen  a  similar  case.  A  maiden  lady,  fifty- 
five  years  of  age,  had  a  large  myoma.  It  was  positively  known 
to  have  existed  twenty- six  years,  and  there  was  reason  to  believe 
that  it  was  present  in  the  womb  thirty  years.  The  menopause 
occurred  at  the  fifty-third  year,  and  the  tumour  diminished 
somewhat.  Two  years  later  it  became  painful,  and  a  foul 
vaginal  discharge,  accompanied  by  rigors  and  elevated  tempera- 
ture (sometimes  reaching  102°),  disturbed  the  patient.  It  was 
clear  that  the  myoma  was  sloughing,  or  perhaps  carcinoma  had 
occurred  in  the  endometrium.  On  October  18th,  1898,  the 
uterus  was  removed  by  supra-vaginal  hysterectomy,  and  the 
tumour,  which  weighed  8  lbs.,  was  a  filthy,  stinking,  sloughing 
mass  covered  by  a  thin  capsule.  Recovery  was  rapid  and  event- 
less. Evidence  was  accumulating  to  prove  that  the  j^atience  of 
patients  was  not  always  rewarded  by  escape  from  the  inconveni- 
ences and  dangers  of  uterine  myomata  when  they  survived  the 
"  change  of  life."  Even  if  the  tumour  "  dried  up,"  it  could  and 
often  did  jeopardise  life. 

Dr.  Herman,  while  recognising  the  difficulty  of  diagnosis,  and 
that  the  operation  performed  was  the  proper  one  for  the  disease 
presumably  present,  yet  thought  that  had  the  correct  diagnosis 
been  made,  the  disintegrating  fibroid  could  have  been  easily  and 


306  UTERINE    APPENDAGES    WITH     H.EMATOSALPINX. 

more  safely  removed  by  dilating  the  cervix,  cutting  up  the  fibroid, 
and  extracting  the  pieces  through  the  vagina,  thus  avoiding  an 
abdominal  scar  and  the  risk  of  peritonitis.  Mr.  Sutton's  case 
was  an  interesting  one,  but  he  (Dr.  Herman)  did  not  see  that  it 
ought  to  alter  the  opinion  of  the  profession  as  to  the  prognosis 
with  uterine  fibroids.  Fibroids  were  exceedingly  common  in 
elderly  women,  and  cases  such  as  Mr.  Sutton  had  described, 
many  of  which  had  been  observed  and  recorded  before  Mr. 
Sutton's,  were  exceedingly  rare. 

Mr.  Alban  Doran  observed  that  a  sloughing  fibroid  in  the 
uterine  cavity  Avas  occasionally  discovered  during  hysterectomy, 
much  to  the  alarm  of  the  operator.  In  the  spring  of  1897  he 
removed  the  uterus  of  a  woman  over  forty  for  fibroid  disease, 
with  the  usual  symptoms ;  though  blood  had  escaped  freely, 
there  was  no  history  of  foetor.  He  amputated  the  fibroid  uterus, 
and  found,  whilst  cutting  through  the  anterior  flap,  that  a 
sloughing  submucous  myoma  occupied  the  uterine  cavity.  Sponges 
had  already  been  packed  around  the  lower  part  of  the  uterus, 
and  the  sloughing  j)ai't  was  at  once  soaked  with  a  1  in  1000  subli- 
mate solution  directly  it  was  discovered.  The  posterior  flap  was 
made  with  a  fresh  scalpel  ;  then  the  uterus,  with  its  interstitial 
and  submucous  growths,  came  away.  The  interior  of  the  flaps 
was  well  washed  with  sublimate,  and  their  serous  and  muscular 
coats  united  with  fine  silk ;  fortunately  the  os  externum  was 
wide,  so  that  there  was  free  drainage.  No  ill  results  followed, 
but  the  risk  of  any  variety  of  hysterectomy  is  greatly  increased 
by  the  presence  of  a  submucous  myoma  in  an  unhealthy  state. 

In  reply.  Dr.  Tate  did  not  consider  that  the  operation  would 
have  caused  the  patient  shock  if  done  entirely  by  the  abdominal 
incision.  The  vaginal  part  of  the  operation  causes  no  shock, 
and  consequently  the  shorter  exposure  of  the  abdominal  incision 
diminishes  shock.  In  reply  to  Dr.  Herman,  Dr.  Tate  considered 
that  the  removal  of  the  whole  uterus  exposed  the  patient  to  far 
less  risk  than  removal  of  the  tumour  morcellement. 


UTERINE    APPENDAGES     SHOWING    A    HEMA- 
TOSALPINX. 

Shown  by  Dr.  Amand  Routh. 

These  bilateral  appendages  were  removed  by  Mr. 
Stanley  Boyd  for  recurrent  mammary  cancer.  The 
patient    was     a    married    woman    of     33,    whose    right 


UTERINE    APPENDAGES    WITH    H.i:MATOSALPINX.  307 

breast  was  removed  by  Mr.  Boyd  in  March _,  1896.  Recur- 
rence took  place  above  the  clavicle  in  August,  1897 ;  and 
in  November,  1897,  Mr.  Boyd  removed  the  ovaries  and 
tubes  on  both  sides,  and  also,  but  incompletely,  the 
recurrence  above  the  right  clavicle. 

At  the  time  of  the  abdominal  section  it  was  noticed 
that  the  uterus  was  enlarged,  and  this  condition,  with  the 
dilated  tube  and  the  corpus  luteum,  was  taken  to  mean 
that  an  early  tubal  gestation  was  present,  especially  as  the 
corpus  luteum  was  on  the  same  side  as  the  tubal  swelling. 
On  further  examination  o£  th.e  tube  by  Dr.  William 
Hunter  the  tubal  swelling  was  proved  to  be  coagulated 
blood,  with  no  trace  of  any  chorionic  villi. 

The  patient  returned  again  in  February,  1898,  and  was 
then  found  to  be  five  months  pregnant,  so  that  at  the  date 
of  the  removal  of  the  appendages  she  must  have  been 
two  and  a  half  months  pregnant.  Her  labour  occurred 
in  June,  1898,  and  was  uneventful.  Her  child  was  small 
but  healthy,  and  her  convalescence  was  normal.  It  was 
noted  that  the  liquor  amnii  was  scanty. 

On  July  21st  involution  was  complete,  the  cervix  being 
atrophic,  and  there  was  no  obvious  increase  of  the  glands 
which  were  noticed  eight  months  previously,  and  the 
patient  was  gaining  weight.  It  seemed  probable  that  the 
oophorectomy  was  holding  the  cancer  in  check. 


308 


ON  A  CASE  OF  TUBO-ABDOMINAL  PREGNANCY 
IN  WHICH  A  LIVING  FCETUS  WAS  EX- 
TRACTED BY  CCELIOTOMY  AFTER  TERM, 
AND    THE    MOTHER^S    LIFE    PRESERVED. 

By  J.  Bland  Sdtton. 

(Received  September  23rd,  1898.) 

[Abstract.) 

The  paper  consists  of  the  record  of  a  case  in  which  a  woman, 
twenty-four  years  of  age,  conceived  in  her  left  Fallopian  tube, 
and  the  pregnancy  went  to  term.  The  foetus  escaped  from  the 
amnion,  and  at  the  operation  was  alive  and  disporting  among  the 
intestines,  merely  tethered  by  the  umbilical  cord. 

The  placenta  was  removed  without  difficulty,  and  a  very 
trifling  loss  of  blood.  The  mother  recovered,  but  the  child  only 
survived  extraction  three  hours. 

In  spite  of  the  great  increase  in  our  knowledge  of  the 
morbid  anatomy  of  tubal  pregnancy,  some  new  light  was 
needed  to  clear  away  certain  mists  which  enveloped  that 
condition  (fortunately  rare)  in  which  a  living  foetus  near, 
at,  or  even  beyond  term  escapes  from  its  amnion  and 
moves  freely  among  the  intestines  merely  tethered  by  the 
umbilical  cord. 

A  married  woman,  24  years  of  age,  who  had  one  child 
twenty  months  previously,  was  admitted  July  3rd,  1898, 
into  Queen  Charlotte's  Lying-in  Hospital,  under  the  care 
of  Dr.  W.  Chapman  Grigg.  The  woman  stated  that  the 
date  of  delivery  according  to  her  reckoning  was  overdue, 


TUBO-ABDOMINAL    PREGNANCY.  309 

and  the  active  movements  of  the  foetus  caused  great  pain. 
The  last  menstruation  happened  in  July,  1897,  but  there 
was  a  slight  stain  in  August,  1897.  Morning  sickness 
began  in  October,  1897.  She  noticed  nothing  abnormal 
in  regard  to  her  pregnancy  until  May,  1898,  when  she 
began  to  suffer  pain. 

On  her  admission  into  the  lying-in  hospital,  the  resi- 
dent officer,  Dr.  Dunn,  from  the  ease  with  which  the 
foetus  could  be  felt  and  its  high  position  in  the  belly, 
came  to  the  conclusion  that  the  foetus  was  not  in  the 
uterus.  Dr.  Grigg  saw  the  case  and  examined  the 
patient  under  chloroform.  The  uterus  was  empty,  and 
the  hypogastric  region  was  occupied  by  a  soft  dome- 
shaped  swelling,  yielding  a  venous  murmur  on  ausculta- 
tion. There  could  be  no  reasonable  doubt  that  the  poor 
woman  had  an  extra-uterine  foetus,  and  that  the  hypo- 
gastric swelling*  was  the  placenta. 

Arrangements  were  made  for  the  transference  of  the 
patient  to  the  Chelsea  Hospital  for  Women  for  the 
purpose  of  extracting  the  foetus  by  coeliotomy. 

The  cosUotomy. — On  July  4th,  1898,  assisted  by  Drs. 
W.  H.  Fenton  and  Giles,  I  incised  the  abdominal  w^all 
freely  in  the  linea  alba,  carrying  the  incision  well  above 
the  navel.  On  dividing  the  peritoneum  some  meconium- 
stained  omentum  and  thickened  amnion  protruded.  Then 
a  foetal  hand  firmly  grasping  a  coil  of  omentum  presented 
at  the  incision  ;  the  fingers  were  gently  extended  and 
the  omentum  released,  and  a  living  foetus  extracted.  The 
umbilical  cord  was  clamped,  cut,  and  the  foetus  handed 
to  a  nurse.  The  intestines  were  covered  with  a  large, 
soft,  warm  sponge,  and  the  placenta  examined  with 
gentleness.  I  satisfied  myself  that  it  rested  on  the  left 
mesometrium  quite  close  to  the  uterus,  and  the  vessels  on 
its  surface  communicated  w^th  large  arteries  and  veins 
in  the  folds  of  the  great  omentum ;  these  folds  were 
intimately  adherent  to  the  amnion  at  the  situation  where 
the  membrane  came  into  close  relation  with  the  foetal 
surface   of   the  placenta.      The  amnion  was  creased  into 

VOL.    XL.  21 


310  TUBO-ABDOMINAL    PREGNANCY. 

irregular  folds,  and  obscured  tlie  pelvic  structures.  The 
left  ovary  and  tube  were  drawn  up,  and  tlie  mesometrium 
transfixed  at  the  outer  edge  of  the  placenta ;  a  thick, 
broad,  muscular,  and  very  vascular  band  ran  up  the 
posterior  aspect  of  the  mesometrium  into  the  base  of  the 
placenta.  This  was  transfixed  with  silk,  securely  liga- 
tured, and  divided.  This  at  once  set  the  placenta  free 
from  its  pelvic  attachments  with  the  most  trifling  loss  of 
blood.  The  omentum  was  then  transfixed  with  thin  silk, 
and  ligatured  in  successive  bundles  and  without  loss  of 
blood.  A  very  vascular  fold  of  omentum  adhered  to  the 
coelomic  end  of  the  right  tube,  which  necessitated  the 
removal  of  the  outer  fifth  of  the  tube  with  the  corre- 
sponding section  of  the  mesosalpinx.  A  critical  survey 
of  the  pelvic  organs  was  then  made.  The  uterus,  which 
reached  well  above  the  pubes,  was  soft  and  enlarged  to 
the  size  of  a  fist.  The  outer  two  thirds  of  the  left  ovary 
and  Fallopian  occupied  the  natural  position,  but  the 
isthmial  segment  was  absent.  The  right  appendages 
were  entire  except  for  the  outer  fifth  of  the  Fallopian 
tube,  which  was  removed  as  already  mentioned.  In 
consequence  of  the  pedicle  being  thick  and  succulent  I 
inserted  a  thin  narrow  rubber  drain,  to  serve  as  a  warn- 
ing tube.  The  wound  was  secured  in  triple  layers  and 
the  patient  returned  to  bed. 

In  the  course  of  the  two  following  days  much  serous 
fluid  escaped  through  the  tube ;  on  the  third  day  the 
drain  was  removed,  but  some  pus  eventually  made  its 
way  along  the  drain  track.  Convalescence  was  somewhat 
retarded  by  some  pulmonary  congestion  present  before 
the  operation,  and  possibly  intensified  by  the  etherisation. 
However,  she  left  for  a  convalescent  home  on  July  26th. 

The  child. — We  were  not  so  fortunate  with  the  child  as 
with  its  mother.  Immediately  on  its  extraction,  Dr. 
Porter  Mathew  successfully  induced  respiration,  and  it 
cried  lustily.  The  child  weighed  7^  lbs.,  was  free 
from  deformity  and  signs  of  compression.  The 
umbilical    cord    was    markedly   oedematous.       Two   hours 


TUBO-ABDOMINAL    PREGNANCY. 


311 


later  tlie  child  appeared  slightly  cyanotic,  and  shortly 
afterwards  fell  into  a  convulsion  and  died.  The  large 
vessels  of  the  heart  aad  thorax  were  carefully  dissected, 
but  the  investigation  revealed  nothing  to  account  for 
death. 

The   placenta. — This    organ    is    ovoid,    and,    with    the 
amnion,    weighed    1^    lbs.       In    order   to    test    the    main 


The  placenta  with  its  amnion  in  its  relation  to  the  Fallopian 
tube.  The  position  of  the  thick  vascular  band  in  the  meso- 
metrium  is  well  shown.  The  parts  are  represented  from 
behind. 

channels  of  communication  with  the  maternal  circulation, 
I  injected  water  into  the  substance  of  the  placenta,  and 
found  it  escape  through  the  large  veins  in  the  fleshy  band 
derived  from  the  left  mesometrium. 

The  amnion  is  particularly  thick,  and  the  tissue  of  the 
umbilical  cord  cedematous. 

A  study  of  the  placenta  combined  with  the  careful 
survey  of  the  parts  made  during  the  operation  satisfied 
me  that  the  course  of  events  may  be  described  thus  : 


312  TUBO- ABDOMINAL  PREGNANCY. 

The  oosperm  suffered  arrest  iu  the  isthmus  of  the  left 
Fallopian  tube  ;  gradually  the  enlarging  amnion  eroded 
the  expanded  tube,  and  slowly  made  its  way  into  the 
belly.  Near  term  the  amnion  ruptured,  and  the  foetus 
escaped  among  the  intestines.  That  it  quitted  its 
amniotic  prison  some  time  previous  to  the  operation  is 
demonstrated  by  the  meconium-stained  omentum. 

It  is  clear  that  in  this  case  the  embryo  never  occupied 
the  mesometrium,  and  it  illustrates  in  every  particular 
the  observations  made  by  Taylor*  in  his  example  of 
tubo-abdominal  pregnancy. 

To  all  interested  in  the  question  of  tubal  pregnancy  it 
should  be  a  matter  of  satisfaction  that  the  difficulty 
surrounding  the  mode  of  origin  of  tubo-abdominal  preg- 
nancy has  been  so  clearly  solved  and  set  at  rest  b}^ 
Taylor.  It  completes  the  evidence  that  these  ^'  ventral  '^ 
pregnancies  like  the  pure  mesometric  forms  are  primarily 
tubal,  and  absolutely  disposes  of  the  myth  that  a  fertilised 
ovum  may  engraft  itself  upon  the  peritoneum. 

*  '  Trans.  Obstet.  Soc./  vol.  xxxix,  178,  and  ^Lancet,'  1898,  vol.  i,  1515. 


313 


ON    SOME    CASES    OF    TUBAL    PEEGNANCY. 
By  J.  Bland  Sutton. 

(Received  September  23rd,  1898.) 

{Abstract.) 

The  criticisms  and  deductions  contained  in  this  essay  are 
based  on  a  report  of  a  specimen  presented  to  the  Society  by  Mr. 
Alban  Doran,  in  May,  1898,  purporting  to  be  "  Haemorrhage 
from  the  Fallopian  Tube  without  Evidence  of  Tubal  Preg- 
nancy." 

The  object  of  the  essayist  is  to  prove  that  the  specimen  was 
an  excellent  example  of  **  complete  tubal  abortion."  This  con- 
tention is  supported  by  a  re-examination  of  the  specimen,  and 
illustrated  by  additional  cases.  Criticism  is  also  extended  to 
some  other  records  recently  published  in  the  Society's  '  Trans- 
actions.' 

This  essay  is^  in  a  sense,  critical  and  deductive.  I 
assume  it  to  be  clearly  established  that  the  presence  of  a 
tubal  mole,  or  the  demonstration  of  chorionic  villi  in  the 
Fallopian  tube,  is  proof  that  pregnancy  has  happened  in 
the  tube,  as  surely  as  laminated  membranes  and  booklets 
indicate  an  echinococcus  colony. 

Although  it  requires  very  little  training  to  recognise 
these  signs,  it  is  remarkable  how  frequently  they  are 
overlooked.  It  is  very  important,  in  judging  of  the  value 
of  a  record,  to  be  satisfied  that  the  recorder,  to  use  a 
legal  phrase,  can  be  regarded  as  a  competent  witness. 
My  astonishment  was  certainly  great  when  I  read  the 
account  of  the  proceedings  of  this  Society  for  May,  1898, 


314  TUBAL    PEEGNANCY. 

that  a  very  competent  witness_,  my  friend  Alban  Doran, 
had  placed  on  record  some  misinterpretations  which, 
issuing  from  such  a  recognised  source^  are  likely  to  cause 
mucli  doubting ;  therefore  I  intend  to  use  his  case  and 
the  observations  made  thereon  by  our  distinguished 
president  as  a  basis  for  my  essay. 

Mr.  Doran  showed  a  specimen  illustrating,  as  he 
believed,  '^  Hgemorrliage  from  the  Fallopian  Tube  without 
Evidence  of  Tubal  Gestation.^'  The  clinical  facts  are 
detailed  at  length,  but  fortunately  there  is  an  excellent 
drawing  of  the  parts.  On  the  strength  of  this  figure 
alone  I  realised  that  the  clot  hanging  from  the  margin 
of  the  coelomic  ostium  of  the  tube  was  a  mole,  and  as 
the  specimen  was  stored  in  a  public  collection  (the  museum 
of  the  Royal  College  of  Surgeons)  I  lost  no  time  in  ex- 
amining it  and  satisfying  myself  that  the  supposed  clot 
is  a  tubal  mole,  and  the  case  is  an  undoubted  example  of 
complete  tubal  abortion. 

In  order  to  establish  my  view  of  this  instructive  case 
it  will  be  necessary  to  consider  four  points  :  1,  the 
nature  of  the  clot ;  2,  the  condition  of  the  tube  ;  3,  the 
absence  of  free  blood  ;    and  4,  the  uterine  decidua. 

1.  Nature  of  the  clot. — The  elliptical  shape  of  the  clot, 
its  investing  membrane  (chorion),  and  the  presence  of  an 
eccentric  smooth-walled  (amniotic)  cavity,  are  more  than 
sufficient  to  prove  it  a  mole. 

I  am  anxious  to  show  that  every  smooth  elliptical  clot 
associated  with  tubal  abortion  is  not  a  mole  :  for  example, 
a  woman  came  under  my  care  in  whom  the  signs  of  tubal 
pregnancy  were  well  marked.  At  the  operation  (October, 
1896)  the  pelvis  was  occupied  by  four  firm  dark  clots. 
Each  clot  was  reniform  (Fig.  1),  and  the  exterior  was 
formed  of  laminated  fibrin.  The  coelomic  ostium  of  the 
tube  was  widely  patent,  and  the  ampullary  Avail  thick, 
succulent,  and  entire  ;  the  tube  contained  a  "  mole  '^ 
which  abounded  in  villi.  The  case  was  one  of  incomplete 
tubal  abortion,  but  peculiar  in  this  respect  :  as  the  blood 
slowly  collected   in  the   tube  it   clotted   firmly,   and    was 


TUBAL    PREGNANCY. 


315 


discharged  witli  pain  through  the  ostium  into  the  pelvis, 
the  "  delivery/^  so  to  speak,  of  each  clot  coinciding  with 
three  definite  attacks  of  ''  pains  ^'  in  the  preceding  July, 
August,  and  September. 


Fig.  1. 


A  gravid  mole-containing  Fiillopian  tube.  The  dark  outline  represents  the 
shape  and  size  of  the  smallest  clot;  it  also  shows  the  shape  of  the 
ampulhi  when  the  tube  is  distended.  From  a  woman  41  years  of  age, 
mother  oF  four  children. 


For  full  clinical  history  see  'Lancet,'  1897,  vol.  i, 
p.  432. 

The  tubal  mole  is  such  a  characteristic  and  usually 
easily  recognised  body  that  I  now  rarely  search  for  the 
villi,  but  in  some  cases  where  the  mole  is  not  found — for 
in  some  instances  it  is  so  small  as  to  be  easily  lost  in  the 
effused  blood — then  in  order  to  establish  the  nature  of 
the  case  it  is  necessary  to  search  for  villi  in  the  tube  at 
the  site  of  implantation  of  the  oosperm.  The  smallest 
mole  I  have  secured  in  a  tube  had  a  diameter  of  a  centi- 


316 


TUBAL    PREGNANCY. 


metre,  equal  in  size  to  an  average  green  pea  ;  lience  it  is 
easy  to  realise  that  moles  so  small  may  be  overlooked. 
In  sucli  cases  it  is  a  simple  and  safe  process  to  search 
for  the  villi  near  the  rent  in  the  tube  if  this  structure 
be  ruptured,  as  was  so  signally  illustrated  in  the  interest- 
ing record  given  by  the  president  (Dr.  Culliugworth)  in 
the  '  Transactions/  May,  1898,  p.  186. 

In  connection  with  the  chorionic  villi  of  a  tubal 
embryo  it  ma}^  be  worth  while  to  mention  that  whilst 
examining  these  structures  in  a  tubal  embryo  of  about 
the  third  month,  I  came  across  a  large  collection  of 
decidual  cells  ;  the  relation  of  the  outer  protoplasmic 
layer  of  the  villi  was  such  as  to  suggest  that  this  so- 
called  outer  layer  of  cells  furnished  the  decidual  cells 
(Fig.  2). 

Fig.  2. 


DECIDUAL     CELLS 


A  cluster  of  decidual  cells,  presumably  derived  from  a  chorionic  villus. 
From  a  tubal  embryo  of  about  the  third  month. 


2.  The  condition  of  the  tube. — Mr,  Doran  points  out  that 
there  was  no  rupture  of  the  tube,  but  the  ostium  was 
patent,  and  continuing  the  narrative  he  writes  : — "  The 
fimbriae  of  the  tube  are  normal,  the  canal  shows  no  sign  of 
dilatation  or  inflammation.^'      This  is  not  strange.      Two 


TUBAL    PREGXAXCY.  317 

years  ago  *  I  recorded  a  case  of  complete  tubal  abortion 
in  wbich  at  the  time  of  operation  there  was  reason  to 
believe  that  the  mole  had  within  a  few  hours  been 
extruded  from  the  tube.  The  right  Fallopian  tube  was 
dilated  to  the  thickness  of  the  forefinger  ;  its  walls  were 
intact  and  its  coelomic  ostium  widely  dilated  and  admitted 
the  tip  of  the  forefinger  ;  the  parts  were  placed  in  water, 
and  as  rigor  mortis  supervened  the  tube  contiacted  to  its 
normal  size. 

In  relation  to  this  fact,  I  pointed  out  that  if  anyone 
practically  unacquainted  with  the  remarkable  properties 
of  un striped  muscle  were  shown  a  foetus  at  term  in  the 
amnion,  and  the  uterus  in  which  it  developed,  an  hour 
after  delivery,  he  would  have  his  credulity  sorely  tried  to 
be  persuaded  that  the  amnion  and  contents  had  been 
housed  in  the  centre  of  that  organ.  I  venture  to  make 
this  observation  because  some  thoughtful  men,  thoroughly 
familiar  with  the  behaviour  of  the  uterus,  fail  to  compre- 
hend that  a  similar  state  of  things  happens  with  the 
Fallopian  tubes.  Dr.  Cullingworth  t  fully  appreciates 
this,  for  he  has  reported  a  case  m  which  a  gravid  tube 
resumed  its  normal  calibre  a  few  hours   after  bursting. 

In  Mr.  Doran^s  specimen  I  found  the  coelomic  ostium 
dilated,  although  he  states  in  his  report  (p.  182)  that 
*^  the  ostium  is  not  dilated.''^  This  patency  of  the  mouth 
of  the  Fallopian  tube  by  itself  is  of  little  value,  but  it 
assumes  significance  in  conjunction  with  other  signs. 

It  is  necessary  to  emphasise  the  fact  that  a  gravid  tube 
will,  after  discharging  a  mole,  resume  a  normal  condition, 
because  in  the  '  Transactions  '  of  the  Society  %  so  recently 
as  March,  1896,  there  is  a  report  from  a  committee  em- 
panelled to  offer  an  opinion  on  a  specimen  exhibited  by 
Dr.  Galabin.  Because  the  tubes  were  normal  the  com- 
mittee cautiously  ventures  to  keep  alive  the  myth  of 
ovarian  pregnancy,  and  it  is  deeply  to   be  deplored  that 

*  'Brit.  Med.  Journ.,'  1896,  vol.  ii,  1308. 
t  *  Trans.  Obstet.  Soc.,'  vol.  xl,  p.  186. 
X  Ibid.,  vol.  xxxviii,  p.  88. 


318 


TUBAL    PREGNANCY. 


the    reporb    winds    up    with    the    opinion    the    case   was 
'^  probably    an    example    of    primary    abdominal    (intra- 


FiG.  3. 


Fallopian  tube,  ovary  (containing'  a  corpus  luteuiu),  and  mole; 
from  a  case  of  complete  tubal  abortion.  The  patient  was 
thirty-tlve  years  of  agfe,  mother  of  ten  cliildreu,  the  youngest 
being-  three  months  old. 


peritoneal)  gestation."  These  views,  of  course,  are  un- 
tenable, and  the  whole  report  is  rendered  nugatory  in 
my  opinion,  because  the  committee  did  not  appreciate 
the  fact  that  a  gravid  Fallopian  tube  may  discharge  a 
mole  into  the  pelvic  cavity  through  its  coelomic  ostium  and 
return  to  its  natural  size  and  shape.  This  is  not  only  a 
matter  of  scientific  value,  but  it  has  practical  importance  ; 
for  it  is  conceivable  that  conditions  may  arise  in  which, 
in  the  performance  of  coeliotomy  for  tubal  abortion  it 
would  be  to  the  patient's  interests  to  remove  the  clots  and 


TUBAL    PREGXANCY.  319 

mole,  and  not  interfere  with  the  ovary  or  tube.  Of  course^ 
the  danger  of  such  a  course  would  be  to  render  the 
patient  liable  to  recurrence  of  pregnancy  in  the  same 
tube. 

Mr. Doranreportsthatinhis specimen  ''the  tube  appeared 
healthy  as  it  la}'  in  the  pelvis,  and  was  proved  healthy  when 
examined  after  removal.''  This  is  no  argument  against 
the  occurrence  of  tubal  pregnancy,  for  I  have  satisfied 
myself  tliat  a  healthy  Fallopian  tube  is  more  Uahle  to 
become  gravid  than  one  that  has  been  inflAimed.  Mr.  Doran's 
statement,  however,  that  the  tube  was  healthy  is  merely 
inference,  for  the  tube  has  not  been  examined  micro- 
scopically. 

3.  The  absence  of  free  blood  in  the  belly. — Mr.  Doran  com- 
ments on  the  circumstance  that  there  was  no  effused 
blood.  It  should  be  remembered  that  the  illness  was  of 
some  standing  (about  twelve  weeks),  which  would  easily 
allow  ample  time  for  the  absorption  of  even  a  great 
quantity  of  blood.  Large  blood  effusions  into  the  belly 
are  easily  and  rapidly  absorbed  if  they  remain  sterile. 

On  one  occasion  I  performed  cceliotomy  on  a  woman 
who  had  an  unextruded  mole  in  the  tube  (incomplete 
tubal  abortion).  She  had  been  resting  in  bed  many 
days  to  allow  the  acute  symptoms  to  subside,  and  this 
had  been  followed  by  absorption  of  the  effused  blood  ;  but 
I  was  able  to  judge  of  the  extent  of  the  effusion,  for  the 
intestines  and  omentum,  as  high  as  the  stomach,  Avere 
covered  with  a  thin  layer  of  viscid  blood,  recalling  the  soft 
ooze  left  on  the  sloping  banks  of  a  pond  which  has  over- 
flowed its  usual  margin,  and  then  slowly  retreated  to  its 
normal  limits. 

The  amount  of  blood  which  is  sometimes  discharged  into 
the  belly  as  a  result  of  tubal  abortion  is  trul}-  astonishing. 
A  woman  twent3'-seven  years  of  age,  who  had  been 
married  one  year,  was  suddenly  seized  with  severe  pain 
in  the  pelvis,  followed  by  marked  collapse  and  all  the 
signs  characteristic  of  severe  internal  haemorrhage  :  the 
doctor  in   charge   feared    for   some    hours   that   she    was 


320  TUBAL    PREGNANCY. 

actually  dying.  The  next  day  she  rallied  and  was 
transferred  to  the  Middlesex  Hospital.  Coeliotomy  was 
performed^  as  I  had  no  doubt  that  she  was  the  victim  of 
a  gravid  tube  which  had  either  ruptured  or  aborted.  The 
belly  contained  a  large  quantity  of  dark  bloody  which  not 
only  filled  the  pelvis^  but  it  obscured  the  intestines, 
reached  to  the  diaphragm,  and  bathed  the  convex  surface 
of  the  liver. 

The  left  Fallopian  tube  was  enlarged,  and  on  drawing 
it  into  the  wound  a  mole  was  found  protruding  from  the 
ostium. 

The  complete  extrusion  of  the  mole  is  usually  a 
fortunate  circumstance,  notwithstanding  the  fact  that  it 
may  be  and  often  is  accompanied  by  profuse  bleeding, 
because  so  long  as  it  is  retained  it  is  liable  to  cause 
bleeding,  or  maintain  a  sustained  ^^  blood-drip/'  as  Taylor 
terms  it,  from  the  unclosed  coelomic  ostium,  and  some 
blood  may  even  leak  through  the  uterine  orifice  and 
simulate  metrorrhagia. 

These  facts  bear  on  Doran^s  case,  because  the  absence 
of  free  blood  at  the  operation  is  accounted  for  by  the 
fact  that  the  mole  had  been  extruded  from  the  tube  some 
weeks  previously. 

This  brings  me  face  to  face  with  another  condition, 
which  I  do  not  think  has  been  previously  considered  with 
any  special  attention.  A  tubal  mole  may  become  seques- 
tered in  the  tube,  or  even  hang  from  the  mouth  of  the 
tube,  and  has  ceased  to  cause  bleeding,  yet  it  necessitates 
operative  interference.  It  so  happened  in  the  early  part 
of  1898  that  two  patients  came  under  my  care  in  the 
Chelsea  Hospital  for  Women  ;  the  clinical  history  of  each 
indicated  very  clearly  that  tubal  abortion  had  occurred 
three  months  previously.  The  acute  symptoms  had 
subsided,  jet  the  patients  were  far  from  well,  could  not 
perform  their  household  work,  and  were  under  the  obser- 
vation of  the  family  physician.  On  physical  examination 
a  rounded  lump  could  be  made  out  in  the  neighbourhood 
of    the    right    ovary    in    each    patient.      Coeliotomy    was 


TUBAL    PKEGXANCY.  321 

performed  in  both  :  a  deliquescent  mole  occupied  tlie 
Fallopian  tube  in  each  patient. 

After  careful  consideration  I  have  come  to  the  conclu- 
sion that  the  absorption  of  liquefying  clot  is  liable  to 
cause  an  elevation  of  temperature  and  disturbance  of 
health.  The  most  marked  example  of  this  kind  which  I 
have  observed  occurred  in  a  woman  admitted  into  the 
Chelsea  Hospital  for  Women  in  desperate  straits ;  she 
had  a  large,  hard,  tender  swelling  occupying  the  lower 
half  of  the  belly  and  pelvis  ;  the  pulse  beat  120  to  the 
minute,  and  a  temperature  ranging  at  night  to  104°  and 
105  .  All  this  seemed  to  point  to  a  large  collection  of 
pus.  I  performed  coeliotomy,  removed  sixty  ounces  of 
old  deliquescent  blood_,  and  a  tubal  mole  as  big  as  a 
turkey's  egg  which  had  escaped  into  the  pelvis  through 
a  rupture  in  the  right  Fallopian  tube.  The  clot,  though 
viscous,  was  sweet.  A  careful  consideration  of  the 
clinical  history  led  me  to  believe  that  the  blood  had  been 
effused  four  weeks  previously.  The  evacuation  of  the 
clot  and  removal  of  the  damaofed  tube  were  followed  bv 
immediate  subsidence  of  the  stormy  signs  and  a  rapid 
restoration  to  health. 

The  facts  are  of  importance  because  it  is  clear  that  a 
mole  even  when  sequestered  in  the  tube  is  an  undesirable 
occupant  of  the  pelvis. 

4.  The  absence  of  a  uterine  decidua. — Mr.  Doran's  failure 
to  find  any  trace  of  a  uterine  decidua  is  not  surprising. 
This  structure  when  present  is  valuable  and  significant  in 
conjunction  with  other  signs,  but  of  itself  is  valueless ; 
few  surgeons  would  exhibit  the  confidence  of  Dr.  Grifiith,"^ 
or  the  enterprise  of  Mr.  Bruce  Clarke,  and  perform 
cceliotomy  on  such  a  slender  sign  as  the  extrusion  of  a 
uterine  decidua  without  any  other  physical  sign  of  tubal 
pregnancy. 

I  have  ventured  to  discuss  these  questions,  because 
there  are  few  pelvic  lesions  which  admit  of  such  clear 
diagnosis   in  the  majority  of  cases  as  tubal   pregnancy; 

*  *  Trans.  Obstet.  Soc./  vol.  xxxvi,  p.  335. 


322  TUBAL    PREGNANCY. 

the  tubal  mole  or  the  chorionic  villi  furnishing  absolute 
proof  of  the  nature  of  the  lesion. 

I  quite  agree  with  Mr.  Doran  that  ''  bleeding  from  the 
Fallopian  tubes  under  exceptional  conditions  is  possible/' 
and  I  would  add  probable  ;  but  I  am  hopeful  that  I  have 
rescued  his  interesting  case  from  ranking  in  such  a 
collection  of  hypothetical  conditions,  for  it  is  in  reality 
an  excellent  example  of  complete  tubal  abortion. 

Mr,  Alban  Doran  wished  it  to  be  remembered  tbat  his  com- 
munication was  designedly  entitled  "  Haemorrhage  from  the 
Fallopian  tube  ivWiout  Evidence  of  Tubal  G-estation,"  and  not 
"  Independent  of  Tubal  Gestation."  In  his  paper  be  further 
declares  that  "  I  am  very  suspicious  of  alleged  cases  of  haeuior- 
rhaoe  from  the  tube  into  the  j^eritoueum  not  due  to  ectopic 
o-estation"  At  the  end  he  remarks  that  "  I  have  endeavoured 
to  show  that  this  case  appears  to  be  one  of  those  rare  exceptions. 
It  may  be  reasonably  suspected  that  some  of  the  blood  which 
issued  from  the  uterus,  as  the  result  of  some  local  condition 
other  than  gestation,  was  forced  not  into  the  vagina,  but  along 
the  tube  and  out  of  the  ostium." 

Mr.  Sutton  concludes,  "  I  am  heartily  glad  tbat  I  have  rescued 
his  interesting  case  from  ranking  in  such  a  collection  of  hypo- 
thetical conditions,  for  it  is  in  reality  an  excellent  example  of 
complete  tubal  abortion."  Just  previously  he  admits  that  "  I 
quite  agree  with  Doran  that  bleeding  from  tbe  Fallopian  tubes 
under  exceptioiial  conditions  is  possible." 

Mr.  Doran  would  have  been  much  interested  to  see  a  demon- 
stration of  chorionic  villi  found  in  the  clot  in  his  specimen. 
But  Mr.  Sutton  and  Mr.  Shattock  have  failed  to  find  any  villi. 
Again,  in  an  article  published  in  the  '  British  Medical  Journal,' 
vol.  X,  1891,  on  a  case  of  "  Tubal  Abortion  with  Double  Haema- 
tosalpinx  ;  Operation ;  Eecovery,"  Mr.  Doran  noted  that 
Walther  "  rightly  warns  us  against  taking  almost  structureless 
fibrinous  deposits  for  chorionic  villi."  "  If,"  he  added,  "  we 
examine  tubes  full  of  blood  in  a  hnrry,  and  prepare  sections 
carelessly,  we  are  certain  to  discover  imaginary  villi."  Mr. 
Sutton  must  agree  with  him  in  bis  caution.  It  follows  the 
description  of  a  section  where  Mr.  Sutton  himself,  as  well  as 
others,  detected  chorionic  villi.  Mr.  Sutton  thinks,  nevertheless, 
"  that  bands  of  fibrin  be  mistaken  for  chorionic  villi  is  a  sug- 
gestion too  feeble  to  be  entertained,"  adding  that  "  Doran  gives 
Walther  of  Giessen  credit  for  this ;  but  I  regret  to  say  that  it 
has  been  made  by  Fellows  of  the  Obstetrical  Society."  Mr. 
Doran  did  not  think  that   Walther's   labours  recorded  in  his 


TDBAL    PREGNANCY.  323 

thesis   **  Zur   Casuistik   der   HaeinatosalpiDx "    sliould   be   dis- 
regarded.     Walther's  microscopical  researches    seem    to    have 
been  conducted  under  the  competent  superintendence  of  Prof. 
Loblein.     The  plates  which  adorn  his  thesis  seem  carefully  pre- 
pared, and  a  true  chorionic  villus  is  compared  -with  a  villus-like 
structure  {GJiorionzotten-iilinliclie  Bildung)    represented  as  em- 
bedded in  a  section  of  clot  from  a  hsematosalpinx.     Walther 
gives  good  reasons  for  believing  that  the  structure  is  but  a  band 
of  fibrin.     For  further  details  Mr.  Doran  referred  Mr.  Sutton 
to  Walther's  thesis.     Anyhow,  no   villi  were  detected  in  Mr. 
Doran's  case,  and  the  most  convincing  evidence  of  tubal  gesta- 
tion remains  absent.     Mr.  Doran  admitted  that  in  Mr.  Butler- 
Smythe's  instructive  case,  read  that  evening,  one  microseopist 
found  no  chorionic  villi,   another  found  them   in    abundance. 
Mr.  Sutton's  statement  that  "the  tubal  mole  is  such  a  charac- 
teristic and  usually  easily  recognised  body  that  I  now  rarely 
search  for  the  villi  "  was  liable  to  mislead  those  less  experienced 
than  himself,  and  required  the  weight  of  Walther's  observations 
as  a  balance.    The  true  conclusion  about  the  villi  in  Mr.  Doran's 
case  is  that  they  may  have  been  overlooked  by  both  of  them, 
but  that  left  the  question  unsettled.     As  for  the  clot  itself,  the 
space  inside  it  near  to  the  ostium  might  represent  an  amniotic 
cavity,  but  hollow  spaces  are  seen  in  clots  far  from  the  genital 
tract.     The  sj^ace  is  open  towards  the  ostium,  and  looks  as  if 
fluid  blood  had  been  in  its  place,  and  had  flown  back  or  drij^ped 
into  the  peritoneum.     Mr.  Sutton  admits  that  "every  smooth 
elliptical  clot  associated   with  tubal  abortion  is  not  a  mole." 
Quite  so,  and  there  is  no  reason  why  clots  from  the  tube  not 
associated  with  tubal  gestation    and    abortion    should    not  be 
smooth  and  elliptical.     Mr.  Doran  agreed  with  Mr.  Sutton  that 
the  involution  of  the  Fallopian  tube  after  tubal  abortion  may 
be  remarkably  rapid,  and  the  clinical  evidence  which  he  gives  is 
of  high   value.     Mr.  Doran  also  agreed  with  him  in  believing 
that  ectopic  gestation  was  always  tubal  at  first,  as  far  as  has 
been  satisfactorily  proved.      Mr.  Doran  showed  the  fallacies  in 
reports  of  alleged  ])rimary  ovarian  and  abdominal  pregnancy  in 
a  note  on  a  case  of  a  foetus  found  in  the  peritoneal  cavity,  pub- 
lished in  the  *  Transactions'  five  years  since  (vol.  xxxv,  p.  222). 
He  is  not  convinced  by  arjzuments  to  the  contrary  brought  for- 
ward by  Mr.  Taylor,  of  Birmingham,  in  his  most   interesting 
Ingleby  Lectures  delivered  at   Mason's  College,  Birmingham, 
last   May.     Mr.   Doran  did   not   say  that   primary  abdominal 
gestation    could   not   occur,  but    he   was   not  convinced   even 
though  lie  was  in  the  committee  on  Dr.  Galabin's  specimen,  to 
which  Mr.  Sutton  refers.     Mr.  Doran  admitted  probabilities, 
but,  like  Dr.  Amand  Routh,  he  agreed  that  "  the  sub-committee 
could  not  be  definite  in  their  conclusions."     Mr.  Sutton  seems 
to  have  proved  that  '*  a  gravid  Fallopian  tube  may  discharge  a 


324  TUBAL    PREGNANCY. 

mole  into  the  pelvic  cavity  through  its  coelomic  ostium,  and 
return  to  its  natural  size  and  shape."  The  absence  of  free 
blood  in  the  peritoneal  cavity  is  not  essential  in  the  discussion, 
as  it  is  quite  possible  to  conceive  that  a  limited  amount  of 
blood  issuing  from  the  ostium  under  any  condition  may  clot  as 
it  escapes,  and  appear  as  a  more  or  less  firm,  well-circumscribed 
coagulum.  In  conclusion,  Mr.  Doran  summed  up  the  question 
by  observing  that  he  agreed  in  general  with  all  Mr.  Sutton's 
views,  and  agreed  with  him  that  in  this  particular  case  there 
might  have  been  tubal  abortion,  but  he  believed,  as  before,  that 
the  haemorrhage  might  have  been  independent  of  ectopic  gesta- 
tion. The  case  remained  unproved,  and  must  still  rank  "  in 
such  a  collection  of  hypothetical  considerations." 

Dr.  Amand  Routh  considered  Mr.  Bland  Sutton's  paper  of 
very  great  value,  for  it  had  brought  out  very  clearly  the  fact 
that  after  tubal  rupture  the  Fallopian  tube  might  recover  itself 
and  look  normal  in  a  few  days,  and  after  tubal  abortion  had 
been  proved  to  have  resumed  its  normal  size  and  appearance 
even  in  a  few  hours.  He  referred  to  the  report  on  Dr.  Galabm's 
specimen  of  extra-uterine  gestation  ('  Obstet.  Soc.  Trans.,'  vol. 
xxxviii,  p.  88),  and  he  reminded  the  Fellows  that  the  diagnosis 
of  tubal  rupture  or  abortion  was  not  then  (1896)  accepted  in 
that  case  for  two  reasons :  first,  because  both  tubes  were 
apparently  normal ;  and  secondly,  because  the  examination  of 
the  pelvic  organs  proved  that,  if  either  of  these  accidents  had 
occurred,  the  ovum  must  have  become  bodily  transplanted  to  a 
spot  at  a  distance  from  the  tube,  and  had  there  continued  to 
develop.  Even  now,  two  years  after  that  report,  he  was  not 
aware  of  any  evidence  which  was  forthcoming  to  show  that  such 
an  event  was  possible. 

Dr.  McCann  :  As  the  case  which  is  the  subject  of  discussion 
this  evening  first  came  under  my  care  at  the  Samaritan  Hospital, 
I  may  be  permitted  to  make  a  few  remarks.  This  patient  had 
suffered  for  some  weeks  from  constant  and  copious  discharge  of 
bright  red  blood  from  the  vagina.  For  this  and  the  accom- 
panying anaemia  she  sought  treatment  at  the  Samaritan 
Hospital.  On  examination  I  diagnosed  tubal  abortion,  and 
she  was  accordingly  admitted  for  operation.  From  my  own 
experience  I  regarded  this  free  hsemorrhage  as  quite  exceptional 
in  such  cases.  A  fortnight  before  seeing  this  patient  I  was 
consulted  by  a  lady  who  gave  the  following  history.  She  had 
been  married  three  years  and  was  sterile.  Since  her  marriage 
she  had  suffered  severely  from  dysmenorrhoea.  Shortly  after 
her  marriage  she  had  an  attack  of  what  was  said  to  be  *'  inflam- 
mation of  the  bowels."  Her  husband  had  a  chronic  gleet  when 
he  married,  and  this  attack  was  probably  gonorrhoea!  sal- 
pingitis. Three  weeks  before  I  saw  her  she  had  sudden  pain  in 
the  left  iliac  region,  accompanied  by  nausea  and  faintness.     At 


TUBAL    PREGNANCY.  325 

that  time  she  had  missed  her  monthly  period  for  fourteen  days. 
On  examination  there  was  an  elongated  fluctuating  swelling  in 
the  position  of  the  left  Fallopian  tube.  As  her  symptoms 
pointed  to  the  leakage  of  the  tubal  contents  into  the  peritoneum, 
I  recommended  an  abdominal  operation.  At  the  operation  the 
dilated  tube  was  removed.  It  contained  an  ovoid  blood-clot 
with  a  small  central  cavity.  A  careful  examination  of  the  clot 
and  the  tubal  wall  failed  to  detect  chorionic  villi.  Some  clots 
found  in  the  peritoneal  cavity  were  also  examined.  This  case 
was  probably  one  of  hsematosalpinx  not  caused  by  tubal 
pregnancy. 

Mr.  Butler-Smythe  pointed  out  that  in  Mr.  Bland  Sutton's 
valuable  work  on  '  Fallopian  G-estation '  it  was  stated  that  the 
most  likely  place  lor  chorionic  villi  to  be  found  was  at  that  spot 
where  the  mole  was  most  adherent  to  the  tube.  But  in  his 
case,  related  that  night,  many  sections  were  cut  at  that  point  in 
all  directions,  and  vet  not  a  single  villus  could  be  discovered. 
On  the  other  hand,  the  specimen  exhibited  that  night  was  cut 
for  him  by  his  colleague,  Mr.  Corrie  Keep,  and  showed  chorionic 
villi  in  abundance.  It  certainly  was  a  fact  that  a  section  cut 
from  any  part  of  the  mole  might  show  several  villi,  and  yet 
section  after  section  might  be  cut  in  the  most  likely  situations 
without  exhibitinsj  a  sinsrle  villus. 

Dr.  Eden  said  that  a  good  deal  of  (iare  was  necessary  in 
examining  masses  of  blood-clot  for  chorionic  villi ;  he  had 
known  fibrin  rings  and  sections  of  the  tubal  plicae  exhibited  as 
chorionic  villi.  It  must  be  remembered  that  villi  embedded  in 
blood-clot  differed  widely  from  healthy  villi  in  apjDearance  ;  at 
the  same  time  they  might  be  preserved  in  their  degenerated 
state  for  very  long  periods,  and  could  be  readily  recognised  as 
such  in  old  clots  by  practised  observers.  If  a  careful  search 
had  been  made  in  Mr.  Doran's  specimen  and  no  villi  were  found, 
he  thought  it  pretty  certain  that  it  was  not  a  mole,  although  of 
course  negative  evidence  was  never  so  satisfactory  as  positive 
evidence. 

The  President  was  fflad  that  Mr.  Bland  Sutton  had  called 
attention  to  the  question  as  to  what  happened  in  cases  of  pelvic 
hsematocele  from  incomplete  tubal  abortion,  where  the  tubal 
mole  remained  in  the  tube  alter  the  hsematocele  had  undergone 
absorption.  It  was  a  question  on  which  more  light  was  needed, 
and  any  well-observed  cases  bearing  upon  it  would  be  most 
valuable.  Did  the  tubal  mole  gradually  undergo  absorption  ? 
If  so,  what  length  of  time  was  required  for  the  absorption  to 
take  place  ?  To  what  extent  was  the  patient  inconvenienced 
and  incapacitated  in  the  meantime?  Was  the  presence  of  ;i 
tubal  mole  under  such  circumstances  a  source  of  danger  to 
health  ?  These  questions  could  not  as  yet  be  answered  because 
we  bad  not  a  sufficient  number  of  observations.  He  himself 
VOL.  XL.  22 


326  TUBAL    PREGNANCY. 

was  disposed  to  agree  with  the  author  of  tlie  papers  that  an 
unremoved  or  unexpelled  tubal  mole  was  apt  to  cause  trouble, 
aud  lie  was  not  at  all  sure  that  it  was  not  a  source  of  serious 
danger  to  the  patient.  He  bad  met  witli  a  case  in  which  tbe 
mole-containing  tube  had  apparently  become  twisted  on  its  axis, 
with  results  similar  to  those  which  occur  when  the  pedicle  of  a 
small  ovarian  cvst  becomes  twisted.  He  had  also  seen  quite 
recently  a  case  in  which  there  was  reason  to  believe  that  the 
mole  bad  become  septic  and  had  suppurated,  setting  up  severe 
septic  peritonitis.  These  cases  seemed  to  show  that  the  condi- 
tion was  not  unattended  with  danger  to  health  and  even  to  life. 
The  point  was  one  of  great  importance  as  bearing  on  the  treat- 
ment of  pelvic  haematocele.  Mr.  Bland  Sutton  had  done  well 
to  call  attention  to  the  rapid  diminution  in  the  size  of  the  uterus 
after  delivery  as  a  help  towards  understanding  how  a  Fallopian 
tube  from  which  a  mole  had  been  expelled  might  present  the 
appearance  and  characters  of  a  normal  or  nearly  normal  tube, 
as  in  a  case  he  (the  President)  had  related  at  the  May  meeting. 

In  reply  to  Dr.  McCann,  he  said  that  tubal  abortion  was 
usually  accompanied  with  a  slight  continuous  flow  from  the 
uterus  of  dark  fluid  blood,  and  that  free  haemorrhage  with  or 
without  the  passage  of  clots  was  exceptional. 

Mr.  Bland  Sutton  in  reply  contended  that  it  was  idle  to 
deny  that  the  clot  in  question  was  the  product  of  tubal  preg- 
nancy. A  tubal  mole  with  such  definite  characters  indicated 
that  it  was  the  result  of  tubal  pregnancy  as  clearly  as  a  potato 
was  known  to  be  the  product  of  Solaiium  tuberosum.  If  such  a 
clot  had  been  expelled  from  the  uterus  no  obstetric  physician 
would  deny  that  it  was  the  product  of  an  oosperm.  Why,  with 
our  present  knowledge  of  tubal  pregnancy,  should  its  nature  be 
regarded  as  doubtful  because  it  came  from  the  tube?  Such 
clots  existed  in  no  other  region  of  the  body  where  bleeding  was 
common,  e.  g.  brain,  lung,  bladder,  kidney,  or  tunica  vaginalis 
testis,  or  even  in  a  sacculated  aneurysm.  The  difficulty  of 
detecting  the  villi  was  probably  due  to  the  fact  that  the  mole 
had  been  extruded  from  the  tube  many  weeks.  If  Mr.  Doran 
absolutely  based  his  objection  on  the  non-detection  of  villi  it 
would  be  a  judicious  measure  to  section  the  whole  chorion,  and 
the  whole  length  of  the  Fallopian  tube ;  this  procedure  would 
occupy  the  laboratory  assistant  several  days ;  it  was,  however, 
well  worth  carrvint;  out. 

In  reply  to  Mr.  Targett  he  observed  that  in  some  cases  of 
tubal  abortion  villi  were  demonstrable  in  the  tube,  in  other 
cases  the  tubal  mucous  membrane  was  quite  smooth. 


DECEMBER  7th,  1898. 

C.  J.  CuLLiNGWORTH,  M.D.,  President,  in  the   Chair. 

Present — 47  Fellows  and  3  visitors. 

Books  were  presented  by  Dr.  Venn,  the  Medical  Society, 
the  Clinical  Society,  Societe  de  Medecine  de  Eouen,  the 
Gesellscliaft  fiir  Natur-  und  Heilkunde  in  Dresden,  Edin- 
burgh Obstetrical  Society,  Dr.  Callingworth,  Dr.  Whitridge 
Williams,  University  College  Staff. 

Haydn  Brown,  L.R.C.P.  (Buckburst  Hill,  Essex),  was 
declared  admitted. 

John  Shields  Fairbairn,  M.B.,  B.Ch.Oxon. ;  Henry 
Gervis,  M.A.,  M.B.,  B.C.Camb.  ;  John  Preston  Maxwell, 
M.B.Lond.,  F.R.C.S.,  were  proposed  for  election. 


A  SERIES  OF  MOUNTED  SPECIMENS,  SHOWING 
THE  DEVELOPMENT  AND  RETROGRESSIVE 
CHANGES  IN  THE  GRAAFIAN  FOLLICLE. 

Shown  by  Dr.  William  Huntek. 


(1)  LARGE  SOLITARY  SUBPERITONEAL  FIBROID 
TUMOUR  OF  THE  UTERUS,  AND  (2)  UTERUS 
WITH  MULTIPLE  FIBROIDS;  BOTH  REMOVED 
BY  LAPAROTOMY. 

Shown  by  Dr.  Lewers. 

Dr.  Lewers  showed  (1)  a  large  solitary  subperitoneal 
fibroid  tumour  of  the  uterus  (9^  pounds),  successfully  re- 
moved  by  laparotomy,  with  intra-peritoueal  treatment  of 


328  FIBROID    TUMOUR    OP    THE    UTERUS. 

the  stump;  (2)  uterus  witli  multiple  fibroids  (8  pounds), 
successfully  removed  by  supra- vaginal  hysterectomy,  also 
with  intra-peritoneal  treatment  of  the  stump. 

He  said  that  both  as  regards  the  history,  symptoms, 
and  signs,  cases  of  large  solitary  subperitoneal  uterine 
fibroid  differed  remarkably  from  the  common  cases  where 
the  uterus  was  the  seat  of  multiple  fibroids. 

In  the  case  from  which  his  specimen  of  solitary  sub- 
peritoneal fibroid  was  removed,  for  instance,  the  patient  had 
been  married  ten  years,  and  had  had  five  children  and  two 
miscarriages,  the  last  ten  months  prior  to  the  operation. 
Menstruation  had  always  been  scant}^,  never  lasting  more 
than  two  days,  and  for  ten  months  prior  to  the  operation 
there  had  been  complete  amenorrhoea.  The  uterus  was 
in  no  way  deformed,  except  at  the  place  at  which  the 
tumour  was  attached.  The  area  of  attachment  was  on 
the  front  and  left  side  of  the  body  of  the  uterus,  and  was 
about  equal  in  area  to  that  of  a  five-shilling  piece.  The 
sound  passed  only  the  normal  distance.  The  left  uterine 
artery  was  tied  in  two  places,  and  the  oozing  surface  con- 
stricted by  several  silk  sutures  passed  rather  deeply. 
The  peritoneal  flaps  were  then  stitched  over  the  stump. 
At  the  end  of  the  operation  the  patient  was  left  with  a 
practically  normal  uterus,  and  with  both  ovaries.  Dr. 
Lowers  believed  that  if  an  opportunity  occurred  of  exa- 
mining the  state  of  the  parts,  in  two  or  three  years  it 
would  puzzle  anyone  unacquainted  with  the  patient^s 
history  to  account  for  the  abdominal  scar.  The  patient 
made  a  perfect  recovery.  In  the  case  from  which  the 
specimen  of  multiple  fibroids  was  removed,  on  the  other 
hand,  the  patient  had  been  married  five  years,  and  had 
not  been  pregnant.  Menstruation  had  always  been  pro- 
fuse, and  for  three  months  preceding  the  operation  there 
had  been  constant  metrorrhagia.  Here  the  uterus  was 
generally  deformed  by  the  presence  of  the  fibroids,  and  the 
sound  passed  seven  to  eight  inches.  Removing  the 
'^  tumour  '^  meant  removing  the  body  of  the  uterus  in  this 
case.      This  patient  also  made  a  good  recovery. 


329 


INCARCERATED  OVARIAN  DERMOID  REMOVED 
AT  THE  FOURTH  MONTH  OF  PREGNANCY; 
DELIVERY  OF  A  LIVING  CHILD  AT  TERM. 

Shown  by  Herbert  R.  Spencek,  M.D.,  B.S. 

The  specimen  is  a  multilocular  ovarian  dermoid  tumour 
of  the  right  side,  containing  three  main  loculi  ;  two  of 
these  are  more  or  less  completely  subdivided  by  septa, 
some  of  which  have  ruptured  and  are  represented  by 
ridges,  threads,  and  spicules.  It  contained  sebaceous 
material  and  brown  hairs,  which  are  seen  to  grow  from 
the  inner  wall  of  the  loculi.  Its  dimensions  are  3 J  x 
3x2  inches.  It  was  removed  entire  from  a  patient 
aged  22,  who  had  had  two  lingering  labours,  terminating 
in  the  birth  of  living  children.  The  tumour  was  known 
to  be  present  at  the  last  labour,  sixteen  months  previously. 
During  that  pregnancy  the  patient  had  been  seen  by  an 
obstetric  physician  and  a  surgeon,  Avho  had  said  that  the 
tumour  was  of  the  size  of  a  hen^s  egg,  and  advised  her 
not  to  have  it  removed.  In  February,  1898,  soon  after 
the  beginning  of  the  third  pregnancy,  the  patient  had  a 
great  deal  of  pelvic  pain  and  rather  severe  haemorrhage, 
which  threatened  to  terminate  the  pregnancy.  In  the 
fourth  month  the  patient  came  home  from  the  south  of 
France  for  advice,  being  very  ill  and  suffering  a  good  deal 
of  pain,  which  persisted  till  the  operation.  On  May  28th, 
1898,  I  saw  the  patient  with  Dr.  Norwood  Brown,  and 
found  the  uterus  four  months  pregnant,  and  the  tumour 
incarcerated  in  the  pelvis  (occupying  chiefly  the  left  side 
of  the  retro-uterine  pouch),  tender,  and  apparently  fixed 
by  adhesions.  [The  tumour,  small  as  it  is,  was,  however, 
only  incarcerated  in  the  pelvis  by  tlie  uterus,  and  there 
were  no  adhesions.]  We  strongly  urged  removal  of  the 
tumour,  and,  the  patient  consenting,  I  removed  it  by  lapa- 
rotomy  on   May  30th   of   this  year.      The   operation   was 


330  INCARCERATED    OVARIAN    DERMOID. 

very  easy  ;  ifc  lasted  thirty  minutes.  The  pedicle  (not 
twisted)  was  tied  with  silk.  The  fascia  in  front  of  the 
rectus  was  stitched  with  buried  silk  sutures.  The 
recovery  of  the  patient  was  quite  uneventful.  The 
highest  temperature  was  99"6°  on  the  second  day;  after 
the  third  day  it  never  rose  above  98'8°.  The  silkworm- 
gut  sutures  were  removed  on  the  eighth  day,  union  being 
perfect.  The  pelvic  pain  from  which  the  patient  had 
suffered  completely  ceased  after  the  operation,  and  there 
was  no  subsequent  haemorrhage.  On  October  29th  the 
patient  was  delivered,  after  a  very  easy  labour,  lasting 
three  hours,  of  a  living  boy  (born  head  first),  weighing 
9  lbs.  4  oz.  The  scar  had  not  stretched  at  all.  The 
patient  got  up  at  the  end  of  the  third  week,  and  she  and 
her  child  continue  well. 

The  case  shows  that  even  such  a  small  tumour  may 
become  firmly  incarcerated  in  the  pelvis  as  early  as  the 
fourth  month  of  pregnancy,  perhaps  especially  when  it 
occupies  the  side  of  the  pelvis  opposite  to  that  from  which 
it  grows,  and  thus  is  drawn  obliquely  by  its  pedicle 
against  the  promontory.  It  also  shows  that  a  small  incar- 
cerated tumour  may  give  rise  to  serious  troubles  during 
the  first  half  of  pregnancy ;  in  my  opinion,  whether  it 
does  or  not,  it  should  be  removed.  At  full  term  the  small 
size  of  this  tumour  might  tempt  the  injudicious  to  endea- 
vour to  drag  the  child  past  the  tumour  by  means  of  forceps 
or  version — modes  of  delivery  which,  I  believe,  are  never 
justifiable  in  these  cases.  A  tumour  with  a  shortest  dia- 
meter of  2  inches  (perhaps  compressible  to  1^  inches)  will, 
while  incarcerated  in  the  pelvis,  practicall}^  give  rise  to  an 
extreme  degree  of  pelvic  contraction  (2|  inches  conjugate 
and  small  transverse  diameter),  through  which  it  will  be 
impossible  to  deliver  a  full-sized  living  child  unless  the 
parturient  canal  becomes  enlarged  by  the  bursting  of  the 
tumour.  The  danger  of  this  accident  is  illustrated  by  a 
specimen  which  has  recently  been  presented  to  me,  and 
which  I  exhibit  to-nigrht. 


331 


INCARCERATED  OYARIAN  DERMOID  RUPTURED 
DURING  DELIVERY  BY  FORCEPS  AND  YER- 
SION,  WITH  FATAL  RESULT. 

Shown    by    Dr.    Heubert    R.    Spencer    (for    Mr.    James 

Jackson.) 

This  specimen  was  presented  to  me  by  Mr.  James 
Jackson,  wlio  found  it  at  the  post-mortem  exaaiiuation  of 
a  patient  who  had  been  attended  by  another  practitioner. 

The  tumour  is  an  ovarian  dermoid,  measuring  4^  x  3 
X  2^  inches.  It  is  bruised  at  one  part,  and  has  a  rup- 
ture about  an  incli  in  length,  through  which  the  contents 
(hair  and  fat)  escaped  into  the  peritoneum. 

The  patient  from  whom  it  was  removed  was  twenty-seven 
years  of  age,  and  had  had  one  child  without  difficulty  four 
years  previously. 

In  the  second  labour  the  membranes  ruptured  prema- 
turely on  a  Tuesday,  but  no  pains  occurred  till  the  follow- 
ing Saturday.  On  that  day  the  doctor  in  attendance 
endeavoured  to  deliver  with  forceps ;  but  owing  to  the 
obstruction  formed  by  the  tumour  he  could  only  apply 
one  of  the  blades  ;  he  therefore  turned  and  delivered  the 
child  (dead)  with  difficulty.  On  the  following  day  the 
patient  was  very  ill,  and  on  Monday  had  signs  of  peri- 
tonitis, from  which  she  died  in  the  evening  of  the  third 
day  after  delivery. 

The  post-mortem  examination  showed  that  the  tumour 
had  been  ruptured,  and  the  contents  escaping  had  set  up 
general  peritonitis  of  an  adhesive  but  not  purulent 
character. 

Dr.  John  Phillips  had  met  a  case  in  which  the  cyst  had 
obstructed  labour  and  necessitated  its  incision  and  suturing  to 
the  vaginal  wall  before  delivery  could  be  effected  ;  a  year  later 
the  patient  was  seized  with  a  rigor  and  abdominal  pain,  and  it 


332         CONGENITAL  TUMOUR  AT  THE   INTERNAL  OS   UTERI. 

was  found  on  operation  that  she  had  a  large  suppurating 
dermoid  cyst,  at  the  bottom  of  which  and  adherent  to  the  old 
scar  in  the  vaginal  cul-de-sac,  was  a  long  coil  of  hair.  The 
patient  made  a  good  recovery.  Dr.  Phillips  had  recently  had 
an  impacted  dermoid  complicating  early  pregnancy,  which  had 
successfully  been  removed. 

Dr.  Arthur  Gtiles  mentioned  a  case  of  an  ovarian  dermoid 
removed  during  pregnancy  that  was  very  similar  to  one  of  Dr. 
Spencer's.  He  first  saw  the  patient  when  she  was  three  months 
pregnant,  and  decided  to  wait  and  see  whether  with  the  progress 
of  pregnancy  the  cyst  would  rise  out  of  the  pelvis  sufficiently  to 
warrant  postponing  operation  till  after  confinement.  Two 
months  later  the  cyst  was  found  still  occupying  the  ]3elvis  to 
the  left  and  behind ;  and  as  the  fundus  was  now  well  raised  the 
pedicle  had  evidently  become  lengthened.  He  then  advised 
operation,  and  had  the  advantage  of  the  opinion  of  Dr.  William 
Duncan,  who  took  the  same  view.  The  cyst  was  removed  by 
abdominal  section,  and  turned  out  to  be  a  dermoid.  There  was 
no  interruption  to  pregnancy,  and  the  patient  was  expecting 
her  confinement  shortly.  The  question  of  dealing  with  the  cyst 
through  the  vagina  was  raised,  but  was  decided  against  on  the 
grounds  of  (a)  the  increased  risk  of  bringing  on  a  miscarriage  ; 
(b)  the  disadvantage,  in  case  of  miscarriage,  of  the  wound 
situated  in  the  parturient  canal. 


THREE  CASES  OF  CONGIENITAL  TUMOUR  AT 
THE  INTERISTAL  OS  UTERI  CAUSING  HYDRO- 
METRA  IN  NEW-BORN  CHILDREN. 

By  Herbert  R.   Spencer,  M.D.^  B.S., 

PiiOFESSOR  OP  Obstetkic  Medicine  in  University  College,  London  ; 
Obstetric  Physician  to  University  College  Hospital. 

The  malformation  I  am  about  to  describe  was  met 
with  in  three  out  of  about  a  hundred  uteri  of  new-born 
children  which  I  examined  some  years  ago.  Two  of 
them  were  briefly  (in  one  case  somewhat  inaccurately) 
described  in  the  catalogue  of  gynaecological  specimens  in 
University  College  Museum  published  in  1891   (Nos.  4063, 


CONGENITAL  TUMOUR  AT   THE   INTERNAL   OS    UTERI.        333 

4063a).  I  am  not  aware  of  tliis  malformation  having 
been  previously  recorded,  and  wish  now  to  give  a  more 
complete  description  of  the  specimens,  with  short  notes 
of  the  foetuses  from  which  they  were  obtained. 

Case  1  (Fig.  1). — The  child  was  a  second  twin,  born 
dead  as  a  shoulder  presentation,  the  first  twin  (a  male) 
having  been  born  alive  head  first. 

The  hymen  was  well  formed,  and  so  distensible  that 
the  forefinger  could  be  passed  through  the  opening  as 
far  as  the  second  joint  without  lacerating  the  membrane 
(a  most  unusual  condition) .  The  bod}^  of  the  uterus  (see 
Fig.  1)  was  of  nearly  twice  the  normal  bulk  ;  the  portio 
projected  for  over  a  quarter  of  an  inch  into  the  vagina, 
which  was  very  rugose,  as  is  usual  in  new-born  infants. 
On  cutting  open  the  uterus  a  slight  smear  of  mucus  was 
found  in  the  cervix,  but  the  body  was  dilated  by  a  plug 
of  yellowish  viscid  mucus  as  big  as  the  end  of  the  little 
finger.  The  lower  end  of  this  plug  rested  on  a  promi- 
nence— the  tumour  to  which  I  wish  to  direct  attention — 
which  surmounted  the  anterior  column  of  the  arbor  vifcae. 

This  anterior  column  was  very  marked,  and  lay  some- 
what to  the  right  of  the  middle  line  ;  from  it  the  plicse 
passed  upwards  and  outwards.  The  little  round  tumour 
of  the  size  of  a  small  pea  is  situated  at  the  internal 
OS  uteri.  It  is  sessile  though  slightly  constricted  at 
its  base,  fairly  smooth,  but  faintly  furrowed  upon  its 
upper  surface,  and  some  of  these  furrows  on  the  side 
of  the  tumour  pass  laterally  over  the  anterior  wall  of 
the  uterus  in  a  transverse  direction.  The  cavity  of  the 
body  was  considerably  distended,  its  inner  walls  concave 
and  fairly  smooth  :  in  the  middle  line  running  from  the 
little  tumour  to  the  fundus  was  a  marked  but  very 
narrow  groove.  It  is  obvious  that  the  tumour  has  acted 
as  a  ball-valve,  blocking  up  the  internal  os,  and  leading 
to  dilatation  of  the  cavity  of  the  body  by  the  retained 
mucus.  The  broad  ligaments,  ovaries,  and  tubes  were 
normal.      There  was  a  well-marked  hydatid  of  Morgagni 


334        CONGENITAL  TUMOUR  AT    THE   INTERNAL  OS  UTEEI. 


Fia.l. 


Uterus  and  appendages  of  a  new-born  child,  showing  the  tumour  at 
the  internal  os.  The  body  of  the  uterus  is  dilated  as  a  result  of 
the  obstruction  to  the  outflow  of  mucus,     (f  nat.  size.) 


Fig.  2. 


Uterus  and  appendages  of  anew-born  child,  showing  tumour  at  internal 
OS  and  polypi  in  cervical  canal.  The  right  Fallopian  tube  is  closed 
at  its  outer  end  and  more  slender  than  the  left.  The  (?)  con- 
genitally  displaced  fimbriae  are  seen  attached  near  the  outer  end  of 
the  ovary.  The  body  of  the  uterus  is  dilated  as  a  result  of  the 
obstruction  to  the  outflow  of  mucus.  N.B. — In  both  these 
specimens,  which  have  been  kept  in  spirit,  the  tumour  and  cavity 
are  smaller  than  in  the  recent  state,     (f  nat.  size.) 


CONGENITAL  TUMOUR  AT  THE  INTERNAL  OS  UTERI.   335 

on  the   right  side.      There  were   no  other  malformations 
in  the  body. 

Case  2. — The  infant  weighed  5  lbs.  10  oz.^  and 
measured  I85  inches  in  length.  It  also  was  a  twin,  its 
fellow  being  a  male  of  exactly  the  same  size  and  weight. 
The  uterus  in  this  case  exactly  resembled  that  in  Case  1, 
but  the  tumour  was  a  little  smaller.  Dissection  showed 
no  other  deformities  in  either  twin.  The  placenta  was 
situated  low  down,  and  gave  rise  to  accidental  haemor- 
rhage. 

Case  3  (Fig.  2).— The  infant  weighed  7  lbs.  8  oz., 
and  measured  20^  inches  in  length;  it  was  not  a  twin. 
[There  is,  however,  no  note  of  the  examination  of  the 
placenta  and  membranes  for  foetus  com'pressiis,  and  the 
absence  of  a  second  fcetus  cannot  therefore  be  asserted 
with  absolute  confidence.]       The  mother  was  a  primipara. 

The  body  of  the  uterus  (see  Fig.  2)  was  of  about  twice 
its  normal  bulk ;  the  cervix  projected  somewhat  more 
than  usual  into  the  vagina.  The  vagina  and  portio 
vaginalis  were  less  rugose  than  in  the  other  cases. 

The  body  of  the  uterus  was  dilated  and  filled  with 
viscid  greenish  mucus.  There  was  li  tumour  at  the 
internal  os,  formed  as  in  the  other  cases  by  the  upper 
extremity  of  the  anterior  median  column  of  the  arbor 
vitae,  but  in  this  specimen  the  column  appeared  to  be 
divided  by  longitudinal  grooves  into  three  parts,  which 
below  swell  out  into  polypoid  growths  at  some  distance 
above  the  external  os.  There  was  a  median  longitudinal 
groove  in  the  body  of  the  uterus  extending  from  the 
tumour  to  the  fundus,  and  on  either  side  of  it  two 
grooves  diverging  from  the  tumour  in  the  direction  of 
the  cornua.  There  was  also  in  this  case  a  slight  enlarge- 
ment of  the  posterior  column  of  the  arbor  vita?,  shown  in 
the  figure  on  the  left  margin  of  the  cut  posterior  wall. 
The  left  Fallopian  tube  was  normal,  the  left  ovary  rather 
short.      The    right  ovary  was  of  usual  length,  but  rather 


336       CONGENITAL  TUMOUR  AT  THE   INTERNAL   OS   UTERI. 

slender.  The  right  Fallopian  tube  ended  blindly  at  its 
outer  extremity^  which  was  not  fimbriated.  Attached 
near  the  outer  end  of  the  right  ovary  was  a  plicated 
body^  which  appeared  to  be  the  congenitally  displaced 
fimbriae.  Between  this  and  the  blind  end  of  the  tube 
was  a  pendulous  structure_,  probably  representing  a  hydatid 
of  Morgagni.  There  were  no  other  abnormalities  in  the 
body.  A  section  of  the  tumour  in  this  case  showed  the 
structure  of  cervical  mucous  membrane,  the  surface 
being  covered  with  cylindrical  ciliated  epithelium,  and 
being  furnished  with  closely-set  simple  crypts  lined  with 
long  cylindrical  cells  and  goblet-cells.  The  tissue 
beneath  the  epithelium  was  loose  in  texture,  and  was 
made  up  of  interlacing  slender  cells  with  oval  or  elon- 
gated nuclei.  There  were  a  few  thin-walled  vessels,  but 
no  clear  evidence  of  muscular  tissue  in  the  tumour. 

Apart  from  the  congenital  malformation  of  the 
Fallopian  tube  in  Case  3,  a  noteworthy  fact  in  the  cases 
is  that  two  of  them  occurred  in  twins,  and  that  the 
fellow-twin  was  in  each  case  a  male. 

The  tumour  at  the  internal  os  appears  to  be  due  to 
some  fault  in  the  fusion  of  the  Miillerian  ducts.  It 
causes  obstruction  to  the  outflow  of  mucus  from  the 
body  and  hydrometra  ;  it  may,  perhaps,  subsequently 
cause  pain  during  menstruation  or  at  other  times.  Some 
uteri  in  new-born  children  have  the  cervical  glands  lined 
apparently  with  several  layers  of  columnar  cells  (I 
exclude,  of  course,  cases  where  this  appearance  is  clearly 
due  to  the  obliquity  of  the  section),  and  I  have  on  a  very 
few  occasions  met  with  a  non-malignant  polypus  at  the 
internal  os  uteri  in  adults  with  a  similar  structure.  It 
is,  I  think,  possible  that  the  persistence  of  the  congenital 
tumour  may  explain  these  cases,  which  give  rise  to  grave 
doubts  as  to  their  malignancy  when  they  are  examined 
with  the  microscope.  I  must  admit,  however,  that  the 
histology  of  the  case  examined  does  not  support  this 
view. 

A  valuable  paper  by  Dr.  Friedrich    von   Friedlander, 


CONGENITAL  TUMOUR  AT  THE   INTERNAL  OS  UTERI.        337 

on  ^^  Some  changes  produced  by  growth  in  the  child's 
uterus,  and  their  reaction  on  subsequent  function/^  has 
recently  appeared  in  the  ^  Archiv  fiir  Gynakologie.'* 
This  important  work  is  based  upon  an  examination  of 
161  uteri  from  children  of  various  ages  from  that  of 
intra-uterine  life  up  to  twenty-four  years.  The  author 
does  not  state  how  many  of  these  were  new-born,  but  he 
has  observed  the  knob-like  swelling  of  the  median  ridge, 
giving  rise  to  dilatation  of  the  body  by  retained  mucus 
five  times  out  of  ninetj^-one  uteri  of  children  of  various 
ages  up  to  six  years.  The  degree  of  dilatation  was 
measured  by  a  separation  of  the  anterior  from  the 
posterior  wall  of  from  2  to  5  mm.  Further,  the  author 
states  that  no  less  than  forty-two  out  of  the  ninety-one 
cases  showed  dilatation  of  the  cavity  of  the  body  by 
mucus  retained  as  a  result  of  the  above  or  other 
abnormality  in  the  plication  of  the  mucous  membrane. 
I  think  that  it  may  be  doubted  whether  a  separation  of 
the  walls  by  2  mm.  (one  line)  is  sufiicient  to  justify  the 
term  "  dilatation/^  and  that  the  term  should  be  limited 
to  cases  in  which  the  uterus  assumes  a  well-marked 
globular  form  with  concave  internal  walls. 

Owing  to  the  uteri  in  my  cases  having  been  opened 
while  fresh,  it  is  impossible  to  give  an  exact  measurement 
of  the  antero-posterior  diameter  of  the  cavity  of  the  body, 
but  in  one  case  the  plug  of  mucus  was  of  the  size  of  the 
end  of  the  little  finger,  and  had,  therefore,  an  antero- 
posterior diameter  of  about  10  mm.  Dr.  von  Friedlander 
says  that  ^^  the  knob-like  swelling  of  the  cervical  plicae 
diminishes,  and  is  no  longer  to  be  found  after  the  eleventh 
year;'^  he,  however,  onl}'  notes  having  examined  tJiirtij- 
four  uteri  of  girls  between  the  ages  of  eleven  and  twenty- 
four.  His  drawings  do  not  show  any  tumour  of  the  shape 
or  dimensions  of  those  I  have  described,  although  the 
uteri   of  which   he  gives  figures   belonged  to  cliildren  of 

*  'Archiv  fiir  Gvnakologie,'  1898,  vol.  xlvi,  p.  634,  "  Ueber  einige  Wach- 
sthums  verandernngen  des  klndlichen  Uterus,  uiul  ihre  Riickwirkung  ant'  die 
spatere  Function." 


338  UTEUUS    WITH    INTERSTITIAL    FIBROID. 

from  three  to  eleven  years  of  age.  His  specimens  appear 
rather  as  slender  (sometimes  almost  thread-like)  polypi, 
and  he  speaks  of  them  as  folds  (Faltungen)  of  the 
endometrium.  It  seems  difficult  to  believe  that  the 
tumours  I  have  described  can  become  obliterated  by  the 
growth  of  the  uterus.  Their  subsequent  history  can, 
however,  only  be  followed  after  an  extensive  series  of 
careful  post-mortem  examinations  of  the  uteri  of  girls,  on 
the  lines  of  the  excellent  work  by  Dr.  von  Friedlander. 
My  present  contribution  to  the  subject  is  limited  to  a 
description  of  three  of  these  congenital  tumours  at  the 
internal  os  uteri,  causing  hydrometra  at  the  time  of 
birth. 


UTBEUS    WITH    INTERSTITIAL    FIBROID    FROM 
A  CASE  OF  PLACENTA  PREVIA  CENTRALIS. 

Shown  by  Robert  Boxall,  M.D.,  M.R.C.P. 

The  patient  from  whom  this  specimen  was  obtained 
was  admitted  to  the  General  Lying-in  Hospital  in  her 
second  confinement,  and  died  forty  minutes  after  delivery 
from  ante-  and  post-partum  haemorrhage.  In  her  previous 
labour,  three  years  ago,  a  large  fibroid,  then  thought  to 
be  submucous,  was  noticed  in  the  lower  pole  of  the 
uterus  on  the  left  side,  and  convalescence  was  compli- 
cated by  the  formation  of  an  abscess  on  the  right  side, 
which  eventually  burst  into  the  vagina.  She  afterwards 
became  an  out-patient  at  Guy^s  Hospital  under  Dr. 
Horrocks,  who  noted  that  the  cervix  had  a  deep  tear  on 
the  right  side  and  was  drawn  over  to  the  same  side  of 
the  pelvis.  The  interest  of  the  specimen  lies  in  these 
lesions.  A  fibroid  in  an  atrophied  condition  exists  in  the 
wall  of  the  lower  part  of  the  uterus  on  the  left  side.  A 
section  of  the  fibroid  under  the  microscope  shows  that 
some    degree   of   hsemorrhage   has   taken   place   into  the 


STUDIES    JN    OBSTETRICS.  339 

tissue,  a  cliaiige  Avliicli  in  the  fresh  state  was  apparent 
to  the  naked  eye.  On  the  right  side  the  cervix  is  deeply 
torn,  and  in  one  place  perforated,  no  doubt  indicating 
the  spot  where  the  abscess  discharged.  An  account  of 
the  previous  labour  has  been  published  by  Dr.  Ezard  in 
the  '  West  Kent  Medico-Chirurgical  Transactions/  1896. 
The  fibroid,  which  from  the  account  given  was  large 
enough  to  give  rise  to  considerable  difficulty  in  the  first 
labour,  must  have  sh'.unk  considerably  since. 


STUDIES    IN    OBSTETRICS. 

By  C.  F.  Ponder,  M.B.Ediu.  (Kalimpong,  Bengal). 

(See   the   ^  Transactions   of   the  Edinburgh  Obstetrical 
Society,^  vol.  xxiii,  p.  148.) 

I.  Midwifery  forceps.      A  lever  of  the  third  class. 

II.  The  action  which  will  be  beneficial  in  parturition. 

III.  The  actions  which  in  parturition  are  not  beneficial, 
but  only  injurious  and  tending  to  disaster. 

IV.  The  proper  time  for  instrumental  interference,  viz. 
early. 

V.  Conclusions. 


i 


INDEX. 


PAGE 

Abortion,  incomplete  tubal ;  hsemorrliage ;  operation ;  recovery 

A.  C.  Butler-Smytbe)  .  .  .  .298 

showing  recent  placental  haemorrhage  (R.  Wise)  .     257 

Addinsell  (Augustus    W.),    intermenstrual    pain    (Mittel- 

schmerz)     ......     137 

RemarJcs  in  discussion  on  C.  Hubert  Roberts's  paper  and 

Alban  Doran's  table  of  cases  of  primary  carcinoma  of  the 
Fallopian  tube  .  .  .  .  .208 

Address  (Annual)  of  the  President,  C.  J.  CuUingworth,  M.D., 

February  2nd,  1898  .  .  .  .  .39 

Address,  bibliographical  appendix  to  Annual  (C.  J.  CuUing- 
worth)       .  .  .  .  .  .91 

Adenoma  (carcinoma),  malignant,  of  the  cervix  uteri  (F.  J. 

McCann)     .  .  .  .  .  .2 

Annual  General  Meeting,  February  2nd,  1898  .  .29 

Antistreptococcic  serum  in  puerperal  septicaemia  (J.  Walters 

and  A.  R.  Walters) .  .  .  .  .277 

Appendages,  see  Utei-ine  Appendages, 

Bedsore,  acute,  following  parturition  (G.  F.  Blacker)  .     247 

Blacker  (G.  F.),  case  of  acute  bedsore  following  parturition     247 
Blood  concretions  in  the  ovary  (Alban  Doran)  .  ,     214 

Box  ALL  (Robert),  incarcerated  ovarian  dermoid ;  Caesarean 
section,  and  removal  of  tumour  at  the  end  of  the  first  stage 
of  labour    .  .  .  .  .  .25 

uterus  with  interstitial  fibroid  from  a  case  of  placenta 

praevia  centralis  (shown)         ....     338 

Remarhs  in  discussion  en  H.  R.  Spencer's  paper  on  two 

cases  of  fibro-myoma  of  the  uterus  removed  by  operation 
from  women  under  twenty-five  years  of  age         .  .     241 

VOL.    XL.  23 


342  INDEX. 


PAGE 


Broad  ligament,  oedematous  subperitoneal  fibro-myomata  of 

uterus   in,    removed   by   abdominal   hysterectomy  (C.  J. 

Cullingwortli)  .  .  .  .  .302 

Burton  (Arthur),  deformed  fcetus  .  .  .     217 

Butler-Smythe  (A.  C),  tubal  gestation ;    incomplete  tubal 

abortion;  haemorrhage;  operation;  recovery  (shown)  .  298 
Remarks  in  discussion  on  J.  Bland   Sutton's   paper   on 

some  cases  of  tubal  pregnancy  .  .  .     325 


Csesarean  section,  and  removal  of  incarcerated  ovarian  dermoid 

at  the  end  of  the  first  stage  of  labour  (R.  Boxall) 
Cancer  of  the  body  of  the  uterus  (M.  Handfield- Jones) 

of  the  Fallopian  tube,  tables  of  cases  of  primary,  reported 

up  to  present  date  (April,  1898) 
Carcinoma   of   cervix   uteri   in  which   the   disease   extended 
upwards  into  the  body  (Walter  W.  H.  Tate) 

of  omentum  and  Fallopian  tube  (Heywood  Smith) 

primary,  of  the  Fallopian  tube  (C.  Hubert  Roberts) 


25 
34 

197 

258 
135 
189 


Cervix,  see  Uterus  {cervix  of ). 

Champneys  (Francis  H.),  Remarks  in  discussion  on  W.  R 

Dakin's  specimen  of  uterine  fibroid  clinically  resembling 

sarcoma      ,  .  .  .  .  .33 

Clarke,  Reginald,  obituary  notice  of  .  .  .       59' 

Coeliotomy,  for  extraction  of  a  living  foetus,  after  term  in  a 

case  of  tubo-abdominal  pregnancy  (J.  Bland  Sutton)  .     308 

Coi'pus  fibrosum,  large  calcified,  in  ovary  (J.  Bland  Sutton)     .     223 
CuLLiNGWORTH  (Charles  J.),  Annual  Address  as  President      .       39' 

bibliographical  appendix  to  Annual  Address  : 

Part  I.  List  of  Sir  Thomas  Spencer  Wells'  published 

writings,  arranged  chronologically  .       91 

Part  II.  List  of  Dr.   J.   Braxton  Hicks's   published 

writings,  arranged  chronologically  ,     102 
early  ectopic  gestation  (?  tubo-uterine)  complicated  by 

fibro-myomata  of  the  uterus   ....     285 

Remarks  in  reply     .....     293 

• malignant  growth  involving  the  right  uterine  appendages 

(shown)      .  .  .  .  ...         6 

oedematous    subperitoneal   fibro-myomata   of    uterus   in 

right  broad  ligament  removed  by  abdominal  hysterectomy 

(shown)       ......     302 

Remarks  in  discussion  on  F.  J.  McCann's  specimen  of 

malignant  adenoma  (carcinoma)  of  the  cervix  uteri  .         3 


INDEX.  343 

FAGB 

CuLLiNGWORTH  (Cliavles  J.),  Remarhs  in  discussion  on  John 
Phillips's  specimen  of  placenta  from  a  case  of  extra-uterine 
foetation     .  .  .  .  .  .5 

in  discussion  on  R.  G.  McKerron's  paper  on  the 

obstruction  of  labour  by  ovarian  tumours  in  the  pelvis      .       13 

in  discussion  on  C.  Hubert  Roberts's  paper  on  a  case 

of  double  pyosalpinx  ....     128 

in  discussion  on  Alban  Doran's  paper  on  haemor- 
rhage from  the  Fallopian  tube  without  evidence  of  tubal 
gestation    ......     180 

in  discussion  on  H.  R.  Spencer's  paper  on  two  cases 

of  fibro-myoma  of  the  uterus  removed  by  operation  from 
women  under  twenty-five  years  of  age  .  .  .     244 

in  discussion  on  M.  S.  Pembrey's  specimen  of  five 

foetal  sacs  from  the  peritoneal  cavity  of  a  rabbit  .     255 

in  discussion  on  J.  Dysart   McGaw's  specimen  of 

cystic  fibro-myoma  of  the  uterus  complicating  pregnancy     256 

in   discussion  on  J.   Walters'  and  A.   R.   Walters' 

paper  on  a  case  of  puerperal  septicaemia  treated  by  anti- 
streptococcic serum  ....     283 

in  discussion  on  J.  Bland  Sutton's  paper  on  some 


cases  of  tubal  pregnancy         ....     326 
Cyst,  incarcerated  ovarian  (dermoid),  removed  during   preg- 
nancy pet'  vaginam  (Amand  Routh)       .  .  .     217 

Dakin  (W.  R.),  uterine  fibroid  clinically  resembling  sarcoma 

(shown)      .  .  .  .  .  .32 

uterus   ruptured   during    unobstructed  labour    (with    a 

microscopic  section)  (shown)  .  .  .29 

Dawson  (E.  Rumley),  rupture  of  an  early  (fifteenth  day)  tubal 

gestation  complicated  by  fibro-myomata   of  the   uterus 

(shown)      ......     155 

Remarks  in  reply     .....     158 

Deciduoma  malignum  (J.  H.  Targett)  .  .  .     113 
primary  sarcoma  of  the  body  of  the  uterus  (A.  H.  N. 

Lewers)      ......     225 

Degeneration,  cystic,  in  large  fibroid  tumour  of  uterus  (P. 

Horrocks)  .  .  .  .  .  .227 

sarcomatous,   with   fibro-myoma   of    the   uterus   (Peter 

Horrocks)  .  .  .  .  .  .178 

Delivery,  incarcerated  ovarian  derfcioid  ruptured  during  (H. 

R.  Spencer)  .  .  .  .  .329 


344  INDEX. 

PAGE 

Dermoid  tumour,  see  Tumours,  ovarian  dermoid. 

DOEAN  (Alban),  blood  concretions  in  the  ovary  (shown)  .     214 

Remarks  in  reply  ...  .  .     217 

fibroma  of  broad  ligament  weighing  forty-four  pounds 

eight  ounces  successfully  removed  from  a  woman  aged 
twenty-eight  (shown)  ....     295 

haemorrhage  from  the  Fallopian  tube  without  evidence 

of  tubal  gestation     .  .  .  ...     180 

BemarJcs  in  reply     .  .  .  .  .188 

sarcoma  of  both  ovaries  (shown)  .  .  .     296 

tables  of  cases  of  primary  cancer  of  the  Fallopian  tube 

reported  up  to  present  date  (April,  1898)  .  .     197 

Remarks  in  reply     .....     211 

in  discussion  on  C.  Hubert  Roberts's  paper  on  a  case 

of  double  pyosalpinx  .  .  .  .127 

in  discussion  on  Peter  Horrocks's  specimen  of  fibro- 

myoma  of  the  uterus  with  sarcomatous  degeneration         .     179 
in  discussion  on  Amand  Routh's  specimen  of  incar- 
cerated ovarian  (dermoid)  cyst,  removed  during  pregnancy 
per  vaginam  .....     217 

in  discussion  on  J.  Bland  Sutton's  specimen  of  an 

ovary  containing  a  calcareous  ball,  probably  a  large  cal- 
cified corpus  fibrosum  ....     225 

in  discussion  on  C.  J.  Oullingworth's  specimen  of 

early  ectopic  gestation   {?  tubo-uterine)  complicated  by 
fibro-myomata  of  the  uterus  .  .  .     292 
in  discussion  on  Walter  W.  H.  Tate's  specimen  of 


sloughing  fibro -myoma  of  uterus  occurring  in  a  patient 
twenty  years  after  the  menopause         .  .  .     306 

in  discussion  on  J.  Bland  Sutton's  paper  on  some 

cases  of  tubal  pregnancy         ....     322 

Duncan  (William),  Remarks  in  discussion  on  H.  R.  Spencer's 
paper  on  two  cases  of  fibro-myoma  of  the  uterus  removed 
by  operation  from  women  under  twenty-five  years  of  age     241 

Eden  (Thomas  Watts),  Remarks  in  discussion  on  J.  B.  Hellier's 

specimen  of  deciduoma  malignum         .  .  .119 

in  discussion  on   J.  Walters'  and  A.  R.  Walters' 

paper  on  a  case  of  puerperal  septicaemia  treated  by  anti- 
streptococcic serum  ....     280 

in  discussion  on  J.  Bland  Sutton's  paper  on  some 

cases  of  tubal  pregnancy        ....     325 


INDEX.  345 

PAGE 

Eden  (Thomas  Watts),  Report  on    H.    Macnaughton-Jones' 

specimen  of  tumour  of  the  ovary  .  .  .     214 

Election  of  New  Fellows   .  .  2,29,113,175,277,295,327 


Fallopian  tube,  hydrocele  of  the  canal  of  Niick,  containing  a 

portion  of  the  left  (L.  Remfry)  .  .  .6 

primary  carcinoma  of  (C.  Hubert  Roberts)        .  .     189 

tables  of  cases   of  primary   cancer   of,    reported   up   to 

present  date  (April,  1898)       .  .  .  .197 

Fellows,  see  Lists,  Elections. 

Fibroid,  see  Tumours,  fibroid. 

Fibroids,  large  solitary  subperitoneal  fibroid  tumour  of  the 

uterus  with  multiple  (A.  H.  N.  Lewers)  .  .     327 

Fibroma  of  broad  ligament  weighing  forty-four  pounds  eight 
ounces,  successfully  removed  from  a  woman  aged  twenty- 
eight  (Alban  Doran)  ....     295 

Fibro-myoma,  cystic,  of  the  uterus,  complicating  pregnancy ; 

removal  at  four  and  a  half  months  (J.  Dysart  McCaw)     .     256 

of  uterus  projecting  into  vagina,  removed  by  abdominal 

hysterectomy  (W.  W.  H.  Tate)  .  .  .159 

removed  by  operation  from  women  under  twenty-five 

years  of  age  (H.  R.  Spencer)  .  .  .     228 

sloughing,  occurring  in  a  patient  twenty  years  after 

the  menopause  (W.  W.  H.  Tate)  .  .  .303 

with  sarcomatous  degeneration  (Peter  Horrocks)     .     178 

of  vaginal  wall  (with  microscopical  slide)  (John  Phillips)     130 

weighing   fourteen  pounds,  large   soft   broad   ligament 

(Ewen  Maclean)        .  .  .  .  .134 

Fibro-myomata  of  uterus  complicating  early  ectopic  gestation 

(?  tubo-uterine)  (C.  J.  Cullingworth)    .  .  .285 
complicating  rupture  of  an  early  tubal   gestation 

(fifteenth  day)  (E.  Rumley  Dawson)     .  .  .     155 
cedematous  subperitoneal,  in  right  broad  ligament, 

removed  by  abdominal  hysterectomy  (C.J.  Cullingworth)     302 
Fcetation,  see  Pregnancy. 
Foetus,  living,  extracted  by  cceliotomy  after  term  in  a  case  of 

tubo-abdominal  pregnancy  (J.  Bland  Sutton)     .  .     308 
note  on  some  diflBcult  cases  of  fronto-anterior  positions 

of  the  head  of  (George  Roper)  .  .  .     271 

Fontanelle,  sagittal,  in  the  heads  of  infants  at  birth  (A.  W.  W. 

Lea)  .  .  .  .  .  .263 


346  INDEX. 

PAGE 

Forceps  and  version,  incarcerated  ovarian  dermoid  ruptured 

during  delivery  by  (H.  R.  Spencer)        .  .  .     329 

Fowler  (Charles  Owen),  double  monster  of  dicepbalous  type 

(shown)       .  .  .  .  .  .119 

Freeman  (Henry  William),  obituary  notice  of  .  .61 

Gardner  (William),  M.D.,  obituary  notice  of  .  .       59 

Gestation,  see  Pregnancy. 

early    ectopic    {?  tubo-uterine),  complicated    bj'    fibro- 

myomataof  uterus  (C.  J.  Cullingworth)  .  .     285 

tubal;  incomplete  tubal  abortion;  haemorrhage;  opera- 
tion ;  recovery  (A.  C.  Butler-Smythe)  .  .  .     298 

Giles  (Arthur),   Remarks   in   discussion   on  W.   R.  Dakin's 

specimen  of  uterine  fibi'oid  clinically  resembling  sarcoma      33 

in  discussion   on  C.   Hubert   Roberts's   paper  and 

Alban  Doran's  tables  of  cases  of  primary  carcinoma  of 

the  Fallopian  tube    .  .  .  .  .209 

'■ —  in  discussion  on  C.  J.   Oullingworth's   specimen   of 


early  ectopic  gestation  (?  tubo-uterine)  complicated  by 
fibro-myomata  of  the  uterus  ....     293 

in  discussion  on  H.  R.  Spencer's  specimen  of  in- 
carcerated ovarian  dermoid  removed  at  the  fourth  month 
of  pregnancy ;  delivery  of  a  living  child  at  term  .     332 

Gow  (W.  J.),    cystic    intra-ligamentous  myoma  with  double 

uterus  (shown)  .....     134 

Hsematosalpinx,    uterine    appendages     showing     a     (Amand 

Routh)        .  .  .  .  .  .306 

Haemorrhage,  abortion  showing  recent  placental  (R.  Wise)       .     257 

from  the  Fallopian  tube  without  evidence  of  tubal  gesta- 
tion (Alban  Doran)  ....     180 

Handfield- Jones  (M.),  cancer  of  the  body  of   the   uterus 

(shown)       .  .  .  .  .  .34 

Remarks  in  discussion  on  W.   R.   Dakin's   specimen  of 

uterus  ruptured  during  unobstructed  labour       .  .       32 

He  APE  (Walter),  menstruation  and  ovulation  of  monkeys  and 

the  human  female         .  ....     161 

Hellier  (John  B.)  see  J.  H.  Targett. 

Herman  (G.  E.),  Remarks  in  discussion  on  Dr.  McKerron's 
paper  on  the  obstruction  of  labour  by  ovarian  tumours  in 
the  pelvis    .  .  .  .  .  .8 

in  discussion  on  E.  Rumley  Dawson's  specimen  of 

rupture  of  an  early  tubal  gestation  (fifteenth  day)  com- 
plicated by  fibro-myomata  of  the  uterus  .  .     157 


INDEX.  347 

PAGE 

Herman  (G.  E.),  RemarJcs  in  discussion  on  Walter  Heape's 
paper  on  the  menstruation  and  ovulation  of  monkeys 
and  the  human  female  ....     173 

in  discussion  on  H.  R.  Spencer's  paper  on  two  cases 

of  fibro-myoma  of  the  uterus  removed  by  operation  from 
women  under  twenty-five  years  of  age  .  .  .     242 

in  discussion  on  G.  F.  Blacker's  note  on  a  case  of 

acute  bedsore  following  parturition      ,  .  .     253 

in   discussion   on   A.    W.    W.  Lea's   paper  on  the 


sagittal  fontanelle  in  the  head  of  infants  at  birth  .     270 

in  discussion  on  G.  Roper's  note  on  some  difficult 

cases  of  fronto-anterior  positions  of  the  fcetal  head  .     275 

in  discussion  on   Walter  W.  H.  Tate's  specimen  of 

sloughing  fibro-myoma  of  uterus  occurring  in  a  patient 
twenty  years  after  the  menopause  .  .  .     305 

Hicks  (J.  Braxton),  list  of  published  writings,  arranged  chrono- 
logically (C.  J.  Cullingworth)  .  .  .102 

obituary  notice  of  .  .  .  .  .65 

HORROCKS  (Peter),  fibro-myoma  of  the  uterus  with  sarcoma- 
tous degeneration  (shown)        ....     178 

large  fibroid  tumour  of   the   uterus   undergoing    cystic 

degeneration  (shown)  ....     227 

RemarTcs  in   discussion  on   John   Phillips's  specimen  of 

placenta  from  a  case  of  extra-uterine  fcetation     .  .         4 

• in  discussion  on    R.  G.  McKerron's    paper   on  the 

obstruction  of    labour  by  ovarian  tumours  in  the  pelvis       11 

in   discussion   on  E.    Rumley  Dawson's   specimen 

of  rupture  of  an  early  tubal  gestation  (fifteenth  day),  com- 
plicated by  fibro-myomata  of  the  uterus  .  .     157 

in  discussion  on  W.  W.  H.  Tate's  specimen  of  fibro- 
myoma  of  uterus  projecting  into  vagina,  removed  by 
abdominal  hysterectomy  ....     159 

■  in  discussion  on  Walter  Heape's  paper  on  the  men- 
struation and  ovulation  of  monkeys  and  the  human 
female        ......     173 

in  discussion   on   C.    Hubert  Roberts's  paper,  and 

Alban  Doran's  tables  of  primary  cancer  of  the  Fallopian 
tube  .  .  .  .  .  .208 

,         in  discussion  on  H.  R.  Spencer's  paper  on  two  cases 

of  fibro-myoma  of  the  uterus,  removed  by  operation  from 
women  under  twenty-five  years  of  age  .  .  .     243 

in  discussion  on  H.  R.  Spencer's  specimen  of  incar- 
cerated ovarian  dermoid  in  the  middle  of  pregnancy  .     259 


348  INDEX. 


PAGE 


HOrrocks  (Peter),  Bemarhs  in  discussion  on  G.  Roper's  note 
on  some  difficult  cases  of  fronto- anterior  positions  of  the 
foetal  head  .  .  .  .  .276 

Hydrocele  of  the  canal  of  Niick  containing  a  portion  of  the 

left  Fallopian  tube  (L.  Remfry)  .  .  .6 

Hydrometra  in  new-born  children,  congenital  tumour   at  the 

internal  os  uteri  causing  (H.  R.  Spencer)  .  .    332 

Hysterectomy,  abdominal,  for  fibro-myoma  of  uterus  project- 
ing into  vagina  (W.  W.  H.  Tate)  .  .  .159 

for    oedematous    subperitoneal    fibro-myomata    of 

uterus  in  right  broad  ligament  (C.  J.  Cullingworth)  .     302 

Ilott  (Herbert  J.),  Remarlcs  in  discussion  on  W.  R.  Dakin's 

specimen  of  uterus  ruptured  during  unobstructed  labour  31 
Incontinence  of  urine,  complete,  cured  by  ventro-fixation  of  the 

uterus  (H.  Macnaughton-Jones)  .  .  •  .     226 

Infants,    sagittal     fontanelle     in    the     heads   of,    at    birth 

(A.  W.  W.  Lea)        .  .  .  .  .263 

Intermenstrual  pain  (Mittelschmerz)  (A.  W.  Addinsell)  .     137 

Intestine,     double     obstruction     of,     following    ovariotomy 

(J.  H.  Targett)         .  .  .  .  .175 

Jackson  (James),  see  Spencer,  Herbert  B.  .  .     329 

JlGER  (Harold),  see  Phillips,  John. 

Labour,  see  Parturition. 

Lea  (Arnold  W.  W.),  the  sagittal  fontanelle  in  the  heads  of 

infants  at  birth         .....     263 

BemarJcs  in  reply     .  .  .  .  .270 

Lewers  (Arthur  H.  N.),  large  solitary  subperitoneal  fibroid 

tumour  of  the  uterus  with  multiple  fibroids  (shown)  .  327 
primary  sarcoma  of  the  body  of  the  uterus  (deciduoma 

malignum)  (shown)  .....  225 
•         BemarJcs  in  discussion  on  H.  R.  Spencer's  paper  on  two 

cases  of  fibro-myoma  of  the  uterus  removed  by  operation 

from  women  under  twenty-five  years  of  age  .  .     244 

Ligament,  see  Broad  Ligament. 
List  of  Officers  elected  for  1898        .  .  .  .89 

/or  1899  .  .  .  .  -         V 

of  past  Presidents     .  .  .  .  .      vii 

of  Beferees  of  Papers  for  1S99  .  .  .     viii 

of  Standing  Committees  .  .  .  .       ix 

of  Honorary  Local  Secretaries  .  .  .         x 


INDEX.  349 

PAGE 

List  of  Honorary  Fellovjs  .  .  .  .       xi 

of  Corresponding  Fellows         .  .  .  .      xii 

of  Ordinary  Felloivs  ....    xiii 

of  Deceased  Felloivs  [with  obituary  notices,  wliicli  see]     51 — 88 

Lusk,  William  Thompson,  M.D.,  obituary  notice  of  .  .62 

McCann  (Frederick  John),  malignant  adenoma  (carcinoma) 

of  the  cervix  uteri  (shown)      .  .  .  .2 

uterine  myoma  (shown)  .  .  .  .3 

Bemarhs  in  discussion  on  J.  Walters'  and  A.  R.  Walters' 

paper  on  a  case  of  puerperal  septicasmia  treated  by  anti- 
streptococcic serum  ....     281 

in  discussion  on  J.  Bland  Sutton's  paper  on  some 

cases  of  tubal  pregnancy         ....     324 

McCaw  (J.  Dysart),  cystic  fibro-myoma  of  the  uterus  compli- 
cating pregnancy;  removal  at  four  and  a  half  months 
(shown)      .  .  .  .  .  .256 

McKereon  (Robert  G.),  adjourned  discussion  on  paper  on 
the  obstruction  of  labour  by  ovaiian  tumours  in  the 
pelvis  .  .  .  .  .  .8 

Maclean  (Ewen),   large  soft    broad  ligament  fibro-myoma, 

weighing  fourteen  pounds  (shown)        .  .  .     134 

Macnatjghton-Jones  (H.),   complete  incontinence  of  urine 

cured  by  ventro-fixation  of  the  uterus  .  .  .     226 

Report  on  specimen  of  tumour  of  the  ovary        .  .     213 

uterine  fibroid  with  anomalous  ovarian  tumour   (shown)     154 

Menopause,  sloughing  fibro-myoma  of  uterus  occurring  in  a 

patient  twenty  years  after  the  (W.  W.  H.  Tate) .  .     303 

Menstruation  and  ovulation  of  monkeys  and  the  human  female 

(Walter  Heape)         .  .  .  .  .161 

IMittelschmerz,  intermenstrual  pain  (A.  W.  Addinsell)  .     137 

Monkeys,   menstruation    and  ovulation  of,    and   the   human 

female  (Walter  Heape)  ....     161 

Monster,  double,  of  dicephalous  type  (C.  O.  Fowler)  .  .     119 

Monstrosity  resulting  from  amniotic  adhesion  to  skull  (John 

Phillips)     .  .  .  .  .  .130 

Myoma,  cystic  intra-ligamentous,  with  double  uterus  (W.  J. 

Gow)  .  .  .  .  .  .134 

uterine  (F.  J.  McCann)  .  .  .  .3 

Niick,  hydrocele  of  the  canal  of,  containing   a  portion  of  the 

left  Fallopian  tube  (L.  Remfry)  .  .  '9 


350  INDEX. 


PAGE 


Obituary  notices  of  deceased  Fellows  : 

Wells,  Sir  Thomas  Spencer,  Bart.,  F.R.C.S.,  Upper  Gros- 

venor  Street  (Trustee)      .  .  .  .51 

Parsons,  Thomas  Edward,  Wimbledon  .  .       58 

Gardner,  William,  M.D.,  Melbourne      .  .  .59 

Clarke,  Reginald,  Lee  .  .  .  .59 

Scott,  John,  M.D.,  Sandwich  .  .  .  .60 

Freeman,  Henry  William,  Bath  .  .  .61 

Lusk,  William   Thompson,  M.D.,  New   York  (Honorary 

Fellow)  .  .  .  .  .62 

Hicks,  John  Braxton,  M.D.,  F.R.C.P.,  F.R.S.,  Lymington 

(Honorary  Fellow)  .  .  .  .65 

Tarnier,  Etienne  Stephane,  M.D,,  Paris  (Honorary  Fellow)  78 
Obstetrics,  studies  in  (C  F.  Ponder)  .  .  .     339 

Os  uteri,  see  Uterus,  os  uteri. 

Ovaries,  sarcoma  of  (Alban  Doran)  .  .  .     296 

Ovariotomy,    double   intestinal   obstruction   following  (J.  H. 

Targett)      .  .  .  .  .  .175 

during  labour  ( H.  R.  Spencer)  .  .  .14 

Ovary,  blood  concretions  in  (Alban  Doran)  .  .     214 

containing  a  calcareous   ball,  probably  a  large  calcified 

corpus  fibrosum  (J.  Bland  Sutton)         .  .  .     223 

Ovulation  and  menstruation  of  monkeys  and  the  human  female 

(Walter  Heape)         .  .  .  .  .161 

Parsons,  Thomas  Edward,  obituary  notice  of  .  .58 
Parturition,  acute  bedsore  following  (G.  F.  Blacker)  .  247 
adjourned  discussion  on  R.  G.  McKerron's  paper  on  the 

obstruction  of,  by  ovarian  tumours  in  the  pelvis  .  .  8 
incarcerated   ovarian   dermoid  ;    CaBsarean    section  and 

removal  of  tumour   at  the   end  of  the  first  stage  of  (R. 

Boxall)  .  .  .  .  .  .25 

incarcerated    ovarian    dermoid     obstructing   ;     manual 

elevation  ;  removal  seven  months  later  (H.  R.  Spencer)  .  22 
incarcerated   ovarian    dermoid    obstructing  ovariotomy 

during  (H.  R.  Spencer)  .  .  .  .14 
uterus  ruptured  during  unobstructed  (with  a  microscopic 

section)  (W.  R.  Dakin)  .  .  .  .29 

Pelvis,  adjourned  discussion  on  R.  G.  McKerron's  paper  on 

the  obstruction  of  labour  by  ovarian  tumours  in  .         8 

Pembrey  (M.  S.),  five  foetal  sacs  from  the  peritoneal  cavity  of 

a  rabbit  (shown)       .....     253 


INDEX.  351 

PAGE 

Phillips  (John),  fibro-myoma  of  vaginal  wall  (with  micro- 
scopical slide)  (shown)  ....     130 

(for  Harold  Jager),  monstrosity  resulting  from  amni- 
otic adhesion  to  skull  ....     130 

placenta  from  a  case  of  extra-uterine  foetation ;  the  child 

at    full     term,    and    removed    five   months   after   death 
(shown)      .  .  .  .  .  .3 

RemarTcs  in  discussion  on  W.   R.  Dakin's   specimen   of 

uterus  ruptured  during  unobstructed  labour        .  .       32 

Report  on  Harold  Jager's  specimen  of  monstrosity  result- 
ing from  amniotic  adhesion  to  skull     .  *  .     134 

Remarks  in  discussion  on  J.  H.   Targett's   specimen   of 

double  intestinal  obstruction  following  ovariotomy  .     178 

in  discussion  on  J.  Walters'   and   A.  R.  Walters' 

paper  on  a  case  of  puerperal  septicaemia  treated  b}'  anti- 
streptococcic serum  ....     282 

in  discussion  on  H.  R.  Spencer's  specimen  of  incar- 
cerated ovarian  dermoid  removed  at  the  fourth  month  of 
pregnancy;  delivery  of  a  living  child  at  term     .  .     330 

Placenta  from  a  case  of  extra-uterine  foetation ;  the  child  at 
full  term,  and  removed  five  months  after  death  (John 
Phillips)     .  .  .  .  .3 

•         pra3via  centralis,  uterus  with  interstitial  fibroid  from  a 

case  of  (R.  Boxall)  .  .  .  .  .338 

Playfair  (W.  S.),  Remarlis  in  discussion  on  R.  G.  McKerron's 
paper  on  the  obstruction  of  labour  by  ovarian  tumours  in 
the  pelvis   .  .  .  .  .  .8 

Pollock  (W.  Rivers),  dermoid  tumour  of  both  ovai-ies,  with 

very  long  ovarian  ligament  on  the  left  side  (shown)  .     119 

Ponder  (C.  F.),  studies  in  obstetrics  .  .  .     339 

Pregnancy,  hsemorrhage    from    the  Fallopian  tube    witbout 

evidence  of  tubal  (Alban  Doran)  .  .  .     180 

incarcerated    ovarian    (dermoid)   cyst,   removed   during 

(Amand  Routh)  .  .  .  .  .217 

in  the  middle  of  (H.  R.  Spencer)        .  .     259 

removed  at  the  fourth  month  of;  delivery  of  a 

living  child  at  term  (H.  R.  Spencer)     .  .  .     330 

placenta  from  a  case  of  extra-uterine;  the  child  at  full 

term,  and  removed  five  months  after  death  (John  Phillips)         3 

■ rupture  of  an  early  tubal  (fifteenth  day),  complicated  by 

fibro-myomata  of  the  uterus  (E.  Runiley  Dawson)  .     155 

ruptured  tubal  (at  fourth  or  fifth  week) ;  operation  ;  reco- 
very (Amand  Routh)  ....     220 


352 


INDEX. 


PAGE 

Pregnancy,  tubal  (J.  Bland  Sutton)  .  .  .313 

tubo-abdominal,  in  which  a  living  foetus  was  extracted  by 

cceliotomy  after  term,  and  the  mother's  life  preserved  (J. 
Bland  Sutton)  .  .  .  .  .308 

Pyosalpinx,  double,  in  which  the  tubes  were  enormously  dis- 
tended (C.  Hubert  Roberts)    .  .  .  .121 

Rabbit,  five  foetal  sacs  from  the  peritoneal  cavity  of  (M.  S. 

Pembrey)  ......     253 

Remfry  (Leonard),  death  of         .  .  .  .174 

hydrocele  of  the  canal  of  Nlick  containing  a  portion  of 

the  left  Fallopian  tube  (shown)  .  .  .6 

Report  {audited)  of  the  Treasurer  for  1897     .  .  35,  36 

of  the  Chairrtian  of  the  Board  for   the   Examination  of 

Midwives    .  .  .  .  .  .37 

of  the  Honorary  Librarian  for  1897      .  .  .37 

of    Committee   on    H.   Macnaughton-Jones'    specirnen    of 

tumour  of  the  ovary,  shown  on  April  6th,  1898       .  .     213 

on  specimen  of  carcinoma  of  omentu')n  and  Fallopian  tube, 

shown  March  Srd,  1897,  by  Heywood  Smith  (not  reported)     135 

on  specimen  of  monstrosity  resulting  from  am^niotic  adhe- 
sion to  skull,  shown  by  John  Phillips  at  same  time  .     131 

on  specimen  of  ruptured  tubal  gestation,  shown  by  Amand 

Routh  at  same  time   .  .  .  .  .222 

Roberts  (C.  Hubert),  a  case  of  double  pyosalpinx,  in  which 

the  tubes  were  enormously  distended    .  .  .     121 

Remarhs  in  reply     .....     129 

a  case  of  primary  carcinoma  of  the  Fallopian  tube  .     189 

Remarks  in  reply     .....     209 

— —  Report  on  John  Phillips's  specimen  of  monstrosity  re- 
sulting from  amniotic  adhesion  to  skull  .  .     134 

Robinson    (G.   Drummond),   Remarks    in   discussion   on  C. 

Hubert  Roberts's  paper  on  a  case  of  double  pyosalpinx    .     128 

in  discussion  on  Amand  Routh's  specimen  of  incar- 
cerated ovarian  (dermoid)  cyst,  removed  during  pregnancy 
per  vaginam  .  .  .  .  .217 

in   discussion   on   J.  Walters'  and   A.  R.  Walters' 

paper  on  a  case  of  puerperal  septicaemia  treated  by  anti- 
streptococcic serum  ....     281 

Roper  (George),  note  on  some  difficult  cases  of  fronto-anterior 

positions  of  the  foetal  head     ....     271 

Routh  (Amand),  incarcerated  ovarian  (dermoid)  cyst,  re- 
moved during  pregnancy  per  vaginam  .  .     217 


INDEX.  353 

PAGE 
RoTJTH  (Amand),  ruptured  tubal  gestation  (at  fourth  or  fifth 

week) ;  operation ;  recovery  (shown)     .  .  .     220 

BemarTis  in  reply     .....     220 

uterine  appendages  showing  a  haematosalpinx  (shown)    .     306 

Bemarlis  in  discussion  on  C.Hubert  Roberts's  paper  and 

Alban  Doran's  tables  of  cases  of  primary  cancer  of  the 
Fallopian  tube  .  .  .  .  .208 

Bemarlcs  in  discussion  on  J.  "Walters'  and  A.  R.  Walters' 

paper  on  a  case  of  puerperal  septicaemia  treated  by  anti- 
streptococcic serum  ....     280 

in  discussion  on  C.  J.  Cullingworth's  specimen  of 

early  ectopic  gestation  {?  tubo-uterine)  complicated  by 
fibro-myomata  of  the  uterus   ....     293 
in  discussion  on  J.  Eland  Sutton's  paper  on  some 


cases  of  tubal  pregnancy        ....     324 

Sacs,  five  foetal,  from  the  peritoneal  cavity  of  a  rabbit  (M.  S. 

Pembrey)    .  .  .  .  .  .253 

Sarcoma  of  both  ovaries  (Alban  Doran)        .  .  .     296 

of  the  body  of  the  uterus,  primary  (A.  H.  N.  Lewers)       .     225 

uterine  fibroid  clinically  resembling  (W.  R.  Dakin)  .       32 

Scott,  John,  M.D.,  obituary  notice  of  .  .  .60 

Septicaemia,   puerperal,    treated    by   antistreptococcic    serum 

(J.  Walters  and  A.  R.  Walters)  .  .  .277 

Severn  (Walter  D.),  Beport  on  Heywood  Smith's  specimen 

shown  March  3rd,  1897  (not  reported)  .  .  .     135 

Skull,  monstrosity  resulting  from  amniotic  adhesion  to  (John 

Phillips)     .  .  .  .  .  .130 

Smith  (Heywood),  Bemarks  in  discussion  on  R.  G.  McKerron's 

paper  on  the  obstruction  of  labour  by  ovarian  tumours  in 

the  pelvis  .  .  .  .  .  .11 

in  discussion  on  J.  H.  Targett's  specimen  of  double 

intestinal  obstruction  following  ovariotomy         .  .     178 
carcinoma  of  omentum  and  Fallopian  tube  shown  March 

3rd,  1897  (not  reported)  .  .  .  .135 

Beport       ......     135 

Spencer  (Herbert  R.)    (for  James   Jackson),  incarcerated 

ovarian  dermoid  ruptured  during  delivery  by  forceps  and 

version,  with  fatal  result  (shown)  .  .  .     329 
incarcerated  ovarian  dermoid  in  the  middle  of  pregnancy  ; 

manual  elevation ;  removal  a  fortnight  after  delivery  at 

term  .  .  .  .  .  .259 

Bemarks  in  reply     .....     262 


354  INDEX. 


PAGE 


Spencer  (Herbert  R.),  incarcerated  ovarian  dermoid  obstruct- 
ing labour ;  manual  elevation ;  removal  seven  months 
later  .  .  .  .  .  .22 

incarcerated  ovarian  dermoid  obstructing  labour  ;  ovari- 

otomy  during  labour  .  .  .  .14 

incarcerated     ovarian    dermoid   removed    at    the   fourth 

month  of  pregnancy  ;  delivery  of  a  living  child  at  term 
(shown)       .  .  .  .  .  .330 

three  cases  of  congenital  tumour  at  the  internal  os  uteri 

causing  hydrometra  in  new-born  children  .  .     332 

two  cases  of  fibro-myoma  of  the  uterus  removed  by  ope- 
ration from  women  under  twenty-five  years  of  age  .     228 

Remarhs  in  reply      .....     245 

in  discussion  on    R.  G.  McKerron's  paper  on  the 

obstruction  of  labour  by  ovarian,  tumours  in  the  pelvis     .       12 

in  discussion  on  E.  Rumley  Dawson's  specimen  of 


rupture  of  an  early  tubal  gestation  (fifteenth  day)  com- 
plicated by  fibro-myomata  of  the  uterus  .  .     157 

Report  on  H.  Macnaughton-Jones's  specimen  of  tumour 

of  the  ovary  .....     214 

Remarks  in  discussion  on  Am  and  Routh's  specimen  of 

incarcerated    ovarian    (dermoid)    cyst,    removed    during 
pregnancy  joer -ya^inam  ....     217 

in   discussion   on  A.   W.   W.    Lea's   paper   on   the 

sagittal  fontanelle  in  the  heads  of  infants  at  birth  .     270 

Studies  in  obstetrics  (0.  F.  Ponder)  .  .  .     339 

SxjTTON  (J.  Bland),  on  a  case  of  tubo-abdominal  pregnancy  in 
which  a  living  foetus  was  extracted  by  coeliotomy  after 
term,  and  the  mother's  life  preserved    .  .  .     308 

on  some  cases  of  tubal  pregnancy         .  .  .     313 

> Remarks  in  reply     .  .  .  .  .     326 

ovary   containing   a   calcareous   ball,   probably  a   large 

calcified  corpus  fibrosum  (shown)  .  .  .     223 

Remarks  in  discussion  on  C.  Hubert  Roberts's  paper  on 

a  case  of  double  pyosalpinx     ....     128 

—  in  discussion  on  Alban  Doran's  specimen  of  blood 

concretions  in  the  ovary  ....     217 

in  discussion  on  M.  S.  Pembrey's  specimen  of  five 

foetal  sacs  from  the  peritoneal  cavity  of  a  rabbit  .     253 

in  discussion  on  Walter  W.  H.  Tate's  specimen  of 

sloughing  fibro-myoma  of  uterus  occurring  in  a  patient 
twenty  years  after  the  menopause  .  .  .     305 


INDEX.  355 

PAGE 

Targett   (J.   H,),   double    intestinal    obstruction    following 

ovariotomy  (shown)  ....     175 

(for  J.  B.  Hellier),  case  of  deciduoma  malignum  (shown)     113 

Report  on  Amand  Routh's  specimen  of  ruptured  tubal 

gestation    ......     223 

on  H.  Macnaughton-Jones'  specimen  of  tumour  of 

the  ovary    ......     214 

Tarnier  (Etienne  Stephane,  M.D.),  obituary  notice  of  .       78 

Tate  (Walter  W,  H.),  carcinoma  of  cervix  uteri  in  which  the 

disease  extended  upwards  into  the  body  .  .     258 

case  of  sloughing  fibro-myoma  of  uterus  occurring  in  a 

patient  twenty  years  after  the  menopause  (shown)  .     303 

BemarJcs  in  reply     .....     806 

fibro-myoma  of  uterus  projecting  into  vagina,  removed 

by  abdominal  hysterectomy  (shown)   .  .  .     159 

Remarlis  in  reply     .....     160 

BemarJcs  in  discussion  on  J.  Walters'  and  A.  R.  Walters' 

paper  on  a  case  of  puerperal  septicaemia  treated  by   anti- 
streptococcic serum  ....     282 

Tubes  enormously  distended  in  a  case  of  double  pyosalpinx 

(C.  Hubert  Roberts)  .  .  .  .121 

Tumour,  anomalous  ovarian,  associated  with  uterine  fibroid 

(H.  Macnaughton-Jones)         ....     154 

congenital,  at  the  internal  os  uteri,  causing  hydrometra 

in  new-born  children  (H,  R.  Spencer)  .  .     332 

dermoid,  of  both  ovaries,  with  very  long  ovarian  ligament 

on  the  left  side  (W.  Rivers  Pollock)     .  .  .119 

incarcerated  ovarian,  removed  at  the  fourth  month 

of  pregnancy ;  delivery  of  a  living  child  at  term  (H.  R. 
Spencer)  .  .  .  .  .  .330 

incarcerated  ovarian,  ruptured  during  delivery  by 

forceps  and  version,  with  fatal  result  (H.  R.  Spencer)     .     329 

incarcerated  ovarian  ;  Caesarean  section,  and  re- 
moval of  tumour  at  the  end  of  the  first  stage  of  labour 
(R.  Boxall)  .  .  .  .  .25 

incarcerated  ovarian,  in  the  middle  of  pregnancy; 

manual  elevation ;  removal  a  fortnight  after  delivery  at 
term  (H.  R.  Spencer)  .  .  .  .259 

incarcerated   ovarian,   obstructing  labour;  manual 

elevation  ;  removal  seven  months  later  (H.  R.  Spencer)    .       22 

incarcerated   ovarian,    obstructing    labour ;    ovario- 
tomy during  labour  (H.  R.  Spencer)      .  .  .14 

fibroid,  uterus  with  interstitial,  from  a  case  of    placenta 

prsevia  centralis  (R.  Boxall)   ....     333 


356  INDEX. 


FAGS 


Tumour,  fibroma  of  broad  ligament  weigbing  forty-four 
pounds  eigbt  ounces  successfully  removed  from  a  woman 
aged  twenty-eight  (Alban  Doran)  .  .  .     295 

fibro-myoma    of     uterus,    sloughing,     occurring   in    a 

patient  twenty   years   after   the   menopause   (W.  W.  H. 
Tate)  .  .  .  .  .  .303 

fibro-myomata  of    uterus,  oedematous  subperitoneal,   in 

right  broad  ligament  removed  by  abdominal  hysterectomy 

(C.  J.  Cullingworth)  .  .  .  .302 

large  solitary  subperitoneal  fibroid  of  the  uterus   with 

multiple  fibroids  (A.  H.  N.  Lewers)        .  .  .     327 

ovarian,  adjourned  discussion  on  R.  G.  McKerron's  paper 

on  the  obstruction  of  labour  by 

uterine    fibroid   clinically   resembling    sarcoma   (W.  R 

Dakin)         .  .  .  .  .  .32 

Urine,  complete  incontinence  of,  cured  by  ventro-fixation  of 

the  uterus  (H.  Macnaughton- Jones)     .  .  .     226 

Uterine  appendages,  malignant  growth  involving  the   right 

(0.  J.  Cullingworth)  .  .  .  .6 

showing  a  hsematosalpinx  (Amand  Routh)  • .     306 

Uterus,  cancer  of  the  body  of  (M.  Handfield-Jones)  .  34 
carcinoma  of  cervix  of,  in  which  the  disease  extended 

upwards  into  the  body  (W.  W.  H.  Tate)  .  .258 
cervix  uteri,  malignant   adenoma  (carcinoma)  of  (F.  J. 

McCann)     .  .  .  .  .  .2 

complete  incontinence  of  urine  cured  by  ventro-fixation 

of  (H.  Macnaughton-Jones)  ....  226 
cystic  fibro-myoma  of,  complicating  pregnancy;  removal 

at  four  and  a  half  months  (J.  Dysart  McCaw)    .  .     256 

double,  with  cystic  intra-ligamentous  myoma  (W.  J.  Gow)     134 

early  ectopic  gestation  (?  tubo-uterine)  complicated  by 

fibro-myomata  of  (0.  J.  Cullingworth)  .  .  285 
fibroid  of,  associated   with    anomalous   ovarian   tumour 

(H.  Macnaughton-Jones)  ....  154 
fibro-myoma  of,  projecting  into  vagina,  removed  by  abdo- 
minal hysterectomy  (W.  W.  H.  Tate)  .  .  .159 

with  sarcomatous  degeneration  (Peter  Horrocks)  178 

fibro-myomata   of,   complicating    rupture    of    an    early 

(fifteenth  day)  tubal  gestation  (E.  Rumley  Dawson)  .  155 
large  fibroid  tumour  of,  undergoing  cystic  degeneration 

(Peter  Horrocks)       .....     227 


INDKX.  'j'M 

PAGE 

Uterus,  large  solitary  subperitoneal  fibroid  tumour  of,  with 

multiple  fibroids  (A,  H.  N.  Lewers)  .  .  .  327 
oedematous     subperitoneal    fibro-myomata    of,   in   right 

broad  ligament,  removed  by  abdominal  hysterectomy  (C. 

J.  Cullingworthj  .....  302 
OS  uteri,  three  cases  of  congenital  tumour  at  the  internal, 

causing  hydrometra  in  new-born  children  (H.  R.  Spencer)  332 
primary  sarcoma  of  the  body  of  (A.  H.  N.  Lewers)  .     225 

ruptured  during  unobstructed  labour  (with  a  microscopic 

section)  (W.  R.  Dakin)  .  .  .  .29 

sloughing  fibro- myoma  of,  occurring  in  a  patient  twenty 

years  after  the  menopause  (W.  W.  H.  Tate)        .  .     303 

two  cases  of  fibro-myoma  of,  removed  by  operation  (H.  R. 

Spencer)     ,  .  .  .  .  .228 

with  interstitial  fibroid  from  a  case  of  placenta  previa 

centralis  (R.  Boxall)  .  .  .  .338 

Vagina,  fibro-myoma  of  wall  of  (with  microscopical  slide)  (John 

Phillips)     .  .  .  .  .  .130 

Ventro- fixation  of  uterus  for  complete  incontinence  of  urine 

(H.  Macnaughton-Jones)         ....     226 

Version,    incarcerated     ovarian     dermoid    ruptured    during 

delivery  by  forceps  and  (H.  R.  Spencer)  .  .     329 

Walters  (J.)  and  A.  R.  Walters,  case  of  puerperal  septi- 

ciemia  treated  by  antistreptococcic  serum  .  .     277 

Remarks  in  reply     .....     284 

Wells   (Sir    Thomas    Spencer),    list   of   published   writings, 

arranged  chronologically  (C.  J.  Cullingworth)     .  .      91 

obituary  notice  of   .  .  .  .  .51 

West  (Charles),  death  of  .  .  .  .174 

Wise   (Robert),  abortion  showing  recent  placental  haemor- 
rhage (shown)  .....     257 


VOL.    XL. 


24 


OBSTETRICAL    SOCIETY. 


ADDITIONS  TO  THE  LIBRARY 


BY  DONATION  OR  PURCHASE  DURING  THE  YEAR  1898. 


Presented  by 
Ahlfeld  (F.).  Lehrbucli  der  Geburtshilfe  ziirwissen- 
schaftlichen  und  praktischeii  Ausbildung  fiir 
Aerzte  und  Studireude.  Zweite,  vollig  umgear- 
beitete  Auflage,  mit  338  Abbildungen  und  16 
Curve ntafebi  im  Text. 

illustrations,  8vo.  Leipzig,  1898    Purchased. 

Arx  (Max  von).  Ueber  die  Ursachen  einer  natiirlicben 
Lage  des  Gebarorgaus.  ('  Volkmann's  Samm- 
lung,'  neue  Folge,  No.  210.) 

8vo.  Leipzig,  1898        Pitto. 

AsHBY  (Henry).     Health  in  the  nursery. 

sm.  8vo.  Lond   1898        Ditto. 

Camboulas  (L.  Bestion  de).  Le  Sue  ovarien :  effets 
physiologiques  et  thcrapeutiques.  Organo- 
therapie  ovarienne.  8vo.  Paris,  1896        Ditto. 

Castan  (Andre).     Les  mctrorrhagies  des  jeunes  filles 

8vo.  Paris,  1898        Ditto. 

Catalogue  of   books  added  to  the   Radclitfe   Library,    Sir  H.  W. 
Oxford  University  Museum,  during  the  year  1897      Acland, 

4to.  Oxford,  1898       K.C.B. 

CuLLiNGWORTH  (Charles  J.).  On  the  importance  of 
personal  character  in  the  profession  of  Medicine. 
An  address  delivered  at  the  opening  of  the 
winter  session  of  the  Medical  Department  of 
the  Yorkshire  College,  Leeds,  October,  1898.  Author. 

Tubal  gestation,  with    special  reference   to  its 

early  diagnosis  and  treatment.  An  address 
delivered  before  the  Oxford  Medical  Society, 
November  12th,  1897.  sm.  8vo.  Lond.  1897 


VOL.  XL. 


Ditto. 
25 


360 


ADDITIONS    TO    THE    LIBRARY. 


Presented  hy 
CuMSTON    (Charles    Greene).     Neuralgia   and   uterine 
affections.      Eepri7ited  from  '  Annals  of   G-ynae- 
cology  and  Psediatry.'  Boston,  1895      Author. 

Note  on  the  pathology  and  treatment  of  osteo- 
malacia, with  a  report  of  a  case  cured  by  bi- 
lateral oophorectomy.     Reprinted  from  'Annals 

of  Gynaecology  and  Paediatry.'         Boston,  1895        Ditto, 

Parietal    fibro-myomata  of    the    uterus,    and 

Prof.    VuUiet's    operation  for   their  extraction. 

Reprinted  from    '  Annals  of     Gynaecology    and 
Psediatry.'  '    Boston,  1895        Ditto. 

The  treatment  of  inoperable   uterine   cancers. 

Reprinted    from    'Annals    of    Gynaecology    and 
Psediatry.'  Boston,  1895        Ditto. 

Det  Kgl.  Norske  Frederiks  Universitet.  Program,  1896, 
2det.  Semester.  8vo.  Christiania,  1897 

DoDERLEiN  (Albert).  Leitfaden  fiir  den  geburtshil- 
flichen  Operationskurs.  Dritte  Auflage. 

illustrations,  8vo.  Leipzig,  1898   Purchased. 

Doyen  (E.).  Technique  chirurgicale.  Avec  la  colla- 
boration du  Dr.  G.  Eouesel  et  de  M.  A.  Millot. 
Technique  chirurgicale  generale.  Operations 
gynecologiques.         illustrations,  8vo.  Paris,  1897 


Feis  (Oswald) .  Ueber  die  Komplikation von  Schwanger- 
schaf  t,  Geburt  und  Wochenbett  mit  chronischem 
Herzfehler.  {'  Volkmann's  Sammlung,'  neue 
Folge,  No.  213.)  Bvo.  Leipzig,  1898 

Freund  (M.  B.).  HalbkanJile  in  der  chirurgisch-gyna- 
kologischen  Praxis.  ('  Volkmann's  Sammlung,' 
neue  Folge,  No.  226  [I].)  8vo.  Leipzig,  1898 

Frumerie  (Gustavo  de).  Massage  gynecologique 
(Methode  Thure  Brandt),      sm.  8vo.  Paris,  1897 

Funke  (Albrecht).  Ueber  die  Exstirpation  der  Scheide 
und  des  Uterus  bei  primilrem  Vaginalcarcinoni. 
('Volkmann's  Sammlung,'  neue  Folge,  No.  226 
[II].)  8vo.  Leipzig,  1898 

Gellhorn  (Georg).  Ueber  die  Resultate  der  Radical- 
Behandluug  des  Gebarmiitter-Scheidenkrebses 
mit  dem  Gliiheisen.  "Arbeiten  aus  der  Privat- 
Frauenklinik  von  Dr.  A.  Mackenrodt  in  Berlin," 
Heft  2.  illustrations,  Bvo.  Berlin,  1898 


Ditto. 

Ditto. 

Ditto. 
Ditto. 

Ditto. 


Ditto. 


ADDITIONS    TO    THE    LIBRARY. 


361 


Presented  by 
GoTTSCHALK    (Sigmuiicl).      Ueber    den    Einfluss    des 
Wochenbetts  auf  cjstische  Eierstockgeschwiilste. 
(*  Volkmann's  Sammluiig,'  neue  Folge,  No.  207.) 

8vo.  Leipzig,  1898   Purchased. 

Heape  (Walter).  Further  note  on  the  transplantation 
and  growth  of  mammalian  ova  within  a  uterine 
foster-mother.  ('  Proc.  of  the  Eoval  Society,' 
vol.  Ixii.)  4to!!  Lond.  1897      Author. 

Herman  (Greorge  Ernest).  Diseases  of  women:  a 
clinical  guide  to  their  diagnosis  and  treatment. 

illustrations,  8vo.  Lond.  1898        Ditto. 

Jellett  (Henry).     See  Hospital  Reports. 

Operative  gynaecology,  m   two 
illustrations,  8vo.  Lond.  1898    Purchased. 

King  (A.  F.  A.).      A   manual  of  obstetrics,  7th  edit. 

illustrations,  8vo.  Lond.  1898        Ditto. 


Kelly  (Howard  A.), 
volumes. 


Kleinwachtee  (Ludwig).  Wichtige  gynakologische 
Heilfactoren.  (Separatabdruck  aus  der  *  Wiener 
Klinik,'  1898,  1  Heft.)  Author. 

Knapp  (Ludwig).  Wochenbettstatistik.  Eine  klinische 
Studie.     Mit  40  Tabellen  iui  Text. 

8vo.  Berlin,  1898   Purchased. 

Kustner  (Otto).  Ueber  die  Freund'sche  Operation  bei 
Gebjirmiitterkrebs.  ('  Volkniann's  Sammlung,' 
neue  Folge,  No.  204.)  8vo.  Leipzig,  1898        Ditto. 

Labadie-Lagrave  (F.)  and  Felix  Legueu.  Traitc 
niedico-chirurgical  de  gynecologic. 

illustrations,  8vo.  Paris,  1898        Ditto. 

Leguetj  (Felix).     See  Labadie-Lagrave  (F.). 

LiNDFORS  (A.  O.).  Zur  Lehre  von  den  angeborenen 
Hirnbriichen  und  deren  chirurgischer  Beliand- 
lung.  ('  Volkmann's  Sammlung,'  nene  Folge, 
Nos.  222,  223).  8vo.  Leipzig,  1898        Ditto. 

LiTTAUER  (Arthur).  Loipzigor  '  Geburtshilflic])o  Sta- 
tistik  '  fiir  das  Jahr  1894.  ('  Volkmann's  Samm- 
lung,' neue  Folge,  No.  219.) 

8vo.  Leipzig,  1898        Ditto. 

LoHLEiN    (Hermann).       Gyniikologischc    Tagesfrac^'on. 

Heft  5.  illustrations.  8vo.  Wiesbaden,  1898        Ditto. 


Lyle  (E.  p.  R.), 


illustrations,  8vo.  Wiesbaden,  1898 
See  Hospital  Reports. 


362 


ADDITIONS    TO    THE    LIBEARY. 


Presented  hy 
Martin  (A.) .     Die  Kranklieiten  der  Eierstocke. 

illustrations,  8vo.  Leipzig,  1898  Purchased. 

Die  Krankheiten  der  Eileiter. 

illustrations,  8vo.  Leipzig,  1895        Ditto. 

Mathew    (Gr.    Porter).     Clinical  observations  on  two 

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Shaw-Mackenzie  (J.  A.).  On  maternal  syphilis,  in- 
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pelvic  disease  in  women.  8vo.  Lond.  1898        Ditto. 

Sheild  (Marmaduke).      A  clinical  treatise  on  diseases 

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Spath  (Dr.).  Geburtshinderniss  durch  eine  Dermoid- 
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Tarnier  (S.)  et  P.  BuDiN.  Traite  de  I'art  des 
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von    den    weiblichen    Genitalien     ausgehenden 

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204,  Kustner,    Ueber     die     Freund'sche     Operation    bei 

Gebarmutterkrebs. 
207.   GottschalJc,  Ueber  den    Einfluss    des   Wochenbetts 

auf  cystiscbe  Eierstockgesebwiilste. 
210.  Arx,  Ueber  die  Ursacben  einer    natiirlicheu    Lage 

des  Gebarorgans. 
213.  Feis,  Ueber  die  Komplikation  von  Schwangerscbaft, 

Geburt  und  Wochenbett  uiit  chroniscbem  Herz- 

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219.  Littauer,     Leipziger     '  Geburtsbilflicbe    Statistik ' 

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Walther  (Heinrich) .  Leitf aden  zur  Pflege  der  Woch- 
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Webster  (J.  C).  Diseases  of  women.  A  text-book 
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Williams  (J.  Whitridge).     Diphtheria  of   the  vulva. 

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Bauchfells  und  des  benachbarten  Zellgewebes. 
(2  Heft  des  I  Supplementbandes  des  'Handbuchs 
der  speciellen  Tliera^ie  innerer  Krankheiten  '). 

8vo.  Jena,  1897 

Bericbte  und  Studien  aus  dem  konigl.     Sacbs. 

Entbindungs-Institute  in  Dresden.  (See  Reports.) 

Dr.  Ludwig  Winckel.     (Separatabdruck  aus  der 

*  Miincbener  medicinische  Wochenscbrift,'  1893.) 

Ueber  die  cbirurgiscbe  Behandlung  der  von  den 

weiblicben  Genitalien  ausgebenden  Baucbfell- 
Entziindung.  (' Volkmann's  Sammlung  klini- 
scber  Vortrage,'  neue  Folge,  No.  201.) 

8vo.  Leipzig,  1897 

■ Ueber     die     Bedeutung     der      intern ationalen 

Aerztecongresse,  speciell  die  des  Moskauer 
Congresses.  (Separatabdruck  aus  der  *  Miincbener 
medicinische  Wochenscbrift,'  Nos.  46  u.  47, 
1897.) 

Sir   Thomas   Spencer  Wells.     (Separatabdruck 

aus  der  '  Miincbener  medicinische  Wochen- 
scbrift,' No.  10,  1897.) 


Presented  hy 


Author. 


Ditto. 


Ditto. 


Ditto. 


Ditto. 


TRANSACTIONS. 


Clinical  Society  op  London— 

With   report   on   the    antitoxin   of     diphtberia. 
Transactions,  vol  xxxi.  8vo.  Lond.  1898      Society. 

Clinical  Society  op  London  — 

Index  to  tbe  Transactions  of,  vols,  i — xxx. 

8vo.  Lond.  1898        Ditto. 

Congres    periodique    international    de    gynecologic    et 

d'obstetrique.      Coniptes-rendus,      2me    Session,    University 
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Gesellschaft     pur     Natur     und     Heilkunde     in 
Dresden — 

Jahresbericbt.  Sitzungsperiode  1897-8. 

8vo.  Dresden,  1898      Society. 


ADDITIONS    TO    THE    LIBRARY. 


365 


Medical  Society  of  London — 
Transactions,  vol.  xx. 

vol.  xxi. 


8vo.  Lend.  1897 
8vo.  Loud.  1898 


Obstetrical  Society  (Edinburgh) — 

Transactions,  Session  1897-8,  vol.  xxiii. 

8vo.  Edin.,  1898 

SOCIETE  DE  MeDECINE  DE  KoUEN 

Bulletin,  2e  Serie,  vol.  x,  35e  an  nee,  1896. 

8vo.  Eouen,  1897 

vol.  xi,  36e  anuee,  1897.  8vo.  Rouen,  1898 

Soci^TE  Obst^tricale  et  Gynecologique  DE  Paris. 
Bulletins  et  Memoires  pour  I'annee,  1894. 

8vo.  Paris,  1895 

1895.  8vo.  Paris,  1896 

1896.  8vo.  Paris,  1897 


Presented  hy 

Society. 
Ditto. 


Ditto. 

Ditto. 
Ditto. 

Ditto. 
Ditto. 
Ditto. 


JOURNALS. 

Revue  pratique  d'Obstetrique  et  de  Gynecologic,  vol. 
xiii,  1897.  8vo.  Paris,  1898. 


Editors. 


REPOHTS. 

America — Boston     Lying-in     Hospital.        Sixty-fifth 

Annual  Report  for  the  year  1897.  Hospital 

8vo.  Boston,  1898        Staff. 

Johns  Hopkins  Hospital  (The),  Reports,  vol.  vi. 

la.  8vo.  Baltimore,  1897        Ditto. 

Vol.vii,  Nos.  1,  2. 

4to.  Baltimore,  1898        Ditto. 

Germany— Berichte  und  Studien  aus  dem  kouigl. 
Sachs.  Entbinduugs-Institute  in  Dresden, 
1873-5,  von  F.  VVinckel,  vols,  i,  ii. 

illustrations,  8vo.  Leipzig,  1874-6      Author. 

Vol.  iii,  illustrations,  8vo.  Leipzig.  1879        Ditto. 


366 


ADDITIONS    TO    THE    LIBRARY. 


Hospitals — Medical  and  Surgical  Report  of  the  Presby- 
terian Hospital  in  the  City  of  New  York, 
vol.  iii,  January,  1898,  edited  by  Andrew  J. 
McCosh,  M.D.,  and  Walter  B.  James,  M.D. 

8vo.  New  York,  1898 

Middlesex  Hospital  Reports  for  1896. 

8vo.  Lond.  1897 

Clinical  Report  of  the  Rotunda  Hospitals  for 

one  year,  November  1st,  1896,  to  October  31st, 
1897^  by  R.  Dancer  Purefoy,  M.D.,  Master ;  T. 
Henry  Wilson,  Henry  Jellett,  and  R.  P.  R.  Lyle, 
Assistant  Masters.  8vo.  Dublin,  1898 

St.     Bartholomew's     Hospital     Reports,     vol. 

xxxiii.  8vo.  Lond.  1897 

St.   Thomas's    Hospital    Reports,     new    series, 

vol.  XXV.  8vo.  Lond.  1896 

The  Society  of  the  New  York  Hospital,  127th 

Annual  Report  for  the  year  1897. 

8vo.  New  York,  1897 


Presented  by 


Author. 

Hospital 
Staff. 


Ditto. 


Ditto. 


Ditto. 


Society. 


RULES  AND  REGULATIONS 

to  be  observed  by  Midwives  holding  the  Certificate  of  the 

OBSTETRICAL   SOCIETY  OF   LONDON. 


The  Certificate  confers  on  the  Midwife  no  right  to  act  as  a 

Medical  Practitioner. 


MIDWIVES  holding  the  certificate  of  the  Obstetrical 
Society  of  London  must  conform  to  the  following  rules 
and  regulations  : 

Section  A. — General. 

1.  The  instruments  and  other  requisites  which  a  mid- 
wife must  take  with  her  when  called  to  a  confinement 
are  the  following  : 

(a)  An  enema-syringe,  a  douche  apparatus  with  vaginal 
nozzle  (preferably  of  glass),  a  catheter,*  a  pair 
of  scissors,  a  clinical  thermometer,  and  a  nail- 
brush. 

(h)  An  efficient  antiseptic  for  disinfecting  the  hands, 
&c.,  such  as  corrosive  sublimate  (perchloride  of 
mercury)  or  carbolic  acid.  Corrosive  subliniato 
may  be  carried  either  in  the  form  of  powders t  or 

*  A  j)latecl  inctiil  catheter  caii  be  obtained  for  the  sum  of  eifj^hteen  pence. 

t  These  sliould  be  carried  in  a  box  containinj^  twelve  antiseptic  powders, 
each  powder  consistitif^:  of  ton  grains  of  corrosive  subliniate  (perclib)ride  of 
mercury),  fifty  grains  of  tartaric  acid,  and  one  grain  of  cocliincaL  Tlie  box 
should  be  labelled  '*  The  Corrosive  Sublimate  Powders — Poison." 

VOL.  XL.  26 


368  RULES   AND    REGULATIONS    FOR    MIDWIVES.  ' 

in  tlie  form  of  tablets  or  soloids.  Great  care 
must  be  taken  that  they  are  not  left  lying  about 
(lest  they  be  swallowed),  and  that  they  are 
thoroughly  dissolved.  As  an  alternative  carbolic 
acid  may  be  used.  It  must  be  carried  in  the  form 
of  liquefied  carbolic  acid  in  a  four-ounce  bottle 
labelled  "Poison  ''  (see  page  371). 

(c)  An  antiseptic  for   douching  in  special  cases.     This 

may  be  carried  in  the  form  of  liquefied  carbolic 
acid,  creolin,  or  liquor  iodi  (see  page  371). 

(d)  An    antiseptic  lubricant  for  smearing  the  fingers, 

catheters,  douche  nozzles,  and  enema  nozzles 
before  they  touch  the  patient.  This  may  be 
carried  in  a  bottle  in  the  form  of  corrosive  sub- 
limate glycerine.  The  bottle  should  hold  two 
ounces,  and  should  be  filled  with  glycerine  con- 
taining half  a  grain  of  corrosive  sublimate  to 
the  ounce.  This  solution  is  of  about  the  strength 
of  one  part  of  corrosive  sublimate  to  one  thousand 
parts  of  gl3^cerine  (1  in  1000). 
It  must  be  remembered  that  the  above   antiseptics  are 

deadly  poisons,  and  must  be  kept  in  the  midwife's  own 

charge. 

2.  Midwives  must  keep  themselves  scrupulously  clean, 
and  avoid  contact  with  cases  of  infectious  disease,  decom- 
posing substances,  and  discharges  from  the  midwife's 
own  nose,  eyes,  ears,  or  mouth  (including  discharges  from 
foul  teeth  and  tooth-plates),  and  foul  discharges  of  any 
other  kind,  so  that  their  fingers,  appliances,  or  clothes 
may  not  harbour  any  infective  material  which  might  be 
conveyed  to  the  lying-in  woman  during  examinations, 
and  thereby  produce  puerperal  fever.  Midwives  are 
strenuously  enjoined  before  touching  a  lying-in  woman 
to  wash  and  disinfect  their  hands  and  instruments  in 
the  manner  to  be  presently  described. 

3.  If  a  midwife  has  charge  of  a  lying-in  case  she  must 
not  leave  the  patient  after  the  commencement  of  the 
second   stage,   and     she    must   stay    with    the   woman  at 


RULES    AND    REGULATIONS    FOR    MIDWIVES.  369 

least  one  hour  after  the  expulsion  of  the  afterbirth  in  a 
normal  labour.  In  cases  of  abnormal  labour,  or  in 
threatened  danger,  she  must  always  await  the  arrival 
of  the  doctor,  remain  with  the  case  as  long  as  he  thinks 
necessary,  and  faithfully  carry  out  his  instructions. 

4.  In  cases  of  threatened  danger  or  of  abnormal  con- 
ditions occurring  in  women  either  pregnant,  in  labour, 
or  lying  in,  or  in  their  new-born  children,  or  on  the 
sudden  death  of  a  pregnant  or  lying-in  woman,  the  midwife 
must  insist  upon  a  registered  medical  practitioner  being 
called  in  at  once. 

5.  In  the  case  of  a  child  (after  the  sixth  month  of 
pregnancy)  being  born  apparently  dead  and  without  any 
signs  of  putrefaction,  the  midwife  should,  until  the 
arrival  of  a  medical  practitioner,  carry  out  for  at  least 
half  an  hour,  or  until  the  child  breathes  regularly,  the 
methods  for  resuscitation  which  have  been  taught  her. 

6.  On  the  birth  of  a  child  which  is  feeble  or  in 
danger  of  death,  it  is  the  midwife^s  duty  to  inform 
one  of  the  parents  of  the  child's  condition  in  case  they 
wish  it  to  be  baptised.  In  case  of  necessity  the  child 
may  be  baptised  by  the  midwife  or  any  other  person. 

7.  The  midwife  is  responsible  for  the  cleanliness, 
comfort,  and  proper  dieting  of  the  mother  and  child 
during  the  lying-in  period,  which  shall  be  held,  for  the 
purpose  of  these  regulations  and  in  a  normal  case,  to 
mean  the  time  occupied  by  the  labour  and  a  period  of  ten 
days  thereafter. 

8.  A  '^  case  of  normal  labour  "  in  these  regulations 
shall  be  hekl  to  mean  a  labour  in  which  there  are  none 
of  the  conditions  specified  in  Section  C  (page  373). 


Section  B. — Instructions  for  Midwives. 

Preca-utions    to  be    observed   by    the   midwife  to  avoid 
carrying  infectious  diseases,  especially  puerperal  fever  ; 
1.   The  midwife  must  be  scrupulously    clean   in  every 


370  RULES    AND    REGULATIONS    FOR    MIDWIVES. 

way^  because  the  smallest  particle  of  decomposing  matter 
may  set  up  puerperal  fever. 

It  is  particularly  dangerous  for  a  midwife  wlio  is 
attending  a  case  in  wbicli  there  are  foul-smelling  dis- 
charges, to  go  direct  to  another  case  without  first 
thoroughly  cleansing  and  disinfecting  her  hands  and  arms 
and  such  appliances  as  she  may  have  had  occasion  to 
use. 

Unless  the  cleansing  process  be  thoroughly  carried  out, 
there  will  be,  even  after  a  healthy  confinement,  remains 
of  blood,  lochia,  or  liquor  amnii  on  the  fingers,  and 
especially  under  the  nails,  which  will  there  undergo 
decomposition,  and  so  become  dangerous  to  the  next 
patient  attended.  The  midwife  must,  therefore,  keep  her 
nails  cut  short,  and  preserve  the  skin  of  her  hands  as 
far  as  possible  from  chaps  and  other  injuries. 

She  should  wear  a  dress  of  washable  material,  and 
over  it  a  clean  white  or  macintosh  apron  ;  it  is  best  to 
have  the  sleeves  of  the  dress  made  so  that  the  midwife 
can  tuck  them  well  up  above  the  elbows. 

2.  Before  touching  the  genital  organs  or  their  neigh- 
bourhood the  midwife  must  disinfect  her  hands  and  arms 
as  follows  : — The  hands  and  arms  must  first  be  scrubbed 
with  soap  and  water^  the  nail-brush  being  used  for  the 
hands  and  nails,  particularly  the  grooves  round  the  roots 
of  the  nails.  The  soap  and  water  must  then  be  rinsed 
off  in  clean  water,  and  the  hands  soaked  for  a  full 
minute  in  the  corrosive  sublimate  solution.  The  hands 
must  be  well  cleansed  and  must  be  soaked  in  the  corrosive 
sublimate  solution  before  each  examination. 

3.  No  more  internal  examinations  should  be  made  than 
are  absolutely  necessary. 

4.  Antiseptic  solutions  : 

Corrosive  Sublimate  Solution. — If  the  corrosive  sub- 
limate powders  are  used  (see  foot-note,  p.  367), 
dissolve  one  powder  thoroughly  in  a  pint  of  warm 
water.  If  corrosive  sublimate  tablets  or  soloids 
are  used,  read  carefully  the  directions  on  the  label. 


rdj.es  and  regulations  for  mid^wives.  371 

and  dissolve  thoroughly  in  warm  water  as  many 
as  will  make  a  solution  of  one  part  of  corrosive 
sublimate  in  one  thousand  parts  of  water.  A 
corrosive  sublimate  solution  being  highly  poisonous 
must  in  no  case  be  used  for  douching  purposes 
except  under  direct  order  from  a  registered  medi- 
cal practitioner  (see  Section  A^  paragraph  h). 

Carhollc  Acid  Solution  :  (a)  Strong  (1  to  20)  solution 
for  disinfecting  the  hands,  arms,  and  metallic  in- 
struments.— Dissolve  one  ounce  of  pure  liquefied 
carbolic  acid  in  one  pint  of  hot  water  with 
thorough  stirring.  This  solution  must  not  be 
used  for  douching  purposes. 

(h)  Weak  (1  to  80)  solution  for  douching  the  vagina. 
— Dissolve  half  an  ounce  of  pure  liquefied  carbolic 
acid  in  one  quart  of  hot  water  with  thorough 
stirring.  This  solution  must  be  made  in  a  jug  or 
basin  and  poured  into  the  douche  can.  It  is 
dangerous  to  mix  the  solution  in  the  douche  can. 

N.B. — Pure  liquefied  carbolic  acid  is  corrosive  and 
highly  poisonous,  and  must  be  carefully  kept  in  a 
coloured  poison  bottle  bearing  a  poison  label  (see 
Section  A,  paragraph  h). 

Iodine  Solution. — Dilute  one  teaspoon ful  of  liquor 
iodi  with  a  pint  of  tepid  water  (see  Section  A, 
paragraph  c). 

Creolin  Solution. — Dilute  one  teaspoonful  of  creolin 
with  a  quart  of  warm  water  (see  Section  A, 
paragraph  c). 

Notice. — Not  less  than  two  quarts  of  solution  should 
be  used  for  douching  the  vagina. 

5.   Disinfection  of  Instruments  : 

(a)    All   glass  or   metal  instruments  must  be  boiled 

in  a  covered  vessel  for  at  least  ten  minutes. 
(6)    All  instruments  which  would  bo  injured  by  being 


372  RULES    AND    REGULATIONS    FOR    MIDWIVES. 

boiled  must  after  use  be  tliorouglily  cleansed  with 
soap  and  water^  then  thoroughly  rinsed  in  clean 
water,  and  afterwards  left  lying  as  long  as  pos- 
sible in  corrosive  sublimate  solution  (1  in  1000). 

6.  Disinfection  of  the  Room  : 

The  midwife  must  remove  soiled  linen^  blood,  fasces, 
urine,  and  the  placenta  from  the  neighbourhood 
of  the  patient  and  from  the  lying-in  room  as  soon 
as  possible  after  the  labour,  and  in  every  case 
before  she  leaves  the  patient's  house. 

7.  Disinfection  of  the  Patient  : 

Before  making  the  first  internal  examination,  and 
always  before  passing  a  catheter,  the  midwife 
must  wash  the  patient's  external  parts  with  soap 
and  water,  and  then  swab  them  with  corrosive 
sublimate  solution  (1  in  1000).  For  this  purpose, 
and  for  washing  the  external  parts  immediately 
after  labour  and  during  the  lying  in,  absorbent 
wool  must  be  used,  and  on  no  account  ordinary 
sponges  or  flannels. 

8.  Disinfection  of  the  Infantas  Eyes  : 

As  soon  as  the  child's  head  is  born,  and  if  pos- 
sible before  the  lids  are  opened,  its  eyelids  should 
be  carefully  wiped  with  pledgets  of  absorbent 
wool  soaked  in  corrosive  sublimate  solution  (1  in 
4000),*  and  as  soon  as  practicable  after  birth  a 
few  drops  of  the  above  solution  should  be  dropped 
into  each  eye. 

9.  A  midwife  may  administer  or  order  only  such  ordi- 
nary remedies  or  drugs  as  may  be  required  during  or  after 
a  normal  labour. 

10.  Whenever  a  midwife  has  been  in  attendance  upon 
a  patient  suffering  from  puerperal  fever,  or  from  any  other 
illness   supposed  to  be  infectious,  she  must  disinfect   her 

*  This  solution  is  made  by  adding  three  parts  of  water  to  one  part  of  the 
already  prepared  solution  of  corrosive  sublimate  (1  in  1000). 


RULES    AND    REGULATIONS    FOR   MIDWIVES.  373 

hands  and   all  her  instruments,  and   have  her    clothing 
thoroughly  disinfected  before  going  to  another  labour. 


Section  C. — Concerning    the    Summoning  of  Registered 
Medical  Practitioners. 

1.  A  midwife  must,  in  all  cases  of  illness  of  the  patient 
or  any  abnormality  occurring  during  pregnancy,  labour, 
or  lying-in,  as  well  as  in  illness  of  the  child,  request 
the  patient  and  her  friends  to  send  for  a  registered 
medical  practitioner.  She  must  under  the  following  cir- 
cumstances more  particularly  insist  upon  a  registered 
medical  practitioner  being  called  in  : 

(a)   In  the  Case  of  a  Pregnant  Woman  : 

(1)  When  she  suspects  a  narrow  pelvis. 

(2)  When  there  is  haemorrhage. 

(3)  When  the  pregnancy  presents  any  other  unusual 
feature  (as,  for  example,  excessive  sickness,  per- 
sistent headache,  dimness  of  vision,  swelling  of 
face  and  ankles,  difficulty  in  emptying  the  bladder, 
large  varicose  veins,  hernia),  or  when  it  is  com- 
plicated by  fever  or  any  other  serious  condition. 

(h)   In  the  Case  of  a  Woman  in  Labour  : 

(1)  In  all  cases  of  presentation  of  the  afterbirth, 
face,  arm,  shoulder,  or  navel-string  ;  and  of  the 
breech  or  feet  in  all  first  labours  ;  and  in  all  cases 
of  flooding  and  convulsions  ;  and  also  whenever 
there  appears  to  be  insufficient  room  for  the  child 
to  pass,  or  when  a  tumour  is  felt  in  nny  part  of 
the  mother's  passages. 

(2)  If  the  midwife  when  the  cervix  has  become  par- 
tially dilated  is  unable  to  make  out  the  presen- 
tation, or  finds  that  no  progress  is  being  made. 

(3)  If  there  is  loss  of  blood  in  excess  of  what  is 
natural,  at  whatever  time  of  the  labour  it  may 
occur. 


374  RULES    AND    REGULATIONS    FOR    MIDWIVES. 

(4)  If  the  placenta  is  not  expelled  within  an  hour 
after  tlie  birtli  of  the  child,  even  if  no  bleeding 
has  occurred. 

(5)  In  cases  of  rupture  of  the  peringeum  or  other 
serious  injury  of  the  soft  parts. 

(c)   In   the  Case  of  Lying-in    Women  and   in   the  Case 
of  newly  horn  Children  : 

Whenever,  after  delivery,  the  progress  of  the  woman 
or  child  is  not  satisfactory. 

2.  When  a  midwife  sends  for  a  doctor  she  must  state 
in  writing  the  condition  of  the  patient  and  her  reason  for 
sending. 


July,  1898. 


TRIITTED    BY   ADLARD   AND    SON,    BARTHOLOMEW    CLOSE,    E.C. 


ci^lAU 


RG  Obstetrical  Society  of 

1  Lor.don 

C3  Transactions 


GEHSTS 


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